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1 2 3 4 5 6 7 12 11 10 09
 Table of Contents

List of Procedures xi American Medical Technologists . . . . . . . . 12 Unit 2: The Therapeutic

Registered Medical Assistant . . . . . . . . . . . . 12 Approach 50
Preface xiii
Certified Medical Administrative Specialist . . 13
Supplements at-a-Glance xvii Continuing Education . . . . . . . . . . . . . . . . . 13
About the Authors xviii National Healthcareer Association . . . . . . . 13 Chapter 4: Therapeutic
Acknowledgments xx Certification . . . . . . . . . . . . . . . . . . . . . . . . . 13 Communication Skills 51
Continuing Education . . . . . . . . . . . . . . . . . 14
Contributors xxii Importance of Communication . . . . . . . . . 53
Regulation of Health Care Providers . . . . . 14
The Communication Cycle . . . . . . . . . . . . . 53
Reviewers xxiii Scope of Practice . . . . . . . . . . . . . . . . . . . . . 14
The Sender . . . . . . . . . . . . . . . . . . . . . . . . . . 53
How to Use the Book xxiv The Message . . . . . . . . . . . . . . . . . . . . . . . . . 54
How to Use the StudyWARE Chapter 2: Health Care Settings The Receiver . . . . . . . . . . . . . . . . . . . . . . . . 54
Software CD xxvi and the Health Care Team 19 Feedback. . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
Listening Skills . . . . . . . . . . . . . . . . . . . . . . . 54
How to Use the Critical Thinking Ambulatory Health Care Settings . . . . . . . . 20
Individual and Group Medical Practices . . . 20 Types of Communication . . . . . . . . . . . . . . 55
Challenge 2.0 xxvii
Urgent Care Centers . . . . . . . . . . . . . . . . . . 22 Verbal Communication . . . . . . . . . . . . . . . . 55
Managed Care Operations . . . . . . . . . . . . . 22 Nonverbal Communication. . . . . . . . . . . . . 56
Congruency in Communication . . . . . . . . . 58
SECTION I: “Boutique” or “Concierge” Medical
Practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 Factors Affecting Therapeutic
GENERAL The Health Care Team . . . . . . . . . . . . . . . . 23 Communication. . . . . . . . . . . . . . . . . . . . . . 59
Age and Gender Barriers. . . . . . . . . . . . . . . 59
The Title “Doctor” . . . . . . . . . . . . . . . . . . . . 23
PROCEDURES 1 Health Care Professionals and Economic Barriers . . . . . . . . . . . . . . . . . . . . 59
Unit 1: Introduction to Their Roles . . . . . . . . . . . . . . . . . . . . . . . . . . 23 Education and Life Experience Barriers . . 59
Integrative Medicine and Alternative Bias and Prejudice Barriers . . . . . . . . . . . . . 59
Medical Assisting and Health Verbal Roadblocks to Therapeutic
Health Care Practitioners . . . . . . . . . . . . . . 25
Professions 2 Communication . . . . . . . . . . . . . . . . . . . . . . 59
Future of Integrative Medicine . . . . . . . . . . 27
Allied Health Professionals and Defense Mechanisms as Barriers . . . . . . . . . 60
Chapter 1: The Medical Assisting Their Roles . . . . . . . . . . . . . . . . . . . . . . . . . 27 Barriers Caused by Cultural and
The Role of the Medical Assistant. . . . . . . . 27 Religious Diversity . . . . . . . . . . . . . . . . . . . . 61
Profession 3 Human Needs as Barriers to
Health Unit Coordinator. . . . . . . . . . . . . . . 28
Historical Perspective of the Profession . . . 5 Therapeutic Communication . . . . . . . . . . . 63
Medical Laboratory Technologist . . . . . . . . 28
Career Opportunities . . . . . . . . . . . . . . . . . . 5 Maslow’s Hierarchy of Needs . . . . . . . . . . . 63
Registered Dietitian . . . . . . . . . . . . . . . . . . . 28
Education of the Medical Assistant . . . . . . . . 6 Establishing Multicultural
Pharmacist . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Courses in a Medical Assisting Program . . . . 6 Communication. . . . . . . . . . . . . . . . . . . . . . 64
Pharmacy Technician. . . . . . . . . . . . . . . . . . 30
Practicum . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Cultural Brokering . . . . . . . . . . . . . . . . . . . . 65
Phlebotomist . . . . . . . . . . . . . . . . . . . . . . . . 30
Associate and Bachelor Degrees . . . . . . . . . . 7 Therapeutic Communication in
Physical Therapist . . . . . . . . . . . . . . . . . . . . 30
Accreditation of Medical Assisting Action . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
Physical Therapy Assistant . . . . . . . . . . . . . . 30
Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Interview Techniques . . . . . . . . . . . . . . . . . . 65
Nurse. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
CAAHEP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Point of Care Techniques . . . . . . . . . . . . . . 66
Physician Assistant . . . . . . . . . . . . . . . . . . . . 31
ABHES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Community Resources . . . . . . . . . . . . . . . . 67
The Value of the Medical Assistant
Attributes of a Medical Assistant
to the Health Care Team . . . . . . . . . . . . . . . 32
Professional . . . . . . . . . . . . . . . . . . . . . . . . . 8
Chapter 5: Coping Skills
Empathy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Attitude . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Chapter 3: History of Medicine 36 for the Medical Assistant 71
Dependability . . . . . . . . . . . . . . . . . . . . . . . . . 9 Cultural Heritage in Medicine . . . . . . . . . . 37 What Is Stress?. . . . . . . . . . . . . . . . . . . . . . . 72
Initiative . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Medical Specialists in History . . . . . . . . . . . 38 Adaptation to Stress . . . . . . . . . . . . . . . . . . . 73
Flexibility . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 History of Medical Education . . . . . . . . . . . 39 Management of Stress . . . . . . . . . . . . . . . . . 73
Desire to Learn . . . . . . . . . . . . . . . . . . . . . . . 9 History of Attitudes toward Illness . . . . . . . 39 What Is Burnout? . . . . . . . . . . . . . . . . . . . . 76
Physical Attributes . . . . . . . . . . . . . . . . . . . . . 9 Historical Medical Treatments . . . . . . . . . . 40 Stages of Burnout. . . . . . . . . . . . . . . . . . . . . 76
Ability to Communicate. . . . . . . . . . . . . . . . 10 The Scourge of Epidemics . . . . . . . . . . . . . 41 Role of Personality and Work
Ethical Behavior . . . . . . . . . . . . . . . . . . . . . . 10 Significant Contributions to Medicine . . . . 43 Environment . . . . . . . . . . . . . . . . . . . . . . . . 76
American Association of Medical Assistants . .11 Women in Medicine. . . . . . . . . . . . . . . . . . . 46 Burnout Prevention . . . . . . . . . . . . . . . . . . . 77
Certification . . . . . . . . . . . . . . . . . . . . . . . . . 11 Frontiers in Medicine . . . . . . . . . . . . . . . . . 46 What to Do If You Are Burned Out . . . . . . 77
Continuing Education . . . . . . . . . . . . . . . . . 12 Goal Setting as a Stress Reliever . . . . . . . . . 77

Table of Contents iii

Chapter 6: The Therapeutic Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108 Breathing Emergencies and Cardiac
Approach to the Patient with a Good Samaritan Laws . . . . . . . . . . . . . . . . 109 Arrest. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157
Advance Directives . . . . . . . . . . . . . . . . . . 110 Rescue Breathing . . . . . . . . . . . . . . . . . . . . 157
Life-Threatening Illness 81 Living Wills/Advance Directives . . . . . . . . 110 Cardiopulmonary Resuscitation . . . . . . . . 157
Life-Threatening Illness . . . . . . . . . . . . . . . 82 Durable Power of Attorney for Safety and Emergency Practices . . . . . . . . 159
Cultural Perspective on Life-Threatening Health Care . . . . . . . . . . . . . . . . . . . . . . . . 110
Illness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82 Patient Self-Determination Act . . . . . . . . . 110
Choices in Life-Threatening Illness . . . . . . 83
The Range of Psychological Suffering . . . . 85
SECTION II:
Chapter 8: Ethical Considerations 120
The Therapeutic Response to the
Ethics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121
CLINICAL
Patient with HIV/AIDS . . . . . . . . . . . . . . . . 85
The Therapeutic Response to the
Principle-Centered Leadership . . . . . . . . . 122 PROCEDURES 167
Five Ps of Ethical Power . . . . . . . . . . . . . . . 123
Patient with Cancer . . . . . . . . . . . . . . . . . . . 86 Unit 4: Integrated
Ethics Check Questions . . . . . . . . . . . . . . . 123
The Therapeutic Response to the Patient
with End-Stage Renal Disease . . . . . . . . . . . 86
Bioethics . . . . . . . . . . . . . . . . . . . . . . . . . . 123 Clinical Procedures 168
Keys to the AAMA Code of Ethics. . . . . . . 125
The Stages of Grief . . . . . . . . . . . . . . . . . . . 87
Ethical Guidelines for Health Care
Denial . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87
Providers . . . . . . . . . . . . . . . . . . . . . . . . . . 126 Chapter 10: Infection Control
Anger . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87 and Medical Asepsis 169
Advertising . . . . . . . . . . . . . . . . . . . . . . . . . 126
Bargaining . . . . . . . . . . . . . . . . . . . . . . . . . . 87
Confidentiality . . . . . . . . . . . . . . . . . . . . . . 126 Impact of Infectious Diseases . . . . . . . . . . 172
Depression . . . . . . . . . . . . . . . . . . . . . . . . . . 87
Medical Records . . . . . . . . . . . . . . . . . . . . . 126 The Process of Infection . . . . . . . . . . . . . 172
Acceptance . . . . . . . . . . . . . . . . . . . . . . . . . . 87
Professional Fees and Charges . . . . . . . . . 127 Growth Requirements for
The Challenge for the Medical Assistant . . . 88
Professional Rights and Microorganisms . . . . . . . . . . . . . . . . . . . . . 173
Unit 3: Responsible Responsibilities. . . . . . . . . . . . . . . . . . . . . . 127 Chain of Infection. . . . . . . . . . . . . . . . . . . 173
Medical Practice 92 Disaster Response . . . . . . . . . . . . . . . . . . . 127 Infectious Agents . . . . . . . . . . . . . . . . . . . . 173
Treatment for a Culturally Diverse Reservoir . . . . . . . . . . . . . . . . . . . . . . . . . . . 175
Clientele . . . . . . . . . . . . . . . . . . . . . . . . . . . 127 Portal of Exit . . . . . . . . . . . . . . . . . . . . . . . 178
Chapter 7: Legal Considerations 93 Care of the Poor . . . . . . . . . . . . . . . . . . . . . 127 Means of Transmission . . . . . . . . . . . . . . . 180
Sources of Law . . . . . . . . . . . . . . . . . . . . . . 95 Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128 Portal of Entry . . . . . . . . . . . . . . . . . . . . . . 180
Statutory Law . . . . . . . . . . . . . . . . . . . . . . . . 95 Bioethical Dilemmas . . . . . . . . . . . . . . . . . 128 Susceptible Host. . . . . . . . . . . . . . . . . . . . . 180
Common Law . . . . . . . . . . . . . . . . . . . . . . . . 95 Allocation of Scarce Medical The Body’s Defense Mechanisms
Criminal Law . . . . . . . . . . . . . . . . . . . . . . . . 96 Resources . . . . . . . . . . . . . . . . . . . . . . . . . . 128 for Fighting Infection and Disease . . . . . . 181
Civil Law . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96 Abortion and Fetal Tissue The Body’s Natural Barriers . . . . . . . . . . . 181
Administrative Law . . . . . . . . . . . . . . . . . . . 96 Research . . . . . . . . . . . . . . . . . . . . . . . . . . . 129 Inflammatory Response . . . . . . . . . . . . . . . 181
Title VII of the Civil Rights Act . . . . . . . . . . 96 Genetic Engineering/Manipulation. . . . . 130 The Immune System and Immunity . . . . . 181
Federal Age Discrimination Act . . . . . . . . . 97 Artificial Insemination/Surrogacy . . . . . . 130 Stages of Infectious Diseases . . . . . . . . . . 189
Uniform Anatomical Gift Act . . . . . . . . . . . 97 In Vitro Fertilization . . . . . . . . . . . . . . . . . 131 Incubation Stage . . . . . . . . . . . . . . . . . . . . 189
Regulation Z of the Consumer Dying and Death . . . . . . . . . . . . . . . . . . . . 131 Prodromal Stage . . . . . . . . . . . . . . . . . . . . 189
Protection Act . . . . . . . . . . . . . . . . . . . . . . . 97 HIV and AIDS . . . . . . . . . . . . . . . . . . . . . . 132 Acute Stage . . . . . . . . . . . . . . . . . . . . . . . . . 189
Occupational Safety and Health Act. . . . . . 97 Declining Stage . . . . . . . . . . . . . . . . . . . . . 190
Controlled Substances Act . . . . . . . . . . . . . 97 Chapter 9: Emergency Procedures Convalescent Stage . . . . . . . . . . . . . . . . . . 190
Americans with Disabilities Act . . . . . . . . . . 98 and First Aid 137 Disease Transmission . . . . . . . . . . . . . . . . 190
Family and Medical Leave Act. . . . . . . . . . . 98 Human Immunodeficiency Virus
Recognizing an Emergency . . . . . . . . . . . . 138
Health Insurance Portability and and Hepatitis B and C . . . . . . . . . . . . . . . . 191
Responding to an Emergency . . . . . . . . . . 139
Accountability Act . . . . . . . . . . . . . . . . . . . . 98 HIV and AIDS . . . . . . . . . . . . . . . . . . . . . . 191
Primary Survey . . . . . . . . . . . . . . . . . . . . . . 140
Contract Law . . . . . . . . . . . . . . . . . . . . . . . . 99 Acute Viral Hepatitis Diseases . . . . . . . . . . 191
Using the 911 or Emergency Medical
Termination of Contracts . . . . . . . . . . . . . 100 Reporting Infectious Disease . . . . . . . . . . 195
Services System . . . . . . . . . . . . . . . . . . . . . . 140
Tort Law . . . . . . . . . . . . . . . . . . . . . . . . . . 101 Standard Precautions . . . . . . . . . . . . . . . . 195
Good Samaritan Laws . . . . . . . . . . . . . . . . 141
Medical Practice Acts . . . . . . . . . . . . . . . . . 101 Transmission-Based Precautions . . . . . . . . 196
Blood, Body Fluids, and Disease
Standard of Care . . . . . . . . . . . . . . . . . . . . 102 Blood and Body Fluids. . . . . . . . . . . . . . . . 196
Transmission. . . . . . . . . . . . . . . . . . . . . . . . 141
Informed Consent . . . . . . . . . . . . . . . . . . 103 Personal Protective Equipment. . . . . . . . . 201
Preparing for an Emergency . . . . . . . . . . . 142
Implied Consent . . . . . . . . . . . . . . . . . . . . 105 Needlestick . . . . . . . . . . . . . . . . . . . . . . . . . 201
The Medical Crash Tray or Cart . . . . . . . . 142
Consent and Legal Incompetence . . . . . . 105 Disposal of Infectious Waste . . . . . . . . . . . 202
Common Emergencies . . . . . . . . . . . . . . . 143
Risk Management . . . . . . . . . . . . . . . . . . . 105 Federal Organizations and Infection
Shock . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143
Civil Litigation Process . . . . . . . . . . . . . . . 106 Control . . . . . . . . . . . . . . . . . . . . . . . . . . . . 202
Wounds . . . . . . . . . . . . . . . . . . . . . . . . . . . . 144
Subpoenas . . . . . . . . . . . . . . . . . . . . . . . . . 106 OSHA Regulations . . . . . . . . . . . . . . . . . . 204
Burns. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146
Discovery. . . . . . . . . . . . . . . . . . . . . . . . . . . 106 The Bloodborne Pathogen Standard . . . . 204
Musculoskeletal Injuries . . . . . . . . . . . . . . 150
Pretrial Conference . . . . . . . . . . . . . . . . . . 107 OSHA Regulations and Students . . . . . . . 211
Heat- and Cold-Related Illnesses . . . . . . . 151
Trial . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107 Avoiding Exposure to Bloodborne
Poisoning . . . . . . . . . . . . . . . . . . . . . . . . . . 153
Statute of Limitations . . . . . . . . . . . . . . . . 107 Pathogens . . . . . . . . . . . . . . . . . . . . . . . . . . 211
Sudden Illness . . . . . . . . . . . . . . . . . . . . . . 154
Public Duties . . . . . . . . . . . . . . . . . . . . . . . 107 Principles of Infection Control. . . . . . . . . 214
Cerebral Vascular Accident . . . . . . . . . . . . 156
Reportable Diseases/Injuries . . . . . . . . . . 107 Medical Asepsis . . . . . . . . . . . . . . . . . . . . . 214
Heart Attack . . . . . . . . . . . . . . . . . . . . . . . . 157

iv Table of Contents
Hand Washing . . . . . . . . . . . . . . . . . . . . . . 215 Pulse Abnormalities . . . . . . . . . . . . . . . . . . 267 Unit 5: Assisting
Sanitization . . . . . . . . . . . . . . . . . . . . . . . . . 216 Recording Pulse Rates . . . . . . . . . . . . . . . . 267 with Specialty Examinations
Disinfection . . . . . . . . . . . . . . . . . . . . . . . . 217 Respiration . . . . . . . . . . . . . . . . . . . . . . . . 267
Bioterrorism . . . . . . . . . . . . . . . . . . . . . . . 218 Respiration Rate . . . . . . . . . . . . . . . . . . . . . 268
and Procedures 314
Abnormalities . . . . . . . . . . . . . . . . . . . . . . . 268
Chapter 11: The Patient History Blood Pressure . . . . . . . . . . . . . . . . . . . . . 269 Chapter 14: Obstetrics
Equipment for Measuring and Gynecology 315
and Documentation 231 Blood Pressure . . . . . . . . . . . . . . . . . . . . . . 269
The Purpose of the Medical History . . . . 233 Measuring Blood Pressure. . . . . . . . . . . . . 272 Obstetrics . . . . . . . . . . . . . . . . . . . . . . . . . 317
Preparing for the Patient . . . . . . . . . . . . . 233 Recording Blood Pressure Initial Prenatal Visit . . . . . . . . . . . . . . . . . . 317
A Cross-Cultural Model . . . . . . . . . . . . . . . 234 Measurement . . . . . . . . . . . . . . . . . . . . . . . 273 Subsequent or Return Prenatal Visits . . . . 321
Patient Information Forms . . . . . . . . . . . . 234 Normal Blood Pressure Readings . . . . . . . 273 Disorders of Pregnancy . . . . . . . . . . . . . . . 326
Demographic Data Form . . . . . . . . . . . . . . 234 Blood Pressure Abnormalities . . . . . . . . . . 274 Parturition . . . . . . . . . . . . . . . . . . . . . . . . . 329
Financial Information Form . . . . . . . . . . . 234 Height and Weight. . . . . . . . . . . . . . . . . . . 275 Postpartum Period . . . . . . . . . . . . . . . . . . . 329
Privacy Information Form . . . . . . . . . . . . . 236 Height . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 275 Gynecology . . . . . . . . . . . . . . . . . . . . . . . . 330
Release of Information Form . . . . . . . . . . 236 Weight . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 276 The Gynecologic Examination . . . . . . . . . 335
Medical History Form . . . . . . . . . . . . . . . . 237 Significance of Weight . . . . . . . . . . . . . . . . 277 Gynecologic Diseases and Conditions . . . 344
Computerized Health History . . . . . . . . . 237 Measuring Chest Circumference . . . . . . . 277 Other Diagnostic Tests and Treatments
The Patient Intake Interview . . . . . . . . . . 237 for Reproductive System Diseases . . . . . . . 347
Interacting with the Patient. . . . . . . . . . . . 237 Complementary Therapy in Obstetrics
Chapter 13: The Physical and Gynecology . . . . . . . . . . . . . . . . . . . . . 354
Displaying Cultural Awareness . . . . . . . . . 238
Being Sensitive to Patient Needs. . . . . . . . 239 Examination 293
Approaching Sensitive Topics . . . . . . . . . . 240 Methods of Examination. . . . . . . . . . . . . . 294 Chapter 15: Pediatrics 365
Communication across the Life Span . . . . 240 Observation or Inspection. . . . . . . . . . . . . 295
What Is Pediatrics? . . . . . . . . . . . . . . . . . . 366
The Medical Health History . . . . . . . . . . . 241 Palpation. . . . . . . . . . . . . . . . . . . . . . . . . . . 295
Preparation of Vaccines for
SOAP/SOAPER and CHEDDAR . . . . . . . 241 Percussion. . . . . . . . . . . . . . . . . . . . . . . . . . 295
Administration . . . . . . . . . . . . . . . . . . . . . . 367
Chief Complaint. . . . . . . . . . . . . . . . . . . . . 242 Auscultation . . . . . . . . . . . . . . . . . . . . . . . . 296
Recommended Vaccination Schedule . . . 375
Present Illness . . . . . . . . . . . . . . . . . . . . . . 242 Mensuration . . . . . . . . . . . . . . . . . . . . . . . . 296
Considerations for Vaccine
Medical History . . . . . . . . . . . . . . . . . . . . . 243 Manipulation . . . . . . . . . . . . . . . . . . . . . . . 296
Administration . . . . . . . . . . . . . . . . . . . . . . 375
Family History . . . . . . . . . . . . . . . . . . . . . . 243 Positioning and Draping . . . . . . . . . . . . . . 296
Giving Injections to Pediatric Patients . . . 378
Social History . . . . . . . . . . . . . . . . . . . . . . . 243 Examination Positions . . . . . . . . . . . . . . . . 297
Theories of Growth and Development . . . 381
Review of Systems (ROS) . . . . . . . . . . . . . . 244 Equipment and Supplies for the
Newborns . . . . . . . . . . . . . . . . . . . . . . . . . . 382
The Patient Record and Its Physical Examination . . . . . . . . . . . . . . . . 299
Infants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 382
Importance . . . . . . . . . . . . . . . . . . . . . . . . 244 Basic Components of a Physical
Toddlers . . . . . . . . . . . . . . . . . . . . . . . . . . . 382
HIPAA Compliance . . . . . . . . . . . . . . . . . . 246 Examination . . . . . . . . . . . . . . . . . . . . . . . 301
Preschoolers . . . . . . . . . . . . . . . . . . . . . . . . 384
Contents of Medical Records . . . . . . . . . . 246 Patient Appearance . . . . . . . . . . . . . . . . . . 301
School-Aged Children . . . . . . . . . . . . . . . . 384
Continuity of Care Record . . . . . . . . . . . . 247 Gait . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 301
Adolescents. . . . . . . . . . . . . . . . . . . . . . . . . 385
Methods of Charting/Documentation . . . 247 Stature. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 302
Growth Patterns . . . . . . . . . . . . . . . . . . . . 386
Source-Oriented Medical Records . . . . . . 247 Posture . . . . . . . . . . . . . . . . . . . . . . . . . . . . 302
Measuring the Infant or Child . . . . . . . . . 386
Problem-Oriented Medical Records . . . . . 247 Body Movements . . . . . . . . . . . . . . . . . . . . 302
Length and Weight Measurements . . . . . . 386
Electronic Medical Records (EMR) . . . . . 248 Speech . . . . . . . . . . . . . . . . . . . . . . . . . . . . 302
Infant Holds and Positions . . . . . . . . . . . . 386
Rules of Charting . . . . . . . . . . . . . . . . . . . 250 Breath Odors . . . . . . . . . . . . . . . . . . . . . . . 302
Height and Weight Measuring Devices . . 389
Abbreviations Used in Charting . . . . . . . . 250 Nutrition . . . . . . . . . . . . . . . . . . . . . . . . . . . 302
Measuring Head Circumference. . . . . . . . 390
Chart Organization . . . . . . . . . . . . . . . . . . 252 Skin and Appendages . . . . . . . . . . . . . . . . 302
Measuring Chest Circumference . . . . . . . 390
The Physical Examination Sequence . . . . 303
Infant/Child Failure to Thrive . . . . . . . . . 391
Chapter 12: Vital Signs Head . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 303
Pediatric Vital Signs . . . . . . . . . . . . . . . . . 391
Eyes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 303
and Measurements 257 Ears . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 306
Temperature . . . . . . . . . . . . . . . . . . . . . . . . 392
The Importance of Accuracy . . . . . . . . . . 258 Pulse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 392
Nose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 307
Temperature . . . . . . . . . . . . . . . . . . . . . . . 259 Respirations . . . . . . . . . . . . . . . . . . . . . . . . 393
Mouth and Throat . . . . . . . . . . . . . . . . . . . 307
Terms Used to Describe Body Blood Pressure . . . . . . . . . . . . . . . . . . . . . . 393
Neck . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 307
Temperature . . . . . . . . . . . . . . . . . . . . . . . . 260 Collecting a Urine Specimen from
Chest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 307
Phase Out of Mercury Thermometers and an Infant . . . . . . . . . . . . . . . . . . . . . . . . . . 393
Breast . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 307
Other Mercury-Containing Equipment . . 260 Screening Infants for Hearing
Abdomen . . . . . . . . . . . . . . . . . . . . . . . . . . 307
Types of Thermometers . . . . . . . . . . . . . . . 262 Impairment . . . . . . . . . . . . . . . . . . . . . . . . 394
Genitals . . . . . . . . . . . . . . . . . . . . . . . . . . . . 307
Measuring Temperature . . . . . . . . . . . . . . 264 Screening Infant and Child Visual
Rectum . . . . . . . . . . . . . . . . . . . . . . . . . . . . 308
Recording Temperature . . . . . . . . . . . . . . 265 Acuity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 394
Reflexes . . . . . . . . . . . . . . . . . . . . . . . . . . . 308
Cleaning and Storage of Thermometers . 265 Common Disorders and Diseases . . . . . . . 394
After the Examination . . . . . . . . . . . . . . . . 308
Pulse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 265 Otitis Media . . . . . . . . . . . . . . . . . . . . . . . . 395
Pulse Sites . . . . . . . . . . . . . . . . . . . . . . . . . . 265 The Common Cold . . . . . . . . . . . . . . . . . . 395
Measuring and Evaluating a Pulse . . . . . . 266 Tonsillitis. . . . . . . . . . . . . . . . . . . . . . . . . . . 396
Normal Pulse Rates . . . . . . . . . . . . . . . . . . 267 Pediculosis . . . . . . . . . . . . . . . . . . . . . . . . . 396

Table of Contents v
Asthma . . . . . . . . . . . . . . . . . . . . . . . . . . . . 396 Digestive System . . . . . . . . . . . . . . . . . . . . 444 Solutions/Creams/Ointments . . . . . . . . . 548
Croup . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 396 Signs and Symptoms of Digestive Dressings and Bandages . . . . . . . . . . . . . . 548
Pertussis (Whooping Cough) . . . . . . . . . . 396 Conditions and Disorders . . . . . . . . . . . . . 444 Anesthetics . . . . . . . . . . . . . . . . . . . . . . . . . 548
Respiratory Syncytial Virus . . . . . . . . . . . . 397 Diagnostic Tests . . . . . . . . . . . . . . . . . . . . . 450 Patient Care and Preparation . . . . . . . . . . 550
Attention Deficit Hyperactivity Bariatrics . . . . . . . . . . . . . . . . . . . . . . . . . . . 454 Patient Preparation and Education . . . . . 550
Disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . 397 Sensory System . . . . . . . . . . . . . . . . . . . . . 457 Informed Consent . . . . . . . . . . . . . . . . . . . 551
Child Abuse . . . . . . . . . . . . . . . . . . . . . . . . 397 The Eye . . . . . . . . . . . . . . . . . . . . . . . . . . . . 457 Medical Assisting Considerations . . . . . . . 551
Male Circumcision . . . . . . . . . . . . . . . . . . 398 The Ear . . . . . . . . . . . . . . . . . . . . . . . . . . . . 463 Postoperative Instructions . . . . . . . . . . . . . 551
The Nose . . . . . . . . . . . . . . . . . . . . . . . . . . 466 Wounds, Wound Care, and the
Chapter 16: Male Reproductive Respiratory System . . . . . . . . . . . . . . . . . . 466 Healing Process . . . . . . . . . . . . . . . . . . . . . 552
Signs and Symptoms of Respiratory Basic Surgery Setup . . . . . . . . . . . . . . . . . 553
System 410 Conditions and Disorders . . . . . . . . . . . . . 466 Basic Rules and Concepts for Setup
Testicular Self-Examination . . . . . . . . . . . 413 Diagnostic Tests . . . . . . . . . . . . . . . . . . . . . 467 of Surgical Trays . . . . . . . . . . . . . . . . . . . . . 554
Disorders of the Male Reproductive Spirometry . . . . . . . . . . . . . . . . . . . . . . . . . 467 Surgery Process . . . . . . . . . . . . . . . . . . . . . 554
System . . . . . . . . . . . . . . . . . . . . . . . . . . . . 413 Peak Expiratory Flow Rates . . . . . . . . . . . . 471 Preparation for Surgery . . . . . . . . . . . . . . 554
Testicular Cancer . . . . . . . . . . . . . . . . . . . . 413 Pulse Oximetry . . . . . . . . . . . . . . . . . . . . . . 471 Using Dry Sterile Transfer Forceps . . . . . . 556
Epididymitis . . . . . . . . . . . . . . . . . . . . . . . . 413 Inhalers . . . . . . . . . . . . . . . . . . . . . . . . . . . . 472
Prostatitis . . . . . . . . . . . . . . . . . . . . . . . . . . 414 Musculoskeletal System . . . . . . . . . . . . . . 472 Chapter 20: Diagnostic Imaging 589
Prostate Cancer . . . . . . . . . . . . . . . . . . . . . 414 Fractures, Casting, and Cast Removal. . . . 474
Benign Prostatic Hypertrophy . . . . . . . . . 415 Radiation Safety . . . . . . . . . . . . . . . . . . . . 590
Neurologic System . . . . . . . . . . . . . . . . . . 478
Sexually Transmitted Diseases . . . . . . . . . . 416 X-Ray Machine . . . . . . . . . . . . . . . . . . . . . 591
Components of a Neurologic
Balanitis . . . . . . . . . . . . . . . . . . . . . . . . . . . 416 Contrast Media . . . . . . . . . . . . . . . . . . . . . 592
Screening . . . . . . . . . . . . . . . . . . . . . . . . . . 481
Infertility . . . . . . . . . . . . . . . . . . . . . . . . . . . 416 Patient Preparation . . . . . . . . . . . . . . . . . . 592
Circulatory System . . . . . . . . . . . . . . . . . . 481
Erectile Dysfunction . . . . . . . . . . . . . . . . . 417 Positioning the Patient . . . . . . . . . . . . . . . 594
Blood and Lymph System . . . . . . . . . . . . . 483
Assisting with the Male Reproductive Fluoroscopy . . . . . . . . . . . . . . . . . . . . . . . . 594
Integumentary System. . . . . . . . . . . . . . . . 484
Examination . . . . . . . . . . . . . . . . . . . . . . . 418 Bone Densitometry . . . . . . . . . . . . . . . . . . 594
Allergy Skin Testing . . . . . . . . . . . . . . . . . . 486
Diagnostic Tests and Procedures . . . . . . . 419 Diagnostic Imaging . . . . . . . . . . . . . . . . . . 594
Vasectomy . . . . . . . . . . . . . . . . . . . . . . . . . . 419 Unit 6: Advanced Positron Emission Tomography (PET). . . 594
Semen Analysis . . . . . . . . . . . . . . . . . . . . . . 419 Techniques Computerized Tomography (CT). . . . . . . 597
Urodynamic Studies. . . . . . . . . . . . . . . . . . 419 Magnetic Resonance Imaging (MRI) . . . . 598
and Procedures 522 X-Rays (Flat Plates) . . . . . . . . . . . . . . . . . . 599
Ultrasonography . . . . . . . . . . . . . . . . . . . . 599
Chapter 17: Gerontology 423
Chapter 19: Assisting Mammography . . . . . . . . . . . . . . . . . . . . . . 601
Societal Bias . . . . . . . . . . . . . . . . . . . . . . . 424 Filing Films and Reports . . . . . . . . . . . . . . 601
Facts about Aging . . . . . . . . . . . . . . . . . . . 425 with Office/Ambulatory Surgery 523
Radiation Therapy . . . . . . . . . . . . . . . . . . 601
Physiologic Changes . . . . . . . . . . . . . . . . . 425 Surgical Asepsis and Sterilization . . . . . . . 525 Nuclear Medicine . . . . . . . . . . . . . . . . . . . 602
Senses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 426 Hand Cleansing (Hand Hygiene)
Integumentary System . . . . . . . . . . . . . . . . 427 for Medical and Surgical Asepsis . . . . . . . 525
Sterile Principles . . . . . . . . . . . . . . . . . . . . 526 Chapter 21: Rehabilitation
Nervous System . . . . . . . . . . . . . . . . . . . . . 427
Musculoskeletal System . . . . . . . . . . . . . . . 427 Methods of Sterilization . . . . . . . . . . . . . . 527 and Therapeutic Modalities 605
Respiratory System . . . . . . . . . . . . . . . . . . . 428 Gas Sterilization . . . . . . . . . . . . . . . . . . . . . 527 The Role of the Medical Assistant
Cardiovascular System . . . . . . . . . . . . . . . . 428 Dry Heat Sterilization . . . . . . . . . . . . . . . . 527 in Rehabilitation . . . . . . . . . . . . . . . . . . . . 607
Gastrointestinal System . . . . . . . . . . . . . . . 429 Chemical (“Cold”) Sterilization . . . . . . . . 527 Principles of Body Mechanics . . . . . . . . . . 608
Urinary System . . . . . . . . . . . . . . . . . . . . . . 429 Steam Sterilization (Autoclave) . . . . . . . . 528 Posture . . . . . . . . . . . . . . . . . . . . . . . . . . . . 608
Reproductive System . . . . . . . . . . . . . . . . . 429 Common Surgical Procedures Using the Body Safely and
Prevention of Complications . . . . . . . . . . 429 Performed in Providers’ Offices Effectively . . . . . . . . . . . . . . . . . . . . . . . . . . 608
Psychological Changes . . . . . . . . . . . . . . . 430 and Clinics. . . . . . . . . . . . . . . . . . . . . . . . . 532 Lifting Techniques . . . . . . . . . . . . . . . . . . . 609
The Medical Assistant and the Additional Surgical Methods . . . . . . . . . . . 533 Transferring Patients . . . . . . . . . . . . . . . . 609
Geriatric Patient . . . . . . . . . . . . . . . . . . . . 430 Electrosurgery . . . . . . . . . . . . . . . . . . . . . . 533 Assisting Patients to Ambulate . . . . . . . . . 611
Memory-Impaired Older Adults . . . . . . . . 431 Cryosurgery . . . . . . . . . . . . . . . . . . . . . . . . 533 Assistive Devices . . . . . . . . . . . . . . . . . . . . 611
Visually Impaired Older Adults. . . . . . . . . 431 Laser Surgery . . . . . . . . . . . . . . . . . . . . . . . 534 Walkers . . . . . . . . . . . . . . . . . . . . . . . . . . . . 611
Hearing-Impaired Older Adults . . . . . . . . 431 Suture Materials and Supplies . . . . . . . . . 534 Crutches . . . . . . . . . . . . . . . . . . . . . . . . . . . 613
Elder Abuse . . . . . . . . . . . . . . . . . . . . . . . . 432 Suture/Ligature . . . . . . . . . . . . . . . . . . . . . 534 Canes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 616
Healthy and Successful Aging . . . . . . . . . . 433 Suture Needles . . . . . . . . . . . . . . . . . . . . . . 535 Wheelchairs . . . . . . . . . . . . . . . . . . . . . . . . 617
Staples . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 535 Therapeutic Exercises . . . . . . . . . . . . . . . . 618
Staple Removal . . . . . . . . . . . . . . . . . . . . . . 535 Range of Motion . . . . . . . . . . . . . . . . . . . . 618
Chapter 18: Examinations and
Instruments . . . . . . . . . . . . . . . . . . . . . . . . 536 Muscle Testing . . . . . . . . . . . . . . . . . . . . . . 620
Procedures of Body Systems 437 Structural Features . . . . . . . . . . . . . . . . . . . 536 Types of Therapeutic Exercise . . . . . . . . . 620
Urinary System . . . . . . . . . . . . . . . . . . . . . 439 Categories and Uses . . . . . . . . . . . . . . . . . . 536 Electromyography . . . . . . . . . . . . . . . . . . . 621
Signs and Symptoms of Urinary Care of Instruments . . . . . . . . . . . . . . . . . . 543 Electrostimulation of Muscle . . . . . . . . . . 621
Conditions and Disorders . . . . . . . . . . . . . 439 Supplies and Equipment . . . . . . . . . . . . . . 546 Therapeutic Modalities . . . . . . . . . . . . . . . 621
Diagnostic Tests . . . . . . . . . . . . . . . . . . . . . 439 Drapes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 547 Heat and Cold . . . . . . . . . . . . . . . . . . . . . . 621
Urinary Catheterization. . . . . . . . . . . . . . . 442 Sponges and Wicks . . . . . . . . . . . . . . . . . . 547 Moist and Dry Heat . . . . . . . . . . . . . . . . . . 622

vi Table of Contents
Moist and Dry Cold . . . . . . . . . . . . . . . . . . 623 Chapter 24: Calculation of Medication Chapter 25: Electrocardiography 760
Ultrasound . . . . . . . . . . . . . . . . . . . . . . . . . 624 Dosage and Medication Anatomy of the Heart . . . . . . . . . . . . . . . . 762
Massage Therapy . . . . . . . . . . . . . . . . . . . . 625
Administration 704 Electrical Conduction System
of the Heart. . . . . . . . . . . . . . . . . . . . . . . . 762
Legal and Ethical Implications
Chapter 22: Nutrition in Health The Cardiac Cycle and the
of Medication Administration . . . . . . . . . . 705
and Disease 638 Ethical Considerations. . . . . . . . . . . . . . . . 706 ECG Cycle . . . . . . . . . . . . . . . . . . . . . . . . . 763
Nutrition and Digestion . . . . . . . . . . . . . . 639 Calculation of Heart Rate on ECG
The Medication Order . . . . . . . . . . . . . . . 706
Types of Nutrients . . . . . . . . . . . . . . . . . . 640 Graph Paper . . . . . . . . . . . . . . . . . . . . . . . . 763
The Prescription . . . . . . . . . . . . . . . . . . . . 706
Energy Nutrients (Organic) . . . . . . . . . . . 640 Types of Electrocardiographs . . . . . . . . . . 765
Drug Dosage . . . . . . . . . . . . . . . . . . . . . . . 709
Other Nutrients (Inorganic) . . . . . . . . . . . 646 Single-Channel Electrocardiograph . . . . . 765
Age . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 709
Reading Food Labels . . . . . . . . . . . . . . . . 654 Multichannel Electrocardiograph . . . . . . 767
Weight . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 709
Items on the Nutrition Label . . . . . . . . . . 654 Automatic Electrocardiograph
Sex. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 709
Comparing Labels . . . . . . . . . . . . . . . . . . . 655 Machines. . . . . . . . . . . . . . . . . . . . . . . . . . . 767
Other Factors . . . . . . . . . . . . . . . . . . . . . . . 710
Nutrition at Various Stages of Life . . . . . . 655 Electrocardiograph Telephone
The Medication Label . . . . . . . . . . . . . . . . 710
Pregnancy and Lactation . . . . . . . . . . . . . . 656 Transmissions . . . . . . . . . . . . . . . . . . . . . . . 768
Calculation of Drug Dosages . . . . . . . . . . 711
Breast-Feeding . . . . . . . . . . . . . . . . . . . . . . 657 Facsimile Electrocardiograph . . . . . . . . . . 768
Understanding Ratio . . . . . . . . . . . . . . . . . 711
Infancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . 657 Interpretive Electrocardiograph . . . . . . . . 768
Understanding Proportion . . . . . . . . . . . . 712
Childhood . . . . . . . . . . . . . . . . . . . . . . . . . 657 ECG Equipment . . . . . . . . . . . . . . . . . . . . 768
Weights and Measures . . . . . . . . . . . . . . . . 713
Adolescence . . . . . . . . . . . . . . . . . . . . . . . . 657 Electrocardiograph Paper . . . . . . . . . . . . . 768
Medications Measured in Units . . . . . . . . 715
Older Adults . . . . . . . . . . . . . . . . . . . . . . . . 660 Electrolyte. . . . . . . . . . . . . . . . . . . . . . . . . . 768
How to Calculate Unit Dosages. . . . . . . . . 715
Therapeutic Diets . . . . . . . . . . . . . . . . . . . 660 Sensors or Electrodes. . . . . . . . . . . . . . . . . 768
Insulin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 716
Weight Control . . . . . . . . . . . . . . . . . . . . . . 661 Lead Wires . . . . . . . . . . . . . . . . . . . . . . . . . 768
Diabetes . . . . . . . . . . . . . . . . . . . . . . . . . . . 716
Diabetes Mellitus . . . . . . . . . . . . . . . . . . . . 662 Electrocardiograph Machine . . . . . . . . . . 769
Calculating Adult Dosages . . . . . . . . . . . . 718
Cardiovascular Disease . . . . . . . . . . . . . . . 663 Care of Equipment . . . . . . . . . . . . . . . . . . 769
The Proportional Method . . . . . . . . . . . . . 718
Cancer. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 664 Lead Coding . . . . . . . . . . . . . . . . . . . . . . . 769
The Formula Method . . . . . . . . . . . . . . . . 719
Diet and Culture . . . . . . . . . . . . . . . . . . . . 664 The Electrocardiograph and Sensor
Calculating Children’s Dosages. . . . . . . . . 719
Placement . . . . . . . . . . . . . . . . . . . . . . . . . 769
Body Surface Area . . . . . . . . . . . . . . . . . . . 719
Standard Limb or Bipolar Leads. . . . . . . . 769
Chapter 23: Basic Pharmacology 672 Kilogram of Body Weight . . . . . . . . . . . . . 720
Augmented Leads . . . . . . . . . . . . . . . . . . . 769
Administration of Medications . . . . . . . . . 721
Medical Uses of Drugs . . . . . . . . . . . . . . . 673 Chest Leads or Precordial Leads . . . . . . . 770
The “Six Rights” of Proper Drug
Drug Names . . . . . . . . . . . . . . . . . . . . . . . 674 Standardization and Adjustment
Administration . . . . . . . . . . . . . . . . . . . . . . 722
History and Sources of Drugs . . . . . . . . . . 674 of the Electrocardiograph . . . . . . . . . . . . . 772
Medication Errors . . . . . . . . . . . . . . . . . . . 723
Plant Sources . . . . . . . . . . . . . . . . . . . . . . . 674 Standard Resting Electrocardiography . . . . 773
Patient Assessment . . . . . . . . . . . . . . . . . . . 723
Animal Sources . . . . . . . . . . . . . . . . . . . . . 675 Mounting the ECG Tracing . . . . . . . . . . . . 773
Administration of Oral
Mineral Sources . . . . . . . . . . . . . . . . . . . . . 675 Interference or Artifacts . . . . . . . . . . . . . . 773
Medications . . . . . . . . . . . . . . . . . . . . . . . . 725
Herbal Supplements . . . . . . . . . . . . . . . . . 675 Somatic Tremor Artifacts . . . . . . . . . . . . . . 773
Equipment and Supplies for
Synthetic Drugs . . . . . . . . . . . . . . . . . . . . . 676 AC Interference . . . . . . . . . . . . . . . . . . . . . 773
Oral Medications . . . . . . . . . . . . . . . . . . . . 725
Genetically Engineered Wandering Baseline Artifacts . . . . . . . . . . 774
Administration of Parenteral
Pharmaceuticals . . . . . . . . . . . . . . . . . . . . . 676 Interrupted Baseline Artifacts . . . . . . . . . . 774
Medications . . . . . . . . . . . . . . . . . . . . . . . . 726
Drug Regulations and Legal Patients with Unique Problems . . . . . . . . . 774
Hazards Associated with Parenteral
Classifications of Drugs . . . . . . . . . . . . . . 676 Myocardial Infarctions
Medications . . . . . . . . . . . . . . . . . . . . . . . . 726
Controlled Substance Act of 1970 . . . . . . 676 (Heart Attacks) . . . . . . . . . . . . . . . . . . . . . 775
Reasons for Parenteral Route
Prescription Drugs . . . . . . . . . . . . . . . . . . . 681 Cardiac Arrhythmias . . . . . . . . . . . . . . . . . 776
Selection . . . . . . . . . . . . . . . . . . . . . . . . . . . 726
Nonprescription Drugs . . . . . . . . . . . . . . . 682 Atrial Arrhythmias . . . . . . . . . . . . . . . . . . . 776
Parenteral Equipment and
Proper Disposal of Drugs. . . . . . . . . . . . . . 682 Ventricular Arrhythmias . . . . . . . . . . . . . . 777
Supplies . . . . . . . . . . . . . . . . . . . . . . . . . . . 727
Administer, Prescribe, Dispense . . . . . . . . 683 Defibrillation . . . . . . . . . . . . . . . . . . . . . . . 779
Principles of Intravenous Therapy . . . . . . 731
Drug References and Standards . . . . . . . . 683 Other Cardiac Diagnostic Tests . . . . . . . . 779
Site Selection and Injection
How to Use the PDR . . . . . . . . . . . . . . . . . 684 Holter Monitor (Portable Ambulatory
Angle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 733
Other Reference Sources . . . . . . . . . . . . . 685 Electrocardiograph) . . . . . . . . . . . . . . . . . 779
Marking the Correct Site for
Classification of Drugs . . . . . . . . . . . . . . . 686 Loop ECG . . . . . . . . . . . . . . . . . . . . . . . . . . 781
Intramuscular Injection . . . . . . . . . . . . . . . 733
Principal Actions of Drugs . . . . . . . . . . . . 686 Treadmill Stress Test or Exercise
Basic Guidelines for Administration
Factors That Affect Drug Action . . . . . . . . 686 Tolerance ECG . . . . . . . . . . . . . . . . . . . . . . 781
of Injections . . . . . . . . . . . . . . . . . . . . . . . 737
Undesirable Actions of Drugs . . . . . . . . . . 686 Thallium Stress Test . . . . . . . . . . . . . . . . . . 782
Z-Track Method of Intramuscular
Drug Routes . . . . . . . . . . . . . . . . . . . . . . . 690 Echocardiography/Ultrasonography . . . . 782
Injection . . . . . . . . . . . . . . . . . . . . . . . . . . 738
Forms of Drugs . . . . . . . . . . . . . . . . . . . . . 690 Cardiac Procedures . . . . . . . . . . . . . . . . . . 783
Administration of Allergenic
Liquid Preparations . . . . . . . . . . . . . . . . . . 690 Procedures for Heart Disease . . . . . . . . . . 783
Extracts . . . . . . . . . . . . . . . . . . . . . . . . . . . 738
Solid and Semisolid Preparations . . . . . . . 690 Procedures for Arrhythmias . . . . . . . . . . . 783
Administration of Inhaled
Other Drug Delivery Systems . . . . . . . . . . 690
Medications . . . . . . . . . . . . . . . . . . . . . . . . 739
Storage and Handling of Medications . . . 692
Implications for Patient Care . . . . . . . . . . 739
Emergency Drugs and Supplies . . . . . . . . 692
Administration of Oxygen . . . . . . . . . . . . . 739
Bioterrorism . . . . . . . . . . . . . . . . . . . . . . . . 693
Drug Abuse . . . . . . . . . . . . . . . . . . . . . . . . 693

Table of Contents vii

Unit 7: Laboratory Chapter 28: Phlebotomy: Erythrocyte Sedimentation Rates
Procedures 791 Venipuncture and Capillary (ESR or SED Rate) . . . . . . . . . . . . . . . . . . 894
Wintrobe Method . . . . . . . . . . . . . . . . . . . 895
Puncture 835 Westergren Method . . . . . . . . . . . . . . . . . 895
Chapter 26: Safety and Regulatory Why Collect Blood? . . . . . . . . . . . . . . . . . 837 Using the ESR to Screen . . . . . . . . . . . . . . 896
Guidelines in the Medical The Medical Assistant’s Role in C-Reactive Proteins . . . . . . . . . . . . . . . . . 896
Phlebotomy . . . . . . . . . . . . . . . . . . . . . . . 837 Coagulation Studies . . . . . . . . . . . . . . . . . 897
Laboratory 792 Anatomy and Physiology of the Automated Hematology . . . . . . . . . . . . . . 897
Clinical Laboratory Improvement Circulatory System . . . . . . . . . . . . . . . . . . 837
Amendments of 1988 . . . . . . . . . . . . . . . . 794 Blood Collection . . . . . . . . . . . . . . . . . . . 838
The Intention of CLIA ‘88 . . . . . . . . . . . . 795 Chapter 30: Urinalysis 907
Plasma and Whole-Blood Collection . . . . 839
General Program Description . . . . . . . . . 795 Collection of Blood Specimens . . . . . . . . 840 Urine Formation . . . . . . . . . . . . . . . . . . . 908
Categories of Testing . . . . . . . . . . . . . . . . 796 Venipuncture Equipment . . . . . . . . . . . . . 841 Filtration . . . . . . . . . . . . . . . . . . . . . . . . . . 908
Contents of the Law . . . . . . . . . . . . . . . . . 796 Syringes and Needles . . . . . . . . . . . . . . . . 841 Reabsorption . . . . . . . . . . . . . . . . . . . . . . . 909
Criteria for PPMP . . . . . . . . . . . . . . . . . . . 798 Safety Needles and Blood Collection Secretion . . . . . . . . . . . . . . . . . . . . . . . . . . 909
Criteria for CLIA Waived Tests . . . . . . . . . 798 Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . 843 Urine Composition . . . . . . . . . . . . . . . . . . 910
CLIA ‘88 Regulation for Quality Vacuum Tubes and Adapters/ Safety . . . . . . . . . . . . . . . . . . . . . . . . . . . . 910
Control in Automated Hematology . . . . . 799 Holders . . . . . . . . . . . . . . . . . . . . . . . . . . . 843 Quality Control . . . . . . . . . . . . . . . . . . . . 910
Aftermath of CLIA ‘88 . . . . . . . . . . . . . . . 799 Anticoagulants, Additives, and Gels . . . . . 844 Clinical Laboratory Improvement
Impact of CLIA on Medical Assistants . . . 800 Order of Draw . . . . . . . . . . . . . . . . . . . . . . 846 Amendments of 1988 (CLIA ‘88) . . . . . . . 911
Where to Find More Information Tourniquets . . . . . . . . . . . . . . . . . . . . . . . . 847 Urine Containers . . . . . . . . . . . . . . . . . . . 911
Regarding CLIA ’88 . . . . . . . . . . . . . . . . . . 800 Specimen Collection Trays . . . . . . . . . . . . 848 Urine Collection . . . . . . . . . . . . . . . . . . . . 912
OSHA Regulations . . . . . . . . . . . . . . . . . . 800 Venipuncture Technique . . . . . . . . . . . . . . 848 Urine Specimen Types . . . . . . . . . . . . . . . 912
The Standard for Occupational Approaching the Patient . . . . . . . . . . . . . 849 Collection Methods . . . . . . . . . . . . . . . . . . 913
Exposure to Hazardous Chemicals Preparing Supplies and Greeting Examination of Urine . . . . . . . . . . . . . . . 913
in the Laboratory . . . . . . . . . . . . . . . . . . . . 801 the Patient . . . . . . . . . . . . . . . . . . . . . . . . . 849 Physical Examination of Urine . . . . . . . . 915
Chemical Hygiene Plan . . . . . . . . . . . . . . 801 Patient and Specimen Identification . . . . 849 Chemical Examination of Urine . . . . . . . 917
OSHA Regulations and Students . . . . . . . 806 Positioning the Patient . . . . . . . . . . . . . . . 850 Microscopic Examination of Urine
Avoiding Exposure to Chemicals . . . . . . . 806 Selecting the Appropriate Sediment . . . . . . . . . . . . . . . . . . . . . . . . . . 921
Cumulative Trauma Disorders . . . . . . . . . 808 Venipuncture Site . . . . . . . . . . . . . . . . . . . 850 Urinalysis Report . . . . . . . . . . . . . . . . . . . . 924
Applying the Tourniquet . . . . . . . . . . . . . 851 Drug Screening . . . . . . . . . . . . . . . . . . . . . 925
Chapter 27: Introduction to the Performing a Safe Venipuncture . . . . . . . 851
Medical Laboratory 811 Specimen Collection . . . . . . . . . . . . . . . . 853 Chapter 31: Basic Microbiology 940
The Syringe Technique . . . . . . . . . . . . . . 853 The Medical Assistant’s Role in the
The Laboratory . . . . . . . . . . . . . . . . . . . . 813
Vacuum Tube Specimen Collection . . . . 854 Microbiology Laboratory . . . . . . . . . . . . . 941
Purposes of Laboratory Testing . . . . . . . . 813
Butterfly Needle Collection System . . . . . 855 Microbiology . . . . . . . . . . . . . . . . . . . . . . 943
Types of Laboratories. . . . . . . . . . . . . . . . . 814
Blood Cultures . . . . . . . . . . . . . . . . . . . . . 856 Classification . . . . . . . . . . . . . . . . . . . . . . . 943
Laboratory Personnel . . . . . . . . . . . . . . . . 815
Patient Reactions . . . . . . . . . . . . . . . . . . . 856 Nomenclature . . . . . . . . . . . . . . . . . . . . . . 943
Laboratory Departments . . . . . . . . . . . . . 815
The Unsuccessful Venipuncture . . . . . . . . 856 Cell Structure . . . . . . . . . . . . . . . . . . . . . . . 944
Panels of Laboratory Tests . . . . . . . . . . . . 820
Criteria for Rejection of a Specimen . . . . 857 Equipment . . . . . . . . . . . . . . . . . . . . . . . . 944
Billing for Laboratory Services . . . . . . . . 820
Factors Affecting Laboratory Values . . . . 857 Autoclave . . . . . . . . . . . . . . . . . . . . . . . . . . 944
Quality Controls/Assurances in the
Capillary Puncture . . . . . . . . . . . . . . . . . . 860 Microscope . . . . . . . . . . . . . . . . . . . . . . . . 944
Laboratory . . . . . . . . . . . . . . . . . . . . . . . . 820
Composition of Capillary Blood . . . . . . . 860 Safety Hood . . . . . . . . . . . . . . . . . . . . . . . . 945
Control Tests . . . . . . . . . . . . . . . . . . . . . . . 822
Capillary Puncture Sites . . . . . . . . . . . . . . 860 Incubator . . . . . . . . . . . . . . . . . . . . . . . . . . 945
Proficiency Testing . . . . . . . . . . . . . . . . . . 822
Preparing the Capillary Puncture Site . . . 860 Anaerobic Equipment . . . . . . . . . . . . . . . 945
Preventative Maintenance . . . . . . . . . . . . 822
Performing the Puncture . . . . . . . . . . . . . 860 Inoculating Equipment . . . . . . . . . . . . . . 945
Instrument Validations . . . . . . . . . . . . . . . 822
Collecting the Blood Sample . . . . . . . . . . 861 Incinerator . . . . . . . . . . . . . . . . . . . . . . . . 946
The Medical Assistant’s Role . . . . . . . . . . 822
Laboratory Requisitions and Reports . . . 822 Media . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 946
Specimen Collection . . . . . . . . . . . . . . . . 826 Chapter 29: Hematology 883 Refrigerator . . . . . . . . . . . . . . . . . . . . . . . . 946
Proper Procurement, Storage, and Hematologic Tests . . . . . . . . . . . . . . . . . . 886 Safety when Handling Microbiology
Handling . . . . . . . . . . . . . . . . . . . . . . . . . . 826 Hemoglobin and Hematocrit Tests . . . . . 887 Specimens . . . . . . . . . . . . . . . . . . . . . . . . 947
Processing and Sending Specimens Hemoglobin . . . . . . . . . . . . . . . . . . . . . . . 887 Personal Protective Equipment. . . . . . . . . 947
to a Laboratory . . . . . . . . . . . . . . . . . . . . . 827 Hematocrit . . . . . . . . . . . . . . . . . . . . . . . . 888 Work Area . . . . . . . . . . . . . . . . . . . . . . . . . 947
Microscopes . . . . . . . . . . . . . . . . . . . . . . . 828 White and Red Blood Cell Counts . . . . . . 890 Specimen Handling . . . . . . . . . . . . . . . . . 947
Types of Microscopes . . . . . . . . . . . . . . . . 828 White Blood Cells and Differential . . . . . 890 Disposal of Waste and Spills . . . . . . . . . . . 947
How to Use a Microscope . . . . . . . . . . . . . 829 Red Blood Cells . . . . . . . . . . . . . . . . . . . . . 893 Quality Control . . . . . . . . . . . . . . . . . . . . 948
How to Care for a Microscope . . . . . . . . . 830 Platelets . . . . . . . . . . . . . . . . . . . . . . . . . . 893 Collection Procedures . . . . . . . . . . . . . . . 948
Erythrocyte Indices . . . . . . . . . . . . . . . . . 893 Specific Collection Requirements
Understanding RBC Indices . . . . . . . . . . 894 for Cultures . . . . . . . . . . . . . . . . . . . . . . . . 949
Using Erythrocyte Indices to Microscopic Examination of
Diagnose . . . . . . . . . . . . . . . . . . . . . . . . . . 894 Bacteria . . . . . . . . . . . . . . . . . . . . . . . . . . 951
Bacterial Shapes . . . . . . . . . . . . . . . . . . . . 952

viii Table of Contents

Dyes (Stains). . . . . . . . . . . . . . . . . . . . . . . . 952 Testing Panels . . . . . . . . . . . . . . . . . . . . . . 984 Employees with Chemical Dependencies
Simple Stain . . . . . . . . . . . . . . . . . . . . . . . 953 Glycosylated Hemoglobin . . . . . . . . . . . . 984 or Emotional Problems . . . . . . . . . . . . . . 1015
Differential Stain . . . . . . . . . . . . . . . . . . . . 953 Cholesterol and Lipids . . . . . . . . . . . . . . . 986 Evaluating Employees and Planning
Acid-Fast Stain . . . . . . . . . . . . . . . . . . . . . . 953 The Chemistry of Cholesterol . . . . . . . . . . 986 Salary Review . . . . . . . . . . . . . . . . . . . . . . 1016
Special Techniques . . . . . . . . . . . . . . . . . . 954 Functions of Cholesterol . . . . . . . . . . . . . 986 Dismissing Employees . . . . . . . . . . . . . . . 1019
Potassium Hydroxide Preparation . . . . . . 955 Lipoproteins and Cholesterol Procedure Manual . . . . . . . . . . . . . . . . . 1020
Culture Media . . . . . . . . . . . . . . . . . . . . . 955 Transport . . . . . . . . . . . . . . . . . . . . . . . . . . 987 Organization of the Procedure
Media Classification . . . . . . . . . . . . . . . . . 956 Triglycerides . . . . . . . . . . . . . . . . . . . . . . . 988 Manual . . . . . . . . . . . . . . . . . . . . . . . . . . . 1020
Microbiology Culture . . . . . . . . . . . . . . . . 956 Blood Chemistry Tests . . . . . . . . . . . . . . . 988 Updating and Reviewing the
Inoculating the Media . . . . . . . . . . . . . . . 956 Alanine Aminotransferase (ALT) . . . . . . 988 Procedure Manual . . . . . . . . . . . . . . . . . . 1020
Other Types of Streaking . . . . . . . . . . . . . . 957 Albumin . . . . . . . . . . . . . . . . . . . . . . . . . . . 988 HIPAA Implications . . . . . . . . . . . . . . . . 1021
Primary Culture . . . . . . . . . . . . . . . . . . . . 958 Alkaline Phosphatase (ALP) . . . . . . . . . . 989 Travel Arrangements . . . . . . . . . . . . . . . 1021
Subculture . . . . . . . . . . . . . . . . . . . . . . . . . 958 Aspartate Aminotransferase (AST) . . . . . . 989 Itinerary . . . . . . . . . . . . . . . . . . . . . . . . . . 1022
Rapid Identification Systems . . . . . . . . . . 958 Bilirubin, Total and Direct . . . . . . . . . . . . 989 Time Management . . . . . . . . . . . . . . . . . 1023
Streptococcus Screening (Rapid Strep Blood Urea Nitrogen Test . . . . . . . . . . . . 989 Marketing Functions . . . . . . . . . . . . . . . . 1023
Testing) . . . . . . . . . . . . . . . . . . . . . . . . . . . 958 Calcium . . . . . . . . . . . . . . . . . . . . . . . . . . . 989 Seminars . . . . . . . . . . . . . . . . . . . . . . . . . 1023
Sensitivity Testing . . . . . . . . . . . . . . . . . . . 959 Chloride . . . . . . . . . . . . . . . . . . . . . . . . . . . 989 Brochures . . . . . . . . . . . . . . . . . . . . . . . . 1024
Parasitology . . . . . . . . . . . . . . . . . . . . . . . 960 Carbon Dioxide (CO2) . . . . . . . . . . . . . . . 990 Newsletters . . . . . . . . . . . . . . . . . . . . . . . . 1025
Examination Methods . . . . . . . . . . . . . . . 960 Creatinine . . . . . . . . . . . . . . . . . . . . . . . . . 990 Press Releases . . . . . . . . . . . . . . . . . . . . . 1025
Specimen Collection . . . . . . . . . . . . . . . . . 960 Gamma Glutamyltransferase (GGT) . . . . 990 Special Events . . . . . . . . . . . . . . . . . . . . . . 1025
Common Parasites . . . . . . . . . . . . . . . . . . 960 Lactate Dehydrogenase (LDH). . . . . . . . . 990 Records and Financial Management . . . . 1027
Mycology . . . . . . . . . . . . . . . . . . . . . . . . . 962 Phosphorus (Phosphate) . . . . . . . . . . . . . 990 Electronic Health Records and the
Potassium (K) . . . . . . . . . . . . . . . . . . . . . . 990 Office Manager . . . . . . . . . . . . . . . . . . . . 1027
Chapter 32: Specialty Sodium . . . . . . . . . . . . . . . . . . . . . . . . . . . . 990 Payroll Processing . . . . . . . . . . . . . . . . . . 1027
Total Protein . . . . . . . . . . . . . . . . . . . . . . . 990 Facility and Equipment Management . . . 1029
Laboratory Tests 969 Uric Acid. . . . . . . . . . . . . . . . . . . . . . . . . . . 990 Administrative and Clinical Inventory
Urine Pregnancy Tests . . . . . . . . . . . . . . . 971 of Supplies and Equipment . . . . . . . . . . 1029
Commercial/Home Urine Pregnancy Administrative and Clinical Equipment
Tests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 971
Testing Methods . . . . . . . . . . . . . . . . . . . . 972
SECTION III: Calibration and Maintenance . . . . . . . . 1030
Liability Coverage and Bonding . . . . . . . 1031
Slide Test or Agglutination PROFESSIONAL Legal Issues . . . . . . . . . . . . . . . . . . . . . . 1031
Inhibition Test . . . . . . . . . . . . . . . . . . . . . . 972
Enzyme Immunoassay Test . . . . . . . . . . . . 972 PROCEDURES 1003
Chapter 34: The Medical Assistant
Infectious Mononucleosis . . . . . . . . . . . . 972 Unit 8: Office and as Human Resources Manager 1041
Transmission of EBV . . . . . . . . . . . . . . . . . 973
Symptoms of IM . . . . . . . . . . . . . . . . . . . . 973 Human Resources Tasks Performed by the Human
Treatment of IM . . . . . . . . . . . . . . . . . . . . 973 Management 1004 Resources Manager . . . . . . . . . . . . . . . . 1042
Diagnosis of IM . . . . . . . . . . . . . . . . . . . . . 973 The Office Policy Manual . . . . . . . . . . . 1043
CLIA Waived IM Tests . . . . . . . . . . . . . . . . 973 Recruiting and Hiring Office
Chapter 33: The Medical
Prothrombin Time/ProTime/INR . . . . . 973 Personnel . . . . . . . . . . . . . . . . . . . . . . . . 1043
Blood Typing . . . . . . . . . . . . . . . . . . . . . . 974 Assistant as Office Manager 1005 Job Descriptions . . . . . . . . . . . . . . . . . . . 1044
ABO Blood Typing . . . . . . . . . . . . . . . . . . 974 The Medical Assistant as Office Recruiting . . . . . . . . . . . . . . . . . . . . . . . . . 1044
Rh Blood Typing . . . . . . . . . . . . . . . . . . . . 974 Manager . . . . . . . . . . . . . . . . . . . . . . . . . 1007 Preparing to Interview Applicants . . . . . 1045
Semen Analysis . . . . . . . . . . . . . . . . . . . . . 976 Qualities of a Manager . . . . . . . . . . . . . . 1007 The Employment Interview . . . . . . . . . . 1046
Semen Composition . . . . . . . . . . . . . . . . . 976 Office Manager Attitude . . . . . . . . . . . . . 1009 Selecting the Finalists . . . . . . . . . . . . . . . 1047
Altering Factors in Semen Analysis . . . . . 976 Professionalism . . . . . . . . . . . . . . . . . . . . 1009 Orienting New Personnel . . . . . . . . . . . . 1048
Phenylketonuria Test . . . . . . . . . . . . . . . . 976 Management Styles . . . . . . . . . . . . . . . . . 1009 Dismissing Employees . . . . . . . . . . . . . . 1048
Blood Testing for PKU . . . . . . . . . . . . . . . 977 Authoritarian Style . . . . . . . . . . . . . . . . . 1010 Exit Interview . . . . . . . . . . . . . . . . . . . . . 1049
Tuberculosis . . . . . . . . . . . . . . . . . . . . . . . 978 Participatory Style . . . . . . . . . . . . . . . . . . 1010 Maintaining Personnel Records . . . . . . . 1049
Cause of TB . . . . . . . . . . . . . . . . . . . . . . . . 978 Management by Walking Around . . . . . 1010 Complying with Personnel Laws . . . . . . 1049
Resistance in Mycobacteria . . . . . . . . . . . . 978 Risk Management . . . . . . . . . . . . . . . . . . 1010 Special Policy Considerations . . . . . . . . 1050
Transmission of Infectious TB. . . . . . . . . . 979 Importance of Teamwork . . . . . . . . . . . 1011 Temporary Employees . . . . . . . . . . . . . . 1050
Diagnosis of TB . . . . . . . . . . . . . . . . . . . . . 979 Getting the Team Started . . . . . . . . . . . . 1011 Smoking Policy . . . . . . . . . . . . . . . . . . . . 1050
Screening for TB: Skin Testing . . . . . . . . 979 Using a Team to Solve a Problem . . . . . 1012 Discrimination . . . . . . . . . . . . . . . . . . . . . 1050
The Mantoux Test . . . . . . . . . . . . . . . . . . . 980 Planning and Implementing Providing/Planning Employee
Blood Glucose . . . . . . . . . . . . . . . . . . . . . 981 a Solution . . . . . . . . . . . . . . . . . . . . . . . . . 1012 Training and Education . . . . . . . . . . . . . 1051
Fasting Blood Glucose . . . . . . . . . . . . . . . 981 Recognition . . . . . . . . . . . . . . . . . . . . . . . 1012
Two-Hour Postprandial Blood Supervising Personnel . . . . . . . . . . . . . . 1012
Glucose . . . . . . . . . . . . . . . . . . . . . . . . . . . . 982 Staff and Team Meetings . . . . . . . . . . . . 1012
Glucose Tolerance Test . . . . . . . . . . . . . . . 983 Conflict Resolution . . . . . . . . . . . . . . . . . 1013
Automated Methods of Glucose Harassment in the Workplace . . . . . . . . 1014
Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . 983 Assimilating New Personnel . . . . . . . . . . 1014

Table of Contents ix
Unit 9: Entry into the Certified Clinical Medical Assistant Closing the Interview . . . . . . . . . . . . . . . 1087
Profession 1057 and Certified Medical Administrative Interview Follow-Up . . . . . . . . . . . . . . . . 1088
Assistant Application Process . . . . . . . . . 1066 Follow-Up Letter . . . . . . . . . . . . . . . . . . . 1088
Certified Clinical Medical Assistant Follow Up by Telephone . . . . . . . . . . . . . 1088
Chapter 35: Preparing for and Certified Medical Administrative After You Are Employed . . . . . . . . . . . . 1088
Medical Assisting Credentials 1058 Assistant Examination Scheduling Dealing with Difficult People . . . . . . . . . 1088
and Administration . . . . . . . . . . . . . . . . . 1066 Getting a Raise . . . . . . . . . . . . . . . . . . . . 1089
Purpose of Certification . . . . . . . . . . . . 1059
Certified Clinical Medical Assistant Professionalism . . . . . . . . . . . . . . . . . . . . 1090
Certification Agencies . . . . . . . . . . . . . . . 1060
and Certified Medical Administrative
Preparing for Certification
Examinations . . . . . . . . . . . . . . . . . . . . . 1061
Assistant Recertification . . . . . . . . . . . . . 1067 Appendix A:
Professional Organizations . . . . . . . . . . 1067 Common Medical
American Association of Medical
American Association of Medical Abbreviations and Symbols 1093
Assistants (AAMA) . . . . . . . . . . . . . . . . . 1061
Assistants (AAMA) . . . . . . . . . . . . . . . . . 1067
Certified Medical Assistant (AAMA) Appendix B:
American Medical Technologists
Examination Format and Content . . . . . 1062 Top 50 Brand Drugs for 2007
(AMT) . . . . . . . . . . . . . . . . . . . . . . . . . . . 1067
Certified Medical Assistant (AAMA)
National Healthcareer Association . . . . . 1068 by Number of U.S. Prescriptions
Application Process . . . . . . . . . . . . . . . . . 1062
Dispensed 1101
Certified Medical Assistant (AAMA)
Examination Scheduling and Chapter 36: Employment Appendix C:
Administration . . . . . . . . . . . . . . . . . . . . 1063 Strategies 1071 Occupational Analysis
Certified Medical Assistant (AAMA) Developing a Strategy . . . . . . . . . . . . . . . 1072 of the CMA (AAMA) 1102
Recertification . . . . . . . . . . . . . . . . . . . . . 1063 Attitude and Mindset . . . . . . . . . . . . . . . 1072 Appendix D:
American Medical Technologists Self-Assessment . . . . . . . . . . . . . . . . . . . . 1073
(AMT) . . . . . . . . . . . . . . . . . . . . . . . . . . . 1064 Medical Assisting Task List 1105
Job Search Analysis and Research. . . . . . 1074
Registered Medical Assistant (RMA) Résumé Preparation . . . . . . . . . . . . . . . . 1075 Appendix E:
Examination Format and Content . . . . . 1064 Résumé Specifications . . . . . . . . . . . . . . . 1075 Software Support:
Registered Medical Assistant (RMA) Clear and Concise Résumés . . . . . . . . . . 1076 The Critical Thinking
Application Process . . . . . . . . . . . . . . . . . 1065 Accomplishments . . . . . . . . . . . . . . . . . . 1076 Challenge 1108
Registered Medical Assistant (RMA) References . . . . . . . . . . . . . . . . . . . . . . . . 1076
Examination Scheduling and Glossary of Terms 1113
Accuracy . . . . . . . . . . . . . . . . . . . . . . . . . 1077
Administration . . . . . . . . . . . . . . . . . . . . 1065 Résumé Styles . . . . . . . . . . . . . . . . . . . . . 1077 Glosario de términos 1143
Registered Medical Assistant (RMA) Vital Résumé Information . . . . . . . . . . . 1081 Index 1175
Recertification . . . . . . . . . . . . . . . . . . . . . 1065 Application/Cover Letters . . . . . . . . . . . 1082
National Healthcareer Association Completing the Application Form . . . . . 1082
(NHA) . . . . . . . . . . . . . . . . . . . . . . . . . . . 1066 The Interview Process . . . . . . . . . . . . . . 1084
Certified Clinical Medical Assistant The Look of Success . . . . . . . . . . . . . . . . 1085
and Certified Medical Administrative Preparing for the Interview . . . . . . . . . . . 1085
Assistant Examination Format The Actual Interview . . . . . . . . . . . . . . . . 1086
and Content . . . . . . . . . . . . . . . . . . . . . . 1066 Interviewing the Employer . . . . . . . . . . . 1087

x Table of Contents
 List of Procedures

4-1 Identifying Community 15-3 Measuring the Infant: Weight, 19-3 Preparing Instruments for
Resources Length, and Head and Chest Sterilization in Autoclave
9-1 Control of Bleeding Circumference 19-4 Sterilization of Instruments
9-2 Applying an Arm Splint 15-4 Taking an Infant’s Rectal (Autoclave)
10-1 Medical Asepsis Hand Wash Temperature with a Digital 19-5 Setting Up and Covering a Sterile
(Hand Hygiene) Thermometer Field
10-2 Removing Contaminated Gloves 15-5 Taking an Apical Pulse on an 19-6 Opening Sterile Packages of
10-3 Transmission-Based Precautions: Infant Instruments and Supplies and
Donning a Gown, Mask, Gloves, 15-6 Measuring Infant’s Respiratory Applying Them to a Sterile Field
and Cap (Isolation Technique) Rate 19-7 Pouring a Sterile Solution into a
10-4 Sanitization of Instruments 15-7 Obtaining a Urine Specimen Cup on a Sterile Field
11-1 Taking a Medical History for a from an Infant or Young Child 19-8 Assisting with Office/Ambulatory
Paper Medical Record 16-1 Instructing Patient in Testicular Surgery
12-1 Measuring an Oral Temperature Self-Examination 19-9 Dressing Change
Using an Electronic 18-1 Urinary Catheterization of a 19-10 Wound Irrigation
Thermometer Female Patient 19-11 Preparation of Patient’s Skin
12-2 Measuring an Aural 18-2 Urinary Catheterization of a Male before Surgery
Temperature Using a Patient 19-12 Suturing of Laceration or Incision
Tympanic Thermometer 18-3 Fecal Occult Blood Test Repair
12-3 Measuring a Temperature 18-4 Performing Visual Acuity Testing 19-13 Sebaceous Cyst Excision
Using a Temporal Artery (TA) Using a Snellen Chart 19-14 Incision and Drainage of
Thermometer 18-5 Measuring Near Visual Acuity Localized Infection
12-4 Measuring a Rectal Temperature 18-6 Testing Color Vision Using the 19-15 Aspiration of Joint Fluid
Using a Digital Thermometer Ishihara Plates 19-16 Hemorrhoid Thrombectomy
12-5 Measuring an Axillary 18-7 Performing Eye Instillation 19-17 Suture/Staple Removal
Temperature 18-8 Performing Eye Patch Dressing 19-18 Application of Sterile Adhesive
12-6 Measuring an Oral Temperature Application Skin Closure Strips
Using a Disposable Oral Strip 18-9 Performing Eye Irrigation 21-1 Transferring Patient from
Thermometer 18-10 Assisting with Audiometry Wheelchair to Examination Table
12-7 Measuring a Radial Pulse 18-11 Performing Ear Irrigation 21-2 Transferring Patient from
12-8 Taking an Apical Pulse 18-12 Performing Ear Instillation Examination Table to Wheelchair
12-9 Measuring the Respiration Rate 18-13 Assisting with Nasal Examination 21-3 Assisting the Patient to Stand and
12-10 Measuring Blood Pressure 18-14 Cautery Treatment of Epistaxis Walk
12-11 Measuring Height 18-15 Performing Nasal Instillation 21-4 Care of the Falling Patient
12-12 Measuring Adult Weight 18-16 Administer Oxygen by Nasal 21-5 Assisting a Patient to Ambulate
13-1 Assisting with a Complete Physical Cannula for Minor Respiratory with a Walker
Examination Distress 21-6 Teaching the Patient to Ambulate
14-1 Assisting with Routine Prenatal 18-17 Instructing Patient in Use of with Crutches
Visits Metered Dose Inhaler 21-7 Assisting a Patient to Ambulate
14-2 Assisting with Pelvic Examination 18-18 Spirometry with a Cane
and Pap Test (Conventional and 18-19 Pulse Oximetry 22-1 Provide Instruction for Health
ThinPrep® Methods) 18-20 Assisting with Plaster Cast Maintenance and Disease
14-3 Assisting with Insertion of an Application Prevention
Intrauterine Device (IUD) 18-21 Assisting with Cast Removal 23-1 Proper Disposal of Drugs
14-4 Wet Prep/Wet Mount and 18-22 Assisting the Physician 24-1 Administration of Oral
Potassium Hydroxide (KOH) during a Lumbar Puncture or Medications
Prep Cerebrospinal Fluid Aspiration 24-2 Withdrawing Medication from a
14-5 Amplified DNA ProbeTec Test 18-23 Assisting the Provider with Vial
for Chlamydia and a Neurologic Screening 24-3 Withdrawing Medication from an
Gonorrhea Examination Ampule
15-1 Administration of a Vaccine 19-1 Applying Sterile Gloves 24-4 Administration of Subcutaneous,
15-2 Maintaining Immunization 19-2 Chemical “Cold” Sterilization of Intramuscular, and Intradermal
Records Endoscopes Injections

List of Procedures xi
24-5 Administering a Subcutaneous 29-1 Hemoglobin Determination 32-2 Performing Infectious
Injection Using a CLIA Waived Mononucleosis Test
24-6 Administering an Intramuscular Hemoglobin Analyzer 32-3 Obtaining Blood Specimen for
Injection 29-2 Microhematocrit Determination Phenylketonuria (PKU) Test
24-7 Administering an Intradermal 29-3 Erythrocyte Sedimentation Rate 32-4 Screening Test for PKU
Injection of Purified Protein 29-4 Prothrombin Time (Using CLIA 32-5 Measurement of Blood Glucose
Derivative (PPD) Waived ProTime Analyzer) Using an Automated Analyzer
24-8 Reconstituting a Powder 30-1 Assessing Urine Volume, Color, 32-6 Cholesterol Testing
Medication for Administration and Clarity 33-1 Completing a Medical Incident
24-9 Z-Track Intramuscular Injection 30-2 Using the Refractometer to Report
Technique Measure Specific Gravity 33-2 Preparing a Meeting Agenda
25-1 Perform Single-Channel or 30-3 Performing a Urinalysis Chemical 33-3 Supervising a Student Practicum
Multichannel Electrocardiogram Examination 33-4 Developing and Maintaining a
25-2 Holter Monitor Application 30-4 Preparing Slide for Microscopic Procedure Manual
(Cassette and Digital) Examination of Urine Sediment 33-5 Making Travel Arrangements with
27-1 Using the Microscope 30-5 Performing a Complete Urinalysis a Travel Agent
28-1 Palpating a Vein and Preparing a 30-6 Utilizing a Urine Transport 33-6 Making Travel Arrangements via
Patient for Venipuncture System for C&S the Internet
28-2 Venipuncture by Syringe 30-7 Instructing a Patient in the 33-7 Processing Employee Payroll
28-3 Venipuncture by Vacuum Tube Collection of a Clean-Catch, 33-8 Perform an Inventory of
System Midstream Urine Specimen Equipment and Supplies
28-4 Venipuncture by Butterfly Needle 31-1 Procedure for Obtaining a Throat 33-9 Perform Routine Maintenance or
System Specimen for Culture Calibration of Administrative and
28-5 Capillary Puncture 31-2 Wet Mount and Hanging Drop Clinical Equipment
28-6 Obtaining a Capillary Specimen Slide Preparations 34-1 Develop and Maintain a Policy
for Transport Using a Microtainer 31-3 Performing Strep Throat Testing Manual
Transport Unit 31-4 Instructing a Patient on 34-2 Prepare a Job Description
28-7 Obtaining Blood for Blood Obtaining a Fecal Specimen 34-3 Conduct Interviews
Culture 32-1 Pregnancy Test 34-4 Orient Personnel

xii List of Procedures

 Preface

The world of health care continues to change rapidly, and, as medical

assistants, you will be called on to do more and respond to an increas-
ing number of responsibilities. Now is the time to equip yourself with
the skills you will need to excel in the field. Now is the time to maximize
your potential, expand your base of knowledge, and dedicate yourself to
becoming the best multifaceted, multiskilled medical assistant that you
can be.
The new edition of Delmar’s Clinical Medical Assisting will guide
you on this journey. This text is part of a dynamic learning system that
includes software, workbook, and online materials. Together, this learn-
ing package includes coverage of the entry-level competencies identi-
fied by the Accrediting Bureau of Health Education Schools (ABHES)
and the Commission on Accreditation of Allied Health Education Pro-
grams (CAAHEP). It will also help you prepare for certification exami-
nations from the American Association of Medical Assistants (AAMA),
the American Medical Technologists (AMT), and the National Health-
career Association (NHA).
You will find this edition continues to provide you with opportu-
nities to use your critical thinking skills, through case studies, critical
thinking boxes, question boxes, scenarios, and features that tie directly
to Delmar’s Skills and Procedures and Critical Thinking for Medical Assistants
DVD Series. You will also see that the text addresses topics that will make
you workplace-ready, including electronic health records (EHRs), Total
Practice Management System (TPMS) software, professionalism, and
confidentiality and privacy issues.
Some of the special new features and updates to this edition
include:
• Emphasis on EHRs and TPMS software; where appropriate, each chapter
includes a figure illustrating how the chapter content relates to TPMS
• More than 200 new photos illustrating a greater number of procedures
and showing the latest equipment
• More than 30 new procedures
• English and Spanish glossary of terms included in the book, with free
downloadable Spanish terms for mp3 players at Delmar’s Mobile Down-
load Web site
• Broadening of cultural diversity in the text and the workbook
• Updated certification and examination information for AAMA, AMT, and
NHA
• Updated to 2008 CAAHEP curriculum standards, including safety and
emergency practices
• New technology initiatives that focus on assessment, interactivity, and com-
petency mapping
Preface xiii
HOW THE TEXT IS ORGANIZED • Expanded information on CLIA, including criteria
for PPMP and updated waived lab test criteria
Section I, General Procedures (Chapters 1 • Applications for EHR and TPMS in the medical
through 9), provides the groundwork for under- laboratory
standing the role and responsibilities of the
• New photo series for each venipuncture method
medical assistant. Topics include the medical
(syringe, vacuum tube, butterfly)
assisting profession, the health care team, the
history of medicine, communication skills, legal • Information and new procedures on protime/
and ethical issues, and emergency and first aid prothrombin time (PT) and International Nor-
procedures. malized Ratio (INR)
New material in this section includes: • Photos of casts, crystals, and miscellaneous struc-
tures found in urine sediment
• Information on National Healthcare Association
(NHA) • New topics in Section III: MRSA, SARS, and avian
flu; HPV; massage therapy; nutrition in childhood;
• Expanded information about AMT, ABHES, RMA,
proper disposal of expired medication; e-prescrib-
CMAS, and CMA (AAMA)
ing; digital Holter monitors
• New Advanced Directives and forms
• New section on Safety and Emergency Practices Section III, Professional Procedures (Chapters 33
• Summary of layperson and provider-level CPR through 36), examines the role of the medical assis-
tant as office manager and human resources man-
• New topics in Section I: Boutique or concierge
ager and provides tools and techniques to use when
medical care; communication barriers caused by
preparing for practicums, medical assistant creden-
cultural and religious diversity; burnout preven-
tials, and employment.
tion; five stages of grief and the acronym TEAR;
New material in this section includes:
intimate partner violence; treating a culturally
diverse clientele • Updated certification and examination information
Section II, Clinical Procedures (Chapters 10 • Information on the NHA and CCMA and CMAA
through 32), gives you a thorough understanding examinations
of clinical, diagnostic, and laboratory procedures • Updated W-4 and W-2 forms
you will be performing and assisting with in the • Expanded typical questions asked during an
medical office. Topics include asepsis, patient his- interview
tory, vital signs, body system examinations, specialty
examinations, minor surgery, diagnostic imaging, • Expanded discussion on employment separations
nutrition, ECG, pharmacology, dosage calculation, • New procedures on processing employee payroll,
venipuncture, urinalysis, and laboratory tests. performing an inventory of equipment and sup-
New material in this section includes: plies, and performing routine maintenance or cal-
ibration of administrative and clinical equipment.
• Information on new charting methodology—
SOAPER and CHEDDAR • New topics in Section IV: Harassment in the work-
place; EHRs and the office manager; common
• The Joint Commission’s goals for Patient Safety errors found in resumes; importance of interview-
Solutions and updated Joint Commission danger- ing the employer; follow-up suggestions for after
ous abbreviations you are employed
• Laboratory procedure documentation samples that
include both patient chart documentation and lab-
oratory report documentation The Complete Learning
• Moved surgical asepsis to Chapter 19 (Assisting Package
with Ambulatory/Office Surgery)
The new Critical Thinking Challenge 2.0 (CD-ROM
• Information and procedure on using a temporal in the back of the book) simulates a 3-month practicum
artery thermometer in a medical office. You will be confronted with a
• New American Cancer Society Guidelines on Pap series of situations in which you must use your crit-
smear and BSE ical thinking skills to choose the most appropriate
xiv Preface
action in response to the situation. Your deci- ˚ Streamlined competency assessment check-
sions will be evaluated in three categories: how lists, with competency mapping and Work
your decisions affect the practice, the patient, and Documentation areas
your career. The 2.0 version includes 10 all-
new video-based scenarios with more branching The Instructor’s Manual (Print) has been revised
options. After successfully completing the pro- to be one comprehensive tool for instructors. Fea-
gram, print out a Certification of Completion. tures include:
See Appendix E for more information about the Critical • Instructor Tips and Strategies for teaching, lesson
Thinking Challenge 2.0. planning, and evaluation
The StudyWARE Software CD-ROM (CD-ROM in • Chapter Overviews, Outlines, and Activities
the back of the book) launches two programs: • Answers to Critical Thinking Boxes in the text

1. StudyWARE is interactive software with learning Instructor Resources (CD-ROM) is a tool to help
activities and quizzes to help study key concepts prepare for class, deliver effective presentations,
and test your comprehension. The activity and and monitor student progress throughout the
quiz content corresponds with each chapter in course. Create a total lesson plan, which includes
the book: visual examples, computer-generated tests, and
more. Tools include:
˚ Multiple choice, true/false, and fill-in-the-blank
quizzes • A Computerized Test Bank in ExamView with
more than 1,200 questions and answers, organized
˚ Flash cards, concentration, hangman, case by chapter
studies
• Instructor slides created in PowerPoint for each
˚ Championship game chapter, which cover key concepts presented in
˚ Visual instrument flash cards the text and includes graphics, animations, and
˚ Visual instrument concentration video clips
˚ Animations library • An Image Library of more than 700 images from
2. Audio Library: Practice pronouncing and rec- the text
ognizing medical terminology using the Audio • Complete, customizable Instructor’s Manual files
Library. Search for terms by word or body system.
Once a word is selected, it is pronounced correctly The Online Companion offers extra content for
and defined on the screen. both instructors and students.
The Workbook (Print) has been fully revised to 1. Instructors—Log on to www.delmar.cengage.com/
map closely to the book. Designed to reinforce companions to get these resources and more:
and apply concepts and develop critical thinking,
the workbook helps strengthen the knowledge ˚ CourseForward curriculum and curriculum
mapping tools
and skills presented in the book. Competency
Assessment Checklists for each procedure track ˚ Customizable Competency Assessment Check-
all of the entry-level competencies designated by lists
ABHES and CAAHEP. Crossover and conversion guides
˚
• Assignment Sheets: ˚ Support documentation for software programs
2. Students—Log on to www.delmarlearning.com/
˚ Incorporate a mix of review exercises and appli-
cation activities in the chapter assignment sheets dl_login.aspx and register your Access Code (located
on the tear-out card in the front of the book) to get
˚ Feature more hands-on application activities, these resources and more:
case studies, and forms practice and certifica-
tion exam practice ˚ The Competency Challenge 2.0
• Competency Assessment Checklists: ˚ Spelling Bee and Image Labeling games to
practice anatomy and physiology
˚ New source materials, scenarios, and forms
accompanying the competency assessment Link to Mobile Download Web site, to access
˚
checklists the free mp3 downloads of Spanish terms
Preface xv
CourseForward Curriculum (on the Online Compan- Web Tutor Advantage on Blackboard or WebCT
ion) is a modular curriculum solution that breaks platforms (Online) is an online classroom man-
down content into topics for ease of learning and agement tool that takes your course beyond the
serves as a road map for course material. Course- classroom wall. Web Tutor provides rich commu-
Forward is designed for instructors to spend less nication and course management tools, including
time planning and more time teaching. Some of a Course Calendar, Chat, email, Threaded Discus-
the features of CourseForward include: sions, Web Links, and a White Board. It also con-
tains additional content to reinforce and enhance
• Equipment lists learning and test student learning, including:
• Homework assignments
• Learning Links explore health care topics through
• In-class discussion topics and suggested responses,
research on the Internet
individual and group activities
• Critical thinking questions and case studies with
• Key Concepts table mapped to activities and
video clips
assignments
• Discussion questions and quizzes for each chapter
The Competency Challenge 2.0 (on the Online Com- • Quizzes by chapter, unit, and section
panion) features interactive activities, better assess-
• A comprehensive terminal examination
ment, and a new concluding capstone element.
To help practice the competencies necessary to • PowerPoint presentations which include anima-
become a medical assistant, you are “virtually” tions and video clips
externing at a local medical office.
Web Tutor Toolbox on Blackboard or WebCT
• Days 1 through 4 focus on 26 video-based case platforms (Online) is an online classroom man-
studies with interactive exercises. agement tool that takes your course beyond the
• Day 5 is a “day in the life” capstone event that classroom wall. Web Tutor provides rich commu-
applies the competencies practiced to a realistic nication and course management tools, including
patient case study. In the case study, you will follow a Course Calendar, Chat, email, Threaded Discus-
a new patient through an office visit for a physical sions, Web Links, and a White Board. Preloaded
exam. content includes objectives, advance preparation,
• Features printable quiz scoring and competency and FAQs.
checklists

xvi Preface
Supplements
At-a-Glance
•••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••

SUPPLEMENT: WHAT IT IS: WHAT’S IN IT:

Critical Thinking Challenge 2.0 Software program 10 all-new video scenarios, with several follow-on scenarios
(CD-ROM in the back Scoring, outcomes, and feedback for each decision selected
of the book)
Printable Certification of Completion at the end of the program

StudyWARE Software CD-ROM Software program StudyWARE software with games, visual instrument flash
(CD-ROM in the back cards, and quizzes
of the book) Audio Library of medical terms

Competency Challenge 2.0 Software program, web 26 video-based case studies with interactive exercises
access (on Online New capstone patient case study
Companion)
Printable quiz scores and Competency Checklists

Workbook Print Streamlined Competency Assessment Checklists

More hands-on application activities, case studies, and forms
practice
Maps more closely to the text

Instructor’s Manual Print Answer Keys to the book and Workbook

Chapter outlines, overviews, and activities

Instructor Resources CD-ROM PowerPoint presentations

Computerized Test Bank
Image library
Electronic Instructor’s Manual files

Student Online Companion Web site (tear-out http://www.delmarlearning.com/dl_login.aspx

access card located in The Competency Challenge 2.0, StudyWARE games, and
front of book) much more

Instructor Online Companion Web site http://www.delmar.cengage.com/companions

Customizable Competency Assessment Checklists
CourseForward Curriculum, mapping tools, and more

CourseForward Curriculum Web access (on Online Modular curriculum solution that breaks down content into
Companion) smaller topics
Key Concepts outline mapped to suggested activities and
homework assignments

Web Tutor Advantage Web access On Blackboard and WebCT platforms

Comprehensive terminal examination
Content and quizzes corresponding to each chapter
Video case studies and critical thinking activities

Web Tutor Toolbox Web access On Blackboard and WebCT platforms

Table of Contents xvii

About the Authors

Wilburta (Billie) Q. Lindh, CMA (AAMA), holds professor emerita

status at Highline Community College, Des Moines, Washington.
She is the former program director and consultant to the medical
assistant program at Highline Community College and recipient
of the 2000 Outstanding Faculty Member of the year award. She is
coauthor of Therapeutic Communications for Health Care published by
Delmar Cengage Learning. She also coauthored The Radiology Word
Book and The Ophthalmology Word Book, texts frequently used by tran-
scriptionists, and is the medical assistant chapter author for Guide
to Careers in the Health Professions. Lindh is a member of the SeaTac
Chapter of the American Association of Medical Assistants (AAMA)
and has lectured at AAMA seminars on the national level and at
Washington and Oregon State meetings. She resides in Federal Way,
Washington, with her husband DeVere.

Marilyn S. Pooler, RN, MEd, served as a professor in medical assist-

ing and taught for more than 25 years at Springfield Technical
Community College in Springfield, Massachusetts, where she served
as the medical assisting department chairperson for several years.
Marilyn also served on the Certifying Board of the AAMA Task
Force for test construction and was a site surveyor for the AAMA for
many years. Pooler is a member of the Hampden District chapter of
the American Association of Medical Assistants (AAMA), and she
has been a speaker at local and state medical assisting meetings and
seminars, emphasizing the importance of education, certification,
and recertification of medical assistants. For a number of years, she
was a member of the Executive Board of the Northeast Association
of Allied Health Educators. Presently, she works in health services at
Baypath College, in Longmeadow, Massachusetts; at Baystate Health
Systems in Springfield, Massachusetts, in their ambulatory/clinic
areas; and for the Center of Business and Technology at Springfield
Technical Community College, where she teaches review courses to
medical assistants.

xviii About the Authors

Carol D. Tamparo, CMA (AAMA), PhD, served as a medical assistant
instructor for 24 years and as program director for medical assisting
for 15 years at Highline Community College, Des Moines, Washington.
She was the Dean of Business and Allied Health programs at Lake
Washington Technical College in Kirkland, Washington, for 4 years.
She is the coauthor of Therapeutic Communications for Health Care; Medi-
cal Law, Ethics, & Bioethics for Ambulatory Care; and Diseases of the Human
Body. She is a member of the SeaTac Chapter of AAMA and is a fre-
quent speaker for medical assistants in the Northwest.

Barbara M. Dahl, CMA (AAMA), CPC, has dedicated her professional

life to the recognition, education, and advancement of medical assis-
tants through quality education, increased public awareness, legislative
compliance, and positive professional development. She is a tenured
faculty member of Whatcom Community College in Bellingham,
Washington and has been the Medical Assisting Program Coordinator
since 1991. She is an active member of the Whatcom County Chapter
of Medical Assistants, Washington State Society of Medical Assistants,
the AAMA, and the Washington State Medical Assisting Educators. She
is a former chapter and state president and has served on and chaired
many committees on the chapter, state, and national levels. She was
instrumental in developing and designing the AAMA Excel award-
winning WSSMA website and continues to serve as the state co-
webmaster. Barbara is currently serving as the state parliamentar-
ian and on the Coalition for the Medical Assisting Scope of Practice
for Washington state. Through the years she has acquired a wealth
of knowledge and understanding about the professional and legal
aspects of medical assisting, particularly in regards to the Washington
State HCA Law. As a Certified Professional Coder she has been a
member of the AAPC for many years. She has served as a presenter for
many conferences and seminars both on the local and state levels in
many clinical, administrative, legal, and leadership topics.

About the Authors xix

Acknowledgments

A special thank you to my husband, DeVere, who continually supports, encour-

ages, and assists me in so many ways. Thank you to my family and friends who
also understood when I was not available for activities, but still encouraged and
accepted my commitment to excellence. I also want to thank the great team I worked
with: Carol, Marilyn, Barbara, and all at Delmar, Cengage Learning. This has
truly been an enriching experience.
Billie Q. Lindh

Thanks to my husband, Jud, and to my family for their patience and under-
standing during the writing of this edition. Thanks also to Billie, Carol, and
Barbara, a great team of authors who together made this text a tremendous
learning tool for medical assistants. A special thank you to Sarah Prime for her
expertise, patience, and kindness.
Marilyn S. Pooler

Writing a textbook, even the revision of a textbook, requires the input and dedica-
tion of many individuals, especially in the field of health care where changes occur
almost daily. Collaborating with Billie, Marilyn, and Barbara has ensured that
the most recent information is included in this text. Thank you, Sarah Prime,
for your vision and guidance. My special thanks to Cecile Favreau, subject mat-
ter expert on MOSS, who provided electronic procedures as appropriate. Thanks
to Tom, my husband, who assumed many household chores and took us out to
dinner at just the right times.
Carol D. Tamparo

First and foremost I would like to thank my husband, Ed, for his support and
encouragement during this 4th edition revision. It has been a very exciting
experience—making sure our textbook is the best and most current representation
of what today’s medical assistant student needs to know to enter the profession;
covering the cognitive, psychomotor, and affective domains; as well as adding
current technology and new clinical diagnostics and equipment. I appreciate the
opportunity to continue working with my diversely talented team members, Billie,
Carol, and Marilyn, to create this nationally respected resource. Special thanks to
Whatcom Community College and my students for supporting me in this phase of
my professional development; to Sarah Prime, Jack Pendleton, and the Cengage
Learning team; Dan Fitzgerald; and Ferndale Family Medical Clinic, especially
Mary Kilmer, CMA (AAMA), for helping with our photo opportunities.
Barbara M. Dahl

xx Table of Contents
Acknowledgments
The Authors and Publisher would like to thank the following people and
locations for assisting with our photo shoots:

Eastside Community Health, Tacoma, WA

Gregory Plancich, DDS, Tacoma, WA

Kathy Bonavita, Springfield Technical Community College, Springfield, MA

Mary Kilmer, CMA (AAMA)

Joanne Kindle, Clinic Manager, Eastside Community Health, Tacoma, WA

Sharon at the Uniform Station in Auburn, WA, for providing scrubs

Connie Pettingill, Springfield Technical Community College,

Springfield, WA

Tom Stock, Stock Studios Photography, Saratoga Springs, NY

Springfield Technical Community College, Springfield, MA

Whatcom Community College, Bellingham, WA

Ferndale Family Medical Center, Ferndale, WA

Acknowledgments
Table of Contents xxi
Contributors

Gerry A. Brasin, AS, CMA (AAMA), CPC

Corporate Education Coordinator
Premier Education Group
Springfield, MA
Subject Matter Expert for the Critical Thinking Challenge 2.0

Cecile Favreau, MBA, CPC

Professional Relations Specialist UMass Memorial Medical Group
Faculty at The Salter School
Worcester, MA
Administrative Procedures for Medical Office Simulation Software 2.0
Subject Matter Expert for Medical Office Simulation Software 2.0

Helen J. Houser, RN, MSHA, RMA

Director, Medical Assisting and Patient Care Technician Programs
Phoenix College
Phoenix, AZ
Subject Matter Expert for the Competency Challenge 2.0

Cathy Kelley-Arney, CMA (AAMA), MLTC, BSHS

Subject Matter Expert for the Critical Thinking Challenge 2.0

Melinda Parker, MA
Developing Administrative StudyWARE Content

Lisa Wright, CMA (AAMA), MT (ASCP), SH

Medical Assisting Program Coordinator
Medical Support Programs Department Chair
Bristol Community College
Fall River, MA
Developing Clinical StudyWARE Content

xxii Contributors
 Reviewers

Diane Alagna, RN, AHI, CPT Robin Kern, RN, BSN Cornelia Mutts, RN, BSN, CMA
Branford Hall Career Institute Medical Assisting Instructor (AAMA), MBA, PhD
Southington, CT Moultrie Technical College Program Director of Allied
Moultrie, GA Health
Ana T. Alvarez-Calonge, MLT, Bryant & Stratton College
RMA, AHI Claire E. Maday-Travis, MA, MBA, Virginia Beach, VA
Medical Assisting Program CPHQ
Director Allied Health Program Director Bev Philpott, BSc, CMA (AAMA)
Keiser Career College The Salter School Kirkwood Community College
Miami Lakes, FL West Boylston, MA Davenport, IA

Michelle Blesi, CMA (AAMA), Lori Malone, CMA (AAMA) Lynn G. Slack, BS, CMA (AAMA)
AA, BA Medical Assistant Program Medical Programs Director
Medical Assistant Program Clinical Lab Assistant Kaplan Career Institute—
Director Century College—East Campus ICM Campus
Century College—East Campus White Bear Lake, MN Pittsburgh, PA
White Bear Lake, MN
Sharon McSain, BS, MA Edu, Lori Starnes, CMA (AAMA), AAS
George Fakhoury, MD, DORCP, CMA (AAMA) Medical Assisting Program
CMA (AAMA) Academic Dean Director
Medical Assisting Program South Piedmont Community
Jeanette Goodwin, BSN, CMA Director College
(AAMA) Elmira Business Institute Monroe, NC
Program Chair Elmira, NY
Southeast Community College Tracy Thomas, BS
Lincoln, NE Pat Gallagher Moeck, PhD, MBA, St. Louis College of Health
CMA (AAMA) Careers
Cynthia Harms, MEd, CMA Director, Medical Assisting St. Louis, MO
(AAMA), CPC, CPC-H Program
Mildred Elley School El Centro College Lisa Wright, CMA (AAMA), MT
Latham, NY Dallas, TX (ASCP), SH
Medical Assisting Program
Shirley Jelmo, CMA (AAMA), Patricia Moseley, BS, MEd Coordinator
RMA Academic Dean Medical Support Programs
Medical Assisting Lead Instructor Concorde Career Institute Department Chair
PIMA Medical Institute Arlington, TX Bristol Community College
Colorado Springs, CO Fall River, MA

Reviewers xxiii
How to Use the Book

Icons
Icons appear throughout the book to highlight
chapter material on topics important to today’s
medical assistant:

Chapter Openers
Using Computers in the Medical Office
At the beginning
of each chapter,
you will find an
Outline, Objec-
Cultural Diversity tives, and a list of
Key Terms. Use
these as a road map
to understand the

E HR Electronic Health Records (EHR) chapter content.

HIPAA HIPAA Compliance

Legal Issues Pharmacy

CLINICAL CARE
Professionalism Patient Assessment
Procedures, Diagnoses & Treatment Plans
Referrals & Follow-up Appointments
Prescriptions
Orders for Tests
Patient Medical History

Safety and Security Total Practice

Test Results Management Figures
Schedules and Tickler Files
Patient Medical History
Medication Administration
Special figures illustrate
Patient Education
Graphical Patient Data Displays
how each chapter’s content
fits in to the overall total

ELECTRONIC practice management data

flow.
RECORDS
Figure 24-1 In a total practice management system,
the patient’s vital signs are often entered by the medi-
cal assistant during clinical care. Many programs have
the ability to output vital signs data in a graph format,
so a provider can easily note fluctuations in a patient’s
weight, blood pressure, normal temperature, etc.

xxiv How to Use the Book

 Spotlight on Certification
RMA Exam Outline
• Vital signs and Measurements Spotlight on Certification
CMA (AAMA) Content Outline This feature maps the chapter material to the content
• Equipment preparation and operation
• Principles of operations
outlines for the RMA, CMA (AAMA), and CMAS exams to
• Vital signs help you prepare to obtain medical assistant credentials.
CMAS Exam Outline
• Vital signs and measurements

Patient Education Patient Education, HIPAA, and Critical Thinking Boxes

These boxes give you specific guidance on how to be pre-
Sensitive medical assistants will encourage
patients to verbalize their concerns. The pared to provide Patient Education instructions and sug-
ability to ask questions in a nonprobing way
and to elicit patient responses is an important gestions as well as comply with HIPAA regulations. Critical
function in any ambulatory care setting, thinking boxes help you think about and deal with issues
because it is critical to know a patient’s
history, current medications, and other you may face on the job.
relevant data.

Critical Thinking
Procedures
What is your opinion of the concierge
type of medical practice? Would you Step-by-step procedures, grouped together at the end of
feel comfortable working in such an each chapter, give instruction on all important adminis-
environment? Why or why not?
trative, clinical, and general competencies. They feature
graphical illustration of the steps to be performed as well as
rationales and correct documentation.

End of Chapter Review

Test your comprehension of the chapter through structured
multiple choice questions and open-ended critical thinking
questions. Web activities give you practice researching on
the Internet.

DVD Series Program Number

Critical Thinking 2
Chapter/Scene Reference
• Forms of Communication

The DVD Hook-Up

Scene references to Delmar’s Skills and Procedures and Critical
Thinking for Medical Assistants DVD Series show the real-world
application of the chapter material. Use the questions to
facilitate thought-provoking discussion and the journal
summary to share the ideas learned.

How to Use the Book xxv

How to Use the StudyWARE
Software CD
Quizzes StudyWARE Instruments Review
StudyWARE is interactive software with activity and quiz con- Practice and expand your knowledge of instrument identifi-
tent corresponding to each chapter in the book. Quizzes can cation through the visual instrument flash card and concen-
be taken in test mode or in practice mode, which gives imme- tration activities.
diate feedback after each question.

Audio Library
Activities Practice pronouncing and recognizing medical terminology
Activities include concentration, hangman, case studies, a using the Audio Library. Search for terms by word or body
championship game, and key term flash cards. system. Once a word is selected, it is pronounced correctly
and defined on the screen.

xxvi How to Use the StudyWARE Software CD

 How to Use the Critical Thinking
Challenge 2.0
About the Game Resources
You are on a 3-month externship in a medical office. You will To help you determine the best action to take, you may con-
be confronted with a series of situations in which you must sult with members of the office staff and document resources.
use your critical thinking skills to choose the most appropri- Keep in mind that, just as in real life, not all of these
ate action in response to the situation. Your decisions will be resources will always be available to you or helpful to you.
evaluated in three categories: how they affect the practice,
the patient, and your career.

Completing the Game Appendix E contains additional information and support

If you make good decisions and actions, you will be hired material for the Critical Thinking Challenge 2.0.
by the office as a full-time medical assistant. However, if you
show a lack of critical thinking skills that threatens the well-
being of the patients and the practice, your practicum will be
terminated and you will have to start over.

How to Use the Critical Thinking Challenge 2.0 xxvii

This page intentionally left blank
SEC TION
General
I Procedures
U NIT Introduction to Medical
1 Assisting and Health
Professions

Chapter 1
The Medical Assisting Profession
Chapter 2
Health Care Settings and the Health
Care Team
Chapter 3
History of Medicine

2
 Chapter
The Medical Assisting
Profession 1
KEY TERMS OUTLINE
Accreditation Historical Perspective Desire to Learn
Ambulatory Care Setting of the Profession Physical Attributes
Attribute Career Opportunities Ability to Communicate
Bachelor’s Degree Education of the Medical Ethical Behavior
Assistant American Association
Certification
Courses in a Medical Assisting of Medical Assistants
Certified Medical Assis-
tant (CMA [AAMA]) Program Certification
Practicum Continuing Education
Competency
Associate and Bachelor American Medical
Compliance Degrees Technologists
Credentialed Accreditation of Medical Assisting Registered Medical Assistant
Dexterity Programs Certified Medical Administra-
Diploma CAAHEP tive Specialist
Disposition ABHES Continuing Education
Empathy Attributes of a Medical Assistant National Healthcareer
Facilitate Professional Association
Empathy Certification
Improvise
Attitude Continuing Education
Integrate
Dependability Regulation of Health Care
License Initiative Providers
Licensure Flexibility Scope of Practice
Litigious
Practicum
Professionalism OBJECTIVES
Proprietary The student should strive to meet the following performance objectives and
Registered Medical demonstrate an understanding of the facts and principles presented in this
Assistant (RMA) chapter through written and oral communication.
Scope of Practice 1. Define the key terms as presented in the glossary.
2. Discuss the history of medical assisting.
3. Describe the practicum experience.
4. Recall two criteria for the selection of practicum sites.
5. List three benefits of the practicum to student and site.
6. Describe the profession of medical assisting and analyze its
career opportunities in relationship to your interests.
7. Identify and discuss nine attributes that are important for a
professional medical assistant to have.

3
OBJECTIVES (continued)
8. Describe the American Association of Medical Assistants and
discuss its major functions.
9. Discuss the role of the American Medical Technologists in the
credentialing of medical assistants.
10. Explain the purpose of the National Healthcareer Association.
11. Explain accreditation, certification, and continuing education
as they pertain to the professional medical assistant.
12. Identify the importance of the accreditation process to an
educational institution.
13. Recall at least two methods available to obtain recertification.
14. List five means of obtaining continuing education units.
15. Differentiate among certification, licensure, and registration.
16. State the importance of understanding the scope of practice for
the medical assistant.

Scenario
A group of high school freshmen have come to tour They tell the high school students about medical
the medical assisting class and laboratory areas. The assisting and describe the personal and physical attri-
Program Director of Medical Assisting is showing the butes desirable for those who want to become medical
students around the department. The Program Director assistants. They explain the importance of these attri-
then takes them into the medical assisting laboratary, butes, as well as what duties a professional medical
where the senior medical assistant students are prac- assistant performs and what education is needed to
ticing their clinical skills. Each senior student pairs up pursue a career in medical assisting.
with a high school freshman, and each pair talks about Throughout the question and answer discus-
medical assisting, with the medical assistant students sions, the senior medical assistant students and the
answering questions the others may have. The medi- program director stress the importance of ethics,
cal assistant students are in uniform as part of their empathy, attitude, dependability, and teamwork as
preparation to go into various health care agencies to favorable attributes. Individuals seeking a career in
do their externship or practicum. The medical assistant medical assisting should develop and maintain these
students look professional, clean, fresh, and motivated. characteristics.

INTRODUCTION
Historically, medical science has been fascinating to most than ever, because of the explosion of knowledge and high
people. Perhaps you have been drawn to medical assisting technology in medicine, medical assistants are involved
because you too are intrigued by medicine and want to in an ever-widening scope of clinical and administrative
learn about advances in health care and become involved duties. With the medical assistant’s expanded role has come
in providing care to patients. More than likely you have a the responsibility to become a well-educated and highly com-
desire to help others. petent professional dedicated to providing the highest qual-
Medical assistants have always played an integral ity of health care.
role in providers’ offices and ambulatory care settings Consumers of health care have become increasingly
such as clinics and urgent care facilities, where health care aware, primarily through the media, of the availability
services are offered on an outpatient basis. And now more of the latest advances, techniques, and discoveries in

4
 CHAPTER 1 The Medical Assisting Profession 5

and dependable medical assistants so they can

Spotlight on Certification focus their time and attention on the medical deci-
sions, treatments, and techniques for which they
RMA Content Outline have been educated and trained. This leaves the
• Medical ethics medical assistant to assist the provider in the oper-
• Human relations ation and management of the practice.
In 1978, the profession of medical assisting was
CMA (AAMA) Outline formally recognized by the United States Department
• Legal concepts of Education. In 1991, the board of trustees of the
American Association of Medical Assistants (AAMA)
CMAS Content Outline approved the current definition of medical assisting:
• Professionalism
Medical Assisting is an allied health pro-
fession whose practitioners function as
members of the health care delivery team
medicine. They realize that they have a right to have and perform administrative and clinical
health care provided to them by educated, skilled, and procedures.
competent professionals.
As you study to become a medical assistant, it is Medical assisting has become well respected
important for you to understand what a professional is. among the professions in allied health.
According to Merriam-Webster’s Collegiate Dictionary,
10th edition, it is “one who has acquired a specialized
body of knowledge, skills, and attitudes.” You will prac- CAREER OPPORTUNITIES
tice professionalism as you learn the technical and ethi-
cal standards of this profession. Medical assistants have been described as health
You will learn to integrate, or unify, your desire care’s most versatile, multifaceted professionals.
and need to help others with the knowledge, skills, and That medical assistants possess a broad scope
attitudes you acquire through your studies. By blending of knowledge and skills makes them ideal profes-
all of these, you will be able to provide patients with the sionals for any ambulatory care setting. Indeed,
best health care possible and will learn what it means to be because of such versatility, medical assistants find
a professional medical assistant. employment in a variety of settings: offices, clin-
ics, medical laboratories, insurance companies,
government agencies, pharmaceutical companies,
HISTORICAL PERSPECTIVE educational institutions, surgical centers, urgent
OF THE PROFESSION care, and electrocardiography (ECG or EKG)
departments in hospitals. Although the range of
Historically, when health care providers began their employment opportunities continues to grow, in
practices, it was common for them to hire individu- the past decade, about four of five medical assis-
als and train them on the job. Originally they hired tants were employed in providers’ offices and clin-
nurses, but eventually they came to realize that nurses ics. About one in five worked in offices of other
alone could not perform the variety of duties that are health care practitioners, such as chiropractors,
required in medical offices and ambulatory care cen- optometrists, and podiatrists. Other career oppor-
ters. The nurse’s role was limited to assisting the pro- tunities are available to the medical assistant. Some
vider with clinical procedures, whereas the medical
assistant’s role was and is much broader and includes
a large number of activities, procedures, and respon-
sibilities, both administrative and clinical. Critical Thinking
Today, with a much more informed patient
comes the need for educated and credentialed Patients and providers prefer to have working
medical assistants. In addition, in today’s litigious for them professional medical assistants who
atmosphere, which makes health care providers have had the benefit of a formal education.
vulnerable to malpractice suits, most employers Discuss the impact of this education on
recognize the importance of employing medical patients and employers. Why is it important
assistants who are professionally prepared through to both groups?
formal education. Providers want knowledgeable
6 UNIT 1 Introduction to Medical Assisting and Health Professions

medical assistants work as phlebotomists, cod- year to complete (a total of 2 years) for an associ-
ing specialists, medical laboratory assistants, and ate’s degree or longer for a bachelor’s degree.
medical administrative specialists. The outlook for
employment of medical assistants is promising. Courses in a Medical
According to the AAMA, there are more than
one million medical assistants in the work force.
Assisting Program
The United States Department of Labor Bureau of Some of the administrative, general, and clinical
Statistics listed medical assisting as one of the fast- courses are listed in Table 1-1. Another aspect of
est growing allied health professions for the years an educational medical assisting program is the
1998 to 2012. Increased employment opportuni- practicum, a period when students participate in
ties for medical assistants result from the increased an on the job training. This provides an excel-
medical needs of an aging population, growth in lent opportunity to apply theory to practices (see
the number of health care practitioners and their Chapter 36).
desire to hire the most qualified person for the
task, increased diagnostic testing, greater volume
and complexity of paperwork and computer infor-
Practicum
mation, managed care’s emphasis on ambulatory Practicum, externship, and internship are all terms
care, and the insurance-mandated shorter stay of used to define the transition period between the
patients in hospitals. classroom and actual employment. A practicum

EDUCATION OF THE MEDICAL Table 1-1 Some Typical Administrative,

ASSISTANT General, and Clinical Courses
in an Accredited Medical
Formal education of medical assistants takes place Assisting Program
in community and junior colleges, as well as in pro-
prietary schools. Educational requirements are Electronic medical records
based on current entry-level responsibilities that (EMRs) and electronic health
records (EHRs)
medical assistants perform in the medical office.
Administrative Word processing
These requirements were previously known as the
Courses Appointments and scheduling
Developing A CUrriculuM (DACUM) Analysis. In
Insurance claims/coding
1997, in coordination with the National Board of
Medical Examiners, educators, and practicing Cer- Billing, collections, patients’
accounts
tified Medical Assistants (CMAs), the AAMA devel-
oped the Medical Assistant Role Delineation Chart,
Anatomy and physiology
now known as Occupational Analysis of the CMA
Medical terminology
(AAMA) (see Appendix C to review this chart). General
Diseases
Entry-level competencies must be mastered by stu- Courses
Law and ethics
dents in academic programs.
Classroom instruction takes place in commu- Patient education
nity colleges, proprietary schools, and junior col-
Infection control
leges that offer courses in medical assisting. The
lecture portion of classes takes place in a classroom Disease prevention
setting. The skills portion take place in a laboratory Medical prevention
setting in which supplies and equipment similar to Pharmacology
those in the medical office/ambulatory care setting Temperature, pulse, respirations,
and blood pressure
are available for practice.
An important new mode of education is Assisting the provider with
Clinical Courses physical exams
online education. Some schools offer medical assis-
Assisting the provider with minor
tant courses online, and, if the school is accredited, surgery
many students who cannot or desire not to take tra- Drawing blood samples
ditional classroom courses can work toward becom-
Urine and blood testing in the
ing certified or registered through this method. laboratory
On graduation, the student will receive a diploma CPR (provider-level
or certificate of completion. If a student decides certification), first aid
to pursue additional courses, it could take another
 CHAPTER 1 The Medical Assisting Profession 7

is planned and supervised by a coordinator from Some of the benefits to the practicum site are:
the medical assisting program and the health care
• Greater alertness of staff because of their educa-
facility that agrees to become a partner in the edu-
tional responsibilities to the student
cation and employability of the student.
• Opportunity for staff to observe students who will
Practicum Sites. Sites for practicum are chosen soon be seeking employment
carefully to ensure that a variety of experiences • Possibility that staff will learn more about the pro-
is available for the student. The sites should pro- fession of medical assisting
vide the student with adequate administrative,
clinical, and general experiences. The staff at the Associate and Bachelor
various sites must be willing to make a commit-
ment to the medical assistant’s education by spend-
Degrees
ing appropriate time observing and instructing Educational institutions that confer associate or
the student. bachelor degrees require general education courses
Students at their practicum site are expected for graduation in addition to the administration
to be: and clinical courses.
Some four-year institutions of higher learn-
• Professional in appearance and demeanor ing offer a bachelor’s degree to medical assis-
• Punctual tants who have graduated with an associate’s
• Willing to learn degree from a community or junior college. The
graduate is accepted as a third-year student and
• Open to criticism
can obtain a bachelor’s degree in areas such as
• Accepting of assignments health care management or health care facility
• Helpful to coworkers administrator.
• Working to the best of their ability Because of the demand for medical assistant
educators, some experienced medical assistants
• Mindful of patient confidentiality
take education courses to become allied health
educators.
Students at their practicum site are expected
not to:
• Consider asking for or taking medication samples
ACCREDITATION OF MEDICAL
without permission ASSISTING PROGRAMS
• Feel entitled to any special treatment
Educational institutions seeking accreditation
• Anticipate free treatment for self, family, or for a medical assisting program must develop
friends the curricula to meet the Standards and Guide-
• Expect to be paid (this is part of the requirements lines set by the Commission on Accreditation for
of the accrediting body) Allied Health Education Programs (CAAHEP),
or the standards set by the Accrediting Bureau
Benefits of Practicum. The practicum experience of Health Education Schools (ABHES) to ensure
is mutually beneficial to the student and staff at the highest quality medical assistant education
the health care facility that is providing the edu- and employment preparedness.
cational experiences. Some of the benefits to the
student are the opportunity to:
CAAHEP
• Apply classroom knowledge and skill in a real-world The Commission on Accreditation for Allied
medical setting Health Education Programs (CAAHEP) is an
• Obtain references for employment accrediting body for medical assisting programs in
• Use externship experience as part of a resume private and public postsecondary institutions and
programs that prepare individuals for entry into
• Recognize improvement in performance and
the profession.
knowledge
A medical assisting program that is accred-
• Understand that there may be more than one ited by CAAHEP meets the standards as outlined
acceptable method of performance in the Standards and Guidelines for an Accredited
• Begin to establish a network of support through Education Program for the Medical Assistant. Stan-
colleagues dards are the minimum standards of quality used
8 UNIT 1 Introduction to Medical Assisting and Health Professions

in accrediting programs that prepare individuals

to enter the medical assisting profession.
On-site review teams evaluate the program’s
compliance with, or adherence to, the standards.
All aspects of programs seeking accreditation sta-
tus undergo scrutiny to ascertain the program’s
quality and to ensure continued compliance with
the standards.
For more information, see the CAAHEP Web
site at http://www.caahep.org.

ABHES
The Accrediting Bureau of Health Education
Schools (ABHES) is the agency that also grants
accreditation to medical assisting programs. ABHES
is recognized by the United States Department of
Education (USDE) as an accrediting agency of pub-
lic and private schools and colleges that primarily Figure 1-1 The medical assistant should have a friendly
offer health education. This includes medical assist- disposition and communicate empathy for the patient.
ing, medical laboratory technology, and surgical
technology programs. Besides being recognized by
the USDE, recognition for ABHES comes from the It is important to realize that patients’ health
AAMA, AMT, National League for Nursing Accred- problems can have a profound effect on you, the
iting (NLNA), and National Board of Surgical Tech- medical assistant. By maintaining a balanced out-
nology and Surgical Assisting (NBSTSA). look, medical assistants can safeguard themselves
More information about ABHES can be from becoming too emotionally involved with
obtained through the ABHES Web site at http:// patients’ problems. Empathy is extremely impor-
www.abhes.org. tant in the health care profession; however, emo-
tionalism can cloud one’s judgment.
ATTRIBUTES OF A MEDICAL
ASSISTANT PROFESSIONAL Attitude
A friendly, warm disposition and a sense of humor
Medical assistants should strive to cultivate will help patients feel more at ease. A sincere affec-
certain characteristics or personal quali- tion for people can be conveyed by actions that
ties. These are the attributes that identify facilitate open and honest communication. Your
a true professional; when caring for patients, these attitude should radiate genuine interest. Be sure all
qualities should be sincere. They will enable the contact with patients is positive.
patient to trust you, the caregiver. On occasion, difficult patients can test the
tolerance level of the most experienced medical
assistant because they seldom seem to be content
Empathy with the care or services received. But no matter
To have empathy means to consider the patient’s what the circumstances, patients should never be
welfare and to be kind. It means stepping into treated with disinterest or in an unfriendly man-
the patient’s place, discovering what the patient is ner. The medical assistant should always be pleas-
experiencing, and then recognizing and identify- ant and courteous.
ing with those feelings.
Medical assistants should treat patients as Patients should be treated equally, with
they themselves would want to be treated. A visit no reservations about their disease,
to the providers’ office is often a time of fear and race, religion, economic status, or sexual
anxiety. Patients can feel vulnerable. Apprehension orientation.
can be allayed tremendously when patients realize
that their caregiver understands their feelings and As a member of the health care delivery
desires to make their lives more pleasant and com- HIPAA team, the medical assistant needs to be
fortable (Figure 1-1). cooperative and supportive of all other
 CHAPTER 1 The Medical Assisting Profession 9

members, working with the team in an honest, your adaptability and willingness to respond to new
open manner while keeping in mind the patient’s circumstances.
right to privacy and confidentiality.
Desire to Learn
Dependability A willingness to continually learn and grow is the
When providing for a patient’s well-being, it is mark of a true professional. With the growing tech-
important to focus attention on activities in the nology in medicine, there is an ongoing necessity
office or clinic environment that will demonstrate for constant learning. Medical assistants must
that you are well organized, accurate, and respon- be dedicated to high standards of performance,
sive to patients’ needs. which can be accomplished by showing a desire to
Being dependable means that employer acquire information and by constantly updating
and coworkers rely on the medical assistant to their knowledge and skills. Keeping abreast of the
be respectful of them, of patients, and of equip- latest diseases, treatments, procedures, and tech-
ment and materials. Other members of the health niques can be achieved in a variety of ways, such
care team will expect you to be accountable for as college courses, seminars, workshops, reading,
the duties and responsibilities you undertake. and simply by being observant. The sharper the
A dependable person interacts with coworkers power of observation, the more the medical assis-
in a supportive manner, is punctual, and limits tant will learn from the provider-employer and
absences from work. coworkers.
The gaining and maintaining of competency
through participation in continuing education is
Initiative the responsibility of every medical assistant. Active
The willingness and ability to work indepen- involvement and membership in the medical assis-
dently shows initiative. A person with initiative tant professional organizations allows students
is observant, notices work that needs to be done, and CMAs (AAMA) and RMAs to participate in
and then takes action to complete those tasks meetings and events that can increase professional
without being told to do them. Employers and skills. This benefits medical assistant skills as well
coworkers must be able to count on one another as future careers. Students can attend medical
to anticipate patients’ needs and be attentive to assisting meetings (usually free of charge), enjoy
work that needs to be accomplished. The success- student discounts, and network at the meetings.
ful medical assistant will be ready to pitch in and
recognize when others need assistance. Team
work and a positive work ethic are valuable char-
Physical Attributes
acteristics. Appearance is important in patients’ perceptions
By asking appropriate questions and seeking of the delivery of their care. Imparting the look of
information that will improve performance, medi- a professional requires an appearance that is clean,
cal assistants will demonstrate that they have the fresh, and wholesome—in general, an appearance
foresight and the “get up and go” needed to com- that reflects good health habits (Figure 1-2). Good
plete the numerous and varied tasks of the ambu- personal hygiene practices (daily shower, deodor-
latory care environment. ant), weight control, and healthy-looking skin,
hair, teeth, and nails all contribute to a professional
appearance. Rest, good nutrition, regular exercise,
Flexibility and recreation all promote good health. A smile
The ability to be adaptable is a trait that serves all can help alleviate some of the anxiety a patient
professionals well. When caring for ill people, unex- may be experiencing. Your smile gives a pleasant
pected situations arise daily, and medical assistants and encouraging appearance to the patient.
must be able to respond to a variety of situations Female medical assistants should wear only
(many of them emergencies and unanticipated) appropriate light daytime makeup. For the safety
without losing a sense of equilibrium. Finding solu- of both the professional and the patient, no neck-
tions to problems and developing alternative action laces or dangling earrings should be worn. The
plans demonstrates flexibility. To improvise, or only jewelry worn should be single earposts or
solve problems that arise either routinely or sponta- wedding rings. Hair should be neat and off the
neously, is a characteristic worth nurturing. Willing- collar. Fingernails should be short and mani-
ness to help with various aspects of the office offers cured. Male medical assistants should be clean-
opportunities to adjust to various situations. It shows shaven and have short hair. Colognes, perfumes,
10 UNIT 1 Introduction to Medical Assisting and Health Professions

tasks as well. Most procedures require that medi-

cal assistants have the ability to hear and see well
for the accurate completion of tasks (Figure 1-3).
Listening to blood pressures, taking a medical
history, observing patients, performing phle-
botomy, and identifying microorganisms under
a microscope are some of the routine tasks and
procedures performed daily in a medical facility.
Manual dexterity is also needed for
manipulating certain instruments and for enter-
ing data using a computer.

Ability to Communicate
It is important that medical assistants learn to develop
the ability to communicate well verbally and nonver-
bally with patients, staff, and other professionals.
Compliance with the provider’s treatment
Figure 1-2 A professional, neat appearance makes plan is important for a positive outcome of patients’
patients feel at ease with their health care provider. illnesses (Figure 1-4). Also, patients will feel more
comfortable and less threatened in a medical office
or ambulatory center that encourages staff to keep
and aftershave should not be worn at work. Body them informed. Consistent kindness and concern
piercings and tattoos should not be visible. Proper help patients develop trust in you.
appearance has a positive effect on the patient.
It is important to know and follow the appro- Ethical Behavior
priate dress code for your facility. The Centers for
Disease Control and Prevention (CDC) recom- No discussion about personal attributes is com-
mends that artificial nails and nail extenders not plete without the mention of ethics. Ethics is a sys-
be worn when caring for “high-risk” patients (inten- tem of values each individual has that determines
sive care, surgery, dialysis). Many ambulatory facili- perceptions of right and wrong. Our life experi-
ties have more stringent rules about artificial nails ences mold this set of values, which is considered a
and extenders. personal code of ethics.
Patient care can place physical demands on
medical assistants. Lifting and moving patients
is often required, and the use of correct body
mechanics will help minimize injuries to the
back. Although every reasonable accommoda-
tion is made for physically challenged medi-
cal assistants, to be mobile without assistance is
important because medical assistants move about
throughout the day while performing tasks and
procedures. It is frequently necessary to bend,
stoop, kneel, and crouch, especially when filing
and retrieving patients’ records and for other

Critical Thinking
Of all the personal attributes that your text
describes, which do you think is your most
developed attribute? Give an example of
that attribute that comes from your daily life. Figure 1-3 Measuring blood pressure is a task that
requires the medical assistant to see and hear well.
 CHAPTER 1 The Medical Assisting Profession 11

the standards and guidelines set by their profes-

sional organizations (AMT, AAMA).

AMERICAN ASSOCIATION
OF MEDICAL ASSISTANTS
Twenty-four years before the official recognition of
the medical assisting profession in 1978, a group
of medical assistants gathered to establish a pro-
fessional organization. With support, encourage-
ment, and guidance from the American Medical
Association (AMA), the American Association of
Medical Assistants (AAMA) was founded in 1956
(Figure 1-5). The first president of the organiza-
Figure 1-4 Patient education requires skill in commu- tion was Maxine Williams.
nicating instructions to patients in language appropriate
to their needs.
Certification
Medical ethics govern medical conduct or that As the profession grew and developed, some states
behavior practiced as health care providers. These came to require special licensure or certification to
ethics involve relationships with patients, their fami- perform certain tasks; in other states, health profes-
lies, fellow professionals, and society in general. sionals were challenged by the skill and broad spec-
Good ethical behavior will have a positive impact on trum of the medical assistant’s ability. To defend
the profession of medical assisting and on the medi- medical assistants whose right to practice clinical pro-
cal community as well. By adhering to the medical cedures was being challenged, the AAMA responded
assistants’ Code of Ethics, we endeavor to elevate the at their 1995 convention with the following policy:
profession to a position of dignity and
HIPAA respect. Medical assistants interact on a daily that any candidate for the AAMA Certi-
basis with patients and are entrusted fication Examination be a graduate of
with information about their medical and personal a CAAHEP-accredited medical assist-
histories. Such information must, by law, be kept ing program or a graduate of an ABHES
confidential. (A more in-depth discussion of ethics accredited program with one year of doc-
and the Code of Ethics can be found in Chapter 8.) umented work experience. Anticipated
The personal qualities of empathy, healthy benefits of the recommendation are to:
attitude, dependability, initiative, flexibility, the (1) safeguard the quality of care to the
desire to learn, a wholesome physical presence, consumer; (2) ensure the CMA’s role in
the ability to communicate well, and ethical behav- the rapidly evolving health care delivery
ior are some of the characteristics that most pro- system; and (3) continue to promote the
fessionals have and that medical assistants should identity and stature of the profession.
strive to develop. When entering into the profes-
sion of medical assisting, it is important to learn
more about these and other qualities and to begin
to use and refine them. Skills and knowledge alone
do not guarantee success. There are personal char-
acteristics that must go along with them.
Professional attitudes, attributes, and values
are important for beginning medical assistant
students to understand. Students’ behaviors can
impact the public’s opinion of the provider and
the medical assistant profession.
The public has a right to expect that the
medical assistant will be competent to practice Figure 1-5 Logo of the AAMA, a professional orga-
medical assisting in accordance with the medical nization founded in 1956. (Courtesy of the American
assistants’ Code of Ethics (see Chapter 8) and with Association of Medical Assistants.)
12 UNIT 1 Introduction to Medical Assisting and Health Professions

Certified Medical Assistant. Certification is volun-

tary, not mandatory, for medical assistants to prac- AMERICAN MEDICAL
tice, although an increasing number of employers TECHNOLOGISTS
are preferring (or even insisting) that their medical
assistants be CMA (AAMA) certified. The examina- Founded in 1939, the American Medical Technol-
tion measures professional knowledge at job entry ogists (AMT) is a national certification and pro-
level. Successful completion of the examination fessional membership association that represents
earns the individual the CMA (AAMA) credential 38,000 allied health care individuals. Its purpose
(Figure 1-6). The initials follow the individual’s is to certify and credential medical assistants, clini-
name. Conferring of the CMA (AAMA) status is cal laboratory personnel, allied health instructors,
referred to as being credentialed. The Certification dental assistants, medical administrative special-
Program of the Certifying Board of the American ists, and others. The AMT has its own bylaws, con-
Association of Medical Assistants is accredited by ventions, committees, state chapters, officers, and
the National Commission for Certifying Agencies registration and certification examinations.
(NCCA) as a result of demonstrating compliance
with the NCCA Standards for the Accreditation of Certifi-
cation Programs.
Registered Medical Assistant
In 1972, the AMT established the certification
examination for medical assistants. The designa-
Continuing Education tion of registered medical assistant (RMA) is con-
The AAMA vigorously encourages continuing ferred on those individuals who successfully pass
education for all medical assistants. This can be the examination (Figure 1-7).
accomplished through various means such as RMA is a voluntary credential for the pro-
educational meetings, seminars, workshops, con- fession of medical assisting. RMA credentials are
ventions, and the AAMA’s self-study publications, national, and examinations are given through-
a series of study courses for continuing education out the United States in both computerized and
credit. paper and pencil format. Voluntary means that
Membership in the AAMA is trilevel: local, neither the federal government nor most states
state, and national. Educational meetings are held require a medical assistant to be registered or cer-
regularly at local and state meetings and conven- tified to practice the profession. Most employers,
tions. The annual AAMA national convention pro- however, prefer to employ credentialed medical
vides an excellent forum for attaining knowledge assistants. Most providers want to hire employees
through its educational offerings and for network- with credentials because they recognize that
ing with other medical assistants. doing so safeguards the quality of patient care and
Continuing an education is a lifelong process reduces the risk for liability issues for themselves.
and serves as testimony to a commitment to profes- Some providers will not hire unless the person is
sionalism (see the AAMA Web site at http://www. credentialed.
aama-ntl.org). The RMA certification examination includes
general medical assisting topics, medical terminol-
ogy, clinical medical assisting, medical law and ethics,
human relations, administrative medical assisting,

(A)

Image not available due to copyright restrictions

(B)

Figure 1-7 (A) Logo of the American Medical

Technologists. (B) Logo of Registered Medical Assis-
tant. (Courtesy of American Medical Technologists.)
 CHAPTER 1 The Medical Assisting Profession 13

pharmacology, therapeutic modalities, laboratory ties that attest to their continued effort to carry
procedures, electrocardiography, and first aid. the competencies needed to maintain certifica-
RMAs have been active in legislation to pro- tion. Proof of compliance is required every three
tect medical assistants, ensuring improvement in years. To maintain the RMA credential, you
medical assistant education. must obtain 30 points in a three-year period.
The points can be earned through professional
Certified Medical Administrative education, authoring textbooks, presentations,
seminars, workshops, and conventions. Another
Specialist avenue for RMAs to earn continuing education
Another profession that the AMT certifies is the credit is through the American Medical Technol-
Medical Administrative Specialist (MAS). Individ- ogists Institute for Education (AMTIE). AMTIE
uals who successfully pass the AMT certification awards certificates of compliance and certificates
examination are conferred with the credential of of excellence to RMAs. It is a continuing education
Certified Medical Administrative Specialist (CMAS). recording system. Yearly compliance with AMTIE
The CMAS exam is given in both computerized and is sufficient to support CCP compliance. Accord-
paper and pencil format. ing to AMT, the CCP program does not change
The CMAS serves an important role in the hos- the AMTIE program. (For more information,
pital, clinic, or medical office. The CMAS is compe- call 1-800-275-1268; write to AMT, 10700 West
tent in a multitude of skills such as medical records Higgins Road, Rosemont, IL 60018; or access the
management, coding and billing for insurance, Web site at http://www.amt1.com).
practice finance management, information process-
ing, and fundamental management practices. The
CMAS also is familiar with the clinical and admin- NATIONAL HEALTHCAREER
istrative concepts that are required to coordinate ASSOCIATION
office functions in the health care setting.
Graduating from a program accredited by The National Healthcareer Association (NHA) is
either CAAHEP or ABHES has significant benefits, a certifying body for health care professionals
such as proof that the student has completed a pro- (Figure 1-8). Its main goals are to certify and to
gram that meets national standards, recognition of offer continuing education course development,
his or her education by professional peers, and eli- membership services for professionals, and a reg-
gibility for AMT or AAMA credentialing exams. istry for certified professionals.
Some medical assistants choose to attain both
RMA and CMA (AAMA) credentials. Neither cre-
dential is higher than the other.
Certification
It is important for graduates to know what NHA offers two ways to attain certification. The first
the employment market is when choosing a pro- is by successful completion of the national certifica-
fessional credential and that personal preference tion exam. The criteria to sit for the exam is to be a
may also be a factor. graduate of a health care training program or have
It is important to remember that credential- one or more years of full-time employment in the
ing, whether through the AAMA (CMA) or AMT profession in which certification is being sought. The
(RMA), is evidence to employers and patients alike second way to achieve certification is through the
that you want the profession of medical assisting NHA home study courses for experienced profession-
to be recognized and promoted. Also, credentials als. The courses cover the skills and competencies
safeguard patients because you will deliver health of the profession and are followed by an assessment.
care at the highest quality with the most current
techniques and procedures. Credentials help
secure the medical assistant’s role in the health
care field. (See Chapter 35 for more information
about credentialing for medical assisting).

Continuing Education
AMT encourages and promotes continuing edu- Figure 1-8 Logo of the National Healthcareer
cation. The Certification Continuation Program Association. (Courtesy of the National Healthcareer
(CCP) requires members to document activi- Association.)
14 UNIT 1 Introduction to Medical Assisting and Health Professions

NHA offers certification to the following pro- • New Jersey Department of Education
fessions as well as others: • U.S. Department of Labor National Office of Job
Corps
• Phlebotomy Technician (CPT)
• U.S. Department of Veterans Affairs
• Electrocardiogram Technician (CET)
• Certified Clinical Medical Assistant (CCMA) There are several more organizations as well.
A complete list can be found at the NHA Web site
• Billing and Coding Specialist (CBCS)
(http://www.nhanow.com). See Chapter 35 for
• Medical Transcription (CMT) more about medical assisting credentials.
• Patient Care Technician (PCT)
• Patient Care Associate (PCA) REGULATION OF HEALTH
• Nurse Technician (NT)
CARE PROVIDERS
• Pharmacy Technician (CPhT)
• Medical Laboratory Assistant (MLA) One way health care providers can be regulated is
through the process of credentialing. Credential-
ing recognizes health care providers who are pro-
Continuing Education fessionally and technically competent. Recognition
Continuing education is another goal of NHA. comes from professional associations, certifying
Courses are offered online and are worth from agencies, and the state or federal government.
1.0 to 2.0 credits, for a total of 5.0 credits yearly. By Regulation ensures:
doing so, the certification remains current. Once
the online topics are completed, they are assessed • Competence of health care providers
by NHA, and, if successfully completed, the • A minimum standard of knowledge, training, and
individual receives a “CREDITS COMPLETED” skill
sticker to affix to the certification ID card. • The limiting of the performance of certain proce-
NHA has been recognized by and has won dures to a specific occupation
approval of many organizations, including the
following: Licensure, certification, and registration are
three kinds of regulations/credentialing (Table 1-2).
• City University of New York (several campuses)
• Elsevier Publishing
Scope of Practice
• Florida Department of Education
Medical assisting is not licensed as a profession;
• Massachusetts Career Vocational Technical Edu-
however, some states require that medical assis-
cation
tants be graduates of an accredited medical
• Massachusetts Department of Education assisting program and be certified to work as
• Mosby Publishing medical assistants.

Table 1-2 Comparison of Requirements for Certification, Licensure, and Registration

Certification Licensure Registration

Practice Voluntary Mandatory Voluntary

Requirement

Nongovernmental agency or Legislated by each state Professional association

professional association
If qualified and meets If qualified and meets If qualified and meets requirements
Conferred By requirements requirements Listed on an official roster
Must pass national examination Must pass state Passing examination not always
examination required

How Restrictive Used by most professionals Most restrictive Least restrictive

 CHAPTER 1 The Medical Assisting Profession 15

Two examples of licensed professions are credentialing standards in order to participate

medicine and nursing. A license regulates the in Medicare and Medicaid. Presently, the law in
activities of these professions by enacting laws that some states requires only voluntary basic train-
specify educational requirements and by defining ing standards. This situation allows individuals
the scope of practice. A license is conferred on without formal education to perform imaging
an individual who successfully completes special- procedures.
ized educational requirements and successfully The AAMA supports the legislation that
passes an examination administered by the state would require specific educational and certifica-
in which the individual resides. The state grants a tion standards for individuals performing medical
license to that individual to practice medicine or imaging. Medical assistants do not perform pro-
nursing. Licensure is mandatory and forbids any- cedures for which they have not been educated
one who is not licensed from performing activities and in which they are not proficient. The AAMA’s
that are designated by that particular license. For Occupational Analysis for the CMA (AAMA) in
example, the law states that the medical license Appendix C, and the AMT’s Medical Assisting
allows diagnosing and prescribing treatment. If Task List in Appendix D are excellent reference
someone were to diagnose or prescribe without sources that identify the clinical, administrative,
a medical license, that individual would be com- and general procedures medical assistants are
mitting an illegal act and would be practicing educated to perform. However, because of the
medicine without a license, which is considered a variability of state statutes, the medical assistant
felony. would be wise to check with the AAMA or AMT
There are state laws that govern the prac- if in doubt about the legality of certain clinical
tice of medicine and nursing (medical practice procedures.
acts, nursing practice acts), and many states have The AMT and the AAMA (the two lead-
acts that give providers the right to delegate ing organizations that certify medical assistants)
certain clinical procedures to qualified allied agreed on a model state law outlining the medi-
health professionals. Because medical assistants cal assistant’s scope of practice. Both the AMT and
are not required to be licensed, they can become AAMA took from existing state laws regarding med-
certified voluntarily. They are allowed to per- ical assistants’ right to practice the most important
form clinical procedures only under the super- aspects of these and developed the model. Both
vision of the provider or other licensed health organizations agreed to require a medical assistant
care professional who is granted the right and to graduate from an accredited medical assistant
who delegates the specific clinical procedures program and to obtain certification from AMT,
to them. AAMA, or other approved agencies that certify.
In some states, including California, Washing- A nonexclusive list of functions that a supervised
ton, and others, unlicensed health care providers medical assistant may perform was developed. The
are required to have authorization from the state purpose of the Model State Legislation is to protect
to perform allergy testing and venipuncture and to the medical assistant’s right to practice. A copy of
give injections. A registration fee and mandatory the model legislation is available at state medical
training are required. In such circumstances, med- assistant societies.
ical assistants or other health care providers would
be breaking the law if they performed these proce-
dures without registration and training.
In some states, authorization is required Critical Thinking
for unlicensed health care providers to expose
patients to X-rays. A medical assistant relates to a patient
On March 30, 2007 a bill called the CARE on the telephone that her symptoms are
bill (Consistency, Accuracy, Responsibility and “probably the flu” and to “take over-the-
Excellence in Medical Imaging and Radiation counter cough syrup” for her cough. Is this
Therapy) was introduced before the U.S. Sen- an appropriate or inappropriate action for
ate. If passed, it would require all persons who the medical assistant to take? Discuss your
perform medical imaging (including X-rays) and answer and explain why you came to your
radiation therapy (excluding ultrasound) pro- decision.
cedures to meet specific federal education and
16 UNIT 1 Introduction to Medical Assisting and Health Professions

Case Study 1-1

Review the scenario at the beginning of the chapter.

