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PROCEDURES
UNIT ONE
Introduction to Medical Assisting
1 Competency-Based Education and the Medical
Assistant Student, 1
2 The Health Record, 15
PROCEDURE 2-1 Create a Patient's Health Record:
Register a New Patient in the Practice Management
Software, 20
PROCEDURE 2-2 Organize a Patient's Health Record:
Upload Documents to the Electronic Health Record, 27
PROCEDURE 2-3 Create and Organize a Patient's Paper
Health Record, 38
PROCEDURE 2-4 File Patient Health Records, 39
3 Infection Control, 45
PROCEDURE 3-1 Participate in Bloodborne Pathogen
Training: Use Standard Precautions to Remove
Contaminated Gloves and Discard Biohazardous
Material, 54
PROCEDURE 3-2 Demonstrate the Proper Use of Eye Wash
Equipment: Perform an Emergency Eye Wash, 56
PROCEDURE 3-3 Participate in Bloodborne Pathogen
Training and a Mock Environmental Exposure Event
with Documentation of Steps, 59
PROCEDURE 3-4 Participate in Bloodborne Pathogen
Training: Perform Medical Aseptic Hand Washing, 62
PROCEDURE 3-5 Select Appropriate Barrier/Personal
Protective Equipment and Demonstrate Proper Disposal
of Biohazardous Material: Use Standard Precautions for
Sanitizing Instruments and Discarding Biohazardous
Material, 64
PROCEDURE 3-6 Perform Compliance Reporting Based on
Public Health Statutes, 67
4 Patient Assessment, 69
PROCEDURE 4-1 Demonstrate Therapeutic Communication
Feedback Techniques to Obtain Patient Information
and Document Patient Care Accurately in the Medical
Record, 74
PROCEDURE 4-2 Respond to Nonverbal
Communication, 79
PROCEDURE 4-3 Use Medical Terminology Correctly and
Pronounce Accurately to Communicate Information to
Providers and Patients, 90
5 Patient Education, 97
PROCEDURE 5-1 Develop a List of Community Resources
for Patients' Healthcare Needs; also, Facilitate Referrals
in the Role of Patient Navigator, 104
PROCEDURE 5-2 Coach Patients in Health Maintenance,
Disease Prevention, and Following the Treatment
Plan, 107
6 Nutrition and Health Promotion, 111
PROCEDURE 6-1 Instruct a Patient According to the
Patient's Dietary Needs: Coach the Patient on the
Basics of the Glycemic Index, 132
PROCEDURE 6-2 Coach a Patient About How to
Understand Food Labels, 134
7 Vital Signs, 141
PROCEDURE 7-1 Obtain Vital Signs: Obtain an Oral
Temperature Using a Digital Thermometer, 145
PROCEDURE 7-2 Obtain Vital Signs: Obtain an Aural
Temperature Using the Tympanic Thermometer, 147
PROCEDURE 7-3 Obtain Vital Signs: Obtain a Temporal
Artery Temperature, 148
PROCEDURE 7-4 Obtain Vital Signs: Obtain an Axillary
Temperature, 150
PROCEDURE 7-5 Obtain Vital Signs: Obtain an Apical
Pulse, 152
PROCEDURE 7-6 Obtain Vital Signs: Assess the Patient's
Radial Pulse and Respiratory Rate, 156
PROCEDURE 7-7 Obtain Vital Signs: Determine a Patient's
Blood Pressure, 161
PROCEDURE 7-8 Obtain Vital Signs: Measure a Patient's
Weight and Height, 165
8 Assisting with the Primary Physical
Examination, 171
PROCEDURE 8-1 Use Proper Body Mechanics, 180
PROCEDURE 8-2 Assist Provider with a Patient Exam:
Fowler's and Semi-Fowler's Positions, 182
PROCEDURE 8-3 Assist Provider with a Patient Exam:
Horizontal Recumbent and Dorsal Recumbent
Positions, 183
PROCEDURE 8-4 Assist Provider with a Patient Exam:
Lithotomy Position, 184
PROCEDURE 8-5 Assist Provider with a Patient Exam: Sims
Position, 185
PROCEDURE 8-6 Assist Provider with a Patient Exam:
Prone Position, 186
PROCEDURE 8-7 Assist Provider with a Patient Exam:
Knee-Chest Position, 187
PROCEDURE 8-8 Assist Provider with a Patient Exam, 191
UNIT TWO
Assisting with Medications
9 Principles of Pharmacology, 196
PROCEDURE 9-1 Prepare a Prescription for the Provider's
Signature, 206
10 Pharmacology Math, 226
PROCEDURE 10-1 Demonstrate Knowledge of Basic Math
Computations, 235
PROCEDURE 10-2 Calculate Proper Dosages of Medication
for Administration: Convert Among Measurement
Systems, 236
PROCEDURE 10-3 Calculate Proper Dosages of Medication
for Administration: Calculate the Correct Pediatric
Dosage Using Body Weight, 237
11 Administering Medications, 241
PROCEDURE 11-1 Administer Oral Medications, 248
PROCEDURE 11-2 Fill a Syringe from an Ampule, 251
PROCEDURE 11-3 Fill a Syringe from a Vial, 252
PROCEDURE 11-4 Reconstitute a Powdered Drug for
Administration, 259
PROCEDURE 11-5 Administer Parenteral (Excluding IV)
Medications: Give an lntradermal Injection, 260
PROCEDURE 11-6 Select the Proper Sites for
Administering a Parenteral Medication: Administer a
Subcutaneous Injection, 264
PROCEDURE 11-7 Mix Two Different Types of Insulin in
One Syringe, 266
PROCEDURE 11-8 Administer Parenteral (Excluding IV)
Medications: Administer an Intramuscular Injection into
the Deltoid Muscle, 270
PROCEDURE 11-9 Select the Proper Sites for
Administering a Parenteral Medication: Administer a
Pediatric Intramuscular Vastus Lateralis Injection, 272
PROCEDURE 11-10 Administer Parenteral (Excluding IV)
Medications: Give a Z-Track Intramuscular Injection into
the Dorsogluteal Site, 275
PROCEDURE 11-11 Complete an Incident Report Related
to an Error in Patient Care, 278
UNIT THREE
Assisting with Medical Specialties
12 Safety and Emergency Practices, 282
PROCEDURE 12-1 Evaluate the Work Environment to
Identify Unsafe Working Conditions and Comply With
Safety Signs and Symbols, 285
PROCEDURE 12-2 Manage a Difficult Patient, 286
PROCEDURE 12-3 Demonstrate the Proper Use of a Fire
Extinguisher, 287
PROCEDURE 12-4 Participate in a Mock Environmental
Exposure Event: Evacuate a Provider's Office, 288
PROCEDURE 12-5 Maintain an Up-to-Date List of
Community Resources for Emergency
Preparedness, 291
PROCEDURE 12-6 Maintain Provider/Professional-
Level CPR Certification: Use an Automated External
Defibrillator (AED), 294
PROCEDURE 12-7 Perform Patient Screening Using
Established Protocols: Telephone Screening and
Appropriate Documentation, 295
PROCEDURE 12-8 Maintain Provider/Professional-Level
CPR Certification: Perform Adult Rescue Breathing
and One-Rescuer CPR; Perform Pediatric and Infant
CPR,298
PROCEDURE 12-9 Perform First Aid Procedures:
Administer Oxygen, 301
PROCEDURE 12-10 Perform First Aid Procedures: Respond
to an Airway Obstruction in an Adult, 302
PROCEDURE 12-11 Perform First Aid Procedures: Care for
a Patient Who Has Fainted or Is in Shock, 305
PROCEDURE 12-12 Perform First Aid Procedures: Care for
a Patient With Seizure Activity, 309
PROCEDURE 12-13 Perform First Aid Procedures: Care
for a Patient With a Suspected Fracture of the Wrist by
Applying a Splint, 310
PROCEDURE 12-14 Perform First Aid Procedures: Control
Bleeding, 312
PROCEDURE 12-15 Perform First Aid Procedures: Care for
a Patient With a Diabetic Emergency, 314
13 Assisting in Ophthalmology and
Otolaryngology, 319
PROCEDURE 13-1 Perform Patient Screening Using
Established Protocols: Measure Distance Visual Acuity
with the Snellen Chart, 328
PROCEDURE 13-2 Instruct and Prepare a Patient for a
Procedure: Assess Color Acuity Using the Ishihara
Test, 330
PROCEDURE 13-3 Instruct and Prepare a Patient
for a Procedure or Treatment: Irrigate a Patient's
Eyes, 332
PROCEDURE 13-4 Instruct and Prepare a Patient for
a Procedure or Treatment: Instill an Eye
Medication, 333
PROCEDURE 13-5 Perform Patient Screening Using
Established Protocols: Measure Hearing Acuity with an
Audiometer, 341
PROCEDURE 13-6 Instruct and Prepare a Patient for a
Procedure or Treatment: Irrigate a Patient's Ear, 342
PROCEDURE 13-7 Instruct and Prepare a Patient for a
Procedure or Treatment: Instill Medicated Ear
Drops, 344
PROCEDURE 13-8 Perform Patient Screening Using
Established Protocols: Collect a Specimen for a Throat
Culture, 346
14 Assisting in Dermatology, 350
15 Assisting in Gastroenterology, 368
PROCEDURE 15-1 Perform Patient Screening Using
Established Protocols: Telephone Screening of a Patient
with a Gastrointestinal Complaint, 373
PROCEDURE 15-2 Assist the Provider with a Patient
Examination: Assist with an Endoscopic Examination of
the Colon, 386
PROCEDURE 15-3 Instruct and Prepare a Patient for a
Procedure: Instruct Patients in the Collection of a Fecal
Specimen, 387
PROCEDURES
16 Assisting in Urology and Male Reproduction, 391
PROCEDURE 16-1 Coach Patients in Health Maintenance:
Teach Testicular Self-Examination, 406
17 Assisting in Obstetrics and Gynecology, 414
PROCEDURE 17-1 Instruct and Prepare a Patient for
Procedures and/or Treatments: Assist with the
Examination of a Female Patient and Obtain a Smear
for a Pap Test, 426
PROCEDURE 17-2 Instruct and Prepare a Patient for
Procedures and/or Treatments: Prepare the Patient for
a LEEP, 429
PROCEDURE 17-3 Coach Patients in Health Maintenance
and Disease Prevention: Teach the Patient Breast Self-
Examination, 432
PROCEDURE 17-4 Instruct and Prepare a Patient for
Procedures and/or Treatments: Assist with a Prenatal
Examination, 439
18 Assisting in Pediatrics, 446
PROCEDURE 18-1 Verify the Rules of Medication
Administration: Document Immunizations, 466
PROCEDURE 18-2 Maintain Growth Charts: Measure the
Circumference of an Infant's Head, 472
PROCEDURE 18-3 Maintain Growth Charts: Measure an
Infant's Length and Weight, 473
PROCEDURE 18-4 Measure and Record Vital Signs: Obtain
Pediatric Vital Signs and Perform Vision Screening, 476
PROCEDURE 18-5 Assist Provider With a Patient Exam:
Applying a Urinary Collection Device, 479
19 Assisting in Orthopedic Medicine, 484
PROCEDURE 19-1 Assist the Provider with Patient Care:
Assist with Cold Application, 505
PROCEDURE 19-2 Assist the Provider with Patient Care:
Assist with Moist Heat Application, 506
PROCEDURE 19-3 Coach Patients in the Treatment Plan:
Teach the Patient Crutch Walking and the Swing-
Through Gait, 509
PROCEDURE 19-4 Assist the Provider with Patient Care:
Assist with Application of a Cast, 511
PROCEDURE 19-5 Assist the Provider with Patient Care:
Assist with Cast Removal, 513
20 Assisting in Neurology and Mental Health, 517
PROCEDURE 20-1 Assist the Provider with Patient Care:
Assist with the Neurologic Examination, 535
PROCEDURE 20-2 Explain the Rationale for Performance
of a Procedure: Prepare the Patient for an
Electroencephalogram, 536
PROCEDURE 20-3 Assist the Provider with Patient Care:
Prepare the Patient for and Assist with a Lumbar
Puncture, 538
21 Assisting in Endocrinology, 542
PROCEDURE 21-1 Assist the Provider with Patient Care:
Perform a Blood Glucose TRUEresult Test, 550
PROCEDURE 21-2 Assist the Provider with Patient Care:
Perform a Monofilament Foot Exam, 555
22 Assisting in Pulmonary Medicine, 560
PROCEDURE 22-1 Instruct Patients According to Their
Needs: Teach a Patient to Use a Peak Flow Meter, 569
PROCEDURE 22-2 Assist the Provider with Patient Care:
Administer a Nebulizer Treatment, 571
PROCEDURE 22-3 Assist the Provider with Patient Care:
Perform Volume Capacity Spirometry Testing, 576
PROCEDURE 22-4 Perform Patient Screening Using
Established Protocols: Perform Pulse Oximetry, 577
PROCEDURE 22-5 Obtain Specimens for Microbiologic
Testing: Obtain a Sputum Sample for Culture, 578
23 Assisting in Cardiology, 582
24 Assisting in Geriatrics, 601
PROCEDURE 24-1 Demonstrate Empathy: Understand the
Sensorimotor Changes of Aging, 603
UNIT FOUR
Diagnostic Procedures
25 Principles of Electrocardiography, 620
PROCEDURE 25-1 Perform Electrocardiography: Obtain a
12-Lead ECG, 629
PROCEDURE 25-2 Instruct and Prepare a Patient for a
Procedure or Treatment: Fit a Patient With a Holter
Monitor, 640
26 Assisting with Diagnostic Imaging, 645
27 Assisting in the Clinical Laboratory, 675
PROCEDURE 27-1 Perform a Quality Control Measure
on a Glucometer and Record the Results on a Flow
Sheet, 683
PROCEDURE 27-2 Use the Microscope and
Perform Routine Maintenance on Clinical
Equipment, 694
28 Assisting in the Analysis of Urine, 699
PROCEDURE 28-1 Instruct and Prepare a Patient for
a Procedure or Treatment: Instruct a Patient in the
Collection of a 24-Hour Urine Specimen, 702
PROCEDURE 28-2 Instruct and Prepare a Patient for
a Procedure or Treatment: Collect a Clean-Catch
Midstream Urine Specimen, 704
PROCEDURE 28-3 Assess Urine for Color and Turbidity:
Physical Test, 707
PROCEDURE 28-4 Perform Quality Control Measures:
Differentiate Between Normal and Abnormal Test
Results while Determining the Reliability of Chemical
Reagent Strips, 713
PROCEDURE 28-5 Obtain a Specimen and Perform a CUA-
Waived Urinalysis: Test Urine with Chemical Reagent
Strips, 713
PROCEDURE 28-6 Prepare a Urine Specimen for
Microscopic Examination, 715
PROCEDURE 28-7 Obtain a Specimen and Perform a CUA-
Waived Urinalysis: Test Urine for Glucose Using the
Clinitest Method, 723
PROCEDURE 28-8 Obtain a Specimen and Perform
a CUA-Waived Urinalysis: Perform a Pregnancy
Test, 725
PROCEDURE 28-9 Obtain a Specimen and Perform
a CUA-Waived Urinalysis: Perform a Multidrug
Screening Test on Urine, 727
PROCEDURE 28-1 OAssess a Urine Specimen for
Adulteration before Drug Testing, 729
29 Assisting in Blood Collection, 733
PROCEDURE 29-1 Instruct and Prepare a Patient for
a Procedure and Perform Venipuncture: Collect a
Venous Blood Sample Using the Vacuum Tube
Method, 744
PROCEDURE 29-2 Perform Venipuncture: Collect a Venous
Blood Sample Using the Syringe Method, 747
PROCEDURE 29-3 Perform Venipuncture: Obtain
a Venous Sample with a Safety Winged Butterfly
Needle, 751
PROCEDURE 29-4 Instruct and Prepare a Patient
for a Procedure and Perform Capillary Puncture:
Obtain a Capillary Blood Sample by Fingertip
Puncture, 758
30 Assisting in the Analysis of Blood, 765
PROCEDURE 30-1 Perform Routine Maintenance of Clinical
Equipment: Perform Preventive Maintenance for the
Microhematocrit Centrifuge, 769
PROCEDURE 30-2 Obtain Specimens and Perform CUA-
Waived Hematology Testing: Perform a Microhematocrit
Test, 770
PROCEDURE 30-3 Perform CUA-Waived Hematology
Testing: Perform a Hemoglobin Test, 772
PROCEDURE 30-4 Obtain a Specimen and Perform
CUA-Waived Hematology Testing: Determine the
Erythrocyte Sedimentation Rate Using a Modified
Westergren Method, 774
PROCEDURE 30-5 Obtain a Specimen and Perform
a CUA-Waived Protime/lNR Test, 777
PROCEDURE 30-6 Perform a CUA-Waived Chemistry Test:
Determine the Cholesterol Level or Lipid Profile Using a
Cholestech Analyzer, 788
31 Assisting in Microbiology and Immunology, 797
PROCEDURE 31-1 Instruct and Prepare a Patient
for a Procedure: Instruct Patients in the Collection
of Fecal Specimens to Be Tested for Ova and
Parasites, 806
PROCEDURE 31-2 Obtain a Specimen and Perform
a CUA-Waived Microbiology Test: Perform a Rapid
Strep Test, 813
PROCEDURE 31-3 Obtain a Specimen and Perform
a CUA-Waived Immunology Test: Perform the
QuickVue+ Infectious Mononucleosis Test, 816
UNIT FIVE
Assisting with Surgeries
32 Surgical Supplies and Instruments, 825
PROCEDURE 32-1 Identify Surgical Instruments, 828
33 Surgical Asepsis and Assisting With Surgical
Procedures, 842
PROCEDURE 33-1 Prepare Items for Autoclaving: Wrap
Instruments and Supplies for Sterilization in an
Autoclave, 846
PROCEDURE 33-2 Perform Sterilization Procedures:
Operate the Autoclave, 849
PROCEDURE 33-3 Perform Skin Prep for
Surgery, 853
PROCEDURE 33-4 Perform Handwashing: Perform a
Surgical Hand Scrub, 855
PROCEDURE 33-5 Prepare a Sterile Field, 858
PROCEDURE 33-6 Perform Within a Sterile Field: Use
Transfer Forceps, 859
PROCEDURE 33-7 Perform Within a Sterile Field: Pour a
Sterile Solution into a Sterile Field, 860
PROCEDURE 33-8 Perform Within a Sterile Field: Put on
Sterile Gloves, 860
PROCEDURE 33-9 Perform Within a Sterile Field: Assist
with Minor Surgery, 864
PROCEDURE 33-10 Perform Wound Care: Assist With
Suturing, 867
PROCEDURE 33-11 Perform Wound Care and
a Dressing Change: Apply or Change a Sterile
Dressing, 868
PROCEDURE 33-12 Perform Wound Care: Remove Sutures
and/or Surgical Staples, 870
PROCEDURE 33-13 Perform Wound Care: Apply an Elastic
Support Bandage Using a Spiral Turn, 876
UNIT SIX
Career Development
34 Career Development and Life Skills, 881
PROCEDURE 34-1 Prepare a Chronologic Resume, 887
PROCEDURE 34-2 Create a Cover Letter, 895
PROCEDURE 34-3 Complete a Job Application, 897
PROCEDURE 34-4 Create a Career Portfolio, 898
PROCEDURE 34-5 Practice Interview Skills During a Mock
Interview, 902
PROCEDURE 34-6 Create a Thank-You Note for an
Interview, 902
THE CLINICAL
MEDICAL ASSISTANT
AN APPLIED LEARNING APPROACH
This page intentionally left blank
KINN'S
THE CLINICAL
MEDICAL ASSISTANT
....
Deborah Proctor, EdD, RN
Adjunct Faculty Member
m
Butler County Community College
Butler, Pennsylvania -
C

-
-I
0
z

Helen Mills, RN, MSN, ~ , LXMO, ~till

Clinical Educator
Mortin Health Sy:stem
Stuart, Florido

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KINN'S THE CLINICAL MEDICAL ASSISTANT: AN APPLIED LEARNING ISBN: 978-0-323-39671-4

APPROACH, THIRTEENTH EDITION

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With respect to any drug or pharmaceutical products identified, readers are advised to check the most
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PREFACE
M edical assisting as a profession has changed dramatically since
1he Office Assistant in Medical and Dental Practice, by Portia
Frederick and Carol Towner, was first published in 1956. Each
subsequent edition of this textbook has reflected the age in which it
was published. Now, Kinn's 1he Medical Assistant: An Applied Learning
Approach, thirteenth edition, in its 60 th year of publication, continues
to represent a long-standing commitment to high-quality medical
assisting education with its engaging, straightforward writing style
and demonstrated positive outcomes. Hundreds of instructors in
classrooms across the country have used this text to teach thousands
of students over the years. Many of these students have gone on to
teach students of their own with this very same trusted resource. To
continue the use and growth of this text and its features, the thirteenth
edition continues to offer the most comprehensive, up-to-date, and
innovative approach to teaching this subject today.
This textbook has endured throughout the years because it
has been able to keep pace with an ever-changing profession while
producing students who are well trained and qualified to enter
medical practices across the country. This dependability is the reason
the market continues to rely on this text, edition after edition.
Underlying this dependability is a foundation of pedagogic features
that has stood the test of time and that has been expanded and
improved upon yet again in this latest edition. Such features include
the following:
• An easy-to-read, highly interactive writing style that engages
students through practical applications of medical assistant
competencies.
• An emphasis on skill development, with procedural steps outlin-
ing each skill, supported by rationales that provide meaning to
each step.
• A pedagogic framework based on the use of learning objectives,
vocabulary terms, and supportive student supplements.
• A package of supportive materials to accommodate a wide variety
of student learning types and instructor teaching styles.
NEW TO THIS EDITION
• Updated Art Program. The artwork throughout has been
updated and modernized, providing a more attractive textbook
for student use. Many new photographs and line drawings
throughout support the revised content more effectively and are
more relevant to the actual healthcare setting. New images show
up-to-date equipment, provide more disease examples, and better
illustrate key procedural steps.
• New chapter on Competency-Based Education for Medical
Assisting. The emphasis of competency mastery is high to meet
accreditation standards. This chapter helps set the stage for
medical assisting students to understand their programming
and how the road to mastery will affect their ability to attain
a job.
• New Chapter on The Health Record. The manner in which the
medical record is maintained in a medical office has changed
dramatically with the move to the EHR. This chapter reviews
how the medical assistant maintains and interacts with the
medical record.
• Learning Objectives are listed in the same order as the flow
of content. The learning objectives are tied to curriculum com-
petencies. This feature makes it easy to see where the learning
objectives are covered to aid in review of the material and mea-
surement of competency coverage.
• Procedures are integrated into the TOC. Provides a quick
reference to where the procedures will be covered and in
what order.
• Professional Behaviors boxes. The medical assistant must
develop the ability to interact professionally with patients, fami-
lies, co-workers, and other members of the healthcare team.
These boxes provide tips on professional behavior that are specific
to each chapter's content.
EVOLVE
The Evolve site features a variety of student resources, including
Chapter Review Quizzes, new Procedure Videos, Medical Terminol-
ogy Audio Glossary, practice CMA and RMA exams, and much
more! The instructors' Evolve Resources site consists of TEACH
Instructor Resources, including Lesson Plans, PowerPoint Presenta-
tions, Answer Keys for Chapter Review Quizzes, and a retooled Test
Bank with more than 3000 questions.
STUDY GUIDE AND PROCEDURE
CHECKLIST MANUAL
The Study Guide provides students with the opportunity to re-
view and build on information they have learned in the text
through vocabulary reviews, case studies, workplace applications,
and more. The updated Procedure Checklists include CAAHEP
and ABHES competencies that can be traced to the online correla-
tion grid.
vii
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 PREFACE ix

Critical Thinking Application boxes prompt Safety Alert boxes alert students to impor-
students to apply what they have learned tant safety information and reinforce the
as they read and study the chapter. importance of safety in the profession.
pREfACE

148 UNIT ONE

INTRODUCT
ION TO MEDIC
AL ASSISTIN
G

7. ~esslhebultj
oo lhe displays lheprobeasdirected.The
8. Remove lhe een in 1ta25 temperaturellil
pr , note lhe '<anrls. lappear 10. Rec
ord lhe temperolu
biohazordw~ rooding, and dis re results (e.g., T-9
aml lhe probe cav
fl!RE!!SE: Th pro con
be
tainer withouttouching
caver is coolomioo it.
e, inlCJ a record.
fl!RE!!SE: Pmcedure
ml
8.6° F in lhe
potienfsheallh
biohozardw ted and must be slhatare not rec
9. Scmitize yo cO flta iner. di~arded in a orded are considered not
ben 3/30/20-2:20 done.
mon~actur rs mods and disinlect lhe equiprn<nt "' T·101.1°F m
cleonirrg • probe nual lor clooning lhe probe tip.I indicoted. See lhe . C. Rkci, CMA WIM
len s wil Many l
h ok recommend
~
oensure infectio ohal llipes.
n control.

Th e tern ral
artery sca
tempera re nner uses
of the blo an infrared
the late od flowing beam to ass the facility's
through th ess the inf
skin (F
forehead, wh
ere the art e temporal used on the ection control procedu
re 7-3). Be ery lies ab an ery of scanner or res, disposab
cause: the an out l mm alcohol wi it can be cle le cove rs can
vides d surfucc ery is so clo below the pe. aned betw be
heat cond se to the ski een patients
obtai a fu uction, all n, it pro- with an
t, accurate, owing the
pc rat re. To and nonin thermomete
perform the vasive me r to
asurem en t
of forehead, ha pro cedure, pla of bo dy tem
lfway betw ce the probe in -
Ban shou een the ey the center
ld be push ebrows an
be ed if ed back off d the hairline
bandages the forehead .
cover the {this metho
ner an d ge area). Depre d cannot
ntly stroke: ss the bu
h line (at the probe tto n on the
the temple across the
s), keeping forehead tow
. k. the 60 the probe ard the
Ulncr moves fiat on the
re measurem across the patient's
ents arc forehead,
orded; keep taken and repeated tem
ing the bu the highe pera-
emporal are tto n dcprcs st measurem
a an d lig .sc:d., lift the ent is
Release the htly place scanner fro
bu tto n an the probe m the
temperature d rem ove the pro be hin d the ear
takes about be. Recordi lobe.
3 seconds ng an acc
(Proccclure urate
7-3). Depe
nding on

Goal: Ta acruro
telt r/etennine am
! recrm/ a paffen
EQUIPMENT fs temparature usi
and SUPPLIE ng o temparo/ ar/
S ery scanner.
• Pa tienfsrecord
• ~essianal 3, Introduce
temporal ar/e~ yoorselt,
• ~cohol swabs lhermam<ter llilh
probe covers fl!RE!!SE: ldenti identify your potiern, and ex~aio
• Biohozord wa
ste container me o moons of ficotionaflhe petientprevenlse lhe procedure.
4, Remove lhe goining implied consellt ond pat noo,arnl explanations
prolec ient
PROCEDUR
AL STEPS
illfection control tive cop an lhe probe. Deper cooperation.
procedures, dispos nlirrg on lhe foc
1, Sanitize your ar rr con be cleoned abl e COVffi can be ilily's
bends. ~ : To ens by l~htty llipirrg lhe surface used on the scanner,
fl!RE!!SE:Toens 5. ure infection con llilh an alcohol
ure infectioo Pus h lhe potienfs hai trol. sw ab.
2. Golher lhe
necesso~ equipm contral. lfre probe an lhe r up off lhe forehead lo expose
ent and supplies.
eyebrows om! the polienfs forehead, halfway bel lhe site. Genlly place
we
fl!Rfj)Sf:Thisplohoiriine. en lhe edg, of
lhe
ceslhe~abedire
dlyaverlhetem
porolarte~.
 PREFACE xi

NEW! Professional Behaviors boxes provide

tips on professional behavior that are spe-
cific to each chapter's content.
xii pREfACE

,,,

112 UNIT TWO

ofsys!oolsof1wore
-•lheoockgro . Thesys!oolsof1woreoodsool
Applirotioosoflwundwhileolherapplicofionsohecompurerond -. K no w il
pofoonspeciocl oreokJw,lheLJ581oolherapplir f1wore,usod . compleresentencgl he po rt ,o f- i,h el
llsk otio
progrom•orollec s.Applirotioosohworemoyco oproi,,msro ps
catioos.lt,ohoimes,'Mlichoreauciolftxprotmiolwm od ic ol --
mdudewoolproc iionofpro i,,m s.f,mnp/esofapp osi sto fosing le pernti,ero" rittencom
10. Explain lhe
wme,onddotnb es,ing,Sjlfeodshee•,tele<OOIITii lirotioosoftware guidoline,l,r "" '""""lheuppror,iai,useo mun~
tl capitalmtion,. fwools.
• E/e<llooicmedl oses. Jll<llliln,ontimol- tuatiollinbusin
KnowilglheQ1JiessCIIIIIIIIUllicC. .,;,,,,, and pull(·
rolreconis(EMRs)o dellnesfcxusmgCC
As11•,eomoolo ndoproctice"""'1J fl}itoization,noom
""'tis IEHRs), 10iyC010foa1ities"""10EMR 811161sys!ool. tion•""""''-'cr
docurnel!,.c.r ucimwhenC ,ondpunc1oo-
ossistontshoo ond proctice - t sof s,electronicheolth ossistontshooldectwool-ondsr,elogohoo"seai
llllf! ingpro
fessionol
twa
procti(e-tsyldbeol..rodistil!guishbe-lhe re, lhe medico! wh use lhe spelktockoinlhe ticol.Themod
1eo1'11 mfonnotion s! oo l.TheEMR,
us
EM Ro ndlhe
roc
enc l80 lng docurnel!•. Pro
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od utr eol cxe
usodto100lhe-. , wbeieos lhe prodice IOOlllflt9ro-i'ltien> 11. D honyincooectwonlsorincompngoso!inostep,oho'1ljlClllollt
....,."Scbeduing es oi be eo
oreportoflheproct ,bffing,ondcolinglll" sof1wore , Me d, - ofo proh.ileresentences.
dicolossishln•s
beolthcoreoge i<e"""10gell10
fsof1worelYl"olflO!IIOIIIS hooldbelomilo onalbminessleHer.
7. Explain t h ncy. lvusodmlhe of Oprofes ol rw
bu5ine "· The ithlheromponell••elemel!•
mlomKltiosion nondpuoossoo""
sewrityactivitiee ~ of dat, backup and o tioninmsyect must mdude lhe
sporfo m, edi nth th er - -
professionolre ionoll oWfOjfliot8
ToobidebyHll'M ehoalthcoresett k lhepo,becl,profe sa,.Propeiondcomist,mspo heott,iroochieve
ogenciesmusterm rulesondlhe-,igMuse1"l ing. striwwhollECltin ssiono lop pm ncefcxwhkhmodi c;,g;,theott,ill"'""
\i,e
lxKlup proceclura elhattheirCOlllpllterootw merll,beolllcae col
golte!sillooghw
s con help p,e,en orksoreseaR"e. 12. 5'mmorizt
the for oolprocessin ossishln•shoolil
COl1flllOIIIO'( by t
o hock• • oo "" problems llhe 11<1wOOc files ore
Dato
WlithlnCClll1IOO mats fur bminess lett,n and g.
llicotionrr001obe me
olthcorelcxilt morandums.
flood) '- ,r ,1 sito
8. lliscussappli otion (e.g., 1i,e • luc ifi~. llsil1g the
mtioo fcxprofessioprop01fu!IOOlfcxbu!iness olte!s y,orellec:tionoolhe!
W-llhlheoovcr sof eledrritechnology. tu11blod
nol,...,.1\e,e., ond a-moils, au
c~
monyci,,nges, osintedmology,lhehoolthcoieo llr
ertoano1,!llll eemoinlypesof-•lte!
roi
procedtm"l\ilfll dillgpoitol,ledevicesmlhe wironmenthos"" •""foano1.c1Pet1 IOC800le 7·1 P"' diliedblodc•""fu!IOOl,on s:
l"ll,ond""""'"elliciel!ci ex ,m """ ,m,pro,ed sioo ol •""· ""g uiclon cefu!Cllllf!"sin d-
lhe use of comput esmlhe ossistontmustE,en lheogh me s g oprofes·
roxtlewyeG eo. More ci,,nges in teclnolog WOlldoyilloogh usethecooectmo fu!
., il1'IIKII doc
umelll,, the
HIPM,"""8oso11;-wilhelpbeolllcae-Sm' y wil ocrur"" lhe 13. C .ssuge.A poorly created memo IOOl~thetthe1eodoobtoinsme
me dica
tbe
of'"""'"Bongllex c,wilsupportQllill;oondll Olllpliontwith
/C - proh.ionalconesp is a reflection on lhewrilef. odeor
iJe on dwilingrousene lO l8o c-l !ol vrl lh, ..,.p o1 on de, Ke "" tle ledrO
wteclnologyw tmolt en•C
s10!f,n-.cfico OIIUMicotillttbvmwiththe lli<technology.
ajf c, modico
l
9. Rec,gnizethe ossistoo• mlhe future. ilbecriti-
elements of fun E-moilsmustsenl-mustbeol..10writeprolesomboo1o1ycora
doment,I wri clodeor""'""11'1
Mediculossis
......,.11eyo1,onhln•neolro"""""co""""'" skills.
ting rest)ectfui1110Me1. 0therecijientilosionole-moils.
eo110a0Jrem oo,nec1 • Proced TheprocessofcOllljlOSilgoproprofessiooolond
emos,meet"'"ingl'ltienSondolh ure 1·2. Whoo sen fes
'"""",ondolhe! e! mu stlolow HIPAAond clogo rro, the mosionolomoi1,
Hll!CH rules. dicol ossishlnt

e vo
kmtotomp lv e ...,"'"""""Go"""°"""
etelhe
7"k•"""·.....,.,,;
chapter tondelheehopterReviewOuiz.Checl:ou
mostolwhlltyoo tlhe
Comrnooiootioo. hove learned from olherre:wcesis?edb-this
ledioobgyond Wri
tten

. ie ot the end o\
1he (onnecn_ons
choµte1 iemmds \e o1en ts o\ oncillo!'I µteoch
stu ·1oble to 0~·
ucts ond ie~ouir assist m
comµiehens1on nsd o:;~once the \eoming
on
exµe1ience .
REVIEWERS
Brenda G. Abplanalp, RN, BSN, MSEd Kimberly Annette Head, DC, BS, BA
Director Director of CE Healthcare Programs
Pennsylvania College of Technology Collin College
Williamsport, Pennsylvania Plano, Texas

Pam Alt, RN, MSN, RMA Judith K. Kline, RMA, NCMA, CCMA, CMAA, AHi,
Medical Assistant Program Director NCET, NC/CS, NCPT
Mid-State Technical College Professor
Marshfield, Wisconsin Miami Lakes Educational Center & Technical College
Miami Lakes, Florida
Deborah A. Balentine, MEd, RH/A, CCS, CCS-P, CHTS-TR
Adjunct Instructor-Adult Education Jennifer K. Lester, BA, NHA, AMT
City Colleges of Chicago Medical Administrative Instructor
Chicago, Illinois Charleston Job Corps Center & Bridge Valley Community &
Technical College Workforce Program
Janet K. Baumann, BS, CMA (AAMA), EMT-8 Charleston, West Virginia
Medical Assistant Program Director
Northcentral Technical College Michelle C. Maus, MBA, BS, PhD, ABD
Wausau, Wisconsin Department Chair/Assistant Professor
Tiffin University
Cynthia A. Bloss, AA, RMA, BMO Tiffin, Ohio
Instructor, Clinical Liaison
Southeastern College Tammy Mcclish, MEd, CMA (AAMA), RTARRT
Clearwater, Florida Allied Health Instructor
The University of Akron
Marquitta Breeding, CMA (AAMA) Akron, Ohio
Wallace State Community College
Hanceville, Alabama Brigitte Niedzwiecki, RN, MSN, RMA
Medical Assistant Program Director & Instructor
Leon Deutsch, RMA, BS, MEd Chippewa Valley Technical College
Dean of Teaching & Learning Eau Claire, Wisconsin
Grayson College
Denison, Texas Cynthia 8. Orlando, GAHi, OBT, NRCMA
Instructor
Jennifer Dietz, BS, CMA (AAMA), PBT (ASCP) CM Eastern College of Health Vocations
Assistant Professor New Orleans, Louisiana
Cuyahoga Community College-Metropolitan Campus
Cleveland, Ohio Julie Pepper, BS, CMA (AAMA)
Medical Assistant Instructor
Tracie Fuqua, BS, CMA (AAMA) Chippewa Valley Technical College
Medical Assistant Program Director Eau Claire, Wisconsin
Wallace State Community College
Hanceville, Alabama Melanie Shearer, MS, MT (ASCPJ PB.,-CM, CMA (AAMA)
Medical Assisting Associate Professor
Deborah S. Gilbert, RH/A, MBA, CMA Cuyahoga Community College
Assistant Professor of School of Allied Health Cleveland, Ohio
Dalton State College
Dalton, Georgia

xiii
xiv REVIEWERS

Paula Denise Silver, BS, PharmD P. Ann Weaver, MSEd, MT (ASCP)

Medical Instructor Instructor
ECPI University: Medical Careers Institute Chippewa Valley Technical College
Newport News, Virginia Eau Claire, Wisconsin

Rayona Mullen Staniec, CMA-AC
Medical Assisting Instructor
Santa Cruz County Regional Occupational Program
Santa Cruz, California
Roelabeth de Leon Villa, MD, RMA
Goodman Career Institute
Rockford, Illinois
Karon G. Walton, CMA (MMA), MS, BS
Program Director
Augusta Technical College
Augusta, Georgia
Barbara Westrick, MS, CPC, CMA (MMA)
Program Chair-Medical Assisting and Medical Insurance
Billing/Office Administration
Ross Education, LLC
Brighton, Michigan
Nicole Ellen Zahuranec, CMA (MMA), ADS
Elmira Business Institute
Elmira, New York
CONTENTS
UNIT ONE
Introduction to Medical Assisting
Deborah Proctor
1 Competency-Based Education and the Medical
Assistant Student, 1
Adult Learners and Competency-Based Education, 2
Portfolios, 2
Who You are as a Learner: How Do You Learn Best?, 3
Coping Mechanisms, 5
Time Management: Putting Time on Your Side, 6
Study Skills: Tricks for Becoming a Successful Student, 7
Test-Taking Strategies: Taking Charge of Your
Success, 9
Becoming a Critical Thinker: Making Mental
Connections, 1O
Problem Solving and Conflict Management, 11
Assertive, Aggressive, and Passive Communication, 12
2 The Health Record, 15
Types of Records, 17
The Importance of Accurate Health Records, 17
Contents of the Health Record, 17
Procedure 2-1: Create a Patient's Health Record:
Register a New Patient in the Practice
Management Software, 20
Ownership of the Health Record, 22
Technologic Terms in Health Information, 22
American Recovery and Reinvestment Act, 23
The Health Information Technology for Economic and
Clinical Health Act and Meaningful Use, 23
Advantages and Disadvantages of the EHR, 23
Procedure 2-2: Organize a Patient's Health Record:
Upload Documents to the Electronic Health
Record, 27
Nonverbal Communication with the Patient When Using the
Electronic Health Record, 27
Backup Systems for the Electronic Health Record, 28
Releasing Health Record Information, 29
Creating an Efficient Paper Health Records Management
System, 31
Documenting in an Electronic Health Record, 31
Documenting in a Paper Health Record, 31
Making Corrections and Alterations to Health
Records, 33
Dictation and Transcription, 33
Filing Equipment, 35
Filing Supplies, 36
Procedure 2-3: Create and Organize a Patient's Paper
Health Record, 38
Filing Methods, 39
Procedure 2-4: File Patient Health Records, 39
Organization of Files, 40
Closing Comments, 41
3 Infection Control, 45
Disease, 46
The Chain of Infection, 47
The Inflammatory Response, 49
Types of Infections, 50
OSHA Standards for the Healthcare Setting, 51
Procedure 3-1: Participate in Bloodborne Pathogen
Training: Use Standard Precautions to Remove
Contaminated Gloves and Discard Biohazardous
Material, 54
Procedure 3-2: Demonstrate the Proper Use of Eye
Wash Equipment: Perform an Emergency Eye
Wash, 56
Procedure 3-3: Participate in Bloodborne Pathogen
Training and a Mock Environmental Exposure
Event with Documentation of Steps, 59
Aseptic Techniques: Preventing Disease Transmission, 60
Procedure 3-4: Participate in Bloodborne Pathogen
Training: Perform Medical Aseptic Hand
Washing, 62
Procedure 3-5: Select Appropriate Barrier/Personal
Protective Equipment and Demonstrate Proper
Disposal of Biohazardous Material: Use Standard
Precautions for Sanitizing Instruments and
Discarding Biohazardous Material, 64
Role of the Medical Assistant in Asepsis, 65
Closing Comments, 65
Procedure 3-6: Perform Compliance Reporting Based
on Public Health Statutes, 67
4 Patient Assessment, 69
Medical History, 70
Understanding and Communicating with Patients, 71
Procedure 4-1: Demonstrate Therapeutic
Communication Feedback Techniques to Obtain
Patient Information and Document Patient Care
Accurately in the Medical Record, 74
Procedure 4-2: Respond to Nonverbal
Communication, 79
Interviewing the Patient, 79
Assessing the Patient, 83
Documentation, 84
Procedure 4-3: Use Medical Terminology Correctly
and Pronounce Accurately to Communicate
Information to Providers and Patients, 90
Closing Comments, 93
xv
xvi CONTENTS

5 Patient Education, 97 8 Assisting with the Primary Physical Examination, 171

Patient Education and Models of Health and
Illness, 98
The Teaching Plan, 102
Procedure 5-1: Develop a List of Community
Resources for Patients' Healthcare Needs;
also, Facilitate Referrals in the Role of Patient
Navigator, 104
Procedure 5-2: Coach Patients in Health
Maintenance, Disease Prevention, and Following
the Treatment Plan, 107
Closing Comments, 108
6 Nutrition and Health Promotion, 111
Nutrition and Dietetics, 113
Choose My Plate, 125
Nutritional Status Assessment, 126
Therapeutic Nutrition, 128
Procedure 6-1: Instruct a Patient According to the
Patient's Dietary Needs: Coach the Patient on the
Basics of the Glycemic Index, 132
Reading Food Labels, 133
Procedure 6-2: Coach a Patient About How to
Understand Food Labels, 134
Food-Borne Diseases, 135
Environmental Contamination of Food, 135
Eating Disorders, 135 UNIT TWO
Obesity, 136 Assisting with Medications
Health Promotion, 137
Deborah Proctor
Closing Comments, 138
7 Vital Signs, 141
Factors That May Influence Vital Signs, 142
Temperature, 143
Procedure 7-1: Obtain Vital Signs: Obtain
an Oral Temperature Using a Digital
Thermometer, 145
Procedure 7-2: Obtain Vital Signs: Obtain an
Aural Temperature Using the Tympanic
Thermometer, 147
Procedure 7-3: Obtain Vital Signs: Obtain a Temporal
Artery Temperature, 148
Procedure 7-4: Obtain Vital Signs: Obtain an Axillary
Temperature, 150
Pulse, 150
Procedure 7-5: Obtain Vital Signs: Obtain an Apical
Pulse, 152
Respiration, 155
Procedure 7-6: Obtain Vital Signs: Assess
the Patient's Radial Pulse and Respiratory
Rate, 156
Blood Pressure, 157
Procedure 7-7: Obtain Vital Signs: Determine a
Patient's Blood Pressure, 161
Anthropometric Measurements, 164
Procedure 7-8: Obtain Vital Signs: Measure a
Patient's Weight and Height, 165
Closing Comments, 167
Anatomy and Physiology, 172
Primary Care Provider, 173
Physical Examination, 175
Principles of Body Mechanics, 177
Procedure 8-1: Use Proper Body Mechanics, 180
Assisting with the Physical Examination, 181
Procedure 8-2: Assist Provider with a Patient Exam:
Fowler's and Semi-Fowler's Positions, 182
Procedure 8-3: Assist Provider with a Patient Exam:
Horizontal Recumbent and Dorsal Recumbent
Positions, 183
Procedure 8-4: Assist Provider with a Patient Exam:
Lithotomy Position, 184
Procedure 8-5: Assist Provider with a Patient Exam:
Sims Position, 185
Procedure 8-6: Assist Provider with a Patient Exam:
Prone Position, 186
Procedure 8-7: Assist Provider with a Patient Exam:
Knee-Chest Position, 187
Examination Sequence, 189
Procedure 8-8: Assist Provider with a Patient
Exam, 191
Closing Comments, 193
9 Principles of Pharmacology, 196
Government Regulation, 197
Drug Abuse, 200
Drug Names, 200
Approaches to Studying Pharmacology, 201
Procedure 9-1: Prepare a Prescription for the
Provider's Signature, 206
Drug Interactions with the Body, 207
Factors Affecting Drug Action, 210
Classifications of Drug Actions, 212
Herbal and Alternative Therapies, 220
Closing Comments, 223
1O Pharmacology Math, 226
Drug Labels, 226
Math Basics, 228
Systems of Measurement, 230
Calculating Drug Dosages for Administration, 233
Procedure 10-1: Demonstrate Knowledge of Basic
Math Computations, 235
Procedure 10-2: Calculate Proper Dosages of
Medication for Administration: Convert Among
Measurement Systems, 236
Pediatric Dosages, 236
Procedure 10-3: Calculate Proper Dosages of
Medication tor Administration: Calculate the
Correct Pediatric Dosage Using Body Weight, 237
Closing Comments, 238

11 Administering Medications, 241
Safety in Drug Administration, 242
Drug Forms and Administration, 245
Procedure 11-1: Administer Oral Medications, 248
Procedure 11-2: Fill a Syringe from an
Ampule, 251
Procedure 11-3: Fill a Syringe from a Vial, 252
Procedure 11-4: Reconstitute a Powdered Drug for
Administration, 259
Procedure 11-5: Administer Parenteral (Excluding IV)
Medications: Give an lntradermal Injection, 260
Procedure 11-6: Select the Proper Sites for
Administering a Parenteral Medication: Administer
a Subcutaneous Injection, 264
Procedure 11-7: Mix Two Different Types of Insulin in
One Syringe, 266
Procedure 11-8: Administer Parenteral (Excluding IV)
Medications: Administer an Intramuscular Injection
into the Deltoid Muscle, 270
Procedure 11-9: Select the Proper Sites for
Administering a Parenteral Medication: Administer
a Pediatric Intramuscular Vastus Lafera/is
Injection, 272
Procedure 11-10: Administer Parenteral
(Excluding IV) Medications: Give a Z-Track
Intramuscular Injection into the Dorsogluteal
Site, 275
Closing Comments, 276
Procedure 11-11: Complete an Incident Report
Related to an Error in Patient Care, 278
UNIT THREE
Assisting with Medical Specialties
Deborah Proctor
12 Safety and Emergency Practices, 282
Safety in the Healthcare Facility, 283
Procedure 12-1: Evaluate the Work Environment to
Identify Unsafe Working Conditions and Comply
With Safety Signs and Symbols, 285
Procedure 12-2: Manage a Difficult Patient, 286
Procedure 12-3: Demonstrate the Proper Use of a
Fire Extinguisher, 287
Procedure 12-4: Participate in a Mock
Environmental Exposure Event: Evacuate a
Provider's Office, 288
Disposal of Hazardous Waste, 289
Emergency Preparedness, 289
Procedure 12-5: Maintain an Up-to-Date List of
Community Resources for Emergency
Preparedness, 291
Assisting with Medical Emergencies, 291
Procedure 12-6: Maintain Provider/Professional-Level
CPR Certification: Use an Automated External
Defibrillator (AED), 294
CONTENTS xvii
General Rules for Emergencies, 294
Procedure 12-7: Perform Patient Screening Using
Established Protocols: Telephone Screening and
Appropriate Documentation, 295
Procedure 12-8: Maintain Provider/Professional-Level
CPR Certification: Perform Adult Rescue Breathing
and One-Rescuer CPR; Perform Pediatric and
Infant CPR, 298
Procedure 12-9: Perform First Aid Procedures:
Administer Oxygen, 301
Procedure 12-10: Perform First Aid Procedures:
Respond to an Airway Obstruction in
an Adult, 302
Procedure 12-11: Perform First Aid Procedures:
Care for a Patient Who Has Fainted or Is
in Shock, 305
Common Office Emergencies, 306
Procedure 12-12: Perform First Aid Procedures: Care
for a Patient With Seizure Activity, 309
Procedure 12-13: Perform First Aid Procedures: Care
for a Patient With a Suspected Fracture of the
Wrist by Applying a Splint, 310
Procedure 12-14: Perform First Aid Procedures:
Control Bleeding, 312
Procedure 12-15: Perform First Aid Procedures: Care
for a Patient With a Diabetic Emergency, 314
Closing Comments, 315
13 Assisting in Ophthalmology and Otolaryngology, 319
Examination of the Eye, 320
Procedure 13-1: Perform Patient Screening Using
Established Protocols: Measure Distance Visual
Acuity with the Snellen Chart, 328
Procedure 13-2: Instruct and Prepare a Patient for a
Procedure: Assess Color Acuity Using the Ishihara
Test, 330
Procedure 13-3: Instruct and Prepare a Patient for
a Procedure or Treatment: Irrigate a Patient's
Eyes, 332
Procedure 13-4: Instruct and Prepare a Patient for
a Procedure or Treatment: Instill an Eye
Medication, 333
Examination of the Ear, 335
Procedure 13-5: Perform Patient Screening Using
Established Protocols: Measure Hearing Acuity
with an Audiometer, 341
Procedure 13-6: Instruct and Prepare a Patient
for a Procedure or Treatment: Irrigate a Patient's
Ear, 342
Procedure 13-7: Instruct and Prepare a Patient for a
Procedure or Treatment: Instill Medicated Ear
Drops, 344
Examination of the Nose and Throat, 345
Procedure 13-8: Perform Patient Screening Using
Established Protocols: Collect a Specimen for a
Throat Culture, 346
Closing Comments, 347
xviii CONTENTS
14 Assisting in Dermatology, 350
Anatomy and Physiology, 351
Diseases and Disorders, 352
Dermatologic Procedures, 364
Closing Comments, 366
15 Assisting in Gastroenterology, 368
Anatomy and Physiology, 369
Diseases of the Gastrointestinal System, 370
Characteristics of the GI System, 371
Procedure 15-1: Perform Patient Screening Using
Established Protocols: Telephone Screening of a
Patient with a Gastrointestinal Complaint, 373
Diseases of the Liver and Gallbladder, 380
The Medical Assistant's Role in the Gastrointestinal
Examination, 383
Procedure 15-2: Assist the Provider with a Patient
Examination: Assist with an Endoscopic
Examination of the Colon, 386
Procedure 15-3: Instruct and Prepare a Patient for a
Procedure: Instruct Patients in the Collection of a
Fecal Specimen, 387
Closing Comments, 388
16 Assisting in Urology and Male Reproduction, 391
Anatomy and Physiology of the Urinary System, 392
Disorders of the Urinary System, 393
Pediatric Urologic Disorders, 400
Anatomy and Physiology of the Male Reproductive
System, 401
Disorders of the Male Reproductive Tract, 402
Procedure 16-1: Coach Patients in Health
Maintenance: Teach Testicular
Self-Examination, 406
The Medical Assistant's Role in Urologic and Male
Reproductive Examinations, 410
Closing Comments, 411
17 Assisting in Obstetrics and Gynecology, 414
Anatomy and Physiology, 415
Contraception, 417
Gynecologic Diseases and Disorders, 420
Procedure 17-1: Instruct and Prepare a Patient for
Procedures and/or Treatments: Assist with the
Examination of a Female Patient and Obtain a
Smear for a Pap Test, 426
Procedure 17-2: Instruct and Prepare a Patient for
Procedures and/or Treatments: Prepare the Patient
for a LEEP, 429
Procedure 17-3: Coach Patients in Health
Maintenance and Disease Prevention: Teach the
Patient Breast Self-Examination, 432
Pregnancy, 434
Menopause, 437
The Medical Assistant's Role in Gynecologic and Obstetric
Procedures, 438
Procedure 17-4: Instruct and Prepare a Patient for
Procedures and/or Treatments: Assist with a
Prenatal Examination, 439
Diagnostic Testing, 441
Closing Comments, 442
18 Assisting in Pediatrics, 446
Normal Growth and Development, 447
Pediatric Diseases and Disorders, 452
Immunizations, 462
Procedure 18-1: Verify the Rules of Medication
Administration: Document Immunizations, 466
The Pediatric Patient, 469
The Medical Assistant's Role in Pediatric Procedures, 470
Procedure 18-2: Maintain Growth Charts: Measure
the Circumference of an Infant's Head, 472
Procedure 18-3: Maintain Growth Charts: Measure an
Infant's Length and Weight, 473
Procedure 18-4: Measure and Record Vital Signs:
Obtain Pediatric Vital Signs and Perform Vision
Screening, 476
Procedure 18-5: Assist Provider With a Patient Exam:
Applying a Urinary Collection Device, 479
The Adolescent Patient, 480
Injury Prevention, 480
Child Abuse, 480
Closing Comments, 481
19 Assisting in Orthopedic Medicine, 484
Anatomy and Physiology of the Musculoskeletal System, 485
Musculoskeletal Diseases and Disorders, 490
The Medical Assistant's Role in Assisting with Orthopedic
Procedures, 502
Specialized Diagnostic Procedures in Orthopedics, 502
Radiology, 503
Therapeutic Modalities, 504
Procedure 19-1: Assist the Provider with Patient Care:
Assist with Cold Application, 505
Procedure 19-2: Assist the Provider with Patient Care:
Assist with Moist Heat Application, 506
Ambulatory Devices, 507
Procedure 19-3: Coach Patients in the Treatment
Plan: Teach the Patient Crutch Walking and the
Swing-Through Gait, 509
Management of Fractures, 511
Procedure 19-4: Assist the Provider with Patient Care:
Assist with Application of a Cast, 511
Procedure 19-5: Assist the Provider with Patient Care:
Assist with Cast Removal, 513
Closing Comments, 514
20 Assisting in Neurology and Mental Health, 517
Anatomy and Physiology of the Nervous System, 518
Diseases and Disorders of the Central Nervous
System, 522
Diseases of the Peripheral Nervous System, 531
The Medical Assistant's Role in the Neurologic
Examination, 533
Procedure 20-1: Assist the Provider with Patient Care:
Assist with the Neurologic Examination, 535
Diagnostic Testing, 535

Procedure 20-2: Explain the Rationale for
Performance of a Procedure: Prepare the Patient
for an Electroencephalogram, 536
Procedure 20-3: Assist the Provider with Patient Care:
Prepare the Patient for and Assist with a Lumbar
Puncture, 538
Closing Comments, 538
21 Assisting in Endocrinology, 542
Anatomy and Physiology of the Endocrine
System, 543
Diseases and Disorders of the Endocrine
System, 545
Procedure 21-1: Assist the Provider with Patient
Care: Perform a Blood Glucose TRUEresult
Test, 550
Procedure 21-2: Assist the Provider with Patient Care:
Perform a Monofilament Foot Exam, 555
Follow-Up for Patients with Diabetes, 557
Closing Comments, 557
22 Assisting in Pulmonary Medicine, 560
The Respiratory System, 561
Ventilation, 562
Respiratory System Defenses, 564
Major Diseases of the Respiratory System, 564
Procedure 22-1: Instruct Patients According to Their
Needs: Teach a Patient to Use a Peak Flow
Meter, 569
Procedure 22-2: Assist the Provider with Patient Care:
Administer a Nebulizer Treatment, 571
The Medical Assistant's Role in Pulmonary
Procedures, 575
Procedure 22-3: Assist the Provider with Patient
Care: Perform Volume Capacity Spirometry
Testing, 576
Procedure 22-4: Perform Patient Screening
Using Established Protocols: Perform Pulse
Oximetry, 577
Procedure 22-5: Obtain Specimens for
Microbiologic Testing: Obtain a Sputum Sample for
Culture, 578
Closing Comments, 579
23 Assisting in Cardiology, 582
Anatomy and Physiology of the Heart, 583
Diseases and Disorders of the Heart, 585
Blood Vessels, 591
Vascular Disorders, 593
Diagnostic Procedures and Treatments, 596
Closing Comments, 598
24 Assisting in Geriatrics, 601
Procedure 24-1: Demonstrate Empathy: Understand
the Sensorimotor Changes of Aging, 603
Changes in Anatomy and Physiology, 603
The Medical Assistant's Role in Caring for the Older
Patient, 615
Closing Comments, 616
CONTENTS xix
UNIT FOUR
Diagnostic Procedures
Deborah Proctor (42), Helen Mills (43), and Martha Garrels
25 Principles of Electrocardiography, 620
The Electrical Conduction System of the Heart, 621
The Electrocardiograph, 624
Performing Electrocardiography, 626
Procedure 25-1: Perform Electrocardiography: Obtain
a 12-Lead ECG, 629
The ECG Strip, 632
Typical ECG Rhythm Abnormalities, 633
Related Cardiac Diagnostic Tests, 638
Procedure 25-2: Instruct and Prepare a Patient for a
Procedure or Treatment: Fit a Patient With a Holter
Monitor, 640
Closing Comments, 643
26 Assisting with Diagnostic Imaging, 645
Other Diagnostic Radiologic Testing, 654
Basic Radiographic Procedure, 661
Closing Comments, 671
27 Assisting in the Clinical Laboratory, 675
Role of the Clinical Laboratory in Patient Care, 676
Divisions of the Clinical Laboratory, 677
Government Legislation Affecting Clinical Laboratory
Testing, 678
Procedure 27-1: Perform a Quality Control Measure
on a Glucometer and Record the Results on a
Flow Sheet, 683
Laboratory Safety, 684
Specimen Collection, Processing, and Storage, 687
Laboratory Mathematics and Measurement, 691
Laboratory Equipment, 692
Procedure 27-2: Use the Microscope and
Perform Routine Maintenance on Clinical
Equipment, 694
Closing Comments, 695
28 Assisting in the Analysis of Urine, 699
History of the Analysis of Urine, 700
Anatomy and Physiology of the Urinary Tract, 700
Collecting a Urine Specimen, 701
Procedure 28-1: Instruct and Prepare a Patient
for a Procedure or Treatment: Instruct
a Patient in the Collection of a 24-Hour Urine
Specimen, 702
Procedure 28-2: Instruct and Prepare a Patient for a
Procedure or Treatment: Collect a Clean-Catch
Midstream Urine Specimen, 704
Routine Urinalysis, 706
Procedure 28-3: Assess Urine for Color and Turbidity:
Physical Test, 707
Procedure 28-4: Perform Quality Control Measures:
Differentiate Between Normal and Abnormal Test
Results while Determining the Reliability of
Chemical Reagent Strips, 713
xx CONTENTS
Procedure 28-5: Obtain a Specimen and Perform a
CL/A-Waived Urinalysis: Test Urine with Chemical
Reagent Strips, 713
Procedure 28-6: Prepare a Urine Specimen for
Microscopic Examination, 715
Procedure 28-7: Obtain a Specimen and Perform a
CL/A-Waived Urinalysis: Test Urine for Glucose
Using the Clinitest Method, 723
Procedure 28-8: Obtain a Specimen and Perform a
CL/A-Waived Urinalysis: Perform a Pregnancy
Test, 725
Urine Toxicology, 726
Procedure 28-9: Obtain a Specimen and Perform a
CL/A-Waived Urinalysis: Perform a Multidrug
Screening Test on Urine, 727
Adulteration Testing and Chain of Custody, 728
Procedure 28-10: Assess a Urine
Specimen for Adulteration before Drug
Testing, 729
Alcohol Testing, 731
Closing Comments, 731
29 Assisting in Blood Collection, 733
Venipuncture Equipment, 734
Routine Venipuncture, 742
Procedure 29-1: Instruct and Prepare a Patient for a
Procedure and Perform Venipuncture: Collect a
Venous Blood Sample Using the Vacuum Tube
Method, 744
Procedure 29-2: Perform Venipuncture: Collect
a Venous Blood Sample Using the Syringe
Method, 747
Procedure 29-3: Perform Venipuncture: Obtain a
Venous Sample with a Safety Winged Butterfly
Needle, 751
Problems Associated with Venipuncture, 752
Specimen Re-collection, 753
Capillary Puncture, 755
Procedure 29-4: Instruct and Prepare a Patient for
a Procedure and Perform Capillary Puncture:
Obtain a Capillary Blood Sample by Fingertip
Puncture, 758
Pediatric Phlebotomy, 760
Handling the Specimen after Collection, 761
Chain of Custody, 761
Closing Comments, 762
30 Assisting in the Analysis of Blood, 765
Hematology, 766
Hematology in the Physician Office Laboratory
(POL), 768
Procedure 30-1: Perform Routine Maintenance of
Clinical Equipment: Perform Preventive
Maintenance for the Microhematocrit
Centrifuge, 769
Procedure 30-2: Obtain Specimens and Perform
CUA-Waived Hematology Testing: Perform a
Microhematocrit Test, 770
Hemoglobin, 772
Procedure 30-3: Perform CL/A-Waived Hematology
Testing: Perform a Hemoglobin Test, 772
Procedure 30-4: Obtain a Specimen and Perform
CUA-Waived Hematology Testing: Determine the
Erythrocyte Sedimentation Rate Using a Modified
Westergren Method, 774
Procedure 30-5: Obtain a Specimen and Perform a
CL/A-Waived Protime/lNR Test, 777
Hematology in the Reference Laboratory, 778
lmmunohematology-Blood Bank, 784
Legal and Ethical Issues Related to Blood
Transfusions, 786
Blood Chemistry in the Physician Office Laboratory
(POL), 786
Cholesterol Testing, 787
Procedure 30-6: Perform a CL/A-Waived
Chemistry Test: Determine the Cholesterol
Level or Lipid Profile Using a Cholestech
Analyzer, 788
Alanine Aminotransferase (ALT) and Aspartate
Aminotransferase (AST) Testing, 790
Thyroid Hormone Testing, 790
Reference Laboratory Chemistry Panels and Single Analyte
Testing and Monitoring, 790
Closing Comments, 790
31 Assisting in Microbiology and Immunology, 797
Classification of Microorganisms, 799
Procedure 31-1: Instruct and Prepare a Patient for a
Procedure: Instruct Patients in the Collection of
Fecal Specimens to Be Tested for Ova and
Parasites, 806
Specimen Collection and Transport in the POL, 809
CUA-Waived Microbiology Tests, 812
Procedure 31-2: Obtain a Specimen and Perform a
CL/A-Waived Microbiology Test: Perform a Rapid
Strep Test, 813
CUA-Waived Immunology Testing, 815
Procedure 31-3: Obtain a Specimen and Perform
a CL/A-Waived Immunology Test: Perform
the QuickVue+ Infectious Mononucleosis
Test, 816
Microbiology Reference Laboratory, 818
Microbiology Culture and Sensitivity Testing, 820
Closing Comments, 821
UNIT FIVE
Assisting with Surgeries
Deborah Proctor
32 Surgical Supplies and Instruments, 825
Minor Surgery Room, 826
Surgical Solutions and Medications, 826
Surgical Instruments, 827
Procedure 32-1: Identify Surgical Instruments, 828
 CONTENTS xxi

Classifications of Surgical Instruments, 829 Wound Care, 871

Specialty Instruments, 834
Care and Handling of Instruments, 836
Drapes, Sutures, and Needles, 837
Closing Comments, 840
33 Surgical Asepsis and Assisting With Surgical
Procedures, 842
Sterilization, 843
Procedure 33-1: Prepare Items tor Autoclaving: Wrap
Instruments and Supplies tor Sterilization in an
Autoclave, 846
Procedure 33-2: Perform Sterilization Procedures:
Operate the Autoclave, 849
Surgical Procedures, 850
Assisting with Surgical Procedures, 852
Procedure 33-3: Perform Skin Prep tor
Surgery, 853
Procedure 33-4: Perform Handwashing: Perform a
Surgical Hand Scrub, 855
Procedure 33-5: Prepare a Sterile Field, 858
Procedure 33-6: Perform Within a Sterile Field: Use
Transfer Forceps, 859
Procedure 33-7: Perform Within a Sterile Field: Pour
a Sterile Solution into a Sterile Field, 860
Procedure 33-8: Perform Within a Sterile Field: Put
on Sterile Gloves, 860
Procedure 33-9: Perform Within a Sterile Field: Assist
with Minor Surgery, 864
Procedure 33-10: Perform Wound Care: Assist
With Suturing, 867
Procedure 33-11: Perform Wound Care and a
Dressing Change: Apply or Change a Sterile
Dressing, 868
Procedure 33-12: Perform Wound Care: Remove
Sutures and/or Surgical Staples, 870
Procedure 33-13: Perform Wound Care: Apply an
Elastic Support Bandage Using a Spiral Turn, 876
Closing Comments, 877
UNIT SIX
Career Development
Brigitte Niedzwiecki and Julie Pepper
34 Career Development and Life Skills, 881
Moving on to the Next Phase of Life, 882
Understanding Personality Traits Important to
Employers, 882
Developing Career Objectives, 884
Knowing Personal Needs, 884
Finding a Job, 885
Developing a Resume, 887
Procedure 34-1: Prepare a Chronologic Resume, 887
Developing a Cover Letter, 893
Procedure 34-2: Create a Cover Letter, 895
Completing Online Profiles and Job Applications, 895
Procedure 34-3: Complete a Job Application, 897
Creating a Career Portfolio, 897
Procedure 34-4: Create a Career Portfolio, 898
Job Interview, 898
Procedure 34-5: Practice Interview Skills During a
Mock Interview, 902
Procedure 34-6: Create a Thank-You Note tor an
Interview, 902
You Got the Job!, 903
Life Skills, 905
Closing Comments, 907
Glossary, 91 O
Index, 927
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COMPETENCY-BASED EDUCATION AND
THE MEDICAL ASSISTANT STUDENT
1-i#iffi#t•i
Shawna Long is a newly admitted student in a medical assistant (MA) program
at your school. Shawna is anxious about starting classes and very concerned
that she may not be a successful student. She had trouble with some of her
While studying this chapter, think about the following questions:
• What is competency-based education and how can it help Shawna learn
and achieve skills?
• Why is it important for Shawna to understand how she learns best?
• Time management is a crucial part of being a successful student
and a successful medical assistant. What are some methods Shawna
can implement to help her manage her time as effectively as
possible?
LEARN I NG OBJECTIVES
1. Define, spell, and pronounce the terms listed in the vocabulary.
2. Discuss competency-based education and adult learners.
3. Summarize the importance of student porrlolios in proving academic
success and skill competency.
4. Examine your learning preferences and interpret how your learning
style affects your success as a student.
5. Differentiate between adaptive and nonadaptive coping mechanisms.
6. Apply time management strategies to make the most of your learning
opportunities.
7. Integrate effective study skills into you daily activities.
VOCABULARY
competencies Mastery of the knowledge, skills, and behaviors
that are expected of the entry-level medical assistant.
critical thinking The constant practice of considering all aspects
of a situation when deciding what to believe or what to do.
empathy (em'-puh-the) Sensitiviry to the individual needs and
reactions of patients.
learning style The way an individual perceives and processes
information to learn new material.
mnemonic A learning device (e.g., an image, a rhyme, or a figure
of speech) that a person uses to help him or her remember
information.
1
classes in high school and must continue to work part time while taking medical
assistant classes. Based on what you discover about the learning process in this
chapter, see whether you can help Shawna take steps toward success.
• Shawna will face many problems and challenges while working through
the MA program. How can sbe '-elop workable strategies for dealing
with these issues?
• What is the role of gssegiveness in effective professional
communications? V
• Studying may be a cnallenge for Shawna. What skills can she use to
help her learn new material and prepare for examinations?
8. Design test-taking strategies that help you take charge of your
success.
9. Incorporate critical thinking and reflection to help you make mental
connections as you learn material.
10. Analyze healthcare results as reported in graphs and tables.
11. Apply problem-solving techniques to manage conflict and overcome
barriers to your success.
12. Relate assertiveness, aggressiveness, and passive behaviors to
professional communication and discuss the role of assertiveness in
effective communication.
perceiving (pur-sev'-ing) How an individual looks at information
and sees it as real.
processing (pro'-ses-ing) How an individual internalizes new
information and makes it his or her own.
reflection (re-flek'-shun) The process of thinking about new
information so as to create new ways of learning.
stressor An event, activity, condition, or other stimulus that
causes stress.
2 UNIT ONE INTRODUCTION TO MEDICAL ASSISTING
F or many years the curriculum for medical assistant programs has
been based on student achievement of specific competencies.
According to the Medical Assisting Education Review Board
(MAERB):
Medical assistants graduating from programs accredited by the Com-
mission on Accreditation of Allied Health Education Programs
(CAAHEP) will demonstrate critical thinking based on knowledge
of academic subject matter required for competence in the profession.
They will incorporate the cognitive knowledge in performance of the
psychomotor and affective domains in their practice as medical assis-
tants in providing patient care.
The Accrediting Bureau of Health Education Schools (ABHES)
also bases its recommended curriculum on student achievement of
identified competencies:
The depth and breadth of the program's curriculum enables graduates
to acquire the knowledge and competencies necessary to become an
entry-level professional in the medical assisting field. Competencies
required for successful completion of the program are delineated, and
the curriculum ensures achievement of these entry-level competencies
through mastery of coursework and skill achievement. Focus is placed
on credentialing requirements and opportunities to obtain employ-
ment and to increase employability.
National curriculum standards for the education of medical assis-
tants are based on recognized competencies that employers expect
entry-level medical assistants to have. The 2015 Core Curriculum
for Medical Assistants established by the MAERB must be followed
for programs accredited by CAAHEP. Those completing a CAAHEP-
accredited program must demonstrate core entry-level competencies
in knowledge of subject matter, be able to perform the psychomotor
skills needed in an ambulatory care center, and have appropriate
behavioral competencies to respond professionally and with empathy
toward patients and their families. The 12 academic subjects in a
CMHEP-approved curriculum are as follows:
I. Anatomy and Physiology
II. Applied Mathematics
III. Infection Control
IV Nutrition
V Concepts of Effective Communication
VI. Administrative Functions
VII. Basic Practice Finances
VIII. Third Party Reimbursement
IX. Procedural and Diagnostic Coding
X. Legal Implications
XI. Ethical Considerations
XII. Protective Practices
ABHES also offers accreditation for medical assisting programs.
The organization focuses its curriculum requirements on student
competency achievement with 11 required areas of study:
1. General Orientation [to the field of medical assisting]
2. Anatomy and Physiology
3. Medical Terminology
4. Medical Law and Ethics
5. Psychology of Human Relations
6. Pharmacology
7. Records Management
8. Administrative Procedures
9. Clinical Procedures
10. Medical Laboratory Procedures
11. Career Development
What does this mean for you, the medical assistant student? To
meet national standards, your MA program must comply with
competency-based learning in multiple areas. The most important
characteristic of competency-based education is that it measures
learning and skill achievement over time. Students progress through
the program by demonstrating their competence, which means they
prove they have mastered the knowledge, skills, and professional
behaviors required to achieve competency in a particular task. For
example, one of the basic skills you must achieve as a medical assis-
tant student is taking an accurate blood pressure. Some students will
have more difficulty consistently achieving this goal than others, but
each student must be able to take a blood pressure accurately before
he or she can move on in the curriculum.
ADULT LEARNERS AND
COMPETENCY-BASED EDUCATION
Competency-based learning is ideal for adult learners who are
attempting to understand new information and achieve new skills.
Educators recognize that adult learners come to the classroom with
different work-related experiences and educational backgrounds.
Therefore, adult students have a wide range of understanding about
the knowledge and skills that must be achieved in the program.
Adult students also learn material at different rates. Competency-
based education recognizes these qualities of adult learners and takes
advantage of them. Let's go back to the blood pressure example.
Perhaps you took a healthcare lab in high school, in which you
learned to take blood pressures; another student may have worked
in a long-term care facility, where he was responsible for monitoring
vital signs throughout the day. You both may need just a review of
the anatomy and physiology aspects of a patient's blood pressure.
However, other students in the class will not know anything about
this skill. With competency-based education, your instructor can
design laboratory activities that meet all students' needs, including
your own.
CRITICAL THINKING APPLICATION 1-1
Can you think of any examples of how competency-based education might
help you succeed as a medical assistant student? Come up with two pos-
sibilities and share them with your classmates.
PORTFOLIOS
Have you taken a class in the past that required you to develop a
portfolio? Portfolios are frequently used in an Art or English class to
demonstrate student skills and learning achievements. Generally, a
portfolio is a collection of student materials that demonstrates learn-
ing. An advantage of developing a portfolio for a medical assistant
program is that you can decide which pieces of your work best
demonstrate your learning and skill achievement over time. Why
would this be beneficial to you?
In a competency-based program, you must achieve a series of
skills, not only to complete the program, but also to prove to future
 CHAPTER 1 Competency-Based Education and the Medical Assistant Student
employers that you are competent in all the identified skills an entry-
level medical assistant should have. Once you complete the program
and are looking for your first medical assistant position, how can
you prove to potential employers that you are competent in all
required skills? What can you bring to an interview that summarizes
your abilities? A comprehensive portfolio that you develop through-
out the courses you take in your MA program contains materials
that you can use to demonstrate the knowledge and skills you have
accumulated throughout your course of study. A comprehensive
portfolio includes examples of work completed in each course and
proof of the skills achieved.
A comprehensive portfolio can be used to create an interview
portfolio that is tailored to prove your competency in the skills
outlined in a specific job description. (Interview portfolios are dis-
cussed in more detail in the chapter, Career Development and Life
Skills.) For example, as a new graduate, you see an ad for a medical
assistant position in a local pediatrician's office that is looking for an
individual who is competent in electronic health records (EHRs),
knowledgeable about immunizations, and who knows how to
perform basic coding skills. If you have retained copies of all of your
achievements in those designated areas in a comprehensive portfolio,
you can pull out those specific copies to create a job interview port-
folio that demonstrates your knowledge base and skill level. Items
that you can feature in a comprehensive portfolio include:
• Samples of projects completed throughout your courses of study,
to demonstrate your learning in a variety of subjects. For example,
perhaps in one of your courses, you developed a list of commu-
nity resources that could help patients with a variety of needs.
Including this project demonstrates your knowledge of local
agencies that might prove useful to the patient population of a
healthcare facility where you are seeking employment. Another
project may require you to investigate a specific disease process,
including expected signs and symptoms, diagnostics, and treat-
ment details. This project would demonstrate your knowledge of
a disease process, management of patients, diagnostic studies, and
medications. Other assignments may require you to demonstrate
your administrative knowledge and skills, such as EHR skills,
basic practice finances, and coding capabilities.
• Samples of key procedural checklists that show evidence of your
achievement of skills in measuring and recording vital signs and
performing hands-on skills, such as electrocardiography (ECG),
phlebotomy, medical laboratory procedures, infection control,
administration of medication, therapeutic communication,
third-party reimbursement, medical law and ethics applications,
and emergency preparedness and practices. Collecting copies of
competency achievement documentation in all these areas will
help you demonstrate entry-level job readiness during an
interview.
• Copies of awards (e.g., scholarships, dean's list), to demonstrate
your academic achievements.
• Copies of any certifications you have achieved (e.g., cardio-
pulmonary resuscitation [CPR] and First Aid and Safety), to
demonstrate your readiness for employment in a healthcare
facility.
• Letters of recommendation from current employers, faculty
members, and others, to highlight your personal and work-
related qualities.
3
Collecting material for a comprehensive portfolio should start
with the very first course in the MA program in which you are
enrolled. Choose examples of work that demonstrate your comple-
tion of core requirements, in addition to competency achievement
across the curriculum. You then will have all the materials needed
to create a specific interview portfolio for each job interview
you earn.
WHO YOU ARE AS A LEARNER: HOW DO YOU
LEARN BEST?
You have taken the first step toward becoming a successful student
by choosing your profession and field of study. The medical assistant
profession is both challenging and rewarding. Becoming a medical
assistant opens the doors to a wide variety of opportunities in both
administrative and clinical practice at ambulatory or institutional
healthcare facilities. To become a successful medical assistant, you
first must become a successful student. This chapter helps you dis-
cover the way you learn best and provides multiple strategies to assist
you in your journey toward success.
CRITICAL THINKING APPLICATION 1-2
Consider your history as a student. What do you think helped you succeed?
What do you think needs improvement? Create a plan for improvement
that includes two or three ways you can become a more successful student.
Be prepared to share this plan with your classmates.
Think about what you do when you are faced with something
new to learn. How do you go about understanding and learning the
new material? Over time you have developed a method for perceiv-
ing and processing information. This pattern of behavior is called
your learning style. Learning styles can be examined in many dif-
ferent ways, but most professionals agree that a student's success
depends more on whether the person can "make sense" of the infor-
mation than on whether the individual is "smart." Determining your
individual learning style and understanding how it applies to your
ability to learn new material are the first steps toward becoming a
successful student (Figure 1-1).
Learning Style Inventory
For you to learn new material, two things must happen. First, you
must perceive the information. This is the method you have devel-
oped over time that helps you examine new information and recog-
nize it as real. Once you have developed a method for learning about
the new material, you must process the information. Processing the
information is how you internalize it and make it your own.
Researchers believe that each of us has a preferred method for learn-
ing new material. By investigating your learning style, you can figure
out how to combine different approaches to perceiving and process-
ing information that will lead to greater success as a student.
The first step in learning new material is determining how you
perceive it, or as some experts explain, what methods you use to
learn the new material. Some learners opt to watch, observe, and use
reflection to think about and learn the new material. These students
are abstract perceivers, who learn by analyzing new material, building
4 UNIT ONE INTRODUCTION TO MEDICAL ASSISTING
FIGURE 1-1 Student learning.
theories about it, and using a step-by-step approach to learning.
Other students need to perform some activity, such as rewriting
notes from class, making flash cards, and outlining chapters, to learn
new information. Students who learn by "doing" are called concrete
perceivers. Concrete learners prefer to learn things that have a per-
sonal meaning or that they believe are relevant to their lives. So,
which type of perceiver do you think you are? Before you actually
learn new material, do you need time to think about it, or do you
prefer to "do" something to help you learn the material?
The second step in learning new material is information process-
ing, which is the way learners internalize the new information and
make it their own. New material can be processed by two methods.
Active processors prefer to jump in and start doing things immediately.
They make sense of the new material by using it now. They look for
practical ways to apply the new material and learn best with practice
and hands-on activities. Reflective processors have to think about the
information before they can internalize it. They prefer to observe
and consider what is going on. The only way they can make sense
of new material is to spend time thinking and learning a great deal
about it before acting. Which type of information processor do you
think you are? Do you prefer to jump in and start doing things to
help you learn, or do you need to analyze and consider the material
before you can actually learn it?
Using Your Learning Profile to Be a Successful Student:
Where Do I Go From Here?
No one falls completely into one or the other of the categories just
discussed. However, by being aware of how we generally prefer first
to perceive information and then to process it, we can be more sensi-
tive to our learning style and can approach new learning situations
with a plan for learning the material in a way that best suits our
learning preferences.
Your preferred perceiving and processing learning profile will fall
into one of the following four stages of the Learning Style Inventory,
which was created by David Kolb of Case Western Reserve
University.
FIGURE 1-2 Learning in a small group.
• Stage I learners have a concrete reflective style. These students want
to know the purpose of the information and have a personal
connection to the content. They like to consider a situation from
many points of view, observe others, and plan before taking
action. They feel most comfortable watching rather than doing,
and their strengths include sensitivity toward others, brainstorm-
ing, and recognizing and creatively solving problems. If you fall
into this stage, you enjoy small-group activities and learn well in
study groups.
• Stage 2 learners have an abstract reflective style. These students are
eager to learn just for the sheer pleasure of learning, rather than
because the material relates to their personal lives. They like to
learn lots of facts and arrange new material in a clear, logical
manner. Stage 2 learners plan studying and like to create ways of
thinking about the material, but they do not always make the
connection with its practical application. If you are a stage 2
learner, you prefer organized, logical presentations of material
and therefore enjoy lectures and readings and generally dislike
group work. You also need time to process and think about new
material before applying it.
• Stage 3 learners have an abstract active style. Learners with this
combination learning style want to experiment and test the infor-
mation they are learning. If you are a stage 3 learner, you want
to know how techniques or ideas work, and you also want to
practice what you are learning. Your strengths are in problem
solving and decision making, but you may lack focus and may
be hasty in making decisions. You learn best with hands-on
practice by doing experiments, projects, and laboratory activities.
You enjoy working alone or in small groups (Figure 1-2).
• Stage 4 learners are concrete active learners. These students are
concerned about how they can use what they learn to make a
difference in their lives. If you fall into this stage, you like to
relate new material to other areas of your life. You have leadership
 CHAPTER 1 Competency-Based Education and the Medical Assistant Student
capabilities, can create on your feet, and usually are vocal in a
group, but you may have difficulty completing your work on
time. Stage 4 learners enjoy teaching others and working in
groups and learn best when they can apply new information to
real-world problems.
CRITICAL THINKING APPLICATION 1-3
• Consider the two ways to perceive new material. Are you a concrete
perceiver, who ties the information to a personal experience, or are you
an abstract perceiver, who likes to analyze or reflect on the meaning of
the material? Choose the type you think most accurately describes your
method of learning.
• Now, think about the way you process learning. Are you an active
processor, who always looks for the practical applications of what you
learn, or are you a reflective processor, who has to think about new
material before internalizing it?
• After completing this activity, write down the combination of your per-
ceiving and processing learning styles and share it with your
instructor.
To get the most out of knowing your learning profile, you need
to apply this knowledge to how you approach learning. Each of the
learning stages has pluses and minuses. When faced with a learning
situation that does not match your learning preference, see how you
can adapt your individual learning profile to make the best of the
information. For example, if you are bored by lectures, look for an
opportunity to apply the information being presented to a real
problem you are facing in the classroom or at home. If you are an
abstract perceiver, take time outside of class to think about new
information so that you are ready to process it into your learning
system. If you benefit from learning in a group, make the effort to
organize review sessions and study groups. If you learn best by teach-
ing others, offer to assist your peers with their learning. By taking
the time now to investigate your preferred method of learning, you
will perceive and process information more effectively throughout
your school career.
CRITICAL THINKING APPLICATION 1-4
Take a few minutes to reflect on a time when you really enjoyed learning
about something new. How was the material presented, and what did you
do to "make it your own"? What do you need to do to become a more
effective learner?
COPING MECHANISMS
Have you ever thought about how you deal or cope with stressful
situations? We each have our own ways of managing stress or con-
flict. We've developed these methods over time, and whether they
are effective depends on the individual's personality and life experi-
ences; the environment or situational specifics that surround the
5
issue; and the type of stress involved. For example, perhaps you have
other demands on your time besides those related to school. Perhaps
you are worried about money, house work, children, jobs, and so
on. All these things can contribute to individual stress levels. Coping
strategies are the methods we consciously use to solve problems and
attempt to minimize the stress associated with them.
CRITICAL THINKING APPLICATION 1-5
Make a list of five things that cause stress in your life. Next to each item,
write down how you typically would cope with that stressor.
Myths About Stress
The following are some commonly held beliefs about stress that, in fact,
are not true. See how many of these myths are part of your beliefs about
stress.
Myth 1: Stress is always negative. If not managed in a positive way, stress
can be very damaging. However, stress can also motivate us to work
harder and achieve more, so it can be quite beneficial in our lives. Can
you think of an example of stress as a positive influence in your life?
Myth 2: We all respond to stress in the some woy. The perception of a
stressful situation is individualized, and each person responds to stress
in his or her own way. For example, students typically are stressed
about exams, but each individual student perceives that stress and
responds to it differently.
Myth 3: If no symptoms are evident, then stress does not exist. Stress is
always present. If you have developed adaptive coping mechanisms,
you may not display the symptoms of stress, such as worry, anxiety,
or difficulty sleeping. Nonetheless, stress is present in all our lives.
Myth 4: We should ignore the symptoms of stress unless they drastically
affect our lives. Manageable symptoms of stress include headache,
backache and upset stomach. However, these minor problems are
warnings that worse health issues can develop if we continue to mis-
manage stress levels.
From the Explorables. Available at https:f/explorable.com/myths·about-stress?gid= 1600.
Accessed June 5, 2015.
Strategies used to reduce stress are called adaptive, or constructive,
coping mechanisms. For example, if finding time to study for an exam
is stressful, an adaptive response to this stress is to use time manage-
ment strategies, such as planning study hours in advance to avoid
the stress of last-minute preparation. However, some coping strate-
gies may actually increase stress levels. These are identified as non-
adaptive coping mechanisms. Therefore, if you have a big project due
and you procrastinate to the last minute to start working on it, your
anxiety over the project may result in even more stress.
Adaptive coping mechanisms can help a person gain control over
a stressful situation. Negative, or nonadaptive, strategies may be
effective short term but often lead to long-term stress. The good news
is that coping mechanisms are learned behaviors. It is possible to
replace coping mechanisms that do not work with ones that are more
successful.
6 UNIT ONE INTRODUCTION TO MEDICAL ASSISTING
One of the keys to managing stress in your life is to maintain
your health. If you are eating properly, exercising regularly, and
consistently getting enough sleep, you are much more capable of
managing stress. Mentally managing your stress levels is also really
important. Learning relaxation techniques, using positive self-talk,
implementing time management strategies, expressing how you feel,
and honestly communicating with others are all factors that can help
you manage your stress levels more effectively.
Adaptive and Nonadaptive Coping Mechanisms
Adaptive Coping Mechanisms:
• Using humor to cope with a painful situation
• Gathering information about the cause of a problem
• Learning new skills to manage a problem
• Trying to derive meaning from a stressful situation
• Accepting the responsibility or blame
• Using distraction to manage negative feelings
• Practicing relaxation methods
• Using positive self-talk
• Seeking social support far the issue
• Anticipating a stressful situation and planning a coping strategy
• Getting adequate nutrition, exercise, and sleep
Nonadaptive Coping Mechanisms
• Compartmentalizing thoughts and emotions
• Anticipating or rehearsing stressful events
• Avoiding anxiety by relying on something (e.g., alcohol or drugs) or
someone to cope with stress
• Doing everything you can to avoid stressful situations
• Running away, either physically or mentally, to escape a stressful
situation
CRITICAL THINKING APPLICATION
Look back on the list of stressors in your life and how you typically
responded to each. Is there anything you have learned from your reading
that might help you better cope with stress? Next ta each stressor, add an
adaptive coping mechanism that could help.
TIME MANAGEMENT: PUTTING TIME ON YOUR SIDE
One of the most complicated tasks for a professional medical assis-
tant is to manage time effectively. No other workplace can compete
with the distractions and demands of a busy healthcare facility. Do
you think you practice effective time management skills? Do you
believe that you are in control of your time, or do you think that
other people or situations control it? How frequently do you say that
you just do not have enough time to do what you are supposed to
do, let alone those things you would like to do? Time management
gives you the opportunity to spend time in the way you choose.
Effective time management is also crucial to your success as a student
and as a future healthcare professional (Figure 1-3).
FIGURE 1-3 Time management in a busy medical practice.
How to Put Time on Your Side
The following time management skills are designed to help you deal
effectively with the demands on your time. Highlight the ones you
think will be most useful in helping you deal with your situation.
1. Determine your purpose. What do you want to accomplish this
semester, in this course, or in this unit of study? What do you
want to achieve as a student? What is one thing you can do to
help achieve your goals?
2. Identify your main concern. Besides school, what other demands
do you have on your time? Based on the learning goals you have
established, what do you need to do to accomplish your goals?
• Plan time: Schedule projects in advance, and make notes to
yourself on deadlines.
• Guard time: Avoid distractions (e.g., television, music, cell
1-6
phones, social media) that interfere with your concentration.
Notice how others abuse your time. Learn to say no to outside
demands on your time.
• Discover time: Think about what you do with your time all
day long. Are there instances where you could "steal" time
from something to "create" more time in your schedule? For
example, maybe you spend time carpooling kids to activities
or waiting for a class to start. Can you keep your books with
you and use that downtime to highlight part of a chapter or
create flash cards for an upcoming test?
• Assign time: Ask for help when you need it from friends and
family.
3. Be organized. What materials (e.g., books, research, supplies) do
you need to have an effective study session? What preparation is
needed to make the most of your time?
• Record time: Use a day planner or calendar, either paper or
electronic, to note the due dates for assignments and tests. If
a paper or project is due on a specific date, put a reminder in
your day planner to start the project on a specific date so that
you are sure to have it done when it is due.
 CHAPTER 1 Competency-Based Education and the Medical Assistant Student
• Optimal time: Take advantage of the time of day when you
study and learn the best. Schedule study time during your
peak performance time. If you are an early riser, make time
for homework first thing in the day; if you are a night owl,
do your homework at night. Plan on dedicating at least some
of your optimal time to your school work.
4. Stop procrastinating. If you avoid working on your goals, you
may not achieve them. Examine the following suggestions as ways
to break the procrastination cycle.
• Make the work meaningful: What is important about the work
you are putting off and what are the benefits ofgetting it done?
Reflect on your long-range goals. Is it important to do a good
job on the work so you can earn an acceptable grade, do well
in the course, complete the medical assisting program, and
ultimately find employment?
• Plan work deadlines: Break assignments into achievable sec-
tions that can be completed in the time slots available. Sched-
ule those work sections in your day planner so that you do
not forget deadlines for assignments.
• Ask for help: Let your support system know you have work to
get done. Ask them for encouragement to stay on track. If
you have school-age children, you can set an excellent example
by planning "family" homework sessions. You can get some
of your work done while acting as a role model for learning
behaviors for your children. Let your partner know when due
dates are looming or tests are scheduled. Ask for help in
meeting day-to-day demands so that you can study or prepare
for school.
• Prioritize: If you keep avoiding a certain task, re-evaluate its
priority. If it is really worth worrying about, get started now,
not later. Don't waste time worrying about how you are going
to get things done. Spend that time actually working on the
projects that worry you the most.
• Reward yourself Create a reward that is meaningful and some-
thing for which you will work. If you want to spend time with
your family or friends on the weekend, develop a plan and
stick to it so that you can share that special time as a reward.
5. Remember you. It is very easy to become overwhelmed with
responsibilities both in school and at home. Part of successful
time management includes setting aside time to do things you
enjoy. You have chosen a profession that can be very demanding.
Now is the time to remember that you have to take care of your-
self in addition to meeting your professional and personal
responsibilities.
CRITICAL THINKING APPLICATION 1-7
How do you spend your time? For 3days this week, write down the amount
of time you spend on each activity. How much television do you watch?
How much time do you spend talking or texting an the phone and checking
social media? How about driving time, visiting time, work time, time for
family and friends, and so on? At the end of the 3-day period, add up the
amount of time you spent on your daily activities. Do you recognize any
time you might be wasting? Can you implement any of the suggested time
management strategies to make more time available?
7
STUDY SKILLS: TRICKS FOR BECOMING A
SUCCESSFUL STUDENT
So far in this chapter, we have looked at the influence of individual
learning styles and time management on learning success. Now we
will investigate some ideas that are useful for learning new material.
These study skills include memory techniques, active learning, brain
tricks, reading methods, and note-taking strategies.
Several techniques can help you store and remember information.
The first of these involves organizing information into recognizable
groups so that the brain can find it easily. You can organize informa-
tion by getting the big picture first before trying to learn the details.
One way to implement this strategy is to skim a reading assignment
before actually reading and taking notes on the material, thus getting
a general impression of what you need to learn before tackling the
details. Depending on your learning style, it may also help to find
a way of making the new information meaningful. Think about your
educational goals and how the new material will help you achieve
those goals.
Another way of remembering material is to create an association
with something you already know. If new material is grouped with
already stored material, the brain remembers it much more easily.
For example, maybe you took a biology class in high school and
learned the basics about human anatomy and physiology. Try to
create a link between what you previously learned and the detail of
the new information you are expected to learn now. Or maybe you
have a family member who suffers from a particular disease. Think
about that individual's signs and symptoms while learning more
details about the disease so that you can apply your learning to his
or her situation.
A useful study skill for some learners is to be physically active
while learning. Some students learn best if they walk or talk out
loud while studying. Besides encouraging learning, moving and
talking while studying relieves boredom and keeps you awake.
Another way to be actively involved in learning is to use pictures or
diagrams to represent the material you are studying. Some people
are visual learners, and creating pictures of the material is the easiest
method for them to retain the information. Other students find that
rewriting notes, making lists of information, creating flash cards,
color-coding notes, or highlighting important material in a textbook
helps them retain the material. Writing also helps students who need
to "do" something to learn.
Studying goes much more smoothly if you work with your brain
rather than against it. If you tend to get anxious and worried while
studying, you may be acting as your own worst enemy. One way of
dealing with a topic you are anxious about is to overlearn it. If mate-
rial is overlearned, you are much less likely to experience test anxiety.
Another method for remembering material is to review it quickly
after class. This mini-review helps the new information become part
of your long-term memory system.
Many students find creating songs, dances, or word associations
an effective way to learn and remember new material. Putting details
into a familiar song and moving to it can help trick the brain into
remembering the information. This is especially helpful when trying
to learn anatomy and physiology. For example, think about one of
your favorite songs and "dance" your way through the blood flow
through the heart. Or, if you are finding the organization of the body
especially tricky to remember, such as the movement of food through
8 UNIT ONE INTRODUCTION TO MEDICAL ASSISTING

the gastrointestinal (GI) system, create a mnemonic that helps you your notes shortly after class to fill in any missing details. If you take
remember the information. The most common one suggested for the notes on paper, use only one side of the page (for easier reading) and
parts of the intestines is: Dow Jones Industrial Climbing Average leave blank spaces where needed to fill in details later. Use key words
Closing Stock Report. The first letter of each word stands for an to help you remember the material, and create pictures or diagrams
anatomic part of the intestines-duodenum, jejunum, ileum, cecum, to help visualize it. If permitted, use tape recorders and make sure
appendix, colon, sigmoid, and rectum. You can make up your own you have copies of any handouts or notes distributed by your instruc-
mnemonics or memory tricks to help you learn complicated tor that cover material written on the board or provided in a Pow-
material. erPoint presentation. If your instructor refers the class to a YouTube
Another excellent way oflearning information is to actually teach video or other website, transcribe the site address correctly to refer
it to someone else. Teaching requires you to have a good understand- to it at a later time. Another helpful tool is to develop your own
ing of the material and the ability to describe it for others. It can be system of abbreviations to help simplify the note-taking process.
an effective reinforcement of complicated material. The most effective way to use your notes is to review them shortly
A great deal of the learning process is expected to take place from after class. This is the time to add details, clarify information, or
assigned readings. You can use several methods to make reading make notes about asking the instructor for explanations during the
assignments more meaningful. If you find a reading assignment next class. You could even exchange notes with students you trust
challenging or difficult to understand, the first step is to take the to compare information (Figure 1-4). Some students find it benefi-
time to read it again. Sometimes the first time through the material cial to create a computerized copy of their notes (if they wrote them
is not enough to gain understanding. As you read, highlight impor- out on paper) or to rewrite them. This gives you an opportunity to
tant words or thoughts and stop periodically to summarize the learn the material as you transcribe it. As you are reviewing your
material. Some students find outlining new material helpful. This is notes, you also can draw mind maps of the information or diagram
another way to use active learning to help you make the information outlines to help you better understand and remember the material.
"your own." Creating mind maps is a way of representing the main idea of a
If you get bored while reading, use your body; walk or talk your topic and supporting important details with a figure or picture.
way through the assignment. Take the time to look up words or Healthcare textbooks present complicated concepts with multiple
terms you do not understand or ask your instructor or tutor for help. main ideas, each with its own important details. Mind maps are a
The best way to determine whether you have learned anything from way of combining complex details and organizing them into a
your reading is to try to explain the material to someone else. For format that is easier to remember. The spider map (Figure 1-5)
example, you can meet with other students and explain to them what
you learned. If you can do that effectively, you know you have
acquired the knowledge needed from the reading assignment.
Many students find effective note taking a challenge. The big
question is, "How much of what the instructor says do I actually
need to write down?" The first step in effective note taking is to come
to class prepared. The more familiar you are with the material, the
easier it will be to determine the important parts of the instructor's
lecture. Pay attention to the instructor and look for clues to what he
or she thinks is important. Ask questions about the material if you
do not understand it, rather than writing down information that
makes no sense to you. Think critically about what you hear before
you write it down so you can start to build relationships among the
things you want or need to know.
If your instructor uses PowerPoint presentations to teach a lesson, FIGURE 1-4 Sharing notes.
request copies of the slides before the lecture so you have an oppor-
tunity to review them as you are doing your reading. Many courses
Detail
have an online website where PowerPoints or other lecture materials
are available for review. Take advantage of these added materials to
be prepared for each class so that you can ask questions about any-
thing you don't understand. In addition, this textbook has an exten-
sive online site (i.e., Evolve) that you can access for learning resources.
Topic main
Investigate the site and see whether something there can help you
idea
reach your learning goals.
When it comes to actual note taking, some strategies can make
the process of recording notes an active learning tool. Organize the
information as much as possible while you are writing or typing,
either in an outline or a paragraph format. If you take notes on a
laptop or tablet, make sure your typing skills are good enough for
you to keep up with the flow of information and that you review FIGURE 1-5 Spider map showing multiple main ideas with supporting details.
 CHAPTER 1 Competency-Based Education and the Medical Assistant Student
presents a method for including several main ideas with details in
one study guide. The fishbone map (Figure 1-6) can be used to learn
complicated causes of disease. The chain-of-events map (Figure 1-7)
displays the cause and effect of events, such as infection control or
the history of medicine. The cycle map (Figure 1-8) shows the con-
nection between factors, such as in the chain of infection. Creating
your own mind maps is a way of making the information more
meaningful and easier for you to understand and remember.
Although many techniques can help you study, perhaps the most
important one is your attitude toward learning. Some students fall
into the "I can't possibly learn this material" trap. That type of atti-
tude only leads to self-defeat. The way to overcome barriers is first
Disease
(main idea)
FIGURE 1-6 Fishbone map used to describe causes of disease.
Beginning
First event
Second event
Final event
FIGURE 1-7 Chain-of-events map showing the cause and effect of events.
1 3
FIGURE 1-8 Cycle map illustrating the way one action leads to another.
9
to recognize that they exist. Once you know your weak spots, use
the suggested study skills to improve in those areas. Do not be afraid
to ask questions or to ask for help if you do not understand the
material. Use as many different strategies as necessary to become a
successful student.
CRITICAL THINKING APPLICATION 1-8
Write down at least two barriers to learning that you face. Review the study
skills suggestions and choose four to try out. Use them over the next week
to help you learn new material. Reflect on whether the chosen study skills
helped you learn the material better.
TEST-TAKING STRATEGIES: TAKING CHARGE OF
YOUR SUCCESS
What happens when you do not know the answer to the first ques-
tion on a test? What if you do not know the next one? Are you able
to go on without panicking? Many people find taking tests the most
challenging part of being a successful student. Multiple approaches
are available that you can use to take charge of your success and
improve your ability to take tests. These include such strategies as
adequate preparation, controlling negative thoughts during test
time, and understanding ways to manage various types of
questions.
The first step is to go into a test adequately prepared. Use the
time management skills already outlined in this chapter to prepare
for the big day. Recognize and use your preferred learning style to
overlearn the material and increase your confidence. Use memory
tools (e.g., flash cards, checklists, and mind maps) to help you visual-
ize the material. Form a study group if you are the type of learner
who benefits from studying in groups. Schedule and plan study time,
and reward yourself for your hard work. It also is important to go
into the test rested and relaxed; therefore, you should eat, exercise
to relieve stress, and sleep before the test so that you are as alert as
possible.
Before you start the test, make sure you read the directions care-
fully. If possible, begin with the easiest or shortest questions to build
your confidence. Be aware of the amount of time allotted for the
examination, and pace yourself accordingly. As you go through the
test, look for clues to answers in other questions. During test time,
remember to use positive self-talk at the first indication of panic.
Repeatedly remind yourself that you are well prepared; relax and
think about the material before you get worried. You need to stop
negative thoughts as soon as they arise and instead visualize yourself
being successful. Use slow, deep breathing to relax and, if helpful,
close your eyes for a minute and visualize a relaxing place before you
go on with the test.
Certain strategies are useful for answering different types of ques-
tions. With multiple choice questions, try to identify key words or
clues in each question. Read the question carefully and answer it in
your head before you review the provided answers. If you are not
absolutely sure of the answer, make an educated guess or follow your
instincts in choosing an answer. If there are answers that you know
are not correct, that can eliminate the "all of the above" answer
choice. By eliminating the answers that you know are incorrect, you
can focus on the other answer choices.
1o UNIT ONE INTRODUCTION TO MEDICAL ASSISTING
"True or false" questions give you a 50/50 chance of being
correct. Remember that if any part of the question is not true, then
the statement is false. Again, check the statements for key words that
help indicate the direction of the answer. Look for qualifying terms
(e.g., always, never, sometimes) that are the key to understanding the
meaning of the true or false statement.
CRITICAL THINKING APPLICATION 1-9
Think about a time you experienced test anxiety. Write down the details af
the situation and how you felt. Choose four test-taking strategies you think
would be beneficial in handling similar situations in the future.
BECOMING A CRITICAL THINKER: MAKING
MENTAL CONNECTIONS
The ability to process information and arrive at reasonable conclu-
sions is crucial to all healthcare workers. The process of critical
thinking involves (1) sorting out conflicting information, (2)
weighing your knowledge about that information, (3) ignoring or
letting go of personal biases, and (4) deciding on a reasonable
belief or action. Critical thinking is actually an active search for
the truth.
Critical thinking could be described as thorough thinking,
because it requires learners to keep an open mind to all possibilities.
Successful students are thorough thinkers because they must deter-
mine the facts about a topic and come to logical conclusions about
the material. Critical thinkers also are inquisitive learners; they con-
stantly analyze and sort out conflicting information to reach
conclusions.
A crucial step in critical thinking is evaluating the results of your
learning. Reflection is the key to critical thinking. "How did I learn
what I learned?" and "What does it mean in my life?" are questions
that must be asked consistently to continue to learn. Becoming a
successful student, and ultimately a successful member of the allied
health team, requires critical thinking skills.
Tables and Graphs
Tables and graphs can be helpful tools in many aspects of health-
care, but you must take the time to analyze the information they
include so that you process it accurately. For example, the body
mass index (BMI) table you will learn about in the chapter, Nutri-
tion and Health Promotion, and the growth chart graphs you will
learn to use in the chapter, Assisting in Pediatrics, provide signifi-
cant information about the health status of individual patients. In
addition, tables throughout this textbook outline and summarize
details about coding, health insurance, disease processes, medica-
tions, and treatments. To maximize your learning throughout the
medical assistant program, you should use the information in tables
and graphs to help prepare yourself to work as an entry-level
medical assistant.
A graph is a diagram or picture that represents information and
its relationships. Analyzing graphs is useful for determining a general
Medical assistants 29%
Other healthcare
23%
support occupations
Total, 11%
all occupations
FIGURE 1-9 Projected percentage change in employment of medical assistants (2012 to 2022).
trend; for example, Figure 1-9 shows the projected increase in
employment opportunities for medical assistants from 2012 to 2022.
The bar graph clearly demonstrates the projected percentage of
changes in employment opportunities for medical assistants. Figure
1-10 shows the projected change in total employment of select
healthcare occupations. Can you see how graphs can help you under-
stand a concept much easier than if the data were written out in
paragraph form? More than one type of graph can be used to repre-
sent a single set of information.
How to Analyze a Graph
1. Read the title and the axes of a graph to determine the information
included.
The Xilxis is the line on a graph that runs horizontally (left to right),
and the y-axis is the line that runs vertically (up and down). For
example, in Figure 1-10, different healthcare occupations are listed
along the y-axis, and projected job opportunities (in hundreds of thou-
sands) are listed on the x-axis. Based on your interpretation of this
information, how many positions did the Bureau of Labor Statistics
project for medical assistants?
2. Determine the general trend of the graph.
For example, if you review the growth chart graph of a 2-year-old girl,
you would be able to see whether her height and weight have consis-
tently increased over time or whether she has had a sudden increase
(maybe agrowth spurt) or adecrease that might reflect a recent illness.
3. Graphs can also be useful in visualizing information that doesn't seem
to fit.
For example, if you are responsible for measuring the length and weight
of a 4-month-old infant and the measurements that you took are mark-
edly different (either larger or smaller) than the measurements recorded
at the last well-child examination, perhaps your measurements are
incorrect. If you check them again and come up with the same numbers,
document your results but inform the provider of the differences so the
provider can investigate the changes with the baby's caregiver. Can you
see how being able to use graphs can help you gain insight into patient
healthcare results?
 CHAPTER 1 Competency-Based Education and the Medical Assistant Student 11

Radiologic technologists and technicians

Medical records and health information technicians
Medical and public health social workers
Emergency medical technicians and paramedics
Medical and health services managers
Physical therapists
Dental hygienists
Pharmacists
Medical secretaries
Dental assistants
Physicians and surgeons
Pharmacy technicians
Licensed practical and licensed vocational nurses
Medical assistants
Nursing aides, orderlies, and attendants
Home health aides
Personal and home care aides
Registered nurses

0 100,000 200,000 300,000 400,000 500,000 600,000

FIGURE 1-10 Projected change in total employment of select health care occupations, 2006-2016. Bureau of Labor Statistics, http://www.bls.gov/spotlight/2009 jhealth_care/home.htm. Accessed
August 31, 2015.

PROBLEM SOLVING AND CONFLICT MANAGEMENT
As a future member of the healthcare team, you frequently will face
problems and conflict. Although we usually look at these situations
as negative factors in our lives, problem solving and conflict manage-
ment actually give us the opportunity to affect a potentially negative
situation in a positive way. Learning how to manage problems can
be very useful for your practice as a medical assistant and for your
success as a student.
The first step in reaching an equitable solution to a problem or
conflict is to identify the central issue. How many times have you
known that you were upset about something but were not really sure
why you felt that way? You cannot solve a problem or resolve a nega-
tive situation unless you are sure of what is at the root of your feel-
ings. You need to understand the problem and gather as much
information about the situation as possible before you decide to act.
One way to do this is to ask yourself these questions:
• When does the situation occur and under what circumstances?
• How does it make me feel?
• Is someone else involved? Who? Is it the same person every time?
• What interferes with making a decision or resolving the conflict?
Once you understand the situation and how you feel about it,
you need to decide whether it is worth the effort to resolve it. Pri-
oritize your involvement. Sometimes situations and problems may
arise that you are unable to resolve or that you may decide are not
important enough to act on. For example, one of the students in
your class occasionally checks her phone during lectures. You find
her behavior distracting at times, but does it bother you enough to
do something about it? If it does, then you need to try to resolve
the conflict. However, if it is a minor problem, then maybe it isn't
worth the effort to talk to her about it. After you have gathered the
details about the problem or conflict and you have decided it is
important enough to act on, it is time to determine possible solu-
tions. One way to do this is to ask for advice or brainstorm ideas
with individuals you respect. Sometimes another person can give you
special insight into the problem that you were unable to see on your
own. After brainstorming for possible solutions, you should get
feedback on the workability of the suggested solutions. An alterna-
tive to brainstorming possible solutions to the problem is to list the
pros and cons of possible solutions on a piece of paper. Simply
looking at a list of the positive and negative aspects of the solution
may clarify how you could solve the problem. Before deciding on a
particular solution, make sure you critically analyze the consequences
of each proposed solution: Which one best meets your needs and
has the potential for providing an outcome you can live with?
Finally, you are ready to implement the chosen solution. However,
your work is not over yet. You need to evaluate the outcome of your
decision and see whether it truly did meet your needs. If not, it may
be time to review other possible solutions and try another approach.
Conflict management requires some additional consideration. If
you are in conflict with a peer, an instructor, or a co-worker, it is
important to follow certain guidelines. First of all, regardless of the
situation, you should follow the chain of command to reach a rea-
sonable resolution to the conflict. If you are in conflict with another
student, then you should attempt to work it out with that person
12 UNIT ONE INTRODUCTION TO MEDICAL ASSISTING
before trying to get your instructor involved. If the problem is with
an instructor, meet with him or her first before contacting the
school's administration. You first must make the effort to work out
the issue directly with the other person involved, rather than jumping
to another level for help.
In addition, you should try to solve the conflict one-on-one in a
private place at a prescheduled time. This ensures that the person
will meet with you and that neither one has to worry about others
overhearing the conversation. At the meeting, clearly state your feel-
ings about the conflict and how you would like it resolved. Then try
to come to an agreeable solution. The best way to deal with conflict
situations is through open, honest, assertive communication.
However, just as with problem solving, it is important to follow up
on the decided course of action to see whether it effectively dealt
with the source of the conflict (Figure 1-11).
CRITICAL THINKING APPLICATION 1-10
Think about a serious problem you are currently facing. Use the brainstorm-
ing and/or pros and cans method for creating solutians to the problem.
Implement your chosen solution, and follow up on its effectiveness. Did the
problem-solving process help you manage the situation more effectively?
ASSERTIVE, AGGRESSIVE, AND
PASSIVE COMMUNICATION
Effective communication is crucial in the healthcare environment.
As a medical assistant, you are expected to communicate clearly and
empathetically with patients, families, peers, and other healthcare
professionals. Your ability to display professional communication
behaviors will determine your success in this new profession. Can
FIGURE 1-11 Dealing with conflict.
you think of an example of a communication problem you are
having right now in your personal life? The way you respond to
communication problems can either help you solve them fairly or
lead to serious problems. We learn how to respond to conflict from
the time we are young children. This learned behavior can range
from passive to aggressive to assertive behaviors. Passive communica-
tion behaviors are on one extreme, and aggressive responses are on
the other; assertive styles balance responses in the middle. Passive
responses consistently protect the interests of another person over
your own, whereas aggressive behaviors demand that your needs be
met at the expense of another. Assertive communication strategies
attempt to defend both your rights and those of the other individual
in the conflict.
Assertive Communication
One of the challenges faced by workers in a healthcare environment
is acting assertively when necessary. Assertive communication allows
you to express your thoughts and feelings honestly and enables you
to stand up for yourself in a reasonable, rational manner without an
emotional scene. However, most of us are not born assertive; it is a
behavior that must be learned, and many of us must practice it over
and over again before it becomes a natural response.
Passive, or nonassertive, individuals often feel hurt when they are
taken advantage of or are anxious about dealing with conflict. Just
because they comply with what they are told to do or do not argue
when they are treated unfairly does not mean that they are not upset
about the situation. Often these individuals internalize their hurt
and anxiety and eventually have an angry outburst because of
built-up stress. Aggressive individuals, on the other hand, take
advantage of others, appear self-righteous, and act in a superior way
to get what they want. People who act aggressively may humiliate
or hurt others to achieve their goals or to have their own needs
satisfied.
Passive and Aggressive Behaviors and Language
An individual with passive or nonassertive body language displays
the following behaviors when attempting to deal with conflict:
• Keeps the eyes downcast
• Shifts his or her weight when talking
• Has a slumped posture or wrings the hands
• Whines or uses a hesitant tone of voice
• May use the following phrases:
• "Maybe" or "I guess"
• "I wonder if you could ... "
• "Would you mind very much if... "
• "It's not really important."
An aggressive person displays the following behaviors:
• Leans forward and points a finger when talking
• Raises the voice or sounds arrogant
• May use the following phrases:
• "You'd better. .. "
• "If you don't watch out. .. "
• "Do it or else!"
• "You should do it this way!"
Learning how to respond assertively in a potentially challenging
situation enables us to be honest and direct with others while at the
same time being emotionally honest with ourselves. The goal of
 CHAPTER 1 Competency-Based Education and the Medical Assistant Student
assertive behavior is to treat others with respect while acknowledging
our own feelings about the problem.
The first step in becoming assertive is to describe the situation
and how it makes you feel. Perhaps you have a co-worker who is
taking advantage of you; coming to work late, taking long breaks,
not answering the phones, and so on. How does that make you feel?
Are you angry, hurt, or disappointed? Decide which word best
describes your feelings and, using an "I" sentence, clearly state how
you feel about the situation. Be specific about the problem. If your
statement is too general (e.g., "I am very hurt when you act like
that"), the person you are confronting can either misunderstand or
ignore you because he or she does not know specifically what is
wrong. A statement such as, "I am very hurt that you take advantage
of me by consistently being late for work, taking long breaks, and
not helping with answering the phones," makes the problem very
clear and expresses your feelings when the behavior occurs.
Acting assertively takes practice, practice, practice. In addition,
just because you deliver a clear, concise, assertive message does not
mean that the problem will be solved that quickly. Your assertive
words must be combined with assertive body language to deliver a
clear message about how serious you consider the situation. Remem-
ber, 80% to 90% of a message is nonverbal. Therefore, your "I"
message must be accompanied by assertive behavior, including estab-
lishing eye contact and slightly raising your voice to get the indi-
vidual's attention. And just because you deliver the perfect message
does not mean you will always get what you want. The message may
Ji1iiilhi;\!i•jii#ihi;lt•i
One of the things Shawna can do to improve her learning is to determine her
individual learning style. By understanding how she typically perceives and
processes new information, she can plan the best methods for learning new
material. In addition to understanding who she is as a learner, Shawna needs
SUMMARY OF LEARNING OBJECTIVES
l. Define, spell, and pronounce the terms listed in the vocabulary.
Spelling and pronouncing medical terms correctly reinforce the medical
assistant's credibility. Knowing the definitions of these terms promotes
confidence in communication with patients and co-workers.
2. Discuss competency-based education and adult learners.
The most important characteristic of competency-based education is that
it measures learning and skill achievement over time. Students progress
by demonstrating their competence, which means they prove that they
have mastered the knowledge, skills, and professional behaviors required
to achieve competency in a particular task.
3. Summarize the importance of student portfolios in proving academic
success and skill competency.
Aportfolio is a collection of student materials that demonstrates learning.
Acomprehensive portfolio is developed throughout the courses in a
medical assistant program and contains materials that demonstrate the
knowledge and skills achieved by the student throughout the course of
13
have to be repeated; do you really think someone who is habitually
late for work is going to start showing up on time because of one
assertive message? However, regardless of the outcome, you will feel
better because you have honestly communicated how you feel about
the situation, and you are actively working on a resolution of the
problem.
CRITICAL THINKING APPLICATION 1-11
Do you consider yourself passive (nonassertive), assertive, or aggressive?
Think about a recent conflict situation. How did you respond? Could asser-
tive behaviors help you solve the problem while making you feel better
about yourself?
Professional Behaviors Box
Perhaps the most difficult thing for you to learn is the art of assertiveness;
that is, honestly informing others how you feel about a conflict situation,
why you feel that way, and what changes you would like to see. The profes-
sional medical assistant faces many challenging situations. Communicating
assertively helps you therapeutically resolve those conflicts. In addition, as
a professional medical assistant, you are expected to act as the patient's
advocate. To perform this crucial duty adequately, you must learn to com-
municate assertively with other individuals and organizations to meet the
needs of your patients.
to practice successful coping mechanisms and time management skills to keep
up with school and work responsibilities. Assertive communication, effective
problem solving, and developing study skills that work for her are also keys to
her success as a student.
study. Acomprehensive portfolio includes examples of work completed
in each course and proof of the skills achieved. It can be used to create
individual interview portfolios that demonstrate knowledge and skill
achievement.
4. Examine your learning preferences and interpret how your learning
style affects your success as a student.
Learning preferences are the ways you like to learn and that have proven
successful in the past. Your learning style is determined by your individual
method of perceiving or examining new material and the way you
process it or make it your own. People are either concrete or abstract
perceivers and either active or reflective processors.
5. Differentiate between adaptive and nonadaptive coping mechanisms.
Adaptive coping mechanisms help a person gain control over a stressful
situation; negative or nonadaptive strategies may be effective short term
but often lead to long-term stress.
Continued
14 UNIT ONE INTRODUCTION TO MEDICAL ASSISTING
SUMMARY OF LEARNING OBJECTIVES-continued
6. Apply lime management slralegies lo make the mosl of your learn-
ing opportunities.
Using effective time management strategies, such as setting goals, pr~
oritizing, getting organized, and avoiding procrastination, results in a
more successful student and an effective medical assistant.
7. Integrate effective study skills into your daily activities.
Study skills, such as memory techniques, active learning, brain tricks,
effective reading methods, note-taking strategies, and mind maps, all
help students ta be mare successful.
8. Design test-taking strategies that help you take charge of your
success.
Test-taking strategies include preparing adequately for the examination,
controlling negative thoughts during the examination, and understanding
how to deal with different types of questions.
9. Incorporate critical thinking and reflection to help you make mental
connections as you learn material.
Critical thinking can be defined as thorough thinking because it considers
all sides of the information without bias. Reflection is the process of
thinking about or reviewing information before acting.
l 0. Analyze healthcare results as reported in graphs and tables.
Tables and graphs can be helpful tools in many aspects of healthcare,
but you must take the time to analyze the information they present so
that you process it accurately. Tables are used to outtine and summarize
significant healthcare information, and graphs diagram or create a picture
that represents information and its relationships. To maximize your
CONNECTIONS
OJ Study Guide Connection: Go to the Chapter 1 Study Guide. Read and complete
the activities.
learning throughout the medical assistant program, you should use the
information in tables and graphs to help prepare you to periorm as an
entry~evel medical assistant.
11. Apply problem-solving techniques to manage conflict and overcome
barriers to your success.
Problem-solving and conflict management techniques are crucial ta your
success. First, identify the central issue and how you feel about it; then,
consider possible solutions and their potential results, implement the
chosen solution, and analyze the results.
12. Relate assertiveness, aggressiveness, and passive behaviors to pro-
fessional communication and discuss the role of assertiveness in
effective communication.
Passive responses consistentty protect the interests of another person
over your own, whereas aggressive behaviors demand that your needs
be met at the expense of another. Assertive communication strategies
attempt to defend both your rights and those of the other individual in
the conflict.
Assertive communication allows you to express your thoughts and
feelings honestty and enables you to stand up for yourself in a reason-
able, rational manner without an emotional scene. Learning how to
respond assertively in a potentially challenging situation enables us to
be honest and direct with others while at the same time being emotion-
ally honest with ourselves. The goal of assertive behavior is ta treat
others with respect while acknowledging our own feelings about the
problem.
evolve Evolve Connection: Go to the Chapter 1 link at evolve.elsevier.com/
kinn to complete the Chapter Review Quiz. Check out the other resources listed for this
chapter to make the most of what you have learned from Competency-Based Education
and the Medical Assistant Student.
THE HEALTH RECORD
i-i#i►iUt•i
Susan Beezler has just begun her career in the medical assisting profession.
She is attending medical assisting school in the morning and works part-time
for a family practitioner in the afternoons as a clerical record assistant. Susan
is eager to learn about medicine and looks forward to taking on more respon­
sibility at the office.
The practice is growing swiftly and recently added a new provider, Dr. Alex
Thomas. Dr. Thomas has enjoyed working with Susan and feels that her
energy will be just what his patients need. He has taken a professional interest
in Susan and often lets her assist him with patients when her other duties
allow.
Susan knows that although she is a beginner in the office, she will gain
trust from her supervisors and patients as long as she projects a teachable
While studying this chapter, think about the following questions:
• Why would some patients have concerns about the healthcare facility
using electronic health records (EHRs)?
• How can the medical assistant earn the patient's trust so that the person
is comfortable revealing the very private information required by a health
history?
LEARNING OBJECTIVES
l. Define, spell, and pronounce the terms listed in the vocabulary.
2. Name and discuss the two types of patient records.
3. State several reasons that accurate health records are important.
4. Differentiate between subjective and objective information in creating a
patient's health record.
5. Explain who owns the health record.
6. Distinguish between an electronic health record (EHR) and an
electronic medical record (EMR).
7. Do the following related to healthcare legislation and EHRs:
• Explain how the American Recovery and Reinvestment Act (ARRA)
applies to the healthcare industry.
• Define meaningful use and relate it to the healthcare industry.
• List the three main components of meaningful use legislation.
8. Explore the advantages, disadvantages, and capabilities of an EHR
system, and explain how to organize a patient's health record.
9. Discuss the importance of nonverbal communication with patients
when an EHR system is used.
l0. Discuss backup systems for the EHR, as well as the transfer,
destruction, and retention of health records as related to the EHR.
2
attitude. The office has recently converted to an electronic records system but
is still using paper records as well. Susan uses the information she learned in
school about both types of health records. She cheerfully performs filing and
even does some transcription for Dr. Thomas. The other staff members are
pleased with her willingness to perform the most mundane tasks.
Susan enjoys sharing her experiences with her classmates. She is the only
one currently working in the medical field, and the other students ask her lots
of questions about the "real world" of medicine. She is very careful not to
breach patient confidentiality; sht"ais�sses situations only in general terms,
never mentioning any patien '�cimes"'.'
Susan feels a great sense of pride that she is already a member of the
healthcare team and able to contribute to the lives of her patients.
• Why is it so important to have a signed release of information form
before sending patient information out?
• Why is it important that the health record be legible?
• Why is it important to know both administrative and clinical skills in the
provider's office?
11. Describe how and when to release health record information; discuss
health information exchanges (HIEs).
12. Identify and discuss the two methods of organizing a patient's paper
medical record.
13. Discuss how to document information in an EHR and a paper health
record, and how to make corrections/alterations to health records.
14. Discuss dictation and transcription, and discuss transfer, destruction,
and retention of medical records as related to paper records.
15. Identify filing equipment and filing supplies needed to create, store,
and maintain medical records.
16. Describe indexing rules, and how to create and organize a patient's
health record.
17. Discuss the pros and cons of various filing methods, as well as how to
file patient health records.
18. Discuss organization of files, as well as health-related correspondence.
19. Discuss patient education, as well as legal and ethical issues, related
to the health record.
16 UNIT ONE INTRODUCTION TO MEDICAL ASSISTING
VOCABULARY
age of majority The age at which a person is recognized by law to
be an adult; can vary by state.
alleviate To partly remove or correct; to relieve or lessen.
alphabetic filing Any system that arranges names or topics
according to the sequence of the letters in the alphabet.
alphanumeric Of or relating to systems made up of combinations
of letters and numbers.
augment To increase in size or amount; to add to in order to
improve or complete.
caption A heading, title, or subtitle under which records are filed.
computerized provider/physician order entry (CPOE) The
process of entering medication orders or other provider
instructions into the electronic health record (EHR).
continuity of care Continuation of care smoothly from one
provider to another, so that the patient receives the most benefit
and no interruption in care.
culpability Meriting condemnation, responsibility, or blame,
especially as wrong or harmful.
dictation (dik-ta'-shun) The act or manner of uttering words to
be transcribed.
direct filing system A filing system in which materials can be
located without consulting an additional source of reference.
e-prescribing The use of electronic sofrware to communicate with
pharmacies and send prescribing information, taking the place
of writing a prescription by hand and physically giving it to a
patient; most new or refill prescriptions can be submitted
electronically, cutting down on fraud and errors.
electronic health record (EHR) An electronic record of health-
related information about a patient that conforms to nationally
recognized interoperability standards and that can be created,
managed, and consulted by authorized clinicians and staff from
more than one healthcare organization.
electronic medical record (EMR) An electronic record of
health-related information about an individual that can be
created, gathered, managed, and consulted by authorized
clinicians and staff within a single healthcare organization.
gleaned Gathered bit by bit (e.g., information or material);
picked over in search of relevant material.
indirect filing system A filing system in which an intermediary
source of reference (e.g., a card file) must be consulted to locate
specific files.
interoperability The ability to work with other systems.
microfilm A film with a photographic record of printed or other
graphic matter on a reduced scale.
numeric filing The filing of records, correspondence, or cards by
number.
objective information Data obtained through physical
examination, laboratory and diagnostic testing, and by
measurable information.
obliteration (uh-blih-tuh-ra'-shun) The act of making
undecipherable or imperceptible by obscuring or wearing away.
outguide A sturdy cardboard or plastic file-sized card used to
replace a folder temporarily removed from the filing space.
parameters Any set of physical properties, the values of which
determine characteristics or behavior.
patient portal A secure online Web site that gives patients
24-hour access to personal health information using a username
and password.
personal health record (PHR) An electronic record of health-
related information about an individual that conforms to
nationally recognized interoperability standards and that can be
drawn from multiple sources but that is managed, shared, and
controlled by the individual.
pressboard A strong, highly glazed composition board resembling
vulcanized fiber; heavy card stock.
provisional diagnosis A temporary diagnosis made before all test
results have been received.
purging The process of moving active files to inactive status.
quality control An aggregate of activities designed to ensure
adequate quality, especially in manufactured products or in the
service industries.
reasonable cause Circumstances that would make it unreasonable
for the covered entity, despite the exercise of ordinary business
care and prudence, to comply with the administrative
simplification provision (part of Health Information Technology
for Economic and Clinical Health Act [HITECH]) that was
violated.
reasonable diligence The business care and prudence expected
from a person seeking to satisfy a legal requirement under
similar circumstances.
requisites (reh'-kwuh-zihts) Entities considered essential or
necessary.
retention schedule A method or plan for retaining or keeping
health records and for their movement from active to inactive to
closed filing.
reverse chronologic order Arranged in order so that the most
recent item is on top and older items are filed further back.
subjective information Data or information elicited from the
patient, including the patient's feelings, perceptions, and
concerns; obtained through interview or questions.
subpoena duces tecum A court order to produce documents or
records.
tickler file A chronologic file used as a reminder that something
must be dealt with on a certain date.
transcription A written copy of something made either in
longhand or by machine.
vested Granted or endowed with a particular authority, right, or
property; to have a special interest in.
willful neglect Conscious, inrentional failure or reckless
indifference to the obligation to comply with the administrative
simplification provision violated.

H ealth records can be found in basically two different formats,
electronic and paper. Most healthcare facilities have switched
to electronic health records (EHRs) for a number of reasons. The
advantages of EHRs include easy storage of patient information,
accessibility by multiple users at the same time, and making elec-
tronic claim submission a more efficient process, to name a few.
The federal government has also offered financial incentives for
providers to implement EHRs. Although most providers are using
EHRs there are still some who are using paper records and others
who are using a combination of both electronic and paper. When a
provider is making a switch to an EHR he or she may decide to
keep the patient's previous records in the paper format and just use
the electronic format from now forward. Some providers may
decide to scan in the last 3 to 5 years of the patient's record into the
electronic record. Whatever the scenario the healthcare facility has
chosen, it is important for the versatile medical assistant to
be knowledgeable about both systems and able to perform well
with either.
TYPES OF RECORDS
The two major types of patient records are the paper health record
and the EHR. With the advances in computer technology, the paper
health record has been shown to be much less efficient than the
EHR. In most cases, only one person at a time can use the paper
record. It is fairly common for information to be filed in the incor-
rect record, and the entire record also can be misfiled. Data cannot
be accessed easily for research and quality control, and in facilities
with multiple departments or locations, the information is difficult
to share. The paper-based record is good evidence of patient care,
but it is not nearly as useful in other capacities.
The EHR is much more efficient than the paper record. Multiple
users can access the record at the same time. There are fewer errors
because handwritten notes do not have to be interpreted. In addi-
tion, most EHRs also link the clinical information needed for billing
purposes, and include practice management capabilities that allow
for patient scheduling and generation of reports needed for research
and quality control.
CRITICAL THINKING APPLICATION 2-1
Some of Dr. Thomas' patients are concerned that computer-based health
records may not be completely private. They are worried that unauthorized
individuals could access their information on the computer and do them
harm. Should patients be allowed to decide whether their records are kept
on computer or on paper?
THE IMPORTANCE OF ACCURATE HEALTH RECORDS
Health records are kept for five basic reasons. First, the health record
helps the provider provide the best possible medical care for the
patient. The provider examines the patient and enters the findings
in the patient's health record. These findings are clues to the diag-
nosis. The provider may order many types of tests to confirm or
augment the clinical findings. As the reports of these tests come in,
the findings fall into place, much like the pieces of a jigsaw puzzle.
CHAPTER 2 The Health Record 17
Then, with the confirmation data to support the diagnosis, the
provider can prescribe treatment and form an opinion about the
patient's chances of recovery, assured that every resource has been
used to arrive at a correct judgment. The health record provides a
complete history of all the care given to the patient.
Second, the health record also provides critical information for
others. By reading through the record and discovering the methods
used to treat the patient, healthcare professionals can provide con-
tinuity of care. Each person knows what the patient has experienced
and can provide continuous care, even from one facility to another.
For example, when a patient is transferred from a hospital to a skilled
nursing facility, the information from the patient's hospital record
helps the nursing facility staff to better care for the patient. When
patients move from place to place or caregivers change, copies of the
pertinent information should move with the patient to provide this
continuity of care.
Third, health records are kept as legal protection for those who
provided care to the patient. A documented health record is excellent
proof that certain procedures were performed or that medical advice
was given. An accurate record is the foundation for a legal defense
in cases of medical professional liability. This is one reason that
writing legibly in the paper record to document exactly what hap-
pened to the patient and the provider's response are critical. Remem-
ber: If it is not documented, it did not happen.
Fourth, health records provide statistical information that is
helpful to researchers. The patient's record provides information
about medications taken and the reactions to them. Health records
may be used to evaluate the effectiveness of certain kinds of treat-
ment or to determine the incidence of a given disease. Providers
often take part in drug studies that track adverse reactions and side
effects. The effects of various treatments and procedures also can be
tracked and statistics gleaned from the information in patients'
records. In tracking statistical information the information that
would identify specific patients is removed. Correlation of such
statistical information may result in a new outlook on some phases
of medicine and can lead to revised techniques and treatments. The
statistical data from health records also are valuable in the prepara-
tion of scientific papers, books, and lectures.
Fifth, health records are vital for financial reimbursement. The
information in the health record supports claims for reimbursement
and is required by most third-party payers.
CONTENTS OF THE HEALTH RECORD
The patient's health record is the most important record in a pro-
vider's practice. For completeness, each patient's record should
contain subjective information provided by the patient and objec-
tive information obtained by the provider and staff of the healthcare
facility. If all entries are completed, the health record will stand the
test of time. No branch of medicine is exempt from the need to keep
patient health records.
Subjective Information
Personal Demographics
The patient's health record begins with routine personal data, which
the patient usually supplies on the first visit when the health record
is established. Most patients are required to complete a patient
18 UNIT ONE INTRODUCTION TO MEDICAL ASSISTING

information form (Figure 2-1 and Procedure 2-1 ). The basic facts • Healthcare insurance information
needed are: • Source of referral
• Patient's full name, spelled correctly • Social Security number
• Names of parents/guardians if the patient is a child
• Patient's gender Past Health, Family, and Social History
• Date of birth The past health, family, and social history is often obtained by having
• Marital status the patient complete a questionnaire. The medical assistant may
• Name of spouse if married review the form for completeness and clarify any questions or
• Home address, telephone number, and e-mail address missing information with the patient before the patient is seen by
• Occupation the provider. The provider will also augment this history with infor-
• Name of employer mation provided during the patient interview. The responses provide
• Business address and telephone number information about any past illnesses (including injuries and/or physi-
• Employment information for spouse cal defects, whether congenital or acquired), hospitalizations, or

Thank you for selecting our health care team!

To help us meet all your health care needs, please
fill out this form completely in ink. If you have any questions
or need assistance, please ask us - we will be happy to help.

d We{come ,,C,
Patient# _ _ __
Soc. Sec.# _ __
Patient Inj ormation (CONFIDENTIAL) Date _ _ __
Name,_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Birth date _ _ _ _ _ Home phone _ __
Addres City Stat0 - Zip _ __
Check appropriate box: D Minor D Single D Married D Divorced D Widowed D Separated Full Part
If student, name of school/college _ _ _ _ _ _ _ _ _ _ _ _ _ City _ _ _ _ _ _ State _ D time O time
Patient's or parent's employer _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Work phone - - -
Business address _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ City _ _ _ _ _ _ Stat0 - Zip _ __
Spouse or parent's name _ _ _ _ _ _ _ _ _ _ _ _ Employer _ _ _ _ _ _ _ _ _ Work phone _ __
Whom may we thank for referring you? _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Person to contact in case of emergency _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Phone _ _ _ __

!l{,esponsi6fe Party Relationship

Name of person responsible for this account _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ to patient _ _ __
Address Home phone _ __
Driver's license # _ _ _ _ _ _ _ _ _ Birth date _ _ _ _ _ _ _ _ Financial institution _ _ _ _ _ _ __
Employer Work phone _ _ _ _ _ _ SSN# _ _ _ __

Is this person currently a patient in our office? D Yes D No

Insurance Information Relationship

Name of insured _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ to patient _ _ __
Birth date _ _ _ _ _ _ _ _ _ _ Social Security # _ _ _ _ _ _ _ _ _ _ _ _ _ Date employed _ _
Name of employer _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Union or local # _ _ _ _ Work phone _ __
Address of employer _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ City _ _ _ _ _ _ _ _ stat0 - Zip _ __
Insurance company _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Group # _ _ _ _ _ _ _ Policy/ID# _ _ __
Ins. co. address _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ City _ _ _ _ _ _ _ _ state _ _ Zip _ _
How much is your deductible? _ _ _ _ _ _ _ How much have you used?_ _ _ _ Max. annual benefit _ _ __

DO YOU HAVE ANY ADDITIONAL INSURANCE? • Yes • No IF YES, COMPLETE THE FOLLOWING:

Relationship
Name of insured _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ to patient _ _ __
Birth date _ _ _ _ _ _ _ _ _ _ Social Security # _ _ _ _ _ _ _ _ _ _ _ _ _ Date employed _ _
Name of employer _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Union or local # _ _ _ _ Work phone _ __
Address of employer _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ City _ _ _ _ _ _ _ _ stat0 - Zip _ __
Insurance company _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Group # _ _ _ _ _ _ _ Policy/ID# _ _ __
Ins. co. address _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ City _ _ _ _ _ _ _ _ State _ _ Zip _ _
How much is your deductible? _ _ _ _ _ _ _ How much have you used?_ _ _ _ Max. annual benefit _ _ __
I authorize release of any information concerning my (or my child's) health care, advice and treatment provided for the purpose of
evaluating and administering claims for insurance benefits. I also hereby authorize payment of insurance benefits otherwise payable to me
directly to the doctor.
X
Signature of patient or parent if minor Date

FIGURE 2-1 The patient information form provides all the information the medical assistant needs to construct the patient's record.
 CHAPTER 2 The Health Record 19

surgeries the patient has had (Figure 2-2). It also includes informa- of this information because it could affect the patient's current
tion about the patient's daily health habits. Stickers can be used on condition.
the front of paper health records to indicate allergies, advance direc- Patient's Family History. The family history comprises the physical
tives, and other information (Figure 2-3). In an EHR there will be condition of the various members of the patient's family, any illnesses
alerts that may appear as a pop-up window when the record is or diseases individual members may have had, and a record of the
accessed that will indicate that the patient has allergies, that immu- causes of death. This information is important because certain dis-
nizations are due, or that there is no advance directive on file. These eases may have a hereditary pattern. Most providers are interested
are useful for helping the health professional keep important facts in the immediate family: parents, grandparents, siblings, and
about the patient in the forefront of the mind while treating the children.
individual. Patient's Social History. The social history includes information
Past Health History. The past health history will include informa- about the patient's lifestyle. If the patient drinks alcohol, how many
tion about previous illnesses/injuries (including childhood illnesses drinks per day or per week are consumed? If the patient uses nico-
such as chickenpox or measles), previous hospitalizations, and previ- tine, how much is used in a day, and what type (i.e., cigarettes or
ous surgeries. The dates that these occurred will need to be docu- smokeless tobacco)? Drug use, living situation, exercise, and nutri-
mented, as well as any complications. The provider needs to be aware tion information can be considered part of the social history.

-- ... __
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FIGURE 2-2 Database self-administered general health history questionnaire: Lengthy questionnaires should be completed by the patient before
the individual is seen by the provider. Either mail the questionnaire to the patient in advance or ask the patient to come in early to complete the
paperwork. (Courtesy Bibbero Systems, Petaluma, California.)
20 UNIT ONE INTRODUCTION TO MEDICAL ASSISTING

ALLERGIC: _ _ _ __
A .__ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ___.

CO-PAY ADVANCE
DIRECTIVES
B ____________ __ Durable Power of
Attorney for
Healthcare
- Living Will
__ Healthcare
Surrogate
C

FIGURE 2-3 Record stickers: Information on stickers on the outside of the record allows the provider and medical staff to see important informa-
tion about the patient quickly. (Courtesy Bibbero Systems, Petaluma, California.)

CRITICAL THINKING APPLICATION
While taking a patient's medical history, Susan asks about his social history.
She asks whether he drinks alcohol. The patient immediately becomes
defensive and accuses Susan of getting too personal about his affairs.
• How might Susan explain her reasons for asking these questions?
What options are available if the patient refuses ta discuss his social
history with Susan?
• Could this apposition to questions about the social history raise
suspicion in Susan's mind? What might she suspect?
Patient's Chief Complaint
The patient's chief complaint is a concise account of the patient's
symptoms, explained in the patient's own words. It should include
the following:
• The nature, location, frequency, and duration of pain, if any
• When the patient first noticed the symptoms
• Treatments the patient may have tried before seeing the pro-
2-2 vider and whether they have helped with the symptoms or
not; when the last dose was taken
• Whether the patient has had the same or a similar condition
in the past
• Other medical treatment received for the same condition in
the past
Most medical facilities use a pain scale to determine the severity
of the patient's discomfort. The medical assistant might ask, "How
bad is your pain on a scale of 1 to 10, with 1 being almost no pain,
and 10 being the worst pain you've ever experienced?" The pain scale
or wording used in individual facilities should be documented in the
office policy and procedures manual and followed by the medical
assistant.

Create a Patient's Health Record: Register a New Patient in the Practice

PROCEDURE 2-1
Management Software

Goal: Register a new patient in the practice management software, prepare a Notice of Privacy Practices (NPP) form and a
Disclosure Authorization form for the new patient, and document this in the electronic health record (EHR).

EQUIPMENT and SUPPLIES PROCEDURAL STEPS

• Computer with SimChart for the Medical Office or practice management and 1. Obtain the new patient's completed registration form. Log into the practice
EHR software management software.
• Completed patient registration form 2. Using the patient's last and first names and date of birth, search the
• Scanner database for the patient.

•;;Mdmj;jfJi -,;ontinued
PURPOSE: To help ensure the integrity of the practice management and
EHR systems, a search far the new patient's name must always be done
before registering that person. This prevents a double record from being
created if the patient had been entered into the database at an earlier time.
3. If the database does not contain the patient's name, add a new patient and
enter the patient's demographics from the completed registration farm.
4. Verify that the information entered is correct and that all fields are completed
before saving the data.
PURPOSE: Errors during the registration process can affect the communica-
tion with the patient (e.g., if a wrong address or e-mail is entered) or can
affect billing (e.g., if the incorrect insurance information is added). Accuracy
is extremely important when entering the patient's information.
NOTE: The software will generate a health record number far the patient.
S. Using the EHR software, prepare and print a copy of the NPP and a Disclo-
sure Authorization farm for the new patient. The Disclosure Authorization
Objective Information
Objective findings, sometimes referred to as signs, are findings that
can be observed and measured. They can include vital signs, mea-
surements, and observations made by the medical assistant and
findings from the provider's examination of the patient.
Vital Signs and Anthropometric Measurements
The medical assistant's responsibilities include taking the patient's
vital signs (i.e., temperature, pulse, respirations, blood pressure,
pulse oximetry) and height and weight. These measurements are
documented in the patient's health record and are used by the pro-
vider in his or her assessment. If the medical assistant observes
other signs such as a rash, this would also be documented in the
patient's health record and brought to the provider's attention.
Findings and Laboratory and Radiology Reports
After the provider has examined the patient, the physical findings
are documented in the health record. The results of other tests or
requests for these tests are then documented or, if they appear on
separate sheets, are attached to the health record. When an EHR is
being used the separate sheet may be scanned so that it is in an
electronic format and can be added to the patient's EHR.
Diagnosis
Based on all the evidence provided in the patient's past history, the
provider's examination, and any supplementary tests, the provider
notes his or her diagnosis of the patient's condition in the health
record. If some doubt remains, this may be labeled a provisional
diagnosis. A differential diagnosis is the process of weighing the
probability of one disease causing the patient's illness against the
probability that other diseases are causative. For example, the dif-
ferential diagnosis of rhinitis, or a runny nose, could indicate allergic
rhinitis (i.e., hay fever), the common cold, or even abuse of drugs
or nasal decongestants.
CHAPTER 2 The Health Record 21
farm should indicate the disclosure will be to the patient's insurance
company.
PURPOSE: Before the medical office can release patient information to the
insurance company, the patient has to give consent in writing.
SCENARIO UPDATE: The patient received both documents and signed the
Disclosure Authorization farm.
6. Using the EHR, document that the patient received a copy of the NPP and
signed the Disclosure Authorization farm. Scan the Disclosure Authorization
form and upload it into the EHR.
PURPOSE: Documentation in the health record provides a legal record of
what was done or communicated to the patient.
7. Log out of the software upon completion of the procedure.
PURPOSE: Logging into and out of the software helps to protect the
integrity of the data saved in the software and prevents unauthorized people
from viewing the information.
Treatment Prescribed and Progress Notes
The provider's suggested treatment is listed after the diagnosis. Gen-
erally, instructions to the patient to return for follow-up treatment
within a specific period also are noted here. If surgery or other treat-
ment is going to be performed during the current visit, the patient
must sign a consent form.
On each subsequent visit, when using a paper record, the date
must be entered on the record; information about the patient's
condition and the results of treatment, based on the provider's obser-
vations, must be added to the health record. Notations of all medica-
tions prescribed or instructions given, and the patient's own report
of how they are doing, should be documented in the health record.
If the patient is hospitalized, the name of the hospital, the reason
for admission, and the dates of admission and discharge are docu-
mented. Much of this information can be obtained from the hospital
discharge summary.
Condition at the Time of Termination of Treatment
When the treatment is terminated, the provider documents that
information. For example: August 18, 2016. Wound completely healed.
Problem resolved.
The Medical Assistant's Role
When the medical assistant is responsible for documenting the
patient's history, care must be taken to ensure that the patient's
answers are not heard by others. If privacy is not possible, the patient
should be given a form to fill out, and the information should be
transferred to the permanent record later. When privacy is available,
the medical assistant may ask the patient questions and document
the answers directly into the health record. This method offers an
opportunity to become better acquainted with the patient while
completing the necessary records and also ensures the patient under-
stands what all the questions mean. If new patients must complete
a lengthy questionnaire, the questionnaire may be mailed to the
22 UNIT ONE INTRODUCTION TO MEDICAL ASSISTING
patient with a request that it be completed and returned to the
provider before the appointment. If the record is electronic the
patient may access his or her record through a patient portal and
document the information directly into the EHR system. It would
then be reviewed by the medical assistant and provider during the
office visit. Another option with an EHR is for the patient to com-
plete a paper form and the medical assistant to enter the information
into the EHR while reviewing the form with the patient.
The medical assistant may document the patient's chief com-
plaint, but the provider will question the patient in more detail.
Many practitioners write their own entries on the record in long-
hand if a paper record is used. Some may document the findings
directly into the computer if an electronic record is used. Others
may dictate the material, either directly to the medical assistant or
by using a recording device. If the material is dictated and tran-
scribed, the provider should verify each entry and then initial the
entry to verify its accuracy before it is entered into the patient's
record. For a record to be admissible as evidence in court, the
person dictating or writing the entries must be able to attest that
they were true and correct at the time they were written. The best
indication of this is the provider's signature or initials on the typed
entry. In an EHR the provider's electronic signature is proof of the
accuracy of the entries.
OWNERSHIP OF THE HEALTH RECORD
Who owns the health record? Patients often assume that because the
information in the health record is about them, ownership of the
record rightfully is theirs. However, the owner of the physical health
record is the provider or medical facility, often called the "maker,"
that initiated and developed the record. The patient has the right of
access to the information within the record but does not own the
physical record or other documents pertaining to the record. The
patient has a vested interest and therefore has the right to demand
confidentiality of all information placed in the record.
The actual paper health record should never leave the medical
facility where it originated. Even the provider should refrain from
taking the record from the office to the hospital or nursing facility. If
information from the record is needed, copies can be placed in a file,
and progress notes can be written on site and inserted into the original
record later. This is not an issue with an EHR because the record can
be accessed by multiple users at the same time. Patients' paper records
should be kept in a locked room or locked filing cabinets when the
office is closed. EHRs must be protected from unauthorized access.
Health Insurance Portability and Accountability Act (HIPM) regula-
tions state that each user must have a unique user name and password;
individual access is determined by the system administrator.
Written health records must be legible. Each record should be
written as if the provider and staff expect it to eventually be involved
in a lawsuit; therefore every word must be legible to an average reader
years after it is written. The record can help the provider prove that
he or she treated a patient in a competent manner, or it can prove
that the patient was not given competent care. Every person on staff
at the provider's office is responsible for writing legibly in every
health record.
EHRs eliminate the issue of legibility in the record, but it is just
as important to be sure that all patient care is documented in the
electronic record. If care is not documented, this will leave the
healthcare facility open to potential lawsuits and can affect patient
care. If services are not documented, they cannot be billed for either.
CRITICAL THINKING APPLICATION 2-3
On Susan's third day at wark, a man cames into the office and demands
to see his mother's health recard. Susan accesses the recard and sees that
the mother has not granted permission for information to be given to her
son. What should Susan do in this situation? Are there any viable reasons
the son should have access to his mother's medical information?
TECHNOLOGIC TERMS IN HEALTH INFORMATION
Some confusion has arisen regarding the acronyms EMR and EHR.
These acronyms have been used interchangeably for many years. To
alleviate the confusion, the Office of the National Coordinator for
Health Information Technology (ONC) has established definitions
for EMR and EHR that are easy to understand. The EHR is an
electronic record of health-related information about a patient that
conforms to nationally recognized interoperability standards and
that can be created, managed, and consulted by authorized clinicians
and staff from more than one healthcare organization. The electronic
medical record (EMR) is an electronic record of health-related
information about an individual that can be created, gathered,
managed, and consulted by authorized clinicians and staff within a
single healthcare organization. An EMR is an electronic version of a
paper record.
EMR is being used less and less as the federal regulations regard-
ing electronic records have been established. There is a significant
push toward having all electronic records meet the definition of an
EHR. There are many advantages to having an electronic record
system that can be accessed from more than one healthcare organiza-
tion. The continuity of patient care is much more easily established
when all providers have access to the same records regardless of what
organization they are working for. There should be less running of
duplicate tests and procedures, which will help reduce the cost of
providing healthcare.
A personal health record (PHR) is defined by the ONC as an
electronic record of health-related information about an individual
that conforms to nationally recognized interoperability standards
and that can be drawn from multiple sources, but that is managed,
shared, and controlled by the individual. There are several ways that
a PHR can be created. Some health insurance companies offer PHRs
for those who they insure; some employers offer it as a service for
their employees; and some healthcare facilities offer it to their
patients. It is important to remember that the patient maintains a
PHR. The information from an EHR does not automatically transfer
to a PHR.
Another way for patients to access their healthcare information
is through a patient portal. Patient portals allow patients to access
their actual EHRs. At any time a patient can view progress notes,
laboratory results, medications, or immunizations. Many patient
portal systems also allow for communication berween the patient
and provider, completion of forms online, and ability to request
prescription refills and schedule appointments. By establishing

effective patient portals, healthcare facilities can meet some of the
meaningful use requirements.
HIPM uses the term protected health information (PHI), which
is any information about health status, the provision of healthcare,
or payment for healthcare that can be linked to an individual patient.
HIPM requires that all PHI be protected; this applies to EHRs,
EMRs, PHRs, and patient portals.
AMERICAN RECOVERY AND REINVESTMENT ACT
The American Recovery and Reinvestment Act of 2009 (ARRA),
commonly known as the Economic Stimulus Package, was passed to
promote economic recovery. This legislation was signed into law by
President Barack Obama on February 17, 2009. The health informa-
tion technology aspects of the bill provide slightly more than $31
billion for healthcare infrastructure and EHR investment. The sec-
tions of the ARRA that pertain to healthcare are collectively known
as the Health Information Technology for Economic and Clinical
Health Act, or HITECH Act.
THE HEALTH INFORMATION TECHNOLOGY FOR
ECONOMIC AND CLINICAL HEALTH ACT AND
MEANINGFUL USE
The HITECH Act provides financial incentives for the meaningful
use of certified EHR technology to achieve health and efficiency
goals. It was incorporated into the ARRA to promote the adoption
and meaningful use of health information technology. Remember,
HIPM was created in large part to simplify administrative processes
using electronic devices. Meaningful use, defined simply, means that
providers must show that they are using EHR technology in ways
that can be measured significantly in quality and quantity. If provid-
ers meet the meaningful use requirements, they will qualify for
incentive payments. Three main components of meaningful use can
be identified, including:
• Use of certified EHR in a meaningful manner, such as
e-prescribing
• Use of certified EHR technology for electronic exchange of
health information to improve the quality of healthcare
• Use of certified EHR technology to submit clinical quality
reports, procedure and diagnosis codes, surveys, and other
measures
Criteria for meaningful use were designed to be implemented in
three stages:
• Stage 1 (2011 and 2012): Electronic data capture and sharing
• Stage 2 (2014): Advanced clinical processes
• Stage 3 (expected to be implemented in 2016): Improved
outcomes
In Subtitle D of the HITECH Act, privacy and security concerns
related to the electronic submission of health information are
addressed. Several provisions strengthen the civil and criminal penal-
ties of the HIPM rules, most of which became effective in February
2009. More of the provisions will become effective over the next few
years, subject to future lawmaking.
Included in the February 2009 modifications of HIPM were:
• Establishment of categories of violations that reflect increasing
levels of culpability
CHAPTER 2 The Health Record 23
TABLE 2-1 Categories of Health Insurance
Portability and Accountability Act Violations and
Associated Penalties
ALL SUCH
VIOLATIONS OF
CATEGORY: AN IDENTICAL
SECTION PROVISION IN A
1176(A)(1) EACH VIOLATION CALENDAR YEAR
(A) Did not know $100 to $50,000 $1.5 million
(B) Reasonable cause $1,000 to $50,000 $1.5 million
(() (i) Willful $10,000 to $50,000 $1.5 million
neglect-corrected
(() (ii) Willful $50,000 $1.5 million
neglect- not corrected
• Requirements that penalties be determined based on the
nature and extent of the violation and the nature and extent
of the harm resulting from the violation
• Establishment of tiers of increasing penalty amounts that
determine the range of and authority to impose civil monetary
penalties (Table 2-1 )
As indicated in Table 2-1 , minimum and maximum penalty
amounts are established and can be assessed by the Department of
Health and Human Services (HHS), depending on the nature of the
violation. The HHS determines the penalties on a case-by-case basis
and may provide or continue to provide a waiver for violations that
arise from a reasonable cause and are not willful neglect incidents
that are not corrected in a timely manner. The DHHS will also
consider whether the covered entity has provided reasonable dili-
gence in its attempts to bring the facility into compliance with the
law. Providers can expect reductions in the amounts they are paid
from Medicare and Medicaid if they are not in compliance. Remem-
ber, the computer system in the medical office must be more than
a tool for data recall to be considered an EHR system; the provider
must use the system for tasks, at a minimum, such as e-prescribing
and computerized provider/provider order entry (CPOE).
ADVANTAGES AND DISADVANTAGES OF THE EHR
According to a 2014 survey done by the National Ambulatory
Medical Care Survey (NAMCS), 82.8% of providers in office-based
practices use full or partial EMR systems. This is up from 18% in
2001.
The EHR has several advantages over a paper health record. Most
experts agree that the EHR can reduce medical errors by keeping
prescriptions, allergies, and other information organized; it also can
reduce costs by preventing duplicate tests. Staffing needs also may
be reduced, because fewer personnel are needed to manage an EHR
system. Because a computer keyboard is used to enter information
into the record, the record is not nearly as likely to be illegible
24 UNIT ONE INTRODUCTION TO MEDICAL ASSISTING
as a written record. Typed copy certainly is easier to read than hand-
writing, even if the record is several years old. EHR systems require
individual user names and passwords, which secure the system from
unauthorized users.
Compared with walls and file cabinets full of paper health records,
the EHR requires less storage space. One or two external hard drives
with a terabyte of disk space each conceivably could hold all the
health records of all patients throughout the life of a provider's
practice. This would eliminate the need to purge inactive files, and
the resulting space requirement for the external hard drive may be
no bigger than a large shoebox. The files may be duplicated regularly
and placed off site as a backup. Using thumb drives as backup would
meet HIPM requirements as long as they were stored somewhere
other than the healthcare facility. More facilities are using cloud
storage to protect the EHR content.
Information can be accessed in a variety of locations, and more
than one person can see the record at any given time. The patient
database usually allows various types of statistical information to be
recalled, which is a valuable tool. Patient information is available
quickly in an emergency, even when the patient is not in his or her
hometown. The provider and medical assistants can access progress
notes, test results, and any other information about the patient,
including patient education and appointment no-shows. The pro-
vider and medical assistants can access patient information using a
smart phone or tablet.
Once the provider and staff become familiar with the system,
they may find that they are able to see more patients in the course
of a day than when paper records were used. All of these advantages
lead to cost savings and more efficient patient care.
However, the EHR system is not without disadvantages. Studies
show that lack of capital is the most significant obstacle to adoption
of the system; another stumbling block is the reluctance of employ-
ees in providers' offices to make such substantial changes and to
learn a new computer system. Employees who are not very familiar
with computers may fear that they will not be able to learn the
system or that an EHR may mean that they no longer will have a
job. Providers may have the same fears of learning a new system and
wonder about how much more time it will take them to do their
job. Employees may not be the only individuals resistant to a
changeover to electronic records; patients often are fearful that their
private health information will be available to unauthorized indi-
viduals, and they often assume that their records will be posted on
the Internet.
The startup costs of conversion to an EHR system usually are
quite high, although most providers realize that the system eventu-
ally will be worth the cost. "The Financial and Nonfinancial Costs
of Implementing Electronic Health Records in Primary Care Prac-
tices," an article in the online journal Health Affairs, suggests that
the startup cost for a five-provider practice is approximately
$162,000, with $85,500 going toward maintenance costs during
the first year (Fleming et al., 2011). The study also suggested that
the implementation team would need an average of 611 hours to
prepare for the implementation, and end-users, such as the provid-
ers, medical assistants, and other staff members, would need about
134 hours of training to use the system. Both the provider and staff
require extensive training in the EHR system and must be receptive
to even more training to use the system to its full capacity. Training
is time-consuming and takes the provider and staff away from treat-
ing patients for certain periods. Because not all computer systems
are user friendly, care must be taken to choose a system that
has technologic support, both live and online, that is available
during the hours the healthcare facility is operating. Space for the
equipment can be an issue, although usually less space is required
than for a paper record system. Finally, security and confidentiality
are major concerns of both the healthcare professionals and
the patients.
Reassuring Patients About the Security and
Confidentiality of the Electronic Health Record
• Explain the conversion before the office changes and during the
conversion.
• Never display a negative attitude about the change to an electronic
health record (EHR) system; patients tend ta reflect the attitude you
show them.
• Prepare a pamphlet explaining the processes that will change in your
particular office with use of the EHR.
• Take a moment ta show the patient a little about the software once it
has been implemented (using only their record). Most patients are
interested in what the EHR can accomplish. Show the individual the
log-in process (without revealing passwords) to reassure him or her that
access to records is private and secure.
• Explain the records backup process to help alleviate patients' fears that
their health information may be lost.
• Explain the office access policy regarding who can access and view
patients' records.
Successful Conversion to an Electronic Health
Record System
• Get the entire facility "on board" with the change.
• Provide leadership to the staff.
• Encourage and praise the staff's hard work in making the conversion
successful.
• As a medical assistant, be loyal and promote loyalty ta the facility
during the change.
• Use good people management skills, especially with those who are
against the conversion. Many people who were initially averse to
conversions later say they do not know how they ever worked without
the EHR.
• Always provide patients, visitors, and co-workers excellent customer
service.
• Work as a team with other staff members.
• Use every employee's strengths where they are needed.
• Be willing to venture into a new system and keep a positive attitude.
• Remember that if healthcare is anything, it is constant change.
 CHAPTER 2 The Health Record 25

CRITICAL THINKING APPLICATION 2-4 Capabilities of Electronic Health Record Systems

Some of the patients who visit Dr. Adkins and Dr. Brooks have expressed
concern that electronic health records (EHRs) may not be private enough
and that their health information will be "floating around on the Internet."
They are worried that unauthorized individuals could somehow access their
information on the computer and do them harm.
• How might Susan alleviate the patients' fears about their records
being available on the Internet?
• What disadvantages with regard to confidentiality are associated
with the EHR?
The EHR system can perform a multitude of tasks, saving time and
money in the provider's office (Figure 2-4). The following are some
of the features of a typical EHR system.
• Specialty software. Patient data are captured and processed
into a system that is specialty specific, so that the terminology
and patient care treatments are compatible with the provider's
specialty. However, additional features can allow the provider
to include terminology from other specialties.
• Appointment scheduler. The appointment scheduler allows
the staff to track and schedule appointments, matrix the
schedule, and account for recurring time blocks (Figure 2-5).
The appointments can be merged into specific types with
default times so that lengthy procedures are not scheduled in
short appointment blocks. The scheduler features also allow
various search parameters; if a patient calls because he or she

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26 UNIT ONE INTRODUCTION TO MEDICAL ASSISTING

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FIGURE 2-5 The EHR usually has a scheduling system that can be changed to manage the needs of the provider and office staff.

cannot remember the appointment time, a search can be initi-
ated using the date, provider's name, patient's name, or other
search keywords.
• Appointment reminder and confirmation. The system can
be programmed to initiate automatic reminder or confirma-
tion calls to patients. The staff can record the reminders, and
patients are prompted to choose options, such as "Press one"
to confirm or reschedule appointments.
• Prescription writer. The EHR system can produce electronic
prescriptions, which can be printed and given to patients or
automatically submitted to a pharmacy. Lists can be created
with the provider's most common drug choices and dosages.
A patient allergies function can block the prescription of drugs
the patient cannot take, and the system can generate a patient
information sheet on new prescriptions.
• Medical billing system. The EHR billing system can manage
all of the practice's billing and accounting systems. The system
also can interface with clearinghouses for electronic claims
submission and tracking. Reports can be generated that
provide accurate details of the financial state of the practice
at certain intervals or whenever requested.
• Charge capture. The charge capture functions can store lists
of billing codes (e.g., International Classification of Diseases
[ICD] and Current Procedural Terminology [CPT]) in addi-
tion to charges associated with procedures, supplies, and labo-
ratory tests. Evaluation and Management (E/M) codes are
used during office visits to obtain the highest possible reim-
bursement; these help the provider maximize profits while
remaining in compliance with the law. Alerts can let the user
know when a certain charge does not match a diagnosis code;
for instance, a blood glucose done for a sore throat. In such
cases, the software alerts the user and helps prevent errors that
can lead to denial of insurance claims.
• Eligibility verification. EHR billing systems can perform
online verification of insurance eligibility and can capture
demographic data.
• Referral management. Current and referring providers can
be coordinated and automated, allowing the provider to share

patient information with another provider. This reduces the
patient's physical effort of transporting copies of records back
and forth to referring providers, eliminates the costs of such
copies, and is faster and more efficient than copying and
mailing patient records.
• Laboratory order integration. The laboratory order integra-
tion feature allows the user to interact with outside laborato-
ries and to receive and post laboratory results to patients'
records. Tests can be ordered from the provider's laptop,
tablet, or smart phone. Results can be transmitted by fax,
scan, or e-mail and uploaded directly into the patient's record
(Procedure 2-2).
Organize a Patient's Health Record: Upload Documents to the
PROCEDURE 2-2
Electronic Health Record
Goal: Scan paper records and upload digital files to the EHR.
Scenario: Anew patient brings in a laboratory report and a radiology report that he would like ta be added ta his EHR. Yau
need to scan in the original documents and upload them to the EHR.
EQUIPMENT and SUPPLIES
• Scanner
• Computer with Sim(hart far the Medical Office or EHR software
• Patient's laboratory and radiology reports
PROCEDURAL STEPS
1. Obtain the patient's name and date af birth if not on the reports.
PURPOSE: You will need the patient's name and date of birth to find the
patient's EHR.
2. Using a scanner that is connected to the computer, scan each document,
creating an individual digital image far each.
PURPOSE: The reports should be scanned separately and not combined to
create one file. Each type of report must be uploaded separately to the
correct location in the EHR.
3. Locate the file of the two scanned images in the computer drive. Open the
files to ensure the images are clear.
NONVERBAL COMMUNICATION WITH THE PATIENT
WHEN USING THE ELECTRONIC HEALTH RECORD
Although many patients are covered under a type of insurance that
requires them to choose a primary care provider (PCP) and to have
a referral to a specialist, remember that the patient has the option
of changing that PCP or specialist. The patient may decide to change
providers simply because he or she does not feel comfortable with
that particular provider.
Because the change process is relatively easy, the provider wants to
keep his or her patients (in most cases), because losing patients means
loss of income. If the care begins to seem impersonal, patients may
feel a strong desire to change providers. Remember, patients are con-
sumers of healthcare services, and they expect quality healthcare.
CHAPTER 2 The Health Record 27
CRITICAL THINKING APPLICATION 2-5
Jennifer, the office manager, has noticed that Susan seems frustrated in the
training classes far the EHR system used by the clinic. During a break,
Jennifer asks Susan whether she is having any specific problems with the
training classes. She also asks far Susan's input on the system. Susan says
that she just prefers clinical work and that her typing skills are a little
"rusty."
• How might Jennifer respond to Susan's comments?
• Why might this be a warning sign that Susan will not be a good
match far the practice?
PURPOSE: When scanning and uploading documents to the EHR, it is crucial
that the image of the document is clear and can be easily read by the
provider. If the image is blurred, rescan the document.
4. In the EHR, search far the patient, using the patient's last and first name.
Verify the patient's date of birth.
PURPOSE: Before uploading to or documenting in the EHR, it is critical to
verify that the correct record is opened.
S. Locate the window to upload diagnostic/laboratory results and add a new
result. Enter the date of the test. Select the correct type of result. Browse
far the image file of the laboratory file and attach it. Save the information.
Select the option to add a new result and repeat the steps to upload the
second report. Verify that both documents were uploaded correctly.
PURPOSE: Errors during the upload may affect the ability to see the files.
Verifying at the time of the upload will help ensure providers can see the
results in the future.
When using the EHR, the medical assistant must make sure his
or her nonverbal communication sends the right message to the
patient. Eye contact is absolutely essential (Figure 2-6). If the medical
assistant constantly looks at the electronic device, the patient feels
largely alienated from the information exchange process. Make eye
contact with the patient while asking questions, looking at the screen
only when needed to enter information. Do not insinuate by physical
action that the EHR is a "hidden entity"; for example, do not neces-
sarily shield the device from the patient's view when entering infor-
mation. Although patients may not understand anything they see
on the screen, they will feel more at ease if their information is not
hidden from them. Also, modify your stance so that the patient feels
like a part of the information process. Just as sitting in a chair across
28 UNIT ONE INTRODUCTION TO MEDICAL ASSISTING
FIGURE 2-6 The medical assistant must make eye contact with the patient when using an EHR.
from a supervisor's desk can be intimidating, the patient may feel
the same emotions sitting across from a medical assistant entering
information into the EHR. Take an open stance; sit next to or at an
angle to the patient to support the impression that those in the
healthcare facility and the patient are partners in the healthcare plan.
Remember that patients have the right to make decisions in most
aspects of their healthcare plans; therefore offer choices wherever
possible. Never expect patients to make quick decisions about their
care. They may want to consult family members or give some
thought to important medical decisions. The medical assistant needs
to promote time to think unless the patient is faced with a critical,
time-sensitive decision. Providers often assume that patients will
automatically follow their instructions or orders; however, some
patients prefer some time to think. Always follow up and make note
of any wait time the patient requests, notify the provider, and enter
that information into the EHR. Make sure timely communication
is done with the patient and that any additional orders that need to
be put in place are completed. The many features of the EHR allow
the medical assistant to be efficient and highly competent if he or
she is willing to make an extra effort to master the EHR system.
Also make sure patients understand all instructions given to them
regarding test procedures or preparation for procedures. Most EHRs
can print an instruction sheet, which the medical assistant can review
with the patient. The customer service aspect of patient care is even
more important when the facility uses an EHR system.
CRITICAL THINKING APPLICATION 2-6
Jennifer walks behind Susan's desk and notices that she is looking at the
progress notes on a patient who was recently arrested and indicted for child
abuse. The case has been in the newspaper and on television consistently
for several weeks. Jennifer asks Susan why she has accessed that record.
Susan hesitates and then says she must have entered the wrong patient ID
number.
• Does Susan's explanation sound convincing?
• Why is Jennifer concerned abaut Susan laoking at the patient's
record?
• Just because the individual is a patient at the clinic, does that mean
any employee has the right to look at the patient's EHR?
BACKUP SYSTEMS FOR THE ELECTRONIC
HEALTH RECORD
Even the best or most expensive EHR system cannot function
without power. If a natural disaster occurs and the provider's office
is without electricity for several days or weeks, the provider must
have a backup system for the EHR so that the office can function.
HIPM requires that the facility adopt a backup and recovery plan
that includes daily off-site software backup for the EHR system.
Several alternatives can be used for data preservation and backup.
• External hard drive. An external hard drive connects to the
main computer, and with fairly simple programming can copy
the information in the EHR daily. Seven electronic folders,
one for each day of the week, can hold the information from
the previous day; these folders are replaced with new, updated
information at designated periods. CDs and DVDs can hold
daily data, and some thumb drives have enough capacity to
perform this task. Once a habit of a daily backup to the
external hard drive has been established, the method is rela-
tively simple and reliable.
• Full server backup. The provider may want to back up the
EHR system on a dedicated server, which is a large-capacity
computer set aside specifically for the EHR system. With
these servers, a full backup should be performed monthly.
Many large medical facilities and hospitals have one or more
dedicated servers for the EHR system.
• Online backup system. An online backup system can be used,
usually for a subscription fee. Although the cost may be higher
than for some other methods, online systems are easy to use
because there is no external drive to carry and no CD or
thumb drive to put through the process of downloading data.
However, a time investment is involved, because the process
of contacting the company that offers the service and then
downloading all the data takes several hours. Also, the initial
download can take quite a while. Even so, an online system
is very stable and reliable.
All these backup methods require an alternative power source in
case of a disaster that interrupts electrical service. Remember that
backup systems are not effective if the data are stored at the medical
facility, and the disaster happens at or affects that physical address.
Information technology professionals usually recommend using two
of these three methods for the best protection. The system must be
protected from theft and unauthorized use, just as is the on-site
system.
Medical assistants should keep their paper health records skills
sharp in case the EHR system is down for an extended period.
Always have a supply of the most commonly used forms in a paper
format available for alternative use in such instances. When the EHR
system comes back up these paper forms can be scanned into the
patients' EHRs.
Transfer, Destruction, and Retention of Electronic
Health Records
In most medical offices, records are classified in three ways:
• Active, which are the records of patients currently receiving
treatment.
• Inactive, which generally are the records of patients whom the
provider has not seen for 6 months or longer.

• Closed, which are the records of patients who have died,
moved away, or otherwise terminated their relationship with
the provider.
The process of moving a file from active to inactive status is called
purging. An EHR system can be set up to automatically move the
inactive records to another server so that processing time will not be
slowed down, but the records are still readily accessible if the patient
returns to the healthcare facility. Closed EHRs are also separated
from the active records and are typically stored elsewhere. They may
be placed on CDs, computer hard drives, or maintained in inactive
cloud space by the EHR vendor.
Retention and Destruction
Providers have an obligation to retain patient records, whether they
are paper or electronic, that may reasonably be of value to a patient,
according to the American Medical Association (AMA) Council on
Ethical and Judicial Affairs. Currently, no nationwide standard rule
exists for establishing a records retention schedule.
Medical considerations are the primary basis for deciding how
long to retain health records. For example, operative notes and
chemotherapy records should always be part of the patient's health
record. The laws regarding the retention of health records vary from
state to state, and many governmental programs have their own
guidelines for specific records retention. When no rules specify the
retention of health records, the best course is to keep the records for
10 years. However, for minors, the facility should keep the records
until the minor reaches the age of majority plus the statute of
limitations.
If a particular record no longer needs to be kept for medical
reasons, the provider should check the state law for any require-
ment that records be kept for a minimum time (most states do
not have such a provision). The time is measured from the last
professional contact with the patient. In all cases, health records
should be kept for at least the period of the statute of limitations
for medical malpractice claims, which may be 3 years or longer,
depending on state law. In the case of a minor, the statute of limi-
tations may not apply until the patient reaches the age of majority.
In summary, know the state requirements related to health records
retention and follow those guidelines; the office policy manual
should address records retention pertaining to the state where the
practice exists.
The records of any patient covered by Medicare or Medicaid must
be kept at least 10 years. The HIPM privacy rule does not include
requirements for the retention of health records. However, the
privacy rule does require that appropriate administrative, technical,
and physical safeguards be applied so that the privacy of health
records is maintained.
Some providers refuse to destroy or discard old records.
Storage is less of an issue with EHRs as they take up much less
physical space. Always refer to state laws when discarding health
records.
Before old records are discarded, patients should be given an
opportunity to claim a copy of the records or have them sent to
another provider. The medical facility should keep a master list of
all records that have been destroyed. To legally destroy an EHR, the
record, including the backup record, has to be overwritten using
utility sofrware.
CHAPTER 2 The Health Record 29
RELEASING HEALTH RECORD INFORMATION
The healthcare facility must be extremely careful when releasing any
type of medical information. The patient must sign a release for
information to be given to any third party.
Requests for medical information should be made in writing
(Figure 2-7). Electronic signatures may be accepted as long as they
are obtained with proper process controls. HIPM has designated
that very specific information must be included on the Release of
Information form, including specifically who the information is
being released to, what specific information is to be released, and
an expiration date for the release. Accepting a faxed request for
medical information or a faxed release of information from a patient
is unwise. Even requests from the patient's attorney or third-
party payers must be cleared by the patient for them to obtain
information.
If a provider is involved in a liability suit there will be a required
exchange of information. As both parties to a lawsuit begin to
prepare their cases, they enter the discovery process. Each side must
disclose the pertinent facts of the case that may influence the final
outcome of that case. On each occasion that information is needed
from the provider, a separate request must be sent. Because this
request form is signed by the patient, it serves as a release.
Most offices charge a fee to print or copy health records, whether
it is a per-page charge or a per-record fee. If the records are sent
electronically there is no fee charged. Follow the steps in the
policy and procedures manual for the release of records. Some pro-
viders designate the office manager to handle requests for records
releases.
Pay particular attention to records release requests involving a
minor. In most cases, the parent or legal guardian is entitled to read
through the patient's health records; however, according to the HHS,
there are three situations in which the parent may not be legally
entitled to review the records of his or her minor child:
• When the minor is the one who consents to care and
the parent is not required to also consent to care under
state law
• When the minor obtains medical care at the direction of a
court or a person authorized by the court
• When the minor, parent, and provider all agree that the
doctor and minor patient can have a private, confidential
relationship
If the provider believes that the minor might be in an abuse situ-
ation or that the parent or legal guardian may be harming the
patient, the provider is required, both legally and ethically, to report
the abuse.
Sometimes patients want to look at their own records. They
certainly have a right to see this information, but some patients may
not understand the terminology used in the record. A staff member
should always remain with a patient who is looking at his or her
health record. Remember, the original health record should never
leave the medical facility. Always follow office policy when releasing
health records.
When a release is presented to the office, copy only the records
requested in the release. Do not provide additional information that
is not requested. The patient must specify that substance abuse,
mental health, and/or human immunodeficiency virus (HIV) records
are to be released. Remember that the patient ultimately decides
30 UNIT ONE INTRODUCTION TO MEDICAL ASSISTING

Central Texas Dermatology Clinic • 102 Westlake Drive • Austin, Texas 78746
AUTHORIZATION TO DISCLOSE HEALTH INFORMATION
I hereby authorize the use or disclosure of information from the medical record of:
Patient Name: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Date of Birth: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Social Security# _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ Daytime Phone: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

I authorize the following individual or organization to disclose the above named individual's health information:
Address: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

This information may be disclosed TO and used by the following individual or organization:
Address: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Please release the following:

__ Progress Notes __ Pathology Reports __ Lab Reports __ Any and all Records
__ Other Diagnostic reports ( s p e c i f y - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
- - Other (specify) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Including Information (if applicable) pertaining to:
Mental Health __ Drug/Alcohol HIV/AIDS Communicable Treatment

Purpose or Need for Disclosure:

Continued Patient Care Personal Use
__ Attorney/Legal __ Insurance Claim/Application
__ Disability Determination __ Other(specify) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

I understand that the information in my health record may include information relating to sexually transmitted disease, acquired
immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV). It may also include information about behavioral or
mental health services, and treatment for alcohol and drug abuse.

I understand that the information released is for the specific purpose stated above. Any other use of this information without the written
consent of the patient is prohibited.

I understand that I have the right to revoke this authorization at any time. I understand that if I revoke this authorization I must do so in
writing and present my written revocation to the individual or organization releasing information. I understand that the revocation will
not apply to information already released in response to this authorization. I understand that the revocation will not apply to my
insurance company when the law provides my insurer the right to contest a claim under my policy. Unless otherwise revoked, this
authorization will expire on following date, event or condition: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

If I fail to specify an expiration date, event or condition, this authorization will expire in six months.

I understand that authorizing the disclosure of this health information is voluntary. I can refuse to sign the authorization. I need not sign
this form in order to ensure treatment. I understand that I may inspect or copy the information to be used or disclosed, as provided in
CFR 164.524. I understand that any disclosure of information carries with it the potential for an unauthorized re-disclosure and the
information may not be protected by federal confidentiality rules. If I have questions about disclosure of my health information, I can
contact Theresa Farren at 512-327-7779.

Signature of Patient or Legal Representative Date

Relationship to Patient (If Legal Representative) Witness

COMPLETE ONLY IF INFORMATION IS TO BE RELEASED DIRECTLY TO PATIENT:

I understand that my medical record may contain reports, test results, and notes that only a physician can interpret. I understand
and have been advised that I should contact my physician regarding the entries made in my medical record to prevent my misunder-
standing of the information contained in these entries. I will not hold Central Texas Dermatology liable for any misinterpretation of
the information in my medical record as a result of not contacting my physician for the correct interpretation.

Signature of Patient or Legal Representative Date

Relationship to Patient (If Legal Representative) Witness

Dr. review/signature/date - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Date request completed _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ # of pages copied _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Staff Signature _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
PHI Log completed _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

FIGURE 2-7 Authorization to release health records: All requests for health records should be made in writing, and the request should be kept
in the patient's record.

whether a record can be released. If any question arises about what
is to be released, consult the office manager or the provider.
Health Information Exchanges
The demand for electronic health information exchange (HIE)
from one healthcare facility to another, together with nationwide
efforts to improve the efficiency and quality of healthcare, is creat-
ing a demand for HIEs. As more and more providers move to
EHRs it only makes sense to have a system in place that will facili-
tate the exchange of that information electronically to improve the
timeliness of that exchange. Patient care can be improved because
all providers will have access to the information needed to treat the
patient.
The ONC states, "There are currently three forms of HIE:
• Directed Exchange-ability to send and receive secure infor-
mation electronically between care providers to support coor-
dinated care
• Query-Based Exchange-ability for providers to find and/or
request information on a patient from other providers, often
used for unplanned care
• Consumer-Mediated Exchange-ability for patient to aggre-
gate and control the use of their health information among
providers"
The implementation of HIE varies from state to state. There is
some federal funding for the implementation of HIE that is being
administered by the ONC.
CREATING AN EFFICIENT PAPER HEALTH RECORDS
MANAGEMENT SYSTEM
The paper health records management system should provide an easy
method of retrieving information. The files should be organized in
an orderly fashion, the information must be documented accurately,
and corrections should be made and documented properly. The
wording in the record should be easily understood and grammati-
cally correct. An efficient method of adding documents to the record
must be established so that the provider always has the most up-to-
date information.
Above all, the health records management system must work for
the individual facility.
Organization of the Health Record
Source-Oriented Medical Records
The traditional patient record is a source-oriented medical record
(SOMR); that is, observations and data are cataloged according to
their source-provider (progress notes), laboratory, radiology, hos-
pital, or consultant. Forms and progress notes are filed in reverse
chronologic order (i.e., most recent on top) and in separate sections
of the record according to the type of form or service rendered (e.g.,
all laboratory reports together, all x-ray reports together, and so on).
Reverse chronologic order is used so that the provider and staff
members do not have to search to the bottom of the record to find
a recent laboratory report or a test.
Problem-Oriented Medical Records
The problem-oriented medical record (POMR) is a departure from
the traditional system of keeping patient records. The POMR is a
CHAPTER 2 The Health Record 31
record of clinical practice that divides medical action into four
categories:
• The database, which includes the chief complaint, present
illness, patient profile, review of systems, physical examina-
tion, and laboratory reports.
• The problem list, a numbered, titled list of every problem the
patient has that requires management or workup. This may
include social and demographic troubles in addition to strictly
medical or surgical ones.
• The treatment plan includes management, additional workups
needed, and therapy. Each plan is titled and numbered with
respect to the problem.
• The progress notes include structured notes that are numbered
to correspond with each problem number.
Several companies have developed file folders for orgamzmg
patient data according to the POMR. The problem list (Figure 2-8)
is placed at the front of the record. Special sections are provided for
current major and chronic diagnoses/health problems and for inac-
tive major or chronic diagnosis/health problems. Progress notes
usually follow the SOAP approach. SOAP is an acronym for the
following:
• Subjective impressions or patient reports
• Objective clinical evidence or observations
• Assessment or diagnosis
• Plans for further studies, treatment, or management
Some medical offices also use an E in the record to represent
evaluation; others include E for education and R for response. The
education notation shows that the patient was educated about his
or her condition or given a patient information sheet. The response
section is used to record an assessment of the patient's understanding
of and possible compliance with the treatment plan.
The POMR has the advantage of imposing order and organiza-
tion on the information added to a patient's health record. The
records are more easily reviewed, and the likelihood of overlooking
a problem is greatly reduced. The SOAP method forces a rational
approach to the patient's problems and assists the formulation of a
logical, orderly plan of patient care (Figure 2-9). The POMR is
especially advantageous in clinics, group practices, and hospitals,
where more than one person must be able to find essential informa-
tion in the record.
DOCUMENTING IN AN ELECTRONIC HEALTH RECORD
Documentation in an EHR involves using radio buttons, drop-down
menus, and free-text boxes. The radio buttons and drop-down
menus allow for standardization of the content in the EHR and the
free-text boxes allow for the documentation of the unique circum-
stance found with each patient (Figure 2-10). It is important to
carefully review the choices made with the radio buttons and drop-
down menus. Information documented using the free-text boxes
should be proofread before submitting.
DOCUMENTING IN A PAPER HEALTH RECORD
When documenting in a paper health record the entry will always
start with the date in the MM/DD/YYYY format. The date will be
followed by the time. This may be written in standard or military
32 UNIT ONE INTRODUCTION TO MEDICAL ASSISTING

MASTER PROBLEM LIST

For use of this form, see AR 40-66; the proponent agency is the Office of The Surgeon General

MAJOR PROBLEMS
PROBLEM DATE DATE DATE
PROBLEM
NUMBER ONSET ENTERED RESOLVED

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

TEMPORARY (MINOR) PROBLEMS

PROBLEM
PROBLEM DATES OF OCCURRENCES
LETTER

A.

B.

C.

D.

E.

F.

G.

H.

PATIENT'S IDENTIFICATION (Use mechanical imprint if available; SUMMARY OF PROBLEMS, ALLERGIES, MEDICATIONS,
for typed or written entries give: Name, SSN, Unit, Sex, Birthdate, SURGERIES AND TRAUMAS:
and Duty Phone)

NOTE: DO NOT DISCARD FROM CHART

FIGURE 2-8 Aproblem list designed for a problem-oriented health record (POMR).
 CHAPTER 2 The Health Record 33

4. The person making the correction should write his or her

·--- - - -, initials or signature below the correction and the date. Follow
OIJTUrt( ,OMIAT PROOIIIIU NOTII

r:.::
-t-- I
OAfl. ..._.,.
0 A

I
- the format indicated in the policy and procedures manual
(Figure 2-11 ).
Errors made while using the computer are corrected in the usual
I
I -- way. However, an error discovered in an entry at a later date is cor-
I rected in the same manner as for a handwritten entry. This is some-
-- - I
times called an addendum. Never attempt to alter health records
without using this specific correction procedure, because this altera-
I
·- t
I
tion of records may indicate a fraudulent attempt to cover up a
I mistake made by a staff member or the provider. Do not hide errors.
I
I -- If the error could in any way affect the patient's health and well-
being, it must be brought to the provider's attention immediately.
An EHR system will track the changes made within the record.

·- f-,.
I
I - DICTATION AND TRANSCRIPTION
With the increased use of EHRs and voice recognition software,
I
--- there is decreased need for transcription. If dictation is still done
1 in the healthcare facility the administrative medical assistant may
- -- find that transcribing the dictation is a job they perform periodically.
I Transcription can be done from handwritten notes, or more likely
~ from machine dictation. Smooth operation of the facility may
I
depend on the timely, accurate performance of assigned responsibili-
I
I ties, such as record documentation and preparation of special reports.
I

....... _...............
..,._.....,_ __ ...._.. ca., ...
I
...
.._.. ..__ ..........,_ _.,......,. ___.,_....,._
,_,,..... ......e.°""" _,....,_. · ·~·--··· - ~ . .• . ,....... w..e,11
FIGURE 2-9 SOAP progress notes: The SOAP method keeps information organized and in a logical
sequence. An actual progress note would include the provider's or medical assistant's signature or
initials after this entry. (Courtesy Bibbero Systems, Petaluma, California.)
time. If standard time is used it must be followed by AM or PM (e.g.,
2:00 PM). If military time is used it is in a four-digit format without
a colon (e.g., 1400). All entries must be written in black or blue ink
following the format designated by the healthcare facility. Documen-
tation should be in the order in which the steps were completed. If
temperature, pulse, and respiration (TPR) measurement is done it
would be documented in the "O" or Objective section of the SOAP
note starting with temperature, then pulse, and lastly respirations.
MAKING CORRECTIONS AND ALTERATIONS TO
HEALTH RECORDS
Corrections sometimes must be made to health records. The first
step is to verify the proper procedure for making corrections in the
facility's policy and procedures manual. Some providers prefer a
specific method for correcting errors in the health record. Erasing,
using correction fluid, or any other type of obliteration is never
acceptable. To correct a handwritten entry:
1. Draw a line through the error.
2. Insert the correction above or immediately after the error in
a spot where it can be read clearly.
3. If indicated by the policy and procedures manual, write
"Error" or "Err." in the margin.
Accuracy and speed are primary requisites, as is a strong grasp
of medical terminology and principles, especially anatomy and
physiology.
Dictation may be done using a machine transcription unit or a
portable transcription unit. Many healthcare facilities now use a
system that is accessed by telephone; the provider calls the system
using passwords or access codes and records the information for the
health record while speaking into the telephone. Later, employees
transcribe the information into the health record. The provider must
acknowledge and initial all transcription before it is placed in the
health record.
Voice Recognition Software
Some healthcare facilities use voice recognition software for tran-
scription. When first installed, the software requires the user to say
several sentences into the unit so that it "learns" to recognize the
user's voice. The system can be used to dictate progress notes, letters,
e-mails, and virtually any document in the healthcare facility that
needs to be created. These documents will need to be approved by
the provider before they are permanently attached to the patient's
record. Some systems have an authentication component that allows
a type of electronic signature, such as those needed for hospital
record dictation.
Transfer, Destruction, and Retention of Paper
Health Records
As with EHRs, paper health records are also classified as active, inac-
tive, and closed. A paper record system must have a system estab-
lished for regular transfer of files from active to inactive status or
possibly destruction. The expansion of records and the file space
available can influence the transfer period. Records for patients cur-
rently hospitalized may be kept in a special section for quick
34 UNIT ONE INTRODUCTION TO MEDICAL ASSISTING

--• •••rr------------•·7
or
Front Office Coding & BIiiing

Patient Charting • Calendar Correspondence If) Pallent Demographics Find Patient

Tapia, Cella B

X
rd
Fields w,th • are mandalOfy
Allergy Type • : O Medication Environmental Food

Allergen •: Amoxicillin/Clavulanate potassi.J •

Dlagnoatlca / Lab Ra ulta
RNctlon1: Anaphylaxlls Headache
Nausea Blurred Vision First Pr1MOUS Next Last
Vomiting Ditficuty Breathing Entry By Action
llehing UMnOWn
Hives OIiier
On:
RNctlon S.writy: Mild Modera Unknown
Informant: Self Confidence Laval : Ve,yReflable
Parent Modera ly Reliable
FamilyMembe< Somewhat Renabfe
Other NotR Ille

Notea:

• ill+ Cancel

Copyright O 2015

FIGURE 2-10 Documentation in an EHR is done using radio buttons, drol}"down menus, ond free-text boxes.

~ -
12 error 10/15/XXXX D. Bennett, CMA (AAMA)
10/15/XXXX 9:30 a.m. Tu11ere;ol Mantoux tee;t:~mm induration.
D. Bennett, CMA (AAMA)

FIGURE 2-11 Corrections to health records must be done in a legible manner and must be clearly understood. Always initial ond date
corrections to health records. (From Bonewit-West K: Toooy's medical assistant, ed 2, St. Louis, Saunders, 2013.)

reference and then placed in the regular active file when the patient
is discharged from the hospital. In a surgical practice, the record
frequently includes the specific date on which the patient is dis-
charged from the provider's care, and the notation is made on the
record, "Return pm" (from the Latin pro re nata, "as the occasion
arises" or "when needed"). This record may safely be placed in the
inactive file.
Most medical facilities use a year sticker on the file folder that
indicates the last year the patient visited the clinic. If the file has a
sticker showing that the patient's last visit was in 2014, and he or
she presents to the clinic on January 5, 2016, a 2016 sticker should
be placed over the one that indicates 2014. These stickers often are
included with color-coded filing systems. The medical assistant can
easily look at a group of files and see which ones need to be changed
to inactive or closed status.
Retention and Destruction
Retention and destruction guidelines are the same for paper health
records as for EHRs.
Long-Term Storage
Large healthcare facilities may find it advisable to convert their paper
health records to microfilm for storage if the facility has not yet
begun to scan documents into an EHR. If documents are stored
 CHAPTER 2 The Health Record 35

electronically, they must be regularly backed up for storage. Another

option is the transfer of paper records onto optical disks. Microfilm
and optical disk technology are both expensive and probably are not
practical for any but a very large group practice or health mainte-
nance organization, so the facility should be moving toward some
form of electronic storage. Using that method, health records can be
kept indefinitely.

CRITICAL THINKING APPLICATION 2-7

Susan learned about SOAP documentation in school and is eager to use it
in her new job. Dr. Thomas is seeing a patient that reports to Susan that
she has had nausea and vomiting for the past 3 days. Susan obtains a
weight of 132.5 pounds, temperature (T): 101.2° Ftympanically, pulse
(P): 94 beats/min, respiration (R): 14 breaths/min, and blood pressure
(BP) 122/84 mm Hg in the right arm. What information would be docu-
mented in the Subjective field? What information would be documented in
the Objective field? Who would document information in the Assessment
field?

FILING EQUIPMENT
The vertical, four-drawer steel filing cabinet, used with manila
folders with the patient's name on the tab, was the traditional system
of choice for years. The most popular system today is color-coding
on open horizontal shelves. Rotary, lateral, compactable, and auto-
mated files also are available. Some records are kept in card or tray
files. Some factors that should be considered when selecting filing
equipment are:
• Office space availability
• Structural considerations
• Cost of space and equipment
• Size, type, and volume of records
• Confidentiality requirements
• Retrieval speed
• Fire protection
• Cost
Drawer Files
Drawer files should be full suspension; they should roll easily, close
securely, and be equipped with a locking device. The best cabinets
have a center trough at the bottom of each drawer with a rod for
holding divider guides. A drawback of the vertical four-drawer files
is that only one person can use a file cabinet at a time. Filing also is
slower, because the drawer must be opened and closed each time a
file is pulled or filed.
File cabinets are heavy and can tip over, causing serious damage
or injury unless reasonable care is taken. Open only one file drawer
at a time, and close it when the filing has been completed. A drawer
left even slightly open can injure a passerby.
Horizontal Shelf Files
Shelf files should have doors that lock to protect the contents. A
popular type of shelf file has doors that slide back into the cabinet;
the door from a lower shelf may be pulled out and used for work
space. Open shelf units hold files sideways and can go higher on the
FIGURE 2-12 Open shelf filing is an efficient method, especially for color1:oded filing systems.
The shelf doors often can be used as workspace.
wall because no drawers need to be pulled out (Figure 2-12).
File retrieval is faster, because several individuals can work
simultaneously.
Rotary Circular Files
Rotary circular files can hold a large volume of records. They save
space and clerical motion. The files revolve easily; some have push-
button controls. Several people can work at one rotary file and use
records at the same time. One disadvantage is that they afford less
privacy and protection than files that can be closed and locked.
Compactable Files
An office with little space and a great volume of records might use
compactable files, which are a variation of open shelf files. The files
are mounted on tracks in the floor, and the units slide along the
tracks so that access is gained to the needed records. One drawback
is that not all records are available at the same time.
Automated Files
Automated files are very expensive initially and require more main-
tenance than other types of filing equipment. They are likely to be
found only in very large facilities, such as clinics or hospitals. These
files bring the record to the operator instead of the operator going
to the record. When the operator presses a button indicating the
appropriate shelf, the shelf automatically moves into position in
front of the operator for record retrieval. The automated or power
file is fast and can store large numbers of records in a small amount
of space. However, only one person can use the unit at one time.
Card Files
Almost every office has some occasion to use a card file. This may
be for patient ledgers, a patient index, a library index, an index of
36 UNIT ONE INTRODUCTION TO MEDICAL ASSISTING
surgical tray setups, telephone numbers, or numerous other records.
A good-quality steel box or tray is a sound investment.
FILING SUPPLIES
Divider Guides
Each file drawer or shelf should be equipped with plenty of dividers
or guides. Some authorities recommend one guide for approximately
each I½ " of material, or every eight to 10 folders. Guides should be
of good-quality pressboard or strong plastic. Less-well-constructed
guides soon become bent and frayed and have to be replaced. Divider
guides have a protruding tab, which may be an integral part of the
card or may be made of metal or plastic. The guides reduce the area
of search and serve as supports for the folders. They are available
in single, third, or fifth cut (i.e., one, three, or five different
positions).
Outguides
Outguides are made of heavyweight cardboard or plastic and are
used to replace a folder that has been removed temporarily (Figure
2-13). They may also have a large pocket to hold any filing that may
come in while the folder is out. They should be of a distinctive color
for quick detection. This makes refiling simpler and alerts the file
clerk that a file is missing. Several colors may be used, each color
designating the temporary location of the file. The outguide may
have lines for recording information, or it may have a plastic pocket
for inserting an information card.
File Folders
Most records to be filed are placed in covers or tabbed folders. The
most commonly used is a general purpose, third-cut manila folder
FIGURE 2-13 Outguides allow tracking of afile not in its proper location by providing information on the location of the file. (Courtesy Bibber•
Systems, Petaluma, California.)
that may be expanded to ¾". These are available with a double-
thickness, reinforced tab, which greatly extends the life of the folder.
Folders kept in drawers have tabs at the top; those kept on shelves
have tabs at the side. Many folder styles are available for special
purposes.
The vertical pocket, which is of heavier weight than the general
purpose folder, has a front that folds down for easy access to contents
and is available with up to a 3½" expansion. These are used for bulky
histories or correspondence.
Hanging, or suspension, folders are made of heavy stock and
hang on metal rods from side to side in a drawer. They can be used
only with files equipped with suspension equipment.
Binder folders have fasteners that are used to bind papers in the
folder. These offer some security for the papers, but filing the materi-
als is time-consuming.
The number of papers that will fit in one folder depends on the
thickness of the papers and the capacity of the folder. Near the
bottom edge of most folders are one or more score marks, which
should be used as the contents of the folders expand. Papers should
never protrude from the folder edges, and they should always be
inserted with their tops to the left. When papers start to ride up in
any folder, the folder is overloaded.
Labels
The label is a necessary filing and finding device. Use labels to iden-
tify each shelf, drawer, divider guide, and folder. A label on the
drawer or shelf identifies the nature of its contents. It should also
indicate the range (i.e., alphabetic, numeric, or chronologic) of the
material filed in that space.
The label on the divider guide identifies the range of folder head-
ings following that divider guide up to the next divider (e.g., BaBo).
 CHAPTER 2 The Health Record 37

The label on the folder identifies the contents of that folder only.
This may be the name of the patient, subject matter of correspon-
dence, a business topic, or anything at all that needs to be filed. Label
a folder when a new patient is seen, existing folders are full, or
materials need to be transferred within the filing system.
Labels are available in almost any size, shape, or color to meet
the individual needs of any facility. Visit an office supply Web site
and review the catalogs to find the best product to meet the needs
of the facility.
A narrow label applied to the front of the folder tab is the easiest
to use and satisfactory for folders kept in a drawer file. Labels for
shelf filing should be identifiable from both front and back. Always
type the label before separating it from the roll or protective sheet.
Type the caption on the label in indexing order (Procedure 2-3).
Indexing Rules
Indexing rules (Table 2-2) are standardized and based on current
business practices. The Association of Records Managers and Admin-
istrators takes an active part in updating these rules. Some establish-
ments adopt variations of these basic rules to accommodate their
needs. In any case, the practices need to be consistent within the
system.
1. Last names are considered first in filing; then the given name
(first name), second; and the middle name or initial, third.
Compare the names beginning with the first letter of the
name. When a letter is different in the two names, that letter
determines the order of filing.
2. Initials precede a name beginning with the same letter.
This illustrates the librarian's rule, "Nothing comes before
something."
3. With hyphenated personal names, the hyphenated elements,
whether first name, middle name, or surname, are consid-
ered to be one unit.
4. The apostrophe is disregarded in filing.
5. When indexing a foreign name in which you cannot distin-
guish between the first and last names, index each part of
the name in the order in which it is written. If you can make
the distinction, use the last name as the first indexing unit.
6. Names with prefixes are filed in the usual alphabetic order,
with the prefix considered part of the name.

TABLE 2-2 Applying Indexing Rules

INDEXING RULE NAME UNIT 1 UNIT 2 UNIT 3
1 Robert F. Grinch Grinch Robert F.
R. Frank Grumman Grumman R. Frank
2 J. Orville Smith Smith J. Orville
Jason 0. Smith Smith Jason 0.
3 M. L. Saint-Vickery Saint-Vickery M. L.
Marie-Louise Taylor Taylar Marielouise
4 Charles S. Anderson Anderson Charles S.
Anderson's Surgical Supply Andersons Surgical Supply
5 Ah Hap Akee Akee Ah Hap
6 Alice Delaney Delaney Alice
Chester K. Delang Delong Chester K.
7 Michael St. Jahn Stjohn Michael
8 Helen M. Maag Maag Helen M.
Frederick Mabry Mabry Frederick
James E. MacDonald Macdonald James E.
9 Mrs. John L. Doe (Mary Jones) Doe Mary Jones (Mrs. John L.)
10 Prof. John J. Breck Breck John J. (Prof.)
Madame Sylvia Madame Sylvia
Sister Mary Catherine Sister Mary Catherine
Theodore Wilson, MD Wilson Theodore (MD)
11 Lawrence W. Jones, Jr. Jones Lawrence W. (Jr.)
Lawrence W. Jones, Sr. Jones Lawrence W. (Sr.)
12 The Moore Clinic Moore Clinic (The)
38 UNIT ONE INTRODUCTION TO MEDICAL ASSISTING
7. Abbreviated parts of a name are indexed as written if that
form generally is used by that person.
8. Mac and Mc are filed in their regular place in the alphabet.
If the files have a great many names beginning with Mac or
Mc, some offices file them as a separate letter of the alphabet
for convenience.
9. The name of a married woman, who has taken her husband's
last name, is indexed by her legal name (her husband's
surname, her given name, and her middle name or maiden
surname). There should be a cross-reference, such as an
•;;m,amj;jfj• Create and Organize a Patient's Paper Health Record
Goal: Create apaper health record for anew patient. Organize health record documents in apaper health record.
EQUIPMENT and SUPPLIES
• End tab file folder
• Completed patient registration form
• Divider sheets with different color labels (4)
• Progress note sheet (l)
• Name label
• Color-coding labels (first twa letters of last name and first letter of first
name)
• Year label
• Allergy label
• Black pen or computer with word processing software to process labels
• Health record documents (i.e., prior records, laboratory reports)
• Hole puncher
PROCEDURAL STEPS
1. Obtain the patient's first and last name.
PURPOSE: To customize the record for the patient, the first and last name
will be required.
2. Neatly write or word process the patient's name on the name label. Left-
justify the last name, followed by a comma, the first name, middle initial
and a period (e.g., Smith, Mary J.).
PURPOSE: The label should be easy to read. The last name always comes
before the first name.
3. Adhere the name label to the bottom left side of the record tab. When
the record is held by the main fold in your left hand, the writing should
be easy to read. (For directional purposes, assume the record main fold
is on the left and the tab is at the bottom.)
4. Put the color-coding labels on the bottom right edge of the folder. Start
by placing the first letter of the last name at the farthest right edge.
Working left, place the second letter of the last name, then the first letter
of the first name, and lastly the year label. The year label should be close
to the name label.
PURPOSE: When the folders are in the file cabinet, the folders are sorted
by the colored labels, starting with the top label (first letter of the last
name), followed by the second and remaining labels.
outguide placed where her maiden name falls directing you
to her new name.
10. When followed by a complete name, titles may be used as
the last filing unit if needed to distinguish the name from
another, identical name. Titles without complete names are
considered the first indexing unit.
11. Terms of seniority or professional or academic degrees are
used only to distinguish the name from an identical name.
12. Articles (e.g., the, a) are disregarded in indexing.
S. Place the allergy label on the front of the record. If allergies are known,
clearly write the allergy on the label in red ink.
6. Place the divider labels on the record divider sheets, if they come sepa-
rately. Ensure the labels on the divider sheets are staggered so they do
not overlap. Print the name of the section on the front and back of the
label. The print should be easy to read when the record is held by the
main fold. (Suggested names for dividers: Progress Notes, Laboratory,
Correspondence, and Miscellaneous.)
PURPOSE: Placing divider labels on the divider sheets in a staggered
pattern allows the provider to easily see all sections of the health record.
7. Using the prongs on the left-hand side of the record, secure the registration
form.
PURPOSE: The registration form should be in an easy-to-find location in
the record.
8. Using the prongs on the right-hand side of the record, secure the index
dividers with a progress note sheet under the progress note tab.
PURPOSE: The provider will need the progress note sheet to document
data regarding the visit.
Scenario: The patient authorized his/her prior provider to send health records
to your agency. You need to organize these records within the paper health
record.
9. Verify the name and the date of birth on the health records and ensure
they match the information on the health record.
PURPOSE: Before organizing and filing documents in a patient's health
record, it is critical to ensure the health record is for the correct patient.
10. Open the prongs on the right side of the record and carefully remove the
record to the point of where the documents need to be inserted. For the
documents being inserted, punch holes in the proper location. Insert
the papers into the record and then reassemble the remaining part of the
record. Continue to do this until all the documents are filed within the
health record.
PURPOSE: Documents need to be placed in the correct location in the
record so the provider can easily find information.

FILING METHODS
The three basic filing methods used in healthcare facilities are:
• Alphabetic by name
• Numeric
• Subject
Patients' records are filed either alphabetically by name or by one
of several numeric methods. Subject filing is used for business
records, correspondence, and topical materials.
Alphabetic Filing
Alphabetic filing by name is the oldest, simplest, and most com-
monly used system. It is the system of choice for filing patients'
records in most small providers' offices.
The alphabetic system of filing is traditional and simple to set up,
requiring only a file cabinet or shelf, folders, and some divider guides
(Procedure 2-4). It is a direct filing system in that the person filing
needs to know only the name to find the desired file. Alphabetic
filing does have some drawbacks:
• The correct spelling of the name must be known.
• As the number of files increases, more space is needed for each
section of the alphabet. This results in periodic shifting of
folders to allow for expansion.
• As the files expand, more time is required for filing or retriev-
ing each folder because of the greater number of folders
involved in the search. The time can be greatly reduced by
color-coding.
Numeric Filing
Some form of numeric filing combined with color and shelf filing
is used by practically every large clinic or hospital. Management
consultants differ in their recommendations; some recommend
numeric filing only if more than 5,000 to 10,000 records are
involved. Others recommend nothing but numeric filing. Numeric
filing is an indirect filing system, or one that requires use of an
•;;mMmmfii File Patient Health Records
Goal: File patient health records using two different filing systems: the alphabetic system and the numeric system.
Scenario: The agency utilizes the alphabetic system. You need to file health records in the correct location.
EQUIPMENT and SUPPLIES
• Paper health records using the alphabetic filing system
• Paper health records using the numeric filing system
• File box(es) or file cabinet
PROCEDURAL STEPS
1. Using alphabetic guidelines, place the records to be filed in alphabetic order.
PURPOSE: Placing the records in alphabetic order before filing in the box
or cabinet will make the filing process more efficient.
CHAPTER 2 The Health Record 39
alphabetic cross-reference to find a given file. Some object to this
added step and overlook the advantages of numeric filing, which are:
• It allows unlimited expansion without periodic shifting of
folders, and shelves usually are filled evenly.
• It provides additional confidentiality to the record.
• It saves time in retrieving and filing records quickly. One
knows immediately that the number 978 falls between 977
and 979. By contrast, an alphabetic system, even with color-
coding, requires a longer search for the exact spot.
Several types of numeric filing systems can be used. In the
straight, or consecutive, numeric system, patients are given consecu-
tive numbers as they first start using the practice. This is the simplest
numeric system and works well for files of up to 10,000 records. It
is time-consuming, and the chance for error is greater, when docu-
ments with five or more digits are filed. Filing activity is greatest at
the end of the numeric series.
In the terminal digit system, patients also are assigned consecutive
numbers, but the digits in the number usually are separated into
groups of twos or threes and are read in groups from right to left
instead of from left to right. The records are filed backward in
groups. For example, all files ending in 00 are grouped together first,
then those ending in O1, and so on. Next the files are grouped by
their middle digits so that the 00 22s come before the O1 22s. Finally,
the files are arranged by their first digits, so that O1 00 22 precedes
02 00 22.
Middle-digit filing begins with the middle digits, followed by the
first digit, and finally by the terminal digits. Numeric filing requires
more training, but once the system has been mastered, fewer errors
occur than with alphabetic filing.
CRITICAL THINKING APPLICATION 2-8
Susan is unsure whether alphabetic or numeric filing is best in the healthcare
facility. What are some advantages and disadvantages of each method?
2. Using the file box or file cabinet, locate the correct spot for the first file.
3. Place the health record in the correct location. Continue these filing steps
until all the health records are filed.
4. Using numeric guidelines, place the records to be filed in numeric order.
PURPOSE: Placing the records in numeric order before filing in the box or
cabinet will make the filing process more efficient.
S. Using the file box or file cabinet, locate the correct spot for the first file.
6. Place the health record in the correct location. Continue these filing steps
until all the health records are filed.
40 UNIT ONE INTRODUCTION TO MEDICAL ASSISTING

Subject Filing
Subject filing can be either alphabetic or alphanumeric (e.g., A 1-3,
B 1-1, B 1-2, and so on) and is used for general correspondence.
The main difficulty with subject filing is indexing, or classifying; that
is, deciding where to file a document. Many papers require cross-
referencing. An example would be if you had a subject folder for
Laboratory Supplies and the same organization provides you with
your General Medical Supplies; there should be a notation in the
Laboratory Supplies folder stating to See Also General Medical Sup-
plies and vice versa. All correspondence dealing with a particular
subject is filed together. The papers in the folders are filed chrono-
logically with the most recent on top. The subject headings are
placed on the tabs of the folders and filed alphabetically.

Color-Coding
When a color-coding system is used, both filing and finding files is
easier, and misfiling of folders is kept to a minimum. The use of
color visually restricts the area of search for a specific record. A
misfiled record is easily spotted even from a distance of several feet.
In color-coding, a specific color is selected to identify each letter of
the alphabet. Any selection of colors may be used, and the division
of the alphabet is determined by one's own needs. However, studies
have shown that the frequency with which different letters occur
varies widely.
Alphabetic Color-Coding
As medicine continues to consolidate into larger facilities with more
patients in one system, the filing of patients' records becomes more
complicated, and color-coding becomes more useful. Several color-
coding systems use two sets of 13 colors: one set for letters A to M,
and a second set of the same colors on a different background for
letters N to Z.
Many ready-made systems are available for use. Self-adhesive,
colored letter blocks with either two or three letters in the specific
colors are supplied in rolls. The color blocks with the appropriate
letter are placed on the index tab of the folder, along with the
patient's full name. The letters are in pairs so that they can be seen
from either side of the record. Strong, easily differentiated colors are
used, creating a band of color in the files that makes spotting out-
of-place folders easy (Figure 2-14).
Numeric Color-Coding
Color-coding is also used in numeric filing. Numbers O through 9
are each assigned a different color. In a terminal digit filing system,
the colors for the last two numbers are affixed to the tab. If the
number 1 is red and 5 is yellow, all files with numbers ending in 15
have a red and yellow band. Usually a predetermined section of the
number is color-coded.
FIGURE 2-14 With color-rnding of patients' records, a misplaced file is easily spotted. (Courtesy
Bibbero Systems, Petaluma, California.)
by a special color tab; and brightly colored labels on the outside of
a patient's record can indicate certain health conditions, such as drug
allergies. In a partnership practice, a different color folder or label
may identify each provider's patients. Color also can be used to dif-
ferentiate dates: one color for each month or year.
The use of color in filing is limited only by the imagination. One
word of caution: Every person in the facility who uses the files must
know the key to the coding, and the key should also be written in
the facility's policy and procedures manual.
ORGANIZATION OF FILES
Providers find studying a disorganized patient record very difficult.
Some systematic method must be followed in placing items in the
patient folder. From the filing standpoint, it should be emphasized
that when a patient record is not in actual use, it should be in only
one place-the filing cabinet or on the shelf. Many precious hours
can be lost searching for misplaced or lost records carelessly left
unfiled.
The patient's full name, in indexing order, should be typed on a
label and the label attached to the folder tab. A strip of transparent
tape can be placed on the label to prevent smudging. The patient's
full name should also be typed on each sheet in the folder. Some of
the types of records common to the healthcare setting, other than
patient records, include health-related correspondence, general cor-
respondence, practice management files, miscellaneous files, and
tickler or follow-up files.

Other Color-Coding Applications Health-Related Correspondence

Color can work in many other ways for the efficient healthcare facil-
ity. Small tabs in a variety of colors can be used to identify certain
types ofinsured patients and other specific information. For example,
a red tab over the edge of the folder may identify a patient on Medi-
care; a blue tab may identify a Medicaid patient; a green tab may
identify a workers' compensation patient; matching tabs may be
attached to the insured's ledger card; research cases may be identified
Correspondence pertaining to patients' health should be filed in the
patient's health record. Other medical correspondence should be
filed in a subject file.
General Correspondence
The provider's office operates as both a business and a professional
service. Correspondence of a general nature pertaining to the

operation of the office is part of the business side of the practice.
Usually, a special drawer or shelf is set aside for the general corre-
spondence. The correspondence is indexed according to subject
matter or the names of the correspondents. The guides in a subject
file may appear in one, two, or three positions, depending on the
number of headings, subheadings, and subdivisions.
Practice Management Files
Of course, the most active financial record is the patient ledger. In
facilities that still use a manual system, this is a card or vertical tray
file, and the accounts are arranged alphabetically by name. At least
two divisions are used: active accounts and paid accounts.
Miscellaneous Files
Papers that do not warrant an individual folder are placed in a mis-
cellaneous folder. In that folder, all papers relating to one subject or
with one correspondent are kept together in chronologic order, with
the most recent on top, and then filed alphabetically with other
miscellaneous material. Related materials may be stapled together.
Never use paper clips for this purpose. When as many as five papers
accumulate with one correspondent or subject, a separate folder
should be prepared. Other business files include records of income
and expenses, financial statements, income and payroll tax records,
canceled checks, and insurance policies. These papers may be filed
chronologically.
Tickler or Follow-Up Files
The most frequently used follow-up method is a tickler file, so called
because it tickles the memory that something needs to be done or
followed up on a particular date. The tickler file is always a chrono-
logic arrangement. In its simplest form, it consists of notations on
the daily calendar. If information, such as an x-ray report or labora-
tory report, is expected about a patient with an appointment to come
in, the medical assistant might make a note on the calendar or tickler
file a day ahead to check on whether the report has arrived.
The tickler file can be a part of a computerized health record
system or could be as simple as an e-mail sent to oneself. Many
people put reminders on their cell phones using an application (app)
specially designed for memos and reminders. The tickler file could
also be a card file; 12 guides, one for each month, are placed at the
front of the cabinet, container, or other object used to hold the
folders. Notations of actions to be taken are placed behind the guides
for specific days of the current month. Notations for future months
are placed behind the guide for that month. To be effective, the
tickler file must be checked first thing each day.
The tickler file can be used in many ways. It is a useful reminder
of recurring events, such as payments, meetings, and so forth. On
the last day of each month, all the notations from behind the next
month's guide are distributed among the daily numbered guides,
and the guide for the month just completed is placed at the back of
the file.
CRITICAL THINKING APPLICATION 2-9
Susan is responsible for checking the tickler file daily. What types of docu-
ments and duties might she find inside these files?
CHAPTER 2 The Health Record 41
Transitory or Temporary File
Many papers are kept longer than necessary because no provision is
made for segregating those with a limited usefulness. This situation
can be prevented by having a transitory or temporary file. For
example, if a medical assistant writes a letter requesting a reprint of
the new patient brochure, the file copy is placed in the transitory
folder until the reprint is received. When the reprint is received, the
file copy is destroyed. The transitory file is used for materials with
no permanent value. The paper may be marked with a T and
destroyed when the action is completed.
CLOSING COMMENTS
Just as in every aspect of the medical profession, advances in health
records management are occurring rapidly, allowing providers and
other caregivers to perform their duties more efficiently and accu-
rately. A medical assistant must constantly be willing to learn and to
adapt to changes arising from legislation and technologic advances.
Computers have become generally accepted as a means of recording
health information.
A primary goal of all healthcare facilities is to provide efficient,
high-quality patient care. The EHR system can help the staff reach
that goal. In the future, every provider's office, hospital, pharmacy,
and healthcare facility may be able to access information in minutes,
which will improve patient care and save lives. Stay abreast of news
and articles related to EHR systems. Remember, the healthcare
industry is one of constant growth and learning, and today's infor-
mation technology provides the medical assistant with endless
opportunities to make that growth rewarding and applicable to your
current position.
Patient Education
Patients worry about the security of their information, particularly
about who can access it. Lawsuits often are filed when patients dis-
cover that an unauthorized person has accessed their PHI. The
medical assistant should listen to a patient's concerns and explain
the safety procedures that apply to the EHR in language the patient
can understand. Some facilities prepare a brochure to explain the
conversion process to the patient and the advantages of the EHR
system.
The medical assistant should expect hesitation and even reluc-
tance from patients who are concerned about the privacy of their
health information. Patients are concerned about lack of control over
who views their records. Be prepared to answer their questions about
the safety of their records as related to the EHR. The medical assis-
tant must know how the EHR is protected and what security mea-
sures are in place to be able to reassure the patients that their records
are protected at all times.
Legal and Ethical Issues
The authority to release information from the health record lies
solely with the patient unless such a release is required by law
through a subpoena duces tecum. Ownership of the record often
is a subject of controversy. The record belongs to the provider; the
information belongs to the patient.
Remember that the EHR system contains information that is
confidential at all times. The patient must authorize the release of
 42 UNIT ONE INTRODUCTION TO MEDICAL ASSISTING
health information in electronic form, just as if it were a piece of
paper. EHR systems must:
• Maintain the security and confidentiality of data
• Be easily retrievable
• Have safeguards against the loss of information
• Protect patients' rights to confidentiality and privacy
• Require identification and authentication for access
By supporting these requirements, the medical facility remains
in compliance with applicable laws and gains the trust of pa-
tients, who are reassured that their health information is secure
and safe.
i-iiiiit+i;it•jii#it+i;l1•i
Susan looks forward to attending her medical assisting classes each day and
works diligently to perform to the best of her ability in the classroom. She
strives to do well on each procedure check-off and each examination she
completes. Her instructors provide excellent feedback and appreciate her con-
tributions to the class.
Susan has the attitude that everything she is allowed to do in the healthcare
facility is a learning tool. She regularly asks for additional responsibilities and
is always ready to assist a co-worker. Dr. Thomas has recognized that she has
the desire to learn, and he gives her many opportunities to glean more knowl-
edge through the everyday activities in the office.
Although she is new to the medical profession, Susan learns quickly and
thinks logically. She knows the rules and regulations on patient confidentiality
and is always careful about the information she provides to those who
request it. She is never hesitant about asking her office manager for guid-
ance if she is unsure about any aspect of her duties. Susan is understanding
and respectful when patients are concerned about their privacy. Her confi-
dence and warm personality play a role in the trust she earns from the
patients at the clinic.
SUMMARY OF LEARNING OBJECTIVES
l. Define, spell, and pronounce the terms listed in the vocabulary.
Spelling and pronouncing terms correctty bolster the medical assistant's
credibility. Knowing the definition of these terms promotes confidence in
communication with patients and co-workers.
2. Name and discuss the two types of patient records.
The two major types of patient records are the paper health record and
the electronic health record (EHR). The EHR is much more efficient
than the paper record and most healthcare facilities have switched to
EHRs for a number of reasons.
Professional Behaviors
Once the medical assistant has been trained an the EHR system and has
had the opportunity to use it for a time, daily use should become second
nature. In fact, it may be difficult to imagine a workday without the
system! By being open to change and willing to learn, the medical assistant
can set a good example for all employees and will be more receptive to
the process of change. Be encouraging to other staff members while train-
ing on the system, and if technology comes easily to you, share your
knowledge with others and assist wherever possible. Do not expect to
master the system in a week; instead, realize that a new system has a
learning curve and be patient with and receptive to the educational process.
Keep technical support phone numbers handy and feel free to use them
whenever a new or complicated issue arises. Work as a team, and if pos-
sible, help others who might find learning the system more of a struggle.
Above all, while getting used to the new technology, make sure your
attitude is one of enthusiasm, interest, and curiosity.
Susan is willing to admit when she has made an error and has sought advice
from Dr. Thomas and her office manager when an error needed correction.
Although filing is not one of her favorite duties, she can be counted on to do
her best while completing this important task. She realizes that filing is critical
because the documents in the patient's health record direct the care provided
to the patient. An abnormal laboratory report that is missing can make a crucial
difference in the patient's care. She takes pride in her work and is efficient and
accurate where health records are concerned. When she is faced with a task
new to her, she considers it a learning experience and asks for help if she is
not completely sure about the way to handle a situation.
Susan's co-workers are supportive and always willing to assist her as she
learns to be the best medical assistant she can be. Her future as a professional
medical assistant certainly holds opportunity and chances for advancement. Just
as important, patients trust her. She has alleviated patients' concerns about
EH Rs by taking the time to explain privacy policies and exactly what information
will be accessible to third parties. This trust also gives patients the confidence
to reveal personal information and to know that it will be held in the strictest
confidence, not just by Susan, but by each employee in the provider's office.
3. State several reasons that accurate health records are important.
Health records must be accurate primarily so that the correct care can be
given to the patient. The record also helps ensure continuity of care
between providers so that no lapse in treatment occurs. The record serves
as indication and proof in court that certain treatments and procedures
were performed on the patient; therefore, it can be excellent legal
support if it is well maintained and accurate. Health records also aid
researchers with statistical information.

SUMMARY OF LEARNING OBJECTIVES-continued
4. Differentiate between subjective and objective information in creat-
ing a patient's health record.
Subjective information is provided by the patient, whereas objective
information is provided by the provider. Examples of subjective inform •·
tion include the patient's address, Social Security number, insurance
information, and description of what he or she is experiencing. Objective
information is obtained through the provider's questions and observations
made during the examination.
Refer to Procedure 2-1 to see how to create a patient's health record
and register a new patient in practice management software.
5. Explain who owns the health record.
The provider owns the physical health record, but the patient controls the
information contained in it.
6. Distinguish between an electronic health record (EHR) and an elec-
tronic medical record (EMR).
The EHR is an electronic record of health-related information about an
individual that conforms to nationally recognized interoperability stan-
dards and that can be created, managed, and consulted by authorized
clinicians and staff from more than one healthcare organization. The EMR
is an electronic record of health-related information about an individual
that can be created, gathered, managed, and consulted by authorized
clinicians and staff within one healthcare organization.
7. Do the following related to healthcare legislation and EHRs:
• Explain how the American Recovery and Reinvestment Act (ARRA) of
2009 applies to the healthcare industry.
ARRA, commonly known as the Economic Stimulus Package, was
meant to promote economic recovery. The health information technol-
ogy aspects of the bill provide slightly more than $31 billion for
healthcare infrastructure and EHR investment. The sections of the
ARRA that pertain to healthcare are collectively known as the Health
Information Technology for Economic and Clinical Health (HITECH)
Act.
• Define meaningful use and relate it to the healthcare industry.
Meaningful use, defined simply, means that providers must show that
they are using EHR technology in ways that can be measured signifi-
cantly in quality and quantity. If providers meet the meaningful use
requirements, they will qualify for incentive payments.
• List the three main components of meaningful use legislation.
The three main components af meaningful use are (1) use of certified
EHR in a meaningful manner, such as e-prescribing; (2) use of certified
EHR technology for electronic exchange of health information to
improve quality of health care; and (3) use of certified EHR technol-
ogy to submit clinical quality reports, procedure and diagnosis codes,
surveys, and other measures.
8. Explore the advantages, disadvantages, and capabilities of an EHR
system, and explain how to organize a patient's health record.
Advantages of the EHR include: reduction of errors, reduction of costs,
reduction of staffing needs, legible documentation, easy accessibility, and
less physical storage space than paper records. Disadvantages of the EHR
CHAPTER 2 The Health Record 43
include: lack of capital, fear of something new, startup costs, and space
for equipment. Some capabilities of an EHR system include specialty
practice components, appointment scheduling features, prescription
writers, medical billing systems, charge capture, eligibility verification,
referral management, laboratory order integration, patient portals, and
many other features that vary from system to system.
Refer to Procedure 2-2 for instructions on how to organize a patient's
health record and upload documents to the EHR.
9. Discuss the importance of nonverbal communication with patients
when an EHR system is used.
Eye contact is critical when an EHR system is used with patients. Body
language must indicate that the medical assistant is open to and listening
to the patient's concerns, not just concentrating on data entry. Providers
and medical assistants alike may have to relearn how to interact with
patients in a natural way while using the laptop or tablet in the examina-
tion room. Realize that during the implementation period, processing and
serving patients may take longer because the staff is using new technol-
ogy. Most patients are understanding about this if the medical assistant
explains that a new system is in place and asks for patience. Because
patients are not always technologically sawy, most will be supportive
and interested in the EHR system.
l 0. Discuss backup systems for the EHR, as well as the transfer, destruc-
tion, and retention of health records as related to the EHR.
The provider must have a backup system for the EHR in case a medical
office is without power for asignificant amount of time. The EHR systems
can be set to automatically back up the information at specified times
during the day. This means that a minimum amount of data would be
lost if the power went out. Options include external hard drive, full server
backup, and online backup systems. In most medical offices, records are
classified in three ways: active, inactive, and closed. The process of
moving a file from active to inactive is called purging. Providers have an
obligation to retain patient records. The records of any patient covered
by Medicare or Medicaid must be kept at least 10 years.
11. Describe how and when to release health record information; discuss
health information exchanges (HIEs).
The healthcare facility must be extremely careful when releasing any type
of medical information; the patient must sign a release for information
to be given to any third party. Requests for medical information should
be made in writing. Pay particular attention to records release requests
involving a minor.
There are currently three kinds of HIE-directed exchange, query-
based exchange, and consumer-mediated exchange- and the imple-
mentation of HIE varies from state to state.
12. Identify and discuss the two methods of organizing a patient's paper
medical record.
The source-oriented medical record (SOMR) categorizes the content by
its source, such as provider, laboratory, radiology, hospital, and consulta-
tion. Within each source category the content is arranged in reverse
chronologic order so that the most recent content is viewed first.
Continued
44 UNIT ONE INTRODUCTION TO MEDICAL ASSISTING
SUMMARY OF LEARNING OBJECTIVES-continued
The problem-oriented medical record (POMR) categorizes each of the
patient's problems and elaborates on the findings and treatment plans
for all concerns. Detailed progress notes are kept for each individual
problem. This method addresses each af the patient's concerns sepa-
rately, whereas a source-oriented record may address all problems and
concerns at one time, usually covering one ta three patient concerns per
office visit. The POMR helps ensure that individual problems are all
addressed.
13. Discuss how to document information in on EHR and a paper health
record, and how to make corrections/alterations to health records.
Documenting information in an EHR involves using radio buttons, drop-
down menus, and free-text boxes. When documenting in a paper health
record, the entry will always start with the date in the MM/DD/YYYY
format. All entries must be written in black or blue ink and follow the
format designated by the healthcare facility.
To create a handwritten correction to a health record, a line should
be drawn through the error, the correction inserted above or immediately
after, and the person making the correction should write his or her initials
or signature and the date below the correction. Errors made while using
an EHR are corrected in the usual way; however, an error discovered in
an entry at alater date is corrected in the same manner as for a handwrit-
ten entry.
14. Discuss dictation and transcription, and discuss transfer, destruction,
and retention of medical records as related to paper records.
With the increased use of EHRs and voice recognition software, there is
decreased need for transcription. Transcription can be done from handwrit-
ten notes, or more likely from machine dictation. Accuracy and speed
are important. Some healthcare offices use voice recognition software
for transcription.
As with EHRs, paper health records are also classified as active,
inactive, and closed. Large healthcare facilities may find it advisable to
convert their paper health records to microfilm.
15. Identify filing equipment and filing supplies needed to create, store,
and maintain medical records.
Several types of equipment and supplies are needed to manage patients'
records. Office space availability; structural considerations; cast of space
and equipment, size, type, and volume of medical records; confidentiality
requirements; retrieval speed; fire protection; and cast should all be
considered when choosing filing equipment. Filing equipment includes:
drawer files, horizontal she~ files, rotary circular files, campactable files,
automated files, and card files. Filing supplies include divider guides,
outguides, file folders, and labels.
CONNECTIONS
CrJ Study Guide Connection: Go to the Chapter 2 Study Guide. Read and complete
the activities.
16. Describe indexing rules, and how to create and organize a patient's
health record.
Five basic steps are involved in document filing. (l) The papers are
conditioned, which is the preparatory stage for filing. (2) The documents
are released, which means they are ready to be filed because they have
been reviewed or read and some type of mark has been placed on the
document to indicate this. (3) The documents are indexed, which
involves deciding where each document should be filed and coding it with
some type of mark on the paper indicating that decision. (4) Sorting
involves placing the files in filing sequence. (5) The actual filing and
storing of the documents is the last step. Refer to Table 2-2 for indexing
rules. Refer to Procedure 2-3 for information on creating and organizing
a paper health record.
17. Discuss the pros and cons of various filing methods, as well as how
to file patient health records.
Both the alphabetic and numeric filing systems have advantages and
disadvantages. Perhaps most important is the staff's preference. Some
find it easier to retrieve files that are in standard alphabetic order,
whereas others prefer a numeric system. The numeric system is more
confidential than an alphabetic system. Some staff members prefer a
combination of the two, called the alphanumeric system. Both effectively
keep health records in good order and allow the medical assistant to spot
a misfiled record quickly.
Refer to Procedure 2-4 to see how to file patient health records.
18. Discuss organization of files, as well as health-related
correspondence.
When a patient record is not in actual use, it should only be in the filing
cabinet or on the shelf. Health-related correspondence, including general
correspondence, should be filed appropriately. Practice management files
are usually divided into active and paid accounts. Papers that do not
warrant an individual folder are placed in the miscellaneous folder.
Follow-up files are frequentty called "tickler files." Transitory (i.e., tem-
porary) files can be helpful for material with no permanent value.
19. Discuss patient education, as well as legal and ethical issues, related
to the health record.
The primary goal of all healthcare facilities is to provide efficient, high-
quality patient care. Patients worry about the security of their information
and lawsuits can be filed when patients discover that an unauthorized
person has accessed their protected health information (PHI). The author-
ity to release information from the health record lies solely with the
patient unless such a release is required by law through a subpoena duces
tecum.
evolve Evolve Connection: Go to the Chapter 2 link at evolve.elsevier.com/
kinn to complete the Chapter Review Quiz. Check out the other resources listed for this
chapter to make the most of what you have learned from The Health Record.
INFECTION CONTROL
i-i#it45t•i
Rosa Lucia is a certified medical assistant working in a pediatric practice with
several physicians. She is quite concerned about contracting an infectious
disease while caring for her patients. Rosa learned about Standard Precautions
while enrolled in her medical assisting program and now must implement that
While studying this chapter, think about the following questions:
• How can Rosa achieve these goals?
• What is the significance of an Exposure Control Plan in Rosa's pediatric
office?
• What are the important details of the office's compliance with the
guidelines established by the Occupational Safety and Health
Administration (OSHA)?
LEARNING OBJECTIVES
1. Define, spell, and pronounce the terms listed in the vocabulary.
2. Describe the characteristics of pathogenic microorganisms.
3. Do the following related to the chain of infection:
• Apply the chain of infection process to healthcare practice.
• Compare viral and bacterial cell invasion.
• Differentiate between humoral and cell-mediated immunity.
4. Summarize the impact of the inflammatory response on the body's
ability to defend itself against infection.
5. Analyze the differences among acute, chronic�atent, and opportunistic
infections.
6. Do the following related to OSHA standards for the healthcare setting:
• Specify potentially infectious body fluids.
• Integrate OSHA's requirement for a site-based Exposure Control
Plan into facility management procedures.
• Explain the major areas included in the OSHA Compliance
Guidelines.
• Discuss protocols for disposal of biologic chemical materials.
7. Remove contaminated gloves while following Standard Precautions
principles.
3
knowledge in the workplace. Two important factors in preventing the spread of
infection are (l) understanding how to break the chain of infection and (2)
recognizing the importance of correct and frequent hand washing.
• How can Rosa implement reQuired infection control procedures in the
pediatric office?
8. Perform an eye wash procedure to remove contaminated material.
9. Summarize the management of postexposure evaluation and follow-up
and participate in blood-borne pathogen training and a mock exposure
event.
10. Identify the regulations established by the Centers for Disease Control
and Prevention (CDC) that affect healthcare workers.
11. Apply the concepts of medical and surgical □sepsis to the healthcare
setting.
12. Discuss proper hand washing, and demonstrate the proper hand­
washing technique for medical □sepsis.
13. Differentiate among sanitization, disinfection, and sterilization
procedures and select barrier/personal protective equipment while
demonstrating the correct procedure for sanitizing contaminated
instruments.
14. Discuss the role of the medical assistant in □sepsis.
15. Apply patient education concepts to infection control.
16. Discuss legal and ethical concerns regarding medical □sepsis and
infection control, and perform compliance reporting based on public
health statutes covering reportable communicable diseases.
46 UNIT ONE INTRODUCTION TO MEDICAL ASSISTING
VOCABULARY
anaphylaxis (an-uh-fuh-lak' -sis) An exaggerated hypersensitivity
reaction that in severe cases leads to vascular collapse,
bronchospasm, and shock.
antibodies (an'-ti-bah-dees) Immunoglobulins produced by the
immune system in response to bacteria, viruses, or other
antigenic substances.
antigen (an'-ti-juhn) A foreign substance that causes the
production of a specific antibody.
antiseptics (an-ti-sep'-tiks) Substances that inhibit the growth of
microorganisms on living tissue (e.g., alcohol and povidone-
iodine solution [Betadine]); they are used to cleanse the skin,
wounds, and so on.
autoimmune (o-to-im'-yuhn) Pertaining to a disturbance in the
immune system in which the body reacts against its own tissue.
Examples of autoimmune disorders are multiple sclerosis,
rheumatoid arthritis, and systemic lupus erythematosus.
candidiasis (kan-duh-de-uh'-sis) An infection caused by a yeast
that typically affects the vaginal mucosa and skin.
coagulate (ko-ag'-yuh-late) To form into clots.
contaminated Soiled with pathogens or infectious material;
nonsterile.
disinfectant A liquid chemical that is capable of eliminating
many or all pathogens but is not effective against bacterial
spores; it cannot be used on the skin.
flora Microorganisms that live on or within the body; they
compete with disease-producing microorganisms and provide a
natural immunity against certain infections.
fomites Contaminated, nonliving objects (e.g., examination room
equipment) that can transmit infectious organisms.
germicides (jur' -muh-sides) Agents that destroy pathogenic
organisms.
hereditary (huh-re'-duh-ter-e) Pertaining to a characteristic,
condition, or disease transmitted from parent to offspring on
the DNA chain.
interferon (in' -tuhr-fir-on) A protein formed when a cell is
exposed to a virus; the protein blocks viral action on the cell
and protects against viral invasion.
T he concepts of disease transmission and the body's response to
infection form the basis for understanding the importance of
the first line of defense in preventing disease. Before we can assist in
the prevention of disease, we have to look at methods we can use to
minimize the chances of being a carrier of disease. One of the sim-
plest ways to prevent the spread of disease is to wash your hands or
use alcohol-based hand rubs. As you continue through the remainder
of this textbook, you should refer to the fundamental concepts of
this chapter when faced with an infection control issue. Because of
the need for infection control and the impact on medical practice
of the guidelines established by the Occupational Safety and Health
Administration (OSHA), every procedure must begin and end with
hand hygiene practices. The guidelines in this chapter are basic to
nosocomial infections (nos-uh-koh'-mee-uhl) Infections that are
acquired in a healthcare setting.
opportunistic infections Infections caused by a normally
nonpathogenic organism in a host whose resistance has been
decreased.
palliative (pah-lee-ah-tive) A substance that relieves or alleviates
the symptoms of a disease without curing the disease.
parenteral (puh-ren'-tuh-ruhl) The injection or introduction of
substances into the body by any route other than the digestive
tract (e.g., subcutaneous, intravenous, or intramuscular
administration).
pathogenic (path' -o-jen-ik) Pertaining to a disease-causing
microorganism.
permeable (pur' -me-uh-huh!) Allowing a substance to pass or
soak through.
pyemia (pi-em'-e-uh) The presence of pus-forming organisms in
the blood.
relapse The recurrence of the symptoms of a disease after
apparent recovery.
remission The partial or complete disappearance of the clinical
and subjective characteristics of a chronic or malignant disease.
rhinitis (rin-i'-tis) Inflammation of the mucous membranes of the
nose.
spore A thick-walled, dormant form of bacteria that is very
resistant to disinfection measures.
sterile (ster'-il) Free of all microorganisms, pathogenic and
nonpathogenic.
tinea (tin'-e-uh) Any fungal skin disease that results in scaling,
itching, and inflammation.
urticaria (uhr-tuh-kar'-e-uh) A skin eruption that creates
inflamed wheals; hives.
vectors Animals or insects (e.g., ticks) that transmit the causative
organisms of disease.
all clinical skills, and following them can reduce the transmission of
disease organisms and lessen the severity of disease. They also may
save a patient's or co-worker's life, or even your own.
DISEASE
Disease is defined as any sustained, harmful alteration of the normal
structure, function, or metabolism of an organism or cell. This
pathologic condition presents a group of clinical signs, symptoms,
and laboratory findings that set it apart as an abnormal entity,
different from other normal and pathologic conditions. We recog-
nize and categorize many types of diseases: hereditary (genetic),
drug induced, autoimmune, degenerative, communicable, and

infectious, to name only a few. Sometimes a specific disease may fit
two or more categories.
Any disease caused by the growth of pathogenic microorganisms
in the body falls into the category of infectious diseases. The entrance
of a living microbe into the body is not disease because until the
infected cell or individual shows a harmful alteration in structure,
physiology, or biochemistry, disease either is not detected or is not
considered present. In fact, a pathogen may be ingested, injected, or
inhaled and never cause disease. However, an unaffected person still
can transmit the infection to another person. In this case we call the
unaffected person a carrier.
Microorganisms are almost everywhere. We carry them on our
skin, in our bodies, and on our clothing. They can be in ice, boiling
water, the soil, and the air. The only places free of microorganisms
are certain internal body organs and tissues and sterilized medical
equipment and supplies. In the normal state, organs and tissues that
do not connect with the outside by means of mucus-lined mem-
branes are free of all living microorganisms.
Conditions Required for Microbial Growth
To grow and flourish, microbes require certain conditions. To maintain a
healthcare environment as free of pathogenic organisms as possible, the
medical assistant must prevent or eliminate as many of these growth
requirements as possible.
• Nutrients: Pathogens thrive on contaminated surtaces and equipment.
Most microbes need the same nutrients we do: carbohydrates, proteins,
and fats.
• Moisture: Microbes require moisture for cellular activities.
• Temperature: Most pathogenic microbes flourish at body temperature
(98.6°F [37°(]).
• Oxygen: Some microbes, called aerobes, require oxygen to grow and
multiply; others, called anaerobes, thrive in environments without
oxygen.
• Neutral pH: pH refers to the acid-base level of a solution on a scale of
l to 14, with 7 being neutral. Most pathogens prefer a neutral pH for
optimum growth.
THE CHAIN OF INFECTION
Certain factors are required for an infectious disease to spread. These
factors, or links, make up the chain of infection. Break the chain,
and you break the infection process (Figure 3-1 ).
The chain of infection starts with the infectious agent. Five
groups make up the potentially pathogenic agents or microorgan-
isms: viruses, bacteria, protozoa and helminths, fungi, and rickettsia.
Infection cannot occur without the presence of an infectious micro-
organism, so the best way for healthcare workers to prevent the
spread of disease is to use adequate infection control procedures,
such as consistent hand washing and proper use of antiseptics, in
addition to effective disinfection and sterilization methods.
The smallest of all pathogens, viruses, lead the list of important
disease-causing agents. Viral microorganisms are intracellular para-
CHAPTER 3 Infection Control 47
6 2
Susceptible host Reservoir host
5 3
Portal of entry Portal of exit
4
Mode of
transmission
FIGURE 3-1 The chain of infection.
sites that take over the deoxyribonucleic acid (DNA) or ribonucleic
acid (RNA) of the invaded cell. Viral invasion may not cause signifi-
cant immediate symptoms because host cells infected with viruses
can produce a substance called interferon, which protects nearby
cells. Interferon leaves the infected cell and acts somewhat like a Paul
Revere, warning neighboring cells that "a virus is coming!" The
neighboring cells then produce antiviral proteins, which prevents
the virus from replicating inside the cells, thus slowing and halting
the infection.
Antibiotics are unable to destroy viral invaders that enter a
normal cell and multiply within the cell. The only way to destroy a
viral invader is to destroy the host cell. Therefore, the treatment for
viral infections rypically focuses on relieving symptoms, or palliative
treatment, and antiviral medications that slow the rate of viral rep-
lication. Interferon and the antiviral agents acyclovir (Zovirax), vala-
cyclovir hydrochloride (Valtrex), adefovir dipivoxil (Hepsera),
penciclovir (Denavir), Oseltamivir (Tamiflu), and famciclovir
(Famvir) may be prescribed, depending on the specific viral agent.
Viral diseases include the common cold, influenza, herpes, infectious
hepatitis (e.g., hepatitis B and C), and acquired immunodeficiency
syndrome (AIDS), which is caused by the human immunodeficiency
virus (HIV).
Bacteria are tiny, simple cells that produce disease in a variety of
ways. Pathogenic bacteria can secrete toxic substances that damage
human tissues, act as parasites inside human cells, or grow on body
surfaces, disrupting normal human functions. Bacteria are classified
according to their shape, or morphology; they may be spherical
(cocci), rod shaped (bacilli), or spiral shaped (spirilla). Some bacteria
can produce resistant internal structures, called spores, that make
treatment difficult. When bacteria invade the body, the patient can
be treated in a number of ways. The most common approach is to
use antibiotics to destroy the invader or inhibit its growth. We all
have nonpathogenic bacteria that reside in various body systems; for
example, a harmless form of Escherichia coli (E. coli) lives in the large
intestine. These bacteria protect against disease by competing for
nutrients that pathogenic bacteria require to grow and multiply.
Common diseases caused by bacteria include tuberculosis, urinary
tract infections, pneumonia, and strep throat.
48 UNIT ONE INTRODUCTION TO MEDICAL ASSISTING
Antibiotic Resistance
Antibiotic resistance is one of the world's most significant public health
problems. Infectious microorganisms that once were easily treated with
antibiotics are growing increasingly resistant to the actions of these drugs.
The Centers for Disease Control and Prevention (CD() reports that at least
2 million people in the United States become infected with antibiotic-
resistant bacteria, and at least 23,000 people die each year as a direct
result of these infections. Resistance occurs when an antibiotic is used
inappropriately to treat an infection, resulting in a change or mutation of
the pathologic organism that in some way reduces or eliminates the
effectiveness of the drug.
If antibiotic medication is prescribed inappropriately (e.g., for a viral
infection) or inaccurately (e.g., lower dosage, fewer days than recom-
mended) or perhaps not taken by the patient as prescribed, some of the
bacteria that survive the initial antibiotic treatment may mutate, allowing
the microorganism to survive even in the presence of the antibiotic. Although
mutations are rare, overuse of antibiotics provides more opportunity for
them to occur. Antibiotics should be used to treat bacterial infections;
however, they are not effective against viral infections, such as the common
cold, most sore throats, and the flu. Cautious use of antibiotics is the key
to preventing the spread of resistance. The CDC recommends that
providers:
• Prescribe antibiotic therapy only when it will benefit the patient.
• Treat the patient with an antibiotic that is specific to the infecting
pathogen.
• Prescribe the recommended dose and treatment duration of the
medication.
CRITICAL THINKING APPLICATION 3-1
Susie Chen, a 3-year-old patient, is being seen today because of complaints
of a cough and nasal congestion. Susie's father does not understand why
the pediatrician did not order an antibiotic for his daughter's viral infection.
Rosa needs to reinforce the doctor's decision. How can she help the father
understand the proper use of antibiotics?
Protozoa are unicellular parasites that can replicate and multiply
rapidly once inside the host. Examples of diseases caused by protozoa
include giardiasis, which typically is caused by the ingestion of water
contaminated by feces, and malaria, in which Plasmodium organisms
invade the blood system. Protozoa! infections frequently are seen in
tropical climates, which have large insect populations. These insects
serve as vectors for many protozoa! diseases. For example, the mos-
quito transmits the organisms that cause malaria. Protozoa and hel-
minths (worms) are usually grouped together as parasites. Helminths
include tapeworms and roundworms. Tapeworms live in the intes-
tines of some animals and can be transferred to humans who eat
undercooked meat from infected animals. Most parasitic round-
worm eggs are found in the soil and enter the human body when a
person picks them up on the hands and then transfers them to the
mouth. Roundworms eventually end up or live in human intestines
and cause infection and disease.
Fungi may be unicellular or multicellular; they include such
organisms as mushrooms, molds, and yeasts. Many forms are patho-
genic and can cause disease, such as candidiasis and tinea infections.
Fungi grow best in warm, moist environments. Treatment with
antifungal agents includes application of topical preparations (e.g.,
Lotrimin) for tinea infections; vaginal suppositories (e.g., Monistat)
for candidiasis; and oral medications, such as fluconazole (Diflucan),
ketoconazole (Nizoral), and terbinafine (Lamisil). Fungal infections
also are called mycotic infections.
Rickettsiae are microorganisms that have characteristics of both
bacteria and viruses. Like viruses, they are obligate parasites that
must live within a host cell for growth; however, they are larger than
viruses, so they can be viewed with a microscope. Vectors such as
fleas, ticks, and mites usually transmit pathogenic forms of rickett-
siae. Diseases caused by rickettsiae can be treated with antibiotics;
they include Rocky Mountain spotted fever, which is transmitted by
a tick.
The second link in the chain of infection is the reservoir. Reser-
voirs may be people, insects, animals, water, food, or contaminated
instruments and equipment. Most pathogens must gain entrance
into a host or else they die. The reservoir host supplies nutrition for
the organism, allowing it to multiply. The pathogen either causes
infection in the host or, in the case of vector-borne diseases, exits
the host in great enough numbers to cause disease in another host.
The chain of infection continues with the means, or portal, of
exit; that is, how the pathogen escapes the reservoir host. Exits
include the mouth, nose, eyes, ears, intestines, urinary tract, repro-
ductive tract, and open wounds. The use of Standard Precautions
(e.g., gloves, masks, proper wound care, correct disposal of contami-
nated products, hand washing) helps control the ability of infectious
material to spread from one host to another.
After exiting the reservoir host, organisms spread by transmission.
Transmission either is direct or indirect. Direct transmission occurs
from contact with an infected person or with discharges from an
infected person, such as feces or urine. Indirect transmission occurs
from droplets in the air expelled by coughing, speaking, or sneezing;
vectors that harbor pathogens; contaminated food or drink; and/or
contact with contaminated objects (called fomites). Proper sanita-
tion of water and food; the use of sanitization, disinfection, and
sterilization procedures; and the use of germicides (e.g., Wavicide
and Cidex) help control the transmission of pathogens.
The next link in the chain of infection is the means, or portal, of
entry. This is how the transmitted pathogen gains entry into a new
host. Like the means of exit, the means of entry may be the mouth,
nose, eyes, intestines, urinary tract, reproductive system, or an open
wound. The first line of defense against pathogenic invasion is the
intact integumentary system, or skin, which serves as a mechanical
barrier to infection. Anatomic defense mechanisms also include
tears, cilia, mucous membranes, and the pH of body fluids. The
body's second line of defense includes the inflammatory process and
immune system response. The immune system responds by produc-
ing antibodies specifically designed to combat the presence of a
foreign substance, or antigen. This process is called humoral immu-
nity and is the responsibility of the body's B cells. The immune
system also reacts at the cellular level, with T-cell activity in eel/-
mediated immunity, by causing the destruction of pathogenic cells at
the site of invasion. An example of cell-mediated immunity is

phagocytosis, in which specialized immune system cells, called mac-
rophages, actually ingest and destroy pathogenic microbes.
The final link in the chain of infection is exposure of the pathogen
to a susceptible host. If the host is susceptible (i.e., capable of sup-
porting the growth of the infecting organism), the organism multi-
plies. Factors that contribute to a host's susceptibility include the
location of entry, the dose of organisms, and the individual's state of
health. Health is affected by a multitude of factors, including stress,
poor nutrition, other illnesses, and contributing lifestyle factors. If
conditions are right, the organism reaches infectious levels, and the
susceptible host can start the chain of infection all over again.
Individuals who are successfully immunized against a disease
(e.g., hepatitis B virus [HBV] infection), are not susceptible to the
disease, even if they are exposed to the pathogen, because their
immune system has created antibodies to protect them. However,
some people do not develop immunity to diseases even after follow-
ing immunization guidelines. The Centers for Disease Control and
Prevention (CDC) estimate that 1% to 5% of the time, depending
on the vaccine, individuals do not develop immunity. The provider
can check for postimmunization effectiveness by ordering an anti-
body titer. A titer is a laboratory test that measures the level of anti-
bodies in a blood sample. If a vaccine stimulated a person's immune
system to create antibodies to a disease, the antibodies will be present
in adequate amounts in the titer. If not, the physician decides
whether another dose of the vaccine should be given to try to boost
the person's immune response.
The Body's Natural Protective Mechanisms
The body has multiple levels of protection against the invasion of pathogenic
microorganisms. The following are some of these mechanisms:
• Intact skin serves as a natural barrier to disease.
• Mucous membranes lining the openings of the body help protect
underlying tissues and trap foreign substances.
• Tiny, hairlike projections, called cilia, line the respiratory tract and
move in a coordinated upward motion to expel trapped foreign
substances.
• Trapped substances can be expelled with sneezing and coughing
before the organisms invade underlying tissue.
• Some body secretions, such as tears, have antimicrobial properties
that help destroy invading pathogens.
• The natural pH of many of the body's organs discourages the growth
of microbes. The acidic pH of urine, the vaginal mucosa, and the
stomach helps prevent pathogenic invasion. The body's resident
microbes create and maintain this environment.
CRITICAL THINKING APPLICATION 3-2
Tommy Anderson, a 5-year-old patient, is seen in the office because of an
outbreak of impetigo. Rosa must apply the concepts of the chain of infection
and infection control methods to teach Tommy and his mother how to
prevent the spread of the infection to other members of the family. What
procedures should she follow after Tommy's visit to prevent the spread of
the infection to other patients, other staff members, and herself?
CHAPTER 3 Infection Control 49
THE INFLAMMATORY RESPONSE
When the body experiences trauma or is exposed to pathogens,
protective mechanisms are alerted, and the body responds in a pre-
dictable manner, called the inflammatory response (Figure 3-2). To
defend itself, the body initiates specific responses to destroy and
remove pathogenic organisms and their byproducts; or, if this is not
possible, to limit the extent of damage caused by the invading patho-
gen. This process results in the four classic symptoms of inflamma-
tion: erythema (redness), edema (swelling), pain, and heat.
When the body is exposed to an infectious agent or a foreign
substance, cellular damage occurs at the site. Inflammation media-
tors (i.e., histamine, prostaglandins, and kinins) are released, causing
three different responses at the cellular level. All three actions are
designed to increase the number of white blood cells (WBCs) at the
injury site.
First, blood vessels at the site dilate, causing an increase in local
blood flow, which results in redness (inflammation) and heat. Blood
vessel walls become more permeable, which assists in the movement
of WBCs through the vessel wall to the site. The WBCs begin to
form a fibrous capsule around the site to protect surrounding cells
from damage or infection. Blood plasma also filters out of the more
permeable vessel walls, resulting in edema (swelling), which puts
pressure on the nerves and causes pain. Finally, chemotaxis, or the
release of chemical agents, occurs, attracting even more WBCs to
the site. The increased number of WBCs at the site results in phago-
cytosis, or the engulfing and destruction of microorganisms and
damaged cells. Destroyed pathogens, cells, and WBCs collect in the
area and form a thick, white substance called pus. If the pathogenic
invasion is too great for localized control, the infection may collect
in the body's lymph nodes, where more WBCs are present to help
fight the battle. This causes swollen glands, or lymphadenopathy. If
the body is too weak or the number of pathogens is too great, the
infection may spread to the bloodstream. A systemic infection, called
septicemia or blood poisoning, may occur, which ultimately could
affect the entire body. Another term for septicemia is pyemia.
Without appropriate medical intervention, death can occur from a
systemic infection.
Cellular damage
Release of inflammation Histamine
mediators causing Prostaglandins
increased WBCs at site Kinin
Blood vessels at Blood vessel walls Chemotaxis
n
site dilate more prmeable attracts WBCs
Inflammation Heat Edema
l
Pain
Phagocytosis
FIGURE 3-2 The inflammatory response.
50 UNIT ONE INTRODUCTION TO MEDICAL ASSISTING
CRITICAL THINKING APPLICATION 3-3
Rosa's next patient appears to have a localized inflammatory response to
asplinter. What signs and symptoms should she expect the patient to show?
Rosa answers a telephone call from a patient who had surgery 3 days
ago. The patient is concerned that the incision site is red, swollen, and hot.
Is this a normal postoperative response? How might Rosa know whether
the response is abnormal?
TYPES OF INFECTIONS
Acute Infection
An acute infection has a rapid onset of symptoms but lasts a relatively
short time. The prodromal period of an acute infection is that time
when the patient first shows vague, nonspecific symptoms of disease.
For example, the person is not vomiting nor does he or she have a
fever, but the individual just doesn't feel well. In an acute viral infec-
tion, the host cell typically dies within hours or days. Symptoms
appear after the tissue damage begins. In most acute infections, such
as the common cold, the body's defense mechanisms eliminate the
virus within 2 to 3 weeks.
Chronic Infection
An infection that persists for a long period, sometimes for life, is
called a chronic infection. In the case of chronic viral hepatitis B
infection, patients are asymptomatic, or without symptoms, but the
virus is detectable with blood tests and remains transmissible
throughout the person's life. Hepatitis B infection, or serum hepati-
tis, is transmitted by blood or blood products and by all body fluids.
It is a serious health hazard to medical personnel. All individuals
employed in a healthcare setting should be immunized against hepa-
titis B. OSHA requires all employers to offer hepatitis B vaccination
to their employees.
Latent Infection
A latent infection is a persistent infection in which the symptoms
cycle through periods of relapse and remission. Cold sores and
genital herpes are latent viral infections caused by the herpes simplex
virus (HSY) types 1 and 2, respectively. The virus enters the body
and causes the original lesion. It then lies dormant, in nerve cells
away from the surface, until a certain trigger (illness with fever,
sunburn, or stress) causes it to leave the nerve cell and seek the
surface again. Once the virus reaches the superficial tissues, it
becomes detectable for a short time and causes a new outbreak at
the site. Another herpes virus, varicella-zoster virus, causes chicken-
pox (varicella). This virus may lie dormant along a nerve pathway
for years and later erupt as the painful disease shingles (herpes
zoster).
Opportunistic Infections
Opportunistic infections are caused by organisms that are not typi-
cally pathogenic but that occur in hosts with an impaired immune
system response, such as individuals infected with HIV. Over time,
the person's immune system becomes weakened, and diseases result
that are not typically seen in patients with a healthy immune system,
such as Pneumocystis carinii pneumonia and oral candidiasis.
Ebola Virus
The Ebola virus causes a type of viral hemorrhagic fever, Ebola hemorrhagic
fever (EHF). Depending on the strain and the individual infected with the
disease, EHF may be fatal in 50% to 90% of cases. Workers performing
tasks involving close contact with symptomatic individuals with EHF are at
risk of exposure. These include healthcare workers, those in mortuary and
death care, and travel service employees.
Individuals with EHF have symptoms typical of viral illnesses, including
fever, fatigue, muscle pain, headache, and sore throat. The illness pro-
gresses to nausea, vomiting, diarrhea, impaired organ function, rash, and
internal and/or external bleeding. Symptoms typically appear abruptly,
within 2 to 20 days after exposure to the virus (8 to l 0 days is most
common). EHF is believed to be contagious only when symptoms appear,
and the illness runs its course within 14 to 20 days of symptom onset.
In areas of Africa where Ebola viruses are common, suspected reservoirs
include primate and bat populations. Naturally occurring EHF outbreaks are
believed to start from contact with infected wildlife (alive or dead) and
then spread from person to person through direct contact with body fluids,
such as blood, urine, sweat, semen, breast milk, vomit, and feces. The
infection is spread when body surfaces that can easily absorb blood-borne
pathogens (e.g., open cuts, scrapes, or mucous membranes such as the
lining of the mouth, eyes, or nose) come into direct contact with infectious
blood or body fluids. There is currently no treatment, antiviral therapy, or
approved vaccine for EHF or Ebola virus.
The risk of infection with Ebola virus is minimal if a person has not
been in close contact with the body fluids of someone sick with or recently
deceased from EHF. Although there are no known animal reservoirs of the
disease in the United States, the possible spread of EHF is a concern
because of the availability and reach of global travel. Under certain condi-
tions, exposure to just one viral particle can result in the development of
EHF.
Ambulatory care facilities may develop policies and procedures to
manage patients who report that they have recently travelled to areas
where Ebola infections have occurred. The CDC recommends the following
measures:
• Staff members should be ready to take three steps: Identify, Isolate,
and Inform.
• Ask every patient if, in the last 20 days, he or she has traveled to
a country with widespread transmission (Guinea, Liberia, or Sierra
Leone) or has had contact with a person with confirmed EHF.
• If a patient appears to be at risk for EHF, isolate the patient imme-
diately, avoid unnecessary direct contact, determine the PPE
needed, and notify the health department. Refer to the CDC website
(www.cdc.gov/vhf/ebolojheolthcore-us/ppe/guidance.htm/) for
detailed information on how to put on and take off appropriate
PPE.
• Do not transfer the patient without first notifying the health depart-
ment; these patients should be transferred only to a facility
approved by public health authorities.
Modified from www.osha.gov/SLT(/ebola/index.html and www.cdc.gov/vhf/ebola/
healthcare-us/outpatient-settings/index.html. Accessed March l l, 2015.

OSHA STANDARDS FOR THE HEALTHCARE SETTING
In 1987, in response to concern about the increasing prevalence of
HIV and HBV, the CDC recommended a new approach to poten-
tially infectious materials called Universal Precautions. The underly-
ing concept of Universal Precautions is that because healthcare
workers cannot know whether a patient has an infectious disorder,
all blood and certain body fluids must be treated as if known to be
infectious for blood-borne pathogens. Therefore, precautions must
be implemented for all patients, regardless of the information avail-
able about the person's individual health history. In turn, Universal
Precautions protect patients from any blood-borne infection the
healthcare worker may carry.
In 2001 OSHA developed the Bloodborne Pathogens Standard
(Standard Precautions) to safeguard all healthcare employees and their
patients who are at risk of exposure from blood and other body fluids.
Potentially Infectious Fluids
Items contaminated with any of the following potentially infectious materi-
als require special handling:
• Cerebrospinal fluid (CSF); mucus; and synovial, pleural, pericardia I,
peritoneal, and amniotic fluids*
• Liquid or semiliquid blood
• Vaginal and seminal secretions
• Saliva in dental procedures
• Body fluid visibly contaminated with blood
• Unknown body fluid
• Wound drainage
• Human tissue, including tissue culture, cells, or exudates
*The human immunodeficiency virus (HIV) has been isolated from (SF, synovial, and amniotic
fluids; hepatitis antigens have been detected in synovial, amniotic, and peritoneal fluids.
Exposure Control Plan
OSHA recognizes that healthcare employees face significant health
risks as the result of occupational exposure to blood or other poten-
tially infectious materials that may contain HBV, the hepatitis C
virus (HCV), or HIV. In July, 1992, OSHA began enforcing work
practice controls to reduce or eliminate occupational exposure to
blood-borne pathogens. Employers whose workers are at risk for
occupational exposure to blood or other infectious materials must
implement an Exposure Control Plan that details employee protec-
tion procedures. The Exposure Control Plan must identify job clas-
sifications and/or specific work-related tasks in which an employee
may be exposed to blood and/or body fluids. The plan must describe
how an employer will use a combination of controls, including
personal protective equipment (PPE), training, medical surveillance,
HBV immunizations, record keeping of occupational injuries, post-
exposure follow-up, and labeling of hazardous materials. Engineer-
ing controls, such as safer medical equipment, puncture-proof sharps
containers, and shielded needle devices, in addition to PPE (e.g.,
gloves, gowns, and face shields), are recommended as the primary
ways to reduce or eliminate employee exposure.
The Exposure Control Plan must be reviewed and updated at
least annually to incorporate the use of safer medical devices designed
to eliminate or minimize occupational exposure to contaminated
CHAPTER 3 Infection Control 51
waste. In addition, the plan must be readily available to all employees
for review and training. It does not have to be a separate document
and may be included as part of the facility's policies and procedures
manual, or in the health and safety manual developed by the site.
CRITICAL THINKING APPLICATION 3-4
Based on what you have learned about OSHA requirements for environmen-
tal safety in a healthcare facility, evaluate your clinical laboratory at school.
Does it meet all of OSHA's standards? Is an environmental safety plan in
place? Develop an Exposure Control Plan for your facility and share it with
your peers.
The Bloodborne Pathogens Standard
In response to the CDC's concern about employee risk, Congress
passed the Needlestick Safety and Prevention Act, which took effect
in April, 2001. Employers are required to keep a confidential sharps
injury log that describes the device involved in the incident and the
details of how and where the incident occurred. Employers also must
make available to employees effective sharps management devices,
such as syringes with self-sheathing needles, needles that retract after
use, and needleless intravenous (IV) systems that do not require
sharps for parenteral administration. Parenteral exposure includes
accidental needlesticks, occupation-related human bites, and expo-
sure of nonintact skin (e.g., cuts and abrasions on the employee's
hands) to potentially infectious material. An employer who fails to
comply with OSHA's Bloodborne Pathogens Standard could face a
maximum penaltyof$7,000 for the first violation and up to $70,000
for repeated violations.
The Bloodborne Pathogens Standard also clarifies the use of
washing or flushing of any exposed body area or mucous membrane
immediately or as soon as possible after exposure to potentially infec-
tious materials. This includes hand washing after the removal of
gloves or other PPE.
Although the hands should be washed with antimicrobial soap
and warm, running water when available, studies have shown that
correct use of alcohol-based hand rubs significantly reduces the
number of microorganisms on the skin, takes less time than tradi-
tional hand washing, and causes less irritation to the skin, especially
if the solution is mixed with emollients (Figure 3-3). Allergic contact
dermatitis from alcohol hand rubs is uncommon.
FIGURE 3-3 Antimicrobial soap and alcohol-based hand rubs.
52 UNIT ONE INTRODUCTION TO MEDICAL ASSISTING
The CDC's recommendations for adequate hand hygiene are as
follows:
• Visibly soiled hands should be washed for a minimum of
15 seconds with antimicrobial soap and warm, running
water.
• Alcohol hand rubs should be used before and after contact
with each patient, and also after removing gloves, to prevent
cross-contamination among patients and healthcare workers.
• To use an alcohol hand rub properly, apply the label-
recommended amount to the palm of one hand and rub
the hands together, covering all surfaces until the hands
are dry.
Requirements of Employers: OSHA Bloodborne Pathogens Standard
EXPOSURE CONTROL PLAN
Each medical office must develop a written exposure control plan (ECP).
The purpose of an ECP is to identify tasks where there is the potential
for exposure to blood and other potentially infectious materials.
• A timetable must be published indicating when and how communica-
tion of potential hazards will occur.
• The employer must offer employees the hepatitis B vaccine within 1O
working days of employment (at no cost to the employee). If employ-
ees sign a form to refuse the vaccine, they can change their mind at
no cost to the employee.
• The employer must document the steps that should be taken in
case of an exposure incident, including a postexposure evaluation
and follow-up, strict record keeping, implementation of engineering
controls, provision for personal protective equipment, and general
housekeeping standards.This plan must be posted in the medical
office.
• There must also be written procedures for evaluating the circum-
stances of an exposure incident.
• Training records must be kept for 3 years.
ENGINEERING CONTROLS AND WORK PRACTICES
The employer must provide engineering controls, or equipment and
facilities that minimize the possibility of exposure. Examples of
engineering controls include the following:
• Providing puncture-resistant containers for used sharps.
• Providing handwashing facilities that are readily accessible.
• Equipment for sanitizing, decontaminating, and sterilizing.
The employer must also enforce work practice controls. Work practice
controls also minimize the possibility of exposure by making sure em-
ployees are using the proper techniques while working. Examples
include the following:
• Enforcing proper handwashing or sanitizing procedures.
• Enforcing proper technique for using and handling needles to
prevent needle sticks.
• Enforcing proper techniques to minimize the splashing of blood.
PERSONAL PROTECTIVE EQUIPMENT
Employers must provide, and employees must use, personal protective
equipment (PPE) when the possibility exists of exposure to blood or con-
taminated body fluids. This equipment must not allow blood or poten-
tially infectious material to pass through to the employee's clothes, skin,
eyes, or mouth. Examples of PPE include the following:
• Gowns
• Face shields
• Goggles
• Gloves
FIGURE 3-4 Requirements of employers: OSHA's Bloodborne Pathogens Standard. (www.osha.gov. Accessed 8/13/2015)
• Artificial nails should not be worn; studies show that even
after careful hand hygiene, healthcare workers with artificial
nails have more pathogenic microbes under their nails and on
their fingertips than workers with natural nails. Artificial nails
also cause nail changes that contribute to the transmission of
microbes.
• Natural nail tips should be no longer than ¼ inch to prevent
microbial growth in the nail bed.
The best way to reduce the occupational risk of infection is
to follow the Bloodborne Pathogens Standard. Healthcare workers
must take adequate and consistent precautions to protect them-
selves and their patients. Figure 3-4 summarizes the Bloodborne
If an employee has an allergy to powder or latex, the employer must
provide hypoallergenic or powderless gloves. The employee cannot be
charged for PPEs.
EXPOSURE INCIDENT MANAGEMENT
An exposure incident is contact with blood or biohazard infectious mate-
rial that occurs when doing one's job. When an exposure incident is
reported, the employer must arrange for an immediate and confidential
medical evaluation. The information and actions required are as follows:
• Documenting how the exposure occurred.
• Identifying and testing the "source" individual, if possible.
• Testing the employee's blood, if consent is granted.
• Providing counseling.
• Evaluating, treating, and following up on any reported illness.
Medical records must be kept for each employee with occupational
exposure for the duration of employment plus 30 years.
COMMUNICATION OF POTENTIAL HAZARDS TO
EMPLOYEES
A medical assistant will be exposed to hazardous chemicals on the job.
Most chemicals handled by assistants are not any more dangerous than
those used in the home. In the workplace, however, exposure is likely to
be greater, concentrations higher, and exposure time longer.
The "right to-know" law, OSHA's hazard communication standard,
states that each employee has a right to know what chemicals he or she
is working with in the workplace. The right-to-know law is intended to
make the workplace safer by making certain that all information
regarding chemical hazards is known to the employee. This information
is supplied in the material safety data sheet (MSDS), a fact sheet about
a chemical that includes the following information:
• Identification of the chemical
• Listing of the physical and health hazards
• Precautions for handling
• Identification of the chemical as a carcinogen
• First-aid procedures
• Name, address, and telephone number of manufacturer
Many SOS information sheets can be obtained in repositories on the
Internet. An SOS should be updated at least every 3 years. Employers
must ensure that all products have an up-to-date SOS when they enter
the workplace.
Potential hazards are also communicated with labels and color. Any
containers with biohazard waste must be orange (or reddish orange)
and must display the biohazard symbol. These labels and colors alert
employees to the risk of possible exposure.

Pathogens Standard. Healthcare facilities must establish specific poli-
cies and procedures for the management of an exposure incident
(e.g., accidental needlestick) and the exposed employee.
Compliance Guidelines
Because the Bloodborne Pathogens Standard is written to cover
employees working in all health fields, only some of the regulations
apply to the ambulatory care setting. Safety and infection control
fundamentals go beyond hand washing and knowledge of the disease
cycle. The information is presented here as it applies to the medical
assisting profession.
Barrier Protection
Medical assistants routinely should use appropriate barrier precau-
tions when contact with blood or other body fluids is expected.
Barrier protection, or PPE, includes specialized clothing or equip-
ment that prevents the healthcare worker from coming in contact
with blood or other potentially infectious material, thereby prevent-
ing or minimizing the entry of infectious material into the body.
Barrier devices include disposable gloves, face masks, face shields,
protective glasses, shoe covers, laboratory coats, barrier gowns,
mouthpieces, and resuscitation bags (Figure 3-5).
Since the implementation of Standard Precautions, the use of
disposable examination gloves is required in healthcare facilities.
Because of the frequent allergic reactions associated with latex prod-
ucts, facilities now use nonlatex gloves. If the facility where you work
still uses latex gloves, signs of an allergic reaction include localized
urticaria, dermatitis, conjunctivitis, and rhinitis. Hypersensitive
reactions can be systemic, producing asthma symptoms or anaphy-
laxis. If a healthcare worker or a patient shows signs of sensitivity
to latex, the healthcare provider is required to provide products made
of nonallergenic materials. Gloves must be worn if the medical
assistant is at all likely to be involved in any of the following activities
(Procedure 3-1 ):
• Touching a patient's blood, body fluids, mucous membranes,
or skin that is not intact.
. •.
.-· ... :.·.
- - ! ·.:: . : • Contaminated needles and other sharps should never be recapped,
FIGURE 3-5 Personal protective equipment.
CHAPTER 3 Infection Control 53
• Handling items and surfaces contaminated with blood and
body fluids.
• Performing venipuncture, finger sticks, injections, and other
vascular procedures.
• Assisting with any surgical procedure. If a glove is torn during
the procedure, the glove should be removed, the hands washed
carefully, and a new glove put on as soon as possible.
• Handling, processing, and disposing of all specimens of blood
and body fluids.
• Cleaning and decontaminating spills of blood or other body
fluids.
The same pair of gloves cannot be worn for the care of more than
one patient; new disposable gloves must be used for each individual
patient.
Safety Alert
Protective equipment contaminated with body fluids of any kind must be
removed and placed in adesignated area or biohazard container. The hands
or any other exposed areas must be washed or flushed as soon as possible.
Face shields that cover the mouth, nose, and eyes must be worn whenever
splashes, sprays, or droplets are possible. Utility gloves may be reused if
they are intact (i.e., have no cracks, tears, or punctures). All PPE must
be removed before the medical assistant leaves the medical facility
(Figure 3-6).
CRITICAL THINKING APPLICATION 3-5
Rosa is caring for an injured 3-year-old child with an open wound on his
right knee. She puts on disposable gloves to clean the wound, and the
mother demands ta know why. Haw can she explain her actions?
Environmental Protection
Environmental protection refers to minimizing the risk of occupa-
tional injury by isolating or removing any physical or mechanical
health hazard in the medical workplace. Every medical assistant must
adhere to these safety rules.
• Read warning labels on biohazard containers and equipment.
• Minimize splashing or spraying of potentially infectious materi-
als. Blood that splatters onto open areas of the skin or mucous
membranes is a proven mode of HBV transmission.
• Bandage any breaks or lesions on your hands before gloving.
• If any body surface is exposed to potentially infectious material,
scrub the area with antimicrobial soap and warm, running water
as soon as possible afrer the exposure.
• If your eyes come in contact with body fluids, continuously
flush them with water as soon as possible for a minimum of 15
minutes using an eye wash unit. A stationary unit connected to
warm, running water is the best method for properly flushing
potentially infectious material out of the eyes (Figure 3-7 and
Procedure 3-2) .
bent, broken, or resheathed; needle units must have protective
safety devices to cover the contaminated needle afrer injection.
 Participate in Bloodborne Pathogen Training: Use Standard Precautions to Remove
PROCEDURE 3-1
Contaminated Gloves and Discard Biohazardous Material

Goal: To minimize exposure to pathogens by aseptically removing and discarding contaminated gloves.
EQUIPMENT and SUPPLIES 3. Insert two fingers of the ungloved hand between the edge of the cuff of
• Disposable examination gloves the other contaminated glove and the hand (Figure 3).
• Biohazard waste container with labeled red biohazard bag
PROCEDURAL STEPS
1. With the dominant hand, grasp the glove of the opposite hand near the
palm and begin removing the first glove (Figure 1). The arms should be
held away from the body with the hands pointed down.
PURPOSE: Holding the hands down and away from the body helps prevent
possible contamination.

4. Push the glove down the hand, inside out, over the contaminated glove
being held, leaving the contaminated side of both gloves on the inside.
PURPOSE: This technique protects the wearer from the contaminated sur-
faces of both gloves.
S. Properly dispose of the inside-out, contaminated gloves in a biohazard waste
container (Figure 4).
PURPOSE: To prevent the spread of infection.

2. Pull the glove inside out (Figure 2). After removal, ball it into the palm of
the remaining gloved hand.
PURPOSE: Taking off the glove inside out prevents transmission of patho-
gens to another surface.

6. Perform a medical aseptic hand wash as described in Procedure 3-4 or sani-

tize the hands with an alcohol-based rub.
PURPOSE: To minimize the number of pathogens on the hands, thereby
reducing the number of transient flora and the risk of transmission of
pathogens.
 CHAPTER 3 Infection Control 55

A
....
r;,,, - ; . -
.,. . ··'--'·
,': ··:
'... B
Q),.,
,'. .
.· .·:
:

FIGURE 3-6 Removing a contaminated gown.

FIGURE 3-7 Eye washing unit.

56 UNIT ONE INTRODUCTION TO MEDICAL ASSISTING

•;;m!,mj;jifl Demonstrate the Proper Use of Eye Wash Equipment: Perform an Emergency Eye Wash
Goal: To minimize the risk of occupational exposure to pathogens if body fluids come in contact with the eyes.

EQUIPMENT and SUPPLIES

• Plumbed or self-contained eye wash unit
• Disposable gloves
PROCEDURAL STEPS
1. Put on gloves and remove contact lenses or glasses.
PURPOSE: To ensure flushing of all material in the eyes.
2. Following the manufacturer's directions, turn on the eye wash unit. If it is
a plumbed unit, the control valve should remain on until the unit is manually
shut off.
PURPOSE: The unit must be plumbed so that it can remain on until manu-
ally turned off.
3. Hold the eyelids open with the thumb and index finger to ensure adequate
rinsing of the entire eye and eyelid surface (Figure 1). 1
PURPOSE: The normal reflex is to close the eyes tightly, which prevents
removal of all the contaminated material.
4. Avoid aiming the water stream directly onto the eyeball.
PURPOSE: Adirect water stream may cause discomfort and/or damage
the eye.
5. Flush the eyes and eyelids for a minimum of 15 minutes, rolling the eyes 7. After completion of the eye wash, follow postexposure follow-up
periodically to ensure complete removal of the foreign material. procedures.
PURPOSE: To completely remove the potentially dangerous substance from PURPOSE: Depending on the type of exposure, the facility's policies may
the eyes. include provider completion of an exposure incident form and provider
6. Remove gloves using Procedure 3-1 , dispose of them in a properly labeled follow-up.
biohazard bag, and sanitize your hands.
PURPOSE: To prevent cross-contamination.

• Contaminated sharp instruments, such as biopsy scissors, should
not be processed in a way that requires employees to reach into
containers to grasp them.
• Immediately after use, dispose of syringes and needles, scalpel
blades, and other disposable sharp items in a labeled, leakproof,
puncture-resistant biohazard container. The container must be
located as close as possible to the area where the item is used.
• All specimens must be placed in a container that prevents leakage
during collection, handling, processing, storage, transport, and
shipping. Avoid contaminating the outside of the container or
the label with the specimen substance. The container must have
a biohazard label to alert others that it holds potentially infectious
material. Gloves should be worn throughout this procedure.
• Equipment requiring repair that has been contaminated with
blood or body fluids should be decontaminated before being
repaired in the office or transported for repair. There is no docu-
mented evidence of HIV transmission from contaminated envi-
ronmental surfaces, but surface contamination is a proven mode
of transmission of HBV.
• Smoking, eating, drinking, applying cosmetics or lip balm, and
handling contact lenses are prohibited in work areas where there
is a reasonable likelihood of contamination by pathogens.
• Food and beverages cannot be kept in refrigerators, freezers, or
cabinets or on countertops where infectious materials could be
present.
Housekeeping Controls
The Bloodborne Pathogens Standard requires certain housekeeping
measures to ensure a sanitary work area. Facilities must post a sched-
ule for cleaning and decontaminating each work area where expo-
sures could occur. This documentation must include information
about the surface cleaned, the type of waste encountered, and pro-
cedures performed in the designated area.
• After accidental spills of blood or body fluids, at the end of
each procedure, and at the end of each shift, work surfaces
must be immediately cleaned and then disinfected with a disin-
fectant registered with the Environmental Protection Agency
(EPA).

• All reusable containers must be disinfected and decontaminated
on a routine basis.
• Sharps containers must be kept as close as possible to the work
area. Never attempt to reach inside a sharps container, and do
not overfill them. Replace containers on a routine basis, and be
certain that the lid is closed securely before preparing them for
biohazard waste disposal.
• Never pick up spilled material or broken glassware with the
hands. Brooms, brushes, dustpans, and pickup tongs or forceps
should be used. The material should be placed immediately
into an impervious biohazard bag or container at the spill site
(Figure 3-8). Use an absorbent, professional biohazard spill prep-
aration as directed to decontaminate the site.
• Handle soiled linen as little as possible and always wear gloves or
other protective equipment during disposal. Linens soiled with
blood or body fluids should be double-bagged and transported
in labeled, leakproof biohazard bags.
• Contaminated materials and/or infectious waste must be handled
with extreme caution to prevent exposure. Biohazard waste must
be collected in impermeable, red polyethylene or polypropylene
FIGURE 3-8 Cleaning up spilled material. A, Clean·up kit with printed instructions. B, Sprinkle congealing powder over the spill. C, Scoop up
the spill. D, Place the contents in a biohazard bag. E, Wipe the area thoroughly with a germicide. F, Place all contaminated material in a biohazard
bag or container.
CHAPTER 3 Infection Control 57
biohazard-labeled bags or containers and sealed (Figure 3-9). This
waste must be disposed of in accordance with all federal, state,
and local regulations. Disposal methods include treatment by
heat, incineration, steam sterilization, chemical treatment, or
other equivalent methods that renders the waste inactive before
it is placed in a landfill.
CRITICAL THINKING APPLICATION 3-6
Your office manager asks you to prepare a fact sheet for your co-workers
that summarizes the details of OSHA's Bloodborne Pathogens Standard.
What should you include?
Protocols for Disposal of Biologic Chemical
Materials
The Medical Waste Tracking Act set the standards for governmental regula-
tion of medical waste; however, that law expired in 1991. The states were
then given responsibility for regulating the disposal of medical waste. The
58 UNIT ONE INTRODUCTION TO MEDICAL ASSISTING
50 states vary in their degree of regulation, ranging from no regulation to
very strict rules. The fallowing are same examples of regulations covering
the disposal of hazardous materials.
• Biomedical waste should be collected in containers that are leakpraof
and strong enough to prevent breakage during handling; the containers
must be labeled with the biohazard symbol.
• Workers who handle biomedical waste should observe Standard
Precautions.
• Biologic waste containers and boxes should not be held in the health-
care facility for longer than 30 days.
• Sharps are instruments intended to cut or penetrate the skin; they
include lancets, scalpel blades, needles, and syringe/needle combina-
tions. Sharps must be placed in red, hard plastic sharps boxes after
use; sharps boxes should be closed when three-fourths full.
• Boxes for disposal of chemicals should be labeled with the chemicals'
names and any other pertinent data; they must be adequately sealed
to prevent breakage or leakage.
• Each healthcare facility must hire a biomedical waste disposal service
whose employees are trained to collect and haul away biomedical
waste in special containers (usually cardboard boxes or reusable plastic
bins) for treatment at a facility designed to handle biomedical waste.
• The cost to the healthcare facility far biomedical waste disposal is typi-
cally based on the weight of the contaminated items collected (i.e.,
the weight of filled sharps containers, biohazard boxes, and bags).
FIGURE 3-9 Biohazard bag and biohazard sharps contoiner.
Hepatitis B Vaccination
HBV vaccination must be available free of charge to all employees
at risk for occupational exposure to blood-borne pathogens, whether
they are full-time or part-time workers, within 10 days of starting
employment. The vaccine is administered by intramuscular injection
in three doses. The second injection is administered 4 weeks after
the first, and the third injection 6 months after the first. The U.S.
Public Health Service does not currently recommend routine boost-
ers for hepatitis B immunization. However, if they are recommended
in the future, boosters must be made available to eligible employees
without cost.
Hepatitis B Vaccine Declination
I understand that due to my occupational exposure to blood
or other potentially infectious materials I may be at risk of
acquiring hepatitis B virus (HBV) infection. I have been
given the opportunity to be vaccinated with hepatitis B vac-
cine, at no charge to myself. However, I decline hepatitis B
vaccination at this time. I understand that by declining this
vaccine, I continue to be at risk of acquiring hepatitis B, a
serious disease. If in the future I continue to have occupa-
tional exposure to blood or other potentially infectious
materials and I want to be vaccinated with hepatitis B vac-
cine, I can receive the vaccination series at no charge to me.
Name: _ _ _ _ _ _ _ __ Date: _ _ _ __
FIGURE 3-10 Sample hepatitis B declination form. (https:j/www.osha.gov/SlTC/etools/
hospital/hazards/bbp/declination.html. Accessed l 0/7/2015.)
After three intramuscular doses of hepatitis B vaccine, more than
90% of healthy adults and more than 95% of infants, children, and
adolescents (from birth to 19 years of age) develop adequate anti-
body responses. Despite this, healthcare workers with a high risk of
exposure should have a blood titer drawn after completion of the
injection cycle ro determine whether they have created antibodies
against the disease. Postvaccination antibody testing should be done
1 to 2 months after completion of the vaccine series. If the employee
did not respond to the first series or if the series was not completed,
revaccination with a second three-dose series is recommended. If
antibodies still do not develop, no further vaccination is given.
Employees have the right to decline hepatitis B immunization,
but they are required to sign a declination form (Figure 3-10) that
is kept on file as a record of their refusal. The statement can be signed
only after the employee has received training about hepatitis B,
hepatitis B vaccination, and the safety, route of administration, and
benefits of vaccination, in addition to being informed that the
vaccine will be administered free of charge. Employees who change
their mind may receive the vaccine at a future date free of charge.
Postexposure Follow-Up
If a worker is exposed through an accidental needlestick, a human
bite, exposure to broken skin, or from a splash or splatter onto
mucous membranes, such as the eyes, certain procedures must be
followed. Procedure 3-3 presents the specific steps to be taken after
exposure to contaminated waste.
• Immediately, or as soon as possible after exposure, the worker
should wash or flush the exposed area.
• The exposure incident must be immediately reported to the
supervisor.
• The employee must immediately receive a confidential medical
evaluation. The provider caring for the exposed employee
must receive written details of the exposure incident, includ-
ing the route and circumstances surrounding the incident. All
documentation related to the exposure must remain confidential,
may not be disclosed to any individual without the employee's
express written permission, and must be kept for at least the
duration of the worker's employment plus 30 years.

Participate in Bloodborne Pathogen Training and a Mock Environmental Exposure
PROCEDURE 3-3
Event with Documentation of Steps
Goal: To manage an exposure incident according to OSHA standards.
Scenario: As Rosa administers a hepatitis Binjection intramuscularly (IM), the patient jumps back. The needle becomes dis-
lodged from the patient's arm, and Rosa is accidentally jabbed in the hand by the contaminated needle. The patient is receiving
ongoing treatment for hepatitis Cbut is not HIV positive. After Rosa notifies her site supervisor, what procedural steps must she
take to comply with OSHA standards?
EQUIPMENT and SUPPLIES
• Antibacterial soap and warm running water
• Exposure incident report form
Sample Blood and Body Fluid Exposure Report Form from the Centers for
Disease Control (CDC) can be found at http:j/www.cdc.gov/sharpssafety/
pdf/AppendixA-7.pdf
PROCEDURAL STEPS
1. Remove gloves and immediately wash the exposed site with antibacterial
soap and warm running water.
PURPOSE: To sanitize and disinfect the exposure site as quickly and thor-
oughly as possible.
• An incident report must be filed that documents the details sur-
rounding the exposure incident, the route or type of exposure,
and the identity, if known, of the source individual. The source
individual is the person, living or dead, whose blood or potentially
infectious material was the source of the occupational exposure.
• The source individual is screened for HBV, HCV, and HIV.
Depending on state regulations, consent may or may not be
required from the source individual to perform the screening. If
consent is required but not given, the employer must document
that consent was not received from the source individual. If
screening is done, OSHA requires that the employee be informed
of the results of the source individual's tests.
• The exposed worker is tested for HBV, HCV, and HIV if consent
is given to determine whether the employee already has one of
these infectious diseases. If the employee refuses the tests but
blood is drawn, the sample must be stored 90 days for the worker
to decide whether screening is wanted.
• If the employee has not been vaccinated against HBV, vaccination
is offered.
• The injured employee must receive a copy of the healthcare pro-
vider's written opinion within 15 days of completion of the
evaluation.
• The exposed worker must receive health counseling about the risk
of illness or other adverse outcomes of exposure and the potential
for and consequences of transmission of the disease to family,
patients, and others.
Healthcare students are at risk for blood-borne pathogen expo-
sure and should follow all OSHA guidelines designed to protect
CHAPTER 3 Infection Control 59
2. Immediately report the exposure incident to the site supervisor.
PURPOSE: The facility supervisor (e.g., office manager, practice manager,
pravider) is responsible for following through with the facility's Exposure
Contral Plan.
3. Complete an exposure incident report that details the type of injury, the
details surrounding the incident, the equipment involved, and any other
pertinent details.
PURPOSE: The facility must report exposure incidents to OSHA. OSHA
evaluates the incident based on required standards, including employee
training, availability of current pratective devices (e.g., needle safety covers
and location of sharps containers), and the extent of employee injury. The
incident report also serves as a written record of the incident, which estab-
lishes the need for employee healthcare.
individuals from exposure. A complete, unabridged copy of OSHA's
Bloodborne Pathogens Standard may be obtained at the OSHA
website (www.osha.gov).
The CDC has developed a checklist that ambulatory care facilities
can use to systematically assess employee adherence to infection
prevention and to ensure that the facility has policies and procedures
Risk of Infection After an Occupational Exposure
Hepatitis B Virus (HBV)
Healthcare workers who have received hepatitis Bvaccine and have devel-
oped immunity to the virus are at virtually na risk for infection. For an
unvaccinated person, the risk from a single needlestick or a cut exposure
to HBV-infected blood ranges from 6% to 30%.
Hepatitis C Virus (HCV)
The estimated risk for infection after a needlestick or cut exposure to HCV-
infected blood is approximately 1.8%. The risk after a blood splash is
unknown but is believed to be very small.
Human Immunodeficiency Virus (HIV)
The average risk for HIV infection after a needlestick or cut exposure to
HIV-infected blood is about 1 in 300; the risk after exposure of the eye,
nose, or mouth is 1 in 1,000; the risk after exposure of the skin to HIV-
infected blood is estimated to be less than 0.1 %.
www.cdc.gov/OralHealth/infectioncontroljfaqjbloodborne_exposures.htm. Accessed March
10, 2015.
60 UNIT ONE INTRODUCTION TO MEDICAL ASSISTING
in place and adequate supplies available to prevent infections at the
site. If the answer to any of the questions is "No," the facility must
do all it can to correct the problems with either staff or supplies
(Table 3-1 ).
Postexposure Management
• Hepatitis Bvirus (HBV): Hepatitis Bvaccine series started in any unvac-
cinated person; postexposure prophylaxis (PEP) with hepatitis B
immune globulin and/or hepatitis Bvaccine series if the post-vaccination
antibody test is negative.
• Hepatitis Cvirus (HCV): Immune globulin and antiviral agents (e.g.,
interferon with or without ribavirin) are not recommended for PEP of
hepatitis (; determine the HCV status af the source and the exposed
person; provide follow-up HCV testing for the employee if the source is
HCV positive.
• Human immunodeficiency virus (HIV): Four-week PEP regimen of
two drugs (zidovudine [ZDV] and lamivudine [3TC]; 3TC and stavu-
dine [d4TI; or didanosine [ddl] and d4T) for most HIV exposures
and a third drug for HIV exposures that pose an increased risk for
transmission; employees should receive follow-up counseling, pastex-
posure testing, and medical evaluation, regardless of whether they
receive PEP. After baseline testing at the time of exposure, follow-up
testing could be performed at 6 weeks, 12 weeks, and 6 months
after exposure.
CRITICAL THINKING APPLICATION 3-7
Rosa's office has been especially busy today. While administering an injec-
tion to a frightened 6-year-old child, a co-worker accidentally sticks herself
with the needle. She tells Rosa about the incident, but she doesn't know
what to do next. What steps should be taken to manage the situation?
ASEPTIC TECHNIQUES: PREVENTING
DISEASE TRANSMISSION
Asepsis means freedom from infection or infectious material. Medical
asepsis is defined as the destruction of disease-causing organisms after
they leave the body. When we practice the principles of medical
asepsis, we are working to prevent reinfection of the patient or the
cross-infection of other patients or ourselves. The goal is to eliminate
or minimize pathogens by following OSHA's Bloodborne Pathogens
Standard and disinfecting objects as soon as possible after contami-
nation. This creates a healthcare environment as free of pathogens
as possible.
Surgical asepsis is the destruction of organisms before they enter
the body. This technique is used for any procedure that invades the
body's skin or tissues, such as surgery or injections. Anytime the skin
or a mucous membrane is punctured, pierced, or incised (or will be
during a procedure), surgical aseptic techniques are practiced. Every-
thing that comes in contact with the patient should be sterile,
including gowns, drapes, instruments, and the gloved hands of the
surgical team. Minor surgery, urinary catheterization, injections, and
some specimen collections, such as blood collection and biopsies,
are performed using surgical aseptic technique.
Because the hands themselves cannot be sterilized, the goal of
hand washing is to reduce the amount of skin flora through the use
of mechanical friction, antimicrobial soaps, and warm, running
water. Normally, two types of flora are found on the skin: normal
resident flora and transient flora that are associated with infection.
Normal resident flora lives harmlessly on the skin; transient flora
includes bacteria, viruses, and other organisms picked up on the
hands. The goal of thorough hand washing is to remove or reduce
the number of transient flora on the surface of the skin, thus prevent-
ing their transfer to patients.
The most effective barrier against infection is the unbroken skin.
If the skin and mucous membranes are intact, medical asepsis can
be practiced for most noninvasive procedures (i.e., those that do not
penetrate human tissues), such as pelvic and proctologic examina-
tions. Instruments and objects used in medical aseptic procedures
must be sanitized and disinfected or sterilized before use on another
patient. Medical aseptic procedures may include the use of gowns
and masks, but these are not sterile and are worn to protect the
healthcare worker more than the patient.
Another practical application of aseptic technique is to set up work
areas in the medical office's laboratory so that one side of the labora-
tory is the "clean" side, where only noninfectious procedures are
performed, and the other is the "dirty'' side, where potentially infec-
tious materials are processed or cleaned.
Hand Washing
The hands must be washed, using the correct technique, before and
after each patient is examined or treated and also when stipulated
by the Bloodborne Pathogens Guidelines. A lengthy scrub is not
necessary each time, but the first scrub in the morning should be
extensive, lasting 2 to 4 minutes. Subsequent hand washing may be
brief unless the hands are excessively contaminated. A good antimi-
crobial soap with chlorhexidine (e.g., Hibiclens), which has antisep-
tic residual action that lasts several hours, should be used. Each office
sink should be equipped with a liquid soap dispenser. A water-
soluble lotion may be rubbed into the hands after they have been
washed and dried. Dry, cracked, chapped skin is no longer intact
and can result in the transmission of disease.
Proper hand washing depends on two factors: running water
and friction. The water should be warm, because water that is too
hot or too cold causes the skin to become chapped. Friction is the
firm rubbing of all surfaces of the hands and wrists. Remember that
your fingers have four sides, and fingernails have two sides. For
medical hand washing, all jewelry except a plain wedding band is
removed. A wristwatch may be lefr on if it can be moved up on the
forearm away from the wrist area. The hands are washed under
running water with the fingertips pointing downward. Soap and
friction are applied to the hands and wrists. The water is allowed to
wash debris away from the wrists and down toward the fingertips
(Procedure 3-4).
Remember, the goal of aseptic hand washing is to protect you
from infection and prevent cross-contamination from one patient to
another. Use this procedure after you finish with one patient and
before you attend to another patient; after you finish handling one
specimen and before you handle another specimen; before and after
you use toilet facilities; whenever you touch something that causes
 CHAPTER 3 Infection Control 61

TABLE 3-1 Modified CDC Infection Prevention Checklist

IF ANSWER IS NO,
PRACTICE DOCUMENT PLAN
FACILITY POLICIES PERFORMED FOR REMEDIATION
1. Administrative Policies and Facility Practices
a. Written infection prevention policies and procedures are available and reflective of current Yes No
research.
b. At least one individual trained in infection prevention is employed by or regularly available to Yes No
the facility.
c. Supplies necessary for adherence ta Standard Precautions are readily available. Yes Na
d. Healthcare personnel receive job-specific training on infection prevention policies and Yes No
procedures and OSHA Blaodbarne Pathogens Standard and are observed for compliance
when hired and at least annually.
e. The facility maintains a log of needlesticks, sharps injuries, and other employee exposure Yes Na
events.
f. Fallowing an exposure event, past-exposure evaluation and follow-up, including prophylaxis Yes No
as appropriate, are available at no cast ta employee.
g. Hepatitis Bvaccination is available at no cast ta all employees at risk of occupational Yes No
exposure.
h. Post-vaccination screening for hepatitis Bsurface antibodies is conducted. Yes No
i. All personnel are offered annual influenza vaccination at no cost. Yes Na
j. All personnel with potential exposure to tuberculosis (TB) are screened for TB upon hire and Yes No
annually (if negative).
2. Surveillance and Disease Reporting
a. Updated list of reportable diseases is readily available to all personnel. Yes No
3. Hand Hygiene
a. Facility provides training and supplies necessary for adherence ta hand hygiene. Yes No
4. Personal Protective Equipment (PPE}
a. Facility provides training and supplies for appropriate PPE. Yes Na
b. Impermeable gowns are worn during procedures where contact with blood or body fluids is Yes No
anticipated.
c. PPE is removed and discarded prior to leaving the exam room. Yes No
d. Hand hygiene is performed immediately after removal of PPE. Yes Na
5. Environmental Cleaning
a. Policies and procedures exist for routine cleaning and disinfection of environmental surfaces. Yes No
b. Cleaning procedures are periodically monitored and assessed to ensure that they are Yes No
consistently and correctly performed.
c. The facility has a policy/procedure for decontamination of spills of blood or other body Yes No
fluids.
Modified from www.cdc.gov/HAl/settings/outpatient/checklist/outpatient-care-checklist.html. Accessed March 5, 2015.
*The complete checklist is available at the CDC website for Infection Prevention in Outpatient Settings: www.cdc.gov/HAl/settings/outpatient/checklist/outpatient-care-checklist.html.
62 UNIT ONE INTRODUCTION TO MEDICAL ASSISTING
your hands to become contaminated; when you arrive at work and
before you leave the facility; before and after eating; and at the end
of the day.
As stated earlier, alcohol-based hand rubs may substitute for
hand washing unless the hands are visibly contaminated. Evidence
suggests that hand antisepsis with an alcohol-based hand rub is
more effective at reducing nosocomial infections than plain hand
washing. Using antimicrobial-impregnated wipes (e.g., towelettes)
is not a substitute for using an alcohol-based hand rub or antimi-
crobial soap.
•;;mdnmjfii Participate in Bloodborne Pathogen Training: Perform Medical Aseptic Hand Washing
Goal: To minimize the number of pathogens on the hands, thus reducing the risk of transmission of pathogens.
EQUIPMENT and SUPPLIES
• Sink with warm running water
• Antimicrobial liquid soap in a dispenser (bar soap is not acceptable)
• Disposable nail brush or orange stick
• Paper towels in a dispenser
• Water-based antimicrobial lotion
• Covered waste container with foot pedal
PROCEDURAL STEPS
1. Remove all jewelry except your wristwatch, if it can be pulled up above
your wrist, and a plain wedding ring.
PURPOSE: Jewelry can harbor microorganisms.
2. Turn on the faucet with a paper towel and regulate the water temperature
to lukewarm.
PURPOSE: Use a paper towel to prevent touching of contaminated sur-
faces; water that is too hot can cause skin to become dry and chapped.
3. Wet your hands, apply soap, and lather using a circular motion with friction
while holding your fingertips downward (Figure 1). Rub well between your
fingers. If this is the first hand wash of the day, use a nail brush or an
orange stick and clean under every fingernail. Inspect your nails
thoroughly.
PURPOSE: Friction removes soil and contaminants from the hands and
wrists.
According to the CDC, proper hand hygiene must be performed
in the following instances even if disposable gloves are worn:
• Before and after contact with the patient or his or her immedi-
ate care environment
• Before performing an aseptic task (e.g., giving an injection,
drawing blood)
• After contact with blood, body fluids, or contaminated
surfaces
• When hands move from a contaminated body site to a clean
body site during patient care
4. Rinse well, holding your hands so that the water flows from your wrists
downward to your fingertips (Figure 2).
PURPOSE: Soil and contaminants will wash off the skin and down the
drain.
S. If this is the first hand wash of the day or if your hands are obviously
contaminated, wet your hands again and repeat the scrubbing procedure
using a vigorous, circular motion over the wrists and hands for at least 1
to 2 minutes.
PURPOSE: Time is required for friction and motion to eliminate all possible
soil and contaminants.
6. Rinse your hands a second time, keeping the fingers lower than your
wrists.
PURPOSE: To ensure removal of all transient flora.
7. Dry your hands with paper towels. Do not touch the paper towel dispenser
as you are obtaining towels (Figure 3).
PURPOSE: Touching the dispenser contaminates your hands, and you will
need to start over.

•;;m,anmjii• -continued
8. If the faucets are not foot operated, turn them off with a paper towel
(Figure 4).
PURPOSE: The faucet is dirty and will contaminate your clean hands.
Sanitization
Instruments and other items used in office surgery, examination, or
treatment must be carefully cleaned before proceeding with the steps
of disinfection or sterilization. Sanitization is the cleansing process
that reduces the number of microorganisms to a safe level, as dictated
in public health guidelines. This cleansing process removes debris
such as blood and other body fluids from instruments or equipment.
Blood and debris must be removed so that later disinfection with
chemicals or sterilization with steam, heat, or gases can penetrate to
all the instrument's surfaces (Procedure 3-5).
The medical assistant should always wear gloves (thick utility
gloves if the instruments have sharp or pointed edges) while per-
forming sanitization to prevent possible personal contamination
with potentially infectious body fluids that may be present on the
articles being cleaned. The procedure should be completed immedi-
ately after use of the instruments in a separate workroom or on the
"dirty'' side of the utility room to prevent cross-contamination of
clean instruments and equipment. If this is not possible, rinse the
used items under cold water immediately after the procedure and
place them in a low-sudsing, rust-inhibiting, enzyme-containing
detergent solution. Never allow blood or other substances that can
coagulate to dry on an instrument.
CHAPTER 3 Infection Control 63
9. After you finish drying your hands and turning off the faucets, place used
towels into a covered waste container.
PURPOSE: Always discard contaminated waste in a covered waste con-
tainer immediately to eliminate the source of infection.
10. If needed, apply a water-based antibacterial hand lotion to prevent
chapped or dry skin.
PURPOSE: Chapped skin eliminates the first line of defense against infec-
tious organisms.
11. Repeat the procedure as indicated throughout the day.
PURPOSE: To eliminate contaminants and prevent the transmission of
pathogens to yourself and others.
When you are ready to sanitize instruments, drain off the soaking
solution and rinse each instrument in cold running water. Separate
the sharp instruments from the others because metal instruments
may damage the cutting edges, and sharp instruments may damage
other instruments or injure you. Clean all sharp instruments at one
time, when you can concentrate on preventing injury to yoursel£
Open all hinges and scrub serrations and ratchets with a small scrub
brush or toothbrush. Rinse the instruments in hot water and then
check carefully that they are in proper working order before they are
disinfected or sterilized. The items should be hand dried with a towel
to prevent spotting.
Sanitization is a very important step, and it cannot be overlooked
or done carelessly. The use of disposable instruments minimizes the
need for sanitization, disinfection, and sterilization.
Ultrasonic Sanitization
Sound waves can be used to sanitize instruments. The instruments
are placed in an ultrasonic bath of cleaner and water. Sound waves
cause the solution to vibrate, which loosens the materials attached
to the instruments. Ultrasonic cleaners are beneficial because they
do not damage even the most delicate instruments, and workers do
not run the risk of an accidental sharps injury.
64 UNIT ONE INTRODUCTION TO MEDICAL ASSISTING
Select Appropriate Barrier/Personal Protective Equipment and Demonstrate Proper
PROCEDURE 3-5 Disposal of Biohazardous Material: Use Standard Precautions for Sanitizing
Instruments and Discarding Biohazardous Material
Goal: To follow Standard Precautions in removing all contaminated matter from instruments in preparation for disinfection or
sterilization while wearing appropriate personal protective equipment (PPE).
EQUIPMENT and SUPPLIES
• Sink with cold and hot running water
• Sanitizing agent or low-sudsing soap with enzymatic action
• Decontaminated utility gloves that show no signs of deterioration
• Chin-length face shield or goggles and face mask if contamination with
blood-borne pathogens is possible
• Impermeable gown
• Disposable brush
• Disposable paper towels
• Disposable gloves
• Disinfectant cleaner prepared according to manufacturer's directions
• Covered waste container with foot pedal
• Biohazard waste container with labeled red biohazard bag
PROCEDURAL STEPS
1. Put on an impermeable gown and face shield or goggles and mask if
potential for splashing of infectious material exists (Figure l).
PURPOSE: To provide personal protection against potentially infectious
matter.
2. Put on utility gloves.
PURPOSE: To provide personal protection against potentially infectious
matter and sharp instruments.
3. Separate the sharp instruments from other instruments to be sanitized.
PURPOSE: To prevent possible self-injury and exposure to infectious
matter.
4. Rinse the instruments under cold running water.
PURPOSE: To help remove debris and prevent coagulation of body fluids.
S. Open hinged instruments and scrub all grooves, crevices, and serrations
with a disposable brush (Figure 2).
PURPOSE: Microorganisms can hide under contaminants and may not be
destroyed by the disinfection process.
6. Rinse well with hot water.
PURPOSE: Hot water removes all soap and contaminant residue.
7. Towel-dry all instruments thoroughly and dispose of contaminated towels
and disposable brush in a biohazard waste container. Do not touch the
paper towel dispenser as you are obtaining towels.
PURPOSE: All contaminated material must be discarded in a labeled
biohazard container and/or a labeled red biohazard bag. Touching the
dispenser with the utility gloves contaminates the dispenser. Wet instru-
ments can rust or become dull and also dilute disinfectant or sterilizing
chemicals.
8. Remove the utility gloves and wash your hands according to
Procedure 3-4.
PURPOSE: To remove any possible contaminants.
9. Towel-dry your hands and put on disposable gloves. Decontaminate the
utility gloves and work surfaces using disinfectant cleaner.
PURPOSE: To prevent personal exposure to contaminants. All equipment
and working surfaces should be cleaned and decontaminated with a dis-
infectant to prevent transmission of infectious organisms.
10. Dispose of the contaminated towels in a covered waste container.
PURPOSE: All contaminated material must be disposed of in a labeled
biohazard container and/or a labeled red biohazard bag.
11. Place sanitized instruments in a designated area for disinfection or
sterilization.
PURPOSE: Sanitized instruments must be removed from the cleaning area
to prevent possible cross-contamination.
12. Remove the disposable gloves according to Procedure 3-1 . Dispose of the
gloves in a biohazard waste container. Sanitize the hands.
PURPOSE: To prevent the spread of infectious organisms and to remove
any possible contaminants.

Disinfection
Disinfection is the process of killing pathogenic organisms or of
rendering them inactive. It is not always effective against spores,
tuberculosis bacilli, and certain viruses. Disinfectant chemicals may
kill microbes within a short time, but they usually are very hard on
instruments. Some chemicals, such as Cidex, are effective enough to
kill all organisms, but the usual immersion time for these sterilants
is 10 hours or longer. For equipment and countertop surfaces, the
cheapest and most reliable method of disinfection is to use a 1 : 10
bleach solution. This is an effective and noncaustic disinfectant that
can be used to wipe laboratory countertops where human blood and
other body fluid samples are handled. It also can be used for soaking
reusable rubber goods before sanitization. In addition, bleach solu-
tion is an effective disinfectant for surfaces that have come in contact
with viruses, including HIV
Many types of disinfecting agents are available and have varying
degrees of effectiveness. It is important to follow the manufacturer's
guidelines on how to use each product properly and to understand
its advantages and disadvantages and the possible sources of error.
Disinfection is very difficult to verify, because no convenient
indicators ensure destruction of organisms. Even when the manu-
facturer's directions for chemical strength and immersion times are
followed, common errors can cause chemicals to lose their
effectiveness:
• Instruments are not thoroughly sanitized, and attached
organic matter inhibits or prevents the action of the disinfec-
tant. No chemical can kill unless it reaches all instrument
surfaces; therefore, complete sanitization is absolutely
necessary.
• Sanitized instruments are not dried, and the moisture on the
instruments dilutes the disinfectant solution beyond effective
concentration levels.
• The disinfectant solution is left in an open container, and
evaporation changes its concentration.
• Solutions are not changed after the recommended period for
use has expired.
• Solutions are not prepared properly or are not mixed properly
before use.
• The manufacturer's recommended temperature for use and
storage is not maintained.
Chemical disinfectants cannot be used on skin or tissues
because they can damage them. Therefore, antiseptics, such as
alcohol, are used on the skin to reduce the number of pathogens.
Alcohol is the most widely used antiseptic, but recent studies indi-
cate that it is not as effective as other products in inhibiting the
growth and reproduction of microorganisms on the skin's surface.
Other antiseptic chemicals, such as povidone-iodine solution
(Betadine), are effective antimicrobial agents that are safe to use on
a patient's skin.
Sterilization
Sterilization, or the destruction of all microorganisms, is essential
for surgical asepsis. Sterilization can be achieved by moist heat in
an autoclave, dry heat, ultraviolet or ionizing radiation, gas, or
with chemicals. Medical facilities typically use the autoclave
method. Steam under pressure in the autoclave is an excellent
method of sterilization because it kills all pathogens and spores.
CHAPTER 3 Infection Control 65
Guidelines for Disinfection of Endoscopes
Because typical sterilization procedures can damage endoscopes, high-level
disinfection of these instruments is crucial to prevent the spread of nosoca-
mial infections. Disinfection must follow the manufacturer's guidelines for
the instrument. This process has five steps:
1. Leak test. Pressurize the endoscope with air and submerge it in
water to check for damage or leaks.
2. Clean: Wipe and/or brush internal and external surfaces; brush
internal channels and flush each internal channel with water and a
detergent or enzymatic cleaner.
3. Disinfect. Immerse the endoscope in a high-level disinfectant or
chemical sterilant (e.g., Cidex). Aspirate and flush all channels with
the chemical for the length of time recommended by the
manufacturer.
4. Rinse: Rinse the endoscope and all channels with water to remove
the chemical disinfectant.
5. Dry: Rinse the insertion tube and inner channels with alcohol, and
dry with forced air before storage. Scopes should be hung vertically
to store.
CRITICAL THINKING APPLICATION 3-8
Rosa is responsible for the orientation of the new medical assistant in the
office's sanitization and disinfection procedures. Outline the important con-
cepts and methods of each.
You will learn more about surgical asepsis and the sterilization
process in the Surgical Asepsis and Assisting with Surgical Proce-
dures chapter.
ROLE OF THE MEDICAL ASSISTANT IN ASEPSIS
Asepsis is one of the few procedures that directly affect the health of
the patient, the provider, and the staff. The spread of pathogens in
the ambulatory care setting can be controlled only through effective,
consistent application of the Bloodborne Pathogens Standard and by
proper sanitization, disinfection, and sterilization of supplies, equip-
ment, and work surfaces.
The medical assistant must develop an inner sense for performing
aseptic procedures properly. It is important that these techniques be
done on such a routine basis that they become an unbreakable habit.
The use of disposable items is highly recommended for infection
control purposes. However, when disposable equipment is used, the
assistant must follow recommended disposal guidelines to ensure
infection control.
CLOSING COMMENTS
Patient Education
The medical assistant should take every opportunity to educate
patients about the infection process and ways to prevent the trans-
mission of disease. The best time to instruct a patient in aseptic
66 UNIT ONE INTRODUCTION TO MEDICAL ASSISTING

techniques that can be used at home is while performing the aseptic
procedure. For example:
• While washing your hands, explain to the patient that this
routine is particularly important for patients who are very
young or old or who seem to get sick frequently. Instruct the
patient that the hands should be washed before and after
meals; after sneezing, coughing, or blowing the nose; after
using the restroom; before and after changing a dressing; and
after changing an infant's diaper.
• Advise the patient to carry an alcohol-based hand rub and to
use it as indicated throughout the day.
• Explain to the patient that coughing or sneezing into a bent
elbow is an effective method for preventing the spread of
disease.
• Instruct the patient in the differences between sterile and
clean dressings and bandages. Demonstrate each step in
changing a dressing properly and explain how to dispose of
contaminated items.
A medical assistant can help patients live healthier lives in many
ways. For example, here are a few more suggestions for teaching the
patient about asepsis and infection control:
• Set up an information table in the waiting room with take-
home pamphlets and literature.
• Mail, e-mail, or post on the healthcare facility's website a
periodic newsletter to patients about infection control, espe-
cially during flu season.
• Demonstrate and explain aseptic procedures to patients and
family members, inviting them to participate.
Legal and Ethical Issues
Medical asepsis and infection control in ambulatory care practices
give rise to numerous legal and ethical concerns. Personal discipline
is the primary concern in medical asepsis. Typically, the medical
assistant is alone when performing an aseptic procedure; therefore,
if contamination occurs, he or she is the only one who knows. If
contamination should occur, the medical assistant must start over
again with clean supplies.
A primary reason for performing aseptic procedures completely
and effectively is to prevent the development of nosocomial infec-
tions in susceptible patients. These infections, which are acquired in
the healthcare environment, can be especially dangerous for elderly
or debilitated patients. Ignorance of the various aseptic techniques
or carelessness can be dangerous and is inexcusable before the law.
Professional Behaviors
One of the medical assistant's main responsibilities is to perform sanitiza-
tion, disinfection, and sterilization procedures with precision and total effec-
tiveness. There is no room for compromise. Patients should have absolute
assurance that they are being treated in an aseptic atmosphere and under
aseptic conditions. This assurance is just as important for the protection of
the provider and staff as it is for the patient. Allowing the provider to as-
sume that the correct aseptic techniques were used when preparing a
procedure and allowing him or her to use contaminated equipment on a pa-
tient may result in a malpractice lawsuit. Honesty on the part of the medical
assistant builds self-respect and contributes to professional achievement.

Partial List of CDC National Notifiable Infectious Conditions

Each state has laws requiring that certain diseases be reported to state health Examples of some of the infectious diseases that may be reported by
authorities when they are identified by healthcare providers, nurses, labora- individual states include:
tory directors, infection control practitioners, healthcare facilities, state institu-
tions, schools, or day care workers (see Procedure 3-6). However, it is Anthrax Mumps
voluntary for states to provide this information to the CDC. The list of report- Botulism Pertussis
able diseases varies among states and over time. Chlamydia trachomatis Poliovirus infection
The procedure for reporting public health threats varies among the states, infection Rabies, animal and human
but the general rules are as follows: Cholera Rubella
• Some infectious diseases, such as anthrax, measles, polio, and tuber- Diphtheria Salmonellasis
culosis, must be reported immediately by phone to the local health Giardiasis Smallpox
department and followed up with submission of a confidential case Gonorrhea Spotted fever rickettsiosis
report form. Hepatitis A, B, C Syphilis
• In addition ta the diseases identified by the state as reportable, any HIV infection Tetanus
unusual disease (e.g., severe food poisoning) that could possibly be Influenza-associated pediatric mortality Tuberculosis
caused by an infectious agent or toxin is reportable. Lyme disease Typhoid fever
• If there is acluster of cases of any communicable disease (e.g., head lice, Malaria Varicella
scabies, streptococcal sore throat), this outbreak should be reported. Measles Viral hemorrhagic fever
• States may require that cases of HIV infection, HIV-related illness, and Meningococcal disease
AIDS be reported on special forms.
Modified from wwwn.cdc.gov/NND55/script/Conditionlist.aspx?Type=O&Yr=2013. Accessed March 11, 2015.
*For the entire list, refer to the CDC website: wwwn.cdc.gov/NND55/script/Conditionlist.aspx?Type=O&Yr=2013

•;;m,imrniii Perform Compliance Reporting Based on Public Health Statutes
Goal: To report suspected or confirmed communicable diseases as mandated by state law.
Scenario: The provider is reviewing laboratory results on anew patient and notes that the patient is hepatitis Cpositive. Hepatitis
Cis areportable infectious disease, so the case must be reported to the local health department. The provider asks Rosa to file
the report. How should she perform this procedure?
EQUIPMENT and SUPPLIES
• Website, mailing address, phone number of the local health department
where the patient resides
• CDC website:
• To find state health departments: www.cdc.gov/mmwrjinternationaV
re/res.html
• To determine individual state reportable diseases: wwwn.cdc.gov/
NNDSS/script/Conditionlist. aspx? Type=O& Yr=2013
i-i1iiiiffiiti•jiii#iffiit•l------------------------------
1mp1ementing Standard Precautions throughout daily practice is crucial to the
welfare and protection both of the patient and the healthcare worker. Rosa
must be sure to wash her hands routinely and/or to use an alcohol hand rub.
She also must familiarize herself with the office's Exposure Control Plan; follow
OSHA's Bloodborne Pathogens Standard; use PPE when needed; follow
SUMMARY OF LEARNING OBJECTIVES
l. Define, spell, and pronounce the terms listed in the vocabulary.
Spelling and pronouncing medical terms correctly reinforce the medical
assistant's credibility. Knowing the definitions of these terms promotes
confidence in communication with patients and co-workers.
2. Describe the characteristics of pathogenic microorganisms.
Pathogenic microorganisms include viruses, bacteria, protozoa, fungi, and
rickettsiae. Viral microorganisms are intracellular parasites that take over
the deoxyribonucleic acid (DNA) or ribonucleic acid (RNA) of the invaded
cell. Bacteria are tiny, simple cells that produce disease by secreting
toxins, act as parasites inside human cells, or grow on body surfaces,
disrupting normal human functions. Bacteria are classified according to
their shape. Protozoa are unicellular parasites that can replicate and
multiply rapidly once inside the host. They are frequenrly carried by insects
that serve as vectors for the disease. Fungi may be unicellular or multicel-
lular; they include molds and yeasts and cause tine• infections. Rickettsia
are microorganisms that have characteristics of both bacteria and viruses;
they are obligate parasites that must live within a host cell for growth
but are larger than viruses so can be viewed with a microscope.
3. Do the following related to the chain of infection:
• Apply the chain-of-infection process to healthcare practice.
The chain of infection is the way infectious disease is spread. It begins
with the infectious agent and moves to the host, the means or portal
CHAPTER 3 Infection Control 67
PROCEDURAL STEPS
1. Search online for procedures for filing reportable diseases to the local health
department. New cases of hepatitis Cmust be reported within 24 hours,
but this can be done either online or by mail.
2. Complete the online form that requests details for new hepatitis Ccases
and submit it to the local health department.
3. Electronically save the submitted form and/or print a copy for the provider's
review.
environmental protection guidelines; use appropriate procedures for cleaning up
contaminated spills and other housekeeping controls; and understand postex-
posure follow-up if an accidental exposure occurs. In addition, Rosa must follow
guidelines for sanitization, disinfection, and sterilization of appropriate instru-
ments and equipment.
of exit from the host, the mode of transmission, and the means or
portal of entry into a new host. It ends with the presence of the
infection in a susceptible host. At least one of these links must be
broken to stop the spread of infection.
• Compare viral and bacterial cell invasion.
Bacterial infections can be treated with antibiotics, but viral infections,
which involve viral takeover of cellular DNA or RNA material, cannot
be treated with antibiotics because viruses are not cells but parasites
within a cell.
• Differentiate between humoral and cell-mediated immunity.
Humoral immunity creates specific antibodies to combat antigens
through the action of Bcells. The immune system also reacts at the
cellular level with T-cell activity in cell-mediated immunity by causing
the destruction of pathogenic cells at the site of invasion.
4. Summarize the impact of the inflammatory response on the body's
ability to defend itself against infection.
The inflammatory response is one aspect of the body's ability to
defend itself against infection. It involves the body's reaction to the
introduction of a foreign substance or antigen, an increase in blood
flow to the site, and the release of inflammatory mediators that attract
white blood cells to the site. WBCs isolate and destroy the source of
inflammation.
Continued
68 UNIT ONE INTRODUCTION TO MEDICAL ASSISTING
SUMMARY OF LEARNING OBJECTIVES-continued
5. Analyze lhe differences among acute, chronic, latent, and opportu-
nistic infections.
Acute diseases have a rapid onset and short duration. Chronic diseases
are present aver a long period, perhaps a lifetime. Latent diseases cycle
through relapse and remission phases. Opportunistic infections are caused
by organisms that are not typically pathogenic but that occur in hosts
with an impaired ar weakened immune system response, such as indi-
viduals with HIV.
6. Do the following related to OSHA standards for the healthcare
setting:
• Specify potentially infectious body fluids.
Potentially infectious body fluids include CSF; mucus; synavial, pleural,
pericardia!, peritoneal, and amniotic fluids; blaad; vaginal and seminal
secretions; saliva; and human tissue.
• Integrate OSHA's requirement for asite-based Exposure Control Plan
into facility management procedures.
OSHA requires incorporation of a site-based Exposure Control Plan into
facility management procedures. The plan must be revised annually
and must be available far employees ta review. It must reflect current
safety technology, identify employees at risk far exposure, and contain
specifics about protection from blaad-barne pathogens, including PPE,
training, hepatitis B immunization, exposure, fallow-up, record
keeping, and the labeling and disposal of all biohazard waste.
• Explain the maior areas included in the OSHA Compliance
Guidelines.
The OSHA Compliance Guidelines include barrier protection devices,
environmental protection, housekeeping controls, hepatitis Bimmuni-
zation, and postexposure fallow-up.
• Discuss protocols for disposal of biologic chemical materials.
States vary in their degree of regulation af disposal af hazardous
waste, ranging from na regulation to very strict rules. Typical regula-
tions include specific hazardous waste containers; the use of standard
precautions; the length of time that the containers should be kept on
site; the management of contaminated sharps; labeling and properly
packing chemicals far disposal; and hiring a biomedical waste disposal
service
7. Remove contaminated gloves while following Standard Precautions
principles.
Refer ta Procedure 3-1 .
8. Perform an eyewash procedure to remove contaminated material.
Refer ta Procedure 3-2.
9. Summarize the management of postexposure evaluation and
follow-up and participate in blood-borne pathogen training and a
mock exposure event.
Postexpasure evaluation and fallow-up are as fallows: The site is cleaned
and the exposed individual reports ta his or her supervisor immediately.
CONNECTIONS
OJ Study Guide Connection: Go to the Chapter 3 Study Guide. Read and complete
the activities.
Medical assessment is performed immediately. Testing of the source
individual's and the worker's blood is performed if possible and if consent
is given. Health counseling is provided. Strict confidentiality of all medical
records is maintained. Procedure 3-3 summarizes the steps required far
the management af a pastexposure needlestick.
l 0. Identify the regulations established by the Centers for Disease
Control and Prevention (CDC) that affect healthcare workers.
Table 3-1 summarizes the main points of the CD(s' Infection Prevention
Checklist that is ta be used by facilities ta systematically assess employee
adherence to infection prevention and to ensure that the facility has poli-
cies and procedures in place and adequate supplies available to prevent
infections at the site. The CDC has also developed specific hand hygiene
guidelines and guidelines far disinfection of endoscopes.
11. Apply the concepts of medical and surgical asepsis to the healthcare
setting.
Medical asepsis is the removal ar destruction af pathogens. Medical
aseptic techniques are used to reduce the number of microorganisms as
much as possible. Surgical asepsis is destruction of all microorganisms.
Surgical asepsis is used when the patient's skin or mucous membranes
are disrupted.
12. Discuss proper hand washing, and demonstrate the proper hand-
washing technique for medical asepsis.
Refer to Procedure 3-4.
13. Differentiate among sanitization, disinfection, and sterilization pro-
cedures and select appropriate barrier/personal protective equip-
ment while demonstrating the correct procedure for sanitizing
contaminated instruments.
Sanitization is cleaning of contaminated articles or surfaces to reduce the
number of microorganisms (refer to Procedure 3-5). Disinfection involves
the use of physical or chemical means to destroy pathogens or their
components on inanimate surfaces or abjects. Sterilization removes all
living microorganisms.
14. Discuss the role of the medical assistant in asepsis.
Asepsis affects the health of the patient, the provider, and the staff. The
medical assistant must develop the necessary skills as well as afirm grasp
of the principles involved far performing aseptic procedures properly.
15. Apply patient education concepts to infection control.
Take every opportunity ta demonstrate aseptic techniques, ta educate
patients about proper management of infectious materials at home, and
to emphasize the importance of frequent and consistent hand washing.
16. Discuss legal and ethical concerns regarding medical asepsis and
infection control and perform compliance reporting based on public
health statutes regarding reportable communicable diseases.
The medical assistant is responsible far applying infection control proce-
dures in all situations at all times to prevent cross-contamination and the
development of nosocomial infections in patients (refer to Procedure 3-6).
evolve Evolve Connection: Go to the Chapter 3 link at evolve.e/sevier.com/
kinn to complete the Chapter Review Quiz. Check out the other resources listed for this
chapter to make the most of what you have learned from Infection Control.
PATIENT ASSESSMENT 4
Chris Isaacson, (MA (MMA), works in an ambulatory care clinic at the com- needed from some of the patients. They do not always respond openly and
munity hospital. He is responsible for initial patient interviews, taking medical honestly to him, and the attending physician is not satisfied with his work. His
histories, and documentation. Chris is having difficulty gathering the information supervisor is responsible for helping him improve his interviewing skills.

While studying this chapter, think about the following questions:

• How can Chris learn to develop helping relationships so that the patient's • How can Chris's supervisor help him become a better communicator and
medical history is as comprehensive as possible? demonstrate comprehensive and accurate documentation in patients'
• Would it help if Chris displayed greater sensitivity to diverse populations? health records?
• Would using active listening techniques and attending to the patient's
nonverbal behaviors better enable Chris to develop therapeutic
communications skills?

LEARNING OBJECTIVES
1. Define, spell, and pronounce the terms listed in the vocabulary. • Detect a patient's use of defense mechanisms and the resultant
2. Employ the concept of holistic care in the patient assessment barriers to therapeutic communication.
process. • Demonstrate professional patient interviewing techniques.
3. Describe the components of the patients medical history and how to 9. Discuss the use of therapeutic communication techniques with patients
collect the history information. across the lifespan.
4. Discuss how to successfully understand and communicate with patients 10. Compare and contrast signs and symptoms.
and display sensitivity to diverse populations. 11. Document patient care accurately in the medical record.
5. Demonstrate therapeutic communication feedback techniques to obtain 12. Identify and define medical terms and abbreviations related to body
information when gathering a patient history. systems; also, use medical terminology correctty and accurately to
6. Respond to nonverbal communication when interacting with patients. communicate information to providers and patients.
7. Identify barriers to communication and their impact on patient 13. Differentiate the documentation systems used in ambulatory care
assessment; also, compare open-ended and closed-ended questions. practices.
8. Do the following related to the patient interview: 14. Explain "meaningful use" as it applies to the electronic health record
• Discuss the patient interview. (EHR).
• Identify barriers to communication and their impact on the patient 15. Describe the role of patient education, in addition to legal and ethical
assessment. issues, in the patient assessment process.
70 UNIT ONE INTRODUCTION TO MEDICAL ASSISTING
VOCABULARY
biophysical (bi-o-fi' -zi-kuhl) The science of applying physical
laws and theories to biologic problems.
cognitive (kog'-nuh-tiv) Pertaining to the operation of the mind;
referring to the process by which we become aware of
perceiving, thinking, and remembering.
congruence (kon-groo'-ents) Agreement; the state that occurs
when the verbal expression of the message matches the sender's
nonverbal body language.
familial Occurring in or affecting members of a family more than
would be expected by chance.
holistic Considering the patient as a whole including the physical,
emotional, social, economic, and spiritual needs of the person.
patient portal A secure online website that gives patients
convenient 24-hour access to personal health information;
A s medical professionals directly involved in gathering informa-
tion from patients about their health status, medical assistants
must remember that a healthy state is more than the absence of
disease. The assessment process should be a reflection of the entire
patient, not just a report about signs and symptoms. Individual
lifestyles and environmental factors can create disease and therefore
should be considered when we gather information about the patient's
chief complaint. For example, if a patient smokes or works in a
stressful occupation, he or she may be more prone to hypertension.
As health professionals, we should consider all patient factors,
including cognitive, psychosocial, and behavioral data, when gath-
ering information about the patient's health status. Consider this:
do you think a patient who has limited insurance coverage for pre-
scription drugs can always afford his medication? The method of
analyzing all factors that may contribute to the development of
disease is based on a holistic perspective. Holistic patient care
recognizes that illness is the result of many factors, not just
physical ones.
Assessment factors are a list of biophysical signs and symptoms.
As the first step in treating a disease process, the provider must
determine the patient's medical diagnosis. A differential diagnosis
considers which one of several diseases may be producing patient
symptoms. The possible causes for a set of symptoms are considered
in order to arrive at a diagnosis. For example, if a patient presents
with moderate to severe knee pain the provider might consider
causes like an injury or arthritis. A differential diagnosis is based on
information gathered from the patient about symptoms; contribut-
ing family, personal, and social histories; and a complete physical
examination. Multiple causes are not ruled out in a differential
diagnosis because it is possible for patients to be sick with more than
one thing at once. Once the provider has considered all the possible
factors, he or she comes up with a working diagnosis and begins
treatment. A working diagnosis is also called a clinical diagnosis. The
patients have a secure user name and password to view their
health information.
present illness The chief complaint, written in chronologic
sequence, with dates of onset.
psychosocial Pertaining to a combination of psychological and
social factors.
rapport (ra-por') A relationship of harmony and accord between
the patient and the healthcare professional.
signs Objective findings determined by a clinician, such as a
fever, hypertension, or rash.
symptoms Subjective complaints reported by the patient, such as
pain or visual disturbances.
clinical diagnosis is arrived at after taking a detailed history and
doing a comprehensive physical examination, but before any labora-
tory tests or x-rays, diagnostic testing is done. For the patient with
knee pain, after gathering detailed patient information and conduct-
ing a comprehensive physical examination, the provider decides that
the clinical diagnosis is arthritic changes in the joint. The provider
orders x-rays and an MRI of the knee to confirm the clinical diag-
nosis. The final diagnosis is determined after all of the diagnostic
studies are completed.
However, patient care does not start with the physical examina-
tion; it begins when the patient first makes contact with the office.
Even before the examination, the medical assistant has the opportu-
nity to interact with the patient to ensure that he or she feels com-
fortable during the process and that all the necessary information is
obtained.
Interviewing patients, assisting with examinations, and docu-
mentation are important responsibilities for a medical assistant. You
must know the components of a medical history and the techniques
for interviewing patients because these will help the provider diag-
nose and treat the patient. The more complete the medical history,
the better able the provider will be to treat the patient.
MEDICAL HISTORY
Collecting the History Information
When a new patient calls or comes in for an appointment, the person
is asked to complete a health history form. Besides being useful for
diagnosing and treating the patient, the self-history allows the
patient more participation in the process. The form may be mailed
to the patient's home before the appointment or may be completed
in the office during the first visit. Some practices now use electronic
forms; these can be e-mailed to the patient before the first appoint-
ment and incorporated into the patient's electronic health record

(EHR) when the completed form is e-mailed back. The patient may
also be able to complete the form online through a patient portal.
If a paper form is used, it can be scanned into the patient's EHR
after it is completed.
If you are responsible for taking a portion of the medical history,
conduct the interview in a private area free of outside interference
and beyond the hearing range of other patients. Patients will not talk
freely where they may be overheard or interrupted. Legally and ethi-
cally, the patient has the right to privacy, and access to the patient's
health record is permitted only for healthcare workers directly
involved in the patient's care or individuals the patient has specified
on his or her Health Insurance Portability and Accountability Act
(HIPM) release form.
Listen to the patient. Do not express surprise or displeasure at
any of the patient's statements. Remember, you are there not to
pass judgment, but to gather medical data. Documentation of
information gathered while taking the medical history is included
in the progress notes section of the medical record. The medical
assistant records the information in an organized manner, exactly
as given by the patient, without opinion or interpretation. The
progress notes should include the purpose of the patient's visit,
written as the chief complaint (CC), and the patient's vital signs
(VS), including height and weight, if preferred by the provider. In
addition, if the patient reports pain, it should be documented
using a scale of 1 to 10, with 1 being the least amount of pain and
10 being the greatest amount.
In some facilities the provider takes the medical history during
the patient's initial visit. The provider correlates the physical findings
in the examination with the information in the history. The com-
plete medical history and the physical examination are the starting
point and foundation of all patient-physician contacts. EHR systems
incorporate the patient's history and physical examination data
directly into the health record (Figure 4-1 ).
Components of the Medical History
Medical history forms vary, depending on the provider's preference,
the practice specialty, and the EHR system used in the facility
(Figure 4-2). The most commonly used medical history forms
include these components:
• Database: The record of the patient's name, address, date of
birth, insurance information, personal data, history, physical
examination, and initial laboratory findings. As new informa-
tion is added, it becomes part of this database.
• Chief complaint (CC) or present illness (history of present
illness [HPI]): The purpose of the patient's visit. The medical
assistant should gather as much information about the health
problem as possible and record it concisely, using the patient's
own words as often as possible.
• Past history (PH) or past medical history (PMH): A summary
of the patient's previous health. It includes dates and details
of the patient's usual childhood diseases (UCD or UCHD),
major illnesses, surgeries, allergies, accidents, and immuniza-
tion record. Each medical practice has a policy on how to
document a patient's allergies; they typically are written in red
ink or identified by a colored sticker so that all healthcare
workers can easily take note of potential allergic reactions.
CHAPTER 4 Patient Assessment 71
EHR systems have methods for including allergy information
on all pertinent screens in the patient's record. Included in the
patient's medication history should be a record of frequently
used over-the-counter (OTC) medications, including supple-
ments and currently prescribed drugs.
• Family history (FH): Details about the patient's parents and
siblings and their health; if they are deceased, the age and
cause of death. This information is important because certain
diseases and disorders have familial and/or hereditary
tendencies.
• Social history (SH): This section includes information about
the patient's lifestyle including whether he or she feels safe at
home; use of tobacco, alcohol, or recreational drugs; sleeping
and exercise habits; typical diet; education and occupation;
dental care history; and for female patients their last menstrual
period (LMP), pregnancy history, and method of birth control
if sexually active. It may be important to note the patient's
cultural and religious background, because these could influ-
ence certain lifestyle and dietary choices. This information
helps the physician to plan treatment for the patient or to
determine causative factors for disease. It also provides a holis-
tic picture of the patient's health.
• Systems review (SR) or review ofsystems (ROS): These questions
provide a guide to the patient's general health and help detect
conditions other than those covered under the present illness.
Often a patient may think certain health problems irrelevant
and may fail to mention them. However, these problems may
help the provider determine the cause of the disorder currently
being explored. A systems review is obtained through a logical
sequence of questions about the state of health of body
systems, beginning with the head and proceeding downward
(Figure 4-3). The provider typically completes this section
of the medical history while conducting the physical
examination.
UNDERSTANDING AND COMMUNICATING
WITH PATIENTS
To provide high-quality patient care, we must communicate effec-
tively with the patient and provide a warm, caring environment.
Positive reactions and interactions with the patient are vital. Because
medical care by nature is extremely personal, a medical assistant must
always remember that each patient is an individual with certain
anxieties. These anxieties often cause people to act and react in dif-
ferent ways; therefore, effective verbal and nonverbal communica-
tion with each patient is absolutely essential.
Healthcare professionals accept the responsibility of developing
helping relationships with their patients. The interpersonal nature
of the patient-medical assistant relationship carries with it a
certain amount of responsibility to forget one's self-interest and
focus on the patient's needs. A medical assistant can elicit either a
positive or a negative response to patient care simply by the way
he or she treats and interacts with patients. You usually are the
first person with whom the patient communicates; therefore, you
play a vital role in initiating therapeutic patient interactions
(Procedure 4-1 ).
72 UNIT ONE INTRODUCTION TO MEDICAL ASSISTING

Front Off,ce Coding & B Jng

Patient Charting a Calecld,r 181 Conesl)Ol1dence P nt Oetoogrophca

Ratnw ter, EU E

Record

Phone Encounter
He.11th History

Diagnoatica I l b Re Ultl Medical HiatCKY Social and f 1111lly Hleiory Pregnancy Hlatory

Family Hl$tory

Wllo •• NI the home?

Encounter Type .... Name Age Rd tionahip ActJon

Uo data av dable II la

1Hiii5
0o you feel • e In your home? Yes llo Com,,,

Pltemal

Age (if living) MedlCII Condi ion Action

' Encounter Type
~ tlodita V

ittiii5
temal

Encou nter Type .... Rel tionahlp Age (if I vlng) Age tO th Medical Condition Action

llodata a,

1Hf/i5
lit St ua: -SELECT- • Com ts·

W1::P Cancel

FIGURE 4-1 Example of an electronic health record (EHR) system.

Sensitivity to Diverse Patient Groups CRITICAL THINKING APPLICATION 4-1

Practicing respectful patient care is extremely important when
working with a diverse patient population. Empathy is the key to
creating a caring, therapeutic environment. Empathy goes beyond
sympathy. A medical assistant who is empathetic respects the indi-
viduality of the patient and attempts to see the person's health
problem through his or her eyes, recognizing the effect of all holistic
factors on the patient's well-being. Empathetic sensitivity to diversity
first requires those interested in healthcare to examine their own
values, beliefs, and actions; you cannot treat all patients with care
and respect until you first recognize and evaluate personal biases. We
think and act a certain way for many reasons. The first step in
understanding the process is to evaluate your individual value system.
Why do you have certain attitudes or beliefs about the worth of
individuals or things?
What do you value most in life? What is important to you? What influences
you to act in a certain way? Make a list of five things you value the most
and share them with the class. Try to determine why you feel so strongly
about those particular things.
Many different factors influence the development of a value
system. Value systems begin as learned beliefs and behaviors. Fami-
lies and cultural influences shape the way we respond to a diverse
society. Other factors that influence reactions include socioeconomic
and educational backgrounds. To develop therapeutic relationships,
you must recognize your own value system to determine whether it
could affect your method of interaction. Preconceived ideas about
 CHAPTER 4 Patient Assessment 73

MEDICAL RECORD
I I
NAME AGE SEX S/M/D/W
ADDRESS PHONE DATE
SPONSOR ADDRESS
OCCUPATION REF BY ACKN

I CHIEF COMPLAINT
PRESENT ILLNESS
I
FAMILY HISTORY
MOTHER FATHER SIBLING(S)
TB DIAB MALIG HTDIS NEPH EPILEP PSYCH
PAST HISTORY - GENERAL HEALTH GASTROINTESTINAL
CHILDHOOD DISEASES APPETITE BOWEL HABITS VOMITING
SC FEV RHEUM FEV ASTHMA INDIGESTION HEMORRHOIDS BLEEDING
OTHER NAUSEA DIET ITCHING
SOCIAL HISTORY JAUNDICE PAIN PAIN WITH STOOL
COFFEE TOBACCO ALCOHOL DRUG USE OTHER
WEIGHT URINARY TRACT
USUAL WEIGHT NOCTURIA INCONTINENCE INFECTION
RECENT WEIGHT FLUCTUATIONS PAIN FREQUENCY
HX OF EATING DISORDER BLEEDING BURNING
REVIEW OF SYSTEMS GENITAL TRACT
EENT AGEATMENST TYPE PERIOD
EYES EARS NOSE THROAT NECK PAINFUL PERIOD INTERMITTENT BLEEDING
NEUROMUSCULAR AMENORRHEA DYSMENORRHEA
STRENGTH ANXIETY VAG DISCH IRRITATION
SLEEP DEPRESSION BREAST EXAM PROSTATE EXAM
MUSCULAR PAIN PERIPHERAL NEUROPATHY TESTICULAR EXAM
JOINT PAIN LMP
CARDIOVASCULAR AGES OF CHILDREN CONTRACEPTION TYPE
HEART DISEASE Ml LMP DATE NO. OF PREGNANCIES
CONGENITAL HEART DEFECTS TIAS NO. OF LIVE BIRTHS AGES OF CHILDREN
HYPERTENSION STROKE OTHER
EDEMA

LUNGS
ACCIDENTS
PAIN DYSPNEA
COUGHING UP BLOOD COUGH
IRREG BREATHING

OPERATIONS CURRENT MEDICATIONS AND TREATMENTS

I COMMENTS

I
FIGURE 4-2 Ageneral medical history form.
74 UNIT ONE INTRODUCTION TO MEDICAL ASSISTING

Front Off"ice Coding & Bllhng

Patient Charting • C M 181 Cofresponcl e 4 P nt Oemogr,phocs Find P

Bowden, C rlC
IN FO PAN EL
Bowden, Carl C 04'0 1954 ~
P llent D hboard
Record .,,.
Office VISII I

Yee No HEENT Yee No

Pllone Encounter
HA &med
Diagnolla I L b R11u1t1
R1n91n9
Dc_::aiess De es,

Ear Ache Vert,go

Sore Throat Epcst 1$

Discharge H0MSe

Cardi c RHp Yee No GI Yee No

ChestP., C0\19h Const,p
p a s Congest,on

DOE Expecto, •tlon

Ed a 1'111 Zlll9
PtlO SOB
Diaphores,s Hemoptysis

GU Yee No MS Yee No
Oysur11 y.ii,11 e
lnconmence Bact P•
Fr uency Rad lion Rashes
tJoctur11 Jo,nt p

St,ual Oyslvnct,on 81UIS_,9

lrreiiul.v enses ln)Jfy ltcM19

Neuro Yee No Psych Yee No

I, mory Loss Dep,ession
Conlvsion •
'ukness
A1 ,..,

FIGURE 4-3 Example of review of systems (ROS) questions in an EHR.

Demonstrate Therapeutic Communication Feedback Techniques to Obtain Patient

PROCEDURE 4-1
Information and Document Patient Care Accurately in the Medical Record

Complete this procedure with another student playing the role of the patient. To make the experience more realistic, choose a
student about whom you know very little. To maintain the student's privacy, he or she does not have to share any confidential
information.
Goal: To use restatement, reflection, and clarification to obtain patient information and document patient care accurately.
EQUIPMENT and SUPPLIES PROCEDURAL STEPS
• History form or EHR system with the patient history window opened 1. Greet and identify the patient in a pleasant manner. Introduce yourself
• If using a paper form - a red pen for recording the patient's allergies, and and explain your role.
a black pen to meet legal documentation guidelines PURPOSE: To make the patient feel comfortable and at ease.
• Quiet, private area

•;;111!,11mjii• -continued
2. Take the patient ta a quiet, private area for the interview and explain why
the information is needed.
PURPOSE: Aquiet, private area is necessary to protect confidentiality and
prevent interruptions. An informed patient is more cooperative and there-
fore more likely to provide useful information.
3. Complete the history form by using therapeutic communication techniques,
including restatement, reflection, and clarification. Make sure all medical
terminology is adequately explained. Aself-history may have been mailed
to the patient before the visit. If so, review the self-history for
completeness.
PURPOSE: Therapeutic communication techniques help the medical assis-
tant gather complete information; the self-history is designed to save time
and to involve the patient in the process.
4. Speak in a pleasant, distinct manner, remembering to maintain eye
contact with your patient.
PURPOSE: Positive nonverbal behaviors create a friendly, caring
atmosphere.
S. Remain sensitive to the diverse needs of your patient throughout the
interview process.
PURPOSE: Incorporate awareness of your personal biases into treating all
patients with respect despite their diverse backgrounds.
6. Record the following statistical information:
• Patient's full name, including middle initial
• Address, including apartment number and ZIP code
• Marital status
• Sex (gender)
• Age and date of birth
• Telephone numbers for home, cell, and work
• Insurance information if not already available
• Employer's name, address, and telephone number
7. Record the following medical history:
• Chief complaint
• Present illness
• Past history
• Family history
• Social history
PURPOSE: The provider needs this information to make an accurate
assessment and diagnosis. The provider usually completes the review of
systems (ROS) during the pre-examination interview.
8. Ask about allergies to drugs and any other substances and record any
allergies in red ink on every page of the history form, on the front of the
CHAPTER 4 Patient Assessment 75
patient record, and on each progress note page; in the EHR, enter allergy
information where designated.
PURPOSE: The presence of an allergy may alter medication and treatment
procedures.
9. If using a paper form, record all information legibly and neatly and spell
words correctly. Print rather than writing in cursive. Do not erase, scribble,
or use whiteout. Do not leave any blank spaces or skip lines between
documentation entries. If yau make an error, draw a single line through
the error, write "error" above it, add the correction, and initial and date
the entry. If recording the information in the patient's EHR, accurately
locate each box; errors in the EHR should be corrected and are automati-
cally tracked within the system.
PURPOSE: To maintain a medical record that is understandable and defen-
sible in a court of law.
10. Thank the patient for cooperating and direct him or her back to the recep-
tion area.
11. Review the record for errors before you pass it to the provider or exit the
EHR health history area.
12. Protect the integrity of the health record and the confidentiality of patient
information. Safeguards mandated by the Health Insurance Portability and
Accountability Act (HIPAA) include:
• Passwords to secure access to all EHRs.
• Computer monitor shields to protect patient information if data are left
on the screen.
• Turning monitors away from patient traffic areas to prevent accidental
release of information.
• Securing all medical records
PURPOSE: Patient information may be legally and ethically shared only
with a member of the healthcare team who is directly providing care to
the patient.
DOCUMENTATION PRACTICE
Mr. Bonski is a new patient being seen today for the first time. His CC is diz-
ziness for 2 weeks. He denies having headaches and has no previous Hx of
ear infections or hypertension. He does not take any prescribed medications but
uses Tylenol as needed for a headache. T97.6, P 88, R21, BP 172/94.
Document pertinent patient findings using the SOAP method.
$ _ _ _ _ _ _ _ _ _ _ _ __
O_ _ _ _ _ _ _ _ _ _ _ __
A_________________
p_________________
76 UNIT ONE INTRODUCTION TO MEDICAL ASSISTING
FIGURE 4-4 Respectful patient care.
people because of their race, religion, income level, ethnic origin,
sexual orientation, or gender can act as barriers to the development
of a therapeutic relationship. You cannot treat your patients empa-
thetically unless you can connect with them in some way. Personal
biases or prejudices are monumental barriers to the development of
therapeutic relationships (Figure 4-4).
CRITICAL THINKING APPLICATION 4-2
Honestly evaluate your personal biases. What do you find unacceptable in
people? Do you prejudge an individual based on his or her affiliation with
a particular group or because of a certain lifestyle decision? Do these biases
create barriers to the development of therapeutic relationships? If so, how
can you get beyond these barriers?
Consider the following scenarios and discuss them with your
classmates:
• While you are conducting a patient interview, the patient informs
you that he has tested positive for the human immunodeficiency
virus (HIV). Do you think this will affect your therapeutic
relationship?
• You are responsible for recording an inilepth interview on a home-
less person with very poor hygiene. Will this cause a problem with
your professional manner?
• You are told by your office manager that an inmate of the county
prison is being brought in this afternoon for an examination. Do you
think his status will affect your interaction with the patient?
• You are attempting to interview a 20-year-old patient who brought
her two young children with her to the office today. She is a single
mother who is pregnant with her third child and receives public
assistance. What do you think? Will you have difficulty being
empathetic?
Therapeutic Techniques
The linear communication model describes communication as an
interactive process involving the sender of the message, the receiver,
and the crucial component of feedback to confirm reception of the
message. The message can be sent by a number of different methods,
Sensitivity to Diverse Patient Populations
Regardless of the type of healthcare facility in which you work, you will
care for a wide variety of patients. The medical assistant should take the
initiative to learn about the cultures represented in the healthcare practice.
Some points to consider about diverse groups include the following:
• Patients of Asian backgrounds may have been raised in a culture
that considers it extremely rude to establish eye contact. Americans
view an unwillingness to establish eye contact as a sign of distrust
or embarrassment; however, far people from Japan or China, lack
of eye contact may be a way of demonstrating respect.
• Personal space may be an issue far patients from diverse back-
grounds. If a patient appears very uncomfortable with touch or lack
of personal space, attempt to accommodate him or her as much as
possible during the office visit.
• Research has shown that older people face unique communications
problems in the healthcare environment. When caring far an aging
individual, it is important to focus patient teaching and information
on the patient rather than the family member who may be present.
• Patients may use their religious beliefs and values ta understand
and cope with their health problems. However, using religion to
guide healthcare decisions may result in a conflict with the pro-
vider's recommendations. Healthcare workers may need to find a
balance between respect for a patient's beliefs and the delivery of
high-quality healthcare.
such as face-to-face communication, telephone, e-mail, and letter;
however, there is no way to confirm the message was actually received
unless the patient provides feedback about what he or she interpreted
from the message. Feedback completes the communication cycle by
providing a means for us to know exactly what message the patient
received and therefore whether it requires clarification.
For example, as a medical assistant, one of your responsibilities
will be to provide patient education on how to prepare for diagnostic
studies. Let's say you have to explain to an elderly patient how to
prepare for a colonoscopy. Even though you provide a detailed
explanation of the preparation procedure, in addition to a handout
explaining the step-by-step process, how do you really know whether
the patient understands? You ask the patient to provide feedback by
explaining the process back to you. AI, a member of the healthcare
team, you must become an effective communicator. You will play a
vital role in collecting and documenting patient information. If your
methods of collection or recording are faulty, the quality of patient
care may be seriously impaired.
Active Listening Techniques
Active listeners go beyond hearing the patient's message to concen-
trating, understanding, and listening to the main points in the dis-
cussion. Active listening techniques encourage patients to expand on
and clarify the content and meaning of their messages. These tech-
niques are very useful communication tools when a patient is agi-
tated or upset because they help the medical assistant clarify the
important details of the patient's chief complaint.
 CHAPTER 4 Patient Assessment 77

Three processes are involved in active listening: restatement, a favorable effect on others. The favorable effect may consist of pro-
reflection, and clarification. Restatement is simply paraphrasing or viding emotional support, conveying that you care, defusing the
repeating the patient's statements with phrases such as, "My under- patient's fear or anger, or providing an invitation to release pent-up
standing of what you are sayin ... " or "You are telling me the feelings by talking about the situation that aroused the feelings. Table
problem is ... " 4-1 lists some nonverbal behaviors by patients that may indicate
Reflection involves repeating the main idea of the conversation anxiety, frustration, or fear.
while also identifying the sender's feelings. For example, if the mother
of a young patient is expressing frustration about her child's behav-
ior, a reflective statement identifies that feeling with the response, Helpful Listening Guidelines
"It sounds like you are frustrated about ... " Or, if a patient who has
been newly diagnosed with insulin-dependent diabetes shows anxiety
• Listen to the main points in the discussion.
about administering injections, an appropriate reflective statement • Attend to both verbal and nonverbal messages.
recognizes the patient's feelings: "You appear anxious about ... " • Be patient and nonjudgmental.
Reflective statements clearly demonstrate to patients that you are not • Do not interrupt.
only listening to their words; you also are concerned and are attend- • Never intimidate your patient.
ing to their feelings. • Use active listening techniques: restatement, reflection, and
Clarification seeks to summarize or simplify the sender's thoughts clarification.
and feelings and to resolve any confusion in the message. Questions
or statements that begin with "Give me an example of ... " or "Explain
to me about ... " or "So what you're saying is ... " help patients focus You can do much to put a patient at ease by the tone of your
on the chief complaint and give you the opportunity to clear up any voice. Your facial expression and the ease and confidence of your
misconceptions before documenting patient information. movements demonstrate a sincere interest to the patient. Therapeutic
Listening is not a passive role in the communication process; it use of space and touch also are important ways of sending nonverbal
is active and demanding. You cannot be preoccupied with your own messages to your patients. You should establish eye contact, sit in a
needs, or you will miss something important. For the duration of relaxed but attentive position, and avoid using furniture as a barrier
the patient interview, no one is more important than this particular between you and the patient. Give the patient your undivided atten-
patient. Listen to the way things are said, the tone of the patient's tion and let your body language inform each patient that you
voice, and even to what the patient may not be saying out loud but are interested in his or her medical problems (Figure 4-5 and
is saying very clearly with body language. Procedure 4-2).
The key to successful patient interaction is congruence between
Nonverbal Communication verbal and nonverbal messages. Although choosing the correct words
Much of what we communicate to our patients is conveyed through is very important, less than 10% of the message received is verbal;
the use of conscious or unconscious body language. Our nonverbal therefore, to be seen as honest and sensitive to the needs of your
actions, such as gestures, facial expressions, and mannerisms, are patients, you must be aware of your nonverbal behavior patterns.
learned behaviors that are greatly influenced by our family and cultural The nonverbal message the patient receives from the medical assis-
backgrounds. The body naturally expresses our true feelings; in fact, tant's listening behavior should be, "You are a person of worth, and
experts say that more than 90% of communication is nonverbal. I am interested in you as a unique individual."
Most of the negative messages communicated through body lan-
guage are unintentional; therefore, it is important to remember while
conducting patient interviews that nonverbal communication can
TABLE 4-1 Observation of Nonverbal
seriously affect the therapeutic process.
The verbal messages you send are only part of the communication Communication in Patients
process. You have a specific context in mind when you send your AREA OBSERVATION INDICATION
words, but the receiver puts his or her own interpretations on them.
The receiver attaches meaning determined by his or her past experi-
Breathing Rapid respirations, sighing, shallow Anxiety, boredom,
ences, culture, self-concept, and current physical and emotional patterns thoracic breathing pain
states. Sometimes these messages and interpretations do not coin- Eye No eye contact, side-to-side movement, Anxiety, distrust,
cide. Feedback from the patient is crucial in determining whether patterns looking down at the hands embarrassment
the patient understood the message. Successful communication
requires mutual understanding by the interviewer and the person Hands Tapping fingers, cracking knuckles, Anxiety, worry, fear
being interviewed. continuous movement, sweaty palms
Observing your patient during the interview fosters mutual un-
derstanding. The purpose of observing nonverbal communication is
Arm Folded across chest, wrapped around Anxiety, worry,
to become sensitive to or aware of the feelings of others as conveyed
placement abdomen fear, pain
by small bits of behavior rather than words. This sensitivity enables Leg Tension, crossed and/or tucked under, Frustration, anger
you to adapt your behavior to these feelings; to deliberately select placement tapping foot, continuous movement
your response, either verbal or nonverbal; and thereby to have
78 UNIT ONE INTRODUCTION TO MEDICAL ASSISTING
A
FIGURE 4-5 A, Ineffective nonverbal language. B, Therapeutic nonverbal language.
Nonverbal Language Behaviors
Nonverbal behavior-your body language-can have either a positive or
negative effect on patient interactions. Positive nonverbal behaviors
enhance the patient's experience in the healthcare setting. Communication
experts recommend the following:
• When gathering a health history, lean toward the patient to show
interest.
• Face the patient squarely and at eye level to help make the process
more comfortable and to demonstrate sensitivity and empathy.
• Eye contact is essential for therapeutic communication unless the
patient is from a culture that discourages this.
• Aclosed posture (crossed arms or legs) may indicate disinterest.
• Be sensitive to the patient's personal space when possible. Maintain
a comfortable distance from the patient, at least an arm's length,
when conducting the interview.
• Be careful with bady gestures, such as hand and arm movements.
Gestures, such as nodding your head when the patient talks, can
display interest, but too much body movement can be distracting.
• Your tone of voice should reflect your interest in the patient. Speak-
ing too quietly or too loudly can detract from therapeutic
communication.
• Continually observe the patient's body language during the inter-
view; watch for signs of confusion, boredom, worry, and so on so
that you can respond appropriately.
• Documenting in an EHR can be distracting to both the medical
assistant and the patient. Remind yourself to frequently look at the
patient and use encouraging body language to maintain a personal
interaction with the patient.
Environmental Factors
Before you meet with the patient, prepare the physical setting,
which may be an examination room or an office. In any location,
optimum conditions are important to achieving a smooth,
productive interview.
Open-Ended Questions or Statements
An open-ended question or statement asks for general information
or states the topic to be discussed, but only in general terms. Use
this communication tool to begin the interview, to introduce a new
section of questions, or whenever the person introduces a new topic.
It is a very effective method of gathering more details from the
patient about the chief complaint or health history. Examples
include:
"What brings you to the doctor?"
"How have you been getting along?"
"You mentioned having dizzy spells. Tell me more about that."
This type of question or statement encourages patients to respond
in a manner they find comfortable. It allows patients to express
themselves fully and provide comprehensive information about their
chief complaint.
Closed Questions
Direct, or dosed, questions ask for specific information. This form
of questioning limits the answer to one or two words, in many cases
yes or no. Use this form of question when you need confirmation
of specific facts, such as when asking about past health problems.
For example:
"Do you have a headache?"
"What is your birth date?''
"Have you ever broken a bone?"
 CHAPTER 4 Patient Assessment 79

•;;mij;mmjfj Respond to Nonverbal Communication

Complete this procedure with another student playing the role of the patient. To make the experience more realistic, choose a
student about whom you know very little. To maintain the student's privacy, he or she does not have to share any confidential
information.
Goal: To observe the patient and respond appropriately to nonverbal communication.
Scenario: Jessica Simpert, 39, is a new patient with the CC of intermittent abdominal pain with alternating diarrhea and
constipation. Ms. Simpert has experienced this discomfort for several months and appears very frustrated. She is sitting on the
end of the exam table with her arms wrapped around her abdomen. She sighs frequently and refuses to maintain eye contact.
What is her nonverbal behavior telling you, and how can you establish therapeutic communication with this patient?
EQUIPMENT and SUPPLIES PURPOSE: Therapeutic communication techniques help the medical assis-
• Patient's record tant gather complete information; using feedback techniques and making
sure the patient understands medical terms helps relieve anxiety.
PROCEDURAL STEPS 4. Speak in a pleasant, distinct manner, remembering to maintain eye contact
1. Greet and identify the patient in a pleasant manner. Introduce yourself and with your patient.
explain your role. PURPOSE: Positive nonverbal behaviors create a friendly, caring atmo-
PURPOSE: To make the patient feel comfortable and at ease. sphere. Remain sensitive ta the diverse needs of your patient throughout
2. Ask the patient the purpose of her visit and the onset, duration, and fre- the interview process.
quency of her symptoms. Pay close attention ta her body language to S. Continue to observe nonverbal patient behaviors and select the appropriate
determine whether what she is telling you is congruent with her body verbal response to demonstrate your sensitivity to her discomfort, frustra-
language. tion, and anxiety.
PURPOSE: Nonverbal language naturally expresses the patient's true feel- PURPOSE: Displaying sensitivity and awareness to the patient's nonverbal
ings. Closely observing body language will help yau reach mare accurate body language demonstrates your concern for the patient and can help
conclusions about the patient's information. defuse the patient's concerns.
3. Use restatement, reflection, and clarification to gather as much information
as possible about the patient's CC. Make sure all medical terminology is
adequately explained.

INTERVIEWING THE PATIENT
The interview, or gathering the patient's medical history, is the
first and most important part of data collection. The medical
history identifies the patient's health strengths and problems and is
a bridge to the next step in data collection, the physical examination
performed by the provider. At this point, the patient knows every-
thing about his or her own health status and you know nothing.
Your skill in interviewing helps glean the necessary information and
builds rapport for a successful working relationship.
Consider the interview a type of contract between you and your
patient. The contract consists of spoken and unspoken language and
addresses what the patient needs and expects from the healthcare
visit. The patient interview consists of three stages: the initiation or
introduction, the body, and the closing.
The initiation of the interview is the time to introduce yourself,
to identify the patient, and to determine the purpose of the interview
(Figure 4-6). If you are nervous about how to begin, remember to
keep it short. The patient probably is nervous, too, and is anxious
to get started. Address the patient by his or her last name and give
the reason for the interview. For example: "Mr. Coleman, my name
is Stacey, and I am a certified medical assistant who works with Dr.
Yang. I have some questions to ask you about your health history."
After the brief introduction, move on to the body of the inter-
view. This is when you use various therapeutic communication tech-
niques to determine the reason the patient is seeking healthcare,
the patient's perception of the problem, the characteristics of the
problem, and the patient's expectations of care. During this time,
use active listening skills, meaningful silence, congruent verbal and
nonverbal communication, and a combination of open-ended and
closed statements and questions to gather the details of the patient's
history and current health problem (Table 4-2).
Conclude the interview by summarizing the results of your
interaction. The closing of the interview should clarify the patient's
chief complaint, the purpose of the health visit, and the patient's
expectations of care. This is the patient's opportunity to add any
additional details or to explain further the characteristics of the
health problem.
80 UNIT ONE INTRODUCTION TO MEDICAL ASSISTING
Preparing the Appropriate Environment
• Ensure privacy: Make sure the room you use is unoccupied for the
entire time allowed for the interview. The patient needs to feel sure
that na one can overhear the conversation or interrupt.
• Prevent interruptions: Inform your co-workers af the interview, and
ask them not ta interrupt you during this time. You need to concentrate
on the patient and establish rapport. An interruption can destroy in
seconds what you have spent many minutes building up.
• Prepare comfortable surroundings: Conducting the interview in com-
fortable surroundings reduces the patient's anxiety. Keep the distance
between you and the patient at arm's length. Arrange chairs so that
you and the patient are comfortably seated at eye level, and the desk
or table does not act as a barrier between you.
• Take judicious notes: Note taking should be kept to a minimum while
you try to focus your attention on the person. Note taking during the
interview has disadvantages, such as breaking eye contact and shifting
your attention away from the patient, which diminishes the patient's
sense of importance. However, it is important to write down pertinent
details as you are interviewing, because you may forget important facts
if you do not note them at the time of the discussion. With experience
you will develop a personal type of shorthand that you can use during
the interview process. If using an EHR medical history template, effi-
ciently open boxes and choose the appropriate data, maintaining eye
contact and using active listening techniques periodically throughout the
interview.
FIGURE 4-6 Greeting the patient.
Interview Barriers
Providing Unwarranted Assurance
Mrs. Miller says to you, "I know this lump is going to turn out to
be cancer." The typical reply is almost automatic: "Don't worry, I'm
sure everything will be fine." This type of answer indicates that her
anxiety is insignificant and denies her the opportunity to discuss her
fears further. A reflective response, such as, "You sound really worried
about ... " acknowledges her feelings and demonstrates empathy and
a willingness to listen to her concerns.
TABLE 4-2 Therapeutic Communication
Techniques
TECHNIQUE VALUE
Open-ended questions Encourage the patient to respond in more detail
and statements
Direct or closed Ask for specific information; usual reply is yes
questions ar no
Active listening Nonverbally communicates your interest in the
patient
Silence Nonverbally communicates your acceptance of the
patient and willingness to wait until the patient is
ready to answer
Establishing guidelines Informs the patient of what to expect during the
interview
Acknowledgment Shows the importance of the patient's role and
respect for autonomy
Restating Checks your interpretation of the patient's
message for validation
Reflecting Shaws the patient your acknowledgment of his or
her feelings
Summarizing Helps the patient separate relevant from irrelevant
material; provides clarity to the interview
Giving Advice
Mrs. Thompson has just finished talking to the doctor. She looks at
you and says, "Dr. Rowe says I need surgery to get rid of these
gallstones. I just don't know. What would you do?" If you tell her
how you would handle the situation, you may have shifted the
accountability for decision making from her to you, and she has not
worked out her own solution. Does this woman really want to know
what you would do? Probably not. You could respond to her ques-
tion with, "Based on what the doctor told you, what do you think
you should do?" or "Do you need further information to make your
decision?" If the patient continues to question the provider's recom-
mendations, the medical assistant should encourage further discus-
sion with the provider.
Using Medical Terminology
You must adjust your vocabulary to fit the patient. The more the
patient understands about what is happening and the management
of the problem, the better the outcome. Misinterpreted communica-
tion is the most common error in patient care. One of the biggest
problems for the patient is understanding medical terminology.
Closely observe the patient's body language while he or she receives
instructions or patient education. If the patient shows signs of not
understanding the procedure, ask the patient to repeat back to
you the information or instructions. This demonstration-return

demonstration form of providing feedback ensures that the patient
completely understands what is happening. It also gives the medical
assistant the opportunity to clarify any misconceptions.
Leading Questions
During the interview, you ask the patient, "You don't smoke, do you?"
By asking questions in this manner, you indicate the preferred answer.
Telling you that he or she does smoke would surely meet with your
disapproval. Keep your questions positive. A better way of asking
would be, "Have you ever smoked?" or "Do you use tobacco?"
Talking Too Much
Some medical assistants associate helpfulness with verbal overload.
The patient may let the interviewer talk at the expense of his or her
own need to explain what is wrong. Always remember that when
interviewing a patient, you should listen more than you talk. Pay
Defense Mechanisms
Patients may use defense mechanisms to protect themselves from a situation
or medical information they cannot manage psychologically. Defense mecha-
nisms may hide any of a variety of thoughts or feelings: anger, fear, sadness,
despair, or helplessness. Apatient who uses defense mechanisms can be very
difficult to deal with; however, if the medical assistant is aware of the patient's
need for psychological protection, he or she may be able to find a way to
provide care for the patient while maintaining a therapeutic relationship. For
example, Mrs. Alicia Simone, a 48-year-old patient, has just been told she
has breast cancer. The following are defense mechanisms she might display
to protect herself from the psychological reality of her disease.
• Denial: The patient completely rejects the information. Example: "
I couldn't possibly have breast cancer. You must be mistaken."
• Suppression: The patient is consciously aware of the information or
feeling but refuses to admit it. Example: "I don't think the test is
accurate. My mammograms are always normal."
• Reaction formation: The patient expresses her feelings as the oppo-
site of what she really feels. Example: If she is angry at the medical
assistant for insisting that a biopsy be scheduled, she may express
the opposite emotion: "I appreciate your trying to help me, but I just
can't come to the hospital that day."
• Projection: The patient accuses someone else of having the feelings
that she has. Example: If the patient is angry about the diagnosis,
CRITICAL THINKING APPLICATION 4-3
Mr. Gonzales, a 48-year-old patient recently diagnosed with hypertension,
did not show up today for his follow-up appointment. Chris calls to find out
why he failed to keep the appointment, and the patient tells Chris he forgot
to come, even though an appointment reminder call was made yesterday.
He also tells Chris he has not been taking his medicine and does not
understand why it is so important for him and his wife to meet with the
dietitian. Is this patient using defense mechanisms? How should Chris
respond to the patient? What communications skills might be helpful to
promote a therapeutic relationship?
CHAPTER 4 Patient Assessment 81
close attention to the patient's body language to make sure you are
giving the patient ample opportunity to discuss the health problem.
Defense Mechanisms
Many individuals respond to anxiety-provoking situations by auto-
matically relying on defense mechanisms. Because defense mecha-
nisms are used consciously or unconsciously to block an emotionally
painful experience, it is understandable that patients facing a trau-
matic diagnosis or a difficult treatment feel the need to protect
themselves from the reality of the situation. The problem is, how
can we ensure compliance with treatment if the patient is in denial,
projecting feelings onto the healthcare worker, or repressing the need
for treatment or diagnostic follow-up? The medical assistant must
be sensitive to patients' use of defense mechanisms and must con-
sistently apply therapeutic communication techniques to interac-
tions with patients.
she may say to the medical assistant, "You don't have to lose your
temper about this," even though the medical assistant's demeanor is
completely professional.
• Rationalization: The patient comes up with various explanations to
justify her response. Example: "I think the results are wrong. Ididn't
follow the directions for the tests like I should have, and besides,
there's no history of breast cancer in my family."
• Undoing: The patient tries to reverse a negative feeling by doing
something that indicates the opposite feeling. Example: If the patient
feels angry and violated about the diagnosis but she finds those
feelings unacceptable, she may say, "Don't worry, dear, I'm not upset
with you for telling me about this."
• Regression: The patient reverts to an old, usually immature behavior
to ventilate her feelings. Example: Perhaps instead of discussing the
diagnosis and the need for treatment, she just storms out of the office.
Or she may say, "I can't possibly schedule a procedure without dis-
cussing this with my mother."
• Sublimation: The patient redirects her negative feelings into asocially
productive activity. Example: Mrs. Simone eventually becomes an
active member of a local support group for women recovering from
breast cancer.
Communication Across the Lifespan
The key to communicating effectively with patients is using an age-
specific approach. Given the age and developmental level of your
patient, how can you best interact with the person and with signifi-
cant family members?
For example, Tasha, a 2-year-old patient, is scheduled for a physi-
cal examination. How can you best interact with her and her father
to ensure that the history phase of the visit is complete and accurate?
Therapeutic use of nonverbal language is essential to interacting with
children of all ages. Getting down on the child's level, establishing
eye contact, and using a gentle but firm voice are ways of gaining
82 UNIT ONE INTRODUCTION TO MEDICAL ASSISTING

FIGURE 4-7 Interacting with a parent and child.

FIGURE 4-8 Responding to parental concerns.

the child's confidence and cooperation. Children fear the unknown,
so explaining all procedures with language the child understands is
important. At the same time, the medical assistant must communi-
cate with the child's caregiver so that he or she can contribute to the
intake process (Figure 4-7). The following are some important guide-
lines for obtaining the health history of a child.
• Make sure the environment is safe and attractive.
• Do not keep children and their caregivers waiting any longer
than necessary because children become anxious and distracted
quickly.
• Do not offer a choice unless the child can truly make one. If part
of the treatment requires an injection, asking the child whether
she'd like her shot now is most likely to get an automatic "No!"
However, giving her a choice of stickers after the injection is
appropriate.
• Praising the child during the examination helps reduce anxiety
and boosts self-esteem. When possible, direct questions to the FIGURE 4-9 Interacting with a schoolilged child.
child so that he or she feels like part of the process.
• Involving the child in the examination by permitting him or her
to manipulate the equipment may help relieve anxiety. If possible,
use your imagination and make a game of the assessment or the Privacy is an important issue to consider with older children,
procedure. especially adolescents. During the physical examination, respect
• A typical defense mechanism seen in sick or anxious children is privacy by keeping body exposure to a minimum and adequately
regression. The child may refuse to leave the mother's lap or may preparing the child for procedures and positions. In addition, older
want to hold a favorite toy during the procedure as a comfort children want to know what is going on during the examination,
measure. Look for signs of anxiety, such as thumb-sucking or what to expect, and what the findings mean; therefore, keeping them
rocking during the assessment, and encourage caregivers to be informed in a language they can understand is important. Teen
involved in the process to help make the child feel as safe as patients should always be encouraged to ask questions, which should
possible. be answered as completely and clearly as possible. Take every oppor-
• Listen to parents' concerns and respond truthfully to questions tunity to teach your patients, regardless of their age, about their
(Figure 4-8). disease and to share information about significant wellness factors
Older children may also have difficulty during the health visit (Figure 4-10).
(Figure 4-9). To help school-aged children gain a sense of control, Patient education is extremely important when interacting with
give them the opportunity to make certain decisions about treat- adult patients. Using language the adult patient understands and
ment. For example, Heather, a 13-year-old patient with diabetes, involving the patient in treatment decisions as much as possible
could be given the choice of having her father present during the are essential to developing a helping relationship with your older
visit. Or, if she requires an insulin injection, she could choose the patients. Adults are bombarded by multiple responsibilities, which
site of the injection or perhaps administer the medication herself. means that stress-related health problems are not unusual in these
This gives the medical assistant an opportunity to observe her tech- patients. Get to know your adult patients, and emphasize preventive
nique and allows Heather to exert her independence. healthcare when possible (Figure 4-1 1).

FIGURE 4-10 Interacting with an adolescent.
Recognizing and Responding to Verbal and
Nonverbal Communications
The medical assistant not only must implement therapeutic com-
munication skills, but also must observe the patient to interpret the
person's message and level of understanding. In the following critical
thinking exercise, Chris, the medical assistant from the opening
scenario, conducts a patient interview using the therapeutic com-
munication skills discussed in this chapter, including active listening
techniques, open-ended and closed questions and statements,
positive nonverbal interview skills, and effective observation of the
patient's body language.
CRITICAL THINKING APPLICATION 4-4
Toby Anderson, a 52-year-old patient, was recently diagnosed with hyperten-
sion and prescribed Lotensin bid for treatment. He is being seen today for
follow-up measurement of his blood pressure. Mr. Anderson is 45 pounds
overweight and was given information about a reduced-calorie, low-sodium
diet l month ago, but he has not lost any weight. He tells Chris that he
has been having side effects from the medication. He is sitting with his
arms across his chest, tapping his foot and occasionally cracking his
knuckles.
Communication factors Chris should consider include the following:
• What nonverbal language is Mr. Anderson using, and how should
Chris interpret it?
• Mr. Anderson tells Chris he is not following that crazy diet and never
will. What therapeutic communication skills can Chris use to get
more information out of Mr. Anderson and to reinforce the provider's
recommendations?
• During the discussion, Mr. Anderson tells Chris he stopped taking the
Lotensin because of the side effects. What communication tech-
niques and therapeutic body language can Chris use to emphasize
the need for Mr. Anderson to take his medicine as prescribed?
CHAPTER 4 Patient Assessment 83
FIGURE 4-11 Adult patient education.
ASSESSING THE PATIENT
After the interview is complete, the patient is escorted to an exami-
nation room and prepared for the physical examination, which is
performed by the physician or a qualified healthcare professional,
such as a physician assistant (PA) or nurse practitioner. During the
examination, the healthcare provider methodically checks all the
body's systems. As this examination proceeds, the provider mentally
compares the system with established norms. If something deviates
from the accepted normal range, it is documented in the patient's
health record. The physical examination typically starts with the
head and progresses downward to the feet. However, the order may
vary, depending on the provider's specialty.
Signs and Symptoms
After completing the examination, the provider documents all the
signs and symptoms gathered during the physical assessment process.
To better understand the examination procedure, the medical assis-
tant must know the difference between a sign and a symptom.
Subjective findings, or symptoms, are perceptible only to the
patient; they are what the patient feels and can be interpreted only
by the patient. For example, only the patient experiences and can
define the quality of his or her discomfort, pain, nausea, or dizzi-
ness. Symptoms of the greatest significance in identifying a disease
are called cardinal symptoms. For example, crushing chest pain and
difficulty breathing are cardinal symptoms of a possible heart attack.
Objective findings, or signs, can be observed and/or measured by
the provider or medical assistant. They are the indicators of health or
disease that a provider detects when examining a patient. The pro-
vider feels, sees, hears, or measures the signs that ofren are associated
with a certain disease or abnormal condition. For example, a mass
that a provider palpates, or feels, in the patient's abdomen is an objec-
tive finding and a sign of an abnormal condition. In addition, objec-
tive data can be measured and recorded, and repeat measurements
can be taken to confirm the presence of or changes in the sign. The
patient's temperature, pulse, respirations, and blood pressure are
objective signs the medical assistant measures and records regularly.
The medical assistant also needs to know the difference between
a functional disorder and an organic (physical) disorder. When a
condition or disease is functional it is without an organic cause; that
is, when inspected, the organ appears normal, without any evidence
84 UNIT ONE INTRODUCTION TO MEDICAL ASSISTING

of disease, even though the patient's signs or symptoms indicate a

problem. An example of a functional problem would be a patient
who has repeated bouts of elevated urinary albumin, but all tests on
the kidneys show normal, healthy organs. Or a patient is diagnosed
with irritable bowel syndrome even though diagnostic studies have
failed to show any evidence of intestinal disease. A functional disor-
der can be difficult for the patient and provider to deal with because
even though the patient is suffering from certain health problems,
all diagnostic tests fail to show that anything is wrong with the
affected system.
An organic disease or condition is one in which the abnormality
can be seen or felt or clinically proven through laboratory or other
diagnostic tests. For example, an electrocardiogram (ECG) can
confirm that a patient with chest pain is having a heart attack. A
colonoscopy performed on a patient who complains of bloody stools
can reveal evidence of ulcers in the colon.
Assessing Pain
Pain is difficult ta assess. We typically rely on the patient's report of
symptoms to determine his or her level of pain. Some questions you can
ask to evaluate the patient's perception of pain are:
• Where is the pain located? Is it associated with any particular
movement?
• Can you describe how it feels? Is it constant or intermittent? Does
anything relieve the pain?
• When was the onset of the pain? Did something cause the pain
to start?
• Are you taking any medication to relieve the pain? What is it,
and how often are you taking it? Is it effective? When was your
last dose?
• Does pain affect your daily activities?
• On a scale of 1 to 10, with 10 being the highest level of pain,
where would you rate your pain?
DOCUMENTATION
Various methods can be used for documentation, depending on the
healthcare provider's preference and/or the facility's EHR system.
However, certain charting procedures have been standardized to
meet the legal requirements for maintaining medical records accu-
rately and concisely. Complete, accurate documentation is one of
the primary responsibilities of a medical assistant (Figure 4-12).
Documentation Guidelines
• Check the name on the record and make sure the information
being documented is recorded on the correct form in the correct
patient's health record or, with an EHR system, that the correct
information is recorded using the correct system prompts.
Confirm the patient's identity by checking his or her birth date.
• The month, day, and year must precede the entry; many facilities
also require the time of the documentation.
• All unusual complaints, symptoms, or reactions must be noted
in detail. Include complete information about the onset (when
the problem started), duration (how long episodes last), and
frequency (how often episodes occur) of each reported sign and
symptom.
Example: Pt reports night cough, which started 2 days ago, lasts
approximately 10 minutes, and occurs 3-4 times per night.
• Describe objective data, such as the presence of a wound, using
correct anatomic medical terminology.
Example: Observed wound on left distal anterior leg approxi-
mately 2 cm long and 1 cm wide.
• If the patient reports pain, record the quality and intensity of the
pain using a pain scale of 1 to 10.
Example: Pt c/o dull pain at wound site, a 4 on a scale of 1-10.
• If the patient's comments are entered in the patient's own words,
enclose them in quotation marks.
Example: Pt states, "I fell against a stone foundation while cutting
the grass and slashed my leg."

Professional Medical Offices

1722 E. North Avenue Suite 109
Aloha, HI 99751

Patient Name G-a..S+ri>" , l;lea.>"or c.. DOB 8/ 15 / &:,J. Chart # __

3 _3 "'
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Last First Ml
Allergies _ I_o_d_i_>"_e_ __
Date Time Progress Note
7/4/2.0~ IO AM c./0 ..fe"er ~ 3 da.'JS, Prodl,,l.c.+i"e c.ol,,l.~h. T-101, P-7J.,
l;rr o r ~ R-f&:, C.I 7/4/X.X. C.. fsa.c.c.Sol'\, c.MA (AAMA) - -
7/4/2.0~ 10:J.OAM La.+e e,.,.+r'/
De,.,.ies wheez.i"'~ SOB C.. fsa.c.c.so,.,., c.MA (AAMA) - -
-

FIGURE 4-12 Documentation correction.

 CHAPTER 4 Patient Assessment 85

Physician's Assessment of Body Systems

Appearance Urinary
Body build, posture, and gait Changes in urinary habits: hesitancy, urgency, frequency, night voiding,
Height and weight fluctuation pain when voiding, loss of stream force
Nutritional status Kidney stones, urinary tract infections
Hygiene and grooming Dribbling, incontinence
Emotional state and mood Indicators of infections
Head and Neck Genitalia (Male)
Size, shape, and contour of head Infertility, sterility, impotence
Hair and scalp Testicular pain or mass
Palpation of neck, thyroid, and trachea Penile discharge or discomfort
Difficulty swallowing Erections, hernias
Change in voice, hoarseness Prostate or testicular enlargement
Eyes Genitalia (Female)
Visual acuity and field Menses regularity, flow, pain, duration
Inspection of eyelids and eyeballs Premenstrual symptoms, menopause
Pupillary reaction and eye movement Obstetric history, birth control method
Inspection of internal eye structures Breast symmetry, discharge, masses
Measurement of ocular pressure Estrogen therapy, reproductive surgeries
Nose Pain during intercourse, sterility
Size, shape, and symmetry Lymph Glands
Deviated septum, nasal congestion Enlargement, tenderness
Sense of smell Neurologic
Ears Level of consciousness, headaches
Hearing deficits Reflex reactions, general weakness
Inspection of size, symmetry, placement Speech changes, memory loss, seizures
Discharge, ringing in the ears, infection Changes in balance, lack of coordination
Mouth and Throat Endocrine
Inspection of gums, teeth, tongue, pharynx Weight change, fatigue, bulging eyes
Bad breath, changes in salivation Increased thirst or hunger, neck swelling
Sense of taste Excessive sweating, heat or cold intolerance
Respiratory Skin
Size and shape of chest Color, turgor, and tone
Breath sounds Lesions or scars
Phlegm, cough, sneezing, wheezing Temperature, rashes, itching
Coughing of blood, asthma, emphysema Moles, sores, acne
Upper or lower respiratory tract infections Arms and Legs
Cardiovascular General appearance and symmetry
Shortness of breath, chest pain Palpation of arm muscles
Reflected pain in the jaw, arms, upper back Range of motion, limitation of movement
Heart murmur, palpitations, night sweats Inspection of fingernails
Cold or bluish hands, leg cramps, varicose veins Deformities, joint stiffness
Hypertension, valvular disease Gait
Gastrointestinal Legs and Feet
Symmetry, tenderness, pain Symmetry, scars, bruises, swelling, open areas
Changes in appetite, nausea, vomiting Broken bones, deformity, sprains, strains
Jaundice, ulcers, gallstones Gout, arthritis, osteoporosis
Bowel sounds Inspection of toenails
Change in bowel habits: diarrhea, constipation, hemorrhoids, stool color
86 UNIT ONE INTRODUCTION TO MEDICAL ASSISTING

• Document the complete medication history, including both pre-
scription and OTC medications taken on a regular basis, the last
dose taken of the medication, its effectiveness, and any other
pertinent details.
Example: Pt reports taking 2 ibuprofen tablets for pain with
moderate relief; last dose taken 45 minutes ago.
• Record details about the previous history of the current CC.
Example: Pt reports having a similar cough 3 weeks ago.
• When entering information in the medical record, sign the
entry, including the appropriate initials after your name
(e.g., CMA).
• Learn to be observant and to note anything that seems
pertinent.
• Use accurate abbreviations, symbols, and terminology
(Table 4-3).
• Review your documentation immediately after completion so
that you can detect errors while the information is fresh in your
mind.
• The electronic record system will automatically track any correc-
tions made to the original documentation entry.
• If documenting in a paper record:
• Do all charting in black ink except for noting allergies in red
ink; never use pencil.
• Write in a clear, legible manner.
• Do not leave any blank spaces on the paper record and do not
skip lines between documentation entries.
• Never scribble, erase, or use whiteout on an error. For legal
purposes, it is crucial that the corrected error be readable.
• Correct the error by drawing one line through it. Write "error"
above the corrected word or words and date and initial the
correction. Then write in the correction.
• If details are omitted, add information by documenting
after the last entry. Record "late entry," include date and
time of note, and document the omitted information (see
Figure 4-13).
Medical Terminology
Medical terminology is a language system based on Latin. It addresses
processes that occur in specific body systems, procedures, diagnos-
tics, and diseases. The system depends on the use of a suffix, which
is defined first, a root word, and many times a prefix. The parts of
the word are connected using a combining form "o," except in terms
with a suffix that begins with a vowel. For example, osteitis is defined
as inflammation (the suffix "-itis") of the bone (root word "oste").
The combining form "o" is not needed to connect the suffix and root
word because the suffix begins with an "i." In the term osteopathic,
the suffix "-ic" means pertaining to, and the two root words "path"
(disease condition of) and "oste" (bone) are connected with the
combining form "o."
If a word is unfamiliar to you, it is important to learn
the meaning, correct spelling, pronunciation, and proper use of the
term. Consistent use of a good medical dictionary is essential. To
aid your learning, some frequently used medical word parts and their
definitions are presented in Table 4-4. In addition, a terminology
glossary is included in the back of this textbook, a vocabulary section
appears at the beginning of each chapter, and an audio glossary of
medical terms can be found on the Evolve website (evolve.elsevier.com/
kinn). Because the provider communicates using medical terminol-
ogy and the medical assistant should use medical terms when docu-
menting in the patient record, it is essential that you become
comfortable and familiar with the medical language system and its
correct use (Procedure 4-3).