CASE STUDY REVIEW

1. If you were a freshman in high school and inter- 2. List 3 or 4 questions you might ask of the senior
ested in medical assisting, would you like to have medical assistant students while you are touring
an opportunity to visit a program and tour the class- the medical assisting department that would help
room and laboratories? Why or why not? to clarify what the profession is, the course require-
ments, etc.

SUMMARY
Progress has been made in the advancement of the profession of medical assisting since the first group of
medical assistants gathered to become organized and formed the AAMA and the AMT. For example, the num-
ber of certified medical assistants has exceeded 47,500 and continues to grow since certification began in 1963.
The total number of medical assistants in the work force is approximately 387,000, and employment opportu-
nities continue to grow. Educational requirements have become increasingly important. The AAMA, the AMT,
and the NHA continue to promote standards of excellence for its members, encouraging continuing educa-
tion and awarding continuing education credits to members of AAMA, AMT, and the NHA via various means.
All of these factors are evidence of a strong professional perspective and should offer encouragement
and support to any student or graduate of medical assisting.
Becoming a professional is a gradual process and cannot be learned in its entirety from a textbook.
The challenge of becoming a professional medical assistant will require open-mindedness and a desire for
continued learning and education, certification and recertification of the CMA (AAMA) or RMA creden-
tial, and professional involvement through organizational participation.
As the scope of work done by medical assistants broadens and medical assistants seek and require for-
mal education, the professional medical assistant will gain additional respect and be in even greater demand.
Medical assistants must continuously pursue excellence, which is the hallmark of all professional behavior.

STUDY FOR SUCCESS

To reinforce your knowledge and skills of information presented in this chapter:
• Review the Key Terms
• Answer the Review Questions

˚ Multiple Choice
˚ Critical Thinking
• Navigate the Internet and complete the Web Activities
• Practice the StudyWARE activities on the textbook CD
• Apply your knowledge in the Student Workbook activities
• Complete the Web Tutor sections
• View and discuss the DVD situations
 CHAPTER 1 The Medical Assisting Profession 17

REVIEW QUESTIONS
Multiple Choice larities. Are there any significant differences?
6. Many employers require credentialed medical assis-
1. The designation CMAS is awarded by the: tants. Give two specific reasons why they do.
a. AAMA 7. Explain two ways in which a certified or registered
b. ABHES medical assistant can remain current with changes
c. AMA in health care and technology.
d. AMT 8. Research which of the credentials is most widely
2. Increased employment opportunities for medical accepted in your geographical area. How would
assistants result from: pursuing a different professional credential affect
a. regulation of diagnostic testing your ability to be employed?
b. the volume of paperwork 9. Contact the AAMA, AMT, or NHA in the state in
c. managed care’s emphasis on ambulatory care which you live. Review newsletters and other peri-
d. “baby boomers” beginning to retire odicals about medical assisting that have been pub-
e. all of the above lished recently. What did you find that promoted
3. Ethics is:
a. a system of values each individual has that deter-
mines perceptions of right and wrong
b. a code established by an agency that has nothing WEB ACTIVITIES
to do with the medical assistant’s belief in right
1. Visit the American Medical Technologists
or wrong
(AMT) Web site at http://www. amt1.com
c. making patients more comfortable
• What allied health professions other
d. willingness to work as a team member
than medical assistants and medical
4. Accreditation means:
laboratory technicians are creden-
a. meeting appropriate standards
tialed by AMT?
b. obtaining the CMA (AAMA) or RMA credential
• Does AMT have a code of ethics for
c. being listed on an official roster
the medical assistant?
d. having a curriculum with courses that are
• What are the eligibility requirements
unrestricted
for individuals to take the RMA
5. Licensure is:
examination?
a. voluntary and up to the individual practitioner
2. Visit the American Association of Medical Assistants
b. unrestrictive in scope
Web site at http://www.aama-ntl.org
c. conferred on an individual through a non-
• What allied health profession(s) does the AAMA
government agency
sponsor?
d. mandatory and legislated by states
• What are the eligibility requirements for indi-
viduals to take the CMA (AAMA) examination?
Critical Thinking • What resources are available on the Web for med-
1. Describe two benefits for medical assistants who ical assistants interested in continuing education?
join their professional organization. 3. Visit the National Healthcareer Association Web
2. Explain what opportunities are available for med- site at http:// www.nhanow.com
ical assistants to improve their skills while • What are five functions of the association?
on practicum. • What is NHA’s goal?
3. Describe how certification or registration can • Describe NHA’s continuing education program.
enhance the medical assistant’s career.
4. What is the primary difference between the CMA
(AAMA) and the RMA credentials?
5. Compare the content of the CMA (AAMA) and
RMA certification examination. Explain six simi-
18 UNIT 1 Introduction to Medical Assisting and Health Professions

REFERENCES/BIBLIOGRAPHY Balasa, D. (2004). Model legislation designed to pro-

American Association of Medical Assistants, Executive tect practice rights. CMA Today, 37(2). Retrieved
Office, 20 N. Wacker Dr., Chicago, IL 60606. April 15, 2007, from http://www. aama-ntl.org/
American Medical Technologists, Allied Health Pro- cmatoday/archives.
fessions, 10700 West Higgins Rd., Rosemont, IL Balasa, D. (2005). CARE bill gains momentum in Con-
60018. gress. CMA Today, 38(4). Retrieved April 15, 2007,
Balasa, D. (2000). Securing the future for medical from http://www.aama-ntl.org/cmatoday/archives.
assistants to practice. Professional medical assistant, McCarty, M. (2003). The lawful scope of a medical assis-
January/February 2000, 6–7. tant’s practice. AMT Events, March 2003.
Balasa, D. (2003). Vigilance is key to protecting prac- Merriam-Webster (2002). Merriam-Webster’s Collegiate
tice rights. CMA Today, 36(4). Retrieved April 15, Dictionary (11th ed.). Springfield, MA: Author.
2007, from http://www.aama-ntl.org/cmatoday/ National Healthcareer Association, 7 Ridgedale Ave.,
archives. Suite 203, Cedar Knolls, NJ 07927.

THE DVD HOOK-UP

As you can see from reading Chapter 1, your character is DVD Journal Summary
important when working as a medical assistant. Taking on After watching the designated scenes from program 1,
a professional demeanor is hard work and takes lots of write a paragraph in your journal that summarizes what
practice. You must start now, while you are in training, to you learned from watching these scenes. What kind of
develop the characteristics of a true professional. verbal and nonverbal messages do you typically send
In the first scene of program 1, we observe Dee walking to your classmates? What will you do to improve other
into class late. Dee’s appearance is in total disarray and people’s impressions of your professional characteristics?
her attitude is poor. Even though Dee promised her teacher
that she would work on her professional characteristics,
Dee enters her externship with the same attitude that she
possessed in school. After Dee speaks with her externship
supervisor, she starts to realize that her teacher is right, and
that she does need to develop her professional skills if she
is going to succeed as a medical assistant.
1. This chapter lists characteristics that are important to DVD Series Program Number
possess as a professional. Using that list, write down all Critical Thinking 1
the characteristics of a professional that Dee was lack- Chapter/Scene Reference
ing in the first three scenes of program 1. • Classroom Performance
2. What kind of verbal and nonverbal messages did Dee • Externship
send to her teacher, classmates, and externship per- • Learning from Supervisors
sonnel? • Growing from Experience
3. Do you see any similarities between Dee and
yourself?
 Chapter
Health Care Settings
and the Health Care Team 2
KEY TERMS OUTLINE
Acupuncture Ambulatory Health Care Settings Allied Health Professionals
Ambulatory Care Setting Individual and Group Medical and Their Roles
Fringe Benefits Practices The Role of the Medical
Health Maintenance Urgent Care Centers Assistant
Organization (HMO) Managed Care Operations Health Unit Coordinator
Homeopathy “Boutique” or “Concierge” Medical Laboratory Technologist
Medical Practice Registered Dietitian
Independent Physician
Association (IPA) The Health Care Team Pharmacist
Integrative Medicine The Title “Doctor” Pharmacy Technician
Health Care Professionals and Phlebotomist
Managed Care Operation
Their Roles Physical Therapist
Preferred Provider
Integrative Medicine and Physical Therapy Assistant
Organization (PPO)
Alternative Health Care Nurse
Practitioners Physician Assistant
Future of Integrative The Value of the Medical Assistant
Medicine to the Health Care Team

OBJECTIVES
The student should strive to meet the following performance objectives and
demonstrate an understanding of the facts and principles presented in this
chapter through written and oral communication.

1. Define the key terms as presented in the glossary.

2. Identify and describe the three primary medical management models.
3. Analyze the benefits and limitations of working in the different
ambulatory health care settings.
4. Assess the role of managed care in the health care environment.
5. Describe the function of the health care team.
6. List and describe a minimum of 12 providers.
7. List and describe a minimum of three alternative health care
specialists.
8. List and describe a minimum of 12 allied health professionals.
9. Discuss the role of the medical assistant in ambulatory health care.
10. Critique alternative therapies and discuss their role in today’s
health care setting.
11. Identity the value of the medical assistant to the health care team.

19
 Scenario
You always had thought you wanted to be a medical cal therapy assistant. What kind of research can you
assistant and work in a clinic where you would see a do to make certain you have chosen the right path?
variety of patients. But after discussing this chapter in Consider working hours, rate of pay, patient contact,
class, you are really intrigued with becoming a physi- required schooling, and job availability.

INTRODUCTION
There are few professions in our society as rich and com- personality, and work preferences. For instance,
plex as the health care profession. Particularly in recent the individual practice may provide medical assis-
years, the health care environment has been very much tants with the opportunity to use their full array of
in flux as the profession seeks ways to provide quality skills, whereas in urgent care centers, the work of
care while containing costs. This effort to curtail costs the medical assistant is often more specialized in
has resulted in the rise of managed care, which, in turn, nature.
has spawned a number of medical models such as health Medical assistants should also recognize the
maintenance organizations (HMOs) and preferred pro- three major forms of medical practice manage-
vider organizations (PPOs), two well-known managed ment and how they affect salary, benefits, and liabil-
care entities. ity issues (Figure 2-1).
Many other types of networks and alliances are
also being established as providers merge to give patients Individual and Group Medical
the best of care while controlling their costs. Ambulatory
care settings, where services are provided on an outpa-
Practices
tient basis, have become increasingly pivotal to consumer For years, the most common form of ambulatory
health care as insurers direct dollars away from hospitals health care was the individual provider or group
and toward outpatient care. practice. This model competes with a variety of
Just as the medical setting continues to evolve other models such as urgent and managed care
to meet new societal needs, health care technology is centers, but many medical assistants find the indi-
ever-changing. Health care is a dynamic, stimulating vidual or group practice the most challenging
industry that requires the medical assistant and other place of employment.
professionals to constantly develop new skills if they
are to contribute to the team effort. The range of skills Individual Practices. In the individual practice,
within the health care team is astonishing and includes also called the solo practice, one primary pro-
providers in more than 25 specialties, an increasing vider sees and treats all patients. Although this
number of nontraditional alternative practitioners type of arrangement is limited in the number
licensed to practice, and more than 20 kinds of allied of people it can serve, many patients feel secure
health professionals. in this kind of health care setting because they
come to know and trust their provider. Because
they always see the same provider, they feel their
AMBULATORY HEALTH CARE health care is being managed in a personal
SETTINGS way. The solo-provider practice, however, can
be an expensive arrangement, because one pro-
Although medical assistants work in a number vider must undertake the costs of office space,
of different environments, including laboratories equipment, and personnel.
or hospitals, most are employed in an ambulatory
care setting such as a medical office or clinic (either Group Practices. Group practices are attrac-
a solo-provider or group practice), an urgent tive arrangements where two or more providers
or primary care center, or a managed care can share the costs of space, equipment, and per-
organization. sonnel. The advantages of a group practice are
Often, the medical assistant chooses to work in not solely economic, however; providers learn
one setting rather than another based on interests, from and consult one another, and patients
20
 CHAPTER 2 Health Care Settings and the Health Care Team 21

FORMS OF MEDICAL PRACTICE Partnerships

MANAGEMENT When two or more providers join together under a
Medical assistants employed in ambulatory care legal agreement to share in the total business opera-
settings or medical offices and clinics are likely to tions of the practice, a partnership is formed. Several
see three major forms of medical practice man- providers who share a facility and practice medi-
agement: sole proprietorships, partnerships, and cine are often referred to as a group. Partners share
corporations. income, expenses, debt, equipment, records, and
personnel according to a predetermined agree-
Whatever form of management is chosen by pro- ment. Partners are liable for only their own actions
viders, they are responsible for the employees that but may be liable for the whole amount of the part-
serve with them. (Refer to the discussion of respon- nership debts.
deat superior in Chapter 7.) Employers and their
medical assistants must have the kind of healthy
working relationship where mutual trust and respect Corporations
are apparent. The provider must understand the Providers may form a corporation, usually referred to
skill level of the medical assistant, and the medical as a professional service corporation. The sharehold-
assistant must feel secure enough to ask any neces- ers are considered employees of the corporation. A
sary questions or admit any errors. Critical errors are corporation allows income and tax advantages to all
often made when this trust does not exist between employees. A variety of fringe benefits can be offered
employer and employee. This causes a breakdown to the employees, which may include pension; profit-
in the delivery of the best health care for patients. sharing plans; medical expense reimbursement; and
life, health, and disability insurance. These benefits
are separate from salary. Another advantage is that
Sole Proprietorships professional employees of a corporation are liable
In the past, many providers preferred a solo practice. only for their own acts, and personal property can-
A solo practice entitles the sole proprietor to hold not be attached in litigation. A sole proprietor may
exclusive right to all aspects of the medical practice incorporate if the practice is large enough.
or sole proprietorship, including profits and debts. If
the business fails, the sole proprietor’s personal prop- The health maintenance organization (HMO) is
erty may also be attached. one type of corporation in which providers often
practice. Basically, providers are employees of the
A sole proprietorship may employ other provid- HMO and are paid by various methods; providers in
ers to participate in the practice. The employed the HMO usually serve as the primary care provider
provider(s) is entitled to any employee fringe ben- (PCP). In this situation, a referral from the PCP may
efits such as health insurance and paid vacation, be necessary before a patient can see a specialist
but the solo practitioner is not so entitled. or allied health professional.

Figure 2-1 Different forms of medical practice management.

receive the benefit of this exchange of informa- Most medical practices are still groups of
tion and knowledge. Often, a group practice has three or four providers, but in the most recent past
more than one office or clinic and some employ- a trend shows a return to one- and two-provider
ees are asked to travel between sites to cut over- practices. Merritt, Hawkins, and Associates, a staff-
head. Group practices may be formed to offer ing and recruiting firm in Texas, reports that pro-
specialized care, such as oncology or women’s viders in two-person partnerships increased from
health care. 9% in 1998 to 22% in 2002. In a 2006 survey the
In most group practices, patients may same firm reported that over 60% of primary care
request that they see the same provider for all providers practice in groups of three or more, 10%
appointments, although sometimes patients are practice in two-provider clinics, and 29% give medi-
assigned to the next available provider. For emer- cal care as solo practitioners.
gencies, group practices have the staff and flex- Many providers in small groups allowed
ibility to ensure that there is always a provider large practice management firms to acquire
on call. their assets and manage the business side of their
22 UNIT 1 Introduction to Medical Assisting and Health Professions

practice. In some cases, these practice manage- “Boutique” or “Concierge”

ment firms were sold to even larger practice
management companies that eventually went
Medical Practice
bankrupt, forcing them to shed all their practices. According to the American Academy of Family Phy-
This dilemma left providers with no recourse sicians, there are several hundred “boutique” or
except to start over. Therefore, a number of pro- “concierge” practices emerging and growing in pop-
viders are returning to the preferred provider ularity with both patients and providers. Providers
organization (PPO), where providers network to who are discouraged by their shrinking insurance
offer discounts to employers and other purchas- reimbursement and managed care plans dictating
ers of health insurance and agree to discounted what procedures and tests will be performed have
fees for services. turned to another avenue for providing health care.
Patients who are disappointed in the quality of care
received and frustrated by being bounced from one
Urgent Care Centers insurer to another as employers seek a cost reduc-
Urgent care centers are usually private, for-profit tion in their health care benefits are willing to pay
centers that provide services for primary care, the extra amount for the “concierge” care.
routine injuries and illnesses, and minor surgery. Concierge care generally offers patients the
Sometimes laboratory services and a radiology following services:
department are located on the premises. Providers
and other health care professionals in the center • Immediate access to their provider by phone
are often salaried employees, not owners who share 24 hours a day, 7 days a week
in the profits, and often are associated with other • Convenient and unhurried appointments
medical facilities. • Unlimited email, fax, or phone consultation with
The pace in most urgent care centers is brisk, their provider
and typically a number of providers are working at
• Home or work visits as needed
one time. Patients are usually encouraged to
make appointments, but drop-ins are accepted, • Coordination of specialist referrals
especially for emergencies. • Friendly staff who understand a patient’s unique
Because these centers often see a higher vol- health needs
ume of patients during expanded hours, usually • Free parking
for a lower cost than a hospital emergency room,
experts predict that urgent care centers will con- Patients who choose this type of service pay
tinue to grow in popularity. a set fee per year from $2,000 to $3,000 for one
individual and up to $5,000 to include a spouse or
$6,000 to include children. Patients are expected
Managed Care Operations to carry a major medical plan to cover referrals to
Health maintenance organizations, or HMOs, are specialists, hospitalization, and emergency care.
probably the most familiar managed care opera- Ethical concerns have been raised regarding
tion. Originally, HMOs were designed to provide concierge services. Some say the “extra” services
a full range of health care services under one should be available to everyone; others believe the
roof. More recently, the HMO without walls has extra fees make the service very exclusive. Some
become established, which is typically a network providers follow a “retainer” model for concierge
of participating providers within a defined geo- services where patients pay a monthly fee for pri-
graphic area. ority access to their provider, unlimited office vis-
Originally, the HMO with walls was conceived its, annual physicals, preventive care, and wellness
to provide patients with comprehensive health
care services at one facility. Today, as managed
care and managed competition sweep the health
care industry, other arrangements include the Critical Thinking
preferred provider organization (PPO), where
providers network to offer discounts to employ- What is your opinion of the concierge
ers and other purchasers of health insurance, and type of medical practice? Would you
the Independent Provider Association (IPA), the feel comfortable working in such an
members of which agree to treat patients for an environment? Why or why not?
agreed-upon fee.
 CHAPTER 2 Health Care Settings and the Health Care Team 23

screenings and compare the cost of the services to have earned the MD, or Doctor of Medicine, degree.
less than a pack of cigarettes a day. Other medical degrees include the Doctor of Oste-
Providers practicing in a concierge service opathy (DO), Doctor of Dentistry (DDS), Doctor
report a greater satisfaction with their chosen pro- of Optometry (OD), Doctor of Podiatric Medicine
fession, enjoy really getting to know their patients, (DPM), Doctor of Chiropracty (DC), and Doctor of
and serve a few hundred patients rather than a Naturopathy (ND). In the medical field, the abbre-
few thousand in a traditional practice. Patients viation Dr. is used and the title doctor is addressed to
report satisfaction in receiving more time and these individuals qualified by education, training,
personal care from a provider who determines and licensure to practice medicine.
the best options for maintaining their health. In nonmedical disciplines, persons who have
achieved a doctorate conferred by a college or
university include the Doctor of Education (EdD),
THE HEALTH CARE TEAM the Doctor of Philosophy (PhD), and the Doctor
of Psychology (PSYD). All three have several areas
In every kind of health care setting, the team con- of specialty and are referred to as doctor.
cept is critical to the quality of patient care. A pri-
mary care provider is most likely the main source Health Care Professionals
of health care for patients. From time to time,
however, a specialist is sought or recommended.
and Their Roles
A number of different allied health professionals, Doctor of Medicine. A doctorate degree in medi-
including the medical assistant, supply additional cine and a license to practice allows a person to
health care as ordered by the provider. Increas- diagnose and treat medical conditions. The doctor
ingly, patients are looking outside traditional med- of medicine candidate attends four years of medi-
icine for portions of their health care. The Centers cal school after receiving a bachelor’s degree. Newly
for Disease Control and Prevention’s (CDC) 2002 graduated MDs enter into a residency program that
National Health Interview Survey revealed that consists of three to seven years of additional training
36% of adults in the United States use some form and education depending on the specialty chosen.
of complementary and/or alternative medical This residency comes under the direct supervision
(CAM) care. The survey also indicated greater of senior medical doctor educators. Family practice,
use of a CAM among women and individuals with internal medicine, and pediatrics require a three-
higher education. In 2001, the World Health Orga- year residency; general surgery requires a five-year
nization (WHO) estimated that between 65% and residency. Some refer to the first year of residency
80% of the world’s population relied on alterna- as an internship; the American Medical Association
tive medicine as their primary health care source. (AMA) no longer uses this term, however. At this
One third of all medical schools in the United point, many medical doctors choose to be board
States now have courses in alternative medicine, certified, which is optional and voluntary. Certifica-
and many people in the United States seem to tion assures the public that the doctor’s knowledge,
desire a more “natural” approach to health care experience, and skills in a particular specialty have
whenever possible. Although alternative care is been tested and deemed qualified to provide care
not always covered by medical insurance, tradi- in that specialty. Doctors of medicine can be certi-
tional and nontraditional health care practices fied through 24 specialty medical boards and in
are nonetheless blending in many areas. 88 subspecialty fields. Table 2-1 gives a partial listing
In whatever manner health care is sought, all of these fields.
members of the health care team must commu- Medical doctors must still obtain a license to
nicate, sometimes in person and sometimes just practice medicine from a state or jurisdiction of
through the medical history and record, with one the United States in which they are planning to
another to ensure quality patient care. The Patient practice. They apply for the permanent license
Education box on page 25 discusses another major after completing a series of examinations and com-
member of the health care team. pleting a minimum number of years of graduate
medical education. Medical doctors must continue
to receive a certain number of continuing medical
The Title “Doctor” education (CME) requirements each year to ensure
The public is often confused by the title doctor. The that their knowledge and skills are current. CME
term implies an earned academic degree of the requirements vary by state, professional organiza-
highest level in a particular area of study. Physicians tions, and hospital staff organizations.
24 UNIT 1 Introduction to Medical Assisting and Health Professions

Table 2-1 Selected Medical and Surgical Specialties

Specialties Title of Doctor Description

Allergy and Allergist and Evaluates diseases/disorders of the immune system and problems
Immunology Immunologist related to asthma and allergy

Cardiology Cardiologist Evaluates and treats medical conditions of the heart

Dermatology Dermatologist Evaluates disorders/diseases of skin, hair, nails, and related tissues

Emergency Emergency Medical Evaluates and treats medical conditions that result from trauma or
Medicine Doctor sudden illness; manages emergency department

Family Practice Family Practitioner Treats the whole family from infancy to death

Internist Provides comprehensive care, practices preventive care, treats long-term

Internal Medicine
and chronic conditions

Obstetrics and Obstetrician and Provides care to pregnant women, delivers babies, treats disorders/
Gynecology Gynecologist diseases of reproductive system

Ophthalmologist Provides comprehensive care of the eye and its structures and offers
Ophthalmology
vision services

Orthopedic Orthopedist Examines, diagnoses, and treats diseases and injuries of the
Surgeon musculoskeletal system

Otolaryngology Otolaryngologist Treats diseases/disorders of the ears, nose, and throat

Pediatrician Treats diseases/disorders of children and adolescents; monitors growth

Pediatrics
and development of children

Psychiatry and Psychiatrist and Diagnoses and treats patients with mental, emotional, or behavioral
Neurology Neurologist disorders

General Surgery Surgeon Operates to repair or remove diseased or injured parts of the body
Colon and Rectal Colorectal Surgeon Operates to remove or repair diseased colon and rectal areas of the body
Neurological Neurosurgeon Treats conditions of the nervous systems, often through surgery
Plastic Plastic Surgeon Repairs and reconstructs physical defects; provides cosmetic
enhancements
Thoracic Thoracic Surgeon Performs surgery on the respiratory system, chest, heart, and
cardiovascular system

Radiologist Interprets diagnostic images, performs special procedures, manages

Radiology
radiological services

Urology Urologist Treats diseases/disorders of the urinary tract

 CHAPTER 2 Health Care Settings and the Health Care Team 25

Patient Education Critical Thinking

Continually remind your patients of the Discuss with a peer what action might be
important role they carry in their own health taken when patients refuse all opportunities
care. Only your patients know exactly what to be a member of their own health care
happens to their bodies and minds in any team. How might you encourage patients
particular illness. Only your patients know to take even a small part in their own health
if their pain is too much to bear. Only your care? How would major decisions be made?
patients know whether they will remain on
any treatment regimen established. Only your
patients know if they are already embracing education. Most patients find little difference
some alternative form of treatment. Only your between an MD and a DO. However, doctors of
patients know how much financial burden osteopathy can incorporate osteopathic manipu-
they can handle for health care. In initial lative treatment (OMT) in their treatment of
interviews and pre-provider preparations, patients as deemed helpful.
ask your patients questions that encourage
them to tell you what is happening, whether
they are coping, and how their particular Integrative Medicine
problem affects their daily lives. Listen to them
carefully. Do not rush or second-guess their
and Alternative Health
responses. Be mindful of the special needs Care Practitioners
of elderly patients and individuals for whom Many integrative medicine and alternative health
English is their second language. They are care practitioners also carry the title doctor, but they
likely unfamiliar with taking a major role in have a different training regimen than required for
their own health care. Always remember to the MD or DO. The training is highly specialized
be therapeutic and observe nonverbal cues. and specific; when licensed, these professionals are
Empower your patients to be a member of allowed to diagnose and treat medical conditions.
their own health care team. As mentioned earlier, alternative therapies
are increasingly being perceived as complements
to traditional health care in a form of integrative
Doctor of Osteopathy. Osteopaths are gener- medicine. In this text, three broad disciplines are
ally recognized as equal to medical doctors in all identified: chiropractic, naturopathy, and Oriental
respects. The Doctor of Osteopathy, or DO, is a medicine/acupuncture.
fully qualified provider licensed to perform sur-
gery and prescribe medication. The training and Doctor of Chiropractic. Chiropractic is a branch
education are quite similar to that of the MD. of the healing arts that gives special attention to
Osteopathic medicine was established in 1874 the physiological and biochemical aspects of the
by Dr. Andrew Taylor Still, who was one of the body’s structure and includes procedures for
first practitioners to study the attributes of good the adjustment and manipulation of the articu-
health to better understand the process of dis- lations and adjacent tissues of the human body,
ease. He identified the musculoskeletal system as particularly of the spinal column. Chiropractic
a key element of health and encouraged preven- is a nonsurgical science that does not include
tive medicine, eating properly, and keeping fit. pharmaceuticals or surgery.
The education of an osteopath includes a four- The roots of chiropractic care can be traced
year undergraduate degree plus four years of back to the beginning of recorded time. Writings
medical school. After graduation from medical from China and Greece written in 2700 b.c. and
school, a DO can choose to practice in any of the 1500 b.c. mention spinal manipulation and maneu-
18 American Osteopathic Association specialty vering of the lower extremities to ease lower back
areas, requiring from two to six years of addi- pain. Daniel David Palmer founded the chiropractic
tional training. Approximately 65% of all osteo- profession in the United States in 1895. Throughout
paths practice in primary care areas such as family the twentieth century, doctors of chiropractic gained
practice, pediatrics, obstetrics/gynecology, and legal recognition and licensure in all 50 states.
internal medicine. DOs must pass a state licen- Doctors of chiropractic (DC) complete four
sure examination and maintain currency in their to five years of study at an accredited chiropractic
26 UNIT 1 Introduction to Medical Assisting and Health Professions

college. The curriculum includes a minimum of with a history of more than 3,000 years. Oriental
4,200 hours of classroom, laboratory, and clinical medicine includes acupuncture, Chinese herbol-
experience. About 555 hours are devoted to adjus- ogy and bodywork, dietary therapy, and exercise
tive techniques and spinal analysis. This specialized based on traditional Oriental medicine principles.
education must be preceded by a minimum of 90 This form of health care is used extensively in Asia
hours of undergraduate courses focusing on science. and is rapidly growing in popularity in the West.
On successful completion of their education and Oriental medicine is based on an energetic
training, doctors of chiropractic must also pass the model rather than the biochemical model of West-
national board examination and all examinations or ern medicine. The ancient Chinese recognized a
licensure requirements identified by the particular vital energy behind all life-forms and processes
state in which the individual wishes to practice. called qi (pronounced “chee”). Oriental healing
Doctors of chiropractic frequently treat practitioners believe that energy flows along spe-
patients with neuromusculoskeletal conditions, cific pathways called meridians. Each pathway is
such as headaches, joint pain, neck pain, lower back associated with a particular physiological system
pain, and sciatica. Chiropractors also treat patients and internal organ. Disease is the result of defi-
with osteoarthritis, spinal disk conditions, carpal ciency or imbalance of energy in the meridians
tunnel syndrome, tendonitis, sprains, and strains. and their associated physiological systems. Acu-
Chiropractors also may treat a variety of other con- puncture points are specific sites along the merid-
ditions, such as allergies, asthma, and digestive dis- ians. Each point has a predictable effect on the
orders. There are obstacles to chiropractors in some vital energy passing through it. Modern science
areas, however, because states vary in what they has measured the electrical charge at these points,
authorize chiropractors to practice and may limit corroborating the locations of the meridians. Tra-
their ability to practice homeopathy or acupuncture ditional Oriental medicine uses an intricate sys-
or to dispense or sell dietary supplements. tem of pulse and tongue diagnosis, palpation of
points and meridians, medical history, and other
Doctor of Naturopathy. Naturopathy, often referred signs and symptoms to create a composite diagno-
to as “natural medicine,” is based on the belief that sis. A treatment plan then is formulated to induce
the cause of disease is violation of nature’s laws. the body to a balanced state of health.
The goal of the naturopath is to remove the under- The WHO recognizes acupuncture and tra-
lying causes of disease and to stimulate the body’s ditional Oriental medicine’s ability to treat many
natural healing processes. Naturopathic treatments common disorders, including the following:
may include fasting; adhering to natural food
diets; taking vitamins and herbs; tissue minerals; • Gastrointestinal disorders: food allergies, peptic
counseling; homeopathic remedies; manipulation ulcer, chronic diarrhea, constipation, indiges-
of the spine and extremities; massage; exercise; tion, anorexia, gastritis
naturopathic hygienic remedies; acupuncture; • Urogenital disorders: stress incontinence, urinary
and applications of water, heat, cold, air, sunlight, tract infections, sexual dysfunction
and electricity. Most of these treatment methods • Gynecological disorders: irregular, heavy, or painful
are used to detoxify the body and strengthen the menstruation; premenstrual syndrome (PMS);
immune system. infertility
In the United States, a Doctor of Naturopathy
• Respiratory disorders: emphysema, sinusitis, asthma,
(ND) or Doctor of Naturopathic Medicine (NMD)
allergies, bronchitis
receives education, training, and credentials from a
full-time naturopathy college. Full-time education • Neuromusculoskeletal disorders: arthritis; migraine
includes two years of science courses and two years headaches; neuralgia; insomnia; dizziness; low
of clinical work. Naturopaths are currently licensed back, neck, and shoulder pain
to practice in 13 states, four Canadian provinces, • Circulatory disorders: hypertension, angina pectoris,
and Puerto Rico and the Virgin Islands. The num- arteriosclerosis, anemia
ber of states licensing NDs is expected to increase. • Eye, ear, nose, and throat disorders: otitis media, sinus-
In many states, naturopaths practice independently itis, sore throats
and unlicensed, or they practice under the direc-
• Emotional and psychological disorders: depression;
tion of a physician.
anxiety; addictions to alcohol, nicotine, and drugs
Oriental Medicine and Acupuncture. Oriental • Pain: elimination or control of pain for chronic
medicine is a comprehensive system of health care and painful debilitating disorders
 CHAPTER 2 Health Care Settings and the Health Care Team 27

In the hands of a comprehensively trained tive forms of treatment, such as massage therapy,
acupuncturist, patients do not find acupuncture aromatherapy, biofeedback, guided imagery,
painful. Sterile, very fine, flexible needles about hydrotherapy, hypnotherapy, and homeopathy.
the diameter of a human hair are used in treat- Furthermore, many patients are seeking the
ment. Practitioners may also recommend herbs, more integrated form of medicine that occurs
dietary changes, and exercise together with lifestyle when primary care providers are willing to refer
changes. to an alternative practitioner and vice versa.
Training for acupuncture and Oriental Table 2-2 gives a brief description of a few alter-
medicine can be obtained in schools and colleges native modalities that integrate fairly easily with
accredited by the Accreditation Commission for traditional medical practices.
Acupuncture and Oriental Medicine. A minimum
of two years of undergraduate study is required, and
some colleges prefer applicants to have a bachelor’s ALLIED HEALTH PROFESSIONALS
degree. Most of these specialized programs are AND THEIR ROLES
three years, and on completion graduates are con-
ferred with a Masters in Acupuncture and Oriental In the health care team, allied health profession-
Medicine (MAOM) or a Masters in Acupuncture als bring specific educational backgrounds and a
(MA) degree. Nearly all states regulate the prac- broad array of skills to the medical environment.
tice of acupuncture and Oriental medicine, either Medical assistants are considered allied health
through licensure or a ruling by the Board of Medi- professionals.
cal Examiners. It is likely that passing a national cer-
tification examination or other testing procedure
is required before licensure. Many doctors (MDs,
The Role of the Medical Assistant
DOs, DCs, and NDs) have become qualified to per- In the ambulatory care setting, a critical allied
form acupuncture and to use Oriental medicine in health professional is the medical assistant. The
their practices through additional education and medical assistant, performing both administra-
training. tive and clinical tasks under the direction of the
provider, is an important link between patient and
provider. The medical assistant serves in many
Future of Integrative Medicine capacities—receptionist, secretary, office manager,
There was a time when osteopaths and chi- bookkeeper, insurance coder and biller, sometimes
ropractors were not accepted by the medical transcriptionist, patient educator, and clinical
establishment and had difficulty with licensure. assistant. The latter requires the medical assistant
Naturopaths, acupuncturists, and Oriental medi- to be able to administer injections and perform
cine practitioners face similar challenges, and venipuncture, prepare patients for examinations,
states vary greatly in their regulations of any form assist with examinations and special procedures,
of alternative medicine. and perform electrocardiography and various lab-
The road may be bumpy for alternative oratory tests. Medical assistants screen and assess
practitioners, but their numbers are increasing patient needs when scheduling appointments and
rapidly. By 2010, the number of chiropractors, tests. However, although medical assistants
naturopaths, and Oriental medicine practitio- have a broad range of responsibilities, it is
ners will increase by 88%. Managed care health critical that they perform only within the
plans are offering increased access to alternative scope of their training and personal capabilities
medicine practitioners, mostly because of the and always function within ethical and legal bound-
ability to expand patient choices at a lower cost. aries and state statutes.
It is expected that states will broaden their licen- Because medical assistants are often the
sure to increased numbers of well-educated and patient’s first contact with the facility and its pro-
trained alternative practitioners. viders, a positive attitude is important. They must
Neither the growth in the number of alter- be excellent communicators, both verbally and
native medicine practitioners nor the laws and nonverbally, and project a professional image of
insurance practices that facilitate their access themselves and their employer. Medical assistants
by patients likely would have occurred without who believe in their work, who are proud of their
broad public acceptance of alternative and com- career, and who convey compassion and caring
plementary medicine. Americans seem quite provide a positive experience for patients who are
willing to pay out-of-pocket expenses for alterna- ill or in a great deal of discomfort.
28 UNIT 1 Introduction to Medical Assisting and Health Professions

Table 2-2 Selected Alternative Medicine Modalities

Acupressure: A massage technique that applies pressure to specific acupuncture-like points on the body; pressure
encourages the flow of vital energy (qi) along the meridian pathways. It is used to control chronic pain, migraine head-
aches, and backaches.

Aromatherapy: The inhalation and bodily application of essential oils from aromatic plants to relax, balance, rejuvenate, restore,
or enhance the body’s mind and spirit. It strengthens the self-healing process by indirect stimulation of the immune system.

Biofeedback: Biofeedback machines gauge internal bodily functions and help patients tune in to these functions and
identify the triggers that evoke symptoms. Relaxation can be taught to relieve the symptoms.

Guided Imagery: Uses images or symbols to train the mind to create a definitive physiological or psychological effect;
relieves stress and anxiety and reduces pain.

Homeopathy: Healing that claims highly diluted doses of certain substances can leave an energy imprint in the body
and bring about a cure. Homeopathic remedies are made from naturally occurring plant, animal, or mineral substances
and are manufactured by pharmaceutical companies under strict guidelines.

Hydrotherapy: Hydrotherapy uses the buoyancy, warmth, and effects of water and its turbulence to speed recovery after
surgery and to reduce pain and stress, spasm and discomfort. It is especially beneficial for work- or sports-related injuries
and arthritis.

Hypnotherapy: Hypnotherapy facilitates communication between the right and left sides of the brain with the patient in
a state of focused relaxation when the subconscious mind is open to suggestions. It is currently used to help people lose
weight; stop smoking; reduce stress; and relieve pain, anxiety, and phobias.

Massage: Massage reduces stress, manages chronic pain, promotes relaxation, and increases circulation of the blood
and lymph. Hand stroking on the body helps patients become more familiar with their pain.

Table 2-3 (see page 29) lists some of the allied stress and hectic pace of coordinating personnel
health professionals recognized by the Commis- and their duties at the nurses’ station. Also called
sion on Accreditation of Allied Health Education unit secretary, administrative specialist, ward clerk,
Programs (CAAHEP) and the Accrediting Bureau or ward secretary, a health unit coordinator receives
of Health Education Schools (ABHES). on-the-job training or completes a six-month to
As a medical assistant, you may not work one-year certificate program.
directly with all the identified allied health care
professionals, but you likely will have contact with
many of them by telephone and written or elec-
Medical Laboratory Technologist
tronic communication. Knowledge of the roles Medical laboratory technologists (MLTs) physically
these health professionals play enables you to and chemically analyze, as well as culture, urine,
interact more intelligently with all members of the blood, and other body fluids and tissues. They
health care team. work closely with specialists such as oncologists,
In addition to the professionals listed in pathologists, and hematologists. Knowledge of spec-
Table 2-3, you may encounter some or all of imen collection, anatomy and physiology, biochem-
the following health care professionals in daily istry, laboratory equipment, asepsis, and quality
patient care. control is essential. The American Society of Clinical
Pathology (ASCP) is a professional organization that
oversees credentialing and education in the medical
Health Unit Coordinator laboratory professions (Figure 2-2 on page 30).
Health unit coordinators (HUCs) perform non-
clinical patient care tasks for the nursing unit of a
hospital. HUCs maintain patients’ charts, schedule
Registered Dietitian
tests, order supplies, screen new patients, and give Registered dietitians (RDs) have specialized train-
directions to visitors. This profession requires a self- ing in the nutritional care of groups and individuals
motivated, mature individual who can handle the and have successfully completed an examination of
 CHAPTER 2 Health Care Settings and the Health Care Team 29

Table 2-3 Selected Allied Health Professions

Occupation Abbreviations Job Description

AA Performs preoperative tasks, performs airway management and drug admin-

Anesthesiologist istration for induction and maintenance of anesthesia during surgery under
Assistant direction of a licensed and qualified anesthesiologist

AT Provides a variety of services including injury prevention, recognition, immedi-

Athletic Trainer ate care, treatment, and rehabilitation after athletic trauma

Clinical Laboratory CLT Performs all routine tests in a medical laboratory and is able to discriminate
Technician Associate and recognize factors that directly affect procedures and results. Works under
Degree direction of pathologist, provider medical technologist, or scientist

Diagnostic Medical DMS Provides patient services using medical ultrasound under the supervision of a
Sonographer provider

Electroneurodiag- EEG-T Possesses the knowledge, attributes, and skills to obtain interpretable record-
nostic Technologist ings of a patient’s nervous system functions

Emergency Medical EMT-P Recognizes, assesses, and manages medical emergencies of acutely ill or
Technician— injured patients in prehospital care settings, working under the direction of a
Paramedic provider (often through radio communication)

MA Functions under the supervision of licensed medical professionals and is compe-

Medical Assistant tent in both administrative/office and clinical/laboratory procedures

MI Creates visual material designed to facilitate the recording and dissemination

Medical Illustrator
of medical, biological, and related knowledge through communication media

OT Educates and trains individuals in the application of purposeful, goal-oriented

Occupational activity in the evaluation, diagnosis, and treatment of loss of ability to cope with
Therapist the tasks of daily living and impairment caused by physical injury, illness, or
emotional disorder; congenital or developmental disability; or the aging process

Ophthalmic Medical OMT Assists ophthalmologists to perform diagnostic and therapeutic procedures
Technician or
Technologist

Personal Fitness PFT Develops activity plans for each individual that integrates a complete approach
Trainer to fitness and wellness through exercise, strength training, and proper diet

RT(R) Provides patient services using imaging modalities, as directed by providers

Radiographer
qualified to order and perform radiologic procedures

Registered Health RHIA Manages health information systems consistent with the medical, adminis-
Information trative, ethical, and legal requirements of the health care delivery system
Administrator

Registered Health RHIT Possesses the technical knowledge and skills necessary to process, maintain,
Information compile, and report patient data
Technician

Respiratory RRT Applies scientific knowledge and theory to practical clinical problems of
Therapist respiratory care

ST Works as an integral member of the surgical team, which includes surgeons, anes-
Surgical
thesiologists, registered nurses, and other surgical personnel delivering patient
Technologist
care and assuming appropriate responsibilities before, during, and after surgery
30 UNIT 1 Introduction to Medical Assisting and Health Professions

state and is administered by state pharmacy asso-

ciations (Figure 2-3).

Phlebotomist
Phlebotomists are trained in the art of drawing
blood for diagnostic laboratory testing. Phleboto-
mists are also referred to as laboratory liaison tech-
nicians. Phlebotomists may be nationally certified
and are employed in medical clinics, hospitals, and
laboratories. Training consists of one to two semes-
ters in a community college program or on-the-job
training.

Figure 2-2 Medical laboratory personnel performing

Physical Therapist
blood analysis. Physical therapists (PTs) are licensed profession-
als who assist in the examination, testing, and
treatment of physically disabled or challenged
people. They also assist in physical rehabilita-
the Commission on Dietetic Registration. Dietitians tion of patients after an accident, injury, or seri-
assist patients in regulating their diets. Although ous illness using special exercises, application
they are typically employed in hospitals and clin- of heat or cold, ultrasound therapy, and other
ics, they can also be found working with the pub- techniques. Educational requirements for a PT
lic in personal nutritional counseling. Education are a minimum of a four-year bachelor’s degree
includes a bachlor’s degree with a major in dietet- (Bachelor of Science) or a special certificate
ics, food and nutrition, or food service systems man- course after obtaining the Bachelor of Science
agement in addition to completion of an approved in a related field. PTs must also successfully com-
internship. plete a state licensure examination (Figure 2-4).

Pharmacist Physical Therapy Assistant

Pharmacists (RPh) are licensed by each state to pre- Physical therapy assistants (PTAs) are trained to
pare and dispense all types of medications as well use and apply physical therapy procedures, such
as medical supplies related to medication admin- as exercise, and physical agents under the super-
istration. They can practice in hospitals, medical vision of a physical therapist. The PTA has earned
centers, and pharmacies. The minimum training
for a pharmacist is a five-year bachelor’s degree;
some pharmacists pursue a Doctor of Pharmacy
degree (PharmD), which is offered by major uni-
versities in the United States.

Pharmacy Technician
Pharmacy technicians assist the pharmacist with
preparation and administration of medications;
they also perform receptionist and billing duties.
In hospitals, nursing homes, and assisted living
facilities, their responsibilities may include read-
ing patient charts and preparing and delivering
medications to patients. Pharmacists must check
all orders before delivery. The technician can copy
the information about the prescribed medication
onto the patient’s profile. Professional certifica- Figure 2-3 Pharmacy technician working with phar-
tion of pharmacy technicians varies from state to macist preparing medications.
 CHAPTER 2 Health Care Settings and the Health Care Team 31

Licensed Practical Nurse. A licensed practical

nurse (LPN) is a professional trained in basic
nursing techniques and direct patient care.
LPNs practice under the direct supervision of an
RN or provider and are employed in similar set-
tings to RNs. Training includes completion of a
state-approved program in practical nursing and
successful completion of a national licensure
examination.

Nurse Practitioner. Sometimes referred to as an

Advanced Registered Nurse Practitioner (ARNP), a
nurse practitioner (NP) is an RN who, by advanced
education (usually a master’s degree) and clinical
experience in a branch of nursing, has acquired
expert knowledge in a specific medical specialty.
Nurse practitioners are employed by providers
in private practice or in clinics and sometimes
practice independently, especially in rural areas.
ARNPs may or may not be licensed to prescribe
medications.

Physician Assistant
Physician assistants (PAs) receive formal educa-
tion and training to provide diagnostic, therapeu-
Figure 2-4 Physical therapist working with a patient tic, and preventive health care services delegated
requiring physical rehabilitation. by and under the supervision of providers and
surgeons. PAs take medical histories, examine and
treat patients, order and interpret laboratory tests
an Associate of Science degree from an accredited and X-rays, and make diagnoses. They also treat
program and must pass a licensure or registry minor injuries by suturing, splinting, and cast-
examination in selected states. ing. PAs write progress notes, instruct and counsel
patients, and order tests and therapy. In 48 states
and the District of Columbia, PAs may prescribe
Nurse some medications. They can supervise techni-
Neither ABHES nor CAAHEP is responsible for cians and medical assistants. PAs may be primary
nurse education or accreditation, but they are care providers in areas where the supervising
listed here as a major participant in health care. physician is not present all the time but is always
Nurses are licensed by the state in which they prac- available for conferring as necessary and required
tice. Although nurses’ education and training are by law.
oriented to bedside care, some are employed in Most PA programs are two years in length
medical offices as clinical assistants, especially in with the added requirement of at least two years
offices where surgery is performed. Nurses play a of college and some health care experience. For
number of roles on the health care team. licensure, all states require PAs to complete an
accredited, formal education program and to
Registered Nurse. In the United States, registered pass the Physician Assistant National Certify-
nurses (RNs) are professionals who have com- ing Examination administered by the National
pleted, at a minimum, a two-year course of study Commission on Certification of Physician Assis-
at a state-approved school of nursing and passed tants (NCCPA). The examination is available
the National Council Licensure Examination only to graduates of an accredited PA education
(NCLEX-RN). Employment settings most often program. Upon successful completion of the
include hospitals, convalescent homes, clinics, and examination, the credential “Physician Assistant-
home health care. Certified” can be used.
32 UNIT 1 Introduction to Medical Assisting and Health Professions

THE VALUE OF THE MEDICAL and hospital staff and between provider and any
number of allied and other health professionals.
ASSISTANT TO THE HEALTH Because they often are the first providers to see or
CARE TEAM speak with patients, they undertake responsibil-
ity for directing, informing, and guiding patient
With their broad range of competencies in both care while establishing a professional and caring
administrative and clinical areas, medical assis- tone for the entire health care team. The value of
tants are increasingly valued as health care team a competent, professional, compassionate medical
members. Medical assistants are the great com- assistant is immeasurable in today’s fast-paced and
municators, serving as liaison between provider challenging health care environment.

Case Study 2-1

Review the scenario at the beginning of the chapter.

CASE STUDY REVIEW

1. Where will you research additional information on 3. If other health professions discussed in the chapter
being a physical therapy assistant? are of special interest to you, answer the same
2. Compare the working hours, rate of pay, contact with questions.This review helps to clarify the position of
patients, required schooling, and job availability to the medical assistant for you.
those of the medical assistant.

Case Study 2-2

You are the medical assistant for a family practice provider, CASE STUDY REVIEW
Bill Claredon, who is close to retirement. He is much adored
by all his patients, but he thinks alternative medicine is out- 1. Describe the discussion that you think will occur
right quackery. Marjorie Johns, a patient with debilitating between Dr. Claredon and Marjorie.
back pain, tells you she is seeing an acupuncturist and is 2. If Marjorie is unhappy when she is ready to leave
taking less and less of her prescribed medications. You qui- the facility, what can you do or say to help her?
etly mention that to Dr. Claredon before he enters the exami- 3. What can you do to help Dr. Claredon?
nation room to see Marjorie. He glares at you with disgust
at the information and is quite agitated when he enters the
examination room.
 CHAPTER 2 Health Care Settings and the Health Care Team 33

SUMMARY
The health care environment is a dynamic service that changes rapidly in response to new technology and
societal needs. In an effort to provide quality care to the most individuals at a reasonable cost, some form
of managed care likely will dominate the health care industry for years to come. A strong health care team
is critical in the health care setting, as primary care providers, specialists of all disciplines, alternative care
practitioners, and allied and other health professionals collaborate on the best way to provide integrative
medicine and quality patient care. In almost any health care environment, but especially the ambulatory
care setting, the medical assistant is a vital link in the team and is responsible for a range of responsibilities,
both clinical and administrative.

STUDY FOR SUCCESS

To reinforce your knowledge and skills of information presented in this chapter:
• Review the Key Terms
• Consider the Case Studies and discuss your conclusions
• Answer the Review Questions

˚ Multiple Choice
˚ Critical Thinking
• Navigate the Internet and complete the Web Activities
• Practice the StudyWARE activities on the textbook CD
• Apply your knowledge in the Student Workbook activities
• Complete the Web Tutor sections
• View and discuss the DVD situations

REVIEW QUESTIONS
Multiple Choice d. includes physicians, nurses, allied health care
professionals, patients, and integrative medicine
1. Medical assistants are mostly employed in: practitioners
a. hospitals 5. Integrative health care approaches:
b. nursing facilities a. are increasingly accepted as complementary to
c. ambulatory care settings traditional health care
d. insurance companies b. are always covered by insurance
2. A health maintenance organization is one c. are seldom approved for licensure
kind of: d. are not important to understand
a. managed care operation 6. A medical assistant permitted by law to draw blood
b. individual practice for diagnostic laboratory testing performs a proce-
c. sole proprietorship dure similar to those performed by a:
d. hospital a. health unit coordinator
3. With its emphasis on controlling costs, managed b. health information technician
care is likely to affect: c. phlebotomist
a. only hospitals d. respiratory therapist
b. all health care settings 7. The “boutique” or “concierge” medical practice:
c. only providers in private practice a. is another form of managed care
d. only patients b. allows patients special privileges in their health
4. The health care team: care
a. should exclude the patient as part of the team c. is covered by all major insurance plans
b. is only important in the hospital setting d. does not require special fees for services
c. is made up of physicians and nurses
34 UNIT 1 Introduction to Medical Assisting and Health Professions

8. Providers just establishing their practice often seek

to work with another provider in the same field.
WEB ACTIVITIES
When expenses and profits are shared, this form of 1. Use the American Board of Medical
management is called a/an: Specialties Web site (http://www.abms.
a. HMO org) to review details of the specialties. What
b. corporation does board certified mean? Identify those for whom
c. sole proprietor you would most enjoy working and give your reasons.
d. group or partnership 2. Scan the Natural Healers Web site (http://www.
9. Which of the following will the medical assistant not naturalhealers.com) for a listing of alternative ther-
do in health care? apy modalities. Select one modality and identify the
a. code and bill insurance, bookkeeping schools/colleges where education is available and
b. diagnose and treat ailments what kind of credentialing is necessary to practice
c. screen when making appointments the modality.
d. assist provider, perform clinical and laboratory 3. American Osteopathic Association (http://www.
procedures osteopathic.org): After you visit this Web site, dis-
10. An alternative approach to medicine that treats cuss the role of the osteopath as a primary care
patients using thin, flexible needles is called: provider in today’s health care structure.
a. acupuncture 4. If you have doubts about alternative medicine, you
b. naturopathy might want to view the following Web site: http://
c. chiropractic www.quackwatch.org. Click on “Whats new?” It is
d. homeopathy helpful to research as many thoughts on a subject as
possible. Examine the validity of the Web site and
Critical Thinking whether any biases are evident.
1. Evaluate the different health care settings and
discuss the pros and cons of working in each
setting. REFERENCES/BIBLIOGRAPHY
2. From a patient’s point of view, which health care American Board of Medical Specialties. (2006).
setting do you think offers the most benefits? Approved ABMS specialty boards & certificate catego-
Why? ries. Evanston, IL: Author.
3. Review the three forms of medical management Bondurant, S. (2005). Mainstream and alternative med-
models. Which is probably the most advanta- icine: Converging paths require common standards.
geous from the provider’s point of view? From Annals of Internal Medicine, 142(2), 149–150.
the medical assistant’s point of view? Justify your Eisenberg, D. M., Cohen, M. H., Hrbek, A., Grayzel, J.,
responses. Van Rompay, M. I., & Cooper, R. A. (2002). Creden-
4. Recall a few types of allied health professionals tialing complementary and alternative medical pro-
and, working in small groups, create scenarios viders. Annals of Internal Medicine, 137(12), 965–973.
in which the medical assistant needs to coordi- Frenkel, M. A., & Borkan, J. M. (2003). An approach for
nate patient care with two or three allied integrating complementary-alternative medicine
professionals. into primary care. Family Practice, 20(3), 324–332.
5. Identify as many reasons as you can for why patients Health professions career & education directory (2007–2008).
might be seeking alternative approaches to tradi- Chicago, IL: American Medical Association.
tional medicine. Explain your choices. Sansweet, J. B. (2005). Choosing the right practice
6. Compare Doctors of Osteopathy and Chiroprac- entity. Family Practice Management, 12(10), 42–49.
tic. When and why might one be selected over the Tamparo, C. D., & Lewis, M. A. (2005). Diseases of the
other? human body (4th ed.). Philadelphia: F. A. Davis
7. Discuss the validity of licensure or national certifi- Publishers.
cation for health care practitioners.
 CHAPTER 2 Health Care Settings and the Health Care Team 35

THE DVD HOOK-UP

This chapter discusses various types of medical specialties DVD Journal Summary
and the importance of choosing a career path that is right After watching the designated scene from program 1, write
for you. You also learned about the role of the medical a paragraph in your journal that summarizes what you
assistant and the importance of being a team player. learned from watching this scene. Are you interested in any
In the scene “Preparing for a Job Interview,” we observe Dee specialty areas? What are some short- and long-term goals
writing to her teacher and sharing her accomplishments that you are interested in achieving after graduation?
after graduation. Dee determined that certification was
essential to climbing the ladder of success as a medical
assistant. Dee also used good critical thinking skills in
establishing what specialty area would work best for her
individual circumstances.
1. What are some of the individual circumstances that
influenced Dee to accept a position in pediatrics?
DVD Series Program Number
2. We can see that Dee has really made progress in
Critical Thinking 1
taking the necessary steps toward becoming a profes-
sional. Would you say that Dee is perfect at this point? Chapter/Scene Reference
• Preparing for a Job Interview
Are you perfect? Will you ever be perfect? Why is it
important to work on your professional skills while you
are still in school?
Chapter

3 History of Medicine

OUTLINE KEY TERMS

Cultural Heritage in Medicine The Scourge of Epidemics Allopathic
Medical Specialists in History Significant Contributions to Asepsis
History of Medical Education Medicine Bubonic Plague
History of Attitudes Toward Women in Medicine Malaria
Illness Frontiers in Medicine
Moxibustion
Historical Medical Treatments Opiates
Pharmacopoeia
OBJECTIVES Pluralistic (Pluralism)
Septicemia
The student should strive to meet the following performance objectives and
demonstrate an understanding of the facts and principles presented in this Trephination
chapter through written and oral communication. Typhus (Typhoid)
Yellow Fever
1. Define the key terms as presented in the glossary.
2. Discuss the effects of culture on medicine.
3. Identify the role of religion, magic, and science in medicine’s
history.
4. Describe how attitudes toward illness are manifested today.
5. Identify a minimum of three previously used common medical
treatments.
6. Recall a minimum of three theories/practices of ancient medicine
that are still prevalent today.
7. Name and describe the historical roles of medical specialists.
8. Describe three major epidemics and their impact on medical
care.
9. Discuss the role of women in medicine.
10. Trace the progression of medical education.
11. Name at least five significant contributions to medicine.
12. Identify a minimum of three recent developments in medicine.

36
 Scenario
You may recall your mom putting a mentholated salve gone by. Many still stand, however, and from them
on your chest when you had a cold. Your cousins had others have developed. Interestingly, medicine has
to take a spoonful of cod-liver oil each night before a rich history, and every culture exhibits that history
they went to bed. Grandma made chicken soup with differently. The more you know and understand of that
homemade noodles when you had the flu. An apple a history and its various cultural influences, the more
day, mustard plaster for the chest, hot or cold steam in effective and therapeutic will be your communication
a room, and many more are medical practices of years with patients.

INTRODUCTION
The historical development of medicine has been driven medicine, and modern day medicine is in many
by many and varied events. These include the presence ways a reflection of this diverse and rich heritage.
of illness and injury, plagues and widespread epidem- It is certain that religion, magic, and science
ics, the dissection first of animals and then of human all played a vital part in the history of medicine.
bodies, the discovery of bacteria, and the experimentation Religion was important because it was perceived
with herbs and potions for medicinal purposes. Medicine that certain gods were to be called on for a cure
as it is known today is the result of multiple revolutions through ceremonies, prayers, and sacrifices. Magic
of thought throughout the world. The history of medicine was practiced because it was such an important part
must remind us that more than one discipline and more of many societies and was seen as an essential ingre-
than one philosophy have contributed to medicine. This dient to chase away evil spirits. The importance
is perhaps more true now than ever as our world becomes of science was demonstrated in the use of plants
smaller and our society becomes increasingly pluralistic, and minerals for medicinal purposes that is found
ethnically, culturally, and religiously. throughout medicine’s history. Unearthed clay
tablets reveal hundreds of plants, minerals, and
animal substances used for medicinal purposes in
CULTURAL HERITAGE ancient Mesopotamia and Babylon. The Chinese
IN MEDICINE pharmacopoeia was rich in the use of herbs.
Skeletal remains of prehistoric cultures show
Today’s health professional will give care advanced stages of arthritis, a nearly toothless jaw,
to individuals of varied cultures who hold and only a 20- to 40-year life span for humans.
differing philosophical beliefs toward Skull bones reveal round holes referred to as
medicine. The informed and caring health profes- trephination, believed necessary to release the evil
sional will recognize that a person’s culture and spirits thought to be causing a person’s illness.
ethnic heritage play an enormous role in any kind Mesopotamian cultures believed that illness was a
of health care. For example, if the patient’s culture punishment by the gods for violation of a moral
and history lean toward a more natural, nonmedi- code. Ancient Egyptians believed the body was
cal form of health care, treating the patient with a system of channels for air, tears, blood, urine,
prescription drugs will necessitate a careful expla- sperm, and feces. All the channels were thought
nation and rationale for the use of medications. to come together in the rectum and were believed
Otherwise, the patient may refuse to take all or to become easily clogged. Thus, emetics, enemas,
part of the medications, thus hindering recovery. It and purges of the anus were common treatments.
would be better to seek a treatment for the patient In ancient India, punishment for adultery was cut-
that embraces both the health care professional’s ting off the nose, therefore allowing practitioners
desire to heal and the individual’s wish to respect many opportunities to practice and refine the art
cultural tradition. of nose reconstruction or plastic surgery.
In every society, medicine has been an The ancient Chinese cultures examined
important element for its people. From the earli- and carefully monitored the pulse in each wrist.
est time, culture was an important influence on It was believed that the pulse had hundreds of

37
38 UNIT 1 Introduction to Medical Assisting and Health Professions

characteristics important in medical treatment. spots is related to a particular organ. Moxibus-

There were five methods of treatment to bring a tion requires the use of a powdered plant sub-
person back to the right track. They were: stance that is made into a small mound on the
person’s skin and then burned, usually raising a
1. Cure the spirit. blister.
2. Nourish the body. Even today’s allopathic, or traditional, practitio-
ners would agree that the first four methods of treat-
3. Give medications.
ment from Chinese culture are excellent guidelines
4. Treat the whole body. for health care. There also is new awareness that
5. Use acupuncture and moxibustion. acupuncture has a valid place in allopathic medi-
cine, not only for the control of some types of pain
Acupuncture is the piercing of the skin by but for treating some illnesses. A type of moxibus-
very thin, sterile, flexible needles into any of 365 tion can be used today with acupuncture treatment.
points along 12 meridians that transverse the There are many different techniques for moxibus-
body and transmit the active life force called “qi” tion in which varying substances are used to apply
(pronounced “chee”) (Figure 3-1). Each of these heat to a broad area of the skin. The intense direct
heating of points is used to treat some diseases, to
relax tense muscles, and to gently relieve aching
and mild pain without making skin blisters.

MEDICAL SPECIALISTS
IN HISTORY
Medicine’s history gives early evidence of many
“specialists” in the healing arts. They were known
by various names—witch doctors, medicine men
and women, shamans or healing priests, and physi-
cians. These healers were more than ancestors of
the modern practitioner, however, for they per-
formed many functions that involved the welfare
of the entire community or village. By today’s stan-
dards, they were considered to be equivalent to
spiritual advisers, social workers, counselors, and
teachers.
These medical specialists were among the
Image not available due to copyright restrictions
world’s earliest professionals. They were present
at important “rites of passage,” such as births and
deaths, puberty initiations, and marriages. The
role of the healers varied among cultures, but cen-
tral to all cultures was the belief that the healers
had the ability to draw upon some power beyond
themselves. Their goal was to help others live and
work in harmony with nature and each other.
Evidence also suggests that many ancient heal-
ers used a variety of mind-altering drugs. A mythical
drug called “soma” is reported in India’s religious
literature. Primitive tribes of Central, South, and
North America used “yage” and “peyote” to induce
trance-like experiences. Many ancient healers also
practiced certain types of what today might be called
yoga and meditation.
These healers were given special status in their
culture. Sometimes they were recognized by their
dress and the pouch or satchel they carried. They
 CHAPTER 3 History of Medicine 39

were not expected to work, and their needs were human dissection, and this anatomical detail is evi-
supplied by the members of their tribe. Much later, dent in his paintings in the Sistine Chapel in the
when medical education was available, a healer was Vatican in Rome. Leonardo da Vinci (1452–1519)
called “physician” if a university degree was held. made anatomical preparations from which he pro-
Surgeons were part of a lower class because they duced drawings representing the skeletal, mus-
usually had only apprentice training and included cular, nervous, and vascular systems. His accurate
the group of barbering surgeons who used their sketch of the spinal vertebrae went undiscovered
razors to cut into blood vessels to relieve infection for more than 100 years.
and fever.
Today the more common term “provider” or
“practitioner” is often used because there are so HISTORY OF ATTITUDES
many health professionals who are a part of the TOWARD ILLNESS
patient’s health care team.
From the earliest times, it appears that some Various attitudes prevailed toward the ill person.
payment was expected for medical services ren- A sick person might be excused from daily activ-
dered. In many instances, the payment was depen- ity but was likely to be shunned if the disease was
dent on the status of the practitioner, as well as the believed to be a punishment by the gods for mortal
patient. At the same time, some cultures punished sin. This forced isolation may well have been ben-
a practitioner who was not successful in treatment eficial to the community. In contrast, touching by
by forcing that practitioner to treat only those too Jesus was an important component of healing, as
poor to pay. was the faith of the individual involved. The New
Testament parable of the Good Samaritan helped
establish a nexus between the early church and a
HISTORY OF MEDICAL concern for the sick. It was believed that though
EDUCATION the body might be wasted and foul with disease,
the purity of the soul guaranteed life everlasting.
During the rise of Christianity, emphasis was This was unlike the pagan religions that tended to
placed on the soul rather than the body; there- abandon individuals thought to be ill because they
fore, early Christian monks held great control were in disfavor with the gods.
over medicine. This is evidenced by St. Benedict Native Americans had various feelings
of Nursia (480–554), who forbade the study of about illness. The ill were treated with kind-
medicine. The care of the sick was encouraged, ness among the Navaho and Cherokee,
but only through prayer and divine intervention. and some who recovered from serious illness were
Thus, Christ’s healing mission was institutional- considered to have extraordinary powers. How-
ized in a fashion that was to control medical care ever, if a tribe was faced with famine, suicide by
almost completely for the next 500 years, until the aged and infirm was considered the high-
the seventh century. est form of bravery. The Eskimos put their older
At that time the religion of Islam moved to adults unprotected onto ice floes. Neither the
preserve the classical learning that had been Romans nor the Greeks treated the hopelessly ill
achieved in medicine, and practitioners were not or deformed, and unwanted infants were disposed
only able to return to the same methods as those of quickly or left to die.
practiced by earlier Greek and Roman cultures, Some of these attitudes are seen even today.
but medical study was now encouraged. The Western medical community and the
Medical education in established universi- consumers it serves are heatedly debating
ties began in the ninth century. These universities the right to choose life or death and the ethics and
included Salerno in southern Italy, the University legality of physician-assisted death, which is accept-
of Montpelier in southern France, and the Univer- able in many other cultures. Even with our vast
sity of Paris. By the time the Renaissance was at its knowledge of medicine and the disease process,
height in the midfifteenth century, the practitio- many individuals are still fearful of any illness they
ner had become licensed, was receiving great sta- do not understand or that they perceive as threat-
tus, and was attending the ill in a velvet bonnet and ening their health—AIDS is a good example. This
fur-trimmed cloak. fear is often accompanied by public ill treatment of
Art and science were more closely related the individuals suffering from certain diseases. For
during the Renaissance than at any other period. example, until 1993, Cuba quarantined everyone
Michelangelo (1475–1564) spent years on careful who tested positive for human immunodeficiency
40 UNIT 1 Introduction to Medical Assisting and Health Professions

Malaria, diphtheria, tuberculosis, typhoid, and dys-

Critical Thinking entery were commonplace. Leprosy was prevalent,
and venereal diseases were rife. Smallpox was fre-
What steps are taken today in hospitals and quent in villages; sometimes the sufferer would be
in ambulatory care settings to prevent the placed in a meat pickling vat and fumigated. The
spread of harmful bacteria and viruses? death toll from such diseases was particularly high
Name the antibiotic-resistant bacteria that among children. Finally, in the eighteenth century,
plagues hospitals today. What steps do you Edward Jenner made a great contribution to the
personally take? prevention of disease by discovering a method of
vaccination against smallpox.
Medicine progressed rapidly during the
virus (HIV) infection, even if they showed no signs nineteenth century. Two important discoveries
of illness. Since that time, Cuba requires individuals occurred: anesthesia to alleviate pain during sur-
who test positive for HIV to spend at least 3 months gery, and the realization that some bacteria cause
in one of Cuba’s 17 AIDS sanitariums, where they disease. Once it had been proved that certain bac-
learn how to live with HIV and protect others from teria were causes of diseases and were transmissi-
infection. The sanitarium model places emphasis ble agents responsible for contagion, greater care
on preventive care rather than acute care and on was taken to prevent that transmission. Asepsis
early diagnosis and treatment. It is reported that became important to reduce the risk for infection.
HIV infection in Cuba affects only 0.1% of adults The Hungarian physician and obstetrician Ignaz
aged 15 to 49 years. According to HIV/AIDS in the Philipp Semmelweis (1818–1865) was able to prove
Caribbean: Issues and Options, that incidence is very that physicians who came from an autopsy directly
low compared to other Caribbean cultures reported to the care of postpartum women, without scrub-
to have an HIV infection rate of 2%, or as high as bing their hands and washing instruments, carried
12% in Haiti. infection with them that often caused puerperal
fever (septicemia after childbirth) and death to the
new mothers.
HISTORICAL MEDICAL The names of Louis Pasteur (1822–1895),
TREATMENTS Joseph Lister (1827–1912), and Robert Koch
(1843–1910) are familiar to all bacteriologists.
The writings of ancient Egypt reveal that when a Louis Pasteur has sometimes been referred to as
woman suspected she was pregnant, she urinated the father of preventive medicine as the result of
over a mixture of wheat and barley seeds combined his work in recognizing the relationship between
with dates and sand. If any of the grains sprouted, bacteria and infectious disease (Figure 3-2). Joseph
she was surely pregnant. If the wheat grew, she would Lister revolutionized surgery because of his belief
have a boy. If the barley grew, it would be a girl. Urine in Pasteur’s theory of using carbolic acid as an anti-
is still used in modern tests to determine pregnancy. septic spray. He insisted that all instruments and
During the Ming dynasty (1368–1644), Chinese physicians’ hands be washed with the solution.
medicine seemed to reach its peak. This is the time Robert Koch used the culture-plate method for
that Li Shih-chen wrote his Pen ts’ao kang mu, isolating bacteria and demonstrated how cholera
“The Great Herbal.” This pharmacopoeia summa- was transmitted by food and water. His discovery
rizes what was known of herbal medicine up to the changed the way health departments cared for
late sixteenth century, describing in detail more than persons with infectious disease.
1,800 plants, animal substances, minerals, and met- Fortunately, early in the twentieth century,
als, together with their medicinal properties and society was finally liberated from many of the infec-
applications. tious and epidemic diseases that had scourged the
Early medical treatments were often crude. For human race for millennia. Smallpox vaccinations
a sore throat, a practitioner might mix barley water, became common, causes of yellow fever, typhus, and
vinegar, and mulberry syrup for a gargle. Someone bubonic plague were determined, and appropri-
suffering with rheumatism might be given a prescrip- ate measures were taken to eradicate the diseases.
tion of chopped mice, lynx claws, and elk hooves. Life expectancy increased. Tuberculosis became
Rhubarb, senna, bitter apple, turpentine, camphor, less frequent. In 1922, Frederick G. Banting and
and mercury were among the practitioners’ staples. a medical student, Charles Best, were able to iso-
Some practitioners washed the instruments used late and inject insulin into a 14-year-old boy who
in treating the ill; others scoffed at such a practice. was dying of diabetes. Two weeks later, the boy was
 CHAPTER 3 History of Medicine 41

eradication of another. What follows is a discus-

sion of three diseases that have caused much fear
in our world, are still a great concern throughout
the world, and are still a challenge for medical
research.

Paralytic Poliomyelitis. Paralytic poliomyelitis, a

virus spread through the fecal–oral route, multi-
plies in the intestine and invades the nervous sys-
tem. It is often referred to as infantile paralysis. It
mostly affects children under the age of 5 years,
and there is no cure.
A 3,000-year-old Egyptian stone carving indi-
cates the presence of the virus in ancient times.
There is evidence of polio outbreaks occurring
during the summer months in the late 1890s in
the U.S. During the Great Depression of the 1930s
and into the 1950s, infantile paralysis was greatly
feared. It struck mostly children, resulted in crip-
pling paralysis within hours, and sometimes caused
death. Children were hospitalized and isolated in
polio wards. Children were kept from swimming
pools and public playgrounds and were reminded
not to get too tired or chilled. A practitioner was
called if headache, fever, sore throat, stiff neck, or
aching muscles occurred.
Those individuals with bulbar polio, a polio-
myelitis that affected nerve cells in the medulla
Figure 3-2 Louis Pasteur, known for his recognition
oblongata or the lowest portion of the brainstem
of the relationship between bacteria and infectious
responsible for regulating heart rate, breathing,
disease.
and blood pressure, were placed in iron lungs.
Iron lungs worked by creating an airtight seal
around individuals placed on their backs so that
alive and alert. By 1923, insulin was available for only their heads were visible. A pump alternately
general sale in pharmacies throughout the world. raised and lowered the air pressure inside to fill
Antibiotics were discovered and the Salk and Sabin and deflate the lungs, forcing the body to simulate
vaccines were found for poliomyelitis. breathing (Figure 3-3). Lying in the iron lung,
The first electrocardiogram machine was
invented in 1903. George Papanicolaou discov-
ered cancer cells in 1928, the same year penicillin
was discovered by Alexander Fleming. Penicillin,
however, required further development, which was
accomplished by Howard Florey and Ernst Chain,
and was finally brought into production in 1945.
C. Walton Lillehei performed the first successful
open-heart surgery in 1952. Dr. Christian Barnard
performed the first human heart transplant in
1967. Advancing technology enabled medicine to
march steadily forward.

The Scourge of Epidemics Figure 3-3 A doctor and nurse with a patient in an
There is a saying, “Two steps forward—one step iron lung during the Rhode Island polio epidemic,
back.” At the same time giant strides are made 1960. (Courtesy of the Centers for Disease Control
in medicine for one disease, the battle rages for and Prevention.)
42 UNIT 1 Introduction to Medical Assisting and Health Professions

individuals were fully dependent on their caregiv- drugs are matched to the specific genetic code of an
ers, relying entirely for their view of the world on individual, can be designed to prevent blood vessel
a mirror suspended above their face and angled growth from surrounding tissue to a solid tumor, or
toward the rest of the room. can prevent cancer cells from multiplying and invad-
President Franklin D. Roosevelt, diagnosed ing other tissues. Recently it was discovered that
with polio in 1921, waged war on the disease. He cancers contain stem cells that produce other can-
funded polio research that eventually led to a vac- cer cells. Research now turns to identifying markers
cine. Roosevelt founded the National Foundation specific to these stem cells and to creating therapies
for Infantile Paralysis, which later became known as that can eliminate the reproducing stem cells.
the March of Dimes. Children throughout the U.S. Even with the many years of research and the
placed dimes in card folders to take to school to millions of dollars spent to cure cancer, nearly
donate to a cure for polio. Dr. Jonas Salk developed 1.5 million new cancers are diagnosed every year
the first polio vaccine in 1952, and Dr. Albert Sabin in the U.S., and more than half a million people
developed an oral polio vaccine in 1961. In 1979 the will die of cancer each year.
last case of polio in the United States was reported.
Scientists knew that children could have lifelong HIV Infection/AIDS. In 1981, a rare cancer outbreak
protection from polio with the polio vaccine given known as Kaposi sarcoma was seen in young gay men
multiple times. in New York and California. In addition, increased
Worldwide, however, polio was still a major cases of a pneumonia called pneumocystitis were
problem. Many agencies, including Rotary Inter- reported among the same demographic group. The
national, the World Health Organization (WHO), CDC later coined the term AIDS (acquired immune
United Nations International Children’s Emergency deficiency syndrome). In 1981, 1,600 cases of AIDS
Fund (UNICEF), and the U.S. Centers for Disease were reported, with close to 700 deaths. As the death
Control and Prevention (CDC), established pro- rate soared in the next few years, researchers sought
grams to vaccinate the world’s children. For 20 years, the cause of and a cure for the disease. In 1984 the
the incidences of polio decreased all around the human immunodeficiency virus (HIV) was discov-
world. The WHO had hoped to announce in 2005 ered to be the cause of AIDS.
that polio had disappeared from the world. Instead, HIV is a virus that slowly destroys the body’s
out of fear and superstition, leaders of a few nations immune system, thus making an individual much
began to counsel against the polio vaccine. They more susceptible to infection and other illnesses.
told mothers the vaccine would make their children There is no cure for AIDS, but with prompt and
infertile and infect them with HIV. Unfortunately, in aggressive treatment, individuals with HIV are liv-
December 2007, there were still 992 cases of polio ing long and productive lives. HIV can be transmit-
diagnosed in the world. ted through bodily fluids during sexual contact; by
sharing contaminated needles to inject drugs; by
Cancer. Cancer was an affliction long before polio accidental sticks or pokes from HIV-contaminated
was first evidenced. The earliest specimen of can- needles; by transfusion of infected blood products
cer was noted in the remains of a skull dated in the (rare since 1992); and from mother to baby during
Bronze Age (1900–1600 b.c.). The writings of Hip- pregnancy, delivery, and breast-feeding (greatly
pocrates describe cancers of many body sites. In the reduced in the last few years).
nineteenth century, the pathology of cancer was Any life-altering, life-threatening disease is
viewed with a microscope, and metastasis was first a challenge, but HIV infection and AIDS come
understood. It was believed that cancer growth was with awareness that some in society will condemn
like planting seeds to be carried through the blood- and shun those infected. Education in the United
stream into another organ that was hospitable. States has done much to calm the nerves and erase
Researchers first believed that cancer resulted some of the fear infected individuals face from
from excess bile collecting in various body sites. those who would condemn.
Some believed cancer was the result of ferment- In 2006, the CDC reported that HIV and
ing and deteriorating lymph fluid. Today, trauma, AIDS had claimed the lives of more than 22 million
chronic irritation, and viral and cellular derivations persons worldwide, including more than 500,000
are considered the primary causes of cancer. persons in the United States. In 2007, more than
Cancer is often removed through surgery. Radi- 1 million persons were living with HIV/AIDS in
ation and/or chemotherapy may also be used to rid the United States, and an estimated 40,000 new
the body of the disease. Today an individual’s DNA HIV infections were expected to occur. Although
structure is considered in treatment. Chemotherapy HIV infection and AIDS cases show decline in the
 CHAPTER 3 History of Medicine 43

U.S., there are still serious challenges to be met. community based. The latter can be found in ath-
A large majority of infected persons are unaware letic locker rooms and in other areas where large
they are infected and are passing the virus on to numbers of individuals congregate. The use of anti-
others. Three quarters of new infections in women biotics completely changed medicine by providing
in the U.S. are heterosexually transmitted. Cultural the ability to cure bacterial-related disease. However,
differences sometimes create difficulty in prevent- bacteria have now evolved to be resistant to those
ing the disease if condoms are frowned upon or antibiotics. This is another example of the earlier
men have multiple heterosexual partners at the statement, “Two steps forward—one step back.” The
same time they are having sex with other men. Of challenge of medicine is as strong today as it was
the 33 million people currently living with HIV/ 100 years ago.
AIDS, 74% live in sub-Saharan Africa. It is esti-
mated that by the year 2010, Ethiopia, Nigeria,
China, India, and Russia will add 50 to 75 million SIGNIFICANT CONTRIBUTIONS
new cases of HIV/AIDS to the statistics. TO MEDICINE
AIDS causes serious and debilitating physical
and mental difficulties. The United Nations esti- Hippocrates (c. 460–c. 377 b.c.) is the physician
mates that by the year 2010, 25 million children most frequently recalled from the Greek culture.
will be orphaned due to the death of both parents It is not known why his name surfaces above all
from AIDS. other Greek physicians, for some were surely just
Early in the twenty-first century, we are still as prominent. His writings, however, have contrib-
quite aware of the limitations of modern medicine. uted much to today’s medical culture. Hippocrates
In developing countries torn with war and strife, is remembered by many for his well-known Hip-
cholera causes the deaths of thousands simply pocratic Oath, which established guidelines for
because there is no proper sanitation. In the micro- a physician’s practice of medicine (Figure 3-4).
bial world, new, drug-resistant strains of malaria, Although few physicians swear to this oath today
tuberculosis, and other diseases are not responding when they embark on their medical career, it
to known treatments. Health professionals in hos- is still recognized for its validity and wisdom.
pitals and health care facilities, especially nursing There are various translations of the Hippocratic
homes and dialysis centers, are very much aware of Oath, but all communicate the same fundamen-
a new type of bacteria known as methicillin-resistant tal message.
staphylococcus aureus (MRSA), which is resistant It would be impossible to identify all the other
to many antibiotics. This infection is especially individuals who made significant contributions to
dangerous to individuals with weakened immune medicine in this text. However, Table 3-1 lists sev-
systems. It can come from medical facilities or be eral notable individuals in the history of medicine.

THE OATH OF HIPPOCRATES

I swear by Apollo Physician and Aesculapius and Hygeia and I will apply dietetic measures for the benefit of the sick according
Panacea and all the gods and goddesses, making them my to my ability and judgment; I will keep them from harm and injustice.
witnesses, that I will fulfill according to my ability and judgment
this oath and this covenant: I will neither give a deadly drug to anybody if asked for it nor
will I make a suggestion to this effect. Similarly, I will not give to a
To hold him who has taught me this art as equal to my par- woman an abortive remedy. In purity and holiness I will guard my
ents and to live my life in partnership with him, and if he is in life and my art.
need of money to give him a share of mine, and to regard his
offspring as equal to my brothers in male lineage and to teach I will not use the knife, not even on sufferers from stone, but will
them this art—if they desire to learn it—without fee and cov- withdraw in favor of such men as are engaged in this work.
enant; to give a share of precepts and oral instruction and all
the other learning to my sons and to the sons of him who has Whatever houses I may visit, I will come for the benefit of the
instructed me and to pupils who have signed the covenant and sick, remaining free of all intentional injustice, of all mischief,
have taken an oath according to the medical law, but to no and in particular of sexual relations with both female and male
one else. persons, be they free or slaves.

Figure 3-4 The Hippocratic Oath.

44 UNIT 1 Introduction to Medical Assisting and Health Professions

Table 3-1 Important Persons And Events In The History Of Medicine

Moses (1205 B.C.) Advocate of health rules in Hebrew religion

1000 B.C. Beginnings of ancient Chinese medicine

Hippocrates (460–377 B.C.) Greek physician; “father of medicine”

Chang Chung-ching (168–196) Chinese physician; called the Hippocrates of China

1368–1644 Chinese medicine reaches its peak

Andreas Vesalius (1514–1564) Brussels physician; wrote first anatomical studies

Anton van Leeuwenhoek (1632–1723) Dutch lens grinder; discovered lens magnification

John Hunter (1728–1793) Founder of scientific surgery

Edward Jenner (1749–1823) Developed smallpox vaccine

Rene Laennec (1781–1826) Invented the stethoscope

Samuel Hahnemann (1755–1843) German physician; established homeopathy

Ignaz Semmelweis (1818–1865) Introduced hand washing to prevent childbed fever

W. T. G. Morton (1819–1868) U.S. physician; introduced ether as anesthetic

Louis Pasteur (1822–1895) “Father of bacteriology”

Florence Nightingale (1820–1910) Founder of modern nursing

Elizabeth Blackwell (1821–1910) First female physician in the United States

Clara Barton (1821–1912) Started the American Red Cross in 1881

Joseph Lister (1827–1912) Laid the groundwork on asepsis

Andrew Taylor (1828–1917) Established the first school of osteopathy in 1892

Daniel David Palmer (1845–1913) Founded chiropractic profession in Iowa in 1895

Elizabeth G. Anderson (1836–1917) First female physician in Great Britain

Frederick G. Banting (1891–1941) Isolated and injected insulin for diabetes treatment in 1922

1903 First electrocardiogram machine invented

Robert Koch (1843–1910) Bacteriologist; developed culture-plate method

Wilhelm Roentgen (1845–1923) Discovered X-rays (roentgenograms)

(continues)
 CHAPTER 3 History of Medicine 45

Table 3-1 (continued)

George Papanicolaou (1883–1962) Discovered cancer cells in 1928

Sir Alexander Fleming (1881–1955) Discovered penicillin in 1928

Albert Schatz (1920–2005) Discovered streptomycin in 1943; cure for tuberculosis

1945 Penicillin brought into production

Paul Zoll (1911–1999) Created the first heart pacemaker in 1952

C. Walton Lillehei (1918–1999) Performed first successful open-heart surgery in 1952

John Gibbon (1903–1973) First heart–lung machine used for surgery (1953)

Joseph Murray (1919–) Performed first person-to-person kidney transplant in 1954

Christian Barnard (1922–2001) Performed first human heart transplant in 1967

Ian Wilmut (1944–) Cloned a Finn Dorset sheep called Dolly in 1996

Three-dimensional structure of DNA discovered

1953
First human heart–lung bypass machine used on human

1950–1960 Vaccines against polio, measles, and rubella developed

1978 First baby born from in vitro fertilization

1982 Hepatitis B vaccine available

1990–2000 Human genome map created by team of scientists

Women’s Health Initiative begins 15-year research on cardiovascular disease,

1991
cancer, and osteoporosis

1995 Varicella (chickenpox) and hepatitis A vaccines available

2005 Combination vaccine for measles-mumps-rubella and varicella (MMRV) available

2006 Vaccine for adult shingles approved

Diabetics using stem-cell therapy stop taking insulin

Minimally invasive procedures performed
• Surgeons at University of California/San Diego Medical Center remove
2007
diseased gallbladder through vagina
• Surgeons at University of Texas Southwestern Medical Center remove
diseased kidney through belly button
46 UNIT 1 Introduction to Medical Assisting and Health Professions

Note that only a few entries are made in the most can perform a whole-body trauma scan in less than
recent years, not because no major medical discov- 10 seconds. People who have worn glasses or con-
eries are occurring, but because so many are occur- tact lenses for many years are turning to laser eye
ing that they cannot all be listed. surgery and implantable lenses.
Surgeons have performed the first successful
human larynx transplant. Consider the implica-
Women in Medicine tions of the AIDS saliva test that creates a needle-
Whereas women were accepted as healers in prim- free way to test for HIV. Needleless injections are
itive societies, later cultures reduced their status now possible. There is a flu prevention inhaler and
to that of being allowed to care only for women an osteoporosis pill.
and to assist in childbirth. In any culture that Since 2000 there has been successful use of
granted women only secondary status, women adult stem cells in the treatment of some diseases.
were also considered unqualified to become phy- Adult bone marrow stem cells are able to produce
sicians. In Chinese culture, the first reference to a multiple tissues, and adult stem cells from various
female physician mentioned by name is in docu- organs of the body have shown amazing abilities
ments from the Han dynasty (206 b.c.–a.d. 220). to develop into healthy tissue. Adult stem cells can
In Muslim society, the reluctance of Arabic physi- be stimulated to form insulin-secreting pancreatic
cians to violate social taboo and touch the genitals cells, to repair eye retinal damage, and to stimulate
of female strangers further encouraged relegat- growth in children with bone disease. There is the
ing the practice of obstetrics and gynecology to possibility that adult stem cells will also be able to
midwives. treat Parkinson’s disease and other degenerating
Women were not accepted as medical physi- neural disorders. In the meantime, the political
cians in Western culture until the nineteenth and debate continues over the use of human embry-
twentieth centuries. Italy granted women the status onic stem cells.
earlier than other cultures. In the United States, the A smooth plastic capsule with a tiny camera
first female physician was Elizabeth Blackwell, who at each end, known as the PillCam ESO, is able
was awarded her degree in 1849. Although she was to take as many as 2,600 pictures of the esopha-
snubbed by the public, she soon earned the respect gus in less that 20 minutes. This marvel makes
of her colleagues. When she refused to be absent it easier to diagnose diseases of the esophagus
from class when the male reproductive system was without sedating a patient as is normally done in
discussed, her fellow male students supported traditional endoscopy. Scientists are developing
her actions. spider silk for extraordinarily fine sutures to be
In 1860 there were nearly 200 female practi- used in nerves and eyes. The combination of the
tioners in the U.S. In 2004, 26.8% of U.S. physi- all-encompassing broadband technology and new
cians were women, and there were ten female cellular infrastructure makes it easier for health
deans in U.S. medical schools. Today women are professionals to stay in touch with patients. Medi-
represented in all areas of medicine; however, the cal Bluetooth makes an easy path for connection
majority work in internal medicine, family prac- of medical devices. For example, remote heart-
tice, pediatrics, obstetrics/gynecology, psychiatry, care diagnostics can be transmitted from a cell
and anesthesiology. phone to providers who can determine if a patient
needs to travel to the clinic for further care. Com-
puter chips are being used to create bionic eyes
FRONTIERS IN MEDICINE for patients with advanced retinal degeneration,
with implanted image sensors taking over the
There has been phenomenal growth in medicine functions of damaged retinal cells.
in the past two decades. Only a few advances are Experimentation with aromatherapy indicates
mentioned here. Much better imaging leading that some aromas actually improve brain function.
to much better diagnosis is now available. Where Research has shown that individuals suffering from
exploratory surgery might have been performed dementia often respond favorably to the odor of
in the past to determine a diagnosis, noninvasive freshly roasted coffee and bread baking. Inhaling
ultrasound, CT scans, and MRIs assist in diagno- the scents of green apple, banana, and peppermint
sis now. A 64-slice cardiac CT scan developed in stimulates positive feelings. It is thought that with
2004 can capture images of a human heart in just aromatherapy we will soon accelerate learning and
five heartbeats. In a technique known as volume speed up rehabilitation for people who have had a
computed tomography (VCT), the VCT system stroke.
 CHAPTER 3 History of Medicine 47

The British Journal of Psychiatry recently re-

ported that music therapy can be of value in indi- Case Study 3-1
viduals with schizophrenic illnesses. There also is
evidence that music therapy can help to: Refer to the scenario at the beginning of the chapter and
recall two or three medical treatments or practices used in
• Relieve treatment-related distress in individuals your family and culture.
with cancer
• Calm individuals undergoing cardiac catheteriza- CASE STUDY REVIEW
tion procedures
1. Were these medical treatments helpful? If so, how?
• Provide pain relief
2. Is any part of these treatments still used today? If
• Decrease apathy in people with dementia
so, describe.
3. Discuss this case study with a friend or classmate.
The American Music Therapy Association
notes that extensive use of specifically chosen
music during massage, acupuncture, yoga, and t’ai
chi ch’uan enhances each type of practice. Some
surgeons report better concentration and more
relaxed patients when certain music is played dur-
ing surgery.
Who can possibly predict what the future will
bring in medicine?
Case Study 3-3
Your employer, Dr. Anne Shea, an internist in Southern
Case Study 3-2 California, is considering renting office space to an acu-
puncturist and a naturopath because many of her patients
You are a male practitioner on call in your hospital’s emer- often seek treatment from both. Dr. Shea believes her prac-
gency department when a woman, 5 months pregnant, is tice can be integrated, therefore allowing patients one-stop
brought in. She is hemorrhaging. Her husband shuns you treatment for their illnesses. As the CMA (AAMA) and office
and requests a female practitioner. You quickly realize this manager, you are asked to participate in a meeting of all
couple is Muslim. Role-play this scenario with a classmate. three practitioners to discuss guidelines for the clinic.

CASE STUDY REVIEW CASE STUDY REVIEW

1. How can you solve the dilemma? 1. What questions will you ask the group?
2. Consider the possibility that your only female 2. What will be necessary to get the word out to
practitioner is out of the country on vacation. patients?

SUMMARY
Medicine’s history leaves us with a rich heritage and a sound basis for the future of health care. Medical
history continues to be in the making today. For example, research in gene manipulation has the poten-
tial benefit of being able to reverse the progression of many debilitating diseases. One day we will look on
medical discoveries of this decade and be impressed by how much further medicine has advanced.
48 UNIT 1 Introduction to Medical Assisting and Health Professions

STUDY FOR SUCCESS

To reinforce your knowledge and skills of information presented in this chapter:
• Review the Key Terms
• Consider the Case Studies and discuss your conclusions
• Answer the Review Questions

˚ Multiple Choice
˚ Critical Thinking
• Navigate the Internet and complete the Web Activities
• Practice the StudyWARE activities on the textbook CD
• Apply your knowledge in the Student Workbook activities
• Complete the Web Tutor sections

REVIEW QUESTIONS
Multiple Choice 7. Medicine was greatly influenced by:
a. Greek and Chinese physicians
1. A pharmacopoeia is: b. Culture and science
a. a book describing drugs and their preparation c. Religion and magic
b. an ancient religious rite used in medicine d. b and c
c. a source of magic 8. Paralytic poliomyelitis
d. used only by twentieth-century physicians a. was first evidenced during the summer of 1890
2. At one time, women were typically allowed to use b. is cured by childhood vaccinations
their health care skills to: c. caused great fear in the U.S. during the 1970s
a. cure everyone in society d. has been eradicated from the world
b. care only for women and to assist in childbirth 9. Cancer
c. become physicians a. metastasis was first understood in the nineteenth
d. care only for older adults century
3. An accurate sketch of the spinal vertebrae was b. is only treated with chemotherapy
created during the Renaissance by: c. deaths will total 1.5 million in 2007
a. Leonardo da Vinci d. is the result of an inherited tendency
b. Michelangelo 10. HIV/AIDS:
c. early Christian monks a. was first known in the Bronze Age
d. Louis Pasteur b. is decreasing in the U.S. but rages on in other
4. Hippocrates is a Greek physician often called: parts of the world
a. the founder of scientific surgery c. only infects gay men
b. the inventor of the smallpox vaccine d. is caused by a bacteriaum transmitted through
c. the father of medicine bodily fluids
d. the father of preventive medicine
5. The first woman physician in the United States was:
a. Florence Nightingale
Critical Thinking
b. Clara Barton 1. With a group of peers, identify the effects of culture
c. Elizabeth Anderson on today’s medicine.
d. Elizabeth Blackwell 2. How does the role of a medical specialist today
6. The physician who introduced hand washing to compare to the role of a medical specialist in the
prevent childbed fever was: past? Consider both similarities and dissimilarities.
a. Joseph Lister 3. You are the medical assistant. Your practitioner–
b. John Hunter employer has just prescribed opiates for a young
c. Ignaz Semmelweis Asian woman suffering from migraine headaches.
d. Edward Jenner You overhear the young woman arguing with her
 CHAPTER 3 History of Medicine 49

mother, who thinks that she should take non- in medicine. The section on the greatest obstacles
addictive Chinese herbs. What, if anything, faced by these women is particularly interesting.
would you do? Who inspires you the most? Explain.
4. Discuss with a peer the role of women in medicine 4. Access the Internet to compare/contrast medical
today. What difficulties, if any, might a female prac- schools and universities in the United States with
titioner face today? Compare today’s difficulties medical universities in China. What major differ-
with those of female health care practitioners ences do you note? Are there any similarities?
100 years ago.
5. Using the example of aromatherapy in Frontiers in
Medicine, identify any new frontiers using integra-
REFERENCES/BIBLIOGRAPHY
tive medicine that you know about or have seen American Cancer Society. (2007). Surveillance research.
used in patient treatment. Retrieved May 23, 2007, from http://www.rare-
cancer.org/.
American Medical Association. (2004). Women in
WEB ACTIVITIES medicine. Retrieved May 20, 2007, from http://
The Internet is an ideal place to seek evidence www.ama-assn.org/go/wpc.
of new and emerging technologies in medicine. Centers for Disease Control and Prevention (CDC).
One such avenue is “Medical Breakthroughs” (2006). Twenty-five years of HIV/AIDS—United
States, 1981–2006. MMWR Weekly. Retrieved
reported by Ivanhoe Broadcast News, Inc. Identify at
April 24, 2007, from http://www.cdc.gov/mmwr/
least two or three recent discoveries you find particu-
preview/.
larly interesting from your research on the Internet.
D’Adesky, A. (2003). Cuba fights AIDS its own way. The
1. Do an Internet search using the keywords “penicil- Gully Online Magazine. Retrieved May 17, 2007, from
lin discovered” to find some interesting sites. Deter- http://www.thegully.com/.
mine the reasons it took so long to put penicillin David, M. (2006). Engineers work medical miracles
into production. What kind of hurdles do new every day. Electronic design. Retrieved May 18, 2007,
medications face today before they are available on from http://www.elecdesign.com/Articles.
the market to consumers and patients? Fenster, J. M. (2003). Mavericks, miracles, and medicine.
2. Search the Internet for “Women in Medicine: An New York: Carroll & Graf Publishers.
AMA Timeline 1800s.” This publication compiled Lewis, M. A., & Tamparo, C. D. (2007). Medical law,
by the American Medical Association provides valu- ethics, and bioethics for health professions (6th ed.).
able and interesting information about women in Philadelphia: F. A. Davis.
medicine. What surprises you the most? Are female Lyons, A. S., & Petrucelli II, J. R. (1978). Medicine: An
applicants to medical school increasing or decreas- illustrated history. New York: Harry N. Abrams.
ing? By what percent? McNeil, D. G. (2007). U.N. to say it overstated H.I.V.
3. The U.S. National Library of Medicine and the cases by millions. The New York Times. Retrieved
National Institutes of Health have a Web site with a January 11, 2008, from http://www.nytimes.
section on “Changing the Face of Medicine.” This com/2007/11/20/world/20aids.html/.
site enables the reader to discover how women have Sanofi Pasteur, SA. (2006). Polio: The disease. Polio eradi-
influenced the practice of medicine and to deter- cation. Retrieved May 17, 2007, from http://www.
mine if the exhibition will be in your geographical polio.info/polio-eradication/.
region any time soon. Go to the Web site http:// Until There’s A Cure. (2006). Vital statistics. Retrieved
www.nlm.nih.gov/changingthefaceofmedicine/ to May 17, 2007, from http://www.until.org/statistics/
view pictures and historical information on women shtm.
UN IT
The Therapeutic
2 Approach

Chapter 4
Therapeutic Communication Skills
Chapter 5
Coping Skills for the Medical Assistant
Chapter 6
The Therapeutic Approach to the Patient with
a Life-Threatening Illness
 Chapter
Therapeutic
Communication Skills 4
KEY TERMS OUTLINE
Active Listening Importance of Communication Bias and Prejudice Barriers
Bias The Communication Cycle Verbal Roadblocks to Thera-
Body Language The Sender peutic Communication
Closed Questions The Message Defense Mechanisms as
The Receiver Barriers
Clustering
Feedback Barriers Caused by Cultural
Compensation and Religious Diversity
Listening Skills
Congruency Human Needs as Barriers to
Types of Communication
Cultural Brokering Therapeutic Communication
Verbal Communication
Culture Maslow’s Hierarchy of Needs
Nonverbal Communication
Decode Establishing Multicultural
Congruency in
Defense Mechanism Communication
Communication
Factors Affecting Therapeutic Cultural Brokering
Denial
Communication Therapeutic Communication in
Displacement
Action
Encoding Age and Gender Barriers
Economic Barriers Interview Techniques
Hierarchy of Needs Point of Care Techniques
Education and Life Experience
High-Context Community Resources
Communication Barriers
Indirect Statements
Interview Techniques OBJECTIVES
Kinesics
The student should strive to meet the following performance objectives and
Low-Context demonstrate an understanding of the facts and principles presented in this
Communication
chapter through written and oral communication.
Masking
Open-Ended Questions 1. Define the key terms as presented in the glossary.
Perception 2. Identify the importance of communication.
Prejudice 3. List and define the four basic elements of the communication
Projection cycle.
Rationalization 4. Identify the four modes or channels of communication most
Regression pertinent in our everyday exchange.
Repression 5. Discuss the importance of active listening in therapeutic
communication.
Roadblocks
Sublimation 6. Differentiate between the terms verbal and nonverbal
communication.
Therapeutic
Communication 7. Analyze the five Cs of communication and describe their effec-
Time Focus tiveness in the communication cycle.
Undoing

51
OBJECTIVES (continued)
8. Demonstrate the following body language or nonverbal commu-
nication behaviors: facial expressions, personal space, position,
posture, gestures/mannerisms, and touch.
9. Identify and explain congruency in communication.
10. Differentiate between low-context and high-context communi-
cation styles.
11. Discuss Table 4-2 and generalizations of cultural/religious effects
on health care.
12. Discuss the use of Maslow’s hierarchy of needs in therapeutic
communication.
13. Recall at least four influences on therapeutic communication
related to culture and describe four common biases/prejudices
in today’s society.
14. Recall at least three steps to building trust with culturally diverse
patients.
15. Discuss cultural brokering and its use in medical facilities.
16. Recall eight significant roadblocks to therapeutic communication.
17. List and describe seven common defense mechanisms.
18. Compare/contrast closed questions, open-ended questions, and
indirect statements.

Scenario
In the two-provider office of Drs. Lewis and King, four depressed and anxious. Marilyn tries to create an
medical assistants constantly interact with patients, environment where they feel free to share their con-
allaying their concerns, scheduling their appointments, cerns and anxieties.
instructing them on medications, and helping them Marilyn demonstrates therapeutic communica-
understand their insurance coverage. On any given tion by acknowledging each patient as they arrive for
day, office manager Marilyn Johnson, CMA (AAMA), is appointments and puts them at ease by providing
greeting patients warmly as they arrive for their instructions. Medical assistants who project a warm,
appointments. Some patients, such as Anna and courteous presence while maintaining composure,
Joseph Ortiz, are new to the practice. Marilyn’s warm even during difficult situations, and who ask the right
manner puts them at ease. Other patients, such as questions in a nonthreatening manner will achieve
Martin Gordon, who has prostate cancer, may be therapeutic communication.

INTRODUCTION
Of all the tasks and skills required of the medical assis- Everyday, Marilyn, Ellen, and the two clinical med-
tant in the ambulatory care setting, none is quite so ical assistants at the offices of Drs. Lewis and King face
important as communication. Communication is the many communication challenges. This chapter describes
foundation for every action taken by health care pro- effective communication principles, applies those prin-
fessionals in the care of their patients. Because medical ciples to face-to-face communication, and describes the
assistants are often the liaison between patient and pro- basic roadblocks to communication. The key word to all
vider, it is critical to be aware of all the complexities of the communication in the medical setting is therapeutic. In
communication process. all conversations with patients, the more therapeutic the

52
 CHAPTER 4 Therapeutic Communication Skills 53

conversation, the more satisfied the patient will be with them. Questions frequently asked by individuals
the care provided. seeking a new provider and clinic include: “Will
the doctor talk with me so that I understand?”
“Will the doctor listen to what I have to say?” and
IMPORTANCE “Can I talk to the doctor honestly and openly?”
OF COMMUNICATION The answer to all of these questions needs to
be “yes.” This chapter discusses these issues
Therapeutic communication differs from normal and presents specific techniques for therapeutic
communication in that it introduces an element of communication.
empathy into what can be a traumatic experience
for the patient. It imparts a feeling of comfort in
the face of even the most horrific news about the THE COMMUNICATION CYCLE
patient’s prognosis. The patient is made to feel vali-
dated and respected. Therapeutic communication All communication, whether social or therapeutic,
uses specific and well-defined professional skills. involves two or more individuals participating in
Communication in the health care setting an exchange of information. The communication
is the foundation of all patient care and is of the cycle involves sending and receiving messages even
utmost importance. Communication must be in when not consciously aware of them.
nontechnical language the patient can under- Four basic elements are included in the com-
stand, delivered with feeling for the patient’s emo- munication cycle. They are (1) the sender, (2) the
tional situation and state of mind, yet it still must message and a channel or mode of communication,
be technically accurate. The medical staff must be (3) the receiver, and (4) feedback (Figure 4-1).
alert to the patient’s state of stress and whether
defense mechanisms have taken over to the extent
that the patient has “tuned out” and is no longer
The Sender
communicating with the staff. The sender begins the communication cycle by
Patients seeking an ambulatory care service encoding or creating the message to be sent. This is
look for medical professionals with technical skills an important step, and much care should be taken
and a clinical staff capable of communicating with in formulating the message. Before creating the
message, the sender must observe the receiver to
determine the complexity of the words to be used
within the message, the receiver’s ability to inter-
Spotlight on Certification pret the message, and the best channel by which to
send the message.
RMA Content Outline
Sender
• Patient relations Encodes
• Other interpersonal relations message

CMA (AAMA) Content Outline

• Basic principles (psychology)
• Defense mechanisms
• Recognizing and responding to verbal Message
and nonverbal communication Speaking
Feedback Listening
• Professional communication and Gesturing
behavior Writing
• Evaluating and understanding
communication
• Interviewing techniques
• Identifying community resources
CMAS Content Outline Receiver
Decodes message
• Professionalism
• Communication Figure 4-1 The communication cycle and channels
of communication.
54 UNIT 2 The Therapeutic Approach

ing the message, the receiver must be aware that

The Message not only the spoken word but the tone and pitch
The message is the content being communicated. of the voice and the speed at which the words are
The message must be understood clearly by the spoken carry meaning and must be evaluated.
receiver. Various levels of complexity in commu-
nication are used depending on the ability of the
receiver to recognize and understand the words
Feedback
contained within the message. Children do not Feedback takes place after the receiver has
have the vocabulary base or the cognitive skills to decoded the message sent by the sender. Feedback
communicate and understand at the same level as is the receiver’s way of ensuring that the message
adults. The health of the receiver also must be con- that is understood is the same as the message that
sidered. A patient who is experiencing stress or is was sent. Feedback also provides an opportunity
in pain may find it difficult to concentrate on the for the receiver to clarify any misunderstanding
message. If the patient is of a different nationality or regarding the original message and to ask for addi-
culture from the sender, verbal communication may tional information.
require special skill. When visual or hearing acuity is
impaired, another challenge must be surmounted.
The four modes of communication, also called
Listening Skills
channels of communication, most pertinent in A vital part of feedback in the communication
our everyday exchange are (1) speaking, (2) listen- cycle is listening. A good listener is alert to all
ing, (3) gestures or body language, and (4) writing. aspects of the communication cycle—the verbal
These modes or channels are affected by our physical and nonverbal message, as well as verification of
and mental development, our culture, our educa- the message through appropriate feedback.
tion and life experiences, our impressions from mod- Active listening is one method used in
els and mentors, and in general by how we feel and therapeutic communication. In this technique,
accept ourselves as individuals. Each mode or chan- the received message is sent back to the sender,
nel of communication has its appropriateness and worded a little differently, for verification from
must be considered when formulating the message. the sender.

Sender: “How can I possibly pay this fee

The Receiver when I have no insurance?”
The receiver is the recipient of the sender’s mes- Receiver: “You’re worried about paying
sage. The receiver must decode, or interpret, the your bill?”
meaning of the message. The primary sensory skill
used in verbal communication is listening. It is The preceding example illustrates how the
hard work to concentrate and listen. When decod- receiver is able to validate the sender’s concerns at
the same time the message is checked for accu-
racy. The door is then left open for a therapeutic
HIPAA response, such as:

The idea of minimum necessary ac- Sender: “Our bookkeeper will be glad
HIPAA cess to protected health information to work out a payment plan with
you that will fit your resources.”
(PHI) is important to job performance.
HIPAA requires that a reasonable effort be
made to limit access to PHI to only what is Active listening involves listening with a “third
necessary to accomplish the intended pur- ear,” that is, being aware of what the patient is not
poses of the use, disclosure, or request. The saying or picking up on hints to the real message
information accessed must fit the needs of the by observing body language. The health care pro-
job description and nothing more. Employees fessional should have three listening goals:
must be careful to not discuss PHI with those • To improve listening skills sufficiently so that
outside the scope of their work. For example, patients are heard accurately
a Certified Medical Administrative Specialist
• To listen either for what is not being said or for
(CMAS) scheduling appointments does not
information transmitted only by hints
need to know the diagnosis after the patient
has been seen by the provider. • To determine how accurately the message has been
received
 CHAPTER 4 Therapeutic Communication Skills 55

So many health professionals try to “fix” every- be able to articulate by using good diction and by
thing with a recommendation, a prescription, even enunciating each word distinctly. The patient must
advice. Sometimes, none of those things is neces- be allowed time to process the message and verify
sary. The patient simply needs someone to listen, its meaning. The message must also be heard to
to acknowledge the difficulty, and to remember promote understanding.
that the patient is not helpless in finding a solution
to the problem. Concise. A concise message is one that does not
Skill in communication takes years of practice include any unnecessary information. It should be
and frequent review. It will never become perfect; brief and to the point (Figure 4-2). Patients must
we can only hope that we will become better at it not be overloaded with technical terms that may
with each passing day. Communication is and not be understood or that tend to distract them by
always will be the basis for any therapeutic relation- diverting their attention away from the balance of
ship (Tamparo & Lindh, 2008). the message.

Cohesive. A cohesive message is organized and

TYPES OF COMMUNICATION logical in its progression. The cohesive message
does not ramble and does not jump from one
We communicate by what we say, and also by subject to another. The patient should be able to
our tone of voice, body movements, and facial follow the message easily. The medical assistant
expressions. The following paragraphs present should always allow time to summarize detailed
the aspects of verbal and nonverbal communica- messages and use responding skills to verify that
tion. The importance of maintaining consistency the patient fully understands the message.
between verbal and nonverbal messages also is When communicating within the health pro-
stressed. fessions, keep in mind the following:
1. Good communication skills are necessary in
Verbal Communication establishing rapport with patients.
Verbal communication takes place when the
message is spoken. However, one must keep in
mind that unless the words have meaning, and
unless the sender and the receiver apply the same
meaning to the spoken words, verbal communi-
cation may be misunderstood. If, for example,
you overhear a conversation in a language foreign
to you, you are indeed a witness to verbal com-
munication, but you may not understand the
message. To have any meaning, the spoken word
must be understood by all parties of the commu-
nication (Tamparo & Lindh, 2008).

The Five Cs of Communication. The book

Legal Nurse Consulting Principles and Practice,
edited by Patricia W. Iyer, identifies the five
Cs of communication. They are (1) complete,
(2) clear, (3) concise, (4) cohesive, and (5) cour-
teous. These five Cs apply equally well in other
health care professions.

Complete. The message must be complete,

with all the necessary information given. The
medical assistant cannot expect the patient to be
compliant if all the instructions are not given and Figure 4-2 To say to the patient after greeting her by
understood. name, “I’ve completed an appointment card to remind
you of your next appointment, Tuesday at 2:00 pm,”
Clear. The information given in the message is an example of a concise message that is brief and to
must also be clear. Health care professionals must the point.
56 UNIT 2 The Therapeutic Approach

2. Patients feel respected and validated when

called by their full name, such as Mary
O’Keefe or Mrs. O’Keefe.
3. Patients should be encouraged to verbalize
their feelings and concerns.
4. Patients should be given technical informa-
tion in a manner that they can understand.
5. Patients should be allowed to make practical
application to their personal health needs.

Courteous. Courtesy is important in all

aspects of communication. It only takes a
moment to acknowledge a patient with a
smile or by name. Knocking on the examination Figure 4-3 Body language can communicate more
room door before entering validates the patient’s than spoken words.
right to privacy and builds self-esteem.
Remember to be courteous to colleagues expresses its true repressed feelings using body lan-
in the office. Good working relationships and guage. Most of the negative messages we communi-
professionalism are always enhanced by simple cate are also expressed nonverbally and usually are
courtesy. unintentional. Experts tell us that 70% of commu-
nication is nonverbal. The tone of voice communi-
cates 23% of the message—only 7% of the message
Nonverbal Communication is actually communicated by the spoken word.
Verbal communication alone is not always ade-
quate in conveying the message being sent. In most Facial Expression. Facial expression is considered
instances, more than one mode or channel of com- one of the most important and observed nonver-
munication is used. Nonverbal communication, bal communicators. Each facet or aspect of the
often referred to as body language, includes the anatomy of the face sends a nonverbal message.
unconscious body movements, gestures, and facial Often expressions of joy and happiness
expressions that accompany speech. The study of or sorrow and grief are reflected through the
body language is known as kinesics (Figure 4-3). eyes. The anatomy of the eyes does not change,
Nonverbal communication is the language but the movements of the structures surrounding
we learn first. It is learned seemingly automatically the eyes enhance or magnify the message being
when infants learn to return a smile or respond to communicated.
touches on the cheek. Much of our body language Children are told it is not polite to stare at
is a learned behavior and is greatly influenced by people. It is acceptable to stare at animals in
the primary caregivers and the culture in which we the zoo or art objects in the museum, but not at
are raised. humans. Staring is dehumanizing and is often
Feelings and emotions are communicated interpreted as an invasion of privacy.
most often through nonverbal means. The body The medical assistant must learn not to stare
when patients present with ailments that make
them “look” different. Patients such as these are
individuals who have needs, who perhaps feel
Patient Education pain and discomfort, and who have decreased
self-esteem and value. These feelings will only be
Sensitive medical assistants will encourage amplified if the medical assistant and other health
patients to verbalize their concerns. The professionals are unable to “see” them as humans.
ability to ask questions in a nonprobing way A lack of eye contact may also be viewed as avoid-
and to elicit patient responses is an impor- ance or disinterest in being involved.
tant function in any ambulatory care setting, The movements of the eyebrow indicate many
because it is critical to know a patient’s nonverbal cues as well. Surprise, puzzlement, worry,
history, current medications, and other amusement, and questioning are often nonverbal
relevant data. messages reflected by the position of the eyebrow.
Wrinkling of the forehead sends similar messages.
 CHAPTER 4 Therapeutic Communication Skills 57

Cultural influences affect customs and handshake as an act of aggression or an offensive

different forms of facial expressions. It behavior. Each culture has its own distinct nonver-
is important to remember that there are bal communication cues.
many cross-cultural similarities in body language, The medical assistant may perform many
but there are also many differences. Various cul- invasive tasks during the course of an office visit.
tures denote different meanings to various ges- Examples include taking vital signs or giving injec-
tures. If your patient is from another culture, tions, both of which require touching the patient.
never assume that gestures used hold the same It is beneficial to explain procedures that invade
meaning for the patient as they do for you. For another’s space before beginning the procedure
example, some cultures believe that prolonged so that it will not be perceived as threatening. This
eye contact is rude and an invasion of privacy, helps to empower the patient by involving the
whereas others consider it a sign of intimacy. patient in the decision-making process and builds
Some people stare at the floor when concentrat- a sense of trust in the medical assistant.
ing or thinking through a process. Other cultures
avoid eye contact to display modesty, whereas oth- Posture. Like personal space, posture is impor-
ers feel eye contact expresses hostility or aggres- tant to health care professionals. Posture relates
sion. It is important to understand the cultures to the position of the body or parts of the body.
of the patients treated in the facility in which you It is the manner in which we carry ourselves,
are employed. or pose in situations. We tend to tighten up in
threatening or unknown situations and to relax
Personal Space. Personal space is the distance in nonthreatening environments. Those who
at which we feel comfortable with others while study kinesics believe that a posture involves at
communicating. In the classroom, for example, least half the body, and that the position can last
students claim their personal space the first day for nearly five minutes.
of class. The area is well defined by using books When the patient is seated with the arms and
and papers, or by placing the arm, hand, or chair legs crossed, the message of closure or being opin-
on boundary lines. When another invades the ionated may be relayed. In contrast, sitting in a chair
personal space, a shift in body position or the relaxed with the hands clasped behind the head
use of eye contact sends the message, “This is my indicates an attitude of being open to suggestions.
area.” Individuals may feel threatened when oth- Slumped shoulders may signal depression, discour-
ers invade their personal space without permis- agement, or, in some cases, even pain.
sion. Some examples of comfortable personal
space for U.S. culture are as follows: Position. Position, the physical stance of two indi-
viduals while communicating, is a key factor to
• Intimate: touching to 11⁄2 feet consider while communicating with the patient.
• Personal: 11⁄2 to 4 feet Most provider–patient relationships use the face-
• Social: 4 to 12 feet (most often observed) to-face communication arrangement. When speak-
ing with a patient, the provider or medical assistant
• Public: 12 to 15 feet
will want to maintain a close but comfortable posi-
As with facial expressions, personal space is tion, enabling observation of all cues being sent,
handled differently by various cultures. For example, both verbal and nonverbal (Figure 4-4).
there is no word for privacy in the Japanese language. Standing over a patient can convey a message
Population numbers require crowding together of superiority, and too much distance between the
publicly, as well as privately. Public crowding is often two parties may be interpreted as avoidance or
viewed as a sign of warmth and pleasant intimacy in exclusivity. Generally, leaning toward the patient
Japan. In the private home, several generations may expresses warmth, caring, interest, acceptance,
live together; however, each considers this space to and trust. Moving away from the patient may be
be his own and resents intrusion into it. interpreted as dislike, disinterest, boredom, indif-
Arabs like to touch their companions, to ference, suspicion, or impatience.
feel and to smell them. To deny a friend Whenever possible, it is best to have a chair
your breath is to be ashamed. When two in the examination room and to have the patient
Arabs talk to each other, they look each other in seated comfortably in the chair to begin the com-
the eyes with great intensity. U.S. businessmen munication cycle. The medical assistant or provider
often end a business arrangement with a hand- can sit on a stool that can be moved easily toward
shake; however, American Indians may view a the patient. This arrangement aids the patient in
58 UNIT 2 The Therapeutic Approach

Asian clients may fear bodily intrusion; therefore,

physical examination and treatment procedures
should be explained carefully and completely
before they are performed. The touch that com-
municates caring, sincerity, understanding, and
reassurance is usually welcomed and considered
to be a therapeutic response. Most patients will
understand and accept the touching behavior as
it relates to the medical setting; however, we must
remember that not all patients are comfortable
with touch. Whenever the patient is not comfort-
able with touch, ask permission and create as safe
and reassuring an environment as possible.
Figure 4-4 Positive posture and position encourage
therapeutic communication. Congruency in Communication
Using some keys to successful communication
promotes effective communication. There must
feeling valued, listened to, and cared for as a fellow be congruency between the verbal and nonverbal
human being. communication. Shaking your head NO while say-
ing YES verbally sends a mixed message. In most
Gestures and Mannerisms. Most of us use ges- cases, the nonverbal messages will be accepted as
tures and mannerisms when we “talk” with our the intended message.
hands. This form of body language may be useful It is also important to remember that most
in enhancing the spoken word by emphasizing nonverbal messages are sent in groups of various
ideas, thus creating and holding the attention of forms of body language. The grouping of non-
others. Some common gestures and their possible verbal messages into statements or conclusions is
meanings are as follows: known as clustering. Masking involves an attempt
Finger-tapping Impatience, nervousness to conceal or repress the true feeling or message.
The perceptive professional will be aware of all
Shrugged shoulders Indifference, these messages.
discouragement Perception as it relates to communication
is the conscious awareness of one’s own feelings
Rubbing the nose Puzzlement
and the feelings of others. To be most useful and
Whitened knuckles Anger therapeutic as health professionals, we must first
and clenched fists explore our own feelings and appreciate and
accept ourselves.
Fidgeting Nervousness Learning to use perception involves the ability
to sense another’s attitudes, moods, and feelings. It
Touch. Touch is a powerful tool that communicates takes practice and experience to develop and use this
what cannot be expressed in words. Its appropriate- skill effectively. Being attentive to other profession-
ness in the patient–health professional relationship als and observing their use of perception will yield
has well-defined boundaries and requires the use insight into its usefulness and provide an example to
of good judgment on the part of the professional. emulate. A word of caution—the use of perception
Infants who are not touched, cuddled, and loved may easily be misinterpreted, especially when going
do not grow and develop as those who receive with your feeling or assessment of what is happen-
these reassuring gestures. Touch is personal and ing regarding the patient. Always follow perceived
is linked closely to personal space. Understanding assessments with verbal validation before assuming
touch as it relates to various cultures must be con- your perception of the circumstance is correct.
sidered. For example, Vietnamese, Cambodian, Nonverbal communication is easily misin-
Hmong, or Thai families traditionally terpreted. Careful observation for congruency
consider the head to be the site of the between verbal and nonverbal communication,
soul. During conversation and patient and clustering nonverbal cues being sent into non-
assessment, avoid touching the patient’s head verbal statements will strengthen your ability to
unless it is necessary for the examination. Southeast interpret the message accurately.
 CHAPTER 4 Therapeutic Communication Skills 59

FACTORS AFFECTING
Critical Thinking
THERAPEUTIC
COMMUNICATION Define in your own words the terms bias and
prejudice. Now identify one bias and one
Anything that interferes with the patient’s abil- prejudice that you have. How will these
ity to focus has a negative impact on therapeutic impact your ability to respond therapeutically
communication. The following paragraphs discuss in the medical setting? What steps can you
significant barriers. The medical assistant must take to become more accepting of the
recognize that until these barriers are dealt with uniqueness of others, thereby improving
or minimized, therapeutic communication will be therapeutic communication?
significantly affected.

Age and Gender Barriers their biases or prejudices, hostile attitudes may
Age and gender are factors with a strong influence prevail.
on communication. How and when do you com- For therapeutic communication to take place,
municate with a young child? What do you com- biases must be examined, a person’s comfort level
municate to that child? How do you impress upon with each bias determined, and measures taken to
an older gentleman who has taken few medications ensure that a hostile attitude is not present. Bias is
throughout his lifetime that he now must take his defined as a slant toward a particular belief. Prej-
pill everyday? In a culture where the husband is the udice is defined as an opinion or judgment that
authority, how does the provider discuss with the is formed before all the facts are known; preju-
female patient the inadvisability of another preg- dice is a preconceived and unfavorable concept.
nancy at this time? Common biases and prejudices in today’s society
include:
Economic Barriers 1. A preference for Western style medicine
The influence of economics may reveal a discom- 2. Choosing providers according to gender
fort if the office staff and patients have a different 3. Prejudice related to a person’s sexual pref-
perception about how billing is managed and when erence
and how payment is expected. A discussion of bill-
4. Discrimination based on race or religion
ing and payment procedures at the first office visit
or before a major procedure will be beneficial to 5. Hostile attitudes toward people with different
all concerned parties. value systems than one’s own
6. A belief that people who cannot afford health
Education and Life Experience care should receive less care than someone
who can pay for full services
Barriers
Educational and life experiences will, in part, Medical assistants must recognize such
determine how patients react to their care. Patients biases and prejudices so that their own cul-
with family members being treated for a chronic ture with its biases does not prevent them
illness will have more knowledge and understand- from responding therapeutically in communica-
ing of that illness in their own lives. Individuals tions with patients. Such recognition requires being
who have already suffered a great deal of loss and aware of the differences among human beings and
grief in their lives may handle the information of a willingly accepting the uniqueness of each person.
life-threatening illness more calmly than someone
who has experienced little grief. Verbal Roadblocks to Therapeutic
Communication
Bias and Prejudice Barriers Being sensitive to patients’ unique personalities
Personal preferences, biases, and prejudices and needs will enable the health care professional
will enter into many provider–patient relation- to avoid roadblocks to communication (Table 4-1).
ships. Such biases affect the types of communica- It must be the concern of each health
tion possible. When individuals are not aware of care professional to facilitate communication by
60 UNIT 2 The Therapeutic Approach

Table 4-1 Roadblocks to Communication

Roadblock Example

Reassuring clichés “Don’t worry about not having a job, Mr. McKay; you’ll find another one really soon.”

“If you were smart, Mrs. Johnson, you’d lose fifty pounds and you wouldn’t have such a
Moralizing/lecturing
problem with your diabetes and hypertension.”

“Why would you not want to have chemotherapy, Mr. Gordon? Seeing your wife die of
Requiring explanations
cancer should surely make you want to seek treatment.”

Ridiculing/shaming “Ha, ha, Mr. Gordon! It’s not prostrate—it’s prostate cancer.”

“Mr. Marshal, I assure you the physician is very busy. He will not see you until he has finished
Defending/contradicting
with his other patients.”

“Yes, Mrs. Jover, your work is very interesting, but I must ask you to sign this permission form to
Shifting subjects
test for HIV.”

Criticizing “Mrs. O’Keefe, why in the world would you stay with an abusive husband?”

Threatening “There is no way you will get rid of this cough if you do not stop smoking, Mr. Fowler.”

encouraging and enabling patients to express or her to address it without unacceptable emo-
themselves honestly without fear. Roadblocks tional pain. Excessive use of defense mechanisms
close communication and prevent quality care of or failure to address a problem even after sufficient
the total person. time has elapsed may be a sign of mental health
issues.
Defense Mechanisms Defense mechanisms are usually readily
apparent to the disaffected observer; however, they
as Barriers are difficult to analyze without knowledge of the
Therapeutic communication becomes difficult if a motive behind the behavior. The following para-
patient is in a highly emotional state. A patient who graphs describe some commonly observed defense
is frightened, ashamed, guilty, or threatened often mechanisms.
will resort to defense mechanisms as a means of Regression is an attempt to withdraw from
avoiding injury to the ego. We all use defense mech- an unpleasant circumstance by retreating to an
anisms to some limited extent, but they become earlier, more secure stage of life. It is usually used
harmful when they result in a breakdown in thera- when the person feels powerless to affect the
peutic communication. Failure by the patient to events causing the pain; it can be thought of as a
face problems often results in inability to provide desperation move. A toddler’s regression to bed-
satisfactory treatment on the part of the medical wetting or soiling himself or herself shortly after
practitioner. Recognizing common defense mecha- a new baby arrives in the family is an example of
nisms enables the medical staff to minimize the trig- this defense mechanism. Use of a security blan-
gering event and to communicate more effectively. ket by an adult or child when faced with some-
Defense mechanisms are defined as behavior thing that disrupts his or her life is another
that is used to protect the ego from guilt, anxiety, example.
or loss of esteem. Use of defense mechanisms is Denial is refusal to accept painful informa-
most often subconscious to the person using them. tion that is readily apparent to others. This defense
It is the body’s way of seeking relief from uncom- mechanism commonly is encountered in the case
fortable or painful reality. A mentally healthy per- of a person being diagnosed with a disease such as
son uses defense mechanisms to put a problem on cancer or experiencing the death of a close family
hold until sufficient time has passed to permit him member or associate. Denial has a devastating
 CHAPTER 4 Therapeutic Communication Skills 61

effect on communication. The person will not Rationalization is the mind’s way of making
hear what you say, but will quite frequently unacceptable behavior or events acceptable by
acknowledge what you are saying. Careful atten- devising a rational reason. The purpose of rational-
tion to what the person is saying will reveal that he ization is to avoid embarrassment or guilt or to avoid
or she does not accept his or her situation and is obeying a directive. The rational reason is usually a
not mentally conscious that it is happening. Denial stretch of the truth and can be quite apparent to
is often the first stage of an emotional response disinterested individuals. An example is the patient
after a traumatic event. The next stage is anger who tells the provider that he or she did not take
toward the event, the medical staff, God, or oth- his or her blood pressure medication because he
ers. The stage after anger is frequently depression. or she did not have enough time before leaving for
A mentally healthy person eventually reaches the work. The medication easily could have been taken
final stage of acceptance. at home or at work. Most people rationalize things
Repression is similar to denial, but it is a to some extent, but excessive rationalization may be
totally subconscious reaction. In the case of repres- construed as unhealthy.
sion, the person seems to experience temporary Undoing is actions designed to make amends
amnesia. It is the mind’s way of defending itself or to cancel out inappropriate behavior. Shower-
from mental trauma by forgetting or wiping things ing the abused person with gifts to compensate for
out of the conscious memory. A child subcon- unacceptable actions that took place in the past is
sciously forgetting to tell parents that he or she an example.
got into trouble at school is an example. The fear
associated with the event becomes overwhelming, Barriers Caused by Cultural
causing the mind to forget. Repression should not
be confused with outright lying. In severe cases,
and Religious Diversity
repression can be related to mental illness. True therapeutic communication cannot
Projection is attributing unacceptable desires, take place without taking into consider-
impulses, and thoughts falsely to others to avoid ation the cultural and religious background
acknowledging they are actually the person’s own of the patient. Culture is a pattern of many concepts,
experiences. It is a means of defending against feel- beliefs, values, habits, skills, instruments, and art of
ings or urges the person does not want to admit a given group of people in a given period. Culture
they are experiencing. A mother who abuses her and religion influence the patient’s communication
child might accuse the medical assistant of being context, caregiving expectations, time focus, and
rough with the child while performing patient attitude toward Western medicine practiced in the
assessment to conceal her feelings of wanting to United States. Table 4-2 presents characteristics that
throttle the child. Projection is an indication of are typical of different cultural and religious groups.
mental illness.
Sublimation is the channeling of a socially Communication Context. Communication con-
unacceptable behavior into a socially acceptable text can be one of two styles: low-context or high-
behavior. An overly aggressive person directed to context. Low-context communication uses few
play football to relieve aggression is an example. environmental idioms to convey an idea. It relies
Constructive behavior is substituted for destructive on explicit and highly detailed language. High-
behavior. context communication relies on body language,
Displacement is the subconscious transfer of reference to environmental objects, and culturally
unacceptable emotions, thoughts, or feelings from relevant phraseology to communicate an idea. Nei-
one’s self to a more acceptable external substi- ther communication style is superior to the other.
tute. A patient who is angry with the provider for It is important, however, that both the speaker and
some reason slams the door as he or she leaves the the listener be cognizant of the style being used in
clinic. the conversation. In the medical office, the medi-
Compensation is a conscious or subconscious cal assistant should be aware of communication
overemphasizing of a characteristic to offset a real content and attempt to utilize the style used by
or imagined deficiency. This defense mechanism the patient to the extent that it is practical.
involves substituting strength for a weakness and Persons having different communication
may be viewed as healthy. An example is the young styles can easily develop an incorrect impression of
boy whose physical stature keeps him from being the other person. Low-context communication is
a football star, so he compensates by achieving an direct and in-your-face, whereas high-context com-
academic award. munication is indirect and seems to take forever
62 UNIT 2 The Therapeutic Approach

TABLE 4-2 Generalization of Cultural/Religious Effects on Health Care

Culture Medical Care Caregiving Communication Time

or Religion Background Structure Traits Focus*

Western Medicine, rely on Individual, imme- Low Context, direct, eye con- Future
Caucasian, prescription medications, prac- diate family, close tact expected, not adverse
Western tice preventive medicine, may friends to therapeutic touching, may
Culture rely on holistic medicine or folk challenge medical opinions,
medicine in some rural areas. basic English, speaks loudly.

Western Medicine, rely on Extended family, rel- Low Context, direct, eye con- Present/
prescription medications, atives, close friends, tact expected, not adverse Future
African practice preventive medicine, neighbors, church to therapeutic touching, may
American, may rely on holistic medicine family. challenge medical opinions
Western or folk medicine in some rural and can distrust medical per-
Culture areas. sonnel, basic English sometimes
mixed with street language
(Ebonics).

Mixture of Western and holistic Extended fam- Low Context, eye contact Present
Black,
medicine combined with ily, relatives, close expected, highly emotional,
African, or
spiritualism friends, neighbors, basic English strongly mixed
Caribbean
church family, tribal with local dialect.
Culture
affiliation

Mixture of Western and holis- Immediate family, High Context, indirect, avoid Present/
tic medicine combined with opinions of family eye contact, show little emotion, Past
Asian Culture
Confucian principals, i.e., mind and particularly avoid therapeutic touching,
Asian, Indian,
control of the body and main- elders are important. youth speak basic English, elders
Chinese,
taining a balance between may speak little English, may
Filipino,
natural forces and energy in the agree with what is said even
Japanese,
body, eating foods designated when they do not understand
Korean, Thai,
as having hot and cold proper- in order to avoid conflict or to
Laotian,
ties to cure illness is common, avoid losing face, speak softly.
Vietnamese
mental illness is considered
shameful and is denied.

Native Mixture of Western and folk Extended family, rel- High Context, avoid eye con- Present
American, medicine combined with impor- atives, close friends, tact, speak softly and slowly,
South Sea tance of a balance between neighbors, tribal basic English mixed with tribal
Island the forces of nature. affiliation. dialects.
Cultures

Mixture of Western and folk Extended family, High Context, be respectful Present/
medicine combined with a relatives, church and make direct eye contact, Past
Hispanic
strong belief in intervention by family, collective speak softly, some basic
and Latino
God, eating foods designated community English, most speak Spanish.
Cultures
as having hot and cold proper-
ties to cure illness is common.

Western Medicine, religion Culturally dependent Culturally dependent Future/

Judaism does not allow eating pork and Present
requires kosher food.

Western Medicine, religions do Culturally dependent Culturally dependent Future/

Hinduism/
not allow eating meat, modest Present
Buddhism
regarding their body.
(continues)
 CHAPTER 4 Therapeutic Communication Skills 63

TABLE 4-2 (continued)

Culture or Medical Care Caregiving Communication Time

Religion Background Structure Traits Focus*

Mixture of Western and folk Immediate family, High Context, touching Future/
medicine combined with a opinions of family between men and women is Present
strong belief in intervention by and particularly prohibited for strict believers, do
Allah, match gender of care- male head of house- not discuss sexual dysfunction,
giver and client, women may hold are important. females do not make direct eye
not be permitted to be exam- contact, will not discuss many
Islam
ined by male medical profes- taboo subjects (mental illness,
sional, mental illness denied, birth defects, contraception,
do not ingest alcohol, believe hospice, those from Middle East
complete rest is proper for all ill- speak loudly to indicate the
nesses, do not eat pork. importance of what they are
saying.

*The bold term represents the predominant focus.

to reach a conclusion. The high-context speaker is needs. It is difficult to plan for the future when basic
often thought of as mentally slow or uneducated, items in the hierarchy of needs have not been met.
and the low-context speaker is thought of as being Punctuality usually is not important to present-focus
rude or arrogant. Conclusions based on commu- persons.
nication style usually are preconceived miscon- Past time focus is associated with persons from
ceptions and should be considered at all times cultures having long-standing traditions. Tradition
when health care professionals are working with becomes the central focus of their life.
patients.
Human Needs as Barriers
Caregiving Expectations. Caregiving expecta- to Therapeutic Communication
tions refer to the arrangements for taking respon-
sibility for medical requirements. Most persons Human needs, such as those discussed in Maslow’s
from the Western culture are individualistic and hierarchy of needs, are barriers to effective ther-
take personal responsibility for their medical care. apeutic communication if they are not met. A
However, many other cultures and religions do patient who does not know where he or she will
not share this philosophy. This can result in prob- find food or shelter or who feels rejected and
lems related to privacy requirements and patient unloved will frequently put these needs first and
compliance. of primary concern in their mind. Communica-
tion regarding other concerns is nearly impossi-
Time Focus. The cultural background as well as the ble to focus upon until the basic needs have been
socioeconomic environment of the patient have met. This section discusses human needs and how
considerable impact on time focus. Time focus they can be satisfied by the medical assistant or by
relates to whether the patient’s attitude toward life referrals provided by health care professionals.
is future, present, or past. Time focus is culture
and religion related and is not necessarily related
to current circumstances.
Maslow’s Hierarchy of Needs
Future time focus is found in persons whose Abraham Maslow is considered the founder of
physical needs have been met and who can sacri- humanistic psychology and is most well known for
fice immediate gratification to achieve perceived his hierarchy of needs (Figure 4-5). Webster’s Dic-
greater future returns. Future-oriented persons tionary defines hierarchy as “a group of persons or
are time conscious and plan out their daily lives in things arranged in order of rank, grade, class etc.”
considerable detail. Persons from affluent Western According to Maslow’s theory, human needs could
cultures usually are future oriented. be grouped into five levels. He also theorized that
Present time focus is found in persons who each level of need must be satisfied before one
are less assured of being able to meet their physical could move on to the next level.
64 UNIT 2 The Therapeutic Approach

worth. The final level is self-actualization. In this

stage, we are at our peak, doing what truly fits us. It
Self- is an achievement of potential.
Actualization
Individuals may move back and forth from
Prestige & one need to another depending on circumstances.
Esteem Needs

Belongingness
and Love Needs
ESTABLISHING MULTICULTURAL
COMMUNICATION
Safety Needs
Multicultural communication is the abil-
ity to communicate effectively with indi-
Survival or Physiological Needs
viduals of other cultures while recognizing
one’s own personal cultural biases and prejudices
Figure 4-5 Maslow’s hierarchy of needs (Adaptation and putting them aside.
based on Maslow’s Hierarchy of Needs). Approximately one third of the population of
the United States comes from a culture other than
mainstream American (i.e., Caucasian, English-
The needs in the first level include physio- speaking, Judeo-Christian). Figure 4-6 illustrates
logic or survival needs. These needs include food, the percentage of various cultures living in the
water, and air to breathe—homeostasis for the United States.
body. The second level includes needs of safety Medical professionals working within a spe-
and security, that is, the need for security, stability, cific cultural community should seek further infor-
and protection. Everyone has the desire to be free mation relating to that particular culture. In many
from fear and anxiety. Safety needs also include instances, health care professionals can develop
the need for structure, law and order, and limits. rapport with their ethnically diverse patients by
The third level involves belonging and love simply demonstrating an interest in their culture
needs. This level of need involves both giving and and background.
receiving affection. Additional words that express Before multicultural or any therapeutic com-
our connectedness are roots, origins, peers, munication can begin, the patient must first be will-
friends, family, neighborhood, territory, clan, class, ing to discuss his or her health care issues, listen to
and gang. We have a basic animal tendency to the professional’s questions, and give honest answers
herd, flock, join, and belong. to those questions. The patient must trust the profes-
The fourth level, prestige and esteem needs, sional. Several steps to building trust include:
comes from a basic need for a stable, healthy self-
respect for ourselves and others. There is the desire • Risk/Trust: The need for the helping professional
for achievement, strength, and confidence. Also, to build an atmosphere of trust, making it easier
there is the need for recognition, prestige, reputa-
tion, status, and even fame. Satisfaction of these Hispanic
needs leads to feelings of self-confidence and culture
Native American/ 14%
South Sea Islander
1%

Critical Thinking Asian culture

4%

An established patient arrives 20 minutes

African American/
early for his appointment. He is in obvious Black culture Caucasian
pain and discomfort and tells the 12% Western culture
administrative medical assistant, “I can’t 69%
sleep, I can’t eat, and I can’t go to work
today.” Which of Maslow’s stages most
accurately describes this patient? What
actions should the medical assistant take to
assist this patient? Figure 4-6 United States demographic make-up
(2000 Census).
 CHAPTER 4 Therapeutic Communication Skills 65

for the patient to risk expressing feelings and atti- everyone understands each other clearly. The goal
tudes about the problem, is essential. Trust has to of cultural brokering is to increase the capacity of
be earned. Remember to promise no more than health care and mental health programs to design,
you can deliver, be honest, and carefully and thor- implement, and evaluate culturally and linguisti-
oughly explain procedures and policies. Answer all cally competent service delivery systems. Cultural
questions truthfully and honestly. and linguistic competence have been determined
• Empathy: Empathy is the ability to accept another’s to be fundamental in the goal of eliminating racial
private world as if it were your own. Empathy com- and ethnic disparities in health care.
municates identification with and understanding Cultural brokers may assume the role of
of another’s situation. It states, “I’m available to medical interpreter. An interpreter is one who
walk this road with you.” takes the spoken message in one language and
converts it to another language. Interpreters do
• Respect: Respect values another person and consid-
not provide word-to-word equivalence, but rather
ers him or her as a special individual. It is important
focus on the accurate expression of equivalent
to respect the patient’s personal space, to provide
meaning. They serve as communicators and liai-
privacy, and to use his or her full name and title
sons between the patient and the provider in
when appropriate.
health care facilities. If an interpreter is neces-
• Genuineness: This means being real and honest with sary, it is important to remember to speak directly
others. The health care professional must be able to the patient, not the interpreter. If English is
to communicate honestly with others, while being the second language or a heavy accent is involved,
careful not to blame or condemn. speaking clearly and slowly can greatly enhance
• Active listening: Active listening involves verbal and communication.
nonverbal clues that send the message you are com- In some cases, a family member may serve as
pletely involved in the communication. Sit facing the interpreter. This may not be the best solution
the patient with no barriers, such as a desk, between because the family member may not understand
you. Lean toward the patient slightly to convey gen- the medical terminology. It would also be diffi-
uine concern and interest. Establish and maintain cult for a family member to be the one to share
appropriate eye contact to elicit interest and con- a life-threatening diagnosis or a poor prognosis
cern. Maintain an open, relaxed posture to estab- report.
lish a nonthreatening environment for the patient. Understanding this hierarchy helps to assess
Listen carefully to the words the patient uses to a patient’s needs. If the most basic of needs are not
describe problems, and use those terms rather than met, it is highly unlikely that a patient can be suc-
medical terminology when discussing symptoms. cessful with any treatment protocol. Keeping this
hierarchy in mind will help to facilitate therapeu-
tic communication.
Cultural Brokering
Cultural brokering is “the act of bridging, linking,
or mediating between groups or persons through THERAPEUTIC
the process of reducing conflict or producing
change” (National Center for Cultural Compe-
COMMUNICATION
tence, Georgetown University Center for Child IN ACTION
and Human Development, Georgetown Uni-
versity Medical Center, 2004). A cultural broker The following section identifies the proper com-
serves as a go-between, or one who advocates on munication techniques medical assistants should
behalf of another individual or group within the use as part of the most important communica-
health care community. The 2000 Census indicates tion function they perform: patient interview
the projected demographic trends in the United techniques.
States are more complex than ever measured pre-
viously. The belief systems related to health, heal-
ing, and wellness are diverse, with many cultural
Interview Techniques
variations in the perception of illness and disease All health professionals must be adept
and their causes. Cultural brokers respect the val- at interview techniques—knowing how
ues of diverse cultures and health care systems to encourage the best communication
and are knowledgeable of both. They are able to between themselves and the patient. It is impor-
overcome any existing language barriers, so that tant to remember that an unequal relationship
66 UNIT 2 The Therapeutic Approach

exists between the health professional and the “I’d like to know more about your exer-
patient. The health professional, whether it be the cise program.”
provider or the medical assistant, is in the power
position and has a great deal of control over the Refer to Chapter 11 for additional informa-
patient. Therefore, it is important to equalize the tion related to patient interviewing.
relationship as much as possible. That is the reason
why some professionals use the term client rather
than patient.
Point of Care Techniques
Early in the interview, the patient must feel Point of care refers to the location in which the
comfortable enough to risk being honest with the patient and provider or patient and office per-
health professional. The health professional must sonnel physically interact. This interaction may
build an atmosphere of trust by showing concern take place at the reception desk, in the labora-
for the patient. A gentle touch and a warm, car- tory, or in the examination room. The goal of
ing facial expression may be all that is necessary. therapeutic communication at the point of care
Always be honest and genuine in your responses is varied. It may be to determine the reason for
to patients. Be sympathetic and empathic and the visit, collect a blood specimen, or explain a
create an environment that is free of hypocrisy. course of treatment to the patient. The principal
When the medical assistant is interviewing the barrier to communication at the point of care is
patient for the presenting problem or chief com- emotional tension, that is, the patient is upset.
plaint, it is important to listen with a “third” ear. The patient may be upset due to fear of the ill-
Listen to what the patient is not saying but is apt to ness or diagnosis, pain, or anger as part of the
exhibit through nonverbal communication. loss of quality of life resulting from the illness.
You might choose to share your observation Other barriers to communication less frequently
of the nonverbal message with the patient, thus encountered are language, speech or hearing
encouraging the patient to verbalize more freely. impairment, or mental conditions such as low
When feelings are shared, validate and acknowl- IQ or old age and were discussed in other sec-
edge those feelings through such statements as “I tions of this chapter.
understand your distress.” You can verify the com- If the patient is delivered unpleasant infor-
munication by reflecting or paraphrasing what the mation skillfully, he or she can take in and pro-
patient has said. cess the material rather than reject it. Words and
You will be asking closed questions during the statements that promote anxiety or anger should
interview. Closed questions can be answered with a be avoided. Examples are complex medical termi-
simple yes or no. nology that the patient may not understand and
judgmental statements about lifestyle. Both can
“Are you still taking your medication?” instill fear and anger in a patient. Every effort
“Are you in pain now?” should be made to clarify the information being
communicated to the patient. Patients should be
You will also use open-ended questions with encouraged to restate the information in their
the patient. These questions encourage therapeu- own words. Under no circumstance should the
tic communication because the patient is required patient be given false reassurance. This can result
to verbalize more information. in a lack of trust if the patient perceives that he
or she is being deceived. The medical assistant
“What kind of help will you have at home should be alert to notice emotional reactions by
during your recovery?” the patient and be prepared to take appropriate
“How are you coming along on this corrective action.
diet?” Avoid familiar phrasings and mannerisms—
for example, the type we use when unsure of what
Indirect statements will also prove helpful in to say in an uncomfortable situation, such as saying
facilitating therapeutic communication. An indi- “perhaps,” rather than the more usual “maybe,” or
rect statement will elicit a response from a patient nervously clearing our throats. All of these are signs
without the patient feeling questioned. of self-protection on the part of the speaker, which
the patient may notice. Good communication skills
“Tell me what you’ve been doing since and forethought make such self-protective mecha-
you retired.” nisms less necessary.
 CHAPTER 4 Therapeutic Communication Skills 67

COMMUNITY RESOURCES
Patient Education
There may be circumstances in which a patient will
Education of a patient or caregiver should need a referral to a community resource. These
consist of the following fundamentals regard- resources range from the more simple acts of
less of the subject: arranging with Meals on Wheels to deliver a hot
• Do not attempt to educate the client meal daily to making complex arrangements for
while he or she is emotionally upset or skilled nursing facilities or hospice care. The medi-
distressed. Under these conditions the cal assistant will need to know the patient’s name,
individual will not be communicative; address, and telephone number, as well as the par-
that is, they are listening but not hearing ticular resource needed, the diagnosis, and the
what is said to them. Make every effort to reason for the service.
calm the client. If necessary, reschedule It is helpful to have a list of community
another time for the educational session. resources readily available. The list may be com-
• Use multiple methods, such as visual, ver- puterized, or hardcopy information may be filed
bal, and action, to convey the message. in a notebook. The information should be put into
This approach ensures that your commu- categories for ease in locating it quickly. See Pro-
nication style will be versatile and meet cedure 4-1 for steps in developing a Community
the needs of the client. Convey informa- Resource reference.
tion in a clear, concise manner using
context that is relevant to the client.
• Limit the amount of material covered. If
necessary, schedule additional sessions
so that the client is not overwhelmed.
• Communicate in simple words, avoiding
medical terminology that may not be
understood by the client.

Procedure 4-1
Identifying Community Resources
PURPOSE: • Visiting nurses
To have a list of community resources readily available • Counselor/social workers at local hospitals
for referral to patients.
• Nursing home associations
EQUIPMENT/SUPPLIES: • Local charities
Computer and printer
Following is a list of information sources to consider PROCEDURE STEPS:
when beginning to put together a Community Resource 1. Determine the type of information to be in your
Reference: database. RATIONALE: Only resources useful to
• Local Public Health Department your specific office should be maintained to save
time and space.
• Internet
2. Contact the sources listed previously and request
• Community service numbers in the local tele- any listings they may have. RATIONALE: This
phone directory will save time.
• State/federal agencies

continues
68 UNIT 2 The Therapeutic Approach

Procedure 4-1 (continued)

3. Search the Internet using your favorite search by a patient and simply print it out. You may wish
engine. Enter the city, state, and community to have a notebook with the information printed
resources. You may have to modify the subject and indexed so that other office staff can sim-
of your search to obtain the desired resources. ply copy a page for a patient. Your data should
RATIONALE: This is an effective way to access include as many resources for assistance as you
information quickly. can find for each type of resource. RATIONALE:
4. Develop a database on your computer so you To have a listing of community resources readily
can search easily for the resource when needed available for office use.

Case Study 4-1

Review the scenario at the beginning of this chapter and threatens to leave, Joe explains to Mr. Marshal that there are
respond to the following. two patients ahead of him, but that the provider will see him
It is a typically active day at the offices of Drs. Lewis at his scheduled appointment time.
and King. Despite the three emergencies in the early after-
noon and the full schedule of patients, everything is running CASE STUDY REVIEW
smoothly with Dr. Lewis, and the entire staff is responding
1. What communication roadblocks did medical assis-
quickly but thoroughly to patient concerns.
tant Joe Guerrero avoid in reacting to Jim Marshal’s
At 4:00 PM, another emergency patient arrives; at the
demands to see the provider?
same time, Jim Marshal, an architect in a downtown firm,
comes in early for a routine appointment and demands to 2. With another student, role-play the scenario, with
be seen immediately. Jim, a regular patient, has a history of one student taking the role of patient and one stu-
being difficult and impatient; being a bit arrogant, he tends dent the role of the medical assistant. Identify road-
to put his needs first. However, Dr. Lewis is occupied with blocks to communication imposed by the patient.
another patient. It is critical to treat the patient with the emer- How is the medical assistant using the five Cs of
gency as soon as possible, and Jim is half an hour early. communication to deal with the situation?
Joe Guerrero, CMA (AAMA), the office’s administrative 3. Do you think the medical assistant reacted appro-
and clinical medical assistant, calmly asks Mr. Marshal to priately? What else could he have done? What
please wait until his scheduled appointment time. When he should he not do in this situation?

Case Study 4-2

You have learned in this chapter that communication has not CASE STUDY REVIEW
been successful until the cycle is complete. Consider the fol-
lowing scenario. 1. What might the staff do to help the patient under-
An 82-year-old woman with moderate dementia and stand the following?
a hearing impairment is brought to the surgeon’s office for • Use the walker consistently.
a follow-up appointment after hip replacement surgery. • Shoes must be leather tennis shoe type or uni-
The woman’s daughter accompanies her. The goal of the form style; consider Velcro closure as opposed
appointment is to make certain the hip is healing nicely to laces that have to be tied.
and to discuss precautions before the patient returns to
• Do not wear pantyhose.
her assisted-living apartment. Almost immediately, the
conversation is directed toward the daughter because it is • You will not be able to walk your dog on a leash.
so much easier to explain to her what should be done. 2. Should the patient be left out of the conversation?
Should the daughter be included?
3. In cases such as these, is something other than
verbal communication indicated?
 CHAPTER 4 Therapeutic Communication Skills 69

SUMMARY
Throughout this text you are reminded of the importance of effective communication techniques. Good
communication takes practice. Use the techniques identified in this chapter with your family and with your
peers. Watch for roadblocks, be aware of defense mechanisms, and remember the five Cs of communication.

STUDY FOR SUCCESS

To reinforce your knowledge and skills of information presented in this chapter:
• Review the Key Terms
• Practice the Procedure
• Consider the Case Studies and discuss your conclusions
• Answer the Review Questions

˚ Multiple Choice
˚ Critical Thinking
• Navigate the Internet by completing the Web Activities
• Practice the StudyWARE activities on the textbook CD
• Apply your knowledge in the Student Workbook activities
• Complete the Web Tutor sections
• View and discuss the DVD situations

REVIEW QUESTIONS
Multiple Choice 5. A reassuring cliché is:
a. a way of calming down a patient
1. Factors affecting therapeutic communication b. a means of rationalizing a decision
include which of the following? c. a roadblock to communication
a. age and gender barriers d. always useful in daily communications
b. education and experience barriers 6. Redirecting a socially unacceptable impulse into
c. bias and prejudice barriers one that is socially acceptable is an example of
d. all of the above which of these defense mechanisms?
2. In the cycle of communication, encoding means: a. sublimation
a. deciphering a message b. rationalization
b. creating the message to be sent c. projection
c. sending the message d. displacement
d. receiving the message 7. When using an open-ended question with a patient,
3. Body language: we expect:
a. is used to express feelings and emotions a. a yes or no answer
b. is not as important as verbal communication b. him or her to tell us the truth
c. only makes up 7% of the message c. a response that permits the patient to elaborate
d. is only used in Eastern cultures d. only the right answers
4. A comfortable social space is defined as: 8. High-context communication relies on all of the
a. touching to 11⁄2 feet following except:
b. 11⁄2 feet to 4 feet a. body language
c. 12 to 15 feet b. reference to environmental objects
d. 4 to 12 feet c. explicit and highly detailed language
d. culturally relevant phraseology
70 UNIT 2 The Therapeutic Approach

Critical Thinking Taber’s cyclopedic medical dictionary. (19th ed.). (2004).

1. A 15-year-old girl awaiting a sports physical exami- Philadelphia: F. A. Davis.
nation says that she is overweight and has pimples. Tamparo, C. D., & Lindh, W. Q. (2008). Therapeutic
How will you respond therapeutically? communications for health care. Albany, NY: Delmar
2. Bill, who is 28 years old, comes for his annual Cengage Learning.
checkup. When reviewing his social data sheet, you
discover he is now living in an apartment and has
a new phone number. He mumbles to you that his
wife left him and won’t let him see the kids. How THE DVD HOOK-UP
will you respond therapeutically?
3. You try to be gentle and gracious with Edith. She In this chapter, you learned the importance of positive
is fragile and difficult to please. While positioning communication and what distractions can impede
her for a radiograph, she sneers and says, “You are the communication process. You also learned the
about the roughest person who ever cared for me.” importance of nonverbal communication and how it is
How will you respond therapeutically, and how will not necessarily what you say, but rather how you say it,
you control your body language? that leaves the strongest impression on others.
4. When you report to Herb that his cholesterol is Program 2 of Critical Thinking deals with many of the
quite high and that the doctor wants to discuss same issues that are listed in this chapter. We observed
medication and diet, he responds, “That is impos- the effects of body language in the communication
sible; you must have made some mistake.” Which process. Communicating with special populations also
defense mechanism is Herb using? How will you was addressed. We learned the office’s responsibility in
respond therapeutically? providing an interpreter for our deaf patients and how
5. How might the unequal relationship between we can better serve our blind patients. We also learned
provider and client/patient impact therapeutic about managing the angry patient.
communication?
1. What are some benefits to being bilingual?
2. What is one mistake that many people make when
WEB ACTIVITIES working with blind patients?
3. What is the best approach to take when dealing with
Select three cultures of particular interest to you an angry patient?
personally and search the Internet for informa-
tion regarding these cultures and communi- DVD Journal Summary
cationt traditions. How might this new information be Write a paragraph that summarizes what you learned
applied to the provider whose clientele is primarily made from watching the designated scenes from today’s DVD
up of these cultures? How might this new knowledge ben- program. How do you feel about working with patients
efit a medical assistant employed in this type of setting? from different cultures? Are you the type of person who
gets angry when conversing with other people who are
angry? What steps will you take to deal with an angry
REFERENCES/BIBLIOGRAPHY patient or coworker?

Blair, G. M. (January 23, 2000). Conversation as communi-

cation. Retrieved August 22, 2008, from http://www.
see.ed.ac.uk/~gerard/Management/art7.html?see.
ed.ac.uk/~gerard/Management/art7.html.
Iyer, P. W. (Ed.) (2002). Legal nurse consulting principles
and practice. Boca Raton, FL: CRC Press. DVD Series Program Number
Luckmann, J. (2000). Transcultural communication Critical Thinking 2
in health care. Clifton Park, NY: Delmar Cengage Chapter/Scene Reference
Learning. • Introduction
National Center for Cultural Competence, Georgetown • Forms of Communication
University Center for Child and Human Develop- • Professional Communication
ment, Georgetown University Medical Center. (Skip: Communicating with Patients and
Communication on the Telephone)
(Spring/Summer 2004). Bridging the cultural divide
• Communicating with Special Populations
in health care settings: The essential role of cultural broker
programs. Washington, DC: Author.
 Chapter
Coping Skills for the Medical
Assistant 5
KEY TERMS OUTLINE
Burnout What Is Stress? Role of Personality and Work
Goal Adaptation to Stress Environnment
Inner-Directed People Management of Stress Burnout Prevention
What Is Burnout? What to Do If You Are Burned
Long-Range Goals
Stages of Burnout Out
Outer-Directed People
Goal Setting as a Stress Reliever
Parasympathetic
Nervous System
Self-Actualization OBJECTIVES
Short-Range Goals The student should strive to meet the following performance objectives and
Stress demonstrate an understanding of the facts and principles presented in this chapter
Stressors through written and oral communication.
Sympathetic Nervous 1. Define the key terms as presented in the glossary.
System
2. Differentiate between stress and stressors.
3. Describe the three categories of stressors.
4. Differentiate between short-duration and long-duration stress.
5. Describe Hans Selye’s General Adaptation Syndrome theory.
6. Identify several approaches to managing stress in the ambulatory
care setting.
7. Identify three characteristics associated with burnout in the
workplace.
8. Describe the four stages of burnout.
9. List a minimum of five ways to reduce the risk for burnout.
10. Differentiate between long-range and short-range goals.

71
 Scenario
At the office of providers Lewis and King, there are four assistant, in charge of a busy reception area and an
full-time medical assistants who collaborate to make ever-ringing telephone.
the office run smoothly, both administratively and clini- On these days, Ellen is particularly careful to orga-
cally. One day a month, though, office manager Mari- nize her work so that things run as they should. Although
lyn Johnson, CMA (AAMA), is out of town, leaving Ellen Ellen cannot anticipate every emergency, she does try to
Armstrong, CMA (AAMA) the administrative medical influence the situation rather than let events control her.

INTRODUCTION
Even in the most well-managed ambulatory care setting, negative events; however, each of these events can
medical assistants and other health providers are likely to result in inducing stress in the body. These events
feel the effects of stress from time to time. They may be over- are called stressors. Stressors can be divided into
worked on certain days, they may face difficult patient sit- three categories:
uations, and they may find that the administrative and
paperwork load is getting ahead of them. 1. Frustrations : Circumstances that prevent us from
This chapter helps today’s busy, multifaceted medi- doing what we want to do
cal assistant pinpoint the symptoms of stress and pro- 2. Conflicts : Incompatibility between two important
vides ideas for coping with stress as it occurs. The better things or objectives equally important to us
equipped the medical assistant is to confront and solve 3. Pressure : Demands of schedule, workload, or expec-
the sources of stress, the less likely stressors will become tations placed on us by ourselves or others
so overwhelming as to lead to burnout on the job. Goal
setting, recognizing one’s limitations and potentials, set- According to Hans Selye, who first conceived
ting priorities, and keeping a balanced perspective can the theory of nonspecific reaction as stress, the
work together to reduce stress and enable the medical body does not differentiate positively and negatively
assistant to take pleasure in working with patients and induced stress. It is only the level of the stress and its
colleagues. duration that affect the body. Short-duration stress,
sometimes called acute stress, can be beneficial.
Short-duration stress adds anticipation and a feel-
WHAT IS STRESS? ing of “being alive,” for example, when we experi-
ence a roller coaster ride or bungee jump off a cliff.
The body’s response to mental and physical The short-lived adrenaline rush brings the world
change is termed stress. What constitutes stress is into sharper focus and enhances our lives. It helps
highly individual and depends to a great extent us focus on details, achieve difficult goals, and per-
on personality type. Events that may be stressful to form at our best. When we have a last-minute rush
one person may be enjoyable to another. A delayed in the office or are hurrying to get an assignment
airplane flight may be very stressful to a person finished for school, we are experiencing short-
who worries about making another connection duration stress. Short-duration stress is experienced
or missing a meeting. Another person will simply when the telephone rings, the examination rooms
look for an alternative flight or notify the people are full, and the provider is called to the hospital on
he or she was to meet and then take the time to an emergency. Immediately, the body’s stress mode
enjoy a good book, experiencing little or no men- is activated and adrenaline is produced, enabling
tal or physical change. Adaptive behavior patterns you to make quick judgements and decisions, to
we assume in response to real physical threats or be organized and efficient, and to accomplish tasks
emotional effects result in either eustress (posi- within minimal time limits.
tive feelings) or distress (negative feelings). Mov- Longer-duration stress is sometimes called
ing to a new city or receiving a promotion usually episodic or chronic stress. Episodic stress is the result
are perceived as positive events, whereas going of events over which we have control. Examples of
through a divorce or losing a job are conversely episodic stress include taking on too many projects

72
 CHAPTER 5 Coping Skills for the Medical Assistant 73

or needlessly worrying. Chronic stress is the result MANAGEMENT OF STRESS

of events over which we have little control, such as
long-term unemployment, dysfunctional relation- Stress cannot be prevented; in fact, life would be
ships, or chronic illness. Longer duration stress, dull without short-duration stress. Anticipating the
normally associated with negative events, can be birth of a child, planning an upcoming wedding,
harmful to the body, resulting in illnesses such as or graduating from school are all stressful changes,
headaches, insomnia, allergies, cancer, acute indi- albeit pleasant ones, that make life interesting.
gestion, stomach ulcers, hypertension, blood clots, Long-duration stressful situations are not desir-
stroke, and immune system disorders. Psychologi- able, but the situations leading to them can be
cally, the body also is influenced by long-duration managed if we understand the causes. Some causes
stress. Onsets of depression and anxiety, as well as of long-duration stress are:
eating problems resulting in weight loss or gain, are
associated with the body’s psychological response • Powerlessness: Inability to control expectations,
to stress. Anorexia and bulimia are common eat- workload, and duties; feelings of frustration and
ing disorders attributed to long-duration stress- panic because of schedules
ful events. Long-duration stress can also affect our • Round peg in square hole: Not suited for the position
ability to think clearly, and objectivity may be you hold
impaired. Physical symptoms of these emotional • Traumatic events on the job: Not emotionally pre-
effects include cigarette smoking, obesity, and lack pared for trauma involved in the job
of interest in or excessive sexual activity.
• Environmental: Physical conditions such as noise,
lighting, or temperature influence work
Adaptation to Stress • Management style: Your manager’s style causes
The body’s response to stress goes back to early uproar or instability in work demands
human development. That response was designed • Failure to satisfy needs: Job conditions do not per-
to help humans survive whatever they were experi- mit achievement of Maslow’s needs (see Chapter 4
encing that caused a fearful response. The sympa- for information related to Maslow’s hierarchy of
thetic nervous system prepared the body for “fight needs)
or flight” to allow humans the best chance of sur-
vival. The brain inhibits short-term memory, pro- Requesting that you have a written job
motes long-term memory, and releases hormones description can control powerlessness. You will
such as adrenaline into the bloodstream. The then know your duties and responsibilities, and
respiration rate becomes more rapid, blood flow you will not experience sudden change when you
increases, red and white blood cells are released least expect it. A job description will also help to
by the spleen, and the immune system is altered avoid some of the instability resulting from a man-
to allow immune-boosting bodies to be sent to the ager who is too sanguine or manages from one
body. Blood vessels in the skin contract to mini-
mize blood loss from wounds, blood vessels in
the muscles dilate to increase circulation, and flu- (2) The sympathetic nervous
ids are diverted from nonessential locations; the system prepares the body
(1) The body begins to for fight or flight.
metabolism rate is diminished to permit all avail- perceive and be
able energy to be focused on the event that trig- aware of stress. Alarm Fight-or-Flight
gered the fight-or-flight response.
All of these caveman responses to stress are
with us today. The symptoms of headache, stom-
ach ache, diarrhea, cold clammy hands, heart
palpitations, indigestion, and short-term memory
loss that we experience are the result of our body’s Return-to-Normal Exhaustion
reaction to stressors that has been developed over (4) The parasympathetic (3) The body becomes
millennia. Short term, these responses are not nervous system is exhausted by its
harmful, and the body’s parasympathetic nervous activated, and the body reaction to stress.
returns to normal.
system returns to normal after the stressor has been
removed. Long term, these responses are harmful Figure 5-1 Hans Selye’s General Adaptation Syn-
to the body. See Figure 5-1 for an illustration of the drome (GAS) theory proposes that four stages are
adaptive stages related to stress. involved in adapting to stress.
74 UNIT 2 The Therapeutic Approach

Managing your lifestyle also becomes part

Critical Thinking of stress management. Finding time to relax and
divert your mind from the worries of the job is
Practice in Time Management an effective tool in managing stress. Instead of
Analysis working during lunch to solve a problem, taking
a break away from the problem will reduce the
List all of the tasks you do in a typical day. stress to the point that you will actually increase
Beside each task write down how many your productivity.
minutes/hours you spend on each task. At This is probably a good time to discuss worry.
the conclusion of the exercise, draw a histo- Worry is defined as undue concern for problems
gram showing the percentage of each day over which you have no control. Worry causes
spent on each task. This will quickly show stress, yet it does nothing to resolve the problem
where you spend most of your time. How causing your worry. Therefore, just remembering
could you save time? Develop a plan to this definition and thinking about it every time
reduce time spent in nonproductive, you are inclined to worry will help you to stop
unessential activities. worrying.
Mental attitude plays a role in tolerance to
stress. Individuals who can focus on the positive
crisis to another. If you know what your job entails, can offset the depression often associated with
you can anticipate the events and take action to stress. Identifying what is being accomplished ver-
prevent a crisis. sus focusing on what is not being accomplished or
Planning and prioritization can help to pre- what does not meet your expectations is what is
vent panic and reduce stress when faced with meant by focusing on the positive. Maintaining an
the inevitable situation of too much work and active social network that allows you to discuss your
too little time. A job that looks impossible can problems is also quite helpful. The network should
be broken down into elements that are manage- not include persons of negative self-attitude who
able. Prioritization of the smaller elements and have common problems. This situation is likely to
proceeding without wasting time procrastinating have as its outcome a “complain session.”
usually results in getting the job finished in the Physical condition affects your body’s toler-
allotted time or at least with a minimum amount ance to stress. Maintaining a regular sleep cycle,
of stress. eating a proper diet, and getting regular exercise

Critical Thinking
Checking Your Success-Oriented Attitude
Select three attitude attributes for which you are quite negative and develop a plan of action
to make them more positive. Implement your plan; after two weeks, review whether your actions
have impacted the stress level associated with that activity.
Negative Positive
Attributes 20% 40% 60% 80% 100% Attributes
Bored Enthusiastic
Unhappy Joyful
Never Can do
Lethargic Energetic
Cut corners Honest
Out of control Under control
Lack of confidence Confident
Selfish Selfless
Unyielding Flexible
Loner Part of a group
Know it all Open to suggestion
 CHAPTER 5 Coping Skills for the Medical Assistant 75

contribute to improving your body’s tolerance to Table 5-1 Techniques for Reducing Stress
stressors (Figure 5-2). Stress can affect sleep and at Work
appetite, but intentionally not getting enough
sleep or not eating a balanced diet makes you more Stretch or change positions.
susceptible to stress in the first place. Anything
that “bugs” you contributes to stress. Some people Slowly roll your head from side to side and forward
believe that soft background music will reduce and back.
stress, but for a job requiring intense concentra-
tion, any distraction contributes to stress. Clothes Slowly rotate your shoulders forward and backward
or shoes that are uncomfortable can “bug” you and several times.
contribute to stress. The color of the walls in your
office can contribute to stress. If the color “bugs” Turn away from the computer, or close your eyes for
you, it will contribute to stress. Telephone interrup- several seconds.
tions can result in a stressful situation. All of these
“minor” things that contribute to stress are man- Walk around and deliver charts or laboratory specimens.
ageable and should be considered as part of a plan
to manage stress. See Table 5-1 for suggested tech- Stand or sit tall and take a few deep breaths.
niques for reducing stress at work.
Maintaining a good interpersonal relation- Meditate for 30 seconds.
ship with fellow employees or fellow students and
faculty is important to achieving a satisfying work Know your limits and be aware of your body’s needs.
or school experience. Before a strong interpersonal
relationship is established with others, a positive
self-attitude is needed. The choices we make affect will affect our school and work environment, and
our positive attitude. Making positive decisions hence the level and duration of stress experienced.
Following are choices we all make in our lives:
• To be respectful of others
• To be a diligent worker
• To be willing to learn
• To be honest
• To be willing to assume responsibility for actions
• To express appropriate humor
• To have an attitude of humility
• To be goal directed
• To understand Maslow’s hierarchy of needs

By anticipating how an organization can

cause stress, we can be prepared and minimize its
effects. Following are common causes of stress in
an organization:
• Low salary: Salary plays an important role in our
needs. It leads to frustration if we believe it is too
low, and this contributes to a negative attitude.
Positive job conditions can overshadow low salary;
however, if combined with other negative feelings,
it is an overpowering cause of stress.
• Little opportunity for career growth: This reason results
in frustration and leads to stress and burnout.
• Overspecialization: This problem results in the em-
Figure 5-2 Regular exercise in some form improves ployee never seeing the overall picture and receiv-
the body’s tolerance to stress. ing little or no satisfaction from his or her work.
76 UNIT 2 The Therapeutic Approach

burnout is so damaging, it needs to be discussed

Critical Thinking as a unique topic.

Self-Evaluation
Stages of Burnout
• List several situations in your life that
are stressful. Select the one that is most Burnout has four stages:
stressful.
• Honeymoon: Love your job and have unrealistic
• List as many things as possible about the
expectation placed on you either by your manager
situation that make it stressful to you.
or by yourself if you are a perfectionist; take work
• How would you change each of the things
home and look for all the work you can get, cannot
you have listed to make them less stressful?
say “no” to accepting additional work
• List the things you “could do” to effect the
changes you listed. • Reality: Begin to have doubts you can meet expec-
• Rank the items in your “could do” list in tations; feel frustrated with your progress, work
terms of achievability. harder to meet expectations; begin to feel pulled in
• Select one or two of the items that are many directions; may not have a role model to fol-
achievable and discuss them with a low, and established guidelines may not be defined
classmate. Now attempt to put them into • Dissatisfaction: Loss of enthusiasm; try to escape
practice for a week. Report back to your frustrations by binges of one sort or another, drink-
classmate on how effective these items ing, partying, shopping, or excessive eating or sex;
were in reducing stress in your life. fatigue and exhaustion develop
• Sad state: Depression, work seems pointless, le-
thargic with little energy, consider quitting, and
look on yourself as a failure; represents full-blown
• Workload: Continual work level beyond your capa-
burnout
bility to complete it results in frustration, and ulti-
mately burnout.
• Job complexity versus skill level: Expectation to perform All of these stages are part of the process leading to
beyond your skill level leads to long-duration stress burnout. The honeymoon stage might seem desir-
but also can lead to personal growth and increased able, and it is pleasant, however, the seeds of the ill-
job satisfaction if the individual is a high achiever. ness are present in the unrealistic expectations and
the workaholic attitude of the employee. Unless
• Responsibility delineation: Lack of delineation of
these causes are eliminated, the progression to full
responsibility leads to continual questioning of
burnout is ensured.
whom is responsible for what job and ultimately
to frustration.
• Organization size: Some individuals can get lost in a
Role of Personality and Work
large organization. Environment
• Discrimination: This illegal activity leads to bad Burnout happens to people who previously were
feelings and frustration. enthusiastic and bursting with energy and new
• Poor time management skills: The inability to priori- ideas when first hired on the job or beginning a
tize and manage time effectively can lead to work new experience. When individuals with a high
overload. need to achieve do not reach their goals, they are
apt to feel angry and frustrated and become neg-
• Technological changes: Change, even good changes,
ative toward their job. Failing to recognize these
can cause stress.
signs as symptoms of burnout, they may throw
• Not being in control of your situation: Lacking control themselves even more fully into work-related goals.
leads to frustration. Unless there is some type of revitalization outside
of the workplace, burnout occurs.
Four characteristics associated with burnout
WHAT IS BURNOUT? in the workplace include:

Burnout is the result of stress and frustration, prin- • Role conflict: When employees have conflicting
cipally brought about by unrealistic expectations. responsibilities, they feel pulled in many direc-
Fatigue and exhaustion resulting from trying to tions. The perfectionist tries to do everything
meet unrealistic expectations compound it. Because equally well without setting priorities. Fatigue
 CHAPTER 5 Coping Skills for the Medical Assistant 77

and exhaustion associated with burnout begin to

set in after time. Critical Thinking
• Role ambiguity: The employee does not know what
Negative attitudes combined with low pay
is expected and how to accomplish it because
are a formula for burnout. Why?
there may not be a role model to follow or ask, or
established guidelines to follow.
• Role overload: If the employee cannot say no and
• If you have more work than you can realistically
continues to accept more responsibility than they
accomplish, either prioritize it with the approval of
can handle, burnout is sure to set in.
your superior or delegate it within the limit of your
• Role value: If the employee feels the job is not worth authority.
doing or that he or she is not appreciated, dissatis-
• Change your work-related environment by creat-
faction sets in and speeds up the burnout process
ing variations. Modify your work routine slightly,
initiated by other factors.
rearrange your workstation to make it more per-
sonal, or change the computer desktop picture or
Burnout Prevention screensaver to something you find pleasant and
which generates positive emotions.
Taking steps to prevent burnout before it occurs is
• Evaluate the negative feelings you have regarding
the best path to follow if you find you have symp-
your job and attempt to replace them with more
toms of burnout or if the characteristics leading to
positive thoughts (i.e., instead of thinking the glass
burnout are present in your job situation.
is half empty, think the glass is half full).
The following changes in your approach to
your work environment and lifestyle will help to • Try to look on work as a “fun” experience.
prevent burnout: • Establish some long- and short-term realistic goals
and write them down along with a plan to make
• Develop time management and prioritization tech- them happen.
niques both at work and outside the work environ-
• Attempt to develop friendships with coworkers and
ment.
occasionally go to lunch together to laugh a little.
• Detach yourself from your work when you leave for
• Embark on a program of relaxation and meditation
the day and do not take work home.
to reduce stress. Relaxation reduces muscle tension
• Develop outside interests that result in an active resulting from stress and can be achieved in a few
social life. minutes. Meditation requires about 20 minutes
• Take steps to live a healthful life by getting enough each day. Meditation affects body processes such
sleep, eating a balanced diet, and getting physical as heart rate, blood pressure, metabolic rate, and
exercise. brain activity and helps to obtain a feeling of “well-
• Conduct a self-evaluation and set realistic goals for being.”
your life and your job.
• Obtain a written job description that defines your
responsibilities and expectations. GOAL SETTING
AS A STRESS RELIEVER
What to Do If You Are Burned Out Do you direct your life, or do you allow others to
If you recognize yourself in one of the stages of influence and make decisions for you? Outer-directed
burnout, you have reached a turning point. It is people let events, other people, or environmental
imperative that you make some changes in your factors dictate their behavior. By contrast, inner-
relationship with your job. All of the suggested directed people decide for themselves what they want
changes given to prevent burnout are applica- to do with their lives. Laurence Peter, author of The
ble and possibly more important once you have Peter Principle, states, “If you don’t know where you
entered one of the stages of burnout. The follow- are going, you will end up somewhere else” (Wilkes
ing changes are in order once you have entered & Crosswait, 1995).
the burnout stage: Discoveries prove that goal-oriented employees
are more effective and assertive than are colleagues
• Make a concerted effort to say “No” when asked to with no goals or future objectives. Recognizing the
assume additional work. Job scope creep is a lead- value of goal planning, many employers arrange
ing factor in burnout. planning sessions or seminars to encourage goal
78 UNIT 2 The Therapeutic Approach

setting as a practical application for coping with Examples of long- and short-range goals might
stress and burnout and to develop career objectives. include:
If your employer does not offer these outlets, seek
your own seminars for goal setting. Such an activ- Long-range goal 1:
ity not only “centers” you in your current employ- • To become proficient in all back-office clinical
ment but helps you clearly picture your future plans skills during the first year of employment.
and hopes.
What is a goal? According to Merriam-Webster’s Short-range goals necessary to achieve this:
Collegiate Dictionary, a goal is “the result or achieve- • Practice accuracy and proficiency when performing
ment toward which effort is directed.” To reach a tasks and skills.
desired goal, a person must implement planning
• Practice efficiency by planning ahead for the equip-
together with a sincere desire to work hard. Skill
ment and supplies needed for each task performed.
in goal setting allows the medical assistant to clar-
ify what must be accomplished and to develop a • Evaluate your progress on a regular basis, and iden-
strategic plan to successfully achieve the goal. tify areas that need improvement.
A goal must be specific, challenging, realis- Long-range goal 2:
tic, attainable, and measurable. Specific goals are
focused and have precise boundaries. A goal that • To add front-office administrative tasks and
is challenging creates enthusiasm and interest in skills to your routine during the second year of
achievement. Realistic goals are practical or benefi- employment.
cial for the present and for future self-actualization.
Short-range goals necessary to achieve this:
An attainable goal refers to the fact that the goal
is possible to fulfill. Measurable goals achieve some • Practice accuracy and proficiency when perform-
form of progress or success. By reflecting on the ing all front-office tasks and skills.
process, one is encouraged to establish additional • Practice efficiency by planning ahead for the
goals. equipment and supplies needed for each task
Long-range goals are achievements that may performed.
take three to five years to accomplish. Long-range
• Evaluate your progress on a regular basis, and iden-
goals give direction and definition to our lives and
tify areas that need improvement.
serve to keep us “on track,” so to speak. Much dis-
cipline, perseverance, determination, and hard Long-range goal 3:
work will be expended in accomplishing long-
range goals. Some adjustment and readjustment to • To begin to focus on office management during
your goals may be necessary, however. The rewards the third year of employment.
of goal achievement include satisfaction, pride, a Short-range goals necessary to achieve this:
sense of accomplishment, and a job well done.
Short-range goals take apart long-range goals • Develop a procedure manual for all back- and
and reassemble the required activities into smaller, front-office tasks and skills.
more manageable time segments. The time seg- • Enroll in office management classes.
ments may be daily, weekly, monthly, quarterly, or • Focus on team-building skills.
yearly periods.
As a graduate and new employee, one of By the fourth year, you will be ready to move
your long-range goals might be to become the into the office manager position.
office manager in the ambulatory care setting in Long- and short-range goals work together
which you are currently employed. You may wish to to help make changes in our lives. Goals keep
attain this goal within the next three to five years; life interesting and give us something for which
by breaking it into three longer range goals and a to strive. We can all reach goals successfully
series of short-range goals, you will be able to mea- with some planning, hard work, discipline, and
sure progress and feel a sense of accomplishment. dedication.
 CHAPTER 5 Coping Skills for the Medical Assistant 79

Case Study 5-1

Review the scenario at the beginning of this chapter.

CASE STUDY REVIEW

1. What work can Ellen Armstrong, CMA (AAMA), 2. How might Ellen relieve stress as the hectic day
organize the night before the office manager is out progresses?
of town, leaving Ellen in charge of the reception
area and ever-ringing telephone the next day?

Case Study 5-2

Ellen Armstrong, CMA (AAMA), has been employed for five CASE STUDY REVIEW
years as an administrative medical assistant with providers
Lewis and King. Ellen is a perfectionist and has pushed herself 1. Do you feel Ellen is stressed or experiencing burn-
to achieve many of her short- and long-term goals. The office out? On what do you base your conclusions?
staff has become aware that Ellen does not have a sense of 2. What might Ellen do to differentiate these two
humor lately. She seems frustrated and irritable, and she is conditions?
becoming critical of herself and others. Ellen has felt physi- 3. What changes might Ellen implement to resolve
cally and emotionally exhausted, yet she continues to focus this problem?
on her high standard of job performance; however, work is
becoming a chore. At the end of the day, if everything has not
been completed to her satisfaction, she feels like a failure.

SUMMARY
Stress is very much a part of the medical profession. Each individual working in a medical career experi-
ences consecutive days of demanding, emotionally and physically draining interactions with patients and
staff members. This highly technical and ever-changing career requires its professionals to maintain a high
level of skill and training and to be familiar with the newest technology.
Goal setting is one approach to reducing stress and burnout and promoting a sense of pride in the
workplace, self-actualization, and possible employment promotion. Both long-range and short-range goal
planning work together to help make changes in our lives.

STUDY FOR SUCCESS

To reinforce your knowledge and skills of information presented in this chapter:
• Review the Key Terms
• Consider the Case Studies and discuss your conclusions
• Answer the Review Questions

˚ Multiple Choice
˚ Critical Thinking
• Navigate the Internet by completing the Web Activities
• Practice the StudyWARE activities on the textbook CD
• Apply your knowledge in the Student Workbook activities
• Complete the Web Tutor sections
80 UNIT 2 The Therapeutic Approach

REVIEW QUESTIONS
Multiple Choice procedures. How do you think this position will
impact your short- and long-duration stress?
1. Which answer is not true about stress? 2. Identify two long-range goals you personally would
a. It does not occur suddenly. like to attain within the next five years. How will
b. It has physical and emotional effects on the body. you achieve these goals?
c. It may be positive or negative on its effects on 3. After you have been on the job for five years, you
the body. begin to recognize signs of burnout. How will you
d. It is the body’s response to change. manage these symptoms?
2. Hans Selye’s General Adaptation Syndrome theory
proposes that adaptation to stress occurs in how
many stages?
a. 2 stages
WEB ACTIVITIES
b. 3 stages
Search the Internet for additional informa-
c. 4 stages
tion about different relaxation and meditation
d. 5 stages
3. Which is not a stage in the General Adaptation
techniques useful in reducing stress. Choose
Syndrome? the technique that interests you the most and research
a. fight-or-flight it completely. Compile your information into a report
b. exhaustion for your instructor. Be sure to include a bibliography
c. burnout identifying your Web sources.
d. alarm
4. Signs and symptoms of burnout include all of the
following except: REFERENCES/BIBLIOGRAPHY
a. emotional and physical exhaustion
Keir, L., Wise, B. A., Krebs, C., & Kelly-Arnex, C. (2008).
b. hair-trigger display of emotion
Medical assisting: Administrative and clinical competen-
c. feelings of accomplishment and pride in work
cies (6th ed.). Clifton Park, NY: Delmar Cengage
d. irritability and impatience
Learning.
5. Long-range goals are easy to achieve if:
Merriam-Webster’s collegiate dictionary (11th ed.). (1998).
a. they are not too challenging
Springfield, MA: Merriam-Webster.
b. they are divided into a series of short-range goals
Milliken, M.E., & Honeycutt, A. (2004). Understanding
c. they don’t involve too much hard work
human behavior: A guide for health care providers.
d. you never change or adjust them
Clifton Park, NY: Delmar Cengage Learning.
Tamparo, C. D., & Lindh, W. Q. (2008). Therapeutic com-
Critical Thinking munications for health care. Clifton Park, NY: Delmar
1. You have just graduated from a two-year medical Cengage Learning.
assisting program and have been hired by a pediatric What you need to know about stress management. (2004).
practice as an administrative medical assistant. The Retrieved February 27, 2008, from http://stress.
practice is busy with many telephone calls daily and about.com.
many new patients who need charts created and Wilkes, M., & Crosswait, C. B. (1995). Professional develop-
information entered into the database. While in ment: The dynamics of success. San Diego: Harcourt
school you learned that you enjoyed the laboratory Brace Jovanovich.
and clinical work much more than the front-office
The Therapeutic Approach Chapter
to the Patient with a
Life-Threatening Illness 6
KEY TERMS OUTLINE
Durable Power of Attorney Life-Threatening Illness The Therapeutic Response to the
for Health Care Cultural Perspective on Life- Patient with End-Stage Renal
Health Care Directive Threatening Illness Disease
Psychomotor Retardation Choices in Life-Threatening The Stages of Grief
Illness Denial
The Range of Psychological Anger
Suffering Bargaining
The Therapeutic Response to the Depression
Patient with HIV/AIDS Acceptance
The Therapeutic Response to the The Challenge for the Medical
Patient with Cancer Assistant

OBJECTIVES
The student should strive to meet the following performance objectives and
demonstrate an understanding of the facts and principles presented in this
chapter through written and oral communication.

1. Define the key terms as presented in the glossary.

2. Describe possible patient perspectives when facing a life-
threatening illness.
3. Define “life-threatening” illness.
4. Discuss cultural manifestations of life-threatening illness.
5. Identify the strongest cultural influence in the life of a patient.
6. List at least four choices to be made when facing a life-threatening
illness.
7. Briefly describe the use of living wills and health care directives.
8. Explain how a durable power of attorney for health care is used.
9. Discuss the range of psychological suffering that accompanies
life-threatening illnesses.
10. Discuss additional concerns/fears when the life-threatening
illness is AIDS, cancer, or end-stage renal disease.
11. List the five stages of grief and the meaning of the acronym
TEAR.
12. Recall a number of challenges faced by the medical assistant
when caring for people with life-threatening illnesses.

81
 Scenario
You have seen the medical reports and agonize with another appointment at this time. You recognize that
your employer who must tell Suzanne Markis, a long- anything you say probably will not be remembered, so
time patient, when she comes in today that she has you focus entirely on this patient and her immediate
inoperable pancreatic cancer. When she arrives, needs. In a day or two, as instructed by your employer,
you treat her as you normally would, making certain you will make a phone call to set up an appointment
she suspects nothing from you. When she emerges for Suzanne and anyone she might want present at
from the physician’s room, you make certain to meet her visit with the physician so any questions can be
her, take her arm, and ask if you can call someone answered.
for her. You do not present her with a bill or make

INTRODUCTION
Everything you learned in Chapter 4 regarding therapeu-
tic communications is heightened and considered more
difficult when the patient has a life-threatening illness. If
you were told today that your life probably would be short-
ened because of a serious illness, your perspective would
likely change. What was important yesterday may mean
little or nothing now. Something that meant nothing to
you yesterday suddenly takes on great importance to you
now. It is essential for the medical assistant to remem-
ber this difference in perspective and what is likely to be
important to patients with a life-threatening illness.
It also must be remembered that no two individuals
respond to a life-threatening illness in the same way. Some Figure 6-1 Establishing a caring and trusting rela-
respond with denial and act as if the information had never tionship can help the patient come to terms with a
been shared with them. Others alter their lives radically and life-threatening illness.
drastically change their priorities. Still others quietly con-
tinue their lives, changing little outwardly, but recognize
that their choices may now be limited (Figure 6-1). Cultural Perspective
on Life-Threatening Illness
LIFE-THREATENING ILLNESS Strong cultural manifestations will be seen
during the treatment of a life-threatening ill-
A life-threatening illness is not easily defined. ness and in anyone facing death. Culture is
Some use the word terminal; others refuse to defined as how we live our lives, how we think, how we
use that word because they believe it removes speak, and how we behave. Cultures can be accepting,
any hope from the situation. Still others believe denying, or even defying of death. Death can be con-
even the term life-threatening is too hopeless and sidered either as the end of existence or as a transi-
prefer to use the term life-limiting. Also, what is tion to another state of being or consciousness. Death
life-threatening for one individual may not be can be considered as profane or sacred. In some
for another. For our purposes, life-threatening cultures, a life-threatening illness may be viewed or
is used to imply a life that in all probability will be referred to as a “slow-motion” death because of degen-
shortened because of a serious or debilitating ill- erative diseases that often exhaust the resources and
ness or disease. It may be defined as death that is emotions of patients and their families.
imminent; it may be defined in terms of a serious Some cultures prefer that the life-threatening
illness that a person will battle for many years but illness not be shared with the patient in the begin-
will ultimately shorten his or her life. ning, but with the family who helps to prepare

82
 CHAPTER 6 The Therapeutic Approach to the Patient with a Life-Threatening Illness 83

taken to determine and understand the patient’s

Spotlight on Certification cultural perspective as much as possible, and the
patient must be given great respect. Often, the cul-
RMA Content Outline tural influence may contradict the standard of care
• Patient relations preferred by the health care provider. It is better to
• Interpersonal skills understand the culture and work within it than to
• Develop, assemble, and maintain deny it and continually work against the patient’s
patient resource materials belief system and influence of family.
CMA (AAMA) Content Outline
• Basic principles (psychology) CHOICES IN LIFE-THREATENING
• Hereditary, cultural, and environmental ILLNESS
influence on behavior
• Communication Many choices are available to a patient with a life-
• Patient instruction
threatening illness, but many decisions are to be
made, also. The urgency of the decisions will
• Professional communication and
depend, in part, on possible life expectancy. Some-
behavior
times these decisions may seem contrary to recom-
• Medicolegal guidelines and mended medical intervention.
requirements Patients have the right to choose or to refuse
• Legislation treatment in most cases. Some rush into a treat-
CMAS Content Outline ment protocol only to discover later that their
choices have brought them pain, disability, and
• Professionalism
expense far beyond what originally was assumed.
• Patient information and community Although it is the health care professional’s goal
resources to heal, if healing is not likely or possible, patients
ought not to be “urged” into treatment protocols
that are likely to be contrary to their personal
wishes for the sake of treatment only.
the patient for the inevitable. A few cultures gen- Although health care professionals seem less
erally do not seek care for an illness until it is comfortable with death than they are with saving
quite advanced; this practice can make pain man- life, there are some issues appropriate to discuss
agement and treatment more difficult or impos- with patients especially when facing life-threatening
sible in some cases. Some cultures surround the illness. Those issues include the following:
person who is ill with great attention, never leaving
the person alone. Other cultures view the illness as 1. Alternative methods of treatment should be dis-
something that must be removed from the body, cussed, as well as the outcome if no treatment is
perhaps even believing that the individual has sought. At some point, many patients will want
been given this illness because of some past sin or to know all the treatment protocols that are fea-
transgression. sible. This is a logical time to discuss any alterna-
Pain is viewed in the same manner. Some cul- tive or integrative medicine therapies that have
tures believe it is to be endured quietly without shown success. Explanations should be made in
complaint; others believe there is to be no pain, language that the patient can understand. Illus-
and family members will go to great lengths to have trations and diagrams can be beneficial. Referrals
health care providers relieve the pain. When ques- might be made to integrative medicine practitio-
tioning a patient about the pain level, it must be ners, and patients are to be encouraged to discuss
within a cultural perspective. For example, cultures any chosen alternative therapies with their pri-
with an Asian influence are more likely to describe mary care provider. Sometimes treatment alterna-
pain in general terms related to the imbalance of tives the patient may consider are not within the
the body than in terms of “piercing, intermittent, realm of recognized medical acceptability, but it
or throbbing” or on a scale from 1 to 10. is better to have that discussion than to ignore the
The strongest influence in managing any life- possibility. Patients may also ask what happens if
threatening illness in the life of the patient is not no treatment is chosen. This question can be dif-
the health care team; it is the family and those clos- ficult for health care providers who are anxious
est to the patient. Therefore, great care must be to provide some form of treatment for patients,
84 UNIT 2 The Therapeutic Approach

but patients may have a number of reasons not to power of attorney for health care). Any documents
seek treatment. Remember the earlier statement of this nature that the patient has should be cop-
indicating that family members and friends bring ied in the medical chart that goes with the patient
more influence to bear than does the health care when admitted to the hospital. At any time the
professional. patient makes a change in such a document, the
old document is to be replaced with the new one.
2. Discussion of pain management and treatment is
essential. The major fears patients have in facing 4. Finances are to be considered. What will insurance
life-threatening illness are pain and loss of inde- cover (if there is insurance)? Who makes the deci-
pendence. A frank discussion of pain control and sions in a managed care environment? What family
how that can be accomplished can alleviate a fair resources can or will be used? Finances are no one’s
amount of concern. Providers should be ready favorite subject, especially for providers. However,
to discuss loss of independence related to any such a discussion is important. Often, patients fear
life-threatening illness or to make a referral to not being able to meet their financial obligations
someone who can be helpful. Patients have con- and leaving large debts to surviving family mem-
cerns such as wanting to know how long before bers almost as much as the life-threatening illness
the disease takes its toll, how long can they drive, itself. As a medical assistant, you can help patients
what kind of care or assistance will be necessary, understand the parameters of their health insur-
whether they can remain in their own home, and ance and any restrictions there might be on partic-
how long before they must have someone make ular illnesses or treatments. Can medical insurance
decisions for them. be canceled if employment pays a portion of the
health insurance and the patient is no longer able
3. A durable power of attorney for to work? If there is a life insurance policy, help
health care allows an individual to patients determine if any portion of the policy can
make decisions related to health care be used for end-of-life expenses. Any services you
when the patient is no longer able to do so. In the can provide to the patient or family members in
best of circumstances, this document will carry relieving the financial stress can bring great relief
out the decisions the patient has already made in to everyone involved.
a health care directive regarding terminal con-
5. Emotional needs of the patient and family mem-
ditions and whether to prolong life. Advances in
bers are important. Emotional support is vital when
medicine allow patients’ lives to be sustained even
dealing with a life-threatening illness. Health care
when they are unlikely to recover from a persis-
professionals will want to determine the source
tent and vegetative state. The health care directive
of that support for the patient. Should a support
and the durable power of attorney for health care
group be suggested for the patient and family mem-
allow patients to make decisions before becoming
bers? For some patients and families, an individual
incapacitated on whether life-prolonging medical
giving spiritual guidance is seen as a member of
or surgical procedures are to be continued, with-
the family and a member of the health care team.
held, or withdrawn, as well as if or when artificial
For others, no spiritual influence is recognized or
feeding and fluids are to be used or withheld.
sought.
These documents can help providers and patients
talk about dying and open the door to a positive, It is not the responsibility of the health care
caring approach to death. The health care direc- professionals treating the individual with life-
tive and the durable power of attorney for health threatening illness to provide all these services,
care documents are legal in all 50 states. Although but a health care professional who raises these
states may vary somewhat in the wording of these issues for patients and families to deal with is
documents, they provide the same overall ben- more closely in tune with a patient’s power in the
efit to patients (see Chapter 7 for more informa- illness.
tion.) The federal government passed the Patient Life-threatening illnesses are family illnesses.
Self-Determination Act in 1990 giving all patients There are primary (the person suffering from the
receiving care in institutions receiving payments illness) and secondary (family and friends) patients.
from Medicare and Medicaid written information Stress on a spouse or partner is enormous as they
about their right to accept or refuse medical or sur- think about taking over the other person’s role and
gical treatment. The act also requires that patients as they try to deal with their own feelings. Patients
be given information about their options to create and their families and friends often feel angry.
living wills and to appoint someone to act on their The situation is especially tragic if it might have
behalf in making health care decisions (durable been avoided (for example, a long-time smoker
 CHAPTER 6 The Therapeutic Approach to the Patient with a Life-Threatening Illness 85

dying of lung cancer). There needs to be time to ing what would be helpful is often beneficial. Be
grieve. Depression is common among patients with ready with a list of community resources that may
life-threatening illness and warning signs should benefit patients at this time.
be reported to the provider. Remember that how It is not the intention of this chapter to spe-
patients live their last days is just as important as the cifically identify the many life-threatening ill-
numbers on the laboratory reports. nesses and their particular needs. However, three
life-threatening illnesses are identified in the fol-
THE RANGE lowing sections with some specific information
(see Chapter 3 for additional information on
OF PSYCHOLOGICAL AIDS and cancer).
SUFFERING
The range of suffering associated with a life- THE THERAPEUTIC RESPONSE
threatening illness is extensive. Patients feel TO THE PATIENT WITH HIV/AIDS
extreme distress. Anxiety and depression are com-
mon. At the time of diagnosis, patients’ responses Patients testing positive for human immuno-
may include denial, numbness, and inability to deficiency virus (HIV) and those with acquired
face the facts. Sadness, hopelessness, helpless- immune deficiency syndrome (AIDS) feel great
ness, and withdrawal often are exhibited. stress from the infection, the disease, and the fear
The range of psychological suffering leads to of other life-threatening illnesses. Persons with
physical symptoms, such as tension, tachycardia, HIV infection may have only a short time before
agitation, insomnia, anorexia, and panic attacks. the onset of AIDS; others may have a much lon-
The provider may be so intent on treating the ger period. AIDS is a disease that can have many
physical ramifications of the illness that the psy- periods of fairly good health and many periods of
chological suffering is mostly ignored. serious near-death illnesses. Recent developments
Relationships of individuals with a life- in the treatment of HIV infection and AIDS help
threatening illness often change. Close friends patients to live longer, but their lives are greatly
may feel uncomfortable with someone who is compromised because of their suppressed immune
dying. Some fear touching or caressing the dying system.
and become aloof and distant. However, new In some cases, guilt develops about past behav-
friendships can often be made if patients meet ior and lifestyles or the possibility of having trans-
others with the same or similar life-threatening mitted the disease to others. Individuals with HIV
issues and help maintain each other’s self-esteem. infection may feel added strain if this is the first
Relationships are important because they pro-
vide support and encouragement beyond any
other source. Patients experience a loss of self-
esteem when they are ill, are in pain, and have a Complex criteria determine whether a patient’s illness is iden-
body that is failing them. When self-image is lost, tified as AIDS rather than HIV infection. Some providers prefer
not to use the term AIDS; rather, they discuss the illness as
patients feel useless, see themselves as burdens,
early or later stage HIV infection. Many providers in the United
and have difficulty accepting help from anyone. States and around the world use the term AIDS when patients’
The psychological effect of this “loss of self ” can CD4 counts (healthy T4 lymphocytes) decline to less than
even hasten death. 200. (The average healthy individual will have CD4 lympho-
It is often helpful to encourage patients to set cyte counts of 800–1,500.) Many developing countries in the
goals for themselves. These can be small goals such world, however, are unable to measure the CD4 counts. AIDS
as walking around the block, eating all their din- is then diagnosed by the symptoms and any immunodefi-
ner, and connecting with a friend. The goals may cient illnesses the patients have. Using only a CD4 count for
also be much larger, such as staying alive until a diagnosis can be quite discouraging for patients who monitor
son graduates from college, or putting all financial those counts quite closely. Also, a patient’s CD4 count can
matters in order for surviving family members. Per- decrease dramatically into the “AIDS zone” one time, and then
increase in sufficient numbers to move the patient back into
sonal goals give the patient something other than
HIV infection another time. Other criteria that may identify an
the illness to plan for and work toward. illness as AIDS are a particular type of opportunistic infection
Careful listening to patients and seeking or tumor, an AIDS-related brain or lung illness, and severe
clues for what may not be said is essential for the body wasting. Allied health professionals will need to take the
medical assistant and support staff caring for lead from their employers.
patients. Putting yourself in their shoes and ask-
86 UNIT 2 The Therapeutic Approach

knowledge their families have of any high-risk behav- be available in treatment. The fact is that many
iors they have that are associated with the transmis- patients diagnosed with cancer will die, whereas
sion of the disease. When the disease is contracted others diagnosed will live many years after diag-
by individuals who feel they are protected or safe nosis and treatment.
from the disease, anger is paramount. HIV affects The three most likely treatments of cancer are
mostly individuals who are relatively young. Thus, surgery, radiation, and chemotherapy. Often, treat-
they are not as likely to have substantial financial ment is a combination of the three. Patients can
resources or permanent housing. Treating HIV is experience serious side effects from both radiation
expensive, and many patients have little or no insur- and chemotherapy. Alternative practitioners have
ance coverage. shown that meditation or acupuncture can help
Patients with HIV may experience central relieve the side effects for some patients. Loss of
nervous system involvement. Forgetfulness and hair, nausea, vomiting, and pain are quite discon-
poor concentration may be followed by psycho- certing to patients trying to cope. The American
motor retardation, or the slowing of physical and Cancer Society (http://www.cancer.org) has a num-
mental responses, decreased alertness, apathy, ber of resources for patients.
withdrawal, and diminished interest in work. The most common signs and symptoms of
Some patients later experience confusion and advanced cancer are weakness, loss of appetite
progressive impairment of intellectual function and weight, pain, nausea, constipation, sleepi-
or dementia. When HIV-infected patients con- ness or confusion, and shortness of breath. Make
tract other opportunistic diseases, those symp- certain your patients understand your provider’s
toms are experienced as well. willingness to relieve and treat these symptoms.
Even when there is “nothing more to do” related
THE THERAPEUTIC RESPONSE to the cancer, there is still “much to do” to main-
tain comfort and to give patients the chance to
TO THE PATIENT WITH do the things that are meaningful to them and
CANCER their families.

The first reaction patients with cancer usually THE THERAPEUTIC RESPONSE
have is the fear of loss of life. Patients think,
“Cancer equals death. Am I going to die?” After TO THE PATIENT WITH
that, issues begin to differ for each person. A few END-STAGE RENAL DISEASE
may choose no treatment and allow life to take
its course. Most, however, will wonder about what Loss of kidney (renal) function leads to serious
treatment to choose, how to make that choice, illness known as end-stage renal disease (ESRD).
and how effective will it be. Many patients are When the kidneys fail completely, patients can-
empowered by taking a major role in the decision not live for long unless they receive dialysis or a
making related to their cancer. Research can be kidney transplant. A successful kidney transplant
helpful in studying the many options that may relieves the person of kidney failure. However,
there are not enough transplants for every per-
son who needs one, and not all transplants are
appropriate or successful. Dialysis is the process
of artificially replacing the main functions of the
Critical Thinking kidneys—filtering blood to remove wastes. Choos-
ing dialysis as a treatment plan can sustain life
Many individuals in the end stages of for years and is covered by Medicare, but it does
both AIDS and cancer have lost their have complications that burden patients and their
image of themselves. Their bodies have caregivers.
been diminished; they may have lost a Depending on age, a patient’s general health,
great deal of weight from the disease or and other circumstances, some patients will opt not
gained much weight from medications to have dialysis and to let death come from kidney
taken. They may have no hair. They may failure. The by-products of the body’s chemistry
have lost their ability to speak or to control accumulate in renal failure and cause an array of
bodily functions. What can you do or say symptoms. Mild confusion and disorientation are
to help them feel like a human being? common. Upsetting hallucinations or agitation can
occur. Certain minerals concentrated in the blood
 CHAPTER 6 The Therapeutic Approach to the Patient with a Life-Threatening Illness 87

can cause muscle twitching, tremors, and shakes. can be helped to express the anger in a realistic
Some patients experience mild or severe itching. and nonhurtful manner.
Appetite decreases early, and breathing can be
rapid and shallow. Many patients with kidney fail-
ure pass little or no urine. Fluid overload results in
Bargaining
edema, or swelling of the body, particularly of the In this stage, patients bargain with God or a higher
legs and abdomen. Patients with some urine out- being and even their providers and express their
put may live for months even after stopping dial- desire to make a certain milestone in their lives. “If
ysis. People with no urine output are likely to die you can just get me through this current crisis so I
within a week or two. Patients will lose energy and can make it to my 40th wedding anniversary, I can
become sleepy and lethargic. Typically, patients slip accept what is happening.” Goals can be very help-
into a deeper sleep and gradually lose conscious- ful to patients, and they can be encouraged to con-
ness. Kidney failure has a reputation for being a tinue to set realistic goals during their grieving.
gentle death.
Depression
THE STAGES OF GRIEF Patients who reach this stage are sad, sometimes
quiet and withdrawn. There is a feeling that they
There are a number of different philosophies on have given up. They often prefer not to be around
grief and the stages patients are apt to experience anyone. The depression can be and often is treated
when they know their lives are about to end, but so that patients’ grief is eased somewhat. This is
none is so widely known as that of Dr. Elisabeth true especially when patients remain in this stage
Kübler-Ross, who was one of the first to conduct for a very long time.
research and determine possible stages of grief.
Those stages are as follows.
Acceptance
This is the time that patients accept the loss. If it is
Denial death that is being faced, they often feel they are
This is the stage where patients cannot believe that ready. Everything is in place, and peace has been
this is happening. They are likely to experience made with the prognosis. If a loss is being suffered,
shock and dismay. If the grief is for the loss of a it is the time when patients begin to move on and
loved one, it is difficult for them to believe that the make other plans for their lives and their future.
loved one is dead. If the grief is for themselves and Dr. Kübler-Ross reminds health care pro-
some incident in their lives, they have a hard time fessionals that not all patients go through all five
accepting the reality of the loss. Words such as “I stages; some patients go through all five stages over
can’t believe it is true,” and “There must be some and over again, each time with a little less stress.
mistake” are common. Others get stuck in one stage, usually denial. Grief
It is difficult to help someone in denial. You and dying are very personal. No two patients will
may be able to reaffirm the reality of the circum- follow the same pattern. Family members suffering
stances, but there is little you can do to move some- grief are often in different stages; therefore, com-
one from the stage of denial. munication and help for each other often are dif-
ficult. Remember that grief work is exhausting. So
much energy is spent in the grief process that it is
Anger often difficult to carry on day-to-day tasks. Any help
Patients express anger, sometimes openly and that can be made available is appreciated.
assertively. Other times, the anger is turned inward
and is difficult to accurately express. Patients ask
the question “Why?” and often need explanations
of what is occurring. Anger is often expressed to Critical Thinking
others who have no idea what is happening in
patients’ lives. What steps would you personally take to
This type of anger should be realized for what make certain you do not burnout from caring
it is when possible and never taken personally. for patients with a life-threatening illness?
Patients are angry at the event, not at you. Patients
88 UNIT 2 The Therapeutic Approach

The acronym TEAR is fairly popular and is want up-to-date information on their disease, its
often used to describe the grieving process. It has causes, modes of transmission, treatments avail-
similarities to the five stages of grief: able, and sources of care and social support. Be
prepared to recommend support groups where
T: To accept the reality of the loss patients can discuss their feelings and express
E: Experience the pain of the loss their concerns. Treat patients with concern and
A: Adjust to what was lost compassion and assure them everything will be
R: Reinvest in a new reality done to provide continuity of care and relief from
distress. Patients also may be encouraged to call
Although the five stages of grief and TEAR dis- on a spiritual advisor.
cussed in this chapter are directed toward patients
with life-threatening illnesses, remember that family
members and loved ones of patients also will expe-
rience grief. Both of these principles can be applied Case Study 6-1
to any kind of serious loss that occurs in one’s life—
loss of a job, divorce, disaster, war, famine, loss of a Review the scenario at the beginning of the chapter. As
limb or important body function, Alzheimer’s dis- you prepare for the second visit of Suzanne Markis, you
ease, loss of a friend, even the death of a beloved make a mental note of what kind of information you will
pet. The stages of grief and the acronym TEAR can have available.
apply just as easily to these situations.
Dr. Kübler-Ross, in her final days before her CASE STUDY REVIEW
own death in 2004, reminded her co-author to
“Listen to the dying. They will tell you everything 1. What paperwork might be necessary?
you need to know about when they are dying. And 2. What questions might you have for Suzanne?
it is easy to miss.”
3. What might family members who may accom-
pany Suzanne want to know?
THE CHALLENGE 4. As the medical assistant, how does your role
FOR THE MEDICAL differ from that of your employer?
ASSISTANT
As a medical assistant, you face the chal-
lenge of caring for people with a life-
threatening illness; you can comfort those Case Study 6-2
who face great suffering and death. You will become
a source of information for patients and their sup- The extended family of Wong Lee is concerned about his
port members. Be sensitive and respectful toward illness and his care. Chronic obstructive pulmonary dis-
individuals who may be shunned by society. Exam- ease (COPD) has ravaged his body. He is on oxygen all
ine your own beliefs, lifestyle, and biases so that you the time now. He wants to remain at home to die; his fam-
can be comfortable treating all patients, no matter ily wants that, too. The family has been with him and has
what the illness is or how it was contracted. been involved in his care plan all along. However, you are
As well as assisting your employer in provid- uncertain of how much information to give to members of
ing the best possible medical care, many nonmedi- his extended family when they call.
cal forms of assistance may be required by patients
suffering from a life-threatening illness. You may CASE STUDY REVIEW
need to make referrals to community-based agen-
1. Are the questions the extended family members
cies or service groups. Health departments, social
raise intended to harm or help Mr. Lee?
workers, trained hospice volunteers, and AIDS and
cancer volunteers may also be helpful to you, your 2. Is there a durable power of attorney for health
patients, and their families. care in place?
The best therapeutic response to the patient 3. Which, if any, of the family’s desires are related to
with a life-threatening illness will build on the the culture?
person’s own culture and coping abilities, capital- 4. What can you and your employer suggest to be
ize on strengths, maintain hope, and show con- of help to everyone involved?
tinued human care and concern. Patients may
 CHAPTER 6 The Therapeutic Approach to the Patient with a Life-Threatening Illness 89

Case Study 6-3

Jeff and Amy live in rural Tennessee. They are expecting their CASE STUDY REVIEW
first baby and are excited beyond belief because they had so
much trouble getting pregnant. You are the medical assistant 1. As the medical assistant, what is your first respon-
for their family practice provider. Test results from their recent sibility to these expectant parents?
ultrasound have been returned to your clinic, and the news 2. Where might you look for possible resources?
is not good. There appears to be some difficulty and one or 3. Identify three to five possible resources.
more apparent birth defects in the developing fetus. You and
4. If referral to a specialist is to be made, what role
your employer discuss possible resources.
might you play in that referral?

SUMMARY
Medical assistants will want to remember that when caring for patients with a life-threatening illness, hav-
ing even the slightest fear of death can undermine the ability to respond professionally, with empathy and
support. If you feel yourself losing the ability to be helpful, it is time to briefly step aside. This does not
mean withdrawal from your position or refusal to care for your patients. It means that you do whatever is
necessary so that your perspective is not lost. It may mean taking a day off from work to “fill up your psyche”
and to give yourself a rest. If the ambulatory care setting has an abundance of patients with life-threatening
illnesses, it may require that you spend some time in a support group of your own so that you are better
able to cope. Never be afraid to feel sad or weep with your patients. It is better to sense their pain and, at
times, feel the pain with them, than it is to be so clinically objective that you miss their true needs.

STUDY FOR SUCCESS

To reinforce your knowledge and skills of information in this chapter:
• Review the Key Terms
• Consider the Case Studies and discuss your conclusions
• Answer the Review Questions

˚ Multiple Choice
˚ Critical Thinking
• Navigate the Internet and complete the Web Activities
• Practice the StudyWARE activities on the textbook CD
• Apply your knowledge in the Student Workbook activities
• Complete the Web Tutor sections
• View and discuss the DVD situations
90 UNIT 2 The Therapeutic Approach

REVIEW QUESTIONS
Multiple Choice b. enables someone other than the patient to make
any decisions for the patient
1. When a practice treats patients with HIV/AIDS, c. makes certain that patients’ financial respon-
cancer, or ESRD, it is important for medical sibilities are met
assistants to: d. makes certain an attorney’s wishes are followed
a. warn other patients about the dangers of 9. The confusion, disorientation, and mental deficiency
transmission sometimes seen in patients with life-threatening
b. segregate these patient reception areas from illness:
other patient areas a. may make communication difficult or impossible
c. be supportive and free of prejudice b. is a good reason for a durable power of attorney
d. deny any information to patients regarding the for health care
seriousness of the illness c. is made easier if patients expressed earlier their
2. The Patient Self-Determination Act: desires in a health care directive
a. allows a patient to have a choice of providers d. all of the above
b. ensures a patient’s right to accept or refuse 10. Effective pain management may depend on:
treatment a. patient’s medical insurance
c. gives patients the right to formulate advance b. family wishes and patient’s needs
directives c. professional nursing criteria
d. all of the above d. all of the above
e. only b and c
3. The strongest influence on a patient with a life- Critical Thinking
threatening illness is:
a. the provider 1. Discuss with a friend what cultural influences
b. the hospital might affect each of you if you were facing a life-
c. the family threatening illness. What choices would each of
d. the patient you make?
4. Life-threatening illness may be defined as: 2. Discuss with a classmate your concerns in dealing
a. a life shortened because of serious illness or with patients with a life-threatening illness. Would
disease you choose to work where you seldom lost a patient
b. death that is imminent to a life-threatening illness? If so, what are your
c. serious illness to battle for many years but may reasons?
shorten life 3. At Inner City Health Care, Dr. Ray Reynolds is
d. all of the above known for his compassion and great warmth toward
5. Culture may be defined in part as: people. On difficult days at the center, this attitude
a. how we choose a friend holds him in good stead. Sometimes, he tends to
b. how we think and live our lives take on the more challenging cases: patients with
c. how we select a medication life-threatening diseases, often young people with
d. all of the above AIDS who should be in the prime of their lives.
6. Therapeutic communication with a patient with a Clinical medical assistant Wanda Slawson always
life-threatening illness: tries to learn from Dr. Reynolds’ example. Although
a. is no different than communicating with any she is quieter and not as outgoing as Dr. Reynolds,
patient Wanda hopes to be both courteous and comforting
b. is heightened and considered more difficult to patients, especially those who are anxious. She
c. is left to nonmedical support staff makes it a point to help patients discover a new way
d. comes naturally and requires no special skill to cope with debilitating diseases. What resources
7. Cultural influence may in part determine: might she use?
a. when/how to involve family members 4. Teri Montague, RMA, is the office manager for a
b. whether spiritual support is sought pediatric oncologist. In the past several months
c. how the illness and its pain is managed there seem to have been more patient deaths than
d. all of the above usual. She notices that the entire staff seems “low
8. Durable power of attorney for health care: and a little depressed.” She discusses this concern
a. enables someone other than the patient to make with her employer, Dr. Anita Glenn. The decision
only health care decisions is made to close the office for a 2-hour lunch on
 CHAPTER 6 The Therapeutic Approach to the Patient with a Life-Threatening Illness 91

Wednesday. The lunch will be catered, and a very 2. Search the Internet for sites on grieving or grief.
good friend of Dr. Glenn will be invited to join Pay particular attention to sites that have resources
everyone. Dr. Penny Hein has a PhD in psycho- for grieving children or teens. What particular help
social nursing and years of experience in grief do you find? Do children and teens grieve differ-
counseling. Teri and Dr. Glenn believe she can give ently than adults? If so, explain.
everyone some helpful information. Is this a good 3. Using the Internet can be challenging, especially if
plan? Why or why not? you find more than a million sites to browse. That is
5. A danger in having a fair amount of knowledge what you will find if you key in “Helping the Dying.”
about life-threatening illnesses and the grief that Choose a couple of the topics that are especially
accompanies them can be that we hope to be helpful to you or might help other students study-
able to “fix” everything. With a friend, discuss ing this chapter. Write a brief paragraph on each.
the following statement made by Dr. Kübler-Ross:
“Listen to the dying. They will tell you everything
you need to know about when they are dying. And REFERENCES/BIBLIOGRAPHY
it is easy to miss.” What does she mean? Why is it
easy to miss? Kübler-Ross, E., & Kessler, D. (2005). On grief and grieving.
New York: Scribner.
Lewis, M., & Tamparo, C. (2007). Medical law, ethics,
WEB ACTIVITIES and bioethics for the health professions. Philadelphia:
F. A. Davis.
1. Using your favorite search engine, key in Purnell, L., & Paulanka, B. (1998). Transcultural health
American Cancer Society and look for care: A culturally competent approach. Philadelphia:
statistics for the current year. Pay particular F. A. Davis.
attention to the area reporting how long patients sur- Tamparo, C., & Lindh, W. (2007). Therapeutic commu-
vive after diagnosis. What are the major changes in the nications for health care. Clifton Park, NY: Delmar
last two years? Cengage Learning.

THE DVD HOOK-UP

This chapter introduces you to the concept of using a DVD Journal Summary
therapeutic approach when working with patients. Write a paragraph that summarizes what you learned from
In the designated DVD clip, we observed Mrs. Smith become watching the designated scene from today’s DVD program.
quite anxious about her abnormal mammogram results. We Did you empathize with Mrs. Smith regarding her anxiety
also observed how Gwen, the medical assistant, addressed over her abnormal mammogram? What will you do when
Mrs. Smith’s concerns. you are faced with similar challenges in the industry? Do
you think that you could ever work in an oncology practice?
1. Do you feel that Gwen demonstrated a therapeutic Why or why not?
approach toward Mrs. Smith’s concern over her abnor-
mal mammogram results?
2. List some gestures that Gwen used that illustrated her
concern and compassion toward the patient.
3. Did Gwen overstep her boundaries as a medical assis-
tant when she discussed the mammogram results
with Mrs. Smith, or do you think that Gwen was trying
DVD Series Program Number
to help the patient understand what the provider had
Critical Thinking 2
already explained?
Chapter/Scene Reference
• Communicating with Patients
UNIT
Responsible Medical
3 Practice

Chapter 7
Legal Considerations
Chapter 8
Ethical Considerations
Chapter 9
Emergency Procedures and First Aid
 Chapter

Legal Considerations 7
KEY TERMS OUTLINE
Administer Sources of Law Informed Consent
Administrative Law Statutory Law Implied Consent
Agent Common Law Consent and Legal
Alternative Dispute Criminal Law Incompetence
Resolution (ADR) Civil Law Risk Management
Arbitration Administrative Law Civil Litigation Process
Civil Law Title VII of the Civil Rights Act Subpoenas
Common Law Federal Age Discrimination Discovery
Act Pretrial Conference
Constitutional Law
Uniform Anatomical Gift Act Trial
Contract Law Regulation Z of the Consumer Statute of Limitations
Criminal Law Protection Act Public Duties
Defendant Occupational Safety and Reportable Diseases/Injuries
Deposition Health Act Abuse
Discovery Controlled Substances Act Good Samaritan Laws
Dispense Americans with Disabilities Act Advance Directives
Family and Medical Leave Act Living Wills/Advance
Durable Power of Attorney
for Health Care Health Insurance Portability Directives
Emancipated Minor and Accountability Act Durable Power of Attorney
Contract Law for Health Care
Expert Witness
Termination of Contracts Patient Self-Determination Act
Expressed Contract
Tort Law
Felony
Medical Practice Acts
Health Insurance Standard of Care
Portability and
Accountability
Act (HIPAA)
Implied Consent
OBJECTIVES
The student should strive to meet the following performance objectives and
Implied Contract
demonstrate an understanding of the facts and principles presented in this chapter
Incompetence through written and oral communication.
Informed Consent
Interrogatory 1. Define the key terms as presented in the glossary.
Intimate Partner 2. List and briefly describe the five sources of law.
Violence (IPV) 3. Compare/contrast civil and criminal law.
Libel 4. Identify the three major areas of civil law that directly affect the
Litigation medical profession.
Malfeasance 5. Recall at least seven of the nine administrative law acts important to
Malpractice the medical profession.

93
93
 OBJECTIVES (continued) KEY TERMS
6. Compare/contrast administering, prescribing, and
(continued)
dispensing of controlled substances. Mature Minor
7. Describe the measures to take for disposal of controlled Mediation
substances.
Medically Indigent
8. Recall the three main goals of HIPAA. Minor
9. Explain the differences between expressed and implied Misdemeanor
contracts.
Misfeasance
10. Identify the three main reasons for a provider/patient Negligence
contract to be terminated.
Noncompliant
11. Define and give examples of torts.
Nonfeasance
12. Compare/contrast intentional and negligent tort. Patient Self-Determination
13. Discuss licensure renewal and revocation for physicians. Act (PSDA)
14. List and describe the 4Ds of negligence. Plaintiff
15. Discuss what constitutes battery in the ambulatory care Precedents
setting. Prescribe
16. Describe the two forms of defamation of character and Risk Management
how it might occur. Slander
17. Recall how medical assistants can help to maintain a Statutory Law
patient’s privacy. Subpoena
18. Discuss informed consent and its importance. Tort
19. Compare/contrast the types of minors. Tort Law
20. Identify at least 10 practices to help in risk management.
21. Outline the necessary steps in civil litigation and how a
medical assistant might be involved.
22. Discuss how and when subpoenas are used.
23. Recall the special considerations for patients related to
issues of confidentiality, the statute of limitations, and
public duties.
24. Describe procedures to follow in reporting abuse.
25. Discuss Good Samaritan laws.
26. Identify various forms of advance directives.
27. Recall maintenance of advance directives in the
ambulatory care setting.
28. Discuss the durable power of attorney for health care.

Scenario
Gwen, the office manager in Dr. Gold’s office, is creeping into their busy activities. Gwen has heard
reviewing legal concerns in a staff meeting. Even voices of staff from the hallway discussing confiden-
though each employee is well aware of privacy, confi- tial matters, notices an occasional medical chart in
dentiality, and the many ways their actions are legally public view, and wants to review HIPAA compliance.
binding, Gwen has noticed occasional carelessness

94
 CHAPTER 7 Legal Considerations 95

INTRODUCTION Spotlight on Certification

The law as it relates to health care has grown increas- RMA Content Outline
ingly complex in the last decade. The agendas of federal • Medical law
and state governments include an investigation of qual- • Licensure, certification, registration
ity health care, a desire to control health care costs (while
• Principles of medical ethics
hoping to ensure equitable access to health care), and
an interest in protecting the patient. A full discussion of • Ethical conduct
health law requires several volumes; therefore, the aim of • Drugs
this chapter is awareness of the law and its implications • Safety
and establishment of sound practices and procedures to • Legal responsibilities
both safeguard patient rights and protect the health care CMA (AAMA) Content Outline
professional.
• Displaying professional attitude
• Performing within ethical boundaries
SOURCES OF LAW • Maintaining confidentiality
• Licenses and accreditation
Law is a binding custom or ruling for • Legislative
conduct that is enforceable by an agency • Documentation/reporting
assigned that authority. The highest au-
• Releasing medical information
thority in the United States is the U.S. Constitu-
tion. Adopted in 1787, this document provides • Provider–patient relationship
the framework for the U.S. government. The Con- CMAS Content Outline
stitution includes 27 amendments, 10 of which • Legal and ethical considerations
are known as the Bill of Rights. This authority is
• Professionalism
sometimes referred to as constitutional law. The
• Confidentiality
U.S. Constitution calls for three branches of the
federal government: • Safety
• Risk management and quality assurance
• Executive branch: the President and Vice Presi-
dent (elected by U.S. citizens), Cabinet officers,
and various other departments of the federal gov- of laws made by states is known as statutory law.
ernment All powers that are not conferred specifically on
• Legislative branch: members of the U.S. Senate the federal government are retained by the state,
and the House of Representatives (elected by U.S. yet states vary widely in their interpretation of
citizens) and the staffs of individual legislators and that power. State law cannot override the power
legislative committees. of any laws defined in the U.S. Constitution or its
• Judicial branch: the courts, including the U.S. amendments.
Supreme Court, Courts of Appeals for the nine
judicial regions, and District Courts Common Law
Laws enacted at the federal level are called acts Common law is not so easily defined but is essen-
or laws. An example is Title XIX of Public Law tial to understanding law in the United States.
established in 1967 to provide health care for the Common law was developed by judges in England
medically indigent. This program is known as and France over many centuries and was brought
Medicaid. to the United States with the early settlers. Com-
mon law is often called judge-made law. The
law consists of rulings made by judges who base
Statutory Law their decisions on a combination of a number
Constitutions in the 50 states identify the rights of factors: (1) individual decisions of a court,
and responsibilities of their citizens and identify (2) interpretation of the U.S. Constitution or a
how their state is organized. States have a gov- particular state constitution, and (3) statutory
ernor as the head and state legislatures (both law. These decisions become known as prece-
elected by the state’s citizens), as well as their own dents and often lay down the foundation for sub-
court systems with a number of levels. The body sequent legal rulings.
96 UNIT 3 Responsible Medical Practice

the defendant. The most common forms of civil

Criminal Law law that directly affect the medical profession are
Criminal law addresses wrongs committed against administrative law, contract law, and tort law.
the welfare and safety of society as a whole. Crimi-
nal law affects relationships between individuals
and between individuals and the government. ADMINISTRATIVE LAW
Another term that might be used to describe a
criminal act is malfeasance. Malfeasance is conduct Administrative law establishes agencies
that is illegal or contrary to an official’s obligation. that are given power to specialize and
Criminal offenses generally are classified into the enact regulations that have the force of
basic categories of a felony or a misdemeanor that law. The Internal Revenue Service is an example
are specifically defined in statutes. of an administrative agency that enacts tax laws
Felonies are more serious crimes and include and regulations. Health care professionals are
murder, larceny or thefts of large amounts of money, bound by federal administrative law through the
assault, and rape. Punishment for a felony is more Medicare and Medicaid program rules adminis-
serious than for a misdemeanor. A convicted felon tered by the Social Security Administration.
cannot vote, hold public office, or own any weapons. There are a number of other regulations in
Felonies often are divided into groups such as first administrative law governing health professionals
degree (most serious), second degree, and third and their employees. It is important that medical
degree. Sentences are generally for longer than one assistants be informed of legislation and any fed-
year and are served in a penitentiary. Misdemeanors eral or state regulations that are critical to patients
are considered lesser offenses and vary from state to and the medical profession. Identified here with
state. Punishment may include probation or a time a brief description are additional administrative
of service to the community, a fine, or a jail sentence acts, some of which also are referred to in other
in a city or county facility. Misdemeanors also can be chapters in this textbook.
divided into groups or classifications, such as A, B,
or C class misdemeanors, denoting the seriousness
of the crime (Class A is the most serious).
Title VII of the Civil Rights Act
For a person to be found guilty of a crime, Title VII of the Civil Rights Act of 1964 protects
a judge or jury must prove the evidence against employees from sexual harassment and a hostile
the individual “beyond a reasonable doubt.” In a work environment. The office of Equal Employ-
criminal case, charges are brought against an indi- ment Opportunities Commission (EEOC) guide-
vidual by the state with the intent of preventing lines make the employer strictly liable for the
any further harm to society. For example, a physi- acts of supervisory employees, as well as for some
cian practicing medicine without a proper license acts of harassment by coworkers and clients (see
may be subject to criminal action by the courts for Chapter 34).
endangering a patient’s life. Harassment occurs when sexual favors are
implied or requested by a supervisor in return for
job advancement or special treatment on the job.
Civil Law Another form of harassment and a more common
Civil law affects relationships between individuals, problem that may exist in the workplace is referred
corporations, government bodies, and other orga- to as a “hostile work environment.” When pervasive
nizations. Terms that may be used in civil law are or severe sexual comments, jokes, or inappropri-
misfeasance, referring to a lawful act that is improp- ate touching create a workplace so negative that it
erly or unlawfully executed, and nonfeasance, interferes with an employee’s work performance, a
referring to the failure to perform an act, official hostile work environment exists.
duty, or legal requirement. The punishment for A written policy on sexual harassment detail-
a civil wrong is usually monetary in nature. When ing inappropriate behavior and stating specific steps
a charge is brought against a defendant in a civil to be taken to correct an inappropriate situation
case, the goal is to reimburse the plaintiff or the should be established. The policy should include
person bringing charges with a monetary amount (1) a statement that harassment is not tolerated,
for suffering, pain, and any loss of wages. Another (2) a statement that an employee who feels harassed
goal might be to make certain the defendant is pre- needs to bring the matter to the immediate atten-
vented from engaging in similar behavior again. In tion of a person designated in the policy, (3) a state-
civil law, cases need to show that a “preponderance ment about the confidentiality of any incidents and
of the evidence” is more than likely true against specific disciplinary action against the harasser, and
 CHAPTER 7 Legal Considerations 97

(4) the procedure to follow when harassment occurs. clients for payment of medical bills in more than
It is illegal for a supervisor or employer to ignore an four installments must be in writing and must
employee’s complaint. An employer or supervisor provide information on any finance charge. This
who does not take corrective action is liable. act is enforced by the Federal Trade Commission.
These guidelines are often seen in prearrange-
ments for surgery or prenatal care and delivery in
Federal Age Discrimination Act fee-for-service plans, because patients may not be
The Federal Age Discrimination Act of 1967 states able to pay the entire fee in one payment.
that an employer with 15 or more employees must
not discriminate in matters of employment related Occupational Safety
to age, sex, race, creed, marital status, national
origin, color, or disabilities. Some states are more
and Health Act
restrictive in their law and identify employers with The Occupational Safety and Health Act
eight or more employees. Valid reasons to decline (OSHA) of 1967 is a division of the U.S.
applicants include (1) health issues that may inter- Department of Labor. Its mission is to
fere with the safe and efficient performance of the ensure that a workplace is safe and has a healthy
job, (2) unavailability for the work schedule of the environment. Penalties can be quite high for
particular job, (3) insufficient training or experi- repeated and willful violations assessed by OSHA.
ence to perform the duties of the particular job, These guidelines make certain that all employees
and (4) someone else is better qualified. Although know what chemicals they are handling, know how
some health care settings have fewer than 15 or to reduce any health risks from hazardous chemi-
even 8 employees, it is best to follow state and fed- cals that are labeled 1 to 4 for severity, and have
eral guidelines on all employment. Material Safety Data Sheets (MSDSs) listing every
As of October 2008, 19 states have laws ban- ingredient in the product. Other sections of this
ning discrimination because of sexual orienta- law protecting medical assistants and patients
tion. Those states are California, Connecticut, are detailed in additional chapters. They include
Hawaii, Illinois, Iowa, Maine, Maryland, Massa- Clinical Lab Improvement Amendments of 1988
chusetts, Minnesota, Nevada, New Hampshire, (CLIA) (see Chapter 26), Blood-borne Pathogens
New Jersey, New Mexico, New York, Oregon, Standard of July 1992 (see Chapter 10), and the
Rhode Island, Vermont, Washington, and Wis- Needle Stick Prevention Amendment of 2001 (see
consin. The District of Columbia passed similar Chapter 10).
legislation.
Controlled Substances Act
Uniform Anatomical Gift Act The Controlled Substances Act of 1970 became
The Uniform Anatomical Gift Act of 1968 allows effective in 1971. The act is administered by the
persons 18 years and older and of sound mind to Drug Enforcement Administration (DEA) under
make a gift of all or any part of their body (1) to any the auspices of the U.S. Department of Justice. The
hospital, surgeon, or physician; (2) to any accred- Controlled Substances Act lists controlled drugs
ited medical or dental school, college, or uni- in five schedules (I, II, III, IV, and V) according
versity; (3) to any organ bank or storage facility; to their potential for abuse and dependence, with
and (4) to any specified individual for educa- Schedule I having the greatest abuse potential
tion, research, advancement of medical/dental and no accepted medical use in the United States.
science, therapy, or transplantation. The gift may This act and the U.S. Code of Federal Regulations
be noted in a will or by signing, in the presence regulate individuals who administer, prescribe, or
of two witnesses, a donor’s card. Some states allow dispense any drug listed in the five schedules. Any
these statements on the driver’s license. There is
no cost to donors or their families for gifts of all
or part of the body.

Regulation Z of the Consumer Critical Thinking

Protection Act
Identify the type of providers or medical spe-
Regulation Z of the Consumer Protection Act of cialties most likely to administer and dispense
1967, referred to as the Truth in Lending Act, controlled substances.
requires that an agreement by providers and their
98 UNIT 3 Responsible Medical Practice

individual who administers, prescribes, or dispenses abilities cannot be accommodated in perform-

any controlled substance must be registered with ing the job requirements. Employers only have to
the DEA. The DEA supplies a form for registration provide reasonable accommodations rather than
and mandates that renewal occurs every 3 years. anything an employee demands or something that
A provider who only prescribes Schedule II, is extraordinarily expensive. Individuals who for-
III, IV, and V controlled substances in the lawful merly abused drugs and alcohol and those who are
course of professional practice is not required to undergoing rehabilitation also are covered by the
keep separate records of those transactions. The ADA and cannot be denied employment because
majority of all providers fall within this category. of their history of substance abuse.
Providers who regularly administer controlled sub- Titles II, III, and IV mandate disabled indi-
stances in Schedules II, III, IV, and V or who dis- viduals access to public services, public accommo-
pense controlled substances are required to keep dations, and telecommunications. ADA protects
records of each transaction. persons with HIV infection or AIDS, making cer-
An inventory must be taken every 2 years of tain they cannot be refused treatment by health
all stocks of the substances on hand. The inventory care professionals because of their health status.
must include (1) a list of the name, address, and Generally speaking, health care professionals with
DEA registration number of the provider; (2) the HIV infection or AIDS cannot be kept from provid-
date and time of the inventory; and (3) the signa- ing treatment either, unless that treatment could
tures of the individuals taking the inventory. This be found to be a significant risk to others. Title V
inventory must be kept at the location identified covers a number of miscellaneous issues such as
on the registration certificate for at least 2 years. All exclusions from the definition of “disability,” retali-
Schedule II drug records must be maintained sepa- ation, insurance, and other issues. The ADA applies
rate from all other controlled substance records. to businesses with at least 15 employees, but some
These records must be made available for inspec- states have more stringent laws.
tion and copying by duly authorized officials of the
DEA. Some states are even more restrictive than the
federal requirements.
Family and Medical Leave Act
Any necessary disposal of controlled sub- The Family and Medical Leave Act (FMLA) of 1993
stances, usually occurring when they become out- is important for large ambulatory care centers and
dated or when a medical practice is closed, requires hospitals. FMLA requires all public employers and
specific action. The provider’s DEA number and reg- any private employer of 50 or more employees to
istration certificate should be returned to the DEA. provide up to 12 weeks of job-protected, unpaid
Specific guidelines for destruction of the controlled leave each year for the following reasons: (1) birth
substances will need to be obtained from the near- and care of the employee’s child, or placement for
est divisional office for the DEA. Using the Internet, adoption or foster care of a child; (2) care of an
search using the words “Controlled Substances Act immediate family member who has a serious health
of 1970” for a listing of sites providing more infor- condition; and (3) care of the employee’s own
mation. You will find a listing of drugs in each of the serious health issue. Employees must have been
five schedules that change from time to time as new employed for at least 12 months and have worked
drugs come on the market and are classified. at least 1,250 hours in the 12 months preceding the
beginning of the FMLA leave.
Americans with Disabilities Act
Health Insurance Portability
The Americans with Disabilities Act (ADA) of
1990 prohibits discrimination preventing individu-
and Accountability Act
als who have physical or mental disabilities from The Health Insurance Portability and Ac-
accessing public services and accommodations, HIPAA countability Act (HIPAA) of 1996 requires
employment, and telecommunications. A disabil- the Department of Health and Human
ity implies that a physical or mental impairment Services to adopt national standards for electronic
substantially limits one or more of an individual’s health care transactions. The law also requires the
major life activities. ADA is identified in five titles. adoption of privacy and security standards to pro-
Title I, enforced by the EEOC, prohibits discrimi- tect an individual’s identifiable health information.
nation in employment (see Chapter 34 for further The goal of HIPAA is also to assist in making health
details). Essentially, Title I requires a potential insurance more affordable and accessible to indi-
employer to identify and prove that certain dis- viduals by protecting health insurance coverage
 CHAPTER 7 Legal Considerations 99

for workers and their families when they change or CONTRACT LAW
lose their jobs.
HIPAA law is identified in seven titles. They The contractual nature of the provider–
are summarized briefly as follows: patient relationship necessitates a discus-
sion of contracts, which are an important
I. Health Insurance Access, Portability, and Renewal: part of any medical practice. A contract is a bind-
Increases the portability of health insurance, allows ing agreement between two or more persons. A
continuance and transfer of insurance even with provider has a legal obligation, or duty, to care for
preexisting conditions, and prohibits discrimina- a patient under the principles of contract law. The
tion based on health status. agreement must be between competent persons to
II. Preventing Health Care Fraud and Abuse: Estab- do or not to do something lawful in exchange for
lishes a fraud and abuse system and spells out a payment.
penalty if either event is documented; improves A contract exists when the patient arrives for
the Medicare program through establishing stan- treatment and the provider accepts the patient by
dards; establishes standards for electronic trans- providing treatment. An example of a valid contract
mission of health information. occurs when a patient calls the office or clinic to
III. Tax-Related Provisions: Promotes the use of medi- make an appointment for an annual physical exam-
cal savings accounts (MSAs) used for medical ination. Assuming both provider and patient are
expenses only. Deposits are tax-deductible for competent, and that the provider performs the law-
self-employed individuals who are able to draw on ful act of the physical examination and the patient
the accounts for medical expenses. pays a fee, all aspects of the contract exist.
There are two types of contracts: expressed
IV. Group Health Plan Requirements: Identifies how
and implied. An expressed contract can be writ-
group health care plans must plan for portability,
ten or verbal and specifically describes what each
access, and transferability of health insurance for its
party in the contract will do. A written contract
members.
requires that all necessary aspects of the agree-
V. Revenue Offsets: Details how HIPAA changed the ment be in writing. An implied contract is indicated
Internal Revenue Code to generate more revenue by actions rather than by words. The majority of
for HIPAA expenses. provider–patient contracts are implied contracts.
VI. General Provisions: Explains how coordination It is not required that the contract be written to
with Medicare-type plans must be carried out to be enforceable as long as all points of the contract
prevent duplication of coverage. exist. An implied contract can exist either by the
VII. Assuring Portability: Ensures employee coverage circumstances of the situation or by the law. When
from one plan to another; written specifically for a patient reports a sore throat and the provider
health insurance plans to ensure portability of cov- takes a swab for a throat culture to diagnose and
erage. treat the ailment, an implied contract exists by the
circumstances. An implied contract by law exists
As of April 21, 2006, all covered health care when a patient goes into anaphylactic shock and
entities were to have been in compliance of the provider administers epinephrine to counter-
HIPAA’s regulations. These regulations caused act shock symptoms. The law says that the provider
concern among providers. However, once the elec- did what the patient would have requested had
tronic codes and transactions for electronic filing there been an expressed contract.
of health insurance claims were identified and For a contract to be valid and binding, the
put in place, the required security and privacy of parties who enter into it must be competent; there-
all patient information was not so complex. Medi- fore, the mentally incompetent, the legally insane,
cal facilities and providers who were consistently individuals under heavy drug or alcohol influ-
diligent about protecting patient confidentiality ences, infants, and some minors cannot enter into
found complying with HIPAA not too difficult. a binding contract.
Many helpful Web sites are available simply by Medical assistants are considered agents of
keying in HIPAA and having your favorite search the employers they serve, and as such must be cau-
engine identify sites. Look for a site that explains tious that their actions and words may become
this public law and gives current updates. You will binding for their employers. For example, to say
see mention of HIPAA throughout this that the provider can cure the patient may cause
HIPAA text as identified by the HIPAA icon as
shown on the left.
serious legal problems when, in fact, a cure may
not be possible.
100 UNIT 3 Responsible Medical Practice

example, the patient becomes noncompliant or

Termination of Contracts the provider feels the patient can no longer be
A broken contract or breach of contract occurs served. Again, notice should be sent to the patient
when one of the parties does not meet contractual by certified mail with return receipt requested,
obligations. A provider is legally bound to treat a and a copy of the notice should be filed in the
patient until: patient’s record (Figures 7-2 and 7-3).
• The patient discharges the provider The Patient No Longer Needs Treatment. Unless
• The provider formally withdraws from patient a formal discharge or withdrawal has occurred, a
care provider is obligated to care for a patient until the
• The patient no longer needs treatment and is for- patient’s condition no longer requires treatment.
mally discharged by the provider

Patient Discharges Provider. When the patient Inner City Health Care
discharges the provider, a letter should be sent to the 222 S. First Avenue
patient to confirm and document the termination of Carlton, MI 11666
the contract. The notice is sent by certified mail with May 9, 20XX
return receipt requested. Keep a copy of the letter in CERTIFIED MAIL
the patient’s record (Figure 7-1).
Lenny Taylor
260 Second Street
Provider Formally Withdraws from the Case. To Carlton, MI 11666
avoid any charges of abandonment, the provider
should formally withdraw from the case when, for Dear Mr. Taylor:
You will recall that we discussed our professional relation-
ship in my office on May 6, 20XX.
Your son, George Taylor, and Bruce Goldman, my medical
assistant, were also present. As you know, the primary difficulty
L&K
LEWIS & King, MD
2501 center street
northborough, oh 12345 has been your failure to cooperate with the medical plan for
your care.
January 6, 20XX While it is unfortunate that our relationship has reached this
CERTIFIED MAIL stage, I will no longer be able to serve as your physician. I will
be available to you on an emergency basis only until June 10,
Jim Marshal 20XX. Meanwhile, you should immediately call or write
76 Georgia Avenue the Medical Society, 123 Omega Drive, Carlton, MI 11666,
Millerton, TX 43912 Tel. 123-456-7899 and obtain a list of providers. Any delay
Dear Mr. Marshal: could jeopardize your health, so please act quickly.
This will confirm our telephone conversation today in which Your physical (and/or mental) problems include hypertensive
you discharged me as your attending physician in your pres- heart disease, decreased kidney function, and arteriosclerosis.
ent illness. In my opinion your condition requires continued You could have additional medical problems that may also
medical supervision by a physician. If you have not already require professional care. Once you have found a new provider
done so, I suggest that you employ another physician have him or her call my office. I will be happy to discuss your
without delay. case with the provider assuming your care and will transfer
a written summary of your case upon the receipt of a written
You may be assured that after receiving a written request from
request from you to do so.
you, I will furnish the physician of your choice with informa-
tion regarding the diagnosis and treatment which you have Thank you for your anticipated cooperation and courtesy.
received from me. Very truly yours,
Very truly yours,
James Whitney
Winston Lewis James Whitney, DO
Winston Lewis, MD JW:kr
WL:ea
Figure 7-2 Letter reiterating “for the record” the
Figure 7-1 Letter confirming a physician’s discharge osteopath’s decision to withdraw from the case dis-
by the patient. cussed during a previous meeting with patient.
 CHAPTER 7 Legal Considerations 101

Inner City Health Care

TORT LAW
222 S. First Avenue
A tort is a wrongful act, other than a breach
Carlton, MI 11666
of contract, resulting in injury to one per-
December 5, 20XX son by another.
CERTIFIED MAIL
Rhoda Au Medical Practice Acts
41 Academy Road
Carlton, MI 11666
Each state has medical practice acts that regu-
late the practice of medicine with the intent
Dear Ms. Au: of protecting its citizens from harm. These stat-
I find it necessary to inform you that I am withdrawing further utes govern licensure, standards of care, profes-
professional medical service to you because of your persis- sional liability and negligence, confidentiality,
tent refusal to follow my medical advice and treatment. and torts. Table 7-1 summarizes medical doctor’s
Because your condition requires medical attention, I suggest licensure, renewal, and revocation. Medical as-
that you place yourself under the care of another provider sistants sometimes are asked to maintain their
without delay. If you so desire, I shall be available to attend you employer’s records of continuing education for
for a reasonable time after you have received this letter, but license renewal and to process the renewal at the
in no event later than January 7, 20XX. This should give you proper time. In some states, the renewal may be
sufficient time to select someone from the many competent done online if the license is active and in good
practitioners in this area. standing.
You may be assured that, upon receiving your written request,
States also may regulate personnel who are
I will make available to the provider of your choice your case
employed in the ambulatory care setting. Gener-
history and information regarding the diagnosis and treatment ally, medical assistants perform their duties and
that you have received from me. responsibilities under the direct supervision of the
physician or doctor, and therefore are governed
Very truly yours, by Medical Practice Acts or the Board of Medi-
Mark Woo cal Examiners. Medical assistants employed and
supervised by independent nurse practitioners are
Mark Woo, MD
governed by the Nurse Practice Act and the Board
MW:kr
of Nursing. Other health professionals, such as
chiropractors and naturopaths, may have separate
Figure 7-3 Letter notifying patient of provider’s practice acts as well. Medical assistants employed
withdrawal from the case. by these practitioners will need to be knowledge-
able of those laws. Some states require that medi-
cal assistants be licensed or certified to perform
any invasive procedures. Other states require addi-
tional training in radiology for the medical assis-
tant to be able to take radiographs. Furthermore,
some states are so strict in their regulations that

Table 7-1 Licensure, Renewal, and Revocation for Medical Doctors

Licensure Renewal Revocation

Completion of medical Payment of a fee Conviction of a crime

education

Completion of Documentation of continuing medical education Unprofessional conduct

internship (CME)

Passing the U.S. Medi- CMEs might include appropriate medical reading, Personal or professional incapacity
cal Licensing Examina- teaching health professionals, attending conferences
tion (USMLE) and workshops
102 UNIT 3 Responsible Medical Practice

medical assistants mostly perform clerical func- from the medical assistant (or other health care
tions and noninvasive clinical duties. professional) not meeting the standard of care
Certainly, medical assistants desiring to governing their respective professions, then litiga-
use their skills must be aware of state reg- tion is a possibility. If, however, the medical assis-
ulations and always perform only within tant (or other health care professional) commits a
the scope of those regulations. Medical assistants wrongful act but the patient experiences no injury
should be as diligent about maintaining their cer- or harm, then no tort exists. If, for example, the
tification, registration, and licensure as any other medical assistant changes a wound dressing, breaks
health professional and should monitor any legis- sterile technique, and the patient suffers a severely
lation that pertains to licensure or certification. infected wound, the medical assistant has commit-
ted a tort and can be held liable, and legal action
can be taken. In contrast, if the medical assistant
Standard of Care changes a wound dressing, breaks sterile technique,
To better understand torts, we must consider the and the patient’s wound does not become infected,
standard of care and the four Ds of negligence. no harm has occurred, and a tort does not exist.
All health care providers have the responsibility If a medical assistant fails to report to the provider
and duty to perform within their scope of training an abnormal result on a blood test that causes the
and to always do what any reasonable and prudent provider to fail to make an early diagnosis of a dis-
health care professional in the same specialty or ease, the assistant’s omission of an act has caused a
general field of practice would do. That is what is breach in the standard of care.
expected of every provider when a contact is made There are two major classifications of torts:
by a patient. Failure to do what any reasonable and intentional and negligent. Intentional torts are delib-
prudent health care professional would do in the erate acts of violation of another’s rights. Negligent
same set of circumstances can be seen as a breach torts are not deliberate and are the result of omis-
of the standard of care. sion and commission of an act. Malpractice is the
Negligence is defined as the failure to exer- unintentional tort of professional negligence; that is,
cise the standard of care that a reasonable per- a professional either failed to act in a reasonable and
son would exercise in similar circumstances. prudent manner and caused harm to the patient or
Negligence occurs when someone experiences did what a reasonable and prudent person would
injury because of another’s failure to live up to not have done and caused harm to a patient.
a required duty of care. This is a primary cause There are two Latin terms that can be used to
of malpractice suits. Malpractice is professional describe aspects of negligence. These are known as
negligence. doctrines. Res ipsa loquitur, or “the thing speaks for
itself,” is the term used in cases that involve situa-
Four Ds of Negligence. The four elements of neg- tions such as a nick made in the bladder when the
ligence, sometimes called the 4 Ds, are: surgeon is performing a hysterectomy. The neg-
ligence is obvious. The other doctrine, respondeat
1. Duty: duty of care superior, “let the master answer,” expresses that pro-
2. Derelict: breach of the duty of care viders are responsible for their employees’ actions.
3. Direct cause: a legally recognizable injury occurs If a medical assistant violates the standard of care,
as a result of the breach of duty of care therein lies the basis for a suit of medical malprac-
tice. For example, the medical assistant used the
4. Damage: wrongful activity must have caused the
incorrect solution to clean the patient’s wound and
injury or harm that occurred
the patient sustained injuries to the wound. The
If an individual has knowledge, skill, or intelli- provider–employer can be sued under the doc-
gence superior to that of a layperson, that individ- trine of respondeat superior because the provider–
ual’s conduct must be consistent with that status. employer is responsible for the acts of employees
Medical assistants are held to a high standard of care committed in the scope of their employment. The
by virtue of their skills, knowledge, and intelligence. medical assistant also can be sued because individ-
As professionals, medical assistants are required to uals are responsible for their own actions.
have a standard minimum level of special knowledge Some common areas of negligence may
and ability. This is what is known as duty of care. result in torts when adherence to the
standard of care has not been carried out.
The Medical Assistant’s Role in Negligence. Med- Specific examples of common torts that can occur
ical assistants may commit a tort that may result in in the office or clinic are battery, defamation of
litigation. If it can be proven that the injury resulted character, and invasion of privacy.
 CHAPTER 7 Legal Considerations 103

Battery. The basis of the tort of battery is unprivi- one other than the patient, her privacy has been
leged touching of one person by another. A patient invaded. A second situation exists when persons
must consent to being touched. When a procedure other than those providing care and performing
is to be performed on a patient, the patient must examinations and procedures (essential or nones-
give consent in full knowledge of all the facts. It does sential personnel) are allowed to be present with-
not matter whether the procedure that constitutes out the patient’s consent. Yet another example
the battery improves the patient’s health. Patients of the patient’s right to privacy being violated is
have the right to withdraw consent at any time. when the patient is asked to walk from the exami-
One example of battery is when a medical nation room across the hall to a treatment room
assistant insists on giving the patient an injection while wearing only a patient gown in full view of
that was ordered for the patient even though the other patients and personnel.
patient refuses the injection. Another example Medical assistants and other health care pro-
can be seen when a surgeon performs additional fessionals should:
surgery beyond the original procedure (the sur-
geon performed a hysterectomy, for which consent • Close a door, pull a curtain, or provide a screen when
was given, but is liable for battery for removing an looking at, handling, or examining the patient
abdominal nevus from the patient’s abdomen with- • Expose only body parts necessary for treatment
out consent). It does not matter that the surgeon (drape the patient, exposing only the part that is
does not charge for the additional procedure. It being treated)
also does not matter if the patient would have given • Discuss patients with no one except those individu-
consent if asked in advance. als involved in the patient’s care, and then discuss
only those aspects of care that relate to the needs
Defamation of Character. The tort of defamation of the patient
of character consists of injury to another person’s
reputation, name, or character through spoken or It is not an invasion of privacy to disclose
written words for which damages can be recovered. information required by a court order, subpoena,
Two kinds of defamation are libel and slander. Libel or by statute to protect the public health and wel-
is false and malicious writing about another, such fare, as in the reporting of violent crime.
as in published materials, pictures, and media. An
example can be seen when the medical assistant
writes in the patient’s record, “Mr. O’Keefe’s wife INFORMED CONSENT
and her negative attitude appear to be the cause of
his ulcer.” A copy of Mr. O’Keefe’s records were later Documentation of informed consent be-
sent to a new provider, who reviewed the record and comes an important part of the patient
read the remarks quoted by the medical assistant. care process. Every patient has a right to
Slander is false and malicious spoken words. know and understand any procedure to be per-
Slander can be seen in the following comment formed. The patient is to be told in language easily
directed by a patient to the provider, “Dr. Woo is understood:
incompetent. He should have his license revoked.”
The statement is overheard by the office adminis- • The nature of any procedure and how it is to be
trative medical assistant and other patients waiting performed
in the reception area. • Any possible risks involved, as well as expected
For a tort of defamation of character (either outcomes of the procedure
libel or slander) to exist, a third party must see or • Any other methods of treatment and those risks
hear the words and understand their meaning.
• Risks if no treatment is given
Invasion of Privacy. Invasion of privacy It is the responsibility of the health care pro-
HIPAA is another kind of tort. It includes unau- vider to make certain the patient understands. If
thorized publicity of patient information, an interpreter is necessary, the provider must pro-
medical records being released without the cure one.
patient’s knowledge and permission, and patients Often, consent forms will be signed if there is
receiving unwanted publicity and exposure to pub- to be a surgical or invasive procedure performed
lic view. For example, if a minor unmarried girl has (Figure 7-4). The medical assistant may be asked to
been examined for possible pregnancy, and the witness the patient’s signature and may be expected
medical assistant telephones the girl’s home and to follow through on any of the provider’s instruc-
inadvertently gives the laboratory results to some- tions or explanations but is not expected to explain
104 UNIT 3 Responsible Medical Practice

CONSENT TO
OPERATION, ADMINISTRATION OF ANESTHETICS AND
RENDERING OF OTHER MEDICAL SERVICES

1. I hereby authorize and direct Dr. , my physician, and

whomever he/she designates as his/her assistants (associates and/or resident physicians), to perform upon
(state name of patient or myself)
The following procedures:

If any unforeseen condition arises in the course of this operation for the physician’s judgment to perform
procedures in addition to or different from those now contemplated, I further request and authorize him/her to do
whatever he/she deems advisable and necessary in these circumstances. Such additional services may include,
but are not limited to, the administration and maintenance of anesthesia and the performance of services involving
pathology and radiology.
2. The following information has been explained to me to the degree that I wish to have it discussed:
• The nature and character of the proposed treatment or procedure;
• The anticipated results;
• Possible recognized alternative methods of treatment, including non-treatment;
• Recognized serious possible risks, complications, and anticipated benefits involved in proposed and alternative
treatments, including non-treatment.
My questions have been answered to my satisfaction. I acknowledge that no guarantee, warrantee, or assurance
has been made as to the results or cure that may be obtained.
3. Federal Regulations (21 CFR Part 821) require manufacturers to track certain medical devices, and assist the U.S.
Food and Drug Administration (FDA) with notification to individuals in the event that a certain medical device
presents serious health risks. I authorize and agree to the release of my contact information to the manufacturer:
for this tracking purpose only.
I understand that the manufacturer may notify me, if necessary, of important safety information about my medical
device, and may release my information to the FDA if ordered to do so. I understand that this consent is valid for
the life of the medical device.

Any sections below that do not apply to the proposed treatment may be crossed out. The patient must initial any
section crossed out.

4. I consent to the administration of blood and blood products if deemed medically necessary. I understand that all
blood and blood products involve the risk of allergic reaction, fever, hives, and in rare circumstances infectious
diseases such as hepatitis and HIV/AIDS. I understand that precautions are taken by the blood bank in screening
donors and in matching blood for transfusion to minimize those risks.
5. I hereby consent to the disposal or use for research purposes any tissues, parts, or products of conception, which
may be removed.
6. I authorize and agree to the presence of observers during my surgical procedure. These observers may include
persons other than the medical staff that are considered appropriate by my health care provider during my care
and treatment. The purpose of these individuals observing would be for instruction and medical study.

I certify that I have read this form and understand its contents.

PATIENT NAME & ID # Signature of Patient or Legally Responsible Party

Relationship to patient, if not signed by patient

Signature of Witness

Printed Name of Witness

Date Time a.m. / p.m.

MRD: HOSP1
DISTRIBUTION: 1-WHITE – CHART 2-CANARY – PATIENT COPY

Figure 7-4 Model formal consent for treatment form.

 CHAPTER 7 Legal Considerations 105

the procedure to the patient. The signed consent statutes vary. Placing a telephone call to the state
form is kept in the medical chart, and a copy also is attorney general’s office can help clarify issues,
given to the patient. questions, and concerns that involve consent and
treatment of minors.
Implied Consent
Two circumstances related to consent are worth men- RISK MANAGEMENT
tioning at this point. Implied consent occurs when
there is a life-threatening emergency, or the patient Practicing good risk management makes the medi-
is unconscious or unable to respond. The provider, cal assistant and the provider–employer less vul-
by law, is allowed to give treatment within his or her nerable to litigation.
scope of practice without a signed consent. Implied Following are some ways to avoid incidents
consent also occurs in more subtle ways. The patient that may lead to litigation:
who rolls up a shirtsleeve for the medical assistant to
• Perform only within the scope of your training and
take a blood pressure reading is implying consent
education.
to the procedure by the action taken.
• Comply with all state and federal regulations and
statutes.
Consent and Legal
• Keep the office or clinic safe and equipment in
Incompetence readiness.
Consent for treatment is not valid if the patient is • Never leave a patient unattended; if you must
legally incompetent to give consent. Legal incompe- leave, pass the responsibility for the patient’s care
tence means that a patient is found by a court to be on to another individual.
insane, inadequate, or to not be an adult. In such
• Keep all patient information confidential.
instances, consent must be obtained from a par-
ent, a legal guardian, or the court on behalf of the • Follow all policies and procedures established for
patient. Consent for treatment can be given only by the office or clinic.
the natural parent or legal guardian as determined • Document fully only facts; formally document
by the court for a minor child. A minor is a person withdrawing from a case and discharging clients.
who has not reached the age of majority (18–21 years • Log telephone calls and return calls to clients
old), depending on the laws of each state. Gener- within a reasonable time frame.
ally, a minor is considered unable to give effective
• Follow up on missed or canceled appointments.
consent for medical treatment; therefore, without
proper consent from parents or guardians, medical • Never guarantee a cure or diagnosis, and never
professionals can be held liable for battery if medi- advise treatment without a provider’s order.
cal treatment is given. Exceptions to this rule are • Secure informed consent as necessary.
in cases of emergency and for mature and emanci- • Do not criticize other practitioners.
pated minors. Emancipated minors are younger than
• Explain any appointment delays.
18 years who are free of parental care and are finan-
cially responsible, married, become parents, or join • Be particularly watchful with patients who have spe-
the Armed Forces. Mature minors are persons, usu- cial needs, such as the elderly, pediatric patients,
ally younger than 18 years, who are able to under- and those with physical and emotional disabilities.
stand and appreciate the nature and consequences • Report any error that may have occurred to your
of treatment despite their young age. Nearly every employer.
state allows minors to give consent for treatment for
pregnancy, drug or alcohol addiction, and sexually
transmitted disease. Some states have passed legisla- Critical Thinking
tion that name minors as statutory adults at 14 years
old for the purpose of receiving medical care. In Identify the suggestions in the previous risk
these states, minors may consent and be protected by management list that are most likely not
confidentiality and privacy even though their parents performed if the staff in the ambulatory care
or legal guardians may still be financially responsible setting find themselves overworked, over-
for their medical bills. whelmed, and behind. What might be done
Questions of ability to give consent related to prevent carelessness brought on by such
to minors and emancipated minors often must be circumstances?
determined on a case-by-case basis because state
106 UNIT 3 Responsible Medical Practice

CIVIL LITIGATION PROCESS sent information in a specific section of the medi-

cal record for quick referral and to demonstrate
Despite all the best efforts of health care HIPAA compliance.
professionals and their employees, litiga- The care taken with subpoenas and court
tion can occur. Litigation is the process orders for certain information is to ensure patients
of taking a lawsuit or a criminal case through the of confidentiality. The information in the medical
courts. It is helpful to understand the steps taken record, including the information a patient shared
for civil litigation to occur. The greatest amount of with the provider and medical assistant, is private.
any litigation seen in the ambulatory care setting No patient information can be given to
occurs when relationships between individuals another person or entity (provider, patient’s attor-
break down for one reason or another. When this ney, insurance company, federal or state agency)
happens, the party, or plaintiff, bringing the action, without the expressed written consent of the
usually a patient, seeks an attorney who agrees to patient. Care must be exercised at all times to
bring the complaint to the courts. The provider, or ensure that the patient’s right to confidentiality is
defendant, is summoned to court. This summons not breached. For example, information given to
or subpoena notifies the provider of the plaintiff’s unauthorized personnel associated with the pro-
suit and allows the defendant to file an answer with vider’s or clinic’s practice in regard to the patient’s
the court. condition or financial status regarding payment
of bills violates the patient’s right to confidential-
ity. Likewise, when discussing issues over the tele-
Subpoenas phone that can be overheard, such as the patient’s
The subpoena is an order from the court naming account being turned over to a collection agency,
the specific date, time, and reason to appear. A the patient’s right to confidentiality has been
portion of a medical record or the entire medical violated.
record may be subpoenaed, the health care pro- Certain disclosures of information about a
vider (subpoena duces tecum) may be subpoenaed to patient’s conditions and suspected illnesses are
testify in court, or both may be subpoenaed. The required by law. Legally required disclosures are
staff in the ambulatory care setting usually will have necessary when the public needs to know certain
ample time to make certain the record is current information for its safety and welfare. The disclo-
and complete before its inclusion in court. Out sures supersede the patient’s right to privacy and
of courtesy, a provider will notify patients whose confidentiality (see section in Public Duties).
records have been subpoenaed. If, for any reason,
the patient does not want the record released,
the provider must call for legal advice on how to
Discovery
respond to the subpoena. In the litigation process, time of discovery follows
Certain records, because of their sensitive the subpoenas. This is the time in which both par-
nature, may require more than a subpoena to be ties are allowed access to all the information and
released. These include records related to sexu- evidence related to the case. Rules of discovery vary
ally transmitted diseases, including AIDS and HIV from state to state but may include the following:
testing; mental health records; substance abuse
records; and sexual assault records. For the courts 1. An interrogatory is a written set of questions that
to have access to these records, a court order is can come from either the plaintiff or the defendant
required in some states. that must be answered, under oath, and within a
HIPAA law requires clinics to identify specific time period.
HIPAA in written policies and procedures what
information they will release regarding
2. A deposition is oral testimony taken with a court
reporter present in a location agreed on by both
patients. Before patient information is released, parties. Both attorneys are usually present when
the following must be identified: (1) the purpose or depositions are taken.
need for the information, (2) the nature or extent
of the information to be released, (3) the date Medical assistants may be asked to respond to an
of the authorization, and (4) the signature(s) of interrogatory or may be deposed by the plaintiff’s
the person(s) authorized to give consent. Release attorney. The defendant’s attorney will provide spe-
only what the subpoena or court order specifically cific instructions in both situations. Because both
requests rather than releasing the entire medical are done under oath, honesty is an absolute. The
record. Many practitioners keep a patient’s con- medical assistant may be asked to refer to certain
 CHAPTER 7 Legal Considerations 107

documents, recall specific information, or identify ing the kinds of damages that can be considered
documentation in a medical record. in that state. A number of states have placed lim-
its on monetary awards in malpractice cases. If
Expert Witnesses. Providers and members of their the defendant’s case is successful, the case is dis-
staff may be called to testify in court to the standard missed. After a court decision, the party that has
of care. In such a case, they are usually considered lost the case can begin an appeal process. The
expert witnesses. An expert witness is one who has appeal requests an opinion from higher courts
enough knowledge and experience in a field to be that review cases usually on the basis of a faulty
able to testify to what is the reasonable and expected legal process or action.
standard of care. Expert witnesses are expected to Figure 7-5 outlines the civil case process.
tell what they know to be fact and are best counseled
to use lay terms rather than complicated medical
language. The goal is for jurors and judges to under-
Statute of Limitations
stand the nature of any medical information shared. No discussion of negligence, malpractice, or medi-
Visual aids, charts, and computer simulations often cal records is complete without a brief statement
are used to illustrate or clarify testimony given by regarding the statute of limitations that will, in
expert witnesses. part, determine how long medical records are kept.
Generally, all records should be retained until
after the statute has run, usually 3 to 6 years. Stat-
Pretrial Conference utes of limitations most commonly begin at the
A pretrial conference is generally held close to the time a negligent act was committed, when the act
trial date to decide if there is just cause for the suit, was discovered, or when the care of the patient and
to make certain that both parties are ready, and to the provider–patient relationship ended. It is easy
determine if there might be an out-of-court settle- to understand why many providers choose to keep
ment. If a trial seems imminent, alternative dispute their records indefinitely, a plan made much easier
resolution (ADR) may be suggested. ADR saves with electronic files.
money, time, and adverse publicity that can come State and federal statutes set maximum time
from a trial. periods during which certain actions can be brought
Mediation allows a neutral facilitator to help or rights enforced; there is a time limit for individu-
the two parties settle their differences and come to als to initiate legal action. The statute of limitations
an acceptable solution. If no settlement is reached, varies from one jurisdiction to another, and a law-
the case can still look to the court for satisfaction. suit may not be brought after the statute of limita-
Arbitration allows the neutral party to settle the dis- tions has run. For example, in the Commonwealth
pute. This arbitration can be binding or nonbind- of Massachusetts, the statute of limitations for an act
ing. In binding arbitration, both parties agree at of medical malpractice committed on an adult is 3
the outset to accept the neutral party’s decision as years. If harm to a patient resulted from a medical
final. In nonbinding arbitration, the case can look assistant administering the wrong dose of medica-
to the court for settlement. tion to a patient in Massachusetts, a lawsuit must be
brought within 3 years from the time the medica-
tion error was made, with the 3 years commencing
Trial at the time the negligent act was committed.
A trial can be held before a judge or before a judge
and a jury. When the trial begins, opening state-
ments outlining the details of the case are made by PUBLIC DUTIES
both sides. The plaintiff’s attorney calls witnesses
to produce evidence first. This is known as direct
Reportable Diseases/Injuries
examination. In cross examination, the defen- All medical providers have a duty to the
dant’s attorney questions the witness. When the public to report diseases and injuries
plaintiff’s case is finished, the defendant presents that jeopardize public health and welfare.
the case in the same manner. When all the infor- Transmittable or contagious diseases and injuries
mation has been presented, the case is turned over resulting from knife or gunshot are examples;
for judgment. these must be reported to the appropriate authori-
If the plaintiff’s case is successful, the judge ties. This is done without the patient’s consent
or jury may award a specific amount of money or because it is required by law. When reporting, it is
damages. The judge will instruct a jury regard- important to do so properly and according to the
108 UNIT 3 Responsible Medical Practice

Plaintiff’s complaint filed in court

Defendant summoned to court

Alternative Dispute
Out of court
Resolution
settlement can
Defendant’s attorney files answer Parties agree to have
occur at
dispute settled by
any time
a neutral party

Discovery
Evidence & Testimony Collected
Settlement

Pre-trial conference

Bench trial Jury trial

Judge decides Jury decides

Judgment

Appeal

Figure 7-5 Civil litigation process.

laws of the state in which one is employed. Knowl- is beneficial to society and all health care managers
edge of which illnesses, injuries, and conditions in tracking and preventing illness. The list changes
to report, to whom to report, and the appropriate as new diseases occur and are diagnosed.
forms to submit is essential. Copies of all informa- Other generally required facts to report
tion must be kept for the office or clinic. include births; deaths; childhood immunizations;
Medline Plus, a Web site sponsored by the rape; and abuse toward a child, elder, or intimate
U.S. National Library of Medicine and the National partner.
Institutes of Health, has an excellent site connected Some states have laws specific to the release
to the Medline Encyclopedia titled “Reportable of information relative to mental or psychological
Diseases” identifying guidelines for reportable dis- treatment, HIV testing, AIDS diagnosis and treat-
eases. Local, state, and national agencies such as the ment, sexually transmitted diseases, and chemical
Centers for Disease Control and Prevention (CDC) substance abuse.
require such diseases to be reported when diag- Local or state health departments can provide
nosed by providers or laboratories. States may vary lists of diseases and injuries to report and will also
in the diseases that require reporting, but their lists provide the appropriate forms.
are likely to include the list of “Nationally Notifiable
Infectious Diseases” listed on the CDC’s Web site
(http://www.cdc.gov). Some diseases require writ-
Abuse
ten reports. Others require reporting electronically Child abuse, intimate partner violence, and elder
or by telephone; they include rubeola (measles) and abuse are becoming more common in our soci-
pertussis (whooping cough). Still others ask only for ety. As a result, patients experiencing such abuse
the number of cases to be reported. Such reporting may be seen in the ambulatory care setting. In
 CHAPTER 7 Legal Considerations 109

all cases of abuse, medical records hold valu- Intimate Partner Violence (IPV). The term
able information if a court procedure ensues. “domestic violence” has been changed to be more
Careful documentation is critical. State laws encompassing of an escalating problem. “Intimate
are fairly specific in mandates to report child partner violence (IPV)” is now used and refers
abuse, but laws related to elder abuse and domes- to violence or abuse between a spouse or former
tic violence are not as detailed. In any case, the spouse; boyfriend, girlfriend, or former boyfriend/
rights of victims must be protected. (See Table 8-1 girlfriend; and same-sex or heterosexual intimate
for a summary.) partner or former same-sex or heterosexual inti-
mate partner. The abuse may include physical or
Child Abuse. All 50 states and the Dis- sexual violence, threats of the same, and psycho-
trict of Columbia mandate, or require, logical or emotional violence. Physical violence is
that health care professionals, teachers, a criminal act, and failure to report it is consid-
social workers, and certain others who suspect ered a misdemeanor in some states. Victims of
child abuse report the incident to the proper IPV should be treated as soon as possible after the
authorities. Confidentiality in the provider–patient assault so that evidence can be preserved for legal
relationship does not exist when children are purposes. Some forms of IPV are con-
abused. If a person has a reason to suspect abuse sidered acceptable behavior in many cul-
and reports the abuse to the police and, in the case tures, even in the United States. Some
of child abuse, to the child protective agency, this cultures believe the woman is chattel, or property,
individual is protected against liability as a result of of her spouse, that she has no rights or authority,
making the report. Failure to report could result and that she must submit to her husband’s, broth-
in criminal or civil penalties. Usually, the Child er’s, or father’s demands.
Protective Unit of the State Department of Social An individual who manages to come to the
Services is called to investigate suspected cases ambulatory care setting with signs of IPV is coura-
of child abuse. Some injuries that are commonly geous and probably is extremely frightened also,
seen in child abuse are bruises, welts, burns, frac- because reporting the violence may increase the
tures, and head injuries. Evidence of neglect, risk for continued violence and even death in some
intimidation, or sexual abuse also may be seen. instances.
If a suspicion of abuse exists, the health care Make certain that community resources are
professional should: readily available for survivers of IPV, even if they
choose to stay in the abusive situation. In many cases,
• Treat the child’s injuries the abused patient’s options are so few that leaving
• Send the child to the hospital for further treatment is more frightening than staying in the abusive rela-
when necessary tionship. Do not pass judgment on these survivors;
• Inform parents of the diagnosis and that it will be they desperately need your understanding and your
reported to the police and social services agency compassion. Your understanding and compassion
is perhaps the only door through which they
• Notify the child protective agency (keep phone
might feel comfortable enough to enter to
number posted)
leave the abusive relationship.
• Document all information
• Provide court testimony if requested
Good Samaritan Laws
Elder Abuse. Elder abuse may consist of neglect, All 50 states have laws regarding the render-
physical abuse, punishment, physical restraint, or ing of first aid by health care profession-
abandonment. Examples are seen when elders als at the scene of an accident or sudden
are overmedicated or undermedicated, physi- injury. Good Samaritan laws, although not always
cally restrained, intimidated by shouting or pro- clearly written, encourage health care profession-
fanity, sexually abused, neglected or abandoned, als to provide medical care within the scope of their
or in any other way have their rights and dignity training without fear of being sued for negligence. In
violated. The person reporting the abuse is gener- an emergency situation, medical assistants cannot be
ally a health care professional who observes or sus- held liable should an injury result from some form
pects the abuse, and the reporting agency is most of first aid rendered or from first aid they omitted
likely one of a social service or welfare nature. The to render as long as they acted in a reasonable way
majority of states have laws protecting vulnerable within the scope of their knowledge. Medical assis-
adults and the elderly from abuse. tants and other health care professionals with skills
110 UNIT 3 Responsible Medical Practice

in cardiopulmonary resuscitation (CPR) who are Persons who prefer not to remain in that state
present when CPR is needed must perform the pro- can use the living will or advance directive to
cedure on the victim or otherwise could be declared make decisions about life support and to direct
negligent. Emergencies that arise in the ambula- others to implement their wishes in that regard.
tory care setting generally are not covered by Good Such a document allows individuals to indicate to
Samaritan laws. family and health care professionals whether life-
prolonging medical or surgical procedures are
to be continued, withheld, or withdrawn, and if
ADVANCE DIRECTIVES artificial feeding and fluids are to be used or with-
held. The document allows individuals to make
Medical assistants in the ambulatory care this decision before incapacitation.
setting will be asked to attach advance To be valid, the proper and particular form,
directives or living wills to patients’ charts different in each state, must be used, and it must
(Figure 7-6). These directives are legal documents be lawfully executed. States vary in the number of
in which patients indicate their wishes in the case witnesses required and whether a Notary Public
of a life-threatening illness or serious injury. Health is required for those signatures. The form goes
care providers in many states and cities have into effect when provided to a patient’s health
adopted the Physician Orders for Life-Sustaining care provider and when the patient is no longer
Treatment (POLST) (Figure 7-7) form. This form capable of making health care decisions. Exam-
is to be completed by a health care provider based ples of incapacity include permanent uncon-
on the patient’s preferences on the type of life- sciousness, life-threatening illness in the latter
sustaining treatment wanted and medical indica- stages, and inability to communicate. The U.S.
tions. POLST is most often brightly colored (neon Legal Forms Web site (http://USlegalforms.com)
pink or green). To be valid, the form must be signed has samples of living wills for all 50 states and the
by the proper authority. Some states may use another District of Columbia under the heading “Living
name than POLST, but the intent is quite similar. Will.” A sample from each state is available with-
POLST is appropriate for seriously ill individuals out a fee.
with life-threatening or terminal illnesses. Some
providers believe that even with an advance direc- Durable Power of Attorney
tive in place, it is advisable to complete a POLST
form. This form goes with the patient when he or
for Health Care
she is moved between care settings. For those in the Another document seen in the ambulatory care
home, it is recommended that the form be posted setting is the durable power of attorney for health
on the refrigerator where emergency responders care or Designation of Health Care Surrogate
can locate it easily. As of October 2008, 33 states (Figure 7-8). This document allows a patient to
had endorsed or are developing POLST documents name another person as the official spokesperson
(http://www.POLST.org). Such documents should for the patient should the patient be unable to
always accompany the patients to the hospital for make health care decisions. The documents may
any treatment or care. They may be updated from allow another person to manage finances and per-
time to time, and patients can ask to rescind such sonal matters (durable power of attorney) or just
a document at any time. Medical assistants must to make medical decisions.
remember that these documents reflect the choices Every state has a slightly different version of
of their patients and are to be respected as such. their living will, advance directive, durable power of
attorney for health care, or POLST. Most forms and
specific information can be found on the Internet by
Living Wills/Advance Directives keying in a particular state and the title of the docu-
Patients’ desire to make known in advance their ment wanted. Also, the Web site for Compassion and
choices related to health care, especially when Choices (http://www.compassionandchoices.org/)
death is near, will have living wills, advance direc- located in Portland, Oregon, is quite helpful.
tives, or a POLST order. The title of such a docu-
ment is largely determined by the state in which
the document is made. These documents are nec-
Patient Self-Determination Act
essary because advances in medicine allow medical In 1991, the federal government passed the Patient
professionals to sustain life even if the individual Self-Determination Act (PSDA), which applies to all
will not recover from a persistent vegetative state. health care institutions receiving payments from
 CHAPTER 7 Legal Considerations 111

HEALTH CARE DIRECTIVE

Directive made this _______________________________ day of _________ , ______________ .
(Year)
I, _____________________________________________ being of sound mind, willfully, and voluntarily make known my desire that my dying
shall not be artificially prolonged under the circumstances set forth below, and do hereby declare that:

(A) If at any time I should have an incurable and irreversible condition certified to be a terminal condition by my attend-
ing physician, and where the application of life-sustaining treatment would serve only to artificially prolong the
process of my dying, I direct that such treatment be withheld or withdrawn, and that I be permitted to die naturally.
I understand “terminal condition” means an incurable and irreversible condition caused by injury, disease or illness
that would, within reasonable medical judgment, cause death within a reasonable period of time in accordance with
accepted medical standards.
(B) If I should be in an irreversible coma or persistent vegetative state, or other permanent unconscious condition as
certified by two physicians, and from which those physicians believe that I have no reasonable probability of recovery,
I direct that life-sustaining treatment be withheld or withdrawn.
(C) If I am diagnosed to be in a terminal or permanent unconscious condition, [Choose one]
I want _________ do not want _________
artificially administered nutrition and hydration to be withdrawn or withheld the same as other forms of life-sustain-
ing treatment. I understand artificially administered nutrition and hydration is a form of life-sustaining treatment in
certain circumstances. I request all health care providers who care for me to honor this directive.
(D) In the absence of my ability to give directions regarding the use of such life-sustaining procedures, it is my intention
that this directive shall be honored by my family, physicians and other health care providers as the final expression of
my fundamental right to refuse medical or surgical treatment, and also honored by any person appointed to make
these decisions for me, whether by durable power of attorney or otherwise. I accept the consequences of such refusal.
(E) If I have been diagnosed as pregnant and that diagnosis is known to my physician, this directive shall have no force or
effect during the course of my pregnancy.
(F) I understand the full import of this directive and I am emotionally and mentally competent to make this directive. I
also understand that I may amend or revoke this directive at any time.
(G) I make the following additional directions regarding my care:

____________________________________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________

Signed: _______________________________________

The declarer has been personally known to me and I believe him or her to be of sound mind. In addition, I am
not the attending physician, an employee of the attending physician or health care facility in which the declarer is
a patient, or any person who has a claim against any portion of the estate of the declarer upon the declarer’s
decease at the time of the execution of the directive.

Witness: __________________________________

Witness: __________________________________

Figure 7-6 Sample health care directive (Reprinted by permission from WSMA, Seattle, Washington.)
 .
Figure 7-7 Physician Orders for Life-Sustaining Treatment (POLST) Form. (Reprinted by permission from WSMA,
Seattle, Washington.)
Figure 7-7 (continued)
114 UNIT 3 Responsible Medical Practice

DURABLE POWER OF ATTORNEY FOR HEALTH CARE

Notice to Person Executing This Document
This is an important legal document. Before executing this document you should know these facts:
< This document gives the person you designate as your Health Care Agent the power to make MOST health care decisions
for you if you lose the capability to make informed health care decisions for yourself. This power is effective only when
you lose the capacity to make informed health care decisions for yourself. As long as you have the capacity to make
informed health care decisions for yourself, you retain the right to make all medical and other health care decisions.
< You may include specific limitations in this document on the authority of the Health Care Agent to make health care
decisions for you.
< Subject to any specific limitations you include in this document, if you do lose the capacity to make an informed
decision on a health care matter, the Health Care Agent GENERALLY will be authorized by this document to make
health care decisions for you to the same extent as you could make those decisions yourself, if you had the capacity to
do so. The authority of the Health Care Agent to make health care decisions for you GENERALLY will include the
authority to give informed consent, to refuse to give informed consent, or to withdraw informed consent to any care,
treatment, service, or procedure to maintain, diagnose, or treat a physical or mental condition. You can limit that right
in this document if you choose.
< A Health Care Agent can only act under state law. “Mercy killing” is not allowed under Washington state law. A
Health Care Agent will NEVER be allowed to authorize “mercy killing,” euthanasia or any procedure which would
actually speed up the natural process of dying.
< When exercising his or her authority to make health care decisions for you when deciding on your behalf, the Health
Care Agent will have to act consistent with your wishes, or if they are unknown, in your best interest. You may make
your wishes known to the Health Care Agent by including them in this document or by making them known in
another manner.
< When acting under this document the Health Care Agent GENERALLY will have the same rights that you have to
receive information about proposed health care, to review health care records, and to consent to the disclosure of health
care records.
1. Creation of Durable Power of Attorney for Health Care
I intend to create a power of attorney (Health Care Agent) by appointing the person or persons designated herein to make
health care decisions for me to the same extent that I could make such decisions for myself if I was capable of doing so, as
recognized by RCW 11.94.010. This designation becomes effective when I cannot make health care decisions for myself
as determined by my attending physician or designee, such as if I am unconscious, or if I am otherwise temporarily or
permanently incapable of making health care decisions. The Health Care Agent’s power shall cease if and when I regain
my capacity to make health care decisions.
2. Designation of Health Care Agent and Alternate Agents
If my attending physician or his or her designee determines that I am not capable of giving informed consent to health
care, I ______________________________________________, designate and appoint:
Name __________________________________________________________ Address ____________________________________________

City ___________________________________________ State __________ Zip ____________ Phone _____________________________

as my attorney-in-fact (Health Care Agent) by granting him or her the Durable Power of Attorney for Health Care recognized in RCW 11.94.010
and authorize her or him to consult with my physicians about the possibility of my regaining the capacity to make treatment decisions and to
accept, plan, stop, and refuse treatment on my behalf with the treating physicians and health personnel.
In the event that _________________________________________________ is unable or unwilling to serve, I grant these powers to

Name__________________________________________________________ Address ____________________________________________

City ___________________________________________ State __________ Zip ____________ Phone _____________________________

In the event that both _____________________________________________ and _______________________________________________

are unable or unwilling to serve, I grant these powers to

Name__________________________________________________________ Address ____________________________________________

City ___________________________________________ State __________ Zip ____________ Phone _____________________________

Figure 7-8 Durable power of attorney for health care (Reprinted by permission from WSMA, Seattle, Washington.)
 CHAPTER 7 Legal Considerations 115

Your name (print)______________________________________

3. General Statement of Authority Granted.
My Health Care Agent is specifically authorized to give informed consent for health care treatment when I am not capable
of doing so. This includes but is not limited to consent to initiate, continue, discontinue, or forgo medical care and
treatment including artificially supplied nutrition and hydration, following and interpreting my instructions for the
provision, withholding, or withdrawing of life-sustaining treatment, which are contained in any Health Care Directive or
other form of “living will” I may have executed or elsewhere, and to receive and consent to the release of medical informa-
tion. When the Health Care Agent does not have any stated desires or instructions from me to follow, he or she shall act
in my best interest in making health care decisions.
The above authorization to make health care decisions does not include the following absent a court order:
(1) Therapy or other procedure given for the purpose of inducing convulsion;
(2) Surgery solely for the purpose of psychosurgery;
(3) Commitment to or placement in a treatment facility for the mentally ill, except pursuant to the provisions of
Chapter 71.05 RCW;
(4) Sterilization.
I hereby revoke any prior grants of durable power of attorney for health care.
4. Special Provisions
____________________________________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________

____________________________________________________________________________________________________

DATED this _______________________ day of _______________________ , ______________ .

(Year)

GRANTOR __________________________________________

STATE OF WASHINGTON )
)ss.
(COUNTY OF ________________________ )

I certify that I know or have satisfactory evidence that the GRANTOR, ___________________________________________________________
signed this instrument and acknowledged it to be his or her free and voluntary act for the uses and purposes mentioned in the instrument.

DATED this _______________________ day of _______________________ , ______________ .

(Year)

_____________________________________________________________________
NOTARY PUBLIC in and for the State of Washington,
residing at _____________________________________________________________

My commission expires __________________________________________________

Figure 7-8 (continued)

116 UNIT 3 Responsible Medical Practice

Medicare and Medicaid. PSDA requires that all

Patient Education adults receiving health care from these institutions
be given the opportunity to provide information
Because of increased awareness of con- about their wishes in an advance directive.
fidentiality as a result of HIPAA, medical Copies of advance directives are to be pro-
assistants can be helpful by suggesting vided to patients’ providers so the documents can
that any family member(s) who might be transferred to a hospital or nursing facility as
be involved and need to know about the necessary. Any named agent should have a copy,
patient’s care be indicated in the patient’s and family members also may have a copy.
chart with a signed release from the patient.
There have been examples recently of adult
children of elder adults who were either
not informed when their ailing parent was Case Study 7-1
taken to emergency services in another
state or were unable to get any informa- Refer to the scenario at the beginning of the chapter. You
tion about their parent from a hospital or realize that any breach of confidentiality is a serious mat-
provider even though a durable power of ter, whether intentional or accidental.
attorney for health care was in place. If that
directive does not go with the patient, no CASE STUDY REVIEW
information can be given. For that reason, it
is suggested that patients may want to keep 1. What corrective measures can you suggest to
a wallet card containing a notice of the decrease voices heard in the hallway or from
advance directive, any appointed agent examination rooms?
named, and any family member(s) who is 2. How can medical charts or private patient infor-
allowed information. mation be kept out of public view?
3. What HIPAA regulations will you want to review?

Case Study 7-2

Three weeks ago, Dr. King treated a new patient, Boris Bolski, CASE STUDY REVIEW
for lower back pain, which the patient believed was the
result of consistent heavy lifting at his job. Medical assis- 1. How will Mr. Bolski’s medical record help Joe answer
tant Joe Guerrero assisted Dr. King during the examination. questions at the hearing?
Today, both Joe and Dr. King were served with subpoenas by 2. What information should Joe gather so that he is
Mr. Bolski’s attorney. Mr. Bolski is alleging that unsafe con- prepared to testify?
ditions at his workplace caused severe strain on his back, 3. As an expert witness, what is Joe expected to com-
and he is suing his employer for damages. Dr. King and municate to the judge in this case?
Joe Guerrero were called as expert witnesses to a civil hear-
ing; Joe, especially, is a bit nervous about this, because he
has never been on the witness stand in court and is not sure
what is expected of him.
 CHAPTER 7 Legal Considerations 117

Case Study 7-3

Wanda Hanson is working on a part-time basis in Hudson, CASE STUDY REVIEW
Florida, as an administrative medical assistant on the phone
desk in the Emergency Department at Hudson Community 1. What can Wanda tell Mr. Nelson, especially after
Hospital when a frantic long-distance call is received. The noting that no records were with the elderly
caller is Larry Nelson from Cheyenne, Wyoming. He received Mrs. Nelson when she arrived at the hospital?
a call from the nursing home where his 95-year-old mother 2. What information would Wanda need from
was living informing him that she was taken by ambulance Mr. Nelson before complying with his request?
to your hospital. Larry wants to know if Muriel Nelson has 3. How can Wanda put Mr. Nelson at ease? What
arrived and what her condition is. Wanda is aware of a can Wanda do to help?
patient’s right to privacy, confidentiality, and the new HIPAA
regulations. Wanda observed Mrs. Nelson arrive at the emer-
gency department quite incoherent and confused.