TABLE 4-3 Medical Abbreviations

ABBREVIATION DEFINITION ABBREVIATION DEFINITION I
abd abdomen BOM bilateral otitis media
ABG arterial blood gases BP blood pressure
ac before eating BUN blood urea nitrogen
ACLS advanced cardiac life support bx biopsy
-
ad lib as desired C with
AFP alpha-fetoprotein C&S culture and sensitivity
AKA above the knee amputation CA cancer
ASAP as soon as possible CABG coronary artery bypass graft
ASHD atherosclerotic heart disease CAD coronary artery disease
BE barium enema CBC complete blood count
bid twice a day cc chief complaint
BM bowel movement CHF congestive heart failure
BMR basal metabolic rate CHO carbohydrate
 CHAPTER 4 Patient Assessment 87

TABLE 4-3 Medical Abbreviations-continued

ABBREVIATION DEFINITION ABBREVIATION DEFINITION I
CNS central nervous system HTN hypertension
c/o complains of Hx history
COPD chronic obstructive pulmonary disease l&D incision and drainage
CPK creatinine phosphokinase l&O intake and output
CPR cardiopulmonary resuscitation IG immunoglobulin
CSF cerebrospinal fluid lytes electrolytes
CT computed tomography Ml myocardial infarction
CVA cerebrovascular accident NG nasogastric
CXR chest x-ray NKA no known allergies
DAT diet as tolerated NPO nothing by mouth
de discontinue N/V nausea and vomiting
D&C dilation and curettage p after
DDx differential diagnosis PE pulmonary embolism
DM diabetes mellitus pm as needed
DNR do not resuscitate pt patient
DVT deep vein thrombosis PE physical examination
Dx diagnosis PT physical therapy
ECG electrocardiogram q every
ENT ears, nose, throat RBC red blood cells
FBS fasting blood sugar R/O rule out
f/u follow up ROM range of motion
FUO fever of unknown origin Rx treatment
fx fracture s without
GC gonorrhea SOB shortness of breath
GI gastrointestinal STD sexually transmitted disease
GTT glucose tolerance test STAT immediately
GU genitourinary Sx symptoms
HCT hematocrit Tx treatment
Hgb hemoglobin UA urinalysis
HIV human immunodeficiency virus URI upper respiratory infection
HPI history of present illness UTI urinary tract infection
hs at bedtime or hour of sleep vs vital signs
88 UNIT ONE INTRODUCTION TO MEDICAL ASSISTING

TABLE 4-4 Medical Word Parts

WORD PART MEANING WORD PART MEANING WORD PART MEANING I
a- without -cele hernia gastr/o stomach
-ac pertaining to cephaljo head -genesis forming
aden/o gland -cide killing gest/o pregnancy
adip/o fat -clast to break -globin protein
-al pertaining to colp/o vagina gloss/a tongue
-algesia sensitivity to pain contra- against gluc/o glucose, sugar
-algia pain crani/a skull -gram recording
angi/o blood vessel -crit to separate hem/o blood
ankyljo stiff cyan/o blue hemi- half
ante- before cyst/o urinary bladder hepat/o liver
anter/o front cyt/o cell hist/o tissue
anti- against -derma skin hydr/o water
arter/o artery dipl/o double hyper- above; excessive
arthro joint dors/o back hyp/o deficient
articulo joint -dynia pain hyster/o uterus
-ase enzyme dys- painful, abnormal -iasis abnormal condition
ather/o fatty plaque -ectasia dilation, stretching infra- below
aur/o ear -ectomy excisian inter- between
auto- self -emesis vomiting intra- within
axilljo armpit -emia blood condition jaund/o yellow
bi- two encephaljo brain kines/o movement
bi/o life endo- within lact/o milk
-blast immature enter/o small intestine -lapse to sag
blephar/o eyelid eosin/o red later/o side
brady- slow epi- above leuk/o white
bucc/o cheek erythem/o flushed; red lip/o fat
carcin/o cancerous -esis condition lith/o stone
cardi/o heart eu- good; normal -lithiasis condition of stones
 CHAPTER 4 Patient Assessment 89

TABLE 4-4 Medical Word Parts-continued

WORD PART MEANING WORD PART MEANING WORD PART MEANING I
-logy study of path/o disease -rrhea flow
-lysis to break down -penia deficiency -sclerosis hardening
macro- large -pepsia digestion -scope instrument to visualize
mal- bad per- through semi- half
-malacia softening peri- surrounding somat/o body
mast/o breast -pexy fixation spl/o spleen
medi/o middle -phagia eating -stasis to stop
mega- large -phasia speech -stenosis tightening
-megaly enlargement phleb/o vein stomat/o mouth
morph/o shape -plasty repair -stomy new opening
my/o muscle -plegia paralysis sub- under
necr/o death -pnea breathing supra- above
neo- new -poiesis formation tachy- fast
nephr/o kidney poly- many thorac/o chest
neur/o nerve post- after thromb/o clot
odyn/o pain -prandial meal -tomy cutting
olig/o scanty pre- before tox/o poison
-oma tumor; mass proxim/o near trans- across; through
onych/o nail prurit/o itching -tresia opening
oophor/o ovary pseudo/o false tri- three
ophthalm/o eye -ptosis drooping; sagging -tripsy to crush
orch/o testis py/o pus ur/o urine
orth/o straight pyeljo renal pelvis varic/o varicose veins
oste/o bone pyr/o fever vasculjo vascular
ot/o ear quadri- four ventr/o front
pan- all ren/o kidney viscer/o internal organs
para near; beside -rrhage bursting forth vit/o life
90 UNIT ONE INTRODUCTION TO MEDICAL ASSISTING

Use Medical Terminology Correctly and Pronounce Accurately to Communicate

PROCEDURE 4-3
Information to Providers and Patients

Goal: To use medical terminology correctly so that you can effectively communicate with providers and explain terminology to
patients.
Scenario: The physician has just examined Antonio Markus, age 19, and documents in the patient's record that he has bilateral
otitis media, an URI, SOB and bronchitis. After the physician leaves the room, Antonio tells you he doesn't understand what the
physician told him. Using your knowledge of medical terminology, review the physician's documentation and explain the medical
terms to the patient.
EQUIPMENT and SUPPLIES and treatment plan. Make sure all medical terminology is adequately
• Patient's record explained.
• Medical terminology dictionary or online reference site if needed PURPOSE: Therapeutic communication techniques help the medical assis-
• Related educational materials tant determine whether the patient understands the terminology; using
feedback methods and making sure the patient understands medical terms
PROCEDURAL STEPS helps relieve anxiety.
1. Greet and identify the patient in a pleasant manner. Introduce yourself and 4. After you have explained the medical terms, make sure all the patient's
explain your role. questions have been answered.
PURPOSE: To make the patient feel comfortable and at ease. S. Provide the patient with education materials that cover the details of his
2. Review the physician's documentation. Look up the terminology if you are diagnosis and treatment plan.
not sure of its meaning. PURPOSE: To reinforce the diagnosis and verify treatment so that the
PURPOSE: Medical terminology can be complicated for patients to under- patient understands; promotes compliance with the treatment plan.
stand. Healthcare workers should be cautious about using medical terms to 6. Document the patient education intervention in the patient's health record.
explain a diagnosis. PURPOSE: Documentation verifies that the patient's questions were
3. Explain the physician's documentation in lay terms. Use restatement answered and educational materials were provided.
and clarification to make sure the patient understands the diagnosis

Documentation Methods
Problem-Oriented Medical Record
The problem-oriented medical record (POMR) is a form of docu-
mentation that introduces a logical sequence to recording the infor-
mation obtained from the patient. It is based on the scientific
method and was designed to present the patient's health problem
efficiently and record systematically how it was managed. The
medical history and physical examination fit into a special format
that clarifies the patient's health problems. Each patient problem, or
diagnosis, is defined and documented on a problem list sheet at the
beginning of the medical record. Each time the patient is diagnosed
with a new health problem, that diagnosis is added to the problem
list in numeric order. If the patient is successfully treated for the
health problem and cured, the provider documents next to that
diagnosis on the problem list "Problem resolved" and dates it accord-
ingly. Typically EHR systems have a section of the medical record
that contains a current list of patient problems. Because the patient's
diagnoses are identified and numbered at the beginning of the
medical record, the POMR is very helpful for record audits. In addi-
tion, the format is designed for and easily adapted to EHR systems.
The POMR system has four basic parts:
I. Database: This includes the patient's health history, the physi-
cal examination findings, and the results of baseline laboratory
and diagnostic procedures. This information allows the pro-
vider to compile a health problem list for the patient.
2. Problem list: This list of the identified patient problems is kept
in the front of the patient's record. It serves as a table of contents
or index for the record and defines the patient's health concerns,
including diagnoses, treatments, and educational needs. The
problem list takes a holistic approach by including both psy-
chosocial and physical needs. Each problem entered is listed
numerically and dated and is supported by the database. The
problems then are identified and referred to throughout prog-
ress note documentation by their assigned number. If over time
an additional problem is identified, it is added to the problem
list. If the problem is resolved, the date of problem resolution
is entered next to the problem. For example, if Mr. Xu is
diagnosed with hypertension and that particular health problem
is listed as diagnosis #3, every time Mr. Xu comes to the office
for follow-up of his blood pressure, the documentation piece
begins by identifying the diagnosis by its number (#3). This
system makes it very easy for the provider or medical assistant
to scan the progress notes, review all documentation relating
to diagnosis #3 (hypertension), and obtain a relatively quick
and comprehensive history of how the patient's blood pressure
is being managed and controlled.
 CHAPTER 4 Patient Assessment 91

I~• 1• l::t~••:1::::191eJ :I •

Name Fiddleman, Fred D. ALLERGIES/SENSITIVITY

Number I Blood Type: A+ Penicillin
Prob. Date Prob. Dalo
No. Date PROBLEM DESCRIPTION Resolved Index No. Date PROBLEM DESCRIPTION Resolved Index

1 10/2014 Hyperteneion • eeeential ✓

2 10/2014 Diabetee mellitue (mild) ✓
3 1/2014 Bilat. Grade II Retinopathy
4 5!.3/2015 L lower lobe 5/2015
pneumonia

Prob. Prob.
No. CONTINUING MEDICATIONS Start Stop No. CONTINUING MEDICATIONS Start Stop
1 5inoeerp 1 mg. 1,.i.d. 10/14 11/14
2 0rinaee 0.5 gm. daily 10/15 11/15
1 Hydrodiuril 50 mg. A.M. 10/14
2 1500 cal. diet low Na hi K 2/15

Period ic Hoo~h
Examination Dates I 1113 I 3114 3/14 6 115 I I I I I

FIGURE 4-13 Initial plan for POMR progress notes.

3. Plan: This is a documented plan for each problem identified
on the problem list. It outlines further studies, treatments,
and patient education (Figure 4-13).
4. Progress notes: Using the first letter of each part of the progress
notes spells the acronym SOAP; therefore, this portion of the
POMR system is called the SOAP notes (or SOAPE notes when
evaluation is included) (Figure 4-14). Each progress note uses
the following format:
• S for subjective data: This information includes the purpose
of the visit, with the patient's words in quotation marks,
or a summary of the patient's statement about the chief
complaint. For example, the subjective note may record
exactly what the patient says, such as "I feel horrible,
exhausted, coughing all night long." If the patient's exact
words are not documented in quotation marks, the subjec-
tive entry typically starts with "Patient states ... , " "Patient
c/o ... ," or "Caregiver reports ... " The medical assistant
documents this information based on details gained from
the patient interview.
• 0 for objective data: This is anything that is observed or
measurable, including vital signs, the exact anatomic loca-
tion of an injury, difficulty with gait, and so on. Objective
data can be measured repeatedly, which means that regard-
less of how many different healthcare workers observe the
patient or document the sign, the same or very similar
numbers or explanations would be given. The medical
assistant is responsible for documenting complete and
accurate objective data about all of the patient's signs. This
information should be in such specific detail that even an
individual who has not seen the patient can visualize the
person's state of health. Typically the medical assistant
documents only the subjective and objective data, leaving
the remainder of the documentation to the provider.
• A for assessment of the problem: Usually this is the pro-
vider's preliminary diagnosis of the cause of the patient's
chief complaint. The provider makes a judgment about
what is wrong with the patient and documents it in this
section; the medical assistant is not involved in this piece.
92 UNIT ONE INTRODUCTION TO MEDICAL ASSISTING

PROBLEM-ORIENTED PROGRESS NOTES

Doctor
Frank Edwarde;, MD
PROBLEM FORMAT: Problem Number and TITLE:
NUMBER =
S Subjective O Objective A = =Assessment P =Plan
10/15/15 9:30 AM 5: Mother e;tatee; child hae; runny noe;e
and e;ore throat x 2d. Taking Tylenol prn.
0: Vital e;igne;: T 98.8 (TA) P 96 R 24; Wt 42 lb.
C. le;acce;on, CMA (AAMA)

A: U tract infection.
P: 1. Pree;cribe Rondec DM, 1/2 te;p q6h prn
cough and congee;tion. ___________

2. Mother to contact office if child doee;

not improve. F. Edwarde; MD

FIGURE 4-14 Structured notes for the POMR system. (Courtesy Bibbero Systems, Petaluma, Calif.)

This is also the section where the medical assistant would
go to abstract the diagnosis for billing purposes.
• P for the plan of care: This is the provider's documentation
of how the health problem will be managed, including
diagnostic studies, treatments, and patient education.
• E for evaluation: This is the assessment of the patient's
understanding of the treatment or of the person's ability
to comply with the treatment plan. It also may be used
to document a follow-up on medication or treatments
administered in the physician's office. For example, if a
patient with asthma receives a breathing treatment during
the office visit, a note is made regarding the effectiveness
of the treatment.
CRITICAL THINKING APPLICATION 4-5
Document the following scenario using the POMR method:
The patient c/oa sore throat with pain of 5 on a 1-10 scale and fever
for 2 days. He has been taking 0TCs for relief of symptoms. His VS are T
100.4, P88, R20. He also has an erythemic, papular rash across his chest.
S: _________________
0: - - - - - - - - - - - - - - - - -
Source-Oriented Medical Record
The source-oriented medical record (SOMR) is the most common
form of record keeping used by physicians practicing in medical
offices. The data in the patient record are organized in divided sec-
tions, which include the History and Physical (H&P), Progress
Notes, Laboratory Results, Consultations, and so on. All informa-
tion is filed in reverse chronologic order, with the most recent report
or progress note placed on top. Progress notes are made each time
the patient is seen or contacted by telephone. Documentation in the
Progress Notes section is based on details surrounding the patient's
chief complaint or the treatment protocol. For example, if a patient
is being seen today for the flu, the note may read, "CC flulike
symptoms, fever X 3 days, general discomfort, yellow nasal drainage,
productive cough." The primary disadvantage of the SOMR system
is that it can be very time-consuming to find a back entry about a
particular problem or treatment.
Electronic Health Records
EHR systems are used in virtually every ambulatory care setting to
collect and maintain patient information and to link healthcare
information across healthcare facilities. EHR systems usually are
designed for the particular needs of the practice. They are set up so
that information is entered directly as the patient is interviewed or

FIGURE 4-15 Amedical assistant uses a tablet to conduct the patient interview.
assessed. This is done using tablets, laptop computers, or computer
stations located throughout the facility (Figure 4-15).
Proponents of the EHR believe this type of record keeping
reduces practice overhead and improves staff efficiency, cuts the cost
of running the practice, and improves patient care. The EHR system
can cut costs by reducing the physical resources needed to operate
the practice (e.g., paper, chart material, copiers, and so on) and by
drastically reducing the amount of space needed to store medical
records. With the EHR, health records are on computerized files and
therefore easily accessible, which saves time for the staff, and all
documentation pieces are easily legible. In addition, the clinic's office
system can be linked to the hospital or laboratory so that diagnostic
tests can be downloaded into a patient's file and be readily available
for the provider to review and share with the patient. The provider
can also send electronic prescriptions to pharmacies, increasing the
efficiency and accuracy of prescribing medication.
The most significant problem with EHR systems is that if a major
electrical or computer malfunction occurs, patient information
cannot be accessed. Backup files must be maintained, and special
attention must be paid to patient confidentiality to prevent acciden-
tal sharing of private information.
"Meaningful Use" and Electronic Health Records
According to the EHR Incentive Programs established by the Centers for
Medicare and Medicaid Services (CMS), "meaningful use" is the use of
certified electronic health record (EHR) technology to:
• Improve the quality, safety, and efficiency of patient care
• Engage and empower patients and their families
• Improve the coordination of care across specialties and between
ambulatory and inpatient care facilities
• Maintain the privacy and security of patient health information
• Improve the health of the general population and that of individual
patients
• Increase the transparency of patient health information
• Enable the collection of health research data
CHAPTER 4 Patient Assessment 93
Medicare and Medicaid EHR Incentive Programs provide finan-
cial incentives for the "meaningful use" of certified EHR technology.
To receive an EHR incentive payment, eligible professionals and
hospitals must show that they are "meaningfully using" their certified
EHR technology by meeting certain established objectives. The
incentive programs have three stages, each with increasing require-
ments for participation. All providers were to start meeting stage 1
requirements in 2011-2012 and stage 2 requirements in 2014 for 2
full years; in stage 3, which starts in 2016, providers are expected to
show improved patient outcomes.
Some of the requirements for stage 1 included using an EHR
system to track patient drug allergies and drug-to-drug interactions;
transmit e-prescriptions; maintain current patient medication lists;
record pertinent patient demographics (e.g., gender, race, ethnicity,
smoking status); document changes in patients' vital signs; provide
patients with electronic copies of their health information and clini-
cal summaries for each office visit; protect EHR information with
current technology; include lab test results in patient EHRs; use drug
formularies; create lists of patients by specific conditions to compare
and identify outcomes and possible outreach needs; communicate
with patients about disease prevention, education, and follow-up
care; evaluate current medication lists on new or referred patients;
and provide a summary of care for patients transferring to another
provider.
In addition to the core requirements listed for stage 1, in stage 2
providers must show they are using an EHR system to give patients
online access to their health information and demonstrate that the
system is capable of electronically submitting patient data to regis-
tries or immunization information systems as allowed by law; they
also must show that they use secure electronic messaging to com-
municate with patients on relevant health information.
CLOSING COMMENTS
Patient Education
Finding time to conduct patient education in a busy healthcare
practice can be challenging. Every opportunity to interact with
patients should be considered a potential teaching moment. The
perfect time to begin the education process is during the initial
patient interview, when you first become aware of lifestyle factors or
financial, social, or psychological problems that may affect the
patient's wellness. Your interactions with patients and your use of
therapeutic communications skills and interview techniques are
crucial to the quality of care patients receive in your practice. One
of the advantages of EHR systems is ready access to educational
materials that can be downloaded and printed for patients to take
home or e-mailed to patients upon request. This electronic tool
makes it possible for healthcare workers to quickly provide educa-
tional materials that meet the patient's current needs.
Legal and Ethical Issues
The medical history is a confidential record that can be shared only
with healthcare personnel directly involved in the patient's care. Data
provided to you by the patient or that you read in the patient's health
record are confidential; you must not share any of this information
with anyone. The consequences for disclosing private information to
individuals not involved in the patient's care can be very serious and
 94 UNIT ONE INTRODUCTION TO MEDICAL ASSISTING
can result in the loss of your job, court-imposed fines, and even
imprisonment.
In addition to maintaining patient confidentiality, consistently
implementing correct documentation procedures is crucial for
medical practices. The medical record is considered a legal docu-
ment, and court cases can be won or lost based on the clarity and
completeness of staff documentation. It is essential that medical
assistants document all patient information in a factual, nonjudg-
mental manner. Risk management practices focus on these problems
as a way of reducing the chances of professional liability claims.
Elements of Sound Risk Management Practices
• Periodic review or audit of patients' records
• Consistent documentation of accurate and complete clinical facts and
test results
• Adequate office procedures for informing patients of test results and for
documenting this communication
• If paper records are used, appropriate use of abbreviations and legible
recording in the patient's file; also, corrections made in the legally
required manner
• Documentation that shows diagnostic test results were received and
reviewed by the provider
• Documented evidence of appropriate discharge and continuing care
instructions
Important Provisions of the Health Insurance Portability
and Accountability Act (HIPM)
• The patient has the right to request that the healthcare facility
limit the disclosure of protected health information (PHI) for
treatment, payment, and healthcare operations (TPO). For
example, if the patient had an abortion 5 years ago, she may
request that this information not be shared unless absolutely
necessary.
• The healthcare facility is not required to comply with this request,
but if agreement is reached, the restriction on sharing the
4i1iiiit+i;it•jii#it+i;l1•i
The office supervisor met with Chris and reviewed essential techniques for
gathering patient information. Therapeutic communication includes demonstrating
respecrlul patient care, using active listening skills, observing nonverbal behaviors,
and using a combination of both open-ended and closed questions to gather the
best possible detail about the patient's chief complaint. The supervisor gave Chris
a variety of information on meeting the needs of a diverse patient population
and also gave him suggestions on how to develop empathetic, helping relation-
ships with patients. One suggestion she made was that Chris develop acommunity
information must be documented, and all employees must
comply with the agreement. Therefore, if a provider referral
includes sending the patient's record to a consulting physician,
the medical assistant must make sure the restricted information
is not included in the material sent or e-mailed.
• The patient has the right to request that confidential information
be sent in a manner that the patient decides is best. For example,
some patients may request that all phone calls from the office be
made to a work number rather than to home, whereas others may
give approval for messages to be left on the home answering
machine or voice mail. Patients also can give approval that e-mail
be used to send test results or confirm appointments. Whatever
the patient's preference, this information must be documented
and followed each time the patient is contacted.
• The healthcare facility owns the patient's record, but the patient
owns the information in the record. Patient confidentiality must
be secured regardless of the type of documentation or record
system used in the healthcare setting. Safeguards mandated by
HIPAA include:
• Passwords to secure access to all electronic health records
• Computer monitor shields to protect patient information if
data are left on the screen
• Turning monitors away from patient traffic areas to prevent
accidental release of information
• Securing all medical records
Professional Behaviors
The ability to communicate effectively is crucial to the role of the profes-
sional medical assistant. Effective communication includes the use of all of
the therapeutic tools discussed in this chapter. The professional medical
assistant should:
• Attend to nonverbal behaviors to verify congruence between what
the patient states verbally and demonstrates via body language.
• Modify communication methods as needed to meet the needs of a
diverse patient population.
• Use restatement, reflection and clarification to gather pertinent and
comprehensive patient information.
• Utilize electronic communication appropriately and effectively.
resource file, to which he can refer if a patient needs assistance outside the
healthcare setting. Chris learned to identify the parts of the patient interview
and became familiar with typical barriers to patient communication so that
interviews would run more smoothly and he could gather more specific informa-
tion from patients. Chris's workplace uses POMR documentation methods, so
he reviewed the specifics of this type of record keeping with his supervisor. The
significance of patient confidentiality was emphasized, and Chris agreed to work
at implementing the techniques for therapeutic communication.

SUMMARY OF LEARNING OBJECTIVES
l. Define, spell, and pronounce the terms listed in the vocabulary.
Spelling and pronouncing medical terms correctly reinforce the medical
assistant's credibility. Knowing the definitions of these terms promotes
confidence in communication with patients and co-workers.
2. Use the concept of holistic care in the patient assessment process.
Holistic care involves assessing the patient's health status through the
collection of physical, cognitive, psychosocial, and behavioral data. The
medical assistant should consider all these factors when collecting data
on the patient's health problems.
3. Describe the components of the patient's medical history and how
to collect the history information.
The medical history consists of the patient's database, past medical
history, and family and social histories, in addition to the review of
systems. Anew patient should fill out a health history form, either online
through a patient portal, electronically, or on paper.
4. Discuss how to successfully understand and communicate with
patients and display sensitivity to diverse populations.
Developing a professional helping relationship with patients is the respon-
sibility of all healthcare workers. The helping relationship involves con-
sistent application of respectful patient care that recognizes the impact
of a patient's anxieties on interactions and responses to treatment. (See
Procedure 4-1 .)
Sensitivity to diverse populations includes the use of empathetic
communications and an awareness of the impact of individual value
systems and personal prejudices on patient interactions.
5. Demonstrate therapeutic communication feedback techniques to
obtain information when gathering a patient history.
The linear communication model illustrates communication as an interac-
tive process between the sender and the receiver of the message, with
feedback as a crucial part of the process. Active listening techniques,
which include restatement, reflection, and clarification, help the medical
assistant go beyond hearing the message to actually listening and
appropriately responding to the patient's main point. (Refer to
Procedure 4-1 .)
6. Respond to nonverbal communication when interacting with patients.
Approximately 90% of patient interactions occur through nonverbal
language. The key to successful patient interaction is congruence be-
tween verbal and nonverbal messages. (Refer to Procedure 4-2 and
Table 4-1 .)
7. Identify barriers to communication and their impact on patient
assessment; also, compare open-ended and closed-ended questions.
Optimum environmental conditions are important to a productive interview.
Open-ended questions ask for general information and should be used to
begin the interview, to introduce a new section of questions, or wherever
the person introduces a new topic. Closed-ended questions are more direct
and limit the answer to one or two words, typically yes or no.
8. Do the following related to the patient interview:
• Discuss the patient interview.
The interview should be considered a contract between you and your
patient. Ask a variety of open-ended and closed-ended questions, and
CHAPTER 4 Patient Assessment 95
conclude the interview by summarizing the results of your
interactions.
• Identify barriers to communication and their impact on patient
assessment.
Certain communication styles can be misleading or can restrict the
patient's response. The medical assistant must be careful to avoid
using such faulty techniques as inappropriately providing reassurance,
giving advice, using medical terminology without clarification, asking
leading questions, and talking too much. These behaviors interfere
with the process of gathering complete data during the interview and
are obstacles to developing rapport with the patient.
• Detect apatient's use of defense mechanisms and the resultant bar-
riers to therapeutic communication.
Patients use defense mechanisms to protect themselves in emotionally
challenging situations. Amedical assistant must consistently apply
nonjudgmental therapeutic communication skills to maintain profes-
sional relationships.
• Demonstrate professional patient interviewing techniques.
The patient interview is divided into the introduction, the body, and
the summary, or closing. Throughout the interview, the medical assis-
tant should use professional interviewing techniques, such as empa-
thetic patient care, sensitivity ta patient diversity, active listening skills,
appropriate nonverbal communication, attention ta the interview envi-
ronment, avoidance of communication barriers, and the framing of
questions and statements in an open or closed manner, depending an
the information needed and the patient's communication behaviors.
9. Discuss the use of therapeutic communication techniques with
patients across the lifespan.
Therapeutic communication techniques vary according to the patient's
age and developmental level. Amedical assistant should be aware of
how to interact most effectively with various age groups, including young
children, adolescents, adults, elderly patients, and family members. Age-
specific application of interview styles enables clear communication
between the health professional and the patient.
l 0. Compare and contrast signs and symptoms.
Subiective findings are symptoms; they are perceptible only to the
patient. Obiective findings are signs; they can be observed and/or
measured by the provider or medical assistant.
11. Document patient care accurately in the medical record.
The ability to document accurately and completely is an essential skill
for all medical assistants. Documentation should describe the patient's
chief complaint, identify all pertinent signs and symptoms, and demon-
strate correct use of medical terminology, with appropriate abbreviations.
Any error in the health record must be corrected according to legally
approved methods.
12. Identify and define medical terms and abbreviations related to body
systems; also, use medical terminology correctly and accurately to
communicate information to providers and patients.
Medical terminology is a language that addresses processes that occur
in specific body systems, procedures, diagnostics, and diseases. The
Continued
96 UNIT ONE INTRODUCTION TO MEDICAL ASSISTING
SUMMARY OF LEARNING OBJECTIVES-continued
system depends on the use of asuffix, which is defined first, a root word,
and often a prefix. The parts of the word are connected using acombining
form "o" except in terms with a suffix that begins with a vawel. (Refer
to Tables 4-3 and 4-4 and Procedure 4-3.)
13. Differentiate the documentation systems used in ambulatory care
practices.
The POMR method uses SOAPE documentation to define the patient's
health problems; the SOMR method organizes patient data into specific
sections.
14. Explain "meaningful use" as it applies to the electronic health record
(EHR).
Eligible professionals and hospitals must achieve specific objectives
to qualify for Medicare and Medicaid EHR Incentive Programs, which
provide financial incentives for the "meaningful use" of certified EHR
technology.
"Meaningful use" includes using EHRs to:
• Improve the quality, safety, and efficiency of patient care
• Engage and empower patients and their families
CONNECTIONS
OJ Study Guide Connection: Go to the Chapter 4 Study Guide. Read and complete
the activities.
• Improve the coordination of care across specialties and between
ambulatory and inpatient care facilities
• Maintain the privacy and security of patient health information
• Improve the health of the general population and that of individual
patients
• Increase the transparency of patient health information
• Enable the callection of health research data
15. Describe the role of patient education, in addition to legal and ethical
issues, in the patient assessment process.
The perfect time to initiate patient education is during the initial patient
interview. Amedical assistant should take advantage of every teaching
moment to get to know his or her patients and promote patient wellness.
Risk management practices focus on reducing the chances of professional
liability claims and maintaining compliance with HIPAA standards. Accu-
rate, complete documentation in the patient's health record is crucial for
successful risk management. In addition, maintaining strict confidentiality
of patient information and factual, nonjudgmental recording of patient
data are essential to professional patient care.
evolve Evolve Connection: Go to the Chapter 4 link at evolve.e/sevier.com/
kinn to complete the Chapter Review Quiz. Check out the other resources listed for this
chapter to make the most of what you have learned from Patient Assessment.
 PATIENT EDUCATION
i-i#H+i;H•i
Taylor DiSalvo is a medical assistant in a busy family practice. He currently is
working with a patient, Sam lgnatio, who is 62 years old and has been married
for 30 years. Mr. lgnatio has just been diagnosed with diabetes mellitus (OM)
type 2. Although his mother and sister developed DM type 2 in their 60s, he
knows very little about the disease and nothing about the strides that have
been made in its treatment. In addition, his diet is high in saturated fat and
carbohydrates (especially simple sugars because he loves sweet treats), and he
does not exercise regularly. Mr. lgnatio is 50 pounds overweight, has functional
While studying this chapter, think about the following questions:
• How should Taylor begin Mr. lgnatio's patient education?
• What are some of Mr. lgnatio's individual characteristics that may affect
his ability to learn all the information required to manage his disease?
• How can Taylor coach Mr. lgnatio so that he understands the importance
of following treatment and disease-monitoring guidelines?
LEARNING OBJECTIVES
l. Discuss the holistic model of patient education related to health and
illness; also, instruct patients according to their needs to promote health
maintenance and disease prevention.
2. Summarize the stages of grief and suggest therapeutic interactions for
grieving patients.
3. List at least five guidelines for patient education that can affect the
patient's overall wellness.
4. Do the following related to patient factors that affect learning:
• Define six patient factors that have an impact on learning.
• Display respect for individual diversity.
• Summarize educational approaches for patients with language
barriers.
5. Do the following related to the teaching plan:
• Determine possible barriers to patient learning.
• Assess the patient's needs.
T his chapter focuses on helping students recognize the individual
learning needs of patients. It also provides guidelines for devel-
oping effective teaching approaches. The key to patient compliance
with prescribed treatments is empowerment; that is, providing the
patient with information and support that enable the person to take
5
deafness in his left ear and decreased saund quality in his right ear, and shows
early signs of diabetic-related vision loss. Taylor is responsible for assisting with
Mr. lgnatio's patient teaching plan.
Mr. lgnatio is faced with a serious illness, and his future health depends on
compliance with a wide range of lifestyle changes. The methods Taylor chooses
to coach this patient in managing his disease can have a significant effect on
his eventual health outcome.
• What teaching approaches and materials would best meet the needs of
this patient?
• Are any community resources available that could help Mr. lgnatio learn
how to manage his disease?
• Determine the teaching priorities.
• Decide on the appropriate teaching materials.
• Develop a list of community resources related to patients' healthcare
needs and facilitate referrals to community resources in the role of
patient navigator.
• Decide on the appropriate teaching methods.
• Implement the teaching plan.
• Demonstrate the ability to develop an appropriate and effective
patient teaching plan.
6. Describe the role of the medical assistant in patient education.
7. Integrate the legal and ethical elements of patient teaching into the
ambulatory care setting; also, discuss applications of the Health
Insurance Portability and Accountability Act (HIPAA).
charge of his or her health problem. The concepts in this chapter are
basic to all patient education interventions. Putting them into prac-
tice, as a medical assistant, can help you improve both a patient's un-
derstanding of the disease process and his or her willingness to comply
with the disease management steps recommended by the provider.
98 UNIT ONE INTRODUCTION TO MEDICAL ASSISTING
PATIENT EDUCATION AND MODELS OF HEALTH
AND ILLNESS
Patient education should begin with the first contact between the
patient and the healthcare team. A well-informed patient is more
likely to comply with treatment and adopt a healthy lifestyle. How-
ever, informing a patient about his or her disease is only part of the
health teaching process. The key to successful health teaching is to
empower the patient to accept the responsibility of his or her disease
process and to become willing to implement teaching guidelines.
As a result of reductions in hospital admissions and shorter hospital
stays, patients and families have had to assume responsibility for care
that once was provided by the hospital staff. This means that those
who work in ambulatory care settings have an even greater responsibil-
ity to meet the educational needs of their patients. To develop an
effective teaching approach, we must implement a holistic model that
considers not only the patient's physical state, but also his or her
psychological, sociocultural, intellectual, and economic needs (Figure
5-1). The holistic model suggests that we look at patients and determine
their needs based on a complete view of their lives rather than just as
an analysis of their specific diseases. It is our responsibility not only
to teach patients about disease processes, but also to help them imple-
ment related skills and changes in lifestyle to promote recovery and
improve function. In the case of Mr. Ignatio, diabetes mellitus is a
complicated disease that requires an in-depth understanding of the
disease process, in addition to making significant lifestyle changes.
When considering the impact of this diagnosis on the patient (in this
case, Mr. Ignatio), the medical assistant should keep in mind the fol-
lowing factors, because they will affect the patient's response.
• Psychological effect of the disease: Is Mr. Ignatio in shock and
denial? Is he angry or depressed? How will his emotional reac-
tion to the diagnosis affect his response to patient education
and coaching efforts?
• Sociocultural impact: How will his family and employer
respond to the demands of the diagnosis? Does he have a
support system that will assist him in making healthy lifestyle
choices?
FIGURE 5-1 The holistic approach.
• Intellectual impact: Is Mr. Ignatio able to understand the com-
plexities of the disease and treatment recommendations?
• Economic impact: Can he afford the treatment for diabetes?
Does he have health insurance to cover the cost, or will he
need assistance in paying for ongoing diagnostic and treat-
ment recommendations?
• Spiritual impact: What is Mr. Ignatio's spiritual response to
his diagnosis? How might his spiritual beliefs affect his com-
pliance with treatment?
The health belief model may help you understand why some
people do not follow recommended guidelines to maintain their
health and prevent the development of disease.
The model focuses on individuals' attitudes toward and beliefs
about themselves and their health. The model suggests that we first
consider how the patient perceives his or her risk of developing
a disease and the possible severity of the condition. For example,
even though Mr. Ignatio's mother and sister developed diabetes type
2, he may believe he is not going to have the same problem. There-
fore, even though wellness information recommends that he lose
weight, exercise, and eat a healthy diet, he may not believe he is in
danger of developing diabetes; consequently, he doesn't believe he
needs to follow disease prevention recommendations. He may also
believe that even if he does develop diabetes, the consequences of
the disease are not that serious, so why bother altering his lifestyle
to prevent it?
Another factor considered in the health belief model is the
patient's perceived benefits of action; that is, whether the patient
believes altering his or her health behaviors will prevent the person
from developing the disease or from suffering serious complica-
tions. In this case, because Mr. Ignatio has a strong family history
of the disease, he may have decided he was going to get diabetes
anyway, so why should he bother exercising and watching his diet?
Until the patient believes that teaching and health promotion
guidelines affect him and are worth pursuing, he will not follow
suggested health promotion tips or comply with treatment
protocols.
 CHAPTER 5 Patient Education 99

the diagnosis and the possible ramifications of the disease, compli-

TABLE 5-1 Health Belief Model ance with patient education will be very difficult to achieve.
PRINCIPLES DEFINITION PATIENT EDUCATION The five stages of grief are:
• Denial and isolation. The patient denies the existence of the
Perceived Patient's opinion on the Supply information on the disease, may be unwilling to accept the reality of the situation,
susceptibility chances of developing a risk level; individual risk is and refuses to discuss the health problem or remember health
disorder based on the patient's teaching interventions. For example, Mr. Ignatio refuses to
health habits and family meet with the dietitian because he says his diet is fine and
history. there is no need to change it.
• Anger. The patient may be very angry and hostile when forced
Perceived Patient's opinion on the Outline the potential to discuss the condition. Mr. Ignatio may say, "Why did this
severity seriousness of the complications of the happen to me? I am a good person, why did I get diabetes?"
condition and its health disease. • Bargaining. The patient tries to bargain for privileges or time.
risks Mr. lgnatio may say, "Look, I know I'm supposed to start this
Perceived Patient's belief in the Emphasize the positive new diet, but Christmas is coming. I'll meet with the dietitian
after the holidays."
benefits value of altering lifestyle results that can be achieved
• Depression. The patient grieves the loss of health. Mr. lgnatio
factors and complying if the patient complies with
may be very sad about the diagnosis. He doesn't want to have
with treatment healthcare to deal with the complexities of the disease, he just wants it
recommendations. to go away so he can live his life without the fear of diabetic
Perceived Patient's opinion on the Identify patient barriers and complications.
barriers financial and psychological work to reduce them • Acceptance. The patient finally gets to the point where he or
costs of compliance through patient education, she accepts the diagnosis and is ready to make the best of it.
At this point, Mr. lgnatio may be willing to use community
family outreach, and use of
resources for education and support.
community resources.
Cues to action Methods developed to Provide one-on-one
activate patient education interventions; Therapeutic Interactions for Grieving Patients
compliance detailed handouts; family Denial and isolation: Reinforce each education intervention with handouts
involvement in education that explain the disease and treatment. Encourage the patient's family
efforts; follow-up at to attend visits to the provider's office and to become involved in the
subsequent office visits; patient's care. For example, if a patient has been diagnosed with dia-
referral to community betes, provide a list of approved online resources or You Tube videos so
resources. that the patient and/or family can learn more about diabetes privately
Self-efficacy Patient has the confidence Provide ongoing education at home.
to take action to achieve and support. Anger: Use therapeutic communication techniques, especially reflection, to
a healthier state acknowledge the patient's feelings about the diagnosis. Recognize the
patient's need to use defense mechanisms as protection from the reality
of the disease (these topics are addressed in more detail in the Patient
Assessment chapter). Remember, the patient is not angry at you or the
Table 5-1 outlines the health belief model and suggests methods provider; he or she is angry about the diagnosis and its accompanying
for applying the model in patient teaching and coaching efforts in
challenges.
the ambulatory care setting.
The five stages of grief, as defined by Dr. Elisabeth Kubler-Ross,
Bargaining: Rely on the provider's recommendations regarding postponing
are another model that may be helpful for understanding the way
certain treatments. Discuss the patient's bargaining requests with the
patients respond to health threats. When a patient faces a serious provider and other staff members to work out a solution that promotes
health threat, the grief process may delay the person in adjusting to patient compliance with healthcare recommendations.
the disease and starting to take control of his or her health. For Depression: Use available community resources to provide support for the
example, Mr. lgnatio may respond to the news of his diagnosis with patient and family. The provider may recommend that the patient attend
what is commonly the first stage of the grief process-denial. Both a support group, meet with a dietitian, or use professional counseling
his father and sister suffered serious complications from diabetes, services to deal with depression.
including blindness and leg amputation, and he may be using denial Acceptance: Take advantage of this time to renew education efforts by
to deal psychologically with the burden of the diagnosis. providing multiple methods for learning about the disease, such as
Each individual goes through the stages of grief in his or her own DVDs, professional websites, You Tube videos, and community support
way and at his or her own pace. This process can take weeks to
services.
months; however, until the patient reaches the point of accepting
100 UNIT ONE INTRODUCTION TO MEDICAL ASSISTING

Patient Factors That Affect Learning
Many factors or characteristics may affect the patient's ability to
learn. Medical assistants must be aware of these factors to develop a
coaching approach that best meets the needs of each patient.
Guidelines for Patient Education
• Provide knowledge and skills to promote recovery and health.
• Encourage patient ownership and participation in the teaching process.
• With the patient's approval, include the family and significant others in
education interventions.
• Promote safe, appropriate use of medications and treatments.
• Encourage patient adaptation to healthy behaviors.
• Provide information about accessing community resources.
Perception of Disease Versus Actual State of Disease
Patients respond to a particular diagnosis in many different ways.
One predictor of how a patient will respond, and therefore how he
or she will react to health education, is the patient's perception of
the disease. Previous life experiences may greatly influence the
patient's knowledge base and/or desire to learn about the disease.
Does the patient recognize and accept the seriousness of the diagno-
sis? Or, perhaps, does the patient overreact to potential disease risks?
Both of these responses affect the patient's willingness to learn about
the disease and his or her compliance with treatment
recommendations.
How do you think Taylor's patient education efforts will be affected
ifMr. Ign,atio does not consider diabetes a serious disease?
disease prevention and health maintenance. Often the key to patient
understanding and compliance is the involvement offamily members.
During his assessment ofMr. Ign,atio's diet, Taylor learns that his wife
cooks all his meals and packs his lunch daily. He loves bread and desserts,
and he tells Taylor he's too old to change his diet now. What should
Taylor do to make sure Mr. Ign,atio's diet complies with diabetic
recommendations?
Patient's Mental and Emotional State
Even a well-planned teaching intervention can be ineffective if the
patient is unable to pay attention because of anxiety, stress, anger,
or denial (Figure 5-2). Frequently patients use defense mechanisms
to protect themselves from the reality of a serious illness. It is impor-
tant that the medical assistant be sensitive to the patient's mental
state and adapt teaching interventions as needed. If a patient is
overwhelmed by the diagnosis and his body language cues are defen-
sive, limit the amount of information at this time to what he must
know immediately about his disease, rather than trying to teach him
detailed facts.
Mr. Ign,atio has just been diagn,osed with diabetes. He has already
shared that his father died of diabetes. Do you think he is able to pay
attention to coaching efforts about a diabetic diet? What should Taylor
do to manage this problem?
Influence of Multicultural and Diversity Factors on
Patient Education
Culture, family background, and religious beliefs influence patients'
actions. Working with patients from diverse backgrounds is an excit-
ing challenge; however, for your patient education to be successful,
it is essential that you recognize and are sensitive to the impact of
these factors on patient learning (Figure 5-3). Some questions you
should consider when teaching a patient from another background
include:

Patient's Need for Information

The patient's perception of the impact of the disease on his or her
general health also determines the need for information about the
disease. Does the patient express a desire to learn all he or she can
about the disease, or does the patient resist or act indifferent to
teaching efforts? A vital part of patient education is encouraging
patient ownership of the learning process. To accomplish this, you
first may have to persuade the patient that he or she needs to under-
stand the disease before an improvement in overall wellness can be
achieved.
Mr. Ign,atio tells Taylor that his father had diabetes and had to have
both legs amputated; eventually he died of the disease. Mr. Ign,atio says
it doesn't matter whether he controls his blood sugar; he'll still have major
health complications. What is the appropriate response?

Patient's Age and Developmental Level

Depending on the patient's age and ability to understand informa-
tion about the disease, you may have to adapt the teaching plan to
meet specific learning needs. For example, educating a 9-year-old
patient with DM type 1 about disease management requires a dif-
ferent approach from one that would be used for Mr. Ignatio. You
should be flexible and creative in providing learning opportunities
that support the provider's attempt to educate the patient about FIGURE 5-2 Demonstrating sensitivity to the patient's needs.

FIGURE 5-3 Considering diversity.
• Is language an issue with your patient (Figure 5-4)? If the
patient is unable to understand spoken English or to read it
correctly, do you have an alternative method for getting the
information across?
• Do the patient's culture, ethnic background, or religious
beliefs influence the way he or she perceives disease and the
role of healthcare workers?
Approaches for Language Barriers
• Determine whether the patient can read and/or understand English.
• Address the patient by his or her last name (e.g., Mrs. Martinez, Mr.
Nugyen).
• Be courteous and use a formal approach to communication.
• Use gestures, tone of voice, facial expressions, and eye contact to
emphasize appropriate parts of the discussion.
• Integrate pictures, handouts, models, and other aids that visually depict
the material.
• Carefully observe the patient's body language, especially facial expres-
sion, for understanding or confusion.
• Use simple, everyday words as much as possible. If available, use a
dictionary that translates as many words as possible for the patient.
• Demonstrate all procedures and have the patient return the demonstra-
tion to check for understanding.
• Implement the teaching plan in small, manageable steps.
• Give the patient written instructions for all procedures and treatments.
• If possible, have an interpreter present ar have access to an online
interpreter; if an interpreter is not available, a family member may be
able to help with communication.
• If available, provide educational materials in the patient's native lan-
guage. For example, vaccine information sheets (VIS) are available
online in multiple languages from the Centers for Disease Control and
Prevention (CDC); send materials home in English if a family member
can interpret the material far the patient; refer the patient and family
to online sources of educational materials in their native language.
CHAPTER 5 Patient Education 101
FIGURE 5-4 Using languageiippropriate educational booklets.
• What strategies or techniques might minimize patient educa-
tion problems?
• Are community resources available that could facilitate patient
learning?
Patient Learning S"lyle
All of us have a preferred way of!earning; that is, methods that work
best for us to learn new material. Patients also have a learning prefer-
ence that reflects their individual learning style. Some patients learn
best from discussion or lecture, whereas others must take time to
think about the material before they understand it. Some patients
can learn from observing; others must act or do something with the
material to learn it. Start your teaching intervention by asking your
patient how he or she prefers to learn new material, and pattern your
teaching interventions along those lines.
Mr. lgnatio tells Taylor that he could never learn things by listening
to someone tell him what to do. What approach to learning might best
meet his needs?
lmpactofPhysica/Disabililies
The patient first must be assessed to determine whether he or she
can adequately hear instructions, see written material, and manipu-
late any required treatment equipment. All teaching efforts are lost
if disabilities interfere with a patient's capacity to understand infor-
mation or to handle equipment properly. A hearing or speech
impairment may require the use of sign language with supplemental
written instructions. If the patient is unable to manipulate equip-
ment because of a physical disability or vision problem, family or
adaptive equipment may be necessary for the patient to manage his
or her care.
Mr. Ignatio's physical assessment revealed hearing and vision prob-
lems. Is he able to understand verbal imtructions clearly? What can be
done to adapt the teaching intervention to meet his needs?
102 UNIT ONE INTRODUCTION TO MEDICAL ASSISTING
Therapeutic Communication With Patients With
Special Needs
Patients With Vision Loss
• Alert the patient that you are in the room and identify yourself; do not
touch the patient without warning.
• The patient is unable to pick up on your body language; use clear,
concise language and a normal tone of voice.
• Provide all written material in a large font or print size; large-print
educational materials often can be ordered.
• Supply reliable Internet sources for information and provide audio mate-
rial if possible.
Patients With Hearing Loss
• Stand in front of the patient or within the person's field of vision before
you begin speaking; the patient may be able to lip-read.
• You may need to touch the patient lightly to get her or his attention.
• Use expanded speech; lower the tone of your voice and pronounce each
syllable. Do not raise your voice or shout to be heard. The louder your
voice, the higher the tone, and aging ears find high-pitched sounds the
most difficult to interpret.
• Carefully observe the patient's body language for understanding or
confusion.
• Use gestures or demonstration as needed to get the message across.
• Clearly print any information needed to clarify the patient teaching.
• If a patient is wearing a hearing aid, ask him or her whether it is on
and working before starting the conversation; the patient may turn a
hearing aid off to prevent annoying background noise.
• Provide written handouts that review the material being taught.
• Request family assistance in verifying that the patient received and
understood the material.
• Refer patients and families to appropriate online resources
CRITICAL THINKING APPLICATION 5-1
Implement the holistic education model and the health belief model to
determine and respond to Mr. lgnatio's individual learning needs.
THE TEACHING PLAN
What is it that patients need to know to manage a disease effec-
tively? What is it about an individual patient that needs to be
addressed for a teaching intervention to work? What are the imme-
diate and long-term goals of patient education? What teaching
materials or strategies should be used to meet the patient's learning
needs and also effectively relay the information? How can the teach-
ing plan be implemented successfully? How do you, as a medical
assistant, manage the limited time available for patient coaching?
How do you know the patient is learning and actually converting
this knowledge into disease management? A vital aspect of patient
teaching is to be flexible and to provide information about what
patients want to know when patients want to know it. These and
other guidelines for developing an appropriate and effective teach-
ing plan follow.
Assess the Patient's Learning Needs
Developing a teaching plan that works for a particular individual
first requires an assessment of the patient as a learner and consider-
ation of any characteristics that might affect the learning process.
Many of these factors already have been addressed, such as the
patient's learning preference, perception of the illness, age, back-
ground, multicultural influences, language barriers, and disabilities.
The medical assistant also must consider what the patient already
knows about the diagnosis and whether that knowledge includes
misconceptions about the disease.
The goal of the assessment process is to create a teaching plan
that meets the patient's needs for understanding and managing his
or her illness. Therefore, in the learning assessment, the medical
assistant should consider what the patient needs to know, what the
patient wants to know, and what can be done in the time available
for learning.
Before developing a specific approach to patient education, you
must consider potential barriers to learning other than those already
presented, such as the presence of pain. A patient in acute distress
is unable to concentrate on the information. In this case, the amount
of material must be adjusted to meet the patient's immediate needs,
and time should be planned in the future for a more in-depth teach-
ing session.
Does Mr. lgnatio exhibit any potential barriers to learning about his
disease?
Possible Barriers to Patient Learning
• Individual learning style
• Age and developmental level
• Use of defense mechanisms
• Language
• Motivation to learn
• Physical limitations or disabilities
• Emotional or mental state
• Cultural or ethnic background
• Pain
• Time limitations
Determine the Teaching Priorities
Once you have done an adequate assessment of your patient as a
learner and you understand your patient's learning needs, the next
question is, "Where do I start?" A patient such as Mr. lgnatio has a
significant amount of information to learn before he can manage his
disease completely. The volume of information might seem over-
whelming unless priorities are established. How do you figure out
what material should be first? The first question to ask is, "What is
the patient's immediate versus long-term needs?" What must this
patient learn today to be able to take care of himself, and what does
he need to know overall about his illness to promote healthy
behaviors?
 CHAPTER 5 Patient Education 103

Because the patient learning assessment told you what your

patient knows about his or her disease, that is a good place to start.
Confirm what the patient knows about the problem and attempt to
correct any potential misconceptions. If you start with something
the patient knows and understands, he or she will feel more compe-
tent and capable of managing new material. You then should go on
to the new material that is causing the patient the most anxiety. If
the patient is nervous or afraid about a particular aspect, he or she
will be unable to pay attention to any other new material until that
anxiety has been addressed.
For example, if Mr. Ignatio is most concerned about pricking his
finger for a glucometer reading, that is the first skill he should learn.
Once he is confident about that particular part of treatment, he will
be able to pay attention to diet and exercise recommendations. You
should always begin with the basic details about the disease and add FIGURE 5-5 Reviewing printed information.
more information during each patient visit.
Every interaction with the patient is an opportunity for health care setting where you are employed may develop its own educa-
education. A major problem with delivering high-quality patient tional materials.
education in an ambulatory healthcare setting is the lack of time you Some guidelines to follow if you are responsible for developing
have to spend with each patient. Therefore, you must take advantage or ordering educational supplies include the following:
of every "teaching moment"; that is, every time you interact with a
patient, use it as an opportunity to assess the patient's current educa- • The material should be written in lay language at about a sixth
tion needs and provide as much information or guidance about that grade level to promote general patient understanding.
specific learning need as possible during the time available. • Information should be well organized and clearly described.
Use the waiting room as a place for learning by providing up-to- • All material should be checked for accuracy.
date educational materials on a wide variety of health issues. Many • Handouts should be attractive and professional.
facilities have DVD equipment in the waiting room for patient • Copies should be available in other languages when possible
education while the patient is waiting to be seen. These can be specific and in large print for visually impaired clients.
to the type of practice or can provide general health information.
Another good location for educational materials is in the examination Identifying Community Resources
rooms. The patient may be more likely to pick up brochures on
One role of the medical assistant in ambulatory care settings is to assist
sensitive topics such as types of contraceptives, the procedures for
performing testicular or breast exams, or information about sexually
patients and their families in finding and using community education and
transmitted infections in the privacy of a closed exam room.
support services. The healthcare facility should keep an up-to-date file of
area resources. The information should include the name of the group and
Decide on the Appropriate Teaching Materials the services provided; the contact person; a telephone number and address;
What teaching materials would best meet the needs of your patient? meeting times and location if applicable; and a related website if available
A wide variety of patient education materials is available, and decid- (see Procedure 5-1 ). This information can be found in a number of loca-
ing which materials best meet your patient's needs depends on the tions, such as the blue pages of the local phone book, through the com-
patient's learning preference, individual characteristics, and lifestyle munity outreach or speakers bureau of area hospitals, or online by searching
factors. Individualized instruction is the key to understanding and for area educational institutions at .edu sites or local chapters of national
patient compliance; however, additional materials can help reinforce organizations at .org sites. For example, the American Cancer Society
the information. operates local branches throughout the United States, and information on
When possible, all patient instruction should include a handout
local services can be found on the national home page (www.cancer.org).
or online reference that reinforces information and that the patient
can use as a resource. Patient factors such as the use of defense
An excellent comprehensive Internet site operated by the U.S. National
mechanisms, emotional state, and language barriers can limit the
Library of Medicine and the National Institutes of Health is MedlinePlus.
patient's ability to comprehend and remember information. Printed Both health professionals and consumers can depend on it for accurate
information is needed to help the patient and the patient's family information that is updated frequently. The site provides a variety of
understand what is happening and what needs to be done to improve information about health issues, an extensive list of diseases and condi-
the patient's health (Figure 5-5). Informational flyers can be ordered tions, a medical encyclopedia and dictionary, health information in Spanish,
from medical office suppliers, pharmaceutical company representa- extensive details on prescription and nonprescription drugs, health informa-
tives, and health education companies. In addition, most electronic tion from the media, and links to thousands of clinical trials. It can be
health record (EHR) systems include a package for printing out or bookmarked at medlineplus.gov. Another excellent source of current infor-
e-mailing diagnose-specific educational materials. Many hospitals mation on diseases is the Centers for Disease Control and Prevention (CDC)
also offer free educational materials about diagnostic procedures, website at www.cdc.gov/
immunizations, and other disease-related topics. The ambulatory
104 UNIT ONE INTRODUCTION TO MEDICAL ASSISTING

Other teaching materials include DVDs, approved YouTube
links, and health-related applications that can be accessed by smart
phone or computer to help patients learn about their disease and
track their progress. These learning aids promote self-directed and
self-paced learning. They also permit the patient to access material
in a nonstressful environment, which improves the patient's
learning potential. Depending on the patient's age or access to the
appropriate technology, using media resources or referring the
patient to provider-approved healthcare sites on the Internet can
help develop patient ownership of the learning process and
provide excellent resources for patient referral. However, using the
Internet as a resource for patient education information has
its drawbacks. It is important that the patient understand that
there is no oversight or control over information posted on
the Web; therefore, some sites may offer information that is erro-
neous, out of date, or misleading. Provide patients with accurate,
well-researched sites and/or keep informed about what sites
patients are accessing to make sure online recommendations
support the provider's treatment protocol. The following website,
posted by the National Institutes of Health, can help you learn
how to assess Internet health information: www.nlm.nih.gov/
medlineplus!webeval!

The Medical Assistant as a Patient Navigator

According to the American Medical Association, a patient navigator is a person
who helps patients and families with insurance problems, explains treatment
and care, communicates with the healthcare team, assists caregivers, and
manages medical paperwork. This definition describes the role of the medical
assistant as a patient advocate in ambulatory care settings.
The concept of patient navigation was pioneered in 1990 by Dr. Harold
P. Freeman, a surgical oncologist at Harlem Hospital, for the purpose of
eliminating barriers to timely cancer care for the indigent and underserved.
In response to this need, the Patient Navigator Outreach and Chronic Disease
Prevention Act of 2005 was passed to make grants available for the develop-
ment of patient navigator programs. The original goal af patient navigation
was to help people overcome barriers such as poverty, low literacy, or lack
of health insurance that were preventing patients from gaining access to
medical care. However, the care for illnesses such as cancer can be so
complicated that patients, regardless of income or education level, can benefit
from expert assistance. In fact, under a new requirement for accreditation by
the American College of Surgeons Commission on Cancer, cancer centers must
have started providing patient navigation services by 2015. Most recently,
the Affordable Care Act required that "insurance navigators" be available to
help consumers research and enroll in health insurance through the law's
health insurance marketplace.
Because medical assistants are cross-trained in both administrative and
clinical skills, they are in a unique position to serve as patient navigators in
ambulatory care settings.

Develop a List of Community Resources for Patients' Healthcare Needs; also, Facilitate
PROCEDURE 5-1
Referrals in the Role of Patient Navigator

As a medical assistant, one of your roles will be to help patients who need community health education or support services. To
prepare for this role, you should collect a minimum of 25 community resources available in your area (e.g., support groups,
educational workshops, dietary assistance, national organizations, medical equipment suppliers). In your directory, include the
fallowing information: name of the group; services provided; contact person; telephone number; address; meeting times and
locations (if applicable); and a related website. As a patient navigator, apply what you have learned about community resources
to assist the patient in the following scenario.
Goal: To develop olist of community resources and perform the role of patient navigator by referring patients to resources.
Scenario: Role-play the following scenario with your partner.
Mr. Tomas Garcia was admitted to the hospital last week for an acute myocardial infarction (Ml). Mr. Garcia is 54 years old,
overweight, smokes two packs of cigarettes aday, eats fast food almost daily, has a family history of heart disease, and works
as a carpenter. The provider recommends that he lose weight follow a diet high in fiber and low in saturated fat; and quit
smoking. What community resources might help educate and support Mr. Garcia in making these complex lifestyle changes?
EQUIPMENT and SUPPLIES PROCEDURAL STEPS
• Patient's health record 1. Greet and identify the patient in a pleasant manner. Introduce yourself and
• Educational handouts explain your role.
• Computer with Internet connection and printer PURPOSE: To make the patient feel comfortable and at ease.
• Quiet, private area
 CHAPTER 5 Patient Education 105

•;;m,anmjJj• -continued

2. Take the patient to a quiet, private area that has computer access.
PURPOSE: Aquiet, private area is necessary to protect confidentiality and
prevent interruptions.
3. Assess Mr. Garcia's needs, and identify factors that may limit his ability to
learn and implement lifestyle changes. Use restatement, reflection, and
clarification to verify the information.
PURPOSE: Therapeutic communication techniques help you gather complete
information and address the patient's immediate needs; it also improves
the likelihood of success.
4. Speak in a pleasant, distinct manner, remembering to maintain eye contact
with your patient.
PURPOSE: Positive nonverbal behaviors create a friendly, caring
atmosphere.
S. Remain sensitive to the individual needs of your patient throughout the
interview process.
PURPOSE: Be aware of your personal biases, but do not let them affect the
way you treat your patients; make sure to respect patients' diverse
backgrounds.
6. Provide Mr. Garcia with appropriate handouts and a list of community
resources that might be helpful. Print out this information or e-mail it to the
patient for future use. One of the handouts could include a list of provider-
approved websites the patient can consult.
PURPOSE: Make sure the patient has all the handouts with him before he
leaves the office; also make sure he has a list of appropriate online sites
he can check out later for additional information and support.
7. Answer any questions the patient may have; use clarification and feedback
methods to make sure all his questions have been addressed.
8. Document the patient education intervention in the health record.

Decide on the Appropriate Teaching Methods

A variety of methods may be used to get the message across to your
patients. One of the best ways to manage a large amount of informa-
tion within a short time is to use community resources to reinforce
the message. Your local area provides a wide range of education
services for your patients to help them better understand and manage
their health problems, to promote wellness, and to provide support
for treatment compliance. Hospitals and many community agencies
and organizations provide patient education opportunities, support
groups for specific problems or diseases, and learning materials.
These same groups may help the patient by providing professional
consultation for many topics, including diet, exercise, and emotional
support. It is important that the medical assistant be aware of the
various resources available in the community for patient education
FIGURE 5-6 Demonstration and return demonstration.
and referral.
Based on your evaluation ofMr. Ignatio's learning needs, what com-
munity resources would help him and his family better understand and that can help patients perform this task. In the case of Mr. lgnatio,
manage his disease? referring to the memory log on his glucometer or tracking blood
Teaching patients specific skills also is an important component glucose levels with an app on his phone or computer could reinforce
of health education. The best way to coach a patient through the the results of his compliance with medication and diet therapies.
process of manipulating and operating medical equipment accu- Another vital link to the success of patient education is family
rately is to use demonstration and return demonstration of the skill involvement. If the patient is being treated holistically, the family
(Figure 5-6). Using the exact piece of equipment the patient will be plays an integral role in patient wellness. Involving family members
using at home, you first should demonstrate to the patient how to in patient education efforts provides support and understanding for
perform the skill, ask for questions and explain further as needed, the patient and manages family concerns about the patient's welfare.
and then have the patient return the demonstration before leaving An educated family member can be an excellent resource for patient
the facility. This gives you the opportunity to observe the patient concerns and a vigilant reinforcer of healthy behaviors.
performing the task and correct any mistakes or clarify any miscon-
ceptions before the patient has to use the equipment at home alone. CRITICAL THINKING APPLICATION 5-2
For some patients, an effective method of monitoring health edu- The provider recommends that Mr. lgnatio start a 1,2OO-calorie diabetic diet
cation is to have the patient keep a journal of his or her activities and for weight reduction and blood glucose control and that he take glucometer
response to treatment. For example, a patient trying to adapt to a new readings three times a day. After you consider various teaching methods,
diet could record daily intake to get a better idea of whether he or she
which strategies do you think would be most useful in helping Mr. lgnatio
is following through with dietary recommendations. Some excellent
learn about his disease and follow the provider's recommendations?
online applications (apps) are available, such as the MyPlate.gov site,
106 UNIT ONE INTRODUCTION TO MEDICAL ASSISTING
Implement the Teaching Plan
After you have completed the patient assessment, decided on teach-
ing materials and methods that match your patient's characteristics
and learning needs, and adapted the material and your approach for
any potential barriers to learning, it is time to implement the plan.
Conduct the lesson in a quiet area away from distractions. Assemble
the equipment the patient will need to follow through with treat-
ment. The patient should learn to handle and practice on the same
type of equipment that will be used at home so that no problem
occurs in transferring the skill. Time is always an issue in the ambula-
tory care setting, so it is important to present only the material or
skill it is possible for the patient to master before the end of the
appointment. Throughout the lesson, remember to maintain an
adequate pace for learning-not too fast and not too slow-to
optimize the patient's understanding.
A crucial aspect of successful patient teaching is to consistently
ask for feedback about the process (Figure 5-7). It also helps to
restate, repeat, or rephrase the material to make sure the patient
understands the process. As patients provide correct feedback about
what they are learning or demonstrate skills correctly, it is important
to be positive about their progress. It also helps to summarize the
material learned or the skills mastered at the end of each teaching
intervention, as a way of reviewing the material and clarifying impor-
tant concepts.
FIGURE 5-7 Patient feedback.
CRITICAL THINKING APPLICATION 5-3
Taylor has just completed the initial patient education session with Mr.
lgnatio and his wife. He used demonstration-return demonstration to teach
Mr. lgnatio how to check his blood glucose levels properly with the glucom-
eter he will be using at home. Taylor answered Mrs. lgnatia's questions
about diabetic diets, but the provider has also referred the couple to the
dietitian at the hospital for further information on that topic. Taylor plans
ta review the skills practiced today at Mr. lgnatio's next appointment and
to continue the teaching intervention, emphasizing the importance of Mr.
lgnatio checking his feet daily for open areas or any signs of infection.
Accurately and completely document Taylor's initial coaching session
with Mr. lgnatio.
The medical assistant should continue to evaluate the teaching
plan throughout the process to make sure the time was adequate for
learning and that the patient understood the information needed to
follow through with care at home. In addition, plans should be made
for the education intervention during the patient's next visit. All of
this information needs to be included in the progress note about the
lesson. Finally, the medical assistant must document details about
the material covered, the patient's competency or level of skill in
learning treatment techniques, and any referrals made for commu-
nity and hospital experts or education groups (Procedure 5-2).
Summary of the Patient Teaching Plan
1. Periorm an assessment.
• Consider pertinent patient factors.
• Identify barriers to learning.
• Prioritize patient information.
2. Determine the patient's immediate and long-term needs.
• Decide on the appropriate teaching materials and methods; prepare
the teaching area; and assemble the necessary equipment and
materials.
• Demonstrate techniques and procedures using the supplies the
patient will use at home.
• Provide positive feedback when the patient performs skills
correctly.
3. Maintain an adequate pace while teaching (not too fast).
4. Repeatedly ask for patient feedback to confirm understanding.
• Barriers to learning are eliminated.
• Immediate learning needs can be addressed.
• Repetition and rephrasing promote understanding.
5. Summarize the material learned or skill mastered at the end of each
teaching interaction.
6. Outline a plan for the next meeting.
7. Evaluate the teaching plan.
• Was there enough time to complete the lesson?
• Was the patient physically and psychologically ready for the
information?
• Were the goals for the session reached?
8. Document the teaching intervention in the patient's health record.
• Material covered
• Patient response or level of skill performance
• Plans for next session
• Community referrals
Role of the Medical Assistant as Patient Coach
• Reinforce provider instructions and information
• Encourage patients to take an active role in their health
• Use each patient interaction as an opportunity for health teaching
• Keep information relevant to the patient's needs
• Establish and maintain rapport with the patient
• Communicate clearly
• Be sensitive to the patient's learning factors
• Modify the teaching plan as needed to best meet the patient's needs
 CHAPTER 5 Patient Education 107

Coach Patients in Health Maintenance, Disease Prevention, and Following the

PROCEDURE 5-2
Treatment Plan

Goal: To consider patient factors, such as cultural diversity, developmental life stage, and communication barriers, when coaching
patients in health maintenance, disease prevention, and following the treatment plan.
Scenario: Role-play the following scenario with your partner.
Samuel Wu is a14-year-old patient who was recenffy diagnosed with hypertension. The provider has designed a treatment
plan for health maintenance and disease prevention that includes alow sodium diet, weight loss, and hypertensive medication.
What patient education approaches should the medical assistant use that are age- and culturally appropriate? Should the medical
assistant provide an educational brochure for Mr. Wu that he can take home for reinforcement of patient education? Include in
your discussion the importance of following the provider's instructions for diet and weight loss.
EQUIPMENT and SUPPLIES different type of equipment. Taking his blood pressure routinely will help
• Patient's health record reinforce diet restrictions, and the need for taking his medication as
• Educational handouts and/or access to on line resources that can be printed ordered.
• Quiet, private area 6. Use restatement, reflection, and clarification to promote understanding.
PURPOSE: Therapeutic communication techniques help you gather com-
PROCEDURAL STEPS plete information.
1. Greet and identify the patient in a pleasant manner. Introduce yourself 7. Remain sensitive to the individual needs of your patient throughout the
and explain your role. interview process.
PURPOSE: To make the patient feel comfortable and at ease. PURPOSE: Consistently keep in mind the patient's cultural background,
2. Take the patient to a quiet, private area. If this room has a computer with developmental stage, and possible communication barriers as you progress
Internet access, you can help Mr. Wu research appropriate sites and print through the teaching intervention. Treat all patients with respect.
educational materials for his use at home. 8. Summarize the material learned or the skill mastered at the end of each
PURPOSE: Aquiet, private area is necessary to protect confidentiality and teaching interaction and outline a plan for the next meeting. Emphasize
prevent interruptions. the importance of following the treatment plan to maintain health and
3. Identify factors that may limit the patient's ability to learn and implement prevent disease complications.
lifestyle changes. Mr. Wu is of Chinese descent and is 74 years old. Will PURPOSE: Summarizing the material covered helps clarify the information
these patient factors affect learning? for the patient and also helps you determine where to start or what to
PURPOSE: You can promote patient learning if you identify and address review at the next appointment.
the patient's primary concern and are sensitive to possible barriers to 9. Give the patient appropriate handouts and/or conduct an online search of
patient education, such as cultural influences, developmental stage, and community resources that might be of benefit. Print out this information
possible communication barriers. or e-mail it to the patient for future use.
4. Prioritize the patient information and determine the patient's immediate PURPOSE: Make sure the patient takes the handouts when leaving the
and long-term needs. What does Mr. Wu need to know to maintain his office; include a list of online sites that can be checked for additional
health, prevent complications related to hypertension, and to follow the information and support.
provider's treatment plan? 10. Document the teaching intervention, including the material covered; the
S. Prepare the teaching area and assemble necessary equipment and materi- patient's response or level of skill performance; plans for the next session;
als, making sure to use the same supplies and equipment the patient will and any community referrals.
use at home. Mr. Wu has a wrist blood pressure machine that he will use PURPOSE: Documentation in the health record of the teaching intervention
at home to monitor his blood pressure. Monitoring his blood pressure at and the patient's comprehension helps ensure consistency and appropriate
home will help Mr. Wu determine if he is following diet restrictions and follow-up for subsequent visits.
taking his medication as ordered.
PURPOSE: Using the same equipment that the patient uses at home
reinforces learning and limits the need to apply newly learned skills to a
 108 UNIT ONE INTRODUCTION TO MEDICAL ASSISTING
CLOSING COMMENTS
Legal and Ethical Issues
Providing adequate, correct, understandable information to patients
is integral to the informed consent mandate in the Patients' Bill of
Rights. All patients have the right to information before they agree
to receive care. An extension of this concept is the right of patients
to understand their disease process and to manage their health.
Another consideration arising from the Patients' Bill of Rights is the
issue of patient confidentiality as it relates to patient education.
When developing and implementing the teaching plan, designing
teaching interventions and strategies, and referring patients for com-
munity assistance, the medical assistant must protect the patient's
confidentiality.
Essential factors in risk management for the ambulatory care
setting include conducting adequate patient education and follow-up.
Also integral to risk management is the importance of documenting
each patient education intervention completely and accurately. The
patient's health record should clearly describe the education inter-
vention, methods and materials used, the patient's response to the
intervention, the date of each session, and the individual who con-
ducted each intervention. Each documentation entry should com-
pletely describe the material covered and the patient's feedback about
the information so that no doubt exists that the patient understood
the information and was able to perform any related skills properly
and adequately.
Teaching interventions should demonstrate sensitivity to multi-
cultural factors and diverse populations. Meeting the needs of all
patients without evidence of prejudice is a key risk management step.
HIPAA Applications
• The patient has the right to restrict who can receive protected
health information (PHI). At the first office visit, the patient
should complete a release of information form, if he or she wants
to do so. This form identifies a particular family member, close
Ji1iiilffi;ti•iii9#iffi;li·i
After working with Mr. lgnatio, Taylor realizes the significance and complexity
of educating patients in the ambulatory care setting. Despite the time con-
straints typical in this particular healthcare setting, patients still must learn
how to manage their disease and follow treatment guidelines. Approaching
each patient as an individual learner with particular needs and characteristics
friend, or any other individual who the patient states can receive
disclosures of health information.
• Only the person or persons identified on the HIPM release form
completed by the patient have the right to the patient's personal
information. Therefore, if an individual requests information
about the patient, the medical assistant first must check the
release form to determine whether the individual was approved
by the patient before discussing the patient's condition. This
holds true regardless of the individual's relationship to the patient.
• If the provider believes that it is in the patient's best interest that
family members be involved in patient health education, the
medical assistant can contact the family only if the patient has
given approval. This permission should be included in the
patient's HIPM information and should be documented in
the medical record so that all employees can read evidence of the
patient's approval.
Professional Behaviors
Medical assistants are members of a profession in which information about
disease, treatment, diagnostics, and management of health problems is
constantly changing. Keeping up with current medical information requires
a commitment to lifelong learning from all members of the healthcare
team. To be effective patient educators, we first must be sure to have
adequate knowledge ourselves. Medical assistants are perfectly placed in
the healthcare team to represent the patient; that is, to perform the duties
of a patient navigator. Who else in the ambulatory care setting is better
able to understand the complex administrative and clinical skills needed for
patients to navigate their care? From understanding treatment protocols to
helping patients with insurance issues, medical assistants can serve as
intermediaries who represent and support the patient throughout the health-
care environment.
is crucial to the ultimate success of the teaching plan. By using a holistic
approach and taking into account the health belief model, Taylor has consid-
ered the ramifications of diabetes mellitus for Mr. lgnatio's life and has made
efforts to include family and community resources in the management of his
disease.

SUMMARY OF LEARNING OBJECTIVES
l. Discuss the holistic model of patient education related to health and
illness; also, instruct patients according to their needs to promote
health maintenance and disease prevention.
The holistic model suggests that patient education should consider all
aspects of the patient's life, including physical, sociocultural, intellectual,
economic, and psychological needs. (See Table 5· l and Figure 5· l .) The
health belief model analyzes what people believe to be true about them-
selves and their health. This model suggests that healthcare practitioners
consider how the patient perceives the risk of developing the disease and
whether he or she believes that altering health behaviors will prevent the
disease. Dr. Elisabeth Kubler-Ross's stages of grief may also help explain
a patient's reaction to a particular diagnosis, especially if the disease
requires a drastic change in lifestyle. Grief is an ongoing process, with
patients moving through denial, anger, bargaining, depression, and finally
resolution, at their own pace and in their own way.
Many factors or patient characteristics may affect the patient's
ability to learn. Medical assistants must be aware of these factors to
develop a patient education approach that best meets the needs of each
patient.
2. Summarize the stages of grief and suggest therapeutic interactions
for grieving patients.
• Denial and isolation: Reinforce each education intervention and encour-
age family members to attend visits.
• Anger: Use therapeutic communication techniques to acknowledge the
patient's feelings about the diagnosis.
• Bargaining: Discuss the patient's bargaining requests with the provider
to work out a solution.
• Depression: Use available community resources to provide support for
the patient and family.
• Acceptance: Renew education efforts by providing multiple methods for
learning about the disease.
3. List at least five guidelines for patient education that can affect the
patient's overall wellness.
The guidelines for patient education include providing knowledge and skills
that promote recovery and health; including family in education interven-
tions; encouraging patient ownership of the education process; promoting
safe use of medications and treatments; encouraging healthy behaviors;
and providing information on how to access community resources.
4. Do the following related to patient factors that affect learning:
• Define six patient factors that have an impact on learning.
Patient factors that have an impact on learning include the patient's
perception of disease versus the actual state of disease; the need for
information; age and developmental level; mental and emotional state;
the influence of multicultural and diversity factors; individual learning
style; and the impact of physical disabilities on the education process.
• Display respect for individual diversity.
Culture, family background, and religious beliefs influence a patient's
actions. For patient education to be successful, it is essential that the
medical assistant be aware of and sensitive to the impact of these
CHAPTER 5 Patient Education 109
factors on patient learning. Consider the patient's language, ability to
understand English verbally or read it correctly, and cultural relationships
to healthcare workers. Develop techniques to minimize the patient's
education problems.
• Summarize educational approaches for patients with language
barriers.
Educational approaches for patients with language barriers include
addressing the patient formally and courteously; using nonverbal lan-
guage to promote understanding; integrating pictures or models that
illustrate the material; observing the patient for understanding or confu-
sion; using simple lay language; demonstrating procedures; implement-
ing teaching in small, manageable steps; providing written instructions;
and using an interpreter when available.
5. Do the following related to the teaching plan:
• Determine possible barriers to patient learning.
Possible barriers to patient education include the patient's learning style,
physical limitations, age, and developmental level; any emotional or
mental state that interferes with learning; use of defense mechanisms;
cultural or ethnic factors; language; the presence of pain; a patient's
lack of motivation to learn; and limited time for teaching.
• Assess the patient's needs.
The goal of the assessment process is to create a teaching plan that
meets the patient's needs for understanding and managing his or her
illness.
• Determine the teaching priorities.
Every interaction with the patient is an opportunity for health education.
Use the waiting room as a place for learning by providing up-to-date
educational materials on a variety of issues.
• Decide on the appropriate teaching materials.
When possible, all patient information should include a handout or
online reference that reinforces information and that can be used as a
resource. Other teaching materials include DVDs, approved You Tube
links, and health-related applications that can be accessed by smart
phone or computer.
• Develop a list of community resources related to patients' healthcare
needs and facilitate referrals to community resources in the role of a
patient navigator.
The medical assistant should assist patients and their families in finding
and using community education and support services when needed.
The healthcare facility should maintain a current file of area resources
that give the name of the group and the services provided; the contact
person; a telephone number and address; meeting times and location
if applicable; and a related website if available. Patients should be
provided with accurate, well-researched sites to make sure that online
recommendations support the provider's treatment protocol. Apatient
navigator is a person who helps patients and families with insurance
problems, explains treatment and care, communicates with the health-
care team, assists caregivers, and manages medical paperwork. This
definition describes the role of the medical assistant as an advocate for
Continued
11 o UNIT ONE INTRODUCTION TO MEDICAL ASSISTING
SUMMARY OF LEARNING OBJECTIVES-continued
the patient in the ambulatory care setting. (Refer to Procedure 5-1 .)
• Decide on the appropriate teaching methods.
Avariety of methods may be used to get the message across to
patients. Some excellent apps are available that can help patients keep
track of their progress. Family involvement is also important.
• Implement the teaching plan.
The medical assistant should consistently ask for feedback about the
process. It also helps to restate, repeat, or rephrase the material to
make sure the patient understands.
• Demonstrate the ability to develop an appropriate and effective patient
teaching plan.
The parts of the teaching plan include assessing learning needs; elimi-
nating learning barriers; determining teaching priorities; using appropri-
ate teaching materials and methods; gathering feedback repeatedly to
ensure that the patient understands; summarizing the material at the
end of each education session; planning for the next meeting; evaluat-
ing the effectiveness of the session; and completely and accurately
CONNECTIONS
CCI Study Guide Connection: Go to the Chapter 5 Study Guide. Read and complete
the activities.
documenting the details of the teaching intervention. (Refer to
Procedure 5-2.)
6. Describe the role of the medical assistant in patient education.
The role of the medical assistant in patient education is to reinforce the
provider's instructions and information by encouraging patients to take an
active part in their health; using teaching moments effectively; keeping
information relevant to the patient; establishing and maintaining patient
rapport; communicating clearly; remaining aware of learning factors; being
flexible with the teaching plan; and using community resources for learning
and support.
7. Integrate the legal and ethical elements of patient teaching into the
ambulatory care setting; also, discuss HIPM applications.
Appropriate patient education reflects the emphasis of the Patients' Bill of
Rights on patient confidentiality and informed consent. Risk management
practices related to patient education include accurate and complete docu-
mentation of patient education sessions, sensitivity to the needs af the
individual patient, and application of HIPM rules.
evolve Evolve Connection: Go to the Chapter 5 link at evolve.elsevier.com/
kinn to complete the Chapter Review Quiz. Check out the other resources listed for this
chapter to make the most of what you have learned from Patient Education.
 NUTRITION AND
HEALTH PROMOTION
i-i#H+i;H•i
Marcia Schwartz, (MA (MMA), is em played by an internal medicine practice
in her hometown. She recognizes that many of the patients seen in the practice
have diseases that are influenced by diet and lifestyle factors. She learned about
the importance of goad nutrition and wellness in her medical assisting program.
While studying this chapter, think about the following questions:
• How can Marcia help her patients understand the importance of and
suggested requirements for the primary nutrients?
• What should Marcia know about the dietary guidelines for carbohydrates,
proteins, and fats?
• What is the importance of vitamins and minerals and in what foods can
they be found?
• How can Marcia educate patients using the Choose My Plate website?
LEARNING OBJECTIVES
1. Define, spell, and pronounce the terms listed in the vocabulary.
2. Analyze the relationship between poor nutrition and lifestyle factors
and the risk of developing diet-related diseases.
3. Recognize the reasons for people's food choices and the effects of
cultural eating patterns.
4. Describe digestion and classify the types and functions of dietary
nutrients.
5. Describe the roles of various nutrient components, including
carbohydrates, fats, and proteins, in the daily diet.
6. Explain the function of appropriate amounts of vitamins, minerals, and
water in the diet.
7. Apply the Dietary Guidelines for Americans using the Choose My Plate
website developed by the U.S. Department of Agriculture (USDA).
8. Implement nutritional assessment techniques by measuring a patient's
body fat and correlating a patient's calculated body mass index (BMI)
with the risk for diet-related diseases.
6
In addition, Marcia has continued ta attend workshops and read about current
trends in nutrition, so she is prepared ta provide assistance ta her patients as
directed by the provider.
• Is Marcia able to teach patients the significance of the body mass index
(BMI)?
• What are the general guidelines for therapeutic nutrition?
• Is it important that Marcia be able to coach patients about understanding
food labels?
• What factors contribute to a healthy lifestyle?
9. Do the following related to therapeutic nutrition:
• Compare the concepts of therapeutic nutrition.
• Instruct a patient according to the patient's dietary needs; coach a
patient with diabetes about the Glycemic Index of foods.
10. Interpret food labels, explain their application to a healthy diet,
and demonstrate to the patient how to understand nutrition labels on
food products.
11. Discuss food-borne diseases and food contaminants.
12. Summarize the causes of eating disorders and obesity and their impact
on a patient's health.
13. Define the concepts of health promotion.
14. Describe the role of the medical assistant in patient education; also,
explain the legal and ethical issues related ta nutrition and health
promotion.
112 UNIT ONE INTRODUCTION TO MEDICAL ASSISTING
VOCABULARY
amino acids The organic compounds that form the chief
constituents of protein; they are used by the body to build and
repair tissues.
cholesterol (kuh-les'-tuh-rol) A substance produced by the liver
and found in animal fats; it can produce fatty deposits or
atherosclerotic plaques in blood vessels.
deficiencies (di-fi'-shun-sees) Conditions that result with
below-normal intake of particular substances.
diabetes mellitus type 1 A disease in which the beta cells in the
pancreas no longer produce insulin. The individual must rely on
daily insulin administration to use glucose for energy and
prevent complications.
diabetes mellitus type 2 A disease in which the body is unable to
use glucose for energy as a result either of inadequate insulin
production in the pancreas or resistance to insulin on the
cellular level.
digestion The process of converting food into chemical substances
that can be absorbed and used by the body.
diverticulosis (di-vuhr-ti-kyuh-lo'-sis) The presence of pouchlike
herniations through the muscular layer of the colon.
free radicals Compounds with at least one unpaired electron,
which makes the compound unstable and highly reactive. Free
radicals are believed to damage cell components, ultimately
leading to cancer, heart disease, or other diseases.
hydrogenated (hi-drah'-juh-na-ted) Combined with, treated with,
or exposed to hydrogen.
macular degeneration A progressive deterioration of the macula
of the eye that causes loss of central vision.
G ood health is a state of emotional and physical well-being that
is determined to a large extent by diet and lifestyle factors.
Health promotion and disease prevention practices focus on sound
nutrition, regular exercise, avoidance of smoking and tobacco,
limited alcohol intake, management of stress, and avoidance of envi-
ronmental contaminants. We are what we eat because the food we
consume is used to build and repair every part of our bodies. A
well-nourished person is also better able to ward off infections.
Consequently, a poor diet and risky lifestyle behaviors are directly
related to multiple health problems.
The provider, the medical assistant, and the registered dietitian
(RD) are all closely involved in the nutritive care of a patient. The
provider prescribes the diet, and ideally the dietitian instructs
the patient in how to follow it. If professional aid is not available,
the medical assistant may be asked to discuss the diet with the
patient, answer questions, and explain certain aspects of the modi-
fications involved. The patient may hesitate to ask the provider about
details of a recommended diet, or he or she may call with questions
on how to implement the diet after leaving the office. Therefore, you
frequently are the person to whom the patient turns for answers. You
should be able to answer basic questions on healthy nutrition, and
you should have a fundamental knowledge of the diets most ofren
prescribed.
neural tube defect Any of a group of congenital anomalies
involving the brain and spinal column that are caused by failure
of the neural tube to close during embryonic development.
obesity An excessive accumulation of body fat; defined as a body
mass index (BMI) of 30 or higher.
osteoporosis (ah-ste-o-puh-ro'-sis) Loss of bone density; lack of
calcium intake is a major factor in its development.
psyllium (si'-le-um) A grain found in some cereal products, in
certain dietary supplements, and in certain bulk fiber laxatives; a
water-soluble fiber.
registered dietitian (RD) An individual with a minimum of a
bachelor's degree in food and nutrition who is concerned with
the maintenance and promotion of health and the treatment of
diseases through diet; to become an RD, the individual must
pass a national examination.
statins A class of drugs that lowers the level of cholesterol in the
blood by reducing the production of cholesterol by the liver;
statins block the enzyme in the liver that is responsible for
making cholesterol.
triglyceride (tri-gli'-suh-ride) A fatty acid and glycerol
compound that combines with a protein molecule to form
high-density or low-density lipoprotein.
turgor A term referring to normal skin tension; the resistance of
the skin to being grasped between the fingers and released.
Turgor is decreased with dehydration and increased with edema.
vertigo Dizziness; a sensation of spinning or an inability to
maintain normal balance.
Health Problems Related to Poor Nutrition and
Lifestyle Factors
• Anemia: Low iron or folate intake
• Cancers: High-fat, low-fiber, low-complex carbohydrate diet; high
alcohol and sodium intake; sedentary lifestyle; tobacco use
• Constipation: Low fiber, inadequate fluids; high-fat diet; sedentary
lifestyle
• Diabetes mellitus type 2: High-calorie, high-fat, low-complex carbohy-
drate diet; obesity; sedentary lifestyle
• Hypercholesterolemia and atherosclerosis: High-fat, low-fiber diet; high
sugar and alcohol intake; tobacco use; sedentary lifestyle
• Hypertension: High-calorie, high-fat diet; high alcohol and sodium
intake; tobacco use; sedentary lifestyle; obesity; stress
• Osteoporosis: Low calcium intake; inadequate vitamin Dintake or lack
of sun exposure; high alcohol intake; sedentary lifestyle; tobacco use
• Stroke: High-fat, low-fiber, low-complex carbohydrate diet; high
alcohol intake; tobacco use; stress

People eat the way they do for many reasons. When encouraging
patients to make significant changes in their diets, the medical assis-
tant must be sensitive to these reasons. The choices people make
about what they eat are greatly influenced by their background and
relationships. Every culture, religion, and ethnic group has its own
beliefs and practices with regard to food. For example, according to
the Hindu religion, eating beef is forbidden. Certain Jewish practices
govern the types of foods that are eaten and how they are prepared.
Food is more than sustenance; it represents family and celebrations
and has an entire psychological component that you must recognize
to care for the individual patient most effectively.
Reasons for People's Food Choices
• Convenience: People choose what is easiest and quickest, including
eating out and take-home meals.
• Cost: What a person can afford.
• Emotionol comfort: "Feel good" foods are chosen based an cultural and
psychological influences.
• Routine: People eat what they always eat out of habit, personal prefer-
ence, and availability.
• Positive experiences: Afood is associated with a fond memory, eaten
by someone the person admires, or chosen because of the influence of
marketing and advertising.
• Ethnic or regional influences: The person grew up with the food; it is
associated with the individual's cultural background; or it is part of the
regional diet where the person lives.
• Health and weight: People think a particular food is good for them or
will help them maintain or lose weight.
Cultural Eating Patterns
• Asian diets emphasize whole grains in the form of millet, rice, and
noodles, in addition to fruits, vegetables, legumes, nuts and seeds; fats
are derived largely from vegetable oils, such as peanut or sesame oils.
Dairy products are not traditionally eaten. Protein sources typically are
broiled or stir-fried fish and seafood, egg whites, tofu, and nuts.
• Latin American diets emphasize food from plant sources at each meal,
especially maize (corn) and potatoes, in addition to fruits, vegetables,
whole grains, beans, and nuts. Poultry, fish, and dairy typically are
consumed daily and meat and eggs weekly.
• Mediterranean diets emphasize whole grains, fresh fruits and vegeta-
bles, and all types of legumes, such as beans, lentils, and peas daily;
olive oil replaces other fats and oils; fish, poultry, and eggs are con-
sumed weekly and meat monthly.
• Mexican diets emphasize corn or flour tortillas, cabbage, legumes,
squash, tomatoes, corn, and potatoes daily. Dairy is used in the form
of cheeses, but milk is not regularly consumed. Protein sources typically
are fish, beef, poultry, lamb, and many types of beans.
CHAPTER 6 Nutrition and Health Promotion 113
NUTRITION AND DIETETICS
The term nutrition refers to all the processes involved in the intake
and use of nutrients. Nutrients are the organic and inorganic chemi-
cals in food that supply the energy and raw materials for cellular
activities. Nutrients include carbohydrate, fat, protein, vitamins,
minerals, and water.
Metabolism is the process in which nutrients are used at the cel-
lular level for growth and energy production and excretion of waste.
Metabolism occurs in two phases, anabolism and catabolism. Anabo-
lism is the building phase, in which smaller molecules, such as amino
acids, are combined to form larger molecules, such as proteins. An
example of anabolism is the liver's creation of glycogen, a stored form
of glucose. In this process, many units of glucose are combined to
form a more complex glycogen molecule. Catabolism is the breaking-
down phase, in which larger molecules are broken down and con-
verted into smaller units, such as when stored glycogen is broken
down into glucose molecules for energy.
Digestion is a combination of mechanical and chemical proc-
esses that occur in the mouth, stomach, and small intestine. These
processes result in the breakdown of nutrients into absorbable forms,
including amino acids, fatty acids, glycerol, and glucose. Most nutri-
ents are absorbed in the small intestine and then carried by the
bloodstream to all parts of the body.
The term nutrition also is used to indicate nutritional status, or
the condition of the body resulting from the use of nutrients. Dietet-
ics is the practical application of nutritional science to individuals;
it is the combined science and art of feeding individuals or groups,
given a wide range of economic factors and/or health conditions,
according to the principles of nutrition and dietary management. A
registered dietitian's role is the promotion of good health through
proper diet and the therapeutic use of diet in the treatment of
disease.
Nutrients
To nurture life, the nutrients in food must perform one or more of
three basic functions in the body: (1) provide a source of fuel or
energy, (2) supply material to build and repair tissues, and (3) regu-
late metabolic processes. Because no one food supplies all the nutri-
ents required, a combination of different foods is necessary to
promote health. With a little planning, all the body's needs can be
met by a well-balanced diet. Dietary deficiencies result in under-
nourishment or malnourishment and may lead to a variety of dis-
eases. Good nutrition is an important part of health promotion for
all individuals but especially for pregnant women, young children,
and the elderly.
The role of diet in supplying energy is crucial to body functions.
Every action of the body, whether voluntary or involuntary, requires
energy. Even when a person is asleep, the body needs a source of
energy to keep vital organs functioning. Basal metabolism is the
amount of energy needed to maintain essential body functions. The
basal metabolic rate (BMR) is the amount of energy used by a fasting,
resting individual to maintain vital functions. The rate is determined
by the amount of oxygen used and is defined in units of heat energy,
called calories (cal). Because this unit represents a relatively small
amount of energy and because metabolism involves much larger
amounts of energy, the large calorie (Cal), or kilocalorie (kcal), is
114 UNIT ONE INTRODUCTION TO MEDICAL ASSISTING
commonly used. A kilocalorie is defined as the amount of heat
required to raise the temperature of 1 kg of water 1° C.
Of the seven food constituents (carbohydrates, proteins, fats,
water, minerals, vitamins, and fiber), only carbohydrates, proteins,
and fats are capable of furnishing the body with energy. The amount
of energy, or kilocalories, a person needs varies according to the
individual's activity level and basal metabolic requirements, and
whether disease is present. Most adults age 20 to 40 require 1,800
to 2,200 kcal/day. A patient generally is said to be overweight or
underweight depending on how his or her current weight compares
with nutritional assessment standards. Obesity is likely to result
when more calories are consumed than are expended or because of
certain endocrine imbalances.
Nutrients can be categorized as those that are a required part of
the diet and those that can be anabolized in the body. An essential
nutrient cannot be manufactured by the body and therefore must
be included in the diet or a deficiency disease occurs. Certain amino
acids are examples of essential nutrients. A nonessential nutrient can
be created in the body and therefore does not need to be included
in the diet; for example, both cholesterol, which is manufactured
in the liver, and vitamin D, which is synthesized from exposure to
the sun, are nonessential nutrients.
Nutrient Components
Carbohydrates
Carbohydrates (CHO) are chemical organic compounds composed
of carbon, hydrogen, and oxygen that are primarily plant products.
They are divided into three groups based on the complexity of their
molecules: simple sugars (e.g., table sugar, molasses, syrup, honey,
candy, baked goods, and milk); complex carbohydrates (starch) (e.g.,
whole-grain products, cereal, pasta, rice, potatoes, legumes, fruits,
vegetables, and seeds); and dietary fiber, which is found in bran,
oatmeal, whole-grain breads, beans, fruits, vegetables, seeds, and
dried fruits. Each has a function in health and consists of many
variations. With the exception of fiber, carbohydrates are easily
digested and absorbed into the body. Simple sugars are quickly
absorbed, whereas complex carbohydrates must be processed before
they can be absorbed in the intestinal tract. Dietary fiber is indigest-
ible and passes through the gastrointestinal tract unchanged.
How Many Terms Can Apply to Bread?
Grains are divided into two groups, whole grains and refined grains. Whole
grains contain the entire grain kernel: the bran, germ, and endosperm.
Examples of whole grains include whole-wheat flour, bulgur (cracked
wheat), oatmeal, whole cornmeal, and brown rice. Refined grains have
been processed to remove the bran and germ. This is done to give grains
afiner texture and improve their shelf life, but it also removes dietary fiber,
iron, and many Bvitamins. Some examples of refined grain products are
white flour, white bread, and white rice. Most refined grains are enriched,
which means certain Bvitamins (thiamin, riboflavin, niacin, folic acid) and
iron are added back after processing. Fiber is not added back to enriched
grains.
Dietary guidelines recommend that at least half of the grains consumed
each day come from a whole-grain source. People who eat whole grains
as part of a healthy diet have a reduced risk of some chronic diseases.
However, labels can be confusing. How do you know which is a healthy
choice? Understanding the following definitions associated with grain foods
can help. Review the definitions and see what you think about the healthi-
est grain choices.
• Bran: The tough, fibrous covering of a grain that is the primary
source of fiber in grain products.
• Enriched or fortified bread: Since 1942, and with legislation
amended in 1996 to include folate, the U.S. government has
required that thiamin, riboflavin, niacin, folate, and iron be added
to refined grain products because the process of creating white flour
destroys these nutrients.
• Refined or white flour bread: Bread produced through a process that
removes the coarse parts of the grain (the fiber and nutrients); the
flour is bleached to create the white color.
• Stone-ground flour: Aprocess used to grind the grain; it may include
white flour.
• Unbleached flour: Similar to white flour in nutritional value and
nutrient content.
• Wheat bread or brown bread: Bread made from wheat (white bread
also is made of wheat) or any other type of flour that contains
molasses or another product to color the bread brown.
• Whole-grain or whole-wheat flour: Flour from which the entire grain
kernel is ground; unrefined flour. This is the healthiest bread choice.
The main function of carbohydrates is to supply fuel for energy
and for all basic cellular activities. To meet energy needs, carbohy-
drate is metabolized at a rate of 4 cal/ g. When digested, carbohydrate
is converted into glucose, which is carried by the bloodstream to
cells that need energy. A small amount of concentrated glucose is
stored in the liver and muscles as glycogen. This stored glucose is
available to supplement dietary supplies of carbohydrate. As with all
nutrients, excess amounts of carbohydrate are converted into fat and
stored in the body as adipose tissue. In addition to serving as the
body's primary energy source, carbohydrate also is needed to regulate
protein and fat metabolism. As long as sufficient amounts of dietary
carbohydrate are available to meet the body's energy needs, protein
and fat are not needed to supply energy. This protein-sparing effect
allows protein to be used for its intended purpose: the repair and
growth of tissues.
Carbohydrate is used for energy with limited production of waste
materials, whereas protein and fat metabolism creates byproducts
that are challenging for the body to process and excrete. For example,
the metabolism of fat for energy results in the production of ketone
bodies, which can cause an increase in the acidity of the blood and
possibly kidney damage from the excretion of ketones. In addition,
the central nervous system (CNS) requires a constant minute-to-
minute supply of glucose to function properly. Neurons find it dif-
ficult to use fat or protein for energy.
Dietary fiber, commonly called roughage, is the portion of a plant
that cannot be digested or absorbed. However, fiber's inability to be
digested makes it an important dietary asset. Fiber adds bulk to the
intestinal tract that stimulates peristalsis and promotes regular bowel
 CHAPTER 6 Nutrition and Health Promotion 115

movements. In addition, soluble fiber, which is found in oat bran,
peas, beans, certain fruits, and psyllium, lowers blood cholesterol
levels, reducing the risk of heart disease. Soluble fiber combines
with cholesterol in the intestine and is excreted through the bowel,
which prevents the absorption of cholesterol into the bloodstream.
Insoluble fiber, which is found in whole grains and beans, promotes
regular bowel movements, which prevents constipation and hemor-
rhoids. It also prevents diverticulosis by stimulating and toning the
muscles lining the large intestine, and it is thought to help prevent
colon cancer. The recommended daily fiber intake is 20 to 35 g, and
5 to 10 g of this should be soluble fiber. Table 6-1 identifies food
sources of both soluble and insoluble fiber. Eating unpeeled
fruit and raw vegetables can greatly increase the fiber content of the
diet.
Recommendations for Carbohydrate Consumption
• Carbohydrates should account for 45 to 65 percent of the total
calories consumed each day (i.e., 225 to 358 g of carbohydrates
a day for a 2,000 to 2,200-calorie diet).
• Fiber-rich fruits, vegetables, and whole grains should be eaten as
often as possible.
• People should consume 14 g of fiber for every 1,000 calories.
• The intake of simple sugars, especially sugar-sweetened drinks,
should be reduced, and snacking on foods high in sugars and
starches should be limited.
• Fruits and vegetables: Based on the typical 2,000-calorie diet,
2 cups of fruit and 2½ cups of vegetables should be eaten daily;
a variety of dark green, orange, and starchy vegetables and
legumes should be consumed.
• Whole grains: At least three I-ounce servings should be eaten
each day. Whole grains should make up at least half of the daily
grain consumption. One ounce is equal to one slice of bread,
1 cup of dry cereal, or ½ cup of cooked rice, pasta, or cereal.
• Dairy: Includes milk, yogurt, cheese, and fortified soymilk. These
provide calcium, vitamin D, potassium, protein, and other nutri-
ents. Choose low-fat or fat-free products to limit calories and
saturated fat. Recommended amounts are 3 cups per day of fat-
free or low-fat milk and milk products for adults and children
and adolescents ages 9 to 18 years; 2½ cups per day for children
ages 4 to 8 years; and 2 cups for children ages 2 to 3 years. Tod-
dlers should have 2 cups of whole milk from age 1 through age
2. One cup is equal to 1 cup of yogurt, I½ ounces of natural
cheese, or 2 ounces of processed cheese.

TABLE 6-1 Food Sources of Fiber

FOOD SERVING SIZE TOTAL FIBER (g) SOLUBLE FIBER (g) INSOLUBLE FIBER (g)
Spaghetti, cooked 1 cup 2 0.5 1.5
Whole-wheat bread 1 slice 2.5 0.5 2
White rice, cooked ½ cup 0.5 0 0.5
Bran flake cereal ¾ cup 5.5 0.5 5
Carn flake cereal 1 cup 1 0 1
Oatmeal, cooked ¾ cup 3 2
Banana 1 medium 2 0.5 1.5
Apple, with skin 1 medium 3 0.5 2.5
Orange 1 medium 2 0.5 1.5
Pear, with skin 1 medium 4.5 0.5 4
Strawberries ½ cup 0
Broccoli ½ cup 2 0 2
Carn ½ cup 1.5 0 1.5
Potato, baked, with skin 1 medium 4 1 3
Spinach ½ cup 2 0.5 1.5
Kidney beans ½ cup 4.5 3.5
Popcorn 1 cup 0
116 UNIT ONE INTRODUCTION TO MEDICAL ASSISTING
CRITICAL THINKING APPLICATION 6-1
Apatient, George Hawthorne, recently was diagnosed with hypertension
and hypercholesterolemia. He has a family history of colon cancer. The
provider recommends a high-fiber diet. Describe how Marcia could reinforce
the provider's information by explaining the purpose of dietary fiber, the
difference between soluble and insoluble fibers, and the types of foods Mr.
Hawthorne should include in his diet.
Fats
Fats are the storage form of fuel used to back up carbohydrates as
an available energy source. Fat is a much more concentrated form
of fuel, producing 9 cal of energy per gram when metabolized.
Dietary fats, or lipids, provide essential fatty acids and are needed
for the absorption of the fat-soluble vitamins, A, D, E, and K. Fat
gives food flavor and creates a feeling of satiety, or satisfaction, after
eating. Adipose tissue, the stored form of fat in the body, supports
and protects vital organs, insulates the body to help in the regulation
of body temperature, and plays an important role in protecting nerve
fibers and relaying nerve impulses. Lipids are also crucial to cell
membrane development.
Saturated and Unsaturated Fatty Acids. When digested, fats are
broken down into fatty acids and glycerol. The main building blocks
of fat are fatty acids, which can be either saturated or unsaturated.
Unsaturated fatty acids can take on more hydrogen under the proper
conditions and therefore are less heavy and less dense. If fatty acids
have one unfilled hydrogen bond, the fat is called monounsaturated
Olives and olive oil, peanuts and peanut oil, canola oil, pecans, and
avocados contain monounsaturated fats. Polyunsaturated fats, such
as saffiower, corn, cottonseed, and soy oils, have two or more unfilled
hydrogen bonds. Unsaturated fats are found in plants and are usually
liquid at room temperature. Monounsaturated fat should be used as
frequently as possible to replace saturated fat in the diet. Research
on olive oil indicates it may offer some protection against heart
disease and breast cancer; canola oil is another rich source of mono-
unsaturated fatty acids.
The chemical structure of a saturated fatty acid contains all the
hydrogen possible; these fats, therefore, are denser, heavier, and solid
at room temperature. Saturated fats are found in whole milk dairy
products, eggs, lard, meat, and hydrogenated fats, such as marga-
rine. Some saturated fats, such as those in soft margarines, are par-
tially hydrogenated. These fats usually are soft at room temperature.
Most saturated fats come from animal sources. The main exceptions
are coconut and palm oils, which are of plant origin but are excep-
tionally high in saturated fat. The primary dietary factor associated
with high blood cholesterol levels is a high intake of foods high in
saturated fat.
What Is a Trans Fat?
Trans-fatty acids are byproducts created when polyunsaturated oils are
solidified by the addition of hydrogen. Manufacturers use this process to
preserve food products because the foods are much more resistant to rancid·
ity after hydrogenation. This lengthens the shelf life of the processed food,
and the product tastes better. Trans fats are found naturally in meat and
dairy products, but Americans consume most of their trans fats in processed
foods, such as margarine, crackers, cookies, doughnuts, biscuits, chips,
frozen meals, french fries, and other items containing or fried in partially
hydrogenated oils.
Trans fats raise the level of low-density lipoprotein (LDL), the so-called
bad cholesterol, and lower the level of high-density lipoprotein (HDL), or
"good" cholesterol, in the blood. Scientific evidence indicates that saturated
fat and trans fat combine to raise the LDL level, resulting in an increased
risk of coronary heart disease (CHO). According to the National Institutes
of Health, more than 12.5 million Americans have CHO, and more than
375,000 die from its complications each year. Food labels must list the
amounts of saturated fat, dietary cholesterol, and trans fats if the amount
exceeds 0.5 g per serving. Label readers should be cautious, however,
because eating more than the designated serving size can drastically
increase the amount of trans fats consumed.
Benefits of Omega-3 Fatty Acids
The omega-3 fatty acids have a number of beneficial effects in the body:
• They are present in large amounts in the cerebral cortex.
• They help form the retina.
• They have antiinflammatory effects, including improving the
immune response, protecting blood vessels (e.g., the coronary
arteries), and inhibiting the formation of blood clots.
Omega-3 fatty acids are found in cold-water fish, including mackerel,
salmon, tuna, and trout; in certain oils, including canal •, flaxseed, soybean,
and wheat germ oil; and in walnuts, soybeans, and soybean kernels. The
benefits of omega-3 fatty acids can be obtained by consuming two servings
of cold-water fish weekly.
Foods High in Saturated Fat. Even a fat-free food can become
high in saturated fat, depending on how it is prepared (e.g., a fat-free
potato cooked as french fries). Therefore, we not only need to lower
our intake of foods with saturated fat, we also need to be cautious
about how foods are prepared. Foods should be grilled, roasted,
broiled, baked, or cooked in the microwave rather than fried. Only
lean meats should be used, and visible fat should be cut off before
eating. Low-fat or fat-free products should be substituted when pos-
sible. Some foods high in saturated fat include the following:
Whole-milk dairy products Oil-packed fish
Whole-milk cheeses Salad dressing
Butter Mayonnaise
Cream Meat (especially red meat)
Ice cream Palm oil
A triglyceride molecule is created when three fatty acids attach
to a molecule of glycerol. This structure is the main storage form of
lipids. Triglyceride molecules are transported throughout the body
via the bloodstream as lipoproteins. Recent research indicates that a
diet high in added sugars, especially in the form of sugar-sweetened
drinks, simple carbohydrates (such as desserts and white bread), and

saturated fat increases serum triglyceride levels and blood pressure.
The total amount of triglycerides in the blood is used as a diagnostic
tool for determining a patient's risk for hypertension and heart
disease. A desirable triglyceride level is less than 150 mg/dL.
Cholesterol. Cholesterol is a nonessential nutrient that plays a vital
role in metabolic activities. It is synthesized only in animal tissue, so
it is not found in plant foods. Research now indicates that cholesterol
in our diet may not be as directly linked to heart disease as has been
thought. All animal sources of food contain cholesterol, but because
cholesterol is a nonessential nutrient (it is manufactured in the liver),
dietary sources of cholesterol may not increase blood cholesterol
levels as much as once was believed. However, that doesn't mean it
is healthy to eat a high-fat diet. High fat means high in calories,
which can lead to obesity, and high cholesterol in the blood still
contributes to the development of heart disease. Just because food
isn't a major direct contributor doesn't mean people can ignore
cholesterol blood levels. What the data show us is that people tend
to replace cholesterol in their diets with foods high in added sugars,
rather than with healthier choices such as fruits and vegetables. Diet
aside, risks that elevate cholesterol in the body include obesity,
smoking, lack of exercise, and diabetes.
The confusion over "good" and "bad" fat stems from the distinc-
tion berween the fat in food and the fat in our bodies. The good fats
in our diet are monounsaturated and polyunsaturated fats. The bad
dietary fats are trans fats and saturated fats. As mentioned, the fat in
our bodies is divided into rwo lipoprotein categories. The good fats,
or high-density lipoproteins (HDLs), carry cholesterol from body
tissues or the bloodstream to the liver for metabolism and excretion.
The bad fats, or low-density lipoproteins (LDLs), carry cholesterol to
the cells. LDL forms atherosclerotic plaques on arterial walls, and these
plaques frequently result in heart disease, hypertension, and strokes.
However, serum LDL levels often can be lowered through diet and
exercise. Using polyunsaturated and monounsaturated fat products
reduces total serum cholesterol levels. In addition, using monounsatu-
rated fats (olive, peanut, and canola oils) reduces LDL levels.
Aerobic exercise is an important tool for lowering total serum
cholesterol levels, increasing HDL levels, and reducing triglycerides.
The higher the serum HDL level, the greater the protection against
cardiovascular disease. The best HDL level is 60 mg/dL or higher.
A level below 40 mg/dL is considered a major risk for heart disease.
A low LDL cholesterol level is considered good for heart health. The
recommended level varies, based on individual heart disease risk. For
those not at risk, an LDL level of 100 to 129 mg/dL is recom-
mended; for those at very high risk, the LDL level should be below
70 mg/ dL. Recent research recommends that individuals with a high
risk of heart disease (e.g., LDL level of 190 mg/dL or higher and
DM type 2) should be treated with statins (Table 6-2).
TABLE 6-2 Recommendations for Total and Low-Density Lipoprotein (LDL) Cholesterol Levels
TOTAL CHOLESTEROL (mg/dL)
AGE (yr) ACCEPTABLE BORDERLINE
2-20 <170 170-199
>20 <200 (<180 is optimal) 200-239
CHAPTER 6 Nutrition and Health Promotion 117
Another potential health risk from a high-fat diet is obesity. Too
much fat in the diet is deposited in the body as stored adipose tissue.
Currently fats make up 35% to 40% of the total calories in the
American diet. Nutritionists and epidemiologists believe that reduc-
ing dietary fat to 30%, with saturated fat and trans fat making up
no more than 10% of calories, would reduce the risks of cancer,
atherosclerosis, hypertension, and heart disease.
Recommendations for Fat Consumption
• Keep total fat intake to 20% to 35%, or approximately 17 g of
fat per day for a 2,000-calorie diet.
• No more than 10% of daily calories should come from saturated
or trans fats.
• Use only lean cuts and smaller portions of meat; trim visible fat.
• Substitute poultry and fish for red meat; remove poultry skin
before eating.
• Avoid adding fat during cooking.
• Limit intake of organ meats.
• Use low-fat or fat-free products, including milk and milk
products.
• Choose liquid monounsaturated oils, such as canola or olive oil.
CRITICAL THINKING APPLICATION 6-2
Mr. Hawthorne is attempting to control his hypercholesterolemia with diet
and exercise. What recommendations about fat intake can Marcia make
that will help him lower his total cholesterol and LDL levels and raise his
HDL level?
Antioxidants. High blood cholesterol levels contribute to the devel-
opment of atherosclerotic plaque and coronary artery disease. Studies
indicate that the problem may lie not with the cholesterol itself, but
with the way it reacts with oxygen, or the process of oxidation, in
the bloodstream. The normal body process of using oxygen for energy,
combined with environmental factors, such as pollution and tobacco
smoke, creates free radicals, which can cause cellular damage. Our
bodies have developed mechanisms to protect us against oxidizing
free radicals through the use of antioxidant vitamins C, E, and beta
carotene, but their amounts are not always sufficient. When enough
antioxidants are circulating in the blood, cholesterol is prevented
from oxidizing. If the level of antioxidants is insufficient, the opposite
is true, and damage to arteries begins. Therefore, in addition to
lowering saturated fat and trans fat intake, increasing dietary intake
of antioxidants may prove beneficial in preventing cardiovascular
disease. Research indicates that a diet rich in antioxidant vitamins
also may be linked to protection against some cancers and macular
degeneration. Naturally occurring antioxidants are found in many
fruits and vegetables and certain seasonings.
LDL CHOLESTEROL (mg/dL)
HIGH ACCEPTABLE BORDERLINE HIGH
>200 <110 110-129 >130
>240 <130 130-159 >160
118 UNIT ONE INTRODUCTION TO MEDICAL ASSISTING

Foods Containing Antioxidants Functions of Protein

Vitamin C Beta Carotene • Builds and repairs body tissue, including new tissue, blood, enzymes,
Broccoli Apricots and hormones
Cabbage Broccoli • Aids the body's defense mechanisms against disease by creating
Cauliflower Cantaloupe antibodies
Grapefruit Carrots • Regulates the fluid and electrolyte balance
Lemons Kale and spinach • Provides energy when carbohydrate and fat stores are depleted
Oranges Mustard greens
Peppers Pumpkin
Strawberries Sweet potatoes
Tangerines Winter squash
Food Sources of Protein
Vitamin E Mixed Antioxidants
Almonds Cloves Complete proteins: Meat, fish, poultry, eggs, and dairy products
Chickpeas Green tea Incomplete proteins: Whole grains (e.g., barley, bulgur, cornmeal, oats,
Oatmeal Oregano rice, whole-grain breads), cashews, sesame seeds, sunflower seeds,
Soybeans Rice walnuts; soy products, dried legumes, peanuts; broccoli; dark green,
Sunflower seeds Rosemary leafy vegetables
Wheat germ Sesame
Thyme
Wheat bran
Red wine Recommendations for Protein Consumption
• Consume no more than 18% of daily calories from protein.
• The U.S. Department of Agriculture (USDA) recommends
Proteins eating 5½ to 6 ounces of cooked lean meat, poultry, or fish
Proteins are very large, complex molecules. They are composed of each day.
units known as amino acids, which are the materials the body uses • One ounce of meat equals 1 egg, ¼ cup of dry beans, 1 table-
to build and repair tissues. Twenty amino acids are necessary for spoon of peanut butter, ½ cup of cooked beans, or ½ cup
normal growth and maintenance of tissues. Of these, eight are essen- of tofu.
tial amino acids that must be included in the diet because humans If incomplete proteins are the only source of protein in the diet,
do not have the enzymes necessary for their formation. a food that is protein deficient in one amino acid should be eaten
Proteins are classified according to whether they contain all essen- with one that is high in the same amino acid to get the needed mix
tial amino acids in good proportion. Complete proteins come from of essential amino acids. Vegetarianism has become increasingly
animal sources and have a mixture of all eight essential amino acids. popular, and there are many different forms. Some vegetarians
Incomplete proteins do not supply the body with all the essential consume no red meat but eat fish and poultry. Lacto-ovo vegetarians
amino acids. These are the vegetable proteins, which must be used eat primarily vegetable foods but include eggs and/or dairy products
in specific combinations because each is missing or extremely low in in their diets. Lacto-vegetarians consume milk and milk products in
one or more of the essential amino acids. addition to vegetables but no other animal sources of food. Vegans
To prevent the wasting of protein for energy and to permit the consume no animal proteins at all, relying solely on vegetable foods
creation of needed amino acid compounds, dietary protein must be for protein.
adequate, the diet must supply essential amino acids, and enough Those who eat some animal protein in the form of fish, eggs, and
carbohydrate and fat must be consumed to prevent the burning of milk generally are not at risk nutritionally. However, vegans must
protein for energy. Fortunately, most foods have a mixture of pro- include a variety of vegetable foods to ensure the nutritional ade-
teins that supplement one another. Because little, if any, storage of quacy of their diets. To supply sufficient protein, vegetables that
amino acids occurs in the body, it is important that a source of complement each other must be eaten together to get the correct
protein be included at each meal. Patients with extensive burns or proportion of amino acids. This is customarily done in the diets of
those with wound healing problems often are prescribed high- different cultures. For example, in Mexico, beans are combined with
protein diets to encourage tissue regeneration. The recommended rice, and in Middle Eastern countries, wheat bread is combined with
dietary allowance for adults over the age of 18 is 0.8 grams per cheese.
kilogram of body weight per day. Each pound is equal to 2.2 kg so Tips for vegetarians from the USDA website (http://www.
a person who weighs 150 pounds should consume about 68 g of choosemyplate.govltips-vegetarians ) include the following:
protein per day. The average North American diet contains close to • Build meals around protein sources that are naturally low in
twice that amount. Excess protein is metabolized and either con- fat, such as beans, lentils, and rice, rather than high-fat
verted to glucose, burned as fuel, or stored as fat in adipose tissue. cheeses.

• Try calcium-fortified, soy-based beverages in place of milk.
• Try vegetarian products such as soy-based sausage patties or
links and veggie burgers made from soybeans, vegetables, and/
or rice.
• Add meat substitutes, such as tempeh (cultured soybeans with
a chewy texture), tofu, or wheat gluten (seitan), to soups and
stews to boost protein without adding saturated fat or
cholesterol.
Examples of Nutritionally Balanced Incomplete
Protein Combinations
Combining two or more sources of incomplete amino acids provides a
complete protein. For example:
• Black beans and rice
• Peanut butter sandwich on whole-grain bread
• Split-pea soup with whole-grain bread
• Lentil soup and cornbread
• Walnuts, peanuts, and rice
• Whole-wheat pasta, broccoli, and spinach
• Sunflower seeds and navy bean soup
Vitamins (Micronutrients)
Vitamins are organic substances that occur in minute quantities in
plant and animal tissues; they are needed for specific metabolic
processes to proceed normally. Vitamins function as catalysts and
help or allow metabolic reactions to proceed. Originally they were
lettered or numbered as they were discovered. However, as they have
been identified chemically, they have been given more specific
names. In many cases their chemical names are as well known as
their letter designations.
Vitamins are divided into two groups: fat soluble (A, D, E, and
K) and water soluble (B complex and C). Some vitamins are nones-
sential, meaning they can be manufactured in the body. Vitamin A
is produced from beta carotene food sources, such as carrots,
pumpkin, and sweet potatoes. Ultraviolet light from the sun initiates
the production of vitamin D in the skin. Vitamin K is created from
intestinal bacteria.
Functions of Vitamins
• Regulate the synthesis of bone, skin, glands, nerves, brain, and
blood
• Aid in the metabolism of protein, carbohydrates, and fats
• Prevent nutritional deficiency diseases
• Support good health at all ages
Vitamins do not cure an illness other than a health problem
that is caused by the lack of a specific vitamin. For example,
adding vitamin C to a patient's diet does not cure bleeding
CHAPTER 6 Nutrition and Health Promotion 119
gums unless the condition is specifically caused by a lack of
ascorbic acid (the chemical name for vitamin C). It should
also be noted that toxic symptoms from excessive ingestion
of fat-soluble vitamins can occur because these vitamins can be
stored in adipose tissue. Water-soluble vitamins typically are
excreted in the urine. However, a large intake of some water-
soluble vitamins may cause adverse effects (Table 6-3). Nutrition
experts agree that vitamins provide the greatest benefit when they
are obtained through food as part of the diet rather than in sup-
plement form. However, supplements may be needed in the fol-
lowing cases:
• Patients showing signs and symptoms of a vitamin or mineral
deficiency
• Folate for women planning to become pregnant or in their
childbearing years
• Iron and folate for pregnant and lactating women
• Calcium for lactose-intolerant individuals
• Daily vitamins for the elderly, who may have difficulty
chewing, have malabsorption problems, live alone, or make
poor food choices
• Postsurgical or burn patients, who require more protein and
nutrients to grow and repair tissue
• Strict vegetarians, who may need vitamins B12 and D, along
with iron and zinc
• Patients who have had gastric bypass surgery, who may
require multiple nutrients, including vitamin B12, protein,
and iron
Extensive research is under way studying the role vitamins play
in disease prevention and treatment. Research indicates that antioxi-
dant vitamins (C, E, and A) may prevent cell membrane damage
that leads to cancer and heart disease. Vitamins C and E also appear
to protect against the development of cataracts. Vitamin E is recom-
mended to help prevent blood clot formation and coronary heart
disease (CHD). The B vitamins may help lower LDL levels, and folic
acid is recommended for women planning a pregnancy to prevent
neural tube defects.
A diet that includes certain vitamins can affect the action of
prescribed medications. For example, vitamin K can interfere with
the action of warfarin anticoagulants. Therefore, a sudden dietary
increase or decrease in vitamin K-rich foods can alter how long it
takes a clot to form in patients undergoing anticoagulant therapy.
High levels of vitamin K are found in dark green, leafy vegetables
such as kale, collards, Swiss chard, broccoli, and spinach; green tea;
and lentils and soybeans. For stable anticoagulant treatment,
patients should not increase or reduce their intake of vitamin K-
rich foods without consulting their provider. They also should
inform the provider if they are taking vitamin supplements that
contain vitamin K.
Because vitamins and dietary supplements are categorized as food
and not as drugs, no standards or regulatory mechanisms apply to
their production. Therefore, various brands differ in the amount of
substance available, its quality, and its level of absorption. The U.S.
Pharmacopoeia (USP), an independent organization that sets stan-
dards for drugs, recently developed standards for vitamins. Consum-
ers should look for the USP label for products that adhere to these
standards.
120 UNIT ONE INTRODUCTION TO MEDICAL ASSISTING

TABLE 6-3 Vitamin Facts

BEST DEFICIENCY PROCESSING DID YOU
VITAMIN U.S. RDA* SOURCES FUNCTIONS SYMPTOMSt TOXIC? TIPS KNOW?
A(carotene) 500-700 mcg/ Yellow or orange Formation and Night blindness; Yes, in high Serve fruits and Low-fat and skim
day fruits and maintenance of dry, scaly skin; doses, but beta vegetables raw milk often are
vegetables; green, skin, hair, and frequent fatigue carotene is and keep covered fortified with vitamin
leafy vegetables; mucous nontoxic and refrigerated; A, which is removed
fortified oatmeal; membranes; aids steam with the fat.
liver; dairy vision in dim light; vegetables; broil,
products bane and tooth bake, or braise
growth meats.
Bi 1.2 mg/day Fortified cereals Helps the body Heart irregularity, No, high doses Do not rinse rice Pasta and breads
(thiamine) and oatmeal, release energy fatigue, nerve are excreted by or pasta before made of refined
meat, rice, pasta, from carbohydrates disorders, mental the kidneys and after flours have Bi
whole grains, liver during metabolism; confusion cooking; cook in added because it is
growth and muscle minimal water. lost in the milling
tone process.
B2 1.1 to Whole grains; Helps the body Cracks in the No toxic effects Store food in Most ready-to-eat
(riboflavin) 1.3 mg/day green, leafy release energy earners of the reported containers that cereals are fortified
vegetables; organ from protein, fat, mouth, rash, light cannot with 25% of the
meats; milk; eggs and carbohydrates anemia penetrate; cook U.S. RDA for vitamin
during metabolism vegetables in B2.
minimal water;
roast or broil
meats.
B6 1.3 mg/day Fish, poultry, lean Helps build body Convulsions, Long-term Serve fruits raw Because vitamin B6
(pyridoxine) meats, bananas, tissue and aids dermatitis, megadoses may or cook for aids in the use of
prunes, dried metabolism of muscular cause nerve shortest time in protein in the body,
beans, whole protein weakness, skin damage in hands little water; roast the need for it
grains, avocados cracks, anemia and feet or broil meats. increases with
protein intake.
B12 2.4 mcg/day Meats, milk Aids cell Anemia, No toxic effects Roast or broil Vegetarians who do
(cabalamin) products, seafood development, nervousness, reported meat and fish. not eat any animal
functioning of the fatigue, and in products may need
nervous system, some cases a supplement.
and metabolism of neuritis and brain
protein and fat degeneration
Biotin 30 mcg/day Cereal/grain Involved in the Nausea; No toxic effects Storage, Biotin deficiency is
products, yeast, metabolism of vomiting; reported processing, and extremely rare in
legumes, liver protein, fats, and depression; hair cooking do not the United States.
carbohydrates loss; dry, scaly appear to affect
skin this vitamin.
Folate 400 mcg/day Green, leafy Aids in genetic Gastrointestinal Some evidence Store vegetables Deficiencies can
(folacin, folic vegetables; organ material (GI) disorders, of toxicity in in refrigerator occur in premature
acid) meats; dried peas, development and is anemia, cracks large doses and steam, boil, infants and pregnant
beans, and lentils involved in red on the lips or simmer in women.
blood cell minimal water.
production
 CHAPTER 6 Nutrition and Health Promotion 121

TABLE 6-3 Vitamin Facts-continued

BEST DEFICIENCY PROCESSING DID YOU
VITAMIN U.S. RDA* SOURCES FUNCTIONS SYMPTOMSt TOXIC? TIPS KNOW?
Niacin 14-16 mg/day Meat, paultry, Involved in Skin disorders, Nicotinic acid Roast or broil Niacin is formed in
fish, enriched carbohydrate, diarrhea, form should be beef, veal, lamb, the body by
cereals, peanuts, protein, and fat indigestion, taken only under and poultry; cook converting an amino
potatoes, dairy metabolism general fatigue provider's care potatoes in acid found in
products, eggs minimal water. proteins.
Pantothenic 5 mg/day Lean meats, Helps in the Fatigue, No toxic effects Serve fruits and It is believed that
acid whole grains, release of energy vomiting, reported vegetables raw. some pantothenic
legumes, from fats and stomach stress, acid is produced in
vegetables, fruits carbohydrates infections, muscle the GI tract.
cramps
C(ascorbic 75-90 mg/day Citrus fruits, Essential for Swollen or Intake of l gor Do not store or Smokers may
acid) berries, and structure of bones, bleeding gums, more can cause soak fruits and benefit from an
vegetables, cartilage, muscle, slow wound nausea, cramps, vegetables in increased intake of
especially peppers and blood vessels; healing, fatigue/ and diarrhea water; refrigerate vitamin C.
also helps maintain depression, poor juices and store
capillaries and digestion only 2 to 3 days.
gums and aids in
absorption of iron
D 15 mcg/day Fortified milk, Aids bone and In children: High intakes may Storage, Sunlight starts
sunlight, fish, tooth formation; Rickets and other cause diarrhea processing, and vitamin Dproduction
eggs, butter, helps maintain bone deformities and weight loss cooking do not in the skin.
fortified margarine heart action and In adults: Calcium appear to affect
nervous system loss from bones this vitamin.
E 15 mg/day Fortified and Protects blood Muscular Relatively Store in airtight Most fortified
multigrain cereals; cells, body tissue, wasting, nerve nontoxic containers away cereals have 40% of
nuts; wheat germ; and essential fatty damage, anemia, from light. RDA.
vegetable oils; acids from harmful reproductive
green, leafy destruction in the failure
vegetables body
K 90-120 mcg/ Green, leafy Essential for blood Bleeding Not toxic as Store in Vitamin Kis also
day vegetables; fruit; clotting functions disorders in found in food containers away formed by bacteria
dairy and grain newborns and from light. in the colon.
products those on
blood-thinning
medications
Information for this chart was obtained from the U.S. Food and Drug Administration at http://fnic.nal.usda.gov/dietary-guidance/dietary-reference-intakes/dri-tables-and-application-reports.
Accessed November 4, 2015.
mg, Milligrams; mcg, micrograms; RDA, recommended dietary allowance.
*For adults and for children over 4 years of age.
1Many of these symptoms also can be attributed to conditions other than vitamin deficiency. If they persist, the patient should see the healthcare provider.
122 UNIT ONE INTRODUCTION TO MEDICAL ASSISTING
Tips for Buying Dietary Supplements
Dietary supplements may contain a combination of vitamins, minerals,
herbs, plants, amino acids, and enzymes. Individuals who have been pre-
scribed other medications should check with their healthcare providers
before taking dietary supplements.
Consider the following tips before buying a dietary supplement:
• Be cautious about chasing the latest headline; watch out for "quick
fix" claims that do not follow well-researched dietary guidelines.
• More may not be better; some products can be harmful when
consumed in high amounts or for a long period.
• Learn to spot false claims in advertising and on supplement labels;
if something sounds too good to be true, it probably is.
• Beware of claims about limited availability and requirements for
advance payment.
• Supplements can be quite expensive; ask yourself if the product is
worth the money.
US Food and Drug Administration: www.fda.gov/ForConsumers/ConsumerUpdates/
ucm 118079 .htrn#why. Accessed March 23, 2015.
Minerals (Electrolytes)
The human body requires minerals in relatively small amounts;
nevertheless, they are absolutely essential for life (Table 6-4). Of the
19 or more minerals that form the mineral composition of the body,
at least 13 are needed to maintain a healthy state. Minerals must be
supplied by the diet or by supplements. Recommended daily intakes
have been established for 12 minerals. Minerals contribute to the
body's water-electrolyte balance and acid-base balance and are essen-
tial components of enzymes. Minerals also help regulate muscular
and nervous activities, blood clotting, and normal heart rhythm.
Dietary recommendations for the daily intake of minerals, based
on a 2,000-calorie diet, are:
• Potassium: 4,000 mg
• Sodium: 1,800 mg
• Calcium: 1,300 mg
• Magnesium: 400 mg
• Copper: 2 mg
• Iron: 18 mg (8 mg for those older than 5 I)
• Phosphorus: 1,800 mg
• Zinc: 14 mg
Minerals recommended in the largest amounts include sodium,
potassium, calcium, chlorine, phosphorus, and magnesium. Those
present in very small amounts, the trace elements, include iron, zinc,
copper, selenium, chromium, manganese, iodine, and fluorine. The
minerals needed only in trace amounts seem either to behave as part
of a hormone or enzyme system or to work with vitamins in various
metabolic reactions throughout the body. For example, iodine is part
of the thyroid hormone thyroxine, and zinc is part of the hormone
insulin. Cobalt is an essential part of vitamin B12 •
Calcium, iodine, and iron are the minerals most frequently missing
in the American diet. One of the leading mineral deficiencies is osteo-
porosis from lack of vitamin D and/or calcium and iron-deficiency
anemia. High sodium levels are associated with hypertension. Current
dietary guidelines recommend that everyone, even children, reduce
their sodium intake to less than 2,300 mg/day, which is about 1 tea-
spoon of salt per day. Adults age 51 or older, African-Americans
of any age, and individuals with high blood pressure, diabetes, or
chronic kidney disease should consume less than 1,500 mg of sodium
a day.
Sodium, Blood Pressure, and the DASH Diet
Thirty percent of U.S. adults have high blood pressure; it is especially
common among African-Americans, who tend to develop it at an earlier
age, and among older Americans. Research has proven that individuals with
asodium intake of more than 2,400 mg aday have a high risk of develop-
ing hypertension. On average, adults in the United States are estimated to
consume almost 4,000 mg of sodium per day. Ahealthy body excretes
excess sodium through the kidneys, but sodium's attraction for fluid can
cause hypertension to develop.
How can you cut down on salt intake? You should avoid pickles, olives,
and sauerkraut; all processed meats (lunch meat) and processed fish, but
especially those that are smoked; salty snacks; fast and processed foods;
canned soups; and cheese, especially processed.
The Dietary Approaches to Stop Hypertension (DASH) diet is recom-
mended to help lower blood pressure. Daily guidelines for the DASH diet
include the following:
• Four to five servings of both fruits and vegetables
• Seven to eight servings of whole grains
• 6 ounces or less of meat, fish, and poultry
• Four to five servings per week of nuts, seeds, and dry beans
• 2 to 3 cups of low-fat or fat-free milk
• 2 to 3 teaspoons of oils
• 5 tablespoons of added sugar per week
• 1,500 to 2,000 mg of sodium per day
• Total fat should not exceed 22% of calories
Water
Water is all too often overlooked when nutritional status is evaluated.
The body is approximately 80% water and can survive longer
without food than it can without water. Water is part of almost every
vital body process.
Water is lost daily from the body in urine, feces, sweat, and
expiration. Extensive water losses from diarrhea, vomiting, burns,
or perspiration can lead to electrolyte losses that result in life-
threatening imbalances. Water is contained in almost all foods;
however, a healthy diet should include about eight 8-ounce glasses
of water a day.
Functions of Water
• Plays a key role in the maintenance of body temperature
• Acts as a solvent and the medium for most biochemical reactions
• Acts as the vehicle for transport of substances such as nutrients, hor-
mones, antibodies, and metabolic waste
• Acts as a lubricant for joints and mucous membranes

TABLE 6-4 Functions of Minerals in the Body
FUNCTIONS
Calcium (Ca 2+)
• Helps muscles contract and relax,
thereby helping to regulate the
heartbeat
• Plays a role in normal functioning af the
nervous system
• Aids blood coagulation and functioning
of some enzymes
• Helps build strong banes and teeth
• May help prevent hypertension
Chloride (Ci-)
• Involved in the maintenance of fluid and Major source is table salt (sodium
acid-base balance chloride); also found in fish and
• Provides an acid medium, in the form of vegetables
hydrochloric acid, for activation of
gastric enzymes
Magnesium (Mg 2+)
• Helps build strong bones and teeth
• Activates many enzymes
• Participates in protein synthesis and lipid
metabolism
• Helps regulate heartbeat
Phosphorus (P)
• Helps build strong bones and teeth
• Present in the nuclei of all cells
• Aids the oxidation of fats and
carbohydrates (energy metabolism)
• Helps maintain acid-base balance
Potassium (K+)
• Plays a key role in fluid and acid-base
balance
• Transmits nerve impulses, helps control
muscle contractions, and promotes
regular heartbeat
• Needed for enzyme reactions
Sodium (Na+)
• Plays a key role in the maintenance of
acid-base balance
• Transmits nerve impulses and helps
control muscle contractions
• Regulates cell membrane permeability
CHAPTER 6 Nutrition and Health Promotion 123
TOXICITY
SOURCES DEFICIENCY SYMPTOMS SYMPTOMS
Primarily found in milk and milk Poor bone growth and tooth Kidney stones
products; also found in dark green, development, leading to stunted
leafy vegetables; tofu and other say growth and increased risk of dental
products; sardines; salmon with bones; caries, rickets (bowing of the legs) in
and hard water children, osteomalacia (soft bones) and
osteoporosis (brittle banes) in adults,
poor blood clotting, and possible
hypertension
Disturbances in acid-base balance, Disturbances in acid-base
with possible growth retardation, balance
psychomotor defects, and memory loss
Raw, dark green vegetables; nuts and Rare but in disease states may lead to Drowsiness, weakness, and
soybeans; whole grains and wheat central nervous system (CNS) problems lethargy
bran; bananas and apricots; seafood; (confusion, apathy, hallucinations, poor Severe toxicity: skeletal
coffee, tea, and cocoa; and hard water memory) and neuromuscular problems paralysis, CNS depression,
(muscle weakness, cramps, tremor, respiratory depression, and
cardiac arrhythmia) ultimately coma and death
Milk and milk products, eggs, meats, Rare but with malabsorption can cause Hypocalcemic tetany
legumes, whole grains, soft drinks anorexia, weakness, stiff joints, and (muscle spasms)
(used to make the "fizz") fragile bones
Apricots, bananas, oranges, grapefruit, Possibly impaired growth, hypertension, Hyperkalemia (excess
raisins, green beans, broccoli, carrots, bone fragility, CNS changes, renal potassium in the blood)
greens, potatoes, meats, milk and milk hypertrophy, diminished heart rate, and with cardiac function
products, peanut butter and legumes, death disturbances
molasses, coffee, tea, cocoa
Salt (sodium chloride) is the major Hyponatremia (too little sodium in the May cause hypertension,
dietary source; minor sources are foods blood) which can lead to
such as milk and milk products and cardiovascular diseases and
several vegetables renal (kidney) disease; salt
tablets can cause gastric
irritation
Continued
124 UNIT ONE INTRODUCTION TO MEDICAL ASSISTING

TABLE 6-4 Functions of Minerals in the Body-continued

TOXICITY
FUNCTIONS SOURCES DEFICIENCY SYMPTOMS SYMPTOMS
Chromium (Cra+)
• Activates several enzymes Liver and other meats, whole grains, Weight loss, abnormalities of the CNS, Inhibited insulin activity
• Enhances the removal of glucose from cheese, legumes, and brewer's yeast and possible aggravation of diabetes
the blood mellitus
Copper (Cu 2+)
• Aids in the production and survival of Shellfish (especially oysters), liver, nuts Anemia, CNS problems, abnormal In Wilson's disease and
red blood cells and seeds, raisins, whole grains, and electrocardiograms, bone fragility, Huntington's chorea (both
• Acomponent of many enzymes involved chocolate impaired immune response; may be a hereditary diseases),
in respiration factor in failure to thrive in premature copper accumulation causes
• Plays a role in normal lipid metabolism infants neuron and liver cell
damage
Fluorine (Fi-)
• Aids the formation of solid bones and Fluoridated water (and foods cooked in Increased susceptibility to dental caries Fluorosis and mottling of
teeth, thereby reducing the incidence of fluoridated water), fish, tea, gelatin teeth
dental caries, and may help prevent
osteoporosis
Iodine (i-)
• Helps regulate energy metabolism as Primarily from iodized salt, also found Goiter, cretinism in infants born to Little toxic effect in
part of thyroid hormones in saltwater fish, seaweed products, iodineileficient mothers, with individuals with normal
• Essential for normal cell functioning, and vegetables grown in iodine-rich accompanying mental retardation and thyroid gland functioning
helps to keep skin, hair, and nails soils diffuse CNS abnormalities
healthy
Iron (Fea+)
• Essential to the formation of Heme sources: Organ meats, especially Iron-deficiency anemia and possible Idiopathic
hemoglobin, which is important for liver, red meats, and other meats alterations that impair behavior hemochromatosis, which
tissue respiration and ultimately growth Nonheme sources: Iron-fortified cereals; can lead to cirrhosis,
and development dark green, leafy vegetables; legumes; diabetes mellitus, skin
• Acomponent of several enzymes and whole grains; blackstrap molasses; pigmentation, arthralgias
proteins in the body dried fruit; and foods cooked in iron (joint pain), and
pans cardiomyopathy
Manganese (Mn2+)
• Needed for normal bone structure, Nuts, whole grains, vegetables and None observed in humans Iron-deficiency anemia
reproduction, and normal functioning of fruits, coffee, tea, cocoa, and egg yolks through inhibiting effect on
cells and the CNS iron absorption; pulmonary
• Acomponent of some enzymes changes, anorexia, apathy,
impotence, headaches, leg
cramps, and speech
impairment; in advanced
stages of toxicity resembles
Parkinson's disease
 CHAPTER 6 Nutrition and Health Promotion 125

TABLE 6-4 Functions of Minerals in the Body-continued

TOXICITY
FUNCTIONS SOURCES DEFICIENCY SYMPTOMS SYMPTOMS
Selenium {Se)
• Acts as an antioxidant with vitamin Eto Protein-rich foods (meat, eggs; milk), Keshan's disease (a human Physical defects of the
protect cells from oxidative damage whole grains, seafood, liver and other cardiomyopathy) and Kashin-Bek fingernails and toenails;
• Acomponent of an enzyme system meats, egg yolks, and garlic disease (an endemic human also hair loss
osteoarthropathy)
Zinc {Zn 2+)
• Plays a role in protein synthesis Whole grains, wheat germ, crabmeat, Depressed immune function, poor Severe anemia, nausea,
• Essential for normal growth and sexual oyster, liver and other meats, brewer's growth, dwarfism, impaired skeletal vomiting, abdominal
development, wound healing, immune yeast growth and delayed sexual maturation, cramps, diarrhea, fever,
function, cell division and differentiation, acrodermatitis hypocupremia (low blood
and smell acuity serum copper), malaise,
fatigue
From Poleman CM, Peckenpaugh NJ: Nutrition essentials and diet therapy, ed 6, Philadelphia, 1991, Saunders; Garrison RH, Somer E: The nutrition desk reference, New Canaan, Conn., 1985,
Keats Publishing; and Griffeth HW: Complete guide to vitamins, minerals and supplements, Tucson, 1988, Fisher Books.

CHOOSE MY PLATE
In 1992, to reflect dietary guidelines that called for more consump-
tion of grains and less consumption of meat, sweets, and fats, the
USDA introduced the Food Guide Pyramid. In 2011 the Pyramid
design was changed to a dinner plate icon that represents how to
build a healthy plate at mealtime. The plate includes choices from
the five basic food groups, with recommendations based on the
Dietary Guidelines for Americans (Figure 6-1 ). At the Choose My
Plate website (www.choosemyplate.gov), consumers can determine
individual dietary needs that match their particular age, health
status, exercise level, and food preferences. Students should use the
website to take advantage of the many learning opportunities it
offers. It is also an excellent source for patient education information
on dietary guidelines.
The Dietary Guidelines for Americans encourages daily dietary
choices that are low in saturated fat, added sugars, and sodium.
Sodium, saturated fat, and added sugars should be reduced and
replaced with healthier options. The guidelines include the following
recommendations:
1. Balance calorie intake: Use the Choose My Plate website to FIGURE 6-1 Choose My Plate. (From the US Department of Agriculture. www.choosemyplate.gov.
determine how many calories are needed each day to manage Accessed March 22, 2015).
your weight; include exercise to help balance calories; enjoy
food but eat less; avoid oversized portions. Use a smaller plate,
bowl, and glass. When eating out, choose a smaller size
option, share a dish, or take home part of your meal.
2. Foods to eat more often: Increase your daily intake of vegetables,
fruits, whole grains, legumes, nuts, and fat-free or 1% milk
and dairy products. Make half your plate fruits and vegetables. Many patients have never been educated in nutrition and do not
Make half your grains whole grains. know how to plan a healthy diet for themselves or their families.
3. Foods to eat less often: Cut back on foods high in solid fats, Good nutrition is a balance of carbohydrates, protein, vitamins,
added sugars, and salt. Use food labels to compare sodium minerals, fiber, and water, with limited amounts of fat, sodium,
content and choose lower sodium versions. sugar, and alcohol. Calorie intake must be balanced with energy
4. Drink water instead ofsugary drinks. output to maintain a healthy body weight.
126 UNIT ONE INTRODUCTION TO MEDICAL ASSISTING
Highlights of the U.S. Department of Agriculture's Dietary Recommendations
Adequate Nutrients Within Caloric Needs
• Consume a variety of nutrient-dense foods while limiting saturated and
trans fats, cholesterol, added sugars and salts, and alcohol.
• Meet dietary recommendations by adopting a balanced eating pattern.
• Added sugars should be reduced in the diet and not replaced with low-
calorie sweeteners, but rather with healthy options, such as water in place
of sugar-sweetened beverages.
• Most Americans need to increase consumption of vitamin E, calcium,
potassium, and fiber.
• Childbearing women should increase their intake of iron-rich and folic
acid-containing foods or take supplements.
• Individuals over age 50 should consume vitamin B12-fortified foods.
• Aging individuals, those with dark skin, and people who are not exposed
to sunlight should eat vitamin D-fortified foods or take a supplement.
Weight Management
• Balance the intake of calories with those expended.
• With aging, calories should be decreased and physical activity increased
to prevent gradual weight gain over time.
• Those who need to lose weight should do so slowly.
• Reducing the caloric intake by 50 to 100 calories per day prevents weight
gain; reducing it by 500 calories a day promotes weight loss.
• Control portion sizes and reduce the intake of saturated fats, added
sugars, and alcohol.
Carbohydrates
• Choose fiber-rich fruits, vegetables, and whole grains.
• Limit the use of added sugar and sweeteners; added sugars should
account for no more than 10% of total calories per day.
• Practice good dental hygiene and limit sugary snacks to reduce dental
caries.
Sodium and Potassium
• Consume less than 2,300 mg of sodium per day (approximately 1 tea-
spoon of salt).
• Consume potassium-rich foods.
Modified from the Dietary Guidelines Advisory Committee. http://health.gov/dietoryguidelines/2015-scientific·report/. Accessed November 4, 2015.
NUTRITIONAL STATUS ASSESSMENT
During the provider's examination, he or she will assess the patient's
nutritional status. The provider considers the patient's age; height
and weight; body mass index (BMI); overall health status; any recent
changes in weight; diet and exercise habits; and lifestyle, culture, and
educational background. In addition to this information, the pro-
vider may check the patient's skin turgor to determine the level of
hydration and perform various techniques to assess the percentage
of body fat.
Body Fat Measurement
The location of body fat may be related to an increased risk of
developing diabetes, stroke, hypertension, and coronary artery
Alcoholic Beverages
• Practice moderate consumption: one drink per day for women and two
for men.
• Avoid alcohol if you are or may become pregnant or if lactating.
Food Safety
• Clean all fruits, vegetables, and cooking surfaces.
• Keep raw, cooked, and ready to eat foods separate.
• Cook foods to the recommended temperature to kill microbes.
• Chill perishable foods and defrost foods properly.
• Avoid unpasteurized milk products, raw eggs, and raw or undercooked
meats.
Physical Activity
• Engage in 30 to 60 minutes of moderate physical activity per day to
prevent weight gain; 60 to 90 minutes for weight loss.
• Children and adolescents should be physically active 60 minutes a day.
• Aging people should participate in regular exercise to maintain function.
• Include aerobic activity, stretching, and weight training.
Food Groups to Encourage
• For a 2,000-calorie diet, consume 2 cups of fruit and 2½ cups of
vegetables a day.
• Eat dark green and orange vegetables, legumes, and starches several
times a week.
• At least half of the grains consumed should be whole grains.
• Consume 3 cups of fat-free or low-fat milk or milk products a day; children
age 2 to 8 years should consume 2 cups a day.
Fats
• Less than 10% of calories should come from saturated fats; keep trans
fats as low as possible.
• Consume less than 35% of calories from fat.
• Choose low-fat or fat-free milk products and lean meats.
disease. Studies indicate that the body has two places to store fat: at
the hips and in the abdomen. Fat at the hips is more common in
women and is used to store energy for special purposes, such as
during pregnancy and breastfeeding. Abdominal fat, or central
obesity, seems to be more dangerous to overall health. Health risks
related to weight range from no increased risk with normal weight
to severe risk from central obesity, with the risk from other types of
obesity falling somewhere in between.
To determine the patient's status, the waist and hips are measured
and correlated with the waist-to-hip ratio (the bigger the belly, the
higher the ratio). Normal ratios are less than 0.75 in women and
0.90 to 0.95 in men. Waist measurements also can predict the risk
of developing a weight-related disease. Men at increased risk for

disease have a waist measurement greater than 40 inches (102 cm);
for women, the risk is increased with a waist measurement greater
than 35 inches (88 cm).
At the provider's request, the medical assistant may perform body
fat measurements on a patient. The percentage of body fat may be
an indicator of overall health and of risk for cardiovascular disease.
Body fat can be measured by several methods. A reliable method of
measuring body fat uses a specially designed caliper to measure the
thickness of a fold of tissue in three areas: the triceps, the subscapu-
lar, and the suprailiac regions (Figure 6-2). However, an increasing
number of patients have fat folds that are too large for calipers to
measure. The provider may also order a dual energy x-ray absorpti-
ometry (DEXA) scan, in which two x-ray beams are used to give
accurate feedback on the body fat percentage, where the fat is dis-
tributed, and bone density.
Body Mass Index
To determine how healthy an adult patient's weight level is, the
provider may ask the medical assistant to calculate the patient's BMI.
The BMI is the relationship of weight to height that mathematically
correlates the patient's measurements with health risks. It is a more
accurate predictor of weight-related diseases than traditional height-
weight charts because it provides a good estimate of the degree of
body fat.
FIGURE 6-2 Determining fat fold measurements. A, Triceps. B, Subscapular. C, Suprailiac.
CHAPTER 6 Nutrition and Health Promotion 127
A patient's BMI can be calculated by dividing the weight in
kilograms by the square of the height in meters: BMI = Weight (kg)
+ Height (m2)]. However, to determine the BMI, clinics can use a
wheel device that compares the patient's height to weight, or an
online BMI calculator, or can refer to a BMI chart (Table 6-5). This
is not necessary with EHR systems because the program automati-
cally calculates the BMI after the patient's height and weight have
been documented. Table 6-6 shows the correlation between a
patient's BMI and the risks for disease.
Individuals with a BMI of 19 to 22 are thought to live the
longest. Death rates are significantly higher for people with a BMI
of 25 or above. If the risk is anything other than acceptable, dietary
modifications may be needed. The provider makes this decision after
evaluating all the patient's data.
CRITICAL THINKING APPLICATION 6-3
The provider encourages Mr. Hawthorne to lose weight to lower his BMI of
29. Explain how Marcia could coach Mr. Hawthorne about the importance
of his BMI and how he can monitor his BMI at home. What educational
materials might be helpful?
128 UNIT ONE INTRODUCTION TO MEDICAL ASSISTING

TABLE 6-5 Body Mass Index Chart

BODY WEIGHT {lb)
HEIGHT (in) 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35
58 91 96 100 105 110 115 119 124 129 134 138 143 148 153 158 162 167
59 94 99 104 109 114 119 124 128 133 138 143 148 153 158 163 168 173
60 97 102 107 112 118 123 128 133 138 143 148 153 158 163 168 174 179
61 100 106 111 116 122 127 132 137 143 148 153 158 164 169 174 180 185
62 104 109 115 120 126 131 136 142 147 153 158 164 169 175 180 186 191
63 107 113 118 124 130 135 141 146 152 158 163 169 175 180 186 191 197
64 110 116 122 128 134 140 145 151 157 163 169 174 180 186 192 197 204
65 114 120 126 132 138 144 150 156 162 168 174 180 186 192 198 204 210
66 118 124 130 136 142 148 155 161 167 173 179 186 192 198 204 210 216
67 121 127 134 140 146 153 159 166 172 178 185 191 198 204 211 217 223
68 125 131 138 144 151 158 164 171 177 184 190 197 203 210 216 223 230
69 128 135 142 149 155 162 169 176 182 189 196 203 209 216 223 230 236
70 132 139 146 153 160 167 174 181 188 195 202 209 216 222 229 236 243
71 136 143 150 157 165 172 179 186 193 200 208 215 222 229 236 243 250
72 140 147 154 162 169 177 184 191 199 206 213 221 228 235 242 250 258
73 144 151 159 166 174 182 189 197 204 212 219 227 235 242 250 257 265
74 148 155 163 171 179 186 194 202 210 218 225 233 241 249 256 264 272
75 152 160 168 176 184 192 200 208 216 224 232 240 248 256 264 272 279
76 156 164 172 180 189 197 205 213 221 230 238 246 254 263 271 279 287
National Institutes of Health/National Heart, Lung, and Blood Institute: Clinical guidelines on the identification, evaluation, and treatment of ovetweight and obesity in adults: the evidence report,
June 1998. www.nhlbi.nih.gov/guidelines/obesity/bmi_tbl.htm. Accessed March 22, 2015.
*To use the table, find the appropriate height in the left-hand column. Move across to a given weight. The number at the top of the column is the BMI at that height and weight. Pounds have
been rounded off.

TABLE 6-6 Body Mass Index and Disease Risk THERAPEUTIC NUTRITION
Although most patients are treated medically without a thera-
BODY MASS INDEX CLASSIFICATION DISEASE RISK peutic diet, patient treatment may include the use of special diets.
:s;l 8.5 Underweight Low For example, patients with hypertension, hypercholesterolemia,
certain gastrointestinal diseases, and diabetes mellitus type 1
18.5-24.9 Normal weight Low and diabetes mellitus type 2 all benefit from a therapeutically
25-29.9 Overweight Increased planned diet. It is important to take into consideration the
patient's lifestyle, cultural influences, and background to ensure
30-34.9 Obese High cooperation.
35-39.9 Obese Very high Modifying a Diet
~40 Extremely obese Extremely high The following features of a normal diet (or combinations of them)
can be modified to create a therapeutic diet:
• Consistency
• Calorie level
• Amounts of one or more nutrients

• Degree of bulk or fiber
• Spiciness
• Levels of specific foods
In general, a normal diet is modified by restricting or increasing
the foods that are sources of the nutrient involved in the disease
process. Except for the nutrient in question, the recommended daily
allowances usually can be met. However, if several restrictions are
ordered for the same patient, a nutrient supplement may be
necessary.
liquid Diet
Two types of liquid diets are used. A clear liquid diet includes only
transparent or translucent liquids, such as broth soups, tea, and
gelatin. In some cases, apple juice and cranberry juice may be
allowed. A full liquid diet includes all foods allowed on a clear liquid
diet plus milk, custards, strained cream soups, refined cereals,
eggnog, milkshakes, and all juices. This diet may be indicated as part
of preparation for certain diagnostic tests (e.g., colonoscopy) or for
the first several days after major surgery.
Soft or Light Diet
When a soft or light diet is prescribed, foods with roughage are
eliminated (no raw fruits or vegetables). No strongly flavored or
gas-forming vegetables are allowed (e.g., onions, beans, broccoli, and
cauliflower), and spices also may be limited. This diet often is used
after surgery to place less strain on the gastrointestinal system or for
patients with certain gastrointestinal disorders.
Mechanical Soft Diet
A mechanical soft diet is a regular diet in which the food is chopped,
ground, or pureed, depending on the degree of texture change
required. No foods or spices are restricted. This diet may be used
after dental or oral surgery or for patients who have difficulty
chewing or swallowing.
Bland Diet
A bland diet restricts dietary components classified as gastrointestinal
irritants. Such a diet limits any foods that are chemically irritating
(e.g., caffeine, pepper, chili, nutmeg, and alcohol) or mechanically
irritating (e.g., high-fiber foods). No fried foods or highly concen-
trated sweets are allowed. Gas-forming vegetables belonging to the
onion and cabbage family also are eliminated. A bland diet com-
monly is used for problems of the gastrointestinal tract. Such a diet
should supply sufficient nutrients for the individual to meet the
recommended daily allowances unless fruits and vegetables are
eliminated.
Lactose Sensitivity and Intolerance
Lactose is a sugar found in milk and milk products. Lactose is an enzyme
produced in the small intestine to break down lactose into two simpler
forms of sugar, glucose and galactose. The body absorbs these simpler
sugars into the bloodstream. Patients with lactose sensitivity or intolerance
have either a lactose deficiency or a problem absorbing lactose. They
experience a number of gastrointestinal (GI) symptoms, including bloating,
diarrhea, and gas after drinking milk or eating dairy products.
CHAPTER 6 Nutrition and Health Promotion 129
Lactose intolerance is sometimes confused with a milk allergy, but an
allergy is an immune system response that may even be life-threatening,
whereas lactose intolerance is a GI disorder that results in uncomfortable
symptoms. Acaw's milk allergy typically occurs in the first year of life,
whereas lactose intolerance occurs more often during adolescence or
adulthood.
Lactose intolerance is mare likely ta occur in certain racial and ethnic
groups, including African-Americans, Hispanics/Latinos, Native Americans,
and Asian-Americans.
The most important health concern with this condition is its effect on
calcium and vitamin Dintake. Individuals with lactose sensitivity or intoler-
ance can manage the condition by using lactose-free and lactose-reduced
milk and milk products and by taking lactose tablets or drops when eating
or drinking milk products. The lactose enzyme digests the lactose in the
food and decreases the chances of developing GI symptoms.
Elimination Diet
Elimination diets involve removing specific foods or ingredients
from the diet to help diagnose food allergies. Common allergy-
causing foods include milk, eggs, fish, crustacean shellfish, wheat,
soy, peanuts, and tree nuts. An elimination diet can vary slightly but
generally involves elimination of certain foods from the diet and then
a gradual reintroduction phase. During the elimination phase, which
should last 4 to 8 weeks, all potentially problematic foods must be
avoided and replaced with safer alternatives. If the elimination phase
results in significant health improvements, the reintroduction phase
begins with systematically reintroducing eliminated foods into the
diet one at a time and every few days to assess tolerance. Any foods
that trigger previous symptoms should be avoided. Foods that don't
appear to cause any reaction are considered safe and can become part
of the regular diet again. Gluten-free and lactose-free diets are types
of elimination diets. Elimination diets may be helpful for individuals
with irritable bowel syndrome (IBS), migraine headaches, and other
inflammatory diseases, such as rheumatoid arthritis.
Gluten-Free Diets
Gluten is found in grains such as wheat, barley, and rye. A gluten-
free diet is primarily used to treat celiac disease, which is an inherited
allergy to the gluten protein. There is no treatment for celiac disease
other than avoiding gluten in the diet. Gluten causes inflammation
in the small intestines of people with celiac disease, and eating a
gluten-free diet helps control signs and symptoms and prevents
destruction of the small intestine wall. People with celiac disease
must eat a strictly gluten-free diet and must remain on the diet for
the remainder of their lives. People who don't have celiac disease but
have symptoms when they eat gluten are diagnosed with nonceliac
gluten sensitivity. People with nonceliac gluten sensitivity may
benefit from a gluten-free diet, but there is still some controversy
over whether it is actually gluten that is causing their symptoms.
Further research is needed in this area.
High- or Low-Fiber Diet
The amount of bulk or fiber in the diet is either increased or
decreased, depending on the specific disorder of the colon or large
130 UNIT ONE INTRODUCTION TO MEDICAL ASSISTING

bowel. In either case, foods high in cellulose are considered high in
fiber because the body does not digest this carbohydrate well, and a
residue is left in the colon. In some instances, a low-residue diet is
distinguished from a low-fiber diet. In this case, a low-fiber diet
eliminates foods with a high cellulose content, and a low-residue diet
restricts milk in addition to fiber content. Either diet should supply
all the nutrients needed; however, if milk is restricted drastically,
the calcium level must be watched carefully. Low-fiber diets are
Cancer and Nutrition
Good nutrition is important when one is diagnosed with cancer and during
cancer treatment. Although the nutrient needs of people with cancer vary,
listed below are some general guidelines.
Extra protein is usually needed to heal tissues and help fight infection.
Choose manaunsaturated and polyunsaturated fats ta help create stared
energy, insulate body tissues, and transport fat-soluble vitamins.
Carbohydrates are needed for energy and proper organ function; fruits,
vegetables, and whole grains provide vitamins, minerals, and fiber.
If there is vomiting or diarrhea, extra fluid intake may be required. Drink
at least 1 cup of liquid after each loose bowel movement to prevent
dehydration.
When undergoing cancer treatment, it is common to have a poor
appetite; try eating frequent small meals, avoiding liquids with meals, and
keeping high-calorie, high-protein snacks on hand.
Try bland, soft, easy-to-digest foods if nauseated.
The provider ar dietitian may suggest a daily multivitamin and mineral
supplement.
Do not take large amounts of vitamins or any herbs unless the provider
is aware of it and approves.
Nutrition for People With Cancer. The American Cancer Society http//www.cancer.org/
treatment/survivorshipduringandaftertreatmentfnutritionforpeoplewithcancer/
index?sitearea=M. Accessed February l 0, 2016.
prescribed for patients with certain gastrointestinal disorders, such
as diverticulitis. High-fiber diets are recommended for patients with
hypercholesterolemia or diabetes mellitus and to prevent certain
forms of cancer.
Diabetic Diet
The specific diet for a patient with diabetes is determined by the
individual's health needs. The basic goal of managing the disease is
to maintain consistent control of blood glucose levels. When devel-
oping a diabetic diet plan, the provider or dietitian must consider
additional factors, such as the need for weight control, individual
patient preferences, exercise patterns, and lifestyle factors. General
guidelines for a healthy diabetic diet include the following:
• Five servings of dark-colored fruits and vegetables and six of
whole grains each day
• Two weekly servings of fatty fish (salmon, cod, mackerel)
• Complex carbohydrates that are high in fiber (e.g., whole
grains)
• Monounsaturated fats (olive and canola oil)
• Daily serving of nuts, seeds, or legumes
• Fish or soy over poultry or other meat
• Avoidance of fad diets, especially those with high-protein,
low-carbohydrate foods
• Reduced salt intake
• Avoidance of saturated fats and trans fats
Traditionally, the diabetic diet has been based on exchange lists,
which group foods according to similar calorie, carbohydrate,
protein, and fat content. The objective of exchange lists is to
achieve the proper balance of carbohydrates, proteins, and fats
while maintaining healthy weight and blood glucose levels. Menus
are developed based on the food groupings and the optimum
number of daily calories needed to meet the patient's needs. Foods
can be substituted for one another within an exchange list but not
among lists. Table 6-7 lists the number of exchanges per day
allowed within certain calorie-restricted diabetic diets.

TABLE 6-7 Diabetic Diet Exchanges per Day

NUMBER OF EXCHANGES OR SERVINGS
IN EACH GROUP
EXCHANGE GROUPS AND SERVING SIZES 1,200* 1,500* 1,800* 2,000* 2,200*
Starch or bread: One exchange equals 1 ounce bread and ½ cup cooked cereal, grain, 5 8 10 11 13
or pasta
Meat and cheese: One exchange equals 1 ounce; high-fat exchanges should be used 4 5 7 8 8
no more than three times per week
Vegetables: One exchange equals ½cup cooked, 1 cup raw, and ½cup juice 2 3 3 4 4
Fruits and sugar: No more than 10% of total daily carbohydrates; each exchange 3 3 3 3 3
equals 15 g carbohydrate
Milk products: One exchange equals 1 cup (8 ounces); skim and very low fat milk 2 2 2 2 2
products are recommended
Fats: One exchange equals 1 teaspoon of fat 3 3 3 4 5
*Number of calories in the prescribed diabetic diet.
 CHAPTER 6 Nutrition and Health Promotion 131

Diabetes educators agree that the simplest way to teach patients control hyperglycemic peaks, which are associated with the compli-
about the relationship between diet and blood glucose levels is to cations of diabetes mellitus. A rating system known as the Glycemic
focus on the total number of carbohydrate grams a patient can Index (GI) may help solve this problem. The GI rates carbohydrate
consume daily (carb counting) while maintaining the recommended foods on a scale from slowest to fastest effects on blood glucose levels.
blood glucose level. In this way, patients can decide how they want The lower the GI value of the food, the longer it takes to raise the
to distribute their carbohydrate intake throughout the day. The patient's blood glucose level. The GI scale is based on 100 glycemic
number of carbohydrate grams a patient with diabetes can eat each units, which is equivalent to the number of units in a glucose tablet.
day is determined by a combination of factors: the patient's weight The Glycemic Index of foods helps people with diabetes understand
and whether weight loss or maintenance is part of the treatment the impact of different carbohydrates on the blood glucose level, but
plan; the level of exercise because physical activity lowers the blood it can be a complicated tool to understand, and it must be used in
glucose level; prescribed diabetic medications, including insulin; and conjunction with a dietary plan that considers the nutritional guide-
other factors, such as age and blood lipid levels. lines for all foods (Procedure 6- 1) . For further information about
Therefore, people with diabetes can eat sugary foods as long as the Glycemic Index, refer to the American Diabetes Association
they restrict themselves to the total number of carbohydrates allowed website (www.diabetes.org/) .
for that snack or meal, and the decision to eat that food adheres to
the rules of healthy nutrition. In other words, a patient with diabetes
Glycemic Index (GI) Values of Some Foods
can have a whole-wheat raisin bagel for breakfast as long as the total
carbohydrate grams for the bagel do not exceed the number of car-
FOOD GI VALUE (0-100 SCALE)
bohydrate grams that should be eaten for that particular meal. Table
6-8 presents breakfast choices for a patient with diabetes restricted Honey 91
to a total of 50 g of carbohydrate per day. Puffed rice 90
All carbohydrates raise the blood glucose level to a similar degree. White potato 87
In general, 1 g of carbohydrate raises the blood sugar level of a Corn chips 72
person who weighs 150 pounds by 4 points; for a person who weighs White rice 72
200 pounds, it raises the level by 3 points. However, not all carbo-
Whole-wheat bread 72
hydrates raise the blood glucose level at the same rate. Choosing a
Shredded wheat 70
carbohydrate that takes longer to affect the blood glucose level helps
Brown rice 66
Refined sugar 64
Rye bread 64
TABLE 6-8 Carbohydrate (CHO) Content of Oatmeal cookies 57
Breakfast Foods Potato chips 56
Oatmeal 53
FOOD TYPE SERVING SIZE CHO (g)
Sweet potato 50
1%Reduced fat milk 1 cup 12 Spaghetti 38
Bran (hex 2/3 cup 23 Yogurt 38
Milk 34
Frosted Flakes 3/4cup 26 Kidney beans 33
Apples and cinnamon instant 1 packet 27 Fructose 22
oatmeal Soybeans 14
Low-fat granola 1/2 cup 30
Toast 1 slice 15 CRITICAL THINKING APPLICATION 6-4
White table sugar 1 teaspoon 4 Samantha Rashad recently was diagnosed with diabetes mellitus type 2.
She has met with the dietitian, but she has some questions about her
Pancakes 2 15 1,200-calorie diabetic diet. The goals of her dietary management are to
Pancake syrup 2 tablespoons 30 maintain blood glucose levels within normal range while encouraging weight
loss. Based on Marcia's knowledge of the components of a healthy diet,
Light pancake syrup 2 tablespoons 4 what recommendations can she make to Ms. Rashad?
Fruit yogurt 1 cup 40
Fruit yogurt with Nutrasweet 1 cup 19 Heart-Healthy Diet
The goals for a heart-healthy diet are to encourage the patient to eat
Fruit juice 1/2 cup 15 foods that reduce overall cholesterol levels and LDL, increase HDL,
Banana 1/2 15 and keep blood pressure within normal limits. Other factors that
must be considered for patients at risk for heart disease are obesity
132 UNIT ONE INTRODUCTION TO MEDICAL ASSISTING

Instruct a Patient According to the Patient's Dietary Needs: Coach the Patient on
PROCEDURE 6-1
the Basics of the Glycemic Index

The Glycemic Index (GI) rates carbohydrate foods on a scale from slowest to fastest effects on blood glucose levels. The
lower the GI value of the food, the longer it takes to raise the patient's blood glucose level. With your partner, role-play how to
teach the follawing patient about the GI index. The patient was recently diagnosed with diabetes type 2, is of Italian descent,
and has a family history of diabetes type 2 and a body mass index (BMI) of 30.*
Goal: To coach the patient the basic principles of adiabetic diet using the Glycemic Index of foods.
EQUIPMENT and SUPPLIES 4. Give the patient the pencil and paper to write down the GI value of five
• Patient's health record favorite carbohydrate foods.
• Handouts and a list of professional websites that discuss a diabetic diet and PURPOSE: Writing down information aids memory retention.
the Glycemic Index of foods S. Compare the numbers and ask the patient to determine which would be a
• Table of the Glycemic Index of foods healthy choice and explain why.
• Pencil and paper PURPOSE: Comparing the results reinforces learning.
6. Together, analyze the patient's choices of foods with a low GI value.
PROCEDURAL STEPS PURPOSE: To gather feedback about the learning experience so that the
1. Using the patient's health and family histories, assess the individual to patient's learning needs are clarified.
determine cultural influences that may affect dietary choices. 7. Ask the patient whether he or she will use this information when shopping
PURPOSE: Cultural factors may influence the patient's dietary choices. and making carbohydrate foad choices.
2. Introduce yourself and explain to the patient that you are going to teach PURPOSE: Role-play implementation of the information to determine the
him or her about the Glycemic Index of foads. Be sure to include reasons patient's level of learning.
the patient should use a food's GI value to help plan carbohydrate food 8. Document the education intervention, including the feedback received from
choices. the patient about his or her understanding of how to use the GI.
PURPOSE: Explaining the rationale for consistently referring to the GI value PURPOSE: Documentation in the health record provides proof of patient
of acarbohydrate food encourages the patient to participate in the education education and an assessment of the patient's ability to apply the knowledge
process. to daily practice.
3. Using the GI table, point out the Glycemic Index value of common carbo-
hydrate foods.
PURPOSE: Using the index when looking up types of carbohydrate foods
that the patient typically eats assists learning and reinforces practical *For further information about the Glycemic Index, refer to the American Diabetes Association
website at www.diabetes.org/.
applications.

American Heart Association's Diet and Lifestyle Recommendations

• Eat at least 4½ cups a day of a variety of fruits and vegetables.
• Eat six or more servings a day of a variety of grain products, with at least
three servings a day of fiber-rich whole grains.
• Eat fish at least twice a week; research indicates that eating oily fish
containing omega-3 fatty acids (salmon, trout, and herring) may help
lower the risk of death from coronary artery disease.
• Include fat-free and low-fat milk products, legumes, skinless poultry, and
lean meats.
• Choose fats and oils with 2 gor less of saturated fat per tablespoon (e.g.,
canola or olive oil).
• Limit the intake of foods high in calories or low in nutrition.
• Limit foods high in saturated fat and trans fat.
American Heart Association. www.heart.org/HEARTORG/. Accessed March 23, 2015.
• Eat less than 1,500 mg of sodium a day.
• Cut back on beverages and foods with added sugars.
• Eat at least four servings a week of nuts, legumes, and seeds.
• Quit smoking and avoid secondhand smoke.
• Women should limit their alcohol intake to one drink a day; men to two
drinks a day.
• Balance calorie intake with the number of calories burned each day. If
overweight or obese, multiply your ideal body weight by 15 (active) or
13 (not active) to find the number of calories you should eat to gradually
achieve your ideal body weight.
• Get enough physical activity to keep fit. Exercise at least 30 minutes
every day.
 CHAPTER 6 Nutrition and Health Promotion 133

and the patient's typical exercise patterns. Obesity is associated with

elevated lipid levels; therefore, weight management must be part of
the patient's dietary plan. In addition, researchers report that an
aerobic exercise program must be included to maintain cholesterol
at a healthy level.
Cross-Cultural Tips for Reducing Sodium and Fat
• Limit the use of soy or teriyaki sauce, even the low-sodium type.
• Eat fresh or frozen fruits and vegetables; rinse fresh produce before
eating, or choose canned products low in sodium.
• Bake or broil meats rather than frying; limit beef products; remove skin
from chicken before cooking; increase the intake of unprocessed fish.
• Cook with olive or canola oil.
• Limit servings of cured foods, such as ham and bacon; avoid pickles
and other foods prepared in brine; limit condiments such as mustard
and ketchup.
• Coak rice and pasta without added salt; do not use instant versions,
which are higher in sodium.
• Do not add salt to food; use substitute spices, such as lemon, lime, and
herbs.
CRITICAL THINKING APPLICATION
Ms. Rashad's blood pressure at this visit was 182/94. She is concerned
about the risks of heart disease and wants to lower her blood pressure.
What facts about a heart-healthy diet should Marcia share with her to help
her understand the importance of nutrition in overall wellness?
READING FOOD LABELS
The USDA requires that all food products carry a nutrition facts
label. Food labels are a source of information about the nutrients in
the product. When a designated diet is planned or implemented, the
food label can be used as a valuable source of nutritional information
(Procedure 6-2).
The U.S. Food and Drug Administration (FDA) is proposing to
update the Nutrition Facts label on food packages by 2016-2017 to
reflect new public health and scientific information. One major
change will be to update the serving size so that it reflects the amount
of food people actually eat and drink. In addition, the format of the
label will be changed so that the key parts (calories, serving sizes, and
percent daily value) are displayed more prominently (Figure 6-3). The
following will be some of the requirements for the new label.
• The Dietary Guidelines for Americans recommend reducing the
intake of calories from added sugars. Americans on average eat
16% of their total calories from added sugars, the major sources
being soda, energy and sports drinks, grain-based desserts, sugar-
sweetened fruit drinks, dairy-based desserts, and candy. The new
label must include an "Added Sugars" category, indented under
"Sugars," so that both are listed.
• "Calories from fat" will no longer be shown because research
6-5 shows that the total fat calories in the diet are less important than
the type of fat consumed. The categories "Total Fat," "Saturated
Fat," and "Trans Fat" must still be listed.
• The new label must show the amount of calcium, vitamin D,
potassium, and iron because studies show that Americans are
consuming inadequate amounts of these nutrients, and their lack

Nutrition Facts Nutrition Facts

Serving size 2/3 cup (55g)
Servings Per Container About 8
8 servings per container
Serving size 2/3 cup (55g)
Amount Per Serving
Calories 230 Calories from Fat 72
% Daily Value*
Amount per 2/3 cup
Calories 230
Total Fat 8g 12% o/oDV*
Saturated Fat 1g 5% 12% Total Fat 8g
Trans Fat Og 5% Saturated Fat 1g
Cholesterol 0mg 0%
Trans Fat Og
Sodium 160mg 7% 0% Cholesterol 0mg
Total Carbohydrate 37g 12% 7% Sodium 160mg
Dietary Fiber 4g 16%
12% Total Carbs 37g
Sugars 1g
14% Dietary Fiber 4g
Protein 3g
Sugars 1g
Vitamin A 10%
Added Sugars Og
Vitamin C 8%
Protein 3g
Calcium 20%
Iron 45% 10% Vitamin D 2mcg
•Percent Daily Values are based on a 2,000 calorie diet. 20% Calcium 260mg
Your daily value may be higher or lower depending on
your calorie needs.
45% Iron 8mg
Calories: 2,000 2,500 5% Potassium 235mg
Total Fat Less than 65g 80g
Sat Fat Less than 20g 25g • Footnote on Daily Values (DV) and calories reference
Cholesterol Less than 300mg 300mg to be inserted here.
Sodium Less than 2,400mg 2,400mg
Total Carbohydrate 300g 375g

A ~-D-iet_ary-Fib_e_r_ _ _ _ _2s_g_ _ _3o_g_~ B

FIGURE 6-3 Nutrition Facts label. (From the US Food and Drug Administration. www.fda.gov/food/ingredientsp•ck•gingl•beling/
labelingnutrition/ucm 114155.htrn. Accessed March 22, 2015.)
134 UNIT ONE INTRODUCTION TO MEDICAL ASSISTING
is associated with the risk of chronic disease. The actual amount
of vitamins and minerals in the food must be included.
• The amount per serving must be given in common household
measures, such as 1 cup.
• If a claim is made about any of the optional components or if a
food is fortified or enriched with any of them, nutrition informa-
tion for these components must be provided.
How to Use Label Information
When evaluating the nutritional value of a food product, begin with
the serving size information, which is listed in household measure-
ments. The amount of each nutrient in the food is expressed in terms
of weight per serving. If you eat more or less than the serving size
on the label, you will need to adjust the amounts of nutrients and
number of calories accordingly. The goal is to choose foods that total
100% of your daily nutrition needs.
The ingredient list on the label also can help you learn more about
the foods you eat. Ingredients are listed in descending order of
weight; that is, the ingredient with the largest amount in the food
is listed first. This helps you get an idea of the proportion of an
ingredient in a food (Figure 6-4). Artificial colors must be named in
the ingredient list; this is important information for individuals with
food allergies and those on specialized diets. In addition, the total
lijiIII!,mmjfj Coach a Patient About How to Understand Food Labels
Goal: To help the patient understand food labels.
EQUIPMENT and SUPPLIES
• Patient's health record
• Food labels from a protein bar, a granola bar, and a pop tart package
• Pencil and paper
PROCEDURAL STEPS
Role-play the following steps with your partner.
1. Using the patient's health and family histories, assess the individual to
determine cultural influences that may affect dietary choices.
PURPOSE: Cultural factors may influence the patient's dietary choices.
2. Introduce yourself and explain to the patient that you are going to teach
him or her how to read afood label. Be sure to include reasons food labels
are a valuable source of nutritional information in meal planning.
PURPOSE: Explaining the rationale for consistently reading food labels
encourages the patient to participate in the education process.
3. Using the labels on each product, point out the nutritional information
according to the guidelines in the text.
PURPOSE: Using actual labels assists learning and reinforces practical
applications.
4. Give the patient the pencil and paper to write down the serving size of
each type of bar.
PURPOSE: Writing down information aids memory retention.
INGREDIENT LABEL
INGREDIENTS: COOKED WHITE RICE, WATER, COOKED
CHICKEN TENDERLOINS, GREEN BEANS, CARROTS,
RED PEPPERS, BROWN SUGAR. CONTAINS LESS THAN
2% OF MODIFIED FOOD STARCH, MUSTARD (VINEGAR,
MUSTARD SEED, SALT, SPICES, TURMERIC), DIJON
MUSTARD (WATER, MUSTARD SEED, DISTILLED
VINEGAR, SALT, WHITE WINE, CITRIC ACID, TARTARIC
ACID, SPICES), HONEY, MALTODEXTRIN (FROM CORN),
SALT, EGG YOLK SOLIDS, SODIUM PHOSPHATE,
VINEGAR POWDER (MALTODEXTRIN, MODIFIED FOOD
STARCH, VINEGAR SOLIDS), XANTHAN GUM FLAVORS,
SPICES, LEMON JUICE CONCENTRATE
FIGURE 6-4 Ingredient label.
percentage of juice in juice drinks must be declared so that you can
see exactly how much juice is in the product.
The front package label is where manufacturers often place state-
ments describing the nutritional qualities of their product. The gov-
ernment has set strict conditions under which statements such as
"low fat," "cholesterol free," and "good source of fiber" can be used
as part of the front label. The FDA permits claims linking a nutrient
or food to the risk of a disease or health-related condition, but only
claims supported by scientific evidence are allowed.
S. Compare the similarities and differences among the products.
PURPOSE: Comparing the results reinforces learning.
6. Have the patient write down the total number of calories for a single
serving of each food product.
PURPOSE: To reinforce the significant effect of high-calorie snacks on
overall nutritional health.
7. Write down the amount of total, saturated, and trans fats in each product.
PURPOSE: To review the role of saturated and trans fats in disease.
8. Recard the total number of added sugars and sodium in each product.
9. Together, analyze the nutritional level of each.
10. Discuss any new information learned.
PURPOSE: To gather feedback about the learning experience so that the
patient's learning needs are clarified.
11. Ask the patient whether he or she will use this information when shopping
and how it will be implemented in menu planning.
PURPOSE: Role-play implementation of the information to determine the
patient's level of learning.
12. Document the education intervention, including the feedback received from
the patient about his or her understanding of how to read food labels.
PURPOSE: Documentation in the health record provides proof of patient
education and an assessment of the patient's ability to apply the knowl-
edge to daily practice.

Regulated Nutritional Claims for Food Labels
Calorie-free Less than 5 calories per serving
Extra lean Cooked meat or poultry with less than 4. 9 gof fat
per serving, of which less than 1.8 g is saturated fat
Fat-free Less than 0.5 g of fat per serving
Fresh Raw; never frozen, processed, or preserved
High Provides more than 20% of the recommended daily
consumption (per serving) of the nutrient (e.g.,
high-fiber)
Lean Cooked meat or poultry with less than 10.5 gof fat
per serving, of which less than 3.5 g is saturated fat
Light One-third fewer calories than the regular product
Low-calorie Less than 40 calories per serving
Low-fat 3 g or less of fat per serving
Low saturated 1 g or less of saturated fat per serving, and not more
fat than 15% of calories from saturated fat
Low-sodium Less than 140 mg of sodium per serving
Saturated Less than 2 gof saturated fat per serving
fat-free
Sodium-free Less than 5 mg of sodium per serving
Sugar-free Less than 0.5 g of sugar per serving
Organic Foods Production Act
In 1990 the USDA initiated regulations for organically grown food,
and in 2002 the agency revised the regulations for the production
and labeling of organic foods. Until then, organizations from state
governments to trade and consumer groups contributed to the regu-
lation of organic products, resulting in ofren-conflicting standards
about which products could be labeled organic. Current government
regulations require that foods labeled organic must have been pro-
duced without exposure to pesticides, chemical fertilizers, or sewage
sludge. The food cannot have been irradiated to extend shelf life,
nor can it contain any genetically modified ingredients. In addition,
animals raised for organic meat, eggs, and milk cannot be given
antibiotics or growth hormones; must be fed organic feed; and must
have had access to the outdoors.
Products with a "100 percent organic" label are limited to strictly
organic ingredients. Products simply labeled "organic" identify the
food as being made up of 95% organic materials. Products that fall
into these two categories can display a "USDA Organic" seal. Foods
containing at least 70% organic ingredients may be labeled "made
with organic ingredients" and may list up to three of them on the
package. Any product containing less than 70% organic ingredients
may not be marketed as an organic food.
FOOD-BORNE DISEASES
Eating or drinking contaminated food can result in a food-borne
disease. Each year, 1 in 6 Americans gets sick by consuming contami-
nated foods or beverages. Many different types of bacteria, viruses,
and parasites can contaminate food, but the most common are Esch-
erichia coli and Salmonel/,a and Campylobacter organisms. Patients
may experience a variety of symptoms, but the first typically are
CHAPTER 6 Nutrition and Health Promotion 135
gastrointestinal: nausea, vomiting, stomach pain, and/or diarrhea.
Usually a delay of several hours to days occurs after ingestion of the
contaminated substance before symptoms begin. This is the incuba-
tion period, when the microbes are attaching to the intestinal wall and
beginning to multiply. The diagnosis is confirmed with laboratory
tests, of which the most common is a stool sample. However, more
sophisticated tests may be needed to diagnose viral pathogens.
Prevention is the most effective way to limit food-borne disease.
Essential to prevention efforts are clean drinking water; inspection of
restaurants and meat production facilities; temperature monitoring of
food; adequate sewage treatment; and public education on proper
hygiene. All patients with a suspected food-borne illness should
perform frequent handwashing to prevent the spread of the disease.
Treatment of a food-borne disease depends on the microorganism
causing the illness and the patient's symptoms; if diarrhea and vomit-
ing are severe, dehydration is a major concern, especially in young
children and older adults. In such cases, replacing fluid and electrolytes
is the most important aspect of care. Other treatments include the use
of antidiarrheal medications (e.g., Imodium) and drugs that coat the
gastrointestinal tract (e.g., Pepto-Bismol). Antibiotics may shorten the
duration of the disease but are only prescribed if the organism causing
the infection can be identified and will respond to antibiotic therapy.
When you are screening phone calls from patients experiencing
gastrointestinal symptoms, complaints that indicate a food-borne
illness include:
• Fever of 101.5°F (38.6°C) or higher
• Diarrhea lasting longer than 3 days
• Prolonged vomiting
• Blood in the stool
• Signs of dehydration (reduced urination, dry mouth, vertigo,
and altered skin turgor)
ENVIRONMENTAL CONTAMINATION OF FOOD
Environmental contamination of food can be a serious problem. The
FDA regularly monitors the presence of contaminants in the food
chain and issues warnings as needed to protect consumers from pos-
sible danger. Mercury is the most common heavy metal found in
food, primarily fish. Other environmental contaminants include
cadmium from industrial processing; lead found in old paint and
old plumbing; and polychlorinated biphenyls (PCBs), which are part
of discarded electrical equipment. Each of these can have serious
toxic effects on humans. For example, mercury at toxic levels can
poison the nervous system, especially that of a developing fetus. The
FDA therefore recommends that pregnant women, women of child-
bearing age, nursing mothers, and young children not eat any fish
known to have high mercury levels. These include king mackerel,
swordfish, shark, and any fresh water fish from lakes or rivers known
to be contaminated with mercury.
EATING DISORDERS
An eating disorder is any eating behavior pattern that can lead to a
health problem. These disorders can damage all the body systems
and can cause death. Although 90% of reported cases occur in ado-
lescent and young adult women, the incidence in males and middle-
aged women is rising.
136 UNIT ONE INTRODUCTION TO MEDICAL ASSISTING
Anorexia nervosa is characterized by self-induced starvation.
Anorexic individuals typically are adolescents when first diagnosed
and tend to be perfectionists who are extremely sensitive to failure
and any criticism. They use avoidance of food as a way of controlling
their feelings and fear of becoming grossly overweight if they allow
themselves to eat. As a result, they lose an excessive amount of
weight, usually 15% to 60% of their normal body weight, resulting
in extreme malnourishment. They can die without medical interven-
tion. If necessary, patients are fed intravenously or by nasogastric
tube feedings to establish an immediate level of nourishment to the
body systems. Patients with anorexia nervosa have a significantly
distorted body image and require psychotherapy to alleviate depres-
sion, to deal with their emotional issues, and for assistance in
forming a positive self-image.
Bulimia is more common than anorexia and is characterized by
cycles of bingeing and purging. This behavior pattern usually begins
in adolescence when an individual who is slightly overweight diets
but fails to achieve the expected results. Psychologically the person
believes that self-worth is related to being thin. Usually the pattern
begins with some form of stress that upsets the individual, who then
turns to food for consolation. Intake during a binge period can reach
as high as 20,000 calories. The eating binge is followed by self-induced
punishment in the form of vomiting, using laxatives and enemas,
excessive exercise, and food abstinence. Most individuals with bulimia
have a normal or an above-normal body weight, but their weight can
vary as much as 10 pounds during bingeing and purging cycles. Treat-
ment programs involve a combination of medication, psychotherapy,
and nutritional counseling. The goal is to help the patient establish
healthy eating patterns and develop an improved self-image.
Binge-eating disorder is similar to bulimia; however, people with
binge-eating disorder do not purge themselves of the extra calories
or exercise excessively. As a result, people with binge-eating disorder
often are overweight or obese. With obesity comes a higher risk of
cardiovascular disease and hypertension. These individuals often
experience guilt, shame, and anxiety about binge eating, which leads
to more binge eating. They have a compulsion to gorge themselves
that they cannot control. Typically, people with binge-eating disor-
der have no obvious physical signs or symptoms. Binge eating is a
complicated psychological disorder in which patients express a com-
bination of shame, poor self-image, and self-disgust. Treatment
works to address these issues through psychotherapy, although anti-
depressants and topiramate (Topamax) may help reduce the episodes
of bingeing. Complementary and alternative therapies, such as
massage, therapeutic touch, and mind-body therapies (meditation,
yoga, and hypnosis) may help reduce anxiety and promote an aware-
ness of the body's cues for hunger and fullness.
CRITICAL THINKING APPLICATION 6-6
A22-year-old patient is being seen for the first time for a work-related
physical examination. While you are gathering her patient history, she
mentions that she takes a laxative after every meal and exercises about 3
hours every night. The young woman is 5 feet, 6 inches tall and is deter-
mined to weigh l 00 pounds by spring. How should you handle this
situation?
OBESITY
Approximately 70% of Americans are overweight or obese. Obese
individuals are at risk for a wide range of health problems, including
hypertension, DM type 2, coronary artery disease, stroke, gallblad-
der disease, osteoarthritis, sleep apnea, and certain types of cancer.
Assessment of weight-related health risks uses three key measures:
the patient's BMI, waist circumference, and the presence of health
problems associated with obesity. As the BMI rises, so do the risks
for cardiovascular disease, hypertension, diabetes type 2, hypercho-
lesterolemia, and death. According to the National Cancer Institute,
obesity is associated with an increased risk of multiple cancers
including:
• Esophageal
• Pancreatic
• Colon and rectum
• Breast (after menopause)
• Endometrial (lining of the uterus)
• Kidney
• Thyroid
• Gallbladder
http://www.cancer.gov/ about-cancer/causes-prevention/ risk/
obesity/obesity-fact-sheet . Accessed February 5, 2016.
Medications for Obesity
Weight-loss medications fall into two categories: appetite suppres-
sants and lipase inhibitors. Appetite-suppressant medications, such
as phentermine (Adipex-P, Obenix, Suprenza) promote weight loss
by reducing the appetite or increasing the feeling of being full. Orli-
stat (Xenical), blocks the release of the enzyme lipase, which metabo-
lizes fat for absorption. If fat is not broken down, it cannot be
absorbed, which results in a decrease in dietary fat absorption by
about one third. The FDA also has approved Alli, an over-the-
counter weight-loss aid for adults that is a lower dose form of
orlistat.
Two new medicines for chronic weight management, lorcaserin
hydrochloride (Belviq) and a combination medication made up of
phentermine hydrochloride and topiramate (Qsymia), have been
approved for adults who have a BMI of 30 or higher, or a BMI of
27 or higher (overweight) if the patient has at least one weight-
related health problem.
The response to medications for weight loss varies among patients,
but the average weight loss is 5 to 22 pounds, which is more than
might have been lost without medication. Most of the weight is lost
in the first 6 months of treatment, after which the patient's weight
stabilizes or may even increase. The use of weight-loss medications
must be combined with improvement in overall nutrition and exer-
cise to have long-lasting effects and reduce weight-related health risks.
Bariatric Surgery for Obesity
Gastrointestinal surgery, or bariatric surgery, may be an option for
people who are severely obese, have attempted unsuccessfully to lose
weight by traditional means, and have been diagnosed with obesity-
related health problems. The operation promotes weight loss by
reducing the size of the stomach to the point that food intake is
restricted and/ or by interrupting the digestive process by surgically
bypassing part of the small intestine. Two common weight-loss

surgeries are banded gastroplasty and Roux-en-Y gastric bypass.
With a gastroplasty the surgeon places a band around the stomach,
or staples are used to create a small pouch at the top of the stomach.
This procedure limits the amount of food and liquids the stomach
can hold. The Roux-en-Y gastric bypass surgery creates a small
stomach pouch with a bypass around part of the small intestine
where most calories are absorbed. This surgery both limits food
intake and reduces the amount of nutrients absorbed through the
small intestine.
Weight-loss surgery can improve health and weight, but it can
be risky. Gastroplasty has fewer long-term side effects, but the
patient must limit food intake dramatically. Gastric bypass side
effects include nausea, bloating, diarrhea, and faintness. After gastric
bypass, the patient typically needs vitamin and mineral supplements
because absorption of nutrients is drastically affected.
Patients seeking bariatric surgery must meet certain criteria,
including a BMI of 40 or greater, or a BMI of 35 to 40 along with
a diagnosed obesity-related health problem, such as DM type 2 or
severe sleep apnea. The patient also must undergo counseling and
psychiatric evaluation because bariatric surgery requires a lifelong
commitment to dietary change. The procedure is successful for
long-term weight loss only if the individual is willing to commit to
making drastic behavioral changes and undergoing regular medical
checkups for the rest of his or her life. In addition, the cost of
the procedure ($20,000 to $35,000) may be prohibitive, and insur-
ance coverage varies by state and insurance provider.
HEALTH PROMOTION
The concept of health promotion includes such aspects as adequate
nutrition, a healthy environment, ongoing health education, and an
overall attempt to prevent disease and maintain optimum wellness.
Wellness goes beyond the absence of disease to a state of moving
toward fitness, managing stress, and maximizing individual poten-
tial. Health promotion uses immunizations, appropriate personal
hygiene, environmental sanitation standards, protection against
occupational hazards, nutritious diets, and periodic health screenings
and examinations to diagnose health problems early and promote
wellness.
As a medical assistant, you will play a key role in assisting the
provider in many of these areas. In addition, you can serve as a
patient navigator by interacting with local social service agencies or
insurance companies on the patient's behalf You also will play an
important role in scheduling and assisting the provider with health
screenings, physical examinations, and health teaching. Compo-
nents of wellness that all medical assistants should promote include
exercise, stress management, and routine health screenings.
Exercise
Exercise is defined as physical exertion for the maintenance or
improvement of health or for the correction of a physical handicap.
Exercise improves cardiorespiratory endurance; maintains musculo-
skeletal health by improving or maintaining strength, flexibility, and
bone integrity; and relieves stress. Although most Americans say they
know about the benefits of exercise, only 20% to 25% of adults
exercise enough to gain significant health benefits. Twenty-five
percent are not active at all, and more than half of all American
CHAPTER 6 Nutrition and Health Promotion 137
youths 12 to 21 years of age are not vigorously active on a regular
basis.
A well-balanced diet is only part of the fitness equation; adequate
exercise and sufficient rest are the other elements that help achieve
good health. As with special diets, exercise programs must be
approved for each individual by the provider. It is the provider who
determines the patient's exercise needs and tolerance levels to safe-
guard the patient from overexertion and possible injury.
Many forms of exercise are available. Some patients may find it
best to go to a gym and develop a formal program of physical fitness.
Others may purchase home exercise equipment so they can exercise
in privacy. Many feel that just getting out in the fresh air and walking
is the best form of exercise. Each individual should find the outlet
that brings enjoyment and enrichment to his or her own life. It is
not the form of exercise, but rather the participation in physical
activity, that promotes wellness.
CRITICAL THINKING APPLICATION 6-7
The provider tells Mr. Hawthorne that he must exercise to maintain a healthy
lifestyle. What can Marcia tell him about the benefits of exercise and pos-
sible methods that might help him follow through with the provider's
recommendation?
Stress Management
Stress stimulates the fight-or-flight response that physically prepares
us to either fight off a stressor or run away from it. Unfortunately,
most of the stress we experience on a daily basis is not something
we can either physically battle or effectively run away from. There-
fore, the stress response can lead to multiple health problems if it is
not managed therapeutically. The stress response results in the
release of epinephrine (adrenaline), which increases the heart and
respiratory rates, slows peristalsis, increases blood supply to the
skeletal muscles while reducing blood to the periphery, causes
overall muscular tension, and raises the blood pressure. If stress is
permitted to build without release, multiple health problems can
occur, some of which can lead to chronic disorders. One of the best
methods for reducing stress is by developing adaptive coping
mechanisms.
Coping mechanisms are thoughts and actions we use to relieve
stressful circumstances over which we have little control. Many
factors shape how we respond to stress, such as cultural and family
influences; financial status; our perception of the seriousness of the
situation; and previous experiences with crisis. Adaptive coping
mechanisms-those considered positive-help us regain control
over the situation and manage stressful situations. These might
include exercise, organizational skills, relaxation techniques,
talking over the situation with a trusted person, or using humor to
relieve stress. Nonadaptive coping mechanisms often make the
stressful situation worse. These negative actions might include
anger, denial, isolation, overeating or undereating, or substance
abuse. Regardless of how we typically respond to a stressful situa-
tion, coping mechanisms are learned behaviors, so it is possible to
identify those that do not work well and replace them with more
adaptive responses.
138 UNIT ONE INTRODUCTION TO MEDICAL ASSISTING
CRITICAL THINKING APPLICATION 6-8
Reflect on your stress management style. Make a list of the adaptive and
nonadaptive coping mechanisms you typically use when faced with a stress-
ful situation. Share your list with the class and discuss alternatives to your
adaptive techniques.
Preventive Services and Health Screening
Routine physical examinations and health screenings are important
components of health promotion. The Affordable Care Act requires
every health plan to cover all costs associated with preventive ser-
vices, meaning there is no co-payment or deductible for preventive
services. The patient scheduled for a physical examination should
have a health history completed or updated and should be weighed;
his or her blood pressure, temperature, pulse, and respirations should
be recorded; and any complaints should be documented in the
health record.
Preventive Services for Women
• Starting at age 21 or approximately 3 years after having sex for
the first time, a Papanicolaou (Pap) test at least every 3 years to
screen for cervical cancer.
• Women age 65 or older should be tested for osteoporosis; women
younger than age 65 who are at risk should also be tested.
• Mammograms should be done every 2 years between the ages of
50 and 74; women with risk factors for breast cancer may need
to have mammograms more often or start having them sooner.
• Begin colorectal cancer screening at age 50 and continue until
age 75; the patient may need to continue testing until age 85.
• Maintain a current immunization schedule.
Preventive Services for Men
• Check cholesterol levels regularly starting at age 35.
• Start colorectal cancer screening at age 50 and continue until age
75; the patient may need to continue testing until age 85.
• Maintain a current immunization schedule.
JfiiiiMH•jiii#IMUt•i
As a certified medical assistant working in an internal medicine practice,
Marcia must be familiar with the types and functions of dietary nutrients, the
USDA dietary recommendations, including the choosemyplate.gov website,
how nutritional assessments are conducted, the concepts of therapeutic nutri-
tion, how to apply the interpretation of food labels to patient practice, and
the concepts of health promotion. Recommendations for nutrition are con-
stantly changing as research continues on the dietary needs of healthy
people. Marcia can refer her patients to the USDA website (www.usda.gov/
dietaryguidelines) or the MyPlate website (www.choosemyplate.gov) for
CLOSING COMMENTS
Patient Education
Because medical assistants may be asked to discuss a diet plan with
a patient, it is extremely important that they have a thorough knowl-
edge of diet therapy. The patient must understand the prescribed
diet and the rationale for following it. If the patient feels uneasy or
has questions that go unanswered, he or she may be less motivated
to follow a diet plan. You can be a valuable asset to the provider, the
dietitian, and the patient in the implementation of a specific diet.
The medical assistant may find the following suggestions helpful
when talking to patients about a diet:
• Use charts and diagrams to illustrate diets.
• Consider the patient's dietary likes and dislikes.
• Remember that ethnic and cultural foods are important.
• Encourage the patient to play an active role in the learning
process.
• Suggest local support groups, other community resources, and
online resources that can help in diet maintenance.
Legal and Ethical Issues
Always remember that you are not a provider, nor are you a dietitian;
follow the provider's instructions. If you are not sure of the answer
to a question, always ask the provider. If your workplace employs a
registered dietitian, refer questions about meal patterns and food
selection changes to that individual. Direct patients seeking advice
in the field of nutrition and exercise programs to a qualified expert.
Use community resources as needed.
Professional Behaviors
The medical assistant plays a vital role in health promotion by making sure
patients are scheduled for annual examinations and that they follow up
with the provider's recommendations for dietary changes, exercise pro-
grams, stress management approaches, and health screening procedures.
In the role of patient navigator, the medical assistant is the link between
the patient and the provider, and between the patient and community
resources.
updated information on dietary recommendations and for educational mate-
rial on nutrition.
Providers rely on the BMI to determine a patient's risk for diet-related dis-
eases, and medical assistants should be familiar with various therapeutic diets
so that they can answer patients' questions about foods that should be included
or avoided.
As a certified medical assistant, Marcia must make a commitment to lifelong
learning so that she can provide her patients with up-to-date information on
nutrition-related topics and can use community resources to support patient care.

SUMMARY OF LEARNING OBJECTIVES
l. Define, spell, and pronounce the terms listed in the vocabulary.
Spelling and pronouncing medical terms correctly reinforce the medical
assistant's credibility. Knowing the definitions of these terms promotes
confidence in communication with patients and co-workers.
2. Analyze the relationship between poor nutrition and lifestyle factors
and the risk of developing diet-related diseases.
Research has found that lifestyle and dietary habits directly correlate with
the development of certain diseases and disorders. These include certain
types of anemia, constipation, diabetes mellitus type 2, hypercholester-
olemia, atherosclerosis, hypertension, osteoporosis, and cerebrovascular
accidents.
3. Recognize the reasons for people's food choices and the effects of
cultural eating patterns.
People eat the way they do for many reasons. Encouraging patients ta
make significant lifestyle changes with regard ta their diets requires
sensitivity to these reasons. The choices people make about what they
eat are greatly influenced by their background and relationships. Every
culture, religion, and ethnic group has its own beliefs and practices with
regard ta food.
4. Describe digestion and classify the types and functions of dietary
nutrients.
Digestion is a combination of mechanical and chemical processes that
occur in the mouth, stomach, and small intestine. Nutrients consist of
carbohydrates, fats, proteins, vitamins, minerals, and water. Their
primary functions are to provide the body with energy, protection, and
insulation; build and repair tissues; and regulate metabolic processes.
5. Describe the roles of various nutrient components, including carbo-
hydrates, fats, and proteins, in the daily diet.
The primary function of carbohydrates is to provide the body with a ready
source of energy. Dietary fat provides essential fatty acids and is needed
far the absorption of fat-soluble vitamins. Adipose tissue helps protect
the organs of the body, insulates, and serves as a concentrated form of
stored energy. Protein builds and repairs tissue and assists with metabolic
functions.
6. Explain the function of appropriate amounts of vitamins, minerals,
and water in the diet.
Vitamins are essential for metabolic functions and are classified as
either fat soluble or water soluble. They regulate the synthesis of body
tissues and aid the metabolism of nutrients. Vitamins also play a vital
role in disease prevention. Minerals help to maintain electrolytes and
acid-base balance and to regulate muscular action and nervous activi-
ties throughout the body. Water is part of almost every vital body
process.
7. Apply the Dietary Guidelines for Americans using the Choose My
Plate website developed by the U.S. Department of Agriculture
(USDA).
In 2011 the Pyramid design was changed ta a dinner plate icon that
represents haw to build a healthy plate at mealtime. The plate includes
CHAPTER 6 Nutrition and Health Promotion 139
choices from the five basic food groups, with recommendations based
on the 2010 Dietary Guidelines far Americans. At the Choose My Plate
website (www.choosemyplate.gov), consumers can determine individual
dietary needs that match their particular age, health status, exercise
level, and food preferences. (See Figure 6-1 .)
8. Implement nutritional assessment techniques by measuring a
patient's body fat and correlating a patient's calculated body mass
index (BMI) with the risk for diet-related diseases.
The provider's assessment of the patient's nutritional status includes an
evaluation of the patient's current health and lifestyle habits and also
body fat measurements. Body fat can be measured by using the waist-
to-hip ratio, by using calipers to measure fat folds, or by calculating the
BMI. (See Figure 6-2.) The BMI is the relationship of weight to height,
which correlates with health risks. The BMI is a more accurate predictor
of weight-related diseases than traditional height-weight charts because
it provides a goad estimate of the degree of body fat. Individuals with
a BMI of 19 to 22 are thought to live longest. The incidence of diet-
related disorders and the mortality rate are significantly higher for people
with a BMI of 25 or higher.
9. Do the following related to therapeutic nutrition:
• Compare the concepts of therapeutic nutrition.
Therapeutic nutrition uses various diets to help treat or prevent
disease. Diets can be modified in many ways, including changes in
consistency and taste, monitoring of caloric levels, altering the
amounts and types of specific nutrients, and managing the fiber
content of foods. Two examples of diet therapies are the diabetic diet
and the heart-healthy diet, both of which can have asignificant impact
on a patient's wellness.
• Instruct a patient according to the patient's dietary needs; coach a
patient with diabetes about the Glycemic Index of foods.
The GI rates carbohydrate foods on a scale from slowest ta fastest
effects an blood glucose levels. The lower the GI value of the food,
the longer it takes ta raise the patient's blood glucose level. (See
Procedure 6-1 .)
l 0. Interpret food labels, explain their application to a healthy diet, and
demonstrate to the patient how to understand nutrition labels on
food products.
The federal government requires all food manufacturers to follow certain
guidelines when labeling packages. Labels provide facts on the nutritional
value of foods. The food label can be a valuable tool in patient compli-
ance with specialized diets (see Figures 6-3 and 6-4). (See Procedure
6-2 to see how to coach a patient about food labels.)
11. Discuss food-borne diseases and food contaminants.
Many different types of bacteria, viruses, and parasites can contaminate
food. The first symptoms of afood-borne disease are usually gastrointes-
tinal. The FDA regularly monitors the presence of contaminants in the
food chain and issues warnings as needed to protect consumers from
possible danger.
Continued
140 UNIT ONE INTRODUCTION TO MEDICAL ASSISTING
SUMMARY OF LEARNING OBJECTIVES-continued
12. Summarize lhe causes of ealing disorders and obesity and lheir
impact on a palient's health.
An eating disorder is defined as any eating behavior pattern that can lead
to a health problem. In anorexia nervosa, profound malnutrition occurs
because of an individual's attempt to control his or her life by not eating.
Bulimia is characterized by bingeing and purging episodes. Obesity has
become a national health emergency. Obese individuals have a higher
risk of a wide range of health problems, including hypertension, diabetes
mellitus type 2, coronary artery disease, stroke, gallbladder disease,
osteoarthritis, sleep apnea, and certain types of cancer. Bariatric surgery
may be an option for people who are severely obese.
13. Define the concepts of health promolion.
Health promotion considers all aspects of patient care, including the
concepts of general wellness, adequate nutrition, environmental health
CONNECTIONS
CrJ Study Guide Connection: Go to the Chapter 6 Study Guide. Read and complete
the activities.
and safety, health education needs, and disease prevention. The
components of health promotion include exercise, stress management,
regular physical examinations, and preventive services and health
screening.
14. Describe the role of the medicol assistant in patient educotion; also,
explain the legal and ethical issues related to nutrition and health
promotion.
The medical assistant plays a key role in promoting nutrition and health.
He or she serves as a patient navigator and as a liaison between the
patient and community resources. It is important that medical assistants
understand the various implications of nutrition and specific diets, so that
they can answer patients' questions, which promotes compliance with
treatment.
evolve Evolve Connection: Go to the Chapter 6 link at evolve.e/sevier.com/
kinn to complete the Chapter Review Quiz. Check out the other resources listed for this
chapter to make the most of what you have learned from Nutrition and Health
Promotion.
VITAL SIGNS
i-i#H+i;H•i
Dr. Susan Xu is a member of a primary care practice with several providers.
Each provider has a medical assistant who works directly with him or her. Carlos
Ricci, CMA (AAMA), is Dr. Xu's assistant. Carlos graduated from a medical
While studying this chapter, think about the following questions:
• What factors might alter a patient's vital signs?
• What methods can Carlos use to gather and record a patient's
temperature, pulse, respirations, blood pressure, height, weight, and body
mass index (BMI) ?
LEARNING OBJECTIVES
l. Define, spell, and pronounce the terms listed in the vocabulary.
2. Do the following related to temperature:
• Cite the average body temperature for various age groups.
• Describe emotional and physical factors that can cause body
temperature to rise and fall.
• Convert temperature readings between Fahrenheit and Celsius
scales.
• Obtain and record an accurate patient temperature using three
different types of thermometers.
3. Do the following related to pulse:
• Cite the average pulse rate for various age groups.
• Describe pulse rate, volume, and rhythm.
• Locate and record pulse at multiple sites.
4. Do the following related to respiration:
• Cite the average respiratory rate for various age groups.
• Demonstrate the best way to obtain an accurate respiratory count.
VOCABULARY
apnea (ap'-nee-uh) Absence or cessation of breathing.
arrhythmia An abnormality or irregularity in the heart rhythm.
arteriosclerosis (ar-ter' -ee-o-scler-o-sis) Thickening, decreased
elasticity, and calcification of arterial walls.
bounding A term used to describe a pulse that feels full because
of increased power of cardiac contraction or as a result of
increased blood volume.
bradycardia (brad-i-kabr'-dee-uh) A slow heartbeat; a pulse below
60 beats per minute.
bradypnea (brad-ip-nee'-uh) Respirations that are regular in
rhythm but slower than normal in rate.
7
assistant program 3 years ago and enjoys the variety of patients seen in Dr.
Xu's practice. One of Carlos' primary responsibilities is to accurately measure
and record each patient's vital signs before the patient is seen by Dr. Xu.
• What are the current guidelines for diagnosing and treating
hypertension?
5. Do the following related to blood pressure:
• Cite the approximate blood pressure range for various age groups.
• Specify physiologic factors that affect blood pressure.
• Differentiate between essential and secondary hypertension.
• Interpret current hypertension guidelines and treatment.
• Describe how to determine the correct cuff size for individual
patients.
• Identify the different Korotkoff phases.
• Accurately measure and document blood pressure.
6. Accurately measure and document height and weight.
7. Convert kilograms to pounds and pounds to kilograms.
8. Identify patient education opportunities when measuring vital signs.
9. Determine the medical assistant's legal and ethical responsibilities in
obtaining vital signs.
cerumen (see-room'-men) A waxy secretion in the ear canal;
commonly called ear wax.
Cheyne-Stokes respirations A breathing pattern characterized by
rhythmic changes in the depth of respiration. The patient
breathes deeply for a short time and then breathes very slightly
or stops breathing altogether; the pattern occurs over and over,
every 45 seconds to 3 minutes. The Cheyne-Stokes breathing
pattern is seen in patients with heart failure or brain damage,
but also in healthy individuals who hyperventilate, at high
altitudes, and with hypnotic drug or narcotic overdose and sleep
apnea.
142 UNIT ONE INTRODUCTION TO MEDICAL ASSISTING
VOCABULARY-continued
chronic obstructive pulmonary disease (COPD) A progressive,
irreversible lung condition that results in diminished lung
capacity.
diurnal rhythm {die-ur'-nl) A pattern of activity or behavior that
follows a day-night cycle.
dyspnea (disp-nee'-uh) Difficult or painful breathing.
essential hypertension Elevated blood pressure of unknown cause
that develops for no apparent reason; sometimes called primary
hypertension.
febrile (feb'-ril) Pertaining to an elevated body temperature.
homeostasis Internal adaptation and change in response to
environmental factors; multiple functions that attempt to keep
the body's functions in balance.
hyperpnea (hahy-per-nee' -uh) An increase in the depth of
breathing.
hyperventilation Abnormally prolonged and deep breathing,
usually associated with acute anxiety or emotional
tension.
hypotension Blood pressure that is below normal (systolic
pressure below 90 mm Hg and diastolic pressure below
50 mm Hg).
intermittent pulse A pulse in which beats occasionally are
skipped.
orthopnea (or-thop'-nee-uh)A condition in which an individual
must sit or stand to breathe comfortably.
orthostatic (postural) hypotension A temporary fall in blood
pressure when a person rapidly changes from a recumbent
position to a standing position.
M easurement of vital signs is an important aspect of almost
every patient visit to the medical office. These signs are the
human body's indicators of internal homeostasis and the patient's
general state of health. Because medical assistants are chiefly respon-
sible for obtaining these measurements, it is imperative that they
have confidence in the theoretic and practical applications of vital
sign measurement. A medical assistant who understands the prin-
ciples of and the reasons for these measurements becomes a valuable
asset to any medical office.
Accuracy is essential. A change in one or more of the patient's
vital signs may indicate a change in general health. Variations may
suggest the presence or disappearance of a disease process and there-
fore may lead to alteration of the treatment plan. Although the
medical assistant obtains vital signs routinely, it is a task that requires
consistent attention to accuracy and detail. These findings are crucial
to a correct diagnosis, and vital signs should never be measured with
indifference or casualness. In addition to performing accurate mea-
surement, care must be taken when charting the findings in the
patient's health record.
The vital signs are the patient's temperature, pulse, respiration,
and blood pressure. These four signs are abbreviated TPR and BP
and may be referred to as cardinal signs. The medical assistant must
ot1t1s externa Inflammation or infection of the external auditory
canal; commonly called swimmer's ear.
peripheral (puh-rif' -er-uhl) A term that refers to an area outside
of or away from an organ or structure.
pulse deficit A condition in which the radial pulse is less than the
apical pulse; it may indicate a peripheral vascular abnormality.
pulse pressure The difference between the systolic and diastolic
blood pressures (30 to 50 mm Hg is considered normal).
pyrexia (pi-rek'-see-uh) A febrile condition or fever.
rales Abnormal or crackling breath sounds during inspiration.
rhonchi (ron'-ki) Abnormal rumbling sounds on expiration that
indicate airway obstruction by thick secretions or spasms.
secondary hypertension Elevated blood pressure resulting from
another condition, typically kidney disease.
sinus arrhythmia An irregular heartbeat that originates in the
sinoatrial node (pacemaker).
spirometer An instrument that measures the volume of air
inhaled and exhaled.
stertorous (stuh-tuh' -rus) A term that describes a strenuous
respiratory effort marked by a snoring sound.
syncope (sing'-kuh-pee) Fainting; a brieflapse in consciousness.
tachycardia (tak-i-kahr'-dee-uh) A rapid but regular heart rate;
one that exceeds 100 beats per minute.
tachypnea (tak-ip-nee'-uh) A condition marked by rapid, shallow
respirations.
thready A term describing a pulse that is scarcely perceptible.
wheezing A high-pitched sound heard on expiration; it indicates
obstruction or narrowing of respiratory passages.
understand the significance of the vital signs and must measure and
record them accurately. Anthropometric measurements are not consid-
ered vital signs but usually are obtained at the same time as vital
signs. These measurements include height, weight, body mass index
(BMI), and other body measurements, such as fat composition and
an infant's head circumference.
FACTORS THAT MAY INFLUENCE VITAL SIGNS
Vital signs are influenced by many factors, both physical and emo-
tional. A patient may have had a hot or cold beverage just before
the examination or may be anxious or fearful about what the pro-
vider may find. For example, consider that a patient has been asked
to return to have a repeat Papanicolaou (Pap) test because the first
one showed the presence of suspicious cells. The medical assistant
measures the patient's blood pressure and finds it significantly ele-
vated compared with previous readings. The patient may be anxious
and apprehensive about the test results, and the elevated blood pres-
sure readings reflect her anxiety.
What temperature reading might be expected in a patient who
could not find a parking place and had to walk four blocks to the

office, knowing he would be late for his appointment? If you said it
would be elevated, you are right. Certainly, this patient's metabolism
would increase because of the physical exercise, and as a result, his
temperature would be elevated, along with his pulse, respirations,
and blood pressure.
Vital signs are often altered if the patient is in pain. Pay attention
to nonverbal signs that might indicate discomfort or pain, especially
if the patient's blood pressure, pulse, and respirations are elevated.
In addition, many patients are apprehensive about being seen by the
provider. These emotions may alter vital signs, and the medical
assistant must help the patient relax before taking any readings.
Measurements sometimes must be obtained a second time, after the
patient is calmer or more comfortable. For a better picture of the
patient's vital signs, the medical assistant may be asked to record
the vital signs twice: at the beginning of the visit and just before the
patient leaves the examination room.
TEMPERATURE
Physiology
Body temperature is defined as the balance between heat lost and heat
produced by the body. It is measured in degrees Fahrenheit (F) or
degrees Celsius (C). The process of chemical and physical change in
the body that produces heat is called metabolism. Body temperature
is a result of this process. The core body temperature is maintained
within a normal range by the thermoregulatory center in the hypo-
thalamus. The average body temperature varies from person to
person and is different in each person at different times throughout
the day. In a healthy adult, this diurnal rhythm varies from 97.6°to
99° F (36.4° to 37.2° C); the average daily temperature is 98.6° F
(37°C). Body temperature is lowest in the morning and highest in
the late afternoon. Factors that may affect body temperature include
the following:
• Age: The body temperature of infants and young children
fluctuates more rapidly in response to external environmental
temperatures. Teething may cause a slight elevation in tem-
perature but should not be the cause of a fever. Aging adults
lose their ability to respond therapeutically to environmental
temperature extremes, making them more susceptible to
hypothermic or hyperthermic reactions.
• Stress and physical activity: Both exercise and emotional stress
can increase the metabolic rate, causing an elevation in
temperature.
• Gender: Hormone secretions result in fluctuations of the
core body temperature in women throughout the menstrual
cycle.
• External factors: Smoking, drinking hot fluids, and chewing
gum can temporarily elevate an oral temperature.
In illness, an individual's metabolic activity is increased; this
causes an increase in internal heat production, which in turn raises
the body temperature. The increase in body temperature is thought
to be the body's defensive reaction because heat inhibits the growth
of some bacteria and viruses.
When a fever is present, superficial blood vessels (those near the
surface of the skin) constrict. The small papillary muscles at the base
of hair follicles also constrict, creating goose bumps. Chills and
shivering may follow, producing internal heat. As this process repeats
CHAPTER 7 Vital Signs 143
itself, more heat is produced, and the body temperature becomes
elevated or rises above the normal range. When more heat is lost
than is produced, the opposite effect occurs, and body temperature
drops below normal range.
Fever
Infection, either bacterial or viral, is the most common cause of fever
in both children and adults.
Infants do not usually develop febrile illnesses during the first 3
months of life; if one is present, it usually is very serious. However,
fever, or pyrexia, is very common in young children and accounts
for an estimated 26% of office visits. Fevers are classified according
to the 24-hour pattern they follow. The three most common patterns
are:
• Continuous fever, which rises and falls only slightly during a
24-hour period. The temperature consistently remains above
the patient's average normal temperature range and fluctuates
less than 3 degrees.
• Intermittent fever, which comes and goes, alternating between
elevated and normal levels.
• Remittent fever, which fluctuates considerably (i.e., by more
than 3 degrees) and never returns to the normal range.
Variation from the patient's average body temperature range may
be the first warning of an illness or a change in the patient's current
condition. Patients with fever usually have loss of appetite (anorexia),
headache, thirst, flushed face, hot skin, and general malaise. Some
patients experience an acute onset of chills and shivering, followed
by an increase in body temperature. A serious possible complication
in young children with high fevers is a febrile seizure. Medication to
reduce the fever, or antipyretic drugs (e.g., acetaminophen or ibupro-
fen), should be taken as instructed to prevent dangerous spikes in
temperature. Age-related normal values for temperature readings are
shown in Table 7- 1.
Temperatures Considered Febrile
• Rectal, temporal, or aural (ear) temperature aver 100.4° F(38° ()
• Oral temperature aver 99 .5° F(37 .5° ()
• Axillary temperature aver 98.6 ° F(37° ()
• Fever of unknown origin (FUO): a temperature over 100. 9° F
(38.3° () that lasts 3 weeks in adults and 1 week in children without
a known related diagnosis
TABLE 7-1 Age-Related Temperature Norms
AGE FAHRENHEIT CELSIUS
Newborn (temporal) 98.2° 36.8°
1 year 99.7° 37.6°
6 years to adult (oral) 98.6° 37°
Elderly over age 70 (oral) 96.8° 36°
144 UNIT ONE INTRODUCTION TO MEDICAL ASSISTING

Temperature Readings
A clinical thermometer is used to measure body temperature. It is TABLE 7-2 Average Adult Temperatures
calibrated in the Fahrenheit or Celsius scale. The Fahrenheit scale is SITE FAHRENHEIT CELSIUS
used most often in the United States, but hospitals and many ambu-
latory care settings use the Celsius scale. Although you can use an Oral 98.6° 37°
online conversion scale or a program in an electronic health record Axillary 97.6° 36.4°
(EHR) system, the mathematical formulas for conversion from one
system to the other are: Tympanic 98.6° 37°
Temporal artery 98.6° 37°
~C=(°F-32)x2
9

°F=(0 cx~)+32

For example, if an infant's temperature is measured at 101 ° F, the Several types of thermometers and several different methods
Celsius conversion would be as follows (remember, always complete can be used to take temperature readings. A digital thermometer
the equation in parentheses first): is placed under the tongue, in the armpit, or rectally; a tympanic
°C = (101 °F- 32) X 2 thermometer is inserted into the ear; and a temporal artery
9 scanner is moved across the forehead. Average temperature
=69x2 values for adults at the four most common sites are shown in
9 Table 7-2.
=345+9 Axillary temperatures (A) are approximately 1° F (0.6° C) lower
=38.3°C than accurate oral readings because axillary readings are not taken
Another formula that can be used is: in an enclosed body cavity. When taken correctly, the tympanic (ear)
temperature (T) is an accurate measure because it records the tem-
°C = (°F - 32) + 1.8 perature of the blood closest to the hypothalamus. However, research
°C=(101-32)+1.8 on the temporal artery (TA) thermometer indicates that this method
= 69+1.8 is more accurate than tympanic measurement for identifying ele-
=38.3°C vated temperatures in infants. Pediatricians, therefore, may prefer TA
temperatures in infants suspected of having a fever. The TA ther-
If the ambulatory care setting where you work uses a Celsius mometer also records accurate temperature readings in all age groups
thermometer, patients may ask you what the temperature is in Fahr- of patients. The tympanic method still is considered a fast, accurate,
enheit degrees because that is the scale they understand. If the facility and noninvasive way of recording temperatures for older children
does not have a conversion chart available, you can convert the and adults.
temperature mathematically. For example, if an infant's temperature When obtaining an oral temperature, you do not have to indi-
is 39° C, what is the Fahrenheit reading? cate the site when documenting the reading in the patient's health
record. However, if you use an alternative site, you should write
°F=(0 cx~ )+32
(or put in the correct window in the EHR) the following identifi-
ers after recording the temperature: (T) for tympanic, (A) for axil-
= (39°C X ~) + 32
lary, or (TA) for temporal artery; this clarifies that an alternative
=(351+5)+32 site was used. The oral temperature cannot be measured accurately
=70.2+32 in young children because the technique requires the patient to
= 102.2°F hold the thermometer under the tongue and keep the mouth
closed. To take an infant's temperature rectally, lubricate the probe
Another formula that can be used is:
tip (most facilities use a lubricating product such as K-Y Jelly),
°F = (°C X 1.8) + 32 hold the baby securely with the legs elevated, and insert the probe
= (39 X 1.8)+ 32 approximately ½ inch; hold the probe carefully and continue to
=70.2+32 secure the infant's legs throughout the procedure to prevent rectal
damage. The red probe must be used when taking a rectal temper-
=102.2°F
ature with an electronic digital thermometer. However, most pedi-
atricians prefer that infants' temperatures be taken with a temporal
CRITICAL THINKING APPLICATION 7-1 thermometer because it is more comfortable for the baby, less
Using the correct formula, convert the following temperatures from one invasive, and eliminates the possible complication of a perforated
system to the other. rectum.
For patients older than 3 years and for those unable to hold a
99° F= - - - -° C 102° F= - - - -° C thermometer properly in their mouth during the procedure, a tym-
380( = °F 39.50(= °F panic or temporal thermometer can be used; if not, a less accurate
axillary temperature can be obtained.
 CHAPTER 7 Vital Signs 145

CRITICAL THINKING APPLICATION 7-2

The mother of a 3-year-old calls the office to report that her child had an
axillary temperature of l Ol ° Fat 9 o'clock this morning. The schedule is
very full today, so Carlos has to decide whether the child should be
seen today or first thing tomorrow. When should Carlos schedule
the appointment? What is the significance of the axillary temperature
reading?

Types of Thermometers and Their Uses

Digital Thermometer
Digital thermometers are battery operated and available in both
Fahrenheit and Celsius scales. Disposable covers fit snugly over the
probes and are easily and quickly removed by pushing in the colored
end of the probe. The instrument sounds a beep when the process
is complete (10 to 60 seconds), and the reading appears on a light-
emitting diode (LED) screen on the face of the instrument (Proce-
dure 7-1 ). Because the only part of the instrument that comes in
contact with the patient is the probe, which is sheathed, the risk of
cross-infection is greatly reduced (Figure 7-1 ). These thermometers
have a digital screen on which the temperature is read, and they
should always be covered by a disposable sheath and wiped with an
alcohol swab after use.
A temperature should not be taken orally if the patient recently FIGURE 7-1 Digital thermometer. (Courtesy Welch Allyn.)
has had something hot or cold to eat or drink or has just smoked
because these factors may artificially alter the patient's temperature.
In addition, the patient must be able to hold the thermometer under contaminate the probe or the processing unit. Both the probe shield
the tongue with the lips tightly sealed around the probe if an accurate and the thermometer sheath should be deposited directly into a
oral reading is to be obtained. The digital unit or individual digital biohazard waste container. If a chance exists that a patient's body
thermometers should be routinely cleaned with disinfectant. When fluids touched the unit, wipe it with disinfectant before returning it
ejecting the probe shield or removing the sheath, be careful not to to the storage area.

•;;m,ammfi • Obtain Vital Signs: Obtain an Oral Temperature Using a Digital Thermometer

Goal: To accurately determine and record apatient's temperature using adigital thermometer.

EQUIPMENT and SUPPLIES 2. Assemble the needed equipment and supplies.

• Patient's record 3. Identify your patient and explain the procedure. Make sure the patient has
• Digital thermometer not eaten, consumed any hot or cold fluids, smoked, or exercised during
• Probe covers the 30 minutes before the temperature is measured.
• Disposable gloves as appropriate PURPOSE: Identification of the patient prevents errors, and explanations are
• Biohazard waste container a means of gaining implied consent and patient cooperation. The tempera-
ture will be inaccurate if hot or cold food or fluids have been consumed or
PROCEDURAL STEPS if the patient has exercised within 30 minutes.
1. Sanitize your hands.
PURPOSE: To ensure infection control.
146 UNIT ONE INTRODUCTION TO MEDICAL ASSISTING

•;iill'91Umfii -continued
4. Prepare the probe for use as described in the package directions (Figure l).
Make sure probe covers are always used.
PURPOSE: To ensure infection control.

S. Place the probe under the patient's tongue (Figure 2) and instruct the
patient to close the mouth tightly without biting down on the thermometer.
Help the patient by holding the probe end, or the patient can hold the probe
end if that is more comfortable.
PURPOSE: Air seeping into the mouth interreres with an accurate body
temperature reading.
6. When a beep is heard, remove the probe from the patient's mouth and
immediately eject the probe caver into an appropriate biohazard waste
container.
PURPOSE: The probe caver is contaminated and must be discarded in a
biohazard waste container.
7. Note the reading in the LED window of the processing unit.
8. Record the reading in the patient's medical record (e.g., T-97.7° F).
PURPOSE: Procedures that are not recorded are considered not done.
9. Sanitize your hands and disinfect the equipment as indicated.
PURPOSE: To observe infection control measures and Standard
Precautions.

3/27/20- l 0:05 AM: T-97.7° F. C. Ricci, (MA (AAMA)

Tympanic Thermometer
The tympanic membrane of the ear can be used for quick, accurate,
and safe assessment of a patient's temperature. It shares the blood
supply that reaches the hypothalamus, which is the brain's tempera-
ture regulator. The ear canal is a protected cavity, so aural tempera-
ture is not affected by factors such as an open mouth, hot or cold
drinks, or even a stuffy nose, which would prevent a patient from
keeping the mouth closed during the procedure. In addition, the
covered probe is designed to bounce an infrared signal off the
eardrum without touching it, so the risk of spreading communicable
diseases during temperature measurement is greatly reduced.
The tympanic measurement system consists of a handheld proces-
sor unit equipped with a tympanic probe, which is covered with a
disposable speculum for use (Figure 7-2).When the probe is placed
into the ear canal, it gently seals the external opening of the canal, FIGURE 7-2 Tympanic thermometer.
and the infrared energy emitted by the tympanic membrane is gath-
ered. This signal is digitized by the processor unit and shown on the
display screen. Accurate readings are obtained in less than 2 seconds
 CHAPTER 7 Vital Signs 147

(Procedure 7-2). Both the speed of the tympanic thermometer and
the comfort it affords the patient have greatly influenced its popular-
ity. However, this unit should not be used if the patient is complain-
ing of pain in both ears when the ear is touched because he or she
may have bilateral otitis externa, and the procedure would be
uncomfortable for the patient. In addition, if the patient has a
history of or has been diagnosed with impacted cerumen in both
ears, do not use a tympanic thermometer because the reading may
be inaccurate.
Insert the probe into the ear canal far enough to seal the opening
without applying pressure. To expose the tympanic membrane in
children younger than age 3, gently pull the earlobe down and back;
for patients older than age 3, gently pull the pinna (top of the ear)
up and back. When using a tympanic thermometer on a small child,
be conscious of what the child touches. If the processing unit is
touched, be sure to wipe it with disinfectant after use. See the manu-
facturer's manual for cleaning the probe tip. Many recommend
cleaning the probe lens with alcohol wipes.

•;;m;immfli Obtain Vital Signs: Obtain an Aural Temperature Using the Tympanic Thermometer

Goal: To accurately determine and record apatient's temperature using atympanic thermometer.

EQUIPMENT and SUPPLIES 6. Insert the probe into the ear canal far enough to seal the opening. Do not
• Patient's record apply pressure. For children younger than age 3, gently pull the earlobe
• Tympanic thermometer dawn and back (Figure 2); far patients alder than age 3, gently pull the
• Disposable probe cavers top of the ear (pinna) up and back (Figure 3).
• Disposable gloves as appropriate PURPOSE: The external ear must be pulled gently to open the external
• Alcohol wipes auditory canal and expose the tympanic membrane for an accurate
• Biohazard waste container reading.

PROCEDURAL STEPS
1. Sanitize your hands.
PURPOSE: To ensure infection control.
2. Gather the necessary equipment and supplies.
3. Identify the patient and explain the procedure.
PURPOSE: Identification af the patient prevents errors, and explanations
are a means af gaining implied consent and patient cooperation.
4. Clean the probe with an alcohol wipe if indicated. Place a disposable caver
on the probe (Figure l).
PURPOSE: To ensure a clean surface and prevent crass-contamination.

S. Follow the package directions to start the thermometer.

148 UNIT ONE INTRODUCTION TO MEDICAL ASSISTING

•;;m!,mj;jfil -continued

7. Press the button on the probe as directed. The temperature will appear 10. Record the temperature results (e.g., T-98.6 ° F[TI) in the patient's health
on the display screen in l to 2 seconds. record.
8. Remove the probe, note the reading, and discard the probe caver into a PURPOSE: Procedures that are not recorded are considered not done.
biohazard waste container without touching it.
PURPOSE: The probe cover is contaminated and must be discarded in a 3/30/20-2:20 PM: T-10l.2°F (T). C. Ricci, CMA (MMA)
biohazard waste container.
9. Sanitize your hands and disinfect the equipment if indicated. See the
manufacturer's manual for cleaning the probe tip. Many recommend
cleaning the probe lens with alcohol wipes.
PURPOSE: To ensure infection control.

Temporal Artery Scanner the facility's infection control procedures, disposable covers can be
The temporal artery scanner uses an infrared beam to assess the used on the scanner or it can be deaned between patients with an
temperature of the blood flowing through the temporal artery of alcohol wipe.
the lateral forehead, where the artery lies about 1 mm below the
skin (Figure 7-3). Because the artery is so dose to the skin, it pro-
vides good surface heat conduction, allowing the thermometer to
obtain a fast, accurate, and noninvasive measurement of body tem-
perature. To perform the procedure, place the probe in the center
of the forehead, halfway between the eyebrows and the hairline.
Bangs should be pushed back off the forehead (this method cannot
be used if bandages cover the area). Depress the button on the
scanner and gently stroke the probe across the forehead toward the
hairline {at the temples), keeping the probe flat on the patient's
skin. As the scanner moves across the forehead, repeated tempera-
ture measurements are taken and the highest measurement is
recorded; keeping the button depressed, lift the scanner from the
temporal area and lightly place the probe behind the earlobe.
Release the button and remove the probe. Recording an accurate
temperature takes about 3 seconds (Procedure 7-3). Depending on FIGURE 7-3 Professional temporal artery scanner.

•;;m,am1;jfi• Obtain Vital Signs: Obtain a Temporal Artery Temperature

Goal: To accurately determine and record apatient's temperature using atemporal artery scanner.
EQUIPMENT and SUPPLIES 3. Introduce yourself, identify your patient, and explain the procedure.
• Patient's record PURPOSE: Identification of the patient prevents errors, and explanations
• Professional temporal artery thermometer with probe covers are a means of gaining implied consent and patient cooperation.
• Alcohol swabs 4. Remove the protective cap on the probe. Depending on the facility's
• Biohazard waste container infection control procedures, disposable covers can be used on the scanner,
or it can be cleaned by lightly wiping the surface with an alcohol swab.
PURPOSE: To ensure infection control.
PROCEDURAL STEPS S. Push the patient's hair up off the forehead to expose the site. Gently place
1. Sanitize your hands. the probe on the patient's forehead, halfway between the edge of the
PURPOSE: To ensure infection control. eyebrows and the hairline.
2. Gather the necessary equipment and supplies. PURPOSE: This places the probe directly over the temporal artery.

•;;m,ammfi• -continued
6. Depress and hold the SCAN button and lightly glide the probe sideways
across the patient's forehead to the hairline just above the ear (Figure l).
As you move the sensor across the forehead, you will hear a beep, and
a red light will flash.
PURPOSE: This verifies that the scanner is recording temperatures as it
moves across the surface of the temporal artery.
Axillary Thermometer
Studies indicate that axillary temperatures are accurate when per-
formed correctly. Axillary temperatures take more time to register
the correct body temperature, but the method is safe, simple,
and easy to perform (Procedure 7-4). Axillary temperatures
are taken with a digital thermometer, which is placed into the axil-
lary fold. If the digital thermometer has more than one probe, the
CHAPTER 7 Vital Signs 149
7. Keeping the button depressed, lift the thermometer, and place the probe
behind the ear lobe (Figure 2). The thermometer may continue to beep,
indicating that the temperature is rising.
PURPOSE: To continue scanning of the temporal artery until the highest
temperature is recorded on the thermometer.
8. When scanning is complete, release the button and lift the probe. Note
the temperature recorded on the digital display. The scanner automatically
turns off 15 to 30 seconds after release of the button.
9. If a probe cover was used, eject it directly into a biohazard waste container.
Disinfect the thermometer if indicated and replace the protective cap.
PURPOSE: To ensure infection control. Depending on the facility's infection
control procedures, disposable covers can be used on the scanner, or it
can be cleaned between patients with a disinfectant wipe.
10. Sanitize your hands.
11. Record the temperature results (e.g., T- l 01.6 ° F[TA]) in the patient's
health record.
PURPOSE: Procedures that are not recorded are considered not done.
oral (blue) probe with a disposable probe cover should be
used. Because tympanic and temporal thermometers are relatively
expensive, the axillary method may be a viable way for parents
of young children to get accurate temperature readings at home.
However, parents should be aware that the axillary tempera-
ture may be as much as 1° less than the child's actual core
temperature.
150 UNIT ONE INTRODUCTION TO MEDICAL ASSISTING
•;;m,ammfj• Obtain Vital Signs: Obtain an Axillary Temperature
Goal: To accurately determine and record apatient's temperature using the axillary method.
EQUIPMENT and SUPPLIES
• Patient's record
• Digital unit
• Thermometer sheath or probe cover
• Supply of tissues
• Disposable gloves as appropriate
• Patient gown as needed
• Biohazard waste container
PROCEDURAL STEPS
1. Sanitize your hands.
PURPOSE: To ensure infection control.
2. Gather the needed equipment and supplies.
3. Introduce yourself, identify your patient, and explain the procedure.
PURPOSE: Identification of the patient prevents errors, and explanations
are a means of gaining implied consent and patient cooperation.
4. Prepare the thermometer or digital unit in the same manner as far oral
use.
S. Expose the axillary region. If necessary provide the patient with a gown
far privacy.
6. Pat the patient's axillary area dry with tissues if needed.
PURPOSE: To ensure an accurate reading. Do not rub the area because
this may cause an elevated reading.
7. Cover the thermometer or probe and place the tip into the center of the
armpit, pointing the stem toward the upper chest, and making sure the
thermometer is touching only skin, not clothing.
PURPOSE: To obtain the mast accurate axillary reading; contact with
clothing alters the reading.
Disposable Thermometer
Disposable thermometers (those that are used only once) may be
used on small children in the home. The reading is obtained by a
heat-sensitive material that changes color according to the elevation
of body temperature. Two types of disposable thermometers fre-
quently are used by parents of young children. One type is placed
under the child's tongue (Figure 7-4); the other is placed on the
forehead. Although both types are fairly reliable, the temperature-
sensing materials have expiration dates, which often are overlooked,
and specific storage requirements may apply. Disposable thermom-
eters are considered to be good screening devices but are not as
accurate as other methods. If you are instructing a parent in the use
of a disposable thermometer at home, be sure to emphasize that it
should be discarded immediately in a childproof container.
PULSE
A patient's pulse rate reflects the palpable beat of the arteries through-
out the body as they expand in response to contraction of the heart.
8. Instruct the patient to hold the arm snugly across the chest or abdomen
until the thermometer beeps (Figure l).
PURPOSE: To prevent air from leaking in and interfering with the tempera-
ture reading.
9. Remove the thermometer, note the digital reading, and dispose of the
cover in the biohazard waste container.
1O. Disinfect the thermometer if indicated.
PURPOSE: To ensure infection control.
11. Sanitize your hands.
12. Record the axillary temperature in the patient's health record (e.g.,
T-97 .6 ° F[A]).
PURPOSE: Procedures that are not recorded are considered not done.
4/2/20- 9:30 AM: T-98.2° F(A). C. Ricci, CMA (MMA)
CRITICAL THINKING APPLICATION 7-3
How should the medical assistant adapt temperature-taking techniques in
the fallowing scenarios?
• Patient who talks continuously with the thermometer in his mouth
• 7-year-old patient with bilateral otitis extern•
• 3-month-old patient when a temporal artery thermometer is available
• 46-year-old patient with a severe asthma attack
• 72-year-old patient with bilateral impacted cerumen
• 28-year-old patient who has just smoked a cigarette
With every beat, the heart pumps an amount of blood, known as
the stroke volume, into the aorta. Arteries branch off the aorta as it
travels down through the center of the abdomen, transferring the
pulse beat throughout the body. To measure the pulse, an artery is
used that is close to the body surface and can be pushed against a
bone. Palpating a peripheral pulse gives the rate and rhythm of the
heartbeat and local information about the condition of the artery
used.
 CHAPTER 7 Vital Signs 151

~.........
..... ......
. .•...~o•~•:.
,.
_.. Temporal
~
-~.....

FIGURE 7-4 Tempo-Dot disposable oral strip thermometer. (Courtesy Tempo-Dot, Somerville, NJ.)

Brachia!

Pulse Sites
A pulse rate may be counted anyplace an artery is near the surface
of the body and the vessel can be pressed against a bone. The most
Radial
common pulse sites are the temporal, carotid, apical, brachia!, radial,
femoral, popliteal, and dorsalis pedis arteries (Figure 7-5).
The temporal pulse is located in the temple area of the skull, paral-
lel and lateral to the eyes (Figure 7-6). It is seldom used as a pulse
site but may be used as a pressure point to help control bleeding
from a head injury.
The carotid artery is located between the larynx and the sterno-
cleidomastoid muscle in the front and to the side of the neck
(Figure 7 -7). It most frequently is used in emergencies and to check
the pulse during cardiopulmonary resuscitation (CPR). It can be
felt by pushing the muscle to the side and pressing against the
larynx.
The apical heart rate, or the heartbeat at the apex of the heart, is
heard with a stethoscope. It is used for infants and young children
because the radial pulse is difficult to palpate in young patients.
Apical rates are also recorded on adult patients who have irregular
or difficult to feel radial pulses just to make sure you are recording
an accurate heart rate. An apical count may be requested if the
patient is taking cardiac drugs or has bradycardia or tachycardia.
To determine the presence of a pulse deficit, the provider may listen
to the apical beat while the medical assistant counts the pulse at
another site (usually the radial pulse). The stethoscope is placed at
the apex of the heart which is located in the lefr fifth intercostal space FIGURE 7-5 Pulse sites.
on the midclavicular line, that is, between the fifth and sixth ribs on
a line with the midpoint of the left clavicle. The pulse should be
counted for 1 full minute and should be documented with (AP) The popliteal pulse is found at the back of the leg behind the
beside the recorded count (Procedure 7-5). knee. Palpation of this pulse requires the patient to be in a recumbent
The brachia! pulse is felt at the inner (antecubital) aspect of the position with the knee slightly flexed. The popliteal artery is deep
elbow. This is the artery that is felt and heard when blood pressure and difficult to feel. It is palpated and also monitored with a stetho-
is measured (Figure 7-8). It also can be felt in the groove between scope when a leg blood pressure reading is necessary. The provider
the biceps and triceps muscles on the inner surface of the middle checks blood flow through the popliteal artery if a circulatory system
upper arm. This is the pulse that is checked on infants and young problem, such as a blood clot, is suspected in the lower leg.
children receiving CPR. The dorsalis pedis (pedal) artery is felt across the arch of the foot,
The radial artery is the most frequently used site for counting the just slightly lateral to the midline, beside the extensor tendon of the
pulse rate. It is best found on the thumb side of the wrist, 1 inch great toe. This pulse may be congenitally absent in some patients.
below the base of the thumb (Figure 7-9). Because a good pulse rate at this site is an indicator of normal lower
The femoral pulse is located at the site where the femoral artery limb circulation and arterial sufficiency, the provider checks the
passes through the groin. The examiner must press deeply below the pedal pulses in patients with peripheral vascular problems, such as
inguinal ligament to palpate this pulse. patients with diabetes mellitus.
152 UNIT ONE INTRODUCTION TO MEDICAL ASSISTING

FIGURE 7-8 Brachia! pulse.

FIGURE 7-6 Temporal pulse.

FIGURE 7-7 Carotid pulse.

FIGURE 7-9 Radial pulse.

•;;m,ammfii Obtain Vital Signs: Obtain an Apical Pulse

Goal: To accurately determine and record the patient's apical heart rate.

EQUIPMENT and SUPPLIES 2. Introduce yourself, identify your patient, and explain the procedure.
• Patient's record PURPOSE: Identification of the patient prevents errors, and explanations
• Watch with a second hand are a means of gaining implied consent and patient cooperation.
• Patient gown as needed 3. If necessary, assist the patient in disrobing from the waist up and provide
• Stethoscope the patient with a gown that opens in the front.
• Alcohol wipes PURPOSE: To expose the chest and provide privacy and warmth.
4. Assist the patient into the sitting or supine position.
PROCEDURAL STEPS PURPOSE: To allow easier access to the apical site at the apex of the
1. Sanitize your hands and clean the stethoscope earpieces and diaphragm heart.
with alcohol swabs. S. Hald the stethoscope's diaphragm against the palm of your hand for a
PURPOSE: To ensure infection control and to follow Standard few seconds.
Precautions. PURPOSE: To warm the diaphragm, promoting patient comfort.

•;;m,ammfii -continued
6. Place the stethoscope at the left midclavicular line in the intercostal space
between the fifth and sixth ribs over the apex of the heart (Figures l and
2). Do not touch the bell end of the stethoscope.
PURPOSE: This is the point of maximum contractile strength, where the
heartbeat can be heard best. Touching the bell end of the stethoscope
may interfere with the sound.
Characteristics of a Pulse
When measuring a pulse, you must note three important character-
istics: rate, rhythm, and volume. These characteristics vary with the
size and elasticity of the artery and the strength and regularity of the
heart's contractions. A patient's pulse may reveal valuable informa-
tion about the cardiovascular system.
Rate
The pulse rate is a measure of the number of heartbeats felt from
the movement of blood through an artery. When the heart contracts,
pressure throughout the arteries is increased, and the arteries expand.
When the heart relaxes, arterial pressure is decreased, and the arteries
relax. Each contraction and relaxation of the heart muscle is a heart-
beat, and each resulting expansion and relaxation of the arteries is
the pulse rate. Normally, the heartbeat (rate) and the pulse rate are
the same. The rate of the pulse is the number of heartbeats (pulsa-
tions) that occur in 1 minute. Because the body must balance heat
loss by increasing circulation (a faster heart rate), the pulse rate is
proportionate to the size of the heart. The smaller the body, the
greater the heat loss and the faster the heart must pump to compen-
sate. Therefore, infants and children normally have a faster pulse
than adults; as aging progresses, the pulse rate declines.
CHAPTER 7 Vital Signs 153
7. Listen carefully for the heartbeat.
8. Count the pulse for l full minute. Nate any irregularities in rhythm and
volume.
PURPOSE: The apical pulse is always measured for l full minute to obtain
the most accurate reading.
9. Help the patient sit up and dress.
10. Disinfect the head of the stethoscope with an alcohol wipe.
PURPOSE: To ensure infection control.
11. Sanitize your hands.
12. Record the pulse in the patient's health record (e.g., AP· 96) and record
any arrhythmias.
4/22/20- 4: l OPM: AP-92 irregular. C. Ricci, CMA (AAMA)
Pulse rates normally vary as a result of a person's age, body size,
gender, and health status. The rate is affected by an individual's
activities and psychological state, and by certain medications. It
usually is faster in women (70 to 80 beats per minute) than in men
(60 to 70 beats per minute). Children tend to have more rapid pulse
rates than adults. The rate is more rapid when a person is sitting
than when he or she is lying down, and it increases when an indi-
vidual stands, walks, or runs. During sleep or rest, the pulse rate may
drop to as low as 45 to 50 beats per minute. Well-conditioned ath-
letes tend to have pulse rates of 50 to 60 beats per minute because
consistent aerobic exercise strengthens the heart muscle (the myo-
cardium) so that each heart contraction ejects an increased volume
of blood into the arterial system. Table 7-3 lists the normal pulse
ranges for various age groups of patients.
Rhythm
The pulse rhythm is the time between pulse beats. A normal rhythm
pattern has an even tempo, which indicates that the intervals between
the beats are of equal duration. An abnormal rhythm, or arrhyth-
mia, is described according to the rhythm pattern detected. An
intermittent pulse may occur in healthy individuals during exercise
or after drinking a beverage containing caffeine. A common
154 UNIT ONE INTRODUCTION TO MEDICAL ASSISTING

rate; the thumb has its own pulse, and your pulse rate may be con-
TABLE 7-3 Approximate Age-Related Pulse fused with the patient's rate. Push the radial artery against the bone
Ranges until the strongest pulsation is felt. The pulse should be counted for
1 full minute. A 15- or 30-second interval may be used once you
RANGE
become proficient at performing the skill.
AGE (beats/min) AVERAGE Variations from normal quality should be noted, such as an
Newborn 120-160 140 arrhythmia or a pulse that is thready or bounding. Some pulses are
more difficult to feel than others, and finding the correct pressure
1-2 years 80-140 120 to be used for each patient and site requires repeated practice and
3-6 years 75-120 100 experience.
Both you and the patient should be in a relaxed position. Too
7-11 years 75-110 95 much pressure obliterates the patient's pulse, and too little pressure
Adolescence to adulthood 60-100 80 prevents detection of irregularities or of all the beats. Record the
number of beats in 1 minute. Assess the pulse, including rate,
rhythm, and volume. If the pulse rate is counted at any site other
than the radial artery, the rate should be recorded along with a nota-
irregularity found in children and young adults is sinus arrhythmia, tion of the site used. The apical pulse should always be auscultated
in which the heart rate varies with the respiratory cycle, speeding up for a full minute to detect any irregularities in rate and rhythm.
at the peak of inspiration and slowing to normal with expiration. If Remember, one reason you would decide to take an apical pulse on
beats are frequently skipped or if the beats are markedly irregular, an adult patient is that you noted irregularities in the heart rate when
the provider should be advised, because this may indicate heart palpating the radial pulse. Therefore, you should listen to an apical
disease. If an irregular rhythm is detected, the apical pulse should pulse for a full minute to make sure you are accurately counting the
be measured for a full minute to ensure accuracy, and the rate should number of heartbeats per minute.
be recorded for the provider's review. A note also should be made
that the patient's pulse was irregular. For example: P-86 irregular.

CRITICAL THINKING APPLICATION 7-4

Volume
The volume (pulse amplitude) reflects the strength of the heart when
it contracts. Volume can be assessed by feeling the strength of the
pulse as blood flows through the vessel. The force of each pulse beat
is described as bounding, or full; strong, or normal; or thready, or
weak. The force of the heartbeat and the condition of the arterial
wall (whether hard or soft) influence the volume. The pulse may vary
only in intensity and otherwise may be perfectly regular. This condi-
tion also can indicate heart disease. The pulse volume is recorded
using a three-point scale.
Three-Point Scale for Measuring Pulse Volume
Mrs. Arnez has a documented thready pulse. What site should Carlos use
to measure the pulse? Why should he listen to the pulse for afull minute?
Femoral, Pop/iteal, and Pedal Pulses
Pulses in the lower extremities may be difficult to find and equally
difficult to hear. A Doppler unit, which is an ultrasound unit that
magnifies the pulsation, may be used to locate and count these pulses
accurately (Figure 7-10). A Doppler unit is battery operated and can
be attached to a stethoscope so that only the provider can hear the
beat, or it can be set so that both the provider and the patient can
hear the pulsations.

3+ Full, bounding Pulsation is very strong and does not

pulse disappear with moderate pressure.
2+ Normal pulse Pulsation is easily felt but disappears with
moderate pressure.
l+ Weak, thready Pulsation is not easily felt and disappears
pulse with slight pressure.

Determining the Pulse Rate

Radial and Apical Pulse Rates
To record an accurate radial pulse, you must have the patient in a
comfortable position with the artery to be used at the same level as
or lower than the heart (Procedure 7-6). The limb should be well
supported and relaxed. The patient may be lying down or sitting. As
with all pulse readings, the pads of the first two or three fingers are FIGURE 7-10 Doppler ultrasound unit measuring the pedal pulse. (From Jarvis (: Physical
placed over the artery. Never use your thumb to determine the pulse examination and health assessment, ed 7, St Louis, 2016, Saunders.)
 CHAPTER 7 Vital Signs 155

RESPIRATION

-
Physiology
The purpose of respiration is to provide for the exchange of oxygen Normal
and carbon dioxide among the atmosphere, the blood, and the Hyperventilation
body cells. Oxygen is taken into the body to be used for life-
sustaining body processes, and carbon dioxide is released as a waste
product.
One complete inspiration and expiration is called a respiration. Bradypnea
During the inspiratory phase, the diaphragm contracts and drops
Periodic
down and the intercostal muscles pull the ribs up and outward; this
causes the lungs to expand and fill with air. During the expiratory
phase, the diaphragm returns to its normal elevated position and the Tachypnea
intercostal muscles relax; this causes the lungs to expel the waste air
back into the atmosphere. Sighing
Respiration is both internal and external. External respiration is Forced rapid
the exchange of oxygen and carbon dioxide in the lungs. Internal res pi ration

respiration occurs at the cellular level, when oxygen in the blood-

Trapping
stream is transferred into the cells for energy, and carbon dioxide is
released as a waste product and transported back to the lungs for FIGURE 7-11 Respiratory rate patterns, called spirograms, are recorded using a spirometer.
exhalation.
The respiratory center in the medulla oblongata, located in the
brain between the top of the spine and the brainstem, is sensitive to
changes in blood oxygen and carbon dioxide levels. When blood TABLE 7-4 Approximate Age-Related Respiration
carbon dioxide levels become elevated, the respiratory control center Ranges
sends a message to the respiratory system that triggers breathing.
Respiration, therefore, is controlled by the involuntary nervous RANGE
system; this means that we breathe automatically. Because a person AGE (breaths/min) AVERAGE
can control respiration to a certain extent, it also is a voluntary body Newborn 30-50 40
function. However, breathing ultimately is under the control of the
medulla oblongata, which is why we can hold our breath only for a 1-3 years 20-30 25
given length of time. Once the blood's carbon dioxide level rises to 4-6 years 18-26 22
the point where cells become oxygen starved, a stimulus is sent to
the respiratory muscles (the diaphragm and intercostal muscles) and 7-11 years 16-22 19
breathing begins involuntarily.
Adolescence to adulthood 12-20 16
Characteristics of Respirations
Normally, a person's breathing is relaxed, automatic, and silent.
However, respiratory disease or chronic conditions can influence the • Rhythm: Rhythm refers to the breathing pattern. A regular breath-
characteristics of an individual's respirations. Dyspnea occurs in ing pattern is normal in adults; however, the breathing pattern
patients with pneumonia, asthma, or chronic obstructive pulmo- for infants varies. Automatic interruptions, such as sighing, are
nary disease (COPD). It also occurs after physical exertion or at also considered normal.
very high altitudes. Other alterations in breathing are bradypnea, • Depth: The depth of respiration is the amount of air inhaled and
apnea, tachypnea, and hyperpnea. Hyperpnea usually is accompa- exhaled. When a patient is at rest, normal respirations have a
nied by hyperventilation and often occurs when the patient is consistent depth, which can be noted as you watch the rise and
extremely anxious or in pain. Orthopnea frequently occurs in fall of the chest. Rapid, shallow breathing at rest occurs with some
patients with congestive heart failure (CHF) and COPD. Wheezing diseases, such as asthma and emphysema. An alteration in the
signals difficulty breathing in patients with asthma. depth and sometimes the rate of breathing is also seen in Cheyne-
When assessing a patient's respirations, you must note three Stokes respirations.
important characteristics: rate, rhythm, and depth. Normally, no noticeable breath sounds occur during the breath-
• Rate: The rate of respiration is the number of respirations per ing process, except during snoring. Noticeable breath sounds are a
minute and is described as normal, rapid, or slow. Figure 7-11 sign of certain diseases, such as pneumonia, asthma, and pulmonary
shows sample rate patterns recorded with a spirometer. Typically, edema. After auscultating breath sounds with a stethoscope, the
a ratio of four pulse beats to one respiration is seen. As a rule, provider can describe the characteristics of breath sounds by using
both the pulse and respiratory rates respond to exercise or emo- specific terminology (e.g., rales, rhonchi, stertorous breathing).
tional upset. Table 7-4 lists normal respiratory ranges for patients When an individual cannot inspire enough oxygen to supply all
in various age groups. body cells with oxygenated blood, normal skin coloring, particularly
156 UNIT ONE INTRODUCTION TO MEDICAL ASSISTING

around the mouth and the nail beds, changes to a bluish, dusky
color. This coloration, which indicates an increased level of carbon
dioxide in the blood, is called cyanosis. The patient also may have
other signs and symptoms, such as vertigo, chest pain (angina), and
numbness in the fingers and toes.

Counting Respirations
Because most people are unaware of their breathing, do not mention
that you will be counting the person's respirations (see Procedure
7-6). The respiratory rate is easily controlled, and patients self-con-
sciously alter their breathing rate when they know they are being
watched. Therefore, count the respirations while appearing to count
the radial pulse. Keep your eyes alternately on the patient's chest and
your watch while you count the pulse rate; then, without removing
your fingers from the pulse site, determine the respiratory rate FIGURE 7-12 Hand position when counting respirations. The hands should be left in place as if
(Figure 7-12). If the patient is supine, the arm on which you are still counting the patient's pulse.
taking the radial pulse may be crossed over the chest so that respira-
tions can be felt with the rise and fall of the chest. Another way of
observing respirations is to watch the movement of the patient's
shoulders with each inspiration. Count the respirations for 30
seconds and multiply the number by 2. Do not use the 15-second CRITICAL THINKING APPLICATION 7-5
interval because this count can vary by a factor of ±4, which is Tina Anderson, a 36-year-old patient who is obese, is wearing a heavy knit
significant when dealing with such a small number. Note any varia- sweater, and Carlos needs to obtain a respiratory count. What could he do
tion or irregularity in the rate. Record the respiratory count in the
to obtain an accurate measurement of Tina's respiratory rate?
health record.

•;;m!,mmf11 Obtain Vital Signs: Assess the Patient's Radial Pulse and Respiratory Rate

Goal: To accurately determine and record apatient's radial pulse rate and rhythm and respiratory rate.
Note: Respirations should be assessed immediately after the radial pulse while the medical assistant is appearing to take the
pulse so the patient does not artificially alter breathing patterns.

EQUIPMENT and SUPPLIES

• Patient's record
• Watch with a second hand
PROCEDURAL STEPS
1. Sanitize your hands.
PURPOSE: To ensure infection control.
2. Introduce yourself, identify your patient, and explain the procedure.
PURPOSE: Identification of the patient prevents errors, and explanations
are a means of gaining implied consent and patient cooperation.
3. Place the patient's arm in a relaxed position, palm at or below the level
of the heart.
PURPOSE: The patient's radial artery is more easily palpated when the
patient is relaxed and in this position.
4. Gently grasp the palm side of the patient's wrist with your first two or three S. Count the beats for 1 full minute using a watch with a second hand.
fingertips approximately 1 inch below the base of the thumb (Figure 1). PURPOSE: Counting for 1 full minute allows you to obtain an accurate
PURPOSE: This position puts your fingertips directly over the radial artery. count, including any irregularities in rhythm and volume. Once you become
Press firmly (but do not press too hard, or you will occlude the artery and more adept at taking a pulse, you can reduce this to 30 seconds and
feel nothing). multiply that number by 2 to record the patient's heart rate.

I; ;m,am);Jf11 -,JOntinued
6. While continuing to hold the patient's arm in the same position used to
count the radial pulse, observe the rise and fall of the patient's chest (see
Figure 7-12). If you have difficulty noticing the patient's breathing, place
the arm across the chest ta detect movement.
PURPOSE: The respiratory count may be altered if the patient is aware
that you are counting his or her breaths; placing the arm across the chest
allows you to feel or see the rise and fall of the chest wall.
7. Inspiration and expiration make up one complete breathing cycle or respira-
tion. Count the respirations for 30 seconds and multiply by 2.
PURPOSE: Counting for 30 seconds allows you to obtain an accurate count
and determine any irregularities in rhythm or depth or unusual breathing
patterns. If respirations are abnormal in any way, count for l full minute.
BLOOD PRESSURE
The blood pressure reading reflects the pressure of the blood against
the walls of the arteries. Each time the ventricles contract, blood is
pushed out of the heart and into the aorta, exerting pressure on the
walls of the arteries. There are actually two blood pressure readings:
the systolic pressure is the highest pressure level that occurs when the
heart is contracting and the first pulse beat heard; the diastolic pres-
sure is the lowest pressure level when the heart is relaxed and is the
last sound heard. Systole (heart contraction) and diastole (heart
relaxation) together make up the cardiac cycle. The difference
between systolic and diastolic pressures is the pulse pressure.
Blood pressure is read in millimeters of mercury, abbreviated
mm Hg. However, you need not include the abbreviation when
documenting the reading in the patient's health record. Blood pres-
sure is recorded as a fraction, with the systolic reading the numerator
(top) and the diastolic reading the denominator (bottom) (e.g.,
130/80). Table 7-5 lists normal blood pressure ranges for patients of
various age groups.
TABLE 7-5 Approximate Age-Related Blood
Pressure Ranges
RANGE
AGE SYSTOLIC DIASTOLIC
Newborn 60-96 30-62
1-3 years 78-112 48-78
4-6 years 78-112 50-79
7-11 years 85-114 52-79
Adolescent 94-119 58-79
Adult 100-119 60-79
CHAPTER 7 Vital Signs 157
8. Release the patient's wrist.
9. Sanitize your hands.
PURPOSE: To ensure infection control.
10. Record both the radial pulse and respiration counts with any irregularities
on the patient's health record. In a paper record the pulse is recorded
immediately after the temperature and respirations after the pulse record-
ing (e.g., P-72, R- 18).
PURPOSE: Procedures that are not recorded are considered not done.
5/6/20- 8:35 AM: P-72 reg, R-18. C. Ricci, CMA (MMA)
Factors Affecting Blood Pressure
Physiologic factors that determine blood pressure include blood
volume, peripheral resistance created by blood viscosity (the thick-
ness of the blood), vessel elasticity, and the condition of the heart
muscle and arterial walls.
Volume is the amount of blood in the arteries. An increased blood
volume raises blood pressure, and a decreased blood volume lowers
blood pressure. Therefore, with extensive bleeding or hemorrhage,
the blood volume drops, and so does the blood pressure.
The peripheral resistance of blood vessels refers to the relationship
of the lumen (the diameter of the vessel) to the amount of blood
flowing through it. The smaller the lumen, the greater the resistance
to blood flow. Blood pressure is higher with a small or reduced-size
lumen and lower with a large lumen. Vessels affected by fatty cho-
lesterol deposits (atherosclerotic plaques) become narrower over time,
resulting in smaller vessel lumens and therefore higher blood
pressure.
Vessel elasticity is the ability of an artery to expand and contract
to supply the body with a steady flow of blood. With advancing age,
certain lifestyle factors, or the presence of arteriosclerosis, vessel
elasticity may decrease, causing the arterial walls to become firm and
resistant; as a result, the blood pressure is increased.
The condition of the myocardium is a primary determinant of
the volume of blood flowing through the body. A strong, forceful
contraction empties the heart and tends to keep the blood pressure
within normal limits. If the myocardium becomes weak, pressure in
the vessels begins to increase in an attempt to maintain an adequate
level of circulating blood to meet the oxygen and nutrient needs of
the body.
Evaluating the Blood Pressure
When a patient's blood pressure is being tracked, frequent readings
should be taken at about the same time of day and by the same
person using the same-sized cuff and the same arm. Secondary
hypertension is caused by another underlying pathologic condition,
such as renal disease, complications of pregnancy, endocrine
158 UNIT ONE INTRODUCTION TO MEDICAL ASSISTING
imbalance, and brain injury. Temporary hypertension may occur
with stress, pain, exercise, and exhaustion. Many patients experience
"white coat hypertension"; that is, their blood pressure becomes
elevated in the medical environment, although it is normal when
they are away from the healthcare facility.
An adult is diagnosed with essential hypertension (stage 1
primary hypertension) if the systolic pressure is 140 to 159 or higher
and/or the diastolic pressure is 90 to 99 or higher. Essential hyper-
tension is the most common type of hypertension. It is idiopathic
(no known cause) but is associated with obesity, a high blood level
of sodium, elevated cholesterol levels, family history, and race.
African-Americans, Mexican-Americans, Native Americans, native
Hawaiians, and some Asian-Americans are at greater risk of develop-
ing hypertension.
Primary, or essential, hypertension is diagnosed if the patient's
blood pressure is persistently higher than 119 mm Hg systolic and/
or 79 mm Hg diastolic (the criteria for prehypertension) at two or
more office visits over several weeks or months. If the medical assis-
tant first notes that a patient's blood pressure is elevated, the pressure
should be checked again after the patient has been allowed to sit
comfortably for at least 2 minutes. Check the blood pressure in both
arms with a cuff that is the proper size for the patient's arm. If the
pressure readings are different, the provider uses the higher value for
diagnostic purposes. All of these readings must be documented in
the patient's record.
The American Heart Association (AHA) guidelines for the diag-
nosis and management of hypertension include three categories for
diagnostic and treatment purposes: prehypertension, stage 1 hyper-
tension, and stage 2 hypertension. The goal of the AHA recommen-
dations is to reduce the number of people who die each year from
hypertension-related illnesses, such as coronary artery disease, heart
attack, heart failure, kidney disease, and stroke. Hypertension can
occur in children or adults, but individuals of African-American
descent, middle-aged and elderly people, patients with diabetes mel-
litus, and those with kidney disease are at greatest risk. Hypertension
has been called the silent killer because it frequently has no symp-
toms, and individuals may go for long periods without knowing they
have a problem. Hypertension often is discovered during medical
treatment for another problem. Signs and symptoms may include
blurred vision, angina, vertigo, dyspnea, fatigue, headache, flushing,
nosebleeds (epistaxis), and palpitations. Table 7-6 summarizes the
stages and recommended treatment for the different levels of elevated
blood pressure.
Treatment guidelines for hypertension have four basic aspects:
1. Individuals with prehypertension should be diagnosed and
encouraged to make lifestyle changes before they require
medical treatment and/or move into the hypertensive cate-
gory. The AHA recommends limiting intake of salt and eating
a diet rich in potassium, calcium, magnesium, and protein
while reducing total fat intake, especially saturated fat.
Individuals with prehypertension also should restrict their
alcohol intake, engage in regular physical activity, and lose
weight if necessary to maintain a healthy BMI range. Many
times, just losing 10% of a person's weight lowers the blood
pressure.
2. In people older than 50 years of age, the systolic reading is
more important than the diastolic reading. Individuals over
TABLE 7-6 Stages and Treatment of Hypertension
BLOOD PRESSURE TREATMENT
Prehypertension • Lifestyle modification (reduced sodium, low
120-139 systolic OR saturated and trans fat diet; regular aerobic
80-89 diastolic activity; moderate alcohol intake; smoking
cessation; weight loss; stress reduction)
• Drug therapy for patients with diabetes
mellitus or chronic kidney disease
Stage l hypertension • Consider coexisting conditions
140-159 systolic OR • Thiazide-type diuretics (e.g., furosemide
90-99 diastolic [Lasix] or hydrochlorothiazide plus
triamterene [Dyazide]) for most patients
Stage 2 hypertension • Consider coexisting conditions
~ 160 systolic OR • Two-drug combination for most patients
~ l 00 diastolic
From the Seventh Report of the Joint National Committee on Prevention, Detection,
Evaluation, and Treatment of High Blood Pressure at http://www.nhlbi.nih.gov/health-pro/
guidelines/currentjhypertension-jnc-7/. Accessed November 4, 2015.
50 should be treated if they have a systolic pressure of
140 mm Hg or higher, regardless of their diastolic blood pres-
sure. Medical treatment at this age can reduce the develop-
ment of cardiac and kidney disease later in life.
3. Most patients with hypertension require two or more medica-
tions to achieve desired blood pressure levels. The goal of
treatment is to maintain blood pressure below 140/90 mm Hg,
or below 130/80 mm Hg in patients with diabetes or kidney
disease. Patients should be treated with both a diuretic, to help
the body excrete excess amounts of fluid and sodium, and an
antihypertensive medication.
4. A patient-centered treatment approach should be imple-
mented to motivate patients and to maintain compliance with
hypertension management. The medical assistant can play an
active role in establishing a therapeutic relationship with the
patient by providing ongoing education and support to ensure
compliance with provider-recommended treatment. Using
community resources, such as local dietitian referrals, may
also help patients comply with treatment.
CRITICAL THINKING APPLICATION 7-6
Mr. Samuel Long, a 43-year-old patient, recently was diagnosed with
essential hypertension. What should Carlos discuss with Mr. Long to empha-
size the dangers of his disease and to teach him about possible lifestyle
modifications that he must make to improve his health? Are any community
resources available that might help Mr. Long and his family effectively
manage his disease?
 CHAPTER 7 Vital Signs 159

FIGURE 7-13 A, Aneroid dial system with an inflatable cuff. B, Aneroid floor model with a large, slanted face.

Hypotension is an abnormally low blood pressure, which may

be caused by emotional or traumatic shock; hemorrhage; central
nervous system (CNS) disorders; and chronic wasting diseases. Per-
sistent readings of 90/60 mm Hg or lower usually are considered
hypotensive. Orthostatic (postural) hypotension can cause patients
to experience vertigo or syncope. Some medications can cause
orthostatic hypotension.

Measuring Blood Pressure

The instrument used to measure blood pressure is called a sphygmo-
manometer. The term manometer refers to an instrument used to
measure the pressure of a liquid or a gas. Sphygmo- means pulse.
Therefore, sphygrnomanometer means an instrument used to measure
blood pressure in the arteries. The instrument consists of an inflat-
able cuff, an inflation bulb with a control valve, and a pressure gauge.
The blood pressure mechanism consists of an aneroid dial attached
to an inflatable cuff (Figure 7 -13, A ); the device may be wall mounted
or a floor model (Figure 7-13, B). Some systems have a trigger-style
air release valve; these can be pumped up and then the air slowly
released simply by pushing the trigger (Figure 7-14). With the more
traditional sphygmomanometers, the valve must be unscrewed.
Sphygmomanometers are delicately calibrated instruments that
must be handled carefully. They should be recalibrated regularly and
checked for accuracy by you or by a medical supply dealer. The
needle on the aneroid dial sphygmomanometer should rest within
the small square or circle at the bottom of the dial. The dial can be
calibrated by connecting it to a calibrated manometer. Pump both
manometers to 250 mm Hg and record the readings on both
machines at least four different times as the pressure is released. A
correctly calibrated mechanism shows a difference of no more than
3 mm Hg between the two readings at any time during the deflation
FIGURE 7-14 Trigger-release aneroid blood pressure valve.
period. If the sphygmomanometer is not correctly calibrated, the
patient's blood pressure reading will be inaccurate.
The sphygmomanometer must be used with a stethoscope. The
objective of the procedure is to use the inflatable cuff to obliterate
(cause to disappear) circulation through an artery. The stethoscope
is placed over the artery just below the cuff, and the cuff is slowly
deflated to allow the blood to flow again. As blood flow resumes,
cardiac cycle sounds are heard through the stethoscope, and gauge
readings are taken when the first (systolic) and last (diastolic) sounds
are heard (Procedure 7-7).
To obtain a correct blood pressure reading, the proper-sized cuff
must be used. The systolic and diastolic blood pressures can be
lowered by as much as 5 mm Hg if the cuff is one size larger than
appropriate; the blood pressure can be elevated by up to 6 mm Hg
160 UNIT ONE INTRODUCTION TO MEDICAL ASSISTING

if the cuff is one size smaller. To make sure you are using the correct
size, the inflatable part (the bladder) should cover about 80 percent
of the circumference of the upper arm. To help with this, most blood
pressure cuffs have predetermined markings on the internal side of
the cuff (the side placed on the patient's arm); as long as the cuff is
secured within these lines it should be the accurate size (Figure 7-15).
Table 7-7 presents the various sizes of blood pressure cuffs
available.
When placed on the patient's arm, the cuff should cover two
thirds of the distance from the elbow to the shoulder. The lower end
of the cuff should be 2 to 3 cm (about 2 finger widths, or 1 inch)
above the elbow or antecubital space to allow plenty of room to place
the stethoscope without touching the cuff. If the stethoscope touches
the cuff during the blood pressure reading, the sound of the deflating
cuff may interfere with your ability to hear the correct reading. The
patient's sleeve must be above the antecubital space; if the sleeve is
tight, ask the patient to remove the arm from the sleeve. This is done
for two reasons: tight clothing can restrict normal blood flow in the
brachial artery, thus altering the blood pressure, and placing the
stethoscope over clothing makes it difficult to hear blood pressure
sounds. Provide a patient gown if needed to maintain the patient's
privacy.
Blood pressure cuffs and stethoscopes are available in drug and
retail stores for patients to use to measure their own blood pressure
at home. These units can be aneroid, electronic, or computerized
sphygmomanometers (Figure 7-16). If you have patients who are
monitoring their pressure at home, be sure they understand the
mechanics of obtaining a reading accurately. It is best to have the
patient bring his or her equipment to the office and demonstrate its
use. While the patient is showing you the home equipment, you will
have an ideal opportunity to check technique and calibration and to
answer any questions the patient may have about use of the equip-
ment. This is also a good opportunity to reinforce treatment plans,
such as medication, diet, and exercise. It is helpful for a patient who
is monitoring blood pressure readings at home to keep a log and
review it with the provider during visits to help detect blood pressure
variations during normal daily activities.

TABLE 7-7 Blood Pressure Cuff Sizes

ARM CIRCUMFERENCE
CUFF CENTIMETERS INCHES
Small adult 22-26 9
Adult 27-34 Up to 13
Large adult 35-44 14-17
Adult thigh 45-52 18-20
Data from Pickering TG, Hall JE, Appel LI et al: Recommendations for blood pressure
measurement in humans and experimental animals: Part 1. Blood pressure measurement in
humans: a statement for professionals from the Subcommittee of Professional and Public
Education of the American Heart Association Council on High Blood Pressure Research,
FIGURE 7-15 Variety of blood pressure cuff sizes. Hypertension 45(1):142-161, 2005.

FIGURE 7-16 Personal blood pressure systems. A, Digital arm cuff. B, Digital wrist cuff.

•;;m,ammfii Obtain Vital Signs: Determine a Patient's Blood Pressure
Goal: To perform ablood pressure measurement that is correct in technique, accurate, and comfortable for the patient.
EQUIPMENT and SUPPLIES
• Patient's record
• Sphygmomanometer
• Stethoscope
• Antiseptic wipes/alcohol swabs
PROCEDURAL STEPS
1. Sanitize your hands.
PURPOSE: To ensure infection control.
2. Assemble the equipment and supplies needed. Clean the earpieces and
diaphragm of the stethoscope with alcohol swabs.
PURPOSE: To follow Standard Precautions.
3. Introduce yourself, identify the patient, and explain the procedure.
PURPOSE: Identification of the patient prevents errors, and explanations
are a means of gaining implied consent and patient cooperation.
4. Select the appropriate arm for application af the cuff (no mastectomy on
that side, no injury or disease). If the patient has had a bilateral mastec-
tomy, the blood pressure should be taken using a large thigh cuff with the
stethoscope over the popliteal artery.
PURPOSE: The pressure of the cuff temporarily interferes with circulation
to the limb.
CAUTION: If a female patient has had a mastectomy, the blood pressure
should never be taken on the affected side. Compressing the arm may cause
complications. If she has had a bilateral mastectomy, another site such as
the popliteal artery must be used, which requires use of a thigh cuff.
S. Seat the patient in a comfortable pasitian with the legs uncrossed and the
arm resting, palm up, at heart level on the arm of a chair or a table next
to where the patient is seated.
PURPOSE: To expose the brachia! artery; also, to promote patient relax-
ation and ensure a true reading. Crossed legs may increase the blood
pressure, and positioning of the arm above heart level may cause an
inaccurate reading.
6. Rall up the sleeve to about 5 inches above the elbow or have the patient
remove the arm from the sleeve.
PURPOSE: Tight clothing prevents an accurate reading.
7. Determine the correct cuff size.
PURPOSE: An incorrect cuff size prevents accurate measurement of blood
pressure. The cuff should fit comfortably around the patient's arm, and
the bladder should be located over the brachia! artery between the lines
designated on the cuff. Pediatric, normal adult, and large adult cuff sizes
should be available. Thigh cuffs may be needed for obese patients.
CHAPTER 7 Vital Signs 161
8. Palpate the brachia! artery at the antecubital space in both arms. If one
arm has a stronger pulse, use that arm. If the pulses are equal, select the
right arm.
PURPOSE: Astronger pulse is easier to measure; the right arm is the
universal arm of choice.
9. Center the cuff bladder over the brachia! artery with the connecting tube
away from the patient's body and the tube ta the bulb close to the bady
(Figure l ).
PURPOSE: Pressure must be applied directly over the artery for an accurate
reading. The cuff and its tubing should not touch the stethoscope. Noise
from the tubing can interfere with a correct reading.
10. Place the lower edge af the cuff about l inch abave the palpable brachia I
pulse, normally located in the natural crease of the inner elbow, and wrap
it snugly and smoothly.
PURPOSE: To help ensure an accurate reading. The cuff should be high
enough on the arm that the stethoscope does not touch it, so that cuff
sounds do not interfere with listening to the blood pressure sounds. Aloose
cuff results in an inaccurate reading.
11. Position the gauge af the sphygmomanometer sa that it is easily seen.
PURPOSE: An aneroid gauge should show the needle within the zero mark.
12. Palpate the brachia! pulse, tighten the screw valve on the air pump, and
inflate the cuff until the pulse can no longer be felt. Make a note at the
point on the gauge where the pulse could no longer be felt. Mentally add
30 mm Hg to the reading. Deflate the cuff and wait 15 seconds (Figure 2).
PURPOSE: The point where the brachia! pulse is no longer felt provides an
estimate of the systolic pressure. Pumping the cuff above that level ensures
that phase I of the Korotkoff sounds will be heard.
162 UNIT ONE INTRODUCTION TO MEDICAL ASSISTING
•;;m,ammfii -continued
13. Insert the earpieces of the stethoscope turned forward into the ear canals.
PURPOSE: With the earpieces in this position, the openings follow the
anatomic line of the ear canal and the blood pressure will be accurately
heard.
14. Place the stethoscope's diaphragm aver the palpated brachia! artery for
an adult patient or the bell for a pediatric patient. Press firmly enough to
obtain a seal but not so tightly that the artery is constricted. Only touch
the edges of the stethoscope head.
PURPOSE: Forming a seal around the head of the stethoscope aids listen-
ing for blood pressure sounds. Placing your fingers directly over the
stethoscope head will cause interference with the sound.
1S. Close the valve and squeeze the bulb to inflate the cuff, rapidly but
smoothly, to 30 mm above the palpated pulse level, which was previously
determined (Figure 3).
16. Open the valve slightly and deflate the cuff at a constant rate of 2 to
3 mm Hg per heartbeat.
PURPOSE: Careful, slow release allows you to listen to all sounds.
17. Listen throughout the entire deflation; note the point on the gauge at
which you hear the first sound (systolic) and the last sound (diastolic)
until the sounds have stopped for at least 10 mm Hg.
18. Do not reinflate the cuff once the air has been released. Wait 30 to 60
seconds to repeat the procedure if needed.
PURPOSE: Not allowing the blood to refill in the brachia! artery results in
inaccurate readings.
Effects of Body Position on Blood Pressure Measurement
Blood pressures are usually taken with the patient in either the
sitting or the supine position. However, the diastolic pressure can
be as much as 5 mm Hg higher when patients are sitting than
when they are supine. In addition, if the patient's back is not sup-
ported and there is some muscle tension in the body (as occurs
when the patient is seated on an examination table rather than in a
chair), the diastolic pressure may be increased by 6 mm Hg; if
patients cross their legs during the reading, the systolic pressure
19. Remove the cuff from the patient's arm.
20. Remove the stethoscope from your ears and record the arm used and the
systolic and diastolic readings as BP systolic/diastolic (e.g., BP 120/80).
NOTE: It is recommended that the blood pressure be checked and recorded
in each arm during the initial assessment of the patient and then bilaterally
periodically after that for patients with hypertension.
21. Clean the earpieces and the head of the stethoscope with alcohol and
return both the cuff and the stethoscope to storage.
22. Sanitize your hands.
PURPOSE: To ensure infection control.
ADDENDUM: The provider may direct the medical assistant to record the
blood pressure with the patient in two different positions to determine
whether orthostatic hypotension is a factor. To perform this skill:
1. Measure and record the patient's blood pressure (as detailed earlier)
while the patient is either supine or sitting.
2. Leave the cuff in place.
3. Have the patient stand, and immediately measure the blood pressure
again.
4. Record the second blood pressure and any patient symptoms, such as
complaints of (c/o) vertigo or lightheadedness.
5/19/20- 11 AM: BP 120/80 <I> arm. C. Ricci, (MA (AAMA)
may be raised by 2 to 8 mm Hg. The position of the patient's arm
can also have a major influence when the blood pressure is mea-
sured. If the upper arm is below the level of the right atrium (e.g.,
dangling at the patient's side), the reading is artificially elevated; if
the arm is above the heart level, the reading is lowered. Or, if the
arm is held up by the patient, muscular tension will raise the pres-
sure. The arm should be placed at the level of the heart on a table
next to an exam room chair or resting on the arm of the chair to
avoid these issues (Figure 7-17).
 CHAPTER 7 Vital Signs 163

When the cuff is

~~
Cuff pressure
inflated so that it > 120 mm Hg
Inflatable stops arterial blood
cuff

0
flow, no sound can
Pressure be heard through
gauge a stethoscope
placed over the
brachia! artery
distal to the cuff.

t~
Korotkoff sounds Cuff pressure
are created by between 80 and
pulsating blood 120 mm Hg
flow through the

~
compressed artery.

Blood flow is Cuff pressure

silent when the < 80 mm Hg

I
artery is no longer

Q
compressed.

FIGURE 7-17 The science of taking a blood pressure.

Common Causes of Error in Blood Pressure Korotkoff Sounds

Readings
• The limb used for measurement is above the level of the heart.
• The rubber bladder in the cuff is not completely deflated before a
reading is started or retaken.
• The pressure in the cuff is released too rapidly.
• The patient is nervous, uncomfortable, or anxious (may cause a reading
higher than the patient's actual blood pressure).
• The patient drank coffee or smoked cigarettes within 30 minutes of
the blood pressure measurement.
• The cuff was applied improperly.
• The cuff is too large, too small, too loose, or too tight.
• The cuff was not placed around the arm smoothly.
• The bladder is not centered over the artery, or the bladder bulges out
from the cover.
• The practitioner fails to wait l to 2 minutes between measurements.
• Instruments are defective:
• Air leaks in the valve
• Air leaks in the bladder
• Aneroid needle not calibrated to zero
Two basic heart sounds are produced by the functioning of the heart
during the cardiac cycle. The first sound, produced at systole (con-
traction), is dull, firm, and prolonged and is heard as a lubb sound.
The second sound, produced at diastole (relaxation), is shorter and
sharper and is heard as a dupp sound. Therefore, lubb-dupp is the
sound of one heartbeat.
Korotkoff sounds are the sounds heard during auscultation of
blood pressure. These sounds are produced by vibrations of the arte-
rial wall when the blood surges back into the vessel after it has been
compressed by the blood pressure cuff. The sounds were first discov-
ered and classified into five distinct phases by Russian neurologist
Nikolai Korotkoff.
Phase I
Phase I is the first sound heard as the cuff deflates. The blood is
resurging into the patient's artery and can be heard quite clearly as
a sharp, tapping sound. Note the gauge reading when this first sound
is heard. Record this as the systolic blood pressure.
Phase II
As the cuff deflates, even more blood flows through the artery. The
movement of the blood makes a swishing sound. If you did not follow
proper procedure in inflating the cuff, you may not hear these sounds
because of their soft quality. Occasionally blood pressure sounds com-
pletely disappear during this phase. Loss of the sounds, followed by
their reappearance later, is called the auscultatory gap. The silence may
164 UNIT ONE INTRODUCTION TO MEDICAL ASSISTING
continue as the needle falls another 30 mm Hg. Auscultatory gaps
occur particularly in hypertension and certain types of heart disease,
so if you notice such a gap, make sure to report it to the provider.
Phase Ill
In phase III, a great deal of blood is pushing down into the artery.
The distinct, sharp tapping sounds return and continue rhythmically.
If you do not inflate the cuff enough, you will miss the first two
phases completely and you will incorrectly interpret the beginning
of phase III as the systolic blood pressure (phase I).
Phase IV
At this point, the blood is flowing easily. The sound changes to a
soft tapping, which becomes muffied and begins to grow fainter.
Occasionally these sounds continue to zero. This may occur in chil-
dren, in patients of any age after exercise or with a fever, or in a
pregnant patient with anemia. The AHA recommends that the
beginning of phase IV be recorded as the diastolic reading for a child.
Some providers call the change at phase IV the fading sound and
want it recorded between systolic and diastolic recordings (e.g.,
120/84/70, with 84 representing the gauge reading when the sounds
of phase III have ended and those of phase IV are beginning). Other
providers consider phase IV the true diastolic pressure.
Phase V
All sounds disappear in this phase. Note the gauge reading when the
last sound is heard. Record this as the diastolic pressure.
Palpatory Method
The systolic pressure may be checked by feeling the radial pulse rather
than hearing it with the stethoscope. Place the cuff in the usual
position and palpate the radial pulse, noting rate and rhythm. Inflate
the cuff until the pulse disappears, then add 30 mm Hg more of
inflation to get above the systolic pressure. Do not remove your
fingers from the pulse or change the pressure of your fingers. Care-
fully watch the gauge while slowly releasing the pressure in the cuff
and wait until you feel the first pulse beat. Note the reading on the
gauge, and record the first pulse felt as the systolic pressure. For
example, if you first felt the radial pulse at 52 mm Hg, the palpated
blood pressure is recorded as 52/P, with P indicating that the systolic
reading was palpated. The diastolic and Korotkoff phases cannot be
determined by this method. This method can be very useful in times
of a medical emergency, such as shock, when the patient's blood
pressure cannot be auscultated. If you are having difficulty hearing
the systolic blood pressure, you can use the palpatory method first to
determine how far you need to pump the cuff to hear that first beat.
CRITICAL THINKING APPLICATION 7-7
Vital signs are documented in a paper record in this order: temperature (T),
pulse (P), and respirations (R). Blood pressure is recorded after TPR.
Depending on the EHR system, they may be ordered differently. Correctly
document the following vital signs:
l. Oral temperature 101.2°; apical pulse 90; respirations 22; and
orthostatic blood pressure in the right arm is 138/88 supine and
110/70 standing
2. Tympanic temperature 36.8°; radial pulse 66; respirations 18; and
bilateral blood pressure 128/7 6 in the left arm and 132/80 in
the right arm
3. Temporal temperature 102.4 °; apical pulse 102; and respirations
27
4. Axillary temperature 97.7°; carotid pulse 58; respirations 24; and
palpated blaod pressure 62
OSHA Guidelines for Measuring Vital Signs
Guidelines established by the Occupational Safety and Health Administra-
tion (OSHA) for the measurement of vital signs include the following:
• Wash hands before and after each procedure.
• Always use protective disposable sheaths on all forms of
thermometers.
• Immediately disinfect any equipment that becomes contaminated
during the procedure.
• Wear gloves if the potential exists for contacting any open areas or
body fluids.
• When caring for a patient with a known respiratory infectious dis-
order (e.g., tuberculosis), use protective clothing, including a face
shield or mask as indicated.
• Dispose of all contaminated material, including thermometer covers,
gloves, and disinfectant swabs, in the proper biohazard waste
containers.
ANTHROPOMETRIC MEASUREMENTS
Anthropometry is the science that deals with measurement of the
size, weight, and proportions of the human body. These measure-
ments often are included in the initial recording of vital signs and
before the provider performs a physical examination or a well-baby
check. Because they are indicators of the patient's state of health and
well-being, height and weight measurements and the associated BMI
are discussed as aspects of the vital signs. Other measurements are
discussed when pertinent in the specialty chapters.
Measuring Weight and Height
A patient's weight and height can be helpful in diagnosis, and the
medical assistant must obtain these readings with accuracy and
empathy (Procedure 7-8). In many medical settings, weight and
height are measured routinely as the patient is escorted to the exami-
nation room. To safeguard patient confidentiality, the scale should
be located in a private area where other individuals are unable to
observe the patient's weight. However, regardless of where the scale
is located in the healthcare facility, be sure to safeguard the patient's
confidentiality by not repeating the measurement out loud so others
nearby can hear this private patient information. If this is the
patient's first visit, anthropometric measurements are recorded in the
history database and are used as reference information during future
visits as needed. EHR systems automatically record vital signs data
so that they can be seen on the majority of screens viewed.
Many providers use the BMI to determine the risk for certain
diseases, so the medical assistant may have to use the accurately
 CHAPTER 7 Vital Signs 165

measured height and weight to determine and record the patient's
BMI. This is typically done using a BMI chart that converts the
patient's height and weight ratio into a BMI number, or with a
wheeled device that calibrates the BMI when the height and weight
intersect. BMI numbers also can be determined using an online
conversion calculator. EHR systems automatically calculate and
record the patient's BMI after the height and weight measurements
are entered.
Certain medical specialties and specific medical problems may
require continuous monitoring of weight. Hormone disorders (e.g.,
diabetes), growth patterns (seen in children), and eating disorders
(e.g., obesity, bulimia) require accurate weight checks as part of every
medical visit. In addition, maternity patients must have their weight
monitored to make sure they are gaining weight, but also as a pre-
caution against too much weight gain, which may indicate fluid
retention. Patients with cardiovascular disorders who tend to retain
fluid should have their weight checked each time they are seen
in the office. Some scales are calibrated in kilograms, others in
pounds. When weight must be converted from one to the other,
use the formulas shown later in this chapter or an online conver-
sion calculator. EHR systems do the conversion automatically
(Figure 7-18).
Accurate height or length measurements are particularly impor-
tant for children (see the Pediatrics chapter). The provider also may
request routine height screening for patients diagnosed with osteo-
porosis because these patients may lose height over time.

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FIGURE 7-18 Electronic health record (EHR) documentation of height, weight, and body mass index (BMI).

•ijm1,ammfj:• Obtain Vital Signs: Measure a Patient's Weight and Height

Goal: To accurately weigh and measure apatient as part of the physical assessment procedure.
Note: Make sure the scale is located in an area away from traffic to maintain the patient's privacy.

EQUIPMENT and SUPPLIES 4. Help the patient onto the scale. Make sure afemale patient is not holding
• Patient's record a purse and that a male or female patient has removed any heavy objects
• Balance scale with a measuring bar from pockets.
• Paper towel S. Move the large weight into the groove closest to the patient's estimated
weight. The grooves are calibrated in 50-lb increments. If you choose a
PROCEDURAL STEPS groove that is more than the patient's weight, the pointer will immediately
1. Sanitize your hands. tilt to the bottom of the balance frame. You then must move it back one
PURPOSE: To ensure infection control. groove (Figure l).
2. Introduce yourself, identify your patient, and explain the procedure. 6. While the patient is standing still, slide the small upper weight to the right
PURPOSE: Identification of the patient prevents errors, and explanations along the pound markers until the pointer balances in the middle of the
are a means of gaining implied consent and patient cooperation. balance frame.
3. If the patient is to remove his or her shoes for weighing, place a PURPOSE: The pointer floats between the bottom and the top of the frame
paper towel on the scale platform. Check to see that the balance bar when both lower and upper weights together balance the scale with the
pointer floats in the middle of the balance frame when all weights are at patient's weight.
zero. 7. Leave the weights in place.
PURPOSE: Afloating pointer indicates that the scale is properly adjusted 8. Ask the patient to stand up straight and to look straight ahead. On some
and in balance. scales, the patient may need to turn with the back to the scale.
166 UNIT ONE INTRODUCTION TO MEDICAL ASSISTING

•;iill'91Umfj:• -continued
10. Leave the elevation bar set.
PURPOSE: To maintain the height recording while protecting the patient
from possible injury.
11. Assist the patient off the scale. Make sure all items that were removed
for weighing are given back to the patient.
12. Read the weight scale. Add the numbers at the markers of the large and
small weights and record the total to the nearest ½ lb in the patient's
health record (e.g., Wt-17 6½ lb).
13. Record the height. Read the marker at the movable point of the ruler and
record the measurement to the nearest ½ inch on the patient's medical
record (e.g., Ht: 66 ½ in) (Figure 3).

P r o f

9. Adjust the height bar so that it just touches the top of the patient's head
(Figure 2).

14. Use the patient's weight and height to record the BMI if it is not automati-
cally done by the EHR program.
15. Return the weights and the measuring bar to zero.
16. Sanitize your hands.
17. Record the results in the patient's health record.

5/26/20- 11 :07 AM: Wt 17 6½ lb, Ht 66 ½in, BMI 28.5. C. Ricci, (MA

(AAMA)
 CHAPTER 7 Vital Signs 167

Weight
Your manner and approach are very important in keeping patients al----·_.
from feeling embarrassed or shy when being weighed. Make sure
heavy items are removed from pockets and that the patient is not
holding a purse. If patients have difficulty with balance or stability,
assist them onto the scale and help them balance themselves. If the
patient is unable to maintain his or her balance while the scale is
calibrating, the ideal equipment to have on hand is a scale with
1
built-in handrails. If the facility does not have this type of scale, a
walker can be placed over the scale for the patient to use as hand
support when getting on or off, or to maintain balance while on the
scale (Figure 7-19).
If the provider prescribes weight measurement at home, make
sure the patient understands the importance of getting weighed at
the same time each day in clothing of similar weight. Body weight
may vary considerably from early morning to late afternoon, so it is
usually best if the patient is weighed in the morning. If it is impor-
tant that the patient be weighed each day, make sure you remind the
patient to record each weight and notify the clinic as directed if there
FIGURE 7-19 Awalker is placed over the scale to aid the patient's balance.
are major shifts in weight.

Weight Conversion Formulas

To Convert Kilograms to Pounds
l kg= 2.2 lb
Multiply the number of kilograms by 2.2.
Example: Apatient weighs 68 kg: 68 x 2.2 = 149.6 lb
To Convert Pounds to Kilograms
l lb= 0.45 kg
Multiply the number of pounds by 0.45, or divide the number of pounds
by 2.2 kg.
Example: A patient weighs 120 lb: 120 x 0.45 = 54 kg, or
120 + 2.2 = 54.5 kg
CRITICAL THINKING APPLICATION 7-8
l. Apatient weighs 87 kg; how many pounds does he weigh?
2. Apatient weighs 148 lb; how many kilograms does she weigh?
Height
Height can be measured in inches or centimeters. Measurement is
easily accomplished by moving the parallel bar attached to a wall
ruler or on the scale. Length measurements used in pediatrics and
pediatric BMis are discussed in the Pediatrics chapter.
CRITICAL THINKING APPLICATION 7-9
Mrs. Johnson is being seen for the first time by Dr. Xu. In what order should
Carlos take her vital signs and her anthropometric measurements? Should
her blood pressure be measured in both arms, with the patient both sitting
and standing? If so, what is the rationale?
CLOSING COMMENTS
Patient Education
All patients should know how to use a thermometer safely and
accurately, in addition to the preferred site based on age and other
patient factors. Because many types of temperature-reading equip-
ment are available, ask the patient what type of equipment he or she
uses at home to obtain temperature readings. Inexpensive digital
models have greatly simplified home temperature taking.
In teaching a patient how to assess the pulse rate, familiarize him
or her with counting the beats and explain how to determine the
rate and regularity of the beat. Use diagrams to teach pulse points,
and have the patient measure your pulse to assess the person's accu-
racy and to provide any needed assistance.
Monitoring blood pressure at home has become very common.
Suggest that the patient bring his or her equipment to the office and
practice with it. In this way, you can make sure the patient is using
the equipment correctly and is recording the results accurately in a
record book. Computerized home measuring devices typically store
a series of recent blood pressure readings in the device's memory. If
the patient brings the home device for clinic visits, you can easily
check the history of blood pressure recordings taken at home.
Weight management can be a trying and emotional experience
for a patient. Explaining to the patient how weight is affected by the
time of day, a particular activity, or the type of scale used can help
him or her maintain a positive attitude. Have an assortment of
weight management literature available for the patient to take home,
and use community resources when indicated to help the patient
with weight-related issues.
 168 UNIT ONE INTRODUCTION TO MEDICAL ASSISTING
Responsibilities of the Medical Assistant in
Obtaining Vital Signs
• Monitoring vital signs is a key responsibility of the medical assistant.
• It is crucial to measure and describe all facets of each vital sign correctly.
• The information must be accurately and clearly documented.
• The medical assistant should take advantage of all opportunities to
answer questions and to help the patient understand the significance
of healthy vital signs.
• The patient's privacy must be maintained throughout all procedures.
• Family members or caregivers should be included in patient care and
education as indicated.
• Community resources should be used to promote holistic patient care.
• The medical assistant should be sensitive to cultural and socioeconomic
factors that may affect the patient's compliance with the provider's
recommendations, such as diet, exercise, weight control, and the use
of medication.
Legal and Ethical Issues
The medical assistant must remember that as the provider's agent,
he or she plays an important role in preventing legal claims against
the provider and the medical office. The medical assistant must
always function within the legal boundaries of the profession. When
obtaining vital signs, carefully select your response to a patient who
asks about the results. Remember, medical assistants are not qualified
to diagnose a patient's problem; that is, never evaluate or give an
Jiiiilt+i;fi•jii#it+i#t•i
Carlos recognizes the significance of measuring and recording each patient's
vital signs and anthropometric measurements. Dr. Xu relies on Carlos to provide
this information accurately. Carlos has never let these procedures become
routine and has never done them without focusing on the task because vital
signs are an important reflection of a person's health status.
Carlos knows that a number of factors can alter a patient's vital signs,
including the external environment, smoking, drinking hot beverages, exercise,
and anxiety and pain. Carlos evaluates patient factors such as age, gender,
level of compliance, and the presence of disease to determine the best method
of accurately measuring vital signs. In addition, Carlos is sensitive to the need
for safeguarding the patient's privacy. When he was first hired by Dr. Xu, he
opinion of what the results may mean. For example, if a patient asks,
"Is my blood pressure better?" you might reply, "The reading is
160/90 today." You have not said that it is worse, the same, or better,
but you have informed the patient of the current blood pressure
reading.
Always be accurate in transcribing results into the patient's health
record. If results are incorrectly recorded, the patient may be incor-
rectly diagnosed or treated; this can result in legal action that may
implicate you. A careless attitude toward assessment of vital signs
and documentation can lead to possible legal entanglement. Every
procedure in this chapter is accompanied by a reminder to record
the test results. If no entry has been made, the assumption is that
the procedure was not done.
Professional Behaviors
Measuring and recording vital signs are a crucial part of the medical
assistant's responsibilities. These procedures can become so routine that
we no longer consider that the results can cause the patient anxiety and
concern. For example, if you have a patient who is struggling to maintain
a healthy blood pressure, it is important that you are sensitive to his con-
cerns. Or if you have a patient who is having difficulty maintaining or losing
weight, she can be quite apprehensive, embarrassed, or even depressed
about weight results. Demonstrating awareness of the patient's concerns
about the measuring and recording of vital signs and showing sensitivity
to his or her needs are part of performing as a professional medical
assistant.
was concerned about privacy and confidentiality when he discovered that the
patient scale was in the hall next to the waiting room. After he discussed this
with the office manager, the scale was moved to an examination room so that
patients could be weighed in privacy.
Carlos attended a workshop last year on the AHA guidelines for the diag-
nosis and treatment of hypertension, and he is prepared to explain those rec-
ommendations to patients. He recognizes his role in motivating patients
diagnosed with prehypertension to stick with recommended lifestyle changes
and follow the provider's treatment protocol. Carlos continues to care for
patients while providing valuable assistance to Dr. Xu in her busy primary care
practice.

SUMMARY OF LEARNING OBJECTIVES
l. Define, spell, and pronounce the terms listed in the vocabulary.
Spelling and pronouncing medical terms correctly reinforce the medical
assistant's credibility. Knowing the definitions of these terms promotes
confidence in communication with patients and co-workers.
2. Do the following related to temperature:
• Cite the average body temperature for various age groups.
The average body temperature varies from person to person; in a healthy
adult, it is typically between 97.6° and 99° F (36.4° and 37.2° ().
(See Tables 7-1 and 7-2.)
• Describe emotional and physical factors that can cause body tempera-
ture to rise and fall.
Multiple factors can affect body temperature, including the external envi-
ronment, age, stress, physical exercise, gender, and illness.
• Convert temperature readings between Fahrenheit and Celsius scales.
Using the formulas presented in this chapter, perform correct calculations
to convert temperatures between Fahrenheit and Celsius scales.
• Obtain and record an accurate patient temperature using three different
types of thermometers.
The patient's temperature can be measured orally and in the axillary
region with a digital thermometer, in the ear using an aural thermometer,
and at the temporal artery using a temporal artery scanner. The axillary
temperature is approximately l ° F(0.6 ° () lower than an accurate oral
reading because the reading is not taken in an enclosed body cavity. The
tympanic temperature is accurate because it records the temperature af
the blood closest to the hypothalamus. The temporal artery scanner is
considered most accurate for infants. After the temperature reading is
documented, (T) is recorded for a tympanic reading; (A) for an axillary
reading; and (TA) for a temporal artery reading, to clarify the site. Proce-
dures 7-1 thru 7-4 explain how to take and record patient temperatures
using a variety of thermometers.
3. Do the following related to pulse:
• Cite the average pulse rate for various age groups.
Infants and children typically have a faster pulse than adults; as aging
progresses, the pulse rate declines. As a rule, both the pulse and respiratory
rates respond to exercise or emotional upset. (See Table 7-3 for approxi-
mate age-related pulse ranges.)
• Describe pulse rate, volume, and rhythm.
The pulse rate reflects the number of times the heart contracts in l minute.
The pulse volume is the amount of force placed on the arterial walls when
the heart beats; the rhythm of the pulse is the length of time between
beats. Monitor and record the pulse rate, noting whether the rhythm is
regular or arrhythmic, and the volume is bounding, normal, or thready.
• Locate and record the pulse at multiple sites.
The most common sites used to feel the pulse are the temporal, carotid,
apical, brachia!, radial, femoral, popliteal, and dorsalis pedis arteries.
(Procedures 7-5 and 7-6 present the specifics on recording apical and radial
pulses.)
CHAPTER 7 Vital Signs 169
4. Do the following related to respiration:
• Cite the average respiratory rate for various age groups.
As a rule, both the pulse and the respiratory rate respond to exercise and
emotional upset. Table 7-4 presents a list of normal respiratory rates for
patients in various age groups.
• Demonstrate the best way to obtain an accurate respiratory count.
Count the number of respirations for 30 seconds and then multiply by 2.
This should be done immediately after taking the patient's pulse, while
still holding the pulse point and without warning the patient, because the
patient may inadvertently alter the respiratory rate if he or she is aware
that breaths are being counted. (See Procedure 7-6.)
5. Do the following related to blood pressure:
• Cite the approximate blood pressure range for various age groups.
Table 7-5 lists the normal blood pressure ranges for patients of various
age groups.
• Specify physiologic factors that affect blood pressure.
Physiologic factors that affect blood pressure include the amount or volume
of blood in circulation; the condition of the blood vessels, including the
presence of atherosclerosis and arteriosclerosis; the degree of blood viscos-
ity; and the strength of the myocardium.
• Differentiate between essential and secondary hypertension.
The cause of essential hypertension is unknown; it is diagnosed when a
patient has a systolic reading higher than 140 mm Hg and/or a diastolic
reading higher than 90 mm Hg. Secondary hypertension is caused by an
underlying condition, such as renal disease, pregnancy, or a congenital
heart defect.
• Interpret current hypertension guidelines and treatment.
AHA guidelines for the diagnosis and management of hypertension include
a prehypertension category. Table 7-6 identifies the categories of prehy-
pertension, stage l hypertension, and stage 2 hypertension, with sug-
gested treatments. The goal of the AHA recommendations is to reduce the
number of people who die each year from hypertension-related illness.
Treatment includes a combination of weight management, sodium reduc-
tion, lifestyle changes, and the use of two or more antihypertensive and
diuretic medications.
• Describe how to determine the correct cuff size for individual patients.
The proper size cuff must be used to obtain a correct blood pressure
reading. To make sure the size is correct, the inflatable part (bladder)
should cover about 80 percent of the circumference of the upper arm.
(Table 7-7 presents the various sizes of blood pressure cuffs available.)
• Identify the different Korotkoff phases.
The Korotkoff phases are the categories of sounds heard during blood
pressure measurement. These sounds are produced by vibrations of the
arterial wall when the blood surges back into the vessel after it has been
compressed by the blood pressure cuff. Phase Iis the first sound heard as
the cuff deflates and is the systolic reading; phase II is the swishing sound
made by the movement of blood through the artery, although an
Continued
170 UNIT ONE INTRODUCTION TO MEDICAL ASSISTING
SUMMARY OF LEARNING OBJECTIVES-continued
auscultatory gap may occur in which sounds completely disappear; phase
Ill involves distinct, sharp tapping sounds made as the blood rushes
through the artery; in phase IV, the sound changes to asoft tapping, which
becomes muffled and begins to grow fainter; and in phase V, sound
completely disappears. The last sound heard is the diastolic reading.
• Accurately measure and document blood pressure.
Asphygmomanometer is used with a stethoscope to hear the systolic over
diastolic sounds. (Procedure 7-7 ourlines the method for performing this
skill.)
6. Accurately measure and document height and weight.
Apatient's height and weight are anthropometric measurements that are
recorded during the initial patient visit and periodically after that, depending
on the patient's needs and the provider's preference. The scale should be
kept in a private location. Variations in weight may indicate physical or
emotional disorders, including diabetes, congestive heart failure, hormone
abnormalities, depression, and eating disorders. (Procedure 7-8 describes
the techniques for weighing a patient; the BMI is determined as
indicated.)
CONNECTIONS
CrJ Study Guide Connection: Go to the Chapter 7 Study Guide. Read and complete
the activities.
7. Convert kilograms to pounds and pounds to kilograms.
To convert kilograms (kg) to pounds (lb), multiply the number of kilograms
by 2.2. To convert pounds ta kilograms, divide the number of pounds by
2.2 kg, ar multiply the number af pounds by 0.45 kg.
8. Identify patient education opportunities when measuring vital signs.
Patient education about vital signs includes confirming the patient's ability
to monitor vital signs at home as needed; providing assistance in helping
the patient learn how to use home equipment systems; and confirming
the patient's understanding af the need ta comply with the provider's
recommendations.
9. Determine the medical assistant's legal and ethical responsibilities in
obtaining vital signs.
Legal and ethical implications for the medical assistant include fallowing
the provider's guidelines regarding patient disclosure, monitoring and
recording vital signs accurately, and being consistenrly alert for inaccurate
readings or possible carelessness.
evolve Evolve Connection: Go to the Chapter 7 link at evolve.elsevier.com/
kinn to complete the Chapter Review Quiz. Check out the other resources listed for this
chapter to make the most of what you have learned from Vital Signs.
ASSISTING WITH THE PRIMARY
PHYSICAL EXAMINATION
i-i#H+i;H•i
Felicia Grand, a newly hired certified medical assistant ((MA, AAMA), works
for Dr. Anna Kosto, a member of a busy primary care practice with several provid-
ers. One of Felicia's chief responsibilities will be to assist Dr. Kosto with physical
examinations. Her duties include preparing and maintaining the examination
room and equipment; getting the patient ready for specific physical examina-
tions; and gowning, draping, and positioning the patient as needed. Because
While studying this chapter, think about the following questions:
• What equipment does Felicia need to gather before the provider enters
the examination room, to make sure the examination goes smoothly and
without interruption?
• What examination and treatment positions should Felicia be familiar with,
and when should the various positions be used?
LEARNING OBJECTIVES
l. Define, spell, and pronounce the terms listed in the vocabulary.
2. Describe the structural organization of the human body and the body
cavities.
3. Identify the functions of the body systems and the major organs and
structures of each system.
4. Discuss the concept of a primary care provider and the role of a
medical assistant in a primary care practice.
5. Ourline the medical assistant's role in preparing for the physical
examination.
6. Summarize the instruments and equipment the provider typically uses
during a physical examination.
7. Identify the principles of body mechanics and demonstrate proper body
mechanics.
VOCABULARY
auscultation The act of listening to body sounds, typically with a
stethoscope, to assess various organs throughout the body.
bruit (broo' -it) An abnormal sound or murmur heard on
auscultation of an organ, vessel (e.g., carotid artery), or gland.
clubbing Abnormal enlargement of the distal phalanges (fingers
and toes) associated with cyanotic heart disease or advanced
chronic pulmonary disease.
colonoscopy A procedure in which a fiberoptic scope is used to
examine the large intestine.
8
Felicia will be assisting with examinations, she must become familiar with the
physical examination procedure and the order in which the provider needs
various pieces of medical equipment. It also is important that Felicia protect
herself from possible injury by using appropriate body mechanics throughout
her day in the office.
• What measures can Felicia take to protect herself from injury when lifting
heavy items or assisting with the transfer of patients?
8. Ourline the basic principles of gowning, positioning, and draping a
patient for examination; also, position and drape a patient in six
different examining positions while remaining mindful of the patient's
privacy and comfort.
9. Describe the methods of examination, and give an example of each.
l 0. Ourline the sequence of a routine physical examination.
11. Prepare for and assist in the physical examination of a patient,
correcrly completing each step of the procedure in the proper
sequence.
12. Discuss the role of patient education during the physical examination,
in addition to the legal and ethical implications and Health Insurance
Portability and Accountability Act (HIPAA) applications.
electrocardiogram (i-lek-tro-kar'-de-uh-gram) A graphic record of
electrical conduction through the heart.
emphysema (em-fuh-ze'-muh) The pathologic accumulation of
air in the alveoli, which results in alveolar destruction and
overall oxygen deprivation; in the lungs, the bronchioles become
plugged with mucus and lose elasticity.
gait The manner or style of walking.
hematopoiesis (hi-ma-tuh-poi-e'-suhs) The formation and
development of blood cells in the red bone marrow.
172 UNIT ONE INTRODUCTION TO MEDICAL ASSISTING
VOCABULARY-continued
intercellular A term referring to the area between cells.
intracellular A term referring to the area within the cell
membrane.
manipulation Movement or exercise of a body part by means of
an externally applied force.
mastication (mas-tuh-ka' -shun) Chewing.
murmur An abnormal sound heard during auscultation of the
heart that may or may not have a pathologic origin; it is
associated with valve disease or a congenital heart defect.
nodules (nah'-juhls) Small lumps, lesions, or swellings that are
felt when the skin is palpated.
palpation The use of touch during the physical examination
to assess the size, consistency, and location of certain body
parts.
T o promote health maintenance, healthcare professionals must
understand the anatomy and physiology of the body, the role
each part plays, how each component functions, and what happens
to the body when disease occurs in body systems.
ANATOMY AND PHYSIOLOGY
Anatomy is the study of how the body is shaped and structured. It
encompasses a wide range of subjects, including structural develop-
ment, levels of organization, relationships among microscopic parts,
and the interrelationship of structure and function.
Physiology is the study of body functions. This field is subdivided
into areas of study; some physiologists spend their entire lives study-
ing only one function, such as how cells work or how a single organ,
such as the small intestine, is interrelated in function with the
stomach and the large intestine.
Separating these two sciences is almost impossible because one
continuously influences the other. Function affects structure, and
structure affects function; for example, an infant can suck effortlessly
because of the lack of teeth in the mouth. Once teeth appear, sucking
becomes more tiresome, and the child begins to chew and bite.
Phenomena in structure and function affect the interrelationships of
all body systems.
Structural Development
Cells
The basic unit of life is the cell. Cells determine the functional and
structural characteristics of the entire body. Cells are microscopic in
size, have a variety of shapes, and perform a vast array of functions.
It is estimated that the human body is composed of approximately
100 trillion living, functioning cells. A cell is made up of three
primary parts: the plasma membrane that surrounds the cell, creat-
ing an outer covering; the intracellular environment, which includes
the cytoplasm that contains the living material that carries on the
peripheral neuropathy A problem with the function of the
nerves outside the spinal cord; symptoms include weakness,
burning pain, and loss of reflexes; a frequent complication of
diabetes mellitus.
peristalsis (per-uh-stahl'-suhs) Rhythmic contraction of
involuntary muscles lining the gastrointestinal tract.
sdera The white part of the eye that forms the orbit.
transillumination Inspection of a cavity or organ by passing light
through its walls.
trauma A physical injury or wound caused by external force or
violence.
vasoconstriction (va-zo-kuhn-strik'-shun) Contraction
of the muscles lining blood vessels, which narrows the
lumen.
cell's function; and the nucleus of the cell, which contains the genetic
code of the cell that determines the cell's function.
Tissues
When cells with similar structure and function are placed together,
they form tissues. The study of tissues is known as histowgy. All of
the body tissues are grouped into four types. The types of tissues
distributed throughout the body and where they are located are as
follows:
• Epithelial tissue: This type of tissue makes up the skin, glands,
and linings of body cavities and organs. It is packed closely
together with little or no intercellular material, and it is clas-
sified according to shape as squamous (flat), cuboidal (square),
columnar (long and narrow), or transitional (varying shapes
that can stretch). Epithelial cells may be arranged in a single
layer of cells of the same shape, called simple epithelium, or in
many layers of cells named according to the shape of the cells
in the outer layer; this is called stratified epithelium.
• Connective tissue: This tissue supports and binds other body
tissues. Types of connective tissue include collagen, bone,
cartilage, adipose, ligaments, tendons, blood, and lymph.
Connective tissue is the most frequently occurring tissue in
the body and has the widest distribution.
• Muscle tissue: This tissue produces movement. It is classified
as skeletal muscle (striated, voluntary), which is attached to
bones and produces voluntary body movements when con-
tracted; cardiac muscle (striated and involuntary), which
forms the heart muscle wall; or smooth muscle (nonstriated
and involuntary), which lines the walls of blood vessels and
hollow organs and causes such actions as peristalsis and
vasoconstriction.
• Nervous tissue: This type of tissue conducts nerve impulses
between the periphery and the central nervous system (CNS).
It also effects rapid communication between body structures
 CHAPTER 8 Assisting with the Primary Physical Examination
Cranial
cavity
Thoracic cavity:
Dorsal
body Pleural cavity - -_,_
cavity
Pericardia! - - -,
cavity within
the mediastinum
Vertebral ---1,----a.1e
cavity
Pelvic cavity
Lateral view
FIGURE 8-1 The body cavities.
and controls the body's functions to maintain homeostasis.
Nervous tissue is made up of neurons and supportive struc-
tures called neuroglial cells.
Organs
An organ is composed of two or more types of tissue bound together
to form a more complex structure for a common purpose or func-
tion. An organ may have one or many functions; for example, the
pancreas has an endocrine function because it produces the hormone
insulin, and a digestive function because it produces digestive
enzymes. Organs also may be part of one or several systems. For
example, in the male system, the urethra is part of both the urinary
and the reproductive system.
Body Cavities
The body is separated into two main cavities called the dorsal (pos-
terior) and ventral (anterior) body cavities. The dorsal body cavity
protects organs of the nervous system and has two primary areas:
the cranial cavity within the skull, which encloses the brain; and the
spinal (vertebral) cavity, which surrounds the vertebral column and
spinal cord. The ventral cavity is separated into two general areas:
the thoracic cavity, which is surrounded by the ribs and muscles in
the chest and includes the pleural cavities (each lung is surrounded
by its own pleural cavity) and the mediastinum; and the pericardia!
cavity, which surrounds the heart and is located in the mediastinum.
The diaphragm separates the thoracic cavity from the abdominopel-
vic cavity. The abdominal cavity contains gastrointestinal organs,
173
Ventral body
cavity
{both thoracic and
abdominopelvic
cavities)
Abdomino-
pelvic cavity
Anterior view
including the stomach, spleen, liver, and intestines. The pelvic cavity
is not physically separated from the abdominal cavity; it contains
the urinary bladder, rectum, and reproductive organs (Figure 8-1 ).
Systems
A body system is composed of several organs and their associated
structures. These structures work together to perform a specific func-
tion in the body. Each system has specific units, and each performs
specific functions. Table 8-1 summarizes the body systems; their
primary cells, organs, and structures; and the major functions
of each.
PRIMARY CARE PROVIDER
A primary care provider (PCP) is a healthcare practitioner who sees
people of all ages for a broad range of diseases and complaints. The
PCP treats common medical problems and serves as the main health-
care provider in nonemergency situations. He or she evaluates the
patient's total healthcare needs, provides personal medical care in
one or more fields of medicine, and refers the patient to a specialist
when an advanced or serious condition warrants additional expertise.
Primary care usually is provided in an ambulatory care setting;
however, the PCP may assist in or direct hospitalized care. PCP
professionals include:
• Family practitioners: Physicians whose scope of practice
includes children and adults of all ages and may include
obstetrics and minor surgery.
174 UNIT ONE INTRODUCTION TO MEDICAL ASSISTING
TABLE 8-1 Organization of Body Systems
BODY SYSTEM CELLS, ORGANS, AND STRUCTURES
Blood Arteries, arterioles, veins, venules, white blood cells,
red blood cells, platelets, plasma
Cardiovascular Heart, valves, arteries, arterioles, veins, venules
Endocrine Pituitary, pineal gland, hypothalamus, thyroid,
pancreas, adrenal cortex and medulla, parathyroid,
thymus, ovaries, testes
lntegumentary Skin, subcutaneous tissue, sweat and sebaceous
glands, hair, nails, sense receptors
Gastrointestinal Mouth, tongue, teeth, pharynx, esophagus, stomach,
small intestine, large intestine, liver, gallbladder,
pancreas, appendix
Lymphatic and Lymph, lymph vessels, lymph nodes, thymus, tonsils,
immune spleen, lymphocytes, antibodies
Musculoskeletal Bones, joints, muscles, tendons, ligaments, cartilage
Nervous Brain, spinal cord, neurons, neuroglial cells, peripheral
nerves, autonomic nerves
Reproductive Female: Estrogen and progesterone, ovum, ovaries,
fallopian tubes, uterus, vagina, vulva, mammary glands
Male: Testosterone, sperm, epididymis, vas deferens,
prostate gland, testes, scrotum, penis, urethra
Respiratory Nose, sinuses, pharynx, larynx, trachea, bronchi, lungs,
bronchioles, alveoli
Sensory Eyes, ears, taste buds, olfactory receptors, sensory
receptors
Urinary Nephron unit, bilateral kidneys, ureters, urinary bladder,
urethra
• Pediatricians: Physicians who care for newborns, infants, chil-
dren, and adolescents.
• Internists: Physicians who care for adults of all ages with many
different medical problems, such as diabetes mellitus.
• Obstetricians/gynecologists: Physicians who serve as PCPs for
women, particularly those of childbearing age.
• Nurse practitioners (NPs) and physician assistants (PAs): Practi-
tioners who have earned advanced degrees and licensure and
FUNCTIONS
Transports materials and collects wastes throughout the body; white
blood cells fight infection; red blood cells carry oxygen; platelets help
form clots; plasma carries dissolved nutrients and other materials
Circulatory system transports materials in the blood throughout the
body; veins return deoxygenated blood ta the heart, which pumps it
into the lungs; oxygenated blood is pumped into the aorta and
branching arteries to cells throughout the body
Produces hormones that circulate in the blood to target tissue that
stimulates a particular action
Protection, temperature regulation; senses organ activity
Mastication, swallowing, digestion, absorption of nutrients, excretion
of waste materials
Maintains fluid balance; protects internal environment; defends against
foreign cells and disease; provides immunity ta same diseases
Movement, posture, heat production, support, protection, mineral
storage, hematopoiesis
Controls body structures ta maintain homeostasis; higher order thinking
and reflex centers that control autonomic processes; carries sensory
stimulus to the brain and motor impulses to the periphery
Produces hormones; reproduction
Responsible for inhalation of oxygen and exhalation of carbon dioxide
externally and exchange of oxygen and carbon dioxide internally at the
cellular level; acid-base regulation
Helps sense changes in the external and internal environments through
vision, hearing, balance, taste, and smell
Filters waste material from the blood; reabsorbs fluid and electrolytes as
needed; excretes waste in the urine; maintains electrolyte, water, and
acid-base balances; regulates blood pressure; activates red blood cells
who can work in primary or specialty medical practices and
clinics.
The medical assistant's clinical responsibilities in a primary care
practice include assisting with patients who may have problems in
any of the body systems and with procedures in all age groups. With
such a diversified scope of practice, the provider and medical assis-
tant must work as a team to use their time efficiently and still provide
quality, patient-centered healthcare.
 CHAPTER 8 Assisting with the Primary Physical Examination
PHYSICAL EXAMINATION
The purpose of a physical examination is to determine the patient's
overall state of well-being. All major organs and body systems are
checked during a physical examination. As the provider examines
the entire body, he or she interprets the findings, and by the time
the examination has been completed, the provider has formed an
initial diagnosis of the patient's condition. Often laboratory and
other diagnostic tests are ordered to supplement the provider's clini-
cal diagnosis. The results of these tests are used to refine the patient's
diagnosis, to help the provider plan or revise treatment for the
patient, to evaluate and maintain current drug therapy, and/or to
determine the patient's progress.
Preparing for the Physical Examination
Role of the Medical Assistant in the Physical Examination
Assessment of the patient begins with the first contact in the office.
The administrative medical assistant is responsible for verifying the
accuracy of the patient's insurance information according to office
policy. In most facilities, the policy is to make a copy of the patient's
insurance card when the patient first enters the office or, if the
patient has been to the office recently, to ask whether any of
the insurance information has changed. Before the examination, the
medical assistant has the opportunity to make sure the patient feels
comfortable during the examination process and that all the neces-
sary medical information has been obtained. The medical assistant's
duties include preparing and maintaining the examination room and
equipment, preparing the patient, and assisting the provider during
the physical examination.
Preparing the Examination Room. The medical assistant is respon-
sible for making sure the examination room is ready for any proce-
dure that might be performed during the physical examination. The
area should be as comfortable as possible for the patient and free of
any potential dangers, such as contaminated equipment or unlocked
drug cabinets. You should prepare the examination room as follows:
• Check the area at the beginning of each day and between
patients to make sure it is completely stocked with equipment
and supplies and that all equipment is functioning properly.
You must understand how to take care of and operate all
equipment and instruments, and you should refer to opera-
tion manuals supplied by manufacturers as needed.
• Regularly check expiration dates on all packages and supplies;
discard expired materials.
• Make sure the room is private, well lit, and at a comfort-
able temperature for the patient during the physical
examination.
• Clean and disinfect the area daily and between patients to
prevent the spread of infection and to ensure patients' com-
fort. When the patient leaves the room, discard the used exam
table paper. Using disinfectant wipes, clean the table and any
other potentially contaminated surface. When the table dries,
replace the exam table paper.
• Arrange drapes, gowns, and all other patient supplies before
the patient enters the room so that they are ready for use.
• To save time, prepare the instruments and equipment needed
for the examination, arranging them for easy access, before
the provider enters the room.
175
• Make sure the examination room has all materials required
for observing Standard Precautions, including disposable
gloves, a sink with an antibacterial hand-washing agent, paper
towels, biohazard waste containers, sharps containers, and
impervious gowns and face guards. Sharps containers are
replaced when they are two-thirds full, as indicated by Stan-
dard Precautions.
Assisting the Patient. Getting the patient ready for the examina-
tion includes taking care of paperwork before the patient enters the
examination room and performing related clinical skills.
• Make sure the health record is complete and that any needed
consent forms have been signed; document current medica-
tions and allergies; identify any medications that need refills.
The medical assistant is not responsible for obtaining informed
consent, but he or she should review the paperwork to make
sure that informed consent forms were reviewed by the pro-
vider and that the patient signed the forms.
• Introduce yourself, verify the patient's identity, and address
the patient by his or her preferred name, making sure to show
respect at all times. Pay close attention to the patient's non-
verbal language to make sure he or she understands what to
expect.
• Obtain specimens (e.g., urine, blood) if they have been pre-
ordered by the provider or if this practice is part of the office
policy.
• Measure and record the patient's height, weight, body mass
index (BMI), and vital signs.
• Conduct the initial investigation into the reason for the visit
and explain the examination procedure to the patient. Be
prepared to answer the patient's questions and allay any fears.
If needed, refer the patient's questions to the provider.
• Ask the patient whether he or she needs to empty the bladder
before the examination because a full bladder may interfere
with the examination and may be uncomfortable for the
patient.
• Help the patient physically prepare for the examination.
Explain to the patient what clothing should be removed and
in what direction to put on the gown (open to the front or
to the back, depending on the type of examination); provide
a drape to ensure the patient's privacy, and offer assistance as
needed.
• Assist the patient into and out of various examination posi-
tions as needed.
• Throughout this entire sequence of events, explain what is
happening, and consistently maintain the patient's privacy
and confidentiality.
• Help the patient with dressing as needed after the
examination.
Assisting the Provider. The medical assistant should be prepared
to help the provider complete the physical examination as compre-
hensively and efficiently as possible. During the examination, the
provider may expect the medical assistant to do the following:
• Hand him or her instruments and equipment as requested
and provide supplies as needed.
• Alter the position of the light source to better illuminate the
area being examined and turn lights off and on during specific
phases of the examination.
176 UNIT ONE INTRODUCTION TO MEDICAL ASSISTING
• Position and drape the patient during different phases of the
examination.
• Assist in collecting and properly labeling specimens such as
urine, Pap test specimens, and throat cultures.
• Conduct any diagnostic tests preordered by the provider,
including hearing and visual screenings.
• Conduct follow-up diagnostic procedures as ordered,
including an electrocardiogram (ECG), urinalysis, and
phlebotomy.
• Document patient data in the health record, completing all
forms required.
• Schedule postexamination diagnostic procedures, such as
mammography, x-ray examination, or colonoscopy.
CRITICAL THINKING APPLICATION 8-1
Felicia's first patient for the day is Harry Garcia, a 51-year-ald truck driver
who is scheduled for a complete physical examination. The provider ordered
an ECG and a complete blood panel to be drawn before the physical. What
does Felicia need to complete before Dr. Kosto sees the patient?
Supplies and Instruments Needed for
the Physical Examination
The instruments typically used during the physical examination are
shown in Figure 8-2. They enable the provider to see, feel, inspect,
and listen to parts of the body. All equipment must be in good
working order, properly disinfected, and readily available for the
provider's use during the examination. The instruments most fre-
Clean Fecal occult Percussion Tongue Tuning Otoscope Ophthalmoscope
nonsterile blood testing hammer depressor forks
gloves supplies
FIGURE 8-2 Instruments for the physical examination.
quently used for a physical examination are described in the follow-
ing paragraphs. Physical examinations typically are performed from
the head to the feet; the instruments are listed in the order in which
the provider typically would request them.
Ophthalmoscope. An ophthalmoscope is used to inspect the inner
structures of the eye. It consists of a stainless steel handle containing
batteries and an attached head, which has a light, magnifying lenses,
and an opening through which the eye is viewed. Examination
rooms usually are equipped with wall-mounted electrical units for
the ophthalmoscope and otoscope, a dispenser for disposable specu-
lums, and a wall-mounted sphygmomanometer.
Tongue Depressor. A tongue depressor is a flat, wooden blade used
to hold down the tongue when the throat is examined.
Otoscope. An otoscope is used to examine the external auditory
canal and tympanic membrane. It has a stainless steel handle con-
taining batteries or is part of a wall-mounted electrical unit. The
head of the otoscope has a light that is focused through a magnifying
lens; it should be covered with a disposable ear speculum. The light
also may be used to illuminate the nasal passages and throat.
Tuning Fork. Tuning forks are aluminum, fork-shaped instruments
that consist of a handle and two prongs (Figure 8-3, A). The prongs
produce a humming sound when the provider strikes them against
his or her hand. Tuning forks are available in different sizes, and each
size produces a different pitch level. A tuning fork is used to check
the patient's auditory acuity (Figure 8-3, B) and to test bone vibra-
tion (Figure 8-3, C) . A tuning fork can also be used to test for
diabetic peripheral neuropathy.
Tape Measure. A tape measure is a flexible ribbon ruler that is
usually printed in inches and feet on one side and in centimeters
and meters on the reverse side. Measurements may be used to assess
length and head circumference in infants, wound size, and so on.
Tape
measure
Ab
 CHAPTER 8 Assisting with the Primary Physical Examination
FIGURE 8-3 A, Tuning forks. B, Sound vibration test. C, Bone vibration test.
Stethoscope. A stethoscope is a listening device used when certain
areas of the body are auscultated, particularly the heart and lungs.
This instrument is available in many shapes and sizes. All have rwo
earpieces that are connected to flexible rubber or vinyl tubing (Figure
8-4). At the distal end of the tubing is a diaphragm or bell (many
have both); when it is placed securely on the patient's skin, it enables
the provider to hear internal body sounds.
Reflex Hammer. A reflex hammer is sometimes called a percussion
hammer. This stainless steel instrument has a hard rubber head that
is used to strike the tendons of the knee and elbow to test the neu-
rologic reflexes.
Gloves. Disposable examination gloves protect the healthcare
worker and the patient from microorganisms. According to Standard
Precautions, gloves must be worn whenever the potential exists for
contact with any body fluid, broken skin or wounds, or contami-
nated items.
Additional Supplies. Gauze squares, cotton balls, cotton-tipped
applicators, disposable tissues, specimen containers, fecal occult
blood test cards, Pap test supplies for female patients, lubricating
177
jelly for vaginal and rectal examinations, and laboratory request
forms should be easily accessible during the examination.
PRINCIPLES OF BODY MECHANICS
Medical assistants should use proper body mechanics consistently
throughout the work environment when sitting or standing, lifting
or carrying objects, pushing or pulling, or transferring patients.
Without consistent application of correct anatomic alignment, inju-
ries, especially lower back injuries, easily occur.
Proper body alignment begins with good posture. Maintaining
posture requires a combination of muscle efforts. Good posture
keeps the spine balanced and aligned while a person is sitting or
standing. A person in good body alignment can maintain balance
without undue strain on the musculoskeletal system.
When reaching for an object, avoid rwisting or turning; instead,
move the feet to face the object needed; this prevents undue strain
on the lumbar region. Do not cross the legs while sitting because
this interferes with circulation to the legs and feet. When sitting,
178 UNIT ONE INTRODUCTION TO MEDICAL ASSISTING

keep the popliteal area (behind the knees) free of the edge of the
chair. Pressure in this area interferes with circulation and may Transferring a Patient
damage nerves behind the knees. Do a mental check of your posture Patients may need assistance in moving from a chair to the examina-
regularly. Hold the head erect, the face forward and the chin slightly tion table or back again. Patients can be transferred in multiple ways,
up, the abdominal muscles contracted up and in, the shoulders but all should focus on correct body mechanics. If the patient is in
relaxed and back, the feet pointed forward and slightly apart, and a wheelchair, move the chair at a 45-degree angle toward the foot
the weight evenly distributed to both legs, with the knees slightly
bent. Always be on the alert for poor body mechanics that may cause
injury (Figures 8-5 and 8-6).

Safe Lifting Techniques

• Always get help if the load is too heavy.
• Maintain correct body alignment, with the legs spread apart far a broad
base of support.
• Do not reach far items; clear barriers out of the way and get as close
as possible to what needs to be lifted.
• Bend at the knees with the feet shoulder width apart and keep the
back straight. Use the major muscle groups of the arms and legs
rather than the weaker ones of the back to help lift a heavy item (see
Figure 8-5).
• When carrying a heavy item, keep the weight as close to the body as
possible (see Figure 8-6).
• Move the feet in the direction of the lift. Do not twist or turn on fixed
feet.
• Bend the knees while keeping the back straight when lowering an item
at the completion of a lift.
• If possible, slide, roll, or push a heavy item rather than lifting or
pulling it. FIGURE 8-4 Stethoscope. (Modified from Ball JW, et al: Seidel's guide to physical examination,
ed 8, St Louis, 2015, Mosby.)

©Elsevier Collection B ©Elsevier Collection

FIGURE 8-5 A, Proper lifting technique. B, Improper lifting technique.

 CHAPTER 8 Assisting with the Primary Physical Examination
FIGURE 8-6 A, Carrying an item close to the body. B, Improper carrying technique.
FIGURE 8-7 Wheelchair at a 45-degree angle at the end of the exam table.
rest that extends from the bottom of the exam table (Figure 8-7),
lock the wheels, and lift the foot rests of the wheelchair out of the
way. Explain the procedure to the patient and ask for his or her
assistance.
If one side of the patient is stronger than the other, always provide
support on the strong side. Support the patient close to your body
on the strong side, with one hand under the axillary region and the
other either grasping the patient's hand or holding the forearm.
When bending, always bend at the knees and maintain the back's
three natural curves, allowing the leg muscles to help in lifting. Give
the patient a signal and lift as the patient assists. Help the patient
step up onto the foot rest with the strong leg first, then pivot. Ease
the patient down onto the table, bending your knees while keeping
your back aligned. Make sure the patient is comfortable and safely
positioned on the table.
Use a gait belt as needed to help transfer patients to prevent
injury to yourself and to safeguard patients from falling. A gait belt
is a safety device that is used to help transfer a patient from a wheel-
chair to the exam table or to help a patient ambulate. The gait belt
179
helps you support the patient while keeping your body in proper
alignment, to prevent back injuries. A gait belt should be used if the
patient is weak and at risk of falling. To use a gait belt:
• Place the belt around the individual's waist over clothing with
the buckle in front.
• Insert the belt through the teeth of the buckle and pull it tight
to lock it.
• The belt should be tight, with just enough room to place your
fingers under it.
• Grip the belt tightly, bend your knees, and keep your back
straight.
• Ask the patient to assist you; then lift, using your arm and leg
muscles.
• Avoid twisting or turning as you help the patient stand.
• Keep your body close to the patient's with your knees in
front of his or hers at all times to stabilize the patient and
prevent falls.
• Complete the transfer without bending or twisting your body;
encourage the patient to bear as much weight as possible and
to gently sit down on the table.
• After transferring the patient, remove the gait belt for the
provider's examination and replace it to help transfer the
patient back to the wheelchair after the provider is finished.
• If the patient should start to fall during a transfer, do not try
to stop the fall because you may be injured; use the gait belt
to help guide the patient to the floor as gently as possible.
You may need to remain with the patient until the examination
has been completed to ensure his or her safety. If the provider prefers
that the patient be in a supine position, place one arm across the
patient's shoulders and the other under the knees, and smoothly
lower the patient's upper body to the table while raising the legs. Use
the same pivoting techniques with proper body mechanics to help
transfer the patient from the examination table back to the locked
wheelchair. If the patient must hold onto you, have the person hold
your waist or shoulders, not your neck (Procedure 8-1 ).
180 UNIT ONE INTRODUCTION TO MEDICAL ASSISTING

•;;J,1,ammj:j• Use Proper Body Mechanics

Goal: To safely transfer apatient from a wheelchair to an examination table using proper body mechanics.

EQUIPMENT and SUPPLIES PURPOSE: This position helps you maintain good body mechanics during
• Patient's record the transfer.
• Wheelchair
• Examination table with pull-out foot rest
• Gait belt
PROCEDURAL STEPS
1. Sanitize your hands.
PURPOSE: To ensure infection control.
2. Greet and identify the patient, introduce yourself, and determine how
much assistance the patient will need to transfer from the wheelchair to
the examination table. Do not proceed if you think you will need additional
help.
PURPOSE: To promote the patient's cooperation during the transfer and
prevent personal injury.
3. Place the wheelchair at a 45-degree angle toward the foot rest at the
base of the examination table (see Figure 8-7) .
4. Lock the brakes on the wheelchair and move the foot rests of the wheel-
8. Slide your fingers under the gait belt on opposite sides of the patient's
chair out of the way (Figure 1).
PURPOSE: Never transfer a patient into or out of a wheelchair until the waist.
9. Instruct the patient at the count of 3 to push off from the armrests while
brakes are locked on both sides af the chair.
you at the same time grasp the gait belt and, using your leg muscles,
straighten your knees so that the patient is in a standing position.
PURPOSE: This position allows the patient to assist as much as possible
while you are using the large muscles of your legs to help lift her.
10. Ask the patient to step up onto the foot rest at the bottom of the exam
table, and assist the person in pivoting and sitting down on the examina-
tion table. Remove the gait belt until the provider has completed the
examination (Figure 3).

S. Place the gait belt around the patient's waist over clothing with the buckle
in front. Insert the belt through the teeth of the buckle and pull it tight to
lock it. The belt should be tight with just enough room to place your fingers
under it.
6. Request that the patient place both feet flat on the floar with the hands
on the armrests.
PURPOSE: This position helps you grasp the gait belt, the patient can use
the wheelchair armrests to help push her into an upright position, and feet 11. After the examination is complete, place the wheelchair at an angle next
flat on the floor help with patient stability. to the exam table and lock the wheels. Replace the gait belt. Make sure
7. Stand directly in front of the patient with your feet apart, back straight, the patient is positioned at the bottom edge of the table.
and knees bent (Figure 2). PURPOSE: To prepare for transfer back to the wheelchair.
 CHAPTER 8 Assisting with the Primary Physical Examination
•;;m!,mj;jj:il -,;ontinued
12. Place yourself directly in front of the patient with your back straight and
your knees bent. Slide your fingers under the gait belt on opposite sides
of the patient's waist.
13. Grasp the gait belt on both sides at the waist. Instruct the patient at the
count of 3 to push •ff fram the examination table and, using your leg
muscles, straighten your knees so that the patient is in a standing position
on the foot rest.
ASSISTING WITH THE PHYSICAL EXAMINATION
Positioning and Draping the Patient for
the Physical Examination
Various patient positions are used to facilitate a physical examina-
tion. The medical assistant instructs the patient about and assists the
patient into these positions, ensuring as much ease and modesty as
possible, and helps the patient maintain the position during the
examination with as little discomfort as possible. Do not place a
patient into a position that is uncomfortable or that compromises
the patient's privacy until it is necessary to complete that part of the
examination. Never leave the patient's side ifhe or she is in a position
that could result in a fall.
Draping the patient with an examination sheet protects the indi-
vidual from embarrassment and keeps the patient warm. However,
the sheet must be positioned so that it allows complete visibility
for the examiner and does not interfere with the examination.
During the general examination, each part of the body is exposed
one portion at a time. For gynecologic and rectal examinations, the
sheet is positioned on the diagonal across the patient, or in a diamond
shape, to provide maximum comfort for the patient while allowing
the provider to perform the examination.
The following sections describe a number of the positions used
during medical examinations.
Fowler's Position
In Fowler's position, the patient sits on the examination table with
the head of the table elevated 90 degrees. This position is useful for
examinations and treatments of the head, neck, and chest, and for
patients with orthopnea who have difficulty breathing while lying
down. Drape placement varies, depending on the type of physical
examination done and the need to maintain the patient's privacy
(Procedure 8-2).
Semi-Fowler's Position
Semi-Fowler's position is a modification of Fowler's position. The
head of the table is positioned at a 45-degree angle instead of at a
full 90-degree angle. This position is useful for postoperative exami-
nation, for patients with breathing disorders, and for patients
suffering from head trauma or pain (see Procedure 8-2). The
181
14. Maintaining your hold on the gait belt, ask the patient to step down. Pivot
the person so that she can slowly sit in the wheelchair; at the same time,
bend your knees but keep your back straight.
1S. Remove the gait belt. Replace the wheelchair foot rests and unlock the
brakes on the wheelchair.
drape and/or gown should cover the entire patient from the nipple
line down.
Supine (Horizontal Recumbent) Position
In the supine position, the patient lies flat with the face upward and
the lower legs supported by the table extension (Procedure 8-3). This
position is used for examination of the front of the body, including
the heart, breasts, and abdominal organs. The patient's gown should
open down the front, and the drape should be placed over any
exposed area that is not being examined.
Dorsal Recumbent Position
In the dorsal recumbent position, the patient lies face upward, with
the weight distributed primarily to the surface of the back. This is
accomplished by flexing the knees so that the feet are flat on the
table. This position relieves muscle tension in the abdomen and
may be used for examination and/ or inspection of the rectal, vaginal,
and perinea! areas; or, it may be used if the patient experiences
back discomfort when lying supine. This position can be used for
digital examination of the vagina and rectum, but it is not used if
an instrument such as a speculum is needed. To ensure the patient's
privacy, it is important to keep the patient completely draped, with
the drape in a diamond shape, until the provider is present (see
Procedure 8-3).
lithotomy Position
The patient should not be placed in the lithotomy position until the
provider is in the examination room and is ready for this part of the
examination. Place the patient on his or her back with the knees
sharply flexed and the arms at the sides or folded over the chest; have
the patient slide the buttocks down to the bottom edge of the table.
Support the feet in stirrups placed wide apart and somewhat away
from the table, with the stirrup arms extended to match the length
of the patient's legs. If the heels are too dose to the buttocks, the
possibility of leg cramps increases, and it is more difficult for the
patient to relax the abdominal muscles. Make sure the stirrups are
locked in place. Place a drape diagonally over the patient's abdomen
and knees. The drape must be long enough to cover the knees and
touch the ankles and wide enough to prevent the sides of the thighs
from being exposed. The provider lifts the drape away from the pubic
182 UNIT ONE INTRODUCTION TO MEDICAL ASSISTING

area when the examination begins (Procedure 8-4). The lithotomy

position is used primarily for vaginal examinations that require the
use of a speculum and for Pap tests.

Sims Position
Sims position is sometimes called the lateral position. The patient is
placed on the left side; the left arm and shoulder are drawn back
behind the body so that the body's weight is predominantly on the
chest. The right arm is flexed upward for support. The left leg is
slightly flexed, and the buttocks are pulled to the edge of the table.
The right leg is sharply flexed upward. The drape extends diagonally
from under the arms to below the knees. The provider can raise a
small portion of the sheet from the back of the patient to expose the
rectum sufficiently. The remaining portion of the sheet covers the
patient's chest area and thighs. This position is used for rectal exami- FIGURE 8-8 Trendelenburg position.
nations, for instillation of rectal medication, and for some perinea!
and pelvic examinations (Procedure 8-5). maintain. These positions are used for proctologic examination and
for sigmoid, rectal, and occasionally vaginal examinations. The
Prone Position patient's gown should open in the back, and a fenestrated (opening)
In the prone position, the patient lies face down on the table on the drape or a single sheet should be draped diagonally over the patient's
ventral surface of the body. This is the opposite of the supine position back at the sacral area (Procedure 8-7).
and is another of the recumbent positions. The drape should cover
from the middle of the back to below the knees, with the gown Trendelenburg Position
opening in the back (Procedure 8-6). This position is used for exami- Trendelenburg position is rarely used in the ambulatory care setting,
nation of the back and for certain surgical procedures. but it may be needed if a patient has severe hypotension or is going
into shock. This position can be achieved only if the examination
Knee-Chest Position table separates so that the legs can be elevated higher than the head
For the knee-chest position, the patient rests on the knees and the (Figure 8-8).
chest with the head turned to one side. The arms can be placed under
the head for support and comfort, or they can be bent and placed
at the sides of the table near the head. The thighs are perpendicular CRITICAL THINKING APPLICATION 8-2
to the table and slightly separated. The buttocks extend up into the Determine the correct patient position and method of gowning and draping
air, and the back should be straight. The patient will need assistance for the following examinations:
to assume the knee-chest position correctly. Most patients have dif- • Insertion of a rectal suppository
ficulty maintaining this position, so they should not be placed into • Annual Papanicolaau (Pap) test
it until it is required. The medical assistant must remain next to the • Examination of the back
patient for assistance and support the entire time the knee-chest • Patient with dyspnea
position is needed. If the correct knee-chest position cannot be
• Breast examination
obtained, the patient may have to be placed in a knee-elbow posi-
tion. This position puts less strain on the patient and is easier to Text continued on p. 521

•;;m!,mmj:fj Assist Provider with a Patient Exam: Fowler's and Semi-Fowler's Positions

Goal: To position and drape the patient for examinations of the head, neck, and chest, or patients who have difficulty breathing
when lying flat.
EQUIPMENT and SUPPLIES PROCEDURAL STEPS
• Patient's record 1. Sanitize your hands.
• Examination table PURPOSE: To ensure infection control.
• Table paper 2. Greet and identify the patient, introduce yourself, and determine whether
• Patient gown the patient understands the procedure. If the patient does not, explain what
• Drape ta expect.
• Disinfectant wipes PURPOSE: To promote the patient's understanding and cooperation during
• Disposable gloves the examination.
 CHAPTER 8 Assisting with the Primary Physical Examination 183

•;;m!,mj;jj:fI -continued
3. Give the patient a gown. Explain what clothing must be removed for the
particular examination being done and whether the gown should open in
the front ar the back. Provide assistance as needed. Give the patient privacy
while changing. Knock on the examination room door before re-entering to
make sure the patient has completed undressing and gowning.
4. For Fowler's position, elevate the head of the bed 90 degrees. If the patient
feels more comfortable, she can sit at the end of the table (Figure l).
Extend the foot rest as needed for patient comfort. The patient may be
more comfortable in semi-Fowler's position. In this modification of Fowler's
position, the head of the table is elevated 45 degrees. Semi-Fowler's posi-
tion may be used for postoperative follow-up or for patients with a fever,
head injury, or pain. It also is a comfortable, supportive position for patients
with breathing disorders (Figure 2).
S. Drape the patient according to the type of examination and the required
patient exposure.
PURPOSE: Draping the patient provides warmth and privacy while giving
the provider access to the examination site.
6. After the examination has been completed, assist the patient as needed to
get off the table and get dressed.
7. Put on gloves and use disinfectant wipes to clean the exam table and all
potentially contaminated suriaces. Dispose of used gloves and examination
table paper according to facility policies. Pull clean paper over the table.
PURPOSE: To ensure infection control and to prevent the transmission of
pathogens from one patient to another.
8. Sanitize your hands.
9. Follow up with the provider's orders regarding scheduling of diagnostic
studies, collection of specimens, and/or scheduling of future appointments.

Assist Provider with a Patient Exam: Horizontal Recumbent and Dorsal

PROCEDURE 8-3
Recumbent Positions

Goal: To position and drape the patient for examinations of the abdomen, heart, and breasts in the horizontal recumbent
(supine) position, and exams of the rectal, vaginal and perinea/ areas in the dorsal recumbent position.
EQUIPMENT and SUPPLIES PROCEDURAL STEPS
• Patient's record 1. Sanitize your hands.
• Examination table PURPOSE: To ensure infection control.
• Table paper 2. Greet and identify the patient, introduce yourself, and determine whether
• Patient gown the patient understands the procedure. If the patient does not, explain
• Drape what to expect.
• Disinfectant wipes PURPOSE: To promote the patient's understanding and cooperation during
• Disposable gloves the examination.
184 UNIT ONE INTRODUCTION TO MEDICAL ASSISTING

•;iI11,ammj:$• -continued

3. Give the patient a gown. Explain the clothing that must be removed for
the particular examination being done and whether the gown should open
in the front or in the back. Provide assistance as needed. Far the horizontal
recumbent position, the gown should be open in the front. Give the patient
privacy while changing. Knock on the examination room door before
re-entering to make sure the patient has completed undressing and
gowning.
4. Do not place the patient in the necessary positions until the provider is
ready for that part of the examination.
PURPOSE: To ensure the patient's privacy, comfort, and modesty.
S. Pull out the table extension that supports the patient's legs. For the hori-
zontal recumbent (supine) position, help the patient lie flat on the table
with the face upward (Figure l). For the dorsal recumbent position, have
6. Drape the patient from nipple line to feet in the supine position, and
the patient lie flat on the back and flex the knees so the feet are flat on
diagonally with the point of the drape between the feet for the dorsal
the table (Figure 2). If needed, help the patient move down toward the
recumbent position.
foot of the table for the examination.
PURPOSE: Draping the patient provides warmth and privacy while giving
the provider access to the examination site.
7. After the examination has been completed, assist the patient as needed
to get off the table and get dressed.
8. Put on gloves and use disinfectant wipes to clean the exam table and all
potentially contaminated surfaces. Dispose of used gloves and examina-
tion table paper according to facility policies. Pull clean paper over the
table.
PURPOSE: To ensure infection control and to prevent the transmission of
pathogens from one patient to another.
9. Sanitize your hands.
10. Follow up with the provider's orders regarding scheduling of diagnostic
studies, collection of specimens, and/or scheduling of future
appointments.

•;;m,ammj:i• Assist Provider with a Patient Exam: Lithotomy Position

Goal: To position and drape the patient primarily for vaginal and pelvic examinations and Pap tests.

EQUIPMENT and SUPPLIES 2. Greet and identify the patient, introduce yourself, and determine whether
• Patient's record the patient understands the procedure. If the patient does not, explain
• Examination table what to expect.
• Table paper PURPOSE: To promote the patient's understanding and cooperation during
• Patient gown the examination.
• Drape 3. Give the patient a gown. Instruct the patient to undress from the waist
• Disinfectant wipes down with the gown open in the back. If the provider also will be doing
• Disposable gloves a breast examination, the patient should undress completely and put on
the gown so that it opens in the front. Provide assistance as needed. Give
PROCEDURAL STEPS the patient privacy while changing. Knock on the examination room door
1. Sanitize your hands. before re-entering to make sure the patient has completed undressing and
PURPOSE: To ensure infection control. gowning.
 CHAPTER 8 Assisting with the Primary Physical Examination 185

•;iI11,ammj:i• -continued

4. Do not place the patient in the lithotomy position until the provider is 7. Drape the patient diagonally, with the paint of the drape between the
ready for that part of the examination.
PURPOSE: Ta promote the patient's privacy, comfort, and safety.
S. Pull out the table extension that supports the patient's legs and help the
patient lie face upward on the table. Pull out the stirrups, adjust their
extension length for the patient's comfort, and lock them in place.
6. Reinsert the table extension and have the patient move toward the foot 8.
of the table with her buttocks on the bottom table edge. Gently place the
patient's legs in the stirrups, checking for comfort. Some offices may stock 9.
cloth or paper stirrup covers to protect the patient and make the position
more comfortable. The patient's arms can be placed alongside the body
or across the chest (Figure l) .
10.
11.
feet. The drape should be large enough to cover the patient fram the
nipple line to the ankles and wide enough so the patient's thighs are not
exposed.
PURPOSE: Ta provide warmth and privacy for the patient while giving the
provider access to the examination site.
After the examination has been completed, assist the patient as needed
to get off the table and get dressed.
Put on gloves and use disinfectant wipes to clean the exam table and all
potentially contaminated surfaces. Dispose af used gloves and examina-
tion table paper according to facility policies. Pull clean paper over the
table.
PURPOSE: Ta ensure infection control and to prevent the transmission of
pathogens from one patient to another.
Sanitize your hands.
Follow up with the provider's orders regarding scheduling of diagnostic
studies, collection of specimens, and/or scheduling of future
appointments.

•;;m,ammj:j.j Assist Provider with a Patient Exam: Sims Position

Goal: To position and drape the patient for examination of the rectum, instillation of rectal medication, perinea/ examination,
and some pelvic examinations.
EQUIPMENT and SUPPLIES PURPOSE: Ta promote the patient's understanding and cooperation during
• Patient's record the examination.
• Examination table 3. Give the patient a gown and explain what clothing must be removed for
• Patient gown the particular examination being dane. Tell the patient that the gawn
• Table paper should open in the back. Provide assistance as needed. Give the patient
• Drape privacy while changing. Knock on the examination room door before
• Disinfectant wipes re-entering ta make sure the patient has completed undressing and
• Disposable gloves gowning.
4. Do nat place the patient in the Sims position until the provider is ready
for that part of the examination.
PROCEDURAL STEPS PURPOSE: Ta promote the patient's privacy, comfort, and safety.
1. Sanitize yaur hands. S. Help the patient turn onto the left side; the left arm and shoulder should
PURPOSE: Ta ensure infection control. be drawn back behind the body so that the patient is tilted onto the chest.
2. Greet and identify the patient, introduce yourself, and determine whether Flex the right arm upward for support, slightly flex the left leg, and sharply
the patient understands the procedure. If the patient does not, explain flex the right leg upward. Help the patient mave the buttocks to the side
what to expect. edge af the table (Figure l).
186 UNIT ONE INTRODUCTION TO MEDICAL ASSISTING

I; d•iM m);j j:Jj -continued

PURPOSE: Draping the patient provides warmth and privacy while giving
the provider access to the examination site.
7. After the examination has been completed, assist the patient as needed
to get off the table and get dressed.
8. Put an gloves and use disinfectant wipes to clean the exam table and all
potentially contaminated surfaces. Dispose af used gloves and examina-
tion table paper according to facility policies. Pull clean paper aver the
table.
PURPOSE: To ensure infection control and prevent the transmission of
pathogens from one patient ta another.
9. Sanitize your hands.
10. Follow up with the provider's orders regarding scheduling of diagnostic
studies, collection of specimens, and/or scheduling of future
appointments.
6. Drape the patient diagonally in a diamond shape, with the point of the
diamond dropping below the buttocks. Make sure the drape is large
enough to prevent exposure of the patient.

•;;m!,m);jj:il Assist Provider with a Patient Exam: Prone Position

Goal: To position and drape the patient for examination of the back and certain surgical procedures.
EQUIPMENT and SUPPLIES 4. Do not place the patient in the prone position until the provider is ready
• Patient's record for that part of the examination.
• Examination table PURPOSE: To promote the patient's privacy, comfort, and safety.
• Patient gown S. Pull out the table extension and help the patient lie down on his ar her
• Table paper stomach (Figure l) .
• Drape
• Disinfectant wipes
• Disposable gloves
PROCEDURAL STEPS
1. Sanitize your hands.
PURPOSE: To ensure infection control.
2. Greet and identify the patient, introduce yourself, and determine whether
the patient understands the procedure. If the patient does not, explain
what to expect.
PURPOSE: To promote the patient's understanding and cooperation during
the examination.
3. Give the patient a gown and explain what clothing must be removed for
the particular examination being done. Tell the patient that the gown
should open in the back. Provide assistance as needed. Give the patient
privacy while changing. Knock on the examination room door before
re-entering ta make sure the patient has completed undressing and 6. Drape the patient aver any exposed area that is not included in the
gowning. examination. Far female patients, the drape should be large enough to
 CHAPTER 8 Assisting with the Primary Physical Examination
•;;J,1!,m);jj:il -continued
cover from the breasts to the feet so that the patient is not exposed
accidentally if she is asked to roll aver.
PURPOSE: Draping the patient provides warmth and privacy while giving
the provider access ta the examination site.
7. After the examination has been completed, assist the patient as needed
to get off the table and get dressed.
8. Put on gloves and use disinfectant wipes to clean the exam table and all
potentially contaminated surfaces. Dispose of used gloves and examina-
•;;m,ammj:fj Assist Provider with a Patient Exam: Knee-Chest Position
Goal: To position and drape the patient for examinations of the back and rectum and for certain surgical procedures.
EQUIPMENT and SUPPLIES
• Examination table
• Table paper
• Patient gown
• Drape
• Disinfectant wipes
• Disposable gloves
PROCEDURAL STEPS
1. Sanitize your hands.
PURPOSE: To ensure infection control.
2. Greet and identify the patient, introduce yourself, and determine whether
the patient understands the procedure. If the patient does not, explain
what to expect.
PURPOSE: To promote the patient's understanding and cooperation during
the examination.
3. Give the patient a gown and explain what clothing must be removed for
the particular examination being done. Tell the patient that the gown
should open in the back. Provide assistance as needed. Give the patient
privacy while changing. Knock on the examination room door before
re-entering ta make sure the patient has completed undressing and
gowning.
4. Do not place the patient in the knee-chest position until the provider is
ready far that part of the examination.
PURPOSE: To promote the patient's privacy, comfort, and safety.
S. Pull out the table extension if necessary. Help the patient lie dawn an his
or her back and then turn over into the prone position. Ask the patient to
move up onto the knees, spread the knees apart, and lean forward onto
the head so that the buttocks are raised. Tell the patient to keep the back
straight and turn the face to either side. The patient should rest his or her
weight on the chest and shoulders (Figure 1).
187
tion table paper according to facility policies. Pull clean paper over the
table.
PURPOSE: To ensure infection control and to prevent the transmission of
pathogens from one patient to another.
9. Sanitize your hands.
10. Follow up with the provider's orders regarding scheduling of diagnostic
studies, collection of specimens, and/or scheduling of future
appointments.
6. If the patient has difficulty maintaining this position, an alternative is ta
place weight on bent elbows with the head off the table.
7. Drape the patient diagonally so that the point af the drape is on the table
between the legs.
PURPOSE: Draping the patient provides warmth and privacy while giving
the provider access to the examination site.
8. After the examination has been completed, assist the patient as needed
to get off the table and get dressed.
9. Put on gloves and use disinfectant wipes to clean the exam table and all
potentially contaminated surfaces. Dispose of used gloves and examina-
tion table paper according to facility policies. Pull clean paper over the
table.
PURPOSE: To ensure infection control and to prevent the transmission of
pathogens from one patient to another.
10. Sanitize your hands.
11. Follow up with the provider's orders regarding scheduling of diagnostic
studies, collection of specimens, and/or scheduling of future
appointments.
188 UNIT ONE INTRODUCTION TO MEDICAL ASSISTING
Methods of Examination
Examinations are performed as both a routine confirmation of the
absence of illness and a means of diagnosing disease. Healthcare
providers use six methods to examine the human body: inspection,
palpation, percussion, auscultation, mensuration, and manipulation.
All six are part of a complete physical examination.
Inspection
During the inspection, the examiner uses observation to detect sig-
nificant physical features or objective data. This method of examina-
tion ranges from focusing on the patient's general appearance
(general state of health, including posture, mannerisms, and groom-
ing) to more detailed observations, including body contour, gait,
symmetry, visible injuries and deformities, tremors, rashes, and color
changes.
Palpation
In palpation, the examiner uses the sense of touch (Figure 8-9, A).
A part of the body is felt with the hand to determine its condition
or the condition of an underlying organ. Palpation may involve
touching the skin or performing a firmer exploration of the abdomen
for underlying masses. This technique involves a wide range of per-
ceptions, including temperature, vibration, consistency, form, size,
rigidity, elasticity, moisture, texture, position, and contour. Palpation
is performed with one hand, both hands (bimanual), one finger
FIGURE 8-9 A, Demonstration of palpation. B, Demonstration of percussion. C, Demonstration of auscultation. (From Ball JW, et al: Seidel's
guide to physical examination, ed 8, St Louis, 2015, Mosby.)
(digital), the fingertips, or the palmar aspect of the hand. A pelvic
examination is done bimanually, whereas an anal examination is
performed digitally. Do not confuse palpation with palpitation,
which is a throbbing pulsation felt in the chest.
Percussion
Percussion involves tapping or striking the body, usually with the
fingers or a small hammer, to elicit sounds or vibratory sensations.
Percussion aids determination of the position, size, and density of
an underlying organ or cavity. The effect of percussion is both heard
and felt by the examiner; it is helpful in determining the amount of
air or solid matter in an underlying organ or cavity. The two basic
methods of percussion are direct percussion and indirect percussion.
Direct (immediate) percussion is performed by striking the body
with a finger or a reflex hammer. With indirect (mediate) percussion,
which is used more frequently, the provider places his or her hand
on the area and then strikes the placed hand with a finger of the
other hand (see Figure 8-9, B). Both a sound and a sense of vibration
are evident. The examiner quantifies the sound in terms of pitch,
quality, duration, and resonance.
Auscultation
For auscultation, the provider uses a stethoscope to listen to sounds
arising from the body (not the sound produced by the provider, as
in percussion, but sounds that originate within the patient's body).
Auscultation is a difficult method of examination because the
 CHAPTER 8 Assisting with the Primary Physical Examination 189

provider must distinguish between a normal sound and an abnormal

sound (see Figure 8-9, C) . It is particularly useful for evaluating
sounds originating in the lungs, heart, and abdomen, such as a
murmur, a bruit, and bowel sounds.
Mensuration
Mensuration is the process of measuring. Measurements that are
recorded include the patient's height and weight, the length and
diameter of an extremity, the extent of flexion or extension of an
extremity, the size of the uterus during pregnancy, the size and depth
of a wound, and the pressure of a grip. Measurements are taken with
a flexible tape measure, a circular wound measurement device (Figure
8-10), or a specialized piece of equipment (e.g., a goniometer, which
is used to measure joint angles) and usually are recorded in
centimeters.
Manipulation
Manipulation is the passive movement of a joint to determine the
range of extension or flexion of a part of the body. Manipulation
may or may not be grouped with palpation. It usually is considered
separate from the four standard methods of examination (inspection,
palpation, percussion, and auscultation) and is grouped with men-
suration, especially by an orthopedist or a neurologist. Insurance
and industrial reports often request this information in detail. For
example, a patient involved in a work-related accident that caused
joint damage may have to perform assisted range-of-motion (ROM)
exercises to the joint, with subsequent measurements of joint flexion
and extension to demonstrate improvement or lack thereo(
Diameter in Centimeters
EXAMINATION SEQUENCE
The physical examination sequence is fairly standard; however, varia-
tions may occur, depending on the provider's specialty, the medical
necessity for the examination, and the provider's preference. Patients
are more cooperative and less anxious if they understand what is
expected of them; therefore, you should start by giving the patient
a brief explanation of the examination process. Assemble all supplies
and instruments needed for the examination before the provider
enters the room. As the provider proceeds with the examination,
make sure the patient remains unexposed by adjusting the drape and
gown as needed. In every examination, the medical assistant assists
the provider by handing the correct instruments and needed sup-
plies. Having an assistant in the room during the examination can
help prevent lawsuits. When the provider begins the examination,
the medical assistant should keep conversation to a minimum and
remain inconspicuous. The examination usually starts with the
patient seated at the end of the exam table or in Fowler's position if
the patient needs support. If the provider uses reflected light, the
light source should be behind the patient's right shoulder. If illumi-
nated instruments are used, standard overhead lights are sufficient.
Take care not to shine a light directly into the patient's eyes; this can
be done by turning on lights while they are directed away from the
patient and carefully moving the light toward the area.
General Appearance
The provider starts the physical examination by observing the
patient's appearance, using an inspection technique. The general
appearance explains whether the patient appears well and in good
health (e.g., the patient appears disoriented or in distress; well-
nourished or undernourished; and answers questions with ease or
confusion).
The patient's gait often provides important information. The
patient may limp, walk with the feet wide apart, have a shuffle step,
or have difficulty maintaining his or her balance. In addition to gait,
all the patient's body movements are observed for possible muscle
actions that the provider deems unusual. Posture also is checked for
indications of pain, stiffness, or difficulty with limb movement. The
provider notes body build and proportions. Any gross (immediately
obvious) deformities are recorded. Sometimes abnormalities in
height or body proportion may be caused by hormonal imbalances.
If the medical assistant notes any of these observations or the patient
reports any complaints, these should be recorded in the patient's
health record, along with the vital signs, before the provider begins
the examination.

Speech
Speech may reveal a pathologic condition. Some basic speech defects
include aphonia, the inability to speak because of loss of the voice,
which is commonly seen with severe laryngitis or overuse of the
voice; aphasia, the loss of expression by speech or writing because of
an injury or disease of the brain; and dysphasia, lack of coordination
and failure to arrange words in proper order, usually caused by a
111111111111111111~11111111~11111111~11111111~1111111~11111111~11111111~11111111~111111~161111111~\llllll\l~lllllll\l~I brain lesion. With motor aphasia, the patient knows what he or she
Centimeters wants to say but cannot use muscles properly to speak; for example,
Discard After Use this may be seen as slurred or incoherent speech that might occur
FIGURE 8-10 Circular wound measurement device. after a cerebrovascular accident (CVA). In semory aphasia, the patient
190 UNIT ONE INTRODUCTION TO MEDICAL ASSISTING
pronounces words easily but uses them inaccurately, as in jumbled
speech. Speech is also assessed in well-child checkups. A delay in
speech development can indicate an issue (e.g., a neurologic deficit
or possible autism spectrum disorder) and the need for a referral.
Breath Odors
Breath odors may or may not be diagnostic, although they often are
associated with poor oral hygiene or dental care. Acidosis produces
a strong odor of acetone, which is sweet and fruity and may result
from diabetes mellitus, starvation, or renal disease. A musty odor
usually is associated with liver disease, and the odor of ammonia may
be noted in cases of uremia.
Skin
The condition of the skin can be a good reflection of the patient's
nutritional status and hydration level. If dehydration is suspected,
skin turgor is checked by pinching the skin on the posterior surface
of the hands. The tissue is observed to see how quickly it returns to
the normal location. A delay indicates a decrease in tissue fluid,
confirming the diagnosis of dehydration. Extreme dryness, scaling,
extended time for wound healing, or frequent breaks in the skin may
indicate systemic disease.
Fingernails and toenails often give some indication of a person's
health. Brittle, grooved, or lined nails may indicate local infection
or systemic disease. Clubbing of the fingertips is associated with
some congenital heart or lung diseases. Spooning of the nail is seen
in some patients with severe iron-deficiency anemia. Beau's lines
appear after an acute illness but grow out and disappear. The pro-
vider may refer a patient with skin disorders to a dermatologist for
diagnosis and treatment.
Head
Once the provider makes the overall observations of the patient's
general condition, the physical examination typically begins with the
head and face and moves downward to the feet. The face reflects
the patient's state and tells the provider a great deal about how the
patient handles stress and illness. The skull, scalp, and face are pal-
pated for size, shape, and symmetry. The distribution or lack of hair
and hair texture may indicate hormonal changes. Excessive hair,
especially facial hair in females, indicates a hormonal imbalance. As
the head is palpated, the provider assesses possible nodules, masses,
or signs of trauma.
Eyes
The pupils are checked for reaction by shining a light into one eye
at a time. If the pupils constrict equally and smoothly to a light
stimulus, the provider documents "PERRLA" (which means the
pupils are equal, round, respond to light, and adjust and focus on
objects). The sclera is checked for color, which ranges from white
to pale yellow. If the eye is inflamed, it will be evident in the sclera.
A sclera with a yellow tone indicates liver disease. Movements of the
eyes are tested by having the patient follow the provider's finger. If
eye movement is within average range, "extraocular movement
(EOM) intact" is documented. The ophthalmoscope is used to
examine the interior of the eye, including the retina and intraocular
vessels. Some diseases, such as diabetes mellitus or hypertension,
damage the blood vessels of the retina.
Ears
The ears are examined with an otoscope covered with a disposable
speculum. The external ear is checked first for inflammation of the
external auditory canal or for earwax (cerumen). The tympanic
membrane (eardrum) is examined and should appear pearly gray.
Scars on the eardrum frequently are the result of earlier, chronic ear
infections or perforations. The color of the eardrum is important to
the diagnosis because it may indicate fluids such as blood or pus
behind the eardrum in the middle ear. The patient may be asked to
swallow several times to allow observation of movement of the tym-
panic membrane, which occurs because of pressure changes in the
eustachian tube. The eustachian tube equalizes air pressure between
the middle ear and the throat. The ability of the tympanic membrane
to move is crucial to the hearing process.
Nose and Sinuses
The mucosa of the nasal cavity is examined for color and texture.
The sinuses cannot be seen, but the frontal and maxillary sinuses
may be examined by firm palpation over the area and by transil-
lumination. When disorders of the eyes, ears, nose, and throat are
observed, and the provider believes that the condition warrants the
attention of a specialist, the patient is referred to an ophthalmologist
or an otorhinolaryngologist (ear, nose, and throat specialist).
Mouth and Throat
The mouth, or oral cavity, usually is thought of in terms of oral
hygiene and dental care. Dental hygiene includes the condition of
the teeth, how the patient cares for the teeth and gums, and whether
the teeth of the upper and lower jaws meet properly (occlude) for
chewing. Healthy gums are pale pink, glossy, and smooth and do
not bleed when pressure from a tongue depressor is applied. The
palatine tonsils usually are visible. The provider may use a tongue
depressor and a piece of gauze to grasp the tongue to examine it
carefully. The floor of the mouth is examined by both inspection and
palpation for enlarged lymph nodes, salivary gland function, and
ulcerations. The insides of the cheeks and the gumline are also
examined for any abnormal marks or color. The provider may use
the otoscope light to help with the examination.
Neck
The neck is examined for ROM by having the patient move the head
in various directions. The thyroid gland is given special attention for
symmetry, size, and texture. The provider manually palpates the
thyroid area while the patient swallows several times because this
action elevates the thyroid lobes. The carotid artery is palpated and
auscultated for possible bruits. The lymph nodes are palpated.
Lymphadenopathy (enlargement of the lymph nodes) can occur if the
patient has an infection of the face, head, or neck.
Chest
While the patient is still in the sitting position, the chest, heart, and
lungs are examined. The chest is examined for symmetric expansion.
A tape measure may be used, especially if variation exists between
the upper and lower chest expansion. A patient with a history of
emphysema may have a barrel-shaped chest. The provider may use
percussion to determine the density of lung tissues.
 CHAPTER 8 Assisting with the Primary Physical Examination
Placing a stethoscope on the patient's back, the examiner auscul-
tates lung sounds. The patient is asked to take deep, regular breaths.
This may produce slight dizziness, but the patient should be assured
that it is only the result of the deep respirations and will rapidly pass.
The provider notes the types of respirations and the presence oflung
sounds in all lobes.
Because considerable concentration is required to interpret heart
sounds, the provider must have complete silence when listening to
the patient's heart. In patients with heart disease, the provider may
spend an extended time listening to heart sounds. If lung or heart
abnormalities are found, the provider typically orders further diag-
nostic tests, including blood analysis, x-ray evaluation, and an ECG.
Once the results of these studies have been analyzed, the provider
may refer the patient to a cardiologist for treatment of a heart condi-
tion, or a pulmonologist or a respiratory care specialist for treatment
of a breathing disorder.
Abdomen
For the abdominal part of the examination, the patient is lowered
to the dorsal recumbent or supine position and the drape is lowered
to the pubic hair line. The gown is raised to just under the breasts.
The patient's arms may be placed at the side, or the hands may be
crossed over the chest or under the head. Relaxation of the abdomi-
nal muscles is needed for the abdominal examination. To assist in
this and to promote patient comfort, a small pillow can be placed
under the head and knees. The provider auscultates the abdomen in
all quadrants to confirm the presence of complete bowel sounds and
palpates the abdomen for any abnormalities. The provider also may
use percussion to determine the density, position, and size of under-
lying abdominal organs.
Reflexes
The patient's reflexes are checked with the patient sitting, in a high
Fowler's position, or supine. While the patient is sitting, the biceps
are checked with the patient's arm flexed and supported by the
examiner. The knee jerk (patellar reflex) and the ankle jerk (Achilles
reflex) are checked using tapotement (a tapping or percussing move-
ment) with either the fingers or the reflex hammer. The plantar
reflexes (Babinski's reflex and Chaddock's reflex) are tested with the
patient in an upright or a supine position.
Breast and Testicles
Careful breast examination is part of the physical examination for
every female, regardless of whether she is symptomatic. The breasts
PROCEDURE 8-8 Assist Provider with a Patient Exam
Goal: To aid the provider in the examination of apatient by preparing the patient and the necessary equipment and ensuring
the patient's safe/lj and comfort during the examination.
EQUIPMENT and SUPPLIES
• Patient's record
• Stethoscope
• Gauze sponges
191
are examined both visually and by palpation with the patient in the
supine position and the arm on the side that is being examined bent
and tucked under the head. Breast cancer is the most common
malignancy in women, and early detection is the key to successful
treatment. This is a good opportunity to discuss and reinforce the
consistent use of monthly breast self-examination (BSE). For male
patients who have reached puberty or are 14 years of age or older,
the provider performs a testicular examination. The testicular self-
examination (TSE) is an important self-examination for all males to
perform each month because testicular carcinoma is a major health
risk that has a high cure rate if discovered early.
CRITICAL THINKING APPLICATION 8-3
Alice Greenbaum, a 68-year-ald patient af Dr. Kasto, is scheduled for an
annual physical examination, including a breast check and a Pap test. Mrs.
Greenbaum appears anxious about the examination and asks Felicia
whether the gynecologic examination is necessary. How should Felicia
answer this patient? What might be helpful in easing the patient's fears
and preparing her for the examination?
Rectum
The rectal examination usually follows the abdominal examination
or may be part of the examination of the male or female genitalia.
Preserving the patient's comfort and dignity is vital. For this part of
the examination, the provider needs examination gloves and water-
soluble lubricating jelly (e.g., K-Y Jelly). The examination light
should be directed at the perineal area during the examination.
Fecal occult blood test specimens often are collected at the time
of the digital rectal examination. If this is a procedure the provider
performs, be sure to include the necessary collection folder with the
examination equipment. Patients diagnosed with gastrointestinal
(GI) disorders may be referred to a gastroenterologist. Procedure 8-8
presents the steps for assisting with the physical examination.
CRITICAL THINKING APPLICATION 8-4
Dr. Kosto is the provider for residents of group homes for the developmen-
tally delayed. Jimmy Cosgrove, a 38-year-old patient, is being seen today
for an annual physical examination. Felicia is responsible for preparing the
patient for the examination. Describe how Felicia should prepare the exami-
nation room and the patient.
• Ophthalmoscope
• Pen light
• Scale with height measurement bar
• Tuning fork
192 UNIT ONE INTRODUCTION TO MEDICAL ASSISTING

I; d•iH mi;j j:j:• -,;ontinued

• Tongue depressor 8. Measure and record the patient's vital signs, height, weight, and body
• Biohazard container mass index (BMI). Instruct the patient on how to collect a urine specimen,
• Cotton balls if ordered, and hand the patient a properly labeled specimen container.
• Examination light Obtain blood samples for any tests ordered.
• Laboratory request forms PURPOSE: To gather data needed before the examination begins.
• Percussion hammer 9. Hand the patient a gown and drape. Explain what clothes should be
• Specimen bottles and laboratory requisitions removed for the examination and whether the gown should open in the
• Lubricating gel front or the back. Help the patient with undressing as needed (most
• Disposable gloves patients prefer to undress in privacy). Knock on the door before re-entering
• Patient gown the room to protect the patient's privacy.
• Sphygmomanometer PURPOSE: To assist the patient in preparing for the examination and to
• Drapes safeguard the patient's privacy, comfort, and safety.
• Otoscope with disposable speculum 10. Assist the patient as needed in sitting at the foot of the examination table;
• Thermometer place the drape over the patient's lap and legs. If the patient is elderly,
• Cotton-tipped applicators confused, or feeling faint or dizzy, do not leave him or her alone.
• Tape measure PURPOSE: To provide for the patient's warmth and privacy and to prevent
• Fecal occult blood test supplies a fall or injury.
• Disinfectant wipes 11. Place the patient's paper health record in the designated area or make
• Table paper sure the computer is ready for the provider to log in and access the
patient's electronic health record (EHR). Be careful to safeguard patient
PROCEDURAL STEPS confidentiality during this step of the procedure.
1. Check the examination room at the beginning of each day and between 12. Assist during the examination by handing the provider instruments as
patients to make sure it is completely stocked with equipment and supplies needed and by positioning and draping the patient.
and that the equipment functions properly. 13. When the provider has completed the examination, allow the patient to
PURPOSE: The room must be ready for patient services. rest for a moment, then help the patient from the table. Assist with dress-
2. Check expiration dates on all packages and supplies regularly and discard ing, if necessary. Use proper body mechanics if assistance in transfer is
expired materials. needed.
PURPOSE: To ensure the patient's safety. PURPOSE: To ensure the patient's stability and safety and to protect
3. Prepare the examining room before and between patients according to yourself from injury.
acceptable medical rules of •sepsis. 14. Return to the patient and ask whether he or she has any questions. Give
PURPOSE: The room must be aseptically clean to prevent the spread of the patient any final instructions, and schedule tests as ordered by the
infection. provider and/or the next appointment.
4. Sanitize your hands. PURPOSE: To clarify instructions, eliminate any misunderstandings, and
PURPOSE: To ensure infection control. allow the patient to discuss any concerns. If the patient's misunderstand-
S. Locate the instruments for the procedure. Set them out in order of use ings or concerns are beyond your scope of experience or skill, arrange for
within reach of the provider and cover them until the provider enters the the provider to speak with the patient again.
examination room. 1S. Put on gloves and dispose of used supplies and linens in designated bio-
PURPOSE: To promote time management and ensure that all needed hazard waste containers. Dispose of exam table paper. Use disinfectant
equipment and supplies are ready. wipes to clean the examination table and any other potentially contami-
6. Greet and identify the patient, introduce yourself, and determine whether nated surface. Disinfect all equipment.
the patient understands the procedure. If the patient does not, explain PURPOSE: To prevent cross-contamination with any potential infectious
what to expect. Refer any unanswered questions to the provider. materials.
PURPOSE: To promote the patient's understanding and cooperation during 16. Remove the gloves, discard them in the biohazard waste container, and
the examination. sanitize your hands.
7. Review the medical history with the patient and investigate the purpose PURPOSE: To ensure infection control.
of the visit. Review current medications, and document any changes or 17. Cover the exam table with fresh paper, replace used supplies, and prepare
prescription refills needed. Document the interview results. the room for the next patient.
PURPOSE: To verify that all information is current and complete.
 CHAPTER 8 Assisting with the Primary Physical Examination
CLOSING COMMENTS
Patient Education
The physical examination process is an excellent time for the medical
assistant to assess the need for patient education. This assessment
should be performed to identify the best ways to meet the patient's
needs. When identifying these needs, consider the following:
• The information the patient needs to know
• How to convey the information so that the patient under-
stands it
• How the patient will use the information
• Whether any community resources are available that might
help the patient understand and learn more about health
problems or treatment protocols
Develop a plan to teach the patient. Think about the different
modalities available, such as pamphlets, pictures, DVDs, demonstra-
tions, websites, and community resources. The more interesting the
information, the more fun it is to teach the patient and the more
enjoyment the patient will get out of learning. Many facilities keep
patient education files that contain handouts on a wide range of
health issues. The medical assistant should always review teaching
plans with the provider and follow the provider's direction in patient
education.
Legal and Ethical Issues
The medical assistant must recognize that a legal and ethical contract
exists between the patient and the provider. As the provider's
employee, the medical assistant is part of that contract. Information
gained during the physical examination is confidential and must
remain that way. The medical assistant must uphold ethical respon-
sibilities as written in the Code of Ethics of the American Association
of Medical Assistants (AAMA): to render service, respect confidential
information, and uphold the honor and high principles of the
profession.
Ji1iiilM;fi•jii#IM;it•i
As a new medical assistant, Felicia has a great deal of responsibility when it
comes to assisting with physical examinations. She must prepare the room for
the particular examination ordered and must prepare and care for the patient
during the procedure. Preparing the room includes making sure appropriate
supplies and equipment are readily available for the provider as well as planning
how to safeguard the patient's privacy during the examination. Each examina-
tion is different, just as each patient has his or her own set of needs. Felicia
helps the patient into a variety of positions, depending on the examination,
SUMMARY OF LEARNING OBJECTIVES
l. Define, spell, and pronounce the terms listed in the vocabulary.
Spelling and pronouncing medical terms correctly reinforce the medical
assistant's credibility. Knowing the definitions of these terms promotes
confidence in communication with patients and co-workers.
193
HIPAA Applications
• Remember that conversations in the healthcare facility may be
overheard. Guard patient confidentiality when gathering infor-
mation about the chief complaint, scheduling diagnostic tests, or
processing samples. If the front desk has a privacy glass, make
sure it remains closed; turn away from the waiting room when
talking on the phone; make sure that computer monitors are
protected and screened; and avoid any conversations about the
patient that may be overheard.
• If paper health records are used in the facility, make sure they are
placed on the examination room door with identifying informa-
tion facing the door to prevent those passing by from recognizing
the patient's name. If EHRs are used, safeguard patient informa-
tion by closing patient files and locking computers when you will
be out of the room and by using privacy screen protectors.
• Maintain patient confidentiality during the admissions procedure
in the facility. Many facilities no longer use sign-in sheets, but if
they are used, the staff must completely block the names of previ-
ous patients from sight to maintain confidentiality.
Professional Behaviors
Courteous and respectful care is the hallmark of professional medical
assistant behavior. Many times the physical examination process requires
patients to expose very private parts of their bodies, which can make them
feel quite uncomfortable. Safeguarding the patient's privacy as much as
possible with adequate gowning and draping helps prevent undue exposure
and embarrassment for patients during the examination process. Treating
patients with thoughtful consideration goes a long way in making them
feel more comfortable with physical examination procedures.
and properly gowns and drapes the patient to safeguard privacy. Felicia is
responsible for making sure the examination runs smoothly for the provider and
for supporting the patient throughout the process. To protect herself against
injury, Felicia uses proper posture and body alignment, remembering to bend
at the knees and use her arm and leg muscles, rather than her back, to lift
heavy items. She always asks for help if a load is too heavy, and she pushes
a heavy item rather than lifting it.
2. Describe the structural organization of the human body and the
body cavities.
The human body is made up of trillions of microscopic cells that determine
the functional and structural characteristics of the entire body. Acell is
Continued
194 UNIT ONE INTRODUCTION TO MEDICAL ASSISTING
SUMMARY OF LEARNING OBJECTIVES-continued
made up of three primary parts: the plasma membrane, the cytoplasm,
and the nucleus. When cells with similar structures and functions combine,
tissues are formed. The body has four types of tissue: epithelial, connec-
tive, muscular, and nervous tissue. Acombination of two or more types
of tissues creates an organ, and a number of organs joined together form
a body system. The body is separated inta the dorsal (posterior) and
ventral (anterior) body cavities. The dorsal body cavity protects organs
of the nervous system and contains the cranial and spinal cavities. The
ventral cavity contains the thoracic cavity, which includes the pleural
cavities and the mediastinum; the pericardia! cavity is in the mediasti-
num. The diaphragm separates the thoracic cavity from the abdomino-
pelvic cavity. The abdominal cavity contains gastrointestinal organs. The
pelvic cavity is not physically separated from the abdominal cavity; it
contains the urinary bladder, rectum, and reproductive organs.
3. Identify the functions of the body systems ond the mojor organs and
structures of each system.
A body system is composed of several organs and their associated
structures. These structures work together to perform a specific function
in the bady. Each of the body's systems has specific units within it, and
each performs specific functions. Table 8-1 summarizes the body systems;
their primary cells, organs, and structures; and the major functions of
each.
4. Discuss the concept of a primary care provider and the role of a
medical assistant in a primary care practice.
Aprimary care provider is a healthcare practitioner who sees people of
all ages for a broad range of diseases and complaints. The medical
assistant's clinical responsibilities in a primary care practice include assist-
ing with patients wha may have problems in any af the body systems
and assisting with procedures in all age groups.
5. Outline the medical assistant's role in preparing for the physical
examination.
Before the examination, the medical assistant has the opportunity to
interact with the patient ta ensure that he ar she feels comfortable during
the examination process and that all necessary medical information has
been obtained. The medical assistant's duties include preparing and
maintaining the examination room and equipment; preparing the patient
by conducting the initial interview and measuring vital signs; assisting
the provider with positioning and draping; and providing instruments and
supplies as needed during the physical examination.
6. Summarize the instruments and equipment the provider typically
uses during a physical examination.
Instruments and supplies typically used in a physical examination include
aphthalmascope, atascope, tongue depressor, reflex hammer, various
tuning forks, stethoscope, sphygmomanometer, thermometer, tape
measure, scale, examination light, disposable gloves, biohazard con-
tainer, specimen battles, laboratory requisitions, fecal occult blood test
supplies, patient gown, drapes, and lubricating gel.
7. Identify the principles of body mechanics and demonstrate proper
body mechanics.
Proper body alignment begins with goad pasture. When reaching for an
abject, avoid twisting ar turning; instead, move the feet ta face the abject
needed. Da not cross the legs while sitting, and keep the papliteal area
free of the edge of the chair. Hold the head erect, the face forward, and
the chin slightly up, the abdominal muscles contracted up and in, the
shoulders relaxed and back, the feet painted forward and slightly
apart, and the weight evenly distributed ta bath legs, with the knees
slightly bent.
Goad body mechanics principles include maintaining balanced pos-
ture, bending the knees while maintaining the back's three natural
curves, and using leg muscles ta help lift. Move the wheelchair close ta
the examination table, lack the wheels, and lift the foot rests af the
wheelchair out af the way. Provide patient support close ta your body
on the patient's strong side. Place the wheelchair at a 45-degree angle
next ta the foot rest at the end af the table, and with one hand under
the axillary region and the other grasping the patient, help the patient
step up anta the foot rest with the strong leg; then help the patient pivot
into a sitting position an the table. Use a gait belt as needed ta assist
in patient transfer. (Refer ta Procedure 8-1 .)
8. Outline the basic principles of gowning, positioning, and draping a
patient for examination; also, position and drape a patient in six
different examining positions while remaining mindful of the
patient's privacy and comfort.
The patient should be instructed on whether to wear the gown open
in the front or the back, depending on the type of examination to be
done. The position assumed by the patient during the examination
depends an the part af the body ta be examined or the procedure ta be
done. Possible patient positions include Fowle( s position, in which the
patient sits straight up, and semi-Fowle( sposition, in which the patient's
torso is elevated 45 degrees; the dorsal recumbent position, in which
the patient lies an the back with the legs bent; the supine position, in
which the patient lies flat an the back; the lithotomy position, in which
the patient's buttocks are at the bottom af the table and the legs are
positioned in stirrups; the prone position, in which the patient lies an the
stomach; Sims position, in which the patient lies an the left side with
the limbs flexed sa that the weight af the body is tilted forward; and the
knee-chest position, in which the patient is an the knees with the buttocks
elevated and the weight af the body tilted downward toward the chest.
Trendelenburg position, in which the patient's head is lower than the legs,
is not typically used in the ambulatory care setting. Draping requires
constant attention to maintaining the patient's privacy throughout the
examination while assisting the provider with exposure of the area being
examined. The general rule is ta cover all exposed body parts until the
paint in the examination when the provider must evaluate that particular
area. Procedures 8-2 through 8-7 outline the steps for positioning and
draping patients.
 CHAPTER 8 Assisting with the Primary Physical Examination
SUMMARY OF LEARNING OBJECTIVES-continued
9. Describe the methods of examination, and give an example of each.
The examiner uses inspection to detect significant physical features, such
as the patient's general appearance. With palpation, the sense of touch
is used to feel the brachia! pulse before a blood pressure reading is taken.
Percussion involves tapping or striking the body to elicit sounds or vibra-
tory sensations, as in percussion of the chest to detect fluid in the lungs.
Astethoscope is used to auscultate or listen to the lungs and heart.
Mensuration is the process of measuring the patient's height and weight.
Manipulation is the passive, assisted movement of a joint to determine
the range of extension or flexion.
l 0. Outline the sequence of a routine physical examination.
The examination sequence depends on the type of examination and the
provider's preference. The provider typically begins the examination by
noting the patient's general health appearance, nutrition status, speech,
breath odor, skin condition, and reflexes. The physical examination
begins at the head and proceeds down through the body. Any abnormali-
ties are noted and may be further investigated with diagnostic tools after
the examination has been completed.
11. Prepare for and assist in the physical examination of a patient,
correctly completing each step of the procedure in the proper
sequence.
Prepare the examination room and the patient; complete the initial
patient interview and measure and record vital signs; gather the needed
CONNECTIONS
CIJ Study Guide Connection: Go to the Chapter 8 Study Guide. Read and complete
the activities.
195
equipment and place it in the order of use; gown and drape the patient
as needed; provide patient instruction and check for understanding
throughout the process; assist during the examination by handing the
provider instruments, managing changes in lighting, collecting samples
as ordered, and conducting diagnostic procedures as ordered; assist the
patient when the examination is complete, including helping the patient
dress, scheduling further diagnostic tests as ordered, and answering the
patient's questions. Complete the documentation, disinfect the examina-
tion room and equipment, and restock supplies to ready the room for
the next patient. Procedure 8-8 presents the steps for assisting with the
physical examination.
12. Discuss the role of patient education during the physical examina-
tion, in addition to the legal and ethical implications and HIPAA
applications.
Before, during, and after the physical examination are excellent times to
provide appropriate patient education. The medical assistant should clarify
or reinforce any information given by the provider and should take
advantage of "teaching moments" to promote patient well-being.
The medical assistant is part of the legal contract established between
the patient and the provider. This contract begins at the time of the first
visit to the ambulatory care facility. Maintaining confidentiality and pro-
viding respectful service are crucial to the integrity of that patient
contract.
evolve Evolve Connection: Go to the Chapter 8 link at evolve.elsevier.com/
kinn to complete the Chapter Review Quiz. Check out the other resources listed for this
chapter to make the most of what you have learned from Assisting with the Primary
Physical Examination.
 9 PRINCIPLES OF PHARMACOLOGY
li#H+i;H•i
Kathy Augustina, (MA (AAMA), was hired recently to work for a primary care
practice in her hometown. Kathy is responsible for managing phone calls and
answering patient questions about their medication and prescriptions. Part of
her job description is to follow the provider's orders to administer medication
While studying this chapter, think about the following questions:
• What should Kathy know about the management of controlled substances
in the ambulatory care setting?
• If Kathy is not familiar with a medication, how can she learn about the
properties of the drug?
• Is it important that Kathy understand the clinical uses of prescribed drugs
and over-the-counter (OTC) drugs?
LEARNING OBJECTIVES
l. Define, spell, and pronounce the terms listed in the vocabulary.
2. Do the following related to government regulation of medications in
the United States:
• Distinguish among the government agencies that regulate drugs in
the United States.
• Cite the areas covered in the regulations established by the Drug
Enforcement Administration (DEA) for the management of
controlled ar regulated substances.
• List the DEA regulations for prescription drugs for each of the five
schedules of the Controlled Substances Act.
3. Explain the medical assistant's role in preventing drug abuse.
4. Differentiate a drug's chemical, generic, and trade names.
5. Describe the use of drug reference materials, and explain the five
pregnancy risk categories for drugs.
6. Discuss tips for studying pharmacology, and define the five medical
terms used to describe the clinical use of drugs.
VOCABULARY
angina pectoris (an-ji'-nuh/pek'-tuh-ruhs) A spasmlike pain in
the chest caused by myocardial anoxia.
bronchodilator (brahn-ko-di'-la-tuhr) A drug that relaxes
contractions of the smooth muscle of the bronchioles to
improve lung ventilation.
cirrhosis (suh-ro' -suhs) A chronic, degenerative disease of the
liver that interferes with normal liver function.
to a wide range of patients. Ta be knowledgeable about the administrative side
of medication management, and to give medications to patients accurately and
safely, Kathy must understand the basic principles of pharmacology.
• The practice uses an electronic prescription program as part of its
electronic health record (EHR) package. How does Kathy transmit the
provider's drug orders electronically?
• Aprimary care practice has patients of all ages. What factors related to
age might affect the action of medications on Kathy's patients?
• What role does patient education play in drug safety?
7. Cite safety measures for the use of OTC drugs.
8. Do the following related to prescription drugs:
• Diagram the parts of a prescription.
• Demonstrate the ability to transcribe a prescription accurately.
• Describe a-prescription methods.
9. Relate the principles of pharmacokinetics to drug use.
l 0. Describe factors that affect the action of a drug, including the
physiologic changes associated with aging.
11. Identify the classifications of drug actions.
12. Differentiate among commonly used herbal remedies and alternative
therapies.
13. Examine the role of the medical assistant in drug therapy education.
14. Identify the medical assistant's legal responsibilities in medication
management in an ambulatory care setting.
colloidal (kah-loid'-uhl) Pertaining to a gluelike substance.
enteric coated A term describing an oral medication that is coated
to protect the drug against the stomach juices; this design is used
to ensure that the medicine is absorbed in the small intestine.
formulary A list of drugs compiled by a health insurance
company that identifies the drugs the insurance company will
cover under benefits.

VOCABULARY -continued
generic A medication that is not protected by copyright.
hypercholesterolemia (hi-per-kuh-les-tuh-ruh-le'-me-uh) Elevated
blood levels of cholesterol.
identity proofing The process by which a credential service
provider validates that a person is who he or she claims to be;
the provider must complete this verification before being
allowed to e-prescribe controlled substances.
lumen An open space, such as within a blood vessel or
the intestine, or within a needle or an examining
instrument.
P harmacology is the broad science of the origin, nature, chemis-
try, effects, and uses of drugs. Clinical pharmacology is the study
of the biologic effects of a drug used as a medical treatment and the
actions of a drug in the body over time, including the rate at which
it is absorbed by body tissues; where it is distributed or localized in
the tissues; the route by which it is excreted; and its toxicity, or
poisonous effect.
Medical assistants must have a general understanding of the types
of drugs available and their uses. For every medication administered,
a medical assistant must understand the drug's action, typical side
effects, route of administration, and recommended dose, in addition
to the individual patient factors that can alter the drug's effects and
elimination. Drugs are constantly being developed and released for
patient treatment; therefore, medical assistants must continually
update their knowledge of specific drugs used in the ambulatory care
setting. Correct management of drug administration and patient
education are crucial factors in providing safe drug therapy for all
patients.
GOVERNMENT REGULATION
Several federal agencies combine forces to regulate, safeguard, and
manage the development and use of medications in the United
States. The Food and Drug Administration (FDA), a division of the
Department of Health and Human Services (HHS), regulates the
development and sale of all prescription and over-the-counter
(OTC) drugs. Pharmaceutical companies developing new medica-
tions must gain FDA approval before the drugs can be sold to
consumers. The approval process begins with chemical testing in the
laboratory and progresses to toxicity testing in laboratory animals,
and finally to human clinical trials, which involve volunteers who
participate in controlled drug studies. Only 1 of 10 new drugs ever
reaches the clinical testing phase. If the drug is found to have an
acceptable benefit-to-risk ratio (i.e., it is effective without causing an
unacceptable degree of harm to the user), the FDA approves the
medication for release.
The original manufacturer of the drug is awarded copyright pro-
tection on that particular chemical compound. Patents expire 20
years from the date of filing; this means that during the 20-year
CHAPTER 9 Principles of Pharmacology 197
metabolic alkalosis A condition characterized by significant loss
of acid in the body or an increased amount of bicarbonate;
severe metabolic alkalosis can lead to coma and death.
over-the-counter (OTC) drugs Medications sold without a
prescription.
spermicide (spuhr'-muh-side) A chemical substance that kills
sperm cells.
therapeutic range The blood concentration of a drug that
produces the desired effect without toxicity.
tinnitus A noise sensation of ringing heard in one or both ears.
period, other pharmaceutical companies cannot produce generic
copies of the drug. However, when patents on brand name drugs are
near expiration, manufacturers can apply to the FDA to sell generic
versions. Besides approving new drugs for the marketplace, the FDA
establishes manufacturing standards for drug purity and strength and
ensures that generic brands are effective and safe.
Standards for Generic Drug Manufacturers
On average, the cost of a generic drug is 80 to 85 percent lower than
the brand name product. The U.S. Food and Drug Administration
(FDA) has found no difference in the rates of reported side effects between
brand name and generic drugs. Generic drugs must meet the following
standards:
• The generic version must have the same active ingredients, labeled
strength, route of administration, and dosage form (tablets,
patches, and so on). However, generic drugs do not need to contain
the same inactive ingredients or fillers as the brand name product.
This difference may alter the absorption rate of a generic product.
Because of this, some patients may require continued use of brand
name drugs even after a generic becomes available.
• Generics do not have to replicate the human clinical trials of the
brand name drugs, but applicants must prove that the product
performs exactly as the brand name version does.
• Generic versions must act in the same period of time as the brand
name version, delivering the same amount of active ingredient into
the bloodstream in the same amount of time.
• The label of the generic drug must contain the same information
as the brand name version for patient education.
• The generic manufacturing process must ensure comparable quality
and production standards. The FDA continues to monitor the quality
of the generic drug and periodically inspects manufacturing facilities
to conduct quality control procedures.
www.fda.gov/Drugs/ResourcesForYou/Consumers/BuyingUsingMedicineSafely/ . Accessed
August 24, 2015.
198 UNIT TWO ASSISTING WITH MEDICATIONS
Federal Agencies Involved in the Regulation
of Drugs
Besides the Food and Drug Administration (FDA), two other agencies are
involved in the regulatian af drugs in the United States:
• Drug Enforcement Administration (DEA): The DEA is the federal law
enforcement agency responsible for controlling narcotics, investigat-
ing the illegal sale of dangerous substances, and preventing drug
abuse through public education.
• Federal Trade Commission (FTC): The FTC regulates the advertising
af over-the-counter drug preparations.
Controlled Substances
The Drug Enforcement Administration (DEA) was established in
1973 as part of the Department of Justice to enforce federal laws
regarding the use of illegal drugs. According to the Controlled Sub-
stances Act (CSA) of 1970, a drug or other substance that has the
potential for illegal use and abuse must be placed on the controlled
substance list. Any new medication with an action similar to a drug
already on the controlled substance list also is considered to have the
potential for abuse.
Most controlled drugs provide significant assistance to patients
in need of their particular actions, such as pain relief or anesthesia
for surgery. However, certain guidelines must be followed to comply
with the storage of controlled substances, their record keeping, and
security requirements. In addition, federal law mandates that all
medical personnel, including medical assistants, share the responsi-
bility for managing controlled substances on site. Precautions must
be taken to monitor patients' drug use, protect prescription pads and
e-prescription programs, maintain the records required by law, and
report any known or suspected drug diversion or theft.
According to the guidelines set forth in the CSA, controlled
substances are divided into five sections, or schedules, depending on
their addictive abilities and likely degree of abuse. The classifications
range from Schedule I drugs, which are illegal and cannot be pre-
scribed, to Schedule V medications, which have the least potential
for addiction and abuse (Table 9-1 ). A limited number of states also
have a Schedule VI category for marijuana (cannabis) and synthetic
cannabis products.
Every medical practice that stores and administers medications
that fall into any of the schedule categories should have a copy of
the controlled substances regulations. This list can be obtained from
the regional DEA office or online. It is also important to ensure
that the facility is included on the DEA's contact list so that the
practice receives updates as drugs are added, deleted, or moved from
one schedule to another.
Regulation of Controlled Substances
Specific CSA regulations govern the record keeping, physician reg-
istration, and inventory of controlled substances. Complete, accurate
records on the purchase and management of scheduled drugs in the
ambulatory care setting must be maintained. These records must be
kept separate from the patient's medical record for 2 years and must
be readily available for inspection by the DEA at all times. Each time
Electronic Prescriptions for Controlled Substances
Aprovider or a provider's agent can use existing electronic health record
(EHR) applications to prepare and print prescriptions for controlled sub-
stances in Schedules II, Ill, IV, and V. These prescriptions must follow
existing requirements for paper prescriptions for controlled substances,
including an electronic signature by the prescribing provider. Paper prescrip-
tions can be phoned or faxed into the pharmacy for controlled substances
in Schedules Ill, IV, and V.
• Apharmacy cannot fill an a-prescription from a provider until the
provider has completed the proper procedures for identity
proofing.
• Astaff person acting as the provider's agent can complete all of
the required information for a controlled substance prescription and
then have the provider electronically sign and authorize the trans-
mission of the prescription. The provider is legally responsible if the
prescription does not follow DEA regulations.
• The provider can print a copy of an electronic prescription after it
has been transmitted for the patient, but the copy must be clearly
labeled: "Copy only-not valid for dispensing."
Department of Justice, Office of Diversion Control. www.deadiversion.usdoj.gov/ecomm/
e_rx/faq/faq.htm. Accessed May 27, 2015.
a controlled substance is dispensed and administered in the office,
documentation of that process includes the number of doses of the
drug on site both before and after the medication is dispensed.
Medical practices that dispense and administer controlled substances
on site use forms developed for this purpose. Any discrepancy in the
count of the medication available must be documented and co-signed
by two employees.
Every physician who prescribes or has controlled substances on
site must register with the DEA for a Controlled Substance Registra-
tion Certificate. The physician receives a specific DEA registration
number that must be included on all controlled substance prescrip-
tions. The certificate is renewable every 3 years and is specific to a
particular site of practice. Therefore, if the physician dispenses or
prescribes scheduled drugs at more than one site, a DEA registration
number must be obtained for each site.
All controlled substances must be stored in a safe or immovable
double-locked cabinet, and the keys must be kept in a secure loca-
tion. Prescription forms should be kept out of areas used by patients
and preferably secured in an area that prohibits unauthorized or
illegal use. All DEA forms used by the facility to order controlled
substances also must be kept in a locked area.
Many ambulatory practices no longer keep controlled substances
on site. However, if drugs are lost or stolen, the incident must be
reported immediately to the regional DEA office and to local law
enforcement authorities. If the facility needs to dispose of controlled
substances a DEA-authorized collector should be contacted to safely
and securely collect and dispose of controlled substances and other
prescription drugs. Authorized collection sites may be retail pharma-
cies, hospital or clinic pharmacies, and law enforcement locations.
If these disposal options are not available, the DEA recommends
that some medicines, such as Demerol, Dilaudid, and OxyContin

TABLE 9-1 Schedule System of Classification of Controlled Substances
SCHEDULE GUIDELINES
• No accepted medical use
• Never prescribed for use
• High potential for abuse
• Possession af these drugs is illegal
II • Accepted for medical use but with severe
restrictions
• High potential for abuse
• May cause severe psychological or physical
dependence
Ill • Accepted for medical use
• Potential for abuse is less than for Schedule I
or II drugs
• May cause moderate to low physical
dependence or high psychological dependence
• Includes combination drugs that contain
limited amounts of narcotics or stimulants
IV • Accepted for medical use
• Low potential for abuse
• May cause limited physical or psychological
dependence compared with Schedule Ill drugs
• Includes minor tranquilizers and hypnotics
V • Accepted for medical use
• Low potential for abuse
• May cause limited physical or psychological
dependence compared with Schedule IV drugs
• Includes drug mixtures containing limited
amounts of narcotics
www.dea.gov/druginfo/ds.shtml. Accessed May 26, 2015.
oral doses, be flushed down the sink or toilet as soon as they are
no longer needed. A list of medicines recommended for disposal
by flushing can be found at http://www.fda.gov/Drugs/Resources
ForYou/Consumers/BuyingUsingMedicineSafely/EnsuringSafeUse
ofMedicine/SafeDisposalofMedicines/ ucm 186187.htm#Flush_List.
CRITICAL THINKING APPLICATION 9-1
Kathy is responsible for maintaining the inventory of controlled substances
in the office. While checking the supply of meperidine, she notices that the
expiration date on the medication is today. She must dispose of the remain-
ing two pills. According to DEA regulations, haw should she dispose af the
medication?
CHAPTER 9 Principles of Pharmacology 199
DRUG EXAMPLES
Heroin, lysergic acid diethylamide (LSD), methaqualone (Quaalude), mescaline
(peyote), amphetamine variations, phencyclidine (PCP), Ecstasy, gamma
hydroxybutyrate (GHB), Acetylcodane, Dipipan. Marijuana is still considered a
Schedule I drug by the DEA, even though some U.S. states have legalized
marijuana for personal or medical use.
Opium extracts, morphine, methadone, cocaine precursors, amphetamine,
barbiturates, methylphenidate (Ritalin), lisdexamfetamine (Vyvanse); oxycodane
(Percocet or OxyContin), hydromorphone HCI (Dilaudid), meperidine HCI
(Demerol), codeine, alfentanil (Alfenta), alphapradine (Nisentil), Burgodin,
secobarbital (Seconal), pentobarbital (Nembutal), fentanyl, anileridine (Leritine)
Acetaminophen and codeine (Tylenol with codeine), benzphetamine,
suppositories with barbiturates, anabolic steroids, testosterone, butabarbital
(Butisol), Fiorino I, Empirin, hydrocodane (Vicodin), buprenorphine, Boldiane,
paregoric, other opium combination products
Chlordiazepoxide (Librium), diazepam (Valium), flurazepam (Dalmane), chloral
hydrate, Rohypnol ("date rape" drug), alprazolam (Xanax), triazolam (Halcion),
tamazepam (Restoril), chlorazepate di potassium (Tranxene), lorazepam (Ativan),
Klonopin, zolpidem tartrate (Ambien), barbital, clonazepam (Klonopin),
diethylpropion (Tenuate), Motofen, midazolam (Versed), Don natal Extentabs,
Carisoprodol (Soma), eszopiclone (Lunesta), butorphanol (Stadol), Zaleplon
(Sonata)
Cough medicines containing limited quantity of codeine (Robitussin A-C),
alkaloids, kaolin and pectin belladonna (Donnagel), diphenoxylate with atropine
(Lomotil), ezogabine (Potiga), lacosamide (Vim pat), pregabalin (Lyrica). May be
said by a pharmacist in some states; buyer must be 18 years old and must show
identification
Individual states also may regulate controlled substances; there-
fore, it is essential that medical assistants know their state's legal
requirements. Specific federal guidelines apply to both written and
e-prescriptions for controlled substances:
1. A written, oral, faxed, or DEA-compliant electronic prescrip-
tion order must include the date the drug is prescribed; the
name and address of the patient; and the name, address, and
DEA number of the physician.
2. The amount prescribed must be written out ("ten" rather than
"IO"); the prescription usually is written for small amounts of
the drug.
3. The provider must manually sign all paper prescriptions for
controlled substances, although the medical assistant can
prepare the prescriptions for the provider's signature.
4. Other specific rules may apply, depending on the schedule to
which the prescribed controlled substance is assigned. The
200 UNIT TWO ASSISTING WITH MEDICATIONS
symbols C-II, C-III, C-IV, and C-V are used to indicate the
specific schedule.
• Schedule II (C-II) prescriptions
• Must be either a written or an e-prescription; telephone
or fax orders are not permitted
• Cannot be refilled
• May require specific types of order forms in some states
• Schedules III (C-III) and IV (C-IV) prescriptions
• May be ordered orally, in writing, or transmitted
electronically
• May be refilled up to five times within 6 months of the
original order
• Schedule V (C-V) prescriptions
• May be ordered orally, in writing, or transmitted
electronically
• May be refilled up to five times within 6 months of the
original order
• Depending on the state, may be dispensed by the phar-
macist without a prescription but typically require a
photo ID
CRITICAL THINKING APPLICATION 9-2
Kathy is responsible for the orientation of a new medical assistant in the
practice. Summarize the important points about government regulation
of controlled substance prescriptions that she should include in the
orientation.
DRUG ABUSE
Any drug, from aspirin to alcohol, can be misused or abused. The
use of illegal and legal drugs has increased tremendously. Treatment
programs for drug abuse are available throughout the United States
for people from all walks of life. Programs include detoxification,
rehabilitation, and long-term rehabilitation maintenance.
Medical assistants may encounter patients who are misusing or
abusing drugs. It is important to be alert to the symptoms of drug
dependence and to notify the provider when you suspect that a
patient, or a co-worker, may have a problem with drug or alcohol
dependency.
Drug misuse is the improper use of common drugs that can lead
to dependence or toxicity. Examples of people with chronic depen-
dencies include those who cannot have a bowel movement unless
they take a laxative; those who have used nasal decongestants for so
long that they cannot breathe without the use of nasal sprays; and
those who take so many antacids that they suffer systemic metabolic
alkalosis.
Drug abuse is the continuous or periodic self-administration of
a drug that could result in addiction (physical dependence). Drug
dependency is the inability to function unless under the influence of
a substance; it may be psychological or physical. Psychologi.cal depen-
dency is the compulsive craving for the effects of a substance. Habitu-
ation is a form of psychological dependency on a substance but
without physiologic dependence, such as the need for tobacco. Physi-
cal dependency, or addiction, is a person's need to use a substance
continuously so that the body can function and also to prevent
physical discomfort. This type of dependency occurs when abused
substances produce biochemical changes in cells and tissues, most
commonly in the nervous system. When a substance that causes
physical dependency is discontinued, withdrawal symptoms occur.
Withdrawal symptoms may be mild or serious, leading to convul-
sions and possibly death.
Regardless of the type of drug abused, it will have two effects on
the person: acute and chronic. The acute effect is what the person
feels when intoxicated, or directly under the influence of a particular
substance. Chronic effects include the temporary or permanent
physical and mental changes that result from long-term abuse.
Patients may question medical assistants about drug abuse. The
medical assistant should read and keep up to date on drug-related
issues. Booklets, websites, and agency referral names should be avail-
able for patients. In addition, patients' concerns and questions about
drug abuse should be conveyed to the provider.
The Medical Assistant's Role in Preventing
Drug Abuse
By following these guidelines, the medical assistant can help prevent drug
abuse:
• Carefully monitor patients who repeatedly call far prescription refills
of controlled substances.
• Request health records from other facilities for patients who repart
previous prescriptions far scheduled drugs.
• If the facility uses paper prescription pads, keep blank pads in a
safe place, away from patient treatment areas, and minimize the
number of prescription pads in use at any given time.
• Never use prescription pads far notepads, and never use preprinted
or presigned farms.
• Secure computers used far electronic health record (EHR) documen-
tation to prevent patient access to prescription generation.
• Keep only a limited supply of controlled substances on hand.
• Keep accurate, complete records of controlled substances dispensed
on site and those prescribed; include specific documentation in the
patient's record far all prescribed controlled substances.
DRUG NAMES
A single drug may have up to three names: a chemical name, a
generic name, and a trade name. The chemical name represents the
drug's exact formula. For example, the chemical name of the anal-
gesic acetaminophen is N-(4-hydroxyphenyl); acetaminophen is the
generic name, and the trade name is Tylenol. All drugs are assigned
a generic, or nonproprietary (official), name. This name is much
simpler than the chemical name, and it is not protected by copyright.
The trade (brand) name is assigned by the manufacturer and is
protected by copyright. To prevent confusion, the use of generic
names rather than trade names is encouraged for medical profession-
als; however, patients may only recognize the trade names of drugs.
Drugs also are classified by their use. For example, Advil is a brand

name for the generic drug ibuprofen, which is classified as an anal-
gesic and an antiinflammatory agent.
APPROACHES TO STUDYING PHARMACOLOGY
A pharmaceutical glossary could be a book in itsel£ Many terms are
combinations of the condition to be treated plus the prefix anti-
(e.g., antianginal, antianxiety, antiarrhythmic, anticoagulant, anti-
convulsant, antidiarrheal). Notice how these names emphasize the
drug's effect (use) rather than its action in the body. More recent
classifications, such as parasympathomimetic and cholinesterase
inhibitor, describe the pharmacologic action rather than the thera-
peutic use. Both viewpoints are necessary for a more complete
understanding of drugs and their action in the human body. No one
can remember all there is to know about clinical pharmacology. The
number of new drugs introduced into use far exceeds the number
of older drugs replaced or discontinued. The number of drugs avail-
able for clinical use grows beyond the ability to learn all there is to
know about each medication. Therefore, it is essential that the
medical assistant understand how to use pharmacology resources as
references. Several drug index resources are available online that can
be used to search for medication information. Examples of these are
Rxlist at http://www.rxlist.com/script/main/hp.asp and Drugs.com
at http://www.drugs.com/. If the facility promotes online drug
research, preferred websites should be posted for staff use.
Drug Reference Materials
Reference books that are updated annually or periodically should be
available for easy reference at all medical facilities. Most references
list drug information in the following sequence:
I. Action: How the drug provides therapeutic results in the body,
or the use of the drug.
2. Indication: The conditions for which the drug is used.
3. Contraindications: Conditions that make administration of
the drug improper or undesirable. For example, aspirin is
contraindicated in patients with GI bleeding.
4. Precautions: Necessary actions that must be taken because of
special conditions of the patient, the drug, or the environ-
ment; these actions must be considered if the drug is to be
successful or not harmful. The drug's pregnancy risk category
is included in this section, as are precautions for nursing
mothers (Table 9-2).
5. Adverse reactions: Commonly observed side effects on a
tissue or organ system other than the one targeted by the
medication. Adverse reactions include hypersensitivity,
which causes an allergic reaction to the drug; idiosyncrasy,
or an unexplained, unusual response to the drug; psycholog-
ical dependence or habituation to the drug; and physical
dependence on the compound, causing signs and symptoms
of withdrawal in the patient if the medication is removed.
For example, patients prescribed certain diuretics (e.g.,
Lasix) are at risk for potassium depletion, so they must take
a potassium supplement or must eat a daily dietary source
of potassium (bananas are a common source) to prevent
complications.
6. Dosage and administration: Usual route, dosage, and timing
for administering the drug.
CHAPTER 9 Principles of Pharmacology 201
TABLE 9-2 FDA's Pregnancy Risk
Drug Categories
CATEGORY RISK LEVELJDESCRIPTION
A Remote risk.
Controlled studies in women have failed to demonstrate
risk to fetus.
B Slightly more risk than Category A.
Animal studies show no risk, but controlled human
studies have not been done; or animal studies show
risk, but controlled studies in women have shown
no risk.
C Greater risk than Category B.
Animal studies have shown risk, but no controlled
human studies have been done; or no studies have
been done in animals or women.
D Proven risk of fetal harm.
Human studies show proof of fetal damage, but the
potential benefits of use during pregnancy may
make its use acceptable.
X Proven risk of fetal harm.
Studies in women or animals show definite risk of fetal
abnormality. Risks outweigh any possible benefit.
FDA, U.S. Food and Drug Administration.
7. How supplied: Description of how the medication is packaged
and specifics on how it should be administered.
Package Inserts
Every drug package contains an insert describing all the significant
aspects of using the drug, including information on the chemical
formulation of the drug and clinical studies. The information in the
insert is controlled by the FDA and serves as an excellent quick refer-
ence on new medications in the ambulatory setting.
Physicians' Desk Reference
The Physicians' Desk Reference (PDR) is published annually by
Thomson Medical Economics (Oradell, New Jersey). It is supplied
free to providers who subscribe to Medical Economics magazine.
Copies can be purchased through the publisher or in local book-
stores. Supplements are published quarterly throughout the year. The
PDR contains information on approximately 3,000 drugs and
includes product descriptions that are identical to the information
provided in package inserts. The drug manufacturers pay for this
space, so the PDR could be considered the Yellow Pages of the drug
industry. The facility can also purchase an online version of the PDR
and smart phone applications that can be used by staff and providers
throughout the facility (www.pdr.net/) .
The print version of the PDR contains color-coded sections,
which allows for easy cross-reference. The various sections enable you
202 UNIT TWO ASSISTING WITH MEDICATIONS
to begin searching for information about a drug from any starting
point. You can start with the usage, classification, generic name,
manufacturer's name, or trade name of a drug, or what the drug
looks like. A special photographic section allows visual identification
of products. Once you know which drug you want to study, the
product information section lists the actual package insert informa-
tion alphabetically, first by the manufacturer, then by the brand
name. (A separate PDR volume, the Physicians' Desk Reference for
Nonprescription Drugs, is published annually for OTC drugs and
dietary supplements.)
The six sections of the PDR are color coded as follows:
• Manufacturer's index (white): Alphabetical listing of pharma-
ceutical companies; it includes the drugs manufactured by
each company and the contact information for each
manufacturer
• Brand and generic section (pink): Alphabetical listing of
all drugs in the PDR volume, with complete information
for each
• Product category index (blue): Alphabetical listing compiled
according to drug category; drugs with similar actions are
listed alphabetically in each category
• Product identification section (gray): Illustrated section that
shows actual-size photographs of the tablets and capsules
listed in the PDR
• General and diagnostic product information area (white): Alpha-
betical listing of diagnostic product information and the uses
of these products
United States Pharmacopeia/National Formu/ary
The United States Pharmacopeia/National Formu/,ary (USP /NF) is the
official source of drug standards for the United States. The Pharma-
copeia was combined with the National Formu/,ary, which lists the
chemical formulas for all accepted drugs. This combined reference
lists and describes all approved medications in the United States
considered useful and therapeutic in the practice of medicine. Single
drugs, rather than combined products (compound mixtures), are
listed. If a drug name is the same as the official name in this volume,
the drug is followed by the initials USP (e.g., digitoxin, USP).
Learning About Drugs
The study of pharmacology is difficult at best. However, the follow-
ing steps can help make it easier:
1. Take advantage of opportunities to observe the use of drugs
in patient care. Studying about atorvastatin calcium (Lipitor)
becomes more meaningful when you see how its lipid-lowering
action actually affects a patient's blood cholesterol level.
2. Concentrate on the most important drugs in each classifica-
tion. As you expand your knowledge to other drugs in each
category, you will easily understand new drugs by noting the
similarities and differences between them and the basic,
important drugs you studied first.
3. Learn about a drug's primary action and use, then expand
your knowledge to its other actions and uses. Soon you will
be able to name the drug that is usually indicated for a par-
ticular condition. Knowing a drug's secondary effects will help
you understand the side effects that are likely to occur with
use of the drug. More important, you will be aware of
contraindications to use of the drug. Knowledge of the drug's
actions will enable you to predict what toxic reactions might
occur from an overdose.
Terms Describing the Uses of Drugs
Diagnostic Helps to determine the cause of a particular health
problem (e.g., injecting antigen serum for allergy
testing).
Palliative Indicates that the drug does not cure, but provides
relief from pain or symptoms related to the disorder
(e.g., the use of an antihistamine for allergy
symptoms or narcotics for pain relief).
Prophylactic Prevents the occurrence of a condition (e.g., vaccines
prevent the occurrence of specific infectious diseases
ar contraceptives prevent pregnancy).
Replacement Provides the patient with a substance needed to
maintain health (e.g., insulin for patients with
diabetes, levothyroxine sodium [Synthroid] for
patients with hypothyroidism).
Therapeutic Treats a disorder and cures it (e.g., antibiotics cure
bacterial infections).
Dispensing Drugs
Drugs are dispensed in two ways: over the counter and by prescrip-
tion. OTC drugs are available to the public for self-medication
without a prescription. These drugs have been approved by the FDA
for general consumer use, but patients taking prescription drugs
should keep their healthcare providers informed about their OTC
drug use.
A medical assistant directly involved in patient care should have
an understanding of some basic facts about OTC drugs and herbal
products. Today patients are better informed about their personal
healthcare, and many want to be active participants in healthcare
decisions. They need facts to make informed choices when using
OTC preparations. Most OTC preparations are safe if used as
directed on the package; however, patient education contributes
greatly to the safe and correct use of OTCs. Patients should be
encouraged to do the following when choosing or using an OTC:
• Carefully read the package label and insert for use
guidelines.
• Take only the recommended dose.
• Monitor the expiration date and discard the medication when
appropriate.
• Never combine an OTC with a prescription drug without the
provider's knowledge.
• Recognize that many OTC drugs are contraindicated in preg-
nancy, for nursing mothers, and for young children, and if
certain diseases are present.
• Check with the pharmacist if questions or concerns arise.
The number of prescription drugs that have been granted OTC
status is constantly increasing, and as the list of OTC drugs increases,
so does the need for consumer education. Many OTC medications
influence the safety and effectiveness of prescription drugs; therefore,
 CHAPTER 9 Principles of Pharmacology 203

TABLE 9-3 Commonly Used OTC Drugs and Possible Complications

INDICATIONS AND
DRUG NAME CLASSIFICATION DESIRED EFFECTS SIDE EFFECTS DRUG INTERACTIONS
Acetylsalicylic acid (ASA), Nonsteroidal Inflammation and pain GI bleeding, compromised ACE inhibitors, warfarin
ibuprofen, naproxen antiinflammatory drugs relief renal function, tinnitus,
(NSAIDs); analgesics diarrhea, and nausea
Acetaminophen (Tylenol) Analgesic, antipyretic Relief of pain and fever Liver damage Warfarin
Pseudoephedrine (Sudafed) Decongestant Relief of common cold Hypertension, vasospasm, Beta blockers, digoxin
and allergy symptoms arrhythmia, (VA
Diphenhydramine (Benadryl and Antihistamines Cough, cold, allergy, Disrupted sleep, confusion, Oxybutynin (Ditropan)
other combination products) and insomnia hallucinations, delirium
Dextromethorphan (Dayquil Antitussive Suppression of cough Dizziness, lethargy,
Cough, Delsym, Robitussin) reflex nausea
Tums, Gaviscon, Pepto-Bismol Antacids Treatment of heartburn, Diarrhea, constipation, Ibuprofen, tetracycline,
GERO symptoms kidney stones isoniazid
ACE, Angiotensin-converting enzyme; CVA, cerebrovascular accident; GERO, gastroesophageal reflux disease; GI, gastrointestinal; OTC, over the counter.

gathering information for a complete and accurate pattern of the

patient's use of OTC drugs should be part of every healthcare visit.
Table 9-3 presents a list of commonly used OTC medications, their
side effects, and possible prescription drug interactions.
Prescription Drugs
Federal law makes drugs that are dangerous, powerful, or habit-
forming illegal to use except under a licensed provider's order. A
prescription is an order written by the provider for the dispensing
of a particular medication by the pharmacist and its administration
to the patient. As electronic health records (EHRs) have come into
use, electronic prescriptions have become commonplace, although
some facilities continue to use paper prescription forms (Figure 9-1 ).
The prescription must be signed by the provider, or the order cannot
be carried out (Procedure 9- 1). If the provider requests that the
medical assistant phone or fax a prescription to the pharmacy, all
pertinent information for the medication order must be written
down and reviewed by the provider for accuracy before the call is
made. A note is made in the patient's record that a medication order
was phoned or faxed into the pharmacy, with all of the pertinent
information about the order included.
Appropriate medical terminology and abbreviations must be
used to complete the prescription. The more common terms and
abbreviations are listed in Table 9-4. In an attempt to reduce the
number of medication errors caused by incorrect use of medical
terminology, The Joint Commission has developed a "Do Not Use"
list of abbreviations, acronyms, and symbols that should not be
used for documentation purposes in accredited institutions. In
addition, the commission created an ancillary list of possible future
inclusions. Both of these lists are presented in Table 9-5 . Besides
The Joint Commission lists, facilities have the option of creating
their own list of problematic abbreviations that employees should
avoid using.
Six Parts of a Prescription
• Superscription: Patient's name, address, and date need to be included
at the top of the paper prescription; the symbol Rx (for the Latin word
recipe, meaning "take")
• Inscription: Main part of the prescription; name of the drug, dosage
form, and strength
• Subscription: Directions for the pharmacist; size of each dose,
amount to be dispensed, and the form of the drug ordered (tablets,
capsules, or some other form)
• Signature: Directions for the patient; usually preceded by the
symbol Sig (for the Latin word signa, meaning "mark"); the place
where the provider indicates the instructions to be put on the label to
tell the patient how, when, and in what quantities to use the
medication
• Refill information: May be regulated by federal law if the drug is a
controlled substance; the provider must write on the script the number
of times a refill is allowed
• Provider's signature: Must include the provider's signature (whether it
is electronic or manual), in addition to his or her Drug Enforcement
Agency (DEA) registration number when indicated
CRITICAL THINKING APPLICATION 9-3
Dr. Simon asks Kathy to prepare the following prescription for his signature:
"Take one 20-mg tablet of Lipitor daily at bedtime. Dispense 4 weeks'
worth, and the prescription may be refilled two times." How would Kathy
write the prescription using the correct format, medical terminology, and
abbreviations?
204 UNIT TWO ASSISTING WITH MEDICATIONS

John Jones, M.D. Tel: 724-544-8976

108 N. Main St.
City, State

Patient Ms. J'ea.n .Sm,rth DATE W/1/~

ADDRESS BW ~. 10th .st, AnljtoWn, .,Sta-t.e,

Rx: Liprtor 40 ~ -ta,b

Disp: :/f BO
Sig: f J,,s

Refill - 8-Times
Please label ~

Chart
Slmu l•tlon Pl• yground
for the Med cal office

FronlOIIOU c~,ea,,g

Patient Charting
blnowat•. Ell E A
INFO PANEL

Pa&.nl 011h0Ntd
,c

J.,.,...A. MO Jt an..,~• nP
Mcccnt , ~ ...... Pr1<-
C!A • 81m0 ~ - 81m0 AcbOfl

Ont:

FIGURE 9-1 A, Sample paper prescription. B, Sample electronic prescription entry. (B from Elsevier: SimChart for the medical office,
St Louis, 2016, Elsevier.)

Electronic Prescriptions
Electronic health record (EHR) systems can create and send prescriptions
directly to a pharmacy. EHR programs are designed to automatically check a
prescribed drug against the patient's allergies, identify possible drug-drug
interactions, access current databases far the patient's medication history,
review the patient's insurance drug formulary far coverage, and electroni-
cally send the script to the patient's pharmacy to be filled. The Department
of Health and Human Services (HHS) recognizes the importance of
e-prescriptions in quality patient care because they reduce the chances of
misinterpretation of a provider's handwriting and promote speed in filling
prescriptions through the instant transfer of the script from the ambulatory
care facility to the patient's pharmacy. The HHS recommends that an indi-
vidual, such as a credentialed medical assistant, be designated the practice's
expert far e-prescribing sa that the process runs smoothly and all regulations
far the delivery of prescriptions electronically are fallowed.
Details on Medicare incentive programs to encourage physicians to adopt
e-prescribing programs can be found at the fallowing website: www.cms.gov/
Medicare/E-Health/Eprescribingjindex.html?redirect=/Eprescribing.
 CHAPTER 9 Principles of Pharmacology 205

TABLE 9-4 Common Prescription Abbreviations

ABBREVIATION MEANING ABBREVIATION MEANING ABBREVIATION MEANING I

aa of each IM intramuscular pt pint

ac before meals inj injection pulv powder
ad lib as desired IV intravenous qh every hour
agit shake, stir K potassium q2h every 2 hours
am morning kg kilogram q3h every 3 hours
amp ampule KVO keep vein open q4h every 4 hours
ASA aspirin L liter qid four times a day
aq water lb pound qm every morning
bid twice a day LR lactated Ringer's solution qn every night
C cup, Celsius mcg microgram qs quantity sufficient
c with med medicine qt quart
cap capsule mEq milliequivalent R rectal
cc chief complaint mg milligram r/o rule out
cm centimeter ml milliliter Rx take, treatment
c/o complaining of MLD minimum lethal dose S, Sig give the following directions
D/C discharge mn midnight s or w/o without
Dx diagnosis MO mineral oil SC, SQ, subQ subcutaneous
dil dilute MOM milk of magnesia SOB shortness of breath
-
disp dispense MTD maximum tolerated dose ss one-half
dr dram NKA no known allergies stat immediately
EENT eye, ear, nose, throat noct at night T, tbs tablespoon
ext extract NPO nothing by mouth t, tsp teaspoon
F Fahrenheit NS normal saline tab tablet
FDA Food and Drug Administration N/V nausea/vomiting tid three times a day
Fe iron 02 oxygen tinct tincture
fl fluid OD overdose TO telephone order
fx fracture OTC over-the-counter (drugs) tus cough
gal gallon oz ounce ung ointment
gm,g gram pc after meals vag vagina
gr grain PL placebo ves bladder
gtt drops pm afternoon VO verbal order
h hour PMI patient medication instruction vs vital signs
hs at bedtime po by mouth WNL within normal limits
HTN hypertension pr per rectum W/0 water in oil
Hx history prn as needed X times
ID intradermal pt patient y/o years old
206 UNIT TWO ASSISTING WITH MEDICATIONS

TABLE 9-5 The Joint Commission's Official "Do Not Use" List1 and Possible Future Inclusions
DO NOT USE POTENTIAL PROBLEM USE INSTEAD
U(unit) Mistaken for "O" (zero), the number "4" (four) or "cc" Write "unit"
IU (international unit) Mistaken for IV (intravenous) or the number 10 (ten) Write "International Unit"
Q.D., QD, q.d., qd (daily) Mistaken for each other Write "daily"
Q.O.D., QOD, q.o.d, qod (every other day) Period after the Qmistaken for "I" and the "O" mistaken for "I" Write "every other day"
Trailing zero (X.O mg)* Decimal point is missed Write Xmg
Lack of leading zero (.X mg) Write O.X mg
MS Can mean morphine sulfate or magnesium sulfate Write "morphine sulfate"
MS04 and MgS04 Confused for ane anather Write "magnesium sulfate"
1Applies to all orders and all medication-related documentation that is handwritten (including free-text)

*Exception: A"trailing zero" may be used only where required to demonstrate the level of precision of the value being reported, such as for laboratory results, imaging studies that report
size of lesions, or catheter/tube sizes. It may not be used in medication orders or other medication-related documentation.
Additional Abbreviations, Acronyms and Symbols (for possible future inclusion in the Official "Do Not Use" List)
> (greater than) Misinterpreted as the number "7" (seven) or the letter "L" Write "greater than"
< (less than) Confused for ane anather Write "less than"
Abbreviations for drug names Misinterpreted due to similar abbreviations for multiple drugs Write drug names in full
Apothecary units Unfamiliar to many practitioners Use metric units
Confused with metric units
@ Mistaken for the number "2" (two) Write "at''
cc Mistaken for U(units) when poorly written Write "ml" or "ml" or "milliliters"
("ml" is preferred)
µg Mistaken for mg (milligrams) resulting in one thousand-fold overdose Write "mcg" or micrograms
www.jointcommission.org. Accessed November 16, 2015.

•;;m,am);j@il Prepare a Prescription for the Provider's Signature

Goal: To accurately prepare aprescription for the provider's signature using the appropriate abbreviations and prescription format.
EQUIPMENT and SUPPLIES PURPOSE: The medical assistant should be familiar with the details of
• Patient's record the drug, including the correct spelling, form in which it is dispensed,
• Prescriptian pad strength, recommended dose, storage guidelines, drug-drug interactions,
• Drug reference materials, if needed and possible side effects, to make sure the transcription is correct and to
• Black pen be prepared to answer the patient's questions about the medication.
3. Ask the patient about drug allergies.
PROCEDURAL STEPS PURPOSE: The patient should be asked about drug allergies each time a
1. Refer to the provider's written order for the prescription. If the provider medication is prescribed or dispensed because these can change over time.
gives a verbal order to write a prescription, write down the order and 4. Using a prescription pad that has the provider's name, address, and
review it with the provider for accuracy. telephone number, begin to transcribe the provider's order. Add the
PURPOSE: To ensure accuracy in writing the ordered medication. provider's DEA number if the script is for a controlled substance (see
2. If you are unfamiliar with the medication, look it up in a drug reference Figure 9-1 ).
book (e.g., the Physicians' Desk Reference [PDR]).

•;iI11,amm@j• -continued
S. Record the patient's name and address and the date on which the prescrip-
tion is being written.
6. Next to the Rx, write in legible handwriting the name of the drug (correctly
spelled), the dosage form (e.g., tablet, capsule, or other, using correct
abbreviations), and the strength ordered. This is the inscription. For
example, if the provider orders Lipitor, 40-mg tablets, by mouth, one tablet
at bedtime, the first line of the prescription should read: Lipitor 40 mg
tabs.
7. On the next line, write Disp. This is the subscription, which includes direc-
tions to the pharmacist on the amount to be dispensed and the form of
the drug. For the Lipitor order, the subscription would read: Disp: #30.
8. Next comes the signature. This includes directions for the patient, such as
how and when to take the medicine; it usually is preceded by the abbrevia-
tion Sig: For the Lipitor order, the signature would read: Sig: t tab PO hs.
9. The provider has told you that the patient can get three refills of the
prescription, so this information should be added at the bottom of the
prescription on the designated line.
10. The provider must review and sign the prescription before it is given to
the patient.
11. Document in the patient's health record the medication order and any
pertinent details, including patient education and refill information.
PURPOSE: All patient education should be documented for future refer-
ence. The details about the prescription, in addition to refill information,
must be included for future prescriptions and/or refill orders.
DRUG INTERACTIONS WITH THE BODY
Pharmacology is the study of drugs, their desired effects, and what
happens to a drug while it is in the body. Different patients may
react to the same dose of a drug in very different ways, and the same
patient may react to the same dose of a drug differently at various
times. Therefore, the management of medication therapy is con-
cerned primarily with the effectiveness of a drug's action and the
drug's potential side effects. Pharmacokinetics is the study of the
movement of drugs throughout the body. Four basic actions occur
when a drug is taken: absorption, distribution, metabolism, and
excretion. If you know what happens to the drug in the body, you
can know the onset of a drug's activity (when the drug action starts),
when the effects of the drug are likely to peak, the minimum amount
of the drug needed to bring about the desired effect (therapeutic
dose), and the duration of a particular drug's activity. All these factors
help the provider determine the appropriate form, amount, route,
and frequency of administration of a medication for a particular
patient.
Drug Absorption
The rate at which drugs are absorbed from the site of administration
into the bloodstream depends on many factors, including the drug's
CHAPTER 9 Principles of Pharmacology 207
Telephoning or Faxing a Prescription Into the Pharmacy or
Transmitting an E-Prescription
Using the steps outlined previously, complete the prescription, making sure
to include the following elements:
1. Patient's full name and address
2. Provider's full name and address
3. DEA number if the prescription is for a controlled substance (Schedule
II drugs must be filled with a written prescription and/or an EHR
program authorized to fill scheduled drugs)
4. For the prescribed drug:
• Quantity prescribed
• Name
• Strength • Directions for use
• Dosage form • Number of refills (if any) authorized
The provider must review the prescription for accuracy before the medical
assistant telephones, faxes, or transmits the prescription to the pharmacy. Docu-
ment the pharmacy order in the patient's health record as you would for any
prescribed drug.
For an e-prescription, access the program for electronic transmission of
prescriptions through the patient's record. Complete all the information required,
and transmit the prescription to the patient's preferred pharmacy.
ability to dissolve, the characteristics of the medication, the concen-
tration of the dose, and the route of administration. Liquid oral
medications dissolve more rapidly than solid forms because they do
not have to be dissolved by GI fluids before they are absorbed. In
addition, drugs soluble in fat pass more readily through the cell
membrane because cell membranes have a fatty acid layer. More
acidic drugs are absorbed well in the stomach, whereas others cannot
be absorbed until they reach the small intestine. For some medica-
tions, such as antibiotics, the physician may order an initial loading
dose of the drug, usually twice the typical amount, so that the
patient's blood levels reach the therapeutic range more quickly.
Oral Route
Oral medications are convenient, safe, and relatively inexpensive.
However, drugs that can be destroyed in any way by the digestive
tract must be given by injection. Insulin and heparin are examples
of drugs that are destroyed by the digestive process and therefore
cannot be administered orally. Injection of medications leads to
rapid absorption into the bloodstream, but this increases the danger
of overdose or infection. Most oral medications are absorbed by the
small intestine. After absorption into the bloodstream from the small
intestine, drugs are carried to the liver. Much of the drug's potency
is inactivated in this organ before the drug circulates to the tissues.
208 UNIT TWO ASSISTING WITH MEDICATIONS
This inactivation by the liver often makes it necessary to administer
higher doses orally than those given by injection.
Food slows the absorption of drugs; therefore, many medications
are absorbed best when taken either 1 hour before or 2 hours after
ingestion of food. Food also may bind with a medication or in some
other way inactivate it. For example, tetracycline is destroyed by milk
products and antacids containing calcium salts. Therefore, patients
taking tetracycline should be advised not to eat dairy products or
take liquid or solid forms of antacids. Stomach acid that naturally
occurs during digestion may destroy certain drugs. Because some
drugs are destroyed by the components of the digestive tract or
irritate the empty lining of the stomach, oral drugs may be enteric
coated to keep them intact for passage into the small intestine or to
prevent gastric irritation or vomiting; therefore, enteric-coated medi-
cations should not be crushed or chewed.
Some drugs are not affected by digestive processes, but they
cannot be absorbed through the intestinal walls into the blood-
stream. For example, neomycin has no therapeutic effect when taken
orally (unless it is used to sterilize the bowel before bowel surgery).
Other drugs may be unable to cross the bowel mucosa because of
their poor solubility in lipids (fats), or because they are inactivated
by the pH of the GI tract.
It is important to remember these absorption factors when
administering medication by the oral route. If a patient has previ-
ously responded to a drug but is no longer responding, it may be
important to question the patient's food-medication cycle. It could
be that the patient is no longer taking the medication on an empty
stomach as directed.
Parenteral Route
Parenteral refers to the administration of drugs by injection. The
parenteral route results in the fastest action because the medication
is administered directly into the bloodstream or into tissues with a
rich blood supply. However, several factors determine the effective-
ness and rate of absorption of injected medications.
A drug in an aqueous (water) solution is absorbed more quickly
in an area with more blood vessels. Therefore, drugs deposited in the
muscle are absorbed faster than drugs given subcutaneously. The
intramuscular (IM) route is chosen in an emergency for fast action
or when larger amounts of the medication must be absorbed. The
IM route is also used for oil-based medications (e.g., testosterone),
which are typically prepared with oil to extend the absorption rate
of the drug. The subcutaneous (SC) route is chosen when a slower,
prolonged effect is desired.
Drug absorption also may be controlled physically. Absorption
may be quickened by hand massage after injection, but massage
should be done only if recommended. Absorption may be slowed by
pharmaceutical preparation of the drug in a physical form that slows
absorption. These methods include suspending the drug in a solution
that prolongs absorption, such as colloidal substances, fatty sub-
stances (oil), or insoluble salts or esters. Drugs suspended in these
substances slowly dissolve in the tissues over a long time, and the
patient can be spared costly, frequent, and sometimes painful injec-
tions. Local anesthetics sometimes are mixed with epinephrine to
keep the medication and its effects in an area longer because epi-
nephrine (adrenalin) constricts blood vessels at the site, reducing
circulation and the rate of absorption.
Another parenteral route is the intravenous (IV) route, in which
the medication is injected directly into the vein. Because of the
dangers of IV administration, only members of the medical team
who are licensed to do so may inject medication intravenously. Other
parenteral routes that are outside the medical assistant's scope of
practice include:
• Intrathecal, or intraspinal, injections are used for spinal anes-
thesia and to administer certain medications into the spinal
column.
• Intra-articular injections are used to administer corticoste-
roids into joints.
• Intralesional medications are injected directly into a lesion,
such as an anticancer drug that is administered into a cancer-
ous tumor.
Safety Alert
It is outside the medical assistants scope of practice to perform IV admin-
istration of medications to patients. Because IV administration is so danger-
ous, medications given intravenously usually are administered in small
doses through an IV infusion (IV drip) so that the effects in the body can
be monitored.
Another form of parenteral route is an intradermal injection,
which is injection of the drug within the dermal layer of the skin
and superficial to the subcutaneous tissues. This route is used mostly
for allergy testing and skin testing, such as testing for tuberculosis.
Mucous Membrane Absorption
Drugs may be absorbed by the mucous membranes of the mouth,
throat, nose, eyes, rectum, vagina, and respiratory tracts. Some appli-
cations, such as nasal sprays, eye drops, and rectal suppositories for
constipation, have a local effect. Others have a systemic effect, such
as a rectal suppository given to control vomiting, or a nitroglycerin
tablet dissolved under the tongue (sublingual) to dilate coronary
arteries and relieve the pain of angina pectoris. Inhalation is used
to concentrate drugs locally in the lower respiratory passages or to
produce systemic effects, such as general anesthesia. For example, a
bronchodilator, such as metaproterenol sulfate (Alupent), is inhaled
during an asthma attack to relieve bronchospasms.
Topical Absorption
Topical routes include the application of medications to the skin,
eyes, and ears. Drugs in ointments, creams, lotions, and aerosols can
be applied for the treatment of skin itching, inflammation, or other
discomforts, and for the treatment of skin infections with antibiot-
ics. Nitroglycerin (for angina) can be absorbed through the skin from
a dermal patch, which releases it systemically. Hormones such as
testosterone and estrogen also can be administered via a dermal patch
for systemic purposes.
Drug Distribution
Once a drug has been absorbed, it must be transported by the cir-
culatory system to the area where it will have its effect. In the
bloodstream, drugs can attach to plasma proteins and then are freed

Terms Related to Drug Interactions
Antagonism The action of one drug diminishes the effect or shortens
the duration of action of another drug. For example,
Naloxone Injection and Evzio (a prefilled naloxone
autoinjector) are used to reverse the life-threatening
effects of a narcotic overdose.
Synergism Adrug enhances the intensity or prolongs the action of
another drug. This can have a positive effect, as when
two different antibiotics are used to treat an infection,
or a negative effect, as when two drugs lower blood
pressure to dangerous levels.
Potentiation Aform of synergism in which the effect of one drug is
enhanced by the presence of another drug. In this case,
the two drugs have different actions, but one increases
the effect of the other. Promethazine, an antihistamine,
when given with a painkilling narcotic such as Demerol,
intensifies the narcotic's effect, thereby reducing the
amount of the narcotic needed.
to pass from the blood into the site of action. Drugs are carried
through the fluids into the cells of the tissues and organs. The blood
supply to a part affects the speed with which drugs reach certain
tissues.
The blood-brain barrier is a functional cellular barrier between the
brain cells and the capillaries circulating blood through the brain.
The barrier is poorly permeable to water-soluble materials, which
makes it difficult for dissolved substances in the blood to pass
through. For substances that do cross through, the barrier regulates
the degree and rate of their absorption into the brain tissue. The
general anesthetic thiopental is able to cross the blood-brain barrier
immediately and produces sleep within seconds, whereas other sleep-
producing drugs, such as the barbiturates, cross slowly and may take
as long as 30 minutes to 1 hour to produce the same effect. The
blood-brain barrier is a mixed blessing. It provides a physical barrier
that protects the brain from potentially dangerous chemicals, but it
also makes it very difficult to treat CNS disorders. In contrast,
the placenta has no method for blocking substances, so whatever
the mother consumes is readily passed through the placenta to the
developing fetus. This means that childbearing women must be
extremely careful of all chemicals they consume or inhale because
they are quickly transferred to the baby's bloodstream.
Drug Action
Regardless of the route of administration, a drug can have one of
two actions on the body: local (restricted to one spot or part; not
general) or systemic (affecting the body as a whole). Most drugs are
used for their systemic effects. Even when drugs are used for local
purposes, no drug remains completely localized in the body. Any
chemical that comes into contact with even the most superficial
surface, such as the skin, has the potential to be absorbed into the
bloodstream and circulate to other tissues and organs.
Multiple theories explain the actions of drugs. Drugs are believed
to combine with body chemicals on the cell surface or within the
CHAPTER 9 Principles of Pharmacology 209
cell itsel( Pharmaceutical developers create compounds that have an
affinity for a specific target cell. The target cell recipient is called a
receptor, and the drug that has the affinity for it and produces a
functional change in the cell is called an agonist. Not all drugs that
bind to specific cells cause a functional change in the cell. These
drugs act as an antagonist to the natural process and work by block-
ing a sequence of biochemical events.
Some drugs are believed to act by affecting the enzyme functions
of the body. Drugs attach to enzyme substances and rob the enzymes
from cells. As a result, the enzyme products needed for normal cel-
lular function are not supplied, and the cell fails to function
properly.
Certain antiinfective drugs have a selected toxicity for pathogens
or parasites that have invaded the body. Penicillin and sulfonamides
work because they poison or interfere with the life processes of
bacteria without affecting the life processes of normal human cells.
Research scientists continue to look for differences between cancer
cells and normal cells so that they can apply the principle of selected
toxicity in cancer treatment. Both drugs that have a selective affinity
for cells and those that bind with enzymes may be counteracted by
administering large amounts of natural substances with which the
drugs compete. This process is known as administering an antidote
to a drug that may be acting as a poison. For example, an antidote
such as naloxone hydrochloride can be administered if a patient
receives too much anesthesia or has taken a drug overdose.
Some drugs alter the function of a cell by affecting the physical
properties of the cell membrane rather than altering biochemical
processes within the cell. This is especially true of drugs that affect
nerve cells, such as anesthetics and alcohol. A change in the cell
membrane alters the permeability of the membrane, which in turn
changes the flow of ions into and out of the cells. This change in
ion flow alters the polarity (opposite effects at two extremities, the
two extremities being inside and outside the cell membrane) on
which nerve pulses are conducted, resulting in general sleep or
stupor.
Drug Metabolism
After the drug has been absorbed and distributed, it is metabolized
for excretion. During metabolism, the drug is converted into harm-
less byproducts, which are more easily eliminated by the kidneys.
Most drugs are broken down by the enzyme activity of the liver. For
oral medications that are absorbed in the small intestine, this process
begins in the liver before distribution.
The ability to break down the chemical components of a drug
varies among individuals. Factors that determine this ability include
age, the presence of other drugs, and liver disease. Infants and aging
individuals have more difficulty effectively metabolizing medica-
tions. Patients taking multiple medications also may be at increased
risk for liver-related problems with metabolism because of the sheer
number of chemicals the liver is exposed to on a daily basis. Indi-
viduals with chronic liver disease, such as cirrhosis, may not be able
to metabolize even normal doses of medications. A cumulative effect,
meaning the total amount of the drug present in the body after
multiple doses, may result in a toxic condition if the drug is absorbed
faster than it is metabolized. Because of these factors, drug therapy
must be monitored closely in very young and aging patients, those
taking multiple medications, and patients with chronic liver disease.
21 o UNIT TWO ASSISTING WITH MEDICATIONS

In contrast, patients receiving long-term drug therapy may develop

overstimulation of the enzyme activity of the liver. This results in TABLE 9-6 Physiologic Changes of Age and
rapid destruction of the drug, and the patient has to take larger and Effects on Medication Usage
larger doses for the drug to be effective. This situation is called
CHANGES WITH AGING EFFECTS ON MEDICATION
tolerance.
Stomach takes longer to empty, Increases the risk of stomach
Drug Excretion and gastric acidity is reduced. irritation and ulceration.
After the drug has been metabolized, its byproducts must be excreted
from the body. The kidneys are the most important route for the
Increased percentage of adipose Increases likelihood of drug storage
elimination of drugs. Most chemicals are filtered out of the blood,
(fat) tissue in the body. in fat; may lead to drug toxicity.
circulated through the kidneys, and excreted in the urine. Because Fewer protein-binding sites Reduces drug passage through cell
the kidneys are so important in the elimination of chemicals from available in bloodstream. membranes; increases blood level
the body, drug therapy must be carefully monitored in patients with of drug; may lead to toxicity.
kidney disease or malfunction. Drugs are also eliminated through
the sweat glands, saliva, and feces. Exhalation, another mechanism Liver function declines. Slows rate of drug metabolism;
for drug elimination, serves as the basis for measuring alcohol con- increases risk of toxicity.
centrations in the blood by the breathalyzer test. Drugs may be
Kidney function declines. Slows rate of elimination of drug
eliminated through the milk glands of a lactating mother, which
means that a breastfeeding woman must be extremely careful about
byproducts; increases risk of
taking medications. toxicity and complications.
The combination of metabolism and excretion reduces the Peripheral vascular disease Reduces distribution of drug to the
amount of drug in the body at any given time. The therapeutic dose present; venous tone periphery.
of a medication depends on many factors, including the drug's half-
diminished.
life. The halflife is the amount of time it takes for half a dose of
medication to be metabolized and excreted from the body. Some Fat-soluble medications pass May affect central nervous system;
drugs have extremely short half-lives (only minutes), whereas others through blood-brain barrier more increases risk of vertigo and
can take days to leave the body. The amount of drug lost during one easily. confusion.
half-life depends on how much drug is present. Providers use the
half-life of a drug to determine the timing of medication administra-
tion, or the dose intervals. The shorter the half-life of the drug, the
closer together are the times when it should be administered. If the number of factors are important in determining the correct medica-
next dose of the drug is not given within the half-life, blood levels tion for a patient.
drop and the patient does not receive adequate therapeutic effects
from the treatment. Body Weight
The effect of a medication is directly related to the person's weight.
Basically, the same dose has a lesser effect on a patient who weighs
Pharmacokinetic Terms more and a greater effect on a person who weighs less. Manufacturers
of adult medications calculate dosages based on a normal adult
Absorption The movement of a drug into the bloodstream. The
weight (approximately 150 pounds). Sometimes the provider adjusts
rate of absorption depends on many factors, including the dose to better suit the patient's body size. Pediatric medications
the route of administration. are designed for the body weight of the child.
Distribution The transport of a drug from the site of administration
to the location in the body where it is meant to act Age
(i.e., the target tissue). The most significant effect of age on the body's response to a drug
Metabolism The inactivation of a drug, including the time required occurs in newborns and elderly individuals. This usually is related
for a drug to be detoxified and broken down into to immature or deteriorating body systems. In addition, both
byproducts. The liver typically metabolizes medications. patient groups are particularly sensitive to drugs that affect the
Excretion The elimination of a drug from the body, including the CNS and are at risk of developing toxic drug levels. Consequently,
route of elimination and the time required for this dosage amounts for these two groups must be carefully calculated.
The provider may opt to start therapy with very small doses and
process. The kidneys typically excrete drug metabolites.
increase the dose over time based on the presence or absence of side
effects. Table 9-6 summarizes the altered effects of medications on
aging individuals.
FACTORS AFFECTING DRUG ACTION
As was stated earlier, different people react to the same dose of Gender
medication in different ways, and the same patient can react to the Drugs may affect men and women differently. As has been men-
same dose of the same drug differently on various occasions. A tioned, a pregnant woman must be extremely cautious when taking

medications to prevent possible damage to the developing fetus. In
addition, the side effects of some drugs can stimulate uterine con-
tractions, causing premature labor and delivery. Intramuscular medi-
cations are absorbed faster by men because they generally have higher
levels of muscle mass, which is rich in blood vessels. Because women
typically have a higher body fat content and less muscle (resulting
in fewer blood vessels in peripheral tissues compared with men),
intramuscular drugs remain in their tissues longer. In the past, most
clinical trials were conducted only on men; therefore, until newer
trial results are released that include women, the effect of gender on
the action and safety of medications is impossible to predict
accurately.
Time of Day
Diurnal refers to during the day or time of light. Diurnal body
rhythms play an important part in the effects of some drugs. Seda-
tives given in the morning are not as effective as those administered
before bedtime because the CNS is more alert in the morning,
causing increased resistance to the effects of the drug. Corticoste-
roid administration is preferred in the morning because this best
mimics the body's natural pattern of corticosteroid production and
elimination.
Pathologic Factors
Patients may adversely respond to drugs if they have liver or kidney
disease because the body is unable to metabolize and excrete chemi-
cals properly. Drugs may also produce pathologic conditions of the
liver or kidneys, and patients may need to be monitored for poten-
tially serious drug complications. For example, patients taking statin
medications (e.g., atorvastatin calcium [Lipitor]) for hypercholes-
terolemia should have liver function studies done routinely because
these drugs are very hard on liver cells.
Patients with liver or kidney disease have an increased risk of drug
toxicity, which may result in unconsciousness or death. Reactions in
patients with other diseases or disorders may be quite different from
the expected response. Therefore, a thorough medical history of the
patient must always be taken before medications are prescribed and
administered.
Immune Responses
The presence of a drug can stimulate a patient's immune response,
causing the patient to develop antibodies to a particular chemical.
If the same drug is administered again, the patient will have an
allergic reaction to the drug, ranging from a mild reaction to ana-
phylaxis, a serious respiratory and circulatory emergency. Antibiotics
are the group of drugs that most commonly cause allergic responses.
A typical low-level allergic response to an antibiotic is urticaria, or
the formation of hives.
Psychological Factors
People may respond differently to a medication because of the way
they feel about the drug. If a patient believes in the therapy, even a
placebo (a sugar pill or sterile water thought to be a drug) may help
or bring about relie£ In addition, a patient's personality can affect
whether he or she will follow directions for a particular drug; also,
a negative mindset or mental attitude can reduce an expected
response to a drug.
CHAPTER 9 Principles of Pharmacology 211
Tolerance
Tolerance is the phenomenon of reduced responsiveness to a drug.
Acquired tolerance occurs after a particular drug has been taken for
a period of time. Cross-tolerance occurs when a patient acquires a
tolerance to one drug and becomes resistant to other, similar drugs.
Physical dependence, such as occurs with narcotic addictions, often
accompanies tolerance. The body becomes so adapted to the pres-
ence of the drug that it cannot function properly without it. To
withdraw the drug is to throw the body out of its equilibrium,
causing withdrawal symptoms.
Accumulation
When a drug is taken too frequently to allow for proper elimination,
it accumulates in the tissues. The result is a more intense effect and
a longer duration. Accumulation can cause overdose and/or toxic
effects. An example of a toxic accumulation of medication is ototox-
icity (a toxic condition affecting the ears), which results in nausea,
vomiting, tinnitus, and vertigo. Proper dosage and timing of admin-
istration are the best methods of preventing drug accumulation.
Idiosyncrasy
Occasionally a person reacts to a drug in a manner that is unexpected
and peculiar to that individual. An idiosyncratic response may mani-
fest in many different ways; for example, a hypnotic drug may keep
a person awake, acting as a stimulant to this person rather than as a
depressant. Usually these reactions cannot be explained.
Drug-Drug Interactions
Special care must be taken with patients who take more than one
drug on a regular basis. One medication may increase or decrease
the effects of another or may cause unexpected side effects. To safe-
guard patients from potentially negative drug interactions, it is
important at each visit to record a complete list of all drugs the
patient is taking, including OTC medications and herbal products.
However, because many patients do not know or get confused about
the names and dosages of their medications, the best way to maintain
an accurate record is to ask that patients bring their medication
containers with them to each office visit. This way, you can list
information about the medications in the patient's EHR and at the
same time ask whether the patient has any questions about his or
her treatment. It is also a good idea to advise patients to fill prescrip-
tions at the same pharmacy because the pharmacist can monitor
medications for potential drug interactions. One of the positive
aspects ofEHRs is that the computer program reviews possible drug-
drug interactions if a correct list of all a patient's medications is
included in the person's electronic record.
An example of a drug interaction is the effect of some antibiotics
on oral contraceptives. Certain antibiotics can interact with birth
control pills, making the birth control pills less effective and preg-
nancy more likely. Patients should be told that spotting (midcycle
bleeding) may be the first sign that an antibiotic is interfering with the
effectiveness of birth control pills. Examples of antibiotics that inter-
act with birth control pills include penicillin (Veetids), amoxicillin
(Amoxil), ampicillin (Omnipen), sulfamethoxazole plus tri-
methoprim (Septra or Bactrim), tetracycline (Sumycin), minocycline
(Minocin), metronidazole (Flagyl), and nitrofurantoin (Macrobid or
212 UNIT TWO ASSISTING WITH MEDICATIONS
Macrodantin). If a woman wants to prevent pregnancy while taking
an antibiotic, the provider may recommend that she use a condom
and spermicide as a backup birth control method while taking the
medication and for at least 1 week after the completion of treatment.
CRITICAL THINKING APPLICATION 9-4
Sylvia Kramer, a 72-year-old patient of Dr. Simon, calls today and asks
Kathy how she should be taking her heart medicine, diltiazem HCI (Cardi-
zem). Mrs. Kramer has diabetes, hypertension, and a history of heart
disease. She is overweight, has the potential far kidney disease, and takes
a number of other prescriptions. What factors may have an impact on the
potential effect af Mrs. Kramer's medication?
CLASSIFICATIONS OF DRUG ACTIONS
Clinical pharmacology is a complex subject. To make it easier, drugs
are classified into groups according to their actions in the body (e.g.,
diuretics, emetics); the symptoms they relieve (e.g., antihistamine);
or the body system they affect (e.g., drugs that act on the cardiovas-
cular system). The following examples of drug classifications serve as
a glossary of terms that describe some basic drug actions. As you
read some of the examples, remember that a drug classified as one
type of agent may have other uses and actions in other body systems.
For example, a drug classified as a diuretic may also be an antihy-
pertensive drug, and a vasodilator may also be a respiratory antispas-
modic. It takes time to understand not only the basic classification
of a particular drug, but also the many secondary uses and effects
the drug has on the human body.
Examples of Drug Classifications
Adrenergics
Desired effects: Cause vasoconstriction (i.e., narrowing of the
lumen of a blood vessel); dilate pupils and bronchioles; relax
muscles of the GI and urinary tracts.
Examples: Adrenergics used to treat hypotension: isoproterenol
(Isuprel); norepinephrine (Levophed). Adrenergi,cs used for nasal
and ophthalmic decongestion: naphazoline (Naphcon); phenyleph-
rine (Neo-Synephrine); pseudoephedrine (Sudafed); tetrahydro-
zoline (Visine).
Indications for use: Stop superficial bleeding; raise and sustain
blood pressure; relieve nasal congestion and relieve redness,
burning, irritation, and dryness of the eyes.
Side effects and adverse reactions: Chest pain, tachycardia, head-
ache, increased blood glucose levels, nervousness, tremors.
Adrenergic Blockers
Desired effects: Cause vasodilation; reduce blood pressure; increase
muscle tone of GI walls.
Examples: valsartan (Diovan); propranolol (Inderal); atenolol
(Tenormin); carvedilol (Coreg); tamsulosin (Flomax); metoprolol
(Lopressor).
Indications for use: Control hypertension and peripheral vascular
disease; treat prostatic hyperplasia.
Side effects and adverse reactions: Confusion, lowering of
blood pressure, lowering of blood glucose levels, fatigue, reduced
heart rate.
Analgesics
Desired effects: Reduce the sensory function of the brain; block
pain receptors.
Examples: Nonnarcotic OTCs: aspirin; acetaminophen (Tylenol);
ibuprofen (Advil, Motrin). Narcotic: hydrocodone w/APAP
(Tylenol with codeine); oxycodone (OxyContin); meperidine
(Demerol); hydrocodone (Vicodin).
Indications for use: Relieve pain.
Side effects and adverse reactions: Nonnarcotic: GI disorders, liver
and kidney disorders, tinnitus. Narcotic: Suppression of vital
signs, agitation, blurred vision, confusion, constipation, overse-
dation, restlessness.
Anesthetics
Desired effects: Produce insensibility to pain or the sensation of
pain; block nerve impulses to the brain, resulting in unconscious-
ness; dilate pupils; lower blood pressure; reduce respiratory and
pulse rates.
Examples: Local· benzocaine (Dermoplast, Solarcaine);
lidocaine (Xylocaine); bupivacaine (Marcaine); lidocaine
topical (Lidoderm); procaine (Novocain). General: midazolam
(Versed).
Indications for use: Produce local anesthesia (absence of sensation
without loss of consciousness) or general anesthesia (loss of
consciousness).
Side effects and adverse reactions: Hypotension, cardiopulmonary
depression, sedation, nausea, vomiting, headaches.
Antacids/Proton-Pump Inhibitors
Desired effect: Reduce acidity in the stomach.
Examples: omeprazole (Prilosec); esomeprazole (Nexium);
rabeprazole (Aciphex); lansoprazole (Prevacid); pantoprazole
(Protonix). OTCs: magaldrate (Riopan); calcium carbonate
(Maalox).
Indications for use: Treat gastric hyperacidity; treatment of gastro-
esophageal reflux disease (GERD).
Side effects and adverse reactions: Constipation, diarrhea, electro-
lyte imbalance, flatulence, kidney stones, osteoporosis.
Antianxiety Agents
Desired effects: Reduce anxiety and tension.
Examples: chlordiazepoxide (Librium); clonazepam (Klonopin);
chlorazepate (Tranxene); diazepam (Valium); alprazolam (Xanax);
temazepam (Restoril); triazolam (Halcion).
Indications for use: Produce calmness and release muscle tension;
sedation.
Side effects and adverse reactions: Agitation, amnesia, bi-
zarre behaviors, confusion, reduced white blood cell (WBC)
count, depression, drowsiness, lethargy, oversedation, tremors,
photosensitivity.
Antibiotics
Desired effects: Kill or inhibit growth of microorganisms.
Examples: azithromycin (Zithromax); levofloxacin (Levaquin);
cefaclor (Ceclor); tetracycline (Sumycin); amoxicillin (Amoxil);
amoxicillin/ clavulanic acid (Augmentin); cefadroxil (Duricef);
ciprofloxacin (Cipro); cephalexin (Keflex); doxycycline
(Vibramycin).

Indications for use: Treat bacterial invasions and infections.
Side effects and adverse reactions: Hypersensitivity reaction,
nausea, diarrhea, GI distress, light sensitivity, urticaria.
Anticholinergics
Desired effects: Parasympathetic blocking agents; reduce spasms in
smooth muscles.
Examples: scopolamine or atropine sulfate; tiotropium inhalation
(Spiriva); dicyclomine (Benty!); ipratropium (Atrovent).
Indications for use: Dry secretions before surgery; prevent
bronchospasm.
Side effects and adverse reactions: Blurred vision, confusion,
reduced GI and genitourinary motility, dilation of pupils, fever,
flushing, headache, increased heart rate.
Anticoagulants
Desired effects: Delay or block clotting of blood.
Examples: rivaroxaban (Xarelto); heparin; enoxaparin sodium
(Lovenox); warfarin sodium (Coumadin); tinzaparin
(Innohep).
Primary uses: Treat blood clots, thrombophlebitis; prevent clot
formation.
Side effects and adverse reactions: Increased bleeding; blood irregu-
larities; GI, liver, and kidney disease.
Anticonvulsants
Desired effects: Prevent seizures; reduce excessive stimulation of
the brain.
Examples: clonazepam (Klonopin); gabapentin (Neurontin); phe-
nytoin (Dilantin); phenobarbital; carbamazepine (Tegretol);
lamotrigine (Lamictal); pregabalin (Lyrica); topiramate
(Topamax); valproic acid (Depakene).
Indications for use: Treat epilepsy and other neurologic disorders
(e.g., peripheral neuropathy).
Side effects and adverse reactions: Sedation, vertigo, visual distur-
bances, GI disturbances, liver complications.
Antidepressants
Desired effect: Treat depression.
Examples: venlafaxine hydrochloride (Effexor); sertraline (Zoloft);
escitalopram (Lexapro); duloxetine (Cymbalta); bupropion
(Wellbutrin); trazodone HCI (Desyrel); fluoxetine (Prozac);
imipramine pamoate (Tofranil); amitriptyline (Elavil); citalo-
pram (Celexa).
Indications for use: Elevate mood; treat other neurologic disorders
(e.g., migraines).
Side effects and adverse reactions: Anorexia, anxiety, sexual dys-
function, fatigue, drowsiness, vertigo, weight gain, confusion,
blurred vision.
Antiemetics
Desired effect: Act on hypothalamic center in the brain to reduce
or prevent nausea and vomiting.
Examples: prochlorperazine (Compazine); trimethobenzamide
(Tigan); metoclopramide (Reglan); granisetron (Kytril); ondan-
setron (Zofran); promethazine (Phenergan).
Indications for use: Prevent and relieve nausea and vomiting;
manage motion sickness.
CHAPTER 9 Principles of Pharmacology 213
Side effects and adverse reactions: Dry mouth, sedation, drowsi-
ness, diarrhea, blurred vision.
Antifungals
Desired effects: Slow or retard multiplication of fungi.
Examples: miconazole (Monistat); nystatin (Mycostatin); flucon-
azole (Diflucan); ketoconazole (Nizoral); terbinafine (Lamisil).
Indications for use: Treat systemic or local fungal infections.
Side effects and adverse reactions: Anemia, chills, hypotension,
vertigo, fever, kidney and liver damage, malaise, photophobia,
muscle and joint pain.
Antihistamines
Desired effects: Counteract the effects of histamine by blocking
action in tissues; may be used to inhibit gastric secretions.
Examples: cetirizine (Zyrtec); fexofenadine (Allegra); loratadine
(Claritin, Alavert); chlorpheniramine (Chlor-Trimeton); diphen-
hydramine (Benadryl); promethazine (Phenergan); cimetidine
(Tagamet); ranitidine (Zantac).
Indications for use: Relieve allergies; prevent gastric ulcers.
Side effects and adverse reactions: CNS depression, muscle weak-
ness, epigastric distress, dry mouth.
Antihypertensive Agents
Desired effects: Block nerve impulses that cause arteries to constrict;
slow the heart rate, reducing its contractility; restrict the hormone
aldosterone in the blood.
Examples: amlodipine (Norvasc); atenolol (Tenormin); doxazosin
mesylate (Cardura); metoprolol (Lopressor or Toprol); methyl-
dopa (Aldomet); valsartan (Diovan); amlodipine plus benazepril
(Lotrel); propranolol (Inderal); diltiazem (Cardizem); nifedipine
(Procardia); benazepril (Lotensin); lisinopril (Prinivil, Zestril);
losartan (Cozaar).
Indications for use: Reduce and control blood pressure.
Side effects and adverse reactions: Headache, vertigo, GI distur-
bances, rash, hypotension, nonproductive cough.
Antiinflammatory Agents
Desired effect: Reduce inflammation.
Examples: Nonsteroidal antiinflammatory drugs (NSAIDs): ibuprofen
(Advil, Motrin); naproxen (Naprosyn); celecoxib (Celebrex);
indomethacin (Indocin). Steroidal antiinflammatory drugs
(SAIDs): dexamethasone (Decadron); prednisone (Cortisone);
methylprednisolone (Medrol, Depo-Medrol); montelukast
sodium (Singulair); fluticasone propionate (Flonase); mometa-
sone (Nasonex). Inhalers: flunisolide (AeroBid); triamcinolone
(Azmacort).
Indications for use: Treat arthritis and other inflammatory disor-
ders, including asthma and allergic rhinitis.
Side effects and adverse reactions: GI upset, GI bleeding, hepatitis,
drowsiness, tinnitus, irregular heart rate, kidney disorders.
Antimigraine Agents
Desired effect: Alter circulation to the brain.
Examples: topiramate (Topamax); sumatriptan (Imitrex); zolmitrip-
tan (Zomig).
Indications for use: Treatment or prevention of migraine head-
aches.
214 UNIT TWO ASSISTING WITH MEDICATIONS
Side effects and adverse reactions: Confusion, psychomotor
slowing, difficulty concentrating, memory problems, rare but
serious cardiac events.
Antineoplastics
Desired effects: Inhibit development of and destroy cancerous cells.
Examples: hydroxyurea (Hydrea); cyclophosphamide (Cytoxan);
chlorambucil (Leukeran); raloxifene (Evista).
Indications for use: Cancer chemotherapy and/or prevention.
Side effects and adverse reactions: Nausea, vomiting, bone marrow
depression, aplastic anemia, hair loss, GI ulcers.
Antipsychotics
Desired effect: Alter chemical actions in the brain.
Examples: quetiapine (Seroquel); risperidone (Risperdal); aripipra-
zole (Abilify); olanzapine (Zyprexa); chlorpromazine (Thorazine);
haloperidol (Haldol).
Indications for use: Treat the symptoms of schizophrenia and
bipolar disorder.
Side effects and adverse reactions: GI distress, hypotension, elec-
trocardiographic (ECG) changes, vertigo, sedation, headache,
photosensitivity.
Antipruritics
Desired effect: Relieve itching.
Examples: calamine lotion; hydrocortisone ointment; diphenhy-
dramine (Benadryl).
Indications for use: Treat allergies or topical exposures that cause
itching.
Side effects and adverse reactions: Topical agents have no side
effects; Benadryl can cause vertigo, sedation, and nervousness.
Antipyretics
Desired effect: Lower body temperature.
Examples: aspirin; acetaminophen; ibuprofen.
Indications for use: Reduce fever.
Side effects and adverse reactions: GI disturbance, liver disease;
with aspirin, possibility of Reye's syndrome if given during or
after a viral disease.
Antispasmodics
Desired effects: Relieve or prevent spasms from musculoskeletal
injury or inflammation.
Examples: methocarbamol (Robaxin); carisoprodol (Soma); cyclo-
benzaprine (Flexeril).
Indications for use: Treat sports injuries.
Side effects and adverse reactions: CNS suppression, drowsiness,
vertigo.
Antitussives
Desired effect: Inhibit the cough center.
Examples: Narcotic: codeine sulfate. Nonnarcotic: dextromethor-
phan (Robitussin DM).
Indications for use: Temporarily suppress a nonproductive cough;
reduce the thickness of secretions.
Side effects and adverse reactions: Codeine cough suppressants
cause CNS depression and constipation.
Antiviral Agents
Desired effects: Inhibit the growth or reduce the spread of viral
cells.
Examples: interferon beta-la (Avonex); sofosbuvir (Sovaldi);
dimethyl fumarate (Tecfidera); acyclovir (Zovirax); interferon;
valacyclovir (Valtrex); oseltamivir (Tamiflu); famciclovir (Famvir);
includes the human immunodeficiency virus (HIV) medications
efavirenz, emtricitabine, and tenofovir (Atripla); emtricitabine
and tenofovir (Truvada); darunavir (Prezista).
Indications for use: Treat viral infections, including oral and genital
herpes, influenza, and HIV.
Side effects and adverse reactions: Confusion, diarrhea, headache,
kidney disease, urticaria, vomiting.
Bronchodilators
Desired effect: Relax the smooth muscle of the bronchi.
Examples: theophylline (Theo-Dur); epinephrine (Adrenalin); al-
buterol (Ventolin HFA, Proventil, ProAir HFA); budesonide and
formoterol (Symbicort); isoproterenol (Isuprel).
Indications for use: Treat asthma, bronchospasm; promote
bronchodilation.
Side effects and adverse reactions: CNS stimulation, tremors, tachy-
cardia, increased blood glucose level, elevated blood pressure.
Cathartics (Laxatives)
Desired effect: Increase peristaltic activity of the large intestine.
Examples: magnesium hydroxide (Milk of Magnesia); bisacodyl
(Dulcolax); casanthranol (Peri-Colace).
Indications for use: Increase and hasten bowel evacuation
(defecation).
Side effects and adverse reactions: Nausea, bloating, flatulence,
cramping.
Central Nervous System Stimulants
Desired effects: Affect chemicals in the brain that contribute to
hyperactivity and impulse control.
Examples: methylphenidate (Concerta, Ritalin); modafinil (Pro-
vigil); lisdexamfetamine (Vyvanse).
Indications for use: Treat attention deficit disorder (ADD) and
attention deficit/hyperactivity disorder (ADHD).
Side effects and adverse reactions: Irregular heartbeat, rash, sore
throat, aggression, hypertension, numbness, fainting.
Contraceptives
Desired effect: Inhibit conception.
Examples: medroxyprogesterone acetate (Depo-Provera); Ortho
Evra; etonogestrel/ethinyl estradiol (NuvaRing).
Indications for use: Prevent pregnancy.
Side effects and adverse reactions: Breast enlargement and tender-
ness; cardiovascular risk; GI upset; headache; irregular menstrual
bleeding; deep vein thrombosis; pulmonary embolus (PE).
Decongestants
Desired effect: Relieve local congestion in the tissues.
Examples: ephedrine or phenylephrine (Neo-Synephrine); pseudo-
ephedrine (Sudafed); oxymetazoline (Afrin); mometasone
(Nasonex).

Indications for use: Relieve nasal and sinus congestion caused by
common cold, hay fever, or upper respiratory tract disorders.
Side effects and adverse reactions: Arrhythmias, hypertension,
headache, nausea, dry mouth.
Diuretics
Desired effects: Inhibit reabsorption of sodium and chloride in the
kidneys; promote excretion of excess fluid in the body.
Examples: hydrochlorothiazide (Dyazide, Esidrix, HydroDiuril);
furosemide (Lasix); triamterene (Dyrenium).
Indications for use: Increase urinary output; lower blood
pressure.
Side effects and adverse reactions: Dehydration, muscle weakness,
fatigue, gout, hyperglycemia.
Erectile Dysfunction Agents
Desired effect: Facilitate an erection.
Examples: sildenafil (Viagra); tadalafil (Cialis).
Indications for use: Facilitates an erection in patients with erectile
dysfunction (impotence) and symptoms of benign prostatic
hypertrophy (enlarged prostate).
Side effects and adverse reactions: Headache, flushing, nasal con-
gestion, myalgia, prolonged erections, vision and hearing prob-
lems, cerebrovascular accident (CVA), myocardial infarction
(MI).
Expectorants
Desired effect: Liquefy secretions in the bronchial tubes so that they
can be coughed out.
Examples: dextromethorphan (Benylin).
Indications for use: Relieve upper respiratory tract congestion.
Side effects and adverse reactions: Vomiting, diarrhea, abdominal
pain.
Hematopoietic Agents
Desired effect: Promote red blood cell production.
Examples: epoetin alfa (Epogen, Procrit); pegfilgrastim (Neulasta).
Primary use: Treat anemia in patients undergoing chemotherapy.
Side effects and adverse reactions: Headache, arthralgia, nausea,
hypertension, diarrhea.
Hemostatic Agents
Desired effects: Control bleeding; act as a blood coagulant.
Examples: phytonadione, vitamin K; absorbable hemostatic agents
(e.g., Gelfoam, Surgicel) are applied directly to a wound.
Indications for use: Control acute or chronic blood-dotting disor-
der; promote formation of absorbable, artificial dot.
Side effects and adverse reactions: Hypersensitivity reactions, tran-
sient flushing, dizziness; newborn hyperbilirubinemia.
Hormone Replacement Agents
Desired effects: Replace hormones or compensate for hormone
deficiency.
Examples: insulin (Levemir, NovoLog, Lamus Solostar, Humalog);
levothyroxine sodium (Synthroid or Levoxyl); estrogen (Prema-
rin); vasopressin (Pitressin).
Indications for use: Maintain adequate hormone levels.
CHAPTER 9 Principles of Pharmacology 215
Side effects and adverse reactions: Estrogen replacement therapy:
Hot flashes, decreased sex drive, nausea, vomiting.
Hypnotics (Sedatives)
Desired effects: Induce sleep; lessen the activity of the brain.
Examples: zolpidem tartrate (Ambien); eszopidone (Lunesta); seco-
barbital (Seconal); flurazepam (Dalmane); temazepam (Restoril);
barbiturates.
Indications for use: Treat insomnia; obtain sedation (lower
doses).
Side effects and adverse reactions: Daytime sedation, confusion,
dry mouth, vertigo.
Lipid-Lowering Agents
Desired effects: Reduce blood cholesterol levels and/or increase
high-density lipoprotein (HDL) level.
Examples: atorvastatin calcium (Lipitor); simvastatin (Zocor); ezeti-
mibe (Vytorin or Zetia); rosuvastatin (Crestor); fenofibrate
(Tricor).
Indications for use: Reduce low-density lipoprotein (LDL) and very
low density lipoprotein (VLDL) levels and triglycerides; increase
HDL.
Side effects and adverse reactions: GI discomfort, muscle pain
and weakness, liver complications, hypersensitivity, cataracts,
myopathy.
Miotics
Desired effect: Cause the pupil to contract.
Examples: carbachol (Isopto Carbachol); pilocarpine (Isopto
Carpine).
Indications for use: Counteract pupil dilation.
Side effects and adverse reactions: Corneal edema, clouding, sting-
ing, tearing, headache.
Monoclonal Antibodies
Desired effect: A class of highly specific antibodies that are pro-
duced in a laboratory and used to treat cancer and conditions
that cause extreme inflammation, such as rheumatoid arthritis
and psoriasis.
Examples: adalimumab (Humira); ustekinumab (Stelara); etaner-
cept (Enbrel); trastuzumab (Herceptin); imatinib (Gleevec);
fingolimod hydrochloride (Gilenya); infliximab (Remicade);
rituximab (Rituxan); pemetrexed (Alimta); glatiramer (Copax-
one); bevacizumab (Avastin).
Indications for use: Cancer treatment; treatment of rheumatoid
arthritis, psoriasis, Crohn's disease, ulcerative colitis, multiple
sclerosis.
Side effects and adverse reactions: Injection site reactions, head-
ache, rash, sinusitis, hypersensitivity, neurologic complications,
respiratory infections.
Mydriatic Agents (Anticholinergic)
Desired effect: Dilate the pupil.
Example: atropine sulfate (Isopto Atropine).
Indications for use: Ophthalmologic examinations.
Side effects and adverse reactions: Stinging, burning,
photosensitivity.
216 UNIT TWO ASSISTING WITH MEDICATIONS

Narcotics Examples: alendronate (Fosamax); risedronate (Actonel); calcitonin

Desired effects: Depress the CNS, causing insensibility or stupor.
Examples: Natural narcotics: opium group (codeine phosphate, mor-
phine sulfate); buprenorphine and naloxone (Suboxone); oxyco-
done (OxyContin). Synthetic narcotics: meperidine (Demerol),
methadone (Dolophine).
Indications for use: Relieve pain.
Side effects and adverse reactions: Suppression of vital signs;
agitation, blurred vision, confusion, constipation, oversedation,
restlessness.
Oral Hypoglycemic Agents
Desired effects: Reduce blood glucose level by increasing insulin
production and/ or reducing target cell resistance to insulin, or by
delaying glucose absorption.
Examples: liraglutide (Victoza 3-Pak); rosiglitazone (Avandia);
sitagliptin (Januvia); metformin HCl (Glucophage); acarbose
(Precose); chlorpropamide (Diabinese); glimepiride (Amaryl);
glipizide (Glucotrol); glyburide (Micronase).
Indications for use: Manage diabetes mellitus type 2.
Side effects and adverse reactions: GI irritation, fatigue, hypogly-
cemia, vertigo; possible hypersensitivity reactions.
Osteoporosis Agents
Desired effects: Inhibit bone reabsorption and/or promote use of
calcium.
(Miacalcin nasal spray and Calcimar); ibandronate (Boniva); ral-
oxifene hydrochloride (Evista); zoledronic acid (Reclast, Zometa).
Indications for use: Promote bone mineral density and reverse
progression of osteoporosis.
Side effects and adverse reactions: GI disorders, esophageal
irritation.
Respiratory Corticosteroid Agents
Desired effects: Reduce airway inflammation and bronchial
resistance.
Examples: fluticasone and salmeterol (Advair Diskus); fluticasone
propionate (Flovent HFA); budesonide and formoterol fumarate
dehydrate (Symbicort); tiotropium bromide (Spiriva Handi-
haler); mometasone furoate monohydrate (Nasonex).
Indications for use: Long-term relief of asthma symptoms; decrease
frequency of asthma attacks; manage chronic obstructive pulmo-
nary disease (COPD) and seasonal allergies.
Side effects and adverse reactions: Headache, pharyngitis, myalgia,
hypersensitivity, oral candidiasis. Advair Diskus is contraindi-
cated in patients with a milk allergy.
Table 9-7 lists details about the top 50 prescribed drugs in 2014.
Review this list to become familiar with some of the most commonly
prescribed medications. These are just a few examples of the different
classifications of medications. Remember to research and review all
medications before administering them.

TABLE 9-7 Top 50 Prescribed Drugs in 2014

BRAND INDICATIONS AND
NAME CLASSIFICATION DESIRED EFFECTS SIDE EFFECTS ADVERSE REACTIONS
Synthroid Thyroid hormone Increase BMR; enhance Reversible hair loss, dry skin, GI Overdosage causes signs of
gluconeogenesis; stimulate protein intolerance hyperthyroidism, cardiac
synthesis arrhythmias
Crestor Cholesterol lowering Decrease LDL, VLDL, triglycerides; Pharyngitis, headache, epigastric Hypersensitivity, cataracts,
(antihyperlipidemic) increase HDL distress, myalgia myopathy
Nexium Proton-pump inhibitor Increase gastric pH; reduce gastric Headache, diarrhea, abdominal Hepatitis, hypersensitivity,
acid production; esophagitis; GERD; pain decreased WBC count
Helicobacter pylori ulcers
Ventolin Bronchodilator Relieve branchospasm, reduce Headache, nausea, restlessness, Palpitations, tachycardia, slight
HFA airway resistance; can function as a tremors, dizziness, throat increase in BP, chest pain
rescue inhaler to relieve immediate irritation, hypertension
symptoms of an asthma attack
Advair Long-acting respiratory Relieve symptoms of asthma; Headache, pharyngitis, URI, Hypersensitivity, palpitations, chest
Diskus corticosteroid agent reduce airway resistance myalgia, nausea pain, oral candidiasis
Diovan Antihypertensive Cause vasodilation; decrease Headache, dizziness, viral Hypotension with overdosage,
peripheral vessel resistance; infection, fatigue, abdominal pain tachycardia, hypersensitivity
decrease BP
Lantus Long-acting insulin Control glucose levels Localized reaction at injection site, Severe hypoglycemia with insulin
Solostar hypokalemia, allergic reaction overdose, diabetic ketoacidosis
 CHAPTER 9 Principles of Pharmacology 217

TABLE 9-7 Top 50 Prescribed Drugs in 2014-continued

BRAND INDICATIONS AND
NAME CLASSIFICATION DESIRED EFFECTS SIDE EFFECTS ADVERSE REACTIONS
Cymbalta Antidepressant Relieve depression Nausea, dry mouth, diarrhea, Increased heart rate, orthostatic
insomnia, headache hypotension, skin rashes, GI
disorders
Vyvanse Stimulant Imp rove attention span; decrease Abdominal discomfort and GI Cardiovascular complications in
distractibility and impulsive symptoms, decreased appetite, patients with heart problems,
behavior; treat ADHD headaches, insomnia, dry mouth, hypersensitivity; overdosage may
dizziness cause arrhythmias, seizures,
psychosis
Lyric• Anticonvulsant Seizure control; treat fibromyalgia; Muscle pain, weakness, or Mood or behavior changes,
treat pain caused by nerve damage tenderness; vision problems; easy anxiety, panic attacks, trouble
in diabetic neuropathy, herpes bruising or bleeding; swelling of sleeping, hyperactive, increased
zoster (postherpetic neuralgia) hands or feet; rapid weight gain depression, suicidal thoughts
Humira Monoclonal antibody Reduce inflammation and joint Injection site reactions, headache, Hypersensitivity, neurologic events,
destruction in rheumatoid arthritis rash, sinusitis, nausea respiratory infections and bronchitis
Enbrel Anti rheumatic, Relieve symptoms of rheumatoid Injection site reaction, abdominal Infections, heart failure,
immunomodulator, arthritis, psoriasis, and other pain, URI, headache hypertension, nervous system
monoclonal antibody inflammatory conditions disorders
Remicade Anti rheumatic, Decrease inflamed areas of Headache, nausea, fatigue, fever Hypersensitivity, infusion reactions,
immunomodulator, intestine, synovitis, and joint lupuslike syndrome
monoclonal antibodies erosion
Copaxone lmmunosuppressant Slow progression of MS Injection site reactions, arthralgia, Infection, lymphadenopathy,
vasodilation, anxiety hypertension, decreased WBC
count
Neulasta Hematopoietic agent Increase phagocytosis and decrease Bone pain, nausea, fatigue, Allergic reactions, spleen
incidence of infection during headache, arthralgia complications
chemotherapy
Rituxan Anti neoplastic, Cytotoxicity, reduce tumor size; Fever, chills, headache, Arrhythmias, acute renal failure,
monoclonal antibodies reduce joint destruction in RA angioedema, nausea, rash hypersensitivity
Spiriva Bronchodilator Relieve bronchospasm for patients Dry mouth, sinusitis, pharyngitis, Chest pain, angioedema,
Handihaler with COPD dyspepsia, UTI, rhinitis hypersensitivity
Januvia Antidiabetic agent, oral Lower blood glucose and A1c levels Headache, nasopharyngitis, URI, Overdose causes severe
hypoglycemic over time hypoglycemia hypoglycemia, pancreatitis,
hypersensitivity
Atripla HIV antiviral combination Decrease viral load Lactic acidosis, serious liver Serious complications from lactic
drug (three drugs) problems, serious psychiatric acidosis and liver disorders
problems, kidney disorder,
osteopenia, skin discoloration,
diarrhea, dizziness, drowsiness
Avastin Antiangiogenic agent, Treatment of metastatic carcinoma Fainting, anorexia, heartburn, Gastric ulcers, bleeding, slow
monoclonal antibody of the colon; glioblastoma, and diarrhea, weight loss, dry mouth, wound healing
renal cell cancer sores on the skin or in the mouth,
voice changes
Continued
218 UNIT TWO ASSISTING WITH MEDICATIONS

TABLE 9-7 Top 50 Prescribed Drugs in 2014-continued

BRAND INDICATIONS AND
NAME CLASSIFICATION DESIRED EFFECTS SIDE EFFECTS ADVERSE REACTIONS
Oxy(ontin Analgesic narcotic; Relieve pain Sleepiness, dizziness, Overdose causes respiratory failure,
contains codeine and hypotension, anorexia, hepatotoxicity from overdose of
acetaminophen constipation acetaminophen; addiction
Epogen Hematopoietic agent Stimulate RBC production; raise Fever, diarrhea, nausea, vomiting, Encephalopathy, thrombosis, CVA,
H&H; treatment of anemia in edema Ml, seizures
chemotherapy patients
Celebrex NSAID, analgesic Reduce inflammation and relieve GI disorders, URI, back pain, Increased risk of CV events and GI
pain; treatment of RA and other peripheral edema, rash bleeding
forms of arthritis
Truvada HIV (combination of two Prevent HIV cells from multiplying New infections, GI disorders, chest Hypersensitivity, lactic acidosis
antiviral drugs) in the body; reduce risk of HIV pain, dry cough, wheezing, cold
infection sores, tachycardia
Gleevec Anti neoplastic, Suppress tumor growth Nausea, diarrhea, vomiting, Severe fluid retention, decreased
monoclonal antibody headache, fluid retention WBC and platelet counts;
pneumonia
Herceptin Chemotherapeutic agent; Interfere with growth and spread of Nausea, diarrhea, weight loss, Cardiomyopathy, infusion reactions,
adjunct therapy for cancer cells in the body fever, headache, sleep problems, embryo-fetal toxicity, pulmonary
cancers of the breast or cough, trouble breathing, skin toxicity
stomach; monoclonal rash, bruising, cold symptoms
antibody
Lucentis Ophthalmic injection Keep new blood vessels from Itchy or watery eyes, dry eyes, Hypersensitivity, exophthalmos
forming under the retina; treat wet swelling of the eyelids, blurred from increased intraocular pressure,
age-related macular degeneration vision, sinus pain, sore throat, detached retina, CVA, Ml
and diabetic retinopathy joint pain
Namenda Alzheimer's disease Reduce deterioration in moderate to Dizziness, headache, confusion, AV block, CNS reactions,
severe Alzheimer's disease constipation, hypertension, cough hypersensitivity
Zetia Cholesterol lowering Reduce total cholesterol, LDL, URI, headache, back pain, None known
(antihyperlipidemic) triglycerides; increase HDL diarrhea, myalgia
Levemir Long-acting insulin Control glucose levels Localized reaction at injection site, Severe hypoglycemia with insulin
hypokalemia, allergic reaction overdose, diabetic ketoacidosis
Symbicort Glucocorticoid inhaler, Relieve symptoms of asthma and Headache, URI, sore throat, Hypersensitivity, palpitations, ECG
long-term treatment of reduce airway resistance sinusitis, oral candidiasis changes
asthma and COPD
Sovaldi Antiviral Prevent hepatitis ( virus cells from Headache, fatigue, mild itching, Hypersensitivity, birth defects or
multiplying nausea, insomnia death in unborn baby
Novolog Combination insulin Control glucose levels Localized reaction at injection site, Severe hypoglycemia with insulin
hypokalemia, allergic reaction overdose, diabetic ketoacidosis
Tecfidera Interferon Treat relapsing multiple sclerosis Nausea, diarrhea, stomach pain, Hypersensitivity, serious viral
flushing infection of the brain
Suboxone Opioid narcotic Treat narcotic addiction; not used as Tongue pain, redness or numbness Respiratory arrest, addictive,
a pain medication inside mouth, constipation, hypersensitivity
headache, insomnia, swelling of
arms or legs
 CHAPTER 9 Principles of Pharmacology 219

TABLE 9-7 Top 50 Prescribed Drugs in 2014-continued

BRAND INDICATIONS AND
NAME CLASSIFICATION DESIRED EFFECTS SIDE EFFECTS ADVERSE REACTIONS
Humalog Rapid acting or a Control glucose levels Localized reaction at injection site, Severe hypoglycemia with insulin
combination insulin hypokalemia, allergic reaction overdose, diabetic ketoacidosis
Xarelto Anticoagulant Prevent new clot formation Bleeding, pruritus, pain in Hemorrhage, hypersensitivity
extremities, muscle spasms
Seroquel Extended-release Manage psychotic disorders and Headache, sleepiness, dizziness, Heart block, hypokalemia,
XR anti psychotic schizophrenia; adjunct constipation, orthostatic tachycardia
antidepressant hypotension
Viagra Erectile dysfunction (ED) Facilitate an erection Headache, flushing, nasal Severe hypotension, prolonged
agent congestion, UTI, diarrhea erections, vision problems, CVA, Ml
Alimta Chemotherapeutic agent Treatment of lung cancer; interfere Fatigue, anorexia, weight loss, Hypersensitivity, kidney and liver
with growth and spread of cancer N/V, diarrhea, rash, hair loss. damage
cells in the body
Victoza Antidiabetic agent Lower blood glucose and A1c Headache, nausea, diarrhea, Severe hypoglycemia, pancreatitis,
3-Pak GERO hypersensitivity
Avonex Interferon antiviral Treatment of relapsing-remitting MS Headache, flulike symptoms, Anemia, rare life-threatening
myalgia, URI, generalized pain, reactions
sinusitis
Nasonex Corticosteroid allergy Decrease response to seasonal Nasal irritation, sore throat, Hypersensitivity, stimulates
agent allergens; stabilize asthma headache wheezing in asthmatics
Cialis ED agent Facilitate erection in ED Headache, myalgia, flushing, Prolonged erections, vision and
nasal congestion hearing problems, CVA, Ml
Gilenya Biologic response Reduce progression of MS Headache, flulike symptoms, Increased risk of infections, CVA,
modifier, MS agent diarrhea, back pain hypersensitivity, dyspnea
Stelara lmmunomodulator, Reduce inflammation, scaling of Headache, fatigue, Hypersensitivity, risk of skin cancer,
antipsoriatic agent, psoriasis plaques nasopharyngitis, URI neurologic complications
monoclonal antibody
Flovent Corticosteroid inhaler Prevent or control inflammation and Throat and nasal irritation, dry Anaphylaxis, glaucoma, nasal
HFA asthma mouth, candidiasis septal perforation
Prezista Antiretroviral; protease Interrupt HIV replication; slow Diarrhea, abdominal pain, Immune system reactions,
inhibitor progression of HIV infection headache, rash, N/V pancreatitis, serious skin rashes,
hepatitis
Procrit Hematopoietic agent, Promote production of RB(s to Fever, diarrhea, N/V, edema Encephalopathy, thrombosis, (VA,
erythropoiesis-stimulating raise H&H; treatment of anemia in Ml, seizures
agent (ESA) chemotherapy patients
lsentress Antiviral; integrase Prevents HIV cells from multiplying; Diarrhea, nausea, headache Increase in total cholesterol, rash,
inhibitor treatment of HIV strains that are increased liver enzymes, increased
resistant to multiple antiretroviral blood glucose, psychiatric disorders
drugs and for people with
drug-sensitive HIV strains
www.medscape.com/viewartic/e/825053; and www.webmd.com/news/20140805/top-1 a-drugs.
AOHD, Attention deficit/hyperactivity disorder; AV, atrioventricular; BMR, basal metabolic rate; BP, blood pressure; CNS, central nervous system; COPD, chronic obstructive pulmonary disease;
CV, cardiovascular; CVA, cerebrovascular accident; ECG, electrocardiogram; GERD, gastroesophageal reflux disease; GI, gastrointestinal; HCV, hepatitis Cvirus; HDL, high-density lipoprotein;
H&H, hemoglobin and hematocrit; HIV, human immunodeficiency virus; LDL, low-density lipoprotein; Ml, myocardial infarction; MS, multiple sclerosis; NSAID, nonsteroidal antiinflammatory drug;
NJv, nausea and vomiting; /?A, rheumatoid arthritis; RBC, red blood cells; URI, upper respiratory infection; UT/, urinary tract infection; VLDL, very low density lipoprotein; WBC, white blood cells.
220 UNIT TWO ASSISTING WITH MEDICATIONS
HERBAL AND ALTERNATIVE THERAPIES
The use of alternative therapies, often called complementary or holis-
tic medicine, has become very popular in the United States. Accord-
ing to estimates, more than 42% of adult patients use some form
of alternative therapy, such as herbal medicine, acupuncture,
massage therapy, chiropractic care, or mind-body therapies. Even
though only limited scientific studies prove the effectiveness of
herbs, their use to relieve the symptoms of common patient com-
plaints is definitely on the rise. It is estimated that 15 million
adults take prescription drugs along with herbal and vitamin sup-
plements. Patients typically are hesitant to discuss their use of
herbal products with their provider, which makes it difficult for
providers to assess potential drug-herb interactions. Therefore, it is
important that medical assistants become familiar with common
alternative therapies and that they include questions about the use
of these therapies when gathering information about the patient's
medication history.
Herbal Products
Regulation of Herbal Products
Herbal medicine uses plant-based products to promote health and
treat the symptoms of a wide range of diseases. These remedies typi-
cally are marketed by manufacturers and are regulated by the federal
government as dietary supplements. The FDA is responsible for
regulating dietary supplements under the Dietary Supplement
Health and Education Act of 1994 (DSHEA). Under DSHEA,
manufacturers are responsible for performing tests and ensuring the
safety of dietary supplements before they are sold. However, these
products are not registered with the FDA and do not have to go
through the rigorous process of FDA approval that new drugs face
before they are produced and sold. In addition, there is no federal
control over the standardization of herbal dietary supplements. Phar-
maceutical companies must prove that each batch of a drug is stan-
dardized or consistent with previous batches. Because this is not
the case with dietary supplements, there are no guarantees that the
amounts of active ingredients in a herbal supplement remain the
same over time or are similar to the amounts found in the same
supplement produced by a different company.
The FDA has the authority to oversee the manufacture of domes-
tically made and foreign-made supplements. Supplement manufac-
turers must provide evidence that their products actually contain
what the labels claim and that the products are free of contaminants.
According to FDA regulations, dietary supplement labels must list
the following:
• Product name with the word "supplement" on the label
• Name and location of the manufacturer or distributor
• Structure/function claim: Claims of specific benefits may be
made, but the following statement must be included: This
statement has not been evaluated by the Food and Drug Admin-
istration. This product is not intended to diagnose, treat, cure, or
prevent any disease.
• Directions for use
• For plant-based herbal preparations: the name of the plant or
the part of the plant used
• For blended products created by the manufacturer: the com-
ponents and the weight of each ingredient
• All nondietary ingredients (e.g., fillers, artificial colors, sweet-
eners, flavors), listed in descending order of weight
• The label may include warnings about use, but the lack of
cautionary statements does not mean that no adverse effects
are associated with the supplement.
Commonly Used Herbal Products
Table 9-8 summarizes the most commonly used herbal products.
Information about herbal remedies is constantly changing, but the
federal government has several websites that can be used as refer-
ences. These include the National Center for Complementary and
Alternative Medicine (http://nccam.nih.gov/) and the National Insti-
tutes of Health Office of Dietary Supplements (http://ods.od.nib.gov/
index.aspx).
Alternative Therapies
Acupuncture
Acupuncture treatments are part of traditional Chinese medicine,
which is based on the concept that disease is caused by a disruption
in the flow of life force and an imbalance between yin and yang. In
acupuncture treatments, thin metal needles are inserted through the
skin to stimulate specific points in the body to restore and maintain
health. Studies indicate that acupuncture may help reduce pain and
relieve the nausea associated with chemotherapy treatments. Therapy
involves a series of treatments, with the placement of as many as 12
needles in various locations on the body.
During the procedure, the patient is placed supine, prone, or in
the Sims position, depending on the needle insertion site. Although
the procedure is not painful, the patient may notice a sharp sensation
when the needles initially are placed. After the needles have been in
place for a time, they may be rotated gently, heated, or electrically
stimulated to achieve the benefit sought by the treatment. The
needles usually are left in place for 5 to 20 minutes, and after they
have been removed, the provider typically discusses the results of
treatment with the patient.
Chiropractic Care
Chiropractic providers apply techniques that focus on the body's
physical structure (usually the spine) and perform manipulations or
anatomic adjustments to correct alignment problems and help the
body heal itsel£ Many patients combine chiropractic therapy with
conventional medical treatment to obtain relief of chronic pain in
the lower back and neck and to relieve persistent headaches. Chiro-
practors must earn a Doctor of Chiropractic degree at an accredited
college and pass a state licensing examination before they can prac-
tice. Besides spinal adjustments, patient treatment plans may include
a combination of hot and cold therapies; electrical stimulation; rest
and rehabilitation exercises; dietary and lifestyle counseling; and the
use of dietary supplements.
Mind-Body Therapy
Mind-body therapy uses biofeedback to teach patients to use their
thoughts to control certain body reactions. It is based on the scien-
tific principle that our thoughts can influence the body's involuntary
functions. For example, a child experiencing the sudden onset of an
asthma attack may become extremely anxious because he or she is
having serious difficulty breathing. Panic and anxiety increase the

TABLE 9-8 Commonly Used Herbal Products
NAME USES
Acai Weight loss and antiaging; antioxidant
Black cohosh Relieve symptoms of menopause; treat menstrual
irregularities and premenstrual syndrome; induce labor
Echinacea Treat or prevent colds, flu, and other infections;
believed to stimulate the immune system
Flaxseed Laxative; treat hot flashes and breast pain; flaxseed
oil used to treat arthritis; both flaxseed and flaxseed
oil used to treat high cholesterol levels and prevent
cancer
Garlic Treat high cholesterol, heart disease, hypertension;
prevent certain types of cancer, including stomach
and colon cancer
Ginger Treat stomach aches, nausea, diarrhea; ginger extract
is a component of many cold and flu dietary
supplements; used to alleviate nausea associated with
postoperative state, motion sickness, chemotherapy,
and pregnancy; used for rheumatoid arthritis,
osteoarthritis, and joint and muscle pain
Asian ginseng Support overall health and boost immune system;
improve mental and physical performance; treat
erectile dysfunction, hepatitis C, and menopause
symptoms; lower blood glucose and control blood
pressure
Ginkgo biloba Treat a variety of conditions, including asthma,
bronchitis, fotigue, and tinnitus (ringing or roaring
sounds in the ears); typically used to improve
memory; treat or help prevent Alzheimer's disease
and other types of dementia; reduce intermittent
claudication (leg pain caused by narrowing arteries);
treat sexual dysfunction and multiple sclerosis
Glucosamine Natural substances found in and around the cells of
plus chondroitin cartilage; used to treat arthritis and joint pain
sulfate
Green tea Prevent and treat a variety of cancers and for mental
alertness, weight loss, lowering cholesterol levels, and
protecting skin from sun damage; laboratory studies
suggest may help protect against or slow the growth
of certain cancers
CHAPTER 9 Principles of Pharmacology 221
SIDE EFFECTS AND CAUTIONS
Little scientific information about the safety of acai; no scientific evidence to
support use for any health-related purpose; might affect magnetic resonance
imaging (MRI) results.
Headaches, gastric complaints, heaviness in the legs, weight problems; safety
unknown for pregnant women or those with breast cancer.
Most studies indicate echinacea does not appear to prevent colds or other
infections; some people experience allergic reactions, including rashes,
increased asthma, and anaphylaxis; gastrointestinal (GI) side effects.
Few reported side effects; contains soluble fiber (such as that found in oat
bran) and is an effective laxative; should be taken with plenty of water; may
diminish body's ability to absorb medications taken by mouth; should not be
taken at same time as oral medications.
Some evidence indicates garlic can slightly lower blood cholesterol levels and
may slow development of atherosclerosis; side effects include breath and body
odor, heartburn, GI upset, and allergic reactions; acts as a mild anticoagulant
(similar to aspirin); may be a problem during or after surgery- avoid dietary
and supplemental garlic for at least l week before surgery; interferes with
effectiveness of saquinavir, a drug used to treat human immunodeficiency virus
(HIV) infection.
Short-term use can safely relieve pregnancy-related nausea and vomiting; side
effects most often reported are gas, bloating, heartburn, and nausea.
Some studies show ginseng may lower blood glucose and possibly boost
immune function; when taken by mouth, it usually is well tolerated; most
common side effects are headaches, sleep disorders, GI problems, and possible
allergic reactions; patients with diabetes using medications for treatment should
use ginseng with caution.
Research indicates that ginkgo is ineffective in treating Alzheimer's disease,
dementia, and intermittent claudication; side effects may include headache,
nausea, GI upset, diarrhea, dizziness, or allergic skin reactions; severe allergic
reactions occasionally are reported; can increase bleeding risk, so people who
take anticoagulant drugs, have bleeding disorders, or have scheduled surgery
or dental procedures should use caution; uncooked ginkgo seeds contain a
toxic chemical that can cause seizures.
Recent study shows participants with moderate to severe pain had significant
relief with the combined supplement. Most common side effect is GI upset.
Safe in moderate amounts; possible complications include liver problems with
concentrated green tea extracts but not when used as a beverage; contains
caffeine; contains small amounts of vitamin K, which can make anticoagulant
drugs less effective.
Continued
222 UNIT TWO ASSISTING WITH MEDICATIONS
TABLE 9-8 Commonly Used Herbal Products-continued
NAME USES
Melatonin Treatment of sleep disorders
Milk thistle Promote liver health, treat cirrhosis, chronic hepatitis,
(silymarin) and gallbladder disorders; lower cholesterol; reduce
insulin resistance
Saw palmetto Primarily used to treat urinary symptoms associated
with an enlarged prostate gland; also used far chronic
pelvic pain, bladder disorders, reduced sex drive, hair
loss, and hormone imbalance
St. John's wort Traditionally used to treat mental disorders and nerve
pain; may be used as a sedative; treatment for
malaria; balm far wounds, burns, and insect bites;
currently used far depression, anxiety, and/or sleep
disorders
Modified from the National Center for Complementary and Alternative Medicine. https:j/nccih.nih.govjheolthjherbsotuglonce.htm. Accessed May 26, 2015.
urgency to breathe. If the child can be taught to relax and keep
breathing at a normal rate, the asthma attack will not be influenced
by the child's anxiety, and medications taken to relieve broncho-
spasm will be more effective.
Biofeedback specialists use special monitoring equipment to
demonstrate the body's reaction to certain stimuli and to help teach
patients how to control physical responses to stress. During a bio-
feedback session, the provider applies electrical sensors to various
locations on the body. These sensors monitor and provide feedback
about the body's physiologic responses to stress. For example, if a
patient is experiencing chronic tension headaches, the sensors dem-
onstrate that the headache is just part of overall muscular tension.
Tension that is registering throughout the body may cause a beeping
sound or lights flashing from the equipment as a cue for the patient
to associate muscular tension with development of the headache.
The goal is to help patients recognize that one body action results
in another. Once this goal has been achieved, patients are taught
SIDE EFFECTS AND CAUTIONS
May help individuals with normal sleep patterns but has limited or no effect on
those with sleep disorders. Most common side effects are nausea and
drowsiness.
Studies suggest it may benefit the liver; associated with fewer and milder
symptoms of liver disease in patients with hepatitis C; may lower blood
glucose levels; can cause allergic reaction.
Studies suggest it may be effective far treating prostate symptoms, but no
evidence indicates that it reduces the size of an enlarged prostate; does not
appear to affect readings of prostate-specific antigen (PSA) level, which is used
as screening tool far cancer of the prostate; may cause mild GI upset, tender
breasts, and decline in sexual desire in male patients.
Some scientific evidence shows it helps treat mild to moderate depression; not
effective in treating major depression. Side effects include photophobia
(increased sensitivity to sunlight), anxiety, dry mouth, dizziness, GI
symptoms, fatigue, headache, and sexual dysfunction.
Affects the way the body processes or breaks down many drugs; may speed or
slow a drug's metabolism. Combined with certain antidepressants, it may
increase side effects such as nausea, anxiety, headache, and confusion.
Drugs that can be affected include:
• Antidepressants
• Birth control pills
• Cyclosporine (prevents rejection of transplants)
• Digoxin (strengthens myocardial contractions)
• lndinavir and possibly other drugs used far HIV
• lrinatecan and possibly other drugs used ta treat cancer
• Warfarin and related anticoagulants
St. John's wart is not a proven therapy far depression. If depression is not
adequately treated, it can become severe.
relaxation techniques designed to prevent the stressful response.
Biofeedback methods are effective in managing multiple stress-
related conditions, including muscle tension, headaches, chronic low
back pain, altered heart rates, and hypertension.
Homeopathic Medicine
Homeopathy, or homeopathic medicine, is a medical approach that
was developed in Germany over 200 years ago. The primary principle
of homeopathic medicine is to administer very dilute substances that
are designed to stimulate the body's ability to heal itsel£ Homeo-
paths work individually with clients to administer the lowest dose
of medication possible, believing that the lower the dose, the more
effective the treatment. Remedies are created from plants, minerals,
or animals, and include red onion, arnica (mountain herb), and
stinging nettle plant.
Homeopaths assess clients holistically and gather details on indi-
vidual and family health histories, body type, and current physical,

emotional, and mental symptoms. Treatments are specifically
designed for each client; therefore, it is not unusual for people with
the same condition to have different treatment protocols. People seek
homeopathic assistance for a wide range of health problems, includ-
ing allergies, asthma, chronic fatigue syndrome, depression, digestive
disorders, ear infections, headaches, and skin rashes.
Homeopathic remedies are regulated in the same manner as OTC
drugs. They do not have to comply with the strict testing guidelines
required for prescription drugs. However, the FDA does require that
homeopathic remedies meet strength, purity, and packaging stan-
dards. Labels must identify at least one health condition that the
remedy can treat, provide an ingredient list, indicate the dilution of
the ingredients, and explain safety instructions.
Homeopathic therapies are not known to interfere with prescrip-
tion and OTC medications; however, it is important to gather infor-
mation from patients about the use of homeopathic remedies and
to document the details in the patient's record for the provider to
review.
CLOSING COMMENTS
Patient Education
It is important for the patient to be aware of the effects a drug may
have and should have on his or her system. The medical assistant
plays an important role in helping patients understand their medica-
tions, promoting compliance with treatment, and preventing com-
plications. Depending on the facility's policies, the administrative
medical assistant may be expected to do many of the following tasks
when gathering initial information from patients. These points
should be considered when gathering a medication history and docu-
menting in the patient's health record.
• Make a comprehensive list of all medications, including OTC
agents and alternative therapies that the patient uses
regularly.
• Ask female patients whether they are pregnant or breast-
feeding.
• Preassess the patient for any adverse effects, such as drug aller-
gies and drug-drug or drug-food interactions.
• Observe the patient for any adverse effects for a minimum of
20 minutes after administration of a medication in the office;
also, inform the patient of possible adverse reactions to the
medication that may occur at home.
• Discuss with the patient how and when the prescribed drug
is to be taken, and whether any special storage precautions are
required.
• Reassess that the patient is taking the medication properly.
• Provide comfort, encouragement, and guidance to patients to
ensure their understanding, safety, and cooperation while
using drug therapy.
• Answer any questions the patient may have. Remember: If
you are not sure of the answer, consult the prescribing
provider.
Therapeutic Communication with Patients from
Diverse Cultures
Health beliefs can affect compliance with medication therapy.
Patients from various cultures may be using home remedies or herbal
CHAPTER 9 Principles of Pharmacology 223
treatments that could interfere with the effectiveness and safety of
medications prescribed by the provider. Guidelines that the medical
assistant may find helpful include the following:
• Investigate the healing practices of the primary cultures in
your area so that you are better equipped to discuss these
practices with your patients.
• Encourage cultural sensitivity in your co-workers.
• Provide patients with educational materials in their native
language.
• Ask patients if they are using home remedies or are consulting
a healer from their culture. If so, get as much detail as possible
so that you can share this information with the provider.
Legal and Ethical Issues
The medical assistant plays a key role in the management of con-
trolled substances in the ambulatory care setting. It is important that
all rules for record keeping, inventory, prescribing, dispensing, and
documenting scheduled drugs are followed according to state and
federal regulations. The medical assistant may be responsible for
requesting the provider's initial DEA registration and for continuing
certification renewal. The area DEA office can provide instructions
on this. Each DEA number is specific to a site, so multiple practice
locations require a DEA number for each facility.
Accurate, complete documentation is essential for correct man-
agement of patient medications. Each time the patient is prescribed
or administered a medication, complete details must be included in
the patient's record using approved medical terminology and abbre-
viations. Failure to do this may result in a serious error that could
harm the patient and result in litigation.
HIPM Applications
According to the Health Insurance Portability and Accountability
Act (HIPM), patients have the right to request restrictions on the
disclosure of protected health information (PHI) for treatment,
payment, and healthcare operations (TPO). For example, if a patient
has a history of substance abuse and this information is not pertinent
to current TPO circumstances, the patient can request that this
information not be disclosed. The facility does not have to agree to
the patient's request; however, a process must be established within
the practice to review the demand and explain the provider's decision
to the patient. If the provider agrees not to release this information,
the specific restriction must be documented in the patient's record,
and staff members must review and comply with the restrictions each
time material is sent out of the facility for TPO purposes.
Professional Behaviors
Participation in drug therapy requires absolute accuracy from the medical
assistant. There is no room for error when gathering a medication history,
documenting in the patient's health record, and understanding the purpose
and effects of prescribed drugs. When a medical assistant performs his or
her duties with accuracy, the message is sent that this is a professional
who is dedicated to quality care and patient safety. Both the provider and
patient rely on the medical assistant to possess accurate information about
drug therapy and perform medication-related duties with meticulous care.
 224 UNIT TWO ASSISTING WITH MEDICATIONS
i-iiiiit-iff•jii9#1MU1•i
Kathy has a great deal af responsibility in managing medications in the primary
care practice where she works. She must be familiar with and follow DEA regula-
tions governing the management af controlled substances. In addition, she must
be able to use drug reference materials; identify the general clinical uses of
SUMMARY OF LEARNING OBJECTIVES
l. Define, spell, and pronounce the terms listed in the vocabulary.
Spelling and pronouncing medical terms correctly reinforce the medical
assistant's credibility. Knowing the definitions of these terms promotes
confidence in communication with patients and co-workers.
2. Do the following related to government regulation of medications
in the United States:
• Distinguish among the government agencies that regulate drugs in
the United States.
Several federal agencies combine forces to regulate drugs in the
United States. The FDA regulates the development and sale of all
prescription and OTC drugs; the DEA enforces laws designed to prevent
drug abuse and educates the public about drug abuse prevention; and
the FTC regulates OTC advertisement.
• Cite the areas covered in the regulations established by the DEA for
the management of controlled or regulated substances.
DEA regulations for the management of controlled substances include
specific record-keeping guidelines, in addition to information on physi-
cian registration and the inventory, storage, and disposal of controlled
substances.
• List the DEA regulations for prescription drugs for each of the five
schedules of the Controlled Substances Act.
Prescriptions written for controlled substances must comply with both
state and federal regulations. The prescription must include details
about the patient; information about the physician, including the DEA
number; and the amount of the drug, written out ("ten" not "l O").
The prescription must be manually or electronically signed by the
physician. Orders for Schedule II drugs cannot be phoned in except
in an absolute emergency, and these prescriptions cannot be refilled.
Schedules Ill, IV, and Vdrugs may be prescribed by phone, faxed, or
e-prescribed and refilled up to five times in a 6-month period. In some
states, Schedule Vdrugs can be dispensed by the pharmacist without
a physician's prescription. (See Table 9-1 .)
3. Explain the medical assistant's role in preventing drug abuse.
The medical assistant should keep track of patients who repeatedly call
for prescription refills of controlled substances; secure computers so there
is no access to e-prescription programs and keep prescription pads secure;
and maintain a small supply of controlled substances in the office and
accurately record their administration.
4. Differentiate a drug's chemical, generic, and trade names.
The chemical name is the drug's formula. The generic (official) name is
assigned to the drug and may reflect the chemical name. The trade
prescribed drugs and OTC products; understand the parts of a prescription and
use accepted medical terms and abbreviations; recognize the significance of
patient education in the safe use of OTC drugs; and understand the factors that
affect drug action.
(brand) name is given to the compound by the pharmaceutical company
that developed it and is protected by law for 20 years.
5. Describe the use of drug reference materials, and explain the five
pregnancy risk categories for drugs.
The use of drug reference materials is crucial for the safe administration
of medications. Most drug references include actions, indications, contra-
indications, precautions, adverse reactions, dosage, administration guide-
lines, and method of packaging. The most frequentty used drug reference
guide is the Physicians' Desk Reference (PDR), but package inserts also
can be used. Anumber of websites provide FDA-approved information
about medications such as Rxlist at http:j/www.rxlist.com/script/
main/hp.asp and Drugs.com at http:j/www.drugs.com/ Table 9-2
presents the FDA's five pregnancy risk categories for drugs.
6. Discuss tips for studying pharmacology, and define the five medical
terms used to describe the clinical use of drugs.
Clinically, drugs are used as therapeutic medications (to cure acondition);
palliative medications (to relieve symptoms); prophylactic medications
(to prevent the occurrence of a condition); diagnostic medications (to
help determine the cause of a disease); and replacement medications
(to provide substances that normally occur in the body).
7. Cite safety measures for the use of OTC drugs.
OTC drugs may interfere or interact with prescription drugs. Some safety
measures for the use of OTC drugs include carefully reading directions,
taking only the recommended dose, discarding the drug when it expires,
informing the provider of OTC drug use, and being aware of contraindica-
tions to OTC drug use in certain conditions. (Refer to Table 9-3.)
8. Do the following related to prescription drugs:
• Diagram the parts of aprescription.
Aprescription consists of the following six parts: (l) superscription,
(2) inscription, (3) subscription, (4) signature, (5) refill information,
and (6) provider's signature. Aprescription also must provide the
patient's name and address and the date the drug is prescribed.
• Demonstrate the ability to transcribe aprescription accurately.
Procedure 9-1 outtines the method for transcribing a prescription for
the physician's signature. It is important that the medical assistant
follow a written order; look up information about the medication in
a drug reference text or online; ask the patient about drug allergies
and record the patient's personal information on the prescription note;
and correctty write the name of the drug, form, dosage, strength,
route of administration, amount of the drug to be given to the patient,
specifics about time of administration if appropriate, and the number

SUMMARY OF LEARNING OBJECTIVES-continued
of refills. The prescription should be reviewed and signed by the
provider before it is given to the patient or before the medical assistant
transmits an electronic prescription. (Refer to Tables 9-4 and 9-5 to
review common prescription abbreviations and The Joint Commission's
"Do Not Use" list.)
• Describe e-prescription methods.
EHR systems can be used to create a prescription, print a paper copy
of it, and/or send it directly to a pharmacy. EHR programs are
designed to automatically check a prescribed drug against the patient's
allergies, identify possible drug-drug interactions, access current data-
bases for the patient's medication history, review the patient's insur-
ance drug formulary for coverage, and either print out the prescription
for the patient to take to the pharmacy or electronically send the script
to the pharmacy.
9. Relate the principles of pharmacokinetics to drug use.
Pharmacokinetics comprises the actions of absorption, which depends on
the route of administration (oral, parenteral, mucous membrane, or
topical); distribution through the bloodstream; metabolism in the liver;
and excretion, primarily by the kidneys.
l 0. Describe factors that affect the action of adrug, including the physi-
ologic changes associated with aging.
Multiple factors affect a drug's action, including weight, age, gender,
diurnal rhythms, pathologic factors, immune responses, psychological
factors, tolerance, accumulation, idiosyncrasy, and drug-drug interactions.
(Refer to Table 9-6 for the effects of aging on the body's processing of
medications.)
11. Identify the classifications of drug actions.
Drugs are classified into groups according to their actions in the body, by
the symptoms they relieve, or according to the body system they affect.
Drugs may have multiple actions and therefore multiple classifications.
CONNECTIONS
CrJ Study Guide Connection: Go to the Chapter 9 Study Guide. Read and complete
the activities.
CHAPTER 9 Principles of Pharmacology 225
(Refer to Table 9-7 for a summary of the top 50 prescribed drugs in
2014.)
12. Differentiate among commonly used herbal remedies and alterna-
tive therapies.
Table 9-8 summarizes common herbal remedies, their uses, and possible
side effects. Acupuncture treatments involve the use of thin metal needles
inserted through the skin to stimulate specific points in the body to restore
and maintain health. Chiropractic providers perform manipulations or
anatomic adjustments to correct alignment problems and help the body
heal itself. Mind-body therapy uses biofeedback to teach the patient to
use his or her thoughts to control certain body reactions. The primary
principle of homeopathic medicine is to administer very dilute substances
that are designed to stimulate the body's ability to heal itself.
13. Examine the role of the medicol assistant in drug therapy
education.
The medical assistant plays an important role in helping patients under-
stand their medications, promoting compliance with treatment, and
preventing complications. Conducting comprehensive interviews that ask
detailed questions about patient use of drugs and documenting this
information in the health record provides vital information for the pro-
vider. Culturally sensitive interviews with patients help the medical assis-
tant gather details about home remedies and patient belief systems that
may affect compliance with drug therapy.
14. Identify the medical assistant's legal responsibilities in medication
management in an ambulatory care setting.
The medical assistant's legal responsibilities in medication management
include documenting compliance with DEA regulations for controlled sub-
stances; maintaining complete and accurate documentation on all med~
cations administered and prescribed for each patient, and following HIPM
regulations on the release of confidential information.
evolve Evolve Connection: Go to the Chapter 9 link at evolve.e/sevier.com/
kinn to complete the Chapter Review Quiz. Check out the other resources listed for this
chapter to make the most of what you have learned from Principles of Pharmacology.
 10 PHARMACOLOGY MATH
li#H+i;H•i
Heather lzacco, a recent graduate of a medical assistant program in the area, math at school and had a difficult time calculating accurate doses and con-
has just been hired by a local family practice physician, Dr. Carlos Angio. One verting between math systems during her medical assisting training. Her
of her responsibilities will be to administer medications under Dr. Angio's supervisor, Mrs. Allison, suggests that Heather review the math section of her
supervision. Heather is confident of her ability to administer medications but textbook at home and be prepared to work out some sample problems
is unsure of her accuracy in pharmacology math. Heather never did well in next week.

While studying this chapter, think about the following questions:

• How can Heather be sure that she has calculated the correct dosages? • How would Heather go about reconstituting an injectable powder?
• What are the parts of a drug label, and why are they important? • How can Heather's ability to analyze tables prove useful when she is
• Is it critical for Heather to be able to convert dosages from one system to performing pharmacology math?
another?
• Are there any differences between calculating an adult dose and
calculating a pediatric dose?

LEARNING OBJECTIVES
l. Define, spell, and pronounce the terms listed in the vocabulary. • Calculate proper dosages of medication for administration while
2. Summarize the important parts of a drug label. using mathematical computations.
3. Demonstrate knowledge of basic math computations. 7. Determine accurate pediatric doses of medication.
4. Define basic units of measurement in the metric and household systems. 8. Summarize how to reconstitute powdered injectable medications.
5. Convert among measurement systems. 9. Specify the legal and ethical responsibilities of a medical assistant in
6. Do the following when calculating drug dosages for administration: calculating drug dosages.
• Demonstrate knowledge of basic match computations by calculating
the correct dose amount.

VOCABULARY
dispense To prepare a drug for administration. individual packet for convenience or safety, such as blister
unit dose Method used by the pharmacy to prepare individual packs.
doses of medication; a dose of medicine prepared in an

M edical assistants are responsible for being absolutely certain

that the medication they prepare and administer to a patient
is exactly what the provider ordered. Although drugs often are deliv-
ered by the pharmacy or supplied by pharmaceutical representatives
in unit dose packs, the dosage ordered may differ from the dosage
on hand. In this case, the medical assistant must be prepared to
calculate the correct dose accurately before dispensing and adminis-
tering the medication. There is never a margin of error in drug
calculations; even a minor mistake may result in serious complica-
tions for the patient. The medical assistant, therefore, must take
meticulous care in calculating all drug dosages.
DRUG LABELS
The first step in safely calculating a drug dosage is to accurately read
the label of the drug on hand to determine whether the provider's
 CHAPTER 10 Pharmacology Math 227

order and the packaged drug are in the same system of measurement.
Starting at the top, the label shows the drug's name with the brand
name capitalized and typically in bold print. The brand name is
copyright protected; therefore, it is followed by an ® symbol that
indicates the U.S. government has granted a Federal Registration
Certificate for the drug. The generic name is printed in lower case
letters under the brand name in smaller print. A patent is granted
on a drug for 20 years from the date of filing for the patent. Patents
are granted at any point in time along the development of a drug.
Exclusivity is granted by the Food and Drug Administration (FDA)
to give exclusive marketing rights to the manufacturers of the drug
when it earns FDA approval. This exclusive marketing right can vary
from 3 to 5 years. If a medication has been on the market longer
than 20 years or after the exclusive rights to the drug have expired,
the generic name may be the only one listed (e.g., meperidine instead
of Demerol, diazepam rather than Valium). If the medication is
ordered from the pharmacy and stocked as a generic drug, only the
generic name is printed on the label. In the label examples in Figure
10-1 , Cardizem is the brand name of the generic drug diltiazem
HCl; on the second label, cephalexin is the generic name for Keflex,
and because patent and exclusivity protections have ended, only the
generic name is listed on the label.
Under the name of the drug, the dosage strength of the medica-
tion is given. Whether listed in milligrams (mg), milliliters (mL), or
another unit of measure, the label states how much of the drug is
contained in each of the identified units. This is what you must
compare with the provider's order to determine whether you must
calculate the amount to administer to match the ordered dose of the
drug. For example, the provider orders 250 mg of cephalexin, and
the label states that the dosage strength is 250 mg per 5 mL; in this
case, no calculation is needed-you simply administer 5 mL of the
medication. However, if the provider orders 500 mg of the medica-
tion for a loading dose of the antibiotic, you must make sure you
administer the correct amount of the medication to match the order.
Sometimes the label helps by providing different but equivalent units
of measurement for the dosage strength. For example, if the provider
orders 250 mg of cephalexin and asks you to make sure the mother
understands how much of the medication she should administer to
her sick child, the label may state that 5 mL is equivalent to 1 tea-
spoon {according to the label, 250 mg of the drug is present in 5 mL
of solution); therefore, you can confirm with the parent that the
child should receive 1 teaspoon of medication without having to do
any calculations.
The label identifies the route, or method of administration, for
the drug. If the medication is packaged as a tablet or a capsule, it
should be given orally; liquid medication is labeled either for oral
or for parenteral use. If the drug is powdered (solute) and it must
be mixed with a liquid (solvent) before administration, the label
provides instructions on how to prepare the medication. At the
bottom of the label is the total amount of the drug contained in the
package. For example, the cephalexin label in Figure 10-1 identifies
it as a multidose bottle that contains 200 mL of total volume when

Manufacturer Storage

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Mosby.)
228 UNIT TWO ASSISTING WITH MEDICATIONS
mixed (e.g., 250 mg of cephalexin in each 5 mL of solution). A
single-dose bottle would contain one dose of the medication. In the
cephalexin example, that would be 250 mg in 5 mL of solution;
therefore, a single-dose bottle would contain 5 mL, or 1 teaspoon,
of cephalexin. Special storage precautions, such as light or heat
sensitivity, are identified on the back or side of the drug container.
The name of the drug's manufacturer appears on the label, as does
an expiration date that must be checked each time the medication
is dispensed. Dispose of all medications that have reached the label's
expiration date. The label also has a lot number stamped on the
package so that it can be identified as belonging to a batch of drugs
manufactured at the same time. This number becomes important if
problems are noted with a particular batch and the medication is
recalled. Depending on your employer's preferences, you may need
to include the lot number in the documentation of the medication
in the patient's record. For example, the lot number of immunization
containers must be documented in the facility's vaccination log and
the patient's health record for each dose administered. Finally, federal
law requires that all labels have a National Drug Code (NDC)
number that identifies that particular drug.
Some of the basic information provided on drug labels includes
the following:
• Strength: The potency of the drug, stated as a percentage of
drug in the solution (2% epinephrine); as a solid weight-
grams (g), milligrams (mg), micrograms (mcg); or as a milli-
equivalent (mEq) or unit.
• Dose: The size or amount of the drug available in the drug
package. This could be expressed in milliliters, teaspoons, or
number of tablets. For example, the label may read "Imitrex,
6 mg/0.5 mL," which means that there is 6 mg of the drug
in each 0.5 mL of liquid.
• Solute: The pure drug that is dissolved in a liquid to form a
solution.
• Solvent or diluent: The liquid (usually sterile water or sterile
saline) that dissolves the solute.
MATH BASICS
You may need to review some basics of arithmetic before you tackle
drug calculations. You must thoroughly understand the addition,
subtraction, multiplication, and division of fractions and decimals;
the relationship of decimals and fractions; and how they are con-
verted from one to the other.
Fractions
A fraction is a part of a whole; that is, fractions are a way of dividing
a whole unit into parts. For example, think of dividing a small cherry
pie into equal parts for friends after dinner. Four people want dessert,
so you can divide the pie into four equal parts; each person receives
¼ of the pie. If only three people want dessert, you can divide the
pie into three equal parts; each person receives ½ of the pie.
The top number in a fraction is the numerator, and the bottom
number is the denominator. In a proper fraction, the numerator is
smaller than the denominator. If we go back to the pie example, ¼
and ½ of the pie are proper fractions.
In improper fractiom, the numerator is equal to or greater than
the denominator. Another way of looking at improper fractions is
that the numerator is so large it is equal to or greater than 1. For
example, the improper fraction ¾ is greater than 1. It is equal to ¼
(the entire pie that was cut into 4 pieces, or 1 whole pie) plus ¼ of
another pie. Therefore, if you wanted everyone to have ¼ of a pie for
dessert, you would need two pies: one whole pie for four guests (¼)
and ¼ of another pie for yourself (l¼ pies). To convert improper
fractions into whole numbers, divide the numerator by the denomina-
tor. In this case, you need five ¼-pieces of pie, or: 5 + 4 = l¼ pies.
Review the following examples. Identify the proper and improper
fractions. If the fraction is improper, perform the math to get the
whole number equivalent.
½
½
Yio
Fractions typically are written in their lowest terms. For example,
can you reduce the fraction ?,{5 to its lowest term? To reduce a frac-
tion, you must divide the numerator and the denominator by the
largest number that goes into each equally. In the case of ?,{5 , 5
divides into 5 (numerator) 1 time, and into 15 (denominator) 3
times; this means that ?,{5 can be reduced to ½. Other examples
include the following:
25 ~
25
-
1 9 + -9 1
-
- -
100 25 4 45 9 5
10
-30 ~ - 3 6 2 3
- -=- - -
100 10 10 8 2 4
In some cases, you may have to multiply fractions. For example,
let's say you want to multiply ½ times ¾. All you have to do is
multiply the two numerators (1 X 3) and the two denominators
(3 X 4), and then reduce the answer to its lowest terms. After mul-
tiplying the numerators and denominators, you have )\2 • Now we
must reduce that fraction to its lowest terms. Three is the largest
number that will divide equally into 3 and 12; therefore, divide the
numerator by 3 (3 + 3 = 1) and the denominator by 3 (12 + 3 =
4); the final answer is ¼ . The problem can be written in a mathe-
matical "sentence" as follows:
1 3 3 1
-X-=-=-
3 4 12 4
To divide fractions, you must invert the divisor (the second frac-
tion) and then multiply the numerators and denominators.
Consider this problem: ½ + ¾. The divisor, we know, is ¾, and
we also know we must invert it to multiply the numerators and
denominators; the problem now is stated: ½ X ½. Next, we multiply
the numerators (1 X 4 = 4) and the denominators (3 X 3 = 9) to get
the answer: ¾; this fraction cannot be reduced and thus is the final
answer.
Decimals
A decimal is similar to a fraction, but it is expressed in units of tenths
(0.1), hundredths (0.01), and thousandths (0.001). To perform drug
calculations, fractions first must be converted into decimals.
To convert a fraction into a decimal, simply divide the numerator
by the denominator.
 CHAPTER 10 Pharmacology Math 229

For example, rather than ordering ¾ of a dose for a patient, the This is read as 4 divided by 16 equals I divided by x , or 4 is to
provider orders the decimal equivalent. To perform this math, you I 6 as I is to x.
may need to add zeroes after the decimal point at the end of the In a proportion, the problem is always solved by cross-
numerator. multiplication. Do not confuse this with plain multiplication. An
3
-=3+4=0.75 equals sign (=) between two fractions always means that in order to
4
solve for x, you must cross-multiply.
If the answer is less than a whole number, it is crucial to place a
zero before the decimal point to prevent a medication error. For Step 1. Set up the equation.
example, if you are to administer .5 mL of a medication and the zero 4 I
is not placed before the decimal point, you may miss the decimal
16 X
point and think that the correct dose is 5 mL. Also, a zero should
never be placed after the decimal point of a whole number. Math- Step 2. Multiply across the equation.
ematically, a whole number such as I mL is actually 1.0 mL.
However, if the decimal point and a zero follow the whole number, 4Xx=l6Xl
the dose may be misinterpreted as 10 mL. Step 3

4x=I6
Percent
We now know what 4x equals, but next we must find what Ix,
A percent is a number expressed as part of 100. Decimal numbers
or x, equals. To find the value of x, we must find a way to leave x
can be converted to percentages by dividing the number by I 00 or by
(or Ix) alone on the lefr side of the equation. We can change 4x to
simply moving the decimal point two spaces to the right. For example:
Ix by dividing the number 4 by itself. However, whatever we do on
25 48 one side of an equation, we must do on the other side, or the equa-
0.25 = 100 = 25% 0.48= - =48%
100 tion will not be equal anymore. Therefore, we also divide 16 by 4:
5 Step 4
0.03 = __2_ = 3% 0.005 = - - = 0.5%
100 1,000
4x+4=lx and 16+4=4
Another way of converting decimals into percentages is simply
to move the decimal point two spaces to the right. This works
Ix=4
because a percentage is based on an expression of 100.
0.43 (move the decimal point two places to the right) = 43%
L_J
Therefore: x=4
0.014
L_J
(move the decimal point two places to the right) = 1.4%
0.06 (move the decimal point two places to the right) = 6% If we go back to our original problem:
L_J

0.5
L_J
(move the decimal point two places to the right) = 50% 4 I 4 I
-=-,then-=-
16 X 16 4
Ratio and Proportion Another way to make sure your proportion answer is correct is
A ratio is one way of expressing a fraction or a division problem; it to check your answer by multiplying the means (the middle numbers
shows the relationship of the numerator to the denominator. The of the equation) and the extremes (the outer numbers of the equa-
comparison of two ratios is called a proportion. A proportion is tion). If your answer is correct, multiplication of the means and
written as follows: extremes produces answers that are equal. For example:
4 I
- = - or 4: 16 =I: 4 3:5=6:x
16 4
If the problem is solved by cross-multiplication, the equation
This is read as 4 divided by 16 equals I divided by 4, or 4 is to
looks like this:
16 as I is to 4.
The provider's order for a medication may be a ratio that is dif- 3 6
ferent from that of the medication in stock. To determine the correct
5 X
proportion for administration, the ordered ratio must be compared
with the available ratio (what is in stock). After cross-multiplying, we have:
The preceding proportion example has all the answers in it; there
is nothing to solve. In calculating dosages, mathematical proportions 3x = 30 (then divide each side by 3 to find x)
are used, but with one element unknown. We must solve for that
unknown, or x. For example: x=IO

4 I Having found x, we can now complete our original equation:

- = - or 4: 16 =I: x
16 X 3:5=6:10
230 UNIT TWO ASSISTING WITH MEDICATIONS

TABLE 10-1 Mathematical Equivalents

PERCENT DECIMAL FRACTION RATIO
25 0.25 Yioo = ,¼
2 l: 4
50 0.5 Yio =½ l: 2
60 0.6 Yio =Ys 3:5
0.5 0.005 Xooo = ½oo l: 200
0.1 0.001 Xooo l: 1,000
85 0.85 Yioo = 1½o
8 17:20 FIGURE 10-2 Examples of scored tablets. (From Fulcher EM, Fulcher RM, Soto CD: Pharmacology:
principles and applications, ed 3, St Louis, 2012, Saunders.)
0.01 Xoo l: 100

To check the accuracy of your equation, multiply the means
(5 X 6 = 30) and the extremes (3 X 10 = 30). Because the answers
are equal, you know you have the correct proportion. Table 10-1
provides some examples of the relationships between percents, deci-
mals, fractions, and ratios.
Determine the following equivalents:
0.20 = _ _ (percent) = _ _ (fraction) = _ _ (ratio)
37% = - - - (decimal) = - - - (fraction) = - - - (ratio)
½ = _ _ (ratio) = _ _ (percent) = _ _ (decimal)
3: 4 = _ _ (fraction) = _ _ (decimal) = _ _ (percent)
Rounding Calculations
What should you do if the dose of the supplied drug does not exactly
match your calculation? For example, what if you calculate a tablet
dose as 1.75 tabs, but you have only whole tablets available? First,
check your calculation for accuracy, then check the stocked supply
of the drug to make sure no other dosages are available. If the cal-
culation is correct and no other dosages of the drug are available,
you will have to round your answer to the nearest amount that
matches the dose available. If the last number in the decimal calcula-
tion is 0.5 or greater, round up to the next whole number. For 1.75
tablets, 0.75 would be rounded up to 1, and the patient should be
given two tabs of the medication. However, make sure you check with
the provider before administering a rounded dose of medication.
Determine the correct doses for the following examples:
1.2 tabs = ___ tablet(s) 1.55 tabs = ___ tablet(s)
1.37 tabs = tablet(s) 0.56 tab = tablet
1.64 tabs = tablet(s) 0.81 tab= tablet
Some tablets are scored, which means that the medication was
manufactured with an impression or groove down the center of the
tablet. This type of tablet can be accurately divided into two equal
parts; therefore, calculations can be rounded to the closest half-tab
(Figure 10-2). For example, 0.4 tab would be rounded up to one
half of a scored tab, and 1. 7 tabs would be 2 tabs. Never give a partial
dose of a tablet unless the tablet has been scored; if the tablet has
been scored, then the dose can be given rounded to the nearest ½.
If a liquid medication is to be administered, it usually is accept-
able to round the dose to the nearest tenth. Rounding calculations
to the nearest tenth is acceptable because most syringes used to
administer injected medications are calibrated by 0.1 mL.
For example, say that the correct calculation for an injection of
an antibiotic is 1.76 mL. First, note that the 6 is in the hundredths
position, and the 7 is in the tenths position. The hundredths number
(6) is 5 or greater, so you round up the tenths number (7), which
increases by one to 8. Therefore, a 1.76 mL calculation, when
rounded to the nearest tenth, equals 1.8 mL of the drug.
There are two important exceptions to this rule:
• The injection is to be given to a pediatric patient, and accurate
doses for children may be much smaller than adult doses.
• The dose is less than 1 mL and the syringe you are using is
calibrated in hundredths (e.g., syringes used for allergy shots
or TB tests); in these cases, the medication is rounded to the
nearest hundredth.
What are the correct doses of the following medications, rounded
to the nearest tenth?
1.47 cc= - - - cc 1.33 ml= ___ ml
2.62 ml= ml 2.15cc= cc
1.08 ml= ml 1.15 ml= ml
What are the correct doses of the following medications, rounded
to the nearest hundredth?
0.078 ml= ___ ml 0.231 ml= _ _ _ ml
0.146 ml= ml 0.937 ml= ml
SYSTEMS OF MEASUREMENT
If the dosage ordered by the provider is different from the dosage on
hand, the medical assistant must follow three basic steps to calculate
the prescribed dose accurately:
1. Compare the system printed on the drug label with the pro-
vider's order to determine whether the order is in the same
 CHAPTER 10 Pharmacology Math 231

mathematical system of measurement. If the systems are dif-
ferent (e.g., the order is in milliliters but the label states that
the medication is prepared in teaspoons), accurately convert
the order so that it matches the system used on the label. The
medical assistant must convert the ordered dose to the mea-
The metric system of weights and measures is a decimal system
based on the number 10, and all calculations are completed by
moving decimal points to the right or to the left. Each higher
measure is 10 times the measure at hand; each lower measure is 0.1
( ,){0 ) the measure. The basic units are multiplied or divided by units

surement system on the drug label (i.e., what is available) of 10. The fraction is always written as a decimal, and the number
because that system must be used to dispense the drug. precedes the letters designating the actual measure. Thus 1½ liters
2. Perform the calculation in equation form using the appropri- would be written 1.5 L. The cubic centimeter (cc) and the milliliter
ate formula. (mL) are interchangeable; however, The Joint Commission advises
3. Check your answer for accuracy and ask someone you trust against the use of the cc abbreviation in documenting medications
to confirm your calculations. in the patient's record.
All three steps must be completed before the medication is dis- In the metric system, 1 cc is a measurement of area, and an area
pensed and administered. Confirm your calculations with the pro- this size holds exactly 1 mL, or 0.001 (Xooo ) of a liter of fluid. The
vider if you have any doubt of their accuracy. milliliter (mL) measures the amount of liquid medication, or the
Two different systems of measurement are used for medications: volume, that is to be given orally or by injection. The gram (g)
the metric system and the household system. In the ambulatory care measures the weight, or strength, of a solid medication, such as a
setting, the provider orders the drug using the metric system, and tablet, powder, or topical preparation. The meter is the measurement
drug labels represent the strength of the drug in the metric system; for length in the metric system. A meter is equal to 39.37 inches,
however, the pharmacist will convert the metric dose into a house- which is slightly longer than a yard, or 3.28 feet. One inch is equal
hold measurement so that patients can accurately dispense the drug to 2.54 centimeters (cm). The medical assistant may use centimeter
at home. The provider may ask the medical assistant to include the measurements when using a wound device to determine the depth
household measurement of the prescribed dose when he or she and borders of a wound.
educates the patient about home administration of the medication. The units of measurement in the metric system are based on their
Table 10-2 presents abbreviations and symbols used in the metric prefixes: kilo- means 1,000, and milli- means 0.001. The prefixes
and household systems. mean the same whether used to measure volume or weight. For
example, a kilogram (kg) is 1,000 grams (g), and a kiloliter (kL) is
Metric System 1,000 liters (L); a milligram (mg) is 0.001(½',ooo) of a gram, and a
The metric system of weights and measures is used throughout the milliliter (mL) is 0.001 (Xooo ) of a liter.
world as the primary system for weight (grams), volume (liters), and Conversions within the metric system may be necessary if the
length (meters). In the United States, the metric system is used for provider orders a unit that is different from the one on the drug
scientific work, including most tasks involving pharmaceuticals. label. One method of converting units of measurement in the metric
system is by moving the decimal point in multiples of 10. For
example, when converting grams to milligrams you are converting a
large unit (grams) into a smaller unit (milligrams, which are 0.001
or Xooo of the larger unit). There are 1,000 mg in each gram of the
TABLE 10-2 Common Pharmacology
drug. When larger units of measurement are converted to smaller ones
Abbreviations and Symbols (in this example, grams to mg) the answer is a larger number, so the
HOUSEHOLD decimal point is moved three places to the right (0.35 g = 350 mg).
METRIC SYSTEM MEASUREMENTS When smaller units of measurement are converted to larger ones (mg
to grams), the answer is a smaller number, so the decimal point is
Kg, kg kilogram gtt drop moved three places to the left (e.g., 150 mL = 0.15 L). If converting
g gram gtt drops mg to micrograms (mcg) you are converting a larger unit of measure-
ment to a smaller one (1 mg= 1,000 mcg), so move the decimal
mg milligram t or tsp teaspoon point three places to the right (0.04 mg= 40 mcg). When convert-
ing mcg to mg (a smaller unit to a larger unit of measurement) move
mcg microgram Tor tbsp tablespoon
the decimal point three places to the left (130 mcg = 0.13 mg).
m meter oz ounce Another way of converting amounts in the metric system is to
multiply or divide the ordered amount by a unit of 10. For example,
mm millimeter fl oz fluid ounce say you want to convert 0.35 g into milligrams. Think it through:
cm centimeter cup 0.35 is part of a gram; you want to convert it to milligrams (larger
unit to a smaller one, therefore the answer will be a larger number);
cc cubic centimeter qt quart there are 1,000 milligrams in 1 gram. So, to convert 0.35 g into mg,
L liter pt pint multiply 0.35 by 1,000, which equals 350 mg. Consider these addi-
tional examples:
ml milliliter gal gallon • To convert the smaller unit of milliliters (150 mL) into liters,
mEq milliequivalent lb pound you divide the number of milliliters by 1,000 (there are
1,000 ml in 1 L); this gives you 0.15 L.
232 UNIT TWO ASSISTING WITH MEDICATIONS

• If you need to convert mg to mcg (there are 1,000 mcg in

1 mg), multiply the number of mg by 1,000 (0.18 mg X TABLE 10-3 Approximate Equivalents for
1,000 = 180 mcg). Commonly Used Measures
• To convert mcg to mg, you would divide the number of mcg
l kilogram (kg) 2.2 pounds (lb)
by 1,000 (462 mcg + 1,000 = 0.462 mg).
As you can see, it is much easier to remember the rules about 1 lb 454 grams (g)
which direction to move decimal points than it is to perform the
math calculation.
1 kilogram (kg) 1,000 g
The following equivalents can be used to make conversions lg 1,000 milligrams (mg)
within the metric system:
1 kg= 1,000 g l mg 1,000 micrograms (mcg)
1 g = 1,000 mg l inch (in) 2.54 centimeters (cm)
1 L = 1,000 mL
1 mg = 1,000 micrograms (mcg) l cup, or 8 ounces (oz), or 16 240 ml
1 mg= 0.001 g or Xooo of a gram tablespoons (T or tbsp)
1 mL = 0.001 Lor Xooo of a liter 16 oz or 2 cups = 1 pint (pt) 480 ml
2 pt l quart (qt)
CRITICAL THINKING APPLICATION 10-1 4 qt l gallon (gal)
The first problems Heather reviewed were conversions within the metric
system. Yesterday, Dr. Angio ordered 0.45 l of a drug, but the label gave l oz, or 2 Tbsp, or 6 teaspoons (tsp) 30 ml
the contents in milliliters. How many milliliters should Heather have given? 1 tsp 5 ml
To determine the correct dosage you would move the decimal point 3 places
l tbsp 15 ml
to the right (you are converting from a larger unit of measurement to a
smaller one, so your answer will be a larger number); or, you could multiply 3 tsp l tbsp
0.45 by 1,000 (because there are 1,000 mg in 1 gram). Review the 15 gtt l ml
examples below. If your answer is less than a whole number, make sure
you place azero before the decimal point so that the number is not mistaken l liter (L) 1,000 ml
for a whole number.
Examples:
directions using the household measurements of volume. Liquid oral
6 g = 6,000 mg 3,200 ml= 3.2 l medications are taken by the drop, teaspoon, or tablespoon and are
0.6 g = 600 mg 320 ml= 0.32 l supplied in bottles labeled in ounces or pints. Pediatric medications
0.06 g = 60 mg 32 ml= 0.032 l frequently are packaged as liquids, and the label gives instructions
for the medication to be given in household measurements (e.g.,
Convert the following measurements: teaspoon [tsp], tablespoon [Tbsp]). The medical assistant should
2.5g= _ _ mg 42g= _ _ mg know that 1 tsp = 5 mL, and 3 tsp = 1 Tbsp = 15 mL. Based on
0.21 g= _ _ mg 150 mcg = _ _ mg the household equivalents in Table 10-3 convert the following orders:
1.7 g= _ _ mg 55 mg= _ _ g
2 tsp= ___ ml 8oz= _ _ ml
3 mg= _ _ mcg 74 l = ml
10 ml= tsp 20 ml= Tbsp
0.28 l = ml 950 ml= l
3 ml= tsp 4 Tbsp= ml

Household Measurements Conversions Among Systems of Measurement

The household system is used in most American homes. This system
of measurement is important for a patient at home who has no
knowledge of the metric system; however, household measurements
are not precise, so they should never be used in the medical setting.
Nevertheless, a medical assistant must understand the conversions
between medical and household measurements so that the patient
can be instructed in how to measure the medication most accurately
at home.
The basic measure of weight in the household system is the pound
(lb); the basic measure of volume is the drop (gt). Medications are
not measured in household weights, but many prescriptions contain
Medication orders may have to be converted from one system to
another if the order is written in one system and the drug label is in
another. Medical assistants can use tables to help convert measure-
ments from metric to household measurements and vice versa. Tables
and charts can be helpful tools in many aspects of healthcare, but
you must take the time to analyze the information so that it is proc-
essed accurately. You can use the conversions in Table 10-3 to
directly convert many measurements, or an equivalent can be chosen
and the order mathematically converted to the system on the drug
label. The conversion is calculated by multiplication or by division.
For example, if the provider orders 0.25 ounce (oz) of a liquid

medication but the label states that the unit dose of the drug is 5 g/
mL, you must convert the order in ounces to milliliters to know how
much of the solution to give the patient.
As Table 10-3 shows, 1 oz equals 30 mL; again, the provider has
ordered 0.25 oz, and you must determine how much that is of the
medication in stock. Therefore, multiply the amount ordered in
ounces (0.25) by 30 (the number of mL in 1 oz) to determine how
many milliliters to give the patient.
0.25 X 30 = 7.5 mL
You can also solve the problem by setting up a proportion:
0.25 1
0.25oz:x=loz:30mL or - -
x 30
x = 0.25 X30 = 7.5 mL
Conversions between units of measurement can be done by
placing the numbers in an algebraic formula. We know that 1 oz
equals 30 mL, and we are looking for the number of milliliters that
is equivalent to 0.25 oz. If the amount ordered is placed on the left
side of the equation and the conversion factor on the right side,
similar units can be cancelled when cross-multiplied, and we can
determine the dose.
30mL
(Ordered amount) 0.25 oz X - - (Conversion factor)
1 oz
Cross-multiply and the oz unit cancels out:
0.25x30mL=7.5mL
To take it one step further, the label states that there are 5 g of
the drug per milliliter; therefore, to determine how many grams of
the drug the patient will receive, multiply the number of mL to be
administered (7.5) by the number of grams per milliliter (5):
7.5x5 = 37.5 g
The patient will receive 37.5 g of the drug.
How would you convert a metric order for a medication into a
household unit of measurement that a parent could administer to a
sick child? For example, the provider orders 30 mL of an oral anti-
biotic. What is the equivalent household unit of measurement? As
has been stated previously, 1 tablespoon equals 15 mL. You can
determine the answer in two ways. Either divide the order by the
conversion factor:
30 mL + 15 mL = 2 Tbsp
or set up the problem as an equation with the ordered amount on the
left side of the equation and the conversion factor on the right side:
30mL 15mL
x 1 Tbsp
15x=30Tbsp
x = 30 Tbsp = 2 Tbsp
15
CHAPTER 10 Pharmacology Math 233
Or the problem can be set up as a proportion:
30: x = 15: 1 Tbsp
15x = 30
x=2 Tbsp
Complete the following conversion problems:
1. A patient scheduled for urinary tract diagnostic tests needs to
drink a minimum of 2 L of water over the next 12 hours.
How many ounces should the patient drink?
2. A pediatric patient is prescribed 8 mL of amoxicillin qid
for 10 days. What is the equivalent dose in household
measurements?
CALCULATING DRUG DOSAGES
FOR ADMINISTRATION
The correct dosage of a medication may depend on the patient's age,
weight, and state of health, or on what other drugs the patient is
taking. Frequently the provider orders a medication in a dosage that
is different from the dosage of the drug in stock. The difference may
be in the system of measurement, the strength, or the form. Formu-
las and mathematical tables of conversion are available online for
calculating the correct dosage of medication to be administered.
However, because you need to check the answer to make sure you
are administering the dose ordered, it is helpful to look at how the
correct calculation is performed, one step at a time.
Calculating Dosages
A standard set of formulas is used for calculating dosages (Procedures
10-1 and 10-2). These formulas use the strength (potency) and dose
unit (amount) of the drug. If the drug label reads "5 g/tab," the
strength is 5 grams, and the dose unit is 1 tablet. For liquids, the
drug strength is an amount of solute, which is dissolved in a liquid
called the solvent. Therefore, if a vial ofinjectable drug reads "500 mg/
mL," 500 mg (strength) of the drug is present in every milliliter
(amount) of liquid.
We can use these two examples and the proportion formula to
work out two problems: (1) preparing an injectable medication and
(2) determining an oral dose.
Problem 1: Preparing an Injectable Dose
Order: Administer 250 mg of cephalexin IM
Available: A vial marked 500 mg/mL
Standard formula:
Available strength _ Available amount
Ordered strength Amount to give
When the standard formula is used, the Available strength is the
strength of the drug that is written on the medication label. In this
case, the cephalexin vial states on the label, "500 mg/mL," meaning
there is 500 mg (available strength) of cephalexin in each milliliter
of the medication. The Ordered strength is the dose ordered by the
provider (i.e., 250 mg). The Available amount is the amount of the
drug that must be used to deliver the strength identified on the label.
Because the label states "500 mg/mL," we know that the available
amount for 500 mg is 1 mL.
234 UNIT TWO ASSISTING WITH MEDICATIONS

Problem: Given the strength of the drug needed (the provider's tablet, and (3) the strength of the drug the provider has ordered
order of 250 mg), the amount of fluid to be dispensed must be for administration. Apply the standard formula to the problem:
determined.
Step 1. Set up a proportion with the three known quantities: (1) the Available strength_ Available amount
strength of the drug in the vial, (2) the unit of fluid in which Ordered strength Amount to give
that strength is contained, and (3) the strength of the drug the
provider has ordered for administration.
with the numbers: 5 mg = ~
10 mg x (tab)
Strength of the drug in the vial
Strength the provider ordered Step 2. The mg units in the numerator and denominator on the left
side of the equation cancel each other out. Cross-multiply:
_ Unit of fluid containing that strength
(?) Amount to be given 5Xx=l0Xl
5x=10
Step 2. Now, restate the problem in the standard formula, and put
in the corresponding numbers. If you get confused about where Step 3. To find x (i.e., the amount to be given), you must divide each
to place the numbers in the equation, remember that like units side of the equation by 5:
of measurement (in this case, mg) must be placed on the same
5x 10
side of the equation.
5 5
x = 2 tablets
Available strength (500) Available amount (1 mL)
Solution: Administer 2 tablets
Ordered strength (250) Amount to give (x mL)
The standard formula can be used for any type of calculation.
Now, with only the numbers: You may be using strengths that are measured in International Units,
as with penicillin, or you may have grams, milligrams, or percent-
500mg lmL ages. The forms in which drugs may be prepared include cc or mL,
250mg x mL oz, pints (pt), and gallons (gal) (for making up diluted stock solu-
tions from concentrated solutions, as with alcohol and hydrogen
The mg units in the numerator and denominator on the left peroxide).
side of the equation cancel each other out. Cross-multiply the Follow the steps previously shown and, above all, discipline your-
equation: self to write down each step with complete calculations. This is
the only way to ensure maximum accuracy and the safety of your
500X x = 250Xl patients. If you have difficulty with the calculation or the answer
500x=250mL does not seem quite right, ask the provider to check your calculation.
A double check is always preferred.
Step 3. To find x (the amount to be given), you must divide each Some of your co-workers may use an alternative formula for
side of the equation by 500. calculating drug dosages:
500x 250mL D
-XQ
500 500 H
1
x= -mL=0.5 mL D-Desired dose (the provider's order)
2
H-What is on hand (the dosage strength listed on the medica-
Solution: Administer 0.5 mL of cephalexin tion label)
Q-Quantity in the unit (identified on the label as 1 tablet,
Problem 2: Determining an Oral Dose 5 mL, and so on)
Order: Give 10 mg of a drug Regardless of the formula used, the answer will be the same.
Available: A bottle with tablets labeled 5 mg each
Standard formula:
More Sample Problems
Available strength _ Available amount Problem 1. Dr. Angio orders 500 mg of an antibiotic. The label
Ordered strength Amount to give states that the dosage strength is 250 mg/2 mL. How much should
the patient receive?
Problem: Given the strength of the drug needed, the number of
tablets to be administered must be determined.
D 500 mg (Physician's order)
Step 1. Set up a proportion with the three known quantities: (1) the - X Q = - - - - - - - - - - - X 2 mL (Label quantity)
strength of the drug in each tablet, (2) the unit amount in 1 H 250 mg (Dosage strength on hand)
 CHAPTER 10 Pharmacology Math 235

The mg quantities cancel out: 2. The patient is prescribed 15 mEq of KCl, and the label reads
"5 mEq/5 mL." How many milliliters should the patient
500 receive?
-x2mL=2X2mL
250 3. The phenobarbital label states "15 mg/5 mL." The patient is
= 4 mL of medication should be given prescribed 45 mg of the drug. How many milliliters should
be administered?
Problem 2. Dr. Angio orders 50 mg of Imitrex to be given to a 4. The provider orders 25 mg of Compazine IM. The label reads
patient with a severe migraine. The label states, "25 mg/tab." "10 mg/mL." How much medicine should be injected?

Dose ordered
- - - - x Quantity= Amount to give
Dose on hand
D . CRITICAL THINKING APPLICATION 10-2
or - X Q = Amount to give
H At work the next day, Dr. Angia asks Heather ta administer Acetaminophen
50mg Elixir 70 mg ta a 6-year-old patient with a fever of l 02.6 ° F(39 .2° ().
- - X 1 tab = 2 tabs
25mg Heather checks the label af the Acetaminophen Elixir in the drug cabinet
and discovers that the battle contains 120 mg per 5 ml in a l 00-ml bottle.
Calculate the following doses. Using the standard formula presented earlier, how many milliliters should
the child receive? If Heather is concerned about her calculation, what should
1. Administer 0.25 mg ofLanoxin. The label reads "0.125 mg/
tab." How many tablets should you give?
she do?

•ijiIII,Smmj11$• Demonstrate Knowledge of Basic Math Computations

Goal: To calculate the correct dose amount and choose the correct equipment to complete the provider's order.
Order: The provider orders l million International Units of penicillin Gbenzathine (Bicillin).

EQUIPMENT and SUPPLIES 4. Rewrite the formula, placing the known quantities into the proper place in
• Patient's record the formula. The unknown value (x) will be the amount of the drug to give.
• Provider's drug order 1.2 million International Units l ml
• Premixed syringes of Bicillin, available as:
• 0.6 million International Units/syringe in a 1-ml syringe l million International Units x
• 1.2 million International Units/syringe in a 1-ml syringe 5. Work the proportion problem by cross-multiplying to solve for x.
• Pencil and paper
xx 1.2 million International Units= l million International Units
PROCEDURAL STEPS
6. To solve for x, divide each side of the equation by 1.2 million International
1. Verify the order with the provider. Read the order in quiet surroundings to
Units:
make sure you fully understand it.
2. Examine the drug labels to see what strengths and amounts are available. 1.2 million International Units l million International Units
xx-------
The premixed Bicillin in a 1-ml syringe with a strength of 1.2 million 1.2 million International Units 1.2 million International Units
International Units/syringe is the closest to the l million International Units
x = 0.83 ml of the 1.2 million International
ordered by the provider. If you chose the syringe with 0.6 million International
Units, you would have to give the patient two injections-a single 0.6 Units per 1-ml syringe
million International Unit syringe plus part of another 0.6 million International
Unit syringe-to administer the l million International Units ordered.
3. Write down the standard formula.
Available strength _ Available amount
Ordered strength - Amount to give
PURPOSE: To eliminate the chance of error, orders should never be carried
out unless the calculations have been completed in writing.
236 UNIT TWO ASSISTING WITH MEDICATIONS

Calculate Proper Dosages of Medication for Administration: Convert Among

PROCEDURE 10-2
Measurement Systems

Goal: To choose the correct system of measurement and calculate the correct dose amount per the provider's order.
Order: The provider orders 4 ml of amoxicillin for a 3-year-old child. She wants the mother to understand the household
measurement equivalent of this dose.
EQUIPMENT and SUPPLIES 6. The label states that there are 50 mg of amoxicillin in every l ml of solu-
• Patient's record tion. To determine how many mg the child will receive in each dose, use
• Provider's drug order the standard formula:
• Amoxicillin solution, 50 mg per l ml Available strength Available amount
• Pencil and paper Ordered strength Amount to give
• Standard mathematical formula:
Available strength Available amount PURPOSE: To eliminate the chance of error, orders should never be carried
out unless the calculations have been completed in writing.
Ordered strength Amount to give 7. Rewrite the formula, placing the known quantities into the proper place in
• Conversion equivalent: 5 ml = l tsp the formula, and using the system of measurement on the label. The
unknown (x) will be the amount of the drug to give (amount to give).
PROCEDURAL STEPS
1ml 50mg
1. Verify the order with the provider. Read the order in quiet surroundings to - --
4ml x
make sure you fully understand it.
2. Write out the order. 8. Work the proportion problem by cross-multiplying to solve for x. The ml
3. Examine the drug labels to see what strengths and amounts are cancel each other out.
available. x=200mg
4. Convert the ordered system of measurement to the system of measurement
on the label. The child should receive 0.8 tsp of amoxicillin, measured in a pediatric oral
S. Place the amount ordered on the left side of the equation and the conversion syringe, which contains 200 mg per dose.
factor on the right side so that similar units (in this problem, ml) can be
cancelled.

4ml x l tsp = 20 = 4ml= 0.8 tsp

5ml 5 5

PEDIATRIC DOSAGES
Calculating the Dose
Pediatric doses are calculated differently from those for other age
groups because of multiple factors, including differences in absorp-
tion and drug metabolism. Although formulas have been used in
the past that based the dose calculation on age, pediatric doses are
much more accurate when based on weight because children of
any age can vary greatly in size and body weight. You must
be especially careful in calculating dosages for children because
even a minor miscalculation can be dangerous. With online calcu-
lators available, in addition to tools in EHR programs designed
to complete accurate calculations, doses can be determined effi-
ciently and accurately without requiring mathematical calcula-
tions. However, it is important that medical assistants be familiar
with traditional methods because some providers may continue to
use them.
Dosages Based on Body Weight
The most frequently used calculation method relies on the child's
accurate weight in kilograms. Kilogram measurements are necessary
because most pediatric medication dosages are based on the metric
system, with a designated number of milligrams to be administered
per kilogram of body weight (mg/kg). Several steps are involved in
this type of calculation, but if you follow them closely, you will
determine the most accurate amount of medication to administer to
a child (Procedure 10-3).
Step 1. Before you begin the dose calculation, carefully weigh the
child to make sure you have an accurate weight. If the scale
provides a reading in pounds, convert the child's weight to
 CHAPTER 10 Pharmacology Math 237

kilograms by dividing the number of pounds by 2.2 (1 kg = 1. Convert 12 lb 6 oz to kg:

2.2 lb). For example, 36 lb is equal to 16.4 kg (36 + 2.2 =
16.36 = 16.4 kg [rounded up]). If the child's weight is in 6 oz+ 16 oz= 0.375 lb (0.4 rounded to the nearest tenth)
pounds and ounces, you must convert the ounces to pounds
as a decimal and add it to the pounds. For example, if an 0.4 lb+ 12 = 12.4 lb (baby's weight in lb)
infant weighs 9 lb 7 oz, first convert 7 oz to the nearest tenth
of pounds (1 lb= 16 oz; 7 oz+ 16 oz= 0.4 lb [rounded from
12.4+ 2.2 = 5.6 kg (baby's weight in kg)
0.4375]) and then add it to 9 lb; thus the baby weighs 9.4 lb.
Then convert pounds to kilograms by dividing 9.4 by 2.2
(9.4 + 2.2 = 4.3 kg [rounded from 4.2727]). 2. The total daily recommended dose of the medication is 30 mg
Step 2. Calculate the total daily dose of the medication by mul- times the infant's weight in kilograms:
tiplying the child's weight in kilograms by the amount of drug
stated on the label that should be administered per kg per day 30 X 5.6 = 168 mg/day
(kg/day). For example, if the label states that the child should
receive 4 mg/kg/day, multiply the child's weight in kg by 3. A single dose of the drug is the total daily dose divided by 4 (there
4 mg to determine the daily dose of the drug. are four 6-hour periods in a 24-hour day):
Step 3. Calculate a single dose of the drug based on how fre-
quently the medication is to be given throughout the day. For 168 mg+4 = 42 mg/dose
example, if the drug is ordered qid, divide the total daily dose
by 4; if the medication is ordered for every 8 hours (q8h), 4. The amount of the medication that should be administered in a
divide the total daily dose by 3, because there are three 8-hour single dose is determined by the drug label, which states that
periods in a 24-hour day; if the drug is ordered tid, divide the there are 200 mg in every 5 mL of the suspension. The standard
total daily dose by 3; if it is ordered bid, divide the total daily formula can be used as follows to find the answer:
dose by 2.
Step 4. After calculating the amount of a single dose, compare Available strength_ Available amount
the ordered amount with the drug label. If necessary, apply Ordered strength Amount to give
the standard formula to calculate the amount of medication
200mg 5mL
that should be administered. ---=--
42 mg x (mL)
Example. An infant who weighs 12 lb 6 oz is prescribed erythro-
mycin q6h. The label states that there is 200 mg of the drug in 200x = 210
5 mL of suspension. The recommended dose of the medication for 200x 210
----
infants is 30 mg/kg/day. How much should the child receive per 200 200
dose? x = 1.05, rounded up to 1.1 mL

Calculate Proper Dosages of Medication for Administration: Calculate the Correct

PROCEDURE 10-3
Pediatric Dosage Using Body Weight

Goal: To calculate the correct pediatric dosage by using the body weight method.
Order: Zithromax suspension 5 mg/kg/day bid for 5 days for a patient who has a diagnosis of otitis media. The patient weighs
22 lb. The suspension is labeled l 00 mg/5 ml. Weight conversion: 2.2 lb = l kg.
EQUIPMENT and SUPPLIES PROCEDURAL STEPS
• Patient's record 1. Verify the order with the provider. Read the order in quiet surroundings to
• Provider's drug order make sure you fully understand it.
• Suspension labeled l 00 mg/5 ml 2. Write out the order.
• Formula for conversion of pounds to kilograms 3. Examine the drug label to check the strength and amount available.
• Standard math formula: 4. Convert the patient's weight from pounds to kilograms.
Available strength Available amount 221b+2.2= 10kg
Ordered strength Amount to give
• Paper and pencil
238 UNIT TWO ASSISTING WITH MEDICATIONS

I; ;m!,mj;j I,.,, -continued

5. Calculate the total daily amount of medication by multiplying the weight 9. Rewrite the formula, placing the known quantities into the proper place
in kilograms by the mg/kg factor. in the formula. The unknown x will be the amount of the drug to give.
5mg x 10 kg = 50 mg of Zithromax daily for 5days 100mg 5ml
-- -
25mg X
6. Calculate the individual dose of Zithromax; divide the daily dose by 2 (bid
is twice a day). 10. Work the problem by cross-multiplying to solve for x.

50 mg+ 2= 25 mg/dose 100x= 125

x=l.25ml
7. Compare the ordered dose with the dose information on the medication
label. The suspension is labeled 100 mg/5 ml (100 mg = 5 ml). 11. State your answer by filling in the blank:
8. Write down the standard formula. To administer 5 mg of Zithromax per kilogram of body weight from a
PURPOSE: To eliminate the chances of error. suspension labeled 100 mg/5 ml, administer _ _ ml.
Available strength Available amount
Ordered strength Amount to give

Reconstituting Powdered Injectable Medications CLOSING COMMENTS

Some medications are packaged in a vial as crystals or powder
(solute) that must be mixed with sterile isotonic saline or sterile
distilled water (solvent) to form a solution before it can be injected.
In such cases, it is essential to read the label directions carefully to
determine how much sterile solvent must be added to the solute to
create the ordered dosage strength.
Example. The provider orders 500 mg of a drug. The label reads,
''Add 5.5 mL of sterile water to make 250 mg/mL; total volume of
available solution will be 6 mL."
1. Inject 5.5 mL of sterile water into the vial of medication. Rotate
the vial between your hands to mix the solutes and the solvent.
The total volume in the vial is now 6 mL.
2. According to the label, every milliliter in the vial contains 250 mg
of the drug.
3. On the vial, write the date and time of reconstitution, because
the guidelines on the drug label state that once the medication
has been mixed, it must be discarded within 7 days.
4. Using the standard formula, calculate the number of milliliters
to withdraw from the vial to fulfill the provider's order for 500 mg
of the drug.
Legal and Ethical Issues
A medical assistant who is responsible for administering medications
must have completely mastered the calculation of dosages, whether
the prescribed dose is for a child or for an adult. If the medical
assistant is ever in doubt about the accuracy of a calculation, he or
she should always have a trusted colleague or the provider check the
calculations.
A medical assistant who prepares and administers medications is
ethically and legally responsible for his or her own actions. Laws vary
from state to state; therefore, it is essential that medical assistants
become familiar with the laws in the states where they are employed
before they administer medications. In some states, legislation gives
physicians broad authority to delegate responsibility for giving medi-
cations. In such a case, the medical assistant acts as the "agent" of
the physician. However, the assistant is responsible and accountable
for the acts performed and may be subject to penalties.
Regardless of the differences in state authorization laws, the
courts do not allow the carelessness of healthcare workers to go
unpunished, especially when such actions result in harm or death
for the patient.

Available strength _ Available amount Professional Behaviors

Ordered strength Amount to give
250mg _ lmL
One of the characteristics that mark a true professional is not being afraid
to ask for help when it is needed. Calculating drug dosages can be intimidat-
500mg x(mL)
ing. The well-being of your patient rests in your hands when you have to
250x= 500
calculate a dose of an ordered drug. If you ever have any doubt that your
250x 500 answer may not be correct, do not hesitate to have someone you trust-
--=-
250 250 either your supervisor or a provider in your practice- check your calcula-
x=2mL
tions. If you give a patient the wrong dose of a medication, the patient
may suffer very serious complications. The best way to prevent this is to
Solution: To administer 500 mg from a vial labeled 250 mg/mL, give
seek help when needed with math calculations.
2 mL of medication

i-iiiiit-iff•jii9#1MU1•i
Heather recognizes how important it is to be able to calculate drug dosages
correctly. To do so, she must understand the terms involved in dosage prepara-
tion, must be able to read a drug label correctly, and must follow the various
steps in calculating an accurate dose. The drug label contains a great deal of
information, including the brand and generic names; dosage strength; route of
administration; instructions on mixing solvents if appropriate; storage guidelines;
total amount of drug in the container; name of the drug manufacturer; expiration
date; and both the lot number and the ND( identification number.
SUMMARY OF LEARNING OBJECTIVES
l. Define, spell, and pronounce the terms listed in the vocabulary.
Spelling and pronouncing medical terms correctly reinforce the medical
assistant's credibility. Knowing the definitions of these terms promotes
confidence in communication with patients and co-workers.
2. Summarize the important parts of a drug label.
The drug label contains a great deal of information, including the brand
and generic names; dosage strength; route of administration; instructions
on mixing solvents if appropriate; storage guidelines; total amount of the
drug in the container; name of the drug manufacturer; expiration date;
and both the lot number and the ND( identification number. Drug label
terms must be understood to implement pharmacology math formulas.
3. Demonstrate knowledge of basic math computations.
The medical assistant must thoroughly understand the addition, subtrac-
tion, multiplication, and division of fractions and decimals; the relationships
of decimals and fractions; and how they are converted from one to the
other. Tobie l 0-1 contains examples of mathematical equivalents.
4. Define basic units of measurement in the metric and household
systems.
The metric system of weights and measures is a decimal system based on
the number l 0, and all calculations are completed by moving decimal
points to the right or to the left. Each higher measure is l Otimes the
measure at hand; each lower measure is 0.1 (Xo ) the measure. The basic
units are multiplied or divided by units of 10. The fraction is always written
as a decimal, and the number precedes the letters designating the actual
measure. The household system is important for a patient at home;
however, it is not precise and therefore should never be used in the medical
setting. Tobie l 0·2 lists common abbreviations and symbols used in the
metric and household systems. Tobie l 0-3 lists approximate equivalents
for commonly used metric and household measures.
5. Convert among measurement systems.
Two systems of measurement are used for drugs. The metric system is
based on units of l 0. The liter is a measure of the liquid volume of a
drug, and the gram is a measure of the weight or strength. Units are
converted within the metric system by moving the decimal point to the
CHAPTER 10 Pharmacology Math 239
Heather also must be able to make conversions within and between mea-
suring systems; use the standard formula to determine drug doses; accurately
calculate pediatric doses based on the child's weight; and reconstitute pow-
dered drugs for administration by following the label directions regarding the
amount of solvent that should be added to the solute. She continues to ask
Mrs. Allison or Dr. Angio to check her calculations for accuracy before dispens-
ing and administering any drug for which the order differs from the medication
label.
right or to the left. Household measurements are based on pounds and
drops. Tobie 10·3 can be used to convert from one system of measurement
to another, or drug measurements can be converted by using the conver-
sion formula.
6. Do the following when calculating drug dosages for administration:
• Demonstrate knowledge of basic math computations by calculating the
correct dose amount.
See Procedure 10-1 .
• Calculate proper dosages of medication for administration while using
mathematical computations.
The correct dose of an ordered drug can be calculated by using basic
arithmetic involving fractions, ratios, and proportions. The standard
formula for calculating drug dosage uses information about the drug's
strength and amount (found on the label) and the strength of the drug
ordered, with the unknown (x) being the answer sought. The only way
to gain confidence in using the standard formula is to practice dose
calculations frequently until you become comfortable with the math.
(Refer to Procedure l 0-2.)
7. Determine accurate pediatric doses of medication.
The medical assistant must be especially vigilant in calculating pediatric
doses, because even a minor error may be dangerous to a child. The most
accurate method for determining a pediatric dose is based on the child's
weight. Procedure l 0-3 describes how to calculate a pediatric dose.
8. Summarize how to reconstitute powdered injectable medications.
In reconstituting powdered injectable medications, the medical assistant
must add a particular amount of solvent (as recommended on the drug
label) to a vial of powdered or crystalloid medication. Once the solute and
the solvent have been combined and mixed in the vial, a solution of medi-
cation is formed; the strength is based on equivalents printed on the drug
label. After the medication has been mixed, it is important for the medical
assistant to read the label carefully to determine how much of the drug
must be withdrawn to fulfill the provider's order. This process frequently
requires use of the standard conversion formula to determine the accurate
dose for administration.
Continued
240 UNIT TWO ASSISTING WITH MEDICATIONS

SUMMARY OF LEARNING OBJECTIVES-continued

9. Specify lhe legal and elhical responsibilities of a medical assistant in
calculating drug dosages.
Amedical assistant who prepares, dispenses, and administers medications
is ethically and legally responsible for his or her own actions. If any doubt
exists about the accuracy of calculations, it is essential that the medical
assistant have the provider ar another trusted employee review the math
before the medication is dispensed and administered. Medical assistants
must be aware of state laws that monitor medication administration by
allied health workers.

CONNECTIONS
OJ Study Guide Connection: Go to the Chapter 10 Study Guide. Read and complete evolve Evolve Connection: Go to the Chapter 10 link at evolve.e/sevier.com/
the activities. kinn to complete the Chapter Review Quiz. Check out the other resources listed for this
chapter to make the most of what you have learned from Pharmacology Math.
ADMINISTERING MEDICATIONS
Ji#IKi;H•i
Dr. Anna Thau just opened a new primary care office in the community. She is
in the process of hiring office staff, and Dorothy Gaston, CMA (AAMA), is being
interviewed for a clinical assisting position. One of Dr. Thau's chief require-
ments is that the medical assistants working in the clinical area be familiar
While studying this chapter, think about the following questions:
• What safety guidelines should Dorothy incorporate into her practice each
time she receives a drug order from Dr. Thau?
• What information must be included in comprehensive documentation of
the administration of medication?
• Are there patient assessment factors that might affect medication
administration?
• Why does Dorothy have to understand the details of various drug farms
and their administration guidelines?
• What practices mandated by the Occupational Safety and Health
Administration (OSHA) must be fallowed in preparing and administering
medications?
LEARNING OBJECTIVES
l. Define, spell, and pronounce the terms listed in the vocabulary.
2. Do the following related to safety in drug administration:
• Follow safety precautions in the management of medication
administration in the ambulatory healthcare setting.
• Analyze safety guidelines for specific patient populations.
• Document the administration of a medication accurately in the
health record.
3. Summarize patient assessment factors that can affect medication
administration.
4. Identify various drug farms and their administration guidelines, and
administer oral medications.
5. Do the following related to parenteral administration of drugs:
• Specify parenteral administration equipment, including details
about needles and syringes.
VOCABULARY
aqueous (ak'-wee-uhs) A waterlike substance; a medication
prepared with water.
asymptomatic Without symptoms of a disease process.
bevel (bev'-uhl) The angled tip of a needle.
11
with medications and competent in their administration. Her primary concern is
the safety of her patients, so she requires that employees take appropriate
safety measures when dispensing and administering oral, topical, and paren-
teral drugs.
• How can Dorothy coach patients about the safe administration of
medications while encouraging compliance with the treatment plan and
following through with adaptations that are appropriate to meet individual
patient needs?
• What does Dorothy need to know about the legal implications of drug
administration?
• Follow OSHA guidelines in the management of parenteral
administration.
• Describe and demonstrate the types and locations of parenteral
administrations with proper use of sharps containers.
6. Recognize the medical assistant's role in coaching patients about the
administration of drugs.
7. Assess legal and ethical issues in drug administration in the ambulatory
care setting, and complete an incident report related to an error in
medication administration.
bronchoconstriction Narrowing of the bronchiole tubes.
edema (i-dee'-muh) An abnormal accumulation of fluid in the
interstitial spaces of tissues.
242 UNIT TWO ASSISTING WITH MEDICATIONS
VOCABULARY-continued
immunosuppressant A substance that suppresses or prevents an
immune system response.
immunotherapy Administration of repeated injections of diluted
extracts of a substance that causes an allergy; also called
desensitization.
induration (in-doo-rey' -shuhn) An abnormally hard, inflamed
area.
loading dose A large dose administered as the first dose of a
medication; it usually is used in antibiotic therapy to quickly
achieve therapeutic blood levels of the drug.
P revious medication chapters in this text explained general phar-
macologic principles and pharmacology math. In this chapter,
you will learn about safety factors in drug administration, documen-
tation guidelines, the forms of medications, and how they are admin-
istered. It is important to remember that medications can cause
serious harm to a patient. Therefore, the process of dispensing and
administering medications must always be treated with great care.
Each member of the healthcare team involved in medication admin-
istration must be constantly vigilant to prevent errors and to deliver
high-quality patient care.
No matter the type of medication administered, the order first
must come from either the physician or a licensed provider, such
as a nurse practitioner or physician assistant. If the provider dele-
gates drug administration to the medical assistant, this must be
allowable under state law. Many states have a medical practice act
that defines whether a medical assistant can administer drugs
under the supervision of a physician. Some states allow medical
assistants to administer only certain types of medications; some
prohibit medical assistants from giving injections. Contact your
state government or medical society for information about the
scope of practice for medical assistants in your particular state. You
should know what the law states and how your duties fit into
that law.
SAFETY IN DRUG ADMINISTRATION
To ensure patient safety in drug administration, the medical assistant
must perform certain procedures every time a medication is ordered.
First, it is essential that the medical assistant understand the pro-
vider's order. Safety starts with a clearly written order that can be
easily read and understood. Many times in the clinical setting the
provider gives a verbal order for a medication. Patient safety requires
that you write down a verbal order and repeat it back to the provider
to make sure there are no errors. Ask the provider for clarification if
you have any questions about the medication, dose, strength, or
route of administration. This step has become much simpler with
the use of the electronic health record (EHR). Once the order has
been clarified, the medical assistant is responsible for looking up the
drug in a pharmacology reference, such as the Physicians' Desk
Reference (PDR), another drug reference book, or an online drug
meniscus (meh-nis'-kus) The curved surface of liquids in a
container.
polyuria (pah-le-yur' -e-uh) Excretion of an unusually large
amount of urine.
scored A term referring to a tablet manufactured with an
indentation for division through the center.
vasodilation An increase in the diameter of a blood vessel.
viscosity (vis-kos'-uh-te) The quality of being thick and oflacking
the capability of easy movement.
wheal (wee!) A localized area of edema or a raised lesion.
reference. A medication should never be given until its purpose,
possible side effects, precautions, route of administration, and rec-
ommended dose are known.
After the medical assistant learns about the drug ordered, the
medication is dispensed and administered. To safeguard the patient
during this process, use the Seven Rights of proper drug administra-
tion. Remember, however, that the patient always has the right to
refuse to take a medication. If this occurs, make sure you inform the
provider immediately, because he or she may want to follow up with
the patient about the importance of the prescribed medication. If a
patient refuses to take an ordered medication, be sure to document
this refusal in the patient's record. The Seven Rights of drug admin-
istration are as follows.
l. The right The patient should be identified in two ways: by
patient his or her full name and date of birth (DOB).
Apatient identification number can also be
used, but most patients will not know their
medical record number.
2. The right drug This check begins with clarification of the
provider's order if needed. Every time a drug
is dispensed or prepared for administration,
and strength. You must be competent in
reading and understanding the information on
drug labels. The drug's name and strength on
the label must exactly match the provider's
written order. Compare the provider's written
order with the medication label when you:
• Take the medication from the storage area
• Check the expiration date and dispense
the medication from the container
• Replace the container to storage or before
discarding the used container
Remember, each time you are checking for
four things- the right (l) drug, (2) dose,
(3) route of administration, and (4)
strength.

3. The right dose If the dose ordered does not match the dose
available according to the drug label, perform
appropriate pharmacology math procedures to
determine the accurate dose. Remember to
always recheck your own calculations, and if
there is any doubt about the accuracy of the
dose, have someone else also check.
4. The right route Check the provider's order to clarify the route of
administration, whether it is oral, via mucous
membrane, or parenteral. Patient assessment
includes determining whether this is an
appropriate route for that particular patient.
5. The right time In the ambulatory care setting, most medications
are ordered on aone-time basis. However, it
is important to check the provider's order to
clarify the time of administration and to refer
to this information when looking up the drug
to clarify any questions the patient may have
about home administration of the drug.
6. The right Amedical assistant must be familiar with
technique the proper techniques for all routes of
administration such as the correct method for
giving injections. If you have any doubts
about your ability to administer a particular
drug, always ask for help.
7. The right Immediately after administering the drug,
documentation document the date and time of
administration; the drug's name, strength,
dose, and route of administration; any
reactions the patient has to the medication;
and the details of patient education about the
drug. Some medications, such as vaccines,
also require documentation of the lot number,
expiration date, and manufacturer. For
parenteral medications, inspect the site of
injection before administration for scarring,
altered pigmentation, or any other indication
of a possible problem with medication
absorption. The exact site of administration
must be documented. If the patient calls in
for a prescription refill, document all pertinent
information in the patient's record.
Additional Safety Steps for Medication
Administration
• Prepare medications in a quiet, well-lit area.
• Pay close attention to all the steps involved in dispensing drugs.
• Never substitute a drug or drug strength. Consult the provider about
any discrepancy between the medication ordered and the medication
available.
CHAPTER 11 Administering Medications 243
• Store medications as ordered on the package, and return containers to
the proper storage area immediately after dispensing the dose.
• The person who administers the medication is responsible for any drug
errors. Never administer a medication that you have not personally
prepared.
• If ordered to prepare a medication for the provider to administer,
place the container with the dispensed drug so that the provider can
verify the seven rights.
• The provider should document every medication order in the patient's
electronic health record (EHR) before the medication is administered.
• Routinely check expiration dates when verifying the Seven Rights.
Properly discard expired drugs.
• Discard medications with damaged labels to avoid errors caused by
inaccurate reading of label information.
• If a medication is not administered after it is dispensed, discard it rather
than returning it to the container.
• Before administering any medication, ask the patient about drug aller-
gies; these can change over time.
• Patients should be observed for side effects or adverse reactions for up
to 30 minutes after administration of a medication. Any reactions must
be reported to the provider and documented in the patient's health
record.
• Always provide and document patient education about the medication,
time of administration, side effects, and so on, when administering a
drug.
CRITICAL THINKING APPLICATION 11-1
Dr. Thau asks Dorathy what safety precautions she would routinely follow
when administering a Vitamin B12 injection. Based on the information you
have learned about safe drug administration, what steps should Dorathy
follow in dispensing and administering the ordered medication?
Patient Assessment Factors
Although medications are given only under the direct order and
supervision of the provider, the medical assistant is part of the assess-
ment and problem-solving process. In medicine, assessment never
ends, and it is never the responsibility of just one person. A provider
gives the order to administer medication to a patient based on a
medical assessment, but you must continue to assess the patient and
the patient's environment as you follow through with that order. The
provider depends on the medical assistant to be alert to patient
changes or to new information that could mean that the use of a
particular drug should be reconsidered. For example, perhaps the
patient denied having any allergies to medications, but right before
you administer an injection of penicillin, the patient mentions that
she developed a rash after her last penicillin shot. You should stop
right then and go back to the provider with this new information.
It is vital to continuing patient safety that you assess the patient, the
drug, and the environment before giving any medication.
Drug therapy should be based on a holistic approach to patient
treatment. The patient is more than a particular disease. Many
factors may have an impact on the patient's compliance with drug
244 UNIT TWO ASSISTING WITH MEDICATIONS
treatment and on the safety and effectiveness of medication therapy.
The first step in holistic medication treatment is collecting a com-
plete and accurate history. This includes gathering details about the
patient's health history, current and past use of both prescription and
over-the-counter (OTC) drugs and herbal supplements, and any
negative responses to medications, especially drug allergies. Every
time a patient is seen in the facility, he or she should be asked about
drug allergies. Most medical practices and electronic health record
(EHR) programs have a specific place on the patient's record to
document drug allergies (e.g., in red ink in the upper right corner
of each paper documentation sheet) or an alert designed into the
EHR template that consistently brings the provider's attention to
patient medication allergies. It is crucial that the provider have
current and accurate information about drug allergies to prevent
serious complications and possibly death.
Patient assessment does not end with the administration of the
drug. Observe patients carefully for drug reactions after the admin-
istration of all medications, especially those that are injected. Patients
receiving penicillin (a drug with a high incidence of allergic response)
or immunotherapy must remain in the office for 20 to 30 minutes
after administration in case of an acute anaphylactic reaction. An
acute anaphylactic reaction can result in respiratory failure and cir-
culatory collapse within minutes if not reversed with epinephrine.
Lesser allergic reactions that may occur include hives, swelling, and
itching. The provider may order an antihistamine, such as diphen-
hydramine (Benadryl), if these reactions occur.
Because patient factors such as age, weight, and height may be
used to determine the correct therapeutic dose, accurate recordings
of this information should be documented in the patient's record.
Chronic conditions, especially liver and kidney disease, may affect
the body's ability to metabolize and excrete medications. Therefore,
a complete and accurate medical history is crucial to the patient's
safety.
Besides the patient's physical state, other holistic factors play a
role in successful drug therapy. The patient must understand the
drug regimen, may require family support to follow treatment guide-
lines, and must be able to afford the prescribed medication. Unless
these criteria can be met, the patient may be unable to follow
through with the treatment protocol. It is important that the medical
assistant investigate these issues and offer appropriate community
support, if available, to help the patient maintain proper drug
therapy.
Approaches to Special Patient Populations
Pregnant and breast-feeding women must be especially careful when
taking OTC and prescription drugs because medications are known
to cross the placenta and may affect the developing fetus. A pregnant
woman should not take any medication without the knowledge and
approval of her provider. The U.S. Food and Drug Administration
(FDA) has identified five pregnancy risk categories of drugs. The
medical assistant should be familiar with the specific drug category
before administering any medication to a pregnant woman. Besides
passing through the placenta, medications also are transmitted
through breast milk. Therefore, similar precautions must be taken
when the provider prescribes medications for a lactating mother.
Special precautions must also be followed in determining the
correct dose of medication for children. Pediatric doses are
determined primarily by the child's weight; therefore, it is important
to measure and record the child's weight accurately at each office
visit. A child's body manages drug absorption, distribution, metabo-
lism, and excretion differently from an adult's body, and the provider
considers these factors when prescribing pediatric doses.
Aging people also are more sensitive to the effects of medications,
so certain factors must be considered when prescribing and admin-
istering drugs to this patient population. The metabolic rate typically
slows with the aging process, resulting in increased susceptibility to
a buildup of chemicals in the body that may lead to toxic conditions.
Part of the normal aging process is loss of subcutaneous fat, which
may affect the route of administration of some medications, espe-
cially parenteral sites. In addition, many elderly people have accom-
panying chronic diseases, such as circulatory, liver, or kidney disease,
that may affect the distribution, metabolism, and excretion of medi-
cations. Geriatric patients frequently take multiple medications
prescribed by more than one practitioner, which increases the
risk of drug contraindications and interactions. In addition, a holis-
tic approach to aging patients should include a nutritional evaluation
because a poor diet or restricted fluid intake affects drug actions.
Another very real concern for aging patients is the cost of drug
therapy. Many patients on fixed incomes may not be able to afford
the ordered drug but hesitate to inform the provider of this problem.
It may be up to the medical assistant to ask the patient about his or
her ability to pay for the ordered medication and to offer available
assistance for prescription drugs. This includes offering drug samples
with provider approval and/or investigating drug coverage offered by
pharmaceutical companies.
Suggestions for Successful Medication
Administration to Children
• Explain why the medication is needed and how it will make the child
feel.
• Attempt to gain cooperation by getting down on the child's level and
using a soft but firm voice.
• When possible, offer choices of care, such as "Would you like your
medicine in your right leg or your left leg?"
• Divert the child to relieve stressful moments.
• If the child refuses to cooperate, get help as needed to restrain the
child so the medication can be given safely.
• Encourage parents to participate as much as possible, and make sure
that both parents and the child (if of an appropriate age) understand
the prescribed drug therapy.
• Offer a "treat," such as a sticker, at the end of the visit.
Guidelines for Administration of Medication to
Geriatric Patients
• Educate the patient and family about the purpose of the drug; the time,
dose, and route of administration; and common side effects. Instruc-
tions should be written clearly for home reference.
• If the patient has difficulty swallowing the medication, crush the medi-
cation (if allowed) or mix it into applesauce or pudding.

• Encourage the patient to drink plenty of fluids (at least eight glasses
of water per day) while taking the medication.
• Reinforce that the patient should take the medication as prescribed and
should not skip or double doses.
• Request that patients bring to every healthcare visit all of the medica-
tions they are currently taking in their labeled containers, including
over-the-counter (OTO medications, so a current medication record can
be accurately maintained in the patient record.
• If patients are taking multiple medications, suggest the use of daily or
weekly medication dispensers. These can be purchased in drugstores
and restocked by family members on a weekly basis. It is safest if all
prescriptions are filled at the same pharmacy, so the pharmacist can
keep track of possible drug interactions or contraindications.
• Encourage patients not to share or "save" medications. All leftover
medications should be discarded to avoid use beyond the expiration
date.
CRITICAL THINKING APPLICATION 11-2
Dr. Thau has both pediatric and geriatric patients. Summarize key items
that Dorothy should consider when administering medications to these
specialty patient population groups.
Assessment of the Patient's Environment
The patient's surroundings affect the success of medication therapy.
The patient may be uncooperative when you attempt to administer
a medication (imagine a young child due for immunization updates),
or the patient's family may protest the use of the drug. A medical
assistant should never administer medication without the presence
of a licensed provider. For example, because of the risk of anaphylactic
shock, allergy injections should not be given unless a licensed provider
is in the facility. In addition, the environment must be safe for drug
administration. Make sure the patient is comfortable and protected
from accidental injury. If a patient is to receive an injection, take
care to place the patient in a position that best exposes the site and
protects the person from injury in case he or she faints or has a drug
reaction. If the patient is to take an oral medication with water, make
sure he or she is seated in a position that prevents choking.
Because any medication is potentially dangerous to a patient,
emergency drugs must be readily available to counteract any adverse
effects that might occur immediately after the administration of a
medication. Emergency drugs should be in injectable form for rapid
effect. Emergency carts typically include adrenergics (e.g., epineph-
rine), anticholinergics (e.g., atropine), bronchodilators, and hista-
mine blockers. Any action to deal with serious adverse effects in a
patient or allergic reactions to administered medications must be
directed by a licensed provider. It is beyond the medical assistant's
scope of practice to make decisions about emergency care for
patients.
The following section presents suggested questions that can be
asked to obtain as much information as possible from the patient
about medication therapy. Any information gathered should be
included in your documentation.
CHAPTER 11 Administering Medications 245
Suggested Questions for Gathering
Medication Information
• What provider-prescribed drugs are you currently taking?
Record the names, doses, strengths, and routes of
administration.
• Do you take any OTC drugs on a regular basis?
Record the purpose, amount, and frequency of use. If appropri-
ate, ask when the last dose was taken. For example, if a mother
reports that her child has a fever but the temperature is normal
at the time of the visit, perhaps she gave the child a dose of
ibuprofen before the visit.
• What medications, including OTC drugs, have you taken over the
past 6 months to 1 year, and why?
Ask this question to gather a history of medication use and
perhaps to discover health problems that have not been
recorded previously.
• Do you regularly use any alternative or herbal products? What are
they? How much do you use and how frequently are they used? For
what purpose are they used?
Herbal products or alternative methods of treatment may inter-
fere with prescribed medications.
• It is important that patients take their medications as prescribed,
so focus a few questions on how currently prescribed drugs
are taken.
• What time of day do you take your medicine?
• How do you remember to take it?
• Are you having any problems or do you notice side effects from
the medication?
• Can you afford to take the medication as prescribed?
• Are you having the desired response to the medication (e.g., pain
relief breathing better, lowered blood pressure)?
• Where do you store your medications at home?
Review any special storage precautions for prescribed drugs. Most
medications should be stored away from any heat source and
sunlight, and some must be refrigerated.
• Have you checked the expiration dates on your containers?
Patients often neglect to dispose of unused medication and may
take it after the expiration date if not informed of this
precaution.
• Can you tell me why you are taking the prescribed medication?
You should periodically check on the need for patient education
about drug therapy. Patients are more likely to be compliant
with treatment protocols if they understand the importance
of taking the medication as prescribed.
• Do you use the same pharmacy to fill all ofyour prescriptions?
Patients may see more than one provider. An excellent method
of keeping track of all prescribed drugs, their contraindica-
tions, and possible drug-drug interactions is to strongly
suggest that the patient use only one pharmacy. The pharma-
cist then can monitor overall medication safety.
DRUG FORMS AND ADMINISTRATION
The chosen route of drug administration determines the rate and
intensity of the drug's effect. A drug prepared for one route but
administered by another route may not have any effect at all and is
potentially dangerous. Each route requires different dosage forms.
246 UNIT TWO ASSISTING WITH MEDICATIONS

FIGURE 11-1 Left to right, Caplets, capsules, and tablets.

Solid Oral Dosage Forms

The basic forms for solid oral dosage are tablets, capsules, and loz-
enges (troches). Figure 11-1 shows typical caplets, capsules, and
tablets. Tablets are compressed powders or granules that, when wet,
break apart in the stomach-or in the mouth if they are not swal-
lowed quickly. Tablets may be sugar coated to improve the taste or
enteric coated (e.g., erythromycin) to protect the stomach mucosa
or to prevent the partial breakdown of the drug in the acidic environ-
ment of the stomach. Buffered tablets are also designed to prevent
stomach irritation by combining the drug with a buffering agent that
reduces the amount of acidity in the compound. Buffered or enteric-
coated tablets should never be crushed or dissolved because that
would expose the stomach to the irritants in the drug or interfere
with the timed-release action of an enteric-coated medication. Only
scored tablets can be cut in half; this is accomplished with a pill
cutter (Figure 11-2).
Some tablets quickly dissolve in the mouth, such as zolmitriptan,
which is prescribed to treat the symptoms of migraine headaches.
The tablet is placed on the tongue, where it quickly dissolves, rather FIGURE 11-2 Pill cutter.
than being swallowed. This allows for rapid absorption of the medi-
cation. Caplets are tablets without a coating; they are solid and
oblong, similar in shape to capsules.
Capsules are gelatin coated and dissolve in the stomach, or they shake the container before administering the medication.
may be enteric coated to protect them from stomach acids. Timed- Examples of suspensions include:
or sustained-release (SR) capsules or spansules are designed to dis- • Emulsions: An emulsion is a mixture of oil and water that
solve at different rates over a period of time to reduce the number improves the taste of otherwise distasteful products (e.g.,
of times a patient has to take a medication. These drugs should never cod liver oil).
be crushed or dissolved because this negates their timed-release • Gels and magmas: Gels and magmas consist of minerals
action and increases the risk that the patient will get an overdose of suspended in water. Minerals settle; therefore, products
medication. Another form of oral medication, the lozenge (or containing minerals must be shaken before use. Milk of
troche), is a flattened disk that is dissolved in the mouth to coat the magnesia is an example.
throat, such as a lozenge for a sore throat. A drug substance can be mixed with alcohol to enhance the drug's
properties. Examples include the following:
Liquid Oral Dosage Forms • Fluid extracts: Fluid extracts are combinations of alcohol
Many liquid forms of medication are available. They differ mainly and vegetable products that are more potent than tinc-
in the type of substance used to dissolve the drug: water, oils, or tures. For example, belladonna fluid extract has a higher
alcohol. percentage of the powdered belladonna leaf than tincture
A solution is a mixture of a liquid, such as normal saline. Liquid of belladonna.
forms include the following: • Tinctures: A tincture is an alcoholic preparation of a soluble
• Syrups: A syrup is a solution of sugar and water, usually con- drug or chemical substance, usually from plant sources.
taining flavoring and medicinal substances. Cough syrups, Examples include tincture of benzoin and tincture of
such as Robitussin, are the most common. iodine, which are applied externally.
• Suspensions: Suspensions are insoluble drug substances con- • Extracts: Extracts are very concentrated combinations
tained in a liquid (e.g., amoxicillin solutions for pediatric of vegetable products and alcohol or ether that are evapo-
patients). A solution separates if left standing, so you must rated until a syrupy liquid, a solid mass, or powder is

formed. Extracts are many times stronger than the crude
drug.
• Elixirs: An elixir is an aromatic, alcoholic, sweetened prep-
aration. Elixir of phenobarbital is one example. Elixirs
differ from tinctures in that they are sweetened. They
should be used with caution in patients with diabetes or a
history of alcohol abuse. Some pediatric medications retain
the name elixir, although they no longer contain alcohol.
CRITICAL THINKING APPLICATION 11-3
Dorothy is ordered to administer a loading dose of cephalexin to a 17-year-
old patient with acute bronchitis. Dr Thau's order reads, "Administer cepha-
lexin 500 mg cap PO." The patient is sent home with a prescription for
Keflex, 250 mg cap q6h times 7 days. Document the details that should
be included in Dorothy's note.
Rectal Administration
The rectal mucosa allows rapid absorption of a drug, even though
the surface of the rectum is small. Drugs are absorbed directly
into the bloodstream without being altered, as they would be by the
digestive processes, and without irritating the patient's gastric
mucosa. Rectal medications are useful if the patient is nauseated,
vomiting, or unconscious. For example, acetaminophen supposito-
ries may be prescribed for a child who has a fever with nausea and
vomiting. Manufacturers supply rectal medications in the form of
gelatin- or cocoa butter-based suppositories, which melt in the
warmth of the rectum and release the medication (Figure 11-3).
Suppositories may also be used to soften the stool or to stimulate
evacuation of the bowel; enemas are used to cleanse and evacuate
the bowel.
The best time to administer a rectal drug intended for a systemic
effect is after a bowel movement or enema. The patient should be
cautioned to remain lying down for 20 to 30 minutes to prevent
FIGURE 11-3 Sample rectal suppositories.
CHAPTER 11 Administering Medications 247
accidental evacuation of the drug. Of course, suppositories intended
to treat constipation are administered to bring about bowel evacua-
tion. The patient should be instructed to remove the outer wrap-
ping and insert the suppository with the pointed end first
approximately 2 inches above the rectal sphincter muscles in adults
and ½ to 1 inch in children; using a lubricating gel (e.g., K-Y
Jelly) can help with insertion. If suppositories are individually
wrapped in foil, make sure the patient knows that the foil is the
wrapper and is not part of the treatment. Suppositories are typically
stored in the refrigerator, but refer to the package insert for storage
information.
Vaginal Administration
Vaginal suppositories, tablets, creams, and fluid solutions are used
to treat local infections. Cream and foam spermicides are available
as local contraceptives. Vaginal instillation is completed with an
applicator and most effective if the patient remains lying down after
administration to prevent leakage; many preparations, therefore, are
intended to be used at bedtime. The patient may need to wear a pad
to absorb drainage.
Administration of Medications by Mouth
If the drug is not intended to coat the oral cavity or throat, oral
medications should be taken with enough water to transport the
drug to the stomach. Make sure the patient is able to swallow the
medication. It may be helpful to place the medication on the back
part of the tongue. Liquid medications are ideal for children. Solid
drugs should not be administered to children until they reach the
age at which they can safely swallow a solid drug form without the
danger that they will aspirate the drug. Oral syringes are the best
way to give liquid medications to children because there is less likeli-
hood the medication will be spilled. Liquid medications, especially
those that stain the teeth, can be taken through a straw. If the patient
has been vomiting or is nauseated, an alternative route of administra-
tion may be necessary. Always remain with the patient until all of
the medication has been swallowed. Procedure 11-1 outlines how to
dispense and administer oral medications.
Mouth and throat agents come in the form of sprays, swabs,
sublingual tablets, and buccal tablets. The mouth and throat mem-
branes may be treated locally with antiseptics for oral hygiene and
local infection, with anesthetics for pain relief, and with astringents
that form a protective film over the mucous membranes. The patient
may have to gargle, or the area may be painted or sprayed. To paint
or spray the throat, first look for the area of inflammation to be
treated. Otherwise, the part needing treatment may be missed
entirely. Avoid touching the posterior pharynx (back of the throat);
this causes gagging and possibly vomiting.
Sublingual (SL) tablets are placed under the tongue, where they
are rapidly absorbed into the bloodstream by the rich supply of
capillaries. Sublingual absorption is systemic and bypasses the acids
in the stomach. Nitroglycerin, which is used for treating the chest
pains of angina pectoris, may be administered sublingually. Patients
should not chew or swallow sublingual medications. Buccal tablets
are placed between the cheek and the upper molars and are quickly
absorbed by the oral capillaries. The patient should be instructed not
to smoke, eat, or drink immediately before or after administration
of SL and buccal medications.
248 UNIT TWO ASSISTING WITH MEDICATIONS

•;;m,ammiii• Administer Oral Medications

Goal: To verify the rules of medication administration and safely dispense, administer, and document the administration of an
oral medication.
Order: Administer hydrochlorothiazide (HydroDiuril) l 00 mg PO tab STAT for hypertension.
EQUIPMENT and SUPPLIES Dispensing Solid Oral Medications (HydroDiuril Tablet)
• Patient's health record 8. Gently tap the prescribed dose into the lid of the medication container. If
• Written provider's order, including the drug name, strength, dose, and route too many tablets are dispensed onto the lid, pour the extra tablets back
of administration into the container. Do not touch the inside of the lid or the medication
• Container of ordered medication (Figure l ).
• Calibrated medication cup PURPOSE: Touching the medication or the inside of the container con-
• Water, if appropriate taminates the drug.
• PDR, online drug reference, or package insert
PROCEDURAL STEPS
1. Read the order and clarify any questions with the provider.
2. If you are unfamiliar with HydroDiuril, refer to the PDR, online drug refer-
ence, or package insert to determine the purpose of the drug, common
side effects, typical dose, and any pertinent precautions or contraindica-
tions. Be prepared to answer any questions the patient may have about
the medication. Use the Seven Rights ta prevent errors. This step com-
pletes the Right Medication rule of medication administration.
3. Perform calculations needed to match the provider's order. Confirm the
answer with the provider if you have any questions.
4. Assemble the equipment and sanitize your hands. 9. Empty the medication in the container lid into a medicine cup.
S. Prepare the medication in a well-lit, quiet area. Dispensing Liquid Oral Preparations (HydroDiuril Solution)
6. Compare the order with the label on the container of medicine when you 10. Mix medication well if required.
remove it from storage. Check the expiration date on the container and 11. When liquid medications are poured, the label should be held in the palm
dispose of the medication if it has expired. of the hand.
PURPOSE: To compare the medication label and the provider's order the PURPOSE: To protect the label from medication spills. The medication
first of three times. must be discarded if staff members are unable to read the drug label
7. Compare the order with the label an the container of medicine just before clearly.
dispensing the ordered dose. Make sure the strength on the label matches 12. Place the medicine cup on aflat surface and, at eye level, pour the medica-
the order or that you dispense the correctly calculated dose. tion to the prescribed dose mark on the medicine cup (Figure 2).
PURPOSE: To compare the medication label and the provider's order the PURPOSE: At eye level, the base of the meniscus is where the prescribed
second of three times. This completes the Right Medication and the Right dose should be measured.
Dose of the rules of medication administration.

•;;m,ammiiii -continued
For Both Solid and Liquid Oral Medications
13. Recap the container and compare the label with the provider's order before
replacing the container in storage.
PURPOSE: To compare the medication label and the provider's order the
third of three times.
14. Take the medication to the patient.
1S. Greet the patient, and identify him or her by name and date of birth
(DOB); compare them ta the name and DOB on the order.
PURPOSE: To make sure you have the right patient. This completes the
Right Patient of the rules of medication administration.
16. Mention the name of the drug and the reason it is being given. Ask the
patient whether she or he has any allergies to the medication.
PURPOSE: To educate the patient about drug treatment and to verify that
the patient is not allergic to the prescribed medication.
17. If necessary, help the patient into a sitting position.
18. Administer tablets, capsules, or caplets with water. If the patient is receiv-
ing liquid medication, offer water after the medication has been taken if
appropriate. Make sure the patient swallows the entire dose. This com-
pletes the Right Route and the Right Time of the rules of medication
administration.
Nasal Administration
Nose drops and nasal sprays may be used for localized effect;
however, like the inhalation drugs, they can spill over into the
bloodstream. Some nasal preparations, such as decongestants, can
cause an increased heart rate, elevated blood pressure, or central
nervous system stimulation. Nasal medications are commonly used
for blocked nasal passages (decongestants) and nosebleeds (hemo-
statics). Nasal decongestant sprays are often misused by patients.
Be sure to teach the patient not to exceed the amount or fre-
quency ordered by the provider. If too much is used, these drugs
can dry the mucosa and make congestion worse. Nasal inhalants
can also be used for their systemic effect, such as the corticosteroid
Flonase, which may be prescribed as part of asthmatic treatment.
Topical Forms
Topical drugs are prescribed for both local and systemic effects. Skin
medication forms include lotions, liniments, ointments, and trans-
dermal patches. The medical assistant should wear gloves when apply-
ing any topical treatment to prevent self-administration of the drug.
Lotions
Often used to control itching, lotions are applied by dabbing with
a soft cloth, a cotton ball, or a tongue blade. To prevent contamina-
tion, only a sterile item, such as a sterile tongue blade, should be
inserted into the lotion container. Calamine is an example. Some
lotions are used to relieve inflammation and pain in muscles and
joints. After the lotion has been applied, the area may be covered
with a thick cloth to retain heat. However, the therapeutic value of
these preparations is controversial. The effects of musculoskeletal
lotions are limited to the skin surface where the medication is applied.
CHAPTER 11 Administering Medications 249
19. Provide patient education about the purpose of the drug, typical side
effects, and dosage and storage recommendations. Consult the provider
to clarify information if needed.
PURPOSE: To ensure compliance with home drug therapy and to monitor
for side effects.
20. The patient must remain in the office for 20 to 30 minutes after drug
administration as a precaution against untoward effects.
21. If the patient experiences any discomfort after taking a medication, the
provider should be notified immediately and the incident documented
completely and accurately.
22. Sanitize your hands.
23. Document the administration of the drug, including the date and time; the
drug name, dose, strength, and route of administration; any patient side
effects; and patient education provided about the drug. This completes the
Right Documentation of the rules of medication administration.
6/8/20-9:45 AM: HydroDiuril 100 mg tab administered PO per Dr. Thau's
order. Pt ed conducted; pt had no questions. Dorothy Gaston, (MA (AAMA)
liniments
Liniments (emulsions) have a higher portion of oil than lotions, and
volatile active ingredients may be added. Liniments are often used
to protect dried, cracked, or fissured skin.
Ointments
Ointments, such as bacitracin, are semisolid medications containing
bases such as petrolatum and lanolin. An ointment should be
removed from a jar or tube with a tongue blade to prevent contami-
nation of the remaining medication.
Transdermal Patches
Certain medications can be absorbed slowly through the skin to
create a constant, timed-release systemic effect (Figure 11-4). The
FIGURE 11-4 Transdermal patch.
250 UNIT TWO ASSISTING WITH MEDICATIONS

nitroglycerin patch is particularly useful for patients with fre-

quent attacks of angina. Estrogen and testosterone patches allow
the hormones to be absorbed slowly through the skin. With
dermal patches, drugs can be administered in a time-released
manner for as long as 7 days. The date and time the patch was
applied should be written on the patch and documented in the
patient's record.

Patient Teaching Recommendations for

Transdermal Patches
l. Wash your hands.
2. Hold the patch so that the plastic backing is facing you. FIGURE 11-5 A, Ampule. B, Singleilose vial. Cand D, Multidose vials.
3. Peel off one side of the plastic backing.
4. Use the other side of the patch as a handle, and apply the sticky half
to your skin in the spot you have chosen.
5. Press the sticky side of the patch against the skin and smooth it down.
6. Fold back the other side of the patch. Hold onto the remaining piece
of plastic backing and use it to pull the patch across the skin.
7. Wash your hands again.
8. When you are ready to remove the patch, press down on its center to
lift the edges away from the skin.
9. Hold the edge gently and slowly peel the patch away from the skin.
The patient may shower with the patch in place. Rotate sites to prevent
skin irritation. Follow package insert directions on where to apply the patch,
avoiding scars and areas with a great deal of body hair. If the patch is to
remain on for 24 hours or for an extended number of days, apply a new
patch at the same time every day. Dispose of used patches by folding them
in half with the sticky side together and placing in a garbage can that is FIGURE 11-6 An ampule opener/breaker.
out of the reach of children and pets because the old patch may still contain
medication.
httpj/www.nursingcenter.com/journalarticle?Article_lD=78912l. Accessed November 16, safety device after use, and must dispose of the unit in a sharps
2015.
container.

Parenteral Medication Forms
Injectable medications must be sterile and in liquid form. These
medications may be supplied in an ampule, a single-dose vial, or a
multidose vial (Figure 11-5). The drug usually is in a solution that
is minimally irritating to human tissues (e.g., normal saline solution,
sterile water) and may contain a preservative or a small amount of
antibiotic to prevent bacterial growth in the vial. All injectable
medications are dated. Before use, check the expiration date and
examine the solution for possible deterioration. If the medication is
discolored or if any sediment has formed at the bottom of the vial,
the vial should be discarded. A parenteral medication is administered
with a sterile syringe and needle.
Guidelines established by the Occupational Safety and Health
Administration (OSHA) must be followed when any sharp instru-
ment is used, including all types of needles, because every needle
used on a patient is contaminated with blood and body fluids. The
medical assistant must wear disposable gloves when administering
parenteral injections, must immediately engage the syringe unit's
Ampule
An ampule is a small glass flask that contains a single dose of med-
ication. Its neck has a scored weak point where the ampule is
broken just before use (see Figure 11-5, A). Figure 11-6 shows a
type of ampule opener/breaker that helps the medical assistant
open a glass ampule without the potential for injury. After
opening, the top of the ampule must be disposed of in a sharps
container. Procedure 11-2 explains the special technique required
for opening an ampule of medication and withdrawing medication
for administration.
Single-Dose Vial
A single-dose vial is a small bottle with a rubber stopper through
which a sterile needle is inserted to withdraw the single dose of
medication inside. Before a sterile syringe and needle unit can be
introduced into the solution, the rubber stopper must be wiped
in a circular motion with alcohol or another suitable disinfectant
(Procedure 11-3). The vial is discarded after medication has been
withdrawn.
•;mf,ammjffI Fill a Syringe from an Ampule
Goal: To correctly and safely remove medication from aglass ampule for administration.
EQUIPMENT and SUPPLIES 8. Compare the order with the label on the container of medicine just before
• Patient's health record dispensing the ordered dose. Make sure the strength on the label matches
• Written provider's order, including the drug name, strength, dose, and route the order or that you dispense the correctly calculated dose.
of administration PURPOSE: To compare the medication label and the provider's order the
• Syringe and needle unit second of three times.
• Needle of the appropriate length and gauge 9. Thoroughly disinfect the neck of the ampule with alcohol squares.
• Medication ampule PURPOSE: To prevent possible contamination of the medication.
• Filter needle 10. Place the ampule breaker over the top of the ampule and follow the
• Sterile gauze squares manufacturer's instructions to open/break the ampule (Figure 2). If no
• Alcohol squares ampule breaker is available, wrap the top of the ampule with a gauze
• Ampule opener/breaker if available square to protect yourself from the glass. Hold the covered ampule
• Sharps container between your thumb and finger, in front of you and above waist level
• PDR, online drug reference, or package insert (Figure 3).
PURPOSE: To protect your fingers and maintain eye contact with the
PROCEDURAL STEPS medication ampule at all times.
1. Read the order and clarify any questions with the provider.
PURPOSE: The medical assistant should never dispense or administer a
drug without making sure the provider's order is legible and the details of
the drug are known.
2. If you are unfamiliar with the medication, refer to the PDR, online drug
reference, or package insert to determine the purpose of the drug,
common side effects, typical dose, and any pertinent precautions or con-
traindications. Be prepared to answer any questions the patient may have
about the medication. Use the Seven Rights to prevent errors.
3. Perform calculations needed to match the provider's order. Confirm the
answer with the provider if you have any questions.
4. Dispense the medication in a well-lit, quiet area.
PURPOSE: To prevent distractions and possible errors.
S. Assemble the equipment and sanitize your hands.
6. Compare the order with the label on the ampule of medicine when you
remove it from storage. Check the expiration date on the container and
dispose of the medication if it has expired.
PURPOSE: To compare the medicatian label and the provider's order the
first of three times.
7. Gently tap the top of the ampule with your fingers to settle all the medica-
tion to the bottom portion of the flask (Figure l).
252 UNIT TWO ASSISTING WITH MEDICATIONS

•;;m!,m);jjffI -continued
11. Follow manufacturer's guidelines for using the ampule opener (Figure 4).
If one is not available push the gauze-covered ampule top away from your
body to break the neck of the ampule. You will hear a pop because the
ampule is vacuum sealed. The glass is designed not to shatter, and the
medication will not spill out. Dispose of the ampule opener with the glass
ampule top inside (or of the gauze square and the glass top) in the sharps
container (Figure 5).
12. Open the sterile syringe and needle unit. Touching the needle covers only,
unscrew the needle from the syringe and place it in the sharps container,
then attach the sterile filter needle.
PURPOSE: To maintain the sterility of the unit, anly the needle covers are
touched. The filter needle is needed to withdraw the medication from the
ampule to prevent accidental aspiration of glass fragments into the injec-
tion unit.
13. Withaut tauching the autside of the opened ampule, insert the syringe
unit with the filter needle attached into the ampule and withdraw the
ordered dose. Then place the needle cover back on the filter needle.
PURPOSE: Touching the needle with anything except the sterile interior
of the ampule contaminates the needle. If this happens, start over again
with a new filter needle. Recover the filter needle so it can be removed
safely.
14. Before discarding the ampule in the sharps container, check the provider's
order against the label one more time to complete the three label checks.
If you are drawing the medication up for the provider to administer, take
the ampule and the syringe unit to the provider for the final safety check.
1S. Change the filter needle, safeguarding the sterility of the injection unit,
for a needle of the appropriate length and gauge based on the provider's
ordered route of administration and patient characteristics. Discard the
used filter needle into the sharps container.
PURPOSE: Anew needle is used to prevent the possible injection of glass
particles on or inside the filter needle.
16. Dispose of used alcohol and gauze squares.

•;;m,ammiii• Fill a Syringe from a Vial

Goal: To fill asyringe from amultidose vial using sterile technique.
EQUIPMENT and SUPPLIES PROCEDURAL STEPS
• Patient's health record 1. Read the order and clarify any questions with the provider.
• Written provider's order, including the drug name, strength, dose, and route PURPOSE: The medical assistant should never dispense or administer a
of administration drug without making sure the provider's order is legible and the details of
• Multidose vial containing the medication ordered the drug are known.
• Alcohol wipes 2. If you are unfamiliar with the medication, refer to the PDR, online drug
• Sterile needle and syringe unit reference, or package insert to determine the purpose of the drug,
• PDR, online drug reference, or package insert common side effects, typical dose, and any pertinent precautions or
 CHAPTER 11 Administering Medications 253

•;;m,ammiii• -continued
contraindications. Be prepared to answer any questions the patient may 8. Gently agitate the medication by rolling the vial between your palms
have about the medication. Use the Seven Rights to prevent errors. (Figure 2).
3. Perform calculations needed to match the provider's order. Confirm the PURPOSE: To mix any medication that may have settled.
answer with the provider if you have any questions.
4. Dispense the medication in a well-lit, quiet area.
PURPOSE: To prevent distractions and possible errors.
5. Assemble the equipment and sanitize your hands. Choose the correct
syringe and needle unit, depending on the site of administration, patient
characteristics, and the amount of medication to be injected (Figure 1).

9. Clean the rubber stopper of the vial with the alcohol wipe using a circular
motion (Figure 3). Place the vial on a secure, flat surface, leaving the
alcohol swab over the rubber stopper.

6. Compare the order with the label on the vial of medicine when you remove
it from storage. Check the quality of the medication and the expiration
date on the container and dispose of the medication if it appears contami-
nated, contains sediment, or has expired.
PURPOSE: To compare the medication label and the provider's order the
first of three times.
7. Compare the order with the label on the vial of medicine just before dis-
pensing the ordered dose. Make sure the strength on the label matches
the order or that you dispense the correctly calculated dose.
PURPOSE: To compare the medication label and the provider's order the
second of three times.
10. With the needle cover in place, grasp the syringe plunger and draw up an
amount of air equal to the amount of medication ordered.
PURPOSE: Not enough replaced air makes it difficult to withdraw the
medication; too much replaced air increases the pressure in the vial so
that medication is forced into the syringe without the plunger being pulled
to withdraw it.
11. Remove the alcohol swab over the rubber stopper and the needle cover
and insert the needle into the center of the rubber stopper. Hold the vial
firmly against a flat surface and watch carefully that the needle touches
only the cleaned rubber area.
PURPOSE: To maintain the sterility of the needle.
12. Inject the aspirated air in the syringe into the vial.
254 UNIT TWO ASSISTING WITH MEDICATIONS
I; ;m!,mj;jiiii -,;ontinued
13. Keeping the syringe unit in the vial, pick up and invert them (Figure 4).
Slowly pull back on the plunger with the unit at eye level and draw up
more medication than ordered into the syringe unit.
PURPOSE: Withdrawing medication rapidly causes air bubbles to form in
the syringe. Draw up extra medication so that any bubbles in the syringe
can be injected back into the vial while maintaining sterility.
Multidose Vial
A multidose vial is a bottle with a rubber stopper that contains
enough medication for multiple injections. Multidose vials are
labeled as such by the manufacturer and typically contain an anti-
microbial preservative to help prevent the growth of bacteria.
However, the preservative has no effect on viruses and does not
protect against contamination when healthcare personnel fail to
follow aseptic practices. The medical assistant should write on the
bottle the date the first dose from a multidose vial is administered
and should follow the manufacturer's guidelines or the facility's
policy on how long the vial can remain on the shel( The Centers
for Disease Control and Prevention (CDC) recommends that if a
multidose vial has been punctured with a needle, the vial should be
dated and discarded within 28 days unless the manufacturer specifies
a different (shorter or longer) date for an opened vial. Because mul-
tidose vials are used more than once, extreme caution must be taken
every time a needle is inserted into the medication, to protect it from
contamination, which could cause a very serious infection in subse-
quent patients. If at any time you believe an error has been made or
you suspect possible contamination, discard the vial. Never return
unused medication to the vial. If you have more medication than
you need in the syringe, eject the excess while the needle remains in
the vial. Never inject unneeded medication into the vial once the
needle has been removed.
14. While the needle is still in the vial, check for air bubbles in the syringe.
PURPOSE: Air bubbles displace medication, and the patient will not
receive the proper amount of medication.
1S. If air bubbles are present, slip the fingers holding the vial down to grasp
the vial and syringe as a single unit.
PURPOSE: This frees your dominant hand.
16. With your free hand, tap the syringe until the air bubbles dislodge and
float into the tip of the syringe.
17. Inject the air bubbles back into the vial with the extra medication that
was withdrawn. At eye level, make sure the accurate amount of medica-
tion is in the syringe unit.
18. Withdraw the needle from the vial and carefully replace the needle cover
without letting the needle touch the outside of the cover.
19. Return the medication to the shelf or the refrigerator, checking the order
against the label one more time ta complete the three label checks.
PURPOSE: This is the third af the three drug label and order checks.
20. Dispose of used alcohol and gauze squares.
Vials are vacuum sealed. Each time you withdraw medication
from a vial, you first must replace the portion of withdrawn medica-
tion with the same portion of air. Not enough replaced air makes it
difficult to withdraw medication, and too much replaced air increases
pressure within the vial, forcing medication into the syringe. See
Procedure 11-3 for instructions on how to safely and accurately
withdraw medication from a vial.
Preti/led Syringe
A prefilled syringe is a sterile, disposable syringe and needle unit
packaged by the manufacturer with a single dose of medication that
is ready to administer. Some prefilled syringe units are designed to
fit into a reusable cartridge injection system (Figure 11-7). The
Carpuject Syringe System is an example of a cartridge system for the
injection of prefilled syringes. Most prefilled syringe units are over-
filled with medication or may contain more medication than was
ordered by the practitioner. Before administration, carefully check
the unit and expel any excess medication or air to make sure the
patient receives an accurate dose.
Parenteral Medication Equipment
Syringes and needles are manufactured in countless varieties for
specific purposes and sometimes for specific medications. For
example, a special syringe unit used for insulin is calibrated in units

FIGURE 11-7 Carpuject Syringe System with a prefilled syringe and needle with safety device.
(From deWit SC, O'Neill PA: Fundamental concepts and skills for nursing, ed 4, Philadelphia, 2014,
Saunders.)
Hub Hilt
~
I
111~ii]6
Shaft
A
~ cJ57iJi? Regular point
~ Short bevel
~ ntradermal bevel
B
FIGURE 11-8 A, The construction of o hypodermic needle. B, Needle points.
of measurement and packaged with a microneedle. Hypodermic
needles are manufactured in many lengths and gauges, depending
on the depth of the injection, the viscosity of the medication to be
injected, the ordered route of administration, and patient character-
istics. Needles may be purchased separately or as part of a needle-
syringe unit. Figure 11-8 shows the parts of a needle and the three
common types of bevel points. Needles are measured for length
from the place where the cannula or shaft joins the hub to the tip
of the point.
Needle Gauge
The diameter, or lumen size, of a needle is called its gauge. Needle
gauges range in size from 14 (the largest) to 31 (the smallest). The
larger the gauge number, the smaller the diameter ofthe needle. Gauges
27 and 28 are used for intradermal (ID) injections, as in screening
for tuberculosis (TB), when a very small opening is desired. These
fine needle widths leave a small amount of medication just below
the surface of the skin with a minimum amount of injury. Gauges
25 and 26 are commonly used for subcutaneous (SC) injections.
Insulin needles may be as small as 31 gauge.
Medications in an aqueous solution and with low viscosity are
easily injected through a small opening. In addition, these two
gauges cause minimal tissue damage, and the patient experiences
CHAPTER 11 Administering Medications 255
1½
2½
3
ml
Lumen
ill---
=~~--Flange
Plunger
l~ Point
FIGURE 11-9 Parts of osyringe.
Bevel less pain. Larger needles (gauges 20 to 23) usually are necessary for
intramuscular (IM) injections when the medication is thick (e.g.,
penicillin) or when the needle length requires the extra support of
a thicker gauge. A patient cannot feel the difference between a 20-
and a 22-gauge needle. In fact, the medication is not forced as
strongly into the tissues with the larger 20-gauge needle as with the
22-gauge needle, and the patient actually experiences less pain.
Needles larger than 20 gauge are not used for drug therapy. They
are used mostly for venipuncture, blood donations, and blood
transfusions.
Needle Length
Needle lengths range from ¾ inch to 4 inches, depending on the
area of the body to be injected, the patient's size, and the route
(depth) used. ID injections require only the short ¾-inch needle.
Needles that are ½ or ¾ inch long are used for SC injections. Longer
needles are needed to deposit drugs intramuscularly. The choice of
a I-inch, I½-inch, 2-inch, 2½-inch, or 3-inch length depends on
both the muscle used and the patient's size.
Syringes
Parts of a syringe include the barrel, a calibrated scale (or scales), the
flange, the plunger, and the tip (Figure 11-9). The typical syringe
holds up to 3 mL and is calibrated with a milliliter (cubic centime-
ter) scale, with each calibrated line marked at 0.1 mL. The tuberculin
syringe, which is used for small amounts of drug, holds up to 1 mL
of injectable material, and each calibrated line is marked at 0.01 mL
(Figure 11-10, A).
The insulin syringe is calibrated in units specifically for the use
of patients with diabetes. Insulin syringes are calibrated to hold 30
units, 50 units, or 100 units of insulin (see Figure 11-10, Band C) .
The type of calibration chosen depends on the total amount of
insulin to be injected in one dose. When less than 30 units is to be
drawn up, the 30-unit syringe should be used; for 30 to 50 units,
the 50-unit syringe is used; and for more than 50 units, the 100-unit
syringe is used.
The establishment of Standard Precautions and recognition of the
danger of needlesticks prompted the development of syringe units
with safety needle devices (Figures 11-11 and 11-12); these must be
256 UNIT TWO ASSISTING WITH MEDICATIONS

.20

.,I

.AO

.60

.80

1.00
ml

FIGURE 11-11 Asafety needle device.

A B C
FIGURE 11-10 Types of syringes. A, 1-ml syringe. B, l OD-unit insulin syringe. C, SO-unit insulin
syringe. (From Perry AG, Potter PA: Clinical nursing skills and techniques, ed 8, St Louis, 2014, Mosby.)

EXAMPLE DEVICES WITH SAFETY FEATURES

Self Re-sheathing Needles

Self Re-sheathing Needle. Before Use.
~ 111111111111111111111111
Self Re-sheathing Needle. After Use.*
Initially the sleeve is located over the barrel of the syringe
with the needle exposed for use.
After the device is used, the user slides the sleeve forward
over the needle, where it locks in place and provides a
guard around the used needle.
llltD=---- ~

Syringe With Retractable Needle

After the needle is used, an extra push on the plunger
retracts the needle into the syringe, removing the hazard
of needle exposure.

111 II II 1111II11111111 II II 1111

Syringe With Retractable Needles. The used needle retracts into the barrel of the syringe. t

From Occupational Safety and Health Administration, http:j/www.osha.gov/SLTCjetoolsjhospituVhazards/sharps/sharps.html#safer

*Please note that these safety devices lock in place and do not reset in actual use situations.
1Please note that these safety devices lock in place and do not reset in actual use situations.

FIGURE 11-12 Examples of safety needles.

made available to employees as an OSHA safeguard against acciden-
tal needlesticks. A safety needle is an injection device designed with
special functions that allow the needle either to be capped after a
patient has been injected or to automatically retract back into the
barrel after use. Using safety needles is important because it prevents
healthcare workers from accidentally being stuck with a needle,
thereby reducing the transmission of diseases such as human immu-
nodeficiency virus (HIV) infection and hepatitis.
Disposable syringe and needle units are packaged in sealed,
rigid plastic containers or in peel-apart paper wrappers. Both indi-
vidual needles and syringe-needle units are color coded for easy
identification.

Specialty Syringe Units
An example of a specialty syringe unit is an injector pen that can be
used by patients who must give themselves injections away from
home. Different types are available, depending on the amount of
medication to be dispensed per injection and the type of medication
used. Administering insulin away from home is easier and more
convenient with an insulin pen (Figure 11-13), which contains a
predetermined type and amount of insulin that can be injected with
minimal preparation.
The EpiPen is an automatic injector system that contains a dose
of epinephrine (Figure 11-14). It must be prescribed by a practi-
tioner and comes packaged with the correct dose for an adult (0.3 mg
of epinephrine) or for a child (0.15 mg of epinephrine). The EpiPen
is carried as a safety precaution by individuals who have anaphylactic
reactions to such allergens as bee stings or certain types of foods.
Anaphylactic reactions can be fatal if not treated immediately, so
patients and their family members should be educated in the signs
and symptoms of anaphylaxis and how to manage the EpiPen injec-
tion. The steps for EpiPen injection are quite simple:
1. Pull back the gray end of the autoinjector. This sets the device
for use.
2. The injector can go through clothing. Firmly press the black
tip on the outer aspect of the thigh and hold in place for 10
seconds. The injector automatically administers the prepack-
aged dose.
3. Remove the EpiPen and massage the injection area for a few
minutes to promote absorption of the epinephrine.
4. The patient still should call a provider or go to the emergency
department of a nearby hospital for follow-up care.
It is important that patients or family members periodically check
the expiration date of the autoinjector. If the device is near its expira-
tion date, another prescription should be filled and the old, unused
device discarded. To be of service in an emergency, the EpiPen must
be readily available at all times.
FIGURE 11-13 NovoPen.
FIGURE 11-14 EpiPen prepackaged autoinjector.
CHAPTER 11 Administering Medications 257
Signs and Symptoms of an Anaphylactic Reaction
• Hypotension resulting from systemic vasodilation
• Hives (urticaria)
• Difficulty breathing (dyspnea) resulting from bronchoconstriction
• Difficulty swallowing as a result of edema
• Vomiting and diarrhea
Parenteral Administration
With practice, giving medications by injection becomes easy and
even automatic. However, the medical assistant must always follow
the provider's orders, perform the three order and label checks while
dispensing the medication, and strictly adhere to the Seven Rights
throughout the procedure.
Develop and practice techniques that provide maximum safety
and comfort for the patient. Injections are least painful when (1) the
needle is inserted swiftly; (2) the medication is injected slowly; and
(3) the needle is removed quickly, with counterpressure when
needed. Remember that the same aseptic conditions necessary for
minor surgery are necessary whenever you penetrate the protective
skin barrier with an injection.
Never give an injection near bones or blood vessels. Avoid areas
that have scar tissue; a change in skin pigmentation or texture; or
excess tissue growth (e.g., a mole or a wart). The point of injection
should be as far as possible from any major nerve, and the site
selected should be capable of holding the amount of medication to
be injected. Large doses of medication are given in muscle because
muscles have a larger tissue mass than SC tissue and a more extensive
blood supply; these factors allow for faster absorption and systemic
distribution.
Make sure all materials are ready for use. Many offices have a
central room where medications are prepared. The medication then
is taken to the waiting patient in another room. Handling medication
administration in this way has many advantages, but care must be
taken that the syringe and the needle unit are transported with sterile
technique. After filling a syringe, replace the cap for transport to the
patient, taking care to keep the needle sterile. The syringe should be
placed on a tray for transport, not in your pocket. Never transport
more than one injection at a time unless two or more are for the
same patient or unless you have a special medication tray that has a
named position for each syringe. Never combine two medications
in a single syringe unless specifically ordered to do so by the provider,
and unless you have checked the Physicians' Desk Reference (PDR),
an online drug resource, or the medication's package insert for con-
traindications on mixing different types of medications. If you are
preparing a medication for the provider to give, place the vial or
empty ampule beside the filled syringe. This shows what medication
is in the syringe and offers a double check for safety.
Some medications for injection are packaged in vials as sterile
powders or crystals that must be mixed with sterile water or saline
before they can be administered; the amount of solvent to be added
to the dry form of the drug (solute) depends on the provider's order
and the label directions. After calculating the correct amount of
liquid that must be added to the dry form of the drug to create the
dose ordered by the provider, follow the guidelines in Procedure 11-4
to prepare the drug and administer it to the patient.
258 UNIT TWO ASSISTING WITH MEDICATIONS
Guidelines for Parenteral Administration
of Medications
l. Use a two-step method to identify the patient, typically asking the
patient his ar her full name and date af birth (DOB).
2. Use a professional approach, and explain what you are going ta da.
3. Sanitize your hands before the procedure-and also afterward.
4. Small talk can keep the patient's mind off the procedure.
5. Never tell a patient that it will not hurt; you may destroy your
credibility.
6. Make the patient as comfortable as possible, and allow for privacy.
7. Never allow the patient to stand during the procedure.
8. Keep the syringe unit out af the patient's sight as much as
possible.
9. Always wear disposable gloves.
l 0. Immediately after the injection, activate the needle safety device and
dispose of it in a sharps container with the needle inserted first.
11. Never recap a contaminated needle.
12. Provide patient education and coaching as needed.
13. Document complete details about the procedure in the patient record.
lntradermallnjecffons
Intradermal injections are given within the skin layers (Figure 11-15
and Procedure 11-5). The ID site is used for allergy testing and
tuberculin screening. The tine test is no longer used to screen for TB
because it was found to be unreliable in diagnosing exposures to the
TB bacillus. The Mantoux (purified protein derivative [PPD]) ID
test now is used routinely to screen for TB exposure. It is the only
widely used test for detecting asymptomatic TB infection, currently
termed latent tuberculosis infection (LTBI).
With the Mantoux test, a 0.1-mL tuberculin solution of PPD is
injected into the intradermal layers. If the person was infected with
Stratum corneum
Stratum lucidum
Stratum granulosum
Stratum germinativum
the TB bacillus in the past, his or her immune system developed
antibodies that recognize and fight the bacteria. When a PPD skin
test is performed, these antibodies move to the injection site to try
to stop the infection. This immune reaction causes swelling and
induration in the area approximately 48 hours after administration
of the skin test. An induration 5 mm in diameter or larger is con-
sidered a positive test result in patients at increased risk of being
infected and in individuals who are most likely to develop active
disease if infected with TB bacteria. These individuals include those
infected with HIV; anyone in close contact with a patient newly
diagnosed with TB (e.g., family members); and patients who have
undergone recent organ transplantation or are taking immunosup-
pressant medications. A 10-mm or greater induration is read as
positive if the person has a moderate likelihood of TB exposure and
infection; these individuals include recent immigrants from coun-
tries in which TB is prevalent; intravenous (IV) drug users; residents
and employees of correctional institutions, homeless shelters, and
healthcare facilities (including medical personnel); and children
younger than 4 years of age. Regardless of risk factors, anyone with
an induration of 15 mm or greater is considered positive.
Patients must return to the office after the specified period so that
a staff member can read the results (see Procedure 11-5). Many
healthcare facilities now require employees to have a two-step tuber-
culin skin test (TST) to more accurately diagnose individuals who
have been previously exposed to TB. The employee is tested as
explained and then 48 to 72 hours later is retested. The first TST
may be negative because the immune system did not immediately
identify the TB bacillus. However, the second dose helps trigger the
immune response and identifies individuals who have been previ-
ously exposed to TB.
When an ID injection is administered correctly, a small wheal is
raised on the skin. A ¾-inch, 27- or 28-gauge needle is used for ID
injections. The angle of insertion is 15 degrees, almost parallel to the
skin surface. The best site for injection is the center of the anterior
forearm, but the upper chest and back are frequently used for allergy
testing (Figure 11-16).
FIGURE 11-15 The intradermal (ID) injection is administered just under the
epidermis. Because the drug is dispersed in an area where many nerves are present,
it causes momentary burning or stinging. Minute amounts of medication are injected.
This method is used to test for allergies, drug sensitivities, and susceptibility to some
diseases. Can also be used as an injection technique for influenza vaccines that are
pre-packaged with microneedles and are injected into the deltoid region.
 CHAPTER 11 Administering Medications 259

ANTERIOR POSTERIOR

@) @)

FIGURE 11-16 Sites recommended for intradermal injections.

Fluzone lntradermal Quadrivalent (Influenza

Vaccine)
Anewly released influenza vaccine is naw packaged with a very small
needle to enable the delivery of the vaccine into the subcutaneous layer.
The technique of administration is similar to an intramuscular injection in CRITICAL THINKING APPLICATION 11-4
the deltoid area but the needle is so small that it only enters the tissue as Dorothy is ordered to give her first Mantoux test since being hired by Dr.
far as the dermal layer. Thau. Document the details that Dorothy should include in the patient's
• The vaccine is indicated for the prevention of 4 different strains of health record. She administered 0.1 ml of PPD by ID injection into the
influenza. patient's right midforearm and instructed the patient on when to return to
• Asingle 0.1 ml dose is available for intradermal injection in adults 18 the office to have the test read.
through 64 years of age.
• Packaged as a suspension for injection in a prefilled microinjectian
system that administers the vaccine into the dermal layer.
• The preferred site of injection is the skin in the region of the deltoid at
a 90-degree angle.
• Contraindicated in anyone with a history of a severe allergic reaction
to egg protein or to a previous dose of any influenza vaccine.

•;;m,am);Jllil Reconstitute a Powdered Drug for Administration

Goal: To reconstitute apowdered drug for intramuscular iniection as ordered by the provider.

EQUIPMENT and SUPPLIES PROCEDURAL STEPS

• Patient's health record 1. Read the order and clarify any questions with the provider.
• Written provider's order, including the drug name, strength, dose, and route PURPOSE: The medical assistant should never dispense or administer a
of administration drug without making sure the provider's order is legible and the details of
• Vial containing the ordered powdered medication the drug are known.
• Diluent: sterile saline 2. If you are unfamiliar with the medication, refer to the PDR, online drug
• Alcohol wipes reference, or package insert to determine the purpose of the drug,
• Two sterile needle and syringe units common side effects, typical dose, and any pertinent precautions or con-
• Sharps container traindications. Be prepared to answer any questions the patient may have
• PDR, online drug reference, or package insert about the medication. Use the Seven Rights to prevent errors.
260 UNIT TWO ASSISTING WITH MEDICATIONS
•;;m,ammiii• -continued
3. Perform calculations needed to match the provider's order. Confirm the
answer with the provider if you have any questions.
4. Dispense the medication in a well-lit, quiet area.
PURPOSE: To prevent distractions and possible errors.
5. Assemble the equipment and sanitize your hands. Choose the correct
syringe and needle unit, depending on the site of administration, patient
characteristics, and the amount of medication to be injected.
6. Select the correct vial of powdered medication from the shelf and the
recommended diluent far reconstitution. Compare the order with the label
on the vial when you remove it from storage. Check the quality of the
medication and the expiration date on the container and dispose of the
medication if it appears contaminated, contains sediment, or has expired.
PURPOSE: To compare the medication label and the provider's order the
first of three times.
7. Compare the order with the label on the vial of medicine just before dis-
pensing the ordered dose. Read the label to determine the correct amount
of diluent to add to create the dose ordered by the provider. Calculate the
correct dose, if necessary.
PURPOSE: To compare the medication label and the provider's order the
second of three times.
8. Remove the tops from each vial and clean each with an alcohol wipe.
Leave the wipes in place on tap of each vial.
9. Using one of the syringe units with the needle cover in place, grasp the
syringe plunger and draw up the amount of air equal to the amount of
diluent needed to reconstitute the drug.
PURPOSE: Not enough replaced air makes it difficult to withdraw the
diluent; too much replaced air farces the diluent into the syringe without
the plunger being pulled to withdraw it.
•;;m!,mj;jiiil Administer Parenteral (Excluding IV) Medications: Give an lntradermal Injection
Goal: To inject 0.1 ml of purified protein derivative (PPD) intradermally (ID) to perform a Mantoux test as ordered by the
provider.
ORDER:
Administer 0.1 ml PPD ID far a Mantoux test far TB screening.
EQUIPMENT and SUPPLIES
• Patient's health record
• Written provider's order, including the drug name, strength, dose, and route
of administration
• Vial of tuberculin PPD
• Alcohol wipes
• 27-gauge, ,¾-inch sterile needle and 1-ml syringe unit with safety needle
cover device
• Disposable gloves
10. Remove the alcohol swab aver the rubber stopper and the needle cover
and insert the needle into the center of the rubber stopper of the diluent.
Hold the vial firmly against a flat surface and watch carefully that the
needle touches only the cleaned rubber area.
11. Inject the aspirated air in the syringe into the diluent vial.
12. Invert the diluent vial and aspirate the calculated or recommended amount
of diluent.
13. Remove the alcohol swab over the rubber stopper of the drug vial. Remove
the needle from the diluent vial and inject the diluent into the center of
the rubber stopper of the drug vial. Remove the needle from the vial and
discard the syringe unit into the sharps container.
PURPOSE: An unused syringe unit should be used to administer the
medication to the patient because the needle on the used unit may not
be as sharp as that on a new syringe unit.
14. Roll the vial with the drug and diluent mixture between the palms of your
hands ta mix it thoroughly. Do not shake the vial unless directed to do so
an the drug label. When the medication is completely mixed, no residue
or crystals are seen on the bottom of the vial.
15. Aspirate air into the second syringe unit that is equal to the calculated
amount of medication to be administered.
16. Inject the air into the mixed drug vial, invert the vial, and withdraw the
ordered amount of medication.
17. Check the order against the label one more time to complete the three
label checks.
PURPOSE: This is the third of the three drug label and order checks.
• Gauze squares
• Sharps container
• PDR, online drug reference, or the package insert
• Written patient instructions far fallow-up
PROCEDURAL STEPS
1. Read the order and clarify any questions with the provider.
PURPOSE: The medical assistant should never dispense or administer a
drug without making sure the provider's order is legible and the details of
the drug are known.
2. If you are unfamiliar with the medication, refer to the PDR, online drug
reference, or package insert to determine the purpose of the drug,
 CHAPTER 11 Administering Medications 261

•;;m,ammiiii -continued
common side effects, typical dose, and any pertinent precautions or con- PURPOSE: To be able to remove the needle cover with one hand and
traindications. Be prepared to answer any questions the patient may have prevent contamination of the needle; once the site has been grasped and
about the medication. Use the Seven Rights to prevent errors. cleaned, you must keep your hand in place on the patient's arm to avoid
3. Perform calculations needed to match the provider's order. Confirm the injecting the PPD solution into an area that was not cleansed with alcohol;
answer with the provider if you have any questions. you also will need to grasp alcohol wipes with one hand while the other
4. Dispense the medication in a well-lit, quiet area. hand is holding tissue up and away from the injection site.
PURPOSE: To prevent distractions ond possible errors. 16. Wrap the thumb and the first two fingers of your nondominant hand
S. Assemble the equipment and sanitize your hands. Choose the correct around the patient's forearm, pulling downward and apart to stretch the
syringe and needle unit, depending on the site of administration, patient skin of the forearm taut at the location of the injection.
characteristics, and the amount of medication to be injected. PURPOSE: Stretching the skin tightens the surface and facilitates insertion
6. Compare the order with the label on the vial of medicine when you remove of the needle with minimum discomfort to the patient. The skin is not
it from storage. Check the quality of the medication and the expiration stretched tightly enough if it begins to wrinkle as you start to insert the
date on the container and dispose of the medication if it appears contami- needle.
nated, contains sediment, or has expired. 17. Cleanse the patient's skin with an alcohol wipe using a circular motion,
PURPOSE: To compare the medication label and the provider's order the moving from the center outward (Figure l).
first of three times.
7. Compare the order with the label on the vial of medicine just before dis-
pensing the ordered dose. Make sure the strength on the label matches
the order or that you dispense the correctly calculated dose.
PURPOSE: To compare the medication label and the provider's order the
second of three times.
8. Warm refrigerated medications by gently rolling the container between
your palms.
9. Prepare the syringe and vial as described in Procedure 11-3 and withdraw
the correct dose of 0.1 ml.
10. Return the medication to the shelf or the refrigerator, checking the order
against the label one more time to complete the three label checks.
PURPOSE: This is the third of the three drug label and order checks.
11. Take the medication to the patient. Greet the patient, and identify him or
her by full name and date of birth; compare them to the name and DOB
on the order.
PURPOSE: To make sure you have the right patient. 18. Allow the antiseptic to dry while maintaining your grip on the patient's
12. Ask the patient whether he or she has ever had a positive reaction to a forearm.
PPD injection (TB test). If yes, report this information to the provider 19. Pick up the syringe unit, shaking off the already loosened needle cover.
before administering the medication. An individual with a history of a 20. Grasp the syringe between the thumb and first two fingers of your domi-
positive PPD test result always has a positive result because of antibody nant hand, palm down, with the needle bevel upward. Hold the syringe
action. close to the plunger end.
13. Put on gloves and position the patient comfortably. 21. At a l 5-degree angle (Figure 2, A), with the syringe unit parallel to the
PURPOSE: To create a wheal successfully, it is easier if the patient is surface of the skin and the bevel up, carefully insert the needle just until
sitting and the medical assistant is lower than the patient (e.g., on a the bevel point is under the skin surface (Figure 2, B).
stool) with the anterior surface of the patient's arm extended straight out
and angled downward.
14. Locate the antecubital space, then find a site several fingerwidths down
the midanterior aspect of the forearm. Avoid any scarred, discolored, or
pigmented areas.
1S. Loosen the needle cover so that the needle can be picked up with one
hand after the site has been cleansed. Open alcohol wipes so they can
be grasped with one hand.
262 UNIT TWO ASSISTING WITH MEDICATIONS
•;;m,ammiiii -continued
lntradermal
Subcutaneous
tissue
2
22. Slowly and steadily inject the medication by depressing the plunger with
your ring or little finger. Do not aspirate. Awheal should appear.
PURPOSE: Arapid injection may force the substance through to the
surface.
23. After administering all the medication (0.1 ml), withdraw the needle.
24. Immediately cover the contaminated needle with the syringe unit safety
device and discard the unit in the sharps container with the needle first.
2S. Do not massage the area, but you may blot it with a cotton ball or a
gauze square. Do not cover the site with a bandage.
PURPOSE: Massaging disturbs the wheal and interferes with the intended
results.
26. Make sure your patient is comfortable and safe.
27. Observe the patient for any adverse reaction.
Subcutaneous Injections
Subcutaneous injections are given between the epidermis and the
muscle, into the fatty areolar layer called adipose tissue (Figure 11-17
and Procedure 11-6). Smaller doses of less irritating drugs (i.e., no
more than 2 mL) are given by this method. A½- to ¾ -inch, 25- or
26-gauge needle is used for SC injections. Insulin microneedles are
31 gauge. The angle of insertion is typically 45 degrees, but the
needle length determines the angle of administration. For example,
heparin and insulin may be administered at a 90-degree angle when
28. Dispose af the gloves in the biohazard container and sanitize your hands.
29. In the patient's health record, document the procedure and any reactions
that occurred at the site of the injection. Include the exact site of the
injection.
PURPOSE: Aprocedure is not considered done until it is recorded. The
exact site must be knawn ta check for reactions to the PPD in 48 ta 72
hours.
30. Help the patient make an appointment to return to the facility for any
reaction to be read in 48 ta 72 hours.
PURPOSE: Patient education must be provided to obtain intended results.
Reading the Mantoux Test Results
31. Use the patient's health record to identify the location of the test.
32. Sanitize your hands and put on gloves; using good lighting and with the
patient's arm slightly flexed, palpate the injection site with your fingertips
and measure the induration. The basis of reading the skin test is the
presence or absence of induration, which is a hard, dense, raised area.
This is the area that is measured using a disposable millimeter ruler. Do
not include any areas of inflammation in the measurement.
PURPOSE: Apositive Mantoux reaction occurs if the induration is inflamed,
raised, and 15 mm or larger; an induration of 5 mm or larger is considered
positive in patients with human immunodeficiency virus (HIV) infection,
thase in recent contact with a person who has TB, patients with a positive
chest x-ray result, thase wha have received organ transplants, and anyone
who is immunosuppressed. An induration of l Omm or larger is considered
positive in recent immigrants, IV drug users, and children younger than 4
years of age. Further diagnostic tests are ordered to rule out or confirm
the diagnosis of tuberculosis.
33. Discard the gloves and measuring device in the biohazard waste container
and sanitize your hands.
34. Document in the patient's record the results of the Mantoux test, including
a complete description of the size of any induration. Notify the provider.
8/22/20-9: l OAM: Administered Mantoux TB test as ordered by Dr. Thau,
0.1 ml ID, lot #MF4780D, exp date 2/20, to® anterior forearm. Pt tolerated
procedure well. No questions. Appointment made to return 8/24 for reading.
Dorothy Gaston, CMA (AAMA)
8/2 4/20-10 AM: Mantoux test site in ® anterior forearm 3 mm. Dorothy
Gaston, CMA (AAMA)
a microneedle (½'6 inch) is used; or, to reach subcutaneous tissue,
the injection may be administered at a 90-degree angle if the patient
is obese. The posterior upper arm (about 3 inches above the elbow
and 3 inches below the shoulder) is the typical injection site, but the
abdomen, the anterior aspect of the thighs, and the upper back also
may be used (Figure 11-18). Regardless of the site of the location,
subcutaneous injections are administered by pinching up the tissue
to create a skinfold before injection to allow for easier access to
subcutaneous tissue.
 CHAPTER 11 Administering Medications 263

FIGURE 11-17 The subcutaneous (SC) injection is administered with a 25- or 26-gauge, ½· or
Ya-inch needle. This method is used for small amounts of nonirritating medications in aqueous solution.
For injection of the medication, the needle is inserted at a 45-degree angle (or, for insulin and heparin,
at a 90-<legree angle). The most common site is the posterior upper arm.

@) @)

LlJ
I\ I I

ANTERIOR POSTERIOR

FIGURE 11-18 Areas of the body commonly used for subcutaneous injections.
264 UNIT TWO ASSISTING WITH MEDICATIONS

When multiple or frequent injections are ordered, as with Posterior view

routine insulin administration that requires the patient to receive

up to four injections a day, the sites must be rotated to prevent
tissue damage and problems with absorption of the medication.
Part of patient education for diabetics who rely on insulin for
therapy is teaching them how to keep a rotation record (Figure
11-19). It might be helpful for patients to mark the site of the last
injection with a spot bandage or a piece of tape. The easiest way
to rotate sites is to give subsequent injections in a circular pattern
around the site of the first injection in a particular location, such
as the right anterior thigh. The goal is to avoid using the same
location again for another month. Patients with diabetes typically Anterior view

have to administer two different types of insulin at one time.

Many different solutions of insulin are available in premixed, mul-
tidose vials; however, you may have to mix two different types of
1 I8

a
=
E
3
5
7
insulin in the ambulatory care setting. Procedure 11-7 explains
how to perform this technique.

Insulin Administration Guidelines

• Typically more than one type of insulin is ordered for immediate admin- INJECTION LOG
istration. Check labels carefully, and follow office policy when mixing
insulins in the same syringe. Not all insulin products can be mixed. SITE 1 2 3 4 5 6 7 8
Right arm A
• Insulin is always ordered in unit amounts. Use the appropriate insulin
Right abdomen B
syringe-30, 50, or 100 units-based on the total amount of insulin Right thigh C
ordered. Left thigh D
• Insulin should be stored in the refrigerator and gently rotated between Left abdomen E
the hands to warm before dispensing. B Left arm F
• Do not massage the site after injection.
FIGURE 11-19 A, Rotation sites for insulin injections. B, Rotation log.

Select the Proper Sites for Administering a Parenteral Medication: Administer a

PROCEDURE 11-6
Subcutaneous Injection

Goal: To inject 0.5 ml of medication into the subcutaneous tissue using a25-gauge, ½-inch needle and syringe of correct size
and type as directed by the provider.
Order: Administer 0.5 ml varicella vaccine SC to Mandy Leno, age 11.
EQUIPMENT and SUPPLIES PROCEDURAL STEPS
• Patients health record 1. Read the order and clarify any questions with the provider.
• Written provider's order, including the drug name, strength, dose, and route PURPOSE: The medical assistant should never dispense or administer a
of administration drug without making sure the provider's order is legible and the details of
• Vial of ordered medication the drug are known.
• Alcohol wipes 2. If you are unfamiliar with the medication, refer to the PDR, online drug
• Gauze squares or cotton balls reference, or package insert to determine the purpose of the drug,
• Sterile, 25-gauge, ½-inch needle and syringe unit with safety cover device common side effects, typical dose, and any pertinent precautions or con-
• Disposable gloves traindications. Be prepared to answer any questions the patient may have
• Sharps container about the medication. Use the Seven Rights to prevent errors.
• PDR, online drug reference, or package insert 3. Perform calculations needed to match the provider's order. Confirm the
• Vaccine Information Sheet (VIS) for varicella answer with the provider if you have any questions.

•;;m,ammiiii -continued
4. Assemble the equipment and sanitize your hands. Dispense the medication
in a well-lit, quiet area to prevent distractions and possible errors. Choose
the correct syringe and needle unit, depending on the site of administra-
tion, patient characteristics, and the amount of medication to be injected.
5. Compare the order with the label on the vial of medicine when you remove
it from storage. Check the quality of the medication and the expiration
date on the container and dispose of the medication if it appears contami-
nated, contains sediment, or has expired.
PURPOSE: To compare the medication label and the provider's order the
first of three times.
6. Warm refrigerated medications by gently rolling the container between
your palms.
7. Compare the order with the label on the vial of medicine just before drawing
the ordered dose into the syringe unit. Make sure the strength on the label
matches the order or that you dispense the correctly calculated dose.
PURPOSE: To compare the medication label and the provider's order the
second of three times. One medication may be manufactured and prepack-
aged in different strengths. For instance, a particular drug may be available
in vials of 250 mg/ml and 500 mg/ml.
8. Prepare the syringe and withdraw the correct dose, maintaining sterile
technique. Compare the order with the label on the vial before disposing
of the vial to complete the third label check.
9. Take the medication to the patient.
10. Greet the patient, and identify him or her by full name and date of birth;
compare them to the name and DOB on the order. Ask about allergies.
Explain the purpose of the immunization, and confirm that the caregiver
was given a VIS form to review before administration of the vaccine and
that the caregiver has given permission for administration.
PURPOSE: To make sure you have the right patient, to gain cooperation,
and to comply with federal VIS regulations.
11. To administer the injection into the arm, ask the patient to sit upright and
help position her comfortably if necessary.
12. Expose the upper posterior arm (back or side of the arm) 3 inches below
the shoulder and 3 inches above the elbow. To locate injection sites on
the thigh, have the patient sit; then draw an imaginary line above the
knee and below the uppermost part of the thigh and down the outer side
and the center front of the leg. The area within these imaginary lines is
where injections may be given. Another way to think of it is, in the middle
third of the lateral aspect of the upper leg. To locate injection sites on the
abdomen, draw an imaginary line below the lower ribs as far around as
you can pinch up fatty tissue folds. Abdominal injections must avoid a
1-inch area around the navel.
13. Loosen the cap on the needle while keeping the caver over the needle.
Open alcohol wipes so that they can be grasped with one hand.
PURPOSE: To be able to remove the needle cover with one hand and
prevent contamination of the needle; you will need to grasp alcohol wipes
with one hand while the other hand is holding tissue up and away from
the injection site.
14. Put on gloves, and with the thumb and fingers of your nondominant hand,
grasp the tissue of the posterior upper arm, pinching up the area to create
CHAPTER 11 Administering Medications 265
a tissue fold. Cleanse the patients skin with the alcohol wipe, using a
circular motion and moving outward from the center (Figure 1).
15. Remove the cap from the needle by gently shaking the loosened cover
free while maintaining the sterility of the needle unit.
16. Hold the syringe between the thumb and the first two fingers of your
dominant hand, and with one swift movement, insert the entire needle
up to the hub at a 45-degree angle.
PURPOSE: The depth of the injection is determined by the choice of
needle length, not by how far you insert the needle. Some subcutaneous
injections, such as insulin injections with microneedles, are administered
at a 90-degree angle.
17. After the needle has been completely inserted into the skin, release the
skin that you are grasping. Use your nondominant hand to stabilize the
syringe area closest to the skin so that the needle does not move during
administration of the drug.
PURPOSE: To prevent discomfort for the patient, do not move the needle
while injecting the medication.
18. Follow the facility's policies and/or the provider's recommendations
regarding aspiration before the drug is administered. Push in the plunger
slowly and steadily until all medication has been administered.
PURPOSE: Aspiration before administration of certain medications (e.g.,
pediatric vaccines, insulin, heparin) is not recommended. Arapid in-
jection may damage the tissues and may be uncomfortable for the
patient.
19. As the needle is pulled out of the skin, gently press a gauze square next
to the needle insertion site. Immediately cover the contaminated needle
with the syringe unit safety device and discard the unit in the sharps
container with the needle first.
PURPOSE: Pressure over the site while removing the needle prevents the
skin from pulling back, which may be uncomfortable. The gauze also helps
seal the punctured tissue and prevents leakage.
266 UNIT TWO ASSISTING WITH MEDICATIONS
I; ;m!,m);Jllii -,;ontinued
20. Follow the facility's policy regarding massaging the injection site after drug
administration (do not massage the site after insulin or heparin injections).
If permitted, press or rub the site far a few seconds.
PURPOSE: Massage helps increase absorption and reduce pain but is not
recommended for certain medications; pressing the site without massage
helps control bleeding.
21. Make sure the patient is comfortable and safe.
22. Dispose of gloves in the biohazard waste container and sanitize your
hands.
23. Observe the patient far any adverse reaction. You may need to keep the
patient under observation far 20 to 30 minutes.
24. Record the drug administration in the patient's medical record, including
the exact injection site. Document the vaccine dose in the vaccination log.
Each facility has a policy far vaccination documentation.
•;;m!,m);Jllii Mix Two Different Types of Insulin in One Syringe
Goal: To mix two different types of insulin from two different multidose vials in one iniection unit for administration.
Order: Administer 5 units of Lispro and 15 units NPH insulin to Gregor Thomas STAT.
EQUIPMENT and SUPPLIES
• Patient's health record
• Written provider's order, including the drug name, strength, dose, and route
of administration
• Multidose vial of Lispro insulin
• Multidose vial of NPH insulin
• Alcohol wipes
• Sterile needle and insulin syringe unit with safety cover device (because the
total amount of insulin ordered is 20 units, use a 30-unit insulin syringe)
• PDR, online drug reference, or the package insert
PROCEDURAL STEPS
1. Read the order and clarify any questions with the provider.
PURPOSE: The medical assistant should never dispense or administer a
drug without making sure the provider's order is legible and the details of
the drug are known.
2. If you are unfamiliar with the medications, refer to the PDR, online drug
reference, or package insert to determine the purpose of the drug,
common side effects, typical dose, and any pertinent precautions or con-
traindications. Be prepared to answer any questions the patient may have
about the medication. Use the Seven Rights to prevent errors.
3. Perform calculations needed to match the provider's order. Confirm the
answer with the provider if you have any questions.
4. Dispense the medication in a well-lit, quiet area.
PURPOSE: To prevent distractions and possible errors.
S. Assemble the equipment and sanitize your hands. Choose the
correct syringe and needle unit, depending on the site of administra-
PURPOSE: The immunization record or vaccination log must be completed
each time a vaccine is administered. Information includes the manufac-
turer; batch and lot numbers, which are stamped on the container; expira-
tion date; dose administered; route of administration; and whether a
patient reaction occurred. You must also document that the caregiver
received a VIS form and that any questions were answered before the
vaccine was administered. (More details about immunization records are
presented in the Pediatrics chapter.)
6/14/20-11 :35 AM: 0.5 ml varicella virus vaccine administered SQ to ®
posterior upper arm as ordered by Dr. Thau, Beck Corp, lot #V5829K, exp date
9/20. VIS form, date l 0/20XX, given to mother. She had no questions. Pt
tolerated procedure well. Dorothy Gaston, CMA (AAM)
tion, patient characteristics, and the amount of medication to be
injected.
6. Select the correct multidose vials of insulin from the refrigerator. Compare
the order with the labels on the vials of insulin when you remove them
from the refrigerator. Check the quality of the medication and the expira-
tion date on the containers; dispose of the medication if it appears con-
taminated, contains sediment, or has expired. Lispra and Regular insulin
are clear and colorless. NPH is opaque or cloudy and colorless.
PURPOSE: To compare the medication label and the provider's order the
first of three times; make sure the Lispro vial is not contaminated with
NPH; if the Lispro vial is cloudy or if either vial has sediment in the mixture,
dispose of the contaminated vial or vials.
7. Mix and warm the insulin vials by gently rolling the vials between your
palms.
PURPOSE: Mixing ensures an equal concentration of medication through-
out the vial. Shaking insulin vials can turn the medication frothy, making
it difficult to measure the dose accurately.
8. Compare the order with the label on each vial of insulin just before drawing
the ordered dose into the syringe unit. Make sure the name on the label
matches the order or that you dispense the correctly calculated dose.
PURPOSE: To compare the medication label and the provider's order the
second of three times.
9. Check to make sure the total amount of insulin ordered is less than the
insulin syringe chosen.
PURPOSE: Insulin syringes are available in 30-unit, SO-unit, and l 00-unit
calibrations. The total amount of insulin ordered in this case is 20 units,
so the 30-unit syringe is the most appropriate.
 CHAPTER 11 Administering Medications 267

•;;m,ammiiii -,;ontinued
10. Clean the taps of each vial with individual alcohol wipes, leaving the wipe
on the top of each vial.
PURPOSE: To disinfect the top of each vial before drawing up the ordered
dose.
11. Remove the alcohol swab and inject 15 units of air into the NPH vial,
being careful not to touch the insulin in the vial with the needle, and
withdraw the needle (Figure 1). Withdraw
Lispro
PURPOSE: The NPH dose is drawn up last to avoid adding NPH insulin to insulin
the Lispro vial. Inject air into the NPH vial before drawing up the Lispro
order so that it is ready for dispensing. Touching the NPH insulin with the
needle contaminates the Lispro vial.
Inject

! air

3 !
13. Reinsert the needle into the NPH vial and carefully withdraw the ordered
15-unit dose. Do not push any insulin back into the vial. If you withdraw
more than the ordered dose, discard the syringe unit and restart the
procedure (Figure 4).

1 NPH vial

12. Remove the alcohol swab and inject 5 units of air into the Lispro vial,
keeping the needle in the vial (Figure 2). Invert the vial and withdraw
the ordered dose of 5 units (Figure 3). Withdraw
NPH insulin
Inject

! air

4 !
14. Complete the third label check by comparing the order with the labels on
the insulin vials before returning the multidose vials to the refrigerator.
15. Dispose of used alcohol wipes.

2 Lispro vial
268 UNIT TWO ASSISTING WITH MEDICATIONS

Intramuscular Injections
Injections are given into muscle if the drug would irritate the SC
tissues, if more rapid absorption is desired, or if a large volume of
medication is to be injected. The angle of insertion is 90 degrees
(Figure 11-20), and the preferred sites in an adult are the vastus
lateralis, deltoid, ventrogluteal, and gluteus medius muscles (Figure
11-21); in an infant or child, the preferred site is the vastus lateralis.
It is important to select a needle that is long enough, especially for
obese patients, to ensure that the medication is injected into the
muscle and is not deposited in the upper adipose tissue. Fatty tissue
does not absorb medication well, and the medication may remain at
the site of the injection rather than being distributed systemically as
intended. The recommended gauge for an adult is 20 to 23, and the
needle length should be 1 to 3 inches, depending on the patient's
size.
1------Subcutaneous tissue
In adults, the deltoid region can hold up to 2 mL of medication,
and the vastus lateralis and gluteal sites can hold up to 3 mL. Infants
and children should be given no more than 2 mL in the vastus
lateralis or the ventrogluteal site. The most important criterion in 1-----Muscle

choosing an IM site is to use one that is not near large nerves, bones,
or blood vessels. If any of these structures are damaged by the injec-
FIGURE 11-20 Anatomic illustration of the intramuscular (IM) injection. Note that the needle is
tion, the patient may experience nerve injury with lingering pain or
inserted at a 90-degree angle, which deposits the medication into the large central part of the muscle.
may develop an abscess or bone inflammation with infection.

Deltoid---+

@) @)

I\ I\

ANTERIOR POSTERIOR

FIGURE 11-21 Muscles commonly used for an intramuscular injection.


When locating a site for an IM injection, expose the site so that
you can see and palpate the landmarks correctly. If the patient must
receive repeated IM injections, the sites should be rotated to prevent
damage to the muscle and to surrounding tissues.
Deltoid Site. The deltoid muscle, the muscular cap of the shoul-
der, is located at the top of the upper arm. The muscle mass is
somewhat limited, so it can hold only 1 to 2 mL of medication.
This triangular muscle is located between the acromion and the
deltoid tuberosities, and the injection site is approximately 2 fin-
gerbreadths below the acromial process (Figure 11-22). The major
nerves and blood vessels, especially the radial nerve and artery,
must be avoided. Aqueous medications, such as vitamin B12 , are
most appropriate here; hepatitis B and flu vaccines are also given
in the deltoid.
If frequent injections are ordered, rotate the site and alternate the
right and left arms. The deltoid site is acceptable for adults and older
children, but it should not be used when the muscle is small or
underdeveloped. For a small arm, you may need only a 25-gauge,
,¾-inch needle; the 23-gauge, I-inch needle most often is used for
an arm of average size. The patient may be seated or lying down. To
administer the injection, expose the entire shoulder rather than
rolling up the sleeve; rest the palm of your hand across the shoulder
and grasp the muscle; inject the medication at a 90-degree angle
(Procedure 11-8).
Vastus Lateralis (Thigh) Site. The vastus lateralis muscle is part of
the quadriceps group of the thigh. It is one of the body's largest
muscles, and because it is developed at birth, it is considered the
safest IM injection site for infants. Many experts believe that as a
site for adult IM injections, the vastus lateralis is better than the
deltoid or the dorsogluteal sites because fewer major nerves and
blood vessels are in the vastus lateralis. The vastus lateralis muscle
fills the midportion of the upper, outer thigh. In an adult, it can be
located from 1 handwidth below the proximal end of the greater
INJECTION SITE
Deltoid
muscle-----+--.....,
Axillary
nerve ----+----'H~
Brachia!
a r t e r y - - - - - - - + - - - - + - -----tl
• m-1> - - + - + - - - - Median and
ulnar nerve
Deep brachia!
a r t e r y - - - - - - + - - - + - --fll
Radial
nerve - - - - - + - - - + - - < r
FIGURE 11-22 Deltoid muscle intramuscular site. This site is not recommended for infants
because the muscle is not well developed until later in childhood.
CHAPTER 11 Administering Medications 269
trochanter to 1 handwidth above the top of the patella (kneecap),
or the middle third of the upper outer leg.
Administering injections to infants and small children requires
some special considerations. The choice of a site is based on muscular
development and the absence of major nerves and blood vessels. As
has been mentioned, the most popular site for IM injections in
children and infants is the vastus lateralis muscle. Other sites are
avoided for the following reasons:
• Infants do not have well-developed deltoid muscles.
• The sciatic nerve, located near the dorsogluteal site, is propor-
tionately larger in the infant.
• The gluteus medius is not well developed until the child is
walking.
If you have any doubts, the best policy is to ask the provider to
show you exactly where to inject the medication or vaccine. Any site
selected for infants and children involves greater risk of error because
the muscles are smaller than the muscles of adults.
Infants should be restrained by a co-worker or a parent to prevent
injury. If the child is old enough to understand, be honest and
explain that the injection may sting for a minute, but that it is
important to hold very still. Always get help if giving an injection
to an uncooperative child.
The recommended site for vastus lateralis injections in infants
and children is below the greater trochanter of the femur but within
the upper lateral quadrant of the thigh (Figure 11-23, A and B).
The Debate Over Needle Aspiration
Traditional procedures for intramuscular (IM) injections of medications and
vaccinations have always recommended needle aspiration before adminis-
tration of asolution into any muscle group. Needle aspiration is the process
of pulling back on the syringe plunger before injection to determine whether
the needle is in a blood vessel. If blood is aspirated into the syringe, it
should be immediately removed and discarded to prevent inadvertent
intravenous (IV) administration of a medication that was ordered for IM
administration. However, recent analysis of research shows there is no
scientific evidence to support this practice.
What does that mean for healthcare workers who administer IM injec-
tions? The most recent guidelines published by the American Academy of
Pediatrics state that aspiration before intramuscular vaccination may not be
necessary. According to the Centers for Disease Control and Prevention
(CDC), because there are only two routinely recommended IM sites for
administration of vaccines (the vastus lateralis and deltoid muscles) and
because there are no large blood vessels in either site, aspiration before
injection of vaccines is not necessary. In addition, aspiration may cause
more pain during an injection procedure.
However, aspiration should still be part of a dorsogluteal injection
because there is danger of needle insertion into the gluteal artery. Because
this is a relatively new area of research, medical assistants should follow
the procedures established by the facilities where they work, and if there
is any question about performing aspiration with IM injections, they should
ask a provider in the practice for clarification.
270 UNIT TWO ASSISTING WITH MEDICATIONS

When the vastus lateralis site is used, the needle should be inserted at
a 90-degree angle. The length of the needle should be adjusted
based on the size of the patient. Needle gauges for adults range from
20 to 23, and lengths range from 1 to l½ inches; the muscle can
hold as much as 3 mL of medication. In pediatric patients, the
needle gauge should be 22 to 25, and the length should be ½ inch;
the muscle can hold 0.5 mL in infants and 0.5 to 2 mL in children
(Procedure 11-9). An adult patient may sit or lie supine; in pediat-
ric patients, the vastus lateralis is easier to locate with the child
lying down.
CRITICAL THINKING APPLICATION 11-5
Dr. Thau wants to make certain that Dorothy is comfortable with the pro-
cedure for administering IM injections to infants. She orders Dorothy to give
the first dose of diphtheria, tetanus, pertussis (DTaP) vaccine IM to a
2-month-old infant who is in the office today for a well-baby checkup.
Dorothy administers the injection in the right vastus lateralis. Document the
information Dorothy should include in the child's record.

Femoral artery----111... , _,,,...,'-_j_Greater

Femoral vein trochanter

Rectus femoris
muscle
Vastus lateralis
muscle

A
FIGURE 11-23 A, Vastus lateralis intramuscular site. B, The recommended site for vastus lateralis injections in infants and children.

Administer Parenteral (Excluding IV) Medications: Administer an Intramuscular Injection

PROCEDURE 11-8
into the Deltoid Muscle

Goal: To inject ordered medication into the muscle using a 22-gauge, 1- to 1½-inch needle and a 3-mL syringe as directed by
the provider.
Order: Administer 300,000 units penicillin GIM STAT to Liz Anderson, age 23.

EQUIPMENT and SUPPLIES 2. If you are unfamiliar with the medication, refer to the PDR, online drug
• Patient's health record reference, or package insert to determine the purpose of the drug,
• Written provider's order, including the drug name, strength, dose, and route common side effects, typical dose, and any pertinent precautions or con-
of administration traindications. Be prepared to answer any questions the patient may have
• Vial containing ordered medication about the medication. Use the Seven Rights to prevent errors.
• Alcohol wipes 3. Perform calculations needed to match the provider's order. Confirm the
• Gauze squares answer with the provider if you have any questions.
• Sterile needle and syringe unit with safety needle cover 4. Dispense the medication in a well-lit, quiet area.
• Disposable gloves PURPOSE: To prevent distractions and possible errors.
• Sharps container S. Assemble the equipment and sanitize your hands. Choose the correct
• PDR, online drug reference, or the package insert syringe and needle unit, depending on the site of administration, patient
characteristics, and the amount of medication to be injected.
PROCEDURAL STEPS 6. Compare the order with the label on the vial when you remove it from
1. Read the order and clarify any questions with the provider. storage. Check the quality of the medication and the expiration date on
PURPOSE: The medical assistant should never dispense or administer a the container; dispose of the medication if it appears contaminated, con-
drug without making sure the provider's order is legible and the details of tains sediment, or has expired.
the drug are known.
 CHAPTER 11 Administering Medications 271

•;;m!,mj;jiil=I -continued
PURPOSE: To compare the medication label and the provider's order the
first of three times; a drug may be manufactured and prepackaged in
different strengths; for instance, penicillin Gis packaged in vials of
300,000 units/ml and 600,000 units/ml.
7. Mix and warm refrigerated medications by gently rolling the vial between
your palms.
PURPOSE: Mixing ensures an equal concentration of medication through-
out the vial. Shaking the vial can turn the medication frothy, making it
difficult to measure the dose accurately.
8. Compare the order with the label on the vial just before drawing
the ordered dose into the syringe unit. Make sure the name on the
label matches the order or that you dispense the correctly cal-
culated dose.
PURPOSE: To compare the medication label and the provider's order the
second of three times.
9. Prepare the syringe and vial as described in Procedure 11-3 and withdraw
the correct dose of medication. Compare the order with the label on the
vial before disposing of the vial or replacing a multidose vial to storage
to complete the third label check. 16. Place your nondominant hand on the patient's shoulder, and with the
PURPOSE: To complete the third of the three label checks. thumb and first two fingers, spread the skin tightly and grasp the muscle
10. Take the medication to the patient. deeply on each side (Figure 2).
11. Greet the patient, and identify her by full name and date of birth; compare PURPOSE: To compress fat and stabilize the muscle.
them to the name and DOB on the order. Ask the patient whether she is
allergic to penicillin or any other antibiotics.
PURPOSE: To make sure you have the right patient. Antibiotics, especially
the penicillin family, are the most likely group of drugs to cause allergies.
The patient's response can change over time, so it is important to request
allergy information before each administration of an antibiotic.
12. Help the patient into an upright sitting position.
13. Put on gloves and expose the deltoid site. The mid-deltoid site is located
approximately 2 to 3 fingerwidths below the acramial process.
14. Loosen the needle cover while keeping the needle within the cover and
maintaining the sterility of the unit. Open alcohol wipes so they can be
grasped with one hand.
PURPOSE: To be able to remove the needle cover with one hand and
prevent contamination of the needle; you will need to grasp alcohol wipes
with one hand while the other hand is holding tissue up and away from
the injection site.
1S. Clean the patient's skin with the alcohol wipe using a circular motion and
moving outward from the center (Figure 1).

17. Shake the needle cover off and grasp the syringe as you would a dart
and with one swift movement, insert the entire needle up to the hub, at
a 9O-degree angle, into the muscle.
PURPOSE: The depth of the injection is determined by the choice of
needle length, not by how far you insert the needle. Once the needle is
at the tissue layer, release the muscle and stabilize the syringe unit with
the nondominant hand so that the needle does not move during aspiration
and injection of the medication.
272 UNIT TWO ASSISTING WITH MEDICATIONS
•;;m!,mj;jiil=I -,;ontinued
18. Aspirate; withdraw the plunger slightly to make sure no blood enters the
syringe.
PURPOSE: Blood in the syringe means that the needle is in a blood vessel
and is not in the muscle tissue. You may not administer an intramuscular
medication by the IV route.
19. If blood appears, immediately withdraw the syringe, cover the contami-
nated needle with the safety device, discard it in the sharps container with
the needle first, and compress the injection site with the cotton ball. Begin
again with step 5. If no blood appears in the syringe, push in the plunger
slowly and steadily until all medication has been administered.
PURPOSE: Arapid injection is uncomfortable for the patient.
20. Place the cotton ball next to the needle and apply counterpressure to the
area while you withdraw the needle at the same angle used for insertion.
Immediately cover the contaminated needle with the syringe unit safety
device and discard the syringe unit in the sharps container with the needle
first.
Select the Proper Sites for Administering a Parenteral Medication: Administer a
PROCEDURE 11-9
Pediatric Intramuscular Vastus Lateralis Injection
Goal: To iniect 0.5 ml of vaccine into the vastus lateralis muscle using a22-gauge, ½-inch needle.
Order: Administer 0.5 ml of Haemophilus influenzae type B(Hib) vaccine IM to Lizzy Dearborne, age 4 months.
EQUIPMENT and SUPPLIES
• Patient's health record
• Written provider's order, including the drug name, strength, dose, and route
of administration
• Vial containing Hib vaccine
• Alcohol wipes
• 2 x 2-inch gauze square
• Sterile needle and syringe unit with safety device
• Disposable gloves
• Sharps container
• PDR, online drug reference, or package insert
• Vaccine Information Sheet (VIS) for Hib
PROCEDURAL STEPS
1. Read the order and clarify any questions with the provider.
PURPOSE: The medical assistant should never dispense or administer a
drug without making sure the provider's order is legible and the details of
the drug are known.
2. If you are unfamiliar with the medication, refer to the PDR, online drug
reference, or package insert to determine the purpose of the drug,
common side effects, typical dose, and any pertinent precautions or
contraindications. Be prepared to answer any questions the caregiver may
have about the medication. Use the Seven Rights to prevent errors.
21. Gently massage the site with a gauze square.
PURPOSE: Massage helps promote absorption and reduce pain.
22. Make sure your patient is comfortable and safe.
23. Observe the patient for any adverse reaction. You may need to keep the
patient under observation for 20 to 30 minutes.
24. Dispose of the gloves and sanitize your hands.
25. Record the drug administration in the patient's health record and in the
required Drug Enforcement Agency (DEA) record if the medication is a
controlled substance.
PURPOSE: Aprocedure is not considered done until it is recorded.
9/8/20-8:35 AM: 300,000 units penicillin Gadministered IM to ® deltoid
as ordered by Dr. Thau without complication. Pt observed for allergic reaction
and none noted. Pt had no questions. Instructed to call office if she experiences
any problems from injection. D. Gaston, (MA (AAMA)
3. Check the patient's record for a previous allergic reaction to the Hib
vaccine. Perform calculations needed to match the provider's order.
Confirm the answer with the provider if you have any questions.
4. Dispense the medication in a well-lit, quiet area.
PURPOSE: To prevent distractions and possible errors.
5. Assemble the equipment and sanitize your hands. Choose the correct
syringe and needle unit, depending on the site of administration, patient
characteristics, and the amount of medication to be injected.
6. Compare the order with the label on the vial of medicine when you remove
it from storage. Check the quality of the medication and the expiration
date on the container and dispose of the medication if it appears contami-
nated, contains sediment, or has expired.
PURPOSE: To compare the medication label and the provider's order the
first of three times.
7. Warm refrigerated medications by gently rolling the vial between your
palms.
8. Compare the order with the label on the vial of medicine just before
drawing the ordered dose into the syringe unit. Make sure the strength on the
label matches the order or that you dispense the correctly calculated dose.
PURPOSE: To compare the medication label and the provider's order the
second of three times.
9. Prepare the syringe and withdraw the correct dose, maintaining sterile
technique as shown in Procedure 11-3. Compare the order with the label

I; ;m!,mj;jjf@i -,;ontinued
on the vial before disposing of the vial or replacing a multidose vial to
storage to complete the third label check.
10. Take the medication to the patient.
11. Greet and identify the patient's caregiver, using the child's full name and
date of birth; compare the child's name and DOB to those on the order.
Check to make sure the caregiver has received the Hib VIS form and that
his or her questions have been answered. Confirm that the caregiver has
given permission for the child to receive the immunization.
PURPOSE: To make sure you have the right patient, and to confirm that
immunization regulations have been followed.
12. Explain the procedure to the caregiver. Check the baby's temperature and
ask the caregiver about recent illnesses. Refer to facility policies if the child
has a fever and/or the caregiver reports a recent illness.
PURPOSE: To promote cooperation; children with a moderate to severe
illness should not be vaccinated.
13. Position the infant on her back. Ask the caregiver to remove any clothing
necessary to expose the infant's thighs. Choose the right or left thigh for
the injection.
PURPOSE: It is important ta expose the entire vastus lateralis muscle ta
prevent injury to the child.
14. Put on gloves and loosen the needle caver while keeping the needle within
the caver and maintaining the sterility of the unit. Open alcohol wipes so
that they can be grasped with one hand.
PURPOSE: To be able to remove the needle caver with one hand and
prevent contamination of the needle; you will need to grasp alcohol wipes
with one hand while the other hand holds tissue up and away from the
injection site.
1S. Locate the injection site. The pediatric vastus lateralis site is located belaw
the greater trochanter of the femur but within the upper lateral quadrant
(fourth) of the thigh. Grasp the muscle with yaur nondominant hand, and
clean the injection site with the alcohol wipe, using a circular motion and
moving outward from the center.
16. Ask for the caregiver's assistance in holding the child still if necessary.
17. Remove the cap from the needle by gently shaking the loosened cover
free while maintaining the sterility of the needle unit.
18. With the thumb and first two fingers of the nondaminant hand, spread
the skin at the site tightly.
19. Grasp the syringe as you would a dart, and with one swift movement,
insert the needle at a 90-degree angle inta the muscle.
20. After the needle has been completely inserted into the skin, release the
muscle that you are grasping. Use your nondominant hand to stabilize the
Dorsogluteal (Gluteus Medius) Site. The dorsogluteal region is the
traditional site for deep IM injections. However, complications from
sciatic nerve injury are common enough that experts have suggested
that use of this site be discontinued and that the vastus lateralis and
ventrogluteal sites be used instead. Regardless, the dorsogluteal site
continues to be popular and is still acceptable for adults if care is
taken to locate the exact site. This site should not be used for pedi-
atric patients.
CHAPTER 11 Administering Medications 273
syringe area closest to the skin so that the needle does not move during
administration of the drug. Aspiration is na longer recommended with
pediatric vaccination injections, but you should follow the facility's policy.
PURPOSE: To prevent discomfort for the patient, do not move the needle
while injecting the medication.
21. As the needle is pulled out of the skin, gently press a gauze square next
to the needle insertion site. Immediately cover the contaminated needle
with the syringe unit safety device and discard the unit in the sharps
container with the needle first.
PURPOSE: Pressure over the site while removing the needle prevents the
skin from pulling back, which may be uncomfortable. The gauze also helps
seal the punctured tissue and prevents leakage.
22. Follow your facility's policy on massaging the injection site after drug
administration. If permitted, press or rub the site for a few seconds.
PURPOSE: Massage helps increase absorption and reduce pain but is not
recommended for certain medications; pressing the site without massage
helps control bleeding.
23. Make sure the infant is safely held by the caregiver. Observe the patient
for 20 ta 30 minutes for any adverse reaction.
24. Dispose of your gloves and sanitize your hands.
25. Record the vaccine administration in the patient's health record and com-
plete the vaccination log according to office procedure.
PURPOSE: Aprocedure is not considered done until it is recorded. It is
important to keep an accurate record of vaccinations performed so that
the next dose is timed properly. The immunization record or vaccination
log must be completed each time a vaccine is administered. Information
includes the manufacturer; batch and lot numbers, which are stamped on
the Hib vial; expiration date; dose administered; raute of administration;
and whether there was a patient reaction. Yau must also record that the
caregiver received a VIS form and that any questions he or she had were
answered before the vaccine was administered. (More details about immu-
nization records are presented in the Pediatrics chapter.)
3/27/20-1 :30 PM: Hib lot #98525, Beck Corp, exp date l 0/20, adminis-
tered 0.5 ml Hib vaccine IM to ~ vastus lateralis per Dr. Thau order. Caregiver
given HIB VIS dated 6/20XX, answered questions regarding follow-up care.
No adverse effects nated. Appointment made for next immunizations in l
month. D. Gaston, (MA (AAMA)
The patient should lie in Sims position with the bottom leg
straight and the top leg slightly bent. To locate the site, put the palm
of your nondominant hand on the greater trochanter of the femur
and point your fingers toward the posterior superior iliac spine.
Palpate these bony prominences to make sure you are at the correct
site, and draw an imaginary line between these two anatomic mark-
ings. The injection is made into the gluteus medius muscle above
the imaginary line (Figure 11-24). Needle gauges 20 to 23 and a
274 UNIT TWO ASSISTING WITH MEDICATIONS

Iliac crest
Gluteus
medius
muscle Posterior Iliac crest
iliac spine
Superior gluteal nerve
Gluteus

Gluteus maximus
muscle
Coccyx
Nerves
Greater
trochanter
of femur Greater trochanter
of femur

FIGURE 11-24 Many providers still prefer the dorsogluteal (gluteus medius) site.

FIGURE 11-25 The ventrogluteal site can be used for most intramuscular injections.

TABLE 11-1 Parenteral Administration of Medications

ROUTE OF NEEDLE NEEDLE DRUG
ADMINISTRATION SITE GAUGE LENGTH (in) SYRINGE AMOUNT EXAMPLE DRUGS
lntradermal Midanterior forearm 27-28 ½ 1 ml: tuberculin 0.1 ml: allergy Tuberculosis skin test
tests (Mantoux)
Subcutaneous Posterior upper arm, 25-26 ½, ½ 3 ml: insulin Adult: 0.1-2 ml Insulin, heparin, vaccines
thigh, abdomen Child: 0.5 ml
Intramuscular Adult deltoid 20-23 1-3 3 ml 1-2 ml Epinephrine, vitamin B12,
Child deltoid 20-23 1-3 ml 0.5-2 ml antibiotics (e.g., penicillin),
Ya-1
meperidine, morphine,
Adult vastus 20-23 1-1½ 3 ml 2-3 ml vaccines
lateralis, 1-3
dorsogluteal, 1-3
ventrogluteal
Infant or child 22-26 Ya 1-3 ml 0.5-2 ml
vastus lateralis

needle length of 1 to 3 inches should be used; the site can hold as
much as 5 mL of medication. Procedure 11-10 can help you practice
finding the dorsogluteal site.
Ventrogluteal (Gluteus Medius) Site. Although considered safe, the
ventrogluteal region is not used as frequently as the others previously
discussed. This technique uses a larger mass of the gluteus medius
muscle than is used for the dorsogluteal site. The area is free of major
nerves and blood vessels, and it is considered safe for both infants
and adults (Figure 11-25). All types of IM medications can be
injected here, including thick, oily preparations. Needle gauges 20
to 23 and needle lengths 1 to 3 inches should be used; the site can
hold as much as 3 mL of medication.
To locate the site, place the patient in Sims position and put the
palm of your nondominant hand on the greater trochanter of the
femur, pointing your fingers toward the patient's head and the index
finger toward the anterior superior iliac spine. Spread your middle
finger back as far as possible from your index finger to form a
triangular injection area. For a child, you will need a I-inch needle;
for an obese adult patient, you may need a 2½- to 3-inch needle to
reach the depth of the muscle. Table 11-1 summarizes the details of
parenteral administration of medications.
Z-Track Intramuscular Injection
Some IM medications are irritating to the skin and SC tissues;
others, such as iron replacement products, leak to the surface and
stain surrounding tissues. These medications should be injected in
such a way as to prevent any leakage from the deep muscle back into
the upper SC layers. The Z-track method displaces the upper tissue
late rally before the needle is inserted.
Prepare the medication according to safety guidelines and then
put on gloves. Palpate the site using anatomically correct markings,
and localize the injection site visually. Push the skin to one side,
and clean it as described for IM injections. Insert the needle into
the anatomically correct location, aspirate, and slowly release the

medication into the deep muscular tissue (see Procedure 11-10).
After withdrawing the needle, release the tissue so that the needle
tract is to the side of the point where the medication was deposited
in the muscle. This process prevents a direct pathway to the surface
for the medication, which protects SC and surface tissues from the
irritating and/or staining properties of the drug.
The medications for which Z-track injection is appropriate
require a large muscle mass, so they should be injected only into the
dorsogluteal site. Because the medication is so irritating to tissues,
the needle should be changed after the medication has been drawn
Administer Parenteral (Excluding IV) Medications: Give a Z-Track Intramuscular
PROCEDURE 11-10
Injection into the Dorsogluteal Site
Goal: ln;ect l ml of medication into the gluteus medius muscle via I-track in;ection using a23-gauge, 2-inch needle.
Order: Administer l ml of INFeD Z-track into the dorsogluteal site to Carlos Langa, age 63.
EQUIPMENT and SUPPLIES
• Patient's health record
• Written provider's order, including the drug name, strength, dose, and route
of administration
• Vial containing the ordered medication
• Alcohol wipes
• Gauze square
• Disposable gloves
• Sharps container
• Sterile needle and syringe unit with safety needle cover
• Additional sterile needle
• PDR, online drug reference, or package insert
PROCEDURAL STEPS
l-track injections are used for medications that irritate or stain the surface
tissues.
1. Read the order and clarify any questions with the provider.
PURPOSE: The medical assistant should never dispense or administer a
drug without making sure the provider's order is legible and the details of
the drug are known.
2. If yau are unfamiliar with the medication, refer to the PDR, online drug
reference, or package insert to determine the purpose of the drug,
common side effects, typical dose, and any pertinent precautions or
contraindications. Be prepared to answer any questions the caregiver
may have about the medication. Use the Seven Rights to prevent errors.
3. Perform calculations needed to match the provider's order. Confirm the
answer with the provider if you have any questions.
4. Dispense the medication in a well-lit, quiet area.
PURPOSE: To prevent distractions and possible errors.
S. Assemble the equipment and sanitize your hands. Choose the correct
syringe and needle unit, depending on the site of administration, patient
characteristics, and the amount of medication to be injected.
6. Compare the order with the label on the vial of medicine when you remove
it from storage. Check the quality of the medication and the expiration
CHAPTER 11 Administering Medications 275
up from the vial and before the injection is given. Some facilities
require personnel to use the Z-track method when administering
abdominal heparin injections because leakage of the drug at the site
may cause localized bleeding. Although heparin is administered by
SC injection, the technique of pushing the surface tissue to the side
before injection is the same.
Medications that require the Z-track method of administration
(e.g., heparin) should not be massaged after injection because mas-
saging encourages spread of the medication. Use alternate sides for
multiple or frequent injections, to prevent tissue damage.
date on the container and dispose of the medication if it appears contami-
nated, contains sediment, or has expired.
PURPOSE: To compare the medication label and the provider's order the
first of three times.
7. Warm refrigerated medications by gently rolling the vial between your
palms.
8. Compare the order with the label on the vial of medicine just before
drawing the ordered dose into the syringe unit. Make sure the
strength on the label matches the order or that you dispense the correctly
calculated dose.
PURPOSE: To compare the medication label and the provider's order the
second of three times.
9. Draw up the ordered amount of medication into the syringe unit following
the steps in Procedure 11-3.
10. Replace the needle cover and give a slight turn to loosen the needle.
Secure a new needle, still in its sheath, to the tip of the syringe, being
careful to not contaminate the needle or hub of the syringe. Discard the
contaminated needle in the sharps container with the needle first.
PURPOSE: The needle that was used to withdraw the medication is
covered with the drug, which might be irritating to the skin and subcutane-
ous tissues.
11. Compare the order with the label on the vial before disposing of the
vial or replacing a multidose vial to storage to complete the third label
check.
12. Take the medication to the patient.
13. Greet the patient, and identify him by name and date of birth (DOB);
compare his name and DOB to those on the order.
PURPOSE: To make sure you have the right patient.
14. Position the patient comfortably in Sims position.
1S. Put on gloves and loosen the needle cover while keeping the needle within
the cover and maintaining the sterility of the unit. Open alcohol wipes so
that they can be grasped with one hand.
PURPOSE: To be able to remove the needle cover with one hand and
prevent contamination of the needle; you will need to grasp alcohol wipes
276 UNIT TWO ASSISTING WITH MEDICATIONS
•;;m,ammif111• -,;ontinued
with one hand while the other hand holds tissue up and away from the
injection site.
16. Expose the dorsogluteal site. This site is found by placing the palm of the
nondominant hand on the greater trochanter of the femur, while pointing
your fingers toward the posterior superior iliac spine and index finger
toward the anterior iliac spine. The injection site is in the upper outer area
of the gluteus medius. Visualize the area for the l-track injection.
17. Apply pressure to the tissue at the dorsogluteal site and push it up and to
one side; hold it firmly in place. If the skin is slippery, use a dry gauze
sponge to hold the skin in place.
PURPOSE: Displacing the skin prevents medication from leaking back to
the surrace.
18. Clean the patient's skin with the alcohol wipe, using a circular motion and
moving outward from the center. Make sure to clean the actual area of
injection.
19. Remove the cap from the needle by gently shaking the loosened cover
free while maintaining the sterility of the needle unit. Grasp the syringe
as you would a dart and with one swift movement, insert the entire needle
up to the hub at a 90-degree angle into the upper outer area of the gluteus
medius muscle.
PURPOSE: The depth of the injection is determined by the choice of
needle length, not by how far you insert the needle. Once the needle is
at the tissue layer, do not move it while injecting the medication. Inserting
the needle as far as the hub helps keep the needle in place.
20. Aspirate; withdraw the plunger slightly to make sure no blood enters the
syringe. If blood appears, immediately withdraw the syringe, apply the
needle safety device and dispose of the syringe unit in the sharps
CLOSING COMMENTS
Patient Education
It is extremely important to coach the patient in how to take a
prescribed drug and to make sure he or she understands the purpose
of the medication. The provider initially educates the patient, but
the medical assistant should be prepared to reinforce the provider's
information or to explain parts of the information the patient did
not understand. When a patient does not understand the need for
the medication or the directions for taking it, the risk is greater that
the medication will be taken incorrectly. As a result, the provider's
orders will not be carried out, and the desired therapeutic effect will
not be achieved. The patient should fully understand the type of
medication, its route of administration, its desired effect, and the
side effects that need to be reported if they occur.
If the patient receives medication in the facility, he or she
should understand the expected results or possible side effects. For
example, if a patient is given a diuretic in the office, he or she
container, and compress the injection site with a gauze square. Begin
again with step 5.
PURPOSE: Blood in the syringe means that the needle is in a blood vessel
and not in the muscle tissue. You may not administer an intramuscular
medication by the IV route.
21. If no blood appears in the syringe, push in the plunger slowly and steadily
until all medication has been administered.
22. Wait l Oseconds for the medication to be dispersed, then withdraw the
needle at the same angle used for insertion. As the needle is withdrawn,
release the displaced tissue to prevent the tracking of medication to the
suriace.
23. Immediately cover the contaminated needle with the syringe unit safety
device and dispose of the needle and syringe unit in a sharps container
with the needle first.
24. If the manufacturer recommends it, gently massage the site with the
gauze square or a cotton ball. Many medications requiring Z-track admin-
istration should not be massaged.
25. Make sure your patient is comfortable and safe.
26. Dispose of your gloves and sanitize your hands.
27. Observe the patient for any adverse reaction. You may need to keep the
patient under observation for 20 to 30 minutes.
28. Record the drug administration in the patient's health record, including the
exact site of injection.
7/13/20-1 :25 PM: l ml INFeD administered Z-track in ® dorsogluteal site
per Dr. Thau order. Injection site not massaged after administration. No evidence
of skin discoloration after administration. Dorothy Gaston, (MA (MMA)
needs to know what the immediate effect is going to be; this pre-
pares the patient for the urinary urgency and polyuria that will
occur within a relatively brief period. When a pain medication is
given, the patient should have full knowledge so that the possibil-
ity of personal injury can be prevented. Any medication given in
the ambulatory care setting that affects the patient's ability to walk
or drive must be used with caution. The patient must be able to
get home safely, and if that is not possible, the medication should
not be given.
The medical assistant should coach the patient to comply with
the treatment plan and take all of the medication as prescribed.
Often if a prescription is not completed, the treatment objectives
may not be achieved. Patients should also be coached to take their
medication in the time sequence prescribed. This keeps the optimum
level of the drug circulating in the bloodstream.
When sample medications are dispensed to the patient in the
facility, the package contains inserts that can be helpful in educa-
tion efforts. Suggest the patient review important parts of the

insert and highlight this information for quick reference. If the
provider has specific written instructions for the patient to follow,
read over the material with the patient before discharge so that any
areas of confusion can be cleared up before the patient leaves the
office. Make sure that all of the adaptations that are relevant to
individual patient needs are considered. For example, if the patient
is hard of hearing, make sure you get feedback that the patient
understands how to take his medication. Including written instruc-
tions will help confirm accuracy in medication administration.
Always remember that the more the patient knows and under-
stands about how to take the medication and why it has been pre-
scribed, the greater the likelihood that the patient will comply with
medication therapy, and the more likely it is that the drug treat-
ment will be successful.
This also would be a good time to suggest that the patient check
the status of medications at home. The National Community Phar-
macists Association (NCPA) recommends that the medicine cabinet
be checked once a month to determine the age and quality of medi-
cations. At that time, the patient should discard any medications
that fall into the following categories:
• Medicines for past illnesses
• Any expired medicines, unidentified medications, or medica-
tions that are more than 2 years old
• Hydrogen peroxide (H 2 O 2) that no longer bubbles or has
changed color (H 2 O 2 typically has a shelflife of at least 1 year
if the bottle is unopened but lasts only 30 to 45 days once
the seal has been broken); ointments or salves that have sepa-
rated or are crumbly; vinegary smelling aspirin; antiseptic
solutions that are cloudy or have a solid residue on the bottom;
and any medicine of uncertain quality
The NCPA also suggests the following:
• Keep medicines stored away from light, heat, air, and moisture.
• Use medicine from the original container until it is completely
used or expired.
• Do not combine medicines from several containers.
• Keep medicine locked away from children.
• Make sure childproof medicine caps are used properly.
Legal and Ethical Issues
A medical assistant must be extremely knowledgeable when admin-
istering medications in the ambulatory care setting. Follow all the
provider's orders exactly as documented. If you have a question about
the order, ask for clarification before you proceed. It is advisable to
give a medication only after the order has been written in the
patient's record. If the provider gives you a verbal order to administer
medication, write it down and review it with the provider before
completing the order. This helps eliminate errors and possible omis-
sions in medication therapy.
Legal responsibilities in medication practice include preventing
errors by carefully following safe practice procedures while dis-
pensing and administering drugs. Always implement the Seven
Rights and perform the three drug order and label checks. Anyone
administering a drug must know the possible serious complica-
tions related to the drug and must be alert for side effects. The
medical assistant must demonstrate compliance with individual
state laws regulating scope of practice regarding medications and
their administration. Precise documentation of the administration
CHAPTER 11 Administering Medications 277
of medications and of the management of prescriptions cannot be
overemphasized.
The administration of drugs involves ethical principles. The
patient always comes first. With that foremost in mind, never risk
giving an incorrect medication. There is no such thing as a small
error because any mistake may result in serious harm or possibly
death. If an error is made, it must be reported immediately to the
provider so that measures can be taken to help the patient. It is dif-
ficult to admit that a mistake has been made, but it is absolutely
necessary. For this reason, be sure to double-check your calculations
with a co-worker or the provider before dispensing the drug. If a
mistake is made, most facilities require the person who made the
mistake to complete an incident report. The incident must be docu-
mented completely, including the details of the error, to whom the
error was reported, any action taken, and subsequent observations
of the patient (Procedure 11-11).
Professional Behaviors
The importance of accuracy and accountability cannot be overstated when
it comes to the responsibility of being involved in drug treatment. Asingle
mistake could be devastating for the patient. Aprofessional medical assis-
tant recognizes the seriousness of accurately completing medication orders.
Do not hesitate to ask for assistance or clarification if you have any doubts
about how to follow a medication order or if you are concerned about
patient safety. As the patient's advocate it is your responsibility to raise
questions as needed to ensure healthy outcomes for your patients.
Medication Errors
According to the U.S. Food and Drug Administration (FDA), medication
errors result in at least one death every day and injure more than 1 million
people annually in the United States. Medication mistakes can occur at any
point in the process between the provider's order up to and including
administration of the medication. If a medication error occurs, most facilities
require completion of a medication error incident form. An incident report
is not part of the patient's record, but it is used by the facility to prevent
similar incidents and is kept as a record in case of litigation in the future.
Common causes of medication errors include:
• Poor communication
• Unclear or mistaken product names, directions for use, medical
abbreviations, or writing
• Poor procedures or techniques when dispensing or administering
the drug
• Inadequate patient preparation and education on the use of the
medication
• Job stress in healthcare facilities and/or pharmacies
• Lack of product knowledge or training for healthcare workers
• Medication labeling or packaging that is too similar to another drug
product
Data from Pullen RLJr: Administering a transdermal drug, Nursing 38(5): 14, 2008.
278 UNIT TWO ASSISTING WITH MEDICATIONS

•;;m,ammiiii• Complete an Incident Report Related to an Error in Patient Care

Goal: To promprly report amedication error to your supervisor and complete an incident report form according to the facility's
policies and procedures.
Scenario: Dr. Thau writes the following order: Administer Vento/in HF, 2 puffs, to Simon Alesiam STAT. You administer 2 puffs
of Spiriva, thinking it is the same drug. The patient notices you used a different inhaler from the one he uses at home, and he
asks the provider about this. Your office manager tells you to complete the required Medication Error Incident Report Form.
EQUIPMENT and SUPPLIES PROCEDURAL STEPS
• Patients health record 1. Complete the facility's Medication Error Incident Report Form (Figure 1).
• Written provider's order, including the drug name, strength, dose, and route
of administration
• PDR, online drug reference, or package insert
• Facility Medication Error Incident Report Form
Northeast Family Practice

1099 McKnight Road

Pittsburgh, PA 15210

MEDICATION ERROR INCIDENT REPORT

EMPLOYEE: Return this COMPLETED FORM to the Office Manager as soon as possible.

Name of Patient Involved: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Address: _ _ _ _ _ _ _ _ _ _ _ _ _ City: _ _ _ _ _ _ _ _ _ _ _ _ _ __

Phone Number: _ _ _ _ _ _ _ _ _ Email _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Age: _ _ _ DOB: _ _ _ _ _ Sex: M _ F __

Patient ID#: _ _ _ _ _ _ _ _ _ Date of Incident: _ _ _ _ _ Time: _ _ am/pm

Check Type of Error:

• Medication given to the wrong patient

• Wrong medication given
• Wrong dose of medication given
• Wrong route of administration
• Proper technique not followed when administering the medication resulting in patient injury
• Medication not given at the right time
• Medication not given
• Medication not documented accurately
• Patient education not given resulting in patient administration error
• Administration of medication resulted in an allergic reaction
• Other _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

EMPLOYEE Involved in the Incident:

Name: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Title: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Information about the drug ordered:

Brand name: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Dosage: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Route of administration: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Contraindications: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

1 Adverse reactions: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
 CHAPTER 11 Administering Medications 279

•;;m,ammiiiii -,;ontinued
Information about the drug administered:

Brand name: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Dosage:--------------------------------
Route of administration: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Contraindications: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Adverse reactions: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Description of Incident (Who, What, Where, How, Why; Include sequence of events, personnel involved,
reason incident occurred):

Actions Taken by Staff Members: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Details of patient injury or adverse reactions:

Witness Name: _ _ _ _ _ _ _ _ _ _ _ _ _ _ Phone Number: _ _ _ _ _ _ _ _ _ _ __

Address:---------------------------------

Corrective Action Taken/Follow-Up (Things that have been or will be done to prevent recurrence):

Office Manager Comments:

Office Manager Signature: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Date: _ _ _ _ _ __

Provider Comments:

Provider Signature: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Title: _ _ _ _ _ _ _ Date: _ _ __

1 Adapted from the Kentucky Cabinet for Health and Family Services at http://chfs.kv.gov/ Accessed June 2, 2015.

2. If you are unfamiliar with the drug, refer to the PDR, online drug reference, 3. Which of the Seven Rights did you not use to prevent the error?
or the package insert to determine the purpose of the drug, common side 4. What did you learn from this experience?
effects, typical dose, and any pertinent precautions or contraindications.
 280 UNIT TWO ASSISTING WITH MEDICATIONS
i-iiiiit-iff•jii9#1MU1•i
Dorothy understands the importance of careful management of medications.
Because of her concern for patient safety, she asks Dr. Thau to check all her
calculations and confers with her if she has any questions about medication
orders or patient education. Dr. Thau is a primary care physician, so it is
important for Dorothy to understand the factors that affect the administration
of medication to patients in all age groups. She routinely uses the standard
three label checks when dispensing medications and implements the Seven
Rights throughout medication administration procedures.
SUMMARY OF LEARNING OBJECTIVES
l. Define, spell, and pronounce the terms listed in the vocabulary.
Spelling and pronouncing medical terms correcrly reinforce the medical
assistant's credibility. Knowing the definitions of these terms promotes
confidence in communication with patients and co-workers.
2. Do the following related to safety in drug administration:
• Follow safety precautions in the management of medication administra-
tion in the ambulatory healthcare setting.
The three label checks and Seven Rights must always be performed.
Medications are prepared in a quiet, welHit area. Asubstitute is never
used for the ordered drug or drug strength. Medications are stored as
ordered on the package. Medical assistants must never administer a
medication they have not prepared personally. If preparing a medication
for the provider to administer, the medical assistant places the container
with the dispensed drug. Only written provider's orders are followed.
The medical assistant must check expiration dates and discard expired
drugs. Medications with damaged labels are discarded. Dispensed medi-
cation that is not given is discarded. Patients must be consistenrly asked
about drug allergies. Patients are observed for at least 20 minutes after
administration of a drug. Drug reactions are reported and documented.
Patient education about drug therapy is provided and documented.
• Analyze safety guidelines for specific patient populations.
Safety precautions in the management of medication administration
should be applied consistenrly. Safe drug administration includes under-
standing the provider's order, looking up the drug if the medical assis-
tant is unfamiliar with it, and using the three label checks and the
Seven Rights every time a drug order is completed.
• Document the administration of a medication accurately in the health
record.
Immediately after administering a drug, the medical assistant should
document the date and time of administration; the drug's name,
strength, dose, and route of administration; any reactions the patient
has to the drug; and patient education about the medication. For par-
enteral medications, the exact site of administration must be recorded.
3. Summarize patient assessment factors that can affect medication
administration.
Such factors include continual evaluation of the patient's physical condition,
in addition to holistic factors, such as the patient's history, an accurate list
Dorothy recognizes the importance of complete and accurate documentation
of medications, whether they are administered in the facility or given to the
patient as a prescription order. In addition, she consistently applies the rules of
Standard Precautions when preparing and administering parenteral medications.
All those administering a drug must know the possible serious complications
related to the drug and must be alert for side effects. Precise documentation
of the administration of medications and of the management of prescriptions
cannot be overemphasized.
of drug allergies, the patient's ability to understand the drug regimen
and to afford the treatment, and special factors based on age, weight,
and condition.
4. Identify various drug forms and their administration guidelines, and
administer oral medications.
Drugs are packaged in a variety of forms with a variety of administration
guidelines. Oral medications include both solid and liquid preparations;
mucous membrane medications are absorbed rectally, vaginally, orally,
nasally, or topically through the skin. Each form of medication has specific
guidelines for administration, but all require consistent use of the three
label checks and the Seven Rights. (See Procedure 11-1 for the steps in
administering oral medications.)
5. Do the following related to parenteral administration of drugs:
• Specify parenteral administration equipment, including details about
needles and syringes.
Parenteral medications are manufactured in ampules and in single-dose
or multidose vials. The ordered route of administration, the drug's
characteristics, and individual patient factors determine the correct
gauge and needle length used for administration. The appropriate
syringe is determined by the type of medication ordered and the
amount of drug to be administered. Specialty syringe units, such as the
insulin pen and the EpiPen, are designed for quick administration of
certain medications. Table 11 ·l provides further details.
• Follow OSHA guidelines in the management of parenteral
administration.
OSHA guidelines include using syringe units with safety needle covers;
wearing disposable, nonsterile gloves and other appropriate protective
gear when administering any medication that involves coming into contact
with blood or body fluids; never recapping a contaminated needle,
applying the unit's needle safety device, and immediately discarding it
into a sharps container with the needle first, disposing of contaminated
nonsharp materials in biohazard containers; disinfecting contaminated
work areas; and washing hands before and after procedures.
• Describe and demonstrate the types and locations of parenteral admin-
istration with proper use of sharps containers.
Parenteral routes of administration include intradermal (ID), subcutane-
ous (SC), and a variety of intramuscular (IM) sites. The type

SUMMARY OF LEARNING OBJECTIVES-continued
of medication, the provider's order, and the unique characteristics of
individual patients determine the route and site of administration. Each
requires specrric administration practices, which are described in Proce-
dures 11-2 through 11-10.
6. Recognize the medical assistant's role in coaching patients about the
administration of drugs.
Patient education is crucial if patients are to administer medications cor-
rec~y at home. The patient should understand the purpose of the drug;
the time, frequency, and amount of the dose; any special storage require-
ments; and the typical side effects. The more the patient knows and
understands about how to take the medication and why it has been pre-
scribed, the greater the chance that drug treatment will be successful.
7. Assess legal and ethical issues in drug administration in the ambula-
tory care setting, and complete an incident report related to an error
in medication administration.
The medical assistant must be extremely knowledgeable when preparing
and administering medications in the ambulatory care facility. If
CONNECTIONS
OJ Study Guide Connection: Go to the Chapter 11 Study Guide. Read and complete
the activities.
CHAPTER 11 Administering Medications 281
any questions arise about the order, the medical assistant must ask for
clarification before proceeding. Legal responsibilities include preventing
plural- errors by carefully following safe practice procedures in dispensing
and administering drugs. The medical assistant must comply with individual
state laws regulating medications and their administration. Precise charting
of the administration of medications and the management of prescriptions
cannot be overemphasized.
According to the FDA, medication errors result in at least one death
every day and injure more than 1 million people annually in the United
States. Medication mistakes can occur at any point in the process
between the provider's order up to and including administration of the
medication. If a medication error occurs, most facilities require completion
of a medication error incident form. An incident report is not part of the
patient's record, but it is used by the facility to prevent similar incidents
and is kept as a record in case of litigation in the future. (Refer to
Procedure 11-11.)
evolve Evolve Connection: Go to the Chapter 11 link at evolve.e/sevier.com/
kinn to complete the Chapter Review Quiz. Check out the other resources listed for this
chapter to make the most of what you have learned from Administering Medications.
 SAFETY AND EMERGENCY
12
li#H+i;H•i
Cheryl Skurka, (MA (AAMA), has been working for Dr. Peter Bendt for
approximately 6 months. During that time, a number of patient emer-
gencies have occurred in the office, and even more potentially serious
problems have been managed by the telephone screening staff. Cheryl
is concerned that she is not prepared to assist with emergencies in an
ambulatory care practice. She decides to ask Dr. Bendt for assistance,
and he suggests that she work with the experienced screening
While studying this chapter, think about the following questions:
• What should Cheryl learn about the medical assistant's responsibilities in
an emergency situation?
• What are some of the general rules for managing a medical emergency
in an ambulatory care practice?
• What types of questions does the telephone screening staff ask if a
patient calls with a medical emergency?
• What information from these phone calls should be documented?
• Is it important for Cheryl to be able to recognize life-threatening
emergencies and to be prepared to respond to them? Why?
• What are some of the typical patient emergencies that occur in a
healthcare facility?
LEARNING OBJECTIVES
1. Define, spell, and pronounce the terms listed in the vocabulary.
2. Describe patient safety factors in the medical office environment.
3. Interpret and comply with safety signs, labels, and symbols and
evaluate the work environment to identify safe and unsafe working
conditions for the employee.
4. Do the following when it comes to environmental safety in the
healthcare setting:
• Identify environmental safety issues in the healthcare setting
• Discuss fire safety issues in a healthcare environment
• Demonstrate the proper use of a fire extinguisher
5. Describe the fundamental principles for evacuation of a healthcare
facility and role-play a mock environmental exposure event and
evacuation of a provider's office.
6. Discuss the requirements for proper disposal of hazardous materials.
7. Identify critical elements of an emergency plan for response to a
natural disaster or other emergency.
8. Maintain an up-to-date list of community resources for emergency
preparedness.
PRACTICES
staff to learn how to manage phone calls from patients calling for
assistance.
Dr. Bendt is participating in a community-wide preparedness effort focused
on both natural and human-made disasters, and he expects his practice and
employees to be ready to respond if needed. This includes creating plans both
to maintain the safety of patients and employees in the facility and to provide
assistance as needed in a community emergency.
• How should Cheryl instruct a patient to control bleeding from a
hemorrhaging wound?
• What safety practices should be followed in the healthcare facility to
protect patients and employees from potential harm?
• What is the medical office's responsibility in preparing for community
emergencies?
• Are there common health emergency topics for patient education that
Cheryl should be prepared to present?
• What legal factors should Cheryl keep in mind when handling ambulatory
care emergencies?
9. Describe the medical assistant's role in emergency response.
10. Summarize typical emergency supplies and equipment.
11. Demonstrate the use of an automated external defibrillator.
12. Summarize the general rules for managing emergencies.
13. Demonstrate telephone screening techniques and documentation
guidelines for ambulatory care emergencies.
14. Recognize and respond to life-threatening emergencies in an
ambulatory care practice.
15. Describe how to handle an unresponsive patient and perform provider/
professional-level CPR.
16. Discuss cardiac emergencies and administer oxygen through a nasal
cannula to a patient in respiratory distress.
17. Identify and assist a patient with an obstructed airway.
18. Discuss cerebrovascular accidents and assist a patient who is in
shock.
19. Determine the appropriate action and documentation procedures for
common office emergencies, such as fainting, poisoning, animal bites,
insect bites and stings, and asthma attacks.

LEARNING OBJECTIVES-continued
20. Discuss seizures and perform first aid procedures for a patient having a
seizure.
21. Discuss abdominal pain, sprains and strains, and fractures, and perform
first aid procedures for a patient with a fracture of the wrist.
22. Discuss burns and tissue injuries, and control of a hemorrhagic wound.
VOCABULARY
arrhythmia (uh-rith'-me-uh) An abnormality or irregularity in
the heart rhythm.
asystole (ay-sis'-toh-le) The absence of a heartbeat.
cyanosis (si-an-oh'-sis) A blue coloration of the mucous
membranes and body extremities caused by lack of oxygen.
diaphoresis (di-uh-fuh-re'-sis) The profuse excretion of sweat.
ecchymosis (eH-kih-moh'-sis) A hemorrhagic skin discoloration
commonly called bruising.
emetic (eh-met'-ik) A substance that causes vomiting.
fibrillation Rapid, random, ineffective contractions of the heart.
hematuria (he-muh-tuhr'-e-uh) Blood in the urine.
idiopathic (ih-dee-oh-path-ik) Pertaining to a condition or a
disease that has no known cause.
mediastinum (me-de-ast'-in-um) The space in the center of the
chest under the sternum.
T he medical assistant typically is responsible for making the
healthcare facility as accident proof as possible. This requires
attention to a number of factors. For example, cupboard doors and
drawers must be kept closed; spills must be wiped up immediately;
and dropped objects must be picked up. The medical assistant also
should make sure that all medications are kept out of sight and away
from busy patient areas. If children are in the office, all sharp objects
and potentially toxic substances must be kept out of reach. In addi-
tion, the medical assistant should never leave a seriously ill patient
or a restless, depressed, or unconscious patient unattended.
SAFETY IN THE HEALTHCARE FACILITY
Patient Safety
Patient safety is a critical component of the quality of care provided
in a healthcare facility. The U.S. Department of Health and Human
Services (DHHS) has conducted extensive research on the features
of safe patient environments in providers' offices. The DHHS has
found the following factors to be crucial to patient safety.
• Open lines of communication must be established among all
employees about possible safety issues, and employees must work
together to solve these problems before a patient is injured.
• If an injury occurs (e.g., a medication is administered to the
wrong patient), policies and procedures must be in place so that
all employees recognize the potential for an error and protocols
are established for preventing a similar problem in the future.
• Procedures must be standardized in the facility's policies and
procedures manual so that all employees can refer to specific
guidelines on how procedures should be performed. For example,
CHAPTER 12 Safety and Emergency Practices 283
23. Discuss nosebleeds, head injuries, foreign bodies in the eye, heat and
cold injuries, dehydration, and diabetic emergencies; also, perform first
aid procedures for a patient with a diabetic emergency.
24. Apply patient education concepts to medical emergencies.
25. Discuss the legal and ethical concerns arising from medical emergencies.
myocardium (my-oh-kar' -de-um) The muscular lining of the
heart.
necrosis (neh-kroh'-sis) The death of cells or tissues.
photophobia An abnormal sensitivity to light.
polydipsia Excessive thirst.
Safety Data Sheets (SDSs) Documents that accompany
hazardous chemicals and substances and outline the dangers,
composition, safe handling, and disposal of these items. Safety
Data Sheets must be formatted to conform to the Globally
Harmonized System (GHS), which mandates that SDS have 16
standardized sections arranged in a strict order.
thrombolytics Agents that dissolve blood clots.
transient ischemic attack (TIA) Temporary neurologic symptoms
caused by gradual or partial occlusion of a cerebral blood vessel.
in the case of a blood spill, the policies and procedures manual
must outline a specific, step-by-step procedure for cleaning up
the spill that safeguards both patients and staff members.
• The facility must provide ongoing staff training in patient safety
factors.
• Staff members must work as a team to maintain a safe environ-
ment for patients. For example, all staff members must follow Stan-
dard Precautions to prevent the spread of disease in the facility.
Throughout this text, you have learned about situations that could
result in serious harm to your patients. You must constantly be on
guard to protect patients from possible injury. For example, studies
have shown that healthcare workers frequently confuse drug names,
which results in administration of the wrong medication; they also
fail to identify a patient correctly before performing a procedure and
neglect to perform hand sanitization consistently, thus promoting
the spread of infectious diseases. The medical assistant is an important
link in the delivery of quality and safe care. Can you think of anything
you have learned thus far in your studies that could help keep patients
safe in the provider's office?
Employee Safety
The healthcare facility should safeguard patients as well as staff
members from the possibility of accidental injury. This includes
making sure the facility has appropriate safety signs throughout the
building as well as appropriate symbols and labels that identify
potentially dangerous items (Figure 12-1). Data compiled by the
Occupational Safety and Health Administration (OSHA) reveal that
the leading causes of accidents in an office are slips, trips, and falls.
You must think and work safely to prevent accidents. The following
284 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES

FIGURE 12-1 Safety signs, symbols, and labels.

CAUTION &•M~®*E
BIOHAZARD
NO FOOD OR
DRINK TO BE
STORED IN
THIS FREEZER
@ NO SMOKING
OXYGEN
IN USE

Fire extinguisher Manual Station Fire hose

Pull Station/ or standpoint
Fire Alarm Box

AED
Automated External Defibrillator

+
Emergency exit directional arrows
(Can be rotated in increments of 45 degrees)
Automated External Defibrillator (AED)

are some suggestions from OSHA for vigilant accident prevention
methods (Procedure 12-1).
1. Use proper body mechanics in all situations. For example, bend
your knees and bring a heavy item close to you before lifting
rather than bending from your back; push heavy items rather
than pulling them; and use a gait belt or ask for assistance when
transferring patients.
2. Constantly check the floors and hallways for obstructions and
possible tripping hazards, such as telephone and computer cables
or boxes.
3. Store supplies inside cabinets rather than on top, where they can
fall off and injure someone; store heavier items on lower shelves
so they do not have to be lifted any higher than necessary.
4. Clean up spills immediately; slippery floors are a danger to
everyone.
5. Use a step stool to reach for things, not a chair or a box that
could collapse or move.
6. Have handrails and grab bars available as needed in the facility;
use them, and encourage patients to use them.
7. Do not overload electrical outlets.
8. Perform a safety check of the facility routinely; look for unsafe
or defective equipment, torn carpeting that could catch heels,
adequate lighting both inside and outside the facility, and so on.
A primary concern for personnel and patient safety is infection
control. Standard Precautions protocols require employers to provide
appropriate and adequate personal protective equipment (PPE). The
goal is to protect staff members from occupational exposure to
blood-borne pathogens while at the same time safeguarding patients
in the facility. OSHA's guidelines include managing sharps and
providing current safety-engineered sharps devices; providing hepa-
titis B immunization free of charge to all employees at risk of expo-
sure to blood and body fluids; using latex-free supplies as much as
possible to prevent allergic reactions in both staff members and
patients; identifying all chemicals in the facility with Safety Data
Sheets (SDSs) and adequately storing potentially dangerous sub-
stances; and performing proper hand hygiene consistently through-
out the workday.
Another serious concern that faces all of us today is the preven-
tion of workplace violence. Unfortunately, rarely does a week go by
without reports of violence in a public place. Employees in a health-
care facility are no exception. We started the text with information
about and exercises in communication techniques in the workplace:
problem solving, therapeutic communication, and assertive behav-
ior. All of these are helpful in dealing with a difficult patient.
Employers should provide training on how to identify potentially
violent patients and should discuss safe methods for managing dif-
ficult patients. Many employers offer training on how to manage
assaultive behaviors. Procedure 12-2 presents a scenario that deals
with employee safety. Follow the steps of this procedure to learn how
to handle such a situation.

OSHA Updates for Signs, Symbols, and Labels
In September, 2013, the Occupational Safety and Health Administration
(OSHA) updated standard formats for safety signs, symbols, and labels. This
is the first standard change since 1971. The revised standards regulate the
color, shape, symbols, and wording that can be used on safety signs and
labels. Figure 12-1 shows some examples af the types af signs, symbols,
and labels that should be used in an ambulatory care office. The four major
types of signs are:
• Danger signs (identify the most severe and immediate hazards)
• Caution signs (warn of possible hazards that require added
precautions)
• Safety instruction signs (communicate directions for safety actions)
• Biologic hazard signs (identify an actual or potential biohazard)
Evaluate the Work Environment to Identify Unsafe Working Conditions and Comply With
PROCEDURE 12-1
Safety Signs and Symbols
Goal: To assess the healthcare facility for possible safety issues and develop asafety plan.
Scenario: Work with apartner to evaluate environmental safety in the laboratory at your school. Record your results and discuss
them with the class. After all members of the class have shared their observations, develop asafety plan for your laboratory.
EQUIPMENT and SUPPLIES
• Pen and paper
• Document or manual on policies and procedures for environmental safety
issues in the facility
PROCEDURAL STEPS
1. Check the floors and hallways for obstructions and possible tripping hazards,
including torn carpets, possible spills, protruding electrical cords, and
so on.
PURPOSE: To prevent accidental falls.
2. Check storage areas to make sure the taps af cabinets are clear and
heavier items have been stored closer to the floor.
PURPOSE: To prevent injuries from items falling off shelves and ta limit
the lifting af heavy items.
3. Assess the location and security of handrails and grab bars placed around
the facility. They should be placed at all stairs, in restrooms, and in any
other areas where staff members or patients may need assistance.
PURPOSE: Handrails and grab bars help safeguard staff members and
patients and provide assistance where needed.
4. Examine all electrical plugs and outlets to prevent electrical overload.
PURPOSE: Overloading electrical outlets could cause a fire.
S. Check all equipment to make sure it is in safe working condition.
CHAPTER 12 Safety and Emergency Practices 285
OSHA specifies the format of each type of sign, the information that must
appear, and where each type of sign must be used. Tags or labels must
contain a signal word ("Danger," "Caution," "Biologic Hazard," "BIOHAZ-
ARD," or the biologic hazard symbol) and a major message, which states a
specific hazard or safety instruction. Employers are required ta train workers
about the information conveyed on safety signs and labels. The signs and
labels use graphic symbols and specific colors to explain the sign's warning
or message so that the problem of language barriers is minimized (see
Procedure 12-1 ).
6. Make sure all lights are working (both inside and outside the facility),
that lighting is adequate, and that light fixtures are in goad condition.
PURPOSE: Adequate lighting bath inside and outside the facility helps
prevent accidents, and faulty fixtures can be a fire hazard.
7. Check the working condition of smoke alarms, and examine all fire
extinguishers.
PURPOSE: To monitor the function of smoke detectors and make sure fire
extinguishers are charged.
8. Make sure evacuation routes are pasted throughout the facility, along with
floor plans with clearly marked exit routes.
PURPOSE: Every roam in the facility must have a map with exit routes
marked an it ta make sure that even those who are unfamiliar with the
facility's flaar plan can safely reach an exit in case of an emergency.
9. Assess the laboratory's compliance with the safety signs, symbols, and
labels required by the Occupational Safety and Health Administration
(OSHA). Are all signs, symbols, labels in place and posted properly?
10. Record your observations and share them with the class.
PURPOSE: To compile a comprehensive list of problem areas.
11. Based an group discussion, develop a plan af action for improving the
safety of the laboratory.
PURPOSE: The student-generated safety plan can be incorporated into the
laboratory's policies and procedures manual.
286 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES
•;;m,inmJitii Manage a Difficult Patient
Goal: To communicate with an angry patient in a safe, therapeutic manner. The following procedure is part of an overall
employee safety plan.
Scenario: You are working at the admissions desk when an extremely angry patient comes storming into the office, screaming
about a mistake on his bill. Although the facility uses an outside billing center, you recognize that you should attempt to help
the patient and try to defuse the situation. Remember: Call 911 immediately and alert any available security if you or one of
your co-workers is threatened with violence.
EQUIPMENT and SUPPLIES
• Patient's record
• Telephone
• Facility's policies and procedures manual
PROCEDURAL STEPS
1. Although it is important to safeguard patients' privacy, do not ask an angry
patient into an isolated room; do not close the door.
PURPOSE: To protect yourself, remain in an open area. If you are in a room
with an angry patient, keep the door open and stand close to the door so
that you can leave the room quickly if necessary.
2. Alert other staff members ta the situation, if possible.
PURPOSE: To have assistance nearby; call 911 immediately if you feel
physically threatened.
3. If you da not feel physically threatened, allow the patient to blow off steam.
PURPOSE: Attempting to interrupt the patient ta give a logical reason for
the problem will only make him angrier. Allowing him to continue to yell
helps him release the anger so that you can work on a reasonable solution
to the problem. Call 911 if at any time you feel threatened.
4. When the patient begins to slaw down, offer supportive statements, such
as, "I understand it is frustrating ta receive a bill you think is unfair."
Continue ta make supportive statements until the patient is calmer (think
af it as the patient screaming his way up a mountain; sooner or later, he
is going to run out of steam; when he begins to slow down, you can then
start offering supportive statements).
Environmental Safety
Environmental safety guidelines include numerous work safety
practices, such as office security, management of smoke detectors
and fire extinguishers, posting of designated fire exit routes, and
securing certain items (e.g., narcotics, dangerous chemicals) in
locked storage areas in the facility. In addition to these concerns,
staff members should constantly be on the alert for possible safety
hazards in and around the building, such as improper lighting,
unlimited access to the facility, and inadequate use of security
systems.
PURPOSE: Providing verbal support helps defuse the situation and gives the
patient the opportunity to become calmer and reach a rational level where
you can discuss the problem.
S. Once you can discuss the situation, ask the patient for the details af the
problem. Gather as much information as possible so you can work together
on a possible solution.
6. After determining the problem, suggest a possible solution to the patient.
For example, tell him that you will contact the billing office with the informa-
tion and will make sure they get back ta the patient as soon as possible.
PURPOSE: Use therapeutic techniques, including restatement, reflection, and
clarification, to gather details and work on a possible solution with the
patient. Make sure you follow up with the action to prevent future
outbursts.
7. Report the incident to your supervisor and document the patient's problem
and the agreed-upon action in the patient's health record, taking care not
to use judgmental statements.
PURPOSE: Documenting the patient's problem and the agreed-upon solution
allows for continuity of care if follow-up is needed. The patient's medical
record is a legal document, and all judgmental statements must be avoided.
8. Discuss your approach to managing the difficult patient at the next staff
meeting. With your supervisor's permission, summarize your approach and
include it as part of the facility's Employee Safety Plan.
PURPOSE: The safety plan should be reviewed frequently, and revisions
should be made as needed.
The medical assistant must be prepared to use a fire extin-
guisher to prevent injury to patients and to protect the medical
facility (Procedure 12-3). An ABC fire extinguisher is effective
against the most common causes of fire, including cloth, paper,
plastics, rubber, flammable liquids, and electrical fires. Most small
extinguishers empty within 15 seconds, so it is important to call
911 immediately if the facility fire is not small and confined. If
the fire is small, no heavy smoke is present, and you have easy
access to an exit route, use the closest fire extinguisher. However,
do not hesitate to evacuate the facility if you believe any danger
exists to yourself or others.

Methods of Fire Prevention and Response
• Store potentially flammable chemicals and supplies according to the
manufacturers' guidelines.
• Inspect electrical equipment and cards throughout the facility; take care
not to overload outlets.
• If a fire is suspected, immediately disconnect oxygen supplies or turn
off oxygen tanks to prevent an explosion.
• Smoke alarms should be located throughout the facility, checked peri-
odically, and replaced as needed.
• Fire safety equipment should be available and current. Fire extinguish-
ers must be inspected at least annually. If an extinguisher is discharged,
it must be replaced immediately.
• Fire extinguishers should be located in multiple sites throughout the
facility and mounted on the wall for easy access.
• If you smell smoke or suspect afire, immediately notify the fire depart-
ment (or call 911) and evacuate the facility. Do not use elevators if a
fire is suspected.
•;;m,inmJiti• Demonstrate the Proper Use of a Fire Extinguisher
Goal: To role-play the safe and proper use of a fire extinguisher.
EQUIPMENT and SUPPLIES
• Portable, office-size ABC fire extinguisher that has been discharged
PROCEDURAL STEPS
Role-play the following with a discharged ABC fire extinguisher.
1. Pull the pin from the handle of the extinguisher.
Each facility should have a policy and procedure in place for
evacuating the building. According to OSHA, the facility's plan first
should identify the situations that might require evacuation, such as
a natural disaster or a fire. The following provisions should be
included in the facility's evacuation plan.
• An emergency action coordinator must be designated, and
all employees must know who this individual is. This person
(usually the office manager) is in charge if an emergency
occurs.
• The coordinator is responsible for managing the emergency at the
facility and for notifying and working with community emer-
gency services.
• Evacuation routes with clearly marked exits must be posted in
multiple locations throughout the facility. Maps of floor diagrams
with arrows pointing to the closest exits are an easy means of
CHAPTER 12 Safety and Emergency Practices 287
CRITICAL THINKING APPLICATION 12-1
Cheryl is in the middle of a busy day; patients are in all of the examination
rooms, and the waiting room is full. She walks past the patient bathroom
and smells smoke. She opens the door and sees smoke and flames coming
from the wastebasket. What should she do? Write down your response to
this scenario and share it with your classmates.
2. Aim the discharge from the extinguisher toward the bottom of the flames.
PURPOSE: Aiming the fire extinguisher directly onto the fire may spread the
flames.
3. Squeeze the handle of the extinguisher so that it begins to discharge.
4. Sweep the extinguisher from side to side toward the base of the fire until
it is out or until fire officials arrive.
S. Check on the safety of all patients and other personnel.
finding the closest door out, even for individuals unfamiliar with
the facility.
• Exit doors must be clearly marked, well lit, and wide enough for
everyone to evacuate.
• Hazardous areas in the facility that should be avoided during an
emergency evacuation must be identified, such as areas where
chemicals and oxygen tanks are stored.
• A meeting place outside the facility must be designated for all
those evacuating to make sure everyone got out of the facility safely.
• Employees should be trained to assist any co-worker or patient
with special needs.
• A designated individual must check the entire facility, including
restrooms, before exiting. He or she must make sure to close all
doors (especially designated fire doors) when leaving to try to
contain the fire or other disaster (Procedure 12-4).
288 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES

Evacuation Levels
Four levels of evacuation are possible, depending on the severity of the need
for evacuation:
Shelter in place: Staff stops all routine activities in preparation for possible
evacuation of the facility; close doors/windows for initial protection
from fire and smoke.
Horizontal evacuation: Patients and staff move away from immediate
danger, but if the facility is located in a multifloor structure, everyone
remains on that floor until it is determined that the entire building
should be evacuated.
Vertical evacuation: Aspecific floor in a building is evacuated vertically
(i.e., toward the ground level) to prepare for evacuation outside.
Total or full evacuation: The facility is completely evacuated (this is used
only as a last resort).

•;;m,inmJiti• Participate in a Mock Environmental Exposure Event: Evacuate a Provider's Office

Goal: To role-play an environmental disaster and implement an evacuation plan.

Scenario: Role-play the following scenario with your lab group: The building next door to the provider's office where you work
is on fire. One member of the group is the designated emergency action coordinator, two individuals are responsible for helping
patients with special needs out of the facility, and one person is designated to be the last to leave after the building is clear. In
acommunity emergency situation, certain staff members may be designated to provide immediate assistance to survivors. Two
medical assistants are sent to help with fire victims. How could medical assistants help in this situation? After the evacuation is
complete, meet in adesignated spot to discuss the process and see whether any aspects of the evacuation plan could be improved.
Document the steps taken throughout the mock environmental event.
EQUIPMENT and SUPPLIES 4. The coordinator designates an employee to shut down immediately any
• Pen and paper combustibles (e.g., oxygen tanks).
• Document ar manual on policies and procedures for evacuation of the facility PURPOSE: To prevent an explosion if the fire spreads.
and response to an environmental disaster S. Using the posted evacuation routes, role-play staff members following floor
plan diagrams to the closest safe exit. Identify any hazardous areas in the
PROCEDURAL STEPS facility that should be avoided during the emergency evacuation. Role-play
1. In an actual emergency, an emergency action coordinator is in charge. staff members assisting patients, especially those with special needs (e.g.,
PURPOSE: All employees must know who this individual is (usually it is individuals in wheelchairs) during the building evacuation.
the office manager) and must follow his or her lead in safely responding PURPOSE: Evacuation routes must be posted throughout the facility, and
to the emergency situation. exit doors must be clearly marked, well lit, and wide enough for everyone
2. The student who is role-playing the emergency action coordinator is to evacuate. The doors facing the building on fire should not be used
responsible for managing the emergency at the facility and for notifying because this could be a hazard.
and working with community emergency services. 6. Role-play the staff member delegated to check that everyone has left the
PURPOSE: The coordinator or someone designated by the coordinator must facility and that fire doors have been closed before he or she leaves the
notify community emergency services of the fire; the coordinator works building.
with emergency services to provide care at the scene. PURPOSE: To make sure the building is clear and that any fire is contained.
3. Fire victims are being cared for across the street, where a triage and This person should leave immediately if there is danger.
treatment center has been set up by the police, fire, and emergency 7. Role-play evacuated personnel and patients meeting in a designated area
responder units in the city. Two students role-play staff members who are to count heads and make sure everyone exited the facility safely.
sent to assist with the victims: PURPOSE: To make sure everyone safely evacuated the facility.
• Use therapeutic communication techniques to calm and care for victims 8. After everyone has been accounted for and the patients are secure, role-
• Implement appropriate Standard Precautions play staff members reporting to the emergency triage area to provide
• Monitor and record vital signs assistance to rescue workers and victims.
• Gather pertinent health histories 9. Discuss with the class the evacuation exercise and response to a com-
• Observe victims for possible complications, such as breathing prob- munity disaster.
lems, shock, angina, and so on 10. Document the specific steps taken during the facility evacuation and your
• Immediately report to emergency responders any life-threatening role in the exercise. What were the strengths and weaknesses of the
changes in a patient's status group's response to an environmental emergency?
• Use first aid skills as needed PURPOSE: To reflect on the learning activity.

DISPOSAL OF HAZARDOUS WASTE
The chapter on Infection Control explained the management of
biohazardous waste; the use of PPE when the potential exists for
exposure to blood and body fluids; the importance of flushing the
eyes with an eye wash unit if they are exposed to potentially infec-
tious or toxic material; and the consistent use of sharps containers.
Regardless of individual responsibilities in the facility, all employ-
ees must be aware of potentially dangerous situations and must
comply with all safety measures to protect themselves and their
patients.
OSHA defines regulated waste as any contaminated item that
might release blood or other potentially infectious material; con-
taminated supplies with dried blood or other potentially infectious
material on their surfaces; contaminated sharps; and waste products
that contain blood or other potentially infectious material. Health-
care facilities must make special arrangements for the disposal of
regulated waste, which often costs as much as 10 times more than
regular garbage disposal. It therefore is important to put only sup-
plies contaminated with blood or body fluids into red bag collection
systems and sharps containers. The following measures should be
used for proper disposal of hazardous materials in the provider's
office.
• Place signs on or near the biohazard container to identify
its purpose and the materials that should be deposited in it.
All biohazardous waste containers should display a biohazard
label.
• Make sure all biohazardous waste containers are covered and have
a foot pedal for opening and closing the container. This prevents
the spread of infectious material and reduces the likelihood that
noninfectious material will be tossed inside. Biohazard containers
should be kept only in treatment areas where contaminated mate-
rials are likely to be produced.
• Place a regular garbage container next to a biohazard container
to encourage staff members to use the biohazard bags only as
needed.
• Place only sharps in sharps containers; gauze, bandages, and so
on belong in a contaminated waste container. Noninfectious
items, such as patient gowns that are not contaminated with
body fluids, and packaging material, belong in the regular
trash.
EMERGENCY PREPAREDNESS
Ambulatory care centers and hospitals may be the first to recognize
and initiate a response to a community emergency. If an infectious
outbreak is suspected, Standard Precautions should be implemented
immediately to control the spread of infection. If the problem has
the potential to affect a large number of individuals in the com-
munity (e.g., suspected food contamination), a communications
network should be established to notify local and state health depart-
ments and perhaps federal officials. Your employer may participate
in an annual community disaster preparedness drill designed to help
facilities improve their response to natural disasters and other
emergencies.
Community preparation and response to emergencies are
managed by several agencies, including the Office of Civil Defense,
CHAPTER 12 Safety and Emergency Practices 289
Local Emergency Management Agency (LEMA), Emergency Ser-
vices, or Homeland Security. Local governments are responsible for
creating a system that coordinates police, fire, emergency medical
services, public health, and area healthcare response to community-
wide emergencies. These agencies develop an all-hazards response
plan that would be appropriate for any community emergency. Local
officials can turn to state, regional, or federal officials for assistance
as needed.
Every healthcare facility should have a policy that includes spe-
cific procedures for the management of emergencies on site. When
a new employee starts on the job, part of the orientation process is
to review the site's policies and procedures manual. As a new
employee, be sure to get answers to any questions you have about
emergency management in that particular facility.
Staff members should discuss emergencies that may occur and
should have an emergency action plan for rapid, systematic interven-
tion. For instance, local industries may present unique problems that
call for very specialized care. Plan for these, and ask the provider's
advice on the procedures to follow and the supplies to have on hand.
If the facility has several employees, each should be assigned specific
duties in the event of an emergency. Organization and planning
make the difference between systematic care for patients and com-
plete chaos.
Emergency Plan for a Natural Disaster or Other
Emergency in an Ambulatory Care Facility
• Evacuate the facility as needed.
• Include procedures for the protection of patients' health records. If the
facility uses electronic health records (EH Rs), make sure this informa-
tion is backed up on offsite systems.
• In the case of a community emergency, provide care to the extent
possible within the facility.
• Coordinate services between the ambulatory facility and other
local healthcare systems, including hospitals and public health
departments.
• Provide staff and supplies as needed to help in a community
emergency.
• Maintain up-to-date phone trees to notify staff members of an
emergency.
• Educate patients in emergency preparedness.
CRITICAL THINKING APPLICATION 12-2
Achemical plant is located about three blacks from Dr. Bendrs office. The
office staff is brainstorming ideas about what should be done if an accident
occurs at the plant. Based on what you have learned so far about emergency
preparedness, what do you think should be included in the office's emer-
gency plan?
Community Resources for Emergency Preparedness
Most communities have an emergency medical services (EMS)
system. This system includes an efficient communications network
290 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES
(e.g., the emergency telephone number 911), well-trained rescue
personnel, properly equipped ambulances, an emergency facility that
is open 24 hours a day to provide advanced life support, and a
hospital intensive care unit for victims.
More than 100 poison control centers in the United States are
ready to provide emergency information for the treatment of victims
of poisoning. Every healthcare facility is required to post a list of
local emergency numbers. This list should be kept in plain sight and
should be known to all office personnel. A good place to post this
vital information is next to all the phones in the facility. Include on
the list the numbers for the local EMS system, poison control center,
ambulance and rescue squad, fire department, and police depart-
ment (Procedure 12-5).
Contact Information for Emergency Preparedness
Keep the following telephone numbers readily available in the facility:
• Local hospital numbers, including the emergency department, infec-
tion control officer, administration contacts, and public affairs office
• Local and state health department numbers
• Centers for Disease Control and Prevention (CDC) Emergency
Response Office
• Telephone: 800-232-4636
• Website: www.cdc.gov/phprjindex.htm
The Centers for Disease Control and Prevention (CDC) recom-
mends that all healthcare facilities be aware of possible agents of
bioterrorism, including anthrax, botulism, plague, and smallpox.
The provider is responsible for diagnosing and reporting any sus-
pected cases, but the medical assistant may be involved in patient
care and certainly will participate in preventing the spread of infec-
tion in the facility. As with any suspected infectious disease, Standard
Precautions should be used to control disease transmission. These
precautions should be implemented with all patients, regardless of
their diagnosis or possible infection status.
Infection control procedures for bioterrorism threats include the
following:
• Sanitize your hands routinely.
• Wear disposable gloves when contamination with blood and
body fluids is possible.
• Use masks/eye protection or face shields if you may be
splashed by secretions or blood and body fluids.
• Wear impermeable gowns to protect your skin and clothes as
needed; remove them promptly and wash your hands to
prevent transmission of infectious material.
• Sanitize, disinfect, and sterilize equipment, supplies, and envi-
ronmental surfaces.
• Dispose of contaminated waste in appropriate biohazard
containers.
Another resource that can aid with community emergency
preparedness is the Laboratory Response Network (LRN), which
coordinates with the DHHS, the CDC, the Federal Bureau oflnves-
tigation (FBI), and the Association of Public Health Laboratories
(APHL) to ensure an effective laboratory response to bioterrorism
threats. The LRN links state and local public health laboratories, and
veterinary, agriculture, military, and water- and food-testing labora-
tories to protect U.S. citizens from bioterrorism, chemical terrorism,
and other public health threats.
Community emergency preparedness plans are required by the
federal government so that a coordinated response is in place if a
natural disaster occurs. The federal government requires all health-
care facilities, including private providers' offices, to be prepared to
provide medical services and to contribute medical supplies if a
natural disaster or other emergency occurs in the area.
Emergency preparedness plans are designed to coordinate the care
provided by all healthcare facilities and agencies in the community,
including local emergency management agencies, EMS, fire depart-
ments, law enforcement agencies, the American Red Cross, and the
National Guard. Each of these groups can provide crucial services
during a community emergency.
Medical assistants also can contribute to rescue and emer-
gency efforts. Services that might be performed by trained medical
assistants include providing emergency first aid at the site of a
disaster; conducting patient interviews in an empathetic manner
while using therapeutic communication to help calm victims and
gather important health-related information; helping with mass
vaccination efforts or antibiotic distribution; performing docu-
mentation and electronic health record management; ensuring
compliance with the procedures required by Standard Precau-
tions; assisting with patient education efforts; and perform-
ing phlebotomy and laboratory procedures according to their
skill level.
Psychological Aspects of an Emergency Situation
Everyone involved in an emergency situation experiences acertain amount
of anxiety and stress. The Centers for Disease Control and Prevention (CDC)
recommends that the following actions be included in afacility's emergency
preparedness plan to minimize these negative psychological effects on both
healthcare workers and patients:
• Provide fact sheets for employees and patients to help them under-
stand the dangers of certain emergencies, and encourage employee
participation in disaster drills.
• Plan in advance for effective communication and action in response
to an emergency; the plan should include methods for coordinating
a response with local and state agencies and media sources.
• Put into place a method for clearly explaining emergency situations
to patients and healthcare workers; offer immediate evaluation and
treatment of an infectious outbreak.
• Treat acute anxiety with reassurance and explanation; provide
follow-up counseling for employees as needed.
Further information on emergency preparedness can be found at the
following CDC websites:
• Emergency preparedness planning: www.bt.cdc.gov/planning
• Coordinating Office for Terrorism Preparedness and Emergency
Response (COTPER): www.bt.cdc.gov

•;;m,inmJitii Maintain an Up-to-Date List of Community Resources for Emergency Preparedness
Goal: To develop and maintain alist of community agencies that would respond to anatural disaster or other emergency.
Scenario: Your employer asks you to develop alist of groups in your community that are part of the community-wide emergency
preparedness plan that has been mandated by the state and federal governments. Using multiple resources, develop a compre-
hensive list of emergency services for your area.
EQUIPMENT and SUPPLIES
• Telephone
• Internet access
• Pen and paper
• Electronic record
PROCEDURAL STEPS
1. Start with an online search for the area office of the Local Emergency
Management Agency (LEMA), which is sponsored by the Department of
Homeland Security. If available, investigate the LEMA website for informa-
tion about the emergency preparedness plan in your community. You can
begin the search at the website www.ready.gov; the Federal Emergency
Management Agency (FEMA) website is www.fema.gov.
PURPOSE: To develop emergency preparedness plans by starting with the
federal and state governments.
ASSISTING WITH MEDICAL EMERGENCIES
First aid is the immediate care given to a person who has been
injured or has suddenly taken ill. Knowledge of first aid and related
skills often can mean the difference between life and death, tempo-
rary and permanent disability, or rapid recovery and long-term hos-
pitalization. The medical assistant may be responsible for initiating
first aid in the office and continuing to administer first aid until the
provider or the trained medical team arrives. Every medical assistant
should successfully complete a course for the professional in cardio-
pulmonary resuscitation (CPR) and should continue to hold a
current CPR card as long as he or she is employed.
Basic knowledge of CPR and life support skills needs to be
updated regularly, because procedures change as new techniques
are developed. For example, both the American Red Cross and
the American Heart Association (AHA) now recommend training
on automated external defibrillators (AEDs) for all healthcare
workers.
Medical assistants need up-to-date training in current emergency
practices. They should encourage their local professional chapters to
offer workshops on the management of emergencies in an ambula-
tory care practice, in addition to community-wide emergency pre-
paredness. Being prepared for both types of emergencies is important.
The facility's employees must be ready to respond both to emergen-
cies on site and to natural disasters or other emergencies that affect
the community.
Medical assistants are not responsible for diagnosing emergencies,
especially over the telephone, but they are expected to make
CHAPTER 12 Safety and Emergency Practices 291
2. Gather contact information for local police, fire, and emergency medical
services (EMS); post this information next to all telephones in the facility.
PURPOSE: To ensure that emergency services contact information is imme-
diately available in case of an emergency in the facility.
3. Investigate services provided by your local Public Health office and the
American Red Cross.
PURPOSE: To coordinate services available to potential victims in the
community.
4. Organize the information gathered about community resources for emer-
gency preparedness. With your supervisor's approval, post a copy of this
information in all appropriate locations in the facility. Prepare a database in
the computer that can be updated as the information changes.
decisions about emergency situations on the basis of their medical
knowledge and training. If any doubt exists about how to manage a
particular situation or emergency phone call, the medical assistant
should not hesitate to consult the provider, the office manager, or
some other, more experienced member of the healthcare team.
The Medical Assistant's Role in Performing
Emergency Procedures
• Perform only the emergency procedures for which you have been
trained.
• If an emergency occurs in the facility, notify the provider.
• If a provider cannot be located, immediately contact the local emer-
gency medical services team (EMS or 911).
Emergency Supplies
Emergency supplies consist of a properly equipped "crash cart" or
box of items needed for a variety of emergencies (Figure 12-2). The
contents vary to some degree, depending on the types of emergencies
the particular office might expect to encounter and whether pediatric
patients are seen in the practice. Emergency supplies should be kept
in an easily accessible place that is known to all personnel in the
office, and the supplies should be inventoried regularly. Expiration
dates of medications and sterile supplies must be checked weekly or
monthly, along with the status of available oxygen tanks and related
292 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES

the treatment of allergic reactions and for anaphylaxis need to be

available to treat any allergic responses to medications administered
in the facility. Such antihistamines include Benadryl for minor reac-
tions and Solu-Medrol, a corticosteroid, for severe anaphylactic
reactions.
Other medications also may be found in a crash cart. For example,
isoproterenol (e.g., Isuprel, Medihaler-Iso, Norisodrine), an anti-
spasmodic used to treat bronchospasms (e.g., as in an asthma attack),
also is effective as a cardiac stimulant. Phenobarbital and diazepam
(Valium) are used for convulsions and/or sedative effects. Furose-
mide (Lasix) is used for CHE Glucagon is used primarily to coun-
teract severe hypoglycemic reactions (low blood glucose) in patients
with diabetes who are taking insulin.

Basic Emergency Supplies

Equipment
• Adhesive tape in 1- and 2-inch widths
• Airways (variety of types and sizes)
FIGURE 12-2 Office emergency cart with defibrillator. Drawers are marked for easy retrieval of • Alcohol wipes
emergency supplies.
• Ambu bag with assorted sizes of facial masks
• Antimicrobial skin ointment
materials. The cart should be replenished with fresh supplies after • Bandage scissors
every use. Each time crash cart supplies are checked, a log must be • Cotton balls and cotton swabs
completed and signed for legal purposes. • Cardiopulmonary resuscitation (CPR) masks (adult and pediatric)
Emergency pharmaceutical supplies should include certain basic • Defibrillator
drugs, such as epinephrine, which has multiple uses in emergency • Elastic bandages in 2- and 3-inch widths
situations. As a vasoconstrictor, it controls hemorrhage, relaxes the
• Filter needles
bronchioles to relieve acute asthma attacks, is administered for an
• Flashlight with batteries
acute anaphylactic reaction, and is an emergency heart stimulant
used to treat shock. Epinephrine should be available in a ready-to-use
• Gauze pads, 2 x 2- and 4 x 4-inch widths, and roller bandage (sterile
cartridge syringe and needle unit. These units are supplied in 1-mL and nonsterile)
cartridges. • Gloves (sterile and nonsterile) in multiple sizes
Other drugs used include atropine, digoxin (Lanoxin), nitroglyc- • Hot and cold packs (instant type)
erin (Nitrostat), lidocaine (Xylocaine), and sodium bicarbonate. • Intravenous catheters, tubing, solutions (variety of types, including D5W
Atropine reduces secretions, increases the respiratory rate and heart and Ringer's lactate), and tourniquet
rate, and is a smooth muscle relaxant. It is administered in a cardiac • Laryngoscope with blades
emergency for asystole, or it can be used to treat bradycardia. • Lubricant
Digoxin is a cardiac drug used to treat arrhythmia and congestive • Endotracheal tubes (variety of sizes with stylets)
heart failure (CHF); it is good for emergency use because it has a • Personal protective equipment (PPE), including impervious gowns,
relatively rapid action. Nitroglycerin is a vasodilator that is given to
splash guards or goggles, and booties
relieve angina; it acts by dilating the coronary arteries so that an
• Portable oxygen tank with regulator, mask, and nasal cannula
increased volume of oxygenated blood can reach the myocardium.
Lidocaine is used intravenously to treat a cardiac arrhythmia and
• Roller gauze (Ace bandages and gauze dressing) in various sizes
locally as an anesthetic, and sodium bicarbonate corrects metabolic • Sharps container
acidosis, which typically occurs after cardiac arrest. Many of the • Sphygmomanometer (pediatric and adult regular and large sizes)
medications administered during a medical emergency are given • Splints (various sizes)
intravenously (IV), which is outside of the medical assistant's scope • Sterile dressings (miscellaneous sizes, including two abdominal pads)
of practice. • Steri-Strips, dermal glue, or suturing material
Emergency medical supplies also should include an emetic, such • Suction machine and catheters
as syrup of ipecac, which causes vomiting soon after the syrup is • Syringes and needles (assorted sizes and gauges)
swallowed, and activated charcoal, an antidote that is swallowed to • Tongue blades
absorb ingested poisons. Narcan, an antidote given intravenously for • Tubex cartridge system
narcotic drug overdoses, is administered when indicated to raise
• Venipuncture supplies and butterfly units
blood pressure and increase the respiratory rate. Antihistamines for
 CHAPTER 12 Safety and Emergency Practices 293

Medications
• Activated charcoal (bottle of 29 to 50 g)
• Antihistamine (injectable and oral)
• Atropine
• Dextrose
• Diazepam (Valium)
• Digoxin (Lanoxin), injectable
• Diphenhydramine (Benadryl)
• Epinephrine (Adrenalin), injectable
• Furosemide (Lasix)
• Glucagon and/or glucose tablets
• Ipecac syrup
• lsoproterenol (lsuprel), injectable
• Lidocaine (Xylocaine), injectable and spray
• Naloxone (Norean), injectable FIGURE 12-3 Fully automated external defibrillator (AED).
• Nitroglycerin tablets
• Phenobarbital, injectable
• Sodium bicarbonate, injectable
• Methylprednisolone (Solu-Medrol), injectable
• Sterile water and saline for injection

Defibrillators
The medical assistant may be required to assist the healthcare team
with defibrillation of emergency patients. Defibrillation is indicated
when a patient is in ventricular fibrillation (VF). VF is a severe
cardiac arrhythmia that is caused by uncoordinated, rapid firing of
the electrical system of the heart, which makes it impossible for the
ventricles to empty. In the absence of ventricular emptying, the
patient has no pulse, blood pressure drops to zero, and the patient
could die within 4 minutes unless help is given immediately.
Defibrillators are devices that send an electrical current through
the myocardium by means of handheld paddles (in a healthcare
facility) or self-adhesive pads applied to the chest. This electrical
shock causes momentary asystole, giving the heart's natural pace-
maker an opportunity to resume the heart rate at a normal rhythm.
An automated external defibrillator has a computerized system
that analyzes a cardiac rhythm and delivers voice-prompt instruc-
tions on how to operate the device (Figure 12-3 and Procedure
12-6). AEDs use self-adhesive pads that record and monitor the
cardiac rhythm, and the device instructs the rescuer when to deliver
the electrical charge. The apex-anterior position is the most com-
monly used pad position, with the anterior (sternum) pad placed
to the right of the upper sternum, and the apex pad placed under
the individual's left nipple at the left middle axillary line (Figure
12-4). To defibrillate a female individual, the apex pad is placed next
to or underneath the left breast. The AED self-adhesive pads are
packaged with expiration dates so these should be checked
periodically.
Precautions for Automated External Defibrillators
• Neither the individual nor the rescuer should be in contact with
any metal during defibrillation. Do not place the AED pad over
jewelry, and remove the patient's glasses to prevent injuries.
FIGURE 12-4 Connect the adhesive pads to the automated external defibrillator (AED) cables;
apply the pads to the patient's chest at the upper right sternal border and at the lower left ribs over
the cardiac apex.
• When available, a pediatric-dose AED system should be used
for children 1 to 8 years of age (it should not be used on infants
younger than 1 year old). These systems deliver a reduced
shock dose for victims up to about 8 years old or weighing 55
pounds.
• All clothing (including bras) must be removed; pads must be
applied directly to the skin. If the individual has a great deal of
hair on the chest, try to push the hair aside before applying the
pads; or, apply the pads and quickly remove them to remove
hair from the area, then reapply new pads. The machine
will prompt you by stating "Check electrode" if the connection
is poor.
• To prevent burns, make sure the individual is lying on a dry
surface and the chest is dry before applying the pads.
• If the patient has an implanted defibrillator or pacemaker, it will
be obvious from the bulged area under the surface of the skin on
the chest. Apply the AED pads at least 1 inch away from implants
to prevent interference.
294 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES

Maintain Provider/Professional-Level CPR Certification: Use an Automated External

PROCEDURE 12-6
Defibrillator (AED)

Goal: To defibrillate adult victims with cardiac arrest. Most adult victims in sudden cardiac arrest are in ventricular fibrillation.
The survival rate for victims with ventricular fibrillation is as high as 90% when defibrillation occurs within the first minute of
collapse; however, the survival rate declines 7% to l0% with every minute defibrillation does not occur.
EQUIPMENT and SUPPLIES 4. All rescuers must clear away from the victim. Press the SHOCK button if the
• Automated external defibrillator (AED) for practice machine is not automated. You may repeat 3 analyze-shock cycles.
• Approved mannequin S. Deliver l shock, leaving the AED attached, and immediately perform car-
diopulmonary resuscitation (CPR), starting with chest compressions.
PROCEDURAL STEPS 6. After 5cycles (about 2 minutes) of CPR, repeat the AED analysis and deliver
These steps are to be performed only on an approved mannequin. another shock, if indicated. If a nonshockable rhythm is detected, the AED
If the healthcare worker witnesses a cardiac arrest, an automated external should instruct the rescuer to resume CPR immediately, beginning with chest
defibrillator (AED) should be used as soon as possible. If cardiopulmonary compressions.
resuscitation (CPR) has already been started, continue performing CPR until the 7. If the machine gives the No Shock Indicated signal, assess the victim. Check
AED machine is turned on, pads are applied, and the machine is ready. the carotid pulse and breathing status and keep the AED attached until
1. Place the AED near the victim's left ear. Turn on the AED. emergency medical services (EMS) arrives.
2. Attach electrode pads to the victim's bare dry chest as pictured on the AED. PURPOSE: Continue to monitor breathing and circulation because these can
Place the electrodes at the sternum and apex of the heart. Make sure the stop at any time. Keep the AED pads in place to diagnose ventricular fibril-
pads are in complete contact with the victim's chest and that they da not lation quickly if it occurs.
overlap (see Figure 12-4).
3. All rescuers must clear away from the victim. Press the ANALYZE button.
The AED analyzes the victim's coronary status, announces whether the
victim is going ta be shocked, and automatically charges the electrodes
(Figure 1).