SUMMARY
Changing societal values have contributed to an increase of lawsuits in medical practice. Patients are more
aware than ever of their rights, especially those of confidentiality and the right to privacy, consent, and
records ownership. They are likely to seek redress when they perceive their rights have been violated.
A healthy relationship between all providers and patients and between medical assistants and patients,
as well as respect for the patient’s rights, reduces the likelihood of a lawsuit.
Additional knowledge of the laws that regulate medical and business practices in your state is neces-
sary to be in compliance. Sources of information regarding state and federal laws can be obtained from the
state medical society, the provider’s liability insurance company, the state medical assistant society, the state
attorney general’s office, the Internet, or the public library.

STUDY FOR SUCCESS

To reinforce your knowledge and skills of information presented in this chapter:
• Review the Key Terms
• Consider the Case Studies and discuss your conclusions
• Answer the Review Questions

˚ Multiple Choice
˚ Critical Thinking
• Navigate the Internet and complete the Web Activities
• Practice the StudyWARE activities on the textbook CD
• Apply your knowledge in the Student Workbook activities
• Complete the Web Tutor sections
• View and discuss the DVD situations
118 UNIT 3 Responsible Medical Practice

REVIEW QUESTIONS
Multiple Choice c. may be ignored without consequences
d. allows the person being served to select a specific
1. The type of contract that most often exists between date or time to appear
provider and patient is: 8. The 4 Ds of negligence are:
a. expressed a. duty, danger, damage, and disaster
b. implied b. derelict, direct cause, damage, and danger
c. privileged c. danger, direct cause, damage, disaster
d. civil d. duty, derelict, direct cause, damage
2. The administrative law act that prohibits discrimi- 9. Emancipated minors:
nation, has five sections, and is enforced by the a. are considered adults and can consent to
EEOC is called the: treatment
a. Controlled Substances Act b. live on their own and are self-supporting
b. Federal Age Discrimination Act c. may be married or serve in the military
c. Americans with Disabilities Act d. all of the above
d. Health Insurance Portability and Accountability e. only b and c
Act 10. Torts:
3. Slander is defamation through: a. include battery, defamation of character, invasion
a. spoken statements that damage an individual’s of privacy
reputation b. are always intentional in nature
b. written statements that damage a person’s c. do not require that harm has occurred
reputation d. do not include malpractice
c. written falsehoods about an individual
d. a, b, and c Critical Thinking
4. Occasionally, a provider will be sued for the negli-
gence of an employee, even though the provider is 1. Chris is a 6-year-old girl who Dr. King treated for a
not guilty of any negligent act. This is done on the broken leg. Chris’ parents fail to follow Dr. King’s
basis of the doctrine of: treatment plan for Chris. What, if any, action can
a. res ipsa loquitur Dr. King take? What is the legal term for this
b. respondeat superior situation?
c. proximate cause 2. Jaime arrived in the clinic having sustained a serious
d. contract law laceration at his construction site. Dr. Woo deter-
5. The standard of care expected of a provider is held mines surgery is required. Should a consent form
by the courts to mean: be prepared? If so, by whom, and what should be
a. on a par with all other providers engaged in the included?
same medical specialty anywhere 3. Do you have a living will or advance directive? Why
b. reasonable, attentive, diligent care comparable or why not? Identify to a family member or a loved
with other providers of the same specialty or one what your wishes might be if you were seriously
general field of practice injured in an accident and were still in what appears
c. the best possible under the circumstances to be an irreversible coma after 10 months.
d. the same as the national norm 4. Discuss the medical assistant’s obligations in regard
6. Advance directives: to public duties.
a. allow patients to direct how their billing is to be 5. What is the Good Samaritan law? What must
handled a medical assistant and any other health care
b. are designed to encourage providers to render professional remember when giving first aid at the
first aid in an emergency scene of an accident?
c. indicate a patient’s wishes in life-threatening 6. Describe three types of abuse. Tell what your role
circumstances as a medical assistant is when Juanita brings her
d. are not considered legal documents 3-year-old son Henry to the clinic. Henry has
7. A subpoena: bruises on his face and chest and appears quite
a. is a court order requesting data, an appearance frightened when you approach him. While you
in court, or both prepare Henry for the pediatrician’s examination,
Juanita’s answers to your questions seem evasive.
b. is sufficient to enforce a release of any type
medical record or information
 CHAPTER 7 Legal Considerations 119

WEB ACTIVITIES REFERENCES/BIBLIOGRAPHY

1. Using the Internet, determine whether or Balasa, D. A. (May/June 2004). Legal environment dif-
when a medical clinic might be required to fers under independent nurse practitioners. CMA
follow the federal guidelines of the Family TODAY, 37(3), 24–25.
and Compassion & Choices. Washington Durable Power of
Medical Leave Act (FMLA). Identify reasons to fol- Attorney for Health Care. Retrieved June 26, 2007,
low the FMLA guidelines. from http://compassionindying.org.
2. Using your favorite search engine, key in the words Krager, D., & Krager, C. (2005). HIPAA for medical
“Medical Malpractice Awards.” A number of sites office personnel. Clifton Park, NY: Delmar Cengage
will appear. Has a national limit been set on mal- Learning.
practice awards? What makes this topic a political Lewis, M. A., & Tamparo, C. D. (2007). Medical law,
one? Identify those who favor malpractice award ethics, and bioethics for health professions (6th ed.).
limits and also those who oppose these limits. Philadelphia: F. A. Davis.
3. Research the Internet for the statute of limitations Washington State Medical Association (WSMA). (2007).
related to claims injuries. What is the time span in Durable power of attorney for health care, health care direc-
your state? tive, and POLST. Retrieved June 2007, from http://
www.wsma.org.

THE DVD HOOK-UP

This chapter deals with legal considerations that must be 3. What will you do if a provider orders you to perform a
adhered to when working in the medical industry. One of procedure that medical assistants are not allowed to
the most important legal responsibilities that you have as perform?
a medical assistant is to stay within the boundaries of your
scope and training as a medical assistant. DVD Journal Summary
In one of the scenes listed above, Barb, the office manager, Write a paragraph that summarizes what you learned from
reprimands Eileen for administering a Demerol injection. watching the designated scenes from today’s DVD program.
Eileen states that the provider ordered her to give the What steps will you take to make certain that you know
injection, which is why she gave it. The office manager what medical assistants can and cannot do in the state in
tells Eileen that medical assistants are not allowed to which you practice?
give controlled substances in that particular state. Eileen
replies that she didn’t know she could not give controlled
substances, and that she gave controlled substances in
the last office that she worked. Barb reminds Eileen that
the information was posted in the office’s procedures
manual that she was suppose to have read at the time of
orientation. Barb told Eileen that she had no other choice DVD Series Program Number
but to document this error in her personal record. Critical Thinking 3
Chapter/Scene Reference
1. Why did Barb take such a hard approach with Eileen?
• Licensing and Scope of Practice
What steps does Barb need to take in the future? What
• Regulating Agencies OSHA, DEA, and CMS
responsibility does the provider have?
2. How could Eileen have avoided this awkward situation?
Chapter

8 Ethical Considerations

OUTLINE KEY TERMS

Ethics Treatment for a Culturally Bioethics
Principle-Centered Leadership Diverse Clientele Cryopreservation
Five Ps of Ethical Power Care of the Poor Ethics
Ethics Check Questions Abuse Genetic Engineering
Bioethics Bioethical Dilemmas
In Vitro Fertilization (IVF)
Keys to the AAMA Code of Allocation of Scarce Medical
Intimate Partner
Ethics Resources
Violence (IPV)
Ethical Guidelines for Health Abortion and Fetal Tissue
Macroallocation
Care Providers Research
Genetic Engineering/ Microallocation
Advertising
Manipulation Surrogate
Confidentiality
Medical Records Artificial Insemination/
Professional Fees and Charges Surrogacy
Professional Rights and In Vitro Fertilization
Responsibilities Dying and Death
Disaster Response HIV and AIDS

OBJECTIVES
The student should strive to meet the following performance objectives and
demonstrate an understanding of the facts and principles presented in this
chapter through written and oral communication.

1. Define the key terms as presented in the glossary.

2. Identify two reasons for Codes of Ethics.
3. Discuss the eight characteristics of principle-centered leadership.
4. Describe the five Ps of ethical power.
5. Recall the ethics check questions.
6. Relate the five principles of the AAMA code to patient care in the
ambulatory care setting.
7. Discuss the ethical guidelines for health care providers, giving at
least four examples.
8. Restate the dilemmas encountered by the following bioethical
issues: (a) allocation of scarce medical resources; (b) abortion
and fetal tissue research; (c) genetic engineering/manipulation;
(d) artificial insemination/surrogacy; (e)in vitro fertilization;
(f) dying and death; (g) HIV and AIDS.

120
 Scenario
Harley Navarro is a new medical assistant in a busy Harley’s patients before he was finished with the read-
internist’s office. He finished school a few months ago ing, and the provider stepped in to take the reading.
and is awaiting the date to take his exam to become a Harley was embarrassed. His current patient is obese.
certified medical assistant. He is nervous and scared. His first attempt at getting a blood pressure reading
All the other medical assistants are female and have failed. He gets a larger cuff for his second reading. His
many years of experience. Harley wants so much to be patient complains, however, that her arm is hurting
accepted and recognized for his skills. Today, however, about halfway through the reading. Harley hurries the
he twice had a rough time taking a blood pressure process and takes a guess at the diastolic pressure
reading. In fact, the provider was ready for one of figure, but he knows it is close.

INTRODUCTION Ethics plays a huge role in such an endeavor. To

function ethically demands that you never func-
It is impossible in today’s world to function as a medi- tion outside the law. Ethics, however, demands
cal assistant without an awareness of the impact of ethics something more—ethics calls for honesty, trustworthiness,
and bioethics on health care. Just as an understanding of integrity, confidentiality, and fairness. To function ethi-
the law and working within the law is vital information cally, you must know yourself well and understand weak-
for the medical assistant, it is equally important to under- nesses and any vulnerabilities that might prevent you from
stand ethics and bioethics. acting ethically.
From Chapter 7, you have come to realize that there The scenario described earlier is just one situation
are many circumstances and situations that occur in in which medical assistants may need to reflect on their
health care that are guided and directed by state and actions and be sure that they are acting ethically and
federal laws. You, personally, are expected to be above within the range of their skills. Medical assistants also
reproach in all your actions in this regard. You must need to recognize the warning signs that they, or some
also work with your employer and other members of the other staff member, may be about to breach a code of ethics.
health care team to ensure that each member of the staff Often, this kind of breach occurs when one has, or seeks
functions within the law—protecting both patients and to have, too much power; when one attempts to take on
providers. too much authority; or when one has too little knowledge
and experience or is afraid to ask for help. When a breach
seems about to occur, the individuals involved should be
Spotlight on Certification encouraged to step back and review their actions and the
likely consequences of those actions.
RMA Content Outline
• Principles of medical ethics
• Ethical conduct ETHICS
CMA (AAMA) Content Outline
Traditionally, ethics is defined in terms of what
• Displaying professional attitude is considered right or wrong. Sometimes ethics
• Performing within ethical boundaries is referred to as “morals.” However, morals refer
• Maintaining confidentiality to personal choices of conduct, whereas ethics is
• Legislation more of a philosophy related to making judgments
• Working as a team member to achieve about right and wrong. Professional organizations
goals often identify their ethics in “codes,” or a set of
principles and guidelines. Providers, through the
CMAS Content Outline American Medical Association (AMA), have estab-
• Legal and ethical considerations lished such a code of ethics called the Principles
• Professionalism of Medical Ethics. This code can be reviewed by
• Confidentiality accessing the AMA Web site (http://www.ama-
assn.org). The Code of Medical Ethics Current

121
122 UNIT 3 Responsible Medical Practice

Opinions with Annotations is published every to how you might perform ethically in a medical
2 years; this document provides up-to-date infor- setting.
mation on a number of ethical dilemmas. Medical
Are you continually learning? Do you seek training, take
assistants have a code of ethics and a creed. The
classes, listen to others, learn from your peers? Are
AAMA Mission Statement, AAMA Medical Assis-
you curious? Do you realize that developing new
tant Code of Ethics, and AAMA Medical Assistant
knowledge and skills is a lifelong endeavor?
Creed appear on the AAMA Web site (http://www.
aama-ntl.org). Clicking on About AAMA will detail Are you service-oriented? Do you see your life as a mission
these statements for you. rather than a career? Are you generally a nurturing
There are more than 50 differing codes of individual who seeks service in the medical field?
ethics for professional organizations, and most are Can you see yourself working alongside a coworker
related to medicine. There are seven ethical codes and pulling together with that person toward a
that relate to the entire world. These include such goal? Can you put yourself in the place of others?
famous codes as the Declaration of Geneva, Dec- Do you radiate positive energy? Are you cheerful, pleasant,
laration of Helsinki, and the International Code optimistic, and positive? Is your spirit hopeful? If it
of Medical Ethics. A listing of these codes is found is, you carry a positive energy field that allows you
by searching the Internet for “world medical eth- to neutralize or sidestep a negative energy source.
ics codes.” Another fascinating Web site identifies Do you see yourself as a peacemaker or one that
the characteristics of Traditional Chinese Medi- can create harmony to undo negative energy?
cal Ethics when you use the Internet to search for Do you believe in other people? Can you keep from labeling,
“Chinese Medical Ethics.” Chinese medical ethics stereotyping, or prejudging other people? Can you
emphasizes self-cultivation and personal ethics of believe in the unseen potential of others? Can you
practitioners rather than a strict organizational keep from overreacting to negative behaviors and
code of ethics. criticism? Can you put aside any grudges?
Codes of ethics bring standards of moral and
The final characteristics of principle-centered
ethical behavior together in one place. They assist
leaders identified in Covey’s 7 Habits of Highly Effec-
organizations and individuals in putting words to
tive People are more personal. They can help you
their expected behaviors and actions. There is a
understand yourself and how you might make ethi-
benefit to such codes when they become reminders
cal decisions in the medical field.
to everyone regarding their conduct. Codes also
can have a limiting effect, however. For instance, Do you lead a balanced life? Do you keep up with current
if an organization does not have a code of ethics, is affairs and events? Do you know what is happening
that organization viewed as unethical? When one in the medical field and how that affects you? Do
answers that question, there also comes the under- you have at least one confidant with whom you can
standing that having a code of ethics does not nec- be transparent? Are you physically active within
essarily create an ethical organization. your limits of age and health? Do you enjoy your-
Medical assistants and medical professionals self? Do you have a good sense of humor? Are you
are asked to balance personal and professional open to communication?
areas of their lives in the middle of constant pres-
Do you see life as an adventure? Are you able to rediscover
sure and crises. At the same time, the quality of
persons each time you meet them? Are you inter-
one’s personal life is going to be shown in the qual-
ested in others? Do you listen well? Are you flexible
ity of their service to others in their professional
and unflappable? Does your security come from
life. To be effective in the medical profession, there
within rather than from without?
needs to be maturity in both the personal and the
professional selves that creates the utmost of ethi- Are you synergistic? Synergy is what happens when the
cal conduct and professionalism. whole of something is greater than the sum of
its parts. Do you know your weaknesses? Can you
complement your weaknesses with the strength of
Principle-Centered Leadership others on the team? Can you work hard to improve
Stephen R. Covey, author of The 7 Habits of Highly most situations? Are you trusting? Can you sepa-
Effective People and Principle-Centered Leadership, has rate the person from the problem?
identified eight characteristics of principle-centered Do you exercise for self-renewal? In this element, Mr. Covey
leaders. Leaders who know themselves and under- identifies four dimensions of the human personal-
stand their principles more easily abide by a code ity that need exercise: physical, mental, emotional,
of ethics. Consider the following questions as guides and spiritual dimensions. How do you keep your
 CHAPTER 8 Ethical Considerations 123

body in shape? How do you keep your mind alert? is what persistence is. If you make a mistake, admit
Do patience, unconditional love, and accepting it, correct it, learn from the mistake, and move on,
responsibility for your own actions keep you emo- but never give up. An individual who is truly aware of
tionally healthy? Do you have a way to meditate, his or her personal ethical power is able to admit an
pray, or “draw away” for a period to “fill up your error, does not compromise any procedure or any
spirit”? technique, and does not ever put the patient at risk,
even if it means facing reprimand from a supervisor.
These questions and your responses to them
can give you insight into your ability to function Perspective: Keep your life and your purpose in per-
ethically and to be successful in the world of spective. Find time each day to maintain balance
medicine. in your life (perhaps looking again at the eight
Covey has another book entitled The 8th Habit: characteristics of principle-centered individuals).
From Effectiveness to Greatness that discusses how indi- Plan some quiet time, some fun time, but certainly
viduals can be more excited about their lives and some reflective time. The constant pressure and
their work when they reach beyond effectiveness the crises will become overwhelming without keep-
toward fulfillment, contribution, and greatness. ing perspective.
Individuals who feel fulfilled and excited about
their work are more apt to perform ethically than
those who do not. Ethics Check Questions
Finally, those striving to act in an ethical manner
Five Ps of Ethical Power can perform a little test each time they have a ques-
tion about ethics. This, too, comes from Blanchard
Kenneth Blanchard and Norman Vincent Peale
and Peale. The questions to ask are: (1) Is it legal?
wrote a simple but powerful little book called The
Is it against the law or any company policy? (2) Is it
Power of Ethical Management. In it they discuss the
balanced? Is this the best possible approach for all
“Five Ps of Ethical Power.” The five Ps are as follows:
concerned? Does it promote a win–win situation?
Purpose: Understand your objective or your purpose. (3) How will it make me feel about myself? Will I
Your purpose may change from time to time, but feel good if my decision is published in a newspa-
it is something that requires you to behave in a way per? Will my family and coworkers be proud of my
that makes you feel good about yourself. decision?
Ethics are not easy. Performing ethically is
Pride: Have pride in what you do. Feel good about your-
hard work. Being ethical means determining who
self and your accomplishments. Nurture your self-
you are and how you will act. Laws are more clearly
esteem while remaining humble. Be proud to be a
defined than ethics, but acting in an unethical
medical assistant.
manner can cause as much pain and difficulty as
Patience: It takes time to create an atmosphere where your can acting illegally. The ideas of Covey, Blanchard,
objective can be obtained. Strive to believe that no and Peale give guidance, thoughts to ponder, and
matter what happens, everything is going to work perhaps goals to reach. Keep them in mind as you
out. Expect results from yourself and your work, but review the next section.
refrain from demanding it “now.”
Persistence: To act in an ethical manner means to strive to
act in that manner all the time, not just when you BIOETHICS
want to or it seems easy to do. Winston Churchill
said, “Never! Never! Never! Never! Give Up!” That Bioethics brings the entire focus of ethics into the
field of health care and into those ethical issues
dealing with life. Never before in the history of
Critical Thinking medical care has bioethics been such a topic of
concern. In the past, most bioethical decisions were
With a peer, identify one or more examples made by physicians and esteemed members of the
in your life when you truly did not give up medical or legal profession. However, advancing
on attaining your goals. Describe what you technology giving patients and consumers numer-
learned from that experience. How might ous choices regarding their health care leads every-
“never giving up” help in your pursuit of a one to take an active role in bioethics.
career? Medical assistants will encounter ethical and
bioethical issues across the lifespan. In Figure 8-1,
124 UNIT 3 Responsible Medical Practice

ETHICAL ISSUES FOR CONTEMPLATION treatment for substance abuse, birth control, even abortion
without parental consent. Does this violate parents’ right to
AND DISCUSSION medical information regarding their children? Should the
adolescent, often fearful of parental reaction, have a right
Infants to treatment?
• Imperiled newborns (those who are severely disabled,
deformed, often premature and have low birth weight)
Adults
have a greater chance for survival with today’s medical • A large number of men and women find that both must be
technology. However, this ability places parents and health employed in order to provide a home for their families. How is
care professionals in an uncomfortable position to deter- it possible to balance full-time employment, full-time parenting,
mine when the costs of expensive intervention outweigh full-time housekeeping, and full-time partnering, and still take
the benefits. Often medical insurance will not pay for care of oneself?
these costs. • Many low-income women lack sufficient access to prenatal
• Vulnerability of infants can lead to negligence, rejection, and care, even though it is a cost-saving medical measure that is
even abuse. Parents also are vulnerable because they often are critical to the health of both mother and infant.
unable to cope with the needs of the entire family. How can • Adequate and quality health care is a problem. Some adults
families be helped in making a choice or in providing care for have no health care coverage; others are part of managed care
their family? programs that keep changing as employers seek lower health
insurance premiums. Many adults do not have an ongoing
Children provider–patient relationship.
• War, terrorist attacks, and an overburdened military place
• Children who are not well fed, housed, educated, and
families in very stressful circumstances. Many who serve in the
clothed exhibit great needs for preventive, curative, and
military are returning with horrendous lifelong and debilitating
rehabilitative health care. They likely do not have medi-
injuries. Lives are forever changed. How do they cope?
cal coverage, do not visit a health care provider regularly,
• Even with an advance directive or living will, a dying patient’s
and make more trips to the hospital emergency room than
wishes may not be followed. Technological advances in medi-
most children.
cine have created situations where patients may not be able to
• Obesity in children is a serious health issue. Increasing numbers
exercise their wishes.
of children receive one or two free or low-cost meals at school,
share few meals with their family members, and eat at fast-food
restaurants. Sweets are often used as reward or to express love.
Senior Adults
How are children educated to make better choices? • Elderly patients have the right to maintain dignity and privacy,
• An increasing number of children live within very dysfunctional but their dependency on others may deprive them of these
families where one or more parent is absent, is a substance basic rights.
abuser, has mental health issues, or has very little time to • Many senior adults are finding that very few providers accept
spend with their children. Many children have multiple parents new Medicare patients. The problem is even more severe when
or caregivers. Many spend large portions of the day in a day- senior adults must rely upon Medicaid for their medical care
care environment. Child abuse is a concern. Children must be because of the few number of providers who accept Medicaid.
protected, but they can be caught in a web of social services • Some elderly patients must choose between food on their
so overloaded and understaffed that only the most severe con- tables or prescribed medications they cannot afford. Although
cerns receive attention. How do health professionals protect Medicare Part D helped some, it did not help all.
these children? • Dementia is a common problem that is physically and finan-
cially exhausting and heartbreaking to the caregiver who usu-
Adolescents ally is a spouse, partner, or adult child. How do individuals cope
in the “sandwich” arrangement of caring for themselves, their
• The adolescent’s growing autonomy, need for independence,
children, and elderly parents, some who may have dementia?
changing values, and desire for peer acceptance often lead
What happens when there are insufficient funds for assisted liv-
to the decision to become sexually active, use birth control, or
ing or long-term care?
experiment with drugs and alcohol.
• Adolescents as young as 14 to 18 years of age may seek

Figure 8-1 Ethical issues across the life span. (Compiled by Carol D. Tamparo, CMA (AAMA), PhD, and Marilyn Pooler,
RN, MEd.)
 CHAPTER 8 Ethical Considerations 125

AAMA CODE OF ETHICS

The Code of Ethics of AAMA shall set forth principles of ethi-
cal and moral conduct as they relate to the medical profes-
sion and the particular practice of medical assisting.
Members of AAMA dedicated to the conscientious pursuit
of their profession, and thus desiring to merit the high regard
of the entire medical profession and the respect of the gen-
eral public which they serve, do pledge themselves to strive
always to:
A. render service with full respect for the dignity of humanity;
B. respect confidential information obtained through employ-
CREED
ment unless legally authorized or required by responsible I believe in the principles and purposes of the Profession of
performance of duty to divulge such information; Medical Assisting.
C. uphold the honor and high principles of the profession and I endeavor to be more effective.
accept its disciplines; I aspire to render greater service.
D. seek to continually improve the knowledge and skills of I protect the confidence entrusted to me.
medical assistants for the benefit of patients and profes- I am dedicated to the care and well-being of all people.
sional colleagues; I am loyal to my employer.
E. participate in additional service activities aimed toward I am true to the ethics of my profession.
improving the health and well-being of the community. I am strengthened by compassion, courage, and faith.

(A) (B)
Figure 8-2 (A) American Association of Medical Assistants (AAMA) Code of Ethics. (B) AAMA Creed. (Copyright
by the American Association of Medical Assistants, Inc. Revised October 1996.)

a few issues are identified for contemplation and •Will I be able to accept the indigent, the physi-
discussion. Issues of bioethics common to every cally and mentally challenged, the infirm, the
medical clinic are the allocation of scarce medi- physically disfigured, and the persons I simply
cal resources; abortion and fetal tissue research; do not like as equal and valid human beings
genetic engineering or manipulation; and the with an equal right to service?
many choices surrounding life, dying, and death. B. Respect confidential information obtained through em-
For medical assistants to fully comprehend ployment unless legally authorized or required by respon-
a discussion of ethics and bioethics, review of sible performance of duty to divulge such information.
the Code of Ethics of AAMA (Figure 8-2) is • Will I refrain from needless comments to a col-
beneficial. league regarding a patient’s problem?
• Will I refrain from discussing my day’s encoun-
KEYS TO THE AAMA CODE ters with patients with my family and friends?
• Will I always protect a patient’s medical
OF ETHICS record and everything in it from unnecessary
observation?
Medical assistants should consider the more salient
points in the AAMA Code of Ethics and ask them- • Will I keep patients’ names and the circum-
selves the following questions: stances that bring them to my place of employ-
ment confidential?
A. Render service with full respect for the dignity of C. Uphold the honor and high principles of the profession
humanity. and accept its disciplines.
• Will I respect every patient even if I • Am I proud to serve as a medical assistant?
do not approve of his or her morals or • Will I always perform within the scope of my
choices in health care? profession, never exceeding the responsibility
• Will I honor each patient’s request for infor- entrusted to me?
mation and explain unfamiliar procedures? • Will I encourage others to enter the profes-
• Will I give my full attention to acknowledging sion and always speak honorably of medical
the needs of every patient? assistants?
126 UNIT 3 Responsible Medical Practice

D. Seek to continually improve the knowledge and skills of

medical assistants for the benefit of patients and profes-
Confidentiality
sional colleagues. Providers must not reveal confidential
• Will I be willing to learn new skills, to update information about patients without their
my skills, and seek improved methods for consent unless the providers are otherwise
assisting the provider in the care of patients? required to do so by law. Confidentiality must be
protected so that patients will feel comfortable and
• Will I keep my credentials current and valid?
safe in revealing information about themselves that
• Can I remember that I am a member of a may be important to their health care. The follow-
group of broad-based health care profession- ing list contains examples of the kinds of reports
als, and that my goal is to complement rather that allow or require health professionals to report
than to compete with that team? a confidence.
E. Participate in additional service activities aimed toward
improving the health and well-being of the community. • A patient threatens another person and there is
reason to believe that the threat may be carried
• Will I be able to serve in the community where
out.
I reside and work to further quality health
care? • Certain injuries and illnesses must be reported.
These include injuries such as knife and gunshot
• Will I promote preventive medicine?
wounds, wounds that may be from suspected child
• Will I practice good health care management abuse, communicable diseases, and sexually trans-
for myself, being a model for others to follow? mitted diseases.
• Information that may have been subpoenaed for
ETHICAL GUIDELINES FOR testimony in a court of law.

HEALTH CARE PROVIDERS When in doubt, it is always recommended

that a provider have the patient’s permission to
It is fairly common for each professional group of reveal any confidential information.
medical practitioners to have their own code of Extra caution must be taken to protect the
ethics. The AMA’s Code of Medical Ethics and the HIPAA confidentiality of any patient’s data that
“Current Opinions with Annotations of the Coun- are kept on a computer database. As few
cil on Ethical and Judicial Affairs” was mentioned people as possible should have access to the com-
earlier. The American Chiropractic Association puter data, and only authorized individuals should
has a Code of Ethics identified in six sections. The be permitted to add or alter data. Adequate security
American Osteopathic Association has a Code of precautions must be used to protect information
Ethics with 19 different sections. Other practitio- stored on a computer. HIPAA has specific guidelines
ners may consider their mission and policies to be for computer privacy.
their code of ethics. Some have no specific written
code of ethics but rather call on their practitioners
to refer to their culture as one based on ethics,
Medical Records
mutual respect, and moral evaluation when ethical Medical records and the information in them
decisions are made. There are many similarities in are the property of the provider and the patient.
these statements on ethics that are important for No information should be revealed without the
patients and medical employees. A few prominent patient’s consent unless required by law. The
statements are provided here. record is confidential. Providers should not refuse
to provide a copy of the record to another pro-
vider treating the patient so long as proper autho-
Advertising rization has been received from the patient. Also,
Health care providers and professional people tradi- providers should provide a copy of the record
tionally have not advertised; however, it is not illegal or summary of its contents if a patient requests
or unethical to do so if claims made are truthful and it. A record cannot be withheld because of an
not misleading. Advertisements may include creden- unpaid bill.
tials of providers and a description of the practice, On a provider’s retirement or death, or when
kinds of services rendered, and how fees are deter- a practice is sold, patients should be notified and
mined. Managed care agencies may advertise their given ample time to have their records transferred
services and the names of participating providers. to another provider of their choice.
 CHAPTER 8 Ethical Considerations 127

Providers who know they are HIV positive

Professional Fees and Charges should refrain from any activity that would risk the
Illegal or excessive fees should not be charged. Fees transmission of the virus to others.
should be based on those customary to the locale Any activity that might be regarded as a “conflict
and should reflect the difficulty of services and the of interest” (for example, a provider holding stock
quality of performance rendered. Fee splitting (a in a pharmaceutical company and prescribing medi-
provider splits the fee with another provider for cations only from that company) should be avoided.
services rendered with or without the patient’s Financial interests are not to influence providers
knowledge) in any form is unethical. Providers in prescribing medications, devices, or appliances.
may charge for missed appointments (if patients
have first been notified of the practice) and may
charge for multiple or complex insurance forms.
Disaster Response
Providers and their employees must be diligent Medical professionals are essential at the time
to ensure that only the services actually rendered of any disaster, such as epidemics, floods, fires,
are charged or indicated on the insurance claim. weather-related disasters, and terrorist attacks.
Only what is documented in the patient’s chart is Care for the sick and injured is of primary concern
to be billed. when disaster strikes. Providers are encouraged to
Increasingly, a number of providers now re- give their medical expertise not only to prepare
fuse any insurance payments and operate strictly for any type of disaster but to provide assistance
on a cash-only basis. Others charge a yearly fee to when one occurs. Providers should consider seek-
care for a family, providing all services necessary at ing training in disaster preparedness and response
that flat fee. Providers, upset by the rules and regu- and lend their knowledge where it is most benefi-
lations of insurance, find this method of payment cial and effective in making certain that medical
creates a simpler form of medical practice. Provid- care is available during such events.
ers and patients alike will be discussing the ethics of
such a move for some time. Although providers may Treatment for a Culturally Diverse
choose whom they wish to serve, the cash-only basis
is difficult for low-income families and the poor.
Clientele
All providers are reminded to strive to pro-
Professional Rights vide the same quality of care to all their
patients regardless of race or ethnicity. Pro-
and Responsibilities viders must remember to eliminate biased behavior
As stated earlier, providers may choose toward any group of patients deemed different from
whom to serve, but they may not refuse a themselves. All patients have the right to participa-
patient on the basis of race, color, religion, tory decision making with their providers based on
national origin, or any other illegal discrimina- mutual trust and understanding. Communication
tion. It is unethical for providers to deny treatment factors are to be considered and interpreters pro-
to HIV-infected individuals on that basis alone if vided as necessary so that patients understand the
they are qualified to treat the patient’s condition. medical information as well as any communication
Once a provider takes a case, the patient cannot exchanged.
be neglected or refused treatment unless official Diversity is to be encouraged in the medical
notice is given from the provider to withdraw from profession and considered when hiring assistants.
the case. Ethnically diverse neighborhoods and clientele
Patients have the right to know their diagnoses deserve an ethnically diverse group of medical pro-
and the nature and purpose of their treatment and fessionals for their care. If it is not possible to employ
to have enough information to be able to make an an ethnically diverse group of medical profession-
informed choice about their treatment protocol. als, then medical professionals who are keenly aware
Providers should inform families of a patient’s death of and knowledgeable of the ethic group served is
and not delegate that responsibility to others. of primary importance.
Providers should expose incompetent, cor-
rupt, dishonest, and unethical conduct by other
providers to the disciplinary board. It is unethical
Care of the Poor
for any provider to treat patients while under the From the earliest history of medical treatment,
influence of alcohol, controlled substances, or any care for the poor has been a concern and a goal
other chemical that impairs the physician’s ability. for medical practitioners. Today that obligation is
128 UNIT 3 Responsible Medical Practice

still mentioned in most ethical codes and discus- suspected child abuse, to protect and care for the
sions. All medical providers have a responsibility abused, and to treat the abuser (if known) as a
to ensure that the needs of the poor in their com- victim also. This is not an easy task. Abuse is not
munities are met. Caring for the poor should be a easy to witness. Although there are specific laws
regular part of every provider’s practice and can be regarding suspected child abuse, and in most
accomplished in a number of ways. Providers can states medical assistants are mandated to report
take a certain number of patients on a reduced- abuse, the laws are vague or nonexistent for
cost basis or provide free services. Providers can older adults or in cases of IPV. However, whatever
volunteer their time and efforts to treat patients form the abuse takes, it is best to treat all forms
in reduced-cost, freestanding clinics that treat of abuse in the same manner by providing a safe
the poor and/or provide services to those in home- environment for those abused and seeking treat-
less shelters for battered and abused individuals. ment for the abused and the abuser.
Providers can volunteer their time to lobbying
and being advocates for those without medical
coverage. BIOETHICAL DILEMMAS
Guidelines for bioethical issues are even harder
Abuse to define than are guidelines for ethics, because
Abuse usually is described as neglect, physi- each of the bioethical issues calls for decisions that
cal, emotional/psychological/mental injury, directly affect a person’s life. In some instances,
or sexual. Child abuse also includes child the bioethical issue requires a choice about who
molestation, sexual exploitation, and incest. Elder lives and requires a definition of the quality of life.
abuse includes the four basic types mentioned Such dilemmas are difficult, if not impossible, to
above and adds financial abuse. Stalking and rape approach from a neutral point of view even though
are also forms of abuse. medical professionals should strive not to impose
All 50 states have legislation defining child their own moral values on patients or coworkers.
abuse and mandate who is responsible for report-
ing such abuse. The majority of states have enacted Allocation of Scarce Medical
legislation regarding the abuse of elder adults
60 years of age or older. Intimate partner (or
Resources
domestic) violence is a criminal offense in some The issue faced daily by health care workers is
states, but whether a state requires that intimate the allocation of scarce medical resources. Even
partner violence (IPV) be reported depends in part with the government’s attempts at health care
upon whether a weapon is used. reform, medical resources still are not available to
Stalking is the repeated act of spying upon, everyone. When the administrative medical assis-
following, or making contact with an individual or tant determines who receives the only available
appearing at an individual’s residence or place of appointment in a day, when patients are turned
employment after being asked not to. It is a crime away because they have no insurance or financial
in some states. Rape, also a crime of violence, is resources to pay for services, when Medicare/
forced sexual intercourse or penetration of a body Medicaid patients are denied services because
orifice with the penis or some other object. Gang of low return from state and federal insurance
rape involves several individuals. Rape is a report- programs, scarce medical resources are being
able criminal act. denied.
Medical assistants must know if their state The U.S. Census Bureau reported that 46.6
specifically names them as a reporter for abuse. million people were without health insurance cov-
A discussion should be held with medical provid- erage in 2006. The number of uninsured is esti-
ers and employers regarding who, when, and how mated to increase by one million each year. Adults
the abuse will be reported and documented. It is were more likely to be uninsured than children
unethical for a medical assistant to fail to report because a number of state and federal programs
abuse simply because an employer prefers “not to cover children. However, more than 6% of chil-
get too involved.” For a clearer understanding of dren under age 18 years have no source of health
some of the factors that constitute abuse, review care. Hispanic and non-Hispanic black children
Table 8-1. were more likely to have no health care than were
It is the responsibility of medical profes- non-Hispanic white children. Of note, the aver-
sionals and their employees to report all cases of age waiting time by new patients for a medical
 CHAPTER 8 Ethical Considerations 129

Table 8-1 Descriptions of Abuse

Child Abuse Elder Abuse Intimate Partner Violence

Failure to provide basic Lack of attention that causes harm;

food, shelter, care; withholding basic needs; abandon-
Neglect
endangers health of ment; lack of help with hygiene or
child bathing

Burns, unusual or severe Assault, beating, whipping, hitting, Intent to harm; hitting, pushing,
bruising, lacerations, punching, pushing, pinching, force- grabbing, biting, punching, slap-
Physical fractures, injury to inter- feeding, shaking, rough handling ping, restraining, burning; use of a
nal organs; usually during caregiving, bodily harm or weapon or one’s own strength to
obvious severe mental stress harm

Harm to child’s emo- Actions that dehumanize; social Humiliating; controlling; isolating
Emotional/ tional and intellectual isolation, name calling, humiliating, partner from friends/family, with-
psychological growth; not always insulting; threats to punish; yelling, holding funds or basic resources
obvious screaming

Using a child to engage Sexual contact without permission; Sexual contact without permission;
in any sexual activity; fondling, touching, kissing, rape, abusive sexual contact; sex with
Sexual
not always obvious coerced nudity; spying while in one who is unable to say “no”
bathroom

Exploitation of an elder’s resources;

forging signature on documents;
Financial
withholding or cashing funds
received

Pornography, prosti-
Sexual
tution; use of child’s
exploitation
image in media

Sexual activity between

Incest
family members

appointment was 14.5 days. Even the elderly, many macroallocation of scarce medical resources. Deci-
of whom have both Medicare and supplemental sions made individually by providers and mem-
health insurance, had difficulty finding providers bers of the health care team at the local level are
who took new Medicare patients. This dilemma termed microallocation of scarce resources. No
can be particularly problematic when the elderly matter what the level, medical assistants will be
move from their home and community to be closer involved.
to their children.
Weightier decisions might include who gets Abortion and Fetal Tissue
the surgery, a kidney transplant, or the experimen-
tal bone marrow transplant. These allocations are
Research
being made and will continue to require decisions The issues associated with abortion and
on the part of the health care team. Rationing fetal tissue research will be with us for quite
of health care may become more widespread as some time. Although the law as set forth
managed care operations try to achieve a balance in Roe v. Wade is specific on abortion guidelines, there
between providing access to care while still curtail- is a continual challenge in the courts of its validity.
ing costs. Some states are more restrictive regarding whether
Decisions made by Congress, health systems and how abortions might be performed in the sec-
agencies, and insurance companies are termed ond and third trimesters of pregnancy. However, the
130 UNIT 3 Responsible Medical Practice

current law stipulates that a woman has a right to an cord blood. Stem cells in cord blood can help
abortion in the first trimester without interference restore red blood cells in people with sickle cell
from regulations in any state. anemia, and a small group of children newly diag-
Medical professionals must decide whether nosed with type 1 diabetes who were transfused
to perform abortions within the legal parameters with their own stored cord blood showed reduced
and under what circumstances. Providers can- severity of the disease.
not be forced to perform abortions, nor can any
employee be forced to participate or assist in an Genetic Engineering/
abortion. Employees not wishing to participate in
abortions are advised to seek employment where
Manipulation
they are not performed. So much is possible today in the area of genetic
Many unanswered ethical questions related engineering, and new discoveries increasingly are
to abortion make the decision difficult for health being made. This biotechnology can be used in
care professionals. Should abortion be considered the diagnosis of disease, in the production of medi-
a form of birth control? If not, should birth control cines, for forensic documentation (DNA used in
be readily available to all who seek it regardless of solving crimes), and for research. Some reasons
age? Should insurance pay for birth control? Is it for continuing study in this area include deter-
ethical to deny an abortion to a woman on welfare mining if anything can be done to prevent or
but provide one to a woman who has money for cure some 4,000 recognized genetic disorders and
the procedure or whose insurance pays? Should major diseases that have large genetic components.
any abortion be legal? And, of course, the major Few individuals would not like to see a cure for cer-
unanswered question that must be considered by tain illnesses, but there is a fear among many that
every individual is: When does life begin? genetic engineering may lead to choices that should
The abortion issue raises another bioethical not be made. Deciding what should be done when
issue—fetal tissue research and transplantation. As the unborn is determined to have a severe birth
early as the 1950s, fetal tissue research led to the defect, manipulating genes to a more perfect off-
development of polio and rubella vaccines. Today, spring, and discarding defective embryos are just a
fetal cells hold promise for medical research into a few of those concerns.
variety of diseases and medical conditions, includ- If the United States moves past the dilemma
ing Alzheimer’s disease, Huntington’s disease, spi- related to the use of embryonic stem cells, then a
nal cord injury, diabetes, and multiple sclerosis. number of significant medical advances might be
Some research indicates that fetal retinal trans- made. Researchers may be able to create custom-
plants may be a successful treatment of macular made organs to replace those that are defective or
degeneration, which is the leading cause of age- diseased. Although it might be a wonderful thing
related blindness in the United States. This issue to create a new pancreas or a semisynthethic liver
is political as well as bioethical, and it changes to replace an organ that is no longer performing its
with each major political shift in our government. necessary function, the greater fear of some indi-
Fetal tissue research also gets caught up in the viduals is that of cloning. Scientists already have
pro-life forces. About half of the states have laws cloned mice, sheep, rabbits, goats, pigs, and a dog.
regulating fetal research. Some ban research using Where does cloning stop? Will human beings be
aborted fetuses. Federal law prohibits the sale of cloned if science moves further into research with
fetal tissue and requires all federally funded fetal stem cells? Some countries with a different politi-
tissue research projects to comply with state and cal arena than the one found in the United States
local laws. Fetal tissue research is not to be used are advancing further into this area. It is interest-
to encourage women to have abortions; rather, the ing to note, however, that the General Assembly of
tissue would be available only after a decision had the United Nations voted to prohibit all forms of
already been made regarding abortion. human cloning in August 2005.
While the debate related to the use of fetal tis-
sues for research marches on, the door has opened
for research using umbilical cord blood. The use of
Artificial Insemination/Surrogacy
cord blood has not met with as much controversy For many individuals, artificial insemination is
as the use of fetal tissue. In 2005, President George the only means by which they can conceive a
W. Bush signed into legislation a federal program child. Providers are called on to perform artificial
to collect and store cord blood and to expand the insemination for couples, and women who want
current bone marrow registry program to include a child. If artificial insemination is performed,
 CHAPTER 8 Ethical Considerations 131

it is recommended that the signed consent of ethical concerns for some and are not addressed
each party involved be obtained. It is also recom- in law.
mended that providers practicing artificial insem- A woman can have a donor’s egg fertilized by
ination by donor use many donors for semen and her husband’s sperm for implantation. A woman
that meticulous screening be performed before can receive donor embryos (embryo adoption)
the insemination. from successfully completed IVF from two unre-
Surrogacy is another bioethical issue. Men lated individuals. Couples who have successfully
have been used as surrogates, or substitutes, for had a baby through IVF are sometimes willing to
decades with the practice of artificial insemina- donate their additional embryos. A woman can
tion, but society seems to have a more difficult carry an embryo created from a donor egg and
time accepting surrogate mothers who are artifi- donor sperm that will have no genetic relationship
cially inseminated by a donor and carry the fetus to her.
to term for another parent. Men seek surrogates It is possible to screen for genetic flaws among
who are able to provide them a child who rep- embryos created by IVF; however, the latest medi-
resents half their genetic makeup. How should cal research indicates that such analysis sometimes
the rights of each individual in the exchange be causes abnormalities.
protected? For many of these issues, there is little Medical assistants who work in fertility clin-
protection or guidance under the law; therefore, ics must at all times respect the choices made by
health professionals must make decisions on the individuals seeking artificial insemination or IVF.
basis of their own belief systems. These procedures are truly private and very per-
Ethical questions are sometimes raised regard- sonal. Anyone who feels uncomfortable with such
ing artificial insemination and surrogacy. Should procedures should seek employment elsewhere.
artificial insemination be performed for individu-
als who do not fit the traditional family model?
Who will be a fit mother or father for this infant?
Dying and Death
Some religious faiths consider artificial insemina- The goal for all health professionals is to preserve
tion by donor to be the same as adultery. Who or and enhance life, thus, making death an event con-
what agency carefully protects the selection and trary to the goals of health care. Yet, death cannot
screening process of donors and surrogates? How be avoided. How death is faced can become both
are donors selected? Is there a responsibility to a legal and an ethical dilemma. Legally, individu-
make certain that individuals with the same father als can make choices about their death and are
through artificial insemination by donor do not encouraged to do so by health care professionals.
marry? Some fertility specialists recommend that When those wishes are indicated in documents
a donor be chosen from a city far from where the such as advance directives and when health profes-
potential mother lives and that formal adoption sionals disagree or refuse to honor those wishes, a
occur immediately when the infant is born. legal problem exists.
Artificial insemination and surrogacy were The legal dilemma was made famous by the
viewed as experimental and quite controversial cases of Karen Ann Quinlan and Theresa (Terri)
just 20 years ago. Today, however, the procedures Schiavo. Both were young women, without any
are widely practiced and available. Both artificial advance health care directives, whose deaths were
insemination and surrogacy are costly and can caught up in battles between family members, the
become legal tangles for all involved if careful steps medical staff, and the courts. Quinlan lived for
are not taken.

In Vitro Fertilization Critical Thinking

In vitro fertilization (IVF) is a process that has
shown to be very successful in the past decade. In When fertilization occurs outside the womb,
IVF, the ovum is fertilized in a culture dish, allowed additional embryos are stored and saved for
to grow, and then implanted into the uterus. This future use. How long should they be stored?
procedure can be used for women with blocked fal- To whom do they belong? What happens if
lopian tubes or oviducts. Ethically, this procedure no one wants those embryos later? Should
faces little controversy when a husband’s sperm they be destroyed, given to some other
is used to fertilize his wife’s ovum, which is then hopeful parent, or used for research?
implanted into her uterus. Other procedures raise
132 UNIT 3 Responsible Medical Practice

11 years in a vegetative state after much duress Cardiopulmonary resuscitation (CPR), intravenous
with health professionals and hospital staff who therapy, and feeding tubes are discouraged. Death
believed she should be kept on a respirator. The is treated as a natural end-of-life experience. Death
family members of Schiavo were in legal battles for is neither hastened nor prevented.
15 years before permission was received to remove Hospice volunteers and trainers indicate that
her feeding tube; she died 14 days later. When although most patients will choose hospice, some
there is conflict among family and those caring family members may not be as comfortable in that
for someone near death, even a well-written and choice. Family members may not be ready to let
executed advance directive can be faced with chal- go of a loved one; also, they may be uncomfort-
lenges. Then a legal dilemma becomes an ethical able if the hospice service is in the home rather
dilemma as well. than the hospital or a hospice facility. The latter
Patients continue to make decisions express- is related to how comfortable family members are
ing their choices in death. Oregon was the first in observing or being a part of the death process.
state to pass legislation allowing physicians to The expense of hospice is often covered by medi-
assist patients in death. Washington state voters cal insurance and is less expensive than inpatient
approved similar legislation November 2008. The hospital care.
Oregon law was voted upon and passed on two
separate occasions and was challenged by the U.S.
Attorney General before the U.S. Supreme Court
HIV and AIDS
determined that the law could stand. Many Ore- The general public’s fear of AIDS has caused some
gonians find comfort in the law that allows them serious bioethical issues. Patients who suspect they
the right to choose the time and place for their have HIV or AIDS should be tested for the virus. In
own death; however, the number of individuals fact, the Centers for Disease Control and Preven-
who choose physician-assisted death still is small— tion (CDC) recommend voluntary screening for
less that nine per 10,000 deaths. Some make the HIV/AIDS to become a routine part of medical
choice, receive the medications from their physi- care for all patients ages 13 to 64 years. Confiden-
cian, and then do not use the medication. Oth- tiality must be protected, however, because indi-
ers receive the medication and find much relief viduals with HIV/AIDS have been denied medical
in their choice and do take the medication. Still insurance, faced loss of employment and housing,
others believe that any intervention that hastens and even suffered the loss of family members and
death is criminal. friends. It is unethical to deny treatment to indi-
Choices available to patients who are dying cre- viduals because they test positive for HIV.
ate the question, what is “quality of life”? Although Although individuals with HIV/AIDS must
the answer to that question is different for every- be protected, so must the public. Therefore, if
one, it is a question often in conflict with today’s providers suspect that an HIV-seropositive patient
medical technology that can, in many instances, is infecting an unsuspecting individual, every
keep a patient alive much longer than the patient attempt should be made to protect the individual
might prefer. The benefits of advanced technology at risk. Health professionals must first encourage
will continue to be weighed against what many con- the infected person to cease endangering any per-
sider the right to die with dignity and a minimum son. Second, if the patient refuses to notify the
of medical intervention. person at risk or wishes the provider to notify the
person, authorities can be contacted. Many states
Hospice. Hospice is the term used to describe either and cities have Partner Notification Programs that
a place of residence for those who are dying or an will anonymously notify any person at risk, keep-
organization whose medical professionals and vol- ing the source confidential. The program informs
unteers are in attendance of someone whose death them that it has been brought to their attention
is imminent. The main objective of hospice is to that they are a “person at risk” and provides them
make patients comfortable and as free from pain as with free testing. Third, the provider can notify the
possible and to allow them dignity in their deaths. person at risk.
 CHAPTER 8 Ethical Considerations 133

Case Study 8-1

Refer to the scenario at the beginning of the chapter. CASE STUDY REVIEW
Harley Navarro, the new medical assistant, is espe-
cially hesitant to ask for assistance or admit that he is hav- 1. If Harley’s behavior does no harm to the patient,
ing a problem. Twice today he was unable to get a good has he acted unethically? Illegally?
blood pressure reading on patients. One patient was very 2. What might the office manager do if she senses
obese, and the other kept trying to carry on a conversation Harley’s lack of certainty?
with him. 3. Discuss the role of female and male medical
assistants working together and how they might
complement each other.

Case Study 8-2

Liz Corbin is a medical assistant in the fertility clinic of a CASE STUDY REVIEW
large metropolitan medical clinic and hospital. Liz really
likes her job and is delighted when parenthood is made 1. Liz is rather hesitant to comply with her employer’s
possible for many of those seeking the clinic’s advanced orders, so she does a little research. She discovers
technology. The clinic also stores and maintains the unused that most fertility clinics ask couples using cryo-
frozen embryos that result from artificial insemination. She preservation to decide early in the process how
is a little alarmed when her provider–employer informs her to handle their excess embryos. The choices are:
that four of the embryos are to be destroyed. Her employer (1) discard the embryos, (2) donate anonymously
has been unable to contact the owners (now parents of to other infertile couples, and (3) donate to scien-
more than one child from artificial insemination) for direc- tific research. What might Liz do to influence the
tions, and space for storage is limited. Liz is instructed to clinic’s policy?
destroy the embryos. 2. Can anything be done to ensure that couples do
not abandon their embryos?
3. If embryos are given to other infertile couples, how
is a decision made on who should have them?

SUMMARY
As medical technology continues to advance, a greater need for ethical guidelines will be necessary. Pro-
viders and health care professionals at all levels must stay abreast of the issues and carefully consider all
aspects before making any decision.
Medical assistants must, however, keep the following legal and ethical guidelines in mind: (1) always
practice within the law; (2) preserve the patient’s confidentiality; (3) maintain meticulous records; (4) obtain
informed, written consent; (5) do not judge patients whose belief system differs from yours.
134 UNIT 3 Responsible Medical Practice

STUDY FOR SUCCESS

To reinforce your knowledge and skills of information in this chapter:
• Review the Key Terms
• Consider the Case Studies and discuss your conclusions
• Answer the Review Questions

˚ Multiple Choice
˚ Critical Thinking
• Navigate the Internet and complete the Web Activities
• Practice the StudyWARE activities on the textbook CD
• Apply your knowledge in the Student Workbook activities
• Complete the Web Tutor sections
• View and discuss the DVD situations

REVIEW QUESTIONS
Multiple Choice 6. Macroallocation of scarce medical resources
implies that
1. Typically, ethics has been defined in terms of: a. the local health care team makes the decisions
a. what is right and wrong b. Congress, health systems agencies, and insurance
b. whether an action is legal companies make the decisions
c. the expedient thing to do c. medical assistants will not be involved
d. professionalism in the workplace d. patients will get the benefit of the best medical
2. Bioethics has to do with: care
a. biological reproduction 7. The eight characteristics of principle-centered
b. the act of artificial insemination leaders originates from the following author:
c. genetic engineering a. James R. Jones
d. ethical issues that deal with life and health care b. Stephen R. Covey
3. The AAMA Code of Ethics: c. Francis H. Ambrose
a. is concerned with principles of ethical and d. Jason N. Diamond
moral conduct 8. The five Ps of ethical power are:
b. defines the duties the medical assistant can a. Personality, performance, purpose, pride,
perform patience
c. is intended for physicians only b. Purpose, patience, perfection, personality,
d. applies only to patient rights procrastination
4. When a provider or medical assistant suspects child c. Patience, purpose, pride, persistence, perspective
abuse, they should: d. Purpose, pride, patience, perfection, perspective
a. give the parent a warning 9. Which of the following is true?
b. report it to the proper authorities a. A provider can choose whom to serve
c. not impose their values on the parents b. A provider may charge for completing multiple
d. give the child some hints on how to protect and complex insurance claims
against abuse c. Providers and their employees cannot be forced
5. When a patient has HIV: to perform abortions
a. it is ethical for the provider not to provide d. All of the above
treatment e. None of the above
b. it is unethical for the provider not to provide 10. You are most likely to make ethical decisions
treatment correctly when:
c. other patients should be warned of the possibil- a. you have a clear picture of the situation
ity of infection b. you leave emotion out of the decision as much
d. all friends and family members of the patient as possible
should be notified
 CHAPTER 8 Ethical Considerations 135

c. you understand your weaknesses and WEB ACTIVITIES

vulnerabilities
1. Using the Internet, print the latest issue of the
d. honesty and integrity are hallmarks of your
AMA Principles of Medical Ethics. Compare
entire life
that code with the AAMA Code of Ethics. Do
e. all of the above
you find this comparison helpful in more clearly
understanding ethics, responsibility, and profes-
Critical Thinking sionalism? Give your reasons.
1. A provider observes another provider put a patient 2. Using the Web site given at the beginning of this
at risk while under the influence of alcohol and chapter, select one additional code of ethics to
does nothing about it. What would constitute compare with the AMA Principles and the AAMA
ethical behavior? Code. What are the similarities?
2. A provider refuses to accept any more Medicaid 3. Using your favorite Internet search engine, key in
patients for medical care. Is this the provider’s two or three of the bioethical issues and do a small-
right? Is it ethical? Why or why not? scale review of items listed. From your research,
3. A clinical medical assistant whispers to the admin- identify at least three ethical/bioethical questions
istrative medical assistant, “There goes the guy with for your class to discuss.
AIDS.” How should the administrative medical
assistant view this behavior?
4. The services reported on the insurance claim are
more complex than those actually rendered. Is this
REFERENCES/BIBLIOGRAPHY
ethical or unethical? Legal or illegal? State your American Diabetes Association. (2007). First use of cord blood
reasons. to alter course of type 1 diabetes. Retrieved July 2007, from
5. A provider performs artificial insemination for http://professional.diabetes.org/UserFiles/File/
a lesbian couple; however, the medical assistant Scientific%20Sessions/Media/2007/Autologoos%
refuses to participate or assist the provider. What 20Cord%20Blood%20Final.doc.
are the ramifications of the medical assistant’s American Medical Association. (2006–2007). Code
behavior? Do you believe the medical assistant has of medical ethics. Current opinions of the council on
a right to refuse? ethical and judicial affairs, 2006. Chicago: American
6. Referring to Figure 8-1, select an ethical issue with Medical Association.
which you may have had some personal experi- Blanchard, K., & Peale, N. V. (1988). The power of ethical
ence. Now, form a small group, with each student management. New York: William Morrow and
leading a discussion on a different issue. Company, Inc.
Covey, S. R. (1991). Principle-centered leadership. New York:
Simon & Schuster.
Lewis, M. A., & Tamparo, C. D., (2007). Medical law,
ethics, and bioethics for health professions (6th ed.).
Philadelphia: F. A. Davis.
136 UNIT 3 Responsible Medical Practice

THE DVD HOOK-UP

In this chapter, you learned about the importance of ethical DVD Journal Summary
behavior when working in the medical field. Ethics are not Write a paragraph that summarizes what you learned
laws, but rather a set of morals or principles to which we from watching the designated scenes from today’s DVD
adhere. program. Ethical dilemmas may involve anyone in the
In the designated DVD clip, we observed Jen talking to medical office. For example, what would you do if you
Sarah about a patient who has diabetes. Jen feels that smelled alcohol on a coworker? What if you suspect the
the patient has complications with her diabetes because coworker is abusing alcohol? Are you obligated to say
she makes poor choices in her eating habits. Barb, the something? To whom? Why or why not?
supervisor, overhears the conversation and talks to Jen
and Sarah about the importance of being compassionate
as health care providers. Even though this clip does not
deal with some of the more noted ethical issues such as
fetal tissue research or genetic engineering, judging the
patient is a violation of ethical behavior and probably
one of the more typical ethical issues that you will DVD Series Program Number
struggle with as a medical assistant. Critical Thinking 3
1. As a medical assistant, you will make observations Chapter/Scene Reference
about your patients that can be helpful to the pro- • Ethical Practice
vider. What was inappropriate in the way Jen handled
her observations?
2. Diseases such as emphysema, obesity, and diabetes can
all be the result of unhealthy lifestyles. How will you as a
medical assistant keep from judging a patient’s actions
or lifestyle that have resulted in illness?
 Chapter
Emergency Procedures
and First Aid 9
KEY TERMS OUTLINE
Anaphylaxis Recognizing an Emergency Burns
Automated External Responding to an Emergency Musculoskeletal Injuries
Defibrillator (AED) Primary Survey Heat- and Cold-Related
Bandage Using the 911 or Emergency Illnesses
Cardiopulmonary Medical Services System Poisoning
Resuscitation (CPR) Good Samaritan Laws Sudden Illness
Cardioversion Blood, Body Fluids, and Cerebral Vascular Accident
Cauterized Disease Transmission Heart Attack
Constriction Band Preparing for an Emergency Breathing Emergencies and
The Medical Crash Tray or Cardiac Arrest
Crash Tray or Cart
Cart Rescue Breathing
Crepitation
Common Emergencies Cardiopulmonary Resuscitation
Dislocation Shock Safety and Emergency Practices
Dressing Wounds
Emergency Medical
Services (EMS)
Explicit OBJECTIVES
First Aid The student should strive to meet the following performance objectives and
Fracture demonstrate an understanding of the facts and principles presented in this
Hypothermia chapter through written and oral communication.
Implicit 1. Define the key terms as presented in the glossary.
Lackluster 2. Learn to recognize, prepare for, and respond to emergencies in
Normal Saline the ambulatory care setting.
Occlusion 3. Understand the legal and disease transmission considerations in
Rescue Breathing emergency caregiving.
Risk Management 4. Perform the primary assessment in emergency situations.
Shock 5. Identify and care for different types of wounds.
Splint 6. Understand the basics of bandage application.
Sprain 7. Discriminate among first-, second-, and third-degree burns.
Standard Precautions
8. Assess injuries to muscles, bones, and joints.
Strain
9. Describe heat- and cold-related illnesses.
Syncope
10. Describe how poisons may enter the body.
Systemic
11. List the symptoms of a poisonous snake bite.
Universal Emergency
Medical Identification 12. Recall the eight types of shock.
Symbol 13. Define a cerebral vascular accident.
Vasovagal Syncope
14. Describe the signs and symptoms of a heart attack.
Wound

137
 Scenario
Inner City Health Care, which is located in Carlton, moderately. Fortunately, Wanda knew that one of
Michigan, has its share of cold, snowy winters, and the providers was still in the office and she led the
when the temperature drops near freezing, that snow woman back to the building, reassuring her along the
sometimes turns to ice. Last night, as Wanda Slawson, way. Once in the office, Wanda assisted Susan Rice,
CMA (AAMA), was leaving for the evening, she noticed the provider, to examine the wound. After determin-
a woman from an adjacent office slip and fall in the ing that sutures were not needed, Dr. Rice and Wanda
parking lot. Wanda immediately went over to the cleansed the wound, applied a dry, sterile dressing,
woman to lend assistance and saw that, in falling, and covered it with an elastic bandage. The patient
the woman had cut the palm of her hand. Appar- was instructed to call her own provider first thing in
ently, the woman had tried to break her fall with her the morning.
hand only to sustain a wound that was now bleeding

INTRODUCTION RECOGNIZING AN EMERGENCY

Although the ambulatory care setting is primarily designed An emergency is considered any instance in which
to see patients under nonemergency conditions, occasion- an individual becomes suddenly ill and requires
ally the provider will need to administer emergency care, immediate attention. Most emergencies develop
and the medical assistant will be called on to assist the quickly and usually without warning. They can
provider in this care. For the medical assistant who may occur unexpectedly at any time to anyone. Some
need to screen or assess the patient’s condition, the first may be gradual, as seen with dehydration or slow
and most critical step in responding to an emergency is blood loss, and become an emergency over time.
developing the skill to recognize when emergency measures
should be taken.
Whereas some emergencies can be treated in the
office, others cannot, and the medical assistant must know
Spotlight on Certification
when to call for outside help. If the emergency occurs in the RMA Content Outline
ambulatory care setting, the provider usually administers
immediate care. It is possible, however, that the medical • Patient education
assistant may be the first emergency caregiver should the • Medical law
provider be out of the office. The medical assistant also • Asepsis
may be called on to provide care in an emergency outside • Vital signs and measurements
of the office environment. • Office safety
This chapter acquaints the medical assistant • First aid and emergency response
with types of emergency situations that may occur either
inside or outside of the office. However, this chapter is CMA (AAMA) Content Outline
merely an introduction to emergency topics and does not • Principles of infection control
substitute for first aid and cardiopulmonary resuscita- (aseptic technique)
tion (CPR) instruction taught through the American • Treatment area (safety precautions)
Red Cross, the American Heart Association, the Ameri- • Emergencies (preplanned action)
can Safety and Health Institute, or the National Safety • First aid
Council. Medical assistants in CAAHEP- and ABHES-
accredited programs must be certified to a provider-level CMAS Content Outline
in CPR and must be taught by instructors who are cer- • Vital signs and measurements
tified to teach CPR. These hands-on classes are vital • Medical office emergencies (recognize
teaching tools, and all medical assistants should take and respond to medical emergencies)
them on a regular basis to continually update their • Safety
skills.

138
 CHAPTER 9 Emergency Procedures and First Aid 139

A common sign that an individual has an emergency is critical to remain calm, to follow the emergency
is unusual noises, such as yelling, moaning, or cry- policies and procedures established by the ambu-
ing. A person may appear to be behaving strangely latory care setting, and to be well-versed in first-aid
when choking or if having difficulty breathing. To and be certified in CPR. The patient should not be
recognize when an emergency exists, it is important further endangered.
to have sharp senses of hearing, sight, and smell and
be acutely sensitive to any unusual behaviors.
In the ambulatory care setting, medical assis-
Responding to an Emergency
tants may encounter a range of emergency situations Once it has been determined that an emergency
requiring first-aid techniques. First aid is designed exists, it is essential to act quickly. Before making
to render immediate and temporary emergency any decisions about how to proceed, it is necessary
care to persons injured or otherwise disabled before to assess the nature of the situation. Does it include
the arrival of a health care practitioner or transport respiratory or circulatory failure, severe bleeding,
to a hospital or other health care agency. burns, poisoning, or severe allergic reaction?
Emergency situations can be minor or severe Sometimes, it is possible that more than one
and can include: type of care must be administered. In this case, it
• Choking and breathing crises is necessary to screen the situation so that treat-
ment can be prioritized. When an individual expe-
• Chest pain riences more than one illness or injury, care must
• Bleeding be given according to the severity of the situation.
• Shock When two or more patients present with emergen-
• Stroke cies simultaneously, screening helps determine
• Poisoning
which patient is treated first. The main principle
of screening states that absence of heartbeat and
• Burns breath and severe bleeding are immediate life
• Wounds threats. Table 9-1 lists the common ordering of
• Sudden illnesses such as fainting/falling screening situations.
• Illnesses related to heat and cold To identify the nature of the emergency and
respond effectively, it is critical that the patient be
• Fractures
assessed. If the patient is conscious, ask for personal
Some of these situations will be life threatening; identification and identification of next of kin.
all will require immediate care. In either case, it Try to obtain information about symptoms being

Table 9-1 Examples of Emergency Categories

First Priority Next Priority Least Priority

Burns on face Second-degree burns not on the neck and face Fractures (simple)

Airway and breathing problems Major or multiple fractures Minor injuries

Cardiac arrest Back injuries Sprains, strains

Severe bleeding that is uncontrolled Severe eye injuries

Head injuries

Poisoning

Open chest or abdominal wounds

Shock

Second- and third-degree burns

140 UNIT 3 Responsible Medical Practice

HIPAA Patient Education

Patient confidentiality must be main- Alert patients to the importance of carrying
HIPAA tained during an emergency situa- the universal emergency medical identifica-
tion symbol and its accompanying identifi-
tion, as it must at all times. Sometimes,
when a situationis urgent and the patient is cation card if the patient has severe heart
having trouble breathing, is bleeding heavily, disease, diabetes, or other life-threatening
or is having a severe allergic reaction or any illnesses or allergies.
other kind of emergency, in your eagerness to
assist the patient, your voice when talking to
other health care providers may be overheard
by other patients. Be certain other patients To assess whether the unresponsive patient is
cannot hear any conversations. Privacy must breathing and to determine if there is an open air-
be maintained when faxing information to way, place your face close to the patient’s face and
the emergency department. Also be cautious look, listen, and feel. Look at the patient’s chest
when speaking on the telephone. Be cautious and notice whether the chest rises and falls with
to keep the patient’s anonymity protected. breathing. Listen for air entering and leaving the
nose and mouth and feel for moving air.
If the individual is not breathing, first open
experienced to identify the problem. Always check the airway either by tilting the head and lifting the
for a universal emergency medical identification chin (Figure 9-2A) or by the jaw-thrust maneu-
symbol (Figure 9-1) and accompanying identifica- ver, which involves placing both thumbs on the
tion card, which will describe any serious or life- patient’s cheekbones and placing the index and
threatening health problems that the patient has. middle fingers on both sides of the lower jaw (see
Quickly observe the patient’s general appearance, Figure 9-2B). CAUTION: Do not attempt to tilt the
including skin color and size and dilation of pupils. head and lift the chin when the patient has a head,
Check pulse and blood pressure. neck, or spinal cord injury.
If the patient still does not breathe after the
airway has been opened, rescue breathing must be
Primary Survey performed.
If the patient is unresponsive, it is critical to assess To assess circulation, check for the presence
the ABCs, which include: of a pulse at the carotid artery on the side of the
neck below the ear. If no pulse is present, the
• Airway patient may be in cardiac arrest and must be given
• Breathing CPR. Use of an automated external defibrillator
• Circulation (AED) may be necessary (see Chapter 25).

Using the 911 or Emergency

Medical Services System
The Emergency Medical Services (EMS) system is
a local network of police, fire, and medical per-
sonnel who are trained to respond to emergency
situations. Other community experts and volun-
teers also act as resources in an EMS system. In
many communities, the network is activated by
calling 911. Even when preliminary emergency
care is provided by the ambulatory care provider,
the patient may still need to be transported to
a hospital for follow-up care. It is also possible
that the provider may not be equipped to deliver
the type of emergency care required, in which
Figure 9-1 The universal emergency medical identifi- case, one person should call for EMS help while
cation symbol. another stays with the patient until help arrives.
 CHAPTER 9 Emergency Procedures and First Aid 141

A B

Figure 9-2 If the individual is not breathing, first open the airway (A) by tilting the head and lifting the chin,
for victim without head or neck trauma, or (B) by the jaw-thrust maneuver, for victim with cervical spine injury.
This involves placing both thumbs on the patient’s cheekbones and placing the index and middle fingers on
both sides of the lower jaw.

Never leave a seriously ill or unconscious patient law vary from state to state. As part of establish-
unattended. ing emergency care guidelines, every ambulatory
While waiting for EMS to arrive, continuously care setting should understand the explicit and
check the patient for the following signs: (1) degree implicit intent of the Good Samaritan law in its
of responsiveness, (2) airway/breathing ability, state (see Chapter 7 for more information on
(3) heartbeat (rate and rhythm), (4) bleeding, and legal guidelines).
(5) signs of shock. Monitor vital signs. Keep patient
warm and lying down. If there are no head injuries, Blood, Body Fluids, and Disease
the legs can be elevated on pillows.
Transmission
When providing emergency care, medical
Good Samaritan Laws assistants should always protect themselves
When delivering or assisting in delivering and the patient from infectious disease
emergency care, the medical assistant may transmission. Serious infectious diseases, such as
be concerned about professional liability. hepatitis B (HBV), hepatitis C (HCV), and HIV,
Most states have enacted Good Samaritan laws, can be transmitted through blood and body fluids
which provide some degree of protection to the (see Chapter 10 for more detailed information).
health care professional who offers first aid. By establishing and following strict guide-
Most Good Samaritan laws provide some legal lines, the risk for contracting or transmitting an
protection to those who provide emergency care infectious disease while providing emergency care
to ill or injured persons. However, when medical is greatly reduced.
assistants or any other individuals give care during
an emergency, they must act as reasonable and pru- • Always wash hands thoroughly before (if possible)
dent individuals and provide care only within the and after every procedure or use hand sanitizer.
scope of their abilities. Remember that a primary • Use protective clothing and other protective equip-
principle of first aid is to prevent further injury. ment (gloves, gown, mask, goggles) during the
Although Good Samaritan laws give some procedure.
measure of protection against being sued for giv-
• Avoid contact with blood and body fluids, if
ing emergency aid, they generally protect off-duty
possible.
health care professionals. Also, conditions of the
142 UNIT 3 Responsible Medical Practice

• Do not touch nose, mouth, or eyes with gloved

hands.
• Carefully handle and safely dispose of soiled gloves
and other objects.

Refer to Chapter 10 for more information on

standard precautions. Standard Precautions were
issued by the Centers for Disease Control and
Prevention (CDC) in 1996 and combine many
of the basic principles of universal precautions
with techniques known as body substance isola-
tion. These augmented 1996 guidelines repre-
sent the standard in infection control and are
intended to protect both patients and health
care professionals.

PREPARING
FOR AN EMERGENCY
Emergencies are unexpected but can and should
be anticipated and prepared for in the ambu-
latory care setting. Being properly prepared
ensures that the office has the materials and
resources needed to respond to emergencies. Figure 9-3 Medical crash cart with defibrillator.
An in-office handbook of policies and proce-
dures should be developed and should be famil-
iar to all staff members. Telephone numbers for medications should be up to date and have not
the local emergency medical services (often this reached their expiration dates.
is 911) and the poison control center (1-800-222- A smaller practice may require only a portable
1222) should be posted and kept in an established tray for emergency and first-aid supplies. Larger
place so that there is no delay in calling for outside urgent care centers may respond more frequently
assistance. Materials and supplies should be main- to emergencies and thus may need a cart that can
tained in proper inventory. All personnel should hold a larger inventory and variety of supplies.
be trained in first aid and CPR so that every staff Whether a tray or cart is used, supplies should be
member can respond to or assist the provider in customized to the facility and the type of emergen-
providing care. Proper documentation should cies frequently encountered. Remember that only
be completed after any emergency situation. The providers can order medications or treatment.
office environment itself should be a safe one Following is a brief list of some common
and as accident-proof as possible. Wipe up spills supplies found on most trays and carts (see
to prevent falls on a slippery floor, keep corri- Chapter 23 for more information on supplies
dors free of clutter, and keep medications out of and medications).
sight. These basic risk management techniques
General supplies:
will help medical personnel focus on giv-
ing emergency care and also will protect • Adhesive and hypoallergenic tape
the facility from possible litigation. • Alcohol wipes
• Bandage scissors
The Medical Crash Tray or Cart • Bandage material
Every health care facility should have a crash tray • Blood pressure cuff (standard, pediatric, large)
or cart, with a carefully controlled inventory of • Constriction band
supplies and equipment (Figure 9-3). These first-
• Defibrillator
aid supplies should be kept in an accessible place,
and the inventory should be routinely moni- • Dressing material
tored to ensure that all supplies are replaced. All • Gloves
 CHAPTER 9 Emergency Procedures and First Aid 143

• Hot/cold packs The type and list of supplies should always be

• Intravenous (IV) tubing overseen by facility providers and tailored to the
emergency demands of the practice. The medical
• Needles and syringes for injection
assistant should be familiar with the equipment
• Glucose tabs or gel and medication on the crash cart or tray. Practice
• Penlight (with extra batteries) “drills” simulating various emergency situations
• Personal protective equipment are helpful for preparing staff members for actual
emergencies.
• Stethoscope

Emergency medications Uses COMMON EMERGENCIES

Activated charcoal Poisonings
Included in this discussion of common emergen-
Aspirin Fever, heart attack cies are shock, wounds, burns, musculoskeletal
Atropine Slow heartbeat injuries, heat- and cold-related illnesses, poison-
ing, snake bite, sudden illness, cerebral vascular
Dextrose Insulin reaction accident, and heart attack.
Diazepam* Antianxiety
Shock
Diphenhydramine Antihistamine
When a severe injury or illness occurs, shock is
Dopamine Increases blood pressure likely to develop. Shock is a condition in which the
Epinephrine Constricts blood vessels, circulatory system is not providing enough blood
increases blood to all parts of the body, causing the body’s organs
pressure to fail to function properly.
Shock is always life threatening, and EMS
Glucagon Insulin reaction should be activated. The body’s attempt to com-
pensate for a massive injury or illness, especially
Insulin Hyperglycemia those involving the heart and lungs and severe
Lidocaine Local anesthetic, IV for bleeding, often lead to other problems. During
cardiac arrhythmia shock, several things occur.
Nitroglycerin tablets, Chest pain from angina • The heart becomes unable to pump blood
patches pectoris properly.
Phenobarbital* Sedative • Consequently, the body’s cells, tissues, and organs
do not get enough oxygen, which is carried by
Verapamil Hypertension, angina the blood.
pectoris, irregular • The body tries to compensate by sending blood to
heartbeat, tachycardia critical organs and reducing the flow of blood to
Xylocaine, Marcaine Local anesthetics arms, legs, and skin.

*Controlled substance—must be kept in locked

cabinet. Signs and Symptoms of Shock. Learn to recog-
nize the signs and symptoms of shock.
Respiratory supplies:
• Patient may be restless or feel irritable.
• Airways of all sizes for nasal and oral use • Weakness, dizziness, thirst, or nausea may occur.
• Ambu bag™ • Breathing may be shallow and rapid.
• Bulb syringe for suction
• Skin is cool, clammy, and pale.
• Oxygen mask
• Pulse is weak and rapid.
• Oxygen tank
• Blood pressure is low.
This list represents just some of the supplies to • Area around the lips, eyes, and fingernails may
be found on a well-stocked crash cart or tray. turn cyanotic (blue) from lack of oxygen.
144 UNIT 3 Responsible Medical Practice

• The patient may be confused or become suddenly • Check breathing.

unconscious, or both. • Control any external bleeding.
• Dilated pupils and lackluster eyes are obvious. • Help the patient maintain normal body tempera-
ture. A blanket over and under the patient can
help avoid chilling. Do not overheat.
Types of Shock. The eight major types of shock
are respiratory, neurogenic, cardiogenic, hemor- • Reassure the patient.
rhagic, anaphylactic, metabolic, psychogenic, and • Elevate the patients legs about 12 inches, unless
septic. Table 9-2 lists a description of each. you suspect head injury, spinal injuries, or broken
bones involving the hips or legs.
Treatment for Shock. A person suffering from • Do not give the patient anything to eat or drink.
shock needs immediate medical attention. Call
• Ascertain that outside help has been called and
for outside emergency help first, then care for the
stay with the patient until help arrives.
patient until help arrives. CAUTION: Shock is
progressive, and, if not treated immediately, most • Monitor vital signs.
types can be life threatening. Once shock reaches
a certain point, it is irreversible.
To care for a patient in shock (regardless of
Wounds
the type), follow these procedures: Typically, wounds are classified as open or closed.
In the closed wound, there is no break in the skin;
• Lay the patient down. This minimizes pain and
a bruise, contusion, and hematoma are common
decreases stress on the body.
closed wounds. An open wound represents a break
• Loosen the patient’s clothing. in the skin and can be classified as an abrasion,
• Check for an open airway. avulsion, incision, laceration, or puncture wound.

Table 9-2 Eight Types of Shock with Descriptions

Type of Shock Description

Trauma to the respiratory tract (trachea, lungs) that causes a reduction of oxygen and carbon
Respiratory
dioxide exchange. Body cells cannot receive enough oxygen.

Injury or trauma to the nervous system (spinal cord, brain). Nerve impulse to blood vessels impaired.
Neurogenic
Blood vessels remain dilated and blood pressure decreases.

Myocardial infarction with damage to heart muscle; heart unable to pump effectively. Inadequate
Cardiogenic
cardiac output. Body cells do not receive enough oxygen.

Severe bleeding or loss of body fluid from trauma, burns, surgery, or dehydration from severe nausea
Hemorrhagic
and vomiting. Blood pressure decreases, thus blood flow is reduced to cells, tissues, and organs.

Results from reaction to substance to which patient is hypersensitive or allergic (allergen extracts,
Anaphylactic bee sting, medication, food). Outpouring of histamine results in dilation of blood vessels throughout
the body, blood pressure decreases and blood flow is reduced to cells, tissue, and organs.

Body’s homeostasis impaired; acid–base balance disturbed (diabetic coma or insulin shock); body
Metabolic
fluids unbalanced.

Shock caused by overwhelming emotional factors (e.g., fear, anger, grief). Sudden dilation of blood
Psychogenic vessels results in fainting because of lack of blood supply to the brain. In most cases, not life threaten-
ing unless it leads to physical trauma as a result of a fall.

An acute infection, usually systemic, that overwhelms the body (e.g., toxic shock syndrome). Poison-
Septic ous substances accumulate in bloodstream and blood pressure decreases, impairing blood flow to
cells, tissues, and organs.
 CHAPTER 9 Emergency Procedures and First Aid 145

Closed Wounds. Most closed wounds do not pres- (see Procedure 9-1). Then clean the wound. If
ent an emergency situation. If there is pain and there is a skin flap, reposition it. Apply a dress-
swelling, the application of a cold compress can ing, then bandage as necessary. Note that pieces
be effective. Protect the patient’s skin by placing of the body may be torn away. If possible, save
a cloth beneath the source of cold; apply the com- the body part, keep moist, and transport with the
press for 20 minutes, then remove for 20 minutes; patient.
continue for 24 hours. Then apply heat 20 minutes 3. Incisions are wounds that result from a sharp object,
on and 20 minutes off for the next 24 hours. A such as a knife or piece of glass. Incisions may need
common procedure for treating closed wounds is sutures. The wound must be cleaned with soap and
to RICE or MICE it. water and a dressing applied.
4. Lacerations tear the body tissue and can be dif-
RICE MICE
ficult to clean; therefore, care must be taken to
• Rest • Motion or Movement avoid infection. If there is not severe bleeding,
• Ice • Ice which in itself is a cleansing mechanism, these
• C ompression • C ompression wounds may need to be soaked in antiseptic soap
and water to remove debris. If there is severe
• E levation • E levation
bleeding, it must be controlled immediately (see
Procedure 9-1). Lacerations with severe bleeding
Recently, some providers, especially those who
need suturing.
treat sport injuries, advocate motion or move-
ment as a means of treating a closed wound 5. Punctures pierce and penetrate the skin and may be
injury. They also advise ice, compression (elastic deep wounds while appearing insignificant. Usu-
bandage), and elevation (MICE). Check for pro- ally, external bleeding is minimal, but the patient
vider preference. should be assessed for internal bleeding. Because
Some closed wounds, such as hematomas, can a puncture wound is deep, the risk for infection is
be dangerous and may cause internal bleeding. great and the patient should be advised to watch
If the patient is in severe pain and was subject to for signals of infection, such as pain, swelling, red-
an injury caused by high impact, call for help and ness, throbbing, and warmth.
keep the patient comfortable until the help arrives.
Watch for symptoms of shock and monitor vital Use of Tourniquets in Emergency Care. In the
signs. past, tourniquets were regularly used in the field
to control hemorrhaging from an extremity when
Open Wounds. Open wounds can be minor tears all other attempts to control bleeding were unsuc-
in the skin or more serious skin breaks, but all cessful. However, because tourniquet application
open wounds represent an opportunity for micro- was meant to completely stop blood flow, many
organisms to gain entry and cause an infection. times the complete lack of blood flow resulted in
Some major open wounds may involve heavy bleed- the death of the arm or leg. Often, the affected
ing, which will need to be controlled, probably by extremity needed to be amputated.
suturing. A tetanus injection is indicated for an To remedy the situation, a “constriction
open wound if the patient has not had a booster in band” was substituted for the tourniquet and is
the last 7 to 10 years (see Chapter 10 for immuni- now widely used. The constriction band is made
zation information). of a material similar to that used in the tourni-
There are five common types of open wounds: quet. When the band is applied to an extremity
to control bleeding, it is applied tightly enough to
1. Abrasions are a superficial scraping of the epider- stem the rapid loss of blood but loosely enough to
mis. Because nerve endings are involved, they allow a small amount of blood to continue to flow.
can be painful. However, they are not usually seri- A pulse should be felt distally to the constriction
ous, unless they cover a large area of the body. band. The use of the constriction band applied in
Administer first aid by cleaning the area carefully this manner allows a blood supply to the remain-
with soap and water, apply an antiseptic oint- der of the extremity, unlike the tourniquet, which
ment if prescribed by a provider, and cover with cuts off all blood flow. Chapter 19 provides infor-
a dressing. mation on wounds and minor surgery.
2. In an avulsion, the skin is torn off and bleeding is
profuse. Avulsion wounds often occur at exposed Dressings and Bandages. After the provider has
parts: fingers, toes, ear. First, control bleeding treated an open wound, it is critical to dress and
146 UNIT 3 Responsible Medical Practice

bandage it properly to curtail infection. Covering

of the wound is accomplished by a series of dress-
ings and bandages.
Typically, dressings are sterile gauze pads
placed directly on the wound; they often have non-
stick, sterile surfaces, but they are absorbent and
will soak up blood and protect the wound from
microorganisms. They are often made of a gauze-
type material.
Bandages, which are nonsterile, are placed
over the dressing. They hold the dressing in place
and are made to conform to the area to be covered.
Sometimes, as in a Band-Aid®, the dressing and ban-
dage are combined. Roller bandages (sometimes
called by their brand name, “Ace Bandages”), such
as those made of elastic, can be placed over a dress-
ing and used to help control bleeding or swelling. Figure 9-5 An elastic figure-eight bandage holds
Kling, a type of gauze that stretches and clings dressings in place or can be used for immobilization, as
as it is applied, and roller bandages, long, soft, elastic with an ankle sprain.
material wound over itself, known by the brand name
Ace Bandages, are other types of bandage materials.
Bandages and their applications can take and 9-8). Using a cylindrical applicator, a quantity
many shapes and forms, depending on the type of of gauze is stretched over the wound site.
injury and the injury site. In all cases, a bandage • Commercial arm slings are used to support injured
must be secure, but not constricting. Avoid too or fractured arms (Figure 9-9). To apply, support
tight or too loose a wrap. the injured arm above and below the injury site
while applying the sling.
• Spiral bandages are useful for injuries to the arms
or legs (Figure 9-4).
• A figure-eight bandage holds the dressing in place
Burns
on a wound on the hand or wrist, knee, or ankle Most burns are caused by heat, chemicals, explo-
(Figure 9-5). sions, and electricity. Critical burns can be life
• Fingers, toes, arms, and legs can also be bandaged threatening and require immediate medical care.
using a tubular gauze bandage (Figures 9-6, 9-7, According to the American Red Cross, critical
burns have the following characteristics:
• Involve breathing difficulty
• Cover more than one body part
• Involve the head, neck, hands, feet, or genitals
• Involve any burns to a child or older adult (other
than minor burns)
To distinguish critical from minor burns, it is
important to understand the degrees of burns and
what they mean.

First-,Second-,andThird-Degree Burns. First-degree

burns are superficial burns that involve only the top
layer of skin. The skin appears red, feels dry, is warm
to the touch, and is painful. First-degree burns usu-
ally heal in a week or so with no permanent scarring.
In a second-degree burn, the skin is red and
blisters are present. The healing process is slower,
usually a month, and some scarring may occur.
Figure 9-4 The spiral bandage is an option for arm Second-degree burns affect the top layers of the
and leg injuries. skin and are very painful. Some scarring may occur.
 CHAPTER 9 Emergency Procedures and First Aid 147

Figure 9-6 The cylindrical applicator is placed over

the finger.

Figure 9-9 A commercial sling is used to support

injured or fractured arms.

upper extremity are 9% each, the back of the

trunk is 18%, as is the front (18%), each lower
extremity is 18%, and the perineum is 1%.
In a child, the head, back, and front of the torso
are 18% each, each upper extremity is 9%, each
lower extremity is 13.5%, and the perineum is 1%.
Providers use the formula to determine the
Figure 9-7 Gauze is stretched over the finger. amount of body surface area that has been burned.
Together with the depth of the burn, it helps the
provider determine the percent of the body burned
and the degree of burn. The severity of a burn can
be determined and appropriate treatment given.
Figure 9-10B shows the relative penetration
level of each degree of burn into the skin and under-
lying structures.

General Guidelines for Caring for Burns. Treat-

ment for burns depends on the type of agent caus-
ing the burn. General treatment strategies for any
degree of burn include the following:
Figure 9-8 Applicator is pulled off, leaving the bandage.
• Cool the burn with large amounts of cool normal
Third-degree burns are the most serious, saline, or water if saline is unavailable.
affecting or destroying all layers of tissue. It is not • Cover the burn with a sterile dressing if one is avail-
unusual for fat, muscles, bones, and nerves to be able and burn is minor. Otherwise, cover the burn
involved. These burns can look charred or brown. with a sheet or other smooth textured cloth for a
There may be great pain or, if nerve endings are burn over a large area of the body.
destroyed, the burn may be painless. Victims of • Be sure the patient is protected from being either
third-degree burns must receive immediate medi- chilled or overheated.
cal attention both for the burn and for shock. Of
serious concern with a third-degree burn is the However, it is important to follow these
likelihood of infection and the amount of fluid guidelines:
loss. Scarring can result in loss of body function. • Do not apply ice or ice water to a burn.
Skin grafts may be necessary.
There is a formula for estimating the per- • Do not touch a burn, except with a sterile dressing.
cent of body surface areas that have been burned • Do not clean a severe burn, break blisters, or use
(Figure 9-10A). In an adult, the head and each any kind of ointment.
148 UNIT 3 Responsible Medical Practice

Front 41/2% Epidermis

18%

41/2% 41/2%

First-degree,
1% superficial
Skin red, dry

9% 9%

Epidermis
Dermis

Back 41/2%
Second-degree,
partial thickness
18% Blistered; skin moist, pink or red

41/2% 41/2%
Epidermis
Dermis

Subcutaneous
9% 9%
tissue

Third-degree,
full thickness
Charring; skin black, brown, red
Figure 9-10B Classification of burn injuries.

Figure 9-10A Diagram for use in calculating the

extent of burns or other injuries in an adult. Patient Education
• Do not remove pieces of clothing that may be stick- Some burns can be prevented. Advise
ing to the burn. patients who insist on sunbathing to protect
themselves against harmful rays by using a
First Aid for Burns. First aid for burns is outlined sunscreen and avoiding the sun between
in Table 9-3. 10 AM and 2 PM.

Types of Burns. Most burns are caused by heat;

however, burns can also be caused by chemicals,
electricity, and solar radiation. Patient Education
Chemical Burns. Chemical burns can occur in Advise patients not to run should their cloth-
the workplace or even in the home with “ordinary” ing catch on fire. They should fall to the ground
household chemicals. To stop the burning process, or wrap themselves in a blanket or rug and roll
you must remove the chemical from the skin. Have on the ground to extinguish the flames.
someone call EMS while you flush the skin or eyes
 CHAPTER 9 Emergency Procedures and First Aid 149

Table 9-3 First Aid for Burns

First-Degree Burn Response Guide

Questions Responses Action to Take Rationale

Is skin reddened without YES ➭ Submerge in cool normal saline or ➭ Stops burning process.
blisters? water 2–5 minutes.
NO
➭

Does area involve: YES ➭ Have patient come to office. ➭ These are potential dan-
• hands? ger areas and require
• feet? evaluation by the
• genitals? provider.
• face?
NO
➭

Is patient: YES ➭ Have patient come to office. ➭ These groups are

• elderly? susceptible to burn
• very young? complications.
NO
➭

Provider has final decision

Consult provider.
whether patient is seen.

Second-Degree Burn Response Guide

Questions Responses Action to Take Rationale

Is skin reddened with blis- YES ➭ Submerge in cool normal saline or ➭ Stops burning process. If
ters or splitting of the skin? water 10–15 minutes if skin is intact. Use com- blisters are broken, can
NO presses if skin is broken. Do not break blisters. allow infection in burn.
➭

Do not use anesthetic creams or sprays. Creams or spray may

slow healing process
and increase severity of
a burn.

Does area involve: YES ➭ Have patient come to office or go to ➭ These are potentially dan-
• hands? the emergency department. gerous areas and require
• feet? medical attention.
• genitals?
• face?
NO
➭

Is the area involved larger YES ➭ Have patient come to office or go to ➭ Burns of this size are sus-
than a child’s hand? the emergency department. ceptible to complications.
NO
➭

Is patient experiencing YES ➭ Patient should go to emergency ➭ There may be swelling of

trouble breathing? department. the airways because of
NO heat and noxious fumes.
➭

(continues)
150 UNIT 3 Responsible Medical Practice

Table 9-3 First Aid for Burns (continued)

Second-Degree Burn Response Guide

Questions Responses Action to Take Rationale

Provider has final decision

Consult provider.
whether patient is seen.

Third-Degree Burn Response Guide

Questions Responses Action to Take Rationale

Is skin gray, black, or charred YES ➭ ➭

Tell patient or family to call EMS Life-threatening emer-
appearing? Can muscle, fat, immediately. Do not apply cold; do not gency that requires
or bone be seen in wound? remove burned clothing from burn area. prompt attention.
NO
➭

Is patient YES ➭ ➭
Patient in shock: Need to control shock
experiencing: Tell family to call EMS and to: caused by fluid loss.
• pallor • maintain airway.
• loss of consciousness? • maintain body temperature.
• shivering? • elevate feet if appropriate.
• monitor breathing.
Patient may need oxygen and intravenous
NO fluids while waiting for EMS to arrive.
➭

Provider has final decision

Consult provider. whether patient is seen.

with cool water. Remove any clothing contaminated he or she should see a provider who will cover
by the chemicals unless they adhere to the skin. If the burn area to reduce infection and protect the
clothing clings to the skin, it can be cut with scis- patient against chill.
sors. Do not attempt to pull clothing away from a
burned area.
Musculoskeletal Injuries
Electrical Burns. Electrical burns can be Most injuries to muscles, bones, and joints are
caused by power lines, lightning, or faulty not life threatening, but they are painful and,
electrical equipment in the home or work if not properly treated, can be disabling. Some
place. It is important to remember never to go near a injuries, such as those to the spinal cord, can be
patient injured by electricity until you are sure the power quite serious and can result in paralysis. These
has been shut off, because you could be injured. If there is injuries are not typically seen in the ambulatory
a downed line, call the power company and EMS. care setting.
A victim of an electricity burn may be suffer-
ing from two burns: one where the power entered Types of Injuries. A sprain is an injury to a joint,
the body, and one where it exited. Often, the burns often an ankle, knee, or wrist, that involves a tear-
themselves may be minor. Of more serious conse- ing of the ligaments. Some sprains are minor and
quence are the possibilities of shock, breathing dif- heal quickly; others are more severe, include swell-
ficulties, and other injuries. CPR often is needed ing, and may not heal properly if the patient con-
in this situation. tinues to put stress on the sprained joint. Signs of
a sprain are rapid swelling, discoloration at the
Solar Radiation. Most “sunburns,” although not site, and limited function. Many times it is difficult
advisable or good for the skin, represent minor to determine whether the patient has sustained
burns. If the patient has a severe burn, however, a sprain or a fracture because the degree of pain
 CHAPTER 9 Emergency Procedures and First Aid 151

may not be a true indicator of the patient’s injury. • Colles: fracture often caused by falling on an out-
As with most closed wounds, treating the injury stretched hand; involves the distal end of the radius
with the RICE or MICE method is beneficial and and results in displacement, causing a bulge at the
determined by the proivder’s choice. wrist
A strain results from the overuse or stretching
of a muscle, tendons, or group of muscles, as with These fractures represent “major” types of frac-
improper lifting or moving heavy objects. Appli- tures. Figure 9-11 shows examples of these fractures.
cations of ice and heat (as described eariler in
“Closed Wounds”), as well as rest, are indicated for Assessing Injuries to Muscles, Bones, and Joints.
treatment of strains. Surgery is not usually required Sometimes it is difficult to determine the extent of
for sprains and strains. Significant injuries (large an injury, especially in closed fractures. There are
tears) may need surgery. Slings, crutches, and some assessment techniques to call on, however, to
removable splints help protect the injury from fur- gauge the seriousness of an injury.
ther damage and limit movement until a more spe-
cific diagnosis can be made. • Note the extent of bruising and swelling.
Dislocations are painful and involve the sepa- • Pain is a signal of injury.
ration of a bone from its normal position. These • There may be noticeable deformity to the bone or
usually occur from the kind of wrenching motion joint.
that might result from a fall, automobile accident,
• Use of the injured area is limited.
or sports injury.
Fractures involve a break in a bone and can • Talk to the patient: What was the cause of the
be caused by a fall, by a blow, from bone disease, injury? What was the sound or sensation at the
or from sports injuries. There are several types time of injury?
of fractures, but all are classified as either open
or closed fractures. An open fracture involves an Caring for Muscle, Bone, and Joint Injuries. Most
open wound and is characterized by a protruding injuries to muscles, bones, and joints are treated
bone. In a closed fracture, the skin is not broken. in a similar way; some require rest, some motion,
Signs and symptoms that occur with a fracture may elevation of the injured part, immobilization, and
include swelling, discoloration, pain, deformity, the application of ice to the injury.
and immobility of the body part. It is not unusual After calling EMS (always check for life-
for patients to tell you that they heard the bone threatening symptoms, such as breathing difficul-
break or that they sensed a grating feeling. Crepita- ties; bleeding; or head, neck, or back injuries), it
tion is the term that describes the grating sensation is important to immobilize the injured area if the
experienced or heard when bone fragments rub patient must be moved. EMS personnel use a vari-
together. Fractures are further defined as follows: ety of splints to immobilize bones and joints. Some
fractures must be treated in the hospital. Com-
• Incomplete or greenstick: fracture in which the bone pound fractures and fractures with nerve or blood
has cracked, but the break is not all the way vessel involvement are some examples. Most often,
through; frequently seen in children a fracture can be treated with outpatient care. A
• Simple: complete bone break in which there is no splint and a cast may be applied to prevent move-
involvement with the skin surface ment and to hold the fracture steady. Procedure
9-2 gives instructions for splinting an arm in the
• Compound: fracture in which the bone protrudes ambulatory care setting.
though the skin surface, creating the possibility of
infection
• Impacted: fracture in which the broken ends are
Heat- and Cold-Related Illnesses
jammed into each other The condition of patients who have been subject to
• Comminuted: more than one fracture line and sev- extreme heat and cold can deteriorate rapidly, and
eral bone fragments are present either a heat- or cold-related illness can result in
death. Individuals especially vulnerable to extreme
• Spiral: fracture that occurs with a severe twisting exposures include the very young and very old,
action, causing the break to wind around the individuals who must work outdoors, and people
bone who suffer from poor circulation.
• Depressed: fracture that occurs with severe head
injuries in which a broken piece of skull is driven Heat-Related Illnesses. Illnesses related to heat, in
inward increasing degree of severity, include heat cramps,
152 UNIT 3 Responsible Medical Practice

Transverse

Oblique

(A) Greenstick (B) Closed (C) Open (D) Impacted (E) Comminuted (F) Spiral
(incomplete) (simple, complete) (compound)

(G) Depressed (H) Colles

Figure 9-11 Types of fractures.

heat exhaustion, and heat stroke. Heat cramps, the heat stroke, the body systems are extremely taxed.
least serious, involve cramping in the legs and abdo- EMS should be alerted; until they arrive, stay with
men caused by excessive body exposure or exercise the patient, watch for breathing problems, and
in hot weather. Heat cramps should be considered attempt to reduce body temperature by applying
a signal to stop, slow down, rest in a cool place, cool, wet towels or sheets.
and drink plenty of water. Salt tablets should not
be taken. The individual should lightly stretch the Cold-Related Illnesses. Exposure to extreme
muscles. Heat cramps can progress to heat exhaus- cold for prolonged periods can lead to frostbite
tion or heat stroke, both of which are more serious or hypothermia.
conditions. Frostbite, which typically affects the extremi-
Heat exhaustion, often experienced by people ties such as fingers, toes, ears, and nose, involves
who work or exercise in extreme heat, is a more the freezing of exposed body parts. Symptoms
serious reaction and is signaled by exhaustion, cold include skin that becomes off-color, is cold, or takes
and clammy skin, profuse sweating, headache, and on a waxy appearance. Severity can range from the
general weakness. The individual should come out superficial (frostnip) to more penetrating stages,
of the heat immediately; apply cool, wet towels; and which may require amputation.
slowly drink cool water. The provider will advise the Individuals with frostbite need immediate
patient not to resume activity in the heat. medical attention. To care for frostbitten extremi-
Heat stroke is the least common but the most ties, warm the area of injury by wrapping cloth-
dangerous of heat-related illnesses and requires ing or blankets around the affected body part. Be
immediate medical attention. Heat stroke is char- careful in handling the frozen part. It is best to
acterized by red, dry, hot skin; an abnormal, weak have the patient transported as soon as possible to
pulse; and breathing that is shallow and fast. In emergency care. This type of facility is better able
 CHAPTER 9 Emergency Procedures and First Aid 153

to properly rewarm the frozen part, preventing Some signs and symptoms of poisoning are
further tissue damage. dyspnea, nausea and vomiting, confusion, and
Hypothermia is a serious illness in which the convulsions. The Poison Control Center (1-800-
body temperature decreases to a perilously low 222-1222) can advise if there is an antidote for
level. It can result in death if the individual does not the poison (if poison is known). For many years,
receive care and if the progression of hypothermia the treatment of choice for ingested poison was to
is not reversed. Hypothermia occurs when a person induce vomiting by using syrup of ipecac. This is
falls through the ice or is exposed to cold tempera- no longer recommended. Activated charcoal given
tures, for example, after getting lost in the woods as soon as possible is the treatment of choice for
while hiking. Symptoms include shivering, cold ingested poison. It is quicker and more effective.
skin, and confusion. If a patient becomed unconscious, the pro-
After checking for breathing problems and vider will be concerned that the patient will vomit
alerting EMS, care for the patient. Make the indi- and aspirate vomitus into the lungs; therefore, the
vidual comfortable, provide a source of warmth, provider may insert a flexible tube into the larynx
such as a blanket, and gradually warm the body. If to alleviate that possibility.
clothing is wet or cold, remove it and put on dry In most poisoning cases, there are specific
clothing. In extreme cases, it may be necessary to antidotes. They work either by reversing the effects
provide rescue breathing. of the poison or by preventing the poison from
working.
On occasion, there is no specific treatment
Poisoning and just the symptoms will be treated. A ventilator
Poisons can enter the body in four ways: may be needed if a patient has stopped breathing.
Medications that control convulsions are available,
• Ingestion. Ingested poisons enter the body by and sedatives can be administered if the patient is
swallowing. Swallowed poisons may include med- disturbed and restless.
ications, plant material, household chemicals, con- Whenever a patient calls regarding poisoning
taminated foods, and drugs. or there is a suspicion of poisoning, call the Poi-
• Inhalation. Poisons are inhaled into the body in son Control Center (1-800-222-1222) or the local
poorly ventilated areas where cleaning fluids, paints emergency number and ask for advice. Telephone
and chemical cleaners, or carbon monoxide may numbers of the poison control center should be
be present. posted in a familiar and accessible place.
• Absorption. Poisons absorbed through the skin in- The treatment for poisoning will vary accord-
clude plant materials such as poison oak or ivy, lawn ing to the source of the poisoning and must be tai-
care products such as chemical pesticides, and other lored to the specific incident. The provider will have
chemical powders or liquids.
• Injection. Drug abuse is the most common cause of
injected poisons. The stingers of insects inject poi-
sons into the body and can be extremely danger- Patient Education
ous and can lead to anaphylactic shock in allergic
individuals. Advise all patients with known allergic re-
actions to be particularly careful when
working or playing outdoors. Insects are
not usually aggressive until their nests are
approached; however, often these nests are
Patient Education not easy to detect, and an individual may
approach one without being aware of its
Remind patients who are parents of young presence. Patients with allergies to insects
children to remove any potential sources should always wear shoes when outside;
of poisoning from their homes or to keep wear light-colored clothing, preferably with
them in locked cabinets. Also advise them long sleeves and pant legs; look before tak-
to include the nearby poison control center ing a sip from a beverage when outdoors;
in their list of emergency phone numbers. and inspect lawn areas, shrubbery, and
They should also keep activated charcoal building walls periodically for evidence of
on hand. stinging insect nests.
154 UNIT 3 Responsible Medical Practice

advised staff regarding specific poisoning antidotes.

Generally, do not give the patient anything to eat or Patient Education
drink; try to determine what poison the patient was
exposed to and, if ingested, how much was taken; Snake Bite
if the patient vomits, save some of the vomitus for Most snakes are not poisonous, and snakes
analysis. usually will not strike unless provoked. Some
If prescribed by a provider or recommended poisonous snakes are rattlesnake, copper
by the poison control center, medication used to snake, cottonmouth water moccasin, and
treat poisoning is activated charcoal, which is used coral snake. Individuals who live in snake-
to absorb certain swallowed poisons. inhabited areas, campers, hikers, and other
outdoor lovers need to be mindful and cau-
Insect Stings. The medical assistant in the ambu- tious when outdoors. To avoid a possible
latory care setting is likely to receive calls every snake bite, wear thick high boots, stay on the
summer from patients who have been stung by hiking path, do not reach down to pick up
insects, typically yellow jackets, hornets, honey- something from the ground unless you have
bees, or wasps. In the nonallergic patient, the sting a clear view around the area, and be care-
is likely to result in localized swelling, tenderness, ful on rocks (snakes like to live in or around
and slight redness. The provider will recommend piles of rocks).
that these localized symptoms be managed with Common signs and symptoms of a snake
a topical cream and oral antihistamines. Swell- bite are rapid pulse, nausea and vomiting,
ing can be significant and cause for serious con- severe pain, swelling, blood and fang
cern if the sting occurred in a vulnerable area of marks at wound site, convulsions, thirst,
the body such as the mouth or tongue. Swelling in and diaphoresis.
these locations can be frightening and dangerous
Emergency treatment consists of the
because it can impair breathing. An antihistamine,
following:
administered as soon as possible after the sting,
may help to curtail symptoms somewhat. Treat- • Call for emergency help immediately
ment of insect stings in nonallergic individuals • Wash wound with soap and water if
consists of removing the stinger by scraping it off possible
with the edge of something rigid such as a credit • Immobilize body part and keep below
card or your fingernail. Tweezers can cause more heart level if possible
venom to be dispersed into the patient’s body tis- • Apply a constriction band 4 inches
sues, so this method should not be used. Wash the above site
area with soap and water, apply a cold pack to the
site, and watch for a possible severe reaction. • Cover with clean cool cloth
The individual who experiences an allergic • Monitor vital signs
reaction or hypersensitivity to a sting needs to be
seen immediately, because in severe cases a sting
may induce an anaphylactic reaction that can lead to Attempt to allay patient apprehension and monitor
death. If allergic, individuals who have been stung are vital signs while waiting for EMS personnel to arrive.
likely to experience symptoms within a half hour of
the incident. Symptoms are generalized throughout
the body and may include hives, itching, and light-
Sudden Illness
headedness and may progress to difficulty breathing, Sudden illness is, by definition, an unexpected
faintness, and eventual loss of consciousness. occurrence. Although the cause of the illness may
For individuals with known allergic reactions, be unexplainable, it is important to respond sensi-
the provider will prescribe epinephrine, which pa- bly and responsibly within the parameters of knowl-
tients should carry with them and self-inject should edge and resources.
they not be able to get immediate emergency care. Sudden illnesses include, but are not lim-
EPIPEN is a brand of epinephrine to self-inject. The ited to, fainting, seizures, diabetic reaction, and
patient should then seek immediate emergency hemorrhage.
treatment. For individuals who present at the ambu-
latory care setting with an apparent allergic reaction Fainting. Also known as syncope, fainting involves
to a sting, the provider will prescribe epinephrine, a loss of consciousness, caused by an insufficient
an antihistamine, and corticosteroids if necessary. supply of blood to the brain. Loss of consciousness
 CHAPTER 9 Emergency Procedures and First Aid 155

may simply be the result of a fainting episode, or it time frame, however, dictate a call to emergency
may indicate a more serious medical problem such services, as does any seizure if the patient is dia-
as diabetic coma or shock. A fall during a fainting betic, pregnant, injured, or does not regain con-
incident may result in bodily harm. sciousness after the incident.
If a patient in the office or clinic “feels
faint,” indicated by lightheadedness, weak- Diabetes. Diabetes is defined by the American Dia-
ness, nausea, or unsteadiness, have the betes Society as the “inability of the body to prop-
individual lie down or sit down with head level with erly convert sugar from food into energy.”
the knees. This may prevent a fainting episode. Under normal functioning, the body pro-
The most common type of fainting episodes duces a hormone called insulin, which transports
occur when the blood pressure drops quickly in sugars into body cells. In some cases, the body does
response to a highly charged emotional or stress- not produce insulin at all or does not produce
ful situation. The name for this common fainting enough; this results in diabetes.
spell is vasovagal syncope. The individual’s skin Diabetes occurs in two major types:
feels sweaty and clammy, and lightheadedness is
common. • Type 1, or insulin-dependent diabetes
If a patient faints, gradually lower the patient • Type 2, or noninsulin-dependent diabetes, which
to a flat surface, loosen any tight clothing, check usually occurs in adults; in type II, the body pro-
breathing and for any life-threatening emergen- duces insulin in insufficient quantities
cies, and apply cool compresses to the forehead.
Elevate the legs if there is no back or head injury. Complications from diabetes, which you may
If vomiting occurs, place the patient on his or her encounter in a medical office or clinic setting,
side. Although fainting is typically not serious in include diabetic coma (acidosis) and insulin shock
itself, 911 or EMS may need to be called because or reaction. The provider will prescribe either insu-
the problem may be indicative of a more complex lin or glucose before the patient is transported to the
medical condition. hospital. Both are serious emergencies that require
immediate EMS assistance. Table 9-4 lists common
Seizures. Seizures or convulsions occur when causes and symptoms of diabetic coma or insulin
normal brain functioning is disrupted, which shock (see Chapter 24 for calculation of medication
can occur for a variety of reasons including fever, dosage and medication administration).
disease such as diabetes, infections, or injury to
the brain. Epilepsy is a common cause of convul- Hemorrhage. The different sources of bleeding
sions. Involuntary spasms or contractions of mus- determine the seriousness of hemorrhage, or
cles characterize seizures. bleeding.
To the onlooker, seizures look frightening
and painful, which may lead inexperienced indi- External Bleeding. External bleeding includes
viduals to try to stop the seizure when they see it capillary, venous, and arterial bleeding. Capillary
occurring in another individual. A patient experi- bleeding, often from cuts and scratches, usually
encing a seizure should never be restrained; simply clots without first-aid measures. Bleeding from a
care for the victim with compassion and medical vein, which is characterized by dark red blood that
understanding. The goal is to protect the patient flows steadily, needs to be controlled quickly (see
from self-injury during the episode. Do not force Procedure 9-1) to prevent excessive blood loss.
anything between the patient’s clenched teeth—an Bleeding from an artery produces bright red bleed-
individual experiencing seizures cannot “swallow” ing that spurts from the wound; this is the most seri-
the tongue. ous type of bleeding and occurs when an artery is
Most patients recover from a seizure in a few punctured or severed. Like venous bleeding, arte-
minutes. During the seizure, protect the rial bleeding requires immediate emergency care
patient from injury, cushion the patient’s because serious loss of blood and profound irre-
head, and roll the patient to the side if any fluid is versible shock can happen quickly.
in the mouth. After the seizure subsides, calm and Epistaxis, or nosebleed, may be the result of
comfort the patient. breathing dry air for a long period; result from
If a patient is known to regularly have seizures injury or blowing the nose too hard; be caused by
and the patient’s seizure subsides in a matter of high altitudes; be caused by hypertension (high
minutes, EMS personnel usually do not need to blood pressure); or result from overuse of medica-
be summoned. Repeated seizures during the same tions such as aspirin and anticoagulants.
156 UNIT 3 Responsible Medical Practice

Table 9-4 Causes and Symptoms of Diabetic Coma and Insulin Shock

Diabetic Coma or Acidosis Insulin Shock or Reaction

Too little insulin, too much to eat, Too much insulin or oral hypoglycemic drug, too
Causes Causes
infections, fever, emotional stress little to eat, an unusual amount of exercise

Skin: Dry and flushed Skin: Moist and pale

Behavior: Drowsy Behavior: Often excited
Mouth: Dry Mouth: Drooling
Thirst: Intense Thirst: Absent
Hunger: Absent Hunger: Present
Vomiting: Common Vomiting: Usually absent
Symptoms Symptoms
Respiration: Exaggerated, air hungry Respiration: Normal or shallow
Breath: Fruity odor of acetone Breath: Usually normal
Pulse: Weak and rapid Pulse: Full and pounding (gives patient feeling
Vision: Dim of heart pounding)
Blood glucose greater than Vision: Diplopia (double)
200 mg/100 mL Low blood glucose level (40–70 mg/100 mL or less)

Keep patient warm If conscious, give patient sugar or any food

First aid First aid containing sugar (fruit juice, candy, crackers)
Obtain medical help immediately
Obtain medical help immediately

To control nosebleeds, seat the patient, ele- lessness, and a feeling of anxiety. There may be
vate the patient’s head, and pinch the nostrils for at pain, tenderness, or swelling at the injury site. The
least 10 minutes. Assist the patient to sit with head abdomen may be boardlike (stiff and hard to the
tilted forward so blood running down the back of touch).
the throat will not be swallowed or aspirated. If If internal bleeding is suspected, ask another
bleeding cannot be controlled, the provider may staff member to call EMS; until they arrive, stay
request that you activate EMS. The patient’s nos- with the patient and take measures to prevent
tril may need to be cauterized or a gauze packing shock. Monitor vital signs.
inserted (see Chapter 18).

Internal Bleeding. Internal bleeding may be

Cerebral Vascular Accident
minor or serious depending on the cause of the The common term for a cerebral vascular accident
injury. A contusion, or bruise, will result in minor (CVA) is stroke. A stroke is the result of a ruptured
internal bleeding. A sharp blow may induce severe blood vessel in the brain, or it can be caused by
internal bleeding. occlusion of a blood vessel by a clot. Both of these
Because there is no visible blood flow, it is situations can result in the brain being deprived of
important to recognize other symptoms of internal oxygen, causing brain cells to die. Symptoms of a
bleeding. Symptoms are similar to those of shock stroke include numbness in the face, arm, and leg
and include a rapid and weak pulse, low blood on one side of the body; loss of vision; severe head-
pressure, shallow breathing, cold and clammy ache, mental confusion; slurred speech; nausea;
skin, dilated pupils, dizziness, faintness, thirst, rest- vomiting; and difficulty in breathing and swallowing.
Paralysis may be present. If a patient is suspected
of having a stroke, call EMS, loosen tight clothing,
lie the patient down, and keep him or her comfort-
Patient Education able. Position the patient’s head to facilitate the flow
of secretion from the mouth to avoid choking and
Advise the patient not to blow the nose for maintain an open airway. Do not give anything by
several hours after an epistaxis. mouth and monitor vital signs. Immediate emer-
gency care is critical for all individuals experiencing
 CHAPTER 9 Emergency Procedures and First Aid 157

strokes. If the stroke is caused by a clot that blocks

blood flow, drugs may be able to protect the individ- Patient Education
ual from permanent injury. Rapid transport to the
hospital is important for treatment to be instituted Lay Person CPR
as soon as possible. Treatment with the clot-dissolv- • Do not need to be certified
ing drug must be given within 3 hours after onset of • Chest compressions alone are sufficient
symptoms for it to be effective.
• Patients more likely to survive without
brain damage with only chest
Heart Attack compressions
Heart attack, also known as myocardial infarction, • 30 compressions keeps blood moving to
is usually caused by blockage of one or more of the brain and heart
coronary arteries. Symptoms include tightness of • Drowning victims and smoke inhalation
the chest, pain radiating down one or both arms, victims are the exception. Both need
or pain radiating into the left shoulder and jaw. rescue breathing and CPR
Other signs include rapid and weak pulse, exces-
sive perspiration, agitation, nausea, and cold and
clammy skin. Heart attack symptoms in a woman
may or may not be similar to those experienced and take first-aid training courses. Frequent re-
by a man. Women may have symptoms such as fresher courses and recertification in CPR are
abdominal discomfort, burning sensation in the necessary.
chest, discomfort or pain in the lower chest or
back, unexplained sudden fatigue, sweating, and
breathlessness.
Rescue Breathing
If you suspect the patient is experiencing a Individuals in respiratory arrest require immediate
heart attack, contact EMS immediately, loosen tight emergency care. Rescue breathing, previously called
clothing, and keep the patient comfortable. Pre- mouth-to-mouth resuscitation, provides oxygen to
pare to give oxygen and other medications such as the patient until emergency personnel arrive.
aspirin, as directed by the provider. Monitor vital When performing rescue breathing proce-
signs. If the patient experiences an episode of car- dures in the ambulatory care setting, it is recom-
diac fibrillation, cardioversion or defibrillation may mended that resuscitation mouthpieces be used and
be necessary with an automatic external defibrilla- that direct mouth-to-mouth (i.e., with no personal
tor. Prepare to begin CPR if necessary. protective equipment) resuscitation never be used.

BREATHING EMERGENCIES Cardiopulmonary Resuscitation

AND CARDIAC ARREST The combination of rescue breathing and chest
compressions is known as CPR. Alone, CPR cannot
Breathing or respiratory emergencies occur for a save an individual from cardiac arrest—it repre-
variety of reasons, including choking, shock, aller- sents preliminary care until advanced medical help
gies, and other illnesses or injuries such as drown- is available to the heart attack victim.
ing and electrical shock. When an individual stops In 2005, the American Heart Association
breathing, artificial or rescue breathing must be (AHA) updated their emergency care guidelines
given quickly, for without a constant supply of oxy- for CPR and Emergency Cardiovascular Care
gen, brain damage or death will occur. (ECC) (http://www.americanheart.org/cpr.html).
When the breathing problem is accompa- The new guidelines emphasize chest compressions
nied by cardiac arrest, the rescue breathing must being done “hard and fast.” Studies have found
be accompanied by chest compressions. This is that if bystanders act quickly and begin CPR, many
known as cardiopulmonary resuscitation (CPR). more victims could be saved. It was determined
Cardiac emergencies may occur in the medical that CPR plus a shock with an AED (Figure 9-12) is
office because of the large number of patients who the treatment for cardiac arrest. The AHA says that
have heart disease. early recognition of the emergency, calling EMS,
In order to graduate from a CAAHEP- and immediate CPR can double or triple a victim’s
accredited program, medical assistants chances of surviving. Furthermore, the AHA says
must attain provider-level CPR certification that CPR plus defibrillation (AED) that is started
158 UNIT 3 Responsible Medical Practice

within 3 to 5 minutes of collapse can boost survival

significantly. Lay rescuer AEDs are available in air-
ports, sports facilities, airplanes, casinos, and many
other locations. The AED is becoming more read-
ily available, is easy to use, and is very accurate.
The most significant change in the AHA’s
guidelines is the ratio of compressions to rescue
breathing. The standard was 15 compressions and
two breaths, but now the ratio is 30 compressions
to two breaths. The 30:2 ratio is the same for adults,
children, and infants. The study showed that blood
circulation increases with each chest compression,
and when compressions were interrupted to give
rescue breaths, circulation drops and must be built
back up again.
Another guideline change made by the AHA
is the use of the AED. One shock is delivered fol-
lowed by about 2 minutes of CPR beginning with
chest compressions before reanalyzing the heart
Figure 9-12 Automated external defibrillator (AED).
rhythm to determine if another shock is needed.
(Courtesy of Welch-Allyn.)
Table 9-5 summarizes the AHA 2005 Guidelines for
CPR, obstructed airway, and defibrillation.
More information is available from the fol-
lowing sources:
• American Heart Association (http://www.american-
heart.org)

Table 9-5 Summary of American Heart Association 2005 CPR Guidelines

Airway Breathing Circulation

Adult—head tilt, chin lift Adult—2 breaths Child—2 breaths Adult—30 compressions center of chest
Child—head tilt, chin lift Infant—2 breaths between the nipples. Use 2 hands; heel of
one hand on chest and other hand on top.
Infant—head tilt, chin lift
Push hard and fast 11⁄2–2 inches
Child—30 compressions center of chest
between the nipples. Hands same as adult
or heel only of one hand. Push hard and
fast 1⁄3 to ½ of the depth of the child’s chest.
Infant—30 compressions just below the
nipples. Use 2 fingers. Push hard and fast
½–1 inch.

Obstructed Airway Use of Automatic External Defibrillator (AED)

Adult—5 abdominal thrusts Adult Adult and child—one shock delivered fol-
Child—5 abdominal thrusts Child—8 years or older lowed by 2 minutes of CPR starting with com-
continuous pressions.
Infant—5 back blows, 5 chest Infant—under 8 years Infant—same as adult. Use pediatric pads
thrusts continuous on AED.
 CHAPTER 9 Emergency Procedures and First Aid 159

• American Red Cross (http://www.redcross.org) able due to the disaster)? Some examples are assist-
• National Safety Council (http://www.nsc.org) ing your neighbors at local shelters, using your first
aid and CPR skills, helping out at a clinic, giving
• National Institutes of Health (http://www.health. injections for mass immunizations, supporting over-
nih.gov) whelmed providers, working with the American Red
Cross, giving emotional support, and filling in at a
hospital.
SAFETY AND EMERGENCY In addition to mass disasters, medical assis-
PRACTICES tants should be prepared to respond to emer-
gency situations in the medical office or a home
The Commission on Accreditation of Allied Health environment. For instance, if a patient goes into
Programs (CAAHEP) believes allied health students shock, or if an elderly family member has a fall,
should understand how to respond in an emergency or if the medical office needs to be evacuated
situation, as health care professionals and citizens. for a fire, are examples of these emergency
Medical assistant programs accredited by CAAHEP situations.
have within their Standards and Guidelines a new Medical assisting curriculum may include
section requirement for safety and emergency prac- courses to be certain medical assisting gradu-
tices. Provider-level CPR and basic first aid are part ates are prepared to help during an emergency
of these requirements for graduation. situation.
Health professionals recognize an obliga- In 2002, President Bush asked for teams of
tion to use their skills and knowledge in a disaster volunteers of medical and health professionals to
environment. contribute their skills during times of need in their
There are many kinds of mass disasters, natu- communities. The Medical Reserve Corps (MRC)
ral and manmade. Some examples are floods, hur- was established (http://www.medicalreservecorps.
ricanes, tornadoes, tsunamis, and earthquakes. gov), and the teams of volunteers within the MRC
Others are explosions, structural collapses (I-35W work with Health and Human Services of the U.S.
bridge collapse in Minneapolis in 2007), trans- government and the American Red Cross. The
portation accidents, and war or terrorism (see MRC is community based. Its goal is to organize and
Chapter 10). use volunteers who want to donate their time and
What would a large-scale disaster be like and expertise to respond to emergencies and to pro-
how could we respond? Disaster threatens pub- mote healthy living throughout the year. The MRC
lic health and safety; disrupts services (gas, water, supplements existing emergency and public health
electricity, transportation); destroys roads, bridges, resources. Volunteers include providers, nurses,
homes, and other buildings; and makes food and respiratory care therapists, massage therapists, phar-
water unsafe or impossible to obtain. Law enforce- macists, dentists, and a whole array of allied health
ment, fire departments, hospitals, and military all professionals such as medical assistants.
could be affected. There is a need for collaboration The MRC volunteer units are assigned to
between disaster experts and health professionals to specific areas. They work with and support the
plan for emergencies. country and state public health departments. The
What can medical assistants do to help? How main office is in the Surgeon General’s office in
could you use your skills without technology (unavail- Washington, DC.
160 UNIT 3 Responsible Medical Practice

Procedure 9-1
Control of Bleeding
STANDARD PRECAUTIONS: 6. If bleeding continues, elevate arm above heart
level (Figure 9-13B). RATIONALE: Raising the
arm above the heart level will slow the flow of
blood because it is flowing against gravity.
PURPOSE: 7. If bleeding continues, press adjacent artery
To control bleeding from an open wound. against bone (Figure 9-13C). Notify the pro-
vider if bleeding cannot be controlled. RATIO-
EQUIPMENT/SUPPLIES: NALE: Pressing the adjacent artery against a
Sterile dressings bone provides solid pressure to help control
Sterile gloves bleeding.
Mask and eye protection 8. Apply pressure bandage over the dressing.
Gown
Biohazard waste container 9. Dispose of waste in biohazard container.
10. Remove gloves and dispose in biohazard con-
PROCEDURE STEPS: tainer.
1. Wash hands.
11. Wash hands.
2. Assemble equipment and supplies.
12. Document procedure in patient’s chart or elec-
3. Apply eye and mask protection and gown if splash- tronic medical record.
ing is likely to occur.
CAUTION: If wound is large and bleeding is not con-
4. Put on gloves. trolled, the patient may go into hemorrhagic shock.
5. Apply dressing and press firmly (Figure 9-13A). Be prepared to call EMS immediately.

A B

Figure 9-13 (A) Apply dressing and press firmly. (B) Elevate arm above heart level.

continues
 CHAPTER 9 Emergency Procedures and First Aid 161

Procedure 9-1 (continued)

DOCUMENTATION
4/4/20XX—10:00 AM Patient sustained small (1 cm)
laceration on inside left forearm. Bleeding moderately. Pres-
sure dressing applied to wound, left arm elevated above heart
level. Bleeding continued. Pressure applied to brachial artery.
Pressure bandage applied over dry sterile dressing. Bleeding
seems to have subsided. BP 118/74, P 92. Seen by Dr. King.
W. Slawson, CMA (AAMA) _________________________

Figure 9-13 (continued) (C) Press artery against

Procedure 9-2
Applying an Arm Splint
STANDARD PRECAUTIONS: (wrist) with gauze pads or other soft material.
RATIONALE: More comfortable for patient.
4. After splinting, check circulation (note color
and temperature of skin, note color of nails,
PURPOSE: check pulse) to ascertain that the splint is not
To immobilize the area above and below the injured too tightly applied. RATIONALE: Checks for
part of the arm in order to reduce pain, immobilize, impaired circulation.
and prevent further injury.
5. A sling will be applied to keep the arm elevated,
EQUIPMENT/SUPPLIES: which increases comfort and reduces swelling.
Thin piece of rigid board; cardboard can be used if 6. Wash hands.
necessary 7. Document the procedure in patient’s chart or
Gauze roller bandage electronic medical record.
PROCEDURE STEPS:
1. Wash hands. DOCUMENTATION
4/4/20XX—2:00 PM Splint applied to right arm above and
2. Place the padded splint under the injured area.
below injured area. Sling applied for comfort. Nail beds pink,
3. Hold the splint in place with gauze roller hand warm, radial pulse easily palpated. Seen by Dr. Woo.
bandage. Pad gaps between arm and board J. Guerro, CMA (AAMA) ___________________________
162 UNIT 3 Responsible Medical Practice

Case Study 9-1

Refer to the scenario at the beginning of the chapter. CASE STUDY REVIEW
1. Dr. Rice and Wanda cleansed the wound. How was
it done?
2. There is another factor to consider with regard to
treating the patient’s wound and providing care for
her. What could it be?

Case Study 9-2

Annette Samuels, a regular patient at Inner City Health Care, CASE STUDY REVIEW
is walking her dog one morning, stops to rest on a grassy
knoll, and notices a wasp on her arm. She brushes it away, 1. Wanda Slawson, CMA (AAMA), is screening calls the
unthinking and then realizes it has stung her. She receives morning Annette is stung. What questions should
two more stings and suddenly notices she is at a nest site. she ask Annette?
Annette is now a half-hour walk from home but is not really 2. Because Annette obviously is having a hypersensi-
concerned because she has never had an allergic reaction tive or an allergic reaction, she is advised to seek
to a wasp sting. However, a few minutes into her walk, her emergency care immediately. What first-aid mea-
palms become itchy, her ears start to burn, and she feels sures might be taken?
lightheaded. She is not having difficulty breathing. She is 3. What advice about precautions against getting
determined to get home and she does, at which point she stung again should Wanda give Annette?
notices she is covered with hives. She calls Inner City Health
Care to ask: Should she come in?

Case Study 9-3

Abigail Johnson has arrived at Inner City Health Care for CASE STUDY REVIEW
her scheduled appointment with Dr. Lewis. As she checks
in with Bruce Goldman, the medical assistant, she reports 1. What immediate actions should Bruce take to
feeling nauseated, having some pressure in her chest, and respond to Mrs. Johnson’s complaints?
being short of breath. 2. What equipment/supplies/medications should be
ready and available for Dr. Lewis?
3. Because of the possibility of myocardial infarction,
what action would Dr. Lewis direct Bruce to take
after Mrs. Johnson has been stabilized?
4. What patient education can Bruce use in this
situation?
 CHAPTER 9 Emergency Procedures and First Aid 163

SUMMARY
Although many of the emergencies covered in this chapter may never be seen by the medical assistant in the
ambulatory care setting, it is nonetheless important to develop a broad base of information about the vari-
ous types of potential emergency situations. This knowledge gives the medical assistant the confidence and
the preparation to manage the emergencies that do occur with speed, accuracy, and understanding until
outside emergency help arrives. Staff will need to assess their response to emergencies on a continual basis.
Was protocol followed? Were there difficulties in the delivery of care? Were staff and equipment prepared
and ready to deal with these potentially life-threatening situations? Staff meetings should be held to discuss
these and other questions that may have arisen and to allow staff the opportunity to talk about any fears or
concerns they might have. It must be stressed that this chapter is at best an introduction to the topic of emer-
gency procedures and first aid; it is essential medical assistants in all ambulatory care settings, whether large
or small, enroll in an American Red Cross, American Heart Association, American Safety and Health Insti-
tute, or National Heart Association first-aid and CPR program, attain provider-level CPR, and take refresher
courses to update skills.

STUDY FOR SUCCESS

To reinforce your knowledge and skills of information presented in this chapter:
• Review the Key Terms
• Practice any Procedures
• Consider the Case Studies and discuss your conclusions
• Answer the Review Questions

˚ Multiple Choice
˚ Critical Thinking
• Navigate the Internet and complete the Web Activities
• Practice the StudyWARE activities on the textbook CD
• Apply your knowledge in the Student Workbook activities
• Complete the Web Tutor sections
• View and discuss the DVD situations

REVIEW QUESTIONS
Multiple Choice c. depressed fracture
d. comminuted fracture
1. Good Samaritan laws: 4. To control a nosebleed, it is important to:
a. are designed to protect the public a. have the patient lie down
b. protect non–health care professionals b. tilt the patient’s head back
c. require that all individuals providing assistance act c. tilt the patient’s head forward
within the scope of their knowledge and training d. call 911 immediately
d. protect health care professionals on the job 5. Another name for a heart attack is:
2. First-degree burns: a. cerebral vascular accident
a. are the most serious and penetrate all layers b. cardiac arrest
of skin c. angina pectoris
b. affect only the top layer of skin d. myocardial infarction
c. often leave scar tissue
d. usually take more than a month to heal
3. A fracture in which the bone protrudes through
the skin is called:
a. greenstick fracture
b. compound fracture
164 UNIT 3 Responsible Medical Practice

Critical Thinking WEB ACTIVITIES

1. Sixteen-year-old Cindy Roland, a patient newly 1. Search the Internet for sites and resources
diagnosed with seizures caused by epilepsy, came on the Emergency Medical Services (EMS)
into the office for a follow-up appointment today. system. Are there any cities or towns within
She approached the reception desk and said she 100 miles of your place of residence that do not use
can see flashing bright lights in both eyes and that the EMS system?
she feels “weird.” The administrative medical assis- 2. What sites can you recommend to patients and
tant alerted the medical assistant, who immediately their families who are looking for first-aid informa-
responded to the patient. tion about diabetes and heart attack?
a. What actions should the medical assistant take? 3. What organizations could you use to search for
b. Is there a significance to the flashing bright information that deals with first aid for convulsions?
lights? Explain. 4. Search the Internet for information regarding first
2. Mrs. Williams, a 75-year-old patient, came to the aid for insect stings.
office today for a routine follow-up appointment 5. What sites are available for information about
for her diabetes. She suddenly collapsed onto the poisonings?
floor of the reception area. What immediate steps
did the medical assistant take to provide care for
this patient in distress? REFERENCES/BIBLIOGRAPHY
3. Define the purpose of a crash cart or tray and com-
pile a list of the major supplies and medications it American Heart Association. (2005). Adult basic life
should contain. support. Circulation, 112, IV19–IV34.
4. Describe shock and tell how and why it is important The American National Red Cross. (2001). Staywell.
to prevent a patient from going into shock. St. Louis, MO: Mosby-Year Book.
5. Recall three types of bandages and give examples American Red Cross. (2005). CPR and emergency car-
of their use. diac care: New CPR guidelines for professionals and
6. Describe the difference between first-, second-, and non-professionals. Retrieved September 19, 2007,
third-degree burns. from http://www.redcross.org/cpr.html.
7. Recall and describe the four ways that poisons may Consumer Reports on Health. (2008). Consumer Unions,
enter the body. 20, 7, 3.
8. What is a hemorrhage? What kinds of bleeding may Medical Reserve Corps. (2008). Emergency medical care.
the medical assistant encounter? What are the symp- Retrieved September 17, 2007, from http://www.
toms of each? medicalreservecorps.gov.
9. Explain when and why back blows and abdominal National Institutes of Health. (2008). New CPR guide-
thrusts, rescue breathing, and CPR techniques are lines. Retrieved September 17, 2007, from http://
performed. www.health.nih.gov.
10. Explain steps to take if a patient has a laceration on Taber’s cyclopedic medical dictionary (21st ed.). (2003).
the hand with moderate to heavy bleeding. Philadelphia: F. A. Davis.
 CHAPTER 9 Emergency Procedures and First Aid 165

THE DVD HOOK-UP

In this chapter, you learned about proper techniques to 3. Why was it important to get the patient’s phone number
follow during emergency situations. In the designated at the beginning of the call?
DVD clip, we observed the medical assistant screen-
ing a call from a mother whose child was experiencing DVD Journal Summary
an asthma attack. The medical assistant used a triage Write a paragraph that summarizes what you learned
manual to assist her in screening the call accurately. from watching the designated scene from today’s DVD
With the aid of the triage manual, the medical assistant program. What are some things you can do to help
instructs the mother to call the EMS. The mother refuses you know how to respond to emergencies before they
to call the EMS and decides to bring the child into the happen?
office. The mother hangs up the phone before the doctor
gets a chance to speak with her. The next scene shows
the mother bringing the child into the office in respiratory
distress. The medical assistant and provider work together
as a team to get the patient’s breathing stabilized.
1. Do you think that it was wise of the medical assistant
to take the extra time to ask screening questions once DVD Series Program Number
the mother stated that the child was having an asthma Skills Based Series 8
attack? Why or why not? Chapter/Scene Reference
2. Why is it necessary for you to follow an approved triage • Triaging Phone Emergencies
manual if you are put into the role of screening patient
calls?
This page intentionally left blank
SEC TION
Clinical
II Procedures
UNIT
Integrated Clinical
4 Procedures

Chapter 10
Infection Control and Medical Asepsis
Chapter 11
The Patient History and Documentation
Chapter 12
Vital Signs and Measurements
Chapter 13
The Physical Examination
 Chapter
Infection Control
and Medical Asepsis 10
KEY TERMS OUTLINE
Acquired Immunodefi- Impact of Infectious Diseases Human Immunodeficiency Virus
ciency Syndrome The Process of Infection and Hepatitis B and C
(AIDS) HIV and AIDS
Growth Requirements for
Acyclovir Microorganisms Acute Viral Hepatitis Diseases
Airborne Transmission Chain of Infection Reporting Infectious Disease
Amoebic Dysentery Infectious Agents Standard Precautions
Antibodies Reservoir Transmission-Based
Asepsis Portal of Exit Precautions
Barrier Means of Transmission Blood and Body Fluids
Bloodborne Pathogen Portal of Entry Personal Protective Equipment
Susceptible Host Needlestick
Carrier
The Body’s Defense Mechanisms Disposal of Infectious Waste
Caustic
for Fighting Infection and Federal Organizations and
Cell-Mediated Immunity Disease Infection Control
Communicable The Body’s Natural Barriers OSHA Regulations
Contact Transmission Inflammatory Response The Bloodborne Pathogen
Contracting The Immune System and Standard
Coryza Immunity OSHA Regulations and Students
Cough Etiquette Stages of Infectious Diseases Avoiding Exposure to
Debris Incubation Stage Bloodborne Pathogens
Prodromal Stage Principles of Infection Control
Declination Form
Acute Stage Medical Asepsis
Droplet Transmission
Declining Stage Hand Washing
Epidemic Convalescent Stage Sanitization
Epidemiology Disease Transmission Disinfection
Excoriated Bioterrorism
Excretion
Expectorate
Fomite
OBJECTIVES
Gross Contamination The student should strive to meet the following performance objectives and
demonstrate an understanding of the facts and principles presented in this
Human Immunodeficiency
Virus (HIV) chapter through written and oral communication.
Humoral Immunity 1. Define the key terms as presented in the glossary.
Immune System 2. Define and state the critical importance of infection control in
Immunoglobulins the ambulatory care setting.
Immunomodulator 3. Outline the six links in the chain of infection.
Immunosuppressed 4. Define the five classifications of infectious microorganisms.

169
OBJECTIVES (continued) KEY TERMS
5. Recall and elaborate on the four phases the immune system uses (continued)
to defend against infectious disease.
Infection Control
6. State the four stages of infectious diseases. Infectious Agent
7. Recall at least five infectious diseases, their agents of transmission, Inflammatory
and their symptoms. Response
8. Compare the routes of transmission of AIDS and hepatitis B and Inoculation
C and discuss the risk for infection from needlestick. Isolation
9. Describe the purpose of Standard Precautions and give six Isolation Categories
examples of ways health care providers should practice Standard Jet Injection
Precautions.
Lesion
10. Differentiate among the three types of Transmission-Based Lymphadenopathy
Precautions, defining what they are and how they are applied.
Macular
11. List eight types of body fluids and give an example of each.
Malaise
12. Describe personal protective equipment. Malaria
13. Recognize five situations in which exposure to a patient’s blood Medical Asepsis
can occur, and discuss why Standard Precautions are important.
Microorganism
14. Describe proper disposal of infectious waste. Morbidity
15. List human fluids that may contain HIV, HBV, and HCV. Mortality
16. Define medical asepsis. Normal Flora
17. Define bioterrorism and describe five agents that could be used Nosocomial
in a bioterrorism attack. Opportunistic
Infections
Palliative
Papular
Parenteral
Pathogen
Pruritus
Regulated Waste
Resistance
Scabies
Scoop Technique
Secretion
Severe Acute Respiratory
Syndrome (SARS)
Sharps
Solvent
Spill Kit
Sputum
Standard Precautions
Transmission-Based
Precautions
Trichomoniasis
Ultrasonic Cleaner
Universal Precautions
Vaccine

170
 KEY TERMS
(continued)
Vector
Vesicular
Virulence

Scenario
At Inner City Health Care, a multiprovider urgent diseases, according to the National Coalition for Adult
care center, medical assistant Bruce Goldman, CMA Immunization and the CDC, can lead to hospitalization
(AAMA), assumes responsibility for all infection control or death.
measures taken in the ambulatory care setting. In Joe learned that as many as 200,000 adults
addition to his daily responsibilities related to medical die yearly of flu-related illnesses; pneumonia causes
and surgical asepsis, Bruce also makes it a point to 40,000 deaths per year; adults are 25 times more
stay current with infection control principles. Recently, likely to die of chickenpox, and most adults with hepa-
Bruce attended a workshop about infection control. titis B and C do not know that they are infected. These
The Centers for Disease Control and Prevention (CDC) and other adult vaccines are available to prevent the
discussed that adults, just like children, need immuni- flu, pneumonia, hepatitis A and B, measles, mumps,
zations to stay well. The immunizations help prevent and rubella, tetanus, diphtheria, chickenpox, pertussis,
diseases that affect millions of adults per year. The herpes zoster, and human papillomavirus.