111·
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©Elsevier

GENERAL RULES FOR EMERGENCIES
A medical assistant will face two types of emergencies in an
ambulatory care practice: office emergencies and home emergen-
cies. Common office emergencies and their management are
discussed later in this chapter. Besides dealing with actual emer-
gency situations on site, a medical assistant frequently is the first
person to interact with patients facing potential emergencies at
home. It is estimated that one third of the telephone calls
received in a provider's office involve some type of problem that
requires attention. An immediate decision must be made on how
to manage that problem: by giving home care advice, scheduling
an appointment, or, in life-threatening cases, notifying EMS.
Many facilities, under the direction and approval of the provider,
create a reference list of appropriate questions for specific patient
complaints.
Regardless of how emergency phone calls are managed in the
facility where you work, consider the following general rules when
faced with an emergency:
• It is most important to stay calm. Reassure the patient and
make him or her as comfortable as possible.

• Assess the situation to determine the nature of the emergency.
Decide whether the need is immediate. This decision requires
calm judgment and medical knowledge.
• Obtain as much information as possible to determine the
appropriate action.
• Immediately refer any concerns to the office supervisor or
provider.
Telephone Screening
Each time the phone rings in a healthcare facility, a person with a
possible life-or-death situation may be on the other end of the line.
One of the most important tasks performed by medical assistants
every day is answering the phones and managing patients' needs
efficiently and appropriately. The following emergency action prin-
ciples serve as a guide for managing emergency phone calls in an
ambulatory care practice.
• If the patient's situation is life-threatening, activate EMS/911.
• Never put a caller with a life-threatening emergency on hold, and
always be the last to hang up.
• Remain on the line until help arrives and you have talked to EMS
personnel.
• Immediately record the names of the caller and the patient,
the location, and the phone number in case the connection
is lost.
• If you are unsure how to manage the emergency situation, contact
the provider.
• If the patient is referred to an emergency department (ED), call
the ED to notify the staff of the patient's arrival, and make a
follow-up call to determine the patient's condition.
• Gather as much information as possible about what is wrong with
the patient and when the problem started. Obtain details about
the patient's condition, including the following:
Perform Patient Screening Using Established Protocols: Telephone Screening and
PROCEDURE 12-7
Appropriate Documentation
Goal: To assess the direction of emergency care and to document information appropriately in the patient's record.
Scenario: Cheryl is working with the telephone screening staff members when they receive acall from the mother of a5-year-
old patient. The mother reports that her son fell and cut his arm. What type of information should Cheryl gather about the iniury?
What action should be taken? How should the incident be documented?
EQUIPMENT and SUPPLIES
• Patient record
• Notepad and pen or pencil
• Facility's emergency procedures manual
• Computer scheduling program
• Area emergency numbers
PROCEDURAL STEPS
1. Stay calm and reassure the caller.
PURPOSE: To enable you to gather accurate details about the patient's
condition.
CHAPTER 12 Safety and Emergency Practices 295
• What is the patient's level of consciousness? Alert, responsive,
lethargic, or confused? Did the patient lose consciousness at
any time? If so, for how long?
• What is the character of the patient's respirations (and pulse,
if the caller is able to determine this): normal, rapid, shallow,
or difficult?
• Is there bleeding? If so, how much and from where?
• Is there a suspected head or neck injury? If so, has the patient
been moved? Is there a suspected fracture? Where?
• Does the patient have a history of this problem?
• Any there other symptoms, such as fever, vomiting, diarrhea,
or pain?
• Obtain details about what has been done for the patient. For
example:
• Medication-What, when? Dose, effectiveness? Current
allergies?
• Thoroughly document the information gathered and any actions
taken, including notification of EMS, whether the patient was
sent to the ED or an appointment was scheduled, all home care
recommendations, and whether the provider was notified and
when.
Based on the outcome of the telephone interaction, a decision is
made on when the provider will see the patient (Procedure 12-7).
Emergency calls require activation of EMS or immediate attention
as soon as the patient arrives. Urgent calls require a same-day
appointment if the patient has an acute condition or is in severe
discomfort. Such cases would include a young child with a high fever
or a patient who complains of moderate to severe abdominal pain.
A new patient will have to be worked into the day's schedule, which
may cause a delay in currently scheduled appointments. Patients
with other, less urgent problems can be scheduled for appointments
within the next 3 to 4 days.
2. Verify the identity of the caller and the injured patient.
3. Immediately record the name of the caller and the patient, their location,
and the phone number.
PURPOSE: To be able to contact the caller if the connection is lost.
4. Determine whether the patient's condition is life-threatening. Quantify the
amount of blood loss, whether the patient is alert and responsive, and
whether breathing is normal. Notify emergency medical services (EMS) if
necessary.
PURPOSE: Notify emergency services immediately if the patient is in
danger.
296 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES
•;;m,ammitii -,;ontinued
5. If EMS is notified, stay on the line with the caller until EMS personnel
arrive at the scene.
PURPOSE: Never break a phone connection in the case of a life-threatening
emergency.
6. If EMS is not needed, gather details about the injury to determine whether
the patient can be seen in the office or should be referred to an emergency
department (ED). Consider the following questions:
• Is there a suspected head or neck injury? Has the patient been
moved?
• Is there a possible fracture? If so, where?
• Is bleeding present? Can it be easily controlled?
• Are there any other symptoms?
• Is there anything pertinent in the patient's health history that would
complicate the situation?
• Has the caller administered any first aid? If so, what was done?
7. Based on the information gathered, determine when the patient
should be seen in the office if he or she has not been referred to
an ED.
Management of On-Site Emergencies
An emergency can occur at any time to anyone. Always follow
Standard Precautions when you are at risk for coming into contact
with blood or body fluids. When an emergency occurs, it is impos-
sible to determine the level of infection. All body fluids must be
considered infectious, and appropriate precautions must be taken to
prevent cross-contamination. If the situation is life-threatening,
notify EMS and stay with the patient until you are relieved by the
EMS provider or the provider in your office. It is important to docu-
ment all details of the incident in the patient's health record.
Documentation of an On-Site Emergency
l. Patient's name, address, age, and health insurance information
2. Allergies, current medications, and pertinent health history
3. Name and relationship of any person with the patient
4. Vital signs and chief complaint
5. Sequence of events, beginning with how the problem occurred, any
changes in the patient's overall condition, and any observations made
about the patient's condition
6. Details about procedures or treatments performed on the patient
CRITICAL THINKING APPLICATION 12-3
Cheryl is working the front desk when a patient comes into the office
limping. She tells Cheryl that she fell in the parking lot and hurt her ankle.
Cheryl helps the patient into an exam room and begins to interview her.
Role-play the situation with a classmate and make a list of at least l 0
questions Cheryl should ask the patient.
PURPOSE: Most emergencies are scheduled for an immediate office visit.
This may require altering the current appointment schedule.
8. At any point in this process, do not hesitate to consult the provider or
experienced staff or refer to the facility's emergency procedures manual
to determine how to manage the patient's problem.
9. Always allow the caller to hang up first, just in case more information or
assistance is needed.
10. Document the information gathered, the actions taken or recommended,
any home care recommendations, and whether the provider was
notified.
PURPOSE: To have a legal record of the management of the emergency
and a comprehensive description of the patient's condition and the recom-
mended management.
7/13/20- l :25 PM: Pt's mother reports child fell against a window and lacer-
ated his arm. Bleeding is moderate but controlled. No reported signs of dyspnea
or altered consciousness. Mother will bring child to office immediately for pro-
vider assessment. Cheryl Skurka, (MA (AAMA)
Life-Threatening Emergencies
If a patient in the facility shows any signs of unresponsiveness, the
provider must be brought to the patient immediately. If no provider
is available in the facility, EMS must be activated. Even when a
provider is present, the provider may order you to call 911 for
immediate emergency care. Put on gloves before you begin to assess
the patient, because any emergency situation may involve exposure
to blood or body fluids.
Unresponsive Patient
If a patient is able to talk to you, he or she has an open airway. If
the patient does not respond to a simple question (e.g., "Are you
OK?"), gently shake the person's shoulder to check responsiveness.
If the patient does not respond, you must assume that the patient is
unconscious. Immediately call for help and activate EMS if that is
office policy.
To care for an unresponsive patient, first assess the patient's res-
pirations to determine whether the person is breathing. When the
patient collapsed, the tongue may have gone limp and occluded
the trachea. Just by changing the individual's position and opening
the airway, you may provide all the assistance the patient needs to
breathe independently.
If the patient is face down, roll the victim onto his or her back
while supporting the head, neck, and back. Apply the head tilt-chin
lift movement to open the airway. The tongue is attached to the
lower jaw, so moving the jaw forward automatically opens the
patient's airway. If a head or neck injury is suspected, the neck should
be manipulated as little as possible; therefore, the airway should be
open with the jaw-thrust maneuver. Both of these actions relieve
possible obstruction of the trachea by the tongue.

Check for breathing or only gasping for breath while checking
the carotid pulse at the same time for 10 seconds. Look for a rise in
the chest while listening or feeling for air exchange (Figure 12-5).
Breathing may stop suddenly for a variety of reasons, including
shock, disease, and trauma. If no breaths are detected but there is a
pulse, artificial ventilation must be started immediately because
death can occur within 4 to 6 minutes. Barrier devices should be
kept on hand for artificial respiration (Figure 12-6), and these should
be used if rescue breaths are required (Procedure 12-8).
Administer one breath every 5 to 6 seconds (about 10 to 12
breaths per minute). Check the carotid pulse about every 2 minutes.
If there is no pulse, begin chest compressions immediately at a ratio
of30 compressions to 2 breaths with about 100 to 120 compressions
per minute.
FIGURE 12-5 Checking for breathing in an unconscious patient.
FIGURE 12-7 A, In an adult, check for a carotid pulse. B, In an infant, check for a brachia! pulse.
CHAPTER 12 Safety and Emergency Practices 297
The AHA uses the acronym CAB (compressions, airway, breath-
ing) to help people remember the order for performing the steps of
CPR (see Procedure 12-8).
When both breathing and pulse stop, the victim has suffered
sudden death. Sudden death has many causes, including heart
disease, choking, drowning, poisoning, suffocation, electrocution,
and smoke inhalation. CPR must be started immediately to attempt
to revive the patient and to prevent permanent damage to body
organs, especially the brain. Continue CPR until the victim begins
to move, an AED is available and ready to use, professional help
arrives, or you are too exhausted to continue. If the patient has a
pulse but is not breathing, continue rescue breathing and occasion-
ally monitor the pulse until help arrives.
For specific procedures and precautions in the management of
respiratory and cardiac emergencies, refer to the Standard First Aid
Manual of the American Red Cross or the American Heart Associa-
tion CPR Manual, or those organizations' websites. As stated earlier,
all healthcare workers should have a current Certification for the
Professional in CPR.
FIGURE 12-6 Cardiopulmonary resuscitation (CPR) mouth barriers.
298 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES

Maintain Provider/Professional-Level CPR Certification: Perform Adult Rescue Breathing

PROCEDURE 12-8
and One-Rescuer CPR; Perform Pediatric and Infant CPR

Goal: To restore breathing and blood circulation when respiration or the pulse (or both) has stopped.

EQUIPMENT and SUPPLIES

8. Bring your shoulders directly over the victim's sternum as you compress
• Disposable gloves downward, keeping your elbows locked (Figure 2).
• Cardiopulmonary resuscitation (CPR) ventilator masks for adults, children,
and infants
• Approved mannequins
PROCEDURAL STEPS
These steps are to be performed only on approved mannequins.
CPR on an Adult
1. Establish unresponsiveness. Tap the victim and ask, "Are you OK?"
PURPOSE: To determine whether the victim is conscious.
2. If unresponsive, shout for help. Activate the emergency response system.
Put on gloves and get a ventilator mask.
PURPOSE: As soon as it is determined that an adult victim requires
emergency care, activate emergency medical services (EMS). Most adults
with sudden, nontraumatic cardiac arrest are in ventricular fibrillation. The
time from collapse to defibrillation is the single most important predictor
af survival.
3. Put the person on his or her back on a firm surface.
4. If an AED is immediately available, deliver 1 shack if instructed by the
device, then begin CPR. 9. Use your upper body weight (not just your arms) as you push straight
S. If an AED is not available, check for breathing or only gasping to breathe down on the sternum at least 2 inches but no more than 2.4 inches in
while at the same time checking the carotid pulse for 10 seconds. an adult victim. Relax the pressure on the sternum after each compression,
6. If there is no pulse, start chest compressions. Kneel at the victim's neck but do not remove your hands from the sternum.
and shoulders a couple of inches away from the chest. Place the heel of PURPOSE: The depth of compression is needed ta circulate blood through
the hand over the lower part af the sternum, between the nipples but the heart. Movement af the hands may injure the victim. Relieving the
above the xiphoid process. pressure on the chest between contractions allows the heart to completely
7. Place your other hand an top af the first and interlace or lift your fingers fill with blood before the next compression.
upward off the chest (Figure 1). 10. After performing 30 compressions (at a rate of about 100-120 compres-
PURPOSE: This position gives you the most control, allowing you to avoid sions per minute), perform the head tilt-chin lift maneuver ta open the
injuring the victim's ribs as you compress the chest. airway. Tilt the victim's head by placing one hand an the forehead and
applying enough pressure to push the head back; with the fingers af the
other hand under the chin, lift up and pull the jaw forward. Look, listen,
and feel for signs of breathing. Place your ear over the mouth and listen
for breathing. Watch the rising and falling of the chest for evidence af
breathing. If breathing is absent ar inadequate, open the airway and place
the ventilator mask over the victim's mouth and nose (Figure 3).
PURPOSE: To open the airway and determine whether the victim is breath-
ing. Give 2 breaths, each breath delivered over 1 second, holding the
ventilator mask tightly against the face while tilting the victim's chin up
to keep the airway open. Remove your mouth from the mouthpiece
between breaths to allow time for the patient to exhale between breaths.

•;;mHmhiiti=I -continued
11. Check the patient's pulse (at the carotid artery for an adult or older child;
at the brachial artery for an infant). If a pulse is present, continue rescue
breathing (l breath every 6 seconds-about l Obreaths per minute). If
no signs of circulation are present, begin cycles of 30 chest compressions
(at a rate of about l 00-120 compressions) followed by 2 breaths.
12. If the person is still not responding after 5 cycles (about 2 minutes) and
an AED is now available, apply it and follow the prompts. Administer l
shock, then resume CPR, starting with chest compressions, for 2 more
minutes before administering a second shock. Continue 30: 2 cycles of
compressions and ventilations. If an AED is not available, continue CPR
until the person shows signs of movement or EMS personnel take over.
CPR on a Child
The procedure for giving CPR to a child ages l through 8 is essentially the same
as that for an adult. The differences are as follows:
• Perform 5 cycles of compressions and breaths on the child (30: 2 ratio,
about 2 minutes) before calling 911 or the local emergency number or
using an AED. If another person is available, have that person activate
EMS while you care for the child.
PURPOSE: It is important to provide immediate circulation of oxygenated
blood to a child to prevent brain damage. Most pediatric cardiac arrests
occur because of a secondary problem, such as airway occlusion, rather
than a cardiac problem. If you know there is an airway obstruction,
clear the obstruction and then proceed with CPR (Figure 4).
CHAPTER 12 Safety and Emergency Practices 299
• Use only one hand to perform chest compressions.
PURPOSE: The pediatric sternum requires less force to achieve the
needed depression.
• Breathe more gently.
• Use the same compression-to-breath ratio as used for adults (30 com-
pressions followed by 2 breaths per cycle); after 2 breaths, immediately
begin the next cycle of compressions and breaths.
• After 5 cycles (about 2 minutes) of CPR without response, apply an
AED if available. Use pediatric pads for children ages l through 8; if
pediatric pads are not available, use adult pads. Do not use an AED on
children younger than age l. Administer l shock, if instructed to do so,
then resume CPR, starting with chest compressions, for 2 more minutes
before administering a second shock.
• Continue until the child responds or help arrives.
Infant Cardiac Arrest
Infant cardiac arrest typically is caused by lack of oxygen from drowning or
choking. If you know the infant has an airway obstruction, clear the obstruction;
if you do not know why the infant is unresponsive, perform CPR for 2 minutes
(about 5 cycles) before calling 911 or the local emergency number. If another
person is available, have that person call for help immediately while you attend
to the baby.
CPR on an Infant
• Draw an imaginary line between the infant's nipples. Place two fingers
on the sternum just below this intermammary line.
• Gently compress the chest at a rate of l 00 to 120 per minute.
• Administer 2 breaths after every 30 compressions.
• After about 5 cycles of a 30: 2 ratio, activate EMS.
• Continue CPR until the infant responds or help arrives.
300 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES
•ijm1iji111j;Jiti=I -continued
Rescue Breathing for an Infant
Use an infant ventilator mask or cover the baby's mouth and nose with your
mouth.
13. Give 2 rescue breaths by gently puffing out the cheeks and slowly breath-
ing into the infant's mouth, taking about 1 second for each breath
(Figure 5).
Cardiac Emergencies
Chest pain or angina can be associated with heart and lung disease,
in addition to a few other conditions. It can be quite serious; a
patient with chest pain is treated as a cardiac emergency until a
provider has ruled this out. A heart attack, or myocardial infarction,
usually is caused by blockage of the coronary arteries, which reduces
the amount of blood delivered to the myocardium. The most
common signal of a heart attack is an uncomfortable pressure,
squeezing, fullness, or pain in the center of the chest (symptoms in
women, which may be different, are presented in the following box).
This may spread to the shoulder, neck, jaw, or arms. The pain may
not be severe. The lips and fingernails may turn blue, which is a sign
of cyanosis (Figure 12-8), or the patient may have a gray, ashen
appearance. Frequently the patient clutches the chest in pain. This
FIGURE 12-8 Cyanosis of the nail beds. (Kamal A, Brockelhurst JC: Color atlas of geriatric medi·
cine, ed 2, St Louis, 1991, Mosby.)
14. Remove your gloves and the ventilator mask valve, and discard them in
the biohazard container. Disinfect the ventilator mask per the manufac-
turer's recommendations. Sanitize your hands.
1S. Document the procedure and the patient's condition.
pain may radiate from the mediastinum down the left arm and up
the left side of the neck. The pulse may be rapid and weak, and the
patient often complains of nausea. Other symptoms include sweat-
ing (diaphoresis); indigestion; shortness of breath (SOB); cold,
clammy skin; and a feeling of weakness (general malaise). Unfortu-
nately, most people deny that the problem is serious until they
require immediate medical attention.
Signs and Symptoms of Myocardial Infarction
in Women
Women may experience symptoms that are different from those tradition-
ally associated with a heart attack. Women's symptoms include a combina-
tion of the following:
• Back pain or aching and throbbing in the biceps or forearms
• Shortness of breath (SOB)
• Clammy perspiration
• Dizziness (vertigo): Unexplained lightheadedness or syncopal
episodes
• Edema, especially of the ankles and/or lower legs
• Fluttering heartbeat or tachycardia
• Gastric upset
• Feeling of heaviness or fullness in the mediastinum
Immediately report any of these signs or symptoms to the pro-
vider. If the provider is not available, activate EMS. Use a wheel-
chair to move the patient to an examination room. Breathing will
be easier if the patient's head is slightly elevated or if the patient is
in a Fowler's or semi-Fowler's position. Keep the patient quiet and
 CHAPTER 12 Safety and Emergency Practices 301

warm. Loosen all tight clothing. Take vital signs, including both
apical and radial pulses. The provider may order oxygen started on
the patient to relieve dyspnea (Procedure 12-9). Bring the emer-
gency cart into the room and open the medication drawer so that
the provider can quickly prepare the medications needed. These
may include epinephrine (adrenaline), atropine, digitalis, calcium
chloride, or morphine.
If the patient is conscious, ask about any medication that he or
she has recently taken or is carrying. If the patient has an established
heart disorder, the person may be carrying nitroglycerin tablets; these
tablets are administered sublingually and may be given with the
patient's consent (Figure 12-9). If the provider is in the office or is
on the way, connect the patient to the electrocardiograph machine
and record a few tracings. If the patient becomes unresponsive before
the provider or EMS arrives, it may be necessary to start rescue
breathing if no evidence of respirations is noted. If chest pain pro-
gresses to cardiac arrest and loss of circulation, CPR must be per-
formed until help arrives.

FIGURE 12-9 Nitroglycerin is administered beneath the patient's tongue.

•ij;m,ammiti• Perform First Aid Procedures: Administer Oxygen

Goal: To provide oxygen for a patient in respiratory distress.

EQUIPMENT and SUPPLIES 6. Insert the tips af the cannula into the nostrils and adjust the tubing around
• Provider's order the back of the patient's ears (Figure l ).
• Patient's health record
• Portable oxygen tank
• Pressure regulator
• Flow meter
• Nasal cannula with connecting tubing
PROCEDURAL STEPS
1. Gather equipment and sanitize your hands.
2. Greet and identify the patient, introduce yourself, and explain the
procedure.
PURPOSE: Anasal cannula is applied with a nasal prong in each nostril
and the tab resting above the upper lip. Patients who will be using oxygen
at home need ta be taught haw to open an oxygen tank or to use an
oxygen compressor. It is vital that patients and their families understand
the dangers of oxygen use in the home. They must avoid open flames 7. Encourage the patient to breathe through the nose with the mouth closed.
and must not smoke when oxygen is in use because it is combustible. 8. Make sure the patient is comfortable, and answer any questions he ar she
The provider typically writes an order far the number af liters af oxygen may have.
to be delivered and for home healthcare services to set up the equipment 9. Sanitize your hands.
in the patient's home. 10. Document the procedure, including the number af liters af oxygen being
3. Check the pressure gauge on the tank to determine the amount of oxygen administered and the patient's condition. Continue ta monitor the patient
in the tank. throughout the procedure and document any changes in condition.
4. If necessary, open the cylinder an the tank one full counterclockwise turn,
then attach the cannula tubing ta the flow meter. 7/24/20- 3:05 PM: R28 and labored. Oxygen initiated at 4 LPM via nasal
S. Adjust the administration af the oxygen according to the provider's order. cannula per provider order. Pt observed for signs of dyspnea and tachypnea.
Usually the flow meter is set at l to 4 liters per minute (LPM). Check to Cheryl Skurka, CMA (AAMA)
make sure oxygen is flowing through the cannula.
302 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES

Choking
Choking is usually caused by a foreign object, often a bolus of food,
lodged in the upper airway. The victim may clutch the neck between
the thumb and the index finger (Figure 12-10); this universal distress
signal should be viewed as a sign the victim needs help. If the victim
has good air exchange or only partial airway obstruction and can
speak, cough, or breathe, do not interfere, but encourage the patient
to continue coughing until the object is expelled. Monitor the
patient for signs of respiratory distress, such as pallor and cyanosis.
If the patient has a pronounced wheeze or a very weak cough, he or
she has a partial airway obstruction with poor air exchange and may
need help. If the patient is unable to speak, breathe, or cough, a
complete airway obstruction exists, and quick action must be taken
to clear the airway. With complete obstruction, the patient eventu-
ally loses consciousness from lack of oxygen to the brain. This condi-
tion may lead to respiratory and cardiac arrest. If the object is not
removed, the victim may die within 4 to 6 minutes. Procedure 12-10
presents the steps involved in clearing an obstructed airway in an
adult. The procedure for removal of a foreign airway obstruction is
exactly the same for a child older than 1 year of age.

FIGURE 12-10 Universal sign of choking.

•;;mi,m);Jltit•i Perform First Aid Procedures: Respond to an Airway Obstruction in an Adult

Goal: To remove an airway obstruction and restore ventilation.

EQUIPMENT and SUPPLIES
• Disposable gloves
• Ventilation mask (for unconscious victim)
• Approved mannequin for practicing removal of a foreign body airway
obstruction (FBAO) in an unconscious person
PROCEDURAL STEPS
Responsive Adult
1. Ask, "Are you choking?" If the victim indicates yes, ask, "Can you speak?"
If the victim is unable to speak, tell the victim you are going to help.
PURPOSE: If the victim is unable to speak, is coughing weakly, and/or is
wheezing, he or she has an obstructed airway with poor air exchange, and
the obstruction must be removed before respiratory arrest occurs.
2. Stand behind the victim with your feet slightly apart.
PURPOSE: With an obstructed airway, the victim may lose consciousness at
any time. The rescuer must be prepared to lower the unconscious victim to
the floor safely.
3. Reach around the victim's abdomen and place an index finger into the
victim's navel or at the level of the belt buckle (Figure 1). Make a fist of 4. Place the opposite hand over the fist and give abdominal thrusts in a quick
the opposite hand (do not tuck the thumb into the fist) and place the thumb inward and upward movement.
side of the fist against the victim's abdomen above the navel. If the victim PURPOSE: Abdominal contents pushing against the diaphragm force trapped
is pregnant, place the fist above the enlarged uterus. If the victim is obese, air out of the lungs, and with it the obstruction.
it may be necessary to place the fist higher in the abdomen. It may be S. Repeat the abdominal thrusts until the object is expelled or the victim
necessary to perform chest thrusts on a victim who is pregnant or obese. becomes unresponsive.
PURPOSE: The fist should be placed in the soft tissue of the abdomen to
avoid injury to the sternum or rib cage.

•;;mHmhiitJ11• -continued
Unresponsive Adult Victim
The technique for an unresponsive victim is to be practiced only on an
approved mannequin.
1. Carefully lower the patient to the ground, activate the emergency response
system, and put on disposable gloves.
2. Immediately begin cardiopulmonary resuscitation (CPR) at cycles of 30: 2
(compressions to breaths) using the ventilator mask.
PURPOSE: Higher airway pressures are maintained with chest compressions
than with abdominal thrusts.
3. Each time the airway is opened to deliver a rescue breath during CPR, look
for an object in the victim's mouth and remove it if visible. If no object is
found, immediately return to the cycle of 30 chest compressions.
4. A finger sweep should be used only if the rescuer can see the
obstruction.
S. Continue cycles of 30 compressions to 2 rescue breaths until the obstruction
is removed or emergency medical services (EMS) arrives.
To dislodge a foreign object from the airway of an infant up to
1 year of age, place the baby face down over your forearm and across
your thigh. The head should be lower than the trunk, and you should
support the baby's head and neck with one hand. Using the heel of
your other hand, deliver 5 blows to the back, between the infant's
shoulder blades (Figure 12-11, A ). Holding the baby between your
arms, turn the infant face up, keeping the head lower than the trunk.
Using two fingers, deliver 5 thrusts to the midsternal area at the
infant's nipple line (Figure 12-11, B). Examine the infant's mouth,
A B
FIGURE 12-11 A, Back blows are administered to an infant supported on the arm and thigh. B, Chest thrusts are administered in the same
position as for cardiac compressions.
CHAPTER 12 Safety and Emergency Practices 303
6. If the obstruction is removed, assess the victim for breathing and circulation.
If a pulse is present but the patient is not breathing, begin rescue
breathing.
7. Once the patient has been stabilized or EMS has taken over care, remove
your gloves and the ventilator mask valve and discard them in the biohazard
container. Disinfect the ventilator mask per the manufacturer's recommenda-
tions. Sanitize your hands.
8. Document the procedure and the patient's condition.
7/22/20- 8:35 AM: Pt in waiting room, clutching throat and coughing weakly.
After confirming pt choking, abdominal thrusts performed until foreign body
expelled. Pt breathing without difficulty; R18 and regular. Incident reported to
provider. Cheryl Skurka, CMA (AAMA)
and if the object is visible, pluck it out with your fingertips. Never
perform a finger sweep on an infant. A baby's oral cavity is too small
for a finger sweep, and such an action may only push the obstruction
farther into the airway. If the obstruction is not visible, administer
2 rescue breaths by covering the baby's nose and mouth with your
mouth, or use a pediatric ventilator mask if available. Repeat the
sequence until the foreign body is expelled or help arrives.
If a choking victim is in the late stages of pregnancy, chest com-
pressions should be delivered by placing your cupped hands above
304 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES
the uterus to prevent possible trauma to the infant. If the patient is
obese and you are unable to wrap your arms around the abdomen,
perform chest compressions as you would for a pregnant woman.
The abdominal thrust maneuver also can be performed on your-
self if you are choking and no one is nearby to help you. Press your
fist into your upper abdomen with quick, upward thrusts, or lean
forward and press the abdomen quickly against a firm object, such
as the back of a chair.
Cerebrovascular Accident (Stroke)
A cerebrovascular accident (CVA), or stroke, is a disorder of the
cerebral blood vessels that results in impairment of the blood supply
to part of the brain. This interruption in normal circulation of
blood through the brain leads to some degree of neurologic damage,
temporary or permanent, depending on the severity of oxygen depri-
vation to the brain cells.
A minor stroke, or transient ischemic attack (TIA), usually does
not cause unconsciousness, and symptoms depend on the location
of the circulatory problem in the brain and the amount of brain
damage. TIA symptoms are temporary and may include headache,
confusion, vertigo, ringing in the ears (tinnitus), temporary paralysis
or weakness of one side of the body, transient limb weakness, slurred
speech, and vision problems. TIA episodes indicate that the patient
is at risk for a major stroke.
Symptoms of a major stroke include unconsciousness, paralysis
on one side of the body, difficulty breathing and swallowing, loss of
bladder and bowel control, unequal pupil size, and slurring of
speech.
Home recommendations for a patient who has suffered a major
stroke should begin with notifying the provider and/or activating
EMS. Keep the patient lying down and lightly covered. Maintain an
open airway. To prevent choking, position the head so that any
secretions drain from the side of the mouth. If the patient is lying
on the floor, did not fall, and shows no indications of a head or neck
injury, he or she can be placed in the recovery position as follows
(Figure 12-12):
1. Place the patient's arm that is farthest from you alongside and
above the head; place the other arm across the chest.
2. Bend the leg that is closest to you, and after placing one arm
under the patient's head and shoulder and the other hand on
FIGURE 12-12 Recovery position.
the flexed knee, roll the patient away from you while you
stabilize the head and neck. The patient's head should be
resting on the extended arm.
The recovery position uses gravity to drain fluids from the mouth
and keep the trachea clear. Keep the patient in this position until
the person is alert or help arrives. Do not give the patient anything
to eat or drink. Vital signs should be measured at regular intervals
and recorded for the provider.
Advances in early treatment of strokes show great promise in
preventing long-term neurologic deficits. However, to prevent per-
manent brain damage, thrombolytics must be administered intra-
venously within 3 hours of the onset of symptoms. If a patient does
not know when the symptoms began (e.g., the person woke up with
the symptoms) or cannot accurately tell the provider when the
symptoms started, the time allotted for administration begins from
the point at which the patient last was known to be asymptomatic.
lntracranial hemorrhage must be ruled out before treatment begins.
The earlier the treatment starts, the better the neurologic outcomes.
The best possible outcomes are seen in patients who receive throm-
bolytic therapy within 90 minutes of the onset of symptoms.
Warning Signs of Stroke: FAST
The American Stroke Association developed the mnemonic FAST to help
people spot the signs of a sudden stroke. If any of these are present, 911
should be called immediately.
Face drooping • Does one side of the face droop or is it numb?
• Ask the person to smile. Is the person's smile
uneven?
Arm weakness • Is one arm weak or numb?
• Ask the person to raise both arms. Does one arm
drift downward?
Speech difficulty • Is speech slurred? Is the person unable to speak
or hard to understand?
• Ask the person to repeat a simple sentence, such
as, "The sky is blue." Is the sentence repeated
correctly?
Time to call 911 • If someone shows any of these symptoms,
even if the symptoms go away, call 911 and
get the person to the hospital immediately.
Note the time the first symptoms appeared.
Source: American Heart Association and The American Stroke Association.
CRITICAL THINKING APPLICATION 12-4
Thomas Antonio, a 67-year-old patient, calls to report that when he woke
up this morning, the left side of his face was drooping and he had difficulty
seeing out of his left eye. The symptoms went away in about 2 hours, and
he is feeling fine now. The schedule does not show any openings for 2
days. When should Cheryl make an appointment for Mr. Antonio? What
questions should Cheryl ask him?
 CHAPTER 12 Safety and Emergency Practices 305

Shock
Shock is a state of collapse caused by failure of the circulatory system
to deliver enough oxygenated blood to the body's vital organs. Injury,
hemorrhage, infection, anesthesia, drug overdose, burns, pain, fear,
or emotional stress can cause this physiologic reaction. Shock can be
immediate or delayed, and it is potentially fatal. Many different types
of shock can occur, but the signs and symptoms are universal. The
most common indicators are a pale, gray, or cyanotic appearance;
moist but cool skin; dilated pupils; a weak, rapid pulse; marked
hypotension; shallow, rapid respirations; lethargy or restlessness;
nausea and vomiting; and extreme thirst.
If a patient shows signs of shock, maintain an open airway and
check for breathing and circulation. Place the patient supine with
the legs elevated approximately 1 foot to return the blood from
the legs to vital organs. Loosen all tight clothing and cover the
patient with a blanket for warmth (Procedure 12-11). Do not
move the patient unnecessarily. Fluids may be given by mouth
if the patient is alert. Because shock can evolve into a life-
threatening situation, only basic first aid should be administered,
and the patient should be transported to the hospital as soon
as possible.
Types and Causes of Shock
Anaphylactic: Asevere allergic reaction
Insulin: Severe hypoglycemia caused by an overdose af insulin
Psychogenic or mental: Excessive fear, joy, anger, or emotional stress
Hypovolemic or hemorrhagic: Excessive loss of blood
Cardiogenic: Myocardial infarction, pulmonary embolism, or severe conges-
tive heart failure
Neurogenic: Dilation of blood vessels as a result of brain or spinal cord
injury
Septic: Systemic infection

•;;mi,m);Jltiil Perform First Aid Procedures: Care for a Patient Who Has Fainted or Is in Shock

Goal: To assess and provide emergency care for apatient who has fainted.
EQUIPMENT and SUPPLIES
• Patient's record
• Sphygmomanometer
• Stethoscope
• Watch with second hand
• Blanket
• Footstool or box
• Pillows
• Oxygen equipment, if ordered by provider:
• Portable oxygen tank
• Pressure regulator
• Flow meter
• Nasal cannula with connecting tubing
PROCEDURAL STEPS
1. If warning is given that the patient feels faint, have the patient lawer the
head to the knees ta increase the bload supply to the brain (Figure l).
If this does not stop the episode, have the patient lie down on the exami-
nation table or lower the patient to the floor. If the patient collapses to 2. Immediately notify the provider of the patient's condition and assess the
the floor when fainting, treat with caution because of possible head or patient for life-threatening emergencies, such as respiratory or cardiac
neck injuries. arrest. If the patient is breathing and has a pulse, monitor the patient's
vital signs.
3. If the patient has fainted and vital signs are unstable or the patient daes
not respond quickly, activate emergency medical services (EMS).
PURPOSE: Fainting may be a sign of a life-threatening problem.
4. Activate EMS if the patient shows signs of shock- pale, gray, or
cyanotic appearance; moist but cool skin; dilated pupils; a weak, rapid
pulse; marked hypatension; shallow, rapid respirations; or lethargy or
restlessness.
306 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES

•ij;m,ammitii• -continued

5. Look, listen, and feel for breathing and check the pulse. Maintain an open
airway and continue to monitor vital signs.
6. Loosen any tight clothing and keep the patient warm, applying a blanket
if needed.
7. If a head or neck injury is not a factor, elevate the patient's legs above
the level of the heart using a footstool with pillow support if available
(Figure 2).
PURPOSE: Elevating the legs assists with venous blood return to the heart.
This may relieve symptoms of fainting or shock by elevating the blood
pressure and increasing blood flow to vital organs.
8. Continue to monitor vital signs, and apply oxygen by nasal cannula if
ordered by the provider until the patient recovers or EMS arrives.
9. If the patient vomits, roll the patient onto his or her side to prevent aspira-
tion of vomitus into the lungs.
10. If the patient completely recovers, assist the patient into a sitting position.
Do not leave the patient unattended on the examination table.
11. Document the incident, including a description of the episode, the patient's
symptoms and vital signs, the duration of the episode, and any complaints.
If oxygen was administered, document the number of liters and how long
oxygen was administered.

7/29/20- 4: 18 PM: Pt in waiting room states she feels faint. Pt lowered to

floor, clothing loosened, legs elevated. Provider notified. P88 and regular, R
22, BP 112/60. Syncopal episode persisted for 90 sec, feeling of vertigo
lasted l Omin post syncope. Pt transferred to exam room via wheelchair after
recovery. Cheryl Skurka, CMA (A.AMA)

COMMON OFFICE EMERGENCIES Poisoning

The remainder of this chapter highlights typical emergencies seen in
an ambulatory care practice or in telephone triage situations. Table
12-1 summarizes common emergencies, the questions that should
be asked, and possible actions for home care.
Fainting (Syncope)
Fainting, or syncope, is a common emergency. It usually is caused by
a transient loss of blood flow to the brain (e.g., a sudden drop in
blood pressure), which results in a temporary loss of consciousness.
It can occur without warning, or the patient may appear pale; may
feel cold, weak, dizzy, or nauseated; and may have numbness of the
Poisonings are considered medical emergencies and are the sixth
leading cause of accidental pediatric death in the United States.
Poisoning can occur by oral intake, absorption, inhalation, or injec-
tion. Over-the-counter (OTC) medications (e.g., acetaminophen);
detergents and bleach; plants; cough and cold medicines; and vita-
mins cause most cases of poisoning seen in young children.
Other typical household poisons include drain cleaner, turpentine,
kerosene, furniture polish, and paint (Figure 12-13). Signs and

\
extremities before the incident. The greatest danger to the patient is
an injury from falling during the attack. Therefore, if a patient has .. L
syncopal symptoms, immediately place the individual in a supine
position. Loosen all tight clothing and maintain an open airway.
11 -
..
Apply a cold washcloth to the forehead. Measure and record the
TRtAZK
patient's pulse, respiratory rate, and blood pressure, and report the
findings to the provider. Keep the patient in a supine position for at
least 10 minutes after the person regains consciousness. A complete 9
tit ,,
-
'
~
~imlo

, ~-~ ,-=:
patient history can help determine the possible causes of the attack
~ ~- /T_• LlJi,r

~
,, ·,._,d_f:R
(e.g., a history of heart disease or diabetes). Document the details of ·,._ ~

the episode and how long it took the patient to recover completely -~--
(see Procedure 12-11). ,1 .'"1
If the patient does not recover quickly, the provider may activate
EMS for transport to the hospital. Syncope might be a brief episode
in the development of a serious underlying illness, such as an abnor-
mal heart rhythm or shock, that could lead to sudden cardiac death. ------ -- ,,-- ,r
©Elsevie..r: Collection:-

FIGURE 12-13 Hazardous household materials.

. ,
 CHAPTER 12 Safety and Emergency Practices 307

TABLE 12-1 Telephone Screening of Possible Emergency Situations

EMERGENCY SITUATION SCREENING QUESTIONS
Syncope • Was the patient injured?
• Does the patient have a history of heart disease,
seizures, or diabetes?
Animal bites • What kind of animal (pet or wild)?
• How severe is the injury?
• Where are the bites?
• When did the bites occur?
Insect bites and stings • Does the patient have a history of an
anaphylactic reaction to insect stings?
• Does the patient have any of these: difficulty
breathing, a widespread rash, or trouble
swallowing?
Asthma • Does the patient show signs of cyanosis?
• Has the patient used prescribed inhalers?
Burns • Where are the burns located, and what caused
them?
• Are signs of shock present-moist, clammy skin;
altered consciousness; and rapid breathing and
pulse?
• If the burn is more than 2 days old, are signs of • The patient must receive a tetanus shot if he or she has not
infection present-foul odor, cloudy drainage?
Wounds • Is the bleeding steady or pulsating?
• How and when did the injury occur?
• Does the patient have any bleeding disorders, or
is the patient taking anticoagulant drugs?
• Is the wound open and deep?
Head injury • Did the patient pass out or have a seizure? Is the • If the answer is yes to any of these questions; activate EMS.
patient confused or vomiting? Is a clear fluid
draining from the nose or ears?
HOME CARE ADVICE
• Syncope does not necessarily indicate a serious disease. If
injured by a fall, the patient may need to be evaluated and
treated.
• The patient should get up very slowly to prevent a recurrence;
he or she should then take it easy and drink plenty of fluids.
• If the patient is to be seen, someone should accompany him or
her to the provider's office.
• The health department or police should be notified. Every effort
must be made to locate the animal and monitor its health.
• If the skin is not broken, wash the area well and observe for
signs of infection.
• If the patient has a history of anaphylaxis and has an EpiPen,
the EpiPen should be used immediately and emergency medical
services (EMS) notified.
• Activate EMS if the patient is having systemic symptoms.
• An antihistamine (Benadryl) relieves local pruritus.
• If a patient with asthma is unable to speak in sentences, has
poor color, and is struggling to breathe even after using an
inhaler, he or she should be seen immediately or EMS should
be activated.
• Activate EMS for the following:
• Burns on the face, hands, feet, or perineum
• Burns caused by electricity or a chemical
• Burns associated with inhalation
• Signs of shock are present
had one in more than l Oyears.
• Schedule an urgent appointment if signs of infection are
reported.
• Pulsating bleeding usually indicates arterial damage; activate
EMS.
• If the injury was caused by a powertul force, other injuries also
may have resulted.
• Patients taking anticoagulants or who have diabetes or anemia
require an urgent appointment.
• Agaping, deep wound requires sutures.

symptoms of poisoning, which vary greatly, include burns on the
hands and mouth, stains on the victim's clothing, open bottles of
medicines or chemicals, changes in skin color, nausea or stomach
cramps, shallow breathing, convulsions, heavy perspiration, dizziness
or drowsiness, and unconsciousness.
If you receive a phone call about a suspected poisoning, tell the
caller not to hang up and not to leave the victim unattended. Call
the local poison control center and forward all directions to the
caller. Syrup of ipecac has been recommended in the past for
home use when a child ingests a poisonous substance, but the
308 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES
American Academy of Pediatrics now recommends that syrup of
ipecac not be kept in the home. There are several reasons for this
decision:
• Ipecac should not be given if the child swallowed chemicals
that cause burns on contact because the substance can burn
the gastrointestinal tract again when it is vomited.
• People with eating disorders often use ipecac to make them-
selves throw up.
• Ipecac may make it difficult to keep down other drugs that
are needed to treat the poison.
If parents believe a child has ingested a poisonous substance,
they should call the national poison control center at 1-800-
222-1222, or call 911. (Always remember, though, that the best
treatment is prevention; parents should be reminded to keep poi-
sonous substances out of sight and out of reach of children). If the
patient is to be seen by the provider or sent to the hospital, tell
the caller to bring the container of poison or a sample of the
vomitus so that the chemical contents of the substance can be
verified.
What to Ask When a Poisoning Is Reported
• Victim's name, weight, and age
• Name of the poison taken and any information on the label
• How much was taken
• How long ago the poison was ingested
• Whether vomiting has occurred
• Whether the person has any pertinent symptoms, such as difficulty
breathing or an altered state of consciousness
• Whether any first aid has been given, and if so, what
CRITICAL THINKING APPLICATION 12-5
Ayoung mother calls in a panic to report that her 18-month-old daughter
swallowed at least half a bottle of cough syrup. The child is fussy and very
sleepy, and the mother wants to give her ipecac immediately. What should
Cheryl do?
Animal Bites
Possible complications from animal bites include rabies, tetanus,
and local skin infection. Any animal bite that is extensive or deep
should be seen by a provider. Human infection with rabies is rare;
however, if the bite is made by a domestic animal, the animal
should be kept quarantined and under observation for 10 days to
be monitored for signs of the disease. The animal should not be
killed, because a positive finding of rabies is almost impossible to
make if the animal has been dead for an extended time. If the bite
is made by a bat, raccoon, or any other wild animal, the animal is
assumed to be rabid, and the patient must undergo a series of
rabies vaccine injections. Local skin infection can be prevented by
immediately cleansing the area with antimicrobial soap and water.
If the bite breaks the skin (including human bites), the patient's
tetanus immunization status must be checked and, if needed, a
booster or the entire four-dose tetanus series must be administered
as indicated.
Insect Bites and Stings
The bite or sting of an insect can be irritating and painful because
of the chemical toxin injected by the insect, but it usually is not
serious. Typical symptoms-inflammation, itching (pruritus), and
edema-are local and are confined to the area of the bite. In rare
cases, a severe allergic reaction may occur; this is a potentially dan-
gerous situation that can lead to anaphylaxis. Signs and symptoms
of a systemic allergic reaction include a dry cough, a feeling of
tightening in the throat or chest, swelling or itching around the eyes,
widespread hives (urticaria), wheezing, dyspnea, and hypotension.
Difficulty talking is a sign of urticaria or edema in the throat and
may indicate the onset of complete airway obstruction. This is a sign
of a true emergency. Epinephrine and oxygen should be ready for
immediate administration on the provider's orders. Antihistamines
and corticosteroids may be used, but these agents act considerably
slower than epinephrine. If acute anaphylactic shock develops, death
may occur within 1 hour without medical intervention.
If the stinger is still lodged in the skin, scrape it off with a dull
knife, a credit card, or a fingernail. Be careful not to squeeze the
stinger, because this injects more venom into the skin. Apply an ice
bag to the site to relieve pain and slow absorption of venom. Cala-
mine lotion or hydrocortisone cream may be applied to relieve
itching. If the patient has a history of allergies, especially to insect
venom, he or she should have access to an EpiPen injection system;
this should be used immediately after the sting. In this case,
the patient should be transported to the nearest hospital for immedi-
ate care.
Removal of a Tick
Ticks can cause a number of diseases, including Rocky Mountain spotted
fever and Lyme disease. The tick embeds its head into the skin to obtain
blood, and it should be removed intact by the following method:
l . Do not handle ticks with uncovered fingers; use tweezers to prevent
personal contamination.
2. Place the tips of the tweezers as close as possible to the area where
the tick has entered the skin.
3. With a slow, steady motion, pull the tick away from the skin. Try
not to squeeze or crush the tick. If the tick's entire body is not
removed, make an appointment with a provider to have the site
evaluated.
4. After removal, place the tick directly into a sealable container.
Disinfect the area around the bite site using standard procedures.
5. If the tick is removed at home, the provider may suggest that it be
brought to the office to be tested for disease.
Asthma Attacks
Asthma is characterized by expiratory wheezing, coughing, a feeling
of tightness in the chest, and shortness of breath. During an asthma
attack, two different physiologic responses occur. The lining of the
respiratory tract becomes inflamed and edematous and produces
mucus, which results in narrowing of the air passages. At the same
time, bronchospasms occur, which also constrict the airways. The
quality and severity of attacks vary greatly among patients, and treat-
ment must be individualized to minimize or eliminate chronic

symptoms. If the patient is prescribed a bronchodilator inhaler, it
should be used at the first indication of symptoms. Depending on
the severity of the attack, give the patient an appointment for the
same day as the call, or consult the provider. The provider may
recommend that the patient go directly to the ED for emergency
respiratory care.
Seizures
Seizures may be idiopathic, or they may result from trauma, injury,
or metabolic alterations, such as hypoglycemia or hypocalcemia. A
febrile seizure is transient and occurs with a rapid rise in body tem-
perature over 10l.8°F (38.8°C). Febrile seizures typically occur in
children between 6 months and 5 years of age. Many different types
of seizures occur, but all are caused by a disruption in the electrical
activity of the brain.
If a patient suffers a grand ma! seizure, which involves uncon-
trolled muscular contractions, the most important point is to protect
the patient from possible injury. Clear everything away from the
patient that could cause accidental injury, and observe him or her
until the seizure ends. Do not place anything into the person's
•ij;m,ammititi Perform First Aid Procedures: Care for a Patient With Seizure Activity
Goal: To assess and provide emergency care for apatient who has agrand ma/ seizure.
EQUIPMENT and SUPPLIES
• Patient's record
• Sphygmomanometer
• Stethoscope
• Watch with second hand
• Blanket
• Pillows
PROCEDURAL STEPS
1. If warning is given that the patient might have a seizure, help lower the
patient to the floor. If the patient collapses with a seizure, clear everything
away from the patient that could cause accidental injury. If you cannot
remove all hard items (e.g., the examination table), pad the hard edges
with a blanket or pillow.
PURPOSE: The patient could be injured when uncontrollable muscular
contractions occur with the seizure.
2. Immediately check the time on your watch and call for help.
PURPOSE: To time the length of the seizure and alert the provider of the
patient's seizure activity.
3. Observe the patient throughout the seizure but do not restrain or confine
the patient's movements.
PURPOSE: Stay with the patient for the entire seizure, but do not
restrain movement. Restraining the patient may cause musculoskeletal
injury.
4. Do not place anything in the patient's mouth during the seizure.
PURPOSE: The patient's jaw is typically clamped tight during the seizure
and trying to force something between the teeth can cause injury.
CHAPTER 12 Safety and Emergency Practices 309
mouth, because it may damage the teeth or tongue and force the
tongue back over the trachea. Do not hold the patient down, because
this may result in muscle injuries or fractures. If unconsciousness
persists after the seizure has subsided, place the patient in the recov-
ery position to maintain an open airway and allow drainage of excess
saliva. After the seizure is over, let the patient rest or sleep, but never
leave the person alone. If the provider is not in the office, check the
office policies and procedures manual to determine how to manage
the situation (Procedure 12-12).
Call 911 for emergency assistance in any of the following
situations:
• The patient does not regain consciousness within 10 to 15
minutes.
• The seizure does not stop within a few minutes.
• The patient begins a second seizure immediately after the first
one.
• The patient is pregnant.
• Signs of head trauma are present.
• The patient is known to have diabetes.
• The seizure was triggered by a high fever in a child.
S. After the muscular contractions have ended, roll the patient into the
recovery position on his or her side, with the top knee bent and the head
resting on the extended arm closest to the floor.
PURPOSE: This position helps maintain an open airway.
6. Loosen any tight clothing and keep the patient warm, using a blanket if
needed. Let the patient rest, but never leave the patient alone.
PURPOSE: To maintain patient safety and comfort.
7. If the provider is not in the facility, check the policies and procedures
manual to determine how to follow up with the patient.
8. Activate emergency medical services (EMS) if any of the following condi-
tions are present:
• The patient does not regain consciousness within 10 to 15 minutes.
• The seizure does not stop within a few minutes.
• The patient begins a second seizure immediately after the first one.
• The patient is pregnant.
• Signs of head trauma are present.
• The patient is known to have diabetes.
• The seizure was triggered by a high fever in a child.
9. If the patient completely recovers, assist him ar her into a sitting position,
check vital signs, and make sure there is someone to accompany the
person home.
10. Document the incident, including a description of the episode, the patient's
symptoms and vital signs, the duration of the seizure activity, and any
complaints.
31 o UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES

Abdominal Pain
Abdominal pain is a symptom caused by many different problems,
which can range from acute discomfort to life-threatening complica-
tions. The clinician should see every patient who reports abdominal
pain; the question is how soon the patient should be seen. A patient
with acute onset of severe, persistent abdominal pain, especially
when this is accompanied by fever, should receive medical attention
as soon as possible. Abdominal pain has a variety of causes, including
intestinal infection, appendicitis, ectopic pregnancy, inflammation,
hemorrhage, obstruction, and tumor.
Treatment in the ambulatory care office depends on the cause of
the pain; however, the medical assistant should follow these general
guidelines:
• Keep the patient warm and quiet.
• Have an emesis basin available.
• Administer nothing by mouth (NPO).
• Do not apply heat to the abdomen unless so instructed by the
provider.
• Administer analgesics as ordered.
• Check and record the patient's vital signs and follow the
provider's orders.
• Does the patient have chest pain, shortness of breath, or a continuous
cough?
• Does the patient have a history of serious illness, such as diabetes,
heart disease, or cancer?
Sprains and Strains
Sprains are tears of the ligaments that support a joint; strains are
injuries to a muscle and its tendons. Both types of injury may
damage surrounding soft tissues and blood vessels and nearby nerves.
With a sprain, the victim develops edema and ecchymosis around
the injury, and any movement of the joint, especially a twisting one,
produces pain. Usually no swelling or discoloration is seen with a
strain, and only mild tenderness is noted unless the injured muscle
or tendon is used.
Tendon strains and ligament sprains take several weeks to heal,
whereas muscle tears usually heal in 1 to 2 weeks because muscle has
such a rich blood supply. These injuries are treated by elevating the
affected area and applying mild compression and ice. Swelling is
reduced if ice is applied within 20 to 29 minutes of the injury. After
24 to 36 hours, alternating applications of mild heat and ice usually
are indicated. The patient may be advised to immobilize the part.

Screening Guidelines for Assessing Fractures

Abdominal Pain
• Assess for shock-related signs and symptoms: diaphoresis; cold, clammy
skin; cyanosis or gray pallor; rapid respirations; altered state of
consciousness.
• Is the pain severe and constant, or does it come in waves?
• Has the patient had any bloody or tarry stools?
• Is the patient's temperature higher than 101 ° F(38.3° ()?
• Could the patient be pregnant or has she missed a menstrual period?
• Has the patient experienced continuous vomiting or severe
constipation?
• Are any urinary symptoms present, such as frequency, hematuria, or
flank pain?
A fracture is a break or crack in a bone, which can result from trauma
or disease. Fractures are very painful and affect the patient's ability
to freely move the injured part. When a patient with a fracture is
brought into the office, the medical assistant should make the patient
as comfortable as possible. Place the patient in a position that sup-
ports the affected area at the joints above and below the suspected
fracture and does not place strain on the injury. Notify the provider
immediately and proceed according to the orders given. Emergency
treatment for fractures includes preventing movement of the injured
part through splinting, elevation of the affected extremity, applica-
tion of ice, and control of any bleeding (Procedure 12-13). If a
patient with an open fracture (i.e., the bone is protruding through
the skin) is seen in an ambulatory care office, he or she should be
transported to the ED.

Perform First Aid Procedures: Care for a Patient With a Suspected Fracture of the
PROCEDURE 12-13
Wrist by Applying a Splint

Goal: To provide emergency care for and assessment of apatient with asuspected fracture of the wrist.

EQUIPMENT and SUPPLIES PROCEDURAL STEPS

• Patient record 1. Gather equipment and sanitize your hands.
• Sphygmomanometer 2. Greet and identify the patient, introduce yourself, and explain the
• Stethoscope procedure.
• Watch with second hand PURPOSE: To relieve the patient's anxiety and earn his or her cooperation
• Splint with padding with the procedure.
• Ace or roller bandage material 3. Obtain vital signs.
• Gloves and sterile dressing (if any open areas on the skin)
 CHAPTER 12 Safety and Emergency Practices 311

•;;m,ammitii• -continued
4. Assess the area of the suspected fracture for swelling, bleeding, bruising, 9. Check the pulse in the affected arm. Note the color and temperature of
or protruding bones. the skin and the color of the nails.
S. If the skin is broken, put on gloves and cover the area with a sterile PURPOSE: To make sure the splint and bandage have not been applied
dressing. too tightly.
PURPOSE: Infection control and compliance with Standard Precautions 10. Make sure the patient is comfortable, and answer any questions he or she
procedures. may have.
6. Moving the limb as little as possible, place the padded splint under the 11. Sanitize your hands.
lower arm and wrist. 12. Document the procedure, including the condition of the patient, the
PURPOSE: Avoid moving the limb any more than necessary to prevent reported pain level, and application of the splint.
movement of the fracture and further pain.
7. The area must be immobilized by the splint above and below the suspected 7/24/20- l :05 PM: Temporary splint applied to CD wrist per provider order.
fracture. Pt reports some relief of discomfort, with pain at 6on a 1-10 scale. Hand warm
PURPOSE: Immobilizing the joint above and below the injury keeps the and normal color, nail beds pink, and radial pulse easily palpated. BP 132/80,
joint in place, preventing further injury and pain. P88 and regular, R22. Cheryl Skurka, CMA (MMA)
8. Secure the splint in place by rolling an Ace bandage or roller bandage
around the splint and arm, starting at the arm and rolling down to the
wrist and hand.

Burns
ADULT
Burns are among the most common causes of injury in the United
States. Burn injuries can result from flame, heat, scalds, electricity,
chemicals, or radiation. The skin surface may be reddened, blistered,
or charred. The depth and extent of a burn are the major determi-
nants in classifying its severity. The extent of the pain is directly INFANT
proportional to the extent of the surface area burned and the depth
and nature of the burn.
To screen a burn injury, the medical assistant must know what
caused the burn, its location and approximate size, the depth of the
burn, and whether any additional injuries occurred. If the patient
reports a chemical burn, it is important to have the person imme-
diately remove all clothing that may have come into contact with
the chemical and flood the affected area with running water to flush
the irritant off the skin. If the chemical is not quickly flushed away
or remains in the patient's clothing, the agent will continue to burn
the skin and may do very serious damage.
\., J
The percentage of the body surface area burned can be estimated
using the Rule of Nines (Figure 12-14). With this assessment tool,
the amount of burned tissue can be quickly calculated. The Rule of
Nines divides the body into areas approximately equal to 9% of the
total body surface area. When a burn victim is assessed, the affected
regions are combined to yield an estimate of the total percentage of
burned tissue. Partial-thickness burns over 15% of the total body
surface and full-thickness burns of less than 2% can be treated in
FIGURE 12-14 Rule of Nines classification of burns.
the ambulatory care office if the patient can be seen immediately.
Patients with larger body surface area involvement or other compli- and is painful. A contusion results in a painful bruise, but the skin
cations should be transported immediately to a hospital, preferably remains intact. A scrape on the surface of the skin (e.g., a skinned
one with a burn unit. knee, rug burn) is called an abrasion. A deeper, jagged wound is
called a laceration. Additional tissue damage may occur around a
Tissue Injuries laceration; depending on its depth, the wound may need to be
Patients may report any of several different types of wounds. A contu- repaired surgically. A puncture wound occurs when an object is
sion is a closed wound with no evidence of injury to the skin; it forced into the body (e.g., stepping on a nail). If an object is lodged
typically is caused by blunt trauma, appears swollen and discolored, in body tissues, the best course is to leave it there, stabilize it as much
312 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES

as possible with rolled-up material, and transport the individual to (Figure 12-15), which eliminates the discomfort of suturing and
a clinic or ED. The puncture may have severed blood vessels, and if suture removal. Another wound closure option is a tissue adhesive
the object is removed, considerable bleeding may occur. An injury product (e.g., Dermabond fluid or LiquiBand), which forms a
in which tissue is torn away (e.g., complete or partial removal of a strong, flexible closure similar in strength to nylon suture material.
finger) is known as an avulsion. Tissue adhesive products are very useful for closing simple lacera-
Lacerations are common presentations in a primary care pro- tions in children; they provide an antimicrobial and waterproof
vider's office. A lacerated wound shows jagged or irregular tearing of coating to the wound site that lasts several days, even with repeated
the tissues. The severity depends on the cause of the laceration, the washing.
site and extent of the injury, and whether the area is contaminated. After the clinician closes the wound, the medical assistant typi-
The injury that caused the laceration also may have damaged blood cally applies a sterile dressing to the site. The size and thickness of
vessels, nerves, bones, joints, and organs in the body cavities. the dressing depend on the type of wound.
When the patient arrives at the facility, put on gloves and notify
the provider immediately. Have the patient lie down, and cover the
injured area with a sterile dressing (use a dressing that is thick
enough to absorb the bleeding) (Procedure 12-14). Reassure the
patient and explain your actions as much as possible. Ask the patient
when he or she last received a tetanus inoculation, and record the
date in the patient's record. If it has been longer than 10 years, the
provider probably will want a booster injection given.
Wounds that are not bleeding severely and that do not involve
deep tissue damage should be cleaned with antimicrobial soap and
water to remove bacteria and other foreign matter. If the laceration
is extremely dirty, the provider may want the area irrigated with
sterile normal saline solution.
A butterfly closure strip may be used over small lacerations to
hold the edges together. If the wound is superficial and has straight
edges, it may be closed with a microporous tape (e.g., Steri-Strips) FIGURE 12-15 Steri-Strips.

•;;m,am);jitiil Perform First Aid Procedures: Control Bleeding

Goal: To stop hemorrhaging from an open wound.

EQUIPMENT and SUPPLIES 4. Wrap the wound with bandage material. Add more dressing and bandaging
• Patients record material if the bleeding continues.
• Gloves (sterile if available) S. If bleeding persists and the wound is on an extremity, elevate the extrem-
• Appropriate personal protective equipment (PPE) as specified by Occupa- ity above the level of the heart. Notify the provider immediately if the
tional Safety and Health Administration (OSHA) guidelines, including: bleeding cannot be controlled.
• Impermeable gown 6. If the bleeding still continues, maintain direct pressure and elevation; also
• Goggles or face shield apply pressure to the appropriate artery. If the bleeding is in the arm,
• Impermeable mask apply pressure to the brachia! artery by squeezing the inner aspect of the
• Impermeable foat covers, if indicated middle upper arm. If the bleeding is in the leg, apply pressure to the
• Sterile dressings femoral artery on the affected side by pushing with the heel of the hand
• Bandaging material into the femoral crease at the groin. If the bleeding cannot be controlled,
• Biohazard waste container activate emergency medical services.
7. Once the bleeding has been brought under control and the patient has
PROCEDURAL STEPS been stabilized, discard contaminated materials in an appropriate biohaz-
1. Sanitize your hands and put on appropriate PPE. ard waste container.
PURPOSE: To follaw Standard Precautions. 8. Disinfect the area, then remove your gloves and discard them in a biohaz-
2. Assemble equipment and supplies. ard waste container.
3. Apply several layers of sterile dressing material directly to the wound and 9. Sanitize your hands.
exert pressure. 10. Document the incident, including details of the wound, when and how it
PURPOSE: Direct pressure to a wound slows or stops the bleeding. Sterile occurred, the patients symptoms and vital signs, treatment provided by
supplies are needed to prevent wound infection. the provider, and the patients current condition.

Nosebleeds (Epistaxis)
A nosebleed, or epistaxis, is a hemorrhage that usually results from
the rupture of small vessels in the nose. Nosebleeds can be caused
by injury, disease, hypertension, strenuous activity, high altitudes,
exposure to cold, overuse of anticoagulant medications (e.g., aspirin),
and nasal recreational drug use. Bleeding from the anterior nostril
area usually is venous, whereas bleeding from the posterior region
usually is arterial and is more difficult to stop. Treatment of epi-
staxis varies according to the amount of bleeding and the presence
of other conditions, and whether the patient is taking anticoagulant
medications.
If the bleeding is mild to moderate and from one side of the nose,
the patient should sit up, lean slightly forward, and apply direct
pressure to the affected nostril by pinching the nose. Constant pres-
sure should be continued for 10 to 15 minutes to allow clotting to
take place. If the bleeding cannot be controlled, insert a clean gauze
pad into the nostril, and notify the provider. If the provider is not
available, proceed with standard EMS protocols. Bleeding should be
considered a medical emergency if it is bilateral and continuous or
if it occurs in a patient who has a bleeding disorder or has been
prescribed anticoagulants.
Head Injuries
The severity of head injuries can vary greatly. The history of the
injury (i.e., details about what it is and how it happened) is crucial
for determining appropriate management. With a head injury, the
patient may appear normal; may experience dizziness, severe head-
ache, mental confusion, or memory loss; or may even be uncon-
scious. Loss of consciousness may be brief or prolonged; it may
appear immediately or may be delayed. The victim may experience
vomiting; loss of bladder and bowel control; and bleeding from the
nose, mouth, or ears. The pupils of the eyes may be unequal and
nonreactive to light.
All head injuries must be considered serious. Notify the provider
or contact EMS immediately. If evidence of a neck injury is seen,
stabilize the neck and do not attempt to move the victim. Do not
administer anything by mouth. Keep the patient warm and quiet.
Watch the pupils of the eyes and record any changes. Measure vital
signs and record the extent and duration of any unconsciousness. If
the patient is at home or is sent home after the provider's assessment,
he or she should be watched closely for 24 hours after the injury for
any change in mental status.
Foreign Bodies in the Eye
The eye is a delicate organ with a unique structure that demands
special handling. This kind of emergency is uncomfortable, and it
often is extremely difficult to keep the patient from rubbing the eye.
Tell the patient not to touch the eye in any way. The provider may
order ophthalmic topical anesthetic drops to relieve pain. The patient
should be placed in a darkened room to wait for the provider because
photophobia is common with eye irritations. If a contusion and
swelling are present, cold, wet compresses can help. Ask the patient
to close both eyes and cover them with eye pads until the provider
arrives. The provider may order an eye irrigation to remove the
object. The medical assistant should not attempt to search for or
remove an object in the eyes.
CHAPTER 12 Safety and Emergency Practices 313
Heat and Cold Injuries
Exposure to extremes in temperature can cause minor to severe
injuries. Heat injuries occur most often on hot, humid days and
result in cramps, heat exhaustion, or heatstroke. Heat-related muscle
cramps may be the first sign of heat exhaustion, which is a serious
heat-related condition. Patients with heat exhaustion appear flushed
and report headaches, nausea, vertigo, and weakness. Heatstroke, the
most dangerous form of heat-related injury, results in a shutdown of
body systems. Patients with heatstroke have red, hot, dry skin;
altered levels of consciousness; tachycardia; and rapid, shallow
breathing. This is a true medical emergency. If heat-related problems
are recognized in the early stages and are adequately treated, the
patient does not usually develop heatstroke. Management of heat-
related conditions includes getting the person out of the heat; loos-
ening clothing or removing perspiration-soaked clothing; and giving
the person cool electrolyte drinks if he or she is alert. An effective
way to lower the victim's temperature is to apply cool, wet cloths
and then fan the moist skin so that heat is released from the body
by evaporation.
The two types of cold-related injuries are frostbite and hypother-
mia. Frostbite, which is the actual freezing of tissue, occurs when the
skin temperature falls to a range of 14° to 25°F (-10°to -3.9°C).
Prolonged exposure of the skin to cold causes damage similar to a
burn. The tissue may appear gray or white, may be swollen, and may
have clear blisters; in full-thickness frostbite, the skin may show signs
of tissue necrosis, including blackened areas and severe deformity.
The more advanced the frostbite, the more serious the tissue damage
and the more likely the body part will be lost. Frozen tissue has no
feeling, but as thawing occurs, the patient reports itching, tingling,
and burning pain. Mild frostbite can be managed by applying con-
stant warmth to the affected areas; this can be done by immersing
the area in warm water (no warmer than 105°F [40.6°C]) or by
wrapping it in warm, dry clothing. Friction should never be used
because this could increase tissue damage. If blisters have formed or
if evidence of full-thickness frostbite is seen, the patient should be
transported to the nearest ED.
Hypothermia is a medical emergency that may result in death
unless the patient receives immediate assistance. Systemic hypother-
mia occurs when the core body temperature drops below 95°F
(35°C). Signs and symptoms of hypothermia include shivering,
numbness, apathy, and loss of consciousness. If hypothermia is sus-
pected, activate EMS and provide care for any life-threatening condi-
tions until help arrives. Remove the victim's wet clothing and wrap
the victim in blankets while moving him or her to a warm place. If
the victim is alert, give warm liquids and apply heating pads (using
a barrier to prevent burns) or chemical hot packs to help slowly raise
the core body temperature.
Dehydration
A person dehydrates when more water is excreted than is taken in.
Dehydration can be a very serious health emergency, leading to
convulsions, coma, and even death. Infants, young children, and
older adult patients are at greatest risk of developing serious compli-
cations from dehydration. Severe dehydration may be caused by
excessive heat loss, vomiting, diarrhea, or lack of fluid intake. Symp-
toms include vertigo; dark yellow urine or no urine output for 8 to
314 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES
10 hours; extreme thirst; lethargy or confusion; and abdominal or
muscle cramps. If the patient shows any of these symptoms and is
unable to retain fluids, schedule an urgent appointment or recom-
mend that the patient be taken to the ED. Replacement oflost fluids
is vital, so the patient should be encouraged to drink water, tea,
sports drinks, fruit juice, or Pedialyte.
Diabetic Emergencies
Diabetes mellitus is caused by a malfunction in the production of
insulin in the pancreas or by an inability of the cells to use insulin.
Insulin is required on the cellular level so that glucose can be used
for energy. Two different diabetic emergencies can occur, one caused
by hyperglycemia (high blood glucose levels) and the other by hypo-
glycemia (low blood glucose levels).
Insulin shock is caused by severe hypoglycemia, which results
when a patient with diabetes takes too much insulin, does not eat
enough food, or exercises an unusual amount. Signs and symptoms,
which have a rapid onset, include tachycardia, profuse sweating
(diaphoresis), headache, irritability, vertigo, fatigue, hunger, seizures,
and coma. It is important to provide glucose immediately, preferably
•;;m,ammiti~i Perform First Aid Procedures: Care for a Patient With a Diabetic Emergency
Goal: To provide emergency care for and assessment of apatient with insulin shock or apending diabetic coma.
EQUIPMENT and SUPPLIES
• Patient record
• Sphygmomanometer
• Stethoscope
• Watch with second hand
• Disposable gloves
• Glucometer
• Disposable lancet
• Glucose tablets
• Insulin
• Insulin syringe unit
• Alcohol swabs
• Sharps container
PROCEDURAL STEPS
1. Gather equipment and sanitize your hands.
2. Greet and identify the patient and introduce yourself.
PURPOSE: To relieve patient anxiety and earn patient cooperation.
3. Obtain vital signs.
4. If the patient is known to have diabetes, observe for signs and symptoms
that indicate a diabetic emergency.
• Signs and symptoms of insulin shock or hypoglycemia: Rapid onset of
vertigo, fatigue, hunger, tachycardia, profuse sweating, headache,
irritability, seizures, and coma.
• Signs and symptoms of impending diabetic coma or hyperglycemia:
Symptoms develop more slowly than those of insulin shock; these
include general malaise, dry mouth, polyuria, polydipsia, nausea,
in the form of glucose tablets, which have a known, concentrated
quantity of glucose.
Diabetic coma results from severe hyperglycemia, which devel-
ops because the body is not producing enough insulin; the patient
eats too much food or is very stressed; or the patient has an infec-
tion. The symptoms of impending diabetic coma, which develop
more slowly than those of insulin shock, include general malaise,
dry mouth, polyuria, polydipsia, nausea, vomiting, SOB, and
breath with an acetone (or "fruity'') smell. If the patient or caregiver
calling for an appointment reports these symptoms, notify the pro-
vider immediately because the patient typically would be admitted
to the hospital.
In an emergency situation, if a patient diagnosed with diabetes
mellitus shows signs and symptoms of a diabetic emergency,
the patient should be given glucose. If the problem is caused by
insulin shock (hypoglycemia), the patient will improve quickly after
receiving glucose; if it is caused by diabetic coma (hyperglycemia),
a small amount of added glucose will not affect the patient's condi-
tion, and he or she must be transported to the hospital regardless
(Procedure 12-15).
vomiting, shortness of breath (SOB), and breath with an acetone (or
"fruity") smell.
S. Immediately report patient's condition to the provider and follow his or
her orders.
PURPOSE: Adiabetic emergency can be life-threatening.
6. In an emergency situation, if a patient diagnosed with diabetes mellitus
shows signs and symptoms of a diabetic emergency, the patient should
be given glucose.
PURPOSE: If the problem is caused by insulin shock (hypoglycemia), the
patient will improve quickly after receiving glucose; if it is caused by
diabetic coma (hyperglycemia), a small amount of added glucose will not
affect the patient's condition, and he or she must be transported to the
hospital regardless.
7. Follow the provider's orders and administer 15 g of carbohydrate imme-
diately, preferably in the form of glucose tablets because they have a
known concentrated quantity of glucose. If glucose tablets are not avail-
able give the patient ½ cup of fruit juice or 5 or 6 pieces of hard candy.
PURPOSE: To quickly stabilize the patient's blood glucose level.
8. Check the patient's blood glucose levels with a glucometer and monitor
vital signs.
PURPOSE: To monitor the patient's current blood glucose level and
the patient's condition so the provider can determine appropriate
treatment.
• If the blood glucose level is below 80 mg/dl (insulin shock), admin-
ister another 15 g of carbohydrate. Wait 15 minutes and check the
glucometer reading again. If the level is still low, repeat steps 7
and 8.

•;;m,ammiti~i -,;ontinued
• If the patient's blood glucose levels are elevated (diabetic coma)
administer insulin as ordered by the provider
PURPOSE: To lower blood glucose levels to within a normal range.
9. Continue to monitor the patient and follow the provider's orders for con-
tinued care.
• Apatient with insulin shock can be stabilized by continued monitoring
of the blood glucose level and administration of glucose every 15
minutes until levels reach normal.
• Apatient with pending diabetic coma may need to be transported to
the hospital.
CLOSING COMMENTS
Patient Education
Emergencies can occur anywhere. Patients need to learn how to
handle emergency situations both by the example of healthcare
workers and through instruction. The medical assistant must remain
calm, screen the situation, call for help, and be prepared to admin-
ister appropriate first aid. Brochures on home safety can be used to
help teach patients methods for preventing accidents in the home.
All patients, even children, should understand how to contact
EMS. This is especially important for families with members who
have chronic diseases that can be life-threatening, such as heart
conditions, severe allergic reactions, diabetes, and asthma. Patients
should be encouraged to post important numbers next to the tele-
phone; these include emergency numbers (local EMS and poison
control center) and the primary care provider's number. Families
with young children must childproof their homes, taking special care
to keep potentially poisonous substances stored where children
cannot get into them. Placing "Mr. Yuk'' stickers on containers of
poisonous substances can be an excellent educational tool for young
children.
Medical assistants must remember to keep their American Red
Cross or AHA certifications current, and they should take advantage
of community workshops to maintain and extend their skills. Also,
a list of community safety workshops should be posted in an area
where patients can see it, and they should be encouraged to attend.
Your participation in emergency care workshops, in addition to
encouraging others to participate, may help to save lives.
Legal and Ethical Issues
The medical assistant works in the healthcare environment as the
provider's agent. Although you are responsible for your own actions,
the provider is legally responsible for the care you administer to
patients while working in the healthcare facility. You are responsible
for knowing the limitations placed on medical assistants in your state
and for adhering strictly to your employer's emergency care policies
and procedures. Medical assistants are not qualified to diagnose a
CHAPTER 12 Safety and Emergency Practices 315
10. Dispose of used supplies and gloves in the appropriate biohazard contain-
ers (sharps containers for used lancets and injection unit).
11. Sanitize your hands.
12. Document the actions taken and the patient's condition, including vital
signs, glucometer readings, administration of glucose and/or insulin, and
whether the patient was stabilized and discharged or emergency medical
services (EMS) were activated and the patient was transported to the
hospital.
patient's problem, but they are responsible for acting appropriately
in a medical emergency.
Most states have enacted Good Samaritan laws to encourage
healthcare professionals to provide medical assistance at the scene of
an accident without fear of being sued for negligence. These statutes
vary greatly, but all have the intent of protecting the caregiver. A
provider or other healthcare professional is not legally obligated to
provide emergency care at the site of an accident, regardless of the
ethical and moral considerations. Legal liability is limited to gross
neglect of the victim or willfully causing further injury to the victim.
As a caregiver, you are required to act as a reasonable person and
cannot be held liable for personal injury resulting from an act of
omission. Good Samaritan statutes provide for evaluation of the
caregiver's judgment but are in effect only at the site of an emergency,
not at your place of employment.
If you have not been trained in CPR, you cannot be expected to
perform the procedure at the emergency site. However, in many
states, a healthcare provider with CPR training and skills who is
present at the scene can be declared negligent if cardiac arrest occurs
and he or she does not administer CPR to the victim.
If the victim is conscious or if a member of his or her immediate
family is present, obtain verbal consent to perform emergency care.
Consent is implied if the patient is unconscious and no family
member is present.
Medical assistants also can play a key role in the community
response to natural or human-caused disasters. The medical assistant
is cross-trained to perform multiple administrative and clinical
duties that would prove very useful in an emergency. These include
management of medical records, interacting professionally with
patients, performing diagnostic tests, performing phlebotomy and
administering medications, assisting with procedures, and adminis-
tering first aid and CPR as needed. Because of their wide range
of skills, medical assistants serve as useful volunteers on local emer-
gency response teams. Investigate agencies and organizations that are
committed to emergency preparedness in your community and see
how a medical assistant could help these organizations if an emer-
gency arises.
 316 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES
Professional Behaviors
In addition to legal responsibilities, you have an ethical responsibility to your
patients to provide the highest standard of care. Always act in the best interest
of the patient, and never hesitate to ask the provider and/or the office
manager for immediate assistance when faced with a medical emergency.
Many types of emergencies can be handled in the provider's office. In an
emergency situation, decisions that must be made quickly can determine
whether the patient lives. Amedical assistant must be prepared to act calmly
and efficiently in all emergency situations.
i-iiiiit+i;it•jii9#it-iU1•i
Cheryl has learned through her work with the telephone screening team and
involvement with emergencies in the office how important it is to gather
complete information about emergency situations and to act calmly and knowl-
edgeably when managing patient problems. She knows she needs to maintain
her certification in CPR for the Professional and to continue to participate in
workshops on emergency care so she is prepared for the wide variety of patient
problems seen in the ambulatory care practice. Working with the screening staff
has reinforced the importance of documenting all interactions on the telephone
and all information gathered during patient visits.
Cheryl recognizes that medical assistants in the office must follow the
facility's policies and procedures manual for handling emergencies. They must
plan ahead and complete their designated duties if an emergency occurs; use
SUMMARY OF LEARNING OBJECTIVES
l. Define, spell, and pronounce the terms listed in the vocabulary.
Spelling and pronouncing medical terms correcrly reinforces the medical
assistant's credibility. Knowing the definitions of these terms promotes
confidence in communication with patients and co-workers.
2. Describe patient safety factors in the medical office environment.
The medical assistant must be constanrly on guard to protect patients
from possible injury. Methods for achieving this goal include communicat-
ing openly about patient safety issues, following standard procedures
when delivering patient care, and working as part of a team to ensure
patients' safety.
3. Interpret and comply with safety signs, labels, and symbols and
evaluate the work environment to identify safe and unsafe working
conditions for the employee.
The four major types of signs are danger signs (identify the most severe
and immediate hazards); caution signs (possible hazards that require
added precautions); safety instruction signs (designed to communicate
directions for safety actions); and biologic hazard signs (identify an actual
or potential biohazard). OSHA specifies the format of each type of sign,
the information that must appear, and where each type of sign must be
used (see Figure 12-1 and Procedures 12-1 and 12-2).
Critical thinking is a crucial part of managing medical emergencies. The
ability to ask pertinent questions, consider all available information, and
distinguish between relevant and irrelevant patient feedback can make the
difference in the immediate management of an emergency situation. Both
the provider and the patient rely on the professional medical assistant when
he or she is managing potentially serious phone calls and/or caring for a
patient with a medical emergency in the healthcare setting.
community emergency services as needed; and keep emergency supplies and
equipment well stocked and ready for any possible emergency. She recognizes
that understanding first aid practices for common patient emergencies allows
her to assist patients by providing instruction on the phone or by periorming
specific skills when emergencies occur in the facility.
Cheryl has investigated her legal standing as a medical assistant in her
home state and recognizes her responsibilities when a patient calls or shows
up at the office with a medical emergency. She will continue to refer to the
more experienced screening staff members or to Dr. Bendt when she has ques-
tions, but she now feels more confident in managing emergency situations at
work. She also recognizes her role as part of the healthcare team if an emer-
gency situation arises in her community.
4. Do the following when it comes to environmental safety in the
healthcare setting:
• Identify environmental safety issues in the healthcare setting
• Discuss fire safety issues in a healthcare environment
• Demonstrate the proper use of a fire extinguisher
Medical assistants must be constanrly on the alert for potentially unsafe
conditions; must consistenrly follow the guidelines established by OSHA
for infection control; and must follow safety procedures to prevent work-
place violence. Combustibles should be stored properly; electrical equip-
ment must be monitored for safety; smoke detectors and fire extinguishers
should be checked routinely; and the facility should be evacuated if a
fire breaks out. Procedure 12-3 details the proper use of a fire
extinguisher.
5. Describe the fundamental principles for evacuation of a healthcare
facility and role-play a mock environmental exposure event and
evacuation of a provider's office.
An emergency action coordinator should be designated. This person is
in charge of delegating duties to staff members. Exit maps should
be posted in multiple areas around the facility. Patients and staff
members should be evacuated safely and should meet in a designated

SUMMARY OF LEARNING OBJECTIVES-continued
spot to make sure all staff members and patients have escaped (see
Procedure 12-4).
6. Discuss the requirements for proper disposal of hazardous
materials.
OSHA has established specific rules about biohazard waste disposal,
including the use of sharps containers and red bag collection systems,
which must be used properly to avoid disease transmission.
7. Identify critical elements of an emergency plan for response to a
natural disaster or other emergency.
Ambulatory care centers may be the first to recognize and initiate a
response to a community emergency. Standard Precautions should be
implemented immediately to control the spread af an infection. Acom-
munication network should be established to notify local and state health
departments and perhaps federal officials. Every healthcare facility should
have a standard policy with specific procedures for the management of
emergencies an site. The CDC recommends that a facility's safety plan
include multiple steps to minimize the negative psychological effects of
an emergency situation.
8. Maintain an up-to-date list of community resources for emergency
preparedness.
See Procedure 12-5.
9. Describe the medical assistant's role in emergency response.
Medical assistants can provide considerable help in a community emer-
gency. They can use therapeutic communicatian to gather patient data;
monitor injured victims; perform first aid and monitor vital signs; and
help with any medically related service.
10. Summarize typical emergency supplies and equipment.
Aprovider's office must have a centrally located crash cart or emergency
bag stocked with all emergency supplies, equipment, and medication.
This material must be inventoried consistently and maintained. This
chapter provides a detailed list of materials that should be readily avail-
able for an on-site emergency, including a defibrillator if indicated by the
provider's practice.
11. Demonstrate the use of an automated external defibrillator.
See Procedure 12-6.
12. Summarize the general rules for managing emergencies.
Management of emergencies requires a calm, efficient approach. The
medical assistant should assess the nature of the emergency and deter-
mine whether EMS should be activated, or whether the patient requires
an immediate or urgent appointment. As many details about the situation
as possible should be gathered, and the provider should be consulted
when the medical assistant is in doubt.
13. Demonstrate telephone screening techniques and documentation
guidelines for ambulatory care emergencies.
Telephone screening is one of the medical assistant's most important
tasks. Emergency actian principles shauld be used to determine the level
of a patient's emergency. These include determining whether the situa-
tion is life-threatening and obtaining the patient's contact information,
in addition to all pertinent information about the injury and the
patient's signs and symptoms. This information must be shared with the
CHAPTER 12 Safety and Emergency Practices 317
provider, and all details must be documented in the patient's record (see
Procedure 12-7).
14. Recognize and respond to life-threatening emergencies in the ambu-
latory care practice.
Life-threatening emergencies require immediate assessment, referral to
the provider or, if the provider is not present, activation of EMS. While
waiting for assistance, the medical assistant should check for breathing
and circulation. Rescue breaths or CPR is administered if indicated.
Depending on the patient's signs and symptoms, the person should be
monitored for signs of a heart attack; the Heimlich maneuver is per-
formed for an airway obstruction; the patient is evaluated for signs of a
(VA and is assessed for shock. The medical assistant should ask for help
when indicated and should perform appropriate procedures based on the
patient's presenting condition.
15. Describe how to handle an unresponsive patient and perform
provider/professional-level CPR.
See Procedure 12-8 for instructions on performing adult, pediatric, and
infant rescue breathing and CPR.
16. Discuss cardiac emergencies and administer oxygen through a nasal
cannula to a patient in respiratory distress.
See Procedure 12-9.
17. Identify and assist a patient with an obstructed airway.
Procedure 12-10 presents instructions for assisting an adult with an
obstructed airway. Infants with an obstructed airway shauld receive
alternating back blows and chest thrusts with attempted rescue breaths
until the item is dislodged or help arrives.
18. Discuss cerebrovascular accidents and assist a patient who is in
shock.
Astroke is a disorder of the cerebral bload vessels that results in impair-
ment af the blood supply to part of the brain. Symptoms of a major
stroke include paralysis on one side of the body, difficulty swallowing,
loss of bladder and bowel control, and slurring of speech. Procedure
12-11 explains how to assist a patient in shock.
19. Determine the appropriate action and documentation procedures for
common office emergencies, such as fainting, poisoning, animal
bites, insect bites and stings, and asthma attacks.
The medical assistant should always follow Standard Precautions when
caring for a patient with a medical emergency. Documentation of emer-
gency treatment should include information about the patient; vital signs;
allergies, current medications, and pertinent health history; the patient's
chief complaint; the sequence of events, including any changes in the
patient's condition since the incident; and any provider's orders and
procedures performed (see Table 12-1 ).
20. Discuss seizures and perform first aid procedures for a patient
having a seizure.
See Procedure 12-12.
21. Discuss abdominal pain, sprains and strains, and fractures, and
perform first aid procedures for a patient with a fracture of
the wrist.
See Procedure 12-13.
Continued
318 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES
SUMMARY OF LEARNING OBJECTIVES-continued
22. Discuss burns and lissue injuries, and control of a hemorrhagic
wound.
See Procedure 12-14.
23. Discuss nosebleeds, head injuries, foreign bodies in lhe eye, heat
and cold injuries, dehydration, and diabetic emergencies; also, per-
form first aid procedures for a patient with a diabetic emergency.
See Procedure 12-15.
24. Apply patient education concepts to medical emergencies.
Patients should know how to contact emergency personnel, and fami-
lies with young children should have telephone numbers for poison
control posted. Educating patients in how to care for minor emergen-
cies at home is an important part of telephone triage in the ambula-
CONNECTIONS
(lJ Study Guide Connection: Go to the Chapter 12 Study Guide. Read and complete
the activities.
tory care practice. Encouraging patients to participate in community
safety workshops and to become certified in CPR may help prevent
emergencies and save lives.
25. Discuss the legal and ethical concerns arising from medical
emergencies.
Good Samaritan laws, which vary from state to state, are designed to
protect any individual from liability, whether a healthcare professional or
a layperson, if he or she provides assistance at the site of an emergency.
The law does not require a medically trained person to act, but if emer-
gency care is given in a reasonable and responsible manner, the health-
care worker is protected from being sued for negligence. This protection,
however, does not extend ta the workplace.
evolve Evolve Connection: Go to the Chapter 12 link at evolve.elsevier.com/
kinn to complete the Chapter Review Quiz. Check out the other resources listed for this
chapter to make the most of what you have learned from Safety and Emergency
Practices.
ASSISTING IN OPHTHALMOLOGY
AND OTOLARYNGOLOGY
i-i#H+i;H•i
Kim Tau, (MA (AAMA), works in an outpatient clinic that specializes in the
diagnosis and treatment of eye and ear disorders. Kim has been asked by her
supervisor to help orient Amy Ling to the practice. Amy recently graduated from
a medical assistant program and is familiar with basic eye and ear procedures,
but she has many questions about her responsibilities at the clinic. Amy will be
responsible for performing initial Snellen and Ishihara screening examinations
on new patients and for assisting the ophthalmologist and the optician in the
While studying this chapter, think about the following questions:
• What is the basic anatomy and physiology of the eye and of the ear?
• What are the major types of refractive errors?
• With what disorders of the eye and ear does Amy need to be
familiar?
• How is a Snellen test performed?
LEARNING OBJECTIVES
1. Define, spell, and pronounce the terms listed in the vocabulary.
2. Explain the differences among an ophthalmologist, an optometrist, and
an optician.
3. Identify the anatomic structures of the eye.
4. Describe the process of vision.
5. Differentiate among the major types of refractive errors.
6. Summarize typical disorders of the eye and eyeball other than
refractive errors.
7. Do the following related to diagnostic procedures for the eye:
• Define the various diagnostic procedures for the eye.
• Perform a visual acuity test using the Snellen chart.
• Assess color acuity using the Ishihara test.
8. Explain the purpose of and the proper procedure for eye irrigation and
the instillation of eye medications.
9. Identify the structures and explain the functions of the external ear,
middle ear, and inner ear.
10. Describe the conditions that can lead to hearing loss, including
conductive and sensorineural impairments.
13
practice. She also must become proficient in conducting audiometry screening
tests on pediatric patients, performing ear irrigations, and administering otic
medications. Kim recognizes that it is important for Amy to be able to perform
these skills with accuracy and confidence; however, she also must develop a
sensitivity to the communication and patient education needs of patients with
eye and ear disorders.
• What are the important steps Amy should follow in performing eye and
ear irrigations and medication applications?
• How is an examination with an audiometer conducted?
• How should Amy perform a throat culture?
• How should Kim prepare Amy to care for patients with sensory loss?
11. Define other major disorders of the ear, including otitis, impacted
cerumen, and Meniere's disease.
12. Do the following related to diagnostic procedures for the ear:
• Explain diagnostic procedures for the ear.
• Use an audiometer to measure a patient's hearing acuity
accurately.
• Identify the purpose of ear irrigations and instillation of ear
medications.
• Demonstrate the procedure for performing ear irrigations.
• Accurately instill medicated ear drops.
13. Summarize the nose and throat examination and perform a throat
culture.
14. Describe the effect of sensory loss an patient education.
15. Discuss legal and ethical issues that might arise when caring for a
patient with a vision or hearing deficit, in addition to requirements
established by HIPAA and the Americans with Disabilities Act
Amendments (ADAA).
320 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES
VOCABULARY
accommodation Adjustment of the eye that allows a person to
see various sizes of objects at different distances.
amblyopia (am-ble-o'-pe-uh) Reduction or dimness of vision with
no apparent organic cause; often referred to as lazy eye syndrome.
audiologist (aw-de-ah'-lah-jist) Allied healthcare professional who
specializes in evaluation of hearing function, detection of
hearing impairment, and determination of the anatomic site of
impairment.
cones Structures in the retina that make the perception of color
possible.
evert To turn the eyelid inside out; this typically is done by the
provider to inspect the area for foreign bodies.
fovea centralis (fo'-ve-uh/sen-trah'-lis) A small pit in the center
of the retina that is considered the center of clearest vision.
gonioscopy (goh-ne-os'-kuh-pe) A procedure in which a mirrored
optical instrument is used to visualize the filtration angle of the
anterior chamber of the eye; the procedure is used to diagnose
glaucoma.
hertz The unit of measurement used in hearing examinations; a
wave frequency equal to 1 cycle per second.
miotic (mi-ah'-tik) Any substance or medication that causes
constriction of the pupil.
mydriatic (mid-re-at'-ik) A topical ophthalmic medication that
dilates the pupil; it is used in diagnostic procedures of the eye
and as treatment for glaucoma.
A. medical assistant is responsible for performing a wide variety of
£"\.procedures in an ophthalmologic or otorhinolaryngologic prac-
tice. First, the medical assistant must be familiar with the normal
anatomy and physiology of the eyes, ears, nose, and throat. With an
understanding of how these specialty sensory organs function, the
medical assistant can master the skills needed to become a valuable
asset to providers who specialize in the treatment of eye and ear
disorders.
This chapter covers the conditions most frequently seen in the
ambulatory care setting. Many subspecialty areas are available to
medical assistants in the fields of ophthalmology (eye) and otolar-
yngology (ear, nose, and throat [ENT]). Learning the fundamental
procedures now provides you with a base on which to build the
advanced techniques you will need if you choose to concentrate your
expertise in these areas.
EXAMINATION OF THE EYE
Ophthalmology is the science of the eye and its disorders and diseases.
A physician who specializes in the diagnosis and treatment of disor-
ders and diseases of the eye is an ophthalmologist. An ophthalmologist
is a licensed medical physician who can diagnose eye disorders,
prescribe medication, conduct eye screenings, prescribe glasses or
contact lenses, and perform optic surgery. An optometrist is not a
medical doctor, but he or she is licensed and has earned a degree as
a Doctor of Optometry (OD). An optometrist can perform eye
examinations, diagnose vision problems and eye diseases, prescribe
ophthalmic medications, and treat visual defects through corrective
optic disc The region at the back of the eye where the optic nerve
meets the retina; it is considered the blind spot of the eye
because it contains only nerve fibers and no rods or cones and
thus is insensitive to light.
optic nerve Cranial nerve II, which carries impulses for the sense
of sight.
otosclerosis (o-tuh-skluh-ro'-sis) The formation of spongy bone
in the labyrinth of the ear, which often causes the auditory
ossicles to become fixed and unable to vibrate when sound
enters the ears.
ototoxic (o-tuh-tahk'-sik) A medicine or substance capable of
damaging cranial nerve VIII or the organs of hearing and
balance.
photophobia Abnormal sensitivity to light.
psoriasis (suh-ri' -uh-sis) A usually chronic, recurrent skin disease
marked by bright red patches covered with silvery
scales.
rods Structures in the retina of the eye that form the light-
sensitive elements.
seborrhea (seh-buh-re' -uh) An excessive discharge of sebum from
the sebaceous glands, forming greasy scales or crusty areas on
the body.
tonometer (toh-nom'-ih-ter) An instrument used to measure
intraocular pressure.
lenses and eye exercises. Opticians are trained to fill prescriptions
written by ophthalmologists and optometrists for corrective lenses
by grinding the lenses and dispensing eyewear.
Anatomy and Physiology of the Eye
The eyes are the smallest, yet the most detailed and complex, organs
of the body. Each is located within a bony cavity (or orbit) in the
skull. The bony orbit protects and supports the eye. Only approxi-
mately one sixth of the eye lies outside the orbit. The eyelid helps
protect the eye from trauma. The eyebrows help keep irritants out
of the eyes. The eyelashes line the margins of the eyelids and help
trap foreign particles.
The conjunctiva is a thin mucous membrane that lines the eyelid
and covers the outside of the eyeball except for the most central
portion, which is covered by the cornea. The mucus secreted from
the conjunctiva helps keep the eye moist. The eye blinks every 2 to
3 seconds, causing the lacrimal gland, located in the superior outer
portion of the upper eyelid, to secrete tears. Tears move across the
eyes, cleansing and moistening the surface, and drain into the lacri-
mal canals in the medial corner of the eye. The tears then drain into
the nasal cavity through the nasolacrimal duct. Consequently, when
a person cries, the excess tears ultimately empty into the nose, pro-
ducing a watery nasal discharge.
The Eyeball
The eyeball consists of three layers. The outermost layer is made up
of the white, opaque sclera and the transparent cornea. The sclera is
a tough, fibrous lining that protects the entire eyeball lying within
 CHAPTER 13 Assisting in Ophthalmology and Otolaryngology 321

the orbit, whereas the transparent cornea covers the exposed one
Ciliary body
sixth of the eyeball. The cornea acts as a clear window that allows
light to enter the eye. The cornea also refracts, or changes, the direc-
tion of light rays after they enter the eye. The cornea was one of the
first tissues to be transplanted, and corneal transplants now are
common. Long-term success after corneal implant surgery is
Fovea
excellent.
central is
The choroid is the posterior portion of the middle layer of the
eye. It is the eye's vascular layer, and it contains many blood vessels Pupil
Optic
that supply nutrients to the outer layers of the retina. The choroid
also has a brown pigment that absorbs excess light rays that could Anterior
interfere with vision. In the anterior part of this layer, the choroid cavity
creates the iris and the ciliary body. The iris is the colored portion filled with
aqueous
of the eye. It is doughnut shaped, with the opening of the pupil in humor
the center. The iris contains muscles that regulate the size of the pupil
according to the intensity of the light; it becomes smaller in bright
light and opens wider in dim light. The ciliary body contains both
the ciliary muscle, which regulates the shape of the lens, and the Iris
ciliary processes, which secrete aqueous humor.
Vitreous humor
The inner layer of the eye includes the retina in the posterior
portion and the lens in the anterior portion. The rods and cones,
FIGURE 13-1 Anatomy of the eye.
optic nerve, optic disc, and fovea centralis are located in the retina.
The delicate tissue of the retina is composed oflight-sensitive neurons
that convert light into neurologic impulses. These impulses travel by TABLE 13-1 Functions of the Major Parts
means of the optic nerve to the brain, where they are converted into
a visual form. Any damage to the retina has the potential to cause
of the Eye
partial or complete blindness because the neurologic center of vision STRUCTURE FUNCTION
is located in the retina.
Sciera External protection
The lens is a transparent, biconvex body that helps focus light
after it passes through the cornea. The lens and the ciliary body Cornea Light refraction
divide the eye into two cavities. The posterior cavity, which is
between the lens and the retina, contains the transparent, gel-like
Choroid Blood supply
vitreous humor. Vitreous humor maintains the shape of the posterior Iris Light absorption and regulation of pupil width
eyeball. The anterior cavity, between the cornea and the lens, is filled
with aqueous humor, which is continuously produced by the ciliary Ciliary body Secretion of vitreous fluid; changes the shape
processes. Aqueous humor helps maintain normal pressure within of the lens
the eye and provides nutrients to the lens and the cornea Lens Light refraction
(Figure 13-1) .
Retinal layer Light receptor that transforms optic signals into
Vision nerve impulses
Vision requires light and depends on the proper functioning of all
Rods Distinguish light from dark and perceive shape
parts of the eye (Table 13-1). A visual impulse begins with the
passage of light through the cornea, where the light is refracted; it
and movement
then passes through the aqueous humor and the pupil into the lens. Cones Color vision
The ciliary muscle adjusts the curvature of the lens to again refract
the light rays so that they pass into the retina, triggering the photo- Central fovea Area of sharpest vision
receptor cells of the rods and cones. At this point, the light energy Marnia lutea Center of the retina; contains the fovea
is converted into an electrical impulse, which is sent through the centralis, the area of most highly acute vision
optic nerve to the visual cortex of the occipital lobe of the brain;
there, the light impulse is interpreted and a picture is created. External ocular muscles Move the eyeball
Disorders of the Eye Optic nerve One of a pair of nerves that transmit visual
stimuli to (cranial nerve II) the brain
Refractive Errors
Four major types of refractive errors result when the eye is unable Lacrimal glands Produce tears
to focus light effectively on the retina. Refraction is the ability of the
lens of the eye to bend parallel light rays coming into the eye so that
Eyelid Protects eye
the rays are focused simultaneously on the retina. An error of refrac- Modified from Damianov I: Pathology for the heolth·reloted professions, Philadelphia, 1996,
tion means that the light rays are not refracted or bent properly and Saunders.
322 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES
consequently do not focus correctly on the retina. Defects in the
shape of the eyeball can cause a refractive error. Most refractive
errors can be corrected with corrective lenses, contacts, or surgery
(Figure 13-2).
Hyperopia (Farsightedness). When light enters the eye and focuses
behind the retina, a person has hyperopia. This disorder occurs when
the eyeball is too short from the anterior to the posterior wall. An
individual with hyperopia has difficulty seeing objects that are close,
at reading or working level. A convex corrective lens helps the eye's
internal lens place objects directly on the retina and creates a sharp,
detailed image, or refractive surgery may be done to correct the shape
of the lens.
Myopia (Nearsightedness). Myopia occurs when light rays entering
the eye focus in front of the retina, causing objects at a distance to
appear blurry and dull. Objects viewed at reading or working level
are seen clearly. In this disorder, the eyeball is elongated from the
anterior to the posterior wall, and the image cannot be sharpened
by the internal lens of the eye. A concave corrective lens is used to
focus the light rays on the retina, or surgery can be done to change
the shape of the cornea. However, the surgery is performed only on
adults who have had a stable eye prescription for at least 1 year.
Presbyopia. As people age, the lens of the eye becomes less flexible,
and the ciliary muscles weaken; consequently, changing the point of
focus from distance to near becomes difficult. This is called presby-
opia. The condition results in difficulty seeing at reading level. A
combination corrective lens, known as a bifocal !em or a progressive
!em correction, is used to focus both distal and proximal objects
directly on the retina. Presbyopia actually starts at approximately age
10, but most people do not report an alteration in vision until their
early forties. Conductive keratoplasty is a laser surgical procedure
used to treat presbyopia.
Astigmatism. Astigmatism occurs when light rays entering the eye
are focused irregularly. This usually occurs because the cornea or
Lengthened
eyeball
A Myopia (nearsightedness)
uncorrected
Myopia (nearsightedness)
corrected
FIGURE 13-2 Errors in refraction. A, Myopia. B, Hyperopia.
the lens is not a smooth sphere, but rather has an irregular shape.
Ophthalmologists describe the lens as being shaped like a football
rather than a sphere, such as a basketball. This causes light rays
to be unevenly or diffusely focused on the retina, resulting in
blurred vision. It is like attempting to focus on objects seen
through a wavy piece of window glass. Astigmatism can be cor-
rected with glasses, contacts, or surgery. Surgical correction
attempts to reshape the cornea into a more spherical or uniformly
curved surface.
Signs and Symptoms of Refractive Errors
Refractive errors in vision can lead to squinting, frequent rubbing
of the eyes, and headaches. The individual notices blurred vision or
fading of words at reading level, or both. Some refractive errors are
familial in nature.
Treatment of Refractive Errors
Eyeglasses and contact lenses are the traditional treatments for visual
acuity problems caused by refractive errors. However, problems with
the shape of the lens can be corrected surgically. Surgery is performed
on an outpatient basis and requires only a short stay in the facility.
Medical assistants employed in an outpatient eye surgery facility
must be trained to fulfill this specialized role.
CRITICAL THINKING APPLICATION 13-1
Amy is assisting Dr. Hanser with visual acuity examinations. He asks her
whether she understands the causes of refractive errors. Amy has difficulty
explaining why refractive errors occur, so she tells Dr. Hanser she will
research the topic and get back to him. What have you learned about the
different refractive disorders and why they occur?
Shortened
eyeball
B Hyperopia (farsightedness)
uncorrected
Hyperopia (farsightedness)
corrected
 CHAPTER 13 Assisting in Ophthalmology and Otolaryngology
Surgical Correction of Refractive Errors
Most types of health insurance do not cover surgery for refractive correc-
tions. On average, each eye costs $1,500 to $2,200. The following are
some of the surgical procedures performed to correct refractive errors.
• Photorefractive keratectomy (PRK): The first surgical procedure devel-
oped to reshape the cornea with a laser. The same type of laser is used
for PRK and lASIK. The major difference between the two types of
surgery is the way the middle layer of the cornea is exposed before it
is vaporized with the laser. In PRK, the top layer of the cornea (the
epithelium) is scraped away to expose the stromal layer underneath.
In lASIK, a flap is cut in the stromal layer.
• Laser-assisted in situ keratomileusis (IASIK): lASIK uses an excimer
laser to reshape the central cornea to treat myopia, hyperopia, and
astigmatism. Athin, hinged flap of cornea is created, the flap is lifted,
and the exposed surface of the cornea is reshaped. After the corneal
curvature has been corrected, the flap is replaced, and the area heals
without stitches.
• Laser-assisted epithelium keratomileusis (IASEK): In lASEK surgery, the
surface epithelial cells of the eye are softened with an alcohol solution,
allowing the epithelial layer to be rolled back and the cornea to be
exposed. Alaser then is used to reshape the cornea and treat myopia,
hyperopia, and astigmatism. The epithelial flap is returned to its original
position, and a contact lens is placed on the cornea as a bandage for
several days to aid healing and reduce pain.
• Conductive keratop/asty (CK): CK uses heat created by a laser to
reshape the cornea. Heat is applied to the cornea's outer edge to tighten
and steepen the cornea. CK is used in patients older than 40 years of
age who need correction for hyperopia, presbyopia, and myopia. The
procedure causes little or no discomfort and improves vision almost
instantly. The corneal changes are not permanent, and retreatment may
be required.
Strabismus
Strabismus is failure of the eyes to track together, which means that
both eyes do not look in the same direction at the same time. Adults
can develop strabismus because of a condition or disease elsewhere
in the body, such as diabetes mellitus, muscular dystrophy, or hyper-
tension, or as the result of a head injury. In children, strabismus is
caused by weakness in the muscles that control eye movement. If
the condition appears in infancy or childhood, it is most commonly
associated with amblyopia. Treatment involves having the child
wear a patch over the unaffected eye so that the muscles of the "lazy''
eye are strengthened and/or administration of atropine eye drops to
the unaffected eye to medically decrease visual acuity in the "sound"
eye, thereby forcing the amblyopic eye to compensate. It was once
standard therapy that an eye patch must be worn up to 6 hours per
day, but getting young children to comply with this treatment is very
challenging. In children with moderate amblyopia, recent research
shows that patching for 2 hours daily is as effective as patching for
6 hours daily, and daily atropine is as effective as daily patching.
323
Children older than 7 years may still benefit from patching or atro-
pine, particularly if they have not previously received treatment for
amblyopia. Amblyopia recurs in 25% of children after patching is
discontinued; however, slowly reducing the amount of time the
patch is worn each day at the end of treatment reduces the risk of
recurrence. The main symptom in all age groups is diplopia (double
vision).
Nystagmus
A constant, involuntary movement of one or both eyes is called
nystagmus. The eye can move in any direction, and the movement
is accompanied by blurred vision. A child may be born with the
problem (congenital nystagmus), or the condition may be acquired
as a result of a brain tumor, an inner ear lesion, multiple sclerosis,
or substance abuse. Nystagmus is caused by an abnormal function
in the part of the brain that controls eye movements. Congenital
nystagmus is more common than acquired nystagmus, is usually
milder, does not worsen over time, and is not associated with any
other disorder. A patient with signs and symptoms of nystagmus
should initially have a neurologic evaluation to determine the
cause of the disorder, with treatment based on those findings.
However, congenital nystagmus has no cure. Affected individuals
typically are not aware of the eye movements, but they may have a
decrease in visual acuity that can be corrected with surgery or cor-
rective lenses.
Infections of the Eye
Many acute disorders of the eye are seen in the ophthalmologist's
office. These include the following:
• Hordeolum (stye): A localized, purulent infection of a seba-
ceous gland of the eyelid. The area is inflamed, swollen, and
painful. The infection usually is caused by staphylococci, and
it is treated with warm compresses and topical or systemic
antibiotics.
• Chalazion: A small cyst that results from blockage of a mei-
bomian gland (sebaceous gland) that lubricates the posterior
margin of each eyelid. The cyst can become infected, inflamed,
swollen, and painful. It may disappear spontaneously or may
need to be removed surgically.
• Keratitis: Inflammation of the cornea that results in superficial
ulcerations. It can be caused by the herpes simplex virus,
bacteria, or fungi, or it may develop as a result of corneal
trauma (e.g., intense light). Symptoms include inflammation,
tearing, pain, and photophobia. The condition is treated with
ophthalmic ointments, eye drops, and use of an eye patch.
• Conjunctivitis: Inflammation of the conjunctiva caused
by irritation, allergy, or bacterial infection. Bacterial con-
junctivitis (pinkeye) is highly contagious and produces
a purulent discharge. Symptoms include inflammation,
swelling and itching of the sclera, photophobia, and tearing.
Bacterial infections are treated with antibiotic ophthalmic
preparations.
• Blepharitis: Inflammation of the glands and lash follicles along
the margins of the eyelids that may be caused by staphylococ-
cal infection, allergies, or irritation. Symptoms include itching
and inflammation along the eyelash margins; the condition is
treated with antibiotic ophthalmic ointment.
324 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES
Disorders of the Eyeball
Corneal Abrasion
The cornea, the transparent outer covering of the eye, is prone to
abrasion because of its location. Symptoms of corneal abrasion
include pain, inflammation, tearing, and photophobia. The abrasion
usually is caused by a foreign body in the eye or by direct trauma,
such as from poorly fitting or dirty contact lenses. A corneal ulcer
may form and become infected.
Diagnosis is based on the patient's signs and symptoms, but it
can be confirmed with the instillation of fluorescein stain (Figure
13-3). After instillation of the stain, the provider uses a cobalt blue
filtered light to visualize the abrasions, which appear green (Figure
13-4). If the abrasions are caused by a foreign body, it must be
removed first; the eye then can be treated with antibiotic ophthalmic
ointment to prevent infection. Although patching the affected eye
has been recommended in the past, studies now show that patching
does not reduce the patient's pain and may actually prolong healing
time. Corneal abrasions are quite painful, so the patient may be
prescribed topical nonsteroidal antiinflammatory ophthalmic drops,
such as diclofenac (Voltaren) and ketorolac (Acular), in addition to
oral analgesics. Most corneal abrasions heal in 24 to 72 hours, but
the patient should be aware that symptoms can worsen if the affected
FIGURE 13-3 Corneal abrasion stained with fluorescein.
FIGURE 13-4 Corneal abrasion stained with fluorescein and highlighted by cobalt blue light.
eye is exposed to bright light, if excessive blinking occurs, or if the
patient rubs the injured surface of the cornea against the inside of
the eyelid. Because the patient may develop a secondary infection
from the corneal injury, topical antibiotics, including ciprofloxacin
0.3% (Ciloxan) ointment or drops and gentamicin 0.3% ointment
or drops, may be prescribed. Patients with contact lenses may be
prescribed oral antibiotics and should not wear their contacts until
the abrasion has healed and the course of antibiotics has been
completed.
Cataract
A cataract is a cloudy or opaque area in the normally clear lens of
the eye that blocks the passage of light into the retina, causing
impaired vision. This condition may result from injury to the eye,
exposure to extreme heat or radiation, or inherited factors. However,
most cataracts develop slowly and progressively as a result of the
natural aging deterioration of the lens of the eye and typically occur
after age 60. With advanced cataracts, the pupil of the eye appears
white or gray.
A cataract scatters the light as it passes through the lens, prevent-
ing a sharply defined image from reaching the retina resulting in
blurred and dimmed vision. The patient may need a brighter reading
light or must hold objects closer to the eyes for better viewing.
Continued clouding of the lens may cause diplopia. The patient also
needs frequent changes of eyeglass prescriptions. Patients with cata-
racts report difficulty with night vision (nyctalopia), seeing halo
images around lights, and increased sensitivity to glare. If left
untreated, cataracts ultimately can lead to blindness.
When the patient's vision becomes distorted or appears to be
deteriorating, the ophthalmologist performs a slit lamp procedure,
in which he or she examines the structures at the front of the eye
using a combination of a low-power microscope and a high-intensity
light that shines into the eye as a slit beam.
The symptoms of early cataract may be improved with new eye-
glasses, brighter lighting, and antiglare sunglasses. If these measures
do not help, surgical removal of the lens is the only effective treat-
ment. This is performed as an outpatient procedure in a clinic or
hospital. After the eye has been anesthetized, the inner portions of
the lens (the nucleus and the cortex) are removed. The provider may
use an extracapsular extraction, in which the cataract is removed in
one piece, or phacoemulsification, in which an ultrasonic probe is
used to break up the cataract and the pieces are aspirated, before an
artificial intraocular lens (IOL) is implanted. The incision may be
closed with fine sutures, or it may be sutureless and self-sealing. The
procedure usually takes 15 minutes, and the patient typically can
leave the facility after 1 hour. Patients should be aware that they will
not be able to drive until cleared by the ophthalmologist, and that
they may need help at home until their vision is clear.
The patient is seen in the office the day after surgery and as fre-
quently as needed for the next month. Vision gradually improves
until it stabilizes, usually within 2 to 6 weeks; the patient then is
fitted with new corrective lenses to match the improved vision.
Glaucoma
One of the most common and serious ocular disorders is a group of
diseases known as glaucoma. Glaucoma is characterized by increased
intraocular pressure (IOP), which damages the optic nerve and
 CHAPTER 13 Assisting in Ophthalmology and Otolaryngology 325

causes blindness if left untreated. It rarely occurs in people younger Diagnosis and immediate treatment for early stage, open-angle
than age 40 and usually is seen in individuals older than age 60. The glaucoma can delay progression of the disease. Open-angle glaucoma
cause is unknown, but a hereditary tendency toward development can be relieved with miotic and beta blocker eye drops. The combi-
of the most common forms has been noted. Glaucoma is responsible nations of drugs used to treat glaucoma can vary considerably.
for approximately 12% of all cases of blindness. After cataracts Miotic medications increase the outflow of aqueous humor, and beta
(which are typically age related and can be resolved surgically), blockers reduce the production of aqueous humor (Table 13-2). It
glaucoma is the leading cause of blindness among African-Americans. is imperative that the patient use prescribed eye drops and take oral
It is estimated that more than 3 million Americans have glaucoma, medications daily to prevent further damage to the optic nerve. Laser
but only half of those know they have it. surgery may be performed to create an opening or to build a new
The ciliary body constantly produces aqueous humor, which channel for drainage of the aqueous humor. The goal of treatment
should circulate freely between the anterior and posterior chambers in any type of glaucoma is to diagnose the disease early and to
of the eye and eventually empty into the general circulation. A effectively treat its progression because any loss of sight that has
healthy eye is filled with fluid in an amount carefully regulated to occurred as the result of increased IOP cannot be regained. In closed-
maintain the shape of the eyeball. In chronic open-angle glaucoma, angle glaucoma, medications to lower IOP are prescribed so that
the channels that drain the fluid malfunction, and over time aqueous surgery can be performed to create a channel in which aqueous fluid
humor builds up, resulting in increased pressure, which affects the can circulate. This is a medical emergency because the pressure must
blood supply to the retina and the optic nerve. With acute closed- be relieved within a few hours or permanent vision damage occurs.
angle glaucoma, the opening of the drainage system narrows or closes
completely, causing a sudden increase in IOP (Figure 13-5). Macular Degeneration
Patients can have chronic open-angle glaucoma for a long time The macula lutea, the part of the retina near the optic nerve, defines
before symptoms occur. Early detection through regular ophthalmic the center of the field of vision. Macular degeneration is progressive
examinations that include IOP measurements is crucial to prevent deterioration of the macula lutea, which causes loss of central vision;
permanent vision loss. The need to change eyeglass prescriptions the patient can see only the edges of the visual field (Figure 13-7).
frequently, loss of peripheral vision (often called "tunnel vision''),
mild headaches, and impaired adaptation to the dark are some of
the signs and symptoms that may be seen with chronic glaucoma.
Acute closed-angle glaucoma has more obvious symptoms; the
patient complains of severe pain, headaches, inflammation, photo-
phobia, and seeing halos around lights. If left untreated, acute
glaucoma can cause permanent blindness in a matter of days
(Figure 13-6).
Screening for glaucoma is conducted during a complete eye
examination. The ophthalmologist first uses a tonometer with a slit
lamp to measure IOP. The air puff tonometer records the degree of
indentation of the cornea from a puff of pressurized air without
touching the eye. An applanation tonometer records the pressure
needed to indent the cornea when the instrument is applied to the
front surface of the eye. Electronic tonometry is the most recently
developed technique. The ophthalmologist gently places the rounded
tip of a tool that looks like a pen directly on the cornea, with results
evident on a small computer panel. Gonioscopy also can be used to
examine the aqueous fluid drainage system and to determine whether
the glaucoma is the open- or closed-angle type. In addition, an
ophthalmoscopic examination can identify cupping of the optic disc,
which indicates atrophy of the optic nerve.

FIGURE 13-6 A, Normal vision. B, The same picture as seen by a person with glaucoma, showing
A B loss of peripheral vision (i.e., "tunnel vision"). (From the National Eye Institute: Age-related macular
FIGURE 13-5 A, Open-angle glaucoma. B, Closedilngle glaucoma. degeneration: what you should know, National Institutes of Health, Bethesda, Md.)
326 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES

TABLE 13-2 Ophthalmic Medications

DRUG NAME
Chloroptic, Ciloxan, erythromycin, Topical antibiotic ointments
Neosporin and Garamycin ung
Viroptic
AK-Pred, Durezol
Ocufen, Acular, Voltaren
lsopto Atropine, (yclogyl
Betoptic
Alphagan
Rescula, Travatan, Lumigan
lsopto Carpine, Pilocar
Alrex, Alocril, Zaditor
ung, Unguent or ointment.
CLASS AND USE
Antiinfective, antiviral
Antiinflammatory agents,
corticosteroids
Topical antiinflammatory agents,
nonsteroidal antiinflammatory drugs,
analgesics
Mydriatic eye drops; eye examinations
Beta blocker eye drops; glaucoma
treatment
Alpha-adrenergic agonist eye drops;
glaucoma treatment
Prostaglandin analog eye drops;
glaucoma treatment
Miotic eye drops; glaucoma treatment
Treatment of seasonal allergies

The condition affects more than 10 million Americans and is a

leading cause of blindness in those older than 50.
Two types of macular degeneration can occur. The dry form
accounts for most cases; it is painless and develops slowly, affecting
sharp vision over time, so that reading and other activities that
require fine, detailed vision become impossible. Wet macular degen-
eration causes 90% of all severe vision losses from the disease and
has a very acute onset and rapid progression. Dry macular degen-
eration is caused by the breakdown of light-sensitive cells in the
region of the macula; the wet form is seen when new blood vessels
behind the retina form and leak blood and fluid into the macula.
The condition is age related, but additional risk factors include ciga-
rette smoking, obesity, family history, cardiovascular disease, ele-
vated blood cholesterol levels, light eye color, and excessive sun
exposure. The disease has no known cure, but recent research indi-
cates that antioxidants, including beta carotene and vitamins C
and E with zinc and copper, may prevent the condition or may
help treat the disease in people who have intermediate macular
degeneration.
Diagnostic Procedures
A complete examination of the eye is technical and requires expen-
sive equipment and the expertise of an ophthalmologist or optom-
etrist. However, a primary care provider performs some basic
examinations and treatments of the eye. The ophthalmoscope is used
to examine the interior of the eye. It projects a bright, narrow beam
of light through the lens and illuminates the interior parts of the eye
FIGURE 13-7 Visual field for a patient with macular degeneration. (From the National Eye
Institute: Age-related macular degeneration: what you should know, National Institutes of Health,
Bethesda, Md.)
and retina. It is helpful for detecting disorders of the eyes and certain
systemic disorders, such as capillary changes that occur with diabetes
mellitus.
The eyelids are examined for edema, which may be the result of
nephrosis, heart failure, allergy, or thyroid deficiency. Blepharoptosis,
also called ptosis, is drooping of the upper eyelid that can be caused
by a disorder of the third cranial nerve, muscular weakness as seen
in muscular dystrophy, or myasthenia gravis.
The pupils of the eyes are normally round and equal. Normal
pupils constrict rapidly in response to light. This is demonstrated by
shining a bright, pinpoint light into one eye from the side of the
patient's head. The pupil of an illuminated eye constricts, and the
pupil of the other eye constricts equally. This test is called light
and accommodation (L&A). An older patient's eyes do not accom-
modate as well as those of a younger person. Each eye is checked
this way. The patient then is asked to look at the provider's finger
as it is moved directly toward the patient's nose to check for eye
coordination. If the pupils are equal and round, respond normally
to light, and adjust and focus on objects at different distances
in a reasonable length of time, the provider charts the acronym
PERRLA.
 CHAPTER 13 Assisting in Ophthalmology and Otolaryngology 327

Special techniques used in the ophthalmologist's office include

PERRLA examinations performed with a slit lamp biomicroscope (Figure
P Pupils 13-8). This device is used to view fine details in the anterior segments
E Equal of the eye. It may be used to view a foreign body because it gives a
R Round well-illuminated and highly magnified view of the area. For this
R Reactive to examination, the provider first orders administration of a mydriatic
L Light [and] eye drop to dilate the pupil and enhance visualization of eye
structures.
A Accommodation
A patient with exophthalmia (abnormal protrusion of the eye,
possibly resulting from an overactive thyroid or a tumor behind the
eyeball) is checked with an exophthalmometer. This instrument mea-
sures how far the eye protrudes beyond the edge of the eye socket
and helps determine the level of tissue swelling and enlargement
behind the eye.

Distance Visual Acuity

Determining distance visual acuity frequently is part of a complete
physical examination (Procedure 13-1). It is widely used in schools
and industry and is the best single test available for vision screening.
Many cases of myopia, astigmatism, and hyperopia have been
detected with this routine test. The chart most commonly used is
the Snellen alphabetical chart (Figure 13-9, A). This chart displays
various letters of the alphabet, which the patient must identify in
ever smaller font sizes. Patients with limited knowledge of the
English alphabet can be tested with the E chart (Figure 13-9, B). In
addition, a chart that uses pictures as symbols is available. This chart
is used for young children or individuals who do not know the
alphabet (Figure 13-9, C) . To avoid patient confusion over the E
FIGURE 13-8 Slit lamp. chart or the symbol chart, the medical assistant should review the

Ep E a
20 200FT
iiio 61M

20 200FT
200 61M 20
iiio
200FT
61M 1
1
20
i"iiii

T
F
0 z
,ooFT
30.SM
2
3
20
ioo
mE ,ooFT
3D.5M 2 ~o
,oo

+ 100FT
3o.5M

-
20 70FT
70 21.3M

2,/!
50
L p E D SOFT
15.2M
4
5
20
70
3 wm 70FT
21.3M
3 fill
70

= .1!l..EI.

w
•
20
p E C F D 40FT 20
E E 3 SOFT
4
"' 12.2M
6 50 i5.FM
fill
" + 1..1 SOFT
15.2M

20
E D F C z p 30FT
30 9.14M
7 5
m w w
-
30FT
ii!!
3 3 IC
~ 0
9.14M 20 40FT

*
30
20
F E L 0 p z D 2'FT 40 ~
25 7.62M
8
20
70 D E F p 0 T E C
20FT
6.10M
ii!!
20 E3WWmE3
20FT
6.10M
6
20
L E F 0 D p C T
'5FT
9
20
:io 0 fJ * If' + 30FT
9.1M

15 4.57M
20
F D p L T C E 0
'3FT 10
20
15 E W 3 mw3 mE .12....E!
4.6M
7 20
20
* + 0
• l!!3
20FT
6.1M

" 3.96M
20
ii, p E Z 0 L C F T D
,OFT
3.05M
11 ii!!
rn
w m 3 w E w m 3 .1Q£I
3.05M 8 fill
rn I. • . * + .19..EI.
3.05M

A B C
FIGURE 13-9 Different types of Snellen charts.
328 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES
charts with patients first to make sure they know how to demonstrate
the E visualized or the meaning of each picture or symbol. The
symbol on the top line of the chart can be read at 200 feet by people
with normal vision. In each of the succeeding rows, from the top
down, the size of the symbols is reduced so that a person with normal
vision can see them at distances of 100, 70, 50, 40, 30, and 20 feet,
consecutively.
The patient must not be allowed to study the chart before taking
the test. The room or hall should be long enough that the 20-foot
distance can be marked off accurately and without interruptions
from patient and staff traffic. The chart should be hung at the
patient's eye level and illuminated with maximum light, without
glare on the chart. Most adults do not need the standard Snellen
chart explained, but if the E chart is used, an explanation must be
given as to how the E's are to be read. The patient may point up or
down or right or left toward the part of the letter that is open. If the
E chart is to be used for a child, practice with an index card that
has a large E drawn on it before the child is tested. Turn the card in
different directions to simulate the position of the "fingers" of the
E on the chart, and give the child the opportunity to demonstrate
the direction of the E fingers by pointing his or her own fingers in
the same direction (Figure 13-10).
FIGURE 13-10 Visual acuity test with the Echart.
Perform Patient Screening Using Established Protocols: Measure Distance Visual Acuity
PROCEDURE 13-1
with the Snellen Chart
Goal: To determine the patient's degree of visual clari/lj at ameasured distance of 20 feet using the Snellen chart.
EQUIPMENT and SUPPLIES
• Patient's health record
• Provider's order
Because this is a gross screening of distance visual acuity, the eyes
typically are tested with corrective lenses; the patient therefore
should not remove glasses or contact lenses unless the provider
requests it. Indicate in the patient's health record whether the assess-
ment was done with or without corrective lenses. Record the results
of each eye separately and as fractions. The numerator (top number)
is the distance of the patient from the chart (always 20 feet), and
the denominator (bottom number) is the lowest line read satisfacto-
rily by the patient. For example, if the patient reads the 20 line at
20 feet, the fraction 20/20 is recorded for that eye. The last line the
patient can read without squinting or straining and with no more than
two mistakes is the line recorded in the patient's record for that eye. The
medical assistant should document the outcomes of the test, specify-
ing the results for each eye and for both eyes. The Joint Commission
no longer recommends the use of medical abbreviations for the eyes
and ears because they are frequently confused or misinterpreted;
therefore, the medical assistant must now document right eye, left
eye, and both eyes.
Interpreting Snellen Results
• The patient always stands 20 feet from the chart.
• Each result is a record of how well the patient can see compared with
normal vision.
• Example: Apatient with a 20/ 40 reading can see that line correctly
standing at 20 feet, but an individual with normal vision can see the
same line correctly at 40 feet, so the patient's vision is not as acute
as someone with normal vision.
• Example: Apatient with a 20/15 reading can see that line accurately
standing at 20 feet, but a person with normal vision must stand at 15
feet ta have the same vision, meaning the patient's vision is better
than someone with normal vision.
CRITICAL THINKING APPLICATION 13-2
Susie Anthony, a 19-year-old patient, is seen today far a general eye
examination. The provider orders a routine Snellen test, and Kim administers
it. Susie wears contacts. With her right eye, she reads without errors to the
20/25 line; however, she squints and makes three errors at the 20/20
line. With her left eye, Susie makes two mistakes at the 20/30 line; with
bath eyes she reads the 20/25 without errors. Haw should Kim document
this procedure?
• Snellen eye chart
• Disposable eye accluder or an alcohol wipe to clean the accluder before use
• Pen ar pencil and paper
 CHAPTER 13 Assisting in Ophthalmology and Otolaryngology
•;;m!,mj;jihii -continued
PROCEDURAL STEPS
1. Sanitize your hands.
PURPOSE: To ensure infection control.
2. Prepare the area. Make sure the room is well lit and that a distance marker
is 20 feet from the chart.
3. Identify the patient by name and date of birth and explain the procedure.
Instruct the patient not to squint during the test because this temporarily
improves vision. The patient should not have an opportunity to study the
chart before the test is given. If the patient wears corrective lenses, they
should be worn during the test.
PURPOSE: Explanations help gain the patient's cooperation and alleviate
apprehension.
4. Position the patient in a standing or sitting position at the 20-foot marker.
PURPOSE: Twenty feet is the standard testing distance.
S. Check that the Snellen chart is positioned at the patient's eye level.
6. If the occluder is not disposable, disinfect it before the procedure starts.
Then, instruct the patient to cover the left eye with the occluder and to
keep both eyes open throughout the test to prevent squinting (Figure l).
PURPOSE: Traditionally, the right eye is tested first.
7. Stand beside the chart and point to each row as the patient reads it aloud,
starting with the 20/70 row (Figure 2).
PURPOSE: Starting with larger letters gives the patient confidence and
allows for accommodation of vision.
Near Visual Acuity
Near visual acuity can be tested with the near vision acuity chart
(Figure 13-11). This test is given to screen for presbyopia or hypero-
pia. If the patient wears corrective lenses, they should be worn during
the test. The size of the type on the card varies from newspaper
headlines to print similar to that found in telephone books. The test
should be given in a well-lit room, with the patient holding the card
329
8. Proceed down the rows of the chart until the smallest row the patient can
read with a maximum of two errors is reached. If one or two letters are
missed, the outcome is recorded with a minus sign and the number of
errors (e.g., 20/40-2). If more than two errors are made, the previous
line should be documented.
9. Record any of the patient's reactions while reading the chart.
PURPOSE: Reactions such as squinting, leaning, tearing, or blinking may
indicate that the patient is having difficulty with the test.
10. Repeat the procedure with the left eye, covering the right eye.
11. Repeat the procedure with both eyes uncovered.
12. Disinfect the occluder, if it is not disposable, and sanitize your hands.
PURPOSE: To follow infection control procedures.
13. Document the procedure in the patient's record, including the date and
time, visual acuity results, and any reactions by the patient. Also record
whether corrective lenses were worn.
PURPOSE: Procedures that are not recorded are considered not done.
Documentation Exercise: The medical assistant conducted a Snellen
exam on Carlene Anderson, who wears contacts. The results were: right eye
20/60; left eye 20/30, but she missed one letter at the 20/30 line; both
eyes 20/40. Carlene did not squint or strain during the exam.
Correct Documentation:
8/01 /20- 2:20 PM: Visual acuity completed c Snellen chart. Right eye
20/60, left eye 20/30-1, both eyes 20/40 c corrective lenses. No squint-
ing noted. Kim Tau, CMA (MMA)
approximately 14 to 16 inches away. As with the Snellen examina-
tion, the near visual acuity test is given for each eye, starting with
the right eye. The eye not being tested should be covered with an
occluder but left open. The patient should be monitored for indica-
tions of difficulty, such as squinting or tearing. The patient reads the
card, starting at the top, until reaching the smallest print that can
be read. The medical assistant should document the number at
330 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES

which the patient had no more than two errors for each eye and also
60 the two eyes together; whether corrective lenses were worn; and any
Nothing can take the place of "the only signs of eye strain.
pair of eyes you will ever have." That is
why you are exercising such good Ishihara Color Vision Test
judgment in taking care of them as you Defects in color vision are classified as congenital or acquired. Con-
are now doing. genital defects are caused by an inherited color vision defect and are
50 found most often in males. Acquired defects are caused by eye injury
For this reason, you will welcome the suggestion or disease. The Ishihara test is a simple, convenient, and accurate
about lenses which are designed and made to
procedure that detects total color-blindness, in addition to the red-
give you "greater comfort and better appearance."
In man's earliest days he had little use for glasses. green blindness prevalent in congenital blindness (Procedure 13-2).
He used his eyes chiefly for long distance. The test assesses the perception of primary colors and shades of
40 colors.
He worked by daylight and at tasks with little detail. But The test booklet contains polychromatic plates made up of
now, you use your eyes for much close work-reading, colored dots in numeric patterns. The numbers are one color, and
writing, sewing and many other uses which the eyes of
primitive man did not know. Now your eyes meet all the background dots are a different color. Patients with average visual
sorts of lighting conditions, artificial and natural. acuity can read the number within the dot matrix without difficulty.
30 Patients with color vision defects are unable to read the number, or
Many of these conditions produce "overbrightness" or glare. they see a totally different number. A section of plates is included
Sometimes it is the direct or reflected glare of sunlight; often it that contains colored line trails through a background of dots. These
is direct or reflected from artificial light. And very often this
glare is uncomfortable-impairs your efficiency. But special plates are designed to be used with children and adults who are
lenses, developed by America's leading optical scientists,
combat this glare.
unable to read numbers. In this situation, the patient uses a finger
to follow the dotted trail through the picture.
25
These lenses give you more commend them because they will
The test should be administered in a quiet room that is well
comfortable vision and blend give you greater comfort and illuminated by sunlight, not by artificial lighting. If this is not pos-
harmoniously with your com- better appearance. Thousands of
plexion. These lenses are less satisfied wearers testify to their sible, create the best situation possible by adjusting lights to resemble
conspicuous. We are glad to rec- real benefits.
the effect of natural daylight. The test uses 14 color plates. The basic
20 test consists of plates 1 through 11. Plates 12 through 14 are used
You are wise in taking good care of ''the suggestion about lenses which are
only pair of eyes you will ever have." designed and made to give you "greater if the patient appears to be having difficulty with red-green differ-
You know how valuable they are, that comfort and better appearance." In
you can never have another pair. For man's earliest days he had little use for entiations. The medical assistant records the number of plates read
this reason, you will welcome the glasses.
correctly. If the score is 10 or higher, the patient is within the average
The above letters subtend the visual angle of 5' at the designated distance in inches.
range. If the score is 7 or lower, the patient is suspected of having a
color deficiency, and the ophthalmologist performs additional assess-
FIGURE 13-11 Near vision acuity chart.
ment tests using more precise color vision testing equipment.

Instruct and Prepare a Patient for a Procedure: Assess Color Acuity Using the Ishihara
PROCEDURE 13-2
Test

Goal: To assess apatient's color acuity correcrly and record the results.

EQUIPMENT and SUPPLIES 2. Check the provider's order. Then introduce yourself and verify the patient's
• Patient's health record identity by name and date of birth. Explain the procedure. Use a practice
• Provider's order card during the explanation and make sure the patient understands that he
• Room with natural light if possible or she has 3 seconds to identify each plate.
• Ishihara color plate book PURPOSE: To make sure you have the right patient. Also, an informed
• Pen, pencil, and paper patient is a cooperative patient. The first plate is a practice plate and is
• Watch with a second hand designed to be read correctly.

PROCEDURAL STEPS
1. Assemble the equipment and prepare the room for testing. The room should
be quiet and illuminated with natural light.
PURPOSE: Natural light is needed to test colors correctly.
 CHAPTER 13 Assisting in Ophthalmology and Otolaryngology
•;;m!,mj;jihfi -continued
3. Hold up the first plate at a right angle to the patient's line of vision and 30
inches from the patient. Be sure both of the patient's eyes are kept open
during the test (Figure l).
Treatment Procedures
Eye Irrigation
The eye is irrigated to relieve inflammation, remove drainage, dilute
chemicals, or wash away foreign bodies. Sterile technique and equip-
ment must be used to prevent contamination (Procedure 13-3).
Follow the procedure as ordered, making sure the patient is comfort-
able. Record the treatment in the patient's health record immediately
after it has been determined. Remember, if it is not recorded, it has
not been done.
Foreign bodies in the eye are very irritating and may cause
considerable pain. Most foreign bodies are superficial and can
be removed easily. Occasionally, a foreign particle may be deeply
embedded, requiring eye surgery. Notify the provider immediately
if a patient comes into the office with something in his or her eye.
331
4. Ask the patient to tell you the number on the plate. Record the plate number
and the patient's answer (Figure 2).
S. Continue this sequence until all 11 plates have been read. If the patient
cannot identify the number on the plate, place an Xin the record for that
plate number. Your record should look like this:
Plate l = pass, Plate 2 = pass, Plate 3 = X, Plate 4 = pass, and so on.
6. Include any unusual symptoms in your record, such as eye rubbing, squint-
ing, or excessive blinking.
7. Place the book back in its cardboard sleeve and return it to its storage space.
PURPOSE: The Ishihara color plates must be stored in a closed position
away from external light to protect the colors.
8. Document the procedure in the patient's health record, including the date
and time, the testing results, and any patient symptoms shown during the
test.
PURPOSE: Procedures that are not recorded are considered not done.
The first objective of the provider's examination is inspection. The
patient is asked to look to either side and up and down so that the
anterior surface of the eye can be inspected. For the provider to fully
inspect under the upper lid, the patient must cooperate by looking
downward while the provider everts the upper lid using a cotton-
tipped applicator. While the lid is maintained in an evened position,
any foreign materials may be rinsed away with sterile water or saline
solution. If the provider's order is for you to remove the foreign body,
do so with irrigation only. If this technique is unsuccessful, cover
both of the patient's eyes with a gauze dressing and notify your
supervisor immediately. The eyes track each other, so to prevent
movement in the affected eye, both eyes must be covered to prevent
possible eye trauma.
332 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES

Safety Alert CRITICAL THINKING APPLICATION 13-3

Never attempt to remove a foreign body from the cornea using a cotton- The provider tells Kim to irrigate the left eye of a 22-year-old patient to
tipped applicator. Scratches to the cornea may result, causing scar forma- remove a foreign body. She is to irrigate the eye with sterile normal saline
tion and impaired vision. solution until clear. How should Kim document this procedure?

Instruct and Prepare a Patient for a Procedure or Treatment: Irrigate a

PROCEDURE 13-3
Patient's Eyes

Goal: To cleanse one or both eyes as ordered by the provider.

EQUIPMENT and SUPPLIES 8. Place (or have the patient hold) a drainage basin next to the affected eye
• Patients health record to receive the solution from the eye. Place a poly-lined drape under the
• Provider's order basin to prevent the solution from getting on the patient.
• Prescribed sterile irrigation solution 9. Moisten a gauze square with solution and cleanse the eyelid and lashes.
• Sterile irrigating bulb syringe and sterile basin or prepackaged solution with Start at the inner canthus (near the nose) and move to the outer canthus
dispenser (farthest from the nose). Dispose of the gauze square in the biohazard
• Basin for drainage waste container after each wipe (Figure l ).
• Sterile gauze squares PURPOSE: Debris on the lids or lashes must be cleaned away before the
• Disposable drape conjunctiva is exposed.
• Towel
• Nonsterile disposable gloves
• Biohazard waste container
PROCEDURAL STEPS
1. Sanitize your hands.
PURPOSE: To ensure infection control.
2. Check the provider's orders to determine which eye requires irrigation (or
whether both eyes require it) and the type of solution to be used.
3. Assemble the materials needed.
4. Check the expiration date of the solution. Follow medication safety pro-
cedures and check the label of the solution three times: (l) when you
remove it from the shelf; (2) when you pour it; and (3) when you return
it to the shelf.
PURPOSE: To follow the rules for safely administering medications. 10. If you are using a bulb syringe, pour the required volume of room-
S. Identify the patient by name and date of birth and explain the temperature irrigating solution into the basin and draw the solution into
procedure. the bulb syringe. If an irrigating solution in a prepackaged dispenser is
PURPOSE: To make sure you have the right patient. Also, explanations used, remove the lid.
help gain the patients cooperation and ease apprehension. PURPOSE: Cold solution causes the patient pain and discomfort.
6. Assist the patient into a sitting or supine position, making sure that the 11. Separate and hold the eyelids with the index finger and thumb of one
head is turned toward the side of the affected eye. Place the disposable hand. With the other hand, place the syringe or dispenser on the bridge
drape over the patient's neck and shoulder. of the nose parallel to the eye.
PURPOSE: This position causes the solution to flow away from the unaf- PURPOSE: To support and steady the dispenser.
fected eye, reducing the chance of cross-contamination of the healthy eye.
7. Put on gloves and rinse your gloved hands under warm water to remove
all powder from the gloves, or wear powder-free gloves.
PURPOSE: Gloves help hold the eye open, but powder may irritate the
eyes.
 CHAPTER 13 Assisting in Ophthalmology and Otolaryngology
I; ;m,ammiFII -continued
12. Squeeze the bulb or dispenser, directing the solution toward the lower
conjunctiva of the inner canthus; allow the solution to flow steadily and
slowly from the inner to the outer canthus. Do not touch the eye or eyelids
with the applicator (Figure 2).
PURPOSE: To prevent possible injury to the eye.
Instillation of Eye Medication
Medication may be instilled into the eye to treat an infection,
soothe an eye irritation, anesthetize the eye, or dilate the pupils
before examination or treatment (Procedure 13-4). Ophthalmic
medications are available in several forms. Liquid drops usually are
supplied in small squeeze bottles with tips that allow one drop at a
time to be dispensed, or the bottle may contain a dropper with a
small rubber attachment used to dispense the medication by
drops. Eye ointments are dispensed in small metal or plastic tubes
with an ophthalmic tip that allows them to be dispensed in a
small ribbon of ointment directly into the bottom eyelid (see
Table 13-2).
Instruct and Prepare a Patient for a Procedure or Treatment: Instill an
PROCEDURE 13-4
Eye Medication
Goal: To apply medication to one or both eyes as ordered by the provider.
EQUIPMENT and SUPPLIES
• Patient's health record
• Provider's order
• Sterile medication with sterile eye dropper or ophthalmic ointment
333
13. Refill the syringe or continue to gently squeeze the prepackaged bottle,
and continue the procedure until the amount of solution ordered by the
provider has been administered or until drainage from the eye is clear.
14. Dry the eyelid with sterile gauze, moving from the inner canthus to the
outer canthus. Do not use cotton balls because fibers might remain in the
eye.
1S. Dispose of the irrigation results and disinfect the work area.
16. Remove your gloves, dispose of them in the biohazard waste container,
and sanitize your hands.
PURPOSE: To ensure infection control.
17. Document the procedure in the patient's health record; include the date
and time, the type and amount of solution used, which eye was irrigated,
any significant reactions by the patient, and the results.
PURPOSE: Procedures that are not recorded are considered not done.
DOCUMENTATION EXERCISE
Eye irrigations until clear are ordered for Toby Kramer because of sand in both
eyes. You use 50 ml of irrigation solution in the right eye and 125 ml in the
left eye. After the procedure is complete, the sclera appears red, and Toby
complains of irritation in both eyes.
Correct Documentation:
8/06/20- 9:00 AM: Right eye irrigated c 50 ml normal saline sol and
left eye c 125 ml. Postprocedure sclera appears inflamed and pt c/o bilateral
irritation. Kim Tau, (MA (AAMA)
Safety Alert
Whatever the medication, the dispenser should never touch the eye while
the prescribed amount of medication is administered. This can traumatize
the eye and can contaminate the medication applicator. If the tip of the
dispenser touches any surface, dispose of it in a biohazard waste container
because it is contaminated.
CRITICAL THINKING APPLICATION 13-4
Amy is ordered to administer Xalatan, l drop each eye, to a 75-year-old
patient recently diagnosed with glaucoma. How should Amy document this
procedure?
• Disposable drape
• Sterile gauze squares
• Disposable nonsterile gloves
• Biohazard waste container
334 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES

•;;m!,mj;jihii -continued
PROCEDURAL STEPS 9. Administer the prescribed number of drops or amount of ointment into the
1. Sanitize your hands. eye. For eye drops, place the drops in the center of the lower conjunctiva!
PURPOSE: To ensure infection control. sac, with the tip of the dropper held parallel to the eye and ½ inch
2. Check the provider's order to determine which eye requires medication (or above the eye sac. For eye ointment (ung), squeeze a thin ribbon along
whether medication is ordered for both eyes) and the name and strength the lower conjunctiva! sac from the inner canthus to the outer canthus
of the medication to be used. making sure not to touch the eye with the applicator. '
PURPOSE: To prevent a medication error. PURPOSE: Placing the medication in the conjunctiva! sac rather than on
3. Assemble the equipment and supplies. the eyeball prevents injury to the cornea. Touching the eye with the
4. Check the expiration date of the solution. Follow medication safety pro- applicator could injure the eye and contaminates the applicator
cedures and check the label of the medication three times: (1) when you (Figure 2).
remove it from the shelf; (2) when you pour it; and (3) when you return
it to the shelf.
PURPOSE: To follow the rules for safely administering medications.
S. Introduce yourself, identify the patient by name and date of birth, and
explain the procedure.
PURPOSE: To make sure you have the right patient. Also, explanations
help gain the patient's cooperation and ease apprehension.
6. Put on nonsterile gloves and rinse your gloved hands under warm water
to remove all powder from the gloves or wear powder-free gloves.
PURPOSE: Gloves help hold the eye open, but powder may irritate the
eyes.
7. Assist the patient into a sitting or supine position. Ask the patient to tilt
the head backward and look up.
PURPOSE: Looking up helps prevent the applicator's tip from touching the
cornea. It also helps keep the patient from blinking as the medication is
instilled. For eye drops, draw the medication into the dropper. For an eye
ointment, remove the cap.
8. Pull the lower conjunctiva! sac downward (Figure 1).
PURPOSE: To create a pocket for the medication. 10. Instruct the patient to close the eye gently and rotate the eyeball.
PURPOSE: Gently closing the eye prevents the medication from being
dispelled, and rotating the eyeball distributes the medication evenly
(Figure 3).
 CHAPTER 13 Assisting in Ophthalmology and Otolaryngology
•;;m!,mj;jihii -continued
11. Dry any excess drainage from the inner canthus to the outer canthus, and
explain that the medication may temporarily blur vision.
12. Discard the unused medication, and disinfect the procedure area.
13. Remove your gloves, dispose of them in the biohazard waste container,
and sanitize your hands.
PURPOSE: To ensure infection control.
14. Record the procedure in the patient's health record, including date and
time, name and strength of the medication, dase administered, eye
Aseptic Procedures in Ophthalmology
A major concern in ophthalmologic procedures is the contamination
of eye medication applicators. Because of the concern of cross-
contamination, use of stock ophthalmic medications is discouraged.
The sterility of all eye medications is critical for good patient care.
Newly opened sterile solutions should be used for each patient and
should be discarded after instillation or given to the patient for home
use. All instruments used to remove a foreign body should be sterile.
EXAMINATION OF THE EAR
Otorhinolaryngology is the medical specialty that deals with the ear,
nose, and throat. It frequently is referred to as otolaryngology or even
as a single specialty of otology or laryngology. Usually, the specialty
otorhinolaryngology is referred to simply as ear, nose, and throat
(ENT).
Anatomy and Physiology of the Ear
The visible portion of the ears is only a small part of the actual organ
of hearing. Most of this structure lies hidden in the temporal bone.
Anatomically, the organ of hearing is divided into three sections: the
outer ear, the middle ear, and the inner ear (Figure 13-12).
Outer (ExternaQ Ear
The outer ear consists of the auricle, or pinna, the fleshy part of the
ear that can be seen on the side of the head, and the external audi-
tory canal, the tube that extends from the auricle to the tympanic
membrane (eardrum).
The auricle collects sound waves and sends them down the audi-
tory canal. The skin that lines the auditory canal contains numerous
hair follicles and many nerve endings, in addition to ceruminous
glands that secrete cerumen (commonly called earwax), which lubri-
cates the canal. Both the hair and the waxy cerumen help prevent
foreign objects from reaching the eardrum. The canal has a slight S
shape and is approximately 1 inch (2.5 cm) long.
Middle Ear
The middle ear, sometimes called the tympanic cavity, is an air-filled
chamber that begins with the tympanic membrane and terminates
at the oval window. The middle ear contains the auditory ossicles or
bones: malleus, incus, and stapes. These three tiny bones are linked
by minute ligaments to form a bridge across the space of the
335
treated, teaching instructions given (if treatment is to continue at home),
and any observations.
PURPOSE: Procedures that are not recorded are considered nat done.
8/8/20- l :45 PM: Thin ribbon of Neosporin ophthalmic ung applied in lower
conjunctiva! sac of right eye. No pt complaints. Pt instructed on home care
application of med, including washing hands before and after procedure and
taking care not to tauch eye c applicator. Kim Tau, (MA (AAMA)
tympanic cavity. The malleus is next to the tympanic membrane,
and the stapes is against the oval window. The eustachian tube opens
into the middle ear cavity and connects to the nasopharynx. It is
designed to equalize pressure in the middle ear with that in the
external auditory canal. This equalized pressure makes hearing pos-
sible. Upper respiratory infections may spread to the middle ear
through the eustachian tube; this is a very common occurrence in
young children.
The tympanic membrane is a thin, disk-shaped tissue that seals
off the outer ear from the middle ear. Sound waves conducted
through the external auditory canal hit this membrane and cause it
to vibrate. These vibrations are picked up by the three ossicles and
are changed from air-conducted sound waves to bone-conducted
sound waves. The ossicles transmit the bone-conducted sound waves
through the middle ear to the oval window, which is the membrane
that connects the middle ear and the inner ear. At the oval window,
the sound waves move into the fluids of the inner ear. This fluid
motion excites the receptors, changing the bone-conducted sound
into sensorineural impulses.
Inner Ear
The inner ear, called the labyrinth, is divided into the cochlea and
the semicircular canals, which are joined by the vestibule. The semi-
circular canals function to maintain equilibrium, and the cochlea is
responsible for the sense of hearing.
The organ of Corti, which contains the receptors for sound, is
located within the cochlea. It is made up of hairlike sensory cells
surrounded by sensory nerve fibers that form the cochlear branch of
the eighth cranial nerve. Sound impulses cause the hairs to bend and
rub against the nerve fibers, which initiate stimuli to travel through
the cochlear nerve into the brain for sound interpretation.
The eighth cranial nerve transmits auditory impulses to the
medulla oblongata. These impulses then travel to the thalamus and
on to the auditory cortex of the temporal lobe of the brain, where
they are interpreted into audible sound and speech patterns.
The semicircular canals are responsible for evaluating the position
of the head in relation to the pull of gravity. The three canals are
positioned at right angles to one another, on different planes (Figure
13-13). When the head turns rapidly, these fluid-filled canals must
rapidly adjust and send the stimulated change into the central
nervous system, which interprets the information and initiates the
desired response to maintain balance. With repetitive or excessive
336 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES

Cartilage

Stapes in
oval window

INNER
Round window ___,.
EAR

process
MIDDLE
EAR

EXTERNAL
EAR
FIGURE 13-12 Anatomy of the ear. (From Jarvis C: Physical examination and health assessment, ed 7, Philadelphia, 2016, Saunders.)

Conductive hearing loss is caused by a problem originating in

Semicircular canals the external or middle ear that prevents sound vibrations from
positioned at right angles passing through the external auditory canal, limits the vibration of
the tympanic membrane, or interferes with the passage of bone-
conducted sound in the middle ear. Some common causative factors
in conductive hearing loss include impacted cerumen; trauma to the
tympanic membrane, especially with scar formation; hemorrhage or
fluid in the middle ear; otosclerosis; and recurrent chronic ear infec-
tions. Patients with conductive hearing loss receive the greatest
benefit from a hearing aid. If the hearing loss is caused by a malfunc-
tion or congenital abnormality of the ossicles, a surgical procedure
can be performed to replace the damaged ossicles with manufactured
models.
FIGURE 13-13 Semicircular canals. (From Applegate EJ: The anatomy and physiology learning
system, ed 4, Philadelphia, 2011, Saunders.) A sensorineural hearing loss results from an abnormality of the
organ of Corti or of the auditory nerve. Viral infection (e.g.,
rubella, influenza, herpes) can result in hearing loss, as can head
stimulation to the equilibrium receptors, some people become nau- trauma or certain ototoxic medications. The first sign of ototoxic
seated and may vomit. This condition is known as motion sensitivity drug complications usually is tinnitus, a ringing in the ears. This
or motion sickness. sometimes occurs with high doses of aspirin, certain antibiotics
(erythromycin and vancomycin), and chemotherapeutic agents. A
Disorders of the Ear sensorineural hearing loss also can occur because of prolonged
Hearing Loss exposure to loud noise, such as repetitive noise in the workplace,
Two problems result in hearing loss: a conduction problem and a or loud music, which damages the delicate cilia lining the organ
sensorineural impairment. Some individuals have both conditions. of Corti.
 CHAPTER 13 Assisting in Ophthalmology and Otolaryngology
CONDUCTION DEAFNESS
Occlusion of ear canal
with cerumen
Otosclerosis
Meniere's
disease
FIGURE 13-14 Causes of deafness.
Presbycusis, the hearing loss that affects aging people, is caused by
a reduction in the number of receptor cells in the organ of Corti
and also is classified as a sensorineural loss. Children can be born
with a congenital hearing deficit or deafness because of an intrauter-
ine infection, such as measles (rubella) (Figure 13-14).
If the sensorineural hearing loss cannot be improved by hearing
aids, an option is surgical implantation of an artificial cochlea.
Cochlear implants are complex devices that use electrical impulses
to stimulate the auditory nerve, which then carries the current to
the brain to be interpreted as sound. Cochlear implants bypass
damaged portions of the ear and directly stimulate the auditory nerve.
These implants do not create normal hearing but provide increased
sound for a person with profound or complete hearing loss.
Mixed hearing loss is a combination of conductive and sensory
deafness. This type of loss can result from tumors, toxic levels of
certain medications, hereditary factors, and stroke.
Otitis
Two common types of otitis are seen in patients in an otology or
family practice. The first affects the external ear canal and is called
otitis externa, or swimmer's ear. Otitis externa may be caused by
dermatologic conditions, such as seborrhea or psoriasis, trauma to
the canal, or continuous use of earplugs or earphones. Swimmers
Risk Factors for Otitis Media
Factors That Cannot Be Controlled
• Gender (male)
• Age (infants and younger children [6 to 18 months])
• Premature birth
337
NERVE DEAFNESS
Labyrinthitis:
• Viral Multiple sclerosis
• Autoimmune Encephalitis
Toxic injury of
labyrinth
Basal skull fracture
frequently have otitis externa because water collects in the ears and
mixes with cerumen to form an ideal culture medium for bacteria
and fungus. Patients with otitis externa complain of severe pain and
have inflammation and swelling of the external auditory canal,
hearing loss, and possibly purulent (containing pus) or serous drain-
age. The inflammation is treated with antibiotic or steroid ear drops,
and the canal must be kept clean and dry, or the condition can
become chronic.
Otitis media is an inflammation of the normally air-filled middle
ear that results in a collection of fluid behind the tympanic mem-
brane. Otitis media can be serous or suppurative. Serous otitis media
occurs because of a buildup of clear fluid in the middle ear; patients
complain of a full feeling and some hearing loss. In suppurative otitis
media, purulent fluid is present in the middle ear, and the patient
has fever, pain, and hearing loss. Otitis media often is associated with
an upper respiratory tract infection caused by a virus or an allergic
reaction that results in swelling and inflammation of the sinuses and
eustachian tubes. A child's eustachian tube is shorter, narrower, and
more horizontal than that of an adult. The small size and decreased
angle for drainage increases the chance that inflammation will block
the tube and cause fluid to collect in the middle ear, which not only
is uncomfortable but also interferes with the conduction hearing
process (Figure 13-15).
• Family history
• Siblings with infections
• Seasonal factors (most common during cold and flu season), seasonal
allergies
338 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES

Risk Factors for Otitis Media-continued

• Underlying disease (cleft palate, Down syndrome, asthma, allergies)
• Ethnicity (Native American and Alaskan Inuit because of the shape of the
eustachian tubes)
• Cochlear implants
Factors That Can Be Controlled
• Limit exposure to large-group child care settings.
• Do not expose the child to second-hand smoke.
• Hold the child upright during bottle feeding.
• Use of pacifiers beyond 6 months may increase the risk.
• Wash hands frequently to prevent the spread of colds and flu.
• Have the child immunized with pneumococcal conjugate vaccine (Prevnar)
and the flu vaccine.

I?titis interna I extension:

lntracranial

• Vertigo • Meningitis
Otitis • Hearing • Brain
media loss abscess

Mastoiditis Tympanic membrane

(eardrum) changes:
• Bulging
• Hyperemia
• Perforation
FIGURE 13-15 Inflammation and infection of the ear and surrounding tissues.

An otoscopic examination reveals that the normally pearly gray

tympanic membrane is inflamed (bright pink or red) and bulging
(Figure 13-16). Areas of fluid or pus may be visible through the
membrane. A tympanogram may be done to determine the air
pressure of the middle ear and the mobility of the tympanic mem-
brane. During a tympanogram test, a small earphone is placed
into the ear canal and the air pressure is gently changed. This test
is helpful for showing whether an ear infection or fluid is present
in the middle ear (Figure 13-17). A tympanic membrane respond-
ing normally to an increase in air pressure will move, resulting in a
peaked tympanogram. If fluid or pus in the middle ear is putting
pressure on the tympanic membrane, the membrane moves only FIGURE 13-16 A, Tympanic membrane with otitis media. B, Normal tympanic membrane. (From
slightly or not at all, resulting in a slight peak or a flat tympano- Lafleur Brooks M: Exploring medical language, ed 9, St Louis, 2014, Mosby.)
gram recording.
Treatment of otitis media may be a conservative "watch and wait" which is the creation of a surgical incision in the tympanic mem-
approach. However, if a fever and pronounced pain are present, the brane to drain the fluid, followed by insertion of a tympanostomy
individual may be given antibiotics and told to take over-the-counter tube to continually drain the middle ear of fluid. This may be neces-
analgesics such as acetaminophen or ibuprofen. If this condition sary to prevent permanent hearing loss caused by damage to the
becomes chronic, the provider may recommend a myringotomy, ossicles (Figure 13-18).
 CHAPTER 13 Assisting in Ophthalmology and Otolaryngology
Type A
1400
1200
1000
Ql
t.)
C:
.!ll 800
a.
E
0
0 600
400
200
-400 -300 -200 -100 0 +100 +200
Pressure (mm H2O)
FIGURE 13-17 Anormal tympanogram shows a peak at normal pressure (0). An ear with fluid
produces a flat tympanogram.
Recommendations for Treating Otitis Media
The development of drug-resistant strains of bacteria as a result of overpre-
scription of antibiotics is a growing concern. The American Academy of
Pediatrics recommends the following for the treatment of otitis media:
• Treatment with antibiotics should be delayed, giving the child's
immune system a chance to fight the infection by itself. This delay
should last 24 hours in children 6 to 24 months old and 72 hours
for older children. Approximately 61 %of children improve within
24 hours, regardless of whether they are treated. If the child's
condition does not improve, an appropriate antibiotic can be
prescribed.
• The child typically improves within 48 to 72 hours, but the parent
should understand how important it is to complete the antibiotic
medication as ordered to prevent the infection from recurring.
• The provider may decide to treat otitis media with a short course
of antibiotics (i.e., 5days) but at a higher dose. The drugs of choice
include amoxicillin (Amoxil), azithromycin (Zithromax), and cefu-
roxime (Rocephin).
• Antibiotics will not help if otitis is caused by avirus. The child should
be observed for possible complications, and analgesics should be
administered for pain control. Viral otitis media typically resolves
within 7 to 14 days.
The medical assistant plays a key role in helping parents understand
why antibiotic therapy may not be recommended. They also must educate
parents about the importance of administering a prescribed antibiotic at the
time ordered, using the correct dose, and completing the entire
prescription.
Impacted Cerumen
Cerumen normally is a soft, yellowish, waxy substance that lubri-
cates the external auditory canal. Excessive secretion of cerumen
can gradually cause hearing loss, tinnitus, a feeling of fullness, and
otalgia (ear pain). Impacted cerumen that has been pushed up
339
FIGURE 13-18 Tympanic membrane with a tympanostomy tube. (From Frazier MS, Drzym·
kowski JW: Essentials of human diseases and conditions, ed 5, St Louis, 2013, Saunders.)
tightly against the eardrum is a common cause of conductive
hearing loss because sound vibrations cannot pass through the
cerumen to initiate movement of the tympanic membrane. Indi-
viduals with psoriasis, abnormally narrow ear canals, or an excessive
amount of hair growing in the ear canals are more prone to this
condition.
An otoscopic examination quickly reveals this problem. If
impacted cerumen is found, it must be removed. This can be done
by softening the wax with oily drops, such as carbamide peroxide
(Debrox), and then irrigating the ear with warm water until the plug
is removed. Because this condition can recur, the patient may need
to schedule periodic examinations. If the patient is experiencing
hearing loss because of the impaction, it is immediately remedied
with removal of the cerumen.
Meniere's Disease
The semicircular canals of the inner ear, in coordination with the
eighth cranial nerve, control balance and give a sense of how
the body is positioned. The canals contain fluid (the endolymph),
the filtration and excretion of which are controlled by the part
of the canal called the endolymphatic sac. Meniere's disease causes
swelling and edema in this part of the semicircular canals, along
with an overproduction or collection of excess endolymph. When
this occurs, the patient shows signs. Although the cause of this
problem is unknown, Meniere's disease is a chronic, progressive
condition that triggers episodes of recurring attacks of vertigo (diz-
ziness), tinnitus, a sensation of pressure in the affected ear, and
advancing hearing loss. During an acute attack, patients experience
nausea, vomiting, and problems with balance. These attacks can
last a few hours to several days, and they increase in severity
over time.
During active periods of the disease, the patient is treated
symptomatically with medications for nausea and vomiting. A
salt-restricted diet, diuretics, and antihistamines may be pre-
scribed to control edema in the labyrinth. Surgical destruction of
the affected labyrinth is an option. Although this relieves symp-
toms, it may also result in permanent deafness if the cochlea is
damaged.
340 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES
Useful Questions for Gathering a History
of Ear Problems
• Are you experiencing nausea, vomiting, dizziness, ear pain, fever,
headache, upper respiratory infection, ringing of the ears, drainage, loss
of balance, or hearing loss?
• What are the onset, duration, and frequency of symptoms?
• Have you taken any medication for the symptoms? If so, what medica-
tion? Has it been helpful?
• Do you have the problem in both ears?
• Are you experiencing pain? On a scale of 1 to 10, with 10 being the
worst pain, how would you rate the pain? Is it localized or radiating,
in one ear or both?
• Has anything you have tried relieved the symptoms?
FIGURE 13-19 Instruments used in an otoscopic examination.
Diagnostic Procedures
An ear examination involves viewing the external auditory canal
with an otoscope covered by an ear speculum (Figure 13-19). Dis-
posable plastic speculum covers should be used each time to
prevent disease transmission. A normal otoscopic examination
reveals an external auditory canal with a small amount of cerumen
and a pearly gray and concave tympanic membrane. In addition to
performing the otoscopic examination, the provider palpates the
area around the pinna for abnormalities or sensations. A number of
tests are used to assess hearing acuity, ranging from simple tuning
fork tests to quantitative and qualitative audiometric testing. If a
hearing loss is suspected, the next test usually is performed with a
tuning fork.
Tuning Fork Testing
Tuning fork tests measure hearing by air conduction and bone con-
duction. Remember that in bone conduction, the sound vibrates
through the cranial bones to the inner ear. Tuning forks are available
in different sizes, each with a different frequency. The most
commonly used tuning fork is the 512 Hz hertz (Hz), which means
that it vibrates 512 cycles per second, the level of normal speech
patterns. To activate the fork, the provider holds it by the stem and
strikes the tines softly on the palm of the hand. Striking the tines
too forcefully creates a tone that is too loud for diagnostic use. The
two tests used to evaluate hearing are the Weber and Rinne tests.
Both of these procedures are commonly used to evaluate conductive
and sensory losses.
The Weber test is used if the patient reports that hearing is better
in one ear than in the other. The vibrating fork is placed in the center
of the top of the head, and the patient is asked in which ear the tone
is louder, or if the tone is the same in both ears. Because the patient
is hearing the tone by bone conduction through the head, a normal
result is hearing the sound equally in both ears.
The Rinne test is designed to compare air conduction sound with
bone conduction sound. In this test, the stem of the vibrating fork
is placed on the patient's mastoid process, and the patient is instructed
to raise a hand when the sound disappears. The fork is quickly
inverted so that the vibrating tines are approximately 1 inch in front
of the external ear canal. If hearing is normal, the patient should still
hear a sound. In normal hearing, the sound is heard twice as long
by air conduction as by bone conduction.
Audiometric Testing
An audiometric test may be done in an otology or a family practice
and is performed by medical assistants who have received additional
training. Audiometry measures the lowest intensity of sound an
individual can hear (Figure 13-20). The patient, frequently a child,
is assisted in placing headphones over the ears.
Newer machines give the operator the choice of performing a
traditional manual hearing test or an automated one. In the auto-
matic mode the patient is prompted through the ear phones to press
a hand button as soon as he hears a tone. The advantages of auto-
mated machines are that voice prompts are available in multiple
languages and the test requires less time to complete. The medical
assistant can watch the progress of the test on the audiometer's LCD
screen. Whether the test is delivered manually or with an automated
model, each ear is tested by delivering a single frequency at a specific
intensity, starting with low-frequency tones and going up to very
high frequencies. The patient is asked to signal when he or she hears
the sound. The results are printed on a graph, called an audiogram,
or the medical assistant charts the results on a graph sheet (Procedure
13-5). An adult with normal hearing can hear tone frequencies below
25 decibels, and children with normal hearing can hear those below
15 decibels.
If initial screening indicates a hearing deficit, the provider may
recommend an appointment with an audiologist for audiometric
evaluation. The evaluation consists of a battery of tests that assesses
the level of hearing impairment and provides valuable information
as to how the patient may be helped. The first test evaluates speech
comprehension and assesses the patient's ability to follow verbal
instructions. Once this evaluation is complete, the patient is placed
in a soundproof booth with earphones over the ears. From this point
on, the audiologist speaks to the patient and conducts all testing
through the earphones. The assessment includes testing the fre-
quency, intensity, and audibility of sound. This process takes approx-
imately 1 hour.
 CHAPTER 13 Assisting in Ophthalmology and Otolaryngology 341

FIGURE 13-20 Audiometer with headset.

Perform Patient Screening Using Established Protocols: Measure Hearing Acuity with
PROCEDURE 13-5
an Audiometer

Goal: To perform audiometric testing of hearing acuity.

EQUIPMENT and SUPPLIES
• Patient's health record
• Provider's order
• Audiometer with adjustable headphones and graph paper
• Quiet area
PROCEDURAL STEPS
1. Sanitize your hands, assemble the equipment, and bring the patient into
a quiet area (see Figure 13-20).
PURPOSE: The testing room should be free of distractions and noise so
the patient can concentrate completely on the hearing evaluation.
2. Introduce yourself, identify the patient by name and date of birth, and
explain the procedure.
PURPOSE: To make sure you have the right patient. Also, explanations
help gain the patient's cooperation and ease apprehension.
3. Explain that the audiometer measures whether the patient can hear various
sound wave frequencies through the headphones. Each ear is tested sepa-
rately. When the patient hears a frequency, he or she should raise a hand
or push the button to signal the medical assistant.
PURPOSE: Patient education is needed for compliance with the
examination.
4. Place the headphones over the patient's ears, making sure they are
adjusted for comfort.
S. The audiometer tests each ear separately, starting at a low frequency. If
the results are not automatically recorded by the machine, the medical
assistant documents the patient's response to the frequencies on a graph
or audiogram. Results for the left ear are marked with an X, and those
for the right ear are marked with an O(see the following figure) (Figure
l). More advanced machines automatically record the results. The medical
assistant must have specialized training to conduct this test.
6. Frequencies are increased gradually to test the patient's ability to hear.
Each response by the patient is documented.
7. After one ear has been tested, the other ear is then tested, and the results
are documented.
8. The results are given to the provider for interpretation or downloaded into
the patient's electronic health record for the provider to review.
9. The equipment is sanitized and disinfected according to the manufacturer's
guidelines.
10. Sanitize your hands.
342 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES

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Aseptic Procedures in Otology
Routine examination instruments should be disinfected or sterilized
after each use according to office policy and stored in a clean area.
Surgical asepsis must be practiced when dressings are changed and
minor surgery is performed. Medications, such as ear drops and nose
drops, must be handled carefully to prevent contamination.
directed at the tympanic membrane. Some discomforts the patient
may experience during ear irrigation include vertigo, ear discomfort,
coughing, or a tickle in the back of the throat. Perform the procedure
as prescribed, making sure the patient is comfortable. Always docu-
ment the treatment and its results immediately after completion.

Treatment Procedures CRITICAL THINKING APPLICATION 13-5

Ear Irrigation
Irrigation of the ear is done to remove excessive or impacted cerumen,
to remove a foreign body, or to treat the inflamed ear with an anti-
septic solution (Procedure 13-6). When an ear irrigation is ordered
by the provider, the medical assistant may perform the procedure if
he or she has had the proper training and is competent in the tech-
nique. To prevent discomfort for the patient, it is important to
administer the irrigating solution with the applicator tilted up,
toward the top of the external canal, so that the solution is not
Kim is instructed to perrorm a bilateral ear irrigation on a 68-year-old patient
with impacted cerumen. Before the procedure, she uses an otoscope to
check the auditory canal and sees a large amount af dark brown cerumen
in the right ear, completely covering the tympanic membrane. The left ear
has a moderate amount of golden brown cerumen covering the bottom half
of the tympanic membrane. After the procedure, both membranes are
visible, and the patient tolerated the procedure without complaints. How
should Kim document the procedure?

Instruct and Prepare a Patient for a Procedure or Treatment: Irrigate a

PROCEDURE 13-6
Patient's Ear

Goal: To remove excess or impacted cerumen from one or both of the patient's ears.

EQUIPMENT and SUPPLIES • Irrigating solution

• Patient's health record • Basin for irrigating solution
• Provider's order • Bulb syringe or an approved otic irrigation device
 CHAPTER 13 Assisting in Ophthalmology and Otolaryngology 343

•;;mHmhiidi -continued
• Gauze squares
• Otoscope
• Drainage basin
• Disposable drape with poly-lined barrier
• Cotton-tipped applicators
• Disposable gloves
• Biohazard waste container
PROCEDURAL STEPS
1. Sanitize your hands.
PURPOSE: To ensure infection control.
2. Check the provider's order and assemble the materials needed (Figure l).

8. Put on gloves and wipe any particles from the outside of the ear with
gauze squares.
PURPOSE: To prevent the introduction of foreign material into the ear
canal.
9. Test to make sure the solution is warm; then fill the syringe and expel air.
PURPOSE: Cold medication may increase the pain level or cause symp·
toms of nausea and vertigo; trapped air in the syringe increases the
pressure of the irrigation, causing discomfort.
10. Straighten the external ear canal. For adults and children older than age
3, gently pull the pinna of the ear up and back; for children younger than
age 3, pull the earlobe down and back (Figure 3).
PURPOSE: Straightening the canal allows the irrigating fluid to circulate
through it.

Children age 3
3. Check the label of the solution three times: (l) when you remove it from through adults
the shelf; (2) when you pour it; and (3) when you return it to the shelf.
PURPOSE: To prevent a medication error.
4. Prepare the solution as ordered. The solution should be kept at body
temperature to help loosen the cerumen.
S. Introduce yourself, identify the patient by name and date of birth, and
explain the procedure.
6. Inspect the affected ear with an otoscope to locate the cerumen Children younger
impaction. than 3
7. Place the patient in a sitting position with the head tilted toward the
affected ear. Place a water-absorbent towel over a poly-lined barrier on
the patient's shoulder, and the collecting basin on the towel at the base
of the ear. The patient can assist you by holding the collecting basin in
place (Figure 2).
PURPOSE: To minimize the risk of getting the patient's clothing wet and
to direct the flow of water into the collecting basin.

3
344 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES

•;;JetHmhiihii -continued
11. Place the tip of the syringe into the meatus of the ear.
12. Gently direct the flaw of the solution toward the roof of the external
auditory canal.
PURPOSE: This helps prevent injury to the tympanic membrane, aids in
the removal of embedded material, and provides the most comfort for the
patient.
13. Refill the syringe with warm solution and continue until the material has
been removed. Note the particles in the collecting basin to be evaluated
when the material has been successfully removed.
14. Dry the patient's external ear with gauze squares and the visible ear canal
gently with cotton-tipped applicators.
PURPOSE: Inserting the applicator into the canal may cause serious
trauma.
1S. Inspect the ear with an otoscope to determine the results (Figure 4).
16. Place a clean, absorbent towel on the examination table and allow the
patient to rest quietly with the head turned to the irrigated side while you
wait for the provider to return to check the affected ear.
17. Disinfect the work area and the equipment. Dispose of your gloves in the
biohazard container, and sanitize your hands.
PURPOSE: To ensure infection control.
18. Document the procedure in the patient's health record, including the date
and time; the ear irrigated; the type and amount of irrigating solution
used; the characteristics of the material returned from the irrigation; the
visibility of the tympanic membrane after irrigation; and any reactions by
the patient.
PURPOSE: Procedures that are not recorded are considered not done.
Documentation Exercise: You are ordered to perform an irrigation of both
ears on Mrs. Ophelia Black because of impacted cerumen. Otoscopic examina-
tion before the irrigation revealed a large amount of dark brown ear wax in
both ears. After irrigation, both tympanic membranes were visible, and Mrs.
Black had no complaints of discomfort.
Correct documentation:
8/12/ 20- l 0: 15 AM: Right and left ears irrigated c 500 ml saline sol
bilaterally. Lrg amt dark brown cerumen expelled; post irrigation both TMs visible
and pearly gray. No c/o discomfort. Kim Tau, (MA (MMA)

Instilling Otic Medications considerable pain and may have difficulty hearing, which makes
Medication ordered for ear instillation is given to soften impacted health teaching a challenge. Wait until after the procedure has been
cerumen, to relieve pain, or as an antibiotic drop for an infectious completed and the patient is more comfortable to reinforce health
pathogen (Procedure 13-7). Patients with ear conditions may be in behaviors.

Instruct and Prepare a Patient for a Procedure or Treatment: Instill Medicated Ear
PROCEDURE 13-7
Drops

Goal: To instill the correct medication in the accurate dose directly into the external auditory canal.

EQUIPMENT and SUPPLIES PROCEDURAL STEPS

• Patient's health record 1. Sanitize your hands and gather the equipment and supplies.
• Provider's order PURPOSE: To control infection and to reduce procedure time.
• Prescribed otic drops in dispenser bottle 2. Check the medication label three times: (l) when you remove it from
• Cotton balls the shelf; (2) when you prepare it; and (3) when you return it to the
• Disposable gloves shelf.
• Biohazard waste container PURPOSE: To prevent a medication error.
 CHAPTER 13 Assisting in Ophthalmology and Otolaryngology
•;;m!,mj;jihfi -continued
3. Introduce yourself, identify the patient by name and date of birth, and
explain the procedure.
4. Have the patient sit up and tilt the head away from the affected ear, or
lie down on the side with the affected ear upward.
PURPOSE: To expose the ear for treatment, allow gravity to help the
medication flow into the canal, and ensure the patient's comfort.
5. Check the temperature of the medication bottle. If it feels cold, gently roll
the bottle back and forth between your hands to warm the drops.
PURPOSE: Cold medication may increase the pain level or cause symp-
toms of nausea and vertigo.
6. Hold the dropper firmly in your dominant hand. With the other hand,
gently pull the pinna up and back if the patient is older than age 3 or the
earlobe down and back if the patient is younger than age 3.
PURPOSE: To straighten the ear canal and make it easier for the medica-
tion to reach the target tissue.
7. Place the tip of the dropper in the ear canal meatus and instill the number
of ordered medication drops along the side of the canal making sure that
the tip of the dropper does not touch the ear canal (Figure 1).
EXAMINATION OF THE NOSE AND THROAT
If you are working in an ENT specialty office, you also will assist in
the examination of the nasal cavity and the throat. The nasal cavity
is examined to inspect the mucous membrane of the nostrils. The
common cold and allergies are the main causes of changes in
the mucosa. The provider may use a nasal speculum to visualize the
nostrils and examines the nasal sinuses by palpation and
transillumination.
The throat is the area that includes the larynx and pharynx; it
can be viewed with the aid of a mirror and either a tongue depressor
or a gauze square for grasping the tongue. In the nasopharynx, the
345
8. Instruct the patient to rest on the side opposite the affected ear and to
remain in this position for approximately 3 minutes.
PURPOSE: To help the medication reach the base of the canal and prevent
it from immediately running out of the ear (Figure 2).
9. If instructed by the provider, place a moistened cotton ball into the ear
canal.
PURPOSE: To protect the ear canal and prevent medication from leaking
out of the ear.
10. Disinfect the work area. Dispose of your gloves in the biohazard waste
container, and sanitize your hands.
PURPOSE: To ensure infection control.
11. Document the procedure in the patient's health record, using the appropri-
ate abbreviations; include the date and time; name, dose, and strength
of the medication; the ear treated; and any reactions by the patient.
PURPOSE: Procedures that are not recorded are considered not done.
8/12/20- 3:22 AM: ii gtts Auralgan otic sol administered to right ear. No c/o
discomfort. Pt instructed on home use. Kim Tau, (MA (AAMA)
provider looks for enlarged adenoids (pharyngeal tonsils) and for the
orifices of the eustachian tubes. The provider may spray the patient's
throat with a topical anesthetic before the examination to prevent
the gag reflex.
Throat specimens frequently are collected in the provider's office
to assist in the diagnosis of strep throat infections. Strep throat is
caused by the group A beta-hemolytic streptococcal bacteria; if left
untreated, it can cause serious complications. Throat cultures are
collected by gently swabbing the back of the throat and the surfaces
of the tonsils with a sterile swab. The mouth and tongue should be
avoided to prevent contamination of the swab with the normal flora
of the mouth (Procedure 13-8).
346 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES

Perform Patient Screening Using Established Protocols: Collect a Specimen for a

PROCEDURE 13-8
Throat Culture

Goal: To collect a throat culture, using sterile technique, for immediate testing or for transportation to the laboratory.
EQUIPMENT and SUPPLIES
• Patients health record
• Provider's order
• Laboratory requisition
• Nonsterile gloves
• Face protection barrier
• Sterile swab
• Sterile tongue depressor
• Transport medium
• Biohazard waste container
PROCEDURAL STEPS
1. Sanitize your hands.
PURPOSE: To ensure infection control.
2. Gather the materials needed.
3. Introduce yourself, identify the patient by name and date of birth, and
explain the procedure.
4. Put on gloves and face protection.
PURPOSE: To follow Standard Precautions.
S. Position the patient so that the light shines into the mouth.
PURPOSE: To illuminate the area to be swabbed.
6. Remove the sterile swab from the sterile wrap with your dominant hand
9. Place the swab in the transport medium, label it, and send it to the labora-
and grasp the sterile tongue depressor with your nondominant hand.
tory (Figure 2). If direct slide testing is requested, return the labeled swab
PURPOSE: To achieve better control of the swabbing process.
to the laboratory.
7. Instruct the patient to open the mouth and say "Ah." Depress the tongue
PURPOSE: Atransport medium prevents the swab from drying. Labeling
with the depressor.
immediately after collection prevents specimens from becoming mixed up.
PURPOSE: Saying "Ah" helps elevate the uvula and reduces the tendency
to gag. The tongue is depressed so that you can see the back of the throat
and prevent contamination of the sterile swab.
8. Swab the back of the throat between the tonsillar pillars, especially any
reddened, patchy areas of the throat, white pus pockets, purulent areas,
and the tonsils; take care not to touch any other areas in the mouth
(Figure 1).
PURPOSE: Pathogenic organisms are found in the back of the throat and
on the tonsils.

10. Dispose of contaminated supplies in the biohazard waste container.

PURPOSE: To prevent the spread of infection.
 CHAPTER 13 Assisting in Ophthalmology and Otolaryngology
•;;m!,mj;jihi=I -,;ontinued
11. Disinfect the work area.
12. Remove your gloves and discard them in the biohazard waste
container.
13. Sanitize your hands.
PURPOSE: To ensure infection control.
CLOSING COMMENTS
Patient Education
Patients with vision or hearing impairment face serious challenges.
For these patients, the medical assistant must use good listening skills,
appropriate nonverbal methods, and touch to communicate empathy
and understanding. Teaching may have to be adapted to meet the
special needs of these patients. A person with a vision loss benefits
from large-print forms and handouts, increased lighting, and verbal
rather than written instructions to reinforce learning. For an indi-
vidual with a hearing deficit, printed instructions, demonstrations
of how to manage treatments, or even sign language interpretation
should be available to ensure accurate communication. Including
family members in the patient's treatment plan and offering referrals
to appropriate community or professional resources may be very
beneficial to a patient with sensory loss. Each patient must be assessed
individually to determine the type of adaptation that he or she needs.
An important part of patient education for those administering
eye medications at home is stressing the need to maintain the sterility
of the medication. Patients and/or family members must be taught
how to apply the medication while preventing trauma to the eye and
contamination of the applicator. Patients administering ear treat-
ments also must understand how to instill the medication.
CRITICAL THINKING APPLICATION 13-6
Mr. Samuel Langton is a 77-year-old patient with profound hearing loss and
severe glaucoma. How would you suggest that Amy communicate thera-
peutically with this patient? Role-play this interaction with one of your
classmates.
Legal and Ethical Issues
Diminished sight or hearing may render a patient seriously impaired.
To prevent accidents and office injuries, always ask a sight- or
hearing-impaired patient whether he or she requires assistance.
When you escort the patient to an examination room, offer your
arm and tell the patient the approximate distance you will be
walking. If the patient is to have an examination that involves local
anesthesia or eye drops that dilate the pupil, be sure the patient has
recovered and someone is available to take the patient home before
allowing him or her to leave the facility. Never assume that the
patient is capable of leaving alone. If the patient insists on leaving
before the designated recovery time, inform the provider and record
the time and circumstances surrounding the event in the patient's
health record. This information should be signed and witnessed. The
provider may want a refusal of care form signed by the patient and
placed in the health record.
347
14. Document the procedure in the patients health record.
PURPOSE: Procedures that are not recorded are considered not done.
8/14/20- 8:35 AM: Throat specimen collected via swab from tonsillar area.
Sent to University Laboratories for strep testing. Kim Tau, CMA (AAMA)
HfPAA Requirements
Regardless of the patient's disability, the ambulatory care center must
follow the guidelines for Notice of Privacy Practices (NPP) estab-
lished by the Health Insurance Portability and Accountability Act
(HIPM). The NPP is a form developed by the facility that outlines
the patient's rights and the facility's legal responsibilities to safeguard
the patient's protected health information. The facility must give the
NPP to each new patient at the first office visit. To comply with
HIPM guidelines, the document must be in a language the patient
easily understands. The staff is responsible for obtaining the patient's
signature on the form, which indicates the patient's agreement with
the stipulations of the facility's privacy practice. An individual with
a vision deficit may require a large-print form, or a staff member
may need to read the document to the person and answer any ques-
tions. The staff must make sure that patients with hearing deficits
have had time to read the document before signing.
Americans with Disabilities Act Requirements
The Americans with Disabilities Act (ADA) was passed in 1990, and
amendments were added in 2008. The Americans with Disabilities
Act Amendments (ADM) prohibits discrimination based on dis-
ability. An individual with a disability is defined by the ADM as a
person who has a physical or mental impairment that substantially
limits one or more major life activities; a person who has a history
or record of such an impairment; or a person who is perceived by
others as having such an impairment. Public facilities, including
ambulatory care facilities and other healthcare buildings, must
comply with ADM requirements for physical accommodations.
Public medical facilities must provide individuals with disabilities
access to communication devices if they have a problem with vision,
hearing, reading, or comprehension. Additional details can be found
at http://www.ada.gov/nprm_adaaa/adaaa-nprm-qa.htm.
Professional Behaviors
Patients with vision and hearing problems require an extra level of profes-
sional courtesy and respectfulness. Imagine what it would be like if you
could not see clearly or if you had difficulty understanding what your pro-
vider is saying to you. How would you like a family member who has
sensory difficulties treated when he or she visits the provider? Focus on
how you can adapt the facility's environment to accommodate the needs
of these patients. Is there adequate lighting? Are patient education materi-
als available that have been adapted for individuals with vision impair-
ment? How can you most effectively and respectfully communicate with a
patient who has a hearing loss? Many times, just the act of empathy-
imagining yourself in the place of the patient-can help guide you to treat
patients with the respect and courtesy they deserve.
 348 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES
i-iiiiit-iff•jii9#1MU1•i
After observing Kim and asking many questions, Amy is beginning to understand
her special responsibilities in the ophthalmology and otorhinolaryngology clinic.
She recognizes the need to be familiar with the anatomy and physiology of
both the eye and the ear, in addition to the importance of being able to perform
specialty-related skills, such as irrigations, medication instillations, and diagnos-
tic procedures. Amy has become quite proficient at performing Snellen and
Ishihara screening examinations and accurately documenting the results of each.
Kim has taught her to use the audiometer and assisted her with the first few
screenings, so she is now ready to do hearing tests on her own.
Although she learned about eye and ear medications in her medical assistant
program, Amy found that instilling these medications in an actual patient is
SUMMARY OF LEARNING OBJECTIVES
l. Define, spell, and pronounce the terms listed in the vocabulary.
Spelling and pronouncing medical terms correctly reinforce the medical
assistant's credibility. Knowing the definitions of these terms promotes
confidence in communication with patients and co-workers.
2. Explain the differences among an ophthalmologist, an optometrist,
and an optician.
An ophthalmologist is a medical doctor who specializes in the diagnosis
and treatment of the eye; an optometrist can examine and treat visual
defects; an optician fills prescriptions for corrective lenses.
3. Identify the anatomic structures of the eye.
The anatomy of the eye begins with the outer covering, the conjunctiva,
and three layers of tissue: sclera, choroid, and retina. The retina is where
light rays are converted into nervous energy for interpretation by the
brain.
4. Describe the process of vision.
Vision begins with the passage of light through the cornea, where it is
refracted. The light rays then pass through the aqueous humor and pupil
into the lens. The ciliary muscle adjusts the curvature of the lens to again
refract the light rays so that they pass into the retina, triggering the
photoreceptor cells of the rods and cones. Light energy is converted into
an electrical impulse that is sent through the optic nerve to the brain,
where interpretation occurs. Table 13-1 shows how vision requires light
and depends on the proper functioning of all parts of the eye.
5. Differentiate among the major types of refractive errors.
Refractive errors include hyperopia, myopia, presbyopia, and astigma-
tism. All are caused by a problem with bending light so that it can be
accurately focused on the retina. These conditions usually are caused by
defects in the shape of the eyeball and can be corrected with glasses,
contacts, or surgery.
6. Summarize typical disorders of the eye and eyeball other than
refractive errors.
Eye disorders can range from problems with eye movement, as in stra-
bismus and nystagmus, to infections of the eye, including hordeolum,
chalazions, keratitis, conjunctivitis, and blepharitis. Disorders of the
different from working on mannequins and classmates. Kim has reinforced the
skills she learned in her program, continually emphasizing infection control
procedures and reinforcing patient education information. Amy realizes that she
needs to understand the pathologic conditions that can occur in the sensory
organs so that she can assist the provider as needed and answer patients'
questions.
After working with patients who have vision and hearing deficits, Amy
understands the importance of adapting communication techniques to meet the
needs of each patient. She has decided to take advantage of educational
opportunities at the hospital and through her professional organization to con-
tinue to learn about this special area of practice.
eyeball include corneal abrasions, cataracts, glaucoma, and macular
degeneration.
7. Do the following related to diagnostic procedures for the eye:
• Define the various diagnostic procedures for the eye.
Diagnostic procedures for the eye begin with a visual examination of
the eye with an ophthalmoscope. Next, the eyelids are examined for
abnormalities, and the pupils are tested for PERRlA. More advanced
techniques include the use of a slit lamp to view the fine details of
the eye and an exophthalmometer to measure the distance of the
eyeball from the orbit. Distance visual acuity typically is assessed with
a Snellen chart; near visual acuity is tested with a near vision acuity
chart. Apatient can be tested for acolor vision defect with the Ishihara
test.
• Perform a visual acuity test using the Snellen chart.
Procedure 13-1 explains the Snellen evaluation.
• Assess color acuity using the Ishihara test.
Procedure 13-2 outlines the color acuity examination.
8. Explain the purpose of and the proper procedure for eye irrigation
and the instillation of eye medication.
Eye irrigation relieves inflammation, removes drainage, dilutes chemicals,
or washes away foreign bodies. Sterile technique and equipment must
be used to prevent contamination. Medication may be instilled into the
eye to treat an infection, soothe an eye irritation, anesthetize the eye,
or dilate the pupils before examination or treatment. Procedure 13-3
describes the method for eye irrigation, and Procedure 13-4 explains how
to administer eye medications.
9. Identify the structures and explain the functions of the external ear,
middle ear, and inner ear.
The external ear consists of the auricle, or pinna, and the external aud~
tory canal, which transmits sound waves to the tympanic membrane.
The middle ear is an air-filled cavity that contains the ossicles. The sound
vibration passes through the tympanic membrane, causing the ossicles
to vibrate. This bone-conducted vibration passes through the oval window
into the inner ear. The organ of Corti, in the cochlea of the inner ear,
 CHAPTER 13 Assisting in Ophthalmology and Otolaryngology
SUMMARY OF LEARNING OBJECTIVES-continued
converts sound waves into nervous energy, which is sent to the brain for
interpretation. The semicircular canals in the inner ear maintain
equilibrium.
l 0. Describe the conditions that can lead to hearing loss, including
conductive and sensorineural impairments.
Conductive hearing loss is caused by a problem that originates in the
external or middle ear and prevents sound vibrations from passing
through the external auditory canal, limiting tympanic membrane vibra-
tions or interfering with the passage of bone-conducted sound in the
middle ear. Asensorineural hearing loss results from damage to the organ
of Corti or the auditory nerve and prevents vibrations from being con-
verted into nervous stimuli.
11. Define other major disorders of the ear, including otitis externa and
media, impacted cerumen, and Meniere's disease.
Otitis externa is an inflammation of the auditory canal, and otitis media
is an inflammation of the normally air-filled middle ear, resulting in the
collection of serous or suppurative fluid behind the tympanic membrane.
Impacted cerumen is a common cause of conductive hearing loss.
Meniere's disease is achronic, progressive condition that affects the laby-
rinth and causes recurring attacks of vertigo, in addition to tinnitus, a
sensation of pressure in the affected ear, and advancing hearing loss.
12. Do the following related to diagnostic procedures for the ear:
• Explain diagnostic procedures for the ear.
The ear examination begins with an otoscopic examination. It can
include various tuning fork tests to detect conductive or sensorineural
hearing deficits and more advanced audiometric testing.
• Use an audiometer to measure a patient's hearing acuity
accurately.
Procedure 13-5 explains the audiometry examination.
• Identify the purpose of ear irrigation and instillation of ear
medications.
Irrigation of the ear is performed to remove excess or impacted
cerumen, to remove a foreign body, or to treat the inflamed ear with
an antiseptic solution. Medication is instilled into the ear to soften
impacted cerumen, relieve pain, or treat an infectious pathogen.
CONNECTIONS
OJ Study Guide Connection: Go to the Chapter 13 Study Guide. Read and complete
the activities.
349
• Demonstrate the procedure for performing ear irrigations.
Procedure 13-6 describes how to perform an ear irrigation.
• Accurately instill medicated ear drops.
Procedure 13-7 explains how to administer otic drugs.
13. Summarize the nose and throat examination and perform a throat
culture.
Examination of the nose and throat begins with inspection of the nasal
cavity; this is followed by visual examination of the throat and the
nasopharynx. Throat cultures may be done to determine whether a
streptococcal infection is present. The anterior and posterior neck regions
are palpated for abnormalities. Procedure 13-8 explains how to perform
a throat culture.
14. Describe the effect of sensory loss on patient education.
Patients with vision and hearing impairments face serious challenges and
require individualized attention to meet their health education needs.
Patients with vision loss may need large-print forms and handouts,
increased levels of lighting, or verbal instructions rather than written ones.
Individuals with hearing deficits may benefit from printed instructions,
demonstrations on how to manage treatments, or even sign language
interpretation. Family members should be included in the patient's treat-
ment plan, and referrals to appropriate community or professional
resources may be very beneficial.
15. Discuss legal and ethical issues that might arise when caring for
a patient with a vision or hearing deficit, in addition to require-
ments established by HIPAA and the ADAA.
Diminished sight or hearing may render a patient seriously impaired. To
prevent accidents and office injuries, the medical assistant should always
ask a sight- or hearing-impaired patient whether he or she requires
assistance. Regardless of the patient's disability, the ambulatory care
center must follow the guidelines for Notice of Privacy Practices (NPP)
established by HIPAA. Public facilities also must comply with ADAA
requirements for physical accommodations. If appropriate, assistive
devices must be provided for individuals with vision or hearing
impairments.
evolve Evolve Connection: Go to the Chapter 13 link at evolve.e/sevier.com/
kinn to complete the Chapter Review Quiz. Check out the other resources listed for this
chapter to make the most of what you have learned from Assisting in Ophthalmology and
Otolaryngology.
 14 ASSISTING IN DERMATOLOGY
li#H+i;H•i
Dr. Sam Lee is a dermatologist who employs several medical assistants in his
busy private practice. Melissa Bauman, CMA (AAMA), has worked for Dr. Lee
since graduating from a medical assisting program last year. Melissa works as
a clinical specialist, whose primary responsibilities are to perform telephone
screening, prepare patients for procedures, and assist Dr. Lee as needed. To
While studying this chapter, think about the following questions:
• What are the basic anatomy and physiology of the integumentary
system?
• What are common diseases and disorders that affect the integumentary
system?
• How can Melissa determine the difference between the levels of burn
injuries?
LEARNING OBJECTIVES
1. Define, spell, and pronounce the terms listed in the vocabulary.
2. Explain the major functions of the skin.
3. Describe the anatomic structures of the skin.
4. Compare various skin lesions and give examples of each.
5. Describe typical integumentary system infections and infestations.
6. Differentiate among various inflammatory and autoimmune
integumentary disorders.
7. Recognize thermal and cold injuries to the skin.
8. Compare the characteristics of benign and malignant neoplasms.
9. Do the following relating to benign and malignant neoplasms:
• Explain the grading and staging of malignant tumors.
• Conduct patient education on the warning signs of cancer.
VOCABULARY
alopecia (al-o-pe'-se-uh) Partial or complete lack of hair.
anaplastic Relating to an alteration in cells to a more primitive
form; a term that describes cancer-producing cells.
basement membrane A deep layer of the skin that secures the
epithelium to underlying tissue; separates the epidermis from
the dermis.
benign A tumor or tissue growth that is not cancerous; it may
require treatment or removal, depending on its location and/or
for cosmetic reasons.
bilirubin (bih-luh-roo'-bin) An orange pigment in bile; its
accumulation leads to jaundice.
fulfill her responsibilities in the dermatology practice, Melissa must be familiar
with common diseases and disorders that affect the skin, assist with dermato-
logic procedures, and be prepared to reinforce patient education about the
treatment and prevention of dermatologic conditions.
• Why is it important that Melissa understand the concepts of staging and
grading of malignant tumors?
• What are the primary malignancies of the skin?
• What dermatologic procedures should Melissa be prepared to be prepared
to assist with in a dermatology practice?
• Describe skin malignancies and their treatment.
• Define the ABCDE rule for identifying a malignant melanoma.
10. Do the following relating to dermatologic procedures:
• Discuss how to assist with a dermatologic examination.
• Summarize allergy testing procedures.
• Describe the diagnosis and treatment of allergies.
11. Explain dermatologic procedures performed in the ambulatory care
setting.
12. Discuss the medical assistants role in patient education, in addition to
legal and ethical issues that would apply to a dermatology practice.
cryosurgery The technique of exposing tissue to extreme cold to
produce a well-defined area of cell destruction.
debridement The removal of foreign material and dead, damaged
tissue from a wound.
ecchymosis Discoloration of the skin caused by the escape of
blood into the tissues from ruptured blood vessels; typically
caused by bruising.
electrodesiccation The destruction of cells and tissue by means of
short high-frequency electrical sparks.
eschar Devitalized skin that forms a scab or a dry crust over a
burn area.

VOCABULARY-continued
exacerbation An increase in the seriousness of a disease, marked
by greater intensity of the signs and symptoms.
excoriated Skin that has been injured by scratching; abraded.
glomerulonephritis (glo-mer' -yoo-loh-nih-fri'-tis) Inflammation
of the glomerulus of the kidney.
hyperplasia An increase in the number of normal cells.
jaundice A yellow discoloration of the skin and mucous
membranes caused by deposits of bile pigments; these deposits
occur because of excess bilirubin in the blood.
keloid A raised, firm scar formation caused by overgrowth of
collagen at the site of a skin injury.
keratin A very hard, tough protein found in the hair, nails, and
epidermal tissue.
keratinocytes The skin cells that synthesize keratin.
leukoderma Lack of skin pigmentation, especially in patches.
T he skin is the largest organ of the human body. In an average-
size adult, it covers a total area of about 20 square feet. Forming
the outer boundary of the body, the skin performs several essential
functions: it acts as a barrier to protect vital internal organs from
infection and injury; it helps dissipate heat and regulate body tem-
perature; and it synthesizes vitamin D when exposed to ultraviolet
(UV) light. In addition, various sensory receptors present through-
out the skin enable it to respond to such sensations as heat, cold,
pain, and pressure.
The specialty of dermatology deals with the skin and its accessory
structures: hair, nails, and sweat glands, and the subcutaneous tissue
that lies beneath the skin. A physician who specializes in dermatol-
ogy is called a dermatologist.
ANATOMY AND PHYSIOLOGY
The integumentary system is composed of the skin and its accessory
organs. Each square inch of the skin contains millions of cells,
Epidermis
Dermis
Subcutaneous
tissue
Hair Sebaceous Sweat
follicle gland gland
FIGURE 14-1 The three layers of the skin.
CHAPTER 14 Assisting in Dermatology 351
malignant A term describing tumor or tissue growth that is
cancerous, anaplastic, invasive, and can metastasize.
opaque Not translucent or transparent; murky.
petechiae (peh-te'-ke-uh) Small, purplish hemorrhagic spots on
the skin.
postherpetic neuralgia Pain that lasts longer than a month after
a shingles infection and is caused by damage to the nerve; the
pain may last for months or years.
recessive A gene that only produces a particular condition if both
the mother and the father carry that particular gene; neither of
the parents have the condition.
teratogen (te-rah'-tuh-jen) Any substance that interferes with
normal prenatal development, resulting in a developmental
abnormality.
numerous specialized nerve endings, hair follicles, muscles, sweat
glands to cool the body, and sebaceous glands, which release sebum,
an oily substance that lubricates the skin. These diverse structures
and glands are nourished by a permeating, elaborate network of
blood vessels. The thickness of human skin varies markedly at dif-
ferent parts of the body, ranging from fairly thin over protected areas
(e.g., the eyelids) to very thick over areas subject to abrasion (e.g.,
the palms and soles).
Skin is composed of three layers: the epidermis (the thin, upper-
most layer); the dermis (the thicker layer beneath that makes up
about 90% of the skin mass and often is referred to as the true skin);
and the subcutaneous layer (the layer composed primarily of fatty,
or adipose, tissue) (Figure 14-1).
Epidermis
New skin cells, called keratinocytes, are found in the basal cell layer
of the epidermis and migrate upward over about 4 weeks. As the
cells move toward the surface, they grow flatter and scalier,
Horny layer of
epidermis
Cellular layer
of epidermis
Basement
membrane
Fat
Blood vessel
352 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES
eventually losing their nuclei and changing into dead skin cells that
contain an inert protein called keratin. Keratin makes up the out-
ermost layer of the epidermis and forms a protective barrier across
the surface of the skin that helps control water loss from the body.
Ultimately, the outermost keratin layer sloughs off as a result of
washing and friction. Hair and nails, which are also composed of
keratin, are products of the epidermis.
About 95% of the cells in the epidermis are keratinocytes. The
other 5% of epidermal cells are pigmented cells, or melanocytes.
Melanin is a protein manufactured in the body that gives coloring
to the skin and protects the body from UV radiation. Skin coloring
is determined not by the total number of melanocytes, which is rela-
tively constant for all races, but rather by the rate at which these cells
produce melanin. The amount of melanin produced depends on
genetics and exposure to UV light. Individuals with albinism, an
inherited recessive trait, are unable to produce melanin, so they have
white hair and skin and lack pigment in the iris. Because they have
no protection from UV light, they must either stay out of the sun
or routinely protect themselves with sunglasses and high level USB
sunscreen.
Dermis
The underlying dermis is a thick layer of connective tissue that
contains collagen and elastin fibers, in addition to water and jelly-
like materials that make the skin compressible. Collagen fibers help
prevent tearing of the skin; elastin is a flexible fiber that makes the
skin resilient. Distributed throughout the dermis are blood vessels,
lymph vessels, muscle cells, hair follicles, and sebaceous and sweat
glands. Sweat glands are exocrine glands. The two types of sweat
glands are eccrine glands and apocrine glands. Eccrine glands, the most
numerous, are present over most of the body; they regulate body
temperature by excreting water (sweat) through the skin pores to
release heat. Apocrine glands, which open into hair follicles and are
located in specific areas, including the axilla, scalp, face, and genita-
lia. Apocrine glands secrete a fatty sweat in response to stress. This
sweat is odorless when excreted; bacterial action results in odor.
A variety of microorganisms, called normal or resident flora, are
found on the skin and may increase the risk of integumentaty system
infection. Healthcare workers are encouraged to sanitize their hands
before and after each procedure to prevent transient microbes picked
up throughout the day from becoming resident flora. If transient
microorganisms are not destroyed and/or removed by good hand
sanitization techniques, they eventually become part of the indi-
vidual's resident flora. Sensory receptors for the nervous system that
detect pain, temperature, pressure, or texture also are located in the
dermis.
Subcutaneous Layer
The subcutaneous layer contains fat cells, which provide insulation
and serve as a depository for reserve calories. It also contains blood
vessels, nerves, and the base of the appendages of the skin (e.g., hair
follicles). Subcutaneous tissue is distributed unevenly, and as the
human body ages, it thins considerably, which can make administer-
ing injections or drawing blood more difficult in aging patients. This
loss of subcutaneous tissue is one reason elderly people are unable
to compensate for changes in temperature, so they are colder when
temperatures drop and hotter when temperatures rise. Aging skin is
very fragile; it is easily traumatized and damaged by items such as
the tourniquets used for drawing blood and bandage adhesives. The
medical assistant must be very careful to avoid injuring the skin of
an elderly person.
DISEASES AND DISORDERS
Skin is continuously exposed to the environment and may be affected
by a wide range of disorders, including infections, inflammatory
processes, allergic reactions, and tumors. Many skin problems resolve
spontaneously; others can be managed with drug therapy; and still
others, such as tumors, large cysts, or moles, may require surgical
intervention.
Skin Lesions
Skin lesions can be caused by a systemic problem, such as an allergic
reaction to medication, or they may develop from a localized infec-
tion. When communicating with the provider and documenting in
the patient's health record, always use correct medical terminology
to describe skin lesions, such as, "The patient reports a widespread
maculopapular rash across the anterior trunk" rather than "The
patient has a red, raised rash on his stomach."
When you gather details from the patient about the characteris-
tics of lesions, some elements you should consider include the
following:
• Describe the color, elevation, and texture of the lesion.
• Does the patient have any pain or pruritus (itching)? If pru-
ritus is present, is the area excoriated or inflamed?
• Is any drainage present? If so, what are its characteristics?
• What is the exact anatomic location of the lesion? Have
changes occurred over time?
Primary lesions are those that appear immediately. Macules,
papules, plaques, nodules, cysts, wheals, and pustules all are primary
lesions. Secondary lesions are the result of alterations in a primary
lesion. Examples of secondary lesions include scales, crusts, fissures,
erosions, ulcerations, and scars (Figure 14-2). For instance, vesicles
(blisters) from a partial-thickness burn are primary lesions, but if the
blisters break and ulcerations form, healing ends in a scar. Ulcer-
ations and scars are secondary lesions.
CRITICAL THINKING APPLICATION 14-1
Using the pictures and definitions in Figure 14-2, identify the correct medical
term far the fallowing skin lesions:
• Crack in the skin that can occur with athlete's foot
• Small blister
• Vesicle filled with pus
• Large blister that can occur with burns
• Flat lesion that has changed color (e.g., freckles)
• Raised lesion (e.g., eczema)
Infections
Bacterial Infections
Impetigo. Impetigo is a common, superficial infection caused by
streptococci or Staphylococcus aureus that usually affects children.
Initially impetigo looks like small vesicles on the face (especially
 CHAPTER 14 Assisting in Dermatology 353

PRIMARY LESIONS SECONDARY LESIONS

MACULE SCALES
Flat area of color change (no elevation or Flakes of cornified skin layer
depression)
Example: Psoriasis
Example: Freckles

PAPULE CRUST
Solid elevation less than 0.5 cm in Dried exudate on skin
diameter
Example: Impetigo
Example: Allergic eczema

NODULE FISSURE
Solid elevation 0.5 to 1 cm in diameter. Cracks in skin
Extends deeper into dermis than papule
Example: Athlete's foot
Example: Mole

TUMOR ULCER
Solid mass-larger than 1 cm Area of destruction of entire epidermis

Example: Squamous cell carcinoma Example: Decubitus (pressure sore)

PLAQUE SCAR
Flat elevated surface found on skin or Excess collagen production after injury
mucous membrane
Example: Surgical healing
Example: Thrush

WHEAL ATROPHY
Type of plaque. Result is transient edema Loss of some portion of the skin
in dermis
Example: Paralysis
Example: lntradermal skin test

VESICLE
Small blister-fluid within or under
epidermis

Example: Herpesvirus infection

BULLA
Large blister (greater than 0.5 cm)

Example: Burn

PUSTULE
Vesicle filled with pus

Example: Acne

FIGURE 14-2 Different types of skin lesions.

354 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES
FIGURE 14-3 Impetigo. (From Marks J, Miller J: Lookingbi/1 and Marks' principles of dermatology,
ed 5, Philadelphia, 2014, Saunders.)
around the nose and mouth) that quickly enlarge and rupture,
excreting a honey-colored exudate. The exudate forms crusty lesions,
and beneath the crust, the area is inflamed and moist (Figure 14-3).
Pruritus accompanies the infection, and scratching helps spread the
lesions at the site. Impetigo is contagious, and bacteria are transmit-
ted by direct contact with the drainage, whether at other sites or
with other children through the sharing of toys and touching. Con-
sistent hand washing is required to help break the chain of infection.
It also is important to keep personal items that may be contami-
nated, such as washcloths, linens, and drinking glasses, away from
other members of the family. If the areas of infection are limited,
topical treatment with an antibiotic ointment may be effective.
However, impetigo caused by streptococci may result in glomeru-
lonephritis; more involved infections may require treatment with
oral antibiotics.
CRITICAL THINKING APPLICATION
Mrs. Allio calls the office because she is concerned that her children have
been exposed to a child in the neighborhood who was diagnosed with
impetigo. She tells Melissa that her 3-year-old woke up this morning with
blisters around his mouth. Dr. Lee prescribes polymixin-bacitracin-neomycin
(Neosporin) ointment to be applied three times daily to the affected areas.
What should Melissa tell Mrs. Allio about preventing the spread of infection
to her other children?
Acne. Acne vulgaris typically begins at puberty and is caused by a
number of factors, including inherited predisposition, hormonal
fluctuations, exposure to heat and humidity, and the use of oily
creams (Figure 14-4). Acne is a disorder of the hair follicle and
sebaceous gland unit. It develops when sebum, which reaches the
skin surface through the hair follicles, stimulates the follicle walls,
causing more rapid shedding of skin cells. Cells and sebum stick
together and form a plug that promotes the growth of staphylococcal
organisms in the follicles. The result is the formation of comedones
(blackheads and whiteheads), pimples, pustules, or larger abscesses
at the site.
Acne treatment begins with twice-daily face washes with benzoyl
peroxide or salicylic acid. Medications include topical antibiotic
FIGURE 14-4 Acne. (From Poller A, Mancini A: Hwwitz clinical pediatric dermatology: atextbook
of skin disorders in childhood and adolescence, ed 4, Philadelphia, 2011, Saunders.)
cream (e.g., erythromycin) or application of a retinoid, such as
Retin-A (tretinoin) or adapalene (Differin). Minocycline (Solodyn)
is an extended-release drug that offers a continuous but very low
dose of the antibiotic minocycline. It is used to treat moderate to
severe acne in patients 12 years of age or older. Severe cystic acne
can be treated with isotretinoin (Claravis), but this drug is a strong
teratogen and should never be prescribed for pregnant women
or women who are not using contraceptives. The use of oral contra-
ceptives (e.g., Ortho Tri-Cyclen and Estrostep) also may reduce
acne outbreaks. Laser resurfacing can be performed to smooth out
14-2 shallow acne scars that form as the result of extreme cases of acne
vulgaris.
Acne conglobata is a severe form of acne that typically occurs later
in life and results in lesions across the back, buttocks, thighs, face,
and chest. Abscesses or cysts may form between affected sites, and
healing frequently results in keloid formation. This type of acne
requires more aggressive treatment with systemic corticosteroids
(e.g., prednisone), oral antibiotics, oral retinals, and laser resurfacing
or debridement to treat excessive scarring.
Rosacea. Rosacea is a chronic disease seen most frequently in
women between the ages of 30 and 60. It causes inflammation and
pustule formation and begins as frequent flushing across the nose,
forehead, cheeks, and chin. As the condition progresses, capillaries
of the face dilate and are visible across affected areas as small, red,
edematous lines; these are accompanied by eye inflammation and
photosensitivity. Over time, the face appears red, eye inflammation
is more apparent, and painful nodules and pustules form. Men with
rosacea may develop rhinophyma, a large, inflamed, bulbous nose
caused by hyperplasia of sebaceous nasal tissue (Figure 14-5). Indi-
viduals with rosacea eventually may develop an obvious thickening
of the skin across the forehead, nose, cheeks, and chin. The condition
is treated with topical antibiotics and, as symptoms progress, with
oral antibiotics, such as doxycycline (Oracea), which helps reduce

FIGURE 14-5 Rhinophyma. (Courtesy Michael 0. Murphy, MD.)
the number of pimples and bumps on the face; however, it may not
reduce the redness and flushing.
Furuncles and Carbuncles. A foruncle, or boil, is a localized staphy-
lococcal infection that begins as inflammation of a hair follicle
(folliculitis) or skin gland. The affected area is raised, inflamed, and
painful and eventually may produce purulent drainage. A carbuncle
is a collection of furuncles that have joined to form a large infected
area that may drain through multiple sites or form an abscess. Both
infections are treated with oral antibiotics, frequent cleansing of the
area, application of an antibiotic ointment and, in some cases, surgi-
cal incision and drainage of the purulent material.
Cellulitis. Cellulitis is an acute infection of the skin and subcutane-
ous tissue caused by staphylococci or streptococci. It begins from a
small cut or as a result of a skin injury, or it develops at the site of
a furuncle or ulcer. The area surrounding the site becomes inflamed,
edematous, and painful with red streaks along the lymph vessels that
lead from the infection. The condition is treated with oral antibiot-
ics. Warm compresses applied locally aid healing, and analgesics may
be needed to relieve discomfort. It is important that patients with
cellulitis are treated appropriately because a systemic infection can
develop if the lymph glands become involved.
Fungal Infections (Dermatophytoses)
Fungal, or mycotic, infections, such as tinea pedis (athlete's foot)
(Figure 14-6, A), tinea cruris (jock itch), and tinea corporis (ring-
worm) (Figure 14-6, B) are extremely common. These pathogens,
which tend to live off dead tissue in the keratin layer of the epider-
mis, the hair, or the nails, cause almost no inflammation in the
underlying skin. The fungus invades the skin where it has been
damaged or is consistently moist. All of these lesions are pruritic and
are characterized by a distinct border with scaling areas that have
a clear center. Secondary bacterial infections may occur with
excoriation.
CHAPTER 14 Assisting in Dermatology 355
FIGURE 14-6 Fungal infections. A, Tineo pedis. B, Tineo corporis. (A from Gawkrodger D:
Dermatology, ed 5, New York, 2012, Churchill Livingstone; Bfrom Mahon CR et al: Textbook of
diagnostic microbiology, ed 5, Philadelphia, 2015, Saunders.)
The provider typically diagnoses a fungal infection by noting the
way the skin looks and the patient's complaints of pruritus. The skin
may be scraped to obtain cells for examination under a microscope,
and sometimes the provider may order a skin culture, for which a
suspicious area is swabbed or scraped using sterile technique. The
sample is sent to the laboratory for analysis. Treatment consists of
topical antifungal agents, such as clotrimazole (Lotrimin), ketocon-
azole (Nizoral), econazole, or nystatin (Mycostatin). Antibiotics may
be necessary if a secondary infection occurs. Because mycotic infec-
tions thrive in dark, moist areas, the patient should be advised to
keep the site clean and dry and to wear loose clothing if possible.
All types of dermatophytoses can become chronic infections if not
managed carefully.
Tinea unguium, or onychomycosis (Figure 14-7), is a fungal infec-
tion of the toenails and fingernails. Unlike athlete's foot, which occurs
on the skin's surface, nail fungus lives in the nail bed and the nail
plate. The nail provides the fungus with an extremely well-protected
place to live, which is why nail fungus may be especially difficult to
treat. The primary sign of nail fungus is the appearance of the nail,
356 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES
FIGURE 14-7 Tineo unguium. (From Habif TP: Clinical dermatology, ed 5, St Louis, 2010,
Mosby.)
which turns yellow, white, or opaque. The texture also changes, and
the nail becomes thick and brittle. If the fungus has been present for
a long time, the nail can become twisted or distorted. The most effec-
tive treatment for nail fungus is oral terbinafine hydrochloride
(Lamisil) or itraconazole (Sporanox), which inhibit the production
of fungal cells. However, the drug must be taken for 6 weeks to treat
fungal infection of a fingernail and for 12 weeks for infection of a
toenail; treatment carries the risk of liver complications.
Viral Infections
Warts. Warts, or verrucae, are caused by the human papillomavirus
(HPV). Infection with HPV results in hyperplasia of the epidermis
and a raised, cauliflower-like appearance. Verrucae can develop any-
where, but the most common sites are the fingers and the soles
(plantar warts). Most warts resolve over time, but they can be treated
with topical chemicals, excised surgically, vaporized with lasers, or
removed with cryosurgery.
Herpes Simplex (Cold Sores). Cold sores, or fever blisters, are
caused by herpes simplex virus type 1 (HSV-1). The initial infection
may be asymptomatic or may cause painful ulcers along the gum
lines of the mouth or on the lips. After the primary infection, the
virus remains dormant in the trigeminal nerve and can be reactivated
by exposure to the sun or to cold; by the presence of another infec-
tion, such as an upper respiratory infection; or when the patient is
under stress. The patient reports a feeling of burning, tingling, or
numbness before the eruption of vesicles. The blisters heal in 2 to 3
weeks, but the process may be speeded up by the use of topical
antiviral drugs, such as acyclovir (Zovirax), docosanol (Abreva), or
penciclovir cream (Denavir), or with oral antivirals, including fam-
ciclovir (Famvir), acyclovir, or valacyclovir (Valtrex). If started at the
first indications of a cold sore, antiviral medications can limit the
duration and severity of the outbreak.
Herpes Zoster (Shingles). Herpes zoster is an acute inflammatory
disorder characterized by highly painful vesicular eruptions on
FIGURE 14-8 Herpes zoster (shingles). (From Swartz MH: Textbook of physical diagnosis,
ed 7, Philadelphia, 2014, Saunders.)
the trunk of the body and occasionally on the face (Figure 14-8).
The lesions develop on one side of the body and follow the course
of the peripheral nerve, or dermatome, that has been infected by the
varicella virus, the same virus that causes chickenpox. The virus lies
dormant in a dorsal root ganglia and is reactivated in later years. The
cause of this reactivation is unclear, although it appears to be related
to stress, immune system problems, and aging.
The onset of the disorder usually is marked by pain along the
nerve pathway, and lesions appear in approximately 3 days. Inflam-
mation lasts 10 days to 5 weeks. The patient is diagnosed by the
characteristic pattern of painful lesions. Patients complain of burning
or tingling pain or in some cases numbness or itching on one side
of the body. The most common location for shingles is a band that
spans one side of the trunk around the waistline. It may also occur
on the forehead, cheek, nose, and around one eye, which may
threaten vision. Besides the characteristic rash and associated pain,
shingles is diagnosed by isolating the virus in cell cultures and by
the presence of varicella zoster antibodies in the blood.
Treatment focuses on promoting the patient's comfort with anal-
gesic and antipruritic medications. Corticosteroid medications
(prednisone) and antiviral drugs (e.g., topical or oral Zovirax, and
oral Famvir or Valtrex) also can be prescribed. Antiviral medications
help shorten the length and severity of the shingles outbreak, but
they must be started as soon as possible after the rash appears to be
most effective. Therefore, individuals who think they might have
shingles should call their provider as soon as possible. One of the
most serious complications of herpes zoster is postherpetic neural-
gia, which causes chronic pain after resolution of the initial out-
break. The condition may require treatment with a combination of
medications, including lidocaine skin patches (Lidoderm), narcotics,
antidepressants (duloxetine [Cymbalta]) or venlafaxine [Effexor
XR]), and the anticonvulsant gabapentin (Horizant).
Two vaccines are available that may help prevent shingles. The
chickenpox (varicella virus) vaccine (Varivax) is given to babies 12
to 18 months old and to older children and adults who have not
had chickenpox; this vaccine reduces the risk and severity of both
chickenpox and shingles. The herpes zoster vaccine (Zostavax) is

recommended for all adults 60 years or older, regardless of whether
they have had shingles. This vaccine does not guarantee protection
against shingles, but it can reduce the duration and severity of the
outbreak, and it helps prevent postherpetic neuralgia.
Parasites
The itch mite (which causes scabies) and lice (which cause pedicu-
losis) are the two most common parasites that infest human beings.
Both scabies and pediculosis are highly contagious. Scabies mites are
tiny organisms, barely visible to the eye, that burrow into the epi-
dermis (Figure 14-9). Diagnosis of scabies may require scraping of
the skin at an inflamed area and examination of the mites under a
low-power microscope. Patients describe symptoms of intense
itching, possibly a body rash, and a sensation of something crawling
on the skin. Treatment consists of ridding the body of the parasite,
controlling the pruritus, and disinfecting the home environment to
prevent reinfestation. There are usually no symptoms during the first
2 to 6 weeks of a scabies infestation, but affected individuals can
spread the scabies mite during this time. Scabies treatment is recom-
mended for all household members and sexual contacts in the
past month; all of these individuals should be treated at the same
time to prevent reinfestation. No over-the-counter products have
been approved for scabies treatment, so the patient must get a
prescription.
Scabies is treated with a single application of 5% permethrin
(Elimite) or crotamiton (Eurax) creams all over the body, from the
neck down. Because the medication should be left on for a minimum
of 8 hours, it typically is applied before bedtime. Treatment must be
repeated in 7 to 10 days to destroy the nits (eggs). If a secondary
infection occurs, antibiotics may also be prescribed. Lindane lotion
(Kwell) is no longer recommended because of widespread resistance
and the potential of severe neurologic side effects.
Pediculosis (infestation with lice) can be caused by three different
types oflice: head lice (Pediculus humanus capitis [Figure 14-10, A]);
body lice (Pediculus humanus corporis); and pubic lice (Pthirus pubis
[Figure 14-10, Bl). Lice are large enough to be seen on the hair
shafts.
FIGURE 14-9 Scabies rash of the hand. (From James WD et al: Andrews' diseases of the skin,
ed 11, Philadelphia, 2011, Saunders.)
CHAPTER 14 Assisting in Dermatology 357
CDC Recommendations for Treating Lice
The Centers for Disease Control and Prevention (CDC) has established the
following recommendations for treating lice:
1. All infested persons (household members and close contacts) and
their bedmates should be treated at the same time.
2. Apply a lice medicated shampoo (Nix or Ovide). Do not use cream
rinse or aconditioner before applying the medication. Do not rewash
the hair for 1 to 2 days after treatment.
3. The American Academy of Pediatrics no longer recommends the use
of Undone shampoo since it can be toxic to the brain and other
parts of the nervous system.
4. After treatment, check the hair and use a nit comb to remove nits
and lice every 2 to 3 days. Continue to check for 2 to 3 weeks to
make sure all lice and nits are gone. Head lice survive less than 1
to 2 days, and nits die within 1 week if they are not on a person.
5. Retreatment is recommended after 9to 10 days to kill any surviving
hatched lice before eggs are produced.
6. The following measures should be taken to prevent reinfestation:
• Machine wash in hot water and dry on high heat: all clothing,
bed linens, and other items worn or used for 2 days before
treatment; and dry-clean items that cannot be washed; or seal
all exposed items in a plastic bag for 2 weeks.
• Soak combs and brushes in hot water for 5 to 10 minutes.
• Vacuum floors and furniture.
Centers for Disease Control and Prevention. www.cdc.gov/parasites/ficejhead/
treatment.html. Accessed April 26, 2015.
CRITICAL THINKING APPLICATION 14-3
Melissa's daughter brought home a note today warning of a scabies out-
break in her school. Melissa has afew red marks on her forearms, and the
areas are quite itchy. Dr. Lee does a skin scraping of one of the areas and
views itch mites under the microscope. How should Melissa and her family
be treated? Should Melissa remain at work?
Inflammatory Skin Disorders
Seborrheic Dermatitis
Seborrheic dermatitis is one of the most common chronic inflam-
matory conditions of the sebaceous glands. It alters the amount and
quality of the sebum, resulting in dry or moist, greasy-appearing
scales and yellowish crusts on the scalp, eyebrows, eyelids, and sides
of the nose, behind the ears, and in the middle of the chest. The
condition has many different forms, including cradle cap in infants
and dandruff in adults. Seborrheic dermatitis of the scalp can be
treated with tar- or sulfur-based shampoos; inflammations of the
skin usually are treated with topical corticosteroids, such as generic
triamcinolone diacetate or betamethasone valerate, or fluocinolone
acetonide (Synalar). Seborrheic keratosis (age spots) is characterized
by benign, slightly raised, tan to black lesions that occur with aging.
Contact Dermatitis
Contact dermatitis is an acute inflammatory response to a skin
irritant or from exposure to a substance that causes an allergic
358 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES

FIGURE 14-10 Types of lice. A, Pediculus humanus copitis (head louse)

and lice in the hair. B, Phthirus pubis (pubic or crab louse) and pubic lice rash.
(A from Lissauer Tet al: Illustrated textbook of paediatrics, ed 4, London,
2012, Mosby; Bfrom Long SS et al: Principles and practice of pediatric infec-
tious diseases, ed 4, Philadelphia, 2012, Sounders.)

reaction. An individual who is allergic to latex gloves or who has

been exposed to poison ivy shows the signs and symptoms of contact
dermatitis. The individual complains of redness (erythema), edema,
pruritus, and vesicles. The patient should be encouraged to wash the
affected area immediately after exposure to remove the irritant.
Medical treatment includes application of a corticosteroid cream or
the use of oral corticosteroid medications (e.g., prednisone, methyl-
prednisolone [Medro]]) if the symptoms are severe.

Eczema (Atopic Dermatitis)

Eczema is an idiopathic inflammatory skin disease that tends to
occur in patients with a family history of allergies. In young children,
it may be caused by food allergies, and in older children, stress or
temperature extremes can trigger flare-ups. The condition usually
improves and may disappear as the child ages. Eczema is character-
ized by a vesicular rash on the face, neck, and elbows and behind
the knees and ears. It causes pronounced pruritus that ifleft untreated
results in excoriation of the affected area from constant scratching.
Eczema is not contagious.
Eczema is diagnosed with a comprehensive family history and
examination of the skin. The patient may be asked to investigate pos-
sible allergens by making a list of all items that might be responsible
for the outbreak, or the provider may recommend allergy testing. The
goal of treatment is to reduce the frequency and number of eruptions
and to relieve the pruritus so that affected areas do not become excori-
ated. The primary inflammation usually is treated with topical corti-
costeroids and oral antihistamines (e.g., diphenhydramine [Benadryl],
cetirizine [Zyrtec], fexofenadine [Allegra]) to control itching. The
provider may recommend controlled exposure to sunlight or UV rays
to prevent and treat outbreaks. Psoralens are a group of light-sensitive FIGURE 14-11 Psoriasis. (From Marks J, Miller J: Lookingbi/1 and Marks' principles of dermatol-
drugs that absorb ultraviolet (UVA) light and are combined with UVA ogy, ed 5, Philadelphia, 2014, Sounders.)
to treat skin conditions such as eczema and psoriasis. An example of
a drug in this classification is methoxsalen (Uvadex). Inflammation of
eczema plaques typically indicates a secondary staphylococcal infec-
tion, which should be treated with an oral antibiotic.
 CHAPTER 14 Assisting in Dermatology 359

Autoimmune Skin Disorders

Psoriasis
Psoriasis is a chronic skin disease that produces discrete pink or red
lesions covered with silvery scales (Figure 14-11 ). The disease may
begin at any age, although most patients develop the problem before
age 40. The lesions are not infectious, and the disease is characterized
by periodic flare-ups throughout life. Psoriasis is caused by an auto-
immune reaction that speeds up the maturation rate of skin cells.
Normal skin cells mature, die, and are shed every 28 to 30 days, but
in patients with psoriasis, cells mature in 3 to 6 days, and instead of
sloughing off the surface of the skin, they build up and form the
classic psoriatic silvery patch. The affected skin is dry, cracked, and
encrusted. Lesions may appear on the scalp, chest, buttocks, and
extremities.
Outbreaks of psoriatic plaques are associated with triggers that
the patient may be able to identify and therefore avoid, such as
infection (e.g., strep throat); an injury to the skin or a bug bite;
stress; cold weather; smoking and heavy alcohol consumption; and
FIGURE 14-12 Butterfly rash of systemic lupus erythematosus (SLE). (Modified from Kliegman
certain medications, such as lithium for mood disorders or beta RM et al: Nelson textbook of pediatrics, ed 18, Philadelphia, 2007, Saunders.)
blockers for hypertension. Psoriasis is diagnosed by observation of
the skin, a careful patient history (a familial link has been estab-
lished), and/or a skin biopsy. Treatment is palliative because the
disease has no cure. Exposure to UV light may slow cell production,
and coal tar preparations help relieve irritation when applied to
Diagnosis of Systemic Lupus Erythematosus
affected areas. The provider also may order a combination of thera- The American Rheumatism Association has developed 11 criteria for the
pies, including methotrexate (Rheumatrex); a retinoid, such as diagnosis of systemic lupus erythematosus (SLE):
acitretin (Soriatane); the immunosuppressant cyclosporine (Neoral); • Malar or "butterfly" rash
low-dose antihistamines; and oatmeal baths to promote the patient's
• Discoid skin rash- patchy redness with hyperpigmentation and
comfort. Biologic medications, which target the body's immune
hypopigmentation
system, are very effective treatments for moderate to severe psoriasis.
Research shows infliximab (Remicade) is the most effective biologic
• Photosensitivity- skin rash in reaction to sunlight
agent for psoriasis. Excimer laser treatments that localize high- • Mucous membrane ulcers of the lining of the mouth, nose, or throat
intensity wavelengths of UV light to targeted plaques, reducing both • Arthritis
cell production and inflammation, may also be effective. • Pleuritis or pericarditis-inflammation of the tissue that lines the
heart or lungs
Systemic Lupus Erythematosus • Kidney abnormalities
Systemic lupus erythematosus (SLE) is a chronic autoimmune • Brain irritation - seizures and/or psychosis
inflammatory disease of the connective tissue. The cause is unknown, • Law blood cell counts
although women are 10 times more likely to develop the disease than • Abnormal immune studies
men. It can affect any connective tissue in the body but typically • Positive antinuclear antibodies (ANAs) in the blood
causes inflammatory changes in the skin, joints, muscles, and
kidneys. SLE usually involves more than one organ, and the patient
experiences periods of exacerbation and remission. A diagnostic
characteristic of the disease is a butterfly-shaped rash that stretches
from one cheek across the nose to the other cheek (Figure 14-12). Thermal Injuries
Other integumentary system symptoms include erythematous Skin can be damaged and injured by exposure to moderately high
patches and plaques, alopecia, and photosensitivity. or low temperatures over an extended period. It also can be
The prognosis for SLE depends on organ involvement; patients injured in a relatively short time when exposed to very high or low
who develop renal, cardiovascular, or neurologic complications temperatures. The most common thermal injuries are burns,
have a poor prognosis. Treatment includes the use of nonsteroidal which are classified as superficial thickness (first degree), partial
antiinflammatory drugs (NSAIDs), including ibuprofen (Advil) and thickness (second degree), or full thickness (third degree), depend-
diclofenac (Voltaren), or controlled low doses of corticosteroids ing on the depth of the wound (Figure 14-13). With severe burns,
(prednisone) when needed. Serious cases are treated with cytotoxic all three types commonly are seen in the same location: superfi-
drugs (cyclophosphamide [Cytoxan]) and antimalarial drugs, such as cial burns along the edges, partial-thickness burns with vesicles
hydroxychloroquine (Plaquenil) as needed to control inflammatory closer to the center, and full-thickness burns at the center of the
reactions. area.
360 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES

APPEARANCE SENSATION COURSE

Sweat duct Mild to severe erythema; Painful Discomfort lasts about
...J
c( skin blanches with pressure 48 hours
Hyperesthetic
EPIDERMIS §z
u.. a: Skin dry Tingling Desquamation in 3-7 days
a::::)
~ID Pain eased
:::) Small, thin-walled blisters
(/) by cooling
Capillary

Sebaceous (/)
gland ----<1-r+- --h"~ ~ ~ -fl':"1 (/) Large thick-walled blisters Painful Superficial partial-thickness
w
z covering extensive area burn heals in 10-14 days
~ (vesiculation) Hyperesthetic
Nerve
endings - -ttt-b"f-:H,..1<....<j~ ~z Deep partial-thickness burn
J: a:
I-;"=> Edema; mottled red base; Sensitive to requires 21-28 days for healing
DERMIS ...J ID
broken epidermis; cold air
c(
Hair follicle - -1-+.H,..._.lili~ j:: wet, shiny, weeping Healing rate varies with burn
a: surface depth and presence or absence
c(
Hair follicle - -"'rrl--+-+,a D. of infection

(/)
(/) Variable, e.g., deep red, Little pain Full-thickness dead skin
Sweat gland w black, white, brown suppurates and liquefies after
z Anesthetic 2-3weeks
~z
Fat
Oa: Dry surface
:i::::) Spontaneous healing impossible
I- ID Requires removal of eschar and
Blood
vessels __,,:a.- lL.~..ll!-:,.d.~~lJ ..:.
...J
Edema
skin grafting
:::)
SUBCUTANEOUS TISSUE
u.. Tissue disrupted Scarring deformities and
function loss
Beneath eschar capillary tufts
and fibroblasts organize into
granulating tissue

FIGURE 14-13 Classification of burns.

Superficial (First-Degree) Burn Patient Education for Burn Care

A superficial burn affects only the epidermis, is erythemic (red),
blanches with pressure, and is painful but does not have blisters at
the site. Mild sunburn and a steam burn without vesicle formation
are examples of superficial burns.
Partial-Thickness (Second-Degree) Burn
A partial-thickness burn destroys the entire epidermal layer and
varying depths of the dermis and causes blister formation and sub-
cutaneous edema and pain. The danger of infection in the blistered
area also is a concern. If a burn is deep enough, some destruction of
the hair follicles and the sebaceous glands may occur.
Treatment of Minor Burns
Because burns damage the natural protection of the skin, preventing
infection at the site is a primary concern. Superficial-thickness burns
typically heal on their own within a week, as long as they are kept
clean and infection does not occur. Medical treatment of partial-
thickness burns includes gentle cleansing of the site with a bacteri-
cidal solution and debridement of broken blisters or dead skin.
Intact blisters should be left alone. Partial-thickness burns may be
treated with a thin layer of silver sulfadiazine cream and application
of a nonadherent, multilayered dressing for several days to I week.
The patient's tetanus immunization status should be reviewed, and
a tetanus injection should be given if needed. The provider also may
order analgesics to relieve pain. Patients with partial-thickness burns
(those reporting blisters at the site of the burn) should be seen by
the provider for treatment.
• Warning signs of infection include fever, malaise, inflammation, swell-
ing, increased pain, odor, and drainage from the burn area. Any of
these should be reported to the provider immediately.
• Review wound care with the patient, including gentle cleansing with
bactericidal solution (e.g., pavidone-iodine solutian [Betadine]) and
covering the wound with an antibiotic ointment (silver sulfadiazine) so
that the dressing does not stick to the burn.
• The patient should eat a high-calorie, high-protein diet to maintain
weight and promote healing.
• For partial-thickness burns, the development of new skin takes 6
weeks, and complete healing occurs in 6 to 12 months, depending on
the extent of the burn.
CRITICAL THINKING APPLICATION 14-4
Thomas Rangoso, a 66-year-old patient, calls the office to report a burn on
his right hand and forearm. He fell while passing the stove and burned
himself on the hot surface. Mr. Rangoso tells Melissa that the area is very
red and painful and has blisters in the center. He wants to break the blisters
and put butter on the burn. Should Mr. Rangoso be seen by Dr. Lee? What
should Melissa tell him about how to care for the burn until he is seen by
the physician?
 CHAPTER 14 Assisting in Dermatology 361

Full-Thickness (Third-Degree) Burn Benign and Malignant Neoplasms

A full-thickness burn destroys all layers of the skin and may involve
underlying fat, muscle, nerves, blood supply, and bone. The area
appears charred or white and has a firm, leathery texture. The patient
feels no pain because nerve endings have been destroyed. Full-
thickness burns have the potential to cause major complications,
including dehydration, circulatory collapse, respiratory distress, and
septic shock. Treatment of major burns includes maintaining the
patient's airway, replacing fluids, preventing infection, and adminis-
tering oxygen. Debridement of affected tissue, including areas of
eschar, and skin grafts are required for wound healing. Depending
on the extent of the burns, the patient may be hospitalized in an
intensive care unit or a specialty burn unit.
Burns are classified according to the percentage of body surface
involved, based on the Rule of Nines. The Rule of Nines is an assess-
ment tool that helps caregivers quickly calculate the amount of
burned tissue. The body is divided into sections equal to about 9%
of the total body surface area (TBSA). When a burn victim is
assessed, the affected regions are combined to yield an estimate of
the total percentage of burned tissue. Partial-thickness burns over
15% of the total body surface and full-thickness burns of less than
2% can be treated in the ambulatory care setting if the patient can
be seen immediately. Patients with larger body surface area involve-
ment or other complications should be transported immediately to
a hospital.
Cold Injuries
Cold injuries usually are less severe than burns, but prolonged
exposure to cold temperatures can result in infection, gangrene,
amputation and, in severe cases, death. Frostbite is caused by expo-
sure to subfreezing temperatures. Damage occurs at the level of the
capillaries, which become permanently dilated and unable to regu-
late local blood flow. Signs and symptoms of superficial frostbite
include burning, tingling, numbness, and a white or grayish color
of the skin. With deep frostbite, blisters form and the area is hard,
mottled, edematous, and blue or gray after thawing.
The extent of injury is determined by visual examination and the
history of the exposure. Treatment consists of warming the area with
immersion in warm water (100° to l06°F [38° to 41°C]). The
affected site should never be rubbed because this increases cellular
destruction. The person's vital signs should be monitored, and the
provider's orders should be followed explicitly.
A neoplasm is an abnormal growth or tumor that may be benign
or malignant. Table 14-1 outlines the differences between benign
and malignant tumors. Invasion and metastasis are the principal
criteria used to distinguish between cancerous and noncancerous
tumors. Benign masses are encapsulated, and although they may
increase in size, they remain confined within a shell; malignant
tumors, on the other hand, invade and take over surrounding
tissues. Local invasion of surrounding tissue occurs when malig-
nant cells break through the basement membrane that separates
epithelial cells from connective tissue. Here the cancerous cells can
invade blood and lymph vessels, which carry the malignant cells to
organs throughout the body. Patients diagnosed with carcinoma in
situ have a malignant tumor that is confined to the original site of
growth without invasion of the basement membrane. Patients with
regional spread have evidence of malignant cells in surrounding
tissues but no evidence of lymph node involvement. Patients with
distant spread, or metastasis, show lymph node involvement locally
and the development of secondary tumors in other organs, includ-
ing the lungs, liver, brain, or bones.
Malignant tumors are classified according to their grade and
stage. A biopsy sample of the tumor is obtained and sent to a
pathologist. The pathologist examines the cells under a microscope
and grades the sample according to its histologic, or cellular, classi-
fication of differentiation. Differentiation is the process that normal
cells go through to mature. Immature, or primitive, cells never
mature and are classified as anaplastic, or cancerous. Therefore, the
more poorly differentiated the cells (i.e., the less they look like
normal cells), the more likely it is that the tissue is cancerous.
If the provider receives a grading report that indicates anaplastic
cancerous cells, the next step is to determine whether the cancerous
cells have spread from the original site; this is called staging the tumor.
With staging, a physical examination and diagnostic tests (e.g., bone,
liver, or positron emission tomography [PET] scans) are done to
determine the degree of tumor spread to a secondary location. The
size and depth of the primary tumor, the degree of lymph node
involvement, and the presence of metastatic spread determine whether
the patient has carcinoma in situ (i.e., a tumor localized to the organ
of origin), direct spread beyond the primary organ, lymph node metas-
tasis, or confirmed secondary tumor growth in a distant metastatic
site. Grading and staging determine the extent of malignant involve-
ment, which allows the provider to plan appropriate treatment.

TABLE 14-1 Differences Between Benign and Malignant Tumors

CHARACTERISTIC BENIGN TUMOR MALIGNANT TUMOR
Cellular structure Same as surrounding tissue Anaplastic changes and poor cellular differentiation
Type of growth Encapsulated mass that Infiltrates and metastasizes; distant spread through the bloodstream or lymph system to
expands over time other body tissues and organs can occur
Rate of growth Usually slow; rarely fatal May be slow, rapid, or very rapid; almost always fatal if left untreated
Destruction of localized tissue None Common; ulceration and necrosis of surrounding tissue
362 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES
A~------~
FIGURE 14-14 A, Punch biopsy. B, Punch biopsy instrument rotated into the skin. C, Cutting the base of the specimen. D, Closure of the
biopsy wound with a simple epidermal stitch. (Modified from Bolognia J: Dermatology, ed 2, Edinburgh, 2008, Mosby.)
Three methods are used to obtain a small piece of tissue for
examination under a microscope. In an excision biopsy, such as
removal of a mole, the entire lesion may be removed for analysis. A
punch biopsy involves removal of a small section from a designated
location in the lesion; the center usually is the optimum site. If the
lesion is on the surface of the skin (e.g., a mole), this is done with
a scalpel-like circular punch instrument (Figure 14-14); in other
cases, a large-gauge needle and syringe unit is used to aspirate cells
and fluid from a suspicious area (e.g., a breast biopsy). A shave biopsy
is performed with a scalpel or razor by cutting or shaving off the
growth or lesion for a thin specimen of combined epidermis and
upper dermis cells. This method is used to biopsy a possible squa-
mous cell carcinoma lesion. The medical assistant may help the
provider perform these biopsy procedures.
The protocol for the treatment of cancer depends on the stage,
grade, and type of carcinoma. Possible treatments include surgical
removal of the tumor, radiation therapy, chemotherapy, hormone
therapy, and immune system boosters. These approaches may be
used singly or in combination and usually are determined by an
oncologist, a physician specialist in the study and treatment of
cancer.
Assisting with a Tissue Biopsy
l. Assemble the necessary supplies far the procedure.
2. Prepare the patient with proper gowning, draping, and positioning and
make sure the patient understands the procedure.
3. Confirm that the provider has obtained the patient's informed consent.
4. Prepare the site of the biopsy according to office protocol.
5. Assist the provider as needed, using appropriate personal protective
equipment according ta Standard Precautions.
6. Label the sample container and prepare it far transport to the testing
laboratory. Remember to include laboratory request farms.
7. Clean the procedure area, properly dispose af all waste materials, and
disinfect and sterilize equipment used in the procedure.
8. Sanitize your hands and document the procedure, including the patient
education provided on biopsy site care.
Patient Education: Cancer's Seven Warning Signs
The initial letters of the warning signs spell out the word CAUTION. Any of
these warning signs should be reported to the provider immediately. Early
detection and self-examination are crucial to cancer survival.
• Change in bowel or bladder habits
• Asore that does not heal
• Unusual bleeding or discharge
• Thickening or a lump in the breast or elsewhere
• Indigestion or difficulty in swallowing
• Obvious change in a wart or mole
• Nagging cough or hoarseness
Neoplasms of the Skin
Neoplasms of the skin may be benign or malignant. Examples of
benign tumors include birthmarks and moles (nevi). However, a
tumor may be benign but have a predisposition to be cancerous,
which means that it can change from a benign state to a malignant
one. Whenever a neoplasm is discovered, the provider usually per-
forms a biopsy of the lesion to establish the type of cells involved.
Three cancerous lesions of the skin can occur: basal cell carci-
noma, squamous cell carcinoma, and malignant melanoma. Basal
cells line the deepest layer of the epidermis. Basal cell carcinoma is
very slow growing and is the most frequently seen form of skin
cancer. The most common sites are areas of the body exposed to the
sun, such as the face and forearms. The typical basal cell carcinoma
appears as a small, pearly, dome-shaped nodule with small, visible
blood vessels called telangiectasias. However, it also can appear as a
persistent sore, with a reddish, irritated appearance (Figure 14-15),
that does not heal.
Squamous cell carcinoma grows rapidly and is more serious
because it has a tendency to metastasize. It appears as a firm, red
nodule with visible scales, and it may ulcerate and form a crust
(Figure 14-16). Patients typically report both basal and squamous
cell skin cancers as sores that persist and never heal.
Malignant melanoma develops from a change in a mole. Sun-
burns increase the risk of melanoma, and individuals with more
moles than average (more than 100) are at greater risk. Individuals
with congenital nevi (moles present at birth) are more likely to
 CHAPTER 14 Assisting in Dermatology 363

I I' ' I I ' ' '

FIGURE 14-17 Pigmented skin lesions. Left, Benign pigmented nevus (mole). Right, Malignant
melanoma. (Courtesy National Cancer Institute, Bethesda, Md.)

All skin cancers are diagnosed by the appearance of the lesions,

and the diagnosis is confirmed by biopsy. Treatment depends on the
type, the level of invasion, and the location of the mass. The provider
may choose to remove the tumor surgically or eradicate it with
FIGURE 14-15 Basal cell c•rcinama. (From James WD et al: Andrews' diseases of the skin, ed
cryosurgery, electrodesiccation, or application of topical chemo-
11, Philadelphia, 2011, Saunders.)
therapeutic agents. Ipilimumab (Yervoy) is used to treat melanoma
that cannot be removed by surgery or that has metastasized. Yervoy
helps the immune system recognize and kill cancer cells. A micro-
scopic surgical procedure (Mohs surgery) is an effective, precise
method for treating and removing basal and squamous cell carcino-
mas. The Mohs technique is performed by specially trained derma-
tologists, who use a microscope to systematically trace the cancerous
lesion down to its roots and remove the tumor layer by layer; this
minimizes the chance of regrowth and reduces scar formation.
The National Cancer Institute has stated that the best way to
prevent skin cancer is to protect the skin from the sun, starting at
an early age. People of all ages should do the following:
• Stay out of the midday sun (10 AM to 4 PM).
• Use protection against UV rays reflected off water and snow.
• Use protection against UV rays even on cloudy days, on which
exposure can still occur.
• Wear protective clothing and a wide-brimmed hat when in
the sun and protect the eyes with sunglasses.
• Use a sunscreen that filters both UVB and UVA rays with a
sun protection factor (SPF) of at least 15.
• Avoid using artificial sun lamps and tanning beds.
FIGURE 14-16 Squamous cell carcinoma. (From Plenninger JL, Fowler GC: ?Fenninger and
Fowler's procedures for primary care, ed 3, Philadelphia, 201 l, Saunders.)
Early Warning Signs of Malignant Melanoma:
ABCDE Rule
develop a melanoma. Additional risk factors include an inability to
tan, light or red hair, fair skin, family history, and a large number If a mole displays any of the following characteristics, a dermatologist
of childhood sunburns. Many forms of melanoma occur, but all are should examine it immediately.
pigmented lesions (usually brown, tan, blue, red, black, or white)
that are asymmetric (i.e., have irregular borders) and usually are A Asymmetry One half of the mole does not match the other half.
larger than 6 mm (Figure 14-17). Staging of the disease depends on B Border The edges of the mole are blurred or irregular.
the depth of the mass, not on the surface size of the mole. If cancer- ( Calor The mole is not the same color thraughout and has
ous cells have invaded the basement membrane, the risk of metastasis
shades of tan, brown, black, red, white, or blue.
via the blood and lymph vessels in the dermis is greater. The inci-
dence of malignant melanoma has doubled in the past 10 years, and D Diameter The mole is larger than 6 mm, about the size of a
the disease causes more deaths than all other skin diseases. Melano- pencil eraser.
mas often recur or metastasize within 5 years of diagnosis. The E Elevation Amole that once was flat against the skin now is
patient should be examined routinely for at least 10 years after raised and elevated.
removal of a melanoma.
364 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES
DERMATOLOGIC PROCEDURES
The integumentary system can reflect both internal and external
reactions and disease processes. The skin holds information about
the body's circulation and nutritional status, and signs of systemic
diseases. It also acts as a mirror, reflecting aging changes that occur
in all organs of the body. For many people, self-esteem is linked to
a youthful appearance, and dermatologic conditions may be very
threatening to feelings of self-worth. As you prepare patients for a
dermatologic examination, allow them to express their anxieties. The
impairments that most frequently bring a patient to the dermatolo-
gist's office are cosmetic disfigurements caused by a skin disease, pain
and pruritus, and interference with sensations or movements.
Assisting with a Dermatologic Examination
During a dermatologic examination, the provider inspects the entire
body, beginning with the scalp and continuing to the soles, including
the genital area. Inspection of the skin is followed by detailed exami-
nation of suspicious areas through palpation, diascopy, and special
tests. A diascope is a glass plate held firmly against the skin to permit
observation of changes produced in underlying areas when pressure
is applied. Inspection may include the use of a magnifying lens and
a bright light to closely examine a suspicious lesion or growth. The
dermatologist frequently asks the medical assistant to take photo-
graphs of moles and/or to document specific measurements and
locations of suspicious lesions. These are placed in the health record
for comparison when the patient returns for follow-up visits.
In the physical examination, concerns about the integumentary
system include abnormal coloring, such as cyanosis, pallor, ery-
thema, leukoderma, or excessive brown patches. Jaundice may
indicate an increase in the level of bilirubin in the blood.
Decreased pigmentation is found in vitiligo, an acquired loss of
melanin characterized by blotchy white patches on the skin.
Lesions, ulcers, and bruises may be the result of pathologic condi-
tions. Localized red or purple changes may be caused by vascular
neoplasms, birthmarks, or subcutaneous hemorrhages (petechiae
and ecchymosis). Palpation helps confirm findings of the inspec-
tion. Therefore, inspection and palpation are interrelated in con-
firming the diagnosis of an integumentary system disorder. Palpated
findings may include the skin's texture or elasticity or the presence
of edema or a neoplasm.
Gowning and draping a patient for a skin examination depend
on the area to be examined. Remember to expose the area adequately
but also to protect the patient's privacy. Try to make the patient as
comfortable as possible and offer support when it is needed.
Skin Testing tor Allergies
Skin testing to detect allergies requires percutaneous application or
intradermal injection of a small amount of antigen (or groups of
antigens) and later examination of the test sites for a visible reaction.
The larger the localized skin reaction, the more profound the patient's
allergic response to the tested allergen.
Percutaneous Test. A percutaneous, or scratch, test may be per-
formed on the forearm, upper arm, or back. The back is favored in
young children because of the large area of skin available. It also is
easier to immobilize the child in this position. The skin surface is
labeled or numbered in rows 1½ to 2 inches apart, and a small
FIGURE 14-18 Results of allergy testing. (From Habif TP: Clinical dermatology, ed 5, St Louis,
2010, Mosby.)
amount of allergen is placed on the skin, which is then scratched or
pricked to place the allergen just under the skin surface. Many aller-
gists use a plastic device that is dipped into the designated allergens
and lightly pressed into the skin so that the prick and allergen depo-
sition occur at the same time. Seventy or more tests may be done at
one time. It is essential to follow a pattern so that the site of each
allergen can be easily identified. This type of allergy testing is used
for allergic rhinitis, asthma, and detection of food allergies.
A reaction usually occurs within 10 to 30 minutes of exposure
to the allergen. If the reaction is positive, a wheal (hive) forms at the
site of the scratch (Figure 14-18). Interpretation of the test result
should always be based on a comparison of this reaction with that
of the control, which is a scratch with a plain fluid free of any allergy-
producing extract.
The interpretation, or reading, of the skin tests is performed by
the provider or a trained technician. Reactions commonly are graded
from 2 to 4. No precise definition of a reaction can be given, and
the intensity of the response may vary among individuals. However,
as a general rule, a 2 reaction implies a wheal that is definitely larger
than that of the control. A larger wheal is interpreted as a 3, whereas
the presence of pseudopods (fingerlike extensions around the periph-
ery of the wheal) may be read as a 4. If a strong reaction occurs, the
allergen extract should be carefully wiped off to prevent any further
exposure. Frequently, large or significant reactions are accompanied
by local itching. Patients should remain in the office for at least 30
minutes after completion of the test in case a delayed systemic aller-
gic response occurs.
Patch Test. This test uses an allergen that is applied to a patch that
is placed on the skin. Patch testing helps detect delayed allergic reac-
tions associated with contact dermatitis. The patches are placed on
the arms or back and must remain in place for 48 hours. The patient
needs to avoid bathing and activities that cause heavy sweating. The
patches are removed at a subsequent office visit. Skin irritation at
the patch site indicates an allergy to that particular substance.

Guidelines for Allergen Skin Testing
• The patient should stop taking all antihistamines or allergy medications
3 ta l Odays before testing ta prevent false-negative results.
• Recommended sites far injection or application of the allergen are the
anterior forearm, the upper arm, and the back.
• Allergen sites must be specifically labeled and spaced approximately
l½ to 2 inches apart.
• If the patient shows signs of anaphylaxis, notify the provider immedi-
ately and prepare emergency supplies. Allergy testing should be per-
formed only when the provider is on site.
• Skin testing may cause a mild systemic allergic response, resulting in
rhinitis, wheezing, and sneezing. The patient should contact the pro-
vider if a mare severe reaction occurs.
lntradermal (lntracutaneous) Test. The intradermal test is more
sensitive than the percutaneous test and usually is used to diagnose
allergies to penicillin and insect venom, such as from bee stings.
Extracts are injected into the intradermal layer of the skin in doses
of 0.1 to 0.2 mL. This method also is used for the tuberculin (puri-
fied protein derivative [PPD]) test and the Valley Fever coccidioido-
mycosis test. When intradermal injections are used for allergy testing,
10 to 15 allergens may be tested at one time on each arm. The reac-
tion time is identical to that of the scratch test; however, the antigen
is more dilute.
Radioallergosorbent Test. The radioallergosorbent test (RAST)
measures the level of antibodies created when a sample of the
patient's blood is mixed with allergens in the laboratory. The RAST
is easier to perform than skin testing because it requires a single
venipuncture. Although skin testing remains the preferred method
of diagnosing hypersensitivity, the RAST may be indicated when the
patient cannot stop antihistamine medications, when a skin disorder
makes accurate interpretation of skin test results difficult, or when
skin test results are negative but the patient's signs and symptoms
support further investigation. RAST blood tests are primarily used
to identify food allergies.
CRITICAL THINKING APPLICATION 14-5
Anew employee in the practice asks Melissa's help in understanding the
different methods of testing far allergies. What should Melissa tell her about
the various skin tests performed in the office and the venipuncture RAST
test?
Treatment of Allergies
The classic treatment of allergies is to encourage the patient to avoid
known or suspected allergens. Unfortunately, this is not always pos-
sible, so the provider may prescribe antihistamine medications, such
as levocetirizine (Xyzal), for relief of allergy symptoms. Over-the-
counter antihistamines include Allegra, Zyrtec, and Clari tin. Another
option is the use of immunotherapy, a series of injections in which
minute doses of known allergens are administered subcutaneously
over time to desensitize the patient's immune system and ultimately
develop a resistance to the immune response. This usually requires
weekly or bimonthly injections over several years. Some patients are
CHAPTER 14 Assisting in Dermatology 365
cured, whereas others have only a minor reduction in allergic symp-
toms. lmmunotherapy is controversial because it is an expensive,
invasive, and potentially dangerous treatment with unpredictable
results. It is recommended only for patients with severe allergic symp-
toms that are not relieved by antihistamine medications.
If you are responsible for administering allergen injections, you
must take great care to dispense the correct dose of each allergen;
administer each subcutaneous injection in a separate site; accurately
document the procedure and the exact location of each injection;
record any local or systemic reactions; and observe the patient for at
least 20 to 30 minutes after the injections to detect possible systemic
allergic responses, including urticaria (hives), wheezing, or hypoten-
sion. If the patient shows any localized or systemic reactions, the
provider should be notified.
Appearance Modification Procedures
Chemical Peel (Chemexfoliation). Topical agents are used in chemi-
cal peels to minimize or remove minor skin features, such as acne scars,
hyperpigmentation, and fine wrinkles. Agents used for chemical peels
include tretinoin cream 0.05% to 0.1 % concentration (Retin-A) and
a number of different acidic preparations. During application, care
must be taken to prevent the solution from entering the eyes. The use
of chemical exfoliating agents may cause the skin to appear inflamed
and dry with crusting and edema. The patient may complain of sting-
ing and burning at the beginning of the treatment regimen. The
patient should avoid sun exposure for the length of treatment and
should use a sunscreen with a minimum SPF of 15 because photo-
phobia (light sensitivity) is a typical side effect of treatment.
Dermabrasion. A dermabrader is a handheld device that mechani-
cally evens the layers of dermal tissue. It is effective in the treatment
of scars from acne vulgaris. Topical anesthetics (e.g., ethyl chloride)
or locally injected anesthetics are used for the procedure. Besides the
dermabrader, the dermatologist may use a variety of wire brushes,
abrasive disks, or other devices to smooth scar tissue. Standard Pre-
cautions must be followed, including the use of face and eye guards,
to prevent aerosol or splatter contamination from the site. The
patient should be educated about wound care, signs of infection,
and the presence of photophobia for 6 to 12 months after the
procedure.
Laser Resurfacing (Photothermolysis). Laser therapy may be used
for fine lines and wrinkles, pigmented areas, shallow scars, and tattoo
removal. Typically, the patient is instructed to prepare the site 3 to
6 weeks before the procedure with tretinoin (Retin-A), alpha hydroxy
solutions, or bleaches. Laser procedures are performed with the
patient under local, regional, or general anesthesia. During the pro-
cedure, it is extremely important that the patient and all personnel
wear the type of eye protection recommended by the laser manufac-
turer. After the procedure, cool packs are applied to help reduce
swelling, and topical antibiotic ointment is used to prevent infection.
The treated area appears inflamed and edematous and can take up
to 2 weeks to heal; it can take as long as 6 months for the inflam-
mation to fade.
Botox Injections. Botox is a strong neurotoxin (a substance toxic to
nerves) produced by Clostridium botulinum, a bacterium that causes
food poisoning. Two strains of the botulism bacterium are used in
dermatologic procedures for appearance modification. Botox treat-
ments involve injection of the substance around the eyes, mouth,
366 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES
and forehead. The toxin interferes with nervous stimulation, which
temporarily paralyzes the muscles of the face that cause wrinkles to
form. It also smoothes out the skin and makes it look younger and
fresher. The effects are short term, so treatments must be repeated
every 3 to 4 months, and some patients complain of an inability to
show facial expression because of muscle paralysis.
CLOSING COMMENTS
Patient Education
The field of dermatology offers medical assistants many opportuni-
ties and topics for patient education. Skin care products are adver-
tised in the newspaper, online, in magazines, and on television.
Consult the dermatologist for whom you work and get approval of
skin care products the provider recommends to patients.
Another area of patient education involves the potentially danger-
ous effects of sunlight and tanning beds. Obtain literature showing
how UV rays cause premature aging and may cause cancerous lesions
later in life. Tanning beds should be avoided, especially by individu-
als with a skin disorder and by those taking medications that cause
photophobia. Providing patients with information about the warning
signs of cancer also is a vital part of patient education in a dermatol-
ogy practice.
Melissa enjoys her work with Dr. Lee, and she recognizes that she needs to
keep up with new developments in the field of dermatology. She has learned
the importance of giving patients accurate information while conducting tele-
phone screening and always refers questions or concerns to Dr. Lee. Melissa
especially enjoys the patient education aspects of working far a dermatologist,
SUMMARY OF LEARNING OBJECTIVES
l. Define, spell, and pronounce the terms listed in the vocabulary.
Spelling and pronouncing medical terms correc~y reinforce the medical
assistant's credibility. Knowing the definitions of these terms promotes
confidence in communication with patients and co-workers.
2. Explain the major functions of the skin.
The skin acts as a barrier to protect vital internal organs from infection
and injury. It also helps dissipate heat and regulate body temperature,
and it synthesizes vitamin Dwhen exposed to UV light. In addition,
various sensory receptors all over the skin enable the body to respond
to heat, cold, pain, and pressure.
3. Describe the anatomic structures of the skin.
The skin is made up of three layers: the epidermis, which is the thin,
uppermost layer; the dermis, the thicker layer beneath, which makes up
approximately 90% of the skin mass; and the subcutaneous layer, which
consists primarily of fatty or adipose tissue.
4. Compare various skin lesions and give examples of each.
Figure 14-2 shows different types of skin lesions. The diagnosis of skin
lesions is based on the color, elevation, and texture of the lesion; whether
Legal and Ethical Issues
While working in a dermatology practice, you will hear many
patients express concern about skin disorders. Allow patients to
express their concerns. Use therapeutic listening techniques, but be
careful when offering encouragement about the course and outcome
of treatment. The improvement made with treatment of a skin dis-
order may be slow and gradual. Keep encouragement on a positive
level. Help the patient recognize small improvements, but remember
that it is the provider's role to explain potential treatment outcomes.
Promising outcomes could lead to a lawsuit.
Professional Behaviors
The medical assistant must develop the ability to interact therapeutically
with patients, families, co-workers, and other members of the healthcare
team. When interacting with patients in adermatology practice, the medical
assistant needs to be especially sensitive to the patient's nonverbal behav-
iors and emotions. Many of the conditions seen in a dermatology practice
affect how patients look and how they view themselves. Sensitivity to the
importance of appearance, especially when skin conditions and/or treat-
ments might alter a patient's appearance, is a crucial trait far healthcare
professionals working in a dermatology practice.
including teaching patients the importance of using sunscreen, controlling sun
exposure, and checking for the warning signs of cancer. Melissa also has learned
how to assist Dr. Lee with dermatologic procedures, including allergy skin
testing and assisting with biopsies, chemical peels, dermabrasions, and laser
resurfacing.
pruritus, excoriation, pain, or drainage is present, and whether the lesion
is a primary or secondary growth.
5. Describe typical integumentary system infections and infestations.
lntegumentary system infections include bacterial infections, such as
impetigo, acne vulgaris, furuncles, carbuncles, and cellulitis; fungal infec-
tions, including a variety of tine• growths; viral infections, which cause
warts, herpes simplex, and herpes zoster outbreaks; and scabies or lice
infestations.
6. Differentiate among various inflammatory and autoimmune integu-
mentary disorders.
Inflammatory and autoimmune integumentary system disorders
include a variety of seborrheic dermatitis inflammations, contact
dermatitis, eczema, and the autoimmune disorders psoriasis, SLE, and
scleroderma.
7. Recognize thermal and cold injuries to the skin.
The most common thermal injuries are burns, which are classified as
superficial, partial-thickness, or full-thickness, depending on the depth of
the wound. The most important concern in the treatment of burns is the

SUMMARY OF LEARNING OBJECTIVES-continued
prevention of infection. Cold injuries usually are less severe than burns,
but prolonged exposure can result in infection, gangrene, amputation,
and death.
8. Compare the characteristics of benign and malignant neoplasms.
Benign masses are encapsulated, whereas malignant tumors invade and
take aver surrounding tissues. Local invasion af surrounding tissue occurs
when malignant cells break through the basement membrane that sepa-
rates epithelial cells from connective tissue. This allows the cancerous
cells ta invade blood and lymph vessels, and blood and lymph then can
carry the malignant cells to organs throughout the body.
9. Do the following relating to benign and malignant neoplasms:
• Explain the grading and staging of malignant tumors.
Grading is the histologic, cellular classification of a tumor. The more
poorly differentiated the cells, the closer the biopsy sample is to an
anaplastic cancerous mass. Staging involves using physical examina-
tion and diagnostic tests (e.g., bane or liver scans) ta determine the
presence of tumor spread.
• Conduct patient education on the warning signs of cancer.
The warning signs of cancer include any change in bowel or bladder
habits; a sore that does not heal; unusual bleeding or discharge; a
thickening or a lump in the breast or elsewhere; indigestion or diffi-
culty swallowing; an obvious change in a wart or male; or a nagging
cough ar hoarseness. Any af these warning signs should be reported
to the provider immediately. Early detection and se~-examinatian are
crucial to cancer survival.
• Describe skin malignancies and their treatment.
Three cancerous lesions of the skin can occur: basal cell carcinoma,
which is very slow growing and the most frequenrly seen form of skin
cancer; squamous cell carcinoma, which grows rapidly and is more
serious because it has a tendency ta metastasize; and melanomas,
which are pigmented lesions that are asymmetric, have irregular
borders, and usually are larger than 6 mm. Treatment depends on the
type af lesion, the level of invasion, and the location. The provider
may surgically remove the tumor or may destroy it with cryosurgery,
electrodesiccation, laser treatment, the application of chemotherapeu-
tic agents, or Mohs surgery.
• Define the ABCDE rule for identifying amalignant melanoma.
The ABCDE rule includes examination of the site for any af the fol-
lowing: asymmetry, irregular oorder, change in color, increase in
alameter, and elevation. If a male displays any of these characteris-
tics, a dermatologist should check it immediately.
CONNECTIONS
CrJ Study Guide Connection: Go to the Chapter 14 Study Guide. Read and complete
the activities.
CHAPTER 14 Assisting in Dermatology 367
l 0. Do the following relating to dermatologic procedures:
• Discuss how to assist with adermatologic examination.
During a dermatologic examination, the dermatologist frequenrly
asks the medical assistant to take photographs of moles and/or
to document specific measurements and locations of suspicious
lesions.
• Summarize allergy testing procedures.
Allergy testing is done by exposing the patient to suspected allergens
through a scratch on the skin or an intradermal injection and then
observing the exposure site to see whether a localized allergic reaction
develops. The patient must be off antihistamine drugs for several days
before testing. Sites for allergen exposure include the upper arms,
anterior forearms, and back. Aprovider must be present in the facility
while allergy testing is done because of the potential for local or
systemic allergic reactions in sensitized individuals. Patch testing can
be done for contact dermatitis. The radioallergosorbent test (RAST)
measures the level of antibodies created when a sample of the
patient's blood is mixed with allergens in the laboratory.
• Describe the diagnosis and treatment of allergies.
Skin testing to detect allergies requires percutaneous application or
intradermal injection of a small amount of antigen and later examina-
tion of the test sites for a visible reaction. The larger the localized
skin reaction, the more profound is the patient's allergic response to
the tested allergen. The classic treatment of allergies consists of
avoiding known or suspected allergens and prescribing antihistamine
medications or immunotherapy.
11. Explain dermatologic procedures performed in the ambulatory core
setting.
Dermatologic procedures that can be perrormed in ambulatory care
practices include allergy skin testing, which can be done with scratch,
patch, or intradermal tests; drawing blood for a RAST test; treating aller-
gies with immunotherapy; perrorming a biopsy or procedure to remove
a cancerous area; and appearance modification procedures, including
chemical peels, dermabrasion, laser resurracing, and Botox injections.
12. Discuss the medical assistant's role in patient education, in addition
to legal and ethical issues that would apply to a dermatology
practice.
Areas for possible patient education include dermatologist recommenda-
tions for skin care products, the dangers of UV exposure, and information
about the warning signs af skin cancer.
evolve Evolve Connection: Go to the Chapter 14 link at evolve.e/sevier.com/
kinn to complete the Chapter Review Quiz. Check out the other resources listed for this
chapter to make the most of what you have learned from Assisting in Dermatology.
 15 ASSISTING IN GASTROENTEROLOGY
li#H+i;H•i
Joan Rothman, (MA (AAMA), was recently hired by United Community Hospital
to work for a group of internists. Joan works primarily with Dr. Raj Sahani, a
provider who specializes in gastroenterology. Although Joan did very well in
school, she has had to learn more advanced information about disorders of
the gastrointestinal (GI) tract so that she can answer patients' questions and
understand the diagnostic procedures ordered by Dr. Sahani.
While studying this chapter, think about the following questions:
• What does Joan need to include in the educational packets so that
patients are prepared for GI examinations?
• What are some of the GI disorders Joan can expect to see in this
specialty practice?
LEARNING OBJECTIVES
1. Define, spell, and pronounce the terms listed in the vocabulary.
2. Describe the primary functions of the GI system.
3. Identify the anatomic structures that make up the GI system and
describe the physiology of each.
4. Differentiate among the abdominal quadrants and regions.
5. Summarize the typical symptoms and characteristics of GI complaints
and pertorm telephone screening for patients with GI complaints.
6. Distinguish among cancers of the GI tract.
7. List common esophageal and gastric disorders; also, describe the signs
and symptoms, diagnostic tests, and treatments of each.
8. List intestinal disorders; also, describe the signs and symptoms,
diagnostic tests, and treatments of each.
9. Do the following related to diseases of the liver and gallbladder:
• Classify disorders of the liver and gallbladder, and list the signs
and symptoms, diagnostic tests, and treatments for each.
VOCABULARY
adhesions (ad-he'-zhuns) Bands of scar tissue that bind together
two anatomic surfaces that normally are separate.
anastomosis (uh-nas-tuh-mo'-sis) Creating a surgical connection
between two body structures, such as blood vessels or loops of
intestine.
anorexia (a-nuh-rek'-se-uh) A lack or loss of appetite for food.
ascites (ah-si' -tez) An abnormal collection of fluid in the
peritoneal cavity containing high levels of protein and
electrolytes.
Dr. Sahani has asked Joan to research and develop educational packets for
common gastrointestinal diagnostic studies and to work with other staff
members on understanding procedures related to the GI system. Part of the
role of the medical assistant working in a gastroenterology practice is to make
sure that patients are properly prepared for diagnostic procedures. Joan also is
expected to help in the orientation of new staff members.
• What information should be included in a pamphlet on infectious viral
hepatitis?
• What should a new medical assistant know about the GI examination,
including instructions for patients on how to collect fecal specimens?
• Describe the similarities and differences among the various forms
of infectious viral hepatitis.
10. Summarize the medical assistant's role in the GI examination.
11. Do the following when it comes to assisting with gastroenterology
diagnostic procedures:
• Explain the common diagnostic procedures for the GI system.
• Demonstrate the procedure for assisting with an endoscopic colon
examination.
• Pertorm the procedural steps for assisting with the collection of a
fecal specimen.
12. Describe the medical assistant's role in the proctologic examination.
13. Describe patient education, in addition to legal and ethical issues,
related to assisting in gastroenterology.
carcinogens (kar-sih'-nuh-jehns) Substances or agents that cause
the development of cancer or increase its incidence.
dysphagia Difficulty swallowing
endemic (en-deh'-mik) A term describing a disease
or microorganism that is specific to a particular
geographic area.
esophageal varices (uh-sah-fuh-je' -uh! var' -uh-sez) Varicose veins
of the esophagus that occur as a result of portal hypertension;
these vessels can easily hemorrhage.

VOCABULARY -continued
fecalith (fe'-kuh-lith) A hard, impacted mass of feces in the
colon.
fissures Narrow slits or clefts in tissue such as the mouth or the
anal area.
fistula (fis' -chuh-luh) An abnormal, tubelike passage between
internal organs or from an internal organ to the body's surface.
flatus Gas expelled through the anus.
gangrene The death of body tissue as a result of loss of nutritive
supply, followed by bacterial invasion and decay.
hematemesis (he-muh-tem'-uh-sis) Vomiting of blood; may be
obviously red (from esophageal varices or a peptic ulcer) or
contains partially digested blood and looks like coffee grounds.
hematocrit The percentage by volume of packed red blood cells
in a given sample of blood after centrifugation.
hemoglobin (he'-muh-glo-buhn) A protein found in erythrocytes
that transports molecular oxygen in the blood.
hepatomegaly (heh-pah-to-meh'-guh-le) Abnormal enlargement
of the liver.
ileostomy The surgical formation of an opening of the ileum
onto the surface of the abdomen, through which fecal material
is emptied.
jaundice Yellowing of the skin and mucous membranes caused by
the deposition of bile pigment. Jaundice is not a disease, but
rather a sign of a number of diseases, especially liver disorders.
I nternal medicine is a nonsurgical specialty consisting of several
subspecialties. Gastroenterology, one of these subspecialties,
covers an extremely wide area known as the gastrointestinal (GI)
system, or the alimentary canal. Gastroenterologists are concerned
with diseases and disorders of the stomach, small intestine, large
intestine (colon), appendix, and accessory organs of the liver, gall-
bladder, and pancreas. Proctology, a subspecialty of gastroenterology,
is concerned with disorders of the rectum and anus. The major
purpose of the GI system is to prepare, digest, and absorb the neces-
sary nutrients to maintain homeostasis and excrete waste products
through the feces.
ANATOMY AND PHYSIOLOGY
The GI system is basically a long, hollow tube with the same struc-
tural organization from its beginning to its termination (Figure
15-1). The muscles lining the GI tract are closely regulated by the
autonomic nervous system, which gives the entire system its unique
ability to move slowly in some locations and to have increased move-
ment in other sections.
The GI system is divided into two parts: the upper digestive
system, which includes the mouth, esophagus, and stomach, and the
lower digestive system, which consists of the small and large intes-
tines. The GI tract is rich in lymphatic tissue, which is very impor-
tant for the absorption of nutrients from ingested food. Unfortunately,
the lymphatic vessels also are the main route for the spread of cancer.
As mentioned, the GI organs have three primary functions:
digestion, absorption, and elimination. When food is taken in
CHAPTER 15 Assisting in Gastroenterology 369
lymphadenopathy (lim-fa-duh-nah'-puh-the) Any disorder of the
lymph nodes or lymph vessels.
peristalsis The rhythmic, involuntary serial contraction of the
smooth muscles lining the GI tract.
polyps (pah'-lips) Outgrowths of tissue found in the mucosa!
lining of the colon. Polyps are considered precancerous.
portal circulation The pathway of blood flow through the portal
vein from the GI system to the liver.
portal hypertension Increased venous pressure in the portal
circulation caused by cirrhosis or compression of the hepatic
vascular system.
pyloric sphincter A muscular ring at the distal end of the
stomach that separates the stomach from the duodenum of the
small intestine.
sclerotherapy (skleh-rah-ther'-ah-pe) The treatment of
hemorrhoids or varicose veins by means of injection of
sclerosing solutions.
Valsalva maneuver The act of attempting to exhale forcibly while
keeping the nose and mouth closed, such as occurs when a
person strains to defecate or urinate; uses the arms and upper
trunk muscles to move up in bed; or strains during laughing,
coughing, or vomiting. This causes trapping of blood in the
great veins, preventing the blood from entering the chest and
right atrium.
through the mouth, it is chewed, or masticated, and moistened
with saliva. Salivary amylase, an enzyme released by the salivary
glands, mixes with the food and begins carbohydrate digestion.
This mass, now called a bolus, is swallowed, and the food enters the
esophagus. Contractions of the smooth muscles are activated, and
the bolus is moved by peristalsis down the esophagus and into the
stomach.
At the distal end of the esophagus is the gastroesophageal, or
cardiac, sphincter, which relaxes as the bolus is swallowed so that it
can pass into the stomach. The muscular walls of the stomach overlap
in folds, or rugae, which permit the stomach to expand and to hold
as much as 1 to 1.5 L of food and liquid. The gastric glands in the
stomach mucosa secrete hydrochloric acid, pepsinogen (which
begins the digestion of protein), and intrinsic factor, which is needed
for the absorption of vitamin B12 • The gastric contents, called chyme,
are slowly emptied through the pyloric sphincter into the small
intestine. The small intestine is made up of the duodenum at the
proximal end, the jejunum, and the ileum at the distal end.
The common bile duct delivers bile, which is produced in the
liver and stored in the gallbladder, to the duodenum. Bile acids
emulsify fat; that is, they break down large fat molecules into smaller
molecules that can be chemically digested by fat enzymes. The pan-
creatic duct delivers digestive enzymes to the duodenum, including
amylase for carbohydrate digestion, trypsin for protein breakdown,
and lipase for fats. This mixture of bile and pancreatic enzymes in
the duodenum completes the digestion of nutrients, converting car-
bohydrates into glucose, protein into amino acids, and fats into fatty
acids and glycerol.
370 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES

Hard palate Events

---+--------1-- Parotid salivary Mouth • Chew food
'---i"'.~::;::;~ gland • Saliva-adds
water and begins
+------,,<---- Oropharynx carbohydrate digestion
~ :--114-+------,,-__ _ _ Submandibular
salivary gland

Esophagus• Swallow
l
Esophagus

Liver Diaphragm
I Stomach • Mix and dilute chyme
- - - - '~ -Cardiac sphincter • Gastric secretions
- Digest protein
--t--Stomach - Add intrinsic factor
-Acidic
- - - - - - - - P y l o r i c sphincter

Gallbladder Pancreas
+
Small intestine • Bile emulsifies fat
• Pancreatic secretions
Common bile duct--,,--_.__~
• Intestinal secretions
Duodenum - Digest fat, protein,
and carbohydrate
Duodenal papilla
• Absorption of
Large intestine nutrients
Ascending colon
Descending colon
+
Colon • Absorbs water
lleocecal valve Jejunum and electrolytes

1
Ileum---'<-* -+
Cecum
Sigmoid colon
Appendix Rectum• Storage until
I defecation
Anus

FIGURE 15-1 Anatomy of the digestive system, with associated events. (From VanMeter KC, Hubert RJ: Gould's pathophysiology for the health
professions, ed 5, Philadelphia, 2015, Saunders.)

Once digestion has been completed in the duodenum, the second

function of the GI tract, absorption of nutrients, begins. The small
intestine is lined with transverse folds of tissue called villi. Approxi-
mately 25,000 of these overlapping projections greatly increase the
surface area available in the small intestine for nutrient absorption.
Each villus is rich with blood vessels that absorb digested nutrients
into the portal circulation system and carry them directly to the
liver for processing. Lymph vessels along the villi absorb fat and
deposit it into the systemic circulation. By the time the chyme
reaches the terminal end of the small intestine, every nutrient the
body needs should have been absorbed. This mass enters the colon,
or large intestine, which is made up of the cecum (extending from
it is the vermiform appendix), ascending colon, transverse colon,
descending colon, sigmoid colon, rectum, and anus. The colon
absorbs large amounts of fluids and electrolytes to prevent dehydra-
tion of body tissues. Once fluid has been reabsorbed, the remaining
solid waste materials, called feces, are moved into the sigmoid colon
and rectum, and elimination occurs through the anus. This final
function is called defecation.
CRITICAL THINKING APPLICATION 15-1
Summarize what you have learned about the anatomy and physiology of
the GI system. Why are the villi of the small intestine so important? If a
patient is diagnosed with celiac disease (a condition that causes destruction
of intestinal villi because of an immune reaction to gluten), why can this
cause malnutrition in an otherwise well-nourished individual?
DISEASES OF THE GASTROINTESTINAL SYSTEM
GI disorders probably are the most common problems seen in a
medical office. Most conditions of the GI system are managed by a
primary care provider. About 5% to 10% of patients with GI prob-
lems are referred to a gastroenterologist for diagnosis and treatment.
It is assumed that problems that stem from dental disorders are
treated by dental professionals. This chapter concentrates on the GI
problems most frequently seen, diagnosed, and treated in an ambula-
tory care center.

CHARACTERISTICS OF THE GI SYSTEM
The following are the primary structures and functions of the GI
system.
The abdominal cavity can be divided into four quadrants or nine
regions.
• The quadrant system is more general than the nine-region
system. However, patients understand quadrants more easily,
and using these terms can help you locate a symptomatic area,
such as the site of abdominal pain.
• The four quadrants are identified with abbreviations: The
right upper quadrant (RUQ), left upper quadrant (LUQ),
right lower quadrant (RLQ), and left lower quadrant (LLQ).
• Figure 15-2 shows the organs located in each quadrant and
region. When documenting in the health record, you should
use correct medical terminology to detail the location of the
patient's complaints. For example, if the patient complains of
..._.,, J...·-+++-+--
Right lower
quadrant
RIGHT UPPER QUADRANT (RUQ)
Liver
Gallbladder
Duodenum
Head of pancreas
Right kidney and adrenal
Hepatic flexure of colon
Part of ascending and
transverse colon
RIGHT LOWER QUADRANT (RLQ)
Cecum
Appendix
Right ovary and tube
Right ureter
Right spermatic cord
FIGURE 15-2 The abdominal quadrants and regions and the organs within each.
CHAPTER 15 Assisting in Gastroenterology 371
pain in the stomach, document it as RUQ pain using an
appropriate pain scale (e.g., 1 to 10); a complaint of heartburn
would be documented as epigastric distress using the regions
identifier.
• The peritoneum is a membrane that lines the abdominal wall and
covers the organs of the abdominal cavity.
• The mesentery is a dorsal peritoneal fold that attaches the jejunum
and ileum to the posterior abdominal wall.
• The omentum is a fold of fatty peritoneal tissue with multiple
lymph nodes. It hangs from the stomach like an apron, covering
the anterior transverse colon and the small intestine. Inflamma-
tion of the omentum results in the formation of scar tissue and
adhesions.
• The GI system digests and absorbs nutrients for the entire body
and excretes waste materials in the feces; if it becomes diseased,
all other systems are affected.
----
Epigastric
Right Left
Left upper hypochondriac hypochondriac
quadrant Left lumbar
Right lumbar
Left lower
Umbilical
quadrant Right inguinal
Left inguinal
Hypogastric
LEFT UPPER QUADRANT (LUQ)
Stomach
Spleen
Left lobe of liver
Body of pancreas
Left kidney and adrenal
Splenic flexure of colon
Part of transverse and
descending colon
LEFT LOWER QUADRANT (LLQ)
Part of descending colon
Sigmoid colon
Left ovary and tube
Left ureter
Left spermatic cord
MIDLINE
Aorta
Uterus (if enlarged)
Bladder (if distended)
372 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES

Common Signs and Symptoms of a Gastrointestinal Disorder

Apatient with a gastrointestinal (GI) problem may complain of multiple quadrant or region is identified, and the patient is properly prepared for the
discomforts, including nausea, vomiting, anorexia, diarrhea, constipation, provider's examination. If possible, document the location of the patient's
and abdominal pain. The medical assistant may find it difficult to identify the complaint using the abdominal regions (see Figure 15-2) because this is
exact location and quality of the patient's discomfort. When you discuss most accurate. For example, if the patient complains of heartburn after
abdominal pain with the patient, ask him or her to point to or touch the area eating, this can be charted as: Pt c/oepigastric discomfort after meals; 6 on
where the pain is located. This is one way of making sure the correct a pain scale of 10.

Table 15-1 outlines the typical signs, symptoms, and character-

istics seen in patients with GI complaints. Telephone screening for
GI complaints involves following the facility's policies and proce-
dures manual for management of disorders; gathering detailed infor-
mation about the onset, duration, and frequency of the problem and
the pertinent patient history; and recording the interaction in the
patient's health record (this should include the use of medications
for relief; a pain scale, if appropriate; and the course of action based
on the provider's recommendations). Using Procedure 15-1 , outline
how you would respond to the scenarios in the following Critical
Thinking Application box.
CRITICAL THINKING APPLICATION 15-2
Two days a week, Joan works in the telephone screening area of the
practice, where she is responsible for the initial management of calls from
Dr. Sahani's patients. The following problems are typical of a call day. What
are some questions Joan should ask and subsequently document in each
patient's health record?
• The mother of a 7-year-old patient is concerned because her son has
been vomiting since yesterday.
• The father of an 18-month-old infant reports that the child has had
diarrhea for 2 days.
• A72-year-old patient is concerned about constipation that has not been
relieved by laxatives.

TABLE 15-1 Characteristics of Common Gastrointestinal Complaints

COMPLAINT CAUSE
Vomiting (emesis) GI irritation, pain or stress, inner ear disturbance, increased
intracranial pressure (l(P), food-borne illness
Diarrhea Infection or inflammation, food allergies, food-borne illness,
malabsorption syndromes
Constipation Lack of dietary fiber; inadequate intake of fluids; lack of
exercise; neurologic disorders, including spinal cord injury
and multiple sclerosis; side effect of medications (e.g.,
codeine, iron, antacids); bowel obstruction or tumor
Abdominal pain Ulcerative disease, tumor, appendicitis, bowel obstruction,
food-borne illness, infection or inflammatory process
CHARACTERISTICS TO REPORT AND RECORD
• Onset, frequency, and duration of the problem
• Yellow or greenish color (indicates bile from the duodenum)
• Pyloric stenosis (causes vomiting of undigested food)
• Projectile vomiting (may indicate pyloric stenosis or
increased ICP)
• Hematemesis
• Onset, frequency, and duration of the problem
• Dehydration (may occur if diarrhea is persistent; occurs
more often in infants and older adults)
• Presence of blood, mucus, or pus in the stool
• Steatorrhea (large, foul-smelling, greasy stools)
• Melena (tarry stools from bleeding higher in the digestive
tract)
• Onset, frequency, and duration of the problem
• Treatment and effectiveness of over-the-counter (OTO
medications
• Diet and fluid intake
• Presence of watery diarrhea (may indicate fecal impaction)
• Onset, frequency, and duration
• Exact location (using quadrants or abdominal regions)
• Quality of the pain (e.g., burning, cramping, sharp, dull)
• Degree of pain (scale of 1 to 10)

Perform Patient Screening Using Established Protocols: Telephone Screening
PROCEDURE 15-1
of a Patient with a Gastrointestinal Complaint
Goal: To answer the telephone professionally and to manage patients' phone calls according to the provider's guidelines.
Scenario: With a fellow student, role-play a telephone call from a22-year-old woman who reports acute abdominal pain.
EQUIPMENT and SUPPLIES
• Access to the patient's health record
• Access to the appointments schedule
• Telephone
• Message pad
• Pen
• Facility's policies and procedures manual for managing patients' phone calls
PROCEDURAL STEPS
1. Answer the telephone by the third ring, speaking directly into the
mouthpiece.
PURPOSE: Answering promptly conveys interest in the caller. Proper position-
ing of the mouthpiece allows for an audible tone.
2. Speak distinctly, using a pleasant tone and expression, at a moderate rate,
and with sufficient volume.
3. Greet the caller, identify the office and/or the provider and yourself, and
offer ta help the caller.
PURPOSE: So the patient knows she has reached the correct number, in
addition to the name of the staff member to whom she is speaking.
4. Verify the identity of the caller and his or her date of birth; access the
patient's record.
PURPOSE: To have the patient's health record ready for reference about the
health history and recent care.
5. Determine the caller's needs using therapeutic communication skills.
PURPOSE: To gather comprehensive information about the caller's complaint
and to communicate empathetically about the caller's needs.
6. Upon learning the patient's complaint, formulate questions designed to
gather the information required to make a decision about when the patient
should be seen and the provider notified. On the basis of the patient's
gender, age, and complaint of acute abdominal pain, consider the following
questions:
• What are the onset, frequency, and duration of the abdominal pain?
• What is the exact anatomic location of the discomfort?
Cancers of the Gastrointestinal Tract
Any organ of the digestive tract can develop cancer. Malignant
tumors can invade surrounding tissues and metastasize through the
blood or lymph system, regardless of their location. Table 15-2
describes some of the common malignant tumors found in the GI
system. The exact cause of a malignancy may not be known, but
exposure to carcinogens increases the risk of developing a cancerous
tumor. Examples of carcinogens include tobacco and alcohol, in
addition to exposure to chemicals and radiation. A family history
CHAPTER 15 Assisting in Gastroenterology 373
• What is the quality of the pain (e.g., sharp, dull, stabbing)?
• On a scale of l to l 0, with l Obeing the worst pain, how does she
rate the pain?
• Does the patient have a history of this occurrence? Does she have a
history of gynecologic or pelvic disorders?
• Has she taken any medication for the discomfort and has it been
effective?
7. Refer to the facility's policies for patients' phone calls as needed.
PURPOSE: The medical assistant is not qualified to diagnose the patient.
The policies and procedures manual developed by the facility should be used
to guide appropriate management of individual patient problems.
8. Depending on the patient's answers to your questions and the facility's poli-
cies for the management of abdominal discomfort, refer to the appointment
schedule and make an appointment or take a message for the provider to
return the patient's call.
9. Document the details of the interaction and the results in the patient's health
record.
PURPOSE: All communications with a patient, including phone calls, are part
of the record of care.
In the space below, document the interaction based on the role-play answers
given to the questions in step 6.
DOCUMENTATION PRACTICE
and lifestyle factors, such as consuming a diet high in fat and low
in fiber, also can increase a person's risk of developing certain types
of cancer.
Disorders of the Esophagus and Stomach
Hiatal Hernia
A hernia is the abnormal protrusion of part of an organ or tissue
through the structures that normally contain it. These protrusions
can develop in various parts of the body but most frequently are seen
374 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES

TABLE 15-2 Cancers of the Gastrointestinal Tract

CAUSE OR CONTRIBUTING
TUMOR CHARACTERISTICS FACTORS
Oral tumor White mass in or on the mouth that bleeds easily (the mass usually is not Cancer of the lip (pipe smoking), cancer of
painful); ulcer or fissure that does not heal the tongue or gums (chewing tobacco)
Esophageal cancer Typically found in the distal esophagus; initial sign is dysphagia (difficulty Associated with chronic irritation resulting
swallowing) from chronic esophagitis, alcohol abuse, or
smoking
Gastric cancer Asymptomatic in early stages; usually not diagnosed until well advanced; Food preservatives, long-term use of
poor prognosis; marked by anorexia, indigestion, weight loss, fatigue; nitrates, smoked foods; genetic association;
positive test result for occult blood in the stool chronic gastritis
Liver cancer Primary malignant tumors rare, usually a metastasized secondary tumor; Primary tumor caused by cirrhosis from
initial symptoms mild; anorexia, vomiting, weight loss, fatigue, hepatitis or chemical exposure
hepatomegaly, splenomegaly, portal hypertension; usually advanced when
diagnosed
Pancreatic cancer Weight loss, jaundice; usually advanced when diagnosed; metastasis occurs Cigarette smoking; increased risk for
early; no effective treatment African-Americans and individuals who are
overweight, obese, diabetic, or have
chronic pancreatitis
Colorectal cancer Usually develops from polyps in the colon; metastasis to the liver common; Genetic or familial link; diet high in fat,
initial signs depend on location of tumor, may include changes in the sugar, and red meat and low in fiber;
character of stool, iron-deficiency anemia, fatigue, weight loss, or melena usually occurs in patients over age 55
(black, tarry, bloody stool)

in the abdominal region. Causes of herniation include congenital

weakness of the structures, trauma, relaxation of ligaments and skel-
etal muscles, and increased upward pressure from the abdomen.
Diaphragm
Herniation most often is found in middle-aged or older
individuals.
The location of the hernia determines the term by which the
protrusion is identified. In patients with a hiatal hernia, the upper
part of the stomach protrudes through the esophageal opening, the
hiatal sphincter of the diaphragm (Figure 15-3). With a sliding hiatal
hernia, part of the stomach moves above the diaphragm when the
individual is supine and slides back down into the abdominal cavity
when the person stands. Part of the fundus of the stomach moves
Sliding Paraesophageal
through the weakened hiatus in a paraesophageal hiatal hernia. Food
FIGURE 15-3 Hiatal hernias.
may lodge in the herniated part of the stomach, causing reflux of
highly acidic stomach contents into the esophagus, dysphagia, and
chronic esophagitis, which may cause fibrosis and stricture. Patients
complain of heartburn, frequent belching, and increased discomfort
when they cough, bend over, or lie down after eating. Gastroesophagea/ Reflux Disease
Patients with hiatal hernias can be treated with over-the-counter Gastroesophageal reflux disease (GERD) occurs when the gastro-
(OTC) medications such as Tagamet, Pepcid, Prilosec, or Prevacid. esophageal sphincter (cardiac sphincter) at the distal end of the
Treatment may involve dietary modifications, such as avoiding caf- esophagus does not close properly, allowing acidic stomach contents
feine, cigarettes, and alcohol; eating six small meals a day; losing to leak back, or reflux, into the esophagus. The regurgitated acidic
weight; avoiding lying down after meals; and raising the head of the contents of the stomach irritate the esophageal lining, causing heart-
bed 6 to 8 inches. burn symptoms. Occasional heartburn is not a problem, bur a

patient who experiences heartburn more than twice a week is diag-
nosed with GERD. All age groups can be diagnosed with GERD;
however, it is seen most frequently in adults and is associated with
alcohol use, pregnancy, and smoking; it is very common in over-
weight patients. Besides persistent heartburn, patients may report
chest pain, hoarseness in the morning, difficulty swallowing, a
feeling of tightness in the throat or a choking sensation, dry cough,
and bad breath from the reflux of partly digested food. GERD fre-
quently is seen in patients with hiatal hernias, and treatment proto-
cols are similar in the two conditions.
Laparoscopic repair of the gastroesophageal sphincter may be
recommended if lifestyle changes and medication are not effective
in curing the problem. The U.S. Food and Drug Administration
(FDA) has approved two different implant systems, LINX and
Enteryx, which are designed to improve the function of the sphincter
muscle. The most important concern with chronic GERD is the
potential for developing Barrett's esophagus, a precancerous condi-
tion caused by long-term exposure of esophageal cells to gastric
contents. Patients diagnosed with GERD are followed regularly by
a gastroenterologist so that abnormal cells can be detected early and
removed before cancerous changes occur.
Gastric and Duodenal Ulcers
Peptic ulcers occur most frequently in the proximal duodenum
(duodenal ulcer) but may also be found in the stomach (gastric
ulcer). Both types are characterized by an area of breakdown of the
mucosa! membrane, which leads to ulceration of the epithelial lining
of the duodenum or stomach (Figure 15-4).
The first sign of a peptic ulcer may be iron-deficiency anemia or
a positive stool test for occult blood, which results from erosion of
blood vessels in the organ wall. Patients typically complain of
gnawing or burning pain in the epigastric area between meals.
Gastric ulcers may cause weight loss, whereas duodenal lesions often
cause nausea and vomiting. If the ulcerative area is bleeding inter-
nally, the patient may have hematemesis or melena (dark, sticky feces
containing partly digested blood).
FIGURE 15-4 Peptic ulcer. (From Frazier MS: Essentials of human diseases and conditions,
ed 4, Philadelphia, 2009, Saunders.)
CHAPTER 15 Assisting in Gastroenterology 375
The description of the patient's pain gives the provider a suspicion
of the disorder. Examination often shows that the patient is guarding
the painful area; this is characterized by clutching the upper abdomi-
nal area and drawing the knees up toward the chest. A definitive
diagnosis is based on an upper GI series (x-ray evaluation) or endos-
copy (visualization) of the upper GI tract (Figure 15-5). A biopsy
sample of the affected area may be taken during the endoscopy to
rule out cancer. A stool test may be ordered to check for occult
blood. Blood tests also are ordered to establish the hemoglobin and
hematocrit levels.
Peptic ulcers can appear under a variety of predisposing circum-
stances, including use of alcohol, smoking, use of nonsteroidal anti-
inflammatory drugs (NSAIDs) or corticosteroids (e.g., prednisone),
and genetic predisposition. However, research indicates that 80% of
gastric ulcers and 90% of duodenal ulcers are caused by the Helico-
bacter pylori bacterium. H. pylori can be diagnosed either by a blood
test that measures the presence of antibodies to the bacteria or by a
breath test that is done after the patient swallows a drink containing
urea and carbon. Expired air is examined to detect the bacteria. The
diagnosis is confirmed with biopsy samples of the gastric and duo-
denal mucosa obtained during an endoscopic examination.
Peptic ulcers caused by H. pylori are treated with a combination
of medications, including antibiotics to kill the bacteria and drugs
to reduce the production of hydrochloric acid and protect the
stomach lining. The most effective treatment is a triple therapy
method that lasts 2 weeks and includes two antibiotics (a combina-
tion of amoxicillin, Flagyl, or Biaxin) and either a histamine blocker
(e.g., Tagamet, Zantac) or a proton pump inhibitor (e.g., Prilosec,
Prevacid). Surgery may be indicated in severe cases, such as with
perforation of the gastric wall. Any ulcer that does not heal is re-
evaluated periodically through gastroscopy to rule out cancer.
Focus
Eyepiece
Air
FIGURE 15-5 Fiberoptic endoscopy of the stomach.
372 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES

Common Signs and Symptoms of a Gastrointestinal Disorder

Apatient with a gastrointestinal (GI) problem may complain of multiple quadrant or region is identified, and the patient is properly prepared for the
discomforts, including nausea, vomiting, anorexia, diarrhea, constipation, provider's examination. If possible, document the location of the patient's
and abdominal pain. The medical assistant may find it difficult to identify the complaint using the abdominal regions (see Figure 15-2) because this is
exact location and quality of the patient's discomfort. When you discuss most accurate. For example, if the patient complains of heartburn after
abdominal pain with the patient, ask him or her to point to or touch the area eating, this can be charted as: Pt c/oepigastric discomfort after meals; 6 on
where the pain is located. This is one way of making sure the correct a pain scale of 10.

Table 15-1 outlines the typical signs, symptoms, and character-

istics seen in patients with GI complaints. Telephone screening for
GI complaints involves following the facility's policies and proce-
dures manual for management of disorders; gathering detailed infor-
mation about the onset, duration, and frequency of the problem and
the pertinent patient history; and recording the interaction in the
patient's health record (this should include the use of medications
for relief; a pain scale, if appropriate; and the course of action based
on the provider's recommendations). Using Procedure 15-1 , outline
how you would respond to the scenarios in the following Critical
Thinking Application box.
CRITICAL THINKING APPLICATION 15-2
Two days a week, Joan works in the telephone screening area of the
practice, where she is responsible for the initial management of calls from
Dr. Sahani's patients. The following problems are typical of a call day. What
are some questions Joan should ask and subsequently document in each
patient's health record?
• The mother of a 7-year-old patient is concerned because her son has
been vomiting since yesterday.
• The father of an 18-month-old infant reports that the child has had
diarrhea for 2 days.
• A72-year-old patient is concerned about constipation that has not been
relieved by laxatives.

TABLE 15-1 Characteristics of Common Gastrointestinal Complaints

COMPLAINT CAUSE
Vomiting (emesis) GI irritation, pain or stress, inner ear disturbance, increased
intracranial pressure (l(P), food-borne illness
Diarrhea Infection or inflammation, food allergies, food-borne illness,
malabsorption syndromes
Constipation Lack of dietary fiber; inadequate intake of fluids; lack of
exercise; neurologic disorders, including spinal cord injury
and multiple sclerosis; side effect of medications (e.g.,
codeine, iron, antacids); bowel obstruction or tumor
Abdominal pain Ulcerative disease, tumor, appendicitis, bowel obstruction,
food-borne illness, infection or inflammatory process
CHARACTERISTICS TO REPORT AND RECORD
• Onset, frequency, and duration of the problem
• Yellow or greenish color (indicates bile from the duodenum)
• Pyloric stenosis (causes vomiting of undigested food)
• Projectile vomiting (may indicate pyloric stenosis or
increased ICP)
• Hematemesis
• Onset, frequency, and duration of the problem
• Dehydration (may occur if diarrhea is persistent; occurs
more often in infants and older adults)
• Presence of blood, mucus, or pus in the stool
• Steatorrhea (large, foul-smelling, greasy stools)
• Melena (tarry stools from bleeding higher in the digestive
tract)
• Onset, frequency, and duration of the problem
• Treatment and effectiveness of over-the-counter (OTO
medications
• Diet and fluid intake
• Presence of watery diarrhea (may indicate fecal impaction)
• Onset, frequency, and duration
• Exact location (using quadrants or abdominal regions)
• Quality of the pain (e.g., burning, cramping, sharp, dull)
• Degree of pain (scale of 1 to 10)

the GI system to determine the extent of the damage or the condi-
tion of the mucosa! lining of the system.
Treatment of a food-borne disease depends on the microorganism
causing the illness and the patient's symptoms. The patient's con-
dition is stabilized and symptoms are treated so that dehydration
is minimized and electrolyte balance is maintained. Antiemetics,
such as Granisetron or Ondansetron (Zofran), may be prescribed to
control nausea and vomiting. Other medications, such as loperamide
(Imodium) or diphenoxylate with atropine (Lomotil), may be used
to control diarrhea. Antibiotics may shorten the length of the disease
but are only prescribed if the organism causing the infection can be
identified and will respond to antibiotic therapy. If vomiting and
diarrhea cannot be corrected within a reasonable time (as determined
by the patient's age, body size, and health condition), the patient
may be hospitalized so that intravenous (IV) fluid replacement can
be administered.
Irritable Bowel Syndrome
Irritable bowel syndrome (IBS) is a recurrent functional bowel dis-
order; this means that the bowel does not work as it should, but
diagnostic studies fail to show an organic cause for the symptoms.
The diagnosis of IBS is made if the patient complains of recurrent
abdominal discomfort of at least 3 months; abdominal pain that is
relieved by defecation; feeling bloated; a change in bowel habits with
constipation, diarrhea, and mucous discharge; and increased flatu-
lence. The most common site of abdominal pain is the left lower
quadrant. Diagnostic studies, such as a complete blood count, stool
testing for occult blood, urinalysis, barium enema, and colonoscopy,
are performed to rule out other GI diseases that have an organic
cause.
IBS is more common in women. Symptoms usually appear in
late adolescence or early adulthood. The condition seems to have a
familial pattern. IBS may account for up to 50% of referrals to
gastroenterologists because of concern about possible organic disease.
IBS is quite common; an estimated 9% to 20% of the adult popula-
tion is affected. The syndrome is associated with food intolerances,
menstruation, and stress levels.
Treatment is primarily pharmaceutical, with bulk-forming agents
(e.g., Metamucil) given for constipation; lmodium or Lomotil for
diarrhea episodes; Lactaid if the patient is lactose intolerant; anti-
spasmodic agents (dicyclomine [Bentyl]) for cramping; and anti-
cholinergic agents (hyoscyamine) and simethicone (Mylicon) for
bloating and flatulence. Lubiprostone (Amitiza) may be indicated
for IBS with constipation. It increases fluid secretion in the small
intestine to help relieve constipation.
Alternative therapies for IBS include acupuncture to relieve
cramping and improve bowel function; the herb peppermint to relax
intestinal smooth muscles; and probiotic foods, such as yogurt, to
provide bacteria that make up the natural flora of the intestinal tract
to help relieve symptoms. The patient should be encouraged to keep
a food diary in an effort to identify foods that exacerbate the symp-
toms; to increase fluid and fiber intake; and to avoid spicy and fatty
foods and caffeine. Routine exercise also can be very helpful in reliev-
ing symptoms.
Patients with IBS can become very frustrated and need confirma-
tion that this is a real problem, even though no organic or anatomic
changes are apparent. Patients should be encouraged to follow
CHAPTER 15 Assisting in Gastroenterology 377
lifestyle recommendations, including actively working to reduce
stress. The medical assistant plays an important role in providing
understanding and support to the patient with IBS.
CRITICAL THINKING APPLICATION 15-3
Dr. Sahani frequently sees patients with IBS. He asks Joan to prepare a
handout for patients describing the disorder, making sure to include possible
treatments. What should Joan include?
Weight Loss Surgery
Several different types of bariatric surgery can be performed to help indi-
viduals lose weight. One of the most common types is the Roux-en-Y gastric
bypass procedure in which surgical staples or a plastic band is used to create
a small pouch at the top of the stomach (about the size of an egg); this
technique bypasses the duodenum, where most of digestion is completed.
The smaller stomach empties directly into the jejunum so that food has
limited exposure to digestive enzymes and therefore cannot be easily
absorbed. After the surgery, patients can eat only small amounts of food
at one time, which reduces the number of calories consumed. This surgery
can be done either as an open procedure or with a laparoscope, although
the laparoscopic procedure is preferred because it is associated with fewer
surgical risks and complications.
Bariatric surgery is an option for patients with a body mass index
(BMI) of 40 or higher or those with a BMI of 35 or higher who have a
serious medical condition, such as diabetes, hypertension, or sleep apnea.
Patients interested in the procedure must undergo a battery of examina-
tions, including a psychological evaluation, and must show that they have
been unable to lose weight with other methods. The average cost of a
bariatric procedure is $20,000 to $25,000. Medical insurance coverage
varies by insurance provider and from state to state. The medical assistant
may work as a patient navigator to help surgical candidates investigate
insurance coverage.
Recent studies indicate that weight loss after stomach-reduction surgery
can drastically improve diabetes mellitus; the greater the weight lost, the
more likely the patient is to improve.
Patients begin to lose weight shortly after the procedure and continue
to lose for approximately 12 to 24 months. Most individuals lose 60% to
80% of their excess body weight, and most experience resolution of weight-
related health issues as the weight comes off, including relief of heartburn,
reduced musculoskeletal discomfort, improved breathing, reduced sleep
apnea, and lower blood pressure. Because of malabsorption problems,
patients may be prone to vitamin B12 deficiency (which may necessitate
either large oral doses or vitamin B12 intramuscular injections on a regular
basis); iron-deficiency anemia; lack of calcium absorption, which may
contribute to osteoporosis; and other vitamin and mineral deficiencies.
Patients should take daily vitamin and mineral supplements to reduce the
effects of these malabsorption problems.
The U.S. Food and Drug Administration (FDA) has also approved a
weight loss procedure, the adjustable gastric band (AGB), for patients with
378 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES
a BMI of 30 or greater who also have at least one condition linked to
obesity, such as heart disease or diabetes. With the AGB, the amount of
food that can be consumed at one time is reduced by placing a small
bracelet-like band around the top of the stomach. Acircular balloon inside
the band can be inflated or deflated with saline solution, allowing the
surgeon to control the size of the opening into the stomach.
Apostsurgical complication of weight loss surgery is rapid gastric empty-
ing, or dumping syndrome. This occurs when the contents of the stomach
empty too quickly into the small intestine, resulting in distention and
increased intestinal motility. Signs and symptoms include nausea, abdomi-
nal cramps, diarrhea, vertigo, tachycardia, and diaphoresis (sweating). The
condition typically occurs after the individual eats sweets or high-fat foods.
Patients undergoing weight loss surgery should be instructed to eat fre-
quent, small meals that are high in protein and low in simple sugars and
to drink fluids between meals rather than with meals. These dietary modi-
fications usually can prevent dumping syndrome.
Acute Appendicitis
The vermiform appendix is a narrow pouch, approximately 3½
inches long, that extends off the cecum of the large intestine. It has
no known function but can become inflamed and ultimately infected
because of obstruction by a fecalith or foreign material. As bacteria
multiply, the appendix becomes inflamed and swollen, causing isch-
emia and necrosis of the appendix wall. If the infectious material
leaks out or bursts from the appendix, a localized infection forms
that may become regional if the abdominal peritoneum becomes
involved, resulting in peritonitis. Peritonitis is a serious infection that
may become life-threatening.
Classic signs of appendicitis include right lower quadrant pain;
nausea and vomiting; tenderness at McBurney's point, which is
located between the umbilicus and the right anterior superior iliac
spine; low-grade fever; and leukocytosis (an increase in the white
blood cell count). Other conditions that might cause similar symp-
toms include ectopic pregnancy or ovarian cyst, a kidney stone
lodged in a ureter, and Crohn's disease. Appendicitis is confirmed
with computed tomography (CT) or ultrasound. The infected
appendix is removed surgically (appendectomy), typically in a lapa-
roscopic procedure, in which a pencil-thin tube with its own lighting
system and a miniature video camera is inserted through a small
incision in the abdomen to visualize the area. The surgeon removes
the appendix with tiny instruments that are inserted through one or
two other small abdominal incisions. However, if the appendix has
ruptured, a larger incision is needed to clean the abdominal cavity.
After surgery, the patient is treated with broad-spectrum antibiotics
to prevent or treat infection at the site.
Crohn's Disease
Crohn's disease, also called regional ileitis or regional enteritis, is an
inflammation that may be located anywhere in the alimentary tract
but most commonly is found in the ileum. The inflammation
begins with a localized area of ulcer development, with healthy
tissue interspersed with areas of affected tissue. Inflammation results
in the formation of ulcers that eventually invade deeper into the
walls of the intestine, creating scar tissue and partial or complete
obstruction at the affected site. If this occurs in the small intestine,
the damaged wall reduces the intestine's ability to digest and absorb
nutrients; if it occurs in the colon, increased motility prevents reab-
sorption of fluids. Scar tissue from the localized ulceration ulti-
mately can lead to a bowel obstruction, or the ulcer may completely
invade the intestinal wall, resulting in perforation and leakage of
intestinal contents into the abdominal cavity. Adhesions may
develop from chronic inflammation, or fistulas may form between
two loops of the intestine or between the intestine and adjacent
organs.
Signs and symptoms of Crohn's disease include loose, semi-
formed stool; melena if the ulcers break through blood vessels; pain
or tenderness in the right lower quadrant; anorexia; weight loss;
anemia; and fatigue. Most patients cycle through periods of remis-
sion and relapse. The cause of the disease is unknown, although
some theories associate the disease with an autoimmune response,
genetic predisposition, or a combination of environmental factors,
including certain medications and a high-fat diet. Risk factors
include age (most cases are diagnosed between 15 and 35 years of
age), smoking, Jewish or European descent, a family history of the
disorder, and residence in a developed country or urban area. The
diagnosis is made from a barium enema, a small bowel series,
abdominal CT scan, and colonoscopy and is confirmed with a
biopsy.
The goals of treatment are to reduce inflammation, manage
symptoms, and provide nutritional support. Antiinflammatory drug
therapy includes sulfasalazine (Azulfidine), mesalamine (Asacol), and
corticosteroids (e.g., prednisone, budesonide [Entocort]), which are
used during the acute phases. Immune system suppressors, such as
infliximab (Remicade), also are recommended to control the immune
system's reaction to the inflammatory process. Flagyl and Cipro are
antibiotics prescribed for fistulas, and antidiarrheal agents (e.g.,
Imodium, Lomotil) may provide symptomatic relief. Certolizumab
(Cimzia) is used to treat the symptoms of Crohn's disease if other
drugs have failed to control the inflammatory process.
Surgical intervention involving resection of the diseased bowel
and anastomosis may be necessary if an intestinal obstruction
occurs; a fistula is present; or abscess formation is seen. Unfortu-
nately, the disease usually recurs at the site of the anastomosis. The
patient may require dietary supplements with a high-protein, high-
calorie diet to maintain a normal weight, and vitamin B12 shots if
ulcerations occur in the distal ileum, where the vitamin is absorbed.
Ulcerative Colitis
Ulcerative colitis causes inflammation that usually starts in the
rectum and moves proximally through the colon, affecting the lining
of the colon in a continuous pattern. The disease causes the forma-
tion of ulcers that invade the mucosa! and submucosal layers but do
not advance through the entire wall of the colon (Figure 15-6).
Ulcerative colitis can affect people of any age; although a familial
tendency exists, the cause is unknown. The patient complains of
abdominal pain, mucoid stools, and intermittent episodes of bloody
diarrhea. As the disease progresses, the patient may experience as
many as 10 to 20 stools a day, along with weight loss, fever, and
general malaise.

FIGURE 15-6 Ulcerative colitis. (From Hagen·Ansert SL: Textbook of diagnostic sonography,
ed 7, St Louis, 2012, Mosby.)
___,~,..__ __,_ Pouch created
to join Ileum
and anus
Anus
FIGURE 15-7 lleoanal Anastomosis. Surgical procedure for advanced ulcerative colitis.
Drug therapy for ulcerative colitis is similar to that for Crohn's
disease, but surgical removal of the colon with an ileostomy is
considered curative for ulcerative colitis. The problem with this
approach is that the patient must wear a bag on the abdomen to
collect drainage from the ileum. The procedure of choice for patients
who must have the colon removed for treatment of severe Crohn's
disease is an ileoanal pouch anastomosis (Figure 15-7). In this pro-
cedure, a pouch is formed out of the ileum and then is connected
directly to the anus. This results in multiple watery bowel move-
ments a day because the colon is not there to absorb fluid; however,
the patient has a continuous GI tract and does not need to wear a
collection bag on the abdomen. Patients with ulcerative colitis must
be screened annually with a colonoscopy because they have an
increased risk of colon cancer.
Celiac Disease
Celiac disease, also known as celiac sprue, is a malabsorption syn-
drome caused by a genetic defect in the intestinal enzyme that
metabolizes gluten. Celiac disease can occur at any age once gluten
CHAPTER 15 Assisting in Gastroenterology 379
is present in the diet, or it may develop after some form of trau-
matic event, such as infection, injury, pregnancy, severe stress, or
surgery. Gluten is found in all grains, including any products
made from wheat, barley, rye, and possibly oats. If the affected
individual eats a product that contains gluten, even a small
amount, an antigen-antibody reaction occurs that causes destruc-
tion of the villi in the small intestine. The intestine is unable to
absorb nutrients, and the result is malnutrition. The patient has
steatorrhea, abdominal pain, and weight loss. Celiac disease can be
treated with strict adherence to a gluten-free diet; rice, soy, corn,
and potato flours can be substituted for gluten products. Although
oats may not be harmful, oat products frequently are contami-
nated with wheat, so these also should be avoided. Gluten-free
products, identified by food label claims, are becoming more
widely available.
Gluten Sensitivity
Until recently, gluten intolerance was believed to be similar to celiac disease
or a wheat allergy. However, recent research indicates that gluten intoler-
ance can affect people who do not have either celiac or an allergic response
to wheat. The new syndrome, now identified as non-celiac gluten sensitivity
(NCGS) or gluten sensitivity (GS), is included in a revised list of gluten·
related disorders. Unlike celiac disease, gluten sensitivity does not cause
damage to the villi, and the patient's symptoms are similar but less severe.
No accepted medical test yet exists for gluten sensitivity. GS is diagnosed
by first ruling out a wheat allergy and celiac disease and then using an
elimination diet, meaning removing all food containing gluten from the
diet, and slowly reintroducing it to see if symptoms recur. If the patient
reports relief of symptoms after gluten is removed from the diet, that is
how the syndrome is managed.
Diverticular Disease
Diverticula are outpouchings or herniations of the muscular lining
of the colon, usually the sigmoid colon. Diverticula develop because
of chronic constipation and muscular hypertrophy in the colon and
become more common as people age. Diverticulosis is an asymptom-
atic diverticular disease in which multiple diverticula are present in
the colon, but the patient has no complaints other than mild dis-
comfort, diarrhea, constipation, or flatulence. However, if the her-
niations become blocked with feces and inflammation develops,
diverticulitis occurs. Signs and symptoms include lower left quadrant
cramping, tenderness, or pain; nausea and vomiting; low-grade fever;
and leukocytosis. A barium enema or colonoscopy may be done to
confirm the presence of diverticula.
Patients with diverticulosis are encouraged to eat a high-fiber
diet, take a fiber product such as methylcellulose (Citrucel) or psyl-
lium (Metamucil) one to three times a day, and drink plenty of
fluids. The goals of dietary management are to prevent the collec-
tion of waste in the herniations and to encourage regular, soft bowel
movements. If diverticula become inflamed, antibiotics are pre-
scribed to treat the infection. An acute attack with severe pain and
380 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES
Intestine has ruptured
through inguinal ring
FIGURE 15-8 Herniated inguinal canal.
infection may require hospitalization, IV antibiotic therapy, and
pain management. Surgery may be necessary if the colon
perforates.
Hernias of the Abdomen
Hernias can develop in various parts of the body but most frequently
are seen in the abdomen when an organ or part of an organ protrudes
through a weakened area in the abdominal muscle wall. The causes
of herniation include congenital weakness of the structures, trauma,
relaxation of ligaments and skeletal muscles, and increased upward
pressure from the abdomen. They most often are found in middle-
aged or older individuals. The location of the hernia establishes the
term by which the protrusion is identified. Types of hernias include
umbilical hernias; incisional hernias at the site of a previous surgery;
and inguinal hernias, in which a loop of the bowel protrudes inro
the inguinal canal (Figure 15-8).
The usual sign of an abdominal hernia is an abnormal lump or
bulge that the patient finds while bathing. This bulge is tender, but
the pain is mild. The patient also may discover that the bulge can
be pushed back into the abdomen, where it remains until movement
or lifting causes it to push through again. If severe pain is present,
the bulging tissue (usually a piece of the intestine) may be trapped
or strangulated if blood flow has been compromised. If immediate
surgical intervention is not performed, the tissue may die, and gan-
grene will set in.
The provider uses palpation to assess an abdominal or inguinal
hernia for size and inspects the area with the patient standing and
lying down. An inguinal hernia can be detected in a male by
having him perform the Valsalva maneuver. The most common
treatment is surgical repair in the form of a herniorrhaphy or a
hernioplasty.
Hemorrhoids
Hemorrhoids are varicose veins of the anus and rectum. They affect
approximately 5% of all adults. The disorder has a familial, heredi-
tary predisposition, and it is common in people with varicose veins
of the lower extremities and inguinal hernias. Hemorrhoid forma-
tion is related to increased pressure in the rectum, often caused by
constipation. If the swollen veins are within the rectal wall, they
are considered internal hemorrhoids, which usually do not cause
uncomfortable symptoms; if they are firm and protruding and can
be felt and/or seen, they are external hemorrhoids, which usually
prompt complaints of pain and itching.
Some patients experience no pain, and other patients experience
rectal irritation and discomfort. Frequently, the patient reports that
anal itching and burning occur immediately after a bowel move-
ment. If the patient must strain to defecate, bleeding and protrusion
of the swollen mass can occur. Patients often state that the anal area
must be bathed or even soaked in warm water after every bowel
movement to relieve the itching and pain.
A proctologic examination and inspection of the anal area reveals
external hemorrhoids. Proctoscopy is performed to detect internal
hemorrhoids of the rectum. A hemoglobin level and red blood cell
count may be ordered to determine whether any significant blood
loss has occurred. Hemorrhoids are treated with stool softeners
(e.g., docusate sodium [Colace]); fiber supplements (e.g., Metamu-
cil, Citrucel); a high-fiber diet; increased fluid intake; and an
analgesic ointment applied locally or by suppository to relieve
swelling. If these measures do not correct the problem, the next
step may be sclerotherapy with a chemical injection, cryosurgery,
infrared coagulation to burn hemorrhoidal tissue, ligation, or
hemorrhoidectomy.
DISEASES OF THE LIVER AND GALLBLADDER
Cirrhosis
The liver is located in the right upper quadrant of the abdomen. Its
primary functions are to metabolize nutrients and detoxify drugs or
other harmful substances. The liver also excretes proteins that aid in
blood clotting and produces bile for fat metabolism. Cirrhosis is a
chronic liver disease in which the lobes of the liver become fibrous
and hard, and liver cells degenerate, causing deterioration of liver
function. Cirrhosis and chronic liver disease are the twelfth leading
cause of death by disease and the fourth most common cause of
death in men 40 to 60 years of age. The primary causes of the
disease in the United States are chronic alcoholism and hepatitis
C. Cirrhosis also can be caused by chronic hepatitis B; nonalcoholic
steatohepatitis (NASH) (sometimes called fatty liver disease, which
is characterized by a buildup of fat in the liver that eventually causes
scar formation and loss of liver function); blocked bile ducts; and
severe reactions to prescription drugs or exposure to environmental
toxins.
The patient is asymptomatic in the early stages of cirrhosis, but
as scar tissue replaces normal hepatocytes, the liver begins to fail and
the patient experiences fatigue, anorexia, weight loss, and abdominal
pain. Complications associated with advanced cases of liver failure
include dependent edema (fluid retention in the legs); ascites (Figure
15-9); bleeding abnormalities; jaundice; pruritus from deposits of
bile salts on the skin; sensitivity to medication because the liver is
unable to metabolize drugs; portal hypertension; esophageal
varices; insulin resistance, with the development of diabetes mellitus
type 2; and cancer of the liver. Treatment is based on the cause
of the problem, but avoiding alcohol and eating a nutritious
diet are key factors. With advanced cases, the only cure is liver
transplantation.
 CHAPTER 15 Assisting in Gastroenterology 381

Nonalcoholic Fatty Liver Disease PATHOGENESIS OF ASCITES

CIRRHOTIC LIVER
• The medical term for nonalcoholic fatty liver disease is nonalcoholic
steatohepatitis (NASH); the condition is similar to alcoholic liver disease
but occurs in people who drink little or no alcohol.
• Fat accumulates in the liver and causes inflammation, which may lead
to scar formation and cirrhosis.
• The condition is very common and affects all age groups, including
children, but is seen most often in middle-aged people who are over-
weight or obese and have high blood cholesterol and diabetes.
• Symptoms are rare in the early stages. The disease often is detected
because of abnormal liver blood test results, and it is diagnosed by a
liver biopsy.
• Treatment includes weight loss, exercise, improved diabetes control,
and anticholesterol medications.
• The disease can be life-threatening. Not every person with NASH devel-
transfer
ops cirrhosis, but once serious scarring is present, little can be done to
stop the progression of liver failure. The only treatment for advanced
cirrhosis with liver failure is liver transplantation. ~~f_AS_CI_TE_S~
Reduced renal
water excretion
Hepatitis
Inflammation of the liver, called hepatitis, may be caused by a local-
ized infection (viral hepatitis), a systemic infection, chemical expo-
sure, or a complication of drug metabolism. Mild inflammation
Sodium
I Reduced circulating
retention plasma volume
temporarily impairs function, but severe inflammation may lead to
necrosis and serious complications.

Viral Hepatitis
\
Acute viral hepatitis is an infection of the liver that causes a sudden Aldosterone Decreased blood
onset of hepatocyte inflammation. Several forms of the hepatitis supply to kidneys
Increased
virus are categorized as hepatitides A (HAY), B (HBV), C (HCV), aldosterone
D (HDV), and E (HEY) (Table 15-4). Hepatic cells can regenerate; (adrenal)
therefore, depending on the degree of liver involvement, the patient Increased
may recover completely from the viral infection or could develop sodium
reabsorption
widespread necrosis, cirrhosis, and liver failure.
(kidney)
Chronic inflammation, defined as the presence of the disease for
longer than 6 months, can occur with HBV, HCV, or HDV. This FIGURE 15-9 Pathology of ascites.
usually results in permanent liver damage and an associated increased
risk of liver cancer. Individuals infected with these three types of
hepatitis may become lifelong carriers of the disease. Hepatitis car- As a healthcare professional, the medical assistant cares for sick
riers are asymptomatic but can transmit the virus to others. people on a daily basis who may be carriers of the hepatitis virus.
HAV is transmitted through contaminated water or shellfish. Changing dressings, collecting specimens, holding a patient's hand
Some parts of the world are endemic for the disease. HAV immu- that was just used to cover the mouth, and discarding a wet baby
nization is part of the pediatric and adult immunization schedules. diaper all are possible ways that exposure can occur. The first line of
HBV has a relatively long incubation period, which makes tracking defense, regardless of whether the medical assistant has been immu-
the source of the infection difficult. Because the virus is found in all nized, is frequent sanitization of the hands and wearing gloves when
blood and body fluids, it can be transmitted in many ways, including exposure to blood or body fluids is possible.
needlesticks, human bites from individuals infected with the virus,
sexual contact, and from mothers to babies. Immunization of indi- Diagnosis and Treatment
viduals at increased risk is highly recommended. All healthcare per- HAY, HBV, and HCV are diagnosed through identification of the
sonnel are included in this group because they are at increased risk virus or antibodies to the virus in the blood. Another useful diag-
for infection through exposure to blood or blood products and body nostic test is a liver biopsy. Once the infection has been diagnosed,
fluids. HBV immunization is part of the pediatric and adult immu- liver function tests are done periodically throughout the course of
nization sequence. the disease to determine the degree of liver damage. Patients with
382 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES

TABLE 15-4 Characteristics of the Viral Hepatitides

TYPE TRANSMISSION INCUBATION SYMPTOMS
A(HAV) Fecal-oral (food or water contaminated by 2-7 weeks • Fatigue
feces from infected person); contaminated raw • Weakness
shellfish; infected household members or • Anorexia
sexual partners • Sometimes joint pain hepatomegaly, lymphadenopathy,
jaundice
B(HBV; serum Blood and body fluids; placental transfer 1-6 months • General malaise
hepatitis) • Joint swelling
• Pruritic rash
• Hepatomegaly
• Anorexia
• Nausea, vomiting
• Dark yellowish-brown urine
• Jaundice
• May become chronic
C(HCV; non-A non-B) Blood and body fluids; frequently seen in 2 weeks-6 months • Acute onset of fever, chills, malaise, nausea, vomiting
intravenous drug users and is the most • Frequently becomes chronic
common type of posttransfusion hepatitis
D(HOV; delta virus) Blood and body fluids Seen only in patients • Similar to those of HBV
with HBV • Increases the severity of HBV
E(HEV) Fecal-oral 2-9 weeks • Similar to those with HAV
• Seen in India, Asia, Africa, and Central America
• Mild form but can cause death in pregnant women

HBV, HCV, or HDV must be monitored for possible chronic

hepatitis and the development of a carrier state. Prescription medi-
cations include interferon (peginterferon), which stimulates the
immune response, and antiviral drugs (Ribavirin) to prevent viral
cell replication. Otherwise, the treatment for all forms of hepatitis
generally consists of bed rest and a high-protein diet.
The HBV vaccine is given intramuscularly in three doses to
prevent the development of hepatitis B. The first two doses are given
30 days apart, and the third is given 6 months after the first. The
Occupational Safety and Health Administration (OSHA) requires
healthcare employers to offer the vaccine to employees free of charge.
Medical assistant programs encourage students to be vaccinated
because they also are at risk for acquiring the disease.
Groups at Risk for Hepatitis A, B, and C
• Hepatitis A(HAV): Day care workers and clients, institutionalized resi-
dents, individuals traveling to infected areas
• Hepatitis B(HBV): Intravenous (IV) drug users, homosexual men,
hemodialysis patients, hemophiliac individuals, healthcare workers,
individuals with a history of frequent sexual partners
• Hepatitis C(HCV): Patients receiving frequent blood transfusions,
homosexual men, IV drug users, healthcare workers
CRITICAL THINKING APPLICATION 15-4
As a healthcare worker who may be exposed to blood and body fluids, Joan
is quite concerned about contracting viral hepatitis. For what types of hepa-
titis is she at risk in Dr. Sahani's office? What can she do to reduce her risk
and protect herself from contracting these diseases?
Cholelithiasis (Gallstones)
The gallbladder is an accessory organ of the GI system that stores
the bile excreted by the liver. Cholelithiasis, or gallstones, form
in the gallbladder from insoluble cholesterol and bile salt. These
stones vary in size and number. The reasons for formation are not
always clear, although gallstones are more common with a diet that
is high in calories and saturated fat; they also are associated with
obesity (Figure 15-10). About 20% of people older than age 65
develop cholelithiasis, and the risk is three times higher for women
than for men.
Signs and Symptoms
Most gallstones are asymptomatic and are discovered during a
routine x-ray. Pain usually occurs when the stones move and obstruct
the cystic or common bile ducts. The pain is felt in the epigastric

region and the right upper quadrant, often radiating into the right
upper back area, and is worse after a high-fat meal. Nausea and
vomiting may accompany the pain. The pain hits in a wavelike
pattern and is called colicky pain or biliary colic. If the obstruction
is not removed, jaundice may develop.
Diagnosis and Treatment
The provider bases the preliminary diagnosis on the patient's symp-
toms and on the signs noted on palpation of the upper right quad-
rant. To confirm the diagnosis, blood tests may be done to detect
signs of infection, obstruction, pancreatitis, or jaundice, and an
abdominal sonogram is performed to visualize the stones. CT scan
may show gallstones, and magnetic resonance (MR) cholangiogra-
phy may be ordered to diagnose blocked bile ducts. In addition, a
hepatobiliary iminodiacetic acid (HIDA) scan can be ordered to
diagnose problems in the liver, gallbladder, and bile ducts. The
patient is given an IV injection of HIDA, which is taken up by the
liver and excreted into the biliary tract. A nuclear scanner then takes
pictures of the biliary tract over 2 to 4 hours.
Treatment involves surgical removal of the gallbladder (cholecys-
tectomy), which usually is done laparoscopically.
THE MEDICAL ASSISTANT'S ROLE IN THE
GASTROINTESTINAL EXAMINATION
Emotional factors play an important part in many GI problems,
often making the separation of functional and organic disorders
difficult. Some forms of GI disease may demand immediate atten-
tion, such as acute appendicitis or acute gastritis with possible hem-
orrhage. Both may require surgical therapy. Careful questioning is
needed to guide the patient to a precise description of the symptoms.
In the role of liaison between the patient and the provider, the
medical assistant can help the provider make the diagnosis so that
the patient receives the treatment needed.
Liver
Pancreatic
duct
FIGURE 15-10 Gallstones.
CHAPTER 15 Assisting in Gastroenterology 383
Assisting with the Examination
When a patient describes and points to the location of the pain, the
medical assistant must know the underlying organs that may be
involved. Record the quadrant or region in which the pain is located
so that the provider can immediately assess this area when the exami-
nation begins. The provider's inspection of the abdomen begins with
noting any change in skin color, such as jaundice. Striae (silver
stretch marks), petechiae (small, purple hemorrhagic spots), scars,
and visible masses may be seen. The contour of the abdomen may
be flat, rounded, or bulging in localized areas.
The provider uses palpation and percussion to evaluate the entire
abdominal area. As this is done, the medical assistant should remove
the drape from the area to be examined and should redrape the
patient once this segment of the examination is completed. In addi-
tion, the provider may want the medical assistant to document
findings as the examination progresses. If the provider wants to
examine the anal area, have the patient turn onto his or her left side,
and then assist the patient into the Sims position. As this is done,
make sure the patient remains draped. After the patient is in the
Sims position, adjust the drape on an angle so that it can be easily
lifted for the final part of the examination.
CRITICAL THINKING APPLICATION 15-5
Joan is responsible for initially questioning patients about complaints and
clearly documenting this information in the patient's record. What informa-
tion should Joan include that details each patient's GI problem and would
be helpful for the provider in determining the patient's diagnosis?
Diagnostic Procedures
Typical diagnostic procedures for the GI system are summarized in
Table 15-5. Although most of these procedures are not performed
in the ambulatory care setting, the medical assistant must under-
stand the procedure and the recommended patient preparation so
that adequate patient education can be provided. If the patient does
not prepare adequately for these procedures, the results will be
inconclusive, and an expensive, time-consuming, uncomfortable test
may have to be rescheduled. It is very important that patients com-
pletely understand what is required; the patient should be given a
handout to review at home that repeats the verbal instructions given
in the office. Providers may vary in their preferences for patient
preparation for GI diagnostic tests. It is important that the medical
assistant refer to the office policies and procedures manual or ask the
provider his or her preference before providing patient education.
The most conclusive diagnostic procedure of the GI system is an
endoscopic analysis. In this procedure, the upper GI system is exam-
ined by passing a soft, flexible tube down the esophagus into the
stomach. The colon is examined through an ascending technique,
with entrance through the anus. Fiberoptic technology allows the
examiner to view the tissues, take images, and collect laboratory
samples during the procedure (e.g., biopsied tissue, gastric fluid,
pathogens, bile crystals, cytology samples) with only minor discom-
fort to the patient.
384 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES
TABLE 15-5 Common Diagnostic Procedures for the Gastrointestinal System
TEST
Barium swallow
Upper gastrointestinal
(UGI) and small bowel
series; air-contrast UGI
Barium enema;
air-contrast barium enema
(ACBE)
Hepatobiliary (H IDA) scan
Ultrasonography of the
liver, gallbladder, biliary
system, pancreas
DESCRIPTION AND PURPOSE
X-ray or fluoroscopic examination of the pharynx and
esophagus after the patient swallows barium sulfate; to
diagnose hiatal hernia, esophageal varices, strictures, and
tumors; takes 15-20 min.
X-ray and fluoroscopic examination of the esophagus,
stomach, and small intestine after patient swallows
barium sulfate; to diagnose ulcers, tumors, regional
enteritis, and malabsorption syndrome; takes
approximately 30 min.
X-ray evaluation of large intestine after rectal instillation
of barium sulfate; to diagnose colorectal cancer,
inflammatory disease of the colon; to detect polyps,
diverticula, or obstructions; takes approximately 45 min.
Nuclear scan after IV injection of radioactive material.
Pictures of biliary tract are taken over time to determine
whether an obstruction caused by cholelithiasis exists.
Best tool for diagnosing acute cholecystitis in patients
with acute RUQ pain. Gallbladder visualized 60 min after
injection of radionuclide; takes 4 hr to get all images. IV
morphine during nuclear scanning speeds up bile
movement to reduce scanning time to 1 hr.
High-frequency sound waves from a transducer penetrate
the organ, bounce back to the transducer, and are
electronically converted into an image that is recorded on
film. Used to diagnose neoplasm of the liver;
cholelithiasis in the gallbladder or ducts; pancreatic tumor,
abscess, or inflammation.
PATIENT PREPARATION
• NPO after midnight
• Remove all metal objects
• Do not take medication for GERO
Laxatives are given after examination to help with
excretion of barium.
• Low-fiber diet 2-3 days before
• NPO after midnight
• No smoking before test
• No medications after midnight unless approved by
provider
• Remove all metal objects
• Explain to patient that he or she will swallow a
carbonated powder that creates carbon dioxide in the
stomach, which helps in visualizing the stomach
mucosa
Stool will be chalky and light colored for 24-72 hr after
test. Laxatives are given after examination to help with
excretion of barium.
• No dairy products and only liquid diet 24 hr before test
• Take bowel preparation as supplied by radiology
department; enemas until clear in the morning
• No breakfast
• Explain to patient that air is insufflated into the colon
after instillation of the barium to aid visualization of
the colonic mucosa
Mild laxative or enema is given after procedure to remove
barium. Stools will be light colored for 24-72 hr after test.
• NPO 2 hr before test (ensures that patient's exposure
to radioactivity during procedure is minimal)
Patient may be given a fatty meal during scanning to
determine gallbladder ejection fraction (measures
percentage of isotope ejected when gallbladder empties).
• Fast before gallbladder and biliary ultrasound
• Must be performed before barium contrast studies
(barium and gas distort sound waves and alter test
results)
Does not use contrast or radiation; useful for patients who
are allergic to contrast media or are pregnant.
 CHAPTER 15 Assisting in Gastroenterology 385

TABLE 15-5 Common Diagnostic Procedures for the Gastrointestinal System-continued

TEST DESCRIPTION AND PURPOSE
Sigmoidoscopy Endoscopic examination of distal sigmoid colon, rectum,
and anal canal. Used to diagnose inflammatory,
infectious, and ulcerative bowel disease and tumors; and
to detect hemorrhoids, polyps, fissures, fistulas, and
abscesses in the rectum and anal canal. Air insufflated to
distend and visualize the lower intestinal tract. Biopsy
specimens may be collected and polyps removed; takes
15-20 min.
Colonoscopy Endoscopic examination of the large intestine to detect or
monitor inflammatory or ulcerative disease; to locate the
site of GI bleeding; and to diagnose tumors or strictures.
Air insufflated for better visualization. Biopsy samples
collected and polyps removed. Recommended for patients
with positive fecal occult blood test result and for those at
high risk for colon cancer; takes 30-60 min.
Endoscopy Fiberoptic view of the esophagus and upper GI tract to
diagnose or monitor cancer, Barrett's esophagus, peptic
ulcers, polyps. Biopsy samples collected and polyps
removed; takes 45-60 min.
GERD, Gastroesophageal reflux disease; GI, gastrointestinal; HIDA, hepatobiliary iminodiacetic acid; IV, intravenous; NPO, nothing by mouth; RUQ, right upper quadrant.
PATIENT PREPARATION
• Clear liquids day before
• NPO night before
• Laxatives and 2 Fleet enemas night before
Usually done without sedation in the provider's office or
outpatient clinic. Patient may experience gas pains after
procedure from air instillation and may have slight rectal
bleeding if specimen is collected.
• Clear liquid diet for 48 hr before test
• Laxatives, enemas until clear, or l gallon of Colyte day
before
• NPO night before
• Must drink large amount of fluid after procedure to
prevent dehydration from test preparation
Large intestine must be completely cleansed. Monitor vital
signs before and during procedure. Done with IV sedation
in a hospital or outpatient clinic. Patient may experience
gas pains after procedure from air instillation and may
have slight rectal bleeding if specimen is collected.
• No food or fluids for 8 hr before test
Back of throat is sprayed with a local anesthetic to reduce
gag reflex as tube is passed.

Endoscopic procedures are performed to allow the clinician to they require IV sedation. The American Cancer Society recommends
observe the function of the gallbladder, biliary ducts, and pancreatic that everyone at average risk for developing colorectal cancer should
ducts. A dye is injected directly into the ducts of the gallbladder and have a colonoscopy beginning at age 50. Colorectal cancer screening
the pancreas, and examination confirms ductal patency and func- should begin before age 50 if the individual has a personal history
tioning of the organs. of polyps, ulcerative colitis, Crohn's disease, or a strong family
history of colorectal cancer or polyps.
Sigmoidoscopy and Colonoscopy Examinations
Sigmoidoscopy is used to diagnose hemorrhoids, polyps, and diver-
ticular disorders. Examination with a flexible sigmoidoscope can be
performed in the provider's office because the patient does not
undergo anesthesia for the procedure. The patient is positioned in a
left-lying Sims position and is draped appropriately. The provider
inserts a short, flexible, lighted tube into the rectum and slowly
guides it into the sigmoid colon. The scope transmits an image of
the inside of the rectum and colon, allowing the provider to examine
the lining of these organs carefully. The scope also blows air into the
colon to inflate the organ and improve visualization. The provider
may remove polyps or biopsy tissue samples during the procedure.
The procedure takes 10 to 20 minutes, during which time the patient
may complain of pressure and slight cramping in the lower abdomen
(Procedure 15-2).
A colonoscope is used to examine the entire length of the large
intestine and can be used to remove polyps and collect tissue samples
throughout the exam (Figure 15-1 1). Colonoscopy procedures are FIGURE 15-11 Flexible colon fiberscopes. (Monohan FD et ol: Phipps' medical-surgical nursing:
performed in a hospital outpatient area or specialty clinic because health and illness perspectives, ed 8, Philadelphia, 2007, Saunders.)
386 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES

Assist the Provider with a Patient Examination: Assist with an Endoscopic Examination
PROCEDURE 15-2
of the Colon

Goal: To assist the provider with the examination, to prepare collected specimens as requested, and to ensure the patient's
comfort and safe/if.
EQUIPMENT and SUPPLIES 8. Put on gloves and assist the provider as requested during the examination,
• Patient's health record including:
• Laboratory requisition forms • Lubricating the provider's gloved index finger for the digital
• Nonsterile gloves (for the medical assistant and the provider) examination
• Appropriate instrument (sigmoidoscope or proctoscope) • Lubricating the obturator tip of the instrument before insertion
• Water-soluble lubricant • Plugging in the scope's light source when the provider is ready
• Drape and patient gown • Handing supplies to the provider
• Long cotton-tipped swabs • Collecting specimens by holding the container to accept the sample
• Suction source • Labeling specimens immediately because several specimens may be
• Sterile biopsy forceps taken from different areas
• Rectal speculum • Disposing of contaminated supplies in the biohazard waste container
• Specimen containers (with appropriate preservative added) as you are given them by the provider
• Tissue wipes 9. Throughout the examination, observe the patient for any undue reactions.
• Biohazard waste container Encourage the patient to breathe slowly through pursed lips to facilitate
relaxation.
10. On completion of the examination, provide the patient with tissues to
PROCEDURAL STEPS cleanse the anal area. Remove your gloves and dispose of them in the
1. Sanitize your hands and assemble all required equipment and supplies. biohazard waste container, then sanitize your hands. Assist the patient
PURPOSE: To ensure infection control. into a resting position. Allow the patient time to recover from the proce-
2. Identify the patient by obtaining his or her full name and date of birth; dure. Monitor the patient's blood pressure if indicated.
introduce yourself; and explain the procedure. Make sure the patient has PURPOSE: Adrop in blood pressure, which often occurs after an invasive
completed the proper preparation measure. procedure, may cause fainting.
3. Ask the patient to empty the bladder. 11. Once the patient's condition has stabilized, assist the patient off the table
PURPOSE: To aid patient comfort during the examination. and instruct him or her to get dressed. Show the patient where the sink,
4. Give the patient an examination gown. Instruct him or her to remove all towels, and tissues are and provide assistance if needed.
clothing below the waist and to put on the gown with the opening to the 12. Complete all laboratory request forms and specimen container labels, and
back. Provide a drape for additional privacy. place specimens in the appropriate location for laboratory pickup.
S. Obtain and record the patient's vital signs. 13. Put on gloves and sanitize and disinfect the work area and all equipment
PURPOSE: Baseline vital signs allow detection of variations that might used. Carefully follow the manufacturer's recommendations for sanitization
occur during the examination. and chemical sterilization of the endoscope. Dispose of your gloves in the
6. Assist the patient onto the table. When the provider is ready, place the biohazard waste container and sanitize your hands.
patient in Sims position. PURPOSE: To ensure infection control.
7. Drape the patient so that only the anus is exposed. Afenestrated drape 14. Record the procedure and any pertinent information in the patient's health
(a drape with a circular opening over the anus) may be used in place of record.
the rectangular drape. PURPOSE: Procedures that are not recorded are considered not done.

Laboratory Tests
Many of the diagnostic tests for GI disorders are noninvasive.
Urine is tested for bilirubin and urinary amylase levels. The stool is
tested for occult blood, intestinal ova and parasites, fat excretion,
and color.
Occult Blood Screening
Fecal examination is one means of evaluating patients with GI
bleeding, obstruction, parasites, dysentery, colitis, or increased fat
excretion. The American Cancer Society recommends that all
patients age 50 or older be screened for occult blood in the stool.
This test may be performed on younger patients if a family history
indicates a need. Blood is not found in the stool of healthy individu-
als. If the person is experiencing bleeding of the intestinal wall, the
blood is likely to be occult, or hidden, which means that it cannot
be seen with the naked eye. A fecal occult test is done to screen for
microscopic bleeding that might occur because of precancerous or
cancerous changes in the bowel.
 CHAPTER 15 Assisting in Gastroenterology 387

The provider may collect a random stool sample during a routine
examination. However, if GI bleeding is suspected, the recommen-
dation is to test three different samples for occult blood. Seven days
before the test, the patient should stop taking aspirin and NSAIDs,
such as ibuprofen and naproxen (Naprosyn). Starting 72 hours
before the stool collections, the patient should not take any more
than 250 mg of vitamin C a day; should not eat red meat, including
processed meats and cold cuts; and should not eat raw fruits and
vegetables, especially melons, radishes, turnips, and horseradish.
These restrictions should continue throughout the time the patient
is collecting the ordered fecal samples (Procedure 15-3). Failure to
follow dietary guidelines or instructions on the use of identified
medications can cause false-positive test results.
CRITICAL THINKING APPLICATION 15-6
Dr. Sahani wants to update the patient handouts on the preparations neces-
sary for common GI diagnostic procedures. He asks Joan to do the initial
research and gather pertinent information that should be included. What
should Joan include about patient preparation for these examinations?

Instruct and Prepare a Patient for a Procedure: Instruct Patients

PROCEDURE 15-3
in the Collection of a Fecal Specimen

Goal: To assist the provider with the callection of a fecal sample, to process the sample for fecal occult blood screening, and
to instruct the patient in fecal occult blood screening at home.
EQUIPMENT and SUPPLIES 8. Wait 3 to 5 minutes before developing the sample.
• Patient's health record 9. Put on gloves and open the flap in the back of the card. Apply 2 drops
• Fecal occult blood cards of fecal occult blood test developer directly over the smear.
• Fecal occult blood developer 10. Interpret the results in 60 seconds.
• Applicator sticks PURPOSE: The fecal occult blood test is negative if no trace of color is
• Disposable examination gloves detectable on or at the edge of the smear; it is positive if any trace of
• Biohazard waste container blue is seen on or at the edge of the smear (see the following figure).

PROCEDURAL STEPS
1. Sanitize your hands and assemble all required equipment and supplies.
PURPOSE: To ensure infection control.
2. Identify the patient by obtaining his or her full name and date of birth;
introduce yourself; and explain the procedure.
3. Give the patient an examination gown. Instruct him or her to remove all
clothing below the waist and to put on the gown with the opening to the
back. Provide a drape for additional privacy.
4. Assist the patient onto the table. When the provider is ready, place the
patient in the appropriate position for the type of examination ordered.
S. Drape the patient so that only the anus is exposed. Afenestrated drape (From Roberts J, Hedges J: Clinical procedures in emergency medicine, ed 5, Philadelphia, 2010,
(drape with a circular opening over the anus) may be used in place of the Saunders.)
rectangular drape.
6. Put on gloves and assist the provider as requested during the examination, 11. Sanitize and disinfect the work area and all equipment used. Dispose
including: of the gloves in the biohazard waste container and sanitize your
• Handing the provider supplies hands.
• Collecting specimens by holding the fecal occult blood card to accept PURPOSE: To ensure infection control.
the sample 12. Record the procedure and any pertinent information in the patient's health
• The provider placing a thin smear of fecal material inside Box A record.
• The provider applying a second sample from a different part of the PURPOSE: Procedures that are not recorded are considered not done.
stool inside Box B
• Closing the cover and disposing of contaminated supplies in the bio- PATIENT INSTRUCTIONS FOR HOME COLLECTION
hazard waste container as you are given them by the provider OF FECAL OCCULT BLOOD SAMPLES
7. On completion of the examination, remove your gloves and dispose of 1. Give the patient a kit for collecting stool samples as ordered by the pro-
them in the biohazard waste container. Sanitize your hands, and assist vider. Typically, the provider orders a sample from three different bowel
the patient into a sitting position. movements. The patient must follow the recommended medication
388 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES
I; ;m!,mj;j I~,- -,;ontinued
restrictions and dietary guidelines throughout the testing period because
false-positive results can occur if the recommended medication and dietary
restrictions are not followed. These include:
• No aspirin or nonsteroidal antiinflammatory drugs (NSAIDs) for 7days
before the test
• No more than 250 mg of vitamin ( per day
• Avoid eating red meat, including processed meats or cold cuts, and
raw fruits and vegetables, especially melons, radishes, turnips, and
horseradish, for 72 hours before the stool collections
The patient then is instructed as follows:
2. Store the kit in the bathroom at home or carry it with you while you are
away from home until the three different stool samples have been
collected.
3. Write your name and other required information on the front of the col-
lection cards.
4. Cover the toilet with plastic wrap or use a toilet cap to collect the stool
specimen.
PURPOSE: Stool samples from toilet bowl water can cause errors in the
test resu It.
Proctologic Examination
Proctology is the branch of internal medicine that is concerned with
diseases and disorders of the colon, rectum, and anus. The anal area
is examined with a proctoscope, which allows detection of hemor-
rhoids, polyps, fissures, fistulas, and abscesses. The rectum and the
sigmoid colon are examined with a flexible sigmoidoscope, and the
descending, transverse, and ascending colon sections (or the entire
colon) are examined with a colonoscope.
Many people are apprehensive about colorectal examinations. To
alleviate this anxiety, instruct the patient in exactly what to do before
the examination, and provide support during the procedure. Let the
patient know that some discomfort, such as cramping, may be expe-
rienced. Furthermore, the sensation of expelling flatus or of an
impending bowel movement may be felt. These sensations are caused
by the instrument and the procedure.
The patient must be given specific instructions on how to prepare
the colon for any endoscopic examination (see Table 15-5). Refer to
your employer's policies and procedures manual to determine the
preferred method of patient preparation for each test because provid-
ers' orders may vary.
CLOSING COMMENTS
Patient Education
The GI system is responsible for the nourishment of the entire body.
When disease interferes with this process, the individual may become
ill and develop serious pathologic disorders. Listen for patients'
concerns that may indicate a problem within the system and its
accessory organs. Report these concerns to the provider or note them
in the patient's health record for the provider to read. If the office
S. Use one of the applicator sticks to collect a small fecal sample and apply
a thin smear inside Box A.
6. Reuse the applicator to obtain another sample from a different part of the
stool and apply it to Box B.
7. Close the cover and label the card with the date and time collected.
8. Store cards away from heat, light, and strong chemicals (e.g., bleach).
Do not place in a plastic bag.
PURPOSE: Strong chemicals can affect the slide. The stool sample must
air dry to be processed properly.
9. Repeat this procedure for the next two bowel movements, as ordered by
the provider, using a different card for each sample.
PURPOSE: To test multiple stool samples for minute amounts of
bleeding.
10. After collecting all samples as ordered, seal the test envelope and return
the kit to the provider's office. Do not send stool samples in the mail
unless you have a special envelope from the provider.
PURPOSE: To prevent contamination of the mail.
has information that may assist the patient in dealing with a particu-
lar problem, lay out the information for the provider to give to the
patient; or, with the provider's authorization, talk to the patient and
offer suggestions that might help the person deal with a particular
concern. Learning to perform and assist with diagnostic procedures
allows the medical assistant to aid in the diagnostic sequence and to
assist the patient in maintaining a healthy GI system.
Legal and Ethical Issues
Legally and ethically, the medical assistant's responsibility is to assist
the provider and act as the patient's advocate. All information dis-
cussed between the patient and the provider, and all testing proce-
dures ordered and done, must remain confidential. Confidentiality
and trust are very closely linked, and these two issues form the basis
of a sound patient-provider relationship. The medical assistant is an
important part of that relationship and can strengthen it through
ethical, professional conduct.
Professional Behaviors
Diagnostic procedures and treatment protocols, especially medications, are
constantly changing. The professional medical assistant must be committed
to lifelong learning to keep up with the rapid changes in the medical field.
Maintaining a current understanding of the human body, the disease
process, and how specific GI system diseases are diagnosed and treated
requires a willingness to learn and adapt over time. This commitment to
lifelong learning is a crucial part of becoming a professional medical
assistant.

i-iiiiit+i;it•jiii#it-iU1•i
Joan enjoys working with Dr. Sahani and his patients with GI disorders, but she
is constantly challenged to learn and update information about diseases and
disorders of the GI system, in addition to their diagnosis and medical manage-
ment. Joan must consistently work at applying correct medical terminology
when documenting patients' complaints and must use her knowledge of
GI disorders to ask pertinent, detailed questions when gathering patient
information.
Joan has also had to update her knowledge of patient preparation for
diagnostic procedures so that patients are adequately educated and prepared
SUMMARY OF LEARNING OBJECTIVES
l. Define, spell, and pronounce the terms listed in the vocabulary.
Spelling and pronouncing medical terms correctly reinforce the medical
assistant's credibility. Knowing the definitions of these terms promotes
confidence in communication with patients and co-workers.
2. Describe the primary functions of the GI system.
The GI system is responsible for the digestion of food, the absorption of
nutrients, and the excretion of waste materials.
3. Identify the anatomic structures that make up the GI system and
describe the physiology of each.
The GI system begins at the mouth and ends at the anal canal. The
digestive process starts in the mouth with mastication and enzyme
action; the bolus of food is swallowed and passes from the esophagus
into the stomach, where digestion continues with the addition of hydro-
chloric acid and further enzyme action. Digestion ends in the duodenum,
with pancreatic juices and emulsification of fat by bile, which is excreted
by the liver and stored in the gallbladder. Absorption of nutrients takes
place in the ileum and jejunum, and fluids are absorbed in the large
intestine. Ultimately, waste materials are excreted through the anus.
(See Figure 15-1 .)
4. Differentiate among the abdominal quadrants and regions.
The abdominal cavity can be divided into four sections, or quadrants: the
right and left upper quadrants and the right and left lower quadrants.
More specifically, the abdominal cavity can be divided into nine regions:
the right hypochondriac, epigastric, and left hypochondriac regions; the
right lumbar, umbilical, and left lumbar regions; and the right inguinal,
hypogastric, and left inguinal regions. These anatomic markers are
important for clearly identifying the location of a GI problem. (See
Figure 15-2.)
5. Summarize the typical symptoms and characteristics of GI com-
plaints and perform telephone screening for patients with GI
complaints.
Patients with GI disorders may complain of vomiting because of pain,
stress, GI upset, or an inner ear or intracranial pressure disturbance;
diarrhea caused by an infection, an allergy, or a malabsorption problem;
constipation that occurs because of a low-fiber diet or inadequate fluids,
CHAPTER 15 Assisting in Gastroenterology 389
for scheduled examinations. She participates in workshops offered by her local
professional organization to stay up-to-date on medications and treatments for
GI diseases, especially current research on infectious hepatitis. Joan is looking
forward to active involvement in patient care as she continues to prepare patient
education materials and to assist Dr. Sahani as needed in providing high-quality
patient care.
as a side effect of medication, or because of a bowel obstruction or
tumor; and abdominal pain that varies in intensity and quality. It is
important for the medical assistant to identify the location of the patient's
discomfort, using either the abdominal quadrants or the abdominal
regions, and to note the onset, duration, and frequency of all symptoms.
(See Table 15-1 .)
Telephone screening for GI complaints involves following the facility's
policies and procedures manual for management of disorders; gathering
detailed information about the onset, duration, and frequency of the
problem and the pertinent patient history; and recording the interaction
in the patient's record, including use of medications for relief; a pain
scale, if appropriate; and the course of action based on the provider's
recommendations. (See Procedure 15-1 .)
6. Distinguish among cancers of the GI tract.
Cancers of the GI tract can occur in any of the primary or accessory
organs of the system. These can include oral tumors, which manifest as
a white mass or as an ulcer; esophageal tumors, which cause dysphagia;
gastric tumors, which cause anorexia and weight loss but are difficult to
diagnose in the early stages; liver tumors, which usually occur secondary
to metastasis from another cancerous site, accompanied by hepato-
megaly and portal hypertension; pancreatic cancer, which usually is
advanced when diagnosed; and colorectal cancer, which causes changes
in bowel function and anemia. (See Table 15-2.)
7. List common esophageal and gastric disorders; also, describe the
signs and symptoms, diagnostic tests, and treatments of each.
Esophageal and gastric disorders include hiatal hernias, in which part of
the stomach pushes through the hiatal sphincter of the diaphragm,
causing GERD; peptic ulcers, associated with H. pylori infections, which
are treated with a combination of antibiotics and proton pump inhibitors;
and pyloric stenosis, seen most frequentty in firstborn male infants, which
causes projectile vomiting and must be corrected by surgery. These dis-
orders usually are diagnosed symptomatically and with the use of a
barium swallow or an upper GI series of x-ray films. Medical treatment
includes the use of Prilosec, Nexium, or Pepcid. Surgery may be indicated
for repair of a hiatal hernia or gastric ulcers if perforation occurs.
Continued
390 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES
SUMMARY OF LEARNING OBJECTIVES-continued
8. Lisi inlestinal disorders; also, describe the signs and symptoms,
diagnostic tests, and treatments of each.
Intestinal disorders include a variety of conditions. Food-borne illnesses
cause mild to severe gastroenteritis, and the symptoms are controlled
with antiemetics and antidiarrheal medications. (See Table 15-3.)
Dumping syndrome, which may occur as a postsurgical complication of
weight loss surgery, results in widespread GI complaints. IBS is a recurrent
functional bowel disorder that causes alternating bouts of diarrhea, flatu-
lence, and constipation; it is treated pharmaceutically with bulk-forming
agents, antidiarrheals, antispasmodics, and anticholinergics. Acute appen-
dicitis is diagnosed through a positive McBurney's sign and ultrasonogra-
phy ar CT scan and is treated surgically. Regional enteritis, ar Crohn's
disease, causes localized areas of ulceration in the intestinal tract and is
treated medically to reduce inflammation, manage symptoms, and main-
tain nutritional status. Ulcerative colitis causes inflammatory ulcers that
typically start in the anus and move proximally through the colon; treat-
ment is similar to Crohn's disease, but surgical removal of the colon is
curative. Celiac disease is a malabsarption disorder caused by a genetic
defect in the ability to metabolize gluten. Gluten sensitivity does not
cause damage to the villi, and the patient's symptoms are similar but
less severe. Diverticular disease consists of small herniations of the
muscular lining af the colon and is managed with dietary changes and
surgery if diverticulitis is advanced. The abdominal musculature can
become weakened and hernias that require surgical repair can develop.
Hemorrhoids, which are varicose veins of the anus, are treated with stool
softeners, a high-fiber diet, or surgical repair.
9. Do the following related to diseases of the liver and gallbladder:
• Classify disorders of the liver and gallbladder, and list the signs and
symptoms, diagnostic tests, and treatments for each.
Disorders of the liver include hepatitis from either viral infection ar a
chemical reaction, such as alcohol abuse, or as a complication of drug
metabolism. Mild inflammation temporarily impairs liver function, but
severe inflammation may lead to necrosis and serious complications,
including jaundice, cirrhosis, and portal hypertension. The gallbladder
stares bile that is excreted by the liver to aid in fat metabolism. If
cholelithiasis or cholecystitis develops, the gallbladder may have to
be removed surgically to relieve symptoms.
• Describe the similarities and differences among the various forms of
infectious viral hepatitis.
Viral hepatitis is an infection of the liver that causes acute inflamma-
tion of hepatocytes. Five forms of this virus exist: A, B, C, D, and E.
Hepatic cells can regenerate; therefore, depending on the degree of
liver involvement, the patient may either recover or may develop
widespread necrosis, cirrhosis, and liver failure. Chronic inflammation
CONNECTIONS
OJ Study Guide Connection: Go to the Chapter 15 Study Guide. Read and complete
the activities.
can occur with hepatitis HBV, HCV, or HOV. This usually results in
permanent liver damage and an associated increased risk of liver
cancer. Vaccinations are available for HAV and HBV. (See Table 15-4.)
l 0. Summarize the medical assistant's role in the GI examination.
The medical assistant provides patient support and education, gathers
and records specific details about the patient's complaints, and assists
the provider with the examination and diagnostic procedures performed
in the ambulatory care setting.
11. Do the following when it comes to assisting with gastroenterology
diagnostic procedures:
• Explain the common diagnostic procedures for the GI system.
Diagnostic procedures for the GI system include laboratory studies,
such as liver panels and urinary tests for bilirubin and amylase, and
stool tests for occult blood, intestinal parasites, and fat excretion.
Radiologic and endoscopic tests include barium swallow, upper GI
series, barium enema, HIDA scan, sigmoidoscopy, and colonoscopy.
(See Table 15-5.)
• Demonstrate the procedure for assisting with an endoscopic colon
examination.
The endoscopic colon examination is described in Procedure 15-2.
The medical assistant prepares the room, equipment, and patient for
the procedure; assists the provider throughout the procedure by posi-
tioning the patient, monitoring vital signs as indicated, helping with
equipment, and labeling specimens for transport ta the laboratory;
assists the patient after the examination; sanitizes and disinfects the
equipment and the room; and documents the procedure in the
patient's health record.
• Perform the procedural steps for assisting with the collection of afecal
specimen.
Procedure 15-3 presents the steps for collecting a fecal specimen.
Patient education includes information on proper dietary and drug
restrictions and collecting three different stool specimens for analysis
for hidden blood in the stool.
12. Describe the medical assistant's role in the proctologic
examination.
The medical assistant supports and prepares the patient; positions and
drapes the patient for the procedure; monitors vital signs before and
during the procedure; and assists the provider with the procedure.
13. Describe patient education, in addition to legal and ethical issues,
related to assisting in gastroenterology.
The GI system is responsible for the nourishment of the entire body. Listen
for concerns the patient expresses that may indicate a problem in the
system or its accessory organs. All information discussed between the
patient and the provider must remain confidential.
evolve Evolve Connection: Go to the Chapter 15 link at evolve.e/sevier.com/
kinn to complete the Chapter Review Quiz. Check out the other resources listed for this
chapter to make the most of what you have learned from Assisting in Gastroenterology.
ASSISTING IN UROLOGY AND
MALE REPRODUCTION
i-i#H+i;H•i
Sara Ricci, (MA (AAMA), who has l Oyears of experience, works for Dr. Samuel
Fineman, a urologist who also manages male reproductive disorders. Dr.
Fineman relies on Sara to handle telephone calls from patients, to have a clear
understanding of the anatomy and physiology of the renal system, and to assist
him in the clinical area of the practice. Although Sara has worked for Dr.
Fineman for almost 2 years, occasionally problems still arise that she is not
sure how to manage. Sara attends workshops and conferences to earn
While studying this chapter, think about the following questions:
• What is the basic anatomy and physiology of the renal and male
reproductive systems?
• What should Sara know about common adult and pediatric urologic
disorders so that she can both assist the provider in the practice and
answer patients' questions?
LEARNING OBJECTIVES
l . Define, spell, and pronounce the terms listed in the vocabulary.
2. Describe the anatomy and physiology of the urinary system.
3. Do the following related to disorders of the urinary system:
• Explain the susceptibility of the urinary system to diseases and
disorders.
• Identify the primary signs and symptoms of urinary problems.
• Detail common diagnostic procedures of the urinary system.
4. Discuss the causative factors of urinary incontinence, in addition to the
various treatments and medications used to treat it.
5. Compare and contrast infections and inflammations of the urinary
tract.
6. Describe urinary tract disorders and cancers.
7. Summarize the causes of renal failure and how it is treated.
VOCABULARY
albuminuria (al-byu-mih-nur' -e-uh) The abnormal presence of
albumin protein in the urine.
azotemia (a-zo-te'-me-uh) The retention of excessive quantities of
nitrogenous wastes in the blood.
casts In kidney disease, fibrous or protein material molded to the
shape of the part in which it has accumulated that is thrown off
into the urine.
copulation Sexual intercourse.
16
continuing education units to maintain her (MA credential and tries to choose
topics that focus on urologic issues. In addition, she keeps up to date on new
diagnostic procedures and treatments for sexually transmitted infections (STls),
including human immunodeficiency virus (HIV) infection and acquired immuno-
deficiency syndrome (AIDS). Sara helps train other medical assistants in the
practice and makes sure adequate patient education supplies are available for
self-testicular examination.
• What are some of the pathologic genital conditions seen in men?
• What are the typical signs, symptoms, and treatments for sexually
transmitted infections in men?
• How can Sara provide patient education and support for individuals with
renal and male reproductive system disorders?
8.Summarize the typical pediatric urologic disorders.
9.Describe the anatomy and physiology of the male reproductive system.
l 0.Determine the causes and effects of prostate disorders.
11. Outtine common types of genital pathologic conditions in men, and
perform patient education for the testicular self-examination.
12. Analyze the effects of sexually transmitted infections in men and
summarize the characteristics of HIV infection, including diagnostic
criteria and treatment protocols.
13. Describe the medical assistant's role in urologic and male reproductive
examinations.
14. Discuss patient education, legal and ethical issues, and HIPAA
applications in the urology practice.
creatinine (kre-ah'-tuhn-in) Nitrogenous waste from muscle
metabolism that is excreted in urine.
dyspepsia An uncomfortable feeling of fullness, heartburn,
bloating, and nausea.
dysuria Painful or difficult urination.
erythropoietin (eh-rith-ruh-poi'-eh-tin) A substance released
by the kidneys and liver that promotes red blood cell
formation.
392 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES
VOCABULARY -continued
Kaposi's sarcoma A malignant tumor of endothelial cells that
begins as red, brown, or purple lesions on the ankles or soles.
leukocytosis An abnormal increase in the number of circulating
white blood cells; it often occurs with bacterial infections but
not viral infections.
renin An enzyme produced and stored in the glomerulus; it is
released by a homeostatic response to raise the blood pressure
when needed.
U rology is the study of the urinary tract in both male and female
patients. A physician who specializes in the diseases and disor-
ders of the urinary system is a urologist. Urologists also specialize in
conditions associated with the male reproductive system.
ANATOMY AND PHYSIOLOGY OF THE
URINARY SYSTEM
The urinary tract consists of bilateral kidneys and ureters, the urinary
bladder, and the urethra (Figure 16-1). The main function of the
urinary system is to remove waste products from the body. Waste
materials are byproducts of the body's metabolic processes, and if
left to accumulate in the bloodstream, they can become toxic. The
urinary system removes salts and nitrogenous wastes (nitrogen is the
product of protein metabolism) from the blood, forming urea, which
is excreted. Besides excreting waste material, the urinary system
performs other functions, such as:
• Helping to maintain homeostasis by regulating water, electrolyte,
and acid-base levels
• Activating vitamin D, which is needed for calcium absorption
• Producing erythropoietin, which helps control the rate of red
blood cell formation
Inferior
vena cava --+------,.,,~--+--'"""-=,...~
Right
adrenal gland ',
Right kidney
-1-11-cW..::....:.....,.....;;,,.;.f--i--Abdominal
Renal artery
and vein
·~ ~~~:______!
a-,-------+--
FIGURE 16-1 The urinary system. (From Frazier MS, Drzymkowski JA: Essentials of human
diseases and conditions, ed 5, St Louis, 2013, Saunders.)
urgency A sudden, compelling desire to urinate and the inability
to control the release of urine.
wasting syndrome Physical deterioration resulting in profound
weight loss, fatigue, anorexia, and mental confusion.
• Helping to maintain blood pressure by secreting the enzyme
renin
The kidneys are red-brown, bean-shaped glandular organs. They
are located posterior to the peritoneum (retroperitoneal) and against
the muscles of the back, roughly between the T12 and L3 vertebrae.
The left kidney is situated about 1 inch (2 cm) higher than the right
because of the location of the liver.
The kidneys remove unwanted substances from the blood and
form urine for excretion. For this crucial function, a great deal of
blood circulates through the kidneys-approximately 15% to 30%
of the total cardiac output. The blood is delivered to the two kidneys
by the renal artery and is distributed through the kidneys by a
highway of smaller arteries. The blood then is returned through a
pathway of veins, including the renal vein, which flows into the
inferior vena cava in the abdominal cavity.
The outer layer of the kidney, the cortex, contains the functional
unit of the kidney, the nephron, where urine is formed as fluid and
dissolved substances move between its vascular and tubular struc-
tures. Three processes are involved in urine formation: filtration,
reabsorption, and excretion. The nephron consists of the glomerulus,
a cluster of capillaries extending from the distal renal artery that is
partly surrounded by Bowman's capsule. Fluid and dissolved sub-
stances are filtered from the glomerulus to Bowman's capsule and
then into the proximal convoluted tubules, where most of the fluid
is reabsorbed by venules and arterioles surrounding the tubules and
sent back into the general circulation. Based on the homeostatic
needs of the body, the kidneys determine the type and quantity of
substances reabsorbed. Finally, the remaining substances are excreted
through the distal convoluted tubules to the collecting tubules and
then on to the medull,a of the kidney. The medulla contains the
renal pelvis, where the urine is deposited before passing down the
aorta
ureters. The distal collection area of the renal pelvis is made up of
fingerlike projections, called the calyces, where urine is first depos-
ited when it leaves the nephron units of the renal cortex
(Figure 16-2).
The bilateral ureters are tubular organs approximately 10 inches
(25 cm) long; with the aid of peristaltic waves generated by the
Urinary ureter's muscle layer, the bilateral ureters move the urine from the
bladder kidneys to the urinary b/,adder. The urinary bladder is a hollow organ
Urethra
lined with smooth muscle that overlaps in rugae formation, which
enables the bladder to expand as it fills. When the bladder is full,
the sphincter opens and urine flows into the urethra. The urethra is
lined with a mucous membrane, and in males it functions both as
 CHAPTER 16 Assisting in Urology and Male Reproduction 393

the vagina and anus exposes the renal system to microorganisms that
NEPHRON
can cause infection. The urethra passes the urine from the bladder
to the urinary meatus and outside the body. The process of urination
is known as voiding or micturition.
F->-l'f-+-!'------ Distal convoluted tubule
, (secretion)

CRITICAL THINKING APPLICATION 16-1

Dr. Fineman wants Sara to review a number of pamphlets on the anatomy
Loop of Henle--~,-----, , and physiology of the urinary system to be used for patient education. Sara
(reabsorption)
has researched the available pamphlets and must decide which is best suited
to the practice. What material should be included in a comprehensive
pamphlet? Are diagrams important for patient understanding?

Pyramids of DISORDERS OF THE URINARY SYSTEM

medulla
- + - - - Ureter
RIGHT KIDNEY
FIGURE 16-2 The kidney. (From Frazier MS, Drzymkowski JA: Essentials of human diseases and
conditions, ed 5, St Louis, 2013, Sounders.)
the urinary canal and as a passageway for cells and secretions from
various reproductive organs. The male urethra is about 8 inches
(20 cm) long and is divided into three sections: the prostatic urethra
(which passes through the prostate gland at the base of the bladder),
the membranous urethra, and the penile urethra. In a female, the
urethra is about 1 to 1½ inches (3 to 4 cm) long. Its proximity to
The urinary tract is made up of a continuous mucosa! lining that
gives organisms entering the urethra a direct pathway through the
system. Of the wide range of symptoms that occur in patients with
disorders of the renal system, the most common involve changes in
the frequency of urination. Dysuria, urgency, retention, and incon-
tinence all are common symptoms. Abnormal functions of any part
of the urinary tract often can be determined through urinalysis,
blood urea nitrogen (BUN) levels, and analysis of creatinine clear-
ance. Radiologic and endoscopic studies also are important in detect-
ing urinary tract diseases. Table 16-1 summarizes common diagnostic
tests of the urinary system.
CRITICAL THINKING APPLICATION 16-2
Sara is responsible for scheduling and providing patient preparation instruc-
tions for diagnostic radiologic and endoscopic procedures. With Dr. Fine-
man's approval, she has prepared patient handouts that summarize the
correct procedures to follow when a patient is scheduled for specific urologic
tests. Today she has a patient who needs to be scheduled for both a cys-
togram and an intravenous pyelogram (IVP). How should the patient
prepare for both of these examinations?

TABLE 16-1 Common Diagnostic Tests of the Urinary System

TEST DESCRIPTION PATIENT PREPARATION
Uroflowmetry Patient urinates into a funnel connected to a measuring • Bladder should be full
instrument, which calculates the amount of urine, rate of • Drink about four glasses of water several hours
flow in seconds, and length of time until completion of before test
the void. • Do not push or strain with urination and remain as
Evaluates function of the lower urinary tract or helps still as possible during test
determine whether an obstruction of normal urine outflow
is present.
Kidney-ureter-bladder (KUB) x-ray Flat plate films of the abdomen show size, shape, location, No specific patient preparation; contraindicated in
and any malformations of the kidneys and bladder. pregnancy.
Used to visualize calculi.
Continued
394 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES

TABLE 16-1 Common Diagnostic Tests of the Urinary System-continued

TEST
Renal scanning
Cystagraphy and voiding
(cystourethrogram)
Intravenous pyelography; may be Dye injected IV, then x-ray films taken at intervals to shaw
called intravenous urography (IUG) passage through kidneys and ureters into bladder.
Used to diagnose tumors, calculi, obstructions, and
congenital renal problems.
Arteriography (angiography)
Renal computed tomography (CT)
Renal ultrasonography
Cystoscopy
Retrograde pyelography
DESCRIPTION
Nuclear scans ta determine the size, shape, and function of
the kidney ar ta diagnose obstruction or hypertension;
radiaisatape is administered intravenously (IV), and images
are taken to show distribution.
X-ray evaluation with contrast dye to study bladder structure • Faley catheter inserted for a cystaurethrogram
or function.
Dye injected into the renal artery, computed fluoroscopy
allows visualization of the blood flow of the kidneys, and
serial x-ray films are taken.
Used to diagnose stenosis af the renal artery and highly
vascular renal cancers.
Can be done with or without contrast dye; transverse views Check for allergies to iodine and shellfish.
of kidney are taken to detect tumors, abscesses, cysts, and • Remove all metal objects
hydronephrosis.
High-frequency sound waves transmitted through kidneys to
detect abnormalities.
Used to determine kidney size and to diagnose
hydronephrosis, palycystic kidneys, and obstructions of
ureters and bladder.
Endoscopic view of urethra and bladder for biopsy.
Used to measure bladder capacity, to find or remove calculi,
for dilation of urethra and ureters, and for placement of
ureteral stents.
Dye injected through cystoscope into bladder, ureters, and
kidneys to detect stones and other obstructions; procedure
can replace intravenous pyelagram (IVP) for patients with
renal failure, obstructions, ar allergies to IV dye.
PATIENT PREPARATION
• Void before procedure
• Drink 2 ar 3 glasses af water before scan
• Contraindicated in pregnancy
• No sedation or fasting required
• Contraindicated in pregnancy
• X-ray films may be taken while patient is voiding
(voiding cystaurethrogram)
• After procedure, patient forces fluids ta eliminate dye
and prevent infection
• Contraindicated in pregnancy and with iodine
allergies
• Liquid diet 8 hr before
• Laxative taken evening before
• May have enema morning of study
• Adequate fluids afterward
Check for allergies to iodine and shellfish.
• Nothing by mouth (NPO) 2-8 hr before
• Preprocedural medications administered as ordered
• Void before study
• Warm flush may occur when dye is injected
• Contraindicated in pregnancy
• If contrast medium will be used, fast 4 hr before
procedure
• Scanner may make loud clicking sounds
• Dye may cause flushing, metallic taste, and
headache
• Contraindicated in pregnancy
No food or fluid restrictions; noninvasive and painless
• Enemas to clear bowel
• Local anesthetic: Force fluids before procedure
• General anesthesia: NPO after midnight
• Preprocedural sedative to reduce bladder spasms
Aftercare: Monitor urinary output for 24 hours.
Same as cystoscopy; check for iodine and shellfish
allergies.
 CHAPTER 16 Assisting in Urology and Male Reproduction 395

Urinary Incontinence
Urinary incontinence, which is a temporary or chronic loss of TABLE 16-2 Anticholinergic Medications for
urinary control, can be the result of many conditions, includ- Treatment of Incontinence, Urinary Bladder
ing urinary tract infections, brain disorders, and tissue damage. Spasms, and Urgency
Incontinence also can be caused by straining or coughing in post-
surgical patients and in female patients with weak pelvic muscula- GENERIC NAME BRAND NAME ADVERSE EFFECTS
ture; in such situations, the condition is called stress incontinence. darifenacin Enablex Dry mouth, constipation,
The treatment of incontinence depends on the causative factor. dyspepsia
Behavioral approaches include bladder or habit training that teaches
the patient to urinate according to an established schedule rather dicyclomine Bentyl Dizziness, blurred vision,
than when he or she has the urge to void. This is helpful for drowsiness
patients who are incontinent as a result of strokes, Parkinson's
fesoterodine Toviaz Dry mouth, constipation
disease, Alzheimer's disease, central nervous system (CNS) lesions,
or cystitis. Pelvic muscle exercises (Kegel exercises) that strengthen oxybutynin Ditropan, Gelnique, Dry mouth, constipation,
the muscles of the pelvic floor are helpful for women with stress Oxytrol drowsiness, nausea
incontinence. Patients are trained to simulate stopping the flow of
urine and holding that contraction for 10 seconds. To strengthen
solifenacin Vesicare Dry mouth, constipation,
the pelvic floor, this exercise should be done in sets of 20 three abdominal pain
times a day. A method for managing male incontinence is with an tolterodine Detrol Dry mouth, blurred vision,
external catheter. External catheters are a type of urine collection constipation
device that resembles a pouch or condom, which is securely placed
around the penis. They are often called condom catheters. The tip
of the device is connected to a drainage tube that empties into a
storage bag. Condom catheters are typically used in long-term care urethritis and that of the bladder is cystitis. The resident flora of the
facilities but are associated with an increased incidence of urinary colon, Escherichia coli, is the usual causative agent.
tract infections (UTis). Women are more susceptible than men to UTis because of the
Patients with neurogenic bladder, who have lost control of urina- female anatomy (i.e., a short urethra and the proximity of the anus)
tion because of CNS trauma or disease, may have to be catheterized and as a result of irritation caused by tampon use and sexual activity.
to remove urine from the bladder. Intermittent catheterization to Older men with prostatic hyperplasia and resultant urinary retention
empty the bladder is preferable to indwelling catheters, which often also are at risk for frequent urinary tract infections.
lead to infection. Clean intermittent catheterization can be done
using medical aseptic techniques on a schedule at home, usually
every 4 to 6 hours. If possible, the patient should be taught to General Signs and Symptoms of Urinary Tract
perform routine catheterization throughout the day, or a family
member may be involved in care.
Infection
Chronic incontinence can be treated pharmacologically with • Overwhelming urge to urinate (urgency)
anticholinergics that act to relax the smooth muscle of the urinary • Burning on urination (dysuria)
bladder and prevent uncontrolled bladder contractions that cause • Urgency with frequent, small amounts of urine
urine to leak out of the bladder (Table 16-2). These medications are • Blood in the urine (hematuria) or a cloudy, dark, foul-smelling
used to treat stress incontinence and urgency.
urine
When all other treatments have failed, surgical intervention for
• Frequent urination at night (nocturia)
urinary incontinence may be the answer. Several different subure-
thral sling procedures have proved successful in treating female
incontinence. An artificial urinary sphincter is helpful for men
with incontinence. A device shaped like a doughnut is implanted Urethritis
around the neck of the bladder; it keeps the urinary sphincter closed Urethritis, or inflammation of the urethra, is more common in men.
until the patient presses a valve implanted under the skin. This It typically is caused by chlamydia or gonorrhea bacteria. Symptoms
deflates the ring and releases urine from the bladder. include the discharge of pus, an itching sensation at the opening of
the urethra, and burning on urination. Infectious urethritis can cause
Urinary Tract Infections and Inflammations cystitis in women, so sexual partners also should be treated. Urinaly-
UTis occur frequently, especially in women, because the urinary sis may show hematuria and pyuria (pus in the urine).
system has a direct opening to the outside, and urine is an excellent
medium for bacterial growth. Most UTis are ascending; that is, they Cystitis
start in the perinea! area with exposure to pathogens, which infect Cystitis, an infection of the urinary bladder, causes inflammation of
the continuous mucosa of the urinary system, which in turn allows the bladder wall and urinary urgency. Symptoms include very mild
the pathogen to travel up through the urethra, bladder, and ureters to acute discomfort in the lower abdomen, urinary frequency, and
to the kidneys. Infection and inflammation of the urethra is called painful urination (dysuria). The patient may have signs of a systemic
396 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES
infection, including fever, general malaise, and leukocytosis. A posi-
tive diagnostic urinalysis shows a bacteria level in the urine of more
than 100,000/mL, pyuria, and hematuria. An infection of the
urinary bladder is especially difficult to eliminate because of the
bladder's overlapping rugae walls. It is very important that patients
understand that, to prevent a recurrence of the infection, they must
complete the entire antibiotic prescription to destroy all the bacteria
in the folds of tissue.
Pyelonephritis
Pyelonephritis, an inflammation of the renal pelvis and kidney, is
the most common type of renal disease. It is caused by bacteria that
ascend from the lower urinary tract and is associated with conditions
such as urinary retention or obstruction that promotes urinary stasis
and the growth of bacteria. It frequently is preceded by urethritis
and cystitis. With pyelonephritis, pus collects in the renal pelvis, and
abscesses form. Symptoms include fever, chills, nausea, vomiting,
and flank (lateral lumbar) pain. The patient reports foul-smelling,
dark urine with frequency and urgency.
Diagnostic studies include urinalysis of a dean-catch urine
sample. It reveals hematuria, pyuria, increased white and red blood
cells, albuminuria, casts, and bacteria. Urine cultures usually are
done to determine the causative agent.
Treatment of Urinary Tract Infections
UTis are treated with antibiotics, such as ciprofloxacin (Cipro),
nitrofurantoin (Macrodantin, Furadantin), sulfamethoxazole
(Bactrim, Septra), and levofloxacin (Levaquin). Patients may also be
prescribed a urinary tract analgesic, such as phenazopyridine hydro-
chloride (Pyridium), which is rapidly excreted in the urine and has
a topical analgesic effect that helps relieve pain, burning, urgency,
and frequency. However, Pyridium gives the urine an orange to red
color, which initially may be misinterpreted as hematuria. Patients
diagnosed with UTis are encouraged to force fluids to dilute the
urine and flush the urinary tract. A follow-up urinalysis should be
run to confirm the effectiveness of antibiotic therapy in curing the
infection. UTis tend to recur unless the cause of the infection is
removed.
The medical assistant should instruct the patient to finish the
entire antibiotic prescription as ordered, to maintain proper hygiene,
to empty the bladder completely when the urge to void arises and,
for female patients, to wipe the perinea! area from front to back to
discourage the spread of E. coli from the anal area toward the urethral
region. Cranberry juice has been recommended for years to help
prevent repeat UTis. However, the American College of Obstetrics
and Gynecology (ACOG) states that drinking cranberry juice can
decrease the symptoms of UTis, but there is insufficient evidence to
recommend its use to prevent them.
CRITICAL THINKING APPLICATION 16-3
Tabitha Allison, a 22-year-old patient of Dr. Fineman, was diagnosed today
with her third UTI in as many months. Patient education on prevention and
treatment of UTls is needed. What information should Sara ga over with
Ms. Allison?
Glomerulonephritis
Many conditions can cause glomerulonephritis, the inflammation of
the glomerulus of the nephron units. Acute glomerulonephritis, or
sudden inflammation of the glomeruli, usually develops in children
and adolescents about 2 weeks after a streptococcal infection, such
as strep throat or scarlet fever. In adults it may also be associated
with infections, including hepatitis B and C, or other conditions,
such as lupus. Symptoms include low-grade fever, anorexia, general
malaise, and flank pain. Hypertension and edema may occur
because of reduced renal function. Urinalysis shows hematuria and
proteinuria. Diuretics, such as triamterene and hydrochlorothiazide
(Dyazide) or furosemide (Lasix), may be given to control hyperten-
sion and reduce edema. The prognosis usually is good; most patients
recover spontaneously, but in some patients, the condition progresses
to a chronic state.
Chronic glomerulonephritis may also be called nephritis or
nephrotic syndrome. It typically develops over many years and may
be associated with chronic diseases that affect the blood vessels, such
as systemic lupus erythematosus (SLE) and diabetes mellitus.
Chronic glomerulonephritis causes progressive, irreversible nephron
damage that frequently results in renal failure. At first the patient is
asymptomatic, but as the disease progresses and more glomerular
damage occurs, the patient develops anorexia, fatigue, hypertension,
hematuria, proteinuria, oliguria (scanty urination), and edema. The
cause of chronic glomerulonephritis is unknown, but it may be
associated with an antigen-antibody reaction in the glomerular
capsule that ultimately destroys the nephron unit. Treatment is sup-
portive and involves an attempt to control symptoms by administer-
ing antihypertensives and diuretics, in addition to prescription of a
diet low in protein with limited sodium and potassium to slow the
progression of the disease. Glomerulonephritis is a leading cause of
kidney failure; ultimately, many patients require kidney dialysis. The
only cure for the disease is kidney transplantation.
Urinary Tract Disorders and Cancers
Renal Calculi
Renal calculi, or kidney stones, are created when crystals in the urine
(e.g., calcium, oxalate, uric acid) collect in the kidney or when fluid
intake is low, creating a highly concentrated filtrate. The tendency
to develop kidney stones runs in families, and patients with a history
of renal calculi are at increased risk for developing more stones in
the future. Small stones usually do not cause any difficulty until they
grow large enough to lodge in the ureters or renal pelvis. If a stone
blocks the flow of urine, infection can develop from the resultant
stasis. This blockage also can result in hydronephrosis, a backup of
urine that causes dilation of the ureters and calyces and increases
pressure on the nephron units. Other signs and symptoms include
hematuria; cloudy, foul-smelling urine; nausea and vomiting; a per-
sistent urge to urinate; and fever and chills if an infection is present.
If stones are located in the kidney or bladder, the patient often
is asymptomatic, and frequent infections are the only presenting
problem. If the calculi begin to move or are lodged in the ureters,
the patient experiences renal colic, which is severe pain in the flank
region that fluctuates in intensity over periods of 5 to 15 minutes.
As the calculi progress down the ureter, the pain radiates to the lower
abdomen, groin, and genital areas on the affected side. If the stone
stops moving, the pain stops until it starts to move again. This
 CHAPTER 16 Assisting in Urology and Male Reproduction 397

pattern, referred to as renal colic, continues until the stone is passed
or it is treated medically. The patient may be able to pass small stones
by drinking large amounts of fluid (2 to 3 quarts of water a day).
However, larger stones or calculi that cause bleeding, kidney damage,
or persistent infection require medical intervention.
The provider may perform a cystoscopic examination to visualize
the urethra and bladder and to remove any stones found (Figure
16-3). The most common procedure for treating calculi is
Light cord
extracorporeal shock wave lithotripsy (ESWL), in which vibrations
of powerful sound waves are used to break the stones into frag-
mented pieces that can be passed through the renal system. Diag-
nostic studies are performed to identify the exact location of the
calculi, and x-rays or ultrasound is used during the procedure to keep
track of the calculi and to monitor treatment progress. The patient
lies on a water-filled cushion as high-energy sound waves are passed
through the body toward the exact location of the calculi (Figure
16-4). The procedure causes moderate pain, so the patient usually is
presedated or given a light anesthetic. The patient wears earphones
during the treatment because of the loud noise created each time a
shock wave is generated. Side effects of the treatment include flank
tenderness, hematoma formation across the treatment site, and
hematuria. Measures for preventing recurrence include drinking 3
to 4 quarts of fluid a day, preferably water, and following a diet that
is low in sodium and animal protein.