INTRODUCTION
Infectious diseases have plagued humans since the begin- single leading cause of death in the history of human-
ning of time. Recent scientific advances have changed kind, yet was drastically reduced with the discovery of
our thoughts and behaviors regarding infectious disease. antituberculosis drugs. Today, however, the tuberculosis
Advances such as antibiotic therapy and vaccination organism may be found that has adapted to the drugs,
have significantly reduced risks for mortality from some thereby becoming resistant to our only line of defense.
previously fatal or debilitating infectious diseases. Infec- Medical assistants must pay close attention to the preven-
tious diseases that once were highly feared because of their tion of infectious diseases.
likelihood of causing premature death are now prevent- This chapter addresses the principles of the process
able or treatable, causing us to forget the virulence and of infection and control measures for use in ambulatory
destructive potential of epidemics of infectious disease. The care settings. Because medical assistants deal directly
presence of acquired immunodeficiency syndrome (AIDS) with patients and other health care professionals, strin-
as an incurable and fatal infectious disease (although gent adherence to the principles can greatly reduce trans-
people are living with HIV and AIDS for many years), mission, or spread, of infectious disease. Continuous
as well as severe acute respiratory syndrome (SARS), reliance on infection control measures ensures a clini-
West Nile virus, avian flu, hepatitis C virus (HCV), cal environment that is as safe as possible for employees,
and others, have caused the world to realize the enduring patients, and families. When infection control principles
impact of pathogens on the human race. are not followed, infectious diseases may be transmitted
Although these medical advances have reduced the to self, coworkers, or patients. The goals of infection con-
incidence of mortality and morbidity from infectious dis- trol are to limit the presence of infectious agents, to create
eases, humans must never underestimate the potential of barriers against transmission, and to decrease the risk to
resurgent infectious diseases. Tuberculosis has been the others for contracting infectious diseases. These goals can

171
172 UNIT 4 Integrated Clinical Procedures

ognized the connection between bubonic plague

Spotlight on Certification and rat infestation. Recent epidemiological studies
have traced infectious diseases such as AIDS from
RMA Content Outline the beginning of the epidemic. The future of stud-
• Asepsis ies in infectious diseases will focus on increasing
• Bloodborne pathogens and Universal the pharmacologic (drugs) war against infectious
(Standard) Precautions diseases.
Reliance only on treatment of infectious
CMA (AAMA) Content Outline disease does not address the crucial step
• Legislation in the spread of infectious diseases, that is,
• Federal compliance of prevention, or infection control. Emerging
• Principles of infection control issues related to infectious diseases involve micro-
organisms that are resistant to present technol-
• Medical asepsis
ogy, bloodborne pathogen transmission, increased
• Equipment preparation and operation immunosuppressed populations, and global access
• Safety precautions to infection control and treatment. Developed
CMAS Content Outline countries become accustomed to antiinfectious
medications, clean water, and laws that protect the
• Asepsis in the medical office
public from infectious agents found in food and
other consumables. These safety measures may not
be present in other countries where political or
economic factors limit access to infection control
be achieved through medical asepsis and sterilization, measures.
by observation of all Standard Precautions and Trans- In the future, drug-resistant infectious diseases
mission-Based Precautions set forth by the CDC, and by will place greater emphasis on prevention because
following the Occupational Safety and Health Adminis- there may never be a safe and universally effective
tration (OSHA) guidelines. drug for all infectious diseases.
Study of the history of infectious diseases
allows us to realize the impact these dis-
IMPACT OF INFECTIOUS eases have on the lifestyles of people in
DISEASES various cultures. Infectious diseases such as AIDS
and other sexually transmitted diseases have dif-
Since the discovery of the germ theory by Louis fering levels of social or cultural impact. Medical
Pasteur and Robert Koch in the nineteenth cen- assistants should be aware of facts regarding the
tury, we have seen dramatic changes in global infectious process of specific diseases to reduce cul-
mortality and morbidity statistics from infectious tural isolation for the patient and to dispel myths
diseases. Many scientists devoted their profes- regarding infectious diseases (see Chapter 6).
sional lives to the quest for the prevention and
cure of infectious diseases, which were the main
cause of death in earlier centuries. In developed THE PROCESS OF INFECTION
countries, deaths from diseases such as tubercu-
losis, pneumonia, and smallpox have been sig- Infectious diseases are caused by pathogenic
nificantly reduced because of pharmacologic microorganisms that are capable of causing dis-
agents such as antibiotics and vaccines. Antibi- ease. Microorganisms are microscopic living crea-
otic agents were widely introduced during World tures capable of reproduction and transmission in
War II, reducing deaths from traumatic wound specific circumstances. Pathogens are microorgan-
infections. Edward Jenner is credited with the dis- isms that can cause infectious disease. Although all
covery of the first vaccine to protect against the pathogens are capable of causing disease, not all
deadly disease smallpox. Because of the vaccine, microorganisms cause disease. Many microorgan-
smallpox is considered to have been eradicated isms are necessary for human, animal, and plant
worldwide. life survival. In the absence of microorganisms,
Epidemiology is the science that studies the life would not be possible. The term normal flora
history, cause, and patterns of infectious diseases. is used to recognize the beneficial role of micro-
This field of medicine is credited to a Japanese bac- organisms in certain parts of the body, in which
teriologist in the late nineteenth century who rec- microorganisms normally occupy space and use
 CHAPTER 10 Infection Control and Medical Asepsis 173

nutrients, thus retarding the potential of patho- diseases will be prevented when any of the levels in
genic growth in that specific body area. A funda- the chain are broken or interrupted (Figure 10-1).
mental concept in the study of infectious disease is The steps are:
that similar steps or phases occur in all infectious
diseases; however, each specific microorganism 1. Infectious agent
causes unique characteristics and alterations in the 2. Reservoir
process of infection. Medical assistants must apply 3. Portal of exit
the theoretical process of infectious disease growth
4. Means of transmission
and transmission to relate to specific pathogens.
The goal is to reduce transmission and incidence 5. Portal of entry
of infectious diseases in patients, employees, and 6. Susceptible host
families.
Infectious Agents
Growth Requirements
Infectious agents are microorganisms that can be
for Microorganisms grouped into five classifications: viruses, bacteria,
For microorganisms to survive and thrive, a suit- fungi, parasites, and rickettsia. For an infection to
able environment must be available to them. occur, an infectious agent or microorganism must
Following is a list of growth requirements for be present. When infectious diseases are identified
microorganisms: according to the specific disease-causing microor-
ganism, the disease may be prevented with the use
• Oxygen: An aerobic microorganism needs oxygen of antiinfective drugs or infection control practices.
to live; most pathogenic microorganisms need Each of the five classifications of infectious micro-
oxygen to survive: for example, streptococcus as in a organisms will be explored.
“strep” throat
• Lack of or no oxygen: An anaerobic microorganism Viruses. Viruses are pathogens that require a liv-
needs little or no oxygen to live; two examples are ing cell for reproduction and activity. These micro-
tetanus and gas gangrene organisms are considered intracellular parasites,
• Moisture: Microorganisms grow well in a moist because they must live inside cells to multiply.
environment; the body provides moisture They do so by altering particles of genetic mate-
rial, such as DNA (deoxyribonucleic acid) or RNA
• Nutrition: The body supplies plenty of nutrients
(ribonucleic acid). Because viruses live inside
• Temperature: The body’s temperature of approxi- cells, they are protected against agents such as
mately 98.6°F is an optimum temperature for chemical disinfectants and antibiotics. To survive,
growth of microorganisms viruses have a notable characteristic of being able
• Darkness: The body’s cavities and organs provide to change specific characteristics over time. For
darkness instance, viruses can adapt to their environment
• Neutral or slightly alkaline pH: The body’s fluids are so they remain resistant to efforts to limit their
neutral when in a healthy state growth. Viral infections have only a few pharma-
cologic treatment agents, and usually these agents
Through the understanding of the optimum are palliative because they only relieve symptoms
growth requirements for microorganisms to grow of the disease instead of curing the infection.
and multiply, elimination of any or all of the fac- Some viral infections can be prevented by vacci-
tors helps keep microorganisms from growing and nation (Table 10-1). Figures 10-2A and B show
causing infection. the CDC’s recommended adult immunization
schedules.

CHAIN OF INFECTION Bacteria. Bacteria are single-celled microorgan-

isms that live in tissues rather than in body cells
For infectious diseases to spread, several necessary and are identified by characteristic shapes, or
steps must occur. These steps, or links, are known morphology. Bacteria may also be grouped accord-
as the “chain of infection.” Each link or step in the ing to ability to accept laboratory staining agents.
infectious process must occur for the spread of Gram-negative bacteria stain visibly red under the
infection to take place. Infection control is based microscope, whereas gram-positive bacteria stain
on the fact that the transmission of infectious purple. The bacteria that do not accept stain are
174 UNIT 4 Integrated Clinical Procedures

Microorganisms
Bacteria
Viruses
Parasites
Rickettsiae

Healthy life-style

Intact immune Infectious Agent

system
Exercise 1. Cleansing People
Elderly Equipment
Immunization
Frail Disinfection Food
Immunosuppressed Proper nutrition
Water
Chronic disease Stress reduction Sterilization Animals
Trauma Insects

Susceptible Reservoir
Host 6. 2. or Source

Skin integrity
Covered wound Proper hygiene
Sterile technique
Hand washing Clean supplies
PPE
Proper disposal Clean equipment
of needles or sharps
Clean linen

Non-intact skin
Mucous membranes Portal of Exit Secretions
Portal of Entry 5. 3. Excretions
Systems: Reproductive from Reservoir
to Host Respiratory droplets
Digestive or Source
Respiratory Blood/body fluids
Wearing gloves, masks,
gowns, goggles
Sterile dressing over wounds
Medical or surgical
asepsis Isolation technique
Proper disposal of 4. Covering mouth and nose
contaminated objects when coughing or sneezing
Means of
Hand washing
Transmission

Indirect contact (fomite)

Direct contact (exudate)
Bloodborne
Airbone
Ingestion

Figure 10-1 Health care worker’s interventions used to break the chain of infection transmission.

considered spores, which are bacteria with a cov- brane areas of the body. These are known as normal
ering that protects them from many chemical flora. Nonpathogenic bacteria use nutrients and
disinfectants and higher levels of heat. The three occupy space, competing with the pathogenic bac-
classifications of bacteria are cocci (sphere or dot teria. When nonpathogenic bacteria are reduced,
shaped), bacilli (rod shaped), and spirilla (spiral the opportunity exists for pathogenic organisms to
shaped). Bacteria are either pathogenic or non- take over and cause infectious disease. A common
pathogenic. Nonpathogenic bacteria normally cause of the reduction of nonpathogenic microor-
reside on the skin of humans and in mucous mem- ganisms is the use of antibiotic drugs. Examples of
 CHAPTER 10 Infection Control and Medical Asepsis 175

Table 10-1 Common Viral Diseases

Disease/Agent Type of Infection and Site Vaccine Availability

Herpes groups
Herpes Simplex Virus 1 (HSV-1) (Figure 10-3) Cold sores/keratitis No
Herpes Simplex Virus 2 (HSV-2) (Figure 10-3) Genital herpes No
Herpes zoster Shingles (neurons) Yes*

Rubeola Measles Yes

Rubella German measles Yes

Poliovirus Poliomyelitis Yes

Influenza (ABC) Flu, pneumonia Yes

Human papillomavirus Genital warts, cervical cancer Yes

Hepatitis (A, B, C, D, E) Liver A, B

Epstein-Barr Infectious mononucleosis No

Varicella zoster Chickenpox (skin) Yes

*The Advisory Council on Immunization Practice (ACIP) recommended to the CDC that adults over age 60 years receive the Zestavar vaccine. The
CDC has given provisional approval.

some bacterial pathogens are listed in Table 10-2 Rickettsiae. Rickettsiae are intracellular para-
and shown in Figure 10-4. sitic, small nonmotive bacteria. They are larger
than viruses and can be seen under conven-
Fungi. Fungi are microorganisms that may be uni- tional microscopes after staining procedures.
cellular (single-cell) or multicellular (many cells). These microorganisms are susceptible to antibi-
Mushrooms and molds are examples of fungi otic therapy. Examples of rickettsial infections
that are nonpathogenic. Pathogenic fungi cause include typhus (transmitted by the body louse);
athlete’s foot, ringworm, and candida infections Lyme disease (transmitted by ticks); and Rocky
(Figure 10-5). Other pathogenic fungi include his- Mountain spotted fever (transmitted by ticks).
toplasmosis and toxoplasmosis, which are fungal Characteristic of rickettsia infections is a skin
infections spread through the air from infected rash caused by the rickettsia invading the small
fowl and bird waste. blood vessels. This appears on the skin as a small
hemorrhagic rash.
Parasites. Organisms that live in or on another
organism are classified as parasites. They may be
single-celled or multicelled. Examples include pro-
Reservoir
tozoa (single-cell microscopic organisms that cause The second link in the chain of infection is the
malaria, amoebic dysentery, and trichomoniasis reservoir or location of the infectious agent. Reser-
[Figure 10-6]); metazoa (multicellular organisms voirs are people, equipment, supplies, water, food,
that cause pinworms, hookworms, and tapeworms); and animals or insects (known as vectors). Methods
and ectoparasites (multicellular organisms that of infection control in the reservoir link include
live superficially on another host, such as lice and hand washing, environmental hygiene, disinfec-
scabies). tion, sterilization, and maintenance of employee
 Recommended Adult Immunization Schedule

176
UNITED STATES · 2009
Note: These recommendations must be read with the footnotes containing number
of doses, intervals between doses, and other important information.

UNIT 4
Figure 1. Recommended adult immunization schedule, by vaccine and age group
AGE GROUP 19–26 years 27–49 years 50–59 years 60–64 years >65 years
VACCINE

Integrated Clinical Procedures

Tetanus, diphtheria, pertussis Td booster
Substitute 1-time dose of Tdap for Td booster; then boost with Td every 10 yrs every 10 yrs
(Td/Tdap)*

Human papillomavirus (HPV)* 3 doses (females)

Varicella* 2 doses

Zoster 1 dose

Measles, mumps, rubella (MMR)* 1 or 2 doses 1 dose

Influenza * 1 dose annually

Pneumococcal (polysaccharide) 1 or 2 doses 1 dose

Hepatitis A* 2 doses

Hepatitis B* 3 doses

Meningococcal* 1 or more doses

*Covered by the Vaccine Injury Compensation Program.

For all persons in this category who meet the age Recommended if some other risk factor is No recommendation
requirements and who lack evidence of immunity present (e.g., on the basis of medical,
(e.g., lack documentation of vaccination or have occupational, lifestyle, or other indications)
no evidence of prior infection)
Report all clinically significant postvaccination reactions to the Vaccine Adverse Event Reporting System (VAERS). Reporting forms and instructions on filing a The recommendations in this schedule were approved by the:
VAERS report are available at www.vaers.hhs.gov or by telephone, 800-822-7967. Information on how to file a Vaccine Injury Compensation Program claim is Centers for Disease Control and Prevention’s (CDC)
available at www.hrsa.gov/vaccinecompensation or by telephone, 800-338-2382. To file a claim for vaccine injury, contact the U.S. Court of Federal Claims, 717 Advisory Committee on Immunization Practices (ACIP)
Madison Place, N.W., Washington, D.C. 20005; telephone, 202-357-6400.
CS124645

American Academy of Family Physicians (AAFP)

Additional information about the vaccines in this schedule, extent of available data, and contraindications for vaccination is also available at www.cdc.gov/
vaccines or from the CDC-INFO Contact Center at 800-CDC-INFO (800-232-4636) in English and Spanish, 24 hours a day, 7 days a week. Use of trade names American College of Obstetricians and Gynecologists (ACOG)
and commercial sources is for identification only and does not imply endorsement by the U.S. Department of Health and Human Services.
American College of Physicians (ACP)
Figure 10-2A Recommended adult immunization schedule, by vaccine and age group. (Courtesy of the Centers for Disease Control and Prevention.)
Figure 2. Vaccines that might be indicated for adults based on medical and
other indications
Asplenia
Immuno- Diabetes, (including
Kidney failure,
compromising heart disease, elective
HIV infection end-stage renal Health-care
conditions chronic splenectomy Chronic liver
INDICATION Pregnancy
(excluding human CD4+ T lympho- lung disease, and terminal disease
disease, personnel
cyte count receipt of
immunodeficiency chronic complement
hemodialysis
virus [HIV]) alcoholism component
<200 >200 deficiencies)
VACCINE cells/µL cells/µL

Tetanus, diphtheria, pertussis

Td Substitute 1-time dose of Tdap for Td booster; then boost with Td every 10 yrs
(Td/Tdap)*

Human papillomavirus (HPV)* 3 doses for females through age 26 yrs

Varicella* Contraindicated 2 doses

Zoster Contraindicated 1 dose

CHAPTER 10
Measles, mumps, rubella (MMR)* Contraindicated 1 or 2 doses

1 dose TIV
Influenza * 1 dose TIV annually or LAIV
annually

Pneumococcal (polysaccharide) 1 or 2 doses

Infection Control and Medical Asepsis

Hepatitis A* 2 doses

Hepatitis B* 3 doses

Meningococcal* 1 or more doses

*Covered by the Vaccine Injury Compensation Program.
For all persons in this category who meet the age Recommended if some other risk factor is No recommendation
requirements and who lack evidence of immunity present (e.g., on the basis of medical,
(e.g., lack documentation of vaccination or have occupational, lifestyle, or other indications)
no evidence of prior infection)

These schedules indicate the recommended age groups and medical indications for which administration of currently
licensed vaccines is commonly indicated for adults ages 19 years and older, as of January 1, 2009. Licensed combination Department of Health and Human Services
vaccines may be used whenever any components of the combination are indicated and when the vaccine’s other components Centers for Disease Control and Prevention
are not contraindicated. For detailed recommendations on all vaccines, including those used primarily for travelers or that
are issued during the year, consult the manufacturers’ package inserts and the complete statements from the Advisory
Committee on Immunization Practices (www.cdc.gov/vaccines/pubs/acip-list.htm).

177
Figure 10-2B Recommended adult immunization schedule, by vaccine and medical and other indications. (Courtesy of the Centers for
Disease Control and Prevention.)
178 UNIT 4 Integrated Clinical Procedures

health standards, such as annual tuberculosis skin

testing.

Portal of Exit
A B C
Although the infectious agent is housed or living
in the reservoir, it must leave the reservoir to infect
another person. The portal of exit is the method
by which an infectious agent leaves the reservoir.
Microorganisms may leave the human body with
D E F normally occurring body fluids, such as excretions,
secretions, skin cells, respiratory droplets, blood, or
Figure 10-3 Electron micrographs of various types of any body fluid. The portal of exit may be continu-
herpes simplex virus. (Courtesy of the Centers for Dis- ous, such as with respiratory droplets, or dependent
ease Control and Prevention, Atlanta, GA) on the body fluid exiting the body under unusual
circumstances, such as when blood leaves the body
during a surgical procedure or phlebotomy.

Table 10-2 Examples of Infectious Bacterial Diseases

Disease Infectious Agent Mode of Transmission

Anthrax Bacillus anthracis Inhalation

Chlamydia (sexually transmitted disease) Chlamydia trachomatis Sexual contact

Clostridial myonecrosis (gas gangrene) Species of gram-positive clostridia Wound entry

Escherichia coli Gram-negative bacilli Ingestion, wound entry

Gonorrhea (sexually transmitted disease) Neisseria gonorrhoeae Sexual contact

Legionnaire’s disease (pneumonia) Legionella pneumophila Inhalation

Normal flora transmitted during

illness/procedures; opportunistic
Nosocomial (hospital-acquired) infection Gram-negative bacteria
pathogens transmitted during
debilitated condition

Pneumococci Streptococcus pneumoniae Respiratory (inhalation)

Staphylococcal infection (abscesses, food Staphylococci Direct contact, ingestion, inhalation,

poisoning, urinary tract infections) bloodborne, vectors (animals)

Streptococcal infection (strep throat, otitis Hemolytic streptococci (usually Inhalation

media, pneumonia) beta-hemolytic group A)

Syphilis (sexually transmitted disease) Treponema pallidum Sexual contact

Tetanus (lockjaw) Clostridium tetani Wound entry

Typhoid fever (enteric fever) Salmonella typhi Fecal-oral

 CHAPTER 10 Infection Control and Medical Asepsis 179

B C

Figure 10-4 Bacterial forms: (A) Escherichia coli, (B) Haemophilus pertussis, (C) Vibria cholerae.
(Courtesy of the Centers for Disease Control and Prevention, Atlanta, GA.)

Figure 10-5 Ringworm of the foot (tinea pedis). Figure 10-6 Intestinal protozoa, Entamoeba coli.
(Courtesy of the Centers for Disease Control and Pre- (Courtesy of the Centers for Disease Control and Pre-
vention, Atlanta, GA.) vention, Atlanta, GA.)
180 UNIT 4 Integrated Clinical Procedures

Standard Precautions and Transmission- organisms allows infectious diseases to be spread to

Based Precautions are infection control the lungs. Eating or drinking contaminated water is
methods based on the knowledge that a cause of gastrointestinal infectious diseases. Sexu-
infectious diseases exiting the body can be spread ally transmitted diseases spread through vaginal,
to others. These precautions attempt to control the oral, and anal intercourse. Care of patients with
spread of infectious diseases as infectious agents infectious diseases includes careful consideration
leave or exit the reservoir. of infection control to limit further spread of the
microorganism. Methods such as correct wound
care, transmission-based precautions, and asep-
Means of Transmission tic technique limit the transmission of infectious
The means of transmission are specific ways in microorganisms. The portals of exit and entry need
which microorganisms travel from one place (res- not be the same for infection to be transmitted.
ervoir) to another (susceptible host). Transmission
depends on the characteristics of the microorgan-
isms. Types of routes of transmission include:
Susceptible Host
Finally, for the infectious process to continue, micro-
• Direct contact (touching the exudate [drainage] organisms must enter another person who is suscep-
from a person with an infected wound) tible. This means that the person is able to contract
• Airborne transmission (inhaling the microorgan- the pathogenic organism. The susceptible host
ism, such as mycobacterium tuberculosis [TB] into is therefore not resistant or immune to the organ-
the susceptible host’s respiratory system) ism. Causes of susceptibility include the presence of
• Bloodborne transmission (infected blood enters other diseases, such as diabetes, immunosuppres-
susceptible host through blood or body fluids) sion (weakened immune system), HIV/AIDS, surgi-
cal procedures, trauma, or the absence of immunity
• Ingestion (eating or drinking contaminated items
to the specific microorganism. Susceptibility of a
such as food or water)
person depends on several factors, including:
• Indirect contact (microorganism, on a fomite, a
nonliving object such as a table or piece of equip- 1. Number and specific type of pathogen
ment that can retain and transmit infection, a 2. Duration of exposure to the pathogen
doorknob or a fomite)
3. General physical condition
• Vector (a carrier of disease, usually an insect, such
4. Psychological health status
as a tick [Lyme disease] or mosquito [Eastern
equine encephalitis]) 5. Occupation or lifestyle environment
6. Presence of underlying diseases or conditions
Infection control measures in the ambulatory 7. Youth or advanced age (young and old at greater
care area specifically address the transmission stage risk)
of the process of infection.
Methods that reduce the transmission of The goal of infection control at this link in
pathogens include adherence to Standard the chain of infection is to identify patients at risk
and Transmission-Based Precautions, hand for susceptibility, treat their underlying conditions
washing, sanitization, disinfection, and steriliza- if possible, and isolate them from those reservoirs
tion. Methods of infection control are used in that could be hazardous to the susceptible person.
health care, food handling, water and sewage pro- Hospitalized patients are at risk for contract-
cessing, and child care. ing a nosocomial infection. Surgical patients are
especially susceptible to becoming infected. Noso-
comial infections are found in all health care set-
Portal of Entry tings; nursing homes, and short-term care settings
After being transmitted, the infectious agent must
enter another person, or a susceptible host. The
portal of entry allows the agent access to the next
person. Common entrance sites to the human body Critical Thinking
include nonintact skin, mucous membranes, and
systems of the body exposed to the external environ- Explain how to interrupt the transmission
ment, such as the respiratory, gastrointestinal, and of infection.
reproductive systems. Breathing in airborne micro-
 CHAPTER 10 Infection Control and Medical Asepsis 181

such as clinics and ambulatory settings. These tion can occur regardless of whether it is caused
patients are at risk for being infected with the same by an agent that is pathogenic, a trauma, a foreign
pathogens as hospital patients. body, or extremes in temperature. If a pathogen is
A number of different pathogens are pres- present, the body goes through a distinct process
ent in the hospital and other health care settings, in an attempt to destroy and eliminate the patho-
and as new patients arrive, new pathogens are genic microorganisms and their by-products and,
introduced to the facility. The overuse of antibi- if that is not possible, to restrict the amount of
otics contributes to microorganisms becoming damage done.
resistant to them. Some health care staff become The cardinal signs of inflammation are red-
carriers of these microorganisms. Table 10-3 ness, heat, swelling, and pain. These symptoms
provides information about methicillin-resistant may be slight, almost unnoticed, or quite evident.
Staphylococcus aureus (MRSA). Remember, inflammation is a natural response and
Patients have compromised immune sys- does not necessarily indicate infection. The two
tems for many reasons. Surgery opens the body to should not be confused. Inflammation can occur
microorganisms, and radiation treatments, certain without infection, but infection does not occur
medications, catheters, and intravenous tubing all without inflammation.
contribute to the means for infection to enter the The steps in the inflammatory process are:
body of a susceptible patient.
Nosocomial infections can occur from the • Local dilation of blood vessels increases blood
hands of health care staff, equipment, and instru- flow to injured (infected) area causing redness
ments. Hand washing and other methods of or heat.
infection control and identification of vulnerable • Plasma moves into the tissue causing swelling and
patients can help control nosocomial infections. pain due to pressure on nerve endings.
• White blood cells move into injured tissue to
THE BODY’S DEFENSE fight infection and phagocytes destroy invading
MECHANISMS FOR FIGHTING pathogens.

INFECTION AND DISEASE After destruction of the pathogen, tissue

repair can begin. If the inflammatory response
is not effective, the specific immune response is
The Body’s Natural Barriers necessary.
The body has many natural barriers and defenses Indications that an inflammatory process is
in place to help us avoid exposure to pathogens inadequate are: (1) the accumulation of purulent
and infection. matter (pus) in the area (due to destroyed patho-
These barriers can be categorized under gens, white blood cells, and body cells); (2) lymph
physical/mechanical, chemical, and cellular fac- node enlargement (swollen glands); and (3) sep-
tors. Physical/mechanical factors include eye- ticemia, which may result because pathogens have
lashes and eyebrows, cilia (tiny hairs in the spread to the bloodstream.
respiratory tract), and barriers such as eyelids and Immediate antibiotic therapy is indicated in
intact skin/mucous membranes. Chemical barri- these circumstances because of the inadequacy of
ers include tears, sweat, mucus, saliva, gastrointes- the inflammatory response.
tinal secretions, and vaginal secretions. Cellular
barriers are also called body defenses and consist The Immune System
of white blood cells, which defend against infec-
tion in many ways in tissues, bloodstream, and lym-
and Immunity
phatic system. Cellular defenses are explained in To fight infectious diseases, our bodies are
more detail in the following two sections. equipped with several effective physical and
chemical barriers such as the skin, mucous mem-
branes, body excretions and secretions, and a
Inflammatory Response complex, highly specific immune system. The
Inflammation is the body’s natural way of respond- immune system’s purpose is to protect against
ing when invaded by a pathogen or physical trauma. pathogens and abnormal cell growth. The sys-
Inflammation is a nonspecific response, meaning tem is composed of various cells that collectively
that it can occur with any threat to the body, not recognize, subdue, attack, and eliminate patho-
just in reaction to a particular pathogen. Inflamma- gens. The two types of immune responses include
 182
Table 10-3 Examples of Infectious Diseases

UNIT 4
Disease Agent Transmission Symptoms Diagnosis Treatment Comments Patient Education

Human • Bloodborne Opportunis- CD4 T-cell level Palliative care World Health Organiza- 1. Careful infection con-
immunode- • Sexual tic infections, less than 200/ and treatment tion (WHO) estimates trol and asepsis to

Integrated Clinical Procedures

Acquired ficiency contact lymphade- mm3; for opportunis- global statistics 40 mil- reduce contact with
immunode- virus (HIV) • Intrauterine nopathy, Viral count tic infections, lion people living with pathogens that cause
ficiency • Lactation fatigue, mal- antiviral drugs HIV/AIDS (2006) opportunistic infections
Chest X-ray
syndrome aise, fever 2. Use of latex condoms
(AIDS) CBC in conjunction with
effective spermicide
3. Support groups/edu-
cation

Flu virus A • Infected birds Flu-like Swab of nose H5NI is resistant Virus does not usually Very rare disease in
found in spread virus cough, sore and/or throat to to two antiviral affect humans, but con- humans. Does not infect
birds to susceptible throat, fever, check for avian medications firmed human infections humans easily. Does not
birds through muscle flu using a now used for have been reported since spread easily from person
bird saliva, aches, pneu- molecular test; the flu; perhaps 1997 and of those who to person.
nasal secre- monia, severe lab may attempt two other antivi- have become infected, 1. Seasonal flu vaccina-
tions, and respiratory to grow the virus; ral medications according to the CDC, tion does not protect
feces. diseases, life- these two labora- could help treat more than 50% have against avian flu.
• Direct human threatening tory tests are best H5NI but more died; influenza viruses 2. Wash hands before
contact with and severe performed within study is needed; have ability to change and after handling raw
infected birds symptoms the first few days symptomatic their form and there is poultry and eggs.
(domesti- of illness. treatment concern that H5NI could 3. Clean cutting board
cated chick- infect humans and and utensils with soap
ens, ducks, spread from person to and water to keep raw
**Avian turkeys) or sur- person; because the poultry from contami-
influenza faces viruses do not usually nating other foods.
H5NI (bird contaminated infect humans, there is lit- 4. Cook poultry to internal
flu) with secre- tle or no immune protec- temperature of 165
tions/excre- tion in humans; scientists degrees; egg yolks and
tions of are concerned about a whites should be firm.
infected birds worldwide outbreak and 5. Practice cough
has resulted in are closely watching and etiquette.
humans con- preparing for that possi-
tracting H5NI. bility; the WHO and vac-
• Virus does not cine manufacturers are
usually infect moving toward creating a
humans but global stockpile of H5NI
can occur. avian flu vaccine; there is
a ban on imported poul-
try from countries
affected by avian flu
viruses including H5NI.
 Bacteria or • Ingestion of Nausea, Culture of feces, Fluid balance Report outbreaks to 1. Teach proper food
viruses (i.e., contami- stomach vomitus, or sus- restoration, local authorities; espe- handling.
staphylo- nated food or pain, vomit- pected food or medications, cially dangerous in chil- 2. Carefully wash hands
cocci, clos- water ing, bloody water emergency dren and older adults; before handling all food.
Foodborne tridium, diarrhea, treatment as undercooked meat, 3. Report to provider all
illnesses botulinum, dehydration, required vegetables and fruits signs of dehydration.
E. coli, respiratory washed in dirty water 4. Gastroenteritis usually
shigella) failure, death can carry E.coli. communicable via
feces for up to 7 weeks
after exposure.

Streptococ- • Direct Vesicles Culture of Antibiotics Good hygiene is neces- 1. Good hygiene neces-
cus contact become pus- discharge po or IV if sary to help prevent sary to help prevent
with moist tular, rupture, severe; local transmission; gloves transmission.
discharges and form antibiotic should be worn when 2. Can be fatal to new-
Impetigo
of the lesions crusts; ointment cleaning lesions; expose borns if not treated
pruritus lesions to air to help dry; promptly.
can be fatal if not 3. Wear gloves when
treated properly. touching lesions.

Influenza • Inhalation Acute Tissue culture of Palliative ther- Report cases to local 1. Bed rest for 2–3 days
viruses A, B, • Aerosolized upper/lower nasal or pharyn- apy, active health authority; may be after fever declines.

CHAPTER 10
or C, Hae- • Mucous drop- respiratory geal secretions immunization fatal in older adults and 2. Force fluids.
mophilus lets infection, (annual vac- children; may cause 3. Report signs of second-
(bacteria) severe cine recom- meningitis; may easily ary infections (pneu-
Influenza cough, fever, mended for become epidemic; 80% monia, otitis media).
malaise, persons at risk of elderly who contract 4. Vaccine available.
sore throat, [older adults, the flu die. 5. Practice cough
coryza heart patients] etiquette.
for complica-

Infection Control and Medical Asepsis

tions from
infection)

Bacteria • Transmitted Rash, flu-like Presence of Antibiotics, The tick is so small and 1. Use insect repellant.
(Borrelia by the bite of symptoms, symptoms; labo- po or IV bite so mild, patients 2. Remove tick promptly
burgdorferi) infected tick headache, ratory tests may may not realized they (save for laboratory
fatigue, joint be inconclusive, were bitten for a few testing if possible).
pain taking 6 weeks or days to weeks later; bac- 3. Wear pants tucked into
Lyme more for antibod- teria spread to other socks when in wooded
disease ies to appear in sites, causing symptoms areas or where ticks are
the blood; eryth- to heart, joints, and ner- present.
rocyte sedimen- vous system; arthritis 4. Complete recovery usu-
tation rate; total develops and may ally occurs if treated
serum; Ig M level; become chronic. with antibiotics.
aspartate amino- 5. Disease has exacerba-
transferase level tions and remissions.

(continues)

183
 184
UNIT 4
Table 10-3 Examples of Infectious Diseases (continued)

Disease Agent Transmission Symptoms Diagnosis Treatment Comments Patient Education

Integrated Clinical Procedures

***Bacteria • Bacterial High fever, Culture and sen- Appropriate Rare but potentially fatal 1. Meningitis usually peaks
(more through severe head- sitivity of cerebral antibiotics, vac- disease; there are two in late winter and early
severe); exchange of ache, stiff spinal fluid cine available forms of meningitis: spring and can be
Neisseria respiratory neck, nau- for the bacteria (1) inflammation of brain mistaken for the flu.
meningiti- and throat sea, rash, responsible for and spinal cord, and 2. High-risk persons are
des is one secretions vomiting, 75% of the dis- (2) meningococcemia college students living
type) (coughing, confusion, ease (vaccine (infection in the blood). in dorms, immunosup-
Virus sneezing, sleepiness, lasts 3–5 years) Bacterial meningitis is pressed individuals,
Meningitis shared seizures contagious but not and persons traveling
drinking spread by casual con- to areas of world
glasses, tact or by breathing the where meningitis is
bottles, cans, air where an infected per- prevalent (these
cigarettes) son is present; leading people should get
cause of meningitis in vaccine).
older children and young 3. The CDC can advise
adults; cases have dou- travelers about areas for
bled since 1991. which they recommend
the vaccine be given.

Bacteria • Direct skin-to- Pus-filled Culture and sensi- Good wound In the past MRSA was pri- 1. Regular hand washing
(Staphylo- skin contact boils, pimples, tivity of discharge and skin care; marily seen in hospital- helps prevent acquiring
coccus (e.g., shaking and rashes; from infected site; keep area ized patients; now, MRSA and spreading Staph,
aureus— hands, wres- same symp- blood and other clean and dry; is seen in healthy including MRSA.
“Staph”) tling, other toms as other body fluids can wear gloves younger people; these 2. Keep open sores and
commonly direct skin “Staph” be tested by and wash infections commonly are breaks in the skin cov-
found on contact) infections culture and hands after not acquired in a hospi- ered until healed.
**Methicil-
skin and in • Shared towels sensitivity caring for site; tal but rather in the com- 3. Avoid contact with other
lin-resistant
nose of or shared antibiotics, but munity; children in day person’s wounds or
Staphylo-
healthy athletic MRSA is resis- care, athletes, prisoners, dressings.
coccus
persons equipment tant to many IV drug users, men who 4. Avoid sharing towels,
aureus
• Bacteria gain common have sex with men are at toothbrushes, wash-
infections
entrance to antibiotics higher risk; can cause cloths, razors.
(MRSA skin
the body surgical wound infec- 5. Keep skin healthy to
infections)
through any tions, septicemia, help avoid Staph on skin
break in the pneumonia; use surface from causing an
skin Standard Precautions. infection in nonintact
skin and tissues.
6. Take all doses of antibi-
otic prescribed and do
not share them with
another person.
 Bordetella • Direct con- Primarily Presence of DPT vaccine High rate of morbidity 1. Highly contagious
pertussis tact with dis- seen in the whooping type prevents and mortality in many 2. Adolescents and adults
(bacteria) charge from pediatric cough; nasal disease; countries; incidence in become susceptible
respiratory population; pharyngeal antibiotics U.S. has increased when immunity wanes.
mucous severe culture PCR may be given steadily since the 1980s. 3. Practice cough
membrane coughing, (polymer chain for secondary In U.S. epidemics occur hygiene****.
*Pertussis
whooping, reaction) in infection of every 3–5 years; Increase
and vomit- patient younger pneumonia seen in adolescents and
ing; apnea, than 11 years; adults.
pneumonia, serology in
seizures patient older
than 11 years

****Bac- • Cough, Cough with Chest X-ray, Antibiotics if Elderly, immunosup- 1. Get vaccine.
teria sneeze, sputum, blood culture, bacterial; pressed, and patients 2. Practice proper respira-
****Viruses droplets in air chills, fever, sputum culture, treatment of with chronic illness are tory hygiene (cover
Fungi chest pain, CBC symptoms if more susceptible; vac- nose and mouth when
Protozoa dyspnea, viral; oxygen cine available; practice coughing or sneezing).
Rickettsia fatigue therapy, bed cough hygiene. 3. Use tissues to contain
Aspirations rest secretions and expecto-
Pneumonia
of chemi- rations; dispose of used
cals and tissues in nearest waste

CHAPTER 10
dust receptacle.
4. If no tissues available,
cover nose and mouth
with bend of the elbow.
5. Practice proper hand
hygiene.

Virus • Spread by Rash, fever Rubella titer; None other Rubella vaccine can pre- 1. The following individu-

Infection Control and Medical Asepsis

contact with for 2–3 days, presence of than treatment vent disease; part of the als should get the MMR
infected lymph node rubella antibod- of symptoms; MMR vaccine; birth vaccine: college stu-
person enlargement ies in blood pain and fever defects if a pregnant dents or any student
through in head and medications as women acquires rubella beyond high school,
coughing neck needed; treat (deafness, mental retar- people employed in a
Rubella and for shock; prac- dation, liver and spleen medical facility, people
(German sneezing tice cough eti- damage to fetus). who travel internation-
measles) quette. ally, people who are a
passenger on a cruise
ship, females of child-
bearing age.
2. Vaccine not given
during pregnancy.

(continues)

185
 186
Table 10-3 Examples of Infectious Diseases (continued)

UNIT 4
Disease Agent Transmission Symptoms Diagnosis Treatment Comments Patient Education

Virus • Close person- High fever, SARS serum anti- None; support- Potentially serious illness; 1. Travel to a previously

Integrated Clinical Procedures

to-person headache, bodies validated ive only; may currently no known SARS SARS-affected area
contact cough, short- by Centers for treat pneumo- transmissions; last trans- (China, Hong Kong,
• Kissing ness of Disease Control nia with antibi- mission was in China, Taiwan) or close
• Sharing eat- breath, and Prevention; otics but will not April 2004; because no contact with an ill
ing or drink- diarrhea blood culture; cure patient one knows if SARS will person who has such
**Severe
ing utensils sputum culture recur, early recognition a travel history.
acute
• Perhaps of cases and appropri- 2. A diagnosis of pneumo-
respiratory
respiratory ate infection control are nia raises the suspicion
syndrome
droplets essential to control out- of exposure to SARS.
(SARS)
breaks; Transmission- 3. Avoid close contact
Based Precautions such as kissing, hug-
(Isolation); airborne and ging, sharing of eating
direct contact or drinking utensils.
4. Practice cough
etiquette.

Staphylo- • Associated Sudden Presence of IV fluids and CDS says TSS could be 1. A woman who has had
coccus with use of onset of fever, symptoms, vagi- antibiotics; stopped if use of vaginal TSS is at risk for recur-
aureus tampons and chills, vomit- nal culture, CBC, management tampons ceases; men- rence and should not
Streptococ- intravaginal ing, muscle blood culture of respiratory struating women, women use tampons at all.
cus contraceptive aches, and disease, renal using barrier contracep- 2. Women should wash
Toxic shock
devices rash; pro- impairment, tives, and persons with hands carefully before
syndrome
• Can occur gresses rap- gastrointestinal postoperative Staphylo- inserting a tampon.
(TSS)
post opera- idly to problems coccus infections are 3. Tampon should be
tionally with hypotension at risk changed every 6–8
staphylococ- and multisys- hours.
cal wound tem break-
infections down, shock,
and death

Mycobac- • Inhalation of Productive Sputum culture Antituberculosis Increase in incidence of 1. Encourage hand wash-
terium contami- cough, for M. tuberculo- agents, air- TB, especially among ing, proper sputum tis-
tuberculosis nated fatigue, fever, sis, Mantoux skin borne transmis- persons with AIDS and sue disposal.
bacillus airborne weight loss test (PPD), chest sion-based the homeless; may 2. Promote compliance
*Tuberculo- mucous (behaviorial X-ray, pleural precautions become drug resistant; with medications.
sis (TB) droplets changes, needle biopsy until drug health care professionals 3. Encourage close con-
• Possibly anorexia, agents started should have annual skin tacts to have skin tests.
ingestion weight loss), testing; report outbreaks. 4. Encourage a well-
night sweats balanced diet.
5. Practice cough
etiquette.
 Bacteria • Direct contact VRE can Culture and sen- Antibiotics Spread directly by con- 1. Wash hands thoroughly
(entero- with blood, cause infec- sitivity of stool, other than tact with feces, urine, or after using toilet and
cocci) nor- urine, feces tions seen as: urine, and/or vancomycin blood; spread indirectly before touching food.
**Vancomy-
mally found • Indirect con- septicemia, blood from hands of health 2. Wear gloves if handling
cin-resistant
in intestines tact with con- pelvic, neo- care workers or on con- body fluids containing
Enterococ-
and female taminated natal, and taminated surfaces; VRE.
cus (VRE)
genital tract surfaces and urinary disor- Standard Precautions
from health ders, otitis used when caring for
care worker’s media patients.
hands

Varicella- • Direct and Sudden- Vesicular fluid Acyclovir Vaccine (varicella virus 1. Communicable
zoster virus indirect con- onset fever, tissue culture helpful to vaccine live) available in 1–2 days before rash
tact with respi- malaise, during first 3 days reduce severity United States for children until lesions crust.
ratory droplets maculo- after eruption; of disease; zos- older than 12 months. 2. Avoid scratching
papular- serology: ter immunoglob- lesions to prevent
Varicella vesicular increased anti- ulin (ZIG) for secondary infection
(chicken- skin rash bodies 2 weeks high-risk persons and scarring.
pox) after rash; lesion only within 96 3. Benadryl and calamine
appearance hours of lotion can be used for
characteristic of exposure; pallia- itch.
varicella tive therapy 4. Acetaminophen can be
used for fever.

CHAPTER 10
5. Practice cough
etiquette.

Virus • Infected Central ner- West Nile virus, None— Potentially serious illness; 1. Use insect repellent
mosquito vous system; IgM capture, supportive may have permanent with DEET.
fever, head- PRNT (plague only; if neurologic effects. 2. Wear long sleeves and
ache, coma, reduction neu- hospitalized pants when outside,

Infection Control and Medical Asepsis

convulsions, tralization test) IV fluids, especially at dawn and
paralysis; 80% ventilator dusk.
of people 3. Get rid of mosquito
infected breeding sites by emp-
West Nile show no tying standing water in
virus signs or flowerpots, buckets,
symptoms and barrels.
4. Keep children’s pools
empty and on their
sides when not in use.
5. A small number of cases
are spread through
blood transfusions, organ
transplants, intrauterine,
and breast feeding.

* Resurgent Diseases: Case rates of recent years have reversed and are now increasing.
** Emerging Diseases: Have become recognized in recent years.

187
*** Although meningitis can be bacterial or viral, the information in this table applies to bacterial meningitis because it is the more severe of the two.
**** Bacteria and viruses are the two main causes of pneumonia. Of the two, bacterial is more serious.
188 UNIT 4 Integrated Clinical Procedures

cell-mediated immunity and humoral immunity. body, the immune system recognizes the antigen
Cell-mediated immunity is usually involved in as foreign and attempts to contain and subdue
attacks against viruses, fungi, organ transplants, the foreign invader. Specific chemical antibod-
or cancer cells. This type of immunity does not ies to the antigen are produced by B cells, which
produce antibodies. Humoral immunity pro- attempt to prevent the antigen from further
duces antibodies that are capable of killing micro- growth. After the completion of the stages of that
organisms and of recognizing the pathogen infectious disease, the body retains the ability to
in the future. Generally, both types of immune produce antibodies in response to that specific
responses occur in four phases: microorganism or antigen. Therefore, immu-
nity can last for some length of time, possibly to
1. Recognition of the invader. The immune system is
provide lifetime protection against specific infec-
equipped with cells that identify agents, pathogens,
tious microorganisms. Several forms of immunity
and abnormal cell growth as foreign substances.
can occur in response to specific antigens:
Macrophages and helper T cells recognize foreign
invaders, whether they are pathogens, cancer cells, • Naturally acquired active immunity results from
or transplanted tissues. contracting an infectious agent and experiencing
2. Growth of defenses, which allows for multiplication of helper either an acute or subclinical infectious disease.
T cells and B cells. After foreign substance recognition, This immunity is usually permanent.
the immune system alerts T and B cells to multiply • Artificially acquired active immunity is achieved
and move to the site of the foreign substance. In after administration of vaccines. This immunity is
cell-mediated immunity, activation of helper T cells semi-permanent to permanent.
means that the T cells are specifically oriented to a
• Naturally, congenitally acquired passive immunity
unique antigen, a substance such as bacteria the body
occurs when antibodies pass to a fetus from the
recognizes as foreign. Activated T cells divide, form-
mother providing short-term immunity for the
ing memory T cells and killer T cells. In humoral
newborn. This immunity is temporary.
immunity, activated B cells are antigen specific and
divide into memory B cells and plasma cells. • Artificially acquired passive immunity may be
achieved through administration of ready-made
3. Attack against the infection. Cell-mediated immunity
antibodies, such as gamma globulin, used to treat
uses killer T cells and macrophages to phagocytize,
or prevent infectious diseases. This immunity is
or engulf and destroy the pathogens. Humoral
temporary.
plasma cells have the ability to produce specific
antibodies that lock on to specific antigens, which Our defenses against diseases can be catego-
prevents the disease-producing characteristics of rized as specific and nonspecific. Specific defenses
the pathogen from forming. These antibodies are include those things that protect us against a
called immunoglobulins and they render the patho- specific pathogen, whereas nonspecific defenses
gen unable to reproduce or continue growth. are not so particular. Some examples of specific
4. Slowdown of the immune response after death of the defenses are:
infectious agent. After the death of the foreign sub-
• Vaccines/immunizations: Designed for specific patho-
stance, the immune response is halted. T and B
gen
cells return to normal levels, and in the case of
humoral immunity, the presence of antibody pro- • Antibodies: Created against a specific pathogen
duction causes the immune system to resist the • Tetanus shot: Protects individuals from tetanus
specific infectious pathogen in future contacts • Active immunities: Created against a specific pathogen
with the pathogen.
• Globulin: Antibodies for exposure to a specific
Susceptibility to some infectious diseases is pathogen
closely linked to the person’s unique resistance,
Some examples of nonspecific defenses are:
or immunity. Immunity is the ability of the body
to resist specific pathogens and their toxins. • Tears: Contain chemical harmful to a variety of
Resistance occurs after an exposure to a patho- pathogens
gen, which is the antigen–antibody reaction. This
• Skin: Creates a barrier against many different
natural body defense to fight infectious disease
pathogens
occurs gradually and over time as pathogens and
other foreign substances such as antigens enter • Saliva: Contains chemicals harmful to a variety of
the human body. When the antigen enters the pathogens
 CHAPTER 10 Infection Control and Medical Asepsis 189

• Species resistance: being human protects us from many production. Examples of toxin vaccines include
diseases to which other animals are susceptible tetanus and diphtheria.
3. Killed pathogens. Inactivated pathogens stimulate anti-
Immunization. Immunizing individuals against body production; however, several vaccines may be
specific infectious diseases provides immunity required to provide sustained protection. Examples
with active or passive vaccines. Most of the severe include pertussis, rabies, and poliomyelitis.
childhood communicable diseases can be pre-
vented. The U.S. Department of Health and
Human Services has estimated that about 80% of STAGES OF INFECTIOUS
U.S. preschoolers younger than 2 years are fully DISEASES
vaccinated according to recommended schedules.
Several factors influence vaccination compliance Depending on the specific pathogen causing an
rates, such as access to health care, cost of vaccina- infectious disease, several stages occur from the
tions, and irregularity or confusion in maintaining time of exposure until full recovery and the absence
young children on the recommended schedule. of infection. These stages are often predictable and
There are pockets within large cities of signifi- offer guidelines for patient education and treat-
cant numbers of under-immunized children. A ment opportunities.
substantial number of these children are minor-
ity children. An outbreak could cause an epidemic
of diseases that are preventable with vaccines (see
Incubation Stage
Chapter 15). The incubation stage is the interval of time between
There is a movement by parents and exposure to a pathogenic microorganism and the
caregivers that is resisting the mandated first appearance of signs and symptoms of the dis-
childhood immunizations even though all ease. Some infectious diseases have short incuba-
states have immunization requirements for school tion stages, whereas other infections have lengthy
admission. These groups want state laws changed stages, lasting for years. If an exposure to an infec-
and feel that they, as parents and caregivers, tious agent occurs, the patient will manifest (reveal
should be allowed to decide if they want their chil- in an obvious why) the disease if the patient’s
dren immunized. immune system cannot contain the agent. If thera-
Exemptions from mandated immuniza- peutic medications are available, it can help to pre-
tions are allowed in all states if there are medi- vent disease progression. Not all infectious agents
cal reasons. Some states will exempt children are treatable or preventable.
for religious reasons and some on philosophical
grounds.
In general, children would more likely suffer
Prodromal Stage
greater complications associated with childhood The prodromal stage is the initial stage of the
diseases than from the immunizations given to pre- disease. It is characterized by common, general
vent them. Because most of the vaccinations are complaints of illness, such as malaise and fever. It
administered in ambulatory health care settings, is the interval between the earliest symptoms and
medical assistants may have the responsibility to the appearance of fever or rash that suggest an
administer, document, and monitor immuniza- impending disease process is occurring.
tions (see Chapter 15).
There are various classifications of vaccines,
depending on the method of immune stimulation:
Acute Stage
Disease processes reach their peak during the acute
1. Live attenuated (changed) pathogens. These patho- stage. Symptoms are fully developed and can often
gens stimulate the body’s own antibody produc- be differentiated from other specific symptoms.
tion. However, the patient does not contract the Treatment modalities are useful to reduce patient
infectious disease (or only a mild or subclinical discomfort, to reduce possibilities of debilitation
case) because the pathogen has been altered in and adverse effects, and to promote healing and
some mechanical or chemical means by the man- recovery.
ufacturer. Examples of live attenuated pathogens The inflammatory process is the body’s natu-
include measles and varicella. ral defensive reaction to the invasion by a foreign
2. Pathogenic toxins. Some pathogens produce toxins substance such as a pathogen, and it is in this acute
(poisonous substances) that can stimulate antibody state that the response is evident.
190 UNIT 4 Integrated Clinical Procedures

improving levels of health. It is often during the

Patient Education declining phase of an illness when patients begin to
feel better that they prematurely discontinue tak-
Drug-Resistant Bacteria ing the antibiotic that may have been prescribed.
This premature discontinuance can result in micro-
Antibiotic resistance occurs because bacteria
organisms becoming resistant to antibiotics. It is
can change their characteristics, thus reduc-
important to educate patients in the proper use of
ing or eliminating the effectiveness of anti-
antibiotics.
biotics. The resistant microorganisms survive,
multiply, and cause a longer illness, neces-
sitating more visits to the provider and more Convalescent Stage
powerful and expensive antibiotics. Death can
Recovery and recuperation from the effects of a spe-
result from resistant bacteria. The number of
cific infectious disease are called the convalescent
antibiotic-resistant bacterial has increased
stage. The patient regains strength and stamina. The
significantly in the past 10 years. For example:
overall goal of this stage is returning the patient to as
• MRSA (methicillin-resistant Staphylococ- close as possible the original state of health.
cus aureus)
• Tuberculosis
• VRE (vancomycin-resistant DISEASE TRANSMISSION
Enterococcus)
• PRSP (penicillin-resistant streptococcus When providing patients with health care, medical
pneumonia) assistants run the risk for contracting, or acquir-
ing, an infection from pathogens that are caus-
These and other infectious diseases are ing patients’ illnesses. Such pathogens are viruses,
becoming more resistant to standard antibi- bacteria, fungi, and others that can be found in
otic treatment. Drug options are increasingly patients’ blood and body fluids. In medical offices,
limited, are expensive, or simply do not exist. ambulatory care centers, and hospitals, many ill
An example of drug-resistant bacteria is the patients are seen everyday. Pathogens can be easily
extensively drug-resistant tuberculosis (XDR transmitted to another person if care is not taken
TB). The bacteria are resistant to almost all to prevent such an occurrence.
antibiotics used to treat TB, including the two Consistent use and adherence to infection
best first-line antibiotics, the second-line anti- control measures significantly reduce the risk for
biotics, and at least one of three injectable disease transmission. The CDC recommends that
antibiotics. Because XDR TB is resistant to health care providers consider each patient to be
several antibiotics, providers are left with potentially infectious for AIDS, hepatitis B and C,
much less effective treatment options that and other bloodborne pathogens and to routinely
frequently have worse treatment outcomes. and conscientiously apply the techniques of Stan-
dard Precautions as a means of infection control.
• Antibiotics should be prescribed by a Infectious diseases are caused by unique infec-
licensed provider and should be taken tious agents, are characterized by various symp-
only when prescribed to treat a bacterial toms, are transmitted by differing means, and have
infection. unique treatments and prognoses. Medical assis-
• Antibiotics should be taken exactly as tants must recognize the unique characteristics of
directed for the entire course. specific infectious diseases to prevent their trans-
mission and help patients suffering from these
• Do not demand antibiotics from your
infections. Table 10-3 classifies several common
provider. They do not cure a viral infec-
infectious diseases by critical components. When
tion.
patients have contracted an infectious disease or
are exposed to the risk for transmission, patient
education plays an important role in infection con-
trol. Although a family member may have an infec-
Declining Stage tious disease, proper training and education may
Patient symptoms begin to subside or wane during protect other family members and close contacts.
the declining stage. The infectious disease remains, Medical assistants are in a unique position
however, though the patient will demonstrate to educate patients and the public about disease
 CHAPTER 10 Infection Control and Medical Asepsis 191

control. These measures become even more impor- count decreases to less than 200, they are con-
tant with the increase in drug-resistant pathogens. sidered to have AIDS. There is no curative treat-
All health care professionals must consistently and ment of HIV infections, but antiviral drugs such
diligently use every infection control measure avail- as lamivudine, azidothymidine, zidovudine, stavu-
able, as well as teach our patients to do the same. dine, and others are used to slow cell processes
and weaken cell protein, which is important in
the virus’s reproduction. Many people are living
HUMAN IMMUNODEFICIENCY for many years with HIV and AIDS. Table 10-4
VIRUS AND HEPATITIS B AND C provides information about HIV and AIDS.

A great deal of attention has been focused on the

human immunodeficiency virus (HIV) that causes
Acute Viral Hepatitis Diseases
AIDS, and yet there remains no cure for the disease, In any of the acute viral hepatitis diseases, the
although great advances have been made. With the liver becomes inflamed, and hepatic cells can be
focus on AIDS, other potentially life-threatening destroyed. Healthy persons can regenerate cells,
and fatal illnesses may seem less dangerous. In real- but older adult patients usually cannot. There are
ity, hepatitis B and C are examples of other diseases several types of viral hepatitis: hepatitis A (HAV),
that place health care providers at great risk for seri- hepatitis B (HBV), hepatitis C (HCV), hepatitis D
ous illness or death. Acute viral hepatitis deserves (HDV), and hepatitis E (HEV) and others. HAV,
close attention. HBV, and HCV are the more common viruses; HDV
and HEV are less common (see Table 10-5).
Despite the similarities among HIV, HBV,
HIV and AIDS and HCV, the risk for contracting HBV and HCV is
AIDS is caused by the bloodborne virus HIV. The greater than for contracting HIV (Figure 10-7).
viral infection directly affects the immune response. Medical assistants and all other health care
The HIV is responsible for T-cell destruction; T cells providers must understand the importance of
are the white blood cells that provide immunity. protecting themselves from the viruses that cause
HIV is carried in semen, blood, and other AIDS, HBV, HCV, and other pathogenic microor-
body fluids, and the virus can penetrate mucous ganisms. Through strict adherence to safety pre-
membranes. Once inside the body, the reduced cautions and routine infectious disease control
number of helper T cells leaves the patient vul- measures such as those found in medical asepsis,
nerable to a wide range of infections and malig- the risk for contracting an infectious disease can
nancies. The infections that the patient contracts be minimized.
can be devastating. When people are positive for There is no vaccine to prevent HCV and no
HIV infection, their T-cell counts must be regu- treatment after an exposure to prevent infection.
larly and closely monitored, and they must live Neither immunoglobulin nor antiviral drugs is rec-
their lives with careful consideration toward pre- ommended. It is a chronic disease, and patients
venting opportunistic infections. If their T-cell carry the virus for the remainder of their lives. The

Table 10-4 Facts About HIV and AIDS

Signs and symptoms*

Early (weeks to months after exposure) • Flu-like illness

• Swollen lymph nodes
Late (years after exposure) • Persistent fevers
• Night sweats
• Prolonged diarrhea
• Unexplained weight loss
• Purple bumps on skin or inside mouth and nose
• Chronic fatigue
• Swollen lymph nodes
• Recurrent respiratory infections
(continues)
192 UNIT 4 Integrated Clinical Procedures

Table 10-4 Facts About HIV and AIDS (continued)

Transmission

• Vaginal sex
• Oral sex
• Anal sex
HIV is spread by:
• Sharing needles to inject drugs, body piercing or tattooing
• Contaminated blood products (rare)
• Infected mother to newborn

• Shaking hands
• A social kiss
• Cups
• Animals
• Hugging
HIV cannot be spread by:
• Swimming pools
• Toilet seats
• Food
• Insects
• Coughing

• Currently no cure available; most people eventually die of the disease

Complications/consequences (most live about 10 years after infection)
• Spread to other sex partners and persons sharing needles

• HIV can be passed to unborn children from infected mother during

Pregnancy and HIV/AIDS pregnancy or childbirth.
• Infected mother may infect infant through breast milk (rare)

• Always use latex condoms during oral, vaginal, and anal sex. Latex
condoms, when used consistently and correctly, are highly effective in
preventing the transmission of HIV, the virus that causes AIDS.
• Use a latex barrier (dental dam or condom cut in half) on a vagina or anus
for oral sex.
• Limit or avoid use of drugs and alcohol.
Prevention • Do not share drug needles, cotton, or cookers.
• Do not share needles for tattooing or body piercing.
• Limit the number of sex partners.
• Tests are available to detect antibodies for HIV through providers, STD
clinics, and HIV counseling and testing sites.
• Notify sex and needle-sharing partners immediately if HIV infected.

• No treatment or medication available to cure HIV/AIDS.

• Early diagnosis and treatment can prolong life for years.
• Medications and treatments available to keep immune system working.
• Antiviral drugs slow cell processes and weaken cell protein.
Treatment
• Medications available to treat AIDS-related illnesses.
• Medications available for HIV-infected pregnant women to greatly
reduce the chance of passing infection to newborn.
• Experimental drug trials are testing new medications.

*NOTE: These symptoms are not specific for HIV and may have other causes. Most persons with HIV have no symptoms at all for several years.
 CHAPTER 10 Infection Control and Medical Asepsis 193

Table 10-5 Hepatitis Viruses A to C

A B C

• Hepatitis A virus (HAV) • Hepatitis B virus (HBV) • Hepatitis C virus (HCV)

• Fecal–oral; person • Blood; sexual contact; • Blood or body fluids; intravenous
Causative to person perinatal; breast milk; drug use; mother to fetus; tattoo and
agent drug use (sharing body piercing; needle exchange
needles); tattooing and
body piercing

• Household/sexual • Injection drug users • Recipients of blood transfusions or

contact with infected • Household/sexual organ transplants before 1992
persons contact with infected • People sharing needles
• International travelers persons • People exposed to blood and blood
Risk groups
• Men having sex • Infants born to infected products
with men mothers • HBV- and HIV-infected persons
• Drug users • Health care workers
• Multiple sex partners

Incubation • 15–50 days • 45–160 days • 14–180 days

period

Infectious • Usually less than • Before symptoms • Before symptoms appear; lifetime if
periods 2 months appear; lifetime if carrier carrier

• IgM anti-HAV • HBsAg • Anti-HCV

Diagnostic
• HBeAg • Serum ALT increased 10 ×
tests
• HCV RNA

• Flu-like • Flu-like • 80% have no symptoms

• Jaundice • May have jaundice • Flu-like
• Dark yellow urine • Dark yellow urine • Jaundice
Symptoms
• Light-colored stools • Light-colored stools • Anorexia
• Anorexia • Malaise
• Fatigue

• Hepatitis A vaccine • Hepatitis B vaccine • Standard Precautions

(entire series) (entire series) • Reduce risk behaviors
• Standard Precautions • Standard Precautions • No vaccine
• Enteric precautions • Reduce risk behaviors
Prevention
• Good personal hygiene, • Good personal hygiene,
sanitization sanitization
• Immunoglobulin (for • Immunoglobulin (for
short term) short term)

• Immunoglobulin within • Immunoglobulin (HBIg) • Alpha-interferon

Treatment 2 weeks of exposure • Alpha-interferon • Ribavirin (Virazole)
• Lamivudine

• Rarely fatal • No cure • 85% or less have chronic infection

• Not a carrier • May become a carrier • Chronic liver disease or cancer
Prognosis
• Liver cancer may develop in 70%
develop

ALT, alanine aminotransferase; HBeHg, hepatitis Be antigen; HBIg, hepatitis B immunoglobulin; HBsAg, hepatitis B surface antigen.
194 UNIT 4 Integrated Clinical Procedures

BLOODBORNE FACTS
WHAT IS HBV? the immunity lasts, so booster shots may be required at some
Hepatitis B virus (HBV) is a potentially life-threatening bloodborne point in the future.
pathogen. Centers for Disease Control estimates there are approx- The vaccine causes no harm to those who are already
imately 280,000 HBV infections each year in the United States. immune or to those who may be HBV carriers. Although employ-
Approximately 8,700 health care workers each year contract ees may opt to have their blood tested for antibodies to determine
hepatitis B, and about 200 will die as a result. In addition, some need for the vaccine, employers may not make such screening a
who contract HBV will become carriers, passing the disease on to condition of receiving vaccination nor are employers required to
others. Carriers also face a significantly higher risk for other liver provide prescreening.
ailments which can be fatal, including cirrhosis of the liver and Each employee should receive counseling from a health care
primary liver cancer. professional when vaccination is offered.This discussion will help an
HBV infection is transmitted through exposure to blood and employee determine whether inoculation is necessary.
other infectious body fluids and tissues. Anyone with occupational
exposure to blood is at risk of contracting the infection.
Employers must provide engineering controls; workers must WHAT IF I DECLINE VACCINATION?
use work practices and protective clothing and equipment to Workers who decide to decline vaccination must complete a
prevent exposure to potentially infectious materials. However, the declination form. Employers must keep these forms on file so that
best defense against hepatitis B is vaccination. they know the vaccination status of everyone who is exposed to
blood. At any time after a worker initially declines to receive the
vaccine, he or she may opt to take it.
WHO NEEDS VACCINATION?
The new OSHA standard covering bloodborne pathogens requires
employers to offer the three-injection vaccination series free to all
WHAT IF I AM EXPOSED BUT HAVE
employees who are exposed to blood or other potentially infec- NOT YET BEEN VACCINATED?
tious materials as part of their job duties. This includes health care
If a worker experiences an exposure incident, such as a needle-
workers, emergency responders, morticians, first-aid personnel,
stick or a blood splash in the eye, he or she must receive
law enforcement officers, correctional facilities staff, launderers,
confidential medical evaluation from a licensed health care pro-
as well as others.
fessional with appropriate follow-up. To the extent possible by law,
The vaccination must be offered within 10 days of initial
the employer is to determine the source individual for HBV as well
assignment to a job where exposure to blood or other potentially
as human immunodeficiency virus (HIV) infectivity. The worker’s
infectious materials can be “reasonably anticipated.” The require-
blood will also be screened if he or she agrees.
ments for vaccinations of those already on the job took effect July
The health care professional is to follow the guidelines of
6, 1992.
the U.S. Public Health Service in providing treatment. This would
include hepatitis B vaccination. The health care professional must
WHAT DOES VACCINATION INVOLVE? give a written opinion on whether or not vaccination is recom-
mended and whether the employee received it. Only this informa-
The hepatitis B vaccination is a noninfectious, yeast-based tion is reported to the employer. Employee medical records must
vaccine given in three injections in the arm. It is prepared from remain confidential. HIV or HBV status must NOT be reported to
recombinant yeast cultures, rather than human blood or plasma. the employer.
Thus, there is no risk of contamination from other bloodborne
pathogens nor is there any chance of developing HBV from the U.S. Department of Labor
vaccine. Occupational Safety and Health Administration
The second injection should be given one month after the
first, and the third injection six months after the initial dose. More Single copies of fact sheets are available from OSHA Publica-
than 90 percent of those vaccinated will develop immunity to the tions, Room N3101, 200 Constitution Ave. N.W., Washington, D.C.
hepatitis B virus. To ensure immunity, it is important for individuals 20210 and from OSHA regional offices.
to receive all three injections. At this point it is unclear how long

Figure 10-7 Bloodborne Facts, published by the U.S. Department of Labor, Occupational Safety and Health Admin-
istration (OSHA). This publication includes facts about hepatitis B virus, declination, and steps to be taken by the
employer should exposure to blood, body fluids, or other potentially infectious material occur. (Courtesy of the U.S.
Department of Labor.)
 CHAPTER 10 Infection Control and Medical Asepsis 195

virus is spread through blood and body fluids, shar-

Table 10-6 Disease that Must Be Reported
ing needles, IV drug use, needlesticks or sharps
to the CDC
exposure, or from mother to baby during deliv-
ery. HCV patients may be at risk for infection with AIDS Poliomyelitis
HAV, HBV, and/or HIV. Patients with HCV should
be vaccinated for HAV and HBV. Infection control Anthrax Rabies (animal and human)
practices (Standard Precautions) are necessary to
prevent infection with HCV through blood and Botulism Rheumatic fever
body fluids. Patients exposed to HCV should be
tested for HCV antibodies and liver enzyme levels Diphtheria Rubella
as soon as possible after exposure and again in 4 to
6 months. Encephalitis Salmonella
Medication known as immunomodulators,
(have the ability to change immune responses) are Hepatitis A, B, C Sexually transmitted diseases
used to treat some patients who have chronic HCV.
Two examples are peginterferon (Pegasys) and rib- Lyme disease Tetanus
avirin (Copegus). Patients being treated with these
medications must be closely monitored with peri- Measles Toxic shock syndrome
odic clinical and laboratory evaluations because
the medications cause decreases in leukocyte and Meningitis Tuberculosis
platelet counts. There are numerous side effects.
The medications are used to prevent progressive Pertussis Tularemia
liver destruction from the virus.

REPORTING INFECTIOUS
DISEASE Pharmacy

Certain infectious diseases must be reported to

the state and county health departments. The
CDC requires that the information be reported to CLINICAL CARE
them. This helps the CDC control the spread of Patient Assessment
infection. Each state health department has forms Procedures, Diagnoses & Treatment Plans
Referrals & Follow-up Appointments
for reportable diseases. Each disease has an iden- Prescriptions
tification number from the health department, Orders for Tests
Patient Medical History
and together with the appropriate form, the
information is sent to the state health department
and then to the CDC. Table 10-6 lists some of the
diseases to be reported to the CDC’s Notifiable Test Results
Disease Surveillance System. Diseases reports can Schedules and Tickler Files
Patient Medical History
be sent via the computer to the appropriate agen- Medication Administration
cies (Figure 10-8), which will reply with orders for Patient Education
Graphical Patient Data Displays
tests and procedures and follow-up orders.

STANDARD PRECAUTIONS ELECTRONIC

The CDC spent several years researching, im-
proving, and developing recommendations to
RECORDS
protect health care providers, patients, and their
visitors from infectious diseases. This intensive
period of research resulted in Standard Precau- Figure 10-8 Diseases reportable to the local health
tions, a set of infection control guidelines that department and CDC can be sent via computer to the
are now used by all health care professionals for appropriate agencies. They will reply with orders for
all patients. tests and procedures and follow-up appointments.
196 UNIT 4 Integrated Clinical Procedures

According to the CDC, Standard Precautions are These airborne, contact, and droplet precau-
“designed to reduce the risk of transmission of micro- tions also list specific syndromes that can appear in
organisms from both recognized and unrecognized adult and pediatric patients who are highly suspi-
sources of infection in hospitals.” They apply to: cious for infection. They identify the appropriate
Transmission-Based Precautions to be used until a
1. Blood
diagnosis can be made. Figures 10-10, 10-11, and
2. All body fluids, secretions, and excretions regard- 10-12 provide specific information on these three
less of whether they contain visible blood Transmission-Based Precautions. Remember that
3. Nonintact skin these precautions are for specific categories of
4. Mucous membranes patients and are to be used in addition to Standard
Precautions, which are used for all patients.
To be effective, Standard Precautions must Some medical assistants’ externship experi-
be practiced conscientiously at all times. Although ences take place in a hospital setting. For example,
the Standard Precautions include many criteria the electrocardiography and clinical laboratory
specific to inpatient settings such as hospitals and departments of the hospital are areas some stu-
skilled nursing facilities, they are absolutely appli- dents rotate through during their externships. It
cable to any medical facility, including ambulatory is important for medical assistants to know and
care settings where medical assistants are more understand how to protect themselves from infec-
likely to work. tious diseases. Transmission-Based Precautions
Figure 10-9 provides a comprehensive review (isolation) reduce the risk for airborne, droplet,
of Standard Precautions. and contact transmission of pathogens. Proce-
dure 10-3 describes the use of barriers (gown,
mask, goggles, gloves, and cap) that are used when
Transmission-Based Precautions entering an isolation room to perform an electro-
When the CDC was in the process of developing a cardiogram or phlebotomy on a patient with an
new guideline for isolation precautions in hospitals, infectious disease such as tuberculosis (airborne
the agency arrived at what it terms two tiers of pre- contact), meningitis (respiratory droplets contact),
cautions. The first tier is called the Standard Pre- and wound drainage (direct contact).
cautions, discussed earlier, designed for all patients
regardless of their diagnosis or presumed infection
status. The second tier of precautions is intended
Blood and Body Fluids
for patients diagnosed with or suspected of having In all infection control efforts, it is important to
specific highly transmissible diseases. These are understand what is meant by blood and body flu-
known as Transmission-Based Precautions. ids. Specifically, they are described as the blood,
Transmission-Based Precautions reduce the secretions, and excretions of a patient. Examples
risk for airborne, droplet, and contact transmission of blood and body fluids and some of the areas in
of pathogens and are always to be used in addition to which medical assistants may become exposed to
Standard Precautions. them are:
Blood:
Latex Sensitivity
• Specimens drawn during venipuncture
Health care providers should be aware that some people,
• Open wounds or lesions of any kind
including professionals and patients, can be allergic to latex
products. Some personal protective equipment (PPE) is made • Epistaxis, or nosebleeds
from latex; medical and surgical products also are often made • Vaginal bleeding, including menses (menstrua-
from this product. tion), lochia (discharge after childbirth), and
The allergic reaction can be a localized one such as
hemorrhage
dermatitis or a more severe systemic reaction such as ana-
phylaxis (see Chapter 9), a form of shock marked by vascular • Feces and vomit or other body fluids with or
collapse, respiratory failure, hypotension, arrhythmia, and without visible blood
laryngeal edema. Vinyl gloves can be worn in place of latex for
hypersensitive individuals. Any person with an allergy to latex Vaginal secretions:
should wear a bracelet or other form of identification indicat-
• Physiologic leukorrhea (normal vaginal dis-
ing this fact because, in any emergency, medical personnel
wear latex gloves (see Chapter 9).
charge)
• Vaginitis with discharge
Figure 10-9 Standard Precautions for Infection Control issued by the Centers for Disease Control
and Prevention. (Courtesy Brevis Corp.)
198 UNIT 4 Integrated Clinical Procedures

Figure 10-10 Airborne Precautions, one category of Transmission-Based Precautions,

for use in hospital settings. (Courtesy of Brevis Corp.)
 CHAPTER 10 Infection Control and Medical Asepsis 199

Figure 10-11 Contact Precautions, one category of Transmission-Based Precautions, for use in hospital settings.
(Courtesy of Brevis Corp.)

Cerebrospinal fluid: Pleural fluid:

• Fluid aspirated, or withdrawn, during a • Fluid aspirated during thoracentesis, a surgical
lumbar puncture (spinal tap) puncture of the thoracic cavity
• Leakage of fluid due to trauma to the brain or • Fluid leakage caused by chest trauma
spinal cord (through ear, nose)
Pericardial fluid:
Synovial fluid:
• Fluid around the heart exposed during car-
• Fluid aspirated during arthroscopic procedures diac surgery or caused by cardiac trauma
200 UNIT 4 Integrated Clinical Procedures

Figure 10-12 Droplet Precautions, one category of Transmission-Based Precautions,

for use in hospital settings. (Courtesy of Brevis Corp.)

Peritoneal fluid: Amniotic fluid:

• Fluid exposed during abdominal surgery (least • Fluid aspirated during amniocentesis, a surgical
likely fluid with which medical assistant will puncture of the amniotic sac
come into contact), but exposure can occur dur- • Vaginal leakage during pregnancy, labor, and
ing a paracentesis delivery
Semen: Breast milk (possibility exists)
Sputum:
• Seminal fluid as a laboratory specimen for
sperm count in examination for fertility • Material coughed up and expectorated from the
level respiratory tract
 CHAPTER 10 Infection Control and Medical Asepsis 201

Saliva:
• Oral mucous gland fluid in mouth during oral/
dental procedures

Any other body fluid visibly contaminated with blood

Thus far, only blood and blood products,
semen, vaginal secretions, and possibly breast milk
have been directly linked to transmission of HIV;
the virus is not spread casually or through close
family contacts. There is not yet a vaccine to protect
individuals from HIV.
HBV has been found in blood and blood
products, vaginal secretions, semen, and saliva.
Infection can spread through close family con-
tacts, kissing, sexual contacts, intrauterinely, and
during delivery. An infant may become a chronic
carrier, one who has no symptoms but can trans-
mit disease. If there has been an exposure to the
virus, a prompt injection of immunoglobulin, an
antibody, will help provide protection from the
virus. HBV vaccine is available, and the series of
three injections usually immunizes an individual
from an attack of hepatitis B for approximately
18 years.
Some states require health care providers Figure 10-13 Medical assistant wearing personal
and allied health students to be immunized before protective equipment. (A) Goggles, mask, gown, latex
employment and before admission into a health gloves. (B) Full-face shield, gown, latex gloves.
program in an educational institution. Also, many
states require infants to be routinely immunized tions and venipuncture. In the past, needlesticks
with HBV vaccine. were common because of the practice of needle
recapping. Contaminated (used) needles should
never be recapped, broken off, removed from
Personal Protective Equipment syringes, or manipulated by hand in any way. They
Standard and Transmission-Based Precautions all are disposed of in the approved puncture-proof
make use of barriers or personal protective equip- container designated for sharps (Figure 10-14). The
ment (PPE). The barriers consist of gloves, mask, disposal container for sharps must be in the clos-
gown, and goggles/face shield. Gloves reduce the est proximity as practical to the area where sharps
risk for contamination to hands but do not prevent are used. If a needle is used and an appropriate
needles or other sharp instruments from penetrat- disposal container is not nearby (“point-of-use dis-
ing the skin. Masks and protective eyewear reduce posal”), the scoop technique of recapping may be
the contamination risk to mucous membranes of used, but only in this circumstance (no appropriate
the eyes, nose, and mouth. Gowns protect cloth- container nearby): the cap may be “scooped up”
ing from contamination. Barriers or PPE are used with the needle, using one hand, and then carried
in various combinations depending on the proce- to the sharps container. The cap is not, under any
dure or treatment being performed on patients. circumstances, pushed into place over the needle
As a medical assistant, you may be exposed to (Figure 10-15). The risk to a health care provider
infected blood and body fluids and must wear PPE of HIV infection caused by a needlestick is slight;
(Figure 10-13). however, the risk for HBV or HCV infection caused
by a needlestick can be significantly greater.
OSHA mandates that (1) employers select
Needlestick the safest needle device available, (2) employ-
One reason for exposure to blood is caused by acci- ers must involve employees in identifying these
dentally sticking oneself with a dirty (used) needle devices, and (3) employers maintain a log of inju-
after performing invasive procedures such as injec- ries caused by contaminated sharps ([66FR5325]
202 UNIT 4 Integrated Clinical Procedures

• The user can easily tell whether the safety feature

has been activated. Some safety features have a
sound, such as a click, indicating that the feature is
engaged.
• The safety feature cannot be deactivated and
remains protective through disposal.
• If the device uses needles, it performs reliably with
all needle sizes.
• The device is easy to use and practical.
• The device is safe and effective in patient care.

Additional information regarding specific

procedures to follow should an accidental needle-
stick occur, as well as other safety procedures
included in the OSHA and CLIA rules and regu-
lations, will be found later in this chapter and in
Chapter 26.

Disposal of Infectious Waste

Figure 10-14 Discard the entire disposable safety
syringe and needle into the biohazard puncture- Infectious waste (contaminated items) is any item
proof sharps container. that has come in contact with patient blood or
body fluids. These items must be handled with
gloves and disposed of by placing them in the
appropriate biohazard containers that are pro-
vided by an agency with which your employer
has contracted (Figure 10-17). Infectious waste
is either incinerated (burned) or subjected to
A sterilization by autoclave to render it harmless
B before it is disposed of in a sanitary landfill. For
C local rules and regulations of how to dispose of
Figure 10-15 (A) Scoop into cap using one hand. Do sharps and biohazard/infectious waste, contact
not touch the cap with the other hand. (B) Slide nee- your local Department of Health. Their staff
dle into cap resting on table. (C) Holding the barrel of can refer you to companies that specialize in the
the syringe in one hand, carry to the sharps container. proper disposal of infectious waste and sharps.
Do not push the cap onto the syringe. These companies follow strict state and federal
regulations and can provide your clinic with con-
tainers, labels, and instructions. They will often
work out a schedule for pickups, such as daily,
OSHA 1910.1030). This is known as the “Needle- weekly, monthly, or “on-call.” Charges will usually
stick Safety and Prevention Act.” The act was be based on the amount of infectious waste that
added to the original act regarding engineering requires disposal.
controls of the OSHA Bloodborne Pathogens
Standard (Figure 10-16). Federal Organizations
Desirable characteristics of safety devices
include:
and Infection Control
The CDC is responsible for studying pathogens
• The device is jet injection.
and diseases in an effort to prevent their spread.
• The safety feature is built into the device. A division of the U.S. Public Health Department,
• The device works passively (i.e., requires no activa- the CDC has issued a number of guidelines over
tion by the user). If user activation is necessary, the the last 25 years that have enabled health care
safety feature can be engaged with a single-handed professionals to practice responsible infection
technique, allowing the worker’s hands to remain control. As diseases evolve and as new diseases are
behind the exposed sharp. introduced into our society, the CDC revises and
 CHAPTER 10 Infection Control and Medical Asepsis 203

EXAMPLES OF SAFETY DEVICES

Type of
Device Safety Features
Syringes and Needleless or jet injection – the medication/immunization is injected under
Injection the skin without a needle, using the force of the liquid under pressure to
Equipment pierce the skin.

Retractable needle – the needle (usually fused to the syringe) is

spring-loaded and retracts into the barrel of the syringe when the plunger
is completely depressed after the injection is given.

Protective sheath – after giving an injection, the worker slides a plastic

barrel over the needle and locks it in place.

Hinged re-cap – after the injection, the worker, using the index finger, flips a
hinged protective cap over the needle, which locks into place. This safety feature
may be fused to the syringe or come separate and detachable from the syringe.

IV Access – Retractable – the spring-loaded needle retracts into the needle holder upon
Insertion pressing a button after use or the needle withdraws into the holder when
Equipment withdrawn from the patient’s arm.

Passive – a metal safety clip unfolds over the needle as it is withdrawn.

Shielded IV catheters (midline and peripheral) – a protective shield slides

over the exposed needle.

Hemodialysis safety fistula sets (butterfly) – a protective shield slides over the
needle as it is withdrawn.

Blood-Collection Retractable needle – the spring-loaded needle is pulled into the vacuum
and Phlebotomy tube holder after use.

Shielded butterfly needle – a protective shield slides over the needle after use.

Self-blunting needle – after use, the needle is blunted while still in the patient.

Plastic blood collection tubes – used to replace glass tubes.

Suture Needles Blunt suture needles – used for sewing internal fascia.

Lancets Retracting lancet – following skin puncture, the sharp automatically retracts back
into the device.

Surgical Retracting scalpel – after use, the blade is withdrawn back into the body of
Scalpels the scalpel.

Quick-release scalpel blade handles – a lever is activated that allows for a

“touchless” attachment of the blade to the handle and releases it after use.

Figure 10-16 Examples of Safety Devices published by the U.S. Department of Labor. This publication includes
information about various types of safety devises and their features. (Courtesy of the U.S. Department of Labor.)
204 UNIT 4 Integrated Clinical Procedures

To understand the intent of these various CDC

infection control guidelines, Standard Precautions
and Transmission-Based Precautions are examined
here in more detail.

OSHA REGULATIONS
OSHA regulations are intended to ensure
that employers have a safe and healthful
work environment for their employees. They
represent requirements that employers must fol-
low to ensure employee safety and health.
There are two standards that comprise the
regulations: The Occupational Exposure to Hazardous
Chemicals in the Laboratory, an amended version of
the original standard The Hazard Communication
Standard, and The Bloodborne Pathogen Standard.

The Bloodborne Pathogen

Figure 10-17 The medical assistant is placing a sturdy
disposable plastic bag marked with the biohazard waste
Standard
symbol into a durable cardboard box for collection of The Bloodborne Pathogen Standard became effective in
infectious waste material. When full, an authorized, March 1992. It came about principally in the hope
licensed waste hauler will dispose of the box (usually by of reducing occupational-related cases of HIV and
incineration) and provide documentation of its disposal. HBV infections among health care workers.
It covers all employees who can be “reason-
ably anticipated” to come into contact, as a result of
updates existing guidelines or issues new control performing their job duties, with blood and other
measures to contain the spread of infection. potentially infectious materials. The Bloodborne Patho-
In 1970, the CDC developed a system of seven gen Standard seeks to limit exposure to bloodborne
isolation categories for patients with known infec- pathogens. The law covers:
tious diseases. This category system included strict
isolation, respiratory isolation, protective isolation, • Exposure determination
enteric precautions, wound and skin precautions, • Methods of control of exposure, especially Stan-
discharge precautions, and blood precautions. dard Precautions
In 1985, the agency released a set of guide-
lines known as Universal Blood and Body Fluid Pre- • HBV vaccine
cautions, or simply Universal Precautions. These • Postexposure follow-up
infection control practices were written in response • Disposal of biohazardous waste
to the increase in AIDS and HBV, both bloodborne • Labeling
diseases, and other infectious diseases as well.
Beginning in 1991, the CDC infection control • Housekeeping and laundry functions
guidelines were reviewed and subsequently revised. • Training for employee safety and documentation
In 1996, a new set of guidelines was released. Stan-
dard Precautions reflect improved recommenda- See Figure 10-29 for an overview and sum-
tions intended to protect all health care providers, mary of the OSHA Bloodborne Pathogen Standard.
patients, and their visitors from a wide range of
communicable diseases. At the same time that Blood and Other Potentially Infectious Material.
the CDC issued the new Standard Precautions, Blood and other potentially infectious material are
they also released a second tier of precautions defined by the CDC and OSHA as the same human
called Transmission-Based Precautions. These are fluids listed previously as well as the following:
intended to be used in addition to Standard Pre-
cautions when caring for patients with known spe- • Unfixed human tissue (alive or dead); e.g., breast
cific infectious diseases. tissue from a frozen section biopsy
 CHAPTER 10 Infection Control and Medical Asepsis 205

• Any tissue culture, cells, or fluid known to be HIV-,

HBV-, or HCV-infected SAMPLE
Exposure Classification Record of Employee
When the origin of a specimen is unknown, it
must be handled as if it were infectious. The following employee was classified according to work task
exposure to certain body fluids as required by the
Bloodborne Pathogens. Disease-producing micro- current OSHA infection control standard on (Date)
organisms are called pathogens; bloodborne refers _____________ as follows:
to the manner in which the microorganisms can Employee Name: _______________ SS# ___________
be transmitted—via blood or other potentially
infectious material. Three pathogens of particular ____ Category 1.“All procedures or other job related tasks
importance to health care professionals are HBV, that involve an inherent potential for mucous membrane
or skin contact with blood, body fluids, or tissues, or a
HCV, and HIV.
potential for spill or splashes of (blood or body fluids).”
Exposure Determination. Exposure determina- ____ Category 2. Tasks in which “The normal work routine
tion requires an employer to list all the job classi- involves no exposure to blood, body fluids, or tissues,
fications and employees in those job classifications but exposure or potential exposure may be required as
who are exposed to blood and other potentially a condition of employment.” For example, receptionists,
infectious material in the course of performing accounting, or insurance staff or others who may, as a
their jobs. Existing job descriptions can be used by part of their duties, be asked to help in clean up, instru-
the employer to identify the job categories that are ment recirculation, laboratory, or other similar proce-
considered high risk for exposure to blood and/or dures where exposure may result.
other potentially infectious material (Figure 10-18). ____ Category 3. Tasks in which “The normal work routine
It is important to note that exposure determination involves no exposure to blood, body fluids, or tissues.
is made without regard to the use of PPE. Persons who perform these duties are not called upon
as part of their employment to perform or assist in
Plan to Control Exposure. Every employer who emergency medical care or first aid or to be potentially
has an employee(s) who is identified and deter- exposed in some other way.”
mined to be at risk for potential exposure must Employer Signature _____________________
have a written exposure control plan (Figures
Because of a change of job assignment, the above employee
10-19 through 10-21). The plan must consist of
was reclassified according to tasks exposure on (Date)
methods of compliance for prevention of expo-
_________ as follows:
sure, HBV vaccination and postexposure evalu-
ation, communication of hazards to employee(s), _______ Category 1
documentation of the bloodborne standard, and _______ Category 2
a procedure for the determination of the events _______ Category 3
surrounding an exposure occurrence. The written
plan must be employee accessible, updated regu- Employer’s Signature _________________________
larly (at least annually), and modified when neces- Because of a change of assignment, the above employee was
sary and appropriate, especially to reflect changes reclassified according to task exposure on (Date) _______
in employee positions. ____ as follows:
_______ Category 1
Methods of Compliance to Prevent Exposure.
_______ Category 2
There are seven major strategies mandated by
_______ Category 3
Employer’s Signature __________________________
NOTE: This record should be retained for length of employment
Critical Thinking plus thirty years.

Give eight examples of body fluids consid-

ered to be biohazardous substances. Explain Figure 10-18 Sample Exposure Classification Record
under what circumstances medical assistants of employee shows exposure categories into which
could become exposed to blood and body employee’s tasks fall. This record is kept for 30 years.
fluids. (Courtesy of POL Consultants, 2 Russ Farm Way,
Delanco, NJ 08075, 856-824-0800)
206 UNIT 4 Integrated Clinical Procedures

OFFICE WORK PRACTICE SAMPLE

EXPOSURE CONTROL PLAN Office Procedures Safety Form

Effective Date: _____________ PROCEDURE: _____________________________________________

Office of ___________________________________
Type of hazard: ___________________________________________
As of the above date the office will follow the rules below to
reduce exposure and contamination: Person performing procedure: _____________________________

Observe Standard Precautions. Person assisting procedure: _______________________________

Wear gloves when drawing blood and performing Personal protective equipment used: _______________________
procedures/tests.
__________________________________________________________
Wash hands after removing gloves.
Change gloves frequently during the day and between Proper techniques for safety:
patients. __________________________________________________________

Do not answer phone, handle papers, or word process __________________________________________________________

while wearing gloves.
__________________________________________________________
Do not cap or break needles.
Dispose of all needles in sharps containers. What is done with used materials and soiled instruments?

Do not allow sharps containers to fill beyond 2⁄3 full. __________________________________________________________

Wear lab coats when performing tests. __________________________________________________________
Leave lab coats in laboratory/work area.
__________________________________________________________
Dispose of all contaminated material in infectious waste
(Biohazard) container. What chemical products are involved?

Disinfect the laboratory work surfaces frequently. __________________________________________________________

Disinfect the examining room surfaces, daily and as
__________________________________________________________
needed.
Sterilize nondisposable examination and testing __________________________________________________________
equipment.
What are the specific risks of procedure?
Monitor sterilization procedure.
__________________________________________________________
Do not eat or drink in work area.
Place gauze over tops of blood tubes when removing caps __________________________________________________________
or use safety caps. __________________________________________________________
Clean up all specimen and chemical spills properly and
immediately. Additional comments:

Label all chemicals according to OSHA regulations. __________________________________________________________

Label refrigerator that blood is stored in. __________________________________________________________
Centrifuges will have lids or specimens will be capped
__________________________________________________________
when spun.
Centrifuges will be disinfected regularly. __________________________________________________________

Hepatitis B vaccines will be offered to all employees. Prepared By: _______________________ Date: _______________
Employees will take a safety training program.
Figure 10-20 Sample Office Procedures Safety Form
Figure 10-19 Office Work Practice Exposure Control lists procedures, type of hazard, employee perform-
Plan indicates a sample list of precautions to take to ing procedure, employee assisting with procedure,
minimize employee risk exposure. (Courtesy of POL and personal protective equipment. (Courtesy of POL
Consultants, 2 Russ Farm Way, Delanco, NJ 08075, 856- Consultants, 2 Russ Farm Way, Delanco, NJ 08075, 856-
824-0800) 824-0800)
 CHAPTER 10 Infection Control and Medical Asepsis 207

SAMPLE
Safety/Work Practice Controls for Office Procedures

Each office has special safety procedures that are unique

to that particular practice. These are also known as work
practice controls. The fundamental work practice control is
using Standard Precautions. Work practice controls reduce
the likelihood of exposure to hazards. Many times the risks
can be eliminated by changing the way a procedure is per-
formed. Make copies of the PROCEDURES SAFETY FORM. Fill
in the information for any procedure that involves exposure
to potentially infectious body fluids. File these procedures
in the office operation section of your manual. Do not limit
this section to only body fluid exposures. General safety for Figure 10-22 Various sizes of puncture-proof sharps
other hazards such as chemicals and X-ray should be listed containers. These and other biohazard waste contain-
as well. Common examples are listed below. Check the ones
ers are autoclaved when full and sent out to a biohaz-
you do and add to this list.
ard agency for safe disposal.
____ Patient exams ____ Arthroscopies
____ Aspirations ____ Vaginal exams and eye wash stations (Figure 10-23). If and when
____ Inoculations ____ PAP smears/IUDs occupational exposure continues after the engi-
____ Taking blood ____ OB care
neering controls are in place, PPE must be used.
samples ____ Implanon
____ Lab testing ____ Vasectomies
Hand washing facilities or appropriate antiseptic
____ Lesion excisions ____ Biopsies hand cleanser (when hand washing facilities are
____ Wound care ____ Sigmoidoscopies unavailable) must be readily available.
____ Dressing changes ____ ______________ 3. Personal Protective Equipment (PPE). The employer
____ Colposcopies ____ ______________ must be certain that PPE is available and acces-
____ Surgical procedures ____ ______________ sible and provide an alternative type of glove if an
____ X-rays employee is allergic to those originally provided
(see Latex Sensitivity box earlier in chapter.) Clean-
Figure 10-21 Sample Safety/Work Practice Controls ing and laundering and disposal of PPE is the
for Office Procedures lists procedures that involve responsibility of the employer, and the employee
exposure to blood, body fluids, and other potentially does not incur any expense for them.
infectious material. (Courtesy of POL Consultants,
All PPE must be removed before the employee
2 Russ Farm Way, Delanco, NJ 08075, 865-824-0800)
leaves the work site and placed in an appropriate

OSHA for the prevention of exposure to blood-

borne pathogens and other potentially infectious
material.
1. Standard Precautions. Adherence to the CDC’s
Standard Precautions is required. Hand washing
is stressed and employers must provide hand wash-
ing facilities and must ascertain that employees use
them frequently and especially following exposure
to blood or other potentially infectious material.
2. Engineering Controls and Work Practice Controls. Engi-
neering controls and work practice controls con-
sist of the physical equipment and mechanical
devices an employer provides in an attempt to safe-
guard and minimize employee exposure. A com-
mon example of an engineering control is sharps Figure 10-23 Emergency eyewash station: two streams
disposal containers (Figure 10-22). Others are of water or saline wash both eyes simultaneously and
mechanical pipettes, fume hoods, splash guards, continuously.
208 UNIT 4 Integrated Clinical Procedures

Nonabsorbent
Combination mask gown
and eye shield

Face shield

Goggles

Plastic
gown
Latex gloves

Mask

Mask

Figure 10-24 Personal protective equipment.

container that is supplied by the employer. Figure laundered at home. All other Standard Precau-
10-24 shows PPE. tions must be adhered to.
4. Cleanliness of Work Areas. The employer must main- 5. Hepatitis B Vaccine. HBV vaccine must be made avail-
tain a work site that is clean and sanitary and have able free of charge to every employee, full-time,
a written schedule for cleaning and decontami- part-time, or temporary, within 10 days of work
nating the work area after contact with blood and assignment (Figure 10-26). This refers to employ-
other potentially infectious material. Spill kits must ees who have the potential for occupational expo-
be readily accessible (Figure 10-25). sure, and who can “reasonably” be expected to have
Broken glass is placed in a sharps container skin, eye, mucous membrane, or parenteral contact
after using cardboard or a dust pan and brush to with blood or other potentially infectious material.
remove it. The vaccine is given in three doses over a six-month
Laundry that is contaminated is handled period and is used to protect the employee from
with gloves and placed in a labeled container. infection with HBV. It is an intramuscular injection
If the laundry is damp or wet, gloves and other with an approximate 96% rate of effectiveness.
appropriate PPE must be worn, and the damp/ An employee has the right to decline taking the
wet laundry must be placed in a plastic bag(s) vaccine but must sign a declination form. There is
to prevent blood or other potentially infectious the option to reconsider receiving the vaccine at a
material from leaking through it. PPE cannot be later time.
 CHAPTER 10 Infection Control and Medical Asepsis 209

A B C

Figure 10-25 (A) Sprinkle coagulating powder over spill wearing protective clothing and gloves. (B) Scoop up
spill with scoop from kit. (C) The spill area is then cleaned with a 10 percent bleach solution.

6. Follow-Up After Exposure. An accidental expo- the employee shall know the results (unless pro-
sure is broadly defined as one in which blood, tected by the law).
blood-contaminated body fluids, or body fluids
or tissues to which Standard Precautions apply • The employee is offered prophylaxis, gamma
are introduced into a mucous surface, into globulin, or HB vaccine after the exposure to
nonintact skin, or into the conjunctiva via a HBV or HIV according to the current recom-
needlestick, skin cut, or direct splash. If an inci- mendation of the U.S. Public Health Service.
dent exposes an employee to any of these, the • The employee is counseled regarding precau-
employer must make available a confidential tions to take to avoid possible transmission
medical evaluation in which is documented: and is provided information on potential ill-
nesses for which to be alert.
• The circumstances surrounding the event
• An OSHA 301 form must be filed.
• The route or routes of exposure
• The identification of the person who was the 7. Medical Records. Medical records of an employee
source of the exposure who has suffered an occupational exposure must
be kept for the length of employment plus 30 years,
The following procedure describes the steps to
and confidentiality must be guaranteed.
take following an exposure incident:
The following information is to be included in
• Immediately wash exposed area with soap and
the employee’s record: name and Social Security
warm water.
number, HB vaccination status with dates, results
• If mouth area is exposed, rinse with water or of any examinations or tests, a copy of the health
mouthwash. care provider’s written opinion, and a copy of the
• If eyes are exposed, flush with large amounts of information that was provided to the health care
warm water. provider.
• Report incident to a supervisor immediately for The records must be available to the employee,
documentation (Figure 10-27). to OSHA, and anyone with the written consent of
the employee, but not the employer.
In addition, OSHA requires the following
information:
Hazard Communication for Blood. The em-
• The exposed employee must be tested for ployer is required to label containers of regulated
HBV, HCV, and HIV only if consent is given. An waste, refrigerators, freezers, and other contain-
employee may refuse or may have blood drawn ers that are used to keep or transport blood or
and stored for 90 days at which time the choice other potentially infectious material with warning
can be made whether to have the blood tested. labels that are orange or orange-red and have the
• The source individual’s blood, if permission is biohazard symbol affixed to them. Red bags can
granted, is tested for HBV, HCV, and HIV and be used in place of labels. The labeling serves to
210 UNIT 4 Integrated Clinical Procedures

SAMPLE SAMPLE
Hepatitis B Employee Vaccination Form Post-Exposure Management Record
MEMO: To all employees with occupational exposure to blood The following employee was the subject of an infectious
or other infectious materials on an average of one or more exposure incident on (date) _______ and was examined and
times per month. treated as follows:
OSHA and the CDC have identified the potential exposure of
Employee Name: ______________ SS# ____________________
health care workers to hepatitis B virus (HBV) in the course of
performing their duties in this office. For the protection of our Type of Incident (describe) ________________________________
employees, we are offering prescreening testing and the HBV __________________________________________________________
vaccination with follow-up evaluation to all employees who Route of Exposure: ________________________________________
are exposed to blood or other potentially infectious materials
Source Patient Information:
on an average of one or more times per month. In accordance
with recommended OSHA guidelines, this vaccine and testing ____ Source patient could not be identified.
will be offered at no cost to the employee. You have the ability ____ Source patient was identified but refused to contribute
to decide whether or not you want the testing and/or vaccine. blood.
At the bottom of this memo, you may indicate your choice. ____ Source patient was identified and blood was secured
Please return this memo with your signature and date to your from such patient. Results of blood testing of source
immediate supervisor. patient’s blood are attached to this form.

[] I want to receive the prescreening (optional) Employee hereby grants permission for tests for antibodies of
[] I want to receive the vaccine and follow-up evaluation human immunodeficiency virus (HIV-1) and/or hepatitis B virus
testing and acknowledges that the employee has been counseled
[] I do not want the vaccine and testing and have read the concerning such tests.
following statement:
Employee Signature _______________ Date ____________
I understand that due to my occupational exposure to blood
or other potentially infectious materials I may be at risk of The following test(s) were administered under supervision of a
acquiring hepatitis B virus (HBV) infection. I have been given qualified provider:
the opportunity to be vaccinated with hepatitis B vaccine at no ____ Human Immunodeficiency Virus (HIV-1) Antibodies
charge to myself. However, I decline hepatitis B vaccination at ____ Hepatitis B Virus Antibodies
this time. I understand that by declining this vaccine I continue
Date(s) of Tests(s): ______________ Results of Test(s)—
to be at risk of acquiring hepatitis B, a serious disease. If in
See attached Provider’s or Laboratory statement/report.
the future I continue to have occupational exposure to blood
or other potentially infectious materials and I want to be vac- Employee hereby acknowledges that the employee was coun-
cinated with hepatitis B vaccine, I can receive the vaccination seled and a written copy(ies) of the results of the
series at no charge to me. above test(s) were furnished to such employee on (date):
_____________________________ _________________________ _________
NAME DATE
Employee Signature _______________ Date ____________
_____________________________ _________________________
____ Additional follow-up was performed as indicated by
SIGNATURE SS# attached reports.
PRESCREENING DATE _________ RESULTS ______________ NOTE: This record should be retained for length of employment
DATE OF VACCINATIONS ___________________________________ PLUS thirty years.
DATE OF FOLLOW-UP EVALUATION _________________________
RESULTS _________________________________________________ Figure 10-27 Sample Post-Exposure Management
NOTES: Record can be used to document employee exposure to
blood, body fluids, or other potentially infectious mate-
rial; tests performed on the employee by a qualified pro-
Figure 10-26 Sample Hepatitis B Employee Vacci- vider; and test results. (Courtesy of POL Consultants,
nation Form provides employee information regard- 2 Russ Farm Way, Delanco, NJ 08075, 856-824-0800)
ing hepatitis B vaccine and space to sign indicating
whether employee declines vaccine. (Courtesy of POL
Consultants, 2 Russ Farm Way, Delanco, NJ 08075,
856-824-0800)
 CHAPTER 10 Infection Control and Medical Asepsis 211

warn employees of the hazard possibility of con- They should, however, take precautions to avoid
tainer contents (Figure 10-28). contact with potentially infectious materials and
toxic chemicals wherever learning is taking place
Information and Training for Employees. Em- (Figure 10-30).
ployers must ascertain that employees take part
in training sessions during working hours at no Avoiding Exposure to Bloodborne
cost to employees. The initial session must be
provided when occupational exposure may occur
Pathogens
and annually thereafter. If employee tasks and Students can come into contact with blood and
job description change, training must take place other potentially infectious material during labo-
at that time. ratory practices and externships. The potential for
Training components are listed in Figure 10-29. exposure and contact increases whenever invasive
Documentation of training sessions must be avail- procedures are being performed. Some examples
able and kept for 3 years. of invasive procedures are:
• Phlebotomy, the process of withdrawing blood
OSHA REGULATIONS • Administering an injection
AND STUDENTS • Performing or assisting with medical/surgical pro-
cedures such as suturing of wounds or removal of
With the passage of the OSHA law, all students sutures; assisting with certain procedures such as
with potential exposure to chemicals and blood- Pap smears, arthroscopies, amniocentesis, thoracen-
borne pathogens should follow all safety proce- tesis, or lumbar puncture; dressing changes, colpos-
dures as outlined by OSHA. Because students are copies, vaginal exams, obstetrical care, vasectomies,
not considered employees of a health care facil- biopsies, sigmoidoscopies, and colonoscopies are
ity and are attending an educational institution, other examples in which students can contact blood
they do not fall under the OSHA guidelines. and other potentially infectious material.

Students must be aware of and think about the

procedures they are involved in and be certain that
BIOHAZARD LABELS they use essential safety equipment (PPE) and pro-
cedures when necessary. Students should adhere to
Containers that hold biohazardous materials the same responsibilities that employees do.
BIOHAZARD
must be properly labeled. Biohazardous PPE should be available in the student labo-
materials include blood and body fluids as
ratory and used as necessary. Standard precautions
well as garments, gloves, masks, needles,
gauze, wipes, aprons, and so on that may be INFECTIOUS WASTE
must be strictly adhered to.
contaminated with blood or other potentially Students should always be on guard and make
contaminated body fluids. Labels shall be used to identify the safety a priority by taking all precautions to avoid
presence of an actual or potential biological hazard. injuries. Some of the precautions are:

CONSIDERATIONS: • Needles and other sharps (such as microscope

slides and coverslips, sharp surgical instruments,
• Labels shall be fluorescent orange or orange-red, with let-
and glass containers) should be handled with the
tering or symbols in a contrasting color.
same strict guidelines as outlined in the OSHA
• Labels should be affixed onto or as close as feasible to the Bloodborne Pathogen Standards and the CDC’s Stan-
container by adhesive, string, wire, or other method. dard Precautions.
• Red bags or red containers may be substituted for labels. • Obey all safety rules and know where the spill kits
• If blood or control serum is stored in a refrigerator, the are located and how to clean up biohazard spills
refrigerator shall be marked with a biohazard label. (see Figure 10-25).
• If blood is stored in a refrigerator for transport or same-day • Know where the eyewash stations are and know
shipment, it does not need to be labeled but should be put how to operate them.
in containment bags.
Be familiar with all the information about
Figure 10-28 Biohazard labels alert employees to solutions and chemicals used in the laboratory as
biohazardous materials, such as blood, body fluids, and outlined in the Material Safety Data Sheet (MSDS)
other potentially infectious material. (see Chapter 26).
212 UNIT 4 Integrated Clinical Procedures

TRAINING COMPONENETS OF THE BLOODBORNE PATHOGEN STANDARD

Scope and Application Personal Protective Equipment (PPE)
• The Standard applies to all occupational exposure to blood and • Includes eye protection, gloves, protective clothing, resuscita-
other potentially infectious materials (OPIM), and includes part- tion equipment.
time employees, designated first aiders, and mental health work- • Must be readily accessible and employers must require their use.
ers as well as exposed medical personnel. • Must be stored at work site.
• OPIM includes saliva in dental procedures, cerebrospinal fluid,
unfixed tissue, semen, vaginal secretions, and body fluids vis- Eye Protection
ibly contaminated with blood.
• Is required whenever there is potential for splashing, spraying,
or splattering to the eyes or mucous membranes.
Methods of Compliance • If necessary, use eye protection in conjunction with a mask or
• General—standard precautions. use a chin-length face shield.
• Engineering and work practice controls. • Prescription glasses may be fitted with solid sideshields.
• Personal protective equipment. • Decontamination procedures must be developed.
• Housekeeping.
Gloves
Standard Precautions • Must be worn whenever hand contact with blood, OPIM, mucous
• All human blood and OPIM are considered to be infectious. membranes, nonintact skin, contaminated surfaces/items, or
• The same precautions must be taken with all blood and OPIM. when performing vascular access procedures (phlebotomy).
• Type required —Vinyl or latex for general use.
Engineering Controls —Alternatives must be available if employee has
allergic reactions (i.e., powderless).
• Whenever feasible, engineering controls (devices that isolate or —Utility gloves for surface disinfection.
remove health hazards from the workplace) must be the primary —Puncture-resistant when handling sharps
method used to control exposure. (i.e., Central Supply).
• Examples include needleless IVs, self-sheathing needles,
sharps disposal containers, covered centrifuge buckets, Protective Clothing
aerosol-free tubes, and leak-proof containers.
• Engineering controls must be evaluated and documented on • Must be worn whenever splashing or splattering to skin or
a regular basis. clothing may occur.
• Type required depends on exposure. Prevention of contamina-
Sharps Containers tion of skin and clothes is the key.
• Examples —Low-level exposure lab coats.
• Readily accessible and as close as practical to work area. —Moderate-level exposure fluid-resistant gown.
• Puncture-resistant. —High-level exposure fluid-proof apron, head and
• Labeled or color-coded. foot covering.
• Leak-proof. • Note: If PPE is considered protective clothing, then the
• Closeable. employer must launder it.
• Routinely replaced so there is no overflow.
Housekeeping
Work Practice Controls • There must be a written schedule for cleaning and disinfection.
• Hand washing following glove removal. • Contaminated equipment and surfaces must be cleaned as
• No recapping, breaking, or bending of needles. soon as feasible for obvious contamination or at end of work
• No eating, drinking, smoking, and so on in work area. shift if no contamination has occurred.
• No storage of food or drink where blood or OPIM are stored. • Protective coverings may be used over equipment.
• Minimize splashing, splattering of blood, and OPIM.
• No mouth pipetting. Regulated Waste Containers (non-sharp)
• Specimens must be transported in leak-proof, labeled contain- • Closeable.
ers. They must be placed in a secondary container if outside • Leak-proof.
contamination of primary container occurs. • Labeled or color-coded.
• Equipment must be decontaminated prior to servicing or ship- • Placed in secondary container if outside of container is
ping. Areas that cannot be decontaminated must be labeled. contaminated.

Figure 10-29 Overview of The Bloodborne Pathogen Standard. (Courtesy of the Occupational Safety and Health
Administration, U.S. Department of Labor.)
 CHAPTER 10 Infection Control and Medical Asepsis 213

TRAINING COMPONENETS OF THE BLOODBORNE PATHOGEN STANDARD

Laundry • Training material must be appropriate for literacy and educa-
tion level of employee.
• Handled as little as possible.
• Training must be interactive and allow for questions and
• Bagged at location of use.
answers.
• Labeled or color-coded.
• Transported in bags that prevent soak-through or leakage.
Training Components
Laundry Facility • Explanation of bloodborne standard.
• Epidemiology and symptoms of bloodborne disease.
• Two options:
• Modes of HIV/HBV transmission.
1. Standard precautions for all laundry (alternative color cod-
• Explanation of exposure control plan.
ing allowed if recognized).
• Explanation of engineering, work practice controls.
2. Precautions only for contaminated laundry (must be red
• How to select the proper PPE.
bags or biohazard labels).
• How to decontaminate equipment, surfaces, and so on.
• Laundry personnel must use PPE and have a sharps container
• Information about hepatitis B vaccine.
accessible.
• Post-exposure follow-up procedures.
• Label/color code system.
Hepatitis B Vaccination
• Made available within ten days to all employees with occupa- Medical Records
tional exposure.
• At no cost to employees. Records must be kept for each employee with occupational expo-
• May be required for student to be admitted to college health sure and include:
program as well as for externship. • A copy of employee’s vaccination status and date.
• Given in accordance with United States Public Health Service • A copy of post-exposure follow-up evaluation procedures.
guidelines. • Health care professional’s written opinions.
• Employee must first be evaluated by health care professional. • Confidentiality must be maintained.
• Health care professional gives a written opinion. • Records must be maintained for thirty years plus the duration
• If the vaccine is refused, the employee signs a declination of employment.
form.
• Vaccine must be available at a future date if initially refused. Training Records
Post-Exposure Follow-Up Records are kept for three years from date of training and include:

• Document exposure incident. • Date of training.

• Identify source individual (if possible). • Summary of contents of training program.
• Attempt to test source if consent obtained. • Name and qualifications of trainer.
• Provide results to exposed employee. • Name and job title of all persons attending.

Labels Exposure Control Plan Components

• A written plan for each workplace with occupational exposure.
• Biohazard symbol and word Biohazard must be visible.
• Written policies/procedures for complying with the standard.
• Fluorescent orange/orange-red with contrasting letters may
• A cohesive document or a guiding document referencing exist-
also be used.
ing policies/procedures.
• Red bags/containers may be substituted for labels.
• Labels required on —Regulated waste.
—Refrigerators/freezers with blood of Exposure Control Plan
OPIM.
• A list of job classifications where occupational exposure con-
—Transport/storage containers.
trol occurs (e.g., medical assistant, clinical laboratory scientist,
—Contaminated equipment.
dental hygienist).
• A list of tasks where exposure occurs (e.g., medical assistant
Information and Training who performs venipuncture).
• Required for all employees with occupational exposure. • Methods/policies/procedures for compliance.
• Training required initially, annually, and if there are new • Procedures for sharps disposal.
procedures. • Disinfection policies/procedures.

Figure 10-29 (continued) (continues )

214 UNIT 4 Integrated Clinical Procedures

TRAINING COMPONENETS OF THE BLOODBORNE PATHOGEN STANDARD

• Procedures for selection of PPE. • Use safe work practices.
• Regulated waste disposal procedures. • Use engineering controls.
• Laundry procedures. • Report unsafe work conditions to employer.
• Hepatitis B vaccination procedures. • Maintain clean work areas.
• Post-exposure follow-up procedures.
Cooperation between employer and employees regarding The
• Training procedures.
Bloodborne Pathogen Standard will facilitate understanding of
• Plan must be accessible to employees and be updated
the law, thereby benefiting all persons who are exposed to HIV,
annually.
HBV, HCV, and OPIM by minimizing the risk of exposure to the
pathogens.
Employee Responsibilities Meeting the OSHA standard is not optional and failure to com-
• Go through training and cooperate. ply can result in a fine that may total $10,000 for each employee.
• Obey policies. To obtain copies of The Bloodborne Pathogen Standard, con-
• Use universal precaution techniques. tact OSHA at 800-321-6742 or www.osha.gov.
• Use PPE.

Figure 10-29 (continued)

Colleges require students studying the health

Student Safety Precautions professions to obtain the hepatitis B vaccine because
it is approximately 96% effective against HBV.
Gloves must be worn:
Because the vaccine is given in three doses over a
• During phlebotomy
• When giving injections
period of 6 months, students should plan to have the
• When performing or assisting with invasive pro- injections in a timely fashion to be prepared for col-
cedures lege laboratory courses and the externship period.
• When processing blood specimens

Eye protection with side projections must be worn: PRINCIPLES OF INFECTION

• Whenever there is the potential for chemical CONTROL
exposure or the possibility of spray, splash, or
splatter from blood or body fluids By understanding the dependent nature of the chain
Face shields or masks must be worn:
of infection which holds that each link in the process
• When there is a chance of spray, splash, or splat- must occur for infectious disease to occur, medical
ter from blood or body fluids assistants can apply principles of infection control to
eliminate or reduce the transmission of infectious
Gowns or aprons must be worn: microorganisms in the health care setting. Con-
• Where there exists any potential for exposure to scious and continual reliance on infection control
contaminated materials is a professional standard and protects employees,
patients, families, and the public from contracting
Lab coats must be worn and buttoned:
infectious diseases. There are two general types of
• When performing laboratory procedures
infection control: medical asepsis and surgical asep-
sis. Each is indicated in specific circumstances and
Figure 10-30 Student safety precautions. each is achieved by the various techniques that are
described in this chapter and in Chapter 19.
An exposure to blood or other potentially
infectious material experienced by a student must
be immediately reported to the instructor if the MEDICAL ASEPSIS
accident occurs at the college or to the supervisor
of the clinical agency and the externship coordi- Medical asepsis is the use of practices such
nator if the student is exposed during externship. as hand washing, general cleaning and
OSHA procedures as outlined earlier in this chap- disinfecting of contaminated surfaces, and
ter should be followed with the exception of the adherence to Standard and Transmission-Based Pre-
filing of the OSHA 200 form. cautions. These measures are aimed at destroying
 CHAPTER 10 Infection Control and Medical Asepsis 215

pathologic organisms. These techniques are used • Keep contaminated equipment and supplies away
to decrease the risk for transmission to others. from clothing to prevent transmission of patho-
Objects should be medically aseptic if they are to be gens to self and others.
used in procedures that are on the external body or • Place dressing materials, gauze, cotton balls, and
if they will enter a usually contaminated body part, any other damp or wet contaminated absorbable
such as the mouth. Many things, such as our hands, material in a waterproof bag before disposal in the
cannot be sterilized or even disinfected, but they can biohazard waste container.
be rendered clean of gross contamination and most • Any break in the medical assistant’s skin should be
pathogens by simple hand washing. Many items, covered with a sterile dressing.
such as stethoscopes or telephones, do not need to
be sterile to be used on a variety of patients. These • Items that fall to the floor are contaminated. Either
items do not enter into the body or into sterile discard or sanitize then disinfect them before
areas of the body. These items should, however, be using.
either cleaned or disinfected routinely. Sphygmoma- • If uncertain whether equipment or supplies are
nometers and stethoscopes are used continuously clean or sterile consider them contaminated. Clean
throughout the day on different patients. Patients or sterilize them before use.
with hypertension, postsurgery patients, and patients
having physical examinations routinely have blood Hand Washing
pressure monitored. Both pieces of equipment
contact patient’s skin, clothing, or both, making Hand washing is the most important aspect of all
the blood pressure equipment an indirect source of the infectious control procedures. Proper hand
of pathogens. Alcohol-based wipes or a simplified washing removes gross contamination and reduces
method of detergent cleaning should be used regu- pathogens that could be transmitted by direct or
larly to decontaminate blood pressure equipment. indirect contact to others. Because hand washing
Medical asepsis also involves environmental hygiene is frequently required, the use of a good lotion
measures such as equipment cleaning and disin- is advised to reduce the possibility of skin breaks
fection procedures. Careful attention to methods caused by dryness. Infectious diseases continue
of medical asepsis greatly reduces the presence of to present serious challenges. One of the biggest
pathogens that could cause disease in others. Spe- concerns is the spread of HIV, HBV, and HCV.
cific procedures to achieve medical asepsis include In May 2007, the WHO issued nine patient safety
adherence to Standard and Transmission-Based Pre- solution recommendations. The Joint Commission
cautions. Standard Precautions and Transmission- has adopted the nine recommendations. Patient
Based Precautions are considered methods of Safety Solutions No. 9 is entitled “Improved Hand
medical asepsis. These precautions should be fol- Hygiene to Prevent Healthcare Associated Infec-
lowed stringently to provide barriers between poten- tion (HAI).” It can be applied to this chapter and
tially infectious blood and body fluids and those to others because, according to the WHO, millions
people who may come into contact with the flu- of people worldwide are suffering from hospital-
ids. Use of PPE, disinfection, and waste control are acquired infections. “Effective hand hygiene is the
crucial steps in practicing these precautions. Hand primary measure for avoiding this problem,” say
washing, sanitization, and disinfection of instru- the WHO and the Joint Commission.
ments or equipment are also essential. Hand washing is the single, most effective
Some specific examples of appropriate use of way to lower the incidence of infectious disease
medical asepsis include: transmission.
The CDC recommends that, as part of hand
• Wash hands before and after handling equipment hygiene, when hands are visibly soiled with blood
and supplies, on arrival and before leaving, and or other body fluids, they should be washed with
before and after working with each patient even either a nonantimicrobial soap or an antimicrobial
when gloves are worn. soap and water. Procedure 10-1 describes medical
• Handle all specimens as if they were contaminated. asepsis hand wash. If hands are not visibly soiled,
an alcohol-based hand rub or gel can be used rou-
• Use disposable equipment whenever possible and tinely for decontaminating hands. When decon-
dispose of it properly in a biohazard waste container. taminating hands with an alcohol-based hand rub,
All equipment is contaminated after patient use. apply to palms of one hand and rub hands together
• Use PPE as outlined in Standard Precautions and covering all surfaces of hands and fingers, palms,
wash hands after removal of any PPE, including back of hands, fingertips, and between fingers,
gloves. wrists, and thumbs until hands are dry.
216 UNIT 4 Integrated Clinical Procedures

The CDC further recommends that hands be

decontaminated in the following situations:
• Before and after patient contact
• After contact with blood or body fluids
• When caring for the patient if moving from a con-
taminated body site (mouth, rectum) to a clean
body site (surgical wound, urinary meatus)
• After contact with inanimate objects such as medi-
cal equipment in close proximity to the patient
• Before inserting a urinary catheter
• After removing gloves and before donning gloves
• Before eating and after using restroom

Antimicrobial wipes cannot be used as a substi-

tute for an alcohol-based hand rub. Wearing gloves
is not a substitute for hand decontamination. Arti-
ficial fingernails or nail extenders cannot be worn
when in direct contact with patients at high risk. Figure 10-31 Medical assistant sanitizing an
Natural nails should be kept less than ¼ inch long. instrument.

Sanitization
Sanitization (washing) of instruments and equip- Larger items such as instrument trays or
ment rids them of gross contamination and blood, Mayo stands, stools, chairs, examination tables,
body fluids, tissue, and other contaminated debris. and lamps should also have a decontaminating
Enzymatic detergent especially designed for medi- sanitization process with thorough washing, rins-
cal instruments and a soft scrub brush are used to ing, and drying.
remove all contaminates from surfaces, crevices, See Procedure 10-4 for instrument sanitiza-
hinges, and serrations. Use of enzymatic detergents tion. Gloves contaminated with blood and body
will help break down the proteins found in body flu-
ids and tissues. Water temperature should be warm
but not hot. Heat coagulates protein, making it more
difficult to remove. A critical component to promot-
ing effective sanitization is to complete the proce-
dure as soon as possible after contamination so that
tissue or body fluids do not have the opportunity to
dry on the instruments. Dried debris is more diffi-
cult to remove and may require much scrubbing.
Instruments may be left to soak in disinfectant solu-
tion or water with a solvent if sanitization cannot be
performed immediately after use (Figure 10-31).
To avoid the risk for punctures or cuts from
sharp instruments during sanitization, heavy-duty
gloves should be worn. Some facilities use an ultra-
sonic cleaner (Figure 10-32). It uses high-frequency
sound waves and agitates the instruments (sanitizes
them) before sterilizing them. Goggles are worn to
protect eyes from splashing of contaminated debris
during the scrubbing procedure. A plastic apron
provides protection from splashing of clothing (see
Chapter 19). Hot water may be used for rinsing to
remove all residue and aid in the drying process.
Check instruments for working condition. Drying
thoroughly will prevent damage from rust or water Figure 10-32 The Branson Ultrasonic Cleaner, model
spots. 1510. (Courtesy of Branson Ultrasonics Corp.)
 CHAPTER 10 Infection Control and Medical Asepsis 217

fluids should be removed carefully to contain the steel gynecologic and proctologic examination
contamination. Procedure 10-2 describes how to instruments. These instruments are not sanitized
remove contaminated gloves, thereby preventing with other instruments because of the risk for trans-
further exposure to biohazard substances. mission of sexually transmitted diseases (STDs).
They are sterilized in the autoclave after sanitiza-
tion to eliminate transmission of microorganisms.
Disinfection Chemical disinfectant solutions must be care-
Disinfection, a third procedure used in medical fully prepared and used according to the manufac-
asepsis practices, consists of various chemicals that turer’s instructions to ensure effective disinfectant
can be used to destroy many pathogenic micro- properties. Medical offices should use the disinfec-
organisms but not necessarily their spores. Disin- tant solution that best meets the needs of the ambu-
fection chemicals are used on inanimate objects. latory care setting as to the quantity of instruments
Because of their caustic nature, these chemicals can to be disinfected, cost, preparation requirements,
irritate the skin and mucous membranes. Chemi- storage needs, and handling procedures. When
cals are used to disinfect items or equipment made choosing a chemical disinfectant solution, pay close
from materials that could be damaged by heat or attention to the manufacturer’s report of the chem-
that are too large to fit into an autoclave such as ical disinfectant properties of the product. Some
stethoscopes, percussion hammers, examination solutions are effective against a wide spectrum of
tables, and Mayo trays and stands. These and other microorganisms, whereas other solutions may be
items that are chemically disinfected are used dur- selective for certain common microorganisms.
ing external physical examination or procedures. When chemically disinfecting, items must be thor-
Boiling water (temperature 212°F) is consid- oughly sanitized and dried. Any debris or water left
ered a form of disinfection because it will kill some on the item being chemically treated will affect the
forms of microorganisms. It is important to note that chemical solution, thereby decreasing its effective-
this method cannot be considered a sterilization tech- ness and compromising the disinfecting process.
nique because the temperature is not high enough For surfaces such as countertops, the least
to kill the hepatitis virus, tuberculosis bacteria, or expensive and most readily available chemical is a
microbial spores. Articles such as nasal and ear spec- 1:10 solution of ordinary household bleach (sodium
ula can be sanitized and disinfected by vigorous boil- hypochlorite). However, besides the obvious disad-
ing for at least 15 minutes, or soaked in a disinfectant vantage of bleaching clothing, bleach is not eas-
according to manufacturer’s instructions. The only ily rinsed, and it is only effective if the solution is
reasonable use for boiling as a means of disinfection mixed fresh daily. Nevertheless, its effectiveness is
in today’s medical setting is for items that: so highly respected that many medical laboratories
depend almost entirely on bleach to chemically kill
1. Will not be used in invasive procedures pathogens on countertops.
2. Will not be inserted into body orifices nor be used In summary, medical asepsis includes pro-
in a sterile procedure cedures for which all medical assistants must be
responsible and qualified to incorporate into daily
Before either chemical disinfection or disin- work practices. The responsibility for maintaining
fection by boiling, articles must first be thoroughly medical asepsis is the combined goal of the office
sanitized and dried. Of special note are stainless staff and providers.

Maximum Process Stethoscope Chair Ear Vaginal Fiberoptic Surgical Skin

Speculum Speculum Endoscope Instrument

Sanitization X X X X X X X

Chemical disinfection X X X
by wiping

Chemical disinfection X
by soaking

Boiling X
218 UNIT 4 Integrated Clinical Procedures

BIOTERRORISM to kill or cause serious illness to hundreds of thou-

sands of people. The agents can be put into food
Bioterrorism is the use of biologic weapons (patho- and/or water, absorbed through or injected into
genic microorganisms) to create fear in people. A the skin, and dispensed as aerosols. Some diseases
bioterrorism attack is the deliberate release of bio- can be treated with pharmaceutical agents such as
logic agents (weapons) such as bacteria, viruses, antibiotics and antitoxins.
and toxins to cause death or illness in people, The most dangerous disease threats are
plants, or animals. The agents can spread through anthrax, botulism, pneumonic/bubonic plague,
the air, food, and water. Terrorists can easily obtain smallpox, and tularemia.
and use biologic agents. The agents can be very dif- Anthrax, pneumonic/bubonic plague, and
ficult to detect and difficult to protect against. They tularemia all can be treated with antibiotics. Small-
have no odor, are invisible, have no taste, and can pox is treated by early vaccination (within 4 days).
be spread quietly. Only small amounts are needed The CDC has the vaccine (Table 10-7).

Table 10-7 Example of Six Agents that Could Be Used in a Bioterrorism Attack

Disease Vaccine
Agent Transmission Availability Treatment

Bacterium Inhalation Yes, but not readily Antibiotics

Anthrax available
Not spread person to person

Toxin Toxin in food Antitoxin (state, Antitoxin should be

Botulism (severe Not spread person to person local health given as soon as
food poisoning) departments, and disease is
CDC have) suspected

Bacterium An infected flea bites someone None Antibiotics

found in Materials that are contami-
rodents and nated with bacteria can enter
their fleas through nonintact skin
Plague (2 types:
bubonic, Bubonic plague does not
pneumonic) spread person to person
Pneumonic plague occurs
when bacteria are inhaled
because it spreads through the
air and from person to person

Virus Skin eruptions occur on arms, After disease was Symptomatic

legs, feet, and face eradicated, supplies FDA has approved
Virus settles in the nose and of the virus were a new smallpox
throat and spreads when to be destroyed or vaccine that will be
infected person coughs, talks, locked away in two used in the event of
or sneezes laboratories, one a bioterrorist attack
Smallpox in the U.S. and the
Can spread through ventilation
other in Russia
systems
Last immunization
Contact with contaminated
for smallpox was
clothes and bedding
1980
Highly contagious
Immunity lasts for
about 10 years

Bacterium Human to human spread Yes Antibiotics

(infected uncommon.
rabbits and Bacterium can enter nonintact
Tularemia ticks spread skin, mucous membranes of
bacteria) eyes, respiratory tract, gastroin-
testinal tract
 CHAPTER 10 Infection Control and Medical Asepsis 219

Education plays a vital role in raising aware- high risk for exposure to smallpox, a highly con-
ness and increasing the knowledge of health care tagious disease. The FDA-said the vaccine could
professionals to aid them in being better prepared be used to protect people during a bioterrorist
for threats to the public health. Protection against attack. There is no FDA-approved treatment for
the agents should be started early. PPE and high- smallpox.
efficiency particulate air (HEPA) filters will filter According to the CDC, the threat that bio-
most biologic agents from the air. Antibiotics given logic agents will be used is more likely now than it
even before the agent is identified helps protect has been throughout history. The WHO, the CDC,
people, as do vaccines. the Department of Homeland Security, and state
The Food and Drug Administration (FDA) and local public health departments are excellent
has approved a new smallpox vaccine. The FDA resources for more information about bioterrorism
said it is intended to inoculate people who are at (see Chapter 9).

Procedure 10-1
Medical Asepsis Hand Wash (Hand Hygiene)
STANDARD PRECAUTIONS: 3. Never allow your clothing to touch the sink; never
touch the inside of the sink with your hands.
RATIONALE: The sink is considered contami-
nated at all times (NOTE: Sinks must be sanitized
and disinfected at the end of each day).
PURPOSE:
To reduce pathogens on the hands and wrists, thereby 4. Turn on the faucet with a dry paper towel (Fig-
decreasing direct and indirect transmission of infec- ure 10-33A). Discard paper towel after adjusting
tious microorganisms. Average duration is 1 minute water temperature to lukewarm. RATIONALE:
before beginning to work with patients, 15 seconds Lukewarm water is best for hand washing
(CDC Hand Hygiene recommendation) following because excessively hot water may overdry the
each patient contact. skin.
5. Wet hands and apply soap using a circular
EQUIPMENT/SUPPLIES: motion and friction; rub into a lather (Figure
Sink (preferably with foot-operated controls) 10-33B). RATIONALE: This initial hand wash is
Soap (preferably liquid soap in foot-operated container; to remove visible soil and some microorganisms.
bar soap discouraged) Interlace fingers to clean between them (Figure
Water-based antibacterial lotion 10-33C).
Disposable paper towels
6. Use an orange stick or brush at the first hand
Nail stick or brush
washing of each day (Figures 10-33D and E).
PROCEDURE STEPS: RATIONALE: Nails harbor microorganisms.
1. Remove all jewelry (plain wedding band is only Even with trimmed nails, this step must be per-
acceptable jewelry). Push watch up on arm or formed on a daily basis.
remove. RATIONALE: Jewelry harbors microor- 7. Rinse hands with hands pointed down and lower
ganisms on the hands. than elbows (Figure 10-33F). RATIONALE:
2. Prepare disposable paper towel (if using pull- When hands are held lower than elbows, patho-
down dispenser, prepare the amount of paper gens and contaminated water run off the hands
towel necessary for drying hands after wash; if and not up on the forearms.
using folded towels, have accessible). RATIO- 8. Repeat soap application and lather; interlace fin-
NALE: After the hand washing, you may not touch gers well; wash with vigorous, circular motions
any contaminated surface, such as the handle on all parts of hands including wrists; wash for
a paper-towel dispenser or the water faucets. at least one minute or longer depending on

continues
220 UNIT 4 Integrated Clinical Procedures

Procedure 10-1 (continued)

A B C

D E F

Figure 10-33 (A) Prepare towels for use. Turn on the faucet and adjust water to a lukewarm temperature.
(B) Wet hands. Let water flow downward off hands and fingertips. (C) Use a circular motion to create friction
and wash the palms and backs of hands. Interlace the fingers to clean between them. (D) Use an orange stick
to clean under fingernails. (E) A hand brush may also be used to clean under fingernails. (F) Rinse hands
thoroughly, letting the water flow downward off your hands and fingertips.

degree of contamination. RATIONALE: Appro- towel to turn off water faucet. RATIONALE:
priate length of hand washing is required to Touching the towel dispenser contaminates the
provide enough friction to remove soil and hands. Blotting the hands dry reduces drying
microorganisms. of the skin. Turning faucet off with paper towel
9. Rinse well, keeping hands pointed downward. prevents recontamination from dirty faucet.
RATIONALE: Rinsing removes microorganisms, 12. Discard paper towel in waste container. Do not
contaminated water, and soap from the hands. leave contaminated towels for repeated use.
10. Repeat hand washing for the first hand washing NOTE: Repeat hand washing procedure before
of the day or if necessary for contaminated or and after each patient contact, procedure, or
visibly soiled hands. Lather wrists using a circu- meal. RATIONALE: Hand washing must be per-
lar motion and friction. Rinse arms and hands. formed on a regular and frequent basis to ensure
RATIONALE: When the hands are excessively the reduction of microorganisms transmitted by
contaminated or soiled, two hand washings may hands.
be necessary to remove microorganisms from Water-based antibacterial lotion can be
the hands. applied to prevent chapped, excoriated skin.
11. Dry hands and wrists with disposable paper If skin is excoriated, the medical assistant may
towel; do not touch towel dispenser after hand not be able to work because of breaks in the
washing; blot instead of rubbing with towel; if skin or may have to wear gloves during any
sink is not foot operated, use a clean disposable patient contact.
 CHAPTER 10 Infection Control and Medical Asepsis 221

Procedure 10-2
Removing Contaminated Gloves
STANDARD PRECAUTIONS: pointed downward (Figure 10-34A and B).
RATIONALE: Holding the hands away from the
body will further prevent exposure to biological
contaminants.
PURPOSE: 2. Turn the used left glove inside out and hold it in
To carefully remove and dispose of contaminated the right gloved hand. Be careful not to touch
gloves to contain exposure. your bare left hand on the contaminated right
glove (Figure 10-34C–E). RATIONALE: Turn-
EQUIPMENT/SUPPLIES: ing the glove inside out helps isolate the biologi-
Biohazard waste container cal contaminants.
3. Holding the glove that has been removed with
PROCEDURE STEPS:
the hand that still has the glove on, insert two fin-
1. Grasp the palm of the used left glove with the
gers of the ungloved hand between your arm and
right hand to begin removing the first glove.
the inside of the dirty glove (Figure 10-34F).
Notice hands are held away from the body and

A B C

D E F

Figure 10-34 (A) Grasp the palm of the used glove with the right hand. (B) Begin removing the first glove.
(C) Glove is turned inside out as it is being removed. Take care to not touch bare skin on the contaminated
glove. (D) Inverted glove is completely removed into the contaminated glove. (E) Contain the inverted glove
completely in the gloved hand. (F) Insert two fingers of the ungloved hand inside the back of the contaminated
glove and turn it inside out over the other.

continues
222 UNIT 4 Integrated Clinical Procedures

Procedure 10-2 (continued)

G H

(G) Invert the second glove over the first. (H) One glove is now inside the other.

4. Turn the right dirty glove inside out over the 5. Dispose of the inverted gloves into a biologi-
other. One glove is inside the other and you cal waste receptacle. RATIONALE: All biologi-
can handle the gloves because the dirty, con- cal waste should be placed into a red biohazard
taminated area is inside the gloves (Figure bag.
10-34G and H). RATIONALE: Both gloves 6. Wash hands thoroughly. RATIONALE: Immedi-
are inverted with the biological contaminates ate washing of hands is an additional precaution.
isolated.

Procedure 10-3
Transmission-Based Precautions: Donning a Gown, Mask, Gloves,
and Cap (Isolation Technique)

STANDARD PRECAUTIONS: PROCEDURE STEPS:

1. Review provider orders and agency protocols
relative to the type of isolation precautions.
RATIONALE: Provides for patient comfort and
decreases the spread of microorganisms. Lim-
PURPOSE:
its the number of personnel coming into the
To provide barriers for medical assistant to be pro-
patient’s room and the patient’s exposure to
tected from airborne, contact, or droplet infectious
microorganisms.
diseases.
2. Place appropriate isolation supplies outside the
EQUIPMENT/SUPPLIES: patient’s room and note type of isolation sign on
Disposable gowns the door (e.g., airborne, droplet, or contact).
Disposable caps if needed RATIONALE: Ensures staff follows isolation pro-
Disposable masks tocol and alerts visitors to check with the nurses’
Gloves (nonsterile and sterile) station before entering the room.
Room with sink and running water 3. Remove jewelry, laboratory coat, and other items
Paper towels not necessary in providing patient care. RATIO-
Other supplies relative to client’s condition NALE: Decreases the spread of microorganisms.

continues
 CHAPTER 10 Infection Control and Medical Asepsis 223

Procedure 10-3 (continued)

4. Wash hands and don disposable clothing: 5. Enter patient’s room with all gathered supplies.
a. Apply cap to cover hair and ears completely. RATIONALE: Prevents trips into and out of the
patient’s room and keeps supplies clean.
b. Apply gown to cover outer garments com-
pletely. Hold gown in front of body and place 6. Assess vital signs and perform other functions
arms through sleeves (Figure 10-35A). Pull (ECG, phlebotomy) of care to meet the needs of
sleeves down to wrist. Tie gown securely at the patient. Record assessment data on a piece
neck and waist (Figure 10-35B and C). of paper, avoiding contact with any articles in
the patient room. RATIONALE: Allows for data
c. Don nonsterile gloves and pull gloves over collection and the performance of patient care.
the cuff to cover completely.
7. Dispose of soiled articles in the impermeable
d. Apply mask by placing the top of the mask biohazard bags, which should be labeled cor-
over the bridge of your nose (top part of rectly according to contents. If soiled, reusable
mask has a metal strip) and pinch the metal equipment is removed from the room; label bag
strip to fit snugly against the skin of the nose. accordingly. RATIONALE: Impermeable biohaz-
RATIONALE: Disposable garments act as a bar- ard bags prevent the leakage of contaminated
rier in preventing the transmission of microor- materials, thereby preventing the transmission
ganisms from medical assistant to patient and of infection. Labeling is a warning to other per-
protect the medical assistant from contact with sonnel that the contents are infectious.
pathogens.

A B C

Figure 10-35 (A) Medical assistant has put on a mask and is donning the gown, pulling on the sleeves.
(B) The neck of the gown is tied first and (C) the back of the gown, last.

continues
224 UNIT 4 Integrated Clinical Procedures

Procedure 10-3 (continued)

Exiting the Isolation Room: Removing 3. Untie neckties of gown (Figure 10-36C). Wash
Gown, Gloves, Mask, and Cap hands. RATIONALE: Removes microorganisms
1. Remove contaminated gloves (see Procedure from hands before proceeding.
10-2). Wash hands and then untie waist tie of 4. Slip fingers of one hand inside cuff (Figure
gown (Figure 10-36A). 10-36D) of the other hand. Pull the gown over
2. Remove mask by untying bottom ties first, then the hand, being careful not to touch the out-
top ties (Figure 10-36B). Holding mask by ties, side of the gown.
place in contaminated waste.

A C

Figure 10-36 (A) When finished in the isolation room, the medical assistant removes the contaminated gloves
(see Procedure 10-2), washes hands (see Procedure 10-1), and then unties waist tie of gown. Remove mask by
untying bottom ties first, then top ties. (B) Holding mask by ties, place in biohazard container. (C) Untie neck
ties of gown. Wash hands.

continues
 CHAPTER 10 Infection Control and Medical Asepsis 225

Procedure 10-3 (continued)

5. Using the hand covered by the gown, pull down 7. Dispose of gown in biohazard container.
the gown over the other hand (Figure 10-36E). 8. Wash hands thoroughly.
6. Pull gown off your arms. Hold gown away from 9. Document procedures performed on patient
yourself and roll into a ball with the contami- (vital signs, EKG, phlebotomy) in patient record
nated side inside (Figure 10-36F). RATIONALE: or electronic medical record.
The gown is removed and folded, touching only
the inside of the gown to prevent transmission of
microorganisms to yourself.

E F

Figure 10-36 (continued) (D) Slip fingers of one hand inside cuff of the other hand. Pull gown over the hand,
being careful not to touch the outside of the gown. (E) Using the hand covered by the gown, pull down the gown
over the other hand. (F) Pull gown off arms and hold away from body and clothing. Roll into a ball with the con-
taminated side of gown on the inside. Wash hands thoroughly.
226 UNIT 4 Integrated Clinical Procedures

Procedure 10-4
Sanitization of Instruments
STANDARD PRECAUTIONS: could quickly dry onto the instrument, making
sanitization more difficult.
3. If contaminated instrument must be carried
from one place to another for sanitization, place
PURPOSE: the instrument in a basin labeled “Biohazard.”
To properly clean contaminated instruments to RATIONALE: Do not carry contaminated instru-
remove tissue and debris. ments in your hands. Biohazard basins must be
sanitized and disinfected daily according to pro-
EQUIPMENT/SUPPLIES: cedures for Standard Precautions.
Sink (or ultrasonic cleaner: follow manufacturer’s 4. Scrub each instrument well with detergent and
instructions) water; scrub under running water, and be sure
Sanitizing agent (low-sudsing detergent, approved chem- to scrub inside any edges, serrations, and all
ical disinfectant, or blood solvent) surfaces. RATIONALE: Thorough scrubbing
Brush removes tissue and debris from all areas of the
Disposable paper towels contaminated instrument. If all tissue is not
Plastic apron removed with scrubbing, the instrument may
Disposable gloves, heavy-duty if cleaning sharps not be sterilized during sterilization procedures.
Goggles
5. Rinse well with hot water. RATIONALE: Tissue
Biohazard waste container
and debris, as well as detergent, must be com-
PROCEDURE STEPS: pletely removed. Hot water will help remove all
1. Wear heavy duty gloves, goggles, and apron. residue and aid in the drying process while rust
RATIONALE: Contaminated instruments pose a and water spots will be eliminated.
blood and body fluid precaution as indicated by 6. After they are rinsed, place instruments on mus-
OSHA standards. Disposable gloves must always lin or disposable paper towel until all instruments
be worn to sanitize instruments. Wear heavy-duty have been scrubbed and rinsed. RATIONALE:
gloves if cleaning sharp instruments. Goggles Often more than one instrument is sanitized; do
are worn to protect eyes from splashing of con- not place sanitized instrument in the bottom of
taminated debris during scrubbing procedure. the sink or on a countertop without a disposable
A plastic apron provides protection from splash- paper towel or muslin towel.
ing of clothing.
7. Dry instruments with muslin or disposable
2. As soon as possible after a procedure in which paper towels. RATIONALE: Wet instruments
an instrument is contaminated, rinse the instru- may rust or corrode. Check instruments for
ment in water and disinfectant solution; rinse working condition.
again under running water. RATIONALE: Rins-
8. Remove gloves and wash hands.
ing contaminated instruments as soon as pos-
sible after use removes debris and tissue that
 CHAPTER 10 Infection Control and Medical Asepsis 227

Case Study 10-1 Case Study 10-2

Refer to the scenario at the beginning of the chapter. Your provider–employer asks you to help develop an expo-
sure control plan. Include the measures the employer must
CASE STUDY REVIEW take to eliminate or lessen an employee’s risk for exposure
to blood or other potentially infectious materials.
1. Explain the patient education Bruce can use to
encourage adults to take advantage of available CASE STUDY REVIEW
immunizations.
2. From where can Inner City Health Care Urgent 1. How often will the plan be reviewed?
Care Center, where Bruce is employed, order or
obtain adult vaccines for immunizations?