Hydronephrosis
Hydronephrosis, or swelling of the kidney caused by inability of
Urinary urine to drain from the renal pelvis, usually results from blockage
bladder
caused by renal calculi, but it may also be caused by an enlarged
prostate or a tumor. Hydronephrosis can occur bilaterally or unilat-
erally. The condition frequently is asymptomatic, or patients may
complain of mild flank pain as the renal capsule is distended. Urine
testing detects hematuria, and, if infection develops from stagnant
urine, pyuria. It is important to treat hydronephrosis aggressively
because continued pressure from blocked urine flow can cause tissue
necrosis and ultimately can lead to irreversible kidney damage.
Removing the blockage corrects the condition (Figure 16-5).
Cystoscope in bladder

Rectum Polycystic Kidneys

Polycystic kidney disease is an autosomal dominant genetic disorder,
which means that one parent has the disease and each child has a
FIGURE 16-3 Cystoscopy. 50% chance of inheriting it. No indications of the disease occur in

Shock waves
~
break up stone
~
in ureter

Extracorporeal shock wave

lithotripsy machine

FIGURE 16-4 Extracorporeal shock wave lithotripsy. (From Linton AO: Introduction to medical-surgical nursing, ed 6, Philadelphia, 2016,
Saunders.)
398 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES
HYDRONEPHROSIS NORMAL KIDNEY
ureter
FIGURE 16-5 Hydronephrosis.
FIGURE 16-6 Polycystic kidney (odult outosomol dominont). A, Cysts on the externol surfoce
of the enlarged kidney. B, Bisected kidney showing large interior cysts. (From Cotron RS, Kumar V,
Collins T: Robbin's pathologic basis of disease, ed 6, Philodelphio, 1999, Sounders.)
children, but as time goes on, normal renal tissue in both kidneys is
replaced by multiple, benign, fluid-filled cysts (Figure 16-6). The
nephrons and collecting tubules become dilated, fused, and infected.
As the cysts enlarge, they compress the surrounding tissue, causing
necrosis, uremia, and renal failure. Symptoms do not usually become
apparent until the individual reaches adolescence or adulthood.
Patients with polycystic disease have a family history of kidney
disease or renal failure, flank pain, hematuria, and hypertension.
They also are more likely to develop UTis and renal calculi. Because
Tumor involvement of
regional lymph nodes,
renal vein, and vena cava
Transitional cell
carcinoma of
the renal pelvis
Renal cell
carcinoma
Carcinoma of the
urinary bladder
(transitional cell 90%)
Carcinoma
of the urethra
(squamous cell)
FIGURE 16-7 Neoplasms of the urinary tract.
cyst formation is progressive, most of these patients eventually
require renal dialysis or kidney transplantation.
Bladder Cancer
The most common cancer of the urinary tract affects the bladder
(Figure 16-7). It is two to three times more common in men than
in women. Bladder cancer is characterized by one or more tumors
that can metastasize through the blood or surrounding pelvic lymph
nodes. Because 50% to 90% of patients experience a recurrence of
bladder tumors, follow-up testing that can identify recurrence is
extremely important. NMP22 is a urine test that screens for recur-
rence of the disease. It identifies a protein in bladder cells that are
either precancerous or cancerous. Ninety percent of bladder cancers
are attributed to these particular cells, which are called transitional
cells because they are cubelike when the bladder is empty and flat
when it is full. The test can be performed in the provider's office,
and the results are available in 1 hour. If the NMP22 test result is
positive, cystoscopy is performed to confirm the presence of abnor-
mal cells.
Smoking is the greatest single risk factor for the development
of bladder cancer. The carcinogens from tobacco become con-
centrated in the bladder and eventually cause cellular changes in
the walls of the organ. Other risk factors include occupational expo-
sure to chemical carcinogens (e.g., oil, rubber, dyes), drinking

pesticide-contaminated water, treatment with certain anticancer
drugs, and recurrent parasitic infections of the bladder. If the cancer-
ous cells are confined to the inner lining of the bladder, a transure-
thral resection of the bladder tumor (TURBT) is performed. The
provider passes a small wire loop through the urethra and uses an
electrical current or a laser to burn away the cancer cells. The pro-
cedure may cause dysuria or hematuria for a few days. If the tumor
has invaded the walls of the bladder, treatment may require a partial
or complete cystectomy (removal of the bladder), chemotherapy,
radiation, and the use of interferon to boost the patient's immune
system.
Renal Carcinoma
Adenocarcinoma of the kidney, or renal cell cancer, is a primary
tumor that can be cured if it is diagnosed and treated in the early
stages. However, affected patients frequently are asymptomatic,
which gives the tumor the opportunity to metastasize to the lungs,
liver, male urogenital system, bone, or brain before it is diagnosed.
Renal cell carcinoma typically occurs in patients over age 50 and is
seen more often in men and in smokers. Signs and symptoms of the
disease include flank pain, anorexia, anemia, hematuria, and an
increased white blood cell count. Surgical nephrectomy is the treat-
ment of choice. Although the prognosis for patients with the tumor
has improved, the 5-year survival rate is still only approximately
40%.
Wilms Tumor
Wilms tumor, or nephroblastoma, is cancer of the kidney in chil-
dren. Although the condition appears to be caused by a genetic
defect, very few of the children diagnosed with Wilms tumor have
a family history of the disease. It usually occurs unilaterally, is diag-
nosed most frequently at age 3, and rarely occurs after age 8. The
tumor may be noticed by parents as a mass in the child's abdomen
or by a provider during a routine physical examination. The pre-
ferred treatment is a partial or complete nephrectomy combined
with chemotherapy. The survival rate for children diagnosed and
treated for Wilms tumor is greater than 90%.
Renal Failure
Acute renal failure has a sudden, severe onset caused by exposure to
toxic chemicals; circulatory collapse from serious burns or heart
disease; acute bilateral kidney infection or inflammation; occlusion
of the renal arteries; or complications from surgery. Blood tests show
high BUN and creatinine levels, and the patient experiences acute
onset of oliguria. The primary problem must be resolved as quickly
as possible to prevent necrosis and permanent kidney failure.
Chronic renal failure is a slowly progressive process caused by
gradual destruction of the kidneys' ability to filter waste materials.
Diabetes mellitus is the leading cause of chronic renal failure in the
United States, but it also may be caused by hypertension, glomeru-
lonephritis, polycystic kidneys, long-term hydronephrosis resulting
from urinary obstruction, lead poisoning, or renal artery stenosis.
Symptoms of the condition may not be evident until as much as
75% of the kidney is no longer functioning.
Patients with chronic renal failure pass through several stages,
starting with an early stage of decreased reserve in which no clinical
signs are apparent but serum creatinine levels are consistently higher
CHAPTER 16 Assisting in Urology and Male Reproduction 399
than average. The middle stage of renal insufficiency is marked by
hypertension, elevated BUN and creatinine levels, and a low urine
specific gravity. End-stage renal failure (uremia) is marked by oliguria
that progresses to anuria (no urine output), edema, hypertension,
acidosis, and azotemia. The end result is that the kidneys can no
longer remove waste products from the blood, and toxicity develops.
To survive, the patient must be placed on dialysis or receive a kidney
transplant.
Treatment
Dialysis, or cleansing of the blood, is used to treat acute renal failure
until the problem is reversed or, for patients in end-stage renal
disease, until they receive a transplant. The two forms of dialysis are
hemodialysis and peritoneal dialysis. Hemodialysis is typically done
in an outpatient clinic or dialysis center, but it can be done at home
with the proper equipment and training. The process uses a machine
known as an artificial kidney, or dialyzer, to filter waste products from
the blood and return the cleansed blood to the body (Figure 16-8).
A surgically placed cannula or shunt creates an internal fistula
between an artery and a vein. During the procedure, approximately
1 cup of blood at a time passes from the shunt through a tube to
the semipermeable membrane of the dialysis machine. The mem-
brane filters the waste out of the blood, which then is returned to
the patient's vein. Patients on hemodialysis require anticoagulant
therapy to prevent clots from forming during the blood transfer
process. Hemodialysis in a clinic setting usually is needed three times
a week; the procedure takes approximately 3 to 4 hours each time.
Peritoneal dialysis uses the capillaries in the peritoneal cavity to
filter the blood by infusing the patient's abdomen with a dialyzing
fluid through a surgically implanted catheter. The dialysate solution
contains a mixture of minerals and sugar dissolved in water that
flows through the implanted catheter into the abdomen. The con-
centrated sugar draws wastes, chemicals, and extra water from the
tiny blood vessels in the peritoneal membrane into the dialysis solu-
tion. After several hours, the used solution is drained from the
abdomen through the tube, taking the waste material with it. Then
the abdomen is refilled with fresh dialysis solution, and the cycle is
repeated (Figure 16-9).
FIGURE 16-8 Hemodi•lysis. (From lgn•t•vicius D: Medical-surgical nursing: patient,;entered
collaborative care, ed 6, St Louis, Saunders.)
400 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES
Peritoneal
space with
dialysate
Dialysate
inserted into
perito~
/kc:::==_=~~-=_C_!!=J:::_catheter
Dialysate with")
waste products
drained from
peritoneal space
FIGURE 16-9 Peritoneal dialysis.
Peritoneal dialysis can be done at home in two different ways.
With continuous ambulatory peritoneal dialysis (CAPD), the patient
exchanges the dialysis solution in the abdomen four times a day, 7
days a week. Continuous cycling peritoneal dialysis (CCPD) uses a
cycler machine at night to automatically infuse the dialysis solution
into and out of the peritoneal cavity. This process takes 10 to 12
hours but can be done while the patient is sleeping.
Although successful kidney transplantation is curative for end-
stage renal failure, finding the right donor can be a problem. Donors
are matched by blood type, cell surface proteins, and antibodies.
Siblings are the best donors, but other blood relatives may also
match. If no blood relative donors are available, an adult donor who
matches the patient's criteria is the next best fit.
CRITICAL THINKING APPLICATION 16-4
Aloysius Gonzales, a 59-year-old patient, is in chronic renal failure. His
family is trying to decide whether their father should be brought to the
dialysis clinic for hemodialysis, or whether they should try to keep him at
home and assist with peritoneal dialysis. Sara will be explaining the mecha-
nism of each procedure to the family. What should she include in her
description?
PEDIATRIC UROLOGIC DISORDERS
Early detection and treatment of urologic disorders in children can
drastically reduce permanent physical damage to the urinary system.
Dialysate bag
Capillary
Waste
products
Dialysate with
_...,_.,. waste products
drained from
peritoneal space
Peritoneal space
with dialysate
Waste products cross the
semipermeable membranes
into the peritoneal space
Drainage bag
Nocturnal Enuresis
One of the most common reasons parents bring a child to a pediatric
urologist is enuresis, or bed-wetting. Enuresis is the lack of voluntary
control of urination at night or during the day by a child considered
to be beyond the age when control should have been acquired
(usually after age 6). This problem has a familial tendency and is
more common in boys than in girls. The urologist first determines
whether the problem is physical or psychological. With primary
enuresis, bladder control was never established in the child. It may
be caused by a physiologic problem with bladder control, such as an
immature bladder with small capacity, a neurologic deficit, diabetes
mellitus or insipidus, a UTI, or sleep apnea, or it may be a result of
stressful events. Secondary enuresis, in which loss of bladder control
occurs in a child who has been consistently dry for at least 6 months,
can develop because of stressful events, UTis, diabetes, or sexual
abuse.
A physical and neurologic examination and urinalysis with a
urine culture help determine whether any physical abnormality or
disease process is causing the problem. If a psychological problem is
suspected, help from a pediatric mental health professional may be
needed. If no known causative factors are present, medications that
relax the bladder muscles or that reduce urine production at night
may be useful. Unfortunately, these may have side effects, so parents
may refuse drug therapy. Parents should positively reinforce dryness
and should not punish or embarrass the child. A moisture alarm can
be used to help train the child to get up at night to go to the bath-
room. This is a small, battery-operated device that connects to a
moisture-sensitive pad placed in the pajamas or on the bed that beeps

when the pad becomes wet. The goal is to wake the child just as he
or she starts to urinate so that the child can stop urinating and get
to a toilet. The success rate is high (80%), but the device must be
used for at least 2 weeks before any change occurs and for up to 12
weeks to stop accidents.
Urinary Reflux Disorder
Urinary reflux disorder may be another reason for pediatric urology
referrals. Reflux nephropathy occurs if the kidneys are damaged by
a backward flow of urine. Each ureter has a one-way valve where it
enters the bladder that is designed to prevent urine from flowing
backward. Reflux may be caused by faulty formation of or damage
to the valves, or it may be associated with cystitis, neurogenic
bladder, or bladder overfilling because of an obstruction. It may be
detected with ultrasonography, a computed tomography (CT) scan
of the kidneys, or a voiding cystourethrogram (VCUG) (Figure
16-10). A VCUG is performed by placing a urinary catheter in the
bladder and injecting a contrast medium that helps visualization of
the bladder and the flow of urine. X-ray films are taken in several
positions, the catheter is removed, and the child is asked to void.
X-ray films are taken while the bladder empties to determine whether
urinary reflux is present. Although a VCUG can be an uncomfort-
able procedure, the benefit of early detection and reduced damage
to the kidneys makes the screening worthwhile. Untreated reflux
nephropathy can lead to renal failure.
The treatment for urinary reflux usually is determined by grading
its severity on a scale of 1 to 5, with 5 being the most severe. Pro-
phylactic antibiotics may be given daily in low doses to prevent
damaging kidney infections, which can cause low-grade reflux.
However, with higher grade reflux that persists after 4 or 5 years of
age, or for patients who have breakthrough infections despite the
antibiotics, surgical repair of the valves of the ureters is necessary.
Parents and providers also may opt for surgery because the procedure
has a 95% success rate and poses little risk.
FIGURE 16-10 Voiding cystourethrogram. (From James AE Jr, Squire LF: Nuclear radiology,
Philadelphia, 1973, Saunders.)
CHAPTER 16 Assisting in Urology and Male Reproduction 401
Cryptorchidism
Cryptorchidism, or undescended testicles, is fairly common in pre-
mature infants and occurs in about 4% of full-term infants (Figure
16-11 ). The testes develop in the abdominal cavity of the fetus and
descend into the scrotum near the end of the pregnancy. If an infant
is born with an undescended testicle, the testicle usually drops without
treatment by 9 months of age. However, persistent cryptorchidism
should be treated because infertility may result from exposure of the
sperm to the slightly warmer temperature in the abdominal cavity. In
addition, it increases the risk of testicular cancer in adolescence. The
current recommendation is that surgical attachment of the testicle
should be done by 1 year of age to reduce the chance of permanent
testicular damage. Parents need to recognize that this child is con-
sidered at increased risk for testicular carcinoma even after treatment
and should be taught testicular examination procedures.
The outpatient surgical procedure known as orchiopexy involves
suturing the undescended testicle in the scrotum. If the testicle is
impalpable (cannot be felt), laparoscopic surgery is necessary to
locate it. The laparoscope is inserted into the abdomen through a
small incision near the navel, and the testicle is moved into proper
position or is removed.
ANATOMY AND PHYSIOLOGY OF THE MALE
REPRODUCTIVE SYSTEM
The male reproductive system plays an important role in the con-
tinuation of the human species (Figure 16-12). Although not neces-
sary for individual survival, the production, sustenance, and transport
of male sex cells are vital to the creation of life.
The primary reproductive organs in the male are a pair of testes.
The testis is an oval structure about l ¾ to 2 inches (4 to 5 cm) long
and 1 to l½ inches (2.5 to 3 cm) in diameter. Each testis is sur-
rounded by a white, fibrous capsule, and the two testes are contained
together in the retractable, saclike scrotum. Lobules in the testes hold
0 Abdom;oal (15%)
High scrotal (60%)
FIGURE 16-11 Cryptorchidism.
402 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES
~ ¥ ~.,;.,z..---,---+ Ejaculatory duct
Prostate gland -71~;:t,~ ;:4) ?~ ~ /,..,~-'._.,L Cowper's gland
. .:=+-----r--Anus
Urethra
Penis
FIGURE 16-12 Male reproductive anatomy. (From Frazier MS, Drzymkowski JA: Essentials of
human diseases and conditions, ed 5, St Louis, 2013, Saunders.)
Head
Midpiece
0.1 mm
Tail
FIGURE 16-13 Sperm.
the seminiferous tubule, where spermatozoa, the male sex cells, are
produced. These cells have 23 chromosomes, or half of the deoxyri-
bonucleic acid (DNA) chain needed to form a complete cell. Sperm
cells are tadpole-like structures less than 0.1 mm long that are carried
ro the epididymis for maturation (Figure 16-13).
The epididymis is a coiled tube almost 20 feet (6 m) long that
rests on the top and lateral side of each testis. Peristaltic waves in the
epididymis help the sperm move into the vas deferens, where the
spermatozoa, which are now capable of movement, are stored until
ejaculation. Each vas deferens is a muscular tunnel about 18 inches
(45 cm) long that connects to the epididymis at the base of that
structure and passes along the side of the testes. The vas deferens
becomes the spermatic cord that passes through the pelvic cavity and
ends behind the urinary bladder. Uniting there with the seminal
vesicle just outside the prostate gland, it passes through the prostate
and into an ejaculatory duct that empties its contents into the
urethra. The male urethra is an organ of rwo body systems: the
urinary and reproductive systems.
The adult prostate gland is roughly 1½ inches (4 cm) wide and
1½ inches (3 cm) thick. It surrounds the urethra at the base of the
bladder. The prostate gland is about the size of a pea at birth, but it
grows rapidly at puberty to its full size (about the size of a walnut)
by age 20. The central part of the gland may start to grow again after
age 45. The primary function of the prostate gland is to secrete a
thin fluid with an alkaline pH that neutralizes vaginal secretions to
provide the optimum pH for fertilization. Secretions from the pros-
tate gland, vas deferens, seminal vesicles, and bulbourethral glands
combine with sperm cells to form semen. The volume of semen in
one ejaculate ranges from 2 to 6 mL and averages roughly 100
million to 200 million sperm cells.
The Penis
The organ of male copulation is the penis. It is a cylindrical organ
consisting of an elongated body with a slightly enlarged end, called
the glam penis. Around the glans penis is a fold of skin that begins
just behind the glans and extends forward to cover it like a sheath.
This is called the prepuce, or foreskin, which sometimes is removed
in a surgical procedure known as circumcision. The penis carries both
urine and semen through the urethra and outside the body. When
transmitting semen to the female tract, the penis must enlarge and
stiffen for insertion. This occurs when three columns of erectile tissue
in the penis become stimulated. The arteries in the penis dilate, and
the veins compress; this compression reduces blood flow away from
the penis, causing it to swell. Motor impulses are stimulated by
swelling of the urethra as a result of semen collection, and contrac-
tion of the urethra causes ejaculation of the semen through the penis.
Hormone Production
Hormone production is also an important aspect of the male repro-
ductive system. As a group, the male sex hormones are called andro-
gens. Testosterone is the primary male hormone. During pubescence,
when the male becomes reproductively functional, the anterior pitu-
itary gland produces gonadotropic hormones that stimulate the
testes to produce testosterone. Testosterone stimulates enlargement
of the testes, growth of body hair, thickening of the skin and bones,
increased muscle growth, and maturation of sperm cells.
DISORDERS OF THE MALE REPRODUCTIVE TRACT
Many diseases and disorders of the male reproductive tract are
known. The most common of these involve enlargement or inflam-
mation of certain organs and malignant tumors. The prostate is the
most widely affected organ.
Diseases of the Prostate
Prostatitis
The cause of inflammation of the prostate is not always known, but
it usually develops in the presence of infection. Bacterial causes may
 CHAPTER 16 Assisting in Urology and Male Reproduction
be E. coli or, in patients with gonorrhea, gonococci. Infection or
inflammation of the prostate gland puts pressure on the urethra,
causing dysuria, tenderness, and secretion of pus from the tip of the
penis. The condition usually is treated with an antibiotic such as
penicillin. Chronic prostatitis may develop as a result of repeated
UTis, urethral obstruction, or urinary retention.
Benign Prostatic Hyperplasia
As men age, the cells of the prostate gland that surround the urethra
can start to reproduce more rapidly, causing the organ to enlarge
(hyperplasia). This nonmalignant process, also known as benign pros-
tatic hyperplasia (BPH), is seen in about half of men over age 50 and
in more than 90% of men in their 70s and 80s. Enlargement of the
prostate gland partly blocks the flow of urine, creating a medium for
bacterial infection that can lead to cystitis. Signs and symptoms
include urinary urgency and frequency; difficulty starting urination;
hematuria; and repeated UTis. The diagnosis is made from the
patient's complaints and a digital rectal examination (DRE), during
which the provider can palpate the enlarged gland (Figure 16-14).
Treatment includes the use of alpha-adrenergic blockers, such as
doxazosin mesylate (Cardura), tamsulosin (Flomax), or alfuzosin
(Uroxatral), which relax the smooth muscles of the bladder, making
it easier to urinate. Finasteride (Proscar) or dutasteride (Avodart)
may also be prescribed to reduce the size of the prostate, increasing
urine flow and providing symptomatic relief. Nonsurgical therapies
include laser treatment or placement of a prostatic stent to keep the
urethra open. Because enlargement of the gland can be a sign of
BENIGN
PROSTATIC
HYPERTROPHY
Posterior
Cross section
Urethra
FIGURE 16-14 Digital rectal examination to diagnose benign prostotic hyperplasia and carcinoma of the prostate.
403
prostate cancer, it is important that the prostrate be biopsied to rule
out possible cancerous cells. If drug therapy and alternative treat-
ments are not successful in relieving the prostate enlargement,
surgery is recommended. Transurethral resection of the prostate
(TURP), the most common surgical treatment, involves threading
a small instrument (a resectoscope) through the urethra to the pros-
tate and scraping away the excess tissue. Laser procedures and micro-
wave therapy can also be performed in the provider's office to remove
or destroy obstructing prostate tissue. These outpatient procedures
typically have less bleeding and a quicker recovery than TURP but
may not be as effective over the long term.
Prostate Cancer
Cancer of the prostate is common in men over age 50 and ranks as
the second highest cause of cancer deaths in men, behind lung
cancer. The patient is asymptomatic in the early stages and may not
become symptomatic until the cancer has spread outside the pros-
tate gland. Once symptoms develop, they include urinary obstruc-
tion, with difficulty urinating, frequent UTis, and nocturia (the
need to void at night); hematuria; and generalized pain in the pelvic
region. Prostate cancer spreads locally to the bladder, rectum, and
lymph nodes of the pelvis, causing metastasis to the bones, lungs,
and brain. The prognosis is poor unless the tumor is discovered in
the early stages of development, when it is still confined to the
prostate gland.
The first indication of a problem may come with a routine DRE,
when the provider notices a firm or irregular area in the prostate.
CARCINOMA
OF PROSTATE
Posterior
Cross section
Rectum
404 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES
The primary screening tool for cancer of the prostate is the prostate-
specific antigen (PSA) blood test. Blood levels of PSA, a protein
produced by the prostate, are elevated with prostatitis, BPH, and
cancer of the prostate. The higher the PSA level, the more likely it
is that the patient has prostate cancer. However, because the PSA
level can be elevated with other disorders, one abnormal screening
value is not enough to diagnose cancer. The test should be repeated
over time, and if levels continue to rise, further diagnostic studies
should be done. If tests indicate cancer, the provider may order a
transrectal ultrasound, which involves inserting a small transducer
into the rectum to bounce sound waves off the prostate, creating a
picture. The ultrasound pictures are used to help pinpoint areas of
concern during a tissue biopsy. If the transrectal ultrasound does not
indicate any suspicious areas, the provider takes multiple biopsies
(usually eight) from different sections of the prostate gland. Tissue
samples are sent to the pathologist for analysis and diagnosis.
A diagnosis of cancer of the prostate results in a complex decision
about treatment because there is no way of knowing how dangerous
the cancer is. Some types of prostate cancer grow slowly and never
metastasize, whereas others are quite aggressive. The patient's deci-
sion to pursue treatment is complicated by the concern over possible
side effects, including impotence and incontinence. Because of these
difficult issues, the American Cancer Society (ACS) recommends
that providers educate patients about prostate cancer screening so
they can make informed decisions about testing. The ACS recom-
mends that men with no symptoms of prostate cancer receive educa-
tion and make informed decisions about screening starting at age
50. Because research indicates that the risks of screening outweigh
the benefits in men without symptoms who are not expected to live
longer than 10 years (because of age or poor health), these patients
should not be offered prostate cancer screening. The ACS continues
to recommend that men at high risk-African-American men and
men who have a father, brother, or son who was diagnosed with
prostate cancer before age 65-begin conversations with their pro-
viders earlier, at age 45. Men at higher risk-those with multiple
family members affected by the disease before age 65-should start
even earlier, at age 40.
The treatment for prostate cancer depends on its stage of spread.
Radiation may be delivered directly to the cancer cells through
external beam radiation therapy (EBRT), which uses high-powered
x-rays to kill the cancer cells. An alternative procedure is implanta-
tion of radioactive seeds, a variant of radiation therapy. In this
procedure, 40 to 100 rice-sized radioactive seeds are implanted
directly into the prostate gland through a precisely placed hollow
needle. The radiation is quite strong but has a very short range; this
allows it to destroy the tumor but minimizes damage to surrounding
tissue. Testosterone can stimulate growth of the tumor, so hormone
therapy frequently is prescribed to block the action of testosterone
or to stop its production.
Surgical treatment options include removal of the prostate gland
by transurethral resection; orchiectomy, in which the testosterone-
producing testicles are removed; and radical prostatectomy, in which
the prostate and local lymph nodes are removed. These are debilitat-
ing surgical procedures that have serious side effects, including
urinary incontinence and erectile dysfunction; therefore, they typi-
cally are used as a last measure. As with all cancers, chemotherapy
may be prescribed for advanced cases or for recurrence.
CRITICAL THINKING APPLICATION 16-5
Dr. Fineman frequently sees patients for prostate-related conditions. Sara
decides to review the information on disorders that affect the prostate gland
so that she is better able to assist Dr. Fineman and answer patients' ques-
tions. What are the important details of prostate disease that Sara should
remember?
Pathologic Conditions of the Genital Organs
Epididymitis
Epididymitis is an inflammation of the tubular epididymis. It most
often is attributed to a UTI in men over age 40; in younger men,
the most common cause is a sexually transmitted infection (STI).
Patients experience severe low abdominal and testicular pain, in
addition to swelling and tenderness of the scrotum. If abscesses form
and produce scar tissue, sterility can occur. Antibiotics, including
cefuroxime (Ceftin), ciprofloxacin (Cipro), doxycycline (Vibramy-
cin), and azithromycin (Zithromax), are prescribed for treatment.
Balanitis
Inflammation of the glans penis and the mucous membrane beneath
it is known as balanitis. It occurs most often in uncircumcised
patients with narrow foreskins that do not retract easily and in men
with diabetes. It has many causes, including an allergic reaction to
certain chemicals (e.g., contraceptive foam), poor personal hygiene
that results in a buildup of skin secretions (smegma) around the glans
penis, and urinary tract and yeast infections. Treatment depends on
the cause of the problem: antibiotics are used for infections, and
cleansing is used for smegma buildup; avoiding chemicals that cause
reactions can help prevent the problem.
Hydrocele
During the descent of the testes, a small canal develops for them to
pass through. If the canal does not close after birth, fluid from the
peritoneal cavity may pass through and collect in the scrotum. This
is called a congenital hydrocele, which must be corrected surgically
(Figure 16-15). Acquired hydroceles usually occur after middle age
because of a scrotal injury or tumor and can form in men who sit
for extended periods (e.g., aging men in long-term care facilities),
causing painful scrotal swelling.
Testicular Cancer
Testicular carcinoma is the most common cancer in Caucasian men
15 to 33 years of age. The cause is unknown, but the primary
-'-~If-- Serous fluid
~ ~~~~ <'..._-Tunica vaginalis
FIGURE 16-15 Hydrocele.
 CHAPTER 16 Assisting in Urology and Male Reproduction
predisposing factor is cryptorchidism. The patient complains of a
mass in either testicle; a heavy sensation in the scrotum accompa-
nied by a sudden collection of fluid; pain in a testicle or in the
scrotum, abdomen, or groin; and unexplained fatigue. Testicular
cancer can be treated successfully if diagnosed early; the survival
rate for stage I testicular cancer is approximately 95%. Unfortu-
nately, because young men may hesitate to go to the provider to
report a mass in the testicle, the cancer may have reached an
advanced stage before it is diagnosed. In advanced stages, treatment
usually involves a combination of orchiectomy, radiation therapy,
and chemotherapy.
The American Cancer Society recommends a testicular exam by
a physician as part of a routine cancer-related checkup; however,
TESTICULAR SELF-EXAM
(TSE)
A simple 3-minute self-examination, once a
month, can detect one of the cancers most
common among men aged 15-34. If detected
early, testicular cancer is one of the most easily
cured. The best time to check yourself is in the
shower or after a wanm bath. Fingers glide over
soapy skin making it easier to concentrate on
the texture underneath. The heat causes the
skin to relax, making the exam easier.
1 symptomless. When symptoms do occur they include:
Start by examining your
testicles. Slowly roll the
testicle between the
thumb and fingers,
applying slight pressure.
Try to find hard, painless
lumps.
2 diagnosis.
Now examine your
epididymis. This
comma-shaped cord is
behind each testicle. It
may be tender to the
touch. It's also the
location of the most
noncancerous problems.
Turn over for further instructions
FIGURE 16-16 Testicular self-examination shower card.
405
routine self-exams have not been found to lower the risk of dying
from this cancer. Nevertheless, the practitioner may still recommend
routine self-screening, beginning in puberty or by age 15 (Procedure
16-1). The practitioner may provide pamphlets or a shower card
showing the steps of testicular self-examination (Figure 16-16). The
medical assistant can approach this teaching intervention in two
ways. One way is to take the information to the patient and tell him
to follow the pictures, and if he has any questions, he should call for
clarification. Will he call? Would you? The second way is to go over
the instructions with the patient. Demonstrate the procedure on a
model, if one is available, or a male medical assistant could observe
the patient doing the examination for the first time and provide
feedback to answer any questions.
3
Continue by examining
the vas (the
sperm-carrying tube that
runs up from your
epididymis). The vas
normally feels like a firm,
movable smooth tube.
Now repeat the exam on the other side.
What are the symptoms?
In the early stages testicular cancer may be
• Lump on the testicle
• Slight enlargement of one of the testicles
• Heavy sensation in the testicles or groin
• Dull ache in lower abdomen or groin
If you find any hard lumps or nodules, see your
doctor promptly. Only your doctor can make a
Penis
Epididymis--+--+<....,_
Testicle - ---H.--
Scrotum-----">;;.::,,,,'
"This self exam is not a substitute for periodic
examinations by a qualified physician.•
406 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES

•;;Miimhiitii Coach Patients in Health Maintenance: Teach Testicular Self-Examination

Goal: To instruct the patient in the steps of testicular self-examination.

EQUIPMENT and SUPPLIES

• Patient's health record
• Testicular self-examination pamphlet and shower card
• Demonstration model
PROCEDURAL STEPS
1. Sanitize your hands and collect the required supplies.
PURPOSE: To ensure infection control.
2. Verify the patient's identity by name and date of birth and explain what
you are going to do. 2
PURPOSE: Understanding helps promote patient cooperation.
3. Begin by explaining to the patient that testicular cancer may cause no 6. Examination of the vas deferens: Continue by examining the sperm-
symptoms in the early stages, so it is important to examine the testes carrying tube that runs up the epididymis. Normally the vas feels like a
once a month for abnormal changes and early detection of the disease. firm, movable, smooth tube (Figure 3).
This should begin at puberty, or approximately 15 years of age. It is best
to do the examination in the shower or in a warm bath. The total examina-
tion takes about 3 minutes.
PURPOSE: Heat causes the scrotal skin to relax, making the examination
easier.
4. Examination of the testis: Using the demonstration model, start by holding
the scrotum in the palms of the hands. Then feel one testicle. Apply asmall
amount of pressure. Slowly roll it between the thumb and fingers and feel
for any hard, painless lumps (Figure l).

7. Now repeat the entire examination on the other testis.

8. After completing the examination on the model, ask the patient to do a
return examination using the model. Amale assistant can have the patient
do a self-testicular examination.
9. Give the pamphlet to the patient, along with the shower card, with instruc-
tions to hang it in the shower as a monthly reminder and guide.
10. Document the instructional interaction in the patient's health record.
PURPOSE: If it is not documented, it was not done.

S. Examination of the epididymis: This comma-shaped cord is found on top 8/19/20- 11: 12 AM: Pt shown and successfully demonstrated testicular self-
of and behind the testis. Its job is to store and transport sperm. Tender exam on model; no questions. Pt given pamphlet and shower card for home
when touched, it is the location of most noncancerous problems. Check use. Dorothy Gaston, (MA (AAMA)
for hard spots and lumps (Figure 2).

Erectile Dysfunction
The inability to achieve and maintain an erection sufficient for sexual
intercourse is a condition known as erectile dysfunction (ED). It has
many causes, both psychological and physiologic. Stress, anxiety,
fear of unsatisfactory performance, and physical diseases that affect
the vascular system, including arteriosclerosis, alcoholism, and
diabetes mellitus, all can lead to ED. Changes in erectile function
are normal as men age. Also, impotency is a side effect of certain
medications, such as some hypertensive drugs. ED can be treated
pharmaceutically with sildenafil (Viagra), tadalafil (Cialis), or var-
denafil (Levitra). However, these medications are contraindicated in
patients with a history of uncontrolled hypertension, myocardial
infarction (heart attack), a cerebrovascular accident (stroke), or a
life-threatening arrhythmia. In addition, they cannot be taken if the
 CHAPTER 16 Assisting in Urology and Male Reproduction 407

patient is prescribed nitrate drugs, such as nitroglycerin, because the
combination of these medications can cause heart complications. If
the patient is taking an alpha blocker (e.g., Flomax, Cardura) for
treatment of an enlarged prostate, ED drugs must be used with
caution because the combination of these medications can cause
dangerous hypotension.
cure is available for viral STis, such as human immunodeficiency
virus (HIV) infection, herpes, and venereal warts. Bacterial infec-
tions are increasingly becoming resistant to antibiotic therapy. STis
frequently are asymptomatic in men, although they can cause serious
health problems and are infectious regardless of whether symptoms
are present.

Infertility Bacterial Sexually Transmitted Infections

Fertility peaks in men at age 25. Infertility can be caused by a
problem in the man, a problem in the woman, or a combination of
the two. About 10% to 20% of male infertility cases have no known
cause. For the remaining cases, many causative factors may be
involved. Cryptorchidism, stricture, and varicoceles (dilated sper-
matic cord veins); a low sperm count and poor motility; obstruction
of the vas deferens; and hormonal imbalances all are factors in
infertility.
Examination of semen specimens is helpful in making a diagnosis
of infertility. These tests determine the presence of sperm, the
number of sperm in an ejaculation, and the health and motility of
the sperm. Ultrasonography also is helpful for detecting blockage of
the vas deferens.
Sexually Transmitted Infections
Diseases of the male reproductive system can be acquired during
sexual intercourse (Table 16-3). No one is immune to these diseases,
and an individual can be infected with more than one at a time. No
STis caused by bacterial infections include chlamydia, gonorrhea,
and syphilis. Gonococci and chlamydiae tend to coexist, so a patient
who has tested positive for one of the organisms typically is treated
for both. Symptoms are similar to those for urethritis and epididy-
mitis, such as painful and frequent urination, discharge from the
penis, and lower abdominal pain. Chlamydia is resistant to penicil-
lin; therefore, a regimen of antibiotics other than penicillin (e.g.,
Zithromax, doxycycline, erythromycin) is prescribed if the patient
has both conditions. Sexual partners must also be treated, or the
infection will continue to be transmitted back and forth.
A syphilitic lesion, called a chancre, develops on the male genita-
lia, usually the penis, a few days to a few weeks after exposure
(Figure 16-17). Syphilis initially is diagnosed through the Venereal
Disease Research Laboratory (VDRL) or the rapid plasma reagin
(RPR) antibody blood test. If the results of these are positive,
the diagnosis is confirmed with a fluorescent Treponema absorp-
tion (FTA) test, which is specific for antibodies to the Treponema
microorganism.

TABLE 16-3 Sexually Transmitted Infections in Men

DISEASE CAUSATIVE ORGANISM SIGNS AND SYMPTOMS TREATMENT
Chlamydia Chlamydia trachomatis May be asymptomatic; dysuria; itching and white Curable with antibiotic therapy: single dose of
(bacterium) discharge from penis; testicular pain. Zithromax or 1 week of doxycycline
(Vibramycin).
Genital herpes Herpes simplex virus type 2 Painful genital vesicles and ulcers; erythema and pruritus; No cure, but antiviral therapy during episodes
simplex virus (HSV-2) tingling or shooting pain 1-2 days before episodes. Viral shortens duration of lesions: acyclovir
shedding may occur during asymptomatic periods. (Zavirax), famciclavir (Famvir), or valacyclavir
(Valtrex).
Genital warts Human papillamavirus (HPV) Most prevalent sexually transmitted disease; period of Goal of treatment is ta remove symptomatic
communicability is unknown; pinhead lesions may or may warts; cryatherapy for lesions; padafilax
not be visible; warts tend to recur. (Condylox) solution or imiquimod (Aldora)
cream for lesions.
Gonorrhea Neisseria gonorrhoeae Dysuria and urinary frequency; thick, cloudy, or bloody Curable with antibiotic therapy: azithromycin,
(bacterium) discharge from penis. doxycycline.
Syphilis Treponema pallidum (spirochete Six stages that can affect multiple body systems; 10- to Penicillin G(Wycillin); if patient is allergic to
bacteria) 90-day incubation; initial sign is a painless lesion, or penicillin, doxycycline or tetracycline.
chancre, at the exposure site (penis); serous discharge
from chancre; lymphadenapathy; if left untreated,
advances to later stages.
Trichomaniasis Trichomonas vagina/is Asymptomatic in mast men; may feel itching or irritation Single oral dose of metronidazole (Flagyl).
(protozoan) inside penis, burning after urination or ejaculation, or
some discharge from penis.
408 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES
FIGURE 16-17 Syphilitic chancre.
Syphilis can be treated successfully with penicillin but may go
unnoticed or unreported. Without treatment, it advances to a sec-
ondary phase, which is marked by low-grade fever, headache, and
sore throat, in addition to a rash that does not itch but can affect
any part of the body. In the secondary phase, the disease is highly
contagious but still can be treated with penicillin. The more advanced
stages of the disease can remain undetected or dormant for years.
Symptoms that appear years after the primary infection show mul-
tisystem involvement, including neurologic and cardiovascular com-
plications. Syphilis is not curable in advanced stages.
Viral Sexually Transmitted Infections
Viral STis include hepatitis B, C, and D; genital herpes; genital warts
(caused by the human papillomavirus [HPV]); and HIV infection.
With genital herpes, the herpes simplex virus (HSV) enters the body
through small breaks in the skin or mucous membranes. Most indi-
viduals with HSV infections are asymptomatic, or signs and symp-
toms are so mild that they go unnoticed. Ifsymptoms are experienced,
the first episode typically is the worst, with the formation of a blis-
tered, inflamed, painful rash on the penis, scrotum, or urethra. After
several days, the vesicles rupture, resulting in painful, ulcerated areas.
The lesions heal in 3 to 4 weeks, but the herpes virus then migrates
to a nerve dermatome. Many factors can reactivate the disease at any
time (e.g., stress, upper respiratory infection), making the individual
infectious again. However, HSV can be spread even when sores are
not present.
Genital warts often are asymptomatic in men and require pre-
liminary treatment with acetic acid to be seen. The incubation period
for HPV infection may be as long as 6 months. In women, these
infections greatly increase the risk of cervical cancer. The Centers for
Disease Control and Prevention (CDC) recommends that routine
HPV vaccination be initiated at age 11 or 12 years for both male
and female children.
Human Immunodeficiency Virus
HIV infection is the most deadly STI. If not treated, HIV infection
can develop into AIDS. The virus invades the CD4 T lymphocytes,
destroying their ability to fight infection on the cellular level.
Within 2 to 4 weeks after HIV infection, many individuals (but not
all) experience flulike symptoms, including fever, arthralgia (joint
pain), myalgia (muscle pain), lymphadenopathy (enlarged lymph
nodes), rash, night sweats, and malaise. In 2013 a new blood test
was approved that can detect the virus during this early stage of
infection. However, with or without symptoms, an individual
newly infected with HIV has a high risk of transmitting the disease
to sexual or needle-sharing partners because viral levels are very
high at this time.
The U.S. Food and Drug Administration (FDA) now recom-
mends pre-exposure prophylaxis (PrEP) with Truvada for individu-
als who are HIV negative and in an ongoing sexual relationship
with an HIV-positive partner. Truvada (emtricitabine and tenofo-
vir) is a combination of two HIV medications that block important
pathways the virus uses to start an infection. If taken as prescribed,
the drug lowers the risk of contracting an HIV infection by up to
92%.
Postexposure prophylaxis (PEP) should start as soon as possible
after occupational exposure to HIV (at least within 72 hours of
exposure) and continue for 4 weeks. PEP medication regimens
should include three (or more) antiretroviral drugs to reduce the
chance of the person becoming HIV positive. Any healthcare worker
who has an accidental exposure (e.g., a needlestick) from an indi-
vidual who may be HIV positive should receive PEP.
HIV is transmitted when infected blood or blood products,
semen, or vaginal secretions come in contact with the mucous mem-
branes or the broken skin of an uninfected person. It also can be
passed in utero from an infected mother to her fetus, during delivery,
or by breast-feeding. Intravenous drug users who share needles and
anyone who has unprotected sex of any kind are at increased risk for
contracting HIV Healthcare workers are also at risk for accidental
exposure in the workplace and should consistently follow Standard
Precautions to protect themselves and their patients from this deadly
disease. HIV is a fragile virus; it cannot survive outside the body,
and it is easily destroyed by chemical disinfectants, such as household
bleach.
All HIV tests screen for antibodies to the virus. The most widely
used screening test for HIV infection is the enzyme immunoassay
(EIA; also called the enzyme-linked immunosorbent assay [ELISA]),
which typically is performed on a venous blood sample. EIA also
can be done on other body fluids, including oral fluid and urine,
although urine screening is not as accurate or as sensitive to antibody
levels. The provider may also order a viral load test, which reflects
the amount of HIV in the blood. Generally, the higher the viral load,
the more aggressive the HIV infection.
Newer developments in rapid HIV screening use either blood or
oral fluid (not the same as saliva; the gums are swabbed) and can
produce results within 20 to 60 minutes with accuracy rates similar
to those of traditional EIA screening. The FDA has approved the
OraQuickAdvance HIVl/2 Antibody Test for use on both oral fluid
and plasma specimens. For the oral test, a single gentle swab is taken
around both the upper and lower outer gums. The swabbing device
is inserted into a vial containing a developer solution, and the result
is positive if two reddish purple lines appear in a small window after
20 minutes. This test is not designed for home screening because it
is restricted to use by trained individuals, such as medical assistants.
However, an FDA-approved home test, the Home Access HIV-1 Test
System, is available at most drugstores or online. The kit provides
the materials for collection of a specimen at home rather than in a
healthcare facility. To perform the test, the individual pricks a finger,
places a blood drop on a specially treated card, and then mails the
card to a licensed laboratory for testing. The individual uses an
identification number provided with the kit to call the laboratory

for results. According to the CDC, it can take up to 6 months to
develop antibodies to HIV, although most people (97%) develop
detectable antibodies within the first 3 months after infection.
The goal of treatment of HIV infection is to reduce the amount
of virus in the body with antiretroviral drugs, thereby slowing the
destruction of the immune system and the onset of AIDS. Currently,
31 antiretroviral drugs (ARVs) have been approved by the FDA to
treat HIV infection. These treatments do not cure HIV or AIDS,
but they suppress the virus so that people infected with HIV can
lead longer and healthier lives. It is important to note, though, that
even when treated with ARVs, a person who is HIV positive remains
infectious and can transmit the virus for the remainder of his or her
life. To prevent the development of resistant HIV strains, a combina-
tion of antiretroviral drugs from at least two different classes are
prescribed in an approach called highly active antiretroviral therapy
(HAART). Recent research indicates that individuals who are HIV
positive and taking antiretroviral medications are less contagious
than those who are not being treated.
Once patients begin antiretroviral treatment, they should con-
tinue to take these drugs for the rest of their lives. The medications
must be taken at the time and frequency prescribed to be effective
in controlling the spread of the virus and to prevent drug-resistant
strains from developing. Unfortunately, HIV medications can cause
multiple side effects, including fever, nausea, fatigue, liver abnor-
malities, diabetes mellitus, hypercholesterolemia, decreased bone
density, skin rash, pancreatitis, and neurologic disorders. Patients
Trends in Reportable Sexually Transmitted Infections
• The Centers for Disease Control and Prevention (CDC) estimates that
nearly 20 million new STls occur every year, costing the healthcare
system an estimated $16 billion annually.
• Many cases of chlamydia, gonorrhea, and syphilis are undiagnosed and
unreported, and data on several STls, including human papillomavirus,
herpes simplex virus, and trichomoniasis, are not routinely reported.
• An estimated 24,000 women become infertile each year because of
undiagnosed STls.
• Chlamydia is the most frequently reported infectious disease in the
United States, with mare than 1.4 million cases reported in 2014; it
is estimated that twice that number are infected but are not diagnosed
or treated; improved testing and treatment among men could help
reduce transmission to women. The infection can be diagnosed with
a urine test, and complications among men are rare.
• Gonorrhea is the second most commonly reported infectious disease
in the United States; more than 350,000 cases were reported in
2014. The CDC estimates that twice as many new infections occur each
year. The number of reported cases is 19 times higher in African-
Americans than in Caucasians. Antibiotic resistance (especially to such
drugs as ciprofloxacin [Cipro] and Levaquin) is a serious concern; if the
disease goes untreated, epididymitis and possibly infertility can result.
Studies indicate that the presence of gonorrhea increases the likelihood
of HIV transmission.
CHAPTER 16 Assisting in Urology and Male Reproduction 409
must be educated on the importance of strictly following their pre-
scribed treatment regimen and of immediately reporting any side
effects to the provider.
AIDS is diagnosed when evidence appears of a wide range of
opportunistic infections that develop because of depressed T-cell
counts. These include Pneumocystis jiroveci (PJP), candidiasis
(yeast infection), Kaposi's sarcoma, dementia, and wasting syn-
drome. A patient is considered to be HIV positive when antibodies
to the virus are detected; however, the diagnosis of AIDS is not
made until the CD4 T-cell count drops below 200 mm3 (the normal
count is 500 to 1,000 mm3) and/or opportunistic infections have
been diagnosed. Current HIV management includes monitoring
of CD4 T-cell counts at diagnosis and every 3 to 6 months
thereafter.
The psychosocial needs of a patient diagnosed with HIV infection
are far-reaching. Treatment is designed to control duplication of the
virus in the body, but the patient will always be infectious. Transmis-
sion of the disease is prevented by sexual abstinence or consistent
use of condoms and precautions with blood spills; these options
must be discussed and consistently reinforced with the patient.
Community organizations can serve as a source of counseling and
support for patients who test HIV positive and for their families. As
mandated by federal law, the medical assistant must remember that
all information about a patient's HIV status must be kept in strict
confidence, and no documentation in the health record can indicate
the patient's HIV or AIDS status.
• Syphilis is highly infectious in the early stages but is easily curable; left
untreated, it can lead to serious long-term complications, including nerve,
cardiovascular, and organ damage and even death. Seventy-five percent
of syphilis cases occur in men who have sex with men. Syphilis infection
can also place a person at increased risk for acquiring or transmitting HIV
infection.
• Males typically are asymptomatic or have minimal signs or symptoms of
herpes infection. With symptoms, the initial outbreak consists of one or
more blisters on or around the genitals that break, leaving tender ulcers
that last 2 to 4 weeks. The outbreaks may lessen in severity aver time.
The virus is present in the body indefinitely, but the frequency of outbreaks
declines over time. The virus can be transmitted by an infected partner
who does not have a visible sore and who may not know that he or she
is infected.
• Herpes simplex virus type 1 (HSV-1) can cause genital herpes, but it
more commonly causes oral herpes or cold sores. HSV-1 infection of the
genitals can be caused by oral-to-genital contact with a person who has
an HSV-1 infection. Condoms do not completely prevent the transmission
of genital herpes.
• Mast human papillomavirus (HPV) infections are asymptomatic in males;
the man may be unaware of the infection but can transmit it ta a sex
partner. Genital warts may disappear without treatment. Because no
diagnostic test for HPV is available for men, the diagnosis is based on
Continued
410 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES
Trends in Reportable Sexually Transmitted Infections-continued
evidence of wart development. Condoms do not completely prevent
transmission of HPV. New research indicates that the rising rate of oral
and throat cancers can be linked to the oral transmission of one of the
cancer-causing types of HPV.
• HIV cannot reproduce outside a living host, and no record exists of infec-
tion from environmental contact. Also, no evidence indicates that the virus
can be transmitted by insects. Latex or polyurethane condoms used
consistently and correctly provide a highly effective mechanical barrier to
From STD Trends in the US. www.cdc.gov. Accessed February 9, 2016.
CRITICAL THINKING APPLICATION 16-6
The number of patients seen weekly in Dr. Fineman's practice who have
STls continues to rise. Sara is responsible for telephone screening and for
clinical medical assisting practices. She is constantly being asked questions
about the signs and symptoms of STls and their treatment. What should
Sara know about bacterial and viral STls and their treatment?
THE MEDICAL ASSISTANT'S ROLE IN UROLOGIC AND
MALE REPRODUCTIVE EXAMINATIONS
Much of the diagnosis of urinary dysfunction depends on the
patient's history, which may include frequency or urgency of urina-
tion, dysuria, or incontinence. A major part of the urologic examina-
tion is urinalysis, and the medical assistant must be able to instruct
the patient in how to obtain a dean-catch urine specimen. It is best
to have the patient collect the specimen during an office visit so that
it can be examined immediately. The urologist may need to examine
a catheterized specimen, which is collected using sterile technique.
This procedure requires advanced training.
Assisting with a Urologic Examination
No special instrument setup is required for a routine urologic exami-
nation unless a special procedure is ordered, such as obtaining a
catheterized urine specimen or a specimen for culture. Most offices
use prepackaged, disposable packs for catheterization and bladder
irrigation.
Both male and female patients disrobe and are given a gown. A
woman is placed in the dorsal recumbent position, and a man is
seated on the examining table. The provider explains what is required
to the patient. The primary responsibility during the examination
process is to assist the provider with any supplies and equipment
needed and to maintain proper draping of the patient.
Assisting with a Male Reproductive Examination
The medical assistant needs to understand the male reproductive
system and to provide patient support throughout the examination.
The patient should empty his bladder and disrobe before the pro-
vider begins the examination. A drape sheet is placed around the
patient's waist, covering the lower extremities. A female medical
assistant is present only if requested by the provider. The provider
inspects the foreskin (if the patient has not been circumcised) and
HIV. Although the number of new HIV infections per year, about 50,000
cases, has stabilized over recent years, the number of cases in men who
have sex with men (MSM) continues to increase. The MSM population
represents about 4%of the males in the United States, but this group
accounts for 78% of new HIV infections and 63% of all HIV cases. The
estimated number of new HIV infections is greatest among MSM in the
youngest age group (13 to 24). The greatest number of new HIV infec-
tions is seen in young African-American MSM.
the glans penis. The penis and scrotum are palpated for possible
masses and tenderness. The patient also is examined for possible
inguinal hernias. A DRE completes the physical assessment.
A male medical assistant may assist the provider with the exami-
nation and help with patient draping and positioning. The medical
assistant should watch the patient for signs of discomfort or anxiety,
answer the patient's questions, and reinforce the provider's orders as
needed.
Vasectomy
A vasectomy is a surgical procedure for sterilizing a male patient
(Figure 16-18). It is performed by surgically removing a section of
each vas deferens to stop sperm from reaching the prostate and mixing
with semen. Sexual function is not affected by the procedure.
The procedure can be performed in a provider's office using a
local anesthetic agent, such as lidocaine (Xylocaine). In the standard
procedure, which takes approximately 30 minutes, the provider
makes a small incision on both sides of the scrotum with a scalpel,
clips both vasa deferens, and closes the site by cauterization or with
sutures.
The no-scalpel vasectomy is another technique that takes approxi-
mately 10 minutes. The provider palpates and clamps the vas defer-
ens under the scrotal sac, makes a tiny puncture through the skin,
pulls the vas deferens out and cuts it, replaces the tube, and seals the
site. The procedure is repeated on the other side. Patients must be
-&==:::- +--Cut and
blocked
vas deferens
11 - - - - - - + - - - Scrotal
sac
FIGURE 16-18 Vasectomy.

informed that sterility is not achieved immediately because sperm
may be present in the ducts; it may take as long as 1 month for the
semen to be sperm free. Patients should use a backup method of
birth control until two sperm counts 4 to 6 weeks apart show no
evidence of sperm.
CRITICAL THINKING APPLICATION 16-7
Sara routinely assists Dr. Fineman with urologic and male reproductive
examinations. She is also responsible for orienting new employees and
helping them learn the procedures that typically are perrormed in the office.
Summarize the role of a medical assistant in helping with these
examinations.
CLOSING COMMENTS
Patient Education
Most men younger than 50 years of age have not seen a provider in
years. Medical studies reveal that attitude, not biology, has a lot to
do with the difference between men's and women's life spans. Men
just do not go to the doctor as often as women and tend to ignore
symptoms of disease. The solution to maintaining good health is
preventive care, and the first step is establishing a good rapport with
a provider of choice. As a general rule, a man in good health should
have three checkups in his twenties, three to four checkups in his
thirties, and a checkup every other year in his forties. After the age
of 50, a yearly checkup is recommended. In addition to testing for
conditions such as cancer, heart disease, and diabetes, patient educa-
tion can help male patients make responsible healthcare decisions.
The urinary system is a very private, personal part of the patient's
body. Patients often feel embarrassed to ask questions about how to
obtain the requested urine or semen sample. The medical assistant
can provide this information in a sincere, confidential manner to
relieve the patient's anxiety and worry. Diagrams, models, and hand-
outs help the patient understand disease processes and treatments
and also encourage patient compliance.
Legal and Ethical Issues
When working in a urology office, the medical assistant must be very
careful to ensure that patients have provided informed consent for
ordered procedures. If the patient refuses a procedure, the assistant
must have the patient sign the appropriate informed refusal forms,
which are then included in the medical record. All patient education
should be done after the provider has completed the explanation and
has given the assistant instructions to do so. Never diagnose, pre-
scribe, or offer comment about a patient's condition. Medical assis-
tants who overstep their professional boundaries may place the
provider and themselves in legal jeopardy. Remember that the
patient who is legally informed and satisfied with the care received
is less likely to take legal action.
Each state has developed special legal guidelines regarding
patients diagnosed with HIV that must be strictly followed to
prevent litigation. The medical assistant caring for patients with HIV
naturally is concerned about possible exposure. Discuss your con-
cerns with your employer and remember that Standard Precautions
have been developed to prevent the accidental spread of
CHAPTER 16 Assisting in Urology and Male Reproduction 411
communicable diseases. If you strictly follow the standards estab-
lished by the CDC, you need not fear contamination.
Local, state, and national public health agencies require that
certain diseases be reported when they are diagnosed by providers or
laboratories. All states have a "reportable diseases" list. Many diseases
on the lists must also be reported to the CDC, including chlamydia;
gonorrhea; the hepatitides A, Band C; syphilis, and HIV/AIDS cases.
HIPM Applications
Staying up-to-date on confidentiality restrictions covering a patient's
HIV status is a major challenge. The Health Insurance Portability
and Accountability Act (HIPM) provides minimum requirements
for protecting personal health information, but state laws can over-
ride HIPM regulations if the state law is considered more stringent.
In addition, individual healthcare institutions (hospitals, universities,
providers' practices) may have their own policies and procedures
for managing confidential information about HIV and AIDS. For
example, if a provider believes that a person who tests positive for
HIV will not disclose his or her HIV status to significant others,
most states permit the provider to act. First, the provider must
attempt to notify the patient that the information is going to be
disclosed. Then the provider can inform the patient's spouse, sexual
partner or partners, child, or needle-sharing partner or partners at
risk of being infected with HIV about their risk of exposure. However,
the state may limit this disclosure by not permitting the provider to
identify the name of the individual who is HIV positive.
• Confidential HIV information includes any records that could
reasonably identify the individual as a person who has had an
HIV test, is HIV positive, has opportunistic diseases related to
HIV, or has AIDS.
• The medical practice must report the names of persons who have
a positive HIV test to public health authorities for infectious
disease surveillance. Some states require that the names of HIV-
positive sexual partners also be reported.
• The patient's medical information can be shared with the patient's
other medical providers to coordinate care and to manage HIV/
AIDS as a chronic condition.
• Depending on state law, written consent may not be needed to
release HIV information if a court order for the information is
issued or if the information will be provided to certain employees
of correctional institutions or residential treatment facilities,
funeral directors, or emergency personnel.
Professional Behaviors
Aurology practice manages many sensitive patient issues that require strict
adherence to confidentiality guidelines. This is especially true for a patient
who has a functional disorder with the reproductive system or who has
been diagnosed with an STI. HIPAA protects the patient's confidential
information, not just the paper or electronic records af that information.
This means that verbal disclosure af an individual's HIV and AIDS status is
limited ta only the personnel who have the right ta that information accord-
ing to individual state laws. For example, if you learn about your neighbor's
HIV status at work and you go home and discuss it with your family, your
employer is responsible for your disclosure of this information, and both
you and your employer may be fined by the state or sued by the patient.
 412 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES
i-iiiiit-iff•jii9#1MU1•i
Sara enjoys working with Dr. Fineman and the patients seen in his urology
practice. She recognizes the need ta stay current with information about disor-
ders af the urologic system and their treatment. Sara continues to learn an the
jab and through workshops about the urinary system and current therapies. Her
expertise is constantly growing, and she uses this knowledge to help with
SUMMARY OF LEARNING OBJECTIVES
l. Define, spell, and pronounce the terms listed in the vocabulary.
Spelling and pronouncing medical terms correctly reinforce the medical
assistant's credibility. Knowing the definitions of these terms promotes
confidence in communication with patients and co-workers.
2. Describe the anatomy and physiology of the urinary system.
The urinary system is made up of two kidneys, the ureters, the urinary
bladder, and the urethra. The functions of the urinary system include
removing waste products; regulating water, electrolyte, and acid-base
levels; activating vitamin D; and secreting erythropoietin and renin. The
three processes involved in urine formation are filtration, reabsorption,
and excretion. The cortex contains the nephron unit, where urine is
farmed; the medulla is the collection site far urine.
3. Do the following related to disorders of the urinary system:
• Explain the susceptibility of the urinary system to diseases and
disorders.
The urinary tract is made up of a continuous mucosal lining, which gives
organisms that enter the urethra a direct pathway through the system.
• Identify the primary signs and symptoms of urinary problems.
The most common signs and symptoms of urinary problems include
changes in the frequency of urination, dysuria, urgency, retention, and
incontinence. Abnormal function of any part of the urinary tract can be
determined with urinalysis, BUN levels, and creatinine clearance.
• Detail common diagnostic procedures of the urinary system.
Diagnostic procedures are summarized in Table 16-1 .
4. Discuss the causative factors of urinary incontinence, in addition to
the various treatments and medications used to treat it.
Urinary incontinence is the temporary or chronic loss of urinary control,
and the treatment depends on the causative factor. Options include
behavioral techniques, pelvic muscle exercises, external catheters, and
condom catheters. Table 16-2 lists various medications used to treat
stress incontinence and urgency.
5. Compare and contrast infections and inflammations of the urinary
tract.
Most UTls are ascending; they start with pathogens in the perinea! area
and infect the continuous mucosa, up through the urethra, bladder, and
ureters to the kidneys. Infections and inflammations include urethritis,
cystitis, pyelonephritis, and acute or chronic glomerulonephritis.
6. Describe urinary tract disorders and cancers.
Renal calculi are created when salts in the urine collect in the kidney or
when fluid intake is low. They can block the flow of urine, causing
hydronephrosis. Polycystic kidney disease, a slowly progressive and
patient education, manage telephone screening, and assist Dr. Fineman with
procedures in the office. She also is working on building a database with local
resources, support groups, and Internet sites that could be helpful far patients
confronted with urologic or male reproductive system problems.
irreversible genetic disorder, causes the formation of multiple, grapelike
cysts in the kidney. Bladder cancer is invasive and can metastasize
through the blood or surrounding pelvic lymph nodes. Adenocarcinoma
of the kidney initially is asymptomatic and therefore frequentty has
metastasized before it is diagnosed. Wilms tumor is cancer of the kidney
in children.
7. Summarize the causes of renal failure and how it is treated.
Acute renal failure has a sudden, severe onset caused by exposure to
toxic chemicals, severe or prolonged circulatory or cardiogenic shock, or
acute bilateral kidney infection. Chronic renal failure is a slowly progres-
sive process caused by gradual destruction of the kidneys' ability to filter
waste materials. Dialysis is used to treat acute renal failure until the
problem is reversed or, far patients in end-stage renal disease, until
transplantation can be pertormed. The two forms of dialysis are hemo-
dialysis and peritoneal dialysis.
8. Summarize the typical pediatric urologic disorders.
Pediatric urologic disorders include enuresis, urine reflux disorder, and
cryptorchidism.
9. Describe the anatomy and physiology of the male reproductive
system.
The male reproductive system is made up of a pair of testes that contain
the seminiferous tubule, where spermatozoa are produced and carried
to the epididymis for maturation and into the vas deferens for storage.
The prostate gland secretes seminal fluid, which is ejaculated with sperm
by the penis. Testosterone stimulates the development of secondary male
characteristics and matures sperm.
l 0. Determine the causes and effects of prostate disorders.
Inflammation of the prostate usually develops because of an infection,
such as an STI. Common symptoms are dysuria, tenderness, and secre-
tion of pus from the tip of the penis. Benign prostatic hyperplasia partially
blocks the flow of urine and is diagnosed from patient complaints and
with a DRE. Treatment includes the use of medication or surgery. Cancer
of the prostate is common in men older than age 50 and is the second
highest cause of male cancer deaths; complaints include urinary obstruc-
tion, UTls, and nocturia. Prostate cancer is diagnosed by a DRE, elevated
PSA level, and biopsy; treatment includes radioactive seed implantation,
hormone therapy, or prostatectomy.
11. Outline common types of genital pathologic conditions in men, and
perform patient education for the testicular self-examination.
Male genital pathologic conditions include epididymitis, balanitis, prosta-
titis, and STls. Testicular tumors usually occur in young men and

SUMMARY OF LEARNING OBJECTIVES-continued
generally are malignant. Erectile dysfunction (ED) typically is treated
with medication. Male infertility may be caused by cryptorchidism, stric-
ture, varicoceles, low sperm count and motility, and hormonal imbal-
ances. Patient education for performing a testicular self-examination is
summarized in Procedure 16-1 .
12. Analyze the effects of sexually transmitted infections in men, and
summarize the characteristics of HIV infection, including diagnostic
criteria and treatment protocols.
Table 16-3 summarizes the signs, symptoms, and treatment of STls in
men. There is no cure for viral STls, and bacterial causes of infection
are becoming increasingly resistant to antibiotic therapy. STls in male
patients frequenrly are asymptomatic. Bacterial STls include gonor-
rhea, chlamydia, and syphilis. Viral infections include genital herpes,
genital warts, and HIV. Trichamaniasis is a protozoa! infection that is
asymptomatic.
HIV invades the CD4 Tlymphocytes, destroying their ability to fight
infection on the cellular level. Initial exposure may cause flulike symp-
toms, but after this it could be many years before clinical symptoms of
AIDS occur. Apatient is considered to be HIV positive when antibodies
are detected, and to have full-blown AIDS when T-cell counts are below
CONNECTIONS
CIJ Study Guide Connection: Go to the Chapter 16 Study Guide. Read and complete
the activities.
CHAPTER 16 Assisting in Urology and Male Reproduction 413
200 mm 3 and/or opportunistic infections are diagnosed. HIV is transmit-
ted when infected blood or blood products, semen, or vaginal secretions
come in contact with the mucous membranes or broken skin of an
uninfected person. It also is transmitted from an infected mother to her
fetus in utero, during delivery, or by breast-feeding. Many methods of
HIV testing are available. Acombination of antiviral drugs is used to
control the virus, but the disease has no cure.
13. Describe the medical assistant's role in urologic and male reproduc-
tive examinations.
In a urology practice, the medical assistant is responsible for taking a
complete patient history that details urinary symptoms, providing patient
instruction for diagnostic tests, assisting with a urologic or male reproduc-
tive examination, and answering patients' questions.
14. Discuss patient education, legal and ethical issues, and HIPAA appli-
cations in the urology practice.
Confidentiality restrictions that apply ta a patients HIV status vary from
state to state. It is the medical assistants responsibility to manage HIV/
AIDS patient confidentiality according to the laws in the state of practice.
State and national laws must be followed regarding reporting of certain
diseases.
evolve Evolve Connection: Go to the Chapter 16 link at evolve.elsevier.com/
kinn to complete the Chapter Review Quiz. Check out the other resources listed for this
chapter to make the most of what you have learned from Assisting in Urology and Male
Reproduction.
 ASSISTING IN OBSTETRICS
17 AND GYNECOLOGY
li#H+i;H•i
Betsy Davis, (MA (MMA), recently was hired by the University Women's
Hospital to work for Dr. Erin Beck, an obstetrician/gynecologist for a busy
family-centered healthcare facility in her community. Betsy has worked for a
family practice provider for 3 years, but this is her first position in a specialty
practice. Betsy is excited about the opportunity to focus on women's health
issues and is especially interested in helping in the obstetric area of the practice.
Betsy's responsibilities will include understanding current methods of contracep-
While studying this chapter, think about the following questions:
• What is the basic anatomy and physiology of the female system?
• What does Betsy need to learn about contraceptives to be able to answer
patients' questions?
• Betsy needs to become familiar with which gynecologic disorders?
• What are the primary malignancies of the female system?
• How should Betsy assist Dr. Beck with a Pap test?
LEARNING OBJECTIVES
1. Define, spell, and pronounce the terms listed in the vocabulary.
2. Explain the anatomy and physiology of the female reproductive system.
3. Trace the ovum through the three phases of menstruation.
4. Compare and contrast current contraceptive methods.
5. Summarize menstrual disorders and conditions.
6. Distinguish among different types of gynecologic infections.
7. Do the following related to benign and malignant tumors of the female
reproductive system:
• Differentiate between benign and malignant neoplasms of the
female reproductive system.
• Prepare for and assist with the female examination, including
obtaining a Papanicolaou (Pap) test.
• Demonstrate patient preparation for a loop electrosurgical excision
procedure (LEEP).
• Teach the patient the technique for breast se~-examination.
VOCABULARY
adnexal (ad-neks-uhl) Pertaining to adjacent or accessory parts.
Bartholin's cyst A fluid-filled cyst in one of the vestibular glands
located on either side of the vaginal orifice.
clitoris (klih'-tuh-ris) A small, elongated erectile body above the
urinary meatus at the superior point of the labia minora.
coitus Sexual union between male and female; also called intercourse.
tion and the patient education factors that are important for each. She alsa
must develop expertise in gynecologic diseases and conditions, including diag-
nostic and treatment protocols for cancers of the female system. Medical
assistants in the practice are expected to be able to teach breast self-examination
and to answer the questions of pregnant patients concerning a healthy preg-
nancy, labor, and delivery.
• How can Betsy teach patients to perform breast self-examination?
• What are the stages of pregnancy and birth?
• How can Betsy help patients understand issues that can arise with
menopause?
• What are the typical diagnostic procedures used in obstetrics and
gynecology?
8. Compare the positional disorders of the pelvic region.
9. Summarize the process of pregnancy and parturition.
10. Describe the common complications of pregnancy.
11. Specify the signs, symptoms, and treatments of conditions related to
menopause.
12. Ou~ine the medical assistant's role in gynecologic and reproductive
examinations and demonstrate how to assist with a prenatal
examination.
13. Distinguish among diagnostic tests that may be done to evaluate the
female reproductive system.
14. Summarize patient education guidelines for obstetric patients, in
addition to legal and ethical implications in a gynecology practice.
colostrum (koh-lahs'-trum) A thin, yellow, milky fluid secreted
by the mammary glands a few days before and after delivery.
dilation The opening of the cervix through the process of labor,
measured as O to 10 cm dilated.
dilation and curettage (D&C) The widening of the cervix and
scraping of the endometrial wall of the uterus.

VOCABULARY-continued
dysplasia (diss-play-zha) An alteration in cell growth, causing
differences in size, shape, and appearance.
effacement The thinning of the cervix during labor, measured in
percentages from 0% to 100% effaced.
endocervical curettage The scraping of cells from the wall of the
uterus.
fundus The curved, top portion of the uterus; the fundal height
can be used as a measurement of fetal growth and estimated
gestation.
human chorionic gonadotropin (HCG) A hormone, secreted by
the placenta, found in the urine of pregnant females.
lymphedema (limf-uh-de' -muh) Swelling caused by the
accumulation of lymph fluid in soft tissues.
mons pubis The fat pad that covers the symphysis pubis.
multiparous Pertaining to women who have had two or more
pregnancies.
neural tube defects Congenital malformations of the skull and
spinal column caused by failure of the neural tube to close
during embryonic development; the neural tube is the origin of
the brain, spinal cord, and other central nervous system tissue.
T he branch of medicine that deals with pregnancy, labor, and
the postnatal period is known as obstetrics, and the branch
of medicine that deals with diseases of the genital tract in women
is called gynecology. Frequently, a provider practices both special-
ties and is known as an OB/GYN provider. Assessment of the
female reproductive system is an important part of healthcare.
Patients often are hesitant and uncomfortable about talking about
sexual matters, so they wait until symptoms are intolerable or
disease is advanced before seeking medical care. In addition to
the signs and symptoms of disease, the medical assistant must be
aware of the patient's emotional state and must give support
when needed.
ANATOMY AND PHYSIOLOGY
Female Reproductive System
The female reproductive system includes both internal and external
organs. The internal organs are located in the pelvis and cannot be
seen without special instruments, such as a vaginal speculum or a
laparoscope. The external organs can be seen during the physical
examination.
The primary parts of the female reproductive system are the
vulva, vagina, uterus, fallopian tubes, and ovaries (Figure 17-1). The
vulva includes the clitoris, the urethral meatus, and the vaginal
orifice. These structures are covered by two sets of lips of tissue. The
inner set, the labia minora, is a thin layer of skin that extends from
the top of the clitoris to the base of the vaginal opening. The external
set, the labia majora, and the mons pubis are covered with hair in
the adult.
The vagina connects the internal and external organs. This tube-
like structure is constructed to receive the penis during coitus. It is
CHAPTER 17 Assisting in Obstetrics and Gynecology 415
nonstress tests (NSTs) Fetal monitoring used in combination
with maternal reports of fetal movement to evaluate the fetal
heart rate response.
parturition (par-too-rih' -shun) The act or process of giving birth
to a child.
stereotactic (stare--ee-oh-tak-tik) Pertaining to an x-ray procedure
used to guide the insertion of a needle into a specific area of the
breast.
teratogen Substance that causes the development of fetal
abnormalities.
transvaginal ultrasound A procedure used to examine the
vagina, uterus, fallopian tubes, and bladder. An ultrasound
transducer (probe) is inserted into the vagina and used to
bounce high-energy sound waves (ultrasound) off internal
tissues or organs and make echoes that form a picture;
the provider can identify tumors by looking at the
sonogram.
vulva The external female genitalia, which begins at the mons
pubis and terminates at the anus.
lubricated by a mucous membrane lining, and its walls are made up
of overlapping tissue in the form of rugae; this allows the vagina to
expand during the birth of an infant. At the distal end of the vagina
is the cervix, often called the neck of the uterus, which is approxi-
mately 1 to 1½ inches long. The uterus is an upside-down, pear-
shaped muscular organ, and its sole purpose is to house and nourish
the fetus from implantation shortly after conception until parturi-
tion. The uterine walls have three layers. The inner layer, the endo-
metrium, is rich in blood and changes in consistency during
the menstrual cycle. The middle layer, the myometrium, is the
powerful muscular layer that contracts to make the birth of a baby
possible. The outer layer, the perimetrium, protects the structure
and attaches to ligaments that support and hold the uterus in
place (Figure 17-2).
On both sides of the fundus of the uterus are the fallopian tubes,
also called the oviducts. These tubes extend from the uterus to the
ovaries but do not attach to the ovaries. The distal end of the tube
opens freely into the abdominopelvic cavity and acts as a passageway
for the ovum to the uterus and for the sperm as they search for the
ovum. At the distal end of the fallopian tubes are fingerlike projec-
tions, called fimbriae, which move in a wavelike pattern to draw the
released ovum into the fallopian tube.
The ovaries are almond-shaped organs that produce and release
the egg (ovum) and excrete the hormones necessary for the devel-
opment of secondary sexual characteristics and the maintenance of
a pregnancy. The ovaries secrete the hormones progesterone and
estrogen, which regulate reproductive function. For pregnancy to
occur, the vagina must receive the sperm from the male; the sperm
move up through the opening in the cervix (the cervical os),
through the uterus, and into the fallopian tubes. As many as 200
million to 600 million sperm can be deposited, and about 100,000
416 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES

:::,::::::....- Mons pubis Fallopian tube--+-,,._.__ _..,.. "cc=----.----,,---:1---'I-Ovary

_ Prepuce
Clitoris
Labia
n"
Urethral orifice
~ Openings for
~ _ Uterus--\,4'6-.,.,.....- -r

minora---- paraurethral glands

!-!tc--+Rectum
Labia ~ Vagina Vestibule
majora ~ "rl'-'----+ Vagina
Anus - - - -.... Opening for greater
vestibular gland
Labia majora-+---

A B

FIGURE 17-1 A, Female external genitalia. B, Normal female reproductive system. (A from Applegate EJ: The anatomy and physiology
learning system, ed 4, Philadelphia, 2011, Saunders; Bfrom Frazier MS, Drzymkowski JA: Essentials of human diseases and conditions, ed 5,
St Louis, 2013, Saunders.)

organs of milk production, and a system of ducts for delivery of milk

to the nipple. Mammary ducts respond to elevated levels of estrogen
and progesterone produced during the menstrual cycle by increasing
in size, resulting in premenstrual fullness and tenderness of the
breasts.
Four hormones control the mammary glands: estrogen is respon-
sible for the increase in size; progesterone stimulates the development
of the duct system; prolactin stimulates the production of milk; and
oxytocin causes the ejection of milk from the glands.

FIGURE 17-2 Uterus and fallopian tubes. (Modified from Applegate EJ: The anatomy and physio~
ogy learning system, ed 4, Philadelphia, 201 l, Saunders.)
survive the acidic environment of the vagina to swim toward
the egg.
Fertilization occurs when one sperm cell penetrates and fertilizes
an egg. Fertilization usually takes place in the distal third of the fal-
lopian tube. The tiny fertilized ovum, now called a zygote, moves by
peristalsis and the massaging motion of the cilia that line the fallo-
pian tube into the uterus and implants itself into the uterine wall.
After implantation, the placenta forms; this structure supplies the
new life with all the nourishment needed for development. Once
pregnancy begins, the serum levels of human chorionic gonadotro-
pin {HCG) rise, and the hormone spills into the woman's urine,
where it can be detected with a pregnancy test.
Breast Tissue
Mammary tissue develops from the increased estrogen secretion that
occurs during puberty. In the center of each breast is a nipple sur-
rounded by a pigmented region called the areola. Inside the breast
are 15 to 20 lobes and their subunits, the lobules of glandular tissue
that are separated by connective support tissue and surrounded by
adipose tissue. The amount and distribution of adipose tissue deter-
mine the size and shape of the breast (Figure 17-3). Breast tissue also
contains mammary glands, modified sweat glands that become the
Menstruation
When a girl enters puberty, one of the many changes that occur is
menarche, or the beginning of the menstrual cycle. Menstruation is
a normal body process that occurs in every female. It is the physi-
ologic means by which the body rids itself of the thickened endo-
metrial wall that develops during the average 28-day cycle. The
menstrual cycle involves a series of events controlled by hormones
from the pituitary gland and the ovaries. The cycle is divided into
three phases: the follicular phase, the luteal phase, and the menstrual
phase.
Follicular Phase (Proliferative Phase)
The hypothalamus begins the follicular phase by secreting
gonadotropin-releasing hormone (GnRH), stimulating the anterior
pituitary to release follicle-stimulating hormone (FSH) and lutein-
izing hormone (LH). These hormones mature a graafian follicle in
an ovary that contains an ovum. The mature ovarian follicle secretes
estrogen, which stimulates the growth of the endometrium. It takes
approximately 9 days (to day 14 of the menstrual cycle) for the
graafian follicle to ripen and bulge out from the ovarian wall. The
ovarian wall becomes thinner as the follicle enlarges until it bursts,
expelling the ovum into the abdominal cavity. Expulsion of the egg
ends the follicular phase. The fallopian fimbriae begin their wave-
like motion to fan the ovum into the fallopian tube. The rupture
spot on the ovary, now called the corpus luteum, begins to secrete
progesterone. Ovulation causes a rise in body temperature, and
some women experience cramping and tenderness in the lower
abdominal area at this time as a result of the rupture of the graafian
follicle.