SUMMARY
Effective infection control measures are the first defense against the transmission of infectious diseases in
the ambulatory care setting. Reliance on Standard and Transmission-Based Precautions, protective barri-
ers, and basic principles of disinfection promotes professional and responsible clinical care for patients.
When the processes of infection control are applied to all clinical procedures, the chain of infection may
be broken by many varied means. Remember that an infectious disease will not spread to another person if
the chain is sufficiently broken at any stage.
Infectious diseases spread and accidents occur through lack of education and carelessness. Medical
assistants must understand the importance of the regulations and guidelines set forth by the federal gov-
ernment and follow through by helping employers and fellow employees implement them. In doing so, the
health and safety of patients and health care workers can be protected, the spread of infectious diseases
can be kept under control, and the risk for contracting a serious infectious disease such as HIV, HBV, or
HCV will be greatly minimized.
Every medical office and ambulatory care setting must, by law, have clearly written and readily avail-
able manuals containing information about Standard Precautions and OSHA for the safe handling, stor-
age, and disposal of blood, body fluids, and chemicals.
Through consistent use of Standard Precautions and adherence to OSHA laws, health care providers
can acquire the behaviors and techniques needed to safeguard themselves and their patients.
Because of frequent changes in the laws, it is necessary for medical assistants and all other health care
providers to keep abreast of the government mandates.
228 UNIT 4 Integrated Clinical Procedures

STUDY FOR SUCCESS

To reinforce your knowledge and skills of information presented in this chapter:
• Review the Key Terms
• Practice any Procedures
• Consider the Case Studies and discuss your conclusions
• Answer the Review Questions

˚ Multiple Choice
˚ Critical Thinking
• Navigate the Internet and complete the Web Activities
• Practice the StudyWARE activities on the textbook CD
• Apply your knowledge in the Student Workbook activities
• Complete the Web Tutor sections
• View and discuss the DVD situations

REVIEW QUESTIONS
Multiple Choice Critical Thinking
1. Standard Precautions are issued by: 1. Analyze the importance of infection control and
a. Health and Human Services give five examples of how a medical assistant would
b. Centers for Disease Control and Prevention practice responsible infection control in the ambu-
c. Food & Drug Administration latory care setting.
d. Occupational Safety and Health Administration 2. Your patient has a draining wound. After you
2. The Bloodborne Pathogen Standard is primarily con- change the dressing, explain how to prevent the
cerned with: transmission of the microorganisms from the
a. reducing the transmission of HIV, HBV, and wound and dressing to you or another patient.
HCV infections 3. Give an example of how the proper disposal of con-
b. protecting the employer from lawsuits taminated objects can break a link in the chain of
c. regulating the use of personal protective infection.
equipment 4. You notice a coworker sanitizing surgical instru-
d. taking blood samples from patients ments in preparation for sterilization. He or she
3. In the chain of infection, the location of the infec- did not scrub the serrations on the instruments
tious agent is known as the: well. What will be the result of his or her improper
a. reservoir sanitization technique? Explain your answer.
b. portal of exit 5. Describe eight procedures/techniques that you
c. portal of entry could be performing on a patient that could
d. means of transmission expose you to bloodborne pathogens.
4. The stage in infectious disease in which symptoms 6. What becomes of the biohazard containers once
are vague and undifferentiated is called the: they are full?
a. incubation stage 7. What alternative do you have if you do not have
b. prodromal stage access to soap and water after performing a proce-
c. acute stage dure on a patient?
d. onset of disease stage 8. Explain the differences between sanitization and
disinfection.
9. Considering the growth requirements for pathogens,
describe how to discourage bacterial growth in the
patient examination room.
 CHAPTER 10 Infection Control and Medical Asepsis 229

WEB ACTIVITIES REFERENCES/BIBLIOGRAPHY

1. The U.S. Department of Labor Occupa- Altman, G. B. (2004). Delmar’s fundamentals and
tional Safety and Health Administration advanced nursing skills (2nd ed.). Clifton Park, NY:
(OSHA) Web site (http://www.osha.gov) Delmar Cengage Learning.
provides you with significant amounts of informa- Extensively drug-resistant tuberculosis. Retrieved June 22,
tion about OSHA—the federal agency that seeks 2007, from http://www.Medicine.Web.com.
to protect health care workers from bloodborne Infectious Disease Epidemiology, Prevention and Con-
pathogens. Visit the site to determine when the trol Division, STD and HIV Section, Minnesota
most recent changes have been made to The Department of Health. (2007). Hepatitis B and HIV/
Bloodborne Pathogen Standard. What are they? AIDS. Retrieved June 9, 2007, from http://www.
2. The HIV and Hepatitis.com Web site (http:// health.state.mn.us.
hivandhepatitis.com/hep_b.html) gives informa- Josephson, D. L. (2004). Intravenous infusion therapy for
tion about simultaneous infections of HIV, HBV, nurses principles and practices (2nd ed.). Clifton Park,
and HBC. What are the statistics for persons who NY: Delmar Cengage Learning.
are infected with HIV and HBV, or HIV and HBC? Keir, L., Wise, B. A., & Krebs, C. (2008). Medical assisting
3. The Centers for Disease Control and Prevention administrative and clinical competencies (6th ed.)
National Center for Infectious Diseases Web site Clifton Park, NY: Delmar Cengage Learning.
(http://www.cdc.gov) provides a tremendous Occupational Safety and Health Administration
amount of information regarding infectious dis- Bloodborne Pathogens-1910.1030 (Regulations
eases and hepatitis in particular. Information also [Standards-29CFR]). Retrieved June 11, 2007,
is available about HIV and AIDS. Are there other from http://osha.gov.
hepatitis viruses in addition to A, B, and C? Look Pommerville, J. C. (2004). Alcamo’s fundamentals of
on this site for the treatment of choice for all hepa- microbiology (7th ed.) Sudbury, MA: Jones and
titis viruses you find, and describe what the most Bartlett Publishers.
common side effects are of treatment. Simmers, L. (2004). Diversified health occupations (6th ed.)
4. Health information from WebMD Healthwise, Inc. Clifton Park, NY: Delmar Cengage Learning.
P.O. Box 1989, Boise, ID 83701 (http://www. Taber’s cyclopedic medical dictionary (21st ed.). (2002).
medscape.com) provides information on current Philadelphia: F. A. Davis.
recommendations for adult immunization in the Tamparao, C. D. & Lewis, M. A. (2005). Diseases of the
United States. Check this site and determine if you, human body (4th ed.) Philadelphia: F. A. Davis.
your adult relatives, and adult friends are current U. S. Department of Health and Human Services, Cen-
and up to date with the recommendations. ters for Disease Control and Prevention. (2001).
5. The Medical College of Wisconsin Web site (Federal Register). Washington DC: U.S. Govern-
(http://www.mcw.edu) provides an antibiotic ment Printing Office. Retrieved June 11, 2007, from
guide and treatment recommendations for com- http://cdc.gov/ncidod/hip/isolat/isoapp_a.html.
mon infections. Visit this site to discover the likely U. S. Department of Health and Human Services, Cen-
antibiotic treatment for (1) pneumonia (commu- ters for Disease Control and Prevention. (2004).
nity acquired), (2) pharyngitis (exudative), and Facts about pneumonic plague. Retrieved June 14,
(3) gonorrhea. 2007, from http:// www.emergency.cdc.gov/agent/
6. The National Coalition for Adult Immunization plague/factsheet.asp.
in Bethesda, Maryland, provides helpful informa-
tion regarding adult immunizations on its Web site
(http://www.medscape.com/NCAU/). Use this
site to find facts about measles, mumps, and rubella
such as: (1) Are these diseases preventable? (2)
Who should get the vaccine? (3) How are measles,
mumps, and rubella spread? (4) What risks are
there for a woman and her fetus in her first trimes-
ter if she contracts rubella during that time?
230 UNIT 4 Integrated Clinical Procedures

THE DVD HOOK-UP

In this chapter, you learned about proper infection control DVD Journal Summary
guidelines. Write a paragraph that summarizes what you learned
During one of the scenes, Mr. Breech became very ill and from watching today’s DVD program. In one of the scenes,
vomited. The vomit sprayed on the medical assisting extern Sandy accidentally stuck herself on a used needle. She was
and on and around the sink area. The extern turned around quite frightened when she spoke with her supervisor. She
and quietly told the medical assistant that there was blood wrestled with the idea of starting treatment. Do you think
in the vomit. that Sandy was overreacting? What do you think you would
do if you accidentally stuck yourself with a contaminated
1. Do you think that the extern should have said some- needle? Would you start treatment right away?
thing in front of the patient about the blood in the
vomit? What might have been a more tactful way of
letting the medical assistant know about the blood in
the vomit?
2. During the aseptic hand cleansing scene, the extern
did not clean under her nails because it was not the
first hand wash of the day. Do you think that the medi- DVD Series Program Number
cal assistant should have instituted a nail cleansing Skills Based Series 4
anyway, because of the particular circumstances? Chapter/Scene Reference
Why? • Watch entire program
 Chapter
The Patient History
and Documentation 11
KEY TERMS OUTLINE
Allergy The Purpose of the Medical History Present Illness
Preparing for the Patient Medical History
CHEDDAR
A Cross-Cultural Model Family History
Chief Complaint
Patient Information Forms Social History
Clinical Diagnosis Review of Systems (ROS)
Demographic Data Form
Objective The Patient Record and Its
Financial Information Form
Problem-Oriented Medical Privacy Information Form Importance
Record (POMR) HIPAA Compliance
Release of Information Form
SOAP/SOAPER Contents of Medical Records
Medical History Form
Source-Oriented Medical Computerized Health History Continuity of Care Record
Record (SOMR) Methods of Charting/
The Patient Intake Interview
Subjective Documentation
Interacting with the Patient
Displaying Cultural Awareness Source-Oriented Medical
Records
Being Sensitive to Patient
Needs Problem-Oriented Medical
Records
Approaching Sensitive Topics
Electronic Medical Records (EMR)
Communication across the Life
Span Rules of Charting
The Medical Health History Abbreviations Used in
Charting
SOAP/SOAPER
and CHEDDAR Chart Organization
Chief Complaint

OBJECTIVES
The student should strive to meet the following performance objectives and
demonstrate an understanding of the facts and principles presented in this
chapter through written and oral communication.

1. Define the terms as presented in the glossary.

2. Explain the purpose of the medical history.
3. Recall three functions to complete prior to a patient’s
appointment.
4. Compare/contrast the cross-cultural concerns between patients
and providers.
5. Describe the four non-medical information forms to be signed by
patients.
6. Discuss the medical assistant’s general approach to the patient
intake interview.

231
OBJECTIVES (continued)
7. Recall at least four circumstances to address in displaying cul-
tural awareness.
8. Develop a strategy for communicating across the life span with
patients.
9. Identify the components of the medical health history and their
documentation.
10. Obtain a medical history from a patient.
11. Restate the function and meaning of SOAP/SOAPER and
CHEDDAR charting.
12. List the characteristics of the patient’s chief complaint and the
present illness.
13. Compare/contrast the patient’s medical, family, and social histories.
14. Discuss the rationale for including adult immunizations in health
histories.
15. Explain how the review of systems is obtained and documented.
16. State five reasons why the medical record is important.
17. Identify three areas of concern regarding HIPAA compliance
and the patient’s chart.
18. Recall the rules for charting and documenting in the patient’s chart.
19. Compare/contrast SOMR and POMR.
20. List the advantages of electronic medical records.
21. Review common charting abbreviations.
22. Describe the organization of a medical record.

Scenario

When clinical medical assistant Joe Guerrero, CMA and sometimes will rearrange the order of the ques-
(AAMA), of Drs. Lewis and King takes a patient his- tions if necessary. Although Joe is adept at gathering
tory, he typically uses a form custom designed for the specific and necessary patient information, he also is
office. Joe uses the form as a guideline to be sure aware of patient concerns and sensitivities and adapts
he gathers all pertinent information. However, he has his approach to accomplish the task while making the
learned that he must tailor his questions to the patient patient feel at ease.

INTRODUCTION
A patient’s medical record and all information in it, will have information updated upon each visit. Essential
including the medical history, is key to competent medi- components of a complete medical record include present
cal care. Ideally, from the first encounter with the patient and past medical history, family and social history, chief
to any subsequent visits, all information regarding a complaints or problems, medications, allergies, laboratory
patient’s medical care is kept in one location—with the results, summaries from other practitioners seen, and a
primary care provider. host of other data related to the patient’s health. A patient’s
A record created for all new patients will include a record will also include demographic data, address, next
number of vital pieces of information. Established patients of kin, and current insurance information.
232
 CHAPTER 11 The Patient History and Documentation 233

Often, a family practice or internal medicine clinic

will have a broad and rather extensive questionnaire for THE PURPOSE
patients to complete which serves as the basis for the medi- OF THE MEDICAL HISTORY
cal history. These questionnaires can be purchased or cre-
ated on the computer, and they may be unique according The medical history is the basis for all treat-
to specialty. The questionnaire can be mailed to patients, ment given by the primary care provider, on-call
even attached to an email to patients, so that questions provider, any other provider, and any specialist
can be answered in the quiet environment of their homes consulted to treat the patient. During the history-
where they likely have access to the information requested. taking process, information is revealed to help
When patients are called the day before their appointment, guide treatment for the patient. The medical his-
they can be reminded to bring the completed questionnaire tory makes it easier to recall previous treatment
with them. and review notes and laboratory results.
The role of the medical assistant in taking the In addition, medical histories give a base
patient history is to be as thorough as possible and still for statistical analysis for research, insur-
remain sensitive to the patient. Respect for the patient’s ance data, and for any health department
privacy is to be balanced with the need for the kind of com- notices. The health history and chart notes are a
plete information that results in informed medical treat- legal record of patient treatment. This is especially
ment and care. important if the patient makes an injury claim
The patient medical record is a collection of confi- against another party or if the patient makes a mal-
dential patient information. Should a patient’s medical practice claim against the provider. If the records
record be introduced in court, it becomes a legal record of in the chart are precise and correct, the chart
care given. It is essential that charting in the record be becomes a good defense; however, if the charting
accurate, clear, concise, and complete. or documentation is sloppy or incomplete, the
entire record may be questioned as insufficient.
The best policy is to document everything con-
cerning patient care.

Spotlight on Certification
PREPARING FOR THE PATIENT
RMA Content Outline
• Oral and written communications
Before the patient’s visit and obtaining the medi-
cal history, perform the following:
• Charts
• Problem oriented records
1. Make certain the examination room is clean, tidy,
CMA (AAMA) Content Outline and ready for the patient.
• Recognizing and responding to verbal 2. Check to see that all necessary supplies are available.
and nonverbal communication 3. Review the patient’s chart. Note the age, any pos-
• Professional communication and sible need for assistance, and identified reason for
behavior appointment.
• Evaluating and understanding
communication When everything is ready, go to the recep-
• Interviewing techniques tion area for the patient. It is preferable to
• Medical records call the patient’s full name (John Nichols
• Documentation/reporting or Mr. Nichols) unless the patient previously
• Performing telephone and in-person requested the use of the first name or a nickname.
screening Speak clearly and plainly, making certain that your
• Patient history interview patient will be able to hear. When the patient stands,
• Organization of patient’s medical quickly determine if assistance is necessary. (The
record physical assessment has begun.) If assistance is war-
ranted, make that offer and accompany the patient
CMAS Exam Outline to the examination room, remembering later to
• Basic health history interview note in the chart the assistance provided. A friendly
• Basic charting greeting is appreciated and helpful; a greeting such
as, “How are you today?” may not be appropriate.
234 UNIT 4 Integrated Clinical Procedures

Patients in the medical clinic generally are not feel-

ing well and take that question seriously. Also, the Patient Education
reception area is not the appropriate place for the
patient to begin sharing his or her medical issues. Some patients may seem reluctant to
The following comments may be acceptable: “Did answer your questions regarding birthplace
you have any trouble finding parking?” or “I really or Social Security number. Noncitizens may
like the colors in the shirt you are wearing. They fear deportation if they are identified in the
remind me of summer.” health care system, especially if they are
Once in the examination room and the door seriously ill. Remind these patients that you
is closed, seat the patient comfortably and sit face- are there solely to assist them with their
to-face with the patient to begin the interview. health care needs and encourage them to
Build rapport with the patient. Use the patient’s provide accurate information to assist you
name often and make certain you pronounce it cor- in appropriate diagnosis and treatment,
rectly. Finally, think globally. Ask about factors in because many diseases are specific to
the patient’s life that might influence health. These geographic locations.
topics might be sports, travel, pets, family, and hob-
bies. Not only does this provide information for the
health history, it usually eases and relaxes the patient
for the more difficult questions in the interview.
1. What do you think caused your problem?
2. When do you think it started?
A CROSS-CULTURAL MODEL 3. What effect does it have on you?
It is important to understand that every 4. What are your concerns about this problem?
patient interview is a cross-cultural one. 5. What kind of treatment do you expect?
Providers and patients view the gathering
of the patient history and the personal visit dif- These questions respect the patient’s percep-
ferently. Health and illness are inseparable from tion while providing helpful information to the
social and cultural beliefs. Who patients are—their provider.
background, their belief system, their family ori-
entation, and their cultural heritage—influences
their choices in health care. Providers and patients PATIENT INFORMATION
have different concerns and anticipations, and the FORMS
medical assistant conducting the interview who is
aware of these perspectives will keep the following A number of important forms are created in the
in mind: medical setting at this time.

• Patient’s chief concern: The illness. The personal and

social significance and the problems created by the Demographic Data Form
illness are important to the patient. The demographic data form (Figure 11-1) registers
the patient’s full name, address, mailing address
• Provider’s chief concern: Disease. The provider is con-
if different, home and work telephone numbers,
cerned with the malfunctioning and maladapta-
cell phone numbers, date of birth, Social Security
tion of biological and psychological processes.
number and all insurance information, person to
• Patient’s idea of treatment success: Being able to suc- be contacted in case of emergency, and a release of
cessfully manage an illness and its problems is information signature.
often more important to the patient than curing
the disease.
• Providers’s idea of treatment success: Successfully man-
Financial Information Form
aging treatments, medications, and procedures to Some facilities include the financial information
control disease problems. form (Figure 11-2) to be signed. This form contains
information on the financial policy of the practice,
The medical assistant may find it helpful to including billing, insurance billing, co-payment
ask certain questions of patients to help them move billing, and any finance charges added to monthly
across cultures; for example: billings.
 CHAPTER 11 The Patient History and Documentation 235

Figure 11-1 Sample patient demographic form. (Courtesy of Bibbero Systems, Inc., Petaluma, CA.)
236 UNIT 4 Integrated Clinical Procedures

brochure format. Details of the Privacy Rule can

FINANCIAL POLICY be found on the CMS Web site (http://cms.hhs.
In order to reduce confusion and misunderstanding gov/HIPAAGenInfo/). Many varieties of privacy
between our patients and the clinic, we have adopted the notices can be viewed online by searching for
following financial policy. If you have any questions about “HIPAA privacy notices.”
this policy, please discuss them with our Billing Manager. There are civil penalties if a medical facility
We are dedicated to providing the best possible care and
fails to comply with the Privacy Rule and criminal
service to you and we regard your complete understand-
ing of your financial responsibilities as an essential ele-
penalties if a person knowingly obtains or discloses
ment of your care and treatment. PHI in violation of the HIPAA guidelines.
Unless other arrangements have been made in advance
by yourself or your health coverage carrier, payment is due Release of Information Form
at time of service. For your convenience, we accept debit or
credit cards or we can arrange a payment schedule. New patients may be asked to complete a Release
YOUR INSURANCE: of Information form (Figure 11-3) that is often cre-
We accept assignment of benefit from Medicare. We ated in the office. This form is sent to their former
also have direct billing agreements with many insurance
companies. We will bill those plans for whom we have
an agreement and will only require that you pay the
co-payment at the time of service. AUTHORIZATION TO RELEASE
If your medical plan determines a service is “not cov- HEALTH CARE INFORMATION
ered,” you will be responsible for the entire charge. Payment Patient ___________ Date of Birth _________________
is due upon receipt of statement from this office. SSN _____________ Previous Name ______________
MINOR PATIENTS: I request and authorize _______________________ to
The adult accompanying the patient and the parent or release the health care information of the patient named
guardian with custody will be billed for all services rendered above to:
to minor patients. Name _______________________________________
Address ______________________________________
MISSED APPOINTMENTS: This request and authorization applies to:
In order to provide the best service and availability to (Please initial the appropriate box)
our patients, we ask you to notify us 24 hours in advance if __ Health care information relating to the following treatment,
you know that you will be unable to keep the appointment. condition, or dates of treatment:
We reserve the right to charge for missed appointments. ____________________________________________
I have read the financial policy and I understand it and __ All health care information EXCLUDING specific informa-
agree to be bound by its terms. tion relating to sexually transmitted diseases (including
HIV/AIDS), alcohol or drug use, or visits related to psychi-
_____________________ Date ______________ atric disorders or mental health.
__ All health care information INCLUDING specific informa-
tion relating to sexually transmitted diseases (including
Figure 11-2 Sample financial information form.
HIV/AIDS), alcohol or drug use, or visits related to psychi-
atric disorders or mental health.
__ Other:________________________________________
Privacy Information Form I understand that my express consent is required to release
Since April 2004, the Health Insurance Portability any health care information relating to testing, diagnosis,
and Accountability Act (HIPAA) privacy rule lim- and/or treatment of HIV (AIDS virus), sexually transmitted
ited the circumstances in which individuals’ pro- disease, psychiatric disorders/mental health, or drug and/or
tected health information (PHI) could be used or alcohol use. If I have been tested, diagnosed, or treated for
HIV (AIDS virus), sexually transmitted disease, psychiatric
disclosed. It also required medical providers to give
disorders/mental health, or drug and/or alcohol use, you are
notice of its privacy practice to all patients. The specifically authorized to release all health care information
notice must describe patients’ rights, the facilities’ relating to such diagnosis, testing, or treatment.
practices related to PHI, and where and how to file
______________________________/ ________________
a complaint if patients feel their rights have been
Signature of patient or patient’s Relationship
violated. Health providers must make a good faith authorized representative to patient
effort to obtain written acknowledgement from
patients that the privacy notice was received. _____________________
Date
The privacy notice has a number of
HIPAA components and can be lengthy. Many
facilities have printed their notice in a Figure 11-3 Sample release of information form.
 CHAPTER 11 The Patient History and Documentation 237

providers to obtain past medical records and in suited to the provider’s specialty. Health history forms
some cases can be used to allow sharing of infor- can be printed in other languages, such as Spanish.
mation with family members at the request of the
patient.
If the patient has several providers, the exam- COMPUTERIZED HEALTH
ining provider will encourage the patient to choose HISTORY
one person to manage primary medical care so that
all medical care and records are concentrated in Health care facilities may use totally com-
one location. Under most managed care insurance E HR puterized health histories. These can be of
policies, patients have one primary care provider two types: patient-generated and provider-
(women may also have an obstetrician/gynecologist) generated. In patient-generated health histories,
who coordinates the patient’s health care. the patient responds on the computer to various
questions and then reviews information with the
medical assistant for completeness. Patients who
Medical History Form do not want to use a computer should be given
The medical health history form can be as short the option of answering questions face to face.
as one page (81⁄2  11) or as long and detailed When using a provider-generated health history,
as six to eight pages. This form includes informa- the medical assistant completes the information
tion on: on the screen during or after the patient interview.
These programs are user-friendly and save time for
1. Present health history, including why the patient is both the patient and medical assistant. The medi-
being seen cal assistant should remember to interact with the
2. Health history, personal and family patient by looking up from the computer from time
3. Social history including marital status, sexual ori- to time during the entry of information. It is easy to
entation, and occupation forget to look at patients as you ask them questions
and enter the information. This habit can make the
4. Military service, including dates and assignment
patient feel disconnected to the process.
(alerts provider to screen for common veteran ill-
nesses and inquire about Agent Orange exposure)
5. Body systems review/questionnaire THE PATIENT INTAKE
6. Medications currently being taken, including over- INTERVIEW
the-counter and prescription medications
Interacting with the Patient
7. Provider’s review of systems (ROS) (completed by
the provider) When the medical assistant takes the medical his-
tory, the first responsibility is to put the patient at
The best form is neither too long nor too ease (Table 11-1). A comfort level must be devel-
complicated. Patients may feel overwhelmed with oped as the medical assistant guides the conver-
a long form and may not finish it, stating they can- sation, keeps it on track, and obtains the most
not remember all the information. The form that information for the provider. Allowing conver-
is simple and brief can provide adequate informa- sation to wander, talking about other people, or
tion in many instances. Some patients find a his- letting the patient tell anecdotes does not help
tory form intimidating. It is often easier for these to complete the history. Explaining a term or
patients to talk directly with the medical assistant concept that the patient does not understand
or the provider about the history, feeling a one-to- is helpful. The medical assistant must remain
one exchange is more personal and private. professional and not be embarrassed or made
Many samples of health history forms can be uncomfortable by the patient’s answers
viewed on the Internet. Facilities often ask patients regarding illness, actions, or personal
who regularly use a computer and have Internet choices (Figure 11-4).
access to go online and print their health history If the patient is already an established
form for completion prior to their appointment. patient but has not seen the provider for several
Depending on the ambulatory care setting, this form months or longer, update the medical history by
can be tailored to include vaccines and immuniza- asking if any illnesses have occurred in the time
tions, usage of recreational drugs, exercise and diet elapsed, if any new allergies to any medications
regimens, accident information (especially if patient or other substances have occurred, and the reac-
was hurt on the job), and any other information tion to each. Document the chief complaint for
238 UNIT 4 Integrated Clinical Procedures

time in the schedule, every effort should be made

Table 11-1 General Approach
to accommodate patients. However, the medical
to the History
assistant notes the chief complaint before the pro-
1. Ensure an appropriate environment that is lit well,
vider sees the patient to ensure the main problem
at a comfortable temperature, quiet, private, and is addressed.
free of distractions. Use of the electronic medical record (EMR)
E HR makes the patient intake process much
easier. Little or no handwritten notes are
2. Sit facing the patient at eye level; the patient also
should be seated. Ensure that the patient is as necessary, and the data can be entered during the
comfortable as possible, because obtaining the communication exchange between the medical assis-
health history can be a lengthy process. Figure 11-4
illustrates an appropriate setting.
tant and the patient. Some settings allow the patient
to see the data as they are entered. Figure 11-5
3. Avoid the use of medical jargon. Use terms the
shows the importance of connecting all these data
patient can understand. in a Total Practice Management System (TPMS).

4. Reserve asking intimate and personal questions

until rapport is established.
Displaying Cultural Awareness
Remembering a cross-cultural model, the
5. Remain flexible in obtaining the health history. It medical assistant begins the encounter with
does not need to be obtained in the exact order it the patient aware of cultural differences
is presented in this chapter or on the form. and other problems that may inhibit communica-
tion. Any number of situations may arise that the
6. Remind the patient that all information will be medical assistant must be prepared to address. The
treated confidentially.
medical assistant will overcome major obstacles if
it is known that the patient does not speak English
7. Ask the patient if he or she has any questions.
as a first language or needs an interpreter, if the
patient is deaf and needs an interpreter, if the
patient is from a culture in which the female patient
the current visit. The chief complaint is the prob- does not disrobe for a male provider, or if the
lem that brings the patient to the provider. Some- patient has a mental disorder making communica-
times patients bring several problems to discuss. tion difficult.
Depending on the appointment schedule for the If there is a language difficulty, the medical
day, this may be difficult to accomplish. If there is assistant may be required to arrange for an inter-
preter. There are language interpreters in most
areas; especially in large urban areas, an inter-
preter might be found for nearly any language.
If the patient is receiving medical care through
Medicaid, special arrangements can be made for
an interpreter through the state agency adminis-
tering the program. Often the patient will bring a
family member to interpret; however, if the mat-
ter is personal, the patient may not want to reveal
personal matters with the family member present
and may prefer an outside, objective interpreter. If
the interpreter comes to the clinic as a contractor,
a business associate contract should be completed
to comply with HIPAA regulations. The contract is
not necessary for a family member, a vol-
HIPAA unteer, or a clinic employee serving as an
interpreter.
The medical assistant will listen attentively
to the patient. The patient may be uneasy talking
Figure 11-4 The medical assistant reviews the medical to the provider and may be more comfortable
history from a computer tablet with a patient while still telling the medical assistant about problems.
maintaining eye contact. Medical assistants can play an important part in
 CHAPTER 11 The Patient History and Documentation 239

Inpatient/Outpatient
Admissions
Referrals Pharmacy

RECEPTION CLINICAL CARE

Patient Assessment
Procedures, Diagnoses & Treatment Plans
Scheduling Referrals & Follow-up Appointments
Patient Demographics Prescriptions
Insurance Information Orders for Tests
Patient Authorizations Patient Medical History

Referrals Test Results

Follow-up Appointments Schedules and Tickler Files
Coordination of Services Patient Medical History
Medication Administration
Patient Education
Graphical Patient Data Displays

ELECTRONIC
RECORDS
Figure 11-5 TPMS diagram illustrating the relationship between reception and clinical care activities to a patient’s
medical record.

the medical practice by listening and communi- is to be taken, permission is not given, and the read-
cating with both the patient and the provider. ing must not be done at that time.) This is charted
as “patient refused.”
Trying to get information from a reluctant
Being Sensitive to Patient Needs patient can be difficult and requires patience and
Some patients are frightened, hostile, or depressed. understanding. If the patient is hesitant to discuss
It is important to be open to nonverbal and ver- a problem, it is better not to press for information.
bal communication in answer to questions. Some Pressing for information may make the patient
patients react positively to a hand placed gently on become defensive or angry and can impair commu-
the forearm; it calms and reassures them. Others nication altogether.
have a negative response, pulling away from any A patient may come to the clinic upset and
such contact. Maintaining a professional bound- crying. This patient must be made to feel more in
ary with the patient is essential. Boundaries respect control, that no one is going to rush care being
the patient’s needs for privacy, nurturing, valida- given. Sometimes just taking a few moments to
tion, and separation (see Chapter 4 for additional sit with such patients until they feel more settled
information). is enough to calm them and enable the history-
The medical assistant will know when to taking interview to proceed.
touch the patient appropriately, always with Uncommunicative patients require special
permission either expressed or implied. questioning techniques. The medical assistant
(If the medical assistant tells the patient a blood may have to supply a sample of problems to get
pressure reading is next and reaches for the these patients to acknowledge the health con-
patient’s arm and the patient extends an arm, per- cerns they have. Or they may shrug their shoul-
mission to take the reading is implied. If, however, ders at every question and be unresponsive.
the patient pulls away and states no blood pressure Some patients may simply say, “I don’t know. I just
240 UNIT 4 Integrated Clinical Procedures

Critical Thinking COMMUNICATION ACROSS

THE LIFE SPAN
With two others in your class, role-play a
scenario where one person is the patient, Keep in mind your patient’s age when communi-
another the medical assistant, and the third cating and seeking information for the medical
is an observer. A social history is being taken. history. A parent or caregiver often accompanies a
Ask the patient about the use of any rec- child. An infant will want to feel your physical sup-
reational drugs or chemicals. The patient port, your warmth, and a smile. As the child grows,
responds, “Yes.” What additional questions will time will be spent communicating with the child
you ask the patient? What will you include in as well as the parent. During this time, you may be
the medical record? dealing with two patients, discussing with the par-
ent the problem the child has and assisting the
parent in understanding procedures, treatment,
and so on. There can come a time, also, when a
child may do much better without a parent pres-
don’t feel well.” If a relative has accompanied the ent. This can be a sensitive issue for parents. Some-
patient to the appointment, it may be appropri- times a couple of simple statements might help; for
ate initially to have the relative present with the example, “Dr. Chalmers will want to establish some
patient. In this way the patient has a familiar face rapport with your son for a few minutes. Please
in the unfamiliar, often frightening, clinic. It is come with me while I get the literature that she
always the patient’s decision if anyone else is to wants you to have. Often these visits can be harder
be in the room. on parents than the children.”
Some patients have particular needs that they Teenagers are old enough to make the decision
are willing to express. Meeting these needs is usu- about being seen alone or with a parent present.
ally a minor matter and makes patients feel more Some are comfortable; others are not. Teenagers
comfortable. For example, “Can you help me who have had the same primary care provider since
undress and get into the gown?” early childhood and have already established a rela-
tionship are more likely to feel comfortable with-
out parents. Review a teenager’s right to consent in
Approaching Sensitive Topics Chapter 7.
Some of the most sensitive topics addressed in the Older adults may be accompanied by an-
health history include the use of alcohol, recre- other adult and may request that individual be
ational drugs or chemicals, smoking, dietary habits, present during the interview. Others may prefer to
obesity, and sexual practices. An honest reporting be alone. Adults who have difficulty hearing, who
on these topics can be important to the patient’s are memory impaired, who are visually impaired,
well-being and treatment. Consider: or whose language may not be understood are
likely to be accompanied by another person.
• Asking these questions in the later stages of the Some older adults find it difficult to answer ques-
interview after rapport has been established. tions in front of their children or even a spouse.
• Using casual, direct eye contact without staring; Although it is not necessary for relatives, it is a
this demonstrates the importance of the topic to
the patient and your lack of embarrassment.
• Posing questions in a matter-of-fact tone.
• Adopting a nonjudgmental demeanor.
Patient Education
• Using the communication technique of “normal- Some Asian cultures calculate age from con-
izing” when appropriate (e.g., “Some high school ception, not from the actual birth date. For
students drink alcohol/use drugs/engage in sex- example, a newborn infant is considered to
ual relationships on a regular basis. Does this hap- be 1 year old. The medical assistant needs to
pen at your school? With you?”). clarify the chronologic age with the patient
or caregiver. This is particularly important
If the medical assistant can enhance commu- for pediatric patients because of the link
nication with the patient, communication between between age and developmental milestones.
provider and patient will be more effective.
 CHAPTER 11 The Patient History and Documentation 241

good idea to have a HIPAA waiver signed by the

patient, as long as they understand what is being
SOAP/SOAPER and CHEDDAR
signed. Remember that the intent of HIPAA is SOAP charting is very common; SOAPER is
not to make communication more difficult or increasing in popularity and is often used in clin-
cumbersome; it is intended to protect a patient’s ics attached to teaching and research hospitals
privacy. (Figure 11-6). CHEDDAR is another approach to
Chapters 15 and 17 have helpful suggestions charting that may be used. These charting meth-
for communications with children and with older ods encourage more comprehensive charting and
adults. make evaluating and managing the levels of ser-
vice easier to document.
SOAP/SOAPER stands for the following:
THE MEDICAL HEALTH
HISTORY S Subjective data; patient’s complaint in his or her
own words
The patient’s medical health history contains the O Objective, observable, measurable findings
following components:
A Assessment, probable diagnosis based on sub-
• Personal data from the demographic form jective and objective factors
• Chief complaint as noted at each visit by the medi- P Plan for treatment, medications, instructions,
cal assistant return visit information
E Education for the patient
• Present illness
R Response of patient to education and care given
• Medications
• Allergies CHEDDAR charting encourages greater de-
tail to SOAP/SOAPER. CHEDDAR stands for the
• Other providers or alternative therapy practi- following:
tioners being seen
• Medical history C Chief complaint, presenting problems, subjec-
tive information
• Family history
H History—social and physical of presenting
• Social and occupational history problem; contributing data
• Review of systems by physician or provider E Examination, body systems reviewed

Walter Pethokoukis
Date of Birth: 01/22/1949
Visit Date: 04/04/20XX

S: Patient returns after undergoing upper GI; not in as much discomfort as last
visit. States he has been taking clear liquids and soft foods. Says he is
hungry.
O: Lab results are back. Chem 7 shows slightly elevated glucose at 133. CBC
and UA normal. Upper GI shows two small areas of ulceration.
A: Gastric ulcer.
P: Reduce omeprazole to 10 mg every day. Recheck glucose at return visit in 4 weeks.
E: Patient was advised not to smoke or chew tobacco, limit alcohol intake, and
avoid aspirin, ibuprofen, and naproxen. Try acetaminophen instead. No diet
restrictions indicated.
R: Patient was relieved; indicates there is no problem following the above plan
and recommendation. MM/tim

Figure 11-6 Sample of a SOAP/SOAPER follow-up visit note.

242 UNIT 4 Integrated Clinical Procedures

D Details of problem(s) and complaint(s) • Alleviating factors

D Drugs and dosages; list of current medications, • Setting and timing
dosages, frequency
A Assessment; diagnostic evaluation, further test- Present Illness
ing, medications
The present illness is usually reflected in the chief
R Return visit, if applicable complaint. The chief complaint is expanded to
give more information and detail. Location will
The medical assistant and the primary care describe the place where the symptom is located.
provider in attendance to the patient both con- Ask the patient to be as specific as possible. For
tribute to the completeness of the medical history instance, “I have pain on the inner thigh of my left
using SOAP/SOAPER and CHEDDAR. A more leg” is more helpful than “my leg hurts.” Radiation
detailed review of the information in these medi- helps describe the symptom more by identifying
cal history components follows. how large an area the symptom covers. The patient
might describe a “tingling sensation” all over my
left leg, for instance. Quality addresses the charac-
Chief Complaint teristic of the symptom. The description might be
The chief complaint (usually abbreviated CC) is the “tingling and buzzing,” or the pain described as
specific reason that brought the patient to see the “a dull ache” or “throbbing” or “stabbing.” Sever-
provider. It should be noted in as few words as pos- ity of symptoms will include such descriptions as
sible but be very specific. It can be a direct quote “keeps me awake at night,” or “causes me to put
from the patient. little or no pressure on the leg.” When the symp-
A good example of a chief complaint nota- tom is pain, patients may be asked to identify the
tion might be: “I’ve had nausea and vomiting pain on a scale of 1 to 10 with 10 being the most
for three days.” This is a subjective complaint in severe. Associated symptoms allows the patient to
that it is known by the patient but cannot be seen describe what other minor symptoms accompany
or measured by the provider. It is specific, how- the chief complaint. “Because I am limping and
ever, in relating the patient’s condition. Another putting more weight on my right leg, my right hip
example is: “I hurt my ankle yesterday when I aches much of the time.” Aggravating factors and
tripped over a curb.” Again this is subjective but alleviating factors get at what makes the symptoms
specific about cause, time of onset, and com- worse and what makes the symptoms decrease.
plaint. The ankle is visibly swollen and painful to “Walking fast or bending forward really hurts. Sit-
touch. The swelling is an objective sign, a mani- ting down with my feet up on a stool makes it all
festation that can be seen, heard, or measured by feel better.” You will also want to know what the
any observer. patient has done to treat the problem and if any
In contrast, a poor example of a chief com- medications have been taken for the symptoms.
plaint is “has not been feeling well.” This notation The setting and timing have to do with when the
tells nothing about what symptoms or problems symptoms started and what the patient was doing
the patient has been experiencing. It gives no at symptom onset.
specific clue as to the problem from the patient’s In the preceding example of nausea and
perspective. The medical assistant should try to vomiting, the patient may indicate inability to eat
pinpoint a complaint to a body system, to a time or take fluids. This would alert the provider to
frame, to discomfort in a specific area. The patient possible dehydration. Often the present illness is
usually will respond to questions that offer several based on a prior health problem. For instance, a
options. history of congestive heart failure gives a patient’s
Certain characteristics of each chief com- symptoms of fluid retention, wheezing, and short-
plaint should be ascertained for a complete his- ness of breath more importance because these are
tory. These characteristics are: common complications. Without knowledge of the
patient’s medical history, these symptoms could be
• Location confused with bronchitis, asthma, or pneumonia.
• Radiation Some practitioners will ask the medical assis-
• Quality tant to address other topics in the present illness.
These questions include the following:
• Severity
• Associated symptoms • Are there any other problems you are experienc-
• Aggravating factors ing at this time? This question allows patients to
 CHAPTER 11 The Patient History and Documentation 243

indicate if there is something other than the chief on the summary page, to alert clinic providers and
complaint about which they have concerns. staff members of possible allergies. The information
• What medications are you taking? Even though the needs to be updated at least annually.
patient’s chart will indicate some of this informa- If possible, update immunizations for adults
tion, this is not the case for a new patient. Most at this time. Childhood immunizations are regu-
patients do not include any over-the-counter medi- larly checked in pediatric examinations. Not all
cations or alternative therapies they may be using. adults recall their records, but some questions can
Some facilities will ask the patients to bring every help providers determine if any immunizations are
medication they are currently taking with them to be given. Refer to Chapter 10 for the immuniza-
to the first visit. Be certain to ask about over-the- tion schedule for adults.
counter items such as vitamins, pain medications,
herbal remedies, and so on. Family History
• Are you allergic to anything? Again, the medi-
The family history can provide clues to the
cal chart may note any allergies, but this ques-
patient’s present condition. By asking open-
tion alerts the staff to any potential problems and
ended questions about medical problems of sib-
updates the chart. It is a safety measure important
lings, parents, and grandparents, the provider is
to both the patient and provider.
alerted to hereditary and familial diseases and
Medications and allergies should be reviewed disorders such as coronary artery disease, hyper-
each time the patient is seen in a medical facility. All tension, breast cancer, and so forth. Present ages
medications are to be listed. Some patients will ben- of siblings, parents, and grandparents or causes of
efit from specific questions about over-the-counter their death and age at time of death are noted.
medications. If there are no known allergies, it should For instance, a family history of diabetes together
be noted so the provider knows the topic has been with the patient’s symptoms of frequent urination
discussed. When there are allergies, they usually are and thirst may make a diagnosis of diabetes mel-
listed on every page of progress notes or on the sum- litus a possibility. Be sensitive to cultural variances,
mary page in an EMR. Some facilities have begun however (see the Patient Education box).
the practice of printing out the list of all medications
and allergies to give to the patient who might want to
provide it to any other practitioners.
Social History
The social history of patients includes their spouse/
partner status; sexual habits; occupation; hob-
Medical History bies; and use of alcohol, tobacco, and recreational
The medical history includes all the patient’s
health problems, major illnesses, and surgeries.
If not included under present illness, all current
medications are noted, including dosages and rea-
sons for taking them, as well as all allergies to any Patient Education
medications and the specific allergic reaction to
each. These are important to the medical history, In some cultures (e.g., Chinese, some Native
because many health problems can overlap and Americans), it is disrespectful to speak of
affect the patient in several areas. A patient with a the dead. Thus, the patient may be reluctant
long history of diabetes mellitus may present with to provide detailed information on the fam-
an ulcer on his foot. Whereas the same ulcer in an ily health history of dead relatives. In these
otherwise healthy patient will heal with little inter- cases, you can ask the patient if there has
vention, the diabetic patient may require major been any history of specific diseases in the
treatment and attention including debridement family and not focus on the specific individ-
(removal of dead or damaged tissue or foreign ual if that person is deceased. The patient
debris), antibiotics, and close monitoring. may be willing to share in which previous
Medications have side effects and contraindi- generation and which side of the family
cations that can affect patients. Allergies to medi- the condition existed. If these approaches
cations can be serious and need to be noted in a are unsuccessful, explain to the patient the
readily visible part of the chart. A red sticker is often importance of this information, because it
placed in a conspicuous area on the inside cover of may provide clues to the patient’s current
the paper chart noting allergies. In a similar fashion, health conditions.
notations will be made in the electronic chart usually
244 UNIT 4 Integrated Clinical Procedures

drugs or other chemical substances. This part of orderly and systematic check of each part of the
the history includes those lifestyles and behaviors body is recorded. The provider asks questions con-
that may put the patient at greater risk for injury cerning each organ and system of the body during
or disease than would normally be found from fac- the examination of the patient. The ROS, in conjunc-
tors in the family history and medical history. tion with the physical examination, helps elicit infor-
Patients may not want to answer questions mation that is essential to the diagnosis of disease.
pertaining to sexual history; attempt to return to The provider usually begins with an overall assess-
these questions later. Ask if a medical assistant of ment and proceeds to check each body system in an
a different sex would make the patient more com- organized manner. The order in which this is done
fortable in discussing sexual practice. may vary by providers, but all will check the cardio-
The adolescent patient may refuse to answer vascular, respiratory, gastrointestinal, genitourinary,
questions of a sexual matter or may provide false and neurologic systems, as well as the extremities, the
answers if the parent or caregiver is present. It may musculoskeletal system, and the skin.
be best to ask the caregiver to leave the room at the Both positive and pertinent negative findings
completion of the health history so that you can ask are documented in the ROS. When a response is
the patient if there is anything else to note in the positive, the patient is asked to describe it as com-
sexual history. pletely as possible. Table 11-2 lists some symptoms
Be alert for cues that demonstrate the and diseases that can be ascertained during the
patient’s desire for knowledge on sexual matters, ROS. Many ambulatory care settings have pre-
such as questions or requests for written infor- printed ROS sheets. These are convenient, as pos-
mation. Answer the patient’s questions, provide itive findings can be circled and noted. Negative
educational materials, and refer the patient to a responses are not circled. In the EMR, the same is
specialist when indicated. available as point and click.
It may be necessary to inquire about the By the completion of this portion of the his-
patient’s home environment. Be attentive for tory, the provider usually has an idea about the
clues that signal the necessity of performing an in- patient’s condition.
depth home environment assessment. Some clues To complete the examination, laboratory tests
include, but are not limited to, poor hygiene, fre- may be ordered depending on the findings and the
quent infections, smoke inhalation, burns, mal- probable diagnosis. These results, together with
nutrition, and falls (especially in older adults). the history, examination, and patient symptoms,
help to determine a clinical diagnosis.
Each piece of the patient’s medical history
Review of Systems (ROS) documents integral parts of the patient’s health. If
Once the medical history has been taken, it is time any part is lacking, the current understanding of
to prepare the patient for the examination. Note the patient’s health is not complete.
for the provider any questions for which you were Procedure 11-1 gives the steps for taking a
unable to get a complete answer from the patient paper medical history.
or any areas where you have concerns. Thank the
patient for his or her time and information during
the interview. In clear terms and not speaking too THE PATIENT RECORD
rapidly, explain to the patient the need to disrobe, AND ITS IMPORTANCE
put on a gown, and be seated on the examination
table. (Chapter 21 describes how to transfer a patient The patient’s record is a collection of confiden-
in a wheelchair to the examination table.) Always ask tial information that concerns the patient, care
if the patient needs assistance in disrobing. It is also given to the patient, patient progress, and labo-
wise to let the patient know that you can return in a ratory and other diagnostic test results that have
few minutes to assist him or her onto the examina- been completed. This information is secured in a
tion table if necessary. This allows you to see that the file folder or binder. The EMR is secured
patient is comfortably settled and to give him or her E HR in appropriate computer storage, is viewed
an estimate of how long it will be before the provider at the computer screen, and can be printed
is coming in for the examination. in part or whole for the provider as necessary. It
The ROS is performed during the physi- is used for a variety of purposes, but primarily the
cal examination. When a patient is seen on a fairly record provides a foundation for planning patient
regular basis, only the pertinent body system will be care and making decisions about patient care.
reviewed. In a complete physical examination, an Other purposes for a medical record include using
 CHAPTER 11 The Patient History and Documentation 245

Table 11-2 Review of Systems

Patient’s perception of general state of health at the present time; difference from usual state; vitality
General
and energy levels

Headache, change in balance, in coordination, loss of movement, change in sensory perception/

Neurological feeling in an extremity, change in speech, change in smell, fainting, loss of memory, tremors, involuntary
movement, loss of consciousness, seizures, weakness, head injury

Irritability, nervousness, tension, increased stress, difficulty concentrating, mood changes, suicidal
Psychological
thoughts, depression

Rashes, itching, changes in skin pigmentation, black and blue marks, change in color or size of mole,
Skin sores, lumps, change in skin texture, odors, excessive sweating, acne, loss of hair, excessive growth of
hair or growth of hair in unusual locations, change in nails, amount of time spent in the sun

Blurry vision, visual acuity, glasses, contact lenses, sensitivity to light, excessive tearing, night blindness,
Eyes double vision, drainage, bloodshot, pain, blind spots, flashing lights, halos around objects, glaucoma,
cataracts

Ears Hearing deficits, hearing aid, pain, discharge, lightheadedness, ringing in the ears, earaches, infection

Nose and Frequent colds, discharge, itching, hay fever, postnasal drip, stuffiness, sinus pain, polyps, obstruction,
Sinuses nosebleed, change in sense of smell

Toothache, tooth abscess, dentures, bleeding/swollen gums, difficulty chewing, sore tongue, change in
Mouth
taste, lesions, change in salivation, bad breath

Throat/Neck Hoarseness, change in voice, frequent sore throats, difficulty swallowing, pain/stiffness, enlarged thyroid

Shortness of breath, shortness of breath on exertion, phlegm, cough, sneezing, wheezing, coughing up
Respiratory
blood, frequent upper respiratory tract infections, pneumonia, emphysema, asthma, tuberculosis

Shortness of breath that wakes patient up in the night, chest pain, heart murmur, palpitations, fainting,
sleep on pillows to breathe better, swelling, cold hands/feet, leg cramps, myocardial infarction, hyper-
Cardiovascular
tension, valvular disease, pain in calf with walking, varicose veins, inflammation of a vein, blood clot in
leg, anemia

Breasts Pain, tenderness, discharge, lumps, change in size, dimpling

Change in appetite, nausea, vomiting, diarrhea, constipation, usual bowel habits, black and tarry
Gastrointestinal stools, vomiting blood, change in stool color, excessive gas, belching, regurgitation or heartburn,
difficulty swallowing, abdominal pain, jaundice, hemorrhoids, hepatitis, peptic ulcers, gallstones

Change in urine color, voiding habits, painful urination, hesitancy, urgency, frequency, excessive
Urinary urination at night, increased urine volume, dribbling, loss in force of stream, bed-wetting, change
in urine volume, incontinence, pain in lower abdomen, kidney stones, urinary tract infections

Musculo- Joint stiffness, muscle pain, back pain, limitation of movement, redness, swelling, weakness, bony
skeletal deformity, broken bones, dislocations, sprains, gout, arthritis, osteoporosis, herniated disc

Vaginal discharge, change in libido, infertility, sterility, pain during intercourse, menses (last menstrual
period, age period started, regularity, duration, amount of bleeding, premenstrual symptoms, intermen-
Female
strual bleeding, painful periods), menopause (age of onset, duration, symptoms, bleeding), obstetrical
Reproductive
(number of pregnancies, number of miscarriages/abortions, number of children, type of delivery,
complications), type of birth control, estrogen therapy

(continues)
246 UNIT 4 Integrated Clinical Procedures

Table 11-2 Review of Systems (continued)

Male Repro- Change in libido, infertility, sterility, impotence, pain during intercourse, age at onset of puberty, testicular
ductive pain, penile discharge, erections, emissions, hernias, enlarged prostate, type of birth control

Nutrition Present weight, usual weight, food intolerances, food likes, food dislikes, where meals are eaten

Bulging eyes, fatigue, change in size of head, hands, or feet, weight change, heat/cold intolerances,
Endocrine excessive sweating, increased thirst, increased hunger, change in body hair distribution, swelling in the
anterior neck, diabetes mellitus

Lymph Nodes Enlarged, tenderness

Hematological Easy bruising/bleeding, anemia, sickle cell anemia, blood type

it as a basis for communi-cation among caregivers, Protection of the patient’s EMR means that
for statistical analysis in research, and for reporting E HR computer workstation terminals should
infectious diseases to the health department. It is have directional screen filters if they are
also a legal document and belongs to the located in areas where unauthorized individuals
provider or the agency in which the pro- may view the screen. Automated screen time-out
vider is employed. Chapter 7 discusses features should be installed to protect information
legal guidelines and medical records. Because it from passersby. If the office connects to the Inter-
is a legal document, the medical record can be net, telecommuters, or hospital networks, a com-
used to determine if patient care has been given mercial-grade network firewall should be installed,
according to the standards of care that the law tested, and maintained to ensure security. Anti-
recognizes; therefore, it must be complete, con- virus software should be in place and updated
cise, accurate, and understandable. Many impor- regularly.
tant items of information must be placed in the Faxing is a growing vulnerability to the threat
patient record and the medical assistant will be of unintended disclosure of patient confidential
one of the professionals making chart entries. information. Unintentional human, software, and
telecommunication carrier code errors contrib-
ute to the security problem. Faxes are easily mis-
HIPAA Compliance directed or intercepted by individuals for whom
HIPAA regulations focus on three vulnerable areas access was neither intended nor authorized. Only
with respect to medical records and the patient’s authorized personnel should have access to the fax
chart: machine area, and patient information should be
faxed only with assurance that the same security is
• Paper record storage and computer/server areas afforded where the fax is being sent.
• Fax machines
• Workstations Contents of Medical Records
A patient’s paper chart must be stored in Each patient has his or her own medical record.
HIPAA secure and locked areas. It is important All patients’ records hold standard information.
that only those persons with need for In addition to the patient information forms
access to charts have a key to the stoage area. previously mentioned, other important compo-
Locks should be changed periodically to ensure nents of the record include:
security. Sprinkler and fire detection systems
should be installed and tested annually to protect • Informed consent forms
paper records. Patients will respect and appre- • Physical examination outcomes
ciate all procedures and policies to keep their
history and medical records confidential and pro- • Laboratory and diagnostic test results
tected from harm. • The provider’s diagnosis and plan of treatment
 CHAPTER 11 The Patient History and Documentation 247

• Surgical reports • Source-oriented medical records

• Progress reports • Problem-oriented medical records
• Follow-up care
• Telephone calls related to care
Source-Oriented Medical
• Discharge summary
Records
• Other communications (from other providers, lab-
oratories, or agencies) The traditional or conventional method of chart-
ing, source-oriented medical record (SOMR), con-
• Patient records from other providers
sists of a chronologic set of notes for each visit begin-
• Medication history ning with the patient’s first visit (Figure 11-7). This
form of charting makes it difficult to follow or track a
specific patient problem. The caregiver must search
Continuity of Care Record through the record to locate information about a
The Continuity of Care Record (CCR) was devel- particular patient problem. Source-oriented notes
oped by a number of medical groups including the may be typed by the medical transcriptionist from
American Academy of Family Physicians and the dictation after the provider has seen the patient.
American Academy of Pediatrics. The CCR makes it The example of handwritten chart (Figure
easier and more effective to transport patient medi- 11-8) notes shows the complete history taken at the
cal information between providers. The CCR is time of examination including the present illness
intended to improve the continuity of patient care, (if any), the medical history, allergies, family his-
reduce errors, and assure a minimum standard tory, habits (social history), and ROS. The physical
of information that is to be shared with another examination follows with each area noted. Impres-
health care provider. The CCR includes patient sions and changes in medications and plan finish
and provider information, insurance data, patient’s the examination notes.
health status, recent care given, recommendations
for future care, and the reason for referral or trans-
fer. The patient’s health status includes allergies,
Problem-Oriented Medical Records
medications, immunizations, vital signs, pertinent A more efficient way of keeping chart notes is
laboratory results and recent procedures, and the problem-oriented medical record (POMR).
diagnoses. An expanded CCR likely includes any This method is used extensively today, especially
advanced directives the patient might have. During by clinics or any medical practice where more than
a time when much referral takes place, especially
in managed care, or when patients are transferred
from a hospital setting to an assisted living envi-
ronment where care is likely provided by someone
other than the current primary care provider, such Leo McKay
Date of Birth 01/22/1949
a record is most beneficial.
Office visit 04/01/20XX
The CCR is likely to be completed by providers,
nurses, medical assistants, and ancillary personnel This 57-year-old patient is seen after a several year absence
such as social workers and physical therapists, among because of abdominal pain which began approximately 2
weeks ago with progressively worsening abdominal pain. He has
others. It can include outpatient, community-based,
stopped eating to see if pain would improve, which it did not.
and inpatient services. It should be machine read- Finally yesterday he stopped taking fluids as well. Until this epi-
able, as well as human readable, and can be trans- sode, he was drinking several beers daily and smoking approxi-
ferred through a number of electronic formats. At mately 2 ppd.
all times, however, the CCR is to be protected and Weight is 192. BP 152/88 rt. arm sitting P 78 R 18 T 97.6.
designed to enhance patient confidentiality. He is a well-developed, moderately obese male in moderate
distress. Abdomen is tense with some guarding at RUQ.
Abdominal pain - pt needs barium swallow, CBC, Chem 7 and
METHODS OF CHARTING/ UA.To restrict diet to clear liquids until seen in 2 days, omepra-
DOCUMENTATION zole 20 mg every day.
JW/tlm
There are two primary ways to maintain chart notes.
These methods can be used in both paper and elec- Figure 11-7 Sample of dictated and transcribed chart
tronic records. They are: note.
248 UNIT 4 Integrated Clinical Procedures

completed and the provider’s plan for treating the

Leo McKay 01/22/1949 patient.
04/01/XX 3:15 pm abdominal pain  3 weeks
WT 192 BP 152/88 rt. arm sitting T 97.6 P78 R18
• Progress notes: These notes are entered on every
Pt complaining severe abdominal pain for 2 wks getting
problem initially recorded. Documentation is done
progressively worse. Describes as burning, pressure.
chronologically and includes patient’s complaints,
Past Med. Hist. chronic Peptic Ulcer Disease
problems, condition, treatment, and responses to
quit smoking 3 yr ago – now back to 2 ppd
treatment and care given.
Allergies–penicillin–hives 1950s The SOAP/SOAPER and CHEDDAR methods of
Family Hist noncontributory charting can be used in either the source-oriented
Habits smokes 2 ppd or the problem-oriented medical record.
beer–several daily Providers may dictate their notes to be typed
ROS by a medical transcriptionist and then filed in the
HEENT noncontributory–PERRLA OU correct to 20/20 chart (see Figure 11-7). These notes may follow
CR–clear, no rales, ronchi; murmurs the form seen in the handwritten chart note or as
GI–some guarding. No masses, tenderness lower shown in Figure 11-8.
abdomen. No nausea, vomiting, diarrhea
GU–clear
PE alert; oriented to time & place ELECTRONIC MEDICAL
HEENT–pupils nat teeth ⎫ RECORDS (EMR)
fundi thyroid ⎬ ∅
carotids ⎭ The EMR can be viewed as simply a different mode
chest–clear of documenting and saving information related to
heart–no murmurs or enlargement a patient’s care—computer storage versus paper
abdomen–∅ masses storage. Most practitioners making the transition
rectal–soft brown stool in vault from paper to electronic records, however, seek a
extremities–neg. more efficient method for documenting patient
neuro–reg. care. Because EMRs are the mandate by 2010,
skin–clear paper medical records will be seen increasingly less
Impression–Chronic Peptic Ulcer Disease in the future.
Hypertension, mild EMRs that are a part of a TPMS can be
Plan–Lab–CBC, Chem 7, UA, barium swallow
Rx–Omeprazole 20 mg every day
E HR viewed at a computer terminal by a pro-
vider, updated, and saved very quickly.
Return 3 days EMRs are available 24 hours per day and can be
M. Woo, MD 04/01/20XX accessed by the provider from an outside location
when necessary. More than one person can view
Figure 11-8 Sample of handwritten chart note. the EMR at the same time. Storage of the EMR
is not a serious problem; hundreds of medical
records can be stored on one CD or disk. Errors
one provider may see the patient. This method are less likely in EMRs because of the lack of hand-
calls for a list of problems to be made, dated, and written data. Medication errors are lessened when
numbers assigned to them. When a patient is seen, they are electronically transmitted to the patient’s
the problems are identified by number through- pharmacy, and there is no confusion over the pro-
out the record. This system makes it easier to fol- vider’s instructions of the medication or dosage.
low the patient’s progress. EMRs have the capability of “flagging” informa-
The POMR has four major components: tion or queries to providers to ensure accuracy and
completeness.
• The database: The patient’s medical history, results
Figures 11-9 and 11-10 show a sample EMR
from laboratory and other diagnostic tests, and
and follow-up note. The record grows in chrono-
results of physical examination are the core of the
logic order, but problems are noted. Past health
record.
problems are shown at the top of each entry, and
• The problem list: Each problem is listed individually all current medications are shown on each sheet.
and assigned a number and dated. Remember, however, that an improperly imple-
• The diagnostic and treatment plan: This component mented EMR is no more effective in quality patient
addresses the laboratory and other diagnostic tests care than is the well-kept paper record. In the EMR
 CHAPTER 11 The Patient History and Documentation 249

Patient: Leo McKay

Date of Birth: 01/22/1949
Visit Date: 04/01/20XX

Chief Complaint: Abdominal pain

History: Has been ill over the last 2 weeks with progressively worsening abdominal pain.
Review of Symptoms: Patient denies the following:
- Chest pain, Chest pressure, Chest heaviness, Circulation problems, Palpitations, Rapid heartbeat, Irregu-
lar heartbeat, Ankle swelling
- Cough, Phlegm, Coughing up blood, Shortness of breath, Wheeze, Change in exercise tolerance
- Burning or pain on urination, Difficulty starting or stopping urination, Dribbling after urination,
Incontinence of urine, Blood in urine, Cloudiness of urine
- Change in appetite, Unexpected weight loss, Nausea, Vomiting, Difficulty Swallowing, Belly pains, Gas pains,
Change in bowel habit: change in frequency, shape, color, consistency, size of stool; Blood, Mucus, or Slime,
Rectal pain or discomfort, Hemorrhoids
- Skin rash, New or changing moles, Excess bruising or bleeding
- Mouth sores, Denture problems, Sinus drainage or stuffiness, Facial pain
- Panic attacks, Anxiety, Depression, Sadness, Seizures, Problems with concentration or memory, Disturbance
of sleep, Insomnia, Early wakefulness
- Dizziness, Fainting, Lightheadedness on standing, Headaches, Vision problems, Hearing problems, Numbness
or tingling in arms or legs, Weakness in arms or legs
Medications, including Herbal, Vitamin, and Mineral Supplements
Drug Dose Freq. Started
none

Medical Problem List

Problem When Dx’d Active?
Peptic Ulcer 1985 no

List of Surgeries
Surgical Procedure When
none

Family History: Parents deceased, father died of heart attack, mother of breast cancer.
Social History: Divorced, no children
Habits: Smokes 2 ppd, Several beers daily
Allergies: Penicillin ________________________________________________
Physical Examination
GENERAL: Well developed and well nourished gentleman in no distress. No jaundice, cyanosis, clubbing, or
edema.
VITALS: Weight = 192, Temp = 97.6, Pulse = 78, R = 18, BP = 152/88
HEENT: Normocephalic and without evidence of trauma, tympanic membranes and external auditory canals are
normal. Pharynx and mouth are normal.
NECK: supple, no masses or thyromegaly.
NODES: No cervical nodes palpable. No axillary or inguinal adenopathy.
CARDIOVASCULAR SYSTEM: Heart sounds: no murmurs, rubs or gallops, carotids with good upstrokes, no bruits
heard. Peripheral pulses including radials, brachials, and femorals intact. Posterior tibial, and dorsalis
pedis pulses intact.
RESPIRATORY SYSTEM: resps 18/min, trachea central, expansion, fremitus, resonance, and breath sounds normal.
ABDOMEN: soft, no masses, organomegaly, or tenderness. No loin or costo-vertebral angle tenderness. Inguinal
canals are intact without herniae. Bowel sounds active.
GENITOURINARY: Penis without lesions or discharge, scrotum, testicles, epididymis and cords all normal
RECTAL: no masses, tenderness, or hemorrhoids. Soft brown stool in vault. Prostate normal in size, and shape
without nodules or tenderness.
MUSCULOSKELETAL SYSTEM: Joints with full ROM, no joint tenderness or swelling. Muscle bulk symmetric and
normal.
SKIN: without masses, skin tags, rash, blisters or ulcerations. Nails are normal without splinter hemor-
rhages.
NEUROLOGICAL SYSTEM: Alert and oriented to place, person, and time. Communicates with good word recognition
and appropriate word usage. Cranial nerves and spinal nerves grossly intact.

Assessment and Plan

Problem Plan/Status
Abdominal pain Reports about two weeks of epigastric and retrosternal chest pain radiating up and
to the left. Episodes of pain occur usually during the day and last for 3-4 hours.
No associated dyspnea, palpitations, sweats, dizziness. No nausea, vomiting or diar-
rhea. No blood in the stool. To get barium swallow, CBC, Chem 7 and UA. Begin omepra-
zole 20 every day.

Follow-up appointment: 3 days

Mark Woo MD
Figure 11-9 Sample of electronic medical history and physical examination.
250 UNIT 4 Integrated Clinical Procedures

Leo McKay
Table 11-3 Charting Rules
Visit Date: 04/04/20XX
Paper Records Electronic Records
___________________________________________
Symptoms: Feeling somewhat better. Always write in black Keyboarding must be accu-
Abdominal pain is less on the Omeprazole. or blue ink rate and appropriate.
Exam: Weight = 185 BP = 150/84
Patient had barium swallow showing two areas After charting, sign Type personal or electronic
of ulceration. Lab tests show normal findings with first initial, last signature after each chart
for CBC and UA. Chem 7 shows slightly elevated name, and title. activity.
glucose at 133.
Leave no space Leave no empty spaces
Assessment Plan between chart entry between chart notes and
Gastric Omeprazole 10 mg every day and initial/ handwrit- electronic signature.
ten signature.
ulcer Recheck glucose at
return visit.
Do not erase or oblit- Do not erase or obliterate
Follow-up appointment: 4 weeks. erate any entry. any entry.
Mark Woo, MD
If an error is discov- Errors made at the moment
ered, draw a single of entry are corrected as
Figure 11-10 Sample of follow-up visit note in EMR. line through the mis- usual. Errors discovered
take and write the later require a new docu-
correct information ment identifying the error,
above it.“Corr” or the correction, the date, and
there can be a tendency to rely too much on tech- “Correction” is written signature of the person mak-
nology, causing providers to become careless in by the entry, which is ing the correction. This docu-
their entries. In any medical record, there is never dated and initialed. ment is added to the original
room for inattention to detail and accuracy. Red pen can be used document with a note. EMR
Keep in mind the standard accepted rules for for the correction and software programs have vari-
notation. Follow your able time lockouts to prevent
charting in both the paper medical record and the clinic policy. tampering with the chart.
EMR. Many of the rules are pertinent to both types
of records.

RULES OF CHARTING Although the use of abbreviations in medi-

cal charts is common, remember that there is an
Charting is required for each medication, treat- increasing expectation that the medical chart
ment/procedure, or provider and medical assis- should be understandable to any person read-
tant action. Accounts of the patient’s condition ing it, especially if it is required in any legal mat-
and activities must be charted in a clear and mean- ter. The Joint Commission’s Journal on Quality
ingful way. Information charted in the patient’s and Patient Safety reports that it is best not to use
record must be accurate, clear, complete, timely, abbreviations when charting medications. Their
and entered properly. There is a saying, “If it is findings report that the most common abbrevia-
not charted, it was not done.” Some basic charting tion resulting in medication error is the use of
rules are given in Tables 11-3 and 11-4. “qd” rather than “every day or once daily.” Their
report also noted that medication errors were
more likely made during prescribing and were
Abbreviations Used in Charting related to improper dose or quantity. There-
Abbreviations are used extensively in charting fore, keep abbreviations to a minimum and use
to document information. Some are used as a only standard abbreviations. Be prepared to pro-
short-hand to save time and space, whereas other vide any attorney a list of commonly used and
abbreviations are used to give an exact meaning accepted abbreviations in your medical practice.
to a finding. For instance, the abbreviation N&V The Joint Commission posts a listing of prohib-
indicates “nausea and vomiting” without having ited abbreviations on their Web site (http://www.
to write out the entire expression. Table 11-5 lists jointcommission.org) to further satisfy their goal
commonly used abbreviations. of patient safety.
 CHAPTER 11 The Patient History and Documentation 251

Table 11-4 Charting Rules That Apply to Both Paper and Electronic Charting

Leave no blank lines in the chart. Enter your data in the next available line.

Ditto marks may not be used.

Use only standard abbreviations that have been determined are not easily misinterpreted. See Abbreviations Common to
Medical Charting (Table 11-5).

Avoid medical terminology unless absolutely certain of spelling and definition. Legal authorities advise keeping medical
terminology to a minimum. The record must be understandable to the patient and to any authorized user.

Confirm the patient’s name is on every page.

Use present tense. Never use future tense, such as “patient to be given a tetanus shot”; instead, wait until the injection is
given, then chart the event.

Never chart for another person; chart only what you know, not what someone else has told you.

Describe events and behaviors; do not label them.“Patient was really angry” does not describe the event as well as
“Patient yelled and threw the pencil on the counter.”

Be as specific as you can. Charting “Patient complained of shoulder pain” is not as clear as “Patient complains of right
shoulder pain when reaching overhead.”

Table 11-5 Abbreviations Common to

Medical Charting

BP or B/P blood pressure pupils equal, round, reactive to light and

PERRLA
accommodation
c
ˉ with
PT physical therapy
CBC complete blood count
R respiration
CC chief complaint
ROM range of motion
CPE complete physical examination
ROS review of systems
D&C dilation and curettage
s̄ without
dx diagnosis
SOAP subjective, objective, assessment, plan
ECG, EKG electrocardiogram
SOB short of breath
EEG electroencephalogram
T temperature
ER emergency room
T&A tonsillectomy and adenoidectomy
GI gastrointestinal
UCHD usual childhood diseases
GU genitourinary
URI upper respiratory infection
GYN gynecology
UTI urinary tract infection
HEENT head, eyes, ears, nose, and throat
WNL within normal limits
I&D incision and drainage
XR X-ray
MI myocardial infarction
> greater than
N&V nausea and vomiting
< less than
NVD nausea, vomiting, and diarrhea
↑ increase
OPD outpatient department
↓ decrease
OR operating room
Δ change
P pulse
252 UNIT 4 Integrated Clinical Procedures

CT scans, exercise tolerance tests (ETTs), echocar-

Chart Organization diograms, and other similar tests. Following these
Chart notes in a paper medical record are kept in are the hospital notes, including the history and
chronologic order for the primary provider. Lab- physical, hospital consultations, and discharge
oratory tests results, hospital notes, consultations summary. Consultations by other providers are
with other providers, and any correspondence grouped next, again in chronologic order.
should be kept in an orderly fashion. The miscellaneous section may include any-
The chart order presents current medica- thing from referrals for insurance companies to
tions followed by laboratory reports and pathology orders and updates from nursing homes or home
reports, each in chronologic order. In the POMR health services. Finally, the correspondence sec-
system, often the list of medical problems is found tion includes letters, insurance claim forms, and
above the current medications. requests for prior medical records.
The provider’s notes are in chronologic If a chart is kept in a specific order, informa-
order with the most recent first. The radiographs tion needed is easily gleaned by each member of
and ECGs follow, including MRIs, mammograms, the clinic staff.

Procedure 11-1
Taking a Medical History for a Paper Medical Record
PURPOSE: 4. Ask each question clearly. Be sure patient under-
To obtain a medical history from a patient new to the stands all questions. Ask about allergies.
ambulatory care setting. 5. Repeat patient answers when needed to confirm.
Be specific when documenting answers. Do not
EQUIPMENT/SUPPLIES: just write “yes” for tobacco use. List “2 packs per
Patient history forms
day.” Be specific.
Clipboard
Pen 6. Write legibly using dark ink (blue or black).
7. Recheck the medical history form to be sure all
PROCEDURE STEPS: parts are complete. Note any additional informa-
1. Introduce yourself to the new patient. Confirm tion provided by patient. Make sure numbers,
identity of the patient and escort to the examina- dates, spelling, and other information are accu-
tion room or private area. rate and legible. RATIONALE: Ensures that all
2. Make eye contact and use positive body language. components of the medical history have been
RATIONALE: Puts patient at ease. completed.
3. Explain the purpose and importance of obtain- 8. Prepare the patient for the review of systems and
ing the patient information. Ask the questions physical examination if this is indicated.
on the form, trying to get as much information 9. Document the procedure. RATIONALE: Iden-
as possible without letting the patient wander tifies person responsible for taking the medical
from the subject. history.
 CHAPTER 11 The Patient History and Documentation 253

Case Study 11-1

Review the scenario at the beginning of the chapter. CASE STUDY REVIEW
Maria Jover, a patient of Dr. Elizabeth King at Drs. Lewis
and King, has finally convinced her teenage son to make an 1. When Joe Guerrero first sits down with Adam to
appointment for a physical. Adam Jover is 17 years old, out- take the history, he notices that Adam is ill at ease
going, fun loving, and apparently healthy. But Maria is con- and nervous. What can Joe do to reassure Adam
cerned that he may be engaging in harmful social activities that his privacy will be protected?
and hopes that by seeing Dr. Winston Lewis, Adam may dis- 2. When Joe attempts to take the social history, Adam
cover ways to protect himself and his health. Adam agreed to seems evasive about answering Joe’s questions
the appointment but is adamant that his mother not accom- and finally admits that he doesn’t want his mother,
pany him. At the ambulatory care setting, it is decided that Maria, to know about his social activities. What is
Adam might be more forthcoming with a male medical assis- Joe’s response?
tant, so Joe Guerrero is scheduled to take Adam’s medical 3. By the end of the interview, it becomes apparent
history before Dr. Winston does an ROS. that Adam may be engaging in some behaviors
that put him at high risk for contracting the human
immunodeficiency virus. How can Joe provide
Adam with guidance without alienating him?

Case Study 11-2

Harvey DiAntonio is a 52-year-old patient who lives at 45 operator on the job with much heavy exertion. Smokes 1½ to
W. Smith Avenue, Baltimore, Maryland, 21208. His date of 2 packs of cigarettes per day and is a moderate drinker. He
birth is July 8, 1954. His phone number is 667-1870. He is has a weight problem off and on and tends to eat too much
a Baltimore City fire fighter and has been for 21 years. He while on duty. Lives in a one-story home. Hobbies include
has union medical insurance, and Blue Cross/Blue Shield carpentry and music. Some family problems and tension
(BC/BS) is his carrier. His number is 211-67-87-56. He exist as both of his children are in adolescence. Patient
also carries major medical and his policy is Diagnostic #4. describes himself as “fun loving” with a “quick temper” and
He has been referred by the fire department practitioner, worries about meeting financial needs of the family. Is in a
Dr. Alan Byers. Mr. DiAntonio’s complaint is severe “gripping” position to retire from active duty but states he could not
pain in the anterior mid-chest sometimes radiating to the tolerate the boredom.
abdomen, neck, and both arms. Pain seems to occur with Family history shows both parents deceased—
strenuous exercise and when walking uphill. Pain usually mother of heart attack, age 59, and father of unknown
lasts 20 minutes with each episode. Pain does “ease up” cause at age 49. Has two siblings, one brother with history
when he ceases activity. Mr. DiAntonio states his episodes of hypertension and one sister living and in good health.
have occurred while he was shaving, climbing stairs at work, Has two children both living and well. Family history other-
after a heavy meal, and during sexual intercourse. One epi- wise negative.
sode last week was accompanied with dizziness, nausea, Physical examination revealed a well-nourished, well-
and fatigue. The episodes have been going on now once or developed male in no acute distress at this time. Patient
twice a month for 5 months. Mr. DiAntonio’s history is essen- does seem a bit anxious about this examination. T. 98.6 - P.
tially noncontributory. It is questionable whether this is due 94 - R. 24 - BP 175/104. Ht. 69, Wt. 198 pounds. HEAD, EYES,
to good health or the fact that the patient has not had a EARS, NOSE, THROAT—normal. NECK—supple. Trachea in
physical examination for 8 years. Surgeries include tonsil- midline. CHEST—normal in contour. Calcium deposit on
lectomy and adenoidectomy, T&A, 1958, and appendectomy left sixth rib probably due to history fracture. HEART—after
in 1964. Fractured rib, left side, in 1984 due to fire fighting careful examination with the patient recumbent and the
incident. Usual childhood diseases. Hospitalized for obser- scope placed lightly on the chest wall near the apex, a left
vation, 1962, Sinai Hospital, for an unusually long episode atrial sound was heard (presystolic gallop). ABDOMEN—
of bronchitis. Social history shows that the patient is a pump negative. EXTREMITIES—negative. GENITALIA—negative.

(continues)
254 UNIT 4 Integrated Clinical Procedures

Case Study 11-2 (continued)

SKIN—negative. NEUROLOGIC—negative. Laboratory tests CASE STUDY REVIEW
performed show a hemoglobin of 11.0 gms. Awaiting results
of serum cholesterol, calcium, phosphorus, and blood urea 1. Identify the following parts of the case study above
nitrogen. Chest radiograph essentially negative. EKG report and extract from the case study the portion that
showed atrial sounds occurring presystolically with long matches the appropriate medical history com-
P-R intervals. DIAGNOSIS: (1) angina pectoris; (2) anemia; ponent.
(3) hypertension. TREATMENT: Nitroglycerin tabs, sublin- • Personal data • Family history
gually as needed. To return to office in 2 weeks to follow • Chief complaint • Social history
medication effects. In consultation with patient, the patient • Present illness • Review of systems
was advised to control physical activity and quantity of food • Medical history
intake. Avoid extreme cold, 8 hours of sleep/night. Avoid
2. Using appropriate terminology and abbreviations,
emotional upsets. Attempt four meals/day. Low-fat 1,600-
make a charting entry for Mr. DiAntonio by using the
calorie diet. No smoking, moderate alcohol intake.
SOAPER method of charting.

SUMMARY
The patient’s medical history and the information that appears in the medical chart form the base for any
and all treatment given to a patient. An efficient and effective medical chart tells the patient’s story. It is
critical that all information be accurate, documented appropriately, and complete in every way. Taking the
medical history, maintaining the patient’s chart, and documenting information is a major task for medical
assistants. Increased use of the EMR makes charting easier and quicker for clinic staff personnel and pro-
viders. Errors are less likely in the EMR, and information is more readily available when needed. Changing
from the paper medical chart to the electronic medical chart is time consuming and often seems over-
whelming, but medical personnel using the EMR cannot imagine functioning without them.

STUDY FOR SUCCESS

To reinforce your knowledge and skills of information presented in this chapter:
• Review the Key Terms
• Practice any Procedures
• Consider the Case Studies and discuss your conclusions
• Answer the Review Questions

˚ Multiple Choice
˚ Critical Thinking
• Navigate the Internet and complete the Web Activities
• Practice the StudyWARE activities on the textbook CD
• Apply your knowledge in the Student Workbook activities
• Complete the Web Tutor sections
• View and discuss the DVD situations
 CHAPTER 11 The Patient History and Documentation 255

REVIEW QUESTIONS
Multiple Choice c. computer skills in medical note taking
d. a major portion of the receptionist’s time and
1. If the patient has difficulty with English, the medi- energy
cal assistant should: 8. The CCR was developed:
a. make the appointment for the patient and obtain a. by medical groups including the American
the services of an interpreter to be present Academy of Family Physicians and the American
b. set the appointment after contact is made with Academy of Pediatrics
the interpreter b. to reduce errors and ensure certain information
c. speak more loudly so the patient will understand is shared among providers
d. suggest that the patient find a provider who c. for input from all health care providers, nurses,
speaks his or her first language and medical assistants
2. A helpful question to ask the returning patient is: d. all the above
a. Are you feeling bad today? 9. Progress notes include:
b. Didn’t you get better with the treatment pre- a. medical history and results of laboratory tests
scribed last visit? b. the provider’s plan for treating the patient
c. Have you noticed any changes in your condition c. the CC, problems, conditions, treatment, and
since your last visit? responses to care
d. Do you realize you have gained six pounds since d. a and c
your visit last week? 10. Subjective, objective, assessment, and plan charting
3. When the patient reports not feeling well, the is sometimes referred to as:
medical assistant should: a. SOAP
a. mark the chief complaint as “patient not feeling b. POMR
well” c. SOMR
b. ask helpful questions to help the patient express d. CCRP
specific problems or symptoms
c. pin down the symptoms by guessing what the Critical Thinking
problem could be
d. let the provider work with the patient 1. Recall your last visit to your personal medical care
4. Source-oriented medical records: provider. How well was the medical history taken?
a. are chronologic notes beginning with the Was it done on paper or electronically? What was
patient’s first visit particularly helpful about the encounter? What
b. have four major components was not helpful? Are there any ways in which you
c. are the best for finding information quickly would like it to be changed? If so, describe the
d. are best when many providers see the patient changes.
5. Name, address, telephone numbers, birth date, 2. Compare and contrast the patient’s chief concern
Social Security number, insurance information, with the provider’s chief concern in the cross-
and person to contact in an emergency is informa- cultural model. How can those concerns be
tion referred to as: brought together into one focus?
a. demographic data 3. A male patient you are interviewing denies that he
b. CCR of patient information smokes, but his fingers are darkened with tobacco
c. social history stain and he reeks of the tobacco odor. What ques-
d. none of the above tions might you ask to clarify his response?
6. The chief complaint: 4. The health and well-being of family members con-
a. often is referred to as the CC in the chart tributes what kind of information to a patient’s
b. is a statement of objective findings made by the medical history? When that information is essen-
staff tially unknown for one reason or another, how is
c. is subjective data as expressed by the patient that information addressed in the chart?
d. a and c 5. There are two major “patient examples” of histo-
7. Interviewing patients for their medical history ries in this chapter: Mr. Leo McKay and Mr. Harvey
requires: DiAntonio. From the social and family history,
a. special credentials such as CMA or RMA identify how that information may or may not
b. cross-cultural interviewing and communication relate to the presenting problem.
skills
256 UNIT 4 Integrated Clinical Procedures

WEB ACTIVITIES the advantages and disadvantages of such a

system.
1. With electronic medical records on the rise, 2. Search the Internet for information on the elec-
there are many products coming on the tronic POMR. Are you able to see samples? Discuss
market to make the transition from paper the advantages and disadvantages of the electronic
to electronic records easier and more efficient. record and the POMR.
Go to http://healthcare.scantron.com/patient-
record/paros/htm for information about a sys-
tem that allows health care providers and patients
quick access to an EMR for patient histories. In
REFERENCES/BIBLIOGRAPHY
this system, the patient fills out the history form U.S. Department of Health and Human Services,
using a digital pen which automatically captures Centers for Disease Control and Prevention. Recom-
the handwritten data by reading special paper on mended adult immunization schedule by age group and
which the form is printed. When the patient com- medical conditions, United States, 2006–2007. Sum-
pletes the form, the pen is slid into a computer mary published by the Advisory Committee on
docking station and the captured information is Immunization Practices. Retrieved August 2007,
instantly transferred to the EMR system. Discuss from http://www.cdc.gov.

THE DVD HOOK-UP

In this chapter, you learned about the proper method for DVD Journal Summary
obtaining a patient’s medical history and the proper tech- Write a paragraph that summarizes what you learned from
nique for recording in a patient’s chart. watching today’s DVD program. How do you feel about ask-
In today’s designated scenes, you observed Anita going over ing patients questions regarding sensitive subject matters
Mrs. O’Neil’s patient history form. Anita first gathered infor- such as sexual health and emotional stability?
mation about the patient’s personal history, and then the
patient’s familial history. Once Anita finished going over the
history form, she asked Mrs. O’Neil what brought her into the
office today.
1. Why did Anita need to ask the patient what brought her
into the office today? After all, she just obtained the DVD Series Program Number
patient’s entire medical history. Skills Based Series 6
2. What do you think of Anita’s personality? Do you think Chapter/Scene Reference
that she was a bit solemn? • Introduction to Taking a Patient History
3. Why must you also include over-the-counter medications • Preparing an Exam Room
when posting current medications being taken • Patient Assessment and Measurement
by the patient?
 Chapter
Vital Signs
and Measurements 12
KEY TERMS OUTLINE
Afebrile The Importance of Accuracy Respiration
Apical Temperature Respiration Rate
Apnea Terms Used to Describe Body Abnormalities
Arrhythmia Temperature Blood Pressure
Atherosclerosis Phase Out of Mercury Equipment for Measuring
Thermometers and Other Blood Pressure
Baseline
Mercury-Containing Measuring Blood Pressure
Bradycardia Equipment Recording Blood Pressure
Bradypnea Types of Thermometers Measurement
Cheyne–Stokes Measuring Temperature Normal Blood Pressure
Diastole Recording Temperature Readings
Dyspnea Cleaning and Storage of Blood Pressure Abnormalities
Eupnea Thermometers Height and Weight
Pulse Height
Febrile
Pulse Sites Weight
Frenulum
Measuring and Evaluating Significance of Weight
Hyperpnea a Pulse Measuring Chest Circumference
Hypertension Normal Pulse Rates
Hyperventilation Pulse Abnormalities
Hypotension Recording Pulse Rates
Hypoventilation
Increment
OBJECTIVES
Lumen
The student should strive to meet the following performance objectives and
Manometer
demonstrate an understanding of the facts and principles presented in this
Meniscus chapter through written and oral communication.
Orthopnea
Peripheral 1. Define the key terms as presented in the glossary.
Pulse Oximeter 2. Discuss normal and abnormal temperatures, including factors
affecting temperature.
Pyrexia
Rales 3. Identify and explain the procedures for using, caring for, and
storing the various types of thermometers.
Stertorous
4. Discuss the Environmental Protection Agency’s initiative to
Stridor
phase out mercury thermometers and other mercury-containing
Systole equipment.
Tachycardia
5. Describe the locations and procedure for obtaining pulse rates.
Tachypnea
6. Explain the procedure for obtaining respiration rates.
Wheezes
7. Identify and describe normal and abnormal pulse and respira-
tory rates and the factors affecting each.

257
OBJECTIVES (continued)
8. Describe the appropriate equipment and procedure for obtain-
ing a blood pressure measurement.
9. Identify normal and abnormal blood pressure, including fac-
tors affecting blood pressure.
10. Describe the procedures for obtaining height, weight, and chest
measurements of adults.
11. Accurately record measurements on the patient’s chart or elec-
tronic medical record.
12. Explain two reasons why a professional individual shows respon-
sibility by learning about the dangers of mercury.

Scenario
The medical office of Drs. Lewis and King, clinical under control. In reviewing Abigail’s chart, Joe notices
medical assistant Joe Guerrero, CMA (AAMA), assists that her blood pressure has been quite stable for the
both providers in taking patients’ vital signs. One of his last few visits. He also checks her weight and notices
favorite patients is Abigail Johnson, a friendly woman that Abigail is slowly losing weight. Abigail’s chart, with
in her 70s who always has a kind disposition despite its history of blood pressure and other measurements,
her financial and medical difficulties. Abigail is over- informs Joe’s perspective and is a helpful record when
weight and has hypertension, so her blood pressure evaluating the progress Abigail has made since she
is monitored on a regular basis to be certain that it is became a patient 3 years ago.

INTRODUCTION
One of the most important and commonly performed before taking vital signs will assist in preventing cross con-
tasks of a medical assistant is obtaining and recording tamination of patients. Refer to the discussion on Standard
patient vital signs and body measurements. Vital signs, Precautions and medical asepsis in Chapter 10. Also, emo-
also sometimes referred to as cardinal signs, include tem- tional factors of patients must be recognized and addressed.
perature, pulse, respiration, and blood pressure, abbrevi- Explaining procedures and allowing the patient the oppor-
ated TPR B/P. They are indicative of the general health tunity to relax will ease apprehension that may affect vital
and well-being of a patient and, with regular monitoring, sign readings.
may measure patient response to treatment. Vital signs,
in total or in part, are an important component of each
patient visit. Height and weight measurements, although THE IMPORTANCE
not considered vital signs, are often a routine part of a OF ACCURACY
patient visit.
Patients will exhibit vital sign readings that are Vital signs may be altered by many factors. Medi-
uniquely their own. As a result, baseline assessments of cal assistants must recognize and correct factors
vital signs are usually obtained during the patient’s ini- that may produce inaccurate results. For example,
tial visit. These baseline results are used as a reference patients may exhibit anxiety over potential test
point for future readings, differentiating between what is results or findings of the provider. They may
normal and abnormal for the patient. be angry or may have rushed into the office. A
Two important habits must be developed by the patient may have had something to eat or drink
medical assistant before taking a patient’s vital before the visit or may have had a long wait in the
signs: aseptic technique in the form of hand reception area. Patient apprehension and mood
washing and recognition and correction of factors that must always be considered by the medical assis-
may influence results of vital signs. Proper hand washing tant, because these factors can affect vital signs.

258
 CHAPTER 12 Vital Signs and Measurements 259

Pharmacy
Spotlight on Certification
RMA Exam Outline
• Vital signs and measurements CLINICAL CARE
CMA (AAMA) Content Outline Patient Assessment
Procedures, Diagnoses & Treatment Plans
• Equipment preparation and operation Referrals & Follow-up Appointments
Prescriptions
• Principles of operations Orders for Tests
Patient Medical History
• Vital signs
CMAS Exam Outline
• Vital signs and measurements
Test Results
Schedules and Tickler Files
Patient Medical History
Medication Administration
Patient Education
Graphical Patient Data Displays
The medical assistant may be required to take
vital signs more than once during an office visit
to ascertain a baseline and obtain an impression
of overall well-being of the patient. Body measure-
ELECTRONIC
ments such as weight may be influenced by what
the patient is wearing; height may be influenced RECORDS
by the patient’s shoes and how his or her posture
is while being measured.
Accuracy in taking vital signs is necessary
Figure 12-1 In a total practice management system,
because treatment plans are developed according
the patient’s vital signs are often entered by the medi-
to the measurement of the vital signs (Figure 12-1).
cal assistant during clinical care. Many programs have
Variations can indicate a new disease process or
the ability to output vital signs data in a graph format,
the patient’s response to treatment. They may also
so a provider can easily note fluctuations in a patient’s
indicate the patient’s compliance with a treatment
weight, blood pressure, normal temperature, etc.
plan. Although taking vital signs is a task commonly
performed by the medical assistant, it is never to
be taken casually or lightly, and it should never be The body loses heat by a combination of
rushed or incompletely performed. Concentration five processes:
and attention to proper procedure will help ensure
1. Convection. The process by which heat is lost
accurate measurements and quality care of the
through the skin by being transferred from the
patient. The following text discusses procedures
skin by air currents flowing across it, such as a fan
used to measure the vital signs of children and
used on a hot day for cooling purposes.
adults. Procedures used for infant examinations
are discussed in Chapter 15. 2. Conduction. The transfer of heat from within the body
to the surface of the skin and then to surrounding
cooler objects touching the skin, such as clothing.
TEMPERATURE 3. Radiation. Body heat lost from the surface of the skin
to a cooler environment, much like a cool room
Body temperature is maintained and regulated by becoming warm when occupied by many people.
two processes functioning in conjunction with one 4. Evaporation. A heat loss mechanism that uses heat
another: heat production and heat loss. absorption through vaporization of perspiration.
Body heat is produced by the actions of
5. Elimination. Heat that is lost through the normal
voluntary and involuntary muscles. As the mus-
functioning of the intestinal, urinary, and respira-
cles move, they use energy, which produces heat.
tory tracts.
Cellular metabolic activities, such as the pro-
cess of breaking down food sugars into simpler The delicate balance between heat produc-
components (catabolism), are another source tion and heat loss is maintained by the hypothal-
of heat. amus in the brain. The hypothalamus monitors
260 UNIT 4 Integrated Clinical Procedures

blood temperature and will trigger either the heat • Continuous: a fever that remains above the baseline;
loss or heat production mechanism with as little as it does not fluctuate but remains fairly constant
0.04°F change in blood temperature.
Body temperature is measured in degrees and Figure 12-2 depicts types of fever.
is influenced by several factors, including:
Phase Out of Mercury
• An increase in temperature may result from a bac-
terial infection, increased physical activity or food
Thermometers and Other
intake, exposure to heat, pregnancy, drugs that Mercury-Containing Equipment
increase metabolism, stress and severe emotional Glass mercury thermometers have been used for
reactions, and age. Age becomes a factor in that decades and have been common in health care
infants have an average body temperature that is agencies as well as the home. In recent years, con-
one to two degrees higher than adults. cerns have arisen about mercury toxicity when
• Decrease in temperature may result from viral mercury thermometers or other equipment con-
infections, decreased muscular activity, fasting, a taining mercury breaks and spills mercury into the
depressed emotional state, exposure to cold, drugs environment.
that decrease metabolic activities, and age. Age in This can create a mercury vapor in the indoor
this instance refers to older adults, in that older air, which is a serious problem. The mercury also
adults have decreased metabolic activity resulting can cause environmental damage if it enters lakes
in a decrease in body temperature. and rivers where it can contaminate fish, which are
• Another factor that can increase or decrease body part of the food chain. Even small amounts of mer-
temperature is time of day. During sleep and early cury can do great harm. The fetus is at risk because
morning, the temperature is at its lowest, whereas its developing nervous system is susceptible to mer-
later in the day with muscular and metabolic activ- cury toxicity if a pregnant woman eats fish contami-
ity, the temperature increases. nated with mercury. When thermometers break or
are disposed of improperly, the mercury can enter
Because of the many factors influencing body the atmosphere, especially if the mercury waste is
temperature and the uniqueness of individuals, burned in an incinerator.
there is no “normal” temperature. The medical If spilled mercury is not cleaned up (perhaps
assistant must think of temperatures in terms of the the individual using the thermometer is unaware
“average,” which for an adult is 98.6°F, or 37.0°C. that it is broken, and the mercury has seeped into
a carpet or crevice), the mercury will evaporate and
Terms Used to Describe can reach dangerous levels in indoor air. There is
medical literature that illustrates some cases of
Body Temperature serious illnesses and even death from exposure to
The following terms are used to describe body tem- mercury from broken thermometers. Most cases
perature: involved young children. According to the Envi-
ronmental Protection Agency (EPA), a 32-month-
• Afebrile: absence of fever old child who was exposed to mercury became ill
• Febrile: fever is present with hypertension, tachycardia, apathy, pulmonary
edema, and coma. The mercury from a broken
• Fever: body temperature increased beyond normal
thermometer had not been cleaned up.
range; pyrexia is another term for fever
Even small mercury spills should be cleaned
• Onset: time when fever begins up as soon as possible. Becton-Dickinson, a
• Lysis: body temperature gradually returns to nor- thermometer manufacturer, makes the follow-
mal after a period of fever ing recommendations for cleaning up a broken
• Crisis: body temperature decreases suddenly to thermometer:
normal levels; the patient may perspire profusely
(diaphoresis) • Pick up the mercury with an eyedropper or scoop
up the beads of mercury with a piece of heavy
• Intermittent: a fluctuating fever that returns to or paper (cardboard, index card, or playing card).
below baseline, then increases again
• Place mercury, the dropper, heavy paper, and any
• Remittent: a fluctuating fever that does not return to broken glass in a plastic resealable bag. Place this
the baseline temperature; it fluctuates but remains bag into two more resealable bags, zipping each
increased within the other, finishing up with the contents
 CHAPTER 12 Vital Signs and Measurements 261

3/28/20XX 3/29/20XX 3/30/20XX 3/31/20XX 4/1/20XX

A.M. P.M. A.M. P.M. A.M. P.M. A.M. P.M. A.M. P.M.
F. 12 4 8 12 4 8 12 4 8 12 4 8 12 4 8 12 4 8 12 4 8 12 4 8 12 4 8 12 4 8

106°
T 105°
E
M 104°
P 103°
E
R 102°
A 101°
T
100°
U
R 99°
E
98°
97°
(A) Continuous

3/28/20XX 3/29/20XX 3/30/20XX 3/31/20XX 4/1/20XX

A.M. P.M. A.M. P.M. A.M. P.M. A.M. P.M. A.M. P.M.
F. 12 4 8 12 4 8 12 4 8 12 4 8 12 4 8 12 4 8 12 4 8 12 4 8 12 4 8 12 4 8

106°
T 105°
E
M 104°
P 103°
E
R 102°
A 101°
T
100°
U
R 99°
E
98°
97°
(B) Intermittent

3/28/20XX 3/29/20XX 3/30/20XX 3/31/20XX 4/1/20XX

A.M. P.M. A.M. P.M. A.M. P.M. A.M. P.M. A.M. P.M.
F. 12 4 8 12 4 8 12 4 8 12 4 8 12 4 8 12 4 8 12 4 8 12 4 8 12 4 8 12 4 8

106°
T 105°
E
M 104°
P 103°
E
R 102°
A 101°
T
100°
U
R 99°
E
98°
97°
(C) Remittent
Figure 12-2 Types of fevers. (A) Continuous—remains above baseline. Does not fluctuate. (B) Intermittent—a
fluctuating fever. Returns to or below baseline, then rises again. (C) Remittent—a fluctuating fever but does not
return to baseline temperature. Remains elevated, but fluctuates.
262 UNIT 4 Integrated Clinical Procedures

bagged three times. Place this into a wide-mouth, temperature. They are used once and then dis-
sealable plastic container. carded. There are strips for use on the forehead
• Call the local health department for the nearest mer- and others for oral use. Although strips are easy
cury disposal location. If no disposal location is avail- to use and prevent patient cross contamination,
able, dispose of the container according to local and accuracy is questionable.
state regulations. The health department can inform
you regarding how to obtain the information. Electronic and Digital Thermometers.
Electronic thermometers are widely used,
• Leave windows open for about 2 days to ensure
handheld, battery-operated or plug-in units
complete ventilation.
that have easy-to-read electronic display screens
These recommendations can be applied to indicate results (Figure 12-3). Electronic ther-
to mercury spillage caused by other mercury- mometers in Fahrenheit or Celsius scales are avail-
containing equipment. Do not do the following: able. Probes are attached and are color-coded blue
for oral and red for rectal. The probes have dis-
• Do not use household cleaning products. Combi- posable plastic covers. The plastic cover acts as a
nations of some cleansers with mercury can release barrier to prevent contamination of the probe and
toxic gases. is replaced for each patient to prevent cross con-
• Do not use a broom or brush to clean up mercury; tamination. An accurate result can be obtained in
they only spread it around. approximately 10 seconds.
• Do not use a vacuum cleaner or shop vacuum. The Inexpensive digital thermometers are widely
mercury vapor escapes into the air and increases available for home use (Figure 12-4). They are
exposure to individuals in the area. quick, easy to use, and accurate. Encourage your
patients to switch to these from the mercury glass
In 1998, the American Hospital Association thermometers. These lightweight thermometers
signed an agreement with the EPA to eliminate do not require recharging; their small imbedded
mercury from their hospitals’ waste systems. Hos- batteries last for years but are not replaceable.
pitals and other health care agencies are phasing Suggest patients watch for “Turn in Your
out the use of mercury thermometers and other Mercury Thermometer Days.” Some communi-
medical equipment that contain mercury, such as ties, in conjunction with local pharmacies, set
sphygmomanometers, among others. Many states aside a day or two each year for residents to take
have recalled mercury thermometers and replaced mercury thermometers to their local pharmacy.
them with digital ones. In exchange for the mercury thermometers, free
The best alternative is use of nonmercury digital thermometers are given as replacements.
thermometers, such as digital and electronic. These
can be used orally, rectally, or axillary. Also available
are tympanic (ear canal) a temporal artery, and flex-
ible, disposable, forehead, or oral thermometers Plastic holder containing digital thermometer Box of disposable Power
probes and rechargeable battery probe covers source
(less accurate). There are no known risks with any
of the above thermometers.

Types of Thermometers Rectal

probe
The following are types of thermometers available
for use in the ambulatory care setting:
• Disposable strips
• Electronic/digital
• Tympanic
Disposable Oral Plastic cord goes
• Temporal artery probe cover probe around the MA’s neck

Disposable Thermometers. Disposable ther- Figure 12-3 Electronic thermometers have inter-
mometers are individually wrapped strips with changeable oral and rectal probes attached to a
heat-sensitive dots that change color to indicate battery-operated portable unit.
 CHAPTER 12 Vital Signs and Measurements 263

perature of the skin surface over the temporal

artery.
(A) The thermometer has a probe that contains a
sensor. When the TA thermometer is slid straight
across the forehead (midline forehead), the infra-
(B)
red heat from the artery is picked up by the sen-
sor (Figure 12-5). Software accurately determines
(C) and displays the temperature. The TA thermom-
eter can also be used behind the ear lobe (if the
forehead is wet with perspiration). See Procedure
(D) 12-3. There are many advantages to the TA ther-
mometer: It can be used for patients of all ages;
it is accurate, painless, fast, convenient, safe, com-
fortable, and noninvasive; and it can be cleaned
Figure 12-4 Digital thermometer. (A) Carrying with an alcohol wipe between patients.
case. (B) Digital thermometer. (C) Probe cover with- Some considerations should be kept in mind
out backing. (D) Probe cover with backing. when using a TA thermometer. If there is perspira-
tion on the forehead, an inaccurate measurement
could occur. Other sites that can be used are the
femoral, axillary, and behind the ear. Scanning
Tympanic Thermometers. The use of tym- too rapidly can cause a false reading, as can a hat
panic thermometers is becoming more or hair covering the forehead. The TA thermom-
popular because they are fast, provide no eter must be the same temperature as the room in
discomfort to the patient, can be used on patients which it is used. It cannot be stored in the sun or
over 2 years of age as well as adults, and usually are
accurate. They consist of a handheld unit with a
probe tip that is inserted into the ear securely to
make a seal. Disposable tips are used to prevent
cross contamination. With the tympanic method
of measuring body temperature, the procedure is
complete in a few seconds. It is comfortable for the
patient, nonthreatening to infants and children,
and can be used when other methods are inappro-
priate. It is the thermometer of choice for pediat-
ric patients older than 2 years. However, providers
have found that inaccurate readings can result if
patients have impacted cerumen in the ear of which
they may be unaware. Also, if the patient has otitis (A)
media, a middle ear infection, the reading tends to
be inaccurate and the procedure is painful.
The most commonly used thermometers are
the digital/electronic, tympanic and temporal
artery thermometer.

Temporal Artery Thermometers. A noninvasive

thermometer known as a temporal artery thermom-
eter, or TA thermometer, has been developed and
is currently in use. Studies performed at Harvard
Medical School and the Hospital for Sick Children
found the TA thermometer to be more accurate
(B)
than the aural (tympanic) and rectal thermometers.
It is used on adults and children. Figure 12-5 Using a temporal artery thermometer.
The temporal artery is a major blood vessel (A) Temporal artery thermometer. (B) Slide thermom-
in the head. The thermometer measures the tem- eter across forehead.
264 UNIT 4 Integrated Clinical Procedures

choice for clinical use. Procedure 12-5 gives steps

Patient Education for taking an oral temperature using a disposable
oral strip thermometer.
Teach patients the importance of replacing The procedure for obtaining an oral tem-
mercury thermometers with an alternative perature with an electronic thermometer is
such as digital, disposable, or aural (tym- quick, easy, and accurate (Procedure 12-1). Some
panic) thermometers. The risk for mercury electronic thermometers are stored on a recharg-
poisoning is great if a mercury thermom- ing base. When removed from the base, they are
eter (or other mercury-containing item) is turned on and ready for use. A disposable cover is
broken and the mercury escapes into the placed over the probe, and the probe is placed in
environment. the patient’s mouth. When temperature measure-
ment is complete, the thermometer beeps and
the temperature is displayed on the screen. The
probe cover is ejected into a biohazard container
without touching the container, and the unit is
in a room where air-conditioned air has been blow- returned to the base. The temperature is then
ing on the thermometer. recorded in the patient’s chart. Always read and
follow the manufacturer’s directions for use and
care of a digital unit.
Measuring Temperature
To convert °F to °C: Aural Temperature. Taking a temperature with a
Subtract 32 from F temperature, then multiply tympanic thermometer is a fast, safe method for
by 5/9. obtaining a patient’s temperature (Figure 12-6).
It is common in ambulatory care settings. Tym-
Example: panic temperature can be obtained without dis-
64.9 comfort for all patients except for children under
)
5 324.9
 30
2 years of age.
The tympanic thermometer measures the
24
20 patient’s temperature by measuring the infrared
49 waves produced by the tympanic membrane and
45 records the temperature in less than 2 to 3 sec-
4
To convert °C to °F: onds on a digital screen. The tympanic membrane
Multiply C temperature by 9/5, then add 32. and the hypothalamus of the brain share the same
blood supply, so an accurate measurement of the
Example: body temperature can be obtained.
The greatest benefits of the tympanic ther-
36.1°C

9
 32
mometer are that it gives nearly instant
1 5 results; does not come into contact with
64.9
36.1 )
5 324.9
mucous membranes, thereby minimizing cross
9  30 contamination; uses a site that is readily accessible;
65
324.9 24 is not affected by the patient smoking or drink-
20 32
49
or ing hot or cold liquids; does not require that the
97° F
45 patient be conscious; and is an easy instrument to
4 use. The unit is battery operated and uses a dispos-
able probe cover or ear speculum.
Drawbacks to the tympanic thermometer
Oral Temperatures. To use an oral strip for taking have been demonstrated in pediatric patients with
a temperature, make certain that the package is ear conditions such as otitis media. An inaccurate
not damaged, then peel it back to reveal the strip. recording can result because fluid buildup in the
Insert the strip into the patient’s mouth. After the inner ear limits infrared wave transmission.
appropriate time interval has elapsed, remove the The tympanic thermometer is a hand-
thermometer. The dots that have changed color are held unit that is inserted into the outer third of
read using the scale located on the strip. Although the ear canal. Procedure 12-2 gives steps for
convenient to use, accuracy is not always ensured obtaining an aural temperature using a tympanic
with the strips, so these strips may not be the best thermometer.
 CHAPTER 12 Vital Signs and Measurements 265

Temperatures is recorded as shown:

Oral T 98.6°F
Rectal T 99.6°(R) F
Axillary T 97.6°(Ax) F
Tympanic T 98.6°(Tym) F
Temporal artery T 99.4°(TA) F

When a facility uses a tympanic thermometer

exclusively, the route is known and therefore does
not have to be labeled.
The medical assistant must read all manufac-
turer’s instructions before using any digital, tym-
panic, or temporal artery thermometer. Each may
have a slight difference in operating procedure.
Procedures 12-1 through 12-6 detail steps
involved in taking temperature by various routes.
Figure 12-6 Thermo-scan tympanic thermometer.
(Courtesy of Welch-Allyn.) Cleaning and Storage
of Thermometers
Oral and rectal thermometers should be
separated. Storage depends on the policy
Rectal and Axillary Temperatures. The rectal and of the facility.
axillary methods for obtaining a temperature were Digital, electronic, tympanic, and temporal
widely used for infants, young children, and patients autery thermometers are cleaned according to
who were unable or uncooperative with oral tem- the manufacturer’s directions. The covers pro-
perature measurement. The new technology— tect the probes from contamination. Each type of
tympanic, temporal artery, and electronic and digi- thermometer has a storage case or a wall-mounted
tal thermometers—have simplified temperature base made especially for storing the unit. Disinfect
measurement. These thermometers are safe, read- these types of thermometers by wiping with a mild
ily accepted by patients, greatly reduce microorgan- disinfectant as instructed by the manufacturer.
ism transmission, are accurate, give a rapid reading,
and are widely used in health care settings includ-
ing ambulatory care. Although the newer eventually PULSE
will replace the electronic digital method for mea-
suring temperatures, including the rectal and axil- The pulse rate consists of two phases of the heart
lary routes, the steps for obtaining rectal and axillary action and can be felt when compressing an artery.
temperature measurements are included in Proce- As the heart contracts, it increases pressure on the
dures 12-4 and 12-5. arterial walls. The increased pressure passes through
the arteries in a wave-like movement resulting in a
slight expansion of the arterial wall (contraction).
Recording Temperature When the heart relaxes, (relaxation) the pressure
Temperature may be taken on each visit is decreased in the arteries, resulting in the wall
E HR to the provider’s office to obtain a base- returning to its previous position. One contraction
line for the patient. When recording the and one relaxation of the heart is equal to one heart
temperature in the patient’s electronic medical cycle or heart beat. The pulse and heartbeat rate
record, the scale used for the results must be des- are usually identical in healthy individuals.
ignated F for Fahrenheit and C for Celsius. The
route used must be labeled as well; methods other
than oral must be labeled according to the route
Pulse Sites
used because there is a difference in the measure- The pulse can be felt in areas of the body where
ment. Use R for rectal, A for axillary, Tym for tym- an artery is close to the surface and to an underly-
panic, and TA for temporal artery. ing solid structure such as a bone. Common pulse
266 UNIT 4 Integrated Clinical Procedures

sites include the radial, carotid, temporal, bra- the head. It is rarely used to obtain a pulse rate but
chial, femoral, popliteal, and dorsalis pedis arter- may be used to monitor circulation, control bleed-
ies (Figure 12-7). An apical pulse, located at the ing from the head and scalp, and to take a tempo-
apex of the heart, may also be taken. Although the ral artery temperature.
radial, brachial, and carotid arteries are the most • The femoral pulse is located in the groin area. It is a
frequently used sites for pulse rates, it is important deep artery and must be compressed firmly to be felt.
to recognize pulse beats because circulation may
be monitored by palpating the other sites. Pulse • The popliteal pulse is located at the back of the knee.
sites are also used when necessary as pressure The patient must be in a supine position with the
points for controlling severe bleeding. knee flexed for it to be felt because the artery is deep
within the knee. This artery is used for leg blood
• The radial pulse is located at the thumb side of the pressure measurements and to monitor circulation.
wrist approximately 1 inch above the base of the • The dorsalis pedis pulse is felt on the top of the foot
thumb. This is the most commonly used site for slightly to the side of midline next to the extensor
obtaining a pulse rate. ligament of the great toe, between the first and
• The carotid pulse, used during emergency situations second metatarsal bones. It is commonly used to
and when performing cardiopulmonary resuscita- monitor lower limb circulation.
tion (CPR), is found between the larynx and sterno- • Apical pulse is found at the apex of the heart,
cleidomastoid muscle in the front side of the neck located at the fifth intercostal space left side, mid-
on either side of the trachea. When measuring the clavicular line, that is, between the fifth and sixth
pulse at the carotid site, compress only one side at a ribs perpendicular to the middle of the clavicle,
time. left of the sternum. A stethoscope is required to
• The brachial pulse is found in the inner aspect of obtain an apical pulse. Apical pulse is used for car-
the elbow called the antecubital space. This pulse diac patients and patients with an arrhythmia, and
site is the most commonly used site to obtain blood to obtain infant pulse rates because they are diffi-
pressure measurements. cult to obtain by the usual methods.
• The temporal pulse is located at the temple area of

Measuring and Evaluating

a Pulse
Temporal
artery When measuring a pulse rate, other characteristics
Carotid besides the rate are noted, such as rhythm, volume
artery of pulse, and condition of the arterial wall.
Apical The rate is the number of pulsations or beats
felt in 1 minute. The pulse is counted for 30 seconds,
then the number is doubled. Pulse rates may vary
Brachial
artery according to age, activities, general health, sex, emo-
tions, pain, and medications. The rate is lower when
sleeping and higher when active or exercising. Rates
Radial for infants and children are greater than for adults.
artery Well-conditioned athletes have a lower than average
resting rate because their cardiovascular system has
Femoral been developed to function more efficiently.
artery Rhythm of the pulse refers to the time
between pulsations and regularity of the beat. Nor-
Popliteal
artery mal rhythm occurs when the beats are felt at regu-
(behind knee) lar intervals. In abnormal rhythms, arrhythmias,
the interval between pulsations is altered by either
an increased or decreased time span. Arrhythmias
Dorsalis pedis
must be noted and reported because they may
artery indicate heart disease.
The volume of the pulse refers to the strength
of the beat that is felt. The pulsations may feel full,
Figure 12-7 Pulse sites in the body. strong, hard, soft, thready, or weak. A pulse may have
 CHAPTER 12 Vital Signs and Measurements 267

a regular rate and yet have a variation in intensity or reported to the provider; for example: P 72 irreg-
volume. Volume should be noted and reported. ular  2 minutes.
Condition of the arterial wall can be felt as Procedure 12-7 describes measuring a radial
the pulse is taken. The normal artery feels soft and pulse; Procedure 12-8 describes measuring an api-
elastic. The abnormal artery may feel hard, knotty, cal pulse.
wiry, or a combination of these. These should be
noted and reported because they may indicate car-
diac disease. RESPIRATION
The function of respiration (breathing) is the
Normal Pulse Rates exchange of the gases oxygen and carbon dioxide.
Average pulse rates vary from birth to adulthood. External respiration occurs when oxygen is drawn
At birth, the pulse rate is much higher; as we age, it into the lungs when breathing in and carbon diox-
generally decreases. ide is expelled from the lungs when breathing out.
Internal respiration occurs when oxygen is used
by the cells for cellular function. Carbon dioxide
is a by-product of cellular function and is expelled
via exhalation as a waste product. Respiration is an
NORMAL PULSE RATES involuntary act controlled by the medulla oblon-
Birth 130–140 beats per minute gata of the brain. The medulla oblongata measures
Infants 110–130 beats per minute blood levels of carbon dioxide and triggers a respi-
Children 1 year 110–130 beats per minute ration when the level of carbon dioxide increases.
2 years 96–115 beats per minute Although it is an involuntary act, respiration may
3 years 86–105 beats per minute be altered by holding the breath or when hyper-
7–14 yerars 76–90 beats per minute ventilation occurs. One inspiration (inhalation)
Adults 60–80 beats per minute
drawing in of air and one expiration (exhalation)
expelling air together equals one respiration.
Abnormalities in the characteristics of respi-
Pulse Abnormalities ration, such as rate, rhythm, and depth, are noted
when measuring respiration.
Abnormalities may occur in the rate, rhythm, Respiratory rate is the number of respirations
and feel of the arterial wall. Common pulse rate per minute. The normal respiratory rate, eupnea,
abnormalities include bradycardia, a pulse rate varies with age, activities, illness, emotions, and
less than 60 beats per minute, and tachycardia, a drugs. The average respiration rate to pulse rate is
pulse rate greater than 100 beats per minute. Com- 1:4, one respiration to four pulse beats.
mon arrhythmias include a pulsation felt before Respiratory rhythm refers to the pattern of
expected, which is called a premature contrac- breathing. It can vary with age, with adults having
tion, and sinus arrhythmia. An occasional prema- a regular pattern, but infants having an irregular
ture contraction can occur in response to stress, pattern. Rhythm may be altered by laughing and
caffeine, nicotine, alcohol, or lack of sleep. Sinus sighing.
arrhythmia may occur during respiration and can
be found in some children and young adults. The
rate increases with inspiration and decreases with
expiration. It usually does not require treatment.
NORMAL RESPIRATORY RATES
When any pulse rate abnormalities or arrhyth- Newborns 44 respirations per minute
mias are felt, take the pulse for 1 full minute, note Infants 20–40 respirations per minute
the frequency of the abnormality, record the abnor- Children (1–7 years) 18–30 respirations per minute
Adults 12–20 respirations per minute
mality, and alert the provider. The provider may
want you to take an apical pulse (see Chapter 25).

Depth of respiration is the amount of air that

Recording Pulse Rates is inspired and expired with each respiration. In the
Pulse rates are normally recorded after the tem- resting state, the amount should be consistent. Depth
perature; for example: T 98.6°F P 72 regular. is noted by watching the degree of rise and fall of
Any unusual findings should be recorded and the chest wall when measuring respiration rate.
268 UNIT 4 Integrated Clinical Procedures

Hypoventilation occurs when respiration

Respiration Rate is decreased in rate and shallow in depth. It may
Respiratory rate is measured by counting breaths result from a depression of nervous stimuli of the
for 30 seconds and doubling the amount. This will respiratory center in the brain.
give the number of respirations per minute. It is Hyperpnea is respiration that is increased
important that patients not be aware you are mea- in both depth and rate. It is commonly seen with
suring their respirations. The rate may change if the activities such as physical exercise. It can also be
patient knows they are being counted. Procedure associated with pain, respiratory diseases, cardiac
12-9 gives steps for measuring respiration rate. diseases, hysteria, and use of certain drugs.
Hyperventilation is a type of breathing in
which the amount of oxygen drawn in during inspi-
Abnormalities ration is greatly increased, resulting in a decrease
Abnormalities of the respiration rate may be found in the amount of blood carbon dioxide. Hyperven-
in the rate, depth, rhythm, and sounds of respi- tilation may be associated with asthma, pulmonary
ration. Some rate abnormalities include apnea, embolism or edema, and acute anxiety. The patient
tachypnea, bradypnea, and Cheyne–Stokes. Sleep can be treated by reducing the amount of oxygen
apnea and narcolepsy are considered sleep disor- inhaled during an inspiration. The patient may be
ders and involve the respiratory system. instructed to hold one nostril closed while breath-
Apnea is the temporary complete absence of ing or may be instructed to breathe into a paper
breathing. It may result from a reduction in stimuli bag. Either procedure will reduce the amount of
to the respiratory center of the brain. Apnea will inspired oxygen and bring the oxygen and carbon
occur when the breath is voluntarily held and in dioxide blood levels back to within normal range.
Cheyne-Stokes respiration. It can be a serious
symptom of other conditions of the cardiovascular Sleep Apnea. Airflow during respiration that
and renal systems. It also can result from a head stops for more than 10 seconds is considered to be
injury such as a concussion. sleep apnea. The periods of apnea cause carbon
Tachypnea is a respiratory rate greater than dioxide to accumulate in the blood and oxygen to
40 respirations per minute. It may be caused by be depleted. For these reasons, sleep apnea can
hysteria or be transient in the newborn. Excessive be dangerous. Oxygen depletion to the brain can
loss of carbon dioxide may occur if tachypnea is cause memory impairment, cognitive changes, and
prolonged; there is a potential for this to lead to daytime sleepiness. If the condition goes untreated,
more serious problems. sleep apnea can result in cardiac arrhythmias, con-
Bradypnea is a decrease in the number of res- gestive heart failure, cerebral vascular accident
pirations and is commonly seen during sleep or (CVA), hypertension, and death.
because of certain diseases. Sleep apnea is associated with airway obstruc-
Cheyne–Stokes is a breathing pattern that tion. The soft palate (especially in males who are
starts with a period of apnea lasting 10 to 60 overweight and who snore) can collapse while the
seconds followed by increasing depth and rate of patient is asleep. The result is apnea. The patient
respiration, which is then followed by a decrease usually awakens from sleep enough to resume
in rate with apnea starting the cycle once again. breathing.
This cycle may be normal for children but may Sleep apnea is diagnosed by sleep laboratory
indicate brain dysfunction in other age groups. studies when apnea is observed while the patient is
Orthopnea is a respiratory condition of severe sleeping.
dyspnea (labored breathing). Breathing is difficult Treatment of sleep apnea consists of weight loss
in any position other than sitting erect or standing. and continuous positive airway pressure (CPAP), a
This condition may be seen in patients with heart device that puts pressure on the airway while the
failure, angina pectoris, asthma, pulmonary edema, patient sleeps. A mask is placed over the patient’s
emphysema, pneumonia, and spasmodic coughing. face to keep the airway open. This prevents sleep
Patients who experience orthopnea must be exam- apnea. A surgical procedure can be performed to
ined in a sitting position. Other positions will cause remove parts of the soft palate and uvula.
discomfort and may not be possible.
Abnormalities in the depth of respiration are Narcolepsy. Narcolepsy is another type of sleep
divided into shallow abnormalities, such as hypoven- disorder that causes patients to have daytime sleep-
tilation, and deep abnormalities, such as hyperpnea ing while driving, eating, or sitting in a movie the-
and hyperventilation. ater. The patient can become paralyzed from the
 CHAPTER 12 Vital Signs and Measurements 269

sleep, being unable to move, but can still breathe. elasticity, condition of the muscle of the heart, genet-
The cause may be genetic. ics, diet and weight, activity, and emotional state.
The diagnosis is made by ruling out sleep
apnea (through sleep studies) and by the history • Blood volume is the amount of blood within the
of repeated episodes of daytime sleeping for a few arteries. Increased volume of blood increases blood
seconds to half an hour. The disorder is not under pressure, whereas a decrease in blood volume
the patient’s control. decreases blood pressure, as in the case of a hemor-
rhage or severe dehydration.
Breath Sounds. The presence or absence of breath • Peripheral resistance is the resistance to blood flow
sounds can be indicative of respiratory problems. within the arteries. The resistance is in direct relation
Sounds should be listened for and noted when tak- to the lumen of the arteries. The smaller the lumen,
ing the patient’s respiratory rate. the more pressure needed to push blood through.
Rales (pronounced “rawles”) are rattling The reverse is also true: the larger the lumen, the
sounds heard during inspiration and expiration less resistance and less pressure needed to push the
when the lung passageways contain secretions. The blood through. The size of the lumen can become
provider uses a stethoscope to auscultate or listen smaller from deposits of fatty cholesterol (plaque),
for rales, which are associated with some lung dis- resulting in an increase in blood pressure.
eases. Rhonchi are sounds similar to snoring, usu- • Vessel elasticity refers to the ability of arteries to
ally produced by a rattle in the throat. These are expand and contract to provide a steady flow of blood.
also heard by auscultation. As a person ages, elasticity of the vessels is reduced.
Wheezes are high-pitched musical sounds Atherosclerosis can cause an increase in arterial wall
heard on expiration. They can be the result of resistance, resulting in an increase in blood pressure.
an obstruction in the bronchi and bronchioles of
• The condition of the heart muscle is extremely
the lungs. Wheezes are commonly associated with
important to blood flow and blood pressure. A
asthma and emphysema, a chronic pulmonary dis-
strong heart muscle provides a forceful pump result-
ease characterized by dilated and damaged alveoli.
ing in efficient blood flow and normal blood pres-
Stridor is a crowing sound heard on inspira-
sure. A weak heart muscle results in an inefficient
tion as a result of an obstruction of the upper air-
pumping action of the heart leading to a decrease in
way. It is associated with laryngitis, a foreign body
blood pressure and blood flow (see Chapter 25).
obstruction, and croup in children.
Stertorous respiration is described as a snoring The viscosity of the blood also is a factor in
sound with labored breathing. The sound usually is blood pressure. Viscosity refers to how sticky a sub-
created by partial obstruction of the upper airway. stance is, in this case, the blood. If the blood is sticky,
it acts thicker. Imagine holding a bottle of thin syrup
upside down over your pancakes. The thin syrup
BLOOD PRESSURE comes out of the bottle quite readily. Now imagine
holding a bottle of thick molasses over the pancakes.
Blood pressure measures cardiovascular function Being very viscous, the molasses is thicker and much
by measuring the force of blood exerted on periph- more difficult to pour. So it is with viscous blood; it
eral arteries during the cardiac cycle or heartbeat. is thicker and requires a lot more work for the heart
The measurement consists of two components. muscle to move it through the vessels, thus increasing
The first is the force exerted on the arterial walls the pressure inside the walls of the arteries. In fact, it
during cardiac contraction and is called systole. may be so viscous that it might not be able to reach
The second is the force exerted during cardiac the tiniest capillaries of the kidney, eyes, and other
relaxation and is called diastole. They represent areas without substantial increase in blood pressure.
the highest (systole) and lowest (diastole) amount
of pressure exerted during the cardiac cycle. Blood Equipment for Measuring
pressure is recordedas a fraction, with the systolic
measurement written, followed by a slash and then
Blood Pressure
the diastolic measurement. Blood pressure is measured by the auscultatory (lis-
tening) method using a sphygmomanometer and
Example: systole/diastole or 120/80 a stethoscope (Figure 12-8). Three types of sphyg-
momanometers are commonly used in the ambula-
Blood pressure may be affected by many factors, tory care setting: mercury, aneroid, and electronic
including blood volume, peripheral resistance, vessel (digital) manometers (Figures 12-9 to 12-12).
270 UNIT 4 Integrated Clinical Procedures

Mercury sphygmomanometers are being

phased out with other mercury-containing medical
equipment, such as mercury thermometers. Aneroid
and electronic blood pressure measuring devices are
more commonly used. Many medical facilities con-
tinue to use mercury sphygmomanometers while
phasing them out in agreement with the EPA, but
the process has been slower than the phasing out

Figure 12-8 Adult stethoscope is used with a sphyg-

momanometer to measure blood pressure. (Courtesy
of Welch-Allyn.)

Figure 12-10 Digital sphygmomanometer.

Figure 12-9 A mercury gravity sphygmomanometer.

Figure 12-11 Aneroid sphygmomanometer. (Cour-

tesy of Welch-Allyn.)
 CHAPTER 12 Vital Signs and Measurements 271

(A)

(B)

Figure 12-12 (A) Mobile aneroid sphygmomanometer. (B) Wall-mounted aneroid sphygmomanometer. (Courtesy
of Welch-Allyn.)

of mercury thermometers; therefore, information cause health and environmental problems. Mercury
about the mercury sphygmomanometers is provided manometers need to be cleaned and checked regu-
in this chapter. larly for accuracy by a professional technician. Care
The mercury manometer consists of a cuff con- in handling and storage is important to prevent air
taining a rubber bladder attached by rubber tubing bubbles and dirt from forming in the column or
to a glass column of mercury. The blood pressure is breaking the glass containing the mercury.
read at the meniscus of the mercury as it descends The aneroid manometer is a cuff containing a
the column. Mercury manometers are the most rubber bladder attached to a dial. The blood pres-
accurate method of blood pressure measurement sure is read at the point of the needle descending
and are considered the standard because blood the dial. Aneroid manometers need to be calibrated
pressure is measured in millimeters of mercury. regularly because they do not maintain calibration
Although the most accurate, mercury manometers easily. Care in handling and storage will decrease
do have disadvantages: they are not as portable as the loss of calibration. Although not as accurate as a
aneroid manometers, and there is always the danger mercury manometer, aneroid manometers are easily
of a mercury spill should the glass column break and portable and there is no danger of a mercury spill.
272 UNIT 4 Integrated Clinical Procedures

An electronic syphmomanometer is auto- Association recommends if there has been a weight

matic and registers blood pressure in digital form loss or gain of 10 pounds, then the cuff size should
on a screen (Figure 12-13). No stethoscope is be reassessed for the appropriate size.
needed. Once the cuff is secured on the patient’s
upper arm, the medical assistant pushes a button
and the cuff inflates; the medical assistant then
Measuring Blood Pressure
releases the pressure slowly. A readout is visible The sounds heard during blood pressure measure-
on the screen (124/75). In addition to blood pres- ment are named the Korotkoff sounds. The cause
sure reading, the unit can automatically measure of the sounds is not known. They may be a result of
pulse rate and other vital signs. A pulse oximeter distention of the vessels or the sound of the blood
(Figure 12-14) measures the amount of oxygen passing through the vessels. In either case, Korot-
present in the patient’s blood. The measurement koff sounds have five distinct phases. Not all phases
automatically appears on the screen when the are heard easily, especially for beginners.
device is attached to the patient.
Cuff sizes for manometers range from the • Phase I. Begins with the first sound heard when
smallest pediatric cuff to the largest obese and deflating the cuff. It is a sharp tapping sound. Note
thigh cuff (Figure 12-15). The appropriate cuff size this first sound as this will be the systolic reading of
is necessary to obtain an accurate blood pressure the blood pressure.
measurement. A cuff that is too small will give an
artificially high blood pressure reading, whereas
a cuff that is too large will give an artificially low
reading. The selection of the cuff size depends on
the size of the arm, not the age of the patient. Due
to the size of the arm, it may be necessary to use
an adult-size cuff on a child or a pediatric-size cuff
on an adult. Adult cuffs should have a width that
covers one third to one half the circumference of
the arm. The length of the bladder should cover
approximately 80% of the arm (about twice the
size of the width). The cuff for a child should cover
two thirds of the upper arm. The American Heart

Figure 12-14 Pulse oximeter.

Figure 12-15 Blood pressure cuffs in sizes to fit the

arm of a small child to the thigh of an adult. It is
Figure 12-13 An electronic sphygmomanometer can important to have the correct size to obtain an accu-
measure pulse and other vital signs simultaneously. rate reading.
 CHAPTER 12 Vital Signs and Measurements 273

• Phase II. This sound is the result of more blood

Table 12-1 Errors in Blood Pressure
passing through the vessels as the cuff is deflated.
Measurement Procedures
The sound is that of a soft swishing sound.
• Phase III. More blood continues to pass through the Errors in measuring blood pressure must be avoided.
vessels as the cuff is deflated. The sound is a rhyth- Common errors include:
mic tapping sound. If blood pressure measure-
ments are not carefully followed and Phases I and II 1. Improper cuff size.
are missed, Phase III may erroneously be reported
as the systolic pressure. 2. The arm is not at heart level. Do not hold the arm
up or let the patient hold up the arm. Pressure is
• Phase IV. Blood is now passing through the ves- increased when this is done.
sels fairly easily as the cuff is deflated. The sounds
heard will be a muffling and fading of the tapping 3. Cuff is not completely deflated before use or after
sounds. This phase may be used to record the dia- palpatory method, resulting in a higher pressure
stolic pressure in children and in those patients measurement.
where a tapping sound is heard to zero.
4. Deflation of the cuff is faster than 2 to 4 mm Hg
• Phase V. Blood is flowing freely at this time; a conse- per heartbeat or 20–30 increments on the aneroid.
quently all sounds disappear. The disappearance of Sounds are missed if this happens.
sounds is noted and recorded as the diastolic pressure.
5. Reinflating the cuff during the procedure without
allowing the arm to rest for 1 to 2 minutes.
When measuring blood pressure, keep two
things in mind: patient comfort and accuracy.
6. Patient is not relaxed and comfortable. An anxious,
Auscultatory gap is heard in some patients. It is apprehensive patient will have a reading that is
a time, usually between Phases I and II or III, when higher than the actual blood pressure.
all sounds disappear. Within 20 to 30 mm Hg, or
20 to 30 increments on the aneroid, the sounds 7. Improper cuff placement. Cuff is too loose, too tight,
reappear. If the procedures are not followed care- or not positioned correctly over the brachial artery.
fully, the auscultatory gap is easily missed, and the
blood pressure measurement is incorrect in that 8. Defective equipment in which there are air leaks in
systolic and diastolic readings may be in error the bladder or valve, the mercury column is dirty,
or air bubbles are present. Mercury and aneroid
according to the length of the gap (Table 12-1). sphygmomanometers are not calibrated at zero.
Pulse pressure is the difference between the
systolic and diastolic measurements. The normal 9. Measuring blood pressure with thumb on the head
range for pulse pressure is 30 to 50 mm Hg. The of the stethoscope.
difference should be no more than one third of
the systolic reading. For example, if the blood All of these errors are easily corrected by following
pressure is 120/80 a normal pulse pressure should careful procedure and by having the manometers
calibrated and cleaned according to a regular main-
be 120 minus 80 or 40. One third of the systolic
tenance schedule.
reading of 120 is 40. Therefore, 40 mm Hg pulse
pressure is within the normal range.

Recording Blood Pressure 120

Example: 120/70/0 or 70
Measurement 0

The blood pressure is recorded on the patient chart

or electronic medical recored in a fraction format. Procedure 12-10 outlines the procedure for
The position of the patient (sitting or lying down) measuring blood pressure.
may be noted. The arm used is also noted, particu-
larly if the blood pressure was taken in both arms.
Normal Blood Pressure Readings
120
Example: 120/80, ® arm, supine or 80 ® arm, supine Normal blood pressure is low at birth and gradu-
ally increases with age until adulthood, at which
For children and those patients whose blood point it should remain fairly constant. Blood pres-
pressure can still be heard to zero, the beginning sure measurements are taken during yearly physi-
of Korotkoff Phase IV and zero both are recorded. cal examinations beginning at age 3.
274 UNIT 4 Integrated Clinical Procedures

blood pressure for adults 18 years and older is less

NORMAL BLOOD PRESSURE READINGS than 120/80, prehypertension is 120–139/80–89,
In a healthy child, blood pressure is taken for the first time hypertension stage 1 is 140–159/90–99, and hyper-
during the physical exam when the child is 3 years old. Blood tension stage 2 is ≥160/≥100.
pressure in children varies based on their gender and height • Secondary hypertension is the result of some
percentile. underlying problem, such as renal disease, preg-
nancy, endocrine imbalances, obesity, arterio-
Child 10 years 100/65
Adolescent 16 years 118/75
sclerosis, or atherosclerosis. Once the underlying
Adult Systolic less than 120 problem is removed, the blood pressure returns to
Diastolic less than 80 normal or near normal. Secondary hypertension
Prehypertension 120–139/80–89 can be successfully treated.
High blood pressure Above 140/90 • Hypertension that has a slow progression but may
progress to the same end point as malignant hyper-
tension is referred to as benign hypertension.
• Malignant hypertension (no association with cancer)
Blood Pressure Abnormalities progresses rapidly with severe damage to the cardio-
There are only two possible blood pressure abnor- vascular system, possibly to the point of death.
malities: hypertension, blood pressure that is con- • White coat hypertension is hypertension that can
sistently above normal, and hypotension, blood occur in some individuals. It is caused by anxiety
pressure that is consistently below normal in which or fear when blood pressure measurements are
patients are unable to perform their normal activi- taken by a provider.
ties without dizziness and extreme fatigue.

Hypertension. There are five types of hyperten- Hypotension. Hypotension is blood pressure per-
sion: primary or essential, secondary, benign, and sistently less than normal, usually less than 90/60,
malignant. although this may be normal for some healthy
adults. Hypotension is defined as a blood pres-
• The most commonly seen form of hypertension sure so low that the patient is unable to function
is primary or essential. It is hypertension with no normally. It is usually a result of various shocklike
apparent cause or cure but is treatable. Treatment conditions such as hemorrhage, traumatic or emo-
is designed to control hypertension and is a life- tional shock, central nervous system disorders, or
long process. It will not be cured, just controlled. chronic wasting diseases. With successful treatment
The American Heart Association (AHA) suggests of the underlying problems, the blood pressure
that to diagnose hypertension, the diagnosis is usually will be in the range of normal readings.
based on the average of three readings at each of Orthostatic hypotension, sometimes called
three visits to the provider’s office after the initial postural hypotension, occurs when a person rapidly
baseline screening. According to the AHA, normal changes position from supine to standing, when

Patient Education
Hypertension is at epidemic proportions in have inherited hypertensive tendencies. With
the United States, and many patients are not the provider’s advice, there are steps to take
treated because they do not know that they include: eating plenty of produce, grains, and
have the problem. It is known as the “silent low-fat dairy foods; cutting back on salt; stop-
epidemic” because most people do not expe- ping smoking; exercising regularly; maintain-
rience any symptoms over a span of years. ing a healthy weight; limiting alcohol intake;
However, untreated or poorly treated hyperten- and reducing stress. It is easy to see that these
sion over time can damage the heart, cause recommendations all are lifestyle changes.
myocardial infarction, cause a stroke (cerebrol They can significantly reduce blood pressure if
vascular accident), or lead to kidney failure. practiced daily. Blood pressure must be moni-
There are several nondrug ways to tored regularly by your provider.
reduce blood pressure, even for people who
 CHAPTER 12 Vital Signs and Measurements 275

standing in one position for too long, or as a side

effect of certain medications. In this instance, the
blood pressure has momentarily decreased, and
the person experiences vertigo (dizziness) and may
have blurred vision. These symptoms usually last
only a few seconds, just long enough for the blood
pressure to return to normal. Care should be taken
when helping patients to an upright position from a
supine position because orthostatic hypotension can
lead to syncope (fainting) and injury from falling.

HEIGHT AND WEIGHT

Although not considered a vital sign, height and
weight are routinely measured if warranted by
the age and the physical condition of the patient.
Many providers prefer that height and weight be
measured as part of a yearly physical examination
and otherwise may vary the frequency of patient
height and weight measurements. Height and
weight are normally measured simultaneously.
For children, height and weight are typically
measured during each provider visit. The height
of adults may be obtained on the initial visit only
and weight taken on all visits. An adolescent or
young adult may have height measured more fre-
quently to plot body changes. Because older adult
patients tend to lose the cushioning between ver-
tebrae through osteoporosis as part of aging, they
may need to have their height measured more fre-
quently to check the stage of any degeneration.
Older adult patients require special atten-
tion by the medical assistant when mea-
suring height and weight. It is especially
important to assist older patients both on and off
the scale, because the scale platform is movable,
and older patients may lose their balance and fall if
unassisted. A stand-alone walker can be placed over Figure 12-16A Traditional beam balance scale with
the scale platform to aid in stabilizing the patient. measuring bar.

Height
To measure a patient’s height, a scale with a mea- The patient is asked to step on the scale and face
suring bar is necessary (Figure 12-16A). A paper away from the measuring bar. Assist patient onto
towel is placed on the scale because the patient’s the scale; the scale platform is movable and the
shoes should be removed for accurate measuring. patient could fall.
There are two reasons for having the patient’s
back to the scale. When the measuring bar is lifted,
it could cause face or eye injuries if the patient were
Critical Thinking facing the bar. Lifting the measuring bar prior to
Discuss the normal vital signs differences the patient stepping on the scale can also lead to
expected between an infant and an adult. eye and face injuries in that the patient could inad-
Why do they occur? vertently walk into the bar. Another reason to have
the patient’s back to the scale is if the patient does
276 UNIT 4 Integrated Clinical Procedures

be measured on each visit, whereas others do not

if there are no health problems that require
weight monitoring. Some health conditions that
do require weight monitoring include obesity, eat-
ing disorders, hormone disorders such as diabetes
and thyroid malfunction, hypertension, pregnancy,
cancer, and some digestive disorders.
When measuring the weight of a patient,
the medical assistant must maintain the
patient’s privacy. Most people are conscious
of their weight and may become embarrassed if the
measurement is taken where others may see and
Figure 12-16B The height is read at the moveable hear. Privacy is important and often overlooked.
point of the ruler. The bars are measured in one- The medical assistant must also be careful of
quarter inches. Note the height measurement is comments regarding a patient’s weight, particularly
74.25 inches or 6 feet 2 ¼ inches. with the obese patient and with those being treated
for eating disorders (see Chapter 22). Encourage-
not look straight ahead, the head is not level, which ment for weight loss for the dieting patient is bene-
could result in a less than accurate measurement. ficial but must be done in privacy. Other comments
After the patient is on the platform, the mea- are inappropriate.
suring bar is placed firmly on the patient’s head, Occasionally a patient will be instructed
and the line between where the solid bar and by the provider to monitor weight at home. It is
sliding bar meet is read. The bars are measured important for the patient to understand the neces-
in quarter inches (Figure 12-16B). Children’s sity of weighing at the same time each day because
heights are recorded in inches, whereas adults weight may vary significantly throughout the day.
are recorded in feet and inches. Conversion from A normal routine is to measure weight before
inches to feet is accomplished by taking the num- breakfast.
ber of inches and dividing by 12. Procedure 12-11 Before an accurate weight can be obtained,
gives steps for measuring height. the scale must be calibrated. The point of the bal-
ance beam must be floating in the center when
no weight is applied to the scale. Some scales are
Weight equipped with a screw at the end that can be turned
Provider preference and patient health dictate slightly until the beam is in the correct floating
the frequency of measuring an adult’s weight. position. Once it is centered, it is calibrated and
Some providers require the patient’s weight to ready for use (Figure 12-17).

0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36 38 40 42 44 46 48 50

0 50 100 150 200 250

50

49

48

47

46
Small Weight 45 Large Weight Balance Bar
Indicator Indicator
44

Figure 12-17 The upper bar indicates small pound weights (from 0−50 lb). The weight shown on the lower bar is
measured in 50-lb increments. The lower measurement is added to the upper bar amount that is shown. The upper
bar shows 22 lb; the lower bar measures 100 lb. Upper bar 22 lb plus lower bar 100 lb equal total weight 122 lb.
 CHAPTER 12 Vital Signs and Measurements 277

An eye-level digital scale with measuring

bar measures height in the same way on the mea-
suring bar of the digital scale as it is on the bal-
ance beam measuring bar. Weight measurement
is quicker, easier, and usually safer taken on the
digital scale. The scale platform is stationary, and
the patient is assisted as needed onto the scale;
the digital reading is ready in a few seconds
(Figure 12-18).
The patient can wear normal indoor clothing,
rather than disrobing, for weight measurement.
Heavy coats or other outerwear should be removed.
Heavy objects and purses should not be held dur-
ing the procedure. A chair or counter should be
provided to place these objects on while the proce-
dure is being performed. Shoes should be removed.
Procedure 12-12 gives steps for measuring adult
weight.
Occasionally, as in the case of medication dos-
age, the medical assistant is required to convert
pound weight into kilogram weight.
1 kilogram  2.2 pounds
To convert pounds to kilograms:
Take the number of pounds and divide by 2.2

Example:
130 pounds divided by
2.2  59.09 kg
Figure 12-18 An electronic scale.
To convert from kilograms to pounds:
Take the number of kilograms and
multiply by 2.2
ration. A comparison is then made to ascertain
Example: chest capacity. To perform the procedure, ask the
patient to disrobe from the waist up. Place a tape
50 kilograms multiplied by measure around the chest at nipple level. Instruct
2.2  110 lb.
the patient to inhale deeply while you measure,
then ask the patient to exhale completely while you
take the second measurement. Record the results
Significance of Weight as inspiration number and expiration number (see
The careful monitoring of a patient’s weight may Chapter 18).
provide an insight into metabolic, nutritional, and
emotional problems.

MEASURING CHEST Critical Thinking

CIRCUMFERENCE
Discuss the methods the medical assistant
Occasionally, the medical assistant is instructed may use to obtain patient cooperation when
to measure the chest of an adult. This procedure taking vital signs. Describe and demonstrate
may be done on patients with emphysema and the appropriate charting procedure for normal
as a requirement for insurance and truck driver vital sign results.
licenses. Two measurements are taken, one on the
deepest inspiration and one on the deepest expi-
278 UNIT 4 Integrated Clinical Procedures

Procedure 12-1
Measuring an Oral Temperature Using an Electronic Thermometer
STANDARD PRECAUTIONS: 8. Cover with probe cover (Figure 12-19).
RATIONALE: To prevent microorganism cross
contamination.
9. Insert under the tongue to either side of the
PURPOSE: mouth (Figure 12-20). RATIONALE: Under
To obtain an oral temperature. the center of the tongue is the frenulum, which
impedes placement in this area.
EQUIPMENT/SUPPLIES:
Electronic thermometer 10. Instruct patient to close mouth without placing
Probe covers teeth on thermometer. RATIONALE: To prevent
Biohazard waste container air leakage.
11. Leave in place until the beep is heard.
PROCEDURE STEPS:
1. Wash hands and follow Standard Precautions. 12. Remove thermometer after appropriate time
has elapsed.
2. Assemble equipment.
13. Read the results on the digital display window.
3. Identify patient.
14. Discard probe cover in biohazard waste container.
4. Position the patient in a comfortable position.
15. Replace electronic thermometer in the base
5. Determine if the patient has ingested hot or holder, if required for recharging.
cold drinks or food or has been smoking within
the previous half hour. RATIONALE: Ingesting 16. Wash hands.
hot or cold substances or smoking can result in 17. Record temperature in patient’s chest or elec-
an arbitrary increase or decrease in temperature tronic medical record.
results.
6. Explain the procedure. RATIONALE: To obtain DOCUMENTATION
patient cooperation and consent. 5/26/20XX 11:00 AM T 99.2°F, P 96, R 14. C. McInnis,
RMA _________________________________________
7. Select blue (oral) probe.

Figure 12-19 Slide the probe into the disposable Figure 12-20 Insert the thermometer under tongue
cover, adjusting if necessary. to either side of mouth.
 CHAPTER 12 Vital Signs and Measurements 279

Procedure 12-2
Measuring an Aural Temperature Using a Tympanic Thermometer

STANDARD PRECAUTIONS: 13. Record temperature in patient’s chart or elec-

tronic medical record, indicating tympanic mea-
surement (Tym).

PURPOSE: DOCUMENTATION
To obtain an aural temperature using a tympanic 5/26/20XX 4:00 PM T 99.6° F (Tym), P 100, R 20. C. McInnis,
thermometer. RMA _________________________________________
EQUIPMENT/SUPPLIES:
Tympanic thermometer (Figure 12-21)
Probe covers or ear speculum
Waste container
PROCEDURE STEPS:
1. Wash hands following Standard Precautions.
2. Assemble equipment.
3. Identify the patient.
4. Explain procedure. RATIONALE: This will help
gain patient’s cooperation and consent.
5. Place cover on thermometer (Figure 12-22).
6. Set thermometer to start.
7. Gently straighten ear canal up and back for adults Figure 12-22 Attach the disposable speculum or
and place probe into ear canal to seal the area and cover to the tympanic thermometer to prevent spread
activate the system (Figure 12-23). RATIONALE: of microorganisms between patients.
Air leaks will occur if the ear canal is not sealed.
8. Wait until the temperature is displayed on the
screen.
9. Remove from the ear.
10. Discard cover into waste container by pressing
the release button.
11. Wash hands.
12. Replace thermometer.

(A) (B) (C)

Figure 12-21 Tympanic thermometer: (A) Holder.

(B) Tympanic thermometer. (C) Disposable speculum Figure 12-23 Pull up on the ear to straighten the
or cover. auditory canal for an accurate reading.
280 UNIT 4 Integrated Clinical Procedures

Procedure 12-3
Measuring a Temperature Using a Temporal Artery (TA) Thermometer
STANDARD PRECAUTIONS: 6. Hold the probe in the center of patient’s fore-
head flush against the skin. RATIONALE:
Probe must be centered properly for accurate
reading over area.
PURPOSE: 7. Press the scan button and hold while sliding the
To obtain a temporal artery temperature using a tem- thermometer slowly across the forehead to the
poral artery (TA) thermometer. temple area hair line. There will be a tapping or
clicking sound that will stop when the tempera-
EQUIPMENT/SUPPLIES: ture has been reached.
Temporal artery thermometer
8. Release the button and remove the thermom-
Alcohol wipes, probe cap or cover, or sheath
eter from the forehead.
PROCEDURE STEPS: 9. Read the display for temperature measurement.
1. Wash hands and follow Standard Precautions. 10. Turn upside down and wipe probe with alcohol
2. Assemble equipment. Clean probe with alcohol wipe. Let dry. Return to holder. RATIONALE:
or attach a probe. RATIONALE: The lens of the TA thermometer must be dry to work effectively.
thermometer must be clean to work properly.
11. Wash hands.
3. Identify the patient. RATIONALE: To be cer-
12. Record temperature in patient’s chart or electronic
tain you have the correct patient.
medical record, indicating TA temperature.
4. Explain the procedure. RATIONALE: Gain
patient’s cooperation and permission. PRECAUTIONS:
5. Remove perspiration from forehead, remove Check the manufacturer’s manual. Some models
hat, push back hair from forehead. RATIO- cannot be used when oxygen is being used or when in
NALE: False readings can occur from moisture close proximity to aerosols.
(perspiration) on forehead cooling the skin or
from a hat or hair covering forehead, raising DOCUMENTATION:
the temperature. 8/31/20XX T. 99.8° F (TA) C. McInnis, RMA ___________

Procedure 12-4
Measuring a Rectal Temperature Using a Digital Thermometer
STANDARD PRECAUTIONS: Lubricating jelly on a 4 x 4 gauze or in packet
Gloves
Biohazard waste container

PURPOSE: PROCEDURE STEPS:

To obtain a rectal temperature using a digital ther- 1. Wash hands and don gloves following Standard
mometer. Precautions.
2. Assemble equipment.
EQUIPMENT/SUPPLIES:
3. Identify patient.
Digital thermometer with red probe (rectal)
Probe cover

continues
 CHAPTER 12 Vital Signs and Measurements 281

Procedure 12-4 (continued)

4. Explain procedure to patient. RATIONALE: 11. Hold in place until the beep is heard.
Ensures understanding and gains patient coop- 12. Read results on digital display window.
eration and consent.
13. Remove from rectum.
5. Remove patient’s clothing from the waist down;
14. Discard probe cover into biohazard waste con-
drape as necessary. RATIONALE: Maintains
tainer by pushing the release button.
patient’s modesty, privacy, and warmth.
15. Replace thermometer on holder base.
6. Position patient in Sims’ position.
16. Remove gloves, discard in biohazard waste con-
7. Place probe cover on red probe (rectal). RATIO-
tainer, and wash hands.
NALE: To prevent microorganism cross contami-
nation. Red probe indicates rectal thermometer. 17. Offer tissue to patient to wipe anus. Assist patient
in dressing and position as necessary.
8. Lubricate with lubricating jelly. RATIONALE: Eas-
ier insertion of thermometer and safety for patient. 18. Record temperature in patient’s chart or elec-
tronic medical record, indicating a rectal tem-
9. Spread buttocks and gently insert thermometer
perature (R).
into the rectum past the sphincter (1½ inches)
for adult.
DOCUMENTATION
10. Hold buttocks together while holding the ther- 5/28/20XX 8:00 AM T 99.6° F (R), P 104, R 20. C. McInnis,
mometer. Do not let go of thermometer. RATIO- RMA _________________________________________
NALE: Holding buttocks together prevents air
leaks and inaccurate recording. Holding onto
thermometer ensures patient safety.

Procedure 12-5
Measuring an Axillary Temperature
STANDARD PRECAUTIONS: 4. Explain procedure. RATIONALE: This elicits
patient cooperation and consent.
5. Ask patient to remove clothing to provide access
to axilla.
PURPOSE:
6. Cover patient with gown as necessary to maintain
To obtain an axillary temperature using a digital ther-
patient modesty and warmth.
mometer.
7. Wipe axillary area with dry towel or towelette to
EQUIPMENT/SUPPLIES: remove moisture. RATIONALE: Moisture in the
Digital thermometer axilla will cause inaccurate reading.
Sheath
8. Place thermometer in axilla (Figure 12-24).
Towelettes
Paper towels 9. Ask patient to fold arm against chest or abdomen.
10. Leave in place for appropriate time according to
PROCEDURE STEPS: manufacturer’s instructions, usually 10 minutes.
1. Wash hands following Standard Precautions.
11. Carefully remove.
2. Assemble equipment; place sheath on ther-
mometer. 12. Remove sheath and discard.

3. Identify patient. 13. Read thermometer.

continues
282 UNIT 4 Integrated Clinical Procedures

Procedure 12-5 (continued)

14. Sanitize thermometer. Place on clean paper towel.

15. Wash hands.
16. Place clean thermometer in alcohol for
30 minutes.
17. Record temperature in patient’s chart or electronic
medical record, indicating axillary temperature
(A).

DOCUMENTATION
4/30/20XX 2:00 pm T 97° F (A), P 64, R 12. J. Guerra,
CMA (AAMA) __________________________________

Figure 12-24 After placing thermometer in axilla,

ask patient to fold arm against chest or abdomen.

Procedure 12-6
Measuring an Oral Temperature Using a Disposable Oral Strip
Thermometer
STANDARD PRECAUTIONS: half hour. RATIONALE: Ingesting hot or cold
substance or smoking can result in an arbitrary
increase or decrease in temperature results.
6. Explain the procedure. RATIONALE: To obtain
PURPOSE: patient cooperation and consent.
To obtain an oral temperature. 7. Apply gloves.
EQUIPMENT/SUPPLIES: 8. Insert disposable oral strip thermometer under
Oral strip thermometer (Figure 12-25) the tongue to the side of the mouth. RATIO-
Gloves NALE: Under the center of the tongue is the
Biohazard waste container frenulum, the fold of mucus membrane that
attaches the tongue to the floor of the mouth,
PROCEDURE STEPS: which impedes placement in this area.
1. Wash hands following Standard Precautions.
9. Instruct patient to close mouth tightly.
2. Assemble equipment. RATIONALE: To prevent air leakage.
3. Identify patient. 10. Leave in place for 60 seconds.
4. Position the patient in a comfortable position. 11. Remove thermometer after appropriate time
5. Determine if the patient has ingested hot or cold has elapsed.
drinks or food or has smoked within the previous

continues
 CHAPTER 12 Vital Signs and Measurements 283

Procedure 12-6 (continued)

12. Wait 10 seconds to read the dots. 17. Record temperature in patient’s chart or elec-
13. Read temperature by locating the last dot that tronic medical record.
has changed color (Figure 12-26).
14. Discard strip in biohazard waste container. DOCUMENTATION
4/16/20XX 3:15 PM T 101°F, P 100, R 22 (disposable oral
15. Remove gloves and discard in biohazard waste thermometer reading) J. Guerra, CMA (AAMA) ________
container.
16. Wash hands.

MATRIX

F
.0 .2 .4 .6 .8
96
97
98
99
Figure 12-25 Disposable oral strip thermometer.

100
101
102
103
104

Figure 12-26 The reading on this disposable oral

thermometer is 101°F.
284 UNIT 4 Integrated Clinical Procedures

Procedure 12-7
Measuring a Radial Pulse

STANDARD PRECAUTIONS:

PURPOSE:
To obtain a radial pulse rate.

EQUIPMENT/SUPPLIES:
Watch with second hand

PROCEDURE STEPS:
1. Wash hands.
2. Identify patient.
3. Explain procedure. RATIONALE: Ensures pa-
tient cooperation and consent.
4. Position patient with the wrist resting either on a
table or on lap (Figure 12-27).
5. Locate the radial pulse with the pads of your first
three fingers. Do not use thumb; it has its own
pulse.
6. Gently compress the radial artery enough to feel
the pulse.
7. Count the pulsations for 1 full minute.
8. Note any irregularities in rhythm, volume, and
condition of artery. Figure 12-27 Position patient with wrist resting on
table or lap.
9. Wash hands.
10. Record pulse in patient chart or electronic med-
ical record after the temperature, noting any
irregularities.

DOCUMENTATION
2/10/20XX 3:00 pm T 98.2˚F P 80, regular and strong. D. Kolter,
RMA _________________________________________
 CHAPTER 12 Vital Signs and Measurements 285

Procedure 12-8
Taking an Apical Pulse
STANDARD PRECAUTIONS: DOCUMENTATION
7/8/20XX 12 PM T 98.6°F, P (AP) 96 reg. (radial) 100
slightly irregular. Dr. King notified. D. Kolter, RMA ________
PURPOSE: Mid-clavicular
To obtain an apical pulse rate.

EQUIPMENT/SUPPLIES:
Stethoscope
1
Watch with second hand
Alcohol wipes 2

3
PROCEDURE STEPS:
4
1. Wash hands.
2. Assemble equipment. 5

3. Wipe earpiece with alcohol wipes. 5th

intercostal
4. Identify patient. space
5. Explain procedure. RATIONALE: Ensures pa-
tient cooperation and consent. Apex
6. Assist patient in disrobing, removing clothing
from the waist up.
7. Provide a gown or drape for patient modesty
and warmth.
8. Position the patient in a supine position.
RATIONALE: Easier access to apex of heart.
9. Locate the fifth intercostal space, midclavicular,
left of sternum (Figure 12-28). RATIONALE: Figure 12-28 Locate the apical pulse by counting
Location of apex of heart. intercostal spaces. Locate the fifth intercostal space.
10. Place stethoscope on the site and listen for the
lub-dub sound of the heart.
11. Count the pulse for 1 minute; each lub-dub
equals one pulse.
12. Assist the patient to sit up and dress.
13. Wash hands.
14. Wipe earpieces, diaphragm, and tubing of
stethoscope.
15. Record pulse in patient chart or electronic med-
ical record with the designation of apical pulse
(AP) to denote method of obtaining the pulse
and note any arrythmias.
NOTE: Apical pulse and radial pulse are frequently taken
simultaneously, with the radial pulse taken by another
individual (Figure 12-29). Both pulse rates should be Figure 12-29 Sometimes apical and radial pulses
identical. A discrepancy may indicate a cardiac problem. are taken simultaneously.
286 UNIT 4 Integrated Clinical Procedures

Procedure 12-9
Measuring the Respiration Rate
3. Position patient in a comfortable position.
STANDARD PRECAUTIONS:
4. Watch the rise and fall of the chest wall for
1 minute, or while holding the patient’s arm,
place it across the chest and feel for the rise and
NOTE: The respiration rate is normally taken immedi- fall of chest wall. Alternatively, place a hand on
ately before or after the pulse rate. It should be taken the patient’s shoulder and feel and watch for the
without patient knowledge because respiration can rise and fall of the chest wall.
voluntarily be altered. While counting respirations, 5. Note depth, rhythm, and breath sounds while
it is best to continue grasping the wrist as if still tak- counting.
ing the pulse. This procedure will assist in preventing
6. Wash hands.
alteration of breathing by the patient.
7. Record respiration rate in patient’s chart or elec-
PURPOSE: tronic medical record, noting any irregularities
To obtain an accurate respiratory rate. and sounds.
EQUIPMENT/SUPPLIES: DOCUMENTATION
Watch with second hand 8/7/20XX 2:00 PM T 98.6°F, P 84. Rate and rhythm regular.
PROCEDURE STEPS: J. Guerra, CMA (AAMA) ___________________________
1. Wash hands.
2. Identify the patient.

Procedure 12-10
Measuring Blood Pressure
STANDARD PRECAUTIONS: 3. Clean earpieces of stethoscope with alcohol wipe.
4. Identify patient.
5. Explain procedure. RATIONALE: May be the first
instance where blood pressure is measured; to allay
PURPOSE: anxiety and ensure cooperation and consent.
To measure blood pressure.
6. Position patient comfortably; feet flat on the
EQUIPMENT/SUPPLIES: floor, arm resting at heart level on the lap or a
Stethoscope table. RATIONALE: Legs crossed may arbitrarily
Sphygmomanometer increase blood pressure; arm above heart level
Alcohol wipes may result in inaccurate reading.
7. Bare the right upper arm. If clothing is restricting,
PROCEDURE STEPS:
have patient remove it. RATIONALE: Tight cloth-
1. Wash hands.
ing on the arm can produce inaccurate results.
2. Assemble equipment, making sure that cuff size Right arm is used for consistency, but if one arm
is correct. RATIONALE: Inappropriate cuff size measures a higher reading, then that arm is used
will result in inaccurate measurement. consistently to measure the blood pressure.

continues
 CHAPTER 12 Vital Signs and Measurements 287

Procedure 12-10 (continued)

8. Palpate brachial artery. 22. Clean earpieces and diaphragm of stethoscope

9. Securely center the bladder of the cuff over the with alcohol wipes.
brachial artery above the bend of the elbow. 23. Wash hands.
RATIONALE: Cuff should be high enough so 24. Record blood pressure in patient’s chart or elec-
stethoscope does not touch it. Extraneous sounds tronic medical record.
may be heard. Be certain the gauge is on zero.
NOTE: On a patient’s initial visit and in patients with
10. Palpate the radial pulse and smoothly inflate cuff hypertension, the provider may want the blood pres-
until the pulse is no longer felt; note the number. sure taken in both arms. There is normally a slight
11. Quickly deflate the cuff and allow arm to rest for variation in pressure between the arms. If it is nec-
about one minute. Calculate peak inflation level. essary to repeat the procedure, wait approximately
RATIONALE: This ensures that an auscultatory 5 minutes before doing so.
gap is not missed.
DOCUMENTATION
12. Make sure cuff is completely deflated.
2/16/20XX 3:00 PM BP 146/90 in right arm. BP 150/92 in left
13. Position stethoscope over the brachial artery and arm. D. Swingle, CMA (AAMA) ________________________
hold in position with the fingers only.
14. Inflate cuff smoothly and quickly to the peak
inflation level plus 30 mm Hg (Figure 12-30).
15. Deflate the cuff at a rate of 2 to 4 mm Hg per
heartbeat. RATIONALE: No matter how expe-
rienced you become, accurate blood pressure
readings cannot be obtained if the cuff deflation
is greater than 2 to 4 mm Hg per heartbeat.
16. Listen for Korotkoff Phase I; note when it
appears.
17. Continue deflation, noting the Korotkoff phases.
18. Note when all sounds disappear, Korotkoff
Phase V.
19. Continue deflating the cuff at the same rate for
at least another 10 mm Hg after sounds have dis-
appeared. RATIONALE: To hear an auscultatory
gap should one be present.
20. Deflate the cuff quickly.
21. Remove the cuff. Figure 12-30 Inflate cuff smoothly and quickly.
288 UNIT 4 Integrated Clinical Procedures

Procedure 12-11
Measuring Height

STANDARD PRECAUTIONS: 9. Lower measuring bar to its original position.

10. Wash hands.
11. Record height in patient’s chart or electronic
medical record.
PURPOSE:
To obtain the height of a patient.
DOCUMENTATION
EQUIPMENT/SUPPLIES: 3/4/20XX 2:00 PM Ht. 59 60. B. Abbott, RMA ____________
Scale with measuring bar
Paper towel

PROCEDURE STEPS:
1. Wash hands.
2. Identify patient.
3. Explain the procedure to patient to ensure
understanding, cooperation, and consent.
4. Instruct patient to remove shoes and stand on
paper towel on scale with back against scale,
looking straight ahead. RATIONALE: Back
against scale aids patient safety.
5. Assist patient onto scale. RATIONALE: Scale
platform is movable, and patient may become
unsteady and lose balance and fall.
6. Lower measuring bar until firmly resting on top
of head (Figure 12-31).
7. Assist patient’s steping off the scale. Allow patient
to sit and help with shoes if necessary. Figure 12-31 To measure height, have the patient
8. Read line where measurement falls. stand with back against scale and keep head level.
 CHAPTER 12 Vital Signs and Measurements 289

Procedure 12-12
Measuring Adult Weight

STANDARD PRECAUTIONS: 8. Slowly slide the upper bar until the balance
beam point is centered (Figure 12-32).
9. Read the weight by adding the upper bar mea-
surement to the lower bar measurement (see
PURPOSE: Figure 12-17).
To obtain the weight of the patient. 10. Assist the patient in stepping off the scale.
EQUIPMENT/SUPPLIES: 11. Provide a chair for the patient to sit and put on
Balance beam or digital scale shoes. Return objects to the patient.
Paper towels 12. Return the weights to zero.
PROCEDURE STEPS: 13. Wash hands.
1. Wash hands. 14. Record weight in patient’s chart or
2. Identify patient. E HR electronic medical record.
3. Explain the procedure to patient to ensure
understanding and cooperation. DOCUMENTATION
4. Place a paper towel on scale. RATIONALE: 5/2/20XX 3:00 PM Wt. 142 lbs. B. Abbott, RMA __________
Paper towel protects patient’s feet from micro-
organisms.
5. Instruct the patient to place heavy objects on the
area provided, including heavy objects that may
be in pockets.
6. Instruct the patient to remove shoes, jacket, and
heavy sweater and step on the scale. Assist patient
to the center of the scale. RATIONALE:The scale
platform is movable, and the patient may become
unsteady, lose balance, and fall. The platform on
the digital scale is stationary, but assist the patient
onto the scale platform and read the digital read-
ing. If using a balance beam scale, continue with
Steps 7 through14.
7. Move the lower weight bar (measured in 50-
pound increments) to the estimated number
(the patient may be asked for approximate Figure 12-32 When weighing the patient, slide the
weight). upper bar until the balance beam point is centered.
290 UNIT 4 Integrated Clinical Procedures

Case Study 12-1

Refer to the scenario at the beginning of the chapter.

CASE STUDY REVIEW

1. There are three different kinds of sphygmomanom- 3. Height and weight measurements are important
eters. Give advantages and disadvantages of each. for many reasons. What do you consider the most
2. When you weigh Mrs. Williams, you notice from her important of the many reasons? What do you con-
record that she has lost 10 pounds in 6 months. What sider the least important reason? Why?
questions will you ask her about her weight loss?

Case Study 12-2

Herb Fowler, a regular patient of Dr. Lewis at the medical CASE STUDY REVIEW
facility of Drs. Lewis and King, is an African-American in his
50s. He has smoked for many years and only recently has 1. Is a blood pressure reading of 156/100 a cause for
thought about quitting smoking because of a chronic cough. concern? Should Audrey take a second reading?
Herb is significantly overweight but is having a hard time 2. In addition to alerting the provider to the change in
making the decision to give up smoking and change his diet. Mr. Fowler’s blood pressure and weight, Audrey feels
Although his blood pressure has been stable for the last few she may be able to provide advice to the patient
years, Audrey Jones, CMA (AAMA), is concerned when she (with provider permission). How can Audrey use her
takes Herb’s vital signs during his most recent checkup. His communication and medical assisting knowledge
weight is slightly up, and his blood pressure has jumped from to counsel Herb Fowler on lifestyle changes?
140/90 to 156/100. 3. To follow up, Audrey reviews her knowledge of
hypertension and discusses the four types with the
provider. What are the four kinds of hypertension
and what are their characteristics?

SUMMARY
Throughout life, a patient will undergo various measurements to ascertain growth, development, and gen-
eral health and well-being. The normal range for each of these measurements will vary according to the
stage of life of the patient at the time of examination. The medical assistant must be aware of what to
expect when measuring a patient in each life stage. Awareness of normal expectations for each stage of life
will help the medical assistant to perform the procedures in a more effective and efficient manner and aid
in observing any abnormal signs and measurements.
Together with differences seen with age, the medical assistant will see differences in patients because
each patient has unique medical problems.
The medical assistant has a great responsibility when performing patient measurements
and must ensure accuracy, patient safety, comfort, and confidentiality while obtaining accurate HIPAA
results.
 CHAPTER 12 Vital Signs and Measurements 291

STUDY FOR SUCCESS

• Review the Key Terms
• Practice the Procedures
• Consider the Case Studies and discuss your conclusions
• Answer the Review Questions

˚ Multiple Choice
˚ Critical Thinking
• Navigate the Internet by completing the Web Activities
• Practice the StudyWARE activities on your student CD
• Apply your knowledge in the Student Workbook activities
• Complete the Web Tutor section
• View and discuss the DVD situations

REVIEW QUESTIONS
Multiple Choice 3. Discuss the reasons that a professional must be aware
that mercury thermometers and other mercury-
1. This type of thermometer measures the tempera- containing equipment are being phased out of use.
ture of the skin surface over the temporal artery: 4. Demonstrate the procedure for converting tempera-
a. aural tures from Fahrenheit to Celsius and vice versa and
b. TA calculate the following conversions:
c. tympanic a. 98.6°F = _________________________ °C
d. axillary b. 39.1°C = _________________________ °F
2. The artery commonly used for taking a patient’s 5. Discuss the rationale for not using the thumb for
pulse is: taking the pulse rate of a patient.
a. carotid c. radial 6. Discuss the reasons for taking the respiratory rate
b. brachial d. popliteal of a patient without the patient’s knowledge.
3. A blood pressure cuff that is too small for the 7. Discuss the importance of using the appropriate
patient’s arm will: blood pressure cuff size when measuring a patient’s
a. have no effect on the results blood pressure.
b. give an arbitrarily low result 8. Describe the following:
c. give an arbitrarily high result a. hypertension c. apnea
d. have an effect on certain patients only b. tachycardia d. remittent fever
4. The term used to indicate a pulse rate significantly
above the average is:
a. bradycardia c. arrhythmia
b. tachycardia d. sinus rhythm WEB ACTIVITIES
1. Using a search engine, access information
Critical Thinking on the Internet from the American Heart
1. Discuss the responsibilities of the medical assistant Association regarding essential hyperten-
when measuring vital signs. sion and answer the following:
2. Describe the care and use for each of the various a. What population of people in the United States
types of thermometers. is at greatest risk for essential hypertension?
292 UNIT 4 Integrated Clinical Procedures

b. List four patient education tips for reducing REFERENCES/BIBLIOGRAPHY

blood pressure without the aid of medication.
c. Check the list of normal blood pressure read- Environmental Protection Agency. (May 18, 2004,
ings in this chapter and compare it with what Federal Register, page 40517 [40CFR 273.81(a)]).
the American Heart Association says are normal Mercury and the environment. Retrieved from http://
blood pressure measurements at various ages. www.epa.gov.
2. Access information on the Internet from the Michigan State University. Mercury containment initiative.
National Research Council and list its recommen- Retrieved March 22, 2004, from http://www.aware.
dations for weight of the following women: msu.edu.
Height Age Weight in Pounds National Library of Medicine, National Institutes of
5 2 19–34 years ? Health. Mercury facts. Retrieved April 28, 2005,
5 4 19–34 years ? from http://cerhr.niehs.nih.gov/genpub/topics/
5 6 19–34 years ? mercury.html.
Taber’s cyclopedic medical dictionary (22nd ed.). (2006).
Philadelphia: F.A. Davis.

THE DVD HOOK-UP

This chapter discusses the proper techniques for obtaining DVD Journal Summary
the patient’s vital signs and steps for measuring and weigh- Write a paragraph that summarizes what you learned from
ing the patient. watching today’s DVD program. At the end of the blood pres-
This program illustrated many techniques for obtaining vari- sure scene, the medical assistant told the patient that her
ous vital signs. In the taking a radial pulse scene, the medi- blood pressure was 158/100, which is quite elevated. Do you
cal assistant noticed a problem with the patient’s rhythm and think it was wise of the medical assistant to tell the patient
decided to take an apical pulse as well. The chapter states her reading? Do you think it is acceptable to tell patients
that you should place the patient in a supine position and their blood pressure when it is normal? Why or why not?
locate the apex of the heart when taking an apical pulse.
The DVD program illustrated the medical assistant taking an
apical pulse with the patient sitting in an upright position. It
also had a more complicated technique for finding the apex
of the heart.
1. How do you think you should manage a patient with an
arrhythmia? How can you keep the patient from becom- DVD Series Program Number
ing concerned? Skills Based Series 5
2. Which method do you think would work better for mea- Chapter/Scene Reference
suring an apical pulse: the method listed in the book or • Watch entire program
in the DVD program? Why?
 Chapter

The Physical Examination 13

KEY TERMS OUTLINE
Ataxia Methods of Examination Breath Odors
Bruits Observation or Inspection Nutrition
Catheterization Palpation Skin and Appendages
Cyanosis Percussion The Physical Examination
Auscultation Sequence
Fenestrated Drape
Mensuration Head
Jaundice
Manipulation Eyes
Labyrinthitis Ears
Positioning and Draping
Pallor Examination Positions Nose
Pyorrhea Equipment and Supplies for the Mouth and Throat
Scleroderma Physical Examination Neck
Symmetry Basic Components of a Chest
Tinnitus Physical Examination Breast
Vertigo Patient Appearance Abdomen
Vitiligo Gait Genitals
Stature Rectum
Posture Reflexes
Body Movements After the Examination
Speech

OBJECTIVES
The student should strive to meet the following performance objectives and
demonstrate an understanding of the facts and principles presented in this
chapter through written and oral communication.

1. Define the key terms as presented in the glossary.

2. Describe the six methods used in physical examinations.
3. Name and describe seven positions used for physical
examinations.
4. Discuss the purpose of draping and demonstrate appropriate
draping for each position.
5. Identify at least 10 instruments and supplies used for examina-
tion of various parts of the body.
6. Identify eight basic components of a physical examination.
7. Describe the sequence followed during a physical examination.
8. Recall method of examination, instrument used, and position for
examination of at least eight body parts.

293
 Scenario
At the multiprovider Inner City Health Care facil- Bruce also coordinate with each other and with
ity, five providers are employed on a rotating basis, office managers Jane O’Hara and Walter Seals,
with two or three working at any one time. Clinical both CMAs, to ensure patient comfort. Depending
medical assistants Wanda Slawson, CMA (AAMA), on the patient and the type of examination, Wanda
and Bruce Goldman, CMA (AAMA), have developed will often assist with patient preparation when the
a clear understanding of what each provider prefers patient is female and Walter will assist when the
in both room and patient preparation. Wanda and patient is male.

INTRODUCTION

Physical examinations are performed to obtain a pic- assistant adheres to the principles of medical asepsis
ture of the health and well-being of the patient. An and Standard Precautions as required by Occupational
initial examination will provide a baseline reference Safety and Health Administration (OSHA). The effec-
for future examinations. The examination follows a tive medical assistant establishes an efficient but flexible
standard routine, usually starting at the head and routine providing for the needs of both the patient and
following through the entire body, including all major the provider.
organs and body systems. Although the sequence of
events for the physical examination is relatively stan-
dard, variations occur according to provider preference, METHODS OF EXAMINATION
type of practice, and patient’s chief complaint. Diag-
nostic procedures such as laboratory tests and X-rays There are six methods used by the provider to
may be ordered or performed in the facility or sent to examine the body. They include observation or
an outside laboratory. At the conclusion of the physical inspection, palpation, percussion, auscultation,
examination, the provider will have an impression of
the patient’s general health, a diagnosis if possible, and
treatment plans. The provider uses information from
three major sources to aid in making a diagnosis: the
health history, the physical examination, and labora-
Spotlight on Certification
tory tests and diagnostic procedures.
RMA Content Outline
The role of the medical assistant throughout the
physical examination greatly depends on the provider. Some • Vital signs and measurements
providers delegate many duties to the medical assistant, • Medical history
whereas others require little assistance. Commonly per- • Patient positions
formed clinical medical assisting duties related to physical • Methods of examination
examinations can be divided into two categories: patient • Specialty examinations
preparation and room preparation. Patient preparation
includes patient explanation and preparation, position- CMA (AAMA) Content Outline
ing, draping, vital signs, specimen collection such as urine • Patient instruction
and blood, and electrocardiogram (ECG). Room prepara- • Treatment area
tion includes assembling the appropriate instruments and • Equipment preparation and operation
equipment for the provider and ensuring patient privacy • Principles of operation
and comfort.
• Patient preparation and assisting the
Additional medical assisting duties include
provider
supporting the patient, handing the provider instru-
ments and equipment as required, and taking notes CMAS Content Outline
to be entered into the electronic medical record (EMR). • Examination preparation
Throughout and after the examination, the medical

294
 CHAPTER 13 The Physical Examination 295

mensuration, and manipulation. The provider

uses all in total or in part, depending on the type
of examination being performed.

Observation or Inspection
Observation or inspection is the process of observ-
ing the patient. The general health, posture, body
movements, skin, mannerisms, and care in groom-
ing are noted. Closer observation focuses on body
symmetry (correspondence in shape and size of
body parts located on opposite sides of the body)
and contour. Deformities and skin rashes are
observed. Skin color is noted (Figure 13-1).

Palpation
Palpation is an examination of the body using
touch and may be used to help verify observations. Figure 13-2 For palpation, the provider uses the
A body part or organ is felt for size and condi- hands and fingers to feel various body parts.
tion. Abdominal masses may be felt through the
abdominal wall. Skin texture, moisture, and tem-
perature can be felt. The contour of limbs and
rigidity and position of bones and joints may be being checked. Healthy structures that are dense,
felt. Palpation may be performed with the use of such as the liver, produce a dull sound. Hollow
fingertips, one or both hands, or the palm of the structures such as the lungs should produce a more
hand (Figure 13-2). hollow sound. There are two methods used to per-
form percussion. The direct method is performed
by tapping directly on the surface of the skin. The
Percussion indirect method is performed by placing a finger
Percussion is the process of eliciting sounds from or hand on the surface of the skin and tapping the
the body by tapping with either a percussion ham- hand (Figure 13-3).
mer or fingers. The vibrations and sounds from
underlying organs and cavities can be felt and
heard. Using this method can determine the pres-
ence of air or solid material in the organ or cavity

Figure 13-3 Percussion involves tapping on body

Figure 13-1 The provider uses observation to inspect parts and listening to sounds coming from body
the body for signs of disease. organs.
296 UNIT 4 Integrated Clinical Procedures

Auscultation
Auscultation is the process of listening directly
to body sounds, normally with a stethoscope.
The provider listens for lung and heart sounds
such as murmurs, rales, or bruits, which gener-
ally are abnormal sounds heard on auscultation
of an organ or vessel such as a vein or an artery.
The abdomen is examined for bowel sounds that
include the clicks and gurgles of normal bowel
activity, the sounds that occur with peristalsis
(Figure 13-4).

Mensuration
The mensuration method of examination uses
the process of measuring. The measurements
of height and weight, the length of a limb, and
the amount of flexion and extension of an
extremity are all forms of mensuration (Figure
13-5). Measurements of chest and infant head Figure 13-5 A tape measure may be used to measure
circumference are also forms of mensuration. the circumference of the calf of the patient’s leg or
In most instances, a tape measure is used to per- other body part. This method of physical examination
form mensuration of an infant’s head or circum- is known as mensuration.
ference of a body part.

Manipulation POSITIONING AND DRAPING

Manipulation checks the amount of flexion and
extension of a joint by applying forceful passive Physical examinations require patients to be
movement on the joint. Range of motion of some placed in various positions. Each position
joints may be checked using this method. is designed to make examination of a par-
ticular area of the body easier and more efficient.
The medical assistant may assist patients in undress-
ing and will provide the appropriate drape and
gown. The medical assistant also instructs patients
about the appropriate position required for the
examination and may assist patients into position
by providing support and guidance. Always pro-
vide for patient safety.
Proper draping to protect modesty, prevent
embarrassment, and provide comfort from chills
is essential. If patients are capable of helping
themselves, the medical assistant should leave
the room while patients undress and put on a
gown. If patients are disoriented or extremely
ill, the medical assistant must stay in the room;
patient privacy can be provided by discreetly
removing clothing and covering patients as
quickly as possible. When the patient is a child,
the medical assistant should note the comfort
level of the child while the child undresses. Chil-
Figure 13-4 The provider is using a stethoscope to dren develop modesty at an early age and may
listen to heart and lung sounds. This is known as aus- be embarrassed by sitting on the examination
cultation. table wearing only underwear. Respect a child’s
 CHAPTER 13 The Physical Examination 297

right to privacy by offering a gown or drape. Supine (Horizontal Recumbent). The supine
Older adults will need assistance with undressing position is assumed when lying flat facing up
and draping. Care must be taken to provide as (Figure 13-6). It is used for examination of the
much modesty and privacy as possible as you anterior surface of the body from head to toe.
assist patients of all ages. When the provider performs a physical exami-
Never turn your back on seriously ill or nation on a female patient that includes a breast
disoriented patients or young children. examination, the patient should be provided with
Ensure patient safety at all times. a gown and instructed to wear it with the opening
in the front. A drape is then placed over the lap
or from the waist down.
Examination Positions
A number of positions may be required of patients Dorsal Recumbent. Patients lie on their back (dor-
during the physical examination. The position sal) face up, legs separated, knees flexed with feet flat
used depends on the type of examination. Seven on the table (Figure 13-7). This is the most comfort-
positions can be used. able position for patients with back and abdominal
problems. Examinations performed in this position
1. Supine (horizontal recumbent)
include rectal, genital, head, neck, and chest, as well
2. Dorsal recumbent as abdominal palpation. It can also be used for uri-
3. Lithotomy nary catheterization. Preteen and early teen girls
4. Fowler’s requiring a pelvic examination may be placed in this
position and will require careful instructions and
5. Knee-chest
procedure explanations. The patient is covered with
6. Prone a drape that is diamond shaped. One edge of the dia-
7. Sims’ mond can be lifted to examine the genitalia without
exposing the rest of the body.

Lithotomy. Patients are assisted to lie on their back

similar to the dorsal recumbent position except the
buttocks should be as close to the bottom edge of
the table as possible, and feet are placed in stirrups
attached to the foot of the table (Figure 13-8). The
lithotomy position is used for genital and pelvic
examinations; it can also be used for urinary cath-
eterization. At the conclusion of the examination,
the patient should slide toward the head of the table
before getting up from this position. Patients with
special needs, such as older adults and
those physically challenged as with severe
arthritis, may not be able to assume this
Figure 13-6 Supine or horizontal recumbent position.
position. If this is the case, assist patient into
Sims’ position or modified dorsal position and

Figure 13-7 Dorsal recumbent position. Figure 13-8 Lithotomy position.

298 UNIT 4 Integrated Clinical Procedures

the sigmoidoscopy, proctoscopy, or pelvic exam A pillow may be placed under the knees. This
can be done in this position for these patients. position is used for patients having cardiovas-
A modification of the dorsal recumbent posi- cular or respiratory problems to facilitate their
tion is often used for female external genitalia breathing, and for examination of the upper
examinations, especially female urologic examina- body and head.
tions, some gynecologic examinations, and exami-
nations during pregnancy. This position consists of Knee-Chest. The knee-chest position is rarely
the patient lying on the examination table on her used. In this position, patients kneel on the
back, with her knees bent. The feet are together examination table with buttocks elevated, back
with the heels pulled up toward the buttocks. Dur- straight, and chest resting on the table. It is an
ing the examination, the knees are relaxed apart. uncomfortable position to get into, even with
The provider may stand to the side of the patient assistance, and it is difficult to maintain. Not
during the examination. This position has many only is it uncomfortable, but it is embarrassing
advantages over the lithotomy position if a full pel- and risky to place patients in the knee-chest posi-
vic examination is not required. tion. The position has been used for proctologic
examinations and sigmoidoscopy procedures;
Fowler’s. Patients sit in a position with the back of however, the proctologic table (Figure 13-11) has
the examination table raised to either 45 degrees made the position unnecessary. The table is used
(semi-Fowler’s; Figure 13-9) or 90 degrees (high- in specialty offices, such as gastroenterology and
fowler’s; Figure 13-10). Legs rest flat on the table. proctology.

Proctologic. This position requires the use of a

proctologic examination table (see Figure 13-11).
The patient is instructed to undress from the waist
down and to kneel on the knee board of the table.
The patient then bends at the hips and rests the
chest on the table. The head is supported by a
head board. The table is then turned to elevate the
buttocks. A triangular, diamond-shaped, or fenes-
trated drape covers the patient from the shoulders
to the knees. This position is used for proctologic
examinations.

BUTTOCKS
Figure 13-9 Semi-Fowler’s position (45-degree
angle).
FEET

HEAD

KNEES

Figure 13-10 High Fowler’s position (90-degree

angle). Figure 13-11 Proctologic table.
 CHAPTER 13 The Physical Examination 299

Prone. The patient is instructed to lie face down Sims’ (lateral). The patient is instructed to lie
on the table with head turned to side; arms may on the left side; the left arm and shoulder may be
be placed above the head or along the side of the drawn back behind the body (Figure 13-13). The
body (Figure 13-12). The drape must cover from left knee is slightly flexed to support the body, and
the mid-chest area to the legs. This position may the right knee is flexed sharply. A small pillow is
be used for examining the posterior aspect of the provided for placement under the patient’s head.
body, including the back or spine and legs. A pillow may also be placed between the patient’s
legs if it will not interfere with the examination
being performed. The drape should be large
enough to cover the patient from the shoulders to
the knees (triangle or diamond shape to expose
rectum). This position may be used for vaginal or
rectal examination, for obtaining a rectal tempera-
ture, for sigmoidoscopy, or for administering an
enema.

Trendelenburg. Trendelenburg position can be

used for two reasons. The first is to aid a person
who is in shock. By lowering the head and ele-
vating the legs, blood flow from the major ves-
sels in the lower extremities will, by gravity, flow
Figure 13-12 Prone position. upward toward the brain and major organs. This
may help to increase blood pressure enough to
sustain the patient until taken to the emergency
department (see Chapter 9). The other reason
for Trendelenburg position is to elevate and
incline the legs so that the abdomen and pelvic
organs are pushed up toward the chest by grav-
ity, making visibility and maneuverability easier
for the provider doing either abdominal or pel-
vic surgery. In this case, the legs are elevated and
inclined (see Chapter 19).

EQUIPMENT AND SUPPLIES

FOR THE PHYSICAL
Figure 13-13 Sim’s or lateral position. EXAMINATION
Equipment and supplies used for physical examina-
tions should be properly cleaned and ready for the
provider’s use (see Chapters 10 and 19 for proper
cleaning and care of instruments). The list of instru-
Critical Thinking ments and supplies in Table 13-1 includes those that
may be used in the physical examination. However,
Describe a type of examination that may be this is a limited list. Actual equipment and supplies
performed while the patient is placed in each needed vary with the provider and with the type of
of the following positions: (1) lithotomy, examination. Figure 13-14 shows some common
(2) Sims’, (3) knee-chest, and (4) supine. instruments that may be used in the physical exami-
Decide in what position you should place nation. (See Chapter 18, for instruments used in
a patient and what manner of draping you specialty examinations.) The medical assistant is
would use for a Pap smear, examining a responsible for room preparation prior to a physi-
patient with shortness of breath, obtaining a cal examination. Equipment must be in working
rectal temperature, and an examination of order (bulbs for scopes, good room lighting) and
the spine. the room properly stocked with gowns, drapes, and
other supplies, such as gloves, an antibacterial hand
300 UNIT 4 Integrated Clinical Procedures

Table 13-1 Some Common Instruments

and Supplies Needed for a
Physical Examination
Balance beam, digital, or electronic scale
Patient gown
Drape
Thermometer
Stethoscope
Sphygmomanometer
Alcohol wipes
Examination lights
Otoscope
Tuning fork
Figure 13-14 Instruments and supplies used in
Ophthalmoscope the physical examination: stethoscope, latex gloves,
Penlight across top of tray: penlight, flexible tape measure,
Nasal speculum urine specimen container, tongue depressor, opthal-
Tongue depressors moscope, otoscope, tuning fork, metal nasal specu-
Percussion hammer
lum, percussion hammer, Guaiac/occult blood slide,
Guaiac/occult blood slide developer, and sphygmo-
Tape measure
manometer.
Cotton balls
Safety pin
Gloves
Tissues
Lubricant
Emesis basin
Gauze sponges
Specimen bottles/slides—request forms
Biohazard and regular waste containers

washing product, biohazard container, and any

other materials needed to comply with Standard
Precautions, such as a sharps container. In addi-
tion, the medical assistant is responsible for patient
preparation. Urine, blood samples, and an ECG
may be performed (if requested by the provider).
Vital signs and height and weight will be measured.
Signed consent forms, if needed, should be in the
patient’s record. If the patient needs help undress-
ing and putting on a gown, the medical assistant
provides assistance. Patient data can be documented
immediately using the computer to elec-
E HR tronically record all of the information (vital
signs, height and weight, known allergies, Figure 13-15 The medical assistant is able to docu-
any medications the patient is taking) (Figure ment patient data immediately in the exam room
13-15). Results of tests and the ECG usually are computer.
available within 24 hours and can be accessed in
the patient EMR. Ensure patient confidentiality
throughout the examination and documentation.
 CHAPTER 13 The Physical Examination 301

unpleasant body order, have poor hygiene, or oth-

BASIC COMPONENTS erwise appear to be different from your culture.
OF A PHYSICAL EXAMINATION In some cultures, a daily bath is considered unnec-
essary, and body odor is not considered offensive.
The physical examination of the patient begins as Regard your patient in a nonjudgmental way, tak-
soon as the patient enters the office. The provider ing into account the other’s cultural beliefs. The
uses information from the health history, physical medical assistant should be alert to a patient with
examination, and laboratory tests to aid in making abnormal skin color, confusion or disorientation,
a diagnosis. Figure 13-16 shows how these compo- or difficulty in movement. Such a patient may
nents are interrelated in a total practice manage- have a serious problem and should be placed in
ment system. Although the physical examination is an examination room and the provider contacted
performed by the provider, it is important for the immediately.
medical assistant to be aware of the various exami- The following aspects of the patient’s health
nation components and the significance of each as are evaluated by the provider through the method
an indicator of patient well-being. of physical examination known as observation.

Patient Appearance Gait

General appearance and actions are noted Gait pertains to the manner or style of walking.
as the patient is received by the medical The patient may have a limp, walk with feet wide
assistant and during the patient history apart, appear to be dragging one leg, or have diffi-
(see Chapter 11). Skin color is checked, and gen- culty maintaining balance. The provider observes
eral grooming, ease of conversation, and answers the patient’s gait by instructing the patient to
to questions are noted. Be aware of cultural dif- walk on a designated straight line. Abnormal gait
ferences while assisting with a physical examina- can include ataxia, uncoordinated wide-based
tion. Some patients of other cultures may appear walk; steppage, in which the leg stepping forward
to you to be unclean in their appearance, have an is raised high enough to raise the toes off the

Inpatient/Outpatient Results from

Admissions Regional/ Results to Outside
Referrals Pharmacy National Labs Providers

RECEPTION CLINICAL CARE LABORATORY

Patient Assessment
Procedures, Diagnoses & Treatment Plans
Scheduling Referrals & Follow-up Appointments
Patient Demographics Prescriptions Test Reports
Insurance Information Orders for Tests Quality Assurance & Controls
Patient Authorizations Patient Medical History Safety Standards

Referrals Test Results Orders for Tests

Follow-up Appointments Schedules and Tickler Files Safety Standards
Coordination of Services Patient Medical History
Medication Administration
Patient Education
Graphical Patient Data Displays

ELECTRONIC RECORDS
Figure 13-16 The provider uses the health history, physical examination, and lab tests to make a diagnosis. These com-
ponents are integrated in a total practice management system.
302 UNIT 4 Integrated Clinical Procedures

ground; drag-to, in which the feet are dragged for- from diabetes mellitus, starvation, or renal disease.
ward rather than lifted and moved; and spastic, in A musty odor may indicate liver disease, and an
which the legs are held stiffly together and the feet ammonia odor may indicate uremia.
are slightly dragged forward. Each of these gaits Poor oral hygiene results in gingivitis (gum
can indicate a disease process or health problem disease), caries (cavities), tooth loss, and foul
associated with poor neurologic functioning. breath odors. Gum disease and caries encourage
the growth of microorganisms in the mouth and
throat. Because of the vascularity of the oral cav-
Stature ity, microorganisms can enter into the circulatory
The height of the patient is measured. The provider system and travel to the heart, causing endocar-
looks for height, trunk, and limb proportion. ditis. The importance of good oral health is nec-
essary for general health and well-being. Regular
dental checkups, cleaning, and daily flossing pro-
Posture mote good health.
Because normal posture is erect with the head held
up, a patient in pain may exhibit postural differ-
ences. The spine might be in a fixed position, or
Nutrition
there may be limited motion in an extremity. The Various published charts contain guidelines for
provider observes spine movement and alignment normal weight established by height and age.
as the patient performs prescribed movements. Overweight and underweight are defined as being
Abnormalities can include kyphosis (humpback), above or below the published charts. Obesity and
which may be seen in older adult patients, particu- underweight are discussed in Chapters 12 and 22.
larly women with osteoporosis; lordosis, abnormal Edema, which is excessive accumulation of fluids
curvature of the lumbar area; and scoliosis, curva- in the body tissues, causes weight gain. To test for
ture of the upper spine. edema, the provider presses a finger against the
skin of the patient in an area over a bony promi-
nence such as the ankle. If edema is present, pit-
Body Movements ting will be evident when the finger is removed. Fat
Body movements may be either voluntary or invol- tissue will not leave an indentation when pressed.
untary. Voluntary body movements describe those
movements intended to be made by the patient.
Involuntary body movements are movements not
Skin and Appendages
controlled by the patient. Tremors are a form of invol- Skin problems include abnormal skin color such
untary movement that may be seen in the mouth, fin- as redness, pallor, cyanosis, jaundice, and vitiligo.
gers, hands, arms, and legs of a patient. Tremors can Pallor is defined as lack of color or paleness often
indicate a neurologic health problem. Involuntary seen with anemia; cyanosis is a slightly blue or gray
body movements usually are easily observed. discoloration of the skin, often seen in patients
with respiratory or cardiac problems; jaundice is a
yellowing of the skin, often caused by obstructed
Speech bile ducts or liver disease; and vitiligo is character-
The patient’s speech may indicate abnormal condi- ized by white patches on the skin, observed against
tions. Abnormalities include aphonia, loss of voice normal pigmentation. Other skin conditions are
usually because of laryngitis, but which may have lesions, ulcers, bruises, and cancer. Texture may be
other causes; aphasia, the inability to express one- smooth, rough, and scaly and have loss of elastic-
self through speech or writing, which may indicate ity. These findings may indicate health problems
brain injury or disease; and dysphasia, an inability or excessive exposure to the sun. The nails can also
to use appropriate speech patterns, such as using indicate some forms of health problems. Infec-
words in the wrong order. This may indicate a tions, either local or systemic, may be observed
brain lesion or disorder. in nails that are brittle, grooved, or lined. The
appearance of the fingertips can be indicators of
disorders as seen in clubbing, which may indicate
Breath Odors congenital heart disease, and spooning, which may
Breath odors may be detected when speaking with be seen in severe iron deficiency anemias. Abnor-
the patient or when obtaining vital signs. A sweet mal hair distribution, as in facial hair on a female
fruity odor may indicate acidosis. This may result patient, may indicate hormonal changes.
 CHAPTER 13 The Physical Examination 303

may leave the room while the patient undresses

HIPAA unless the patient asks for help or is unable to
manage alone. It is appropriate to knock before
When patients arrive for their appoint- reentering the room.
HIPAA ments, the medical assistant will con- It is customary for the medical assis-
sider confidentiality to be of utmost tant to remain in the room when the
importance. From the time the patient arrives provider is examining a patient for the
until the patient leaves, there are multiple patient’s comfort, to assist the provider, and as a
occasions to protect patient confidentiality. deterrent to potential lawsuits.
The medical history, personal finances, and The medical assistant places the instruments
insurance matters must be handled privately, for the examination on the counter or Mayo stand,
out of the hearing range of others. Pertinent according to provider preference, but usually in order
personal information that you may elicit of use. When lamps are used for the examination, the
from the patient that will be helpful to the medical assistant may turn them on and have them
provider during his or her examination also ready for the provider. Make sure that the light is not
must be kept private. When the directed into the patient’s eyes. When the patient is
patient is undergoing testing such comfortably positioned on the examination table,
as electrocardiology that requires the inform the provider that the patient is ready. Nor-
patient to undress in preparation for the mally the physical examination starts at the head and
examination, care must be taken to avoid vio- proceeds downward. Table 13-2 gives a detailed review
lating the patient’s right to privacy. Respect- of the components of the physical examination.
ing the dignity of all patients by protecting
their privacy and confidentiality is a sign of a
professional who is aware of patient rights.
Head
The patient is in a sitting position for this examina-
tion. The face is checked for puffiness, especially
around the eyes. Facial skin is checked for sclero-
derma, a tight and atrophied skin. The older adult
THE PHYSICAL EXAMINATION patient may have fatty patches that appear raised
SEQUENCE and yellowish on the eyelids. The hair and scalp
are checked. The head and neck are palpated for
A sequence is followed for a physical examination, lumps and swelling.
although provider preference and the patient’s
chief complaint can produce a variation to the
sequence.
Eyes
The physical examination begins with the The appearance of the eyes is examined. The
medical assistant taking and recording the patient’s pupils of the eyes are checked for light and accom-
vital signs, height, and weight, and testing visual modation. When a penlight or flashlight is placed
acuity as well as auditory ability when appropriate. in front of the pupil, the pupil will constrict. The
Additional laboratory procedures, such as urinaly- other pupil should constrict equally. The pro-
sis and blood analysis or ECG may be performed vider notes whether or not pupils are equal and
as directed by the provider before the physical react to light and accommodation (abbreviated as
examination. Before the examination, a patient PERRLA). Pupils that do not constrict and return
is instructed to empty the bladder, saving a urine to normal equally may indicate a problem in the
specimen for analysis. The patient is then told brain. A tonometer may be used to measure the
what to expect during the examination. Any ques- intraocular eye pressure of patients older than
tions the patient has should be answered by the 35 years. Normal eye pressure is 13 to 22 mm Hg. An
medical assistant or referred to the provider. The increase above normal will be found in glaucoma.
patient should be instructed about undressing (a The provider uses an ophthalmoscope to view the
private area should be provided for undressing). blood vessels of the retina. This is done by turning
The medical assistant should be explicit as to what out the lights in the room, allowing the patient’s
clothing is to be removed and what can be left on. pupils to dilate. The patient is instructed to look
If a complete physical examination is required, all straight ahead while the provider looks into the eye.
clothing should be removed. A gown and drape Retinal changes may indicate disease such as hyper-
are provided for the patient. The medical assistant tension. The sclera are checked for jaundice.
304 UNIT 4 Integrated Clinical Procedures

Table 13-2 Components of the Physical Examination

Provider’s Findings

Body Instrument Method

Part Position Used of Exam Normal Abnormal

General Standing — Inspection Patient is cooperative, Uncooperative, behav-

appear- good hygiene, good ior inappropriate,
ance skin color, ease of gait unkempt appearance

Supine Flashlight Inspection Good color, warm Jaundice, cyanosis,

Prone Palpation to touch; no lesion pallor, redness, flaki-
Skin
such as warts, moles, ness of skin, lesions,
abscesses, rashes rashes

Supine or semi- Light source Inspection Symmetry of head; Asymmetry of head;

Fowler’s or sitting Palpation hair not dry or oily and alopecia, dry, flaky
Head and on edge of table distributed evenly; scalp; swelling, lumps
neck scalp free of lesions or pain in head or
and not dry; no lymph neck
node enlargement

Supine or semi- Ophthalmo- Inspection Snellen test shows Poor visual and color
Fowler’s or sitting scope Mensuration accurate visual acu- ability; dull-
on edge of table ity; able to identify appearing eyes;
color plates; no tear- drainage; unequal
ing; pupillary reaction pupils; clouded lens;
to light equal; retina unequal pupillary
Eyes
pink and blood ves- reaction; intraocular
sels healthy; measure- pressure increased;
ment of intraocular torturous, unhealthy
pressure within nor- retinal blood vessels;
mal limits; no bulging bulging eyeballs
of eyeballs

Supine or semi- Otoscope Inspection Cerumen not Impacted cerumen;

Fowler’s or sitting Tuning fork and Percussion impacted on tym- red, bulging tympanic
on edge of table audiometer panic membrane; membrane; discharge
tympanic membrane (pus or blood); inability
Ears
gray and intact; no to hear sound from tun-
discharge or pain; ing fork; poor auditory
able to hear tuning ability when checked
fork or audiometer with audiometer

Supine or semi- Nasal speculum Inspection Mucous membranes Dry, red, swollen
Fowler’s or sitting Flashlight moist and pink; mucous membranes;
on edge of table Aromatic able to detect spe- unable to detect
Nose substance cific odors; septum odors; deviated sep-
straight; nostrils equal tum; nostrils flaring;
in size; no abnormal discharge, polyps
discharge; no lesions noted

Supine or semi- Flashlight Inspection Gag reflex present; No gag reflex; tongue
Fowler’s or sitting Tongue depres- mucous membranes rough; pallor of
Mouth on edge of table sors moist and pink; teeth mucous membranes;
and intact, pink tongue; dental caries; swollen
throat tonsils nonswollen, pink tonsils

(continues)
 CHAPTER 13 The Physical Examination 305

Table 13-2 (continued)

Provider’s Findings

Body Instrument Method

Part Position Used of Exam Normal Abnormal

Supine or semi- Percussion ham- Inspection Good muscle tone; Poor muscle tone;
Fowler’s or sitting mer Palpation normal range of poor range of motion;
on edge of table Percussion motion; nails pink, nails cyanotic; brittle,
Arms and smooth; ability to ridged nails; abnormal
hands squeeze provider’s reflexes
hands with equal
strength; normal
reflexes

Supine or semi- Stethoscope Inspection Axillary lymph nodes Enlarged axillary

Fowler’s or sitting Tape measure Palpation not palpable; lungs lymph nodes; asym-
on edge of table Auscultation clear; no cough; ribs metry of chest wall;
Chest and Mensuration nontender; symmetri- respiration and heart
lungs Percussion cal chest wall; respira- rate abnormal; abnor-
tions and heart rate mal chest sounds
normal; normal chest
sounds

Supine or semi- Stethoscope Auscultation Normal heart func- Abnormal heart

Fowler’s or sitting Sphygmoma- Palpation tion per ECG; regular function per ECG;
on edge of table nometer Mensuration rhythm, rate of heart irregularity of rhythm,
Heart Electrocardio- sounds; no murmurs; rate; murmurs; blood
gram (ECG) blood pressure nor- pressure outside nor-
mal range; pulse mal range; poor pulse
points good quality quality

Supine — Inspection No lumps, tenderness, Lumps, tenderness,

Palpation swelling, or thickening; swelling, thickening;
no sores or lesions; no sores or lesions; bleed-
bleeding or discharge ing or discharge from
Breasts from nipples; no nipple; lymph node
lymph node swelling enlargement in axilla;
in axilla; no dimpling “orange peel” appear-
or “orange peel” ance to breast tissue;
appearance dimpling of skin

Supine Stethoscope Inspection Liver, spleen not pal- Liver, spleen enlarged;
Measuring tape Palpation pable; symmetry to asymmetric abdo-
abdomen; no abnor- men; increased or
Auscultation
mal bowel sounds; decreased bowel
Mensuration no abnormal sounds sounds; unusual
Percussion from organs in abdo- sounds elicited
Abdomen men; abdomen soft; from percussion of
no abdominal or abdominal organs;
inguinal hernias abdominal distention;
ascites; presence of
abdominal, umbilical,
or inguinal hernia
(continues)
306 UNIT 4 Integrated Clinical Procedures

Table 13-2 Components of the Physical Examination (continued)

Provider’s Findings

Body Instrument Method

Part Position Used of Exam Normal Abnormal

Lithotomy or dor- Vaginal specu- Inspection External genitalia Lesions, sores, ulcer-
sal recumbent lum Palpation without lesions, sores, ations; discharge from
or Sims’ Examination ulcerations; vaginal vagina, cervix; painful
light mucosa pink and ovaries; cervix ulcer-
Slides for occult without discharge; ated, inflamed; poor
Female blood (Hemoc- nontender ova- muscle tone in peri-
genitalia cult) ries; cervix smooth, neal and rectum floor;
and noneroded, nonin- prolapse of uterus or
rectum flamed; good muscle bladder into vagina;
tone in perineal floor hemorrhoids; positive
and rectum; negative hemoccult; enlarged
stool for occult blood; inguinal lymph nodes
nonpalpable lymph
nodes in groin

Supine — Inspection Penis pink, no dis- Discharge from penis;

Standing Palpation charge; no lesions, ulcers, sores, other
sores, ulcers; testicles types of lesions; tes-
firm, nontender, and ticles tender, swollen;
Male gen-
movable; rectal relaxed anal sphinc-
italia and
musculature intact; ter; hemorrhoids; posi-
rectum
nonpalpable prostate; tive hemoccult slide;
nonpalpable lymph enlarged prostate;
nodes in groin enlarged lymph nodes
in groin

Supine Tape measure Inspection Normal muscle tone Muscle weakness;

Prone Mensuration and range of motion; poor range of motion;
Palpation no edema; pulses edema; diminished
Legs and normal; no varicosi- pulse; varicose veins;
feet ties; toenails smooth; toenails ridged,
no signs of fungus or infected; unequal
other infection; calves calf measurements
equal in size

Supine Percussion ham- Percussion Normal reflexes; ori- All reflexes disori-
mer Inspection ented to time and ented; inappropriate
Neuro- Safety pin place; appropriate responses; dulled
logic Cotton ball responses; normal response to pain and
examina- responses to sensa- sensation; lethargic;
tion tion; alert; steady gait; unsteady gait; poor
no vertigo or syncope coordination; vertigo;
syncope

Ears tis media. Vertigo (dizziness)may indicate that the

An otoscope is used by the provider to examine patient has an inner ear infection (labyrinthitis).
the ears. The external ear is checked for redness in Tinnitus (ringing in the ears) may indicate inner
the ear canal and buildup of cerumen. A healthy ear problems. Other symptoms of ear problems
tympanic membrane has a pearly gray appearance. include pain, discharge, and deafness. The tuning
A red appearance to the tympanic membrane may fork is used in testing the sensations of hearing,
indicate infection in the middle ear, known as oti- including bone conduction and air conduction.
 CHAPTER 13 The Physical Examination 307

Nose Breast
The nasal cavity is visualized by the provider with the The patient is placed in a supine position and
use of a nasal speculum and flashlight. Discharge instructed to place the hand behind the head on
from the nose may indicate a postnasal drip in the side on which the examination is taking place.
which the sinuses may be draining into the nose and The provider examines the breast for masses by
throat. Other abnormalities may include obstruc- using a circular motion, starting at the outer edge
tion because of a deviated septum. Polyps and ulcer- of the breast and working toward the center. The
ations may be found in the nasal cavity. Epistaxis or nipple is gently squeezed to see if there is any dis-
nosebleed may be seen when the capillaries rupture charge. The patient is then instructed to change
on the surface of the nasal mucosa. arm positions so that the other breast can be exam-
ined. With the patient in a sitting position, the pro-
vider observes the breasts for symmetry. Female
Mouth and Throat patients should be instructed on the procedure
The provider uses a tongue blade or depressor and for performing monthly breast self-examination.
a light source. The teeth and gums are checked This may be an embarrassing procedure for the
for dental hygiene such as caries and the gums are female patient. Maintain as much patient modesty
checked for signs of pyorrhea (discharge of pus as possible by carefully draping and giving emo-
from the gums around the teeth). If the tonsils are tional support (see Chapter 14 for more detailed
present, they are checked for signs of infection, such information on breast examination and breast self-
as redness or white pockets of pus. The floor of the examination).
mouth is examined both visually and by palpation
for indications of swollen glands and ulcerations.
Abdomen
The patient is placed in a dorsal recumbent or supine
Neck position with the arms at the sides for examination of
The provider palpates the neck, looking for swol- the abdomen. The drape is lowered to just above the
len lymph nodes. The thyroid gland is palpated pubic hair. The female patient wears a gown open
anteriorly and posteriorly for size, symmetry, and in the front that can be pulled to the sides while still
texture. The patient is asked to swallow several covering the breasts. The provider normally stands
times while the provider feels the thyroid gland. on the right side of the patient while performing this
A small glass of water may be given to the patient part of the examination. The abdomen is examined
to aid in swallowing. Range of motion is checked by palpation, percussion, and auscultation. Following
by having the patient turn the head in each direc- the quadrants of the abdomen, the provider gently
tion. Care must be taken with older adult patients. palpates the organs in each quadrant, working from
The patient should be instructed to move the head side to side. The provider feels for organ size and
slowly to avoid syncope. location, as well as the presence of masses; percusses
the abdomen listening for sounds from abdominal
organs; uses the stethoscope to listen for abdominal
Chest sounds; and visually inspects the abdominal area for
The symmetry of the chest is observed, both changes in skin color, scars, or other abnormalities.
anteriorly and posteriorly. Chest measurement The contour of the abdomen may be flat or slightly
may have been performed before the examina- convex. The presence of hernias is checked in both
tion. The chest of a patient with emphysema will the supine and the standing positions. Patients with
appear barrel-like in shape. While the patient is abdominal disorders may give a history of dyspepsia,
sitting, the provider listens to the lungs with a dysphagia or excessive flatulence, nausea, vomiting,
stethoscope. The patient may be instructed to bloating, and pain.
take several deep breaths during this process.
Carefully monitor the patient, particu-
larly the older adult patient, because
Genitals
deep breathing may cause dizziness. The Refer to Chapters 14 and 16 for more detailed
provider is listening for abnormal lung sounds. The information about genitalia examinations.
provider may examine the lungs by percussion.
Heart sounds will be auscultated both anteriorly and Female Genitals. The patient is placed in the
posteriorly. lithotomy position. The provider examines both
308 UNIT 4 Integrated Clinical Procedures

the external genitalia and the reproductive organs. AFTER THE EXAMINATION
The rectum may be examined and a Hemoccult test
done at the conclusion of the pelvic examination. Once the examination has been com-
(See Chapters 18 and 32 for information regarding pleted the patient is instructed to dress.
the Hemoccult slide test.) After the examination, The patient should be given privacy while
the patient is instructed to slide toward the head dressing. Assist the patient as needed. Do not
of the table and may be allowed to sit up slowly. Sit- remain in the room to clean it while the patient
ting up quickly may cause orthostatic hypotension is dressing. Remain in the room if the patient
and dizziness. requires assistance. Further instructions regarding
other testing procedures and treatment plans will
Male Genitals. Care must be taken to protect all be given by the provider. Be specific with instruc-
patients’ modesty and privacy. The provider begins tions to patients regarding what they should do
the examination by inspecting and retracting the after they are completely dressed.
foreskin of the penis if the patient is uncircum- Once the examination is finished and the
cised. The glans penis is inspected for discharge patient has left the examination room, the equip-
and redness. The penis and scrotum are palpated ment and supplies (including the examination
for possible tenderness and masses. Because of the table) should be sanitized, disinfected, and steril-
seriousness of testicular cancer, the patient will be ized as appropriate.
instructed, usually by the provider, on the proce-
dure for performing monthly testicular examina-
tions (see Chapter 16).
Patient Education
Rectum
Throughout the physical examination, from
The provider may examine the rectum as a part
the time the patient arrives until the patient
of the male and female genitals examination. The
leaves, there are many opportunities for
patient may be placed in the Sims’ position. The
patient education. Written instructions should
provider performs a manual examination. The pros-
be given when necessary, and provider
tate gland is examined by digital rectal palpation.
information should be clarified if needed
The provider inserts the gloved index finger into
(Figure 13-17).
the rectum and palpates the prostate gland for any
masses or swelling (see Chapter 16). A lubricated Opportunities for teaching the patient
rectal speculum may then be inserted for visual how to adopt a healthy lifestyle are abun-
examination. Because this is uncomfortable for the dant. Regular exercise, no smoking, weight
patient, emotional support is important. The pro- control, limiting alcohol consumption, and
vider can visualize the rectum for bleeding, fissures, using stress reduction techniques, such as
polyps, or other lesions. meditation, yoga, massage therapy, and so
forth, all help to decrease blood pressure and
reduce risk for heart attack, stroke, and other
Reflexes illnesses.
The patient’s reflexes in both the supine and sit-
ting positions are observed by the provider. A per-
cussion hammer is used. While sitting with the arm
flexed, the elbow is lightly tapped to elicit move- Critical Thinking
ment from the biceps. The patellar or knee-jerk
reflex is tested by tapping the area just below the At the conclusion of the physical examina-
patella at the knee. The Achilles reflex or ankle- tion, the provider will have an impression of
jerk is tested by tapping the Achilles tendon. The the patient’s general health. What specific
Babinski reflex is tested on the sole of a relaxed information can the provider obtain from the
foot (the great toe will flex) with the patient in a examination? From what sources other than
supine position. Reflexes determine the integrity the physical examination does the provider
of the neurologic system. gain information to help in making a
Procedure 13-1 outlines the steps in assisting diagnosis?
with the physical examination.
 CHAPTER 13 The Physical Examination 309

Figure 13-17 Patient education forms can be printed from an electronic medical records software and given to the
patient right in the exam room.

Procedure 13-1
Assisting with a Complete Physical Examination
STANDARD PRECAUTIONS: Safety pin Specimen bottles/slides—
Gloves request forms
Tissues Biohazard and regular
Lubricant waste containers
Emesis basin
PURPOSE:
Gauze sponges
To assist provider with a complete physical exami-
nation. PROCEDURE STEPS:
1. Wash hands. Adhere to Standard Precautions.
EQUIPMENT/SUPPLIES:
Balance beam, digital, or Otoscope 2. Assemble equipment.
electronic scale Tuning fork 3. Place instruments in easily accessible sequence
Patient gown Ophthalmoscope for provider use. RATIONALE: Efficient use of
Drape Penlight time and space.
Thermometer Nasal speculum 4. Greet and identify patient.
Stethoscope Tongue depressor
Sphygmomanometer Percussion hammer 5. Explain procedure to patient. RATIONALE:
Alcohol wipes Tape measure To obtain patient cooperation, allay appre-
Examination lights Cotton balls hension, and gain consent.

continues
310 UNIT 4 Integrated Clinical Procedures

Procedure 13-1 (continued)

6. Review medical history with patient (see Chapter 23. Gynecologic examination may then be per-
11 for obtaining patient history). RATIONALE: formed (see Chapter 14). Assist female patient
To ensure complete history has been obtained into lithotomy position for gynecologic exami-
and is current. nation. Male genitals are examined.
7. Take patient vital signs, test visual acuity, and 24. If rectal examination is necessary, assist patient
check hearing ability. into Sims’ position.
8. Obtain a urine specimen (see Chapter 30 for 25. Place patient in prone position for examination
urine collection procedures). of posterior aspect of body.
9. Obtain all required blood samples (see Chapters 26. On completion of the examination, assist
28 and 29 for blood specimen collection proce- patient to sitting position and allow patient to
dures). sit at end of table for a few minutes. RATIO-
10. Perform electrocardiogram (ECG) if directed by NALE: Allows patient to recover from potential
provider (see Chapter 25 for ECG procedure). dizziness.
11. Provide patient with appropriate gown and 27. Ensure patient stability (check color of skin,
drape. pulse) before allowing patient to stand up.
RATIONALE: Prevents the patient from faint-
12. Assist patient to disrobe completely; explain ing due to orthostatic hypotension.
where the opening for the gown is to be placed.
RATIONALE: To assist patient in maintaining 28. Assist patient with dressing; provide privacy.
modesty, privacy, and warmth. 29. Enter any notes or patient instructions
13. Assist patient in sitting at the end of the table; E HR on computer in patient’s EMR per pro-
vider orders.
drape patient across lap and legs. RATIONALE:
Always drape patient to maintain modesty. 30. Escort patient to provider’s office for discussion
14. Inform provider when patient is ready. of examination results.
15. When the provider arrives, remain by the patient 31. Put on disposable gloves.
ready to assist the patient and provider. 32. Dispose of gown and drape in biohazard waste
16. Position patient in a sitting or supine position container. RATIONALE: Prevents microorgan-
for the head, throat, eye, ear, and neck examina- ism cross-contamination; gown and drape may
tion. have body secretions on them.
17. Lights may be turned off to allow pupils to dilate 33. Dispose of contaminated materials in biohazard
for retinal examination. container. RATIONALE: Prevents microorgan-
ism cross-contamination of bloodborne patho-
18. Hand the provider instruments as required gens and other potentially infectious materials
(some providers do not require the medical (OPIM).
assistant to hand the instruments).
34. Remove table paper and dispose in biohazard
19. The sitting position is maintained for ausculta- waste container. RATIONALE: Prevents micro-
tion of the chest and heart. organism cross-contamination.
20. Assist the patient into a supine position and 35. Disinfect counters and examination table with a
drape for examination of the chest. Breast exam- solution of 10% bleach. RATIONALE: Prevents
ination is discussed in Chapter 14. microorganism cross-contamination by blood
21. Maintain a quiet atmosphere to enhance the and OPIM.
ability of the provider in listening to heart and 36. Clean, disinfect, or sterilize reusable instru-
lung sounds. RATIONALE: Quiet is necessary to ments as appropriate (see Chapters 10 and 19).
hear heart and chest sounds accurately. RATIONALE: Prevents microorganism cross-
22. Position patient in supine position and drape for contamination.
examinations of abdomen and extremities.

continues
 CHAPTER 13 The Physical Examination 311

Procedure 13-1 (continued)

37. Remove gloves and discard in biohazard waste DOCUMENTATION

container. RATIONALE: Prevents microorganism 11/8/20XX T 98.2, P 84, R 16 BP 124/76 Complete physi-
cross-contamination by blood and OPIM. cal examination performed by Dr. Woo. Urinalysis nega-
38. Wash hands. tive, Hemoccult slide negative. Venipuncture performed
39. Replace table paper and equipment in prepara-
and specimens sent to laboratory for complete blood count
tion for the next patient.
and electrolytes. Electrocardiogram completed. Patient given
written instructions and appointment made for a colonos-
40. Document the procedure on computer copy. Says she understands the preparation for the colonos-
E HR in patient’s EMR. copy. W. Slawson, CMA (AAMA) ____________________

Case Study 13-1

Refer to the scenario at the beginning of the CASE STUDY REVIEW
chapter.
1. Why do Wanda and Bruce prepare and assist
for physical exams with patients of their own
gender?

Case Study 13-2

At Inner City Health Care, clinical medical assistant Wanda CASE STUDY REVIEW
Slawson is helping Liz Corbin, a part-time administrative/
clinical medical assistant, learn to prepare the examination 1. In reviewing with Liz the methods of examination
room and patients for the physical examination. In addition used by provider, what six primary methods would
to alerting Liz to provider preferences, Wanda wants to be Wanda have Liz describe?
sure that Liz has a solid understanding of the methods of 2. What patient positions would Liz need to know?
examination, positions and draping, and the components 3. Wanda asks Liz to recall the various examination
of the physical examination. components and their significance. How should
Liz respond?

Case Study 13-3

Mrs. Mason, a 72-year-old somewhat frail woman with CASE STUDY REVIEW
arthritis and hypertensive heart disease, has an appoint-
ment today for a complete physical examination. It will 1. Discuss positions and draping for the physical
include a basic physical examination and an examina- examination, including pelvic examination for this
tion of the pelvis because she has had bright red vaginal patient.
spotting. 2. Discuss any special safety needs for Mrs. Mason.
3. What additional supplies and equipment should
be available for the provider?
312 UNIT 4 Integrated Clinical Procedures

SUMMARY
A complete physical examination will be performed during the patient’s initial visit. Findings at this exami-
nation, both normal and abnormal, provide a baseline for future examinations.
The role of the medical assistant throughout the examination is twofold. The assistant assembles the
necessary instruments and may hand them to the provider when requested. The medical assistant will also
prepare the patient and obtain specimens as required by the examination and provider. Responsibilities
to the patient include explanations and careful positioning, protecting modesty by careful draping, and,
most important, providing comfort, emotional support, and safety. By performing these duties, the medi-
cal assistant can ensure patient compliance and provider efficiency.

STUDY FOR SUCCESS

To reinforce your knowledge and skills of information presented in this chapter:
• Review the Key Terms
• Practice the Procedures
• Consider the Case Studies and discuss your conclusions
• Answer the Review Questions

˚ Multiple Choice
˚ Critical Thinking
• Navigate the Internet by completing the Web Activities
• Practice the StudyWARE activities on your student CD
• Apply your knowledge in the Student Workbook activities
• Complete the Web Tutor sections
• View and discuss the DVD situations

REVIEW QUESTIONS
Multiple Choice c. body movement
d. speech
1. The method of examination that is the process of 4. When the patient asks a question of the medical
listening directly to body sounds is called: assistant, the medical assistant should:
a. percussion a. refer all questions to the provider
b. auditory b. try to answer all questions, even if uncertain
c. auscultation c. answer questions to the extent of knowledge;
d. the direct method refer others to the provider
2. The supine position is also known as: d. ask the patient to please hold all questions until
a. horizontal recumbent the examination is complete
b. dorsal recumbent 5. When the abdomen is being examined, the patient
c. knee-chest is typically in a:
d. Sims’ a. supine position
3. During the physical examination, ataxia might be b. prone position
observed, which relates to: c. Fowler’s position
a. stature d. Sims’ position
b. posture
 CHAPTER 13 The Physical Examination 313

Critical Thinking WEB ACTIVITIES

1. Discuss the responsibilities of the medical assis-
tant when preparing the patient for a physical 1. Using one of the “gateways” for general
examination. health and medical information and its
2. Review the six methods used in the physical links to other sites, gather information
examination. about the U.S. government’s guidelines for average
3. Evelyn Williams has a physical examination sched- adult height and weight measurements. According
uled for today. She is recuperating from back sur- to the government tables, what is considered an
gery and still has pain when she moves to raise her appropriate weight for your height?
legs. What position is most comfortable for her? 2. Explore the Web for information about the follow-
Which body parts can be examined with her in this ing conditions and their possible causes:
position? • Changes in retinal blood vessels
4. Explain the sequence of a physical examination. • Enlarged liver
5. List the instruments and supplies needed for • Ascites
examining the following body areas:
a. head • Varicose veins
b. reflexes • Vertigo
c. chest
d. abdomen
6. Describe the cleaning process that the following REFERENCES/BIBLIOGRAPHY
instruments will need after their use in an Hegner, B. R., Acello, B., & Caldwell, E. (2008). Nursing
examination: assistant: A nursing process approach (10th ed.). Clifton
a. nasal speculum Park, NY: Delmar Cengage Learning.
b. tuning fork Keir, L., Wise, B., Krebs, C., & Kelley-Arney, C. (2008).
c. percussion hammer Medical assisting administration and clinical competen-
d. reusable otoscope speculum cies (6th ed.). Clifton Park, NY: Delmar Cengage
7. List and describe the three sources of information Learning.
the provider uses to aid in making a diagnosis. Simmers, L. (2004). Diversified health occupations (6th ed.).
8. List two procedures or tests the medical assistant Clifton Park, NY: Delmar Cengage Learning.
might perform as part of the patient’s physical Taber’s cyclopedic medical dictionary (22nd ed.). (2003).
examination. Philadelphia: F. A. Davis.
Tamparo, C., & Lewis, M. (2005). Diseases of the human
body (4th ed.). Philadelphia: F. A. Davis.

THE DVD HOOK-UP

This chapter discusses the proper techniques for positioning DVD Journal Summary
patients and various methods that providers use to examine Write a paragraph that summarizes what you learned from
the patient. watching the scenes in today’s DVD program. When position-
In the designated scene, the medical assistant is seen ing patients, you are going to see parts of the body that the
placing the patient in various positions. You probably noticed that patient may not be able to see. What would you do if you saw
many of the positions were awkward for the patient. It should be some fecal matter on the back part of the patient’s upper leg?
noted that the position that the DVD lists as the Trendelenburg
position is not the true Trendelenburg position. The position
illustrated in the DVD starts off by having the patient lying in a
supine position. The medical assistant then carefully lifts the
patient’s legs and feet straight up in into the air. This is actually a
maneuver that can be used in place of the Trendelenburg posi-
tion when you do not have access to a tilt table. DVD Series Program Number
1. What types of physical concerns do you need to be Skills Based Series 6
aware of when using this alternative maneuver to the Chapter/Scene Reference
Trendelenburg position? • Positioning the Patient
2. What is the purpose of lifting the legs straight up into the air
instead of just propping them up on some pillows?
UNIT
Assisting with Specialty
5 Examinations
and Procedures

Chapter 14
Obstetrics and Gynecology
Chapter 15
Pediatrics
Chapter 16
Male Reproductive System
Chapter 17
Gerontology
Chapter 18
Examinations and Procedures
of Body Systems
 Chapter
Obstetrics
and Gynecology 14
KEY TERMS OUTLINE
Abortion Obstetrics Gynecology
Amniocentesis Initial Prenatal Visit The Gynecologic Examination
Amniotomy Subsequent or Return Gynecologic Diseases and
Bartholin Gland Prenatal Visits Conditions
Disorders of Pregnancy Other Diagnostic Tests and
Bimanual Examination
Parturition Treatments for Reproductive
Braxton–Hicks System Diseases
Postpartum Period
Candidiasis Complementary Therapy in
Carcinoma in situ Obstetrics and Gynecology
Cervical Punch Biopsy
Cesarean Section
Chlamydia
OBJECTIVES
The student should strive to meet the following performance objectives and
Colposcopy
demonstrate an understanding of the facts and principles presented in this
Condylomata chapter through written and oral communication.
Congenital Anomalies
Coupling Agent 1. Define the key terms as presented in the glossary.
Cryosurgery 2. Explain the importance of prenatal care, and discuss what
Diethylstilbestrol (DES) examinations will be performed as part of the initial visit.
Dilation 3. Explain why the initial prenatal visit is important.
Dysmenorrhea 4. List 12 conditions or diseases that can cause a pregnant woman and
Dyspareunia her fetus to be at greater risk for problems during the pregnancy.
Dysplasia 5. List signs and symptoms and their possible corresponding
conditions that the provider searches for during the prenatal his-
Eclampsia
tory and physical examination.
Ectopic
6. Calculate an expected date of confinement (EDC) or expected
Effacement date of birth (EDB) using Nägele’s Rule.
Endometriosis
7. Calculate an EDC (EDB) using a gestation wheel.
Erosion
8. Explain the purpose of ultrasonography and amniocentesis.
Exfoliated
9. List and describe six types of abortion.
Formalin
Fulgarated 10. Explain what occurs in each of the three stages of labor.
Genitalia 11. Describe what takes place during the postpartum examination.
Gestation 12. List and describe the diseases and disorders that can affect the
Gestational Diabetes female patient.
Gravidity 13. Describe the laboratory tests and procedures that can help
diagnose the diseases and disorders that can affect the female
Human Chorionic
Gonadotropin patient.

315
OBJECTIVES (continued) KEY TERMS
14. Describe seven sexually transmitted diseases. (continued)
15. Explain the medical assistant’s responsibilities with a gynecologic Hyperemesis Gravidarum
examination. Hypoxia
16. Describe breast self-examination and method of teaching patient Hysterosalpingogram
breast self-examination.
Intraepithelium
17. Discuss menopause. Involution
18. Describe the findings and concerns surrounding hormone Lamaze
replacement therapy.
Lochia
19. Describe several methods of contraception. Meconium
20. Explain reasons for impaired fertility. Metrorrhagia
21. Describe three therapies that assist in reproduction. Multigravida
Nägele’s Rule
Neonatal
Nullipara
Oxytocin
Parity
Parturition
Patent
Pelvic Inflamma-
tory Disease
Placenta Abruptio
Placenta Previa
Polycystic
Postcoital
Preeclampsia
Prenatal
Primigravida
Prostaglandin
Puerperium
Sickle Cell Anemia
Stigma
Supine Hypotension
Tay–Sachs
Thalassemia
Titer
Trichomoniasis
Trimester
Ultrasonography
Vesicle
Viable
Wet Mount

316
 CHAPTER 14 Obstetrics and Gynecology 317

Scenario
In the obstetrics department at Inner City Health Pap smear, and breast examinations scheduled for
Care, Wanda Slawson and Bruce Goldman, both certi- the afternoon. Wanda is responsible for assisting the
fied medical assistants, are preparing for the day’s provider with each of them. She is careful to follow all
appointments. Both take responsibility for being safety precautions before, during, and after assisting
certain all rooms have appropriate equipment and with examinations and procedures. She is careful to
supplies needed for today’s patients. There are three explain procedures to the patients and to direct any
ultrasonograms in addition to the pelvic examinations, questions to the provider.

INTRODUCTION
Obstetrics is the medical specialty in which the provider
treats the female patient from the prenatal period through Spotlight on Certification
labor, delivery, and during the 6-week postpartum period.
Gynecology is the specialty that treats the medical and RMA Content Outline
surgical disorders and diseases of the female reproduc- • Anatomy and physiology
tive tract. Both specialties are usually combined, and the • Patient education
provider who practices them is known as an obstetrician/
• Obstetrics and gynecology
gynecologist, or simply, an OB/GYN provider. Knowledge
of the female anatomy, the laboratory tests and procedures CMA (AAMA) Content Outline
for both specialties, the diseases and disorders that affect • Medical terminology
the female patient during her nonpregnant and pregnant • Anatomy and physiology
states, and patient education are essential for the medical
• Patient instruction
assistant who will care for these patients. The goal of the
OB/GYN specialty is to promote the health and well-being • Patient preparation and assisting the
of the woman and her baby. provider
• Collecting and processing specimens;
diagnostic testing
OBSTETRICS CMAS Content Outline
• Medical terminology
Obstetrics is the branch of medicine that pro-
vides care to the mother and fetus during preg- • Anatomy and physiology
nancy, labor, delivery, and the postpartum period • Examination preparation
known as the puerperium. Pregnancy is a period of
approximately 40 weeks from the day conception
takes place (Figure 14-1). The puerperium is the used as a baseline on which to compare future tests
period of 6 weeks after delivery when the mother’s and procedures. It is a risk assessment of maternal
body is returning to its prepregnant state. Visits to health for identification and prevention of compli-
the provider for prenatal and postnatal care are cations. For example, blood pressure measurement
the initial prenatal visit, return visits, and the 6- performed prepregnancy and not during the first
week postpartum checkup. trimester can rule out pregnancy-induced hyperten-
sion. The prenatal visit is a time of health promotion
for the expectant mother and her baby. It is also the
Initial Prenatal Visit time for diagnosis and treatment of maternal disor-
The initial prenatal visit is of utmost importance and ders that may have been present before the preg-
usually occurs after a woman has missed a second nancy or that may have developed during the course
menstrual period or after an at-home pregnancy test of the pregnancy. Growth and development of the
result is positive. Some obstetricians recommend pre- fetus are followed and identification of problems
pregnancy or preconception physical examinations. that may impede a normal labor are sought. There
The information guide at this appointment can be is ongoing assessment of the expectant mother
318 UNIT 5 Assisting with Specialty Examinations and Procedures

Uterus

Umbilical cord

Placenta

Cervix and
cervical os (opening)
Rectum Vagina

Figure 14-1 Normal uterine pregnancy.

and the fetus. Any abnormalities can indicate a prob- communication by health care providers are some
lem or complication necessitating further testing of the reasons that some women do not participate
and assessment. Early detection and management of in prenatal care. Modesty may deter some women
conditions such as gestational diabetes, urinary tract from seeking prenatal care. Exposing the body to
infections, anemia, and preeclampsia can prevent a man is viewed as a major violation of modesty in
serious complications. some cultures. This is why protecting the privacy of
The initial visit requires more time than subse- all patients is critical.
quent visits because a thorough history and physical
examination are done, including breast, abdomi-
nal, pelvic, and vaginal examinations. Pelvic mea- HIPAA
surements are taken to help ascertain if the pelvis is
adequate for a fetus to be delivered vaginally. Cultural differences are another
The initial visit is followed by monthly visits and
then weekly visits beginning at the 28th week, weeks
HIPAA reason to keep the Health Insur-
ance Portability and Account-
29–36 every 2 weeks, and at weeks 37–40 weekly. The ability Act (HIPAA) regulation in mind. During
routine visits consist of checking weight, measuring pregnancy, some women’s cultures demand
blood pressure, and testing blood and urine; educa- modesty, and protecting their privacy is critical.
tion about nutrition, activity, and rest; and prepar- Infertility is a stigma in some cultures. Maintain-
ing for childbirth (see Procedure 14-1). Data are ing confidentiality is a requirement of HIPAA for
entered into the computer each time the patient has all patients.
an appointment (Figure 14-2). They include find- The patient’s partner may be unaware of
ings from the provider’s examination, vital signs, the patient’s obstetrical history such as previ-
weight, blood and urine tests, and patient education ous pregnancies, abortion, or sexually trans-
for preparing for childbirth. Data are retrievable for mitted diseases. Confidentiality is of utmost
comparison purposes and treatment options. importance, and it is best to be alone with the
Many groups of women do not receive patient when obtaining this type of medical
prenatal care. Lack of financial resources, information.
insurance, or transportation and poor
 CHAPTER 14 Obstetrics and Gynecology 319

Results from
Regional/ Results to Outside
Pharmacy National Labs Providers

CLINICAL CARE LABORATORY

Patient Assessment
Procedures, Diagnoses & Treatment Plans
Referrals & Follow-up Appointments
Prescriptions
Orders for Tests Test Reports
Patient Medical History Quality Assurance & Controls
Safety Standards

Test Results Orders for Tests

Schedules and Tickler Files Safety Standards
Patient Medical History
Medication Administration
Patient Education
Graphical Patient Data Displays

ELECTRONIC RECORDS
Figure 14-2 Clinical care and laboratory arms of the total practice management system data flow.

Certain cultures expect their women to

observe practices believed to ensure a Patient Education
favorable pregnancy. Mexican women are
advised not to watch an eclipse of the moon; the Whatever the pregnant woman ingests or
belief is that the baby will be born with congeni- inhales affects the fetus. Smoking during
tal anomalies. Some Spanish women in the United pregnancy poses serious risks to mother and
States wear a braided cord around the midsection fetus. Low birth weight, placenta abruptio, and
to ward off nausea and to ensure safe birth. Med- deliveries before term are some of the possible
als and beads, often worn by women, are believed effects to the fetus. Lung cancer, emphysema,
to ward off evil spirits. Other cultures believe that and cardiovascular disease can affect the
inactivity during pregnancy will safeguard the mother. Other kinds of substance abuse such
mother and baby. There are also many dietary as alcohol, cocaine, and other recreational
influences within different cultures. (Chapter 22 drugs are commonly seen in pregnant women
gives more information on culture, diet, and food who are abused, such as in a domestic abuse
choices.) Respect for all cultures is of great impor- situation; however, women do not have to
tance, and judgments should not be made that be in an abusive situation to abuse drugs or
some women are ignorant or lazy. Incorporating alcohol. Ask the patient if she is in immediate
customs and beliefs demonstrates that you value danger. If so, a referral can be made to a com-
cultural diversity and women’s self-esteem. munity resource (e.g., women’s shelter, hotline
All women should be fully involved in their phone number, district attorney’s office) or the
care. Women with physical or emotional disabilities provider can help devise a safety plan until the
must have their particular needs addressed. When community resource steps in to help. (Chap-
necessary, make adaptations whenever possible for ters 7 and 23 provide more information about
women who are mentally challenged, blind, deaf, domestic violence and drug abuse.)
or physically incapacitated.

Laboratory Tests. The laboratory tests and proce- Patient Education. Patient education includes
dures that may be part of the initial prenatal visit such topics as nutrition, dental care, rest, and exer-
are described in Table 14-1. cise, as well as discussion about over-the-counter
320 UNIT 5 Assisting with Specialty Examinations and Procedures

Table 14-1 Laboratory Tests at the Initial Prenatal Visit

Laboratory Test Disease or Condition

Complete blood count (CBC), hemoglobin, and hematocrit To detect anemia or infection

Urinalysis with microscopic examination (pH, specific gravity, To screen for diabetes mellitus, renal disease,
color, glucose, albumin, proteins, white and red blood cell counts, infection, hypertensive disease, pregnancy
casts, acetone, human chorionic gonadotropin [HCG])

Blood type, Rh factor To detect Rh incompatibility

Rubella titer To determine immunity to rubella

Renal function To evaluate renal impairment in women with history

Alpha-fetoprotein (if initial visit is at 16-18 weeks gestation) of diabetes mellitus, hypertension, or kidney disease

Tuberculin skin test To screen for tuberculosis

Venereal Disease Research Laboratory (VDRL) and rapid To detect syphilis

plasma reagin (RPR)

Human Immunodeficiency Virus (HIV) with patient permission To screen for HIV antibodies

Hepatitis B and C virus To screen for hepatitis B and C viruses

Blood glucose To screen for gestational diabetes

Cardiac evaluation electrocardiogram (ECG), chest radiograph, To evaluate cardiac function in women with history
or echocardiogram of heart disease or hypertension

Pap smear To check for cervical dysplasia, herpes simplex virus 2

Vaginal, cervical, or rectal smear or culture for gonorrhea, To check for gonorrhea, chlamydia, human
chlamydia, and Streptococcus group B papilloma virus (HPV)

(OTC) remedies, prescription medications, and

herbal products (Figure 14-3). Alcohol and tobacco
and their dangers and potential harm to fetus and
mother should also be discussed. Medications, alco-
hol, cigarettes, and mind-altering substances taken
by the mother have harmful effects on the fetus and
should not be used.
Before the birth, the expectant couple is
encouraged to choose a method of feeding the
infant. During the initial prenatal visit, benefits of
breast-feeding the newborn are discussed. If the
mother is HIV negative, breast-feeding is encour-
aged because it offers many nutritional, psycho-
logical, and immunologic benefits. Because the
immune system of newborns is not fully devel- Figure 14-3 Supplying patients with information on a
oped, the high level of immunoglobulins in healthy pregnancy and potential risks and danger signs
breast milk gives them protection against some is an important responsibility of the medical assistant.
 CHAPTER 14 Obstetrics and Gynecology 321

pathogenic diseases of the respiratory and gastro- total number of pregnancies, including the pres-
intestinal tracts. Close contact between mother ent pregnancy, regardless of duration. The history
and newborn is certain with breast-feeding, also includes the parity, the number of pregnan-
and bonding can readily take place. Breast-fed cies carried to the point of viability regardless of
infants seem to have fewer allergic reactions. For whether the baby was born alive or dead. Multiple
the mother, one benefit of breast-feeding is that births, twins, and triplets count as one pregnancy
the uterus involutes, or returns more quickly (gravida) and one delivery (para). For example, a
to the nonpregnant state. Breast-feeding is the woman pregnant for the first time is referred to as
optimal way to feed a newborn. The services of Gravida 1, Para 0. After this woman delivers, regard-
a lactation consultant (available in most women’s less if the baby is born alive or dead, if it reached
hospitals and some pediatric offices) can be help- the age of viability, the history of the woman is
ful especially during the initial phase of breast- Gravida 1, Para 1. Viability is the ability to grow and
feeding. The consultant can provide hands-on develop after birth. The term multigravida refers to
instructions to the patient to optimize the experi- a woman who has been pregnant more than once.
ence for the mother and baby. Nullipara describes a woman who has not carried a
Formal childbirth education classes given in pregnancy to viability.
various languages teach the fundamentals of labor, Para sometimes has four letters that can be
delivery, and newborn care and feeding. used to give more information about past deliver-
ies. It does not include the present pregnancy. The
Prenatal History. The prenatal history will be four letters are FPAL:
comprehensive and include much of the same
information that is obtained during the taking of a F—number of full-term deliveries (37–40 weeks’
regular medical history. However, emphasis will be gestation)
on identification of the high-risk patient. Particu- P—number of preterm or premature deliveries (20–
lar attention is given to women who have a history 36 weeks’ gestation)
of one or more of the following situations or con- A—number of abortions (induced or spontaneous
ditions because they may place a woman and her terminations before 20 weeks’ gestation)
fetus at greater risk during pregnancy: L—number of living children born to the patient who
are still alive at the time of history data collection
• Use of legal drugs (OTC, prescription, tobacco, caf-
feine, alcohol), illegal drugs (marijuana, cocaine), For example, a woman has had four term pregnan-
and herbal products cies, delivered four live infants, but lost a child to
• Age under 16 or over 35 years leukemia at 7 years of age. This women is considered
• Rh-negative blood to be 4-0-0-3.
The present prenatal history includes infor-
• A history of repeated premature labors and
mation about the present pregnancy. The provider
deliveries, abortions, or stillbirths
searches for problems indicative of high-risk factors.
• Genetic diseases in the family Identifying high-risk patients helps to limit mater-
• Previous Cesarean section nal and newborn deaths and diseases. Some factors
• Diabetes that indicate a patient is at high risk are inadequate
nutrition; use of drugs such as alcohol, tobacco, or
• Hypothyroidism or hyperthyroidism
cocaine; existing medical conditions such as high
• Sexually transmitted disease blood pressure or diabetes; sexually transmitted
• Hypertension disease; and poverty. The provider watches for signs
• Nutritional deficiencies and symptoms that indicate a potentially serious
condition. Examples are listed in Table 14-2.
• Cardiac problems
• Kidney conditions
Subsequent or Return
• Epilepsy
Prenatal Visits
• Headaches
Subsequent visits include weight, blood pressure,
Any of these conditions or diseases can place the urinalysis, complete blood count with hemoglobin
woman and fetus at risk for serious complications. and hematocrit, measurement of the height of the
During the initial prenatal visit, an obstetri- uterine fundus (a tape measure is used by placing
cal history is taken, which includes the gravidity, or it on the anterior symphysis pubis and the crest of
322 UNIT 5 Assisting with Specialty Examinations and Procedures

Table 14-2 Signs and Symptoms of

Potentially Serious Conditions

Signs and
Symptoms Possible Condition

Rapid weight Preeclampsia

gain

Headaches Preeclampsia

Hypertension Preeclampsia
A
Vision changes Preeclampsia

Severe nausea Hyperemesis gravidarum/

and vomiting dehydration

Bleeding, Threatened abortion, placenta

discharge, previa, placenta abruptio
abdominal
pain/cramping

Edema Preeclampsia

One-sided pelvic Ectopic pregnancy (Figure 14-4)

or abdominal
pain B

Vaginal infection, sexually trans- Figure 14-5 Fundal height is measured by placing the
Chills, fever
mitted disease, other infections end of the tape at the symphysis pubis and extending it in
either a (A) curved or (B) straight pattern to the fundus.

the uterus) (Figure 14-5), and fetal heart measure- reasonably accurate. Nägele’s rule is to add 7 days
ments (Figure 14-6). Generally, it is not possible to to the first day of the last menstrual period (LMP),
determine with accuracy the exact date of concep- subtract 3 months, and add 1 year. An example is:
tion. Many formulas have been used for calculating
the EDB (expected date of birth) or EDC (expected The first day of LMP  July 10, 2007
date of confinement). Although none is foolproof, Add 7 days  July 17
Nägele’s rule is the usual method used because it is Subtract 3 months  April 17
Add 1 year  April 17, 2008
Tubal Another method to calculate EDB or EDC is
to add 7 days to LMP and count forward 9 months.
Most women give birth within 7 days before or
after the EDB or EDC.
Pregnancy wheels help determine the EDC.
Line up the arrow of the first day of the LMP, then
Peritoneal read off the date that corresponds to the 40-week
Ovarian
designation (Figure 14-7).
Vaginal examinations are only done periodically
up to 2 to 3 weeks before the EDB or EDC. Patients
are encouraged to attend classes in the Lamaze
method of childbirth, as well as classes in the care of
Figure 14-4 Sites of ectopic pregnancy. the newborn (Figures 14-8 through 14-10).
 CHAPTER 14 Obstetrics and Gynecology 323

Figure 14-8 Blood pressure is measured at each

prenatal visit.
B

Figure 14-6 (A) Fetal heart tones are measured with

a handheld Doppler. (B) Handheld Doppler.

Figure 14-7 Gestation wheel. Place arrow labeled

“first day of LMP” on date of last menstrual period
(LMP). Read date at arrow labeled “expected
delivery date.”

Figure 14-9 Weight gain is tracked throughout the

pregnancy.
324 UNIT 5 Assisting with Specialty Examinations and Procedures

A B

Figure 14-10 Urine is tested for glucose and protein at each visit. (A) Client provides a urine sample. (B) Medical
assistant uses dipstick to check for glucose and protein.

Tests and Procedures catheter by means of suction. The sample is ana-

Alpha Fetoprotein. Another test that may be lyzed in the laboratory for genetic abnormalities.
done during a subsequent visit is the mother’s An ultrasonogram is done simultaneously with
serum alpha fetoprotein (MSAFP) blood test. It an amniocentesis to avoid possible injury to the
is done about the 16th week of pregnancy. It is a fetus or placenta.
screening test only, done to rule out neural tube
defects, abdominal wall defects, and chromosomal Ultrasonography/Amniocentesis. Two tests
problems such as Down syndrome. If the test is can be done that can supply vital information:
positive, additional testing such as an amniocen- ultrasonography, or ultrasound, and amniocen-
tesis or an ultrasound will be used to help make tesis. Ultrasound can be performed in the first,
a diagnosis. second, or third trimester. It uses high-frequency
sound waves to produce an image of the fetus.
Chorionic Villus Sampling (CVS). Chori- A coupling agent is spread onto the mother’s
onic villius sampling (CVS) is a test performed abdomen to enhance penetration of sound waves
on women who are older than 35 years, have a through the tissue, and the scanning mecha-
history of chromosomal abnormalities, and are nism is moved over the abdomen. An image of
known carriers of a genetic disorder such as thal- the fetus can be viewed on a screen similar to a
assemia, sickle cell anemia, or Tay–Sachs. The television screen. Photos are taken during the
test is done at about 8 to 10 weeks’ gestation and examination. The technique usually takes about
has an advantage over amniocentesis because a half hour. There are no known side effects
the latter cannot be done before the 14th week. to the fetus or mother, and ultrasound uses no
In one method of the CVS test, a sample of tis- X-rays. There is no pain involved, but slight dis-
sue that surrounds the fetus is taken through a comfort can occur due to a full bladder. (A quart
 CHAPTER 14 Obstetrics and Gynecology 325

of fluid should be consumed 1 hour before the Percutaneous umbilical blood sampling (PUBS),
test and finished within 15 or 20 minutes.) A also known as cordocentesis, is another procedure
full bladder is essential to a good-quality ultra- that can be done. It accesses fetal circulation by aspi-
sound because it supports the uterus in position rating blood from the fetal umbilical cord vessels.
for good imaging. This procedure may be used Because the procedure is invasive, it is performed
to identify the number of fetuses, check the age in conjunction with ultrasound. Many blood stud-
of the fetus (number of weeks gestation), and ies can be performed, and many conditions can be
detect some fetal abnormalities (e.g., Down syn- diagnosed using fetal cord blood, such as chromo-
drome; Figure 14-11). somal abnormalities, infections within the uterus,
A high-resolution three-dimensional ultraso- and fetal hypoxia. Drug therapy and transfusions
nographic test is used more and more frequently can be given through the umbilical vein in the fetal
to check for Down syndrome. The test is useful umbilical cord.
because it can detect chromosomal abnormalities. Fetal heart rate is another test. Monitoring
It can be done sooner in a pregnancy than blood can be done in one of two ways: a nonstress test
testing and could minimize the need for CVS or monitors the fetus’s heart rate while it is moving
amniocentesis, both of which create risks to the spontaneously, or a stress test monitors the fetal
mother and fetus. heart rate while the mother is stimulated with
An amniocentesis is the surgical punctur- medication to have mild uterine contractions. Nor-
ing, with a long, thin needle, of the amniotic sac mally, the fetal heart rate will accelerate to a higher
through the woman’s abdomen. The purpose of but safe limit while it is being stressed.
this test is to obtain, by aspiration, a sample of amni- Entering data electronically during each
otic fluid that contains fetal cells. The procedure E HR visit allows immediate access to the patient’s
can be done as early as 14 weeks and helps to diag- medical record and comparisons of vital
nose genetic problems, congenital anomalies (pres- signs, laboratory values, ultrasounds, amniocente-
ent at birth), and chromosomal defects. It also can sis, and all other diagnostic tests and procedures
be used to determine the lung capacity of the fetus to previous data entries. Baseline values are impor-
(Figure 14-12). tant, and timing of certain laboratory tests is crucial
Ultrasonography is performed while the pro- for accurate evaluation. Providers can refer back to
vider is doing the amniocentesis to identify the it throughout the pregnancy. The electronic medi-
position of the fetus and placenta, thereby avoid- cal record (EMR) is a communication mechanism
ing injury to either. There can be bleeding, leaking for organizing a patient’s care. All data entry should
of amniotic fluid, and infection. be dated and include the time and your signature.

A B

Figure 14-11 (A) Abdominal ultrasound. (B) Transducer for transvaginal ultrasound.
326 UNIT 5 Assisting with Specialty Examinations and Procedures

Uterine Amniotic
wall cavity
Placenta

A B

Figure 14-12 (A) An amniocentesis setup. (B) During amniocentesis, a sample of amniotic fluid is aspirated for evalu-
ation. An ultrasonogram is done simultaneously with an amniocentesis to avoid possible injury to the fetus or placenta.

woman and her fetus in grave danger and can be fatal if

Disorders of Pregnancy not treated. Preeclampsia is less severe. The symptoms
The following sections address some problems that are the same, except there are no convulsions. This is
may occur during pregnancy. why weight is measured, blood pressure checked, and
a urinalysis (including a check for protein) is routinely
Abortion/Interruption of Pregnancy. The interrup- performed. Sudden significant weight gain, increase
tion of pregnancy before the fetus is viable is known in blood pressure, and the presence of protein in
as abortion. Six types of abortion are listed here: the urine can indicate possible preeclampsia. The
cause is unknown. Prophylaxis is of great importance.
1. Spontaneous: Unknown etiology (miscarriage) The problem is seen more often in women who have
2. Complete: Expulsion of all products of conception, received inadequate prenatal care, especially poor
fetus, and placenta with no surgical intervention nutrition, in primigravida (pregnant for the first
3. Missed: Fetus dies in the uterus and must be time) younger than 18 years, in women with preex-
removed; usually a dilation and curettage (D&C) is isting cardiovascular and renal conditions, as well as
the surgical procedure performed in women who are diabetic.
4. Incomplete: Only parts of the fetus and placenta are
expelled. Tissue remains in the uterus and a D&C
Gestational Diabetes. Gestational diabetes first
appears during the second or third trimester of the
usually must be performed.
pregnancy and usually disappears after the woman
5. Threatened: Bleeding from the uterus, but there are has delivered her baby or when the pregnancy ter-
no contractions or dilation of cervix. Pregnancy minates for any other reason. This type of diabetes is
continues. usually a milder form of the disease. Prompt detec-
6. Induced: Evacuation of the fetus and placenta tion (through blood and urine glucose testing) and
from the uterus at the mother’s request or
because mother’s health is in jeopardy.
Critical Thinking
Eclampsia. Eclampsia syndrome, also known as
pregnancy-induced hypertension, can occur in preg- A 17-year-old girl has missed her period and
nancy and result in convulsions unrelated to epilepsy has called the clinic describing sharp right
or other brain conditions. It is a potentially life- quadrant pain. What tests/procedures will
threatening disorder characterized by hypertension, help the provider make a diagnosis?
generalized edema, and proteinuria. It can put the
 CHAPTER 14 Obstetrics and Gynecology 327

therapy are essential to avoid fetal and neonatal nausea and vomiting, inability to eat, and exhaus-
(newborn) illness and death. tion from inability to sleep. Severe dehydration can
A blood glucose is drawn 1-hour after the result and starvation may ensue. This complication
patient is given a high-glucose drink. If the test is usually not fatal, but it is a severe problem that
result is elevated, than a 3-hour glucose tolerance warrants immediate treatment. Treatment includes
test is done. Prenatal visits for the patient with ges- intravenous fluids to replace those lost through
tational diabetes requires more frequent visits to vomiting and mild sedation to aid rest and sleep.
the provider. The fetus is evaluated at each visit.
Ultrasound evaluation of fetal growth is performed Placenta Previa. Placenta previa occurs when the
more often. The patient must control her diet and placenta implants low in the uterus and partially or
monitor blood glucose levels at home several times completely covers the cervical os. It is an emergency.
daily. A nutritionist will help by teaching the patient The cause is unknown. When labor ensues and the
about a diabetic diet. The appropriate number of cervix begins to dilate, the placenta is pulled away
calories and percent of carbohydrates, proteins, from the wall of the uterus and causes bleeding. On
and fats are calculated to keep the blood glucose occasion, the bleeding, which comes on suddenly
as close to 100 mg/dL as possible. If the diabetic and is painless, will stop spontaneously. If it continues,
diet does not control blood glucose levels, insulin significant maternal blood is lost, and the fetus may
therapy is started. Usually the patient is admitted suffer anoxia and die when the placenta separates
to the hospital if she has poorly controlled diabetes from the blood supply (Figure 14-13B).
and has the additional factor of hypertension. Ultrasonography can determine where the pla-
Pregnant women with gestational diabetes centa is attached, at which time the diagnosis can
have a strong possibility of developing diabetes be made and treatment begun. Treatment depends
within their lifetime. The provider will order a on the gestational age of the fetus and the percent
blood glucose (1-hour glucose tolerance) when of placenta that covers the cervical os. Cesarean sec-
the woman is 6 to 8 weeks postpartum. The results tion may be necessary to remove the placenta, con-
will determine whether or not the patient’s blood trol bleeding, and deliver the fetus safely.
glucose level has dropped to the normal range. Some of the factors associated with placenta
previa are advanced maternal age, maternal smok-
Hyperemesis Gravidarum. Hyperemesis gravi- ing, and cocaine use. Maternal exposure to passive
darum, or excessive vomiting during pregnancy, smoke and use of tobacco by the woman have been
can be harmful and is more than morning sickness, shown to be risky to the fetus, resulting in lower
which is a common complaint during the first tri- birth weight, premature birth, and infant death.
mester. The cause of the condition is not known, but
it is thought to be related to the cells that become Placenta Abruptio. Placenta abruptio occurs
the placenta and to the production of pregnancy when the placenta prematurely and abruptly sep-
hormones. The symptoms include uncontrollable arates from the uterine lining (Figure 14-13A). It

Placenta
pulled away
from uterus

Placenta positioned
over cervical
opening

Cervix

Placenta abruptio
A B Placenta previa

Figure 14-13 (A) Placenta abruptio. (B) Placenta previa.

328 UNIT 5 Assisting with Specialty Examinations and Procedures

can result in fetal distress and death and maternal in life when fertility is naturally lower. The increase
shock and death. It usually occurs late in preg- in the incidence of pelvic inflammatory disease
nancy but can occur during labor. (PID), endometriosis, substance abuse, and envi-
Factors that contribute to this complica- ronmental factors such as pesticides and lead all
tion are multiple pregnancies, chronic hyperten- can contribute to impaired fertility.
sion, trauma to the uterus, and sudden release of Diagnosis and treatment of impaired fertility
amniotic fluid. Delivery as soon as possible either requires a physical, emotional, and financial invest-
vaginally or by Cesarean section is indicated. The ment over a long period. To diagnose impaired
prognosis of the newborn depends on the extent fertility in the female patient, a complete history
of hypoxia suffered during labor and delivery. and physical examination are performed. Endo-
The infant should begin to cry and its color crine system and anatomic and physiologic abnor-
turn pink (hands and feet may remain blue for malities are sought. Laboratory tests on urine and
about a week). Abnormalities, if any, are docu- blood are performed. Proof of ovulation can be
mented. The Apgar score is an indication of the determined by retrieving an ovum from the uter-
newborn’s well-being. Assessments, in numbers ine tube, performing an endometrial biopsy, assess-
from 1 to 10, are made at 1, 5, and 15 minutes. ing mucus characteristics, and taking the basal
Five aspects of the newborn are evaluated: respi- body temperature. Levels of estrogen, progester-
ratory ease, heart rate, skin color, reflexes, and one, follicle-stimulating hormone, and lutenizing
muscle tone. Each is assigned a number, which hormone are also measured. A hysterosalpingo-
added together determines the newborn’s Apgar gram, a radiograph of the uterus and tubes after the
score. The closer to 10 the score is, the closer the injection of dye, reveals defects in either the uterus
newborn is adapting to life outside the uterus. or tubes.
A lower score indicates a problem with the new- Laparoscopy can be performed to visual-
born’s respirations, heart rate, color, and muscle ize the internal pelvic structures. Tubal patency,
tone. Oxygen and other measures may be nec- endometriosis, pelvic adhesions, or polycystic
essary to stabilize a newborn with a low Apgar ovaries can be seen. Endometrial biopsy is done
score. to examine the tissue and determine whether the
endometrium is capable of accepting a fertilized
Impaired Fertility. The inability to conceive and ovum for implantation. Ultrasonography, either
bear a child after a period of unprotected sex is abdominal or transvaginal, can assess pelvic
known as impaired fertility. One reason for this organs for abnormalities.
problem is that couples delay pregnancy until later Tests that can be performed on a male to
diagnose impaired fertility are semen analysis, hor-
mone analysis, and biopsy of a testicle.
Once a diagnosis of impaired fertility has
been made, a number of therapies are available
Patient Education to assist in reproduction. This is known as assisted
reproductive technology (ART).
Alcohol Exposure
• In vitro fertilization (IVF), indicated for fallo-
Alcohol along with tobacco exposure dur- pian tube blockage and endometriosis: Eggs are
ing pregnancy is common. Drinking during retrieved from the woman’s ovaries, fertilized with
pregnancy is the leading cause of childhood sperm from her partner in the laboratory, then
mental retardation. Two or more drinks a day transferred to her uterus.
while a woman is pregnant increases the risk
of the newborn being born with fetal alcohol • Gamete intrafallopian transfer (GIFT): Eggs are
syndrome (FAS). Birth defects include small retrieved from the woman’s ovaries. An egg and
brain size, growth retardation, specific facial sperm from her partner are aspirated into a spe-
deformities (e.g., flat middle of the face, wide cial catheter, then placed into the fallopian tube
bridge of the nose, thin upper lip), and heart, where fertilization may occur naturally.
kidney, and eye abnormalities. Behavioral • In vitro fertilization and gamete intrafallopian
problems (e.g., learning and attention difficul- transfer (IVF + GIFT) with donor sperm: Eggs
ties, hyperactivity) occur. No safe amount of are retrieved from the woman’s ovaries, fertilized
alcohol can be consumed during pregnancy, with donor sperm in the laboratory, aspirated into
so abstention from all alcohol is necessary. a special catheter, then placed into the fallopian
tube where fertilization may take place naturally.
 CHAPTER 14 Obstetrics and Gynecology 329

New technology allows retrieval sperm level of other hormones decreases. When the oxy-
from the testicles if ejaculation is impossi- tocin is released, it causes the muscles of the uterus
ble. Sperm can be injected into the ovum, to contract. Braxton–Hicks contractions, often
embryos can be frozen, and surrogate pregnancies referred to as false labor, can usually be differenti-
are possible. With technology come the ethical and ated from real labor because of their irregularity
legal questions of donor eggs and embryos, preg- and tendency to disappear when the woman moves
nancies in older adult women, how to define who about and changes positions. When the woman is
the parents are, what to do with frozen embryos lying in supine position, the heavy, large uterus can
after death or divorce, and other issues such as dis- press on the inferior vena cava and aorta, reducing
posal of unused (extra) embryos. blood flow back to the heart. The patient becomes
In some cultures, a woman is deemed pale, sweaty, and dizzy, and blood pressure drops.
the responsible party for impaired fertil- The condition is known as supine hypotension.
ity, and the impairment is thought to be When the patient is turned onto her side, the pres-
caused by her sins, evil spirits, or her own deficien- sure on the vena cava is removed and the hypoten-
cies. The virility of a male is questioned unless he is sion resolves.
able to manifest his sexual potency by having a child. If fetal membranes do not spontaneously rup-
ture during labor, an amniotomy (artificial rupture
Incompatibility. The pregnant woman’s blood of the membranes) can be done. The procedure
type and Rh factor are determined at the first pre- uses a sterile amniohook, and it may shorten the
natal visit. If the woman has Rh-negative blood length of labor (Figure 14-14).
and the fetus has Rh-positive blood, problems can Signs and symptoms to watch for during
occur. When the fetus’s blood (red blood cells) labor that indicate complications are heavy vaginal
leak into the woman’s body during birth, an Rh- bleeding, sudden increase or decrease in blood
negative woman may develop antibodies against pressure, increased activity by the fetus, headache,
the fetus’s Rh-positive blood. The antibodies can extreme restlessness, and visual changes. Meco-
pass through the placenta and kill the RBCs in nium, the first stool of the newborn, in the vaginal
the fetus. The fetus becomes anemic and jaun- discharge can indicate fetal distress.
diced. Death of the fetus is possible if too much
fetal blood is destroyed. When an injection of Rh-
immune globulin (RhoGAM) is given at around
Postpartum Period
the 28th week of pregnancy and 72 hours postpar- The postpartum period is the time known as the
tum, and after percutaneous umbilical blood sam- puerperium during which the body returns to its
pling (PUBS), CVS, abortion, or amniocentesis, nonpregnant state. It is usually 4 to 6 weeks after
then sensitization is prevented. Rh incompatibility
should not occur with any subsequent pregnancy. A
RhoGAM must be given after every birth, abortion,
miscarriage, amniocentesis, CVS, and PUBS to pre-
vent sensitization.

Parturition
Parturition, or labor, is the process during which
the uterus, through contractions, expels the fetus
and placenta. There are three stages of labor:
• Stage I—Dilation: from onset of labor until com-
plete dilation (expansion) and effacement (thin-
ning and shortening) of cervix
• Stage II—Expulsion: from complete dilation and
effacement through the birth of fetus (expulsion)
• Stage III—Placental: from birth of fetus through
expulsion of the placenta B
Labor is believed to be triggered by the Figure 14-14 (A) Disposable amniohook used to
release of oxytocin and prostaglandins after the rupture membranes. (B) Amniotomy technique.
330 UNIT 5 Assisting with Specialty Examinations and Procedures

delivery. The body undergoes changes during this device made of copper or progesterone-medicated
time. The uterus involutes (returns to normal size) plastic; see Procedure 14-3); and vaginal rings.
and healing of any injuries takes place. Sterilization is a surgical procedure that ren-
A vaginal discharge, known as lochia, appears ders the individual infertile. The woman’s uterine
during the puerperium. It consists of tissue, blood, tubes are fulgarated (destroyed by means of an elec-
white blood cells, mucus, and bacteria. It can be tric current) or bands and clips are placed around
described by its appearance. Lochia rubra is bright the tubes to block them (ligation). Both fulgara-
red and appears the first 3 days after delivery. tion and ligation are considered to be permanent
Lochia serosa is pink or brown and is indicative of methods. Female sterilization can be performed
less blood. By about 10 days, the flow decreases, immediately after giving birth or any time afterward
becomes whitish-yellow, and is known as lochia during any phase of the menstrual cycle. Laparo-
alba. Lochia usually disappears by the third week scopic surgery is the usual approach. Tubal ligation
postpartum but may last for up to 6 weeks. Men- and oral contraceptives are the top contraceptive
struation usually begins in a nursing mother 3 to choices in the United States (Figure 14-20).
6 months after delivery, 2 months for nonnursing The surgical procedure performed on a male
mothers. The mother is told to avoid heavy lift- to render him sterile is a vasectomy. It can be per-
ing, not to become fatigued, to eat a well-balanced formed on an outpatient basis under localanes-
diet, and to continue to take her prenatal tablets. thesia. Small incisions are made into the scrotum
Report any feelings of depression as soon as pos- above and to the side of each testicle. Each vas def-
sible. An appointment in 6 weeks will evaluate the erens is identified, ligated twice, and then severed
mother’s general health, and the provider will dis- (Figure 14-21). It is important for the patient to
cuss infant care, breast-feeding, the importance realize that sterility is not immediate because some
of exercise, good nutrition, and birth control. sperm remain in the sperm ducts after vasectomy.
The medical assistant can stress the importance One week to several months may elapse before the
of yearly Pap smears and of monthly breast self- ducts are sperm free. Some form of contraception
examinations because these are important aspects is necessary until two consecutive sperm counts
of patient education. are zero.
Another method of contraception approved
Contraception. Voluntary prevention of preg- by the Food and Drug Administration (FDA) is a
nancy is known as contraception. The opportune medication known as RU-486, which is used to cause
time to discuss contraception with the mother is or induce an abortion. It’s safety has been ques-
soon after delivery and before discharge from the tioned by experts. Injectable contraceptives are avail-
hospital. She should know what method of con- able. Depo-Provera® is given intramuscularly every
traception she and her partner will use before 3 months. Lunelle® is given intramuscularly monthly.
resuming sexual activity. To discuss contracep- These injectables are best given within the first
tion at the 6-week postpartum checkup can be too 5 days of the menstrual cycle to be certain the woman
late. Sexually transmitted disease (STD) protec- is not pregnant. The majority of states mandate that
tion should also be reviewed before discharge. health insurance cover the cost of contraception.
Written instructions about methods of contra-
ception are important and help the patient under-
stand options that are available. GYNECOLOGY
Some nonprescription kinds of contraception
are the various barrier methods: condoms; male Gynecology is the specialty that studies diseases of
(latex) and female (nonlatex); contraceptive foam; the female reproductive tract and the breasts. The
spermicide (nonoxynol-9) used with a condom to gynecologic examination is routinely performed in
help prevent STDs; vaginal sponges that contain a an office or clinic. It usually includes abdominal,
spermicide; and abstinence. pelvic, and breast examination and a Pap smear.
Many types of prescription contraceptives are It can be done as part of the female’s complete
available (see Figures 14-15 to 14-19 and Table 14- physical examination, or it can be a separate exam-
3). They include hormonal contraception in the ination performed in the gynecologist’s office or
form of oral birth control pills; Implanon®, a surgi- gynecology clinic. Early diagnosis and treatment of
cal implant of progestin in the upper arm, which problems associated with the female reproductive
provides up to 3 years of contraception; a dia- organs help the female to achieve optimum health
phragm used with a spermicide; a cervical cap to of these organs and is the goal of the OB/GYN
fit over the cervix; an intrauterine device (a small provider (Figure 14-22).
 A B

Figure 14-15 (A) Female condom. (B) Proper insertion of female condom.

A B

Figure 14-16 (A) Diaphragm with contraceptive jelly. (B) Various sizes of diaphragms. They must be fitted by the
provider.

A B
Figure 14-17 (A) Cervical cap. (B) Proper insertion of cervical cap.
332 UNIT 5 Assisting with Specialty Examinations and Procedures

B
B

C Figure 14-19 (A) Intrauterine device (IUD) and plas-

tic uterus for patient education. (B, C) A plastic uterus
Figure 14-18 Spermicides. (A) Foam. (B) Sponge. can be used to demonstrate proper insertion and place-
(C) Film. ment of IUD during a patient education session.

Table 14-3 Various Contraception (Birth Control) Methods

Mechanism
Method Description Effectiveness of Action

Male and female condoms Less effective than hormonal Inhibits sperm from
available. Male condoms are latex; methods or IUD. entering the vagina.
female condoms are nonlatex. Use with spermicide. Used only once.
Barrier (over-the-
counter condom) Use to protect from STDs. To prevent STD
(see Figure 14-15) and pregnancy, use
a condom and
another method
of contraception.

Use with spermicide. Must be Moderately effective if used Provides barrier

measured and fitted by provider. correctly. Must fit perfectly. between sperm and
Diaphragm
Fits up against the cervical opening Spermicide is placed inside opening to cervix.
(prescription
so that cervix is within the cap. and around the diaphragm.
needed)
Must remain in place for 6
(see Figure 14-16)
hours after intercourse. Will last
for years if cared for properly.

Made of rubber. Fitted to cover Moderately effective if used Provides rubber barrier
Cervical cap the cervix. Folded to insert into the correctly, similar to diaphragm. between sperm and
(must be fitted vagina. Must be applied to cervix. Potential for infection because opening to cervix.
by provider) Suction keeps the cap in place. Use cap can be left in place up to
(see Figure 14-17) with spermicide. 2 days. Must remain at least
6 hours after intercourse. (continues)
 CHAPTER 14 Obstetrics and Gynecology 333

Table 14-3 Various Contraception (Birth Control) Methods (continued)

Mechanism
Method Description Effectiveness of Action

Chemical known as nonoxynol-9. When used alone, failure rate Destroys sperm cells.
is high compared to other
methods. Used with condom,
Spermicide sponge diaphragm, or cervical cap, it
foam cream/gel is more effective. No bathing or
(over the counter) douching for 6 hours after inter-
(see Figure 14-18) course. Must allow 15 minutes
before engaging in intercourse.
Reapply spermicide with
repeated intercourse.

Hormonal pills (pre- Various combinations of estrogen Highest effectiveness rate Prevents ovulation
scription needed and progestin or progestin only. when taken correctly. Can every month.
for all hormonal help reduce dysmenorrheal
contraceptives) and heavy menses.

Intramuscular injection (Depo- Highly effective. One of most Prevents ovulation for
Provera®) every 3 months. effective contraceptives. Best 3 months.
Injection given within first 5 days of Stops ovulation for
Lunelle®, injected once per month. menstrual period to be sure 1 month.
patient is not pregnant.

Applied to body and contraceptive Highly effective. Worn for Prevents ovulation
is absorbed through the skin. 1 week and then replaced for 1 month.
Patch same day of week for 3 con-
secutive weeks. Fourth week
patch free.

Small flexible ring inserted into the Highly effective. Prevents ovulation.
vagina. Releases steady flow of
Vaginal ring
hormones. Left in for 3 weeks.
Removed for 1 week.

Continuous contraception. No Effective. Prevents ovulation.

menstrual cycles for indefinite time Reduces mood swings,
Lybrel* period. Breakthrough bleeding migraines, and premen-
Seasonique* possible. strual syndrome (PMS).
Continuous contraception for Highly effective. Prevents ovulation for
3 months. 3 months.

T-shaped device made of copper. Both highly effective. Copper slowly

Intrauterine device Good for 10 years. A second One of the most effective released into uterus
(IUD) (must be T-shaped device good for 1 year. contraceptives. and kills sperm.
inserted by Mirena® is an IUD that releases Hormones in Mirena®
provider) (see hormones. Remains in place for cause thickening of
Figure 14-19; 5 years. To prevent STDs, IUDs should the mucus in the cervix,
Procedure 14-3). be used in conjunction with a so sperm cannot reach
condom. the ovum.

(continues)
334 UNIT 5 Assisting with Specialty Examinations and Procedures

Table 14-3 Various Contraception (Birth Control) Methods (continued)

Mechanism
Method Description Effectiveness of Action

Device known as Implanon® is Highly effective. One of the Inhibits ovulation and
composed of one rod that is most effective contraceptives. changes the cervi-
implanted. Lasts up to 3 years. cal and endometrial
Minor surgical procedure is required mucus.
to implant and remove.
Implantable Becomes more effective as Implanted device
(must be implanted Essure® is a spring-like device scar tissue grows thicker. Use causes scar tissue to
by provider) implanted in fallopian tubes via another form of contraceptive build up within the
the cervix. for at least 3 months. fallopian tubes, even-
tually blocking them.
When blocked, neither
sperm nor ovum can
pass through.

Sterilization procedure performed in Considered permanent, but Fallopian tubes are

Tubal ligation or which the fallopian tubes are tied there is a small failure rate. severed and/or
hysterectomy (per- or bands and/or clips are placed burned, banded, and/
manent method) around the tubes to block them or clipped. Because
(performed when (ligation). The tubes can also be fallopian tubes now
the woman has a burned with electrocautery. are incapable of trans-
gynecologic prob- porting either sperm
lem that requires or ovum, fertilization is
surgery and she not possible.
wants permanent
sterilization) Hysterectomy is the surgical removal Permanent sterilization. Uterus is surgically
of the uterus. removed.

Ovulation prediction (rhythm Can be effective if done cor- Prevents conception

method). The woman charts her rectly. However, method must by avoiding inter-
temperature and her changes in be used consistently and course during the
Family planning vaginal mucus and abstains from the woman must realize that period of ovulation.
intercourse during the time she is she may ovulate on a differ-
ovulating (as predicted by tempera- ent day each month or at
ture and mucus changes) another time.

Prevents unintended pregnancy Very effective. Not the same as

when the woman has had unpro- RU-486, an abortion
Emergency tected sexual intercourse. Prevents pill. Prevents ovulation
contraception unwanted pregnancy. Pills (known or stops fertilization.
(postcoital con- as “morning after pills”) that con-
traception) also tain birth control hormones can be
called Preven® or taken as soon after unprotected sex
plan B (over the as possible and up to 5 days after
counter for age 18 and still prevent pregnancy. Take a
and over, prescrip- second dose 12 hours after the first
tion if under 18) dose. Will not interrupt an estab-
lished pregnancy and will not harm
the embryo. No prescription needed.

IUD made of copper, Very effective. Kills sperm or prevents

and the copper helps ovum fertilization.
kill sperm. (Mirena®
IUD cannot be used
as an emergency
contraceptive).

*Newest oral contraceptives called extended hormonal contraceptives

 CHAPTER 14 Obstetrics and Gynecology 335

The Gynecologic Examination

It is recommended that a gynecologic examination
be done annually on all women beginning when
Ampulla
Fallopian Tube
they become sexually active or by age 21 years. It
is done to assess the female’s health and to screen
for cancer of the reproductive organs. It includes
Uterus a breast examination by the provider and instruc-
Ovary tions for the patient about how to perform her
Fimbriae
own breast self-examination (BSE). It also includes
a pelvic examination and Pap smear. Pap tests are
done to detect cervical cancer. Women should be
especially conscientioust in scheduling annual
Pap tests and mammograms if they have a family
history of breast, uterine, ovarian, or cervical can-
Figure 14-20 Tubal ligation. cer. Early detection of cervical and breast cancers
and appropriate treatment may cure the disease.
Women who have had a hysterectomy because of
cancer should continue to be tested for pelvic can-
cer annually by having a Pap smear. Because the
cervix has been removed, the specimen cells are
taken from the inner vaginal vault instead. Even
after hysterectomy, the woman still remains at risk
for cancer cells to grow within the vagina and she
should be encouraged to continue with her regular
pelvic examinations and Pap tests. Others believe
that in healthy women a Pap test done every 1 to
3 years is sufficient. The American Cancer Soci-
ety (ACS) recommends that all women have a
Pap test about every 3 years, after they become sex-
ually active, or at age 21 years, whichever is sooner,
then testing every year with the regular (conven-
tional) Pap test or every 2 years with the newer
liquid-based Pap test (e.g., ThinPrep®) should be
done.
Further, the ACS recommends that at age
30 women who have had three sequential normal
Pap tests be tested every 2 to 3 years with either
Figure 14-21 Vasectomy.

Mons pubis Symphysis pubis

Prepuce of
clitoris Labia majora
Clitoris
Glans of
clitoris
Labia minora

Urethral orifice

Hymen

Vaginal orifice Anus

Coccyx

Figure 14-22 External genitalia of the female.

336 UNIT 5 Assisting with Specialty Examinations and Procedures

be done to aid in diagnosis. (Chapter 31 provides

Patient Education more information.)

Post IUD Insertion Human Papillomavirus (HPV) and Gardasil®. In

June 2006, the FDA approved a vaccine that targets
1. Report any bleeding other than spotting
the virus responsible for most cervical cancers and
that occurs in the first 2 days.
condylomata (genital warts). The vaccine, called
2. Report fever, vaginal discharge, or pain at Gardasil, protects against four HPVs. According to
once. an article on women’s health on Web MD Medical
3. A small percentage of IUDs are expelled News, two of the four viruses are responsible for
from the uterus into the vagina during the 70% of all cervical cancers. The other two viruses
first year. Another contraceptive should be are responsible for 90% of condylomata. Gardasil
used to prevent pregnancy. was approved to help prevent vaginal and vulvar
4. There is a risk of perforation of the uterus, cancers, which can be caused by HPV.
but this is most likely to occur during HPV is spread through sexual contact. Accord-
insertion. ing to the CDC, by age 50 years, at least 80% of
5. There is no protection against STDs. women will have had an HPV infection. However,
most women with HPV do not get cervical cancer.
6. Some women experience headaches, Gardasil is 100% effective in protecting against two
breast tenderness, and mood swings. of the HPV strains if the individual has not been
These symptoms usually subside in a few exposed to the virus previously. The vaccine will
months. not protect people already exposed to the virus.
7. It is possible (rare) to become pregnant The vaccine does not contain a live virus. It lasts for
with an IUD. It is recommended in this sit- at least 5 years.
uation that the IUD be removed because The FDA approved Gardasil for girls and
it can cause miscarriage or premature women aged 9 to 26 years. It is on the CDC’s
birth. recommended vaccine schedule. Screening for
8. The IUD can remain in place for as long as cervical cancer (as with the Pap test) still is neces-
10 years depending on the type. sary because Gardasil does not protect against all
9. An IUD must be removed by the provider. HPV types. Pap tests also are essential for women
10. An IUD is safe and highly effective.
who have not been vaccinated or who already
are infected with HPV. The vaccine is not recom-
mended during pregnancy.
The Advisory Committee on Immunization
Practices (ACIP) recommends that girls 11 to
the conventional Pap test or with the liquid-based 12 years of age be immunized with three doses of
Pap test and be tested for human papillomavirus HPV vaccines, but the series can be started as early
(HPV) DNA. as age 9. The second and third doses should be
Women 70 years or older who have had three given 2 and 6 months after the first dose.
sequential negative Pap tests in 10 years can stop HPV vaccines can be administered with other
cervical cancer testing. age-appropriate vaccines. Catch-up vaccinations are
Women with a history of cervical cancer, DES available for females 13 to 26 years of age who have
exposure before birth, HIV infection, or weak not been vaccinated previously or who have not
immune system should continue testing. Risk fac- completed the full series. The vaccine is licensed
tors for cervical cancer are first sexual intercourse only for females 9 to 26 years of age. Each dose is
at an early age, multiple sex partners, sex with 0.5 mL given intramuscularly. Continuous research
partners who have multiple partners, and a history is being done to determine if HPV vaccine can be
of HPV. used on males.
Encourage patients to have regular Pap tests.
Women at high risk should have a Pap test and Scheduling Pap Smear Tests. Encourage female
a mammogram according to their provider’s rec- patients to schedule their Pap smear and annual
ommendations. If the patient is experiencing a vag- gynecologic examination on a date that will be
inal discharge and there is a suspicion of a vaginal easy to remember, such as April Fool’s Day, Flag
infection, smear(s) and cultures of discharge can Day, tax day, or first day of summer. Keep a tickler
 CHAPTER 14 Obstetrics and Gynecology 337

file to remind patients who “forget.” Women may ization into the role of a woman. Surgery is usually
believe that because they have had a hysterectomy, performed by a lay midwife, and a razor or broken
they no longer need their annual examination and glass is used; infections and hemorrhages are com-
Pap smear. Every woman should have an annual mon. If an infibulation is performed, the two sides
(or regular) examination even if the Pap test is not of the vulva are sewn together. Scar tissue forms
included. A woman who has had a hysterectomy over the vagina. A small opening for urination and
because of cancer should continue to have Pap menstruation is made by inserting a foreign object
smears on a regular basis. Many women are not until the area heals. The most common reason given
aware of this and need to be educated. for this procedure is that it follows customs and tra-
Other gynecologic problems may arise between dition. During childbirth, the infibulation is cut to
annual gynecologic examinations and require an allow for delivery, then resutured after delivery.
appointment. They include symptoms and prob- Always view patients as individuals whose cul-
lems such as severe dysmenorrhea (painful men- tural beliefs and practices may differ greatly from
ses), lower abdominal pain, metrorrhagia, bleeding your own. Treat them as you do all patients, with
between menstrual periods, dyspareunia (painful respect and empathy (see Chapters 15 and 16 for
intercourse), sexual dysfunction, infertility, and dis- male circumcision).
comfort from menstrual symptoms. Women expe-
riencing these problems should have a gynecologic Breast Examination. The provider performs a
examination, and the provider will determine a diag- breast examination on the patient as part of a
nosis based on the examination, the patient’s history, gynecologic examination. Looking for redness,
symptoms, signs, and laboratory data. The data from dimpling, and puckering, each breast is palpated
previous appointments are available to the provider and the axilla felt for lumps or thickening. Part
via the computer. Comparisons can be made quickly of the medical assistant’s responsibility is to teach
with previous entries, saving time and possibly pre- patients how to perform the breast self-examina-
venting errors. tion (BSE). Figure 14-23 provides illustrations for
It is important to realize that patients’ performing the BSE. The provider may supply
health practices related to culture, values, several pamphlets and a breast model with lumps
and belief systems are deeply ingrained and thickening for enhancing patient educa-
and not easily changed. Being aware of some of tion and awareness about the importance of the
these practices and beliefs will benefit both you and examination (Figure 14-24A and B).
your patients. You will have a better understanding
of their cultural heritage and beliefs that are dif- Breast Self-Examination (BSE). Provide the patient
ferent from yours, and this will help patients to be with these steps to follow:
more comfortable. At times, it might be necessary
to modify care according to the patient’s cultural 1. Examine your breasts when they are not tender or
background and practice. swollen and at the same time each month, about 1
week after menses.
Female Circumcision. Female circumcision is an 2. Women who are breast-feeding or pregnant or
ancient cultural custom that has been practiced have breast implants can do a BSE.
worldwide for more than 2,000 years. Between 100 3. Ask the medical assistant to review your tech-
and 130 million women in 40 countries have had nique when you have your yearly examination.
female circumcisions. Central Africa is one of the
4. Lie on your back and put your right arm behind
main areas where various forms of the procedure
your head. This spreads out the breast tissue, mak-
are performed.
ing it easier to feel all of the tissue (Figure 14-23A).
There are four different types of female cir-
cumcision: (1) removal of the prepuce of the cli- 5. Using your left hand and the finger pads of the
toris; (2) clitoridectomy, removal of prepuce and three middle fingers (Figure 14-23B), feel for
clitoris; (3) removal of prepuce, clitoris, upper labia lumps or abnormalities in your right breast.
minora, and some labia majora; and (4) infibulation, 6. Use three degrees of pressure—light, medium,
removal of all external genitalia (prepuce, clitoris, and strong (or firm)—to feel all of the tissue.
labia majora, labia minora). Some reasons given for Light pressure is used for skin and tissue just
this practice are that it is a right of passage, a sign beneath the surface, and medium pressure is used
of purity, marriage availability, sexual faithfulness, for tissue in the middle of the breasts, strong pres-
protection from rape and abortion, and for social- sure is used to feel the tissue closest to the ribs
338 UNIT 5 Assisting with Specialty Examinations and Procedures

11. The ACS recommends that women without

Critical Thinking symptoms of breast cancer aged 40 to 49 years
have a mammogram every 1 to 2 years, and
A 27-year-old woman wants to schedule an women aged 50 years and older, once a year
appointment because she has some bright (Figures 14-25 and 14-26).
red bleeding after sexual intercourse. What
conditions or diseases might this woman The American College of Obstetricians and
have? Discuss your reasons for choosing the Gynecologists endorses the guidelines set forth by
conditions or diseases. What equipment and the ACS.
supplies might the provider require for her Breast cancer risk factors include:
examination?
• A family history of breast cancer
• Being female (males can get breast cancer, but
and chest. Use all three degrees of pressure on there is much less chance)
each spot on your breast before feeling another • A biopsy of a breast lesion that showed atypical
spot. hyperplasia
7. Use an up-and-down pattern as you move around
• Early menarche (younger than 12 years)
the breast, starting at your imaginary seam line
(straight down from the underarm) and moving • Late menopause (after 55 years)
up and down to the middle of the chest bone. Be • No children, or first child after 30 years of age
certain you have examined your entire breast,
• More than 2 to 5 alcoholic drinks per week
from the collar bone to the ribs.
• BRCA1 and BRCA2 gene mutations
8. Do the same examination on your left breast,
starting with step 4.
According to the ACS, breast cancer is the
9. Looking in a mirror with hands pressing down second leading cause of death in women in the
on your hips, check your breasts for redness; United States; the leading cause of death in
dimpling; and change in shape, size, or contour women is lung cancer.
(Figure 14-23C). Diagnosis of breast cancer is made by the
10. Examine each underarm while sitting or standing provider using some or all of the following diag-
while your arm is raised slightly so that the area is nostic tools: mammography, tissue biopsy, MRI,
easily felt. ultrasound, and MRI-guided breast biopsies.

A B Finger pads C

Figure 14-23 Breast self-examination.(A) Lie on your back and put your right arm behind your head. (B) Use the
finger pads of your three middle fingers, making an up and down pattern to examine the breast. (C) Look in a mir-
ror and observe the breasts for abnormalities.
 CHAPTER 14 Obstetrics and Gynecology 339

Figure 14-24A Informational pamphlets detailing

the breast self-examination and its importance can be
helpful to patients.

Instructions Figure 14-25 Breasts are compressed by the plates of

mammographic X-ray unit.

Prosthesis
Powder

Figure 14-24B Breast self-examination model kit

contains instructions for breast self-examination and
powder to aid fingers in gliding over the breast pros- Figure 14-26 The technologist positions the patient
thesis. The prosthesis contains lumps and thickened for a mammography. The procedure requires the
areas for identification and location. patient to move into various positions so that different
angles of the breast tissue can be imaged.

The four standard treatment options for Herceptin is a medication (nonhormonal)

patients with breast cancer are surgery, radiation that can be administered to women with breast
therapy, chemotherapy, and hormone therapy. cancer if a sample of breast cancer cells shows a
Hormonal therapy with tamoxifen acts against particular abnormal protein. Herceptin targets
the effects of estrogen. In women who are at risk the abnormal protein.
for breast cancer, tamoxifen reduces the chances
of developing breast cancer. Tamoxifen for preven- Assisting with a Gynecologic Examination. The
tion of breast cancer continues to be studied. gynecologic examination consists of four parts:
340 UNIT 5 Assisting with Specialty Examinations and Procedures

1. Inspection of external genitalia (labia minora,

labia majora, urinary meatus, clitoris, Bartho- Patient Education
lin glands, and vagina) for swelling, lesions, or
ulcerations Many women think that if they have had a
2. Pelvic examination of cervix, uterus, tubes, and hysterectomy because of cancer they no
ovaries including a bimanual examination; may or longer need to have Pap smears performed.
may not include a Pap test This is not true, and it is up to health care
professionals to educate them. If the hyster-
3. Rectal examination
ectomy was performed because of cancer,
4. Breast examination the cancer cells can reappear in the vagi-
nal vault after the surgery. During the pelvic
The medical assistant should prepare the
examination, because the cervix has been
patient, equipment, and room before the exami-
removed, the provider will scrape the inner
nation.
walls of the vaginal vault for cells to include
in the Pap smear.
Gynecologic Examination with Pap Equipment.
On a Mayo tray near the end of the examination
table, place the instruments and supplies the pro-
vider needs to perform the gynecologic or pelvic necessary medical and laboratory information.
examination with Pap test. Figure 14-27 shows the The data needed include:
equipment commonly needed for the examination.
To aid in the inspection portion of the examination, • Last normal menstrual period. This question will
you should place a gooseneck lamp at the foot of bring up information about breakthrough bleed-
the table behind the stool on which the provider ing (if patient is taking oral contraceptives), dys-
will sit (see Procedure 14-2). menorrhea, metrorrhagia, postcoital bleeding,
In preparation for the annual examina- perimenopausal irregularities, and other idiosyn-
tion, the patient is asked to avoid using tampons, crasies of the menstrual patterns.
foams, and gels; douching; and sexual intercourse • Hormonal therapies, either oral contraceptives or
for 2 days before a Pap test. Five days after men- hormone therapy (HT). These are excellent ques-
ses is a good time to have a Pap test. Immediately tions for birth control history, successes/failures,
before a pelvic examination, the patient is encour- problems/solutions, and menopausal issues, con-
aged to empty her bladder. The urine may be col- cerns, and problems.
lected for testing according to the clinic policy or • Surgical history, especially related to the genitouri-
the provider’s preference and depending on any nary tract. These questions will initiate discussions
urinary tract complaints or symptoms the patient about bladder problems and hysterectomies.
may have. If a Pap test is being performed, take
a minute to interview the patient and gather the • Sexual history/habits. This will open discussions with
the patient about disease prevention, birth control,
hormonal problems, and menopausal conditions.
• Symptoms of diseases/disorders, such as pelvic
or genital pain or discomfort; vaginal discharge,
irritation, or itching; painful intercourse; dysuria;
urinary frequency or incontinence; and breast
pain or breast conditions/concerns.