Lactiferous
duct -------------
Lactiferous--=--- -;::7;
sinus
Lobule
Lobe
FIGURE 17-3 Normal female breast. (From Jarvis(: Physical examination and health assessment, ed 4, Philadelphia, 2004, Saunders.)
Luteal Phase (Secretory Phase)
Once ovulation is complete, the luteal phase begins (day 15).
During this phase, progesterone secreted by the corpus luteum
causes extensive growth of the endometrium as it prepares for a
possible pregnancy. If conception occurs, the corpus luteum con-
tinues to secrete progesterone until the placenta is well established
and can secrete progesterone and HCG to maintain the preg-
nancy. If conception does not occur, HCG is not secreted, and the
corpus luteum atrophies. Without increased levels of progesterone
and HCG, the endometrium breaks down, and menstruation
begins.
Menstrual Phase
Menstrual discharge is made up of necrotic endometrial tissue,
mucus, and the blood from endometrial engorgement. As the uterus
contracts to shed the excess tissue, a woman may experience cramp-
ing pain and irritability. This phase usually lasts approximately 5
days, and then the follicular phase begins again.
CONTRACEPTION
A woman's choice of a contraceptive method is based on many
factors. To make an informed choice, a patient should know the
risks, benefits, side effects, costs, failure rates, and convenience of
each available method. In addition, although condoms are only
moderately successful at preventing pregnancy, they should be
used consistently to prevent transmission of sexually transmitted
infections (STis). The medical assistant may help provide patient
education on contraceptive methods. Table 17-1 summarizes the
characteristics of various contraceptive methods.
CHAPTER 17 Assisting in Obstetrics and Gynecology 417
~~~,-,c:......::- ~ -,----Cooper's
ligaments
Barrier Methods
Barrier methods of contraception either kill sperm through the use
of a chemical spermicide or prevent them from entering the cervical
os. These methods, which are relatively inexpensive, include the
condom, diaphragm, and cervical cap or sponge. Each method must
be used every time the person has intercourse, which means the
patient must be motivated to follow through on using it. Patient
education on the use of a diaphragm includes the following
instructions:
• Examine the diaphragm before each use by holding it up to
a bright light to check for holes or cracks.
• Place 1 to 2 tablespoons of spermicidal jelly or cream into the
diaphragm dome before insertion.
• Leave the diaphragm in place for 6 hours after intercourse; do
not douche until after you have removed it.
• Before repeated intercourse, add spermicide to the outside of
the diaphragm with an applicator. Do not remove the dia-
phragm until 6 hours after the last intercourse.
• After removal, wash the diaphragm with soap and water, allow
it to air dry, and inspect it for breaks or holes before storing.
• Have the diaphragm refitted if (1) you gain or lose more than
10 to 15 pounds; (2) you have a miscarriage, give birth, or
undergo any type of pelvic surgery; or (3) you have difficulty
voiding or moving your bowels with the diaphragm in place.
The cervical cap is a thimble-sized, domed barrier device that fits
over the end of the cervix. It also is used with spermicidal jelly
(Figure 17-4).
The cervical cap is 92% to 96% effective if used properly. An
advantage of this barrier method is that the cap can be inserted up
to 12 hours before intercourse and can stay in place up to 72 hours
418 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES

TABLE 17-1 Commonly Used Contraceptive Methods

TYPE
Male or female condom
(barrier method)
Diaphragm, cervical cap,
cervical sponge (barrier
method)
Intrauterine device (IUD)
lmplanon or Nexplanon
Depo-Provera (DMPA)
Oral contraceptives (O(Ps) 1%
Hormonal patch
Vaginal ring
HIV, Human immunodeficiency virus; IM, intramuscular; PIO, pelvic inflammatory disease; ST/, sexually transmitted infection; UT/, urinary tract infection.
FAILURE RATE CHARACTERISTICS
2%-10% No prescription or examination
needed; easily available; inexpensive
2%-19% Must be fitted by clinician; requires
instruction on how to insert and
remove; spermicide must be used
each time; diaphragm and sponge
must be left in place for 6 hours
after intercourse
2%-6% ParaGard releases copper, which
slows sperm in the cervix; Mirena
and Skyla release progestin, which
reduces sperm mobility and prevents
thickening of the endametrial wall
1% Flexible plastic implant inserted
under skin of upper arm; releases
progestin to prevent ovulation,
thickens cervical secretions to block
semen, thins endometrial wall;
effective for up to 3 years
0.5% Requires 150-mg IM injection every Intention of becoming pregnant Return of fertility may be
3 months within l year; breast cancer; delayed 10-18 months; should
liver disease
Suppress ovulation; atrophy of the
endometrium
CONTRAINDICATIONS SIDE EFFECTS
Latex allergy in either partner Possible allergic response to latex
or spermicide
Latex, rubber, or spermicide Increased risk for UTI
allergy; uterine prolapse; severe (diaphragm); increased risk of
cystocele or rectocele abnormal Pap test result (cap)
Cervicitis, vaginitis, ParaGard may temporarily
endometriosis, pelvic infection, increase vaginal bleeding and
history of STI ar ectopic menstrual pain; hormonal IUDs
pregnancy (Mirena and Skyla) decrease
menstrual flow and cramping
Certain antibiotics, HIV drugs, Irregular bleeding in first 6-12
seizure medications may make months; nausea, headache, sore
it less effective; history of breasts, scarring at implantation
blood clots, liver disease, or site
breast cancer
not be used more than 2 years
in a row because it can cause a
temporary loss of bone density;
headache, weight gain, possibly
depression
Thrombolytic, liver, or coronary Nausea, breakthrough bleeding,
artery disease; breast, liver, breast tenderness, fluid retention;
reproductive tract cancer; hypertension, elevated lipid
smoker over age 35; diabetes; levels, blood clots, strokes
sickle cell disease

without decreasing effectiveness or safety. The cervical sponge con-
tains spermicide and also can be inserted hours before intercourse
and is effective for 24 hours. The sponge is 80% to 91 % effective if
always used as directed.
Hormonal Contraceptives
Hormonal contraceptives are a highly effective and reversible form
of contraception. They work by inhibiting ovulation, changing the
cervical mucosa, affecting sperm mobility, and preventing thickening
of the endometrial wall. Hormonal contraceptives include the birth
control pill or patch, the vaginal ring, Depo-Provera injections, and
hormonal implants.
Besides being a highly effective method of birth control, oral
contraceptives can be used to treat a wide range of gynecologic
conditions, including menstrual irregularities, premenstrual syn-
drome (PMS) symptoms, and anovulation; they also can be used to
prevent ovarian cysts and may be prescribed to increase bone density.
However, to be effective, the pills must be taken daily. Failure rates
are associated with noncompliance and can range from less than 1%
in highly compliant women to greater than 15% in those who do
not take the pills as prescribed. Oral contraceptive pills (OCPs) can
have serious side effects, so patients should be informed of condi-
tions that require immediate medical attention. These can be remem-
bered with the mnemonic ACHES: abdominal pain (new and
severe), chest pain (new and severe), headaches (new or more fre-
quent), eye problems (blurred vision or vision loss), and severe
leg pain. These symptoms may indicate the formation of a blood
clot in the abdomen, chest, or leg, or they may be signs of a stroke;

FIGURE 17-4 Cervical cop with spermicide.
blood clot formation and stroke are the most serious complications
ofOCPs.
A type of oral contraception, Seasonale, limits the number of
menstrual periods to four a year, although patients are more likely
to have spotting and breakthrough bleeding with this hormone
therapy than with the traditional 28-day birth control pill. Seasonale
is designed to be taken once a day for 84 days, and then an inactive
dose is taken for a week, during which the woman would menstru-
ate. Yaz or Beyaz may be prescribed for women suffering from a
severe form of PMS called premenstrual dysphoric disorder (PMD D);
it also is useful for treating acne in female patients at least 14 years
of age who have started menstruating.
As mentioned, hormonal contraception also can be delivered via
a transdermal patch, the Ortho Evra patch. The patch is a l ¾-inch
square that slowly releases estrogen and progestin through the skin
and into the bloodstream. It is considered as effective as oral contra-
ceptives in women who weigh less than 198 pounds; however, the
patch is still a very effective method for women who weigh more
than this. Current research shows that the risk of blood clots with
the contraceptive patch is similar to that observed with oral contra-
ceptives. However, cigarette smoking increases the risk of serious
cardiovascular side effects, especially if the patient is over age 35.
Patients should be told not to apply any creams or oils at the applica-
tion site, to change the patch weekly for 3 consecutive weeks, and
to go patch free the fourth week, allowing menstruation to occur.
The patch can be applied to the buttocks, lower abdomen, and upper
body but not to the breasts. The woman can bathe, shower, and
swim while wearing the patch, but if it comes off, it should be
replaced immediately.
The vaginal ring (NuvaRing) contraceptive device is made of
flexible plastic and is inserted into the vagina. The ring slowly releases
estrogen and progestin to prevent pregnancy and provide effective
contraceptive action for 1 month after insertion. The device is 2
inches in diameter and can be inserted anywhere in the vagina;
however, the deeper it is placed, the less likely it is to be felt after
CHAPTER 17 Assisting in Obstetrics and Gynecology 419
insertion. Side effects of the NuvaRing are similar to those of other
hormonal contraceptives, and it may increase the risk of heart attack,
stroke, and blood clots. When the patient first starts using the ring,
an additional method of birth control must be used for the first
week. If the ring falls out, it should be rinsed with warm water and
reinserted within 3 hours. If it is out for longer than 3 hours, con-
traception is not certain and the patient should use another birth
control method for 1 week.
Depo-Provera is an injectable contraceptive that contains high
doses of progestin. Each dose prevents pregnancy for up to 3 months,
but women must be compliant in returning to the healthcare facility
for follow-up and repeat doses every 9 to 13 weeks. The first injection
should be administered within the first 5 days of the menstrual
period for birth control coverage. This is a highly effective method
of contraception and is ideal for women who either do not comply
with a birth control regimen or do not want to take a pill every day.
However, using Depo-Provera for 2 years or longer may increase the
risk of bone loss and the eventual development of osteoporosis.
Almost all patients using the injections experience some menstrual
irregularities, but these usually subside after two doses. Women using
this form of hormonal contraception are not at risk for the side
effects of estrogen exposure, such as increased risk of blood clots and
cardiovascular disease.
The lmplanon and Nexplanon implants are a single, flexible rod,
about the size of a match, that is inserted under the skin of the upper
arm. The birth control implant releases a low, steady dose of proges-
tin, which suppresses ovulation, thickens cervical mucus to block the
passage of sperm, and thins the endometrial wall to prevent implan-
tation. It prevents pregnancy for up to 3 years after insertion. Hor-
monal implants have similar risks and contraindications as other
hormonal types of contraception.
Intrauterine Devices
The intrauterine device (IUD) (Figure 17-5) is a T-shaped plastic
frame with threads attached that is inserted by the provider into the
420 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES
FIGURE 17-5 Mirena IUD.
uterus to prevent pregnancy. Two general types of IUDs are avail-
able: the copper type (ParaGard) and the hormonal type (Mirena or
Skyla). Both products inhibit fertilization by blocking the sperm's
journey to the fallopian tubes, and if fertilization does occur, they
prevent the embryo from implanting in the uterine wall. In addi-
tion, ParaGard releases copper, which acts to slow sperm in the
cervix, whereas Mirena and Skyla release progestin, which reduces
sperm mobility and prevents thickening of the endometrial wall
during the menstrual cycle. Both types of IUDs are extremely effec-
tive at preventing pregnancy (over 99%); the copper type can
remain in place as long as 12 years, whereas Mirena IUDs must be
replaced every 5 years and Skyla every 3 years. The copper IUD
may temporarily increase vaginal bleeding and menstrual pain, but
the hormonal IUD results in both decreased menstrual flow and
cramping. To remove an IUD, the provider gently withdraws it by
pulling on the IUD string. In rare instances, it must be removed
surgically.
Permanent Methods
Both male and female patients can undergo surgical procedures that
are considered permanent contraceptive methods. Vasectomies in the
male were addressed in the urology chapter. For the female, a bilat-
eral tubal ligation can be performed in which a portion of both
fallopian tubes is excised or ligated. The cost and rate of complica-
tions are higher for tubal ligations than for vasectomies. In addition,
tubal ligations must be done on an outpatient basis with general
anesthesia, so the woman has that additional risk. Both procedures
can be reversed, but not always successfully.
CRITICAL THINKING APPLICATION 17-1
Dr. Beck's patients often ask questions about birth control methods, includ-
ing the pros and cons of each. Although Betsy's former employer also
prescribed contraceptives, Betsy was not involved in patient education. Dr.
Beck expects Betsy to be aware of all birth control options, their character-
istics and side effects, and any patient education details that might be
requested or appropriate. Betsy has decided to create a reference sheet for
herself that includes all these details. What should she include?
GYNECOLOGIC DISEASES AND DISORDERS
Menstrual Disorders and Conditions
Amenorrhea is the absence of menstruation for a minimum of 6
months; in oligomenorrhea, the woman has not experienced a period
for 35 days to 6 months. The absence of menstruation outside preg-
nancy could be the result of a number of factors, including hormonal
imbalance, thyroid disease, ovarian failure, or structural defects in
the female sex organs. If a patient has established menstruation that
stops, this usually is the result of a problem with the hypothalamus
or the pituitary. Suppression of the hypothalamus can occur as the
result of an eating disorder, stress, or extreme exercise that results in
low body fat content.
Women who do not ovulate and therefore do not go through a
monthly shedding of the endometrial wall of the uterus are at greater
risk for cancer of the endometrium and the breast. Patients usually
are started on oral contraceptives that artificially provide the hor-
mones needed to create a monthly menstrual cycle. These women
may experience fertility problems and require further testing and
medical intervention to become pregnant.
Abnormal menstrual bleeding is a common cause of OB/GYN
visits. Menorrhagia is excessive menstrual blood loss, such as a menses
lasting longer than 7 days. The provider may ask the patient to count
the number of tampons or pads used for several cycles to establish
a method of determining an estimate of blood loss. Iron-deficiency
anemia is a sign that a woman is losing excessive amounts of blood.
Metrorrhagia is spotting or bleeding between menstrual cycles. The
practitioner may prescribe oral contraceptives to atrophy the endo-
metrium and lessen the bleeding. Surgical options for excessive men-
strual flow include dilation and curettage (D&C) or, in extreme
cases, hysterectomy.
Endometriosis
Endometriosis is characterized by the presence of functional endo-
metrial tissue outside the uterus. It commonly is found attached to
the ovaries, urinary bladder, fallopian tubes, uterosacral ligaments,
intestines, and peritoneum. Many hypotheses have been offered to
explain this migration of endometrial tissue, but the most widely
accepted is a retrograde flow during menstruation that causes men-
strual fluid and stray endometrial cells to migrate out of the fallopian
tubes and implant in the pelvic region. The use of tampons has been
suggested as a possible cause. A familial tendency also has been
noted; a woman with a first-degree relative (a mother or sister) who
has the condition has a 10 times greater risk of developing the
disorder.
The ectopic endometrial tissue responds to routine hormonal
changes; it proliferates, degenerates, and bleeds just as does the
endometrium of the uterus throughout the menstrual cycle. This
causes inflammation at the site of the implantation that recurs with
each cycle, ultimately leading to adhesions and obstruction of the
affected tissue. Pain from endometriosis can be severe, interfering
with day-to-day activities. The primary symptom of endometriosis
is dysmenorrhea (painful menstruation). More than one-third of
affected patients also report dyspareunia (painful intercourse), and
others complain of contact pain in the lower abdomen, pelvis, and
back beginning 7 days before menses and lasting 3 days after onset.
Other symptoms can include profuse menses, hematuria, rectal
 CHAPTER 17 Assisting in Obstetrics and Gynecology 421

bleeding, nausea, vomiting, and abdominal cramps. Infertility is a

serious problem for approximately 70% of women afflicted with
endometriosis because of the buildup of scar tissue and adhesions in
and around the fallopian tubes.
Conservative treatment through the use of hormones is recom-
mended when the woman wants to have children. Treatment may
consist of a laparoscopy to remove the ectopic endometrial tissue.
Pharmaceutical treatment includes continuous use of oral contracep-
tives to prevent menstruation or Depo-Provera injections. Leupro-
lide acetate (Lupron) injections may be prescribed intramuscularly
every month for 6 months; however, Lupron puts the patient into a
state of artificial menopause and can cause menopausal symptoms,
including hot flashes, vaginal dryness, and bone density loss. Another
medication that causes induced menopause is oral danazol. Danazol
lowers estrogen levels and increases androgen levels, which stops
ovulation and shrinks endometrial growths; however, it can cause
the development of male physical traits, an elevated cholesterol level,
and liver disease. In severe cases, a total hysterectomy may be
indicated. No cure for endometriosis is known, but pregnancy,
breast-feeding, or natural menopause frequently causes remission
(Figure 17 -6).
CRITICAL THINKING APPLICATION 17-2
Melissa Steiner, a 19-year-old patient of Dr. Beck, was diagnosed with
endometriosis when she was 17. She has had two laparotomy procedures
and continues to complain of moderate to severe pain before and during
menstruation. What can Betsy tell her about the disease to help her under-
stand why she has the pain? Melissa also wants to know about long-term
complications, including the impact of the disease on fertility. She asks Betsy
to help her understand Dr. Beck's explanation of the disease. How should
Betsy handle her request?
Infections
Candidiasis
Candida albicans is the yeastlike fungus responsible for candidiasis.
Candida organisms are commonly part of the normal flora of
the mouth, skin, intestinal tract, and vagina. Overgrowth of the
organism can be caused by antibiotic use, high estrogen levels,
oral contraceptive use, diabetes mellitus, and immunosuppressive
disorders, including acquired immunodeficiency syndrome (AIDS).

Umbilicus

Fallopian tube

Posterior
cul-de-sac
Ileum
t:='i-~---1--fl--+- Posterior surface
Appendix of uterus and
uterosacral
Ovary ligaments
Anterior cul-de-sac
Cervix
and bladder

Uterine
wall

Left
ovary

Right ovary -
endometriosis

B
FIGURE 17-6 Endometriosis. A, Possible ectopic sites. B, Endometriosis involving the right ovary (chocolate cyst) and the left ovary, showing
the inner lining of a large cyst with excrescences. (B courtesy RW Shaw, MO, North York General Hospital, Toronto, Ontario, Canada.)
422 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES
Candidiasis also can be spread through sexual contact. Symptoms
include vulvovaginal itching; dry, bright red vaginal tissue; and an
odorless, white, "cottage cheese" vaginal discharge. This infection can
be treated with prescription antifungal medications, such as a single
dose of oral fluconazole (Diflucan) or terconazole vaginal supposi-
tories. It also can be treated with over-the-counter (OTC) creams or
suppositories, such as Gyne-Lotrimin or Monistat. Women pre-
scribed an antibiotic for an infection may develop vaginal candidiasis
as a side effect. Dietary probiotics that are found in yogurt and soy
products can help prevent the development of a vaginal fungal infec-
tion during antibiotic therapy.
Bacterial Vaginosis
Bacterial vaginosis (BV) occurs when the normal level of bacteria in
the vagina is disrupted and secondary bacteria begin to grow and
infect the tissue lining. Signs and symptoms include vaginal dis-
charge, odor, pain, pruritus, or burning. Although BV is the most
common vaginal infection in women of childbearing age in the
United States, it does not usually cause complications. However, an
infection of the vagina appears to make women more susceptible to
STis, including infection with the human immunodeficiency virus
(HIV); it may lead to pelvic inflammatory disease (PID) if the infec-
tion spreads; and in pregnant women, it is associated with a prema-
ture or low-birth-weight infant. For these reasons, antibiotic therapy
is especially important for pregnant women. The antibiotic of choice
is either metronidazole (Flagyl) or clindamycin (Cleocin).
Cervicitis
Cervicitis is an inflammation of the cervix caused by an invading
organism. The main sign is a thick, purulent, whitish discharge with
an acrid odor. Dysuria may also be noted. Cervicitis can occur after
Trends in Sexually Transmitted Infections
• Syphilis, gonorrhea, chlamydia and herpes infections increase the risk of
getting the human immunodeficiency virus (HIV).
• Patients infected with gonorrhea frequently are co-infected with chla-
mydia. Researchers recommend that patients who test positive for either
sexually transmitted infection (STI) be treated with a combination of
antibiotics such as Rocephin with azithromycin.
• Chlamydia is the most commonly reported notifiable disease in the United
States; more than 1.4 million cases were reported in 2014. It is known
as the "silent" STI because 75% of infected women and 50% of infected
men are asymptomatic. An estimated 40% of women with untreated
chlamydia infections develop pelvic inflammatory disease (PIO), and
infertility results in 20% of those. The condition is diagnosed in African-
American women almost seven times more frequently than in Caucasian
women. The highest rates are seen in l 5- to 24-year-olds. The Centers
for Disease Control and Prevention (CDC) recommends yearly chlamydia
screening for sexually active women younger than 26 years of age and
for those older with risk factors, including new or multiple sex partners.
Women infected with chlamydia are up to five times more likely to
become infected with HIV if exposed. If chlamydia is diagnosed, the
vaginal delivery as a result of an infected cervical laceration, but most
cases are caused by an STI. Treatment consists primarily of antibiot-
ics, although cauterization may be indicated if cervical ulcers are
present.
Pelvic Inflammatory Disease
PID is any acute or chronic infection of the reproductive system that
ascends from the vagina (vaginitis), cervix (cervicitis), uterus (endo-
metritis), fallopian tubes (salpingitis), and ovaries (oophoritis).
These infections may cause the fallopian tubes to fill with pus, and
chronic episodes can result in scarring of the fallopian tubes and the
formation of adhesions. PID is caused by advanced, untreated vagi-
nosis, gonorrhea, or chlamydia! infection; or it can develop from
infection after pelvic surgery, tubal examination, or abortion. PID
is responsible for a large percentage of cases of infertility in women
as a result of adhesions that form in the fallopian tubes, preventing
the ovum from migrating through the tube. Therefore, it is critical
that a woman receive care immediately if she has pelvic pain or other
symptoms of PID. The patient may be asymptomatic or may com-
plain of purulent vaginal discharge, fever, malaise, dysuria, lower
abdominal pain, bleeding, nausea, and vomiting. Cultures of cervi-
cal discharge typically are done to determine the pathogenic organ-
ism. Several types of antibiotics can cure PID; however, antibiotic
therapy cannot reverse any scarring that has occurred in the fallo-
pian tubes because of an infection. The longer a woman delays
treatment for PID, the more likely she is to become infertile or to
have a future ectopic pregnancy. Treatment should include broad-
spectrum antibiotic therapy, such as Flagyl or ceftriaxone (Rocephin)
with doxycycline (Vibramycin). If cultures are positive for an STI,
treatment of the patient's sexual partner is necessary to prevent
reinfection.
patient and partner should abstain from sexual intercourse until treatment
has been completed to prevent reinfection.
• Gonorrhea is a major cause of PIO. Most affected women are asymptom-
atic. Transmission can occur during vaginal birth, causing fetal blindness,
joint infection, or a life-threatening blood infection. Pregnant women
should be treated as soon as gonorrhea is diagnosed, to reduce
these risks.
• Congenital syphilis can cause stillbirth, neonatal death, physical deformi-
ties, and neurologic complications.
• Approximately l in 5women 14 to 49years of age have agenital herpes
simplex virus (HSV) infection, which can cause potentially fatal infections
in babies. Herpes can be spread by having vaginal, anal, or oral sex with
someone who has the disease, and condoms do not completely protect
from transmission. Herpes can be contracted from an infected sex partner
who does not have a visible sore or who may not know he or she is
infected. There is no cure for genital herpes. Treatment with prescription
antiviral medications may reduce the frequency, severity, and duration of
symptoms in recurrent outbreaks. Antiviral medications include acyclovir
(Zovirax), famciclovir (Famvir), and valacyclovir (Valtrex). Studies show

Trends in Sexually Transmitted Infections-continued
that individuals with HSV are more susceptible to HIV infection and that
an HIV-positive person with HSV is more infectious.
• At least 50% of sexually active men and women acquire genital
human papillomavirus (HPV) infection at some point. By age 50, at
least 80% of women will have acquired a genital HPV infection. Each
year, about 21,000 women are diagnosed with HPV-associated cervical
cancer.
• Trichomoniasis is the most common curable STI in young, sexually active
women. Symptoms usually appear in women within 5 to 28 days of
Modified from the CDC Sexually Transmitted Diseases (STD) Fact Sheets. www.cdc.gov/std/healthcomm/fact_sheets.htm. Accessed May 14, 2015.
Sexually Transmitted Infections
The list of infectious diseases spread by sexual contact continues to
grow. These diseases are considered the most common contagious
diseases in the United States. All STis are transmitted from one
person to another through body fluids, such as blood, semen, or
vaginal secretions during vaginal, anal, or oral sex (Figure 17-7). A
summary of STis and their effect on men was presented in the
Urology and Male Reproduction chapter. This chapter focuses on
the impact of STis on women.
The human papillomavirus (HPV), which causes genital warts,
is a matter of special concern in women. The infection may be
asymptomatic up to 2 years after exposure; however, regardless of
whether the virus causes symptomatic wart development, the
Blood-borne infection
(e.g., M. tuberculosis)
Ascending infection
Vulvitis (e.g., Genital warts
herpesvirus)
Syphilitic chancre
(T. pallidum)
FIGURE 17-7 Ascending infections of the female genital organs ore usually mused by sexual contact, pregnancy, or instrumentation. Descending infections usually begin in the blood or lymph nodes.
CHAPTER 17 Assisting in Obstetrics and Gynecology 423
exposure. Pregnant women with trichomoniasis may have premature or
low-birth-weight (less than 5 pounds) infants. It is treated with a single
dose of either metronidazole (Flagyl) or tinidazole (Tindamax).
• HIV can cross the placenta during pregnancy and infect the baby during
birth; it is also found in breast milk. An elective cesarean birth at 38
weeks is recommended to reduce the risk of transmission during the birth
process.
• Women who test negative for hepatitis B may receive the hepatitis B
vaccine during pregnancy.
infection can lead to serious complications in women. There are
more than 40 identified types of HPV, and HPV infection typi-
cally is first diagnosed by abnormal Pap test results because the
virus can cause such abnormalities. A positive Pap test result is fol-
lowed up with an HPV DNA test to diagnose the specific strain of
HPV that caused the infection. Although most women have a
healthy immune system that can successfully clear the virus
without the development of future health problems, approximately
13 high-risk HPV types are linked to the development of cervical
carcinoma. Women diagnosed with one of these carcinogenic
strains must have regular Pap testing, usually every 3 to 6 months,
for early detection and treatment of precancerous and cancerous
cells of the cervix.
Salpingitis
Pelvic
inflammatory
disease
(PIO)
Vaginitis
(e.g., Trichomonas
vagina/is)
424 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES

Three HPV vaccines are available: Cervarix, Gardasil, and Gar-
dasil 9. The vaccines are given in a three-shot series over 6 months
to protect girls and young women from HPV infection and the pos-
sibility of cervical cancer. Gardasil and Gardasil 9 also protect against
genital warts and anal cancer in both females and males. Routine
vaccination is recommended for females aged 11 or 12 years, and
through age 26 years for those not previously vaccinated. In addi-
tion, the vaccines are recommended for routine use in males aged
11 or 12 years and through age 21 years. The goal is to immunize
the individual before sexual activity is initiated. The vaccine is also
recommended for any man who has sex with men through age 26.
Table 17-2 summarizes the effects of STis on women. The per-
centage of women and girls infected with HIV is declining, largely
because of educational emphasis on the use of condoms; however,
women account for approximately 1 in 4 people living with HIV
infection in the United States. Because HIV can be transmitted
through the placenta to the developing fetus, it is crucial that women
be diagnosed either before pregnancy or as early in the pregnancy as
possible. Treatment of pregnant women who are HIV positive with
a three-part regimen of zidovudine (ZDV, Retrovir; formerly AZT)
can cut the risk of transmission to below 2%. Even where resources
are limited, a single dose of medicine given to mother and baby can
reduce the risk of HIV infection in the infant by 50%. According
to this treatment protocol, the pregnant woman should start taking
ZDV at 14 to 34 weeks; it should be administered intravenously
during labor and delivery; and it should be given to the infant every
6 hours for 6 weeks after birth. Because some AIDS drugs are very
dangerous for developing infants, the medication regimen of a
woman currently receiving treatment may be changed during preg-
nancy. Women who are HIV positive should never breast-feed
because the virus is present in breast milk.
CRITICAL THINKING APPLICATION 17-3
A28-year-old patient recently was diagnosed with an acute gonorrheal and
chlamydial infection. She first tested positive for HPV when she was 22.
Dr. Beck asks Betsy to give the patient educational materials, including
information on the potential long-term complications of HPV, and to confirm
that she understands the signs and symptoms of STls in herself and her
partner. What should Betsy include in the information?

TABLE 17-2 Sexually Transmitted Infections in Women

INFECTION CAUSATIVE ORGANISM SIGNS AND SYMPTOMS TREATMENT
Chlamydia Chlamydia trachomatis Often asymptomatic; dysuria; urinary frequency; abdominal pain; Curable with antibiotic therapy;
(bacterium) increased or decreased vaginal discharge. May cause endometritis, single dose of Zithromax or l week
PIO, and urethritis. Transmission to newborn can occur during vaginal of doxycycline (Vibramycin).
delivery; causes neonatal eye infections and pneumonia.
Genital herpes Herpes simplex virus type 2 Painful genital vesicles and ulcers; erythema and pruritus; tingling or No cure, but antiviral therapy during
(HSV-2) shooting pain 1-2 days before outbreak; cycle through episodes. episodes shortens duration of
Viral shedding may occur during asymptomatic periods. Newborns lesions; Zovirax, Famvir, or Valtrex
can be infected by active lesions in vagina at birth. Brain damage,
blindness, or death of the newborn may occur. Cesarean section if
active lesions at time of birth. Increases risk for cervical cancer.
Genital warts Human papillomavirus (HPV) Most prevalent STI; period of communicability is unknown; lesions Goal of treatment is to remove
seen more frequently in women; tend to recur; 25% of women with symptomatic warts; cryotherapy to
HPV develop invasive cervical cancer; should be followed with lesions; podofilox solution or
routine Pap test (every 3-6 months if diagnosed with one of the imiquimod (Aldora) cream to
carcinogenic strains). lesions
Gonorrhea Neisseria gonorrhoeae Dysuria; urinary frequency; abdominal pain; increased or decreased Curable with antibiotic therapy;
(bacterium) vaginal discharge. May cause endometritis, PIO, and urethritis. azithromycin or doxycycline
Syphilis Treponema pallidum Six stages that can affect multiple body systems; l 0- to 90-day Penicillin G; if patient is allergic to
(spirochete bacterium) incubation; initial sign is a painless lesion, or chancre, at the penicillin, doxycycline or tetracycline
exposure site (vulva or vagina); serous discharge from chancre;
lymphadenopathy. If not treated, advances to later stages. Can
infect fetus via the placenta, resulting in congenital syphilis.
Trichomoniasis Trichomonas vagina/is May be asymptomatic; urinary frequency, urgency, and dysuria; Single dose of metronidazole
(protozoan) frothy yellow-green vaginal discharge; pruritus. (Flagyl) or tinidazole (Tindamax);
partner must be treated
HPV, Human papilloma virus; PID, pelvic inflammatory disease; ST/, sexually transmitted infection.

Benign Tumors
Fibroid Tumors
Uterine fibroid tumors, also called fibromyomas, leiomyomas, or
myomas, are idiopathic benign tumors composed mainly of smooth
muscle and some fibrous connective tissue. These tumors appear to
have a genetic link because they tend to run in families. Fibroids
vary in number, size, and location in the uterus and are quite
common. Menorrhagia is the primary symptom, although the
patient may experience bladder or rectal pressure, pelvic pressure,
pain, abdominal distortion, and infertility. Fibroid tumors affect
premenopausal women because they consist of estrogen-sensitive
cells. Fibroid tumors do not recur and do not undergo malignant
transformation; therefore, patients with fibroid tumors have an
excellent prognosis. Treatment depends on the severity of the symp-
toms and the patient's age because fibroid tumors tend to become
smaller and to calcify after menopause. The masses can be removed
surgically, or a hysterectomy may be indicated if bleeding is a serious
problem (Figure 17-8).
Ovarian Cysts
Ovarian cysts are sacs of fluid or semisolid material that form on or
near the ovaries. They can occur in the follicle or the corpus luteum
at any time between puberty and menopause. Most cysts are benign,
and small, asymptomatic cysts do not require treatment. Large or
multiple cysts may cause discomfort, low back pain, nausea, vomit-
ing, and abnormal uterine bleeding. These can be treated with birth
control pills over a period of several months to reduce the size of the
cysts or to prevent the development of new cysts. If pharmaceutical
therapy is not sufficient, laparoscopic procedures can be done to
drain or remove large cysts. Surgery may be indicated if a cyst rup-
tures, or in cases of torsion of the ovary, in which twisting cuts off
the blood supply to the ovary.
Polycystic ovary syndrome is a hormonal problem that may
cause cysts to develop over enlarged ovaries. The diagnosis depends
Pedunculated
abdominal
Submucosal
FIGURE 17-8 Uterine fibroid tumors are composed of hormone-sensitive cells and are designated
subserosal, intramural, submucosal, or pedunculated, depending on their location. (From Salvo SG:
Mosby's pathology for massage therapists, ed 2, St Louis, 2009, Mosby.)
CHAPTER 17 Assisting in Obstetrics and Gynecology 425
on the presence of two or more indicators, including irregular or no
menstruation, high testosterone levels, hirsutism (excessive body
hair in a masculine pattern), acne, and male pattern baldness
(androgenic alopecia). Women affected by this disorder have unusu-
ally high levels of testosterone, estrogen, and LH and decreased
amounts of FSH. They initially may be diagnosed because of fertil-
ity problems. The combination of hormone irregularities causes the
symptoms associated with the disorder; however, some women are
diagnosed by menstrual irregularity alone. These women are at
greater risk of uterine cancer, because the endometrium does not
slough off monthly. Also, there appears to be a link with insulin and
cholesterol metabolism, so women with this disorder are at greater
risk of developing diabetes mellitus type 2, obesity, and heart
disease. The condition is treated with OCPs to stimulate menses
artificially, to lower androgen levels, and to reduce masculine-type
symptoms if present.
Fibrocystic Breast Disease
Fibrocystic breast disease is characterized by the presence of multiple,
palpable nodules in the breasts; these nodules usually are associated
with pain and tenderness and fluctuate with the menstrual cycle
(Figure 17-9). Over time, the cysts enlarge, and the connective tissue
of the breast is replaced with dense, firm fibrous tissue. The masses
may be fibrous tumors that have degenerated or sacs filled with fluid.
The cysts feel firm and movable, and the degree of tenderness and
the size depend on the point in the menstrual cycle, with tenderness
peaking just before and during the secretory phase. Several different
cellular types of cysts can form, but fibrocystic changes in the breast
are not considered precancerous.
Although the risk of breast cancer is not increased with fibrocys-
tic breast disease, the diagnosis of cancerous breast masses becomes
more complicated. Because the breasts consistently feel lumpy,
breast examinations may not isolate a suspicious mass. In addition,
accurate mammography screening is complicated by the dense
FIGURE 17-9 Fibrocystic breast disease.
426 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES

nature of the cysts, making visualization of a cancerous area more
difficult. Patients should be encouraged to perform monthly breast
self-examination (BSE) and to report any changes in the breast
immediately.
Malignant Tumors
Most problems with the female reproductive organs are related to
abnormal cell growth. Early screening and preventive intervention
are essential. Most malignant tumors require surgical removal. Radi-
ation, chemotherapy, and hormone therapy are alternative treatment
choices.
Cervical Cancer
Almost all cervical carcinomas are caused by HPV. The first stage of
cervical cancer is asymptomatic, but early diagnosis of cervical cel-
lular changes is possible with a Papanicolaou (Pap) test (Procedure
17 -1 ). During the invasive stage, the patient reports abnormal
vaginal bleeding and persistent discharge, in addition to bleeding
and pain during intercourse. The average age of diagnosis for carci-
noma in situ (cancerous cells restricted to the original site) currently
is 35; however, it continues to drop because the number of cases in
young women is increasing. Women with HPV infection may be
tested every 3 to 6 months, depending on previous Pap results.

Pap Test and Other Guidelines for Women

• The first screening Pap test should be performed at age 21 unless the
patient has a history of an abnormal Pap test.
• Women ages 21 to 29 should have a Pap test once every 3 years.
• Women ages 30 to 65 who have a history of negative Pap test results
should have co-testing (Pap test combined with human papillomavirus
[HPV] testing) once every 5 years.
• Women who have had a hysterectomy far noncancerous reasons do not
need a Pap test unless they have a cervix.
• Cervical cancer screening with Pap tests should not be done in women
older than age 65 if they have no history of cervical cancer and if they
The American Congress of Obstetricians and Gynecologists (ACOG). www.ocog.org/About-ACOG/News-Room/News-Releoses/2012/0b-Gyns-Recommend-Women-Wait-3-to-5-Years-Between-Pap-
Tests. Accessed May 14, 2015.
have also had either three consecutive negative Pap test results or two
consecutive negative co-test results within the past l Oyears.
• These guidelines should be fallowed regardless of whether the patient has
had the HPV vaccine.
• Women should have a yearly physical examination, including breast
exam, pelvic exam (with or without a Pap test), and sexually transmitted
infection (STI) screening if indicated.
• Patients must have an annual exam to receive birth control.
• Patients with a history of an abnormal Pap test result should consult their
provider about how often to schedule Pap tests.

Instruct and Prepare a Patient for Procedures and/or Treatments: Assist with the
PROCEDURE 17-1
Examination of a Female Patient and Obtain a Smear for a Pap Test

Goal: To assist the provider in the examination of afemale patient and in obtaining a diagnostic Pap smear.

EQUIPMENT and SUPPLIES PROCEDURAL STEPS

• Patient's health record 1. Assemble the materials needed and prepare the room. Prepare the equip·
• Laboratory requisition slips ment and supplies needed far the Pap test.
• Patient gown 2. Sanitize your hands and fallow Standard Precautions.
• Lubricant PURPOSE: To ensure infection control.
• 4 x 4-inch gauze squares 3. Introduce yourself, greet the patient and verify her identity by name and
• Drape sheet date of birth, then, briefly explain the procedure.
• Examination light PURPOSE: Explanations gain the patient's cooperation and alleviate
• Cervical spatula and Cytobrush apprehension.
• ThinPrep container 4. Instruct the patient to empty the bladder, and collect a urine specimen if
• Vaginal speculum needed.
• Uterine sponge forceps PURPOSE: The provider's bimanual examination (see Figure 17-18) is
• Disposable examination gloves performed on an empty bladder.
• Urine specimen container, if needed S. Instruct the patient to disrobe completely and to put on a gown with the
• Stool far occult blood test cards with developer if needed opening in the front.
• Biohazard waste container 6. Assist the provider with the breast examination. To start, have the patient
• Appropriate patient education materials sit at the end of the examination table. Drape the patient and reassure
her as needed.

•;;m,ammjrji -,;ontinued
7. When the provider is ready to examine the breasts and the abdomen with
the patient in the supine position, assist the patient into the supine position
and drape as needed.
PURPOSE: To prevent unnecessary exposure of the patient.
8. When the provider is ready to begin the vaginal examination, assist the
patient into the lithotomy position. Have the patient slide down to the end
of the table; then adjust the stirrups as needed so that the knees are
relaxed and rotated outward. Remember always to position the patient
while she is underneath the drape.
9. Direct the light source onto the perineum.
PURPOSE: To facilitate better viewing of the cervix.
10. Put on gloves. Warm the stainless steel vaginal speculum in warm water
(the provider may prefer a disposable plastic speculum). Pass the proper
instruments to the provider in the proper sequence. The provider will need
the Cytobrush for cervical cells and the spatula for the cervical sample.
PURPOSE: Teamwork enhances efficiency.
11. Assist the provider with Thin Prep preparation by swirling the cervical speci-
men in the preservative solution at least 10 times to ensure that the
specimen has been mixed with the preservative solution.
12. Label the specimen container and place it in a biohazard bag.
13. Apply water-soluble lubricant to the provider's fingers.
PURPOSE: To facilitate the bimanual examination.
14. The provider may prepare a stool sample for occult blood testing after the
rectal examination. Have the materials ready.
The patient should be informed of factors that can interfere with
Pap test results, including menstruation and the use of vaginal
creams, spermicidal foams, and douching 2 to 3 days before the
examination. Also, the patient should refrain from vaginal inter-
course for 24 hours before the examination because it may cause
inflammation. The medical assistant should include in the patient
history the use of certain medications (e.g., tetracycline), which may
interfere with results; whether the patient has a latex allergy; the date
of the last menstrual period (LMP); whether the patient has a history
of a bleeding disorder or is taking anticoagulant medications; and
whether the patient is pregnant or may be pregnant.
The provider obtains the cervical smear with a Cytobrush or a
small wooden spatula that is inserted and rotated in the cervical canal
to obtain endocervical cells for cytology. A liquid-based cytology
exam, such as the ThinPrep Pap test, has replaced the traditional
slide preparation method for analyzing these cells because it is more
accurate in diagnosing precancerous and cancerous lesions and rarely
has to be repeated because of an inadequate cellular sample. The
provider uses the same technique to collect the cellular sample, but
instead of fixing it onto a glass slide, the collection device is rinsed
into a vial containing a preservative solution. In the laboratory, a
processor filters the sample and creates a slide with a thin layer of
cervical cells that is more uniform and better preserved than is pos-
sible with the traditional method.
CHAPTER 17 Assisting in Obstetrics and Gynecology 427
15. Instruct the patient to breathe deeply through the mouth with the hands
crossed over the chest.
PURPOSE: To help relax the muscles.
16. Place the soiled instruments in a basin.
PURPOSE: To help create better aesthetic surroundings.
17. Assist the patient off the table and with dressing if needed.
18. While the patient is in the dressing room, sanitize and disinfect the
examination room, removing used equipment.
19. Sanitize, disinfect, and sterilize stainless steel equipment. Remove your
gloves, dispose of them in a biohazard waste container, and sanitize your
hands.
PURPOSE: To ensure infection control.
20. Prepare the Pap test and other samples for transportation to the laboratory.
Complete the requisitions, including the date of the patient's last menstrual
period (LMP) and whether she is on hormone therapy.
21. Record all procedures in the patient's health record.
PURPOSE: Aprocedure is not done until it is entered into the patient's
record.
8/23/20-2:00 PM: Pap test and pelvic examination completed by provider.
ThinPrep specimen placed for pickup by University Laboratory for cytology. Pt
tolerated procedure well. Betsy Davis, CMA (MMA)
The pathologist examines the slide to determine whether cellular
abnormalities are present. The results are classified into one of five
categories: negative or normal, atypical squamous cells, abnormal
with low-grade squamous lesions, abnormal with high-grade lesions
(precancerous), or carcinoma cells. Inflammation or an STI infection
can cause abnormal changes in cervical cells, so the provider decides
how to manage abnormal results on the basis of other diagnostic
studies.
If the Pap test indicates abnormal cells, the pathologist can grade
cervical changes using a cervical intraepithelial neoplasia (CIN)
system of I to III, depending on the degree of cellular dysplasia
(Figure 17-10). CIN I indicates mild to moderate dysplasia; CIN
II, moderate and moderate to severe dysplasia; and CIN III, carci-
noma in situ. Patients whose Pap tests indicate dysplasia of any
severity should have a colposcopy with biopsy if indicated and
possibly an endocervical curettage. If adequately diagnosed and
treated, carcinoma in situ of the cervix has a 100% survival rate at
5 years.
Carcinoma of the cervix is classified into the following stages:
• Stage 0: Carcinoma in situ
• Stage I: Carcinoma of the cervix with no adnexal
involvement
• Stage II: Carcinoma of the cervix that has not spread into the
pelvic wall or vagina
428 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES

Superficial
cells

Parabasal
cells

Basal cells

Basement--.~~.___,,,,,.....
membrane --t- ---.----'11,.,____ ,.,..._-~ ---ii-- - -----=:i

Mild Moderate Severe Carcinoma Invasive

Normal
Dysplasia in situ cancer

FIGURE 17-10 Cervical dysplasia and carcinoma.

• Stage III: Carcinoma of the cervix that has spread into the
lower part of the vagina; may be blocking the ureters
• Stage IV: Carcinoma of the cervix that has spread to nearby
organs, such as the bladder or rectum, with involvement of
structures outside the pelvic area
Colposcopy is the visual examination of the vagina and cervical
surfaces with a colposcope (Figure 17-1 1) . The colposcope is a
microscope with a light source and a magnifying lens that can be
used during a vaginal examination to locate and evaluate abnormal
cells and to detect cancer of the cervix in the early stages, to examine
tissue from which an abnormal Pap test has been obtained, and to
monitor areas of the cervix where malignant lesions have been
removed. A cervical biopsy may be performed in conjunction with
a colposcopy. A major advantage of obtaining a biopsy during
colposcopy is that the instrument permits visualization of the
suspicious area so that the biopsy can be taken from the most atypi-
cal site.
Colposcopy is a relatively safe, painless procedure performed in
the provider's office. Discomfort may occur when the speculum is
inserted into the vagina to improve visualization of the tissue. Dis-
comfort and bleeding can occur when tissue is taken for biopsy.
Depending on the results of a previous biopsy, the patient may need
a more extensive procedure or conization, in which a cone-shaped
wedge of cervical tissue is removed for treatment or further analysis.
More often, a less invasive loop electrosurgical excision procedure
(LEEP) is performed with injection of a local anesthetic to the cervix
and insertion of a wire loop into the vagina. A high-frequency electri-
cal current running through the wire is used to remove abnormal
tissue from both the cervix and the endocervical canal. Like coniza-
tion, LEEP can be used as a diagnostic tool to collect biopsy samples FIGURE 17-11 Colposcopic appearance of normal cervix (Al and abnormal cervix (B). (A from
Swartz MH: Textbook of physical diagnosis, ed 7, Philadelphia, 2014, Saunders; Bfrom Pfenninger
and as a treatment to remove abnormal tissue (Figure 17-12).
Jl, Fowler GC: ffenninger and Fowler's procedures for primary care, ed 3, Philadelphia, 201 l,
Depending on the condition of the cervix, cryosurgery, or the Saunders.)
application of freezing temperatures, may be used to treat chronic
cervicitis and cervical erosion. Freezing causes cellular necrosis, and
 CHAPTER 17 Assisting in Obstetrics and Gynecology 429

Abnormal cells

A Cervix Uterus

A close-up view of The loop removes

the surface of the the abnormal tissue
cervix shows areas from the cervix.
B of abnormal cells.
FIGURE 17-12 A, Colposcopic view of cervix and LEEP procedure. B, LEEP biopsy of abnormal cells.

in approximately I month, the dead cells are replaced with healthy
cells. The procedure involves placing a probe against the problem
area on the cervix and applying liquid nitrogen to the area for
approximately 3 to 4 minutes or until the site is frozen (Procedure
17-2). The patient may experience some pain for 30 minutes or so
after the procedure and a slight watery discharge for up to a week.
If any signs of infection, foul discharge, or pain develop, the patient
should call the provider's office. Advise the patient not to engage in
sexual intercourse for 1 month and to expect a heavier than usual
menstrual flow for the first cycle after the procedure.

Instruct and Prepare a Patient for Procedures and/or Treatments: Prepare the Patient
PROCEDURE 17-2
for a LEEP

Goal: To prepare the patient and assist the provider in a LEEP.

EQUIPMENT and SUPPLIES PROCEDURAL STEPS

• Patient's health record 1. Assemble the necessary equipment.
• Cytology request forms PURPOSE: To expedite the procedure.
• Colposcope 2. Sanitize your hands.
• LEEP instrument PURPOSE: To ensure infection control.
• Vaginal speculum 3. Greet the patient, introduce yourself, and verify the patient's identity by
• Local anesthetic with syringe unit name and date of birth. Record the patient's vital signs. Check to make
• Monsel's solution or similar solution to prevent cervical bleeding sure a signed informed consent form is in the patient's record.
• Disposable examination gloves PURPOSE: To establish a baseline for vital signs and to follow legal
• Specimen containers protocols.
• Biohazard waste container 4. Drape the patient and assist her into the lithotomy position. Put on gloves.
430 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES
•;;m,ammjrfj -,;ontinued
5. Assist the provider with the procedure by handing equipment and supplies
as needed.
• The colposcope is used to visualize abnormal cells.
• The provider administers a local anesthetic to the cervical area.
• The LEEP instrument is used to remove abnormal cells.
• The cervix may be coated with Monsel's solution or a similar solution
ta prevent cervical bleeding
6. Encourage the patient to take deep breaths to promote relaxation of the
pelvic muscles during the procedure. Observe the patient for any signs of
distress.
PURPOSE: Ta ensure the patient's safety.
7. If a biopsy sample is taken, place the tissue in a specimen cup and label
it for the lab.
8. When the procedure is complete, place the patient in a supine position
and allow her to rest while you tidy the room and remove the used sup-
plies. Retake her vital signs.
PURPOSE: Ta ensure that the vital signs return ta baseline levels.
9. Remove your gloves, discard them in a biohazard waste container, and
sanitize your hands.
PURPOSE: Ta ensure infection control.
Endometriaf Cancer
The inner lining of the uterus, the endometrium, is at increased risk
for dysplasia in postmenopausal women who have never had chil-
dren and in those who experienced early menarche and late meno-
pause. Certain conditions, such as obesity, hypertension, and diabetes
mellitus, may increase the risk of endometrial cancer. Taking tamoxi-
fen for breast cancer can increase the risk of developing endometrial
cancer. This slow-growing cancer begins with hyperplasia of the
endometrial wall, followed by dysplasia. Early signs are irregular
vaginal bleeding and leukorrhea (white or yellow) vaginal discharge;
difficult or painful urination; pain during sexual intercourse; and
pelvic pain. The diagnosis usually is made with an endometrial
biopsy, transvaginal ultrasound, or a CT scan. Treatment involves
a complete hysterectomy with radiation therapy and chemotherapy.
Because most of these tumors develop after menopause, vaginal
bleeding is unusual, and the woman is more likely to seek medical
attention. Because of this, early diagnosis and treatment lead to a
survival rate of almost 90%.
Ovarian Cancer
Ovarian neoplasms are the most important pathologic disorder of
the ovaries. Ovarian cancer causes more deaths than any other cancer
of the female reproductive system, but it accounts for only about
3% of all cancers in women. Most of the time the cancer has already
metastasized before the tumor is diagnosed. Symptoms do not
appear until the tumor has enlarged enough to exert pressure on
nearby structures; patients complain of vague abdominal discomfort,
bloating, urinary urgency, weight loss, and general malaise.
Researchers are working to perfect a blood test that can be used
to screen for ovarian cancer so that the disease can be diagnosed in
10. Help the patient sit up and assist her in dressing if needed.
PURPOSE: Ta ensure the patient's safety.
11. Apply gloves and prepare the specimen for lab delivery.
12. Sanitize, disinfect, and sterilize the equipment per the manufacturer's
directions and return it to the proper storage area.
13. Remove gloves, dispose in a biohazard waste container, and sanitize your
hands. Provide the patient with instructions on follow-up care as ordered
by the provider.
14. Record the procedure and the final vital signs measurements in the
patient's record.
PURPOSE: Aprocedure is not done until it is recorded.
7/22/20-10:25 t,.M: Cervical LEEP completed by provider without incident. Pt
stable, T98.6°, P82, R20, BP 118/72. No c/o discomfort. Pt to call office
if any problems noted. Betsy Davis, (MA (AAMA)
earlier, more treatable stages. Currently, ovarian cancer is diagnosed
by a combination of a pelvic examination that indicates a mass in
an ovary; a cancer antigen CA125 blood test, which identifies a
protein found in abnormally high levels in women with ovarian
cancer (although the test can produce false-positive and false-negative
results); and a pelvic or transvaginal ultrasound to evaluate the size
and shape of the ovaries. The ultimate diagnosis is based on a biopsy
to confirm the presence of cancerous cells.
Little is known about how or why ovarian cancer occurs, but
pregnancy, breast-feeding, and oral contraceptive use may reduce the
risk. Risk factors include aging (most ovarian cancers are diagnosed
in women age 55 or older), family history, genetic mutations, a
personal history of breast cancer, and obesity. Treatment consists of
a complete hysterectomy (removal of the uterus, fallopian tubes, and
ovaries), radiation therapy, and chemotherapy. About 20% of all
ovarian tumors are cancerous, and the recovery rate is linked to the
location, the stage of tumor development, and the patient's age.
Breast Cancer
Breast cancer is the second leading cause of cancer deaths in women.
According to the American Cancer Society, 1 in 8 women have a
lifetime risk of developing breast cancer and a 1 in 28 risk of dying
from the disease. Predisposing factors include a family history of
breast cancer (especially in the mother, sister, or daughter, although
fewer than 15% of women with breast cancer have a family history),
early menarche and late menopause, first pregnancy after age 30 or
no pregnancy, prolonged use of estrogen replacement therapy, excess
alcohol intake, smoking, and obesiry.
Because research does not link reduced death rates from
breast cancer with monthly BSE, the American Cancer Society

recommends that women have their practitioner perform a clinical
breast examination (CBE) rather than rely on monthly BSEs for
early detection. However, although a monthly BSE is now consid-
ered optional, women still should be aware of the normal appearance
and texture of the breasts and should immediately report to the
provider any changes or new breast symptoms. The medical assistant
should be prepared to teach the BSE technique (Procedure 17-3).
CBEs should be done every 3 years from age 20 to 39 and annually
at 40 years of age and older. A mammogram (discussed later in the
chapter) should be done annually starting at age 40. If a woman has
an increased risk of breast cancer (e.g., family history), the provider
may recommend annual mammography screening before age 40 or
other diagnostic procedures, such as ultrasound or magnetic reso-
nance imaging (MRI). An MRI scan can reveal tumors too small to
detect with a breast examination and that may not show up clearly
on a mammogram. The American Cancer Society recommends that
those with a high risk for breast cancer have an MRI scan and a
mammogram every year.
Women who are genetically predisposed to breast cancer and
are at very high risk may opt for a bilateral prophylactic mastec-
tomy, in which both breasts are removed to eliminate the possibil-
ity of breast cancer developing in the future. This surgery reduces
the risk of breast cancer by at least 95% in women with genetic
mutations.
Indications of breast cancer include a palpable breast mass that
is firm and immovable, breast pain, tissue thickening, nipple retrac-
tion or dimpling, nipple discharge, and axillary lymphadenopathy.
If a breast mass is palpated, a mammogram or ultrasound of the area
is ordered and, if indicated, a biopsy is performed. The provider may
perform a needle biopsy to remove cells and/or tissue from a palpated
mass for evaluation by the pathologist. If a nonpalpable mass is
found on a mammogram, a stereotactically guided needle aspiration
is done, and surgical biopsy is a possible follow-up. During this
procedure, the provider uses a mammogram to guide the needle
toward the suspicious mass, from which a biopsy sample can be
taken. If a tissue sample cannot be obtained through a needle, wire
localization may be done to pinpoint the areas of concern from the
mammogram. During this diagnostic procedure, a thin wire is
passed through the breast to the point of concern (based on
mammogram visualization). This wire marking is used during a
surgical biopsy procedure, to pinpoint tissue that was suspicious on
the mammogram.
If a biopsy shows malignant cells, the provider orders an estro-
gen and progesterone receptor test to determine whether hor-
mones affect the way the cancer grows. If the cancer cells' growth
patterns increase when exposed to hormone levels, the provider
may recommend treatment with a drug such as tamoxifen, which
prevents estrogen from binding to these sites. Tamoxifen may also
be prescribed to reduce the risk of breast cancer in high-risk
women.
The treatment of breast cancer depends on the type of carci-
noma and its staging. Treatment almost always begins with
surgery, but the type of surgery and the extent of the tissue
removed depend on several factors. One type of breast-saving
surgery is lumpectomy, in which only the suspicious mass plus a
surrounding area of normal tissue is removed; radiation therapy is
used as a follow-up to destroy any remaining cancerous cells. A
CHAPTER 17 Assisting in Obstetrics and Gynecology 431
partial mastectomy may be done for more advanced cases; this pro-
cedure involves removal of the tumor and tissue surrounding it,
part of the chest muscle beneath the mass, and some of the lymph
nodes in the axillary region. A complete mastectomy, which involves
removal of the entire breast, chest muscle, and axillary lymph
nodes, may still be indicated if the mass has spread. However,
removal of multiple axillary lymph nodes greatly increases the risk
that subsequent lymphedema and recurrent infections in the arm
on the affected side.
New techniques recommend the removal of the sentinel lymph
node; this is the first lymph node to receive lymphatic drainage
from a tumor and therefore the one most likely to spread cancer
cells to other areas of the body. The sentinel node is found by
injecting a blue dye near the tumor; the lymph vessels absorb the
dye and carry it toward the lymph nodes, and the first node to
receive the dye and turn blue is the one that is removed for patho-
logic testing. If the sentinel node is cancer free, there is very little
chance that the breast tumor has metastasized, and no other nodes
need to be removed. If cancer cells are evident, further diagnostic
procedures are indicated to determine the possible locations of
metastatic tumors.
Targeted therapy is a newer type of cancer treatment in which
drugs are used to identify and attack cancer cells; as a result, very
little damage is done to healthy cells. Targeted therapy is a growing
part of many cancer treatment regimens.
Many patients now opt for breast reconstruction after a partial
or complete mastectomy. This procedure typically is performed by
a plastic surgeon, and a variety of methods can be used to recon-
struct breast tissue, including implantation of a silicone or gel
material or the use of fat and other tissue from another part of the
body, such as the abdomen. Either the surgeon saves a tissue flap
that includes the nipple or, after the breast is reformed, tattoo
techniques are used to create an areola and nipple. The patient
must discuss these options with her surgeon before the mastec-
tomy is performed, and the medical assistant may be involved in
the referral process.
Inflammatory Breast Cancer
• Inflammatory breast cancer is a rare, aggressive cancer that causes
the sudden onset of discoloration and warmth in the affected breast,
along with edema, dimpling of the skin, enlarged axillary lymph nodes,
and pain.
• The condition is easily confused with a breast infection, so patients
should contact their provider as soon as symptoms appear.
• Cancer cells spread rapidly and block lymph vessels in the skin, which
results in the classic symptoms.
• The condition is diagnosed by an excisional biopsy to confirm the pres-
ence of clumped cancer cells in the area lymph vessels.
• Inflammatory breast cancer typically is diagnosed as stage Ill, which
means that the cancer has spread to local lymph nodes. However, one
third of patients are diagnosed with stage IV carcinoma, in which
metastasis already has occurred.
432 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES

Coach Patients in Health Maintenance and Disease Prevention: Teach the Patient
PROCEDURE 17-3
Breast Self-Examination

Goal: To teach the patient how to palpate her breasts to check for possible abnormalities.

EQUIPMENT and SUPPLIES

• Patient's health record
• Instruction pamphlet/shower card
• Teaching model (to demonstrate the technique before a return demonstra-
tion by the patient)
PROCEDURAL STEPS
1. Assemble the necessary equipment.
2. Sanitize your hands and follow Standard Precautions.
PURPOSE: To ensure infection control.
3. Greet the patient, introduce yourself, and verify the patient's identity by
2
name and date of birth, then briefly explain the procedure.
PURPOSE: Explanations gain the patient's cooperation and alleviate
apprehension. 7. Instruct the patient to squeeze both nipples gently and to look for dis-
4. Instruct the patient to examine her breasts while bathing or showering in charge (Figure 3).
warm water because the fingers glide more easily over wet tissue. The
best time to perform this examination is immediately after the end of the
menstrual period, when breast engorgement is minimal. Nonmenstruating
women should examine their breasts the first of each month.
S. Instruct the patient to raise one arm, using the right hand to examine the
left breast and the left hand for the right breast. Using the finger pads of
the three middle fingers, move in a small circular pattern up and down
the breast. Starting at the axillary region, work down the area and back
up again from the axillary to the ribs below the breast, back up to the
clavicle, and repeatedly across to the sternum bilaterally (Figure l ).

8. Before dressing, the patient should lie on a bed. Atowel or pillow is placed
under the right shoulder, and the right hand is placed behind the head.
The right breast is examined with the left hand. Instruct the patient to
press gently in small circles, starting at the top outermost edge, including
the axillary region, and spiraling in toward the nipple. This is repeated
with the left breast (Figure 4).

6. After finishing her bath or shower, the patient should continue the examina-
tion in front of a mirror with the arms at the sides. Then, with her arms
raised above her head, she should look carefully for changes in the size,
shape, and contour of each breast. She should look for puckering, dim-
pling, or changes in skin texture (Figure 2).

4

•ijm1iji111j;jjf& -continued
9. The patient should provide a return demonstration using the teaching
model to confirm her understanding.
10. Give the patient an instruction pamphlet and/ or shower card to use at
home.
Positional Disorders of the Pelvic Region
The correct anatomic position for the uterus is tipped slightly ante-
riorly (anteverted) and bent over the bladder, with the cervix down
and back. However, the uterus may be positioned at various angles
because of a congenital anomaly, aging, or the effects of childbirth.
With the aging process and/or multiple pregnancies, the muscles and
ligaments that support the uterus, bladder, and rectum can stretch
or weaken. This weakening of the supportive structures of the pelvic
floor can result in multiple structural disorders.
A cystocele is a protrusion of the bladder into the anterior wall of
the vagina. The bladder becomes angled, and urinary retention is
common, along with frequent cystitis. The diagnosis can be made
by having the patient bear down as the vaginal opening is examined;
this allows the provider to feel the bladder protrusion. A cystocele
can result from injury during childbirth, obesity, heavy lifting,
chronic coughing, and poor musculature that occurs with aging
(Figure 17-13).
A rectocele is a protrusion of the rectum into the posterior wall
of the vagina. The patient complains of difficulty with bowel move-
ments and pressure in the pelvic region. The diagnosis can be made
by having the patient bear down as the vaginal opening is examined
so that the provider can palpate the posterior wall. Rectoceles are
most ofren seen in postmenopausal women. A rectocele may result
from pregnancy, difficult delivery, prolonged labor, obesity, chronic
coughing, and repeated lifting of heavy objects.
Normal female pelvic anatomy
FIGURE 17-13 Acystocele is a protrusion of the bladder into the anterior wall of the vagina.
CHAPTER 17 Assisting in Obstetrics and Gynecology 433
11. Record the patient education intervention in the patient's health record.
PURPOSE: Patient education interventions should always be docu-
mented; a procedure is not done until it is entered into the patient's
record.
The uterus also may lose supportive structure and drop into the
vagina. This structural disorder is called uterine prolapse. The prolapse
may involve only descent of the cervix into the vaginal area, or it
may progress to protrusion of both the uterus and the cervix from
the vaginal opening.
The first step in the treatment of pelvic positional disorders is to
teach the patient how to perform pelvic floor muscle exercises, or
Kegel exercises. The patient may be referred to a physical therapist
that specializes in female disorders and uses biofeedback to help train
the patient to perform the exercises accurately. If severe, all three of
these structural abnormalities can be corrected with surgery.
Kegel Exercises
Kegel exercises help strengthen the pelvic floor muscles. They are done to
prevent or treat pelvic organ prolapse and incontinence. The steps are as
follows:
1. Contract the muscles that make up the pelvic floor by visualizing
that you are stopping the flow of urine midstream.
2. Hold the contraction to the count of 3 and then slowly relax for a
count of 3.
3. Repeat the exercise until you are performing 20 contractions in a
set, with up to three sets throughout the day.
Cystocele
434 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES
PREGNANCY
Anatomy and Physiology
Fertilization usually takes place in the distal third of the fallopian
tube when one sperm cell penetrates and fertilizes an egg, which is
then called a zygote. The zygote, which is made up of 23 chromo-
somes from the ovum and 23 chromosomes from the sperm, forms
the first complete cell. This cell begins to grow and multiply imme-
diately. The zygote travels down the fallopian tube and reaches the
uterus in 5 to 6 days, implanting in the uterine endometrium.
Enzymes are secreted by the zygote to aid the implantation process.
After implantation, the placenta forms within the uterine wall.
It is derived from maternal endometrial tissue and from the chorion,
the outermost membrane that surrounds the developing zygote. The
amnion, the innermost layer of the membranes, holds the fetus
suspended in an amniotic cavity surrounded by a fluid called amni-
otic fluid. The amnion and the fluid sometimes are called the "bag
of water." In about 25% of pregnancies, breaking of the amniotic
sac signals the onset of labor.
Within 2 weeks of fertilization, the zygote has undergone mitosis
and is well established in the uterus. The next stage of development
is the embryonic period, which includes week 3 to week 12 of preg-
nancy (the first trimester). The embryonic period is a crucial time
because this is when all tissues and organs develop. During the
second and third trimesters, the embryo becomes a fetus; this is when
cells develop and begin their primary functions, organs mature, and
the fetus gains weight and grows in length.
Throughout the pregnancy, maternal and fetal blood never mixes.
Nutrients and oxygen diffuse from the mother's blood across the
placental membrane into the blood vessels of the fetus's umbilical
cord. Carbon dioxide and waste materials pass from the umbilical
cord, through the placenta, and into the mother's circulatory system
for excretion (Figure 17-14).
The placenta also acts as a gland by producing HCG and proges-
terone to maintain the pregnancy. Low levels of progesterone can
lead to spontaneous abortion in pregnant women and menstrual
irregularities in nonpregnant women. The average gestation is calcu-
Placenta
Umbilical
vein
Amnion----
Chorion - ~ -- -
FIGURE 17-14 Structural features of the placenta and exchange of nutrients and wastes between maternal and fetal blood.
lated at 9 calendar months, 10 lunar months, or 266 to 280 days.
As previously mentioned, it is divided into three trimesters.
First Trimester
The first trimester is the period from the beginning of the LMP
through week 14. It is a time of multiple physical and psychological
changes for the woman and a crucial time for fetal organ develop-
ment. It is essential that the pregnant woman understand the impor-
tance of a nutritious diet and of avoiding potential teratogens. The
woman may complain of breast tenderness, constipation, headaches,
urinary frequency, and nausea and vomiting. Rest, relaxation exer-
cises, plenty of fluids, regular exercise, and small, frequent meals help
relieve these discomforts. During this time, the obstetrician obtains
a complete health history of the patient, including family, medical,
menstrual, and obstetric histories. The obstetric history includes
the number of times the patient has been pregnant (gravida)
and the number of pregnancies carried to more than 20 weeks'
gestation (para).
CRITICAL THINKING APPLICATION 17-4
You are interviewing a new OB patient. She tells you that this is her fourth
pregnancy, and she has two children. She had two early miscarriages. How
would you document this obstetric history?
Second Trimester
The second trimester extends from week 15 through week 28 afrer
the LMP. The uterus has enlarged to above the umbilicus, and the
patient feels the first fetal movements, called quickening. In addition
to the basic health history and physical examination, assessment is
performed by abdominal palpation and fetal heart monitoring. The
height of the fundus may be measured in centimeters from the
symphysis pubis to the fundus. At each office visit, a urine sample
is screened with a dipstick to detect protein and/or glucose, and the
woman's blood pressure is monitored for signs of hypertension. The
mother may complain of backache, dizziness, leukorrhea, and leg
cramps from the increasing size of the uterus.
Maternal
blood pool
Chorionic villus
Maternal

Third Trimester
The third trimester begins at week 28 and lasts until delivery. This
period is marked by rapid fetal growth, with the baby gaining close
to 1 pound per week. The patient continues to be closely monitored.
Childbirth preparation classes usually begin during this time. The
patient experiences noticeable breast enlargement and may have an
occasional discharge from the nipples of the clear, sticky fluid colos-
trum. The pregnant woman may complain of uterine cramping
(Braxton-Hicks contractions), heartburn, edema, and frequent urina-
tion. Lightening, the dropping of the fetus into the pelvis, may occur
a few weeks before birth, especially in primigravidas (women in their
first pregnancy). Tdap (immunization for diphtheria, tetanus, and
- ~ - - - - - Ruptured
membranes
FIGURE 17-15 The labor process. A, Effaced cervix. B, Dilation stage. C, Expulsion stage. D, Placental stage. (From Applegate EJ: The
anatomy and physiology learning system, ed 4, Philadelphia, 2011, Saunders.)
CHAPTER 17 Assisting in Obstetrics and Gynecology 435
pertussis [whooping cough]) should be administered between 27 and
36 weeks' gestation to maximize maternal antibody response and
passive antibody transfer levels to the baby. Anyone caring for the
newborn, including husbands, grandparents, older siblings, and
babysitters, should also be vaccinated. This vaccination has become
more important because of an increase in whooping cough outbreaks
in recent years. Pertussis is a very serious respiratory infection in
newborns and young children.
Parturition
Labor is the physiologic process by which the uterus expels the fetus
and the placenta (Figure 17-15). To be born vaginally, the baby must
Effaced cervix
Amnion
Umbilical cord
436 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES
drop down into the pelvic floor, and the cervix must efface (thin
out) and dilate (open up). Effacement is the thinning of the cervix
from its prelabor length of 1 to l½ inches to a completely thin tissue
(Figure 17-15, A). This occurs when uterine contractions pull cervi-
cal tissue upward as labor progresses so that the bottom uterine
segment (the cervix) becomes thinner and the top uterine segment
(the fundus) becomes thicker. Effacement is measured as a percent-
age; the cervix is said to be 0% to 100% effaced. Dilation (some-
times called dilatation) is the opening of the cervix, which allows the
infant to pass out of the uterus and into the vaginal birth canal.
Dilation is measured in centimeters, which are estimated during
vaginal examinations by manual palpation. Labor is divided into
three stages:
• Stage I: Lasts from the onset of labor through complete dila-
tion and effacement of the cervix (Figure 17-15, B). During
this time, uterine contractions become longer, stronger, and
closer together until complete dilation and effacement occur
and pushing begins. Stage I is divided into early active (up to
3 cm dilation and 80% to 100% effaced), active (4 to 7 cm
dilation and completion of effacement), and transition (8 to
10 cm dilation). The average length of time for primigravidas
in stage I is 9 to 11 hours.
• Stage II: Lasts from complete dilation and effacement of the
cervix through the birth of the fetus (Figure 17-15, C) . This
is the pushing stage, which lasts approximately 1 hour for
primigravidas.
• Stage III: Lasts from the birth of the fetus through expulsion
of the placenta (Figure 17-15, D). This occurs approximately
20 minutes after the birth of the baby.
Pregnancy Complications
Infertility and Abortions
Fertility problems in women can occur for many different reasons,
including a history of STis that have caused scarring or adhesions
of the fallopian tubes, failure to ovulate or irregular ovulation, con-
genital anomalies of the reproductive organs, endometriosis, medica-
tions that reduce fertility, and advancing age.
Problems in becoming pregnant can occur at several points in
time, the first being abnormal fertilization. Some couples are unable
to have a child because of the inability of the sperm and the ovum
to unite. Ovarian factors are not totally understood; however, it is
known that as women age, the ova become less viable. If the couple
is able to fertilize an egg, another problem that can occur is improper
implantation.
An ectopic pregnancy is one that occurs outside the uterus.
Although an ectopic pregnancy can develop on or near the ovary or
in the abdominal cavity, most occur in the fallopian tube. As the
zygote develops, the cells that form the placenta begin to erode the
muscle layer of the tube, bleeding and destruction of the muscular
layer occur, and the tube ruptures. Rupture of the fallopian tube
containing an ectopic pregnancy is a serious event that requires
immediate surgical intervention to prevent serious hemorrhage.
Once a woman becomes pregnant, problems can occur with car-
rying the infant to term. Interruption of a pregnancy before the term
of fetal viability is called an abortion, which is identified in lay terms
as a miscarriage. There are several different categories of naturally
occurring abortions, including the following:
• Spontaneous: No identifiable cause.
• Complete: Complete expulsion of both fetus and placenta
with no medical intervention.
• Incomplete: Expulsion of only parts of the fetus and placenta;
a D&C must be done to remove the remaining pieces or the
mother will continue to bleed.
• Missed: The fetus dies in utero and must be removed
surgically.
• Threatened: Cervical bleeding occurs, but dilation does not,
and the pregnancy continues uninterrupted.
It is estimated that 1 in 3 pregnancies terminates by a naturally
occurring abortion, and in most cases, the causes are not clear.
Chromosomal anomalies frequently are detected in an aborted fetus
or placenta and may be the primary reason for the abortion. Spon-
taneous abortion is the loss of a pregnancy before week 20 of fetal
development. Common causes are defective development of the
embryo, abnormalities of the placenta, endocrine disorders, malnu-
trition, infection, drug reaction, blood group incompatibilities,
severe trauma, and shock. Symptoms include vaginal bleeding of
varying degrees of severity and lower abdominal cramping that pro-
gresses to cervical dilation with rupture of membranes and complete
expulsion of the products of conception. Induced abortions involve
evacuation of the uterus at the request of the mother.
Listeria Infection
Listeria manocytogenes (Listeria) is a bacterium that can be found in soft
cheeses, hot dogs, and luncheon meats. Mast healthy people exposed to
Listeria organisms don't become ill. However, pregnant women, newborns,
older adults, and people with weakened immune systems are mare sus-
ceptible. In same cases a Listeria infection can lead ta life-threatening
complications, including the following:
• Ageneralized blood infection (septicemia)
• Inflammation of the membranes and fluid surrounding the brain
(meningitis)
Complications of a Listeria infection may be most severe for an unborn
baby; a Listeria infection early in the pregnancy may lead to miscarriage.
Listeria organisms can cross the placental barrier, and infections in late
pregnancy may cause stillbirth, or an infant may die shortly after birth. This
is why pregnant women must avoid potentially contaminated foods.
Placental Abnormalities
Pregnancy complications can occur because of the site of placental
implantation. In placenta previa, the placenta implants in the lower
uterine segment. If routine sonograms diagnose placenta previa early
in a pregnancy, the placenta may migrate upward with uterine wall
enlargement. However, if the previa persists throughout the preg-
nancy and the placenta is implanted on or near the cervix when the
mother goes into labor, dilation and effacement of the cervix can
cause the placenta to tear loose (Figure 17-16). Complete dilation
and effacement cannot progress without serious oxygen deprivation
to the fetus and hemorrhaging in the mother. The signs of placenta
previa include painless, bright red vaginal bleeding during or near
the last trimester. The diagnosis is confirmed with a sonogram. A

Placenta
Internal
cervical os
FIGURE 17-16 Placenta previa.
cesarean section is done as close to term as possible to prevent com-
plications in both mother and fetus.
Another placental problem, abruptio placentae, occurs when the
placenta detaches from the uterine wall. The pregnant woman
reports an acute onset of severe abdominal pain; firmness on palpa-
tion and hemorrhaging from the vagina also are factors. She also
shows signs of shock, including tachycardia, a thready pulse, hypo-
tension, and clammy, cool skin. The fetus shows signs of distress
from lack of oxygen, including a decreased fetal heart rate and lack
of movement. This is a true obstetric emergency and requires imme-
diate cesarean delivery to save the infant and the mother.
Maternal Disorders
Gestational Diabetes. Any degree of impaired glucose tolerance
during pregnancy is diagnosed as gestational diabetes mellitus
(GDM). Gestational diabetes occurs in 5% to 9% of pregnancies,
and the number is growing, primarily because of the increased inci-
dence of obesity. Women at greatest risk are over age 30; have a
family history of diabetes mellitus; had a body mass index (BMI)
greater than 25 before pregnancy; and are members of certain
racial groups, including African-Americans, Hispanics, and Native
Americans.
The American Congress of Obstetricians and Gynecologists
(ACOG) recommends that all pregnant patients be screened for
GDM at 24 to 28 weeks' gestation using a 50-g, 1-hour glucose
challenge test. The patient is given a concentrated drink equivalent
to 50 g of glucose, and blood is drawn 1 hour afrerward to measure
blood glucose levels. A level higher than 140 mg/dL indicates GDM,
but these patients are retested with a 3-hour glucose challenge. Blood
is checked every hour for 3 hours after the patient drinks a concen-
trated glucose solution, and elevation in two of these blood draws is
considered a positive result for GDM.
It is very important that women diagnosed with GDM carefully
monitor their blood glucose levels regularly using a glucometer. This
requires the patient to place a drop of blood on a machine that
CHAPTER 17 Assisting in Obstetrics and Gynecology 437
analyzes it and reports the current blood glucose level. Patients may
be able to achieve normal glucose levels with diet therapy and exer-
cise. However, studies indicate that the best medical treatment for
GDM is insulin therapy. The mother's problem with glucose metab-
olism typically goes away after the birth of the infant, but these
women are at greater risk of developing diabetes mellitus type 2 later
in life. Patient education on healthy lifestyles, including the impor-
tance of a nutritious diet, weight management, and exercise, is
needed to help prevent adult-onset diabetes mellitus type 2.
The medical assistant's responsibilities include performing blood
tests as ordered, completing routine urinary dipstick tests at each
visit, and providing referral to a dietitian for help with diet therapy
management.
Hypertension. Most women who develop hypertension during
pregnancy have normal blood pressure before becoming pregnant
and also during early pregnancy but develop hypertension in the
second half of the pregnancy. Gestational hypertension (pregnancy-
induced hypertension) can be mild to severe and occurs in approxi-
mately 10% to 15% of pregnancies.
If hypertension is accompanied by proteinuria after 20 weeks of
pregnancy, the patient is diagnosed with pre-eclampsia, or toxemia,
which occurs in approximately 2% to 3% of pregnancies. Pre-
eclampsia usually shows up unexpectedly during a routine prenatal
visit. The patient has an elevated blood pressure with protein or
albumin in the urine and may also have uremia, altered liver func-
tion, and a reduced platelet count. The birth of the baby cures pre-
eclampsia, with blood pressure returning to normal within a few days
of delivery. However, if indicators of pre-eclampsia occur early in the
pregnancy, the provider attempts to balance the need to prevent
premature birth of the infant with what is best for the mother. The
baby is monitored with routine nonstress tests (NSTs), sonograms,
and maternal reports of fetal movement. If pre-eclampsia persists,
the patient is at risk of severe headaches, vision disturbances, oligu-
ria, and convulsions either before or during labor, and an emergency
cesarean section may be required to prevent serious maternal
complications.
The medical assistant is responsible for monitoring the pregnant
woman's vital signs at each visit, including any report of a sudden
weight gain that may indicate edema, and for performing routine
urine dipstick tests. Complete and accurate documentation of
findings helps alert the provider to possible problems with
hypertension.
MENOPAUSE
Menopause is the permanent ending of menstruation as a result of
cessation of ovarian function. It usually occurs between 45 and 55
years of age but can occur as early as the 30s and as late as the 60s.
Menses may stop suddenly, flow may decrease over time, or the time
between menses may lengthen until complete cessation occurs.
Menopause can be diagnosed only retrospectively. Only after 12
months of amenorrhea is a woman said to be in menopause, and the
years after this are called postmenopause.
Perimenopause begins when hormone-related changes start to
appear, and it lasts until the final menses; this can be as long as 10
years before menopause. During this time, women are still ovulating,
but the uneven rise and fall of estrogen and progesterone may cause
438 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES
symptoms. Some women experience few or no symptoms, whereas
others have hot flashes, concentration problems, mood swings, irri-
tability, migraines, vaginal dryness, urinary incontinence, dry skin,
and sleep disorders. Treatment focuses on relieving these signs and
symptoms. The provider may prescribe vety low-dose oral contracep-
tives (Loestrin 1/20, Alesse) to balance estrogen and progesterone
levels or short-term hormone replacement therapy (HRT) (e.g., Pre-
marin, Prempro) to treat symptoms. The provider also may recom-
mend that the patient consume soy products or take soy supplements
for a plant source of estrogen. Vitamin E may help alleviate hot
flashes, and vitamin B6 helps create natural serotonin, a neurotrans-
mitter that affects mood. Other methods that help alleviate symp-
toms include avoiding caffeine and spicy foods to reduce hot flashes,
using relaxation techniques to aid with sleep disorders, consuming
a low-fat diet high in calcium and vitamin D, and performing regular
weight-bearing exercise to help prevent osteoporosis and heart
disease.
Medical treatment of menopause focuses on managing uncom-
fortable symptoms and preventing conditions associated with a drop
in blood levels of estrogen, such as osteoporosis and coronary artery
disease. Providers traditionally treated perimenopause and meno-
pause with long-term HRT for most women; however, studies indi-
cate that although HRT does protect the menopausal woman from
osteoporosis, hip fracture, and colon cancer, at the same time it
increases the risk of heart attack, stroke, breast cancer, and blood
dotting. It is now recommended that providers prescribe HRT to
meet individual patient needs over a short term (i.e., no longer than
5 years) rather than as routine treatment for all menopausal women.
Studies show that the risk for heart disease and other complications
increases after 5 years of HRT. The medical assistant must be aware
of the provider's recommendations regarding HRT.
Other medications that may be prescribed include antidepres-
sants, such as venlafaxine or fluoxetine (Prozac, Sarafem), to prevent
hot flashes. Gabapentin (Neurontin) and clonidine (Catapres) also
may be prescribed to reduce the frequency of hot flashes. Because
the development of osteoporosis is a concern in perimenopausal and
postmenopausal women, the provider may prescribe alendronate
(Fosamax), risedronate (Actonel), or ibandronate (Boniva) to reduce
bone loss and the risk of fracture. Another drug that may be used
to improve postmenopausal bone density is raloxifene (Evista);
however, hot flashes are a common side effect of this medication.
Vaginal dryness can be treated with estrogen administered locally by
vaginal tablet, ring, or cream, or the patient can use K-Y Jelly or
some other vaginal moisturizer as a lubricant.
CRITICAL THINKING APPLICATION 17-5
Rose Conrad, a 53-year-old patient of Dr. Beck, calls because she read
recently that the hormone replacement therapy she has been taking for 3
years may be dangerous. Dr. Beck has reviewed her case and agrees that
if she is concerned, she can stop taking the medication; however, she recom-
mends that Mrs. Conrad try some alternative therapies. What suggestions
might Dr. Beck make for nonpharmaceutical treatment of perimenopausal
symptoms?
THE MEDICAL ASSISTANT'S ROLE IN GYNECOLOGIC
AND OBSTETRIC PROCEDURES
As the female progresses from menarche through the childbearing
years and then into menopause, her medical concerns change, and
the focal point of the physical examination may change as well. The
overall goal of the medical office is to keep her physically and men-
tally healthy. Being able to assist the provider in identifying possible
problems before the problem becomes a threat to the patient's health
is a major priority of care. This is best accomplished by listening to
the patient. Remember, to the patient, there is no such thing as a
routine examination.
Examination Preparation
An annual or semiannual examination of the female reproductive
system is done to ensure normality of the reproductive organs or to
diagnose and treat abnormalities of these organs. Before the provider
begins the examination, the medical assistant should obtain a com-
plete gynecologic history. After documenting the patient's history
and chief complaint, the medical assistant should prepare the room
and the patient for the examination (see Procedure 17-1).
The following should be included in the gynecologic history:
• Age at menarche
• Details about the regularity of the menstrual cycle; the amount
and duration of menstrual flow; and a history of menstrual
disturbances and their treatment
• Any current indicators of infection, including vaginal dis-
charge, pelvic pain, urinary difficulties, and so on
• Feedback on any breast abnormalities and the date of the
patient's last mammogram
• Date of the last Pap test
• Sexual history; STI history
• Number of pregnancies and live births
• Date ofLMP
• Lifestyle factors, including diet, exercise, smoking, alcohol
use, and so on
The physical examination during a first prenatal visit includes an
overall assessment of the woman's health status, including vital signs,
weight, and urinalysis. The medical assistant must prepare the
patient and also the supplies and equipment necessary to obtain
pelvic measurements, perform serologic tests, and prepare for labora-
tory tests (Procedure 17-4). The provider assesses heart, lung, and
thyroid function and performs a physical examination to rule out
any other abnormality. Next, the provider performs an obstetric
examination that includes palpation of the mother's abdomen, mea-
surement of the height of the uterus, and an internal or pelvic
examination.
A series of blood tests also is performed during the initial prenatal
visit. In follow-up prenatal visits, the medical assistant should collect
a urine specimen for urinalysis, weigh the patient, measure her blood
pressure, and answer questions about diet and health habits. The
mother should gain approximately 10 to 12 pounds in the first half
of pregnancy and another 15 to 17 pounds during the second half.
Experts believe that a healthy weight gain is somewhere between 25
and 35 pounds. The baby's heart tones can be picked up through a
specialized method, called Doppler ultrasound, somewhere between
9 and 12 weeks' gestation. Once recorded, the fetal heart rate is
assessed at each subsequent visit. Ultrasound exams are typically

done once during the first trimester and then again between weeks
18 and 20 to assess fetal development, confirm the age of the fetus
and proper growth, and to determine the gender of the baby. Pre-
natal blood and laboratory tests include the following:
• Hematocrit and hemoglobin levels to check for anemia.
• Blood type and Rh with antibody screening for possible Rh
incompatibility.
• Rubella titer to determine whether the mother is immune to
German measles; rubella infection during pregnancy can
cause multiple birth defects, including deafness, vision disor-
ders, and mental retardation.
• Syphilis screening; if the result is positive, antibiotic treatment
is initiated to protect the fetus from congenital syphilis.
• Hepatitis B screening because this virus can be passed to the
fetus in utero.
• HIV screening is suggested; if the result is positive, treatment
of the mother greatly reduces the risk of transmission to the
fetus.
• Pap test to check for abnormal cervical cells.
• Gonorrhea and chlamydia cultures to prevent infection of the
baby at birth.
• Urinalysis to detect protein, white blood cells, or glucose.
• Maternal blood screen (at 15 to 20 weeks) to detect any risk
of fetal chromosomal disorders.
• Cystic fibrosis carrier screening.
• Group B streptococcus culture of the lower vagina for strep
B infection, performed between weeks 32 and 36; if the result
Instruct and Prepare a Patient for Procedures and/or Treatments: Assist with a
PROCEDURE 17-4
Prenatal Examination
Goal: To promote ahealthy pregnancy for the mother and fetus and to screen for potential problems.
EQUIPMENT and SUPPLIES
• Patient's health record
• Scale with height measure
• Sphygmomanometer
• Stethoscape
• Tape measure
• Doppler fetoscope
• Ultrasound gel
• Urine specimen container
• Disposable examination gloves, vaginal speculum, and lubricant if vaginal
examination is to be performed
• Sexually transmitted infection (STI) test setups
• Laboratory requisition slips
• Biohazard waste container
• Biohazard bags for specimen transport
• Patient education materials
PROCEDURAL STEPS
1. Sanitize your hands and assemble the necessary equipment.
2. Greet the patient, introduce yourself, and verify the patient's identity by
name and date of birth.
CHAPTER 17 Assisting in Obstetrics and Gynecology 439
is positive, the mother is treated with antibiotics to prevent
fetal exposure during vaginal birth.
• If indicated, an NST to evaluate the fetal heart rate; the
mother is attached to a fetal monitor, with the goal of seeing
accelerations in the fetal heart rate with movement; performed
in a hospital.
• Stress test or oxytocin challenge test (OCT) if the NST is
abnormal; a small amount of oxytocin (which causes the
uterus to contract) is administered intravenously while the
mother is attached to a fetal monitor to see how the fetus
responds to the normal stresses of labor; this test is performed
in a hospital.
Any concerns the patient has should be noted and reported to
the provider. The medical assistant should be prepared to suggest
community resources that can provide assistance to new parents,
such as childbirth and parenting classes; infant cardiopulmonary
resuscitation (CPR) courses; nutritional counseling if needed; and
contact information for the Special Supplemental Nutrition Program
for Women, Infants, and Children (WIC), which helps lower-
income expectant mothers get nutritious food.
The examination room must be adequately equipped and the
surroundings pleasant. A dressing area with an adjacent toilet
should be provided. The dressing area should ensure privacy and
should be equipped with tissues and sanitary protection items,
in addition to disposable examination gowns and drapes. The
medical assistant should restock supplies as needed throughout
the day.
3. Weigh the patient and record the weight.
PURPOSE: An expectant mother's weight reflects both maternal nutri-
tional status and fetal growth; an unusual weight gain may indicate fluid
retention.
4. Apply gloves and collect a urine specimen and perform a urinalysis to detect
protein, glucose, or ketones in the urine; remove gloves, dispose in a bio-
hazard waste container, and sanitize hands. Record the urinalysis results.
PURPOSE: Protein, glucose, or ketones in the urine may indicate problems
with the pregnancy.
S. Measure and record the patient's blood pressure.
6. Instruct the patient to disrobe from the waist down and to put on a gown
open to the front so that the uterine fundal height can be measured.
PURPOSE: The provider will palpate the abdomen and may use a tape
measure to assess the fundal height as a determinant of fetal growth.
7. Assist the patient onto the examination table, if needed, and provide a
drape for privacy.
8. Assist the provider as needed throughout the examination. If a Doppler
fetoscope is to be used to listen to the fetal heart tones, apply a liberal
amount of ultrasound gel to the patient's abdomen and hand the fetoscope
to the provider. After the procedure, clean the Doppler head with a paper
towel and offer the patient tissues to wipe the gel off her abdomen.
440 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES
•;;m,ammjrj• -,;ontinued
9. After the examination is complete, assist the patient off the examination
table; make sure to observe for signs of dizziness or problems with
balance.
PURPOSE: Lying supine or in the lithotomy position puts pressure on the
aorta, which may result in momentary vertigo when the patient sits or
stands.
10. Answer the patient's questions and provide patient education materials as
needed.
PURPOSE: To take advantage of "teaching moments" to provide informa-
tion on diet, health habits, and community resources.
Assisting with the Examination
The female reproductive system examination is probably the most
emotionally charged medical experience the average woman under-
goes. Even women with relatively sophisticated attitudes toward
their bodies and sexuality may be embarrassed by the casual, imper-
sonal approach of the medical team during this procedure. Many
women fear the provider's findings. Anxieties and fears are best
handled through explanations and by showing a genuine interest in
the patient's concerns. The medical assistant is responsible for sup-
porting the patient and assisting the provider during the procedure.
The procedure should be fully explained to the patient to prevent
unnecessary embarrassment and discomfort. During the explana-
tion, the assistant has the opportunity to conduct patient teaching.
In preparation for the examination, the patient should empty her
bladder, completely disrobe, and put on an examination gown that
opens in the front. The patient should have been advised at the time
the appointment was made not to douche or have sexual intercourse
for 24 hours before the examination so that vaginal discharges can
be evaluated properly and to ensure accurate results of cytologic
studies.
Breast Examination
Begin the examination by assisting the patient into a sitting posi-
tion and by adjusting the gown so that the breast tissue can be
easily exposed. The provider will instruct the patient to place her
arms above her head, and the assistant should be present to assist
the patient if she has difficulty following these instructions. When
the patient is instructed to assume a supine position, help the
patient, adjust the gown, and drape as needed to assist the pro-
vider and to protect the patient's privacy. The foot rest should also
be extended. A small pillow may be placed under the patient's
head for comfort. When the examination is complete, the gown is
readjusted to cover the breasts. The provider may choose to discuss
breast self-examination with the patient at this time or may
inform the patient that the medical assistant will be explaining the
technique at the end of the examination (see Procedure 17-3).
Abdominal Examination
After the breasts have been examined, cover them and position the
drape to allow the provider to palpate the abdomen; this is done to
confirm normal symmetry and to detect any masses. In the case of
11. Apply gloves, collect and package all specimens for transport. Complete
labels as needed.
12. Discard supplies and disinfect the equipment according to the manufac-
turer's guidelines.
13. Remove gloves and dispose in a biohazard waste container. Sanitize your
hands.
14. Document the pertinent information in the patient's health record.
PURPOSE: Aprocedure is not dane until it is recorded.
pregnancy, the level of the fundus is measured to determine fetal
growth. For this examination, the patient's arms should be placed at
her sides to achieve better relaxation of the abdominal muscles.
Pelvic Examination
The medical assistant should remain in the examination room to
provide reassurance to the patient and as legal protection for the
provider while the patient's vaginal and perinea! areas are examined.
Furthermore, the lithotomy position is awkward to assume without
assistance and may be embarrassing to the patient. Never place the
patient in the lithotomy position until the provider is ready to begin
the examination. When you assist the patient into the lithotomy
position, always keep her totally covered.
You should stand at the patient's side so that you can observe the
patient, yet still be able to move quickly if needed by the provider.
First, the provider inspects the external genitalia and palpates the
perineal body. The patient may be asked to bear down to show any
muscular weaknesses that may be the result of lacerations of the
perinea! body during childbirth. A third-degree laceration may have
involved the rectal sphincter and may cause rectal incontinence.
Next, the vaginal speculum, without lubrication, is inserted for
examination of the cervix and the vaginal canal and for obtaining
the Pap specimen. The speculum should be prewarmed with warm
water. Have the patient take some deep breaths to help relax the
abdominal muscles. The normal cervix points posteriorly and has
smooth, pink, squamous epithelium. Abnormalities most frequently
seen are ulcerations (erosions), Bartholin's cysts, and cervical polyps.
Because erosions cannot be palpated, inspection is the only method
of detecting them. Healed lacerations from childbirth are common
in a multiparous patient. Pregnancy increases the size of the cervix,
and hormone deficiency causes it to atrophy. The vaginal wall is
reddish pink and has a corrugated appearance from the overlapping
tissue (rugae) lining. Vaginal infections change the appearance of the
vaginal mucosa. After the Pap specimen has been obtained, you
may be responsible for labeling the specimen and preparing it for
transport to the cytology laboratory. Be sure to follow laboratory
instructions during the preparation to avoid having to repeat
the examination.
After removal of the vaginal speculum, the provider does a
bimanual examination; that is, two gloved fingers are lubricated with
a water-soluble jelly (lubricant) and inserted into the vaginal canal,

( ducer bounce off the structure being studied and are converted into
FIGURE 17-17 Bimanual examination.
and the other hand palpates the abdomen over the pelvic organs and
the mons pubis (Figure 17-17). The uterus is examined for shape,
size, and consistency, and its position is noted. A normal uterus is
freely movable with limited discomfort. A laterally displaced uterus
usually is the result of pelvic adhesions or displacement caused by a
pelvic tumor. The fallopian tubes and ovaries are evaluated. Normal
tubes and ovaries are difficult to palpate, which is why the provider
may have to press firmly in the pelvic area, causing minor discomfort
for the patient. A stool test for occult blood may also be done.
Postexamination Duties
When the examination is finished, help the patient into a sitting
position and into the dressing room if needed. Following the Stan-
dard Precautions established by the Occupational Safety and Health
Administration (OSHA), remove the examination equipment and
supplies while the patient is dressing so that when the provider
returns to talk to the patient, the room is neat and clean. Once the
patient has left, the room should be sanitized, disinfected, and
restocked as necessary so it is ready for the next patient.
Safety Alert
Instruments that come in contact with a patient, including vaginal specu-
lums, should be sanitized, disinfected, and sterilized before they are used
for another patient. If the instrument does not penetrate tissue, it can be
stored under clean or medically aseptic conditions. Some providers prefer
to use disposable speculums for routine pelvic examinations. Instruments
that penetrate tissue (e.g., uterine biopsy punch, uterine tenaculum, cervi-
cal dilators and sounds) must be sterilized, stored, and handled under
sterile conditions.
CHAPTER 17 Assisting in Obstetrics and Gynecology 441
DIAGNOSTIC TESTING
Sonography
Sonography is a technique in which high-frequency sound waves are
used to ptoduce images of the body's soft tissues. It can distinguish
between cysts and tumors, and it is used during pregnancy to deter-
mine the number of fetuses and their age and gender; fetal abnor-
malities; and the position of the placenta. The skin over the area to
be studied is coated with conductive gel or lotion, and the transducer
is pressed lightly against the area. Sound waves emitted by the trans-
electrical impulses that create a picture for analysis. The mother may
be asked to drink several glasses of water 1 hour before the procedure
so the full bladder can be used as a reference point.
Sonograph technology is divided into two methods. The grayscale
image converts sound wave echoes into graphs or dots that form
pictures of organs and blood vessels (Figure 17-18). The Doppler
method converts the ultrasound into audible sounds that are heard
as pulsations and is used in the obstetrician's office to monitor
the heartbeat of the fetus. Color-coded Doppler signals, three-
dimensional imaging, and contrast medium enhancement of ultra-
sound images provide more accurate images and data on organ
structure and function.
Fetal Diagnostic Tests
• Chorionic villus sampling: Chorionic villi are tiny placental projections,
the cells of which have the same genetic material found in fetal cells.
Cellular screening at 8 to 12 weeks' gestation provides early detection
of genetic or chromosomal disorders. Potential complications include
accidental abortion, infection, bleeding, and fetal limb deformities.
Results are available within several days.
• Amniocentesis: This procedure involves needle aspiration of approxi-
mately 2 tablespoons of amniotic fluid after week 14 of pregnancy to
detect genetic and chromosomal abnormalities or inherited metabolic
disorders (Figure 17-19). Potential complications include miscarriage,
fetal injury, infection, premature labor, and maternal hemorrhage.
Results take up to 2 weeks.
Mammography
Mammography is a specialized x-ray technique that provides images
of breast tissue and is performed to identify abnormal masses
that would go undetected in a breast palpation examination
(Figure 17-20).
Special x-ray equipment is used that compresses the breast firmly
during each exposure. Compression is essential to provide the high
degree of detail needed to visualize the significant but often subtle
signs of a tumor. This process is not usually painful, but some
patients, especially those with fibrocystic breast disease, may find it
uncomfortable. If pain persists after the examination, ibuprofen is
recommended for relie£
Patients with breast implants should follow routine guidelines for
mammography; however, implants may make diagnosing breast
cancer more difficult because they tend to obscure the breast image.
It is recommended that women with implants have mammograms
done at a facility where the radiologist is experienced at interpreting
442 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES
FIGURE 17-18 Sonogram of a fetus.
Vagina
FIGURE 17-19 Amniocentesis.
these particular studies. In addition, women with silicone implants
should have an MRI examination to check for recurrence or rupture
of the implants.
In preparation for mammography, patients are instructed not to
use underarm deodorant and not to apply powder or lotion on the
breasts or axillary areas. These products may contain ingredients that
produce artifacts on mammographic images. This is especially true
of antiperspirants that contain aluminum salts. When previous
mammograms are available, every effort must be made to obtain
them because comparative evaluation often is significant in the
radiologic diagnosis.
Pregnancy Testing
Pregnancy tests are designed to detect HCG, which is secreted after
the ovum has been fertilized. It appears in the blood and urine of
pregnant women as early as 10 days after conception. Once preg-
nancy has been confirmed, the patient undergoes a complete medical
and obstetric examination, which includes a number of laboratory
FIGURE 17-20 Proper position of the breast for a mammogram. (From Bontrager KL, Lompignono
J: Textbook of radiographic positioning and related anatomy, ed 8, St Louis, 2014, Mosby.)
tests. The estimated date of delivery (EDD) is calculated at the first
office visit (the EDD frequently is called the expected due date). The
EDD typically is determined with a gestational wheel (Figure 17-21 ),
or it may be calculated by the electronic health record (EHR) soft-
ware. However, most obstetricians rely on fetal sonograms to deter-
mine the expected due date.
CLOSING COMMENTS
Patient Education
Depending on the provider's policies, the medical assistant can dis-
tribute patient education materials that promote sexual health
and prevent gynecologic and obstetric disorders throughout the
patient's life.
A woman who is planning a pregnancy or who has just found
out that she is pregnant may benefit from some simple guidelines
for healthy living.
• Nutrition: Before pregnancy, emphasize the need for folic acid to
prevent neural tube defects. The woman can take a supplement
or can eat dark green, leafy vegetables. Many women have iron-
deficiency anemia, and eating foods high in iron (red meat,
spinach, or enriched cereal) is helpful. A pregnant woman must
meet the calcium needs of both herself and her fetus; therefore,
she needs about 1,000 mg of calcium a day. Most pregnant
women should consume about 2,500 calories a day. Women of
average weight should gain 25 to 35 pounds, but underweight
women should gain 28 to 40 pounds for a healthy infant.
• Alcohol: Alcohol passes through the placenta to the fetus and
can cause serious problems. No one knows how much is safe,
so it is a good idea for pregnant women to avoid alcohol
completely.
• Smoking: Smoking can cause premature birth and low-birth-
weight full-term infants. Smoking is linked to an increased
risk of otitis media, heart problems, and upper respiratory
infection in infants, and also to sudden infant death syndrome

FIGURE 17-21 Gestational wheel. (From Jarvis (: Physical examination and health assessment,
ed 6, St Louis, 2012, Saunders.)
(SIDS). Pregnant women should not smoke and should not
be exposed to secondhand smoke.
• Medicine: All chemicals pass through the placenta; there-
fore, a pregnant woman should never take any medicine
(even over-the-counter drugs) without the knowledge and
approval of her obstetrician. If the medical assistant is
managing telephone screening, having a list of provider-
approved medications next to the phone helps in answering
patients' questions.
• ST! screening: STI screening should be done before a woman
becomes pregnant. Many STis are asymptomatic in women
but treatable. Infants are at risk for serious health problems if
exposed to certain STis in utero or during the birth process.
Advantages of Breast-Feeding
For the Infant
• Completely digestible nutrition source for the infant
• Protects against gastrointestinal infection
• Protects against food allergies
• Provides newborn with mother's antibodies to infectious disease
• Associated with higher infant IQ
• Promotes muscular eye and facial development
• Promotes maternal-infant bonding
For the Mother
• Simple, safe, and economical
• Promotes uterine involution, which reduces postpartum bleeding
• Reduces the incidence of breast cancer
• Promotes maternal-infant bonding
Pregnant women usually are searching for information about
pregnancy and wellness both during and after the birth. Use the
waiting room as an education center and provide videos, books, and
CHAPTER 17 Assisting in Obstetrics and Gynecology 443
pamphlets on health issues and parenting. Keeping an up-to-date list
of community education and support programs also is helpful. The
obstetric patient who is interested in breast-feeding may need educa-
tion and support to be successful. The American College of Pediatri-
cians recommends breast milk as the optimum food for newborns.
Referral to a breast-feeding support group or a lactation consultant
can help a new mother solve her breast-feeding problems and find
answers to her questions.
Legal and Ethical Issues
Many ethical and legal issues arise as a result of missed communica-
tion. Listen to what every patient reports, and write down any
information that will assist the provider in treating the patient. The
issue may appear to be an insignificant problem, but to the patient,
it may be a major concern. Let the provider be the judge of whether
the problem is relevant. As the patient's advocate and the provider's
assistant, the medical assistant plays an important role in establishing
good communication as a vital link in patient care.
Confidentiality is crucial in dealing with obstetric and gyneco-
logic disorders. Only healthcare professionals directly involved in the
patient's care should know the purpose of the patient's visit, diagno-
sis, or treatment. Maintaining patient confidentiality is not just an
ethical responsibility; in the case of HIV status, it is a legal
requirement.
Professional Behaviors
The medical assistant may be in the position to recognize and provide
assistance to women who are being mistreated. Battered women seldom
come forward and tell healthcare workers they are being abused. If the
patient reports such problems to the medical assistant, or if an abusive situ-
ation is suspected, the medical assistant should nat hesitate ta report this
information ta the provider. The American Medical Association (AMA) has
developed guidelines ta help caregivers recognize victims af abuse.
• Know what to look for: Suspicious findings include multiple injuries at
different sites, especially areas that normally are covered by clothing.
Also, the patient may be frightened, anxious, and passive and may
have a history of "accidents."
• Know what to ask when obtaining apatient history. Even patients who
show no signs of abuse should be asked whether they have ever been
in an abusive relationship; if verbal arguments ever become physical;
if their partner acts differently when drinking or using drugs; and if their
partner is overprotective and jealous.
• Know what to say and do: Abattered woman suffers both physical and
emotional abuse. She may begin to believe that she deserves to be mis-
treated, and she needs unconditional and nonjudgmental emotional sup-
port from the healthcare worker. She needs to be treated with warmth
and respect and encouraged to develop a plan of action to deal with
the next violent episode. Suggestions include having immediate access
to important documents, keys, money, and transportation; the address
of a safe house; and phone numbers for the police and local domestic
violence hotline, if available. The National Domestic Violence Hotline
can be reached at 1-800-799-SAFE (7233) or at www.thehotline.org/
It provides 24-hour help for victims seeking local shelters. Contact in-
formation for local shelters or sources of help could be posted in patient
bathrooms to encourage those in need to turn to these services.
444 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES
Having worked with obstetric and gynecologic patients, Betsy has learned
that a wide range of disorders and conditions can affect a woman's health
and pregnancy. She also has learned how to assist with a number of differ-
ent diagnostic procedures performed in the ambulatory care setting. An inte-
gral role of the medical assistant in the OB/GYN practice is reinforcing the
provider's patient education efforts. Betsy enjoys this part of the practice but
realizes that it involves extensive reading and discussion with Dr. Beck to
determine her preferred method of teaching. Betsy stays up-to-date on
SUMMARY OF LEARNING OBJECTIVES
l. Define, spell, and pronounce the terms listed in the vocabulary.
Spelling and pronouncing medical terms correctly reinforce the medical
assistant's credibility. Knowing the definitions of these terms promotes
confidence in communication with patients and co-workers.
2. Explain the anatomy and physiology of the female reproductive
system.
The female reproductive system is made up of the external genitalia and
the internal organs, including the vagina; the cervix, which must dilate
and efface for vaginal birth of a child; the uterus; the fallopian tubes;
and the ovaries, which mature and produce ova.
3. Trace the ovum through the three phases of menstruation.
The follicular phase matures a graafian follicle so that an ovum can be
released at the same time the endometrial wall is thickening; the luteal
phase causes extensive growth of the endometrium; if conception does
not occur, the menstrual cycle begins with the breakdown of the endo-
metrium and menstrual flow.
4. Compare and contrast current contraceptive methods.
Barrier contraceptive methods include the use of condoms, a diaphragm,
a cervical cap, or a cervical sponge; all of these are relatively inexpen-
sive and reversible, but they must be used with each instance of inter-
course. Two general types of IUDs are available to inhibit fertilization
and prevent the embryo from implanting in the uterine wall. Hormonal
contraceptives include Depo-Provera injections, the lmplanon or Nex-
planon implants, oral and patch contraceptives, and the vaginal ring, all
of which are very effective but have side effects and contraindications.
(See Table 17-1.)
5. Summarize menstrual disorders and conditions.
Menstrual disorders include amenorrhea and oligomenorrhea; abnormal
menstrual bleeding includes menorrhagia and metrorrhagia; endometrio-
sis is characterized by the presence of functional endometrial tissue
outside the uterus.
6. Distinguish among different types of gynecologic infections.
Gynecologic infections include candidiasis; BV; cervicitis; and PIO, which
is any acute or chronic infection of the reproductive system that ascends
from the vagina (vaginitis), cervix (cervicitis), uterus (endometritis),
fallopian tubes (salpingitis), or ovaries (oophoritis). (See Table 17-2.)
current contraceptive practices by attending local workshops offered by the
American Association of Medical Assistants (MMA), along with regional con-
ferences. She has networked with other CMAs to develop a comprehensive
community resource guide for obstetric and gynecologic patients in the prac-
tice and has created an educational center in the patient waiting room. Betsy
recognizes that she must continue to learn about new practices and recent
research to help provide the best possible care for the women in Dr. Beck's
practice.
7. Do the following related to benign and malignant tumors of the
female reproductive system:
• Differentiate between benign and malignant neoplasms of the female
reproductive system.
Benign tumors of the reproductive system include uterine fibroids,
ovarian cysts, the hormonal disease of polycystic ovary syndrome,
and fibrocystic breast disease, the presence of multiple palpable
nodules in the breasts. Malignant tumors include cervical, endome-
trial, and ovarian cancers that vary in their diagnostic features and
symptoms. Breast cancer can have multiple origins. Treatment of all
forms of reproductive cancer depends on the staging and grading of
the tumors.
• Prepare for and assist with the female examination, including obtain-
ing aPapanicolaou (Pap) test.
Procedure 17-1 explains the steps for assisting with examination of
a female patient.
• Demonstrate patient preparation for aLEEP.
Procedure 17-2 describes how to prepare a patient for cryosurgery.
• Teach the patient the technique for breast self-examination.
Procedure 17-3 explains how to teach breast self-examination.
8. Compare the positional disorders of the pelvic region.
Positional disorders of the pelvic region include cystocele or rectocele,
which causes protrusion of the bladder or the rectum into the vaginal
wall, and uterine prolapse, in which the cervix or uterus drops into the
vaginal area. Kegel exercises can help improve these problems, but if
they are severe, all three structural abnormalities can be corrected with
surgery.
9. Summarize the process of pregnancy and parturition.
Pregnancy occurs when the ovum and the sperm meet in the fallopian
tube and a zygote is formed. The zygote implants in the uterine wall,
and the placenta begins to form, which provides hormonal support for
the pregnancy. The fetus is surrounded by an amniotic sac and floats in
amniotic fluid. Oxygen and nutrients for the fetus pass through the pla-
centa to the umbilical cord. The embryonic period ends at 12 weeks; by
then, all tissues and organs have developed. During the remainder of the
pregnancy, the organs mature and begin to function, and the fetus grows.

SUMMARY OF LEARNING OBJECTIVES-continued
Pregnancy is divided into three trimesters. The first trimester is a crucial
time for fetal organ development; the second trimester brings quickening
and many physiologic changes in the mother; during the third trimester,
the fetal organ systems mature. The three stages of labor are dilation
and effacement of the cervix, birth, and expulsion of the placenta.
l 0. Describe the common complications of pregnancy.
Complications of pregnancy include potential loss of the pregnancy as a
result of different types of abortions (miscarriages). Placental abnormali-
ties include placenta previa, in which the placenta covers the cervical os,
and abruptio placentae, in which the placenta breaks away from the
uterine wall. Both cause maternal hemorrhage, threaten fetal oxygen
supply, and require a cesarean birth to protect the fetus and mother.
Maternal disorders include GDM, which requires dietary changes and
possible insulin therapy, and hypertension, which may progress to pre-
eclampsia, a life-threatening rise in blood pressure accompanied by
edema, uremia, and possibly seizure activity.
11. Specify the signs, symptoms, and treatments of conditions related
to menopause.
Menopause is the permanent ending of menstruation caused by the
cessation of ovarian function. Perimenopause begins when hormone-
related changes start to appear and lasts until the final menses. Some
women experience few or no symptoms, whereas others have hot
flashes, concentration problems, mood swings, irritability, migraines,
vaginal dryness, urinary incontinence, dry skin, and sleep disorders. The
provider may prescribe low-dose oral contraceptives or HRT, weight-
bearing exercise, soy products or vitamin supplements, dietary changes,
and medication to manage hot flashes, mood swings, vaginal dryness,
and to prevent osteoporosis.
12. Outline the medical assistant's role in gynecologic and reproductive
examinations and demonstrate how to assist with a prenatal
examination.
CONNECTIONS
OJ Study Guide Connection: Go to the Chapter 17 Study Guide. Read and complete
the activities.
CHAPTER 17 Assisting in Obstetrics and Gynecology 445
The medical assistant prepares the patient for the examination, equips
the room, makes sure supplies are available and properly prepared,
positions and drapes the patient as needed, assists with the Pap smear
or any other procedures, and provides support and understanding for the
patient. (See Procedure 17-4.)
13. Distinguish among diagnostic tests that may be done to evaluate the
female reproductive system.
Diagnostic tests for the female reproductive system include sonography
during pregnancy to determine the number of fetuses, fetal age and
gender, fetal abnormalities, and the position of the placenta; chorionic
villus sampling or amniocentesis; maternal blood tests to diagnose
genetic disorders; mammography, which provides an x-ray image of the
breast tissue to identify cancerous tumors; colposcopy procedures that
permit visualization of abnormal cervical tissue for evaluation or biopsy;
and a variety of tests done during pregnancy.
14. Summarize patient education guidelines for obstetric patients, in
addition to legal and ethical implications in a gynecology practice.
Awoman who is planning a pregnancy or who has just found out she is
pregnant may benefit from some simple guidelines about nutrition,
alcohol consumption during pregnancy, medications that might affect the
developing fetus, STI screenings, and breast-feeding.
Confidentiality is crucial in dealing with obstetric and gynecologic
disorders. Only healthcare professionals directly involved in the patient's
care should know the purpose of the patient's visit, diagnosis, or treat-
ment. The medical assistant may be in the position to recognize and
provide assistance to women who are being mistreated. If the patient
reports such problems to the medical assistant or if an abusive situation
is suspected, the medical assistant should not hesitate to report this
information to the provider.
evolve Evolve Connection: Go to the Chapter 17 link at evolve.elsevier.com/
kinn to complete the Chapter Review Quiz. Check out the other resources listed for this
chapter to make the most of what you have learned from Assisting in Obstetrics and
Gynecology.
 18 ASSISTING IN PEDIATRICS
li#H+i;H•i
Susie Kwong, (MA (MMA), who has 2 years of experience, has accepted a
new position with North Hills Pediatrics, a large practice with several physicians.
Susie's primary responsibility will be to assist in the clinical area, but she also
will have to rotate through the message screening center in the office. Office
policy states that telephone screening employees should manage problems as
much as possible. However, if patient callbacks are needed, they are to be
While studying this chapter, think about the following questions:
• What other clinical responsibilities should Susie be prepared to
perform?
• Are patient and caregiver health education an important part of delivering
high-quality care in a pediatric setting?
LEARNING OBJECTIVES
1. Define, spell, and pronounce the terms listed in the vocabulary.
2. Describe childhood growth patterns.
3. Summarize the important features of the Denver II Developmental
Screening Test.
4. Discuss developmental patterns and therapeutic approaches for
pediatric patients.
5. Identify four different growth and development theories.
6. Consider the implications of postpartum depression.
7. Explain common pediatric gastrointestinal disorders, in addition to
failure to thrive and obesity.
8. Describe disorders of the respiratory system in children.
9. Distinguish among pediatric infectious diseases.
l 0. Recognize the etiologic factors and signs and symptoms of the two
primary pediatric inherited disorders.
11. Summarize the immunizations recommended for children by the
Centers for Disease Control and Prevention (CDC).
VOCABULARY
anomaly (uh-nom'-uh-le) A congenital malformation that occurs
during fetal development.
attenuated (uh-ten'-yuh-wat-ed) Weakened or changed; refers to
the virulence of a pathogenic microorganism in reference to
vaccine development.
autonomy (aw-ton' -oh-me) The ability to function
independently.
referred to the physician on call that day by noon for morning calls and no later
than 5 PM for afternoon calls. Although the physicians in the practice have
developed specific guidelines for managing patient problems, Susie is anxious
about this responsibility, so she asks to work with the screening staff for several
days before she starts answering incoming calls.
• Does Susie need to be clinically competent to perform immunizations and
document their administration?
• How can Susie maintain her skill level and continue to learn about
patient-centered pediatric care?
12. Demonstrate how to document immunizations and maintain accurate
immunization records.
13. Compare a well-child examination with a sick-child examination.
14. Outtine the medical assistant's role in pediatric procedures.
15. Measure the circumference of an infant's head.
16. Obtain accurate length and weight measurements, and plot pediatric
growth patterns.
17. Accurately measure pediatric vital signs, and perform vision screening.
18. Correctty apply a pediatric urine collection device.
19. Describe the characteristics and needs of the adolescent patient.
20. Specify child safety guidelines for injury prevention, and explain the
management of suspected child abuse, neglect, or exploitation.
21. Summarize patient education guidelines for pediatric patients.
22. Discuss the legal and ethical implications in a pediatric practice.
congenital (kuhn-jen' -ih-tul) An anomaly or defect that is present
at birth.
dermatome (dur'-muh-tohm) An area on the surface of the
body that is innervated by nerve fibers from one spinal nerve
root.
epiphyseal plate (ih-pe-fis' -e-uhl) A thin layer of cartilage located
at the ends of a long bone where new bone forms.

VOCABULARY -continued
excoriation (ek-skawr-e-ay'-shun) Inflammation and irritation of
the skin.
fontanelle (fon-tan-el') A space covered by thick membranes
between the sutures of an infant's skull; called the baby's "soft
spots"; there are both anterior and posterior fontanelles.
hydrocephaly (hi-dro-seh'-fuh-le) Enlargement of the cranium
caused by abnormal accumulation of cerebrospinal fluid in the
cerebral system.
laryngoscopy (lar-in-gahs'-kuh-pe) Visual examination of the
voice box area through an endoscope equipped with a light and
mirrors for illumination.
lymphadenopathy (lim-fad-en-op'-uh-the) An abnormal
enlargement of a lymph gland.
microcephaly (mahy-kroh-seh'-fal-e) Small size of the head in
relation to the rest of the body.
P ediatrics is the medical specialty that deals with the development
and care of children and with the treatment of childhood dis-
eases. Pediatric patients range in age from newborn to puberty. Some
practices continue to see the child until he or she graduates from
high school. Subspecialties within pediatrics include surgery, cardiol-
ogy, and psychiatry.
Approximately 50% of the patients in a pediatric office are there
for well-baby or well-child visits. The roles of the pediatrician and
the medical office staff are to supervise and help maintain the health
of these patients. Parents must be involved in the care and develop-
ment of their young children for treatment to be a success. The
medical assistant can help by encouraging therapeutic communica-
tion among the patient, parents, and medical staff. The trust a child
develops in these relationships and the consideration the family
receives in the physician's office form the basis of good medical care.
Pediatric care actually starts before the child is born, with the
promotion of good general health for mothers before conception and
during pregnancy. The confidence and enthusiasm of parents can
have a significant impact on an infant's physical and emotional
well-being.
NORMAL GROWTH AND DEVELOPMENT
The terms growth and development often are used together. They refer
to the combination of changes a child goes through as he or she
matures. Growth refers to measurable changes, such as height and
weight. The first determinant of these physical characteristics is the
genetics inherited from the parents; however, a child's growth can
be influenced by many factors, including nutritional status, environ-
mental factors, and the presence of disease. Development encom-
passes qualitative maturation in motor, mental, social, and language
skills. A child's development is determined by a combination of
prenatal, environmental, and caregiver factors. Each child has his or
her own pattern of growth and development. Pediatric assessments
are individualized for each child according to age, developmental
level, health condition, family characteristics, and past experiences
CHAPTER 18 Assisting in Pediatrics 447
nonorganic (nahn-or-gan'-ik) Refers to not having an organic or
physiologic cause; a disorder that does not have a cause that can
be found in the body.
perinatal (per-uh-neyt'-1) The period between the 28th week of
pregnancy and the 28th day after birth.
rhonchi (rong'-ki) Abnormal sounds heard on auscultation of an
airway obstructed by thick secretions; a continuous rumbling
sound that is more pronounced on expiration.
serous (seer' -uhs) A thin, watery, serumlike drainage.
stridor (stri'-der) A shrill, harsh respiratory sound heard during
inhalation when a laryngeal obstruction is present.
suppurative (suhp'-yuh-rey-tiv) Characterized by the formation
and/or discharge of pus.
urticaria (ur-tih-kair'-e-uh) Hives.
with healthcare professionals. The pediatrician checks for indications
of irregularities in growth and development by comparing a child's
physical, intellectual, and social levels with published national
standards. This comparison indicates whether the child is at the
appropriate stage of growth and development for his or her chrono-
logic age.
Growth Patterns
Physical growth is one of the most visible changes in childhood. The
average birth weight is 7 to 7 ½ pounds, and in 6 months, the baby's
birth weight doubles. Growth then slows slightly; by 1 year of age,
the birth weight has tripled and length has increased by 50%. By
age 2, the child has reached approximately 50% of his or her adult
height. Between ages 1 and 2, the child gains approximately ½
pound per month. Between ages 2 and 3, weight gain averages 3 to
5 pounds and height increases 2 to 2½ inches. Most children slim
down during this period, so that by the time the third birthday
arrives, the potbellied toddler has become the characteristic
preschooler.
During the preschool period (ages 3 to 6 years), weight increases
3 to 5 pounds per year; height increases at a slower but steady rate
of 1½ to 2½ inches per year. By age 4, the child usually has doubled
the birth length. During this time, the legs are the fastest growing
part; fatty connective tissue continues to increase slowly until
approximately age 7. This same growth rate continues through the
school-aged period (6 to 12 years), and as this period of development
ends, the child usually is into a growth spurt that indicates impend-
ing puberty.
The growth spurt continues for approximately 2 years, and the
child then reaches adolescence (ages 12 to 18 years). During this
period, the adolescent gains almost half of his or her adult weight,
and the skeleton and organs double in size. Weight increases in girls
by 20 to 25 pounds and in boys by 15 to 20 pounds. Girls grow 5
to 6 inches, and boys grow 4 to 5 inches. As the growth spurt is
completed, the teenager reaches sexual maturity. In girls, sexual
maturity is signaled by the onset of the menstrual cycle; in boys, it
448 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES
is determined by the presence of sperm in the semen. The timing of
sexual maturity in both genders varies greatly.
Skeletal growth is complete in girls between 15 and 16 years of
age and in boys between ages 17 and 18. Skeletal growth is consid-
ered complete when the growth plates (epiphyseal plates) of the
long bones of the extremities have fused completely.
Growth charts that can be used to compare the child's individual
growth pattern with national standards have been used since 1977,
but in 2000 the Centers for Disease Control and Prevention (CDC)
revised the charts to reflect cultural and racial diversity (samples are
available at the website www.cdc.gov/growthcharts). The CDC charts
take into account whether an infant was formula-fed or breast-fed
because breast-fed infants may grow differently during the first year
of life.
In addition, the CDC growth charts include information on the
average body mass index (BMI) for infants and young adults 2 to
20 years of age, giving pediatricians another weapon in the fight
against childhood obesity. The BMI is a means of assessing the
relationship between height and weight. BMI conversion charts
typically are available or they are calculated automatically in elec-
tronic health record (EHR) programs, but the BMI can be calculated
by dividing the child's weight in kilograms by the height in meters
squared:
BMI = _W_e_ig_ht_(_kg_)
Height(m)2
Denver II Developmental Screening Test
Each child develops individually and attains developmental plateaus
differently. The Denver II Developmental Screening Test is a stan-
dardized tool used to screen for developmental delays, to investigate
concerns about an infant's development, or to monitor high-risk
children for potential problems (Figures 18-1 and 18-2). The Denver
Developmental Materials were originally created in the 1960s to help
identify children from birth to six years of age with potential devel-
opmental delays who then could be referred for assistance and treat-
ment. The test should be given at ages 3 to 4 months, 10 months,
and 3 years. Although it is not difficult to administer, only those
trained in the procedure and in interpretation of the results should
give it. The assessment focuses on four developmental areas:
• Gross motor skills: Evaluates the child's ability to control large
muscle groups (e.g., sitting, standing, kicking, running, and
balance).
• Language: Assesses the child's hearing and understanding and use
of language (e.g., word comprehension, ability to follow simple
commands, use of subjects, and counting).
• Fine motor skills: Tests the child's coordination of fine motor
muscles and eye-hand coordination (e.g., reaching, grasping,
piling blocks, and drawing).
• Personal skills: Examines the child's self-confidence, socialization,
and ability to care for personal needs (e.g., playing games, using
a fork and spoon, dressing, and brushing the teeth).
The results of the test are analyzed and determined to be normal
or suspect, or the child is diagnosed as untestable. With an abnormal
finding, the child should be rescreened in 1 to 2 weeks to rule out
temporary developmental delays caused by fatigue or anxiety. If
those results are abnormal, the child may be retested with other
developmental tests, either by the pediatrician or by a professional
pediatric testing agency.
Developmental Patterns
General patterns of child development occur rapidly during the first
year of life as the infant progresses from reflex activities (e.g., grasp-
ing fingers and sucking) to learning to manipulate simple objects
(e.g., pulling open drawers or throwing toys out of the crib). In
addition to these motor skills, the child learns verbal patterns, pro-
gressing from cooing and crying for attention to speaking his or her
first words.
Therapeutic Approaches for Infants (Newborn to
12 Months)
• Crying is normal; use distraction, but da not overstimulate.
• It is important ta keep the infant close to the caregiver; either have the
parent hold the infant, or keep the parent in the child's line of vision.
• Involve the parent as much as possible, depending on the task and the
parent's level of comfort.
• Place a familiar object near the infant, and keep frightening ones out
of view.
• An infant's negative response to strangers usually develops at approxi-
mately 8 months; do not take the rejection personally.
• Do not restrain the infant any more than necessary, but be ready
to use restraint at times (e.g., when giving an injection) to keep the
infant safe.
• Encourage the caregiver to cuddle and hug the child after the procedure
is complete.
• Unpleasant procedures are associated with other objects, so do not use
play areas for treatment, and do not use afavorite toy or object during
the procedure; offer it afterward for comfort.
CRITICAL THINKING APPLICATION 18-1
Susie receives a call from the mother of a 6-month-old child. The woman
is concerned that her child may not be reaching his developmental mile-
stones. What type of information about the child's growth and development
should Susie gather? If Susie is unable to answer the mother's questions,
what should she do?
By age 3, the child is showing increased autonomy. Now the
child can walk, is toilet trained, sits at the table and eats with the
family, can make simple sentences, understands the word "no," and
even imitates the parent by using verbal gestures that he or she has
seen used. The child's vocabulary consists of up to 900 words.
During the preschool stage the child becomes increasingly inde-
pendent and initiates activities. Preschoolers have mastered many
gross motor skills and are perfecting their fine motor development.
Verbal communication has increased to full simple and even complex
sentences but remains quite literal. For example, if you tell a pre-
school child that you are going to fly to visit Aunt Sue, the child
 CHAPTER 18 Assisting in Pediatrics 449

Denver II Examiner: Name:

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FIGURE 18-1 Denver II Developmental Screening Test (DOST). (From http://www.fpnotebook.com/Peds/Neuro/DnvrPrscrngDvlpmntl

Qstnrl.htm.)
450 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES

DIRECTIONS FOR ADMINISTRATION

1. Try to get child to smile by smiling, talking or waving . Do not touch him/her.
2. Child must stare at hand several seconds .
3. Parent may help guide toothbrush and put toothpaste on brush .
4. Child does not have to be able to tie shoes or button/zip in the back.
5. Move yarn slowly in an arc from one side to the other, about 8" above child's face .
6. Pass if child grasps rattle when it is touched to the backs or tips of fingers.
7. Pass if child tries to see where yarn went. Yarn should be dropped quickly from sight from tester's hand without arm movement.
8. Child must transfer cube from hand to hand without help of body , mouth, or table.
9. Pass if child picks up raisin with any part of thumb and finger.
10. Line can vary only 30 degrees or less from tester's line.V
11 . Make a fist with thumb pointing upward and wiggle only the thumb. Pass if child imitates and does not move any fingers other
than the thumb.

0
12. Pass any enclosed
form . Fail continuous
13. Which line is longer?
(Not bigger.) Turn paper
+ •
14. Pass any lines
crossing near
15. Have child copy first.
If failed , demonstrate.
round motions. upside down and repeat. midpoint.
(pass 3 of 3 or 5 of 6)
When giving items 12, 14, and 15. do not name the forms. Do not demonstrate 12 and 14.
16. When scoring, each pair (2 arms, 2 legs, etc.) counts as one part.
17. Place one cube in cup and shake gently near child's ear, but out of sight. Repeat for other ear.
18. Point to picture and have child name it. (No credit is given for sounds only .)
If less than 4 pictures are named correctly, have child point to picture as each is named by tester.

19. Using doll, tell child : Show me the nose, eyes , ears , mouth, hands, feet , tummy, hair. Pass 6 of 8.
20. Using pictures, ask child : Which one flies? ... says meow? ... talks? ... barks? ... gallops? Pass 2 of 5, 4 of 5.
21 . Ask child : What do you do when you are cold? .. . tired? ... hungry? Pass 2 of 3, 3 of 3.
22. Ask child : What do you do with a cup? What is a chair used for? What is a pencil used for?
Action words must be included in answers.
23. Pass if child correctly places aill! says how many blocks are on paper. (1, 5).
24. Tell child : Put block on table ; under table ; in front of me, behind me. Pass 4 of 4.
(Do not help child by pointing , moving head or eyes.)
25. Ask child: What is a ball? ... lake? ... desk? ... house? ... banana? ... curtain? ... fence? ... ceiling? Pass if defined in terms
of use, shape , what it is made of, or general category (such as banana is fruit. not just yellow) . Pass 5 of 8, 7 of 8.
26. Ask child : If a horse is big , a mouse is _ ? If fire is hot, ice is_? If the sun shines during the day, the moon shines
during the _? Pass 2 of 3.
27. Child may use wall or rail only, not person . May not crawl.
28. Child must throw ball overhand 3 feet to within arm's reach of tester.
29. Child must perform standing broad jump over wid th of test sheet (8 1/2 inches).
30. Tell child to walk forward , c::::>c:::::,~ • heel within 1 inch of toe. Tester may demonstrate.
Child must walk 4 consecutive steps.
31. In the second year, half of normal children are non-compliant.
OBSERVATIONS:

FIGURE 18-2 Instructions for the DDST. (From ht1p//www.fpnotebook.com/Peds/Neuro/DnvrPrscrngDvlpmntlQstnrl.htm.)


thinks you are going to flap your arms and fly. Nonverbal commu-
nication skills are also being mastered. The vocabulary now includes
more than 2,000 words. During this period, children need to develop
social skills, such as sharing and taking part in peer group
activities.
Therapeutic Approaches for Toddlers and
Preschoolers (2 to 6 Years)
• Toddlers and preschoolers often fear visits to the doctor; ignore temper
tantrums and negative behavior.
• Praise the child as much as possible.
• Perform unpleasant procedures as quickly as possible; the fear of the
procedure is worse than the actual discomfort.
• Allow the child to keep on as much clothing as possible for security and
comfort.
• Use words familiar to the child, and do not use words the child could
misinterpret. For example, "The test uses dye" (the child may think
you mean "die"); "The doctor will put you to sleep so it doesn't hurt"
(the family dog may have been put to sleep).
• Explain a procedure as the child would sense it; that is, what it will
look like, how it will smell, how it will feel, and so on.
• Allow the child to handle equipment when possible.
• Do not use the child's favorite doll or stuffed animal to demonstrate;
the child may believe the toy feels pain.
• Explain procedures to the parents away from the child when possible;
the child may misinterpret the information.
School-aged children have perfected fine motor skills and can
paint, draw, and play an instrument. They enjoy team activities and
are expanding their reading and writing skills. Their intellectual skills
are developing, and social skills are going through refinement as a
sense of self-achievement and self-worth is developed. During this
time the child learns and tests the rules for socializing outside the
immediate family as an independent individual.
Therapeutic Approaches for School-Aged Children
(7 to 11 Years)
• Allow choices when possible, such as which arm to use for an
injection.
• Aparent or caregiver should always be present during examinations.
• Remove only as much clothing as needed for the examination or
procedure.
• Explain procedures in concrete terms; use pictures and diagrams when
possible.
• Give the child time to ask questions.
• School-aged children often are curious, and they can be cooperative if
they know what is expected of them.
• Address the conversation to the child; involve the child in decision
making as much as possible.
• Provide privacy.
CHAPTER 18 Assisting in Pediatrics 451
Adolescence, or the transition stage, is the time when the indi-
vidual attempts to establish an adult identity. The teenager proceeds
by trial and error, experimenting with adult roles and behavior pat-
terns. Traditional values learned in childhood may be questioned,
and peer relationships take on new importance. During this time
teenagers must develop the emotional maturity and motivation to
make reasonable decisions. They look to family members for encour-
agement and guidance in making decisions that will help them
develop self-confidence and to become patient and less impulsive
and self-centered.
Therapeutic Approaches for Adolescents
(12 to 18 Years)
• Adolescents are self-conscious and strongly influenced by peers.
• Privacy is very important to them.
• Address how a procedure might affect the adolescent's appearance.
• Do not be judgmental; listen without condemning.
• Encourage the adolescent to verbalize his or her concerns and fears.
• The adolescent may regress to more childish behaviors when sick.
• Teenagers want to be treated as adults; they want to know what is
being done and why.
• To promote honest discussion about lifestyle issues, encourage the
teenager to see the physician without the parent present.
CRITICAL THINKING APPLICATION 18-2
Based on what you have learned about therapeutic approaches for the
pediatric patient, what would be the best way to deal with the following
patient situations?
1. Acrying 3-month-old being seen for a well-child visit
2. A10-month-old with otitis media
3. A2-year-old who needs the dressing changed on an infected wound
4. A5-year-old scheduled for vision and hearing screening
5. An 8-year-old who needs a throat culture to rule out a strep
infection
6. A12-year-old who needs a penicillin injection in the dorsogluteal
site
7. A15-year-old girl who complains of abdominal pain and is accom-
panied by her mother
Developmental Theories
Psychologists have been researching and developing theories about
human behavior since the beginning of the twentieth century. The
first psychologist to gain influence from his theories about human
behavior was Sigmund Freud, who believed that the motivating
stimulus for human behavior is the libido, which is defined as an
individual's pleasure-seeking instincts. Freud's theory describes four
major components of the mind: the unconscious mind, which cannot
be accessed but affects our behavior; the id, which focuses on imme-
diate self-gratification; the ego, which develops throughout life and
balances the immediate desires of the id with the reality of the social
world; and the superego, the individual's conscience, which helps the
child incorporate social expectations and norms. Freud also was the
452 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES
first therapist to identify five developmental stages: the oral, anal,
phallic, latency, and genital stages.
The next developmental theory to gain general acceptance was
the psychosocial approach of Erik Erikson. Erikson expanded Freud's
work to recognize cultural and social influences on individual devel-
opment. His theory is based on stages of development that the
individual must pass through and master. Each stage focuses on a
developmental crisis, starting in infancy and ending in old age.
According to Erikson, the following are the stages that children must
master:
• Trust versus mistrust: Infants learn to rely on caregivers; mis-
trust occurs if needs are not met.
• Autonomy versus shame and doubt: Toddlers learn language
skills and gain independence; they may feel shame and doubt if
they cannot meet parental expectations or are overprotected.
• Initiative versus guilt: Preschoolers actively seek out new expe-
riences; children become hesitant if restrictions or reprimands
make them feel guilty or afraid to try more challenging skills.
• Industry versus inferiority: School-aged children enjoy finishing
projects and receiving recognition; they develop feelings of
inferiority if not accepted by peers or if they cannot please
their parents.
• Identity versus role confusion: Adolescents face many physical
and hormonal changes in this stage. Teenagers work at figur-
ing out who they are and where they fit; they are looking for
a direction for their lives. If they are unable to establish an
identity and sense of direction, they become role confused.
Jean Piaget's developmental theory focuses on intellectual growth,
with four stages of cognitive development. From birth to 24 months,
children progress through the semorimotor stage, which starts with
reflexive behavior and advances to learning by doing. The preopera-
tional stage (2 to 7 years) is characterized by language development
and using play to understand the world. In the concrete operational
stage (7 to 11 years), children develop logical thinking and become
less egocentric. Finally, the formal operational stage (11 years or older)
brings abstract thinking and deductive reasoning to establish values
and determine the meaning of life.
Lawrence Kohlberg's theory, which focuses on moral reasoning,
involves levels similar to Piaget's cognitive development theory, yet
recognizes the influence of culture and interpersonal relationships
on the child's moral development. In preconventional morality, the
child's behavior is based on the external control of authority figures.
The child perceives the goodness or badness of a behavior based on
parental reaction. In the conventional level the child wants to follow
the rules of the group or society and internalizes the values of others.
As the child reaches adolescence, the postconventional level he or she
develops individual morality and values, and behavior is regulated
internally rather than externally. Table 18-1 summarizes these growth
and development theories.
Postpartum Depression
• The incidence of postpartum depression (PPD) is not clear, but an
estimated l 0% to 20% of women struggle with major depression
before, during, and after delivery of a baby. Fewer than half of these
are diagnosed in routine office visits.
• Postpartum depression can be diagnosed a month to a year after
childbirth. Women with a history of depression during pregnancy should
be monitored for signs of postpartum depression for a minimum of 4
months.
• Risk factors include a history of depression, abuse, or mental illness;
smoking or alcohol use; anxiety during pregnancy and fears over child
care; lack of financial resources and secure relationships; a fussy or
colicky infant; and lack of social support.
• Symptoms of postpartum depression include anorexia and insomnia;
irritability and anger; overwhelming fatigue; loss of interest in sex and
lack of a feeling of joy in life; feelings of shame, guilt, or inadequacy;
severe mood swings; difficulty bonding with the baby; withdrawal from
family and friends; and thoughts of harming herself or the baby.
• Postpartum depression must be detected as soon as possible so that
treatment can begin; untreated postpartum depression may last for a
year or longer. Treatment includes both counseling and antidepressant
medication.
The l 0-question Edinburgh Postnatal Depression Scale (EPDS) is a
valuable and efficient way of identifying patients at risk for perinatal
depression. Healthcare professionals working with the perinatal population
should use the EPDS as a routine part of postnatal care because the EPDS
is a valid and reliable means of detecting PPD. This screening tool is user
friendly, easy to administer, and easy to score. Ascore of l Oto 12 is
considered the cutoff for PPD; the mother should be referred for further
evaluation or treatment. Users may reproduce the scale without further
permission, providing they respect the copyright by quoting the names
of the authors and the title and the source of the paper in all
reproduced copies. The EPDS can be accessed at the American Academy
of Pediatrics website at: www2.aap.org/sections/scan/practicingsafety/
Toolkit_Resources/Module2/EPDS.pdf
From www2.aap.org/sections/scan/practicingsafety/foolkit_Resources/Module2/EPDS.pdf.
Accessed January 12, 2015.
CRITICAL THINKING APPLICATION 18-3
The pediatricians in Susie's office routinely screen new mothers for postpar-
tum depression using the Edinburgh Postnatal Depression Scale (EPDS).
Research the EPDS questionnaire online. In Susie's office, the medical
assistants periorm the assessment. With a classmate, role-play the use of
the form.
PEDIATRIC DISEASES AND DISORDERS
The disease process in pediatric patients poses special problems,
because children are constantly changing both physically and func-
tionally. As a child grows and develops, the immune system matures,
and with the aid of routine prophylactic immunizations, the child
acquires long-term protection against certain infectious diseases.
Gastrointestinal Disorders
Colic
Colic usually is seen in the newborn period or in early infancy.
The problem is intermittent. The classic situation is an infant
 CHAPTER 18 Assisting in Pediatrics 453

TABLE 18-1 Summary of Growth and Development Theories

FREUD:
PSYCHOSEXUAL
AGE GROUP THEORY
Infant Oral stage; child operates
with the pleasure principle,
and the id develops.
Toddler Passes through oral
aggressive stage to anal
stage; elimination is used to
control and inhibit.
Preschool to early From phallic stage, in which
school years the ego (conscious reality)
develops, to latent stage, in
which the superego
(morality) develops.
School age Latent stage continues;
superego develops morality
or a conscience; represses the
sexual drive.
Adolescence Genital stage
*Freud (1856-1939); Piaget (1896-1980); Erikson (1902-1994); Kohlberg (1927-1987).
PIAGET: COGNITIVE
THEORY
Sensorimotor level; uses reflexive
behavior; has to do things to
learn.
Coordinates more than one
thought at a time; uses thought
to create new solutions.
lntuitive-preoperational;
preschoolers are egocentric and
have magical thinking. Early
school-aged children begin to
develop understanding of cause
and effect. Child functions
symbolically using language;
develops understanding of life
events and relationships.
Concrete operations: uses mental
reasoning to solve problems;
attempts to reach logical
solutions; tests beliefs to establish
values.
Formal operations developing;
adolescents are determining
values that will guide their lives
and religious affiliations; they
develop abstract ideas that can be
based in reality.
ERIKSON:
PSYCHOSOCIAL
THEORY
Building basic trust versus
mistrust; learning drive and
hope.
Autonomy versus shame and Avoids punishment and the
doubt; learning self-control power of authority figures.
and willpower.
Preschoolers process initiative
versus guilt and attempt to
develop direction and
purpose. Children mimic
others and are more
purposeful in establishing
goals.
Industry versus inferiority;
establishing methods for
solving problems and a
feeling of competence;
mastering tasks and using
hands to create things.
Identity versus role confusion;
developing self-identity that
will determine devotion and
fidelity in future relationships.
KOHLBERG: MORAL
REASONING
Avoids punishment and obeys
for obedience's sake.
Develops preconventional
morality; follows the standards
of others to avoid punishment
or to earn a reward; recognizes
some things are self-satisfying
and some are done to satisfy
others.
Conventional morality; doing
what is expected is important.
Children need to be good in
their own eyes in addition to
doing what they perceive others
expect of them; they want to
please others.
Postconventional morality;
developing respect for the laws
of society; learning to consider
the greatest good for the
greatest number; values are
related to one's group. Behavior
is controlled internally.

between 2 weeks and 4 months of age who has crying episodes
that occur at least three times a week for longer than 3 hours a
day and lasting 3 weeks. During an attack, the infant draws up
the legs, clenches the fists, and cries inconsolably. The abdominal
distress of colic usually occurs in the late afternoon and evening.
Many theories have been suggested for why infants have colic, but
none has been proven correct. If the baby is fed infant formula,
pediatricians recommend switching formulas, perhaps to a non-
cow's milk type, because this may help relieve the infant's dis-
comfort. Treatment consists of determining the cause; however,
the child frequently outgrows the condition before the causative
agent can be identified. Drugs are not helpful and in some cases
may be dangerous for the infant. Parents need reassurance that
they are not responsible for the child's discomfort, and they may
find counseling and assistance in developing coping techniques
helpful.
Diarrhea
Diarrhea can be caused by a variety of microorganisms, including
bacteria, viruses, and parasites. However, children sometimes can
have diarrhea without having an infection, such as when diarrhea is
caused by food allergies or by certain medications, such as antibiot-
ics. Diarrhea is diagnosed when the child has two or more watery
or apparently abnormal stools within 24 hours. The child may not
show other signs of illness or may have nausea, vomiting, stomach
aches, headache, or fever. If the diarrhea continues for longer than
2 days, medical intervention is needed, because prolonged diarrhea,
in which fluid loss becomes excessive, can cause dehydration and
454 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES
electrolyte imbalance. In addition, a resultant diaper rash and exco-
riation can be very painful.
Pediatric diarrhea needs to be followed closely with observation.
In the case of bloody stools, laboratory analysis should be ordered
to determine the causative factors. Infants and small children should
be followed up by telephone in 12 hours and then daily until the
diarrhea has stopped. Parents should know the indications of dehy-
dration, including lack of tears when crying, lethargy, fewer wet
diapers or decreased urination, dry mouth and lips, and weight loss.
The physician may recommend the use of oral rehydration therapy,
such as Pedialyte or Infalyte; small amounts (approximately 2 table-
spoons) are offered at a time (i.e., every 15 minutes) to prevent
vomiting. Soft drinks, juices, sports drinks, and tea should be avoided
because they lack electrolytes and may lead to even more diarrhea.
Parents should be informed that the child's diarrhea may not stop
when the child is given oral rehydration therapy, but the fluids
prevent the child from becoming dehydrated. It is important to
continue to feed the child because lack of food can damage the villi
in the small intestine. If breast-fed, the baby should continue to
nurse because breast milk is shown to protect the gastrointestinal
lining.
The banana, rice, applesauce, and toast (BRAT) diet has been the
traditional approach for children with diarrhea, but it is no longer
recommended because there is no evidence that it is useful. In fact,
the poor protein content of the BRAT diet may contribute to con-
tinued diarrhea and poor nutrition. Pediatricians now recommend
that children resume their prediarrhea diet as soon as possible so that
they continue to eat something they prefer while the intestine heals.
Probiotics found in certain yogurt products can also be helpful in
stabilizing the child while the intestinal tract gets back to normal.
The child should not be given over-the-counter (OTC) antidiar-
rheal medications, such as Pepto-Bismol, Kaopectate, Imodium, or
Lomotil, because these can cause serious side effects, including de-
creased motility of the bowel, respiratory depression, and drowsiness.
The provider may prescribe antibiotics if stool cultures test positive
for pathogens. Children with severe dehydration require hospitaliza-
tion and intravenous (IV) hydration to replace electrolytes and fluids.
CRITICAL THINKING APPLICATION 18-4
Susie receives a call from the grandmother of a 3-year-old child who has
had diarrhea since last night. What are some questions Susie should ask to
determine the seriousness of the problem? Should the child be seen today,
even though appointments are already overbooked?
Failure to Thrive
Failure to thrive is a symptom more than a disease. Failure to thrive
refers to children whose current weight or rate of weight gain is much
lower than that of other children of similar age and gender. It is
diagnosed in an infant or young child whose weight is consistently
below the 3rd percentile on standardized growth charts or one who
is 20% below the ideal body weight for length. Physical, mental, and
social skills also are delayed in these children. Manifestations include
failure to roll over, smile, coo, stand, or walk at age-appropriate
developmental levels. Failure to thrive can be caused by a physiologic
factor (e.g., malabsorption disease or cleft palate), or it may be
related to a problem with the parent-child relationship. The physi-
cian needs an accurately recorded history of the child's birth weight
and subsequent length, weight, and head circumference measure-
ments. A comprehensive family history is important to rule out
genetic growth abnormalities or a history of malabsorption prob-
lems, such as cystic fibrosis or celiac disease.
Children with failure to thrive need more calories than usual-
approximately 150% of their normal calorie load-to catch up to
their target weight. Both medical and social factors are evaluated in
the treatment of children with this problem. Experts believe that
infants may suffer from this problem if they are being neglected;
however, low weight gains also are possible with extremely attentive
and cautious parents. The family must be considered as a whole to
treat nonorganic causes effectively. Treatment may include the use
of support groups and parental counseling.
Obesity
Just as with adult weight patterns, children are assessed according to
their BMI. A child's level of body fat varies as the child grows; for
example, children normally slim down as they reach school age, and
very often their weight increases as they mature from adolescence to
adulthood. In addition, body fat levels vary between boys and girls
as they reach puberty. Pediatricians use growth charts that plot the
child's BMI-for-age to determine whether the child's weight, in
comparison with height, is within healthy limits. A child is consid-
ered overweight if the BMI-for-age is between the 85th and 94th
percentiles; the child is identified as obese if the BMI is at or greater
than the 95th percentile. Obesity now affects nearly 18% of all
children and adolescents in the United States, and since 1980 the
number has almost tripled. Children who are overweight or obese
as preschoolers are five times as likely as normal-weight children to
be overweight or obese as adults. Studies have shown that a child
who is obese between the ages of 10 and 13 has an 80% chance of
becoming an obese adult.
The reasons for childhood obesity vary; they include a family
history of obesity, inactivity, high-calorie diets, and stress. In rare
cases, childhood obesity may be caused by metabolic or endocrine
disorders. Overweight and obese children are at greater risk of devel-
oping serious health conditions, including asthma, diabetes mellitus
type 2, sleep apnea, and hypercholesterolemia, which increases the
risk of cardiovascular disease and hypertension. The psychosocial
impact of obesity can be overwhelming for many children because
isolation, loneliness, and lack of self-esteem are common. The pedia-
trician can provide assistance by recommending a comprehensive
diet and exercise program that emphasizes healthy living. The
medical assistant can help by providing educational materials,
encouragement for the child and parents, and referral to community
education and support programs.
CRITICAL THINKING APPLICATION 18-5
Juanita Johnston is a 12-year-old patient who was recently diagnosed as
being obese. You are asked to help Juanita and her mother access online
information about healthy nutrition options. What websites would be most
appropriate for Juanita and her family? What other community resources
can you recommend to support the family in making healthier nutrition
decisions?

Respiratory Disorders
Common Cold
The common cold, or infectious rhinitis, has more than 100 caus-
ative pathogens and is highly contagious. It is spread through respira-
tory droplets from rhinitis, sneezing, or coughing, either from direct
contact or from touching contaminated items. The signs include
nasal congestion, low-grade fever, and general malaise. Most colds
are self-limiting and run their course in about a week. In infants and
young children, the primary concerns are nasal congestion and loss
of appetite. The parent may need to be shown how to use a nasal
bulb syringe to suction the nose of an infant (Figure 18-3). Second-
ary infections in the lower respiratory tract or in the middle ear can
occur.
Cautions on the Use of Over-the-Counter Cough
and Cold Medicines in Children
The U.S. Food and Drug Administration (FDA) strongly recommends that
over-the-counter (OTC) cough and cold products not be given to children
under 2 years of age. Anumber of serious complications may occur, includ-
ing death, convulsions, rapid heart rate, and diminished levels of conscious-
ness. These medications are given for symptomatic relief and have not been
proven to be safe or effective for very young children. Manufacturers have
responded to the FDA's recommendation by voluntarily removing the prod-
ucts from shelves.
The FDA also is concerned about the use of these products in children
ages 2 to 11 years. Parents need to know that many OTC cough and cold
products contain the same active ingredients. Giving a child more than one
product that contains the same active ingredient can result in overdose,
especially if the wrong dose is given or the product is administered too
frequently. Parents of older children are encouraged to read the Drug Facts
section on the label of each product to familiarize themselves with the
active ingredients in the product and to follow dosing guidelines strictly to
reduce the risk of complications.
FIGURE 18-3 Nasal bulb syringe.
CHAPTER 18 Assisting in Pediatrics 455
One of the secondary infections that can occur is strep throat,
which is caused by group A Streptococcus bacteria. It is easily spread
when an infected person coughs or sneezes contaminated droplets
into the air and another person inhales them. A person also can
become infected by touching such secretions and then touching the
mouth or nose. Symptoms of strep throat infections may include
severe sore throat, fever, headache, and lymphadenopathy; also, the
throat appears bright red, and pustules may be present on the tonsils.
If they are not treated with antibiotics, strep infections can lead to
scarlet or rheumatic fever; infections of the skin, bloodstream, or
ears; and pneumonia. Scarlet fever is characterized by a bright red,
rough-textured rash that spreads over the child's body. Rheumatic
fever is a serious disease that can damage the heart valves.
Otitis Media
Infection or inflammation of the middle ear usually is a side effect
of a cold or other upper respiratory tract disorder, but it also can
be caused by allergies. Otitis media (OM) usually occurs in chil-
dren younger than 3 years of age. Signs include inflammation of
the middle ear, with fluid building up behind the tympanic mem-
brane. The child may cry persistently, tug at the ear, have a fever, be
irritable, and have diminished hearing in the affected ear. These
symptoms sometimes may be accompanied by diarrhea, nausea, and
vomiting.
Otitis media is classified as either serous (Figure 18-4) or sup-
purative (Figure 18-5), depending on the composition of the accu-
mulated fluid in the middle ear. In Figure 18-5, pus is in the middle
ear and shows up as white in the image. Because otitis media may
be caused by bacteria or a virus, determining the most appropriate
treatment can be difficult. Traditionally, children with indications of
a middle ear infection were treated with antibiotics; however, if the
infection is caused by a virus, antibiotics do not help.
In 2013, the American Academy of Pediatrics (AAP) and the
American Academy of Family Physicians (AAFP) released an
updated clinical practice guideline for the diagnosis and manage-
ment of otitis media in children age 6 months to 12 years. Antibi-
otics should be prescribed for children 6 months or older who have
severe signs and symptoms (typically amoxicillin or azithromycin
FIGURE 18-4 Serous otitis media. (From Swartz MH: Textbook of physical diagnosis, ed 5,
Philadelphia, 2006, Saunders.)
456 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES
FIGURE 18-5 Suppurative otitis media. (Courtesy Dr. Richard A. Buckingham and Dr. George E.
Shambaugh, Jr.)
[Zithromax]). Antibiotics can also be prescribed in patients under
24 months of age who are experiencing nonsevere bilateral infec-
tions. However, in children over 6 months with nonsevere symp-
toms, observation and a follow-up within 48 to 72 hours before
initiating antibiotics may be offered to assess patient improve-
ment. If no improvement is noticed or symptoms have worsened,
antibiotic therapy should be started. In all cases, if the child has
not improved in 48 to 72 hours, the current antibiotic should be
switched. Because antibiotics do not provide immediate relief from
symptoms, children can be given oral acetaminophen and/or ibu-
profen for pain relief.
If fluid in the middle ear persists for longer than 3 months and/
or if the child experiences hearing loss, the physician may recom-
mend a myringotomy; in this operation, a small incision is made in
the tympanic membrane and a tube is inserted to drain the fluid and
balance the pressure between the outer and middle ear. The tube
typically stays in the eardrum for 6 to 12 months and falls out as
the child grows.
CRITICAL THINKING APPLICATION
Ayoung mother calls, extremely upset about her 4-year-old son. His symp-
toms started 3 days ago with a cold, but now the child complains of a sore
throat and an earache. What questions should Susie ask ta determine
whether the child should be seen today?
Croup
Croup is a viral inflammation of the larynx and the trachea that
causes edema and spasm of the vocal cords. This varying degree of
obstruction of the cords produces hoarseness; a harsh, barking
cough; and stridor during inhalation. The episodes usually occur at
night, and symptoms ease by morning. The infection usually is self-
limiting, and the child typically recovers without treatment. Mild
croup can be relieved by using a cool mist humidifier in the child's
room, sitting with the child in a steamy bathroom, or even taking
the child outside if the air is cool. Children with allergies may require
medical treatment. If the problem becomes chronic or continues for
a longer period, the child may need to be treated with corticosteroids
(e.g., prednisone). The physician may recommend laryngoscopy to
visualize the vocal cords or may order throat cultures to determine
the underlying cause of the inflammation.
Pertussis (Whooping Cough)
Pertussis is a very contagious respiratory illness, commonly known
as whooping cough, which is caused by bacteria that attach to the cilia
(tiny, hairlike extensions) that line part of the upper respiratory
system. The bacteria release toxins that damage the cilia and cause
inflammation and swelling. Whooping cough is spread by coughing
or sneezing while in dose contact with others. Infants who get per-
tussis are typically infected by older siblings, parents, or caregivers
who might not even know they have the disease.
Pertussis can cause violent and rapid coughing, over and over,
until the air is gone from the lungs and the child is forced to inhale
with a loud "whooping" sound. Infants may not exhibit the classic
cough associated with pertussis but can develop life-threatening
apnea, which is a pause in the child's breathing. About half of infants
younger than 1 year of age who get the disease are hospitalized.
Early treatment with antibiotics, before the coughing fits start, is
very important. The best way to prevent pertussis is through
vaccination.
The recommended pertussis vaccine for infants and children is
DTaP. This is a combination vaccine that protects most children for
at least 5 years from three diseases: diphtheria, tetanus and pertussis.
However, complete vaccination requires five doses starting at 2
months of age up through 4 to 6 years of age. In addition, vaccine
protection for these three diseases fades with time. The CDC recom-
mends that adults get a Tdap booster at least every 10 years. Being
up-to-date with the pertussis vaccine is especially important for
families with and caregivers of newborns.
Current recommendations are that pregnant women get a dose
ofTdap during each pregnancy, preferably at 27 through 36 weeks'
gestation. If the expectant woman receives the immunization in her
final trimester, maternal pertussis antibodies transfer to the newborn
in utero, providing the baby protection against pertussis in early life.
In addition, T dap helps protect the mother, so she does not become
18-6 infected and transmit the disease to her newborn. All family members
and caregivers of the infant also should receive a T dap booster before
coming into contact with the infant.
Bronchiolitis
Bronchiolitis is a viral infection of the small bronchi and bronchioles
that usually affects children younger than 3 years of age. The infec-
tion varies in severity and is seen in children with a family history
of asthma and those exposed to cigarette smoke. The child typically
has a previous history of rhinitis and cough, with an acute onset of
wheezing and dyspnea. Symptoms occur because of inflammation,
edema, increased secretions, and bronchospasm in the respiratory
pathway. Treatment includes acetaminophen for discomfort and
fever and a bronchodilator inhaler (albuterol sulfate [Proventil]) or
nebulizer treatments for relief of wheezing. Most children fully
recover in 2 weeks, but as many as 50% have recurrent wheezing
and coughing.

Respiratory Syncytial Virus
Respiratory syncytial virus (RSV) infects the lungs and bronchioles.
Healthy older children and adults usually experience mild, coldlike
symptoms and recover in a week or two. However, RSV can cause
a serious respiratory infection in infants and older adults. Premature
infants, children younger than 2 years of age with congenital heart
or chronic lung disease, and children with weakened immune
systems are at highest risk for severe RSV infections. RSV is the most
common cause of bronchiolitis and pneumonia in children younger
than 1 year of age.
Symptoms start out similar to those of the common cold, includ-
ing runny nose, decreased appetite, coughing, sneezing, and fever.
Wheezing associated with bronchiole irritation and inflammation
may also occur. In very young infants, irritability, decreased activity,
and breathing difficulties may indicate that hospitalization is neces-
sary. Because the infection is caused by a virus, there are no medica-
tions that can cure RSV; however, other drugs may be prescribed to
help treat symptoms.
Researchers are working to develop a vaccine for RSV. The physi-
cian may prescribe the drug palivizumab (Synagis) for infants and
children at great risk of developing severe RSV infections. Palivi-
zumab does not cure the infection but can help prevent serious
illness by boosting the child's immune system. It is given in monthly
intramuscular injections during the fall, winter, and spring, when
most RSV infections occur.
Asthma
Asthma is the most common chronic health problem among
children. It is the result of two specific reactions, broncho-
spasm and inflammation. During an asthma attack, the bronchial
tubes begin to spasm, which reduces the amount of air that
can pass through them. At the same time, the tissue lining the
bronchioles becomes edematous and secretes mucus; therefore,
in an asthma attack, the smaller airways are filling up with
mucus and secretions. Air passing through these secretions causes
the classic symptom of asthma, wheezing on expiration. Asthma
has a strong hereditary link. Factors that can trigger an attack
include:
• Respiratory infections, including infections caused by
common cold viruses
• Exposure to cigarette smoke
• Stress
• Strenuous exercise
• Weather conditions, including cold, windy, or rainy days and
extreme humidity
• Allergies to animals, dust, pollen, or mold
• Indoor air pollutants, such as paint, cleaning materials, chemi-
cals, or perfumes
• Outdoor air pollutants, such as ozone
Children with asthma have a nonproductive cough accompa-
nied by an expiratory wheeze and shortness of breath. Shallow
breathing makes it difficult for the child to speak more than a few
words at a time. The child complains of tightness or pressure in
the chest, and the provider hears rhonchi on auscultation. An
asthma attack can last minutes to days and may develop into a
medical emergency. Each child and each attack must be evaluated
independently.
CHAPTER 18 Assisting in Pediatrics 457
The therapeutic plan is determined by the severity and fre-
quency of attacks. Children with mild to moderately persistent
disease (i.e., symptoms that occur less than twice a week or as
often as daily) should be referred to a specialist. A child who expe-
riences symptoms two or more times a week should take daily
medication to prevent asthma attacks. Such medications may
include inhaled corticosteroids that deliver an antiinflammatory
directly to the bronchioles (e.g., fluticasone [Advair Diskus, Flo-
vent]); long-acting bronchodilators, including salmeterol (Ser-
event); and oral medications, such as montelukast (Singulair) or
zafirlukast (Accolate). The child also is prescribed a quick-acting
medication, or "rescue inhaler," such as albuterol (Proventil, Vento-
lin), for acute relief of bronchospasm or exercise-induced asthma;
this inhaler should be readily available at all times. (Further man-
agement of asthma is covered in the Assisting in Pulmonary Medi-
cine chapter.)
Influenza
Influenza (the "flu") is an acute, highly contagious viral infection of
the respiratory tract. The highest incidence is seen in school-aged
children, but it is most severe in infants and toddlers. It is transmit-
ted by direct contact with moist secretions. Children tend to have
high fevers with influenza and are susceptible to pulmonary compli-
cations. Influenza can vary widely in severity, ranging from very
mild to life-threatening. The virus can destroy the respiratory epi-
thelium, which is one of the body's defense mechanisms against
bacterial invasion. With the loss of this protective mechanism, bac-
teria can invade any part of the respiratory tract and cause
pneumonia.
No medication cures influenza. However, antiviral medica-
tions can make the illness milder and make patients feel better
faster. They may also prevent serious complications from the flu;
however, they work best when started within the first 2 days of
initial symptoms. Zanamivir (Relenza), an antiviral, is inhaled
every 12 hours, but it cannot be prescribed for children under 5
years of age. In 2012 the U.S. Food and Drug Administration
(FDA) approved the use of oseltamivir (Tamiflu) to treat children
as young as 2 weeks of age who have shown symptoms of flu for
no longer than 2 days.
Antibiotics are prescribed only if a secondary bacterial infection
develops, such as sinusitis. The usual treatment for influenza is bed
rest, increased fluids, and a nonaspirin analgesic to reduce fever and
relieve discomfort.
Flu vaccines are available but are beneficial only if the individ-
ual is vaccinated before the onset of the disease. Furthermore,
annual vaccines do not provide immunity from all strains of the
flu virus. The CDC recommends annual flu vaccinations for all
healthy children from age 6 months to 19 years of age and their
caregivers. The nasal spray vaccine is approved for use in people 2
years through 49 years of age. The flu shot is recommended for
any child over 6 months of age who has a chronic health problem,
such as children with chronic heart or lung diseases (including
asthma); those undergoing long-term aspirin therapy; children
with diabetes mellitus or sickle cell anemia; and those with kidney,
blood, or suppressed immune system diseases. The first influenza
immunization for children age 6 months to 8 years requires two
doses given about 1 month apart. Children 9 years of age or older
458 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES
need only one dose per season. Influenza strains continually
change, so the child must receive an updated version of the
vaccine each year.
Infectious Diseases
Conjunctivitis
Pinkeye, also called conjunctivitis, is discussed in the Ophthalmol-
ogy chapter. It is a common infection in children and is highly
contagious, especially in day care centers and schools. It can be
caused by a bacterial or viral infection that produces white or
yellowish pus, which may cause the eyelids to stick shut in the
morning. Health teaching for caregivers of infected children
includes the following:
• Use good hand sanitization practices and hygiene, including
proper use and disposal of tissues.
• Do not share towels or any other item that comes in contact
with the child's face.
• Disinfect any articles that may have been contaminated.
• Children diagnosed with infectious conjunctivitis should be
treated with an antibiotic for at least 24 hours before return-
ing to day care or school.
Tonsillitis
Tonsillitis is caused by many infectious agents, but the most common
is Streptococcus A. The onset is sudden, and the disorder can cause
intense pain within a short time, in addition to fever and general
malaise. The tonsils appear enlarged and inflamed and may be
covered with pustules. A throat culture usually is performed to
determine the causative organism. Treatment consists of bed rest, a
liquid to soft diet, an analgesic throat spray, and oral antibiotics if
the causative organism is a bacterium. The danger lies in the second-
ary problems that can occur, which include rheumatic heart disease
and kidney disease if the streptococcal infection is not treated with
antibiotics.
Fifth Disease
Fifth disease, also called erythema infectiosum, parvovirus infection, or
sl,apped cheek disease, is an infection caused by parvovirus Bl 9. Out-
breaks are most common in the winter and spring. Symptoms begin
with a mild fever and general malaise. After a few days, the cheeks
take on a flushed appearance, making the face look as if it has been
slapped. A lacy rash also may be seen on the trunk, arms, and legs,
but not all those infected develop the rash.
Most children who get fifth disease are not very ill and recover
without any serious consequences. However, children with sickle
cell anemia, chronic anemia, or an impaired immune system may
become seriously ill when infected and require medical care. If a
pregnant woman becomes infected with parvovirus Bl9, she has
an increased risk of miscarriage, and the fetus may suffer from
severe anemia. The woman herself may have no symptoms or may
have a mild illness with a rash and/or arthralgia (joint pain).
Fifth disease is spread through direct contact or by breathing in
respiratory secretions from an infected person. Patients are most
contagious before the onset of the rash; once the rash appears, they
are no longer considered contagious. Once individuals recover from
fifth disease, they develop immunity that generally protects them
from parvovirus Bl9 infection in the future.
FIGURE 18-6 Vesicular palm lesions in hand-foot·and·mouth disease. (From Schachner lA,
Hansen RC: Pediatric dermatology, ed 4, St Louis, 2011, Mosby.)
Hand-Foot-and-Mouth Disease
Hand-foot-and-mouth disease is caused by the coxsackievirus,
which is transmitted by direct contact with nose and throat drain-
age, saliva, or the stool of an infected individual. The disease is
seen most often in day care settings, where children can easily
come in contact with infected bodily secretions. Symptoms
include a combination of fever; sore throat; painful red blisters on
the tongue, mouth, palms, and soles; headache; anorexia; and irri-
tability (Figure 18-6). Most cases of hand-foot-and-mouth disease
are not serious. The most common complication of the infection
is dehydration. Young children may stop eating and drinking
because sores in the mouth make swallowing painful. Because the
infection is caused by a virus, antibiotic therapy is not helpful,
and the disease must run its course. Supportive therapy is recom-
mended, consisting of plenty of rest, fluids, and acetaminophen or
ibuprofen for fever or discomfort. To prevent the spread of the
disease, family members should be instructed to wash their hands
thoroughly, especially after diaper changes, and frequently disinfect
shared items (e.g., toys). Individuals with the disease are highly
contagious during the first week; however, the virus may be spread
for weeks after symptoms have cleared. Children with hand-foot-
and-mouth disease should be kept out of day care or school until
the fever is gone and mouth sores have healed.
Varicel/a (Chickenpox)
Chickenpox is caused by a member of the herpes virus group and is
transmitted by direct or indirect droplets from the respiratory tract
of an infected person. The incubation period is 14 to 21 days. Chil-
dren usually run a slight fever for up to 3 days before the skin erup-
tions occur, and they are contagious at this time. Skin lesions
continue to erupt for 3 to 4 days and cause intense itching. The
infection lasts approximately 2 weeks and in most cases leaves the
child with lifetime immunity. The disease is so contagious in its early
stages that an exposed person who is not immune to the virus has a
70% to 80% chance of contracting the disease.

The varicella virus vaccine, Varivax, is available for protection
against chickenpox. Varivax is very effective; 80% to 90% of those
vaccinated are completely protected from chickenpox. If a child does
get chickenpox after vaccination, it is usually a very mild case, lasting
only a few days, and involving limited skin lesions, low-grade or no
fever, and few other symptoms.
The CDC recommends that children receive two doses of the
vaccine, the first between 12 and 15 months of age and the second
between 4 and 6 years. Adolescents and adults who have never had
chickenpox also should receive two doses of the vaccine. Varivax has
proved to be safe and effective and can be administered at the same
time as the measles, mumps, and rubella (MMR) vaccine. An alter-
native combination vaccine for the measles, mumps, rubella, and
varicella (MMRV) is recommended for children between 12 months
to 12 years old. It is a single shot that can be used in place of the
MMR and MMRV vaccines. Two doses of MMRV are recom-
mended, the first dose at 12 through 15 months of age and the
second dose at 4 through 6 years of age. The one MMRV vaccine
licensed in the United States is ProQuad.
Chickenpox is not a serious disease for most children.
However, newborns and individuals with an impaired immune
system (e.g., those undergoing chemotherapy for cancer, those
with acquired immunodeficiency syndrome [AIDS], and those
who take steroid medications [e.g., prednisone]) may have a severe
case or can even die. Chickenpox can be very dangerous for preg-
nant women, causing stillbirths or birth defects, and can be spread
to their babies during childbirth. Occasionally chickenpox can
cause serious, life-threatening illnesses, such as encephalitis or
pneumonia, especially in adults. After infection, the virus migrates
to a dermatome and may cause shingles (herpes zoster) later
in life.
Meningitis
Meningitis is an inflammation of the membranes that cover the
brain and spinal cord. It is caused by a bacterial, fungal, or viral
infection. Viral meningitis usually is mild and clears up on its own
within 10 to 14 days. Fungal meningitis can be quite serious and
typically is seen in immunocompromised individuals, such as
those with AIDS. Meningitis caused by a bacterial infection
(sometimes called spinal meningitis) is one of the most serious
types, sometimes leading to permanent brain damage or even
death. Bacterial meningitis most often is caused by three different
bacteria: Neisseria meningitidis (meningococcal meningitis), Strepto-
coccus pneumoniae, and Haemophilus influenzae serotype b (H
influenzae meningitis). These bacteria are carried in the upper back
part of the throat (nasopharynx) of an infected person and are
spread either through the air (when the person coughs or sneezes)
or by direct contact with secretions, such as through kissing or
sharing eating or drinking utensils. However, transmission usually
occurs only after very close contact with the infected person. Signs
and symptoms of bacterial meningitis include a sudden onset of
fever, headache, neck pain or stiffness, vomiting (often without
abdominal complaints), and irritability. These signs and symptoms
may quickly progress to a decreased level of consciousness (the
person is difficult to rouse), convulsions, and death. For this
reason, if any child displays symptoms of possible meningitis, he
or she should receive medical care immediately. Bacterial meningi-
CHAPTER 18 Assisting in Pediatrics 459
tis is treated with immediate hospitalization and IV antibiotic
therapy.
Meningitis caused by H influenzae serotype b (Hib) can be
prevented with the Hib vaccine, which is given as part of the routine
childhood immunizations in three or four doses starting at 2 months
of age. Some cases of meningococcal meningitis also can be pre-
vented by vaccination. However, this vaccine is not used routinely
outside of childhood except during outbreaks or for high-risk chil-
dren who did not receive the original immunization. Many states
require reporting of bacterial meningitis cases to the health depart-
ment, which probably will recommend preventive antibiotics for
potentially exposed people.
Hepatitis B
Infection with the hepatitis B virus (HBV) can lead to a serious,
chronic infection of the liver. The virus can be transmitted across
the placenta or during the birth process if the mother is infected.
HBV also can be transmitted sexually, by blood transfusion, or by
direct contact. A child can carry the virus for years and only later
develop liver failure or liver cancer. Many states now include immu-
nization for HBV in the recommended immunization schedule,
which usually is begun in the newborn nursery. The CDC recom-
mends that all infants receive their first intramuscular injection
before leaving the hospital, the second dose at 1 to 2 months of age,
and the third dose at 6 months. The vaccination schedule most
often used for adults and children has been three intramuscular
injections, the second and third administered 1 and 6 months after
the first.
CRITICAL THINKING APPLICATION 18-7
An expectant mother is questioning the administration of her infant's first
hepatitis immunization in the newborn nursery. What details can you share
with her about the importance of the infant starting the hepatitis Bvirus
(HBV) series? Can you refer her to any online sources of information?
Reye's Syndrome
The cause ofReye's syndrome is unknown, but the disorder has been
linked to the use of aspirin during a viral illness. Reye's syndrome is
an acute and sometimes fatal illness characterized by fatty invasion
of the inner organs, especially the liver, and swelling of the brain. It
most often is seen in children from infancy through puberty
(age 16).
Prevention is the best treatment, which means children up to age
14 should never be given aspirin unless prescribed by a physician for
a chronic condition such as juvenile rheumatoid arthritis. Parents
should be advised to use nonsalicylate analgesics and antipyretics
(e.g., ibuprofen and acetaminophen) for fevers or discomfort. Parents
should also be warned to read the labels of OTC medications care-
fully because cold and flu remedies may contain aspirin. The syn-
drome is rare because of well-informed caregivers and a responsive
pharmacology industry that no longer puts aspirin into products for
children.
460 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES

Autism Spectrum Disorder

• Children diagnosed with autism spectrum disorder (ASD) show a wide
range of neurologic and developmental behaviors. The most severe form
is autism, or classical ASD; a milder form may present as Asperger syn-
drome; and sometimes a child cannot be categorized into a specific
diagnosis and so is labeled with a pervasive developmental disorder
(PDD).
• ASD occurs in all ethnic and socioeconomic groups and affects every age
group.
• The Centers for Disease Control and Prevention (CDC) estimates the
prevalence af ASD to be l in 68; it is almost five times more common
among boys (l in 42) than among girls (l in 189).
• Children with autism have impaired social interaction, do not respond to
their name, avoid eye contact, and show limited interest in their surround-
ings. They rarely communicate with others and display repetitive move-
ments or mannerisms, such as rocking or twirling. They may also have
self-abusive behaviors, such as biting and head banging. Many children
From https:j/www.aap.org/en·us/about·the·aap/Committees-Councils·Sections/Council·on-Children·with·Disabilities/Pages/Autism.aspx. Accessed February 9, 2016.
with autism have a very high pain tolerance but are extremely sensitive
to noise, touch, or other sensory stimulation.
• The cause of this developmental disorder is unknown, but researchers
believe it is due to a combination of genetic errors and environmental
factors, perhaps a problem with fetal brain development. Although many
parents are concerned about aconnection with vaccines, extensive studies
have failed to show a link between the two.
• The American Academy of Pediatrics (AAP) recommends a general devel-
opmental screening at every well-child visit and a developmental screen-
ing using a standardized tool at 9, 18, and 30 months, or whenever a
caregiver expresses concern. In addition, autism-specific screening is rec-
ommended for all children at the 18- and 24-month visits.
• Treatment involves coordinated educational and behavioral interventions
to help the child develop social and language skills. Medications may
be prescribed to treat depression, anxiety, and obsessive-compulsive
behaviors.

Modified Checklist for Autism in Toddlers: M-CHAT-R

The M-CHAT-R has been validated to assess risk for autism spectrum disorders 5. Does your child make unusual finger movements near Yes No
(ASDs) in toddlers between 16 and 30 months of age. The M-CHAT-R can his or her eyes?
be administered and scored as part of a well-child checkup. Caregivers com- (FOR EXAMPLE, does your child wiggle his or her
plete the questionnaire based on the child's typical behavior. The medical fingers close to his or her eyes?)
assistant may be asked questions about the form, so you should be familiar 6. Does your child point with one finger to ask for Yes No
with its purpose and instructions for completion. something or to get help?
The primary goal of the M-CHAT-R is to detect as many cases of ASD as (FOR EXAMPLE, pointing to a snack or toy that is out
possible. It therefore has a high false-positive rate; this means that not all of reach)
children who score at risk will be diagnosed with ASD. If the initial tool is
7. Does your child point with one finger to show you Yes No
positive, the Follow-Up questions (M-CHAT-R/F) should also be administered.
something interesting?
If results remain positive, the child should be referred for diagnostic evaluation
(FOR EXAMPLE, pointing to an airplane in the sky or a
by a specialist trained to evaluate ASD in very young children. Scoring instruc-
big truck in the road)
tions can be downloaded from the website www.mchatscreen.com.
The following are the questions on the M-CHAT-R. 8. Is your child interested in other children? Yes No
(FOR EXAMPLE, does your child watch other children,
smile at them, or go to them?)
l. If you point at something across the room, does your Yes No
9. Does your child show you things by bringing them to Yes No
child look at it?
(FOR EXAMPLE, if you point at a toy or an animal, you or holding them up for you to see- not to get
help, but just to share?
does your child look at the toy or animal?)
(FOR EXAMPLE, showing you a flower, a stuffed
2. Have you ever wondered if your child might be deaf? Yes No animal, or a toy truck)
3. Does your child play pretend or make-believe? Yes No l 0. Does your child respond when you call his or her Yes No
(FOR EXAMPLE, pretend to drink from an empty cup, name?
pretend to talk on a phone, or pretend to feed a doll or (FOR EXAMPLE, does he or she look up, talk or babble,
stuffed animal?) or stop what he or she is doing when you call his or
4. Does your child like climbing on things? Yes No her name?)
(FOR EXAMPLE, furniture, playground equipment, or 11. When you smile at your child, does he or she smile Yes No
stairs) back at you?

Modified Checklist for Autism in Toddlers: M-CHAT-~continued
12. Does your child get upset by everyday noises?
(FOR EXAMPLE, does your child scream or cry to noise
such as a vacuum cleaner or loud music?)
13. Does your child walk?
14. Does your child look you in the eye when you are
talking to him or her, playing with him or her, or
dressing him or her?
15. Does your child try ta copy what you do?
(FOR EXAMPLE, wave bye-bye, clap, or make a funny
noise when you do)
16. If you turn your head ta look at something, does your
child look around to see what you are looking at?
17. Does your child try ta get you to watch him or her?
(FOR EXAMPLE, does your child look at you for praise,
or say "look" or "watch me"?)
Official M-CHAT Website at http://www2.gsu.edu/-psydlr/Site/Official_M-CHAT_Website.html. Accessed February 9, 2016.
© 2009 Robins, Fein, & Barton
Inherited Disorders
Cystic Fibrosis
Cystic fibrosis (CF) is an autosomal recessive genetic disorder (i.e.,
both parents are carriers, but neither has the disease). CF prevents
the normal movement of sodium chloride (salt) into and out of cells.
The lungs and pancreas are primarily affected, resulting in a buildup
of abnormally thick secretions in the lungs and blockage of the
pancreatic ducts, which prevents the excretion of pancreatic digestive
enzymes and results in malabsorption problems. The child is prone
to developing an emphysema-like lung condition because of the
obstruction of the air pathways with mucus. There is also an abnor-
mality in the sweat glands, which produce sweat that is very high in
sodium chloride.
Signs and symptoms of cystic fibrosis include a salty taste to the
skin, which may be noticed when parents kiss the child, steatorrhea
(large, greasy, foul-smelling stools), abdominal distention, failure to
thrive, chronic cough, and frequent respiratory infections. All states
screen newborns for CF using either a genetic test or a blood test.
The genetic test shows whether the newborn has the CF gene, and
the blood test evaluates pancreatic function. If either of these tests
suggests CF, the diagnosis is confirmed using a sweat test, which
shows an elevated chlorine level.
Treatment of the disease is complicated and requires a mul-
tispecialty approach because so many systems are involved. The first
line of treatment is prevention of bronchial obstruction through
routine chest percussion therapy (CPT). Mechanical devices have
been developed to assist with CPT. Two examples are an electric
chest clapper, known as a mechanical percussor, and an inflatable
therapy vest that uses high-frequency airwaves to force the mucus
that is deep in the lungs toward the upper airways. Medical treat-
ments include bronchodilators and antibiotics for signs of infection.
More recent therapies have included medications such as aerosolized
dornase alfa (Pulmozyme), which makes mucus thinner and easier
CHAPTER 18 Assisting in Pediatrics 461
Yes No 18. Does your child understand when you tell him or her to Yes No
do something?
(FOR EXAMPLE, if you don't point, can your child
Yes Na understand "put the book on the chair" or "bring me
the blanket"?)
Yes No
19. If something new happens, does your child look at your Yes No
face ta see how you feel about it?
(FOR EXAMPLE, if he or she hears a strange or funny
Yes No
noise, or sees a new toy, will he or she look at your
face?)
20. Does your child like movement activities? Yes Na
Yes No
(FOR EXAMPLE, being swung or bounced an your knee)
Yes Na
to cough up. The child also is given pancreatic enzymes to improve
digestion and absorption of nutrients. Ivacaftor (Kalydeco), the first
drug to target the genetic cause of CF, was approved by the FDA in
2012 for patients 6 years of age or older who have certain genetic
mutations of CF. lvacaftor, an oral medication taken twice a day,
helps improve lung function, lower sweat chloride levels, and help
patients gain weight. The drug marks a breakthrough in CF treat-
ment because it is the first to address the underlying cause of
the disease.
Cystic fibrosis is a chronic, progressive disease that has no cure;
the life expectancy is 35 to 40 years. Genetic testing can identify
carriers, and its presence can be detected through prenatal genetic
testing with either chorionic villi sampling or amniocentesis. Cystic
fibrosis usually occurs without any warning (parents have no idea
they are carriers), so families need support and understanding to
cope with the demands of caring for a child with the disease.
Duchenne's Muscular Dystrophy
Muscular dystrophy is an X-linked genetic disease (passed from
mothers to sons) that causes progressive muscle degeneration. The
disease usually develops between 3 and 5 years of age and is marked
by progressive muscular breakdown and weakness, frequent falls, a
waddling gait, possible swallowing problems, and difficulty climbing
stairs. The disorder is diagnosed with a blood test that shows an
elevated level of creatine kinase (CK) (an enzyme that leaks out of
damaged muscle), electromyography, muscle biopsy, and genetic
testing. As the disease progresses and the necrotic skeletal muscles
are replaced with fat and fibrous connective tissue, muscle function
is gradually lost. Respiratory insufficiency and infections are common
because of involvement of the diaphragm and intercostal muscles
required for breathing. The disease has no cure and no specific treat-
ment except for supportive care. Family counseling is helpful so that
family members can learn to cope with the disease. Because of
462 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES
improved cardiac and respiratory care, life expectancy is increasing.
Survival into the early 30s is becoming more common, and some
men have lived into their 40s and 50s.
IMMUNIZATIONS
Over the years, immunization has helped dramatically reduce poten-
tially lethal childhood infections. Figure 18-7 summarizes the 2016
immunization recommendations from the CDC for children 0
through 18 years of age. These can be found at the CDC's website:
http://www.cdc.gov/vaccines/schedules/downloadslchild!0-18yrs-child-
combined-schedule.pdf
The schedules are updated periodically as new vaccines become
available and/or research indicates a better method for giving the
vaccine. The CDC recommends immunization against infectious
diseases for all children, except those for whom a particular vaccina-
tion would pose a risk. However, each state develops its own immu-
nization program and methods of enforcement.
2016 Immunization Schedule
2016 immunization schedule changes include the following:
• The vaccine order was changed to group them by the recommended
age of administration.
• Apurple bar was added for Haemophilus influenzae type b (Hib)
vaccine for children aged 5 to 18 years that recommends vaccination
administration to certain high-risk children.
• The inactivated polio vaccine footnote was updated for children who
received only the oral poliovirus vaccine and received all doses before
age 4.
• The hepatitis Bvaccine footnote was revised to clarify when postvac-
cination serologic testing should be done on infants born to mothers
with hepatitis B.
• It includes recommendations for the use of two recently licensed menin-
gococcal Bvaccines (Trumenba and Bexsero) and the 9-valent human
papillomavirus vaccine (Gardasil 9).
Summary of changes in the 2016 Pediatric Immunization Schedule. http://www.medscape.
com/viewarticle/858103?nlid=98844_3901 &src=wnl_newsalrt_ l 6020l_MSCPEDIT&uac
=235043AJ&implD=977298&faf=1. Accessed February l 0, 2016.
The vaccines used in immunizations consist of a suspension of
attenuated organisms or their toxins, which is administered to stimu-
late an active immune response in the child's body, resulting in the
production of antibodies against the specific pathogens. Booster doses
usually are equivalent to a single dose of the initial immunization;
for some immunizations, such as tetanus, boosters are prescribed at
designated intervals to ensure maintenance of immune levels.
Vaccine manufacturers have trade names for each product
and have established protocols to ensure potency and stability.
All vaccines are tested for safety and effectiveness. In every package
of vaccine is an insert that fully describes the vaccine, its use,
the route of administration, adverse reactions, and signs and symp-
toms the parent might observe after immunization that would indi-
cate a potential problem. Untoward responses include high fever,
swelling at the site of the injection, urticaria, breathing difficulties,
severe headache, and convulsions. Any of these should be reported
to the physician immediately. Vaccine storage should follow the
manufacturer's guidelines (e.g., some vaccines must be refrigerated;
others must not be exposed to sunlight).
Some vaccines are grown in birds' eggs or in a medium made of
animal organs or are weakened with chemicals. Therefore, a child
who is allergic to eggs cannot receive some of the vaccines, such
as the MMR, and the vaccine for varicella. The medical assistant
must know the potential allergic problems, common symptoms,
and adverse reactions to immunizations and must make sure the
parent is informed. Table 18-2 details guidelines for childhood
immunizations.
Before a child or adult receives a vaccine, the healthcare provider
is required by the National Childhood Vaccine Injury Act (NCVIA)
to provide a copy of a Vaccine Information Sheet (VIS) to either the
adult patient or the child's parent or legal guardian. A VIS provides
information about the risks and benefits of each vaccine. If providing
the parent or guardian with the VIS is the medical assistant's respon-
sibility, he or she should do the following (Procedure 18-1 ):
• Before administering the vaccine, give the parent the most
current VIS available for that particular vaccine. Give the
parent enough time to review the information and then
answer any questions or refer the parent's concerns to the
physician before administering the vaccine. VIS forms are
available online in a number of different languages to meet
the needs of a diverse patient population.
• Document in the child's health record the date the VIS was
given and the publication date of the VIS (which appears on
the bottom of the form).
• To make sure the office has the most current VIS forms, either
call the state health department or refer to the CDC website
(www.cdc.gov/vaccineslhcplvislcurrent-vis.html). Forms can be
printed directly from the site.
• An informed consent form must be signed and attached to
the child's health record or electronically signed in the child's
electronic health record (EHR) before immunizations are
given. Documentation of immunization administration must
include the date the vaccine was administered, the manufac-
turer of the vaccine, the manufacturer's lot number, the type
of vaccine, the exact site of administration if an injection was
given, any reported or observed side effects, the name and title
of the person who administered the vaccine, and the address
of the medical office where the vaccine was administered.
• An official immunization booklet should be given to the
parent and updated as needed to reflect the child's current
immunization status. The medical assistant should not only
document the required details in the patient's health record,
but also complete the parent's immunization booklet each
time the child receives another vaccination or booster. These
parent records help schools and day care centers determine
the child's immunization status. Some states are developing
computerized immunization record systems.
• It is very important that vaccine vials be handled and stored
properly to maintain the compound's ability to fight disease.
The CDC's recommendations for vaccine management
practices can be found at http://www.cdc.gov/vaccines/recs/
storage/.
Text continued on p. 469
 19-23
Vaccine Birth 1 mo 2mos 4mos 6mos 9mos 12mos 15mos 18mos 2-3yrs 4-6yrs 7-10yrs 11-12yrs 13-15yrs 16-18yrs
mos

Hepatitis B1 (HepB) 1 ,~dose If,,(-------- 2"' dose ------- •

D f,,(----------------------------------3,d dose---------------------------------~ I
Rotavirus' (RV) RV1 (2-dose
series); RVS (3-dose series) B 12"' dose I See
footnote 2

Diphtheria, tetanus, & acellular

pertussis' (DTaP: <7 yrs) B I 2°' dose II 3rn dose 11 r-------4 th dose------- • I I5 th dose

Haemophilus influenzae type b'

(Hib) B I 2addose I See
footnote4 D r_ _ 3rn or 4th doseL---~
See footnote 4
I II
Pneumococcal conjugate'
(PCV13) B I 2addose II 3rn dose ID !..:-------4th dose------- • I II
Inactivated poliovirus'
(IPV:<18yrs) B I 2°' dose I1-oE---------------------------------
3rn dose ---------------------------------, I I 4th dose 11 I
11 Annual vaccination (LAIV or 11 Annual vaccination (LAIV or IIV)
Influenza' (IIV; LAIV) Annual vaccination (IIV only) 1 or 2 doses
IIV) 1 or 2 doses 1 dose only

Measles, mumps, rubella' (MMR) See footnote 8 I ~------- l"dose--------.i I I 200 dose 11

Varicella' (VAR) r"E------- l"dose-------->I I I 2addose 11

Hepatitis A 10 (HepA) 1-(----------2-dose series, See footnote 10----------- • :

MeningococcaI 11 (Hib-MenCY
.<'. 6 weeks; MenACWY-D .<'.9 mos;
MenACWY-CRM ;;, 2 mos)
See footnote 11
I I l"dose
I 1-·..I
Tetanus, diphtheria, &acellular
pertussis' 2 (Tdap: >7 yrs) D ~I I
Human

males and females)

(2vHPV:
papillomavirus 13
females only; 4vHPV, 9vHPV:

Meningococcal B11
• I
I (3-dose
series)
I
See footnote 11
C")
:::c
:J>
Pneumococcal polysaccharide'
(PPSV23) I See footnote 5
~
m
1 1 Range of recommended 1 1 Range of recommended ages 1 1 Range of recommended ages 1 1Range of recommended ages for non-high-risk CJ No recommendation ....
:ICI
00
L____J ages for all children L____J for catch-up immunization l___J for certain high-risk groups L____J groups that may receive vaccine, subject to
individual clinical decision making
This schedule includes recommendations in effect as of January 1, 2016. Any dose not administered at the recommended age should be administered at a subsequent visit, when indicated and ~
feasible. The use of a combination vaccine generally is preferred over separate injections of its equivalent component vaccines. Vaccination providers should consult the relevant Advisory Committee
on Immunization Practices (ACIP) statement for detailed recommendations, available online at http://www.cdc.gov/vaccines/hcp/acip-recs/index.html. Clinically significant adverse events that follow
a5·
vaccination should be reported to the Vaccine Adverse Event Reporting System (VAERS) online (http://www.vaers.hhs.gov) or by telephone (800-822-7967). Suspected cases of vaccine-preventable co
diseases should be reported to the state or local health department. Additional information, including precautions and contraindications for vaccination, is available from CDC on line 5·
(http://www.cdc.gov/vaccines/recs/vac-admin/contraindications.htm) or by telephone (800-CDC-INFO [800-232-4636]). ""C
CD
c..
This schedule is approved by the Advisory Committee on Immunization Practices (http//www.cdc.gov/vaccines/acip), the American Academy of Pediatrics (http://www.aap.org), the American Academy of
Family Physicians (http://www.aafp.org), and the American College of Obstetricians and Gynecologists (http://www.acog.org). a
-,
c=;·
en
NOTE: The above recommendations must be read along with the footnotes of this schedule.
FIGURE 18-7 Recommended immunization schedule for children ages birth to 18 years. (From www.cdc.gov/vaccines/schedules/downloads/
child/0-1 Byrs-child-rnmbined-schedule.pdf. Accessed January 13, 2015.) Continued -1>-
a,
w
5. Pneumococcal vaccines. (Minimum age: 6 weeks for PCV13, 2 years for PPSV23) 11. Meningococcal vaccines (cont'd)
.!>,,
Routine vaccination with PCV13: Catch-up vaccination: a,
• Administer a 4-dose series of PCV13 vaccine at ages 2, 4, and 6 months and at age 12 through 15 months. Administer Menactra or Menveo vaccine at age 13 through 18 years if not previously vaccinated. -I>-
• For children aged 14 through 59 months who have received an age-appropriate series of 7-valent PCV If the first dose is administered at age 13 through 15 years, a booster dose should be administered at age 16
(PCV7), administer a single supplemental dose of 13-valent PCV (PCV13). through 18 years with a minimum interval of at least 8 weeks between doses.
Catch-up vaccination with PCV13: If the first dose is administered at age 16 years or older, a booster dose is not needed.
• Administer 1 dose of PCV13 to all healthy children aged 24 through 59 months who are not completely For other catch-up guidance, see Figure 2. C
vaccinated for their age. Clinical discretion: z
• For other catch-up guidance, see Figure 2. Young adults aged 16 through 23 years (preferred age range is 16 through 18 years) may be vaccinated ::::j
Vaccination of persons with high-risk conditions with PCV13 and PPSV23: with either a 2-dose series of Bexsero or a 3-dose series ofTrumenba vaccine to provide short-term -I
All recommended PCV13 doses should be administered prior to PPSV23 vaccination if possible. protection against most strains of serogroup B meningococcal disease. The two MenB vaccines are not :::c
For children 2 through 5 years of age with any of the following conditions: chronic heart disease interchangeable; the same vaccine product must be used for all doses. :a
m
(particularly cyanotic congenital heart disease and cardiac failure); chronic lung disease (including asthma Vaccination of persons with high-risk conditions and other persons at increased risk of disease: m
if treated with high-dose oral corticosteroid therapy); diabetes mellitus; cerebrospinal fluid leak; cochlear Children with anatomic or functional asplenia !including sickle cell disease):
implant; sickle cell disease and other hemoglobinopathies; anatomic or functional asplenia; HIV infection;
chronic renal failure; nephrotic syndrome; diseases associated with treatment with immunosuppressive
Meningococcal conjugate ACWY vaccines:
1. Menveo
o;
en
drugs or radiation therapy, including malignant neoplasms, leukemias, lymphomas, and Hodgkin disease; o Children who initiate vaccination at 8 weeks: Administer doses at 2, 4, 6, and 12 months of age.

z~
solid organ transplantation; or congenital immunodeficiency: o Unvaccinated children who initiate vaccination at 7 through 23 months:Administer 2 doses, with the second
1. Administer 1 dose of PCV13 if any incomplete schedule of 3 doses of PCV (PCV7 and/or PCV13) were
dose at least 12 weeks after the first dose AND after the first birthday.
received previously. o Children 24months and older who have not received a complete series:Administer 2 primary doses at least G)
2. Administer 2 doses of PCV13 at least 8 weeks apart if unvaccinated or any incomplete schedule of fewer
than 3 doses of PCV (PCV7 and/or PCV13) were received previously.
8 weeks apart. :E
3. Administer 1 supplemental dose of PCV13 if 4 doses of PCV7 or other age-appropriate complete PCV7
2. MenHibrix =i
o Children who initiate vaccination at6 weeks:Administer doses at 2, 4, 6, and 12 through 15 months of age. ::I:
series was received previously.
4. The minimum interval between doses of PCV (PCV7 or PCVl 3) is 8 weeks.
o If the first dose of MenHibrix is given at or after 12 months of age, a total of 2 doses should be given at s::
m
least 8 weeks apart to ensure protection against serogroups C and Y meningococcal disease.
5. For children with no history of PPSV23 vaccination, administer PPSV23 at least 8 weeks after the most Cl
3. Menactra

recent dose of PCV13.
For children aged 6 through 18 years who have cerebrospinal fluid leak; cochlear implant; sickle cell
disease and other hemoglobinopathies; anatomic or functional asplenia; congenital or acquired
immunodeficiencies; HIV infection; chronic renal failure; nephrotic syndrome; diseases associated
with treatment with immunosuppressive drugs or radiation therapy, including malignant neoplasms,
leukemias, lymphomas, and Hodgkin disease; generalized malignancy; solid organ transplantation; or
multiple myeloma:
1. If neither PCVl 3 nor PPSV23 has been received previously, administer 1 dose of PCV13 now and 1 dose
of PPSV23 at least 8 weeks later.
2. If PCVl 3 has been received previously but PPSV23 has not, administer 1 dose of PPSV23 at least 8 weeks
after the most recent dose of PCVl 3.
3. If PPSV23 has been received but PCV13 has not, administer 1 dose of PCV13 at least 8 weeks after the
most recent dose of PPSV23.
For children aged 6 through 18 years with chronic heart disease (particularly cyanotic congenital heart
disease and cardiac failure), chronic lung disease (including asthma if treated with high-dose oral
corticosteroid therapy), diabetes mellitus, alcoholism, or chronic liver disease, who have not received
PPSV23, administer 1 dose of PPSV23. If PCV13 has been received previously, then PPSV23 should be
administered at least 8 weeks after any prior PCV13 dose.
A single revaccination with PPSV23 should be administered 5 years after the first dose to children with
sickle cell disease or other hemoglobinopathies; anatomic or functional asplenia; congenital or acquired
immunodeficiencies; HIV infection; chronic renal failure; nephrotic syndrome; diseases associated
with treatment with immunosuppressive drugs or radiation therapy, including malignant neoplasms,
leukemias, lymphomas, and Hodgkin disease; generalized malignancy; solid organ transplantation; or
multiple myeloma.
8. Measles, mumps, and rubella (MMR) vaccine. (Minimum age: 12 months for routine vaccination)
Routine vaccination:
Administer a 2-dose series of MMR vaccine at ages 12 through 15 months and 4 through 6 years. The
second dose may be administered before age 4 years, provided at least 4 weeks have elapsed since the first
dose.
Administer 1 dose of MMR vaccine to infants aged 6 through 11 months before departure from the United
States for international travel. These children should be revaccinated with 2 doses of MMR vaccine, the first
at age 12 through 15 months (12 months if the child remains in an area where disease risk is high), and the
second dose at least 4 weeks later.
Administer 2 doses of MMR vaccine to children aged 12 months and older before departure from the
United States for international travel. The first dose should be administered on or after age 12 months and
the second dose at least 4 weeks later.
Catch-up vaccination:
• Ensure that all school-aged children and adolescents have had 2 doses of MMR vaccine; the minimum
interval between the 2 doses is 4 weeks.
11. Meningococcal vaccines. (Minimum age: 6 weeks for Hib-MenCY [MenHibrix], 9 months for
MenACWY-D [Menactra], 2 months for MenACWY-CRM [Menveo], 10 years for serogroup B
meningococcal [MenB] vaccines: MenB-4C [Bexsero] and MenB-FHbp [Trumenba])
Routine vaccination:
Administer a single dose of Menactra or Menveo vaccine at age 11 through 12 years, with a booster dose at
age 16 years.
Adolescents aged 11 through 18 years with human immunodeficiency virus (HIV) infection should receive a
2-dose primary series of Menactra or Menveo with at least 8 weeks between doses.
For children aged 2 months through 18 years with high-risk conditions, see below.
~
o Children 24 months and older who have notreceived a complete series: Administer 2 primary doses at least
8 weeks apart. If Menactra is administered to a child with asplenia (including sickle cell disease), do not
administer Menactra until 2 years of age and at least 4 weeks after the completion of all PCV13 doses. en
Meningococcal B vaccines: -c
m
1. BexseroorTrumenba C')
o Persons 10 years or older who have not received a complete series. Administer a 2-dose series of Bexsero, at S>
least 1 month apart. Or a 3-dose series ofTrumenba, with the second dose at least 2 months after the ~
first and the third dose at least 6 months after the first. The two MenB vaccines are not interchangeable;
the same vaccine product must be used for all doses.
Children with persistent complement component deficiency (includes persons with inherited or chronic
rn
deficiencies in C3, cs-9, properidin, factor D, factor H or taking eculizumab CSoliriis"l·
Meningococcal conjugate ACWY vaccines:
1. Menveo
o Children who initiate vaccination at 8 weeks: Administer doses at 2, 4, 6, and 12 months of age.
o Unvaccinated children who initiate vaccination at 7 through 23 months: Administer 2 doses, with the
second dose at least 12 weeks after the first dose AND after the first birthday.
o Children 24 months and older who have not received a complete series: Administer 2 primary doses at
least 8 weeks apart.
2. MenHibrix
o Children who initiate vaccination 6 weeks: Administer doses at 2, 4, 6, and 12 through 15 months ofage.
o If the first dose of MenHibrix is given at or after 12 months of age, a total of2 doses should be given
at least 8 weeks apart to ensure protection against serogroups C and Y meningococcal disease.
3. Menactra
o Children 9 through 23 months: Administer 2 primary doses at least 12 weeks apart.
o Children 24 months and older who have not received a complete series: Administer 2 primary doses at
least 8 weeks apart.
Meningococcal B vaccines:
1. BexseroorTrumenba
o Persons 10 years or older who have not received a complete series. Administer a 2-dose series ofBexsero,
at least 1 month apart. Or a 3-dose series ofTrumenba, with the second dose at least 2 months after
the first and the third dose at least6 months after the first. The two MenB vaccines are not interchange-
able; the same vaccine product must be used for all doses.
For children who travel to or reside in countries in which meningococcal disease is hyperendemic or
epidemic, including countries in the African meningitis belt or the Hajj
• administer an age-appropriate formulation and series of Menactra or Menveo for protection against
serogroups A and W meningococcal disease. Prior receipt of MenHibrix is not sufficient for children
traveling to the meningitis belt or the Hajj because it does not contain serogroups A or W.
For children at risk during a community outbreak attributable to a vaccine serogroup
• administer or complete an age- and formulation-appropriate series of MenHibrix, Menactra, or Menveo,
Bexsero orTrumenba.
For booster doses among persons with high-risk conditions, refer to MMWR 2013 / 62(RR02);1-22, available
at http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6202a 1.htm.
For other catch-up recommendations for these persons, and complete information on use of
meningococcal vaccines, including guidance related to vaccination of persons at increased risk of infection,
see MMWR March 22, 2013 / 62(RR02);1-22, and MMWR October 23, 2015 / 64(41); 1171-1176 available at
http://www.cdc.gov/mmwr/pdf/rr/rr6202.pdf, and http://www.cdc.gov/mmwr/pdf/wk/mm644 l .pdf.

FIGURE 18-7, cont'd

 CHAPTER 18 Assisting in Pediatrics 465

TABLE 18-2 Guidelines for Childhood Immunizations

ROUTE OF
VACCINE TRADE NAME ADMINISTRATION CONTRAINDICATIONS* SIDE EFFECTS
DTaP Daptacel, lnfanrix IM; Td (tetanus and diphtheria) Moderate or severe acute illness; Mild fever, anorexia,
Diphtheria, tetanus, boosters at 11-12 yr if at least neurologic problem; complication irritability, drowsiness
pertussis (whooping 5 yr since last dose; subsequent after previous dose (e.g., fever,
cough) booster every l Oyr convulsions)
HAV Havrix, Vaqta IM; all children l yr; 2 doses 6 mo Hypersensitivity to product, acute Localized injection site
Hepatitis A(can use apart infection or fever reaction, fever,
either Havrix or Vaqta) headache
HBV Engerix-B, Recombivax HB IM; may give with all other Moderate or severe acute illness; Fever, pain at site,
Hepatitis B vaccines but at a separate site; yeast allergy; severe cardiovascular headache, malaise,
requires 3 injections disease vomiting
Hib COMVAX, PedvaxHIB, IM; may give with all other Not routinely given to children older Minimal
Haemophilus influenzae Pentacel, ActHIB, vaccines but at a separate site. than 5; moderate or severe acute
serotype Bmeningitis Men-Hibrix Three doses of ActHIB, MenHibrix, illness
or Pentacel at 2, 4, and 6 months
or 2 doses PedvaxHib or COMVAX
at 2 and 4 months of age; booster
dose at 12 through 15 months
HPV 2vHPV (Cervarix) females IM; routine vaccination at age 11 Hypersensitivity to ingredients; Relatively few; mild
Human papillomavirus only; 4vHPV (Gardasil), or 12 years; second dose l to 2 pregnancy headache and GI upset
9vHPV (Gardasil 9) males months after first dose; third dose
and females 16 weeks after second dose
Influenza Flulaval, Fluzone, FluMist IM; annually each fall Allergy to eggs; recent fever Uncommon; fever, local
Trivalent inactivated (nasal spray) irritation at injection
vaccine for 6 months; at site, general malaise
2 years, use live,
attenuated vaccine
IPV lpol SC or IM; 4 doses; may give with Moderate or severe acute illness; Uncommon
Inactive poliovirus for all other vaccines but at a separate egg allergy
polio site
Meningococcal vaccine for Menactra, Menveo, IM; single dose of Menactra or Moderate or severe acute illness; Uncommon
meningitis (MCV4) Bexsero, or Trumenba Menveo vaccine at age 11 through history of allergic reaction to MCV4
12 years, with a booster dose at
age 16 years; aged 16 through
23 years vaccinated with a 2-dose
series of Bexsero or a 3-dose
series of Trumenba vaccine to
provide short-term protection
MMR M-M-R II SC; may give with all other Moderate or severe acute illness; Fever
Measles, mumps, rubella vaccines but at a separate site immunocompromised patients (may
be given if HIV positive); pregnancy
or possible pregnancy in 3 mo; egg
allergy
Continued
466 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES

TABLE 18-2 Guidelines for Childhood Immunizations-continued

ROUTE OF
VACCINE TRADE NAME ADMINISTRATION CONTRAINDICATIONS* SIDE EFFECTS
Pneumococcal (PCV) Pneumovax 23, Prevnar IM or SC; all children 2-23 mo; Moderate ar severe acute illness; Drowsiness, local
Pneumococcal pneumonia 13 administer every 6 yr for high-risk hypersensitivity irritation at site, mild
patients fever
Rotavirus (Rota) Rotarix PO; 3 doses at 6-12 wk; Hypersensitivity GI upset and blood
Rota Teq for prevention of subsequent doses at 4-10 wk disorders
rotavirus gastroenteritis intervals
Varicella Varivax SC; may give with all other Confirmed history of chickenpox; No salicylates for 6 wk
(chickenpox) vaccines but at a separate site; pregnancy or possible pregnancy in afterward to prevent
2-dose series at ages 12 through l mo; moderate or severe acute risk of Reye's syndrome
15 months and 4 through 6 years illness; immunocompromised
patients; egg allergy
May give combination ProQuad SC; may give with all other Confirmed history of chickenpox; No salicylates for 6 wk
vaccine: measles, mumps, vaccines but at a separate site; all pregnancy or possible pregnancy in afterward to prevent
rubella, varicella (MMRV) susceptible children 12 mo or older l mo; moderate or severe acute risk of Reye's syndrome
illness; immunocompromised
patients; egg allergy
GI, Gastrointestinal; HIV, human immunodeficiency virus; IM, intramuscular; PO, oral; SC, subcutaneous.
*Mild illness is not a contraindication.

•;;m,immj1:j• Verify the Rules of Medication Administration: Document Immunizations

Goal: To document accurately the administration of apediatric immunization.

Scenario: Samantha Anderson, a 5-week-old infant, has iust received her second dose of the hepatitis B (HBV) vaccine.
Document the administration of the vaccine.
EQUIPMENT and SUPPLIES
• Patient's record
• Vaccine administration record (VAR)
• Parent's immunization booklet (if used in the medical practice)
• Vaccine Information Sheet (VIS) for hepatitis B(a link to the current VIS
forms can be accessed at www.cdc.gov/vaccines/hep/vis/current-vis.html)
PROCEDURAL STEPS
1. Gather the necessary forms.
2. Make sure the provider obtained informed consent from the parent, that
the hepatitis BVIS form was given, and that all the parent's questions were
answered before the vaccine is dispensed and administered.
PURPOSE: To follow risk management practices.
3. After dispensing the vaccine dose and before administering it, complete the
information required on the VAR, including the name of the vaccine, the
date given, the route of administration and site, the vaccine lot number and
manufacturer, the date on the VIS form, the date it was given to the parent,
and your signature or initials.
PURPOSE: To meet the legal requirements of the National Childhood
Vaccine Injury Act.
4. Administer the vaccine intramuscularly (see the Administering Medications
chapter).
S. In the parent's immunization booklet, record the date of administration, the
name and address of the physician's practice, and the type of vaccine
administered.
PURPOSE: To maintain an accurate and comprehensive parental record of
childhood immunizations for school and/or day care purposes.
6. After administering the HBV vaccine, record the following details in the
child's health record:
• Date the vaccine was administered
• Vaccine's manufacturer, batch and lot numbers, and expiration date
• Type of vaccine administered and dose
• Route of administration and exact site if an injection was given
• Any reported or observed side effects
• Publication date of the VIS form given to the parent (on the bottom of
the form)
• Parent education about possible side effects of the vaccine
• Name and title of the person who administered the vaccine
4/2/20- 3:25 pm: Mother given VIS form for Hep B. Had no questions.
Administered second dose of Hep BIM to <D vastus lateralis per Dr. Flint's order.
No problems noted after injection. S. Kwong, CMA (AAMA)
 CHAPTER 18 Assisting in Pediatrics 467

•;;m!,mj;jji:II -,;ontinued
(Page 1 of 2)
Vaccine Administration Record Patient name: _ _ _ _ _ _ _ _ __
Birthdate: _ _ _ _ _ _ _ Patient ID number: _ __

for Children and T e e n s l~ C-lin-ic-na-me-a-nd-a-dd-re-ss---------~

Before administering any vaccines, give copies of all pertinent Vaccine Information Statements (VISs) to the child's parent or legal representative
and make sure he/she understands the risks and benefits of the vaccine(s). Always provide or update the patient's personal record card.

Funding Vaccine Information Vaccinator•

Type of Date given Route Vaccine
Vaccine Vaccine' (mo/day/yr)
Source
& Site•
Statement (VIS) (signature or
(F,S,P)2 initials & title)
Lot# Mfr. Date on VIS' Date given•
Hepatitis B'
(e.g., HepB, Hib-HepB,
DTaP-HepB-IPV)
Give IM. 3

Diphtheria, Tetanus,
Pertussis•
(e.g., DTaP, DTaP/Hib,
DTaP-HepB-IPV, DT,
DTaP-IPV/Hib, Tdap,
DTaP-IPV, Td)
Give IM. 3

Haemophilus influen-
zaetype b'
(e.g., Hib, Hib-HepB,
DTaP-IPV/Hib, DTaP/Hib,
Hib-MenCY) Give IM. 3

Polio'
(e.g., IPV, DTaP-HepB-
DTaP-IPV/Hib, DTaP-IPV)
Give IPV SC or IM. 3
Give all others IM. 3

Pneumococcal
(e.g., PCV7, PCV13, con-
jugate; PPSV23, polysac-
charide)
Give PCV IM. 3
Give PPSV SC or IM. 3

Rotavirus (RV1, RV5)

Give orally (po). 3

See page 2 to record measles-mumps-rubella, varicella, hepatitis A, meningococcal, HPV, influenza, and other vaccines (e.g., travel vaccines).
How to Complete This Record Abbreviation Trade Name and Manufacturer
DTaP Daptacel (sanofi); lnfanrix (GlaxoSmithKline [GSK]); Tripedia (sanofi pasteur)
1. Record the generic abbreviation (e.g., Tdap) or the trade name for each vac- DT (pediatric) Generic DT (sanofi pasteur)
cine (see table at right). DTaP-HepB-IPV Pediarix (GSK)
2. Record the funding source of the vaccine given as either F (federal), DTaP/Hib TriHIBit (sanofi pasteur)
S (state), or P (private). DTaP-IPV/Hib Pentaoel (sanofi pasteur)
DTaP-IPV Kinrix(GSK)
3. Record the route by which the vaccine was given as either intramuscular
HepB Engerix-B (GSK); Recombivax HB (Merck)
(IM), subcutaneous (SC), intradermal (ID), intranasal (IN), or oral (PO)
and also the site where it was administered as either RA (right arm), HepA-HepB Twinrix (GSK), can be given to teens age 18 and older
LA (left arm), RT (right thigh), or LT (left thigh). Hib ActHIB (sanofi pasteur); Hiberix (GSK); PedvaxHIB (Merck)
Hib-HepB Comvax (Merck)
4. Record the publication date of each VIS as well as the date the VIS is given Hib-MenCY MenHibrix (GSK)
to the patient. IPV lpol (sanofi pasteur)
5. To meet the space constraints of this form and federal requirements for docu- PCV13 Prevnar 13 (Pfizer)
mentation, a healthcare setting may want to keep a reference list of vaccinators PPSV23 Pneumovax 23 (Merck)
that includes their initials and titles. RV1 Rotarix (GSK)
RVS RotaTeq (Merck)
6. For combination vaccines, fill in a row for each antigen in the combination.
Tdap Adaoel (sanofi pasteur); Boostrix (GSK)
Td Decavac (sanofi pasteur); Generic Td (MA Biological Labs)
Technical content reviewed by the Centers for Disease Control and Prevention For additional copies, visit www.immunize.org/catg.d/p2022.pdl • Item #P2022 (4/14)

This form was created by the Immunization Action Coalition • www.immunize.org • www.vaccineinformation.org
468 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES

•;;m!,mj;jji:II -,;ontinued
(Page 2 of 2)

Vaccine Administration Record Patient name: _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Birthdate: _ _ _ _ _ _ _ Patient ID number:
for Children and Teens

Before administering any vaccines, give copies of all pertinent Vaccine Information Statements (VISs) to the child's parent or legal representative
and make sure he/she understands the risks and benefits of the vaccine(s). Always provide or update the patient's personal record card.

Funding Vaccine Information Vaccinator•

Type of Date given Route Vaccine
Vaccine Source Statement (VIS) (signature or
Vaccine' (mo/day/yr) & Site•
(F,S,P) 2 initials & title)
Lot# Mfr. Date on VIS' Date given'
Measles, Mumps,
Rubella6 (e.g., MMR,
MMRV) Give SC. 3
Varicella• (e.g., VAR,
MMRV) Give SC. 3

Hepatitis A'
(HepA) Give IM. 3

Meningococcal (e.g.,
MenACWY-CRM; Men-
ACWY-D; Hib-MenCY;
MPSV4) Give MenACWY
and Hib-MenCY IM 3 and
give MPSV4SC. 3

Human papillomavirus•
(e.g., HPV2, HPV4)
Give IM. 3

Influenza
(e.g., IIV3, trivalent inacti-
vated; IIV4, quadrivalent in-
activated; RIV, recombinant
inactivated [for ages 18--49
yrs]; LAIV4, quadrivalent
live attenuated)
Give IIV and RIV IM. 3
Give LAIV IN. 3

Other

See page 1 to record hepatitis B, diphtheria, tetanus, pertussis, Haemophi/us influenzae type b, polio, pneumococcal, and rotavirus vaccines.

How to Complete This Record I Abbreviation Trade Name and Manufacturer

I MMR
1. Record the generic abbreviation (e.g., Tdap) or the trade name for each vaccine I VAR
(see table at right). I MMRV
2. Record the funding source of the vaccine given as either F (federal), S (state), or I HepA
P (private). HepA-HepB
HPV2
3. Record the route by which the vaccine was given as either intramuscular (IM),
HPV4
subcutaneous (SC), intradermal (ID), intranasal (IN), or oral (PO) and also the site LAIV (Live attenuated
where it was administered as either RA (right arm), LA (left arm), RT (right thigh), influenza vaccine]
or LT (left thigh). TIV (Trivalent inactivat-
ed influenza vaccine);
4. Record the publication date of each VIS as well as the date the VIS is given to the RIV (Recombinant
influenza vaccine)
patient.
MCV4 or MenACWY,
5. To meet the space constraints of this form and federal requirements for documenta- MenACWY-CRM,
MenACWY-D;
tion, a healthcare setting may want to keep a reference list of vaccinators that Hib-MenCY
includes their initials and titles. MPSV4
6. For combination vaccines, fill in a row for each antigen in the combination.
MMRII (Merck)
Varivax (Merck)
ProQuad (Merck)
Havrix (GlaxoSmithKline IGSK]); Vaqta (Merck)
Twinnx (GSK)
Cervarix (GSK)
Gardasil IMerckl
FluMist {Medlmmune)
Afluria (CSL Biotherapies); Agnflu~Novartis)/ Fluarix \GSK);
Flublok \Protein Sciences Corp~; lucelvax: Novartis ;
Flulava (GSK); Fluvirin (Nova is); Fluzone, Fluzone
lntradennal lfor ages 1&-<l4 yrs] (sanofi)
MenACWY-D = Menactra (sanofi pasteur);
MenACWY-CRM = Menveo (Novartis);
Hib-MenCY (MenHibrix IGSK])
Menomune (sanofi pasteur)

Technical content reviewed by the Centers for Disease Control and Prevention For additional copies, visit www.immunize.org/catg.d/p2022.pdf • Item #P2022 (4/14)

This form was created by the Immunization Action Coalition • www.immunize.org • www.vaccineinformation.org

Safe Handling and Storage of Vaccines
The Centers for Disease Control and Prevention (CD() have devised a list of
important rules and steps to ensure safekeeping of a practice's vaccine supply.
This list can be used as a checklist in the office.
1. One person should be in charge of the handling and storage
of vaccines at the facility, with a backup person to ensure
proper management.
2. Avaccine inventory log should be maintained that includes the
following:
(l) Vaccine name
__ (2) Number of doses
__ (3) Date vaccine was received
__ (4) Condition of vaccine on arrival
__ (5) Manufacturer
_ (6) Lot number
__ (7) Expiration date
3. Vaccines should be stored in separate, self-contained units that
refrigerate or freeze only. Ahousehold-style combination unit
can be used to store only refrigerated vaccines; frozen vaccines
must be kept in a separate, stand-alone freezer.
4. The vaccine refrigerator and freezer should not be used for
food or drinks.
5. Vaccines should be stored in the middle of the refrigerator or
freezer, not in the door.
6. New supplies should be placed behind the vials with the
closest expiration date; the vials with the nearest expiration
date should be used first.
CRITICAL THINKING APPLICATION 18-8
Susie will be administering pediatric immunizations during the well-baby
visits scheduled for today. To prepare for this responsibility, she looked up
the primary vaccinations, their routes of administration, contraindications,
and possible side effects. The first child arrives for her 4-month checkup.
What immunizations should the child receive, and how should they be
administered? The baby's father asks whether she will get sick from the
vaccines. What should Susie tell him? What does Susie need to do to meet
the requirements of the National Childhood Vaccine Injury Act?
THE PEDIATRIC PATIENT
An infant's first physical assessment comes at the time of delivery,
when the pediatrician assesses the newborn's ability to thrive outside
the uterus. The Apgar score is a system for evaluating the infant's
physical condition at 1 and 5 minutes after birth (Table 18-3).
Developed by pediatrician Virginia Apgar, the scoring system evalu-
ates the following: appearance (color); pulse (heart rate); grimace
(reflex; response to stimuli); activity (muscle tone); and respiration
(breathing). These parameters are each rated 0, 1, or 2. The maximum
CHAPTER 18 Assisting in Pediatrics 469
7. Asign should be posted on the refrigerator door identifying
which vaccines should be stored in either the refrigerator or
the freezer.
8. One thermometer should be kept in the refrigerator and one
in the freezer; the refrigerator temperature should be main-
tained at 35° to 46 ° F(2° to 8° () and the freezer tempera-
ture at -58° to 5° F(-50° to 15° () or colder.
9. Containers of water should be kept in the refrigerator and ice
packs in the freezer to help maintain cold temperatures.
_ _ 10. Atemperature log should be kept on the refrigerator door; the
refrigerator and freezer temperatures should be recorded twice
a day: first thing in the morning and at the end of the day.
_ _ 11. A"Do Not Unplug" sign should be posted next to the refrigera-
tor's electrical outlet.
_ _ 12. If the refrigerator or freezer stops working, the following steps
should be taken:
• Immediately place the vaccines in another refrigerator or
freezer, and mark them so that they can be separated
from vaccines that were not affected.
• Record the temperature of the refrigerator or freezer, and
contact the vaccine manufacturer or state health depart-
ment. Follow their instructions on the use, alteration of
expiration dates, or disposal of the vaccines.
_ _ 13. The facility should have a copy of the health department's
general and emergency vaccine management policies.
total score is 10. Infants with low scores require immediate medical
attention.
Well-Child Visits
The frequency of well-child visits varies with the provider and the
community. It may follow this pattern: 2 weeks, 4 weeks, 8 weeks,
4 months, 6 months, 12 months, 18 months, 2 years, 5 years, 10
years, and 15 years. These visits focus on maintaining the child's
health through basic system examinations, immunizations, and
upgrading of the child's medical history record.
The decision on whether the child is to be seen alone or with
the parent depends on the pediatrician and the child's age. Often
the child looks to the parent for approval before answering or per-
forming a skill; for this reason, the provider may want to assess the
child alone. If this is the case, explain to the parent that the pro-
vider wants to evaluate the child's independent abilities and that as
soon as testing is complete, the provider will explain the results of
the tests.
The medical history is an essential guide to the pediatric examina-
tion. With an infant, the provider depends on the caregiver for the
history, but as the child gets older, some history may be obtained
from the child and clarified or amplified by the parent. Close obser-
vation also gives the provider considerable information.
470 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES
Lead Paint Exposure
Children are especially vulnerable to lead levels in their environment. High
blood lead levels can result in serious brain injury, including seizures, coma,
and death; lower levels can cause learning problems, stunted growth, and
behavior disorders. The most common causes of lead exposure are lead-
based paint in homes and on imported toys and chronic exposure
TABLE 18-3 Apgar Scoring System
CLINICAL SIGN 0 1
Heart rate Absent
Respiratory effort Absent
Muscle tone Limp
Reflex irritability No response
Color Blue and pale
*Readings are taken by the pediatrician at 1 minute and 5 minutes after birth. At I minute: If the score is 7 or lower, some nervous system problems are suspected. If the score is below 4,
resuscitation usually is necessary. At 5 minutes: If the score is at least 8, the child probably is reacting normally.
Sick-Child Visits
Sick-child visits occur whenever needed, usually on short notice. For
this reason, most pediatric offices keep open appointments in the
schedule to accommodate calls for sick-child visits. The length and
frequency of this type of visit depends entirely on the child and the
illness. The medical assistant frequently is the first point of contact
for a sick child and the child's caregiver.
Determining whether the child should be seen immediately or
the problem can wait for an opening in the schedule is crucial to
pediatric care. The medical assistant should follow established office
policies, but when in doubt about the seriousness of the problem,
he or she should ask the office manager or physician for advice.
Usually the provider prefers to see the child rather than delay seeing
a patient with a potentially serious condition. When the medical
assistant conducts telephone screening, if the child is young (under
2 years old) and the parent reports frequent cycles of crying, lethargy,
vomiting that lasts longer than 24 hours, diarrhea (more than six
stools in the past 12 hours), or fever of 10l°F (38.3°C) or higher,
the best course is to see the child right away. He or she cannot
verbalize associated pain or problems.
Table 18-4 summarizes some important questions for telephone
screening of an older child who can communicate symptoms. It is
important to focus on the onset (when symptoms first started), fre-
quency (are symptoms constant, or do they cycle through recur-
rences), and duration (how long the episodes last) of the problem,
in addition to attempted treatments and their effectiveness. As with
any other patient, all telephone communication should be docu-
mented to record the reason for the call; the information gathered;
the action taken, including whether the provider was consulted;
any orders given; and whether and when an appointment was
scheduled.
to lead-contaminated dust and water. The Centers for Disease Control and
Prevention (CDC) recommend a screening blood test for lead levels in all
children between l and 2 years of age. For children who show elevated
levels, follow-up should include home and school environmental testing to
determine the cause of lead exposure.
ASSIGNED SCORE
2
100 100
Slow and irregular Good and crying
Some flexion of the arms and legs Active movement
Grimace Coughing and sneezing
Body pink and extremities blue Pink all over
THE MEDICAL ASSISTANT'S ROLE IN
PEDIATRIC PROCEDURES
The medical assistant is responsible for assisting the pediatrician
with examinations; updating patient histories; performing ordered
screening tests (e.g., vision, hearing, urinalysis, and hemoglobin
checks); administering immunizations; measuring and weighing
children as needed; and providing patient and caregiver support. A
medical assistant must develop a relationship with the pediatric
patient that encourages cooperation and compliance with tests and
treatment plans. If the child becomes upset, everything that needs
to be done during that visit will be done under duress, and the
chance for future mistrust intensifies.
Interacting with children requires special techniques, depending
on the child's age. A calm, unhurried manner is essential to gaining
cooperation. The tone of voice should be gentle but confident. Using
a firm, direct approach about expected behavior is important in
gaining the cooperation of older children. Offer reasonable choices
when possible, such as, "Would you like your shot in your left leg
or your right leg?" not, ''Are you ready for your shot now?" Offering
sincere praise for the child during the examination or procedures
helps ease anxiety and builds self-esteem. If the child is having an
unusually difficult time, try to discover the reason. If he or she has
had a bad medical experience in the past, the child may be afraid of
what might happen. Each step should be explained in a language
the child (and parent) can understand. Children younger than age
2 feel better when the parent holds them or remains very close
(Figure 18-8). Preschool children enjoy playing, so making a game
out of the situation is helpful (Figure 18-9). Whatever the child's
age, the medical assistant should be sensitive to his or her individual
needs and should adapt the examination and procedures as much as
possible to meet those needs.
 CHAPTER 18 Assisting in Pediatrics 471

TABLE 18-4 Important Questions for Telephone Screening of Pediatric Problems

COMPLAINT SCREENING QUESTIONS
Pain • What are the onset, frequency, and duration of the pain?
• On a scale of l to l 0, how severe is the pain?
• Where is the exact location?
• Was any accident involved? (include details).
• Has the pain gotten worse over time?
• Has the pain interfered with sleep?
• Is there associated fever, vomiting, diarrhea, or rash?
Gastrointestinal • What are the onset, duration, and frequency of the symptoms? Has the child been vomiting longer than 24 hours without
improvement?
• Is the child drinking and/or eating?
• Is the child dehydrated (e.g., dry mouth, no urination in 8-10 hours, listless)?
• If the child has diarrhea, have there been more than five or six watery stools in 12 hours?
• Does the child have other symptoms (e.g., vomiting, fever of 101 ° F[38.3° Cl, rapid breathing)?
Respiratory • What are the onset, duration, and frequency of the symptoms?
• How would you describe the child's breathing?
• Has the child been diagnosed with a breathing disorder?
• Is a prescribed treatment being used?
• Are any other signs or symptoms present (e.g., severe headache, stiff neck, fever, cough)?
• If the child is coughing, what does it sound like?
• Are there signs of a sore throat or earache?

FIGURE 18-9 Making a game out of a procedure.

FIGURE 18-8 Sometimes a pediatric patient is more comfortable when held by a parent.

The sequence of the physician's examination varies and frequently
is based on the child's cooperation. The pediatrician probably will
leave procedures and tests that are likely to cause the most objections
until the end of the appointment. The provider is constantly evaluat-
ing the child's growth and development. A child's alertness and
responses tell the provider a considerable amount. With infants and
young children of preschool age, the parent is closely questioned
about the child's eating, sleeping, and elimination habits. A school-
aged child usually is a little more cooperative during an examination
and can answer most questions without parental assistance. Adoles-
cent patients should be given the option of not having parents
present during an examination. This may permit teenagers to respond
more honestly about lifestyle factors and also protects their privacy.
Measurement
Examination of the child during routine well-child care includes
measurement of the circumference of the infant's head to determine
normal growth and development (Procedure 18-2). The size of the
472 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES

child's head reflects the growth of the brain. Brain growth is 50%
complete by 1 year of age, 75% by age 3, and 90% by age 6. Routine
head measurement is recommended in children until 36 months of
age and in older children whose head size is not within norms. If
the circumference of the head deviates greatly from normal measure-
ments, hydrocephaly or microcephaly may be suspected. It is
important to discover any congenital problem as early as possible so
that appropriate treatment can be started.
Along with the head circumference, the medical assistant should
record the child's length (or height) and weight (Procedure 18-3) on
growth charts so that the provider can compare the child's measure-
ment statistics with national standards. Growth charts consist of a
series of percentile curves that illustrate the distribution of selected
body measurements.
The current version of the CDC's growth records consists of
16 charts (eight for boys and eight for girls) (Figures 18-10
and 18-11). These charts, which represent revisions of the 14
previous charts, include the BMI-for-age charts for boys and for girls
ages 2 to 20 years. As mentioned previously, the BMI is the recom-
mended method of determining whether children or adults are over-
weight or obese. The BMI growth charts can be used beginning at
2 years of age, when height can be measured accurately.
Ziko Virus. http://www.cdc.gov/zika/index.html. Accessed February 10, 2016.
The Zika Virus and Microcephaly
The Ziko virus is spread ta people through mosquito bites. The most
common symptoms of Ziko are fever, rash, joint pain, and conjunctivitis.
Affected individuals typically have mild symptoms that last from several
days to a week. The CDC and other world health organizations are inves-
tigating a link between pregnant women who have contracted the Zika
virus and the risk of having an infant with microcephaly. There is currently
no vaccine or specific medicine to prevent Ziko infections. The only method
for controlling the spread of the disease is through mosquito control. The
CDC recommends that pregnant women in any trimester consider postpon-
ing travel to areas where there are known Ziko virus infections.
Microcephaly is linked with the following problems:
• Seizures
• Developmental delays
• Intellectual disability
• Problems with movement and balance
• Feeding problems, such as difficulty swallowing
• Hearing loss
• Vision problems

•;;m,inlj;jj1:fi Maintain Growth Charts: Measure the Circumference of an Infant's Head

Goal: To obtain an accurate measurement of the circumference of an infant's head and plot the result on the patient's
growth chart.
EQUIPMENT and SUPPLIES
• Patient's record, with appropriate growth chart
• Flexible disposable tape measure
• Age- and gender-specific growth chart
• Pen
PROCEDURAL STEPS
1. Sanitize your hands.
PURPOSE: To ensure infection control.
2. Identify the patient by name and date of birth. If he or she is old enough,
gain the child's cooperation through conversation.
PURPOSE: To alleviate anxiety and gain the child's trust.
3. Place an infant in the supine position, or the infant may be held by the
parent. An older child may sit on the examination table.
4. Hold the tape measure with the zero mark against the infant's forehead,
slightly above the eyebrows and the top of the ears. Ask the parent for
assistance if necessary.
S. Bring the tape measure around the head, just above the ears, until it meets 6. Read to the nearest 0.6 cm or ¼ inch.
(Figure 1). 7. Record the measurement on the growth chart and in the patient's health
record.
PURPOSE: Aprocedure is not done until it is recorded.
8. Dispose of the tape measure.
9. Sanitize your hands.
PURPOSE: To ensure infection control.

•;;m,i11mjj1:f• Maintain Growth Charts: Measure an Infant's Length and Weight
Goal: To measure an infant's length and weight accurately so that growth patterns can be monitored and recorded.
EQUIPMENT and SUPPLIES
• Patient's record
• Infant scale with paper cover
• Flexible measuring tape
• Examination table paper
• Pen
• Pediatric length board, if available
• Gender-specific infant growth chart
• Biohazard waste container
PROCEDURAL STEPS
Measuring an Infant's Length
1. Sanitize your hands, identify the child by name and date of birth, assemble
the necessary equipment, and explain the procedure to the infant's
caregiver.
2. Undress the infant. The diaper may be left on while the length is measured,
but it must be removed before the infant is weighed.
3. Cover the examination table with smooth, flat paper. Ask the caregiver to
place the infant on his or her back on the examination table. If the table
is a pediatric table with a headboard, ask the caregiver to hold the infant's
head gently against the headboard while you straighten the infant's leg and
note the location of the heel on the measurement area. If there is no
headboard, ask the caregiver to gently hold the infant's head still while you
draw a line on the paper at the back of the baby's head and at the heel
after extending the leg (Figure 1).
4. Measure the infant's length with the tape measure and record it.
S. Document the results in either inches or centimeters, depending on office
policy, on the infant's growth chart, in the progress notes, and in the
caregiver's record if requested. Complete the growth chart graph by con-
necting the dot from the last visit.
CHAPTER 18 Assisting in Pediatrics 473
Weighing an Infant
1. Sanitize your hands, identify the child by name and date of birth, assemble
the necessary equipment, and explain the procedure to the infant's
caregiver.
2. If the scale is not a digital model, prepare the scale by sliding weights to
the left; line the scale with disposable paper to reduce the risk of pathogen
transmission.
3. Completely undress the infant, including removing the diaper.
PURPOSE: It is important to get the most accurate weight possible and a
diaper, especially a wet one, will add to the total weight.
4. Place the infant gently on the center of the scale, keeping your hand directly
above the infant's trunk for safety (Figure 2).
PURPOSE: To protect the infant from possible injury.
S. If the scale is not a digital model, slide the weights across the scale until
balance is achieved. Attempt to read the infant's weight while he or she is
still.
6. If the scale is not a digital model, return the weights to the far left of the
scale and remove the baby. The caregiver can rediaper the baby while you
discard the paper lining the scale. If the scale became contaminated during
the procedure, follow Occupational Safety and Health Administration
(OSHA) guidelines for use af gloves and disposal of contaminated waste.
Disinfect the equipment according to the manufacturer's guidelines.
PURPOSE: Infection control.
7. Sanitize your hands.
8. Document the results in either pounds or kilograms, depending on office
policy, on the infant's growth chart, in the progress notes, and in the
caregiver's record if requested. Complete the growth chart graph by con-
necting the dot from the last visit.
8/24/20-10:20 AM: Wt 17 lb 4 oz. Length 27 in. S. Kwong, CMA (AAMA)
474 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES

Birth to 36 months: Boys NAME _____________

Length-for-age and Weight-for-age percentiles RECORD#

Birth 3 6 9 12 15 18 21 24 27 30 33 36
in-= cm AGE (MONTHS)
cm- tin-=
41- ~41-
~
L
-
40- 95 ~40- E
100 go::::.. 100
N
39 : 39-
75 G
38- >-38-
37
95 _,,. -- 50,0:::: -95 t - - -
: 37-
T
H
25
36-
90 - .... - /

_.. 10':;;; -90

-35-
., ...
V ~

. . 35-
- - .,,,,. - -
-
/
35 I/' /
_,,.. 5
34-
,,, ...
- ,- .,...
V I/
_,,.
.,

- .,....,... .,...-- ,... ----- - - -

85 ,.,... / V /
_,,..
33 _,,.

32
80 ,,. ~
~
~ /
,,, .,...
- - - -
V ,JO

/ - -17--.... 38-
~
_,,..
_ 95

L
31 ,.rv
/
/

~
- -- /
/
/

- -36- 90_,,.
30 ,, V ~ /
_,,. I/"

E
29-
75 ,, ,,, ,,.
/
I/ /

- 16--
-34-
N -,, /
,,
- ----- V
L.r /

_ 75
28 ,, ,, .,.
G 70 ,,
/
~
- - 15- t - - -
, .... ... ,... -
,,,
--
T 21- /

,, V ,, 1/1/ V -32-
H / /'I f-
26 65 ,-

25- IJ /
'r/ I/ 'I'
,, ,,
,v ,,,
I//
'/
,, - V
,... _..
-
50_
-14- ~

30- w
,,
-
<:."t
60
'/
IJ I/, /
✓ II
,, /

,, ,
~

V
.,... ~

- -
25_ -13-.... E
-23- ,. , , ,_
I

,., /
/

.,...
.,... - :28- I
G
II I
-22 ~55 ,, ', ,.
-,

I
,,
I
,
/

- 10
5
12- -26- H
-21-
-20 -50
~,11,.,. I ",,
,,,
/
/

,
~
~

V
_..
- 11- >--24-
T

-19 ,,• I
II

/
/

V
/
~
.,.
,,, ~ -
- -
II /
-1a- -45
,,,,
/ / II' /
,, 10--22-
, ,, ,, _,,.
/ V
I/ I/
-17 /
, J /

-15- -40 ,, I

,
, /
,, / , ""
/

9- -20-
-1,, I
I
II
I
/ .,. ,,,
, , ,,
/

,, ,, .,.
I

I
I
I/
/
8->- 18-
I J I
,_
-16- ., :16-
--1 J I ✓ / I
AGE (MONTHS)
-14
,,
I

rt
, , , I
I / /
I
I
12 -
Mother's Stature
15 - 18 - 21H24H27+- 30 Gestational
- 33 -
kg- :=-lb-
36· -

w 6 IJ I
- r, I I
Father's Stature Age: _ _ _ Weeks Comment
E -12- ,. ,,,, I
Ill /
I 'I Date AQe WeiQht LenQth Head Gire.

., , ,,
I 5 II I
II I I Birth
G -10 II
- ,,
H
T -8-
--4 I II
I 'I

I,

- -3 ,,II
-6 -

--2
lb- -Kg
Birth 3 6 9
Published May 30, 2000 (modified 4/20/01),
SOURCE: Developed by the National Center for Health Statistics in collaboration with
the National Center for Chronic Disease Prevention and Health Promotion (2000).
SAFER•HEALTHIER•PEOPLE™
http://www.cdc.gov/growthcharts

FIGURE 18-10 Growth chart: males (birth to 36 months).

 CHAPTER 18 Assisting in Pediatrics 475

2 to 20 years: Girls NAME _ _ _ _ _ _ _ _ _ __

Stature-for-age and Weight-for-age percentiles RECORD# _ _ _ __

12 13 14 15 16 17 18 19 20
Mother's Stature Father's Stature cm =-in-
AGE (YEARS) 76-
Date Aae Weiaht Stature BMI*
190 -:74-
185
180
-- 72- s
T

*To Calculate BMI: Weight (kg) : Stature (cm) : Stature (cm) x 10,000
95-
90=
175
170
-
JO-
:68- u
A
T

or Weight (lb) : Stature (in) : Stature (in) x 703 -- 75

R
:as- E
in cm - =3= ::4= :::5= ::a= =7= :::8= =9= 10 11 I I
- 50"'
165
:s4-
---62 _ 160 ,
- 25- 160 --62-
155 , ,
,
- 10- 155
f-

.... 60
--58_ 150 , ,
- 5
150
-60-
f-

I
,, , I

145
,
-56- I

140 105 230

,
,-54_
s 135 , , , I
100 220
T ,-52_ ,
A 130 I I
95 210f-
t-50_
T
u t-48_
125
, ,, ,,
, - 90 200
f-

R 120
,
,
- 85f-
f-
. .190
E
--
-46_
-44_
115
, , ,, ,
-
95
80f-
180
170

--
110 9p:'." t:::::75
,, ,
- - 160
-
t-42-::
t-40--
105
100 ,
,

,, I
,
, ,
,

I
I
I

- 75:: ~65
70
150 w
140 E
t-38_ I
=95 , , , 60 ~130 G
, 50
t-36-:: -90 ,, ,, f-

H
.~ 55 J20
25 T
-34_ =85 ,_50 J10
,. ,, ~
1p-
-32: =80 5-
-45 100
-30-
I
- - f-

40 ---90
- -
,_ ~

--
-80_ =35 , , t 80
35
w -70= :::30
, ,
-
,
-,, 30 E 70

-- - -
E t-60: , , _ 60
I
>-50:
::25 , ,
- ~ 25 t
- 50
G
H
- :::20
>-40:
- - - --
-- - - 20 f-

~ 40
T
-30- ::15 15 ~ 30
:

- =10 10 ~
lb: =kg AGE (YEARS) kg: tlb
2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19
Published May 30, 2000 (modified 11 /21 /00).
SOURCE: Developed by the National Center for Health Statistics in collaboration with
the National Center for Chronic Disease Prevention and Health Promotion (2000).
http://www.cdc.gov/growthcharts SAFER•HEALTHIER•PEOPLE™

FIGURE 18-11 Growth chart: females (2 to 20 years).

476 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES

Assisting with the Examination

The pediatrician will have a designated set of procedures that the TABLE 18-5 Reference Ranges for Pediatric
medical assistant completes before the physician sees the child (Pro- Vital Signs
cedure 18-4). Vital signs are measured first (Table 18-5). Depending
VITAL SIGN REFERENCE RANGE
on the child's age and level of cooperation, the temperature may be
obtained by the axillary, oral, rectal, tympanic, or temporal method. Temperature
The rectal and temporal methods are considered most accurate in 98.6 ° F(37° ()
Oral
infants; however, the temporal method is easiest, quickest, and less
invasive. It is important to remember that the younger the child, the Aural 100.4° F(38° ()
more immature the ability to regulate body heat. Therefore the
Axillary 97.6°F (36.4°()
temperature of an infant may fluctuate easily and rapidly. The child's
pulse rate is affected similarly to that of an adult; it can increase as Pulse
a result of activity, anxiety, illness, and environmental temperature.
If the child is younger than age 2, the pulse is measured apically by
Newborn 100-180 beats per minute
placing the stethoscope on the left side of the chest medial to the 3 mo-2 yr 80-150 beats per minute
nipple. Always count the beats for 1 full minute for accuracy.
An alternative method of obtaining the pulse of a very young 2-10 yr 65-130 beats per minute
child is to use the brachia! artery in the upper arm. After age 2, the Respirations
child's pulse may be taken at the radial pulse site. Anticipate a pulse
rate higher than that of an adult; the younger the child, the faster Newborn 30-50 breaths per minute
the pulse. The respiratory rate is easily obtained in a child because 1-3 yr 25-30 breaths per minute
the chest can be readily observed. Expect the rate to be increased
according to the child's age (the younger the child, the faster the 4-6 yr 23-25 breaths per minute
normal respiratory rate) and health. The ratio of four pulse beats to
7+yr 16-20 breaths per minute
one respiration should remain constant in a healthy child.
Blood pressure measurements are not included in most pediatric Blood Pressure
examinations. However, if the child has a heart or kidney anomaly,
Newborn Systolic 90 mm Hg; diastolic 70 mm Hg
a blood pressure reading may be ordered. The cuff must be the
appropriate width to obtain an accurate reading, and the bell of the 1-5 yr Systolic 100 mm Hg; diastolic 70 mm Hg
stethoscope must be small enough to seal over the site. It is best to
use a pediatric stethoscope with a pediatric bell when obtaining an
6-12 yr Systolic 120 mm Hg; diastolic 84 mm Hg
infant's pressure. Blood pressure readings in a young child are lower 13+yr Systolic, 100 mm Hg + age; diastolic,
than those in an adult. 30-40 mm Hg less
To prevent a small child or infant from rolling the head from side
to side during the provider's examination, stand at the head of the
table and support the child's head berween your hands, taking care
not to press on the ears or on the anterior or posterior fontanelles.
An infant need not be draped, but privacy is important to an older Accurately judging the level of pain a young patient is experienc-
child. Sincere respect and friendly conversation at the child's level ing can be difficult. If the child is able to communicate, the Wong-
accomplishes a great deal. Always be patient with children. Make Baker Faces Pain Scale could be used, which shows simple drawings
sure they understand what is expected. Always involve the parents of faces that express varying levels of pain on a O to 10 scale
or caregivers as much as possible. (Figure 18-12).

Measure and Record Vital Signs: Obtain Pediatric Vital Signs and Perform
PROCEDURE 18-4
Vision Screening

Goal: To accurately obtain vital signs and assess the vision of apediatric patient.

EQUIPMENT and SUPPLIES

• Patient's record • Weight scale with height bar
• Digital, tympanic, or temporal thermometer • Stethoscope
• Pediatric blood pressure cuff • Snellen Eeye chart and aculator
• Wristwatch with sweep second hand • Pen
•;;m,ammjt:j• -continued
PROCEDURAL STEPS
1. Gather the necessary equipment.
2. Sanitize your hands. Identify the child by name and date af birth.
PURPOSE: To ensure infection control.
3. Explain the procedure to the parent, and if you want the parent to help
by holding the child, explain haw you want him or her to da that.
PURPOSE: Explanations ahead of time save time and improve
cooperation.
4. Help the child stand in the center af the scale, then weigh the child. Ask
the child to turn around, then measure the child's height. Record your
findings.
S. Obtain the tympanic, temporal, or axillary temperature using the procedure
explained in the Vital Signs chapter. Vital Signs (Figure 1).
1 record.
6. Record the temperature and indicate the method used.
PURPOSE: Aprocedure is not done until it is recorded in the patient's
record.
7. Place the stethoscope on the child's chest at the midpoint between the
sternum and the left nipple. Listen for the apical beat (Figure 2).
8. Count the apical beat for 1 full minute.
9. Record the apical pulse. Be sure to place "Ap" before the rate to indicate
that this is an apical pulse reading.
PURPOSE: Aprocedure is not done until it is recorded in the patient's
record.
10. Observe the child's chest, or place your palm an the child's chest, and
count the respirations for 1 full minute.
11. Record the respiratory rate.
PURPOSE: Aprocedure is not done until it is recorded in the patient's
record.
12. Check to make sure you have the correct-sized blood pressure cuff and
then take the child's blood pressure (see the procedure in the Vital Signs
chapter) (Figure 3).
13. Record the blood pressure.
PURPOSE: Aprocedure is not done until it is recorded in the patient's
14. If vision screening is to be done, familiarize the child with the Echart by
asking him or her to make an Ethat points the same way your Eis
pointing. Then position the child in front of the pediatric Snellen Echart
(Figure 4) and have the child match the Esign (using the fingers) with
the Eon the chart to which you are pointing.
478 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES

•;;m,ammj1:i• -,;ontinued
1S. Record the vision results. 17. Sanitize your hands.
PURPOSE: Aprocedure is not done until it is recorded in the patient's PURPOSE: To ensure infection control.
record. 18. Perform appropriate disinfection and return all equipment to the proper
16. Compliment the child on his or her performance, and if the parent is storage area.
present, share the praise with the parent.
PURPOSE: To build rapport and encourage self-confidence in the child.

WORST PAIN POSSIBLE

UNBEARABLE
Unable to do any activities
because of pain.
Hurts Worst 9

•
INTENSE, DREADFUL
8 HORRIBLE
Unable to do most activities
because of pain.
Hurts Whole Lot 7

MISERABLE
6 DISTRESSING
Unable to do some activities
because of pain.
Hurts Even More 5

®
Hurts Little More
4

3
NAGGING PAIN
UNCOMFORTABLE
TROUBLESOME
Can do most activities
with rest periods.

®
Hurts Little Bit
2

1
MILD PAIN
ANNOYING
Pain is present but does
not limit activity.

0 NO PAIN

No Hurt

FIGURE 18-12 Wong-Baker Faces Pain Scale for children age 3 to 7years. (From Hockenberry MJ, Wilson D: Wong's essentials of pediatric
nursing, ed 8, St Louis, 2009, Mosby.)

Obtaining a Urine Sample
The easiest way to obtain a urine sample from a child who is toilet
trained is to give the parent the container and instructions ahead of
time. Then, when the child arrives at the office for the examination,
the sample is available to be tested. If the sample is needed while the
child is at the office, consult with the parent for the best method to
use. If the child is not toilet trained, a pediatric urine collection
device can be put on him or her to collect the sample (Figure 18-13
and Procedure 18-5). This device is placed as soon as the child is
checked in to increase the chance of obtaining the needed sample
 CHAPTER 18 Assisting in Pediatrics 479

before the child leaves. Once the device is in place, the child can be
diapered to help hold it properly. Make sure the adhesive sticks
tightly so that the specimen collects in the device when the child
urinates.
In some cases the child may need to be catheterized to obtain the
specimen. Pediatric catheterization kits contain all the supplies
needed for this procedure. When preparing the kit, always remember
that this is a sterile procedure. The pediatrician usually asks
the parent to help with the infant while the medical assistant labels
and prepares the specimen for the laboratory. In some practices
a registered nurse (RN) or a specially trained medical assistant
may perform a catheterization procedure to collect a pediatric urine
sample.

FIGURE 18-13 Urine collection devices.

•;;m,i11mjj1:Jj Assist Provider With a Patient Exam: Applying a Urinary Collection Device

Goal: To apply apediatric urinary collection device properly.

EQUIPMENT and SUPPLIES S. Make sure the area is dry. Unfold the collection device, remove the paper
• Patient's record from the upper portion, place this portion over the mans pubis, and press
• Pediatric urine collection bag it securely into place. Continue by removing the lower portion of the paper
• Labeled laboratory urinary container and securing this portion against the perineum. In male children the penis
• Laboratory test request form and scrotum should be in the opening of the collection bag. Make sure
• Antiseptic wipes the device is attached smoothly and that you have not taped it to part of
• Biohazard waste container the infant's thigh (Figure 1). Rediaper the infant or, if the parent is helping,
• Disposable examination gloves have the parent rediaper the infant at this time. The diaper will help hold
the bag in place.
PROCEDURAL STEPS
1. Assemble all needed supplies. Identify the child by name and date of birth.
PURPOSE: To manage time efficiently.
2. Sanitize your hands and put on gloves.
PURPOSE: To ensure infection control.
3. Ask the parent to remove the child's diaper, or place the child in a supine
position on the examination table and remove the diaper.
4. Cleanse the genitalia with antiseptic wipes.
Male: Cleanse the urinary meatus in a circular motion, starting directly on
the meatus and working in an outward pattern. Repeat with a clean wipe.
If the child has not been circumcised, gently retract the foreskin to expose
the meatus; using a fresh wipe, cleanse the area around the meatus and
return the foreskin to its natural position. Cleanse the scrotum last using
a fresh wipe. 6. If allowed, suggest that the parent give the child liquids (or nurse
Female: Hold the labia open with your nondominant hand; with your the infant if breast-feeding); check the bag for urine at 15-minute
dominant hand, cleanse each side of the inner labia, from the clitoris to intervals.
the vaginal meatus, in a superior to inferior pattern, using a fresh wipe PURPOSE: Increasing intake helps increase output.
for each side. With a third wipe, cleanse directly down the middle over 7. When a noticeable amount of urine has collected in the bag, put on gloves,
the urinary meatus. Discard all wipes in a biohazard container. remove the device, cleanse the skin area where the device was attached,
PURPOSE: To prevent contamination of the urine specimen with surface and rediaper the child.
pathogens.
480 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES
•;;m,ammj1:Jj -,;ontinued
8. Pour the urine carefully into the laboratory urine container, and handle the
sample in a routine manner.
9. Dispose of all used equipment in a biohazard waste container.
10. Remove your gloves, dispose of them in a biohazard container, and sani-
tize your hands.
THE ADOLESCENT PATIENT
The adolescent patient may present the greatest challenge to health
education and disease management. Adolescence begins with the
onset of puberty, a time when the child's reproductive system
matures; this is a period marked by rapid changes in the endocrine
and musculoskeletal systems. The adolescent undergoes rapid growth
spurts and the development of secondary sexual characteristics.
Health examinations for patients in this age group should include
screening for height and weight; gathering details about diet and
exercise routines; screening for sexually transmitted infections (STis)
(and, for sexually active female adolescents, a Pap test, especially to
screen for infection with the human papillomavirus [HPV]); review-
ing the vaccination history and administering boosters as indicated;
and assessing for high-risk behaviors, such as substance abuse,
smoking, and sexual behavior.
Health problems most frequently seen in adolescent patients
include eating disorders (anorexia nervosa and bulimia nervosa),
obesity, and injury-related problems. Accidents are the leading cause
of death and injury in adolescence, and suicide is the third leading
cause of death. All healthcare personnel should be on the alert for
indicators of suicide, including:
• Signs of depression, such as headaches, abdominal discomfort,
anorexia, fatigue, aggressiveness, drug or alcohol abuse, and
sexual promiscuity
• Verbal statements that hint at the adolescent's intention to
commit suicide; talking about dying
• Actions such as giving away prized objects, withdrawing from
social groups, suddenly changing normal behavior patterns,
or writing a suicide note
INJURY PREVENTION
Unintentional injuries are the leading cause of death and disability
in children in the United States. Injuries cause more childhood
deaths than all diseases combined. The primary causes of childhood
injuries are motor vehicle accidents, drowning, burns, falls, poison-
ing, aspiration with airway obstruction, and firearm accidents.
Childhood injuries are linked to the child's growth and development
level and usually are preventable. Young children are totally depen-
dent on caregivers to keep them safe, so constant supervision and a
childproof environment are essential for this age group. Older chil-
dren need to be aware of health hazards and should be encouraged
11. Document the procedure in the patients record.
PURPOSE: Aprocedure is not done until it is recorded.
8/24/20-10:45 AM: Urine specimen collected for culture as ordered by Dr.
Flint. Placed for pickup by North Hills Laboratory. S. Kwong, CMA (AAMA)
to protect themselves from injury (e.g., use bike helmets, protective
padding when skateboarding, seat belts, and so on). The highest
incidence of accidental injuries is seen in children under age 9, but
as children grow older, the percentage of deaths from injuries
increases. In the United States, more than 9,000 children die each
year-about 25 deaths a day-from injuries. Healthcare workers
play a major role in injury prevention. The medical assistant is
responsible for making sure the ambulatory care office is safe and
parents are educated about potential hazards.
CRITICAL THINKING APPLICATION 18-9
The office manager asks Susie to check the entire office for potential child
safety problems. After inspecting the facility, Susie is concerned about some
safety issues, so she decides to create a checklist for future use. What
precautions or safety features should she include?
CHILD ABUSE
The Child Abuse Prevention and Treatment Act states that all threats
to a child's physical and/or mental welfare must be reported. This
means that every teacher, healthcare worker, and social worker-in
fact, every citizen-who suspects that a child is being neglected,
abused, or exploited must report this to the proper authority. The
agency must record the report, and after three similar reports, the
agency must investigate.
When suspected abuse, neglect, or exploitation are reported, the
individual must provide his or her name; however, this is considered
confidential information and is not given to the child's parent or
guardian, nor is it given to the investigating officer. The individual
making the report also is protected under the law from any liability
for reporting suspicions of child abuse.
If the medical assistant suspects that a child is a victim of abuse,
neglect, or exploitation, he or she should consult with the pediatri-
cian immediately. In most states, the medical assistant and the pro-
vider can make separate reports to the authorities. However, state
laws vary, so state and local reporting protocols should be outlined
in the office procedures manual.

Signs of Child Abuse
Obvious Signs
• Previously filed reports of physical or sexual abuse of the child
• Documented abuse of other family members
• Different stories from the parents and the child on how an accident
happened
• Stories of incidents and injuries that are suspicious
• Injuries blamed on other family members
• Repeated visits to the emergency department for injuries
Examination Findings
• Trauma to the nervous system
• Internal abdominal pain
• Discolorations/bruising on the buttocks, back, and abdomen
• Elbow, wrist, and shoulder dislocations
Changes in Child Behavior
• Too eager to please the parent
• Overly passive and too compliant
• Aggressive and demanding
• Parenting the parent (role reversal)
• Delays in the normal growth and development patterns
• Erratic school attendance
Physical Indicators
• Poor hygiene
• Malnutrition
• Obvious dental neglect
• Neglected well-baby procedures (e.g., immunizations)
CLOSING COMMENTS
Patient Education
In a pediatric practice, the child usually is joined by one or both
parents during visits to the physician. Parents need reinforcement,
praise, and understanding in dealing with the health and welfare of
their child. Provide parents with information to help them under-
stand their children's behavior and improve their parenting skills.
Understanding the normal behavioral characteristics of a particular
developmental stage may increase the parents' confidence and rein-
force expectations for the child.
The waiting room is an ideal place for parent education. Use
the space and resources available to provide up-to-date infor-
mation on child health issues and on local resources for support
and assistance. If the pediatrician has pamphlets available, discuss
them with the parents. Answer questions when possible, or alert
the provider so that questions can be answered during the office
visit. Every opportunity should be taken to teach parents about
sound healthcare. Because so many ambulatory care visits involve
infectious disorders, educating children and parents on the follow-
ing infection control measures may help reduce the spread of
disease:
• Children should cover their mouth with a disposable tissue
when they cough and/or cough into their bent arm rather
than their hands.
CHAPTER 18 Assisting in Pediatrics 481
• A tissue should be used only once and then immediately
thrown away.
• Children should not be allowed to share toys they have put
in their mouth.
• After a child has discarded a toy that was in the mouth, it
should be placed in a bin for dirty toys that is out of reach of
others. Wash and disinfect these toys before allowing children
to play with them again.
• Make sure all children and adults follow good hand-washing
practices. Have pump hand sanitizers available throughout the
office.
Legal and Ethical Issues
In the United States, children are considered persons who are
growing and developing physically, emotionally, and mentally. Our
laws view children as a distinct group, and laws and customs have
been established that deal with the protection of children's rights.
Occasionally in the pediatric office, legal and ethical issues arise,
and the entire office staff may be faced with an ethical situation. If
this type of situation occurs, the first option is to talk it over with
the pediatrician. It may be necessary to have an office staff
meeting to identify the conflict, note pertinent laws and facts,
consider possible options and the consequences of each, and
decide on a course of action. Facing ethical issues confidently may
reduce the risk of liability. If the pediatrician's feelings are different
from yours, this might be a totally separate dilemma with which
you will have to deal. Always remember that as your employer,
the physician makes the final decision, and as long as you work
in that office, you are required to do things according to that
decision.
If something happens that you cannot ethically support, seek the
help of your local medical assistant organization. You may find that
others have been in similar situations and that they can suggest pos-
sible methods of solving the problem.
Professional Behaviors
Working as a medical assistant in a busy pediatric practice can be very
challenging. In essence, you are faced with two clients: a child who may
be frightened and not feeling well, and acaregiver who typically is stressed.
When you are dealing with emotionally charged situations, it is very easy
to lose patience and act out yourself. Continuing to act professionally can
help you manage these difficult situations. Consider the following
suggestions:
• Routinely use active listening to get as much information as possible
from the parents. Paying attention not only to the parents' words, but
also to their feelings, helps the parents feel valued.
• Focus on age-appropriate methods for communicating with the child.
Interacting with children on a level that they can understand helps them
feel more comfortable and hopefully promotes cooperative behavior.
• Use time management techniques to handle the work challenges
you face each day. Staying organized keeps you from feeling
overwhelmed.
 482 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES
i-iiiiit-iff•jii9#1MU1•i
After working with the telephone screening staff, Susie realizes the importance
of becoming familiar with childhood diseases and disorders and the manage-
ment policy of her physician-employers. Many times Susie has had to refer to
the office disease manual to make sure she is asking the right questions and
gathering all the information needed for the physician who will make the daily
response calls. From working in the clinical area, Susie also has realized that
a pediatric practice actually has two groups of patients: the child and the caregiv-
ers. She must be sensitive to the needs of both groups and develop communica-
tion skills that build trust with the child and his or her parents. Susie is working
SUMMARY OF LEARNING OBJECTIVES
l. Define, spell, and pronounce the terms listed in the vocabulary.
Spelling and pronouncing medical terms correctly reinforce the medical
assistant's credibility. Knowing the definitions of these terms promotes
confidence in communication with patients and co-workers.
2. Describe childhood growth patterns.
By 6 months of age, the child's birth weight has doubled; at l year it
has tripled, and the child's length has increased by 50%. By age 2 the
child has reached approximately 50% of adult height. This same growth
rate continues through the school-aged period, 6to 12 years, which leads
into a growth spurt that indicates impending puberty. In adolescence,
ages 12 to 18 years, the adolescent gains almost ha~ of his or her adult
weight and the skeleton and organs double in size.
3. Summarize the important features of the Denver II Developmental
Screening Test.
The Denver II Developmental Screening Test is a standardized tool used
for children between l month and 6 years of age to screen healthy
infants for developmental delays, to validate concerns about an infant's
development, or to monitor high-risk children for potential problems.
4. Discuss developmental patterns and therapeutic approaches for
pediatric patients.
Using therapeutic approaches for infants, toddlers, school-age, and ado-
lescent patients improves communication with a variety of patient age
groups and promotes quality patient care.
5. Identify four different growth and development theories.
Table 18-1 summarizes Freud's psychosexual, Piaget's cognitive, Erik-
son's psychosocial, and Kohlberg's moral reasoning theories.
6. Consider the implications of postpartum depression.
The American Academy of Pediatrics recommends that pediatricians
perform postpartum screening on all new mothers to promote total
child care.
7. Explain common pediatric gastrointestinal disorders, in addition to
failure to thrive and obesity.
Pediatric gastrointestinal disorders include infant colic; diarrhea, which
can be caused by a variety of different microorganisms and is treated
medically when it continues for longer than 2 days; failure to thrive
on developing acomprehensive education site in the office for interested parents
and is creating a community resource guide for interested caregivers. She rec-
ognizes the need to stay up to date on the CDC's recommendations for childhood
immunizations, and routinely refers to the CDC's website to make sure the office
has the most recently published VIS forms. Susie regularly attends her local
American Association of Medical Assistants (AAMA) chapter meetings to main-
tain her certification and to continue to learn about the pediatric practice
specialty.
caused by a physiologic factor (e.g., malabsorption disease or cleft
palate) or a nonorganic cause that is associated with the parent-child
relationship; and obesity if the child's BMI is equal to or greater than the
95th percentile.
8. Describe disorders of the respiratory system in children.
The common cold may lead to secondary bacterial infections, including
strep throat or otitis media; croup is a viral disorder that affects the
larynx; pertussis, commonly known as whooping cough, is caused by
bacteria that attach to the cilia of the upper respiratory system and can
cause violent, rapid coughing and apnea in infants; bronchiolitis is a viral
infection of the bronchioles that causes acute onset of wheezing and
dyspnea; RSV is a virus that infects the lungs and bronchioles; asthma
causes bronchospasms and inflammation of the bronchioles; and influ-
enza is an acute, highly contagious viral infection of the respiratory
tract.
9. Distinguish among pediatric infectious diseases.
Pediatric infectious diseases include conjunctivitis, caused by a bacterial
or viral infection; tonsillitis, typically caused by beta-hemolytic strepto-
cocci; fifth disease, also called erythema infectiosum, a mild infection
caused by parvovirus Bl 9; hand-foot-and-mouth disease, caused by the
coxsackievirus, which causes multiple symptoms, including painful blis-
ters on the tongue, mouth, palms of the hands, and soles of the feet;
chickenpox, caused by a member of the herpesvirus group; meningitis,
an inflammation of the membranes that cover the brain and spinal cord,
caused by bacteria or viruses (bacterial meningitis is the more danger-
ous); HBV, which can lead to serious and chronic infection of the liver
and can be transmitted across the placenta; and Reye's syndrome, which
is linked with the use of aspirin during a viral illness.
l 0. Recognize the etiologic factors and signs and symptoms of the two
primary pediatric inherited disorders.
Pediatric inherited disorders include cystic fibrosis, an autosomal recessive
genetic disorder that causes exocrine glands to produce abnormally thick
secretions and primarily affects the lungs and pancreas; and Duchenne's
muscular dystrophy, an X~inked genetic disease that causes progressive
muscle degeneration.

SUMMARY OF LEARNING OBJECTIVES-continued
11. Summarize the immunizations recommended for children by the
Centers for Disease Control and Prevention (CDC).
The CDC's recommendations for childhood immunization are summarized
in Table 18-2 and Figure 18-7.
12. Demonstrate how to document immunizations and maintain accu-
rate immunization records.
Procedure 18-1 summarizes how to document immunizations in both the
official vaccination record and the parents immunization booklet. Docu-
mentation of immunization administration on the VIS form must include
the date the vaccine was administered, the vaccine's manufacturer, the
manufacturer's lot number, the type of vaccine, the route of administra-
tion and exact site if an injection is given, any reported or observed side
effects, the name and titte of the person administering the vaccine, the
address of the medical office where the vaccine was administered, and
the date.
13. Compare a well-child examination with a sick-child examination.
Well-child visits are typically scheduled from age 2 weeks through 15
years to focus on maintaining the child's health with physical examina-
tions, immunizations, and upgrading of the child's medical health history
record. Sick-child visits occur whenever the child needs to be seen
because of illness or injury. Table 18·4 summarizes important questions
for telephone screening of pediatric problems.
14. Outline the medical assistant's role in pediatric procedures.
The medical assistant assists the pediatrician with examinations; main-
tains patient histories; performs ordered screening tests, such as vision,
hearing, urinalysis, and hemoglobin checks; administers immunizations;
measures and weighs children as needed; documents accurately; and
provides support to patients and caregivers.
15. Measure the circumference of on infant's head.
Procedure 18-2 outtines the steps for measuring an infant's head.
16. Obtain accurate length and weight measurements and plot pediatric
growth patterns.
Procedure 18-3 outtines the steps for measuring an infant's length and
weight and documenting on the child's growth chart.
17. Accurately measure pediatric vital signs, and perform vision
screening.
Procedure 18-4 summarizes the steps for obtaining accurate pediatric
vital signs and performing vision screening on a child. Tympanic or
CONNECTIONS
OJ Study Guide Connection: Go to the Chapter 18 Study Guide. Read and complete
the activities.
CHAPTER 18 Assisting in Pediatrics 483
temporal thermometers are the easiest and quickest method for measur-
ing temperature; the apical pulse should be taken for a full minute,
respirations observed and recorded, and blood pressures taken with
the appropriate-sized cuff when indicated. After patient education, the
Snellen Echart is used to perform vision screening and to record results
accurately.
18. Correctly apply a pediatric urine collection device.
Procedure 18-5 summarizes the steps for applying a urinary collection
device.
19. Describe the characteristics and needs of the adolescent patient.
Adolescents are going through extreme physical and emotional changes,
and an extra measure of patience and understanding is required to
establish therapeutic interactions. Ensuring their privacy, giving them the
option of being seen without parents, and providing pertinent education
materials all are important factors in patient-centered adolescent care.
20. Specify child safety guidelines for injury prevention, and explain the
management of suspected child abuse, neglect, or exploitation.
The medical assistant should be involved in parent education on injury
prevention for children. Childhood injuries are linked to the child's growth
and development level and therefore are often predictable and many
times preventable. If the medical assistant suspects that achild is avictim
of abuse, neglect, or exploitation he or she should consult with the
pediatrician immediately. In most states, the medical assistant and the
physician can make separate reports to the authorities.
21. Summarize patient education guidelines for pediatric patients.
Parents need reinforcement, praise, and understanding in dealing with
the health and we~are of their child. Provide parents with information
to help them understand their children's behavior and improve their
parenting skills.
22. Discuss the legal and ethical implications in a pediatric practice.
Occasionally in the pediatric office, legal and ethical issues arise, and the
entire office staff may be faced with an ethical situation. If this type of
situation occurs, the first option is to talk it over with the pediatrician. It
may be necessary to have an office staff meeting to identify the conflict,
note pertinent laws and facts, consider possible options and the conse-
quences of each, and decide on a course of action.
8 VO IVe Evolve Connection: Go to the Chapter 18 link at evolve.elsevier.com/
kinn to complete the Chapter Review Quiz. Check out the other resources listed for this
chapter to make the most of what you have learned from Assisting in Pediatrics.
 ASSISTING IN ORTHOPEDIC
19
li#H+i;H•i
Kaiwan Tillman became interested in orthopedics before he even knew what
the word meant. In the sixth grade, he broke his right femur in a bicycle
accident. He had to have multiple operations and undergo lengthy rehabilitation
to regain complete movement in the leg. On graduation from high school, he
attended the local community college and enrolled in a medical assisting
program that offered an associate's degree. Since earning his (MA (MMA),
While studying this chapter, think about the following questions:
• What are the primary responsibilities of the medical assistant in an
orthopedic practice?
• What clinical skills are required in this specialty practice?
LEARNING OBJECTIVES
1. Define, spell, and pronounce the terms listed in the vocabulary.
2. Describe the principal anatomic structures of the musculoskeletal
system and their functions.
3. Differentiate among tendons, bursae, and ligaments.
4. Summarize the major muscular disorders.
5. Identify and describe the common types of fractures.
6. Explain the difference between osteomalacia and osteoporosis.
7. Classify typical spinal column disorders.
8. Differentiate among the various joint disorders.
9. Summarize the medical assistant's role in assisting with orthopedic
procedures.
l 0. Explain the common diagnostic procedures used in orthopedics.
11. Discuss therapeutic modalities used in orthopedic medicine.
VOCABULARY
arthritis (ahr-thri'-tis) Inflammation of a joint.
articular (ar-tih'-kyuh-luhr) Pertaining to a joint.
bursae (bur'-suh) Fluid-filled, saclike membranes that provide
cushioning and allow frictionless motion between two tissues.
cartilage (kahr' -tl-ij) A rubbery, smooth, somewhat elastic
connective tissue that covers the ends of bones.
cervical (ser'-vih-kuhl) Pertaining to the neck region containing
seven cervical vertebrae.
corticosteroids (kawr-tuh-koh-ster'-oidz) Antiinflammatory
hormones, natural or synthetic.
crepitation (kreh-puh-ta'-shun) A dry, crackling sound or sensation.
':,
MEDICINE
Kaiwan has worked in asports medicine clinic. The clinic staff at Sports Medicine
Associates includes three orthopedic surgeons, two physical therapists, and two
massage therapists. Kaiwan is very excited about working in the clinic, although
he initially was somewhat intimidated. Dr. Steve Alexander is the team physician
for a local professional baseball team, and Kaiwan's responsibilities include
assisting Dr. Alexander with treating the team.
• What are the common musculoskeletal injuries and disorders that the
medical assistant should understand?
• What diagnostic and treatment procedures typically are used in an
orthopedic practice?
12. Apply cold therapy to an injury.
13. Discuss various heat treatments and assist with hot moist heat
application to an orthopedic injury.
14. Discuss therapeutic ultrasonography, massage, exercise, and electrical
muscle stimulation.
15. Explain the use of common ambulatory devices, properly fit a patient
with crutches, and coach a patient in the correct mechanics of crutch
walking.
16. Discuss the management of fractures and prepare for and assist with
both the application and removal of a cast.
17. Summarize patient education guidelines for orthopedic patients.
18. Discuss the legal and ethical implications in an orthopedic practice.
diaphysis (di-ah'-fuh-suhs) The midportion of a long bone; it
contains the medullary cavity.
endoscope (en'-duh-skohp) An illuminated optic instrument for
visualization of the inside of the body; it may be inserted
through an incision in minimally invasive surgery.
epiphysis (eh-pih'-fuh-sis) The end of a long bone; it contains the
growth (epiphyseal) plates.
goniometer (go-ne-om'-ih-ter) An instrument for measuring the
degrees of motion in a joint.
inflammation (in-fluh-ma' -shun) A tissue reaction to trauma or
disease that includes redness, heat, swelling, and pain.

VOCABULARY-continued
kyphotic (ki-fot'-ik) Relating to the normal convex curvature of
the thoracic spine.
ligaments (lig'-uh-ments) Tough connective tissue bands that
hold joints together by attaching to the bones on either side of
the joint.
lordotic (lor-do'-tik) Relating to the normal concave curvature of
the cervical and lumbar spines.
lumbar (lum'-bahr) Relating to the lower back region that
contains the five lumbar vertebrae.
luxation (luhk' -sa-shun) Dislocation of a bone from its normal
anatomic location.
malaise (muh-layz') An indefinite feeling of debility or lack of
health, often indicating or accompanying the onset of an
illness.
medullary cavity (meh-duhl'-a-re) The inner portion of the
diaphysis; it contains the bone marrow.
periosteum (per-e-os'-te-uhm) The thin, highly innervated,
membranous covering of a bone.
A physician who specializes in orthopedics is responsible for diag-
.finosing and treating diseases and disorders of the musculoskel-
etal system, especially those affecting the bones. Rheumatologists are
specialists in treating inflammatory joint disorders. Chiropractors are
doctors of chiropractic (DC) but are not medical physicians; they
use manual adjusting procedures to correct subluxations or misalign-
ments of the spine to allow maximum function, thus facilitating the
body's ability to maintain homeostasis and prevent disease.
The musculoskeletal system includes all of the skeletal muscles,
bones, joints, and supportive connective tissues (cartilage, tendons,
and ligaments). The general functions of the musculoskeletal system
are to:
• Protect the internal organs
• Support the body in standing erect
• Produce movement
• Perform hemopoietic functions (production of blood cells in
the red bone marrow)
• Store the minerals calcium and phosphorus in the bones
ANATOMY AND PHYSIOLOGY OF THE
MUSCULOSKELETAL SYSTEM
Muscles
More than 600 muscles attach to the human skeleton (Figure 19-1) .
These muscles account for approximately half of a person's weight,
and they contribute to the body's distinct shape. This chapter dis-
cusses the skeletal muscles that attach to bones and allow movement.
Skeletal muscle fibers are voluntary and striated (Figure 19-2, A).
The body has two other types of muscle: smooth muscle (Figure
19-2, B), which lines organs and blood vessel walls and is nonstri-
ated, and cardiac muscle (Figure 19-2, C), a striated muscle in the
heart. Both of these types are involuntary muscles; that is, the indi-
vidual cannot control their function. Skeletal muscles are voluntary;
when they contract or relax can be controlled. Special fibers in
CHAPTER 19 Assisting in Orthopedic Medicine 485
prosthesis (pros-the'-suhs) An artificial replacement for a body
part.
range of motion {ROM) The extent of movement possible in a
joint; the degree of motion depends on the type of joint and
whether a disease process is present; ROM exercises are applied
actively (independently) or passively (with assistance) to prevent
or treat joint problems.
reduction Return to correct anatomic position, as in reduction of
a fracture.
sarcoma A malignant tumor in fibrous, fatty, muscular, synovial,
vascular, or neural tissue.
scoliosis An abnormal lateral curvature of the spine.
striated A muscle that contains fibers divided by bands of cross
stripes or striations because of overlapping myofilaments.
synovial fluid A clear fluid found in joint cavities that facilitates
smooth movements and nourishes joint structures.
tendons Tough bands of connective tissue that connect muscle to
bone.
skeletal muscles allow them to shorten (contract) and lengthen
(relax), which creates movement (Table 19-1). These muscles are
connected to bone with bands of tough, fibrous connective tissues
called tendons.
Bones
The human skeleton is composed of more than 200 bones (Figure
19-3). Bones provide a framework to protect vital organs. In general,
the size and shape of a bone is related either to how much it moves
and how much body weight it must carry, or to its protective func-
tion for the underlying organs.
Bones generally are categorized by shape: long, short, flat,
rounded, or irregular. A long bone is made up of a diaphysis (the
shaft), which has an expansion at each end (the epiphysis) (Figure
19-4). The epiphysis is covered with articular cartilage and is
attached by ligaments to the epiphysis of another bone, forming a
joint. Articular cartilage reduces the stress of weight bearing and the
friction of movement. The thickness of the cartilage depends largely
on the amount of stress placed on a particular joint. The medullary
cavity, inside the diaphysis, contains yellow bone marrow.
Bone is living tissue that is constantly being remodeled in
response to stress or injury. It also is a storage location for minerals,
including calcium and phosphorus. Red bone marrow produces
blood cells and is found in the spongy (cancellous) bone of the
proximal epiphyses of the humerus and femur, sternum, ribs, and
vertebrae of adults. Bones are covered with a thin, membranous
tissue, the periosteum, which contains many sensory nerves.
CRITICAL THINKING APPLICATION 19-1
In what way does Kaiwan benefit by being familiar with the names and
locations of the major bones of the extremities? How might this knowledge
make his job at Sports Medicine Associates more interesting? What is the
difference between tendons and ligaments?
486 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES

- - - - Pectoralis major

Biceps brachii - - - - - - Brachialis

Serratus anterior ---==--=-- - - Linea alba

Brachioradialis i--'~ ~- - External abdominal
oblique

7'.- ~ ~ ,------ lliopsoas

Cut edge of
Rhomboideus major trapezius
- - - - - Supraspinatus
Deltoid---~
Trapezius - - - - - , - - - lnfraspinatus
Teres minor
Latissimus dorsi

"'"'"--+---Tensor fasciae
latae

Gastrocnemius

Soleus - - - -iii
Calcaneal tendon - - - ----;

B
FIGURE 19-1 Muscles of the body. A, Anterior view. B, Posterior view.
 CHAPTER 19 Assisting in Orthopedic Medicine 487

-=- Nucleus
of skeletal
muscle cell
Nucleus
-c ~ :---7"=-:----t-- of smooth
muscle cell

Intercalated
disks

Nucleus
".';:,..:~a--.....:i..-+--Of cardiac
muscle cell

FIGURE 19-2 A, Skeletal muscle. B, Smooth muscle. C, Cardiac muscle. (From Applegate E: The anatomy and physiologylearning system,
ed 4, St Louis, 2011, Saunders.)

TABLE 19-1 Types of Body Movement

MOVEMENT DEFINITION OR EXAMPLE MOVEMENT DEFINITION OR EXAMPLE
Flexion Reduces the angle of the joint Abduction Moving the body port away from
and brings the two bones closer the midline or median plane of
together. the body.

Extension The opposite of flexion; increases 1--- - - - - - - - - - - - - - - - - - -

the angle or distance between Adduction The opposite of abduction;
two bones or ports of the body. moving the body port toward the
midline of the body.

Hyperextension Extension 180 degrees (e.g., the 1--- - - - - - - - - - - - - - - - - -

neck is extended backward or the Rotation Moving a bone around its central
toes ore pointed downward) . axis; common in boll-and-socket
joints.

Continued
488 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES

TABLE 19-1 Types of Body Movement-continued

MOVEMENT DEFINITION OR EXAMPLE MOVEMENT DEFINITION OR EXAMPLE
Circumduction Circular movement of a limb; a Eversion Turning the sole of the foot
combination of abduction, laterally, or outward.
adduction, extension, and flexion.

Dorsiflexion Moving the instep of the foot up

and dorsally, reducing the angle Inversion The opposite of eversion; turning
between the foot and the leg. the sole of the foot medially, or
inward.

Plantar flexion Atoe-down movement of the

foot at the ankle; increases the
angle of the joint. Pro nation Rotation of the forearm that turns
the palm of the hand downward,
l or posteriorly.

Supination The opposite of pronation;

rotation of the forearm that turns
the palm of the hand upward, or
anteriorly.

Joints Types of Joints

Bones are connected to each other at junctions known as joints. The
two main kinds of joints are nonsynovial joints and synovial joints.
In nonsynovial joints, the bones are joined with fibrous cartilage and
are immovable (e.g., the sutures of the skull) or only slightly move-
able (e.g., the vertebrae). Synovial joints are freely moveable because
the adjacent ends of two bones are covered with cartilage and are
enclosed in a joint cavity that contains a viscous, slippery fluid called
synovial fluid, which is an excellent lubricant. Synovial joints such
as the elbow and the knee are hinge joints, which allow movement
in only one plane (Figure 19-5). Other synovial joints, such as the
hip and shoulder, allow movement in many planes, which permits
a wider range of motion (ROM) than a hinge joint has.
As mentioned, joints are classified by the way they are shaped or by
their ability to move. The joints of the skull are known as sutures.
Sutures permit the skull to grow with the child but have very limited
flexibility. The hinge joints of the elbow and knee allow for move-
ment in one plane, such as bending back and forth. A gliding joint,
as in the wrist and foot, is made up of two flat-surfaced bones that
slide over each other, allowing limited movement. Ball-and-socket
joints, as in the shoulder and hip, allow for the greatest ROM by
permitting the joint to rotate in a complete circle. Artificial joints
have been successfully implanted to replace joints that have been
damaged by disease or trauma, including the joints of the hip, knee,
ankle, shoulder, elbow, wrist, and finger.
 CHAPTER 19 Assisting in Orthopedic Medicine 489

Axial skeleton Axial skeleton

Vertebral :L.7"'--------'.---i:;,,__ Vertebral

column - ---+h,__--=---9:~ column

Appendicular skeleton
FIGURE 19-3 Axial skeletal bones (outside columns) ond oppendiculor skeletal bones (middle column).

Ligaments, Tendons, and Bursae

Ligaments are powerful, strong, fibrous bands of connective tissue
that connect bone to bone at the joint and encase the joint capsule.
Ligaments allow purposeful joint movement and prevent excessive
movement in any particular joint. Ligaments may be oblique or
parallel to the joint, as in the knee, or may surround the joint, as in
the hip.
Plantar Fasciitis
Plantar fasciitis (pronounced PlAN-ter fash-ee-EYE-tus) is the most common
cause of heel pain. The plantar fascia is a flat ligament that connects
the heel bones of the foot to the toes. It supports the arch of the foot. If
the plantar fascia is strained, it becomes weak, swollen, and inflamed.
The primary symptom is pain that radiates from the heel or the bottom
of the foot when standing or walking. Risk factors for plantar fasciitis
include:
• Excessive pronation (the feet roll inward when walking)
• High arches or flat feet
• Walking, standing, or running for long periods
• Overweight
• Tight Achilles tendons or calf muscles
Most people with plantar fasciitis have pain when they take their first
steps after they get out of bed or sit for a long time. Stretching and
strengthening exercises or use of specialized devices, such as splints or
orthotics (customized arch supports), may provide symptomatic relief.
490 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES

__,....,___ _ Articular cartilage a ligament. Bursae reduce friction and help muscles and tendons
Epiphysis glide smoothly over bone.
Epiphyseal line

Spongy bone
MUSCULOSKELETAL DISEASES AND DISORDERS
Compact bone Musculoskeletal diseases and conditions can affect any of the muscles,
Medullary cavity bones, or joints. These problems are common and have a tremendous
impact on a person's quality of life. Brittle or deformed bones that
are prone to fracture often mark bone disorders such as osteoporosis
and osteomalacia. Joint disorders, such as osteoarthritis (OA), rheu-
Nutrient foramen matoid arthritis (RA), and gout, can lead to painful, swollen, or
Diaphysis Endosteum inflamed joints. Muscle problems, such as sprains and spasms, can
Periosteum bring on sudden pain or cause stiffness (Table 19-2).
Trauma to the musculoskeletal system can quickly lead to inflam-
mation in the area of injury. This type of injury is one of the leading
causes of time lost from work and for visits to primary care physi-
cians and emergency departments. As soon as possible after injury,
even before a patient is seen by a provider, treatment involving rest,
ice, compression, and elevation (RICE therapy) should be started.
The combination of these measures can help reduce swelling and
inflammation and enhance healing.

Using Frozen Peas for an Ice Bag

FIGURE 19-4 Long bone features. (From Applegate E: The anatomy and physiology learning
system, ed 4, St Louis, 2011, Saunders.) Abag of frozen peas (or corn) easily conforms to the shape of a body part
and serves as an excellent means of immediately applying ice to a mus-
culoskeletal injury. The vegetable ice bag should be wrapped in a towel to
protect tissue from overexposure to the cold. It should be applied for 20
minutes, put back into the freezer for 30 to 60 minutes, and applied again.
Femur

Synovial To maintain musculoskeletal health, a person must have a signifi-

(joint) cavity
cant dietary intake of foods rich in calcium and vitamin D; must
Synovial Prepatellar avoid smoking; and must include weight-bearing exercises (e.g.,
membrane bursa
walking) in the daily routine. In addition to these lifestyle measures,
Articular
Patella medications sometimes are required for conditions that impair
cartilage
Synovial normal functioning of the musculoskeletal system. The conditions
Medial (joint) cavity
meniscus
discussed in the following sections are typically seen in an orthopedic
Fat pad practice.
Tibia lnfrapatellar
bursa

CRITICAL THINKING APPLICATION 19-2

Why is it important to obtain an accurate history from an injured patient
who comes to the office for the first time? What is Kaiwan's responsibility
FIGURE 19-5 Sagittal section of the knee joint. (From Applegate E: The anatomy and physiology in finding out the reason a new patient is being seen?
learning system, ed 4, St Louis, 2011, Saunders.)

A tendon is a strong bundle of connective tissue that attaches
muscle to bone. Tendons can be flat or round and can pass between
muscles, between bones, or through specialized openings between
bones; for example, the carpal tunnel is a narrow opening in the
bones at the base of the hand.
Bursae are fibrous sacs that lie between tendons and bones; they
are lined with synovial membranes that secrete synovial fluid and act
as cushions between a bone and a tendon or between a tendon and
Muscular Disorders
Fibromyalgia
Fibromyalgia is a condition of widespread connective tissue and
muscular pain and often includes severe fatigue of unknown origin.
A patient with fibromyalgia usually complains of diffuse aches and
pains all over the body. The disorder can affect people of all ages and
is seen more frequently in women than in men. Chronic pain and
fatigue are the cardinal signs in the absence of any other known
cause. Associated conditions can include sleep disorders, irritable

TABLE 19-2 Common Musculoskeletal Conditions
SYMPTOMS, SIGNS, AND
DISEASE ETIOLOGY
Bursitis and Painful joint with reduced ROM;
tendanitis caused by overuse of the joint,
injury, or disease
Carpal tunnel Hand and finger pain, numbness,
syndrome tingling, difficulty grasping or
holding objects, especially in the
morning; caused by compression
of the median nerve at the
carpal tunnel area
Dislocation Painful joint that is out of place History of trauma, physical
and has severely reduced ROM; examination, x-ray studies
caused by traumatic injury to the
joint
Fibromyalgia Chronic, severe musculoskeletal
pain, generalized weakness;
cause unknown but has
contributing factors
Fractures Severe pain, swelling, reduced
ROM
Gout Painful joint inflammation, often
affects great toe, very sensitive
to touch and movement;
metabolic disease caused by
buildup of uric acid
Herniated Depend on location and severity
disk of herniation; back pain,
extremity pain or weakness;
caused by trauma or stress
Infectious Severely infected and inflamed
arthritis joint; usually result of surgery or
trauma
Lupus Painful or swollen joints and
muscle pain; unexplained fever
or rash; chest pain with deep
breathing; hair loss; Raynaud's
phenomenon; sun sensitivity; leg
and eye edema; mouth ulcers;
swollen glands; extreme fatigue;
autoimmune disease
CHAPTER 19 Assisting in Orthopedic Medicine 491
DIAGNOSTIC TREATMENT AND
PROCEDURES LABORATORY TESTS MEDICATIONS
History, physical examination, CBC to rule out infectious RICE, temporary immobilization, NSAIDs
x-ray studies ta rule out arthritis
fracture
Physical examination; Tinel Routine lab tests to rule out Rest and splint wrist; OTC NSAIDs,
and Phalen compression other conditions diuretics, oral prednisone or
tests; NCS and EMG; corticosteroid injections; forearm
ultrasonography of the wrist extensor stretching and strengthening
exercises; endoscopic surgical
decompression in severe cases
None Reduce and temporarily immobilize
joint; analgesics
History, physical examination As appropriate to rule out NSAIDs, analgesics, rest, control of
to rule out other causes other conditions stress. Pregabalin (Lyric •);
milnacipran (Savella) for pain, fatigue,
and depression; zolpidem (Ambien) for
sleep; tramadol (Ultram) for relief of
pain; and antidepressants duloxetine
(Cymbalta) and fluoxetine (Prozac)
History, physical examination, Nane Reduction, immobilization, analgesics,
x-ray studies NSAIDs
History, physical examination, Serum uric acid test Low purine diet, limit alcohol, NSAIDs,
microscopic synovial fluid analgesics, prednisone, colchicine
examination for uric acid (Colcrys); allopurinol (Lopurin,
crystals Zyloprim); and probenecid (Probalan)
History, physical examination; None Rest, antiinflammatories, analgesics,
MRI; EMG or NCS physical therapy, epidural corticosteroid
injections, surgical laminectomy in
severe cases
History, physical examination, CBC, culture of joint fluid NSAIDs, corticosteroids, appropriate
microscopic synovial fluid antibiotic or antiviral agents
examination for cell count
and presence of bacteria
Very careful history and Diagnostic tests as needed to No known cure; type of pharmaceutical
physical examination to rule rule out possible causes of treatment depends on organs involved;
out possible causes of symptoms, renal lab tests, medications include NSAIDs;
presenting symptoms; blood tests for hemolytic antimalarial hydroxychloroquine
frequently a diagnosis of anemia or low platelet and (Plaquenil); prednisone;
exclusion WBCs; antinuclear antibody immunosuppressives azathioprine
test (lmuran), cyclophosphamide (Cytoxan);
IV belimumab (Benlysta)
Continued
492 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES

TABLE 19-2 Common Musculoskeletal Conditions-continued

SYMPTOMS, SIGNS, AND
DISEASE ETIOLOGY
Lyme disease Bull's-eye lesion, flulike
symptams, arthritic pain,
meningitis, Bell's palsy, memory
loss, mood disorders; bacterial
infection carried by ticks
Myasthenia Profound muscular weakness,
gravis frequently starting with facial
muscles; can invalve any;
voluntary muscles; autoimmune
neuromuscular disease; unknown
cause
Osteoarthritis Gradually increasing joint pain;
gradually decreasing ROM in
affected joint; caused by
degeneration of articular cartilage
Osteomalacia Fractures, muscle weakness,
bone pain; metabolic disease
caused by vitamin Ddeficiency or
problems with its metabolism
Osteoporosis Frequent fractures, exaggerated
thoracic kyphosis, reduced
height, back pain; multiple risk
factors; low calcium/vitamin D
diet; lack of exercise; genetic
factors
Rheumatoid Severe joint pain and joint
arthritis deformity; autoimmune response
to synovial membrane; unknown
cause
Scoliosis Lateral spinal deformity
accompanied by back pain;
congenital defect
Sprain, strain, Cardinal signs: inflammation,
spasm redness, heat, swelling, pain,
reduced ROM; caused by trauma
AChR, Acetylcholine receptor; CBC, complete blood count; DXA, dual energy x-ray absorptiometry; EMG, electromyography; IV, intravenous; MRI, magnetic resonance imaging; NCS, nerve conduction
studies; NSA/Ds, nonsteroidal anti-inflammatory drugs; OTC, over-the-counter; PTH, parathyroid; RA, Rheumatoid arthritis; RF, rheumatoid factor; RICE, rest, ice, compression, elevation; ROM, range
of motion; WBCs, white blood cells.
DIAGNOSTIC TREATMENT AND
PROCEDURES LABORATORY TESTS MEDICATIONS
Careful history; physical Two-step blood test; enzyme Initially antibiotics; later stages IV
examination to check for tick immunaassay and Western ceftriaxone (Rocephin)
bite blot test
History, neurologic Anti-AChR antibody test Acetylcholinesterase, steroids; immune
examination, EMG inhibitor cyclosporine (Sandimmune),
thymectomy
History, physical examination, RA test to rule out Exercise and weight control, NSAIDs,
x-ray studies, MRI rheumatoid arthritis; CBC to physical therapy, analgesics, ambulatory
rule out infectious arthritis support, intra-articular steroid injections
History, physical examination, Serum vitamin D, serum Vitamin Dand calcium supplements
x-ray studies, bone scan calcium, serum alkaline
phosphatase, PTH level,
occasionally bone biopsy
History, physical examination; None Weight-bearing exercise; calcium
DXA scan; ultrasound of the supplementation; pharmaceutical
heel treatment with alendronate (Fosamax),
risedronate (Actonel), zoledronic acid
(Reclast), and ibandronate sodium
(Boniva); raloxifene (Evista)
History, physical examination, RF and blood antibody tests NSAIDs; corticosteroids; methotrexate
x-ray studies (Rheumatrex), leflunomide (Arava),
hydroxychloroquine (Plaquenil) and
sulfasalazine (Azulfidine), etanercept
(Enbrel), infliximab (Remicade), and
adalimumab (Humira); analgesics;
low-impact exercise; joint replacement
in severe cases
Physical examination, None Braces, casts, surgery
radiographic studies
History, physical examination, None RICE and NSAIDs
including active and passive
ROM, x-ray studies to rule
out fracture

bowel syndrome, chronic headaches, temporomandibular joint
(TMJ) problems, painful menstrual periods, increased chemical sen-
sitivity, and other musculoskeletal complaints.
Although the cause remains unknown, fibromyalgia can be trig-
gered by an automobile accident or a bacterial or viral infection,
or it can follow the diagnosis of other medical conditions, such
as RA, lupus, or hypothyroidism. It is aggravated by changes in
the weather or temperature, monthly hormonal variations, stress,
anxiety, and depression. In the past, a physical examination for
possible fibromyalgia would include a check for 18 specific tender
points on a person's body ro see how many of them were painful
when pressed firmly. However, current diagnostic guidelines no
longer suggest checking for tender points. A fibromyalgia diagnosis
is made if a person reports widespread pain for longer than 3
months without any other medical condition. There are no blood
tests specifically to diagnose fibromyalgia, but the provider may
order certain laboratory studies to rule out other possible causes of
the widespread pain.
Treatment goals include reducing pain, enhancing sleep, and
reducing anxiety and stress. Pregabalin (Lyrica), an antiseizure medi-
cation, is the first drug approved by the U.S. Food and Drug Admin-
istration (FDA) to treat fibromyalgia. Milnacipran (Savella) may be
prescribed to reduce pain and fatigue and help with the depression
associated with fibromyalgia. Prescription sleeping pills, such as zol-
pidem (Ambien), are prescribed only for the short term because the
body eventually becomes tolerant to the medication, rendering it
ineffective. Other medical treatments include over-the-counter
(OTC) analgesics (e.g., Tylenol or ibuprofen) and antiinflammatory
agents, including tramadol (Ultram) for relief of pain; and antide-
pressants, such as duloxetine (Cymbalta) to ease the pain and fatigue
associated with fibromyalgia and fluoxetine (Prozac) to help promote
sleep. Stress reduction, physical therapy, and relaxation exercises help
control symptoms. Fibromyalgia has no known cure.
Myasthenia Gravis
Myasthenia gravis is a chronic autoimmune neuromuscular disease
of unknown origin that affects voluntary muscle contraction. It can
occur at any age but most frequently affects young adult women
(under age 40) and older men (over age 60). Often the patient
Fibula
Anterior
talofibular
ligament ---\-l~-c1--
Calcaneofibular
ligament
FIGURE 19-6 Ankle sprain.
CHAPTER 19 Assisting in Orthopedic Medicine 493
experiences a sudden onset of weakness in the muscles that control
eye and eyelid movement, facial expression, and swallowing. Symp-
toms vary in type and severity and may include drooping of one or
both eyelids (ptosis); blurred or double vision (diplopia) as a result
of weakness of the muscles that control eye movements; an unstable
or waddling gait; weakness in the arms, hands, fingers, legs, and
neck; altered facial expressions; difficulty swallowing; shortness of
breath; and impaired speech (dysarthria).
Myasthenia gravis is caused by a defect in the transmission of
nerve impulses to muscles. It occurs when a nervous stimulus is
unable to stimulate a muscle at the neuromuscular junction, the
place where nerve cells connect with the muscles they control. Nor-
mally, when impulses travel down the nerve, the nerve endings
release acetylcholine (ACh), a neurotransmitter that activates mus-
cular contraction. In myasthenia gravis, antibodies block, alter, or
destroy the receptors for ACh at the neuromuscular junction, which
prevents the muscle contraction. The condition is diagnosed with a
complete history and physical exam, including a neurology exam to
detect muscular weakness, especially in the movement of the eyes.
Blood tests for certain antibodies are also ordered, but they are not
always conclusive. The primary treatment is a medication that inhib-
its acetylcholinesterase, the enzyme that normally breaks down ACh.
This allows ACh to remain at the neuromuscular junction longer
than usual so that more of the remaining receptor sites can be acti-
vated. lmmunosuppressive drugs, such as prednisone or cyclosporine
(Sandimmune), may be prescribed to improve muscle strength by
suppressing the production of abnormal antibodies. Surgical removal
of the thymus gland (thymectomy) reduces symptoms and may cure
some individuals. Spontaneous improvement and remissions can
occur.
Sprains, Strains, and Spasms
A sprain is a wrenching or twisting of a joint in an abnormal plane
of motion or beyond its normal ROM that results in stretching and/
or tearing of a ligament. Concurrent damage to area blood vessels,
muscles, tendons, and nerves may occur. Probably the most common
sprain is the ankle sprain (Figure 19-6), which can occur when a
person steps off a curb or into a small depression and twists the ankle.
Severe sprains are so painful the joint cannot be used, and they are
494 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES
accompanied by swelling and reddish to bluish discoloration because
of ruptured blood vessels in the area.
A strain may be a simple overstretching of a muscle or tendon,
or it can be caused by partial or complete tearing of the tissue away
from the bone.
These soft tissue injuries are diagnosed by a comprehensive
history and physical examination. Usually x-ray films are taken to
rule out fractures. The treatment includes RICE: rest of the injured
joint with no weight bearing to prevent further damage; ice or cold
application for 20 minutes at a time, four to eight times a day, during
the first 24 to 48 hours to reduce pain and swelling; compression with
an elastic wrap or air cast to reduce swelling; and elevation of the
injured part. The provider also may recommend OTC antiinflam-
matory drugs (e.g., naproxen or ibuprofen) to help reduce pain and
inflammation at the site. A severe soft tissue injury may require the
use of crutches to prevent weight bearing, immobilization by casting,
or surgical repair.
Treatment of a sprain or strain may also include rehabilitative
exercises. The provider typically prescribes an exercise program
designed to prevent stiffness, improve the joint's ROM, and restore
normal flexibility and strength. Some patients may also be referred
to physical therapy for complete return of function after the initial
pain and swelling have subsided.
Telephone Screening of Joint Injuries
The following factors can help the medical assistant determine the need
for an appointment when a patient calls to report a joint injury:
• Presence of severe pain and inability ta put any weight on the
injured joint
• Crooked appearance of injured area or unusual lumps and bumps
• Inability to move the injured joint
• Inability to walk more than four steps without significant pain
• Limb buckles or gives way if attempts are made to use the joint
• Numbness in any part of the injured area
• Inflammation that spreads out from the injured area
• History of injury to this particular joint
• Pain, swelling, or inflammation over a bony prominence
CRITICAL THINKING APPLICATION 19-3
Apatient comes into the clinic hopping on one foot and holding the other
in the air. She says she thinks she broke her ankle when she stepped off
the curb wrong and fell. What is the first thing Kaiwan should do for this
patient? What tests will Dr. Alexander most likely order? Why?
Muscle spasms occur spontaneously and may persist for hours.
They typically are caused by heavy exercise and muscle fatigue, but
they also can be caused by dehydration, hypothyroidism, lack of
calcium or magnesium, kidney failure, and alcoholism. Muscle
spasms can be quite painful. Treatment includes massage, direct
pressure, ultrasound therapy, stress reduction, stretching exercises,
and muscle relaxants in some cases.
Restless Legs Syndrome
Apatient with restless legs syndrome (RLS) reports unpleasant sensations,
such as tingling, aching, and twitching of the legs, during periods of inactiv-
ity, especially at night. The individual feels an overwhelming urge to move
the affected leg (or legs) to relieve these abnormal feelings. Patients with
nighttime leg twitching are diagnosed with periodic limb movements of
sleep (PLMS), which causes involuntary flexion and extension of the legs
during sleep. Most people with this disorder have difficulty getting to sleep
or staying asleep.
Initial treatment plans include lifestyle changes, such as relaxation
exercises, soaking in a warm bath, cutting back on caffeine, and moderate
exercise. If these methods do not relieve the symptoms, patients may be
prescribed medications, including ropinirole (Requip), rotigotine (Neupro),
or pramipexole (Mirapex) to increase the amount of the neurotransmitter
dopamine in the brain; anticonvulsants, such as gabapentin (Neurontin)
and pregabalin (Lyrica); or sleep agents, such as zolpidem (Ambien) or
eszopiclone (Lunesta).
Skeletal Disorders
Fractures
A fracture is a break or crack in a bone, generally as the result of
trauma or disease. Many different types of fractures occur, and each
produces its own set of problems (Table 19-3). The common
symptom of all fractures is pain. Other symptoms may include swell-
ing, bleeding, inability to move, misalignment of the bone, and
discoloration of the immediate area.
When a patient with a suspected fracture comes into the office,
you should make the person as comfortable as possible. First aid
includes positioning the patient to prevent stress on the injured area;
elevating the injured extremity if possible; and controlling any bleed-
ing but never applying pressure over a suspected fracture. Do not
attempt to straighten the fracture or move it in any way. If the patient
must be moved, either apply a splint or support the joints above and
below the suspected fracture before and while moving the patient.
The fracture must be confirmed by x-ray examination as soon as
possible.
Treatment includes reduction, if necessary, and immobilization.
Reduction places the fractured bone back into its correct anatomic
alignment. Reduction may be closed or open. In a closed reduction,
the provider manipulates the bone into its correct position. If this is
not possible or if the fractured bones have pierced the skin, an open
reduction is required, which is surgical realignment of the bone.
During an open reduction, the orthopedic surgeon may have to
install metal pins, plates, or screws to facilitate and maintain correct
bone alignment. These metal implants may be temporary or perma-
nent, depending on the extent of injury (Figure 19-7). After the
fracture has been reduced, it must be immobilized with a brace,
splint, or cast to prevent movement of the fracture site and thereby
facilitate healing. The duration of immobilization depends on the
severity of the fracture.
Osteomalacia
The term osteomalacia literally means "softening of the bones."
Osteomalacia is a metabolic disease in which inadequate calcium or
 CHAPTER 19 Assisting in Orthopedic Medicine 495

TABLE 19-3 Types of Fractures

FRACTURE DEFINITION FRACTURE DEFINITION
Closed, or simple Broken bone is contained within intact skin. Comminuted Break is caused by severe, direct force, which creates a
fracture with multiple fragments.

Open, or compound Skin is broken above the fracture; open to the external Impacted Break is caused by strong forces that drive bone
environment creating the potential for infection. fragments firmly together.

Longitudinal Fracture extends along the length of the bone.

Pathologic Break results from weakening of the bones by disease,
as in osteoporosis or sarcoma.

Transverse Break is caused by direct force applied perpendicular to 1--- - - - - - - - - - - - - - - - - -

a bone; fracture runs across the bone. Nondisplaced Bone ends remain in alignment.

Oblique Break is caused by a twisting force with an upward

thrust; fracture ends are short and run at an oblique Displaced Bone ends are moved out of alignment.
angle across the bone.

Greenstick Break is caused by compression or angulation forces in 1--- - - - - - - - - - - - - - - - - -

the long bones of children under age l O; because of Spiral Break is caused by a twisting or rotary force, which
its softness, the bone is cracked on one side and intact results in long, sharp, pointed bone ends; suspicious as
on the other side. a child abuse injury.

Continued
496 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES
TABLE 19-3 Types of Fractures-continued
FRACTURE DEFINITION
Compression Break is caused by forces that drive bones together;
typically seen in the vertebrae.
Avulsion Break is caused by forceful contraction of a muscle
against resistance, and a bone fragment tears at the
site of muscle insertion.
From Chester GA: Modern medical assisting, Philadelphia, 1999, Saunders.
FIGURE 19-7 Orthopedic hardware from open reduction of fractures of the radius and ulna. (From
Mettler MA: Essentials of radiology, ed 3, Philadelphia, 2004, Sounders.)
phosphorus (or both) is available for building new bone during
growth or remodeling. It is caused by either a lack of vitamin D or
problems with its metabolism. The skeleton gradually loses calcium,
and the bones soften and become more flexible. Weight bearing
gradually changes the shape of the softened bones. Symptoms can
include reduced endurance, easy fatigability, malaise, and general-
ized bone tenderness and pain. Osteomalacia in children is called
rickets.
Osteomalacia may be caused by a fat absorption problem in the
gastrointestinal tract that prevents adequate absorption of dietary
fats, resulting in steatorrhea and vitamin D deficiency. Vitamin D
promotes the body's absorption of calcium, which is essential for
normal development and maintenance of healthy teeth and bones.
Vitamin D can be produced by the body with adequate sun expo-
sure, and nearly all milk sold in the United States is fortified with
FRACTURE DEFINITION
Depression Bone fragments of the skull are driven inward.
vitamin D. Osteomalacia can occur in individuals who use very
strong sunscreen, have limited exposure to sunlight, experience short
days of sunlight, live in a smoggy environment, or do not drink milk
because of lactose intolerance. The condition is treated with vitamin
D, calcium, and phosphorus supplements.
Osteoporosis
Osteoporosis is a disease in which calcium deposits in the bone
gradually decline, and bones become increasingly weak and brittle
so that even small stressors, such as bending over or coughing, can
cause fractures. Bone strength depends on the size and density of the
bone structure and the amount of calcium, phosphorus, and other
materials deposited and maintained in the bone. Bones are con-
stantly changing through a process called remodeling, or bone turn-
over. This process allows bones to grow and heal. As we age,
remodeling breaks down bone more quickly than it forms new bone.
Peak bone mass is reached by the middle 30s, so a person's risk of
developing osteoporosis depends on the bone mass collected by age
25 to 35 and how rapidly bone tissue is lost after that. Lack of
vitamin D and calcium in the diet results in a lower peak bone mass
and a more rapid onset of bone loss later in life. People over age 50
are particularly at risk, and women are four times more likely to
develop osteoporosis than men. Osteoporosis is a major public
health threat in the United States; more than 40 million people
either already have osteoporosis or are at high risk of developing it
because of low bone mass.
Osteoporosis often is called a "silent" disease because the progres-
sive loss of bone density occurs without any symptoms. Osteopenia
is mild bone loss that is not severe enough to be called osteoporosis
but that increases the risk of osteoporosis. By the time fractures
occur, the disease is quite advanced. Patients with osteoporosis com-
plain of back pain because of a fractured or collapsed vertebra; loss
of height over time, with stooped posture (kyphosis, or "dowager's
hump"); and fractures, typically of the vertebrae, wrists, and hips.
Risk factors include being a postmenopausal woman over age 50; a
slight build with a family history of osteoporosis; a history of amen-
orrhea; anorexia nervosa; a low dietary calcium intake; an excessive
 CHAPTER 19 Assisting in Orthopedic Medicine 497

intake of caffeinated soda; an inactive lifestyle; smoking; alcohol Cervical vertebrae

abuse; hyperthyroidism; a reduced lifetime exposure to estrogen; and
long-term treatment with certain medications, including antiseizure
drugs, corticosteroids, and heparin. Men over age 50 with low tes-
tosterone levels also are at risk. Osteoporosis occurs in all races but
is slightly more common in Caucasian and Asian individuals. Thoracic vertebrae
The diagnosis is made by a specialized form of x-ray evaluation
that specifically measures bone density. This study allows the diag-
nosis of osteoporosis before a fracture occurs and thus intervention
to prevent fractures. Readings are repeated annually to determine
the rate of bone loss and to monitor the effectiveness of treatment.
Thoracic curve
Intervention and treatment include increasing dietary intake of
calcium and vitamin D; increasing weight-bearing exercise; and
pharmaceutical treatment with bisphosphonates (alendronate
[Fosamax], risedronate [Actonel], zoledronic acid [Reclastl, and
ibandronate sodium [Boniva]); in addition, hormone therapy, such
as estrogen and some hormone-like medications (e.g., raloxifene
[£vista]) may be prescribed to slow bone breakdown. The best L1 Lumbar vertebrae

screening test is a dual energy x-ray absorptiometry (DXA) scan, 2

which measures the bone density of the spine and hip. Ultrasound of
3
the heel can also be used to diagnose osteoporosis.
The National Osteoporosis Foundation recommends that all 4
women have a bone density test if they are not receiving estrogen
replacement therapy and are in any of the following categories:
• Undergoing long-term treatment with medications that can Sacrum
cause osteoporosis, such as prednisone Sacral curve
• Have diabetes type 1, liver disease, kidney disease, or a family
history of osteoporosis Coccygeal vertebrae

• Experienced early menopause (in the early 40s)

• Are postmenopausal, over age 50, and have at least one risk
FIGURE 19-8 Normal curves of the spine. (From Applegate E: The anatomy and physiology
learning system, ed 4, St Louis, 201 l, Sounders.)
factor for osteoporosis
• Are postmenopausal, over age 65, and have never had a bone
density test

CRITICAL THINKING APPLICATION 19-4

Mrs. Viola Carson, a 78-year-old patient, is being seen in the office today
for follow-up after hip replacement surgery. Mrs. Carson fractured her hip
from a simple fall at the grocery store. Why would the physician suspect
she has osteoporosis? What treatment might be recommended to prevent
further fractures in this patient?

Spinal Column Disorders

Abnormal Spinal Curvatures
When the medical assistant looks at a patient's back, the spine should
be vertically straight. Any abnormal deviation or curvature to the
right or left is called scoliosis. Mild scoliosis generally causes no
problems and usually is not even noticeable. When scoliosis is severe,
it can cause significant back pain and possibly heart or lung problems
because of the diminished space in the thoracic cavity on one side.
When the spine is viewed from a lateral position, four normal
curves are seen (Figure 19-8). The cervical and lumbar regions
should have curves toward the front of the body; these are called
lordotic curves. The normal curves in the thoracic region of the
spine and the sacrum are toward the back and are called kyphotic
Hunchback Swayback Scoliosis
FIGURE 19-9 Spinal curve abnormalities.
curves. Loss of cervical lordosis is called military neck. Excessive
lumbar lordosis is called swayback. Excessive upper thoracic kyphosis
is called hunchback (Figure 19-9).
These conditions are diagnosed by inspection and palpation and
may be confirmed with x-ray studies. Treatment may include chiro-
practic care, orthopedic devices (e.g., braces), shoe lifts, exercises,
498 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES
and electrical muscle stimulation. In severe cases, rigid casting with
or without surgery may be necessary.
Herniated Disk
A herniated disk occurs when the soft nucleus of an intervertebral
disk protrudes through a tear or weakened area in its tough outer
cartilaginous covering (Figure 19-10). This condition occurs most
often in the lumbar region of the spine, frequently in the cervical
region, and rarely in the thoracic region. In children and young
adults, disks have a high water content. As people age, this water
content declines, and the structures begin to shrink and become less
flexible. This causes the spaces between the vertebrae to narrow.
Factors that can weaken intervertebral disks include improper lifting;
smoking; excessive body weight that places added stress on the disks
of the lower back; sudden, possibly slight pressure; and repetitive
strenuous activities. Herniation may also occur gradually over time
as a result of a progressive deterioration of the disks.
Symptoms depend on the location and extent of the protrusion
of the nucleus beyond its normal location. If the herniation occurs
in the lumbar region, it usually causes severe low back pain that can
radiate down the leg and cause difficulty walking. If the herniated
disk is in the cervical region, the person usually has a burning pain
in the neck that can radiate down the arms to the fingers.
The diagnosis is made from a careful history; physical examina-
tion; either magnetic resonance imaging (MRI) or computed to-
mography (CT) scans to confirm which disk is injured; and
electromyography (EMG) or nerve conduction studies (NCS),
which measure nervous stimulation of affected muscles. Treatment
depends on the severity of the herniation and the symptoms. Con-
servative treatments include rest and nonsteroidal antiinflammatory
drugs (NSAIDs); analgesics for the pain; physical therapy; chiro-
practic adjustments; and epidural steroid injections into the exact
level of the disk herniation to reduce swelling around the disk and
relieve symptoms. Spinal injections are usually done in the provider's
office under x-ray guidance to the injection site. If these measures
FIGURE 19-10 Herniation of a vertebral disk.
are ineffective and the patient has recurring pain, numbness, and
progressive weakness, surgery may be necessary.
Joint Disorders
Dislocation
Dislocation of a joint is also called a luxation, a condition in which
two bones of a joint are no longer in approximation (Figure 19-11).
A subluxation is an incomplete dislocation of a joint, meaning that
the bones are only slightly out of proper alignment and location. It
is possible to have a congenital dislocation, especially of the hip.
Common dislocations occur in the finger, thumb, and shoulder and
usually are caused by trauma, frequently while a person is playing
sports. Symptoms include pain, swelling, loss of motion, and some-
times temporary paralysis of the affected part. A dislocation requires
immediate reduction and immobilization to prevent permanent
injury to nerves and major blood vessels near the joint. Occasionally,
surgical reduction and repair may be necessary to stabilize the joint.
Chiropractic treatments relieve subluxations.
CRITICAL THINKING APPLICATION 19-5
Apatient comes into the office from her weekly softball game. After sliding
into home plate, she immediately was unable to move her right arm, and
she says that she has a lot of pain in her right shoulder. What steps should
Kaiwan take to help this patient?
Gout
Gout, which may also be called gouty arthritis, is a metabolic disease
involving overproduction or improper elimination of uric acid. Uric
acid is a waste product formed from the breakdown of purines,
which are found naturally in the body and in certain foods, including
organ meats (liver, brains, and kidney), anchovies, herring, aspara-
gus, mushrooms, and dried beans. Drinking too much alcohol is a
risk factor because alcohol interferes with the removal of uric acid
Normal position of humerus Clavicle
Humerus Scapula
FIGURE 19-11 Luxation (dislocation) of the shoulder. (From Frazier MS, Drzyrnkowski JW:
Essentials of human diseases and conditions, ed 3, Philadelphia, 2004, Saunders.)

from the body. Uric acid should dissolve in the blood so that it can
be excreted as it passes through the kidneys. However, with gout,
uric acid is not effectively excreted, and needle-like crystals of uric
acid collect in the synovial fluid of the affected joint, causing extreme
sensitivity to touch, pronounced inflammation, and severe pain. The
most frequently affected area is the great toe (Figure 19-12). Risk
factors include kidney disease, consumption of alcohol, obesity,
untreated hypertension, and a family history of the disease. Men are
more likely to experience gout than women, but women become
increasingly susceptible to gout after menopause.
In general, keeping uric acid levels within a normal range is the
key to preventing future episodes of gout. Therefore, long-range
treatment includes dietary modifications to eliminate foods contain-
ing purine. To treat an acute onset, the patient may take NSAIDs
(e.g., ibuprofen and naproxen [Aleve]) for pain and joint inflamma-
tion. In severe cases the provider may prescribe prednisone. Pharma-
ceutical treatment may begin with colchicine (Colcrys), an
antiinflammatory medication that is most effective if taken within
12 hours of an attack, to help prevent the buildup of uric acid crys-
tals in the joints. To reduce the risk or lessen the severity of episodes,
treatment includes allopurinol (Lopurin, Zyloprim), which slows
uric acid production and helps dissolve crystals, and probenecid
(Probalan), to increase uric acid excretion through the kidneys.
Lupus
The three main types of lupus are systemic lupus erythematosus
(SLE), discoid lupus erythematosus, and drug-induced lupus. Of
these, SLE is the most common and serious form of the disease. SLE
attracts
leukocytes
Phagocytosis
of crystals
-:;,.
Rupture of
leukocytes
Release of:
• Cytokines
• Enzymes
Deposits
of urate -+--+-+
Joint space - + - - + - 1 -
Uric acid crystals
FIGURE 19-12 Gout is characterized by deposits of uric acid crystals in the connective tissue.
The inflammation most often affects the joint of the big toe. (From Damjanov I: Pathology for the
health-related professions, ed 4, St Louis, 2012, Saunders.)
CHAPTER 19 Assisting in Orthopedic Medicine 499
is an autoimmune disease of unknown cause. It occurs primarily in
women 20 to 50 years of age, although it can occur in both younger
and older individuals. Other risk factors include recurrent infections
caused by the Epstein-Barr virus, a family history of the disease, and
African-American race.
SLE is difficult to diagnose and entirely unpredictable. The
patient develops autoantibodies (antibodies to self) that can attack
any tissue or organ in the body; this may result in severe inflamma-
tion with tissue changes and destruction. According to the National
Institutes of Health (NIH), the common symptoms oflupus include:
• Painful or swollen joints and muscle pain
• Unexplained fever
• Red rashes, most commonly on the face
• Chest pain upon deep breathing
• Unusual loss of hair
• Pale or purple fingers or toes from cold or stress (Raynaud's
phenomenon)
• Sensitivity to the sun
• Edema in the legs or around the eyes
• Mouth ulcers
• Swollen glands
• Extreme fatigue
The progression and severity of the disease vary widely among
patients. Furthermore, problems associated with SLE change over
time and overlap with those of many other disorders. For these
reasons, providers may not initially consider lupus until the signs
and symptoms become more obvious. At times the disease may
become severe, and at other times it may subside completely.
There is no known cure for lupus; the therapeutic goal is to
maintain patient function as much as possible. The type of pharma-
ceutical treatment prescribed depends on which parts of the body
are affected by the disease and the severity of the symptoms. Some
medications used to treat SLE include NSAIDs (e.g., naproxen and
ibuprofen) to reduce joint pain and inflammation; antimalarials
(e.g., hydroxychloroquine [Plaquenil]) to treat skin and joint prob-
lems and the ulcers that some people develop in the mouth or nose;
corticosteroids (prednisone) during acute inflammatory processes;
and immunosuppressive medications (e.g., azathioprine [Imuran]
and cyclophosphamide [Cytoxan]) to suppress the immune system.
Belimumab (Benlysta), which is administered intravenously (IV),
may be prescribed for patients receiving other standard lupus medi-
cations. The kidneys may fail even with treatment, which may neces-
sitate either kidney dialysis or a kidney transplant.
Criteria for Diagnosing Systemic Lupus
Erythematosus
Providers use the American College of Rheumatology's 11 criteria of lupus
to help diagnose systemic lupus erythematosus (SLE). Four or more of the
following criteria must be present to make the diagnosis.
l . Malar rash: Butterfly-shaped rash across cheeks and nose
2. Discoid (skin) rash: Raised, red patches
3. Skin rash as the result of an unusual reaction to sunlight
4. Mouth or nose ulcers: Usually painless
500 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES
5. Arthritis of two or more joints without bone destruction
6. Inflammation of the lining around the heart (pericarditis) and/or
lungs (pleuritis)
7. Neurologic disorder: Seizures and/or psychosis
8. Renal (kidney) disorder: Excessive protein in the urine
9. Hematologic (blood) disorder: Hemolytic anemia or low platelet
and white blood cell (WBO counts
l 0. Immunologic disorder: Presence of unusual antibodies
11. Elevated antinuclear antibodies: Indicates an autoimmune disease
Lupus Research Institute. http://lupusresearchinstitute.org/lupus-facts/lupus-diagnosis.
Accessed January 15, 2015.
Infectious Arthritis
Infectious arthritis usually occurs after some type of systemic or local
infection in some other part of the body or after a joint has been
exposed to a pathogen by trauma or surgery. The infection can be
caused by bacteria, fungi, or viruses. The joint usually shows signs
of severe inflammation and significantly reduced ROM. To deter-
mine the diagnosis, the provider may order an x-ray evaluation and
bone scan and may withdraw synovial fluid for microscopic exami-
nation and culture. The goals of treatment are to reduce inflamma-
tion, increase ROM, and treat the causative organism with the
appropriate medication.
Lyme Disease
Lyme disease is an infection caused by the Borrelia burgdorferi
and the Borrelia mayonii bacteria. It is transmitted to humans by
a bite from ticks of the Ixodes family. The disease is named after
Lyme, Connecticut, where it was first identified in 1975 in a
cluster of children who showed signs of what was thought to be
rheumatoid arthritis. Eventually epidemiologists traced the cause
of the problem to a bacterial infection. Signs and symptoms may
include a "bull's-eye" lesion, called erythema migrans, surrounding
the area of the tick bite; this lesion can appear within a few days
or up to a month after exposure. The rash can last several days
to several weeks and occurs in as many as 80% of people infected
with Lyme disease. Additional indicators of the disease include
flulike symptoms, such as fever, chills, fatigue, body aches, and
headache. If the infection remains untreated, the patient can
develop arthritic pain in the large joints (e.g., the knees); men-
ingitis; Bell's palsy; numbness or weakness of the limbs; memory
loss and difficulty concentrating; and changes in mood or sleep
habits.
The diagnosis is made by taking a careful history, including the
patient's level of outdoor exposure, locating the tick bite, and
ruling out other causes for presenting symptoms. Laboratory
blood tests to identify antibodies to the bacterium are used to help
confirm the diagnosis. These tests are most reliable a few weeks
after an infection because it takes some time for antibodies to
develop. The Centers for Disease Control and Prevention (CDC)
currently recommends a two-step process using the same blood
sample. An enzyme immunoassay (EIA) is done. If the result is
negative, Lyme disease is ruled out. If the result is positive, an
immunoblot test (e.g., the Western blot test) is done next to
confirm the diagnosis. Antibiotics, such as doxycycline (Doryx,
Monodox) and amoxicillin (Amoxil), are the standard treatment
for Lyme disease in its early stages. If the disease has progressed to
a later stage, the patient may be hospitalized for treatment with IV
ceftriaxone (Rocephin).
Patient Education for Preventing Lyme Disease
• Wear pants tucked inta sacks and long-sleeved shirts when walking in
wooded or grassy areas.
• Use insect repellents that contain 20% to 30% diethyltoluamide
(DEET).
• Tick-proof your yard by clearing brush and leaves, where ticks live.
• Check yourself, your children, and your pets for ticks; deer ticks are no
bigger than the head of a pin or a grain of pepper; shower immediately
after returning from wooded areas because ticks can remain on the
skin for hours before attaching themselves.
• Da not assume you are immune; Lyme disease can accur in the same
persan more than ance.
• Use fine-tipped tweezers to remove a tick. Grasp the tick as close to
the skin's surface as possible; pull upward with steady, even pressure;
thoroughly clean the bite area and your hands with rubbing alcohol, an
iodine scrub, or soap and water; dispose of a live tick by submerging
it in alcohol, placing it in a sealed bag/container, wrapping it tightly
in tape, or flushing it dawn the tailet. Never crush a tick with your
fingers.
• If you develop a rash or fever within several weeks of removing a tick,
see your healthcare provider. Be sure ta tell him ar her about your
recent tick bite and when the bite occurred.
Centers for Disease Control and Prevention (CD(). www.cdc.gov/lyme/. Accessed January 15,
2015.
Osteoarthritis
OA, also called degenerative joint disease (DJD), is marked by signifi-
cant thinning and degeneration of the articular cartilage of synovial
joints. The symptoms range from mild to severe, depending on the
amount of degeneration. As the articular cartilage disintegrates and
wears away, the roughened surface of the bone is exposed, leaving
bone rubbing against bone, with resultant pain and stiffness of the
involved joint. Commonly involved joints include the fingers, the
spine, and the weight-bearing joints of the hips, knees, and feet.
Diagnosis frequently includes x-ray films and an MRI, which show
degenerative changes in the joint surfaces and uneven joint space
narrowing.
Treatment goals include relieving pain, maintaining normal
motion in the joint, and attempting to prevent crippling deformi-
ties. Exercise and weight control are important components of
treatment to keep the joints mobile and prevent additional wear
and tear on joint tissues. Medications may include analgesics,
NSAIDs, and intra-articular steroid injections. Using a walker or
cane may be helpful for maintaining mobility. Severe cases require
surgery to remove the affected joint and replace it with a joint
prosthesis.
 CHAPTER 19 Assisting in Orthopedic Medicine 501

Rheumatoid Arthritis
RA is an autoimmune inflammatory condition that involves an Nonspecific
systemic
immune system response to the synovial membranes, causing syno- symptoms:
vitis. Proteins are released at the site of the joint inflammation, • Low-grade fever
• Fatigue
eventually resulting in thickening of the synovium and damage to • Loss of appetite
the cartilage, bone, tendons, and ligaments of the affected joint. • Anemia

Gradually the joint loses its shape and alignment, causing deformity
and pain. Scientists still do not know exactly what causes the immune
Symmetric
system to turn against the body's own tissues in RA, but research polyarthritis Lymphadenopathy
indicates it is a combination of factors, including genetic predisposi-
tion, environmental factors, and hormone interactions, because most
individuals with RA are female.
Rheumatoid
Early symptoms include malaise, fever, weight loss, and morning subcutaneous
stiffness of the affected joints. RA typically occurs in a symmetric nodules

pattern, meaning that if one knee or hand is involved, the other one
also is. The disease often affects the wrist and finger joints. Usually,
bouts of arthritis increase in frequency and severity over time. As
this occurs, the joints become damaged, and joint swelling and
deformity occur. The patient ultimately loses the ability to move the
affected joints, and a pronounced loss of strength occurs in the
muscles attached to the inflamed joints. Small lumps, called rheu-
matoid nodules, may form at pressure points in the elbows, hands,
feet, Achilles tendons, knees, and posterior scalp, and even in the
lungs. Patients with RA may appear undernourished and chroni-
cally ill because of the formation of degenerative lesions in the col-
lagen (connective tissues) in the lungs, heart, blood vessels, and
pleura (Figure 19-13). Periods of increased disease activity, called
flare-ups, alternate with periods of relative remission, during which
the swelling, pain, difficulty sleeping, and weakness fade or disap-
pear. X-ray findings show uniform joint space narrowing, which is
different from the degenerative changes seen in OA.
Rest and exercise seem to be the key elements in treating RA.
Therapeutic exercises are designed to prevent and correct deformi-
ties, control pain, strengthen weakened muscles, and improve joint
function. The most frequently prescribed medications are NSAIDs,
including aspirin (acetylsalicylic acid), indomethacin (Indocin),
diclofenac (Voltaren), naproxen (Naprosyn), and ibuprofen (Motrin).
Corticosteroids (prednisone and Medrol) may be prescribed for
severe flare-ups. To limit the extent of joint damage early in the
disease, the provider prescribes disease-modifying antirheumatic
drugs (DMARDs), including methotrexate (Rheumatrex), lefluno-
mide (Arava), hydroxychloroquine (Plaquenil), and sulfasalazine
(Azulfidine). Biologics used include etanercept (Enbrel), infliximab
(Remicade), and adalimumab (Humira). In severe cases, surgical
joint replacement may be necessary.
CRITICAL THINKING APPLICATION 19-6
An 80-year-old male patient with arthritis comes into the office complaining
of severe pain in his knees, hips, and lower back. The pain makes it impos-
sible for him to get up onto the examination table. What should Kaiwan
do? Is this patient required to get onto the examination table? Why ar why
not?
Raynaud's
phenomenon:
• Numbness
• Pallor
Serology:
• Rheumatoid factor
-1(
lgG)()(j
~ lgMC
n
FIGURE 19-13 Signs and symptoms of rheumatoid arthritis. (From Damjanov I: Pathology for
the health-related professions, ed 4, St Louis, 2012, Saunders.)
Tendonitis and Bursitis
Tendonitis is one of the most common causes of pain in the shoulder
and elbow. Inflammation of tendons may be associated with calcium
deposits in the bursae around the joint, causing concurrent bursitis.
The diagnosis is made if the patient has increased severity of pain
when abducting the arm beyond 50 degrees. Treatment includes pain
relief and reducing the localized inflammation to make exercise pos-
sible and to prevent shoulder immobility, called frozen shoulder.
Medications might include analgesics, NSAIDs, and injections of
long-acting corticosteroids. Cold applications are helpful in relieving
pain; heat applications are contraindicated because they tend to
aggravate calcium tendonitis.
Bursitis is a painful inflammation of a joint bursa that most com-
monly follows repetitive movement or prolonged pressure on a joint.
The pain is increased with movement of the affected joint. It also
can occur from staphylococcal or tubercular infections and with
some joint diseases, such as gout and arthritis. Treatment includes
preventing the activity that caused the bursitis and protecting the
affected site from excessive pressure and movement. NSAIDs may
provide pain relief, but corticosteroid antiinflammatories may be
needed in severe cases.
502 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES
Carpal Tunnel Syndrome
As mentioned, the carpal tunnel is a narrow opening in the bones
at the base of the hand; this is where the median nerve passes to send
nervous stimuli to the hand. Sometimes the passageway becomes
narrowed because of inflammation and swelling of the tendons in
the area; the result is compression of the nerve, which in turn pro-
duces pain, weakness, or numbness in the hand and wrist, radiating
up the arm. Symptoms usually start gradually, with frequent burning,
tingling, or itching numbness in the palm of the hand and the
fingers, especially the thumb and the index and middle fingers.
Symptoms are worse in the morning because many people sleep with
flexed wrists. As symptoms progress, the individual experiences
decreased grip strength, difficulty making a fist and grasping small
objects, and problems with fine motor movements.
Carpal tunnel syndrome results from a combination of factors
that increase pressure on the median nerve and tendons in the carpal
tunnel. Research indicates it may be due to a congenital narrowing
of the carpal tunnel area. Contributing factors include trauma or
injury to the wrist that cause swelling; hypothyroidism; rheumatoid
arthritis; work stress; repeated use of vibrating hand tools; fluid
retention during pregnancy or menopause; or the development of a
cyst or tumor in the canal. Although carpal tunnel syndrome has
long been blamed on repetitive movements of the hand and wrist,
there are very limited data to support this belie£
A complete physical examination and routine lab tests to rule out
diabetes, arthritis, and fractures are done initially to determine the
cause of the discomfort. Diagnostic examinations include the Tine!
test, in which pressure on the median nerve in the wrist causes
tingling in the fingers or a shocklike sensation in the hand. Another
test done during the physical examination is the Phalen, or wrist-
flexion, test, in which the patient holds the forearms upright while
pointing the fingers down and pressing the backs of the hands
together; a positive result is when tingling or increased numbness is
felt in the fingers within 1 minute. To confirm the diagnosis the
provider typically orders an electrodiagnostic test. In a nerve conduc-
tion study, electrodes are placed on the hand and wrist and small
electric shocks are applied while a technician measures the speed of
the nervous impulses to the area. For electromyography, a fine needle
is inserted into a muscle and the patient is asked to contract his or
her muscles by moving a small amount. The electrical activity of the
muscle is viewed on a screen and can determine the severity of
damage to the median nerve. Ultrasounds can also show an impaired
median nerve.
Initial treatment recommendations are to rest the hand and
wrist for at least 2 weeks, avoiding activities that may worsen symp-
toms, and immobilize the wrist in a splint to avoid further damage.
Patients are told to wear the splint to bed each night to prevent
pressure on the median nerve while sleeping. Cool packs to the
wrist can help reduce inflammation and swelling in the carpal
tunnel area. Treatment includes over-the-counter NSAIDs; diuretics
to reduce swelling and fluid accumulation at the site; or corticoste-
roid injections directly into the wrist or taken orally to provide
immediate, temporary relief of symptoms. Once symptoms have
been relieved, physical therapy to promote stretching and strength-
ening can be helpful. Surgery is recommended if symptoms last
for 6 months. This is a simple endoscopic procedure in which
the carpal ligament is cut and the tunnel area is enlarged. The
procedure is generally done with an endoscope, using local anes-
thesia, on an outpatient basis.
THE MEDICAL ASSISTANT'S ROLE IN ASSISTING
WITH ORTHOPEDIC PROCEDURES
The role of the medical assistant begins with accurately recording
the patient's description of the circumstances surrounding the onset
of the problem, what measures were taken to alleviate the problem,
and the patient's current concerns. Record the exact anatomic loca-
tion of the pain and ask the patient to quantify its intensity on a
scale of 1 to 10; also ask about both OTC and prescription medica-
tions taken, including the names of drugs, the dosage and frequency,
the date and time of the last dose, and whether the drug has been
helpful in relieving symptoms.
Offer assistance when escorting the patient to the examination
room. Use a wheelchair, if necessary. Assist the patient into a com-
fortable position in the examination room by offering a pillow or
folded blanket to support the painful or injured body part. The
patient may have limited mobility because of pain, so you may need
to provide assistance with disrobing and getting into an examination
gown. Make sure the patient is warm enough by offering an addi-
tional sheet or blanket. Explain clearly what is happening and what
the patient can expect. Notify the provider as soon as the patient is
ready for the examination.
Assisting With the Examination
The provider may use inspection, palpation, ROM testing, and
muscle testing to examine the major skeletal muscles and joints.
Much of the examination involves comparing muscles and joints on
the affected side with those on the contralateral side for size, posi-
tion, and strength. When the patient needs to assume a certain
position, demonstrating the position or movement desired may be
helpful. Watch the patient during the manipulative and palpatory
portion of the examination for a facial grimace or physical jerk or
jump, which may indicate pain.
As a general rule, the unaffected side is examined first, then the
affected side, and the two are compared. You may be responsible for
taking notes during the examination. Keep the patient properly
draped and assist the provider by handing equipment as needed.
Most examinations require the use of a measuring tape, goniometer,
blood pressure cuff, and stethoscope. Be alert and ready to prevent
the patient from falling during the examination because some of the
requested movements and positions may place the injured patient
off balance.
The provider performs a gait analysis by watching the patient
walk in a straight line, with or without the patient knowing he or
she is being observed. In addition to being associated with disorders
of the musculoskeletal system, gait abnormalities may be caused by
an associated neurologic condition.
SPECIALIZED DIAGNOSTIC PROCEDURES
IN ORTHOPEDICS
Range-of-Motion Evaluation
Often orthopedic injuries severely affect the normal ROM of a joint.
Measuring the ROM of specific joints is an objective measure of
 CHAPTER 19 Assisting in Orthopedic Medicine 503

both the seriousness of an injury and the recovery progress. When in each hemisphere of the body, such as using a blood pressure cuff
the ROM of a particular joint is evaluated, usually both active and to compare the grip of the right hand with the grip of the left hand
passive ROM results are measured and recorded. (Figure 19-15).
The joint movement in a single plane is measured with a goni-
ometer. A goniometer has two arms that are fixed together with a
Using a Blood Pressure Cuff to Assess Grip
hinge joint at one end (Figure 19-14). Each of the arms is lined up
with a bone on each side of the joint being tested. The degrees of Strength
motion are indicated on a scale on the hinged center of the instru- 1. Roll up an aneroid blood pressure cuff and have the patient hold it in
ment. To determine the active ROM of a joint, the patient is asked one hand.
to move the joint as far as possible. For evaluation of passive ROM,
2. Inflate the cuff to 20 mm Hg of pressure and lock the valve.
the patient is asked to relax, and the provider moves the joint as far
3. Ask the patient to squeeze the cuff as tightly as possible.
as possible. All ROMs are measured in degrees. During these exami-
nations, you may be asked to record the degrees of motion for active
4. Note the increase in pressure on the dial (a normal grip registers above
and/or passive ROM for specific joints and to note any pain, tender-
150 mm Hg).
ness, or crepitation during the examination. 5. Record the hand tested and the results of the test.
6. Repeat on the other hand.
CRITICAL THINKING APPLICATION 19-7
How can Kaiwan best assist Dr. Alexander in testing upper extremity ROM RADIOLOGY
in a new patient? What equipment should Kaiwan have ready? What Radiology and diagnostic imaging frequently are used to help diag-
patient position would best facilitate this examination? Why? nose orthopedic conditions (Figure 19-16). X-ray evaluation is nec-
essary to diagnose fractures, dislocations, and bone and joint diseases
accurately. X-ray films also can be used to track the healing of a
Muscle Strength Evaluation fracture.
During the ROM evaluation, the provider also assesses each muscle
group for strength. Normal muscle strength allows for complete
voluntary ROM despite resistance. This resistance can be gravity, as
when rising from sitting to a standing position, or physical, as in
pulling, pushing, or lifting an object. Muscle strength is bilaterally
equal in normal conditions. The evaluation compares like muscles

FIGURE 19-15 Assessing grip strength using a blood pressure cuff.

FIGURE 19-14 A, Goniometer. B, Correct position of the goniometer on the orm. FIGURE 19-16 Reading a lumbor radiograph.
504 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES
CRITICAL THINKING APPLICATION 19-8
Apatient who has just undergone x-ray studies stops Kaiwan and wants to
see his x-ray films. How should Kaiwan handle this situation? In another
case, if a patient is in an examination room with her own x-ray film on the
view box and she asks Kaiwan to show her where the break is, how should
he respond to this request?
When a diagnostic test is necessary, you should explain the pro-
cedure to the patient. Your explanation should include what will be
done, how it is done, where it will take place, and approximately
how long it will take. Patients always are concerned about whether
the procedure will hurt. Tell the truth. If the procedure is painful,
let the patient know so that he or she can prepare for it. Discuss the
procedure in a professional yet empathetic manner. If the patient
wants to talk with the provider about the test, make sure this
happens.
Specialized Imaging Techniques Used
in Orthopedics
• Arthrogram -Visualizes the joints with an x-ray after the injection of
a radiopaque dye.
• Bone scan - Evaluates areas of bone growth, bone tumors, and other
bone disease patterns; requires the use of an injected dye or isotope.
• Dual energy x-ray absorptiometry (DEXA or DXA) scan-Specialized
x-ray that assesses bone density; used to diagnose and manage
osteoporosis.
• Computed tomography (CT) scan -Visualizes multiple planes of soft
tissue such as tumors, lesions, or some spinal injuries; usually used with
an injected dye.
TABLE 19-4 Effects of Heat and Cold Application
APPLICATION CAUSES
Heat Vasodilation, muscle relaxation, increased
metabolism, local warmth
Cold Vasoconstriction, numbness of nerve endings,
reduced metabolism, increased blood viscosity
• Electromyography (EMG) and nerve conduction velocity (NCV)
studies- Evaluate muscle and nerve response to stimulus.
• Biopsy of bone and muscle- Tissue is examined by a pathologist ta
identify cancerous tumors, neoplasms, and pathogens.
THERAPEUTIC MODALITIES
Physical treatment methods called modalities often are used in ortho-
pedic, chiropractic, and physical therapy offices to treat orthopedic
conditions. These can include the application of cold, heat, baths,
electric currents, therapeutic ultrasonography, massage, and thera-
peutic exercises. Cold applications are recommended for the first 48
hours after an injury to help control pain and swelling. Heat applica-
tion is used after this to help improve circulation, reduce pain, and
maintain muscle and joint function (Table 19-4). Diathermy is a
technique for creating deep tissue heat through the use of a high-
frequency current, ultrasonic waves, or microwave radiation. Deep
heat is used to reduce pain, relieve muscle spasms, resolve inflam-
mation, and promote healing. Deep heat may be used to treat
chronic arthritis, bursitis, fractures, and other musculoskeletal
problems.
General Principles of Cold Application
Cold applications, such as ice packs and cold compresses, act as
vasoconstrictors and also cause contraction of the involuntary
muscles of the skin ("goose bumps"). These two actions reduce the
blood supply to the area and exert a numbing effect on the sensory
nerve endings. Cold applications can help control bleeding, prevent
further swelling and inflammation, and reduce pain. Disposable,
reusable, or homemade ice packs most commonly are used for cold
application (Procedure 19-1 ).
TISSUE RESPONSE THERAPEUTIC EFFECT
Increased blood flow, more white blood cells to • Increased nutrients to site
area, reduced muscle spasm, decreased pain • Faster removal of wastes
• Phagocytosis
• Faster tissue repair
Reduced blood flow, local anesthesia, reduced • Inhibition of swelling
oxygen need, faster blood clotting • Reduced inflammation
• Reduced pain
 CHAPTER 19 Assisting in Orthopedic Medicine 505

•;;m,inmjjijj• Assist the Provider with Patient Care: Assist with Cold Application

Goal: To apply acold compress to abody area to reduce pain, prevent further swelling, and/or reduce inflammation.

EQUIPMENT and SUPPLIES 6. Dry the outside af the bag and caver it with one or two towel layers.
• Patient's health record 7. Help the patient position the ice bag on the injured area.
• Small ice cubes or ice chips (at home, patient can use frozen bag of peas 8. Advise the patient to leave the ice bag in place for about 20 to 30 minutes
or corn) or until the area feels numb, whichever comes first.
• Ice bag or closeable disposable plastic kitchen food bag PURPOSE: Leaving the ice in place for longer than 20 to 30 minutes may
• 2-3 Towels cause tissue damage.
9. After removing the ice pack, check the skin for color, feeling, and pain.
PROCEDURAL STEPS PURPOSE: If the treated area becomes very painful, remains numb, or is
1. Sanitize your hands. pale or cyanotic, the ice bag should be removed and the provider
2. Greet the patient, introduce yourself and verify the patient's identity by notified.
name and date of birth, and explain the procedure. Answer any 10. Dispose of ice pack and towels; if supplies are not disposable follow
questions. manufacturer recommendations on sanitizing the bag and place towels in
3. Check the ice bag for leaks. facility laundry. Sanitize your hands.
4. Fill the bag with small cubes or chips of ice until it is about two thirds 11. Record the procedure in the patient's health record.
full. PURPOSE: Aprocedure is not considered done until it is recorded.
PURPOSE: Small chips conform more easily to the shape of the body.
S. Push down on the top of the bag to expel excess air and put on the cap 8/27/20-1 :45 PM: Ice pack applied to® knee far 20 min. No c/o discom-
or seal the plastic bag. fort. Pt instructed to continue ice application at home for 20-30 min q 3 hr
PURPOSE: Ta remove as much air as possible from the bag because air is while awake for 24 hr as ordered by Dr. Alexander. Call provider if edema
a poor conductor of cold. persists or pain increases. K. Tillman, (MA (AAMA)

Heat Modalities Body parts may safely be heated to ll0°F (44°C) without any
Heat produces local vasodilation, which increases circulation. This tissue damage. Redness appears, because the skin capillaries become
accelerates the inflammatory process, promotes local drainage, congested at the skin's surface. Heat modalities may be either wet or
reduces swelling, relaxes muscles, and repairs tissues and cells. The dry and can have either superficial or deep effects. Dry heat therapies
effects of external heat application depend on the type of heat used, include heating pads, infrared radiation lamps, ultraviolet radiation,
the length of time it is applied, the frequency with which it is applied, and hot-water bottles. More penetrating methods of dry heat appli-
the patient's general condition, and the size of the area treated. Heat cation include diathermy and ultrasound. Moist heat modalities
application is an excellent therapeutic modality, but it must be used (Procedure 19-2) include soaks, whirlpool treatments, hot moist
with caution to prevent overheating and burning of surface tissues. compresses (Figure 19-17), and paraffin baths.
Special care must be taken in patients who have reduced sensation
because they may not sense a burn occurring. Therefore, heat applica-
tion is contraindicated in the following circumstances:
• With acute inflammatory conditions, particularly during the
first 48 hours; heat will increase swelling if applied immedi-
ately afrer the injury
• In individuals with severe circulatory problems of any kind
• In those with diminished or abnormal sensation
• Over areas with encapsulated pus
• On blisters from previous burns
• Over scar tissue, which does not have a normal blood supply
and easily overheats
• Over the abdomen in a pregnant woman
• Over inflamed skin because the initial erythema caused by a
burn cannot be detected
• Over any metal jewelry or any area with metal implants FIGURE 19-17 Commercial hot packs made of canvas containing a silicone gel.
506 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES

•;;m,inmjjijfj Assist the Provider with Patient Care: Assist with Moist Heat Application

Goal: To apply moist heat to abody area to increase circulation, increase metabolism, and relax muscles.

EQUIPMENT and SUPPLIES

• Patient's health record
• Commercial hot moist heat packs
• 2-3 Towels
PROCEDURAL STEPS
1. Sanitize your hands.
2. Greet the patient, introduce yourself and verify the patient's identity by
name and date of birth, and explain the procedure. Answer any
questions.
3. Ask the patient to remove all jewelry from the area to be treated.
PURPOSE: To prevent trauma to the area and the collection of heat at the
jewelry site. 8. Record the procedure in the patient's health record.
4. Place one or two towel layers over the area ta be treated. PURPOSE: Aprocedure is not considered done until it is recorded.
PURPOSE: To prevent trauma and a burn in the area.
S. Apply the commercial moist heat packs (Figure 1). 9/2/20-8:35 w.: Commercial moist heat pack applied to cervical/thoracic
6. Cover with a towel. region as ordered by Dr. Alexander for 20 min. Pt states muscle cramps relieved.
7. Advise the patient to leave the heat pack in place no longer than 20 to 30 Instructed to continue moist heat packs at home q 2 hr for 20 min for relief
minutes, off for the same amount of time, and then repeat if needed. of muscular pain. Cautioned pt about danger of accidental burn to the area. To
CAUTION: Monitor the patient for complaints of discomfort or signs of a return to office 9/ 6/20 for F/U. K. Tillman, (MA (MMA)
burn, including erythema and blister formation.

Paraffin Bath
A paraffin bath is especially useful for treating chronic joint inflam-
mation. A mixture of7 parts paraffin and 1 part mineral oil is melted
and heated to approximately 125°F (52°C). The body part (usually
a hand, an elbow, or a foot) is dipped into the warm paraffin mixture
and removed immediately, leaving a thin coating on the skin. This
dipping is repeated six to 12 times, until a thick coating of paraffin
remains on the body part (Figure 19-18). The part then is wrapped
with plastic and a towel to allow the heat to penetrate the tissues.
The paraffin is kept on for 30 minutes and then is peeled off. The
process leaves the skin soft, warm, moisturized, and pliable, with
slight erythema. The treatment provides relief from aching joints,
especially for patients with rheumatoid arthritis.

FIGURE 19-18 Aparaffin bath is especially helpful for relieving pain in patients with arthritis.
The hand is dipped in warm paraffin, which is left on for about 30 minutes and then peeled off.

CRITICAL THINKING APPLICATION 19-9

Kaiwan is helping a 56-year-old patient with RA who is receiving a paraffin
bath treatment for both hands. He did not check the temperature before
having the patient put her hands in the bath, and when she puts her hands
in, she immediately pulls them out and complains that it is too hot. How
should Kaiwan handle this situation? What should he say to the patient?
What steps should he take to prevent this from occurring with another
patient?
Heating Pads
Electric heating pads are often used at home without any concern
for correct technique. People consider an electric heating pad a safe
household product that is often used to treat sore muscles or joints;
however, it can be dangerous for patients with decreased temperature
sensation, diabetes, spinal cord injuries, patients who have suffered
a stroke, patients taking medication for pain or sleep or those who
have consumed alcohol. Prolonged use on one area of the body can

cause a severe burn, even when the heating pad is at a low tempera-
ture setting. The FDA recommends the following precautions to
avoid possible injury when using electric heating pads:
• Inspect the heating pad before each use; throw it away if it
looks worn or cracked or if the electrical cord is frayed.
• Keep the removable cover on the pad during use.
• Place the heating pad on top of the body part in need of heat
(do not lie or sit on the pad because the temperature increases
if heat is trapped).
• Unplug the heating pad when not in use.
• Read and follow all manufacturer's instructions.
• Never use a heating pad on an infant; on a person who is
unable to feel the temperature of the pad (e.g., after a stroke);
on a sleeping or unconscious person; or near an oxygen tank.
• Electric heating pads should be left in place no longer than
30 minutes.
Therapeutic Ultrasonography
Ultrasound is the energy carried by very-high-frequency sound
waves. Audible sounds are the result of sound waves vibrating from
100 to 12,000 hertz (Hz; cycles per second). Ultrasonic waves
vibrate at a rate of up to 1 million Hz and cannot be heard by the
human ear. The ultrasound transducer contains a quartz crystal that
vibrates very rapidly when an electric current is passed through it.
It is placed in contact with the body, and the vibrations are passed
into the tissues. Because these waves do not travel through air, com-
plete contact with the body must be maintained during treatment
by using a coupling agent (a water-soluble gel) between the ultra-
sound transducer and the skin.
The ultrasound waves cause the tissue to vibrate, generating heat
as they penetrate superficial tissues and speeding up circulation to
the area. This increases the metabolism in the local area, which has
a beneficial effect on the body's healing process. Because ultrasound
waves travel best through water, they penetrate deeper into body
tissues with high water content, such as muscles. Ultrasonography
may reduce pain and increase the rate of collagen synthesis, which
promotes healing. It is often used to improve wound healing and
relieve the swelling and edema associated with sofr tissue injuries.
Bone tissue contains almost no water; therefore, ultrasonography
must be used very carefully around bony areas because the waves
may concentrate and cause damage.
Massage and Exercise
Massage is the systematic, therapeutic stroking or kneading of the
body or a body part, which can effectively relieve or significantly
reduce both localized and referred pain. Medical assistants are not
usually asked to perform therapeutic massage on patients, but you
should be familiar with the terminology.
A growing branch of healthcare uses exercise to aid muscle relax-
ation, promote healing, and provide relief from tension and pain
caused by stress or a wide variety of physical disorders. Exercise also
can be used to restore mobility, coordination, and strength. If the
motion in a joint is restricted even for a short time, the joint tissues
become dense, hard, and shortened. These changes can begin to
occur in as little as 4 days. This can be prevented or reduced by the
use of active or passive exercises.
In active exercise, the patient initiates and controls movements
of a particular part of the body. Special equipment may be used,
CHAPTER 19 Assisting in Orthopedic Medicine 507
FIGURE 19-19 Application of o tronscutaneous electrical nerve stimulation (TENS) unit.
such as stationary bicycles, treadmills, resistance bands, and/or
weight machines. In passive exercise, the therapist moves the body
part without the voluntary action of the patient. Both active and
passive exercises can be performed to maintain normal ROM or to
remedy diminished ROM after an injury.
Electrical Muscle Stimulation
A transcutaneous electrical nerve stimulation (TENS) unit is a low-
voltage machine that creates a controlled electrical current through
disposable gel electrodes. The electrodes are typically placed on the
area of pain or at a pressure point, creating a circuit of electrical
impulses that travels along nerve fibers. This low-voltage current is
useful for stimulating the motor and sensory nerves that supply
muscles. Stimulation provides a passive means of exercising a muscle
when a patient cannot activate the muscle voluntarily because of
injury. Electrical muscle stimulation frequently is used to prevent
atrophy of a normal muscle. TENS treatments are used most often
to treat muscle, joint, or bone problems that occur with illnesses
such as osteoarthritis or fibromyalgia, or for conditions such as
low back pain, neck pain, tendonitis, or bursitis (Figure 19-19).
AMBULATORY DEVICES
Crutches
Axillary crutches are made of wood or aluminum and must be mea-
sured to fit the patient, as described in Figure 19-20 and Procedure
19-3. It is very important to fit the crutches properly and to make
sure the patient understands the importance of not bearing weight
in the axillary region. If the crutch is too long or the handgrips are
too low, or if the patient leans forward bearing weight on the armpit,
serious injury can occur to the nerves in the brachia! plexus. Patient
guidelines for the correct use of crutches include the following:
• Wear flat shoes with nonskid soles to prevent accidents.
• Bear weight on your hands and the handgrips, not on your
armpits.
• Report any numbness or tingling of the upper body or arms
to the provider; this may indicate nerve damage from axillary
weight bearing.
• Keep your elbows close to your body so that the crutches are
against your side.
508 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES

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both feet together with leg with both feet crutches unaffected
together. one crutch on opposing together. together with leg.
A opposite side. crutch. B affected leg.

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Stand with Move both Move both legs Move Move Move Move
both feet crutches. by swinging right left left right
C together. them forward. D crutch. foot. crutch. foot.
FIGURE 19-20 Crutch gaits. A, Two-point crutch gait. B, Three-point crutch gait. C, Swing-through gait. D, Four-point crutch gait.

• Place the crutch tips about 2 inches to the side of each foot
so that you do not trip over them.
• Keep your elbows slightly bent when doing crutch walking.
• Keep your head up; do not look at your feet when using your
crutches.
• Make sure the crutch tips, handgrip pads, and axillary pads
on your crutches are in good condition at all times.
• Remove all throw rugs to keep from tripping or sliding.
• To stand up from a chair: Place both crutches on the injured
side, tilt forward and push off with the arm on your uninjured
side while bearing weight on the uninjured leg.
• To sit down: Place both crutches on the uninjured side, ease
yourself down onto the chair while bearing weight with the
uninjured arm and leg.
• To get into and out of a car: Make sure the front seat is
moved back as much as possible. Back up toward the seat
until you feel its edge; hold both crutches on the side of the
body closest to the car door; grab the seat's head rest, tilt
your head forward so that you do not bump it, and sit down.
Place the heel of your uninjured leg on the car frame and
push yourself back into the seat until you can swing the
injured leg into the car.

Coach Patients in the Treatment Plan: Teach the Patient Crutch Walking and the
PROCEDURE 19-3
Swing-Through Gait
Goal: To fit crutches accurately and to teach the patient to use the crutches properly in three-point walking.
EQUIPMENT and SUPPLIES
• Patient's health record
• Crutches with arm pads and foam handgrips
PROCEDURAL STEPS
1. Greet the patient, introduce yourself, and verify the patient's identity by
name and date of birth. Explain the procedure, and answer any questions
the patient may have. Sanitize your hands.
2. Ask the patient to stand up straight.
3. Fit the crutches to the patient so that they are 1 to 1½ inches (2 finger-
widths) below the armpits when they are standing up straight. The
handgrips should be even with the tap of the hip line (Figure 1).
4. Make sure all wing nuts are tight.
S. Make sure the foam pads at the armpits and around the handgrips are
comfortable.
6. Instruct the patient to keep the injured leg as relaxed as possible and
slightly bent at the knee.
7. Adjust the handgrips on the crutches so that the patient's elbow is bent
approximately 30 degrees when he or she is holding the handgrip.
8. Place the crutch tips about 2inches in front of each foot and approximately
6 inches to the side of each foot before beginning crutch walking.
9. Ask the patient to push down on the crutches and lift the body slightly,
nearly straightening the arms. The patient should hold the top of the
crutches tightly to the sides and use the hands to absorb the weight. Do
not let the tops of the crutches press into the armpits.
PURPOSE: To prevent injury to the muscles and nerves of the axillary
region.
Walkers
Walkers are used primarily by geriatric patients to help with balance
and support. A walker's wide base helps stabilize the gait of weakened
patients and can support up to 50% of the patient's body weight.
Walkers are made of aluminum and can easily be adjusted to fit an
CHAPTER 19 Assisting in Orthopedic Medicine 509
10. Have the patient swing the body forward about 12 inches (see Figure
19-20, C) .
PURPOSE: The swing-through gait is one of the fastest crutch gaits that
can be used, but it requires agreat deal of energy and upper body strength.
11. Instruct the patient to stand on the good leg, then move the crutches just
ahead of the good foot, and repeat.
12. Additional crutch gait patterns can be taught as needed.
• Two-point crutch gait: Move the left crutch and the right foot together,
then the right crutch and the left foot together. Repeat. This gait is
used if both legs are weak; it can be a challenge for the patient to
learn the pattern (see Figure 19-20, A).
• Three-point crutch gait: Move both crutches and the affected leg
forward, then bear weight down through the crutches and move the
unaffected leg forward. Repeat. This gait is used if the patient is unable
to bear weight on one leg (see Figure 19-20, B) .
• Four-point crutch gait: Move the right crutch forward, then the left
foot, followed by the left crutch and then the right foot. This gait
provides the best stability, but it is slow; however, it can be helpful
for patients in whom both legs are weak (see Figure 19-20, D) .
13. Stairs: Face the steps, hold the handrail with one hand, and tuck both
crutches under the armpit on the other side. To go up the steps, start with
the uninjured side, keeping the injured side raised behind. If the stairway
does not have handrails, keep one crutch under each arm. With the
crutches on the step where you are standing, step up with your stranger
leg, push down on the crutches, and then step up with the weaker leg.
Once both feet are on the same step, bring the crutches up. To go down
steps, hold onto the hand rail with 1 hand with both crutches under the
opposite arm. If there is no hand rail, keep 1 crutch under each arm, first
place crutches on next step down, step down with weaker leg followed
by the strong leg. If necessary, the patient can sit on the stairs and move
up or down each step.
14. Document the patient education intervention in the patient's record.
PURPOSE: Aprocedure is not considered done until it is recorded.
9/7/20-3: 17 PM: Pt instructed in crutch walking using 3-point gait on steps
and floor. Pt understands need to avoid weight bearing on <D leg. Pt demon-
strated technique s difficulty. K. Tillman, (MA (AAMA)
individual. They are lightweight, can fold flat for storage and travel-
ing, and can be equipped with a front pack to carry personal items
or supplies. They also can be fitted with a fold-down seat. The dis-
advantage of a walker is that it cannot be used in small, cramped
quarters.
51 o UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES
FIGURE 19-21 Properly fitted walker. Note the angle of the arms and the height of the walker.
To adjust the height of a walker, have the patient stand by the ex-
amination table. The top of the walker should be just below the
patient's waist at the same height as the top of the hip bone. If the
walker has been correctly adjusted to the patient, the patient's
elbows will bend about 30 degrees while he or she uses the walker
(Figure 19-21). Patient guidelines for walker use include the
following:
• Lift the walker (or roll it if it is fitted with wheels) about an
arm's length in front of you.
• Take your first step with the weaker leg, using the walker for
support. If both legs are weak or you are using the walker for
general support, start with either leg.
• Take smaller, slower steps than usual; if you step too close to
the front of the walker, you can lose your balance.
• Hold your head up and look straight ahead.
• To sit down, back up with the walker until you feel the back
of the chair against your legs; let go of the walker and reach
back for the chair; slowly lower yourself into the chair.
Canes
Canes are available in a variety of designs (Figure 19-22). The
single-tipped cane with a curved handgrip is indicated for individ-
uals who need only minimal assistance with walking. Another type
is the legged cane, which has a tripod or quad base. This base pro-
vides greater stability for the patient than does a single-tipped cane.
FIGURE 19-22 Types of standard canes. (From DeWit S: Fundamental concepts and skills for
nursing, ed 4, St Louis, 2014, Saunders.)
It is heavier and is recommended for patients who need greater
support.
To fit a cane properly, have the patient stand up straight and
measure the distance from the wrist crease to the floor. If the patient
is age 70 or older or finds that extra length would feel more comfort-
able, up to 2 inches can be added to the previous measurement. This
is the total length of the cane fitted to the patient. The patient's
elbow should be bent to approximately 20 to 30 degrees if the cane
has been correctly adjusted.
Canes typically are used to help a patient with balance problems,
to widen the base of support so that falls are less likely, and to reduce
weight bearing on an affected leg. To walk safely with a cane, the
patient needs to be taught the following steps:
• Always use the cane on the side opposite the affected leg so
that it can provide additional support as you walk through
the step.
• The cane and the injured or weak leg should be advanced
at the same time so that the cane and the leg are hitting the
ground at the same time.
• Start by positioning the cane one small stride ahead on the
strong side and step off with the injured leg, finishing the step
with the stronger leg.
• Bear weight with the arm holding the cane as needed.
• The unaffected leg should bear the weight through the step.
Wheelchairs
Wheelchairs provide mobility for patients who cannot walk or who
are able to walk only short distances. With a manual wheelchair, the
patient uses arm muscles for mobility. Wheelchairs also come with
motors that can be controlled by the patient. The patient is referred
to an orthopedic appliance store, where the appropriate wheelchair
is fitted to the individual.

Safety Alert
Always set the brakes on a wheelchair before transferring the patient into
or out of the chair.
MANAGEMENT OF FRACTURES
When a patient is diagnosed with a fracture or another injury that
requires immobilization, the provider must decide whether a tradi-
tional cast (typically of fiberglass), a splint, or a brace is most appro-
priate to promote healing. Splints and braces have a slight opening
in the front which allows for possible swelling at the site; these are
often used with acute fractures or sprains or for initial stabilization
of a fracture before surgery (Figure 19-23). If the patient needs to
wear a cast only when using the limb, braces or splints are available
in the shape of a boot or sleeve with Velcro fasteners that fit over the
fracture to immobilize the area. An air cast is a temporary cast that
is inflated around the limb to immobilize it. The type of cast used
depends on the location and severity of the injury, the patient's age
and occupation, and the provider's preference.
Casts provide superior immobilization because they completely
surround the injury, but they are less forgiving if the area swells and
FIGURE 19-23 Examples of braces and splints.
•;;mdmhii€11 Assist the Provider with Patient Care: Assist with Application of a Cast
Goal: To assist the provider in applying a fiberglass cast.
EQUIPMENT and SUPPLIES
• Patient's health record
• Rolls of fiberglass
• Basin for casting material
• Bandage
• Stockinette
• Gloves for provider and medical assistant
• Sheet wadding and/or spongy padding
• Stand to support foot (lower extremity)
• Tape
• Scissors
CHAPTER 19 Assisting in Orthopedic Medicine 511
could have higher complication rates; for these reasons, they are
generally reserved for complex fractures. Casts are made up of fiber-
glass that has fiber or resin in the roller gauze; this creates a strong,
lightweight, and relatively waterproof material (Procedures 19-4 and
19-5).
Before applying a cast, first wrap the area with cotton padding
or a stockinette to protect the skin. To immobilize the injured area,
the splint or cast must cover the joints above and below the fracture.
As a fracture heals, the provider may decide to remove the cast and
apply a splint until the fracture has mended completely. A patient
may call the office complaining that the splint or cast feels tight.
Swelling typically occurs in the first 48 to 72 hours after the injury.
The patient should be told to elevate the injured part above the heart
to help collected fluid drain from the site; to gently move the fingers
or toes at the affected area to improve circulation; and to apply ice
around the splint or cast in a plastic bag at the level of the injury to
help reduce swelling.
Warning Signs after Application of a Splint or Cast
The patient should be told to contact the provider's office if any of the
following occurs after the application of a splint or cast:
• Increased pain and/or a feeling that the splint or cast is too tight
• Numbness and tingling in the affected hand or foot, indicating
pressure on the nerves
• Burning and stinging because of pressure on the skin
• Excessive swelling below the cast, which may mean the cast is
slowing circulation
• Loss of active movement of toes or fingers (this requires an urgent
evaluation by the provider)
CRITICAL THINKING APPLICATION 19-10
Kaiwan has just finished helping Dr. Alexander put a cast on the arm of a
6-year-old girl who fell out of her neighbor's tree house and fractured her
radius. Her mother wants to take her home immediately. Should the patient
be allowed to leave immediately? Why? What might happen?
• 2-3 Towels
• Water
PROCEDURAL STEPS
1. Sanitize your hands.
2. Greet the patient, then introduce yourself and verify the patient's identity
by name and date of birth.
3. Explain the procedure for applying a cast and answer any questions.
PURPOSE: Knowing what to expect reassures the patient. Questions about
the injury should be directed to the provider.
4. Assemble the necessary equipment.
512 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES

•;;m!,mj;jj§il -continued
S. Seat the patient comfortably, as directed by the provider. If the cast is
being applied to the lower extremity, the toes must be supported by a
stand.
PURPOSE: The amount of flexion of the ankle can be controlled by sup-
porting the toes so that the patient can more easily maintain the desired
position without fatigue.
6. Clean the area that the cast will cover. Note any objective signs and ask
about subjective symptams (chart them at the end af the procedure).
PURPOSE: The condition of the area under the cast must be noted before
the cast is applied so that it can be compared with the site when the cast
is removed. Clean the area with a mild soap solution or as directed. Dry
thoroughly.
7. Cut the stockinette to fit the area the cast will cover.
8. Apply the stockinette smoothly to the area the cast will cover. Leave l or
2 inches of excess stockinette above and belaw the cast area to finish the
cast (Figure 1).

10. Apply sheet wadding along the length of the cast using a spiral bandage
turn. Extra padding may be used over bony prominences, such as the
bones of the elbow or ankle.
PURPOSE: Padding the cast helps reduce pressure against bony promi-
nences, which could cause skin breakdown.
11. Put on glaves.
12. With lukewarm water in the basin, wet the fiberglass tape as directed by
the provider (Figure 3).
PURPOSE: Immersing the roll of fiberglass tape in water begins the chemi-
cal reaction that will cause the cast to harden. The cast can be shaped
while wet and will harden in the shape that is formed.

9. Excess stockinette may be cut away where wrinkles form, such as at the
front of the ankle (Figure 2).
PURPOSE: Stockinette must lie smoothly and cannot be too bulky or
wrinkled because this may cause a pressure wound.
 CHAPTER 19 Assisting in Orthopedic Medicine 513

•;;m!,mj;jj§il -continued
13. Assist as directed as the provider applies the inner layer af fiberglass tape.
Alength of l to 2 inches of stockinette is rolled over the inner layer of
the cast to form a smooth edge when the outer layer is applied.
14. As directed by the provider, help to open and apply an outer layer of
fiberglass tape (shown in the following figure as blue) (Figure 4).

1S. Help shape the cast as directed. All contours must be smooth (Figure 5).
PURPOSE: If flat or dented areas develop on the cast, they may cause
pressure on the skin below.
16. Discard the water and excess materials. Remove your gloves and wash
your hands.
17. Reassure the patient, review cast care verbally, and provide written
instructions.
18. Document observations and the procedure in the patient's health record.
PURPOSE: Aprocedure is not considered done until it is recorded in the
patient's health record.
9/8/20-1 PM: Assisted with application of knee to toe cast to ® leg. Skin
under cast dry and intact. Pt given written instructions on cast care. Material
reviewed s questions. Instructed to call physician if there is numbness, tingling,
swelling of toes, blue discoloration. K. Tillman, CMA (AAMA)

•;;m,anmJIGil Assist the Provider with Patient Care: Assist with Cast Removal

Goal: To remove ocost.

EQUIPMENT and SUPPLIES PROCEDURAL STEPS
• Patient's health record 1. Greet the patient, introduce yourself and verify the patient's identity by
• Cast cutter name and date of birth, and then explain the procedure. Answer any
• Cast spreader questions the patient may have.
• Large bandage scissors PURPOSE: The patient may think cast removal is painful; explain how it
• Basin of warm water is done to allay the patient's anxiety and ensure cooperation.
• Mild soap 2. Provide adequate support for the limb throughout the procedure.
• Towel PURPOSE: To ensure the patient's comfort.
• Skin lotion
514 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES
•;;m!,mj;jj§il -continued
3. Sanitize your hands. Using the cast cutter, make a cut on the medial and
lateral sides of the long axis of the cast (Figure 1).
10. Record the procedure in the patient's health record.
4. Use the cast spreader to pry apart the two halves using the cast spreader
(Figure 2).
CLOSING COMMENTS
Patient Education
An informed patient is better prepared to continue with home care.
Musculoskeletal conditions, particularly arthritis, can be so painful
and debilitating that these patients may be easy prey for miracle drug
promotions. It is important for you to recognize the need for patient
education about the condition and to work diligently with the
patient and family to encourage participation in effective care pro-
grams. When you work with the provider and the physical therapist
in helping the patient, you become an important member of the
healthcare team. This type of involvement leads to patient satisfac-
tion and to personal satisfaction and a sense of achievement for the
medical assistant.
S. Carefully remove the two parts of the cast.
6. Use the large bandage scissors to cut away the stockinette and padding
remaining.
7. Gently wash the area that was covered by the cast with mild soap and
warm water.
PURPOSE: To ensure the patient's comfort.
8. Dry the area and apply a gentle skin lotion.
PURPOSE: To ensure the patient's comfort.
9. Give the patient appropriate instructions about exercising and using the
limb, as directed by the provider.
PURPOSE: To enhance continued healing, restore lost strength, and prevent
injury.
PURPOSE: Aprocedure is not considered done until it is recorded.
Patient Education for the Care of a Splint or Cast
The American Academy of Orthopedic Surgeons recommends the following
measures for caring for a cast or splint:
• Keep the splint or cast dry; moisture weakens the material, and
damp padding can irritate the skin. Use two layers of plastic or buy
waterproof shields to keep the splint or cast dry while you shower
or bathe. In special circumstances, the provider can apply a water-
proof cast.
• Do not walk on a "walking cast" until it is completely dry and hard;
it takes at least l hour for fiberglass to become hard enough to
walk on.
• Prevent dirt, sand, and powder from getting inside the splint or cast.

• Do not pull out the padding.
• Do not stick objects (e.g., coat hangers) inside the splint or cast to
scratch itching skin; if itching persists, contact your provider.
• Do not break off rough edges of the cast or trim the cast before
asking your provider.
• Inspect the skin around the cast; if it is red or raw, contact your
provider.
• Inspect the cast regularly; let your provider know if it becomes
cracked or develops soft spots.
Legal and Ethical Issues
Working with orthopedic patients may require assisting with assess-
ments and performing procedures that directly involve the patient's
recovery plan. Many of the procedures in this chapter are not the
basic procedures you will be required to perform when you are first
hired as a medical assistant. These techniques all involve additional
on-the-job training and practice. Before performing any of the
described procedures, you should check with your local and state
medical assistant organizations about the laws in your state. When-
ever you perform the procedures and techniques described in this
chapter, you are responsible for them. The following steps are all
required before you perform any procedure on a patient:
• You must have a written order before performing a procedure.
• You must follow the procedure precisely as it is ordered,
without variation.
i-iiiiit+i;it•jii9#it-iU1•i-- - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Kaiwan is becoming more and more comfortable in his position as an orthopedic
medical assistant at the sports medicine clinic. His enthusiasm is contagious.
Patients consistently comment on his positive, upbeat manner. Kaiwan is moti-
vated to learn new methods of better assisting the providers with routine pro-
cedures. He always seeks answers to questions that occur with new patients.
He has gained a great deal of confidence and now remembers always to check
the temperature of the paraffin bath before starting a treatment. One of the
SUMMARY OF LEARNING OBJECTIVES
l. Define, spell, and pronounce the terms listed in the vocabulary.
Spelling and pronouncing medical terms correctly reinforce the medical
assistant's credibility. Knowing the definitions of these terms promotes
confidence in communication with patients and co-workers.
2. Describe the principal anatomic structures of the musculoskeletal
system and their functions.
The main structures of the musculoskeletal system are the skeletal
muscles, which provide movement; tendons, which connect muscles to
bones; bones, which provide support, protection, mineral storage, and
blood cell development, and ligaments, which connect bone to bone.
3. Differentiate among tendons, bursae, and ligaments.
Tendons are the tough bands that connect muscles to bones; ligaments
provide support by connecting bone to bone and preventing a joint from
CHAPTER 19 Assisting in Orthopedic Medicine 515
• Never advise the patient without permission.
• Make sure you know what instructions the provider gave the
patient and reinforce them.
• If you have any concerns about a procedure, discuss them with
the provider privately before proceeding.
• Do not perform a procedure if you are uncomfortable; get
someone to help you.
Always remember: You are the assistant, and this is the provider's
patient. The physician ultimately is responsible for every aspect of
the patient's care. If you feel uncertain or unsure of any order the
provider has written for a patient, you must get it clarified before
you proceed. Always stay within the legal and ethical guidelines of
the medical assisting profession in your state.
Professional Behaviors
Musculoskeletal injuries and disorders are commonplace in the ambulatory
care setting. Because of this, patients may ask for your advice on how to
manage their health problems. Remember that as the medical assistant
you should never diagnose or recommend treatment for a patient. That is
the provider's responsibility. Responding professionally to inquiries, offering
provider-approved educational materials, and/or referring patients and
family members to accepted websites can be very helpful. Respectful and
courteous behavior should be standard practice for a medical assistant when
he or she interacts with patients and their families.
most enjoyable aspects of his job continues to be assisting Dr. Alexander with
treating the team members. Kaiwan has attended two continuing education
seminars in sports medicine with Dr. Alexander. He now is thinking about
continuing his education part time to became an athletic trainer while still
working at the clinic. Kaiwan recognizes the importance of continuing education
in maintaining orthopedic skills.
moving beyond its normal ROM. Bursae prevent friction between different
tissues in the musculoskeletal system.
4. Summarize the major muscular disorders.
Fibromyalgia is a condition of unknown origin that causes widespread
connective tissue and muscular pain, along with sleep disorders and
extreme fatigue. Myasthenia gravis is an autoimmune disorder that
affects the use of A(h at the neuromuscular junction, resulting in muscular
weakness, especially in the face and eyes. Asprain is the tearing of liga-
ments, and astrain is the overstretching or tearing of a muscle or tendon.
(See Table 19-2.)
5. Identify and describe the common types of fractures.
The common types of fractures are explained in Table 19-3.
Continued
516 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES
SUMMARY OF LEARNING OBJECTIVES-continued
6. Explain lhe difference belween osteomalacia and osleoporosis.
Osteomalacia is softening of the bones, which occurs because of a
problem with the metabolism or absorption of vitamin D, calcium, and
phosphorus; in children the condition is called rickets. Osteoporosis is a
reduction in bone density, which can be caused by many factors, including
lack of dietary calcium early in life; it leads to brittle bones that fracture
easily. (See Table 19-2.)
7. Classify typical spinal column disorders.
Spinal column disorders are related to the shape of the spine: scoliosis
is a lateral deviation; lordosis (swayback) is a pronounced curve of the
lower back; and kyphosis is a pronounced cervical curve, or hunchback.
Aherniated disk occurs when the soft nucleus of an intervertebral disk
protrudes through atear or weakened area in its tough outer cartilaginous
covering.
8. Differentiate among the various joint disorders.
Joint disorders include dislocations, in which the two bones of the joint
are no longer approximated; gout, which is a form of arthritis caused by
the collection of uric acid crystals, most commonly in the synovial
membrane of the great toe; SLE, which is a widespread autoimmune
disorder that can affect any organ system in the body; Lyme disease, a
form of infectious arthritis caused by bacteria transmitted via a tick bite,
can cause extensive joint and neurologic problems if left untreated; OA,
caused by degeneration of the articular cartilage of synovial joints; RA,
an autoimmune disorder that causes crippling pain and deformity of the
joints; and tendonitis and bursitis, which are inflammatory reactions of
supportive tissue typically caused by overuse of a joint.
9. Summarize the medical assistant's role in assisting with orthopedic
procedures.
The medical assistant is responsible for gathering and recording adetailed
history of the patient's presenting problem; providing the patient with
assistance as needed; and assisting with the orthopedic examination.
10. Explain the common diagnostic procedures used in orthopedics.
Common diagnostic procedures routinely perrormed in the orthopedic
office include ROM evaluation, inspection, palpation, percussion, muscle
strength evaluation, and x-ray studies. Other diagnostic tools include
arthrograms, myelograms, bone scans, CT, MRI, electromyography, biop-
sies, and diagnostic ultrasonography.
11. Discuss therapeutic modalities used in orthopedic medicine.
Therapeutic modalities include the application of cold and heat (see Table
19-4); paraffin baths; hot-water bottles and moist heat packs; therapeu-
tic ultrasonography; massage and therapeutic exercise; and electric
muscle stimulation.
12. Apply cold therapy to an injury.
Cold should be used immediately after an injury to help reduce inflam-
mation, inhibit additional swelling, and help relieve pain. The ice pack
CONNECTIONS
CrJ Study Guide Connection: Go to the Chapter 19 Study Guide. Read and complete
the activities.
should remain in place for 20 minutes at a time, several times a day,
and the area should be checked for feeling and color after each applica-
tion. (See Procedure 19-1 .)
13. Discuss various heat treatments and assist with hot, moist, heat
application to an orthopedic injury.
Heat should be used on injuries after 48 hours to promote circulation and
healing, reduce swelling, and promote soft tissue relaxation in the affected
area. Care must be taken to prevent burns. (See Procedure 19-2 .)
14. Discuss therapeutic ultrasonography, massage, exercise, and electri-
cal muscle stimulation.
Therapeutic ultrasound applies deep tissue heat to an injured area. It is
important to keep the applicator head constantly moving in a circular
fashion over the injured site during the treatment. Massage is systematic
stroking of the body or body part. Medical assistants are not usually
asked to perform therapeutic massage on patients. Atranscutaneous
electrical nerve stimulation (TENS) unit is often used to treat muscle,
joint, or bone problems that occur with osteoarthritis and fibromyalgia,
in addition to neck and back issues.
15. Explain the use of common ambulatory devices, properly fit a
patient with crutches, and coach a patient in the correct mechanics
of crutch walking.
The most common ambulatory assistive devices are crutches, canes,
walkers, and wheelchairs. The most important aspects of using these
assistive devices in an orthopedic practice are to fit them properly to the
patient and to instruct the patient adequately in how to use the device
properly and safely. Procedure 19-3 presents the steps for properly fitting
a patient with crutches and explaining the correct mechanics of crutch
walking. (See Figure 19-20 for various crutch gaits.)
16. Discuss the management of fractures and prepare for and assist with
both the application and removal of a cast.
The management of fractures includes reduction, immobilization, analge-
sics, and NSAIDs. The tissue beneath the cast must be safeguarded by
applying a stockinette and sheet wadding. The casting material then is
immersed in water and carefully rolled around the limb (see Procedure
19-4). The steps for preparing for and assisting with cast removal are
shown in Procedure 19-5.
17. Summarize patient education guidelines for orthopedic patients.
Musculoskeletal conditions are often painful and debilitating. The medical
assistant should recognize the need for patient education and work with
the patient, family, and healthcare team to promote recovery.
18. Discuss the legal and ethical implications in an orthopedic practice.
Before perrorming any orthopedic procedures, the medical assistant
should check with local and state medical assistant organizations about
applicable state laws. Procedures and techniques should be performed
only under the direct supervision of the physician.
evo Ive Evolve Connection: Go to the Chapter 19 link at evolve.e/sevier.com/
kinn to complete the Chapter Review Quiz. Check out the other resources listed for this
chapter to make the most of what you have learned from Assisting in Orthopedic
Medicine.
ASSISTING IN NEUROLOGY AND
MENTAL HEALTH
i-i#H+i;H•i
Mai Lee, (MA (AAMA), has been working in Dr. Kim Song's neurology practice
for 2 years. Dr. Song has always been pleased with Mai's professional behavior
toward all patients in his practice. She uses therapeutic communication when
interacting with the diverse patient population and is conscientious about accu-
rately maintaining electronic health records (EH Rs). Dr. Song has just asked
While studying this chapter, think about the following questions:
• What is the basic anatomy and physiology of the neurologic system?
• What should Mai know about typical neurologic disorders?
• What are the diagnostic and treatment procedures for common nervous
system disorders?
LEARNING OBJECTIVES
1. Define, spell, and pronounce the terms listed in the vocabulary.
2. Summarize the anatomy and physiology of the nervous system.
3. Differentiate between the central and peripheral nervous systems.
4. Distinguish among common nervous system diseases and conditions
and identify the typical symptoms associated with neurologic disorders.
5. Describe the pathology of cerebrovascular diseases.
6. Identify the various types of epilepsy.
7. Compare and contrast encephalitis and meningitis.
8. Explain the dynamics of brain and spinal cord injuries.
9. Summarize common central nervous system (CNS) and peripheral
nervous system (PNS) diseases.
10. Differentiate among common mental health disorders.
VOCABULARY
anomalies (uh-noh'-muh-leez) Deformities or deviations from
a normal condition, resulting from faulty development of
a fetus.
ataxia (uh-taks'-e-uh) Failure or irregularity of muscle actions and
coordination.
aura A peculiar sensation that precedes the appearance of a more
definite disturbance; commonly seen with migraines or seizure
activity.
benign Not cancerous and not recurring.
blood-brain barrier An anatomic-physiologic structure made up
of astrocyte glial cells that prevents or slows the transfer of
chemicals into the neurons of the central nervous system
(CNS).
20
Mai to train a new medical assistant in the clinical procedures of the office. He
is expanding his clinic hours and wants to have Mai more involved in assisting
him with patients, particularly in patient education. She is excited to have
additional responsibilities with Dr. Song's patients, and she is quite happy about
the raise in salary that goes along with her new position.
• What is the medical assistant's role in the neurologic examination?
• Is patient education a significant factor when working with patients
diagnosed with either nervous system or mental health disorders?
11. Analyze the medical assistant's role in the neurologic examination.
12. Explain the common diagnostic procedures for the nervous system.
13. Ou~ine the steps needed to prepare a patient for an
electroencephalogram (EEG).
14. Describe the steps for preparing a patient for and assisting with a
lumbar puncture.
15. Discuss the implications of patient education in a neurologic and
mental health practice.
16. Explain the legal issues and Health Insurance Portability and
Accountability Act (HIPM) applications associated with neurology and
mental health.
bruit (broot) An abnormal sound heard during auscultation of a
carotid artery; it is caused by the flow of blood through a
narrowed or partially occluded vessel.
coma An unconscious state from which the patient cannot be
aroused.
cryptogenic (krip-tuh-jeh'-nik) Pertaining to a disease with an
unknown origin.
diplopia (dih-ploh'-pe-uh) Double vision.
embolus A mass of undissolved matter that blocks a blood vessel;
frequently a blood clot that has traveled from some other part
of the body.
exacerbation (ig-zas'-er-bay-shun) An increase in the seriousness
of a disease marked by greater intensity of signs and symptoms.
518 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES
VOCABULARY -continued
ischemic (ih-ske'-mik) Pertaining to a decreased supply of
oxygenated blood to a body part.
malaise A generalized feeling of weakness or discomfort; usually
marks the onset of a disease.
malignant Cancerous.
myelin sheath A segmented, fatty tissue that wraps around the
axon of the nerve cell and acts as an electrical insulator to speed
the conduction of nerve impulses.
occlusion Complete obstruction of an opening.
palliative Therapy that relieves or reduces symptoms but does not
result in a cure.
papilledema Swelling of the optic disc as a result of increased
intracranial pressure.
T he human brain weighs about 3 pounds, requires about the
same amount of energy needed to light a 20-watt bulb, stores
more than 100 trillion bits of information, and works better than
any computer. The matter that makes up the brain is approximately
85% water and therefore has a soft texture. Early scientists believed
that the brain's function was to cool the blood. Today's scientists have
shown us that even though the brain receives 20% of the body's
blood supply, its function is much more complex than simply
cooling blood.
Neurologists specialize in the diagnosis and treatment of medical
disorders and conditions of the nervous system. A neurosurgeon
provides surgical management and treatment for trauma and
other conditions requiring surgery. A psychiatrist is a physician who
treats behavioral disorders and neurologic conditions that affect
behavior.
ANATOMY AND PHYSIOLOGY OF
THE NERVOUS SYSTEM
The nervous system works with the endocrine system to integrate
stimuli, both from within the body and from the outside environ-
ment, to regulate body systems; this allows homeostasis to be main-
tained. The nervous system is divided into two major parts: the
central nervous system (CNS), which is made up of the brain and
spinal cord, and the peripheral nervous system (PNS), which includes
all the nervous tissue and neurologic responses found outside
the CNS.
The brain is the "president" or "chief executive officer" of the
body. It constantly receives information from the periphery, includ-
ing all the organs and systems inside the body and on its surface.
This information (i.e., stimuli) is carried to the brain by the periph-
eral nerves along the afferent, or ascending, nerve tract. The brain
monitors and interprets the stimuli received from the afferent nerves
and sends appropriate responses back along efferent pathways to the
organs or to the body's surface. These responses from the brain cause
a specific reaction in the organ, in the glands, or in skeletal muscles.
These reactions keep the body running smoothly and allow it to react
instantly to both external and internal stimuli.
paresthesia (par-uhs-the'-ze-uh) An abnormal sensation of
burning, prickling, or stinging.
paroxysmal (par-ok-siz' -muhl) Pertaining to a sudden recurrence
of symptoms; a sudden spasm or convulsion of any kind.
plaque An abnormal accumulation of a fatty substance.
proprioception The sensation of awareness of body movements
and posture; nerve impulses that provide the central nervous
system with information about the position of body parts.
radiopaque A substance that can easily be visualized on an x-ray
film.
thrombus A blood clot.
transection Cross section; a division made by cutting across.
The functioning cell of the nervous system is the neuron
(Figure 20- 1) . The brain contains billions of individual neurons.
Formation of the nervous system starts very early in embryonic
development (i.e., by week 3); it begins as the neural rube, which
eventually develops into the brain and spinal cord. Each neuron is
made up of a main cell body that contains the nucleus and a rela-
tively long extension of the cell, called the axon, which may be
covered with a myelin sheath. Multiple filaments, called dendrites,
extend from the neuron body. Dendrites receive the nervous
impulse from a preceding neuron and carry it into the cell body.
Impulses are carried away from the cell body through the axon to
another neuron or to cells in another tissue. This transfer of
stimuli begins as an electrical impulse that travels down an axon of
one neuron and becomes a chemical impulse while moving across
the synapse (the space between two neurons) to the dendrite of
another neuron. The transfer of impulses from the end of one
neuron to the dendrites of another is enhanced by chemical
neurotransmitters, which bind to specific receptor sites on the
dendrites of the next neuron. If the nerve impulse is traveling to
a muscle or to any other organ or tissue instead of another
neuron, the chemical neurotransmitters bind to special receptors
in the target tissue. Messages move throughout the entire nervous
system in this manner. Impulses in the neuron are electrical; the
impulses become chemical as a specific neurotransmitter is released
at each synapse, and they become electrical again as they are
picked up by the subsequent dendrites of another neuron or by
the target tissue.
Supportive cells of the nervous system are called glial or neuroglial
cells. Glial cells do not carry on any of the functions of the nervous
system; these specialized cells perform specific functions within the
nervous system; for example, Schwann cells form the myelin sheath,
and astrocytes help form the blood-brain barrier. The blood-brain
barrier closely regulates what substances enter the brain tissue.
Oxygen, water, and glucose molecules easily pass into the brain,
whereas many chemicals and drugs are prevented from moving into
brain tissue. Brain inflammation can increase the ability of many
drugs to cross the blood-brain barrier because of damage to the
specialized glial cells.

Dendrites
Node
FIGURE 20-1 Aneuron.
What Happens When You Accidentally Touch a
Hot Pan
l. When your hand comes into contact with a hot pan on the stove,
impulses travel from the area of contact to the central nervous system
(CNS) along an afferent (sensory neurons) nervous pathway, carrying
the information "hot."
2. The CNS perrorms a hasty analysis and determines that a heat danger
is present.
3. The CNS sends a quick, strong message back to skeletal muscles
via the efferent (motor neurons) pathway to move the finger
immediately.
4. You quickly pull your hand away from the hot pan, preventing a serious
burn and maintaining homeostasis.
Central Nervous System
As mentioned, the brain and spinal cord together make up the CNS.
The brain is encased within the skull in the cranial cavity. The spinal
cord is a bundle of nervous tissue that extends inferiorly from the
brainstem at the base of the brain and exits the skull at the foramen
magnum. It descends for about 17 inches inside the spinal canal,
which courses through the vertebrae of the backbone.
CHAPTER 20 Assisting in Neurology and Mental Health 519
Brain
The brain accounts for only about 2% of a person's weight, but it
consumes about 20% of the body's oxygen. The brain is divided
into three main areas: the cerebrum, the cerebellum, and the brain-
stem (Figure 20-2). The cerebrum, the largest and uppermost
section of the brain, has multiple convolutions along its surface,
called gyri, which are formed by the folding in of the cerebral
cortex. The gyri are separated by shallow grooves, called sulci. The
gyri greatly increase the surface area of the cerebrum, which maxi-
mizes the potential of the CNS neurons in each area. The cere-
brum is divided into lobes, which are named after the region of the
skull under which they are located. The cerebrum is separated by a
longitudinal fissure into lefr and right hemispheres. The right
hemisphere usually controls artistic functions, such as drawing,
rhythm, and picture memory. The left hemisphere controls verbal
functions, such as reading, writing, speaking, and mathematic cal-
culations. The two halves of the brain are connected by the corpus
callosum. This bundle of nerve tissue facilitates communication
between the two sides of the brain. The corpus callosum is the
largest collection of white matter within the brain; it has a high
myelin content, which allows for quicker transmission of infor-
mation. Some congenital defects include a complete lack of this
neural tissue.
The diencephalon, located deep in the center of the cere-
brum near the superior portion of the brainstem, is made up of
the thalamus and the hypothalamus. The thalamus acts as a relay
station between sensory neurons and the cerebral cortex. The func-
tions of the hypothalamus include controlling the autonomic
nervous system; regulating endocrine processes; and managing
body temperature, sleep, and appetite to maintain homeostasis.
Within the cerebrum are four spaces, called ventricles, which
contain cerebrospinal fluid (CSF). CSF nourishes, lubricates,
and provides some cushioning protection for the brain and the
spinal cord.
The cerebellum, which is just inferior to the occipital lobe of the
cerebrum, controls balance, equilibrium, posture, and muscle coor-
dination. The brainstem controls reflexes and serves as a sensory relay
station for input coming into the brain from the body. The brain-
stem plays a vital role in vision, hearing, respiration, heart rate, blood
pressure, waking, and sleeping.
Spinal Cord
The spinal cord extends from the inferior portion of the brainstem
to approximately the second lumbar vertebra. Thirty-one pairs of
spinal nerves extend from the spinal cord through openings in the
vertebrae. Starting just below the first cervical vertebra in the neck,
a nerve extends from the spinal cord on each side; therefore, a pair
of spinal nerves originates at each level. Each of these pairs of nerves
innervates a specific organ or area of the body. The spinal cord carries
messages between the spinal nerves and the brain.
Meninges
Because the brain and the spinal cord are critical to life, they
are well protected. They both are encased in some of the
thickest bones in the body; they also are surrounded by three
membranes, called meninges; and they are cushioned by the CSF
(Figure 20-3).
520 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES

FIGURE 20-2 The brain.

Superior sagittal sinus

(of dura)

R
+L
I

FIGURE 20-3 Protective coverings of the brain. (Modified from Patton K, Thibodeou G: Anatomy and physiology, ed 9, St Louis, 2016, Mosby.)

The outer layer of the meninges is called the dura mater ("hard
mother") because it is a tough membrane, similar to a very strong
rubber band. The subdural space lies below the dura mater and
contains small veins that have little protection. Trauma to the head
can cause bleeding of these tiny vessels, ultimately leading to the
development of a subdural hematoma. Above the dura mater is the
epidural space. The arterial supply to the meninges comes from blood
vessels that line the inner aspect of the skull. If the skull is fractured,
these arteries can be damaged, resulting in a collection of blood
between the skull and the dura mater called an epidural hematoma.
 CHAPTER 20 Assisting in Neurology and Mental Health 521

TABLE 20-1 Typical Laboratory Values for Cerebrospinal Fluid

CONDITION PRESSURE (mm) APPEARANCE CELLS PROTEIN (mg/dL) GLUCOSE (mg/dL)
Normal 50-200 Clear, colorless 0-10 lymphocytes and <45 50-80
monocytes
Acute bacterial meningitis 200-500 Turbid 100-10,000 50-500 Absent or low
granulocytic neutrophils
Subarachnoid hemorrhage 200-500 Bloody Red blood cells (RBCs) 50-1000 50-80

The middle meningeal layer is the arachnoid, which was given

that name because of its fine spider-web appearance. Beneath TABLE 20-2 Cranial Nerves and Their Functions
the arachnoid membrane in the subarachnoid space is the cere- CRANIAL
brospinal fluid, a clear liquid that contains glucose, protein, and NERVE NAME FUNCTION
chloride produced by specialized cells in the ventricles (Table
20-1 ). CSF circulates continuously through the ventricles and I Olfactory Smell
around the brain and spinal cord, carrying nutrients and remov-
II Optic Vision
ing wastes.
The innermost meningeal layer, which covers the brain and spinal Ill Oculomotor Eye movement
cord, is the delicate pia mater ("tender mother"); it is highly vascular Pupil constriction and
and the thinnest of the three layers. The pia mater provides support accommodation
for the blood vessels of the brain.
IV Trochlear Eye movement
V Trigeminal Muscles of chewing
Hydrocephalus General sensations from anterior
Hydrocephalus is the abnormal accumulation of cerebrospinal fluid (CSF) half of head, including entire
in the ventricles of the brain. It can be detected in utero with sonography face and meninges
or diagnosed at birth. It is the result either of overproduction of (SF or of Eye movement
VI Abducent
failure of the fluid to drain properly. If left untreated, hydrocephalus causes
gross enlargement of the skull and severe damage to brain tissue from VII Facial Muscles of facial expression
increased intracranial pressure. The only treatment is surgery to place a Tearing, salivation, and taste
shunt (tube) from a ventricle in the brain to the right atrium or to the VIII Vestibulocochlear Hearing and equilibrium
abdominal cavity. The shunt allows the excess (SF to drain away from the
brain. IX Glossopharyngeal Swallowing and taste
X Vogus Breathing, speech, sweating,
Peripheral Nervous System regulating heartbeat, stimulating
muscles of gastric region
The PNS is made up of the nerves that exit the brain or spinal cord.
The peripheral nerves exiting the brain directly through the cranium XI Spinal accessory Shoulder and head movements
are called cranial nerves. Cranial nerves originate from the underside
of the brain and relay information to and from the sensory organs
XII Hypoglossal Tongue movements
and muscles of the face and neck (Table 20-2). The spinal nerves
from the spinal cord enter and exit the spinal canal through spaces
between the vertebrae. Spinal nerves carry information to and from room. The ANS (Figure 20-4) is an automatic system that regulates
the brain through the spinal cord. Sensory fibers in these nerves carry body functions such as breathing, heart rate, sweating, circulation,
stimuli from the skin and internal organs to the CNS. Motor fibers and digestion. It also controls the actions of muscles in blood vessel
carry messages from the CNS to skeletal muscles, causing them to walls, organs, and glands. Just as a thermostat can control both
contract. heating and cooling in a room to maintain a comfortable tempera-
The autonomic nervous system (ANS) is part of the PNS. Auto- ture, the autonomic system is made up of two divisions, called the
nomic nerves control homeostasis; that is, they keep the body running sympathetic system and the parasympathetic system. The sympathetic
smoothly, much like a thermostat controls the temperature in a system promotes responses geared toward protecting the individual
522 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES

Terminal ganglia Constrict pupil

Increase saliva Dilate pupil

Decrease saliva

Dilate bronchioles
Increase heart rate

Constrict
bronchioles
Slow heart rate
Release glucose
in liver
Empty gallbladder
Increase digestion
I
L---t-6t--;::::~~~~~~~"i-===i=lrj digestion
Decrease

Decrease
Increase intestinal activity
intestinal activity
Close sphincters of
bladder and colon
Open sphincters of
bladder and colon Collateral ganglia

Sympathetic chain ganglia

- - Parasympathetic
- - Sympathetic

FIGURE 20-4 Structure and function of the autonomic nervous system. (From Applegate E: The anatomy and physiology learning system,
ed 4, St Louis, 2011, Saunders.)

("fight or flight"), generally causing a stimulating effect: it speeds up
the heart, raises blood glucose levels and blood pressure, reduces
peristalsis, and widens the bronchioles, allowing more oxygen to
enter the body quickly. The parasympathetic system generally pro-
motes rest or a reducing effect: it slows the heart rate, constricts the
bronchioles, and increases digestive system function.
CRITICAL THINKING APPLICATION 20-1
Dr. Song mentions a patient's nervous system function to Mai. The patient
hears this conversation and later asks Mai, "What does my nervous system
do?" How should Mai answer this question? What resources could she use
to help explain the nervous system to the patient?
DISEASES AND DISORDERS OF THE CENTRAL
NERVOUS SYSTEM
Because the CNS and PNS are so complex, diseases and conditions
that affect them can produce a wide range of signs and symptoms.
Causes include trauma, infection, congenital anomalies, degenera-
tion, tumors, and vascular disorders (Table 20-3). The medical
assistant needs to listen carefully when a patient describes his or her
neurologic symptoms. Many different types of symptoms can indi-
cate a serious condition of the nervous system.
Cerebrovascular Disease
Cerebrovascular disease (CVD) is the fourth leading cause of death
and the most frequent cause of crippling disease in the United
States. Generally, CVD is related to arteriosclerosis or atherosclero-
sis of the cerebral arteries, but it also can be caused by untreated
or uncontrolled hypertension, cerebral hemorrhage, thrombi, or
emboli. Arteriosclerosis causes progressive loss of elasticity of
the arterial wall and is seen in elderly individuals with CVD.
Atherosclerosis, the deposit of fatty plaque on the inside of the
arterial wall, can involve any of the major arteries supplying the
brain or any of their branches. Sudden narrowing, or occlusion,
may occur when an artery becomes blocked by a thrombus or an
embolus.
CVD usually is diagnosed through cerebral arterial angiography,
in which a radiopaque dye is injected into the suspect vessel and
an x-ray film is immediately taken. Other confirming tests include
magnetic resonance imaging (MRI), computed tomography (CT),
and electroencephalography.
 CHAPTER 20 Assisting in Neurology and Mental Health 523

TABLE 20-3 Common Diseases and Conditions of the Nervous System

SIGNS, SYMPTOMS, AND DIAGNOSTIC LABORATORY
DISEASE ETIOLOGY PROCEDURES TESTS TREATMENT AND MEDICATIONS
Alzheimer's Short-term memory loss; progressive, History, MRI None specific; Supportive care, donepezil (Aricept),
disease irreversible confusion and disorientation; ordered to rule galantamine (Razadyne), rivastigmine
cause unknown, familial link out other causes (Exelon), memantine (Namenda)
of dementia
Brain tumor Depend on location; generally caused History, neurologic None Estrogen, surgery, radiation,
by increased ICP; can be primary tumor examination, imaging studies chemotherapy
but typically metastasis
CVA Depend on severity; speech difficulties, History, neurologic MRI, CT, carotid Thrombolytics within 3 to 4½ hours of
hemiplegia, confusion, loss of muscle examination, CT, MRI angiogram, when the symptoms first started,
coordination; caused by thrombus, echocardiogram, antiinflammatories, anticoagulants,
embolus, hemorrhage lumbar puncture hyperbaric oxygen, rehabilitation,
with CSF pressure supportive care
and analysis
Encephalitis Increased ICP, cerebral edema; caused History, lumbar puncture (SF analysis, Antivirals, supportive care
by virus blood cultures,
routine blood labs
Epilepsy Grand ma/: Tonic-clonic muscle History, neurologic Blood work Anticonvulsants phenytoin (Dilantin),
contractions examination, CT, MRI, HG carbamazepine (Tegretol), valproic acid
Petit ma/: Momentary absence, stare, (Depakene), gabapentin (Neurontin),
amnesia; cause unknown levetiracetam (Keppra), clonazepam
(Klonopin), lamotrigine (Lamictal)
Closed head Depend on location and severity of History, neurologic (SF analysis Corticosteroids, diuretics; reduce ICP
injury caused injury; headache, increased ICP; caused examination, CT, MRI, cranial
by trauma by trauma x-ray studies, lumbar puncture
Meningitis Headache, flulike symptoms, nuchal History, neurologic (SF analysis, Antibiotics, analgesics, drugs to reduce
rigidity, seizures examination, Kernig's and cultures cerebral edema, anticonvulsants,
Brudzinski's signs, lumbar antiinflammatories
puncture
Migraine Unilateral throbbing headache, nausea, History, neurologic Tests to rule out NSAIDs, sumatriptan (lmitrex), rizatriptan
vomiting, blurred vision; individual examination, MRI organic causes of (Maxalt), zolmitriptan (Zomig),
triggers, caused by combination of headaches topiramate (Topamax), gabapentin
trigeminal nerve abnormality and (Neurontin)
imbalance of neurotransmitter serotonin
Multiple Problems with vision, sensation, motor History, neurologic None Corticosteroids, interreron (Betaseron,
sclerosis function; autoimmune disease, examination, MRI Avonex), glatiramer acetate (Copaxone)
progressive inflammation and fingolimod (Gilenya), and additional
deterioration (demyelination) of the medications to treat fatigue, pain,
myelin sheath spasticity, and bladder control problems
Parkinson's Resting tremor, shuffling gait, masklike History, neurologic None (arbidopa-levodopa (Sinemet),
disease face; combination of genetic and examination pramipexole (Mirapex), ropinirole
environmental factors, deficiency of (Requip); surgical destruction of affected
neurotransmitter dopamine area of the brain; deep brain stimulation
CSF. Cerebra spinal fluid; CT, computed tomography; CVA, cerebrovascular accident; EEG, electroencephalogram; ICP, intracranial pressure; MRI, magnetic resonance imaging; NSA/0s, nonsteroidal
antiinflammatory drugs.
524 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES
Signs and Symptoms Suggesting Possible
Neurologic Problems
• Recurrent headache
• Periodic memory loss
• Change in sleeping patterns
• Frequently dropping items
• Difficulty with particular speech patterns
• Numbness in a specific body area
• Visual disturbances or abrupt changes in vision
• Loss of consciousness
• Confusion or disorientation as to date, time, and place
Transient /schemic Attacks
Transient ischemic attacks (TIAs), also called ministrokes, occur
when the blood supply to a particular part of the brain is inadequate
for a limited time, and symptoms typically disappear within an hour.
TIAs occur when brain tissue becomes ischemic for a short time,
causing the same symptoms as a stroke. Because the cause of the
ischemia is limited, the symptoms dissipate quickly. Symptoms can
include numbness or weakness in the face, arm, or leg or on one side
of the body; confusion or difficulty talking or understanding speech;
vision abnormalities, including diplopia; difficulty walking; and
vertigo or loss of balance and coordination.
These episodes may occur in the days, weeks, or months before
a stroke. Patients and their families should understand that any
strokelike symptom should be taken seriously. Approximately one
third of individuals experiencing TIAs have an acute stroke some-
time in the future. Therefore, those experiencing TIAs should be
seen within 1 hour of the onset of symptoms so that they can be
evaluated carefully and treated to prevent a possible stroke. Depend-
ing on the person's health history and the results of a medical
examination, the provider will recommend medications or surgery
to reduce the risk of stroke. Individuals with atrial fibrillation (an
irregular, rapid firing of electrical activity in the atria of the heart)
may be prescribed anticoagulants (e.g., heparin or warfarin [Cou-
madin]), or they may be put on daily low-dose aspirin or clopidogrel
(Plavix), because these individuals are at increased risk of emboli
formation. When TIAs occur, it is time for preventive treatment and
patient education, including altering and/or treating such factors as
hypertension, smoking, heart disease, diabetes, carotid artery disease
(carotid artery occlusion with atherosclerotic plaques), and heavy
alcohol abuse.
Cerebrovascular Accident
A cerebrovascular accident (CVA) is the most important clinical
manifestation of CVD. A CVA, commonly referred to as a stroke,
occurs when a vessel in the brain either ruptures or becomes occluded,
and brain cells on the other side of the damaged vessel become
oxygen deprived. Cerebral artery ruptures are caused by uncontrolled
hypertension or hemorrhaging of a weakened section of an artery in
the brain. As a result of the rupture, the surrounding brain tissue
fills with blood, damaging and possibly destroying the affected tissue.
An occlusion occurs when an embolus or thrombus becomes wedged
in an artery and obstructs the flow of blood to an area of the brain
(Figure 20-5).
The patient's symptoms depend on the location of the arterial
occlusion or rupture. Some of the more common symptoms include
slurred speech; unexplained confusion; sudden, severe headache;
difficulty swallowing; vertigo; diplopia; loss of consciousness; per-
sonality change; loss of bowel or bladder control; and paralysis on
one side of the body. The diagnosis of a CVA begins with a physical
examination to assess the patient for the signs and symptoms of a
stroke. The exam is repeated over time to see whether symptoms are
getting worse or improving. The medical assistant should immedi-
ately check the patient's blood pressure to determine whether the
cause of the CVA is hypertension. The physician will also listen to
the carotid arteries with a stethoscope for a bruit. If a bruit is
present, it indicates atherosclerotic buildup in the carotid arteries.
The CVA may have been caused by a piece of the plaque that broke
off and became lodged in a cerebral blood vessel.
The type of CVA must be determined as soon as possible so that
the best treatment can be provided. The following diagnostic studies
are ordered immediately:
• Angiogram of the head to look for a blood vessel that is
blocked or bleeding
• Carotid duplex (ultrasound) to see whether the carotid arteries
are blocked or narrowed
• Echocardiogram to see whether the stroke was caused by a
blood clot from the heart (this frequently occurs with atrial
fibrillation)
• Magnetic resonance angiography (MRA) or CT angiography
to check for abnormal blood vessels in the brain; this confirms
the presence of a vessel bleed
Treatment of a stroke requires immediate emergency transport to
the hospital. The initial emphasis is on minimizing the long-term
disabilities often seen with strokes by providing immediate treatment
to prevent additional brain tissue damage. Thrombolytic drugs to
dissolve the clot and anticoagulants may be given if the cause of the
stroke was a thrombus or an embolus. However, thrombolytic medi-
cation can effectively treat resulting ischemia only if they are given
within the first 3 to 4½ hours of when the symptoms first started.
The sooner this treatment begins, the better the chance of a good
outcome. If cerebral edema is present, the patient is treated with
corticosteroids and diuretics to reverse the swelling. Hyperbaric
oxygen also can be used to increase oxygenation of the brain. An
important part of recovery is extensive treatment in a stroke reha-
bilitation program that includes physical, occupational, swallowing,
and speech therapies.
CRITICAL THINKING APPLICATION 20-2
Mai answers the phone at the clinic. The caller is a patient, an anxious
woman who is desperately trying to say something but appears unable to
do so. Mai thinks the patient is trying to say something like "Help." Mai
checks the number on the caller ID display, looks it up in the office computer,
and finds that it belongs to a 50-year-old patient who came in 2days earlier
because af frequent, severe headaches and hypertension. How should Mai
handle this situation? Be sure to think about what she should do, why she
should do it, and what might happen if she does nothing.
 CHAPTER 20 Assisting in Neurology and Mental Health 525

Affected area Blockage

"

Results: Results:
• Right side paralysis • Lett side paralysis
• Speech and memory deficits • Perceptual and
• Cautious and slow behavior memory deficits
• Quick and impulsive
behavior

FIGURE 20-5 Cerebral artery occlusion (A) and hemiplegia (B). (Modified from Frazier MS, Drzymkowski JW: Essentials of human diseases
and conditions, ed 5, St Louis, 2013, Saunders.)

Types, Causes, and Risks of Cerebrovascular Accidents

Thrombotic stroke: Ablood clot (thrombus) forms in a cerebral artery and • Endocarditis (may promote thrombus formation)
blocks distal blood flow. • Arteriosclerosis and atherosclerosis
Embolic stroke: Ablood clot from elsewhere in the body (e.g., the lower leg) • Heart disease (e.g., atrial fibrillation, which increases the risk by five
or a piece of plaque (typically from the carotid arteries) breaks away and times)
flows through the bloodstream to the brain; the embolus eventually blocks • Sleep apnea
a cerebral artery, causing distal ischemia. • Sickle cell anemia
Cerebral hemorrhage: An artery in the brain ruptures, possibly because of • Cocaine abuse
untreated or uncontrolled hypertension or a congenital aneurysm. Individuals with three or more of the following five health conditions are
Any of the following factors can increase the risk of a stroke: twice as likely to have a cerebrovascular accident:
• Hypertension • Obesity
• Diabetes (increases the risk by two to three times) • Low level of high-density lipoprotein (HDL) cholesterol
• Hypercholesterolemia • High triglyceride level
• Cigarette smoking (increases the risk by 50%) • Blood pressure ~ 130/85 mm Hg
• Obesity • Diabetes and/or prediabetes (fasting blood sugar of 100 to
• Family history of stroke; risk of a first stroke is nearly twice as high 125 mg/dl)
for African-Americans
www.cdc.gov/stroke/facts.htm. Accessed January 19, 2015
526 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES
Migraine Headache
About 12% of the U.S. population suffers from migraine headaches;
three times more women than men are affected. Migraine headaches
are paroxysmal attacks of headaches that can be completely inca-
pacitating and frequently are associated with other symptoms, such
as nausea, vomiting, visual disturbances, and throbbing pain on one
side of the head. The manifestations of migraine headaches differ
from one individual to another. The patient may experience a sensory
warning sign, or aura, before the onset of the headache. An aura
often consists of some form of visual disturbance, such as dark lines
or spots within the visual field or a flash of light.
Medical science has not yet discovered the underlying cause of
migraines. However, researchers believe they may be caused by a
combination of a problem with the trigeminal nerve and an imbal-
ance of chemicals in the brain, especially the neurotransmitter sero-
tonin. Individuals who suffer from migraine headaches report a
number of different triggers, including changes in estrogen levels;
certain foods, such as alcohol, chocolate, aspartame, caffeine, and
monosodium glutamate (MSG); elevated stress levels; bright lights,
sun glare, and certain smells; altered sleep patterns; and changes in
the weather, especially with changing altitude levels and barometric
pressures. The diagnosis usually is established from a complete
medical history. An EEG, a CT scan, or an MRI study may be
performed as part of the diagnostic process to rule out other causes
of the headaches.
Drugs used to treat migraines include nonsteroidal anti-
inflammatory drugs (NSAIDs) and triptans, such as sumatriptan
(Imitrex), rizatriptan (Maxalt), and zolmitriptan (Zomig), which
mimic the effects of serotonin, causing vascular constriction. These
drugs must be taken at the onset of the headache to be effective and
can be delivered via different routes: oral medications, nasal sprays,
or intravenously (IV). Other medications recommended for the
prevention of migraines include beta blockers and antidepressants.
Antiseizure medications, such as topiramate (Topamax) and gaba-
pentin (Neurontin), may be effective in reducing the frequency and
severity of the headaches. Other treatments include biofeedback
techniques and elimination diets to avoid migraine triggers.
Dementia and Alzheimer's Disease
The term dementia describes a group of symptoms caused by altered
brain function. Dementia symptoms may include short-term memory
loss; disorientation about person, time, and place; neglect of personal
hygiene, nutrition, and safety; personality changes; and inability to
follow simple directions. Dementia can be caused by multiple condi-
tions. Some can be reversed, such as nutrition disorders or disorienta-
tion caused by a minor head injury. Others are irreversible, such as
multi-infarct (vascular) dementia and Alzheimer's disease.
Multi-infarct dementia is caused by a series of small strokes that
interfere with the brain's blood supply, resulting in multiple areas of
tissue necrosis. The location of the infarcts determines the degree of
disability and the dementia symptoms that might occur. Symptoms
of an acute onset of dementia typically are caused by this type of
dementia. People with multi-infarct dementia are likely to show
signs of improvement or remain stable for long periods and then
quickly develop new symptoms if more strokes occur. Untreated
or uncontrolled hypertension usually is the cause of this type of
dementia.
Alzheimer's disease is the most common form of dementia among
older people today. It is a devastating, chronic, progressive, and
degenerative disease that begins in the parts of the brain that control
thought, memory, and language. The patient exhibits slow, increas-
ing loss of recent memory; loss of recognition of people, places, and
events; confusion and disorientation; and physical deterioration that
leads to death. The cause remains unknown, and there is no known
cure. Treatment is supportive care only. Alzheimer's disease is talked
about in more detail in the Geriatrics chapter.
CRITICAL THINKING APPLICATION 20-3
Mr. Jackson, a 75-year-old patient with dementia, is coming in for his first
visit. He does not respond to verbal commands and is unable to answer
direct questions. How can Mai get him into the examination room and into
a patient gown while preserving his dignity?
Epilepsy and Seizure Disorders
Epilepsy is a chronic brain disorder associated with abnormal electri-
cal impulses generated by some of the neurons in the brain. These
errant impulses cause seizures (Figure 20-6). A seizure is character-
ized by abnormalities in levels of consciousness, sensory distur-
bances, and impaired motor function. A diagnosis of a seizure
disorder is made if the individual has two or more seizures. Children
may have a single seizure associated with a high fever (i.e., febrile
seizure), but that alone does not mean that the child has a seizure
disorder. However, most individuals with the disorder have an onset
of seizures during childhood, although many children grow out of
the problem. In many cases the cause is never identified; some
known causes include brain tumors, CNS infections, anoxia, CVA,
and traumatic head injury.
Seizures are classified as either partial or generalized, based on
how much of the brain is involved in the abnormal electrical activity.
Partial seizures result from abnormal electrical activity in just one
part of the brain, whereas generalized seizures involve most or all of
the brain. Seizure classifications are divided into more specific cat-
egories. Simple partial seizures originate in a small, localized area of
the brain, do not cause loss of consciousness, and are identified by
a repetitive action, such as shaking of an arm or a leg or altered
speech. Complex partial seizures also begin in a small area of the
brain but cause staring and repeated movements, such as hand
rubbing, lip smacking, swallowing, and postseizure confusion or
amnesia. Generalized seizures include petit mal seizures, which are
brief episodes characterized by staring, subtle body movement, and
brief lapses of awareness.
Probably the best-known seizure disorder is the generalized tonic-
clonic form that causes grand mal seizures, with loss of consciousness
and tonic (stiffening) muscle contractions, followed by clonic
(twitching, jerking) muscle contractions of the limbs, clenched teeth,
and/ or loss of bowel or bladder control. After the shaking subsides,
the individual may fall asleep or appear confused for a few minutes.
The patient may experience an aura, usually a sensory warning (e.g.,
a specific smell or taste) before a grand mal seizure.
Diagnosis depends on an accurate seizure history, EEG, and CT
or MRI scans. Seizures cannot be cured but usually can be controlled
effectively by pharmaceutical treatment; however, finding the most

Cushion head Loosen tight neckwear
Nothing in mouth
As seizure ends
Most seizures in people with epilepsy are
not medical emergencies. They end after
a minute or two without harm and usually
do not require a trip to the emergency room.
But sometimes there are good reasons
to call for emergency help. A seizure in
someone who does not have epilepsy could
be a sign of serious illness.
FIGURE 20-6 First aid for seizures. (Modified from www.epilepsyfoundation.org.)
effective medication at the right dose can be complex. Depending
on the seizure type, different medications are prescribed. Some indi-
viduals with epilepsy require more than one drug or have to try
multiple medications until the most effective one is found. Antisei-
zure (anticonvulsant) medications include phenytoin (Dilantin),
carbamazepine (Tegretol), valproic acid (Depakene), gabapentin
(Neurontin), levetiracetam (Keppra), clonazepam (Klonopin), and
lamotrigine (Lamictal). It is very important that patients know never
to stop taking their seizure medication without the physician's super-
vision because this may trigger more frequent and severe seizure
episodes.
Central Nervous System Infections
Encephalitis
Most cases of encephalitis are viral in origin and are transmitted to
humans from mosquitoes and ticks or are caused by other infections,
such as herpes infections. In mild cases symptoms include stiff neck
and headache, muscle aches, malaise, and general flulike symptoms.
In more severe cases, the symptoms can include fever, delirium,
seizures, coma, and even death.
CHAPTER 20 Assisting in Neurology and Mental Health 527
f"-
1
'
- --- --
Turn on side
Look for I.D. Don't hold down
... offer help
Other reasons to call an ambulance include:
• A seizure that lasts more than 5 minutes
• No "epilepsy'' or "seizure disorder'' I.D.
• Slow recovery, a second seizure, or difficulty
breathing afterward
• Pregnancy or other medical I.D.
• Any signs of injury or sickness
Encephalitis is diagnosed by an MRI or a CT scan of the brain;
lumbar puncture with CSF analysis, including cultures to determine
the causative microorganism; EEG; and blood tests to detect viral
antibodies. A patient with cerebral inflammation from encephalitis
may suffer from confusion, disorientation, and other behavioral
changes. These symptoms are part of the disease and usually disap-
pear when the condition improves.
Patient management treats the symptoms and is aimed at control-
ling fever and seizure activity, in addition to constant monitoring of
respiratory and urinary functions. Viral encephalitis is treated with
antiviral medications, such as acyclovir (Zovirax) and foscarnet
(Foscavir); if the condition is caused by herpes simplex, acyclovir
(Zovirax) or ganciclovir (Cytovene) is prescribed; bacterial encepha-
litis is treated with antibiotics. In patients with severe CNS damage,
recovery usually is prolonged, and physical therapy is necessary to
overcome the neurologic and musculoskeletal complications.
Meningitis
Meningitis is an infection and inflammation of the meninges and
CSF of the brain and spinal cord that can be caused by
528 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES

viruses, bacteria, or fungi. Meningitis is transmitted from an infected The extent of CNS injury can be limited with the proper use of
individual through coughing, sneezing, kissing, or sharing personal child car seats, adult safety belts, helmets in childhood sports and
items, such as eating utensils or a toothbrush. Viral meningitis usually activities, and reducing the frequency of drinking and driving.
is mild and has flulike symptoms that typically resolve in about 2 Several types of brain injuries can occur, depending on the type and
weeks without treatment. Fungal meningitis is seen in patients with amount of force with which the head is struck.
immune deficiencies, such as acquired immunodeficiency syndrome
(AIDS), and can be life-threatening. Acute bacterial meningitis can Cerebral Concussion and Contusion
occur as a complication of an earlier infection of the ears, sinuses, or Concussion is the mildest and the most common type of brain
lungs, or it can be transmitted from an infected person. injury. Trauma from an impact or a sudden change in motion can
Distinguishing between the types of meningitis is difficult but cause a concussion with loss of consciousness, which may last
extremely important for effective, early treatment. Haemophilus seconds to several minutes and may be followed by a period of
meningitis was once the most common form of bacterial meningitis disorientation that lasts up to 24 hours (Figure 20-7). A single con-
but the Haemophilus influenzae b (Hib) pediatric vaccine has greatly cussion may disrupt the normal electrical activity in the brain, but
reduced the number of cases. Bacterial meningitis can be quite the brain usually is not injured permanently. However, research
serious; symptoms include a high fever, severe headache, stiff has shown that the damage from multiple concussions may be
neck, photophobia, confusion, seizures, and positive Brudzinski's
and Kernig's signs. The diagnosis is confirmed by analysis of a CSF
sample, which is tested for bacteria or blood; glucose levels (low
levels occur in bacterial or fungal meningitis); and white blood cells
(elevated WBCs indicate infection). The procedure is done in a
hospital and takes about 45 minutes. Additional diagnostic tests
include a CT scan to identify brain swelling, hemorrhage, or abscess
and/or an MRI scan, which produces clearer pictures than a CT scan
and can help identify brain and spinal cord inflammation and infec-
tion. The individual typically is ordered antibiotics and antiviral
medications while waiting for final laboratory results because a delay
in treatment can be life-threatening. The patient also is treated with
analgesics and medications to reduce cerebral edema. Despite treat- Concussion
ment, bacterial meningitis can be fatal or can cause long-term neu-
rologic damage.

Brain and Spinal Cord Injuries

Traumatic brain injuries are caused by a blow or jolt to the head.
They may be limited to a particular section of the brain or may result
in generalized neurologic damage. Injuries can range from a mild
concussion to severe injury, coma, and death. A minor concussion
usually has no long-term side effects; however, a moderate to severe
brain injury can result in headaches, amnesia, confusion, personality
changes, and seizures. Spinal cord injuries usually result from severe,
accidental trauma to the back or neck. These injuries are most Contusion
common in the 16- to 30-year-old age group and are associated with
automobile and sports accidents. The higher the damage to the FIGURE 20-7 Brain concussion and contusion. (Modified from Frazier MS, Drzymkowski JW:
spinal cord, the more serious the injury. Essentials of human diseases and conditions, ed 5, St Louis, 2013, Saunders.)

Signs of a Concussion
Signs of a concussion that occur seconds to minutes after a head injury The patient should be seen immediately if he or she reports any of the
include: following signs and symptoms days or weeks after a head injury:
• Possible loss of consciousness • Persistent headache
• Difficulty focusing, with slowed responses • Vertigo (dizziness)
• Slurred speech • Inability to concentrate
• Nausea and vomiting • Repeated problems with memory
• Headache • Nausea or vomiting (especially if vomiting is projectile)
• Blurred vision • Unusual anger, irritability, anxiety, or depression
• Confusion and disorientation or amnesia • Sleep disorders
• Seizures

TABLE 20-4 Glasgow Coma Scale
SCORE 1 2
Eye opening No response To pain
Best motor response No response Extension to pain
(movement of arms and legs)
Best verbal response No response Incomprehensible sounds
Scoring: 13 to 15, mild head injury; 9 to 12, moderate head injury; 3 to 8, severe head injury.
cumulative. No one knows how many concussions are too many
before permanent damage occurs. The medical assistant should help
gather a comprehensive head injury history so that the provider is
aware of all previous concussions, including those that occurred
outside playing sports, to determine when or if a child should return
to sports activities.
A more serious injury to the brain can cause the formation of a
contusion, or bruised area, usually because of a skull fracture. Symp-
toms can include headache, nausea, vomiting, vision disturbances,
and sensitivity to light. Talking with the patient may reveal reduced
levels of concentration, irritability, or periods of amnesia. The
Glasgow Coma Scale (GCS) is one of the most commonly used
severity scoring systems for assessing coma and impaired conscious-
ness (Table 20-4).
Brain Injuries
The Centers for Disease Control and Prevention (CDC) has developed a free,
downloadable tool kit, "Heads Up: Brain Injury in Your Practice," which is
available at the following website: http://www.cdc.govjheodsupjindex
.html. It provides practical, easy-to-use clinical tools for assessing and manag-
ing head injuries. Medical assistants should be knowledgeable about the
potentially serious damage that can occur with concussions and the importance
of early diagnosis. Information on the website includes:
• Abooklet for physicians with information on the diagnosis and
management of mild traumatic brain injury (MTBI) or concussion
• Apatient assessment tool (Acute Concussion Evaluation [ACE])
• Acare plan to help guide a patient's recovery
• Fact sheets in English and Spanish on preventing concussion
• Apalm card for on-field management of sports-related concussion
(ideal for education of coaches)
From http:j/www.cdc.govjheadsupjindex.html. Accessed February 11, 2016.
CRITICAL THINKING APPLICATION 20-4
• Mai is putting together information on head injuries for the family of a
patient who recently suffered a minor concussion. The family should watch
for what symptoms? When should the family seek additional medical
care? What resources could Mai use to develop the pamphlet?
• Dr. Song said he would approve the pamphlet after Mai completed it,
but he was called away on an emergency before he saw it. Apatient
sees it behind the desk and asks to take one. Should Mai let him? Why
or why not?
CHAPTER 20 Assisting in Neurology and Mental Health 529
3 4 5
To voice Spontaneously
Flexion to pain Localizes to pain Follows commands
Inappropriate words Disoriented and converses Oriented and converses
Open and Closed Head Injuries
In a closed head injury, a brain injury occurs but the skull is not
fractured. A more serious brain injury can occur with an open head
injury because the skull is fractured or displaced. A serious head
injury can cause life-threatening damage to the intracerebral struc-
tures. Subarachnoid hemorrhage may occur when the delicate men-
ingeal blood vessels are ruptured, resulting in the collection of blood
in the subarachnoid space. This causes a rapid increase in intracranial
pressure, which may give rise to sudden, severe headache; nausea and
severe projectile vomiting; motor disturbances; visual disturbances;
and seizures. In addition to trauma, other predisposing factors that
can cause subarachnoid hemorrhage include hypertension, a family
history of the condition, and congenital malformations of cranial
blood vessels. Treatment is designed to reduce the intracranial pres-
sure, sometimes surgically.
A subdural hematoma develops when blood collects in the space
between the dura mater and the arachnoid layers of the meninges,
usually as a result of head trauma that has caused slow bleeding from
ruptured blood vessels in the meningeal layers. Symptoms of
increased intracranial pressure occur over several days as the hema-
toma increases in size. Signs and symptoms build over time and
include headache, motor disturbances, speech abnormalities, nausea
and vomiting, seizures, and a decreased level of consciousness. Treat-
ment requires surgery to stop the bleeding and reduce the pressure
inside the skull. People age 75 or older are at greatest risk of develop-
ing a subdural hematoma after a minor fall.
Shaken Baby Syndrome
Shaken baby syndrome is the most common reason for serious head
injury in infants. It is caused by violently shaking the infant back
and forth, forcing the brain against opposite ends of the skull.
Shaking is so dangerous for babies because of their small size com-
pared to their relatively large head size, in addition to their undevel-
oped neck muscles. The typical presentation is a child approximately
6 months old who is brought to the clinic or emergency department
because of difficulty breathing or marked lethargy. Usually little or
no external bruising or trauma is seen. Physical findings on examina-
tion or autopsy include a subdural hematoma and retinal hemor-
rhages. The history given by the caregiver usually indicates that the
baby "fell" from the sofa, coffee table, or bed or was "dropped."
Approximately one fourth of these infants die of their injuries.
Spinal Cord Injuries
If a traumatic accident completely transects the spinal cord, all CNS
stimulation to nerves distal to the injury stops, resulting in paralysis
of the areas below the injury. The most common causes of spinal cord
530 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES
Quadriplegia Paraplegia
FIGURE 20-8 Types of paralysis: quadriplegia and paraplegia. (Modified from Frazier MS,
Drzymkowski JW: Essentials of human diseases and conditions, ed 5, St Louis, 2013, Saunders.)
injuries in the United States are car or motorcycle accidents; falls,
especially in those over age 65; violence; sports injuries; and diseases
that cause inflammation of the spinal cord, including arthritis and
cancer. Paralysis from spinal cord transection is classified into one
of two categories (Figure 20-8). In paraplegi,a, transection occurs
below the midpoint of the spinal cord, causing paralysis of both legs;
loss of function below the level of injury, including loss of bladder
and bowel control; and sexual dysfunction in males. In quadriplegi,a,
transection occurs in the upper thoracic or cervical region of the
spinal cord, causing paralysis of all four limbs, respiratory difficulty,
and loss of function to all muscles below the injury point. Hemiplegi,a
is unrelated to spinal cord injury and occurs when a CVA, a vascular
injury such as a ruptured aneurysm, or a tumor occurs on one side
of the brain, resulting in paralysis on the opposite side of the body.
No surgery or treatment can restore a transected cord, although
much research currently is under way, including electrical stimulation
of nerves and medications to promote nerve cell regeneration or
improve the function of the nerves that remain after a spinal cord
injury. Treatment also includes surgical stabilization of the spine, physi-
cal and occupational therapy, and the use of assistive devices. If the
spinal cord is injured but not completely transected, the degree of
paralysis depends on the degree ofinjury. Such patients usually respond
well to physical therapy, and their ability to restore motor function is
good, although they may always have some functional limitations.
Additional Central Nervous System Pathologies
Parkinson's Disease
Parkinson's disease (PD) is a chronic, progressive, debilitating disease
that affects about 1% of individuals over age 60; more than 50,000
new cases are reported annually in the United States. PD is slightly
more common in men than women. The four primary symptoms of
PD are tremors of the hands, arms, legs, jaw, and face; rigidity of
the limbs and trunk; bradykinesia, or slowness of movement; and
postural instability with impaired balance and coordination. The
typical presentation of PD includes a unilateral, pill-rolling tremor;
a high-pitched, monotone voice; difficulty swallowing; a masklike
facial expression; and bowed head and forward-bent posture. Tremors
and rigidity increase in severity over time. Currently there are no
laboratory tests specific for PD; therefore, the diagnosis is based on
a comprehensive medical history and neurologic examination.
Parkinson's disease is believed to be caused by a combination of
genetic and environmental factors that result in a deficiency of the
neurotransmitter dopamine in the brain. It is diagnosed with a com-
prehensive neurologic examination to determine symptoms and their
severity. There is no test that clearly identifies the disease. PD has no
cure, but the most common medication prescribed for symptomatic
relief is carbidopa-levodopa (Sinemet). Levodopa enters the brain and
is converted to dopamine; carbidopa increases levodopa's effectiveness
and prevents or decreases many of the side effects of levodopa. Dopa-
mine agonists, which mimic the effects of dopamine, are also pre-
scribed; these include pramipexole (Mirapex) and ropinirole (Requip).
Although the initial response to medical treatment can reflect dramatic
relief of symptoms, over time the body's response to parkinsonian
medications declines. Surgical destruction of the most affected area of
the brain may produce some relief of symptoms.
Another treatment option is deep brain stimulation (DBS), in
which a surgically implanted device similar to a cardiac pacemaker
delivers electrical stimulation to specific areas in the brain that
control movement; this also blocks the abnormal nerve signals that
cause PD symptoms.
Tumors
The symptoms of a brain tumor depend on the type and location of
the mass, but generally the initial symptoms are headaches, vomit-
ing, dizziness, diplopia, and alterations in muscle strength and
coordination. Changes in personality and mental function, seizures,
progressive paralysis, loss of speech, and sensory disorders appear as
the tumor enlarges.
CNS tumors can be diagnosed by means of CT, MRI, EEG, or
lumbar puncture. Ophthalmoscopic examination may reveal papil-
ledema. Accurate diagnosis of a brain tumor includes determining its
precise location in the brain and whether it is benign or malignant.
Approximately half of all brain tumors are metastatic growths from
other primary cancer sites in the body. Lung cancer, breast cancer, and
melanoma frequently spread to the brain by metastasis. Regardless of
whether the mass is benign or malignant, as brain tumors grow, they
cause serious problems and complications for the patient because of
the limited space inside the skull. Treatment of brain tumors can
include surgery, chemotherapy, and radiation in any combination.
CRITICAL THINKING APPLICATION 20-5
A34-year-old man has just found out that he has a brain tumor, and Mai
is ta schedule him for surgery next week. Before he leaves the office, he
says he wants to talk to Mai privately. They go into an examination roam,
and he says, "Tell me the truth; this is cancer, and I'm going to die, right?"
How should Mai respond to this frightened patient?

DISEASES OF THE PERIPHERAL NERVOUS SYSTEM
Multiple Sclerosis
The axon of a nerve cell is covered with a myelin sheath to protect
and insulate electrical stimulation as it passes to the terminal end of
the neuron. Multiple sclerosis (MS) is an autoimmune disease that
causes progressive inflammation and deterioration (demyelination)
of the myelin sheath; this leaves nerve fibers uncovered, which results
in scattering of the nervous message as it passes down the axon.
Myelinated axons are commonly called white matter. Researchers
have learned that MS also damages the nerve cell bodies, which are
found in the brain's gray matter, in addition to the axons themselves
in the brain, spinal cord, and optic nerve. The term multiple sclerosis
refers to the distinctive areas of scar tissue (sclerosis, or plaques)
present in the white matter of people who have MS. These areas are
visible on MRI brain scans.
There is no single test used to diagnose MS. Diagnosis is difficult
because the signs and symptoms of the disease mimic those of other
neurologic disorders. Diagnostic studies include a complete history and
physical with a detailed neurologic examination and an MRI of the
brain and spinal cord to look for distinctive plaques and areas of scle-
rosis from scar tissue at the inflammation sites. MS frequently is
diagnosed by the exacerbation and remission of neurologic symptoms
characteristic of the condition. Patients cycle through remission and
relapse with an ever-increasing degree of dysfunction after each episode.
Early symptoms may include numbness, paresthesia, diplopia,
ataxia, and bladder control problems. As the disease progresses,
patients experience increased spasticity, vertigo, depression, gait
problems, joint pain, fatigue, and varying degrees of paralysis. MS
most commonly begins in women between the ages of 20 and 40.
The cause remains unknown; however, the common belief is that it
is due to a combination of genetic and environmental factors,
including family history, living in a Northern climate, low vitamin
D levels, smoking, and viral infection.
MS has no cure; therefore, treatment focuses on alleviating symp-
toms and delaying the progression of the disease. Medications used
to treat the disease include corticosteroids during periods of
exacerbation: interferon (Betaseron, Avonex) and glatiramer acetate
(Copaxone) to reduce the frequency and severity of relapses; fingoli-
mod (Gilenya) for relapsing forms of MS, and additional medications
to treat fatigue, pain, spasticity, and bladder control problems. Some
patients live an essentially normal life with only occasional attacks,
whereas others experience rapidly progressive incapacitation.
Amyotrophic Lateral Sclerosis
Amyotrophic lateral sclerosis (ALS), or Lou Gehrig's disease, is a
rapidly progressive, ultimately fatal neurologic disease that destroys
the motor neurons responsible for voluntary muscle control. Without
stimulation from motor neurons, muscles cannot function and
gradually weaken and atrophy. The cause is unknown. The disease
is more common among white males 60 to 69 years of age, but
younger and older people also can develop the disease. In about 5%
to 10% of individuals with ALS, the disease is inherited, with one
parent carrying the faulty gene. The diagnosis is primarily based on
symptoms and signs and a series of tests to rule out other diseases.
ALS usually begins with small, local, involuntary muscle contrac-
tions in the forearms and hands. As the disease progresses, the patient
CHAPTER 20 Assisting in Neurology and Mental Health 531
has difficulty with speech, chewing, swallowing, and breathing. In
most cases the disease does not affect a person's personality, intelli-
gence, or memory, nor does it affect the ability to see, smell, taste,
hear, or recognize touch. The first drug treatment for the disease is
riluzole (Rilutek), which reduces damage to motor neurons and
prolongs survival, especially in patients with difficulty swallowing.
Other treatments, which are palliative, include attempts to keep the
individual as comfortable as possible and to help with pain, depres-
sion, sleep disturbances, and constipation. Death from failure of the
respiratory muscles usually occurs within 3 to 5 years after the onset
of symptoms.
Bell's Palsy
Bell's palsy is a temporary facial paralysis. It results from inflamma-
tion and edema of cranial nerve VII, which in turn are caused by a
viral infection (e.g., herpes simplex or Epstein-Barr virus). The con-
dition occurs suddenly, and symptoms reach their peak within 48
hours. The disorder usually subsides spontaneously over several
weeks to months. Symptoms range in severity from mild weakness
to complete paralysis on the affected side, depending on the degree
of nervous involvement. The patient can experience facial twitching,
eyelid drooping, excessive tearing of the affected eye, and drooping
of the mouth with drooling of saliva. The patient is unable to close
the eye on the affected side completely and may have taste distur-
bances. The antiviral drug acyclovir may be prescribed, in addition
to prednisone to reduce the inflammation and control edema. The
physician recommends an eye patch to protect the exposed eye,
especially at night, to prevent corneal abrasions.
Peripheral Neuropathy
Peripheral neuropathy is not a disease in itself, but rather a condi-
tion of peripheral nerve dysfunction that can have more than 100
different known causes. It can be cryptogenic, or idiopathic, which
means that the underlying cause cannot be identified. Conditions
that can cause peripheral neuropathy include diabetes mellitus,
human immunodeficiency virus (HIV) infection, nutritional defi-
ciencies, and neurologic side effects of some medications. Symp-
toms usually affect the legs and arms and can include muscular
weakness and pain or sensory disturbances such as burning, numb-
ness, and tingling.
Symptoms can vary widely from person to person in both number
and severity. Patients often feel extremely frustrated when they try
to explain to the physician the abnormal sensations they are experi-
encing. Peripheral neuropathies can result from damage or injury to
any portion of the neuron. Treatment of peripheral neuropathy is
most effective when the causative condition is diagnosed and then
treated successfully. Encouraging a healthy lifestyle, including weight
control, exercise, a nutritious diet, and limiting or avoiding alcohol,
helps control the physical and emotional effects of peripheral
neuropathy.
Mental Health
Each year more than 44 million Americans are affected by a diagnos-
able mental condition that adversely affects their work, their rela-
tionships with family and friends, and their activities of daily living.
Mental health disorders can be caused by a number of factors, alone
or in combination, including changes in brain chemicals, hereditary
532 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES
makeup, psychological disposition, and life experiences. Emotional
and physical symptoms can occur for no apparent reason and can
be quite persistent. Emotional symptoms may include panic, appre-
hension, fear, anxiety, nightmares, withdrawal, flashbacks, and ritu-
alized repetitive behaviors, such as constant hand washing. Possible
physical symptoms include tachycardia, shortness of breath, sleep
disturbances, gastrointestinal upset, muscular tension, and cold,
clammy hands. Patients often do not associate these symptoms with
a mental health disorder and therefore do not get the appropriate
diagnosis and treatment.
Depressive Disorders
About 10% of adults in America experience depression each year.
Almost twice as many women as men are affected by the disorder.
Depression interferes with daily activities and causes pain and suf-
fering not only to those who have the disorder, but also to those who
care about them. Although multiple medications and psychosocial
therapies are available to treat and manage depression, most indi-
viduals do not seek treatment. Depressive disorders affect the way a
person thinks, feels, eats, and sleeps. People with depression cannot
"snap out of it" and without treatment may experience symptoms
that persist for weeks, months, or years.
Depressive disorders can be categorized as major depressive dis-
orders, dysthymic disorders, and bipolar disorders. Individuals with
major depression show a combination of symptoms that interfere
with their ability to work, study, sleep, eat, and enjoy activities they
once considered pleasurable. Dysthymic disorders are a less severe
type of depression in which patients experience long-term, chronic
symptoms that are not incapacitating but that affect their level of
performance and daily emotions. Many people with dysthymia also
experience major depression at some time in their lives. Individuals
with bipolar disorders, also called mood disorders or manic-depression,
cycle through a wide range of moods from extreme highs (mania)
to extreme lows (depression). When in the depression cycle, they
may show any or all of the symptoms of a depressive disorder. When
cycling through mania, they may make decisions or act in a way that
can be both embarrassing and dangerous. Manic individuals are
extremely energetic and rarely sleep. If left untreated, the disorder
can progress to a psychotic state.
Patients must understand that antidepressant medications take a
minimum of 3 to 4 weeks for the full therapeutic effects of the drug
to occur. Once they start to feel better, many individuals are tempted
to stop taking the medication. It is important to continue treatment
for a minimum of 4 to 9 months to prevent a recurrence of the depres-
sion. The patient should never stop taking antidepressant medication
suddenly or without the direction of a physician. Individuals with
bipolar disorders or chronic major depression may need maintenance
therapy indefinitely.
Treatment for depression typically begins with a selective sero-
tonin reuptake inhibitor (SSRI) because these medications have
limited side effects. SSRis include fluoxetine (Prozac), paroxetine
(Paxil), sertraline (Zoloft), and citaloprarn (Celexa). Other medica-
tions include duloxetine (Cymbalta), venlafaxine, and bupropion
(Wellbutrin). If the patient's symptoms are not relieved, the physi-
cian may order an older group of drugs called tricyclic antidepressants
(TCAs), such as imiprarnine (Tofranil), which inhibit the reabsorp-
tion of serotonin and norepinephrine.
Recently, concern has arisen about the association of suicidal
thoughts with antidepressant medications in children and adults in
the first few weeks of treatment and also when dosages are altered.
The U.S. Food and Drug Administration (FDA) has warned physi-
cians to monitor patients closely when starting antidepressant
therapy and to provide patient and family education on the impor-
tance of reporting to the physician any changes in symptoms.
Symptoms of Depression
According to the National Institute of Mental Health (NIMH), the severity
of depressive symptoms varies among individuals and also with each
episode. Adiscussion of the following symptoms can be found at the NIMH
website: http:j/www.nimh.nih.gov/index.shtml.
• Persistent sad, anxious, or "empty" feeling
• Feelings of hopelessness and pessimism
• Feelings of guilt, worthlessness, and helplessness
• Loss of interest or pleasure in hobbies and activities that once were
enjoyed, including sex
• Decreased energy and complaints of fatigue
• Difficulty concentrating, remembering, and making decisions
• Insomnia, early morning awakening, or oversleeping
• Either anorexia and weight loss or overeating and weight gain
• Thoughts of death or suicide, with possible suicide attempts
• Restlessness, irritability
• Persistent physical complaints that do not respond to treatment (e.g.,
headaches, gastrointestinal disturbances, or chronic pain)
Anxiety Disorders
Anxiety disorders affect approximately 19 million American adults.
The primary symptoms are an overwhelming, irrational feeling of
anxiety and fear. Anxiety disorders include panic disorder, obsessive-
compulsive disorder (OCD), post-traumatic stress disorder (PTSD),
and phobias. Individuals with panic disorder report feelings of terror
that strike unexpectedly and are accompanied by nausea, chest pain,
palpitations, diaphoresis, weakness, vertigo, syncope, and a fear of
impending doom or loss of control. People with OCD experience
anxious thoughts or images (obsessions) that they cannot control, so
they resort to performing specific rituals (compulsions) to try to
prevent or dispel the obsession. For example, an individual may be
obsessed with germs or dirt, so he or she repeatedly washes the
hands; or an individual may have to check repeatedly to make sure
a door is locked because of fear that it will be left open. Performing
the ritual does not bring pleasure, only temporary relief of the
anxiety caused by the obsession, which will grow if the compulsion
is not performed.
PTSD can occur after a patient is a part of or witnesses some
terrifying, horrendous, or violent physical or emotional event, such
as assault, battery, rape, war, natural disasters, acts of terrorism, and
serious accidents during which many people are killed or injured.
The person who survives the ordeal often has flashbacks; feelings of
panic, fear, or guilt; constant replaying of the event in his or her
mind; or deep feelings of emotional numbness.
As a result, the person is constantly on guard for a possible threat;
has an exaggerated reaction when startled; and is frequently irritable,

has difficulty concentrating, and experiences sleep problems. Severe
depression and inability to function normally in daily activities also
may be present.
A phobia is an intense, irrational fear of something that poses
little or no actual danger. It may include such things as fear of
heights, escalators, tunnels, and water. Although the individual may
realize that the fear is unreasonable, just the thought of facing the
feared object or situation causes a panic attack or severe anxiety. The
two types of treatment for anxiety disorders are antianxiety medica-
tion, such as alprazolam (Xanax) or buspirone, and specific types of
psychotherapy.
Schizophrenia
Schizophrenia is a chronic, severe, disabling brain disorder with
symptoms that include hallucinations and delusions; difficulty speak-
ing and expressing emotions; and cognitive deficits, such as problems
with concentration and memory loss. Schizophrenia cannot be cured,
but psychotic episodes can be reduced significantly by long-term,
consistent pharmaceutical treatment. However, relapses are not
unusual, because most individuals with schizophrenia stop taking
their antipsychotic medication periodically because they feel better,
they do not believe they need the medication, or they do not think
that taking it regularly is important. In addition, the earliest antipsy-
chotic medications, such as chlorpromazine (Thorazine) and halo-
peridol (Haldol), caused disturbing side effects, including rigidity,
persistent muscle spasms, tremors, and restlessness. Newer drugs,
which have limited side effects, include risperidone (Risperdal),
olanzapine (Zyprexa), and aripiprazole (Abilify).
Suicide Facts from the National Institute
of Mental Health
• More than 90% of individuals who commit suicide have a diagnosable
mental disorder, typically depression, or are substance abusers.
• The highest suicide rate in the United States is seen in Caucasian men
ages 45 to 59.
• Suicide is the tenth leading cause of death in the United States, but
the third leading cause of death among 15- to 24-year-olds.
• Although women attempt suicide two to three times more often than
men, four times as many men are successful.
• Twenty percent of those who commit suicide in the United States are
veterans.
• Risk factors vary with age, gender, and ethnic group. They include
serious depressive disorders; reduced levels of serotonin (a neurotrans-
mitter); a prior suicide attempt; family violence, including physical or
sexual abuse; and exposure to the suicidal behavior of others, including
family members and peers.
www.nimh.nih.govjhea/th/statistics/suicidejindex.shtml. Accessed January 20, 2015.
CHAPTER 20 Assisting in Neurology and Mental Health 533
THE MEDICAL ASSISTANT'S ROLE IN
THE NEUROLOGIC EXAMINATION
As with other physical examinations, a careful history provides the
physician with valuable clues in diagnosing neurologic conditions.
Such clues may include a record of seizures, syncope, diplopia,
incontinence, or any of the previously mentioned subjective symp-
toms. The patient's general health often complicates a neurologic
diagnosis.
The purposes of a neurologic examination are to determine
whether a nervous system problem is present, to discover its loca-
tion (or locations), and to identify the type and extent of the
malfunction. During the examination, the physician may deter-
mine the effect of the symptoms on the patient's emotional status,
intellectual performance, cognitive ability, and general behavior
(Procedure 20-1 ). The patient's grooming and mannerisms are
carefully observed, as is his or her ability to communicate effec-
tively, including the appropriate use of speech, language, and
writing skills. The medical assistant should listen carefully for dif-
ficulty putting words together, slurred speech, and whether the
conversation makes sense. If you notice inappropriate changes in
the patient, note them on the patient's record for the physician's
attention and evaluation.
The physical examination of the neurologic system includes eval-
uation of the cranial nerves. You can assist by helping the patient
assume the proper position necessary for each test and by having the
instruments the physician needs ready for use. For example, cranial
nerve I (the olfactory nerve) is tested by determining the patient's
ability to identify familiar odors, such as coffee, tobacco, or cloves.
Cranial nerve V (the trigeminal nerve) is checked by having the
patient differentiate between warm and cold objects held against the
right and left cheeks.
Peripheral nerve function is evaluated by examining the motor
system, including muscular strength, gait, and movements. The
diameters of the upper arms and the calves of the legs may be
measured and compared to diagnose muscle atrophy. Motor func-
tioning can be assessed through Romberg's test, in which the
patient is asked to stand with the feet together, arms horizontal to
the body, and eyes closed. The sensory system is examined by
noting the patient's ability to perceive superficial sensations, such as
a wisp of cotton brushed on the skin, a light pinprick, or hot and
cold touching certain areas. Several deep tendon reflexes (DTRs),
such as the patellar and Achilles reflexes, are checked (Figure 20-9).
Babinski's reflex is tested by stroking the lateral aspect of the sole
of the foot with a dull instrument (e.g., the handle of a reflex
hammer or a tongue blade). For a positive Babinski's sign, the great
toe dorsiflexes while the other toes fan out. This may indicate a
possible stroke or brain lesion. Other diagnostic tests may include
a skull radiograph, carotid arteriogram, EEG, and MRI and CT
studies.
534 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES

FIGURE 20-9 Testing deep tendon reflexes. A, Biceps reflex-results in flexion of the elbow. B, Brachioradialis reflex-results in flexion
and supination of the forearm. C, Triceps reflex-results in extension of the arm. D, Patellar reflex-results in extension of the leg. E, Achilles
reflex- results in plantar flexion of the foot.
 CHAPTER 20 Assisting in Neurology and Mental Health 535

•;;m,i11mjfJ1j• Assist the Provider with Patient Care: Assist with the Neurologic Examination

Goal: To assist the provider in performing aneurologic examination of the patient.

EQUIPMENT and SUPPLIES 2. Sanitize your hands and fallow Standard Precautions.
• Patient's record PURPOSE: To ensure infection control.
• Patient gown 3. Greet and identify the patient by name and date of birth, and introduce
• Drape yourself. Briefly explain the procedure.
• Otoscope PURPOSE: Explanations gain the patient's cooperation and ease
• Ophthalmoscope apprehension.
• Percussion hammer 4. Instruct the patient to disrobe as needed far the examination and to put on
• Disposable pinwheel an exam gown with the opening in the back.
• Penlight S. During the examination, be prepared to assist the patient in changing posi-
• Tuning fork tions as necessary. Have the necessary examination instruments ready far
• Cotton ball the provider at the appropriate time during the examination. Record all
• Tongue depressor results from the examination as indicated by the provider.
• Small vials of warm and cold liquids prepared according to the provider's PURPOSE: To facilitate a thorough, accurate neurolagic examination.
instructions 6. Aneurologic examination proceeds as fallows but can be modified according
• Small vials of sweet and salty liquids prepared according to the provider's to the provider's preference:
instructions • Mental status examination
• Small vials containing substances with distinct odors (e.g., instant coffee, • Proprioception and cerebellar function
cinnamon, vanilla) prepared according ta the provider's instructions • Cranial nerve assessment
• Sensory nerve function
PROCEDURAL STEPS • Reflexes
1. Assemble and prepare the equipment and supplies needed far the neurologic
examination, and prepare the roam.

DIAGNOSTIC TESTING
Several tests are used to help the physician accurately diagnose condi-
tions and diseases of the neurologic system. The most common
diagnostic procedures are the lumbar puncture and various radio-
graphic studies (Table 20-5).

Electroencephalography
Electroencephalography is used to record the brain wave activity of
a patient suspected of having a seizure disorder or to determine the
effectiveness of pharmaceutical treatment to control the brain's
abnormal electrical activity. The particular pattern of brainwave activ-
ity helps diagnose the seizure disorder type. EEGs also are used to
help localize the area of the brain that is causing a partial seizure
disorder. To prepare for the test, the patient may be told to stop taking FIGURE 20-10 Patient undergoing electroencephalography. (From Linton A: lntroducfion to
certain medicines (sedatives, muscle relaxants, sleeping aids, or anti-
medical-surgical nursing, ed 4, St Louis, 2008, Saunders.)
seizure drugs) and to avoid all caffeine for 12 hours before the test.
During an EEG, 16 to 25 electrodes are placed on the patient's scalp
with either paste or an elastic cap to record the electrical activity of from the back of the head. Irregular slow waves are called delta waves,
the brain. The patient must remain very still during the examination, which normally are found in people deeply asleep and in infants and
even sleep if possible, so that the electrodes can pick up the electrical young children. A delta wave pattern is abnormal in an awake adult.
impulses of the brain without interference. Once the electrodes are Rhythmic slow waves, called theta waves, show a decrease in brain
in place, an EEG typically takes up to 60 minutes. Sedation may be activity. Electrical silence (fladine EEG) indicates no evidence of
required for pediatric patients (Figure 20-10). brain activity and is one of the criteria used to determine brain death.
Every individual has a unique EEG pattern. In a healthy brain, EEG is valuable for diagnosing epilepsy, brain tumors, and other
most of the recorded waves are the occipital alpha waves coming brain conditions (Procedure 20-2).
536 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES

TABLE 20-5 Diagnostic Tests for the Nervous System

TEST PROCEDURE AND PATIENT PREPARATION PURPOSE
Arteriography Patient usually is given a sedative. Then, after injection of a local anesthetic, a Ta visualize the vertebral and carotid
(angiography) catheter is threaded into an artery toward the head. Acontrast medium is arteries, cerebral arterial circulation, leaking
injected, and videofluoroscopic studies are recorded. The patient must remain still vessels, aneurysms, and occluded vessels
during the procedure, which may last up to 1 hour.
CT scan Patient's head is strapped into a foam black ta prevent movement, and patient Ta visualize multiple, serial, radiographic
lies on a moveable table. The table moves into the CT machine, which converts an sections of a structure, differentiating
x-ray study into a visual image of multiple transverse sections of the test structure. between bone and soft tissues
Procedure can last up ta 1 hour, and the patient must remain still the entire time.
EEG Patient relaxes comfortably on a recliner or bed. Electrodes are attached to the Ta record electrical activity of the brain ta
head. The examiner may ask the patient questions, give the patient various forms determine cerebral function or origin of
of visual or auditory stimulation, or have the patient sleep. seizure activity, diagnose sleep disorders, or
determine lack of brain function
Lumbar puncture With the patient in a side-lying fetal position, a local anesthetic is injected. A Ta determine (SF pressure, obtain (SF
needle then is inserted into the subarachnoid space between the third and fourth specimens for testing, reduce intracranial
lumbar vertebrae; (SF leaks out and is collected for analysis. Patient must remain pressure, and inject contrast medium for
very still during the procedure, which normally takes 5-20 minutes. radiographic studies
MRI Patient should not have any metal in the body. Patient lies down on a moveable As with CT, to visualize multiple, serial,
table, and the head is strapped into a foam block to prevent movement. The table radiographic sections of a structure; shows
moves into the MRI machine, which converts the cells' electromagnetic energy images of the brain, spinal cord, and
into a visual image. Patient must remain still during the procedure, which lasts up surrounding vascular and soft tissue
ta l hour.
PET scan Radioactive isotope is injected into the patient, and the brain is scanned to locate Aradionuclide study that can identify areas
areas of isotope concentration. Patient must remain still during the procedure, of increased metabolic activity, vascular
which lasts up to 2 hours. abnormalities, and space-occupying lesions
X-ray studies Patient's head is placed in a specific position in front of the x-ray film; patient Bone studies to identify fractures and other
must remain still for about 1 minute while x-ray is taken. bone pathologies
CSF, Cerebrospinal fluid; CT, computed tomography; EEG, electroencephalography; MRI, magnetic resonance imaging; PET, positron emission tomography.

Explain the Rationale for Performance of a Procedure: Prepare the Patient for an
PROCEDURE 20-2
Electroencephalogram

Goal: To prepare a patient physically and psychologically so that an accurate, useful electroencephalogram (EEG) can be
obtained.
EQUIPMENT and SUPPLIES 3. Tell the patient that the electrodes pick up tiny electrical signals from the
• Patient's record body and that there is no danger of electrical shock.
4. Explain that the test is painless, because the electrodes are attached to
PROCEDURAL STEPS the scalp with paste or an electrode cap is worn.
1. Greet and identify the patient by name and date of birth. Introduce S. If this is a sleep EEG, suggest that the patient stay up later than usual
yourself and explain that you will go over what is going to happen step the night before the test so that it will be easier to fall asleep.
by step to ensure the best results. PURPOSE: Sleep medications usually are not used because they may alter
2. Explain the purpose of the EEG, how the procedure is performed, and the brain wave pattern.
what is expected of the patient during the test.
 CHAPTER 20 Assisting in Neurology and Mental Health 537

6. Go over the physical preparation, including the diet to be followed for the 9. Ask the patient whether he or she has any questions. If so, answer the
48 hours before the test. This usually includes no stimulants (e.g., coffee, questions so that the patient understands the procedure clearly.
chocolate, or sodas) and no skipping meals. PURPOSE: Patients are more likely to cooperate if they understand the
PURPOSE: Meal skipping may cause hypoglycemia, which alters brain process so that they are not unduly apprehensive before and during the
function. test.
7. Explain that a baseline EEG will be taken at the beginning of the test and 10. Document patient education in the patient's record.
during this time the patient will be asked to avoid all movement, even
eye and tongue movement. NOTE: Advanced training is required ta perform an EEG.
PURPOSE: These activities can be very disruptive to the brain wave tracing.
8. If a stimulation examination is ordered, explain that the patient will be
asked to view flickering lights to stimulate the brain. The EEG will measure
the brain's response to this stimulation.

Lumbar Puncture
If the physician suspects that an infection or inflammation of the
CNS is present, a lumbar puncture (spinal tap) is ordered to collect
a CSF sample for culture and analysis of glucose and protein, or to
detect increased intracranial pressure or an area of intracranial bleed-
ing. The patient is placed on the left side in the fetal position; using
sterile technique, the physician injects the lumbar puncture site with
a local anesthetic, and the puncture is performed by inserting a
special needle into the subarachnoid space, usually between the L4
and L5 vertebrae (Figure 20-11 ). The pressure in the subarachnoid
space is recorded, and at least four tubes of CSF are collected for
laboratory analysis.
The most common complaint after the procedure is a severe
headache. Extended bed rest once was recommended to prevent a
spinal headache, but research no longer supports this approach. After
the procedure, the patient is encouraged to drink fluids to rehydrate
so that the CSF that was withdrawn during the spinal tap is replaced
as quickly as possible. Medical practices usually have a specially
equipped room where this procedure is performed. If you are
working in such an office, you may be responsible both for assisting
FIGURE 20-11 Lumbar puncture.
with the procedure and for monitoring the patient after the proce-
dure until he or she is sent home. Watch for side effects such as
severe headaches, visual disturbances, and pain. You also will have
particular office protocols to follow regarding the frequency of vital CRITICAL THINKING APPLICATION 20-6
signs, liquid intake, urine output, and visitors. Lumbar punctures Dr. Song wants to perform a lumbar puncture on a 10-year-old girl who he
usually are performed in hospitals, outpatient clinics, or surgical suspects has bacterial meningitis. Her mother agreed to the procedure, but
centers (Procedure 20-3). On discharge, patients should be told to while Mai is preparing the girl, the mother changes her mind. She is afraid
notify the physician immediately if they experience any numbness
that inserting a needle into her daughter's spine will paralyze the girl. What
and tingling of the legs; drainage of blood or liquid from the punc-
ture site; inability to urinate; or a persistent headache.
should Mai do in this situation?
538 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES

Assist the Provider with Patient Care: Prepare the Patient for and Assist with a Lumbar
PROCEDURE 20-3
Puncture

Goal: To prepare apatient physically and mentally for alumbar puncture so that aspecimen of cerebrospinal fluid (CSF) can
be obtained for testing.
EQUIPMENT and SUPPLIES 9. Perform a sterile skin preparation of the lumbar region in the usual
• Patient's record manner.
• Patient gown PURPOSE: To prevent bacterial infection at the puncture site.
• Drape 10. Place the sterile disposable lumbar puncture kit on an instrument stand
• Local anesthetic with appropriate syringe unit for the provider's use. Include a syringe with needle for aspiration of the
• Sterile, disposable lumbar puncture kit with specimen tubes local anesthetic.
• Instrument stand 11. When the provider is ready to perform the lumbar puncture, cleanse the
• Sterile gloves rubber top of the local anesthetic vial and hold the vial for the provider
• Permanent marker to label tubes or printed labels to aspirate the desired amount of drug.
• Laboratory requisitions as needed PURPOSE: To maintain sterile technique and expedite the procedure.
• Biohazard laboratory transport bag 12. Reassure the patient and help him or her hold still during injection of the
• Biohazard waste container local anesthetic and insertion of the spinal needle.
PURPOSE: To facilitate accurate insertion of the spinal needle.
PROCEDURAL STEPS 13. Attach the printed labels to the specimen tubes or, using the permanent
1. Assemble the materials needed, and prepare the room. Prepare the equip- marker, label the specimens #1, #2, and #3 in the order in which they
ment and supplies needed for the lumbar puncture. are collected. This is a crucial step in the procedure.
2. Sanitize your hands and follow Standard Precautions. PURPOSE: Different tests are done on different tubes. The accuracy of
PURPOSE: To ensure infection control. these tests depends on the tube on which they are performed.
3. Identify the patient by name and date of birth and introduce yourself. 14. Complete the laboratory requisition form and prepare the CSF specimens
Explain that you will go over what will happen step by step to ensure the for transport to the laboratory.
best results. PURPOSE: To ensure that all the necessary tests are ordered correctly.
4. Make sure the signed consent form is in the patient's record. 1S. Apply gloves and clean the area by disposing of sharps, biohazard materi-
S. Have the patient void just before the procedure. als, and regular waste in the normal manner. Sanitize your hands.
PURPOSE: To improve the patient's comfort during the procedure. 16. Monitor the patient and give liquids as directed by the provider.
6. Give the patient a hospital gown and have him or her put it on with the 17. Document the procedure in the patient's health record.
opening in the back. PURPOSE: Aprocedure is not complete until it has been documented
7. Place the patient in aleft side-lying fetal position for the lumbar puncture. accurately in the patient's health record.
PURPOSE: To give the provider the easiest access to the lumbar region.
8. Support the patient's head with a pillow as necessary and provide a pillow 9/15/20-8:32 AM: Lumbar puncture performed by Dr. Song. 300 cc CSF
for between the knees if needed. labeled and placed for pickup by North Hills Laboratory. Pt stable, no c/o dis-
PURPOSE: To make the patient as comfortable as possible for the comfort. Pt given instructions for home care before leaving office. M. Lee, (MA
procedure. (MMA)

CLOSING COMMENTS
Patient Education
The nervous system is the major communication and control system
in the human body. It influences and regulates all mental activity,
including thought, learning, and memory. It is responsible for main-
taining homeostasis (constant internal environmental conditions
that are compatible with life) among the body's systems. Through
its many receptors, the nervous system constantly monitors what is
going on inside the body and in the environment outside the body.
When the nervous system becomes damaged or diseased, signs
and symptoms can appear in every other body system. Motor activity
can become erratic, or the person's activity level can decline to the
point where the individual becomes unable to communicate or func-
tion normally.
Your main responsibilities as a medical assistant in neurology are
to observe, listen, and report any changes in patients. Even signs and
symptoms that may seem rather slight can give the physician the one
clue needed to put the puzzle together and arrive at a correct diag-
nosis before proceeding to the appropriate treatment. It is crucial
that medical assistants working in a neurology practice recognize the
importance and significance of a variety of symptoms. For example,
severe headache accompanied by vomiting may indicate a serious
intracranial problem that requires immediate attention. The medical

assistant in a neurology practice must remain alert to these types of
situations at all times, because neurologic emergencies can develop
quite rapidly.
Legal and Ethical Issues
In neurology you will be faced with a variety of behaviors and per-
sonality changes that frequently are a part of neurologic conditions.
Often a patient is not aware of these changes and may appear as
though nothing is wrong. You must treat this patient with the same
dignity and respect as you would all other patients, despite how the
patient may treat you. Some patients are concerned that loved ones
have turned against them and are treating them in an abusive
manner. A patient's family may be experiencing severe emotional
stress in coping with the patient's behavior. You must remember
the medical assistant's code of ethics and the need for total confi-
dentiality. Whatever is discussed in the examination room cannot
be repeated to other staff members in the office and can never be
discussed outside the office. Confidentiality must be strictly
maintained.
HIPAA Applications
Under the privacy regulations of the Health Insurance Portability
and Accountability Act (HIPM), patients typically have the right
to obtain a copy of their confidential health information. However,
access to psychotherapy notes is limited. HIPM defines psycho-
therapy notes as the documentation completed by a mental health
professional that describes and analyzes the conversations with a
patient during counseling sessions. These notes are not supposed to
i-fiiiiMH•jiii#IMUt•i
Mai has excelled in her new position as clinical assistant and patient educator.
With Dr. Sang's approval, she has developed a series af patient information
sheets that explain the functions of the nervous system, the symptoms to watch
for after a head injury, the kinds and causes of headaches, and infections of
the nervous system. Patients often ask for information sheets far other family
members and far their friends and neighbors. She also developed a set of
SUMMARY OF LEARNING OBJECTIVES
l. Define, spell, and pronounce the terms listed in the vocabulary.
Spelling and pronouncing medical terms correctty reinforce the medical
assistant's credibility. Knowing the definitions of these terms promotes
confidence in communication with patients and co-workers.
2. Summarize the anatomy and physiology of the nervous system.
The main function of the nervous system is to control body functions so
that homeostasis can be maintained. It does this by receiving messages
in the CNS from the PNS, then sending a response to the appropriate
location in the body, again via the PNS. The neuron is the functional cell
af the nervous system, and neuroglial cells support and protect neurons
CHAPTER 20 Assisting in Neurology and Mental Health 539
be stored in the patient's general chart and should not be released to
third-party payers. Disclosure of psychotherapy notes requires spe-
cific permission from the patient before any documentation can be
released to an insurance provider. Under federal law, the therapist
must decide whether to release the notes to the patient, and if the
therapist decides not to release the information, the patient cannot
appeal this decision. However, the final authority rests with indi-
vidual state laws. If a state law is stricter than the federal mandate
or gives the patient greater access to psychotherapy notes, state law
takes precedence over federal law. Further details about the HIPM
Privacy Rule are available at the following website: http://www.hhs
.govlhipaa!for-professionalslspecial-topicslmental-healthlindex.html.
Professional Behaviors
The ability to think critically is a crucial component of acting professionally,
especially in a neurologic practice, because patients present with a wide
variety of signs, symptoms, and mental health states. An important com-
ponent of critical thinking is the ability to question patients logically and
distinguish between relevant and irrelevant information. We must always
be on the alert far any personal bias that may prevent us from delivering
respecrlul patient care. This is especially true for interacting with patients
who have been diagnosed with mental illness. The medical assistant's
ability to conduct a professional and respecrlul patient history and to use
appropriate interpersonal communication skills lays the groundwork far the
client's care in the neurology office.
information sheets to explain typical neurolagic diagnostic tests and how best
ta prepare far them. Although the patient receives a copy of the information
sheet, Mai still talks with each patient to make sure he or she understands
exactly what will happen in the test and to answer all questions completely.
Mai feels a great deal of personal satisfaction from working with patients and
helping them understand their diagnosis and treatment protocols.
throughout the system. The brain is made up of the cerebrum, cerebe~
lum, and brainstem. The CNS is well protected, first by the skull and
then by the dura mater, arachnoid mater, and pia mater meninges.
3. Differentiate between the central and peripheral nervous systems.
The nervous system is made up of two parts: the CNS, which includes
the brain and spinal cord, and the PNS, which includes all the nerves
outside the CNS.
4. Distinguish among common nervous system diseases and conditions
and identify the typical symptoms associated with neurologic
disorders.
Continued
540 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES
SUMMARY OF LEARNING OBJECTIVES-continued
Symptoms of potentially serious neurologic conditions include headache,
nausea and vomiting, change in vision, altered level of consciousness,
memory loss, sleep disorders, confusion or disorientation, and problems
with mobility. Table 20-3 summarizes the most common diseases and
conditions of the nervous system.
5. Describe the pathology of cerebrovascular diseases.
(VD may be caused by atherosclerosis, hypertension, thrombi, emboli,
ar aneurysm. ATIA is a temporary limitation of function as a result af
short-term ischemia. A(VA occurs when the blood supply to a particular
part of the brain is cut off by an embolus, a thrombus, or an aneurysm
that bursts. Migraine headaches are related to a combination of a
problem with the trigeminal nerve and an imbalance of chemicals in the
brain. Multi-infarct dementia is caused by a series of small strokes that
interfere with the brain's blood supply, resulting in multiple areas of tissue
necrosis. Alzheimer's disease is the most common form of dementia in
older people.
6. Identify the various types of epilepsy.
Seizures are classified as either partial or generalized, based an how
much af the brain is involved in the abnormal electrical activity. Partial
seizures result from abnormal electrical activity in just one part of the
brain, whereas generalized seizures involve most or all of the brain.
Generalized seizures include petit mal seizures, which are brief episodes
characterized by staring, subtle body movement, and brief lapses of
awareness. Probably the best-known seizure disorder is the generalized
tonic-clonic disorder, which causes grand mal seizures.
7. Compare and contrast encephalitis and meningitis.
Encephalitis is a viral infection of the brain that can cause serious CNS
symptoms. Meningitis may be caused by viruses, bacteria, or fungi.
Bacterial meningitis is most serious. Viral meningitis usually resolves
without treatment or incident.
8. Explain the dynamics of brain and spinal cord injuries.
Traumatic brain injuries can range from a mild concussion ta severe injury,
coma, and death. Aminor concussion usually causes na long-term side
effects; however, a moderate to severe brain injury can result in head-
aches, amnesia, confusion, personality changes, and seizures. Head
injuries can be either open or closed, with possible serious intracerebral
damage and potential complications within the meningeal layers. Shaken
baby syndrome is caused by violently shaking an infant back and forth,
forcing the brain against apposite ends of the skull. The higher the
damage to the spinal cord, the more serious the injury.
9. Summarize common central nervous system (CNS) and peripheral
nervous system (PNS) diseases.
Parkinson's disease (PD) is a chronic, progressive, debilitating neuro-
logic disease that is caused by a combination of genetic and environ-
mental factors that result in a deficiency of the neurotransmitter
dopamine in the brain. Approximately half of all brain tumors are meta-
static growths from other primary cancer sites in the body. Multiple
sclerosis (MS) causes progressive inflammation and demyelination of
the axon, resulting in a scattering of the nervous message as it passes
down the axon. Amyotrophic lateral sclerosis (ALS) is a rapidly progres-
sive, ultimately fatal neurologic disease that destroys the motor neurons
responsible for voluntary muscle control. Bell's palsy causes temporary
facial paralysis because of damage or trauma to cranial nerve VII.
Peripheral neuropathies can result from damage or injury to any part of
the neuron and typically are caused by other systemic diseases, such as
diabetes.
l 0. Differentiate among common mental health disorders.
Depressive disorders affect the way a person thinks, feels, eats, and
sleeps. People with depression cannot "snap out of it" and without
treatment may suffer from symptoms that last weeks, months, or years.
Types of depressive disorders include major depression, dysthymia, and
bipolar disorders. Anxiety disorders cause an overwhelming, irrational
feeling of anxiety and fear; these include panic disorder, obsessive-
compulsive disorder (0CD), post-traumatic stress disorder (PTSD), and
phobias. Risk factors for suicide include serious depressive disorders;
reduced serotonin levels; a previous suicide attempt; family violence; and
exposure to the suicidal behavior of others. Schizophrenia is a chronic,
severe, and disabling brain disorder with symptoms that include hallucina-
tions and delusions; difficulty speaking and expressing emotions; and
cognitive deficits. Suicide is the tenth leading cause of death in the
United States. Mental health disorders are treated with psychotherapy
and appropriate medications.
11. Analyze the medical assistant's role in the neurologic examination.
When assisting in neurology, the medical assistant must be particularly
careful to recognize signs and symptoms, which frequently are quite
subtle but yet can be extremely significant in helping to assess and
diagnose the neurologic patient accurately (see Procedure 20-1 ).
12. Explain the common diagnostic procedures for the nervous system.
Diagnostic tests for the neurologic system are summarized in Table 20-5.
They include arteriograms; CT, MRI, and PET scans; EEG; lumbar puncture
and (SF analysis; and various x-ray studies.
13. Outline the steps needed to prepare a patient for an electroencepha-
logram (EEG).
Procedure 20-2 outlines the steps for preparing a patient for an EEG.
14. Describe the steps for preparing a patient for and assisting with a
lumbar puncture.
Procedure 20-3 describes the procedural steps for preparing a patient for
and assisting with a lumbar puncture.
15. Discuss the implications of patient education in a neurologic and
mental health practice.
When the nervous system becomes damaged or diseased, signs and
symptoms can appear in every other body system. Motor activity can
become erratic, or activity level can decline to the point that the person
becomes unable to communicate or function normally. Your main

SUMMARY OF LEARNING OBJECTIVES-continued
responsibilities as a medical assistant in neurology are to observe, listen,
and report any changes in patients.
16. Explain the legal issues and HIPAA applications associated with
neurology and mental health.
Whatever is discussed in the examination room cannot be repeated to
other staff members in the office and can never be discussed outside the
CONNECTIONS
DJ Study Guide Connection: Go to the Chapter 20 Study Guide. Read and complete
the activities.
CHAPTER 20 Assisting in Neurology and Mental Health 541
office. Confidentiality must be stric~y maintained. Disclosure of psycho-
therapy notes requires specific patient permission. Under federal law, the
therapist must decide whether to release the notes to the patient, and
if the therapist decides not to release the information, the patient cannot
appeal this decision. However, the final authority rests with individual
state laws.
evolve Evolve Connection: Go to the Chapter 20 link at evolve.elsevier.com/
kinn to complete the Chapter Review Quiz. Check out the other resources listed for this
chapter to make the most of what you have learned from Assisting in Neurology and
Mental Health.
 21 ASSISTING IN ENDOCRINOLOGY
li#H+i;H•i
Miguel Vasco has been acertified medical assistant ((MA [AAMA]) for 10 years
and has worked for the past 3 years in an endocrinology and internal medicine
practice with several physicians. Although he has taken care of patients with
many different disorders of the endocrine system, most of the practice's patients
While studying this chapter, think about the following questions:
• What are the primary responsibilities of a medical assistant in an internal
medicine practice?
• What clinical skills are required in this specialty practice?
• What common diseases and disorders of the endocrine system should
medical assistants working in this field be able to discuss and explain?
LEARNING OBJECTIVES
l. Define, spell, and pronounce the terms listed in the vocabulary.
2. Summarize the anatomy and physiology of the endocrine system.
3. Explain the mechanism of hormone action.
4. Differentiate among the diseases and disorders of the endocrine
system.
5. Describe the diagnostic criteria for diabetes mellitus.
6. Do the following with regard to diabetes mellitus:
• Compare and contrast prediabetes, diabetes type l, diabetes type
2, and gestational diabetes.
• Outtine the treatment plan and management of the different types
of diabetes mellitus.
VOCABULARY
adrenocorticotropic hormone (ACTH) (uh-dre-no-cor-tih-ko-
tro'-pik) A hormone released by the anterior pituitary gland
that stimulates the production and secretion of glucocorticoids.
diabetic retinopathy A condition in which microaneurysms and
weakness in the capillary wall within the retina result in
ischemia and tissue death.
follicle-stimulating hormone (FSH) A hormone secreted by
the anterior pituitary; it stimulates oogenesis and
spermatogenesis.
gluconeogenesis (glu-ko-ne-oh-jeh'-nuh-sis) The formation of
glucose in the liver from proteins and fats.
glycogen The sugar (starch) formed from glucose; it is stored
mainly in the liver.
are individuals with diabetes mellitus type 2. One of Miguel's responsibilities is
coaching patients newly diagnosed with diabetes in how to monitor their blood
glucose levels and maintain a healthy lifestyle.
• What diagnostic and treatment procedures typically are used in an
endocrinology practice?
• What information should the medical assistant know about the
management of diabetes and the possible complications associated with
the disease?
• Perform blood glucose screening with a glucometer.
• Identify the characteristics of hypoglycemia and hyperglycemia.
• Describe acute and chronic complications associated with diabetes
mellitus.
7. Discuss follow-up for patients with diabetes and summarize patient
education approaches to diabetes.
8. Discuss legal and ethical issues to consider when caring for patients with
endocrine system disorders.
glycosuria The abnormal presence of glucose in the urine.
growth hormone (GH) Also called somatotropic hormone; it
stimulates tissue growth and restricts tissue glucose dependence
when nutrients are not available.
luteinizing hormone (LH) (lu-te-uh-niz'-ing) A hormone
produced by the anterior pituitary gland that promotes
ovulation.
nocturia Excessive urination during the night.
polydipsia Excessive thirst.
polyphagia (pah-le-faj'-e-uh) Increased appetite.
prolactin (PRL) A hormone secreted by the anterior pituitary
gland that stimulates the development of the mammary gland;
it also stimulates the production of breast milk.
 CHAPTER 21 Assisting in Endocrinology 543

VOCABULARY-continued
satiety The state of being satisfied or of feeling full after eating. thyroid-stimulating hormone (TSH) A hormone secreted by the
specific gravity The density of urine compared with an equal anterior pituitary gland that stimulates the secretion of
volume of water. hormones produced by the thyroid gland.

I ndividuals with disorders of the endocrine system usually are seen

first by the primary care physician (PCP), who may refer them to
Hypothalamus
an internist or an endocrinologist for specialized care. Patients with
certain endocrine disorders, such as diabetes mellitus (DM), also
may be seen in a specialty clinic for follow-up and treatment. A
medical assistant employed in any of these ambulatory care practices
assists with diagnostic procedures, specialized examinations, and
patient education. It is important that medical assistants recognize
the dynamics of endocrine system diseases, so they can help patients
understand the importance of lifestyle factors, how to administer
their medications, and how to prevent long-term complications from
the disease.

ANATOMY AND PHYSIOLOGY OF

THE ENDOCRINE SYSTEM
Both the nervous system and the endocrine system control the body's
physiologic responses to internal and external stimuli. The nervous
system is electrical in nature and sends immediate messages along a
nerve pathway to evoke a response; the endocrine system relies on
the bloodstream to carry hormonal messages to a target cell for
action. Through hormonal action, the endocrine system regulates all
body functions. Endocrinology is the study of hormones, their
receptor cells, and the results of hormone action.
The word part endo- means "in" or "within"; the suffix -crine
means "secrete." The endocrine system consists of glands located
throughout the body that produce and secrete chemicals known as
hormones. Hormones are excreted directly into the bloodstream,
which carries them to the target tissue. They function as the body's
chemical messengers, transferring information from one group of
FIGURE 21-1 location of the endocrine glands. (From Patton KT, Thibodeau GA: Anatomy and
cells to another. They control growth, mood, system functions,
physiology, ed 9, St Louis, 2016, Mosby.)
metabolism, sexual maturity, and reproduction. Hormone levels vary
and can be affected by outside factors, such as illness and stress.
The pituitary gland consists of two parts, the anterior and pos-
Basic Anatomy terior lobes. The anterior pituitary, or adenohypophysis, regulates
Glands are categorized as either exocrine or endocrine. Exocrine the functions of the thyroid, adrenals, and reproductive glands. It
glands, such as sweat glands and salivary glands, secrete either produces growth hormone (GH), thyroid-stimulating hormone
through a duct or directly onto the surface of the skin or in the (TSH), adrenocorticotropic hormone (ACTH), prolactin (PRL),
mouth. Endocrine glands release hormones directly into the blood- follicle-stimulating hormone (FSH), and luteinizing hormone
stream, which transports the hormones to target cells for action. (LH). The posterior lobe of the pituitary, or neurohypophysis,
The glands of the endocrine system are the hypothalamus, pitu- excretes oxytocin, which stimulates the contractions of the smooth
itary, pineal gland, thyroid, parathyroids, thymus, and adrenals, and muscle of the uterus that occur during labor and the flow of breast
the reproductive glands (i.e., the ovaries and the testes) (Figure milk toward the nipple when an infant breast-feeds. The posterior
21-1 ). Some nonendocrine organs, especially the pancreas, also can pituitary also produces antidiuretic hormone (ADH), which helps
produce and release hormones. The hypothalamus, located in the control fluid balance by acting on the kidneys, causing them to
inferior midportion of the brain, is the major connection between reabsorb fluid as needed to maintain homeostasis (Figure 21-2).
the nervous and endocrine systems. The hypothalamus controls the The pineal gland, which is located deep within the brain, excretes
action of the pituitary, a pea-sized gland located below the hypo- the hormone melatonin. Melatonin helps regulate waking and sleep-
thalamus. The pituitary often is called the "master gland" because it ing patterns and also may affect seasonal reactions to alterations in
secretes hormones that regulate multiple endocrine glands. the availability of sunlight.
544 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES
Hypothalamic
neurosecretory cell _ _ ____,
Bone
Anterior pituitary
\
Adrenal Growth
cortex hormone (GH)
Adrenocorticotropic
hormone (ACTH)
Thyroid-
Thyroid stimulating
gland hormone (TSH)
Prolactin
Gonadotropic
hormones
(FSH and LH}
Testis
Ovary
Mammary glands
FIGURE 21-2 The principal anterior and posterior pituitary hormones and their target organs. (From Patton KT, Thibodeau GA: The human
body in health and disease, ed 6, St Louis, 2014, Mosby.)
When stimulated byTSH, the thyroid gland produces the thyroid
hormones triiodothyronine (T3) and thyroxine (T4), which control
the body's metabolic rate and are important factors in bone growth
and nervous system development in children. On the dorsal aspect
of the thyroid gland are several small parathyroid glands, which
release hormones (parathyroid and calcitonin) that regulate the level
of calcium in the blood. Parathyroid hormone (PTH) maintains a
constant concentration of calcium in the body by regulating the
absorption of calcium from the gastrointestinal tract and stimulating
the reabsorption of calcium stored in the bone, as needed, to main-
tain homeostasis. Calcitonin stimulates deposition of calcium into
the bone when excess amounts of calcium are available.
The thymus gland, located behind the upper portion of the
sternum, produces hormones that stimulate the production of spe-
cialized immune system cells called T cells. The thymus gland is
present at birth and enlarges as the child ages but begins to atrophy
as the child reaches puberty. It once was thought that the thymus
played no role in the physiology of adults, but we now know that
its hormone action is crucial to T-cell maturation.
On top of each kidney are the adrenal glands, which are triangular-
shaped glands consisting of an outer layer, called the adrenal cortex,
and an inner body, called the adrenal medul/,a. The adrenal cortex
secretes corticosteroid hormones, including cortisol, aldosterone,
and adrenal androgens, all of which influence a wide range of bodily
functions. The adrenal medulla produces epinephrine, also called
adrenaline, which activates the body's reaction to stress.
The gonads produce sex hormones. The male gonads are the
testes; they secrete testosterone, which regulates the development of
secondary sexual characteristics (e.g., voice changes and the growth
of facial and pubic hair) and promotes the production of sperm. The
female gonads, the ovaries, produce eggs, or ova (oogenesis), and
secrete estrogen and progesterone. The female hormones control
the development of breast tissue and other secondary sexual
Kidney
tubules
Posterior
pi?ary
Antidiuretic
hormone
(ADH)
Oxytocin
(OT) Uterus
smooth
(PRL)
muscle
Mammary
glands
characteristics; they also regulate menstruation and play important
roles during pregnancy.
The pancreas performs essential endocrine functions by produc-
ing insulin and glucagon, which work together to maintain normal
blood glucose levels and store glucose for energy.
CRITICAL THINKING APPLICATION 21-1
Miguel is asked to order educational supplies for patients with endocrine
system disorders. Because he thinks it is important for patients to under-
stand their health problems, he wants to order a brochure that clearly depicts
and describes the anatomy of the endocrine system. What glands and
organs should be included in the handout? How can Miguel meet the
particular needs of the Hispanic patients in the practice?
Mechanisms of Hormone Action
The goal of hormone regulation is to maintain homeostasis. Hormone
secretion is regulated by a number of mechanisms, including nervous
stimulation, endocrine control (a hormone from one gland, such as
the anterior pituitary, stimulates the release of a hormone from
another gland), and feedback systems. An example of nervous system
regulation of endocrine function is the release of adrenaline from the
adrenal medulla in response to stimulation from the sympathetic
nervous system during a stressful episode. In the most common
feedback system, negative feedback, an endocrine gland is activated
by an imbalance and acts to correct the imbalance by stopping the
secretion process. For example, if calcium blood levels fall below
normal, the parathyroid glands are stimulated to release PTH. PTH
acts to increase blood calcium levels either by stimulating the absorp-
tion of calcium from the gut or by demineralizing bone to release

stored calcium. This change in the blood calcium level is detected
by the parathyroid gland, which then stops production of PTH.
Each hormone released into the bloodstream has particular target
cells for action. The target cells have receptors that attract only spe-
cific hormones and permit the hormone to pass through the cell
membrane and affect cellular action.
DISEASES AND DISORDERS OF
THE ENDOCRINE SYSTEM
Faulty secretion of any hormone, whether too much or too little,
can cause health problems for patients. The goal of treatment is
either to control the hypersecretion of hormones or to replace hor-
mones that are not being secreted at therapeutic levels.
Posterior Pituitary Gland Disorder
Diabetes lnsipidus
When ADH, or vasopressin, is not produced or released in sufficient
amounts, the patient develops a condition called diabetes insipidus.
ADH increases the permeability of the renal tubules and the collect-
ing tubules in the kidneys; this permits fluid to be reabsorbed to
prevent dehydration and causes the urine to become more concen-
trated. Without the action of ADH, fluid is not reabsorbed from the
renal tubules, resulting in excretion of a large amount of fluid in the
urine, with the potential onset of high blood sodium levels and
severe dehydration. A lack of ADH can occur because of a tumor
(either in the hypothalamus or the posterior pituitary gland) that
prevents adequate secretion of the hormone, or it can be induced by
trauma, pituitary surgery, or lack of blood supply to that area of the
brain. Diabetes insipidus may also develop because of an inadequate
response to ADH in the renal tubules, which may be caused by
kidney disease or the side effects of certain medications. Diabetes
insipidus has no connection to blood glucose levels or diabetes
mellitus.
Diabetes insipidus usually has an acute onset, and the patient
presents with polyuria, polydipsia, nocturia, low urine specific
gravity, and high blood plasma osmolality (concentration). It can
result in fatal dehydration if fluid and electrolyte levels cannot be
controlled. Diagnostic studies include blood sodium and osmolarity
levels, magnetic resonance imaging (MRI) of the head, urinalysis and
urine concentration studies, and monitoring of urine output.
Replacement therapy with a synthetic vasopressin (desmopressin)
nasal spray, oral tablets, or injections is used to treat the disorder.
Diseases of the Anterior Pituitary
Hormones secreted by the anterior pituitary control a number of
glandular functions. The effects on the body of changes in anterior
pituitary gland secretion depend on whether the hormones are pro-
duced at an abnormally low level (hypopituitarism) or at a very high
level (hyperpituitarism). A patient diagnosed with panhypopituita-
rism has a deficiency of all the hormones produced by the anterior
pituitary, and the symptoms reflect systemic inactivity of all the
glands stimulated by the anterior pituitary hormones.
Growth Hormone Abnormalities
Hypopituitary dwarfism occurs when the pituitary gland fails to
produce normal amounts of GH. The child's height is impaired, but
CHAPTER 21 Assisting in Endocrinology 545
he or she will have a normal-sized head and trunk. Hypersecretion
of GH causes two different disorders, depending on the patient's
developmental age. Oversecretion of GH in childhood, before
closure of the epiphyseal plates in the long bones, causes the long
bones to grow excessively. Affected individuals may reach a height
of 8 feet or taller. Because GH has a secondary effect on the blood
glucose level, these individuals may develop diabetes mellitus. Slow-
growing, benign anterior pituitary adenomas frequently are the cause
of gigantism, and treatment consists of removing the tumor when
possible and radiation therapy or drug therapy.
If hypersecretion of GH occurs in adulthood, the disorder is
called acromegaly. Because the epiphyseal plates are closed, the long
bones cannot grow. Consequently, a wide range of manifestations
can occur because of excessive connective tissue growth and overpro-
duction of bone. Signs and symptoms include arthralgia, an enlarged
tongue, overactive sebaceous and sweat glands, coarse skin, excessive
body hair, and nerve damage caused by pressure on peripheral nerves
from increasing amounts of bone and soft tissue. A gradual but
noticeable enlargement occurs in the bones of the jaw, face, hands,
and feet (Figure 21-3). Advanced acromegaly causes complications
such as congestive heart failure, DM, cerebrovascular abnormalities,
and neurologic symptoms as the tumor grows within the confined
space of the hypothalamus. Treatment of acromegaly requires either
surgical removal or irradiation of the pituitary tumor.
CRITICAL THINKING APPLICATION 21-2
Many different disorders can occur when problems arise with the anterior
pituitary gland. Describe two such health problems, using your knowledge
af target organ action. What psychosocial issues might patients with growth
hormone disorders face?
Disorders of the Thyroid
Hypothyroidism
Deficient secretion of the thyroid hormones may result from a
number of factors. One cause of hypothyroidism is endemic iodine
deficiency, a lack of iodine in the diet, resulting in the formation of
a simple goiter. A simple goiter is any thyroid enlargement that has
not been caused by an infection or neoplasm. Endemic goiters occur
in certain geographic areas. If more than 10% of children 6 to 12
years of age in a particular area have goiters, that geographic location
is defined as endemic for goiters.
T 3 and T 4 are produced in the thyroid gland from iodine and are
responsible for the regulation of metabolic activities in all body cells.
When the thyroid gland is unable to obtain sufficient amounts of
iodine from the circulating blood, it enlarges, or hypertrophies, in
an attempt to produce the hormones needed by the body. A decreased
amount of thyroid hormones results in a lower metabolic rate, heat
loss, and poor mental and physical development. The primary
sources of dietary iodine are saltwater fish, seaweed, and trace
amounts in grains. Iodine deficiency is rare in the United States
because of the widespread use of iodized table salt and the distribu-
tion of foods from iodine-rich areas. The treatment for a simple
goiter is to reduce its size by prescribing dietary supplements of
iodine, thyroid hormone replacement, or surgery.
546 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES
Improper development of the thyroid in an infant or young child
usually is congenital. The absence of adequate levels of thyroid hor-
mones results in a condition known as cretinism. Newborns have
feeding problems, constipation, and a hoarse cry and sleep for
extreme lengths of time. Symptoms include lethargy, bradycardia,
stunted skeletal growth, and varying degrees of developmental
delays, depending on the severity and duration of the hypothyroid-
ism. All newborns in the United States are tested for congenital
hypothyroidism. If treatment begins in the first month after birth,
infants usually develop normally.
When severe or chronic hypothyroidism occurs in an adult or
older child, the condition is called myxedema. The patient shows
fatigue, weight gain, hair loss, a slower pulse rate, a lowered body
temperature, muscle cramps, menorrhagia, and thick, dry, puffy
skin. Routine tests to diagnose hypothyroidism include radioim-
munoassay (a radiologic blood test) for T 3, T 4 , and TSH. Adequate
doses of thyroxine (Levothroid, Levoxyl, or Synthroid) restore
normal function and appearance. Patients diagnosed with hypothy-
roidism must take hormone replacement therapy daily for the rest
FIGURE 21-3 Progression of acromegaly. A, Patient at age 9. B, Patient at
age 16, with possible early features of acromegaly. C, Patient at age 33, with
wel~stablished acromegaly. D, Patient at age 52, end-stage acromegaly. (From
Clinical Pathological Conference, Am JMed 20: 133, 1956.)
of their lives, and thyroid function tests are typically rechecked once
a year.
Hyperthyroidism
Hyperthyroidism, or thyrotoxicosis, is a condition in which serum
levels of thyroid hormones are excessively high. Signs and symptoms
include weight loss, tachycardia, palpitations, hypertension, agita-
tion, nervousness, depression, tremor, excessive sweating, goiter, and
exophthalmia (protruding eyes) (Figure 21-4). Graves' disease, an
autoimmune disorder that stimulates overactive thyroid hormone
production, is the most common cause of thyrotoxicosis. The goal
of treatment is to control excessive production of thyroid hormone
with the antithyroid drugs propylthiouracil (PTU) and methima-
zole (Tapazole); ingestion of radioactive iodine, which concentrates
in the thyroid gland, destroying overactive cells; or surgical thyroid-
ectomy to remove a section of the gland. All of these methods
may inadvertently result in hypothyroidism, so the patient's thyroid
hormone levels are evaluated after treatment. The patient frequently
has to take replacement hormone therapy (Levothroid, Levoxyl, or

FIGURE 21-4 Exophthalmos in Graves' disease. (From Seidel HM et al: Mosby's guide to physical
examination, ed 6, St Louis, 2006, Mosby.)
Synthroid) after treatment to maintain normal thyroid hormone
levels. Individuals who develop exophthalmia from hyperthyroidism
may require orbital decompression surgery, in which the bone
between the eye socket and sinuses is removed, giving the eyes room
to return to their normal position.
CRITICAL THINKING APPLICATION
One of the internists, Dr. Misha, asks Miguel if he can describe the signs
and symptoms of a patient with hypothyroidism and one with hyperthyroid-
ism. How would you answer this question?
Disorders of the Adrenal Glands
Adrenal insufficiency is called Addison's disease. This condition is
relatively rare and is caused by an autoimmune reaction that affects
the adrenal cortex, which secretes corticosteroid hormones. Symp-
toms include hypoglycemia, increased pigmentation of the skin,
muscle weakness, gastrointestinal disturbances, and fatigue. Cortisol
and aldosterone deficiencies lead to retention of potassium and the
excretion of water and sodium in the urine. Severe dehydration, low
blood volume, low blood pressure, and circulatory shock can occur.
Treatment includes replacement of cortisol with the long-term daily
administration of glucocorticoids (e.g., prednisone) and replacement
of aldosterone with fludrocortisone (Florinef) to control sodium and
potassium levels while helping to maintain normal blood pressure
levels. Patients should also be encouraged to eat a diet high in
complex carbohydrates and protein and to maintain an adequate
fluid intake. Patients with Addison's disease are at risk for addisonian
crisis, a condition marked by a life-threatening drop in blood pres-
sure, hypoglycemia, and high blood potassium levels. A crisis can be
brought on by stressful situations, infections, minor illness, or
surgery. Treatment requires immediate administration of an intrave-
nous saline and dextrose solution with corticosteroids.
Hypersecretion of the adrenal cortex, causing increased levels of
cortisol, is known as Cushing's syndrome. Usually a benign pituitary
CHAPTER 21 Assisting in Endocrinology 547
FIGURE 21-5 Cushing's syndrome. (From Seidel HM et al: Mosby's guide to physical examina-
fion, ed 6, St Louis, 2006, Mosby.)
tumor causes the release of excessive amounts of ACTH. Symptoms
associated with Cushing's syndrome may be seen in individuals
taking corticosteroids for medical reasons, such as organ transplanta-
tion, severe asthma, or rheumatoid arthritis. Excessive levels of cor-
tisol cause an accumulation of adipose tissue in the trunk; a round,
or "moon," face; and fat pads in the cervical spine region, causing
the formation of a "buffalo hump" (Figure 21-5). The patient also
has glucose intolerance because of insulin resistance at the target cell
21-3 level.
Additional symptoms include hyperpigmentation, muscle
wasting, problems with wound healing, hypertension, kidney stones,
and osteoporosis. Female patients have menstrual irregularity, and
many patients with Cushing's syndrome experience mental disorders
such as irritability, depression, or severe psychiatric disorders. Treat-
ment depends on the cause of the disorder; it includes medication
to control cortisol levels, radiation therapy to reduce the size of the
tumor, and surgery to remove the tumor.
Endocrine Dysfunction of the Pancreas:
Diabetes Mellitus
Diabetes mellitus is a common hormonal imbalance that has reached
epidemic proportions in the United States because of the huge
increase in the incidence ofDM type 2. Approximately 29.1 million
Americans, or 9.3% of the population, have DM, and the number
is growing. Based on fasting glucose (i.e., A,J levels, 37% of Ameri-
cans age 20 or older (86 million people) have prediabetes. In the
over-65 age group, this percentage increases to 51 %. Diabetes occurs
in people of all ages and races but is more common in those over
age 60 and in African-Americans, Latinos, Native Americans, and
Asian-Americans/Pacific Islanders.
DM is characterized by chronic hyperglycemia and problems
with carbohydrate metabolism. This problem with glucose manage-
ment is caused by a lack of insulin production and/or resistance to
insulin at the target cell level. In the pancreas, specialized cells in the
islets of Langerhans produce and secrete the hormones insulin and
glucagon. When the blood glucose level is too high, beta islet cells
secrete insulin, which is sent through the bloodstream to the target

Diabetes Mellitus Type 1
DM type 1 most often develops in children and young adults. This
disease previously was known as either juvenile-onset diabetes or
insulin-dependent diabetes. In DM type 1 the pancreas is unable to
produce insulin because autoimmune, genetic, or environmental
factors have destroyed the beta islet cells. The cause is unknown, but
experts believe an autoimmune reaction destroys these cells. The
most common theory is that a virus stimulates the autoimmune
reaction, although genetics may also play a role in triggering the
disease. DM type 1 affects about 5% of patients with diabetes.
Symptoms usually have an acute onset; the affected child becomes
very ill within a short time. Treatment of DM type 1 requires insulin
administration. The goal for insulin therapy is to maintain blood
glucose levels as close to normal as possible without causing hypo-
glycemia. Insulin must be injected under the skin with a syringe, an
insulin pen (Figure 21-7), or an insulin pump; it cannot be taken
by mouth because the acid in the stomach destroys it.
The U.S. Food and Drug Administration (FDA) recently
approved the drug Afrezza, a rapid-acting inhaled insulin that is
administered at the beginning of each meal. It is not a substitute for
long-acting insulin; it is not recommended for patients who smoke;
and it should not be used for patients with a chronic lung disease,
such as asthma or chronic obstructive pulmonary disease (COPD).
The medical assistant usually is involved in coaching patients on
how to administer their insulin accurately (Table 21-1 summarizes
the various types of insulin). Manufacturers recommend that insulin
be stored in a refrigerator at approximately 36° to 46° F (2.2° to
7.8° C). Unopened and stored in this manner, insulin remains potent
until the expiration date on the package.
Although insulin should be stored in the refrigerator, injecting
the cold solution may be painful for the patient, and patients who
must travel with insulin doses need to understand correct storage
procedures. The provider may recommend that the patient store
the bottle currently in use at room temperature. Depending on the
type of insulin, it can be stored safely at room temperatures for 7
to 28 days. For example, Humalog and Regular insulins can be
stored at room temperature for 28 days, whereas NPH and pre-
mixed solutions containing NPH can be stored this way only for
7 to 14 days. Extreme temperatures can make the drug less effec-
tive, so it should not be frozen (frozen insulin must be discarded),
left in the sunlight, or carried in the glove compartment of a car.
Temperatures below 59° F (I 5° C) or above 86° F (30° C) must be
avoided. Successful treatment of DM type 1 involves a complicated
regimen in which various types of insulin are given in multiple
injections (typically three or four) throughout the day. The insulin
type and dosage are balanced by the patient's typical exercise
regimen and diet. The patient must monitor blood glucose levels
with a glucometer periodically throughout the day to determine
FIGURE 21-7 NovoPen.
CHAPTER 21 Assisting in Endocrinology 549
whether the levels are within normal range. The provider typically
prescribes glucometer testing in the morning before breakfast,
before dinner, and possibly before lunch and at bedtime if the
patient is having difficulty keeping blood plasma levels stabilized.
A range of insulin types and doses are recommended by the provider
based on daily glucometer readings. An important responsibility of
the medical assistant is to teach the patient how to perform glu-
cometer screening (Procedure 21-1 ).
Alternative Methods of Insulin Administration
• Insulin pump: Acomputerized device that administers a constant dose
of insulin using a small portable pump. The pump is programmed to
deliver a measured dose of insulin by continuous subcutaneous infusion
through a needle-tipped catheter, which is placed in the abdomen or
buttocks area. This method more closely resembles the body's normal
surge of insulin and is designed to maintain blood glucose levels con-
sistently within normal limits.
• Injector pen: An injection device that is preloaded with insulin cartridges
for easy use (see Figure 21-7). Insulin pens are disposable or refillable
and easily portable and therefore can be used by patients with diabetes
when they are away from home.
Glucometers are palm sized and use very small amounts of capil-
lary blood from a site in the finger (Figure 21-8), forearm, upper
arm, or abdomen. Many different types of glucometers are available,
but all display test results within seconds, and the results are stored
in the memory function of the machine for future reference. Some
more advanced features include a blood analysis display that shows
a precise evaluation of blood glucose levels. Other glucometers can
be directly downloaded to a computer to help the patient and provider
monitor test results. Glucometers are frequently used in the healthcare
setting to check both fasting blood sugar (FBS) and nonfasting blood
sugar (NFBS) levels. The medical assistant should stress that the
accuracy of blood glucose results depends on following the instruc-
tions for the particular type of glucometer the patient uses. When
FIGURE 21-8 Capillary puncture sites on the fingers.
550 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES

TABLE 21-1 Types and Characteristics of Insulin

TYPE BRAND NAME(S) APPEARANCE ONSET* PEAK DURATION
Rapid acting Humalag, NovoLog, Clear 10-30 min 30 min-3 hr 3-5 hr (taken just before or just
Apidra after meals)
Rapid-acting Afrezza Single-use plastic 12-15 min 60 min 2.5-3 hr
inhaled cartridges used with
an Afrezza inhaler
Short acting Regular (Novolin R, Clear 30 min-1 hr 2-5 hr Up to 12 hr (taken 30 min
Humulin R) before meals)
Intermediate NPH (Novolin N, Cloudy 1.5-4 hr 4-12 hr Up to 24 hr (taken at bedtime to
acting Humulin N) minimize nighttime hypoglycemia)
Long acting Lantus, t Levemir Clear 0.8-4 hr Minimal peak Up to 24 hr
*The onset is the length of time before the insulin begins to work; the peak is the period when the insulin is most effective; and the duration is the length of time the insulin exerts an effect in
the body.
!Lanius must not be mixed with other insulins.

teaching the patient about glucometer screening, the medical assistant
must use the same machine the patient will use at home. Patients
should be encouraged to bring their glucometers with them to each
office visit so that the provider can review recorded glucose levels.
Patient education for glucometer use should include not only the
steps for successfully checking blood glucose levels, but also quality-
control mechanisms, as suggested by the manufacturer of the device.
Some examples of quality controls include the following:
• Follow the manufacturer's instructions exactly.
• Perform the instrument maintenance specified by the manu-
facturer, including correct cleaning and storage of the
instrument.
• Check the expiration dates on test strips and solutions and
store these products correctly.
• Match and correctly enter the test strip code into the instru-
ment before use if required.
• Contact the provider if test results do not match symptoms.
Patients with diabetes also need to find the best method of dispos-
ing of their syringes and lancets. Most pharmacies provide a sharps
container with a syringe purchase. Local pharmacies or hospitals may
offer assistance with disposal of used sharps. If the patient does not
have access to a sharps return program, a puncture-resistant con-
tainer with an opening that can be easily and tightly sealed before
disposal is a good choice.

•;;m,am);jfJII Assist the Provider with Patient Care: Perform a Blood Glucose TRUEresult Test
Goal: To perform ablood test for diabetes mellitus accurately.
EQUIPMENT and SUPPLIES 2. Sanitize your hands and put on gloves.
• Patient's record PURPOSE: To ensure infection control.
• TRUEresult glucometer ar similar glucose monitoring device 3. Identify the patient by name and date af birth and ask the person to wash
• TRUEtest strip his or her hands in warm, soapy water, then rinse them in warm water,
• Lancet and autoloading finger-puncturing device and finally dry them completely.
• Alcohol preps PURPOSE: To clean the area that will be punctured; also, warming the
• Gauze squares fingers may increase peripheral blood flow.
• Sharps container 4. Check the patient's index and ring fingers and select the site for puncture
• Disposable gloves (bath forearm and fingertip testing can be done).
• Biohazard waste container PURPOSE: To make sure the site of puncture is free of trauma.
PROCEDURAL STEPS S. Turn on the TRUE result glucometer by pressing the ON button (Figure 1).
No coding is necessary with this monitor; you do not have to match the
1. Check the provider's order and collect the necessary equipment and sup- code on the test strip vial with the code on the glucometer.
plies. Perform quality-control measures according to the manufacturer's
guidelines and office policy.

•;;m,am);Jf411 -continued
6. The glucometer should be preloaded with test strips. Before doing this,
check the expiration date on the container of test strips. Push the test
strip release button; a test strip is automatically in place.
7. Cleanse the selected site on the patient's fingertip with the alcohol wipe
and allow the finger to air dry (this step is done in the healthcare setting
to reduce infections but does not have to be performed by patients at
home).
8. Perform the finger puncture and wipe away the first drop of blood.
PURPOSE: Tissue fluid may be present in the first drop of blood.
9. Apply a small blood sample (0.5 ml) to the end of the test strip
(Figure 2).
Diabetes Mellitus Type 2
DM type 2, once called adult-onset or non-insulin-dependent diabe-
tes, usually develops in adults but may be seen at any age. Factors that
increase the risk of DM type 2 include a family history, a history of
gestational diabetes, impaired glucose tolerance, physical inactivity,
CHAPTER 21 Assisting in Endocrinology 551
10. Give the patient a gauze square to hold securely over the puncture site;
apply an adhesive bandage if needed.
11. The glucometer automatically begins the measurement process, and
results are obtained in as soon as 4 seconds.
12. The test result is shown in the display window in milligrams per deciliter
(mg/dU.
13. The patient can set up to four testing reminders on his or her personal
glucameter; a ketone alarm signals when the blood glucose reading rises
above a certain level.
14. The glucometer stores 30 daily average test results, up to 500 individual
results, along with the date and time of each recording. Encourage patients
to bring their personal glucometer to the clinic so the provider can review
daily averages and previous test results.
1S. The glucometer automatically turns off.
16. Discard all biohazardous waste in the proper waste containers.
PURPOSE: To ensure infection control.
17. Clean the glucometer according to the manufacturer's guidelines, disinfect
the work area, remove your gloves and dispose of them properly, and
sanitize your hands.
18. Record the test results in the patient's health record.
PURPOSE: Aprocedure is considered not done until it is recorded.
8/16/20-1 :00 PM: Glucometer screening completed as ordered by Dr. Misha.
NFBS 144. Pt took routine dose of 10 units Humalog insulin at noon. Pt had
no questions. M. Vasco, CMA (AAMA)
and obesity. In this type of DM, the pancreas produces insulin, but
not enough, and/or the target cells are resistant to insulin action.
Diabetes type 2 is responsible for 95% of cases of diabetes mellitus.
This form of diabetes frequently goes undetected for many years
because of the gradual onset of hyperglycemia and the absence of
552 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES
Insulin Resistance and Diabetes Type 2
in Children
Factors that affect insulin resistance in childhood include:
• Puberty: Growth hormone released during puberty makes it more
difficult for the body to use insulin correctly.
• Female gender: Girls develop insulin resistance more frequently than
boys.
• Race: Hispanic, African-American, Native American, Asian-American,
or Pacific Island ancestry raises the risk for DM type 2.
• Diet: High-carbohydrate and high-fat diets increase the incidence of
DM type 2.
• Obesity: Insulin resistance increases as the amount of fat around
the waist increases.
• Activity: Exercise improves how the body's cells use insulin.
classic diabetic symptoms. However, because of the insidious onset
over time, patients with diabetes type 2 are at even greater risk of
developing vascular complications. Treatment for diabetes type 2
includes weight loss, exercise, dietary restrictions, and oral hypogly-
cemic medications that act to stimulate insulin production and/or
improve tissue response to insulin (Table 21-2). Medications for
diabetes type 2 have multiple functions, including stimulating
insulin secretion from pancreatic islet cells in patients with some
pancreatic function; reducing insulin resistance at the cellular level;
improving sensitivity to insulin in muscle and adipose tissue; and
inhibiting hepatic gluconeogenesis.
As with diabetes type 1, the goal of treatment is to maintain
blood glucose levels within the normal range. For some patients,
exercise, diet, and weight loss are sufficient to control blood glucose
levels. Sometimes just the loss of 10 to 20 pounds is enough to bring
blood glucose levels under control. Other patients may need medica-
tion to maintain normal blood glucose levels; however, levels must
be monitored daily with a glucometer to determine the success of
treatment. Over time, the individual with DM type 2 may require
insulin to control hyperglycemia.
CRITICAL THINKING APPLICATION 21-4
Carlos Vespa is a 47-year-old patient recently diagnosed with DM type 2.
He has a BMI of 32; eats a high-fat, high-carbohydrate diet; and does not
exercise. What lifestyle issues should Miguel include in his patient teaching
intervention? Mr. Vespa tells Miguel he cannot afford the medication pre-
scribed by the provider or the glucometer needed to monitor his blood
glucose levels. Is there anything Miguel can do ta help him with these
issues?
Gestational Diabetes
A pregnant woman is diagnosed as having gestational diabetes if two
or more of the following tests show these results:
• FBS or FPG: Glucose level> 95 mg/dL
Injectable Drugs Used to Manage Diabetes Types
1 and 2
• Pramlintide (Symlin): Asynthetic form of the hormone amylin that
works with insulin and glucagon ta maintain normal blood glucose
levels. Injections administered before meals help improve A1c levels by
reducing the rate at which food moves through the stomach, thereby
preventing a sharp increase in blood plasma levels after meals. The
drug has been approved for people with DM type 1who are not achiev-
ing the recommended A1c levels and for those with DM type 2 who are
using insulin but not achieving A1c goals. The drug improves satiety,
reduces caloric intake, and may assist with weight loss. Insulin and
Symlin dose adjustments, including reducing mealtime insulin doses by
50%, must be managed by the provider to reduce the risk of severe
hypoglycemia.
• Exenatide (Byetta): Lowers blood glucose levels by increasing insulin
secretion. It is injected 60 minutes before breakfast and dinner. The
drug helps patients achieve modest weight loss and improves glycemic
control. It is not for use by patients with DM type 1. Side effects can
include nausea, vomiting, weight loss, heartburn, dizziness, or
headache.
• Dulaglutide (Trulicity): Adrug administered once aweek with an injector
pen by subcutaneous injection into the abdomen, thigh, or upper arm.
It can be given at any time of day, independent of meals. It is used
with diet and exercise to improve blood glucose levels in adults with
DM type 2. The most common side effects are nausea, diarrhea, vomit-
ing, abdominal pain, decreased appetite, dyspepsia, and fatigue.
• OGTT (using 100 g of glucose):
• I-hour glucose level: ~180 mg/dL
• 2-hour glucose level: ~155 mg/dL
• 3-hour glucose level: ~138 mg/dL
According to a 2014 analysis by the Centers for Disease Control
and Prevention (CDC), gestational diabetes affects approximately
9% of pregnant women in the United States each year and is con-
sidered a risk factor for the development of DM type 2 later in life.
Factors that increase the risk of gestational diabetes are obesity;
maternal age over 38; history of delivering infants who weigh more
than 10 pounds at birth; a family history of diabetes; previous,
unexplained stillbirth; previous birth with congenital anomalies;
smoking; and belonging to certain ethnic groups, including Hispan-
ics, Native Americans, Asian-Americans, and African-Americans.
Some women are asymptomatic, whereas others show classic symp-
toms of diabetes. Because many pregnant women have gestational
diabetes without apparent symptoms, all pregnant women are rou-
tinely screened between 24 and 28 weeks of pregnancy.
Gestational diabetes is caused by insulin resistance at the cellular
level, resulting in hyperglycemia. The elevated glucose in the moth-
er's blood passes through the placenta into the baby, causing hyper-
glycemia, with increased insulin production in the fetus. The extra
carbohydrate energy is stored in the infant as fat and may result in
a macrosomic, or "fat" baby, who is at higher risk for breathing
problems at birth, obesity, and diabetes type 2.
 CHAPTER 21 Assisting in Endocrinology 553

TABLE 21-2 Oral Hypoglycemics Used in the Treatment of Diabetes Type 2

MEDICATION CLASSIFICATION ACTION SIDE EFFECTS
Tolinase, Diabinese Sulfonylureas, first generation Increase insulin production Hypoglycemia, weight gain
Micronase, Glucotrol, Amaryl Sulfonylureas, second generation Increase insulin production Hypoglycemia, weight gain
Prandin Meglitinide Increases insulin release from the pancreas Hypoglycemia, weight gain
Metformin (Fortamet, Biguanide Reduces hepatic glucose production; slightly Nausea, diarrhea, metallic
Glucophage) increases muscle glucose uptake taste
Avandia Thiazolidinediones Reduces insulin resistance; increases glucose Minar weight increase;
uptake; redistributes fat; reduces vascular edema
inflammation; preserves beta cells in the pancreas
Precose, Glyset Alpha glucosidase inhibitor Slow absorption of complex carbohydrates Gas and bloating, diarrhea
Glucovance (Micronase and Sulfonylurea and biguanide Reduces hepatic glucose production and increases Hypoglycemia, weight gain
Glucophage) insulin secretion

The treatment goal for gestational diabetes is to keep plasma
glucose levels equal to those of pregnant women without the disor-
der. The treatment plan always includes diabetic diet counseling and
regular physical activity. In obese women, a 30% calorie reduction
is effective in reducing hyperglycemia. The American Congress of
Obstetricians and Gynecologists (ACOG) now recommends that all
pregnant women with fasting glucose levels higher than 95 mg/dL
receive daily insulin injections for glucose control. Most women
return to normal blood glucose levels after the baby is born; however,
two out of three women experience gestational diabetes in future
pregnancies. In addition, approximately 50% of women who experi-
ence gestational diabetes develop DM type 2 within 5 to 10 years.
Because of these risk factors, patient education for women diagnosed
with gestational diabetes should stress the following after the baby
is born:
• Weight management: If the woman is unable to reach a
healthy body mass index (BMI), losing 5% to 7% of her
current body weight will lower blood glucose levels.
• Exercise: Minimum of 30 minutes a day.
• Diet: Reduce saturated fat and calorie intake and increase
consumption of whole grains, complex carbohydrates, fruits,
and vegetables.
Complications of Diabetes Mellitus
Acute Complications. Two acute complications can occur in
patients with diabetes, depending on the level of glucose in the
bloodstream. If an adult patient's blood glucose level is below 70 mg/
dL, the symptoms seen are caused by hypoglycemia (Table 21-3).
This reaction, which is related to insulin treatment, may also be
called insulin shock. The goal is to prevent such episodes with ade-
quate patient education and reinforcement of individualized medical
management of diabetes, in addition to frequent blood glucose
monitoring. The treatment for hypoglycemia is immediate glucose
replacement. The recommended form of sugar supplement is
glucose tablets because each tablet contains a known amount of
glucose (5 g). The patient can use other sugar supplements; however,
the amount of glucose in these items is unknown, and the patient
actually may become hyperglycemic from ingesting too much
glucose. After the hypoglycemic crisis has ended, if the next meal is
more than 1 hour away, the patient should have a mixed protein and
carbohydrate snack (peanut butter crackers, cheese crackers) to
maintain blood glucose levels until the next meal.
Treating Hypoglycemia: the Rule of 15
Teach patients and their caregivers the following steps for treating
hypoglycemia:
1. Treat the hypoglycemia immediately (while the patient remains
conscious).
2. If the glucometer reading is below 70 mg/dl, take 15 gof carbo-
hydrate; this is the equivalent of:
• 3 glucose tablets
• 1 serving of glucose gel
• ½ cup of any fruit juice
• ½ cup of a regular (not diet) soft drink
• 1 cup of milk
• 5 or 6 pieces of hard candy
• 1 tablespoon of sugar or honey
3. Wait 15 minutes, then check the glucometer reading again; if the
level is still low, repeat steps 1 and 2.
4. After the symptoms have been relieved, eat a regular meal, as
planned, to maintain plasma glucose levels.
5. The provider may order injected glucagon to quickly raise blood
plasma levels.
554 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES

TABLE 21-3 Characteristics of Hypoglycemia and Hyperglycemia

DISEASE CAUSES SIGNS AND SYMPTOMS TREATMENT
Hypoglycemia Too much insulin; insufficient calories; Shakiness, vertigo, palpitations, • Ingest sugar (3 glucose tablets
(low serum excessive exercise; individual with diaphoresis, headache, hunger, pallor, recommended); monitor blood
glucose level) DM type 2 using insulin-boosting fatigue, confusion, irritability, poor glucose level in 15 min
medications judgment, visual disturbances, • If level still low and symptoms
seizures, coma persist, take another glucose tablet
• If patient passes out, provider-
injected glucagon may be needed;
call far emergency services
Hyperglycemia Too little insulin; body unable to use Polyphagia, polyuria, glycosuria, • Exercise if blood glucose level
(high serum insulin properly; excessive caloric ketonuria, weight loss, pruritus; <238 mg/dl
glucose level) intake; inadequate exercise; illness; possibly ketoacidosis, with shortness • Reduce caloric intake
stress of breath, "fruity" breath, dry mouth, • Provider may alter amount and
nausea and vomiting, lethargy timing of insulin

A second acute complication of diabetes is diabetic ketoacidosis,
or diabetic coma. In this case the person with diabetes is unable to
use glucose for energy because insulin is absent or insufficient, or
there is resistance to insulin at the target cell site. Hyperglycemia
results, with blood glucose levels rising as high as 300 to 750 mg/dL.
Because cells cannot use carbohydrates for energy, the body begins
to burn fat. Ketones are waste materials from fat metabolism that
build up in the bloodstream and cause it to become more acidic.
Although the development of ketoacidosis takes longer than insulin
shock, it can become a medical emergency if the patient does not
recognize the signs, monitor his or her blood glucose levels, and
administer insulin as prescribed by the provider.
CRITICAL THINKING APPLICATION 21-5
Mr. Vespa returns to the office l week later and tells Dr. Misha that he has
not been feeling well. Sometimes he feels very shaky, dizzy, and tired; he
has been getting headaches and cannot think straight. Dr. Misha orders a
glucometer reading, which shows Mr. Vespa's blood glucose level at 65. Dr.
Misha's diagnosis is hypoglycemic episodes, and the physician asks Miguel
to reinforce patient teaching about hypoglycemic and hyperglycemic signs
and symptoms and treatment. What should Miguel include in the teaching
intervention? How can he best reinforce the material so that Mr. Vespa will
remember how to manage his disease?
Chronic Complications
Microvascular Disease. Arterial changes at the capillary level
can occur within 1 to 2 years of the onset of DM. Hyperglycemic
episodes combined with the duration of the disease cause degenera-
tion of tissue arterioles, which results in multiple system disorders,
including diabetic retinopathy. Diabetes is a leading cause of new
blindness in people 20 to 74 years of age. Of patients with DM type
1, 90% have retinopathy after 10 to 15 years; of patients with DM
type 2 who require insulin therapy, 84% develop retinopathy in 15
to 19 years.
Hyperglycemic episodes damage the blood vessels in the retina;
therefore, strict glucose control helps delay the onset of retinopathy
and slows its progression. Vision disturbances occur as a result of
vascular changes in the capillaries of the retina. These complications
can lead to retinal detachment and blindness. In addition, people
with diabetes are at much higher risk of developing glaucoma and
cataracts; they should have yearly eye screenings and frequent oph-
thalmologic examinations during routine office visits so that diabetic
retinopathy can be diagnosed early.
Microvascular disease also can cause diabetic nephropathy; 20%
to 30% of patients with DM type 1 or type 2 have kidney disease.
In addition, diabetes is the most common cause of kidney failure in
the United States. Diabetic kidney disease is the greatest threat to
life in adults with DM type 1. Diabetes damages the small blood
vessels in the kidneys and impairs their ability to filter waste from
the blood. Degenerative changes cause destruction of the glomerular
unit and can lead to renal failure. High blood pressure and smoking
often are associated with diabetic nephropathy. Because urinary
protein usually is the first sign of kidney damage, frequent testing
for albuminuria is suggested. Early treatment slows down the pro-
gression of kidney disease. Good glucose control often can reverse
early stages of diabetic nephropathy. With disease progression, renal
failure may occur, resulting in the need for dialysis and possibly
kidney transplantation.
Diabetic Neuropathy. Diabetic neuropathy is the most
common complication of diabetes; 60% to 70% of those with dia-
betes have some form of diabetic nerve damage. This type of nerve
damage is caused both by vascular changes and by hyperglycemia.
The chief areas that show pathologic changes are the nerves and
blood vessels in the eyes, kidneys, legs, and feet. The first signs of
diabetic neuropathy usually are numbness, pain, or tingling in the
hands, feet, or legs. The loss of sensation in the extremities is
important because it affects the patient's ability to be aware of
injuries, especially to the feet. Because of peripheral vascular com-
promise, foot injuries can develop into ulcers, or lesions can
become infected and ultimately lead to gangrene and amputation.
 CHAPTER 21 Assisting in Endocrinology 555

Even a minor undetected injury, such as a foot blister, can lead to
a serious problem for a patient with diabetes. Individuals with
diabetes also may lose temperature sensation and thus are more
susceptible to heat or cold injuries, such as burns and frostbite
(Figure 21-9). Patients with diabetes should have their feet
inspected and a monofilament test done at every clinical visit to
ensure early detection and treatment of problems (Procedure
21-2). Healthcare providers should provide patients with verbal
and written advice to help prevent or reduce these potentially
serious injuries.

Questions to Ask When Screening for Diabetic

FIGURE 21-9 Patient with diabetes who hos peripheral neurapothy and on insensate foot. Cold
pocks were applied to the patient's foot for treatment of osprain. Frostbite developed, and the patient
required o transmetotorsol amputation. (From Levin ME: Pathogenesis and general management of
foot lesions in the diabetic patient. In Bowker JH, Pfeifer MA, editors: Levin and O'Neal's the diabetic
foot, ed 6, St Louis, 2001, Mosby.)
Neuropathy
• Con you feel your feet when walking?
• Hove you noticed weakness in the muscles of your feet and legs?
• Do you hove problems with balance when standing or walking?
• Do you hove trouble feeling heat or cold in your feet or hands?
• Do you hove open sores on your feet and legs that heal slowly?
• Hove you noticed that your feet hove changed shape?
• Do your feet tingle or feel like "pins and needles," or do you hove
burning or shooting pains in your feet? Do they hurt at night? Are they
numb?
• Are your feet very sensitive to touch?
• Do your feet and hands get very cold or very hot?
http://professional.diabetes.org/?loc=rp·slabnav. Accessed January 22, 2015.

•ijm1ijimmf411 Assist the Provider with Patient Care: Perform a Monofilament Foot Exam
Goal: To assess neuropathy in patients with diabetes.

EQUIPMENT and SUPPLIES 7. Instruct the patient to close his or her eyes and respond with "yes" when
• Patient's record the monofiloment is felt on the feet.
• l 0-g monofiloment tool PURPOSE: The patient should hove the eyes closed so he or she cannot
• Good lighting see where you ore touching with the monofiloment.
• Disposable gloves 8. Randomly test nine to 12 areas on the anterior and posterior of each foot,
• Poper towels according to the instructions on the monofiloment tool.
PURPOSE: To determine areas where the patient hos lock of feeling from
PROCEDURAL STEPS peripheral neuropothy (Figure l).
1. Check the provider's order and collect the necessary equipment and
supplies.
2. Greet and identify the patient by name and dote of birth. Introduce yourself
and explain the filament testing procedure.
PURPOSE: To help the patient understand the purpose of the test and to 0 0
answer any questions.
3. Sanitize your hands and put on gloves.
PURPOSE: To ensure infection control.
4. Ask the patient to remove socks and shoes and rest the feet comfortably 0 0 0 0
on a stool covered with paper towels or the exam table paper.
S. Using your hand, demonstrate that the monofiloment is flexible, not sharp.
PURPOSE: To alleviate the patient's anxiety.
6. Demonstrate the monofiloment on the patient's hand so that there is a
0 0
point of reference.
PURPOSE: To help the patient understand what you will be doing when
you examine the feet with the filament and what should be felt at each
point of assessment.
556 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES
•ijiIII'31Umf411 -continued
9. Starting with the great toe, place the monafilament perpendicular to the
skin. Press until the monafilament bends, hold for one second, and then
release (Figure 2).
10. The test result is abnormal if the patient cannot feel the monafilament in
any one af the areas.
Macrovascular Disease. Macrovascular disease, in the form of
atherosclerosis, is a serious health issue for all patients with diabetes,
especially those with DM type 2. People with diabetes are two to
four times more likely to have atherosclerotic heart disease or strokes.
Coronary artery disease (CAD) is the most common cause of death
in people with DM type 2. The longer the patient has had diabetes,
the greater the risk of CAD. Strokes occur twice as often in patients
with diabetes as in those without the disease. Hypertension is
common in patients with diabetes and contributes to the rates of
CAD and CVA.
Peripheral vascular disease (PVD), a disease process in blood
vessels outside the heart, is associated with atherosclerotic changes
in small arteries and arterioles and contributes to the incidence of
gangrene and amputations in patients with diabetes. Patients with
DM type 2 frequently have signs and symptoms of PVD when first
diagnosed. Compromised circulation in the lower extremities causes
the formation of ulcers, poor wound healing, and possible progres-
sion to gangrene. This progression of PVD may result in amputation
of the toes, foot, or leg. An estimated 35% to 75% of men with dia-
betes experience at least some degree of erectile dysfunction (ED,
or impotence) in their lifetime because of vascular and nerve damage.
Infection. All patients with diabetes are at increased risk for
infection because of a number of different factors. Those with
impaired vision and neuropathies have an increased risk of injury
because they may not be able to see or feel potentially dangerous
items to prevent injury. Once an injury occurs and the integrity of
the skin has been compromised, damaged or atherosclerotic blood
vessels are unable to deliver the blood needed for healing, and the
thickened blood vessel walls impede the release of white blood cells
(WBCs) to the area. The WBCs of patients with diabetes show
11. Perform the test an bath feet and record the number af times the patient
felt the monofilament for each foot.
12. Discard all biohazardous waste in the proper waste containers.
PURPOSE: Ta ensure infection control.
13. Disinfect the work area, remove your gloves and dispose af them properly,
and sanitize your hands.
14. Record the number af positive results from the sites tested in the patient's
health record. Far example, if the filament was used ta test 12 locations
on each foot, and the patient felt it in l Oof 12 locations on the right
foot and in 8 of 12 on the left foot, record those numbers. Also record
the locations where an absence of feeling was noted.
PURPOSE: Aprocedure is considered not done until it is recorded.
8/22/20-10 AM: Bilateral manofilament foot exam completed as ordered by
Dr. Misha. Pt did not have feeling in ® posterior great toe (11 /12) and ©
4th and 5th posterior metatarsals (10/12). Reinforced pt coaching on ade-
quate blood glucose control and proper foot care. Pt had na questions. M. Vasca,
CMA (AAMA)
reduced phagocytosis, so their ability to destroy pathogens is limited.
In addition, some pathogens multiply rapidly in the glucose-rich
environment ofindividuals with diabetes. Therefore, the best method
of controlling infections in these patients is to control blood glucose
levels and prevent skin trauma or damage.
Foot Care for Patients with Diabetes
Patients with diabetes need instruction in foot hygiene and also a foot
inspection during each clinical visit, regardless of the reason the patient is
being seen. Education guidelines should include the following:
• Wash your feet every day with warm (not hat) water and mild
soap.
• Cut your nails straight across to prevent ingrown toenails and pos-
sible injuries.
• Apply lotion ta your feet, especially the heels. If the skin is cracked
or red, speak to your doctor.
• Check your feet every day, using a mirror if necessary. Call your
doctor at the first sign of redness, swelling, or numbness.
• Speak with your doctor before seeking treatment of earns, calluses,
or bunions.
• Da not ga barefoot ar allow your feet ta get too hot ar tao cold.
• Check your shoes for foreign objects or rough areas before wearing
them.
• Wear comfortable, well-fitting shoes.
• Stop smoking. Smoking causes vasocanstrictian, which reduces
circulation to the extremities.
 CHAPTER 21 Assisting in Endocrinology 557

CRITICAL THINKING APPLICATION 21-6

Mr. Vespa and his wife are scheduled for a long visit today so that Dr. Misha
can review his treatment plan. Dr. Misha asks Miguel to reinforce the pos-
sible camplications of OM and the elements of foot care. What should Miguel
include in his teaching intervention? How can he make sure Mr. and Mrs.
Vespa understand the disease, its management, and possible complica-
tions? What resources should Miguel use to reinforce the information he is
sharing?

FOLLOW-UP FOR PATIENTS WITH DIABETES

Experts agree that the best method of preventing diabetic complica-
tions is to maintain blood glucose levels consistently at near-normal
ranges. Several laboratory tests can be ordered to monitor a patient's
blood glucose levels. The FBS or FPG test measures the glucose levels
in a blood specimen after a 12-hour fast. The normal range for an
FBS is 70 to 110 mg/ dL. Even though the provider may order peri-
odic FBS tests, patients with diabetes still need to check their blood
glucose levels as instructed with a home glucometer.
A routine test for monitoring long-term diabetes therapy is the
glycosylated hemoglobin (HbA1c or A 1c) test. This test has distinct
advantages over routine FBS studies because the FBS reflects glucose
levels at a given point in time, whereas the glycosylated hemoglobin
test reflects serum glucose control over several months. The test
measures glucose levels that have been chemically bound to the
hemoglobin molecule on the red blood cell (RBC) over a 120-day
period (the lifespan of an RBC). The provider can assess average daily
glucose levels over the preceding 2 to 3 months and evaluate treat-
ment compliance and results. The patient does not need to restrict
food or fluid intake for this test and should continue to take pre-
scribed medication before the blood sample is drawn. The patient's
total A 1c should be less than 7%. The higher the glycosylated hemo-
globin result, the higher the risk the patient will develop diabetic
complications.
Developing an Education Plan for Patients Newly
Diagnosed With Diabetes
The plan of care for individuals newly diagnosed with diabetes should
be developed from a holistic point of view. Holistic care means that
the diabetic team (including the medical assistant) considers all
Relationship Between the A1c and Average Plasma
Glucose Levels
A1c (%) AVERAGE PLASMA GLUCOSE (mg/dl)
6 126
7 154
8 183
9 212
10 240
NIH. http://www.niddk.nih.govjhealth·informationjhealth·topics/diagnostic·tests/a l c·test
-diabetes/Pages/index.aspx#l 4. Accessed February 11, 2016.
FIGURE 21-10 The medical assistant can use premade educational materials to discuss new
lifestyle habits with a patient with diabetes.
aspects of the patient's needs, including lifestyle factors, such as diet
and level of exercise; medications and the education needed to
comply with their use; education that includes the details of the
disease and its possible complications; demonstration and return
demonstration as needed until the patient is proficient in glucometer
testing and/or insulin administration; family involvement in the
treatment process; and the use of community resources (e.g., a dia-
betic educator, support group, and dietitian) to assist with manage-
ment of the disease (Figure 21-10). The equipment and supplies
needed to treat diabetes effectively can be extremely expensive, so
the medical assistant should investigate alternative methods of getting
these materials if the patient is unable to afford them. The need for
continuous daily glucose control must be emphasized at each patient
visit. The medical assistant can also suggest provider- approved online
resources that promote information about diabetes.
CLOSING COMMENTS
Patient Education
Because the management of endocrine disorders can be quite com-
plicated, the medical assistant must make sure the patient under-
stands the proper procedures for at-home treatment. By demonstrating
a given procedure in the office, the medical assistant can address any
inaccurate information or answer any questions the patient may
have. Visual materials, such as brochures and procedure cards, also
are helpful because they can be taken from the office and used as a
reminder. If the patient is taking medication, the medical assistant
should review the dosage schedule with the individual, discuss the
purpose of the treatment, and clear up any confusion over the pro-
vider's instructions. As always, if the medical assistant is uncertain
of any procedures or information, he or she should ask the provider
for assistance before explaining anything to the patient.
 558 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES
Important Points in Patient Education About
Diabetes
• Physical activity (too much or too little), stress, disease, medications,
and diet all combine ta affect blood glucose levels; fallowing an effec-
tive dietary plan is the first step in self-management.
• The medical assistant should weigh the patient and measure his or her
height. The medical assistant also should reinforce the body mass index
(BMI) recommended by the provider and offer information about the
basic nutritional requirements needed to help the individual either
maintain his ar her ideal body weight ar to lose weight.
• The goal of a diet plan is to help maintain a homeostatic blood glucose
level. If a healthy blood glucose level is maintained, the patient will
avoid complications that can develop with hypoglycemia or hyperglyce-
mia. Basic guidelines, according to the person's ethnic influences, age,
gender, and physical activity, are used ta establish a therapeutic meal
plan. Family members should be involved in dietary health teaching,
and appropriate community resources, such as a registered dietitian,
should be used to help the patient understand and comply with dietary
guidelines.
• The medical management of diabetes can be quite complicated and
overwhelming far many patients. People with DM type 2 who are
prescribed oral hypoglycemics must understand the drugs' mechanism
of action and accurate dosage. Patients with DM type l or type 2 who
require daily insulin must be able to prepare and administer their medi-
cation accurately and must understand the connection between glucom-
eter readings and insulin dosage. All patients with diabetes must be
able to use a glucometer accurately and must be aware of the possible
complications of the disease. Emergency glucose tablets should be
available at all times, and family and friends must be educated about
the signs and symptoms of hypoglycemia so it can be treated promptly.
Jiiiiit-i:fi•jiii#it-i#t•i
In his interactions with patients, Miguel has learned to pay attention to both
verbal and nonverbal messages. He has used this technique consistently when
interacting with Mr. Vespa. Miguel recognizes the importance of understanding
the anatomy and physiology of the system, the complexity of endocrine system
disorders, and the most frequently seen endocrine disorders. As a concerned
SUMMARY OF LEARNING OBJECTIVES
l. Define, spell, and pronounce the terms listed in the vocabulary.
Spelling and pronouncing medical terms correctly reinforce the medical
assistant's credibility. Knowing the definitions af these terms promotes
confidence in communication with patients and co-workers.
2. Summarize the anatomy and physiology of the endocrine system.
The endocrine system consists of glands located throughout the body
that produce and secrete chemicals known as hormones. The glands
of the endocrine system are the hypothalamus, pituitary, pineal, thyroid,
parathyroids, thymus, adrenals, and reproductive glands (i.e., the ovaries
Legal and Ethical Issues
Pathophysiology of the endocrine system can have far-reaching
effects on the body's ability to function. Patient education interven-
tions should be documented completely to establish legal proof of
the information shared with the patient. Never just assume that the
patient understands the disease process and treatment recommenda-
tions. The following suggestions can help ensure the patient's welfare
and promote risk management:
• Advise patients that a MedicAlert bracelet with their diagnosis
and medication information is an important safeguard.
• Patients must take medication as prescribed, following the
directions for dosage, route of administration, and storage;
they also must be alert for possible side effects.
• Patients newly diagnosed with diabetes should not drive until
glycemic control has stabilized. These patients also should be
warned about possible visual impairment from the disease.
• Remember that you are always representing your profession
and employer, and respond to each situation accordingly.
• Ask for assistance or further information if you feel unprepared
to perform a procedure or to give accurate information.
Professional Behaviors
An important part af becoming a professional medical assistant is a com-
mitment ta lifelong learning. This chapter focused on the details af diabetes
mellitus because it is the most common endocrine system disease and also
one of the most serious. Regardless of where you work as a medical
assistant, you will end up caring for patients with diabetes and interacting
with their families on some level. Diabetes researchers are constantly dis-
covering more information about the disease: how it is diagnosed, the best
treatment methods, and the pathophysiology of possible complications. You
must commit to continual learning about diabetes so that you are best
prepared to care for patients with this life-threatening disorder.
medical assistant, Miguel continues to read professional journals and attend
workshops so that he is prepared ta answer questions from patients and assist
with current therapies. He is especially interested in DM, because the practice for
which he works has so many patients with diabetes. Miguel never hesitates to
ask the attending physicians questions about the disease and its management.
and the testes). Some nonendocrine organs, such as the pancreas, produce
and release hormones. Through hormonal action, the endocrine system
regulates all body functions.
3. Explain the mechanism of hormone action.
Hormones are chemical transmitters produced by glands and transported
to the target tissue by the bloodstream. Hormone secretion is regulated
by a combination of nervous stimulation, endocrine control, and feedback
systems. Each hormone released into the bloodstream has particular target
cells on which it acts.

SUMMARY OF LEARNING OBJECTIVES-continued
4. Differentiate among the diseases and disorders of the endocrine
system.
Hypersecretion or hyposecretion of hormones can cause endocrine disor-
ders. When ADH is not produced or is not released in sufficient amounts,
the patient develops diabetes insipid us. Gigantism and acromegaly are both
diseases of the pituitary gland involving GH. When this condition affects
children, gigantism is the result; in adults, acromegaly causes awide range
of manifestations that occur because of excessive connective tissue growth
and overproduction of bone. Deficient secretion of thyroid hormone may
be caused by an endemic iodine deficiency, resulting in a simple goiter.
Improper development of the thyroid in an infant or young child causes
cretinism; in an adult or older child, severe hypothyroidism causes myx-
edema. Hypersecretion of the thyroid gland causes thyrotoxicosis, or
Graves' disease. Adrenal cortex insufficiency is called Addison's disease.
Hypersecretion of the adrenal cortex, which results in elevated levels of
cortisol, is known as Cushing's syndrome.
5. Describe the diagnostic criteria for diabetes mellitus.
Diabetes is diagnosed if the patient has a plasma glucose level of 200 mg/
dl or higher with polyuria, polydipsia, and unexplained weight loss; an
FPG level of 126 mg/dl or higher on more than one occasion; a 2-hour
OGTT of 200 mg/dl or higher; a positive urinalysis result for glucose and
possibly ketones; or a glycosylated hemoglobin of 6.5% or higher.
6. Do the following with regard to diabetes mellitus:
• Compare and contrast prediabetes, diabetes type 1, diabetes type 2,
and gestational diabetes.
Prediabetes is a condition in which an individual has a higher than
normal blood glucose level that is not high enough for a diagnosis of
diabetes type 2. Diabetes type 1 is seen in children and young adults
and is characterized by a complete absence of insulin production.
Patients must receive daily injections of insulin to survive. Diabetes type
2 develops gradually because of an insufficient amount of insulin or
resistance to insulin at the target cell site, or both. Weight manage-
ment, diet therapy, exercise, and medications are used to control
glucose levels. Gestational diabetes occurs in approximately 9% of
pregnancies but typically resolves after the infant is born. Diet therapy,
exercise, and insulin are used for blood glucose control.
• Outline the treatment plan and management of the different types of
diabetes mellitus.
All patients with diabetes must monitor their blood glucose levels regu-
larly to determine the effectiveness of treatment. The goal of treatment
is to maintain plasma glucose levels as close to the normal range as
possible, as consistently as possible. Management of OM is a compli-
cated interaction involving exercise, therapeutic diet, weight control,
and medication. Patients with diabetes type 1 require daily injections
of a combination of insulins. Table 21-1 summarizes the types and
CONNECTIONS
CO Study Guide Connection: Go to the Chapter 21 Study Guide. Read and complete
the activities.
CHAPTER 21 Assisting in Endocrinology 559
characteristics of a variety of insulins. Patients with diabetes type 2
may be prescribed oral hypoglycemics or insulin if needed. Table 21-2
explains typical oral hypoglycemics used to treat OM type 2. Diet
therapy, exercise, and insulin are used to treat gestational diabetes.
• Perform blood glucose screening with aglucometer.
Procedure 21-1 describes haw to perform plasma glucose screening
accurately with a glucometer. Many types of glucometers are available,
so it is important that the patient be taught how to perform testing
using the type of device that will be used at home.
• Identify the characteristics of hypoglycemia and hyperglycemia.
With hyperglycemia, the patient experiences a sudden onset of poly-
phagia, polyuria, glycosuria, ketonuria, weight loss, pruritus, "fruity"
breath, dry mouth, nausea and vomiting, and lethargy. This occurs as
a result of an inadequate dosage of insulin, target cell resistance,
overeating, lack of exercise, illness, or stress. Hypoglycemia causes
shakiness, vertigo, headache, hunger, pallor, fatigue, confusion, irritabil-
ity, visual disturbances, seizures, and possibly coma (see Table 21-3).
• Describe acute and chronic complications associated with diabetes
mellitus.
Complications of OM include hypoglycemia; hyperglycemia and diabetic
coma; diabetic neuropathy; microvascular diseases, including diabetic
retinopathy and nephropathy; macrovascular diseases, such as athero-
sclerosis, CAD, (VA, and PVD; and decreased resistance to infection.
7. Discuss follow-up for patients with diabetes and summarize patient
education approaches to diabetes.
Patient education for patients with diabetes is an intricate mix of information
on the dynamics of the disease; the importance of exercise, diet, and
weight control in preventing complications and maintaining health; an
understanding of the various types of insulin and when and how they
should be administered; and, for patients with diabetes type 2, aknowledge
of oral medications, their side effects and dosages; home care management,
including proper use of glucometers and insulin administration; prevention
of complications through effective control of blood glucose levels; proper
foot care; and monitoring for and immediately contacting the provider
about infections or other complications. Developing an education plan for
patients with diabetes is ideal.
8. Discuss legal and ethical issues to consider when caring for patients
with endocrine system disorders.
The pathophysiology of the endocrine system can have far-reaching effects
on the body's ability to function. Patient education interventions should be
documented completely to establish legal proof of the information shared
with the patient. Never assume that the patient understands the disease
process and treatment recommendations. Specific risk management pro-
cedures may be instituted, depending on the patient's characteristics and
diagnosis.
evolve Evolve Connection: Go to the Chapter 21 link at evolve.e/sevier.com/
kinn to complete the Chapter Review Quiz. Check out the other resources listed for this
chapter to make the most of what you have learned from Assisting in Endocrinology.
 ASSISTING IN PULMONARY
22
li#H+i;H•i
Michael McGuire, (MA (AAMA), works for a primary care physician, Dr. John
Samuelson, in the small town in which Michael grew up. Dr. Samuelson's
practice is open to all patients, but a large number of individuals with respiratory
disease seek his help in managing their pulmonary problems. In the 6 months
since he started with the practice, Michael has learned how to assist with
pulmonary diagnostic tests and the special needs of patients with respiratory
diseases. Michael has become familiar with the diagnosis and treatment of
While studying this chapter, think about the following questions:
• What are the common pathologic conditions of the pulmonary system?
What medical terms must Michael know to identify and explain these
patient disorders?
• What are the medical assistant's primary responsibilities in working with
patients with pulmonary problems?
LEARNING OBJECTIVES
1. Define, spell, and pronounce the terms listed in the vocabulary.
2. Describe the organs of the respiratory system and their functions.
3. Explain the process of ventilation.
4. Discuss respiratory system defenses and use correct respiratory system
terminology when documenting in the health record.
5. Describe upper respiratory infections (e.g., the common cold, sinusitis,
and allergic rhinitis) in addition to lower respiratory infections (e.g.,
pneumonia).
6. Explain the diagnosis and treatment of tuberculosis.
7. Do the following related to chronic obstructive pulmonary disease:
• Summarize the disorders associated with chronic obstructive
pulmonary disease and their treatments.
• Teach a patient how to use a peak flow meter.
VOCABULARY
bifurcates Divides from one into two branches.
bronchiectasis (brong'-ke-ek-tuh-sis) Dilation of the bronchi and
bronchioles associated with secondary infection or ciliary
dysfunction.
cell-mediated immunity An immune response that occurs from
the action ofT lymphocytes rather than from
the production of antibodies.
chronic bronchitis Recurrent inflammation of the membranes
lining the bronchial tubes.
,I
MEDICINE
common pulmonary problems and adept at using the practice's new electronic
health records (EHR) system. The office manager recently asked Michael to
help her orient the staff to the new system so they are able to document
respiratory system signs, symptoms, and diagnostic studies accurately. The main
employers in the community are coal mining and construction companies, so
many patients are at risk for occupation-related respiratory problems.
• What clinical skills are required in this specialty practice?
• What pulmonary complications are associated with smoking and
occupational respiratory hazards?
• What diagnostic and treatment procedures typically are ordered for
patients with pulmonary disease?
• Administer a nebulizer treatment.
• Detail patient teaching for the use of a metered-dose inhaler.
8. Discuss obstructive sleep apnea, including causes, risk factors,
complications, and treatment.
9. Describe the cancers associated with the pulmonary system.
10. Summarize the medical assistant's role in assisting with pulmonary
procedures.
11. Distinguish among common diagnostic procedures for the respiratory
system; perform a volume capacity spirometry test and a pulse
oximeter procedure; and collect a sputum sample for culture.
12. Discuss patient education, in addition to legal and ethical issues
associated with pulmonary medicine.
cilia (sil' -e-uh) Hairlike projections capable of movement; in the
lungs, cilia waves move unwanted substances (e.g., mucus, dust,
and pus) upward; cilia are destroyed by smoking.
hypercapnia (hi-per-kap'-ne-uh) Excess levels of carbon dioxide
in the blood.
metastatic (meh-tuh-stah'-tik) Pertaining to the process by which
cancerous cells spread from the site of origin to a distant site via
lymph and blood circulation.

VOCABULARY -continued
pleurisy Inflammation of the parietal pleura of the lungs; it
causes dyspnea and stabbing chest pain, which result in
restriction of breathing because of the pain.
pulmonary consolidation In pneumonia, the process by which
the lungs become solidified as they fill with exudates.
rhinorrhea (ri-no-re' -uh) The discharge of nasal drainage.
T he respiratory system has two primary functions: to exchange
oxygen from the atmosphere for carbon dioxide waste and to
maintain the acid-base balance in the body.
The two types of respiration are external respiration, which brings
oxygen into the lungs, where carbon dioxide exchange occurs in the
blood vessels surrounding the alveoli, and internal respiration, in
which oxygen is exchanged for carbon dioxide at the cellular level.
Cells soon stop functioning and die if they are deprived of oxygen.
Maintaining the acid-base balance in the body is critical because
failure of this function may result in respiratory acidosis or alkalosis.
Respiratory acidosis occurs if the patient experiences hypoventila-
tion; carbon dioxide levels increase in the body, causing hypercap-
nia. Respiratory alkalosis occurs with an excess release of carbon
dioxide caused by hyperventilation, which may be associated with
anxiety or an acute asthma attack. Both conditions can be life-
threatening if the underlying causes are not corrected. The respira-
tory and circulatory systems work together to supply body cells with
oxygen and remove metabolic wastes. The ventilation process is
controlled by the respiratory center in the central nervous system
and assisted by the intercostal muscles and the diaphragm.
THE RESPIRATORY SYSTEM
The thoracic cage, sometimes called the rib cage, is a bony structure
that is narrower at the top and wider at the base. It is held in place
by the thoracic vertebrae of the spine in the center of the back and
by the sternum in the center of the anterior aspect of the body. The
first seven ribs attach directly to the sternum and are called the true
ribs. Ribs 8, 9, and 10 fasten one to another, forming the false ribs,
and ribs 11 and 12 are the "floating" ribs, or half ribs, because their
only attachment is to the thoracic vertebrae. At the base or floor of
the rib cage is the diaphragm, a musculotendinous membrane that
separates the thoracic cavity and the abdominal cavity (Figure 22-1 ).
The respiratory system is divided into two anatomic regions, the
upper respiratory tract and the lower respiratory tract.
Requirements for Normal Respiration
• An open airway leading to the lungs
• Ability of the lungs to expand rhythmically
• Intact alveolar membranes
• Coordination of the intercostal muscles and the diaphragm
• Proper action of the central nervous system's respiratory control center
CHAPTER 22 Assisting in Pulmonary Medicine 561
tubercle (too'-buhr-kuhl) A nodule produced by the tuberculosis
bacillus.
tracheostomy (tra-ke-os'-tuh-me) A surgical opening made
through the neck into the trachea to allow breathing.
virulent (vir'-yoo-lent) Exceedingly pathogenic, noxious, or
deadly.
Upper Respiratory Tract
The upper respiratory tract, which transports air from the atmo-
sphere to the lungs, includes the nose, pharynx (throat), and larynx
(Figure 22-2). As air enters the nasal cavity, it is filtered by the cilia,
warmed by surface capillaries, and moistened by mucous mem-
branes. The paranasal sinuses, hollow cavities that also are lined with
mucous cells and cilia, open into the nasal cavity and help warm and
moisten inhaled air. The filtered, warmed, and moistened air moves
past the tonsils (which have an immunity function and help defend
the body from potential pathogens) and through the pharynx. As
the air continues toward the lungs, it passes through the larynx. The
opening into the larynx is protected by a moveable piece of cartilage,
the epiglottis. The larynx, or voice box, is made up of vocal cords,
which vibrate when air is exhaled, creating the sound of the voice.
Once the air passes through the larynx, it enters the lower respiratory
tract.
Lower Respiratory Tract
The lower respiratory tract consists of the trachea, bronchial tubes,
and lungs (see Figure 22-2). These structures are also lined with
mucous tissue that is covered with cilia. The collection of dust and
foreign particles in the cilia initiates the coughing reflex; this helps
expectorate mucus and foreign bodies that may contain pathogens.
Without these defense mechanisms, pathogens would remain in
the lungs and may cause disease. Cigarette smoke and other air
pollutants slow or paralyze the cleansing action of the cilia and
damage the mucous membrane lining throughout the respiratory
tract.
The trachea (windpipe) is a tube that begins at the larynx and
extends into the center of the chest, where it divides, or bifurcates,
into the right and left bronchi. It is about 5 inches long and is sur-
rounded by C-shaped cartilaginous rings. These rings hold the
trachea open regardless of changes in air pressure.
It is often said that the bronchial tubes look like a tree hanging
in the chest (Figure 22-3). The right bronchus is wider than the left
to accommodate the right lung lobes, which also are larger. This
means that foreign substances are more frequently seen in the right
bronchus. Once the bronchi enter the lungs, they branch into
smaller and smaller passageways, much as blood vessels do in the
circulatory system. This branching continues until it becomes micro-
scopic. These very tiny bronchi are called bronchioles. Every bronchi-
ole terminates in microscopic air sacs called alveoli. The alveoli
are made of thin tissue, only one cell wall thick, which allows
for the exchange of oxygen and carbon dioxide through the cell
membrane.
562 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES

Suprasternal notch

__,-;.~;".e.;;f_-,.,.,ljt}Jl!--~- --I!~ - - Manubrium of

sternum
2nd intercostal
space ~ --F'~.-&----,,j!ll!~ - ----l!:--- Sternal angle
(angle of Louis)
Costal cartilage------- Body of sternum
Costochondral
junction
Dome of the_~ - -
diaphragm
Xiphoid process
7th intercostal
space
Costal angle

Costal margin

A ANTERIOR THORACIC CAGE

Vertebra
prominens of C7
Spinous
process of T3

B POSTERIOR THORACIC CAGE

FIGURE 22-1 A, Anterior thoracic cage. B, Posterior thoracic cage. (From Jarvis (: Physical examination and health assessment, ed 6,
St Louis, 2012, Saunders.)

The bronchial tree and alveoli are the major structures in the right
and left lungs. The lungs are soft and spongy because of the air sacs
that make up most of their mass. They hang in the right and left
sides of the chest, separated by the pericardia! sac, which contains
the heart. The right lung is divided into three lobes and has a greater
volume capacity than the left lung. Because each lobe has its own
bronchus and blood supply, the removal of one lobe (lobectomy)
results in little or no damage to the rest of the lung. The left lung is
longer and narrower and has a distinct indentation in its center,
known as the cardiac notch, where the left ventricle of the heart is
located and an apical pulse is heard. The left lung has only two lobes,
the upper and lower sections (Figure 22-4).
Each lung is encased in a double-layered sac called the pleural
membrane. The membrane closest to the lung is called the visceral
pleura, which doubles back to form the parietal pleural membrane.
Small amounts of pleural fluid fill the space between the two mem-
branes and provide lubrication for the movement of the lungs during
inhalation and exhalation.
VENTILATION
In the very delicate lung tissue, the bronchioles deposit oxygenated
air into the grapelike structures of the alveoli. Surrounding each
alveolus is a network of pulmonary capillaries. The oxygenated air
moves through the single-celled walls of the alveoli and into the
single-celled walls of the pulmonary capillaries (Figure 22-5). As this
is happening, carbon dioxide and other wastes are forced out of the
capillaries into the alveoli and then into the bronchioles. This carbon
dioxide-oxygen exchange provides oxygen-rich blood that is returned
to the heart for distribution throughout the body; carbon dioxide

....,~ -
Pharynx------- ~~-.....____..;:-
1,~~~..J!-- - - - - - - - - Epiglottis
Space
occupied
byheart--7 ' - - - ---i-~ ::----~ ;;;:;;;:::;::;:;:=-,,c--
FIGURE 22-2 Anatomic structures of the respiratory system. (From Solomon EP: Introduction to human anatomy and physiology, ed 3,
St Louis, 2009, Sounders.)
and other waste materials are excreted with exhalation. The process
involved in this gaseous exchange is called ventilation. The move-
ment of oxygen from the atmosphere into the alveoli is known as
inspiration, and the movement of waste gases from the alveoli into
the atmosphere is called expiration.
Inspiration
Inspiration begins with a signal from the medulla oblongata in the
brainstem. The signal originates because of an increase in blood
carbon dioxide levels, or in the case of patients with chronic obstruc-
tive pulmonary disease (COPD), a decrease in blood oxygen levels.
The stimulus is carried by the phrenic nerve to the major muscle of
inspiration, the diaphragm. When the diaphragm receives the signal,
it flattens out and pulls downward. At the same moment, the inter-
costal muscles between the ribs contract, causing the ribs to move
outward and the chest cavity to enlarge. This movement causes the
CHAPTER 22 Assisting in Pulmonary Medicine 563
-~-.---,,_ _ _ _ _ _ _ Nasal
conchae
Tongue
, - - - - - - - - - - - - - Primary
bronchus
--------:-':-===------'---- Secondary
bronchus
lungs to expand and increase their volume. The more these muscles
are contracted, the deeper the inhalation and the greater the air
volume becomes. Respiratory distress occurs when an individual is
unable to move an adequate amount of air into the lungs, using the
diaphragm and intercostal muscles, to meet the body's needs.
Expiration
The second half of ventilation is expiration. Once inspiration is
complete, the diaphragm and intercostal muscles relax, causing the
diaphragm to move upward into the thoracic cavity and the ribs to
move inward, reducing lung capacity. This movement forces waste
air out of the lungs and back into the atmosphere. Expiration
requires very little energy and takes place with minimal effort by
the body. However, in certain respiratory conditions, such as asthma
or emphysema, the person has difficulty getting air out of the
lungs, and accessory muscles in the chest and abdomen are needed
564 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES
Terminal
bronchiole
FIGURE 22-3 Bronchial tree.
FIGURE 22-4 Lobes of the lungs.
to assist the intercostal and diaphragm muscles for complete
exhalation.
RESPIRATORY SYSTEM DEFENSES
Every part of the respiratory system has a defense mechanism. In the
upper respiratory tract, the mucus-covered ciliated surface of the
mucous membranes traps particles and by the continuous flow of
the cilia back toward the nasopharynx, the particles are either sneezed
outward or swallowed.
The lower respiratory tract is sterile, which is phenomenal con-
sidering that each day these airways are exposed to approximately
10,000 L of air containing an endless number of microorganisms
and foreign material. The ever-changing airflow, inspiration to expi-
ration, creates a turbulence that makes remaining in the bronchi very
difficult for these invading substances. This, combined with cough-
ing, sneezing, and a functioning immune system, protects the
Bronchioles and Alveoli
Smooth muscle
Bronchiole
Alveolar
capillary
FIGURE 22-5 Alveoli with their copillory network.
respiratory tract and helps the body maintain homeostasis. Disease
occurs when something disrupts the normal homeostatic chain of
events.
MAJOR DISEASES OF THE RESPIRATORY SYSTEM
Many diseases affect the respiratory system. The major ones can be
divided into infectious diseases, obstructive disorders, and tumors.
Chronic lower respiratory diseases (e.g., emphysema) are the third
leading cause of death, and influenza and pneumonia are the eighth
leading causes of death in the United States. Respiratory diseases
cause common symptoms, including sneezing, a productive or non-
productive cough, sore throat or hoarseness, fever, general malaise,
altered breath sounds, and changes in breathing patterns. The
medical assistant must be familiar with common respiratory terms
and use them in documenting a patient's signs and symptoms
(Table 22-1 ).
Infectious Diseases
Respiratory tract infections fall into two categories, depending
on their location. Diseases of the nose and upper respiratory
tract are more common than diseases of the lower respiratory tract
(e.g., pneumonia). Respiratory tract infections account for ap-
proximately 75% of all clinically diagnosed infections. Only about
5% of these infections involve the lungs. Most lung infections
are seen in hospitalized patients, the elderly, substance abusers, al-
coholics, and patients with acquired immunodeficiency syndrome
(AIDS).
 CHAPTER 22 Assisting in Pulmonary Medicine 565

Upper Respiratory Tract Infections

TABLE 22-1 Respiratory System Terms Common Cold. The common cold is an acute inflammatory process
MEDICAL TERM DEFINITION affecting the mucous membranes that line the nose, pharynx, larynx,
and bronchus. A cold virus spreads through tiny air droplets released
Apnea Absence of breathing when a sick person sneezes, coughs, or blows his or her nose. Usually
Atelectasis Collapsed lung the term "cold" is used when only the membranes of the nose and
pharynx are affected; however, the same virus can affect the larynx
Dyspnea Difficulty breathing and lungs. The viral invasion can be followed by bacterial infections
Empyema Accumulation of pus in the pleural space of the pharynx, sinuses, and middle ear. Common signs of an upper
respiratory tract infection (URTI or URI) include nasal congestion
Hemoptysis Expectoration of blood and rhinorrhea, sneezing, watery eyes, pharyngitis (sore throat),
laryngitis (hoarseness), and coughing. Nasal discharge usually is clear
Hemothorax Accumulation of blood and fluid in the pleural
and watery in the early stage but can become greenish yellow as the
cavity
virus becomes more virulent or when bacteria invade. The patient
Hypercapnia Greater than normal amounts of carbon dioxide in usually complains of headache, low-grade fever, chills, and anorexia.
the blood Currently there is no cure for the common cold; the infection
usually runs its course in 10 to 14 days. The best way to treat it is
Hyperpnea Deep, rapid, labored respiration that may occur to get plenty of rest and drink fluids. An over-the-counter (OTC)
because of exercise or pain and fever cold remedy, cough syrup, and acetaminophen may lessen the dis-
Hypoxemia Low level of oxygen in the blood comfort of cold-related symptoms; however, OTC cold remedies are
not recommended for children under age 4. Antibiotics are pre-
Orthopnea The need to sit or stand to breathe comfortably scribed only if there is evidence of a secondary bacterial infection.
Pleurisy Inflammation of the parietal pleura, causing Echinacea has been promoted as an effective preventive and/or treat-
ment for the common cold, but most studies show little or no evi-
dyspnea and stabbing pain; a friction rub may be
dence that it is effective. However, zinc taken within 24 hours of the
auscultated onset of cold symptoms may reduce the duration and severity of the
Pneumothorax Collapse of the lung as a result of the collection common cold in healthy people. In addition, research shows that
of air or gas in the pleural space although vitamin C is not effective at preventing the common cold,
taking vitamin C regularly may reduce the duration of cold symp-
Pyothorax Collection of pus in the pleural cavity, caused by toms in both adults and children, even though it does not diminish
infection the severity of symptoms.
Roles Bubbling or popping sound heard on auscultation; Sinusitis. The paranasal sinuses are air-filled spaces in the skull
located in the brow area over the eyes, inside each cheekbone, behind
it is produced by the passage of air through
the bridge of the nose, and behind the eyes. Each sinus has an
bronchi that are constricted or contain secretions opening into the nose for the free exchange of air and is lined with
Rhinoplasty Plastic surgery to repair or alter the structure of a continuous mucous membrane. Healthy sinuses are sterile, but an
the nose infection or an allergic reaction can cause one or more of the sinuses
to become inflamed or infected. Inflammation causes edema and the
Rhinorrhea Excessive drainage from the nose collection of mucus within the sinus cavity, creating a feeling of
Rhonchi Continuous rumbling sound heard on auscultation; pressure, nasal congestion or rhinorrhea, and classic sinus headaches.
it is caused by thick secretions or spasms The location of sinus pain depends on the sinus cavity involved but
can be described as pain in the forehead (frontal sinuses), upper jaw
Tachypnea Abnormally rapid rate of breathing and teeth discomfort (maxillary sinuses), pain between the eyes
(ethmoid sinuses), and/or an earache and neck pain (sphenoid
Thoracotomy Surgical opening into the thoracic cavity
sinuses). The condition is treated with decongestants, antibiotics for
bacterial infections, and analgesics. Sinusitis can be acute, lasting 2
to 8 weeks, or chronic, with symptoms lingering much longer.
CRITICAL THINKING APPLICATION 22-1 Allergic Rhinitis (Hay Fever). Although it is not caused by a patho-
Michael is taking a patient history for a new patient, who reports the fol- genic organism, allergic rhinitis frequently is confused with infec-
lowing problems: Difficulty breathing; sometimes she has to sit up to breathe tious disease. This disorder affects millions of people every year. It is
comfortably; occasionally she coughs up blood and has excessive nasal caused by a reaction of the nasal mucosa to an environmental aller-
drainage. Six months ago, she experienced very rapid breathing and a blue gen. The most common allergen is plant pollen; this is where the
color to her skin, so she was admitted to the hospital. She was diagnosed term "hay fever" originated. Signs and symptoms include sneezing,
with blood and fluid around her right lung, which had become infected, nasal congestion, nasal itching, and rhinorrhea. Symptoms can be
controlled either with OTC antihistamines, such as Sudafed, Zyrtec,
causing her lung to collapse. Based on what Michael knows about respira-
and fexofenadine hydrochloride (Allegra), or with prescription anti-
tory system terminology, how should he document this information? histamines, such as montelukast (Singulair), and fluticasone (Flonase)
566 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES
and cromolyn sodium nasal sprays. The list of possible allergens is
extensive. When this condition is seen in the respiratory practice,
the patient usually is referred to an allergist for testing and possible
immunotherapy.
Patients may have difficulty determining whether symptoms are
caused by a cold or an allergy. The condition usually is an allergy if
the eyes, ears, nose, throat, and roof of the mouth (palate) are itchy;
the eyes are red and watery; a clear, thin nasal discharge is present;
symptoms are seasonal and last for weeks or months; and the indi-
vidual does not have a fever.
Lower Respiratory Tract Infections
Pneumonia. Pneumonia is both a specific disorder and a general
term meaning inflammation of all or part of the lungs (Figure 22-6).
Pneumonia can be caused by bacteria, viruses, or other pathogens
(Table 22-2). It also can be caused by inhalation of irritants or gas
and by aspiration of solids or fluids into the lungs. The most common
cause of bacterial pneumonia is streptococci, and influenza is the
most common viral cause of pneumonia.
Pneumonia can occur in any age group but most often affects
children under the age of2 and individuals over age 65. It can range
from a mild complication to a life-threatening illness. Risk factors
include smoking, alcoholism, and immunosuppression caused by
diseases or treatment. The patient usually comes to the office with
symptoms of high fever, chills, and general malaise. Signs of the
illness include dyspnea, tachypnea, chest pain during inspiration,
and a relentless cough with possible hemoptysis. Auscultation of the
chest reveals rales, rhonchi, and other signs of pulmonary consoli-
dation. The infection may spread into the pleural cavity, causing
empyema and pleurisy.
The diagnosis is confirmed with a chest x-ray evaluation; sputum
culture and sensitivity testing to identify the invading organism and
determine the appropriate antibiotic therapy; and a white blood cell
(WBC) count. A WBC differential is also ordered to determine
Right superior lobe
,v:;~,---- Apex of lung
Right primary
bronchus
'"'--:::::=_-=:._:;,..::.....,/~~ '\
Right inferior lobe 1. Bronchopneumonia Base of lung
(Diffuse - bacterial)
FIGURE 22-6 Types of pneumonia. (From VanMeter KC, Hubert RJ: Gould's pathophysiology for
the health professions, ed 5, St Louis, 2015, Saunders.)
whether the pneumonia is viral or bacterial. If the pneumonia is
viral, the number of WBCs does not increase; if it is bacterial, the
greater the invasion, the higher the WBC count. With bacterial
pneumonias, the differential count shows elevated neutrophil and
monocyte levels. If the invading organism is bacterial, the treatment
of choice is antibiotics and lung function therapy until the patient
has recovered. If the organism is viral, the patient is given supportive
care (e.g., antipyretics, fluids, and oxygen) until the immune system
can control the spread of the virus.
Tuberculosis. According to the Centers for Disease Control and
Prevention (CDC), approximately one third of the world's population
is infected with tuberculosis (TB). TB causes more deaths than any
other infectious agent in the world. For more than 50 years, the
incidence ofTB in the United States steadily declined; however, from
the late 1980s through the 1990s, a resurgence in reported cases
occurred. This increase was believed to be the result of increased
travel and immigration; the number of individuals with AIDS, who
have little resistance to disease; an increase in the number of homeless
and malnourished people; and the overwhelming proliferation of
drug-resistant TB bacilli. An international TB vaccine, bacille
Calmette-Guerin (BCG), is available but is rarely used in the United
States. The vaccine does not always provide protection from the
disease, and those who are vaccinated may show a positive Mantoux
test result.
TB is caused by the bacterium Mycobacterium tuberculosis. This
organism is covered with a waxy substance that enables it to survive
outside a living host for a long time. It is transmitted by droplets of
sputum expectorated into the environment by an infected host; these
droplets are inhaled by another person. In the warm, moist respira-
tory tract, the organisms again can become active if the individual
is susceptible to the disease. TB also can be spread when an infected
person coughs or sneezes, releasing airborne infected droplets, which
are inhaled and cause an infection if the person is susceptible.
TB develops in two stages. The primary infection occurs when
the person is first infected with the bacteria and the lungs become
inflamed. Cell-mediated immunity ensues, isolating the bacteria
and forming a tubercle. At this point a healthy individual can stop
the spread of infection, causing the TB bacillus in the tubercle to
TABLE 22-2 Pathogens That Cause Pneumonia
Left superior lobe PATHOGEN TYPE OF INFECTION
Bacteria Streptococcus pneumoniae
3. Primary atypical
pneumonia Haemophilus influenzae
(interstitial - viral/
mycoplasmal)
Staphylococcus aureus
Mycobacteria
Virus Influenza virus
pneumonia Fungi Aspergillus fumigatus
(consolidation -
bacterial)
Candida albicans
with pleurisy Mycoplasma pneumoniae
Left inferior lobe
Parasite Pneumocystis jiroveci (opportunistic infection,
seen in immunosuppressed, debilitated, or
terminally ill patients)
 CHAPTER 22 Assisting in Pulmonary Medicine 567

become inactive. In this case, the person was exposed to the patho- bacteria; others develop it later in life, when the immune system is
gen but never developed active disease and so is said to have a latent weakened for other reasons.
TB infection. Individuals with latent TB are asymptomatic and are TB is diagnosed most frequently in people living in crowded
not infectious. However, because an exposed person develops anti- conditions with poor hygiene, those who are malnourished, and
bodies to the disease, he or she consistently tests positive on TB skin those who have other chronic conditions. It spreads most rapidly in
screening tests. Therefore, rather than the purified protein derivative large cities, in the elderly, alcoholics, and the homeless. Symptoms
(PPD), or Mantoux, test, these patients should have chest x-ray of an active infection include an intermittent fever that peaks in the
studies to diagnose active TB. afternoon, night sweats, weight loss, and general malaise. As the
At any time the bacilli in the tubercles can be reactivated, and infection becomes virulent in the host, a productive cough develops,
secondary, or active, TB can develop. The patient now is actively and thick, dark, frequently blood-tinged mucus is expectorated.
infected with the disease, which can spread to the bones, brain, and The primary diagnosis of TB is established through the patient's
kidneys (Figure 22-7). Some people develop active TB soon after signs and symptoms. The infection is suspected with a positive chest
becoming infected, before the immune system can fight the TB x-ray film but is confirmed with a sputum culture. Traditional
culture methods originally took 4 to 6 weeks, and this extended
period allowed a potentially infectious individual to continue to
spread the disease. New culture techniques identify the bacterium in
as little as 36 to 48 hours. The practitioner may order the
QuantiFERON-TB Gold (QFT) or the T-Spot blood tests to diag-
nose TB infection. A positive blood test means the person has been
LYMPHATIC SPREAD
A. Pleural surface infected with TB bacteria, but additional tests must be done to
B. Lung parenchyma
C. Contralateral lung
determine whether the person has latent TB infection or TB disease.
A negative TB blood test indicates that latent TB infection or TB
disease is not likely. Blood tests for TB are preferred if the individual
has received the BCG vaccine or if the patient cannot return for a
second appointment to look for a reaction to a Mantoux skin test.
A two-step Mantoux test may be ordered for individuals who
have lowered immunity (e.g., human immunodeficiency virus [HIV]
HEMATOGENOUSSPREAD infection); the elderly who are entering long-term care; and as a
Meningitis
Tuberculosis of urogenital baseline for pre-employment testing of healthcare workers and staff
tract members in prisons and long-term care facilities, and those employed
Bone tuberculosis
in substance abuse centers. Some people infected with M. tubercu-
losis may have a negative reaction to a Mantoux test if many years
have passed since they became infected. However, they may have a
positive reaction to a second skin test because the initial Mantoux
stimulated their immune system's ability to react to the test. If
the first test result is negative, the Mantoux should be repeated in
1 to 3 weeks. If the second test result is positive, the person is con-
sidered infected and should be treated accordingly. Healthcare pro-
viders are required by law to report TB illness to the local health
department.
Once a diagnosis of TB has been confirmed, the patient is pre-
scribed long-term treatment with a combination of drugs to eradicate
the bacilli. If the patient has tested positive for TB but does not have
an active infection, the standard treatment regimen for latent TB is
9 months of daily isoniazid. If the patient is healthy but has recently
been exposed to active TB, the provider may opt for a 12-dose
regimen of isoniazid and rifapentine (RPT). Rifarnpin (RIF) may
also be prescribed daily for 4 months. All of these treatments are
recommended to treat any possible tubercle formations. If the patient
SPREAD THROUGH AIRWAYS
A. Bronchial spread in has active pulmonary TB, the CDC recommends a four-drug
the same lung regimen-isoniazid, RIF, pyrazinamide, and ethambutol-daily for
B. Spread to the larynx
C. Aspirated TB swallowed 2 months; the regimen then is reduced to two drugs for an additional
into the esophagus leads
to intestinal TB
4 to 7 months, depending on sputum culture outcomes. It is crucial
that patients being treated with TB medications strictly comply with
medication orders to prevent the creation of multidrug-resistant TB
FIGURE 22-7 Spread of tuberculosis. (From Damjanov I: Pathology for the health-related profes· (MDR-TB). Resistant strains ofTB develop because of skipped doses
sions, ed 4, St Louis, 2010, Saunders.) or failure to take the medication as long as prescribed. MDR-TB
568 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES
requires at least 2 years of drug therapy with medications that can
cause serious side effects, especially liver damage. All tuberculin-
negative healthcare workers should have a PPD test annually; workers
who show a positive reaction but are not actively infected with TB
should have an annual chest x-ray evaluation to screen for the disease.
Signs and Symptoms of Latent and Active
Tuberculosis
Latent Tuberculosis
• Asymptomatic
• Not infectious
• Positive purified protein derivative (PPD) test result
• Positive QuantiFERON-TB Gold blood test result
• Normal chest x-ray studies
• Negative sputum culture
Active Tuberculosis
• Symptoms include cough for 3 weeks or longer, chest pain, hemoptysis,
fatigue, weight loss, anorexia, fever with chills, and night sweats
• Infectious (highest risk of infection is with close family members or
associates)
• Positive PPD and QuantiFERON-TB Gold blood tests
• Abnormal chest x-ray studies and/or positive sputum culture
Centers for Disease Control and Prevention. Available at www.cdc.gov/tb/publications/
factsheets/generaVLTB/andActiveTB.htm. Accessed January 27, 2015.
CRITICAL THINKING APPLICATION 22-2
Dr. Samuelson is the primary care physician for anursing home in the area.
He is concerned because one of the employees had a positive result on a
Mantoux test. What other tests will Dr. Samuelson order to confirm the
diagnosis? If those test results come back positive, how will the patient be
treated? What about the other employees and residents of the nursing
home?
Normal airway
A B
FIGURE 22-8 Inflammation and bronchospasm.
Chronic Obstructive Pulmonary Disease
COPD is a group of diseases with the common characteristic of
chronic airway obstruction. COPD is the third leading cause of
death in America, and most of those deaths are related to smoking.
Among the diseases in this group are chronic bronchitis, bronchi-
ectasis, asthma, pneumoconiosis, and emphysema. Although the
mechanism of the obstruction may vary, a patient with COPD is
unable to ventilate the lungs freely, which results in an ineffective
exchange of respiratory gases, dyspnea, and productive cough. Over
time, eliminating carbon dioxide from the lungs during expiration
becomes increasingly difficult. Although COPD can be medically
managed, it is not curable.
Asthma
Asthma attacks occur in response to a number of triggers that
cause both inflammation and bronchospasm, with resultant air-
flow obstruction. Asthma can develop into a chronic disease char-
acterized by increased sensitivity of the bronchial tubes to external
factors (e.g., environmental irritants, poor air quality, and allergies)
or to internal factors (e.g., stress, exercise, infection, and allergen
inhalation). Asthma also has a strong hereditary factor.
Asthma attacks can be mild to severe and can last minutes to
days. Bronchospasms trap air in the lungs, and the inflammatory
response creates edema and causes secretion of mucus into the con-
stricted bronchioles. A patient with asthma complains of a nonpro-
ductive cough, dyspnea, expiratory wheezing, and chest tightness.
Because the individual has difficulty breathing, tachycardia, pallor,
and diaphoresis also may occur. The patient can speak only a few
words at a time, stopping intermittently to regulate air intake. When
the chest is auscultated, the provider hears diminished breath sounds,
with wheezes and rhonchi in the lungs. Peak flow meters and spi-
rometry are used to measure the degree of airflow obstruction. Chest
x-ray studies may show changes in the lungs from mucous obstruc-
tions. Blood tests include a complete blood cell count with a dif-
ferential count to determine whether the attack is allergy related
(Figure 22-8).
During asthma symptoms
Narrowed airway
(limited air flow)
Tightened
muscles
constrict
C
 CHAPTER 22 Assisting in Pulmonary Medicine 569

Regardless of their age, patients with asthma should be actively
involved in the day-to-day management of their disease. The medical
assistant may be responsible for teaching the patient how to perform
peak flow measurements either daily or at the onset of an attack.
Peak flow meters assess the individual's ability to move air into and
out of the lungs. The provider may want the patient to keep a log
of daily peak flow results or to use the instrument as an at-home
monitoring device when chest tightness and wheezing occur. The
meter measures the peak expiratory flow rate, which is the fastest
speed at which the patient can blow air out of the lungs after taking
in as big a breath as possible (Procedure 22-1 ). Peak flow readings
provide an evaluation of bronchiole function that the patient can
perform at home with limited assistance. Readings can help predict
an asthma attack iflevels are falling; measure the degree ofbroncho-
spasm; and provide the provider with feedback on the effectiveness
of asthma treatment.

•;;m,immf}j• Instruct Patients According to Their Needs: Teach a Patient to Use a Peak Flow Meter

Goal: To instruct the patient in the proper method of performing apeak flow meter test.

EQUIPMENT and SUPPLIES 7. Loosen any tight clothing, such as a necktie, bra, or belt.
• Patient's health record PURPOSE: Tight clothing may restrict breathing capacity.
• Peak flow meter 8. Hold the meter upright, taking care not to block the opening with the
• Disposable mouthpiece fingers (Figure 2).
• Biohazardous waste container PURPOSE: To prevent obstruction of forced exhalation.
PROCEDURAL STEPS
'=
1. Sanitize your hands.
2. Place the mouthpiece on the peak flow meter and slide the marker to the
bottom of the scale.
1-
:==-
,--
,--
.:=-
PURPOSE: The indicator must be at the bottom of the scale for proper
measurement of expiratory effort (Figure l). ·-
,_-
·-
·-
·--
·-
·-·
·-
·--
·-·
·-
--
--
--

9. Instruct the patient to inhale as deeply as possible, to place the mouthpiece

3. Introduce yourself and confirm the patient's identity by name and date of
birth.
4. Explain the purpose of the test.
PURPOSE: To help reassure the patient.
S. Explain the actual maneuver of forced expiration.
PURPOSE: The patient must understand the maneuver so that he or she
can cooperate fully; this produces the best test results.
6. Make sure the patient is comfortable and in a proper position, either sitting
upright or standing (standing is preferred).
PURPOSE: Proper positioning ensures maximum lung expansion and accu-
rate test results.
into the mouth beyond the teeth, and to form a tight seal with the lips.
Caution the patient not to put the tongue in the mouthpiece when
exhaling.
PURPOSE: To prevent any leakage of air around the mouthpiece and any
obstruction of airflow.
10. Instruct the patient to exhale as fast and as forcefully as possible into the
peak flow meter.
11. The forced exhalation will move the marker up the scale and stop at the
point of the peak expiratory flow. Record this number and return the
marker to the bottom of the scale.
12. Repeat the procedure two more times, sliding the indicator to the bottom
of the scale before each reading, and record each result.
13. Encourage the patient to inhale as deeply as possible and to exhale as
fast and as forcefully as possible with each effort.
570 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES
•;mi,9mmf}ii -continued
14. Place the test results in the patient's record for the provider to review,
noting the time and date of the highest reading.
1S. Clean and disinfect the equipment, discarding waste in a biohaz-
ardous waste container, and give the patient the meter for continued use
at home with instructions to follow the manufacturer's cleaning
recommendations.
16. Sanitize your hands.
PURPOSE: To ensure infection control.
Digital peak flow meters are available that automatically record
and track peak flow readings (Figure 22-9). However, these models
are more expensive, so providers may still use the traditional peak
flow meter shown in Procedure 22-1 . Three zones of measurement
are used to interpret peak flow rates. The green zone is considered
normal: the reading is 80% to 100% of normal peak flow rates,
indicating the patient's asthma is under control. The yellow zone
signals caution: the patient's highest reading is 50% to 80% of
normal. The provider makes treatment decisions and recommenda-
tions at this point, or the patient may already be instructed on how
to manage medications if readings are within this level. The red zone
includes readings below 50% of the normal level, and immediate
action must be taken to prevent severe bronchospasms.
If the patient is having an asthma attack, the bronchioles are
constricting, becoming edematous, and filling up with mucus, so the
patient is unable to exhale strongly enough to raise the peak flow
indicator to a normal level. If readings are below normal, the pro-
vider prescribes a treatment plan that may include contacting the
FIGURE 22-9 Digital peak flow meter.
17. Record the testing information in the patient's health record.
PURPOSE: Procedures that are not recorded are considered not done.
CAUTION: Peak flow readings may trigger bronchospasms or severe coughing
in patients experiencing an asthma attack. If this occurs, instruct the patient to
rest and try again. If the patient is unable to perform three readings because
of bronchospasms and/or coughing, follow the provider's guidelines for manag-
ing this situation.
provider when peak flow levels are below a certain point or starting
nebulizer treatments. The provider may recommend an increase in
antiinflammatory medication if more than a 20% variation from
normal is seen in the readings. The medication therapy chosen
depends on the severity and frequency of acute attacks, but man-
agement is necessary to prevent permanent lung damage and
emphysema-like changes in the lungs.
The treatment of asthma consists of a regimen of medications,
including "rescue" inhalers (e.g., pirbuterol [Maxair] or albuterol
[Ventolin]), which are used to relieve bronchospasms or for exercise-
induced asthma (Figure 22-10). Tissue inflammation can be treated
with steroid inhalers (e.g., budesonide [Pulmicort Flexhaler], triam-
cinolone acetonide [Azmacortl, or fluticasone [Flovent Diskus])
and/or an oral leukotriene-receptor antagonist taken daily, such as
zafirlukast (Accolate) or montelukast sodium (Singulair). Another
option is a combination inhaler, such as fluticasone and salmeterol
(Advair Diskus), or budesonide and formoterol (Symbicort), to
prevent and treat bronchiole inflammation. A severe attack may
require injections of epinephrine, oral corticosteroids (prednisone)
and/or nebulizer treatments with a bronchodilator (Procedure 22-2).
A nebulizer forces compressed air through a medication chamber
that converts liquid medication (albuterol or budesonide) into an
aerosol or mist that can be inhaled though a mask or mouthpiece.
FIGURE 22-10 Use of a meteredilose inhaler.
 CHAPTER 22 Assisting in Pulmonary Medicine 571

•;;mdmhif}Ii Assist the Provider with Patient Care: Administer a Nebulizer Treatment

Goal: To perform anebulizer treatment.

EQUIPMENT and SUPPLIES 11. If using a mouthpiece, instruct the patient to hold it between the teeth
• Patient's health record with the lips pursed around the mouthpiece (Figure 2).
• Nebulizer machine
• Disposable connector tubing with medication dispenser
• Disposable mouthpiece or mask as ordered
• Disposable tissues
• Medication as ordered
• Biohazardous waste container
PROCEDURAL STEPS
1. Plug the nebulizer into a properly grounded electrical outlet.
2. Introduce yourself and confirm the patient's identity by name and date of
birth.
3. Explain the purpose of the treatment.
PURPOSE: To help reassure the patient.
4. Sanitize your hands.
S. Perform the three routine medication checks and measure the prescribed 12. Encourage the patient to take slow, deep breaths through the mouth and
dose of drug into the nebulizer medication cup (Figure l). to hold each breath 2 to 3 seconds to allow the medication to disperse
through the lungs.
PURPOSE: To ensure maximum distribution of the medication in the lung
tissue.
13. Continue the treatment until aerosol is no longer produced (approximately
l Ominutes).
CAUTION: If the patient is receiving a bronchodilator (albuterol), he or she
may experience dizziness, tremors, or tachycardia. Continue the treatment
unless otherwise ordered by the provider.
14. Turn off the nebulizer.
1S. Encourage the patient to take several deep breaths and to cough loosened
secretions into disposable tissues.
16. Dispose of the mouthpiece or mask and tubing in a biohazard container
and instruct the patient also to dispose of the contaminated tissues in the
biohazard container.
PURPOSE: To ensure infection control.
6. Replace the top of the medication cup and connect it to the mouthpiece 17. Sanitize your hands.
or face mask. PURPOSE: To ensure infection control.
7. Connect the disposable tubing to the nebulizer and the medication cup. 18. Record the nebulizer treatment; the patient's response, including the
8. The patient should be sitting upright to allow for total lung expansion. amount of coughing and whether coughing was productive or nonproduc-
PURPOSE: Proper positioning ensures adequate dispersal of the tive; and any side effects of the medication.
medication. PURPOSE: Procedures that are not recorded are considered not done.
9. Turn on the nebulizer (a mist should be visible coming from the back of 19. If the patient is to continue home nebulizer treatments, provide patient
the tube opposite the mouthpiece or into the face mask). education for both the patient and caregivers as appropriate. Make sure
PURPOSE: The mist is the aerosolized medication. they demonstrate the treatment steps to confirm understanding.
10. If using a mask, position it camfortably but securely over the patient's PURPOSE: Feedback through demonstration of technique ensures patient
mouth and nose. follow-through.
572 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES
The provider prescribes an inhaler dose according to the number
of "puffs" of a metered-dose inhaler (MDI) the patient should
administer. MDis consist of a pressurized canister containing medi-
cation and a mouthpiece. Most MDis hold about 200 doses of
medication combined with a pressurized gas propellant, which forces
the drug out of the canister. When the canister is inverted and
depressed, a metered dose (premeasured) is delivered through the
mouthpiece in aerosol form. Patient teaching is very important to
ensure that the patient operates the device correctly so that the
medication can be administered as ordered. If both a steroid and a
bronchodilator have been prescribed, the bronchodilator should be
taken first, because this opens the airways so that the steroid is better
distributed throughout the lungs.
Patient Education for a Metered-Dose HFA Inhaler
The chemical used to deliver medication in most metered-dose inhalers was
changed to hydrofluoroalkane (HFA) in 2008. The following are instructions
for patients for these devices:
l. The inhaler must be primed (l) before you use it the first time;
(2) if it hasn't been used for several days; or (3) if you dropped
it. Shake the inhaler and spray into the air (away from your face)
up to four times. (See the information that came with your inhaler
for exact instructions.)
2. Shake the canister vigorously for 5 seconds.
3. Hold the inhaler upright; put your index finger on the top of the
canister, and have your thumb supporting the bottom of the
inhaler.
4. Breathe out normally.
5. Place the mouthpiece between your teeth, and close your lips
around it; keep your tongue away from the opening of the
mouthpiece.
6. Press down the top of the canister with your index finger to
release the medication.
7. As you press down on the canister, breathe in deeply and slowly
through your mouth until your lungs are completely filled; this
should take 4 to 6 seconds (see Figure 22-10).
8. Hold the medication in your lungs for about 5 seconds before
breathing out.
9. If you need a second puff, wait about 15 to 30 seconds; shake
the canister again before the next puff.
l 0. Inhalers can be attached to spacers to meet the needs of children
or older patients who have difficulty managing the technique.
When the canister is depressed, the medication is held in the
spacer so the patient has more time to inhale the particles (Figure
22-1 1).
11. Recap the mouthpiece. HFA inhalers must be cleaned at least once
a week to prevent blockage. Remove the medication canister and
run warm tap water through the top and bottom of the plastic
mouthpiece for 30 to 60 seconds; shake off the excess water
and allow the mouthpiece to dry completely (overnight is
recommended).
12. After each use of a steroid inhaler, rinse your mouth with water,
gargle, and spit out the water to prevent an oral yeast infection
(thrush).
NOTE: Follow these steps for a metered-dose inhaler only; to use a dry
powder inhaler (e.g., Advair Diskus), close your mouth tightly around the
mouthpiece of the inhaler and breathe in quickly.
(Reproduced with permission from Moore RH: Patient information: asthma inhaler techniques
in children [Beyond the Basics]. In UpToDate: Post TW, editor, UpToDate, Waltham, MA.
[Accessed on April 11, 2016.]) Copyright © 2016 UpToDate, Inc. For more information visit
www.uptodate.com.
FIGURE 22-11 Use of a metered-oose inhaler with a spacer.
Pneumoconioses
Environmental causes of respiratory diseases include inhaled dusts,
fumes, and various kinds of organic or inorganic matter. Most of
these respiratory diseases are occupational; a consequence of long-
term exposure to unsafe air in the workplace. Although the respira-
tory system is designed to filter and trap air contaminants, it can
become overloaded after intense exposure. Subsequently, irritants
enter the lungs, and the damage to pulmonary tissue increases if the
particles are very small and can enter the alveoli; if the individual is
exposed to a large amount of contaminants over a long period; and
if the added irritation of cigarette smoking is a factor.
Some occupations that can cause pneumoconiosis include coal
mining (anthracosis); insulation manufacturing and shipbuilding
(asbestosis); and stonecutting or sandblasting (silicosis). The tissue
changes caused by inhalation of these substances into the lungs are
irreversible. Patients develop dyspnea, cough, and emphysema-like
changes and have an increased risk of lung cancer.
Emphysema
Emphysema is a progressive obstructive disease of the pulmonary
system that is irreversible. Emphysema causes loss of elasticity in the
walls of the alveoli. Eventually these one-cell-thick walls stretch and
break, creating air spaces that cannot perform oxygen-carbon
dioxide exchange. The remaining alveoli become overinflated, and
as time progresses, pressure increases in the affected alveoli, and those
walls burst. This chain reaction of alveolar destruction causes trapped
air to fill the spaces of the no longer functioning alveoli, making
complete exhalation very difficult. Cigarette smoking is the primary
contributing factor, although patients who develop emphysema at
 CHAPTER 22 Assisting in Pulmonary Medicine 573

TABLE 22-3 Pulmonary Function Tests

LUNG PATIENT
FUNCTION DESCRIPTION INSTRUCTIONS
Tidal volume (TV) Volume of air inspired Patient breathes in and out
and expired during a normally with lips pursed
normal respiration around mouthpiece.
Vital capacity (VO Maximum amount of Patient takes deep breath
air that can be expired and exhales completely
after maximum (not forcefully).
inspiration
lnspiratory capacity Maximum amount of Patient breathes in and out
(IC) air that can be inspired normally, then forcibly
after a normal inhales at the end of the
FIGURE 22-12 Clubbing. (From Zitelli 8, Davis H: A#as of pediatric physical diagnosis, ed 5, expiration TV.
Philadelphia, 2007, Mosby.)
Expiratory reserve Maximum volume of Patient breathes in and out
an early age may have a genetic predisposition to the disease. Other volume (ERV) air that can be exhaled normally, then exhales
contributors include exposure to pollutants (pneumoconioses) or after a normal forcibly at the end of the
chronic respiratory disorders (chronic bronchitis or uncontrolled expiration TV.
asthma).
Symptoms may not be seen until irreversible damage has occurred. Residual volume Volume of air left in
When signs and symptoms occur, they include dyspnea, shortness (RV) lungs after forced
of breath (SOB), wheezing, production of thick mucus, restlessness, expiration
fatigue, anorexia, persistent cough (productive or nonproductive),
and peripheral cyanosis with clubbing (Figure 22-12). The patient
Functional residual Amount of air left in FRV =ERV+ RV
typically is diagnosed from presenting signs and symptoms and a
volume (FRV) the lungs after a
chest x-ray examination, in addition to a pulmonary function test normal expiration
(PFT) that shows increased residual volume and decreased forced Forced vital Amount of air that can Patient inhales as deeply
expiratory volume (Table 22-3). capacity (FV() be forcefully exhaled as possible, then forcibly
Patients with emphysema are encouraged to avoid respiratory
from a maximum exhales as much as
irritants and individuals with respiratory infections and to stop
smoking. Many of these patients require oxygen therapy and benefit
inhalation possible.
from postural drainage and chest percussion, which help them Maximum volume Maximum volume the Patient breathes in and out
expectorate trapped mucus. Nebulizer treatments also may be ventilation (MVV) patient can breathe in as deeply and as
prescribed. and out in 1 minute frequently as possible for
Patients with emphysema expend a great deal of energy just trying 15 seconds (total volume
to exhale air from the lungs, so they should consume a high-calorie,
is multiplied by 4).
high-fluid diet and perform certain exercises, such as pursed-lip
breathing, to help them conserve energy. Individuals with emphy-
sema require continuous care and support; therefore, encouraging
family involvement in the treatment plan is important. Referral to Obstructive Sleep Apnea
a pulmonary rehabilitation program or support group can benefit Obstructive sleep apnea occurs when the muscles in the posterior
both patient and family members. pharynx that support the soft palate, uvula, tonsils, and tongue relax
during sleep. This relaxation causes the trachea to narrow or close
with inhalation, momentarily stopping breathing. Blood oxygen
CRITICAL THINKING APPLICATION 22-3 levels are lowered, and the brain senses hypoxemia, so it stimulates
Dr. Samuelson has quite a few patients with either asthma or emphysema. the patient from sleep to reopen the trachea. The patient is awake
Under Dr. Samuelson's direction, Michael is expected to reinforce patient so briefly he or she is not aware of the arousal, but this occurs repeat-
education and answer patients' and family members' questions. Michael edly throughout the night, preventing the person from achieving a
decides to make afile on pertinent health education information and review deeper, more restful level of sleep. Because of this interrupted sleep,
it with Dr. Samuelson before using it to help coordinate the care of these the individual frequently complains of sleepiness during the day.
Risk factors for developing obstructive sleep apnea include being
patients. What information should Michael include in the file? What com-
overweight (a fat or thick neck may narrow the trachea); enlarged
munity resources or groups should be included for patient support?
adenoids or tonsils; male gender (men develop sleep apnea twice as
574 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES
often as women); a family history of sleep apnea; and alcohol con-
sumption or sedative use, because these chemicals relax throat
muscles.
Patients with suspected sleep apnea report chronic fatigue (from
the constant startling out of a restful sleep) and pronounced snoring.
Sleep apnea is diagnosed after the patient has been monitored during
a sleep study, a process called nocturnal polysomnography. The patient
is connected to equipment that monitors the pulse rate, brain activ-
ity, breathing patterns, blood oxygen levels, and limb movements
during sleep.
Multiple complications in addition to chronic daytime fatigue
can occur because of sleep apnea. Patients are more susceptible to
hypertension and resultant heart disease because hypoxic episodes
during sleep raise blood pressure and put a strain on the heart.
Individuals with sleep apnea also tend to complain of memory
problems, morning headaches, depression, and nocturia.
Sleep apnea typically is treated with a continuous positive airway
pressure (CPAP) machine (Figure 22-13), which delivers air pressure
through a mask placed over the mouth or nose, or through a cannula
in the nose. The air pressure created by the machine is greater than
that of the surrounding air; this forces the upper airway passages
open and prevents tracheal collapse. Although CPAP is the preferred
method of treatment, it can be awkward and uncomfortable, making
it difficult to sleep. Patients may have to experiment with different
types of masks and need to be encouraged to follow through with
the recommended treatment. Individuals with mild obstructive sleep
apnea can try alternative treatment with a dental device that opens
the throat by bringing the jaw forward. Surgery may also be an
option to remove the uvula, tonsils, and adenoids, in addition to
excess tissue from the nose and back of the throat that vibrates
during sleep, resulting in snoring.
Common Signs and Symptoms of Obstructive
Sleep Apnea
• Excessive daytime sleepiness (hypersomnia)
• Persistently loud, disruptive snoring
• Snoring, choking, or gasping sounds while asleep
• Episodes of breathing cessation during sleep (apnea)
• Dry mouth or sore throat on awakening
• Morning headache
FIGURE 22-13 Patient with a (PAP machine. (Courtesy Respironics, Murrysville, Pa.)
Cancer of the Pulmonary System
The most prevalent neoplasms of the respiratory system are lung
cancer and carcinoma of the larynx.
Lung Cancer
Lung cancer is the leading cause of cancer-related deaths for both
men and women in the United States. It is estimated that 90% of
lung tumors are linked to cigarette smoking; other risk factors
include chronic exposure to second-hand smoke, carcinogens (e.g.,
radon gas and asbestos), and a genetic predisposition. The risk of
developing cancer is higher for patients who started to smoke at a
young age and who have smoked more than a pack a day for a long
period (Figure 22-14). Individuals who quit smoking can signifi-
cantly lower their risk oflung cancer; after 10 years, the risk of dying
from lung cancer is about half that of a person who is still smoking.
Female smokers are at greater risk oflung cancer than male smokers.
The lung is a common site of secondary tumors from metastasis
in addition to primary carcinomas. Several different cellular types of
tumors can develop in the lungs, but the one seen most frequently
is bronchogenic carcinoma, which originates in the epithelial lining
of the bronchioles (Figure 22-15). The early symptoms of lung
cancer (i.e., a chronic, productive cough; SOB; and chest tightness)
are masked by symptoms regularly displayed by habitual smokers. A
tumor may be discovered accidentally during a routine chest x-ray
evaluation or may not be discovered until metastatic symptoms
(e.g., anemia, weight loss, and fatigue) lead to the diagnosis of
a primary lung tumor. Patients who show symptoms usually display
local effects of a tumor in the chest, such as bronchial obstruc-
tion, atelectasis, hemoptysis, chest pain, and pleural membrane
Adenocarcinoma
(ciliated cells and
m@
ucous cells)
•
• ,.
®§)
Oat cell
Large cell
undifferentiated
carcinoma
FIGURE 22-14 Classification of lung cancer. (From Damianov IL: Pathology for the health-related
professions, ed 4, St Louis, 2010, Saunders.)

FIGURE 22-15 Lung cancer. (From Damjanov IL: Pathology for the health-related professions,
ed 4, St Louis, 2010, Saunders.)
involvement. Unless the tumor is diagnosed very early, lung cancer
has a poor prognosis. Treatment consists of surgery, radiation therapy,
and chemotherapy.
Carcinoma of the Larynx
Carcinoma of the larynx is pathologically linked to tobacco use
(including smokeless tobacco) and chronic alcohol consumption.
Ninety percent of cases of laryngeal cancer occur in men; most of
those affected are 60 to 70 years of age. Patients show early signs of
hoarseness, loss of voice, ear pain, and dysphagia (difficulty swallow-
ing); occasionally, respiration becomes impaired. Because of these
early symptoms, most laryngeal tumors are discovered in the early
stages and can be removed, resulting in a good prognosis. Surgical
treatment consists of a partial or total laryngectomy. With a total
laryngectomy, the voice is permanently lost, and a tracheostomy is
performed. Patients undergoing such procedures need comprehen-
sive preparation and benefit from meeting a laryngectomy survivor,
in addition to participating in a support group to deal with postsur-
gical adjustments.
THE MEDICAL ASSISTANT'S ROLE
IN PULMONARY PROCEDURES
Assisting with the Examination
Preparing a patient for a respiratory examination includes having the
patient disrobe to the waist and put on a gown with the opening in
the front or back, depending on the provider's preference. To assess
the status of the respiratory system, the provider uses inspection,
palpation, percussion, and auscultation on the anterior thorax, then
repeats the process on the posterior and lateral thorax. The medical
assistant is responsible for assisting the provider throughout the
examination, providing privacy and support for the patient, and
performing diagnostic tests as ordered.
Diagnostic Procedures
Tuberculosis
If the provider orders TB screening, the medical assistant administers
the Mantoux test. An intradermal injection of PPD from a live
tuberculin bacillus culture is given to test for the presence of
CHAPTER 22 Assisting in Pulmonary Medicine 575
FIGURE 22-16 Spirometer.
tuberculin antibodies. A positive Mantoux reaction indicates the
possibility of active or latent TB or exposure to the disease. Further
testing by chest x-ray examination and sputum culture is required
for a definitive diagnosis. Sometimes the provider orders a blood test
to diagnose the disease.
Spirometry
PFTs are performed to diagnose a pulmonary abnormality and/or to
determine the extent of a pulmonary disease (see Table 22-3). In
providers' offices, lung function measurements are taken with a
spirometer (Figure 22-16). Successful spirometry requires consistent
methods of preparing the patient, explaining and performing the
procedure, and determining the results. Patient preparation begins
when the procedure is scheduled. The patient should be instructed
to wear loose fitting clothing; avoid eating a large meal within 2
hours of taking the test; avoid smoking for at least 1 hour before the
test; and avoid taking bronchodilators or nebulizers for 6 hours
before the test.
The medical assistant may be responsible for conducting this
test in the ambulatory care setting (Procedure 22-3). Before the
patient is scheduled for the procedure, the provider considers
certain health problems that would contraindicate the test, such as
a pneumothorax, a history of angina or recent myocardial infarc-
tion, or the presence of vascular aneurysms. When the patient
arrives for testing, the medical assistant should explain the purpose
of the test, obtain the patient's vital signs (including height and
weight), and explain the maneuver. The medical assistant should
refer to the patient's health history to make sure that age, gender,
and ethnicity have been recorded because these also help deter-
mine lung volumes. Spirometry should be described briefly, in
simple terms. One explanation that works well is "I am going to
have you blow into a machine to see how much air your lungs
hold and how fast you can expel it. The test does not hurt, but it
does require your cooperation and lots of effort." The patient
should be in a comfortable sitting position with the legs uncrossed
and both feet on the floor. Dentures that fit poorly may be a nui-
sance and should be removed if they might interfere. The chin
should be slightly elevated and the neck slightly extended. This
position should be maintained throughout the forced expiratory
procedure. A nose clip is applied to make sure the patient only
exhales through the mouth.
576 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES
•;;m,inlj;jf}II Assist the Provider with Patient Care: Perform Volume Capacity Spirometry Testing
Goal: To perform volume capacity testing.
EQUIPMENT and SUPPLIES
• Patient's health record
• Scale with height measuring device
• Sphygmomanometer and stethascope
• Spirometer with recording paper in place
• External spirometric tubing
• Disposable mouthpiece
• Nasal clip if needed
• Biohazardous waste container
PROCEDURAL STEPS
1. Sanitize your hands and assemble the spirometer.
2. Introduce yourself and confirm the patient's identity by name and date of
birth. Determine whether the patient needed any special preparation (e.g.,
no smoking, not taking bronchodilators) and if so, whether it was done.
PURPOSE: If special procedures were not followed, the test may have to
be rescheduled.
3. Explain the purpose of the test.
PURPOSE: To help reassure the patient.
4. Measure and record the patient's vital signs, height, and weight.
S. Explain the actual maneuver.
PURPOSE: The patient must understand the maneuver so that he or she
can cooperate fully; this produces the best test results.
6. Make sure the patient is comfortable and either is standing or is sitting
(preferred) with the legs uncrossed and the feet on the floor.
PURPOSE: Proper positioning ensures maximum lung expansion and accu-
rate test results. The test may cause dizziness, so sitting is preferred. If
the patient stands, a chair must be next to the person.
7. Loosen any tight clothing, such as a necktie, bra, or belt.
PURPOSE: Tight clothing may restrict breathing capacity.
8. Show the patient the proper chin and neck position: the chin should be
slightly elevated and the neck slightly extended.
9. Practice the maneuver with the patient before beginning the test.
PURPOSE: To relieve apprehension and enhance understanding.
10. Place a soft nose clip on the patient's nose if this is part of the facility's
procedure.
PURPOSE: To prevent air from escaping through the nose during
exhalation.
Give specific instructions in simple, direct terms; for exam-
ple, "I want you to take the deepest breath possible, put the
mouthpiece in your mouth and seal your lips tightly around
it, and then blow into the tube as hard and as fast as you can
in one long, complete breath." An analogy that sometimes is
helpful for further explaining the maneuver is "It's like blow-
ing out the candles on a birthday cake when they don't all
11. Instruct the patient to place the mouthpiece in the mouth and to seal the
lips around it when exhaling (Figure l).
1
12. Tell the patient to inhale according to instructions; take as deep a breath
as possible and blow air out hard and long.
13. Use active, forceful coaching during exhalation. Patient must exhale com-
pletely to get accurate test results.
PURPOSE: Coaching improves performance. The patient should continue
to exhale even after he or she thinks the process is complete.
14. Provide the patient with feedback after he or she completes the
maneuver.
PURPOSE: Encouragement and explanations of mistakes in the maneuver
can help improve the patient's compliance.
1S. Carefully observe the patient for indications of vertigo or dyspnea or any
other signs of difficulty. If complications occur, stop the test and inform
the provider.
16. Continue testing until three acceptable maneuvers have been performed.
17. Clean and disinfect the equipment. Discard waste, including the disposable
mouthpiece and tubing, in a biohazardous waste container.
18. Sanitize your hands.
PURPOSE: To ensure infection control.
19. Record the procedure in the patient's EHR and/or place the spirometer
printout in the records for the provider to review.
PURPOSE: Procedures that are not recorded are considered not done.
go out; you need to keep blowing the same breath until
they do."
Next, demonstrate the maneuver. Many patients forget some
or all of the instructions they have just received, so demonstra-
tion reinforces exactly what to do. Show the patient the proper
chin and neck position, how to place the mouthpiece at the right
time, and how to blow the air out and continue to blow.
 CHAPTER 22 Assisting in Pulmonary Medicine 577

When the demonstration is finished, remind the patient of the Pulse Oximetry
following points: Pulse oximetry is a noninvasive method of evaluating both the
• Take as deep a breath as possible. pulse rate and the oxygen saturation of hemoglobin in arterial
• Blow air out hard and long. blood. It identifies the percentage of hemoglobin that is oxygen-
• Blow until all of the air is out of your lungs. ated compared with the total amount of hemoglobin available.
Use active and forceful coaching while the patient is performing Many ambulatory settings use pulse oximeters to assess a patient's
the maneuver. You may need to raise your voice with some urgency oxygenation status in such disorders as pneumonia, bronchitis,
to improve the patient's performance, using such phrases as, "Blow, emphysema, or asthma.
blow, blow!" "Keep blowing, keep blowing!" and "Don't stop To perform the procedure, the medical assistant clips a probe on
blowing!" After the maneuver, give the patient some feedback on the the patient's earlobe or finger (Figure 22-17). Fingernail polish
quality of the test and describe what improvements could be made. must be removed before the clip is applied. A beam of infrared light
Continue to repeat efforts until the patient has completed three passes through the tissue, and the machine measures the amount of
acceptable maneuvers. The two best efforts are used to calculate light absorbed by oxygenated hemoglobin, which is displayed on
pulmonary function. Although most spirometers calculate the the digital screen as a percentage. At the same time the light mea-
normal values for each patient based on the information entered into sures the patient's pulse rate, which also is shown on the screen. A
the machine, the provider can calculate them from the individual's normal pulse oximetry reading is 95% or higher (meaning 95%
ethnicity, age, height, weight, and gender; the test results are docu- of the total available hemoglobin attachments for oxygen are
mented as a percentage. If the patient's best efforts are greater than carrying oxygen). Treatment, such as oxygen or bronchodilator
80% of pretest calculated values, pulmonary function is considered therapies, usually is started when readings are 90% to 92% or lower
normal. Spirometry tests provide the provider information about the (Procedure 22-4).
impact of obstruction or pulmonary disease on airflow. If the results
are less than 60% of the predicted value, the patient may be given
bronchodilators and retested to determine the impact of the inhalant
on function.
Test Results. Document the procedure in the patient's EHR and
give the provider the printout from the spirometer for review. The
results can be uploaded directly into the patient's EHR so a printout
may not be necessary. Documentation should include the patient's
compliance with preparation, condition during the test, and force-
fulness of exhalation when coached during the exam. If any ques-
tions arise about the quality of the results, ask the patient to wait
while the provider reviews them. If the patient has delayed taking
medication, check with the provider as to when the patient should
resume taking it.

CRITICAL THINKING APPLICATION 22-4

Michael is teaching Cinda, a new employee, how to perform a spirometry
test. He has summarized the steps of the procedure on a card, which is
kept next to the machine for easy reference. Cinda knows nothing about
the procedure. What would be the best way for Michael to teach her
about the test? What information should he include? How should she docu-
ment the procedure in the patient's EHR?
FIGURE 22-17 Pulse oximeter.

•;;m,imi;jf}II Perform Patient Screening Using Established Protocols: Perform Pulse Oximetry

Goal: To assess the adequacy of oxygen levels (or oxygen saturation) in the blood using apulse oximeter.
EQUIPMENT and SUPPLIES 2. Confirm the patient's identity by name and date of birth and explain the
• Patient's health record procedure.
• Pulse oximeter monitor and appropriate sized probe PURPOSE: An informed patient is more cooperative.
3. Sanitize your hands.
PROCEDURAL STEPS PURPOSE: Standard Precautions must be followed to prevent spread of
1. Assemble the equipment. disease.
578 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES
•;;m,imj;jf}II -,;ontinued
4. Turn on the monitor and attach the probe to the finger (preferred) or ear
lobe so it is flush with the skin.
S. The light-emitting diode (LED) should be placed on top of the nail. If the
patient is wearing nail polish or has artificial nails, these may have to be
removed to get a strong pulse signal.
PURPOSE: To measure the pulse and oxygen saturation level.
6. Record the oxygen saturation percentage and pulse in patient's health
record. Include date, time, and if the patient is receiving supplemental
oxygen record the amount in liters.
PURPOSE: Procedures that are not recorded are considered not done.
Obtaining Sputum for Culture
A sputum culture is requested when signs and symptoms are accom-
panied by physical evidence of pneumonia, TB, or other infectious
diseases of the lower respiratory tract. The specimen is sent to a labo-
ratory equipped to handle potentially infectious bacteriologic
samples. The sample is cultured and incubated, and the pathogenic
organism grown in the culture medium is identified. If possible, the
provider refrains from starting antibiotic therapy until the sputum
has been collected. The sample may also be sent to the laboratory
for cytologic analysis, which may indicate a cancerous condition of
the lungs or bronchi.
Methods of Collection. In the ambulatory care setting, the primary
method of collecting a sputum sample is expectoration (Procedure
22-5). However, sputum also can be collected by tracheal suctioning
and bronchoscopy. If the sample is to be collected by expectoration,
•;;m,immf}ii Obtain Specimens for Microbiologic Testing: Obtain a Sputum Sample for Culture
Goal: To collect asputum sample, following Standard Precautions.
EQUIPMENT and SUPPLIES
• Patient's health record
• Sterile laboratory specimen cup, accurately labeled
• Biohazard laboratory specimen bag with laboratory requisition
• Disposable examination gloves
• Face shield with goggles
• Impervious gown
• Biohazardous waste container
• Cup of water
• Ginger ale or juice
PROCEDURAL STEPS
1. Assemble the equipment and label the specimen cup.
2. Identify the patient by name and date of birth and explain the procedure.
PURPOSE: An informed patient is more cooperative.
7. Sanitize the patient probe and the external portion of the monitor with an
aseptic cleaner.
PURPOSE: To follow Standard Precautions.
8. Sanitize your hands.
PURPOSE: To ensure infection control.
most providers have the patient perform the procedure at home with
instruction. The medical assistant may be responsible for explaining
the procedure to the patient or reinforcing the provider's instruc-
tions. The patient should understand that the best time for collecting
a sputum specimen is in the morning when the patient first wakes
up, before eating or drinking. The patient can rinse out the mouth
with water before collecting the sample to reduce contamination
from the oropharynx. The sample is collected from sputum coughed
up from the lungs, not from saliva, so the patient should be encour-
aged to cough deeply and forcefully to collect a satisfactory sample.
It may help to have the patient take several deep breaths and then
cough. At least 1 teaspoon of sputum should be collected in a sterile
specimen cup (the patient needs to know how to handle the speci-
men cup to maintain sterility), which must be returned to the office
or laboratory as soon as possible after collection.
3. Sanitize your hands and put on gloves, a face shield with goggles, and
an impervious gown.
PURPOSE: Standard Precautions must be followed when potentially infec-
tious materials are collected.
4. Have the patient rinse his or her mouth with water.
PURPOSE: Any food particles in the mouth will contaminate the
specimen.
S. Carefully remove the specimen cup lid, taking care not to touch the inside
of the lid or the inside of the container, and place it upside down on a
side table.
PURPOSE: To maintain the sterile environment of the specimen cup.
6. Instruct the patient to take three deep breaths and then cough deeply to
bring up secretions from the lower respiratory tract.
PURPOSE: The organisms for culture must be from the lung fields in the
lower respiratory tract.

•;;m!,mj;jf}II -,;ontinued
7. Tell the patient to spit directly into the specimen container and to avoid
getting any sputum on the exterior of the container. Do not touch the
inside of the container during the procedure.
PURPOSE: Sputum on the exterior of the container is considered hazard-
ous. Prevent contamination of the inside of the container.
8. Place the lid securely on the container, taking care not to touch the inside
of the lid, and then place the container in the plastic specimen bag.
PURPOSE: To maintain the sterility af the container and to minimize the
chance of spreading the potentially infectious organisms.
9. Offer the patient a glass of juice or ginger ale.
PURPOSE: The patient may have a bad taste in the mouth after the test,
and this may cause nausea.
10. If another sputum test is ordered for the next morning, instruct the patient
when to come to the office or explain how to perrorm the procedure at
If the patient is taking antibiotic medications at the time of the
specimen collection, this information should be included on the
laboratory slip. If the cough does not produce sputum, chest phys-
iotherapy or nebulization may be ordered by the provider to induce
it. In some cases the provider may order sputum collection for three
consecutive mornings.
CRITICAL THINKING APPLICATION 22-5
Tomas Garcia, a68-year-old patient, has achronic cough, and Dr. Samuelson
orders a sputum culture to rule out an infectious disease. Mr. Garcia is
supposed to collect the specimens every morning for the next 3 days, but
he is very hard of hearing and does not understand English very well. His
daughter, who is bilingual, is with him at today's visit. How should Michael
relay the information about how to collect the sputum sample? What
important details should be reviewed with Mr. Garcia's daughter?
Bronchoscopy
Bronchoscopy typically is performed in an outpatient clinic or a
hospital. However, the medical assistant should be familiar with the
procedure because he or she probably will schedule the test, instruct
the patient on preparation, and help answer questions from the
patient or family.
Bronchoscopy provides an endoscopic view of the larynx, trachea,
and bronchi. A pulmonary specialist or surgeon performs the pro-
cedure, using a flexible fiberoptic instrument through which the
physician can visualize respiratory tissues and collect biopsy speci-
mens or bronchial washings as needed for cytologic evaluation or
culture. Laser therapy to treat endotracheal lesions also is possible
through the flexible scope.
The patient should remain on nothing by mouth (NPO) status
for 6 to 12 hours before the test to reduce the risk of aspiration.
Also, the patient should ask the physician whether to continue
CHAPTER 22 Assisting in Pulmonary Medicine 579
home. Remind the person to follow the same instructions for preparation.
Stress the importance of maintaining the sterility of the container and of
collecting the specimen first thing in the morning.
11. Sanitize the work area and properly dispose of all supplies.
PURPOSE: To follow Standard Precautions.
12. Sanitize your hands.
PURPOSE: To ensure infection control.
13. Process the specimen immediately to ensure optimum test results or
refrigerate the specimen until it is sent to the laboratory for analysis.
PURPOSE: Microorganisms may propagate or die, which can result in a
false-positive or false-negative result.
14. Record the procedure in the patient's health record.
PURPOSE: Procedures that are not recorded are considered not done.
taking routine medications and when to stop taking aspirin, ibupro-
fen, or other anticoagulant drugs before the procedure. The patient
should perform good mouth care before the procedure to reduce
the number of bacteria present, and dentures should be removed.
The patient will be given medication before the procedure to aid
relaxation and to dry up oral secretions. The medical assistant
should reassure the patient the procedure does not interfere with
breathing.
Before the instrument is inserted, the physician sprays a topical
anesthetic (lidocaine) into the mouth and on the back of the
throat to help suppress the gag reflex and reduce any discomfort
from passage of the instrument. The tube can be inserted through
the nose or mouth, and as it reaches the glottis, more lidocaine is
sprayed to control the cough reflex. The physician continues to
pass the tube through the bronchi and larger bronchioles, collect-
ing biopsy specimens of any suspicious tissue and obtaining cellu-
lar washings if indicated. Because the patient is sedated, it is not
an uncomfortable procedure, but the patient may complain of a
sore throat and may experience hemoptysis for several hours after
the procedure. Biopsy and culture reports usually are available in 2
to 7 days.
CLOSING COMMENTS
Patient Education
It is often said that the greatest fear a person has is the fear of the
unknown. Patients frequently worry about tests the physician has
ordered. The imagination can create all types of frightening scenar-
ios with even more alarming outcomes. The medical assistant plays
a vital role in allaying patients' fears by explaining diagnostic tests,
making sure the patient understands how to prepare for the
examination and what will be expected of him or her during the
procedure. Make sure to give the patient brochures or handouts
explaining the procedure that he or she can review at home.
Answer all the patient's questions, and consult the provider about
580 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES
questions or concerns you cannot address before the patient leaves
the office.
Legal and Ethical Issues
If the pulmonary test ordered is an invasive test, such as bronchos-
copy, make sure a written consent form is obtained from the patient
and is in the patient's health record. If oxygen therapy is ordered,
the physician must write a prescription that specifies the amount of
oxygen to be given and the type of device to be used for delivery.
The physician also may write an order for a respiratory care practi-
tioner to follow up on the patient at home.
Ji1iiiit+i;fi•jii#IM;it•i
Michael has become very adept at performing respiratory diagnostic procedures
and treatments for ambulatory patients. He enjoys interacting with this special
group of patients and works at maintaining an up-to-date file on educational
and resource assistance in the community. Michael especially enjoys the patient
education aspect of caring for people with respiratory diseases. Many of these
patients have chronic diseases that require long-term care by a physician, and
Michael attempts to use available "teaching moments" to reinforce healthy
lifestyle habits and to confirm patients' understanding of the treatments.
SUMMARY OF LEARNING OBJECTIVES
l. Define, spell, and pronounce the terms listed in the vocabulary.
Spelling and pronouncing medical terms correctly reinforce the medical
assistant's credibility. Knowing the definitions of these terms promotes
confidence in communication with patients and co-workers.
2. Describe the organs of the respiratory system and their functions.
The respiratory system exchanges oxygen for carbon dioxide waste
through external and internal respiration and helps maintain the acid-base
balance in the body. It works with the circulatory system to supply body
cells with oxygen and remove metabolic wastes. The upper respiratory
tract transports air through the nose, pharynx, and larynx. The lower
respiratory tract consists of the trachea, bronchial tubes, and lungs.
3. Explain the process of ventilation.
Ventilation is the process by which the bronchioles deposit oxygenated
air into the alveoli. Anetwork of pulmonary capillaries surround the
alveoli, and oxygenated air moves out of the single-celled walls of the
alveoli and into the capillaries. Carbon dioxide is forced out of the capil-
laries, into the alveoli, and then out through the bronchioles. Inspiration
is the movement of oxygen from the atmosphere into the alveoli; expira-
tion is the movement of carbon dioxide from the alveoli into the
atmosphere.
Professional Behaviors
Many of the respiratory conditions you learned about in this chapter have
the potential of becoming chronic or lifelong health concerns. Astrong link
has been established between tobacco use and the development of respira-
tory disease. It can be quite frustrating for a healthcare professional to
work with a patient who continues to smoke despite provider recommenda-
tions and the signs of serious respiratory disease. The medical assistant
must provide respectful care to all individuals, regardless of their lifestyle
choices. Approaching patients with a professional attitude and therapeutic
communication techniques can go a long way in strengthening the patient-
caregiver relationship.
Michael continues to participate in local meetings of the American Associa-
tion of Medical Assistants (AAMA) to keep up with recent practice trends, and
he took a medical terminology refresher course at the local community college
to improve his patient interviewing and documentation skills. He is investigating
starting a Smoke Stoppers group out of Dr. Samuelson's office to encourage
patients to develop a healthier lifestyle, and he emphasizes to his patients who
work in the area's coal mines and construction businesses the importance of
consistently wearing respirators.
4. Discuss respiratory system defenses and use correct respiratory
system terminology when documenting in the medical record.
Every part of the respiratory system has a defense mechanism; disease
occurs when something disrupts the normal homeostatic chain of events.
Table 22-1 defines common terms related to the respiratory system that
should be used when charting a patient's signs and symptoms.
5. Describe upper respiratory infections (e.g., the common cold, sinus-
itis, and allergic rhinitis), in addition to lower respiratory infections
(e.g., pneumonia).
URls include the common cold, which is caused by a virus; sinusitis, which
may be a result of an infection or allergic reaction; and allergic rhinitis,
which is triggered by multiple factors and causes nasal symptoms. Lower
respiratory infections include pneumonia, an infection of the lungs that
can be caused by multiple pathogens and that may range from a minor
infection to a life-threatening disease.
6. Explain the diagnosis and treatment of tuberculosis.
TB, caused by M. tuberculosis, can be either active or latent. Individuals
with active TB are infectious and show the symptoms of the disease;
those with latent TB have activated tubercles because of a weakened
immune system. TB is diagnosed by a combination of PPD testing, chest

SUMMARY OF LEARNING OBJECTIVES-continued
x-ray studies, blood tests, and sputum cultures. It is treated with multiple
medications, depending on the type and stage of the disease.
7. Do the following related to chronic obstructive pulmonary disease:
• Summarize the disorders associated with chronic obstructive pulmo-
nary disease and their treatments.
COPD is a group of diseases with the common characteristic of chronic
airway obstruction. They include chronic bronchitis, bronchiectasis,
asthma, pneumoconiosis, emphysema, and sleep apnea. The mecha-
nism of obstruction may vary, but all these patients are unable to
ventilate the lungs freely, which results in ineffective exchange of
respiratory gases. Treatments include bronchodilator and corticosteroid
inhalers, evaluation of peak flow values, nebulizer treatments,
oxygen, chest therapy, and CPAP machines.
• Teach apatient how to use apeak flow meter.
Procedure 22-1 outlines the procedure for teaching a patient how to
obtain an accurate peak flow reading.
• Administer anebulizer treatment.
Procedure 22-2 outlines the procedure for administering a nebulizer
treatment.
• Detail patient teaching for the use of ametered-dose inhaler.
Shake the canister, and hold it upright, breathe out normally, place
the mouthpiece between the teeth, and close the lips around it; press
down on the top of the canister and breathe in deeply and slowly
through the mouth until the lungs are completely filled; hold the
breath about 5 seconds. Wait about 15 to 30 seconds before the
next puff. After using a steroid inhaler, rinse the mouth with water,
gargle, and spit out the water to prevent an oral yeast infection.
8. Discuss obstructive sleep apnea, including causes, risk factors, com-
plications, and treatment.
Obstructive sleep apnea occurs when the muscles in the posterior pharynx
relax during sleep. Risk factors for developing sleep apnea include being
overweight, a family history, and alcohol or sedative consumption.
Patients with sleep apnea are more susceptible to hypertension and also
could have headaches, depression, and nocturia. Sleep apnea is typically
treated with a (PAP machine.
9. Describe the cancers associated with the pulmonary system.
Lung cancer is the leading cause of cancer-related deaths for both men
and women; the lung also is a common site of metastatic tumors. The
CONNECTIONS
CrJ Study Guide Connection: Go to the Chapter 22 Study Guide. Read and complete
the activities.
CHAPTER 22 Assisting in Pulmonary Medicine 581
prognosis is very poor for lung cancer because early symptoms mimic
chronic conditions present in long-term smokers. Carcinoma of the larynx
is linked to smoking and chronic alcohol consumption.
l 0. Summarize the medical assistant's role in assisting with pulmonary
procedures.
Preparing a patient for a respiratory examination includes having the
patient disrobe to the waist and put on a gown with the opening in the
front or back, depending on the provider's preference. The medical
assistant is responsible for assisting the provider throughout the examina-
tion, providing privacy and support for the patient, and performing
diagnostic tests as ordered.
11. Distinguish among common diagnostic procedures for the respira-
tory system; perform a volume capacity spirometry test and a pulse
oximeter procedure; and collect a sputum sample for culture.
Respiratory diagnostic procedures include the Mantoux intradermal test
for TB; PFTs, in which a spirometer is used to diagnose pulmonary
abnormalities; pulse oximetry, a noninvasive method of evaluating both
the pulse rate and the oxygen saturation of hemoglobin in the arterial
blood; culturing of expectorated sputum; and bronchoscopy, in which a
flexible fiberoptic instrument is used to view the larynx, trachea, and
bronchi endoscopically.
Procedure 22-3 summarizes the steps in spirometry testing. Proce-
dure 22-4 summarizes the steps in performing pulse oximetry. The
oximeter probe is placed on the patient's earlobe or finger. An infrared
light passes through the tissue, and the machine measures the amount
of light absorbed by oxygenated hemoglobin, which is displayed on the
digital screen as a percentage. The patients pulse rate also is displayed.
Procedure 22-5 explains how to collect a sputum sample for culture.
12. Discuss patient education, in addition to legal and ethical issues,
associated with pulmonary medicine.
If the pulmonary test ordered is an invasive test, written informed consent
must be obtained from the patient and filed in the patient's health record.
If oxygen therapy is ordered, the provider must write a prescription that
specifies the amount of oxygen to be given and the type of device to be
used for delivery. The provider also may write an order for a respiratory
care practitioner to follow up on the patient at home.
evolve Evolve Connection: Go to the Chapter 22 link at evolve.e/sevier.com/
kinn to complete the Chapter Review Quiz. Check out the other resources listed for this
chapter to make the most of what you have learned from Assisting in Pulmonary
Medicine.
 23 ASSISTING IN CARDIOLOGY
li#H+i;H•i
Adam Stern, (MA (AAMA), has been working for more than 3years as a medical
assistant in a variety of providers' offices. Adam recently was hired to work at
City Hospital in the cardiology department. His job description includes working
in the clinical area of the practice and assisting the attending physicians with
patient education and follow-up. Because Adam has never worked for a cardiolo-
gist, he is concerned about his knowledge base and competency in cardiac
While studying this chapter, think about the following questions:
• Why is it important that Adam understand the normal anatomy and
physiology of the cardiovascular system if he is going to work in a
cardiologist's practice?
• What are some common diseases and disorders of the cardiovascular
system with which Adam should be familiar?
LEARNING OBJECTIVES
1. Define, spell, and pronounce the terms listed in the vocabulary.
2. Explain the anatomy and physiology of the heart and its significant
structures.
3. Summarize risk factors for the development of heart disease.
4. Do the following related to coronary artery disease and myocardial
infarction:
• Describe the signs, symptoms, and medical procedures used in the
diagnosis and treatment of coronary artery disease and myocardial
infarction.
• Summarize metabolic syndrome and associated risk factors.
• Explain the signs and symptoms of myocardial infarction in
women.
VOCABULARY
ablation (a-blay' -shun) An amputation or removal of any body
part.
angioplasty A procedure used to widen vessels narrowed by
stenoses or occlusions.
chordae tendineae (kor'-duh/ten'-din-uh) The tendons that
anchor the cusps of the heart valves to the papillary muscles of
the myocardium, preventing valvular prolapse.
intermittent claudication Recurring cramping in the calves
caused by poor circulation of blood to the muscles of the lower
leg.
patient care. Part of Adam's responsibilities will be to help evaluate patient educa-
tion materials about the warning signs of aheart attack, especially the differences
between the symptoms seen in men and those seen in women. The providers
expect Adam to be familiar with the electrical conduction system of the heart,
typical medications prescribed in a cardiology practice, and common diagnostic
procedures that are ordered for patients with cardiovascular diseases.
• What are the common cardiovascular diagnostic procedures that Adam
should be prepared to discuss and explain to patients?
5. Compare and contrast the treatment protocols for hypertension.
6. Outtine the causes and results of congestive heart failure.
7. Summarize the effects of inflammation and valve disorders on cardiac
function.
8. Describe the anatomy and physiology of the vascular system.
9. Differentiate among the various types of shock.
10. Summarize the characteristics of common vascular disorders.
11. Discuss arterial disorders, including causes, risk factors, and common
treatments.
12. Outtine typical cardiovascular diagnostic procedures.
13. Describe patient education topics, and legal and ethical issues, for
cardiovascular patients.
ischemia (is-ke' -mia) A decreased supply of oxygenated blood to
an area or body part.
Marfan syndrome An inherited condition characterized by
elongation of the bones, joint hypermobility, abnormalities of
the eyes, and the development of an aortic aneurysm.
occlude To close off or block (e.g., a blood vessel).
scleroderma (skleh-ruh-der' -muh) An autoimmune disorder that
affects the blood vessels and connective tissue, causing fibrous
degeneration of the major organs.

VOCABULARY-continued
statins A class of drugs that lower the level of cholesterol in the
blood by reducing the production of cholesterol by the liver;
they block the enzyme in the liver that is responsible for making
cholesterol.
I n the past, cardiac disease was frequently seen in men but seldom
in women. That has changed, and today the most common cause
of illness and death, regardless of gender, is cardiovascular disease.
Medical assistants in all specialties often care for patients with heart
disorders. Seldom does the cardiologist discover the heart problem.
Most patients who see this specialist already have been diagnosed
with a suspected heart disorder and were referred to the cardiologist
for verification of the initial diagnosis and specialized treatment.
Because of the overwhelming number of people with cardiovas-
cular problems, all medical assistants must understand the cardio-
vascular system, be able to recognize early symptoms of potential
disorders, perform basic screening tests when ordered by the pro-
vider, and assist the provider in the examination of the heart and
blood vessels.
ANATOMY AND PHYSIOLOGY OF THE HEART
The heart is a hollow, muscular organ situated in the thoracic cavity
in the mediastinal region, between the right and left pleural spaces.
It weighs about 9 ounces and is about the size of a fist; approximately
two thirds of it is located to the left of the sternum (Figure 23-1 ).
The heart is a pump that provides the force needed to push blood
through all the arteries of the body; the blood circulates a continuous
supply of oxygen and nutrients to the cells and picks up the meta-
bolic waste products from them. If deprived of these vital functions,
the cells die. At the same time, the heart pushes deoxygenated blood
through the pulmonary artery to the lungs for oxygen saturation and
Rightventricle - - - - - - - - - -r
Inferior vena cava - - - - - - - - --
- -- - - - - - - - - Aorta (thoracic)
FIGURE 23-1 Location of the heart in the thoracic cavity. (From Applegate EJ: The anatomy and physiology learning system, ed 4, St Louis, 2010, Saunders.)
CHAPTER 23 Assisting in Cardiology 583
trans fats Substances that form from hydrogenation of an
unsaturated fatty acid; they make a dietary fat more saturated
and solid at room temperature.
vegetations Abnormal growth of tissue surrounding a valve
consisting of fibrin, platelets, and bacteria.
receives oxygenated blood back through the pulmonary veins into
the left side of the heart. The average adult heart pumps about 5 L
of blood every minute. If the heart loses its pumping action for even
a few brief minutes, death or permanent damage can result.
Layers of the Heart
The heart is enclosed in a double-membrane sac called the pericar-
dium. The outer layer of the pericardia! sac, the parietal pericardium,
is a tough membrane that connects the heart to the diaphragm and
serves as a physical barrier to protect the heart against infection or
inflammation from the lungs or pleural space. The inner layer, the
visceral pericardium, or epicardium, forms the first layer of the heart.
Between the two membranes is a small space, the pericardia! cavity,
which contains about 30 mL of pericardia! fluid; this fluid lubricates
the internal surfaces of the pericardia! membranes, enabling them to
slide across each other during heart contractions. The middle layer
of the heart, the myocardium, is the muscle layer that constitutes the
largest percentage of the heart wall. Contractions of this muscle layer
force the blood from the heart into the vessels. The inner layer of
the heart, the endocardium, includes the heart valves that separate
the chambers of the heart and provide a means of blocking the flow
of blood from major blood vessels entering and exiting the heart
(Figure 23-2).
Heart Chambers and Arteries
The heart is divided into four chambers (Figure 23-3). The atria,
the top chambers, receive blood, and the ventricles, the bottom
Common carotid
arteries
..• - - - : - - - - - Apex
584 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES

chambers, pump the blood out. The blood flow through the heart
begins in the right atrium, which receives deoxygenated blood from
the inferior and superior venae cavae. The atria contract, and blood
passes through the tricuspid valve into the right ventricle; the ven-
tricles contract, and blood passes from the right ventricle through
the pulmonary valve to the lungs via the pulmonary artery (the only
artery in the body that contains deoxygenated blood). Oxygenation
occurs in the alveoli of the lungs, and the now oxygenated blood
returns to the left atria through the pulmonary veins (the only veins
Fatty
HEART LAYERS
connective
tissue
in the body that carry oxygen-rich blood). The atria contract, and
blood passes through the mitral (bicuspid) valve into the left ven-
tricle; the ventricles contract, and oxygen-rich blood is sent through
the aortic valve out to the body through the aorta (the largest artery
in the body).
The myocardium requires a continuous supply of oxygen and
nutrients, which are delivered through two coronary arteries that
branch off the aorta above the aortic valve (Figure 23-4). The right
coronary artery nourishes the anterior and posterior myocardium on
the right side of the heart, and the left coronary artery does the same
on the left side. The left coronary artery quickly divides and forms
the left anterior descending artery and the left circumflex artery.
Smaller branches of the coronary arteries feed the myocardium and
the endocardium. Any interference in blood flow in any of the coro-
nary vessels can alter the action of the heart.

Coronary
artery and vein
Heart Conduction
A sophisticated electrical conduction system operated by specialized
cells located at various sites in the myocardium stimulates contrac-
tions. These muscle contractions move blood through the chambers
Pericardia! space / of the heart and out through the aorta to the rest of the body. Each
electrical impulse passes through the heart muscle in a twisting,
Epicardium
spiral motion. These rhythmic waves stimulate the cardiac cells to
Myocardium beat, which causes the heart to contract.
Endocardium The cardiac impulse originates in specialized muscle tissue called
the sinoatrial (SA) node. The SA node rhythmically initiates impulses
FIGURE 23-2 Layers of the heart. (From Damjanov I: Pathology for the health-related professions, 60 to 100 times a minute; because it creates the basic rhythm, it is
ed 4, St Louis, 2012, Saunders.) the pacemaker of the heart. It is located in the posterior, superior

Myocardium

Tricuspid valve lnterventricular septum Apex

FIGURE 23-3 Chambers of the heart. (From Damjanov I: Pathology for the health-related professions, ed 4, St Louis, 2012, Saunders.)
 CHAPTER 23 Assisting in Cardiology 585

Right
coronary artery
Great
cardiac vein
Left
coronary artery
Circumflex
Circumflex branch
branch
Left
Anterior coronary
interventricular artery
branch

Great
Right
cardiac vein
coronary
artery

FIGURE 23-4 Coronary arteries. (From Frazier MS, Drzymkowski JW: Essentials of human diseases and conditions, ed 5, St Louis, 2013,
Saunders.)

wall of the right atrium, at the junction of the superior vena cava
and the atrium and just above the tricuspid valve. When the SA node
discharges its rhythm pattern into the myocardium, it passes across
both atria, resulting in atrial contraction and forcing blood through
the valves and into the ventricles. The wave then passes through a
second area of specialized muscle tissue on the septa! wall between
the right atrium and right ventricle, called the atrioventricular (Av;
node. The AV node holds the impulse for a fraction of a second to Bundle
of His
prevent inappropriately high atrial rates and to permit the blood to
empty from the atria through the tricuspid and mitral valves. At this Sinoatrial Left
moment the chordae tendineae tightly close the valves between the (SA) node anterior
bundle
atria and the ventricles. The AV node then releases the charge, branch
Atrioventricular
sending it down through the bundle of His, which is located in the (AV) junction
septum between the right and left ventricles. This bundle is divided Left
into two main branches: the right bundle, on the right side of the posterior
bundle
septum, and the left bundle, on the left side. From the bundle Right bundle
branch
branch
branches, transmission of the cardiac wave continues through a mass
of cardiac muscle fibers known as the Purkinje fibers. The Purkinje Purkinje
fibers
fibers completely encase both ventricles, and the cardiac wave causes
the ventricles to contract (Figure 23-5).
FIGURE 23-5 Cardiac conduction system.
The electrical impulses that cause the contraction of the atria and
the ventricles are called depolarization. After depolarization, the cells
need a period of electric recovery (repolarization). Once recovery is
complete, the cells are in a resting phase (polarization), and then the
entire cycle starts again. The normal cardiac cycle consists of atrial Risk Factors for Heart Disease
contraction, ventricular contraction, recovery, and heart rest. This
Risk Factors That Cannot Be Changed
cycle maintains the average range of 60 to 100 beats per minute and
a normal heart rhythm. It is this electrical force that is traced and
• Advancing age: More than 80% of people who die of coronary heart
evaluated when an electrocardiogram (ECG) is done.
disease are 65 or older; older women are more likely to die of myo-
cardial infarctions (Mis) than are older men.
• Gender: Men are at greater risk of Mis and experience heart attacks
DISEASES AND DISORDERS OF THE HEART earlier in life; women are at greater risk after menopause, but their risk
Many diseases and disorders affect the heart and its blood vessels. still is not as great as the risk for men.
Disorders that occur when the rhythm of the heart becomes irregular • Family history and race: The children of parents with heart disease are
are addressed in the Principles of Electrocardiography chapter. more likely to develop it; African-Americans are at greater risk of
Cardiac disease has multiple risk factors; some of these cannot be developing hypertension and the heart disease associated with it;
changed, and others people can change or seek to have treated. The Mexican-Americans, Native Americans, native Hawaiians, and some
more risk factors a person has, the greater his or her risk of develop-
Asian-Americans also are at greater risk.
ing cardiovascular disease.
586 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES
Lifestyle Risk Factors That Can Be Modified
or Treated
• Smoking: Smokers' risk of developing coronary heart disease is two to
four times that of nonsmokers. Male smokers develop heart disease
three times more often than women; female smokers develop heart
disease six times more often than those who never smoked. Smoking
is associated with sudden cardiac death. Exposure ta secondhand smoke
also increases the risk.
• High blood cholesterol: The risk of heart disease rises with rising blood
cholesterol levels.
• Hypertension: Hypertension increases the amount of work the heart
must do to circulate blood throughout the body.
• Sedentary lifestyle: Regular exercise helps prevent cardiovascular
disease.
• Obesity and overweight: Excess weight, especially increased body fat
at the waist, is associated with an increased risk of heart disease and
stroke; losing as little as l Opounds can lower the risk.
• Diabetes mellitus: The risk of heart disease is even greater if blood
glucose levels are not controlled; at least 65% of people with diabetes
die of some form of heart or blood vessel disease.
http.j/www.heart.org/HEARTORG/Condilions/HeartAttack/UnderstandYourRiskofHeartAttack/
Understand-Your-Risk-of-Heart-Attack_UCM_002040_Article.isp#. VsH3EflrKUI. Accessed
February 15, 2016.
Coronary Artery Disease and Myocardial Infarction
Coronary artery disease (CAD) causes almost half a million deaths
in the United States every year. In CAD the formation of athero-
sclerotic plaques narrows the arteries supplying the myocardium,
which results in a lack of blood supply to the heart muscle and may
ultimately lead to a myocardial infarction (MI). Atherosclerotic
plaque buildup is primarily related to cholesterol blood levels.
Understanding cholesterol levels is crucial for understanding the risk
of CAD. To monitor cholesterol levels, the provider will order a
complete fasting lipoprotein profile. The profile studies four different
levels of fat in the blood:
I. Total cholesterol: A score of!ess than 180 mg/dL is considered
optimal.
2. HDL ("good") cholesterol: The higher the level the better; a low
level of high-density lipoprotein (HDL) cholesterol increases
the risk of heart disease. The best levels are 60 mg/ dL and
above.
3. LDL ("bad") cholesterol· A low level of!ow-density lipoprotein
(LDL) cholesterol is considered good for heart health; the
recommendations vary based on an individual's heart disease
risk. For individuals not at risk, an LDL level of 100 to
129 mg/dL is recommended; for those at very high risk, the
LDL level should be below 70 mg/dL. Recent research recom-
mends that individuals with a high risk of heart disease (e.g.,
LDL level of 190 mg/dL or higher and diabetes type 2) be
treated with statins. Medications for treatment of hypercho-
lesterolemia are described in Table 23-1 .
4. Triglycerides: Triglyceride is the most common type of fat in
the body; a desirable level is less than 150 mg/ dL. High
triglyceride levels combined with low HDL cholesterol or
high LDL cholesterol is associated with atherosclerosis and an
increased risk for heart attack and stroke.
An atherosclerotic plaque originates at the site of a chronic
injury to the endothelial lining of the artery caused by risk factors
associated with heart disease (e.g., smoking or hypertension). Plate-
lets attach to the site of the endothelial injury, and lipids begin to
accumulate. Eventually an atheroma forms, which is made up of a
tough collagen shell covering a fatty center that extends out into the
lumen of the vessel, restricting blood flow past the plaque buildup.
Inflammation at the site attracts platelets to the surface of the ath-
eroma, resulting in the formation of a clot (thrombus) that can
completely block the lumen of the vessel, depriving the myocar-
dium of an adequate nutritious blood supply (Figure 23-6). The
cardinal symptom of myocardial ischemia is angina pectoris.
Angina pectoris is pain behind the sternum that is precipitated by
exertion but that can be relieved either by rest or by sublingual
nitroglycerin.
Patients may be asymptomatic until the disease becomes fully
developed. The first symptom of an MI may be angina, followed by
pressure or fullness in the chest, syncope, shortness of breath, edema,
unexplained coughing spells, and fatigue. A patient reporting any of
these symptoms is considered to have a medical emergency and
should be seen by the provider immediately.
Telephone Screening for Chest Pain
The medical assistant should activate emergency medical services if the
patient reports any of the following:
• Current chest pain that is crushing, pressing, or radiating to the
arms, upper back, or jaw
• Sweating, difficulty breathing, nausea, indigestion, or dizziness
• Any of these symptoms, along with a history of coronary artery
disease, myocardial infarction, or angina
• Achange in the pattern of the angina
• Chest pain that occurs during rest or with minimum exertion
In recent years the rate of heart disease has declined in men but
not in women. Traditional risk factors negatively affect both
genders; however, women are at greater risk if they have metabolic
syndrome (a combination of hypertension, elevated insulin levels,
excess body fat around the waist, and high blood cholesterol levels);
if they have increased levels of stress and/or depression; if they
smoke (female smokers are at much greater risk than women who
do not smoke); and if they have reduced estrogen production before
menopause. The difference in female risks and symptoms is associ-
ated with the method of plaque buildup in women; the plaque
tends to develop as an evenly spread layer along the entire lumen of
the blood vessels rather than as a localized plaque buildup, as is seen
in men. Women with heart disease typically experience this diffuse
atheroma buildup in smaller vessels, which causes more subtle
symptoms than the crushing chest pain associated with classic myo-
cardial infarctions.
 CHAPTER 23 Assisting in Cardiology 587

TABLE 23-1 Prescription Medications to Lower Blood Cholesterol Levels

CLASSIFICATION ACTION SIDE EFFECTS AND CAUTIONS
Stalins Lower LDL and triglycerides; slightly increase Headaches, minor itching, constipation, nausea, diarrhea,
Atorvastatin (Lipitor) HDL stomach pain, back pain, pain in the lower legs and arms,
Fluvastatin (Lescol) liver abnormalities; possible interaction with grapefruit juice
Lovastatin (Altoprev, Mevacor)
Pitavastatin (Livalo)
Pravastatin (Pravachol)
Rasuvastatin (Crestor)
Simvastatin (Zocor)
Bile acid-binding resins Lower LDL by binding bile acids in the Constipation, bloating, nausea, gas; may increase
Cholestyramine (Locholest, Prevalite) intestine for excretion in the stool; liver triglycerides
Cholestyramine sucrose (Questran) converts cholesterol into bile acids, thus
Colesevelam (Weichai) lowering the blood cholesterol level
Colestipol (Colestid)
Cholesterol absorption inhibitor Reduces the amount of cholesterol absorbed; Fatigue, gas, constipation, abdominal pain, cramps, muscle
Ezetimibe (Zetia) lowers total cholesterol and LDL soreness; possible interaction with grapefruit juice
Fibrates Lower lipid levels, including cholesterol and Fever or chills, nausea, stomach pain, gallstones, fatigue,
Fenofibrate (Lofibra, Tricor) triglycerides; reduce production of vertigo
Gemfibrozil (Lopid) triglycerides and increase their rate of
removal from the bloodstream; modestly
increase HDL
Statin/niacin combinations Reduce LDL and triglycerides; increase HDL Muscle, skin and gastrointestinal problems; facial and neck
Niacin extended release/simvastatin (Simcor) flushing; dizziness, heart palpitations, shortness of breath,
Niacin/lovastatin (Advicor) sweating, chills; possible interaction with grapefruit juice
HDL, High-density lipoprotein; LDL, low-density lipoprotein.
The major concern in heart disease is the lack of blood to the
myocardium, which occurs when a vessel becomes totally blocked.
Ischemia over a prolonged period leads to necrosis (death) of a
portion of the myocardium, resulting in an MI, or heart attack.
Symptoms of an MI are similar to those of angina; however, an MI
Metabolic Syndrome is identified by pain that lasts longer than 30 minutes and is not
Metabolic syndrome is a group of risk factors that raise the risk of heart relieved by rest or nitroglycerin tablets. An MI is a life-threatening
disease, diabetes, and stroke. Aperson with metabolic syndrome is twice event; intervention must begin within the first hour for the best
chance for survival.
as likely to develop heart disease and five times as likely to develop dia-
betes. To be diagnosed with metabolic syndrome, the patient must have Signs and Symptoms of Myocardial Infarction
at least three of the following risk factors:
in Women
• Abdominal obesity or excess fat in the stomach area (this is a
greater risk factor for heart disease than excess fat in other parts In addition to angina, the signs and symptoms of a heart attack in women
of the body, such as on the hips) may start weeks before the actual cardiac injury and could include the
• Ahigh triglyceride level following:
• Alow high-density lipoprotein (HDL) cholesterol level (HDL helps • Abdominal, neck, shoulder, or upper back pain
remove low-density lipoprotein [LDL] cholesterol from the • Jaw pain
arteries) • Shortness of breath
• High blood pressure (hypertension can damage the heart and lead • Vertigo (dizziness)
to plaque buildup in the arteries) • Sweating
• Ahigh fasting blood glucose level (almost 85% of people with • Indigestion or nausea and vomiting
diabetes type 2 also have metabolic syndrome) • Extreme fatigue
• Aching in both arms
www.nhlbi.nih.govjhea/thjhea/th-topics/topics/ms. Accessed February 16, 2016.
588 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES

Atheroma-
Tunica
mass of
intima
fibrofatty
Tunica material,
media cells, and
- · --Tunica lipid
adventitia

A Fatty streak B Plaque

Small lumen
Total occlusion
Artery of artery
partially by thrombus
obstructed

Thrombus Necrosis or
calcification
Atheromatous weakens wall
plaque

C Formation of thrombus D Complications

3. Embolus
blocks small

2. Embolus flows
along artery

1. Thrombus
breaks off a
plaque formation

E Embolus
FIGURE 23-6 Development of an atheroma, leading to arterial occlusion.

hours, and return to baseline after 48 to 72 hours. The more severe

CRITICAL THINKING APPLICATION 23-1
Apatient who is scheduled for an appointment in 2 days calls the office
and reports that she is not feeling well. She complains that she has afeeling
of fullness in the chest, her arms ache, and she is very tired. Although this
patient does not have a history of myocardial infarction, what should
Adam do?
Diagnostic and Therapeutic Procedures
An MI is diagnosed by ECG changes and elevated cardiac enzymes.
The traditional blood test that indicates myocardial damage is the
creatine kinase (CK) level. CK levels begin to increase within 3 to
12 hours of the onset of chest pain, reach peak values within 24
the cardiac damage, the longer it takes for CK levels to peak and
then return to normal. However, another blood test for possible
myocardial damage measures troponin levels. Troponin is a protein
that is released into the blood only when myocardial damage occurs.
Therefore, even slight elevations may indicate some degree of heart
muscle damage. Troponins increase in the bloodstream within 4 to
6 hours after initial myocardial damage and peak in 10 to 24 hours.
In the case of minor myocardial damage, troponin levels remain
elevated up to 10 to 14 days, allowing for later diagnosis of the event.
Patients diagnosed with an MI typically are hospitalized immedi-
ately, started on oxygen, and continuously monitored by ECG.
(Additional diagnostic procedures, such as an echocardiogram and
heart catheterization, are discussed later in this chapter.)

Medical treatment of an MI includes the use of thrombolytic
medications, such as alteplase (Activase) and reteplase (Retavase), to
dissolve the blood clot that is blocking the coronary artery and
prevent permanent myocardial damage. There is a better chance of
survival and recovery from certain types of heart attacks if a throm-
bolytic drug is administered within 12 hours after the heart attack
starts. Ideally, the patient should receive thrombolytic medications
within the first 30 minutes of arrival at a hospital for treatment. This
timetable makes it extremely important that patients be diagnosed
and treated as soon as possible. Thrombolytic medications are
administered intravenously (IV) along with heparin to prevent clots
that are being dissolved from reforming. Aspirin also is used to
prevent the formation of blood clots in affected blood vessels. Addi-
tional pharmaceutical treatment includes the use of nitroglycerin to
dilate the coronary arteries so that more blood can be delivered to
the myocardium; beta blockers (atenolol [Tenormin], metoprolol
[Lopressor], or propranolol) to slow the heart rate and lower blood
pressure; anticoagulants (warfarin [Coumadin]) for 3 to 6 months
after the MI to prevent thrombus formation and/or the antiplatelet
agent clopidogrel (Plavix); and anticholesterol agents to lower blood
cholesterol levels and prevent subsequent formation of atheroscle-
rotic plaques.
When the coronary arteries that supply blood to the myocardium
are blocked, or occluded, either percutaneous transluminal coronary
angioplasty (PTCA) or coronary artery bypass grafting (CABG)
may be indicated. (These surgical procedures are discussed later in
this chapter.)
After discharge from the hospital, patients with CAD that has
resulted in an MI face multiple lifestyle changes to prevent another
episode. Recommendations include no smoking; regular light exer-
cise, such as walking 30 minutes a day, 5 days a week; a diet low in
salt, saturated fat, and cholesterol; maintaining a healthy weight;
controlling hypertension; reducing stress; and limiting alcohol intake
to one or two drinks a day. The medical assistant should be prepared
to provide encouragement and to reinforce the importance of life-
style changes to prevent future heart problems. If ordered by the
provider, professional referrals to a cardiac rehabilitation program
and dietitian can also be helpful.
CRITICAL THINKING APPLICATION 23-2
Adam receives a telephone call from a patient who complains of nausea
and difficulty taking a deep breath; the patient says he feels as if he is
going to faint. What questions should Adam ask to determine the serious-
ness of the problem?
Hypertensive Heart Disease
Chronic elevated blood pressure can result in left ventricular hyper-
trophy (enlargement), angina, MI, or heart failure. Hypertension
also is a major cause of stroke and nephropathy (kidney disease).
Some of the risk factors for hypertension include a family history of
hypertension or stroke, hypercholesterolemia (high blood choles-
terol), smoking, high sodium intake, diabetes, excessive alcohol
intake, sedentary lifestyle, obesity, aging, prolonged stress, and race
(African-Americans have a higher incidence than Caucasians).
Hypertension has an insidious onset, and the patient shows few, if
any, signs and symptoms until permanent damage has occurred.
CHAPTER 23 Assisting in Cardiology 589
Initial symptoms may include general malaise and headache; epi-
staxis (nosebleed), vertigo, nausea, or syncope can occur with pro-
longed hypertension.
The two types of hypertension are primary hypertension and
secondary hypertension. Secondary hypertension occurs because of
a disease process in another body system, such as renal disease or an
endocrine disorder. Before secondary hypertension can be properly
treated, the underlying disease process must be resolved.
Primary, or essential, hypertension is idiopathic (of unknown
cause) and is diagnosed if the patient's blood pressure is persistently
higher than 119 mm Hg systolic and/ or 79 mm Hg diastolic at two
or more office visits over several weeks or months. If the medical
assistant first notes that a patient's blood pressure is elevated, the
pressure should be checked in both arms with the patient seated and
after the patient has been standing for at least 2 minutes with a cuff
that is the proper size for the patient's arm. If the pressure readings
are different, the provider uses the higher value for diagnostic pur-
poses. The patient's blood pressures should be checked again after at
least 2 minutes. All of these readings must be documented in the
patient's record. Some patients have "white coat hypertension,"
which appears only when they visit the provider. If the patient has
a history of this problem, have him or her lie down on the examina-
tion table and rest for a few minutes before the blood pressure is
taken; this may help in obtaining a more accurate reading.
Hypertension is treated according to the stage of the disease and
any accompanying health problems. Table 23-2 summarizes the
stages and treatment of hypertension. In all cases the patient needs
education and counseling on making lifestyle changes. Components
of lifestyle modifications include weight reduction; the Dietary
Approaches to Stop Hypertension (DASH) eating plan, which is a
diet rich in fruits, vegetables, and low-fat dairy products with
reduced saturated and total fat; a reduction in dietary sodium;
aerobic physical activity; and moderation of alcohol consumption.
It is recommended that patients with diabetes and/or chronic kidney
disease start medication therapy if they have a diastolic reading above
130 or a systolic reading above 80 mm Hg. The goal of drug treat-
ment is to stabilize the patient's blood pressure to no more than
140/90 mm Hg; however, in patients with diabetes or chronic
kidney disease, the goal blood pressure reading is no more than
130/80 mm Hg.
The medical assistant can play an important role in antihyper-
tensive therapy by teaching the patient how to take his or her own
blood pressure at home, providing literature that reinforces the neces-
sity of monitoring the blood pressure, and helping the patient under-
stand that this condition cannot be cured but can be controlled for
the rest of his or her life. Continued encouragement and support are
needed because compliance with the treatment regimen and making
permanent lifestyle changes is difficult for a patient who is not
showing any symptoms of disease. Table 23-3 summarizes some of
the medications that may be prescribed to manage hypertension.
CRITICAL THINKING APPLICATION 23-3
Essential hypertension is acommon problem for patients seen in the cardiol-
ogy department where Adam works. What could Adam do to help patients
with primary hypertension? What informational materials or community
resources would be helpful in gaining patient compliance with treatment?
590 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES

Congestive Heart Failure

TABLE 23-2 Stages and Treatment Congestive heart failure (CHF) occurs when the myocardium is
of Hypertension unable to pump an adequate amount of blood to meet the body's
needs. Although the onset can be acute, the condition typically
BLOOD PRESSURE
develops over time because of weakness in the left ventricle as a result
(mm Hg) TREATMENT
of chronic hypertension, MI of the left ventricular wall, valvular
Prehyperlension • Lifestyle modification (reduced sodium, heart disease, or pulmonary complications. Typically, heart failure
120-139 systolic or low saturated and trans fat diet; regular initially occurs on one side of the heart and then on the other side.
80-89 diastolic aerobic activity; moderate alcohol intake; Left-sided heart failure usually results from essential hypertension or
smoking cessation; weight loss; stress left ventricular disease, whereas right-sided heart failure can develop
reduction) as a result of lung disease. Right-sided heart failure that occurs
because of pulmonary hypertension associated with chronic obstruc-
• Drug therapy for patients with diabetes
tive pulmonary disease (COPD) is called cor pulmonale.
mellitus or chronic kidney disease
Consider the blood flow through the heart and what happens if
Slage l hyperlension • Consider coexisting conditions it is blocked or inhibited in some way. In left-sided heart failure, the
140-159 systolic or • Thiazide-type diuretics (e.g., furosemide left ventricle cannot empty completely because of a weakness in the
90-99 diastolic [Lasix] or hydrochlarothiazide plus myocardial wall from an MI or because of long-term hypertension.
triamterene [Dyazide]) for most patients As a result, blood backs up in the left atria, increasing the pressure
inside the chamber, and emptying blood from the lungs becomes
Slage 2 hyperlension • Consider coexisting conditions difficult. Ultimately the lungs begin to fill up with fluid because of
2:: 160 systolic or • Two-drug combination for most patients the sluggish blood flow, and pulmonary edema results. Signs and
2:: 100 diastolic symptoms of pulmonary edema include dyspnea, orthopnea, non-
productive cough, rales, and tachycardia. In right-sided heart failure,
Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and the right ventricle cannot maintain complete output, and blood
Treatment of High Blood Pressure. Available at http://www.nhlbi.nih.gov/fi/es/docs/
guidelinesfinclfu/1.pdf. Accessed February 15, 2016. backs up in the right atrium; this prevents complete emptying of
the vena cava, resulting in systemic edema, especially dependent
edema in the legs and feet. Both types of heart failure cause fatigue,
weakness, exercise intolerance, dyspnea, and sensitivity to cold
temperatures.

TABLE 23-3 Medications Used to Treat Hypertension

CLASSIFICATION
Thiazide diurelics
(Lasix, Aldactone)
Bela blockers
(Tenormin, Sectral, Lopressor, Ziac)
Angiolensin-converling enzyme (ACE) inhibilors Cause vasadilatian and reduced vascular resistance; May be used with a diuretic for stage l and stage
(Lotensin, Capoten, Vasotec)
Angiolensin II receplor blockers
(Cozaar, Atacand, Avapro, Diovan)
Calcium channel blockers
(Norvasc, Lotrel, Cardizem, Plendil)
ACTION TREATMENT PROTOCOL
Act on kidneys to increase elimination of sodium Drugs of choice ta treat hypertension; enhance the
and water, thereby reducing blood volume action of other blood pressure (BP) medications;
used in patients with diabetes and those with
chronic kidney disease with prehypertension
Reduce the heart rate and cardiac output; reduce May be used with a diuretic for stage 1 and stage
the workload of the heart and open blood vessels 2 hypertension
reduce the workload of the heart 2 hypertension; also may be used for hypertension
in patients with coronary artery disease, heart
failure, or kidney failure
Block the action of chemicals that cause May be used with a diuretic for stage 1 and stage
vasoconstriction 2 hypertension; also may be used for hypertension
in patients with coronary artery disease, heart
failure, or kidney failure
Interrupt the movement of calcium into the heart May be used with a diuretic for stage l and stage
and vessel cells, causing vasodilation 2 hypertension; also used to treat angina and/or
some arrhythmias

Nonpharmaceutical treatment for CHF includes limiting physi-
cal activity so that the heart does not have to work so hard, restricting
salt, not smoking, reducing stress, and controlling weight. Patient
education for an individual with CHF must stress the importance
of monitoring weight gain because a sudden increase in weight may
indicate fluid retention. Patients should weigh themselves once or
rwice a week and report any gain of more than 3 pounds to the
provider.
Drug therapy for CHF begins with diuretics to treat dyspnea and
orthopnea and control edema. Other medications may include an
angiotensin-converting enzyme (ACE) inhibitor, a type of vasodila-
tor that widens blood vessels to lower blood pressure and reduce the
workload of the heart. Examples of ACE inhibitors include enalapril
(Vasotec), lisinopril and captopril (Capoten). Digoxin often is pre-
scribed to increase the strength of myocardial contractions, and beta
blockers (carvedilol [Coreg] and metoprolol [Lopressor]) are used to
slow the heart rate and improve heart function. Because potassium
loss is a common side effect of diuretic and digoxin therapy, patients
may also be prescribed a potassium (KC!) supplement. Routine
monitoring of serum electrolytes is ordered to determine the need
for a potassium supplement so that potential complications can
be prevented.
CRITICAL THINKING APPLICATION 23-4
Kate Glasgow, a 76-year-old patient with a history of CHF, is in the office
today for a checkup. She does not understand why she must stop using
salt and start weighing herself regularly at home. What can Adam do to
help this patient understand the importance of her treatment regimen?
Orthostatic Hypotension
Orthostatic, or postural, hypotension is diagnosed if the patient
experiences a drop in blood pressure when standing, especially when
quickly changing from a prone or seated position to an upright one.
When we stand, our blood pressure quickly adapts to the pull of
gravity by reflexively increasing the heart rate and constricting sys-
temic arterioles. In a patient with orthostatic hypotension, the blood
pressure adjusts sluggishly or not at all to rapid changes in position.
An acute episode of orthostatic hypotension may be caused by blood
pooling in the lower extremities, a reaction to antihypertensive
or antidepressant medication, or prolonged immobility. This is a
common problem in elderly people and may contribute significantly
to falls and related injuries. Patients need to be evaluated for second-
ary causes and encouraged to adjust from a prone position by sitting
on the side of the bed for a bit before standing.
To evaluate orthostatic hypotension, the provider may ask the
medical assistant to check the patient's blood pressure while the
person is seated, leave the cuff in place, then have the patient stand
and immediately check the blood pressure again. Both blood pres-
sure readings should be recorded in the patient's health record for
the provider to evaluate. Include in your note any patient complaints
after standing, such as dizziness or a feeling of lightheadedness.
Inflammatory and Valvular Disorders
Rheumatic Heart Disease
Rheumatic heart disease develops because of an unusual immune
reaction that typically occurs 2 to 4 weeks after an untreated group
CHAPTER 23 Assisting in Cardiology 591
A beta-hemolytic streptococcal infection. The infection typically
starts as "strep" throat or an upper respiratory infection but pro-
gresses to the creation of antibodies that react with collagen to cause
inflammation in the joints, skin, brain, and heart. About half of
those affected develop heart inflammation, but most have a com-
plete recovery. However, in some people the heart is permanently
damaged. The disease process in the heart can involve all layers of
heart tissue.
Pericarditis, or inflammation of the outer layer of the heart,
causes reduced cardiac activity and pericardia! effusion (the collec-
tion of blood or fluid in the pericardium). Myocarditis, or inflam-
mation of the muscular lining of the heart, usually is self-limiting
but may lead to acute heart failure because of weakening of the
myocardial wall. Endocarditis, or inflammation of the inner lining
of the heart and the heart valves, is the most common heart com-
plication. Vegetations form along the outer edges of the valve cusps,
causing scarring and stenosis and preventing the damaged heart valve
from closing or opening completely. The valvular damage may be
asymptomatic at first but eventually can cause serious problems. The
mitral valve is affected most frequently, which impairs the ability of
the left ventricle to function normally.
Treatment includes the use of antibiotics (penicillin) to eliminate
the streptococcal infection completely and antiinflammatory agents
for the inflammatory reaction. In 2007 the American Heart Associa-
tion changed its guidelines on the prophylactic use of antibiotics
before a dental or other invasive procedure. No research links dental,
gastrointestinal, or genitourinary tract procedures with the develop-
ment of endocarditis. Therefore, prophylactic use of antibiotics now
is recommended only for patients with the highest risk of complica-
tions from endocarditis, such as those with artificial heart valves or
certain types of congenital heart disease.
Valve Disorders
Disorders of the valves of the heart may be caused by a congenital
defect or an infection, such as endocarditis. Two specific problems
can occur with valve disease. The valve can be stenosed, or hardened,
which restricts the forward flow of blood, or it can be incompetent,
which means that it does not close completely, so blood can
leak backward, or regurgitate. The most common valve defect is
mitral valve prolapse (MVP), an incompetence in the mitral valve
caused by a congenital defect or vegetation and scarring from
endocarditis.
Valve disorders ultimately can lead to ventricular hypertrophy
and cardiomegaly (enlargement of the heart). Severely damaged
valves or serious congenital defects may require surgical replacement
of the affected valve.
BLOOD VESSELS
Blood vessels are divided into rwo systems that begin and end with
the heart (Figure 23-7). The pulmonary system carries deoxygenated
blood from the right ventricle to the lungs and oxygenated blood
back to the left atrium. The systemic system carries blood from the
left ventricle throughout the entire body and back to the right
atrium. The vessels are classified according to their structure and
function: arteries carry oxygenated blood away from the heart; capil-
laries are the microscopic vessels responsible for the exchange of
592 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES

Occipital
Common carotid
Internal carotid

Vertebral

Brachiocephalic

Aortic arch

Celiac

Left gastric

Hepatic

Splenic

Superior mesenteric Radial

Ulnar
Abdominal aorta
Deep volar arch
Right common iliac
Superficial
Internal iliac volar arch
External iliac Peroneal
Femoral

Popliteal

Anterior tibial
Posterior tibial
A Dorsalis pedalis

Superior sagittal sinus

Anterior facial

Transverse sinus

Internal jugular
Subclavian
Brachiocephalic
Pulmonary
Hepatic
Hepatic portal
Left gastric
Superior
mesenteric , Renal
Volar Splenic
venous arch
Inferior mesenteric
Volar digital Internal iliac
External iliac
Femoral
Greatsaphenous
Popliteal
Small saphenous
Anterior tibial
B Dorsal arch

FIGURE 23-7 A, Systemic arteries. B, Systemic veins.


oxygen and carbon dioxide in the tissue; and veins are the vessels
that carry deoxygenated blood back to the heart.
Arteries
All arteries except the pulmonary artery carry oxygenated blood away
from the heart to all the cells of the body. The largest of these vessels
is the aorta, which starts at the left ventricle and travels through the
center of the body into the lower abdomen, where it bifurcates into
the right and left femoral arteries, with arteries branching off this
system down to the feet. As the aorta passes through the trunk of
the body, arteries branch off from it into smaller and smaller vessels,
which ultimately become microscopic. These vessels are called arte-
rioles, which terminate into tissue capillaries, the smallest and most
plentiful of the blood vessels. Capillaries are a single epithelial cell
thick, so nutrients and gases can pass through the vessel wall for
exchange at the cellular level. Arterioles deliver erythrocytes (red
blood cells [RBCs]), which carry oxygen attached to hemoglobin
molecules to surrounding tissues. While in the capillary bed, the
oxygen that was bound to the RBC hemoglobin is unloaded to
the surrounding tissues. When the blood leaves the capillary bed,
the oxygen supply has been depleted, and the return portion of the
blood cycle now begins.
Veins
As the blood leaves the capillary beds, it enters the smallest veins,
called venules. From this point on, the blood flows into larger and
larger veins until it reaches the largest veins in the body, the inferior
and superior venae cavae. The venae cavae deposit deoxygenated
blood into the right atrium, where the blood again begins its trip
through the heart through the tricuspid valve, into the right ven-
tricle, then through the pulmonary arteries to the lungs, where gas
exchange occurs at the alveoli level. Oxygen-rich blood is returned
to the left atrium via the pulmonary veins. The walls of veins are
thinner than those of arteries because they do not have a muscular
lining. Instead, veins have valves that open and close to prevent the
backflow of blood. The valves operate by the contraction of muscles
around the veins; these contractions massage the blood in the direc-
tion of venous flow back to the heart. Venous valves are especially
important in the arms and legs because they prevent pooling of
blood in the extremities.
VASCULAR DISORDERS
The vascular system constantly supplies blood containing oxygen
and nutrients to all the body's tissues and picks up waste from tissue
metabolism. For tissues to receive an adequate amount of oxygen
and nutrients, the arterial vessels must maintain elasticity, and their
linings must remain smooth to prevent occlusion and reduced
blood flow.
Shock
Shock can occur in many different situations (Table 23-4), but they
all result in the same signs and symptoms and possible complica-
tions. Shock is the general collapse of the circulatory system, includ-
ing reduced cardiac output, hypotension, and hypoxemia (decreased
oxygen in the blood). The initial signs of shock are extreme thirsti-
ness, restlessness, and irritability. The body attempts to compensate
CHAPTER 23 Assisting in Cardiology 593
TABLE 23-4 Types and Causes of Shock
TYPE DEFINITION CAUSES
Cardiogenic Low cardiac output caused Acute Ml, arrhythmias,
by inability of the heart to pulmonary embolism, (HF
pump
Hypovolemic Excessive loss of blood or GI bleeding, internal or
body fluids external hemorrhage,
excessive loss of plasma or
body fluids, burns
Neurogenic Peripheral vascular dilation Spinal cord injury, emotional
resulting from neurologic stress, drug reaction
injury or disorder
Anaphylactic Systemic hypersensitivity Drug, vaccine, food allergies,
to an allergen, causing insect venom, or chemical
respiratory distress and allergies
vascular collapse
Septic Systemic vasodilation Systemic infection or
(septicemia) caused by the release of bacteremia
bacterial endotoxins
CHF, Congestive heart failure; GI, gastrointestinal; Ml, myocardial infarction.
for circulatory collapse with constriction of peripheral blood vessels,
allowing blood to pool in the vital organs. This vasoconstriction
causes a generalized feeling of cool, clammy skin; pallor; tachycardia;
and reduced urinary output. Symptoms progress to a rapid, weak,
thready pulse; tachypnea; and altered levels of consciousness. If the
process is not reversed, the central nervous system becomes depressed,
and acute renal failure may occur.
The cause of the shock must be treated for the patient to survive.
If the medical assistant identifies a patient in shock, emergency treat-
ment should be started at once. Do not wait for the first indicators
of shock to worsen before calling for help. If the provider is not
available, call 911 for emergency medical care. Place the patient in
a supine position, assess the vital signs frequently, keep the patient
warm, administer oxygen as ordered by the provider, and, if there is
no indication of head or neck trauma, elevate the legs about 12
inches to encourage the flow of blood back to the heart.
Vein Disorders
Varicose Veins
Veins have one-way valves that help keep blood flowing toward the
heart. Varicose veins are dilated, tortuous, superficial veins in the
legs (Figure 23-8). Varicosities can be caused by congenitally defec-
tive valves in the saphenous veins and the veins branching off them.
Other contributing factors are pregnancy, obesity, prolonged stand-
ing or sitting, and heavy lifting. Whatever the cause, the vein valves
do not close completely; this allows blood to flow backward, causing
the vein to distend from the increased pressure.
Treatment includes consistent aerobic exercise and limiting heavy
lifting. The legs should be elevated when possible, and compression
594 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES
FIGURE 23-8 Varicose veins of the calf. (From Damjanov I: Pathology for the health-related
professions, ed 4, St Louis, 2012, Saunders.)
stockings should be worn by those who must stand for long periods.
Medical intervention includes:
• Sclerotherapy: A treatment in which a chemical is injected into
the vein to cause irritation and scarring inside the vein, closing
it off.
• Laser surgery: A procedure in which light energy from a laser
is applied to a varicose vein.
• Endovenous ablation therapy: A procedure in which a small
incision is made near the varicose vein and a catheter is
inserted; a device at the tip of the tube heats up the inside of
the vein and closes it off.
• Endoscopic vein surgery: An outpatient procedure in which a
small incision is made near a varicose vein, and a tiny camera
at the end of a thin tube is inserted and moved through the
vein; a surgical device at the end of the camera is used to close
the vein.
• Vein stripping and ligation: This procedure typically is done
only in severe cases; the veins are tied shut and removed
through small incisions.
Although treatment may be successful, varicosities can recur over
time. Patients should be warned to investigate insurance coverage of
treatment costs because many insurance companies consider treat-
ment of varicose veins cosmetic surgery. However, if the patient has
documented proof of a health risk associated with the varicosities,
insurance companies are more likely to pay for treatment.
Deep Vein Thrombosis
Phlebitis is an inflammation of a vein, most commonly seen in the
lower legs. When a vein becomes inflamed, a blood dot, or
thrombus, may develop at the site. A thrombus is a dot formed by
the collection of platelets that attaches to the interior wall of a vessel.
Deep vein thrombosis (DVT) is a thrombus with inflammatory
changes that has attached to the deep venous system of the lower
legs, causing partial or complete obstruction of the vessel. The calf
veins are the most common sites of DVT, but it also can develop in
the iliac and femoral veins. Risk factors for the formation of a DVT
are recent surgery, immobilization, older age (an increased risk is
seen after age 50), trauma, obesity, use of oral contraceptives, vari-
cose veins, pancreatic cancer, and pregnancy.
In the early stages, approximately 50% of patients with DVT are
asymptomatic. Some patients complain of calf pain or cramping and
edema of the affected leg, with warmth and erythema at the site. A
thrombus that dislodges and begins to move through the general
circulation is called an embolus. A pulmonary embolism (PE), which
is a thrombus that breaks loose and is carried to the lungs, causing
blockage of a pulmonary artery, is the most serious complication and
may be the first indication that the thrombus was present. Signs and
symptoms of a PE include an acute onset of chest pain that worsens
with a deep breath or cough; unexplained shortness of breath; vertigo
or syncope (dizziness or fainting); hemoptysis (coughing up blood);
and a feeling of anxiety. Patients with any of these indicators should
seek immediate medical attention.
DVT typically is diagnosed with venous Doppler studies, which
use ultrasound to measure the rate of blood flow through the vessel
and can accurately detect venous obstruction. Ultrasound can be
used to create an image of the blood flow through the targeted vessel,
allowing visualization of the thrombus. Venography also may be
ordered; in venography a dye is injected into a large vein of the foot
or ankle in the affected leg, and x-ray films of the veins are taken.
Once the diagnosis has been confirmed, patients usually are hospital-
ized for IV anticoagulant therapy (heparin) or subcutaneous (SQ)
injections of enoxaparin sodium (Lovenox).
Anticoagulant therapy does not dissolve existing dots; rather, it
prevents dots from increasing in size and reduces the potential for
additional dots. Oral anticoagulant treatment (warfarin [Couma-
din]) is usually continued for 6 months. Patients require regular
follow-up, including prothrombin time analysis. The medical assis-
tant may perform venipuncture on these patients, and if so, should
follow the office policy for blood draws on patients taking antico-
agulants. The medical assistant also should reinforce the provider's
recommendations about the prevention of further thrombi and pre-
cautions about anticoagulant use.
Patient Education for Prevention of Deep Vein
Thrombosis (DVT)
• Take your prescribed medications as directed.
• If you have been prescribed anticoagulants, eat foods high in vitamin
Kin small amounts (e.g., dark green, leafy vegetables and canala and
say ails).
• Avoid sitting still for long periods; walk around several times during the
day or move your legs frequently.
• Alter lifestyle factors such as obesity, smoking, and hypertension,
because they increase the risk of DVT.
• Wear compression stockings as ordered by the provider.

CRITICAL THINKING APPLICATION 23-5
Alitza Lincoln, a 43-year-old patient, has large varicose veins in both legs
and a history of phlebitis. She is a checkout clerk at a large local store, so
she stands for extended periods. The provider is concerned about the
development of DVT, and she instructs Ms. Lincoln in the prevention, signs,
and symptoms of a thrombus. Ms. Lincoln asks Adam what she can do to
prevent further problems with the veins in her legs. Adam uses a picture to
illustrate the valves in the leg veins and explains preventive measures. What
measures should Adam include?
Arterial Disorders
Arteriosclerosis and Atherosclerosis
Arteriosclerosis is a general term for the thickening and loss of elastic-
ity of the arterial walls that is associated with aging. Other conditions
that can lead to hardening of the arterial wall are hypertension,
scleroderma, and diabetes mellitus. Arteriosclerosis, which can
occur in arteries throughout the body, causes systemic ischemia and
necrosis over time.
Atherosclerosis is a form of arteriosclerosis marked by the forma-
tion of an atheroma, a buildup of cholesterol, cellular debris, and
platelets along the inside vessel wall (Figure 23-9).
Cholesterol is a nonessential nutrient that can be produced in the
liver. It forms the base for many of the hormones created in the body.
Problems arise from dietary and lifestyle factors that elevate blood
cholesterol levels to a dangerous point, causing the formation of
atheromas, which ultimately block arteries and cause such disorders
as heart attacks and strokes.
Treatment of elevated blood cholesterol levels consists of dietary
reductions in saturated and trans fats, in addition to aerobic exercise
to elevate HDL levels. Patients are encouraged to stop smoking (see
Table 25-1 for prescription medications for hypercholesterolemia).
The medical assistant can help by educating the patient about risk
factors and promoting changes in lifestyle. Referrals to a dietitian
may be helpful for patients having a difficult time controlling their
saturated fat intake.
Aneurysm
An aneurysm is a ballooning or dilation of a blood vessel wall
(Figure 23-10). The patient may have an inherited factor for the
FIGURE 23-9 Atherosclerotic vessel. (From Damjanov I: Pathology for the health-related profes-
sions, ed 4, St Louis, 2012, Saunders.)
CHAPTER 23 Assisting in Cardiology 595
development of aneurysms (e.g., Marfan syndrome), but a common
cause is the buildup of atherosclerotic plaques, which weaken the
vessel wall. Aneurysms can occur in any artery but usually develop
in either the abdominal aorta or the cerebral arteries. In either case,
the patient seldom has any signs or symptoms. Occasionally the
patient describes a pounding or pulsating pain in the area of the
aneurysm.
Screening is recommended for people between the ages of 65 and
75 if they have a family history of aneurysms, or if they are men
who have smoked. An aneurysm can be diagnosed when auscultation
of the affected vessel over the area of the aneurysm reveals turbulent
blood flow sounds, or a bruit. Radiologic studies, sonography, and
computed tomography (CT) all help confirm the diagnosis. Patients
are monitored on a routine basis for changes in the size of the aneu-
rysm. Surgical repair is recommended for all aneurysms 6 cm or
larger, but smaller ones also can rupture. If an aneurysm is tender
and known to be enlarging rapidly, surgery is essential, no matter
the size. If a rupture occurs, immediate lifesaving intervention is
required.
The medical assistant may aid the provider by observing the
patient for signs of pain, mental changes, and changes in pulse and
respirations. If any of these signs is observed, the provider must be
notified immediately. As with any serious condition, the patient may
have a high level of anxiety, and the medical assistant's role is to
support the patient and family while encouraging consistent
follow-up.
Peripheral Arterial Disease
Peripheral arterial disease develops because of widespread atheroscle-
rotic plaque buildup in the arteries outside the heart, especially in
the legs. Plaque deposits reduce the size of the lumen of the blood
vessel, thereby reducing the amount of oxygenated blood delivered
to the tissues. This lack of oxygen causes symptoms, most notably
leg pain when walking, a condition called intermittent claudica-
tion. Other signs and symptoms of peripheral arterial disease are leg
numbness or weakness; persistently cold extremities; sores on the
feet or legs that do not heal; and hair loss on the extremities. The
most effective methods for controlling intermittent claudication are
Aneurysm
FIGURE 23-10 Aneurysm caused by weakening of the vessel wall. (From Damjanov I: Pathology
for the health-related professions, ed 4, St Louis, 2012, Saunders.)
596 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES

regular exercise, smoking cessation, control of hypertension and

diabetes, and prescription of statins and antiplatelet drugs. Bypass
surgery or angioplasty may be necessary if these methods do not
improve blood flow to tissues.

DIAGNOSTIC PROCEDURES AND TREATMENTS

The cardiovascular examination begins with the medical assistant
measuring the patient's height and weight, temperature, radial and
apical pulses, respirations, and blood pressure in both arms. Most
cardiologists also want a complete list of the prescription and over-
the-counter (OTC) medications the patient is taking, including the
strength and frequency of use for each. A large part of the provider's
examination focuses on subjective symptoms. The physical examina-
tion covers the chest, heart, and vascular systems. General appear-
ance, color of the skin, symmetry, dubbing of the fingers, jugular FIGURE 23-11 Doppler study. (From Jarvis C: Physical examination and health assessment,
vein distention, temperature of the extremities, and breathing pat- ed 7, St Louis, 2016, Saunders.)
terns are a few of the notations made by the cardiologist.
A very common diagnostic test for the cardiovascular system
performed in the ambulatory care setting is the electrocardiogram
(ECG), which records the electrical activity of the heart. An ECG
is a routine part of many physical examinations, and it also may be
ordered if the provider is trying to rule out an MI or to diagnose a
cardiac arrhythmia. If the provider wants to evaluate potential
cardiac problems in patients over a specific period (usually 24 hours),
a Holter monitor may be ordered. The Holter monitor continuously
records the patient's cardiac activity, which is compared to symptoms
the patient documents during the test period (see the Electrocardi-
ography chapter for further details about diagnostic tools for cardiac
conditions). Patient support and education are two very important
areas in which medical assistants are deeply involved. When patients
understand their condition and are encouraged to take an active role
in their treatments, they are inclined to comply with the provider's
orders in a more precise and orderly way. Although cardiovascular
diagnostic procedures are not typically done in the ambulatory care
setting, medical assistants should be familiar with the purpose of the
tests so that they can answer patients' questions knowledgeably. FIGURE 23-12 Coronary angiography showing stenosis (arrow) of the left anterior descending
coronary artery. (From Braunwald E: Heart disease: atextbook of cardiovascular medicine, ed 4, Philo·
delphia, 1992, Saunders.)
Doppler Studies
Doppler studies can identify occlusions of both veins and arteries
from thrombi, emboli, or atherosderotic plaques. The provider may laboratory but may be done in a vascular surgeon's office as an initial
order arterial Doppler studies for patients with intermittent daudi- assessment of the patient or follow-up after bypass grafting. The
cation, lack of a pedal pulse, or leg ulcers that refuse to heal. Venous medical assistant working in this type of practice requires additional
sonography is ordered to assess patients with pronounced varicosities training to perform this procedure.
or those with a swollen, painful leg to rule out the possibility of
DVT. For a continuous-wave Doppler study, a conductive gel is Angiography
applied to the skin over the test site. The Doppler transducer is Angiography (arteriography) can be used to evaluate any of the arte-
moved over the site, directing an ultrasound beam at the vessel being rial pathways in the body (Figure 23-12). A catheter is inserted into
checked (Figure 23-11 ). The sonographic beam picks up the speed a major artery (usually the femoral artery) and advanced to the artery
of the RBCs as they travel through the vessel; this is heard as a under study. A radiopaque contrast medium is rapidly injected while
"swishing" sound. The physician listens to the change in the pitch x-ray films are taken. The study is used to identify abnormal blood
of the sound produced by the transducer to evaluate the blood flow vessels, determine blood flow through the vessel, and diagnose arte-
through an area that may be blocked or narrowed. Variations in RBC rial anomalies. Angiography also can be used to identify and locate
velocity indicate either partial or complete occlusion of the blood occlusions of the aorta and arteries of the lower extremities. If the
vessel. A two-dimensional image of an artery can be produced with radiopaque substance does not pass through or only partially passes
a duplex Doppler scan that directly shows stenosis or occlusion of through the vessel, the distal end of the artery will not be visualized
the artery. These studies usually are conducted in a vascular or will be only partly visible on the x-ray films. Arteriosderotic

disease can create a total or partial occlusion; emboli typically cause
total occlusion of the artery. The study also can diagnose dilation of
a vessel caused by an aneurysm.
Echocardiography
Echocardiography is a noninvasive, sonographic procedure that
assesses the structure and movement of the various parts of the heart.
High-frequency sound waves from a transducer held against the
chest wall penetrate the heart. The sound waves bounce off the heart
and echo back through the transducer into the machine, where they
are converted into a picture that shows the exact size and movement
of the parts of the heart being measured. Two-dimensional echocar-
diography also can be done to provide a spatial picture of the ana-
tomic structures of the heart. Echocardiography usually includes
color Doppler studies to show the pattern and velocity of blood flow
within the heart and in the great vessels. As with an incompetent
valve, backflow of blood can be identified by changes in color
(Figure 23-13).
A transesophageal echocardiogram (TEE) uses a long tube with
a microphone-like device mounted on one end that the patient swal-
lows into the esophagus. Once in place, the device is very close to
the heart, and sound waves emitted by the microphone create high-
quality views of the heart and heart valves. Before the patient swal-
lows the device, the mouth and throat are sprayed with medication
that numbs the area. The patient may be given a sedative to help
him or her relax and remain still during the procedure. Echocardiog-
raphy is used to diagnose pericardia! effusion, valvular heart disease,
aneurysms, and myocardial wall abnormalities seen in CHF or MI.
Cardiac Catheterization and Angioplasty
Cardiac catheterization is used to diagnose or evaluate a variety of
heart disorders. Patients who have chronic shortness of breath,
vertigo or syncope, chest pain, heart palpitations, arrhythmias, or
abnormal stress test or echocardiography results or who have recently
had an MI all are considered likely candidates for a heart catheteriza-
tion procedure.
FIGURE 23-13 Transesophageal echocardiogram recorded in a patient with an acute myocardial
infarction. Color flow imaging demonstrates the presence of severe mitral regurgitation. Ao, Aorta; LA,
left atrium; LV, left ventricle. (From Mann D, Zipes D, Libby Pet al: Braunwald's heatt disease, ed 7,
Philadelphia, 2005, Saunders.)
CHAPTER 23 Assisting in Cardiology 597
In this procedure, a catheter is passed into the heart through a
peripheral vein or artery. If the right side of the heart is to be evalu-
ated, the catheter usually is passed through the subclavian, brachia!,
or femoral vein; for left-sided views, the right femoral artery usually
is used. As the catheter is passed through the vessels into the heart
and coronary arteries, pressures are monitored, oxygen levels are
measured, and cardiac output is determined. Once the catheter has
reached the desired position, a contrast medium is injected and fluo-
roscopy is used to visualize the heart chambers, valves, and coronary
arteries. The cardiologist evaluates the condition of these structures,
and any deviation from normal is noted. Cardiac catheterization is
performed in a hospital and usually takes 2 to 3 hours. Patients are
required to remain immobile and under observation for 4 to 6 hours
after the procedure.
During a heart catheterization procedure, if atherosclerotic
plaques are discovered to be occluding the coronary arteries, PTCA
may be performed. The goals of angioplasty are to restore blood flow
to ischemic myocardial tissue, reduce the need for cardiac medica-
tion, and eliminate or reduce the number of episodes of angina.
When the area of plaque is found, a balloon that surrounds the upper
portion of the catheter is inflated and the atherosclerotic material is
pressed against the vessel walls, relieving the obstruction. More than
one blockage can be treated during a single session, depending on
the location of the blockages and the patient's condition. The pro-
cedure can take 30 minutes to several hours, depending on the
number of blockages treated.
Lasers also may be used to dissolve the obstruction, or a coronary
arterial stent (a mesh wire that stretches and molds to the arterial
wall) may be inserted and left in place in the vessel to keep it open
(Figure 23-14). If multiple coronary artery occlusions are present,
the patient may need a CABG procedure. In this surgery, either part
of the saphenous vein or an artificial Dacron graft is used to bypass
the occluded, diseased section of the coronary artery. The blood
flows through the graft to bring nourishment to the ischemic
myocardium.
Stent is closed
~ 4;+ ~
m ~l o c
A Atherosclerotic plaque
;,nated
i:™ Stent 1s
expanded
b] 8288 ;Q)
Expanded
stent is left
in place
C
FIGURE 23-14 Angioplasty with stent placement. (From Lafleur Brooks M: Exploring medical
language, ed 9, St Louis, 2014, Mosby.)
598 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES
Cardiac Pacemakers
A cardiac pacemaker is a small, battery-powered device that is
implanted in the chest wall. It generates an electrical impulse, which
is sent to the heart along flexible lead wires (Figure 23-15). Current
pacemakers are designed to monitor several different types of data,
including blood pressure, temperature, and breathing rate, to deter-
mine whether the heart needs to be stimulated to contract more
frequently. Patients who require the external electrical stimulation of
a pacemaker have an arrhythmia (most often bradycardia) either
because of injury to the myocardium or as a consequence of the
aging process. Biventricular pacemakers, which deliver electrical
impulses to both of the ventricles so that they contract and empty
at the same time, are the most recent types. Most biventricular
pacemakers can also work as implantable cardioverter-defibrillators,
which restore a normal heartbeat.
Pacemakers continually get smaller, from the size of a pack of
cigarettes in previous years to models that now are as small as a
quarter. The pacemaker must be replaced when the battery pack
wears out, and the typical battery life ranges from 5 to 10 years.
Implantable Cardioverter-Defibrillator
An implantable cardioverter-defibrillator (ICD) is a device the size
of a pocket watch that is implanted in the chest just below the col-
larbone and attached to the heart with small wires. It continuously
monitors the heart rhythm and is designed to deliver a measured
electric shock to the myocardium to correct life-threatening arrhyth-
mias, such as ventricular tachycardia or ventricular fibrillation. I CDs
have become the standard treatment for any patient with a serious
arrhythmia who is at risk of sudden death from cardiac arrest.
CLOSING COMMENTS
Patient Education
Heart disease and stroke account for more than one third of all
deaths in the United States. Genetics, predisposition, and lifestyle
Superior vena cava - - - -
Right atrium - - -~
Tricuspid valve - - - -
U
Dual Chamber Pacemaker
FIGURE 23-15 Pacemaker and placement in the chest.
factors, such as smoking, lack of exercise, and poor diet, play signifi-
cant roles in the development of heart disease. Successful manage-
ment of cardiovascular disease requires major lifestyle changes for
most patients. The medical assistant can help by providing encour-
agement and support and by using community resources to help the
patient find assistance with these changes.
Sources for information include the American Heart Association
(www.heart.org/) ; workshops and conferences; professional organiza-
tions, such as the American Association of Medical Assistants
(AAMA); and reputable Internet sites.
Because many patients learn best through visual aids, providing
them with pictures, brochures, and pamphlets is an effective means
of helping them in this learning process. Always document educa-
tion interventions so that the provider and/or medical assistant can
clarify or expand upon the information on a return visit.
Legal and Ethical Issues
Diagnostic procedures can have a marked effect on the patient's
treatment. When entrusted with performing testing procedures, the
medical assistant assumes responsibility for the test's accuracy
and for performing the test precisely. This is an important role
because the results submitted could strongly influence the plan of
treatment.
Professional Behaviors
Critical thinking is a crucial part of professional behavior. The ability to
question patients logically and comprehensively about possible cardiac signs
and symptoms can greatly contribute to high-quality care. The provider
relies on the medical assistant for initial information about the patient.
Given the seriousness of cardiac conditions, the medical assistant must use
his or her knowledge about the topic to gather and analyze the patient's
comments so that the provider is better prepared to make an accurate
diagnosis and develop an effective treatment plan.
Left subclavian vein
Lead insertion

i-iiiiit-iff•jii9#1MU1•i
Adam enjoys his new position but recognizes the challenges of interacting
with patients wha have cardiovascular problems. Most individuals seen at the
clinic must make significant changes in their lifestyle to improve their health
or prevent further complications. Adam has found it difficult at times to try to
help patients who refuse to quit smoking, who do not exercise regularly, and
who continue to eat a diet high in saturated and trans fat. He relies on the
hospital dietitian for educational support, and he encourages patients who
have had an Ml to follow the cardiologist's advice and participate actively in
SUMMARY OF LEARNING OBJECTIVES
l. Define, spell, and pronounce the terms listed in the vocabulary.
Spelling and pronouncing medical terms correctly reinforce the medical
assistant's credibility. Knowing the definitions of these terms promotes
confidence in communication with patients and co-workers.
2. Explain the anatomy and physiology of the heart and its significant
structures.
The heart is a muscular argan that pumps blood through all the arteries
of the body. It has three layers of tissue surrounded by a double-
membrane sac (the pericardium): the epicardium, or first, layer; the
myocardium, the middle, muscular layer; and the endocardium, the
inner layer, which forms the heart valves. Bload flaw through the heart
begins in the right atrium, which receives deoxygenated blood from the
inferior and superior venae cavae. The atria contract, and blood passes
through the tricuspid valve into the right ventricle; the ventricles con-
tract, and the blood passes from the right ventricle to the lungs via the
pulmonary artery. Oxygenation occurs in the lungs, and the blaod
returns to the left atria through the pulmonary veins; the atria contract,
and blood passes through the mitral (bicuspid) valve into the left ven-
tricle; the ventricles contract, and oxygen-rich blood is sent out to the
body through the aorta.
3. Summarize risk factors for the development of heart disease.
Risk factors for the development of cardiovascular disease that cannot
be changed are familial history, aging, and race; factors that can be
altered are hypertension, diabetes, elevated blood cholesterol levels,
smoking, obesity, lack of exercise, and stress.
4. Do the following related to coronary artery disease and myocardial
infarction:
• Describe the signs, symptoms, and medical procedures used in the
diagnosis and treatment of coronary artery disease and myocardial
infarction.
In CAD, the arteries supplying the myocardium become narrowed by
atherosclerotic plaque, resulting in ischemia of the myocardium. The
cardinal symptom is angina pectoris, followed by pressure or fullness
in the chest, syncope, unexplained coughing spells, and fatigue;
however, women may have a different clinical picture. lschemia leads
to necrosis of a portion of the myocardium, resulting in an Ml. An Ml
CHAPTER 23 Assisting in Cardiology 599
the cardiac rehabilitation program offered by the department. He also works
hard to stay up ta date an cardiovascular medications and treatments
because so many of the department's patients have complicated therapeu-
tic plans.
Adam has attended several workshops recently to help him choose educa-
tion materials that meet the needs of the patients in his practice. He recognizes
the need to continue his education in the area of cardiology to stay current with
the rapid developments in medication and treatments.
is characterized by pain that lasts longer than 30 minutes and is
unrelieved by rest or nitroglycerin tablets. It is diagnosed by ECG
changes and elevated cardiac enzymes. Medical treatment includes
thrombolytic medications, aspirin, beta blockers, ACE inhibitors, anti-
coagulants, and anticholesterol agents. With occlusion, either PTCA or
CABG surgery may be indicated. (Table 23-1 reviews medications
prescribed to treat hypercholesterolemia.)
• Summarize metabolic syndrome and associated risk factors.
Metabolic syndrome is a group of risk factors that raise the risk of
heart disease, diabetes and stroke. To be diagnosed with metabolic
syndrome, the patient must have at least three risk factors, including
abdominal obesity, high triglyceride levels, low HDL cholesterol levels,
hypertension, and high fasting blood glucose levels.
• Explain the signs and symptoms of myocardial infarction in women.
The signs and symptoms of a heart attack in women may start weeks
before the actual cardiac injury and could include abdominal, neck,
shoulder, or upper back pain; jaw pain; shortness of breath; vertigo;
sweating; indigestion or nausea and vomiting; extreme fatigue; and/
or aching in both arms.
5. Compare and contrast the treatment protocols for hypertension.
The two types of hypertension are primary and secondary hypertension.
Secondary hypertension occurs because of a disease process in another
body system. Primary hypertension is idiopathic and is diagnosed when
the patient's blood pressure is consistently above 119 mm Hg systolic
and/or 79 mm Hg diastolic. Table 23-2 summarizes how the varying
stages of hypertension are identified and treated, and Table 23-3 lists
antihypertensive medications. Chronic elevated blood pressure can result
in left ventricular hypertrophy, angina, Ml, heart failure, cerebrovascular
accident, and nephropathy. Risk factors for hypertension include afamily
history of hypertension or stroke, hypercholesterolemia, smoking, high
sodium intake, diabetes, excessive alcohol intake, aging, prolonged
stress, and race.
6. Outline the causes and results of congestive heart failure.
(HF accurs when the myocardium is unable ta pump an adequate amount
of blaod to meet the bady's needs. It typically develops over time and
initially involves one side of the heart and then the other side. Left-sided
Continued
600 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES
SUMMARY OF LEARNING OBJECTIVES-continued
heart failure causes a backup of blood in the left atria and lungs, resulting
in pulmonary edema with dyspnea, orthopnea, nonproductive cough,
roles, and tachycardia. Right-sided heart failure causes a backup of blood
in the right atrium, preventing emptying af the vena cava, resulting in
systemic edema, especially in the legs and feet. Bath types af heart
failure cause fatigue, weakness, exercise intolerance, dyspnea, and sen-
sitivity to cold temperatures.
7. Summarize the effects of inflammation and valve disorders on
cardiac function.
Rheumatic heart disease develops because of an unusual immune reac-
tion that typically occurs 2 to 4 weeks after an untreated beta-hemolytic
streptococcal infection; endocarditis is the mast common heart complica-
tion, with valve damage. Disorders af the heart valves may be caused
by a congenital defect or an infection. Two specific problems can occur
with valve disease. The valve can be stenosed, which restricts the
forward flow of blood, or it can be incompetent, which allows blood
to leak backward. The most common valvular defect is MVP, which
results from a congenital defect or vegetation and scarring caused by
endocarditis.
8. Describe the anatomy and physiology of the vascular system.
Blood vessels are divided into two systems that begin and end with the
heart. Vessels are classified according to their structure and function as
arteries, which carry oxygenated blood away fram the heart; capillaries,
the microscopic vessels responsible for the exchange of oxygen and
carbon dioxide in the tissue; and veins, the vessels that carry deoxygen-
ated blood back to the heart.
9. Differentiate among the various types of shock.
Table 23-4 ourlines the various types of shock. All result in the same
signs and symptoms and possible complications. Shock is the general
collapse of the circulatory system, marked by reduced cardiac output,
hypotension, and hypoxemia. Symptoms progress to a rapid, weak,
thready pulse; tachypnea; and altered levels of consciousness. If the
process is not reversed, the central nervous system becomes depressed
and acute renal failure may occur.
l 0. Summarize the characteristics of common vascular disorders.
Varicose veins are dilated, tortuous, superficial veins in the legs that
develop because the valves do not completely close, allowing blood to
flow backward, thus causing the vein to distend from the increased
CONNECTIONS
O:J Study Guide Connection: Go to the Chapter 23 Study Guide. Read and complete
the activities.
pressure. Phlebitis is an inflammation of the veins most commonly seen
in the lower legs. DVT is a thrombus with inflammatory changes that has
attached to the deep venous system of the lower legs and has caused
a partial or complete obstruction of the vessel. Athrombus that dislodges
and begins to circulate through the general circulation is an embolus.
Arteriosclerosis is a general term for the thickening and loss of elasticity
of arterial walls; it can occur in arteries throughout the body and cause
systemic ischemia and necrosis over time. Atherosclerosis is a form of
arteriosclerosis in which an atheroma develops. An aneurysm is a ba~
loaning or dilation of the wall of a vessel caused by weakening of the
vessel wall. Peripheral arterial disease affects the vessels outside of the
heart, especially the legs and feet, in which circulation is reduced and
ischemia can occur.
11. Discuss arterial disorders, including causes, risk factors, and common
treatments.
Arteriosclerosis can occur in arteries throughout the body and causes
systemic ischemia and necrosis over time. An aneurysm is a ballooning
or dilation of a blood vessel wall, and peripheral arterial disease develops
because of widespread atherosclerotic plaque buildup in the arteries
outside the heart.
12. Outline typical cardiovascular diagnostic procedures.
Cardiovascular diagnostic procedures include Doppler studies of the
patency of blood vessels; angiography to visualize arterial pathways;
echocardiography to assess the structure and movement of the parts
of the heart, especially the valves; cardiac catheterization to shaw the
heart chambers, valves, and coronary arteries; cardiac pacemaker to
monitor blood pressure, temperature, and breathing rate; or placement
of implantable cardioverter-defibrillator to monitor the heart rhythm and
deliver an electric shock to the myocardium to correct life-threatening
arrhythmias.
13. Describe patient education topics, and legal and ethical issues, for
cardiovascular patients.
Successful management of cardiovascular disease requires major lifestyle
changes for most patients. The medical assistant can help by providing
encouragement and support and by using community resources to help
the patient find assistance with these changes. Sources for information
include the American Heart Association, workshops and conferences,
professional organizations, and reputable Internet sites.
evolve Evolve Connection: Go to the Chapter 23 link at evolve.elsevier.com/
kinn to complete the Chapter Review Quiz. Check out the other resources listed for this
chapter to make the most of what you have learned from Assisting in Cardiology.
ASSISTING IN GERIATRICS
i-i#H+i;H•i
Bill Novelli, (MA (AAMA), works for Dr. Sara Kennedy, a primary care physician
in a small town close to where he grew up. Although patients af all ages are
seen in the practice, most patients are age 65 or older. Bill has learned to
24
recognize the unique communication needs of aging individuals and the impor-
tance af using family and community resources to maintain optimum health in
this special population.

While studying this chapter, think about the following questions:

• Do myths about aging and stereotypes about aging people negatively
affect older individuals?
• What are the most common changes that occur in the aging body and
what recommendations can be made for health promotion in this age
group?
• What suggestions can be made to aging patients and their families
to optimize older adults' health and protect them from injury and
disease?
• How is Alzheimer's disease diagnosed and what are the stages of its
development?
• Why is depression so common in aging individuals and how is it
diagnosed and treated?
• How can the medical assistant most effectively communicate with an
older person?
• Why is the use of community resources such an important factor in the
care of aging people?

LEARNING OBJECTIVES
l. Define, spell, and pronounce the terms listed in the vocabulary.
2. Do the following related to the aging process:
• Discuss the impact of a growing aging population on society.
• Identify the stereotypes and myths associated with aging.
• Role-play the effect of sensorimotor changes of aging. 5.
3. Do the following related to the cardiovascular, endocrine, 6.
gastrointestinal, integumentary, and musculoskeletal body systems: 7.
• Explain the changes in the anatomy and physiology caused by 8.
aging. 9.
• Summarize the major related diseases and disorders faced by older
patients.
4. Do the following related to the nervous system, pulmonary system,
sensory organs, urinary system, and reproductive systems:
• Explain the changes in the anatomy and physiology caused by
aging.
• Summarize the major related diseases and disorders faced by older
patients.
• Describe various screening tools for dementia, depression, and
malnutrition in aging adults.
Explain the effect of aging on sleep.
Differentiate among independent, assisted, and skilled nursing facilities.
Summarize the role of the medical assistant in caring for aging patients.
Determine the principles of effective communication with older adults.
Discuss patient education, as well as legal and ethical issues, associated
with aging patients.

VOCABULARY
collagen (kah'-luh-jen) The protein that forms the inelastic fibers
of tendons, ligaments, and fascia.
costal Pertaining to the ribs.
decubitus ulcers Sores or ulcers that develop over a
bony prominence as the result of ischemia from
prolonged pressure; also called bed sores or pressure
sores.
elastin An essential part of elastic connective tissue; when moist,
it is flexible and elastic.
lacrimation (lah-krih-ma'-shun) The secretion or discharge of
tears.
Meniere's disease (mayn-yayrz') Chronic disease of the inner ear
causing recurrent episodes of vertigo, progressive sensorineural
hearing loss, and tinnitus.

,I
602 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES
VOCABULARY-continued
nocturia Frequent urination at night.
oophorectomy Surgical removal of the ovaries
otosclerosis A condition that causes calcification of the ossicles of
the inner ear; the exact cause of otosclerosis is unknown, but it
may have a familial or genetic link.
A ccording to the Administration on Aging, an agency of the U.S.
J"\..Department of Health and Human Services, the aging popula-
tion (those age 65 or older) numbered almost 48 million in 2013.
By 2030, almost 1 of every 5 Americans (about 72 million people)
will be 65 years or older.
The average life expectancy of an individual who reaches age
65 is an additional 19.3 years (20.5 years for females and 17.9
years for males). A child born in 2013 can expect to live 78.8
years, about 30 years longer than a child born in 1900. Older
women outnumber older men; 25.1 million women are over age
65, as are 19.6 million men. About 30% of older people who
live outside of institutions live alone; half of women over age 75
live alone. More than half a million grandparents over the age
of 65 are the primary caregivers for their grandchildren who live
with them. Most older people have at least one chronic medical
condition, and many have multiple conditions. Hypertension,
arthritis, heart disease, cancer, and diabetes are the health prob-
lems most commonly seen in the elderly, and a significant
number also suffer from strokes, asthma, emphysema, and chronic
bronchitis.
What does all this mean to those who have chosen careers in
healthcare? As the aging population expands, it will affect all
aspects of society. One area in particular will be these individuals'
increased use of health services. To provide quality care to aging
patients, medical assistants must understand the aging process,
including the physical and sensory changes that occur with aging
(Procedure 24-1). This knowledge enables medical assistants to
recognize the special needs of the aged and to develop therapeutic
management and communication skills that can help them effec-
tively care for the older patient. Ongoing research and educa-
tion about the aging process have dispelled many of the old
stereotypes.
Aging is a complex physiologic, psychological, and social process.
Old age is not an illness but a normal life process that people experi-
ence in different ways. Lack of exercise, poor nutrition, substance
abuse, continual stress, and air pollutants all are factors that cause a
person to show the effects of aging decades earlier than someone
who has practiced healthy living habits.
As people age, changes occur in their physical appearance
and abilities, along with sensory changes in vision, hearing, taste,
and smell. These changes do not occur at the same time in
ototoxic Medications that have a harmful effect on
the eighth cranial nerve or the organs of hearing and
balance.
postherpetic neuralgia Nerve pain that occurs after a shingles
outbreak and may become chronic.
everyone; however, sensorimotor changes can have a profound
effect on the individual's ability to interact with his or her
environment.
Stereotypes and Myths About Aging
• Most aging people will develop dementia. Dementia is not part of the
normal aging process. However, the older the person, the greater the
risk of dementia. About 6% of those over age 65 and almost 50% af
those over age 85 are diagnosed with significant memory and disori-
entation issues.
• Disease is a normal and an unavoidable part of the aging process.
Recent research verifies that individuals who have established healthy
lifestyles as they age remain healthy well into their older years. Aging
people are more likely to have health issues, but these are not inevi-
table for all persons over age 65.
• Older workers are less productive than younger ones. Individuals with
a strong work ethic continue ta perform in this way. It may take aging
people longer to learn new material, but they continue to be capable
of learning and applying new knowledge.
• Most older people end up in long-term care facilities. At any given time,
approximately 5% of the aging population lives in long-term care facili-
ties; 80% of aging individuals live independently, with or without a
partner.
• Most aging people have no interest in or capacity for sexual relations.
Sexual interest does not change significantly with age; a decrease in
sexual activity is usually related to the loss of a partner.
• Damage to health because of lifestyle factors is irreversible. It is never
too late to benefit from healthy lifestyle choices.
CRITICAL THINKING APPLICATION 24-1
When Bill first started working with aging patients, he believed many of
the stereotypes about people over age 65. Through his work with Dr.
Kennedy, he has come to realize that many of these myths have no founda-
tion in actual practice. Based on the myths mentioned in the text, what do
you think about these beliefs on aging?
 CHAPTER 24 Assisting in Geriatrics 603

•;;m,immfii• Demonstrate Empathy: Understand the Sensorimotor Changes of Aging

Goal: To role-play an alder adult so as to better understand the needs of aging people.

EQUIPMENT and SUPPLIES 3. Role-play difficulty with focusing.

• Yellow-tinted glasses, ski goggles, or laboratory gaggles • Put on goggles smeared with petroleum jelly and fallow your partner's
• Pink, white, yellow "pills" (e.g., various colors af Tic lacs) directions.
• Petroleum jelly (e.g., Vaseline) • Partner: Stand at least 3 feet in front of your partner and motion far
• Cotton balls him ar her ta come to you (your partner is deaf, sa talking will not
• Eye patches help).
• Tape 4. Role-play loss of peripheral vision.
• Thick gloves • Put on goggles with black paper taped to the sides.
• Utility glove • Partner: Stand to the side, out of the field of vision, and motion far
• Tongue depressors your patient to fallow you.
• Elastic bandages S. Role-play aphasia and partial paralysis.
• Medical farms in small print • You are unable to use your right arm or leg. Place tape over your mouth.
• Pennies Let your partner know you need to go to the bathroom.
• Button shirts • Partner: Stand at least 3 feet away with your back to your partner and
• Walker wait far instructions.
6. Role-play problems with dexterity.
PROCEDURAL STEPS • Put thick gloves on your hands and try to sign your name, button a
1. Role-play vision and hearing lass. shirt, tie your shoes, and pick up pennies.
• Put two cotton balls in each ear and an eye patch aver one eye. Fallaw 7. Role-play problems with mobility.
your partner's instructions. • Use the walker to cross the room.
• Partner: Stand out of the line af vision (ta prevent lip-reading). Without • Partner: After your partner starts to use the walker, hand him or her a
using gestures ar changing your voice volume, tell your partner ta crass book to carry.
the room and pick up a baak. 8. Role-play changes in sensation.
2. Role-play yellowing of the lens of the eye. • Put a rubber utility glove on; turn on hot water; test the difference in
• Line up "pills" of different pastel colors. temperature between the gloved hand and the ungloved hand.
• Partner: Pick out the different colors while wearing the yellow-tinted 9. Summarize and share with the group your impressions of the effect of
glasses. age-related sensorimotor changes.

CHANGES IN ANATOMY AND PHYSIOLOGY
The aging process brings about changes in all of the body's systems.
Table 24-1 summarizes these changes and what can be done to
promote healthy aging.
Cardiovascular System
Cardiovascular disease is the most frequent cause of illness and dis-
ability in the aging population, and congestive heart failure (CHF)
is the most common reason for hospitalization. Age-related changes
occur in the cardiovascular system, but disease and lifestyle habits
such as lack of exercise, poor diet, and stress contribute to these
changes. Heart disease is ranked as the leading cause of death among
men and women; therefore, proper management of cardiovascular
disease can help maintain the health of an aging population and
reduce mortality rates.
The aging process causes structural changes in the heart. Myocar-
dial cells enlarge, and deposits of fat and connective tissue increase;
these combine to make the myocardial wall stiffer and to lengthen
the time needed for the relaxation phase of the cardiac cycle. As a
result, cardiac output declines, making aging people more suscep-
tible to CHF. The reduction in cardiac output leads to pooling of
blood in the legs, cold extremities, and edema (Table 24-2). In addi-
tion, the heart cannot respond as quickly or as forcefully to an
increased workload, so exercise, sudden movements, and changes in
position can result in dizziness and loss of balance. Aging typically
brings with it an increase in blood pressure, requiring the heart to
work harder to pump blood into the systemic circulation. Hyperten-
sion increases the workload of the left ventricle, and this may result
in hypertrophy of the chamber and weakening of the myocardial
wall. The valves of the heart tend to thicken and become more rigid,
making it more difficult for blood to circulate through the cardio-
pulmonary vessels. With these cardiovascular problems, arrhythmias
become more common.
Aging causes the walls of the veins to weaken and stretch. This
damages the valves, especially in the veins of the legs, where the walls
are subject to greater pressure as blood struggles to return to the
604 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES

TABLE 24-1 System Changes with Aging and Measures to Promote Health
SYSTEM AGE-RELATED CHANGES
Cardiovascular system Arteriosclerosis and atherosclerotic plaque buildup reduces blood
flaw to major argans; 50% of the aging papulatian have
hypertension; (VD is the number one killer of women and men in
their 60s.
Central nervous system Brain shrinks by 10% between ages 30 and 90; takes longer to Aerobic exercise to increase blood flow to CNS; maintaining
learn new material; attention span and language remain the same; mental activities (e.g., reading, interacting with others)
signs and symptoms may be caused by depression, vascular
disease, and drug reactions.
Endocrine system After age 50, women have a sharp decline in estrogen; men have
a more gradual decline in testosterone.
Gastrointestinal system Decline in gastric juices and enzymes by age 60; decreased
peristalsis with increased constipation; some nutrients are not
absorbed as well.
Musculoskeletal system Muscle mass decreases; tendency to gain weight; gradual loss of
bone density; deterioration of joint cartilage.
Pulmonary system At age 55 the lungs become less elastic and the chest wall
gradually stiffens, making oxygenation more difficult.
Sensory organs Hearing is intact through the mid-50s but declines by 25% by age
80; oral problems are common; skin thins and loses elasticity;
presbyopia after age 40; cataracts common after age 60.
Urinary system Kidneys become less efficient; bladder muscles weaken; one third
of seniors experience incontinence; prostate enlargement is
common.
Sexuality Men: Impotence is not a symptom of normal aging; men over age
50 may have some altered function.
Women: Menopause causes vaginal narrowing and dryness,
resulting in painful intercourse.
CNS, Central nervous system; CVD, cardiovascular disease; PSA, prostate-specific antigen.
HEALTH PROMOTION
Regular exercise; weight control; diet rich in fruits,
vegetables, and whale grains; cholesterol, blood glucose
monitoring
Possible hormone replacement therapy or natural soy
supplements
High-fiber diet and adequate fluid intake; regular exercise to
prevent constipation
Strength training to increase muscle mass; stretching to
remain limber; exercise; vitamin Dand calcium supplements
Quit smoking; regular aerobic exercise
Avoid exposure to loud noise, use hearing aids; good dental
hygiene; prevention of sun damage to the skin; annual eye
examinations; diet rich in dark green, leafy vegetables to
prevent cataracts and macular degeneration
Pelvic exercises, drugs, or surgery for incontinence; annual
PSA with digital rectal exam monitoring for men
Men: Maintenance of cardiovascular health with exercise,
weight control, no smoking, diabetes management
Women: Use of vaginal lubricants or estrogen cream

heart against the force of gravity. As a result, edema and varicose

TABLE 24-2 Normal Changes in Cardiac Output veins of the lower extremities are common in the elderly, increasing
with Age the risk of phlebitis and the formation of thrombi in the deep veins,
or deep vein thrombosis (DVT).
BLOOD PUMPED BY MAXIMUM HEARTBEAT
Arteriosclerosis is considered part of the aging process. The vessel
RESTING HEART DURING EXERCISE walls thicken and become less elastic as a result of the calcification
AGE (quarts/min) (beats/min) and buildup of connective tissue. In addition, the artery's ability to
30 3.6 200 dilate and contract diminishes. To maintain an adequate blood
supply throughout the body, the heart must work harder to over-
40 3.4 182 come the resistance caused by stiffened vessels. Older adults have a
50 3.2 171 higher incidence of orthostatic hypotension. The clinical criterion
for alterations in blood pressure from sitting to standing is a drop
60 2.9 159 of more than 20 mm Hg in the systolic pressure, or more than
10 mm Hg in the diastolic pressure, when the position is changed.
70 2.6 150
When a person with orthostatic hypotension stands, gravity causes
American Heart Association. www.americanheart.org. Accessed July 20, 2012. blood to pool in the legs resulting in a drop in the amount of blood

returning to the heart for circulation. This decrease in circulating
blood volume causes a sudden drop in blood pressure. The provider
may have the medical assistant take orthostatic blood pressures as
part of routine intake protocol for aging patients. To perform this
procedure, apply a blood pressure cuff and take the individual's
blood pressure while sitting. Leave the cuff in place and have the
patient stand. Record the standing blood pressure immediately to
document any differences in readings when the position is changed.
Endocrine System
Hormonal changes that occur with aging are related to a general
decrease in hormone production combined with changes in tissue
receptor binding. The most common endocrine system disorder seen
in aging patients is diabetes mellitus (DM) type 2. As a person ages,
insulin production by the beta cells in the pancreas decreases and
insulin resistance at the tissue level increases. According to the
National Institutes of Health, more than half of the 16 million
Americans diagnosed with diabetes type 2 are over age 65. Elderly
patients with diabetes are at increased risk of developing vascular
disease, including renal disorders, retinopathy, neuropathy, myocar-
dial ischemia, angina, myocardial infarction, cerebrovascular acci-
dents, and peripheral vascular disease, such as lower extremity ulcers.
Older patients do not always experience the classic symptoms of
diabetes, which are polyuria, polydipsia, and polyphagia. They may
show a variety of problems, including unexplained weight loss, slow
wound healing, recurrent bacterial or fungal infections, changes in
mental state, cataracts, macular disease, muscle weakness and pain,
angina, foot ulcers, and uremia. The range of symptoms is due to
the insidious onset of diabetes in older people, who may have gradu-
ally developing hyperglycemia for years before diagnosis.
The treatment protocol for aging patients with diabetes is the
same as for other age groups; however, special consideration must
be given to the patient's ability to understand and comply with the
therapeutic plan. In addition, because the person may have other
health problems that are being treated with medications, an aging
patient newly diagnosed with diabetes may face a complicated treat-
ment regimen that requires explicit instruction and continual
follow-up in the ambulatory care setting.
The medical assistant must be aware of any sensory abnormalities,
such as diminished vision or problems with fine motor skills, which
may interfere with the patient's ability to follow treatment guide-
lines. Teaching and treatment plans must be adapted to meet the
individual needs of each patient. For example, if the patient has
vision difficulties, an injector pen can be used to deliver a preset
amount of insulin.
Factors That Can Affect Diabetes Management
in Older People
• Modifying lifestyle risk factors may be more difficult because of poor
nutrition, inability to exercise, and long-standing habits, such as
smoking and a diet high in saturated fats and calories.
• Previously diagnosed health conditions, such as hypertension and heart
disease, in addition to an age-related decline in kidney and liver func-
tion, increase the challenge of treating diabetes.
CHAPTER 24 Assisting in Geriatrics 605
• Older people are more likely to be prescribed multiple medications
(polypharmacy), which increases the risk of adverse drug
interactions.
• Elderly patients with diabetes are more prone to hypoglycemia and may
not recognize and respond quickly to the signs of low blood glucose
levels.
• Diabetic complications can develop quickly because of a long history of
prediabetes before diagnosis.
• Older people may have decreased physical and/or mental abilities that
make it difficult for them to understand and adhere to a complicated
treatment regimen.
• Older patients may not be able to afford the medications and supplies
needed to maintain health.
CRITICAL THINKING APPLICATION 24-2
Quite a few of the elderly patients in Dr. Kennedy's practice have type 2
diabetes. Based on what you have learned about the difficulty of managing
diabetes in aging people, what factors do you need to consider when
conducting patient education for an elderly person with diabetes? Are there
any community resources that might be useful for patients and their
families?
Gastrointestinal System
Age-related changes in the gastrointestinal system begin in the
mouth with dental problems, a decrease in the number of taste buds
and the production of saliva, and a diminishing sense of smell. Older
people generally find eating less pleasurable, have a reduced appetite,
and are unable to chew and lubricate their food as well as younger
people; this makes dysphagia (difficulty swallowing) a common age-
related problem. Aging also brings a decrease in the production of
hydrochloric acid, which affects the digestion of calcium and iron.
Secretion of intrinsic factor, a protein that is needed for the absorp-
tion of vitamin B12, also declines, which affects the function of the
nervous system and the formation of red blood cells, resulting in
excessive fatigue. It is not unusual for aging patients to be on regular
vitamin B12 replacement therapy, either through large oral doses or
by intramuscular (IM) or subcutaneous (SC) injection.
Food passes more quickly through the small intestine, resulting
in poorer absorption of vitamins and minerals. Peristalsis in the
colon decreases, making aging patients more susceptible to constipa-
tion and diverticular disease. Poor eating habits, a reduced fluid
intake, and some medications (e.g., antidepressants, diuretics, ant-
acids containing aluminum or calcium, and medications for Parkin-
son's disease) also contribute to constipation. The liver decreases in
size and weight after age 70. It is still able to perform vital functions,
but more time is required to metabolize drugs and alcohol. All of
these factors combine to increase the potential for adverse drug reac-
tions in older adults.
Aging individuals have a higher incidence of several gastrointes-
tinal system diseases, such as gastroesophageal reflux disease (GERD),
peptic ulcers, diverticulosis (related to lack of dietary fiber
606 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES
and constipation), cholelithiasis, and colorectal cancer. Dietary
counseling and annual screenings should be part of the routine care
of aging patients.
lntegumentary System
The skin is the body's first line of protection against infection, and
it also is responsible for preventing the loss of body fluid and regulat-
ing body temperature. Changes in the appearance and function of
the integumentary system usually are caused by a combination of
ordinary age-related changes and environmental factors, especially
the amount of sun exposure over time. Exposure to ultraviolet light
from the sun frequently is the cause of wrinkles, age spots, blotches,
and leathery, dry, loose skin, all of which are associated with aging.
Changes caused by the ultraviolet light from the sun or by the
normal aging process can affect all three layers of the skin: the epi-
dermis, dermis, and subcutaneous tissue.
The cells in the epidermis reproduce more slowly as people age,
and this slower regeneration causes the skin to appear thinner. The
skin becomes more prone to tearing and blistering. The risk of
infections increases, the healing process takes longer, and older
people are more susceptible to bruising. Because the skin can be
easily torn, it is important to be very careful when performing phle-
botomy or covering a wound on an older patient. Vitamin D syn-
thesis, a major function of the epidermis, significantly declines in
aged skin, and a decrease in the number of melanocytes increases
photosensitivity.
The dermis loses 20% of its mass during the aging process, result-
ing in the paper-thin or transparent skin seen in older adults. The
number of collagen cells in the dermis also declines with age,
causing the skin to sag and wrinkle. Because both sweat and seba-
ceous glands decrease in number, aging people have difficulty tolerat-
ing higher temperatures because they perspire less. At the same time,
the blood supply to the dermis decreases; this makes it difficult to
regulate the body temperature and leads to an increased susceptibil-
ity to both hypothermia and heat stroke in aging individuals. Any
situation in which an older adult would be exposed to extremes of
cold or heat should be avoided. Make sure a blanket is available in
the examining room if the air conditioning is on. Ask the person if
he or she is too cold or too hot and take the necessary steps to make
the patient feel more comfortable.
Atrophy of the subcutaneous layer increases the skin's susceptibil-
ity to trauma, so patients bruise much more easily. The skin is denied
natural lubrication, and dry skin is one of the most common com-
plaints among older people. In addition, fat deposits increase in the
abdomen in men and in the abdomen and thighs in women as they
age.
Suggestions that might help older people prevent and treat dry
skin include:
• Use a room humidifier to moisten the air
• Bathe less frequently and use warm rather than hot water
• Use a mild soap or cleansing cream (e.g., Aveeno, Basis, or
Dove)
• Wear protective clothing in cold weather
• Moisturize dry skin
Pain receptors are distributed throughout the skin. Because of
age-related changes in the receptors, older people have a higher pain
threshold. They may not notice a cut or burn as quickly as a younger
person would, so a more serious burn may occur before it is noticed.
In addition, wound healing becomes a problem because of decreased
blood flow to dermal tissues.
Other changes occur in the skin's appendages. Hair changes in
color, growth, and distribution. Hair grays because of the decreased
rate of melanin production and the replacement of pigmented hair
with nonpigmented hair. Women lose hair on the trunk and have
increased facial hair. Although alopecia (loss of hair) is caused by an
inherited trait, aging also causes hair loss. Hair on the eyebrows,
nose, and ears becomes coarser and longer in men. The nails of older
people take longer to grow and are more brittle. Nails, particularly
toenails, thicken as a result of trauma or nutritional deficiencies. It
is not unusual for nails to split, making them more susceptible to
fungal infections.
Seborrheic keratoses, usually referred to as "age spots," are one
of the most common benign skin disorders found in the aging
population. They appear as waxy, scaly papules that vary from tan
to dark brown (Figure 24-1 ) and typically are found in areas of
sun exposure, such as the trunk, back, face, neck, extremities, and
scalp. They are not dangerous but may be removed for cosmetic
purposes.
Shingles Risk Reduction
In 2011 the U.S. Food and Drug Administration (FDA) approved a vaccine,
Zostavax, developed to reduce the risk of shingles in people age 60 or
older. The varicella-zoster virus causes both shingles and chickenpox. After
an active chickenpox infection, the virus lies dormant in a nerve derma-
tome. As people age, their risk increases that the virus will reactivate,
causing the formation of blisters and varying degrees of pain along the
affected nerve pathway. It is estimated that 2 in l 0 people will develop
shingles in their lifetime. Zostavax is a live virus vaccine that boosts
immunity against the varicella-zoster virus. The vaccine is administered as
a single subcutaneous injection. Studies have shown that the vaccine
reduces the risk of shingles by about half (51 %) and the risk of posther-
petic neuralgia by 67%; it is most effective in people ages 60 to 69 years.
For individuals who develop shingles even though they were immunized,
the duration of symptoms is shorter. It is recommended that all individuals
over age 60 receive the Zostavax vaccine, even if they have had shingles,
to help prevent future occurrences of the disease. Shingles vaccination can
be somewhat difficult to get because the vaccine requires storage in a
special freezer, and it can be quite expensive ($200 to $250). Therefore,
it is important that the patient or the medical assistant first check with the
individual's insurance carrier to see whether the injection is covered.
CRITICAL THINKING APPLICATION 24-3
Rose Deluca, a 71-year-old patient of Dr. Kennedy, is unhappy about the
changes in her skin that have occurred in the past several years. Based on
what Bill knows about the normal changes that occur in the skin as people
age, how can he explain these changes to Mrs. Deluca, and what can he
suggest to help with dryness and other typical aging changes?

FIGURE 24-1 Seborrheic keratosis. (From Habif TP: Clinical dermatology: acolor guide to diag-
nosis and therapy, ed 6, St Louis, 2016, Mosby.)
Musculoskeletal System
As the body ages, changes occur in the muscles, bones, and joints
that affect the individual's appearance, strength, and mobility. The
extent of change depends on the person's diet, exercise pattern, and
heredity. Cartilage loss and degeneration, which produce osteoarthri-
tis, commonly occur in the weight-bearing joints of older people.
Joint range of motion is affected, and the intervertebral disc spaces
are decreased, causing loss of height as a person ages. A breakdown
in joint structures may lead to inflammation, pain, stiffness, and
deformity.
Aging brings a decrease in the strength and speed of muscle
contractions in the extremities but only a slight decline in overall
muscle endurance. Muscular changes in the aging patient are directly
related to the individual's activity level. Research shows that muscu-
loskeletal disease is not an inevitable result of the aging process;
however, 40% to 50% of women over age 50 have a serious problem
with bone demineralization. Men also experience bone loss, but at
a later age and a much slower rate than women.
Suggestions for Helping the Older Adult with
Mobility, Dexterity, and Balance
• Encourage the person to use assistive devices, such as adaptive silver-
ware, a tub seat or shower chair, electric razor, and reaching devices.
• Assist the person with gripping devices as needed (wait for the patient
to place his or her hand around a cup or help him or her with it before
letting go).
• Provide older adults with enough time to complete tasks
independently.
CHAPTER 24 Assisting in Geriatrics 607
• Support a post-stroke patient who is ambulatory on the weak side; use
a gait belt as needed when transferring a patient from a chair to an
examination table.
• The provider may recommend physical therapy for range-of-motion
exercises.
• Encourage activity approved by the provider; lack of activity results in
a decline in the ability to function.
Osteoporosis
Osteoporosis is the primary cause of hip fractures, which can lead
to a loss of independence and also to complications that ultimately
can end in death. The spinal vertebrae also can collapse, producing
the stooped posture associated with "dowager's hump." Sometimes
bones break because of the sheer weight of the body on them. Often
people say they fell and broke a bone, when in reality the bone
fractured, causing them to fall. Multiple factors contribute to the
development of osteoporosis, but it is most common in postmeno-
pausal women. Risk factors for osteoporosis include:
• Female gender (women have a five times greater risk than
men)
• Thin; small-boned frame
• Family history of osteoporosis
• Estrogen deficiency before age 45, either from early meno-
pause or oophorectomy
• Estrogen deficiency resulting from an abnormal absence of
menses (eating disorders, excessive aerobic exercise, fibrocystic
ovaries)
• Racial background (Caucasian and Asian women have the
highest risk)
• Aging
• Extended use of anticonvulsant drugs, prednisone, and exces-
sive thyroid hormone medications
• Sedentary lifestyle, smoking, excessive alcohol intake, and lack
of calcium and vitamin D when growing up
Weight-bearing exercises and calcium and vitamin D supple-
ments are recommended to prevent demineralization of the bones.
Medications used to prevent and/or treat osteoporosis include alen-
dronate (Fosamax) and risedronate (Actonel), which reduce the rate
of demineralization; raloxifene (Evista), which slows bone thinning
and causes some increase in bone thickness; and calcitonin (Calci-
mar, Miacalcin), which is either injected or inhaled as a nasal spray
and results in a decrease in the rate of bone thinning and relieves
the pain associated with spinal compression. Another option is an
IV medication, zoledronic acid (Reclast), for the once yearly treat-
ment of postmenopausal women with osteoporosis. Reclast helps
increase bone density in the spine and hip, thus reducing the risk of
fractures.
Falls
The risk of injuries from falls increases with age; falls cause the great-
est number of injuries in people over age 70. Aging individuals are
at greater risk of falling because of sensorimotor changes in vision
and mobility, osteoporosis, and cerebrovascular accidents. Falls in
older patients usually result in fractures because a large percentage
of these individuals have osteoporosis. Serious fractures, such as
608 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES
those of the hip, require the patient to be immobile for extended
periods, and this opens the door to a wide range of debilitating
complications, such as decubitus ulcers, pneumonia, placement in
long-term care facilities, and even death. Falls are largely preventable.
The medical assistant can play an active role in helping family
members and patients become aware of risk factors and safety mea-
sures. Suggestions that can help patients prevent falls are:
• Have regular vision tests.
• Understand the side effects of medications, especially those
that cause vertigo.
• If you experience orthostatic hypotension, rise slowly and
stand still for a moment with support before moving.
• Limit the use of alcohol.
• If needed, consistently use assistive devices, such as a cane or
walker, for support.
• Wear low-heeled, rubber-soled shoes with good support.
• Avoid going outside in icy weather.
• Engage in regular weight-bearing exercise for muscle and bone
strength.
• Keep hallways, stairs, and bathrooms well lit.
• Assess the home for possible danger areas; remove throw rugs;
use handrails on steps and grab bars in bathrooms; keep
emergency numbers handy.
CRITICAL THINKING APPLICATION 24-4
The family of Rita Schaeffer, a 73-year-old patient, is concerned about the
risk of falls. Mrs. Schaeffer recently was diagnosed with osteoporosis, and
she lives alone. What information should Bill give the family to help them
prevent accidents in their mother's home? Also, Mrs. Schaeffer's 45-year-old
daughter is concerned about developing osteoporosis. What steps should
the daughter take to prevent the disease?
Nervous System
Cognitive ability (i.e., the ability of a person to think) is influ-
enced by many factors, including a person's general state of health,
educational background, and genetic code. The normal process of
aging may contribute to a change in the thinking process. The
brain begins to get smaller at approximately age 50 and continues
to do so as we age because of a loss of fluid within the neurons
and shrinkage of dendrites. Thinning of the dendrites makes trans-
mitting messages from one neuron to the next more difficult. As a
result of all these factors, the aging brain weighs less, is smaller,
and has started to pull away from the sheath or cortical mantle.
Older neurons process information more slowly, so retrieving old
information and learning new information takes longer. Reaction
time also slows, and aging individuals are distracted more easily;
however, recent research shows that the loss of brain cells is
minimal and that the older brain is still capable of generating new
neurons. Researchers believe that continued, moderate physical
and mental activity can maintain the cognitive abilities of aging
individuals.
Dementia, the severe loss of intellectual ability, is not an inevi-
table part of aging but rather the result of an organic disorder. Most
men and women remain mentally competent until the end of their
lives. Sudden loss of memory, disorientation, and trouble performing
the daily tasks of life indicate a problem that should be investigated.
Many conditions can cause signs and symptoms of dementia, includ-
ing depression; reactions to prescription and over-the-counter
(OTC) drugs; alcoholism; malnutrition; thyroid, liver, heart, and
vascular disorders; and Parkinson's disease. Multiple factors can
interfere with mental judgment and motor skills, giving the impres-
sion of decreased mental status.
The best way to ensure mental functioning in later life is to
remain mentally and physically stimulated. Exercise improves
memory and thinking because of its positive effect on vascular
health, increasing the amount of oxygen delivered to the aging brain.
Other ways to maintain mental function are to keep socially active;
practice stress-reduction activities; quit smoking; drink alcohol in
moderation; use hearing aids and glasses if needed to stay in touch
with the world; and receive treatment for depression, diabetes,
hypertension, and high cholesterol levels. Risk factors for cognitive
decline include:
• Hypertension, diabetes, and heart disease (these reduce blood
flow to the brain)
• Environmental exposure to lead
• High stress levels
• Sedentary lifestyle and lack of social interaction
• Low education level
• Smoking and substance abuse
One of the most frequently used screening tools for dementia
is the Mini-Mental State Examination, a 5-minute test designed
to evaluate basic mental function in a number of different areas.
The test assesses the patient's ability to recall facts, write, and cal-
culate numbers. It gives the provider a quick way to determine
whether more in-depth testing is needed. Each area of the exami-
nation is given a score, and these scores show whether the person
is functioning within the expected range for his or her age (Figure
24-2). The medical assistant may be expected to administer this
examination.
Alzheimer's Disease
Alzheimer's disease (AD) is a progressive deterioration of the brain
caused by the destruction of central nervous system (CNS) neurons,
leading to problems with memory, language, thinking, and behavior.
Three major changes occur in the brain:
• Amyloid plaques form.
• Neurofibrillary tangles clump together, affecting neuron func-
tion (neurons eventually die).
• The connections between neurons that are responsible for
memory and learning are lost, resulting in neuron destruction;
as neurons die throughout the brain, the affected regions
begin to atrophy, or shrink. By the final stage of AD, damage
is widespread and brain tissue has shrunk significantly.
Patients who show signs and symptoms of dementia are first
evaluated for organic causes, such as systemic disease or depression.
AD has no definitive diagnostic test because it can be confirmed only
through examination of the brain at autopsy. If the patient shows a
gradual onset of progressive difficulty with memory, functional abili-
ties, and behavior and has no evidence of other causes of these dis-
turbances, the physician makes the diagnosis of AD. Imaging studies,
 CHAPTER 24 Assisting in Geriatrics 609

Patient _ _ _ _ _ _ _ _ _ __ Examiner _ _ _ __ Date _ _ _ __

Maximum
Score Score

Orientation
5 What is the (year) (season) (date) (day) (month)?
5 Where are we: (state) (county) (town) (hospital) (floor)

Registration
3 Name three objects: (Apple, Penny, Table) 1 second to say each. Then ask the patient all three after you have said them.
Give 1 point for each correct answer. Then repeat them until he or she learns all three. Count trials
and record.
Trials----
Attention and Calculation
5 Serial 7's. 1 point for each correct. Stop after five answers. Alternatively spell "world" backwards.

Recall
3 Ask for the three objects repeated above. Give 1 point for each correct.

Language
9 Name a pencil, and watch (2 points) Overlapping pentagons
Repeat the following "No ifs, ands, or buts." (1 point)
Follow a three-stage command:
"Take a paper in your right hand, fold it in half, and put it on the floor." (3 points)
Read and obey the following:
CLOSE YOUR EYES (1 point)
Write a sentence (1 point)
Copy design (overlapping pentagons) (1 point)
Total Score
ASSESS level of consciousness along a c o n t i n u u m - - - - - - - - - - - - - - - - - - - - - - -
Alert Drowsy Stupor Coma

Instructions for Administration of Mini-Mental State Examination

Orientation
(1) Ask for the date. Then ask specifically for parts omitted, e.g., "Can you also tell me what season it is?" One point for each correct.
(2) Ask in turn "Can you tell me the name of this hospital?" (town, country, etc.). One point for each correct.
Registration

Ask the patient if you may test his or her memory. Then say the names of three unrelated objects, clearly and slowly, about 1 second for
each. After you have said all three, ask him or her to repeat them. This first repetition determines his or her score (Q-3), but keep saying
them until he or she can repeat all three, up to six trials. If he or she does not eventually learn all three, recall cannot be meaningfully tested.

Attention and Calculation

Ask the patient to begin with 100 and count backwards by 7. Stop after five subtractions (93, 86, 79, 72, 65). Score the total number of
correct answers.
If the patient cannot or will not perform this task, ask him or her to spell the word "world" backwards. The score is the number of letters in
correct order, e.g., dlrow = 5, dlorw = 3.
Recall

Ask the patient if he or she can recall the three words you previously asked him or her to remember. Score 0-3.
Language
Naming: Show the patient a wrist watch and ask him or her what it is. Repeat for pencil. Score 0-2.
Repetition: Ask the patient to repeat the sentence after you. Allow only one trial. Score O or 1.
Three-stage command: Give the patient a piece of plain blank paper and repeat the command. Score 1 point for each part correctly
executed.
Reading: On a blank piece of paper print the sentence "Close your eyes," in letters large enough for the patient to see clearly. Ask him or
her to read it and do what it says. Score 1 point only if he or she actually closes his or her eyes.
Writing: Give the patient a blank piece of paper and ask him or her to write a sentence for you. Do not dictate a sentence, it is to be written
spontaneously. It must contain a subject and verb and be sensible. Correct grammar and punctuation are not necessary.
Copying: On a clean piece of paper, draw intersecting pentagons, each side about 1 inch, and ask him or her to copy it exactly as it is.
All 10 angles must be present, and 2 must intersect to score 1 point. Tremor and rotation are ignored.
Estimate the patient's level of sensorium along a continuum, from alert on the left to coma on the right.

FIGURE 24-2 Min~Mental State Examination. (From Folstein Met al: Mini mental state, J Psychiatry Res 12: 196, 1975.)
61 o UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES
including computed tomography (CT), magnetic resonance imaging
(MRI), and positron emission tomography (PET), may help show
the structural and functional changes in the brain associated with
Alzheimer's disease.
Researchers estimate that about 5 million Americans suffer from
AD. The disease typically begins after age 60, and the risk of devel-
oping the disorder increases with age, although younger people as
early as age 30 have been diagnosed with AD. Research shows that
1 in 9 Americans over age 65 has Alzheimer's disease; almost 50%
of people age 85 or older are diagnosed with the disease. Despite
these statistics, AD is not considered a normal part of the aging
process. Alzheimer's disease is the sixth leading cause of death (across
all ages) in the United States and the fifth leading cause of death for
those age 65 to 85.
Alzheimer's Disease Warning Signs
l. Memory loss that affects daily life: Forgetting important dates; repeat-
edly asking the same questions; relying on reminders or family
members to remember things.
2. Changes in the ability to follow a plan or solve a problem: Difficulty
concentrating on a problem; unable to follow directions; forgetting to
pay monthly bills.
3. Changes in the ability to complete familiar tasks: Difficulty completing
chores at home, running errands, or performing routine tasks at work.
4. Confusion about time or place: Losing track of time; unable to recall
the date or day of the week; forgetting where you are and how you
got there.
5. Problems with vision or understanding visual information: Difficulty
reading, identifying colors, or judging distances.
6. Problems with words: Forgetting words in the middle of a conversa-
tion; repeating parts of a conversation; problems with vocabulary,
such as calling things by the wrong names.
7. Misplacing things: Putting things in unusual places or frequently losing
things; unable to retrace steps to find a lost object
8. Poor judgment: Paying less attention to appearance or cleanliness and
using poor judgment with money.
9. Withdrawal from social activities, work projects, hobbies, or family
gatherings.
l 0. Changes in mood and personality: Confusion, anxiety, depression, or
fear, especially when in new or unfamiliar places.
American Academy of Family Physicians. http:j/familydoctor.org/familydoctorjen/
diseases,:onditions/alzheimers-disease/alzheimers-disease-symptoms.html. Accessed February
15, 2016.
AD is a slowly progressive disease that begins with mild memory
problems and ends with severe brain damage. The course the disease
takes and how fast changes occur varies among individuals, but on
average, patients live for 8 to 10 years after they have been diagnosed.
Currently no treatment can stop the progression of the disease.
However, a great deal of research on the diagnosis and treatment of
AD is under way.
The goal of treatment is to maintain normal activities as long as
possible. Currently no medicines can slow the progression of AD,
Stages of Alzheimer's Disease
Alzheimer's disease (AD) typically progresses slowly in three general
stages. However, each person experiences symptoms and progresses
through Alzheimer's stages differently.
• Stage l (mild AD): Covers the 2 to 4 years leading up to diagnosis.
Memory loss affects the person's job performance, and confusion and
disorientation are common. The patient experiences mood or personal-
ity changes, has difficulty making decisions and paying bills, gets lost
easily, withdraws from others, and loses things.
• Stage 2 (moderate AD): Lasts 2 to 10 years after diagnosis. This stage
involves increased memory loss and confusion, ashorter attention span,
and restlessness. The patient makes constant, repetitive statements;
has problems with reading, writing, and numbers; may be irritable or
suspicious; experiences motor problems; and has difficulty recognizing
close friends and family members.
• Stage 3 (severe AD): Lasts l to 3years. The patient does not recognize
family; experiences weight loss; is unable to care for himself or herself;
is incontinent of bladder and bowel; and requires complete care.
but the U.S. Food and Drug Administration (FDA) has approved
four medications for the treatment of AD symptoms. These drugs
help individuals carry out the activities of daily living by maintaining
thinking, memory, or speaking skills. They can also help with some
of the behavioral and personality changes associated with AD.
However, they will not stop or reverse AD and appear to help indi-
viduals for only a few months to a few years. Cholinesterase inhibi-
tors improve the production of neurotransmitters in the brain, which
helps prevent memory loss from becoming worse for a limited time.
These drugs do not help everyone; as many as 50% of patients show
no improvement in mental function. Memantine (Namenda) was
the first drug to be approved for the treatment of moderate to severe
AD, although it also has limited effects (Table 24-3). Individuals
with AD frequently experience changes in behavior, so medications
may be prescribed to help control sleeplessness, agitation, wander-
ing, anxiety, and depression. Treating these problems helps make the
patient more comfortable while easing the burden on caregivers.
Supportive care for family members is absolutely essential because
they are faced with caring for a loved one who is suffering progressive
memory loss. The medical assistant can be especially helpful in
recommending educational workshops, support groups, and stress
management skills for caregivers. Multiple resources are available,
including online information and support groups, which family
members may find helpful.
CRITICAL THINKING APPLICATION 24-5
Maria Angelone, an 86-year-old patient of Dr. Kennedy, is in the second
stage of AD. Her husband and children are showing signs of stress from the
continuous care Mrs. Angelone requires. Her family still does not understand
what is happening to her and what to expect in the future. What information
can Bill share with them about the disease, and what resources could be
helpful to the family in dealing with the stress of caring for a loved one
with dementia?
 CHAPTER 24 Assisting in Geriatrics 611

TABLE 24-3 Medications Approved for the TABLE 24-4 Age-Related Changes in the
Treatment of Alzheimer's Disease Anatomic Structures of the Eye
STAGE OF COMMON ADVERSE AGE-RELATED
DRUG TREATMENT EFFECTS STRUCTURE CHANGE EFFECTS
Cholinesterase Inhibitors Lens Thickens, becomes Decreased refraction, causing
Donepezil (Aricept) All stages • Appetite loss more opaque blurred vision; decreased color
Galantamine Mild to • Dizziness acuity; cataracts
(Razadyne) moderate • Fatigue Anterior Decrease in size and May develop increased
Rivastigmine (Exelon) All stages • Increased frequency chamber volume intraocular pressure and
tablet, liquid, or topical of bowel movements glaucoma
patch and diarrhea Ciliary muscles Affects pupil Limits light accommodation;
• Insomnia
constriction and dilation night blindness
• Muscle cramps
• Nausea, vomiting Cornea Thickens, curve Problems with refraction
• Weight lass decreases
Receptor Antagonist Retina Decrease in number of Decreased clarity; requires
rods and nerves increase in minimum amount
Memantine (Namenda) Moderate to • Confusion of light needed to see clearly
Prescribed alone or in severe • Constipation
combination with • Diarrhea
donepezil • Dizziness
• Headache
Sensory Organs
Pharmacy Times: Alzheimer's disease: a disease of deterioration. www.pharmacytimes.com/
publications/issue/2014/January2014/Alzheimers-Disease-A-Disease-of-Deterioration. Vision
Accessed February 18, 2015. By the time a person reaches age 50, structural and functional
changes in the eye become noticeable (Table 24-4). The eyebrows
and eyelashes start to gray. The skin around the eyelids wrinkles, and
the loss of orbital fat allows the eye to sink deeper into the orbit.
Pulmonary System The cornea increases in thickness and has reduced refractive power.
Maximum lung function decreases with age. The rate of airflow A yellow-gray ring (arcus senilis) may develop on the periphery of
through the bronchi slowly declines after age 30, and the the cornea. The iris loses pigmentation, and as a result older people
maximum force one is able to achieve on inspiration and expira- appear to have gray eyes.
tion declines. The lungs lose their elasticity because of changes in The lens of the eye continues to grow. As new lens fibers grow,
elastin and collagen. They become smaller and flabbier. The alveoli old lens fibers are compressed and pushed to the center, causing the
enlarge, their walls become thinner, and the number of capillaries lens to become denser. The lens becomes flatter, thicker, less elastic,
is reduced. As a result, the effective area for gas exchange in the and more opaque, progressively yellowing with age. By age 70, the
lungs is reduced. The chest wall may stiffen from osteoporosis lens has tripled in mass. Clouding of the lens causes light rays to
of the ribs and vertebrae and calcification of the costal cartilage. scatter, creating glare.
The respiratory muscles become weaker, making it harder to move The pupil is designed to adjust to control the amount of light
air into and out of the lungs. To compensate, older adults rely entering the eye. The ciliary muscle that causes the pupil to dilate
more on accessory muscles, such as the diaphragm. Weakening of weakens during the aging process. As a result, a reduction in the size
the respiratory muscles and stiffening of the chest wall make it of the pupil occurs, limiting the amount of light available to reach
harder to cough deeply enough to clear mucus from the lungs. the retina. Tear production normally decreases. Tear glands do not
Pulmonary function tests reveal a decrease in vital capacity and an make enough tears, or the tears are of poor quality and do not keep
increase in residual volume. The incidence of sleep apnea and sleep the eyes wet enough. Eye irritation and excessive tearing are a result
disorders increases, causing a potential problem with nocturnal of decreased lacrimation.
hypoxemia. All these factors combine to put the older adult at By the early to mid-40s, presbyopia develops, which makes it
greater risk for pneumonia and aspiration and for reactivation of difficult to focus in detail on objects close at hand. This requires the
tuberculosis. use of corrective lenses to accommodate age-related farsightedness.
The larynx also changes with aging, causing a change in the pitch The ability to refocus quickly from far to near or near to far decreases.
and quality of the voice. The voice sounds quieter and slightly Also, the ability to follow a moving object is decreased. The yellow-
hoarse. The individual's voice may sound weaker, but it should not ing of the lens causes it to act like a filter, making it difficult to
interfere with the ability to communicate effectively. distinguish certain color intensities. Blues, greens, and violets are
612 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES
hard to differentiate, whereas yellows, reds, and oranges are easier to
identify. The loss in the ability to discriminate closely related colors
can affect the older person's ability to judge distances or his or her
depth perception. This increases an aging person's susceptibility to
falls and accidents. Stairs become a potential hazard because the
edges of the steps cannot be seen clearly.
Older people need as much as six times more light to read;
however, increasing the level of light does not completely compen-
sate for visual decline because the elderly also experience an increased
sensitivity to glare. Glare is probably one of the most painful experi-
ences for the aging eye. Exposed light bulbs, such as those used in
chandeliers, and light from highly reflective surfaces, such as glass
tables and floors, can produce excessive glare. The eye has a decreased
ability to respond to abrupt changes from light to dark or dark to
light. Going from a well-lit waiting room into a dim hallway or
negotiating the way down dimly lit aisles in a movie theater could
be treacherous for an older person.
Cataracts, Glaucoma, and Macular Degeneration. Eye diseases
and disorders that occur frequently in older individuals are cataracts,
glaucoma, and macular degeneration. Cataracts are cloudy or opaque
areas in the lens that cause blurring of vision; rings or halos around
lights and objects; and a blue or yellow tint to the visual field. Surgi-
cal lens extraction and implantation with an artificial lens improves
vision in 95% of cases. The procedure, which is performed in an
outpatient facility, involves a small incision to remove the lens, laser
therapy, or phacoemulsification (ultrasonic vibrations), which breaks
up the lens and removes it without the need for an incision. After
the procedure, patients must avoid bending or lifting heavy objects
for 3 to 4 weeks, and wearing an eye shield at night and glasses
during the day helps protect the eye until it heals. Recovery takes
about 2 weeks.
Glaucoma is a result of blockage of the outflow of aqueous
humor, which causes an increase in intraocular pressure and damage
to the optic nerve. If not treated, glaucoma can cause progressive
loss of peripheral vision and ultimately lead to blindness; however,
it can be treated with medication.
The macula is the part of the eye responsible for sharp vision and
color. Damage to or breakdown of the macula is called macular
degeneration, which causes progressive loss of the central field of
vision. Macular degeneration is the leading cause of blindness in
aging people, and at this time there is no effective treatment or cure.
(All three of these eye disorders are discussed in more detail in the
chapter on Assisting in Ophthamology and Otolaryngology).
Suggestions for Helping the Visually Impaired
Older Adult
• When escorting an older person, regardless of whether he or she is
visually impaired, allow the patient to place his or her hand above your
elbow. It is easier for the person to follow your movements. This
method also provides a source of support and security.
• Use high levels of evenly distributed, glare-free light.
• Ask the pharmacist to use large lettering when labeling medicine
bottles.
• Use paper that has a nonglare finish and large print for forms and
educational materials.
• Make distinct differences (e.g., size of containers or color coding with
bright primary colors) for pills that are similar in size and color.
• Place all objects within the visual field and prevent clutter.
Hearing
Hearing loss can have a profound psychological effect on aging
people, causing depression, social withdrawal, and feelings of isola-
tion. Hearing loss occurs gradually over a long period and may go
undetected by the older person and healthcare providers. Lack of
attention when addressed, inappropriate responses, asking to have
statements repeated, and speaking too loudly or too softly often are
signs of hearing loss. Changes in auditory ability begin around age
30; by age 65, one out of three people has a hearing loss, and the
number increases to 65% of those over age 80. Age-related hearing
loss usually is caused by a dysfunction or loss of cochlear cilia, result-
ing in an inability to hear high-frequency sounds and difficulty
understanding speech. Hearing impairment is compounded by
impacted cerumen, otitis media, otosclerosis, Meniere's disease,
long-term exposure to intense noise, and certain ototoxic drugs,
such as aspirin.
Presbycusis is associated with normal aging and causes a
decreased ability to hear high frequencies and to discriminate
sounds. Parts of a conversation may be missed because the sound of
the word goes above the 2,000-cycle frequency. Often words that
sound similar are difficult to differentiate. Consonants such as g, f,
s, sh, t, and z produce high-pitched sounds that are more difficult to
hear and differentiate. Low-frequency pitched sounds, such as the
vowels a, e, i, o, and u, may be more easily heard by people with
presbycusis. Inability to hear different frequencies combined with
low background noise from groups of people talking, noise from
appliances, or busy public places compromises an older person's
ability to hear clearly. Hearing aids, which can be used to amplify
speech, may increase background noises, resulting in sensory
overload.
Another hearing disorder common among older people is tin-
nitus, a ringing or buzzing in the ear. It can be caused by impacted
cerumen, an ear infection, use of antibiotics, a reaction to a medica-
tion, or a nerve disorder. Tinnitus can cause difficulty understanding
conversational speech and can make sleeping difficult because of the
continuous sensation of ringing in the ears.
Hearing loss, with its resultant isolation, is directly related to the
development of depression in older adults. Treatable depression
often is overlooked in elderly people because of coexisting physical
illnesses that mask the symptoms of depression. The medical assis-
tant may be able to contribute to information about depression in
elderly patients through conversations with the individual and
family members. The provider may use or may train the medical
assistant to use the Geriatric Depression Scale Short Form, which
includes questions for the patient about daily activities, interests, and
feelings to help diagnose depression in the ambulatory setting
(Figure 24-3).

GERIATRIC DEPRESSION SCALE
(SHORT FORM)
Choose the best answer for how you have felt over
the past week:
1. Are you basically satisfied with your life?
YES/NO
2. Have you dropped many of your activities and
interests? YES / NO
3. Do you feel that your life is empty? YES/ NO
4. Do you often get bored? YES / NO
5. Are you in good spirits most of the time?
YES/NO
6. Are you afraid that something bad is going to
happen to you? YES / NO
7. Do you feel happy most of the time? YES/ NO
8. Do you often feel helpless? YES/ NO
9. Do you prefer to stay at home, rather than
going out and doing new things? YES / NO
10. Do you feel you have more problems with
memory than most? YES / NO
11. Do you think it is wonderful to be alive now?
YES/NO
12. Do you feel pretty worthless the way you are
now? YES/NO
13. Do you feel full of energy? YES/ NO
14. Do you feel that your situation is hopeless?
YES /NO
15. Do you think that most people are better off
than you are? YES / NO
Answers in bold indicate depression. Although
differing sensitivities and specificities have been
obtained across studies. for clinical purposes a
score > 5 points is suggestive of depression and
should warrant a follow-up interview. Scores > to
almost always indicate depression.
FIGURE 24-3 Geriatric Depression Scale.
Suggestions for Helping the Hearing-Impaired
Older Adult
• Stand in the patient's direct line of vision and gently touch the person
to get his or her attention.
• Use gestures, pictures, and large, bold print to communicate.
• Talk in short sentences into the ear with better hearing.
• Do not increase the volume of your speech; this also raises the fre-
quency of the voice, which is the hearing most impaired in aging
people. Use expanded speech; lower the tone of your voice and talk
in distinct syllables.
• Avoid background noise. Give instructions in a quiet room with the door
closed. If the patient has a hearing aid, make sure it is on.
Taste and Smell
During the aging process the abilities to taste and smell decline
subtly. Deterioration and atrophy of the taste buds are part of the
aging process. The ability to taste salt and sweet flavors is reduced,
whereas the ability to detect bitter and sour flavors remains relatively
the same. As a result, food frequently tastes bland and unappetizing.
CHAPTER 24 Assisting in Geriatrics 613
Patients on salt-restricted diets and patients with diabetes must be
cautioned about the use of excessive amounts of salt and sugar. A
decrease in the sense of smell accompanies the decrease in taste. Not
only does this affect the individual's enjoyment of food; it also
exposes the person to environmental dangers, such as gas leaks,
smoke, and other dangerous odors that may go undetected. Check-
ing for gas leaks around stoves and heaters and using smoke alarms
reduce some of the danger. Also, dating food when it is put in the
refrigerator is a good idea.
Nutritional Status. Because of the many environmental, social, eco-
nomic, and physical changes of aging, older people are at greater risk
for poor nutrition, which can adversely affect their health and energy
level. It is estimated that 25% of the aging population suffers from
malnutrition. Nutrition screening should be part of routine primary
care to identify nutritional deficiencies and correct them before
a disease process develops or to assist in the treatment of chronic
disease. Patients with chronic conditions, such as cardiovascular
disease, hypertension, and diabetes, can benefit from nutrition
assessments and interventions. Malnourished older patients get more
infections; their injuries take longer to heal; surgery is riskier for
them; and their hospital stays are longer and more expensive.
The most effective method of assessing a patient's nutritional
status is through a comprehensive patient interview that considers
all potential stumbling blocks to adequate nutrition. The medical
assistant can help determine the nutritional status of older patients
by considering the following factors when conducting patient
interviews:
• Oral health: Does the patient wear dentures and if so, do they
fit properly? Does the patient have mouth pain? Can he or
she swallow without difficulty?
• Gastrointestinal complaints: Does the patient have anorexia,
nausea, vomiting, diarrhea, or constipation? Is the patient
lactose intolerant (the incidence increases with age)?
• Sensorimotor changes: Does the patient have loss of vision or
hearing or changes in taste and smell? Can the patient feed
herself or himself? Does the patient need adaptive utensils?
• Diet influences: Can the patient afford, shop for, and prepare
food? Are ethnic or religious influences a factor? Does the
patient have any disease-related diet restrictions? What is the
patient's alcohol consumption?
• Social and mental influences: Is the patient depressed, lonely,
or isolated? Are support systems available?
CRITICAL THINKING APPLICATION 24-6
Multiple sensory changes occur as people age. Dr. Kennedy asks Bill to
develop a handout for patients and family members to help them under-
stand these normal, age-related sensorimotor changes and also adaptations
that can improve communication. What information should Bill include?
Urinary System
As the body ages, structural changes in the kidneys cause the urinary
system to become less efficient. Between the ages of 40 and 80, the
kidney loses about 20% of its mass. The number of functional
nephron units decreases. Blood flow to the kidneys is reduced
614 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES
because of a decrease in cardiovascular efficiency. Because of the
reduction of blood flow to the kidneys and the decreased number
of nephrons, the kidneys become less efficient at filtering waste from
the blood. This results in a more diluted, less concentrated urine.
The kidneys require more water to excrete the same amount of waste.
Medication takes longer to be removed from the body. Older adults
are at increased risk for toxic levels of medication in the bloodstream
because of this reduced filtration rate.
Fibrous connective tissue replaces the smooth muscle and elastic
tissue in the bladder. This thickening of the bladder wall reduces the
bladder's ability to expand. The bladder's capacity to store fluid
comfortably is reduced from 400 to 250 mL. These structural
changes lead to increased frequency of urination and urinary reten-
tion. Older adults are at increased risk of urinary tract infections
because of residual urine. Sleep is interrupted by the need to void
during the night. The sensation of bladder fullness is not recognized
as quickly by the older brain. Reduced time between awareness of
the need to void and involuntary urination can cause anxiety. Often
older adults reduce their fluid intake to prevent possible embarrass-
ment. Unfortunately, this causes dehydration and an increased risk
of urinary tract infections. Another change is loss of muscle tone in
the urethra. In addition, the pelvic floor muscles in an aging woman
relax as a result of decreased estrogen levels or previous pregnancy
and childbirth.
Despite these changes, the kidneys have great reserve capacity and
are able to continue functioning normally. Urinary incontinence, the
involuntary loss of urine, is a significant problem for aging patients
but is not a normal part of the aging process. Changes in the urinary
system make older people more vulnerable to incontinence, but
factors such as infection, confusion, difficulty with mobility, and side
effects of medications contribute to the development of the problem.
Incontinence is both an emotional and a physical problem. To avoid
the risk of an embarrassing accident, people with this problem may
avoid social occasions or activities they enjoy. Often people are too
embarrassed to admit they have this condition, or they believe it is
just part of aging. Once the condition has been diagnosed by a
urologist, pelvic floor muscle exercises, medication, or surgery may
be recommended.
Reproductive System
Aging brings a decrease in circulating levels of the female hormones
estrogen and progesterone, whereas androgen levels increase. The
results of this decrease are changes in the genital tract. The vagina
diminishes in width and length and becomes less elastic. The cervix,
uterus, and ovaries decrease in size. Vaginal secretions decline; there-
fore, lubrication diminishes, resulting in vaginal dryness. Bacterial
or yeast infections may occur because vaginal secretions are less
acidic. Estrogen cream applied to vaginal tissue may be prescribed
by the provider for help with dryness and thinning of the vaginal
tissue. The patient should discuss the benefits and risks of estrogen
replacement therapy with the provider to determine whether it
should be used.
Even though sperm production may decline in men over age 50,
men remain virile well into old age. However, they experience a
change in hormonal levels of testosterone, and these changes can
affect the prostate gland. The prostate enlarges over time and presses
down on the urethra, causing difficulty with urination. Surgery may
be required to remove excess portions of the gland. Unfortunately,
the operation may cause impotence, which can be treated medically
with erectile dysfunction medications.
Men experience some changes in sexual functioning as they age.
It takes longer for the penis to become erect, longer for an orgasm
to occur, and longer to recover. Direct stimulation may be required
before an erection occurs, and when it does, it may be less firm than
in younger years.
Some drugs and illnesses can interfere with sexual function.
Drugs used to control high blood pressure, antihistamines, antide-
pressants, and some stomach acid blockers, in addition to the dis-
eases diabetes, arthritis, and arteriosclerosis, can have an adverse
effect on sexual function. Often people who have had heart surgery
or a heart attack are concerned about sexual activity. Patients need
to feel comfortable and should not be embarrassed to discuss their
concerns openly with their provider. It is important for healthcare
practitioners to dismiss the myth that older patients have lost the
desire for and interest in sexual intercourse.
Sleep Disorders
Complaints of sleeping difficulties increase with age. The amount of
time spent sleeping may be slightly longer than in a younger person,
but the quality of sleep declines. Older people often are light sleepers
and have periods of wakefulness in bed. Rapid eye movement (REM)
sleep is the stage of sleep when people experience dreaming.
Non-REM sleep is the period of deepest sleep. The amount of time
spent in the deepest stages of sleep decreases with age. Sleep that is
disturbed or that leaves the person feeling tired is not part of the
aging process and may indicate some underlying emotional or physi-
cal problem. Lack of sleep can result in restlessness, disorientation,
"thick'' speech, and mispronounced words. Often these symptoms
are mistaken as signs of dementia. Other factors that might influence
sleep patterns are medications, caffeine, alcohol, depression, and
environmental or physical changes.
Common sleep problems in older adults include dyssomnias,
such as periodic limb movement disorder (PLMD), in which peri-
odic jerking of the legs occurs during sleep, and sleep apnea, which
is common among overweight individuals and can occur frequently
during the night, interrupting sleep. Numerous medical conditions
can interfere with sleep, including joint and bone pain; Parkinson's
disease (because of difficulty changing positions); CHF; chronic
obstructive pulmonary disease; diabetes mellitus, which increases
nocturia; depression; and certain medications (e.g., beta blockers
can cause nightmares, antidepressants increase PLMD, and barbitu-
rates may result in nightmares or hallucinations).
It is important to be aware of the effect of sleep problems because
often these can be confused with dementia. Patients who are expe-
riencing difficulty with sleeping should be encouraged to document
their sleeping patterns, napping patterns, medications, diet, exercise
routines, and any events that have resulted in a change of lifestyle.
They should discuss this problem with their provider. Simple modi-
fication of behavioral patterns may resolve the problem. Taking fewer
naps, completing exercise several hours before bedtime, changing
eating times, reducing the amount of alcohol and caffeine ingested,
drinking a glass of milk before bedtime, or changing medications or
the time they are taken all are suggestions that might alter the factors
responsible for sleep disturbances.

If behavioral approaches are not effective, medications may be
considered for short-term use only, because they have a high inci-
dence of physical and psychological dependence. Elderly people are
especially susceptible to side effects from these drugs, such as next-
day drowsiness and temporary memory loss. Sedatives or hypnotics
that may be prescribed include zolpidem (Ambien), eszopiclone
(Lunesta), zaleplon (Sonata), and ramelteon (Rozerem).
Living Arrangements
At any given time, only 5% of the elderly population lives in long-
term care facilities. According to information published by the
National Institute on Aging, older people live close to their children
and are in frequent contact with them. People prefer to age in place;
that is, they want to live in their own home environment as long as
possible. Individuals are admitted to nursing homes because they are
no longer able to perform activities of daily living, such as bathing,
dressing, eating, walking, and maintaining bladder and bowel con-
tinence. They also have difficulty with grocery shopping, housekeep-
ing, and money management. Chronic health conditions and
accidents interfere with the older person's ability to perform these
tasks.
Many resources are available to help seniors maintain their inde-
pendence. Outreach programs, such as Meals on Wheels, deliver
nutritious meals to the homes of older adults. Senior centers serve
as a focal point for many activities and as a source of information.
Transportation services provide rides to doctors' appointments, day
care centers, shopping centers, and community events. Home health
agencies provide several types of services, including personal care,
shopping, transportation, and meal preparation. Some home health
agencies provide a range of activities, from patient education to IV
therapy; medical-social services; physical, speech, and occupational
therapies; and nutrition and dietary counseling. Advanced technol-
ogy allows people to receive services at home that formerly were
provided only at a hospital or a physician's office.
Adult day care centers provide socialization, recreation, meals
and, in some centers, physical therapy, occupational therapy, and
transportation. These centers offer supervision for older adults who
may be taken care of by family members in the evening but need
care during the day. They also serve as respite for a caregiver.
Assisted-living facilities can be retirement homes or board and
care homes. These facilities are appropriate for older adults who need
assistance with some activities of daily living, such as bathing, dress-
ing, and walking. Skilled nursing facilities provide 24-hour medical
care and supervision. In addition to medical care, residents receive
care that may include physical, occupational, and speech therapies.
The objective of treatment is to improve or maintain the person's
abilities.
THE MEDICAL ASSISTANT'S ROLE IN CARING FOR
THE OLDER PATIENT
Elderly patients in the ambulatory care setting present a specific set
of needs that require a certain amount of accommodation by the
staff. For example, aging patients typically require more time to
perform tasks and have questions answered. The office staff may
want to hurry them so that the day's schedule can be maintained.
In the best interests of the patient, however, he or she should be
CHAPTER 24 Assisting in Geriatrics 615
treated with respect and given whatever time is needed to prepare
for examinations, ask questions and receive answers, and have pro-
cedures explained. A system that is sensitive to the needs of older
patients schedules longer periods for appointments; has adequate
lighting in the waiting room; provides forms in large print; has
an examination room equipped with furniture, magazines, and
treatment folders especially designed for older adults; and invites a
professional in the management of older patients for in-service
training.
The primary issue in elder care is effective communication. How
you communicate with people is often influenced by what you know
or do not know about them. Older people are subject to many
changes that affect how they are able to interact with their environ-
ment. It is important to recognize these changes and to investigate
one's personal perception of older people to break down the barriers
that prohibit effective communication.
As people age, they frequently experience a loss of control over
their lives because of physical disabilities, economic constraints, and
institutional living. Part of the medical assistant's job is to help aging
people maintain their dignity and independence while in the ambu-
latory care setting. Remember, each patient, regardless of his or her
education, socioeconomic status, or age, deserves to be treated with
compassion and respect. Ask the patient directly what is wrong
rather than discussing the patient with family members. It also is
important to listen carefully and to be specific and sincere when
responding. When a patient is talking, take time to allow him or her
to complete the sentence; do not finish it for the person. Give the
patient your full attention rather than continuing with other tasks
while he or she is speaking. Older people may take a little longer to
process information, but they are capable of understanding. Do not
hurry through explanations or questions; rather, take time to review
a form or give instructions as needed.
Suggestions for Effective Communication With
Aging Patients
• Address the patient as Mr., Mrs., or Miss unless the patient has given
you permission to use his or her first name.
• Introduce yourself and explain the purpose of a procedure before per-
forming the procedure.
• Face the aging person and softly touch the individual to get his or her
attention before beginning to speak.
• Use expanded speech, gestures, demonstrations, or written instructions
in black print.
• If the message must be repeated, paraphrase or find other wards ta
say the same thing.
• Observe the patient's nonverbal behavior for cues indicating whether
he or she understands.
• Provide adequate lighting without glare.
• Allow patients time ta process information and take care of themselves
unless they ask for assistance.
• Conduct communication in a quiet room without distractions.
• Involve family members as needed for continuity of care.
616 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES
• When leaving a telephone message, remember to speak slowly and
clearly and repeat the message in the same manner. It is difficult to
interpret a message, and even more difficult to write it down, if the
message was delivered in a hurried manner.
• Use referrals and community resources for support, such as the
following:
• Alzheimer's Association: www.alz.org/ (l-800-272-3900).
• American Council of the Blind: http://acb.org/ (l-800-424-
8666): Provides referrals to state and other organizations that
provide services and equipment for the blind.
• American Speech-Language-Hearing Association: www.asha.org/
(l-800-638-8255): Offers information on hearing aids, hearing
loss, and communication problems in older people and provides a
list of certified audiologists and speech pathologists.
• Arthritis Foundation Information Line: www.arthritis.org (404-872-
7100): Makes referrals to local chapters and provides information
on various types of arthritis.
• American Diabetes Association: www.diabetes.org/ (l-800-34 2-
2383): Provides information and support for those with diabetes.
• Eldercare Locator: www.eldercare.gov/Eldercare.NEVPublic/lndex
.aspx (l-800-677-1116): Run by the National Association of Area
Agencies on Aging; help line provides information on contacting
local chapters that oversee services to older adults.
• National Institute on Aging Information Center: www.nia.nih.gov/
(l-800-222- 2225): Provides information on aging health issues
for patients, families, and healthcare professionals.
• National Meals-on-Wheels Foundation: www.mowaa.org/
(l-888-998-6325).
• National Hospice and Palliative Care Organization: www.nhpco.org/
(703-837-1500): Anonprofit organization committed to improving
end of life care and expanding access to hospice care.
CRITICAL THINKING APPLICATION 24-7
New staff members in the practice are complaining of having to repeat
information to older patients, who they say do not pay attention when
procedures are explained. Dr. Kennedy has decided to invite a gerontologist
from the local university to present an in-service workshop on healthy aging.
She asks Bill to coordinate the in-service workshop and prepare materials
requested by the guest speaker. What information about caring for the
ambulatory aging patient should be included in the workshop?
CLOSING COMMENTS
Patient Education
The medical assistant must keep the sensorimotor changes that
accompany aging and also respectful patient communication in
mind when conducting patient education with older patients.
Remember, the aging process does not affect a person's ability to
learn; it just may take longer to process the information, and the
material may need to be repeated for understanding. Showing
sensitivity to the needs of aging learners ensures successful patient
education and improves compliance with prescribed treatment
plans. The current aging population generally is respectful toward
authority; therefore, if the medical assistant cannot gain the patient's
cooperation, the physician may be able to provide authoritative
reinforcement of material. General guidelines for effective patient
education with older adults include the following:
• The patient may have short-term memory loss, so you may
need to repeat the information using different words.
• The patient may be distracted more easily, so learning in a
group may be difficult.
• The patient may take longer to process information, so teach
at a pace that matches the patient's needs.
• Provide the patient with handouts that have large print and
block letters for reviewing information at home.
• Involve family members as needed for continuity of care;
provide physician-approved websites for reference.
Legal and Ethical Issues
All patients have the right to know about the medications, treat-
ments, and alternatives available to them. The Patients' Bill of Rights
informs the patient of those rights in a healthcare setting. They
include the right to privacy about personal and medical information
and the right to informed consent, which holds the provider account-
able for explaining clearly the advantages and risks of any procedures,
tests, or treatments. The patient must give permission for medical
care and has the right to refuse treatment. The patient has the right
to be informed about his or her condition and treatment and the
chances of recovery. The patient also has the right to have advance
directives explained to him or her.
Consent must be given by the individual undergoing the proce-
dure, as long as he or she is judged to be competent; that is, as long
as the patient is able to understand the consequences of the proce-
dure. In an emergency situation or if a court has ruled that the
patient is incompetent, someone else must give consent. This may
be a person who already was designated to hold the durable power
of attorney, a close family member (spouse, adult child, parent,
sibling), or a court-appointed guardian.
Most states have legal documents available that provide written
instructions specifying the type of medical care a person wants in
the event she or he becomes incapacitated; these are called living
wills or advanced directives. The document designates a person who
has a durable power of attorney; this is an authorization for making
medical decisions on an individual's behalf if he or she is unable to
make treatment decisions. The document provides a list of specific
instructions for the proxy to follow.
Various issues may be covered in these documents. A "do not
resuscitate" (DNR) order allows a patient to refuse attempts to
restore a heartbeat. The patient also may decide to withdraw life-
sustaining treatment, such as respirators or feeding tubes. A copy of
the directive should be kept on file as part of the patient's health
record. It is important to check the laws of the state in which you
practice with regard to advanced directives, because they vary from
state to state (Figure 24-4).
Another legal issue in the care of aging patients is the possibil-
ity of elder abuse, neglect, and exploitation. Mistreatment of aging
people occurs at all social, racial, and economic levels. The abuse
 CHAPTER 24 Assisting in Geriatrics 617

Directive made this ___ th day of _ _ _ _ _ _ _ in the year _ __

(day) (month) (year)

I, _ _ _ _ _ _ _ _ _ _ _ _ _ , being of sound mind, willfully and voluntarily

make known my desire that my life shall not be artificially prolonged under the circumstances set
forth in this directive.

If at any time I should have

- an incurable or irreversible condition caused by injury,
-disease,
- or illness certified to be a terminal condition by two physicians

and if the application of life-sustaining procedures would serve only to artificially postpone the
moment of my death, and if my attending physician determines that my death is imminent or will
result within a relatively short time without the application of life-sustaining procedures. I direct that
those procedures be withheld or withdrawn, and that I be permitted to die naturally.

In the absence of my ability to give directions regarding the use of those life-sustaining procedures,
it is my intention that this directive be honored by my family and physicians as the final expression
of my legal right to refuse medical or surgical treatment and accept the consequences from that
refusal.

If I have been diagnosed as pregnant and that diagnosis is known to my physician, this directive has
no effect during my pregnancy. This directive is in effect until it is revoked.

I understand the full import of this directive and I am emotionally and mentally competent to make
this directive. I understand that I may revoke this directive at any time.

I request that only comfort care be provided to me, no antibiotics, no artificial nutrition, no
mechanical ventilation, and no hydration. It is my strong preference to be allowed to die outside of a
care facility if possible, even if that preference is determined by my physician to shorten my period of
dying. The only condition under which I desire these preferences for end of life care to be altered is
in the case of possible organ and tissue donation. I request that any and all organs and tissue that
may be salvaged be provided for transplant. My remains may then be cremated.

Signed _________ in the City of _______ etc.

I am not a person designated by the declarant to make a treatment decision. I am not related to the
declarant by blood or marriage. I would not be entitled to any portion of the declarant's estate on the
declarant's death. I am not the attending physician of the declarant or an employee of the attending
physician.

I have no claim in against any portion of the declarant's estate on the declarant's death. Furthermore,
if I am an employee of the health care facility in which the declarant is a patient, I am not involved in
providing direct patient care to the declarant and am not an officer, director, partner, or business
office employee of the heath care facility or of any parent organization of the health care facility.

Witness _ _ _ _ _ _ __

Witness _ _ _ _ _ _ __

FIGURE 24-4 Sample advanced directive.

may be physical, mental, sexual, material, or financial; it may
involve neglect or failure to provide adequate care, or it may
involve self-neglect when aging people are unable or refuse to care
for themselves. Abuse, neglect, and exploitation of elders by their
caregivers may be difficult to identify. The aging victim could
feel embarrassed, guilty, or afraid to report the abuse. Indications
that a patient may be a victim of elder abuse, neglect, or exploita-
tion are:
• Poor general appearance and poor hygiene
• Pattern of changing doctors and frequent emergency depart-
ment visits
• Skin lesions, signs of dehydration, bruises (signs of new and
old bruising together), abrasions, welts, burns, or pressure sores
• Recurrent injuries caused by accidents
• Signs of malnutrition and weight loss without related illness
• Any injury that does not fit the given history
If abuse, neglect, or exploitation is suspected, interviewing the
caregiver and questioning the demands of care and self-reported
perceptions of stress levels may help the provider detect the problem.
Many states now have laws that require reporting of suspected elder
abuse, neglect, or exploitation. Check your state laws to determine
the requirements for healthcare workers.
 618 UNIT THREE ASSISTING WITH MEDICAL SPECIALTIES

Professional Behaviors
Your future employers will expect you to use problem-solving techniques,
including recognizing and defining a problem, analyzing the issue, and
developing a plan of action. Elderly patients typically have multiple health
problems that are frequently complicated by physical, psychological, and
environmental factors. To provide quality care for these individuals, you
must look at their health issues in a holistic way, taking into consideration
all the factors that affect their eventual ability to follow treatment plans
and improve their health status. Part of the process involves identifying
resources that might help the aging person be better equipped to take care
of himself or herself. Consistently using community and online resources
may mean the difference between an aging person being able to stay in
her home or having to go to long-term care. The professional medical
assistant can play a crucial role in providing assistance to aging clients.

Jiiiiit-i:fi•jiii#it-i#t•i
Through his work with Dr. Kennedy, Bill has learned to understand the special
needs of aging patients. He used to think that most older people were chroni-
cally sick and would ultimately end up in long-term care facilities. Now he
understands that most aging people lead healthy, active lives and that the
disorders that occur in later life usually are the result of lifestyle factors, such
as diet and lack of exercise. Bill also has learned how to communicate effectively
with older patients and to conduct patient interviews so as to evaluate the
patient's physical, mental, emotional, and nutritional health.

SUMMARY OF LEARNING OBJECTIVES

l. Define, spell, and pronounce the terms listed in the vocabulary.
Spelling and pronouncing medical terms correctly reinforce the medical
assistant's credibility. Knowing the definitions of these terms promotes
confidence in communication with patients and co-workers.
2. Do the following related to the aging process:
• Discuss the impact of agrowing aging population on society.
More than 48 million Americans are 65 years of age or older. By 2030
almost l of every 5 Americans (about 72 million people) will be 65
years or older. Most older people have at least one chronic medical
condition, and many have multiple conditions. The aging population
will affect all aspects of society.
• Identify the stereotypes and myths associated with aging.
Stereotypes and myths associated with aging include the likelihood of
developing dementia, aging and disease development, productivity of
older workers, long-term care, sexual activity, and significance of life-
style factors. To avoid age discrimination and lack of respectful care,
the medical assistant should be educated about the realities of aging
and the elderly population.
• Role-play the effect of the sensorimotor changes of aging.
Procedure 24-1 ourlines the steps in role-playing the sensorimotor
changes that accompany aging.
3. Do the following related to the cardiovascular, endocrine, gastroin-
testinal, integumentary, and musculoskeletal body systems:
• Explain the changes in the anatomy and physiology caused by aging.
Table 24-1 summarizes changes associated with aging that occur across
all body systems. Normal age-related changes are expected, and the
individual can compensate for them. However, these changes intensify
with poor health habits and chronic disease. Age-related changes can
be managed through regular exercise, a healthy diet, prevention of sun
damage, and annual physical examinations with health screening.
• Summarize the maior related diseases and disorders faced by older
patients.
Major health issues of older people are related to an increase in ath-
erosclerosis and potential cardiovascular disease; hypertension; diabetes
mellitus type 2; integumentary system changes; arthritis; osteoporosis;
and an increased risk of injury from falls.
4. Do the following related to the nervous system, pulmonary system,
sensory organs, urinary system, and reproductive system:
• Explain the changes in the anatomy and physiology caused by aging.
Cognitive ability is influenced by many factors, including the aging
process. Maximum lung capacity also decreases with age. By the age
of 50, structural and functional changes in the eye become noticeable.

SUMMARY OF LEARNING OBJECTIVES-continued
Hearing loss occurs gradually over a long period and can go undetected.
The ability to taste and smell declines subtty as a person ages. As a
person ages, structural changes in the kidneys cause the urinary system
to become less efficient. Finally, aging brings a decrease in circulating
levels of the female hormones estrogen and progesterone and an
increase of androgen.
• Summarize the major related diseases and disorders faced by older
patients.
Alzheimer's disease is a progressive deterioration of the brain caused
by the destruction of CNS neurons; it develops in three stages. Various
structures of the eye are affected by aging. Presbycusis, which is associ-
ated with normal aging, diminishes the older person's ability to hear
high frequencies and to discriminate sounds.
• Describe various screening tools for dementia, depression, and malnutrf
tion in aging adults.
Acommonly used screening tool for dementia is the Folstein Mini-
Mental State Examination, a 5-minute screening test that is designed
to evaluate basic mental function. The provider may use the Geriatric
Depression Scale short form, which questions the patient about daily
activities, interests, and feelings. Nutritional status can be assessed
through a comprehensive patient interview that considers all potential
problems preventing adequate nutrition.
5. Explain the effect of aging on sleep.
Complaints of sleeping difficulties increase with age. The amount of time
spent in the deepest stages of sleep declines with age. Factors that might
influence sleep patterns are medications, caffeine, alcohol, depression, and
environmental or physical changes. Common sleep problems in older adults
include PLMD and sleep apnea.
6. Differentiate among independent, assisted, and skilled nursing
facilities.
Aging people prefer to remain in their home environment for as long as
possible. Adult day care centers can provide supervision for older adults
CONNECTIONS
OJ Study Guide Connection: Go to the Chapter 24 Study Guide. Read and complete
the activities.
CHAPTER 24 Assisting in Geriatrics 619
who may be taken care of by family members in the evening but need
care during the day. Assisted-living facilities are appropriate for older adults
who need assistance with some activities of daily living. Skilled nursing
facilities provide 24-hour medical care and supervision.
7. Summarize the role of the medical assistant in caring for aging
patients.
The medical assistant's role in caring for the older patient is to develop
effective communication skills that accommodate age-related sensorimotor
changes; to allow time for longer appointments; to provide adequate
lighting and forms in large print, and to develop appropriate in-service
training as requested by the provider. Examination rooms should have
furniture and treatment folders especially designed for the elderly patient.
Referrals and community resources should be used for patient and family
support.
8. Determine the principles of effective communication with older adults.
Effective communication with aging patients includes addressing the
patient with an appropriate titte; introducing yourself and explaining the
purpose of a procedure before touching the patient; establishing eye
contact and getting the patient's attention before beginning to speak; using
expanded speech, gestures, demonstrations, or written instructions in block
print; repeating the message as needed for understanding; observing the
patient's nonverbal behaviors for cues that indicate whether he or she
understands; allowing time to process information; preventing distractions;
and involving family members as needed.
9. Discuss patient education, as well as legal and ethical issues, associ-
ated with aging patients.
Legal and ethical issues associated with aging patients include adequate
informed consent, the use of advanced directives, and staying alert for
signs of possible elder abuse.
evolve Evolve Connection: Go to the Chapter 24 link at evolve.elsevier.com/
kinn to complete the Chapter Review Quiz. Check out the other resources listed for this
chapter to make the most of what you have learned from Assisting in Geriatrics.
 PRINCIPLES OF
25 ELECTROCARDIOGRAPHY
Martha Reyes has worked for almost 4 years at a local family practice office,
but she has decided to take a new position in the cardiology practice next door,
where she will be working for Dr. Julie Lee. Martha is very enthusiastic about
the new position, but she realizes that she has a great deal to learn to provide
While studying this chapter, think about the following questions:
• To fulfill her job description with Dr. Lee, what does Martha need to know
about the electrical conduction system of the heart?
• How does an electrocardiography machine work?
• How should a patient be prepared for an electrocardiogram?
• How will Martha perform an ECG diagnostic procedure?
LEARNING OBJECTIVES
1. Define, spell, and pronounce the terms listed in the vocabulary.
2. Illustrate the electrical conduction system through the heart and discuss
the cardiac cycle.
3. Explain the concepts of cardiac polarization, depolarization, and
repolarization.
4. Identify the PQRST complex on an electrocardiographic tracing.
5. Summarize the properties of the electrocardiograph and discuss the
features of electrocardiograph paper.
6. Describe the electrical views of the heart recorded by the l 2~ead
electrocardiograph.
VOCABULARY
atria The two upper chambers of the heart.
atrioventricular (AV) node The part of the cardiac conduction
system between the atria and the ventricles.
bundle of His Specialized muscle fibers that conduct electrical
impulses from the AV node to the ventricular myocardium.
cardiac arrest A condition in which cardiac contractions stop
completely.
cardioversion The use of electroshock to convert an abnormal
cardiac rhythm to a normal one.
defibrillator A machine that delivers an electroshock to the heart
through electrodes placed on the chest wall.
diastole The period of relaxation of the chambers of the heart,
during which blood enters the heart from the vascular system
and the lungs.
ectopic (ek-toh'-pik) Originating outside the normal tissue.
• I
the best patient service possible in Dr. Lee's practice. Although Martha is familiar
with general cardiology practices from her previous employment, she must
understand and be able to perform procedures specific for cardiac patients,
especially electrocardiography.
• What is the normal appearance of ECG complexes?
• What are the characteristics of common ECG arrhythmias that Martha
must be able to recognize?
• What additional cardiac tests should Martha be prepared to assist with
and explain to patients?
7. Discuss the process of recording an electrocardiogram and perform an
accurate reading of the electrical activity of the heart.
8. Compare and contrast electrocardiographic artifacts and the probable
cause of each.
9. Interpret a typical electrocardiograph tracing.
l 0. Describe common electrocardiographic arrhythmias.
11. Summarize cardiac diagnostic tests and fit a patient with a Holter
monitor.
12. Discuss patient education and the legal and ethical issues involved
when performing ECGs.
infarction An area of tissue that has died from lack of blood supply.
ischemia (is-ke' -me-ah) Decreased blood flow to a body part or
organ, caused by constriction or blockage of the supplying artery.
leads Electrical connections attached to the body to record
electrical heart activity; any of the conductors connected to the
electrocardiograph, each comprising two or more electrodes that
are attached at specific body sites and used to examine and
record the electrical activity of the heart.
myocardial (mi-oh-kar'-de-uhl) Pertaining to the heart muscle.
palpitations Pounding or racing of the heart; it may or may not
indicate a serious heart disorder.
sinoatrial (SA) node The pacemaker of the heart, located in the
right atrium.
systole The period of contraction of the heart.
ventricles The two lower chambers of the heart.

E lectrocardiography is the test most frequently used to diagnose
heart disease in ambulatory care practices. It is a painless, safe
procedure. In electrocardiography, electrodes are attached to the
patient's skin and connected to wires that go to the electrocardio-
graph. Electrocardiography amplifies the electrical impulses from the
beating heart, and a pattern of these impulses is recorded on elec-
trocardiographic paper. This record is called the electrocardiogram
(ECG). The ECG is read and evaluated by the practitioner and
becomes a part of the patient's health record (Figure 25-1 ). Medical
practices using electronic health records can record an ECG tracing
directly into the patient's electronic record.
To accurately represent the true cardiac activity, the ECG must
be performed with a high degree of accuracy and skill. A medical
assistant must have an understanding of both the normal cardiac
function and the relationship of the ECG recordings to cardiac func-
tion. The medical assistant is responsible for ensuring that the patient
is prepared mentally and physically for the test and that the equip-
ment is set up properly. When performing electrocardiography, the
medical assistant must be able to recognize problems with the
recording and make appropriate corrections so that the provider has
a clear record of the patient's cardiac activity. The goal is to obtain
the most accurate ECG possible.
History of Electrocardiography
Dutch physiologist Willem Einthoven developed techniques to record the
electrical activity of the heart in the late 1800s. He called this recording
an Electro Kardio Gramm; hence the acronym EKG. Many physicians and
other healthcare providers still call the recording an EKG, although the
newer, preferred term for an electrocardiogram is ECG.
Vent. rate
Female Caucasian PR interval
Room: QRS duration
Loe: QT/QTc
P-R-T axes
FIGURE 25-1 Example of a 12-lead ECG. (Phalen T, Aehlert BJ: The 12-/ead ECG in acute coronary syndromes, ed 3, St Louis, 2012, Mosby.)
CHAPTER 25 Principles of Electrocardiography 621
THE ELECTRICAL CONDUCTION SYSTEM
OF THE HEART
The Cardiac Cycle
The cardiac cycle includes all the events that occur in the heart during
one single heartbeat. Each chamber of the heart goes through two
phases during the cardiac cycle: systole and diastole. During systole,
both the atria and the ventricles contract and empty of blood.
During diastole, the relaxation phase of the heart, the chambers refill
with blood. Venous blood from the inferior and superior venae cavae
empties into the right atrium during atrial diastole. As the right
atrium fills, increased pressure in the chamber causes the tricuspid
valve to open, and the right ventricle begins to fill. At the same time,
blood returning from the lungs via the pulmonary veins fills the left
atrium, causing the mitral valve, or bicuspid valve, to open, emptying
blood into the left ventricle. Before systole occurs, the ventricles are
already 70% filled. The cardiac cycle for a healthy adult lasts approxi-
mately 0.8 second. However, the amount of time it takes for the
heart to empty and refill depends on many factors, including the
condition of the myocardium and the heart's electrical system.
The electrocardiograph records both the intensity of the electrical
impulses and the actual time it takes for each part of the cardiac
cycle to occur. It measures the electrical conductive impulses of the
heart muscle, allowing the provider to see any disturbances or dis-
ruptions in normal heart activity. In addition to being recorded as
an ECG, the cardiac cycle can appear as a continuously moving
pattern on a monitor screen, accompanied by a sound for each beat.
The specialized electrical conduction system of the heart (Figure
25-2) initiates each heartbeat. The main part of this system is the
sinoatrial (SA) node, which is located in the upper back wall of the
77 bpm Normal sinus rhythm
156 ms Normal ECG
80ms
356/402 ms
73 56 60
622 UNIT FOUR DIAGNOSTIC PROCEDURES

SA node

Impulse is initiated in the SA node and spreads

throughout the atria. Upon completion of the P
wave the right and left atria have begun to contract.

Pwave
I

AV node

Bundle of A short delay at the AV node (seen as an

His isoelectric or undeflected line) allows the atria to
finish contracting. The impulse travels through the
AV node and activates the bundle of His.

QwavY

Activation of the septum between the ventricles

produces a small Q wave.

QRS
complex

Purkinje The impulse travels quickly along the right and left
fibers---'-----"-- - . _, , bundle branch into the Purkinje fibers in the wall of
the ventricles. Contraction of the ventricles is repre-
sented by the sharp spike of the ORS complex. While
the ventricles contract, the atria repolarize (return to
their original state and become able to contract again).

QRS
complex
,......1-
I I I I
ST
I I I I I
SA node I I I I segment

--
---,
->- Pwave f--
-r f--
- Twave
' ,I, '
- t -1
- t-1

, ,,.- ....
',
-m
- t -1
l

,
-~,
There is no electrical activity for a short period
as represented by the isoelectric ST segment.
Repolarization of the ventricles produces the
Twave. I
PR interval QT interval

FIGURE 25-2 Electrical conduction system of the heart. (From Hunt SA: Saunders fundamentals of medical assisting, revised reprint, Philadel-
phia, 2007, Saunders.)
 CHAPTER 25 Principles of Electrocardiography 623

right atrium at the junction of the superior vena cava and the right
atrium. The SA node controls the rate of heart contractions by ini- TABLE 25-1 Cardiac Cycle
tiating electrical impulses 60 to 100 times per minute. Each cardiac ELECTRICAL
cycle, or heartbeat, starts with the SA node generating an electrical STAGE HEART ACTIVITY CURRENT
impulse that travels in a wavelike pattern across the cardiac muscle
of the atria, causing them to contract almost simultaneously. This Pwave* Atrial contraction Atrial depolarization
electrical impulse then stimulates the atrioventricular (AV) node, PR intervalt Contraction traversing Depolarization traversing the
which is located in the posterior, superior portion of the right atrial the atrioventricular (AV) AV node
septa! wall, directly behind the tricuspid valve. A slight delay in
node
conduction at this point allows the atria to empty completely. The
electrical impulse then is transmitted to a special group of conduc- QRS complex* Ventricular contraction; Ventricular depolarization
tion fibers, the bundle of His, in the upper part of the interven- electrical stimulation and atrial repolarization
tricular septa! wall. The bundle of His divides into two branches; the travels from the AV node
right bundle branch carries electrical impulses to the right ventricle, to the Purkinje fibers
and the left bundle branch carries impulses to the left ventricle. The
right and left bundle branches divide into smaller and smaller ST segment Time interval between Time interval between
branches, ending in the Purkinje fibers, which spread across the apex ventricular contraction ventricular depolarization
of the heart and through the myocardium, stimulating ventricular and the beginning of and ventricular repolarization
contraction. The ventricles contract in a twisting sort of action, ventricular recovery
forcing the blood out of the chambers and into the pulmonary artery
on the right side of the heart and the aorta on the left side.
Twave Ventricular contraction Ventricular repolarization
Normal sinus rhythm (NSR) refers to a regular heart rate that subsides (electrical recovery); atrial
falls within the average range of 60 to 100 beats per minute (beats/ polarization begins
min). Sinus bradycardia is a heart rate below 60 beats/min; sinus Uwave (not Associated with further Purkinje fibers repolarization
tachycardia is a rate above 100 beats/ min. In both of these condi- always present) ventricular relaxation
tions, the rhythm remains even, but the rate can be a problem. An
irregular cardiac rhythm is called an arrhythmia. Conditions that Baseline§ The heart at rest Ventricular and atrial
interrupt the conduction pathway, SA node to AV node to bundle polarization
of His to right and left bundle branches, can cause arrhythmias.
PR interval Time interval between Time interval between atrial
Polarization, Depolarization, and Repolarization atrial contraction and depolarization and
Polarization is the resting state of the myocardial wall; no electrical ventricular contraction; ventricular depolarization
activity occurs in the heart during this phase, which is recorded on electrical stimulation
the ECG strip as a flatline. In this state the myocardial cells are ready travels from the SA to
for stimulation. When the electrical system of the heart stimulates the AV nodes
myocardial cells, depolarization occurs, resulting in the contraction
of the stimulated heart muscle. After depolarization the heart muscle
QT interval Time interval between Time interval between the
cells must return to a resting state before they can be electrically
the beginning of beginning of ventricular
stimulated again. The process of reaching this resting state is called ventricular contraction depolarization and
repolariza,tion. and the subsiding of ventricular repolarization
The electrocardiograph records a series of waves, or deflections, ventricular contraction; (electrical recovery)
above or below a baseline on the ECG paper. Each deflection cor- electrical stimulation
responds to a particular part of the cardiac cycle {Table 25-1 ). The travels from the AV node
normal ECG cycle consists of waveforms that are labeled the P wave, to the Purkinje fibers
the Q wave, the R wave, the S wave, and the T wave. The Q, R, and
S waves usually are grouped together; this is called the QRS complex. * Wave: Auniformly advancing deflection (upward or downward) from a baseline on a
recording.
One entire cardiac cycle can be called the PQRST complex. In the 1Interval: The period of time between two different electrocardiographic events.
next section, each part of the ECG is discussed in more detail. *Complex: The portion of the ECG tracing that represents the sum of three waves (contraction
of the ventricles).
PQRST Complex §Baseline: Aneutral line against which waves are valued as they deflect upward (positive) or

The P wave signifies the beginning of atrial depolarization. The SA
node initiates the electrical impulse, which then moves through the
myocardial cells in the atria. Immediately after the electrical stimula-
tion, the cells start to contract, causing the atrial chambers to con-
tract. The P wave is the first deflection from the baseline; it typically
is smooth and rounded, and one P wave should occur before each
QRS complex. Atrial repolarization is not recorded on the ECG strip
downward (negative) from the line.
because its electrical impulse is small and hidden in the QRS
complex. When the electrical impulse reaches the AV node, there is
a pause in electrical activity. This lack of electrical impulse creates
the PR segment, which is a return to baseline. This pause allows the
atrial chambers to finish contracting and completely empty.
624 UNIT FOUR DIAGNOSTIC PROCEDURES
The electrical impulse then moves from the AV node through the
Bundle of His and into the right and left bundle branches. This
depolarization of the interventricular septum creates the Q wave, a
downward deflection and the start of the QRS complex. As the
electrical impulse moves from the bundle branches to the Purkinje
fibers, the R wave and the S wave are created. As the ventricular
tissue depolarizes, the chambers start to contract, moving the blood
out of the heart.
Following the QRS complex, the ST segment is created from the
electrical activity generated by the beginning of the repolarization of
the ventricular chambers. An upright, slightly rounded asymmetrical
wave called the T wave follows the ST segment. This wave is created
from the electricity produced from the repolarization of the ventricu-
lar chambers. At this time, the atrial chambers are in the polarized
state and will remain there until the next heartbeat.
After the T wave, a U wave may be present, though it is not very
common. It is thought that the U wave reflects the repolarization of
the Purkinje fibers. It can also be seen in patients with potassium
imbalances. After the last wave (either T or U), the tracing is an
isoelectric line until the next impulse from the SA node. Both cham-
bers are polarized.
The ECG tracing can be divided into two intervals, the PR
interval and the QT interval. The term interval reflects a period of
time. The PR interval starts at the beginning of the P wave and
finishes at the end of the PR segment. During this interval of time,
atrial depolarization and contraction occur. The QT interval starts
at the beginning of the Q wave and finishes at the end of the T wave.
The electrical activities that occur in the heart and conduction
system from the Q through the T wave are reflected during this
interval.
By measuring the actual configuration and location of each wave
in relation to the other waves and to the baseline, in addition to the
intervals between waves and segments, the physician can detect
rhythmic disturbances of the heart and identify different types of
cardiac disorders.
THE ELECTROCARDIOGRAPH
Electrocardiograph machines (Figure 25-3) record 12 leads simulta-
neously and are also referred to as six-channel ECG machines. Four
FIGURE 25-3 ECG machine.
limb and six chest electrodes must be placed on the patient at specific
anatomic locations before the recording starts. When the ECG is
started, the machine records all 12 leads automatically and marks
each lead with identifying letters. These multichannel ECG tracings
take seconds to perform and can be placed in the patient's health
record without mounting, or they can be recorded directly into the
patient's electronic health record.
Digital ECGs
Newer versions of ECG machines can be connected into the facility's elec-
tronic health record (EHR) system so that ECGs can be recorded directly
into a patient's EHR. These machines include advanced technologic func-
tions, such as the following:
• They enable a continuous view of 3-, 6-, and 12-leads of data on
the machine's color display.
• They can store up to 300 ECG records.
• They reduce typing mistakes and save time by downloading patient
information from the EHR system.
• They eliminate the need for scanning and filing.
• They can recognize and accommodate patients with pacemakers.
• They provide an interpretation of ECGs that considers the patient's
gender, age, medication, and so on.
• They include communication tools (e.g., Ethernet), in addition to
wireless and Bluetooth technology.
• They can connect with EHR systems to download patient demo-
graphics and orders, perrorm tests, and upload test results to
patients' EHRs.
CRITICAL THINKING APPLICATION 25-1
Martha has not yet been taught how to use the ECG machine in Dr. Lee's
office. What steps should she take to learn how to use this machine and
to feel comfortable and confident using it to obtain ECGs?
Electrocardiograph Paper
Electrocardiograph paper is heat and pressure sensitive, which means
that either heat or pressure can cause a mark to appear. The stylus
on an ECG machine makes the image on the ECG paper. When the
machine is on, the stylus becomes hot and burns a marking on the
paper as it moves horizontally past the stylus. Because the paper is
pressure sensitive, it must be handled carefully to prevent any addi-
tional markings that would blemish the tracing.
ECG paper is graph paper that has horizontal and vertical lines
at 1-mm intervals. This is an agreed-on international standard that
allows providers anywhere in the world to interpret a patient's ECG
in the same manner. A medical assistant needs to know both the size
and the meaning of each square on the ECG paper to understand
its significance.
The horizontal axis represents time, and the vertical axis repre-
sents amplitude. Each small square measures 1 mm on each side.
Every fifth line, both vertically and horizontally, is darker than the
other lines and creates a larger square measuring 5 mm on each side.
 CHAPTER 25 Principles of Electrocardiography 625

I I
Voltage
I I
Time
I
I I I
I I I
I I I
t
-- 1- = .04 sec

•
• -1 mm

--- I

I
I I
= .08 sec
I I
= .12 sec
I I I
___________.. = .16sec
= 10 mm I I I
=5mm or 1 mV = .20 sec
I I I
I I I
1 sec
I I I I I I I
I I I I I I I RL
I I I I I I I I I I I I I I I I I I I I I I I I I I
A Lead I Lead II Lead Ill
FIGURE 25-4 ECG paper.

When the electrocardiograph runs at normal speed, one small 1-mm

square passes the stylus every 0.04 second, which means that one
large 5-mm square passes the stylus every 0.2 second. Continuing
this logic, in 1 second, five large squares pass the stylus. Therefore,
five sequential large squares show the record of what occurred in the
heart during a time span of 1 second (5 large squares X 0.2 second
= 1 second). Another way to say this is that at normal speed, the
ECG paper travels past the stylus at a rate of 25 mm per second
(Figure 25-4).
The voltage, or strength, of the heartbeat also is recorded on the
paper. Voltage can be displayed as either a positive or a negative
deflection. One millivolt (mV) of electrical activity moves the stylus
upward over 10 mm (two large squares). This is the standard nor-
mally used for obtaining an ECG, and it can be adjusted to match
the strength of the electrical activity of the heart. The machine must
be calibrated so that 1 m V of electrical activity produces a deflection
that is 10 mm either above or below the baseline. When properly
calibrated, the ECG records both the strength of the electrical activ-
ity of the heartbeat in millivolts and the speed of the heartbeat over
time.
Electrodes and Lead Wires
Ten sensors, called electrodes, are placed on the patient's arms (two),
legs (two), and chest (six) to pick up the electrical activity of the
heart. Electrodes must be applied to specific locations to record the
heart's electrical activity from different angles and planes. Ten color-
coded and labeled lead wires that end in a small metal clip are
attached to the electrodes. The lead wires carry the signal of the
heart's electrical activity to the ECG machine. Single-use, self-stick,
disposable electrodes, which contain a thin layer of a metallic sub-
stance that is a good conductor of electricity, are packaged with
conductive jelly in the center. Skin is a poor conductor of electricity,
so the conductive jelly serves as an electrolyte that enables the trans-
fer of the electrical activity of the heart into the lead wires of the
ECG machine. The electrodes will not work as efficiently if the
conductive jelly is dried out, so they should not be used if the pack-
age's expiration date has passed.
The lead wires to the electrocardiograph carry the cardiac electri-
cal impulses into the machine, where they are magnified by an
amplifier. These amplified impulses are converted into mechanical
action, which is recorded on the ECG paper by the stylus and/or
RL LL
B Lead aVR Lead aVL Lead aVF
FIGURE 25-5 Standard (A) and augmented (B) limb leads.
shown on a monitor. A single lead records the electrical activity of
the heart between two different electrodes, one positive and one
negative. The placement of the positive electrode determines the
particular view of the heart recorded. If depolarization occurs toward
the positive electrode, the deflection is upright; if it moves toward
the negative electrode, the waveform is deflected downward. Each
lead records the average electrical flow at a specific time in a specific
location of the heart.
Lead Recordings
The standard ECG consists of 12 separate leads, or recordings of the
electrical activity of the heart, from 12 different angles. The ECG
records views of the heart on both a frontal and a transverse plane.
The frontal leads include leads I, II, III, aVR, aVL, and aVF, Transverse
plane leads include the six precordial, or chest, leads (V 1 to V6).
Standard Leads
The first three leads recorded are called the standard or bipolar
leads because they each use two limb electrodes to record the
heart's electrical activity (Figure 25-5, A). The right arm electrode
is the negative pole, and the left leg or left arm electrodes are the
positive poles. Roman numerals I, II, and III are used to designate
these leads.
• Lead I records tracings between the right arm and left arm,
recording the electrical activity of the lateral part of the left
ventricle.
• Lead II records tracings between the right arm and left leg,
recording the electrical activity of the inferior surface of the
626 UNIT FOUR DIAGNOSTIC PROCEDURES
left ventricle; this is the lead recorded on a cardiac monitor
or on the rhythm strip at the bottom of the 12-lead ECG.
• Lead III records tracings between the left arm and left leg,
which reflects the electrical activity of the inferior surface of
the left ventricle.
Augmented Leads
The next three leads are the augmented, or combined, leads (Figure
25-5, B). These are designated augmented voltage right arm (aVR),
augmented voltage left arm (aVL), and augmented voltage left leg
(aVF). Because the electrical activity recorded by these leads is rela-
tively small, the ECG machine amplifies (or augments) the electrical
potential when recorded. These are all unipolar leads with a single
positive electrode that uses the right leg for grounding.
• aVR records the electrical activity of the atria from the right
shoulder; P waves and QRS complexes are deflected below the
baseline.
• aVL records the electrical activity of the lateral wall of the lefr
ventricle from the left shoulder.
• aVp records the electrical activity of the inferior surface of the
left ventricle from the left leg.
Precordial Leads
The precordial, or chest, leads are unipolar and provide a transverse
plane view of the heart. They are designated V 1, V2, V 3, V 4, V 5, and
V 6• The V means chest, and each of the numbers represents a specific
location on the chest. The QRS complex shows as a negative deflec-
tion in V 1 and V 2 , and views with each subsequent lead become more
positive. Precordial leads measure the electrical activity among six
specific points on the chest wall and a point within the heart (Figure
25-6). It is important to avoid placing electrodes directly over a bony
prominence.
Midclavicular
line
Anterior
:',/axillary line
1 0\..--""
Midaxillary
I I I line
I I
I vent artifacts during the tracing. Check to see whether the patient
I
I followed all the instructions provided in Figure 25-7 . Record the
I
I I
FIGURE 25-6 Chest leads. /CS, lntercostal space.
Placed in the fourth intercostal space, just to the right of the
sternum
Placed in the fourth intercostal space, just to the left of the
sternum
Placed midway between V2 and V4
V4 Placed in the fifth intercostal space, at the left midclavicular
line
V5 Placed horizontal to V4 in the left anterior axillary line
V6 Placed horizontal to V4 in the left midaxillary line
CRITICAL THINKING APPLICATION 25-2
Dr. Lee has asked Martha to perform her first ECG on a patient who just
came into the office. Martha is not confident that she knows how to place
the chest leads properly in the correct locations. How should she handle this
situation? Should she perform the ECG procedure as best she can? Why or
why not?
PERFORMING ELECTROCARDIOGRAPHY
Preparation of the Room and Patient
The room should be in the quietest location in the office and should
be as far as possible from all other electrical equipment, including
x-ray machines, diathermy devices, laboratory equipment, centri-
fuges, fans, refrigerators, and air conditioners. The room should be
warm and should have adjustable lighting.
The treatment table should be comfortable and wide enough to
provide full support for the patient. The table should be wood or
should have an electrically insulated surface. Position the table so
that you can work from the side of the patient that is most com-
fortabl e for you. Electrocardiographers most often work on the
patient's left side, but as long as the electrodes are placed in the
proper position, it really makes no difference which side you use.
Small pillows can help the patient relax and provide maximum
comfort during the procedure. Offer a pillow for the head and one
for under the knees. If a head pillow is used, it should not elevate
the patient's shoulders.
The patient should disrobe to the waist and put on the
patient gown with the opening in the front; easy access to the
patient's extremities must be available. Pantyhose must be removed.
Place the patient in a supine position with the arms comfortably
at the sides and the legs not touching one another. If the patient has
dyspnea or orthopnea, a semi-Fowler's position should be used, or
the patient can be seated on a wooden chair. However, make sure
you check with the provider before obtaining an ECG in an alterna-
tive position. If a seated position is used, the patient's feet must rest
comfortably on the floor or on a footstool. Note any alternative
position on the ECG recording.
The patient should empty his or her bladder if needed to help
with comfort and relaxation during the procedure. This will help pre-
patient's vital signs and current medications on his or her health re-
cord. This information can be programmed into some ECG machines
 CHAPTER 25 Principles of Electrocardiography 627

INSTRUCTIONS FOR PATIENT BEFORE AN ELECTROCARDIOGRAM

Name: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
AM
Your cardiogram appointment is _ _ _ _ _ _ __ - - - - -D-a-te- - - - - at _ T
_ i_m_e_ PM
Day

These instructions are simple, but it is important that you follow them. Please call us if you are unable to follow these instructions or
keep your appointment so we may make another appointment.

1. There is no discomfort or sensation in having an electrocardiogram. No electricity is put into the patient in any way. Small
disposable electrodes are placed on the calf of each leg and on each arm and at different places on the chest. The minute
impulse generated by your heart is simply picked up by these electrodes and recorded by the machine.

2. You will be asked to lie down on a comfortable table while the test is being performed by the technician.

3. For your convenience, it is best to wear loose clothing. You will be asked to disrobe to your waist to expose the chest. It will also
be necessary to expose your lower legs from the knees down and the upper arms just below the shoulders.

4. The actual test only takes about 5 minutes, but you will be asked to rest for about one-half hour before the test. It is best you do
not have a heavy meal for about 2 hours before the test. You should not consume any cold drinks or ice cream or smoke just
before the test. It is also advisable to refrain from excessive exercise just before the test. Do not take any medications without
the physician's usual instructions and knowledge.

5. During the test, you will be asked to lie absolutely still and relax, because the slightest movement interferes with an accurate
tracing. Do not talk.

6. The skin on the legs, arms, and chest must be free from skin ointments, oils, and medications.

7. The technician taking the test is specially trained to perform the test but is unable to tell you the results of the test, because he
or she is neither trained nor authorized to make any interpretations of the cardiogram. This is the task of the physician.

FIGURE 25-7 ECG patient instructions.

A
FIGURE 25-8 Chest lead locations. (Thompson P: Coronary care manual, ed 2, Australia, 2010, Churchill Livingstone.)

and automatically printed on the ECG recording; if a digital elec-
trocardiograph is used, the information can be recorded directly into
the patient's electronic health record (EHR). If the facility where you
work does not have a digital machine, then part of your responsibility
is to scan the ECG recording into the patient's EHR.
Explain to the patient the nature and purpose of the ECG.
Attempt to answer all questions and make the patient as comfortable
as possible during the procedure. Stress the importance of not
moving during the entire procedure, and assure the patient that there
is no danger of shock. Soften the lighting in the room to obtain
maximum patient comfort. When you tell the patient to lie still,
make sure that he or she is breathing normally. Patients often hold
their breath when asked to lie still.
Attaching Leads to the Patient
Disposable, single-use electrodes are placed on the patient's limbs
and chest in very specific locations (Figure 25-8). The lead wires
from the machine then are connected to the electrodes. Specific lead
628 UNIT FOUR DIAGNOSTIC PROCEDURES

Midclavicular
line
Anterior
axillary line
Midaxillary
line

\ } \ )
' I

RL 0 g LL

V1 V2 V3 V4 V5 V6

Right leg: Greeno V1: Red ~ Right arm: White o

Left leg: Red ~ V2: Yellowo Left arm: Black •
V3: Greeno
V4: Blue Q
V5: Orange o
V6: Purple ~
FIGURE 25-9 Color codes.

markings or color coding on the end of each lead wire help ensure
that the proper connections are made (Figure 25-9). The leads are
attached as follows:
LEAD ATTACH TO ELECTRODE ON:
RA Fleshy part of patient's right upper arm
LA Fleshy part of patient's left upper arm
RL Fleshy part of patient's right lower leg
LL Fleshy part of patient's left lower leg
The labeled lead wires then are placed on each precordial electrode.
Special Considerations. If the patient has had a limb amputated,
the electrodes are placed above the amputation site. The leg elec-
trodes should be placed on the thighs. With an arm amputation, the
electrodes should be placed on the upper arm if it is intact or on the
shoulders. The opposite extremity electrode should be in the same
location. For people with the heart on the right side, the electrodes
are placed in the same locations except that those on the left side are
placed on the right side, and those on the right are placed on the
left. Electrodes should not be placed over a new surgical incision.
Place the electrode near the location, but not on the incision. Any
changes ro electrode placement must be documented on the ECG.
CRITICAL THINKING APPLICATION 25-3
Two weeks later, after Martha feels much more confident in her skills for
electrode placement and recording an ECG, a new patient, Mr. Sanderford,
comes to the office complaining of mild chest pain that he noted when he got
out of bed this morning. What concerns might Martha have about Mr.
Sanderford? His vital signs are: P104 weak and irregular; R24 and quite
shallow. Mr. Sanderford is sweating profusely. What should Martha do?
Why?
Recording the Electrocardiogram
Procedure 25-1 explains how to record an ECG. It is important that
you become familiar with the type of machine used in your practice.
Machines vary according to the age and make of the model, but
most electrocardiographs currently in use perform standardization
functions and labeling auromatically. You may have the option of
entering specific information about the patient, such as age, gender,
prescriptions, and so on. Follow office protocol when performing
the procedure. After the machine has been programmed, remind the
patient to lie still, and then press the appropriate key to run the ECG
strip. Six-channel machines print and label all 12 leads, with a rhythm
strip across the bottom of the paper in lead II, in a matter of seconds.
Review the printout for clarity, and ifit is acceptable, give the record-
ing to the provider for review. If your facility uses a digital electro-
cardiograph, the ECG is automatically downloaded into the patient's
EHR. If a printed ECG is recorded, it may be the medical assistant's
responsibility to scan and download the graph into the patient's
EHR. Once the provider has approved the ECG and/or the recording
is in the patient's EHR, remove the leads and electrodes from the
patient, help the person into a sitting position, and provide assistance
in getting off the table and dressing if necessary.
Standardization, Sensitivity, and Speed
Standardization has been determined by international agreement so
that an ECG can be interpreted in the same way anywhere in the
world. This requires the electrocardiograph to be calibrated accord-
ing to universal measurements. Each time you record an ECG, you
must make sure the machine is correctly standardized.
When a machine is in standard mode or set at 1 STD, 1 m V
of electricity causes the stylus to move vertically 10 mm, or two
large squares. When the machine has been properly set in this way,
electrical voltages can be calculated by measuring the vertical
 CHAPTER 25 Principles of Electrocardiography 629

movement of the stylus on the paper. The stylus should deflect
exactly 10 mm when the standardization button is depressed
with a quick pecking motion. The recording of the standardiza-
tion would be 2 mm wide and rectangular. Each manufacturer's
manual explains the exact method of adjustment to obtain a
perfect standardization. Most machines have three sensitivity stan-
dards that can be selected: ½ STD, which deflects the stylus
5 mm, or one large square; 1 STD, which deflects the stylus
10 mm, or two large squares; and 2 STD, which deflects the
stylus 20 mm or four large squares. The appropriate standard is
selected as follows: If the QRS complex is too tall and is causing
the stylus to move off the paper, the STD should be set to ½
STD. If the QRS complex is too short, the STD should be set to
2 STD. Figure 25-10 shows the three sensitivity standards as they
appear when recorded on the ECG paper.
The usual speed for an ECG recording is 25 mm/sec. If the
patient's heart rate is vety rapid or if certain parts of the complex are
too close together, the paper may need to be adjusted to run at
double speed, or 50 mm/sec. This extends the recording to twice the
normal length. Any change in the speed must be noted on the ECG.

A Normal standard B One-half standard

Standardization mark is 1O mm high Standardization mark is 5 mm high

C Double standard
Standardization mark is 20 mm high

FIGURE 25-10 Sensitivity standards.

•;;MMmhii+ii Perform Electrocardiography: Obtain a 12-Lead ECG

Goal: To obtain an accurate, artifact-free recording of the electrical activity of the heart.
EQUIPMENT and SUPPLIES • Patient gown and drape
• Patient's health record • Disposable alcohol wipes
• Three-channel electrocardiograph with patient lead cable and labeled lead • Disposable razor
wires • Sharps container
• l Odisposable, self-adhesive electrodes
630 UNIT FOUR DIAGNOSTIC PROCEDURES

•;;m,ami;jffii -continued
PROCEDURAL STEPS
1. Perform the ECG in a quiet examination room away from electrical equip-
ment to avoid artifacts.
2. Sanitize your hands.
PURPOSE: To ensure infection control.
3. Greet the patient, confirm identity by name and date of birth, and explain
the procedure.
PURPOSE: To alleviate apprehension and gain the patient's cooperation.
4. Ask the patient to disrobe to the waist (including the bra for women) and
remove belts, jewelry, socks, stockings, or pantyhose as necessary; have
the patient put the exam gown on so that it opens in the front. Provide
the patient with privacy while he or she prepares.
PURPOSE: Electrodes must be applied to bare skin without interference
from clothing.
S. Position the patient supine on the examination table and drape appropri-
ately. The table should support the patient's arms and legs.
PURPOSE: To ensure the patient's modesty and comfort and the accuracy
of the recording. Limb support is needed to prevent muscle artifacts. 9. Carefully connect the lead wires to the correct electrode with the alligator
6. Turn on the machine and enter the patient's demographic information, clips on the end of each lead. The lead wires are color coded and have
including name, age, date, time, current medications, and identification abbreviations on each clip to match the electrode location. The lead wires
number, if this system is used at your facility. If you are using a digital should follow the body's contour. Make sure the lead wires are not crossed
ECG machine, you can download this information onto the ECG recording (Figure 2).
directly from the patient's EHR. PURPOSE: To prevent artifacts.
PURPOSE: To identify the ECG recording properly.
7. At each location where an electrode will be placed, clean the skin with an
alcohol wipe. If the areas are extremely hairy and the electrodes cannot
be completely attached to the skin, it may be necessary to shave the
areas of electrode attachment.
PURPOSE: To obtain good electrode adhesion to the skin.
8. After the alcohol has completely dried, apply the self-adhesive electrodes
to clean, dry, fleshy areas of the four extremities. The leg electrodes are
placed with the tabs facing toward the abdomen on the fleshy part of the
calves and the tabs facing down on the inner aspect of the upper arms.
The l Oelectrodes needed for the procedure are packaged on a card in a
multipack, foil-lined envelope. Reseal the envelope after removing the card
to prevent the electrolyte gel on the other electrodes from drying out. 10. Remind the patient to remain still, breathe normally, and not to talk during
Apply the self-adhesive electrodes to the clean areas on the chest with the the recording.
tabs downward. It is important to avoid placing electrodes directly over a PURPOSE: To prevent artifacts.
bony prominence. Apply the electrodes as follows (Figure l): 11. Press the AUTO button on the machine and run the ECG tracing. The
V1-fourth intercostal space, just to the right of the sternum. machine automatically places the standardization at the beginning, and
V2-fourth intercostal space, just to the left of the sternum. the 12 leads then follow in the three-channel matrix with a lead II rhythm
V3- midway between V2 and V4. strip across the bottom of the page.
V4-fifth intercostal space, at the left midclavicular line. 12. Watch for artifacts during the recording. If artifacts are present, make
V5-horizontal to V4 in the left anterior axillary line. appropriate corrections and repeat the recording to get a clean reading.
V6-horizontal to V4 in the left midaxillary line. 13. Remove the lead wires from the electrodes and then remove the elec-
trodes. If the razor was used, dispose of it in the sharps container. Sanitize
your hands.
14. Assist the patient with getting dressed as needed. Clean the ECG machine
and return it to its storage area.
 CHAPTER 25 Principles of Electrocardiography 631

•;;m,ammffii -,;ontinued
1S. If a digital machine is used, the ECG recording will be automatically added
to the patient's EHR. If not, place the printed recording with the patient's
health record for the provider to review. The medical assistant may have
to scan the document into the patient's EHR.
16. Document the procedure in the patient's health record.
PURPOSE: Procedures are not considered done until they are documented
in the patient's health record.
9/22/20- 3: l OPM: 12-lead ECG recorded per Dr. Lee order without incident.
Martha Reyes, CMA (MMA)

difficult. The medical assistant should have a thorough understand-

The ECG Tracing and the Health Record
ECG tracings usually are retained in health records for many years
to provide a history of the patient's cardiac activity. Paper graphs are
typically scanned and downloaded into the patient's EHR. However,
if your facility still files paper copies, remember that the ECG paper
is both heat, light, and pressure sensitive. Paper clips and staples
cannot be used because they scratch and mark a tracing. A single
photocopy of the ECG can be made without damaging the original.
Many offices routinely put a photocopy in the patient's paper health
record because it is less likely to be damaged by handling. If the
practice has electronic health records, the tracing is scanned into the
patient's electronic record or recorded directly into the patient's
EHR.
Regardless of the particular method used, each ECG should be
labeled with the following information:
• Patient's full name and identification number if this system is
used in the facility
• Gender
• Age
• Date and time of ECG
• List of all medications and/or supplements the patient takes
• Adaptations from normal sensitivity and normal speed
Additional notations should be recorded for any variation from
the routine, such as the following:
• Very nervous or anxious patient
• Lack of rest before the test
• Smoking immediately before the test
• Failure to follow any pretest instructions
ing of the causes of and remedies for these artifacts. The main types
of artifacts are wandering baseline, somatic tremor, alternating
current (AC) interference, and interrupted baseline.
Wandering Baseline
With a wandering baseline, the stylus gradually shifts away from the
center of the paper. This usually happens because of slight movement
of the patient during the tracing or poor electrode attachment
(Figure 25-11 ). A wandering baseline is resolved by reminding the
patient to remain as still as possible; this can be facilitated by keeping
the patient comfortable. Make sure electrodes are securely and com-
pletely attached to each specific site to eliminate this artifact.
Somatic Tremor
The term somatic tremor means muscle movement. Any muscle
movement, including movement of skeletal muscle, produces a mea-
surable electrical impulse. This additional input causes unwanted
stylus movement during the tracing; this shows up on the recording
as jagged peaks of irregular height and spacing with a shifting base-
line (Figure 25-12). The most common causes include patient dis-
comfort, apprehension, movement, talking, or a condition that
causes uncontrollable body tremors. A patient with uncontrolled
tremors must be as calm and comfortable as possible to minimize

Interpretive Electrocardiographs
Interpretive electrocardiographs are equipped with a computer that
analyzes the recording as it is being run. With this capability, imme-
diate information on the heart's activity is available, which can be
valuable for reaching an early diagnosis and initiating immediate FIGURE 25-11 Wandering baseline.
treatment. Patient baseline data must be entered into the computer
before the ECG is recorded. The computer analysis of the ECG and
the reason for each interpretation are then printed on the top of the
recording or downloaded directly into the patient's EHR.

Artifacts
An artifact is an unwanted, erratic movement of the stylus on the
paper caused by outside interference. The electrocardiograph is
extremely sensitive to any kind of nearby electrical activity. Electrical
artifacts on the tracing make accurate interpretation of the ECG FIGURE 25-12 Somatic tremor.
632 UNIT FOUR DIAGNOSTIC PROCEDURES
the somatic tremor artifact. The other causes all can be resolved after
they have been identified correctly.
Alternating Current Interference
AC interference appears as a series of uniform small spikes on the
paper (Figure 25-13). Electrical currents in nearby equipment or
wiring can leak small amounts of electrical energy into the area where
the ECG machine is located. The electrocardiograph can pick up
this additional electrical energy signal. This can be minimized by
making sure the machine is plugged into a three-pronged, grounded
outlet; keeping lead wires uncrossed; unplugging other electrical
appliances in the room; moving the table away from the wall; and
perhaps even turning off overhead fluorescent lights. If all these
measures fail, you may need to move to another examination room
for the procedure. The last step is to call the manufacturer or your
local service representative.
Interrupted Baseline
Baseline interruption occurs when the electrical connection has been
interrupted. The stylus moves onto the margin of the paper errati-
cally (Figure 25-14). It moves violently up and down across the
paper, or it may record a straight line across the top or bottom of
the paper. If the electrodes are dislodged, an interrupted baseline
occurs. This cause is virtually eliminated by making sure the elec-
trodes are properly attached to the skin. Other causes include a
broken cable wire and cable tips that are attached too loosely or
become separated from any electrode.
CRITICAL THINKING APPLICATION 25-4
Dr. Lee asks Martha to explain the causes of artifacts and the methods for
correcting ECG recordings that show outside interierence. Based on what
you have learned about ECG artifacts, what are the typical causes and how
would you recommend correcting each?
FIGURE 25-13 Sixty-qde interference. (From Urden L, Stacy K, Lough M: The/an's critical care
nursing: diagnosis and management, ed 7, St Louis, 2014, Mosby.)
FIGURE 25-14 Interrupted baseline.
THE ECG STRIP
The medical assistant working in a cardiovascular practice must be
able to recognize rhythm abnormalities that may appear on the
tracing. Alerting the provider to the presence of an arrhythmia while
the patient is still connected to the machine may give the provider
the opportunity to observe the patient while the machine is running
or immediately institute some type of therapeutic or prophylactic
intervention. The provider can determine two important heart func-
tions when interpreting the ECG: heart rate and heart rhythm.
Normal Appearance of ECG Complexes
When you examine the ECG recording, first look at the character-
istics of each of the waves in the recording {Table 25-2). Are the P
waves, QRS complexes, and T waves clearly present? Do they have
a consistent appearance, and do they occur at regular intervals? Are
any odd beats present that do not fit in with the others? Is the rate
normal, fast, or slow? Is the rhythm regular or irregular?
In NSR {see Figure 25-1 ), each beat of the heart is initiated by
an impulse from the SA node that travels without interruption along
the normal conduction pathway of the heart. In NSR each beat on
the ECG shows a P wave followed by a QRS complex.
Rate
To calculate the heart rate from the ECG recording, count the
number of P waves in a 6-second strip (30 large squares) and mul-
tiply by 10. In the same manner, you can count the number of P
waves in a 3-second strip (15 large squares) and multiply by 20. To
get the number of ventricular contractions in 1 minute, you can
count the number of complete QRS complexes that occur within 6
seconds and multiply that number by 10.
The heart rate also can be calculated by counting the number of
small squares between two R waves and then dividing that number
into 1,500 (1 minute on an ECG strip passes 1,500 small boxes).
When the number of boxes from one cardiac event to the next same
event is divided into 1,500, the result is the patient's heart rate. You
can use Figure 25-1 to practice these techniques.
Rhythm
The rhythm of a patient's heartbeat is either regular or irregular. You
may pick up an irregular heartbeat when taking the patient's pulse.
This same patient will show an irregularity {i.e., a difference in the
length of time between cardiac cycles) when an ECG is recorded. If
the patient's heart is beating in a regular rhythm, each cardiac cycle
occurs within the same time frame, and individual cardiac cycles
occur exactly the same length of time apart. To check for ventricular
rhythm, you can measure the distance between two consecutive RR
intervals. Atrial rhythm is determined by measuring the distance
between two consecutive PP intervals. If the heart rhythm is regular,
each of these interval measurements is the same.
Calculating a Patient's Heart Rate
To calculate the patient's heart rate from an ECG strip, remember the
following:
• 5 large boxes on the graph paper = l second
• 15 large boxes = 3 seconds
• 30 large boxes = 6 seconds
 CHAPTER 25 Principles of Electrocardiography 633

Analyzing an ECG Strip

The ECG rhythm strip (lead II view) is evaluated from left to right. Each strip
should be assessed for the following:
• Rate
• Rhythm
• Pwaves (there should be one Pwave before each QRS complex;
each is a positive deflection, and they are similar in size and shape)
• Intervals (assess for duration and distance)
• Appearance of the segments and waveforms (Are rhythmic PQRST
cycles present? Are there any abnormalities, such as more than one
Pwave, QRS segments without a previous Pwave, or an elevated
ST segment? Any such abnormalities should be brought to the pro-
vider's attention immediately.)

TABLE 25-2 Normal Appearance of ECG Waveforms and Complexes

WAVE OR COMPLEX DURATION (sec or amplitude) CHARACTERISTICS TO EXAMINE
Pwave 0.06-0.11 • Are Pwaves present?
• Are they normal in shape (not notched or peaked)?
• Do all deflect upward (positive)? Is there one for each QRS? Are they
evenly spaced from the QRS?
PR interval 0.12-0.20 • Is it constant?
QRS complex 0.08-0.12 • Are the complexes evenly spaced from Twaves?
• Do all point in the same direction?
• Do all appear the same?
• Is each preceded by a Pwave?
• Does the Qwave have a pronounced negative deflection?
ST segment On baseline (isoelectric line) • Is it on baseline?
• Is it constant?
• Is it elevated above the baseline?
Twaves ~5 mm in leads I, II, Ill • Are they present?
~l Omm in VrV6 • Are all the same?
• Do all show upward deflection (positive)?
QT interval Should not be more than half the RR interval* if • Is it constant?
patient has a regular rhythm
Uwave Rounded, upright deflection • Is it present?
*RR interval: Period from onset of one QRS complex to onset of next QRS complex.

several arrhythmias in each of these categories are compared in

TYPICAL ECG RHYTHM ABNORMALITIES
Abnormalities in cardiac rhythm are called arrhythmias. These can
result from disturbances anywhere along the electrical conduction
pathway in the heart from the SA node through the right and left
bundle branches. The best way to determine whether an arrhythmia
is present is to know what the NSR looks like on an ECG. Study
the NSR in the ECG in Figure 25-1 . NSR is a heart rate between
60 and 100 beats/min. Any deviations from this should be recog-
nized during the ECG recording, and the medical assistant should
notify the physician immediately.
Cardiac arrhythmias commonly fall into one of four broad
categories: sinus arrhythmias, atrial arrhythmias, ventricular ar-
rhythmias, and biochemical arrhythmias. The characteristics of
Table 25-3 .
Sinus Arrhythmias
Sinus rhythm is considered normal; the heart's electrical activity
begins in the SA node and follows through the electrical system,
ending in atrial and ventricular depolarization. In sinus arrhyth-
mias, the pathway of the electrical charge is normal, but the rate
or rhythm of the heartbeat is altered. Sinus arrhythmias may be
caused by the SA node firing too slowly or too quickly. In sinus
bradycardia, the heart rate is below 60 beats/ min. This can be a
normal heart rate in well-conditioned athletes, but it is abnormal
in other individuals. In sinus tachycardia, the heart rate is above
100 beats/min. This can be a normal heart rate in a person doing
634 UNIT FOUR DIAGNOSTIC PROCEDURES

TABLE 25-3 Characteristics of Arrhythmias

TYPE SIGNS AND SYMPTOMS ETIOLOGY ECG CHANGES
Sinus Arrhythmias
Bradycardia <60 beats/min Vagal nerve stimulation; sleep; SA node ischemia; Essentially "normal" appearing, but slow
digitalis toxicity; drugs
Can be normal in athletes
Tachycardia Nonpathologic; heart rate >100 Increased demand for cardiac output; ectopic Pwave can be obscured by ST segment
beats/min is pathologic pacemaker (increasing the ECG speed can reduce this
problem)
Atrial Arrhythmias
PAC Not pathologic if only several per Increased SA node excitability, causing premature "Extra" Pwaves
minute beats of atria
Can be caused by nicotine ar caffeine
Flutter 200-350 beats/min Many ectopic atrial pacemakers; normally unstable Multiple, sawtoathed Pwaves before
and progresses ta atrial fibrillation if not corrected essentially normal-appearing QRS complexes
Ventricular Arrhythmias (See Figure 25-16)
PVC Generally none Ectopic pacemakers originating in ventricles from Widened QRS complex
electrolyte imbalance, hypoxia, acute Ml
V-tach Heart rate >100 beats/min, always Damaged tissue around one of the "bundles," Rapid rate, irregular pattern that includes
pathologic causing a difference in conduction speed between "extra" or erratic, irregular, or wide QRS
the two branches ar ectopic pacemaker cells complexes
V-fib* Shack, lass of consciousness, no Complete loss of synchronization af conduction Erratic deflections on the ECG (can be either
pulse system coarse ar fine)
Na identifiable ECG waves
Asystole <5 beats/min Death imminent Flatline
Biochemical Arrhythmias
Digitalis toxicity Abnormal bradycardia, abnormal Digitalis dose that is too high "Swooping" ST segment depression and/or
tachycardia extended PR intervals
Hypokalemia Malaise, fatigue, weakness, muscle Potassium too low, usually from unsupplemented Prominent Uwaves; Twave and Uwave
cramps diuresis, from IV fluid administration, or from together look like a two-hump camel
excessive vomiting
Hyperkalemia t May have none Potassium too high, usually from IV Peaked Twave (can be as tall as Rwave)
supplementation with widening of all waveforms
IV, Intravenous; Ml, myocardial infarction; PAC, premature atrial contraction; PVC, premature ventricular contraction; SA, sinoatrial.
*Most common life-threatening arrhythmia; frequently precedes •systole if not reversed.
!Life-threatening condition; must be corrected immediately.

aerobic exercise, but it can be abnormal in a resting individual
(Figure 25-15).
Atrial Arrhythmias
Problems with electrical discharge of the atria are caused by faulty
electrical impulse formation or conduction defects within the atria.
Premature atrial contraction (PAC) occurs when the atria contract
before they should for the next cardiac cycle. This can appear on the
ECG as an abnormally shaped P wave or an extra P wave. PACs can
be seen in smokers and people who consume large amounts of caf-
feine. Occasional PACs are not abnormal, but they become a
medical concern if they regularly occur more than six times a
minute. In this situation, the PACs can indicate developing cardiac
abnormalities.
Atrial flutter occurs when the atria beat at an extremely rapid
rate, up to 300 beats/min. In atrial flutter the impulses come from
 CHAPTER 25 Principles of Electrocardiography 635

B
FIGURE 25-15 Sinus tachycardia with frequent, uniform PV(s (A) and with multiform PV(s (B). (From Aehlert B: ECGs made easy, ed 5,
St Louis, 2013, Mosby.)

I I
25-15). PVCs can result from the use of tobacco, alcohol, medica-
n \ II tions containing epinephrine, and occasionally from anxiety. Infre-
I ~ II 'F
-
IA
' quent PVCs are not abnormal, but they become a medical concern
\ if they regularly occur more than six times a minute. Pathologic
A PVCs occur in patients with hypertension, coronary artery disease,
and lung disease.
Ventricular tachycardia (commonly referred to as V-tach)
(Figure 25-16, C) is diagnosed when the ventricles beat at
extremely rapid rates. It may be seen when multiple PVCs occur
in a row or as a short run of fast beats, or it may persist longer
than 30 seconds. The patient's heart rate may range from 101 to
250 beats/min. V-tach can precede ventricular fibrillation if not
reversed with drugs, cardioversion, or both. V-tach always reflects
a pathologic state.
Ventricular fibrillation (commonly referred to as V-fib) (Figure
25-16, D ) is the most critical, life-threatening arrhythmia; it
quickly results in death if not treated. V-fib is estimated to precede
85% of cases of cardiac arrest in adults. In V-fib, the electrical
conduction system of the heart is in total dysfunction. The heart
muscle quivers uncontrollably and is essentially ineffective at
""" pumping any blood; therefore, there is no pulse, and the patient is
E unresponsive and not breathing. Cardioversion with a defibrilla-
FIGURE 25-16 Ventricular arrhythmias. A, PVC. B, Three PVCs in a row. C, V-tach. D, V-fib. tor is necessary to restore normal function of the electrical con-
E, Asystole.
duction system.
Asystole is the result of absence of a heartbeat, or cardiac cessa-
tion, which shows as a flatline on the ECG (Figure 25-16, E) .
many ectopic atrial locations but are blocked at the AV node,
which prevents ventricular fibrillation. Atrial flutter is reversed with Biochemical Arrhythmias
medication to slow the heart or with cardioversion (electrical Heart or blood pressure medications may cause an arrhythmia. For
shock). example, digitalis, frequently called dig (pronounced dij), is a
common cardiac drug used to slow and strengthen the heartbeat.
Ventricular Arrhythmias The heart is quite sensitive to digitalis, and too much can prove toxic
Premature ventricular contractions (PVCs; Figure 25-16, A and B) and cause changes in the ECG (Figure 25-17). This condition can
occur when the ventricles contract before they should for the next be reversed by reducing the dosage of digoxin or digitoxin (both are
cardiac cycle; that is, a QRS complex appears before a P wave. forms of digitalis).
PVCs occur when an electrical charge originates in either ventricle. Potassium is a critical mineral for normal cardiac function. Too
This can appear on the ECG as an absent P wave, an abnormally much potassium in the blood (hyperkalemia) or too little (hypoka-
shaped T wave, and a widened QRS complex. This is followed by a lemia) can both cause life-threatening arrhythmias that must be
pause before the initiation of the next cardiac cycle (see Figure corrected quickly.
636 UNIT FOUR DIAGNOSTIC PROCEDURES

FIGURE 25-17 ECG showing the effects of digitalis. Note the "scooping" of the ST segment, as seen in leads V5 and V6• (Goldberger A: Clinical
electrocardiography: asimplified approach, ed 6, St Louis, 1999, Mosby.)

f\ r' r, I~ ~
.
l I'
i\
r-1\
' n '
I

~
11
' .... .,
I
~
- l ' ,
- l\ \
- nl
I
1 1
V I I

Pacemaker spike
FIGURE 25-18 Pacemaker rhythm strip. (From lewis Set al: Medical-surgical nursing, ed 9, St Louis, 2014, Mosby.)

Pacemakers are implanted in a hospital, and local anesthesia is

Pacemaker Rhythms
A pacemaker is a device implanted under the skin that stimulates
the electrical activity of the heart. It consists of a small metal pulse
generator with a battery and electronic leads that extend from the
generator to the myocardium. The entire pulse generator is replaced
when the battery wears out, usually every 5 to 10 years.
used. Before the patient is discharged, the device is programmed to
fire according to the needs of the individual patient. The patient is
instructed to telephone the physician's office periodically to transmit
pacemaker readings across the phone lines; however, this method is
being replaced by Internet transmission of data. Internet diagnostic
reports can be exported to the patient's EHR. Pacemakers cause wide
variations in the appearance of an ECG (Figure 25-18).

Pacemakers Implanted Cardioverter-Defibrillator

Apacemaker is a small device that is placed in the chest or abdomen to
help control abnormal heart rhythms. It uses electrical pulses to prompt the
heart to beat at a normal rate. Pacemakers can do the following:
• Speed up a slow heart rhythm.
• Help control an abnormal or fast heart rhythm.
• Make sure the ventricles contract normally if the atria are quivering
instead of beating with a normal rhythm (atrial fibrillation).
• Coordinate electrical signaling between the upper and lower cham-
bers of the heart.
• Cardiac resynchronization therapy (CRT) pacemakers: Coordinate
electrical signaling between the ventricles (these are used to treat
congestive heart failure).
• Prevent dangerous arrhythmias.
• Monitor and record the heart's electrical activity and heart rhythm.
• Can monitor blood temperature, breathing rate, and other factors
(some brands).
• Adjust the heart rate to changes in activity.
National Heart, lung, and Blood Institute. www.nhlbi.nih.govjhealthjhealth-topics/
topics/pace. Accessed February 16, 2016.
An implanted cardioverter-defibrillator, or ICD, monitors the heart
rhythm and delivers a shock to the heart if it detects a dangerous
ventricular tachycardia or fibrillation (Figure 25-19). It is a small,
battery-operated device that is implanted under the skin in the chest
or abdomen. An ICD can be used to reverse V-tach and V-fib, espe-
cially after the patient has previously had a myocardial infarction
(MI), or heart attack. The generator is programmed specifically to
treat the patient's particular or potential cardiac arrhythmia. An ICD
has wires with electrodes on the ends that connect to the heart
chambers. If the device detects an irregular rhythm in the ventricles,
it uses low-energy electrical pulses to restore a normal rhythm. If the
low-energy pulses do not restore normal heart rhythm, the ICD
switches to high-energy pulses for defibrillation. The device also
switches to high-energy pulses if the ventricles start to quiver rather
than contract strongly. The high-energy pulses last only a fraction of
a second, but they can be painful.
Just as with pacemakers, the device is programmed to meet the
needs of each individual patient. Some ICD functions can be
checked over the phone or through a computer connection to the
Internet. ICD batteries last 5 to 7 years. The generator and battery
are replaced before the battery begins to run down.
 CHAPTER 25 Principles of Electrocardiography 637

•
• HIGH-ENERGY
DEFIBRILLATION

•
PACING
CARDIOVERSION

If dysrhythmia continues,
High-energy shock
therapy for ventricular
fibrillation, designed to
stop the heart and
•
the IC automatically
instantly reset the rhythm.
delivers low-energy
In most cases of This feels like a sudden
synchronized shocks.
ventricular tachycardia, "kick in the chest."
•
the IC can restore
Mild discomfort.
normal heart rhythm with
C painless pacing therapy.

FIGURE 25-19 Implanted cardioverter-defibrillator. (From Urden L, Stacy K, Lough M: Thelan's critical care nursing: diagnosis and management,
ed 7, St Louis, 2014, Mosby.)

Myocardial Infarction MI causes specific, recognizable changes on the ECG recording,

Sudden heart attack, or MI, occurs in more than 1 million Ameri-
cans each year, according to the American Heart Association.
Approximately 20% of these patients die before reaching the hospi-
tal, and approximately 30% die within 30 days of the heart attack.
An MI occurs when a portion of the heart muscle becomes ischemic
because the blood supply to that area has been interrupted. Ischemia
eventually leads to tissue necrosis, or infarction.
The heart muscle, the myocardium, receives its oxygen supply
from a network of coronary arteries (Figure 25-20) on the surface
of the heart. The right coronary artery supplies much of the right
side of the heart. The left coronary artery bifurcates into two main
branches: the left circumflex artery, which supplies blood principally
to the left lateral and posterior walls of the left ventricle, and the left
anterior descending coronary artery, which supplies principally the
anterior wall of the left ventricle and the interventricular septum.
The left anterior descending coronary artery is sometimes called the
"sudden death artery'' because it feeds such a large portion of the
left ventricle.
based on the phase the patient is in when the ECG is recorded (Table
25-4). The three most common changes are elevated ST segments,
inverted (upside-down) T waves, and abnormal (pathologic) Q
waves (Figure 25-21 ).
The sooner treatment is initiated after the patient's first awareness
of a heart attack, the more effective treatment is and the better the
chances for the patient's survival. Immediate treatment for a heart
attack includes administration of nasal oxygen, sublingual nitroglyc-
erin (to dilate the coronary arteries), a narcotic analgesic (to eliminate
pain), aspirin (to reduce inflammation and decrease clotting time),
and possibly a thrombolytic agent to dissolve the clot causing the
coronary artery obstruction. Early administration of thrombolytic
agents enhances the likelihood of restoring circulation to the myo-
cardium distal to the occluding thrombus (blood clot). After dis-
charge from the hospital, the patient should quit smoking, modify
the diet as instructed by a nutritionist, and enter a cardiac rehabilita-
tion program to improve cardiac strength and recovery through
exercise.
638 UNIT FOUR DIAGNOSTIC PROCEDURES

Right common c a r o t i d - - - - - --- Left common carotid artery

artery ,___ _ _ _ _ _ Left subclavian artery
Right subclavian artery Aortic arch
Brachiocephalic artery

Superior vena cava

~ - - - Left pulmonary artery

1=~ - - - Left atrium

Left coronary artery

Left coronary vein

Right atrium

Left ventricle
Right coronary artery

Right coronary vein

Anterior coronary artery
Right ventricle
Apex

Pericardium
FIGURE 25-20 Coronary vessels.

25-22). The goal is to determine if the myocardium is getting enough

TABLE 25-4 Phases of Myocardial Infarction With blood during exercise. A stress test is done to:
Electrocardiographic Changes • Diagnose cardiac disease that cannot be detected by a standard
PERIOD OF SPECIFIC ECG resting ECG
• Determine abnormal changes in heart rate or blood
PHASE ECG CHANGES CHANGES
pressure
I (hyperacute) First few hours ST segment elevated from • Detect symptoms such as shortness of breath or angina, espe-
baseline (earliest indication cially if they occur at low levels of exercise
on ECG); peaked • Identify and record abnormal changes in the heart's rhythm
"hyperacute" Twaves or electrical activity
A stress test is performed while the patient is exercising on either
II (fully evolved) After hours or days Deep Twaves; pathologic Q a bicycle or a treadmill, under careful supervision. The patient must
waves appear (negative be given the appropriate information explaining the purpose, prepa-
deflection) ration, and procedure for the test (Figure 25-23).
Myocardial ischemia and even cardiac arrest are serious risks
Ill (resolution) Days to weeks ST segment returns to
with a cardiac stress test. The medical assistant must be able to
normal position; Twaves
recognize symptoms of dyspnea, vertigo, extreme fatigue, severe
return to normal arrhythmia, and other abnormal ECG readings that may develop
IV (stabilized chronic) Permanent Negative Qwave deflection during the stress test or immediately after the test during the rest
remains period. All members of a cardiac stress testing team must be pre-
pared to terminate testing immediately if the patient is unable
to continue or if abnormalities appear on the monitor. Team
members also must be certified in cardiopulmonary resuscitation
Complications of acute MI include a sudden episode of atrial (CPR) and emergency intervention. The physician must always
fibrillation, V-fib, or bradycardia that may necessitate implantation be present during this procedure. In addition to the routine moni-
of a pacemaker. toring equipment, the team must have oxygen, a defibrillator, an
endotracheal intubation tray, an artificial breathing bag, and emer-
gency cardiac medications available in case of cardiac crisis.
RELATED CARDIAC DIAGNOSTIC TESTS
Because of the potential for life-threatening incidents, most physi-
Stress Test cians have stress tests performed in a hospital or specialized cardiac
Cardiac stress testing is performed to observe and record the patient's center, where personnel are trained and ready to assist if a cardiac
cardiovascular response to measured exercise challenges (Figure emergency occurs.

Hyperacute phase Early acute phase
Tall Twave
I /\
- J,
Fully evolved phase
Elevated ST-
segment
~ --,
A
Inverted T wave
\ Qwave
FIGURE 25-21 Changes in the PQRST segment associated with a myocardial infarction. (Butler HA, Caplin M, McCully Eet al: Managing
major diseases: cardiac disorders, vol 2, St Louis, 1999, Mosby.)
FIGURE 25-22 Cardiac stress test. (Courtesy Cardiac Science, Bothell, Wash.)
CRITICAL THINKING APPLICATION
Mr. Sonderford actually had an Ml when he was previously at Dr. Lee's
office. He now has completed cardiac rehabilitation and is at the office for
a checkup. Dr. Lee wants him ta be scheduled for a stress test. Mr. Sonder-
ford has never had one before. He confides to Martha that he is afraid if
he does the test, he will die from another heart attack. How should Martha
handle this situation?
Holter Monitor
A Holter monitor is a portable system for recording a patient's
cardiac activity over a 24-hour period or longer (Procedure 25-2).
The monitor is a small, lightweight device that the patient wears
while going about usual daily activities. The Holter monitor can be
programmed to record cardiac information continuously or periodi-
cally, when activated by the patient if symptoms occur, or during
periods of stress.
The entire time the monitor is worn, the patient must keep a
journal of all stressful events and activities (and also specific details
CHAPTER 25 Principles of Electrocardiography 639
Later acute phase
Tall Twave Elevated ST-
A
~
Elevated ST-
Iu --\ segment
Inverted T wave
I segment I
Healed phase (stabilized chronic)
A. t -----
I
Qwave
about activities when any cardiac symptoms occur). Journal entries
include the time, duration, and specific activity during the cardiac
event, such as rush hour traffic, bowel movements, intercourse,
climbing stairs, and periods of anger or emotional distress. Some
monitors can even record the patient's voice describing a symptom
or event so that it can later be correlated with the ECG recording
in the same time frame.
Many cardiologists routinely use Holter monitors in their prac-
tices. A medical assistant ofren is responsible for fitting the monitor
on the patient and for removing it after the test period. The patient
must have a full understanding of what is required during monitor-
ing, particularly how to use the event marker in case a significant
symptom is experienced. The patient also must know how to record
the event in a written diary when the event marker is used. The
patient may take only sponge baths during the 24 hours of the test.
The number of electrodes and leads varies with the number of chan-
nels on the particular monitor. Electrode placement is determined
by the provider or by the manufacturer's guidelines and should be
followed precisely. The skin of male patients may need to be shaved
so that the electrodes can be firmly attached. The lead wires are
25-5 attached to the electrodes and to the Holter monitor, which is worn
around the waist or on a belt or in a pouch slung over the
shoulder.
At the end of the monitoring period, the patient returns to the
clinic, the monitor is disconnected, and electrodes are removed. The
recording is placed in a Holter scanner or computer, and the results
are analyzed. Any part of the recording can be printed or down-
loaded into the patient's EHR for further study.
CRITICAL THINKING APPLICATION 25-6
Mrs. Jamison was fitted with a Halter monitor at the clinic yesterday at 4
PM. When Martha arrived at 8 o'clock this morning, she found that Mrs.
Jamison had left a message with the answering service to call her as soon
as possible. When Martha returns the call, Mrs. Jamison tells her that she
had taken a shower last night, and she noticed that when she got up ta
go to the bathroom, "the light was not on" on the monitor. How should
Martha handle this situation?
640 UNIT FOUR DIAGNOSTIC PROCEDURES

Cardiac Stress Test The Procedure

Cardiac stress testing (also known as an exercise tolerance
test or treadmill test) is a means of observing, evaluating, and
recording your heart's response during a measured exercise
test. This test determines your capacity to adapt to physical
stress.
There are various reasons that your physician may suggest
this test for you:
1. To aid in determining the presence of suspected coronary
heart disease.
2. To aid in the selection of therapy.
a. For angina pectoris (tightness or pain in the chest).
b. Following a myocardial infarction (heart attack).
c. Following coronary bypass surgery (open heart surgery).
3. To determine your physical work capacity.
4. To authorize participation in a physical exercise program.
Preparation for the Test
1. Avoid eating a heavy meal within 2 hours of your
appointment.
2. Take your medications as you usually do, unless your doctor
advises you not to take them.
3. Wear a shirt or blouse that buttons down the front with
slacks, a skirt, jogging pants, or shorts.
4. Do not wear one-piece undergarments, jumpsuits, or
dresses.
5. Tennis shoes are ideal if you have them. Otherwise, wear
comfortable flat or low-heeled shoes. Do not wear clogs,
sling-backs, crepe soles, boots, or high heels, as they make
walking on the treadmill more difficult.
When you arrive in the Cardiology Department, areas of your
chest may be shaved (men only) to allow the electrodes to
adhere tightly to your chest. A blood pressure cuff will be
wrapped around your arm, and an electrocardiogram (ECG) is
taken while you are at rest. The technician will then
demonstrate how to walk on the treadmill and will answer any
questions you may have.
You will then perform a graded exercise test on a
motor-driven treadmill. You will begin walking very gradually at
a rate you can easily accomplish.
Progressively throughout the test, the speed and grade of the
treadmill will be increased, and you will be walking at a faster
pace up a slight incline. At no time will you be asked to jog or
run, nor will you be asked to exercise beyond your capabilities.
At all times during the test, trained personnel are in the room
with you, monitoring your heart rate and blood pressure and
observing you for signs of fatigue or discomfort. We do not wish
to exercise you to a level that is medically unsafe or physically
distressing.
An ECG is taken again when you finish walking. Your
cardiologist will immediately interpret the results of the test and
explain his or her findings to you. If necessary, medications or
treatment will be discussed. A letter with the results of the
stress test will be sent to your referring physician.
The entire procedure will take 1 to 1 1/2 hours. If you have
any questions regarding the cardiac stress test or any problems
with your appointment, please contact us.

FIGURE 25-23 Patient information for a cardiac stress test.

Instruct and Prepare a Patient for a Procedure or Treatment: Fit a Patient With a
PROCEDURE 25-2
Holter Monitor

Goal: To establish apossible correlation between ECG abnormalities and the patient's 24-hour daily activities.

EQUIPMENT and SUPPLIES

• Patient's health record
• Holter monitor with new batteries
• Disposable electrodes
• Razor
• Sharps container

cl
• Gauze pads or abrasive tool as needed
• Activity diary
• Carrying case with belt or shoulder strap
• Alcohol swabs ~
• Cloth tape (nonallergenic)
PROCEDURAL STEPS
1. Sanitize your hands.
PURPOSE: To ensure infection control.
f --
2. Greet the patient and confirm his or her identity by name and date of
birth.
3. Assemble the needed equipment, and install batteries in the monitor
(Figure 1). 1 (Courtesy Welch Allyn, Skaneateles Falls, NY.)
 CHAPTER 25 Principles of Electrocardiography 641

•;;m!,mj;jfffI -continued
PURPOSE: New or fully charged batteries ensure accurate monitor function
for 24 hours.
4. Explain the procedure. Sanitize your hands.
PURPOSE: An informed patient helps ensure testing accuracy.
S. Ask the patient to disrobe to the waist and to sit at the end of the examina-
tion table or to lie down.
PURPOSE: This places the patient at the best working level for the medical
assistant.
6. Clean each electrode application site with an alcohol swab and allow the
sites to air dry.
PURPOSE: To remove all surface skin oil to ensure maximum electrode
adherence. If shaving will be necessary, clean before shaving to prevent
irritation and patient discomfort.
7. If the patient has a hairy chest, dry shave the area at each of the electrode
sites.
PURPOSE: The skin must be hairless to provide maximum electrode
adherence.
8. Fold a gauze pad over your index finger and briskly rub the sites or use
an abrasive tool as indicated (Figure 2).
PURPOSE: To help electrodes stick more tightly to the skin.

2 11. Place a strip of cloth tape over each electrode.
9. Apply the electrodes to the sites recommended by the manufacturer; use
enough pressure to make sure they adhere completely to the skin. Rub
the edges of each electrode a second time to make sure the electrode will
stay in place (Figures 3 and 4).
PURPOSE: Secure attachment of the electrodes is absolutely necessary to
produce an accurate tracing.
1o. Attach the lead wires to the electrodes and connect the end terminal to
the patient cable.
PURPOSE: To help secure the electrodes in place in case the wires are
pulled during the testing period.
12. Attach the test cable to the monitor and plug it into the electrocardiograph.
Run a baseline test tracing as directed by the manufacturer's guidelines.
PURPOSE: To ensure proper connections of the electrodes and running of
the monitor.
13. Help the patient get dressed without disturbing the connected electrodes.
Make sure the cable extends through the buttoned front or out the bottom
of the shirt or blouse.
14. Place the monitor in the carrying case and attach it to the patient's belt
or pocket or place it over the shoulder. Be sure the wires are not being
pulled or bent.
PURPOSE: Tout or badly bent wires may loosen or malfunction.
1S. Plug the electrode cable into the monitor.
16. Record the patient's name and date of birth and the starting date and
time in the patient's activity diary.
PURPOSE: To establish the starting time of the test and cardiac activity.
642 UNIT FOUR DIAGNOSTIC PROCEDURES
•;;m!,mj;jfffI -continued
17. Give the patient the activity diary and advise him or her to begin by writing
in his or her present activity (Figure 5). Include patient education informa-
tion on the importance of continually recording activities in the diary; using
the event marker on the monitor if he or she experiences any symptoms;
and correlating the event with a recording in the diary, including the time
and details of the related activity before or during the event.
PURPOSE: The diary should correlate the patient's activity with any cardiac
symptoms.
Cardiac Event Monitor
The cardiac event monitor is a small recording device that can be
worn up to 30 days to catch events that are difficult to record in a
24-hour period on a Holter monitor, such as chest pain, vertigo,
weakness, and palpitations. Some monitors have a feature (memory
loop recorder) that captures a short period before the moment the
recording is triggered and for a short time afterward. This feature
can help the provider learn more details about the possible change
in the ECG at the time the symptoms started. Other monitors, called
"post-event recorders," start recording the ECG from the moment
it is triggered. Post-event recorders are quite small and may be worn
on the wrist (similar to a wristwatch). Memory-loop recorders are
about the size of a pager. Any recordings of cardiac events are sent
to either the healthcare facility for the physician to interpret or to a
central monitoring center. The transmission is done either over the
telephone or wirelessly using cellular technology. Before leaving the
office, the patient needs instruction on how to transmit data. The
patient is also told to write down all symptoms with whatever activ-
ity was occurring at the time (as is done during the Holter monitor-
ing procedure).
Using the information gathered during the recording period, the
physician can diagnose heart abnormalities and design the most
effective treatment. The monitor must be removed during bathing,
so the patient must be taught how to remove and reapply the elec-
trodes throughout the test period. Patient education for using an
event monitor includes the following instructions:
18. Schedule the patient far a return appointment in 24 hours.
19. Sanitize your hands.
PURPOSE: To ensure infection control.
20. Record the procedure in the patient's health record.
PURPOSE: Aprocedure is not considered done until it is documented in
the patient's health record.
9/29/20- 3: 10 PM: Holter monitor applied per Dr. Lee's order. Pt instructed
to leave leads in place until he returns to office tomorrow. Understands to record
cardiac symptoms in diary, to use event marker if symptoms occur, and not to
shower until monitor is removed. Martha Reyes, (MA (AAMA)
• Protect the monitor from damage, and wear it at all times
except when bathing.
• Do not alter your lifestyle; regular activities need to be main-
tained to reflect the cause of cardiac symptoms.
• Trigger the recording by pushing the event monitor when
symptoms occur.
• Use the diary to record activities when events occur.
• Change the electrodes daily and the batteries at the same time
each day.
• To prevent skin irritation, do not put replacement electrodes
in the same spot.
• Put the electrodes on the rib cage under the left breast and in
the midaxillary region under the right shoulder.
• If you have any questions, use the contact information
provided.
Heart Scan
A noninvasive method of assessing possible cardiac risk is a special-
ized type of computed tomography called an electron beam tomogra-
phy (EBT) heart scan (also called an ultrafast CT). The heart scan
takes less than 5 minutes and does not require any needles or injec-
tions. It is a screening tool that allows physicians to see the amount
of plaque in the coronary arteries by showing the presence of calcium
deposits. Calcium makes up approximately 20% of arterial plaque
deposits. The EBT heart scan is read, and the physician assigns the
patient a calcium score that can be a predictor of future cardiac
problems.

CLOSING COMMENTS
Patient Education
Heart disease and stroke account for more than one third of all
deaths. Genetic predisposition and detrimental lifestyle habits, such
as smoking, lack of exercise, a diet high in saturated fats, and obesity,
play significant roles in the development of heart disease. The
medical assistant should talk to the patient about factors that can be
changed or modified and should encourage any attempt by the
patient to make these changes.
Before you can successfully counsel a patient to change a habit,
you need to familiarize yourself with possible techniques and
approaches to use. Such information can be obtained from the
American Heart Association and reputable Internet sites.
Many patients like visual aids when they are learning new infor-
mation, and brochures with pictures or posters in the office are
effective means of promoting learning and eliciting questions from
patients. Make a note in the health record of the educational items
you give the patient on each visit. On a subsequent visit, ask about
the helpfulness of the information, whether the patient tried any
modifications, and what the results were. Ask for any suggestions
that might help another patient in a similar situation.
Legal and Ethical Issues
An ECG is a valuable diagnostic tool, and it continues to be one of
the most common procedures used in the diagnosis of cardiac dis-
eases and conditions. The cardiologist measures the heart's activity
and compares the results with known values by analyzing the ECG
tracing. Comparing an ECG tracing with previous tracings can
identify changes in the condition of the patient's heart.
SCENARIO
Martha has worked in Dr. Lee's office for almost 8 months. She has become
quite confident in her ability to perform electrocardiography quickly and accu-
rately. She also has learned to communicate effectively with patients about
their fears and concerns about various cardiac diagnostic tests. She never forgets
to emphasize to a patient the importance of not taking a shower during the
SUMMARY OF LEARNING OBJECTIVES
l. Define, spell, and pronounce the terms listed in the vocabulary.
Spelling and pronouncing medical terms correctly reinforce the medical
assistant's credibility. Knowing the definitions of these terms promotes
confidence in communication with patients and co-workers.
2. Illustrate the electrical conduction system through the heart and
discuss the cardiac cycle.
The heart beats in response to an electrical signal that originates in the
SA node in the right atrium, spreads over the atria, and causes atrial
contraction. This impulse continues to the AV node, through the bundle
of His, through the right and left bundle branches, and into the Purkinje
fibers, eventually causing ventricular contraction.
3. Explain the concepts of cardiac polarization, depolarization, and
repolarization.
CHAPTER 25 Principles of Electrocardiography 643
The provider must be able to interpret the ECG tracing accu-
rately and to establish its value in correctly diagnosing the patient's
condition; the medical assistant, therefore, has the ethical obligation
to complete the task as accurately and carefully as possible. Diagnos-
tic procedures have a profound effect on a patient's subsequent
treatment. When you are entrusted with performing testing proce-
dures, you assume full responsibility for the accuracy and precision
of each test you perform. This is a critical role in the medical assisting
profession. The results you submit strongly influence each patient's
therapeutic treatment plan. No test is ever just routine.
Professional Behaviors
Cardiovascular disease affects a wide variety af individuals across all
genders, races, and incomes. Each one af us will likely know someone or
have a close personal connection to an individual who has some type of
cardiovascular condition. Because of this, it can be very easy to assume
you know how to answer patients' questions, and it may be tempting to
offer advice about how to manage their conditions. Always remember that
medical assistants do not have the knowledge or authority to diagnose or
prescribe treatment, regardless of how familiar they are personally with the
topic. Refer complex patient questions to the physician, document patients'
concerns in the health record, and always follow the practice's policies and
procedures when giving the patient information. Professional behavior
means being empathetic toward the patient, but always remember that
the medical assistant is part of a healthcare team, and restrict your practice
to what is ethically and legally permitted.
24-hour Holter monitoring period. In 2 months she and Dr. Lee will attend a
national meeting of cardiologists in Chicago. Two days of continuing education
classes will be offered for medical assistants who work in cardiology. Martha is
very excited to be able to continue learning and to sharpen her skills as a
medical assistant in cardiology.
Polarization is the resting state of the myocardial wall, when there is no
electrical activity in the heart. When the electrical system of the heart
stimulates a myocardial cell, depolarization occurs, resulting in contrac-
tion of the stimulated heart muscle. The heart muscle cells must then
return to a resting state; the process of reaching this resting state is
repolarization.
4. Identify the PQRST complex on an electrocardiograph tracing.
The Pwave shows atrial contraction, the beginning of cardiac depolariza-
tion; the PR segment is the return to baseline after atrial contraction; the
PR interval is the time from the beginning of atrial contraction to the
beginning of ventricular contraction; the QRS complex shows the contrac-
tion of both ventricles and the completion of cardiac depolarization; the
ST segment is the time between the end of ventricular contraction and
Continued
644 UNIT FOUR DIAGNOSTIC PROCEDURES
SUMMARY OF LEARNING OBJECTIVES-continued
the beginning of ventricular recovery; the Twave is repolarization of the
ventricles; the QT interval is the time between the beginning of the QRS
complex through the Twave; a Uwave occasionally can be seen as a
small waveform just after the Twave in certain patients.
5. Summarize the properties of the electrocardiograph and discuss the
features of electrocardiograph paper.
Asix-channel ECG machine records all 12 leads simultaneously within
seconds. Limb and chest electrodes with leads must be placed on the
patient at specific anatomic locations before the recording starts. ECG
paper is standardized to represent amplitude and time. The horizontal
lines allow determination of the intensity of the electrical activity, and
the vertical lines represent time; each of the large squares represents 0.2
second; five of them equals 1 second.
6. Describe the electrical views of the heart recorded by the 12-lead
electrocardiograph.
Lead Irecords the electrical activity af the lateral part af the left ventricle;
leads II and Ill record the electrical activity of the inferior surface of the
left ventricle. The augmented lead aVR records the electrical activity of
the atria with negative deflection of the Pwaves and QRS complexes;
aVL records the electrical activity of the lateral wall of the left ventricle;
and aVF records the electrical activity of the inferior surface of the left
ventricle. The precordial leads provide a transverse plane view of the
heart. They include Vi, V2, V3, V4, V5, and V6, with each number repre-
senting a specific location on the chest. The QRS complex is a negative
deflection in Vi and V2views, and each subsequent lead becomes more
positive.
7. Discuss the process of recording an electrocardiogram and perform
an accurate recording of the electrical activity of the heart.
Recording an ECG requires knowledge of how to prepare the room and
patient; where ta place the electrodes and connect the leads to obtain
the mast accurate recording possible; the ability to recognize and correct
the most common types af artifacts on the ECG recording; proper use of
the machine available; and knowledge of how best to record ECG tracings
in the medical record. Procedure 25-1 outlines the steps for performing
a 12-lead ECG recording.
8. Compare and contrast electrocardiographic artifacts and the prob-
able cause of each.
An artifact is an unwanted, erratic movement of the stylus on the paper
caused by outside interference. The main types include wandering base-
line artifacts, in which the stylus gradually shifts away from the center
of the paper because of slight movement or poor electrode attachment;
somatic tremor artifacts, which are a result of muscle movements in the
patient that cause jagged peaks of irregular height and spacing and a
shifting baseline; AC interference, which causes a series af uniform, small
CONNECTIONS
CrJ Study Guide Connection: Go to the Chapter 25 Study Guide. Read and complete
the activities.
spikes an the paper because of electrical energy in the area; and inter-
rupted baseline artifacts, which occur when the electrical connection
between the electrode and the lead is interrupted.
9. Interpret a typical electrocardiograph tracing.
Table 25-2 summarizes the normal appearance of ECG waveforms and
complexes. The ECG tracing is made up of repeated cardiac cycle (PQRST)
recordings. The heart rate is calculated from the ECG recording by count-
ing the number of Pwaves in a 6-second strip (30 large squares) and
multiplying by l 0. Far the ventricular contraction rate, the number of
complete QRS complexes within 6 seconds is counted and multiplied by
10 to get the number of ventricular contractions in 1 minute. The rhythm
of the patient's heartbeat indicates whether it is regular. If the patient's
heart is beating at a regular rhythm, each cardiac cycle occurs within the
same time frame and individual cardiac cycles occur exactly the same
length of time apart.
l 0. Describe common electrocardiographic arrhythmias.
In sinus rhythm, the heart's electrical activity begins in the SA node and
follows through the electrical system, ending in atrial and ventricular
depolarization. In sinus bradycardia, the heart rate is less than 60 beats/
min; in sinus tachycardia, the rate is more than l 00 beats/min. APAC
occurs when the atria contract before they should for the next cardiac
cycle. Atrial flutter occurs when the atria beat at an extremely rapid rate,
up to 300 beats/min. PVCs occur when the ventricles contract before
they should for the next cardiac cycle. V-tach causes the ventricles to
beat at an extremely rapid rate, from l 01 to 250 beats/min. V-fib is
the most critical, life-threatening arrhythmia and results in death if not
effectively treated. Asystole is the result of no heartbeat. Biochemical
systemic problems also can cause arrhythmias.
11. Summarize cardiac diagnostic tests and fit a patient with a Holter
monitor.
Cardiac diagnostic tests include an ECG; a stress test to determine the
patient's cardiac response to exercise; a 24-hour Holter monitor to pick
up abnormalities during the patient's routine day; a 30-day event monitor
to record infrequent cardiac symptoms; and a heart scan to provide
noninvasive diagnostic information. Procedure 25-2 explains how to fit
a patient with a Holter monitor.
12. Discuss patient education and the legal and ethical issues involved
when performing ECGs.
Diagnostic procedures have a profound effect an a patient's subsequent
treatment. When the medical assistant is entrusted with performing
testing procedures, he or she assumes full responsibility for the accuracy
and precision of tests performed. This is a critical role in the medical
assisting profession. The results you submit strongly influence each
patient's therapeutic treatment plan. No test is ever just routine.
evolve Evolve Connection: Go to the Chapter 25 link at evolve.e/sevier.com/
kinn to complete the Chapter Review Quiz. Check out the other resources listed for this
chapter to make the most of what you have learned from Principles of
Electrocardiography.
ASSISTING WITH
DIAGNOSTIC IMAGING
Sara Elwood, (MA (AAMA), is employed by Metro Urgicenter, an urgent care
clinic in an urban setting. Metro is staffed around the clock and sees patients
with urgent problems that are not immediately life-threatening. The facilities
at the center include an x-ray department, where images of the spine and
the extremities are taken to evaluate for possible fractures. Chest images
also are taken to aid the diagnosis of patients with respiratory complaints.
The center's staff physicians read the x-ray images as they are taken.
While studying this chapter, think about the following questions:
• To fulfill her job description at Metro Urgicenter, what does Sara
need to know about preparing patients for routine x-ray
examinations?
LEARNING OBJECTIVES
1. Define, spell, and pronounce the terms listed in the vocabulary.
2. Discuss basic principles of radiography and the types of Xiays.
3. Identify the principal components of radiographic equipment.
4. Discuss the four prime factors of Xiay exposure.
5. Do the following related to radiographic positioning:
• Distinguish among the three body planes and use these terms
correctly when discussing radiographic positions.
• Differentiate between anteroposterior (AP) and posteroanterior
(PA) projections and describe the lateral and oblique radiographic
positions.
6. Discuss fluoroscopy and contrast media.
7. Discuss cardiovascular and interventional radiography, computed
tomography, magnetic resonance imaging, sonography, and nuclear
medicine.
VOCABULARY
air kerma Kinetic energy released in matter (Gy-.); this is the SI
unit term for radiation exposure that represents the amount of
radiation in the air to reach the patient. It is measured in Gray,
and a subscript "a'' is added to indicate that it is a measurement
of the radiation in the air.
angiocardiography (an-je-o-kahr-de-og'-ruh-fe) Radiography of both
the heart and great vessels using an iodinated contrast medium.
angiography (an-je-og'-ruh-fe) The process of producing an
image of blood vessels using an iodine contrast medium.
26
Afterward, the images are sent to a local hospital for formal interpretation by
a radiologist. Sara often assists Dr. David Swain, a staff physician, by prepar-
ing patients for x-ray examinations and processing images. Sometimes she is
responsible for sending the images to the hospital for interpretation. When a
patient is sent to another facility for special imaging studies, Sara makes the
arrangements and provides the patient with a preliminary explanation of the
procedure.
• What should Sara know about various diagnostic procedures so that she can
effectively provide patient education and answer patients' scheduling questions?
• How are images stored and relayed?
8. Do the following related to basic radiographic procedures:
• Explain the patient preparation guidelines for typical diagnostic
imaging examinations.
• Outline the general procedure for scheduling and sequencing
diagnostic imagining procedures.
• Apply patient education principles when providing instructions for
preparing for diagnostic procedures.
9. Describe the health risks associated with low doses of x-ray exposure,
such as those used in radiography.
10. Describe precautions for ensuring the safety of equipment operators
and staff members during Xi•y procedures.
11. Summarize the steps for ensuring that patients receive the least
possible exposure during Xi•y procedures.
12. Explain the legal responsibilities associated with x-ray procedures and
the administrative management of diagnostic images.
angioplasty (an'-je-o-plas-te) An interventional technique in
which a catheter is used to open or widen a blood vessel to
improve circulation.
anterior (an-ter'-e-ohr) The front part of the body or body part
while in anatomic position.
anteroposterior (AP) projection (an-tuhr-o-pos-ter'-e-ohr) A
frontal projection in which the central ray enters the front of
the patient and exits the back to reach the image receptor; the
patient is supine or facing the x-ray tube.
646 UNIT FOUR DIAGNOSTIC PROCEDURES
VOCABULARY -continued
aortogram (a-or' -tuh-gram) An image of the aorta, created by
using an iodinated contrast medium.
arteriography (ahr-ter-e-og' -ruh-fe) The process of producing an
image of arteries using an iodinated contrast medium.
arthrogram (ahr' -thro-gram) Fluoroscopic record of the soft
tissue components of joints with direct injection of a contrast
medium into the joint capsule.
axial projections Radiographs taken with a longitudinal angulation
of the x-ray beam; sometimes referred to as semiaxial projectiom.
Bucky A moving grid device that holds an image receptor and
prevents scatter radiation from fogging the image.
cassette A special container that holds either film or a
phosphorescent screen inside; it is used to transform an x-ray
beam into a visible image; also referred to as an image receptor
when loaded.
cathartics Laxative preparations.
central ray (CR) An imaginary line in the center of the x-ray
beam that leaves the tube and reaches the patient.
computed tomography (CT) A computerized x-ray imaging
modality that provides axial and three-dimensional scans.
contrast media Substances used to enhance the visibility of soft
tissues in imaging studies.
computed radiography (CR) A modernized x-ray film that uses a
reusable cassette-plate image receptor that stores the image
much like a flash drive used in household computers.
control booth A separated area or room where the x-ray machine
operator can remain safe from radiation while operating
radiography equipment. It is protected by a special wall and/or
window lined with lead. This area houses the control console,
which contains the settings for the machine.
digital radiography (DR) Cassetteless radiography equipment
with built-in image receptors that react to radiation and
transmit a digital signal directly to the computer.
exposure time The duration of the patient's x-ray exposure, in
seconds; the amount of x-rays produced depends on the length
of exposure.
dosimeter A badge for monitoring the radiation exposure of personnel.
fluoroscopy (floo-ros'-kuh-pe) Direct observation of an x-ray
image in motion.
gantry A doughnut-shaped portion of a scanner that surrounds
the patient and functions, at least partly, to gather imaging data.
gray (Gy) The international unit of radiation dose.
image receptor (IR) A device used to transform an x-ray beam
into a visible image; it may include a cassette (with either film
or a phosphorescent screen inside) or a special detector that is
built into the table or Bucky.
intravenous urogram (IVU) Radiographic examination of the
urinary tract using intravenous injection of an iodinated
contrast medium; also called an intravenous pyelogram (IVP).
kilovoltage (kVp) The electrical control setting that determines
the penetrating power of the x-ray beam; the higher the voltage,
the shorter the x-ray wavelengths and the greater the energy of
the x-ray beam.
lateral position A radiographic position labeled according to
which of the patient's sides is facing the image receptor.
limited radiography A simplified role in radiography, usually in
an outpatient setting; also called practical radiography. The
limited radiographer may be referred to as a limited operator or
basic machine operator.
lower gastrointestinal (LGI) series Fluoroscopic examination of
the colon; barium sulfate usually is used as a contrast medium
and is administered rectally; also called a barium enema.
magnetic resonance imaging (MRI) An imaging modality that
uses a magnetic field and radiofrequency pulses to create
computer images of both bones and soft tissues in multiple planes.
milliamperage (mA) The electrical control setting that determines
the amount or concentration of the x-rays by controlling how
rapidly the radiation is produced; the higher the mA setting, the
more x-rays are produced.
myelography (mi-uh-log' -ruh-fe) Fluoroscopic examination of the
spinal canal with spinal injection of an iodinated contrast medium.
NPO Nothing by mouth, from the Latin nil per os.
nuclear medicine An imaging modality that uses radioactive
materials injected or ingested into the body to provide
information about the function of organs and tissues.
oblique position Radiographic position in which the body or
part is rotated at an angle that is neither frontal nor lateral.
posterior The back portion of the body or body part.
posteroanterior (PA) projection A view in which the central ray
enters the back and exits the front of the patient's body; the
patient is prone or facing the image receptor.
radiograph An x-ray image taken by a radiographer in the process
of radiography.
radiographer One who takes x-rays.
radiography The process of creating an x-ray image to examine
internal structures of the body.
radiographic position In radiography, this refers to the
placement of a body part, as seen by the image receptor.
radiographic projection In radiography, this refers to the path
of the central ray from the radiographic tube, through the
patient, and to the image receptor. It is a view, as seen by the
x-ray tube.
radiologist A physician who specializes in medical imaging or
therapeutic applications of radiation.
sievert (Sv) (se'-vuhrt) The international unit of radiation dose
equivalent.
sonography A noninvasive procedure that uses high-frequency
sound waves to produce echoes in the body, which are used to
create images; common, but not limited to fetal imaging (often
referred to as diagnostic ultrasound) .
source-to-image distance (SID) The distance between the x-ray
tube and the film or other image receptor; the greater the
distance, the more widely the x-ray beam is spread and the
lower the intensity of the beam.
tracers Special radioactive materials that are swallowed or injected
intravenously, to track the activity of cells and determine the
location of fractures.
upper gastrointestinal (UGI) series Fluoroscopic examination of
the esophagus, stomach, and duodenum; barium sulfate is used
as a contrast medium and is administered orally.
 CHAPTER 26 Assisting with Diagnostic Imaging 647

X ray images have been used for more than I 00 years to examine
he internal structures of the body. The fascinating field of
medical imaging now includes a wide variety of diagnostic imaging
methods. This chapter provides an overview of imaging modalities
and introduces you to radiography. Emphasis is placed on x-ray
examinations because these are the procedures most commonly per-
formed in the medical assistant's practice setting.

Basic Principles of Radiography

Radiography is the process of creating an x-ray image to examine
internal structures of the body. On November 8, 1895, radiography
was born when Wilhelm Konrad Roentgen (Figure 26-1 ) acciden-
tally discovered the first x-ray during an experiment at a German
university. Thereafter, scientists and physicians became the first
radiographers. Over the years, the process has been further refined,
resulting in more advanced discoveries in diagnostic imaging.
FIGURE 26-1 Wilhelm Konrad Roentgen. (Dibner B: The new rays of Professor Roentgen,
Norwalk, Conn, 1962, Burndy Library Collection, The Huntington Library, San Marino, Calif.)
How X-Rays Are Created
Ironically, x-rays are created from the tiniest possible particles of matter:
atoms. Up close, atoms look a lot like a solar system, with protons and
neutrons combining at the core and electrons circling in orbit. When atoms
get hot, the orbiting electrons spin faster. The hotter it gets, the faster they
spin. Eventually, the force created from the speed causes the electron to
break loose and fly out of orbit, producing an energy stream in its wake.
When enough electrons are involved and are directed by magnetic pull, a
forceful x-ray beam is created.
Because a great deal of heat is needed to create an x-ray beam, a
material that can withstand excessive heat must be used. Tungsten metal
is the preferred material because it has a very high melting point. As a
result, it creates the ability to produce x-rays that are forceful enough to
penetrate and exit the body.

It's All in the Name

• Because the process in radiographic imaging is invisible to the naked
eye, Wilhelm Konrad Roentgen didn't initially know what kind of ray
caused the image he created. Therefore, he called it an "x" ray.
• It is important to note that radiography is different than radiology, which
involves interpretation of images and requires more extensive education
in medical school.

A radiographer is much like a photographer who takes a picture
with a camera and then processes it (Figure 26-2). In radiography,
the camera is larger and more complicated. However, the philosophy
is much the same. The radiographer positions a patient in front of
the "film" and then directs a beam of radiation onto the targeted
area. When the x-ray beam passes through the patient, solid struc-
tures (like bones) leave behind a "shadow," or image, known as a
radiograph (or x-ray).
As with a flashlight beam, when x-rays emerge from the machine,
they create a beam in a conelike field that enlarges as it moves farther
from the energy source. In radiography, the beam of x-rays is called
the radiation field (Figure 26-3, A ). Only items placed within this
FIGURE 26-2 A, Aradiographer is much like a photographer who takes a picture with a camera
and then processes it. B, The x·ray tube housing and collimator appear somewhat similar to a camera.
(A courtesy Helen Mills; Bfrom Frank ED, Long BW, Smith BJ: Merrill's atlas of radiographic positioning
and procedures, ed 12, St Louis, 2013, Mosby.)
field can be imaged. The very center of this field is called the central
ray (CR) (Figure 26-3, B). Because it is the most concentrated point
of radiation, the targeted part typically is placed in this area. Also
similar to a flashlight, the radiation field creates shadows by invisibly
"shining" onto the body and penetrating through everything except
bone. As a result, the area around the bone is darkened, and the
unpenetrated "shadow'' remains white (Figure 26-4).
648 UNIT FOUR DIAGNOSTIC PROCEDURES

~
OI Radiation source
(X-ray tube)

I \
I \
I \
I \
\
I
I \
I \
I \
\
Central ray----+'- __, \
\
I
I \
\
I
\
I
I \
\

Radiation field

B
FIGURE 26-3 A, The collimator's light beam demonstrates the radiation field and aids alignment of the image receptor. As does the x-ray
beam, the conelike shape of the light becomes larger and less concentrated as it gets farther from the x-ray tube. B, The primary x-ray beam leaves
the x-ray tube. The useful part of the beam is called the radiation field. The center of the beam is called the central ray. (A from Bontrager KL,
Lampignano J: Textbook of radiographic positioning and related anatomy, ed 7, St Louis, 2009, Mosby.)

Phalanges

Carpals

Radius

FIGURE 26-4 A, An x-ray creates an image in a manner similar to the way a flashlight beam creates a shadow. B, The hand is placed on
the film, and invisible radiation shines down from above during exposure, as demonstrated by the light of the collimator. (, PA projection of the
hand: the bones block x-rays from reaching the film, creating a white shadow. (A and Bcourtesy Helen Mills; Cfrom Long BW, Frank ED, Ehrlich
RA: Radiography essentials for limited practice, ed 4, Philadelphia, 2013, Sounders.)

Consider a piece of chicken on your dinner plate. Which is
hardest to push a knife through: an area of fat, the thickest area of
meat, or bone? Of course, the bone is hardest because it is the most
dense. As a result, more force is needed to penetrate bone than
muscle or fat. Other factors must be considered, too, such as size.
Less power is needed to pierce a thin bone than a thicker bone.
X-rays work in much the same way. To determine how to adjust
imaging settings, factors such as body size and shape must be taken
into account so that the beam properly penetrates the tissues and
produces a clear image of the area of concern.
Types of X-rays
Radiation is invisible, and it always travels in straight lines. When
an x-ray beam leaves the machine, it is called primary radiation
(Figure 26-5). After it passes through the patient, it is referred to as
remnant radiation; this is what creates the image. When an x-ray
strikes something and bounces in a different direction, it is referred
to as scatter radiation.
Not all x-rays that are produced are useful. When a primary x-ray
beam reaches a patient, the following may occur:
1. Some of the x-ray beam is absorbed by the body, but enough exits
to create an image. This is the main goal in radiography.
2. The x-ray beam is totally absorbed by the body. It does not
produce an image and is not useful.
3. The x-ray beam bounces off the patient or table and lands in
unintended places (scatter radiation). When it lands around the
image, it makes the picture cloudy and more difficult to see. To
obtain a clear image, it is important to reduce scatter radiation
as much as possible.
Aluminum is the primary filtration material used in radiographic
equipment. It is placed between the tube housing port and the
patient, to contain and remove useless radiation. This reduces the
patient dose and makes the process safer. It also results in a cleaner
image, which reduces the likelihood of having to retake a radiograph
for better visualization.
Routine plain images are simple radiographs taken of specific
body structures, such as the chest or the bones of the extremities or
~
Scatt~ ~
II \ ~;:i, /
Radiatio1 /~ ~
r ~
~
I Remnant
Radiation
Image Receptor
(contains the latent image)
FIGURE 26-5 X-ray beam.
CHAPTER 26 Assisting with Diagnostic Imaging 649
spine. These are the examinations most often performed in ambula-
tory care centers and most likely to be performed by limited opera-
tors, who typically are medical assistants licensed to practice
radiography in their state.
Radiographic Equipment
Control Booth
A control booth is a separated area or room where the radiographer
can remain safe from radiation while operating the equipment. It is
protected by a special wall and/or window lined with lead. This area
houses the control console, which contains the settings for the
machine. The control console typically is able to adjust the primary
settings: kilovoltage (kVp), milliamperage (mA), and exposure time
in seconds (s). It also has a button for turning the power to the
console on and off, in addition to two exposure control buttons,
which must be pressed in unison to take the x-ray image.
Image Receptor Systems
The image receptor (IR) creates the x-ray picture when exposed to
radiation. Depending on the type of equipment used, it can take
specific forms.
In older x-ray machines, the IR is a special cassette that holds
traditional film, which must be removed and developed after use
(Figure 26-6). This requires special training in handling and process-
ing the film. A separate "light tight" room is used strictly for devel-
oping. This room must have enough space to store large chemical
tanks, equipment, special lights, unprocessed film, and other materi-
als, in addition to plumbing to provide water for the developing
machine. Once processed, the film also must be stored, which
requires additional storage space. This is an antiquated method that
is being phased out in most offices, but it may still be in use in some
cases.
In computed radiography (CR), the image receptor includes a
reusable cassette plate, also considered an IR, that stores the image
much like a flash drive used in household computers. The x-ray
machine operator inserts the CR plate into a reader, which loads the
image into the computer (Figure 26-7). A high-intensity laser beam
in the processor produces a visible image. This image either is dis-
played on a monitor or printed with a laser film printer. CR has
replaced most film systems to date because it is more convenient and
saves time, money, and space. Processing images on the computer
FIGURE 26-6 Image receptors (IRs). Traditional IR (gray) and computed radiography IR (red).
(Courtesy Helen Mills.)
650 UNIT FOUR DIAGNOSTIC PROCEDURES
FIGURE 26-7 Acomputed radiography image receptor (IR) plate is inserted into a reader to load
the image into the computer. (Courtesy Helen Mills.)
requires much less room and equipment and allows for electronic
storage and transmission.
Digital radiography (DR) is the most modern radiography
equipment. With DR, the image receptor is built into the Bucky;
thus, this system is considered cassetteless, although cassettes are
available for mobile imaging. The digital IR reacts to the radiation
shadow and transmits a digital signal directly to the computer. As a
result, no cassettes or processing typically are involved. In addition,
the computer software may have the capacity to provide further
assistance in determining appropriate settings. This is the preferred
method of radiography because it provides a multitude of options.
As a result of technologic advances, a traditional or computerized
Bucky can be converted to DR by inserting a digital detector into
the existing equipment. Digital sensor Wi-Fi cassettes can also be
used for mobile radiography.
Both CR and DR allow for image adjustments after the x-ray
image is taken. This is preferred because it may reduce the number
of retakes resulting from operator error and thus reduce the patient's
exposure to radiation. Conventional radiographs can be added to the
electronic system by scanning them with a laser device called a film
digitizer; however, both the quality of the images and the ability to
adjust them are limited.
Identification. It is essential to label all images with the patient's
name and birthdate or medical records ID number, in addition to
the date and location of the examination. Serious errors in diagnosis
and treatment might occur if images are not correctly identified.
When traditional film is used, the identification information is typed
on a card that is inserted into the photographic printer in the dark-
room. The printer is used to stamp the information on the film after
it has been removed from the cassette and before it is processed.
With DR and CR, the information is typed into the computer and
superimposed on the image.
TABLE 26-1 Essential Elements of Electronic
Imaging
DICOM Standards for exchanging radiographic
(Digital Imaging and images
Communications in Medicine)
PACS Aserver that stores radiographic images
(Picture Archiving and
Communication System)
Various viewers Software applications that allow the viewer
to study and manipulate images
Technology in Radiography
The computer technology used to store digital images in hospitals
and large healthcare systems is the Picture Archiving and Commu-
nication System (PACS). Viewer software can be used to connect
images with patient database information (e.g., electronic health
records [EHRs]), facilitate laser printing of images, and display
both images and information at workstations throughout the
network as needed. PACS may include transmission equipment
for teleradiology, which allows images both to be viewed in remote
locations (e.g., a physician's home) and received from remote
locations, such as outlying clinics. Through PACS technology,
images can be transmitted directly over telephone lines and via the
Internet.
The software that accesses the PACS system must conform to
specific formats. Digital Imaging and Communications in Medicine
(DICOM) is universally accepted (Table 26-1 ). DICOM is a set of
rules or standards set to ensure that the quality of an image stays the
same, regardless of the equipment used to take, view, or store it.
Because the slightest difference in a radiographic image can have a
significant impact on the patient's diagnosis and care, this is
essential.
Radiographic Table
During testing, patients remain in the x-ray room. They may be lying
on a radiographic table (Figure 26-8) capable of sliding around to
move them into place. The table either has filmlike elements built
into it or a cassette holder that allows an image receptor to be
inserted beneath the patient. It also has a grid, a device that absorbs
unwanted scatter radiation. Together, the grid and image receptor
tray are called a Bucky (Figure 26-9). Body parts less than 10 cm
thick produce relatively less scatter radiation and do not require a
Bucky. In this instance, an image receptor would be placed on top
of the table, with the body part directly on top of it.
An upright cassette holder or upright IR holder is like a miniature
radiographic table that is placed against the wall; with a grid, it is
also called a Bucky. It is useful for x-ray studies that require a patient
to sit or stand.
X-ray Tubes
X-rays are produced in a vacuum-sealed Pyrex glass tube, where
all the components can come together without disruption from

FIGURE 26-8 Radiography table with a tube stand and tube housing; to the side is a standing
Bucky. (From Long BW, Frank ED, Ehrlich RA: Radiography essentials for limited pradice, ed 3, Phila-
delphia, 2010, Saunders.)
FIGURE 26-9 Bucky grid in place under the surface of the x-ray table.
contaminants in the air. To produce the intense heat needed, high-
voltage electrical currents must be created and sent into the tube to
heat a tungsten coil. Once the coil is heated, electrons fly out of
orbit and are flung into a tungsten target, which directs the flow
toward the patient.
The x-ray tube is attached to the wall and/or ceiling to allow it
to hover over the radiographic table. It is surrounded by a lead-lined
housing, which protects the tube and contains the radiation. Tube
supports allow the operator to move the tube in different directions
and to adjust its height. The tube automatically locks into place at
stopping points, known as detents. The lock must be released each
time the tube must be moved. The distance from the tube to the
image receptor typically is set at 40 or 72 inches, depending on the
requirements of the procedure.
Collimator
The collimator is a boxlike device attached beneath the tube housing.
It allows the operator to adjust the size of the radiation field. A light
at the base of the collimator is used to help the operator see the area
that will be affected by radiation, for ease of adjustment. When col-
limating, it is important to make the field large enough to cover the
body part being evaluated, but not so large that it results in unneces-
sary radiation that can cloud the picture and be absorbed by the
patient. Collimation should occur at the center of the image receptor
to allow for a clean, complete image.
CHAPTER 26 Assisting with Diagnostic Imaging 651
Power Supply
A transformer cabinet typically stands in the corner of the room. It
is connected both to the x-ray tube and to the control console by
cables. It produces the high voltage required to create x-rays and the
low mA needed in the x-ray tube.
X-ray Exposure
Prime Factors
The radiographer must take a number of factors into consideration
in determining the proper technique and exposure factors for an
x-ray examination. The four principal exposure factors are called the
prime factors of exposure. The interaction of these factors determines
the level of x-ray production and ultimately the amount of the
patient's x-ray exposure. The prime factors are:
• Milliamperage (mA): The electrical control setting that deter-
mines the amount or concentration of the x-rays by controlling
how rapidly the radiation is produced; the higher the mA setting,
the more x-rays are produced.
• Exposure time (in seconds [s]): The duration of the patient's
x-ray exposure; most exposures are less than 1 second, so the total
time a patient is exposed to the x-ray is measured in milliseconds.
The amount of x-rays produced depends on the length of
exposure.
• Kilovoltage (kVp): The electrical control setting that determines
the penetrating power of the x-ray beam; voltage controls the
speed and power of x-ray beams; the higher the voltage, the shorter
the x-ray wavelengths and the greater the energy of the x-ray
beam. The following box distinguishes between mA and kVp.
• Source-to-image distance (SID): The distance between the x-ray
tube and the film or other image receptor; the greater the dis-
tance, the more widely the x-ray beam will spread and the lower
the intensity of the beam
Memory Aids: kVp versus mA
kVp=power
mA=Amount
The total amount of radiation in an exposure is indicated by the
milliampere-seconds (mAs), which are determined by multiplying
the rate of x-ray current flow (mA) by the exposure time (s).
The mAs directly affects the degree of detail or density visible on the
image. The operator can adjust the amount of radiation to the
patient by adjusting the mA and time settings to administer higher
doses of radiation (mA) for shorter periods (s) (especially useful
when there is uncontrolled movement, such as with a crying child)
or a lower dose for a longer period. The total amount of x-ray expo-
sure used to perform a particular diagnostic study is a combination
ofkVp, mA, exposure time, and SID.
Technique Charts. A technique chart located near the control
console or on the computer screen provides the radiographer with a
list of recommended milliampere-seconds, kilovoltage, and source-
to-image distance settings for x-ray studies of various body parts in
patients of different sizes. The radiographer must refer to technique
charts before performing the ordered radiographic procedure. Some
652 UNIT FOUR DIAGNOSTIC PROCEDURES
control consoles have computerized units that are preprogrammed
with the required exposure settings for the selected body part and
its size.
Radiographic Positioning
Anatomic Locations
To understand how to read an x-ray order and properly position
a patient on the radiographic table, it is essential to understand
anatomic terminology. Terms that indicate the surfaces, directions,
and planes of various body locations are based on anatomic
positioning.
Anatomic position (Figure 26-10) is a view of the body in which
the individual is standing, facing the observer, with the palms of the
hands forward and the thumbs out. When considering these terms,
it is important that you imagine the patient as though standing in
this position. It is also important to remember that designations such
as "right" or "left" are from the patient's viewpoint (i.e., the patient's
right, not the observer's right).
Terms that describe locations on and within the body include the
following:
• Anterior(ventraO: Forward or front portion of the body or body part.
• Cephalic: Pertaining to the head; toward the head.
• Caudal: Toward the tail or end of the body; away from the head;
the opposite of cephalic.
• Distal: Away from the source or point of origin. For example, the
wrist is distal to the elbow, the elbow distal to the shoulder.
• External: To the outside, at or near the surface of the body or a
body part.
• Inferior: Below, farther from the head. For example, the dia-
phragm is inferior to the lungs.
• Internal: Deep, near the center of the body or a part; the opposite
of external.
• Lateral: Referring to the side or away from the center.
FIGURE 26-10 Anatomical position. (From Frank ED, long BW, Smith BJ: Merrill's atlas of
radiographic positioning and procedures, ed 12, St Louis, 2013, Mosby.)
• Medial: Toward the center of the body or body part; the opposite
of lateral.
• Palmar: Referring to the palm (anterior surface) of the hand.
• Plantar: Referring to the sole of the foot.
• Posterior (dorsal): Backward or back portion of the body or body
part; the opposite of anterior.
• Proximal: Toward the source or point of origin; the opposite of
distal. For example, the part of the femur that is attached at the
hip is the proximal end of the femur, and the part of the bone
that is located at the knee is the distal end of the femur.
• Superior: Above, toward the head; the opposite of inferior. For
example, the esophagus is superior to the stomach.
Body Planes
Besides anatomic position terms, the planes of the body may be used
in radiographic imaging (Figure 26-11 ). The sagittal plane divides
the body into right and left parts, and the midsagittal plane divides
the body into equal right and left parts. The coronal plane (some-
times called the frontal plane) divides the body into anterior and
posterior parts. The midcoronal or midfrontal plane divides the body
into relatively equal parts; it passes through the external auditory
meatus (the opening of the ear), the center of the shoulder, the
greater trochanter (the bony prominence in the lateral hip area), and
the lateral malleolus (the bony prominence on the lateral surface of
the ankle). The transverse plane divides the body into superior and
inferior portions; it may be drawn at any level.
Positions
The medical assistant may assist with radiographic procedures by
helping position the patient for a particular x-ray view. Body posi-
tions describe the way a patient is placed.
• Recumbent: Lying down (in any position); the position may be
further described by adding the name of the body surface on
which the patient is lying:
• Dorsal recumbent: Lying on the back (supine) with the knees
bent and the feet flat on the table
Median or
midsagittal
plane
Transverse or
horizontal plane
FIGURE 26-11 Body planes.

• Lateral recumbent: Lying on the side
• Ventral recumbent: Lying face down, prone
• Supine: Lying on the back, face up
• Prone: Lying face down
• Upright: Standing or seated
Radiographic positions describe how a patient is placed as if
seen by the image receptor. These positions can be used as follows
in x-ray positioning:
• Oblique position: At an angle or a slant (Figure 26-12); always
named for the side of the patient nearest the image receptor;
further described by combining with projection terms discussed
later in this chapter.
• Left anterior oblique: Patient's left side is on the image receptor,
with his or her anterior (front) leaning toward the IR.
• Right anterior oblique: Patient's right side is on the image
receptor, with his or her anterior (front) leaning toward the
IR.
• Left posterior oblique: Patient's left side is on the image recep-
tor, with his or her posterior (back) leaning toward the IR.
• Right posterior oblique: Patient's right side is on the image
receptor, with his or her posterior (back) leaning toward the
IR.
• Lateral position: On the side; always named for the side of the
patient nearest the image receptor (Figure 26-13).
• Left lateral: Patient's left side is on the image receptor.
• Right lateral: Patient's right side is on the image receptor.
Radiographic Projections
Sometimes it is helpful to take x-ray images from different views,
to get a complete understanding from different angles. A radio-
A B
FIGURE 26-12 Oblique positions. A, Right onterior oblique (RAO). B, Left anterior oblique (LAO). C, Left posterior oblique (LPO). D, Right
posterior oblique (RPO).
Left lateral
FIGURE 26-13 Lateral positions are named for the side of the body nearer the image receptor.
CHAPTER 26 Assisting with Diagnostic Imaging 653
graphic projection (or view) describes the position of the patient
as though seen by the x-ray tube. 1his is the most accurate term to
describe how the patient is placed for the procedure. It can be used
as follows:
• Anteroposterior (AP) projection: The x-ray beam leaves the
tube, passes through the front of the patient, and exits through
the patient's back to reach the image receptor (Figure 26-14). In
other words, the patient is supine or facing the x-ray tube.
• Posteroanterior (PA) projection: The x-ray beam leaves the
tube, passes through the back of the patient, and exits through
the patient's front to reach the image receptor (Figure 26-15).
In other words, the patient is prone or facing the image
receptor.
With both AP and PA projections, the x-ray beam typically
reaches the patient at a direct 90-degree (perpendicular) angle. When
the beam is tilted slightly, an image can be seen around structures
that otherwise would block the view. Axial projections (or semi-
axial projections) are radiographs taken with a longitudinal angula-
tion of the x-ray beam. The beam is projected at an angle, which is
further described by the beam's direction (Figure 26-16). If the
central ray is described as being cephalad or as having a cephalic
angulation, it enters the patient at an angle, directed toward the
patient's head.
Memory Aids: Position versus Projection
Position: What the image receptor sees
Projection: What the x-ray tube sees
C D
Right lateral
654 UNIT FOUR DIAGNOSTIC PROCEDURES
FIGURE 26-14 Anteroposterior (AP) projection.
FIGURE 26-15 Posteroonterior (PA) projection.
A B
FIGURE 26-16 In axial projections, the x-ray tube is angled to direct the central ray along the long axis of the body or part. A, AP projection
with a cephalic angulation. B, AP projection with a caudal angulation.
Axial Projections
If the central ray (CR) is described as being caudad or having a caudal
angulation, it enters the patient at an angle that is directed away from the
patient's head. This is a method of further detailing both posteroanterior
(PA) and anteroposterior (AP) projections.
For example:
• AP: CR 15-30 degrees cephalad: The x-ray beam is tilted at a 15- to
30-degree angle, rotated toward the patient's head while the patient
is supine or facing the x-ray tube.
• PA: CR ID-20 degrees caudad: The x-ray beam is tilted at a 10- to
20-degree angle, rotated away from the patient's head while the
patient is prone or facing the image receptor.
Markers
When a patient is positioned for an x-ray image, it is important to
align the image receptor, grid, and x-ray beam, with the central ray
at the center of the body part to be evaluated. Markers are then used
to indicate which side of the body is being imaged. Markers are small
squares of plastic with a metal letter in the center that is captured
on the image when placed in the radiation field. Right (R) and left
(L) are used to indicate the side of the body according to anatomic
position (i.e., from the patient's viewpoint). An R or L marker is
placed within the radiation field and appears on the image; this helps
the viewer identify which part is being viewed.
A technique handbook should be kept on hand to ensure that
the correct position is used for the ordered x-ray image.
OTHER DIAGNOSTIC RADIOLOGIC TESTING
Patients typically are sent to another department or facility for more
advanced radiologic testing. Although medical assistants do not gen-
erally perform the procedures for these tests, it is important that they
understand them so that they can educate and prepare the patient.
Some tests focus on a specific organ or body part, whereas others
create images of a general area. Some tests require the administration
of a contrast medium, which enables specific structures to light
up and be seen more easily. Some tests involve fluoroscopy, which
uses special screens that allow movement to be seen as it occurs.
 CHAPTER 26 Assisting with Diagnostic Imaging 655

Regardless of the specifics, all tests require patient education to
prepare patients and ease their concerns.
Fluoroscopy and X-ray Studies That Use
Contrast Media
Fluoroscopy
Fluoroscopy is a technique in which special equipment is used to
allow the radiologist to view x-ray images in motion. Fluoroscopy
also allows the physician to survey an area quickly, without the delay
involved in taking and processing images. Most fluoroscopic units
are properly called radiographicljluoroscopic (RIF) units because they
are designed to take both x-ray images and fluoroscopic views. The
x-ray images taken during a fluoroscopic procedure, which are called
spot films, record the image as seen on the fluoroscope; sometimes
the entire fluoroscopic examination is recorded digitally. After the
fluoroscopic portion of the study is complete, larger radiographs
usually are taken for comprehensive visualization of the entire ana-
tomic region.
An example of a fluoroscopic diagnostic procedure is a barium
swallow. If the provider suspects that the patient has difficulty swal-
lowing, a fluoroscope is used to visualize the actual movement of the
substance down the esophagus and into the stomach while the
patient is in the act of swallowing. Fluoroscopic procedures typically
require the use of a contrast medium, such as barium.
X-ray Studies That Use Contrast Media
Although the lungs and bony structures of the body produce clear
x-ray images on radiographs, internal organs, such as the stomach
and the kidneys, are difficult to see because they absorb radiation to
the same degree as the tissues that surround them. To enhance the
visibility of these structures, special agents, called contrast media,
can be used to fill hollow organs and demonstrate their inner con-
tours. Although gases such as air and carbon dioxide sometimes are
used as contrast media, radiopaque substances (materials that stop
the passage of x-rays, to highlight a particular area), such as barium
sulfate or iodine compounds, are used far more often. The agent and
the technique vary with the structures to be viewed (Table 26-2).
Among the most common fluoroscopic examinations are studies
of the upper and lower gastrointestinal (GI) tract using barium
sulfate as a contrast medium. Both require careful patient instruction
and advance preparation for a successful study. For an upper gas-
trointestinal (UGI) series (Figure 26-17), the patient swallows a
barium sulfate suspension; this study is performed to aid in the
diagnosis of ulcers, tumors, and other abnormalities of the esopha-
gus, stomach, and duodenum.
A lower gastrointestinal (LGI) series (Figure 26-18) involves a
barium enema, which fills the colon and aids visualization of its
inner surfaces. This procedure is especially useful in the diagnosis of
polyps, tumors, and diverticulosis. For this examination, the inner
lining of the large intestine must be clean and free of all fecal matter.
The provider prescribes a commercial bowel preparation kit to ensure
complete emptying of the large intestine. If the preparation is not
adequate, the examination must be rescheduled.
Water-soluble iodine compounds are used as contrast media for
a wide variety of applications. When injected intravenously (IV), the
contrast agent circulates in the blood and is excreted by the kidneys,

TABLE 26-2 Radiographic Procedures That Use Contrast Media

EXAMINATION
Angiocardiography
Angiography
Arteriography
Arthrography
Hysterosalpingography
Intravenous urography;
intravenous pyelography (IVP)
Lower gastrointestinal (GI)
series (barium enema)
Lymphangiography
Myelography
Upper GI series (barium
swallow)
CONTRAST MEDIUM ROUTE OF ADMINISTRATION STRUCTURES SHOWN
Iodine compounds Intra-arterial injection via femoral or brachia! Heart and large vessels
catheter
Iodine compounds Intra-arterial or intravenous injection Blood vessels (further defined by region, i.e.
renal, cerebral, pulmonary, gastrointestinal [GI],
choljgallbladder)
Iodine compounds Intra-arterial injection via catheter Arteries
Iodine compounds Direct injection into joint capsule Joints, especially knee, shoulder, and ankle
Iodine compounds Direct injection via cannula Uterus and fallopian tubes
Iodine compounds, Intravenous injection Kidneys, ureters, and urinary bladder
sometimes air
Barium sulfate suspension, Rectal catheter Colon
sometimes also with air
Iodine compounds Direct injection into lymphatic vessels in the Lymphatic vessels and lymph nodes
feet
Iodine compounds lntrathecal injection (spinal tap) Spinal canal
Barium sulfate suspension Oral Esophagus, stomach, and duodenum
656 UNIT FOUR DIAGNOSTIC PROCEDURES
FIGURE 26-17 Radiographic image of the stomach, part of an upper gastrointestinal (UGI) series
using oral administration of barium sulfate to provide contrast. (From Ballinger PW, Frank ED: Merrill's
arias of radiographic positions and radiologic procedures, ed l 0, vol 2, St Louis, 2003, Mosby.)
FIGURE 26-18 lower gastrointestinal (LGI) series. Radiograph of the colon filled with barium
sulfate administered by barium enema. (From Ballinger PW, Frank ED: Merrill's arias of radiographic
positions and radiologic procedures, ed 10, vol 2, St Louis, 2003, Mosby.)
causing the urine to become radiopaque. Radiography of the kidneys,
ureters, and bladder after IV injection of a contrast medium is called
an intravenous urogram (IVU) (also called an intravenous pyelogram
[IVP]); this study is useful for identifying kidney stones, tumors,
and other abnormalities of the urinary tract. Preparation for an IVU
involves fasting and bowel cleansing because material in the colon
can obstruct a clear picture of the urinary system.
Iodine contrast agents also can be injected into joint capsules to
produce an arthrogram, an image of the soft tissue components of
joints, especially the knee and the shoulder. Myelography involves
injection of iodine compounds and sometimes air into the spinal
FIGURE 26-19 Cerebral angiogram showing the circulation of the brain enhanced by iodine
contrast medium. (From Ballinger PW, Frank ED: Merrill's atlas of radiographic positions and radiologic
procedures, ed l 0, vol 2, St Louis, 2003, Mosby.)
canal to demonstrate pathologic spinal conditions, such as tumors
and herniated intervertebral disks. This diagnostic technique is being
replaced by magnetic resonance imaging (MRI) and computed
tomography (CT) studies, which are less invasive and do not have
the potential complications of a myelogram; however, myelography
is still useful for patients who cannot undergo MRI or CT for other
reasons or if MRI or CT does not provide enough clinical
information.
Part of the screening process for diagnostic procedures that use
iodine contrast injections is careful questioning of the patient about
a history of iodine allergy. All patients who are allergic to shellfish
also will be allergic to iodine dye and are at risk for a serious ana-
phylactic reaction if the contrast agent is injected. The medical
assistant is responsible for clarifying allergies with the patient and/
or family members and alerting the diagnostic facility if the patient
has an iodine allergy. In addition, patients must understand that it
is normal to feel flushed or a heat rush when the dye is injected, and
some patients initially experience waves of nausea. However, both of
these sensations pass quickly.
Cardiovascular and lnterventional Radiography
The highly specialized radiographic procedures that display blood
vessels are collectively known as angiography. A cerebral angiogram,
for example, demonstrates the vessels of the brain (Figure 26-19),
and renal angiograms show the arteries and veins of the kidneys. An
angiocardiogram is a contrast study that shows the interior of the
heart chambers and the great vessels that enter and exit the heart,
and an aortogram demonstrates the aorta. Selective angiocardiog-
raphy, or cardiac catheterization, is used to display the coronary
arteries. Arteriograms are pictures of specific arteries, and venograms
are studies of veins.
For all these examinations, iodine compounds are injected for
radiographic contrast and a rapid series of images are taken or fl.uo-
roscopy is used to show the area of concern. Direct injection may

be used for some angiographic studies, such as those of the extremi-
ties, but the preferred injection method for angiocardiography, aor-
tography, and most arteriography procedures is to use a special
catheter. A large artery (usually the femoral or brachia! artery) is
entered with a large-bore needle, and a guidewire is threaded through
the needle and into the artery under fluoroscopic control. The needle
is removed, the guidewire is left in the vessel, and the catheter is
threaded over the wire. The wire then is removed, and the catheter
remains in the artery for the duration of the examination. Further
manipulation of the catheter may be needed to ensure correct place-
ment in the vessel before injection of the iodine compound. For
selective catheterization of smaller vessels, the catheter tip is maneu-
vered into the root of the vessel of interest, such as the coronary,
celiac, renal, or carotid artery.
A timed sequence of images is taken during and after injection
of the contrast medium, usually with the aid of an automatic power
injector that is electronically coordinated with an automated expo-
sure control. Angiography is used extensively because it provides the
best anatomic view of structures within the circulatory system and
also offers the opportunity for immediate therapeutic interventions
to treat vascular problems as they are identified. Specialized catheter
techniques are used for vessel repair, called angioplasty, to widen or
open arteries that are narrowed or occluded. Embolization is a
therapeutic intervention technique that reduces or stops blood flow
to control hemorrhage, cut off the blood supply to a tumor, or
reduce blood loss during surgery.
Computed Tomography
Computed tomography (CT), formerly called computerized axial
tomography (CAT) scanning, uses a special x-ray scanner to produce
detailed pictures of a cross section of tissue. The x-ray studies are
taken in the transverse plane and also can be "reconstructed" by the
computer to display anatomic structures in other planes. The images
are viewed in a variety of formats, called windows, which are designed
to enhance the views of specific tissues (Figure 26-20). Multiple
levels of pictures can be taken in a very short period, with up to 25
continuous images recorded in the time it takes the patient to hold
a single breath. Most CT examinations are noninvasive, painless, and
do not require any special patient preparation. However, the proce-
dure involves a considerable amount of radiation. Also, patients may
FIGURE 26-20 Two computed tomography (CT) windows demonstrating structures of the chest from the same image. A, Mediastinal structures
are demonstrated in the center of the field, but the lungs are not well seen. B, "lung window" demonstrates the blood vessels of the lungs and
a lung tumor (arrow). (From Seerom E: Computed tomography: physical principles, clinical applications, and quality control, ed 2, Philadelphia,
2001, Saunders.)
CHAPTER 26 Assisting with Diagnostic Imaging 657
feel apprehensive about the equipment because standard machines
require the patient enter a tube for the procedure.
Careful explanations are necessary to obtain the patient's coopera-
tion and a satisfactory outcome of the study. The CT scanner consists
of a movable table with remote control, a circular gantry structure
that supports the x-ray tube and detectors, an operator console with
a monitor, and a supporting computer system. The CT unit also
includes both hardware and software to archive and manage data
and to produce hard copies of images. During a scan, the x-ray tube
rotates around the patient to collect data. In conventional CT units,
the tube makes a complete rotation to gather data for each slice. The
table then moves, and the tube rotates again to obtain the next slice.
Spiral or helical scanners scan a spiral path around the patient and
can collect data on a larger volume of tissue. These scanners can
reconstruct views to create three-dimensional (3D) images. CTs with
spectral detectors include the use of color to further enhance visual-
ization for cleaner identification.
The versatility of CT is illustrated by its wide range of applica-
tions, including studies of the brain, spine, abdomen, pelvis, chest,
neck, and paranasal sinuses. CT is a valuable tool for emergency use,
especially in the detection of intracerebral or intra-abdominal hem-
orrhage. It also is used for orthopedic examinations of the extremities
and for contrast-enhanced vascular studies. CT is useful for local-
izing both lesions and needle position during needle aspiration
biopsy, a nonsurgical method of obtaining cells for laboratory exami-
nation, and it may be used either in place of or with myelography
to expand the range of information available.
More recent advances in CT include the cone beam, which pro-
vides high-resolution 3D images of extremities. It uses cone-shaped
x-rays to dramatically decrease the radiation dosage, making it faster
and safer than standard CT imaging.
Although many CT examinations do not require contrast media,
the use of contrast agents vastly increases the scope of CT imaging.
Studies of the abdomen usually use oral contrast media to help dif-
ferentiate the GI tract from the surrounding tissues. The patient
ingests a special barium compound or an oral iodine preparation
over a specified period before the study. The amount of contrast
medium and the time period vary, depending on whether the exami-
nation includes only the upper abdomen or the entire abdomen and
pelvis. For these studies, the patient is instructed not to eat for 12
658 UNIT FOUR DIAGNOSTIC PROCEDURES

hours and to report to the facility early to drink the contrast prepara-
tion before the procedure is scheduled. Some departments have the
patient take the contrast medium home, with instructions to drink
it before reporting for the appointment.
IV injection of an iodine contrast medium also may be used to
increase the contrast level of the patient's tissues. This is advanta-
geous for studies of the chest, abdomen, and soft tissues of the neck
because it highlights blood vessels and enhances the visibility of
vascular organs such as the liver and spleen. The contrast defines the
internal structures of the kidneys, ureters, and bladder as the agent
is excreted in the urine. In selected cases, IV contrast agents are used
in CT scans of the head to demonstrate brain lesions. Be sure to
notify the provider of any iodine or shellfish allergies, and inform
the patient not to arrive with a full stomach, which may trigger
nausea and vomiting.
Magnetic Resonance Imaging
Magnetic resonance imaging (MRI) is a noninvasive diagnostic
modality that allows visualization of anatomic structures without the
use of radioactive x-rays. A powerful magnetic field and radiofre-
quency pulses are combined to produce a radio signal in the body
that can be detected and processed electronically to provide images
on a computer monitor. The images can be managed in a computer
database and can also be stored on magnetic tape and photographed
with a special camera to produce film copies that appear similar to
x-ray images. The greatest advantage of an MRI is that it can see
through bones and focus on specific areas of soft tissue in great detail
without the use of radiation (Table 26-3).
TABLE 26-3 MRI and CT: What's the Difference?
The MRI gantry houses the magnet and the main radiofrequency
coil. Conventional gantries are tubular, 5 to 8 feet long, and typically
require the body part being studied to be placed in the tube during
the scanning process. An open gantry design, the open MRI, pro-
vides better accommodation for large or claustrophobic patients, but
it does not always provide image quality equal to that produced by
conventional units. Open gantry units allow for an open view of the
four sides surrounding the unit, to feel less confining to patients.
Tilting MRI units have an open gantry that can be rotated to allow
patients to stand, for weight-bearing images. This is particularly
useful for musculoskeletal evaluation.
MRI provides excellent imaging of the soft tissues of the nervous
system (Figure 26-21 ). It is useful in the diagnosis of many types of
pathology, including brain and spinal cord tumors and diseases such
as multiple sclerosis. MRI also is used for the diagnosis of herniated
intervertebral disks and to obtain images of the soft tissue compo-
nents of joints, particularly the knee, shoulder, and temporoman-
dibular joint. However, it does not generate a clear image of bones.
Magnetic resonance angiography (MRA) is an advanced MRI
that focuses specifically on blood vessels and the cardiovascular
system. MRA aids in the diagnosis and treatment of heart disorders,
stroke, and blood vessel diseases. It is different from traditional
angiography because it does not require the insertion of a catheter
into the area being imaged. This allows for a faster and more cost-
effective diagnosis with less risk to the patient.
The typical scan time for a series of slicelike images ranges from
1 to 10 minutes, and several series, demonstrating different body
planes and using a variety of radiofrequency pulse sequences, may
be included in an examination. The average time for an MRI study
is 30 to 45 minutes. It is critical that the patient remain still, main-
taining the desired position, throughout the procedure.

MRI CT
Full Magnetic resonance Computed (axial) tomography
Name imaging
Use Greatest detail for soft Identifies both bone and soft
tissues; superior for tumor tissue injuries; used more
detection; poor bone frequently because of
imaging decreased time and cost
Effects No known biologic hazards Radiation up to S00x that of
x-rays
Cost Varies by facility from Varies by facility from about
about $400 to $4,000 $400 to $3,200
Limits No metal implants or Not recommended in
pacemakers; tattoos may pregnancy or for children
blur images because of high radiation level
Time Typically less than 30 Typically less than 5 minutes;
minutes speed results in less sensitivity
to movement
Contrast Rare allergic reaction in Iodine based; risk of a reaction
those with liver ar kidney for those with allergies; may
disease lead to nephropathy FIGURE 26-21 Midsagittal magnetic resonance image (MRI) al the brain. (From Ehrlich RA:
Pafient care in radiography, ed 8, St Louis, 2013, Mosby.)

Although contrast media are not required for most MRI studies,
special paramagnetic agents sometimes are injected intravenously.
These agents provide contrast enhancement of certain lesions, par-
ticularly brain and spinal cord tumors, and help differentiate disk
material from scar tissue in postoperative spinal examinations. Con-
trast injections also are used in MRA studies. Typically, a series of
images is recorded, the contrast agent is injected intravenously, and
a second series of images is taken.
The unique MRI environment requires special safety precautions.
Conditions that affect patient safety involve both the powerful mag-
netic field in the gantry and the thermal effects of radiofrequency
pulses on certain materials that could overheat and possibly burn the
patient. The principal means of ensuring patient safety during an
MRI is careful patient screening before the procedure. Although
extensive patient interviews are conducted in the magnetic resonance
department, preliminary screening of patients should be conducted
by the medical assistant before the appointment is made. The mag-
netic field or the rapid radiofrequency pulses may be hazardous for
patients with artificial heart valves, aneurysm clips, neurostimula-
tors, middle ear prostheses, or intrauterine devices. Cardiac pace-
makers are a particular hazard, and patients with pacemakers cannot
have MRI examinations. Fatalities have resulted from overheating of
these implanted devices when patients with pacemakers were
scanned.
Other factors that may prohibit the use of MRI technology
include patients with orthopedic pins and screws and metal frag-
ments or shrapnel in the soft tissues. Metalworkers who might have
steel slivers in their tissues must have a screening x-ray or CT head
examination to detect fragments that could damage the eyes or brain,
because the pull of the magnetic field is so strong that it could cause
the fragments to move. Although the energies involved in MRI have
not been demonstrated to cause complications with pregnancy, the
current philosophy is to avoid examination of pregnant patients
except in urgent cases, especially during the first trimester.
Patients should be assured that everything possible will be done
to provide assistance in dealing with both physical and emotional
discomfort. Few people are completely comfortable for any length
of time in a tightly enclosed space. Even patients with no history of
claustrophobia may feel anxious when entering a conventional
tubular MRI gantry. Occasionally, this anxiety is so severe that it
creates panic, preventing the patient from continuing the
examination.
Patients may be reassured if they know what to expect in advance.
The procedure requires that the patient lie down on the MRI table,
which then automatically moves into the gantry. Plenty of air is
available, and there is no physical discomfort except for the need to
lie still. The machine makes a very loud "knocking" noise during the
scanning process (similar to a jack hammer or heavy machinery).
Earplugs or earphones with recorded music may be offered. Patients
can communicate with the technologist through an intercom, and
the technologist is watching and listening from an adjacent area
throughout the procedure. The patient is given a "panic button'' to
push in case the procedure needs to be stopped because of patient
discomfort or anxiety. Because no radiation danger exists, a friend
or family member can sit in the room if the patient feels more
comfortable with company. Severely claustrophobic patients may be
scheduled at a facility with an open gantry MRI or may be given an
CHAPTER 26 Assisting with Diagnostic Imaging 659
antianxiety medication before the procedure. Analgesic medications
may be administered to patients whose pain makes it impossible to
lie still for the duration of the study.
Sonography
Diagnostic medical sonography is a noninvasive procedure that is
considered very safe for the patient. Sonography is used extensively
for fetal imaging. This imaging modality, often referred to as diag-
nostic ultrasound, uses high-frequency sound waves to produce echoes
in the body. As the echoes return to the hand-held transducer, their
strength and timing are interpreted by a computer to produce a map
or graphic image of the echo distribution.
The transducer is covered with a lubricant and moved over the
surface of the body so that the image can be viewed in real time on
a computer monitor. Special transducer probes can be inserted into
body cavities (e.g., the rectum and the vagina) to obtain more
detailed examinations of the prostate gland and the uterus. Any
interface between substances or tissues of varying density produces
an ultrasound echo, which makes sonography an effective technique
for showing the shape, size, and condition of organs such as the
heart, spleen, gallbladder, breast, and pancreas (Figure 26-22).
Sonography, therefore, can be used to diagnose or investigate gall-
stones or suspicious masses in the breast. For example, if a woman
has a suspicious breast mass, the mass can be visualized with a sono-
gram, and while the radiologist has a clear view of the location of
the mass, a needle biopsy sample of the suspicious tissue is collected
and sent to the pathologist for examination. This procedure limits
the need for invasive surgical biopsies.
Sonography can also be used to detect an abscess, a cyst, or a
tumor in adipose tissue. Recent advances in ultrasound technology
include computer integration of data to produce 3D images. In
addition, Doppler ultrasound is used to detect vascular disease, such
as atherosclerosis in the carotid arteries and venous thrombosis of
the lower extremities. Echocardiograms involve the use of Doppler
ultrasound to evaluate the structure and function of the heart while
in motion and can include colorized video to detect the flow of
arterial and venous blood.
FIGURE 26-22 Abdominal sonogram. (From Bollinger PW, Frank ED: Merrill's a#as of radio-
graphic positions and radiologic procedures, ed l 0, vol 2, St Louis, 2003, Mosby.)
660 UNIT FOUR DIAGNOSTIC PROCEDURES
Ultrasound is also a diagnostic procedure commonly used in
obstetrics to evaluate a developing fetus during pregnancy. Recent
advances allow for video and still shots of real-time movement in
3D and even 4D, with astounding detail visible. It is used to
detect the size and position of the baby and the function of its
organs, and placental placement. Ultrasound can also determine
the sex of the fetus, in addition to how many fetuses are present in
the womb.
Nuclear Medicine
Nuclear medicine images are created by scanning the patient after
special radioactive materials, called tracers, have been swallowed or
injected intravenously (Table 26-4). Tracers are similar to substances
that are commonly used by the body, so they enter into the same
chemical reactions and are metabolized in a similar way. They are
taken up in the target organ or tissue over a period that may vary
from half an hour to several days, making cellular activities and even
fractures more visible. The tracer then can be detected and its loca-
tion recorded by a special nuclear medicine scanner, called a gamma
camera. Two types of tracers used in diagnostic studies are radioactive
iodine and radioactive carbon.
Nuclear medicine scans do not provide clear images of anatomic
structures. They are used to obtain information about the function
TABLE 26-4 Common Nuclear Medicine
Procedures
PROCEDURE PURPOSE
Bone scan Helps detect fractures, tumors, and
inflammation; used to determine bone growth
Brain scan Often used with other imaging methods to
detect tumors and vascular problems; commonly
tested with single photon emission computed
tomography (SPECT)
Liver scan Useful for diagnosing cirrhosis and hepatitis and
for detecting tumors and liver abscesses
Lung scan Often done to detect emboli, blood clots that
have traveled through the bloodstream to the
lungs
Multiple gated Evaluates the condition of the heart's
acquisition (MUGA) myocardium while at rest and/or during stress
scan
Positron emission Done for cancer investigation; evaluation of
tomography (PET) scan myocardial blood supply; investigation of central
nervous system disorders by evaluating
metabolic activity
Thallium stress test Used to evaluate cardiac condition and response
to stress
Thyroid scan Rate of contrast uptake is an indicator of thyroid
function; scan also is useful for detecting tumors
of organs and tissues. Abnormal tissues are demonstrated on the
image because the tracer is metabolized at a different rate, at a dif-
ferent location, or to a greater or lesser extent than in normal tissue.
Figure 26-23 shows an example of a nuclear medicine bone scan.
The tracer is absorbed by the bones and appears in greater or lesser
amounts, depending on the level of metabolic activity within the
bone. In this scan, the region shows a high level of radioactivity,
which indicates an inflammatory process. Tumors of the bone can
be diagnosed by "hot spots" in the x-ray image; these show up much
more brightly because of rapid cellular division, which results in a
higher level of metabolic activity.
Structures visualized with nuclear medicine techniques include
the thyroid gland, liver, lungs, brain, skeletal system, kidneys, heart,
and blood vessels. Thallium stress studies of the heart are nuclear
medicine examinations that permit the physician to view the coro-
nary arteries to diagnose or rule out blockage. Incomplete visualiza-
tion of the myocardium after administration of a nuclear tracer
indicates lack of blood supply to the area and damage to the muscle
of the heart.
The radioisotopes used in nuclear medicine decay within a short
time (from a few hours to a few days) and are eliminated in the urine
or feces. They have a very low level of radioactivity and involve less
patient exposure than most x-ray examinations. Positron emission
tomography (PET) and single photon emission computed tomogra-
phy (SPECT) are highly specialized nuclear medicine techniques
that use different types of tracers and scanners than conventional
nuclear medicine, but the basic principle is the same. Radioactive
substances from within the body are detected and mapped by spe-
cialized equipment to obtain information about the function of
organs, tissues, or systems. Most PET scans today are combined with
CT to merge the technology of nuclear medicine procedures with
FIGURE 26-23 Bone scan showing increased tracer uptake in the proximal femur. (From Baker
A, Macnicol MF: Haematogenous osteomyelitis in children: epidemiology, classification, aetiology and
treatment, Paediatr Child Health 18(2):75-84, 2008.)

the multiplane view of CT scanners. PET/CT scans are ordered for
the following purposes:
• To diagnose a cancerous tumor, evaluate its spread, or determine
whether cancer has returned after treatment
• To evaluate the blood flow to the heart
• To determine the extent of damage to the myocardial wall after
a heart attack
• To investigate lung lesions visualized with traditional x-ray images
• To diagnose central nervous system disorders, including epilepsy,
Alzheimer's disease, Parkinson's disease, and strokes, and to locate
brain tumors
Dual Energy X-ray Absorptiometry
Dual energy x-ray absorptiometry (DXA) scans use x-ray technology
to evaluate a patient's bone density. A decrease in bone density is
diagnostic proof of osteoporosis; evidence of bone density loss
(osteopenia) may indicate the individual's risk of developing osteo-
porosis over time. The test typically evaluates the bone density of the
spine and hip. For the examination, the patient lies supine on an
x-ray table with the knees flexed and the lower legs elevated (Figure
26-24).
The DXA scanner directs an x-ray from rwo different sources
toward the hip. The greater the mineral density of the bone, the
longer the x-ray image is transmitted and the highest test number
recorded. The scan is completed within a few seconds and also can
be used to evaluate the density of the spine and hips. The patient's
density results are compared with standard bone density tables to
determine the presence and/or level of demineralization. These
numbers are used to predict the patient's risk of an osteoporosis-
related fracture. DXA scans are recommended for the following
individuals:
• Women with multiple risk factors for osteoporosis
• Women with long-term estrogen deficiencies
• Individuals taking steroids for an extended period
• Individuals taking osteoporosis medications (to evaluate the
effectiveness of treatment)
• Patients with unexplained fractures and/or deformities of the
vertebra
FIGURE 26-24 Patient undergoing a bone density test, or dual energy x-ray absorptiometry
(DEXA or DXA).
CHAPTER 26 Assisting with Diagnostic Imaging 661
BASIC RADIOGRAPHIC PROCEDURE
Patient Preparation and Explanation
Before a patient undergoes x-ray studies, a provider examines the
individual and orders one or more specific x-ray procedures to help
diagnose the patient's problem or to follow up on a previously diag-
nosed condition. The provider is responsible for getting the patient's
informed consent for any procedure, but he or she may ask the
medical assistant to make sure the consent form is signed. The
patient may not have to sign a consent form for noninvasive diag-
nostic studies because acceptance of the procedure is adequate evi-
dence of consent. In some facilities, however, patients may be asked
to sign a consent form regardless of the type of radiographic proce-
dure. If it is your duty to answer patients' questions about the
procedure or to assist with obtaining consent, make sure you are
prepared to do so.
Patients often express concern about radiation exposure. You can
assure them with confidence that the risks are extremely small and
ourweigh the health risks of treatment without the information the
examination will provide. It may help to point out that the radiog-
rapher is well trained in radiation safety and that the equipment is
designed to provide good images with the least possible exposure.
You can explain that the amount of radiation involved in the pro-
cedure is typically less than the exposure to natural background
radiation that people in general receive every year.
Patient preparation for routine radiography involves having the
patient remove the outer clothing from the area to be radiographed
and instructing the person to wear a gown if appropriate. Underwear
usually is not a problem. No metal objects should be included in
the radiation field because these items appear as artifacts on the
images. This includes jewelry (including piercings); zippers, snaps,
and other clothing fasteners; underwire bras; and the contents of
pockets. Nonmetal objects that are thick or heavy should also be
removed. Buttons and the heavy seams in jeans are examples of other
clothing items that can cause artifacts on radiographs if they are in
the imaging field. Metal items that are not in the radiation field are
not a problem, so patients need not remove jewelry or clothing from
areas that will not be included in the radiograph.
When the patient is ready, the next step is to assist the patient
into the general position required for the x-ray examination. For
example, if a hand is to be imaged, the patient can be seated at the
end of the x-ray examination table (Figure 26-25 and Figure 26-26,
A). For a spinal examination, the patient may need to lie on the table
(Figure 26-26, B). If a chest examination has been ordered, the
patient stands at an upright image receptor holder (Figure 26-26,
C).
The radiographer then selects the correct image receptor, labels
it or places a lead marker on it to identify the patient's right or left
side, and moves it into position for the exposure (Figure 26-27).
Next, the patient is positioned precisely, and the x-ray tube is aligned
with the body part and the image receptor at a specific distance
(Figure 26-28). The body part must be measured to determine the
proper exposure factors according to a technique chart. At this point,
lead shields are positioned for radiation protection. The radiographer
then goes to the control booth, consults the technique chart, and
sets the x-ray control panel to the desired exposure. Final instructions
are given to the patient (typically that the patient must remain still
662 UNIT FOUR DIAGNOSTIC PROCEDURES

during the x-ray procedure), and the exposure is made. If more than
one exposure is needed, the image receptor is changed, the patient
is repositioned, and the steps are repeated until the examination is
complete.
After the patient's safety and comfort have been ensured, the
image is processed. If the image is satisfactory and no further expo-
sures are needed, the patient is returned to an examination room or
dressing room. The radiographer or the medical assistant then readies
the x-ray room for the next examination.
Although the use of traditional film copies is quickly becoming
outdated, some smaller or older offices may still maintain such
copies. Traditional films are kept together and given to the provider
with the appropriate paperwork. They are kept in large file envelopes
that may contain more than one set of films for the same patient.
These envelopes must be accurately identified for proper filing.
When images are added to the file, notations often are added to the
envelope. After the films have been read, they are promptly filed so
that they can be retrieved quickly when needed for future reference.
Radiology reports also must be filed. Usually the original is filed in
the patient's health record; copies may be filed separately or with the
films. Digital images are stored in electronic files and can be trans-
FIGURE 26-25 An x-ray table for an x-ray of the hand. (Courtesy Helen Mills.)
mitted electronically or burned onto a CD. However, these images
can be viewed only if a viewing sofrware is used.

FIGURE 26-26 General positions for radiography. A, The patient may be seated at the x-ray table for some upper extremity examinations.
B, The radiographer helps the patient lie down for spine radiography. C, The radiographer assists the patient into position at an upright Bucky for
chest radiographs. (From Long BW, Frank ED, Ehrlich RA: Radiography essentials for limited practice, ed 4, Philadelphia, 2013, Saunders.)

FIGURE 26-27 The cassette or image receptor must be latched securely in the Bucky tray, and
the tray must be aligned to the anatomy of interest. (From Ehrlich RA: Patient care in radiography,
ed 8, St Louis, 2013, Mosby.)
Scheduling and Sequencing Diagnostic
Imaging Procedures
One of the most important communications between medical assis-
tants and imaging departments involves the scheduling of multiple
diagnostic procedures that may all be ordered at one time by the
provider. Consultation often is needed to decide how many proce-
dures can be done in one day and to sequence them in such a way
that they will not interfere with one another. For example, a UGI
series usually results in barium sulfate scattered throughout the intes-
tinal tract for several days. Even tiny amounts of residual barium
cause complications in radiographic examinations of the urinary
tract and biliary system, where tiny opacifications are diagnostically
significant. Residual barium in the digestive tract also causes unac-
ceptable artifacts on abdominal CT scans. For this reason, barium
studies are scheduled last in any series of procedures.
Some imaging departments schedule a series of several examina-
tions in one day for patients who are able to tolerate this approach.
Radiologists prefer various scheduling practices. For example, some
departments schedule gallbladder and upper and lower GI studies
on the same day. Others may insist on 2 or 3 days to complete the
same examinations. You should become familiar with the practice in
the facility where you usually schedule patients.
Scheduling several examinations on the same day may be less
stressful for the patient, resulting in a single bowel preparation, a
single period of fasting, and a single trip to the imaging center.
However, the number of examinations an individual patient can
tolerate varies, especially if the patient is elderly or ill. Make sure you
discuss scheduling options with the patient and/or family before
planning more than one examination per day.
When fiberoptic studies, such as gastroscopy or colonoscopy, are
ordered in conjunction with radiographic examinations requiring
barium as a contrast medium, the fiberoptic studies are done first.
This avoids the possibility that the barium will interfere with visual
assessment during the fiberoptic examination. Patients undergoing
CHAPTER 26 Assisting with Diagnostic Imaging 663
FIGURE 26-28 The x-ray tube must be aligned with the patient and image receptor at the proper
distance. (From Ehrlich RA: Patient care in radiography, ed 8, St Louis, 2013, Mosby.)
gastroscopy usually receive sedation and a muscle relaxant before the
physician inserts the gastroscope. When a UGI series is to follow, it
should be delayed to allow sufficient time for the patient to become
responsive and alert because oral administration of barium to a
sedated patient increases the risk that the patient may choke on the
barium.
Another study to be considered when sequencing diagnostic pro-
cedures is any thyroid assessment test that involves iodine uptake.
Because the administration of a contrast medium containing iodine
causes inaccurate results in such tests for at least 3 weeks, thyroid
assessment blood tests (T3 or T 4) or nuclear medicine thyroid scans
must be performed before any contrast medium with iodine is
administered.
Sequencing Order for Diagnostic Studies
When more than one diagnostic study is to be done, they are per-
formed in the following order:
1. All x-ray examinations that do not require contrast media
2. Any laboratory studies or nuclear medicine procedures that
involve iodine uptake
3. CT studies with IV contrast any time after iodine uptake blood
studies
4. Radiographic examinations of the urinary tract
5. Radiographic examinations of the biliary system
6. Fiberoptic studies (e.g., gastroscopy, endoscopy, sigmoidoscopy,
colonoscopy)
7. CT studies of the abdomen or pelvis (done before barium
studies)
8. Lower gastrointestinal (GI) series (barium enema)
9. Upper gastrointestinal (UGI) series (barium swallow)
An additional consideration in patient scheduling involves decid-
ing which patients need early morning appointments and which can
be scheduled later in the day. Imaging departments always begin the
daily routine with patients who must fast in preparation for their
664 UNIT FOUR DIAGNOSTIC PROCEDURES
examination so that they do not have to go too long without food.
When scheduling, request early priority for pediatric and geriatric
patients because they have the most difficulty maintaining nothing
by mouth (NPO) status for long periods, and extended fasting may
actually interfere with their recovery.
Patients with diabetes who must postpone their insulin until their
morning meal also need priority in scheduling. Outpatients who are
diabetic should be reminded to postpone their morning insulin until
the examination is complete, even if they have been scheduled for
an early appointment. If an emergency should cause a delay, the
patient who has had insulin may suffer a reaction. Paperwork done
in the office for diagnostic studies needs to include information
about patients with diabetes so that the radiology staff is aware of
their status.
Although actual scheduling may be done by phone or computer,
the patient is typically given a printed copy of the provider's order
and any necessary instructions.
CRITICAL THINKING APPLICATION 26-1
Mrs. Pellegrini, a 62-year-ald patient with diabetes, calls Metro Urgicenter
at 8:30 AM ta confirm her 10 AM appointment far an outpatient imaging
procedure that requires fasting. On speaking with her, Sara learns that Mrs.
Pellegrini has already taken her morning insulin. Should Mrs. Pellegrini keep
her appointment or be rescheduled? Why or why not?
When you instruct the patient about preparing for an examina-
tion, it is important to have printed instructions ready in advance.
If more than one alternative is printed on any given paper, be sure
to indicate, both orally and in writing, which instructions are to be
followed. Review the sheet with the patient slowly, explaining any
words or procedures that may not be familiar. Have the patient
explain back to you what is to be done (remember the importance
of feedback in establishing whether the patient understands). If the
patient is too young, too ill, confused, or incapable of understanding
and following the instructions, give the instructions (oral and
written) to the person who will be responsible for assisting the
patient. Be sure to include the telephone numbers of your clinical
facility and of the imaging department so that the patient or the
patient's family may call if any questions arise after the patient leaves
the office.
In preparation for a UGI series, the patient must fast, avoiding
water, smoking, and chewing gum. The NPO order usually is for a
limited period (commonly 8 to 12 hours) before the procedure. This
ensures that the stomach is empty at the time of the examination so
that an accurate radiographic image of its inner surfaces can be
produced. Chewing gum and smoking are avoided because they tend
to increase gastric secretions.
The preparation for a barium enema involves the use of a bowel
cleansing kit. These kits usually contain one or more types of cathar-
tics, a suppository, a low-volume enema, and illustrated instructions
in several languages. Research has demonstrated that increased fluid
intake enhances the effectiveness of cathartics and helps minimize
the patient's discomfort. For this reason, instructions for cathartics
are accompanied by a fluid intake schedule that suggests at least 8
ounces of water or clear liquid every 2 hours between noon and
midnight on the day preceding the examination. The medical assis-
tant should emphasize the importance of fluid intake. The required
doses of cathartics have a strong, thorough action that occasionally
causes patients to experience painful spasms of the bowel and irrita-
tion of the intestinal lining. Persistent diarrhea may last through the
night, preventing sleep. Although patients may find this preparation
uncomfortable and inconvenient, its effectiveness in cleansing the
bowel usually outweighs these considerations.
Caution must be exercised in implementing an aggressive prepa-
ration for elderly or frail patients who are likely to be adversely
affected. A gentler alternative should be available for these debilitated
patients. Those with chronic or acute diarrhea may require a lower
dose or less active preparation than is usually given. When the
routine strength or amount of cathartics is reduced, several days of
a low-residue diet and an increased fluid intake become critical to
the success of preparation. Patients should always be advised of the
nature of the action expected from the cathartic when it is given.
Table 26-5 summarizes common diagnostic procedures and the
patient preparation required for each.
CRITICAL THINKING APPLICATION 26-2
Dr. Roberts, a physician at Metro Urgicenter, has ordered a barium enema
far Mr. Tillman, and Dr. Swain asks Sara to provide Mr. Tillman with the
preparation instructions far the procedure. What information should Sara
obtain from Mr. Tillman ta determine whether the usual bowel preparation
is appropriate? If Sara thinks the usual preparation might be tao harsh far
Mr. Tillman, how should she explain her concern to Dr. Swain and Dr.
Roberts? Who should decide whether to implement a variation in protocol:
Sara, Dr. Swain, or someone else?
Radiation Safety
Radiation Units
Two systems are used to measure radiation and radiation dose: the
conventional (British) system and the international system (Systeme
International [SI]) established in 1981 (Table 26-6). The conven-
tional system includes the roentgen (R), the rad (rad), and the rem
(rem), which are all being phased out.
The SI unit for dose measurement is the gray (Gy), which is most
commonly used today. Air kerma (Gy-J is the SI unit term for
radiation exposure that represents the amount of radiation in the air
to reach the patient. The subscript "i' is added to indicate that the
radiation in the air is taken into account. The word "exposure" is
used to describe air kerma because this is the amount of radiation
in the air to which the patient is exposed.
As an x-ray passes through a patient, some of the radiation is
absorbed by the patient's tissues; this is referred to as the absorbed
dose (D). The symbol for absorbed dose (Gy-J includes a subscript
"t" to indicate that it takes into account the radiation remaining in
tissue. The absorbed dose is always less than the initial exposure
because some of the radiation continues through and exits the
patient. References to absorbed dose are often indicated by simply
using the word "dose" because this is the dose of radiation that stops
in the patient's body.
 CHAPTER 26 Assisting with Diagnostic Imaging 665

TABLE 26-5 Diagnostic Procedures and Patient Preparation

STUDY PURPOSE PROCEDURE PATIENT PREPARATION
Angiography: arteriogram To aid diagnosis of arterial occlusion, Catheter is inserted into femoral, Clear liquids 24 hr before test; nothing by
(artery) or venogram (vein) aneurysm, hemorrhage, abnormal brachial, or carotid artery and advanced mouth (NPO) 8 hr before test; if
vessels, and transient ischemic under fluoroscopy to site; dye is abdominal vasculature is to be imaged,
attacks injected, and x-ray images are taken. patient may need laxative and enemas.
Arthrogram To detect damage to joint connective Fluoroscopic and radiographic NPO 8 hr
tissue and structures examination of a joint after injection of
air or contrast dye.
Barium enema To detect bowel obstruction, celiac Fluoroscopic and radiographic Bowel must be emptied before procedure;
sprue, colon cancer, polyps, examination of the colon after barium clear liquid diet 24 hr before test (no
diverticulitis, irritable bowel syndrome enema to find internal structural milk); laxatives day before test; enemas
abnormalities; takes approximately 1 hr. morning of test; increase fluids after
test-pale stools and constipation are
typical.
Barium swallow To detect esophageal varices, hiatal Fluoroscopic and radiographic NPO and no smoking 8 hr before; if small
hernia, pyloric stenosis, obstructions, examination as barium is swallowed to bowel is included in imaging, instruct on
polyps, tumors, ulcers detect abnormalities of the pharynx, laxative use as prescribed; a barium drink
esophagus, and stomach; takes about is consumed just before testing;
15 min. afterward, stools are expected to be white
or pale; lower GI tests may require repeat
imaging after 24 hr.
Bone scan To detect bone cancer, bone infection, Nuclear medicine: Radioactive isotope is NPO 4 hr before; must void before scan;
osteoarthritis, osteomyelitis injected intravenously (IV), body is radioactive material is excreted in urine
scanned, and levels of isotope are within 48 hr and is not harmful to others.
imaged. Areas of high metabolism show
as "hot spots"; scan is done 1-3 hr after
isotope injection.
Computed tomography (CT) Provides detailed, cross-sectional Special x-ray equipment and computers NPO 4 hr before if IV contrast medium
views of all types of body structures; are used to obtain image data from will be used; no metal objects; must lie
one of the best tools for studying the different angles around the body, and very still; advise of confined space and
chest and abdomen multiple cross-sectional views possible claustrophobia.
(tamographs) are produced.
Intravenous urogram (IVU) or To evaluate structure and function of IV contrast medium is injected, and x-ray Bowel cleansing and liquid diet 24 hr
intravenous pyelogram (IVP) kidneys, ureters, and bladder images are taken of renal structures. before with laxatives and possibly enema
to prevent obstruction af views; NPO 8 hr.
Magnetic resonance imaging To aid diagnosis of intracranial and Magnetic field and radiofrequency No caffeine 4 hr before testing; normal
(MRI) spinal lesions, aneurysms, heart energy are transmitted to a computer, diet, unless pelvic testing (6 hr NPO); no
defects, multiple sclerosis, and soft which produces cross-sectional images of eye makeup; must remove all metal;
tissue abnormalities throughout the soft tissue; this may eliminate the need contraindications include tattoos,
body for arthrography and myelography. No permanent makeup, and any metallic
radiation exposure is involved. Patient implants with iron (e.g., pacemakers,
lies on a flat table that moves into a artificial heart valves, aneurysm clips,
tunnel-shaped scanner; takes material associated with metal-related
45-90 min. occupation); patient will hear loud tapping
during test and must remain still; notify
provider if patient has iodine allergies or
is claustrophobic.
Continued
666 UNIT FOUR DIAGNOSTIC PROCEDURES

TABLE 26-5 Diagnostic Procedures and Patient Preparation-continued

STUDY PURPOSE PROCEDURE
Mammography For early detection of breast cancer Low-energy x-rays are used to examine
and abnormalities through detection the breast; parallel plate compression
of masses evens out the thickness of breast tissue
far easier viewing.
Myelogram To aid diagnosis of spinal lesions, Fluoroscopic and radiographic
ruptured disk, spinal stenasis examination of the spinal column after
injection of contrast medium into the
subarachnaid space; takes about 1 hr.
Retrograde pyelography To evaluate structure and function af Contrast medium is injected through a
kidneys, ureters, and bladder urethral catheter, and x-ray images are
taken of renal structures.
Tomasynthesis Recent innovation far early detection High-resolution three-dimensional (30)
af breast cancer and breast imaging (similar to a CT scan) used to
abnormalities examine the breast at different angles;
parallel plate compression evens out the
thickness of breast tissue far easier
viewing while the camera makes an arc
around the breast, taking multiple
images.
*With any test that uses contrast dye, ask the patient whether he or she has allergies to iodine, contrast media, or shellfish; if the answer is yes, notify the provider.
PATIENT PREPARATION
Scheduled the first week after a menstrual
cycle; shower beforehand- no deodorant,
talcum powder, or lotion; avoid caffeine
7-10 days before testing. Explain that the
position is uncomfortable (breast is
sandwiched between two plates) but
should take only a short time to
complete.
NPO 8 hr
Bowel cleansing and liquid diet 24 hr
before with laxatives and possibly enema
to prevent obstruction af views; NPO 8 hr.
Scheduled the first week after a menstrual
cycle; shower beforehand- no deodorant,
talcum powder, or lotion; avoid caffeine
7-10 days before testing. Explain that the
position is uncomfortable (breast is
sandwiched between two plates) but
should take only a short time to
complete.

TABLE 26-6 Units of Radiation Measurement Equivalent Dose

CONVENTIONAL NEWSI The effect that radiation has on the body depends an the type and charac-
UNITS UNITS teristics af a particular test. Similarly, occupational radiation can vary based
on the type of radiation to which employees are exposed. For example,
Quantity af radiation exposure in roentgen (R) Air kerma (Gy-a)
advanced tests use much higher concentration of radiation and pose a
air
higher risk than a simple x-ray image. Because this difference can have
Absorbed dose in tissue rad (rad) gray (Gy-1) varying levels of biologic effects, it is necessary to clarify the type and
Type or energy of radiation rem (rem) sieve rt (Sv) energy of exposure ta determine an employee's safe level of exposure; this
equivalent dose is referred to as equivalent dose (EqD). In the SI system, this is called the
sievert (Sv). For advanced radiographers, the equivalent dose is evaluated
by using a radiation weighing factor to calculate exposure specific to that
occupation. However, because limited operators have limited exposure, the
To put it all together: During x-ray imaging, the patient may absorbed dose and equivalent dose are always the same.
receive an exposure of 16 mGy-•. From that exposure, he or she may
receive an absorbed dose of 1. 1 mGy-,. The remaining radiation is
the useful remnant radiation that creates the x-ray image. Effects of Low-Dose Radiation Exposure
Cellular Response to Exposure. Most people don't realize that
radiation naturally occurs every day in the environment. It seeps out
Memory Aid: Exposure versus Dose of the ground and settles down from outer space. It is in the food
Exposure: Radiation in the !!ir. that we eat, the water that we drink, and the homes that we live in.
Even our own bodies produce radiation to a certain extent. In fact,
Dose: The amount of radiation absorbed within the .bill!y.
according to the U.S. Food and Drug Administration (FDA), in 2½

days of routine activity, we are naturally exposed to the same amount
of radiation as we would get with a typical chest x-ray image. This
is an important thing to remind patients who are worried about x-ray
exposure.
Many cellular effects of radiation exposure are extremely short
lived because chemical alterations within the cells are quickly repaired
or the cell is replaced. Even if a cell dies, cell death is an insignificant
injury unless the number of cells involved is massive. Although most
diagnostic x-ray studies are relatively safe, sometimes a cell may be
damaged in such a way that its DNA "programming" is changed and
the cell no longer behaves normally. This type of injury eventually
may result in runaway production of new, abnormal cells, causing a
tumor or malignant blood disease.
The relative sensitivity of different types of cells is summarized in
the laws of Bergonie and Tribondeau, which state that cell sensitivity
to radiation exposure depends on four characteristics of the cell:
• Age: Younger cells are more sensitive than older ones.
• Differentiation: Simple cells are more sensitive than highly
complex ones.
• Metabolic rate: Cells that use energy rapidly are more sensitive
than those that have a slower metabolism.
• Mitotic rate: Cells that divide and multiply rapidly are more sensi-
tive than those that replicate slowly.
According to these laws, blood cells and blood-producing cells
are the most sensitive. Cells that are in contact with the environment
(e.g., those of the skin and mucosa! lining of the mouth, nose, and
GI tract) are also fragile. Some glandular tissue also is particularly
delicate, especially that of the thyroid gland and the female breast.
The tissues of embryos, fetuses, infants, children, and adolescents
tend to be more sensitive than those of adults because of their young
age and higher metabolic and mitotic rates. Nerve cells, which have
a long life and are quite complex, are much less vulnerable to radia-
tion injury.
Somatic Effects. Radiation effects can be classified as somatic or
genetic. Somatic effects are those that occur to the body of the person
who is irradiated. Whereas the effects of relatively high doses of
radiation are immediate and predictable, the effects of the very low
doses associated with radiography produce long-term effects. They
are not easily identified as a result of radiation exposure because they
occur 3 to 30 years after treatment and because the same problems
can occur in the absence of radiation exposure. Only extensive
research with large populations can demonstrate the role of radiation
in causing these effects. In other words, radiation causes increased
risk for health problems, but the complications cannot be predicted
with respect to any one individual. Although the individual risk is
extremely small, increasing exposure to the entire population poses
public health risks that require the attention and concern of everyone
involved in applying ionizing radiation to human beings.
The documented latent effects of low doses of ionizing radiation
include the following:
• Cataract formation: This is a risk for radiologists and radiogra-
phers who work extensively in fluoroscopy and those who
perform other work that involves repeated exposure to the eyes.
• Carcinogenesis: Increased risk of malignant disease, particularly
cancer of the skin, thyroid, breast, and leukemia.
• Shortened life span: A study of the life span of radiologists who
died before 1945 showed that they had shorter life spans than
CHAPTER 26 Assisting with Diagnostic Imaging 667
physicians who did not use radiation in their practices. This
group included radiologists who had used radiation since the
early days of x-ray science. More recent studies show that occu-
pational exposure no longer has a measurable effect on the life
span of radiologists. Nevertheless, because radiation exposure has
been linked to shortening of the life span, it is a public health
concern and another reason to practice a high level of radiation
safety.
Genetic Effects. Genetic effects, in the form of changes or mutations
in the hereditary material of reproductive cells, may occur if the
ovaries or testes are exposed to radiation. In the female, all the ova
cells the individual will ever produce are present at birth. Because
no new egg cells are created as the individual ages, the effect of
radiation exposure to the ovaries accumulates over time. In addition,
the genetic effects of radiation to the testes may include damage to
stem cells that produce sperm, resulting in the production of sperm
with a genetic mutation. Most genetic mutations threaten the survival
of an individual. Even when these changes are recessive (not apparent
in the offspring), they may be passed on to future generations.
Radiation and Pregnancy. Radiation exposure poses risks to the
developing embryo or fetus. Research has demonstrated that exces-
sive radiation during pregnancy may result in spontaneous abortion,
congenital defects in the child, growth retardation, increased risk of
cancer and leukemia in childhood, and an increase in significant
genetic abnormalities in the children of parents who were exposed
in utero. According to the National Council on Radiation Protection
and Measurements (NCRP), studies of women exposed to radiation
as a result of diagnostic and therapeutic procedures confirm that
radiation to the uterus in excess of 150 mGy-, (5 rad) is cause for
concern, with the greatest risk occurring in the first three months of
pregnancy. This is more exposure than is received with most x-ray
examinations, but these levels may be encountered with direct expo-
sure to the pelvis, especially with CT examinations or fluoroscopic
studies. If pregnancy is suspected or likely, always notify the provider
and await further orders before proceeding.
Guidelines for Pediatric X-ray Examinations
The following guidelines should be applied for all pediatric x-ray
examinations:
• Provide age-appropriate explanations about the procedure and
instructions for patient compliance.
• Inform the parents about the procedure and answer questions.
• Give the patient or parents written information when needed
about preparation for the examination.
• Explain that allowing parents in the x-ray room will be up to the
facility.
• When possible, use commercial immobilization devices to posi-
tion the child (e.g., restraint board with Velcro closures, papoose
board, positioning chair [Figure 26-29]).
• Have a parent help the child maintain a particular position when
immobilization devices are not available or are ineffective. The
parent must wear the appropriate lead shielding equipment and
cannot be pregnant.
Radiation Protection
Clearly, exposure to x-rays creates some risk for both patients
and radiographers; therefore, it is essential that those performing
668 UNIT FOUR DIAGNOSTIC PROCEDURES
FIGURE 26-29 Immobilization device for a pediatric patient. (From Frank ED, Long BW, Smith
BJ: Merrill's atlas of radiographic positioning and procedures, ed 12, St Louis, 2013, Mosby.)
radiographic studies be knowledgeable about and diligently practice
radiation safety. All unnecessary radiation exposure to patients,
co-workers, and oneself must be prevented.
Personnel Safety
In diagnostic x-ray departments, radiation hazards exist only in the
radiography room and only while the x-ray is being taken. This is
due mostly to scatter radiation, which deflects off the patient. X-rays
travel at the speed of light. They do not linger in the room after the
exposure, and they are not capable of making the objects in the room
radioactive. Therefore, the only time a radiation hazard exists is
during the x-ray exposure itsel£
Because radiographers operate equipment from the protected
control booth, their exposure is purposefully limited. However,
because radiographers are considered occupationally exposed indi-
viduals, they are prohibited from activities that would result in direct
exposure to the primary x-ray beam. This means that they are not
allowed to hold patients or cassettes during x-ray exposures and must
stand clear of the path of the primary x-ray beam during fluoroscopic
and mobile radiographic examinations. Whenever possible, patients
should be immobilized without someone holding them. When
infants or children must be held, a parent (as long as the parent is
not pregnant) usually is the appropriate person to perform this duty,
with the required lead covering.
Medical assistants may or may not be considered occupationally
exposed persons, depending on their work assignments and the
frequency with which they are involved with radiation use. Medical
assistants who are not routinely exposed occasionally may assist with
procedures by holding patients or cassettes. When this is the case,
the medical assistant should wear a lead apron and should avoid
direct exposure to the primary x-ray beam if possible (Figure 26-30).
If the hands will be in the primary beam, lead gloves should also be
worn.
Personnel are not exposed to any significant amount of radiation
when standing well behind the protective lead barrier of the control
booth. X-rays travel in straight lines and do not turn corners. Scatter
radiation is not powerful enough to generate additional radiation of
concern when it interacts with matter, so the control booth need not
be sealed.
Occupational exposure increases when an employee assists with
fluoroscopic procedures or uses mobile x-ray equipment. The three
FIGURE 26-30 When holding a child for a radiographic procedure, wear a lead apron and stay
as far from the primary x·ray beam as possible. (From Frank ED, Long BW, Smith BJ: Merrill's a#as
of radiographic positioning and procedures, ed 12, St Louis, 2013, Mosby.)
principal methods used to protect personnel from unnecessary radia-
tion exposure are time, distance, and shielding.
• Because the amount of exposure received is directly propor-
tional to the time spent in a radiation area, dose is decreased
when this time is minimized. For example, you might shorten
the time of exposure by stepping into the control booth during
fluoroscopic procedures when not required to be near the
patient.
• Increasing the distance between yourself and a radiation source
reduces your exposure in proportion to the square of the distance;
therefore, small increases in distance have a relatively large effect.
Mobile x-ray units have long cords on the exposure switches,
which allows the radiographer to get as far from the radiation
source as possible while making an exposure.
• Shielding is the most common type of personnel protection used
in outpatient radiography settings. The lead wall of the control
booth provides a radiation safety barrier and is the principal
defense for personnel. Other types of shielding include lead
aprons, gloves, goggles, and thyroid shields. These types of shield-
ing are worn during fluoroscopic procedures and mobile radio-
graphic examinations.
Pre-exposure Safety Check. Before an x-ray image is taken,
double-check to make sure of the following:
• The x-ray room door is closed; a closed door indicates that an
exposure is in progress and no one may enter the room.
• No nonessential individuals are in the x-ray room; all essential
individuals outside the lead barrier are appropriately shielded.
• All those in the control booth are completely behind the lead
barrier.
Personnel Monitoring. A device for monitoring radiation exposure
to personnel is called a dosimeter. The three basic types of dosim-
eters are film badges, thermoluminescent dosimeters (TLDs), and
optically stimulated luminescence dosimeters (OSLs). OSLs, the
most recently developed monitoring dosimeter (Figure 26-31 ), use
aluminum oxide as the radiation detector. OSLs provide greater
stability and precision plus the ability to reanalyze and confirm
results. For this reason, they are most commonly used.

FIGURE 26-31 Optically stimulated luminescence (OSL) dosimeter.
A personnel dosimeter should be worn near the collar, on the
front of the body. If a lead apron is worn, the dosimeter should stay
on the outside. At the end of the workday, the dosimeter should
remain at the medical facility and should not be taken home. Preg-
nant personnel should also wear a second dosimeter at the waist,
which should remain beneath any lead shielding.
Your facility will contract with a radiation monitor badge service
laboratory to provide badges, processing services, and reports. The
laboratory also is responsible for maintaining permanent records of
the radiation exposure of each person monitored. Previously, depend-
ing on facility policy, badges were sent for evaluation of radiation
exposure on a weekly, monthly, or quarterly basis. Personnel who
receive relatively high doses of occupational exposure have histori-
cally changed their badges most frequently. Enhanced electronics
may allow doses to be automatically read and captured by smart
phones and computers, with online report access available for
evaluation.
Service companies provide an extra badge in every batch that is
marked CONTROL. This badge's purpose is to measure any radia-
tion exposure to the entire batch while in transit. Any amount of
exposure measured from the control badge is subtracted from the
amounts measured from the other badges in the batch. The control
badge should be kept in a safe place, away from anywhere x-ray
exposure could occur. It should never be used to measure occupational
dose or for any other purpose.
Exposure reports are sent to the facility for each batch with an
annual summary of personnel exposure. The report sent by the labo-
ratory that processes the personnel dosimeters reports occupational
dose in rem. Personnel should be advised of the radiation exposure
reported from their badges and should be provided with copies of
the annual reports for their own records. Employers are required to
provide a complete record of an employee's radiation exposure
history to all employees who have radiation exposure records before
the individual leaves the employment of that facility.
CHAPTER 26 Assisting with Diagnostic Imaging 669
Effective Dose Equivalent Limits
The effective dose equivalent (EDE) limiting system is used to calculate the
upper limit of permitted occupational exposure. For occupationally exposed
personnel, the EDE limit is 50 mSv (5 rem) per year. This is assumed to
be a whole body dose that affects workers over age 18. These limits apply
to occupational exposure only and do not include diagnostic imaging
exposure that the worker may receive as a result of tests related to his or
her own healthcare.
The established EDE limits ensure that the safety of radiation workers
is comparable to that of workers in other, safe occupations. The allowable
exposure is considered to be so low as to pose an insignificant risk. The
occupational exposure received by radiographers usually is well below the
established limit.
Occupational Precautions during Pregnancy
Radiation exposure during pregnancy must be closely monitored because
of possible complications for the developing fetus. The National Council on
Radiation Protection and Measurements (NCRP) has recommended an
equivalent dose (EqD) limit of whole body radiation for the pregnant worker
of less than 0.5 mSv per month, with a cumulative total of 5 mSv (0.5
rem) over the 9-month course of the pregnancy. The worker first must
submit a written document to her employer declaring the pregnancy. The
employer then is responsible for providing fetal radiation monitoring and
for ensuring that the occupational dose does not exceed the effective dose
equivalent (EDE) limit for pregnant workers. Every effort should be made
to minimize exposure, keeping the dose as far below the limit as
possible.
For a pregnant radiographer, the safest work assignment is one in which
a permanent lead barrier (control booth) always shields the worker during
exposures. Pregnant radiographers and those of childbearing age who may
be pregnant should pay particular attention to personal safety measures
when assisting with fluoroscopy or using mobile x-ray equipment. An
additional dosimeter should be worn at waist level, inside of protective
shielding.
Patient Protection
The acronym ALARA stands for "as low as reasonably achievable."
This is a safety principle in radiography that reminds the radiogra-
pher to limit levels of radiation exposure to humans whenever pos-
sible. The idea is to use enough radiation to get the job done right
the first time, but not more than is needed to obtain a good image.
If too low a dose is used and an x-ray must be repeated, the patient
is exposed to much more radiation than if a slightly higher dose was
used just once. This is the greatest cause of unnecessary radiation
that can be controlled by limited radiographers. However, using too
high a dose of radiation makes it difficult to see details in a radio-
graph clearly. This too can lead to repeat exposure and additional
radiation. Therefore, it is wise to consult a radiographic chart specifi-
cally designed for the radiographic laboratory being used to deter-
mine the best setting for the patient's size and position.
670 UNIT FOUR DIAGNOSTIC PROCEDURES

The following methods are used to minimize the radiation dose
to patients:
• Avoid errors. Double-check requisitions and patient identifica-
tion so that the right patient gets the right examination.
• Establish good routine procedures and follow them strictly so
that errors caused by carelessness do not necessitate repeat
exposures.
• Collimate. Use the smallest radiation field needed to fulfill the
physician's order. The size of the radiation field should always be
less than the size of the image receptor.
• Use the highest kVp consistent with acceptable image quality.
This permits use of the least possible mAs to obtain an acceptable
exposure.
• Use an SID of at least 40 inches. This limits patient exposure
from tube housing leakage and collimator scatter.
• Provide shielding for gonads, eyes, breasts, and thyroid as
appropriate.
Gonad Shielding. Lead shields that prevent unnecessary radiation
exposure to the reproductive organs are required when the patient
is of reproductive age or younger; whenever the gonads are within
the primary radiation field; and when the shield will not interfere
with the examination. This applies to most patients under age 55.
A shield device consisting of at least 0.5 mm of lead or equivalent
is placed between the x-ray tube and the patient. Shields attached to
the collimator (shadow shields) may be positioned by viewing their
shadows within the collimator light field. Shields placed on or near
the patient's body are referred to as contact shields and are more
effective than shadow shields. Both types meet the legal requirements
for gonad shielding. The female shield is placed with its lower margin
at the level of the pubic symphysis (Figure 26-32). The male shield
is positioned with its upper margin about 1 inch below the pubic
symphysis (Figure 26-33). It is helpful to note that the pubic sym-
physis is at about the same level as the greater trochanter of the
femur, which prevents the need to palpate the pubic symphysis for
proper shield placement.
Pregnant or Possibly Pregnant Patients. The greatest risks for
spontaneous abortion, fetal death, and significant birth defects exist
when significant levels of exposure occur during the first trimester
of pregnancy. The embryo is most vulnerable to radiation insult
while tissues are in the process of differentiation. Unfortunately, this
creates the greatest hazard at a time when a woman may not yet be
aware she is pregnant.
The public is generally aware that x-ray imaging should be
avoided during pregnancy, and this may lead to irrational fears on

Pubic
symphysis

Greater
trochanter

FIGURE 26-32 When precise gonod shielding is required for female patients, place the lower margin of the shield on the upper margin of
the pubic symphysis. (Bontrager Kl, lompignono J: Textbook of radiographic positioning and related anatomy, ed 8, St Louis, 2014, Mosby.)

Pubic
symphysis

Greater
trochanter

FIGURE 26-33 When precise gonad shielding is required for male patients, place the upper margin of the shield l inch below the pubic
symphysis. (Bontrager Kl, lompignono J: Textbook of radiographic positioning and related anatomy, ed 8, St Louis, 2014, Mosby.)

the part of pregnant women or their families. The chance is extremely
remote that a routine x-ray examination of the chest or an extremity
would harm the developing child. On the other hand, examinations
requiring direct radiation to the pelvis, especially relatively high-dose
fluoroscopy studies or CT scans of the abdomen or lumbar spine,
may be cause for concern.
Radiation control regulations require that female patients of
childbearing age be advised of potential radiation hazards before
an x-ray examination. This requirement usually is met by posting
signs in the radiology department advising women to tell the
radiographer before the examination if they may be pregnant.
These signs should be written in all languages commonly used in
the community.
The medical assistant should ask specific questions to rule out
pregnancy when taking a medical history. If pregnancy is a possibil-
ity, an early pregnancy test should be done to rule out the possibility.
If the patient is pregnant and the proposed x-ray examination
involves direct pelvic radiation, the physician must weigh the poten-
tial risks and benefits of the examination and discuss them with the
patient before proceeding with the study. In the case of minor or
chronic complaints, the examination typically is delayed until after
the child is born. In practice, however, the possibility of pregnancy
may not even be considered. This is especially true with accident or
injury, when the patient is being cared for by unfamiliar physicians
in an emergency situation. For this reason, it is essential to consider
the possibility of pregnancy in any female of childbearing age and
to ask specific questions to determine whether the provider has
addressed the issue of pregnancy before proceeding with scheduling
or assisting with an x-ray examination.
If an x-ray examination of a pregnant patient must be done,
modifications in procedure can help minimize the dose to the
embryo or fetus. If the part to be examined is not the abdomen or
pelvis, those areas can be shielded with a lead apron. If the abdomen
or pelvis is to be evaluated, the number of views or the size of the
radiation field may be minimized, resulting in less radiation exposure
than that required for a routine procedure.
CRITICAL THINKING APPLICATION 26-3
Ingrid White is gowned and ready for a lumbar spine x-ray examination
when Sara asks her whether there is any possibility she might be pregnant.
Mrs. White confides that she and her husband have been trying to conceive
for several months, and she is not sure whether she currently is pregnant.
What should Sara do?
CLOSING COMMENTS
Role of the Medical Assistant
Depending on your location, you may or may not be legally permit-
ted to take x-rays. Most states require some sort of license or permit
to practice radiography. Some grant licenses only to professional
radiologic technologists who have completed at least a 2-year educa-
tion program and obtained certification in radiography from the
American Registry of Radiologic Technologists (ARRT). Other
states have a reciprocity policy that allows a medical assistant with a
CHAPTER 26 Assisting with Diagnostic Imaging 671
limited operator's license from another state to work in that
capacity.
Limited radiography, sometimes called practical radiography, is
practiced primarily in clinics and physicians' offices. This field devel-
oped as nurses, medical assistants, chiropractic assistants, and other
healthcare office personnel were trained to perform basic x-ray pro-
cedures in addition to their primary duties. It is called limited
because the scope of practice is restricted compared with that of
registered radiologic technologists. However, the actual title may
vary by state. Limited practice does not usually involve the use of
contrast media, and additional restrictions may apply, depending on
the scope of practice permitted in the states where limited radiogra-
phy can be legally practiced.
However, even if you are not qualified as a limited operator, it
may be helpful to understand the general procedures involved in
an x-ray examination and to identify areas where the medical assis-
tant might be of help to the patient or radiographer, or both. The
exact nature of your duties will vary with your qualifications, your
place of employment, the size of the staff, and the equipment
available.
The process of radiography involves validation of orders, patient
preparation, image receptor placement, correct positioning of the
patient and equipment, measurement of the part to be examined,
protective shielding, correct setting of the exposure controls, and
identification and processing of the image. These basic procedures
vary considerably, depending on the body part to be examined.
Patient Education
In radiography, patient education is the best way to achieve success-
ful participation and to alleviate fears. It is important to tell the
patient exactly what to expect in advance. This may require explana-
tion of diet restrictions, medication or contrast usage, the process of
imaging itself, and if invasive procedures are included. It is essential
to be honest and straightforward with patients, yet to use care and
gentleness during the process. Be sure to smile and make good eye
contact while discussing details. Always give the patient time to ask
any questions or to talk about any concerns.
Legal and Ethical Issues
Only licensed health practitioners are permitted to order x-ray exam-
inations. Interpretation of diagnostic images is part of the profes-
sional practice of making a diagnosis and is solely the privilege of
specifically trained providers, such as physicians. Although you may
learn to recognize certain conditions represented in diagnostic
images, you must never discuss your observations with the patient
(Figure 26-34).
In most states, x-ray machines must be licensed, and personnel
operating this equipment must have a current license or permit.
However, according to the American Society of Radiologic Tech-
nologists (ASRT), most states allow employees to be trained to
operate equipment and position patients, as long as a licensed
radiographer supervises and pushes the final exposure button. Always
check your specific state standards and institutional policy before
engaging in any radiography practice to avoid improperly acting
without a license. Practicing without a valid license or permit or
practicing outside the scope of one's credentials may result in fines,
imprisonment, or both. Employers may also be penalized if their
672 UNIT FOUR DIAGNOSTIC PROCEDURES
FIGURE 26-34 Although the medical assistant may learn to identify differences in x-ray images,
it is important never to discuss them with the patient because this may be considered a diagnosis.
(Courtesy Helen Mills.)
employees practice radiography in violation of regulations. Even if
you work in a state that currently has no requirements for practicing
radiography, you should be aware that the safe practice of radiogra-
phy requires additional experience, in addition to education beyond
that provided in this chapter.
If a patient does not comply with instructions, it is illegal to lay
hands on the patient or to hold a patient in position without verbal
permission. In legal terms, this is called battery, and it is considered
a criminal charge. There are only a few exceptions to this law. If a
patient is not conscious, consent is not necessary. If a patient is a
minor, parental consent is required; however, it is best to have the
parent or family member assist. If a patient is mentally confused, a
signed order of judgment should be obtained before you assist an
unwilling patient.
Patients should never be threatened into compliance. This is
considered assault, even if the patient is never touched. To avoid this,
simply take a few moments to make the patient feel more comfort-
able by building rapport with him or her. Small talk is a great way
SCENARIO
The providers and radiographer at Metro Urgicenter depend on Sara's assistance
to keep the x-ray department running smoothly. Today, for example, she
instructed four patients in how to gown and prepare for routine x-ray examina-
tions, and she processed the images after the exams. Greg Nolan had PA and
lateral views of the chest because of a persistent cough and fever. Margaret
and Jeff Barge both needed spine x-ray studies to rule out possible fractures
from a car accident. Dr. Farnsworth, a physician at the practice, ordered AP and
lateral views of Ella Jackson's left hip. Sara was proud to see that the images
to make people relax, particularly if you ask questions that get them
to talk about themselves. Then, calmly explain the procedure and
offer reassurance. In this instance, a little kindness can go a long way.
X-ray and other diagnostic images are the property of the institu-
tion or facility where they are taken. Images are considered part of
the health record and are subject to the same kinds of requirements
with respect to confidentiality, retention, and availability to the
patient. The retention period varies from state to state; usually it is
5 to 7 years. Images may be loaned or transferred to other healthcare
providers to assist in the patient's care. The patient should sign a
release when images or copies of images are to be sent to another
healthcare provider. This process is much less complicated in prac-
tices with electronic health records.
CRITICAL THINKING APPLICATION 26-4
One of the new medical assistants at Metro Urgicenter, Carla O'Neal, tells
Sara that she is not qualified to practice radiography in the office's jurisdic-
tion. Dr. Swain had instructed her to position a patient and set up the
equipment for an x-ray examination. When Carla told him that she was not
yet qualified to practice radiography, he replied, "Don't worry. I'll come by
in a few minutes and make the exposure." What should Sara and Carla do
about this?
Professional Behaviors
Most important in radiographic testing is the rapport that is developed
between the medical assistant and the patient. Rushing a patient or being
insensitive to his or her fears or needs is likely to cost you more time and
effort in gaining cooperation. The best way to get a patient to respond
favorably is to look the individual in the eye, smile, and take a little time
for small talk.
Patients tend to react to the behavior of the medical assistant in adirect
manner. If the radiographer has wrinkled clothing and poor body hygiene,
the patient automatically assumes that the provider doesn't care about
details, and he or she loses faith immediately. Factors such as gum
chewing, untoward body language, and inconsiderate behavior can make
a patient distrustful and resistant to cooperation. Aprofessional appearance
and a courteous method of communication can go a long way toward
helping a frightened patient relax and follow directions.
had no handling artifacts after she had processed them. This afternoon, Sara
made an appointment for Cecile Marsden to have a bone scan at University
Imaging Center. She was able to describe the procedure for Ms. Marsden so
that she would know exactly what to expect. Sara recognizes that she must
remain up to date on the current radiologic diagnostic procedures to provide
assistance when needed and to answer patients' questions. Sara enjoys her
work at Metro Urgicenter; she is attending evening classes to become certified
as a limited radiographer.

SUMMARY OF LEARNING OBJECTIVES
l. Define, spell, and pronounce the terms listed in the vocabulary.
Spelling and pronouncing medical terms correctly reinforce the medical
assistant's credibility. Knowing the definitions of these terms promotes
confidence in communication with patients and co-workers.
2. Discuss basic principles of radiography and the types of x-rays.
Radiography is the process of creating an x-ray image to examine internal
structures of the body. Aradiographer is much like a photographer who
takes pictures with a camera and is responsible for processing them. The
various types of x-rays are primary radiation, remnant radiation, and
scatter radiation.
3. Identify the principal components of radiographic equipment.
The main component of the x-ray machine is the tube in its barrel-
shaped tube housing. The collimator is mounted on the tube housing.
The tube housing, with its attachments, is mounted on the tube support.
The radiographic table and an upright cassette holder provide support
for the patient and the image receptor and incorporate a grid device.
At the control console, the operator selects the exposure settings
and makes the exposure. The collimator is a boxlike device attached
beneath the tube housing that allows the operator to adjust the size of
the radiation field. The power supply can be controlled in the trans-
former cabinet.
4. Discuss the four prime factors of x-ray exposure.
The four principal exposure factors are called the prime factors of expo-
sure. They include milliamperage, exposure time, kilovoltage, and source-
to-image distance. Technique charts provide the radiographer with a
listing of recommended millampere-seconds, kilovoltage, and source-to-
image distance settings for x-ray studies of various body parts in patients
of different sizes.
5. Do the following related to radiographic positioning:
• Distinguish among the three body planes and use these terms correctly
when discussing radiographic positions.
The three body planes are the sagittal plane, which divides the body
into right and left parts; the coronal plane, which divides the body
into anterior and posterior parts; and the transverse plane, which
divides the body into superior and inferior parts. For a frontal projec-
tion (AP or PA), the coronal plane is parallel to the image receptor
and the sagittal plane is perpendicular ta it. Far a lateral projection,
the sagittal plane is parallel ta the image receptor and the coronal
plane is perpendicular to it. Neither the sagittal plane nor the coronal
plane is parallel to the image receptor on an oblique position.
• Differentiate between anteroposterior (AP) and posteroanterior (PA)
proiections and describe the lateral and oblique radiographic
positions.
• AP proiection: The patient is supine or facing the x-ray tube. The
x-ray beam leaves the tube, passes through the front of the patient,
and then exits through the back to strike the image receptor.
• PA proiection: The patient is prone or facing the image receptor.
The x-ray beam leaves the tube, passes through the back of the
patient, and then exits through the front to strike the image
receptor.
CHAPTER 26 Assisting with Diagnostic Imaging 673
The oblique and lateral radiographic positions are:
• Left anterior oblique: Patient's left side is on the image receptor
with the anterior (front) leaning toward the image receptor.
• Right anterior oblique: Patient's right side is on the image receptor
with the anterior (front) leaning toward the image receptor.
• Left posterior oblique: Patient's left side is an the image receptor
with the posterior (back) leaning toward the image receptor.
• Right posterior oblique: Patient's right side is on the image receptor
with the posterior (back) leaning toward the image receptor.
• Left lateral: Patient's left side is on the image receptor.
• Right lateral: Patient's right side is on the image receptor.
6. Discuss fluoroscopy and contrast media.
Radiography and fluoroscopy are both x-ray imaging procedures with a
wide variety of applications. Radiography produces still images; fluoros-
copy enables the radiologist to view the x-ray image directly and to
observe motion. Contrast media are substances that enhance the visibility
of soft tissues. Examples of x-ray studies that use contrast media are an
upper gastrointestinal (UGI) series, a lower gastrointestinal series, an
intravenous urogram (IVU), an arthrogram, and myelography.
7. Discuss cardiovascular and interventional radiography, computed
tomography, magnetic resonance imaging, sonography, and nuclear
medicine.
The highly specialized radiographic procedures that display blood vessels
are collectively known as angiography. Computed tomography uses a
special x-ray scanner to produce detailed pictures of a cross section of a
tissue. MRI uses a strong magnetic field and radiofrequency pulses to
produce images of all parts of the body, including bone, soft tissue, and
blood vessels. Nuclear medicine studies demonstrate the function of
organs and tissues by mapping the radiation given off within the body
when radioactive tracers have been ingested or injected into the patient.
Sonography is avery safe imaging method that demonstrates soft tissues
using high-frequency sound waves. Nuclear medicine images are created
by scanning the patient after special radioactive materials, called tracers,
have been swallowed or injected intravenously. Dual energy x-ray absorp-
tiometry (DEXA) scans use x-ray technology to evaluate a patient's bone
density level.
8. Do the following related to basic radiographic procedures:
• Explain the patient preparation guidelines for typical diagnostic
imaging examinations.
Table 26-5 summarizes patient preparation.
• Outline the general procedure for scheduling and sequencing diagnos-
tic imaging procedures.
When possible, several examinations should be scheduled on the
same day if the patient is strong enough. Imaging that requires fasting
is easier on the patient if scheduled in the morning. Diagnostic
imaging that does not require contrast media or nuclear medicine
should be scheduled first. Next are examinations of the urinary tract
and biliary system. Fiberoptic studies (e.g., colonoscopy) and CT
studies of the abdomen and pelvis should be scheduled before any
GI studies that require barium. CT and MRI can be scheduled any time
Continued
674 UNIT FOUR DIAGNOSTIC PROCEDURES
SUMMARY OF LEARNING OBJECTIVES-continued
unless they require IV contrast; if iodine dye is needed, the procedure
is scheduled after examinations that do not require visualization.
Barium studies are always scheduled last, and a UGI series (barium
swallow) is the final procedure.
• Apply patient education principles when providing instructions for
preparation for diagnostic procedures.
Table 26-5 summarizes patient preparation guidelines for diagnostic
imaging procedures. The patient must be informed of the purpose of
the study, how the procedure will be performed, and any important
patient preparation steps to make sure the examination can be
completed successfully. The healthcare facility should have instruction
sheets ready to distribute to patients scheduled for diagnostic studies.
The medical assistant must understand diagnostic procedures so that
the patient's questions can be answered and informed consent can
be obtained. The medical assistant should review instruction sheets
with the patient to make sure the preparation is done as recom-
mended. Whenever contrast is to be administered, it is essential to
ask the patient about iodine or shelmsh allergies and whether he or
she has ever had a negative reaction to contrast media; if so, the
provider should be informed.
9. Describe the health risks associated with low doses of x-ray expo-
sure, such as those used in radiography.
The health risks associated with radiography are extremely small and
consist of a slightly increased likelihood of developing cataracts, cancer,
or leukemia. The potential also exists for a minimal decrease in life span
and for a negative outcome if the abdominal area is exposed to radiation
CONNECTIONS
OJ Study Guide Connection: Go to the Chapter 26 Study Guide. Read and complete
the activities.
during pregnancy. Exposure of the reproductive organs may cause genetic
changes that can be passed on to future generations.
l 0. Describe precautions for ensuring the safety of equipment operators
and staff members during x-ray procedures.
The principal safety precaution for Xi•y equipment operators and
staff members is ta stay completely behind the lead barrier af the
control booth during exposures. Occupationally exposed individuals
must not hold patients or image receptors during exposures. Any staff
member required to be in the x-ray room during an exposure should
be shielded by a lead apron, should stay as far from radiation sources
as possible, and should minimize the time spent in the room during
exposures.
11. Summarize the steps for ensuring that patients receive the least
possible exposure during x-ray procedures.
To ensure that patients receive the least possible exposure during
xiay procedures, radiology personnel should avoid errors that could
require repeat exposures; establish good routine procedures and follow
them strictly; collimate to the smallest radiation field; use the highest
kVp possible; use an SID of at least 40 inches; and shield the repro-
ductive organs and other sensitive organs (e.g., eyes, thyroid, and
breasts).
12. Explain the legal responsibilities associated with x-ray procedures
and the administrative management of diagnostic images.
Diagnostic images are the property of the facility in which they are made.
Only licensed healthcare providers are permitted to order Xi•yexamina-
tions and/or to interpret x-ray images.
evolve Evolve Connection: Go to the Chapter 26 link at evolve.elsevier.com/
kinn to complete the Chapter Review Quiz. Check out the other resources listed for this
chapter to make the most of what you have learned from Assisting with Diagnostic
Imaging.
ASSISTING IN THE CLINICAL
LABORATORY
Marsha Rollins, (MA (AAMA), has been employed for 3 years as a Certified
Medical Assistant in a medical practice. The providers have a medical laboratory
on site, and Marsha has become experienced in collecting specimens, perform-
ing laboratory tests, and reporting results. Recently she was offered a position
While studying this chapter, think about the following questions:
• What agencies can assist Marsha as she researches the feasibility of
setting up a laboratory in the new office?
• What regulations will guide the testing that can be performed in the
laboratory?
LEARNING OBJECTIVES
1. Define, spell, and pronounce the terms listed in the vocabulary.
2. Discuss the role of the clinical laboratory personnel in patient care
and the medical assistant's role in coordinating laboratory tests and
results.
3. Describe the divisions of the clinical laboratory and give an example of
a test performed in each division.
4. Explain the three regulatory categories established by the Clinical
Laboratory Improvement Amendments (CUA) and identify CUA-waived
tests associated with common diseases.
5. Identify quality assurance practices in healthcare, document the results
on a laboratory flow sheet, and discuss quality control guidelines.
6. Do the following related to laboratory safety:
• Compare the agencies that govern or influence practice in the
clinical laboratory.
• Discuss the purpose of a Safety Data Sheet.
• Summarize safety techniques to minimize physical, chemical, and
biologic hazards in the clinical laboratory.
7. Describe the essential elements of a laboratory requisition.
VOCABULARY
aliquot (ah'-luh-kwaht) A portion of a well-mixed sample
removed for testing.
analyte The substance or chemical being analyzed or detected in a
specimen.
anticoagulants Chemicals added to a blood sample after
collection to prevent clotting.
27
in a smaller practice closer to home; she has accepted the position, knowing
that her experience will benefit the practice because the providers would like
to expand their on-site medical laboratory testing. One of Marsha's new respon-
sibilities will be equipping the office laboratory.
• What equipment will Marsha need, and how will she make sure that it
stays in good working order?
8. Discuss specimen collection, including the importance of sensitivity to
patients' rights and feelings when collecting specimen. Also, discuss the 8
steps in collecting specimens and informing patients of their results.
9. Explain the chain of custody and why it is important.
10. Describe the differences between Greenwich time and military time.
11. Identify the Fahrenheit temperature and the Celsius temperature of
common pieces of laboratory equipment.
12. Name the metric units used for measuring liquid volume, distance, and
mass.
13. Do the following related to laboratory equipment
• Name the parts of a microscope and describe their functions.
• Summarize selected microscopy tests that may be performed in
the ambulatory care setting.
• Demonstrate the proper use and maintenance of the microscope.
• Describe the safe use of a centrifuge.
• Discuss the use of an incubator.
14. Identify patient education issues, as well as legal and ethical issues, in
the clinical laboratory setting.
calibration Determining the accuracy of an instrument by
comparing its output with that of a known standard or another
instrument known to be accurate.
caustic (kos' -tik) Capable of burning, corroding, or damaging
tissue by chemical action.
676 UNIT FOUR DIAGNOSTIC PROCEDURES
VOCABULARY -continued
cytology (si-tah'-luh-je) The study of cells using microscopic
methods.
exudates (ek'-syu-dayts) Fluids with high concentrations of
protein and cellular debris that have escaped from the blood
vessels and have been deposited in tissues or on tissue surfaces.
hemolyzed A blood sample in which the red blood cells have
ruptured.
in vitro Latin term meaning "in the laboratory."
preservatives Substances added to a specimen to prevent
deterioration of cells or chemicals.
profile testing A series of laboratory tests associated with a
particular organ or disease; also referred to as a "panel" of tests.
qualitative A laboratory test result expressed as positive or
negative.
quality assurance The process of monitoring all the processes
involved before, during, and after a laboratory test is performed
in order to produce reliable patient test results.
ROLE OF THE CLINICAL LABORATORY
IN PATIENT CARE
Laboratory medicine, or clinical pathology, is the medical discipline
that applies clinical laboratory science and technology to the care of
patients. The clinical laboratory is the place in which a collected
specimen is analyzed and evaluated. Tests are performed manually
(by hand) or through automation (using specialized instruments).
Personnel in the Clinical Laboratory
Medical laboratories are located in hospitals or in facilities such as
providers' offices, clinics, public health departments, health mainte-
nance organizations, and private referral laboratories. The director
of a laboratory may be a pathologist, a physician specially trained in
the nature and cause of disease, or a clinical laboratory scientist with
a doctorate. The laboratory is staffed by various professionally trained
individuals, including certified medical technologists (MTs), who
have earned a baccalaureate degree, have had additional formal train-
ing, and have passed a national certification examination. Other
personnel include certified medical laboratory technicians (MLTs)
or medical laboratory assistants (MLAs) and credentialed medical
assistants (CMAs, RMAs). These employees have completed a 1- to
2-year specialized training program and have passed a national exam-
ination. Laboratory assistants and phlebotomists, who have received
specialized training in the collection and preparation of laboratory
specimens, also work in laboratories. The agencies granting certifica-
tions and titles are listed in Table 27-1 .
In ambulatory facilities, the lab director may be the physician.
These labs are referred to as physician office laboratories (POLs). The
medical assistant is trained both to perform certain testing proce-
dures in the POL and in methods of collecting specimens that are
sent to outside reference laboratories for testing.
Laboratory tests may be used to screen patients for diseases such
as diabetes or urinary tract infections. They are also an essential part
quality control Manufactured samples with known values used to
determine whether a test method is reliable
quantitative A laboratory test result expressed in numeric units of
measure.
reagent (re-a'-gent) A testing substance that produces a reaction
when interacting with the patient sample
referral laboratory A private or hospital-based laboratory that
performs a wide variety of tests, many of them specialized;
providers often send specimens collected in the office to referral
laboratories for testing.
reference range The numeric range of test values for which the
general population consistently shows similar results 95% of the
time.
specimen A sample of body fluid, waste product, or tissue
collected for analysis.
STAT Immediately.
of a medical diagnosis. In addition, they may be performed to help
the provider decide the most appropriate treatment to prescribe and
to monitor the effects of medications and/or a disease process. Only
healthcare practitioners may request laboratory testing for a patient.
The medical assistant may be responsible for a number of these
testing procedures. To assume this responsibility, the medical assis-
tant must know proper patient preparation, the procedure for each
test, and the normal range of results for the test. The medical assis-
tant must carefully follow all laboratory instructions in obtaining
and labeling specimens and sending them to the laboratory. Good
communication among the patient, office staff, and laboratory per-
sonnel is important. The medical assistant should make the patient
feel at ease with these procedures and thus gain the patient's
cooperation.
Clinical Laboratory Testing
Clinical laboratory testing is used in conjunction with a thorough
health history and physical examination to obtain essential data for
screening, diagnosis, and/or management of a patient's condition.
The body is considered to be healthy when a state of equilibrium
exists in the internal environment. In this healthy state of equilib-
rium, called homeostasis, the physical and chemical characteristics of
body substances (e.g., fluids, secretions, and excretions) are within a
certain acceptable range, known as the normal range, or reference
range. A change in homeostasis results in abnormal test values that
are outside the population's reference range. When a provider uses a
laboratory test for diagnosis, the patient's results are compared to the
reference range of values. Reference values are also useful for assess-
ing the progress of a patient's course of treatment.
Abnormal values for a particular test may be seen with more than
one pathologic condition. For example, a decrease in the hemoglobin
level in red blood cells (RBCs) is seen in iron-deficiency anemia, but
also in hyperthyroidism and cirrhosis of the liver. Therefore, provid-
ers cannot rely solely on one laboratory test to make a diagnosis;
 CHAPTER 27 Assisting in the Clinical Laboratory 677

TABLE 27-1 Certifying Agencies for Laboratory Personnel

CERTIFYING AGENCY TITLE POSITION
American Society for Clinical Pathologists (ASCP) MT (ASCP) Medical technologist
MLT (ASCP) Medical laboratory technician - certificate
MLT-AD (ASCP) Medical laboratory technician - associate's degree
American Medical Technologists (AMT) MT (AMT) Medical technologist
MLT (AMT) Medical laboratory technician
MIA Medical laboratory assistant
RMA Registered medical assistant
Department of Health and Human Services (DHHS) CLT (HHS) Clinical laboratory technologist
National Certification Agency for Medical Laboratory Personnel (NCA) CLS (NCA) Certified laboratory scientist
CLT (NCA) Certified laboratory technician
International Society for Clinical Laboratory Technology (ISCLT) RMT (ISCLT) Registered medical technologist
RLT (ISCLT) Registered laboratory technician
American Association of Medical Assistants (AAMA) CMA (AAMA) Certified medical assistant
National Healthcareer Association (NHA) CCMA Certified clinical medical assistant
CPT Certified phlebotomy technician
CMIA Certified medical laboratory assistant

they must use a combination of data obtained from the health
history and physical examination, and a number of diagnostic and
laboratory results.
Tests performed in a clinical laboratory range from simple screen-
ing of one analyte (e.g., measuring glucose to assess for diabetes) to
complex profile testing, in which more than one analyte is related
to a particular organ or disease (e.g., performing a lipid profile to
determine the various fats in the blood). A screening test examines
a particular specimen for the presence of an analyte that may indicate
a disease state. Screening tests are not diagnostic for any particular
disease, but rather indicate that the disease state may exist. Screening
tests are done routinely on patients on the basis of their age, history,
or gender. The results are often qualitative in that a numeric value
is not attached to the result; they may be simply reported as "posi-
tive" or "negative." The fecal occult blood test for blood in the stool
(feces) is an example of a screening test. Blood is not normally found
in the stool, and its presence may indicate a cancerous lesion in the
colon. A positive test result indicates that blood is present, but
additional testing is required to determine the source of the blood.
For example, in a female patient, further testing or examination may
reveal that the patient was having her menstrual period at the time
of the first collection of the specimen or that she had bleeding
hemorrhoids.
In a quantitative test, units of measure are attached to numeric
values. These values often are represented as the numeric amount of
an analyte per given volume of specimen. It is essential that the
quantitative test results be reported with the units of measure. For
example, a complete blood cell count for a healthy adult would show
these values: RBCs, 5 million per cubic millimeter (5 X 106/mm 3);
hemoglobin, 15 grams per deciliter (I 5 g/ dL); and hematocrit, 45%.
Generally the units are printed on the laboratory report, but the
medical assistant must always make sure that the values are consis-
tent with the test performed.
CRITICAL THINKING APPLICATION 27-1
The referral laboratory calls to report the values on several tests performed
on the urine of a patient, Cecelia Roberts. Marsha jots down the following:
Total protein, 0.12; Occult blood, positive; Albumin, 50; Glucose, 120.
What is wrong with the notations she has just made? Are these tests qualita-
tive or quantitative?
DIVISIONS OF THE CLINICAL LABORATORY
Large laboratories are divided into various departments, which may
include urinalysis, hematology, chemistry, microbiology, specimen
collection and processing, blood bank, coagulation, serology, histol-
ogy, cytology, toxicology, and special chemistry. The small labora-
tory area in the physician's office provides test procedures in urinalysis,
hematology, chemistry, and microbiology.
Urinalysis
Urinalysis includes the physical, chemical, and microscopic examina-
tion of urine. In the physical examination, the color, clarity, and
specific gravity are noted. The specimen's temperature also may be
measured to verify that the sample is a fresh one taken at body
678 UNIT FOUR DIAGNOSTIC PROCEDURES

temperature, because some individuals may bring a urine sample

from elsewhere and try to pass it off as their own. Chemical analysis
is performed to measure levels of such analytes as glucose, protein,
ketones, blood, bilirubin, urobilinogen, nitrites, and pH. Micro-
scopically, the urine is examined for the visual presence of red, white,
and epithelial cells; mucus; casts; crystals; yeasts; parasites; and bac-
teria. Additional quantitative tests may be performed in the urinaly-
sis department of a reference laboratory to confirm routine screening
test results.
CRITICAL THINKING APPLICATION 27-2
Dr. Watkins has ordered a routine urinalysis (UA), a urine culture and
sensitivity (C&S), a blood glucose test, and a complete blood count (CB()
for his patient. Which division of the laboratory is responsible for analyzing
the specimens for each test?

Hematology
Hematology is the study of blood cells and coagulation. Laboratory
testing in the hematology division may be qualitative or quantitative.
Screening tests for hemoglobin and hematocrit are typically per-
formed in the ambulatory setting. Blood cell counts determine the
exact number of RBCs, or erythrocytes; white blood cells (WBCs,
or leukocytes); and platelets (thrombocytes), either by manual or
automated counting. Microscopic tests determine the characteristics
of cells, such as size, shape, and maturity. In addition, the hematol-
ogy department performs tests to determine the coagulating ability
of blood components.
GOVERNMENT LEGISLATION AFFECTING CLINICAL
LABORATORY TESTING
In 1988 Congress passed the Clinical Laboratory Improvement
Amendments (CLIA), establishing quality standards for all clinical
laboratory testing to ensure the accuracy, precision, reliability, and
timeliness of patient test results, regardless of where the test was
performed. A clinical laboratory is defined as any facility that per-
forms laboratory testing on specimens derived from humans for the
purpose of providing information about the diagnosis, prevention,
and treatment of disease or the impairment of health.

Chemistry Clinical Laboratory Improvement Amendments

The clinical chemistry department analyzes the chemicals found in
blood, cerebrospinal fluid (CSF), urine, and joint fluid (synovial
fluid). Procedures may include single tests or profiles, which include
tests for a number of related analytes. Lipid profiles, for example,
include assessments of total cholesterol, triglycerides, and low-
density lipoprotein (LDL) and high-density lipoprotein (HDL)
cholesterol.
Microbiology
Microbiology involves the study of bacteria, fungi, yeasts, parasites,
and viruses. In the microbiology laboratory, microorganisms are
grown (cultured) from blood, urine, sputum, CSF, and wound speci-
mens and are identified under the microscope. Sensitivity testing is
performed on these organisms to determine the proper antibiotic
therapy. Specimens for microbiology must be collected aseptically in
sterile containers.
Under CLIA, all entities that perform even one test, including
waived tests, must meet certain federal requirements and must reg-
ister with the Centers for Medicare and Medicaid Services (CMS)
as a laboratory. The registration application must be submitted to
CMS with information about the laboratory's operations. The type
of certificate to be issued and the fees to be assessed are determined
from this information. (Note: Most POLs are registered as CLIA-
waived laboratories.)
CLIA categorization of the commercially marketed tests per-
formed in vitro (in a laboratory) is the responsibility of the U.S.
Food and Drug Administration (FDA). The FDA has assumed
primary responsibility for determining the CLIA complexity catego-
rization of all laboratory tests. Every laboratory test product is
assigned to one of three CLIA categories on the basis of the product's
potential risk to public health: CUA-waived tests, moderate-
complexity tests, and high-complexity tests.

Common Government Acronyms in the Clinical Laboratory

ACRONYM TERM APPLICATION

BBPS Bloodborne Pathogens Standard OSHA standard that established precautions for dealing with all blood specimens
CDC Centers for Disease Control and Prevention Provides information for CLIA-waived laboratories in Ready! Set! Test! booklet
CLIA Clinical Laboratory Improvement Amendments Law that regulates all clinical laboratory testing products and sites
CMS Centers for Medicare and Medicaid Services Agency with which all labs must register and pay biannual fee based on complexity
of tests perrormed in the lab
CoW Certificate of waiver The most common CLIA lab classification for physician office laboratories (POLs)
HHS Department of Health and Human Services Federal department that oversees the CMS, FDA, and CDC
FDA Food and Drug Administration Approves and categorizes CUA-waived tests
HCS Hazard Communication Standard Standard regulated by OSHA that requires employers to communicate hazards to
employees
 CHAPTER 27 Assisting in the Clinical Laboratory 679

Common Government Acronyms in the Clinical Laboratory-continued

ACRONYM TERM APPLICATION

HIPM Health Insurance Portability and Accountability Act Law that enforces regulations for protected health information
HMIS Hazardous Materials Information System Identifies four color-coded chemical hazards (health, flammable, reactive, and other)
OPIM Other Potentially Infectious Materials Other materials related to blood-borne pathogens
OSHA Occupational Safety and Health Administration Regulates BBPS and HCS to ensure the safety of healthcare workers
PEP Postexposure prophylaxis Steps taken if a person is exposed to blood or OPIM
PHI Protected health information All test results are considered PHI and must be confidential
POL Physician office laboratory Located in ambulatory care facilities
PPE Personal protective equipment Gloves, gowns, and face protection worn when dealing with specimens
PPM Provider-periormed microscopy CUA moderate to complex microscopy tests available to POl.s
QA Quality assurance
QC Quality control
sos Safety Data Sheet (formerly MSDS) Must be in a uniform format with 16 section numbers, headings, and associated
information to inform employees of chemical hazards in the laboratory

CL/A-Waived Tests and Laboratories
CUA-waived tests are defined as laboratory examinations and pro-
cedures that have been approved by the FDA for home use or that
are simple laboratory examinations and procedures that have an
insignificant risk of an erroneous result, including those that (1) use
methodologies so simple and accurate that the likelihood of errone-
ous user results is negligible, or (2) pose no unreasonable risk of
harm to the patient if performed incorrectly. Table 27-2 shows
common CUA-waived tests performed in ambulatory care facilities
registered as CUA-waived laboratories.
The FDA's CUA-waived database of tests is available to the
public on the Internet. This database contains the commercially
marketed in vitro test systems categorized by the FDA since January
31, 2000, and tests categorized by the Centers for Disease Control
and Prevention (CDC) before that date. The records can be searched
by test system name, specialty or subspecialty, the analyte, document
number, qualifier, effective date, and complexity.
Moderate- and High-Complexity Tests and Laboratories
The CUA program oversees the quality of nearly 200,000 different
laboratory procedures. An estimated 10,000 different laboratory
tests are performed in the United States every day; most of them are
categorized by the FDA as moderate-complexity tests. Some of
the moderate-complexity tests are performed in POLs, including

TABLE 27-2 CUA-Waived Tests and Their Purposes

CPT CODES SPECIMEN AND TEST PURPOSE
Urine and Feces
81002 Dipstick or tablet reagent urinalysis (manual or automated) Urine screening to assess or diagnose diseases such as diabetes mellitus,
kidney disease, and urinary tract infection
81025 Urine pregnancy tests: visual color comparison tests Diagnose pregnancy
82270 Fecal occult blood Colorectal screening to detect hidden blood in the stool
82272
Blood (Hematology)
85651 Erythrocyte sedimentation rate, nonautomated Diagnose inflammatory process; increases in arthritis, infection, leukemia,
and most cancers
85013 Spun microhematocrit Measure RB(s; screening for certain types of anemia
85014QW STAHRIT hematocrit Screening for certain types of anemia
85018QW Hemoglobin Measure hemoglobin level in whole blood
Continued
680 UNIT FOUR DIAGNOSTIC PROCEDURES

TABLE 27-2 CUA-Waived Tests and Their Purposes-continued

CPT CODES SPECIMEN AND TEST PURPOSE
Blood (Chemistry)
82947QW Blood glucose by glucose-monitoring devices cleared by the Monitor blood glucose levels
FDA specifically for home use
83036QW Hemoglobin A1c by single analyte instruments with Measure A1c levels to assess and manage long-term care of patients with
self-contained or component features to perrorm specimen- diabetes
reagent interaction
82465QW, Cholestech LOX Measure total blood cholesterol, triglycerides, HDL, and glucose levels
80061QW
80047QW Whole-Blood i-STAT Chem8+ Cartridge Measure ionized calcium, carbon dioxide, chloride, creatinine, glucose,
82330QW potassium, sodium, urea nitrogen, and hematocrit in whole blood
82374QW
84443QW Whole-blood thyroid-stimulating hormone (TSH) assay Qualitative determination of TSH in whole blood
Blood (Immunology)
86308QW Blood mononucleosis antibodies Rapid whole-blood test to detect heterophile antibodies to help diagnose
infectious mononucleosis
86318QW Helicobacter pylori antibodies Rapid whole-blood test to detect H. pylori antibodies to determine the
cause of peptic ulcer
866 l 8QW Borrelia burgdorferi antibodies Rapid whole-blood test to detect B. burgdorferi antibodies to diagnose
Lyme disease
Microbiology
86701 QW Trinity Biotech Uni-Gold Recombigen HIV Test Detect HIV-1 in a blood specimen
87804QW Nasal influenza Aand B Quick qualitative diagnosis of influenza antigens in nasal secretions or
swab
87889QW Streptococcus Athroat swab Rapid strep test
Toxicology and Gynecology
G0434QW Urine and/or blood drug tests Multiple tests for the presence of a variety of substance abuse agents
83001QW Urine fertility and menopause Detect follicle-stimulating hormone in urine
84830 Ovulation tests; visual color comparison tests for luteinizing Detect ovulation
hormone
CL/A, Clinical Laboratory Improvement Amendments; CPT, Current Procedural Terminology; FDA, U.S. Food and Drug Administration; HDL, high-density lipoprotein; HIV-I, human immunodeficiency
virus type l.
Centers for Medicare and Medicaid Services. www.cms.gov/CL/A/downloads/waivetbl.pdf. Accessed February 6, 2015.

hematology and chemistry testing done on an automated analyzer,
Gram staining, and microscopic analysis of urine sediment. High-
complexity tests usually are not performed in a POL; these include
Papanicolaou (Pap) smear analysis; blood typing and cross-matching;
and cytologic testing.
Laboratories that perform moderate- to high-complexity testing
must meet rigorous CLIA regulations and are subject to unan-
nounced inspections every 2 years. Each laboratory that performs
these tests must establish a system to maintain the integrity and
identification of patients' specimens throughout the testing process
and to ensure accurate reporting of results. The laboratory also must
establish and follow written quality control and quality assurance
procedures and must participate in proficiency testing, a form of
external quality control. Three times a year, the laboratory must test
samples provided by an approved proficiency-testing agency using
the same tests the laboratory would use to test a patient's sample.
Additionally, CLIA regulations specify qualifications and responsi-
bilities for personnel in the moderate- to high-complexity laboratory,

from directors to testing personnel. Personnel requirements are most
stringent for high-complexity testing.
Medical assistants may perform all CUA-waived tests and some
moderate-complexity tests with additional training, depending on
the certification of the POL in which they are employed. Although
medical assistants may not perform high-complexity tests, they are
involved in preparing the patient for tests (e.g., explaining the need
to fast before blood collection), collecting the specimens required,
and recording the results in the patient's health record.
Quality Assurance Guidelines
Quality assurance (QA) is the pledge of healthcare professionals to
achieve the highest degree of excellence in the healthcare given to
every patient. QA encompasses a comprehensive set of policies devel-
oped to ensure excellent documentation and reliability of laboratory
testing. These policies benefit the provider by reducing the liability
for inaccurate reporting of test results. QA also focuses on establish-
ing a series of operating procedures for the benefit of the patient and
the medical assistant who does the laboratory testing. The QA system
enables the laboratory to assess, verify, and document the quality of
the laboratory process. This documentation is a way of comparing
"what is happening" with "what should be happening."
As mandated by law, QA programs monitor all aspects of labora-
tory activity, from specimen collection through processing, testing,
and reporting steps. Programs check supplies, reagents, machinery,
and actual test performance. It includes quality control, personnel
orientation, laboratory documentation, knowledge of laboratory
instrumentation, and enrollment in a proficiency testing program (if
the lab performs moderate- or high-complexity tests).
The Three Stages of Quality Assurance
in the Laboratory
The overall process required to ensure quality assurance (QA) in the labora-
tory is divided into three stages, which must be applied to each test or
"analytic" procedure. If any of these steps are missed or pertormed incor-
rectly, QA has been broken.
Preanalytic Stage
l. The provider orders a test to screen, monitor, or diagnose a patient's
condition.
2. Awritten or an electronic requisition is filled out, showing the test
requested, the specimen required, and where the specimen will be
tested.
3. The specimen is collected, labeled, and processed (e.g., centrifuged or
refrigerated).
4. The specimen is transported to the appropriate laboratory (in the office
or pickup for an off-site laboratory).
Analytic Stage
l. Instruments are maintained and calibrated.
2. Controls are run and analyzed for each test method (QC).
3. The specimen is tested, and the results are compared to reference
ranges.
4. The test results are logged and documented in the patient's health
record.
CHAPTER 27 Assisting in the Clinical Laboratory 681
Postanalytic Stage
1. Specimens are properly discarded.
2. Analyses of control results are compared over time.
3. Patient reports from outside labs are logged.
4. The provider interprets and signs all lab reports.
5. The patient is notified of the results in the office or is contacted by labora-
tory personnel.
6. The final report and all communication with the patient is documented
in the patient's health record.
Accurate record keeping is one of the key responsibilities of a
medical assistant. Various forms are available to assist in the record-
ing of laboratory information, although much of this information
now can be found online and recorded in an electronic format. If
your office uses hard copies (e.g., paper records), the primary record
is the laboratory master logbook, in which each procedure per-
formed in the POL is entered, with the dates clearly shown.
POLs are also required to have a procedure manual that describes
the processes for testing and reporting patients' results. Personnel are
required to perform calibration or optic checks on laboratory
instruments that utilize light in determining results. In addition,
they must run control material each day before patient testing based
on the manufacturer's instructions and document the results, and
they must perform and document remedial action when errors or
problems are identified. Finally, preventive maintenance schedules
must be followed and documented. Preventive maintenance pro-
longs the life of equipment and reduces breakdown; it includes daily
cleaning and adjustment and replacement of parts when necessary.
Each instrument should have a log or worksheet for recording all
changes, including daily maintenance details.
Ready? Set? Test! is an excellent on-line resource provided by the
CDC for setting up and maintaining a CUA-waived laboratory.
Figure 27-1 shows the checklist summary of the steps needed to
assure proper CUA-waived testing in a POL.
Quality Control Guidelines
A crucial step in the QA process is the running of quality controls
(QC) (Procedure 27-1 ). Specially prepared QC samples are tested
daily, along with patient samples. The results of testing performed
on QC samples must be within a pre-established range before patient
results can be reported. QC samples, called controls, usually are sup-
plied with the manufacturer's prepackaged kits, which are intended
for use in the small laboratory. These controls should be analyzed at
specified intervals. For example, positive and negative controls sup-
plied with pregnancy test kits should be performed with each patient
specimen. Urinalysis dipstick controls (used for chemical examina-
tion of urine) should be checked daily before patient testing and
each time a new reagent container is opened. Controls for auto-
mated chemistry analyses should be performed at specified intervals
during the day. Consistent results of controls ensure constant condi-
tions throughout the testing sequence.
The objective of QC in the laboratory is to ensure the reliability
of test results while detecting and eliminating error. Accurary refers
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FIGURE 27-1 Summary checklist from Ready? Set? Test?

 CHAPTER 27 Assisting in the Clinical Laboratory 683

to how close the obtained control result is to the manufacturer's
control range, and precision refers to the consistent reproducibility
of the test results. When a series of control results show both accu-
racy and precision, the test is considered reliable and may be used
for testing patients. QC monitoring is crucial because patient treat-
ment often is based on or reinforced by the results of laboratory tests.
Without QC monitoring, laboratory error is difficult to detect unless
the provider notices test results inconsistent with a patient's history.
Undetected laboratory errors may result in harm to the patient.
On every day that patient tests are performed, QC tests must also
be performed and the results entered on the control flow sheet.
When new control vials are opened and used, the results and dates
must be entered on a new control flow sheet, along with the expira-
tion dates of the controls. Everyone performing a specific lab test
should be "checked out" by performing the test using the manufac-
turer's control before running patient tests. These records must be
retained for several years; the exact number of years is determined
by state law and CUA mandates.

Preventive Maintenance Program for Laboratory Equipment

• Follow the manufacturer's instructions for calibrating instruments (this is • Keep spare parts available for immediate use.
also referred to as an optics check on instruments dependent on light). • Record the name, address, and phone number of a contact person for
• Read and understand the instructions for routine instrument care. maintenance or repair.
• Perform all preventive maintenance specified by the manufacturer's • Create a maintenance form or use the one provided.
instructions.

CRITICAL THINKING APPLICATION 27-3 CRITICAL THINKING APPLICATION 27-4

Procedure 27-1 uses the glucose control by which the overall quality control
(QC) results for the class will be analyzed. When all the results are logged
on the flow sheet, the class will determine whether the glucometer results
are accurate, precise, and reliable. Based on the results, may the glucometer
be used to test patients? If not, what should be done?
Marsha will be performing a hemoglobin test on a blood sample that was
collected into a test device. The device will be placed in a HemoCue instru-
ment that produces a digital readout based an the amount of light that
passes through the specimen. First, Marsha must perform an optics check,
using the control device provided by the manufacturer, to see whether the
instrument has been calibrated correctly. If the control does not match the
manufacturer's reference value, would Marsha be able to run the patient's
test? Why or why not?

Perform a Quality Control Measure on a Glucometer and Record the Results

PROCEDURE 27-1
on a Flow Sheet

Goal: To test and analyze the results of glucometer controls to see whether a glucometer is producing reliable test results,
and to record the results on the laboratory flow sheet.
EQUIPMENT and SUPPLIES
• Disposable gloves
• Glucometer
• Coded test strips designed for the glucometer used
• Control solution provided by the manufacturer
• Package insert showing directions on how to run the glucometer
• Biohazard waste container
• Glucose test control flow sheet

The three color-coded bottles of controls (1, 2, and 3) in the figure will produce
high, low, and normal test results. The test strip is to the right of the glucometer,
and the container for the test strips is on the far right (Figure l).
684 UNIT FOUR DIAGNOSTIC PROCEDURES
•;;m!,mj;jflii -continued
PROCEDURAL STEPS
The following can be a class exercise in which all the students participate.
1. Sanitize your hands and put on disposable gloves.
PURPOSE: All controls and specimens are considered biohazardous.
2. Take a coded strip and note the control level and range listed on the control
bottle or the strip container.
3. Review the directions on the glucometer package insert and calibrate the
meter by inserting the precoded test strip into the monitor or by manually
inserting the code number into the monitor (Figure 2).
PURPOSE: Manufacturers must provide directions on how to calibrate light-
sensitive meters every time a new container of test strips is used. Note:
The newer test strips will code themselves when inserted into the meter.
4. Check the expiration date on the liquid control bottle and mix well by
inverting and rolling the bottle between your hands.
PURPOSE: If the control bottle date is expired, the control cannot be run.
And, it is crucial to have all the reagents in the bottle in suspension to
produce reliable results.
GLUCOSE TEST CONTROL FLOW SHEET
Control Lot #-. - - - - - - -
Control Range:
DATE STUDENT/MA INITIALS RESULT
LABORATORY SAFETY
The importance of safety in the laboratory cannot be over-
emphasized. Most laboratory accidents can be prevented through
the use of proper techniques and common sense. Following safe
practices in the laboratory requires a personal commitment and
concern for others; an unsafe act may also harm an innocent
bystander without harming the person who performs the act.
S. Complete the top portion of the control log sheet with the test name, control
lot number, and expiration date, and also the control's reference range
based on whether it is a low-, normal, or high-level control.
PURPOSE: All this information is checked each time a control is run to
compare the results of the same control.
6. Insert your strip into the glucometer and apply a drop of the liquid control
to the strip according to the directions.
PURPOSE: The manufacturer must supply clear directions that are consistent
every time a control or patient specimen is run.
7. Record the result on the glucose test control flow sheet and note whether
it falls within the manufacturer's reference range. If not, the test should be
repeated with a new strip.
PURPOSE: An occasional "out of range" result can occur. If the repeated
new strip is back in range, proceed with patient testing. If the second strip
falls outside the range, the patient may not be tested until the cause of the
error is determined.
8. When you have finished running the controls, dispose of the strips, remove
your gloves, and sanitize your hands.
9. Observe all the results obtained by the students and compare them to the
control ranges provided on the test strip bottle and/or liquid control bottle.
Discuss the following:
• Accuracy: Did all the results fall near the middle of the reference range?
• Precision: Were the results consistently close to each other (without
extreme highs and lows)?
• Reliability: If both of the previous points are affirmed, the test is reliable
and may be used to test patients.
Expiration Date: _ _ _ _ __
Level: Low/Normal/High
ACCEPT REJECT CORRECTIVE ACTION
Safety Standards and Governing Agencies
The U.S. government created a system of safeguards and regulations
under the Occupational Safety and Health Act of 1970. This system
affects nearly every worker in the United States because the regula-
tions apply to all businesses with one or more employees (the regula-
tions are discussed in detail in the "Safety and Emergency Practices"
chapter.). Two programs have been mandated by the Occupational
 CHAPTER 27 Assisting in the Clinical Laboratory 685

Safety and Health Administration (OSHA) to ensure the safety of • Caviwipes and glutaraldehyde (solutions for disinfection)
personnel working in clinical laboratories. One covers occupational • Acetone and dyes used in staining slides
exposure to chemical hazards; the other covers exposure to blood- It should be noted that all the above disinfectants and dyes are
borne pathogens. available in premixed sprays and/or wipes to reduce chemical expo-
The CDC also has established recommendations and resources sure during dilution. For example, in the past, bleach needed to be
in Standard Precautions and Transmission Precautions as they relate diluted daily with water in a 1 : 10 dilution using 1 part bleach to 9
to specimen collection. (These recommendations were discussed in parts of water. Now, bleach/water sprays are available that make the
the Infection Control chapter.) dilution as they are dispensed.
Following principles of proper handling reduces the risk of
Chemical Hazards harmful effects. If a chemical produces toxic or flammable vapors,
The clinical laboratory is home to chemicals that are flammable, work under a fume hood that exhausts air to the outside. In case of
caustic, and potentially poisonous. Exposure to these dangerous accidental exposure of the skin, rinse the affected area under running
chemicals can occur through inhalation, direct absorption through water for at least 5 minutes. Remove any contaminated clothing. If
the skin, ingestion, entty through a mucous membrane, or entry chemicals are splashed in the eyes, flush the eyes with water from an
through a break in the skin. OSHA is involved in regulating the eyewash station for a minimum of 15 minutes (Figure 27-2). Prompt
standards directed at minimizing occupational exposure to hazard- medical attention must be given to victims of chemical exposure.
ous chemicals in laboratories. OSHA's Hazard Communication Chemicals should be tightly sealed and properly labeled. A hazard
Standard (HCS) (known as the employee "right to know" rule) identification system, developed by the National Fire Protection
became law in 1991. It ensures that laboratory workers are made Association (NFPA), provides information at a glance on the poten-
fully aware of the hazards associated with their workplace. The law tial health, flammability, and chemical reactivity hazards of materi-
requires the development of a comprehensive plan to implement safe als. This identification system consists of four small, diamond-shaped,
practice throughout the laboratory with regard to chemicals. All colored symbols grouped into a larger diamond shape. The top
workers must be provided with information and training, and a diamond is red and indicates flammability (the potential to catch on
Safety Data Sheet (SDS; formerly MSDS) must be on file for all fire). The diamond on the left is blue and indicates a health hazard
chemicals used in the laboratory. OSHA requires the manufacturer such as a dangerous inhalant or corrosive acid. The bottom diamond
of the chemical to make these sheets available, usually as a package is white and provides special hazard information, including recom-
insert and/ or online. mended personal protective equipment (PPE) if biohazards are
Since June, 2015, OSHA has required all SDSs to use a uniform present, and other dangerous situations. The diamond on the right
format that includes the following section numbers, headings, and is yellow and indicates a reactivity or stability hazard. An example
associated information: of reactivity is mixing an acid (e.g., bleach) with a base (e.g.,
ammonia), creating a dangerous gas. The four-color system also
Section 1. Identification indicates the severity of the hazard by using numbers imprinted in
Section 2. Hazard(s) identification the diamonds from O to 4, with O representing no hazard and 4
Section 3. Composition/information on ingredients representing an extremely hazardous substance (Figure 27-3).
Section 4. First-aid measures
Section 5. Fire-fighting measures
Section 6. Accidental release measures
Section 7. Handling and storage
Section 8. Exposure controls/personal protection
Section 9. Physical and chemical properties
Section 10. Stability and reactivity
Section 11. Toxicologic information
Section 12. Ecologic information*
Section 13. Disposal considerations*
Section 14.Transport information*
Section 15. Regulatory information*
Section 16. Other information

Employers must ensure that SDSs are readily accessible to

employees.
In the POL, the most common hazardous chemicals are:
• Sodium hypochlorite (bleach) for disinfecting laboratory
work areas

*Sections 12-15 are regulated by agencies other than OSHA and are required
of the manufacturers, not the employees. FIGURE 27-2 Eyewash station for chemical exposure.
686 UNIT FOUR DIAGNOSTIC PROCEDURES
FIGURE 27-3 Three laboratory bottles with chemical labels using the identification system of the
National Fire Protection Association. Note the number and color used for bleach, and compare them
to the number and color used for water.
Biohazards and Infection Control
Biohazards, or biologic hazards, are materials or situations that
present the risk or potential risk of infection. Infection with biohaz-
ardous material can occur during specimen collection, handling,
transportation, or testing. Specimens with the potential to be infec-
tious include blood, body tissue biopsy specimens, urine, exudates,
and bacterial cultures and smears. Infection can occur through aspi-
ration of a pathogen, accidental inoculation by a needlestick, aerosols
created by uncapping specimen tubes, centrifuge accidents, and
entry of pathogens through cuts and scratches.
Standard Precautions
As described in the Infection Control chapter, the CDC continu-
ously monitors infection and disease in the United States and
has recommended prevention practices called Standard Precautions.
These precautions apply to all patient care, regardless of the sus-
pected or confirmed infection status of the patient, in any setting
where healthcare is delivered. The precautions are designed both to
protect the healthcare provider and to prevent the healthcare pro-
vider from spreading infections among patients. Standard Precau-
tions include these five elements: (1) hand hygiene, (2) use of PPE
(e.g., gloves, gowns, masks), (3) safe needle practices, (4) safe han-
dling of potentially contaminated equipment or surfaces in the
patient environment, and (5) respiratory hygiene/cough etiquette.
Washing or sanitizing your hands is the most effective means of
preventing infection. It also is the single most effective way of pre-
venting the spread of all infections. Proper hand sanitation protects
you, your patient, and your co-workers because it removes and/or
kills organisms. In the laboratory area, it is absolutely essential to
sanitize your hands with soap and water or a hand sanitizing product
in the following situations:
• When entering and before leaving the area
• Before gloving
• After removing gloves
• After contact with body fluid
• Before and after eating
• Before and after using the restroom
After blood-borne pathogens were identified in the 1970s and
1980s (i.e., hepatitis B virus [HBV], hepatitis C virus [HCV], the
human immunodeficiency virus [HIV], and the Ebola virus), the
CDC stepped up its infection control recommendations. It acknowl-
edged that all blood in all patients is potentially infectious and
therefore required additional monitoring and regulation for the
safety of both the healthcare provider and the patient. These guide-
lines became known as Universal Precautions. Regulation of the new
law, referred to as the Bloodborne Pathogens Standard (BBPS), was
delegated to OSHA.
In 2014 Ebola infection reappeared in Africa and was transmitted
to several other continents. The Ebola virus is a blood-borne patho-
gen that causes bleeding throughout the body. In the United States,
a key factor in stopping its spread was the rigorous training in
donning and doffing (putting on and taking off) PPE that covered
every part of the healthcare worker's body. The CDC provided an
Ebola bulletin for ambulatory healthcare practices on the evaluation
of patients who may have been infected with the Ebola virus.
Bloodborne Pathogens Standard
OSHA's Bloodborne Pathogens Standard has been law since 1992.
It regulates the handling of blood and blood products, but it also
includes other potentially infectious materials (OPIM) that may
contain blood-borne pathogens. Urine is the only fluid not specifi-
cally included in the standard. However, because blood and blood
elements frequently are associated with urine, it must be included
and considered a possible source of exposure.
The Bloodborne Pathogens Standard covers all employees who
could "reasonably anticipate contact with blood and other poten-
tially infectious materials as the result of performing their job
duties." HBV, HCV, and HIV are a constant threat to the health
and safety of clinical laboratory personnel. Ebola virus infection is a
serious concern, although not as common in the United States.
These blood-borne pathogens are transmitted through exposure to
blood and body fluids, which are the primary substances handled
in the laboratory. The Bloodborne Pathogens Standard requires that
the laboratory employer have a written exposure control plan that
proves the following steps have been taken to protect the lab's
employees:
• Written job categories of employees at risk of exposure to
blood (laboratory workers are considered "high risk'')
• HBV vaccination guidelines and records for each employee at
risk
• Record of initial and annual Universal Standard training ses-
sions for blood-borne pathogens and safety training for each
employee (including proper use of safety needles)
• Definition and listing of safe work practices: PPE for all lab
personnel (fluid-impermeable lab coats that do not leave the
laboratory area, disposable gloves, face protection) and label-
ing of biohazardous sharps and waste containers and their
proper disposal
• Sharps injury log of all work-related needlesticks and expo-
sures to blood, with medical intervention after exposure
incidents
• Written plan to maintain privacy of the individual exposed to
blood
• Documentation of employee input on new safety devices

Safety Guidelines for Other Potentially Infectious
Materials (OPIM)
• Handle and process all specimens as if they contained infectious
material.
• Wipe the outside of specimen containers with a germicide.
• Dispose of all infectious materials according to state and federal
guidelines.
• Clean up spills using a disinfectant (see "Infection Control" chapter).
• Immediately dispose of any chipped or broken glassware into a sharps
container using appropriate safety methods to prevent accidental
punctures.
Physical Hazards
Physical hazards in the laboratory can be classified as electrical, fire,
and mechanical hazards. Electric shock is a threat when any elec-
trical equipment is in use. It is imperative to keep all electrical
equipment in proper repair and always to follow manufacturers'
instructions.
Use surge protectors, inspect all cords and plugs frequently, never
use extension cords, and do not overload circuits. Unplug the electri-
cal device before servicing, and never operate electrical instruments
with wet hands. If a sink is nearby, make sure electrical cords do not
come in contact with the water supply. Signs and labels should be
placed on specific electrical hazards (Figure 27-4).
Open flames are rarely used in a laboratory, but the potential for
fire still exists. Fires may be ignited by smoking, heating elements,
and sparks. Flammable materials should not be stored near any
source of ignition. All laboratory personnel should be familiar with
the locations of fire extinguishers and fire safety blankets. Fire extin-
guishers should be the carbon dioxide (CO 2), dry chemical, or halon
type, known as the ABC type of extinguisher. ABC extinguishers can
be used on all types of fires. These extinguishers should be inspected
regularly by a licensed inspector and replaced or recharged if used.
The medical assistant may be responsible for maintaining records on
the care and maintenance of fire extinguishers.
Fire safety blankets should be used to smother flames on burning
clothing. However, a victim should not be wrapped in a fire blanket,
because this may intensify burns. Instead, the flames should be
patted out or the victim directed to roll on the blanket.
HIGH ELECTRICAL
VOLTAGE HAZARD
FIGURE 27-4 High-voltage and electrical hazard labels.
CHAPTER 27 Assisting in the Clinical Laboratory 687
Emergency phone numbers should be posted on the wall near
the telephone, and all personnel should know the locations of fire
alarms, the fire escape routes, and procedures to follow if exits are
blocked. Periodic fire drills should be conducted, and hallways and
exits should be kept free of clutter.
Mechanical hazards arise from the use of laboratory equipment.
Special care should be exercised when using equipment with moving
parts, such as centrifuges, and those that rely on pressure, including
autoclaves. Centrifuges, devices that separate liquids from solids,
present a hazard not only from moving parts but also from glassware
that might break during centrifugation and from aerosols that might
be created if tubes are not capped tightly. Pressurized types of equip-
ment, such as autoclaves used in sterilization, present a danger if
opened prematurely. Although centrifuges and autoclaves ofren have
built-in safeguards, such as locks that prevent entry until the envi-
ronment is safe, improper care of the equipment can result in failure
of the safety measures.
SPECIMEN COLLECTION, PROCESSING,
AND STORAGE
Laboratory Requisitions and Reports
When the provider orders laboratory testing that must be done
outside the office, an electronic requisition for the work must be sent
to the laboratory, or a paper requisition is given to the patient. (It
is important to note that the patient's health insurance may only
reimburse if specific labs are used.) Paper requisition forms specific
to the labs are preprinted, with the most commonly requested tests
indicated in a logical sequence (Figure 27-5). Patient information
on the requisitions must be complete, accurate, and legible. The
patient is then directed to the lab, or the specimen is collected and
sent to the lab.
Figure 27-6 shows the electronic lab requisition form used in
Sim Chart for the Medical Office. The following information typically
is required on the requisition when specimens are sent to a reference
laboratory:
• Provider's name, account number, address, and phone number
• Patient's full name, surname first; age, date of birth, and
gender; address and insurance information
• Source of specimen
• Date and time of collection
• Specific test (or tests) requested
• Medications the patient is taking
• Whether the patient fasted or followed dietary restrictions if
required; time of last intake
• Possible diagnosis
• Indication of whether the test is to be performed STAT (i.e.,
immediately)
When the results of the tests are obtained, a laboratory report is
sent to the office. The laboratory reports are typically sent directly
from the referral laboratory to the patient's electronic health record
(EHR), or they are received electronically as a general electronic
record source and then transferred to the correct patient record by
practice staff members.
The medical assistant's responsibility is to make sure that all
reports are received for the tests performed on the patient outside
the provider's office and that the provider has reviewed them, and
688 UNIT FOUR DIAGNOSTIC PROCEDURES

Lab Services IMPORTANT

Patient instructions
and map on back
PHYSICIAN ORDERS
MO Patient
Patient _ _ _ _ _ _ _ _ _ _ _ _ __ D.O.B. _ _ _ _ F O SS# _ _ _ _ _ __
M.I.
Address _ _ _ _ _ _ _ _ _ _ _ _ _ _ City _ _ _ _ _ _ _ _ __ Zip _____ Phone# _ _ _ _ _ _ __

Dall & Time ol ~

Physician _ _ _ =----.,...,...,,,.,....-----,--------------
ATTACH COPY OF INSURANCE CARD
Diagnosis/lCD-9 Code _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

0l'lt.00_...,
0295.9 Anema(NOSl

HEr.lATOLOGY
0 414.1
0250.0
0 m.o
=-~(CAO)
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0 780.7 F ~

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<-codNon,->
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0401.t~
a
=
485.9 ~ , 1- ~ . . . . . . , ,

CHEMISTRY I
0 ROUTINE O PHONE RESULTS TO:
• ASAP
O STAT
CHEMISTRY
OFAXRESULTSTO: # _ _ _ _ __
0 COPY TO: _ _ _ _ _ _ _ _ __
I
#

MICROBIOLOGY
D 1021 cec, Aulomated Oiff ~ncl. Plalelet Ct.) D 5550 ~ha FetoprOtNi, Prenalll 0 5232 HBsAg
Source _ _ _ _ _ _ _ __
D 102:1 HemoglobWHefflatocnt D 3000 Amylase D 3175 HIV (Consent required)
0 1020 Hemogram D 3153 B12/Folale 0 3581 Iron & Iron Binding Capac:fty 0 7240 CIA\ure, AFB
0 1025 Platelet Count O 3156 Beta HCG, Ouanti1aliYe 0 3195 lH 0 7200 C"1ure, Blood x _ _ __ _
0 1150 Pio Th>e [Xagnostie O 3321 Biflnilin, Total D 3590 Masinesun D Draw l<Ulllal _ _ _ __
O 1151 Pro n-ne, Therapeutic D 3324 Bi lini>in, TotaV!liroct D 3521 Phenobarbital D 7280 C"1ure, Fungus
0 1155 PTT O 3009 BUN D 3095 Potassium D CtJture, ROI.in&
0 1315 f!edewcy1eColrlt O 3159 CEA 0 31189 Prfl9WIC)I Test Serum (HCG, qua D 7005 CI.Cture, Stool
D 1310 S.cl Rata/Westeroren D 3346 Choltltl<OI D 3653 Pr~ancy TNt Urtne D 7010 CI.Cture, Throat
D 3030 ereatr,;ne, Senm D 3197 Prolactin 0 7000 CI.Cture, Urine
URINE D 3509 Olgoidn(_,._ 12tn..a11w-, 0 3199 PSA D 7300 Gram Sim
D 3515 Dilllllin 0 D 7355 Occult Blood x _ _ _ _ __
D 1059 IJmattsi• 3339 SOOT/AST
D 7365 Ova & Parasbs x _ _ _ __
D 1082 llmllysls wlCIAlre ff indicated D 3168 Fenitin 0 3342 SGPT/ALT
t.kfne.24 Hr _ _ Spo1 _ _ 0 3193 FSH D 3093 Sodum'Potass<um. Serum D 7400 Smear& Suspension
Ht. wt. 0 3066 T Glucose, Fuir,g D 3510 Tegretol (lnckldes Gram Stain/Wet Moult)
D 3CX33 Creatinine 0 3081 GIUCOM, 1' Pocl 50 g Glucota D 3551 Theoph(lne 0 7080 Rapid Strep A Scteen _ _ .,...,.

D 3036 Creatinine Cle111not -...:;- D 3075 • Glucose, 2' Post Glucola 0 3333 Uric Acid D 706.5 Rapid Strep A Saeen only
• 3398 Plotein 0
0
3060 Glucose, 2' Post Prandial (meal) D 7030 Beta Strep Culture
0 5207 GC by DNA Probe
D 3096 Sodium'P01assun 3049 •~TolnnoeOrllGTT
D Microll>umin24Hr _ _ spo1_ 0 3047 TGUCOM Tollfanoe Gestational GTT 0 5130 Chlamyda by ONA Probe
0 3650 Hemoglobin, A1C 0 SSSS Chlamyda/GC by DNA Probe
0 7375 Wright Stall\ Stool
0 8020 ~A (Antinuclear~)
D 8040 Mono 5po1
0 3494 Rhel.rnllOid Faclor
0 8010 APR
Additional Tests _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
D 5365 f\Jbela

PANELS & PROFILES

D 1 3309 CHEM 12
Abml\-~- D 5242 HEPATTTtS PANEL, ACUTE 0 .- 3391 PANEL G
Ho\~ltll,lg.llllAl>,HllcAb. HCYAb 0,.,,, 20.-llll l'lnll, CIC.
1)¥adCaocado
.. . patient required to fast
for 12·14 hours
BUN,c.lci,,n.~-. T 3355 UPIO MONITORING PANEL
UlH.~AST. TOIII D ~ T~Hlll,Ull. VIJlt.. 0 .- 3393 PAHEl H X . patient recommended to
81iRbin. TOIII-,_ Uric Add a.. 20. C8C. ColdK Rs l'lnol
ALT. AST fast 12-1 4 hours
D .. 3315 CHEM 20
D 3312 UVER PANEL - FadO<. Thy,l,id Oacado
a,.,,,12.~ ....... _,.,_....AST. TCIOI ....... 0 .. 3397 PANEL J LAB USE ONLY INIT
~ l t o n . 0 - 0T, AI.T,
T~
GMrnlGT,TOIIIP!Ollln,Abnn,AI.T a..20.c.-RiaPnJ a SST a PlASMA
D .- 3357 CARDIAC RISK PANEL 0 1 3013 IETABOUC STATUS PANEL D 5351 PRENATAL PANEL a PURPLE a SERUM
.,_..,HCLLDl.AillF-. 9UN, ~(.........,,, CNol'do. C()q ,.,_,Sc,-,A801Rll,C8C a YEU.OW a SWAB
8,-....
c.ti-..--~Sodk-. IU!lla.HWe,RPII
VUllT~ 0 SI.VE a SLIOES

·-
~ Rik-Gip \Mooljlll,-
D 1 3042 CRITICAL CARE PANEL 0 1 3376 PANEL B
1082 w i l l l ~ - a GREEN a DNAPAOBE
BUN, ~CO2.-- a,.,,, 12.cac.~-
0 OREY a a.CUI.Tens
-.....Sccfun 0 1 3102 RENAL PANEL 0 URINE
D 30MELECTROLYTEPANB. 0 .. 3382 PANEL D -S1111al'lnll,c...n_ 0 lllACK
C,,..20.C8C.Tl'lft'ldC...
~C02.-.n.Sodom ~ 0 OTHER:
D .- 3399 EXECUTIVE PANEL 0 1 3319PANELF 0 3181 THYIIOl0 CASCADE REC'V. SPECIMEN: a FROZEN
a...12.c:ec.e.ctot,11Pan11,
a...20,1ron.c.,..,Aill<Pan11, n,...,~ TSH.-T~ 0 AMBIENT a ON ICE
CIC, Rl'II, ~Caocado

Physician'• Signature _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ Date _ _ _ _ _ _ _ _ __

These Ofders may be FAXed to: 449-5288 7060-500 (7196)
LAB

FIGURE 27-5 Laboratory requisition form.

 CHAPTER 27 Assisting in the Clinical Laboratory 689

Si mCha rt· for the medical office

lli-uCodc:I
Form Repository
INFO PANEL Requisition
~1Jt01IOI ....

-. -
Adv..a Dftctn,•

......
Ccrt,tut•toA:e1,..mto\' di;or

CMtcloM.lre AI.TChonutloll

I
OOCIOI"• rnt Repett S.VlctO...
Cencnl Procodu,. (Oft.Mftl
1n,u,.""C: r,1

Modbil RoOCOtdl Rdc~M

NturotoQc.elS.•N•b.a
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fra«t

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<• lltetO):
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P~.-,it lnfo!INIIOft _,,_,

P,thc1tt Rc<eenh Acccn Aeq"nt
PMl!titl $Wil . .Cf\1 -Cao,.
Prior Autlloiwt,bOft RCCIIJttl
Rtffff'&I
"-fQ"•bO•

--- _A_ . .
--·- -··--
Schott Plrft•n:11 Ac.W Ht1Mfillt l'Mtl
V'1CICIMAutl'k>n,...,n
tla,tc,,C~co,
eu,
_co,,,.. e•- ~i.-.•s.m.:•~ .,
c, . . . .. e-,
GV.01t

C-,,,thtll.M Mitt•~• ,._.. TOIICH-

&Mt~,,,....

FIGURE 27-6 Electronic laboratory requisition form. (From Elsevier: SimChart for the medical office, St Louis, 2015, Elsevier.)

the patient has received the results. This can be accomplished by

maintaining a master laboratory specimen log sheet that tracks
patient specimens, tests ordered, designated lab, results, and provider
response.

Specimen Collection
The medical assistant is responsible for the collection of many dif-
ferent types of specimens. It is important to recognize that clinical
laboratory results are only as good as the specimen received. The
importance of proper specimen collection cannot be overempha-
sized. If test results are to be accurate indicators of the patient's state
of health, it is imperative that the concepts of specimen collection
be understood and followed exactly. The most common specimens
are blood, urine, and swab samples collected from wounds or mucous
membranes. Less often, feces, gastric contents, CSF, tissue samples,
semen, and aspirates (e.g., synovial fluid) are submitted for testing.
These specimens are analyzed for levels of many chemicals and FIGURE 27-7 Vacutainer tubes; note the color-coded tops.
drugs, types and numbers of cells present, and the presence of
microorganisms.
Verifying the patient's identity before the procedure is essential, which sometimes can affect the patient's understanding of the
as is collection of the specimen in an appropriate collection con- instructions and his or her ability to follow through on them.
tainer. For example, blood may be collected using a vacuum tube The medical assistant should always check the laboratory's speci-
system. These tubes are available in a variety of sizes, with and men requirements manual or website for any unfamiliar tests. The
without preservatives and anticoagulants. The tubes are color manual lists all information on specimen collection. Any unan-
coded; the color of the stopper denotes which, if any, additive is swered questions should be resolved by calling the laboratory before
present (Figure 27-7). Collection in an incorrect tube results in an collecting the specimen. The container must be labeled properly at
unacceptable specimen, and recollection is necessary. If the specimen the time of collection; unlabeled containers are not accepted for
is to be tested for the presence of microorganisms, a sterile container laboratory testing. Labels should include the patient's full name, the
must be used. If the patient is to collect the specimen at home, he date and time of collection, and the type of specimen.
or she should be provided with the appropriate container and com- Most offices have a laboratory courier service that picks up
plete instructions for collection. Bear in mind the principles of specimens periodically throughout the day. Specimens should be
patient education, and be sensitive to individual patient factors, properly stored (some require refrigeration) until the courier arrives.
690 UNIT FOUR DIAGNOSTIC PROCEDURES
FIGURE 27-8 Specimen mailers.
Instructions for properly obtaining, processing, and preparing a
specimen for transport are usually supplied by the testing laboratory.
If the instructions are not clear or if you have a question about a
particular collection, the laboratory can answer your question over
the phone. Criteria for safe shipping of specimens include the length
of time acceptable for transport; recommended temperature ranges
to maintain the integrity of the specimen; and whether light can
affect the specimen.
If the specimen is to be mailed, it must be carefully packaged to
prevent breakage, damage, or contamination by all persons handling
it. Place specimens in unbreakable tubes with safe-top lids and wrap
the containers in absorbent material. Tape the lid of the container
shut so that no leakage occurs if the specimen container breaks. Place
all specimens in a second container, such as an impervious biohazard
bag, for transport. The completed requisition goes inside the outer-
most wrap. Styrofoam mailers (Figure 27-8) may be used, because
they cushion the sample and provide insulation. Styrofoam inserts
can be shaped to fit around the specimen container. A warning label
specifying the etiologic agent or biologic specimen is placed on the
outside of the container.
Preventing Contamination
Medical assistants must take care to prevent contamination of speci-
mens and themselves. Expiration dates on swabs, tubes, transport
media, and other collection containers should be checked before
these items are used. Any expired materials should not be used and
should be discarded properly. An improperly handled specimen may
become contaminated or may contaminate the surrounding environ-
ment. Standard Precautions should be followed. All blood and other
body fluids from all patients should be considered infectious.
Sufficient samples should be collected for the tests requested by
the provider. Amounts may vary on the basis of methods used. A
report returned from the laboratory marked "QNS" (quantity not
sufficient) indicates a request for an additional specimen. Make sure
to clarify any questions about the previous specimen by calling the
laboratory before collecting a new one.
The specimen collected must be a true representative sample. A
swab for a wound culture collected from the surface of the wound
generally does not yield the same results as one taken from the depths
of the wound. A hemolyzed blood specimen or one taken from an
atypical area, such as a hematoma or the area above or below an
intravenous (IV) drip, shows marked differences in many tests. If a
large volume of specimen is collected (e.g., a 24-hour urine speci-
men), the total volume or weight must be carefully measured and
recorded. The specimen must be well mixed before an aliquot is
removed and submitted for testing.
Handling, Processing, and Storage of Specimens
The specimen must be handled, processed, and stored according to
individual guidelines to prevent any alterations that would affect
test results. The medical assistant should determine whether the
specimen needs to be kept warm or cool. Specimens such as urine
require chilling if testing will not be performed immediately. Some
cultures or specimens (e.g., gonorrhea cultures and semen analysis)
need to be kept at body temperature after collection because
cooling kills microorganisms and sperm. When required, serum
must be separated from the cells as soon as possible after the speci-
men has clotted to prevent changes caused by the metabolism of
the blood cells. Specimens for bilirubin testing must be protected
from light. Some specimens need to be frozen to prevent chemical
constituents from changing. Laboratory specimen requirements
should be consulted to ensure that each specimen is handled and
processed properly.
Chain of Custody
When a specimen may be needed as evidence in a court case, cer-
tain procedures must be followed in collecting and handling the
specimen. Forensic or medicolegal implications require that any
results gathered on testing of a specimen should be obtained in such
a fashion that they are recognized by a court of law. Specimen proc-
essing must be documented meticulously, ensuring that no tamper-
ing with evidence has occurred. Chain ofcustody refers to the stepwise
method used to collect, process, and test a specimen. The documen-
tation must be signed by every person who has contact with the
specimen, from collection to final reporting of results. Blood alcohol
level testing and drug screening often require chain of custody han-
dling. Everything needed for collection of the specimen is provided
in a kit-even the gloves, the vacuum tube, and the needle used to
collect the blood specimen. Documentation is included and must
be signed by all personnel. Medical assistants and phlebotomists have
been subpoenaed to testify in court about specimens they have col-
lected; therefore, it is in your best interest to follow chain of custody
procedures rigorously.
Steps in Collecting Specimens and Informing
the Patient of the Results
1. The healthcare practitioner orders laboratory tests on the basis of
physical examination findings and/or to diagnose a disorder.
2. Complete all the fields on the lab requisition or EHR
transmission.
3. Collect the specimen after receiving the provider's order, or
instruct the patient on how to collect the specimen at home.
4. Label the appropriate specimen container.
 CHAPTER 27 Assisting in the Clinical Laboratory 691

5. Process the specimen as you have been trained, or prepare the

specimen for transport to a reference laboratory. TABLE 27-3 Greenwich Time and Military Time
6. Properly dispose of specimens collected and tested in the office GREENWICH TIME MILITARY TIME
in biohazard waste containers after tests are completed.
7. Reference laboratory test results are sent to the patient's EHR or 1:00 AM 0100 hours
provided in an electronic form that the provider reviews and 3:00 AM 0300 hours
shares with the patient. The results of tests performed in the office
are recorded in the patient's EHR and reviewed by the provider, 5:00 AM 0500 hours
who then shares the results with the patient. 7:00 AM 0700 hours
8. Confidentially notify the patient of test results according to
office policy, and document in the patient's health record 9:00 AM 0900 hours
that test results were received and the patient notified of the
11 :00 AM 1100 hours
results.
1:00 PM 1300 hours
LABORATORY MATHEMATICS AND MEASUREMENT 3:00 PM 1500 hours
All laboratory testing, from specimen collection through reporting 5:00 PM 1700 hours
of results, relies on the accurate use of values and measurements. For
example, values are used for reporting the time the sample was col-
7:00 PM 1900 hours
lected, the volume of the specimen, the amount of analyte found in 9:00 PM 2100 hours
a specimen, and dilutions used in sample preparation and for record-
ing QC results. 11 :00 PM 2300 hours
12:00 AM (midnight) 2400 hours
Measuring Time
Time of day often is a critical factor in patient care. Medications
must be administered, diets must be followed, and specimens must
be collected on a particular schedule. Many clinical laboratories use
the 24-hour clock when recording time; this method avoids the TABLE 27-4 Common Laboratory Temperatures
confusion that comes with the Greenwich clock, which uses AM
(morning) and PM (afternoon) designations. FAHRENHEIT CELSIUS
The 24-hour clock system, also known as military time, is Refrigerator 35°-46° 20-80
expressed with four digits in terms of "hundred hours." Noon is
referred to as 1200 (twelve hundred) hours; midnight is 0000 (zero Freezer 32° oo
hundred), or 2400 hours. The military clock is based on 24 60-minute Room 59°-86° l 5°-30°
hours, as is the Greenwich clock; therefore, 5:35 PM is expressed as
1735 (seventeen thirty-five) hours (Table 27-3). Incubator 98.6° 37°
Measuring Temperature Body temperature 98.6° 37°
Two scales currently are used for measuring temperature; each is Autoclave 254° 121°
divided into units called degrees (Table 27-4). The Fahrenheit scale
is considered part of the English system of measurement and is the
scale most commonly used in the United States. The Celsius scale,
formerly called the centigrade scale, is used in countries that apply The metric system is based on a decimal system, which consists
the metric system. On the Celsius (C) scale, water freezes at 0°C of basic units and prefixes that indicate a system of division in mul-
and boils at 100° F. On the Fahrenheit (F) scale, water freezes at 32° F tiples of 10. The basic units of the metric system are the gram (g)
and boils at 212°F. for weight, the meter (m) for length, and the liter (L) for volume.
Prefixes are added to each symbol to reduce or enlarge them by units
Units of Measurement of 10. The most common metric units used in the laboratory are
The units of measurement that we commonly use in the United millimeters (mm), centimeters (cm), micrograms (mcg), milligrams
States differ from those used in the clinical laboratory. In every- (mg), grams (g), microliters (mcL), milliliters (mL), liters (L), and
day life we use the English system of measurement, in which cubic centimeters (cc). The cubic centimeter and the milliliter are
weight is measured in ounces and pounds, length is measured in used interchangeably in the clinical laboratory.
inches and feet, and volume is measured in cups and quarts. Quantitative test results are reported using the appropriate units
In the laboratory, the metric system and the Systeme Interna- of measurement. Some commonly used designations for reporting
tional (SI) are used. It is important that medical assistants memo- analytes are mcg, mg, g, dL, and L. Blood glucose, for example, is
rize and practice these systems so that they can communicate reported in milligrams per deciliter (mg/dL); hemoglobin levels are
professionally. reported as grams per deciliter (g/dL).
692 UNIT FOUR DIAGNOSTIC PROCEDURES

International organizations, such as the World Health Organiza-
tion (WHO), officially recognize SI units. Many countries have
adopted this system, but the United States has not completely con-
verted to it. The SI is an adaptation of the metric system that uses
several of the basic units, although many are different for reporting
results. For example, blood glucose is reported in millimoles per liter
(mmol/L), and hemoglobin is reported in grams per liter (g/L).
Therefore, it is very important that the medical assistant double-
check the laboratory's standard and include the appropriate units of
measurement when reporting test values.
Microscopic procedures are not considered CLIA waived because
they require judgment and additional training. In addition, an error
in reading microscopic findings may have a detrimental effect on the
patient's care. Providers petitioned the CMS to create a new labora-
tory category that would allow them to perform a set of simple
microscopic tests that could be performed in the ambulatory setting
(Table 27-5). CMS approved the list and created an additional CLIA
category called provider-performed microscopy procedures (PPMP).
Certified CLIA-PPMP laboratories must meet the same quality

Measuring Liquid Volume

Test tubes come in many sizes and are typically disposable. Test tubes
may be sterile, and some may be calibrated. Micropipettors (Figure
27-9) are used to deliver very small amounts of liquid, from 1 ro
1,000 microliters (mcL). It is important to follow the manufacturer's
instructions for the device because each may be slightly different.
These pipetting devices must be fitted with an appropriate disposable
tip. The tips may be sterile, depending on their use. The device is
fitted with a piston at the top, which must be depressed before the
pipet is filled and when the pipet is drained.

LABORATORY EQUIPMENT
Microscope
Nearly every medical laboratory is equipped with a microscope. This
indispensable instrument is used to view objects too small to be seen
with the naked eye (Figure 27-10). The microscope is used to evalu-
ate stained blood smears, urine sediment, vaginal secretions, and
smears made from body fluids or microbiologic cultures. FIGURE 27-9 Piston-type automatic micropipettor.

Mechanical stage control

Coarse adjustment
Light source

FIGURE 27-10 The parts of a microscope. (Courtesy Cynmar, Carlinville, Ill.)

 CHAPTER 27 Assisting in the Clinical Laboratory 693

TABLE 27-5 CUA-Approved Procedures for PPM (Provider Performed Microscopy)

TEST NAME/CODE* DESCRIPTION EXAMPLE
Direct wet mount (QOl l l) Examination of specimens for presence or absence Observing vaginal secretions for presence of yeast to assist
of bacteria, fungi, parasites, and human cellular with diagnosis of vulvovaginal candidiasis
elements
KOH preparation Any preparation using potassium hydroxide Observing skin scrapings for the presence of fungi
(QOl 12)
Fecal leukocyte examination Simple stain of fecal specimen; assists in diagnosis Leukocytes are found in stool in antibiotic-associated colitis,
(89055) of diarrheal disease ulcerative colitis, shigellosis, and salmonellosis
Pinworm examination Preparations are observed for the presence or Performing a cellulose tape collection for pinworms
(QOl 13) absence of Enterobius vermicularis eggs
Postcoital direct, qualitative examinations Vaginal or cervical mucus is examined 4-10 hours Assists in the diagnosis of infertility
(QO 115) after intercourse for presence of live, motile sperm
Qualitative semen analysis Semen is examined for presence or absence of Assists in postvasectomy semen analysis and in the diagnosis
(G0027) spermatozoa; motility of the sperm is noted of infertility
Urine sediment examination Urine sediment is examined for presence or Part of a routine urinalysis (see the procedure in the Assisting
(81015) absence of formed elements in the Analysis of Urine chapter for Procedure 28-5, Prepare
a Urine Specimen for Microscopic Examination).
*The test's official code for billing purposes is shown in parentheses. Codes that do not begin with a letter are Current Procedural Terminology ((PT) codes; codes that do begin with a letter are
Healthcare Common Procedure Coding System (HCPCS) codes, which are used for Medicare patients.
CL/A, Clinical Laboratory Improvement Amendments; KOH, potassium hydroxide.

standards as laboratories that perform moderate-complexity tests,
including passing three proficiency tests from an outside agency per
year. The medical assistant is taught to prepare the microscope slide
and bring it into focus, but the final analysis may be made only
by a provider, an MA, a dentist, or other highly trained labora-
tory personnel.
Microscopes have three components: the magnification system,
which focuses the image; the illumination system, which brings the
image from the slide to the viewer; and the framework, which
includes all components responsible for positioning the slide.
The magnification system includes the ocular and the objective
lenses plus the fine and coarse knobs to adjust the clarity. Micro-
scopes may be monocular or binocular. A monocular microscope has
one eyepiece for viewing, and a binocular microscope has two. The
eyepiece, or ocular, is located at the top of the microscope and con-
tains a lens to magnify what is being viewed.
The usual magnification is 10 times (l0x). In addition to the
ocular, compound microscopes have objective lenses that increase
the magnification of the specimen. The objectives are attached to the
revolving nosepiece. Most microscopes have four objectives, each
with a different magnifying power. The shortest objective has the
lowest power (4x) and is called the scanning lens. This lens is used
to scan the field of interest and then focus on a particular object.
Greater detail is observed with the next longest objective, which is
low power (l0x). The high or high dry objective usually has a mag-
nification of 40x or 45x; the longest objective, oil immersion
(l00x), allows the finest focusing of the object and requires the use
of a special oil that is placed directly on the slide. This special oil,
called immersion oil prevents refraction of the light and improves
the resolution (clarity) of the magnified image. Oil immersion is
used to view cells and extremely small materials (e.g., bacteria and
platelets) and to examine stained specimens.
The total magnification of the specimen is determined by multi-
plying the magnification of the objective lens by 10 (the magnifica-
tion of the ocular lens). Therefore, if you have the l0X objective in
place when observing blood cells, you are magnifying the image 100
times. Just above the base are the focusing knobs. The coarse adjust-
ment is used only with scanning and low-power lenses, and the fine
adjustment is used with high-power and oil immersion lenses.
The arm of the microscope connects the objectives and the
oculars to the base, which supports the microscope and contains its
light source. The stage of the microscope holds the slide to be viewed.
Under the stage is the light source, the condenser, and the iris dia-
phragm, which make up the illumination system. The condenser
directs light up through the slide, and the iris diaphragm regulates
the amount of light passing through the specimen.
Microscopes are very precise and expensive instruments that
require careful handling. The amount of routine maintenance
required depends on the amount of daily use. Dirt is the enemy of
the microscope, which must be kept scrupulously clean at all times.
Oil, makeup, dust, and eye secretions all can obstruct vision through
the lens and may transmit infective organisms. The microscope should
always be stored in a plastic dust cover when not in use. Lenses
should be cleaned before and after each use with lens paper and lens
694 UNIT FOUR DIAGNOSTIC PROCEDURES

cleaner. Any other type of tissue scratches the lenses or leaves lint
residue behind. Routine use of solvent cleaners, such as xylene, is
not recommended, because these cleaners may loosen lenses. The
body of the microscope should be dusted with a soft cloth.
The microscope should be placed in a permanent location in the
laboratory, on a sturdy table in an area where it cannot be bumped.
If a microscope must be moved, it should be carried securely, with
one hand supporting the base and the other holding the arm. When
the microscope is stored, it should be left covered and with the
low-power objective in the highest position. The stage should be
centered.
Using a microscope involves focusing and illumination (Proce-
dure 27-2). The image is focused by moving the objectives closer to
the specimen using the fine and coarse knobs. Proper focusing begins
with the objective at lowest power. The coarse adjustment moves the
objective very quickly. This knob is used first to bring the specimen
into approximate focus. The fine adjustment focus knob then brings
the specimen into precise focus. The fine focus moves the objective
more slowly to allow the viewer to zero in on the specimen with
greater accuracy. Illumination is accomplished by raising or lowering
the condenser and by opening and closing the diaphragm on the
condenser.
If the microscope is a binocular model, the eyepieces may need
to be adjusted to accommodate the distance between the pupils and
the individual's point of greatest visual acuity. A gentle push inward
or pull outward adjusts the distance between the eyepieces.

•;;m,immf.flj Use the Microscope and Perform Routine Maintenance on Clinical Equipment

Goal: To focus the microscope properly using aprepared slide under low power, high power, and oil immersion, and to perform
routine maintenance on the microscope before storing it.

EQUIPMENT and SUPPLIES 12. Turn the revolving nosepiece to the area between the high-power objective
• Microscope and oil immersion.
• Lens cleaner 13. Place a small drop of oil on the slide.
• Lens tissue PURPOSE: Immersion oil has nearly the same refractive index as glass and
• Slide containing specimen prevents refraction of the light, thus improving resolution.
• Immersion ail 14. Carefully rotate the oil immersion objective into place. The objective will
be immersed in the oil.
PROCEDURAL STEPS 1S. Adjust the focus with the fine adjustment knob.
1. Sanitize your hands. PURPOSE: The fine adjustment knob moves the objective slowly, prevent-
2. Gather the needed materials. ing damage to the microscope and the slide.
3. Clean the lenses with lens tissue and lens cleaner. 16. Increase the light by opening the iris diaphragm and raising the
PURPOSE: Dust an lenses can obscure elements in the microscopic field. condenser.
4. Adjust the seating to a comfortable height. PURPOSE: Lighting is crucial to microscopy; the higher the magnification,
S. Plug the microscope into an electrical outlet and turn on the light switch. the more light that is needed.
6. Place the slide specimen on the stage and secure it. 17. Identify the specimen.
7. Turn the revolving nosepiece to engage the 4x or l Ox lens. 18. Return to low power but do not drag the 40x lens through the oil.
PURPOSE: Always begin microscopic observations at low power. 19. Remove the slide and dispose of it in a biohazard container.
8. Carefully raise the stage while observing with the naked eye from the 20. Lower the stage.
side. 21. Center the stage.
PURPOSE: Observing from the side prevents breaking of the slide if the PURPOSE: Returning the microscope to this position protects it during
coarse adjustment knob is advanced too far. storage.
9. Focus the specimen using the coarse adjustment knob. 22. Switch off the light and unplug the microscope.
PURPOSE: The coarse adjustment knob quickly brings the specimen into 23. Clean the lenses with lens tissue and remove oil with lens cleaner.
focus. PURPOSE: Dust and oil must be removed from the lenses after a
10. Adjust the amount of light by closing the iris diaphragm, by bringing the procedure.
condenser up or down, or by adjusting the light from the source. 24. Wipe the microscope with a cloth.
PURPOSE: Too much light when the low-power objective is used can be 25. Cover the microscope.
irritating to the eyes. 26. Sanitize the work area.
11. Switch to the 40x lens. Use the fine adjustment knob to focus the speci- 27. Sanitize your hands.
men in detail.

Centrifuge
Centrifugation, which is used when solids must be separated from
liquids, involves the application of increased gravitational force
achieved by rapid spinning. Centrifugation is used to separate blood
cells from serum and also solid materials, such as cells and crystals,
from urine.
Centrifuges (Figure 27-11 ) are designed for specific uses. They
may be bench-top or floor models; some may be refrigerated. Some
may have rotors or heads that are interchangeable. A typical clinical
centrifuge may have a rotor that is set at a fixed angle, in which the
specimen cups are held in a rigid position at a fixed angle; another
type has a horizontal head with swinging buckets that swing out
horizontally during centrifugation; and a third type is used for cen-
trifuging capillary tubes for microhematocrit determination (see the
Assisting in the Analysis of Blood chapter). Centrifuges also may
be equipped with timers to automatically stop centrifugation at a
set time.
Directions for using a centrifuge usually are given in terms of
revolutions per minute (rpm). Spinning generates centrifugal force,
causing the heaviest particles in a liquid to migrate to the bottom of
the tube. Centrifuges can be dangerous if not used correctly. The
most important rule is to ensure that the centrifuge is balanced so
that tubes of equal size and containing equal volume are directly
across from one another in the rotor holders. Therefore, there must
always be an even number of tubes in the centrifuge. If a second
specimen of the same volume in the same-sized tube is not available
for balance, a tube of water may be used to balance the load. Tubes
being centrifuged should be capped to prevent emission of aerosols.
Rubber cups should be placed in the bottom of the carrier cups to
prevent breakage of glass tubes.
Centrifuges should never be opened while they are in operation,
nor should you attempt to slow a centrifuge with your hands. Most
models are equipped with a brake, which should be used only in an
emergency, the most common of which is a broken glass tube. In this
FIGURE 27-11 Acentrifuge.
CHAPTER 27 Assisting in the Clinical Laboratory 695
case, wait until the centrifuge comes to a complete stop and follow
the manufacturer's instructions for disinfecting the unit; also follow
Standard Precautions to prevent injury and disease transmission.
Centrifuges should be checked, cleaned, and lubricated regularly
to ensure proper operation. A certified technician must use a pho-
toelectric device or a strobe tachometer to ensure the centrifuge's
speed to comply with quality assurance guidelines set forth by the
College of American Pathologists (CAP).
Incubator
Incubators are cabinets that maintain constant temperatures (Figure
27-12). Generally used in the microbiology laboratory, they main-
tain a constant temperature of95°to 98.6° F (35° to 37°C), although
other temperatures may also be appropriate. Incubators may have
warning alarms that sound if the temperature exceeds or falls below
a specified range. The temperature should be checked daily, and the
cabinets should be cleaned regularly with a disinfectant approved by
the manufacturer.
CLOSING COMMENTS
Patient Education
For many testing procedures, patients must be given a specific set of
instructions to follow. For example, patients may be required to fast
8 to 12 hours before blood samples are collected. The consumption
of some foods and medication may need to be discontinued prior
to laboratory testing. The provider discusses medication alternatives
with the patient. In some cases, discontinuing the medication may
not be medically advisable, and this must be noted on the laboratory
requisition. The laboratory then is alerted to the possibility of drug
interference, and an alternative test method may be used.
Often the medical assistant is responsible for explaining to the
patient the measures to be taken before laboratory testing. Make sure
you have interpreted the provider's orders correctly before explaining
FIGURE 27-12 An incubator. (Courtesy NuAire, Plymouth, Minn.)
696 UNIT FOUR DIAGNOSTIC PROCEDURES

the procedure to the patient. The patient should be given written
instructions, and a phone number should be included on the instruc-
tion sheet so that the patient can call if he or she has questions after
returning home.
Legal and Ethical Issues
If disease did not exist, there would be little need for clinical labo-
ratories. The fact that the human body is susceptible to disease
necessitates the existence of laboratory testing. All health and safety
risks cannot be anticipated or eliminated, but the risks are greatly
reduced when everyone who works in the laboratory is conscious of
safety guidelines.
Use common sense and document everything. If you are in doubt
about the safety of a procedure, ask your supervisor. If you are aware
of a potential safety problem, report it to the person in charge. Your
welfare, the welfare of the patient, and the welfare of your co-workers
may depend on your commitment to safety.
Before the patient receives test results, the medical assistant must
make sure the provider has reviewed and signed the results and has
given permission for the patient to be told about them. Most provid-
ers personally inform patients of!aboratory results, but some provid-
ers may delegate this duty to office staff. Regardless of who informs
the patient of test results, the individual must make sure the
specific guidelines for communication are followed as stipulated in
the patient's Health Insurance Portability and Accountability Act
(HIPAA) release form. Maintaining a patient's privacy and confiden-
tiality are crucial factors that must be considered when dealing with
test results.

Professional Behaviors
The next four chapters discuss the most common (LIA-waived tests performed
in the POL. They cover patient education, preparation, specimen collection,
and testing procedures, which are all aspects of professionalism you must
develop as you work with others and document your results appropriately.
Look over the Professionalism evaluation form in your study guide to see
what actions you should take to become a professional in the laboratory
classroom. At the end of the laboratory chapters, your instructor may meet
with you one on one to discuss your evaluation results, and/or you may do
a self-evaluation of your performance.

SCENABIO

Marsha's experience in clinical laboratory testing has made her a valuable
asset to her new employer. A thorough understanding of government
rules and regulations, including specifics about CLIA, the guidelines published
by the CDC, and the regulations established by OSHA have helped Marsha
implement laboratory testing in the clinic. Marsha helped the providers
design a safe, efficient laboratory space with a refrigerator, a centrifuge,
and a biohazard waste station. She developed a rigorous QA program and
is now training other medical assistants to perform CLIA-waived testing and
daily laboratory maintenance (Table 27-6).
Marsha pays close attention to CLIA regulations and receives regular updates
on the tests that can be performed in a POL. She currently is determining the
feasibility of performing drug screenings for local businesses. Her employers are
pleased with her efforts, and the patients appreciate the convenience of on-site
testing.

TABLE 27-6 Laboratory Maintenance Log

MEDICAL CLINIC
DAILY MAINTENANCE CONTROL CHART
MONTH YEAR
DAILY MONTHLY
REFRIG FREEZER ROOM INCUBATOR BLEACH EYEWASH SHOWER BY
DAY 2-8°C -o-20°c 15-30°C 34-36°c COUNTERS CHECKED CHECKED

2
3
4
5

SUMMARY OF LEARNING OBJECTIVES
l. Define, spell, and pronounce the terms listed in the vocabulary.
Spelling and pronouncing medical terms correctly reinforce the medical
assistant's credibility. Knowing the definitions of these terms promotes
confidence in communication with patients and co-workers.
2. Discuss the role of clinical laboratory personnel in patient care and
the medical assistant's role in coordinating laboratory tests and
results.
Clinical laboratory personnel are responsible for analyzing blood and body
fluids and sending the provider the test results, which become part of the
essential data for diagnosing and managing a patient's condition. Medical
assistants are responsible for collecting specimens, instructing patients,
and performing CUA-waived and some moderately complex testing.
3. Describe the divisions of the clinical laboratory and give an example
of a test performed in each division.
Most physician offices that perform laboratory testing do so in the areas
of urinalysis, hematology, chemistry, and microbiology. Routine urinaly-
sis, complete blood counts, glucose tests, and throat cultures are some
of the tests that might be perrormed in a POL.
4. Explain the three regulatory categories established by the Clinical
Laboratory Improvement Amendments (CUA) and identify CUA-
waived tests associated with common diseases.
ACUA-waived test is one that has been approved by the FDA for over-
the-counter sales and that may be performed in certified (LIA-waived
laboratories (i.e., POLs). The test has been determined to pose no
unreasonable risk of harm if perrormed incorrectly. More complex tests
that require additional training or education may be performed only in
CUA-certified moderate- and/or high-complexity laboratories.
Note: Providers may perrorm certain microscopic exams if they are certi-
fied to perform provider-perrarmed microscopy (PPM).
CUA established the standards of quality for laboratory testing.
Medical assistants are allowed to perrorm and monitor all (LIA-waived
tests. Table 27-2 summarizes the CUA-waived tests that may be per-
formed in a registered CUA-waived laboratory and the common diseases
or conditions in which they are used.
5. Identify quality assurance practices in healthcare, document the
results on a laboratory flow sheet, and discuss quality control
guidelines.
QA involves all the procedures undertaken to ensure that each patient is
provided excellent care. QC, which determines whether a laboratory test
is accurate, precise, and reliable, is one part of a QA program. Procedure
27-1 outlines the steps for analyzing the reliability of a test based on
the results of running its control and documenting the results on a labor•·
tory flow sheet.
6. Do the following related to laboratory safety:
• Compare and contrast the agencies that govern or influence practice
in the clinical laboratory.
The federal agencies that regulate clinical laboratories are:
• Food and Drug Administration (FDA): Regulates the complexity of
laboratory tests through the Clinical Laboratory Improvement
Amendments (CUA)
CHAPTER 27 Assisting in the Clinical Laboratory 697
• Centers for Medicare and Medicaid Services (CMS): Certifies and
monitors all clinical laboratories based on the complexity of
testing
• Centers for Disease Control and Prevention (CD(): Oversees the
presences of diseases and provides recommendations to prevent
the spread of disease
• Occupational Safety and Health Administration (OSHA): Regu-
lates the Bloodborne Pathogens Standard and the Hazard Com-
munication Standard
• Environment Protection Agency (EPA) regulates the disposal of
biohazard and chemical wastes.
Although all these agencies provide recommendations for operational
procedures in the clinical laboratory, not all have the power to enforce
them. For example, the FDA, OSHA and the EPA can impose significant
fines for failing to follow regulations, but the Standard Precautions
set forth by the CDC are recommended but not enforced.
• Discuss the purpose of aSafety Data Sheet.
All workers must be provided with information and training, and a
Safety Data Sheet (SOS, formerly MSDS) must be on file for all
chemicals used in the laboratory. OSHA requires the manufacturer of
the chemical to make these sheets available, usually as a package
insert and/or on line.
• Summarize safety techniques to minimize physical, chemical, and
biologic hazards in the clinical laboratory.
The medical facility must do the following: provide annual formal
safety training program to review and update physical, biologic, and
chemical hazards that apply to the laboratory; maintain an up-to-date
safety procedures manual; provide safety equipment (e.g., fire blan-
kets, fire extinguishers, eyewash stations, and personal protective
equipment) to all employees; make sure chemicals are clearly marked
with the National Fire Protection Association (N FPA) diamond; make
sure SDSs are bound in an accessible manual; and reinforce the
principles of Standard Precautions when any biologic material is
handled.
Note: Risks can be minimized in all areas of the laboratory by
using common sense.
7. Describe the essential elements of a laboratory requisition.
The laboratory requisition must include all information needed to identify
the patient, the ordering provider, the test ordered, insurance information,
and the specific details of collection of the specimen (e.g., time and
source).
8. Discuss specimen collection, including the importance of sensitivity
to patients' rights and feelings when collecting specimens. Also,
discuss the 8 steps in collecting specimens and informing patients of
their results.
Identification of the patient is the first essential step. If the patient is to
collect the specimen at home, he or she should be provided with the
appropriate container and complete instructions for collection. Bear in
mind the principles of patient education, and be sensitive to factors that
can affect the patient's understanding of the instructions for specimen
Continued
698 UNIT FOUR DIAGNOSTIC PROCEDURES
SUMMARY OF LEARNING OBJECTIVES-continued
collection. Review the 8 steps in collecting Specimens and informing
Patient of result.
9. Explain the chain of custody and why it is important.
Chain of custody is a method used to ensure that a specimen provided
by a patient who may be involved in a legal matter is handled in a
fashion that does not compromise the test results. All individuals who
handle or test the specimen must be identified in writing and must
provide a signature.
l 0. Describe the differences between Greenwich time and military time.
Greenwich time uses the designations AM and PM, whereas military time
uses the 24-hour clock. Therefore, 3: 15 PM Greenwich time is 1515 hours
in military time. Table 27-3 gives examples of Greenwich time and mili-
tary time.
11. Identify the Fahrenheit temperature and the Celsius temperature of
common pieces of laboratory equipment.
Although the Celsius (centigrade) thermometer is used in the clinical
laboratory, in everyday life we commonly use the Fahrenheit system.
The incubator is usually set at 37° C(98° F); the autoclave sterilizes at
121 ° C(254 ° F); and the refrigerator temperature is 2° to 8° C(35° to
44 ° F) (see Table 27-4).
12. Name the metric units used for measuring liquid volume, distance,
and mass.
Liquid volume is measured in liters; distance is measured in meters; and
mass is measured in grams. Prefixes commonly used in the clinical labora-
tory include decHO. l), centi-(0.01), mil/i-(0.001), micro-(0.000001),
and kilo- (1,000).
13. Do the following related to laboratory equipment:
• Name the parts of amicroscope and describe their functions.
The parts af the microscope can be divided into the illumination
system (light source, condenser, and iris diaphragm lever), the frame
(base, adjustment knobs, arm, stage, and stage control), and the
CONNECTIONS
OJ Study Guide Connection: Go to the Chapter 27 Study Guide. Read and complete
the activities.
magnification system (objective lenses on the revolving nosepiece and
oculars). The illumination system controls the light that passes through
the specimen to the eye; the frame provides the structure for the
instrument and the components that allow for adjustment of the
sample; and the magnification system provides the ground-glass
lenses that magnify the specimen.
• Summarize selected microscopy tests that can be performed in the
ambulatory care setting.
Refer ta Table 27-5.
• Demonstrate the proper use and maintenance of the microscope.
Procedure 27-2 outlines the steps for using and maintaining a
microscope.
• Describe the safe use of a centrifuge.
Far safe use af a centrifuge, the proper tube must be used and it
must be protected from breakage. Centrifuge loads must be carefully
balanced, and specimens must be capped ta prevent aerosols. Under
no circumstances should a centrifuge be opened while it is in
operation.
• Discuss the use of an incubator.
Incubators are cabinets that maintain constant temperatures. They
generally are used in a microbiology laboratory. The temperature
should be checked daily.
14. Identify patient education issues, as well as legal and ethical issues,
in the clinical laboratory setting.
If you are aware of a potential safety problem, report it ta the person
in charge. Make sure the provider has reviewed and signed test results
and has given permission for the patient to be told the results of testing.
Follow specific guidelines for communication as stipulated in the patient's
HIPM release form. Maintaining the patient's privacy and confidentiality
are crucial factors when communicating with the patient about test
results.
evolve Evolve Connection: Go to the Chapter 27 link at evolve.e/sevier.com/
kinn to complete the Chapter Review Quiz. Check out the other resources listed for this
chapter to make the most of what you have learned from Assisting in the Clinical
Laboratory.
ASSISTING IN THE ANALYSIS
OF URINE
As part of her duties as a (MA (AAMA), Rosa Gonzales performs tests on
patients' urine ordered by her employer, Dr. Ronald Hill. Rosa knows that uri-
nalysis (UA) is avery important part of patient care, and a number of urinary
tests are performed in the laboratory in Dr. Hill's busy practice. Dr. Hill most
While studying this chapter, think about the following questions:
• What is involved in a routine urinalysis?
• What quality assurance measures will Rosa follow when performing
laboratory tests on urine?
• How are pregnancy and drug tests performed on urine?
LEARNING OBJECTIVES
1. Define, spell, and pronounce the terms listed in the vocabulary.
2. Describe the history of the analysis of urine.
3. Describe the anatomy and physiology of the urinary tract, and discuss
the formation and elimination of urine by describing the processes of
filtration, reabsorption, secretion, and elimination.
4. Do the following related to collecting a urine specimen:
• Show sensitivity to patients' rights and feelings when collecting
specimens.
• Discuss collection containers.
• Explain the various means and methods used to collect urine
specimens.
• Instruct a patient in the collection of a 24-hour urine specimen.
• Instruct a patient in the collection of a clean-catch midstream urine
specimen.
5. Examine and report the physical aspects of urine.
6. Perform quality control measures and reassure a patient of the
accuracy of the test results based on the steps taken for quality
VOCABULARY
anuria The absence of urine production.
bacteriuria The presence of bacteria in the urine (possible infection).
bilirubinuria (bih-li-roo'-bin-yuhr-e-uh) The presence of
bilirubin in the urine (possible liver damage).
cast A protein that has taken on the size and shape of the renal
tubules and is washed into the urine. The cast may be identified
as hyaline, cellular, granular, or waxy.
Clinitest A test tablet commonly used to screen for and confirm
glucose and/or to detect other sugars in urine.
28
commonly orders routine urinalysis testing, but Rosa also performs some special-
ized tests. Today Dr. Hill has ordered a UA on a specimen from Mr. Parks; a
UA and pregnancy test on aspecimen from Mrs. Carpenter; and aUA and culture
and sensitivity (C&S) on a specimen from Ms. Hillman.
• How will Rosa instruct patients in the collection of urine for a routine
urinalysis, a urine culture, and other specialized tests such as pregnancy
and drug tests?
assurance and quality control when performing the chemical
urinalysis.
7. Test and record the chemical aspects of urine using CLIA-waived
methods.
8. Prepare a urine specimen for microscopic evaluation, and understand
the significance of casts, cells, crystals, and miscellaneous findings in
the microscopic report.
9. Explain or perform the following (LIA-waived urine tests:
• Glucose testing using the Clinitest method
• Urine pregnancy test
• Fertility and menopause tests
• Urine toxicology and drug testing
10. List the means by which urine could be adulterated before drug
testing.
11. Discuss patient education and legal and ethical issues related to
urinalysis.
crenate A term describing notched or leaflike, scalloped edges (as
seen in shrinking red blood cells).
culture and sensitivity (C&S) A procedure in which a specimen
is cultured on artificial media to detect bacterial or fungal
growth; this is followed by appropriate screening for antibiotic
sensitivity. C&S is performed in the microbiology referral
laboratory.
enzymatic reaction A specific chemical reaction controlled by an
enzyme.
700 UNIT FOUR DIAGNOSTIC PROCEDURES
VOCABULARY-continued
filtrate The fluid that remains after a liquid is passed through a
filter.
glomerulonephritis A serious kidney condition in which the
filtrating capsules are inflamed.
glycosuria An elevated urinary glucose level (possible diabetes
mellitus).
hematuria Blood in the urine (possible trauma or infection in the
urinary tract).
hemoglobinuria Hemoglobin in the urine (from destruction of
red blood cells).
human chorionic gonadotropin (hCG) A substance detected in
a positive pregnancy test.
iatrogenic A test result or condition caused by medication or
treatment.
ketonuria Ketones in the urine (possible dehydration or diabetic
ketoacidosis).
lysed To break open cells (e.g., white or red blood cells).
metabolite The by-product of the metabolism of a substance,
such as a drug.
mononuclear white blood cells Leukocytes with an unsegmented
nucleus; monocytes and lymphocytes in particular.
myoglobinuria The abnormal presence of a hemoglobin-like
chemical of muscle tissue in the urine; it is the result of muscle
deterioration.
HISTORY OF THE ANALYSIS OF URINE
For centuries abnormalities in the urine have been recognized as
possible indicators of a disruption of homeostasis. One of the earliest
known tests of urine involved pouring it on the ground to see
whether it attracted insects. Such attraction indicated "honey urine,"
which was known to be excreted by people with skin eruptions.
Today, urine is still checked for glucose as a means of detecting
diabetes.
During the twentieth century, urinalysis (UA) became a practical
laboratory procedure, and today urine is the most commonly ana-
lyzed body fluid in the clinical laboratory.
Urine is analyzed for several reasons. First, to detect extrinsic
conditions, in which the kidneys are functioning normally but
abnormal end products of metabolism are excreted as a result of an
imbalance in homeostasis. For example, individuals with diabetes
mellitus may excrete glucose in the urine when they are experiencing
hyperglycemia. Second, UA is performed to detect intrinsic patho-
logic conditions that involve the kidneys or the urinary tract, such
as the presence of kidney stones or of a urinary tract infection. In
addition, because chemicals are excreted through the kidneys, uri-
nalysis can be used to determine the effectiveness of medications
and/or the possibility of urinary system side effects from prescribed
drugs.
phenylalanine (fe-il-ahl'-uh-neen) An essential amino acid found
in milk, eggs, and other foods. Children unable to metabolize
this amino acid eliminate it in the urine.
polymorphonuclear (PMN) white blood cells Leukocytes with a
segmented nucleus; also known as segmented neutrophils, which
appear in the urine during a bacterial infection.
polyuria Excretion of abnormally large amounts of urine in 24
hours.
proteinuria Protein in the urine (possible kidney destruction,
especially with casts).
reagent strips Strips used to test the specific gravity, pH, and
chemical analytes in urine.
renal thresholds Levels above which substances cannot be
reabsorbed into the blood from the renal tubules and therefore
are excreted in the urine (e.g., when glucose reaches its renal
threshold, the excess glucose appears in the urine).
sediment Insoluble material that settles to the bottom of a urine
specimen and to the bottom of centrifuged urine.
supernatant The liquid above the sediment in a centrifuged urine
specimen.
urochrome The yellow pigment normally found in urine; it is
described as straw, yellow, or amber based on its concentration.
ANATOMY AND PHYSIOLOGY OF THE
URINARY TRACT
Medical assistants must have a basic knowledge of kidney structure
and urine formation to understand the results of a UA. The urinary
tract consists of two kidneys, two ureters, one bladder, and one
urethra. The functional unit of the kidney is the nephron (Figure
28-1 ). Each kidney has more than 1 million nephrons, and each
nephron interacts with the blood in the following ways: filtration,
reabsorption, and secretion. The kidney selectively excretes or
retains substances from the blood according to the body's needs.
Approximately 1,200 mL of blood flow through the kidneys each
minute.
Formation and Elimination of Urine
Filtration
The blood enters the glomerulus of the nephron through the afferent
arterioles. The capillary walls of the glomerulus are highly permeable
to the water and to the low-molecular-weight components of the
plasma (e.g., glucose, urea, electrolytes). These substances filter out
of the blood into Bowman's space and then into tubules of the nephron
(see Figure 28-1 ). Protein and blood cells are too large to be filtrated;
therefore, when these substances appear in the urine, it may indicate
kidney damage.
 CHAPTER 28 Assisting in the Analysis of Urine 701

Juxtaglomerular cells

Efferent arteriole
Glomerulus
Proximal
convoluted ~
tubule ~

~Macula densa

Ascending limb

Distal convoluted tubule

Neph ron IOOp----------f

FIGURE 28-1 Nephron. Notice the blood vessels entering and exiting the glomerulus, where the small particles in the blood are filtered
out of the blood into the surrounding capsule of the nephron. Then, follow the filtrate through the proximal convoluted tubule, the descending limb,
the loop of Henle, and the ascending limb of the nephron. This is where water and substances from the filtrate are reabsorbed back into the
blood vessels. Finally, in the distal convoluted tubule of the nephron, additional waste products are selectively secreted into the filtrate by the
blood vessels. The collection duct continues to concentrate the filtrate to form urine ready for excretion. (From Applegate EJ: The anatomy and
physiology learning system, ed 4, Philadelphia, 2011, Saunders.)

Reabsorption
The filtrate then travels through the proximal convoluted tubule
and the loop of Henle segments of the nephron, where some of
the filtrated products (e.g., glucose) and nearly all of the water are
reabsorbed into the blood. The reabsorption of glucose depends
on its renal threshold; this means that all the glucose will be
reabsorbed into the blood if the blood glucose level is below
160 mg/dL. If the blood glucose level is higher than 160 mg/dL,
the blood will not reabsorb the glucose. The filtered glucose then
remains in the urine, which will test positive for glucose during
urinalysis.
Secretion
As the filtrate travels through the last portion of the nephron, known
as the distal convoluted tubule, the blood vessels selectively secrete
additional products into the urine, such as potassium and hydrogen.
Some of the secreted substances are the metabolites of drugs that
may be measured in urine drug testing.
Elimination
The final filtrate formed throughout the nephron drains into a col-
lecting tubule, several of which join to form a collecting duct. The
collecting ducts send the filtrate into the renal pelvis, where the
filtrate is now called urine. Urine passes from the pelvis of the kidneys
down the ureters and into the bladder, where it remains until it is
voided through the urethra. The kidneys convert nearly 180,000 mL
of filtered blood plasma per day into a final urine volume of 750 to
2000 mL, or approximately 1% of the filtered plasma volume.
The largest component of urine is water. The normal waste prod-
ucts found in urine are urea, creatinine, and uric acid, plus the
electrolytes chloride, sodium, potassium, phosphate, and sulfate.
COLLECTING A URINE SPECIMEN
Patient Sensitivity
The request for a urine specimen may create an embarrassing
moment for the patient. The request should be made in private, such
702 UNIT FOUR DIAGNOSTIC PROCEDURES

as after the patient is seated in the examination room or while escort-

ing the patient to the restroom. The individual should be given
explicit instructions so that he or she understands what is expected.
The medical assistant should use therapeutic communication to
explain the details of the procedure to the patient and should be
observant for indications of confusion. If a language barrier exists,
be creative but respectful of the patient's need to follow through
correctly on the instructions for collection of the specimen. A picture
with directions in a variety of languages could also be posted in the
restroom.

Containers
The most important requirement for a collection container is scru-
pulous cleanliness. The physician office laboratory (POL) should
FIGURE 28-2 Sterile container for a midstream specimen.
provide the container; patients should not use jars from home. Dis-
posable, nonsterile, plastic, or coated paper containers are the most
common and are available in many sizes with tight-fitting lids. Most
routine UA testing, pregnancy testing, and tests for abnormal CRITICAL THINKING APPLICATION 28-1
analytes are performed on urine collected in nonsterile containers.
It is 9 AM, and Raso has received three urine specimens in the laboratory.
Special pliable polyethylene bags with adhesive are used to collect
One of the specimens is in a cup with a paper tab, indicating that the
urine from infants and children who are not toilet trained (see the
chapter on Pediatrics). For specimens that must be collected over a
container was sterile, and the other two are in nonsterile containers. What
specified period, large, wide-mouth plastic containers with screw-cap
procedures do you think might be performed on the urine collected in the
tops are used (Procedure 28-1 ). sterile container? What might Rosa do with the other urine specimens?
If the sample is being sent to the laboratory for a culture, the What information should she look for on the label af each specimen?
specimen must be collected in a sterile container, and the patient
must understand how to collect the specimen and how to handle
the sterile specimen cup. Such containers are packaged with an intact called a first morning specimen. These specimens are most concen-
paper seal over the cap and/or in sterile envelopes (Figure 28-2). trated and are best for nitrite and protein determination, bacterial
The label on all specimens must include the patient's name, the culture, pregnancy testing, and microscopic examination. Two-hour
date and time of collection, and the type of specimen. Always put postprandial urine specimens, collected 2 hours after a meal, are used
on gloves before handling filled specimen containers. in diabetes screening and for home diabetes testing programs. The
24-hour urine specimen is collected over 24 hours to provide a quan-
Methods of Specimen Collection titative chemical analysis, such as hormone levels and creatinine
Most analyses are performed on freshly voided urine collected in clearance rates (a procedure for evaluating the glomerular filtration
clean containers; this is called a random specimen. If the specimen is rate of the kidneys). The patient must understand the proper way to
ordered to be collected when the patient arises in the morning, it is collect a 24-hour urine specimen (see Procedure 28-1 ).

Instruct and Prepare a Patient for a Procedure or Treatment: Instruct a Patient in the
PROCEDURE 28-1
Collection of a 24-Hour Urine Specimen

Goal: To collect a24-hour urine sample to test for creatinine clearance.

EQUIPMENT and SUPPLIES PROCEDURAL STEPS

• Patient's health record 1. Greet the patient by name and confirm his or her identity using two identi-
• 3-L urine collection container fiers (typically have patients spell their name and give their date of birth).
• Plastic cup or specimen collection pan for collecting urine (which is then PURPOSE: To make sure you have the right patient.
poured into the collection container) 2. Label the container with the patient's name and the current date; identify
• Printed patient instructions the specimen as a 24-hour urine specimen; and include your initials.
• Laboratory requisition PURPOSE: Labeling the container prevents a possible mix-up af
specimens.

3. Explain the following instructions to adult patients or to the guardians of
pediatric patients.
Patient Instructions: Obtaining a 24-Haur Urine Specimen
(1) Empty your bladder into the toilet in the morning without saving any
of the specimen. Record the time you first emptied your bladder on
the label.
(2) For the next 24 hours, each time you empty your bladder, all the urine
should be collected into the plastic cup or nun's cap that is placed on
the toilet. Then pour all the collected urine directly into the large
specimen container (Figure l).
PURPOSE: Do not urinate directly into the large specimen container
because it may have a caustic preservative that you do not want to
splash out while urinating.
Patient Instructions for Caring for a Urine Specimen Obtained at Home
• Do not put anything but your urine into the container.
• Do not pour out any liquid or powdered preservative from the
container.
• If you accidentally spill some of the preservative on yourself, immediately
wash with water and call the testing center or designated laboratory.
A second-voided specimen usually is collected to determine glucose
levels; the first void of the morning is discarded, and the second void
of the day is collected. For a catheterized specimen, the provider,
nurse, or a specially trained medical assistant inserts a sterile catheter
into the bladder to collect the specimen.
CHAPTER 28 Assisting in the Analysis of Urine 703
(3) Put the lid back on the container after each urination and rinse out
the plastic cup or nun's cap and store the container in the refrigerator
or at room temperature, as directed, throughout the 24 hours of the
study.
PURPOSE: Refrigeration or the preservative inhibits microbial growth
in the specimen.
(4) If at any time you forget to collect your specimen or if some urine is
accidentally spilled, the test must be started all over again with a new
container and a newly recorded start time.
PURPOSE: The test will be inaccurate if you fail to collect all urine
produced during the designated 24-hour period.
{S) Collect the final urine specimen at the same time the next morning
as the first specimen on the previous day was discarded. This last
collected specimen is placed in the large container. Collection ends
with this voided morning specimen on the second day, which com-
pletes the 24-hour period.
(6) As soon as possible after completing collection, return the specimen
container to the provider's office or the designated laboratory.
4. Give the patient the specimen container and supplies with written instruc-
tions to confirm understanding.
S. Document the details of the patient education intervention in the patient's
record.
Processing a 24-Hour Urine Specimen
1. Ask the patient whether he or she collected all voided urine throughout the
24-hour period or whether any problems occurred during the collection
process.
PURPOSE: To confirm the accuracy of the specimen.
2. Complete the laboratory request form and put an disposable gloves before
preparing the specimen for transport.
3. Store the specimen in the refrigerator until it is picked up by the
laboratory.
4. Document that the specimen was sent to the laboratory, including the type
of test ordered, the date and time, the type of specimen, and your
initials.
• Always keep the collection container cool. Refrigerate the container, or
keep it in an ice-filled cooler or pail.
• Keep the cap on the container.
The minimum volume needed for a routine UA usually is
12 mL, but 50 mL is preferred. For any type of collection, it is
imperative that the patient receive adequate verbal and/or written
instructions. The easiest direction to give a patient is "fill the con-
tainer halfway."
704 UNIT FOUR DIAGNOSTIC PROCEDURES
A clean-catch midstream specimen (CCMS) is ordered when the
provider suspects a urinary tract infection and therefore orders a
urine culture for examination of microorganisms. The clean-catch
technique is used to remove microorganisms from the urinary
meatus (opening) by thoroughly cleansing the area around the
meatus and then urinating a small amount of urine into the toilet
to flush out the distal portion of the urethra. Because the
Instruct and Prepare a Patient for a Procedure or Treatment: Collect a Clean-Catch
PROCEDURE 28-2
Midstream Urine Specimen
Goal: To collect a contaminant-free urine sample for culture or analysis using the clean-catch midstream specimen (CCMS)
technique.
EQUIPMENT and SUPPLIES
• Patient's record
• Sterile container with lid and label
• Antiseptic towelettes
PROCEDURAL STEPS
1. Greet the patient by name and confirm his or her identity using two identi·
fiers (typically have patients spell their name and give their date of birth).
PU RPO SE: To make sure you have the right patient.
2. Label the sterile, sealed container and give the patient the towelette supplies
(Figure 1).
PURPOSE: Labeling the container prevents a possible mix-up of
specimens.
3. Explain the following instructions to adult patients or to the guardians of
pediatric patients, making sure you show sensitivity to privacy issues.
PURPOSE: Instructions must be understood if they are to be followed
correctly. By talking to the patient, you can determine whether the patient
understands or has any questions.
Patient Instructions: Obtaining a Clean-Catch Midstream Specimen
(Female Patient)
( 1) Wash your hands and open the towelette packages for easy access.
(2) Remove the lid from the specimen container, being careful not to
touch the inside of the lid or the inside of the container. Place the
lid, facing up, on a paper towel.
specimen is collected in the medical facility by the patient, the
medical assistant needs to give complete, understandable instruc-
tions to the patient on the method of collection (Procedure 28-2).
Failure to do so may mean that the patient will have to return to
the office to provide another specimen. For a urine culture, the
urine is collected either by catheterization or by the clean-catch
method into a sterile container.
PU RPO SE: The lid and the container must be handled carefully to
maintain the internal sterility of the container and prevent contamina·
tion of the urine sample.
(3) Lower your underclothing and sit on the toilet.
(4) Expose the urinary meatus by spreading apart the labia with one
hand (Figure 2, A).
2 A
(S) Cleanse each side of the urinary meatus with a front-to-back motion,
from the pubis toward the anus. Use a separate antiseptic wipe to
cleanse each side of the meatus.
PU RPO SE: Cleansing the area around the urinary meatus prevents
contamination of the urine sample. Wiping in one stroke from front
to back prevents the passage of microorganisms from the anal region
to the area around the urinary meatus.
(6) Cleanse directly across the meatus, front to back, using a third
antiseptic wipe (see Figure 2, A).
(7) Hold the labia apart throughout this procedure.
(8) Void a small amount of urine into the toilet (Figure 2, B).
PURPOSE: Allowing the initial flow of urine to pass into the toilet
flushes the opening of the urethra.
(9) Move the specimen container into position and void the next portion
of urine into it. Fill the container halfway. Remember, this is a sterile
container. Do not put your fingers on the inside of the container.
(10) Remove the cup and void the last amount of urine into the toilet.
(This means that the first part and the last part of the urinary flow
 CHAPTER 28 Assisting in the Analysis of Urine 705

•;;m;imj;jf;:fI -continued
have been excluded from the specimen. Only the middle portion of
the flow is included.)
(11) Place the lid on the container, taking care not to touch the interior
surface of the lid. Wipe in your usual manner, redress, wash your
hands and return the sterile specimen to the place designated by the
medical facility.
Patient Instructions: Obtaining a Clean-Catch Midstream Specimen (Male
Patient)
(1) Wash your hands and expose the penis.
(2) Retract the foreskin of the penis (if not circumcised).
(3) Cleanse the area around the glans penis (tip of the penis) and the
urethral opening (meatus) by washing each side of the glans with a
separate antiseptic wipe (Figure 3, A).
(4) Cleanse directly across the urethral opening using a third antiseptic
wipe.
(S) Void a small amount of urine into the toilet or urinal (Figure 3, B).
(6) Collect the next portion of the urine in the sterile container, filling the
container halfway without touching the inside of the container with
the hands or the penis (Figure 3, Cl .
(7) Void the last amount of urine into the toilet or urinal.
(8) Place the lid on the container, taking care not to touch the interior
surface of the lid. Wipe, wash your hands, and redress.
(9) Return the specimen to the designated area.
Processing a Clean-Catch Urine Specimen
1. Document the date, time, and collection type.
2. Process the specimen according to the provider's orders. Perform urinalysis
in the office or prepare the specimen for transport to the laboratory. If it is
to be sent to an outside laboratory, complete the following steps:
• Make sure the label is properly completed with the patient's information
and the date, time, test ordered, and your initials.
• Place the specimen in a biohazard specimen bag.
• Complete a laboratory requisition and place it in the outside pocket of
the specimen bag.
• Keep the specimen refrigerated until pickup.
• Document that the specimen was sent.

3 A B C

Handling and Transportation of a Specimen

Proper handling of specimens is essential. The chemical and cellular
components of urine change if the urine is allowed to stand at room
temperature (Table 28-1 ). Urine specimens should therefore be kept
refrigerated and should be processed within 1 hour of collection. If
the specimen must be transported to a referral laboratory, evacuated
transport tubes are available; these contain preservatives and look
much like blood collection tubes (Figure 28-3). The vacuum in the
tube allows for the delivery of 7 to 8 mL of urine, using a transfer
straw or a urine collection cup with an integrated sampling device.
Alternatively, the urine can be poured into the tube after the stopper
is removed. The preservatives in the BD Vacutainer cherry red/
yellow-stoppered tube (i.e., chlorhexidine, ethylparaben, and sodium
propionate) prevent the overgrowth of bacteria and inhibit changes FIGURE 28-3 BD Vacutainer urine preservation tubes. (Courtesy Becton, Dickinson &Co., Franklin
in the urine that can affect test results. Chemical reagent strip testing Lakes, NJ.)
706 UNIT FOUR DIAGNOSTIC PROCEDURES

sign after he or she has reviewed the results. Specimens are sent to
TABLE 28-1 Changes in Urine after 1 Hour at the laboratory in a plastic biohazard bag that zips closed and has
Room Temperature an outside pocket, where the laboratory request is placed. After
the test has been performed, the lab sends back the results
CONSTITUENT CHANGE
electronically.
Clarity Urine becomes cloudy as crystals precipitate
and bacteria multiply
Color May change if pH becomes alkaline CRITICAL THINKING APPLICATION 28-2
pH Becomes alkaline as bacteria form ammonia Dr. Hill has ordered a UA an a specimen from Mr. Parks; a UA and preg-
from urea nancy test on the specimen from Mrs. Carpenter; and a UA and C&S on
Glucose Decreases as it is metabolized by bacteria a specimen from Ms. Hillman. After reviewing the requisitions and enter-
ing the patient information into the daily logbook, Raso notes that Mrs.
Ketones Decreases because of evaporation Carpenter's specimen was collected at 6 AM-3 hours ago. Is this accept-
Bilirubin and urobilinogen Undergo degradation in light able? Explain your answer. Rosa also notes that the specimen collected
in the sterile container from Ms. Hillman is marked "(CMS." Why is this
Blood May hemolyze; false-positive results are important?
possible because of bacterial enzymes
Nitrite Test result may change from negative ta
positive as bacteria multiply and reduce
nitrates to nitrites
TABLE 28-2 Components of Physical and
Casts Lyse or dissolve in alkaline urine Chemical Urinalysis
Cells Lyse or dissolve in alkaline urine PHYSICAL PROPERTIES CHEMICAL PROPERTIES
Bacteria Multiply twofold approximately every 20 Color Protein
minutes
Clarity Glucose
Yeasts Multiply
Specific gravity Ketones
Crystals Precipitate as urine cools; may dissolve if pH
changes Volume* Bilirubin
Odor* Blood
Foam* Nitrite
pH
can be performed on preserved specimens; however, it should be Urobilinogen
performed within 72 hours. Tubes may be held at room temperature Leukocyte enzyme
during this time.
A different preservative must be used for urine specimens slated *Not always assessed.
for culture. The BD Vacutainer urine collection kit contains the
preservatives sodium formate and boric acid to help preserve the level
of bacteria present at the time of collection. This transport system
should be used only for urine specimens that will be cultured. Results ROUTINE URINALYSIS
on the chemical reagent strip may be altered by these preservatives. A complete UA is assessment of the physical properties of the urine
Culture and sensitivity (C&S) testing should be performed within and the measurement of selected chemical constituents that are
72 hours. These C&S tubes can be held at room temperature to diagnostically important (see Table 28-2).
preserve the bacteria that need to be cultured and then tested for
sensitivity.
A laboratory request form must be completed for all specimens Physical Examination of the Urine
that will be transported to another site for analysis. Typical forms Appearance
include the patient's name and the date; the type of urinalysis Color. Normal urine is a shade of yellow, ranging from pale straw
ordered; the name of the provider requesting the examination; the to yellow to amber. The color depends on the concentration of
appropriate code for the diagnosis that warranted the test accord- the pigment urochrome and the amount of water in the spe-
ing to the International Classification of Diseases, Tenth Revision, cimen. A dilute specimen should be pale (straw), and a more
Clinical Modification (ICD-10-CM); and a line for the provider to concentrated specimen should be a darker yellow (amber). First
 CHAPTER 28 Assisting in the Analysis of Urine 707

morning specimens will likely be amber in color due to the con-

centration of the urochrome during the night. Variations in color
may also be caused by diet, medication, and disease. Abnormal
colors may be related to pathologic or nonpathologic factors
(Table 28-3).
Turbidity. Both normal and abnormal urine specimens may range
in appearance from clear to very cloudy. Cloudiness may be caused
by cells, bacteria, yeast, vaginal contaminants, or crystals. Often a
urine specimen that was clear when voided becomes cloudy as it
cools, as crystals form and precipitate.
CRITICAL THINKING APPLICATION 28-3
1. The requisitions accompanying the urine specimens indicate that all three
require a UA. Rosa performs the physical analysis and notes that Mrs.
Carpenter's urine, which requires the pregnancy test, is amber, whereas
the other two specimens are pale yellow. What are possible explanations
for Rosa's observations? Should Rosa be concerned about the darker
colar of Mrs. Carpenter's urine? Should she document this in the
patient's electronic health record (EHR) so that Dr. Hill is alerted?
2. Ms. Hillman's urine is turbid, whereas Mr. Parks's urine is clear. What
might be causing the cloudiness in Ms. Hillman's urine? Is a cloudy
urine cause for concern?

TABLE 28-3 Possible Causes of Urine Colors

COLOR PATHOLOGIC CAUSE NONPATHOLOGIC CAUSE
Straw Diabetes Diuretics; high fluid intake (coffee, beer)
Amber Dehydration Concentrated first morning specimen: Excessive sweating; low fluid intake
Bright yellow Carotene, vitamins
Red Blood, porphyrins Menstruation, beets, drugs, dyes
Orange-yellow Bile, hepatitis Pyridium (phenazopyridine hydrochloride), dyes, drugs
Greenish yellow Bile, hepatitis Senna, cascara, rhubarb
Reddish brown Old blood, methemoglobin
Brownish black Methemoglobin, melanin Levodopa (Levodopa, Dopar)
Salmon pink Amorphous urates
White (milky) Fats, pus Amorphous phosphates
Blue-green Biliverdin, infection with Pseudomonas organisms Vitamin B, drugs, dyes

•;;mdmi;Jf.j:f• Assess Urine for Color and Turbidity: Physical Test

Goal: To assess and record the color and clarity of a urine specimen.

EQUIPMENT and SUPPLIES 2. Mix the urine by swirling.

• Patient's record PURPOSE: Suspended substances settle when urine stands. If urine is not
• Urine specimen mixed before its appearance is assessed, the finding will be incorrect.
• Centrifuge tube 3. Label a centrifuge tube if a complete urinalysis is to be done.
• Fluid-impermeable lab coat and disposable gloves PURPOSE: If a complete urinalysis is to be done, a portion of the specimen
• Biohazard container will be centrifuged for microscopic examination. The centrifuged specimen
must be labeled to prevent specimen confusion.
PROCEDURAL STEPS 4. Pour the specimen into a standard-sized centrifuge tube.
1. Sanitize your hands. Put on the fluid-impermeable lab coat and disposable PURPOSE: Standard-sized containers are better for assessing color and
gloves. clarity results.
708 UNIT FOUR DIAGNOSTIC PROCEDURES

•;;m,ammf1:$• -continued
S. Assess and record the color (Figure l): 6. Assess the clarity by placing a piece of white paper with fine and dark black
• Pale straw print behind the specimen and see if yau can see the print:
• Yellow • Clear-Able to read through the specimen; no cloudiness
• Amber • Slightly turbid- Can barely see fine print on white paper through the
tube
• Moderately turbid-Cannot see fine print; only dark print can be seen

88
.A
f
I
I through the tube
• Very turbid-Cannot see any print on white paper through the tube
7. Clean the work area, and dispose of gloves and procedure supplies in the
I
biohazard waste container. Remove lab coat and sanitize your hands.
Straw Yellow Amber PURPOSE: To ensure infection control.
8. Record the results in the patient's record.
PURPOSE: Aprocedure is considered not done until it is recorded.

Volume
The amount of urine is rarely measured in a random specimen. With
a timed specimen, volume is measured by pouring the entire collec-
tion into a large, graduated cylinder. Generally, it is not accurate
enough to use the markings on the side of the collection container.
Once the volume has been measured and recorded, a portion of
well-mixed specimen, called an aliquot, is removed for testing. The
remainder is discarded or stored, depending on the preference of the
laboratory.
The normal volume of urine produced every 24 hours varies
according to the age of the individual. Infants and children produce
smaller volumes than adults. The normal adult volume is 750 to
2,000 mL in 24 hours; the average amount is about 1,500 mL.
Excessive production of urine is called polyuria This is common in
diabetes mellitus, diabetes insipidus, and in certain kidney disorders.
Oliguria is insufficient production of urine, which can be caused FIGURE 28-4 Dark amber-red urine with foam may indicate an increased protein level and
by dehydration, decreased fluid intake, shock, or renal disease, and hematuria. Note: If the urine were orange-green and the foam greenish yellow, this might indicate
urinary tract infections. The absence of urine production, anuria, bilirubinuria.
occurs in renal obstruction and renal failure.

Foam
Normally the presence of foam is not recorded, but careful observa-
tion of this property can be a significant due to an abnormality.
Foam is seen as small bubbles that persist for a long time after the
specimen has been shaken; they must not be confused with any
bubbles that rapidly disperse. White foam can indicate the presence
of increased protein (Figure 28-4). Greenish yellow foam can mean
bilirubinuria. Care should be taken in handling such urine speci-
mens because the greenish yellow color may indicate that the patient
has viral hepatitis, which is highly contagious.
Odor
As with foam, odor is not normally recorded but can be an important
due to metabolic disorders. Normal urine is said to be aromatic.
Changes in the odor of urine may be caused by disease, the presence
of bacteria, or diet. The odor of the urine of a patient with uncon-
trolled diabetes is described as fruity because of the presence of
ketones, which are the products of fat metabolism. An ammonia or
putrid smell in the urine can be caused by an infection or may be
noted in urine that has been allowed to stand before it is tested. The
bacteria break down the urea in the urine to form ammonia. Foods
such as asparagus and garlic also can produce an abnormal odor in
the urine. Urine from a child with phenylketonuria (PKU) is said
to smell "mousy." PKU is a rare hereditary condition in which the
amino acid phenylalanine is not properly metabolized, which can
lead to severe mental retardation. Accumulation of phenylalanine in
the blood and urine gives body fluids an odor like wet fur. (Blood
sampling for PKU is discussed in the chapter, Assisting in Blood
Collection.)
 CHAPTER 28 Assisting in the Analysis of Urine 709

SERUM OR Pl.ASMA
PROTEIN
"""""'"'
TIC
PMCMTIOU•

1 03'5---=
URINE 1 030
INCIIIIC GAAVfTY 1 02S
TIC Hll:!O
=
;;

:;:
101S~
1010 ~
100&~
10 0 0 ~

FIGURE 28-5 Refractometer. Adrop of urine is placed on the prism surface of the refractometer on the left, and the cover plate is dosed.
When the examiner looks through the lens, the two graphs are seen in the circular field of vision on the right. The urine specific gravity (SG) is
read from the left scale, where the blue shadow meets the lighted bottom. The SG is 1.020.

Specific Gravity
The specific gravity is the weight of a substance compared with the
weight of an equal volume of distilled water. In UA, it is the rough 15~
=
~320
310
:;;._ 300
measurement of the concentration, or amount, of substances dis- 14;;;;; ~ 290
--280
solved in the urine. The specific gravity of distilled water is 1.000. 13 :;;._ ~ 270
SERUM OR PLASMA --260
The normal specific gravity of urine ranges from 1.005 to 1.030, PROTEIN 12:;; : : 250
...,..._240
depending on the patient's fluid intake. Most samples fall between --230
1.010 and 1.025. The urine specific gravity indicates whether the
GMS/100 ml
TIC
11~
=
~
220
210
10i
PR/N RATIO 6.54 ~ 200
kidneys are able to concentrate the urine. A change in specific 9 ::

= = iii---190

--
180
gravity is one of the first indications of kidney disease. For 8 ~ 170
~ 160
example, glomerulonephritis, the presence of glucose, protein, or 7 ~ ~ 150
an x-ray contrast medium used in diagnostic studies may increase 1.035----= 6 ~ ~ ): REFRACTION
~ 120 (n-na)x104
=
i-- =---
the specific gravity of urine, whereas chronic renal insufficiency or URINE 1.030 5 -- ~ 110 TIC
...,..._ 100
diabetes insipidus may lower the specific gravity in urine. To SPECIFIC GRAVITY 1.025
4
;a;a 90

measure the specific gravity, laboratories may use a Clinical Labo-

ratory Improvement Amendments (CLIA)-waived refractometer or
TIC
1.020
1.015
=
3 -
-- ~ 70
~60
~50
80

a chemical reagent strip. 1.010

1.005 =
i
=: 20
A refractometer measures the refraction of light through solids in ~ 10
1.000 ~o
a liquid. The result is called the refractive index, which for our pur-
poses is the same as specific gravity. The refractometer requires only
a drop of urine. One drop of well-mixed urine is placed under the
hinged cover of the instrument, and the value is read directly from FIGURE 28-6 Refractometer reading using a distilled water control. Note that the urine specific
a scale viewed through an ocular. Figure 28-5 shows the refractom- gravity (SG) is 1.000 on both scales.
eter on the left and the visual results of the urine in the circle on the
right. The scale on the left side of the circle shows a urine specific
gravity of 1.020. The refractometer must be calibrated daily with Chemical Examination of Urine
distilled water, which should read 1.000 (Figure 28-6). Note that Tests can be performed on urine to detect the presence of certain
the measurement of specific gravity carries no unit of measure after chemicals, which can provide valuable information to the provider.
the number. In certain situations, these chemical test results can be critical to the
The reagent strip (dipstick) test, a CLIA-waived test, is the method diagnosis.
most commonly used for measuring specific gravity in the POL. The Reagent strip testing is the most widely used technique for
pad on the strip contains a chemical that is sensitive to positively detecting chemicals in the urine (Procedure 28-4); these strips are
charged ions, such as sodium (Na+) and potassium (K+). The pad available in a variety of types (Figure 28-7). Generally, they are
detects the urine's specific gravity. Various color changes indicate plastic strips to which one or more pads containing chemical reagents
values between 1.000 and 1.030 (see the SPECIFIC GRAVITY row are attached. Test pads are available for measuring pH and specific
of colors in the second figure in Procedure 28-4). gravity (physical properties of urine), and for measuring the
71 o UNIT FOUR DIAGNOSTIC PROCEDURES
following chemicals: glucose, ketones, leukocyte esterase, protein,
blood, bilirubin, nitrite, urobilinogen, phenylketones, vitamin C,
and others. The presence or absence of these chemicals in the urine
provides information on the status of carbohydrate metabolism, liver
and kidney function, and the patient's acid-base balance.
Reagent strips are designed to be used once and then discarded
in a biohazard waste container. The directions for each strip are
included inside the package, and these instructions must be followed
exactly if accurate results are to be obtained. A color comparison
chart is provided on the label of the container. In addition to reagent
strips, various tablet tests are available.
All strips and tablets must be kept in tightly closed containers in
a cool, dry area and should be removed just before testing. To prevent
contamination of the bottle, never touch a strip that has been
exposed to urine against the color comparison chart on the bottle.
If both a UA and a C&S have been ordered for a specimen, the urine
must be cultured or separated into a urine culture tube before the
UA is started because introducing a reagent strip into the urine
contaminates it.
pH
The pH is a measurement of the degree of acidity or alkalinity of
the urine. A urine specimen with a pH of7 is neutral (Figure 28-8).
FIGURE 28-7 Examples of two controls (left) and two reagent strip bottles for testing various
chemicals in urine (right).
Acid -+--•----+Alkaline
Urine
Acid
5.0---8.0
Saliva
6.0
FIGURE 28-8 The pH scale.
A value below 7 indicates acidity, and one above 7 indicates alkalin-
ity. Normal, freshly voided urine may have a pH range of 5.5 to 8.
The urinary pH varies with an individual's metabolic status, diet,
drug therapy, and disease. In the case of gross bacteriuria, the urine
pH is alkaline as a result of bacterial conversion of urea to ammonia.
Knowing the pH of the urine also assists in identification of crystals
if they are found in the urine sediment.
Glucose
Glucose is filtered at the glomerulus, but under normal conditions
most of it is reabsorbed in the tubules. The minute quantities nor-
mally present in the urine are not detected by reagent strips and
tablets. Detectable glycosuria occurs whenever the filtered glucose
in the renal tubules is so high it cannot be reabsorbed into the blood
because its renal threshold has been met. The excess glucose is then
excreted and detected in the urine specimen. A positive glucose
finding is common in urine from patients with diabetes and may be
the first indication of the disease. The reagent strip glucose testing
method is based on an enzymatic reaction. It detects only glucose;
in other words, it is specific for glucose.
Ketones
Ketones are the end product of fat metabolism in the body. Aceto-
acetate, acetone, and beta hydroxybutyric acid are collectively called
ketone bodies, or ketones. Ketonuria is common with starvation,
low-carbohydrate diets, excessive vomiting, and diabetes mellitus.
Because ketones evaporate at room temperature, urine should be
tested immediately, or the specimen should be tightly covered and
refrigerated. The reagent strip detects only acetoacetate. The Acetest,
discussed later in this chapter, can be used to detect both acetone
and acetoacetate.
Protein
Protein in the urine in detectable amounts is called proteinuria,
which is one of the first signs of renal disease. We normally excrete
a small amount of protein every day; proteinuria may be light to
heavy, constant or sporadic. It may be affected by posture. In ortho-
static proteinuria, protein is excreted only when the patient is in an
upright position. Generally, first morning specimens from these
patients are negative, but protein is found in urine passed throughout
Alkaline
+
Pure Blood 7.35-7.45
water
7.0
 CHAPTER 28 Assisting in the Analysis of Urine 711

the day. Proteinuria is a common finding in pregnancy and must be
monitored along with excessive weight gain and increased blood
pressure (three possible symptoms of pre-eclampsia). Protein is almost
always present in the urine after heavy exercise. The reagent strip is
highly sensitive to urinary albumin and is less sensitive to the other
proteins: hemoglobin, immunoglobulin, and mucoproteins.
Blood
The presence of blood in the urine may indicate infection or trauma
to the urinary tract, resulting in bleeding in the kidneys, bladder, or
urethra. The blood test pad on the reagent strip reacts with three
different blood constituents: intact red blood cells, hemoglobin from
lysed red blood cells, and myoglobin, a hemoglobin-like molecule
that transports oxygen in muscle tissue.
Hematuria is the presence of intact red blood cells in urine. The
color reaction on the reagent strip ranges from yellow through green
to dark green when hematuria is present, revealing a speckled appear-
ance. Hematuria can be caused by irritation of the ureters, bladder,
or urethra. It also is a common finding in cystitis and in individuals
passing kidney stones. A random specimen may contain blood from
vaginal contamination if the woman is menstruating.
Hemoglobinuria is the presence of hemolyzed red blood cells.
True hemoglobinuria is rare. It occurs as a result of intravascular red
blood cell destruction and can be caused by transfusion reactions,
malaria, drug reactions, snakebites, and severe burns.
Myoglobinuria occurs when muscle tissue is damaged or injured,
as in crushing injuries, myocardial infarctions, and contact sports.
Patients with muscular dystrophy ofren have myoglobinuria. Hemo-
globinuria cannot be distinguished from myoglobinuria by reagent
strip testing; both cause a uniform change in color from light green
to dark green on the strip.
presence of a urinary tract infection (UTI). However, not all bacteria
are able to reduce nitrate to nitrite. Negative nitrite test results also
can occur when bacteria are insufficient or when the urine has not
incubated in the bladder long enough for the reaction to occur.
Escherichia coli, the organism that causes most UTls, reduces nitrate
to nitrite. False-positive results can occur if a specimen is allowed to
sit at room temperature and contaminating bacteria multiply. False-
negative results may occur if the bacteria further metabolize the
nitrite and produce ammonia.
Leukocyte Esterase
Leukocytes (white blood cells) are present in urine during infections
of the urinary tract. Leukocytes may also be contaminants from the
vagina. The leukocyte esterase test pad on the reagent strips takes 2
minutes to release the esterase in the lysed polymorphonuclear
white blood cells (PMNs) before showing a positive reaction. It
does not detect mononuclear white blood cells, which occasionally
are present during infection. The test does not react with small
numbers of white blood cells found in normal urine.
limitations of Reagent Strip Testing
The reagent strip is a reliable method of chemical analysis of urine
if used properly. The normal urine reference ranges for a reagent
strip are presented in Table 28-4. Errors can arise from a number
of sources. For example, if the strip is soaked excessively in the
specimen, chemicals in the pads may be overly diluted. If the strip
is not held horizontally while read, colors from one pad may bleed
onto another. If the test areas on the strip are not read at their
prescribed time, the chemical interaction may be misread. Finally,
certain chemicals, such as ascorbic acid (vitamin C), may affect
the results of nitrite, glucose, bilirubin, and occult blood tests.

Bilirubin and Urobilinogen

Bilirubin is a product of the breakdown of hemoglobin. Hemoglobin
is released from old red blood cells and is gradually converted to TABLE 28-4 Normal Urine Reference Ranges for
bilirubin in the liver. The liver continues to convert bilirubin to Reagent Strips
urobilinogen, which is sent to the intestines for excretion. Bilirubin
is a bile pigment not normally found in urine. Its presence in urine REFERENCE RANGE
is one of the first signs of liver disease or other diseases in which the Color Pale yellow to amber
liver may be involved.
Bilirubinuria can occur even before jaundice or other symptoms Clarity Clear to slightly turbid
of liver disease are evident. It is the result of liver cell damage or Specific gravity 1.001-1.035
obstruction of the common bile duct by stones or neoplasms
(tumors). Excessive bilirubin colors the urine yellow-brown to pH 4.6-8
greenish orange. Because direct light causes decomposition of
Protein (mg/dL) NEG
bilirubin, urine samples must be protected from light until testing
is complete. Glucose (mg/dl) NEG
Urobilinogen normally is present in urine in small amounts.
Increases are seen with increased red blood cell destruction and in
Ketone (mg/dl) NEG
liver disease. With total obstruction of the bile duct, no urobilinogen Bilirubin (mg/dl) NEG
is found in the intestines and none is reabsorbed into the circulation;
therefore, none is present in the urine. Reagent strip methods cannot
Blood (mg/dl) NEG
detect a decrease in urobilinogen. Nitrite (mg/dl) NEG
Nitrite Urobilinogen (Ehrlich units) 0.1-1
Nitrite occurs in urine when bacteria break down nitrate, a common White blood cells NEG
component of urine. A positive nitrite test result may indicate the
712 UNIT FOUR DIAGNOSTIC PROCEDURES

Normal levels of vitamin C do not interfere with analysis, but if a

person consumes large amounts of the vitamin, a special strip can
be used to detect interfering levels of vitamin C. If an elevated
level is found, the patient should be instructed to discontinue
vitamin C intake for 24 hours, and then another urine specimen
should be collected for testing.
Visual interpretation of color on the reagent strip pads is likely
to vary among individuals. Some laboratories use automated instru-
ments to read the strips. Several companies manufacture instruments
that use the principle of reflectance photometry in the analysis of
reagent strip color. Once the strip has been placed in the instrument,
a microprocessor controls the movement of the strip into the reflec-
tometer. Light of a specific wavelength is beamed onto each of the
test areas on the strip. Some light is absorbed, and some is scattered
or reflected. The amount of reflected light is analyzed by the micro-
processor and converted into a digital reading, and the results are
printed out (Figure 28-9). The advantage of this method is that
timing and color interpretation are consistent. The disadvantage is
that the instrument is not able to identify and compensate for highly
pigmented urine, leading to false-positive results. The medical assis-
tant should be aware of this and should manually test urine speci-
mens that are darkly pigmented.
CRITICAL THINKING APPLICATION 28-4
1. Rosa prepares to do the chemical examination of the three urine speci-
mens. (Remember, Dr. Hill has ordered the following:)
• UA an the specimen from Mr. Parks
• UA and pregnancy test on the specimen from Mrs. Carpenter
• UA and C&S on the specimen from Ms. Hillman
Should Rosa proceed with the chemical analysis of each specimen
in exactly the same manner? Explain your answer.
2. After completing the chemical analysis of the three specimens, Rosa
notes several differences among the samples:
• Mr. Parks's test results reveal elevated glucose and ketone levels
and an SG of 1.035.
• Mrs. Carpenter's sample has a high specific gravity (SG).
• Ms. Hillman's sample reveals an elevated nitrite level, a pH of 8,
and an elevated leukocyte esterase reading.
Based on this information, what are the probable reasons each of
these patients visited Dr. Hill today?

Quality Assurance and Quality Control in Urinalysis
The U.S. Food and Drug Administration (FDA) categorizes the
chemical analysis of urine performed by an instrument or a reagent
strip as a CUA-waived test. The chemical analysis includes the
reagent strip (dipstick) tests for bilirubin, glucose, hemoglobin or
blood, ketones, leukocyte esterase, nitrite, pH, protein, specific
graviry, and urobilinogen. A commercially available control strip
should be used to determine the reliability of the reagent strips used
in chemical analysis. One such control strip is the Chek-Stix. The
plastic control strip has seven pads, each of which contains synthetic
ingredients that mimic human urine when reconstituted in water.
After reconstitution, a reagent test strip is immersed in the control
solution and the results are compared with a chart that accompanies
the Chek-Stix. Both positive and negative Chek-Stix controls are
available (Procedure 28-4). The positive reconstituted control shows
positive (abnormal) results when a test strip is inserted and read,
whereas the negative reconstituted control shows normal urinalysis
results along its test strip. It is important to observe and record the
abnormal and normal results produced by the positive and negative
controls. Also, make sure the test results are consistent with the
Chek-Stix charts provided by the manufacturer before testing urine
specimens.

ID: __ Erika Sea9er __

11-16-XX 5:37 PM

CLARITY: Clear
COLOR: YELLOW

MULTISTIX 10 SG

GLU NEGATIVE
BIL NEGATIVE
KET NEGATIVE
SG 1.025
BLO TRACE -LYSED
pH 5.5
PRO NEGATIVE
URO 0.2 E.U./dl
NIT NEGATIVE
LEU NEGATIVE

B
FIGURE 28-9 A, Clinitek 50 Urine Chemistry Analyzer. The reagent strip is placed on the tray before the test is begun. B, Sample of the Clinitek
results.
 CHAPTER 28 Assisting in the Analysis of Urine 713

Perform Quality Control Measures: Differentiate Between Normal and Abnormal Test
PROCEDURE 28-4
Results while Determining the Reliability of Chemical Reagent Strips

Goal: To reconstitute acontrol sample and test the reliability of the urinalysis chemical testing strip.

EQUIPMENT and SUPPLIES PURPOSE: The control strips have chemicals that you should not handle
• Chek-Stix Control Strips with reference ranges for urinalysis or contaminate with your hands. Any mottling or discoloration may
• Distilled water mean that the strips have been exposed to moisture, light, or solvents.
• Capped tube with milliliter markings Improperly stored control strips should not be used.
• Test tube rack 6. Place the strip into the water and tightly cap the tube.
• Forceps 7. Invert the tube for 2 minutes.
• Timer PURPOSE: Chemicals embedded in the pads must be thoroughly dissolved
• Urine chemical strips for urine testing in the water.
• Color chart for interpreting the chemical strip results 8. Allow the tube to sit in the rack for 30 minutes.
• Fluid-impermeable lab coat and disposable gloves 9. Invert the tube one time and remove the strip with forceps.
• Biohazard waste container 10. Discard the strip in the biohazard waste container. Once reconstituted, the
• Control reference sheet and control flow sheet control solution is stable for 8 hours at room temperature.
PURPOSE: To ensure infection control.
PROCEDURAL STEPS 11. Perform quality control of the chemical reagent strip by dipping it into
1. Assemble the equipment and supplies. Record the lot number and the the control solution according to Procedure 28-4.
expiration date of the Chek-Stix on the control log sheet. 12. Read and record the results.
PURPOSE: Chek-Stix cannot be used if the expiration date has passed. 13. Compare the results with the control reference ranges provided on the
Recording the lot number and expiration date is an important part of Chek-Stix package insert.
quality assurance. PURPOSE: Results should fall within a given range provided by the manu-
2. Sanitize your hands. Put on the fluid-impermeable lab coat and disposable facturer. If they do not, the chemical reagent strips cannot be used to test
gloves. patients' urine.
PURPOSE: To ensure infection control. 14. Discard the chemical reagent strip and the control solution in the biohazard
3. Place a conical tube in the rack and remove the cap. waste container.
4. Pour 15 ml of distilled water into the tube. 1S. Clean up the work area, remove lab coat, and discard gloves in the
S. Using forceps, remove one strip from the Chek-Stix bottle. Inspect the biohazard waste container, and sanitize your hands.
strips for mottling or discoloration. PURPOSE: To ensure infection control.

Obtain a Specimen and Perform a CUA-Waived Urinalysis: Test Urine with Chemical
PROCEDURE 28-5
Reagent Strips

Goal: To perform chemical testing on aurine sample and to reassure the patient of its accuracy.

EQUIPMENT and SUPPLIES PURPOSE: Proper specimen identification and screening of specimens for
• Patient's record appropriate collection containers and collection procedures prevent testing
• Urine specimen of inappropriate specimens.
• Reagent strips 3. If the specimen has been refrigerated, allow it to warm to room
• Timer temperature.
• Fluid-impermeable lab coat and disposable gloves PURPOSE: Certain tests are temperature dependent. Testing of cold speci-
• Biohazard waste container mens may cause false-negative results.
4. Check the reagent strip container for the expiration date.
PROCEDURAL STEPS PURPOSE: Do not use expired reagents.
1. Sanitize your hands. Put on the fluid-impermeable lab coat and nonsterile S. Remove the reagent strip from the container. Hold it in your hand or place
gloves. it on a clean paper towel. Recap the container tightly.
PURPOSE: To ensure infection control. PURPOSE: Test strips are sensitive to moisture and light and must be
2. Check the time of collection, the container, and the mode of stored in tightly sealed containers. Contamination from chemical residues
preservation. on countertops can affect results.
I; ;mi,m);jf.f:Ii -continued
6. Compare nonreactive test pads with the negative color blocks on the color
chart on the container.
PURPOSE: Discolored pads indicate that the product has not been properly
stored and must not be used for testing.
7. Thoroughly mix the specimen by swirling.
PURPOSE: If settling occurs, certain elements may not be detected.
8. Following the manufacturer's directions, note the time, dip the strip into
the urine, and then remove it.
PURPOSE: Tests are time dependent. Some pads darken over time.
9. Quickly remove the excess urine from the strip by pulling the back of the 1
strip across the lip of the specimen container and then blotting the edge
of the strip on a paper towel or the side of the specimen container. two reagent pads closest to your hand with the bottom two rows of the
PURPOSE: Excess urine on the strip or prolonged dipping time affects test color chart (Figure 2). Continue reading and recording each row of possible
results. results with its appropriate reagent pad at its designated time.
10. Hold the strip horizontally (Figure 1). At the required time, compare the PURPOSE: Timing is critical. Allowing the strip to come in contact with
strip with the appropriate color chart on the reagent container. Do not the bottle contaminates the bottle.
touch the strip to the bottle. 13. Clean the work area and remove gloves. If a paper towel was used,
11. Alternately, the strip can be placed on a paper towel. dispose of it, the reagent strip, and the gloves in the biohazard container.
PURPOSE: Holding the strip horizontally prevents runover from one test Remove lab coat and sanitize your hands.
pad to another and prevents interference from mixing of chemicals in the PURPOSE: To ensure infection control.
test pads. 14. Document the results in the patient's record, and reassure the patient of
12. Read and record the first two results 30 seconds after dipping the strip the accuracy of the test results.
(the indicated time to read the "Glucose" and "Bilirubin"). Compare the PURPOSE: Aprocedure is considered not done until it is recorded.

SIEMENS • • •• •••••• ••
•
• • • • ••••
Multistix® 10 SG • •• •• ••• • ••
• • • • ••• •••••
Reagent Strips for Urinalysis • • • • • • •• • •
• • • • ••• • •••
• • • • • ••• •••
• • • •• • •• • •
• •• • ••
12)TESTS AND READING TIME
NEGATIVE

- TRACE

lllil ~Positive____..,..
LARG E

- - -- -- --
m60s NEGATIVE (Any degree of uniform
pink color) -

1--
a:: - 60
0.2 NORMAL 1 mg/dLURINE 2 4 8
(1 mg - approx.1 EU)
s

-
2 000

~ m60. 0.30 100 300

-- - - -- -- -- --
NEGATIVE TRACE mg/dl
' #

u 1160s
5.0 6.0 6.5 7.0 7.5 8.0 8.5

NON-HEMOLYZED HEMOLYIED

a:: 1!1160 L{RjE

-- - -- -- -- -- --
SM:LL MOD+\RATE
NEGATIVE TRACE TRACE

0 m45s 1.000 1.005 1.010 1.015 1.020 1.025 1.030

...J TRACE SMALL MODERATE "+--LARGE_____.,.

0 1140 s
NEGATIVE mg/dL 5 15 40 80 160

u m30s SMALL MODERATE LARGE

- ----
NEGATIVE

1/10(tr.) 1/4 1/2 1

lllil
2ormore

l!!hos NEGATIVE g/dl('lb) 100 250 500 1000 2000ormore

mgldl

~IDBAND Replace cap immediately and tightly.

2 IMI ~\ef:;~e~f~i~i:~~~i;~~;~~~nI,n~Y 10591-5097 USA www.siemens.com/poc 11065546 Rev. A

(©Siemens Healthcare 2016. Used with permission.)


Microscopic Preparation and Examination of
Urine Sediment
Microscopic examination of urine consists of categorizing and
counting cells, casts, crystals, and miscellaneous constituents in the
sediment obtained after a measured portion of urine is centrifuged.
Many formed elements are found in the urine. Some are significant,
and others are not. Most important, the microscopic examination
should correlate with the physical and chemical analyses. For
example, if the physical examination of the urine appeared pink or
red tinged, and the reagent strip tested positive for blood, then one
would look for red blood cells during the microscopic examination.
Medical assistants should be familiar with the preparation of
urine specimens for this test and with the possible test results
(Procedure 28-5).
Microscopic Preparation of Urine
To perform the microscopic UA procedure, a laboratory must be
certified to perform CUA Provider Performed Microscopy Pro-
cedures (PPMPs), a subcategory of CUA moderate-complexity
laboratories. Quality assurance is as important in the microscopic
examination as in the chemical analysis of urine. To ensure consis-
tency and standardization, commercially available systems can be
•;;m,inmjfJ:il Prepare a Urine Specimen for Microscopic Examination
Goal: To prepare aurine specimen for the provider's microscopic examination to determine the presence of normal and abnormal
elements.
EQUIPMENT and SUPPLIES
• Patient's record
• Urine specimen
• Centrifuge tube
• Centrifuge
• Disposable pipet
• Sedi-Stain
• Microscope slide and coverslip
• Microscope
• Permanent marker
• Fluid-impermeable lab coat and disposable gloves
• Face protection
• Biahazard waste container
PROCEDURAL STEPS
1. Sanitize your hands. Put on the fluid-impermeable lab coat and disposable
gloves.
PURPOSE: Ta ensure infection control.
2. Gently mix the urine specimen by swirling the covered specimen
container.
PURPOSE: If the urine is not well mixed, elements that have settled to
the bottom of the specimen container will be missed.
3. Pour l Oml of urine into a labeled centrifuge tube and cap the tube.
CHAPTER 28 Assisting in the Analysis of Urine 715
used, such as the KOVA System or the UriSystem. These systems
may include specially designed, graduated centrifuge tubes with
devices or pipets that allow easy decanting of supernatant and reten-
tion of an exact amount of sediment. They also use specially designed
plastic slides with wells or coverslips that accept only a given amount
of sediment. Control solutions containing preserved cells to be iden-
tified are also available from KOVA. Whatever system is used, the
Clinical and Laboratory Standards Institute (CLSI) recommends the
following:
• The urine volume should be 12 mL.
• The specimen should be centrifuged for 5 minutes at a
relative centrifugal force of 400 g (i.e., 400 times normal
gravity).
• A standardized slide should be used to view the sediment.
• A consistent reporting format should be used.
When a urine sample is centrifuged, the clear upper portion of
the specimen is called the supernatant. It is poured off, and a drop
of the well-mixed sediment at the bottom of the centrifuged tube is
examined under a microscope. The sediment may be stained to give
greater contrast to the formed elements. The stain assists in the
identification of formed elements by enhancing the detail of internal
cellular structure.
4. Place the tube in the centrifuge (Figure l).
(From Stepp CA, Woods MA: Laboratory procedures for medical office personnel, Philadelphia, 1998,
Saunders.)
S. Place another tube containing l Oml af urine or water in the opposite
cup.
PURPOSE: For proper operation, centrifuges must be carefully balanced.
If not properly balanced, damage to the instrument can occur.
6. Secure the lid and centrifuge for 5 minutes ar for the time specified for
your instrument.
716 UNIT FOUR DIAGNOSTIC PROCEDURES
•ijm1iji11mjf;:jj -continued
PURPOSE: Timing varies according to the speed and the size of the
centrifuge head.
7. Remove the tube from the centrifuge after the instrument has come to a
full stop.
8. Pour off the clear supernatant from the top of the specimen by inverting
the centrifuge tube over the sink drain while allowing the running water
from the faucet to flush the urine down. Turn the tube upright when the
supernatant has been decanted, allowing a small amount to return to
the sediment on the bottom of the tube without losing sediment down
the drain (Figures 2 and 3).
PURPOSE: The sediment will be examined under the microscope.
2 S.
3 materials in the biohazard waste container. Remove lab coat and sanitize
9. Thoroughly mix the sediment with a drop of Sedi-Stain by grasping the
tube near the top and rapidly flicking it with the fingers of the other hand
until all sediment is thoroughly resuspended.
PURPOSE: Elements centrifuge at different rates. Failure to mix the entire
sediment completely results in quantification errors. Sedi-Stain colors the
sediment for easier viewing.
Microscopic Examination of Urine
The examination of urine is not categorized as CUA waived; there-
fore, it cannot be performed by a medical assistant without addi-
tional training and rigid compliance with CLIA quality assurance
protocols for the laboratory, including periodic proficiency testing.
The three main categories of microscopic findings are casts, cells,
and crystals.
Casts
Casts are formed when protein accumulates and precipitates in the
kidney tubules and is washed into the urine. The protein takes on
10. Transfer 1 drop of sediment to a clean, labeled slide using a clean, dispos-
able transfer pipet.
11. Place a clean coverslip over the drop and place the slide on the microscope
stage. Remove face protection.
Note: The remaining steps typically are performed by the trained
healthcare provider.
1. Focus under low power and reduce the light.
PURPOSE: Mucus and casts are easily missed if reduced light is not used.
Constant focusing helps locate them.
2. First, scan the entire coverslip for abnormal findings.
PURPOSE: Casts tend to migrate to the edges of the coverslips.
3. Examine five low-power fields. Count and classify each type of cast seen,
if any, and note mucus if present.
PURPOSE: Choose five fields so that one is selected from each corner of
the coverslip and the last one is chosen from the middle of the coverslip.
If you move to an area and nothing is there, record a zero.
4. Switch to high-power magnification and adjust the light.
PURPOSE: As magnification increases, more light is needed.
In five high-power fields, count the following elements: red blood cells, white
blood cells, and round, transitional, and squamous epithelial cells.
6. In the same five fields, report the following as few, moderate, or many:
crystals (identify and report each type seen separately), bacteria (identify
as rods or cocci), sperm, yeast, and parasites.
PURPOSE: "Few," "moderate," and "many" are more easily and univer-
sally understood than are exact numbers.
7. Average the five fields and report the results.
8. Disinfect work area and remove gloves. Dispose of them and contaminated
your hands.
9. Document the results in the patient's record.
PURPOSE: Aprocedure is not considered finished until it is recorded.
the size and shape of the tubules; hence the term casts. Casts are
cylindric, with flat or rounded ends, and are classified according to
the substances observed in them. Certain types of casts are associated
with renal pathologic conditions; others are physiologic and are
generally caused by strenuous exercise. Because casts dissolve in
alkaline urine on standing, examination of a fresh urine specimen is
very important.
Hyaline casts are pale, transparent, cylindric structures that have
rounded ends and parallel sides (Figure 28-10). Hyaline casts will be
missed entirely if the light is not reduced at the condenser. They are
formed when urine flow through individual nephrons is diminished.

((
,.
• FIGURE 28-12 Red blood cell casts. (From Stepp CA, Woods MA: Laboratory procedures for
FIGURE 28-10 Hyaline casts. (Brightfield; x200.) (From Brunzel NA: Fundamentals of urine
and body fluid analysis, ed 3, Philadelphia, 2013, Saunders.)
'· .
. .
•
f :} .. ,
. .
,,. i .. ~•, .
FIGURE 28-11 White blood cell casts. (From Stepp CA, Woods MA: Laboratory procedures for
medical office personnel, Philadelphia, 1998, Saunders.)
They can be found in the urine of individuals with kidney disease,
but also in the urine of people without such disease who have exer-
cised heavily. Occasionally, hyaline casts have granular or cellular
inclusions.
White blood cell casts are hyaline casts that contain leukocytes.
White blood cells usually have a multilobed nucleus; this differenti-
ates them from renal tubular epithelial cells, which have single,
round nuclei. White blood cell casts are seen in pyelonephritis
(Figure 28-11 ).
Red blood cell casts always indicate a pathologic condition and
are highly diagnostic. These casts occur in glomerulonephritis.
They are hyaline casts with embedded red cells, and their presence
indicates damage to the glomerular membrane. They may appear
brown as a result of the color of the red blood cells present
(Figure 28-12).
Renal tubu/,ar epithelial cell casts contain embedded renal tubular
epithelial cells. These casts are easily confused with white blood
CHAPTER 28 Assisting in the Analysis of Urine 717
•
medical office personnel, Philadelphia, 1998, Saunders.)
.
FIGURE 28-13 Renal tubular cell cast, seen with brightfield microscopy. (Sedi-Stain; x400.)
(From Brunzel NA: Fundamentals of urine and body fluid analysis, ed 2, St Louis, 2004, Saunders.)
....
cell casts, particularly if the cells have started to degenerate. Renal
tubular epithelial cell casts are found when excessive damage has
occurred in the kidney. Causes are shock, renal ischemia, heavy-
metal poisoning, certain allergic reactions, and nephrotoxic drugs
(Figure 28-13).
Finely and coarsely granu/,ar casts may indicate renal disease. On
close examination, granular casts show a hyaline matrix with coarse
or fine granular inclusions. The granules are thought to be caused
by protein aggregation or degeneration of cellular inclusions
(Figure 28-14).
Waxy casts are rarely seen. They appear as glassy, brittle, smooth,
homogeneous structures. They usually are yellowish, have cracks or
fissures, and have squared or broken ends. They are considered to be
degenerated cellular casts and are found in individuals with severe
renal disease (Figure 28-15).
Occasionally more than one type of cell is found in a single cast.
Mixed cellular casts have been reported, and absolute identification
of the cell types present may be difficult.
Cells
Cells found in the urine include epithelial cells, which are derived
from the lining of the genitourinary tract. Red blood cells and white
718 UNIT FOUR DIAGNOSTIC PROCEDURES

~
... ':

'
'-

' , ' I:') ·:

FIGURE 28-14 Granular casts. (From Stepp CA, Woods MA: Laboratory procedures for medical
office personnel Philadelphia, 1998, Saunders.)
.J

'
FIGURE 28-16 Red blood cells in the urine. (From Stepp CA, Woods MA: Laboratory procedures
for medical office personnel, Philadelphia, 1998, Saunders.)

I
I t
I -
.,

fa'
,i-"-'
(

.. . t.,

FIGURE 28-15 Waxy casts. (From Stepp CA, Woods MA: Laboratory procedures for medical office FIGURE 28-17 Yeast in the urine. (From Stepp CA, Woods MA: Laboratory procedures for medical
personnel, Philadelphia, 1998, Saunders.) office personnel, Philadelphia, 1998, Saunders.)

blood cells are derived from the bloodstream. Cells are classified and
counted under high-power magnification.
Red blood cells may enter the urinary tract at any point of inflam-
mation or injury. They may be found in normal urine in small
numbers. Persistent hematuria should be investigated. Red blood
cells are pale, round, nongranular, and flat or biconcave (Figure
28-16). They are smaller than white blood cells and have no nucleus.
In hypotonic (dilute) urine, they swell and burst. In hypertonic (con-
centrated) urine, they may crenate and wrinkle.
Yeast cells in the urine may indicate vaginal contamination or
infection of the urine with yeast (Figure 28-17). Yeast is common in
..
the urine of patients with diabetes. Yeasts are easily confused with
red blood cells; they usually are oval and may show budding.
White blood cells, also called leukocytes, occasionally may be found
in normal urine, but increased numbers are associated with a UTI FIGURE 28-18 Alarge squamous epithelial cell (left arrow) and a white blood cell (right arrow).
or with vaginal contamination of the specimen during collection. (Unstained; x640.) (From Ringsrud KM, Linne JJ: Urinalysis and body fluids: a color text and arias,
White blood cells are larger than red blood cells, have a granular St Louis, 1995, Mosby.)
appearance, and usually have a mu!tilobed nucleus, although nuclear
detail may not be evident. Most white blood cells in the urine are
neutrophils (Figure 28-18).

Squamous epithelial cells line the lower portion of the genitouri-
nary tract. When present in large numbers in female patients, they
usually indicate vaginal contamination. Squamous epithelial cells are
large, flat, irregular cells. They have a single, small, round, centrally
located nucleus and often occur in sheets or clumps. Because of their
flat nature, the edges of the cells often are rolled or folded (see
Figure 28-18).
Transitional epithelial cells line the urinary tract from the renal
pelvis to the upper portion of the urethra. They vary from slightly
larger than a round epithelial cell to smaller than a squamous epi-
thelial cell. They are round or oval and may have a tail. Occasionally,
rwo nuclei are seen. When transitional cells are present in large
numbers, a pathologic condition may exist (Figure 28-19).
Renal tubular or round epithelial cells are somewhat larger than
white blood cells, are round or oval, and have a nucleus that is single,
large, oval, and sometimes eccentric. A few may be found in normal
urine specimens, but their presence in increased numbers indicates
tubular damage (Figure 28-20).
To describe epithelial cells, it is helpful to remember the
appearance of eggs: Squamous cells resemble fried eggs with a
large nuclear "yolk" surrounded by the runny whites; transitional
cells are much smaller and resemble poached eggs; and renal
FIGURE 28-19 Cluster of small, unstained transitional epithelial cells. (x400.) (From Ringsrud
KM, Linne JJ: Urinalysis and body fluids: acolor text and aHas, St Louis, 1995, Mosby.)
...
FIGURE 28-20 Renal epithelial cell (arrow). (Sedi-Stain; x400.) (From Ringsrud KM, Linne JJ:
Urinalysis and body fluids: acolor text and aHas, St Louis, 1995, Mosby.)
CHAPTER 28 Assisting in the Analysis of Urine 719
tubular round epithelial cells resemble hard-boiled eggs that have
been cut in hal£
Crystals
Crystals are common in urine specimens, particularly if the speci-
men has been allowed to cool. Cooling causes solid crystals to pre-
cipitate out of the urine, which changes the urine's appearance
from clear to cloudy. The presence of most crystals is not clinically
significant unless the crystals are found in large numbers. With
only very rare exceptions, abnormal crystals are seen in acidic
urine. Abnormal crystals may be of metabolic origin and are
present because of certain disease states or an inherited metabolic
condition, or they may be of iatrogenic origin and are present as
a result of medication or treatment. Identification of crystals
begins with determination of the pH of the urine to ascertain
whether the sample is acidic or alkaline. Next, the color, shape,
and refractivity are observed. Often a history of medication intake
and recent diagnostic testing is helpful.
Crystals are reported as occasional, few, moderate, or many per
high-power field (Table 28-5). At times crystals can be amorphous
(lacking a defined shape). Amorphous urates (Figure 28-21 ) are salts
of uric acid and are seen as shapeless granulation in acidic urine.
-!,;
a,y,, ·-·~
, ~· 1 ~
•' , ., ;"(:,,•,,
...
I
FIGURE 28-21 Amorphous urates. (x400.) (From Ringsrud KM, Linne JJ: Urinalysis and body
fluids: a color text and atlas, St Louis, 1995, Mosby.)
FIGURE 28-22 Amorphous phosphates. (x400.) (From Ringsrud KM, Linne JJ: Urinalysis and
body fluids: acolor text and aHas, St Louis, 1995, Mosby.)
 --.I
~
0

C
z
::::j
TABLE 28-5 Normal and Abnormal Crystals Found in the Urine
iB
C
NORMAL CRYSTALS ABNORMAL CRYSTALS ::ICI

ACID URINE ALKALINE URINE Cl

~

,
Calcium oxalate* Ammonium biuratet Sulfonamide :z
0
.... ~
c.=5
~
.l ""CJ
:::0
0
C")
m

,
Cl
C:
:::0
m
en
,t

~
Uric acidt Triple phosphate* Cholesterol*

,
0

•
*From Stepp CA, Woods MA: Laboratory procedures for medical office personnel, Philadelphia, 1998, Saunders.
1From Brunzel NA: Fundamentals of urine and body fluid analysis, ed 3, Philadelphia, 2013, Saunders.

Amorphous phosphates (Figure 28-22) are found in alkaline urine
and are seen as fluffy white precipitate. Amorphous crystals often are
so profuse they obscure other formed elements in the sediment.
Frequently crystals are difficult to identify without additional chemi-
cal testing, such as solubility testing in acid and base.
Miscellaneous Findings
Oval fat bodies are formed when renal tubular epithelial cells or
macrophages absorb fats. The fat droplets in the cells vary in size.
They are characteristic of kidney distress (Figure 28-23).
A few bacteria may be found in normal urine specimens. Heavy
bacterial concentrations in the absence of white blood cells may
indicate that the specimen was allowed to sit at room temperature
and the bacteria multiplied. Urine specimens with a putrid odor,
numerous white blood cells, and bacteria (Figure 28-24) are common
in UTis. The bacteria may be bacilli (rod shaped) or cocci (spherical)
and are seen under high-power magnification. They are often motile
(moving).
Spermatozoa can be found in the urine specimens of both male
and female patients. In the latter case, their presence represents
FIGURE 28-23 Small cluster of oval fat bodies. (Unstained; x400.) (From Ringsrud KM, Linne
JJ: Urinalysis and body fluids: acolor text and a#as, St Louis, 1995, Mosby.)
FIGURE 28-24 Numerous small bacteria (arrows) and white cells (WB(). (Unstained; x400.)
(From Ringsrud KM, Linne JJ: Urinalysis and body fluids: acolor text and atlas, St Louis, 1995, Mosby.)
CHAPTER 28 Assisting in the Analysis of Urine 721
vaginal contamination of the specimen. Sperm usually have pointed,
oval heads and long, threadlike tails. They may be motile in fresh
urine.
Trichomonas vaginalis is the most commonly encountered parasite
in urine (Figure 28-25). It is usually a vaginal contaminant but may
also be found in urine specimens from male patients. When urine
is fresh and warm, Trichomonas organisms may be motile and may
dart about rapidly when seen under the microscope. Trichomonas
organisms are pear-shaped protozoa with four flagella. They are
larger than round epithelial cells but smaller than squamous cells.
Trichomonas organisms die when the specimen is cooled.
Mucous threads can be found in most urine specimens. They
appear as pale, irregular, threadlike structures with tapered ends.
Beginners often confuse hyaline casts with mucous threads. Increased
numbers are seen with inflammation and in specimens contaminated
with vaginal secretions (Figure 28-26).
Artifacts and contaminants often are found in urine sediment.
Training is required to differentiate them. Fibers are common in the
sediment and come from clothing, diapers, or digested plant mate-
rial. Clothing fibers often are long and twisted and sometimes are
FIGURE 28-25 Trichomonas organisms (arrow) in the urine. (From Stepp CA, Woods MA: Labora-
tory procedures for medical office personnel, Philadelphia, 1998, Saunders.)
FIGURE 28-26 Mucous threads in the urine. (From Stepp CA, Woods MA: Laboratory procedures
for medical office personnel, Philadelphia, 1998, Saunders.)
722 UNIT FOUR DIAGNOSTIC PROCEDURES
FIGURE 28-27 Diaper fibers. (From Brunzel NA: Fundamentals of urine and body fluid analysis,
ed 3, Philadelphia, 2013, Saunders.)
FIGURE 28-28 Plant fiber from fecal contamination; cells and bacteria also are present. (x400.)
(From Ringsrud KM, Linne JJ: Urinalysis and body fluids: acolor text and affas, St Louis, 1995, Mosby.)
~-
FIGURE 28-29 Fiber, probably hair (left); waxy cast (right). (Sed~Stain; x400.) (From Ringsrud
KM, Linne JJ: Urinalysis and body fluids: acolor text and affas, St Louis, 1995, Mosby.)
FIGURE 28-30 large air bubble. (x400.) (From Ringsrud KM, Linne JJ: Urinalysis and body
fluids: a color text and atlas, St Louis, 1995, Mosby.)
colored. Diaper fibers can be confused with casts (Figure 28-27).
Plant fibers appear in the urine as a result of fecal contamination
(Figure 28-28). Hair is distinguishable not only because of the
visible rough and fragmented cuticle, but also because of the size
(Figure 28-29). Air bubbles are common if the coverslip was improp-
erly placed over the sediment. Air bubbles are structureless and
refractile (refracting light causing a glow) and have a dark outline
(Figure 28-30).
Interpretation of the Microscopic Examination
The medical assistant should understand how the microscopic find-
ings of the sediment are reported. First, the sediment is examined
under the low-power objective and low light to locate casts, which
generally are found around the edges of the coverslip. Ten to 15
low-power fields are scanned, and the number of casts is counted
and reported. The high-power objective and increased light then are
used to identify red and white blood cells, epithelial cells, yeasts,
bacteria, and crystals. From 10 to 15 high-powered fields should be
scanned and the number counted, averaged, and reported. The
method of counting varies considerably among laboratories. It is
important that all workers in the same laboratory use the same
counting and reporting systems. The results of the microscopic
examination are reported as follows:
1. The numbers for each element are counted, then averaged. Casts,
white blood cells, red blood cells, and the three categories of
epithelial cells are counted, totaled, and averaged. Casts, white
blood cells, and red blood cells are reported using numeric ranges
based on the average:
0
0-1
1-2
2-5
5-10
10-20 and so forth
TNTC: too numerous to count
 CHAPTER 28 Assisting in the Analysis of Urine 723

Epithelial cells are reported as occasional, few, moderate, or many,

as follows: Additional Tests Performed on Urine
Clinitest
0 The glucose test on the reagent strip detects only glucose, the most
0-3 Occasional common sugar found in the urine. However, sugars other than
glucose also can appear in the urine. Certain metabolic disorders
3-6 Few can result in the excretion of sugars such as galactose, fructose,
6-12 Moderate lactose, maltose, or pentose. Galactosemia, a rare pathologic condi-
~12 Many tion, is a congenital deficiency in the body's ability to metabolize
galactose to glucose; galactosemia results in excretion of galactose
2. The remaining elements are estimated as occasional few, moderate, in the urine. Seen in infants, it results in failure to thrive, vomiting,
or many, as follows: and diarrhea. If detected early, galactose can be eliminated from the
diet, and the child develops normally. Lactose may be found in
Occasional Not seen in every field the urine of pregnant women or premature infants. Maltose may
be excreted in patients with diabetes. Of the many sugars, only
Few Covers less than a quarter of the field the presence of glucose or galactose signifies possible pathologic
Moderate Covers approximately half af the field conditions.
The Clinitest, which is based on the chemical reduction of
Many Covers the entire field
copper, is commonly used to screen for and confirm glucose and/
or to detect other sugars (e.g., galactose in infants) (Procedure
28-7). Copper reduction tests are based on the principle that
reducing substances can chemically convert cupric sulfate to
CRITICAL THINKING APPLICATION 28-5
cuprous oxide, resulting in a color change. A sugar's reducing
After centrifuging the three urine specimens, Rosa prepares the slides for ability is determined by the presence of a "chemical reducing
microscopic examination by a physician. She has learned to correlate the group" present in all simple sugars (monosaccharides). The Clinit-
findings from the physician's microscopic findings with the chemical exami- est tablet is dropped directly into a test tube containing diluted
nations she has already performed an these specimens. She reviews the urine. A heat-releasing reaction occurs, and the color of the tube's
final results and notes that Mr. Parks's and Mrs. Carpenter's specimens were contents is observed during and after the boiling stops. It is
clear and they had no abnormal microscopic results. Ms. Hillman's specimen compared with a chart provided by the manufacturer. Note: If
was turbid, and Rosa's chemical results showed an alkaline pH, an elevated the color change shows a pass-through that reaches the orange
nitrite level, and an elevated leukocyte esterase reading. What would be maximum color during the reaction and then ends in a lower
color range, the test result is reported as "greater than" the highest
the likely microscopic findings for Ms. Hillman's urine?
positive result.

Obtain a Specimen and Perform a CUA-Waived Urinalysis: Test Urine for Glucose Using
PROCEDURE 28-7
the Clinitest Method

Goal: To perform confirmatory testing for glucose and other simple sugars in the urine using the Clinitest procedure for reducing
substances.

EQUIPMENT and SUPPLIES PROCEDURAL STEPS

• Patient's record 1. Sanitize your hands. Put on the fluid-impermeable lab coat and disposable
• Urine specimen gloves.
• Clinitest tablet, tube, and dropper 2. Holding a Clinitest dropper vertically, add l Odrops of distilled water and
• Distilled water then 5 drops of urine to a Clinitest tube.
• Test tube rack PURPOSE: Holding the dropper vertically prevents alteration of the size
• Color chart of the drops.
• Timer 3. Place the prepared tube in the rack (Figure 1).
• Fluid-impermeable lab coat and disposable gloves PURPOSE: The tube will become too hot to hold after the tablet is placed
• Biohazard waste container in the tube.
724 UNIT FOUR DIAGNOSTIC PROCEDURES
4. Remove a Clinitest tablet from the bottle by shaking a tablet into the
bottle cap. ( First, make sure your hands are dry and gloved.)
PURPOSE: Clinitest tablets react with moisture and became caustic.
Handling tablets with moist hands could result in hydroxide burns.
S. Tap the tablet into the test tube and recap the container.
6. Observe the entire reaction to detect the rapid pass-through phenomenon,
which indicates that the glucose level in the urine is very high (see Note
in step 8).
PURPOSE: If pass-through occurs but is not detected, the reading will be
falsely low.
7. When boiling stops, time exactly 15 seconds and then gently shake the
tube to mix the entire contents.
8. Immediately compare the color of the specimen with the five-drop color
chart and record your findings (Figure 2).
Urine Pregnancy Testing
All pregnancy tests detect the presence of human chorionic gonad-
otropin (hCG), a hormone produced by the placenta and present
in urine during pregnancy (Procedure 28-8). After the fertilized egg
has implanted in the uterus, the hCG levels in serum double every
few days. This rapid rise occurs for approximately 7 weeks, and then
the level begins to decline. Within 72 hours of delivery, the hormone
disappears.
The most common type of test for pregnancy is the lateral flow
immunoassay test. Many brands are available for laboratory use and
are also available over the counter for home use. These tests can be
sensitive enough to detect the presence of hCG as early as 1 week
after implantation or 4 to 5 days before a missed menstrual period.
The tests can be performed in as little as 5 minutes, and the results
are easy to interpret; usually as easy as reading a color change. For
optimum results, the test should be performed on the first morning
voided specimen because of its higher concentration.
Note: If an orange color briefly develops during the reaction and then converts
to a lower, darker color, rapid pass-through has occurred, meaning that the
glucose was greater than the highest reading; this is recorded as "greater than
2%."
PURPOSE: For accurate results, time carefully because all the final color
results continue to darken over time.
9. Record the results.
10. Clean up the work area, remove your gloves and fluid-impermeable lab
coat, and sanitize your hands.
PURPOSE: To ensure infection control.
11. Record the results in the patient's record.
PURPOSE: Aprocedure is not considered finished until it is recorded.
The test is based on reactions that occur between antibodies and
antigens. Antibodies are proteins formed in response to antigens; the
antibody is specific for the antigen (e.g., as with a lock and key).
When antibodies and antigens come in contact, the antibody binds
to the antigen, as long as the two are present in sufficient quantity.
The pregnancy test cartridge contains a membrane with an absor-
bent pad. The urine sample is introduced into the device and wicks
through the absorbent pad, reaching the chromatographic (color
producing) membrane that will change color in two areas. In a posi-
tive sample, the hCG antigen attaches to the antibodies in the test
zone (T) forming a pink line. All samples (positive or negative) cause
the control zone (C) line to turn blue. The presence of this line
indicates that the test has been carried out correctly. If the C control
zone does not show a color reaction, the test is considered invalid
and must be repeated using another test device. The QuickVue test
(see Procedure 28-8) is a lateral flow pregnancy test that can be
performed on urine. It is used routinely in many POLs.
 CHAPTER 28 Assisting in the Analysis of Urine 725

•;m1,a11mjf1:j:• Obtain a Specimen and Perform a CUA-Waived Urinalysis: Perform a Pregnancy Test
Goal: To perform apregnancy test on urine using the QuickVue pregnancy test method.

EQUIPMENT and SUPPLIES 6. Dispose of the pipet in a biohazard container.

• Patient's record 7. Wait 3 minutes and read the test results.
• Urine specimen PURPOSE: To ensure accurate test results, timing must be exact.
• QuickVue test kit 8. Interpret the results as:
• Fluid-impermeable lab coat and disposable gloves • (Figure 3).
• Biohazard waste container • Negative: Ablue control line is next ta the letter C; na line is seen
next to the letter T. (See results below on the left)
PROCEDURAL STEPS • Positive: Ablue control line is next ta the letter C; a pink line is next
1. Sanitize your hands. Put on the fluid-impermeable lab coat and disposable to the letter T. (See results below on the right)
gloves. • Invalid: If a blue line does not appear in the Carea, the test is invalid
2. Prepare the testing equipment (Figure 1). and the specimen must be retested using another kit. Check the expira-
tion date of the kit before proceeding.

3. Collect the specimen (preferably a first morning specimen).

4. Remove the test cassette from the foil pouch.
5. Add 3 drops of urine using the pipet (dropper) that accompanies the kit
(Figure 2).
PURPOSE: To ensure accurate test results, the specimen amount must be
exact.
9. Discard the cassette in the biahazard waste container, remove and discard
gloves in the biohazard waste container, then remove lab coat, and sani-
tize your hands.
PURPOSE: To ensure infection control.
10. Record the results in the patient's record as either positive or negative for
pregnancy.
PURPOSE: Aprocedure is not considered finished until it is recorded.

10/2/20-3:45 PM: Last menstrual period (LMP) 9/16/20-. QuickVue

pregnancy test: Positive. Raso Gonzales, (MA (AAMA)
726 UNIT FOUR DIAGNOSTIC PROCEDURES

Ovulation Testing
CUA-waived lateral flow urine tests are available to assist in the TABLE 28-6 Commonly Abused Drugs and Body
prediction of ovulation for women attempting to conceive either Retention Times
naturally or using artificial insemination. During the menstrual
DRUG RETENTION TIME
cycle, luteinizing hormone (LH) remains at a relatively stable level.
Approximately 14 days before menstruation, the body experiences Alcohol 2-10 hr
the "LH surge," a brief, rapid increase in LH. This surge triggers the
Amphetamine 24-48 hr
release of the ovum from the ovary. Two to 3 days after the surge,
the LH level returns to the base level. Conception is most likely to Methamphetamine 3-5+ days
occur within 36 hours after the LH surge. The principle of this test
is similar to that of the pregnancy test: the reservoir pad contains
Barbiturates
anti-LH antibodies. A positive test result indicates a urine LH level Phenobarbital 2-6 days
of20 mlU/mL or higher. Testing usually is performed for 5 consecu-
tive days in the middle of the cycle. Once the surge is detected,
Secobarbital 24 hr
ovulation can be expected within 2 to 3 days. Cocaine, cocaine metabolites 12 hr-3 days
Menopause Testing Opiates, heroin, morphine 3-4 days
A woman is said to have reached menopause when menstruation has Phencyclidine (PCP) 3-7+ days
not occurred for at least 12 months. The time before menopause,
called perimenopause, can last for years, bringing with it uncomfort- Marijuana (tetrahydrocannabinal metabolites) 2 days-11 wk
able symptoms such as irregular periods, hot flashes, vaginal dryness, Oxycodone 3 days
and sleep problems. Some of this may be due to an increase in
follicle-stimulating hormone (FSH). Levels of FSH, which is pro-
duced by the pituitary gland, increase temporarily each month to
stimulate the ovaries. When a woman enters menopause, the ovaries
stop producing eggs, and the levels of FSH rise. CUA-waived lateral
flow tests detect FSH in the urine. A positive test result indicates
that a woman may be in menopause; a negative test result, along
with symptoms of menopause, may indicate that a woman is in
perimenopause.
The qualitative lateral flow test should never be used to direct a
woman to stop using birth control methods if she does not want to
conceive because pregnancy is still possible during perimenopause.

URINE TOXICOLOGY
Toxicology is the study of poisonous substances and drugs, and their
effects on the body. The clinical laboratory performs testing on body
fluids and tissues to monitor the use of therapeutic drugs such as
antibiotics, anticonvulsants, antidepressants, and barbiturates. They
may also test for poisoning by herbicides, metals, animal toxins, and
poisonous gases (e.g., carbon monoxide).
Laboratory testing for illegal drugs or alcohol is also done, most
commonly for employment, insurance, or as a legal requirement
(Table 28-6). Although blood serum tests are more accurate for
determining current impairment or the time of ingestion, urine is
the specimen of choice for most routine screening procedures to
determine whether an illegal drug is present. For routine screening,
a random specimen is usually collected.
Often, the following safeguards are used to ensure that a speci-
men is fresh and is truly from the patient: water may be temporarily
unavailable in the restroom; bluing agents may be added to the
toilets; a sealed container with a temperature-sensitive strip may be
provided; and someone may accompany the patient into the rest-
room during the collection. In some cases a strict chain of custody
is required; this means that everyone handling the specimen is docu-
mented. The substance for which the test is performed, or its
FIGURE 28-31 Instant-View Drug Test. (Courtesy Alfa Scientific, Poway, California.)
metabolite, often remains in urine much longer than the impairment
or intoxication lasts. This is one reason urine screening is favored
over serum or blood screening.
As a medical assistant, you may be responsible for collecting
specimens for toxicology tests and for performing certain tests.
Rapid drug screening devices are about the size and shape of a credit
card (Figure 28-31 ). The device is dipped into a urine sample, or
urine is directly applied to the device. The results are read according
to the manufacturer's instructions in just minutes. Negative results
indicate that none of the targeted drugs were detected in the urine
sample at specified cutoff levels; inconclusive results indicate that the
device reacted with something in the urine and confirmation testing
is required.
 CHAPTER 28 Assisting in the Analysis of Urine 727

Urine multidrug screening tests are lateral flow chromatographic
immunoassays that test for urine metabolites of a variety of drugs,
including amphetamines, barbiturates, benzodiazepines, cocaine,
morphine, methadone, phencyclidine (PCP), tricyclic antidepres-
sants, marijuana, Ecstasy, methamphetamines, methadone, oxyco-
done, and opiates. Available in cartridges that test two to six drugs,
the test is a competitive binding immunoassay in which drug and
drug metabolites in a urine sample compete with immobilized drug
conjugate for antibody binding sites. By using antibodies specific to
different drug classes, the test permits independent, simultaneous
detection of up to 10 drugs from a single sample in 5 minutes.
In the procedure, urine mixes with a labeled antibody-dye con-
jugate and migrates along a porous membrane. If the concentration
of a given drug is below the detection limit of the test, the antibody-
dye conjugate that did not bind to a drug metabolite binds to
antigen conjugate immobilized on the membrane, producing a rose-
pink band in the appropriate place for that drug. If the level of the
drug in the urine is at or above the detection limit, free drug com-
petes with the immobilized antigen conjugate on the membrane by
binding to the antibody-dye conjugate, forming an antigen-antibody
complex and preventing the development of a rose-pink band
(Procedure 28-9).
Note: Unlike with the lateral flow tests for pregnancy, ovulation,
and menopause, the appearance of a line in the T band during a
drug screening test indicates a negative test result.

Obtain a Specimen and Perform a CUA-Waived Urinalysis: Perform a Multidrug

PROCEDURE 28-9
Screening Test on Urine

Goal: To screen aurine specimen for drugs or drug metabolites at their specified cutoff levels.
EQUIPMENT and SUPPLIES
• Patient's record
• Multi-Drug Screen Urine Test in a sealed container
• Freshly voided urine sample
• Timer
• Fluid-impermeable lab coat and disposable gloves
• Biohazard waste container

PROCEDURAL STEPS
1. Sanitize your hands. Put on the fluid-impermeable lab coat and disposable
gloves.
2. Assemble the equipment and specimen. Check the expiration date on the (Courtesy Alfa Scientific, Poway, Calif.)
test kit. Alternate Method
PURPOSE: An expired test strip may yield inaccurate results. 7. Remove the pipet from the pouch, and fill it to the line on the barrel with
3. Determine the temperature of the urine (within 4 minutes of voiding). urine. Dispense the entire volume onto the sample well on the testing
The temperature should be between 32° and 38° C(90° and 100° F). device (Figure 2).
PURPOSE: If the urine temperature is below or above this range, the PURPOSE: If insufficient urine is available in the cup to use the dip
sample may have been adulterated. Once it has been determined that the method, this method applies urine to the device.
sample is at the correct temperature, it may be stored at roam temperature
for 8 hours or in the refrigerator for up to 3 days before testing.
4. Bring the specimen and the testing device to room temperature.
PURPOSE: Both the specimen and the device must be at room tempera-
ture to ensure accurate results.
S. Remove the device from the foil pouch and label it with the specimen
identification.
Dip Method
6. Remove the cap of the specimen and dip the device into the specimen for
10 seconds, making sure the surface of the urine is above the sample
well and below the arrowheads in the window (Figure 1).
PURPOSE: The pads must be saturated with urine. (Courtesy Alfa Scientific, Poway, Calif.)
728 UNIT FOUR DIAGNOSTIC PROCEDURES
8. Recap the urine specimen.
9. Set the timer for the designated time: 4 to 7 minutes. Do not read the
results until after 7 minutes.
PURPOSE: Correct timing is essential for reliable, accurate results.
10. Interpret the results (Figure 3):
• Positive: If the Cline appears but the Tline does not, the result is
positive for that drug.
• Negative: If both the Cline and the Tline appear, the level of the drug
or its metabolites is below the cutoff level (i.e., negative for that drug).
• Invalid: If no Cline develops within 5 minutes on any test strip, the
assay is invalid. Make sure the urine has not been adulterated (see
Procedure 28-10) and/or repeat the assay with a new test device.
ADULTERATION TESTING AND CHAIN OF CUSTODY
Drug testing has legal ramifications; therefore, additional testing
often is necessary to ensure that samples have not been adulterated
(Procedure 28-10). Adulteration is the intentional manipulation of
a urine sample to allow someone to falsely pass a drug screening test.
It may involve using urine from another person or an animal, dilut-
ing the sample with water, or adding substances such as bleach,
vinegar, eye drops, baking soda, drain openers, soft drinks, or hydro-
gen peroxide.
Urine collection cups with built-in thermometer panels often are
used to ensure that urine has been freshly voided from the bladder.
A temperature of 32° to 38° C (90° to 100° F) within 4 minutes of
collection is expected. Test strips that detect human immunoglobu-
lins (antibodies) in urine can determine whether the specimen is
human in origin and whether it is naturally dilute or has been
diluted. Human immunoglobulin G (IgG) is exclusive to humans
and is always found at certain levels in urine, even if the urine is
naturally dilute. The addition of chemicals to the urine prevents the
IgG reaction on the test strip.
Adulteration test strips are also available that detect creatinine,
nitrite, pH, specific gravity, glutaraldehyde, and oxidants (see
Procedure 28-10).
Creatinine is always present in normal urine because it is excreted
from the body at a constant rate. Low or absent levels indicate
diluted or substituted nonhuman samples. Urine can be diluted if
the person being tested drinks abnormally large amounts of water
before the test or if water or another liquid is added to the sample.
Creatinine levels usually are checked in conjunction with the specific
gravity to screen for dilution or substitution adulteration. Specific
gravity readings also determine whether substances such as table salt
have been added to the urine.
(+) (-)
Positive Negative Invalid
3
11. Discard the urine and the device in the biohazard container.
12. Disinfect the area. Remave your gloves and dispose in biohazard container.
Remove lab coat, and sanitize your hands.
PURPOSE: To ensure infection control.
13. Record the results in the patient's record.
PURPOSE: Aprocedure is not considered complete until it is recorded.
Nitrites are oxidizing substances that react with the drug
or drug metabolite molecules in the urine. Nitrites primarily
interfere with antibody binding in lateral flow tests. Nitrates
must be added to the urine after voiding. Commercial adulter-
ants (e.g., Whizzies, Klear, and UrineLuck) are tablets or powders
that can be added to voided urine. They do not change the
color or temperature of the urine. The level of nitrites found in
urine with gross bacteriuria or from therapeutic drug metabolites
(e.g., nitroglycerin) is below the cutoff for adulteration screening
tests.
The pH of the sample can affect enzymatic and antibody reac-
tions in lateral flow drug tests. Levels higher than 9.5 or lower
than 3 may hamper the enzymatic rate. Alteration of the pH may
also affect the stability of the drug or its metabolite. Adulteration
of a sample with bleach, drain cleaners, or baking soda changes
the pH, but this type of tampering can be detected by an adulter-
ation strip test.
Glutaraldehyde can mask the presence of illegal drugs. Commer-
cially available products such as UrinAid and Clear Choice contain
glutaraldehyde intended to adulterate urine. In addition, a 10%
solution of glutaraldehyde is sold over the counter for the treatment
of warts. This chemical prevents the enzymes in lateral flow tests
from reacting properly.
Sensitivity limits for drug screening are set by the U.S.
Substance Abuse and Mental Health Services Administration
(SAMHSA), the National Institute on Drug Abuse (NIDA), and
the U.S. Department of Health and Human Services (DHHS).
Positive results on urine samples tested for substances should be
confirmed by more specific chemical methods, such as gas chroma-
tography (GC), mass spectrometry (MS), and enzyme-multiplied
immunoassay technique (EMIT).
 CHAPTER 28 Assisting in the Analysis of Urine 729

Chain of Custody Rules

l. The individual being tested must provide photo identification.
2. Indirect observation of specimen collection is important to make sure the
sample is actually provided by the patient being tested. Indirect methods
af observation include:
• Measuring the specimen's temperature
• Securing water faucets in the restroom so that urine cannot be diluted
• Having the patient remove outer clothing and leave personal belong-
ings in the examination room
• Not allowing water to be run or the toilet to be flushed in the restroom
during the collection
Note: If you suspect the sample has been adulterated, ask the patient
to provide another specimen.
3. Within 4 minutes of receiving the specimen, check its temperature (range
should be 32° to 38° C[90° to 100° Fl) and volume (30 to 45 ml
is required), and inspect it for any indications of adulteration (e.g., an
unusual color, the presence of foreign materials).
4. Pour the specimen into aspecimen bottle and seal the lid with the tamper-
evident label/seal provided at the bottom of the chain of custody form
with the donor present; include the date and your initials on the label
(Figure 28-32).
5. Ship the specimen to the testing laboratory as soon as possible; it must
be sent the same day it was collected.
6. Individual results may vary, which can make some results positive at lower
substance levels; also, diet, the volume of urine flow, and the amount of
substance used can alter results.
7. Because of the legal implications of drug testing, chain of custody must
be strictly followed. Each step from collection of the specimen to reporting
of test results to the patient must be strictly monitored. Requirements
include sealed specimen containers; supervised laboratory analysis
throughout the process; and authorized signatures at each step.

•;;m,ammf1:j11• Assess a Urine Specimen for Adulteration before Drug Testing

Goal: To assess aurine specimen for additive adulteration.

EQUIPMENT and SUPPLIES

• Patient's record Abnormal Normal
• Adulterant test strips
• Urine sample (freshly voided; urine should be stored at room temperature
for no longer than 2 hours or at refrigerator temperature for no longer than
Creatinine (mg/dl)
0 10
I I
20 100
4 hours before testing)
• Paper towels
Nitrite (mg/dl) I I 50 100
DI
Neg. 20
• Timer Glutaraldehyde I I I
• Fluid-impermeable lab coat and disposable gloves Pos. Pos. Neg.

• Biohazard waste container pH 11 1 1

2.0 3.0 10.0 11.0 12.0 4.0 7.0
I
9.0
PROCEDURAL STEPS S.G. I II
•
1.000. 21.035 1.003 1.005 1.015 1.025
1. Sanitize your hands. Put on the fluid-impermeable lab coat and disposable

2.
gloves.
Assemble the equipment and the specimen. Check the expiration date on
Oxidant/PCC
Pos.
Ii
Pos. I Neg. Neg.

the test kit.

PURPOSE: An expired test strip may yield inaccurate results. 7. Dispose of the paper towels and the strip in the biohazard container.
3. Remove one strip from the container and recap tightly. 8. Disinfect the area, and remove your lab coat. Remove your gloves and
4. Dip the test strip briefly into the urine and then remove it. dispose of them in the biohazard waste container. Sanitize your hands.
S. Blot the strip by touching the side of the strip to a paper towel. PURPOSE: To ensure infection control.
PURPOSE: Oversaturated strips may not react consistently. 9. Record the results in the patient's record.
6. Read the results within l minute by comparing each pad with the color PURPOSE: Aprocedure is not considered complete until it is recorded.
strips an the canister (Figure l). These results are for the Quik Test Adulter-
ant Strips. Because the monitor color may vary from manufacturer to manu-
facturer, always refer to the specific product's package for accurate color
reference.
PURPOSE: Reading the strip results at the incorrect time may result in error.
730 UNIT FOUR DIAGNOSTIC PROCEDURES

FEDERAL DRUG TESTING CUSTODY AND CONTROL FORM

+ 11111111111111111 111111111111111111111111 1111 +

•
1A
SPECIMEN ID NO.
STEP 1: COMPLETED BY COLLECTOR OR EMPLOYER REPRESENTATIVE
1234567 LAB ACCESSION NO.

A. Employer Name, Address, I.D. No. B. MRO Name, Address, Phone and Fax No.

C. Donor SSN or Employee I.D. No. _ _ _ _ _ _ _ _ _ _ __

D. Reason for Test: D Pre-employment D Random D Reasonable Suspicion/Cause D Post Accident
D Return to Duty D Follow-up D Other (specify) _ _ _ _ _ _ _ _ _ __
E. Drug Tests to be Performed: • THC, coc, PCP, OPI, AMP • THC & COC Only • Other (specify) _ _ _ _ _ _ _ _ _ __
F. Collection Site Address:
Collector Phone No. _ _ _ _ _ _ _ _ _ __

Collector Fax No. _ _ _ _ _ _ _ _ _ _ __

STEP 2: COMPLETED BY COLLECTOR

Read specimen temperature within 4 minutes. Is temperature !Specimen Collection: I "ti
between 90° and 100° F? D Yes D No, Enter Remark D Split D Single D None Provided (Enter Remark) D Observed (Enter Remark) ;u
m

REMARKS
ill
::c
STEP 3: Collector affixes bottle seal(s) to bottle(s). Collector dates seal(s). Donor initials seal(s). Donor completes STEP 5 on Copy 2 (MRO Copy) :i-
;u
STEP 4: CHAIN OF CUSTODY· INITIATED BY COLLECTOR AND COMPLETED BY LABORATORY C
I certify that the specimen given to me by the donor identified in the certification section on Copy 2 of this form was colfected, labeled, sealed and released to the Delivery Service noted in
accordance with applicable Federal requirements.
AM SPECIMEN BOTTLE{S) RELEASED TO: ~
y C
PM
Signature of Collector Time of Collection • :i-
;u
I I m
(PRINT) Collector's Name (First, Ml, Last) Date (MoJDayNr.)
• Name of Delivery Service Transferring Specimen to Lab s:
:i-
RECEIVED AT LAB: Primary Specimen SPECIMEN BOTTLE{S) RELEASED TO: 25
y Bottle Seal Intact z
• I:)
s:
Signature of Accessioner

I I
• Yes C
(PRINT) Accessioner's Name (First, Ml, Last) Date (Mo./DayMr.) • D No, Enter Remark Below !:j
STEP Sa: PRIMARY SPECIMEN TEST RESULTS - COMPLETED BY PRIMARY LABORATORY 'ti
r
m
• NEGATIVE • POSITIVE for: • MARIJUANA METABOLITE • CODEINE • AMPHETAMINE • ADULTERATED 0
• DILUTE • COCAINE METABOLITE • MORPHINE • METHAMPHETAMINE • SUBSTITUTED 0
• REJECTED FOR TESTING • PCP 06-ACETYLMORPHINE • INVALID RESULT "ti
m
C/1
REMARKS _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
TEST LAB (if different from above) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
I certify that the specimen identified on this form was examined upon receipt, handled using chain of custody procedures, analyzed, and reported in accordance with applicable Federal requirements.

Si nature of Certifyin Scientist (PRINT) Certifyin Scientist's Name (First, Ml, Last) Date (Mo./DayMr.)
STEP Sb: SPLIT SPECIMEN TEST RESULTS· (IF TESTED) COMPLETED BY SECONDARY LABORATORY

• RECONFIRMED • FAILED TO RECONFIRM· R E A S 0 " " - - - - - - - - - - - - - - - - - - - -

1certify that the split specimen identified on this form was examined upon receipt, handled using chain of custody procedures, analyzed,
Laboratory Name
and reported in accordance with applicable Federal requirements.
IY I I
Laboratory Address Signature of Certifying Scientist (PRINn Certifying Scientist's Name (First, Ml, Last) Date (Mo./DayMr.)

rrr
w
0..
111111111111 11111 11111 11111 111111111111111111
1234567 A
1234567
SPECIMEN BOTTLE
SPECIMEN ID NO. SEAL

-' 111111111111 11111 11III IIII IIIIII IIIII IIII1111

1234567
w
w
0..
1234567 B SPECIMEN BOTTLE
SPECIMEN ID NO. (SPLIT) SEAL

COPY 1 - LABORATORY

Drua Form Part 1

Face Inks: OOll""BLK / 000 RED
Date: 05/09/00
Not To Use For Colormatch
Follow PMS Guide For Colors

FIGURE 28-32 First page of the five-page Federal Drug Testing Custody and Control Form.

ALCOHOL TESTING
Alcohol testing is not performed on urine, but CUA-waived tests
are available to detect alcohol using saliva. Saliva-based tests have a
high degree of correlation to blood alcohol analysis. The saliva
alcohol test uses a Dacron swab saturated with saliva to detect
ethanol. The test is used primarily for workplace testing, including
the federally mandated testing of transportation workers, but also in
private company "drug-free workplace" programs and by emergency
departments.
CLOSING COMMENTS
Patient Education
Frequently a medical assistant is called on to explain specimen
collection techniques to the patient. Patients want to do the proce-
dure correctly but often lack the knowledge of urinary terminol-
ogy. They may be embarrassed or may not know how to ask
questions about cleaning the genital area. When explaining a
urinary collection procedure, you should use pictures and words
that the patient will understand. As you explain the procedure
in terms the patient knows, he or she will feel comfortable
telling you or asking you about pertinent details that may have
a definite impact on treatment of the problem. Providing the
patient with a clearly written instruction sheet also is helpful. The
instruction sheet should be personalized with the patient's name,
the time to begin collection or testing (if applicable), what sup-
plies should be used, and a phone number to call if questions
arise.
SCENARIO
Rosa's skills in the laboratory analysis of urine are highly valued by Dr. Hill.
When tests are performed in the office laboratory, Dr. Hill has the results
immediately. Dr. Hill's patients also appreciate the convenience of office labora-
tory testing, in which the physical and chemical analyses are performed by Rosa
and other medical assistants. The microscopic analysis is performed by Dr. Hill.
Mrs. Carpenter will find out the results of her pregnancy test without having ta
SUMMARY OF LEARNING OBJECTIVES
l. Define, spell, and pronounce the terms listed in the vocabulary.
Spelling and pronouncing medical terms correctly reinforce the medical
assistant's credibility. Knowing the definitions of these terms promotes
confidence in communication with patients and co-workers.
2. Describe the history of the analysis of urine.
Far centuries, abnormalities in the urine have been recognized as possible
indicators of disruption of homeostasis. During the twentieth century,
urinalysis became a practical laboratory procedure, and today urine is the
most commonly analyzed body fluid in the clinical laboratory.
3. Describe the anatomy and physiology of the urinary tract, and
discuss the formation and elimination of urine by describing the
processes of filtration, reabsorption, secretion, and elimination.
CHAPTER 28 Assisting in the Analysis of Urine 731
Legal and Ethical Issues
Similar to all other procedures, the test is only as valid as the speci-
men and the procedure performed on that specimen. You, as the
provider's agent, are responsible for that validity when you instruct
the patient and when you perform the test.
A medical assistant responsible for office laboratory testing must
clearly understand the basic concepts oflaboratory medicine. There-
fore, you must stay current with the rapid technologic advances in
laboratory medicine and help establish a protocol of the tests best
suited to your provider-employer.
You are responsible for properly collecting specimens and testing
them accurately. In addition, you are responsible for strict adherence
to protocol when collecting and testing specimens when legal rami-
fications are associated with the test results. Patient confidentiality
is paramount when drug testing is performed, as is rigid conforma-
tion to all established rules and regulations.
Professional Behaviors
Attributes of a laboratory professional performing urinalysis include:
• Adiscreet, respectful attitude when communicating with patients,
co-workers, and supervisors
• Good eyesight and manual dexterity
• Accountability, honesty, and integrity when unsure of the
procedure
• Ability to multitask, manage his or her time, pay attention to details,
and problem-solve if test results are suspicious
wait for a call from the laboratory, and UA of Ms. Hillman's (CMS urine sample
will help Dr. Hill diagnose a UTI (urinary tract infection) within minutes. Rosa
knows that the laboratory services and the quality control measures she takes
when performing the complete UA or lateral flow tests are an integral part of
the excellent patient care provided by Dr. Hill.
The urinary tract consists of two kidneys, two ureters, one bladder, and
one urethra. The functional unit of the kidney is the nephron and each
nephron interacts with the blood by filtration, reabsorption, and secretion.
Urine passes from the pelvis of the kidney down the ureter and into the
bladder, where it remains until it is voided through the urethra.
4. Do the following related to collecting a urine specimen:
• Show sensitivity to patients' rights and feelings when collecting
specimens.
Requesting a urine specimen from a patient may be an embarrassing
moment for the patient. The request should be made in private, and
the patient should be given explicit instructions so that he or she
understands what is expected.
Continued
732 UNIT FOUR DIAGNOSTIC PROCEDURES
SUMMARY OF LEARNING OBJECTIVES-continued
• Discuss collection containers.
The most important requirement for a collection container is that it
be scrupulously clean. The physician's office laboratory should provide
the container.
• Explain the various means and methods used to collect urine
specimens.
Some urine collections, such as the 2-hour postprandial specimen,
must be timed around meals or fasts. Routine UA requires no special
preparation, whereas a (CMS requires cleansing of the external geni-
talia. Only urine that will be cultured must be collected in a sterile
container. Urine to be sent to a referral laboratory may require the
addition of preservatives.
• Instruct apatient in the collection of a24-hour urine specimen.
Timed urine specimens are collected to determine the amount of a
particular analyte in the urine during a given time frame. Proper
patient instruction is necessary to obtain an acceptable specimen (see
Procedure 28-1).
• Instruct a patient in the collection of a clean-catch midstream urine
specimen.
Proper patient instruction is necessary for an acceptable (CMS. Both
men and women are given instructions in cleaning the external geni-
talia to prevent contamination of the urine. Urine must be collected
in a sterile container and refrigerated if it cannot be tested within l
hour (see Procedure 28-2).
5. Examine and report the physical aspects of urine.
Physical examination of the urine involves determination of the color,
turbidity, and specific gravity. Odor and foam color also may be noted
(see Procedure 28-3).
6. Perform quality control measures and reassure a patient of the
accuracy of the test results based on the steps taken for quality
assurance and quality control when performing the chemical
urinalysis.
The chemical examination of urine involves determination of the pH level
and the levels of glucose, protein, ketones, blood, bilirubin, urobilinogen,
and nitrite, in addition to specific gravity and leukocyte esterase, using
a reagent strip. The medical assistant should analyze and differentiate
the normal and abnormal control results for the reagent strips before
running the patient's chemical urinalysis (see Procedure 28-4).
7. Test and record the chemical aspects of urine using CUA-waived
methods.
Perform a chemical urinalysis with a chemical reagent strip. The chemical
examination of urine involves determination of the pH level and the levels
of glucose, protein, ketones, blood, bilirubin, urobilinogen, and nitrite, in
addition to specific gravity and leukocyte esterase, using a reagent strip.
CONNECTIONS
OJ Study Guide Connection: Go to the Chapter 28 Study Guide. Read and complete
the activities.
Most chemical urine testing requires reagent strips. It is essential that
these supplies be stored in adark, cool, moisture-free area (see Procedure
28-5).
8. Prepare a urine specimen for microscopic evaluation, and under-
stand the significance of casts, cells, crystals, and miscellaneous
findings in the microscopy report.
Acomplete UA involves physical, chemical, and microscopic assessment.
The results of these three assessments must correlate with one another.
Refer to Procedure 28-6.
9. Explain or perform the following CUA-waived urine tests:
• Glucose testing using the Clinitest method
The Clinitest detects reducing sugars in the urine, including glucose
and galactose. It is superior to the reagent strip test because it detects
sugars other than glucose (see Procedure 28-7) .
• Urine pregnancy test
Pregnancy tests detect h(G, a hormone produced by the placenta.
Urine moves through the test (T) and control (() areas of the test
device by lateral absorption. Anti-h(G antibodies embedded in the test
cartridge bind to hCG in the urine, causing a color change in the test
area (see Procedure 28-8).
• Fertility and menopause tests
Fertility can be assessed using lateral flow tests that detect LH, which
increases in concentration in the urine shortly before ovulation. Meno-
pause can be assessed using lateral flow tests that detect FSH, which
increases as menopause approaches.
• Urine toxicology and drug testing
Drug testing with lateral flow technology is similar to pregnancy
testing except that it uses a competitive binding principle. Unlike with
the pregnancy test, a line in the Tregion indicates a negative test
(see Procedure 28-9).
l 0. List the means by which urine could be adulterated before drug
testing.
Drinking excessive water before urinating, adding water to a urine speci-
men, and adding chemicals or products sold specifically to adulterate
urine all can render a drug test invalid. Adulteration test strips can detect
most methods of adulteration (see Procedure 28-10).
11. Discuss patient education and legal and ethical issues related to
urinalysis.
The medical assistant should always carefully explain urinary collection
procedures to the patient. Providing a clearly written instruction sheet is
also helpful. Amedical assistant who is responsible for office laboratory
testing must clearly understand the basic concepts of laboratory medicine.
He or she is responsible for properly collecting specimens and testing
them accurately.
evolve Evolve Connection: Go to the Chapter 28 link at evolve.elsevier.com/
kinn to complete the Chapter Review Quiz. Check out the other resources listed for this
chapter to make the most of what you have learned from Assisting in the Analysis of
Urine.
ASSISTING IN BLOOD COLLECTION
Leah Barney, arecent graduate of a(MA (AAMA) program, is anew employee
at the Health Alliance Medical Clinic. The class on medical laboratory procedures
was Leah's favorite in her medical assisting program at the community college.
In that class, she learned the principles of phlebotomy and performed several
While studying this chapter, think about the following questions:
• How will Leah know which tubes or which needle size to use?
• How will Leah approach phlebotomy on a child or an elderly person?
• What conditions will require a capillary puncture?
LEARNING OBJECTIVES
1. Define, spell, and pronounce the terms listed in the vocabulary.
2. List the equipment needed for venipuncture.
3. Explain the purpose of a tourniquet, how to apply it, and the
consequences of improper tourniquet application.
4. Explain why the stopper colors on vacuum tubes differ, and state the
correct order of drawing samples for various types of tests.
5. Describe the types of safety needles used in phlebotomy.
6. Explain why a syringe rather than an evacuated tube would be chosen
for blood collection.
7. Discuss the use of safety-engineered needles and collection devices
required for injury protection.
8. Summarize postexposure management of accidental needlesticks.
9. Do the following related to routine venipuncture:
• Detail patient preparation for venipuncture that shows sensitivity to
the patient's rights and feelings.
• Describe and name the veins that may be used for blood
collection.
• List in order the steps of a routine venipuncture.
• Perform avenipuncture using the evacuated tube method.
• Perform a venipuncture using the syringe method.
10. Do the following related to problems associated with venipuncture and
specimen r~ollection:
• Discuss various problems associated with venipuncture.
• Discuss possible solutions ta venipuncture complications.
29
phlebotomy procedures both in the school's laboratory and at her externship
site. Her employer has arranged for Leah to spend time with an experienced
phlebotomist at the clinic so that she is prepared to perform phlebotomy duties
in her new position. Nervous but excited, she begins her training.
• How can Leah make the clinic patients comfortable and at ease?
• How will Leah handle a difficult "stick"?
• Discuss why a specimen may have to be re-collected.
• Describe the major causes of hemolysis during collection.
11. Do the following related to capillary puncture:
• Explain why awinged infusion set (butterfly needle) would be
chosen over avacuum tube or syringe needle.
• Perform avenipuncture using awinged infusion set (butterfly
needle).
• List situations in which capillary puncture would be preferred over
venipuncture.
• Discuss proper dermal puncture sites.
• Describe containers that may be used to collect capillary blood.
• Explain why the first drop of blood is wiped away when a capillary
puncture is performed.
• Perform a capillary puncture.
12. Discuss pediatric phlebotomy, including typical childhood behavior and
parental involvement during phlebotomy and general guidelines for
pediatric venipuncture.
13. Describe handling and transport methods for blood after collection.
14. Explain chain af custody procedures when blood samples are drawn.
15. Discuss patient education, in addition to legal and ethical issues,
related to assisting in blood collection.
734 UNIT FOUR DIAGNOSTIC PROCEDURES

VOCABULARY
anticoagulant An additive that prevents blood from dotting. serum The liquid portion of a dotted blood specimen that no
antiseptic An agent that inhibits bacterial growth and can be used longer contains its active dotting agents.
on human tissue. syncope Temporary loss of consciousness; also known as fainting.
hemoconcentration A condition in which the concentration of thixotropic gel A material that appears to be a solid until
blood cells is increased in proportion to the plasma. subjected to a disturbance, such as centrifugation, whereupon it
hemolysis (he-mah'-lih-sis) The destruction or dissolution of red becomes a liquid gel that separates blood cells from their serum
blood cells, with subsequent release of hemoglobin. or plasma.
phlebotomy The practice of drawing blood from a vein
plasma The liquid portion of a whole blood specimen that has
not dotted due to anticoagulant additives. The plasma still
contains its natural dotting agents.

P hlebotomy is performed primarily to diagnose and to monitor

a patient's condition. According to the American Society of
transferred into the vacuum tube. The procedure is safe when per-
formed by a trained professional, but it must be performed with
Clinical Pathologists (ASCP), nearly 80% of providers' diagnostic care. Much practice is required to become skilled and confident in
decisions are based on the results of laboratory tests, most of which the technique of venipuncture.
are blood tests. Phlebotomy involves highly developed procedures
and equipment to ensure the patient's comfort and safety.
Before the 1960s the diseases found in blood were primarily VENIPUNCTURE EQUIPMENT
vector transmitted (e.g., malaria from mosquitos). Then several Proper collection of blood requires specialized equipment. A com-
blood-borne viral diseases began to emerge that could be spread by plete list of materials used in routine venipuncture is shown in the
exposure of an infected person's contaminated blood to another following box. Phlebotomists in hospitals generally carry the equip-
person's blood via mucous membranes or a break in the skin. The ment in a portable tray (Figure 29-1 ). A physician office laboratory
blood-borne viruses detected were identified as hepatitis B virus (POL) often has a permanent location where the same supplies are
(HBV), hepatitis C virus (HCV), human immunodeficiency virus stored and venipuncture is performed. In such cases you likely will
(HIV), and a hemorrhagic virus (Ebola). The diseases caused by these seat the patient in a venipuncture chair, which has an adjustable
viruses were found in individuals engaged in high-risk sexual behav- locking armrest to protect the patient ifhe or she should faint (Figure
ior; those who had received blood transfusions; and those exposed 29-2). However, if the patient has a history of syncope, it is best to
to blood by contaminated needles or bloody ritual practices. perform phlebotomy while the patient is lying on an examination
The high standards necessary for the safe practice of phlebotomy table.
led to the creation of the Bloodborne Pathogens Standard (overseen
by the Occupational Safety and Health Administration [OSHA])
and by different organizations that develop additional standards for
training. Medical assistants are trained to perform phlebotomy. To
be certified as a phlebotomist, however, they must complete course
work and training at an accredited institution, perform a specified
amount of witnessed "sticks," and then pass a national examination.
Some medical assistant programs include this specialized training in
their curriculum.
Phlebotomy certifying agencies include the ASCP, the Interna-
tional Academy of Phlebotomy Sciences (IAPS), the National Cer-
tification Agency (NCA), and the National Phlebotomy Association
(NPA). Continuing education ofren is required to maintain certifica-
tion. California and Louisiana were the first states to create state
phlebotomy certification requirements. It is important that medical
assistants become familiar with the guidelines of the states in which
they work because not all states require a certificate to perform
phlebotomy.
The most common method of obtaining a blood specimen is
venipuncture, in which the blood is taken directly from a surface
vein. The vein is punctured with a needle, and the blood is collected
directly into a stoppered vacuum tube, or into a syringe and then FIGURE 29-1 Afully stocked venipuncture tray.

FIGURE 29-2 Aphlebotomy chair.
Equipment Used in Routine Venipuncture
• Personal protective equipment (PPE): nonlatex gloves, fluid-impermeable
lab coat, and face shield (if necessary)
• Marking pen
• Alcohol swabs
• Gauze pads
• Nonlatex bandages
• Nonlatex tourniquets
• Double-pointed safety needles
• Winged infusion sets (butterfly needles)
• Disposable needle holders
• Evacuated, stoppered tubes
• Syringes and removable needles with safety devices
• Biohazard sharps container
Personal Protective Equipment
Employers must provide employees with personal protective equip-
ment (PPE), such as gloves, including the hypoallergenic, powder-
less, and nitrile or vinyl types. Latex gloves are no longer recommended
because the phlebotomist and/or the patient may be allergic to latex.
The medical assistant must also use other nonlatex supplies, such as
tourniquets and adhesive bandages. All facilities must stock only
latex-free supplies because of the potential for allergic responses in
workers and patients. Some people with latex allergies can have life-
threatening reactions with a latex exposure.
OSHA requires healthcare workers to wear gloves during veni-
puncture. Because veins can be difficult to locate with gloved finger-
tips, the site may be palpated before gloves are put on, as long as the
hands have been sanitized. The standard procedure for venipuncture
established by the Clinical and Laboratory Standards Institute
(CLSI) states that gloves may be put on after vein palpation but
before preparation of the site. Those who need the final assurance of
one last palpation before the needle is inserted must remember that
touching the prepared site, even with gloves, contaminates the area.
CHAPTER 29 Assisting in Blood Collection 735
FIGURE 29-3 Example of a latex-free nitrile tourniquet.
To help yourself find the vein after the area has been cleansed, make
note of certain skin markers, such as creases, freckles, or scars. If the
area is touched, it must be cleansed again. Keep in mind that the
tourniquet should be tied for no longer than 1 minute at a time.
Tourniquets
Before blood can be drawn, a vein must be located. Application of
a tourniquet is the most common way to do this; it prevents venous
flow out of the site, causing the veins to bulge. The tourniquet is
tied around the upper arm so that it is tight but not uncomfortable
and can be released easily with one hand. Single-use, nonlatex tour-
niquets are available (Figure 29-3) and currently are recommended
for reducing cross-contamination between patients and healthcare
workers, preventing nosocomial infection, and preventing latex
exposure. Other tourniquets with quick-release closures are available
and may be more comfortable for the patient, but they must be
disinfected after each use.
Tourniquets are applied 3 to 4 inches above the elbow immedi-
ately before the venipuncture procedure begins. Because a tourniquet
impedes blood flow, leaving it on for longer than 1 minute greatly
increases the possibility of hemoconcentration and altered test
results. The tourniquet should not be tied so tightly as to impede
arterial blood flow; this restricts venous blood return, resulting in
poor venous distention. Checking the pulse at the wrist ensures that
arterial flow is not restricted. Tourniquets also are used when blood
is drawn from hand and foot veins and are tied on the wrist or ankle,
respectively.
Tourniquets can be uncomfortable for patients, especially those
with heavy-set or hairy upper arms, if they are not applied correctly.
Make sure the tourniquet is flat against the skin, and if necessary,
tie it over the clothing if it is causing the patient discomfort. This
may be especially important when blood is drawn in an aging indi-
vidual because of the fragility of the skin.
Antiseptics
To prevent infection, a venipuncture site must be cleansed with an
antiseptic. The most commonly used one is 70% isopropyl alcohol,
also known as rubbing alcohol. Prepackaged alcohol "prep pads" are
the product used most often. The square prep pad is rubbed on the
skin in a circular motion, and the alcohol is allowed to dry. Alcohol
736 UNIT FOUR DIAGNOSTIC PROCEDURES
does not sterilize the skin; it inhibits the reproduction of bacteria
that might contaminate the sample. To be most effective, the alcohol
should remain on the skin 30 to 60 seconds. However, isopropyl
alcohol should not be used when a sample for a blood alcohol test
is drawn. Sterile soap pads, benzalkonium chloride, or povidone-
iodine (Betadine) can be used instead.
If a blood culture is ordered, additional preparation is needed at
the venipuncture site to eliminate contaminating bacteria. Povidone-
iodine solution commonly is used; chlorhexidine gluconate or ben-
zalkonium chloride can be used for patients who are allergic to
iodine. More vigorous cleansing is required for a blood culture
sample than for a routine venipuncture. Blood cultures must be
drawn into a sterile tube or a bottle specifically designed for the test
(Figure 29-4).
Evacuated Collection Tubes
The most common collection system is the evacuated tube system
(these tubes are also called vacuum tubes; a particular brand is the
Vacutainer). It consists of evacuated tubes of various sizes that have
color-coded tops, which indicate the tube's contents (Table 29- 1) .
Before the discovery of blood-borne pathogens, tubes were all glass
with color-coded rubber stoppers. Now the tubes must be either
shatter-resistant glass or plastic, and the rubber tops are being
replaced by safer plastic Hemogard colored tops, which do not splat-
ter blood when removed. In Table 29-1 , note how the tubes with
different-colored stoppers contain different chemical additives, anti-
coagulants, clot activators, and/or thixotropic gel. The vacuum in
each tube draws a measured amount of blood into the tube. Tube
volumes range from 2 to 15 mL.
The size of the tube to be used depends on several factors. Each
test performed in the laboratory requires a specific amount of blood.
Consult the manual provided by the laboratory to make sure you
are drawing the right amount of blood for the test. Tests can often
be combined, which reduces the number of tubes that must be
FIGURE 29-4 Bactec blood culture bottles.
drawn. For example, both a complete blood count and an erythro-
cyte sedimentation rate test (discussed in the next chapter) are per-
formed on a sample from a lavender-topped tube; you need not draw
two tubes, because the 7-mL volume is sufficient for both tests.
When in doubt, call the laboratory. Keep in mind that blood is
approximately half cells and half liquid. If a test requires 3 mL of
serum, 6 mL of blood must be collected.
Patients often express great concern when several tubes of blood
must be drawn. You can allay their fears by explaining that the
average adult has a little less than 10 pints of blood (5 L). Most
adults can relate to donating a unit of blood, which is around a pint
(400 to 500 mL). Because the red-topped tube contains 10 mL, you
would have to draw 40 to 50 tubes to remove a pint.
Tube Additives
All plastic vacuum tubes contain an additive. The red-topped plastic
tube contains a silicone additive to activate clotting. All the other
color-topped plastic tubes contain some form of anticoagulant to
prevent blood from clotting. The additive may be a powder, a liquid
visible in the tube, or a liquid sprayed inside the tube by the manu-
facturer and allowed to dry. The choice of anticoagulant depends on
the test to be done.
Anticoagulant additives prevent blood from clotting, which
allows the contents of the tube to be used in two ways. First, the
sample can be used as whole blood; second, the sample can be cen-
trifuged, and the liquid portion, called plasma, can be retrieved for
testing. Whole blood is used for tests such as a complete blood count
(CBC) and blood typing, whereas the plasma is used for STAT
(immediate) chemistry testing and coagulation studies.
Ethylenediaminetetraacetic acid (EDTA) is the anticoagulant
found in the lavender-topped tube. It prevents platelet clumping
and preserves the appearance of blood cells for microscopic examina-
tion; however, it is incompatible with the testing reagents used in
coagulation studies. Consult the manual provided by the laboratory
before obtaining more than one type of specimen from the patient
so as to avoid cross-contamination of additives from one tube to
another.
Clot activators promote blood clotting in the red plastic tubes.
For example, silica particles in the red-topped plastic tubes enhance
clotting by providing a surface for platelet activation. Thrombin
from the platelets quickly promotes clotting and is used in tubes
drawn for chemistry testing or in the event a sample is needed from
a patient taking a prescribed anticoagulant, such as heparin.
If blood is allowed to clot and then is centrifuged, the liquid
portion is referred to as serum. Without a clot activator, blood clots
in 30 to 60 minutes, after which it must be centrifuged. The serum
must be separated from the cells quickly because cells may continue
to metabolize substances such as glucose or may release metabolites
that interfere with testing.
Thixotropic gel can be found in some tubes, including the serum
separator tube (SST). SST tubes are identified by the red-gray
(marbled) rubber stopper on glass tubes and the gold Hemogard top
on plastic tubes. The plasma separator tube (PST) also contains
thixotropic gel; the glass tubes have a green-gray (marbled) top, and
the plastic tubes have a light green top. Thixotropic gel, a synthetic
gel, has a density between that of red cells and plasma or serum; it
settles between the two during centrifugation, forming a barrier
 CHAPTER 29 Assisting in Blood Collection 737

that facilitates retrieval of the liquid portion without cellular

contamination.
It is important to avoid a "short draw" (i.e., a tube that is not
completely filled). Table 29-2 lists the consequences of underfilling
tubes. Some tubes are designed to fill only partially, according to
their preset vacuum. For example, a 5-mL tube that is set to draw
up 3 mL of blood stops drawing up blood when it is a little over
half filled. Having the proper ratio of blood to additive is crucial.
Always check the tube for an expiration date; outdated tubes may
have a diminished vacuum, or the additive may have degraded.
CRITICAL THINKING APPLICATION 29-1
l . Melissa Machen has been assigned to orient Leah to the clinic and her
duties as a certified medical assistant. Melissa takes Leah to the labora-
tory in the clinic, which has a small room with a blood collection chair
and a table. What supplies should be on the table for perrorming
venipuncture?
2. What else might Leah find in this room?

TABLE 29-1 Common Stoppers and Additives and Their Laboratory Uses
VACUUM HEMOGARD OPTIMUM VOLUME/
TUBE COLOR* COLOR COLORt ADDITIVE AND ITS FUNCTIONt LABORATORY USE MINIMUM VOLUME
Adult Tubes
Pale yellow
• Pale yellow SPS prevents blood from clotting and
stabilizes bacterial growth
Blood or body fluid cultures 5 ml/NA

Light blue
• Light blue Sodium citrate; removes calcium to prevent
blood from clotting
Coagulation testing 4.5 ml/4.5 ml

Red
• Red None Serum tests; chemistry
studies, blood bank,
serology
10 ml/NA

Red-gray
(marbled) • Gold None, but contains silica particles to enhance
clot formation
Serum tests 10 ml/NA

Green
• Green
-
Heparin (sodium/lithium/ammonium);
inhibits thrombin formation to prevent clotting
Chemistry tests 10 ml/3.5 ml

Green-gray Lithium heparin and gel for plasma separation Plasma determinations in 2 ml/2 ml
(marbled) chemistry studies

Lavender
• Lavender EDTA; removes calcium to prevent blood from
clotting
Hematology tests 7 ml/2 ml

Gray
• Gray Potassium oxalate and sodium fluoride;
removes calcium to prevent blood from
clotting; fluoride inhibits glycolysis
Chemistry testing,
especially glucose and
alcohol levels
10 ml/10 ml

Royal blue
• Royal blue Sodium heparin (also sodium EDTA); inhibits
thrombin formation to prevent clotting
Chemistry trace elements 7 ml

Continued
738 UNIT FOUR DIAGNOSTIC PROCEDURES

TABLE 29-1 Common Stoppers and Additives and Their Laboratory Uses-continued
VACUUM HEMOGARD OPTIMUM VOLUME/
TUBE COLOR* COLOR COLORt ADDITIVE AND ITS FUNCTION* LABORATORY USE MINIMUM VOLUME
Pediatric Tubes
Red
• Red 2 ml/NA
3 ml/NA
4 ml/NA
Lavender
• Lavender 2 ml/0.6 ml
3 ml/0.9 ml
4 ml/1 ml
Green
• Green 2 ml/2 ml

Light blue
• Light blue

EDTA, Ethylenediaminetetraacetic acid; SPS, sodium polyanethol sulfonate.

2.7 ml/2.7 ml

*Stopper colors are based on BD Vacutainer tubes.

1Hemogard closures provide a protective plastic cover over the rubber stopper as an additional safety feature.
1Additives, additive functions, and laboratory uses are the same for both pediatric and adult tubes.

and erroneous results. CLSI has established a set of standards

TABLE 29-2 Effects of Underfilling Collection outlining the order of draw for a multitube draw. The same
Tubes order applies to the filling of tubes when blood is collected in
a syringe.
STOPPER COLOR EFFECTS OF UNDERFILLING
1. Yellow top: These blood culture tubes are filled first because
Yellow Reduces possibility of bacterial recovery they are sterile and should not be contaminated by the other
tubes.
Light blue Coagulation test results falsely prolonged
2. Light blue top: These tubes, which contain sodium citrate, are
Red Insufficient sample next because other anticoagulants might contaminate the
sample collected for coagulation studies. If no blood culture
Red-gray, and Gold (SST Poor barrier formation; insufficient sample has been ordered, CLSI recommends that blood for the light
tubes) blue-topped tube be drawn first if routine coagulation testing
Green False results because of excess heparin has been ordered (i.e., prothrombin time [PT] and activated
partial thromboplastin time [APTT]; see next chapter). Some
Green-gray and light green False results because of excess heparin laboratories recommend that a red-topped "waste" tube with
(PST tubes) no additives be partially filled before the light blue-topped
Lavender Falsely low blood cell counts and citrate tube to remove any thromboplastin that was released
during the venipuncture, because thromboplastin interferes
hematocrits; morphologic changes to red
with the coagulation testing. CLSI also recommends that,
blood cells; staining alteration
when a winged infusion set is used, blood be drawn into the
Gray False results red-topped tube even if the order does not call for it. This is
done to fill the tubing's dead space with blood before drawing
Yellow-gray False results the light blue-topped citrate tube, which must have an exact
Royal blue False results blood-to-citrate dilution .. It is not necessary to fill the waste
tube to be discarded because it is just removing the air from
PST, Plasma separation tube; SST, serum separation tube. the tubing.
3. Red top: Glass serum tubes without clot activator, or plastic
tubes with clot activator, are filled next. These clotted speci-
Order of Collection mens are drawn to test the serum after the specimens have
If samples for more than one tube must be drawn during a veni- clotted and been centrifuged. SSTs with thixotropic gel are
puncture, a specified order must be followed so that material from also drawn at this time. Glass SSTs have a red-gray marbled
a previous tube is not transferred to the next tube. Carryover of rubber stopper; plastic SSTs have a gold plastic Hemogard
additives from one tube to the next could cause sample alteration top.

4. Green top: These tubes are drawn next because the plasma in
their anticoagulated specimen is used for testing when STAT
results are needed. The dark green tops contain no thixotropic
gel. The marbled green-gray rubber tops and the light green
plastic Hemogard tops both contain the gel to help separate
the plasma from the cells when centrifuged.
5. Lavender top: These tubes are now drawn. They contain an
EDTA anticoagulant that binds the calcium to prevent clot-
ting and preserves the blood cells. Blood for this tube is drawn
near the end because the EDTA additive interferes with the
chemistry and coagulation specimens.
6. Gray top: This tube is drawn last, and the blood is used to test
glucose. Its additives may elevate electrolyte levels and damage
cells if passed into the other tubes
To recap, Table 29-1 shows the order of draw of the colored
tube tops, in addition to the additives, laboratory uses, and
accepted volumes per tube. Table 29-2 lists the effects of underfill-
ing the collection tubes. Table 29-3 shows how many times the
various tubes need to be inverted after they have been filled with
blood. It is important to mix the contents of the tubes well
after collection by inverting them several times (do not shake the
tubes).
Types of Needles and Supplies Used in Phlebotomy
A critical part of phlebotomy is knowing which needle and which
tube or syringe should be used in each situation. All needles used in
phlebotomy are sterile and have a safety device that is activated
immediately before or after withdrawal from the vein. The needle is
then discarded in a biohazard sharps container. Each needle is
housed in a protected cover, which should be inspected before use
to ensure that sterility has not been compromised (i.e., the seal
should be intact) and that the needle has no manufacturing defects,
such as burs or nicks.
Needles have two parts, the hub and the shaft. The hub of the
needle is designed to attach the needle to the syringe or the vacuum
tube's needle holder. Shafts differ in length, ranging from ¾ to 1½
inches. The length of the shaft has no bearing on the venipuncture
procedure. Some phlebotomists prefer a longer needle because it is
less likely to slip out of the vein, whereas others prefer a shorter
needle because it makes patients less uneasy. One end of the shaft
is cut at an angle and forms the bevel, which creates a very
sharp point.
TABLE 29-3 Stopper Color and Inversion Mixing
STOPPER COLOR MIX BY INVERSION
Yellow 8-10 times
Light blue 3-4 times
Red or red speckled 5 times
Green 8-10 times
Lavender 8-10 times
Gray 8-10 times
CHAPTER 29 Assisting in Blood Collection 739
The bore, or hollow space, inside the needle is called the lumen.
Lumen size is important in venipuncture and is referred to as the
gauge. The gauge is designated by a numeric value. The higher the
gauge number, the smaller the lumen. Be sure to match the needle
gauge to the size of the tube. A large vacuum tube is more likely to
hemolyze the blood if a high-gauge needle (i.e., with a small lumen)
is used. For example, a blood bank uses a large, 16-gauge needle to
collect pints of blood for transfusions. The lumen is wide, which
reduces the chance of hemolysis. The small, 23-gauge needle is used
to collect blood from small or fragile veins, such as those in elderly
and very young patients. Routine adult venipuncture requires a 20-
to 21-gauge needle.
Multisample Needles
Multisample needles are commonly used in routine adult venipunc-
ture. They are so called because they are used when several tubes are
to be drawn during a single venipuncture. These needles are double
pointed (Figure 29-5). One point enters the patient's vein, and the
other punctures the rubber stopper of the collection tube. The point
that enters the tube is sheathed with a retractable rubber sleeve that
allows tubes to be changed without blood leaking into the needle
holder or tube holder.
Needle Holders
Double-pointed needles must be firmly placed into a needle adapter
or tube holder (Figure 29-6). Usually these are translucent cylin-
ders, and they come in different sizes to accommodate the tube
used. The holders often have a ring that indicates how far the tube
Retractable sheath during blood collection
Retractable sheath when no tube is engaged
c:::;;;;;;~I;:J~i==========B=e=v=e=I=e=n~==-
1½or 1 inch
FIGURE 29-5 Multisample needles. The sheathed needle on the left penetrates the vacuum tubes
when the needle on the right is in the vein.
Vacuum tube Holder Needle
I Rubber stopper
( fl] ,~~~
Hub Shaft Tip
Flange Rubber sleeve
FIGURE 29-6 Vacuum system. Left, Vacutainer tube. Right, Needle holder with multisample
needle attached. (From Hunt SA: Saunders fundamentals of medical assisting, Revised reprint,
St Louis, 2007, Saunders.)
740 UNIT FOUR DIAGNOSTIC PROCEDURES
can be pushed onto the needle without losing the vacuum. OSHA
requires that, to prevent accidental needlesticks, the needle holder,
with its safety-activated needle still attached, be discarded into the
biohazard sharps container immediately after withdrawal from
the vein.
Syringes
Syringes are used when there is concern that the strong vacuum in
a stoppered tube might collapse the vein. The syringe needle fits on
the end of the barrel and also comes in different gauges. The amount
of blood drawn into the barrel depends on how much is to be trans-
ferred to the stoppered tubes. When blood is drawn into a syringe,
it must be transferred immediately to the evacuated tube because the
blood will dot in the syringe barrel. In these situations, the syringe's
needle safety device must be activated before the needle is discarded
in the sharps container. A special transfer tube device is then used
to transfer the blood to the vacuum tubes. This device connects to
the top of the syringe; it contains an enclosed needle that punctures
the vacuum tube's stopper and delivers the blood into the tube
(Figure 29-7).
Winged Infusion Sets (Butterfly Needles)
Butterfly needles (Figure 29-8) are designed for use on small veins,
such as those in the hand or in pediatric patients. The most common
needle size is the small, 23 gauge; the needle is ½- to ¾-inch long
and has a plastic, flexible, butterfly-shaped grip attached to a short
length of tubing. The hub end is fitted into the syringe or the
vacuum tube adapter. Often a syringe is used because pulling in the
blood can be controlled more easily. The syringe blood sample must
be transferred to the evacuated tubes using the transfer device
described previously.
FIGURE 29-7 BD Vacutainer blood transfer device, showing the blood from the syringe above
about to be pulled into the vacuum tube on the bottom when the vacuum tube is pushed into the
holder. (Courtesy Becton, Dickinson, Franklin lakes, NJ.)
Needle Safety
Healthcare workers who use or may be exposed to needles are at
increased risk of needlestick injury. Such injuries can lead to serious
or fatal infections with blood-borne pathogens such as HBV, HCV,
and HIV. Nursing and phlebotomy staff members are most fre-
quently injured. Needlestick injuries account for most accidental
exposures to blood. As is discussed in the Infection Control chapter,
used needles should never be recapped except with the appropriate
engineered safety devices.
According to OSHA, the best practice for preventing needlestick
injuries after phlebotomy is to use safety needles that are activated
with one hand immediately after use. The U.S. Food and Drug
Administration (FDA), which is responsible for approving medical
devices marketed and sold in the United States, recommends devices
that provide a barrier between the hands and the needle, after use,
in which the phlebotomist's hands remain behind the needle at all
times. Safety shields that can be activated before or immediately after
removal of the needle from the vein and that remain in effect after
disposal also should be an integral part of the device. Finally, these
devices should be as simple as possible, requiring little or no training
to use. Some examples of needle safety devices are:
• One-handed vacuum tube needle: After the needle has been
used and removed from the vein, the thumb holding the
vacuum tube holder slides under the base of the pink safety
device, causing it to snap over the contaminated needle (Figure
29-9, A). Or, an orange needle shield on the holder is activated
by pressing the device against a surface (Figure 29-9, B).
• Syringe needle safety devices (Figure 29-10): These devices have
a spring-activated shield attached to a disposable syringe
needle. After the venipuncture, the phlebotomist activates the
device with the thumb holding the syringe, and a spring locks
FIGURE 29-8 Winged infusion (butterfly) set with sterile tubing containing a white Luer needle
adapter that will attach to a syringe, and a Vacutainer-sheathed needle that will attach to a Vacutainer
holder. (Courtesy Becton, Dickinson, Franklin lakes, NJ.)
 CHAPTER 29 Assisting in Blood Collection 741

FIGURE 29-9 Hinged or sliding sharps with safety-engineered sharps injury protection (SESIP). A, One-handed activation by sliding thumb at
the base of device, causing it to cover the needle. B, One-handed activation by pressing the orange protective device against an inanimate object.
(Modified from Garrels M, Oatis C: Laboratory testing for ambulatory settings, ed 2, St Louis, 2011, Saunders.)

FIGURE 29-10 Top left, Blood transfer device for transferring asyringe blood sample to avacuum
tube. Top right is the syringe. Bottom left, Syringe safety needle that has been activated. After safety FIGURE 29-11 The Safety-Lok butterfly needle and the blue "wings" are pulled back into the
activation, the needle is removed from the syringe, and the blood transfer device is attached to the butterfly body by pulling back on the tubing while holding the "tail" of the butterfly.
syringe to transfer blood into vacuum tubes. Bottom right, Exposed needle that has not been
activated.

a protective plastic tip into place, protecting the needle. The

needle then can be removed and discarded. The syringe is
attached to the safety transfer device to deliver the collected
blood into the appropriate vacuum tubes (see Figure 29-7).
• Butterfly needle safety lock (Figure 29-11 ): After the venipunc-
ture, the dominant hand holds the butterfly tail while the
nondominant hand pulls back on the tubing, causing the
needle to slide into the tubing and lock into place.
• Push-button butterfly safety device (Figure 29-12): While the
needle is still in the arm, the medical assistant grasps the tail
of the butterfly with the dominant hand while the nondomi-
nant hand presses the button just below the wings, causing
the needle to retract into the butterfly body as it leaves the
vein.
• Needle blunting butterfly set (Figure 29-13): A third "wing" is FIGURE 29-12 The push-button butterfly needle is activated while in the vein. When the black
rotated after collection and before removal of the needle from button just below the green wings is pushed, the needle immediately is pulled out of the vein and
the vein. As the third wing is rotated, it moves the blunt into the body of the butterfly.
needle down the shaft before it is removed from the patient.
742 UNIT FOUR DIAGNOSTIC PROCEDURES
A B
FIGURE 29-13 Needle-blunting sharp with safety-engineered sharps injury protection (SESIP) for winged infusion (butterfly) sets. A, Before
activation, with needle in vein. B, After activation.
It should be noted that OSHA'.s Bloodborne Pathogens Standard
emphasizes that phlebotomists should have direct input on the type
of safety needles they will be using. The following steps should be
taken to protect against needlestick injuries:
• Help your employer evaluate and select devices with safety
features.
• Use devices with safety features provided by your employer.
• Never recap a contaminated needle except with a safety device.
• Plan for safe handling and disposal before beginning any
procedure using needles.
• Dispose of used needles and needle holders promptly in
appropriate biohazard sharps containers.
• Report all needlestick and other sharps-related injuries
promptly to ensure that you receive appropriate follow-up
care.
• Tell your employer about hazards from needles that you
observe in your work environment.
• Participate in blood-borne pathogen training and follow rec-
ommended infection prevention practices, including vaccina-
tion against HBV.
OSHA requires employers to establish and maintain a sharps
injury log for recording injuries from contaminated sharps. This log
should contain information about the device involved in the inci-
dent and the department or work area where the incident occurred,
in addition to an explanation of the incident. Employee confidential-
ity must be maintained.
Postexposure Management of Needlesticks
An accidental needlestick is a medical emergency. (OSHA-
recommended management procedures are discussed in the Infec-
tion Control chapter.) Effective management of an accidental sharps
exposure includes the following measures:
• Immediately after injury, the wound is inspected for foreign
material, which is removed. The site is washed for 10 minutes
with an antimicrobial soap, 10% iodine solution, or chlorine-
based antiseptic.
• The injury is reported to the supervisor, and an incident report
is completed.
• The employee is referred to a physician for confidential assess-
ment and follow-up. Baseline testing for HBV, HCV, and
HIV is recommended for both the employee and the source
individual. If the employee has been immunized for HBV and
has a positive postimmunization titer, there is no risk of
acquiring HBV and no source testing is needed. If the worker
has not been immunized or the postimmunization titer is
negative, source testing for infection with HBV is recom-
mended if the source is known and can be located. If the
source patient tests positive for HBV, the employee should
receive HBV immune globulin (HBIG), and the series of
HBV immunizations should be initiated. If the source tests
negative, no treatment is indicated. If the source patient
cannot be tested, the employee should be treated as if the
source patient were positive for HBV. The source should also
be tested for HCV. If the source is positive, the employee
should be monitored for signs and symptoms of hepatitis for
6 months. No postexposure prophylaxis is recommended for
HCV infection. For HIV exposure, most employers recom-
mend a 4-week regimen of antiretroviral drugs. To best protect
the victim, antiretroviral therapy should be administered
within hours of exposure. Early HIV drug therapy is now
recommended for anyone who may be at risk of infection.
Because these medications have side effects, the employee is
the one who decides whether the medications are started. If
the source is found to be negative, antiretroviral therapy can
be discontinued.
• Interim testing may be performed if the healthcare worker
experiences symptoms of acute HIV exposure or hepatitis. For
HIV, antibody testing should be repeated at 6 weeks, 12
weeks, and 6 months if the source was HIV positive or the
source's status remains unknown. Confidential follow-up care
must include provisions for emotional support and counseling
for the healthcare worker.
ROUTINE VENIPUNCTURE
Venipuncture involves several important steps, and the medical assis-
tant must be thoroughly familiar with these steps before attempting
the procedure. The first step is to select the proper method for veni-
puncture (evacuated tube or syringe). Next, the patient must be
prepared for the procedure. Patient preparation is followed by the
actual venipuncture and specimen collection, and care of the punc-
ture site is provided before the patient is discharged. The final step
is proper processing of the specimen.
Patient Preparation
All blood collections begin with a requmuon, a form from the
patient's provider requesting a test. Requisitions may be computer
generated or handwritten and at a minimum must include the fol-
lowing information:
• Patient's name
• Date of birth
• Identification number
• Name of the provider submitting the order
• Type of test requested
• Test status (timed, fasting, STAT, and so forth)

Venipuncture begins with greeting the patient and verifying his
or her identity. According to CLSI, proper identification includes
asking outpatients to (1) spell their full name and state their address,
which are verified on the requisition, and (2) verify their birth date.
All the information must be compared with the written information
on the requisition. If the patient speaks a different language, has
limited language skills (e.g., he or she is a child), or is otherwise
unable to communicate, a family member or medical translator must
provide the information. The name of this person should be
documented.
Introduce yourself and briefly explain the purpose and procedure
of the venipuncture. If the patient has questions about the ordered
tests, politely request that the patient speak to the provider, and ask
whether the individual would like to do so before you collect the
sample. Obtain verbal consent to perform the procedure simply by
asking whether you have permission to take some blood from the
patient's arm. Always ask the patient whether he or she has experi-
enced problems during routine venipuncture in the past, and take
steps to prevent such problems. Your self-confidence in the proce-
dure should be evident to the patient and will help allay any fears.
Instilling confidence in your patients means acting and speaking
professionally. You may want to ask what the patient would prefer
to be called, or you can call the person by his or her formal name.
Refer to the patient as "Mr. Jones" or "Ms. Smith," not "honey,"
"sweetie," "Bill," or "Margaret." Being friendly is important, but
make sure your patients feel respected and understand that you take
your role in their care seriously.
Preparing for the Venipuncture
Seat the patient in a chair; or, if the patient has a history of syncope,
have him or her lie down on an examination table. Ask the patient
to extend an arm (and place his or her other hand under the elbow
to help straighten the venipuncture area). Inspect both arms and ask
whether the patient has a preference. Generally, veins in the forearm
or the elbow (antecubital area) are used for venipuncture (Figure
29-14). The puncture site should be carefully selected after both
arms have been inspected. Alternative sites may be indicated if the
area is cyanotic, scarred, bruised, edematous, or burned. You may
use veins on the back of the hand or the thumb side of the wrist.
Median cephalic vein
Basilic
Median antebrachial vein
FIGURE 29-14 The veins of the forearm. (From Stepp CA, Woods MA: Laboratory procedures
for medical office personnel, Philadelphia, 1998, Saunders.)
CHAPTER 29 Assisting in Blood Collection 743
Use foot or ankle veins only if the patient has good circulation in
the legs and you have received permission from your supervisor or
the physician. Never draw blood from this area if the patient is
diabetic.
As mentioned, inspect both arms thoroughly before you choose
the venipuncture site. Veins bounce lightly when palpated. The
medial veins generally run at a slight right angle to the fold in the
antecubital area, whereas the cephalic veins run lateral to the thumb
side of the antecubital area. These veins are the veins of choice. The
basilic vein, which lies on the inside part of the antecubital area, is
very close to the brachia! artery and median nerves and should be
used only if the medial or cephalic veins are inaccessible. The most
common injury patients suffer from phlebotomy is nerve injury. If
the patient complains of tingling, numbness, or a shooting pain,
discontinue the procedure and choose another site before continu-
ing. Do not probe with the needle under this condition; any
attempt at relocating the needle puts the patient at great risk of
nerve injury.
To apply a tourniquet, place the tourniquet 3 to 4 inches above
the patient's elbow, making sure it is not twisted (Figure 29-15).
Grasp the tourniquet ends, one in each hand, at the part of the
tourniquet closest to the patient's skin. Pull the ends apart to stretch
the tourniquet, then cross one end over the other while maintaining
the tension. Tuck the top end of the tourniquet underneath the
bottom piece, creating a loop with the upper flap free so that the
tourniquet can be released with one hand. The tourniquet should be
tight without pinching the patient's skin. Both ends of the tourni-
quet should be pointing upward so that they do not contaminate
the blood draw site.
When the tourniquet is in place, ask the patient to place a fist
under the elbow of the arm with the tourniquet and make a fist with
the tourniquet arm. Palpate for an acceptable vein using your
ungloved, sanitized index finger. If you are able to palpate the vein
through gloved fingers, you can continue with the phlebotomy
process.
Performing the Venipuncture
When you have located a vein, remove the tourniquet. A tourniquet
can remain in place for 1 minute. After its removal, you must wait
FIGURE 29-15 Placement of a tourniquet.
744 UNIT FOUR DIAGNOSTIC PROCEDURES
2 minutes before reapplying it. During this time, sanitize your hands
and put on your gloves (if they are not already on) and cleanse the
antecubital area with alcohol wipes, starting with a small area and
working outward in larger circles. Do not touch this area after cleans-
ing. Assemble the appropriate equipment, making sure everything is
within easy reach, that the gauze packets are torn open, and that the
contents are easily accessible.
Reapply the tourniquet, ask the patient to reclench the hand into
a fist. Do not have the patient pump the fist because this may tem-
porarily increase the level of potassium and ionized calcium in the
blood. Relocate the vein. (Note: If you need to palpate, place your
gloved finger on the alcohol wipe first and then palpate with the
finger covered by the disinfectant.) Anchor the vein by stretching
the skin downward below the collection site with the thumb of the
nondominant hand, and swiftly insert the needle into the vein at a
15-degree angle. The bevel should be facing up. If the needle is
inserted at an angle greater than 15 degrees, it quickly penetrates the
other side of the vein and enters other structures, such as nerves or
the brachia! artery, and very likely will cause a hematoma or an
injury. Push the evacuated tube into the double-pointed needle or
pull back on the syringe plunger. When blood enters the tube or
barrel, ask the patient to unclench the fist.
Completing the Venipuncture
Continue to draw the specimens, checking periodically on the
patient's condition. As you remove each tube from the needle holder,
gently invert it several times before you place it in the rack. Tubes
with clot activator should be inverted 5 times; light-blue-topped
tubes for coagulation studies should be inverted 3 or 4 times; all
other anticoagulant tubes should be inverted 8 to 10 times (refer
back to Table 29-3). If the tubes are not inverted immediately after
collection, small clots can form in the specimen. When you are
nearing the end of the draw and the last tube to be collected has
been filled, carefully release the tourniquet without jarring the
needle, and remove the final vacuum tube. Remove the needle
quickly and apply gauze with pressure to the puncture site. Ask
Instruct and Prepare a Patient for a Procedure and Perform Venipuncture: Collect a
PROCEDURE 29-1
Venous Blood Sample Using the Vacuum Tube Method
Goal: To collect a venous blood specimen by the vacuum tube technique.
EQUIPMENT and SUPPLIES
• Patient's health record
• Provider's order and/or lab requisition
• Vacuum tube needle, needle holder, and proper tubes for requested tests
• 70% isopropyl alcohol pads
• Gauze pads
• Tourniquet
• Hypoallergenic tape or bandage
• Permanent marking pen or printed labels
• Biohazard bag
• Sharps container and biohazard waste container
the patient to apply direct pressure to the gauze but not to bend
the arm.
Immediately activate the safety device to cover the needle and
dispose of the entire needle/needle holder unit into a sharps con-
tainer. While the patient is applying pressure to the site, label the
tubes with the labels that accompanied the requisition, or write
the following on the vacuum tube's label: patient's last name,
then first name; on the next line, write the date and time; on the
third line, state whether the patient had been fasting; then sign
your initials.
Before putting on the bandage, perform a two-point check to
make sure the vein is not leaking. Observe the site for 5 to 10 seconds
after releasing pressure and removing the gauze. If visible bleeding
occurs or if the tissue around the puncture site rises, continue apply-
ing pressure until the bleeding has stopped. Special precautions must
be taken for patients taking anticoagulants because the phlebotomy
site will bleed longer than is the norm. Put on a pressure bandage
by placing a folded gauze pad over the site and then applying the
bandage over the gauze. Clean gauze, not a cotton ball, can be held
in place by wrapping a stretchy gauze around the arm to hold the
gauze in place against the puncture site. Never leave the room or
release an outpatient until all the tubes have been labeled. Assess the
patient's status one last time, then dismiss the patient or leave
the room.
Procedures 29-1 and 29-2 outline the proper procedures for
venipuncture using the evacuated tube method and the syringe
method. Certain patients, such as those with narrow veins, young
children, and aging adults, may require a winged infusion set (but-
terfly needle) rather than the previously mentioned methods. But-
terfly units also can be used to draw blood from the hands of adults.
As mentioned, the needle in a winged infusion unit is shorter, and
the wings help you grasp and guide the needle more easily. The
tubing also minimizes the strength of the vacuum, thus preventing
the collapse of fragile veins, which is a common problem with elderly
patients (Procedure 29-3).
Text continued on p. 752
PROCEDURAL STEPS
1. Check the provider's order and/or requisition form to determine the tests
ordered. Gather the appropriate tubes and supplies.
PURPOSE: Each test requires a specific tube color that is indicated on the
requisition.
2. Sanitize your hands and put on the fluid-impermeable lab coat and dispos-
able gloves.
PURPOSE: To ensure infection control.
3. Verify the patient's identity using two identifiers (e.g., have the person
spell his or her last name, state the birth date, and/or show a picture
ID). Explain the procedure and obtain permission for the venipuncture.
 CHAPTER 29 Assisting in Blood Collection 745

•;;m,ammf411 -continued
PURPOSE: To make sure you have the right patient; explanations help gain
the patient's cooperation.
4. Assist the patient to sit with his or her arm well supported in a slightly
downward position.
PURPOSE: The veins of the antecubital fossa are more easily located when
the elbow is straight.
5. Assemble the equipment. The choice of needle size depends on your
inspection of the patient's veins. Attach the needle firmly to the vacuum
tube holder. Keep the cover on the needle.
PURPOSE: If the needle is loose, it may turn during the procedure, causing
the bevel of the needle to turn away from its upward position.
6. Apply the tourniquet around the patient's arm 3 to 4 inches above the
elbow. The tourniquet should never be tied so tightly that it restricts blood
flow in the artery (Figure 1). Tourniquets should remain in place no longer
than 60 seconds.
PURPOSE: The tourniquet is used to make the veins more prominent. A
quick check of the radial pulse ensures that the tourniquet has not been
applied too tightly. (From Garrels M, Oatis C: Laboratory and diagnostic testing for ambulatory settings, ed 3, St Louis,
2015, Saunders.)

9. Cleanse the site, starting in the center of the area and working outward
in a circular pattern with the alcohol pad (Figure 3).
PURPOSE: The circular pattern helps prevent recontamination of the area.

(From Garrels M, Oatis C: Laboratory and diagnostic testing for ambulatory settings, ed 3, St Louis,
2015, Saunders.)

7. Ask the patient to make a fist.

PURPOSE: Clenching the fist produces engorgement of the vein. Do not
ask the patient to pump the fist because this may disrupt the blood's
electrolyte balance.
8. Select the venipuncture site by palpating the antecubital space. Use your
index finger to trace the path of the vein and to judge its depth. The vein
most often used is the median cephalic vein, which lies in the middle of
the elbow (Figure 2).
PURPOSE: The index finger is most sensitive for palpating. Do not use the
thumb because it has a pulse of its own, which may confuse you.
(From Garrels M, Oatis C: Laboratory and diagnostic testing for ambulatory settings, ed 3, St Louis,
2015, Saunders.)
10. It is recommended to take the tourniquet off while you assemble your
equipment and supplies on the nondominant side of the arm. Then reapply
it when the alcohol is dry. Alternatively, dry the site with a sterile gauze
pad.
PURPOSE: Puncturing an area that is still wet with alcohol stings and can
cause hemolysis of the sample.
746 UNIT FOUR DIAGNOSTIC PROCEDURES
•;;m,ammf411 -continued
11. Hold the vacuum tube assembly in your dominant hand. Your thumb
should be on top and your fingers underneath. You may want to position
the first tube to be drawn in the needle holder, but do not push it onto
the double-pointed needle past the marking on the holder. Remove the
needle sheath.
PURPOSE: Positioning the hand in this manner provides the best visibility
of the needle entering the site and accessibility to insert and withdraw
tubes with the nondominant hand. Pushing the tube into the double-
pointed needle before it is in the arm causes air to rush into the tube,
destroying the vacuum.
12. Grasp the patient's arm with the nondominant hand and anchor the vein
by stretching the skin downward below the collection site with the thumb
of the nondominant hand.
PURPOSE: Failure to anchor the vein may cause the vein to move away
from the needle as it enters the arm, resulting in a missed vein.
13. With the bevel up and the needle aligned parallel to the vein, insert the
needle at a l 5-degree angle through the skin and into the vein quickly
and smoothly (Figure 4).
PURPOSE: The sharpest point of the needle is inserted first. Inserting the
needle quickly minimizes pain.
(From Garrels M, Oatis (: Laboratory and diagnostic testing for ambulatory settings, ed 3, St Louis,
2015, Saunders.)
14. Place two fingers on the flanges of the needle holder and use the thumb
to push the tube onto the double-pointed needle. Make sure you do not
change the needle's position in the vein. When blood begins to flow into
the tube, ask the patient to release the fist.
PURPOSE: The thumb has the strength to push the needle swiftly through
the stopper. However, if you are not careful, the needle can easily be
pushed farther into the site when the tube is pushed.
15. Allow the tube to fill to its maximum capacity. Remove the tube by curling
the fingers underneath and pushing on the needle holder with the thumb.
Take care not to move the needle when removing the tube. Immediately
after removing it from the needle holder, gently invert the tube to mix the
additives and the blood.
PURPOSE: Tubes must be full to ensure the proper anticoagulant-to-blood
ratio. Moving the needle may result in inadvertent penetration of the other
side of the vein or slipping of the needle out of the vein. Gentle inversion
prevents clotting of blood, whereas vigorous mixing may cause
hemolysis.
16. Insert the second tube into the needle holder, following the instructions in
the previous steps. Continue filling tubes until the order on the requisition
has been filled. Gently invert each tube after removing it from the needle
holder. As the last tube is filling, release the tourniquet.
PURPOSE: The tourniquet should remain in place for no longer than l
minute to prevent hemoconcentration.
17. Remove the last tube from the holder. Place gauze over the puncture site
and quickly remove the needle, engaging the safety device (Figure 5).
Dispose of the entire unit in the sharps container.
PURPOSE: The gauze over the puncture site and activation of the safety
needle ensure infection control.
(From Garrels M, Oatis (: Laboratory and diagnostic testing for ambulatory settings, ed 3, St Louis,
2015, Saunders.)
18. Apply pressure to the gauze or instruct the patient to do so. The patient
may elevate the arm but should not bend it.
PURPOSE: Applying direct pressure is the best method to stop bleeding.
Elevating the arm above the heart also stops bleeding.
 CHAPTER 29 Assisting in Blood Collection 747

•;;m,ammf411 -continued
19. Label the tubes with the patient's name, the date, and the time, or affix
the preprinted tube labels while the patient is applying pressure
(Figure 6).

(From Garrels M, Oatis (: Laboratory and diagnostic testing for ambulatory settings, ed 3, St Louis,
2015, Saunders.)
20. Check the puncture site for bleeding and hematoma formation.
21. Apply a hypoallergenic pressure bandage using a clean, folded gauze pad
under the bandage (Figure 7) .
(From Garrels M, Oatis (: Laboratory and diagnostic testing for ambulatory settings, ed 3, St Louis,
2015, Saunders.)
22. Disinfect the work area. Dispose of blood-contaminated materials (e.g.,
gauze and gloves) in the biahazard waste container. Remove your lab
coat and sanitize your hands.
PURPOSE: Ta ensure infection control.
23. Complete the laboratory requisition form and route the specimen ta the
proper place. Record the procedure in the patient's record.
PURPOSE: Aprocedure is considered not done until it is recorded.

10/5/20- 1:45 PM: Venous blood drawn from antecubital space of® arm.
Lavender tube for CBC with differential, and gold tube for SMA 12. Placed for
pickup by Health Alliance Labs. Leah Barney, CMA (AAMA)

•;;m!,mj;jfjfI Perform Venipuncture: Collect a Venous Blood Sample Using the Syringe Method

Goal: To collect a venous blood specimen using the syringe technique.

EQUIPMENT and SUPPLIES • Fluid-impermeable lab coat and disposable gloves
• Patient's health record • Biohazard bag
• Provider's order and/or lab requisition • Sharps container and biohazard waste container
• Syringe with 21- or 22-gauge safety needle
• Vacuum tubes appropriate for tests ordered PROCEDURAL STEPS
• 70% isopropyl alcohol pads 1. Check the provider's order and/or requisition form ta determine the tests
• Gauze pads ordered. Gather the appropriate tubes and supplies.
• Tourniquet PURPOSE: To collect the specimen properly based on the tube requirements
• Safety transfer device to transfer blood from syringe to vacuum an the requisition.
tubes 2. Sanitize your hands and put on the fluid-impermeable lab coat and dispos-
• Hypoallergenic tape or bandage able gloves.
• Permanent marking pen or printed labels PURPOSE: Ta ensure infection control.
748 UNIT FOUR DIAGNOSTIC PROCEDURES

•;;m!,mj;jfJfi -continued

3. Verify the patient's identity using two identifiers (e.g., have the person palpate the vein and visibly mark its location, then put on new gloves
spell his ar her last name, state the birth date, and/or show a picture before continuing); use your index finger to trace the path of the vein and
ID). Explain the procedure and obtain permission for the venipuncture. to judge its depth. The vein most often used is the median cephalic vein,
PURPOSE: To make sure you have the right patient; explanations help gain which lies in the middle of the elbow (Figure 2).
the patient's cooperation. PURPOSE: The index finger is most sensitive for palpating. Do not use the
4. Assist the patient to sit with his ar her arm well supported and straight in thumb because it has a pulse of its own, which may confuse you.
a slightly downward position.
PURPOSE: The veins af the antecubital fossa are more easily located when
the elbow is straight.
5. Assemble the equipment. The choice of syringe barrel size and needle size
depends an the amount af blood required for the ordered tests and your
inspection of the patient's veins. Attach the needle firmly to the syringe.
Pull and depress the plunger several times to loosen it in the barrel while
keeping the cover on the needle. The plunger must be pushed in com-
pletely after it has been loosened in the barrel.
PURPOSE: Using the smallest syringe possible minimizes the chance of
hemolysis. Engaging the plunger ensures that you will not have to use as
much force to pull the blood into the barrel, thereby minimizing the chance
of hemolysis.
6. Apply the tourniquet around the patient's arm 3 to 4 inches above the
elbow. The tourniquet should never be tied so tightly that it restricts blood
flow in the artery (Figure 1). The tourniquet should remain in place no
longer than 1 minute.
PURPOSE: The tourniquet is used to make the veins mare prominent. A
(From Garrels M, Oatis C: Laboratory and diagnostic testing for ambulatory settings, ed 3, St Louis,
quick check of the radial pulse ensures that the tourniquet has not been 2015, Saunders.)
applied too tightly.
9. Cleanse the site, starting in the center of the area and working outward
in a circular pattern with the alcohol pad (Figure 3). Allow the area to
dry before proceeding.
PURPOSE: The circular pattern helps prevent recontamination of the area.
Puncturing an area that is still wet with alcohol stings and can cause
hemolysis of the sample.

(From Garrels M, Oatis C: Laboratory and diagnostic testing for ambulatory settings, ed 3, St Louis,
2015, Saunders.)

7. Ask the patient to make a fist.

PURPOSE: Clenching the fist produces engorgement of the vein.
8. Select the venipuncture site by palpating the antecubital space (if you
have difficulty palpating the vein with gloves, you can remove the gloves, (From Garrels M, Oatis (: Laboratory and diagnostic testing for ambulatory settings, ed 3, St Louis,
2015, Saunders.)
 CHAPTER 29 Assisting in Blood Collection 749

•;;m!,mj;jfJfi -continued

10. Hold the syringe in your dominant hand. Your thumb should be on top
and your fingers underneath, the same as in the vacuum tube method.
Remove the needle sheath.
11. Grasp the patient's arm with the nondaminant hand and anchor the vein
by stretching the skin downward below the collection site with the thumb
of the nondominant hand.
PURPOSE: Failure to anchor the vein may cause the vein to move away
from the needle when it is inserted, resulting in a missed vein.
12. With the bevel up and the needle aligned parallel to the vein, insert the
needle at a l 5-degree angle through the skin and into the vein rapidly
and smoothly (Figure 4). Observe for a "flash" of blood in the hub of the
syringe. Ask the patient to release the fist.
PURPOSE: The sharpest point of the needle is inserted first. The angle
ensures that the needle does not penetrate through the vein. The appear-
ance (flash) of blood in the hub ensures that the needle is in the vein.

(From Garrels M, Oatis (: Laboratory and diagnostic testing for ambulatory settings, ed 3, St Louis,
2015, Saunders.)

14. Release the tourniquet when the proper volume is reached. The tourniquet
must be released before the needle is removed from the arm (Figure 6).
PURPOSE: Removal of the tourniquet releases pressure on the vein and
helps prevent blood from getting into adjacent tissues, causing a
hematoma.

(From Garrels M, Oatis C: Laboratory and diagnostic testing for ambulatory settings, ed 3, St Louis,
2015, Saunders.)

13. Slowly pull back the plunger of the syringe with the nondominant hand.
Do not allow more than l ml of head space between the blood and the
top of the plunger. Make sure you do not move the needle after entering
the vein. Fill the barrel to the needed volume (Figure 5).

(From Garrels M, Oatis (: laboratory and diagnostic testing for ambulatory settings, ed 3, St Louis,
2015, Saunders.)
750 UNIT FOUR DIAGNOSTIC PROCEDURES

•;;m!,mj;jfJfi -continued

1S. Place sterile gauze over the puncture site at the time of needle withdrawal
(Figure 7) . Then, immediately activate the needle safety device using the
syringe hand and apply pressure to the site with the nondominant hand.
.'

(From Garrels M, Oatis C: Laboratory and diagnostic testing for ambulatory settings, ed 3, St Louis,
2015, Saunders.)

18. Inspect the puncture site for bleeding or a hematoma.

(From Garrels M, Oatis (: Laboratory and diagnostic testing for ambulatory settings, ed 3, St Louis,
19. Apply a hypoallergenic pressure bandage (Figure 9).
2015, Saunders.) 20. Disinfect the work area. Dispose of blood-contaminated materials (e.g.,
gauze and gloves) in the biohazard waste container. Remove your lab
16. Instruct the patient to apply direct pressure on the puncture site with sterile
coat and sanitize your hands.
gauze. The patient may elevate the arm but should not bend it. PURPOSE: To ensure infection control.
PURPOSE: Direct pressure is the best method to stop bleeding. Elevating
the arm above the heart also stops bleeding.
17. Remove the syringe safety needle and transfer the blood immediately to
the required tube or tubes using a safety transfer device. Do not push on
the syringe plunger during transfer. Discard the entire unit in the sharps
container when transfer is complete. Invert the tubes after the addition of
blood and label them with the necessary patient information (Figure 8).
PURPOSE: The safety transfer device protects against accidental needle-
sticks and allows the correct amount of blood to be delivered into the tube
by vacuum. Pushing the plunger hemolyzes the blood and may alter the
amount of blood intended in each tube. Blood begins to clot shortly after
collection, so it must be transferred into the vacuum tube and mixed with
anticoagulant immediately after collection. Inverting the tubes ensures
anticoagulation.

(From Garrels M, Oatis (: Laboratory and diagnostic testing for ambulatory settings, ed 3, St Louis,
2015, Saunders.)

21. Complete the laboratory requisition form and route it and the specimen
to the proper place. Record the procedure in the patient's record.
PURPOSE: Aprocedure is not considered complete until it is recorded.
 CHAPTER 29 Assisting in Blood Collection 751

Perform Venipuncture: Obtain a Venous Sample with a Safety Winged

PROCEDURE 29-3
Butterfly Needle

Goal: To obtain a venous sample accurately from ahand or arm vein using abutterfly needle with the vacuum tube method.
EQUIPMENT and SUPPLIES
• Patient's health record
• Provider's order and/or lab requisition
• Tourniquet
• Alcohol pads or other antiseptic preps
• Gauze pads
• Safety winged (butterfly) needle set
• Appropriate vacuum tubes
• Hypoallergenic bandage
• Permanent marking pen or printed labels
• Fluid-impermeable lab coat and disposable gloves
• Biohazard bag
• Sharps container and biohazard waste container

PROCEDURAL STEPS
1. Check the provider's order and/or requisition form to determine the tests
ordered. Gather the appropriate tubes and supplies.
PURPOSE: For efficiency in preparation
2. Sanitize your hands and put on the fluid-impermeable lab coat and dispos-
able gloves.
PURPOSE: To ensure infection control.
3. Verify the patient's identity using two identifiers (e.g., have the person
spell his or her last name, state the birth date, and/or show a picture
ID). Explain the procedure and obtain permission for the venipuncture.
PURPOSE: To make sure you have the right patient; explanations help gain
the patient's cooperation.
4. Remove the butterfly device from the package and stretch the tubing
slightly. Take care not to activate the needle-retracting safety device
accidentally.
PURPOSE: To keep the tube from recoiling.
S. Attach the butterfly device firmly to the vacuum tube holder using the
sheathed needle at the end of the tubing (Figure l). Note: The sheathed
vacuum tube needle is attached to a syringe adapter. Make sure the two
are seated firmly together to prevent air from leaking into the vacuum
tube when the sheathed needle makes contact with the vacuum.
(From Garrels M, Oatis C: Laboratory and diagnostic testing for ambulatory settings, ed 3, St Louis,
2015, Saunders.)
6. Seat the first tube in the vacuum tube holder and place the unit carefully
where it will not roll away.
7. Apply a tourniquet to the patient's arm or wrist just proximal to the wrist
bone. Do not apply the tourniquet so tightly that blood flow in the arteries
is impeded.
8. Have the patient place the venipuncture hand over his or her other, fisted
hand (or around your nondominant hand) with the fingers lower than the
wrist. Or place the patient's arm in the same position as for the previous
venipuncture procedures with the arm straight and slightly downward.
PURPOSE: These positions help blood fill the veins in the hand; this makes
it easier for you to identify the veins and choose the draw site.
9. Select a vein and cleanse the site at the bifurcation (forking) of the veins.
10. Using your thumb, pull the patient's skin taut over the knuckles.
PURPOSE: Stretching the skin prevents the veins from rolling
underneath.
11. With the needle bevel up and at a l 0- to 15-degree angle, align it with
the vein.
12. Insert the needle by holding the wings or the rear of the set. After insertion
the wings are never touched again. Make sure the safety device is not
activated.
PURPOSE: Inserting the needle by holding the wings gives a greater sense
of control. If the sides are held, the safety shield slides forward over the
needle when the point of the needle makes contact with the skin.
752 UNIT FOUR DIAGNOSTIC PROCEDURES
•;;m,ammf4i• -continued
13. Push the blood collecting tube into the end of the holder (Figure 2). Note
the position of the hands while drawing the blood. When drawing blood
into a syringe, make sure the vacuum you create is slow and steady and
that no more than l ml of head space exists between the blood and the
plunger.
PURPOSE: Drawing blood too forcefully into the syringe may collapse the
vein or hemolyze the blood.
(From Garrels M, Oatis C: Laboratory and diagnostic testing for ambulatory settings, ed 3, St Louis,
2015, Saunders.)
PROBLEMS ASSOCIATED WITH VENIPUNCTURE
Failure to obtain blood can occur because of a number of factors.
Determining the cause of the problem may help you decide whether
a second attempt would be successful. The first rule is to remain
calm so that you can think clearly and systematically determine the
possible cause of the problem.
A hematoma is a large, painful, bruised area at the puncture site
caused by blood leaking into the tissue, which causes the tissue
around the puncture site to swell. The most common causes of
hematoma formation during the draw are excessive probing with the
needle to locate a vein, failure to insert the needle far enough into
the vein, and passing the needle through the vein. A hematoma also
can form after a draw if you fail to remove the tourniquet before
removing the needle; fail to withdraw the vacuum tube before the
needle is withdrawn or fail to apply adequate pressure on the punc-
ture site; or the elbow is bent while pressure is applied. If a hema-
toma forms, discontinue the procedure STAT, apply pressure to the
area for a minimum of 3 minutes, and then apply an ice pack to the
area. Notify the provider and observe the site to determine whether
the bleeding has stopped. Depending on the facility's policy, an
incident report may have to be completed and documented in the
14. Release the tourniquet when the blood appears in the tubing or a "flash"
of blood is seen in the hub of the syringe.
PURPOSE: To prevent hemoconcentration, the tourniquet should remain in
place no longer than l minute.
15. Always keep the tube and the holder in a downward position so that the
tube fills from the bottom up.
16. Place a gauze pad over the puncture site and gently remove the needle,
engaging the safety device. Dispose of the entire unit in the sharps con-
tainer (Figure 3).
(From Garrels M, Oatis C: Laboratory and diagnostic testing for ambulatory settings, ed 3, St Louis,
2015, Saunders.)
17. Complete the procedure as you would for an antecubital draw (see Pro-
cedure 29-1 , steps 19 through 23).
patient's record. A hematoma may also occur if the puncture reopens
and bleeds into the tissue due to heavy lifting with the venipuncture
arm. Instruct the patient to be careful with the arm for several hours
after the procedure.
Fainting, or syncope, can have serious consequences, and the
phlebotomist must always be prepared. Securing the patient in a
blood collection chair (by turning the armrest pad in front of the
patient) prevents bodily injury if the person faints. Constant light
conversation with the patient during the procedure can help identify
an impending episode, as can observing the patient's face and breath-
ing rate.
Nerve damage can be a consequence of venipuncture, albeit an
unlikely one. Preventive measures include avoiding the basilic vein
and refraining from blind probing if the vein is missed.
Table 29-4 lists some possible solutions to complications. As a
general rule, it is wise to limit yourself to two attempts to obtain
blood from a patient. If you fail on the second attempt, ask the
patient whether he or she would prefer having someone else try, or
whether it would be better to come back at another time. This
maneuver lets the patient feel that he or she is in control of the
situation. At one time or another, everyone is unsuccessful in
obtaining a blood sample, so do not feel that you are a failure.
 CHAPTER 29 Assisting in Blood Collection 753

TABLE 29-4 Managing Possible Blood Draw Complications

COMPLICATION MANAGEMENT STRATEGIES
Burned area Choose another site because these areas are prone to infection.
Convulsions Stay calm. Remove the needle and quickly dispose of it in a sharps container. Then help guide the
patient to the floor, protecting him or her from injury. Call for help.
Damaged or scarred veins or infected areas Look for an alternative site; do not draw blood from scarred or infected areas.
Edema Avoid the area; look for an alternative site.
Hematoma Adjust the depth of the needle or remove the needle and apply pressure.
Intravenous (IV) therapy or blood transfusion Blood samples should not be drawn from an arm that is also the site for IV infusion or blood transfusion
sites because of the dilution factor.
Mastectomy Do not draw blood from the side of the mastectomy, because mastectomy surgery causes lymphostasis,
which may produce false results.
Nausea Place a cold cloth on the patient's forehead, give the patient a basin in case of vomiting, and instruct
him or her to take deep breaths. Alert the provider.
No blood Manipulate the needle slightly or remove the vacuum tube and perform the blood draw again using a
syringe or butterfly setup.
Petechiae Loosen the tourniquet because this complication usually results from the tourniquet being in place longer
than 2 minutes.
Syncope Position the patient's head between the knees (if in a sitting position). Check and record the patient's
pulse, blood pressure, and respiration rate, and continue to observe the patient. Never leave the patient
unattended.

Fainting CRITICAL THINKING APPLICATION 29-2

According to the Clinical and Laboratory Standards Institute ((LSI), the
procedure for a fainting patient or one who is nonresponsive is as follows:
• If the patient begins to faint, quickly remove the tourniquet and
needle from the arm, immediately activate the needle safety device,
apply pressure to the site, and dispose of the unit in a sharps
container to prevent an accidental exposure.
• Notify staff members for assistance.
• Lay the patient flat or lower the head if the patient is sitting.
• Loosen tight clothing.
• Do not use ammonia inhalants/capsules because these are associ-
ated with adverse effects and are no longer recommended.
• Apply a cold compress or washcloth to the patient's forehead and
back of the neck.
• Stay with the patient until recovery is complete.
• Document the incident according to facility policies.
• When the patient regains consciousness, he or she must remain in
the facility for at least 15 minutes and should not operate a vehicle
for at least 30 minutes.
Leah is in her second week at the clinic, and she is confident that she can
perform phlebotomy on her own. Melissa has been a good mentor, and
Leah has done quite afew successful "sticks" without any problems. Today,
however, she is just having a bad day. Mr. Godfrey Lawrence has come to
the clinic with numerous problems, and Dr. Gupta has ordered several blood
tests. Mr. Lawrence is uncooperative when he sees that Leah must draw
four tubes of blood. He angrily tells her that she cannot take that much
blood out of him; she is a vampire and she will drain him. How should Leah
deal with this problem?
SPECIMEN RE-COLLECTION
Sometimes problems with a sample cannot be determined until the
specimen is analyzed in the laboratory. Rejected specimens must be
re-collected. The laboratory may reject a specimen for reasons that
include the following:
• Unlabeled or mislabeled specimen
• Insufficient quantity
• Defective tube
• Incorrect tube used for the test ordered
• Hemolysis (Table 29-5)
• Clotted blood in an anticoagulated specimen
• Improper handling
754 UNIT FOUR DIAGNOSTIC PROCEDURES

TABLE 29-5 Major Causes of Hemolysis during Collection

CAUSE
Alcohol preparation
Incorrect needle size
Loose connections on the vacuum tube If the connection between the needle holder and
assembly
Removing the needle from the vein
with the tube intact
Underfilled tubes
Syringe collections
Mixing tubes too vigorously
Temperature and transport problems
Separation of plasma or serum from
red blood cells
Prolonged tourniquet time
Paor collection; blood flowing too
slowly into the tube
EXPLANATION PREVENTION
Transfer of alcohol into the specimen causes Allow venipuncture site to dry completely.
hemolysis.
Ahigh-gauge needle causes the blood to be forced Choose the correct needle for the job, aiming for a 19- to
through a small lumen with great force, shearing 23-gauge needle.
the cell membranes; a very-low-gauge needle
allows a large amount of blood to suddenly enter
the tube with great force, causing frothing.
Make sure all connections are tight before beginning the
the double-pointed needle or the syringe and the venipuncture.
needle is loose, air can enter the sample and
cause frothing.
The remaining vacuum in the tube can cause air to Remove the final tube from the needle holder before
be drawn forcefully into the tube, causing frothing. withdrawing the needle from the patient's vein.
Underfilling tubes leads to an improper blood/ Permit blood to flow into the tubes until no more movement
additive ratio. Certain additives in disproportionate can be seen.
amounts (e.g., sodium fluoride) can cause
hemolysis.
Pulling back forcibly on the plunger draws blood Pump the plunger several times before use to loosen it in the
too quickly through the needle, shearing cell barrel. Use the smallest syringe possible. Pace the aspiration
membranes; transferring blood into a vacuum tube rate so that no more than 1 ml of air space is present at any
further traumatizes red blood cells. time. Transfer blaod into the vacuum tube immediately,
preferably using a transfer device. Never push on the plunger
when transferring to a vacuum tube. Angle the syringe so that
the blood runs gently down the side of the tube, preventing
the cells from hitting the bottom of the tube with force.
All tubes except the red-topped tube must be Gently invert tubes immediately after the draw. Anything other
mixed. than gentle inversion (e.g., shaking) can hemolyze cells.
Trauma and temperature extremes can damage Tubes should be transported in the upright position with as
cells. Freezing results in ice crystals that puncture little trauma as possible. Temperature should be controlled;
cell membranes. neither too hot nor too cold.
Removing the serum or plasma from the cells Blood samples should be centrifuged, when applicable, as
minimizes the risk of contaminating the specimen soon as possible and serum or plasma removed from the cells.
with red blood cell contents.
While the tourniquet restricts blood flow, interstitial Adhere to the 1-minute rule for tourniquet application.
fluid can leak into the veins and hemalyze red
blood cells.
The needle lumen may be blocked because it is Withdraw the needle slightly to center it within the vein.
too close to the inner wall of the vein.

Hemolysis is the major cause of specimen rejection. Because
it cannot be detected until the blood cells separate from the
plasma or serum, it is crucial to take steps to prevent red
blood cell damage during collection. Hemolyzed serum or plasma
appears rosy to bright red because of the release of hemoglo-
bin from the cells. Some of the more routine tests that are
adversely affected by hemolysis are chemistry tests for electro-
lytes (e.g., potassium, sodium), bilirubin, total protein, and nu-
merous liver enzymes (e.g., alkaline phosphatase, gamma glutamyl
transferase).
 CHAPTER 29 Assisting in Blood Collection 755

CRITICAL THINKING APPLICATION 29-3

l. Leah next must draw a sample from Ms. Danielle Rollins. Ms. Rollins
indicates that she has a history of bruising after venipuncture, and sure
enough, a hematoma begins to rise shortly after Leah inserts the needle.
She then notices that Ms. Rollins has become pale and is perspiring.
What should Leah do first?
2. What other steps should Leah take? Can she still obtain the sample?

CAPILLARY PUNCTURE
Capillaries are small blood vessels that connect small arterioles to
small venules. A capillary, or dermal, puncture is an efficient means
of collecting a blood specimen when only a small amount of blood
--
........._....
-..·--
...
=-:.c:--
___ .,.,.

is required or when a patient's condition makes venipuncture diffi-

cult. Because the requisition will not indicate that the collection is
to be made in this manner, you must be familiar with the advantages,
limitations, and appropriate uses of this technique. Capillary punc-
ture is warranted in the following situations:
• Older patients
• Pediatric patients (especially younger than age 2)
• Patients who require frequent glucose monitoring
• Patients with burns or scars in venipuncture sites FIGURE 29-16 Skin puncture devices (lancets) include safety needles (blue and white) and
• Obese patients safety blades (green and pink) that control the depth and width of the incision. Both types automatically
retract after use. (Courtesy Becton, Dickinson, Franklin lakes, N.J.)
• Patients receiving intravenous (IV) therapy
• Patients who have had a mastectomy
• Patients at risk for venous thrombosis
• Patients who are severely dehydrated TABLE 29-6 Lancet Blade Recommendations
• Tests that require a small volume of blood (i.e., CUA-waived
DEPTH AND BLOOD
tests)
Because capillaries are bridges between arteries and veins, capil-
DIMENSION VOLUME APPLICATION
lary blood is a mixture of the two. Small amounts of tissue fluid also 2.25-mm, 28-gauge Single drop Fingersticks
are present in capillary blood, especially in the first drop. Analyte needle
levels are usually the same in capillary and venous blood, with a few
exceptions. Hemoglobin and glucose values are higher in capillary 2.25-mm, 23-gauge Single drop Fingersticks, glucose test
blood; potassium, calcium, and total protein are higher in venous needle
blood. l x 1.5-mm blade Low blood flow Fingersticks, microhematocrit
Equipment tube, or drop of blood for glucose
Skin Puncture Devices
or cholesterol test
The device used to perform a dermal puncture is the lancet, which 1.5 x 1.5-mm Medium blood Fingersticks; ta fill a single
delivers a quick puncture to a predetermined depth (Figure 29-16). blade flaw Microtainer tube
OSHA has directed that lancets must have retractable blades; they
also must have locks that prevent accidental puncture after use and 2 x 1.5-mm blade High blood flaw Fingersticks; ta fill multiple
that prevent the device from being reused. Table 29-6 lists the Micratainer tubes
lancet needles and blades that are used for various testing applica-
Modified from Beckton, Dickinson. www.bd.com/vacutainer/faqs/#urine_faq. Accessed
tions. Skin puncture devices should always be discarded in a sharps December 30, 2015.
container.

Collection Containers
Different types of containers and collection devices are available, and
the ones used depend on the test to be performed. Microcollection,
or Microtainer tubes (Figure 29-17) are available with a variety of
anticoagulants and additives. Their color-coded tops indicate the
same additives as evacuated tubes. Blood is collected drop-wise into
the Microtainers through a funnel-like device. Capillary tubes are
another means of collecting blood from a dermal puncture. These
are glass with an exterior protective plastic coating for safety. The
blood is drawn into the tube by capillary action; that is, the blood
fills into these narrow tubes without the need for suction. If the
capillary tube is coated with the anticoagulant heparin, a red band
756 UNIT FOUR DIAGNOSTIC PROCEDURES
FIGURE 29-17 Pink lancet is to the left of the white container containing self-sealing capillary
blood collection tubes (seen in the middle). Right, another blue lancet above three color-coded Micro-
sample containers.
will be seen at the top. A common, heparin-coated capillary tube is
the microhematocrit tube, which is used for determining the per-
centage of packed red blood cells in the microhematocrit test (dis-
cussed in the next chapter). Figure 29-17 also shows a capillary tube
being sealed in a clay sealant. Some self-sealing capillary tubes no
longer need to be pressed into the sealant.
Manufacturers also provide various collection devices for obtain-
ing small amounts of blood for point-of-care testing, such as for
glucose, hemoglobin A, 0 and cholesterol (see next chapter). The
blood is pulled into the collecting device by capillary action after
puncture, or it is applied into or onto a reagent strip that has been
inserted into the instrument to be analyzed.
Blood from a capillary puncture may also be deposited on paper
cards. The Guthrie card (Figure 29-18) is used to test neonates for
certain metabolic disorders, such as phenylketonuria (PKU). Blood
is deposited into circles on biologically inactive filter paper and is
sent to a referral laboratory for analysis within 24 hours of sampling.
Federal postal regulations for the mailing of biohazardous material
must be followed.
Routine Capillary Puncture
Site Selection
In adults and children, the usual puncture site is the ring finger, but
capillary blood can be obtained from the middle finger or heel
(Figure 29-19). The thumb usually is too callused, and the index
finger has extra nerve endings that make the puncture more painful.
The fifth finger has too little tissue for a successful puncture. The
puncture is made at the tip and slightly to the side of the finger. Be
sure to puncture a fleshy area closer to the center of the finger to
prevent damage to underlying bone. Avoid areas that are callused,
scarred, burned, infected, cyanotic, or edematous.
For children younger than 1 year, dermal puncture is performed
on the medial and lateral areas of the plantar surface (bottom) of the
heel. Areas other than these are unsafe, and bone or nerve damage
to an infant may occur. Blood flow from an infant's heel can be
increased as much as sevenfold by applying a warm, moist towel (or
other warming device) at a temperature no higher than 42° C
(l08°F) for 3 to 5 minutes. Never place bandages on the heel or
anywhere on infants younger than age 2, because they may peel off
and become a choking hazard.
PaffentPreparaffon
Preparation for a capillary puncture is similar to that for venipunc-
ture. Put on a fluid-impermeable lab coat, sanitize your hands, and
put on gloves. Cleanse the finger well with an alcohol prep pad. If
the patient's hands are excessively soiled, ask the person to wash them
before the procedure. If the patient's hands are cold, warm them in
warm water and dry them thoroughly, or ask the person to rub or
shake them vigorously.
Generally, you must work very efficiently when performing a
capillary puncture because blood flow stops quickly. Be sure to have
your supplies organized and within easy reach. Grasp the finger
firmly and apply gentle, intermittent pressure, but do not squeeze
or "milk" it. Press the puncture device firmly against the skin and
quickly depress the plunger.
Collecting the Specimen
After the dermis has been punctured, it is important to wipe away
the first drop of blood with sterile gauze. This drop contains tissue
fluid that could interfere with test results. Fill the sampling con-
tainers according to the manufacturer's directions. Touch the con-
tainer to the drop of blood as it is released from the puncture site,
but do not touch the skin. If blood flow stops, wiping the site
with gauze may restart the flow. Be prepared for blood to contam-
inate your gloves or other surfaces; have spare gloves, extra gauze
pads, and disinfectant nearby. After the containers have been
filled, ask the patient to apply pressure to the gauze you have
placed over the puncture site if he or she is able. Seal and mix the
containers by tilting as recommended by the manufacturer if
necessary.
Specimen Handling
Capillary collection containers often are too small for a label to be
applied. The most efficient way to transport capillary tubes is to
remove the stopper from a red-topped tube, insert the capillary
tubes, sealed-end down, replace the stopper, and label the tube.
Microtainer tubes have plastic plugs that fit over the top. They may
be placed in a labeled tube or in a labeled zipper-lock bag for trans-
port. Always decontaminate collection containers before delivering
them to the laboratory if blood was deposited on the surface during
collection. The procedure for routine capillary collection is outlined
in Procedure 29-4.
CRITICAL THINKING APPLICATION 29-4
l. Melissa calls Mrs. Cara Miata into the room. Mrs. Miata, who is 88, is
seeing the physician today to have a blood glucose test done. She is a
pleasant, talkative woman. Melissa begins to organize her supplies. She
examines Mrs. Miata's arms and decides that drawing from the hand
would be best. Why do you think she made this decision?
2. What supplies will she need to draw from the hand? What tubes and/
or testing supplies will she use to collect samples?
 CHAPTER 29 Assisting in Blood Collection 757

DO NOT WRITE IN BLUE SHADED AREAS-DO NOT WRITE ON BARCO DE

,~,
111111111111111111111111111111111111111111111111111111111111111111111111
,::~.

O
~
Z
Birthdate: [I] [I] [I] MM/DD/YY Time [I] [I]
Baby/sname: ~I~I~l_,l~I~'-'-~'-'-~~I~l_,l~I~l~l'-'---1~l~l_,_I~I~
(last,first)
Hospital provider number: ~--'---''-'--'--'--' (mandatory)
(Use 24 hr time only)
TEST RESULTS
•
•
Screening test normal for
PKU, HOM, GAL, Hypothyroidism
Screening test nom1al for
0
a:C..
0
PKU and HOM only
Hospitalname: ~I~~~~~~~~~~~~~~~ • Screening test normal
w •PKU HOM • GAL •
C'.l
1-
Mother's name: ~I~-'-~-'--'--'--'--'--'--'--'--'--'-~-'-~-'-.,_, • Hypothyroidism

~
(last, first, Initial)
Mother's ID: ""I~I~l~l~I~~~~ Baby's ID:~I~~~~~~
• Screening test abnormal

~
0
~
Mother's address: ~I~I

Mother's phone:
~l-1~~~~~1~l-1~1~~~~~~
( [ I I ] [ I I ] ITIIJ
•
See footnote _ _ _ _ on back
Specimen rejected for reason:

Baby sex: D Male D Female

0
Specimen date [I] [I] [I] MM/DD/YY Time [I] [I] (Use 24 hr time only)

0
::i: Birth weight: ITIIJ grams
a:
~ Physician's name: ~I~~~_,l~I~I_,l~~l~I~I_,l'-'---1~I_,l_,_I~I_,l~I Premature: D Yes D No
z Antibiotics: D Yes D No
....I Physician's address: ~I~I~l_,l~I~I_,l~I~I_,l~~l~I~I_,l'-'---1~I_,l_,_I~I_,l~I
Transfusion: D Yes D No
....I
D First D Second
IIIJ
0
<t'. City I I I I I I I I I I I I I I Ohio zip I I I I I I I Specimen:

Physician's phone: ([II]) [II]- ITIIJ ODHCOPY

Submittor: D Hospital
D Physician
Physician's provider number: I I I I I I I I (mandatory) D Health department
D Other (name below)
ODH COPY: 0 SPECIAL: HEA 2518

Correct Incorrect

1111111111111111111111111111111111111111 11111111111111111111111111111111111111111
I40H 1088462C* I40H 1088462C*
I
ULTS ULTS (!)
ening test nom1al for ening test normal for ::::> w

•• •
' HOM, GAL, Hypothyroidism ' HOM, GAL, Hypothyroidism Oo
ening test nom,al for ening test normal for 0 a: -
and HOM only and HOM only
0IC/J
0 f- Cl)
ening test nom,al ening test normal --' >- :i:
PKU • HOM • GAL PKU • HOM • GAL CD [TI f-
I f- 0
Hypothyroidism Hypothyroidism f- w f-
ening test abnormal ening test abnormal ~ 1[ 0
footnote _ _ _ _ on back
imen rejected for reason:
footnote _ _ _ _ on back
imen rejected for reason:
Cl)::i:O
woo
c30ffi (j)

•• •
a:~>-
D Male D Female • Male • Female - <( ...J
OQo..
Jht: ITIIJ grams Jht: •• DD grams ...J Cl) 0..
...J f- <(
e: OYes D No ·e: OYes ONo <( Cl) f-
OYes D No OYes ONo
--' ::::io
z
::::! ::!:
on: OYes D No on: OYes ONo LL O Q

~
1: D First D Second 1: OFirst D Second 00
D Hospital • Hospital 0
...J
CD
D Physician D Physician
D Health department D Health department
D Other (name below) D Other (name below)
B
FIGURE 29-18 A, AGuthrie card used in neonatal screening. B, Correct and incorrect ways to fill in the circles. (From Warekois RS, Robinson
R: Phlebotomy: worktext and procedures manual, ed 4, St Louis, 2016, Saunders.)

FIGURE 29-19 Capillary puncture sites on the heel and on the fingers.
758 UNIT FOUR DIAGNOSTIC PROCEDURES

Instruct and Prepare a Patient for a Procedure and Perform Capillary Puncture: Obtain
PROCEDURE 29-4
a Capillary Blood Sample by Fingertip Puncture

Goal: To collect acapillary blood specimen suitable for testing using the fingertip puncture technique.

EQUIPMENT and SUPPLIES

• Patient's health record
• Pravider's order and/or lab requisition
• Sterile, disposable safety lancet
• 70% alcohol prep pads
• Gauze pads
• Nonallergenic tape
• Apprapriate collection containers (e.g., capillary tubes, Micratainer tubes)
• Sealing clay or caps for capillary tubes
• Permanent marking pen or printed labels
• Fluid-impermeable lab caat and disposable gloves
• Biohazard bag
• Sharps container and biohazard waste container
PROCEDURAL STEPS
1. Check the pravider's order and/or requisition form to determine the tests
(From Garrels M, Oatis C: Laborato,y and diagnostic testing for ambulato,y settings, ed 3, St Louis,
ordered. Gather the apprapriate tubes and supplies. 2015, Saunders.)
PURPOSE: To perform the pracedure efficiently. Once the skin has been
punctured, the callection must praceed as rapidly as possible so that the 7. Grasp the patient's finger on the sides near the puncture site with your
blood does not clot before the entire specimen has been collected. nondominant forefinger and thumb.
2. Sanitize your hands and put on the fluid-impermeable lab caat and dispos- PURPOSE: Firmly holding the site allows contral of the puncture.
able gloves. 8. Hold the safety lancet against the patient's finger and press down on the
PURPOSE: To ensure infection contral. button that activates the needle or blade to penetrate the skin and then
3. Verify the patient's identity using two identifiers (e.g., have the person automatically retract (Figure 2).
spell his or her last name, state the birth date, and/or show a picture PURPOSE: Lancets are designed to puncture at specific depths that permit
ID). Explain the pracedure and obtain permission for the venipuncture. the free flow of blood.
PURPOSE: To make sure you have the right patient; explanations help gain
the patient's cooperation.
4. Select a puncture site, depending on the patient's age and the sample to
be obtained (e.g., side of middle or ring finger of nondominant hand,
medial or lateral curved surface of the heel for an infant).
PURPOSE: The nondominant hand may have fewer calluses. The side of
the finger is less sensitive, and the skin usually is not as thick. Use great
caution when performing capillary puncture on infants.
S. Gently rub the finger along the sides.
PURPOSE: To pramote circulation. If the finger is very cold, you may
immerse it in warm water or moisten it with warm towels.
6. Clean the site with alcohol, allow it to air dry, or dry it with sterile gauze
(Figure l ).
PURPOSE: Puncturing skin that is wet with alcohol is painful and can
hemolyze the specimen.

(From Garrels M, Oatis C: Laborato,y and diagnostic testing for ambulato,y settings, ed 3, St Louis,
2015, Saunders.)
 CHAPTER 29 Assisting in Blood Collection 759

•;;m,ammf41• -continued
9. Dispose of the lancet in the sharps container. Wipe away the first drop of
blood with clean, sterile gauze.
PURPOSE: The first drop of blood contains tissue fluid, which may alter
test results.
10. Apply gentle, intermittent pressure to cause the blood to flow freely
(Figure 3).
PURPOSE: Forceful squeezing liberates fluid that dilutes the blood and
causes inaccurate results.

(From Garrels M, Oatis (: Laboratory and diagnostic testing for ambulatory settings, ed 3, St Louis,
2015, Saunders.)

(2) Wipe the patient's finger with a clean, sterile gauze pad. Express
another large drop of blood and fill a Microtainer (Figure 5). Do not
touch the container to the finger. If more blood is needed, wipe the
puncture with sterile gauze and gently squeeze another drop. Cap
(From Garrels M, Oatis (: Laboratory and diagnostic testing for ambulatory settings, ed 3, St Louis,
2015, Saunders.) the Microtainer tube when the collection is complete.
PURPOSE: Touching the container to the finger irritates the puncture
11. Collect the blood samples. site and may cause infection.
(1) Express a large drop of blood. Touch the end of the tube to the drop
of blood (not the finger) and fill the capillary to approximately
three-fourths full or to the indicated line (Figure 4). Then tip the
tube with the presealed end down. When the blood flows down and
touches the sealant, hold it for 30 seconds to allow it to seal
automatically. Alternatively, place your finger over the blood-free end
of the tube and seal the other end of the tube by inserting it into
the sealing clay. In both cases, the tube should be approximately
three-fourths full before it is sealed.
PURPOSE: The specimen needs to be without air bubbles and
then sealed in preparation for centrifuging. Placing your finger over
the capillary tube prevents the blood from dripping onto the sealing
clay.

(From Garrels M, Oatis C: Laboratory and diagnostic testing for ambulatory settings, ed 3, St Louis,
2015, Saunders.)
760 UNIT FOUR DIAGNOSTIC PROCEDURES
•;;m,ammf41• -continued
12. When collection is complete, apply pressure to the site with clean, sterile
gauze (Figure 6). The patient may be able to assist with this step.
(From Garrels M, Oatis (: Laboratory and diagnostic testing for ambulatory settings, ed 3, St Louis,
2015, Saunders.)
PEDIATRIC PHLEBOTOMY
Obtaining blood from children and infants may be difficult and
potentially hazardous. The procedure should be performed only by
personnel trained in the techniques for pediatric phlebotomy. Suc-
cessfully obtaining blood from children requires skill and an under-
standing of pediatric psychological development, in addition to
appropriate communication skills. The phlebotomist must gain the
child's confidence and often that of the parent. Parents frequently
ask the phlebotomist to explain the tests being done and the reasons
for them. You should be very careful when divulging information;
never tell the parents what disease or condition a specific blood test
detects. Refer questions to the child's provider.
A parent or guardian may or may not be an asset during the
procedure. Ask the parent about the child's previous phlebotomy
TABLE 29-7 Childhood Behavior and Parental Involvement during Phlebotomy
AGE TYPICAL MENTAL STATE
Newborns (0-12 months) Trust that adults will respond to their needs.
Infants and toddlers (1-3 years) Minimal fear of danger but fear of separation; limited
language and understanding of procedure.
Preschoolers (3-6 years) Fearful of injury to body; still dependent on parent.
School-aged children (7-12 years) Less dependent on parent and more willing to cooperate;
fear of loss of self-control (crying).
Teenagers (13-18 years) Fully engaged in the process; embarrassed to show fear
and may show hostility to cover emotions.
13. Select an appropriate means of labeling the containers. Sealed capillary
tubes can be placed in a red-topped tube, which is then labeled. Microtain-
ers can be placed in zipper-lock biohazard bags that are subsequently
labeled.
14. Check the patient for bleeding and clean the site if traces of blood are
visible. Apply a nonallergenic bandage if indicated.
15. Disinfect the work area. Dispose of blood-contaminated materials (e.g.,
gauze and gloves) in the biohazard waste container. Remove your lab
coat and sanitize your hands.
PURPOSE: To ensure infection control.
16. Complete the laboratory requisition form and route the specimen to the
proper place. Record the procedure in the patient's record.
PURPOSE: Aprocedure is considered not done until it is recorded.
experiences and how cooperative the child is likely to be. Tactfully
determine whether the parent is comfortable with assisting in
restraining an uncooperative child. Parental behavior greatly influ-
ences the child's behavior during the procedure. Children should
never be restrained in a way that might cause physical injury. If the
parent is unable or unwilling to assist with necessary restraint, always
refer to the office or laboratory policy on restraints and procedural
holds. Table 29-7 provides information on the typical fears and
concerns of children during the procedure and suggested parental
involvement.
Removing large amounts of blood, especially from premature
infants, may result in anemia (Table 29-8). The amount of blood
withdrawn must be recorded in the child's chart. Puncturing deep
veins in children may result in cardiac arrest, hemorrhage, venous
SUGGESTED PARENTAL INVOLVEMENT
Parent should assist by cradling and comforting child.
Parent should assist by holding the child and providing
emotional support.
Parent may be present to provide emotional support and to
assist in obtaining child's cooperation.
Child may not want parent present.
Teen may not want parent present.

TABLE 29-8 General Guidelines for Pediatric
Venipuncture
WEIGHT (lb) SINGLE DRAW LIMIT
8-10 3.5 ml
11-15 5 ml
16-40 10 ml
41-60 20 ml
61-65 25 ml
66-80 30 ml
thrombosis, damage to surrounding tissues, or infection. In addition,
the child could be harmed during forceful restraint. To prevent these
problems, blood should be collected only by dermal puncture from
children younger than age 2 unless the procedure warrants venous
collection (lead levels or blood culture). Venipuncture on children
younger than age 2 should be performed only on surface veins,
including the dorsal hand vein, using a 23-gauge winged infusion
set coupled to a syringe or a pediatric vacuum tube collection set.
When the medical assistant is required to perform pediatric phle-
botomy, wearing a colorful, fluid-impermeable jacket; being truthful
about the discomfort the child will feel; and providing tokens and
praise for bravery go a long way toward allaying the child's fears.
Topical anesthetics (e.g., ethyl chloride [EC] spray or EMLA cream)
may be used to reduce pain at the puncture site. A new Buzzy Bee
device is very effective in reducing pain during venipunctures and
injections. In most cases a calm, professional phlebotomist who
understands the developmental needs of the child and relates to the
child on that level can gain the acceptance necessary to perform a
successful venipuncture or dermal puncture with a minimum of
restraint and frustration.
CRITICAL THINKING APPLICATION 29-5
l. As much as Leah likes children, pertorming capillary puncture on little
fingers is not one of her favorite things to do. Mrs. Spix brings in her
son, Garrett, for a hemoglobin and hematocrit test. Garrett is 3 years
old. Mrs. Spix nervously asks Leah about the procedure and the tests
Garrett must have. How can Leah adequately answer Mrs. Spix's ques-
tions and make Garrett and his mother feel at ease about this
procedure?
2. What supplies will Leah need? Explain how she will pertorm the capillary
puncture and pertorm the tests.
HANDLING THE SPECIMEN AFTER COLLECTION
It has been said that the results of laboratory testing are only as good
as the specimen sent for testing. Specimens handled improperly after
collection may provide erroneous results and unnecessarily compro-
mise the patient's health. From the moment the specimen is
CHAPTER 29 Assisting in Blood Collection 761
collected, analytes in the blood begin to decay, and it is a race against
time to provide results that accurately represent a patient's condition
at the time of the blood collection. After collection, blood may need
to be processed before the sample is sent to its final destination. For
most samples, this involves separation of the plasma or serum from
the red blood cells. If the tube contains no anticoagulant, blood
begins to clot when it comes in contact with the red glass tube. The
red-topped plastic tubes require the addition of a clot activator; the
glass SST red-gray marble-topped tube and the plastic SST gold-
topped tube have silica additives to accelerate clotting. All of these
"clot" tubes should be allowed to sit upright in a rack for 30 to 60
minutes at room temperature while a solid clot forms. Tubes with
clot accelerator should form a dense clot within 30 minutes. The
presence of anticoagulants in the patient's blood, such as warfarin
(Coumadin) or heparin, may delay clotting. Once the clot has
formed, every effort should be made to remove the clot from the
serum within 2 hours.
Removal of the clot from the serum requires centrifugation. For
the thixotropic gel to form the barrier between the clot and the
serum, certain g-force, time, and temperature requirements must be
met. The clinical centrifuge instruction manual should provide the
appropriate settings for spinning blood specimens. The serum does
not have to be removed from the tube after centrifugation because
the gel has formed a barrier over the red blood cells. Once a tube
with thixotropic gel has been centrifuged, it cannot be centrifuged
again. The serum, however, can be decanted and centrifuged in
another tube.
For tests that require plasma, the plasma should be removed from
the cells as soon as possible. This can be accomplished with centrifu-
gation followed by aspiration of the plasma and transfer to another
tube using a disposable pipet. A safer method of obtaining plasma
is the use of the glass PST green-gray marble-topped tube or the
plastic PST light green-topped tube. Both contain lithium heparin
anticoagulant and a thixotropic gel, which forms the necessary
barrier when centrifuged as described previously.
Certain blood tests, such as the CBC, require whole blood. It is
wise to check the requirements of the laboratory that will perform
the test as to how the specimen should be transported and stored.
The College of American Pathologists recommends that whole blood
for automated blood counts be refrigerated and tested within 72
hours.
Often specimens must be transported by courier to other facili-
ties. The Hazardous Materials Shipping Regulations, established by
the Department of Transportation, apply to the packaging or ship-
ping of hazardous materials by ground transportation. Those who
ship human specimens must be trained in all aspects of handling,
packing, and shipping ofbiohazardous materials. Reference labs will
also send couriers to pick up the specimens. The specimens and their
requisitions are typically placed in individual biohazard bags and
sorted according to which reference lab is affiliated with the patient's
insurance.
CHAIN OF CUSTODY
Blood samples may be collected as evidence in legal proceedings.
Blood may be drawn for drug and alcohol testing, DNA analysis, or
parentage testing. These samples must be handled according to
762 UNIT FOUR DIAGNOSTIC PROCEDURES
special procedures to prevent tampering, misidentification, or inter-
ference with the test results.
Chain of custody is a legal term that refers to the ability to guar-
antee the identity and integrity of the specimen from collection to
reporting of test results. It is a process used to maintain and docu-
ment the chronologic history of a specimen. Documents should
include the name or initials of the individual collecting the speci-
men, each person or entity subsequently having custody of it, the
date the specimen was collected or transferred, the employer or
agency, the specimen number, the patient's or employee's name, and
a brief description of the specimen.
Collection kits are available that contain everything needed for
the venipuncture, including the tube, the needle, the chain of
custody forms and seals, the antiseptic, and even the tourniquet.
Familiarize yourself with these kits before you are required to use
them. You may be required to testify at a legal proceeding if you are
involved in the collection or testing of a sample.
CLOSING COMMENTS
Patient Education
Provide as much explanation as needed to ease the patient's anxiety.
Often the patient can help by identifying the site of the last success-
ful blood draw. Follow the patient's suggestion in choosing the
site for obtaining a blood specimen. When a patient is allowed to
become an active participant in the procedure, he or she remains
more relaxed, talkative, and confident in your expertise as a
phlebotomist.
Legal and Ethical Issues
Venipuncture and microcapillary blood collection are invasive pro-
cedures in which a sterile needle or a lancet is inserted through the
skin. Because the skin is penetrated, drawing blood becomes a surgi-
cal procedure and is subject to the laws and regulations of surgery.
When venipuncture is performed, the rules and regulations must be
enforced with no deviations. Be sure to follow the procedures as
SCENABIO
Leah has learned that phlebotomy is truly an art. Although she was nervous at
first, she has become quite proficient with this new skill. She discovered that
her nervousness was "contagious," and that if she remains calm and organized,
her patients are more likely to feel at ease with the procedure. She has learned
that it is necessary to talk with patients before drawing their blood, not only
to allay their fears, but also to get clues about past problems or the best site
for the draw. She has learned that she is responsible for explaining the tests
ordered and how much blood she will draw, but that she is not responsible for
explaining the reasons the tests are being done. Effective communication is the
most important aspect of phlebotomy.
written and to become familiar with the regulations and standards
established by local and state agencies, in addition to CLSI and
OSHA. Deviations leave the medical assistant open to accusations
of malpractice. Document any situations that arise in which observa-
tion of the standard of care comes into question.
Professional Behaviors
Your appearance and actions reflect your laboratory or facility. Apatient's
first impression of the facility often comes from you. Clean fluid-impermeable
laboratory coats and scrubs tell the patient the facility is clean; sanitizing
your hands and wearing gloves tells the patient you will treat him or her
with care; and speaking knowledgeably provides the impression that the
facility is staffed with professionals.
Medical assistants who perform venous and capillary blood collection
must maintain a professional attitude, yet remain sympathetic to the
patient's fears and anxiety about being "stuck with a needle." Establishing
an environment that encourages the person to relax can minimize the
patient's pain and discomfort during the procedure. Always remember to
verify your patient's identity and explain what you are going to do. Answer
any questions the patient may have, and perrorm the procedure skillfully
before anxiety has time to set in.
The atmosphere can change dramatically if the patient has had an
unpleasant experience and associates pain and discomfort with venipunc-
ture. Such a patient usually is ill at ease and apprehensive. In this case,
you need to make every effort to perrorm the procedure quickly, efficiently,
and effectively. Once the blood has been drawn and the patient has relaxed,
you can help the patient develop a positive attitude.
If your patient has a history of syncope when blood is drawn or if you
suspect the patient may faint during the procedure, have the person lie
down. Assemble your equipment and alert the provider before beginning
the procedure. This type of professional care may help the patient get
through the procedure without a traumatic effect.
Through practice and careful attention, Leah has come to recognize the
proper equipment to use in phlebotomy, and she never hesitates to call the
referral laboratory used by her employer if she has a question about proper
collection of a specimen. Communicating with children and adults is as different
as the equipment she uses for venipuncture; the small veins of children and the
elderly require special care, and she has become proficient in the use of winged
infusion sets and syringes to prevent vein collapse. Leah is well aware of the
dangers of phlebotomy, and through education and the use of approved safety
devices, she is confident that she can provide excellent care for her patients at
the Health Alliance Medical Clinic.

SUMMARY OF LEARNING OBJECTIVES
l. Define, spell, and pronounce the terms listed in the vocabulary.
Spelling and pronouncing medical terms correctly reinforce the medical
assistant's credibility. Knowing the definitions of these terms promotes
confidence in communication with patients and co-workers.
2. List the equipment needed for venipuncture.
Venipuncture requires a double-pointed safety needle, evacuated collec-
tion tubes, a needle holder or a syringe fitted with a safety needle, a
tourniquet, an alcohol prep pad, gauze or cotton, a sterile bandage,
nonlatex gloves, and a biohazard sharps container.
3. Explain the purpose of a tourniquet, how to apply it, and the con-
sequences of improper tourniquet application.
Atourniquet is used to hold back venous flow out of the site, which
causes the veins to bulge. The tourniquet makes veins easier to locate
and puncture. Tourniquets are applied snugly around the upper arm (or
wrist for a hand draw) in a fashion that permits easy release. Leaving
the tourniquet on a prolonged time results in hemoconcentration; apply-
ing the tourniquet too tightly results in unnecessary discomfort to the
patient and the release of tissue fluid into the blood.
4. Explain why the stopper colors on vacuum tubes differ, and state
the correct order of drawing samples for various types of tests.
The various colors of vacuum tube stoppers indicate the contents of the
tube. Certain additives are compatible with certain laboratory tests. The
phlebotomist must be knowledgeable about blood tests and the types of
tubes needed. Consulting literature provided by the manufacturer ensures
the proper choice of a collection tube. The correct order af draw is (1)
pale yellow (sterile or SPS), (2) light blue, (3) red, red-gray marbled,
or gald plastic top, (4) green, (5) lavender, and (6) gray. Vacuum tubes
are collected in a specific order to prevent carryover af tube additives.
5. Describe the types of safety needles used in phlebotomy.
The venipuncture needle has ashaft with one end cut at an angle (bevel).
The other end (the hub) attaches to the syringe or ta a needle holder. The
inner bore or space in the needle is called the lumen. It is measured in
gauge numbers (the higher the gauge number, the smaller the lumen).
Double-pointed needles are used for the evacuated tube method in which
the blood flows directly from the vein into the evacuated tube. Removable
safety needles are used with disposable syringes. The collected blood in
the syringe is then transferred to the appropriate evacuated tubes using
a safety transfer device. Safety lancets are used for dermal puncture.
6. Explain why a syringe rather than an evacuated tube would be
chosen for blood collection.
Syringes are more commonly used for blood collection from elderly
patients, whose veins tend to be more fragile; from children, whose veins
tend to be small; and from obese patients, whose veins tend to be deep.
Using a syringe allows a more controlled draw. Syringes commonly are
used with winged infusion sets.
7. Discuss the use of safety-engineered needles and collection devices
required for injury protection.
OSHA requires that all sharp items (i.e., needles and glass) used for
phlebotomy should be engineered with safety devices, such as retractable
CHAPTER 29 Assisting in Blood Collection 763
needles, self-sheathing needles, and blunting devices. Needles should
never be recapped with two hands, and in mast cases they are not
removed from the venipuncture unit. All sharps must be disposed of in
an approved biohazard sharps container.
8. Summarize postexposure management of needlesticks.
OSHA requires employers to have a pastexposure plan in place for
accidental sharps exposures. These plans generally include a means to
cleanse the wound with an appropriate antiseptic cleanser; evaluation of
the exposure to determine whether the employee is at risk for contracting
HBV, HCV, or HIV, depending on the circumstance of the injury; gathering
of information about the source of the blood involved; prophylactic care
if necessary; confidential counseling for the injured; and follow-up on the
exposure.
9. Do the following related to routine venipuncture:
• Detail patient preparation for venipuncture that shows sensitivity to
the patient's rights and feelings.
The medical assistant must be sensitive to the needs and concerns of
patients both before and during the phlebotomy procedure. The pro-
cedure should be explained to the patient, and all questions should
be answered. The patient should be observed for any problems
during the procedure, and the medical assistant should use therapeu-
tic communication techniques throughout the intervention.
• Describe and name the veins that may be used for blood collection.
The median cephalic vein is the vein of choice for phlebotomy, but
blood can be drawn from the cephalic vein and the median basilic
vein. The basilic vein should not be used if possible. The dorsal vein
on the hand may be used.
• List in order the steps of aroutine venipuncture.
Aroutine venipuncture begins with greeting the patient and verifying
his or her identity. The medical assistant then sanitizes his or her
hands, assembles the equipment and PPE, locates the vein, disinfects
the area over the vein, allows the alcohol to dry, draws the blood into
the correct vacuum tubes in the proper order of draw, removes and
properly disposes of the needle, tends to the puncture site, labels the
tubes, and delivers them to the laboratory. Standard Precautions are
followed during the procedure.
• Perform avenipuncture using the evacuated tube method.
Refer to Procedure 29-1 .
• Perform avenipuncture using the syringe method.
Refer to Procedure 29-2.
l 0. Do the following related to problems associated with venipuncture
and specimen re-collection:
• Discuss various problems associated with venipuncture.
Failure to obtain blood can occur because of a variety of factors.
Several possible causes, such as hematomas, fainting, and nerve
damage, are discussed in the text.
• Discuss possible solutions to venipuncture complications.
Refer to Table 29-4 for a list of solutions to possible complications.
Continued
764 UNIT FOUR DIAGNOSTIC PROCEDURES
SUMMARY OF LEARNING OBJECTIVES-continued
• Discuss why aspecimen may have to be re-collected.
Specimens can be rejected by a laboratory for a variety of reasons.
Hemolysis is the major cause of specimen re-collection.
• Describe the major causes of hemolysis during collection.
Refer to Table 29-5.
11. Do the following related to capillary puncture:
• Explain why awinged infusion set (butterfly needle) would be chosen
over a vacuum tube or syringe needle.
Awinged infusion set (butterfly needle) is used on blood draws from
the hand and from children. The needle is shorter, and the wings assist
with holding and guiding the needle. The tubing minimizes the force
of the vacuum and prevents collapse of fragile veins. Using a syringe
can also control the vacuum to a greater extent than using vacuum
tubes.
• Perform avenipuncture using awinged infusion set (butterfly needle).
Refer to Procedure 29-3.
• List situations in which capillary puncture would be preferred over
venipuncture.
Capillary puncture is preferred over venipuncture for certain point-of-
care tests, such as hematocrit or hemoglobin analysis. It is performed
routinely on children younger than age 2.
• Discuss proper dermal puncture sites.
The lateral sides of the tips of the middle two fingers generally are
used for capillary puncture. In infants, the medial and lateral sides on
the plantar surface of the heel are the sites of choice. The center of
the heel must be avoided.
• Describe containers that may be used to collect capillary blood.
Capillary blood can be collected in or on specific devices related to
point-of-care tests. Microtainer tubes, capillary tubes, and paper test
cards are also used to send specimens ta the lab for testing. The
Microtainer tubes may contain anticoagulants and additives and have
stopper colors consistent with vacuum tubes.
CONNECTIONS
OJ Study Guide Connection: Go to the Chapter 29 Study Guide. Read and complete
the activities.
• Explain why the first drop of blood is wiped away when a capillary
puncture is performed.
The first drop of blood contains tissue fluid that could affect the test
results.
• Perform acapillary puncture.
Refer to Procedure 29-4.
12. Discuss pediatric phlebotomy, including typical childhood behavior
and parental involvement during phlebotomy and general guide-
lines for pediatric venipuncture.
Obtaining blood from children and infants may be difficult and potentially
hazardous. Refer to Table 29-7 for information on typical fears
and concerns of children during the procedure and suggested parental
involvement. Refer to Table 29-8 for general guidelines for pediatric
venipuncture.
13. Describe handling and transport methods for blood ofler
collection.
From the moment the specimen is collected, analytes in the blood begin
to decay, and it is a race against time ta provide results that accurately
represent a patient's condition at the time of the blood collectian. There
are variaus procedures based on the type af test performed.
14. Explain chain of custody procedures when blood samples ore drown.
Chain of custody is a legal term that refers to the ability to guarantee
the identity and integrity of the specimen from collection to reporting of
the test results. It is a process used ta maintain and document the
chronologic history of a specimen.
15. Discuss patient education, in addition to legal and ethical issues,
related to assisting in blood collection.
Provide as much information as needed to ease the patient's anxiety.
Document any situatians that arise in which observations of the standard
of care comes into question.
evolve Evolve Connection: Go to the Chapter 29 link at evolve.elsevier.com/
kinn to complete the Chapter Review Quiz. Check out the other resources listed for this
chapter to make the most of what you have learned from Assisting in Blood Collection.
ASSISTING IN THE ANALYSIS
OF BLOOD
Dana Cummings, CMA (AAMA) is working in the Westhills Family Practice
Center. She is preparing to collect blood from Mr. Corrigan, who recently
underwent renal transplantation because of complications from diabetes type
l. He has come to the office today for a routine examination. Dr. Fischbach
suspects that Mr. Corrigan is anemic and orders an anemia panel in addition to
While studying this chapter, think about the following questions:
• Why are so many tests being performed for Mr. Corrigan?
• Which of these tests probably will be completed today in the office laboratory?
LEARNING OBJECTIVES
l . Define, spell, and pronounce the terms listed in the vocabulary.
2. Name the main functions of blood.
3. Describe the appearance and function of erythrocytes.
4. Describe the appearance and function of granular and agranular
leukocytes.
5. Differentiate between Tcells and Bcells.
6. Describe the appearance and function of thrombocytes, explain the
process of clot formation, and discuss plasma.
7. Do the following related to hematology in the POL:
• Identify the anticoagulant of choice for hematology testing.
• Explain the purpose of the microhematocrit test.
• Perform routine maintenance of a microhematocrit centrifuge.
• Obtain a specimen and perform a microhematocrit test.
8. Do the following related to hemoglobin:
• Explain the role of hemoglobin in the body.
• Obtain a specimen and perform a hemoglobin test.
9. Do the following related to the erythrocyte sedimentation rate:
• Cite the reasons for performing an erythrocyte sedimentation rate
(ESR) test.
• Describe the sources of error for the erythrocyte sedimentation rate
(ESR) test.
• Perform an erythrocyte sedimentation rate (ESR) test using a
modified Westergren method.
l 0. Do the following related to coagulation testing:
• Explain how to determine prothrombin time (PT).
• Obtain a specimen and perform a CUA-waived PT/INR test.
• Reassure a patient of the accuracy of the test results.
• Maintain lab test results using laboratory flow sheets.
30
a renal panel; a hemoglobin A1c level; a complete blood count (CBC), including
hemoglobin, hematocrit, and differential; prothrombin time/international nor-
malized ratio (PT/INR); and alanine aminotransferase/aspartate aminotrans-
ferase (ALT/AST) testing.
11. Identify the tests included in a complete blood count (CBC) and their
reference ranges, and differentiate between normal and abnormal test
results.
12. Describe the red blood cell (RB() indices and how they are calculated.
13. Explain the reasons for performing a white blood cell (WBO count and
differential, and discuss preparation of blood smears for the
differential.
14. Discuss the identification of normal blood cells and describe the basic
appearance of the five different types of leukocytes seen in a normal
Wright-stained differential.
15. Discuss red blood cell morphology.
16. Differentiate between the ABO blood groupings and the Rh blood
groupings.
17. Describe the medical assistant's responsibility for legally preparing a
patient for a blood transfusion.
18. Do the following related to blood chemistry testing:
• Explain the reasons for testing blood glucose, hemoglobin A1c,
cholesterol, liver enzymes, and thyroid hormones.
• Obtain a specimen and perform a blood glucose, hemoglobin A1c,
and cholesterol test using CUA-waived test methods approved by
the U.S. Food and Drug Administration (FDA).
19. Summarize typical chemistry panels, the reason for performing each
panel, and the individual tests performed in the panels.
20. Discuss patient education and professionalism related to assisting in
the analysis of blood.
766 UNIT FOUR DIAGNOSTIC PROCEDURES
VOCABULARY
anemia A condition marked by a deficiency of red blood cells
(RBCs).
antibody A specific protein produced by a lymphocytic plasma
cell to destroy a specific foreign invader (antigen) in the body.
antigen A foreign invader (e.g., bacterium, virus, toxin, allergen)
that generates an immune response with the production of
antibodies.
artifacts Structures or features not normally present but visible as
a result of an external agent or action.
basophils White blood cells with granules that stain deep blue
and play a part in the inflammatory process.
huffy coat The layer of white cells and platelets found between
the plasma and the packed RBCs after whole blood is
centrifuged.
centrifuge (sen'-trih-fuj) An apparatus consisting essentially of a
compartment that spins about a central axis to separate
contained materials of different specific gravities or to separate
colloidal particles suspended in a liquid.
cuvette A specimen container made of plastic or glass designed to
hold samples for laboratory tests using light meter technology
(spectrophotometry).
T he average body holds 10 to 12 pints of blood. The heart cir-
culates the blood through the circulatory system more than
1,000 times every day. More than 70,000 miles of passageways, most
of which are narrower than a human hair, carry blood throughout
the body. The blood is contained in a closed system of vessels; the
largest is the aorta, and the smallest are the capillaries. The capillaries
are only one cell layer thick, and their thin, permeable walls allow
certain substances to move back and forth between blood vessels and
surrounding tissue. The circulating blood contains more than 25
trillion cells, and every second the body replaces 8 million old red
blood cells (RBCs) with 8 million new RBCs.
The circulating blood supplies the body's cells with nutrients and
oxygen. The blood carries away carbon dioxide and urea, the waste
products of normal cell activity. If the blood did not carry away these
waste products, they would accumulate and damage the cells.
Carbon dioxide is carried in the blood to the lungs, where it is
exhaled as part of normal breathing. The blood carries urea to the
kidneys, where it is excreted in the urine along with other body
wastes. The blood also distributes enzymes, hormones, and other
chemicals needed for control and regulation of body activities. In
addition, the blood functions to maintain the body at a uniform
temperature, to keep other body fluids in a state of pH balance, and
to carry hormones from the secreting gland to the tissues where they
are needed.
Blood tests are done routinely in the hematology, immunohema-
tology (blood banking), chemistry, and immunology (serology)
departments of the laboratory. The degree of blood testing per-
formed by medical assistants depends on the level of service offered
by the ambulatory care facility and the regulations established by the
Clinical Laboratory Improvement Amendments (CLIA). As a
enzymes Complex proteins produced by cells that act as catalysts
in specific biochemical reactions.
eosinophils White blood cells with granules that stain red. Their
numbers increase during allergic reactions.
leukocytosis An increase in the number of white blood cells
(WBCs).
lymphocytes Non-granular small white blood cells with a dense
nucleus. Their numbers increase during a viral infection.
monocytes Non-granular large white blood cells with a large
lobular nucleus. Their numbers increase during the recovery
phase of tissue damage.
neutrophils White blood cells with small granules that stain
lavender. They are the most common WBC and fight bacterial
infections.
polycythemia vera (pah-le-si-the'-me-uh/veh'-rah) A condition
marked by an abnormally large number of red blood cells
(RBCs) in the circulatory system.
type and cross-match Tests performed to assess the compatibility
of blood to be transfused.
urea The major nitrogenous end product of protein metabolism
and the chief nitrogenous waste product in the urine.
medical assistant, you are qualified to perform the CUA-waived
procedures described in the physician office laboratory (POL) sec-
tions of this chapter. The more highly complex CLIA blood tests are
performed at reference and hospital laboratories and are not per-
formed by medical assistants. Nevertheless, this chapter explains
these procedures to provide background information critical to an
understanding of the analysis of blood, from collection of the speci-
men, through testing, to recording of the results.
HEMATOLOGY
Whole blood is composed of visible formed elements suspended in
plasma (a clear, yellow liquid). Plasma makes up approximately 55%
of blood by volume. The remaining 45% consists of the following
visible cellular elements: erythrocytes (RBCs), leukocytes (WBCs),
and thrombocytes (platelets). All these cellular elements have special
functions.
Erythrocytes
RBCs, or erythrocytes, are formed in the red bone marrow of the
ribs, sternum, pelvis, and skull and in the ends of long bones in
adults. The nucleus of the immature RBC disintegrates as the cell
matures. Loss of the nucleus results in the familiar shape of the
RBC: a biconcave disk that is thicker at the rim than in the
middle. Erythrocytes transport oxygen from the lungs to the body
cells, and they carry some of the carbon dioxide away from cells
back to the lungs to be exhaled. The main constituent of the RBC
is the red pigment, hemoglobin, which is composed of iron and
protein. Hemoglobin is the carrier of oxygen and some carbon
dioxide.

The life span of an erythrocyte is approximately 120 days. As the
cell nears the end of its life, it becomes more fragile and eventually
ruptures and breaks. The iron is reused for the formation of new
RBCs, and the remaining portion is converted into bilirubin, which
then becomes bile in the liver.
Leukocytes
WBCs, or leukocytes, have a nucleus and are larger than erythro-
cytes. The primary function of the leukocytes is to protect the body
against infection and disease. The five types of leukocytes are classi-
fied into two categories: granular (three types; cells with granules)
and agranular (two types; cells without granules).
Granular Leukocytes
The three granular leukocytes are the polymorphonuclear neutro-
phils (PMNs), eosinophils (EOs), and basophils (BASOs). They
are characterized by their heavily granulated cytoplasm and seg-
mented nuclei. The neutrophils are phagocytic; that is, they engulf
and destroy invading bacteria and viruses. Unlike erythrocytes, leu-
kocytes are found in both the bloodstream and the tissues. During
inflammation, the blood carries the PMNs through dilated vessels
to the site of injury. Capillary walls become more permeable, and
the granular cells squeeze through to the site of infection. Once at
the site of infection or injury, the PMNs engulf the invading micro-
organism, creating pus, which contains dead leukocytes, bacteria,
and tissue cells. The eosinophils are associated with allergies, and the
basophils play a part in inflammation.
Nongranular Leukocytes
The two nongranular leukocytes are the monocytes and lympho-
cytes, both of which have clear cytoplasm (no granules) and a solid
nucleus. The large monocytes become macrophages (large engulfing)
cells when they enter the tissues and engulf pathogens and debris.
The small lymphocytes are responsible for immunity and are further
classified into T cells and B cells based on their functional
characteristics.
T Cells: Cell-Mediated Immunity. T lymphocytes make up about
65% to 80% of the circulating lymphocytes; they have a life span
of months to years. This is important for obtaining long-lasting
immunity to microbial infections. Four types of T cells mount an
immune response to parasites, viruses, fungi, and bacteria:
• Natural killer cells: These T cells kill virus-infected cells and
tumor cells without previous sensitization.
• Helper T cells: These are the most numerous type of T cell.
They stimulate the activity of other T cells and help the B cells
produce their antibodies. Note: These are the T lymphocytes
that are destroyed by the human immunodeficiency virus
(HIV), causing the individual to be immunodeficient.
• Suppressor T cells: These cells inhibit the activity of other T
cells once the invaders are under control.
• Memory T cells: These cells, which have a long life span,
respond quickly to the presentation of the same antigen at a
later date.
B Cells: Humoral Immunity (Antibody-Mediated). B cells are
formed in bone marrow and then migrate to other lymph organs
(i.e., lymph nodes and the spleen), where they multiply and reside.
When stimulated by the T cells, B cells differentiate into plasma cells
CHAPTER 30 Assisting in the Analysis of Blood 767
that produce the specific antibody needed to destroy a specific
antigen. The antibodies circulate in the plasma or are present in
secretions.
Antibodies are protein molecules that specifically attach to
antigens. Very small antigens, such as toxins and viruses, can be
directly neutralized by antibodies. Larger antigens, such as bacte-
ria, require the help of neutrophils to phagocytize (engulf) and
destroy them.
Three steps are required to activate the B cells to produce their
specific antibody that then attacks the particular antigen or the
pathogen:
I. Antigen processing: When the macrophage (formerly a mono-
cyte) phagocytizes (engulfs) bacteria, proteins from the bacteria
are broken down into smaller molecules, which are then "dis-
played" on the surface of the macrophage.
2. Lymphocyte stimulation: When a T lymphocyte "sees" the mol-
ecules displayed on the macrophage, the T cell brings the
message to the B cell which becomes a plasma cell capable of
making the specific antibodies to destroy the foreign invader
(antigen).
3. Antibody production: The stimulated B cell also undergoes
repeated cell division, enlargement, and differentiation to
form a clone of antibody-secreting plasma cells. The anti-
bodies then bind to the bacteria, making them easier for the
white cells to ingest, or the antibodies combine with a
plasma component called complement that kills the bacteria
directly.
Hypersensitivity reactions, such as allergies and autoimmune dis-
eases, are the result of overactive lymphocytic defenses.
Thrombocytes
Thrombocytes are not true cells, but rather cytoplasmic fragments
of a megakaryocyte, a large cell in the bone marrow. They are the
smallest formed elements of the blood. They typically have a discoid
shape; however, when activated, they become globular and form
fingerlike cytoplasmic extensions called pseudopodia.
Clot Formation
In minor injuries, thrombocytes (platelets) tend to collect and
form plugs in blood vessel openings. To control bleeding from
vessels larger than capillaries, a dot must form at the point of
injury. Coagulation (dotting) of the blood is also initiated by
blood platelets. The platelets produce a substance that combines
with calcium ions in the blood to form thromboplastin, which in
turn converts the protein prothrombin into thrombin through a
complex series of reactions. Thrombin, an enzyme, converts fibrin-
ogen, a protein substance, into fibrin, an insoluble protein that
forms an intricate network of minute, threadlike structures .. The
blood cells and plasma become enmeshed in the network forming
a dot.
More than 30 substances in the blood have been found to affect
dotting; whether blood will coagulate depends on a balance between
the substances that promote coagulation and those that inhibit it
(anticoagulants). Coagulation of blood within blood vessels in the
absence of injury (thrombosis) can cause serious illness or death,
especially when a dot forms in the coronary arteries, causing heart
attacks, or in the cerebral arteries, causing strokes.
768 UNIT FOUR DIAGNOSTIC PROCEDURES

Hemophilia, a bleeding disorder, occurs when a person has a

mutation in one of the clotting factor genes. It is a hereditary,
gender-linked disorder that affects males of all races and ethnic
groups. The mutated gene is on the X chromosome inherited from
the mother. Approximately one in 5,000 males is born with the
disorder; it is rare, but possible, for a female to have hemophilia.
People with hemophilia are treated with intravenous (IV) purified
clotting factor and/or DDAVP to prevent bleeding episodes. Inter-
nal bleeding can affect the joints and the neurologic system.
Bleeding within the joints can cause chronic joint disease and
pain. Bleeding in the brain can cause seizures, paralysis, and even
death.

Plasma
Plasma is the highly complex liquid that is the carrier for the formed
elements plus other substances, such as proteins, carbohydrates, fats,
hormones, enzymes, mineral salts, gases, and waste products. Plasma
is composed of approximately 90% water, 9% protein, and 1%
various other chemical substances. When the clotting proteins (pro-
thrombin and fibrinogen) and the other clotting components are
used up during the clotting process (e.g. within a "clot" or "SST"
FIGURE 30-1 Centrifuge with indicators for capillary tube placement.
specimen), the remaining liquid is called serum.

HEMATOLOGY IN THE PHYSICIAN OFFICE Capillary tube

LABORATORY (POL)
For most POL hematology tests, an adequate blood sample can
be obtained from capillary punctures of the finger. If a larger
sample is required, blood can be obtained via venipuncture. For a
complete blood count (CBC), venous blood is collected in a
lavender-topped tube containing ethylenediarninetetraacetic acid The results are read
(EDTA), an anticoagulant that prevents clotting. EDTA is the at the top of the
packed cell column
anticoagulant of choice for hematology testing because it also
acts as a preservative for the blood cells. It is very important to
prevent blood from being hemolyzed during collection for hema-
tology testing. Packed red
blood cells
Hematocrit
The hematocrit (Hct) is a measurement of the percentage of packed
RBCs in a volume of blood. The spun microhematocrit test is based Sealing compound
on the principle of separating the cellular elements from plasma by
FIGURE 30-2 Hematocrit test results. Cellular elements are separated from plasma by centrifuging
centrifugation (Procedures 30-1 and 30-2). Two or three drops of
an anticoagulated blood specimen, and the results are read at the top of the packed cell column.
blood are collected from a capillary puncture in two capillary tubes
that are placed in a specially designed microhematocrit centrifuge
(Figure 30- 1). Alternatively, the capillary tubes can be filled with
EDTA-anticoagulated blood from a lavender-topped vacuum tube. is determined by comparing the volume ofRBCs to the total volume
As required by the Occupational Safety and Health Administration of the whole blood sample. The percentage is read by placing the
(OSHA), capillary tubes must be safe, with plastic-coated glass or tubes on a special microhematocrit reader. Some microhematocrit
all plastic to avoid sharps injuries. They may be either self-sealing at centrifuges have a built-in reading scale that reads the calibrated
one end or open-ended on both ends. If the tube is self-sealing, it capillary tubes. Microhematocrits should be performed in duplicate
must be tilted upright, causing the blood sample to flow down the and the average of the two results reported.
tube and come into contact with the seal, and then held in place for Normal Hct values vary with gender and age (Table 30-1 ).
15 seconds. The open-ended tubes must be sealed with special clay They range from a low of 36% in women to a high of 52% in
before centrifugation. men. Low microhematocrit values can indicate anemia or the
Afrer centrifugation, the packed RBCs are at the bottom of the presence of bleeding. High values may be caused by dehydration
tube against the sealant, the WBCs and platelets are in the center or by a condition such as polycythemia vera. Values can be in-
huffy coat, and plasma is on top (Figure 30-2). The microhematocrit fluenced by physiologic or pathologic factors and by collection
 CHAPTER 30 Assisting in the Analysis of Blood 769

techniques. Normal Hct ranges are also affected by geographic lo-

TABLE 30-1 Hematocrit (Hct) Reference Values cation; for example, people living in high altitudes have a higher
AGE/GENDER Hct VALUE (%) percentage of RBCs to compensate for the lower oxygen levels in
the atmosphere.
Neonate (new born-under l month) 44-64 The microhematocrit is a commonly performed test requested by
Infant (l month-1 yr) 37-41 providers either separately or as part of the CBC. Because it is a
simple procedure that requires only a small amount of blood, it is
Child (l-10 yr) 35-41 an ideal screening test and often is part of a routine physical exami-
Men (greater than 10 yrs) 42-52 nation. Quality assurance includes care and maintenance of the
microhematocrit instrument.
Women (greater than l Oyrs) 36-45

Perform Routine Maintenance of Clinical Equipment: Perform Preventive Maintenance

PROCEDURE 30-1
for the Microhematocrit Centrifuge

Goal: To perform daily, monthly, and quarterly preventive maintenance on amicrohematocrit centrifuge.
EQUIPMENT and SUPPLIES
• Microhematocrit centrifuge
• Maintenance logbaok
• Utility gloves
• Disposable gloves
• Face shield, fluid-impermeable gown as needed
• Disinfectant
• Biohazard waste container
• Maintenance logbook
PROCEDURAL STEPS
PPE: Always sanitize your hands; then put on fluid-impermeable gown, face
shield, and gloves. In all maintenance procedures, disposable gloves are worn
under the utility gloves.
Note: These are generic recommendations. Always check the manufacturer's
guidelines for specific instructions.
Always unplug the power cord before cleaning or servicing the centrifuge.
Daily Maintenance
1. Clean the inside of the centrifuge and the gasket with a disinfectant recom-
mended by the manufacturer. Plastic and nonmetal parts may be cleaned
with afresh solution of 5% sodium hypochlorite (bleach) mixed l : l Owith
water (1 part bleach plus 9 parts water).
PURPOSE: To remove any dried blood or shattered glass. Do not use bleach
on the gasket because it may harden the rubber.
Monthly Maintenance
1. Check the reading device. Misuse and zeroing of the reading devices can
result in considerable error. Always use a second, simple reading device as
a cross-check. Use a ruler or a flat plastic card specially made for this
purpose. To use these cards, lay the spun hematocrit tube on the card and
align the red cells with a line on the card to obtain the reading.
2. Check the rotor for cracks or corrosion and check the interior for signs of
white powder.
PURPOSE: Cracks, corrosion, or powder may indicate impending rotor failure;
these findings require the immediate attention of aservice technician.
3. Record all preventive maintenance in the laboratory logbook.
PURPOSE: Recording maintenance is necessary to maintain warranties
and to comply with regulations established by CUA and other regulatory
agencies.
Semiannual Maintenance
1. Check the gasket for cuts and breaks.
PURPOSE: Cut gaskets allow tubes to leak and must be replaced.
2. Check the timer with a stopwatch.
3. Perform a maximum cell pack to verify the time required for complete
packing by reading a sample after centrifugation and then recentrifuging for
l minute. The results should be the same. If they are not, perrorm preven-
tive maintenance and/or call the service technician.
PURPOSE: If the cells compact further during recentrifugation, the centri-
fuge is not rotating at the proper speed, and hematocrit results will be falsely
elevated.
4. Record all preventive measures in the equipment maintenance log.
PURPOSE: Recording maintenance is necessary to maintain warranties
and to comply with regulations established by CUA and other regulatory
agencies.
Annual Maintenance (or Maintenance Performed as Needed)
1. The centrifuge functions and maintenance verification should be perrormed
by qualified personnel. This includes checking the centrifuge mechanism,
rotors, timer, speed, and electrical leads.
2. Record all professional service calls in the laboratory logbook.
MICROHEMATOCRIT CENTRIFUGE MAINTENANCE LOG
DATE SERVICE INITIALS
10/7/20XX Performed routine daily and monthly DC
preventive maintenance
770 UNIT FOUR DIAGNOSTIC PROCEDURES
Obtain Specimens and Perform CUA-Waived Hematology Testing: Perform a
PROCEDURE 30-2
Microhematocrit Test
Goal: To perform amicrohematocrit test accurately.
EQUIPMENT and SUPPLIES
• Provider's order and/or lab requisition, microhematacrit lab log, patient's
health record
• Fresh sample of blood collected in a tube containing ethylenediaminetet-
raacetic acid (EDTA) anticoagulant (ar equipment for finger stick specimen:
lancet, alcohol pad, gauze, bandage)
• Plastic-coated self-sealing capillary tubes, or plain capillary tubes
(blue-tipped)
• Sealing clay (if capillary tubes are not self-sealing)
• Gauze
• Hematocrit centrifuge
• Fluid-impermeable lab coat, disposable gloves
• Biahazard waste and sharps containers
PROCEDURAL STEPS
1. Sanitize your hands. Put on disposable gloves, fluid-impermeable lab coat,
and protective eyewear.
PURPOSE: To ensure infection control.
2. Assemble the materials needed.
3. A) If the capillary tubes are self-sealing. fill two tubes by inserting the
end apposite the sealed end into the well mixed EDTA blood sample. Note:
If the capillary tube and the EDTA tube are held almost parallel to the
table, the capillary tubes fill easily by capillary action. When the self-
sealing capillary tubes are two thirds ta three fourths filled, tilt them
upright causing the blaad sample to flaw dawn the tube and come into
contact with the sealant. Continue to hold the tube vertical when the blood
makes contact with the sealant for an additional 15 seconds.
PURPOSE: Duplicates should always be done as a means of quality
control. Tubes are not filled completely to provide space for the sealing
clay.
B) Alternatively, fill two plain (blue-tipped) capillary tubes two thirds to
three fourths full with the well-mixed EDTA blood by tipping the blood tube
slightly and touching the capillary tube into the blood using the tip that
is opposite the blue band. When enough blood is in the capillary tube, tip
the blue end of the tube down causing the blood to flow towards the blue
tip. Then readjust the tube horizontally while inserting the blue tip of the
capillary tube into the clay sealant. Insert the tube as many times as
needed ta achieve a plug up to the blue band.
Clay
Filled hematocrit
tube
Tabletop
(From Keohane Eet al: Rodak's hematology: clinical principles and applications, ed 5, St Louis, 2016,
Saunders.)
4. Wipe the outside of the tubes with clean gauze without touching the wet
open end of the tube.
PURPOSE: Wiping the outside of the capillary tube removes any blood.
Touching the blood inside the capillary tube with absorbent material
removes more plasma than blood cells and can alter the hematocrit.
5. Place the tubes opposite each other in the centrifuge with the sealed ends
securely against the gasket. (See Figure 30-1 ).
PURPOSE: The centrifuge must always be balanced to prevent damage.
If the clay ends of the capillary tubes are not outer-most against the
gasket, the sample will spin out of the tubes, contaminating the
centrifuge.
6. Note the numbers on the centrifuge slots and record the numbers on the
log sheet along with the patient's name
PURPOSE: The sample must be identified throughout the entire
procedure.
7. Secure the locking top, fasten the lid down, and lack it.
PURPOSE: If the locking top is not firmly in place during the spinning
cycle, the tubes will came out of their slots and break. The lid is always
locked during centrifugation for safety purposes; that is, to prevent ejection
of aerosols or broken glass.
8. Set the timer and adjust the speed as needed.
PURPOSE: The prescribed time is 3 to 5 minutes at 11,000 to
12,000 rpm. Check the manufacturer's instructions for time and speed.
9. Allow the centrifuge to came to a complete stop. Unlock the outer locking
top and then remove the inner lid.
PURPOSE: Opening the centrifuge before it has stopped could result in
harm to the user.
 CHAPTER 30 Assisting in the Analysis of Blood 771

•;;m,ammi!lfj -,;ontinued

10. Remove the tubes immediately and read the results. If this is not possible,
stare the tubes in an upright position.
PURPOSE: Tubes left in the centrifuge will show altered results because
the red blood cell (RB() layer will spread out horizontally
11. Determine the microhematocrit values using one of the following methods:
(1) Centrifuge with built-in reader using calibrated capillary tubes.
• Position the tubes as directed by the manufacturer's
instructions.
• Read both tubes.
• The average of the two results is reported.
• The two values should not vary by more than 2%.
(2) Centrifuge without a built-in reader.
• Carefully remove the tubes from the centrifuge.
• Place a tube on the microhematocrit reader.
• Align the clay-RB( junction with the zero line on the reader. Align
the plasma meniscus with the 100% line. The value is read at
the junction of the red cell layer and the buffy coat. The buffy
coat is not included in the reading (see the following figure). (From Keohane Eet ol: Rodak's hematology: clinical principles and applications, ed 5, St Louis, 2016,
• Read both tubes. Saunders.)
• The average of the two results is reported.
• The two values should not vary by more than 2%.
12. Dispose of the capillary tubes in the sharps container.
13. Disinfect the work area and properly dispose of all biohazardous materials. 14. Record the results in the Hematocrit Patient Log and document the results
Remove your lab coat, gloves, and eyewear and sanitize your hands. in the patient's medical record below..
PURPOSE: To ensure infection control. PURPOSE: Aprocedure is not considered done until it is charted.

HEMATOCRIT-PATIENT LOG
Hematocrit expected values: Adult Males = 42-52 %
Adult Females = 36-48 %
Infants = 32-38 %
Children = increase to adult
DATE TECH PATIENT I.D. SLOT# RESULT CHARTED

10/7/20-- de # 12345 1&4 44% &44% ✓

Documentation in the medical record:

10/7/20- 11 :25 AM: Hct 44%. Dana Cummings, (MA (AAMA)

772 UNIT FOUR DIAGNOSTIC PROCEDURES

HEMOGLOBIN
The hemoglobin (Hgb) determination is another way to measure the
oxygen-carrying capacity of blood. The hemoglobin concentration
can be determined as part of the CBC or as an individual test.
CUA-waived methods include the portable STAT-Site M Hgb,
a completely portable, battery-operated hemoglobin analyzer that
fits in the palm of the hand (Figure 30-3), and the HemoPointH2
(Procedure 30-3). The HemoPointH2 uses plastic microcuvettes that
contain chemicals that lyse (break apart) the erythrocytes in the
sample, releasing their hemoglobin. The hemoglobin reacts with
chemicals and forms a color, which is detected and measured in the
instrument, producing a digital readout. Capillary, venous, or arte-
rial blood can be used in the disposable micro-cuvette, and the
cuvettes have a long shelf life.
Normal hemoglobin values vary throughout life. They typically
are quite high at birth, decline during childhood, and then increase
through the teens until adult levels are reached (Table 30-2). Values
range from a low of 12 g/dL in women to a high of 17.5 g/dL in
men. The various factors that affect the hemoglobin level include
age, gender, diet, altitude, and disease.
Hemoglobin and hematocrit tests often are performed together
and are referred to as an "H&H." A quick mental calculation should
always be done before H&H results are reported: the hemoglobin
value X 3 (± 3) should equal the hematocrit value. For example, if
the hemoglobin is 15 g/dL, the hematocrit should be 42% to 48%.

CRITICAL THINKING APPLICATION 30-1

Mr. Corrigan's hematocrit value is 37%. What does Dana calculate as the
expected hemoglobin value? Does this test confirm the physician's suspi-
cions of anemia?

TABLE 30-2 Hemoglobin (Hgb) Reference Values

AGE/GENDER HGB LEVEL (g/dL)
Neonate (new born-under 1 month) 17-23
Infant (1 month-1 yr) 9-14
Child (l-10 yr) 10-15
Female (greater than l Oyrs) 12-16
FIGURE 30-3 Handheld instruments, such as the STAT·Site system, can analyze hemoglobin Male (greater than l Oyrs) 14-18
quickly and accurately. (Courtesy Stanbio Laboratory, Boerne, Texas.)

•;;m,immjnf• Perform CUA-Waived Hematology Testing: Perform a Hemoglobin Test

Goal: To determine accurately the level of hemoglobin present in ablood sample using the HemoCue 8-Hemoglobin System.
EQUIPMENT and SUPPLIES PROCEDURAL STEPS
• Patient's health record 1. Perform an instrument quality control check by inserting the control cuvette
• Provider's order and/or lab requisition into the instrument. Make sure the reading is within acceptable limits
• Hemoglobin laboratory log before proceeding.
• Hemo(ue PURPOSE: Only instruments that record values within acceptable control
• Hemo(ue microcuvette limits can be used for patient testing. If the value is outside the control
• Autolet or blood lancet limits, refer to the troubleshooting guide for the instrument or contact the
• Alcohol prep pads manufacturer.
• Gauze squares 2. Sanitize your hands. Put on fluid-impermeable lab coat and disposable
• Fluid-impermeable lab coat and disposable gloves gloves.
• Biohazard waste and sharps containers PURPOSE: To ensure infection control.
 CHAPTER 30 Assisting in the Analysis of Blood 773

•;;Md mi;jjnf• -continued

3. Assemble all equipment and supplies needed.
4. Greet the patient and verify his ar her identity using twa identifiers (e.g.,
have the patient spell the last name, state the birth date, and/ar shaw
a picture ID). Explain the procedure to the patient.
PURPOSE: Explaining the reason for a diagnostic procedure helps gain
,
the patient's compliance and addresses the person's questions and
concerns.
S. Examine the patient's fingers and choose the site to be used to obtain the
blood sample. 2
PURPOSE: The site must be free of trauma, calluses, and scarring.
6. Clean the site with alcohol or another recommended antiseptic 10. Place the cuvette in the cuvette holder and insert it into the instrument
preparation. (see the following figure).
7. Perform a capillary puncture and wipe away the first drop of blood.
PURPOSE: This drop may contain tissue fluid.
8. Obtain a large drop blood on the surface of the finger.
9. Touch the microcuvette to the drop of blood. Do not touch the finger. The
correct volume is drawn into the cuvette by capillary action. Wipe off any
excess blood from the sides of the cuvette (see the following figures).
PURPOSE: Blood on the cuvette may alter the readings ar contaminate
the instrument.

11. Read the result and record it in the lab's hemoglobin log and the patient's
health record.
PURPOSE: Aprocedure is not completed until the results are recorded.
12. Turn off the instrument. Dispose of biohazardous waste in the correct
containers and properly disinfect the wark area.
13. Remove gloves and dispose in biohazard waste. Remove lab coat and
sanitize your hands.
PURPOSE: To ensure infection control.

HEMOCUE B HEMOGLOBIN SYSTEM PATIENT LOG

TEST: _ _ _ _ _ _ _ _ _ _ KIT LOT# _ _ __
Hemoglobin expected values = Adult Males =13.0-18.0 g/dl
Adult Females = 12.0-16.0 g/dl
Infants= 10.0-14.0 g/dl
Children = increase to adult
DATE TECH PATIENT I.D. RESULT CHARTED
10/09/20-- DC #12345 15.5 g/dl ✓

Documentation in the medical record:

l 0/9/20-9:30 AM: Hgb 15.5 g/dl. Dana Cummings, CMA (MMA)

774 UNIT FOUR DIAGNOSTIC PROCEDURES

of blood before testing. A closed- tube Streck ESR method uti-

Erythrocyte Sedimentation Rate lizes a Streck black-topped vacutainer sample of blood that is
The erythrocyte sedimentation rate (ESR) is a laboratory test that directly placed in a Streck rack that provides results in 30-minute
measures the rate at which erythrocytes gradually separate from (Figure 30-4).
plasma and settle to the bottom of a specially calibrated tube in 1 Many factors can affect the ESR. The tube must be completely
hour. The test is not specific for a particular disease but is used as a filled with blood and must not have air bubbles. The tube must
general indication of inflammation. Increases are found in such be allowed to sit in a vertical position, undisturbed, for the full
conditions as acute and chronic infections, rheumatoid arthritis, designated time; careful timing is important. Minor degrees of
tuberculosis, hepatitis, cancer, multiple myeloma, rheumatic fever, tilting may increase the sedimentation rate. Jarring or vibrations
and lupus erythematosus. from nearby machinery will falsely increase the ESR.
Normal values vary slightly with age and gender (Table 30-3).
Only increased ESR rates are significant. Several CUA-waived
methods of measuring the ESR are used, including the Sediplast
procedure (Procedure 30-4). This closed system incorporates a
pierceable stopper that ensures a leak-proof seal when pierced by
a pipet. An automatic self-zeroing cap and reservoir accurately
bring the blood level to the zero mark and prevent overfilling.
A prefilled vial of sodium citrate diluent is provided for dilution

TABLE 30-3 Erythrocyte Sedimentation Rate

(ESR) Reference Values
SEDIPLAST TEST (mm/hr)
Men ::;SO yr: 0-15
>50 yr: 0-20
Women ::;SO yr: 0-20
>50 yr: 0-30
FIGURE 30-4 30-minute Streck ESR CUA-waived test.

Obtain a Specimen and Perform CUA-Waived Hematology Testing: Determine the

PROCEDURE 30-4
Erythrocyte Sedimentation Rate Using a Modified Westergren Method

Goal: To fill a Westergren tube properly and to observe and record an erythrocyte sedimentation rate (ESR) obtained by using
omodified Westergren method.
EQUIPMENT and SUPPLIES 2. Assemble the materials needed.
• Patient's health record 3. Check the leveling bubble of the Sediplast rack.
• Provider's order and/or lab requisition PURPOSE: The rack must be horizontal on the table or bench to ensure
• Erythrocyte sedimentation rate (ESR) laboratory log that the tube is vertical.
• Ethylenediaminetetraacetic acid (EDTA)-;:mticoagulated blood specimen 4. Bring the blood sample to room temperature if it has been refrigerated
• Safety tube decapper (if tubes do not have a Hemogard plastic top) and mix the sample well by inverting the tube gently several times,
• Disposable transfer pipet making sure the tube has no bubbles.
• Sediplast ESR system (pre-filled Sediplast vial) PURPOSE: Cells settle when a specimen stands, and blood must always
• Sediplast rack be well mixed before sampling. Test results will be altered if refrigerated
• Timer blood is not brought to room temperature.
• Fluid-impermeable lab coat, disposable gloves, and face protector/shield S. Remove the plastic Hemogard stopper on the blood sample by twisting
• Biohazardous waste container and slowly pushing up on the stopper with your thumbs (or by using a
tube decapper on rubber-stoppered blood tubes). Also remove the stopper
PROCEDURAL STEPS on the prefilled Sediplast vial.
1. Sanitize your hands. Put on fluid-impermeable lab coat, face protection, PURPOSE: Using the Hemogard cover or removing the rubber cap with a
and disposable gloves. protective device blocks blood splashes and helps prevent aerosolization
PURPOSE: To ensure infection control. of the specimen.
 CHAPTER 30 Assisting in the Analysis of Blood 775

i; ;m!,mj;j11'1i -,;ontinued
6. Fill the Sediplast vial with blood to the indicated line using a disposable
transfer pipet. (See the following figure.) Replace the stopper on the
prefilled vial and invert it several times to mix. Recap the blood collection
tube with its stopper.
PURPOSE: This dilutes the blood in accordance with the Westergren
procedure.

(Courtesy Polymedco, Cor~and Manor, N.Y.)

(Courtesy Polymedco, Cortland Manor, N.Y.)
7. Insert a Sediplast pipet through the pierceable stopper on the prefilled
vial and push down until the pipet touches the bottom of the vial.
The pipet automatically draws the blood up and over the zero mark (see
Figure 2).
8. Insert the filled Sediplast pipet and its vial into the Sediplast rack, making
sure the vial is vertical.
PURPOSE: Apipet that is not vertical produces erroneous results.
9. Note the start time on the ESR log sheet and allow the vial to stand
undisturbed for 60 minutes.
PURPOSE: Jarring increases the sedimentation rate.
10. After 60 minutes, measure the distance the erythrocytes have fallen at
the top of the tube. The scale reads in millimeters; each line is 1 mm.
11. Disinfect the work area and properly dispose of all biohazardous materials.
Dispose the plastic Sediplast pipet and its vial into a biohazard container.
Remove your gloves, face protection, and lab coat, and sanitize your
hands.
12. Record the findings in the lab's ESR log and the patient's health record.
Remember-the Westergren ESR is reported in millimeters per hour
(mm/hr).
PURPOSE: Aprocedure is considered not done until it is recorded.

ESR-SEDIPL.AST-PATIENT LOG
ESR expected values: Adult Males < 50 years = 0-15 mm/hr
Adult Males > 50 years = 0-20 mm/hr
Adult Females< 50 years= 0-20 mm/hr
Adult Females > 50 years = 0-30 mm/hr
DATE TECH PATIENT I.D. SLOT# TIME RESULT CHARTED
10/09/20-- DC #12345 2 60 min 15mm ✓

Documentation in the medical record:

10/9/20- 9:30 AM: ESR 15 mm in 60 minutes. Dana Cummings, (MA (AAMA)

776 UNIT FOUR DIAGNOSTIC PROCEDURES
Coagulation Testing
The medical assistant may be asked to perform a test to determine
prothrombin time (PT) using a handheld, CUA-waived instru-
ment that uses whole blood from a fingerstick (Figure 30-5). The
PT is a method of measuring how long it takes blood to clot. Pro-
thrombin is a protein in the liquid part of blood (plasma) that is
converted to thrombin as part of the clotting process. Thrombin
then causes fibrinogen to be converted to fibrin during the clot-
ting process.
The PT is often used in combination with the partial thrombo-
plastin time (PTT) to screen for hemophilia and other hereditary
clotting disorders. The PT also is used to monitor the condition of
FIGURE 30-5 Applying blood sample to the Coagu(hek XS PT Test monitor.
Westhills Family Practice Center
Warfarin Anticoagulant Record
Patient's Name: _ _ _ _ _ _ _ _ _ _ _ _ __
Address: _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Patient's Phone: _ _ _ _ _ _ _ _ _ _ _ _ __
Dx for Anticoagulation: _ _ _ _ _ _ _ _ _ _ __
Date Warfarin Started: _ _ _ _ _ _ _ _ _ _ __
Phone for Outside Lab: _ _ _ _ _ _ _ _ _ __
Warfarin
Date Dose Pre-Test PT INR
FIGURE 30-6 Warfarin flow sheet.
patients taking the anticoagulant drug warfarin (Coumadin). War-
farin is given to prevent clots in the deep veins of the legs and to
treat pulmonary embolism. It interferes with blood clotting by low-
ering the liver's production of certain clotting factors.
The CUA-waived CoaguChek XS PT (Figure 30-6) measures the
PT according to the time it takes the blood to form a fibrin clot. A
precise amount of blood is dispensed from a fingerstick into the
channels in a testing strip, where it is mixed with a thromboplastin
reagent (see Figure 30-5). The blood is pumped back and forth
in the channel, and a series of light-emitting diodes (LEDs)
detect formation of the clot when movement of the blood stops
(Procedure 30-5).
PT test results are reported as the number of seconds the blood
takes to clot when mixed with the thromboplastin reagent. The
international normalized ratio (INR) was created by the World
Health Organization (WHO) because PT test results can vary,
depending on the thromboplastin reagent used. The INR is a conver-
sion unit that takes into account the different sensitivities of available
reagents. It is widely accepted as the standard unit for reporting PT
results rather than the time in seconds. Normal PT values are 10 to
13 seconds, or an INR of 1 to 1.4. The warfarin dosage in people
treated to prevent the formation of blood clots and in those
with artificial heart valves is monitored and adjusted so that the
PT is about 1.5 to 2.5 times the normal value (or an INR value
of2to3).
It is important that the medical assistant know how to accurately
document INR follow-up and related warfarin dosages on a patient
flow sheet. The provider will balance repeated INR levels with war-
farin doses so the INR is maintained at 2 throughout the anticoagu-
lant treatment period (see Figure 30-6).
DOB: _ _ _ _ _ _ __
SSN: _ _ _ _ _ _ _ __
ICDM Code: _ _ _ _ _ __
INR Goal: _ _ _ _ _ _ __
Warfarin Next
Dose Order INR/PT Signature
 CHAPTER 30 Assisting in the Analysis of Blood 777

•;;m,inmjjuj.j Obtain a Specimen and Perform a CUA-Waived Protime/lNR Test

Goal: To perform acoagulation test to determine protime/lNR using the CoaguChek XS instrument with built-in quality control.
Order: Perform a protime/lNR test an Connie Lange STAT.

EQUIPMENT and SUPPLIES PURPOSE: The hanging drop blood sample must be sufficient ta travel
• Patient's health record or flow chart (see Figure 30-6) dawn the three channels an the test strip. It must be free of contaminants,
• Provider's order and/or lab requisition tissue fluids, and alcohol.
• PT/INR lab lag 8. When you are ready to test, remove a test strip from the container and
• gauze, alcohol, bandage for capillary blood specimen immediately close the container. Make sure it seals tightly. Do not open
• CoaguChek XS PT Test monitor (see Figure 30-5) the container or touch the test strips with wet hands or wet gloves.
• CoaguChek lancet PURPOSE: Exposure to moisture damages the test strips.
• CaaguChek test strip container and code chip 9. Insert test strip as far as you can into the meter. This powers the meter
• Package insert or flow chart with directions ON (see the following figure).
• Fluid-impermeable lab coat, gloves, and face protection (if necessary)
• Biahazard waste and sharps containers
PROCEDURAL STEPS
1. Sanitize your hands. Put an fluid-impermeable lab coat, face protection,
and disposable gloves.
PURPOSE: To ensure infection control.
2. Assemble the materials needed.
3. If you are using test strips from a new, unopened container, you must
change the test strip code chip. The three-number code on the test strip
container must match the three-number code on the code strip. To install
the code strip, follow the instructions in the Code Chip section of the User's
Manual.
PURPOSE: To ensure that the instrument is calibrated correctly ta produce 10. Disinfect the finger with alcohol and wipe dry. Perform the fingerstick.
accurate, precise, and reliable results. 11. Hald the incised finger very close to the target (the clear area af the test
4. Place the meter on aflat surface sa that it will not vibrate ar move during strip). Apply 1 drop af blood ta the top or side of the target area and wait
testing. until you hear the beep. You must apply a hanging drop of blood to
PURPOSE: The test results are based on the back-and-forth movement of the test strip within 15 seconds of lancing the finger. Do not add more
the blood sample that stops when the clot has formed. Vibrations or other blood. Do not touch or remove the test strip while the test is in
movements will result in an error message, and the test will have to be progress. The flashing blood drop symbol changes to an hourglass symbol
repeated. when the meter detects a sufficient sample (see Figure 30-5).
S. Greet the patient and verify his ar her identity using two identifiers (e.g., 12. The result appears in approximately 1minute. It may be displayed in three
have the patient spell the last name, state the birth date, and/or show ways: as the international normalized ratio (INR); as the protime (PT) in
a picture ID). Explain the procedure to the patient. seconds; or as %Quick (a unit used mainly in Europe) (see the following
PURPOSE: Explaining the reason for a diagnostic procedure helps gain figure displaying the INR result of 1.0).
the patient's compliance and addresses the person's questions and
concerns.
6. Examine the patient's fingers and choose the site to be used to obtain
the blood sample.
7. Prepare the site by doing the following before lancing the finger:
• Warm the hand by placing it under the arm, using a hand warmer,
and/or washing the hand in warm water.
• Have the patient hold his or her arm down to the side so that the
hand is below the waist.
• Massage the palm of the hand toward the base of the finger and
toward the tip until the fingertip has increased color.
• If necessary, immediately after lancing, gently squeeze the finger from
its base ta encourage blaad flow.
778 UNIT FOUR DIAGNOSTIC PROCEDURES

•;;m!,mminii -continued
See the following chort. 13. Record the result in the lab's PT/INR log and in the patient's warforin
PROTIME EXPECTED VALUES FOR NORMAL AND
therapy flow sheet and/or electronic record. Circle any results that do not
THERAPEUTIC WHOLE BLOOD
fall into the Desirable Ranges column of the preceding table based on a
patient who is on "low anticoagulation therapy." You may add comments
INR PT (sec) to the test result about the test conditions or the patient. Identify "critical
Normal 0.8-1.2 6.5-11. 9* values" and take appropriate steps to notify the provider.
Low anticoagulation therapy 1.5-2 Vories with method used PURPOSE: The provider needs to know the result while the patient is still
Moderate anticoagulation therapy 2-3 Vories with method used in the office, for proper follow-up with the patient.
High anticoagulation therapy 3-4 Vories with method used 14. Dispose of all shorps into the biohazord shorps container and regulated
*Note: Laboratory reports and manufacturers must supply their own reference ranges for PT
medical waste into the biohazord waste container. Disinfect the test orea
results along with each patients results. This is because different methodologies may create and remove your PPE. Sanitize your hands.
different reference ranges and different units of measurement. PURPOSE: To ensure infection control.

PROTIME-PATIENT LOG
Protime expected values far both normal and therapeutic whole blood:
INR PT seconds (ISi = 1.0)
Normal 0.8-1.2 10.4-15.7 sec
Low anticoagulation 1.5-2.0 19.6-26.l sec
Moderate anticoagulation 2.0-3.0 26.1-39.2 sec
High anticoagulation 2.5-4.0 32.6-52.2 sec
DATE TECH PATIENT I.D. INR PT SECONDS CHARTED

10/09/20-- DC #12345 1.0 19.7 ✓

Documentation in the medical record:

l 0/9/20- 9:30 AM: INR = 1.0 and PT= 19.7 seconds. Patient is on low anticoagulation therapy. Dana Cummings, CMA (AAMA)

It is also important to educate patients regarding their behaviors
when a blood test such as the PT/INR is being monitored. For
example, if they are taking the anticoagulant warfarin (Coumadin),
they will need to follow up with the required lab work for monitor-
ing their protime/INR. Patients should understand how their
vitamin K intake from food directly affects their lab results. Vitamin
K can clot the blood faster, thus working against warfarin. Helping
patients identify foods high in vitamin K is crucial to maintaining
a balance between the warfarin dosage and the lab values. Many
providers do not instruct patients to stop eating foods high in
vitamin K, but rather stress the importance of eating the same
amounts. For instance, during the summer, with all the fresh vege-
tables available, some patients tend to eat more foods high in vitamin
K. This changes their lab results, and they need to take an increased
dose of warfarin. If they eat the same amounts of food high in
vitamin K and do not overindulge, their lab values remain constant.
Foods high in vitamin K include leafy greens (e.g., kale, collards,
spinach, and turnip greens), Brussel sprouts, and broccoli.
HEMATOLOGY IN THE REFERENCE LABORATORY
The CBC is the reference laboratory procedure most frequently
ordered for blood specimens and it requires a lavender-topped
EDTA tube. It gives a fairly complete look at the cellular compo-
nents of blood and can provide a wealth of information about a
patient's condition. It routinely includes the following:
• RBC count
• Hct
• Hgb
• Red cell indices
• WBC count and differential WBC count
• Estimation of platelet numbers
 CHAPTER 30 Assisting in the Analysis of Blood 779

CRITICAL THINKING APPLICATION 30-2 CRITICAL THINKING APPLICATION 30-3

l. Dana will collect the specimen for Mr. Corrigan's CBC. What tests are
included in the CBC? Can any of these tests be performed by capillary
puncture? Explain.
2. Which vacuum tube will Dana use to collect the CBC sample?
CBC Laboratory Reports
It is important that medical assistants understand the hematology
laboratory reports that arrive from the reference laboratories, and
that they are able to distinguish between normal and abnormal
levels. Use the following references to complete the Critical Thinking
Application exercise that follows:
• Hematology reference ranges in Table 30-4
• The patient report form (Figure 30-7) is a sample lab report
that also identifies the particular lab's reference ranges. Lab
reports, both electronic and paper, must supply their own
reference ranges along with each patient's results. This is
because different methodologies may create different reference
ranges and different units of measurement.
Distinguish between normal and abnormal test results in the following
patients's report forms by comparing them with the laboratory's reference
ranges.
l. Maggie McGuire, age 6, has a hematocrit of 38%. Is that normal? Is
it high or low?
2. Carlos Santiago, age 54, has a WBC count of l 3,000/mm3• Is it high
or low? Dr. Fischbach asks to see his previous blood work. Why?
3. Angelina Washington, age 23, has an Hct of 32% and an Hgb of l 0 g/
dl. Are these values high or low? Why would she be diagnosed with
anemia?
4. Rose Conrad has a platelet count of l 42,000/mm 3• Is it high or low?
Why is Dr. Fischbach concerned about a bleeding disorder?
Red Blood Cell Count
The RBC count is a commonly performed procedure and is part
of the CBC (see Table 30-4). It approximates the number of cir-
culating RBCs. The function of RBCs is to transport oxygen to
tissues. The condition in which the oxygen-carrying capacity of
blood is below normal is called anemia. The RBC count often is
decreased in anemia. Increases are found in people with dehydration,

TABLE 30-4 Reference Ranges for Complete Blood Count (CBC) Values
NEONATES (new INFANTS CHILDREN MEN WOMEN
TEST born-1 month) (1 month-1 yr) (1-10 yr) (>10 yrs) (>10 yrs)
RBCs 4.8-7. l million/mm 3 3.8-5.5 million/mm 3 4.5-4.8 million/mm 3 4.5-6 million/mm 3 4-5.5 million/mm 3
Hematocrit (Hct) 44%-64% 30%-40% 35%-41% 42%-52% 36%-45%
Hemoglobin (Hgb) 17-23 g/dl 9-14g/dl 11-16 g/dl 15-17g/dl 12-16 g/dl
WBCs 9,000-30,000/mm 3 6,000-l 6,000/mm 3 5,000-l 3,000/mm3 4,000-l l,000/mm3
RBC Indices
MCV 96-108 fl 82-99 fl
MCH 32-34 pg 26-34 pg
MCHC 31-33 g/dl 31-37 g/dl
WBC Differential
Neutrophils :2'.45% by age l wk 32% 60% for children :2'.2 yr 50%-65%
Bands 0%-7%
Eosinophils 0%-3% 1%-3%
Basophils 1%-3% 0%-1%
Monocytes 4%-9% 3%-9%
Lymphocytes :2'.41% by age l wk 61% 59% for children :2'.2 yr 25%-40%
Platelets l 40,000-300,000/mm 3 200,000-473,000/mm 3 l 50,000-450,000/mm 3 l 50,000-400,000/mm 3
fl, Femtoliter; MCH, mean corpuscular hemoglobin; MCHC, mean corpuscular hemoglobin concentration; MCV, mean corpuscular volume; pg, picograms; RBC, red blood cell; WBC, white blood cell.
*Lab reports, both electronic and paper, must supply their own reference ranges along with each patient's results. This is because different methodologies may create different reference ranges and
different units of measurement.
780 UNIT FOUR DIAGNOSTIC PROCEDURES

DATE & TIME RECEIVED ACCESSION NUMBER

10/20/2013
20:45

LOCATION DATE REPORTED

10/21/2000

PHYSICIAN PATIENT INFORMATION

TEST RESULTS REFERENCE RANGE UNITS

HEMOGRAM LO 2.9 4. 5-10. 5 CU.MM.

WHITE BLOOD COUNT LO 2.39 4.40-5.90 CU.MM.

RED BLOOD COUNT LO 7.4 14.0-18.0 GM/100ML

HEMOGLOBIN LO 22.3 40. 0-52.0 %

MEAN CORPUSCULAR VOLUME 93 80-100 IL

MEAN CORPUSCULAR HGB 31.0 27. 0-32.0 PG

MEAN CORPUSCULAR HgB CONC 33.2 31.0-36.0 %

DIFFERENTIAL, WBC

SEGMENTED NEUTROPHILS 57 38-80 %

LYMPHOCYTE 29 15-45 %

MONOCYTES 7 1-10 %

EOSINOPHILS 1 0-4 %

BAND NEUTROPHILS HI 6 0-5 %

ANISOCYTOSIS ABN SLIGHT

HYPOCHROMIA ABN SLIGHT

PLATELET ESTIMATE ABN DECREASED

PARTIAL THROMBOPLASTIN TIME

PARTIAL THROMBOPLASTIN TIME 31.7 20.0-40.0 SECONDS

CONTROL PTT 30.4 20.0-40.0 SECONDS

PROTHROMBIN TIME

PROTHROMBIN TIME 12.2 10.0-13.5 SECONDS

CONTROL PT 12.0 11.0-13.0 SECONDS

FINAL Report (Summary)

FIGURE 30-7 Sample Laboratory Report. Both electronic and paper lab reports must supply their own reference ranges along with each
patient's results. This is because different methodologies may create different reference ranges and different units of measurement.

polycythemia vera, or severe burns and in those who live at high
altitudes, in whom it reflects an adaptation to the lower oxygen
content of the air.
Normal RBC values range from 4 million to 6 million cells/mm3 •
RBC counts usually are higher in males than in females.
Red Cell Indices
A variety of calculations can be performed using the information
obtained from the CBC to produce indices that provide informa-
tion about RBC disorders. The indices are used to classify anemias
and to select additional tests to determine the cause of anemia.
They also may be used to monitor the treatment of anemia
because they may change in response to treatment. The indices are
mathematical ratios of the three red cell tests: Hct, Hgb, and the
RBC count.
• Mean cell volume (MCV): MCV = (HCT/RBC) x 10. The
average size of the RBCs is the most important index for clas-
sifying anemias. Abnormally large RBCs are macrocytic and
have a higher than normal MCV. Small RBCS are microcytic
and have a lower than normal MCV. The normal reference
range is 82 to 108 femtoliters (fl).
• Mean cell hemoglobin (MCH): MCH = (HGB/RBC) x 10.
The MCH is calculated to give the average weight of
hemoglobin in the RBC. The reference range is 26 to 34
picograms (pg).
• Mean cell ratio ofHgb and Hct (MCHC): MCHC = (HGB x
100)/RBC. The MCHC indicates the average weight of
hemoglobin compared with the cell size. The reference range
is 32 to 37 g/dL. A decreased MCHC shows pale (or hypo-
chromic) RBCs in a stained blood smear. An increased MCHC
is rare and probably represents an error in measurement of the
Hgb or Hct.
White Blood Cell Count
The WBC count gives an approximation of the total number of
leukocytes in circulating blood. The count is performed to help the
provider determine whether an infection is present or to aid in the
diagnosis of leukemia. It also may be used to follow the course of a
disease and as an indication of whether the patient is responding to
treatment.
The normal WBC count varies with age. It is higher in newborns
and decreases throughout life. The average adult range is 4,000 to
11,000 cells/mm3• Many factors can affect the WBC count.
An increase in the number of normal WBCs is a condition called
leukocytosis. Physiologic increases in the WBC count are seen with
pregnancy, stress, anesthesia, exercise, exposure to temperature
extremes, and afrer treatment with corticosteroids. Pathologic causes
of leukocytosis include many bacterial infections, leukemia, appen-
dicitis, and pneumonia.
A decrease in the WBC count is called leukopenia. This condition
may be caused by viral infection or by exposure to radiation and
certain chemicals and drugs.
Differential Cell Count
The purpose of the differential, or "cliff," in the CBC is to analyze
and quantitate the types of WBCs found in a sample of blood. The
differential can be performed manually using a stained blood smear
CHAPTER 30 Assisting in the Analysis of Blood 781
and a microscope, or with an automated instrument. A number of
automated cell counters have integrated differential analyzers that
use high-frequency conductivity to gather information about cell
size, internal structure, and density.
Preparation of Blood Smears for the Differential
A blood smear enables the examiner to view the cellular components
of blood in as natural a state as possible. The morphology of leuko-
cytes, erythrocytes, and platelets can be studied, and their size, shape,
and maturity can be evaluated.
A blood smear is prepared by placing a drop of blood from a
fingerstick or from an EDTA tube (using a DIFF-SAFE blood dis-
penser) onto a clean glass slide (Figure 30-8). The slide must be free
of dust and grease. The best specimen for a blood smear is capillary
blood that has no anticoagulant added. EDTA-anticoagulated blood
can be used, provided the smear is made within 2 hours of collection.
Because of these time constraints, the medical assistant may be asked
to prepare a smear during collection of the CBC specimen.
The wedge smear is used most frequently. It involves placing a
small drop of blood ½ inch from the right end of a glass slide. The
end of a second glass spreader slide is placed in front (to the left) of
the drop of blood at an angle of30 to 35 degrees. The spreader slide
is brought back into the drop with a quick but smooth gliding
motion until the blood spreads along the edge of the spreader slide.
The spreader slide is then pushed to the lefr with a quick, steady
motion, spreading the blood across the slide. Care should be taken
when making a smear because of the sharp glass slides and the pos-
sible exposure to blood.
A good wedge smear should cover one half to three fourths of
the slide. It should show a gradual transition from a thick to a thin
end with a feathered edge (Figure 30-9). It should have a smooth
appearance with no ridges, holes, lines, streaks, or clumps. On
microscopic examination, the cells should be distributed evenly.
After the smear has been made, it should be allowed to dry.
The slide should be propped up to dry with the thick end (heel)
down. Do not blow on the slide to dry it. This can cause artifacts
in the RBCs from the moisture in your breath. Once dry, the patient's
name is written on the frosted end of the slide with a pencil or
marker.
After it has been labeled, the slide is fixed in methanol, a fixative
that preserves and prevents changes or deterioration of the cellular
components. Many of the quick stains available on the market
contain the fixative in the stain.
FIGURE 30-8 Note the white DIFF·SAFE device with the needle that will be pushed into the
lavender-topped EDTA tube of blood. When the device is inverted and pressed against the slide, a drop
of blood is delivered (see slide to the right). (Courtesy Zack Bent)
782 UNIT FOUR DIAGNOSTIC PROCEDURES
Area in smear
where cells do
not overlap
Serpentine
counting
pattern
LFeathered Edge----
FIGURE 30-9 Right, Appearance of a properly prepared wedge smear. Left, Serpentine (winding) pattern used to count the cells.
2 micrometers
in depth
7 micrometers
in diameter
FIGURE 30-10 Red blood cell morphology.
Staining of Blood Smears
Stains commonly used in the examination of blood cells are described
as polychromatic because they contain dyes that stain various cell
components different colors. These stains are attracted to different
parts of the cell, which makes the cells and their structures easier to
see and differentiate. The most commonly used differential blood
stain is Wright's stain. The traditional Wright's stain dates from the
early 1890s; it was an alcoholic solution of methylene blue dye and
an eosin red dye. The blue dye attached to the alkaline granules of
the basophils, and eosin red dye attached to the acidic eosinophil
granules. The granules in neurrophils take up both dyes, appearing
as a lavender-pink "neutral" color. Many modifications of the origi-
nal Wright's stain have been produced, including the Diff-Quick
method used in ambulatory facility labs.
Identification of Normal Blood Cells
Much useful information can be gathered from microscopic identi-
fication and evaluation of blood cells in a stained smear. A great deal
more information can be acquired from observation of these blood
cells than from actual cell counts.
The three features hematologists look for in blood cells are cell
size, nuclear appearance, and cytoplasm characteristics.
RBCs are the most numerous of the cellular elements. They are
biconcave disks with no nuclei (Figure 30-10).
Thrombocytes, or platelets, the smallest of the cellular elements,
may be round or oval. They have no nucleus because a platelet is
just a fragment of cytoplasm from a large bone marrow cell.
Leukocytes are the largest of the normal circulating blood
cells (Table 30-5). Each of the five types has a characteristic
appearance.
FIGURE 30-11 Neutrophils. A, Segmented. B, Band.
As has been mentioned earlier, the granulocytes include neutro-
phils, eosinophils, and basophils. Granulocytes have distinctive gran-
ules in the cytoplasm and may have segmented nuclei.
Neutrophils are known by a variety of names, including PMNs,
segmented neutrophils, "polys," and "segs." They are the most numer-
ous WBCs in circulation in adults. Many types of bacterial infections
stimulate increased production of neutrophils. The nucleus of a
segmented neutrophil (Figure 30-11, A) is divided into rwo to five
lobes connected by a strand. An immature form of a neutrophil is
called a band, or stab (Figure 30-11, B). Instead of having a segmented
nucleus in which the lobes are separated by a thin filament, the band
has an unsegmented nucleus shaped like a horseshoe or banana. An
increase in bands indicates a recent bacterial infection, such as bacte-
rial meningitis, pneumonia, appendicitis, strep throat, or abscesses.
Neutrophils are also increased in chronic granulocytic leukemia.
Eosinophils have large red granules. They are phagocytic and
closely associated with allergies (e.g., hay fever) and with asthma, in
addition to certain parasitic infestations, such as tapeworm and
amebic dysentery.
The basophil has large, dark, blue-black granules. It contains
histamine, which mediates the inflammatory response, and heparin,
which helps prevent excessive clotting of blood.
The agranulocytes include lymphocytes and monocytes. They
have few, if any, granules and nonsegmented nuclei.
Lymphocytes are the smallest WBCs and are the second most
numerous type of WBC in adults. In children they usually are the
most numerous. "Lymphs," as they are commonly called, are respon-
sible for recognizing foreign antigens and producing circulating anti-
bodies for immunity to disease. Increased numbers of lymphocytes
are found with most viral diseases; with some bacterial infections,
 CHAPTER 30 Assisting in the Analysis of Blood 783

TABLE 30-5 Characteristics of Leukocytes

GRANULOCYTES AGRANULOCYTES

NEUTROPHIL, NEUTROPHIL,
SEGMENTED BAND
(MATURE) (IMMATURE) EOSINOPHIL BASOPHIL LYMPHOCYTE MONOCYTE
Cell size 10-15 mcL 10-15 mcL 10-15 mcL 10-15 mcL 6-15 mcL 12-20 mcL
Nucleus shape Two to five lobes Band or LI-shaped Bilobed or band Slightly segmented, Round or oval Round, indented,
connected by granular, or band or superimposed
threadlike filaments lobes
Nucleus structure Coarse Coarse Coarse Obscured by Smudged, lumpy, Brainlike
granules or clumped convolutions or
folded
Cytoplasm amount Abundant Abundant Abundant Abundant Scant Abundant
Cytoplasm color Colorless to light Colorless to light Colorless to light Colorless to light Sky blue to dark Dull gray to
pink pink pink pink blue blue-gray
Cytoplasm Many tiny tan, Many tiny tan, Large, rounder oval Large, coarse None to few Ground-glass
inclusions pink, or red-purple pink granules, red to red-orange blue-black granules round red-purple appearance, fine
granules with increased granules granules red-purple granules,
red-purple granules rare blue granules

such as syphilis and tuberculosis; with agranulocytic leukemias;

and in young children who are actively making antibodies. In
many viral infections, stimulated or reactive lymphocytes, called
atypical lymphocytes, are found. These are common in infectious
mononucleosis.
Monocytes are the largest type ofWBC in circulation. Monocytes
are called macrophages when they enter tissues and ingest bacteria
and debris of cellular breakdown. They are increased in patients with
certain viral infections, such as hepatitis and mumps; rickettsial
infections, such as Rocky Mountain spotted fever; and bacterial
infections, such as tuberculosis and ryphoid fever.

Differential Examination
A specific area of a stained smear is examined microscopically when
the differential count is done. The slide is examined near the feath- FIGURE 30-12 Microscope with differential cell counter. (Courtesy Cynmar, Carlinville, Ill.)
ered end of the smear, where cells are barely touching one another
and are easiest to identify. Cells are examined with the oil immersion
objective of the microscope. The light should be bright to facilitate ologies may create different reference ranges and different units
visualization of colors and small structures. The differential examina- of measurement.
tion consists of counting and classifying 100 consecutive WBCs Typical reference ranges for adults are:
while moving in a specific winding pattern through the smear (see • Neutrophils: 40% to 60%
Figure 30-9). A tally of the cells observed is kept on a differential • Lymphocytes: 20% to 40%
cell counter or a computer (Figure 30-12). • Monocytes: 2% to 8%
Normal values for a differential vary with age. As mentioned • Eosinophils: 1% to 4%
previously, laboratory reports must include the lab's own reference • Basophils: 0.5% to 1%
ranges along with each patient's results because different method- • Bands: 0% to 3%
784 UNIT FOUR DIAGNOSTIC PROCEDURES

Many disease states alter the ratios of the different types of leu-
kocytes, and the differential can be very useful in assisting with the
provider's diagnosis. The differential examination typically is per-
formed in a reference laboratory.
Red Blood Cell Morphology
After the differential cell count has been determined, the RBCs are
observed and evaluated. Normally, stained RBCs are the same size
and shape and are well filled with hemoglobin. Any variations from
the normal state are reported (Figure 30-13). The appearance of the
RBCs should correlate with the RBC indices.
hemoglobin than normal. Any inclusions in red cells should be
reported.
Platelet Analysis
On a stained smear, the morphology of platelets is observed for any
abnormalities. Platelets are small and irregularly shaped and may
vary considerably in size. The normal platelet count is 150,000 to
400,000/mm 3 • An increase in platelets is called thrombocytosis, and
a decrease is called thrombocytopenia. Excessive clumping of platelets
is also reported in a platelet analysis.

Size IMMUNOHEMATOLOGY-BLOOD BANK

Normal-sized RBCs are said to be normocytic. If the cells are larger
than normal, they are macrocytic; if smaller than normal, they are
microcytic. The condition in which different sizes ofRBCs are present
is known as anisocytosis.
Shape
Normal RBCs are round or slightly oval. Cells may be shaped like
sickles, targets, crescents, or burs. Poikilocytosis is a significant varia-
tion in the shape of RBCs.
Formerly called the blood bank, the immunohematology division of
the laboratory is responsible for blood typing. The major reason for
performing immunohematology tests is to prevent problems caused
by incompatibility of blood types during blood transfusions. Com-
patibility testing (cross-matching) is performed to prevent transfu-
sion reactions in patients receiving blood transfusions and to identify
potential Rh-incompatibility problems in expectant mothers. Rh
incompatibility between an expectant mother and the unborn child
may result in hemolytic disease of the newborn.

Content Blood Grouping

An RBC with a normal amount of hemoglobin is said to be
normochromic. Pale-staining cells are hypochromic and have less
Normocytic
The two major blood antigen systems are the ABO (or Landsteiner)
system and the Rh system. The ABO system has four major blood
groups: A, B, 0, and AB. A person is either Rh positive or Rh nega-
tive. Certain blood types are more common in certain countries. For
example, in China, more than 99% of the population has Rh-positive

~
blood. In the United States, about 85% of the population is Rh
positive. Blood type, like eye color, is inherited. Racial and ethnic
differences in blood type and composition exist as a result of inheri-
SIZE SHAPE COLOR tance and populations that have migrated and mixed over time.

e~~
Table 30-6 shows the distribution of blood types of the peoples of
the United States for which data are available.

Macrocytic Target cells Hypochromic

TABLE 30-6 Blood Type Distribution

~ ~ I! in the United States

••
Microcytic Spherocytes Basophilic stippling TYPE CAUCASIAN
AFRICAN-
AMERICAN HISPANIC ASIAN
O+ 37% 47% 53% 39%

~
Anisocytosis
~
Ovalocytes
I~
Polychromic
0-
A+
8%
33%
4%
24%
4%
29%
1%
27%

~
A- 7% 2% 2% 0.5%
B+ 9% 18% 9% 25%
Teardrop cells B- 2% 1% 1% 0.4%
AB+ 3% 4% 2% 7%
AB- 1% 0.3% 0.2% 0.1%
Poikilocytosis
Doto from the American Red Crass. www.redcrassblood.org/leorn-obout-blood/blood-types.
FIGURE 30-13 Abnormal erythrocytes. Accessed September 27, 2015.

Determination of ABO Blood Group
Determination of ABO blood groups is a simple test that can easily
be performed, but because of the implications of performing the test
incorrectly, blood typing is not a CLIA waived. The test detects the
presence of A or B antigens on RBCs on the basis of the presence
or absence of agglutination with a known antiserum. When the
antigen on a patient's RBCs corresponds to the test antibody, agglu-
tination occurs. If the corresponding antigen is not present on the
cells, agglutination does not occur.
In addition to the blood antigens found on RBCs, naturally
occurring antibodies are found in plasma. These antibodies appear
shortly after birth, and the body never produces an antibody that
can combine with its own blood antigen. Because of the blood group
antibodies, blood transfusions ideally should be specific: Type A
blood should receive type A blood in a transfusion. In emergencies,
if there is no time for the laboratory to perform a type and cross-
match, type O negative (O-) blood is administered. Type Onega-
tive is referred to as the "universal donor," because there are no
circulating antibodies to the ABO antigen, nor are there Rh antigens
that might sensitize an Rh-negative recipient. Table 30-7 shows the
compatibility among ABO blood types for transfusion.
Determination of Rh Factor
Determination of the Rh type is another simple test (although it is
not CLIA waived) that can be performed with a minimum amount
of equipment. The Rh factor is so called because it was first discov-
ered in rhesus monkeys. Later this same protein was found on the
RBCs of some humans. This test detects the presence of proteins (D
antigens) on the surface of RBCs on the basis of the presence or
absence of agglutination with anti-D antiserum. When the D
antigen is present, agglutination occurs when the anti-D antiserum
is mixed with RBCs. If the D antigen is not present, agglutination
does not occur. Rh-positive blood agglutinates in the presence of
anti-D antiserum but not in the presence of the Rh control (that has
no anti-D antibodies). Rh-negative blood does not agglutinate in
the presence of anti-D antiserum, nor does it agglutinate in the
presence of the Rh control.
There are no naturally occurring antibodies to the Rh factor as
there are to the A and B antigens. A person develops antibodies to
TABLE 30-7 Blood Compatibility
RECIPIENT BLOOD*
PLASMA COMPATIBLE WITH
RBC ANTIGEN ANTIBODIES DONOR TYPESt
Type O(no antigens) Anti-A and anti-B 0 descendants of African populations.
Type A(type Aantigen) Anti-B 0 and A
Type B(type Bantigen) Anti-A 0 and B
Type AB (type AB antigen) None 0, A, B, and AB
RBC, Red blood cell.
*Patients with type AB blood are considered universal recipients.
%tients with type Oblood are considered universal donors.
CHAPTER 30 Assisting in the Analysis of Blood 785
the D antigen only in the event of exposure to the antigen. This is
possible if an incompatible transfusion is administered, or if an
Rh-negative mother is exposed to the Rh-positive blood of her
infant during pregnancy, a miscarriage, abortion, or delivery. If this
occurs, the mother may develop antibodies to the D antigen. This
usually does not cause a problem during the first pregnancy.
However, in a subsequent pregnancy with an Rh-positive fetus, the
woman's immune system begins to produce more antibodies
because she was sensitized during the first pregnancy. These anti-
bodies cross the placenta and destroy the RBCs of the fetus, which
can lead to anemia, heart failure, or brain damage in the infant and
may even cause death. These events are collectively called hemolytic
disease of the newborn (HDN). The disease may also be called
hydrops feta/is.
Until 1968 no preventive measure could be taken for this
problem. Exchange transfusion, in which all of the infant's blood is
replaced, was the only option. Today, however, HDN can be pre-
vented by administration of Rh immune globulin products. Rho(D)
immune globulin (rhoGAM) is a protein solution containing large
numbers of Rh(D) antibodies. RhoGAM is given at 28 to 30 weeks
of gestation to Rh-negative mothers, regardless of the father's Rh
type. After delivery, the cord blood is tested, and a dose of rhoGAM
is given to the mother only if the baby is Rh positive. rhoGAM is
also given for miscarriages or abortions. The immune globulin pre-
vents the infant's Rh-positive cells from stimulating the mother's
immune system, thus preventing HDN. The source of Rho(D)
immune globulin is plasma from women who have had children
affected by HDN or from Rh-negative men who are voluntarily
injected with Rh-positive RBCs.
Other Blood Types
In addition to the A and B antigens that characterize the ABO blood
grouping, more than 600 antigens and more than 20 other blood
type systems are known. Many are named after the person or family
in which the blood type system was discovered. Table 30-8 describes
other blood systems.
TABLE 30-8 Other Blood Typing Systems
SYSTEM REMARKS
Diego Found only among East Asians and Native Americans.
MNS Useful in maternity and paternity testing.
Duffy The malarial parasite requires the Duffy antigen to enter
the red blood cells. Lack of the antigen confers resistance
to malaria. Duffy-negative blood is found only in
Lewis Antigens are soluble in blood rather than attached to the
red blood cells. These are the only blood group antibodies
that have never been implicated in hemolytic disease af
the newborn.
Other blood group systems include Colton, M, Kell, Kidd, Landsteiner-Wiener, P, Yt or
Cartwright, XG, Scianna, Dombrock, Chido/Rodgers, Kx, Gerbich, Cromer, Knops, Indian, Ok,
Raph, and JMH.
786 UNIT FOUR DIAGNOSTIC PROCEDURES
CRITICAL THINKING APPLICATION 30-4
Before Mr. Corrigan's kidney transplantation, he had a type and cross-match
and was determined to be type 0+. Explain what antigen/antigens are on
his cells. Could he receive blood from a type A+ individual? Why or why
not? Could he receive blood from a type 0- individual? Why or why not?
LEGAL AND ETHICAL ISSUES RELATED
TO BLOOD TRANSFUSIONS
The Blood Safety Act was passed in 1991 to ensure that all donor
blood is tested for HIV and other viral diseases. The impact of this
law can be seen in the ambulatory care environment. The law
requires providers to explain to each elective surgery patient the
chances of the need for a blood transfusion. The discussion must
include the positive and negative aspects of autologous transfusions
(transfusion with a person's own blood) and transfusions of blood
from family, friends, or other donors. This discussion must be doc-
umented in the patient's health record. Before the surgery, the
patient must sign a form giving consent to any needed blood
transfusions. The medical assistant should be aware that certain
populations (e.g., Jehovah's Witnesses) do not believe in blood
transfusions.
If the patient decides to use autologous transfusions, this may
require the patient to donate blood several weeks before the proce-
dure. Usually autologous transfusions are performed for stable
patients undergoing major orthopedic, vascular, cardiac, or thoracic
surgery. The medical assistant might have to assist the patient in
making arrangements for the blood donation. Another type of autol-
ogous transfusion can occur if the surgeon inserts an autologous
drain in the surgical wound. The drain collects the blood from the
surgical wound to prevent postoperative hematomas, and the col-
lected blood then is reinfused into the person.
BLOOD CHEMISTRY IN THE PHYSICIAN
OFFICE LABO RATORY (POL)
CUA-waived chemistry tests using whole blood from fingersticks
have become popular in ambulatory practices because of the
increase in diabetes and cardiovascular disease in the United States.
Both of these metabolic diseases benefit from early diagnosis and
treatment based on continued monitoring of glucose and hemo-
globin A1c for diabetes; and cholesterol, lipid panels, and liver
enzymes for cardiovascular diseases related to fatty plaque in the
arteries.
Blood Glucose Testing
Glucose is used as a fuel by all body cells. Under normal circum-
stances, it is the only substance used to nourish brain cells. Mainte-
nance of blood glucose levels within a normal range is vital to
homeostasis of the human body. Understanding the importance of
glucose can help the medical assistant understand why glucose is the
most frequently tested chemical analyte in the blood.
Elevated blood glucose levels most ofren are associated with dia-
betes mellitus, but they also may indicate pancreatitis, endocrine
disorders, or chronic renal failure. Diabetes mellitus is a disorder of
carbohydrate metabolism that results in elevated blood and urine
glucose levels secondary to the inability of the pancreas to produce
sufficient insulin or because of insulin resistance at the cellular level
(see Chapter 21 ).
For initial screening of a patient for diabetes type 2, a fasting
blood sample is usually taken in the morning, afrer a fast of 10 to
14 hours. The patient's fasting blood glucose (FBG) level should be
less than 100 mg/ dL. If it is higher than 110 mg/ dL, the provider
may request a blood glucose tolerance test (GTT). For this test, the
fasting patient receives a sugary liquid to drink that contains 100 g
of glucose. (The amount may be adjusted according to the patient's
weight.) A blood sugar level ofless than 140 mg/dL after 2 hours is
normal. A reading of more than 200 mg/dL after 2 hours may
indicate diabetes. A reading between 140 and 199 mg/ dL indicates
impaired glucose tolerance, or prediabetes.
Self-monitoring of blood glucose levels has become an impor-
tant part of the management of diabetes. A very small amount of
blood from a capillary stick is "sipped" into a strip that turns on
the glucose monitor and electronically calibrates the monitor.
These rapid-test glucose monitors use an enzymatic method that
converts glucose into a product that is measureable and recorded
by the monitor.
The medical assistant can screen a patient's blood glucose levels
by using a glucometer cleared for home use by the U.S. Food
and Drug Administration (FDA). (This procedure is described in
Chapter 2 1.) The blood glucose level is routinely monitored by
patients with diabetes mellitus type 1 or type 2. Glucose levels
also may be monitored by women with gestational diabetes, a
condition seen during pregnancy in which the effect of insulin
is partially blocked by a variety of other hormones made in
the placenta.
Hemoglobin A1c Testing
Hemoglobin A1c is also described as glycosylated hemoglobin (sugar-
coated hemoglobin), which is the result of glucose binding irrevers-
ibly to the hemoglobin molecules in the RBCs. It is also simply
referred to "the A 1c."
As mentioned, RBCs have a life span of approximately 120
days. Therefore, measuring the amount of glucose that has been
irreversibly bound to hemoglobin provides an assessment of the
average blood sugar during the 60 to 90 days preceding the test. The
A1c test is performed every 3 months in patients with diabetes to
monitor the person's average blood glucose level during those
months. An A1c value higher than the normal range indicates that
the average blood sugar has been elevated during the past 2-3
months. A normal A1c level for a person without diabetes ranges from
4% to 5.6%. For patients with diabetes, the goal is to maintain the
glycosylated hemoglobin level below 7%. Table 30-9 associates gly-
cosylated hemoglobin A1c levels with blood glucose levels. The goal
for people with diabetes type 2 is to have A1c levels of 7% or lower.
With higher levels, the risk of developing complications from dia-
betes increases.
Several methods can be used to measure the A1c level, and the
medical assistant can perform A 1c testing using several CUA-waived
devices. The DCA AlcNOW+ for Professionals (Bayer Diagnos-
tics) provides A1c values in 6 minutes from one drop of capillary
 CHAPTER 30 Assisting in the Analysis of Blood 787

form plaque, a thick, hard deposit that can clog those arteries. This
TABLE 30-9 Relationship Between Glycosylated condition is known as atherosclerosis. If a clot (thrombus) forms at
Hemoglobin Levels and Blood Glucose Levels the site of plaque, blood flow can be blocked in the coronary arteries
of the heart muscle, causing a heart attack. If a clot blocks blood
GLYCOSYLATED BLOOD GLUCOSE
flow to part of the brain, a stroke results. LDL results are often
HEMOGLOBIN A1c (%) (mg/dL)
interpreted as follows:
14.0 380 • LDL less than 100 mg/dL = Optimal
• LDL 100-129 = Near optimal/above optimal
13.0 350 • LDL 130-159 = Borderline high
12.0 315 • LDL 160-189 = High
• LDL 190 +=Very high
11.0 280 About one third to one fourth of blood cholesterol is carried by
10.0 250 high-density lipoprotein (HDL). HDL cholesterol is known as the
"good" or "healthy'' cholesterol because a high level ofHDL choles-
9.0 215 terol seems to protect against heart attack. HDL is able to carry
8.0 180 cholesterol away from the arteries and back to the liver, where it is
passed from the body. It is believed that cholesterol is removed from
7.0 150 the lining of the arteries when high levels of HDL exist; in contrast,
low levels ofHDL cholesterol (i.e., lower than 40 mg/dL) may result
6.0 115
in a greater risk of heart disease.
5.0 80 Adults older than 20 years of age should have a cholesterol
test at least once every 5 years. Total cholesterol and the com-
4.0 50 bination of LDL and HDL typically are screened and monitored
(Procedure 30-6). All three tests are considered screening tests, and
elevated results always require additional testing before a diagnosis
can be made. In general, total cholesterol levels under 200 mg/ dL
blood obtained from a fingerstick. Patients also can perform A1c are considered normal. Results over 240 mg/dL are considered ele-
testing at home using FDA-approved instruments, such as the vated and, on the basis of confirmed testing, place a person in the
AlCNow SelfCheck (Bayer) and the in2it (II) Self-Test Ale System high-risk category for coronary heart disease. An HDL cholesterol
(Bio-Rad). level of 40 mg/dL or higher is considered acceptable for men, and
values of 50 or higher are acceptable for women. Conversely,
HDL levels below 40 mg/dL for men and below 50 mg/dL for
women place a person at risk of coronary heart disease.
CRITICAL THINKING APPLICATION 30-5 Although total cholesterol and HDL cholesterol levels are not
Mr. Corrigan routinely monitors his blood sugar. Why is Dr. Fischbach also significantly affected by food consumption, most providers prefer
interested in his A1c levels? that patients fast from food and liquids, with the exception of water,
for 12 hours before cholesterol levels are checked. If the total cho-
lesterol is elevated, the provider is likely to order a lipid profile, which
is a series of tests that measures the total cholesterol, HDL and LDL
CHOLESTEROL TESTING cholesterol levels, and triglyceride levels,. Triglycerides are fat in the
Cholesterol is a fatlike substance (lipid) present in cell membranes. blood related to caloric intake. Therefore, the patient must be
It is needed to form bile acids and steroid hormones, to name a few instructed to fast from all food and alcoholic beverages 12 hours
of its functions. Cholesterol travels in the blood as distinct particles before the triglyceride test and/or lipid profiles. Consistently high
containing both lipid and proteins. These particles are called lipopro- triglyceride levels may lead to heart disease, especially in people with
teins. The cholesterol level in the blood is determined partly by low levels of "good" HDL cholesterol and high levels of "bad" LDL
inheritance and partly by acquired factors, such as diet, calorie cholesterol, and in people with diabetes type 2. Elevated levels of
balance, and level of physical activity. triglycerides are typically stored in the belly and are associated with
Patients ofren are confused by cholesterol testing. The confusion central obesity.
is caused partly by the way some people use the term cholesterol CUA-waived cholesterol monitors can measure total cholesterol
which often is a catchall term for both the cholesterol a person eats from a fingerstick. The Cholestech LDX analyzer is capable of mea-
and the cholesterol that is maintained in the body. A high blood suring a lipid panel of tests and providing a risk assessment using
level of low-density lipoprotein, or LDL, cholesterol reflects an capillary blood from a finger (see Procedure 30-6). This system uses
increased risk of heart disease, which is why LDL cholesterol is often a cassette testing device capable of measuring glucose, total choles-
called "bad" or "lousy" cholesterol. Lower levels of LDL cholesterol terol, HDL, LDL, VLDL, triglycerides, and the TC/HDL ratio. It
reflect a lower risk of heart disease. When too much LDL cholesterol uses a combination of enzymatic reactions and reflectance photom-
circulates in the blood, it can slowly build up in the walls of arteries etry to detect the resulting color changes caused by each of the lipid
that feed the heart and brain. Together with other substances, it can panel analytes.
788 UNIT FOUR DIAGNOSTIC PROCEDURES

Perform a CUA-Waived Chemistry Test: Determine the Cholesterol Level or Lipid Profile
PROCEDURE 30-6
Using a Cholestech Analyzer

Goal: To perform a Cholestech test for total cholesterol level and/or alipid panel and accurately report the results.
Order: Perform a total blood cholesterol level or lipid panel an Connie Lange STAT.

EQUIPMENT and SUPPLIES 4. Allow refrigerated testing cassettes to come to room temperature (at least
• Patient's health record 10 minutes before opening).
• Provider's order and/or lab requisition PURPOSE: Test is temperature and time sensitive when reading results.
• Cholestech analyzer S. Remove cassette from its pouch and place on flat surface without touching
• Package insert or flow chart with directions the black bar or magnetic strip.
• Optics check cassette PURPOSE: The black bar is the testing area, and the magnetic strip must
• Test cassettes (provided by Cholestech) be read by the analyzer. Touching either may interfere with test results
• Level l and 2 liquid controls 6. Press RUN, allowing the analyzer to do a self-test; this will be followed
• Capillary tubes and plungers for fingerstick sample (provided by by OK an the screen, and then the test drawer will open. The drawer will
Chalestech) stay open for 4 minutes while the specimen is prepared.
• Mini-Pet pipet and pipet tips for venipuncture sample (provided by 7. Incise the finger, and collect the capillary blood to the black line of the
Cholestech) Cholestech capillary tube with its plunger inserted into the red end of the
• Lancet, gauze, alcohol, bandage for capillary blood, or lithium heparin tube. Or collect the fresh venous whole blood with the Cholestech Mini-Pet
(green-topped) tube for venous blood pipet.
• Safety tube decapper (if tubes do not have a Hemogard plastic top) PURPOSE: Both collecting devices are provided by Chalestech to ensure
• Fluid-impermeable lab coat, disposable gloves, and protective eyewear (if that the exact volume af blood necessary is tested.
needed) 8. Place the either whale blaad sample into the well af the cassette. Note:
• Biohazard waste and sharps containers The capillary specimen must be in the cassette within 5 minutes of col-
lection. (see the following figure).
PROCEDURAL STEPS PURPOSE: Fingerstick blood will clot if not tested within 5 minutes.
1. Sanitize your hands. Put on fluid-impermeable lab coat, disposable gloves,
and protective eyewear (if needed).
PURPOSE: To ensure infection control.
2. Assemble the materials needed.
3. Perform quantitative quality control by performing a calibration check with
the optics check cassette. (see the fol lawing figure). Then test level l and
level 2 liquid controls if using a new set af cassettes
PURPOSE: To ensure instrument is reading results accurately, precisely,
and reliably.

9. Immediately put the cassette into the drawer of the analyzer and press
RUN (Note: if the drawer has closed, press RUN again to open the drawer
and proceed with loading into the drawer, and then pressing to close the
drawer).
PURPOSE: This is a test with a color reaction that continues to change
over time.
 CHAPTER 30 Assisting in the Analysis of Blood 789

I; ;m,a m);j inii -,JOntinued

10. When the test is complete, the analyzer beeps, and the screen displays PURPOSE: The provider needs to know the results while the patient is
and prints out the results (see the following figure). still in the office, for proper follow-up with the patient.
LIPID PROFILE (CHOLESTECH TESTI
LIPID PROFILE DESIRABLE RANGES
Total cholesterol <200 mg/dl
HDL cholesterol >40 mg/dl
LDL cholesterol <130 mg/dl
Triglycerides <150 mg/dl
TC/HDL ratio 4.5 or less
Glucose Fasting: 60-110 mg/dl
Nonfasting: <160 mg/dl
Note: Laboratory reports and manufacturers must supply their own reference ranges along with
each patient's results. This is because different methodologies may create different reference
ranges and different units of measurement.

11. Record the findings in the laboratory log and in the patient's health record
if they have not been transmitted electronically.
PURPOSE: Aprocedure is considered not done until it is recorded.
12. Circle the results that do not fall within the Desirable Ranges column of
the following table. Identify "critical values" and take appropriate steps
to notify the provider.
13. Dispose of all sharps in the biohazard sharps container (i.e. lancet and
capillary pipette with plunger). Place all regulated medical waste into the
biohazard waste container (i.e. gauze, alcohol pads, and cassettes).
Disinfect test area, remove PPE, and dispose gloves in biohazard waste.
Sanitize your hands.
PURPOSE: To ensure infection control.

CHOLESTECH LDX PATIENT/CONTROL LOG

Cassette Lat#-. _ _ _ _ Expiration Date: _ _ _ _ _ LDX Serial#-. _ _

DATE TECH PT ID TC HDL LDL TRG TC/HDL GLU CHARTED

10/09/20-- DC #12345 190 50 120 135 4.3 80 ✓

Documentation in the medical record:

Attach printed readout, or record results on the electronic chart:

TEST RESULTS DESIRABLE

Total cholesterol (TC) 190 <200 mg/dl
HDL cholesterol 50 >40 mg/dl
LDL cholesterol 120 <130 mg/dl
Triglycerides 135 <150 mg/dl
TC/HDL ratia 4.3 ::::;4_5
Other
Glucose 80 Fasting: 60-110 mg/dl
Nonfasting: <160 mg/dl
790 UNIT FOUR DIAGNOSTIC PROCEDURES
ALANINE AMINOTRANSFERASE (AL AND n measurement.
ASPARTATE AMINOTRANSFERASE (ASD TESTING
Certain drugs can impair liver function and require the monitor-
ing of two liver enzymes (ALT and AST) that rise in the blood
during liver damage. Drugs that cause liver damage include statins
and fibrates, pharmaceutical agents used to lower blood cholesterol,
and certain antidiabetic and antihypertensive drugs. Liver function
tests and panels are ordered by the provider to monitor the liver
during therapy with drugs that have the potential to cause liver
malfunction.
CUA-waived liver enzyme testing for ALT and AST may be
monitored on the same Cholestech LDX System using ALT/AST
test cassettes.
CRITICAL THINKING APPLICATION 30-6
For what reason might Dr. Fischbach want to evaluate Mr. Corrigan's liver
enzymes? What clinical chemistry tests might he order from the referral
laboratory? What tests for liver enzymes might Dana be able to perform
in the POL? What sample will she need for those tests?
THYROID HORMONE TESTING
The thyroid gland is located anterior to the trachea in the throat. It
produces the hormones triiodothyronine (T3) and thyroxine (T4).
These hormones are essential for life and have many effects on body
metabolism, growth, and development. The thyroid gland is influ-
enced by hormones produced by two other organs found in the
brain, the pituitary gland and the hypothalamus. The pituitary gland
produces thyroid-stimulating hormone (TSH), and the hypothala-
mus produces thyrotropin-releasing hormone (TRH). (Regulation
of thyroid hormone production and thyroid disorders are discussed
in Chapter 21.)
CUA-waived rapid diagnostic tests to qualitatively measure
TSH are available for point-of-care testing. Using whole blood
from a fingerstick, these tests screen patients for hypothyroidism
by detecting elevated levels of TSH, which constitutes a sign of
hypothyroidism. The tests use lateral flow chromatographic immu-
noassay technology housed in a plastic cassette. One such com-
mercially available test is the Thyro Test Whole Blood TSH Test.
REFERENCE LABORATORY CHEMISTRY PANELS
AND SINGLE ANALYTE TESTING AND MONITORING
Automated blood chemistry analyzers often are used to perform
blood chemistry testing. It is not uncommon for several analytes to
be detected at once. A physician may order a chemistry panel, such
as a renal or liver panel, to determine the levels of several related
analytes (Figure 30-14). Analytes commonly detected in the chem-
istry laboratory are listed in Table 30-10. In general, serum from a
clotted specimen is needed for these tests. Typical panels are shown
in Table 30-11 . As noted previously, laboratory reports on patients,
both electronic and paper, must provide their own reference ranges
along with each patient's results. This is because different methodolo-
gies may create different reference ranges and different units of
CRITICAL THINKING APPLICATION 30-7
What tests are routinely done as part of the renal panel? What information
will these tests give Dr. Fischbach about the status of Mr. Corrigan's kidney?
What color of rubber stopper or plastic stopper on vacuum tubes would need
to be drawn for a serum specimen that will be processed and sent to the
reference lab? (Hint: There are three colors based on plain "clot" tubes and
SST tubes. How will you know which serum tube to use?)
CLOSING COMMENTS
Patient Education
Similar to all other procedures, the test is only as valid as the speci-
men and the procedure performed on that specimen. You, as the
provider's agent, are responsible for that validity when you instruct
the patient and when you perform the test.
Legal and Ethical Issues
A medical assistant who is responsible for office laboratory testing
must clearly understand the basic concepts of laboratory medicine.
Therefore, you must stay current with the rapid technologic advances
in laboratory medicine and help establish a protocol of the tests best
suited to your provider-employer.
You are responsible for properly collecting specimens and testing
them accurately. Patient confidentiality is paramount when testing
is performed, as is rigid conformation to all established quality
control procedures.
Professional Behaviors
An ever-increasing number of CUA-waived hematology and chemistry blood
tests are relatively simple to perform and require minimal training. This has
allowed the provider to share the results with the patient immediately,
resulting in greater patient compliance with the prescribed treatment plan.
Proper patient care demands attention to detail in all three areas of the
testing process:
• Preanalytic: Proper care of the testing supplies and equipment, and
proper patient identification and specimen collection
• Analytic: Running the tests according the specific manufacturer's
instructions; recording and analyzing the controls and the patient
results
• Postanalytic: Proper disposal of biohazardous supplies; routing of
test results to the provider and patient.
The medical assistant is the traffic controller for all of these elements.
He or she is responsible for the organization and documentation of each
performed test on the appropriate lab flow sheet and in the patient's health
record.
 CHAPTER 30 Assisting in the Analysis of Blood 791

Physician's Medical Center Ronald J. Halder, M.D.

77332 E. Capital Drive Kaye M. Jones, M.D.
Anytown, USA 11123 Nicholas P. Stepp, M.D.

PATIENT-PLEASE NOTE PATIENT NAME _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

LAST FIRST M.I.

•
If this box is checked, don't
eat or drink anything, except
water, for 14 hours before
going to the lab.
ADDRESS---------------DOB----------
CITY STATE _ _ Z I P - - - SEX: M F
TELEPHONE# SOCIAL SECURITY# _ _ _ _ _ _ _ _ _ __
ORDERING P H Y S I C I A N - - - - - - - - - - - - - DATE - - - - - -
BILLING: D HMO D MEDICARE D MEDICAL D OTHER # _ _ _ _ _ _ _ _ __
GUARANTOR (If other than patient)_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
• PHONE RESULTS TO _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

D SEND ADDITIONAL COPIES OF REPORT T O - - - - - - - - - - - - -

(Please attach copy of eligibilty card.)

Patient Diagnosis _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

D 906 ARTERIAL BLOOD GASES D 3035 PANEL 17 D 3010 METABOLIC 8

ROOM A I R - - - - - - - - (Panel 13 +Na+ K +Cl+ CO2) (Na, K, CO2, Cl, Glu, BUN)
RESP. ASSIST _ _ _ _ __ D 3020 METABOLIC 10 D 3040 PANEL 20 - SMAC
D 105 BLOOD CELL PROFILE (Hgb + Hct) (Na, K, CO2, Cl, Glu, BUN, Great) (Panel 17 + SGPT (ALT) +
• 862 BILI RUBIN (NEONATAL) • 3015 METABOLIC 11 GGT + Osmolality)
D 868 BILI RUBIN (TOTAL & DIRECT) (Met 10 & Phos) D 3043 S-1 Panel (Panel 20 + Triglyceride)
D 100 CBC (Complete Blood Count & Diff) D 3160 OBSTETRICAL PANEL 1 D 500 PROTHROMBIN TIME (PT)
D 3000 ELECTROLYTES (CBC, UA, ABO/Rh, Antibody D 505 Partial Thromboplastin Time (PPT)
D (NA, K, CO2, Cl) Screen, Rubella, RPR) D 7500 RPR
D FANA D 3172 OBSTETRICAL PANEL 3 D 7515 RUBELLA
D GLUCOSE (CBC, ABO/Rh, Antibody Screen, D 2030 THYROID SCREEN
D 915 GLUCOSE, PRE-NATAL DIABETIC SCR. Rubella, RPR) (T4, T3, Uptake, Adj T4)
(1 Hour Post-Glucola) • 3445 OBSTETRICAL PANEL 7 • 704 URINALYSIS
• GLUCOSE TOLERANCE TEST (ABO/Rh, Antibody Screen,
# OF HOURS,_ _ _ DOSE _ __ Rubella, RPR)
D 3398 HEPATITIS PANEL D 3447 OBSTETRICAL PANEL 7A
(B-Surf Ag/Ab, B-Core Ab, A-Ab) (ABO/Rh, Antibody Screen,
D 988 LIPID PROFILE Rubella, RPR, Hepatitis B Surt Ag) BACTERIOLOGY
(Chol, Trig, HDL, LDL, Cardiac Risk) D 3025 PANEL 13
D 3380 LIVER PANEL (Glu, BUN, Great, Uric Acid, Ca, SPECIMEN SOURCE (REQUIRED)
(Alk Phos, Bili, TP, Alb, GGT, SGOT Tp, Alb, Bili, Chol, Alk, Phos, COLLECTION D A T E - - - -
(AST) SGPT (ALT), & Consult) SGOT (AST), LDH, Phos) • __ ROUTINE CULTURE
D 3006 METABOLIC 7 D 3030 PANEL 15 • 8919 AFB CULTURE
(Na, K, CO2, Cl, Glu, Mg) (Panel 13 +Na+ K) • 8921 FUNGAL CULTURE

ADDITIONAL LABORATORY T E S T S : - - - - - - - - - - - - - - - - - - - - - - - - - - - -

2804 (4/93)
LABORATORY OUTPATIENT REQUEST OFFICE USE ONLY
Telephone Order per _ _ _ _ __

Order Received b Y - - - - - - -

FIGURE 30-14 Panel request form.

792 UNIT FOUR DIAGNOSTIC PROCEDURES

TABLE 30-10 Blood Chemistry Tests

TEST ABBREVIATION NORMAL VALUES DESCRIPTION PURPOSE
Alanine ALT (SGPT) <45 units/L Enzyme found predominantly in Ta detect liver disease
aminotransferase the liver but also in the kidney
Albumin 3.5-5 g/dL Protein Ta assess kidney function
Alkaline phosphatase ALP 20-70 units/L Enzyme found in several tissues Ta detect liver and bone disease
Aspartate AST (SGOT) <40 units/L Enzyme found in several tissues. Ta detect tissue damage
aminotransferase
Blood urea nitrogen BUN 7-18 mg/dL or Metabolic products of protein Ta detect renal disease
2.5-6.4 mmol/L catabolism
Calcium Ca 8.4-10.2 mg/dL or Mineral Ta assess parathyroid function and
2.1-2.6 mmol/L calcium metabolism
Chloride Cl 98-106 mmol/L Electrolyte Ta determine acid-base and water
balance
Cholesterol CH, Chol Total: <200 mg/dL or Lipid Ta screen for atherosclerosis related
<5.18 mmol/L to heart disease
LDL: <130 mg/dL or
<3.37 mmol/L
HDL: >35 mg/dL or
>0.91 mmol/L
Creatine CPK Specific to testing method Enzyme found in several tissues Ta assess source of muscle damage
phosphokinase used (myocardial infarct)
Creatinine creat 0.2-0.8 mg/dL Metabolic product of protein Ta screen for renal function
catabolism
Ferritin 20-50 ng/mL Iron-carrying protein Ta detect amount of iron stored in the
body
Gamma glutamyl GGT 0-45 units/L Enzyme found mainly in liver cells Ta detect liver disease
transferase
Globulin glob, lg Varies according to type Protein Ta detect abnormalities in protein
synthesis and removal
Glucose fasting blood FBS 70-100 mg/dL or Carbohydrate Ta detect disorders of glucose
sugar 3. 9-6.1 mmal/L metabolism (diabetes)
Glucose tolerance test GIT Varies with time Carbohydrate Ta detect disorders of glucose
metabolism (diabetes)
Iron Fe 35-140 mcg/dL Mineral Ta assist in diagnosis of anemia
Lactate dehydrogenase LOH <240 units/L Enzyme found in several tissues Ta assist in confirmation af
myocardial ar pulmonary infarct
pH pH 7.35-7.45 Measurement of the acid/base Ta assess acidity or alkalinity of blaad
(acidity and alkalinity)
Phosphorus p 3-4.5 mg/dL or Mineral Ta assist in proper evaluation of
0.97-1.45 mmal/L calcium levels and to detect endocrine
system disorders
 CHAPTER 30 Assisting in the Analysis of Blood 793

TABLE 30-10 Blood Chemistry Tests-continued

TEST ABBREVIATION NORMAL VALUES DESCRIPTION PURPOSE
Potassium K 3.5-5.1 mmol/L Mineral To assist in diagnosis of acid-base and
water balance
Sodium Na 135-146 mmol/L Mineral To assist in diagnosis of acid-base and
water balance
Total bilirubin TB 0.2-1 mg/dL or Metabolic product af hemoglobin To evaluate liver function and ta aid
3.4-17 .1 mmal/L catabolism in diagnosis af anemia
Total iron-binding TIBC 245-400 mcg/dL Ameasure of the potential to
capacity transport iron
Total protein TP 6-8 g/dL; 60-80 g/L To assess the state of hydration; to
screen for diseases that alter protein
balance
Troponin I and T <0.4 Cardiac-specific protein found only To aid in diagnosis of myocardial
with heart muscle damage infarct
Thyroid-stimulating TSH 5-6 milliunits/L Hormone produced by the To assess thyroid and pituitary gland
hormone (thyrotropin) pituitary function
Thyroxine T4 5-12 mcg/dL or Hormone produced by the thyroid To assess thyroid function
64-155 mmol/L gland
Triglycerides Trig 30-190 mg/dL or To screen for atherosclerosis related
0.34-2.15 mmol/L to heart disease
Triiodothyronine T3 27%-47% Hormone produced by the thyroid To assess thyroid function
gland
Uric acid UA Male: 3.4-7 mg/dL or Metabolic product of protein To evaluate renal failure, gout, and
202-416 mcmol/L catabolism leukemia
Female: 2.4-6 mg/dL or
143-357 mcmol/L
HDL, High-density lipoprotein cholesterol; LDL, low-density lipoprotein cholesterol.
*Lab reports, both electronic and paper, must supply their own reference ranges along with each patient's results. This is because different methodologies may create different reference ranges and
different units of measurement.

TABLE 30-11 Typical Chemistry Panels

PANEL COMPONENT PANEL COMPONENT
Liver Alkaline phosphatase (ALP) Cardiac Creatine phasphakinase ((PK)
Gamma glutamyl transferase (GGT) Troponin I
Aspartate aminotransferase (AST) Troponin T
Alanine aminotransferase (ALT)
Lactate dehydrogenase (LOH)
Anemia Iron Electrolyte Sodium
Total iron-binding capacity Potassium
Ferritin Chloride
Transferrin
Thyroid Thyroid-stimulating hormone (TSH) Renal Creatinine
Thyroxine (T4) Bload urea nitrogen (BUN)
Triiodothyronine (T3) Uric acid
Glucose
794 UNIT FOUR DIAGNOSTIC PROCEDURES
SCENABIO
Dana knows the important role laboratory analysis of blood plays in patient
care. Often many different tests are needed ta assess a patient's health. Mr.
Carrigan appreciates that he can have many of these tests done during his
routine visits with a simple fingerstick, such as the hemoglobin and hematocrit,
PT, A1c level, and ALT/AST testing. The hemoglobin and hematocrit provide Dr.
Fischbach with essential information for diagnosing anemia, and the A1c level
SUMMARY OF LEARNING OBJECTIVES
l. Define, spell, and pronounce the terms listed in the vocabulary.
Spelling and pronouncing medical terms correctly reinforce the medical
assistant's credibility. Knowing the definitions of these terms promotes
confidence in communication with patients and co-workers.
2. Name the main functions of blood.
Blood contains RBCs to deliver oxygen to tissues through hemoglobin,
WB(s to fight infections, and platelets to aid in coagulation and the
formation of clots. The plasma carries needed nutrients to the cells
throughout the body, and removes waste products from the cells and
carries them to the lungs and kidneys for elimination.
3. Describe the appearance and function of erythrocytes.
Erythrocytes are also called red blood cells because of their red color,
which comes from hemoglobin. The biconcave disks lack a nucleus and
are responsible for transporting oxygen and carbon dioxide to and from
tissues.
4. Describe the appearance and function of granular and agranular
leukocytes.
Leukocytes are also called white blood cells. Agranular leukocytes lack
granules in the cytoplasm, and granular leukocytes have granules. All
leukocytes function in fighting infection.
5. Differentiate between Tcells and Bcells.
Tlymphocytes are important in immunity and play roles in killing foreign,
virus-infected, and tumor cells; they also assist in antibody production
and keep the immune system in check. Bcells are responsible for anti-
body production.
6. Describe the appearance and function of thrombocytes, explain the
process of clot formation, and discuss plasma.
Athrombocyte (platelet) is a fragment of a larger cell (megakaryocyte)
found in the bone marrow. Thrombocytes play an important role in clot
formation, both physically and chemically. Clot formation begins with the
aggregation of thrombocytes, which release a substance that initiates the
clotting cascade, resulting in a network of minute threads that trap
plasma and blood cells. Plasma is approximately 90% water and is the
carrier for the formed elements and other substances.
7. Do the following related to hematology in the POL:
• Identify the anticoagulant of choice for hematology testing.
The anticoagulant required for most hematology testing is ethylene-
diaminetetraacetic acid (EDTA). The lavender-topped vacuum tube
used in phlebotomy contains this anticoagulant.
is used to monitor Mr. Carrigan's diabetes. The prothrombin time/international
normalized ratio (PT/INR), which monitors coagulation, and the liver enzyme
tests (AST/ALT) assure Dr. Fischbach that Mr. Corrigan's liver is functioning
properly while he is taking medication to treat his diabetes and to manage the
kidney transplant.
• Explain the purpose of amicrohematocrit test.
A microhematocrit (or hematocrit) test is perrarmed to assess
the volume of erythrocytes in relation to the total blood volume.
The test is perrarmed by centrifuging a small amount of whole
blood in a capillary tube. Whole blood normally consists of slighrly
less than 50% RBCs. Hematocrit is reported as a percentage
and is roughly three times the value of hemoglobin in the same
specimen.
• Perform routine maintenance of amicrohematocrit centrifuge.
Refer to Procedure 30-l .
• Obtain aspecimen and perform amicrohematocrit test.
Refer to Procedure 30-2.
8. Do the following related to hemoglobin:
• Explain the role of hemoglobin in the body.
Hemoglobin is the RBC protein responsible for oxygen transport from
the lungs to the tissues. It gives the blood its red color.
• Obtain aspecimen and perform ahemoglobin test.
Refer to Procedure 30-3.
9. Do the following related to the erythrocyte sedimentation rate:
• Cite the reasons for performing an erythrocyte sedimentation rate
(ESR) test.
An ESR test is perrormed to assess inflammation and often is used to
monitor rheumatoid arthritis. This test measures the rate at which
RBCs fall in a calibrated tube in a 60-minute period.
• Describe the sources of error for the erythrocyte sedimentation
rate test.
An ESR test result may be erroneous if a tube is not standing vertically
in the rack; bubbles are present in the Sediplast or Streck ESR tube;
dilutions are incorrect; vibrations or jarring occurs; the blood is at a
temperature other than room temperature; and the blood has
hemolyzed.
• Perform an erythrocyte sedimentation rate test using a modified
Westergren method.
Refer to Procedure 30-4.
l 0. Do the following related to coagulation testing:
• Explain how to determine prothrombin time (PT).
The PT is a method of measuring how well the blood clots and is used
in combination with the partial thromboplastin time (PTT) to screen
for hemophilia and other hereditary clotting disorders. It is important

SUMMARY OF LEARNING OBJECTIVES-continued
to educate patients who take warfarin (Coumadin) about the need
for follow-up laboratory monitoring of their protime/lNR. Helping
patients identify foods high in vitamin Kis crucial to maintaining a
balance between the warfarin dosage and the lab values.
• Obtain aspecimen and perform o CL/A-waived PT/INR test.
Refer to Procedure 30-5.
• Reassure apatient of the accuracy of the test results.
Refer to Procedure 30-5.
• Maintain lab test results using laboratory flow sheets.
Refer to Procedure 30-5.
11. Identify the tests included in a complete blood count (CBC) and their
reference ranges, and differentiate between normal and abnormal
test results.
In the hematology laboratory, blood cells are counted, WBCs are differ-
entiated, and the oxygen-carrying capacity of blood is determined. Hema-
tology testing provides an excellent overview of homeostasis. The CBC
involves an erythrocyte count, leukocyte count, thrombocyte count,
hemoglobin and hematocrit determination, differential examination of
leukocytes, and calculation of red cell indices. Refer to the hematology
diagnostic reference ranges in Table 30-4 and Figure 30-7.
12. Describe the red blood cell (RB() indices and how they are
calculated.
RB( indices are calculated using values obtained from the CBC; namely,
RB( count, hemoglobin, and hematocrit. They help the provider diagnose
blood disorders, such as a variety of anemias.
13. Explain the reasons for performing a white blood cell (WBC) count
and differential, and discuss the preparation of blood smears for the
differential.
Adifferential WBC count is performed to assess the percentages of the
five types of WBCs in the blood. In addition, the red cells and platelets
are examined for distribution and abnormalities. Ablood smear is pre-
pared by placing a drop of blood from a fingerstick, or from an EDTA
tube using a DIFF-SAFE blood dispenser, onto a clean glass slide that is
free of dust and grease. Athin smear of whole blood is spread across
the slide, and then stained, typically with Wright's stain, followed by
microscopic examination.
14. Discuss the identification of normal blood cells and describe the basic
appearance of the five different types of leukocytes seen in a
normal Wright-stained differential.
The three features hematologists look for in blood cells are cell size,
nuclear appearance, and cytoplasm characteristics. The typical leukocytes
seen in the differential examination are (l) the segmented neutrophil,
which has a segmented blue nucleus and small lavender granules in the
cytoplasm; (2) the eosinophil, resembles the neutrophil but has large
red/orange granules; (3) the basophil, which resembles the neutrophil
has large blue-black granules; (4) the lymphocyte, which is the smallest
WBC, has a light blue cytoplasm (with no granules) and a large dark
blue nucleus; and (5) the monocyte, the largest WBC, has an ovulated
CHAPTER 30 Assisting in the Analysis of Blood 795
blue nucleus and a light blue cytoplasm that appears to have bubble-like
inclusions.
15. Discuss red blood cell morphology.
After the differential WBC cell count has been determined, the RBCs are
observed and evaluated. The appearance of the RB(s should correlate
with the RB( indices.
16. Differentiate between the ABO blood groupings and the Rh blood
groupings.
Both the ABO blood type and the Rh type result from antigens on the
surfaces of RBCs, and both groups are crucial when it comes to transfu-
sion. There are four different ABO types (A, AB, B, and 0), The body
produces natural antibodies against the AB antigens that are not present
in the blood cells. For example, if a person has type Aantigens on the
cells, there will be anti-B antibodies in the plasma. Atype Oblood type
would have both anti-A antibodies and anti-B antibodies since they are
both foreign to someone with type Oblood. There are only two Rh types
(positive and negative). Unlike the ABO group, an Rh negative blood
type does not have natural antibodies against Rh positive cells. The Rh
negative individual must first be exposed to Rh positive cells via transfu-
sion or childbirth which initiates the formation of anti-Rh antibodies that
attack and destroy Rh positive cells.
17. Describe the medical assistant's responsibility for legally preparing
a patient for a blood transfusion.
The medical practice must comply with the stipulations of the Blood
Safety Act if a patient may require a blood transfusion during a procedure.
The law requires providers to explain to each elective surgery patient the
chances of the need for a blood transfusion. The discussion must include
the positive and negative aspects of autologous transfusions (transfusion
with a person's own blood) and transfusions of blood from family, friends,
or other donors. This discussion must be documented in the patient's
health record. Before the surgery, the patient must sign a form giving
consent to any needed blood transfusions. The medical assistant may
then sign as the witness to the patient's consent.
18. Do the following related to other blood chemistry testing:
• Explain the reasons for testing blood glucose, hemoglobin A1c, choles-
terol liver enzymes, and thyroid hormones.
The blood glucose level is monitored routinely in patients with diabetes
type l or type 2 and in women who have gestational diabetes during
pregnancy. Hemoglobin A,c levels are measured to determine the
average blood glucose level during the 2 to 3 months before the test;
this test assists in the management of diabetes. Cholesterol testing
generally refers to assessing levels of total cholesterol, HDL and LDL;
it is done to help determine a patient's susceptibility to coronary artery
disease .. Liver enzyme testing (ALT and AST) is performed in the POL
primarily to monitor the side effects of certain therapeutic drugs, such
as those used to treat elevated cholesterol and diabetes. Thyroid
testing is performed in the POL to detect elevated TSH levels and to
assist in the diagnosis of hypothyroidism .. Refer to Table 30-11 .
Continued
796 UNIT FOUR DIAGNOSTIC PROCEDURES

SUMMARY OF LEARNING OBJECTIVES-continued

• Obtain aspecimen and perform acholesterol test using acholesterol
monitor approved by the FDA.
Refer to Procedure 30-6.
19. Summarize lypical chemistry panels, the reason for performing each
panel, and lhe individual lests performed in lhe panels.
Certain tests that provide information about a disease or syndrome are
grouped together in panels. For example, a liver panel detects abnormali-
ties in a number of different liver enzymes (see Tables 30-10 and
30-11).
20. Discuss palienl educalion and professionalism related to assisting in
lhe analysis of blood,
You, as the provider's agent, are responsible when you instruct the
patient and when you perform laboratory tests. Amedical assistant who
is responsible far office laboratory testing must clearly understand the
basic concepts of laboratory medicine. You must stay current and help
establish a protocol of the tests best suited to your provider-employer.
You are responsible collecting specimens and testing them accurately.
Patient confidentiality is paramount when testing is performed, as is rigid
conformation to all established quality control procedures.

CONNECTIONS
CO Study Guide Connection: Go to the Chapter 30 Study Guide. Read and complete evolve Evolve Connection: Go to the Chapter 30 link at evolve.elsevier.com/
the activities. kinn to complete the Chapter Review Quiz. Check out the other resources listed for this
chapter to make the most of what you have learned from Assisting in the Analysis of
Blood.
ASSISTING IN MICROBIOLOGY
AND IMMUNOLOGY
Infectious diseases are a continuing threat for everyone. Anna McIntyre, (MA
(AAMA), who works in the physician office laboratory (POL) of a local clinic,
knows that some diseases have been effectively controlled with the help
of modern technology and antibiotics. However, new diseases are constantly
appearing, such as the 2014 Ebola epidemic, which affected multiple
countries in West Africa; the bird flu (H l Nl) pandemic in 201 O; and the
emergence of the human immunodeficiency virus (HIV) in the 1980s. In
While studying this chapter, think about the following questions:
• How can Anna protect herself and other patients in the facility from
infectious microorganisms?
• How can body fluids or other samples be collected and tested for the
presence of pathogenic organisms?
LEARNING OBJECTIVES
l . Define, spell, and pronounce the terms listed in the vocabulary.
2. Describe the naming of microorganisms.
3. Describe various bacterial staining characteristics, shapes, oxygen
requirements, and physical structures; also, explain the characteristics
of common diseases caused by bacteria.
4. Describe the unusual characteristics of Chlamydia, Mycoplasma, and
Rickettsia organisms.
5. Do the following related to fungi, protozoa, and parasites:
• Compare bacteria with fungi, protozoa, and parasites.
• Identify the characteristics of common diseases caused by fungi,
protozoa, and parasites.
• Perform patient education on the collection of a stool specimen for
ova and parasite testing.
6. Compare bacteria with viruses, and describe the characteristics of
common viral diseases.
7. Cite the protocols for the collection, transport, and processing of
specimens.
8. Explain how pinworm testing is done and when it is recommended.
31
addition, other familiar infectious diseases, such as staph infections, tubercu-
losis, bacterial pneumonia, salmonella poisoning, and malaria, now are
appearing in forms that are resistant to drug treatment. Anna knows that
it is important to identify pathogens quickly so that proper treatment can
begin as soon as possible. Identification of pathogens, she has discovered,
can involve several different types of tests, many of which can be performed
in the POL.
• How are pathogenic organisms differentiated from normal, nonpathogenic
species?
• What role do laboratory healthcare workers play in the identification and
treatment of infections caused by microorganisms?
9. Describe and perform CUA-waived microbiology tests:
• Describe three CUA-waived microbiology tests that use a rapid
identification technique.
• Obtain a specimen and perform the CUA-waived rapid
Streptococcus test.
l 0. Do the following related to CUA-waived immunology testing:
• Discuss the purpose of indirect immunology testing.
• Describe three CUA-waived immunology tests that could be done in
the physician office laboratory.
• Obtain a specimen and perform the CUA-waived mononucleosis
strep test.
11. Detail the equipment needed in a microbiology reference laboratory,
and discuss identification of pathogens in the microbiology laboratory
by describing various staining techniques.
12. Describe the reference laboratory assessment of a throat culture and a
urine culture.
13. Explain the method used for culture and sensitivity testing.
14. Discuss patient education, in addition to legal and ethical issues,
involved in laboratory testing.
798 UNIT FOUR DIAGNOSTIC PROCEDURES
VOCABULARY
antibodies Molecular proteins (immunoglobulins) produced by
the blood's plasma cells that specifically destroy a foreign
invader or substance that has infected the body.
antigens Foreign invaders or substances that cause an immune
response in the body in which specific antibodies are produced
to attack and destroy it.
antimicrobial agents A general term for drugs, chemicals, or
other substances that either kill or slow the growth of microbes.
Among the antimicrobial agents are antibacterial drugs, antiviral
agents, antifungal agents, and antiparasitic drugs.
arthropods (ahr'-thro-podz) Members of a class of invertebrate
animals that includes insects, crustaceans, spiders, scorpions,
and others.
broad-spectrum antimicrobial agents Drugs used to treat a wide
range of infections.
chromosomes Thread-like molecules that carry hereditary
information
cyst A small, capsule-like sac that encloses certain organisms in
their dormant or larval stage.
eukaryote (yoo-kar'-e-oht) Single-celled or multicellular
organism in which each cell contains a distinct membrane-
bound nucleus.
genus A classification representing a family of microorganisms
and all living beings. The genus is the first name assigned to a
microorganism and it is italicized and capitalized.
in vitro A term referring to conditions or tests performed outside
a living body.
macromolecules The molecules needed for metabolism:
carbohydrates, lipids, proteins, and nucleic acids.
microorganisms Organisms of microscopic or submicroscopic
size.
I nfectious diseases caused by microorganisms have gotten a lot
of publicity. In 2015 the evening news followed the latest out-
breaks of viral influenza and Ebola virus as they swept across par-
ticular nations and threatened to spread worldwide. The news also
reported on the contaminated water supplies that followed weather
catastrophes. Healthcare-associated infections (HAis), such as
methicillin-resistant Staphylococcus aureus (MRSA) and Clostridium
difficile infection, in addition to other intestinal and respiratory
diseases, are becoming more and more difficult to control because
of the new strains of drug-resistant microorganisms. Bioterrorism
became a reality when Bacillus anthracis spores were sent through
the mail, causing anthrax. Products line the pharmacy shelves,
declaring their ability to keep us "germ free." It is no wonder
many people have the impression that all microorganisms are
harmful. In reality, less than 1% of known microorganisms are
pathogens.
In fact, without microorganisms we could not survive. Beneficial
microorganisms are responsible for the decomposition of waste and
molecule A group of like or different atoms held together by
chemical forces.
normal flora Microorganisms normally present on and in our
bodies; they perform vital functions and protect the body
against infection.
opportunistic organisms Microorganisms normally present in
low numbers that are capable of causing disease when the
conditions are favorable.
organelles (or-gah-nels') Structures within a cell that perform a
specific function.
pathogen An agent that causes disease, especially a living
microorganism such as a bacterium or fungus
prokaryote (pro-kar'-e-oht) A unicellular organism that lacks a
membrane-bound nucleus.
pure culture A bacterial or fungal culture that contains a single
organism.
reagent (re-a'-gent) An ingredient used in a laboratory test to
detect or produce a reaction.
species A category of microorganisms below genus in rank;
a genetically distinct group. It is the second name given to
the microorganism and it is written in all lower case italic
letters.
tissue culture The technique or process of keeping tissue alive
and growing in a culture medium.
transport medium A medium used to keep an organism alive
during transport to the laboratory.
viable Capable of living, developing, or germinating under
favorable conditions.
wet mount A slide preparation in which a drop of liquid
specimen or the like is covered with a coverslip and observed
with a microscope.
natural recycling. The normal flora in and on our bodies is needed
for the following processes:
• Digesting food
• Forming blood clots properly as a result of vitamin K produc-
tion by the organisms inhabiting our intestines
• Preventing pathogens from invading our skin, mucous mem-
branes, and gastrointestinal and genitourinary tracts
When the body's normal flora is weakened (e.g., by antibiotic
overuse or hormonal changes), certain opportunistic organisms
that normally are present in low numbers begin to overgrow, causing
a superinfection. For example, vulvovaginal candidiasis, a yeast infec-
tion of the vaginal tract, is common in women that have taken
broad-spectrum antimicrobial agents.
As a medical assistant, you need to understand basic microbiol-
ogy and the role of microorganisms in both health and disease. The
main objective in medical microbiology procedures is to identify the
organisms responsible for illness so that the provider can properly
treat the patient. In addition, your responsibilities will include

preventing HAis by observing infection control in the physician
office laboratory (POL) and in the patients the POL serves. Micro-
biology testing procedures may be performed in the POL or in the
microbiology department of a medical referral laboratory.
The study of immunology, or the immune system, is closely
tied to microbiology. Invasive microorganisms induce an immune
response, leading to the production of a variety of molecular anti-
bodies that come to our defense. Often a bacterial or viral infec-
tion is diagnosed by testing for the specific antibody that fights
the specific infectious agent, rather than by isolating the pathogen
itself.
The previous chapters on Infection Control and Assisting in the
Clinical Laboratory discussed the chain of infection and how it can
be broken through the use of diligent infection control procedures,
such as proper hand sanitizing, wearing appropriate personal protec-
tive equipment (PPE), observing recommended precautions based
on how infectious agents are transmitted, using antiseptics and dis-
infectants, and performing sterilization procedures.
This chapter covers the major types of infectious agents; the
quality control issues related to the collection and handling of micro-
biologic specimens; and common microbiology and immunology
tests that are CUA waived (i.e., allowed to be performed in the POL
under the Clinical Laboratory Improvement Amendments). The
chapter concludes with an overview of the more complex microbiol-
ogy procedures and tests performed in hospitals and reference
laboratories.
CLASSIFICATION OF MICROORGANISMS
Although the medical assistant is not responsible for identifying
microorganisms, a working knowledge of the terminology used in
the classification of microorganisms is essential.
Microorganisms are too small to be seen without magnification.
Bacteria are the most prevalent type of microorganism. Other micro-
organisms include fungi and protozoa. Parasitic worm infections also
are identified in the microbiology laboratory because their eggs
are seen under the microscope. Viruses are the smallest microorgan-
ism and are visible only under the highly magnified electron
microscope.
Naming of Microorganisms
Scientists have used the binomial system of nomenclature devel-
oped by Swedish botanist Carl Linnaeus to name all living organ-
isms: animals, plants, fungi, protozoa, and bacteria. This binomial
system assigns two names; the first name is the genus (plural,
genera) and the second is the species. Both names are either itali-
cized or underlined when written. The genus begins with a capital
letter, the species with a lowercase letter. Often the name reveals
some characteristic about the organism. For example, Neisseria gon-
orrhoeae is a bacterium that was studied extensively by Albert
Neisser, and it causes the sexually transmitted infection gonorrhea.
When microbiology laboratory results are reported, it is essential
that both the genus and species names be recorded. Different
species may cause different symptoms or require different antibiotic
treatment. For example, Neisseria gonorrhoeae causes disease, whereas
Neisseria sicca is found in the mouth and does not cause disease
under normal conditions.
CHAPTER 31 Assisting in Microbiology and Immunology 799
The genus name of the organism may be represented by a single
letter after the organism's full genus and species name has been
written once in a report. For example, Escherichia coli is commonly
referred to as E. coli.
CRITICAL THINKING APPLICATION 31-1
Anna receives a telephone call fram BioStatlab, the referral laboratory the
clinic uses. The results from Ms. Tina Walker's urine culture are ready. The
technician says that the organism causing Ms. Walker's urinary tract infec-
tion was identified as Escherichia coli. How could f. coli have infected the
urinary tract? (Hint: What body part is similar in spelling to "coli"?)
Typical Pathogenic Bacteria
Bacteria are single-celled prokaryote organisms that reproduce by
binary fission, a process that involves duplication of their genetic
chromosomes and subsequent fission (splitting in half) of the cell.
This process of asexual reproduction results in tremendous
numbers of bacteria from a single cell, which explains how bacte-
rial infections can quickly overwhelm a person's immune system.
Some bacteria reproduce in as little as 14 minutes, whereas others
take days to divide. Theoretically, a single E. coli cell, which has
a reproduction time of about 30 minutes, produces 351,843,
724,088,831 offspring in 24 hours if it is able to enter the urinary
bladder.
Bacteria often are classified according to their staining character-
istics, their shapes, and the environmental conditions in which they
thrive. Both shape and staining characteristics are direct results of
the cell wall composition.
Bacterial Staining Characteristics
Three types of cell wall structures are found among pathogenic
bacteria: gram positive, gram negative, and acid fast. These designa-
tions are based on reactions in specialized stains used to visualize the
bacteria under the microscope. Bacterial cell walls are composed of
peptidoglycan (PG), a molecule composed of carbohydrate and
protein.
• Gram-positive cells contain a thick layer of PG with no lipid
layer surrounding it; this produces a deep blue/violet when
stained with Gram's stain (Figure 31-1, A).
• Gram-negative cells contain a thin layer of PG with a lipid
layer surrounding it; this produces a pinkish red color when
stained with Gram's stain (Figure 31-1, B).
• Acidjast cells contain a thin layer of PG surrounded by a thick
layer of wax-like lipids. Acid-fast bacteria do not stain well
with Gram's stain; these cells stain pink with the acid-fast stain
(Figure 31-2).
Bacterial Shapes
Pathogenic bacteria assume three different morphologic shapes.
Spherical bacteria are called cocci (singular, coccus); rod-shaped bac-
teria are bacilli (singular, bacillus); and spiral bacteria are spirilla
(singular, spirillum). Tightly coiled spirilla are called spirochetes.
Certain arrangements are also seen in the different genera
and species. For example, when bacteria are in a chain formation,
800 UNIT FOUR DIAGNOSTIC PROCEDURES

-,
I

•
-
....
\

A B
FIGURE 31-1 Gram stain. A, Red blood cells (RBCs) and gram-positive cocci. B, RBCs with gram-negative bacilli. (Fram De la Maza lM,
Pezzlo MT, Baron EJ: Color atlas of diagnostic microbiology, St Louis, 1997, Mosby.)

• .. Cocci, diplococci

--· ......... Streptococci

a Tetrad , sarcinae

•
Staphylococci

- Bacillus • Coccobacillus
FIGURE 31-2 The acid-fast stain. Pink acid-fast bacilli (AFB) are seen in this smear. (Fram De la
Maza LM, Pezzla MT, Baran EJ: Color atlas of diagnostic microbiology, St Louis, 1997, Mosby.)
Not diplobacillus

the prefix strepto- is used. When bacteria are found in pairs, - - Diplobacillus
the prefix diplo- is used, and when they are found in grapelike
clusters, the prefix staphylo- is used. Cocci in packets of four are
called tetrads, and in packets of eight or 16 are called sarcinae
(Figure 31-3).

Streptobacillus
CRITICAL THINKING APPLICATION 31-2
Anna knows that impetigo is caused by Staphylococcus aureus. Without
using a microscope, she knows what the organism's shape looks like. How
does she know? (Hint: Examine the two parts of the organism's genus.)
Spirochete
Bacterial Oxygen Requirements FIGURE 31-3 Typical morphologic arrangements of bacteria.
Bacteria are also classified according to oxygen requirements. Those
that require oxygen to live are called aerobes; those that die in the
presence of oxygen are anaerobes. Some bacteria are flexible concern-
ing oxygen requirements and, although they are anaerobes, can
 CHAPTER 31 Assisting in Microbiology and Immunology 801

survive in the presence of oxygen. These organisms are called faculta-
tive anaerobes. Mycobacterium tuberculosis thrives in white blood cells
in the lungs, causing tuberculosis; it is an aerobe. Bacteroides fragilis
is the predominant bacterium found in the intestines. This gram-
negative bacillus is an anaerobe. E. coli, also an inhabitant of the
intestines and the most common cause of urinary tract infections, is
a facultative anaerobe.
Bacterial Physical Structures
Bacteria can be classified and identified according to additional
physical structures. Some bacteria have thin, long structures, called
flagella, that aid propulsion movement. Proteus vulgaris is a gram-
negative bacillus with many flagella surrounding the cell. It can
propel itself into the bladder and is the primary cause of HAI
(Healthcare Acquired Infection) urinary tract infections. In some
bacteria, thick, gelatinous coats surround the cell wall; these are
called capsules. Streptococcus pneumoniae is nonpathogenic if it is
not producing a capsule; however, it is the most common cause of
pneumonia in older adults when it becomes encapsulated. There-
fore, the Pneumovax vaccine is given to older patients and to those
at high risk for respiratory complications (e.g., patients with
asthma). Certain bacteria are also able to form intracellular struc-
tures, called endospores, that allow the cell to remain viable when
environmental conditions are not favorable. Bacillus anthracis pro-
duces such spores, as does Clostridium tetani. If spores of C. tetani
enter a wound and germinate, they cause the disease known
as tetanus.
Tables 31-1 to 31-3 list some important infectious diseases caused
by typical pathogenic bacilli, cocci, and spirilla.

TABLE 31-1 Common Diseases Caused by Bacilli

DISEASE OR SPECIMENS PREVENTION AND
CONDITION ORGANISM TRANSMISSION SYMPTOMS AND TESTS IMMUNIZATION
Tuberculosis Mycobacterium Inhalation Pulmonary: Cough, Sputum for culture; BCG vaccine (not routinely
tuberculosis hemoptysis, sweats, x-ray films, skin tests given in the United States);
-Acid-fast branching weight loss isolation when infection is
bacilli May affect other active
systems
Urinary tract Escherichia coli, Proteus Ascends urethra; Cystitis: Frequency, Clean-catch urine for Good personal hygiene
infections spp., Klebsiella spp., catheterization burning, bloody urine culture and analysis (always wipe from front to
Pseudomonas Pyelonephritis: Flank back)
aeruginosa pain, fever
-Gram-negative bacilli,
many flagellated
Legionnaires' Legionella pneumophila Grows freely in water Pneumonia-like Sputum; blood for Avoid smoking; patient
disease -Gram-negative bacillus (air conditioning symptoms culture and analysis isolation and proper
(stains poorly with systems) ventilation to avoid
usual methods) spreading organisms through
ducts
Tetanus (lockjaw) Clostridium tetani Open wounds, fractures, Toxin affects motor Blood tests DTaP in childhood; Tdap is a
-Gram-positive punctures nerves; muscle spasms, booster immunization given
spore-forming bacilli, convulsions, rigidity at age 11 that offers
anaerobic continued protection; it is
also routinely given to
pregnant women and infant
care providers
Botulism Clostridium botulinum Improperly cooked Neurotoxin affects Contaminated food; Botulinus antitoxin; boil
-Gram-positive, canned foods speech, swallowing, blood for culture and canned goods 20 min
spore-forming bacilli, vision; paralysis of analysis before tasting or eating
anaerobic respiratory muscles,
death
Continued
802 UNIT FOUR DIAGNOSTIC PROCEDURES

TABLE 31-1 Common Diseases Caused by Bacilli-continued

DISEASE OR SPECIMENS PREVENTION AND
CONDITION ORGANISM TRANSMISSION SYMPTOMS AND TESTS IMMUNIZATION
Diphtheria Corynebacterium Inhalation Sare throat, fever, Swabs; Gram stain, DTaP in childhaad; Tdap is a
(respiratory diphtheriae headache, gray culture booster immunization given
secretions) -Gram-positive bacilli, membrane in the throat at age 11 that offers
club shaped continued protection; also
routinely given to pregnant
women and infant care
providers
Whooping cough Bordetella pertussis Respiratory secretions Upper respiratory tract Swabs for culture DTaP in childhood
-Gram-negative bacilli symptoms; high-pitched, See Tetanus.
crowing whoop
Clostridium difficile Clostridium difficile Hospital-acquired Diarrhea, abdominal Fecal sample; stool Change antibiotic based on
infection -Gram-positive, infection resistant to cramping, blood or pus tests, colon examination C. diff culture and sensitivity
spore-forming bacilli antibiotic treatment in the stool, fever, test results
kidney failure
Salmonella infection Salmonella Food-borne Fever, diarrhea, Fecal sample; stool Wash hands and surfaces
(multiple species) illness abdominal cramps, tests when preparing eggs, raw
-Gram-negative headache, possibly meat; refrigerate meat
nausea, vomiting, and leftovers; avoid crass-
loss of appetite contamination of food
Courtesy Kathleen Moody.
BCG, Bacille Calmette·Guerin vaccine; DTaP, diphtheria·tetanus·acellular pertussis vaccine; T, tetanus (toxoid).

TABLE 31-2 Common Diseases Caused by Cocci

SPECIMENS
DISEASE ORGANISM TRANSMISSION SYMPTOMS AND TESTS PREVENTION
Pneumonia Streptococcus Direct contact, droplets Productive cough, fever, Sputum; branchoscopy Vaccines:
pneumoniae chest pain secretions PCVl 3 recommended for
-Gram-positive Culture, Gram stain all children <5 yr and