All the information gathered during the

E HR patient interview can be entered into the
patient’s medical record on the computer
while sitting with the patient. There may be a
health form on the computer for the medical assis-
Figure 14-27 Setup for gynecologic examination tant to fill out with the patient. The provider then
including equipment for a Thin-Prep® Pap smear: will input the information and any other perti-
transport medium container, spatula, cytology brush nent data gathered during the examination. The
and broom, Specula (disposable and reusable), electronic medical record is stored and can be
lubricant, gloves, tissues. accessed at any time for laboratory and diagnostic
 CHAPTER 14 Obstetrics and Gynecology 341

tests and procedures, prescriptions, and previous warmth from the light bulb can warm the specu-
data entry. lum. The provider may hold the speculum under
In preparation for the examination, have the warm running water just before use. Whichever
patient undress and don a patient gown with the method is used, the provider will test the specu-
opening positioned in the front (for the breast lum to make sure it is not too hot before use.
examination) and a drape sheet. The patient This is often done by touching the speculum on
is seated on the examination table. Provide the the patient’s inner thigh to determine if the tem-
patient with privacy during the undressing. Ensure perature is comfortable.
the patient’s comfort by providing her with a blan- During the examination, the medical assis-
ket if she is cold and have her leave her socks on if tant will support the patient, hand the provider
her feet are cold. supplies as needed, and adjust the light source
During the breast and abdominal examina- as needed. When the provider has obtained the
tions, the patient is placed into the supine or dorsal appropriate cervical cells, the medical assistant will
recumbent position. Provide a pillow for comfort. take the cytology broom or brush and uncap the
For the pelvic examination, the patient is placed ThinPrep container, swish the broom or brush vig-
into the lithotomy position. Assist the patient into orously in the ThinPrep solution until all the speci-
this position, providing leg and back support as men has been deposited, dispose of the broom or
needed. brush in a biohazard container, reapply the cap,
During the pelvic examination and the Pap and complete the container label. If the patient is
smear, the medical assistant assists the provider “status post hysterectomy,” the provider will scrape
as needed (Figure 14-28). The tray of supplies cells (using the spatula) from the inner walls of the
should be at an appropriate height and posi- vaginal vault rather than from the cervix, which
tion for access by the provider while seated. The will no longer be present. Those cells are depos-
vaginal speculum (metal or plastic) should be ited into the ThinPrep solution in the same man-
warmed to body temperature. Some examina- ner as a cervical specimen.
tion tables are equipped with warming drawers After the Pap test is performed, the provider
for storing the specula so that they are warm and will examine the internal organs. This is done using
ready for use. The medical assistant may set up the bimanual (two-handed) examination (Figure
the pelvic exam/Pap smear supplies on a Mayo 14-29). By inserting two fingers into the vagina and
tray and position the gooseneck lamp so that the pressing on the outside abdominal wall, the shape,

Vagina Bladder

Speculum Fallopian
Speculum tube

Vaginal walls Ovary

Uterus

Cervix

Vertebra

Cytology brush

Rectum
Cervix
A B of uterus

Figure 14-28 Use of speculum, cytology brush, and spatula to obtain material for a Pap smear. (A) The provider
uses a spatula to obtain cells from the cervix. (B) The provider uses a cytology brush to obtain cells from the cervix.
342 UNIT 5 Assisting with Specialty Examinations and Procedures

80% of the specimen remains on the collecting

device, with only about 20% being submitted
on the slide. With the ThinPrep Pap test, virtu-
ally 100% of the collected cells are rinsed off the
collecting device and submitted in the vial. The
conventional Pap slide preparation results in an
inconsistently distributed specimen containing
blood cells, mucus, and other debris that can
interfere with the viewing. The ThinPrep Pap test
uses a ThinPrep processor to suspend the cervi-
cal cells; to eliminate the blood cells, mucus, and
other debris; and to distribute a thin and even
layer of cells onto a slide for analyzing. The Thin-
Prep Pap test slide is of better quality, is much
clearer and easier to read, and increases accuracy
for both the manual assessment and the comput-
erized assessment. It greatly improves detection
of precancerous cells.
Although the conventional Pap smear has
undoubtedly saved countless lives by detecting
cervical cancer, the ThinPrep Pap test is signifi-
Figure 14-29 Bimanual pelvic examination. cantly more effective. Another advantage of the
ThinPrep Pap test is that the same specimen may
be used to determine the presence of HPV or chla-
consistency, movement, and positioning of the mydia/gonorrhea if needed.
uterus and the ovaries can be felt. If any abnormali- The federal government regulates labo-
ties are felt, further testing may be required. After ratories that perform testing on Pap
the bimanual examination, a rectal examination is smears. Requirements are placed on the
performed. This examination enables the provider individuals who study the specimens for malig-
to assess the back side of the uterus, which is not nant cells, and they include specialized training.
felt during the bimanual examination. Limits are placed on the number of slides that
When the pelvic examination is completed, can be read in one day. Proficiency testing, man-
the medical assistant will help the patient off the dated by the Clinical Laboratory Improvement
table, offer tissue and the sink for her to clean up Act of 1988 (CLIA ’88), ensures accuracy and
and wash her hands, and let her know you will be precision of test results and is a requirement for
back in a few minutes. When you return, you may Pap smear examination (Chapter 26 gives more
take the patient to the provider’s office for private information about CLIA ’88).
discussion. Occasionally, the provider will hold A computerized method, known as Auto-
the discussion in the examination room after the Pap, is used to retest Pap smears that
patient has dressed. have been analyzed by technologists and
The ThinPrep containe and cognisition are found to be normal. The method duplicates the
sent to the cytology laboratory (Figure 14-30). process that the technologists perform. AutoPap
can be used for an initial Pap test as long as a tech-
Pap Smear. The conventional Pap smear is per- nologists examines all abnormal smears.
formed by scraping the patient’s cervix with a Another test, known as ViraPap, can be used
spatula and cytology brush and smearing the cells to screen for HPV in a Pap smear. There is higher
onto a microscopic slide. The slide is then placed
into a bottle of Pap fixative or sprayed with Pap
fixative and sent to the regional laboratory for
viewing. The ThinPrep Pap test differs in that the Critical Thinking
cells that are obtained on the collecting devices
are swished vigorously into a vial of fluid transport A 38-year-old woman has been diagnosed
medium rather than placed on a slide. The vial with HPV infection. What is the significance of
is sent to the regional laboratory for processing. this infection?
Using the conventional method, approximately
 CHAPTER 14 Obstetrics and Gynecology 343

Figure 14-30 Laboratory requisition for OB/GYN practice.

344 UNIT 5 Assisting with Specialty Examinations and Procedures

incidence of cervical cancer in women who have b. Squamous Interepithelial Lesions (SILs). There are
HPV, and the test can help identify these women. low- and high-grade SILs. All patients in this
Vaginal cancer can also be detected by a Pap category require a colposcopy. High-grade SILs
smear. There is an increased risk for both cervical can develop into cancer if not treated. Treat-
and vaginal cancer in daughters of women who ment can cure both high- and low-grade SILs
used diethylstilbestrol (DES) during pregnancy. and prevent cancer from developing. The Pap
Some advocate “at home” testing. The test does not identify which SIL the patient has;
woman collects her cervical cells by inserting a rather, it shows that the results fit into one of
small plastic applicator into the vagina up the the abnormal categories.
cervix (as far as she can comfortably insert appli- c. Squamous Cell Carcinoma. This test result shows
cator) and moving it around to collect cells. The that the woman likely has an invasive squamous
applicator is placed in a special container to pre- cell carcinoma. Further testing, colposcopy,
serve cells that will be tested by a laboratory. The and biopsy are needed to be certain of the diag-
ACS does not endorse “home” testing. Perhaps nosis. If the biopsy proves positive, the provider
in the future “home” testing will become accu- will recommend surgery, radiation, and/or
rate for scientific use and accepted by the medi- chemotherapy.
cal community.
d. Adenocarcinomas. These carcinomas are abnor-
One system for cytologic reporting of a Pap
malities of glandular cells. If a clear deci-
smear is a descriptive report that tells the pro-
sion can not be made by the pathologist as to
vider exactly what cellular changes have taken
whether the cells are malignant, the term used
place. The classification includes the grades of
is atypical glandular cells (AGS). Further test-
cervical intraepithelial neoplasia (CIN).
ing is done to decide on a treatment plan.
CIN 1  mild dysplasia (abnormal tissue Category 3  other malignant neoplasms, including
development) malignant melanoma, carcinoma, and lymphoma.
CIN 2  moderate dysplasia These malignant neoplasms affect the cervix very
CIN 3  severe dysplasia or carcinoma in situ rarely compared to squamous cell carcinoma and
adenocarcinoma.
Another system used to report Pap test results
is the Bethesda System (TBS). The Bethesda System Pap Smear Results. The Pap smear usually is
for reporting results of Pap tests has three main cat- sent to a reference laboratory where a pathologist
egories, some of which have subcategories: examines it and records the results on the cytol-
ogy report form and in the computer. The form
Category 1  negative for intraepithelial lesion or
is returned to the provider, and the report can be
malignancy. These are known signs of cancer
accessed on the computer. Figure 14-31 lists some
or precancerous cells or other abnormalities
of the terms used on the cytology report form.
found.
Category 2  epithelial cell abnormalities. The cells
of the lining of the cervix show changes that might
Gynecologic Diseases
be cancer or precancerous. There are several sub- and Conditions
groups within this group for squamous cells and The female reproductive system is affected by
glandular cells. many diseases and conditions caused by hormonal
imbalance, cysts, infection, and tumors. Some of
1. Atypical Squamous Cells (ASCs). The name given to
the more common disorders and diseases are cov-
what the cells look like under a microscope. It
ered here.
is difficult to determine whether the abnormal
cells are caused by an infection, an irritation, or
a precancerous condition. This group is divided
Infertility. Most women, with unprotected inter-
course, will be able to conceive within a year. The
again.
inability to conceive can be caused by a problem
a. Atypical Squamous Cells of Uncertain Significance with either the male or the female individual.
(ASC-US) and atypical squamous cells where high- Some common causes of infertility in a female
grade squamous intraepithelial lesions (SILs) can- patient are:
not be excluded. A repeat Pap test is done; biopsy
and/or colposcopy and HPV DNA testing may • Endometriosis
be recommended. • Certain medications
 CHAPTER 14 Obstetrics and Gynecology 345

35 and 58 years. There may be a gradual decline

atypical—not typical
CIN—cervical intraepithelial neoplasia
in monthly menstrual flow, or a woman may sud-
CIS—carcinoma in situ denly cease to menstruate. Natural menopause
condyloma—a lesion caused by human papillomavirus occurs when the ovaries produce less and less
dysplasia—precancerous lesion estrogen. This causes the ovaries to cease ovula-
epithelial—pertaining to epithelium tion and, therefore, menstruation stops. Surgical
epithelium—cellular tissue that covers the surface of a menopause is caused by the surgical removal of
body or that lines a body cavity both ovaries (bilateral oophorectomy). Symptoms
glandular—the cell making up the epithelium of a body occur soon after ovulation ceases with both natu-
cavity ral and surgical menopause. Symptoms may last
HPV—human papillomavirus for a few months to several years and include mild
lesion—a change in the tissue cells or a wound
to severe symptoms. Hot flashes, chills, nervous-
malignant—a lesion that spreads out of the epithelium
into underlying tissues
ness, fatigue, apathy, mental depression, crying
reactive changes—changes in cells caused by their episodes, insomnia, palpitations, and headache
reaction to infectious agents or a foreign body are some common symptoms experienced by some
reparative changes—changes in cells as they divide women. A long-term effect of lower estrogen lev-
rapidly in an attempt to repair damaged tissue els is osteoporosis. Hormone therapy (HT) was
SIL—squamous intraepithelial lesion (that lies within thought to prevent osteoporosis and heart disease.
the squamous epithelium) A federally funded HT study, the Women’s Health
squamous—a type of cell that makes up the epithe- Initiative (WHI), which was slated to run for
lium, the purpose of which is to protect underlying 15 years, stopped testing in 2002 what had been
tissues the most widely prescribed estrogen and progestin
combination. Safety concerns brought an early end
Figure 14-31 Terms and abbreviations used in (5.5 years) to the trial testing the long-term ben-
cytology Pap test reports. efits and risks of combined estrogen and progestin
therapy (HT). The testing was halted earlier than
intended because it was determined that HT, spe-
• Blocked fallopian tubes cifically Prempro®, was more harmful than help-
ful. There were increased risks for breast cancer
• Problems ovulating
and cardiovascular incidents; therefore, research-
• Chronic stress ers told the women in the study to stop taking the
• Scar tissue from surgery, infection, or ectopic combination medication. This situation has left
pregnancy many women with few choices for treating meno-
• Tumors pausal symptoms such as night sweats, hot flashes,
dyspareunia, mood swings, fatigue, and osteopo-
A woman who is having difficulty conceiving rosis. Switching to something else is risky because
and has a history of any of the above will have a no other hormones have been as well studied as
physical examination by a provider who special- estrogen and progestin in Prempro®. There are
izes in infertility. The specialist will decide what many safe options for prevention and treatment of
tests and procedures are necessary. Hormone lev- osteoporosis.
els may be measured to look for hypothyroidism. Researchers continued to study the estrogen-
Ovarian function can be determined through a only hormone after halting the estrogen–
surgical procedure, such as laparoscopy. A test progesterone trial. Because progesterone was ini-
for patency (openness) of the fallopian tubes can tially added to the estrogen to protect women from
be performed by a hysterosalpingogram, a radio- uterine cancer, the thinking was that healthy post-
graphic procedure done after injection of dye into menopausal women who had a hysterectomy and
the vagina, through the cervix, into the uterus, and were given the estrogen-only hormone would not be
out the fallopian tubes. The dye will pass through at risk. However, data showed an increase in stroke
all of these organs if there is no blockage in any in postmenopausal women given estrogen only.
of them (see “Impaired Fertility” section earlier in As of February 2004, the estrogen-only arm of the
this chapter). WHI study was halted, and the recommendation is
for only short-term use of the hormone for women
Menopause. The period of time that marks per- with moderate-to-severe menopausal symptoms.
manent cessation of menstrual activity is known as The FDA has urged manufacturers to add warnings
menopause. It usually occurs between the ages of to their labels on the estrogen-only hormone about
346 UNIT 5 Assisting with Specialty Examinations and Procedures

the increased risk for dementia, strokes, abnormal • Exercise regularly

mammograms, and uterine cancer in women who • Maintain a healthy weight
have not had a hysterectomy.
• Get regular mammograms with ultrasound if neces-
Reanalysis of the data from the WHI found
sary and Pap tests
that the risk of heart disease was greatest in women
who started HT 10 or more years after meno- • Practice good nutrition (go to the FDA Web site
pause began. Women with a history of heart dis- http://www.MyPyramid.gov for information)
ease or heart attack should not take menopause • Avoid regular al]cohol use
hormones. Older women also have an increased
risk for clot formation around the plaque in their Endometriosis. Endometriosis is a painful, com-
arteries. This plaque can rupture, causing a stroke mon condition characterized by endometrial tis-
or heart attack. sue adhering to tissue and organs outside of the
The American College of Obstetricians and uterus. It is primarily found in the pelvis, adhering
Gynecologists and the National Institutes of Health to an ovary, fallopian tube, or pelvic peritoneum.
recommended that HT is a reasonable choice It also can be found outside of the pelvis, even in
and likely safe for women to use as short-term the abdomen adhering to tissue and organs, such
treatment of menopausal symptoms. Use of the as the bowel. The cause is unknown. The abnormal
lowest effective dose for the shortest period of and engorged endometrial tissue responds to hor-
time and yearly reevaluation of women taking HT monal stimulation (estrogen) and builds up along
should be done. However, HT increases the risk of with the normal endometrium of the menstrual
breast cancer in women regardless of when they cycle. It sloughs off at time of menstruation and is
started HT. painful. The blood has no way to leave the body and
Regardless of whether a woman chooses to is discharged into the pelvic or abdominal cavities.
use HT (a decision based on discussions with her Endometriosis symptoms may respond to
provider) or decides against HT, the following contraceptive medication because these pills sup-
behaviors are beneficial to all women: press menstruation and no further treatment may
be necessary (Figure 14-32). However, long-term
• Do not smoke
hormonal treatment may help alleviate symptoms.
• Keep blood pressure within normal limits Hysterectomy may be necessary if the woman does
• Keep cholesterol level within normal limits not respond to hormonal therapy.

Uterus

Urinary
bladder
Rectum
Urethral
orifice
Anus

Vaginal
orifice
Figure 14-32 Endometriosis—common sites of endometrial implants.
 CHAPTER 14 Obstetrics and Gynecology 347

Ovarian Cysts. Cysts that appear on the ovary are caused by scar tissue that forms in the pelvis and
relatively common. As part of the menstrual cycle, organs. Delayed treatment can cause septic shock,
the ovarian follicles enlarge and become graafian which can be life-threatening. Infertility and ecto-
follicles. Only one graafian follicle ruptures at the pic pregnancy are long-range problems that also
time of ovulation. The follicles that do not rupture, can occur (Tables 14-4, 14-5, and 14-6).
but remain, are filled with fluid. They may enlarge
and become cysts (Figure 14-33).
Ultrasonography will aid in viewing the ova- Other Diagnostic Tests
ries. Most ovarian cysts resolve without treatment. and Treatments for Reproductive
Laparoscopy can be done to either drain or remove
the cyst. Contraceptive therapy many times is help-
System Diseases
ful in resolving the cyst without surgery. Colposcopy. Colposcopy is examination of the
Direct viewing of the ovaries and surgery may vagina and cervix by means of a lighted instru-
be necessary because cancer of the ovary must be ment that has a three-dimensional magnifying lens
ruled out. called a colposcope. The examination is done to
determine if areas in the vagina or the cervix con-
Ovarian Cancer. Because the symptoms of ovarian tain precancerous cells or tissue. The procedure is
cancer do not appear until the disease has become performed after an abnormal Pap test. It can also
established, it is difficult to make a diagnosis early be performed to evaluate a lesion noted during
in the disease process. Therefore, if a woman has a pelvic examination and to follow up after treat-
any symptoms, the cancer usually has been present ment of cervical cancer. Because the instrument
for some time. Symptoms may be pressure in the has the ability to magnify tissue, the cervix can be
pelvis, lower abdominal discomfort, weight loss, more readily examined and a biopsy taken.
bloating, and fluid in the abdomen. Diagnosis can The patient is placed in lithotomy position
be made by laparoscopic surgery and a biopsy. Hys- and is prepared as she would be for a gyneco-
terectomy and bilateral salpingo-oophorectomy logic examination. A nonlubricated speculum is
are done, followed by radiation therapy or chemo- inserted into the vagina. The vagina is swabbed
therapy. The cause is not known. with a long cotton-tipped applicator that has
been moistened with saline. (This provides better
Pelvic Inflammatory Disease (PID). PID involves visualization of the cervical tissue.) The cervix is
some or all of the female reproductive tract and then swabbed with acetic acid to dissolve mucus
can be a serious infection. The causative microor- and provide a good contrast between normal and
ganism is usually a sexually transmitted pathogen abnormal tissue. A staining medium can be used
such as gonorrhea or chlamydia. The microorgan- as another means of identifying abnormal cells.
ism enters through the vagina and ascends through If the provider finds an area of abnormal tissue,
the cervix into the body of the uterus. It can spread a biopsy can be performed using cervical punch
out through the fallopian tubes into the pelvic cav- biopsy forceps (Figure 14-34). The specimen is
ity. Culture and sensitivity of the vaginal discharge examined by a pathologist to determine whether
are performed, and appropriate antibiotics are malignant cells are present.
prescribed. Early treatment helps to lessen damage
Endometrial Biopsy/Sampling. An endome-
trial biopsy/sampling is often performed when
Ovaries
patients are experiencing postmenopausal bleed-
Fallopian ing. It is a fairly simple procedure. The sampling
tube
device is housed in a long strawlike tube that slides
through the cervical os quite easily. Once the end
of the tube is inside the uterus, a plunger is pulled
back. The action of pulling the plunger suctions
a sampling of the endometrial tissue. This is a
sterile procedure and requires an application of
a cleansing solution (such as Betadine) to the cer-
Uterus vix before performing the biopsy. Endometrial
biopsy/sampling is quick and almost painless for
the patient. The patient might experience slight
Figure 14-33 Ovarian cyst. cramping.
 348
UNIT 5
Assisting with Specialty Examinations and Procedures
Table 14-4 Female Reproductive System Laboratory and Diagnostic Tests

Medical Tests Disease/

or Procedures Disorder Blood Other Radiography Surgery

Pelvic Bartholin gland Exudate culture and sensitivity Incision and drainage
examination infection

Breast cancer Breast cancer Mammography Biopsy of breast lesion

Monthly breast
gene detection Ultrasonography Lumpectomy
self-examination
BRCA1, BRCA2

Cervical cancer Pap smear Cone biopsy

Punch biopsy
Dilation & curettage (D&C)
Pelvic
Cryosurgery
examination
Colposcopy LEEP (loop electrosurgical
excision procedure)
Laser surgery
Hysterectomy

Endometriosis Urinalysis Abdominal Laparoscopy

Pelvic ultrasonography
examination Hysterectomy
Chest radiograph

Monthly breast Fibrocystic Mammography Biopsy

self-examination breasts Ultrasonography

Pelvic inflamma- Complete blood Urinalysis Pelvic ultraso- Laparoscopy

Pelvic tory disease count and differ- Culture and sensitivity nography
examination ential (CBC) of vaginal discharge
Tests for Sexually Transmitted Diseases

Chlamydia Serology Urinalysis

Pelvic Direct urethral or cervical smear
examination using monoclonal antibodies
ThinPrep Pap Test

Pelvic Condylomata/ ThinPrep Pap Test Excisional biopsy

examination HPV (genital
Pap smear warts)

Neisseria CBC Urinalysis Pelvic

gonorrhoeae Direct smear of vaginal discharge, ultrasonography
anal canal, and oropharynx
Pelvic
Thayer-Martin culture
examination
ThinPrep® Pap Test
Hepatitis B and C Virology Liver function Abdominal Liver biopsy
and HIV ultrasonography

Tests for Vaginitis

Candidiasis Blood glucose Urinalysis

Pelvic Wet mount: direct vaginal smear

CHAPTER 14
examination with potassium hydroxide and/or
saline (1 drop)

Trichomoniasis Urinalysis
Pelvic Wet mount: direct vaginal smear
examination with isotonic saline (1 drop) and/or
potassium hydroxide (KOH)

Obstetrics and Gynecology

Pelvic Bacterial CBC Culture and sensitivity of vaginal
examination vaginosis discharge

349
350 UNIT 5 Assisting with Specialty Examinations and Procedures

Table 14-5 Female Reproductive System Disorders and Conditions

Bartholin Gland Infection. Infection of the mucous gland(s) that open near the vaginal opening.

Breast Cancer. Most common diagnosed cancer in females. A genetic cause has been identified for some breast
cancers. Some symptoms are lump, thickening, swelling, dimpling, pain, and nipple discharge.

Cervical Cancer. A carcinoma of the cervix of the uterus caused by a progressive cervical dysplasia. Most common in
women aged 30 to 40 years. A significant risk factor is seen in women who become sexually active early in their lives and
who have multiple sex partners. Presence of HPV poses greater risk.

Cystocele. Herniation of the urinary bladder into the vagina. May cause urgency and frequency. Injury to the bladder
during delivery of the fetus is one cause.

Endometriosis. Presence of endometrium in sites other than inside the uterus. May be found on the ovaries, fallopian
tubes, large bowel, lungs, and pleura. Causes pelvic pain, dysmenorrhea, and infertility.

Fibrocystic Breasts. Benign cysts in breast tissue that increase or decrease in size during menses. Thought to be a normal
variation in breast tissue due to monthly hormonal influence.

Pelvic Inflammatory Disease (PID). Pelvic reproductive organs become inflamed and infected by bacteria, viruses,
or parasites. An ascending infection can ensue involving the vagina, cervix of uterus, body of uterus, fallopian tubes,
and ovaries. Symptoms include vaginal discharge, pain, fever. May cause infertility. Majority caused by sexually
transmitted disease (Neisseria gonorrhea, chlamydia).

Premenstrual Syndrome (PMS). Cluster of symptoms that occur monthly before the onset of menses thought to be caused
by progesterone–estrogen imbalance. Symptoms include fluid retention, weight gain, irritability, and mood swings.

Rectocele. Herniation of the posterial wall of the vagina with the anterior wall of the rectum through the vagina.

Sexually Transmitted Diseases (STDs). Diseases caused by bacteria, viruses, and protozoa that are transmitted through
sexual intercourse (vaginal, anal, oral).
– Chlamydia. An invasion by an intracellular parasite causing urethritis, cervicitis, PID, proctitis, infant pneumonia, and
conjunctivitis.
– Condylomata (HPV). Genital warts caused by a virus. Grow around the external genitalia, rectum, and cervix.
Associated with abnormal Pap smears.
– Neisseria gonorrhoeae. An infection by a bacterium that can involve the cervix, urethra, fallopian tubes and ovaries,
rectum, and mouth.

Vaginitis. Inflammation of the vagina that may be caused by bacteria, fungus, protozoa, chemical irritants, irritation from
foreign bodies, vitamin deficiency, uncleanliness, and intestinal worms.
– Candidiasis. A yeast (fungal) infection of the vagina caused by prolonged antibiotic therapy, pregnancy, or diabetes,
which can change the normal vaginal flora leading to overgrowth of the fungus.
– Trichomoniasis. An infection by a protozoan most commonly spread through sexual intercourse or may come from
fecal contamination of the vagina.
 CHAPTER 14 Obstetrics and Gynecology 351

Table 14-6 Common Sexually Transmitted Diseases

Pathology Symptoms Test Treatment

Flulike, lymphadenopathy, HIV Medication: antiretroviral medi-

AIDS infections, malignancies, CBC cations such as zidovudine,
pneumonia didanosine, Ritonavir

Usually asymptomatic Vaginal culture Doxycyline, azithromycin

Chlamydia ThinPrep® Pap test
Urinalysis

Warts on external and internal Visual exam Cryocautery or chemocautery

genitalia ThinPrep Pap test
® preferred but electrocautery can
Condylomata be used
HPV
Keratolytic agents such as Podo-
filox, CO2 laser

Usually asymptomatic; Gram stain or Ofloxacin, ceftriaxone, cefixine

Gonorrhea yellowish-green discharge Thayer-Martin culture
with dysuria in advanced stages ThinPrep® Pap test

Itching and soreness followed Visual exam Acyclovir®, Valtrex, Famvir

Herpes simplex I by genital vesicles, which heal in
and II Viral isolation by tissue
10 to 14 days culture

Stage I: papule develops into Venereal Disease Penicillin

ulcer, which develops into Research Laboratory,
chancre on vulva fluorescent antibody
Stage II: fever, general malaise, test
Syphilis dermal and mucosal lesions Dark-field exam
Stage III: degeneration of Rapid Plasma Reagin
central nervous system, lesions (RPR)
of internal structures Culture and sensitivity
of spinal fluid

Milky white, frothy, malodorous Wet mount for Oral Flagel®: partner(s) must also
Trichomonas discharge with genital burning microscopic be treated
and itching examination

Cervical Punch Biopsy. The cervical punch biopsy poscope is being used, it illuminates and magni-
is usually done in conjunction with a colposcopy fies the cervical tissue. The provider takes several
to obtain a sample of cervical tissue for pathologic tissue samples using the cervical punch biopsy
examination. The specimen is examined for malig- forceps. If bleeding ensues, it can be controlled
nant cells and the biopsy usually follows an abnor- with a vaginal packing, or the area can be cauter-
mal Pap smear report. ized to stop the bleeding. The specimen is placed
The procedure is performed with the patient in a container with formalin, a completed req-
in lithotomy position and with a vaginal specu- uisition form is attached to the container, and it
lum in place. The provider may stain the cervix is sent to the pathology laboratory for examina-
to aid in identifying abnormal tissue. If the col- tion. The patient may expect a small amount of
352 UNIT 5 Assisting with Specialty Examinations and Procedures

Patient Education
Post Cervical Biopsy and Cervical Cone Biopsy
1. Rest for 24 hours after the procedure.
2. Do not lift heavy objects for two weeks.
3. Leave packing in place for 24 hours or as
directed. Do not insert another tampon
unless told to do so by the physician.
4. Report any bleeding greater than a
normal menstrual period.

and eventually replaced with healthy cells about a

month after the procedure.
The procedure is performed with the patient
Figure 14-34 Toms-Gaylor uterine punch biopsy
in lithotomy position. The cervix is swabbed to
forceps. (Courtesy of Jarit Surgical Instruments.)
remove mucus. The cryo probe is placed against
the affected area of the cervix and the machine
is turned on. The liquid nitrogen flows over the
area for about 3 minutes and freezes the tissue.
bleeding and should notify the provider if bleed- The tissue is allowed to thaw, and the treatment
ing ensues that is greater than a menstrual period. is repeated for another 3 minutes. The patient
A discharge that has a strong, foul odor is to be may have some pain similar to dysmenorrhea
expected and can last for up to one month after that may last for about a half hour. There should
the procedure. be no strong, foul odor, but there can be a dis-
charge for up to 1 month. Patients should report
Cervical Cone Biopsy. Another type of biopsy, any malodorous discharges because this may
known as a cone biopsy, can be performed. An
inverted cone of tissue is excised by scalpel or laser
under general anesthesia. In this procedure, a
larger sample of tissue is excised to rule out invasive
cancer and to remove the lesion. It is the most com- Patient Education
prehensive specimen to diagnose a premalignant
or malignant lesion. This is known as a cold knife After Cryosurgery of Cervix
biopsy. 1. Expect a clear, watery, heavy discharge
Another type of cervical biopsy is the loop for several weeks, eventually tapering
electrosurgical excision procedure (LEEP), also off.
called large loop excision of the transformation 2. Use only sanitary pads, not tampons.
zone (border between ectocervix and exocer- Change often, cleansing perineal area
vix). This area is common for development of with each pad change.
precancers and cancers. Either type of cervical 3. Report signs of infection: fever,
cone biopsy can be used as a treatment to com- malodorous discharge, pain, nausea, or
pletely remove many precancers and very early vomiting.
cancers.
4. Do not engage in sexual intercourse,
Cryosurgery. Cryosurgery is used to treat tissue by douche, or use tampons for 4 weeks
freezing temperatures. Chronic cervicitis and cer- (unless instructed otherwise by provider).
vical erosion are two common problems treated in 5. Expect a somewhat heavier than usual
this manner (see Chapter 19 for information about menstrual period the following month.
cryosurgery). The freezing temperature causes 6. Report excessive bleeding.
cells to die; they are then cast off from the cervix
 CHAPTER 14 Obstetrics and Gynecology 353

indicate an infection. Healing usually takes 4 to tains preservative, swabs (one large swab and one
6 weeks. small Mini-Tip Culturette Swab), and instructions.
This test needs to be performed on the female
Wet Prep/Wet Mount for Yeast, Bacteria, and patient before the digital/bimanual examina-
Trichomonas. The wet prep or wet mount is tion so that no lubricating jelly is present. Using
an office procedure to determine the cause of the large swab, the provider will clean the cer-
vaginitis in women and urethritis in men. The vix of any mucus, blood, and cellular debris and
provider takes a sample of the discharge on a discard the swab. The Mini-Tip Culturette Swab is
cotton-tipped applicator, the medical assistant then inserted into the cervical canal and rotated
rinses it vigorously in a test tube containing a for 15 to 30 seconds. Immediately it is placed into
few drops (about 0.5 mL) of normal saline press- the transport tube. If the ProbeTec Wet Transport
ing the swab against the inside of the test tube tube is used (Figure 14-35), the swab is broken
to express all the specimen, places a drop of the off into the liquid before recapping. This test
solution onto a microscope slide, and covers it also may be used to test for chlamydia and
with a coverslip; then the provider views it micro- gonorrhea in a urine specimen, following the man-
scopically for the following: ufacturer’s instructions for collection and testing
(see Procedure 14-5).
• If a yeast infection is present, budding yeast will
be seen. Laparoscopy. Laparoscopy is a procedure in which
• If a bacterial infection is present, clue cells will be a lighted instrument is used to view the inside of the
seen. Clue cells are vaginal epithelial cells that pelvic cavity. It can be helpful in diagnosing endome-
appear fuzzy with no clear cell edge. They appear triosis and ovarian cysts or other abnormalities in
this way because the outside edge is covered with the pelvic cavity. A tubal ligation, severing of the
bacteria. fallopian tubes, and an oophorectomy can be done
laparoscopically. Laparoscopy can be done abdomi-
• If trichomonas are present, they appear as motile nally or vaginally (Figure 14-36).
single-cell protozoa. Movement will be noted.
The trichomonas are sometimes identified in a Dilation and Curettage. Dilation and curettage
microscopic portion of the urinalysis as well (see (D&C) is a surgical procedure that involves dilat-
Procedure 14-4). ing and scraping the cervix of endometrial tissue.
It is commonly performed to remove any remain-
Potassium Hydroxide Prep for Fungus. After ing tissue after an incomplete abortion or to
performing the previously mentioned test, a few
drops of 10% potassium hydroxide (KOH) may
be added to the remaining solution in the test
tube and examined microscopically for fungi.
The KOH destroys bacteria and vaginal epithe-
lial cells, leaving only the cell walls of the fungus,
which makes visualization easier. This slide is
prepared in the same way as the wet prep: Place
a drop of the solution onto a clean slide, cover
with a coverslip. Dispose of all glass slides, cover-
slips, and test tubes into a sharps container (see
Procedure 14-4).

Amplified DNA Probe Test for Chlamydia and

Gonorrhea. The Amplified DNA Probe Test for
Chlamydia and Gonorrhea is used as a screening
tool for both men and women and on all preg-
nant women. It is not a culture. Two types of kits
are available: the ProbeTec® blue kit for urethral
specimens from the male patient (see Chapter 16)
and the ProbeTec® pink kit for endocervical speci- Figure 14-35 BD’s ProbeTec Amplified DNA test kit
mens from the female patient. The female kit con- for chlamydia and gonorrhea.
354 UNIT 5 Assisting with Specialty Examinations and Procedures

Viewer cally or transvaginally (see Figure 14-11A and

14-11B.)

Laparoscope Complementary Therapy

Symphysis Abdomen in Obstetrics and Gynecology
pubis
Most of the complementary therapy practiced today
can be helpful to women in easing the discomforts
of pregnancy and labor. In our stress-filled world,
emotional calm can be provided through the use
Laparoscope of some of these therapies.
with light Neonatal intensive care unit infants benefit
source
from a calm, warm touch, rocking, hugging, and
Uterus singing softly.
Sacrum Information about any form of comple-
Rectum mentary therapy (stress reduction, imagery, acu-
puncture, biofeedback, massage therapy, music
therapy, among others) should be obtained from
Anal opening the obstetrics patient at each visit. Consultation
with the provider concerning their safety during
Figure 14-36 Laparoscopy.
pregnancy is advisable.
Caution is advised when the use of herbal
medicine is considered during the pregnancy.
Because herbal supplements are available over the
examine the tissue if the patient has had abnormal counter and little is known about their effects on
uterine bleeding. the fetus, women should be cautioned to avoid
Diagnostic ultrasonography is used to help using any kind of herbal supplement during their
diagnose many gynecologic conditions, such first trimester. Women should ask their provider’s
as ovarian masses, fibroids, and endometriosis. advice about the use of the supplements after the
The ultrasound can be performed transcervi- first trimester.
 CHAPTER 14 Obstetrics and Gynecology 355

Procedure 14-1
Assisting with Routine Prenatal Visits
STANDARD PRECAUTIONS: 9. Assist patient onto examination table and drape
her. RATIONALE: The patient may be off balance
and unsteady on her feet because of the enlarge-
ment of the abdomen. Provide for her safety.
PURPOSE: 10. Assist the provider as the examination is per-
To monitor the progress of the pregnancy. formed.
• Hand the provider the tape measure to
EQUIPMENT/SUPPLIES: measure height of fundus
Scale Doppler fetoscope
• Hand the provider the Doppler fetal pulse
Disposable gloves and coupling agent
detector for measurement of fetal heart
Patient gown Urine specimen container
rate. The medical assistant may spread the
Tape measure Urinalysis testing supplies
coupling agent onto the patient’s abdomen.
Sphygmomanometer Biohazard waste container
Stethoscope 11. After the examination, assist patient to sit for
a few moments. Assess her color and pulse.
PROCEDURE STEPS: RATIONALE: Orthostatic hypotension can occur
1. Wash hands. when a patient rises from a recumbent position.
2. Set up equipment. Give the patient time for the blood pressure
to go back to normal so she will not experience
3. Identify patient.
dizziness from decreased blood pressure.
4. Obtain urine specimen. RATIONALE: A urine
12. Provide towel to patient to wipe off coupling
specimen for analysis is necessary for two reasons.
agent.
An empty bladder facilitates the examination and
is more comfortable for the patient. The urine 13. Provide any instruction or clarification of provid-
sample will be tested. er’s orders.
5. Weigh patient. RATIONALE: Assesses gain or loss 14. Apply gloves. Discard disposable supplies per
of weight to help determine fetal development OSHA guidelines. Disinfect equipment used.
and maternal nutrition. 15. Remove gloves.
6. Measure blood pressure. 16. Wash hands.
7. Have patient disrobe from waist down and put 17. Set up for the next patient.
on a gown open in the front. RATIONALE: An
18. Record all information in patient’s chart or
open gown facilitates access to the abdomen for
electronic medical record.
examination and measurement of the fundal
height.
DOCUMENTATION
8. Test the urine specimen while waiting for the 4/14/20XX 2:30 PM Wt. 148 3/4 lbs., T 98.8°F, P 82, R 16,
provider. RATIONALE: Urinalysis is done for BP 118/72L sitting. Urine dipstick negative for glucose
detection of glucose and protein, which may and protein. Fundal height at 22 wks. FHR 120. Says she
indicate disease. feels well and is sleeping and eating well. C. McInnis, CMA
(AAMA) ______________________________________
356 UNIT 5 Assisting with Specialty Examinations and Procedures

Procedure 14-2
Assisting with Pelvic Examination and Pap Test (Conventional
and ThinPrep® Methods)
STANDARD PRECAUTIONS: specimen container if ordered by provider.)
RATIONALE: An empty bladder facilitates
examination of the uterus and a urine speci-
men is frequently used for a urinalysis.
PURPOSE: 3. Provide patient with gown and request her to
To assist the provider in collecting cervical cells for completely undress.
laboratory analysis for early detection of malignant 4. Explain procedure to patient.
cells of the cervix and to assess the health of the 5. Instruct patient to sit at end of table when ready
reproductive organs to detect diseases leading to for pelvic examination. Drape patient for pri-
early diagnosis and treatment. vacy. If performing conventional Pap test, label
the frosted end of the slide with a marking pen-
EQUIPMENT/SUPPLIES:
cil. Include patient’s name on slide. Indicate site
Nonsterile gloves (2–3 pair)
from where specimen is collected: c = cervix, v =
Vaginal speculum, disposable or nondisposable
vagina, e = endocervical.
Warm water or warming light
Light source 6. Assist patient into lithotomy position. Patient’s
Drape sheet knees should be relaxed and thighs rotated out
Patient gown as far as comfortable. Drape for privacy and
Tissues warmth.
Vaginal lubricant 7. Encourage patient to breathe slowly and deeply
Lab requisition (see Figure 14-30) through the mouth during examination.
Urine specimen container RATIONALE: Allows for relaxation of pel-
Urine testing supplies vic muscles and easier insertion of vaginal
Biohazard specimen bag speculum.
Biohazard waste container
8. Warm vaginal speculum with either warm water
Adjustable stool for provider
or under heat lamp or place on a heating pad.
Supplies for the Pap test according to the method used NOTE: Do not lubricate speculum. Lubricant
for ThinPrep® Pap: obscures exfoliated cervical cells when Pap test
• Cervical spatula is being performed.
• Brush and broom 9. Hand speculum and spatula, cytology brush, and
• ThinPrep® container with solution broom to the provider as needed.
10. Apply gloves.
For conventional Pap test:
• Microscope slides 11. For conventional Pap test, hold slides for pro-
vider to apply smear of exfoliated cells, one for
• Fixative and/or specimen bottle
vaginal (v), one for cervical (c), and one for
• Cervical spatula endocervical (e), in that order. If spraying Pap
• Cytology brush fixative, spray it over the slide within 10 seconds
at a distance of about 6 inches. Allow to dry
PROCEDURE STEPS: for at least 10 minutes. If using Pap fixative in
1. Wash hands and assemble necessary supplies a bottle, place slide directly into bottle. If using
near patient. ThinPrep®, swish the cytology broom vigorously
2. Request that patient empty her bladder. (Instruct in the ThinPrep® solution until all the speci-
patient to save urine specimen and provide men has been deposited. Dispose of brush into

continues
 CHAPTER 14 Obstetrics and Gynecology 357

Procedure 14-2 (continued)

biohazard container. RATIONALE: This main- RATIONALE: Some patients, especially older
tains cell appearance and avoids contamina- adult patients, can experience orthostatic hypo-
tion of cells. Avoid getting too close to slide with tension.
spray because this may destroy or damage cells. 17. Discard disposable supplies per OSHA guide-
Slides must be fixed before they dry to protect lines. If stainless steel speculum was used, soak
the appearance of the cells. in cool water. Sanitize and sterilize as soon as
12. For ThinPrep® Pap test, hand the speculum and convenient.
cytology broom to the provider. Open the Thin- 18. Remove gloves and wash hands.
Prep® solution container. When the cells have
been obtained, take the broom and vigorously 19. Assist patient down and off the table if necessary.
swish it into the container of solution until all 20. Instruct patient to dress. Inform patient of how
the cells have been deposited. Replace the cap and when test results will be reported to her.
and label. Dispose of the broom into biohazard 21. Prepare laboratory requisition (cytology request)
waste. RATIONALE: The ThinPrep® procedure form. Include provider name and address, date,
requires that all cells obtained from the cervix be source of specimen, patient’s name and address,
presented in the solution for complete testing. date of LMP, and hormone therapy if any. Place
13. Place lubricant on provider’s gloved fingers slides in slide container or ThinPrep® container
without touching gloves, for bimanual and rectal into biohazard specimen bag. Place requisition
examinations. The provider will insert the index into outer pocket of bag and send to laboratory.
and middle fingers into the vagina. The other 22. Wash hands.
hand is placed on the lower abdomen. The size,
23. Document procedure in patient’s chart or elec-
shape, and position of the uterus and ovaries are
tronic medical record.
palpated.
14. The provider will insert one gloved finger into DOCUMENTATION
the rectum to check the ovaries and the tone of 4/14/20XX 11:00 AM Wt. 138 lbs., T 98°F, P 68, R 20,
the rectal and pelvic muscles. Hemorrhoids, rec- BP 138/72L sitting. Urine dipstick negative for protein and
tal fissures, or other lesions may be palpated. glucose. Pap smear performed by Dr. Woo. Slides of vagi-
15. Give the patient tissues to wipe genitalia and nal, cervical, endometrial cells sent to lab with requisition.
rectum. Pelvic and rectal exams performed by Dr. Woo. Patient
16. Help patient to a sitting position, allowing her expressed no complaints of discomfort. BP 142/78 P 80. C.
to rest a while. Check her pulse and skin color. McInnis, RMA __________________________________

Procedure 14-3
Assisting with Insertion of an Intrauterine Device (IUD)
STANDARD PRECAUTIONS: EQUIPMENT/SUPPLIES:
Nonsterile gloves (2−3 pair)
Sterile gloves
Vaginal speculum
Light source and stool for provider
PURPOSE:
Drape and gown
To assist the provider with the insertion of an intrauter-
Tissue
ine device (see Figure 14-19).
Lubricant

continues
358 UNIT 5 Assisting with Specialty Examinations and Procedures

Procedure 14-3 (continued)

Prepackaged IUD the patient can feel for the string through her
Biohazard waste container vagina after every period. The provider will have
Local anesthetic the patient check the string after the procedure.
Syringe and needle RATIONALE: Ensures that patient knows how to
Antiseptic such as Betadine® solution or swabs check for and find the string.
Emesis basin for used items such as speculum 16. Place disposable speculum in biohazard waste
container. Place nondisposable speculum into
PROCEDURE STEPS:
emesis basin.
1. Wash hands and assemble necessary supplies
near patient. 17. Help patient into sitting position and allow her
to remain seated while you check her pulse,
2. Draw up local anesthetic into syringe as directed
skin color, and blood pressure if needed.
by provider.
RATIONALE: Some patients can experience
3. Ask patient to empty her bladder. Save urine for orthostatic hypotension and become dizzy if
pregnancy test. RATIONALE: If patient is preg- they rise too quickly.
nant, the IUD will not be inserted.
18. Discard disposable supplies according to OSHA
4. Ask patient to undress from the waist down and guidelines. If stainless steel speculum was used,
put on a gown. soak in cool water. Sanitize and sterilize later
5. Explain procedure to patient. when convenient.
6. Give medication to patient for pain as prescribed 19. Remove gloves. Dispose in biohazard waster con-
by provider. tainer. Wash hands.
7. Help patient into lithotomy position. Drape for 20. Assist patient off table if she needs help.
warmth and privacy. 21. Tell patient she can get dressed.
8. Hand speculum to provider. 22. Explain to patient that she may experience light
9. The provider does a pelvic examination after cramping and perhaps spotting for 1−2 days.
donning nonsterile gloves. 23. Make an appointment in 4−6 weeks for patient.
10. The provider checks for pelvic infection and posi- Inform patient to make a yearly appointment
tion of the uterus. RATIONALE: An IUD cannot thereafter for a check-up.
be inserted if the woman has a pelvic infection 24. Document procedure in patient’s chart or elec-
because the procedure can carry microorgan- tronic medical record.
isms into the uterus. The position of the uterus is
important for the provider to know before inser- DOCUMENTATION
tion. 8/23/20XX 10:30 AM Pregnancy test negative. 1.0 mL
11. The provider swabs the cervix with an antiseptic of lidocaine injected into cervix by Dr. King. Pelvic exami-
and may inject a local anesthetic into the cervix. nation done by Dr. King, and a copper IUD was inserted
12. The provider puts the IUD into the insertion after anesthetic took effect. Small amount (approximately
device. The arms of the IUD flatten (the top of 15 mL) of bright red blood noted after insertion. Patient
the “T”) states she is “having slight cramping.” BP 134/88, P 100
immediately after procedure. Patient able to feel string com-
13. The provider inserts the IUD with the insertion ing out of cervix into vagina. Explained to patient to call
device through the cervix into the uterus. the office if she cannot feel the string, that sometimes the
14. The insertion tube is withdrawn completely. string tangles around the cervix and is hard to find. Told
15. Dispose of insertion device into biohazard waste the patient that an ultrasound, if necessary, will show
container or emesis basin. The provider short- whether the IUD is still in place. Instructed patient to
ens the string on the IUD to 1−2 inches from the use another form of contraceptive until placement of IUD
cervix and then removes speculum. Dispose of is confirmed. Blood pressure 10 minutes after procedure
speculum into waste container or emesis basin. 124/82, P 92, color good. Patient left accompanied by her
RATIONALE: The string is left long enough so sister. C. McInnis, RMA ___________________________
 CHAPTER 14 Obstetrics and Gynecology 359

Procedure 14-4
Wet Prep/Wet Mount and Potassium Hydroxide (KOH) Prep
STANDARD PRECAUTIONS: vagina and hands it to the medical assistant.
RATIONALE: The provider will complete the
examination of the patient while the medical
assistant prepares the sample for viewing.
PURPOSE: 5. Rinse the swab vigorously in the test tube con-
To test a vaginal specimen to determine the cause of taining saline, pressing the cotton tip against
vaginitis. The wet prep/wet mount tests for yeast, bac- the inside of the test tube to express all the
teria, and trichomonas; the KOH prep tests for yeast. specimen. RATIONALE: It is important to get as
much of the sample as possible for a more accu-
EQUIPMENT/SUPPLIES: rate diagnosis.
Cotton-tipped applicator 6. Dispose of the cotton-tipped applicator into a
Small test tube biohazard container. RATIONALE: All body
Normal saline (0.5 mL, or a few drops) fluid–contaminated supplies should be handled
10% potassium hydroxide (KOH; 0.5 mL, or a few with care and disposed of according to Standard
drops) Precautions.
Two microscope slides and coverslips
7. Apply a drop on a microscope slide and cover
Microscope
with a coverslip. Hand the slide to the provider
Vaginal speculum
for the microscopy examination. RATIONALE:
Patient drape
Only a provider may perform the PPMP (Phy-
Gloves
sician Performed Microscopy Procedure) for
Other equipment as necessary for a vaginal examination
diagnosis, according to CLIA regulations.
PROCEDURE STEPS: 8. Assist the patient back to a sitting position.
1. Prepare the patient for a pelvic examination as Instruct her to dress and offer to assist if needed.
outlined in Procedure 14-2 (Figure 14-37). RATIONALE: While the provider is viewing the
2. Place several drops of normal saline into a small slide, your responsibility is the safety and com-
test tube. RATIONALE: Preparing the test tube fort of the patient.
for the specimen. 9. In the laboratory, the provider will view the slide
3. Put on gloves. for yeast, bacteria, and trichomonas. RATIO-
NALE: The provider will take the slide to the
4. Using the cotton-tipped applicator, the pro-
laboratory where the microscope is located.
vider obtains a sampling of discharge from the
10. After completion of the wet prep/wet mount,
apply a few drops of KOH into the remaining
solution in the test tube, place a drop on a fresh
slide, and cover with a coverslip. RATIONALE:
This is the second part of the microscopy test
that can be performed on the vaginal secretion
to diagnose the cause of vaginitis.
11. The provider will perform a microscopic exami-
nation for yeast. RATIONALE: This is a PPMP.
12. Dispose of all slides and the test tube into a
sharps container. RATIONALE: As stated in Stan-
Figure 14-37 Supplies for wet mount and KOH dard Precautions, all sharps must be disposed of
prep: Pipette, cotton-tipped swabs, small test tube, in a sharps container.
and microscope slide with coverslip (not shown:
saline and KOH solution).

continues
360 UNIT 5 Assisting with Specialty Examinations and Procedures

Procedure 14-4 (continued)

13. Disinfect the laboratory area and equipment. the provider examined the specimen. The pro-
RATIONALE: As stated in Standard Precau- vider will add his or her findings to the patient’s
tions, all biohazard contaminated surfaces must electronic medical record. Be sure you sign the
be disinfected after contamination. entry.
14. Return to the patient and assist as needed.
RATIONALE: The patient may need assistance DOCUMENTATION
and direction. 6/10/20XX 2:15 PM Wet mount and KOH prep done.
Candidiasis identified. Patient given prescription for Gyne-
15. Remove gloves. Wash hands.
Lotrimin 3 Vaginal suppositories (200 mg) at bedtime for
16. Document procedure in patient’s chart or three consecutive nights. J. Woo, MD.Patient will call on
electronic medical record. Input that a pelvic Monday to tell us how she feels. C. McInnis, RMA ________
examination and wet prep were done, and that

Procedure 14-5
Amplified DNA ProbeTec Test for Chlamydia and Gonorrhea
STANDARD PRECAUTIONS: waste must be handled carefully and disposed
of properly.
5. Hand the small Mini-tip Culturette Swab to
the provider, who will insert the swab into the
PURPOSE: cervical os and rotate it for 15 to 20 seconds.
To test a vaginal specimen for diagnosis of chlamydia RATIONALE: Accurate test results require
and gonorrhea and as a screening tool for the same obtaining adequate endocervical cells and
for a pregnant woman. secretions.
6. Immediately place the swab into the transport
EQUIPMENT/SUPPLIES: tube and recap. RATIONALE: The specimen
Amplified DNA ProbeTec Kit (pink): must to be placed in the tube with preservative
• Transport tube containing preservative immediately to preserve it.
• Swabs (one large and one small Mini-Tip Culturette) 7. If using the ProbeTec Wet Transport tube, break
Vaginal speculum the tip of the swab off into the the liquid before
Patient drape recapping. RATIONALE: The tip of the swab is
Gloves scored and will snap off easily. This allows the
Other equipment as necessary for a vaginal examination entire specimen to be transported in a small
amount of preservative.
PROCEDURE STEPS:
8. Remove gloves. Wash hands.
1. Prepare the patient for a pelvic examination as
outlined in Procedure 14-2. 9. Attach requisition to specimen.
2. Put on gloves. 10. Attend to your patient.
3. Hand the large swab to the provider, who will 11. Document the procedure in the patient’s chart
use it to clean the cervix. RATIONALE: Mucus or electronic medical record.
or blood on the cervix will interfere with the
purity of the specimen. DOCUMENTATION
4. Discard the large swab into the biohazard waste
6/10/20XX 10:00 AM DNA ProbeTec test done by Dr. Woo.
container. RATIONALE: According to Stan-
Entire specimen transported to laboratory. C. McInnis,
dard Precautions, all biohazard contaminated
RMA _________________________________________
 CHAPTER 14 Obstetrics and Gynecology 361

Case Study 14-1

Refer to the scenario at the beginning of the chapter. CASE STUDY REVIEW
Mrs. Sanderson has an appointment today in the obstet-
ric clinic at Inner City Health Care. Wanda is respon- 1. What are some potential problems with Mrs.
sible for preparing Mrs. Sanderson for a repeat prenatal Sanderson’s pregnancy that Wanda can discover
visit. Besides getting her patient ready, Wanda has other and then can alert Dr. King?
responsibilities to Mrs. Sanderson. Vital signs and certain
laboratory tests must be done.

Case Study 14-2

Maria Rodriguez has an appointment to see Dr. King today. CASE STUDY REVIEW
It is her initial prenatal visit. She tells Liz Corbin, the medical
assistant, as she is escorted from the reception area that 1. Explain the importance of the initial prenatal visit.
she has been feeling “pretty good.” Discuss.
2. Name five specific diseases and conditions for
which Dr. King will be on the alert during Maria’s
pregnancy, and what signs and symptoms to look
for.
3. What laboratory and other procedural tests may be
performed at the initial visit?
4. Discuss areas of patient education and health
promotion that Liz will discuss with Maria at the
initial visit.

Case Study 14-3

Annette Sanderson has made an appointment with Dr. King CASE STUDY REVIEW
because she has had symptoms of vaginitis. When she
arrives at the clinic, you take her chief complaint and history. 1. What tests/procedures will you prepare for
She tells you that she has a milky-white, frothy vaginal dis- Dr. King in consideration of Annette’s symptoms?
charge and that she itches in the genital area. 2. What is the most likely causative microorganism for
these symptoms?
3. Describe the treatment that Dr. King may prescribe.

SUMMARY
Obstetrics and gynecology are two specialties that are usually practiced by the same provider. The OB/GYN
provider will care for the health and well-being of the female patient in her pregnant and nonpregnant
states. Knowledge of the numerous tests and procedures that are performed to diagnose and treat prob-
lems in the female patient are essential. Health promotion and patient education are of extreme impor-
tance whether the patient is an obstetric patient and scheduled for her initial prenatal visit or a gynecologic
patient scheduled for yearly pelvic, Pap, and breast examinations.
362 UNIT 5 Assisting with Specialty Examinations and Procedures

STUDY FOR SUCCESS

To reinforce your knowledge and skills of information presented in this chapter:
• Review the Key Terms
• Practice any Procedures
• Consider the Case Studies and discuss your conclusions
• Answer the Review Questions

˚ Multiple Choice
˚ Critical Thinking
• Navigate the Internet and complete the Web Activities
• Practice the StudyWARE activities on the textbook CD
• Apply your knowledge in the Student Workbook activities
• Complete the Web Tutor sections
• View and discuss the DVD situations

REVIEW QUESTIONS
Multiple Choice 5. Ultrasonography is done to check for which of the
following?
1. Which of the following conditions or diseases that
a. gestational diabetes
an obstetrics patient experiences is considered to
b. preeclampsia
place her in the high-risk category?
c. degree of effacement
a. urinary tract infection
d. number of weeks of gestation
b. 19 years of age
6. After a cervical punch biopsy, it is normal for the
c. both partners Rh negative
patient to experience which of the following?
d. poor nutritional habits
a. bleeding greater than a normal menstrual
e. poor hygiene
period
2. Using Nägele’s Rule, calculate the expected date of
b. no odor to vaginal discharge
birth of the baby of a patient whose last menstrual
c. malodorous vaginal discharge
period was August 20, 2005.
d. severe abdominal cramps
a. November 27, 2006
7. To make the diagnosis of trichomoniasis, the med-
b. December 13, 2006
ical assistant will need to prepare for which of the
c. May 27, 2006
following?
d. April 20, 2006
a. Pap smear
3. The primary test performed at about the 16th
b. ultrasonography
week to check the fetus for neural tube defects is
c. wet mount
known as:
d. culture and sensitivity
a. alpha-fetoprotein test
e. blood glucose
b. amniocentesis
8. To diagnose pelvic inflammatory disease (PID), the
c. chorionic villus sampling (CVS)
provider may order which of the following?
d. rubella titer
a. culture and sensitivity
e. Rh factor
b. Pap smear
4. The release of which of the following hormones is
c. urinalysis
thought to cause labor to begin?
d. rubella titer
a. progesterone
e. ultrasonography
b. estrogen
c. oxytocin
d. thyroxine
 CHAPTER 14 Obstetrics and Gynecology 363

9. Which of the following is/are primarily associated Gynecology

with abnormal Pap smears? Locate a Web site specific to cancer of the female
a. endometriosis reproductive tract to complete the following:
b. Bartholin cysts
1. What treatment options are available for cancer of
c. condylomata
the endometrium?
d. ovarian cysts
2. What tests are available to help diagnose the can-
e. PID
cer?
10. The primary purpose of colposcopy is to:
3. Print a list of local support groups for women with
a. treat advanced cancer of the vagina and cervix
endometrial cancer.
b. detect dysplastic cells of cervix after an abnor-
4. Visit the American College of Obstetricians and
mal Pap test
Gynecologists Web site for information about man-
c. treat PID in the fallopian tube
aging pregnant patients with the following disor-
d. treat endometriosis of the pelvic cavity
ders or conditions:
Critical Thinking Questions a. hypertension
b. cardiovascular disease
1. A pregnant woman who has had no prenatal care c. Rh factor incompatibility
has not had a period for 6 months. She has called 5. Visit the American Cancer Society’s Web site. Find
the OB/GYN clinic to schedule an appointment information about diethylstilbestrol (DES) and
because she has had vaginal bleeding. She contin- male offspring malignancies.
ues to feel fetal movement.
a. What laboratory tests or procedures will the pro-
vider order?
b. What diagnosis is the provider most likely to
REFERENCES/BIBLIOGRAPHY
make? Centers for Disease Control and Prevention. (n.d.).
2. Lower abdominal and back pain that increases just Genital HPV infection, CDC fact sheet. Retrieved
before and during menses may be caused by what August 24, 2008, from http://www.cdc.gov/std/
condition? HPV/STDFact-HPV.htm.
3. Emily Harris is scheduled to have a cervical punch Decision (pp. 165−192). Published by Rodale: Distrib-
biopsy. What is the primary reason for a cervical uted to the trade by Holtzbrink Publishers, 2007.
punch biopsy? Explain the post-biopsy instructions Estrogen therapy: Not for prevention. (2004). Consumer
she will need. Report on Health, 16(5), 3.
Littleton, L. Y., & Engebretson, J. C. (2002). Maternal,
neonatal, and women’s health nursing. Clifton Park,
WEB ACTIVITIES NY: Delmar Cengage Learning.
“The menopause–hormone discussion: how to weigh the
Obstetrics
risks,” (June 11, 2007). Parker-Pope. Adapted from
Access a Web site for expectant parents to
“The hormone decision.” The Wall Street Journal.
locate information about the following:
Published by Rodale: Distributed to the trade by
1. Obtain fact sheets about each trimester. Holtzbrink Publishers, 2007.
2. Compile a list of tests, complications, and postpar- Morrison, R. W., & Lett, S. M. (2007). Human papilloma-
tum recovery. virus (HPV) vaccine for VFC-eligible girls now available
3. Visit the National Library of Medicine Web site. (memorandum). Jamaica Plain, MA: The Common-
a. What are the time frames for the various stages wealth of Massachusetts, Executive Office of Health
of labor? and Human Services, Department of Public Health,
b. What are the various breech presentations? State Laboratory Institute. Retrieved August 24,
4. Find a Web site that gives information about the 2008, from http://www.mass.gov/Eeohhs2/docs/
Lamaze method of childbirth. Is this something dph/cdc/immunization/alerts_hpv_vaccine_
you might consider for yourself or your partner? availability.pdf.
5. Search the Internet for a Web site that gives infor- National Cancer Institute. (2007). Tamoxifen: Ques-
mation about postpartum exercise routines. Also tions and answers. Retrieved August 29, 2007, from
visit http://www.medscape.com for information. http://www.cancer.gov/cancertopics/factsheet/
therapy/tamoxifen.
364 UNIT 5 Assisting with Specialty Examinations and Procedures

National Cancer Institute Fact Sheet 4.21. Human pap- Web MD, Birth Control Health Center by Kelly Coli-
illomavirus (HPV) vaccines: Questions and answers. han, reviewed by Louise Change, MD,
Retrieved October 5, 2008, from www.cancer.gov/ August 13, 2008. “More women ask for birth con-
cancertopics/factsheet/prevention/HPV-vaccine. trol.” Retrieved October 5, 2008.
Spratto, G. R., & Woods, A. L. (2009). 2008/9 edition Web MD, Medical News Women’s Health, Cervical
nurse’s drug handbook. Clifton Park, NY: Delmar Cancer Vaccine by Miranda Hitti, reviewed by
Cengage Learning. Louise Chany, MD, September 12, 2008. “Gardisil
Taber’s cyclopedic medical dictionary (21st ed.). (2002). approved to target more cancers.” Retrieved
Philadelphia: F. A. Davis. October 5, 2008.
Tamparo, C., & Lewis, M. (2005). Diseases of the human
body (4th ed.). Philadelphia: F. A. Davis.

THE DVD HOOK-UP

In this chapter, you learned about the proper techniques assistant to stay in the room with a male provider during
for preparing a patient for a Pap and pelvic examination as a pelvic examination? What kinds of things will you do to
well as a prenatal examination. make your patient feel more comfortable during a Pap/pel-
The selected scene from today’s program illustrates Anita vic procedure?
preparing a tray for a Pap procedure. Anita places the
speculum into some warm water.
1. What are two reasons to place the speculum in water?
2. Why did Anita stay positioned above the drape?
3. What was the purpose of the Hemoccult Card? DVD Series Program Number
Skills Based Series 6
DVD Journal Summary Chapter/Scene Reference
Write a paragraph that summarizes what you learned from • Pap Examination
watching today’s selected DVD scene. Think of how you feel
when you have to have a pelvic examination. Do you like
having the assistant in the room when you are examined?
Why is it considered good practice for a female medical
 Chapter

Pediatrics 15
KEY TERMS OUTLINE
Aerosolyzed What Is Pediatrics? Infant/Child Failure to Thrive
Cochlear Implantation Preparation of Vaccines for Pediatric Vital Signs
Exudate Administration Temperature
Fontanel Recommended Vaccination Pulse
Schedule Respirations
Lyophilized
Considerations for Vaccine Blood Pressure
Myringotomy Administration Collecting a Urine Specimen
Neonate Giving Injections to Pediatric from an Infant
Organomercurial Patients Screening Infants for Hearing
Phenylketonuria (PKU) Theories of Growth and Impairment
Sensorineural Development Screening Infant and Child Visual
Suppurative Newborns Acuity
Tympanostomy Infants Common Disorders and
Toddlers Diseases
Preschoolers Otitis Media
School-Aged Children The Common Cold
Adolescents Tonsillitis
Growth Patterns Pediculosis
Measuring the Infant or Child Asthma
Length and Weight Croup
Measurements Pertussis (Whooping Cough)
Infant Holds and Positions Respiratory Syncytial Virus
Height and Weight Measuring Attention Deficit Hyperactivity
Devices Disorder
Measuring Head Child Abuse
Circumference Male Circumcision
Measuring Chest
Circumference

OBJECTIVES
The student should strive to meet the following performance objectives and
demonstrate an understanding of the facts and principles presented in this chapter
through written and oral communication.

1. Define the key terms as presented in the glossary.

2. Describe the various theories of human development.
3. Describe pediatric care including measuring height, weight,
head, chest circumference, and vital signs.

365
OBJECTIVES (continued)
4. Explain the process of collecting a urine specimen.
5. Explain the process of screening for hearing and visual
impairments.
6. Describe common pediatric diseases and disorders.
7. Explain the importance of immunizations and scheduling of them.
8. Describe infant holds for injections and procedures.

Scenario
At Inner City Health Care, clinical assistant Bruce immunizations for long-term health protection and the
Goldman, CMA (AAMA), is responsible for encouraging importance of following recommended vaccination
parents to keep track of their children’s immunization schedules for maximum benefit.
records. Bruce teaches parents the importance of

INTRODUCTION
New techniques and developments occur frequently in
medicine, and medical assistants must refine existing
skills and learn new ones to be knowledgeable and profi-
cient and to provide the most current, up-to-date quality
care to patients. The medical assistant who works in a Spotlight on Certification
pediatrician’s office or a pediatric ambulatory care set-
ting that treats infants and children will need additional RMA Content Outline
skills when providing pediatric care to patients. • Anatomy and physiology
Knowledge of the developmental stages, knowledge
• Patient education
of diseases of infants and children, and the ability to gain
the child’s confidence and trust and the caregivers’ coop- • Vital signs and mensurations
eration are all skills required to provide for the physiologi- • Pediatrics
cal, emotional, and psychological needs of the pediatric • Parenteral medications
patient. This chapter covers the specialty examination • Drugs
and the appropriate clinical procedures in pediatrics. • Minor surgery
• Surgical supplies
• Surgical procedures
WHAT IS PEDIATRICS?
CMA (AAMA) Content Outline
Pediatrics is the branch of medicine that cares • Psychology
for newborns, infants, children, and adolescents. • Adapting communication to an
Pediatricians are providers who diagnose and treat individual’s ability to understand
health problems and diseases specific to these age (e.g., patients with special needs)
groups. This patient population has special needs, • Equipment preparation and operation
and medical assistants must be knowledgeable
• Patient preparation and assisting the
about the growth and development phases of life
provider
and diseases unique to pediatric patients. Children
form judgments and have fears about health care CMAS Content Outline
providers. They need an atmosphere that is com- • Anatomy and physiology
fortable and one in which their physiological, emo- • Vital signs and measurements
tional, and psychological needs are recognized and
• Examination preparation
addressed.

366
 CHAPTER 15 Pediatrics 367

Medical assistants must gain the confidence determine the neonate’s physical condition at 1, 5,
and trust of the child and parent(s), allay fear, and and 15 minutes after birth. It is known as the APGAR
help to promote positive relationships between (appearance, pulse, grimace, activity, and respira-
the child and the provider and must themselves tion) score. Muscle tone, skin color, respiration, heart
develop a positive relationship with the child. Chil- rate, and response to stimuli are given a score 0, 1,
dren are likely to be cooperative when being exam- 2, and so on, with the highest score 10. Infants with
ined or during a procedure if good rapport has low APGAR scores need immediate attention, such
been established. It is important to be honest with as stimulation, oxygen, medication, and so on. Their
young patients and approach them at their level of condition is monitored closely (see Chapter 14).
understanding. Allow children to touch and hold Tests are done to detect problems the neonate
a “safe” instrument, such as a stethoscope, and may have. Phenylketonuria (PKU), iron deficiency
explain its purpose to them. Doing so can reduce anemia, lead poisoning, and hypothyroidism are
anxiety and fear (Figure 15-1). It is important also problems for which neonates are screened shortly
for the medical assistant to recognize pediatric after the APGAR scoring is done.
patients by their names no matter what their ages. Many patients seen in the pediatric setting
Taking a history of the child; assessing the are babies or children who are not ill. They are
child; measuring vital signs, height, weight, vision, considered “well-baby” or “well-child” patients and
and hearing; laboratory work; administration of are having routine checkups. Ill babies or children
injections; observing the parent–child interac- are often called “sick-child” or “sick-baby” patients.
tions; and noting the child’s development level Well-baby appointments are regularly scheduled
are all responsibilities in which a medical assistant appointments during which time the provider
takes part. examines the child and evaluates the growth and
The first physical examination of a newborn development of the child. Most offices schedule
is performed immediately after delivery. The pedia- well-baby appointments after birth according to
trician assesses the neonate’s ability to exist outside the following time frame: 1, 2, 4, 6, 9, 12, 15, 18, 24
of the mother’s uterus. A scoring system is used to months, and yearly thereafter.
The goal of well-baby visits or checkups is pre-
vention of health problems and diseases. Typically,
immunizations are given during these appoint-
ments. The charts shown in Figures 15-2, 15-3, and
15-4 include immunization schedules from the
National Immunization Program. The program
urges that all children be immunized because the
vaccines provide the best defense against many dan-
gerous childhood diseases. Immunizations protect
children against hepatitis A and B, polio, measles,
mumps, rubella, pertussis, diphtheria, tetanus, Hae-
mophilus influenza type b, pneumonia, chicken pox,
influenza, rotavirus, meningitis, and human papil-
lomavirus (HPV) (see Chapter 14). Immunizations
are given by mouth, injection, and intranasal spray.
All of these need to be given before age 2 when chil-
dren are most susceptible to infectious diseases. Vac-
cines protect children during these periods. HPV is
the exception. It is given between ages 13 to 18 with
the minimum age 9 years.

Preparation of Vaccines
for Administration
Careful attention to both proper storage of vaccines
and thorough patient preparation for immunization
Figure 15-1 The medical assistant allows the child to will promote effective vaccination results. Access to
touch the stethoscope and “listen” to her heartbeat to vaccination should be available to all patients, espe-
gain the child’s cooperation. cially to families with young infants and children.
368 UNIT 5 Assisting with Specialty Examinations and Procedures

Figure 15-2 The recommended immunization schedule for persons aged 0−6 years is approved by the Advisory
Committee on Immunization Practices (http://www.cdc.gov/vaccines/recs/acip), the American Academy of Pediat-
rics (http://www.aap.org), and the American Academy of Family Physicians (http://www.aafp.org).
 CHAPTER 15 Pediatrics 369

Figure 15-3 The recommended immunization schedule for persons aged 7−18 years is approved by the Advisory
Committee on Immunization Practices (http://www.cdc.gov/vaccines/recs/acip), the American Academy of Pediat-
rics (http://www.aap.org), and the American Academy of Family Physicians (http://www.aafp.org).
370 UNIT 5 Assisting with Specialty Examinations and Procedures

Figure 15-4 Catch-up immunization schedule for persons aged 4 months−18 years who start late or who are more than
one month behind. Information about reporting reactions after immunization is available at the VAERS Web site (http://
www.vaers.hhs.gov) or by telephone via the VAERS national toll-free information line (800-822-7967). Suspected cases of
vaccine-preventable diseases should be reported to the state or local health department. Additional information, includ-
ing precautions and contraindications for immunization, is available from the National Center for Immunization and
Respiratory Diseases Web site (http://www.cdc.gov/vaccines) or by telephone (800-CDC-INFO).
 CHAPTER 15 Pediatrics 371

Table 15-1 Vaccine Administration Guidelines

Precautions Side Effects

and Contra- and Adverse Vaccine
Vaccine Disease About the Disease indications Reactions Schedule

Diphtheria, tet- Diphtheria can cause Moderate to Local reactions, 2 months, 4

anus, pertussis breathing problems, severe acute fussiness, seizures, months, 6 months,
paralysis, heart failure, illness, neuro- fever, allergic 15–18 months, 4–6
and death; tetanus logic disorder, reaction years; not given at
causes paralysis of the allergic reac- 7 years
jaw—cannot open tion to prior or older
DTaP, DT, Td mouth or swallow; pertus- dose
sis (whooping cough)
causes severe coughing
so infants have difficulty
eating, drinking, or
breathing or causes
brain damage/death

Poliomyelitis Causes paralysis of Allergic Local reactions, 2 months,

skeletal muscles and reaction to allergic reaction 4 months,
diaphragm so that prior dose or to 16–18 months,
infants cannot breathe neomycin, 4–6 years
Inactive
on their own streptomycin, (booster)
poliovirus
or polymixin B;
(IPV)*
moderate to
severe acute
illness;
pregnancy

Meningitis, Causes bacterial menin- Moderate to Fever, swelling, 2 months, 4

pneumonia, gitis, pneumonia, epiglot- severe acute redness and/or months, 6 months,
Haemophilus epiglottitis, titis, septicemia, death illness, allergic pain; allergic 12–15 months
influenzae pericarditis reaction to reaction (booster); children
type B (Hib) prior dose younger than 6
weeks old should
not get vaccine

Moderate to Local reaction, Cannot be used

Combination severe acute allergic reaction at 2 months, 4
vaccines illness months, or 6
containing months; may be
Hib Diphtheria, used as booster
• DTaP_Hib tetanus,
(TriHIBit) pertussis,
Haemophilus
influenzae
Hepatitis B and 2 months, 4
• Hepatitis Haemophilus months, 12–15
B-Hib influenzae months; not given
(-Comvax) to infants younger
than 6 weeks old

Hepatitis B Anorexia, fatigue, diar- Pregnancy, Mild systemic Within 12 hrs of

rhea, vomiting, liver dam- moderate to effects, soreness, birth, 1–2 months,
Hepatitis B age, cancer, death severe acute fever, allergic 6 months (3 doses
(HBV) illness, allergic reaction needed)
reaction to
baker’s yeast
(continues)

*Oral polio vaccine no longer recommended

372 UNIT 5 Assisting with Specialty Examinations and Procedures

Table 15-1 Vaccine Administration Guidelines (continued)

Precautions Side Effects

and Contra- and Adverse Vaccine
Vaccine Disease About the Disease indications Reactions Schedule

Diphtheria, teta- Moderate to Mild systemic 2 months,

nus, pertussis, severe acute effects, local 4 months,
Pediatrix,
Haemophilus illness reaction, allergic 6 months
DTap, HepV,
influenzae, hep- reaction
IPV
atitis B, inactive
poliovirus

Tetanus, diph- Moderate to Soreness; swell- 7 years or older

theria severe acute ing; severe aller- then every
illness, severe gic reaction; 10 years for life
Td
allergic reac- deep, aching
tion to prior pain in muscles
dose of upper arm(s)

Measles, Measles can cause otitis Do not give if Fever, mild rash, Two doses:
mumps, rubella media, pneumonia, allergic to swelling of glands 12–15 months and
seizures, brain damage, gelatin or the in cheeks and 4–6 years (or any
death; mumps can antibiotic neo- neck, seizures, age if longer than
cause fever, swollen mycin, moder- temporary pain in 28 days from first
glands, deafness, menin- ate to severe joints, severe aller- dose)
MMR
gitis, swelling of testicles acute illness, gic reaction
or ovaries, death; rubella breast-feeding,
can cause pregnant pregnancy,
women to have miscar- immunosup-
riages or babies born pressed
with severe anomalies individuals

Chicken pox Severe skin infection, Do not give if Soreness and 12–18 months or
pneumonia, brain dam- allergic to swelling at site, any age if never
age, death; shingles gelatin or the fever, mild rash, had chicken pox
Varicella (herpes zoster) may antibiotic neo- seizures,
occur years later mycin, moder- pneumonia
ate to severe
acute illness

Hepatitis A Liver disease with flu-like Allergic reac- Soreness at site, 1 month before
symptoms, jaundice, tion to prior headache, severe traveling or when
nausea and vomiting, dose, tell doc- allergic reaction at risk for infection
abdominal pain tor if pregnant (two doses
HAV (safety of vac- needed 6 months
cine during apart); children
pregnancy 12–24 months with
has not been second dose 6
determined) months later

Influenza Influenza (flu) Fever, cough, chills, Do not give to Soreness, redness, All children
Inactivated aches, death pregnant fever, aches, aller- 6–23 months
(I.M.) Live, women, egg gic reaction
intranasal allergy, history
(I.N.) of Guillain-
Ages 5–49 Barré syndrome

Pneumonia, Meningitis, septicemia, Moderate to Redness, swelling 2 months,

Pneumococ- bacterial otitis media, pneumonia, severe illness, at site, fever, 4 months,
cal congu- meningitis deafness, brain damage allergic reaction drowsiness 6 months,
gate to prior dose 12–15 months
(continues)
 CHAPTER 15 Pediatrics 373

Table 15-1 (continued)

Precautions Side Effects

and Contra- and Adverse Vaccine
Vaccine Disease About the Disease indications Reactions Schedule

Meningitis Infection of the brain Severe allergic Allergic reaction, Not for children
and coverings of the reaction to redness or pain at younger than
Meningococ-
spinal cord, septicemia, prior dose site, fever 2 years (two doses
cal
mental retardation, needed
seizures, stroke, death 3 months apart)

Kowasaki Severe diarrhea, vomit- Serious aller- 2 months,

disease ing, fever, dehydration; gic reaction 4 months,
cause unknown; serious from previous 6 months
in children; inflammation vaccine dose,
Rotavirus of small- and medium- serious allergic
(ROTA) sized arteries, including reaction to
coronary arteries; no test vaccine com-
to diagnose disease ponent
(signs and symptoms
used to help diagnose)

Most of the recommended vaccines are administered rations require refrigeration or protection from
in the child’s first 15 to 18 months of life. Access light.
involves cost of vaccines, appointment requirements, Vaccines have trade names, and manufactur-
and time required to receive vaccines. Some offices ers have been tested for safety. The package insert
permit walk-in vaccination administration with free of each vaccine describes the vaccine including
or low co-payment fee only. Routine well-infant its route of administration, purpose, contrain-
examinations should be scheduled according to the dications, and possible side effects (see Table
recommended vaccination schedule to promote and 15-1). Because some vaccines are grown in bird
facilitate maintenance of the schedule. eggs weakened by addition of chemicals or are
Vaccine storage should follow specific made from animals, it is essential to know what
manufacturer’s guidelines. Some vaccine prepa- allergies a child has. For example, a child who is
allergic to eggs cannot receive an MMR, varicella,
or influenza vaccine because of the possibility of
Patient Education the child being allergic to the egg protein that
is used in the manufacturing of the vaccine
Encourage parents to be aware of different (Figure 15-5). Symptoms of side effects, con-
vaccines and to keep track of vaccina- traindications, and allergies must be known by
tion schedules. By posting recommended the medical assistant, who will ensure that the
schedules in visible locations in the ambula- parents are informed and have given written con-
tory care setting, parents can be reminded. sent before the vaccines are given. After admin-
istration of vaccines (see Procedure 15-1), the
Figures 15-2 and 15-3 illustrates the rec-
medical assistant is responsible for documen-
ommended vaccination schedule for chil-
tation of the types of vaccines, site of adminis-
dren and adolescents, which is supported
tration, manufacturer’s lot number, and side
by the American Academy of Pediatrics, the
effects, if any have been reported by the parents
Advisory Committee on Immunization Prac-
(Figure 15-6). The provider will report any clini-
tices (ACIP), the Committee on Infectious
cally significant adverse reactions to the Vaccine
Diseases (COID), the Commission of Public
Adverse Event Reporting System (VAERS) and
Health and Scientific Affairs (COPHSA),
will file a VAERS Events Form for the National
and the American Academy of Family
Immunization Program. Vaccine records can be
Physicians (AAFP).
kept electronically. All children must have a
374 UNIT 5 Assisting with Specialty Examinations and Procedures

EMERGENCY TREATMENT
• If itching and swelling are confined to the injection site where the vaccination was given,

observe patient closely for development of generalized symptoms.

• If symptoms are generalized, activate the emergency medical system (EMS; call

911) and notify the on-call provider. This should be done by a second person, while the

vaccinator assesses the airway, breathing, circulation, and level of consciousness of the

patient.

• The provider will administer aqueous epinephrine 1:1000 dilution subcutaneously.

The standard dose is 0.01 mg/kg body weight, up to 0.3 mg maximum

single dose in children and 0.5 mg maximum in a single dose for a pediatric patient.

• In addition, for anaphylaxis, the provider will administer diphenhydramine (Benadryl)

either orally or by intramuscular injection. The standard dose is 1 mg/kg body weight, up

to 30 mg maximum dose in children and 100 mg maximum dose in adolescents.

• Monitor the patient closely until EMS arrives. Perform cardiopulmonary resuscitation

(CPR), if necessary, and maintain airway. Keep patient in supine position (flat on back)

unless he or she is having breathing difficulty. If breathing is difficult, patient’s head

may be elevated, provided blood pressure is adequate to prevent loss of consciousness. If

blood pressure is low, elevate legs. Monitor blood pressure and pulse every 5 minutes.

• If EMS has not arrived and symptoms are still present, the provider will repeat dose of

epinephrine every 10–20 minutes for up to 3 doses, depending on patient’s response.

• Record all vital signs; medications administered to the patient, including time, dosage,

response; name of the provider who administered the medication, and other

relevant clinical information.

• Notify the patient’s primary care provider.

Figure 15-5 Emergency treatment for children and teens experiencing an allergic reaction to a vaccine

personal immunization record as part of their

• Month, day, and year of administration
permanent medical record. It is mandated that
the following information be included in • Vaccine given
E HR the patient’s electronic medical record • Vaccine information sheet (VIS) given to a parent
with each immunization: or guardian
 CHAPTER 15 Pediatrics 375

Figure 15-6 Immunizations recorded in (A) a patient’s electronic medical record and (B) in the practice’s global
immunization log for that vaccine.

• Manufacturer name
Recommended Vaccination
• Lot number and expiration date
Schedule
• Site and route of administration
The recommended vaccination schedule for infants
• Name, address, and title of health care provider
and children is based on the premise that repeated
giving the vaccine
doses of several vaccines are required and vaccine
• Source of vaccine, (F) federal, (S) state, (P) private manufacturers recommend administering only
compatible vaccines at any one visit to avoid drug
Immunization recordkeeping is mandated by interactions. If no contraindications are present at
state and federal laws. Total practice management the various ages, vaccines should be administered
systems include immunization recordkeeping as according to the schedule to ensure complete vac-
part of clinical care (Figure 15-7). Procedure 15-2 cination by the age of 15 to 18 months, with booster
gives more information about maintaining immu- vaccines on school entry and again every 10 years
nization records. throughout adult life. Should any vaccine be missed
Vaccines stimulate the immune system to pro- for any reason, vaccine “catch-up” schedules are
duce antibodies against pathogens (see Chapter available to ensure adequate vaccine administra-
10). Some patients may have conditions or preex- tion (see Figure 15-4).
isting conditions that would contraindicate vaccine
administration. Safe vaccine administration requires Considerations for Vaccine
assessment and recognition of conditions that would
contraindicate vaccine administration at any specific
Administration
time. When any vaccine is not given because of an • Infection control. Health care providers should fol-
existing contraindication, careful documentation low Standard Precautions to minimize the risks of
and notification of the provider are required. spreading disease during vaccine administration.
376 UNIT 5 Assisting with Specialty Examinations and Procedures

Pharmacy disease transmission. Personnel should be involved

in evaluation and selection of these products. Staff
should receive training with these devices before
using them in the clinical area.
CLINICAL CARE • Needle selection. Vaccine must reach the desired tis-
Patient Assessment sue site for optimal immune response. Therefore,
Procedures, Diagnoses & Treatment Plans needle selection should be based on the prescribed
Referrals & Follow-up Appointments
Prescriptions route, size of the individual, volume and viscosity
Orders for Tests of the vaccine, and injection technique. Typically,
Patient Medical History
vaccines are not highly viscous; therefore, a fine-
gauge needle (22–25 gauge) can be used.
• Needle-free injection. A new generation of needle-free
Test Results vaccine delivery devices has been developed in an
Schedules and Tickler Files effort to decrease the risks of needlestick injuries
Patient Medical History
Medication Administration to health care workers and to prevent improper
Patient Education reuse of syringes and needles. For more informa-
Graphical Patient Data Displays
tion on needle-free injection technology, see the
Centers for Disease Control and Prevention (CDC)
ELECTRONIC Web site: (http://www.cdc.gov/nip/dev/jetinject.
htm).

RECORDS • Inspecting vaccine. Each vaccine vial should be care-

fully inspected for damage or contamination prior
to use. The expiration date printed on the vial or
box should be checked. Vaccine can be used up to
and including the last day of the month indicated
Figure 15-7 In a total practice management system, by the expiration date unless otherwise stated
all the necessary data are documented at the time of on the package labeling. Expired vaccine should
clinical care, are electronically stored, and are acces- never be used.
sible on demand.
• Reconstitution. Some vaccines are prepared in a
lyophilized form that requires reconstitution,
which should be done according to manufacturer
• Hand washing. The single most effective disease guidelines. Diluent solutions vary; use only the spe-
prevention activity is good hand washing. Hands cific diluent supplied for the vaccine. Once recon-
should be washed thoroughly with soap and water stituted, the vaccine must be either administered
or cleansed with an alcohol-based waterless antisep- within the time guidelines provided by the manu-
tic between patients, before vaccine preparation, facturer or discarded. Changing the needle after
or any time hands become soiled (e.g., diapering, reconstitution of the vaccine is not necessary unless
cleaning excreta). the needle has become contaminated or bent.
• Gloving. Gloves are not required to be worn when Continue with standard medication preparation
administering vaccines unless the person admin- guidelines.
istering the vaccine is likely to come into contact • Prefilling syringes. The CDC strongly discourages fill-
with potentially infectious body fluids or has open ing syringes in advance because of the increased
lesions on the hands. Office policy may require risk of administration errors. Once the vaccine
gloves be worn. It is important to remember that is in the syringe, it is difficult to identify the type
gloves cannot prevent needlestick injuries. or brand of vaccine. Other problems associated
• Syringe selection. A separate needle and syringe with this practice are vaccine wastage and possible
should be used for each injection. A parenteral bacterial growth in vaccines that do not contain
vaccine can be delivered in either a 1-mL or 3-mL a preservative. Furthermore, medication admin-
syringe as long as the prescribed dosage is deliv- istration guidelines state that the individual who
ered. Syringe devices with engineered sharps injury administers a medication should be the one to
protection are available, recommended by the draw up and prepare it. An alternative to prefilling
Occupational Safety and Health Administration syringes is to use filled syringes supplied by the vac-
(OSHA), and required in many states to reduce cine manufacturer. Syringes other than those filled
the incidence of needlestick injuries and potential by the manufacturer are designed for immediate
 CHAPTER 15 Pediatrics 377

administration, not for vaccine storage. In certain two IM vaccines into the same muscle would not
circumstances, such as in large influenza clinics, exceed any suggested volume ranges for either
more than one syringe can be filled. One person the vastus lateralis or the deltoid muscle in any
should prefill only a few syringes at a time, and the age group. The option to also administer a sub-
same person should administer them. Any syringes cutaneous vaccine into the same limb, if neces-
left at the end of the clinic day should be discarded. sary, is acceptable because a different tissue site
Under no circumstances should measles, mumps, is involved. If a vaccine and an immune globu-
and rubella (MMR), varicella, or zoster vaccines lin preparation are administered simultaneously
ever be reconstituted and drawn prior to the imme- (e.g., Td/Tdap and tetanus immune globulin
diate need for them. These live virus vaccines are [TIG] or hepatitis B vaccine and hepatitis B
unstable and begin to deteriorate as soon as they immune globulin [HBIG]), a separate anatomic
are reconstituted with the diluent. site should be used for each injection. The loca-
• Labeling. Once a vaccine is drawn into a syringe, the tion of each injection should be documented in
content should be indicated on the syringe. There the patient’s chart or electronic medical record
are a variety of methods for identifying or labeling (Figure 15-8).
syringes (e.g., keep syringes with the appropriate • Nonstandard administration. Deviation from the rec-
vaccine vials, place the syringes in a labeled parti- ommended route, site, and dosage of vaccine is
tioned tray, use color coded labels or preprinted strongly discouraged and can result in inadequate
labels). protection.
• Multiple vaccinations. When administering mul- • Needle gauge. 22- to 25-gauge needle.
tiple vaccines, never mix vaccines in the same • Needle length. For all IM injections, the needle
syringe unless approved for mixing by the Food should be long enough to reach the muscle mass
and Drug Administration (FDA). If more than and prevent vaccine from seeping into subcutane-
one vaccine must be administered in the same ous tissue, but not so long as to involve underly-
limb, the injection sites should be separated by ing nerves, blood vessels, or bone. The vaccinator
1 to 2 inches so that any local reactions can be should be familiar with the anatomy of the area
differentiated. Vaccine doses range from 0.2 to into which the vaccine will be injected. Decision
1 mL. The recommended maximum volume of on needle size and site of injections must be made
medication for an intramuscular (IM) site varies for each patient based on the size of the muscle,
among references and depends on the muscle the thickness of adipose tissue at the injection site,
mass of the individual. However, administering the volume of the material to be administered,

IPV (SC)
IPV (SC) Varicella (SC)
MMR (SC)

Hib (IM) PCV7 (IM)

PCV7 (IM) DTaP (IM) DTaP (IM) Hep B (IM)

Hep B (IM) Hib (IM)

A B

Figure 15-8 (A) An example of one way to give five doses at one visit. (B) An example of one way to give seven
doses at one visit.
378 UNIT 5 Assisting with Specialty Examinations and Procedures

the injection technique, and the depth below the (60–118 kg), a 1- to 1½-inch needle is needed. For
muscle surface into which the material is to be women weighing more than 200 pounds (90 kg)
injected. or men weighing more than 260 pounds (118 kg),
• Infants (younger than 12 months). For the majority a 1½-inch needle is required.
of infants, the anterolateral aspect of the thigh
is the recommended site for injection because Figure 15-9 gives information on administer-
it provides a large muscle mass. The muscles of ing vaccines.
the buttock have not been used for administra-
tion of vaccines in infants and children because Giving Injections to Pediatric
of concern about potential injury to the sciatic Patients
nerve, which is well documented after injection
of antimicrobial agents into the buttock. If the Infants and toddlers who have injections must be
gluteal muscle must be used, care should be held in such a way that they cannot move. This is
taken to define the anatomic landmarks. If the done for two reasons: to protect the child from
gluteal muscle is chosen, injection should be adminis- injury and to provide access to an injection site.
tered lateral and superior to a line between the poste- For a child from birth to about 2 years of age,
rior superior iliac spine and the greater trochanter or in the vastus lateralis muscle is the preferred site. It is
the ventrogluteal site, the center of a triangle bounded readily accessible when the infant is lying supine
by the anterior superior iliac spine, the tubercle of on the examination table.
the iliac crest, and the upper border of the greater Children who are 2 to about 4 years old
trochanter. are not emotionally developed enough to
understand the need for cooperation. You
• Injection technique. This is the most important fac-
will need help from the parent or another staff mem-
tor to ensure efficient intramuscular vaccine
ber to hold the child securely, thus avoiding injury.
delivery. If the subcutaneous and muscle tissue
The deltoid is the preferred site for this age group.
are bunched to minimize the chance of striking
One method used to restrict the child’s movement
bone, a 1-inch needle is required to ensure intra-
is to seat the child on the parent’s lap. The parent
muscular administration in infants. For the major-
wraps his or her legs around the child’s legs to limit
ity of infants, a 1-inch, 22- to 25-gauge needle is
movement. The parent or staff member holds down
sufficient to penetrate muscle in an infant’s thigh.
the noninjection arm. The injection can be given
For newborn (first 28 days of life) and premature
once the child is securely immobilized.
infants, a 5⁄8-inch needle usually is adequate if the
Keep the syringe and needle out of the
skin is stretched flat between thumb and forefin-
child’s sight, because pediatric patients learn
ger and the needle is inserted at a 90-degree angle
quickly that doctor office visits many times mean
to the skin.
an injection, and with the injection is some
• Toddlers and older children (12 months to 10 years). degree of fear and pain.
The deltoid muscle should be used if the muscle Do not tell the child that the injection will
mass is adequate. The needle size for deltoid site not hurt; rather, explain that it will sting for a short
injections can range from 22 to 25 gauge and from while, but it will help to keep him or her strong
5
⁄8 to 1 inch based on the size of the muscle and the and healthy. A cartoon character adhesive strip
thickness of adipose tissue at the injection site. A applied to the site after the injection helps direct
5
⁄8-inch needle is adequate only for the deltoid the child’s attention away from the discomfort.
muscle and only if the skin is stretched flat between Although the vastus lateralis is the preferred
thumb and forefinger and the needle is inserted site for intramuscular injections, the deltoid is used
at a 90-degree angle to the skin. For toddlers, the for subcutaneous pediatric injections (see Figures
anterolateral thigh can be used, but the needle 15-10 and 15-11).
should be at least 1 inch long. Sick-baby or sick-child visits are appointments
• Adolescents and adults (11 years and older). For that have been arranged for ill babies or children
adults and adolescents, the deltoid muscle is rec- who will be examined by the pediatrician to deter-
ommended for routine IM vaccinations. The mine a diagnosis and appropriate treatment for a
anterolateral thigh can also be used. For men and particular problem.
women weighing less than 130 pounds (60 kg), a Clinical responsibilities for medical assistants
5
⁄8 to 1-inch needle is sufficient to ensure IM injec- during either type of visit include the same or simi-
tion. For women weighing 130 to 200 pounds lar procedures as the adult examination. The instru-
(60–90 kg) and men weighting 130 to 260 pounds ments used for the pediatric physical examination
 CHAPTER 15 Pediatrics 379

Figure 15-9 Administering vaccines: dose, route, site, and needle size. (From the Immunization Action
Coalition, http://www.immunize.org.)
380 UNIT 5 Assisting with Specialty Examinations and Procedures

Figure 15-10 Administering intramuscular injections. The usual site for vaccine administration in infants is the
vastus lateralis muscle of the upper thigh. (From the Immunization Action Coalition, http://www.immunize.org.)

are similar to those used for an adult physical exam- containing compound) has been used as a preser-
ination. Vital signs are taken, visual acuity is mea- vative in multidose vials of vaccine. It was added
sured, a urine specimen may be obtained, blood in very small amounts to kill bacteria that could
may be drawn and processed, height and weight be or were introduced into the multidose vial
measurements are taken, and head circumference is through improper sterile technique when draw-
measured. To gain the child’s confidence, begin the ing the vaccines into a syringe. Fatalities from
examination at the feet and work up to the head. septicemia after vaccine administration using a
These are some of the skills and procedures medical multiple-dose vial have been reported.
assistants will perform or with which they will assist There has been growing concern that the thi-
during the pediatric office or clinic visit. merosal in the vaccine is related to problems such
It is important for the medical assistant to as attention deficit hyperactivity disorder (ADHD),
know that parents may ask about vaccine safety autism, and speech or language delays.
and preservatives. The following information is Many studies have been done over the last
helpful; however, the provider is the best individ- 30 years. The Institute of Medicine, the Immuniza-
ual to answer specific questions parents may have. tion Safety Committee, the FDA, the CDC, and the
Preservatives have been used in vaccines National Institutes of Health (NIH) were involved
for more than 70 years. According to the CDC, throughout the studies. All have determined that
Thimerosol (an organomercurial, i.e., a mercury- there is no relationship between thimerosol and
 CHAPTER 15 Pediatrics 381

Figure 15-11 Administering subcutaneous injections. Subcutaneous tissue can be found all over the body. The
usual sites for vaccine administration are the thigh (for infants) and the upper outer triceps of the arm (for children
older than 12 months). If necessary, the upper outer triceps area can be used to administer subcutaneous injections
to infants. (From the Immunization Action Coalition, http://www.immunize.org.)

neurotoxicity from vaccine administration. The nant women, infants, and children. Perhaps over
latest study in 2004 again investigated the situation time all vaccines will be preservative-free.
and rejected the relationship between thimerosol
and vaccines as a cause of neurotoxicity.
In 2000, the CDC, FDA, NIH, and the THEORIES OF GROWTH
American Academy of Pediatrics (AAP) told the AND DEVELOPMENT
CDC to have thimerosol removed from all vac-
cines or to reduce it to trace amounts as soon as Before providing more indepth information about
possible. There had been a movement by parents the various stages of growth and development in
to remove all the preservatives. Parents still are children, it is important to review the major theo-
involved in ongoing discussion about “reduced rists who contributed to understanding human
to trace amounts” in all routine vaccines for chil- growth and development.
dren 6 years and under. An exception, however, There are at least eight or nine theories of
is inactivated flu vaccine. It contains thimerosol. human development put forth by Freud (psycho-
A limited supply of preservative-free inactivated sexual), Erickson (psychosocial), Sullivan (inter-
flu vaccine is available, but it is used for preg- personal), Piaget (cognitive), Kohlberg (moral),
382 UNIT 5 Assisting with Specialty Examinations and Procedures

Bronfenbrenner (ecology), Pavlov, Skinner (behav- be kept on newborns whenever they are on top of
ioral), and Bandura (social learning). Each theory any object because they can easily roll off. The saf-
focuses on particular aspects of human develop- est place is in a crib with the sides raised.
ment and its principles, strengths, and weaknesses. It is important to note the vital signs at dif-
No single theory can explain human devel- ferent ages will vary according to size, age, and
opment. The medical assistant can apply the the- gender. Comparisons can be made by
ory or theories with relevance and understanding E HR finding values within the electronic med-
to each individual child or adult. This will allow ical record.
for an inclusive approach to human development
that is appropriate for children and families
(Figure 15-12).
Infants
The following sections provide more informa- The infant stage is from 1 month to 1 year. Gross
tion about growth and development at the various and fine motor skills develop starting at the head
stages of a child’s life (Figure 15-13). and moving toward the feet.
The infant usually doubles his or her birth
weight during the first 6 months; by 12 months,
Newborns birth weight has tripled. Height increases about
Even at a few days old, a newborn can imitate facial 1 inch per month. By 12 months, the infant’s height
and manual gestures that adults make and can show a has slowed, and there can be a 50% increase from
preference for certain colors (red, black, and white). the birth length.
The newborn can respond to auditory stimuli and Head size changes quickly to accommodate
is sensitive to being touched and handled. Respira- fast brain growth. By 1 year old, the infant’s brain is
tory rate is usually 30 to 60 breaths/min; breaths about 66% of the size of an adult brain, but growth
are somewhat irregular in depth and rhythm, shal- does slow during the second 6 months of the first
low and abdominal. The heart rate ranges from 110 year. The fontanels (anterior and posterior) close
to 130 beats/min depending on whether the infant by 2 months old (anterior) and 12 to 18 months
is awake or asleep. Urinary output is about 1 to old (posterior). The infant cannot control head
3 mL/hour or about 2 to 6 voidings a day. movement until about 4 months old. This is known
Newborns can move and wiggle and as “head lag,” and the amount of head lag can be
can place themselves into dangerous or determined by pulling the infant by the arms from
unsafe positions. One hand should always a supine to a sitting position. Because the infant
cannot control the head, it will fall back until about
4 months old, at which time the infant has no head
Ps

lag and can control the head while sitting.

e

yc
tiv

ho

Gross and fine motor development occurs

ec

an
sp

l
d) exua

al

quickly during the infant stage, but once devel-

r

So andu
Pe

yt
(B

ic
cia ra

oped, the infant can begin to walk, first with help,

al

(Fr chos

Pe
or

ial
lL )

r
vi

then alone. By 1 year old, in addition to being able

sp

oc
ha

ea

eu
y

ec

s
Be

Ps

ho ) to walk alone, the infant can feed himself or herself

rni

tiv

yc on
e

Ps riks
ng

finger foods, grasp with his or her index finger and

(E
Behaviorism Interpersonal
thumb, place and remove small objects from a con-
(Pavlov, Skinner) (Sullivan) tainer, and hold a crayon and make a mark with it.
The medical assistant can be helpful in relay-
ing information to the infant’s parents or caregiv-
Cognitive ers regarding growth and development, nutrition,
Ecology (Piaget) hygiene, safety, and vaccines.
(Bronfenbrenner)
Moral
C

Toddlers
ra
on

(Kohlberg)
ive u
ct uct
te
xt

pe tr
ua

The toddler period covers 2 years in the child’s life

rs -S
lP

Pe itive

from about 1 to 3 years of age. During the toddler

er

n
sp

og

period, there is rapid change. The child is becom-

ec

C
tiv

ing more independent, is able to move about

e

Figure 15-12 The eclectic nature of human devel- quickly, and is verbal and inquisitive. Environmen-
opment. tal dangers are of utmost concern because of the
 CHAPTER 15 Pediatrics 383

0 to 2 months 2 to 3 months 3 to 4 months

4 to 6 months 6 to 9 months 9 to 12 months

12 to 16 months 16 to 20 months 20 to 24 months

Figure 15-13 Growth and development stages of infants and toddlers.

toddler’s rapid development of motor skills and walk by 12 to 15 months old and climb stairs by
lack of judgment. This is a time for discipline and 18 months old.
guidelines but also for encouraging independence Bladder and bowel control usually occur dur-
and natural curiosity. Most injuries and deaths ing this period. Vital signs move closer to adult
occur as a result of airway obstruction, poisoning, norms, respiration (25–30 breaths/min awake) and
drowning, falls, burns, and auto accidents. pulse rates (96–105 beats/min) slow, and blood
During the 2 years that the toddler is devel- pressure increases to greater than 90/50 mm Hg.
oping, his or her physical growth slows. Height Serum lead levels are checked during this time.
gain averages about 3 inches per year; weight It is during the toddler period that rapid onset
gain is about 5 pounds per year. Most toddlers of respiratory distress can occur, and there is an
384 UNIT 5 Assisting with Specialty Examinations and Procedures

increase in tendency for airways to collapse. Otitis profile. This age group suffers from otitis media,
media, tonsillitis, and upper respiratory infections upper respiratory infections, and common stom-
are common. ach viruses. Teaching children the importance of
Often parents or caregivers are concerned good hand washing techniques and its significance
their toddlers are eating little or they focus only on in preventing illness is important.
one particular food. Most toddlers eat when they Some preschoolers may refuse to eat for a few
are hungry and caregivers worry unnecessarily. days or prefer one particular food everyday. Par-
The toddler is less interested in food because of his ents and caregivers should avoid issues over these
or her slowdown in growth, thus fewer calories are matters. Instead, spend mealtimes in a pleasant
needed. way.
Eating habits are established during the first Regular physical activity is beneficial because
2 to 3 years of life, and good eating habits with chil- it helps develop lifetime habits of exercise, lead-
dren should start when they are toddlers. The early ing to disease prevention and health promotion.
years are the time to teach lifelong healthy eating Sports are an ideal way to get preschoolers active
habits together with regular exercise. These two and to have fun. Noncompetitive activities such as
factors will significantly add years and quality of life dance, T-ball, karate, gymnastics, and bicycling also
because of disease prevention and maintenance keep children active and healthy. Love of reading
of health. Many children in the United States are can be established now, especially when parents/
obese, perhaps because their parents are. A 2004 caregivers read to their youngsters.
study reported in Annals of Human Biology found Playing near the road is an area of great con-
that almost half of children who were overweight cern for these children. They will listen to adults
at 1 year old were obese by 21 years old. The earlier who set limits for their safety.
that one can prevent obesity, the healthier one’s
children will be. Parents are their children’s role
models.
School-Aged Children
The school-aged group encompasses children
from 6 to 12 years of age. A steady progression in
Preschoolers children’s rate of growth occurs during these years.
The preschool years include ages 3 to 6 years. The Weight increases by about 5 pounds per year, and
child now has control over bowel and bladder, can height increases about 2 inches per year. Muscle
dress and feed himself or herself, and can interact size increases, and the following motor skills con-
with others. During this period, preschoolers gain tinue to improve: climbing, running, jumping,
about 2 pounds of weight per year and 3 inches throwing, catching, and balancing.
in height per year. Visual acuity rates decrease The circulatory and respiratory functions
slightly. develop. The pulse and respiration rates slow. The
The Denver Developmental Screening Test pulse rate in this age group is about 90 beats/min;
can be used to determine motor skills develop- the average respiration rate is about 20 breaths/
ment levels. Running, jumping, skipping, jumping min. Both rates are while the children are at rest.
rope, and bike riding with training wheels usually This period shows relatively few infectious dis-
occur in this time period. Preschoolers may begin eases because of the immunity the children devel-
to tie shoelaces. oped to microorganisms during their preschool
Sexual curiosity is displayed, and questions years.
about body parts, including genitalia, should be The last years of the school-aged period are
answered honestly. Children learn at this age that known as prepuberty. Breast development, axil-
“private” body parts should not be touched by lary and pubic hair, and body odor may appear as
strangers. early as 9 or 10 years of age.
Preschoolers learn through play and by imi- Peers begin to play a major role, and children
tating adult behaviors. It is now that children will seek support from their peers to begin gaining inde-
play well with others and share. Preschoolers are pendence from their parents and family. Children
creative and use their imaginations well. have a sense of accomplishment when they focus
During preschool years, a yearly physical their energy on sports, hobbies, and schoolwork
examination should be done to note growth, and see themselves succeed in these activities.
vision, hearing, and blood pressure. Laboratory Language is the way to communicate, and
work includes a test for lead exposure, a tuberculo- children use their language skills to socialize with
sis test (once before beginning school), and a lipid their family and peers.
 CHAPTER 15 Pediatrics 385

Usually school-aged children experience excel- body temperature than boys; girls’ systolic blood
lent health, and when they do become ill, it is usu- pressure is a bit less. Respiration rates in both sexes
ally a minor illness. The AAP recommends routine average about 16 to 20 breaths/min.
physical examinations about every 2 years, at ages Adolescents direct their energy to nonfamily
5, 6, 8, 10, 11, and 12 years old. Height, weight, vital relationships and career goals. It is a time of con-
signs, physical examination, vision and hearing tests, flict as adolescents try to become independent from
review of nutrition, scoliosis screening, and tubercu- their parents and establish their own identities.
losis testing are checked. Use of recreational drugs, The Department of Adolescent Health of the
tobacco, and alcohol is addressed. American Medical Association urges annual health
Booster immunizations of DPT (diphtheria, screenings that focus not only on the physiologi-
pertussis, tetanus) and MMR (measles, mumps, and cal and psychological health of the adolescent,
rubella) are typically given between 4 and 6 years of but also on such matters as physical activity, birth
age. Tetanus and diphtheria (Td) is usually repeated control, recreational drugs, alcohol, depression,
every 10 years. suicide ideation, injury prevention, and school
Nutrition education is an ongoing process accomplishments.
and children should be taught to eat breakfast Laboratory tests include human immuno-
daily and to make intelligent, healthy food choices. deficiency virus (HIV) and other sexually
Good nutrition and physical activity are essential transmitted diseases (gonorrhea, syphilis,
for their physical and emotional well-being and for chlamydia, and hepatitis B and C if sexually
long-range health maintenance and disease pre- active). Tuberculosis testing is also recommended.
vention. The physical examination is comprehensive and
Accidents in this age group are the leading includes vital signs, height and weight, vision and
cause of death. The increased independence, need hearing testing, urinalysis, and complete blood
for their peer’s approval, and increased involve- count (CBC). At this time, the provider discusses
ment in physically challenging activities are some issues of injury prevention (wearing seat belts, hel-
of the reasons. Most injuries are related to auto mets for biking, no drinking and driving, contact
accidents and firearms. Violent crimes against chil- sports, among others), violence prevention (gang
dren in this age group have increased dramatically memberships and anger management), nutrition
in the last 20 years. (fast foods, high-sodium and fatty foods), how
School-aged children comprehend rules to avoid becoming overweight and obese, and
about safety with regard to automobiles, bikes, regular physical activity. Motor vehicle accidents
swimming, and firearms, but they frequently resist cause 50% of teenage deaths between ages 16 and
these rules. 19 years, and they are common in drivers who use
This group of children suffers from not looking alcohol or other drugs.
the “same” as their peers, bullying, stress (peer pres- To be effective at all stages of growth and
sure, divorce, drugs), and both parents/caregivers development, the medical assistant must under-
working and not being home when the children go stand the age and maturity level of pediatric
home after school (latchkey children). patients, the psychological changes that occur,
and the psychosocial aspects of the child at various
ages.
Adolescents Communication with pediatric patients
The adolescent period of growth and development needs to be individualized, showing accep-
is noticeable for its wide range of physiological tance, empathy, honesty, and openness.
changes. It is the period between 11 and 21 years Confidentiality must be maintained regard-
of age. During adolescence, there is a large growth HIPAA less of age. Parents and caregivers are
spurt with gains in weight and height that occur involved with the care of their youngsters;
rapidly. Boys can gain up to about 14 pounds and therefore, they have the legal right to know the
grow as much as 6 inches; girls gain up to about medical matters relating to their minor children.
10 pounds and grow up to 5 inches. Girls usually Adolescents may share information with the medi-
attain their adult height about 1 year before onset cal assistant that they do not want their parents or
of menses; boys reach their adult height at about caregivers to know. It is important to stress that
13 years old, after axillary and pubic hair appear. some matters may need to be shared with parents
The average heart rate is about 60 to 70 beats/ or caregivers, especially when adolescents are living
min; average blood pressure is 100/50 to 120/ at home (certain matters pertaining to birth con-
70 mm Hg. Girls have a slightly higher pulse and trol, abortion, pregnancy, and sexually transmitted
386 UNIT 5 Assisting with Specialty Examinations and Procedures

diseases pose special problems). Some states allow tiles of other children the same age. To determine
minors to give their consent under these circum- into which percentile the infant falls in relation to
stances (see Chapter 7). other infants of the same age, follow the line (per-
Medical assistants can teach parents and care- centile) upward to the percentage values along the
givers in various ways. Handouts, demonstrations, edge of the graph. The National Center for Health
videos, and one-on-one instruction are helpful in Statistics (NCHS) growth charts become a perma-
keeping children safe and healthy. nent record of the child’s development. These give
The medical assistant must be caring, the provider a quick way to check the child’s growth
respectful, supportive, and nonjudgmental in relation to that of other children the same age.
of all patients. The caregiver to pediatric Growth charts aid in the diagnosis of growth abnor-
patients must reflect these values. Family beliefs malities and nutritional disorders and disease.
and values also must be taken into account. This Hereditary factors also influence growth patterns;
will foster care for pediatric patients that is compli- therefore, having the family’s history is important.
ant and in the best interest of all.
Infant Holds and Positions
GROWTH PATTERNS Lifting and carrying infants must be done safely.
The medical assistant should be especially careful
Growth patterns provide valuable information to of the infant’s neck. It should be supported when-
the pediatrician regarding the infant’s physical ever the infant is lifted or held. About the age of
progress. They are also used to calculate pediat- 4 months, an infant begins to be able to hold up its
ric doses of medication. Height, weight, and head head without support. (Each infant’s growth and
circumference are measured at each regularly development is unique; therefore, 4 months is an
scheduled appointment at the pediatric facility. approximate age.)
The measurements are then plotted on a physical There are two primary positions that the
growth percentile chart that is part of the patient’s medical assistant uses when lifting or carrying an
permanent record (Figure 15-14). infant. The first is the upright position in which
the anterior surface of the infant’s body is held
against the medical assistant’s body with one hand,
MEASURING THE INFANT which supports the infant’s buttocks. The other
OR CHILD hand is placed behind the head and neck of the
infant for support (Figure 15-16). This position
Careful measuring of the infant or child and moni- can be used to carry the infant and to place him or
toring of growth patterns are essential and should her on the scale or examination table. The second
be done in a consistent and accurate manner. position is called the cradle position; the medical
assistant holds the infant under his back and neck
with one arm, and the other arm supports the but-
Length and Weight Measurements tocks and legs (Figure 15-17). This position is com-
To record or plot length and weight measure- monly used by mothers when feeding their babies.
ments, you must first locate one growth value, It is comforting to infants when they are able to
either length or weight, in the vertical columns see the parent or the familiar person. A third posi-
of the physical growth percentile chart shown in tion that is used less often is the “football” carry or
Figure 15-15. Find the child’s age in months in the position. The posterior of the infant lays across the
horizontal rows. Locate the area where the growth medical assistant’s dominant outstretched arm and
value lines intersect on the graph and plot the hand, and the infant’s legs straddle the medical
length and weight by marking with a dot. Connect assistant’s arm. The medical assistant supports the
dots from previous values with a ruler to provide head, neck, and back of the infant with the domi-
a neat and accurate graphic recording. The date, nant hand and arm and keeps the infant close to
age, measurements, and comments should also be the body (Figure 15-18). If transporting the infant
indicated at the bottom of the chart. in this position, the medical assistant uses the non-
The curved lines printed across the growth dominant hand to protect the back and top of the
charts show the normal range of growth of infants infant’s head. When the medical assistant is station-
and children in the United States. The numbers ary, the nondominant hand can be used if needed.
on the right side of the chart, in the vertical boxes When done properly, this position keeps the infant
between age 34 and 35 months, show the percen- safe and secure.
 CHAPTER 15 Pediatrics 387

Birth to 36 months: Girls NAME Birth to 36 months: Boys NAME

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

Birth 3 6 9 12 15 18 21 24 27 30 33 36 Birth 3 6 9 12 15 18 21 24 27 30 33 36
in cm cm in in cm AGE (MONTHS)
cm in
AGE (MONTHS)
41 41 41 41 L
L
40 40 E 40 95 40 E
100 95 100 100 90 100 N
39 90 39 N 39 39
75 G
38 G 38 38
75 38 95 T
95 95 T 50 95
37 50 37 37 37 H
H 25
36 25 36 36 36
90 90 90 10 90
35 10 35 35 5 35
5
34 34
85 85
33 33
32 38 32 95 38
80 95 17 80 17
31 31
L 90 36
L 30 36 30
E 75 90 16 E 75 16
29 N
29
N 34 34
28 75
G 28 G 70 15
70 75
15
T 27 T 27
32 32
H H 26
26 65 65 50
14
14
25 50 30 W 25 30 W
24 E 24 25 E
60 13 60 13
I 23 28 I
23 25 28
G 10 G
22 12 22 55 12 H
55 10 H 5 26
21 26 21 T
5 T
20 50 20 50 11
11 24 24
19 19
18 45 10 22 18 45 10 22
17 17
16 40 20 16 40 9 20
9
15 15
18 8 18
8

16 16 16 16
7 AGE (MONTHS) 7 AGE (MONTHS)
kg lb kg lb
12 15 18 21 24 27 30 33 36 12 15 18 21 24 27 30 33 36
14 14
Mother’s Stature Gestational 6 Mother’s Stature Gestational
W
6 W
Father’s Stature Age: Weeks Comment Father’s Stature Age: Weeks Comment
E 12 E 12
Date Age Weight Length Head Circ. Date Age Weight Length Head Circ.
I 5 I 5 Birth
Birth G
G 10 10
H H
4 T
4
T 8
8
3 3
6 6

2 2
lb kg lb kg
Birth 3 6 9 Birth 3 6 9
Published May 30, 2000 (modified 4/20/01). Published May 30, 2000 (modified 4/20/01).
SOURCE: Developed by the National Center for Health Statistics in collaboration with SOURCE: Developed by the National Center for Health Statistics in collaboration with

A the National Center for Chronic Disease Prevention and Health Promotion (2000).
http://www.cdc.gov/growthcharts B the National Center for Chronic Disease Prevention and Health Promotion (2000).
http://www.cdc.gov/growthcharts

2 to 20 years: Girls NAME 2 to 20 years: Boys NAME

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

12 13 14 15 16 17 18 19 20 12 13 14 15 16 17 18 19 20
Mother’s Stature Father’s Stature cm in Mother’s Stature Father’s Stature cm in
Date Age Weight Stature BMI*
AGE (YEARS) 76 Date Age Weight Stature BMI*
AGE (YEARS) 76
190 95
190
74 74
90
185 S
185 S
72 75
72
180 T 180 T
70 A 50 70 A
95
175 T 175 T
90
68 U 25 68 U
170 R 170 R
75 66 10 66
165 E 165 E
in cm 3 4 5 6 7 8 9 10 11 50
in cm 3 4 5 6 7 8 9 10 11 5
64 64
160 25 160 160 160
62 62 62 62
155 10 155 155 155
60 5 60 S 60 60
150 150 T 150 150
58 A 58
145 T 145
56 U 56
140 105 230 140 105 230
R
54 54
S 135 100 220 E 135 100 220
T 52 52
A 130 95 210 130 95 95 210
50 50
T 125 90 200 125 90 200
U 90
48 190 48 190
R 120 85 120 85
E 95 180 46 180
46
115 80 115 80
75
44 170 44 170
110 90 75 110 75
160 42 160
42
105 70 105 50 70
150 W 150 W
40 75
40
100 65 140 E 100 65 140 E
25
38 I 38 I
95 60 130 G 95 60 130 G
50 10
36 H 36 90 5 H
90 55 120 55 120
25 T T
34 34 50 110
85
10
50 110 85
32 80
5
45 100 32 80 45 100
30 30
40 90 40 90
80 80 80 35 35 80
35 35
W 70 70 W 70 70
30 30 30 30
E 60 60 E 60 60
I 25 25 I 25 25
G 50 50 G 50 50
H 20 20 H 20 20
40 40 40 40
T T
15 15 15 15
30 30 30 30
10 10 10 10
lb kg AGE (YEARS) kg lb lb kg AGE (YEARS) kg lb
2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
Published May 30, 2000 (modified 11/21/00). Published May 30, 2000 (modified 11/21/00).
SOURCE: Developed by the National Center for Health Statistics in collaboration with SOURCE: Developed by the National Center for Health Statistics in collaboration with

C the National Center for Chronic Disease Prevention and Health Promotion (2000).
http://www.cdc.gov/growthcharts D the National Center for Chronic Disease Prevention and Health Promotion (2000).
http://www.cdc.gov/growthcharts

Figure 15-14 (A) Growth chart for girls’ height and weight, age birth to 36 months. (B) Growth chart for boys’
height and weight, age birth to 36 months. (C) Growth chart for girls’ height and weight, age 2 to 20 years.
(D) Growth chart for boys’ height and weight, age 2 to 20 years. (Note that the growth charts shown in (A) and
(B) provide space at bottom right of chart for date, age, weight, length and head circumference.) (Courtesy of the
Centers for Disease Control and Prevention.)
388 UNIT 5 Assisting with Specialty Examinations and Procedures

9-15-XX 7¼ 18” 13¾” mp

12-15-XX 3mo 12 23½” 15½” mp
3-10-XX 6mo 15 26” 17” mp
6-8-XX 9mo 18½ 28” 17¾” mp

Figure 15-15 Sample growth chart with information plotted at birth, 3, 6, and 9 months. Sections in this figure
are highlighted to help you locate the values: length (yellow), weight (pink), age (green), and percentiles (white).
(Courtesy of the Centers for Disease Control and Prevention.)
 CHAPTER 15 Pediatrics 389

Figure 15-17 Infant carry—cradle.

Figure 15-16 Infant carry—upright.

Figure 15-19 Infants who are able to sit and small

Figure 15-18 Infant carry—football. children can be weighed on a platform scale.

Height and Weight Measuring should be placed on the scale before weighing the
infant or child, to avoid the transfer of microorgan-
Devices isms from bare skin. (The scale is sanitized and dis-
Various devices are available for measuring height infected between patients.)
and weight in children. Infants and small children Infant length can be measured using an
are weighed on an infant platform scale, which pro- infant measuring board, which consists of a
vides a measurement in pounds and ounces and rigid headboard and movable footboard. Place
kilograms and grams (Figure 15-19). The scale has the measuring board on a table and position
a platform with curved sides in which the child may the infant on his or her back on the board, with
sit or lie. Weigh the infant or child in as few clothes the head touching the headboard. Move the
as possible, removing the diaper and shoes or slip- footboard up until it touches the bottom of the
pers. A small sheet, cloth diaper, or paper towel infant’s feet (Figure 15-20).
390 UNIT 5 Assisting with Specialty Examinations and Procedures

placed on the platform before use to avoid the

potential transmission of microorganisms from
bare feet.

Measuring Head
Circumference
Head circumference measurement is routinely
recorded on an infant’s chart to alert the pro-
vider to any abnormal development. This proce-
dure should be performed during routine visits
until the child is 36 months old. Thereafter, it
should be measured on a yearly basis until the
age of 6 years. Head circumference measure-
Figure 15-20 Measuring the recumbent length of an
ment requires a flexible paper or metal mea-
infant, from the vertex of the head to the heel.
suring tape. A cloth tape may stretch and give
a false measurement. Head circumference is
An infant can also be measured on a pad by plotted similarly to height and weight but on
placing a pin into the pad or making a pencil mark separate growth percentile charts for head mea-
at the top of the head and a second pin or mark surements (Figure 15-22). Generally, head and
at the heel of the extended leg. The length is the chest circumference are equal at about 1 to
distance between the two pins. A tape measure can 2 years of age. Rapid growth above the normal
also be used. NOTE: 1 inch = 2.54 cm. percentile may indicate hydrocephalus, a disor-
A stature-measuring device can be used to der in which excessive fluid accumulates around
measure height once the child is able to stand erect the brain causing an increase in intracranial pres-
without support. The device consists of a movable sure and possible brain damage. This could lead
headpiece attached to a rigid measuring bar and to mental and physical problems. Conversely, the
platform (Figure 15-21). A paper towel should be growth of the head that falls below the normal
percentile may indicate microencephaly caused
by a premature closure of the fontanels. In this
instance, there is not enough room for the devel-
opment of the brain, and mental retardation
can result. Head circumference for a newborn
should be between 12.5 and 14.5 inches or 31.75
and 36.83 cm.

Measuring Chest
Circumference
Measuring the chest circumference of an infant
is not normally performed during routine exami-
nations. It may be performed and monitored
when there is a suspicion of overdevelopment or
underdevelopment of the heart or lungs or cal-
cification of rib cartilage. To measure the chest
of an infant, snugly wrap the measuring tape
around the chest at nipple level. It is preferable to
read the measurement during the resting phase
between respirations.
Occasionally it is necessary for the medical
assistant to convert measurement results into inches
or centimeters. To accomplish the task accurately,
note that 1 inch equals 2.54 cm. (Procedure 15-3
gives steps for measuring infant chest and head cir-
Figure 15-21 Measuring height in children. cumference, weight, and height.)
 CHAPTER 15 Pediatrics 391

A B
Figure 15-22 (A) Growth chart for girls’ head circumference, birth to 36 months. (B) Growth chart for boys’ head
circumference, birth to 36 months. (Courtesy of the Centers for Disease Control and Prevention.)

Example: will not grow, because of lack of growth hormone

production. Once this child is given physical and
To convert inches to centimeters, multiply the number
of inches by 2.54:
emotional warmth, the growth hormone is pro-
Inches × 2.54 = Centimeters
duced and the child will grow. Other reasons for
an infant failing to thrive may be because the
infant has a chronic disease; has a diet that is inad-
Example: equate especially in calories and proteins; has
a disorder of the heart, brain, or kidneys; or has
To convert centimeters to inches, divide the number of been improperly fed.
centimeters by 2.54:
Centimeters ÷ 2.54 = Inches
PEDIATRIC VITAL SIGNS
As with older children and adults, pediatric vital
Infant/Child Failure to Thrive signs are commonly taken by the medical assistant.
The failure of an infant or a child to grow and The vital signs are more fully covered in Chapter
thrive may have many organic and inorganic 12 for adult patients; however, specific procedures
causes. There may be social and emotional causes. for taking an infant’s temperature, pulse, respi-
Many causes an infant or a child failing to grow ration, and blood pressure are explained here.
and thrive may be treated if found in time. The These procedures are done differently for infants
emotionally deprived infant needing affection than for older children and adults.
392 UNIT 5 Assisting with Specialty Examinations and Procedures

place until beep is heard. This route is not used if

Temperature accuracy is critical.
Body temperature may be measured in Fahr-
enheit (F) or Celsius (C) degrees through oral, Temporal Artery Temperature. Chapter 12 pro-
rectal, axillary, or tympanic routes. Many types vides information and the procedure for taking a
of thermometers are used. Mercury (glass) ther- temperature using a temporal artery thermometer
mometers have been replaced in ambulatory care (TAT). Temporal artery thermometers are used
areas and offices by digital thermometers, elec- almost exclusively.
tronic thermometers, tympanic membrane sen-
sors (aural), and temporal artery thermometers,
which provide accurate temperature readings in
Pulse
less time. Broken mercury thermometers release The apical pulse is heard at the apex of the heart,
vapors into the air that are toxic when inhaled located at the fi fth intercostal space left side,
and lead to mercury poisoning. They should not midclavicular line, that is, between the fi fth and
be used. Proper disposal of mercury is regulated sixth ribs in the middle of the clavicle (usually
by the health department and varies from state to below the nipple), left of the sternum. A stetho-
state. Electronic and digital thermometers can dis- scope is required to obtain an apical pulse. The
play temperature within 15 to 60 seconds, depend- apical pulse is generally preferred over pulses
ing on the model used. A reading can be obtained from other locations for infants and small chil-
by infrared tympanic membrane and temporal dren (younger than 5 years). Each “lub-dub”
artery sensor in a matter of seconds (see Proce- sound is counted as one heartbeat. The pulse is
dure 15-3). counted for 1 full minute (see Procedure 15-4).
The normal pulse rate varies with age,
Oral Temperature. The oral route is used for chil- decreasing as the child grows older (Table 15-2).
dren older than 5 years. Caution the child against The heart rate may also vary considerably among
biting down on the thermometer. Do not take children of the same age and size. The heart rate
an oral temperature if the child has a history of increases in response to exercise, excitement, anx-
seizures. iety, and fever and decreases to a resting rate when
the child is still.
Aural Temperature. The aural route uses the Listen to the heart rate, noting whether the
tympanic membrane thermometer. It is used heart rhythm is regular or irregular. Children
on children older than 2 years because it is con- often have a normal cycle of irregular rhythm
sidered less accurate for children younger than associated with respiration called sinus arrhyth-
2 years. Otitis media and impacted cerumen mia. In sinus arrhythmia, the child’s heart rate
are two other reasons why this route may not be is faster on inspiration and slower on expiration.
selected. A reading can be obtained in a matter Record whether the pulse is normal, bounding,
of seconds. or thready.

Rectal Temperature. Rectal temperatures may

be taken with caution in infants and toddlers Table 15-2 Normal Heart Rate Ranges for
when other methods or routes are not advised. Children
Place the child supine, with the knees flexed. An
infant can also lie prone on a parent’s lap. Do not Heart Rate Range
force the thermometer. Rectal temperatures are Age (beats/min)
not indicated for children who have had rectal
surgery or for those who have diarrhea (see Pro- Newborns 130–140
cedure 15-4).
Infants to 2 years 110–130
Axillary Temperature. Axillary temperatures are
2 to 6 years 96–115
often preferable to rectal or oral temperatures for
toddlers and preschoolers because they are safe 6 to 10 years 70–110
and nonintrusive to take. Place the probe of the
digital thermometer in the axillary space and have 10 to 16 years 60–100
the child hold the arm close to the trunk. Leave in
 CHAPTER 15 Pediatrics 393

for the pulse. Keeping your fingers on the pulse,

Respirations pump up the cuff until the pulse is no longer felt.
In older children and adolescents, respiratory Slowly open the air valve, watching the dial, and
rate is counted in the same way as in an adult. In note the number where the pulse is again palpated.
infants and children younger than 6 years, how- This is called the palpated systolic blood pressure
ever, the respiratory rate is assessed by observing (Table 15-4).
the rise and fall of the abdomen. Inspiration,
when the chest or abdomen rises, and expiration,
when the chest or abdomen falls, are counted COLLECTING A URINE
as one respiration. Because these movements SPECIMEN FROM AN INFANT
are often irregular, they should be counted for
1 full minute for accuracy. Normal respiratory Occasionally the medical assistant is required to
rate varies with the child’s age (Table 15-3; see obtain a urine specimen from an infant for labo-
Procedure 15-6). ratory testing. Special procedures and equipment
are required for this procedure. The collection
bag is clear plastic with adhesive tabs (clean catch
Blood Pressure bag) for application to the perineum of the infant
The blood pressure of an infant is not normally (Figure 15-23; see Procedure 15-7).
taken unless requested by the provider. In children The clean catch bag has been a popular
3 years of age and older, blood pressure should be way to obtain a clean catch specimen for urinal-
measured annually as part of a routine vital sign ysis in pediatric patients. The urinalysis is essen-
assessment. tial to the provider’s work-up of the patient. Not
Blood pressure can be measured using elec- only is it time-consuming to wait for a child to
tronic or aneroid equipment and a pediatric cuff. void, but many times the bag is empty. There are
The size of the blood pressure cuff is determined risks of contamination of the specimen by the
by the size of the child’s arm or leg. A general rule bag method. According to The Internet Journal of
of thumb is that the width of the inflatable bladder Emergency Medicine, a procedure known as direct
should be 40% of the circumference of the extrem- urethral bladder catheterization is the preferred
ity used. If the cuff is too small, pressure will be method for obtaining a sterile urine specimen. A
falsely high; if too large, falsely low. Sometimes it is very small catheter (5 French) is used. Using ster-
difficult to hear the blood pressure in an infant or ile technique, the catheter is inserted through the
small child. Use a pediatric stethoscope over pulse urethra into the bladder of the pediatric patient.
sites if possible. The procedure used on an infant or child is the
If the pulse still cannot be auscultated, the same as the procedures for performing a uri-
blood pressure can be measured by touch. Palpate nary catheterization on a male or female patient
described in Chapter 18. Catheterization of a
pediatric patient in order to obtain a sterile urine
specimen is an invasive procedure performed by
Table 15-3 Normal Respiratory Rate a licensed provider. A California study confirmed
Ranges for Children

Age Respiratory Rate (breaths/min) Table 15-4 Normal Blood Pressure Ranges
for Children
Newborn 30–60
Systolic
1 year 20–40 Age (mm Hg) Diastolic (mm Hg)

3 years 18–30 3 years 110 65

6 years 18–30 6 years 110 65

10 years 12–20 10 years 118 75

17 years 12–20 17 years 118 75

394 UNIT 5 Assisting with Specialty Examinations and Procedures

until the light is removed. Older infants will follow

an object up and down when it is placed directly
in front of the eyes. It is estimated that a newborn
has the vision equivalent to 20/150, which will reach
the adult level of 20/20 by the age of 6 months.
The medical assistant will be required to maintain
a nonstimulating environment while the provider is
screening the infant, because any interference may
invalidate results.
The kindergarten chart or Allen cards are
used to test visual acuity in young children. It con-
tains pictures in descending size, and the lines are
labeled in the same manner as the Snellen Chart.
The child is asked to identify the picture as the
medical assistant points to it (Figure 15-24).
The E chart is a series of Es pointing in different
directions in descending size. The size and labeling
Figure 15-23 Pediatric urine collector. The col- are the same as the Snellen chart. This chart is used
lector is opened, and the paper backing is removed, for older children. The child will be asked to point in
exposing the adhesive surface. The collector is firmly the direction of the E as the medical assistant points
attached over the child’s cleansed genitalia to prevent to it (Figure 15-25).
leakage. Make a game out of measuring young chil-
dren’s visual acuity because their attention span is
very limited.
that catheterization is safe and effective particu-
larly in the emergency department when a pediat-
ric patient has a fever and symptoms of a urinary COMMON DISORDERS
tract infection. AND DISEASES
Young children grow and physically change very
SCREENING INFANTS quickly. Their immune systems develop normally
FOR HEARING IMPAIRMENT when they are healthy infants and children.

In some hospitals, infants are screened for hear-

ing impairment immediately after delivery. An
automated system for checking hearing ability is
used by some clinics. It is a more complex screen-
ing requiring the use of sensors. As the infant
moves in response to sounds produced by the
system, these responses are recorded by sensors
attached to the infant. The procedure is a more
definitive screening process. The medical assis-
tant must maintain a quiet environment while
these screening procedures are being performed
because extraneous sounds may invalidate the
results.

SCREENING INFANT
AND CHILD VISUAL ACUITY
Measuring the visual acuity of an infant is difficult
and is not usually performed unless visual impair-
ment is suspected. Newborns will respond to light by Figure 15-24 Measuring distance visual acuity of a
tightly shutting their eyes and keeping them closed child using a kindergarten vision screening chart.
 CHAPTER 15 Pediatrics 395

Otitis Media
Otitis media is a commonly occurring disorder in
infants and young children. It is characterized by
inflammation of the middle ear. Fluid accumu-
lates behind the tympanic membrane, resulting
in a degree of temporary hearing loss. It is com-
monly known as a middle ear infection. Because
of the infant and young child’s eustachian tubes’
connection to the nose and throat, bacteria that
causes throat and respiratory infections can easily
access the inner ear via the eustachian tube. The
fluid in the middle ear can become infected by
the bacteria present in the nose and throat. The
fluid turns to pus and is known as suppurative oti-
tis media. Pain and loss of hearing are common
symptoms. Many young children have eustachian
tubes that are horizontal and narrow, which pre-
disposes them to otitis media. As children develop
physically, they can outgrow otitis media.
The provider can diagnosis otitis media by visu-
ally examining the tympanic membrane with an oto-
scope. The membrane will be bulging and appear
red and inflamed (Figure 15-26). If exudate or an
oozing of pus is present, a culture and sensitivity can
be done. The treatment for otitis media is antibiot-
ics. To prevent antiobiotic overuse and pathogen
resistance, providers attempt to prescribe antibiotic
therapy only when necessary. Decongestants are
helpful in some children. For chronic otitis media,
a myringotomy, incision into the tympanic mem-
brane, may be necessary to prevent rupture of the
tympanic membrane and the scarring that results.
Scarring can cause permanently impaired hearing
ability.
Tympanostomy is a surgical procedure in
which pediatric ear tubes are placed through the
tympanic membrane to promote ongoing drain-
age. Chronic otitis media that is left untreated can
result in permanent hearing loss.
Hearing loss causes serious major problems in
a child’s development. Treatment of hearing loss
depends on its cause. Hearing aids may be helpful
Figure 15-25 Snellen E or Big E chart for testing dis-
to amplify sounds if the loss is caused by sounds
tance visual acuity of children.
not being conducted to the inner ear. Sensorineu-
ral hearing loss does not improve with hearing
aids. Cochlear implantation, approved by the FDA
since 1990, is a procedure that can help children
Immunizations, together with their own develop- with bilateral sensorineural deafness.
ing immune system, give them protection from
dangerous childhood diseases. Many life-threat-
ening illnesses have been controlled because of
The Common Cold
scheduled immunization, the child’s own devel- The common cold is aptly named because it is
oping immune system, and the wise use of antibi- the most common and frequent disease that
otics for infections. young children experience. Viruses are the usual
396 UNIT 5 Assisting with Specialty Examinations and Procedures

A B

Figure 15-26 Comparison of (A) normal tympanic membrane and (B) acute otitis media.

microorganisms that cause a cold, and they are

spread by direct contact and droplets through
Asthma
the air when children cough and sneeze. Some Asthma has increased dramatically in the general
symptoms are inflammation of the nasopharynx, population but especially in children. The cause of
coughing, nasal discharge, sneezing, and fever. asthma is not known, but it can be brought on by
Treatment consists of getting sufficient rest, forc- environmental substances, such as pollen, chemi-
ing fluids, and eating a well-balanced diet. Anti- cals, cigarette smoke, mold, and dog and cat hair.
biotics are not helpful. Its symptoms include wheezing, coughing, and
shortness of breath. It is a serious chronic respira-
tory disease. Spasms of the bronchi trap air and
Tonsillitis mucus in the lungs. The child will complain of a
The tonsils are located in the back of the nose and tight chest and will have shallow respirations and
throat. They aid in protecting the respiratory tract a nonproductive cough. The asthma attack may
from infection but frequently become inflamed become an emergency situation. The pediatrician
and infected while doing their job. The cause most may refer the child to an allergy specialist who
often is group A beta-hemolytic streptococcus or a will test the child for various allergies. Respiratory
virus. Fever, cough, sore throat, and red, swollen therapy is helpful for some children. Airways can
tonsils are common symptoms. Diagnosis can be become damaged over time as a result of chronic
made by doing a culture and sensitivity of tonsillar inflammation.
exudate. Antibiotics will rid the child of infection
if it is bacterial, and must be taken as prescribed.
Tonsillectomy is considered for older children
Croup
who have chronic tonsillitis. The common viral condition croup has symptoms
of a croupy or “barking”-type cough, a high-pitched
sound on inspiration (stridor), and respiratory dis-
Pediculosis tress. The condition is often associated with an
Infestation with the head louse is known as pedic- upper respiratory infection that leads to inflamma-
ulosis capitus and is common among school-aged tion of the larynx, trachea, and bronchi. Respiratory
children. The parasites suck blood from humans obstruction can occur if severe, but children with
and are highly contagious. Diagnosis can be made croup generally are not seriously ill.
by visual examination of the hair and scalp and
observing the eggs (known as nits) on the hair.
Special medications applied to the hair is an effec-
Pertussis (Whooping Cough)
tive treatment. Care should be taken to launder Pertussis is a highly contagious respiratory tract
bed linens and clothing everyday. The louse is not infection caused by a bacterium. At the start, the
a vector for disease. disease appears to be a cold, but pertussis may
 CHAPTER 15 Pediatrics 397

become serious, especially in infants. Infected Stimulant medications (e.g., Adderall, Ritalin,
infants are at risk for pneumonia, seizures, brain Concerta) and behaviorial therapy help control
diseases, and death. After about 2 weeks, the the symptoms.
child has numerous rapid coughs that can last for
months. Vaccines are available to prevent the dis-
ease. In recent years there have been outbreaks of
Child Abuse
pertussis in college-age individuals and adults. The Child abuse has increased significantly
thinking by providers is that these people have lost in recent years. By law, health care pro-
their immunity to pertussis and need to be revac- fessionals, including medical assistants,
cinated with a booster vaccine. as well as others, must report suspected child
abuse. The individual reporting the suspected
abuse is protected against liability as a result of the
Respiratory Syncytial Virus reporting. If suspicion of abuse exists, the provider
In most children, the virus causes mild cold-like and health care professional should:
symptoms. Death can occur in high-risk babies,
such as premature infants, infants with a sup- • Treat the child’s injuries
pressed immune system, and infants with conges- • Send the child to the hospital if necessary
tive heart failure. It is the most common cause of • Inform parents of the diagnosis
pneumonia in children under 1 year.
• Inform parents that the incident will be reported
The virus spreads easily and rapidly through
to the public and social service agency
the air and can survive for 1 hour on hands and
clothes and for several hours on toys, counter- • Notify child protective agency
tops, and other surfaces. There is no vaccine, but • Document all information
the infection can be treated with antiviral drugs • Provide court testimony if requested
such as ribavirin in aerosolized form. The drug
inhibits the virus from replicating, so the sooner Child abuse is any physical or mental injury,
it is given, the better the results. This treatment sexual abuse, negligence, or mistreatment of a
is recommended only for severely ill and high-risk child under 18 years of age. Some child abuse
patients. signs are:
• Bruises
Attention Deficit Hyperactivity • Broken bones
Disorder
• Lacerations
Attention deficit hyperactivity disorder is a con- • Burns (cigarette, rope, and burns from being
dition in which children have difficulties paying immersed in scalding water)
attention and focusing on the task at hand. Parents
• Poor hygiene
question whether the disorder is overdiagnosed.
Many researches believe that the increase in diag- • Malnutrition
noses comes from improved techniques to detect • Head injuries
the condition. There are three types of symptoms: • Neglected well-baby appointments
hyperactivity, impulsivity, and inattention. Symp-
toms range from mild to severe. The AAP recommends parents be taught to
The cause is uncertain, but researchers note monitor television, videos, DVDs, and other types
that ADHD runs in families, with a possible genetic of media to limit viewing time and exposure to vio-
link. There also may be a link between ADHD and lence. Children 2 years and younger should not be
tobacco and alcohol use during pregnancy. exposed to any of these media.
Diagnosis is made when a child is about 6 to The cultural background of the family
12 years old. Observation of the child’s behavior should be taken into consideration, as
is documented by parents, teachers, pediatrician, should some folk medicine practices. Latin
family care provider, psychologist, and psychia- American and Russian cultures treat headaches
trist. Tests are done to identify other medical or abdominal pain by placing a cup on the skin,
problems that can help explain the child’s symp- creating a vacuum, and placing a small amount
toms such as hearing or vision impairment, lead of burning material on the skin. These children
exposure, anemia, and thyroid disease. Symp- may present with burns. To treat minor ailments,
toms can be controlled, but there is no cure. Southeast Asians rub a coin or spoon in hot oil and
398 UNIT 5 Assisting with Specialty Examinations and Procedures

rub it onto the child’s neck, spine, and ribs, and a feel pain, thus accomplishing a means of averting
burn may occur. masturbation.) Scientists have shown that during
circumcision, without analgesia, the infant’s heart
rate and blood pressure rise. There is a risk of hem-
MALE CIRCUMCISION orrhage, sepsis, and laceration.
Advocates for not circumcising male infants
Circumcision of the male is the surgical removal claim there is no medical reason to perform the
of the foreskin (prepuce) of the penis. Female procedure. Research has shown that urinary tract
circumcision includes a variety of surgical pro- infections and sexually transmitted diseases are
cedures performed on a female’s genitalia (see no more common in noncircumcised infants
Chapter 18). than in circumcised infants. Some view the sur-
Male circumcision is a religious rite in the gery as a profit-driven surgery. According to the
Jewish and Muslim religions. It is performed on a AAP about 80% of American male babies are cir-
majority of males in the United States for hygienic cumcised yearly. At one time the AAP had a pro-
reasons. The belief is that male circumcision is a circumcision stance, but in 1975 it reversed its
prophylaxis against urinary tract infections and position stating there is “no absolute medical indi-
sexually transmitted diseases, especially HIV. cation for routine circumcision of newborns.” If
Most circumcisions usually are performed it is performed, the AAP recommended that pain
in the hospital shortly after birth. Some con- relief be provided.
sider the procedure to be “cultural” surgery. It Furthermore, those who are adverse to the
has become a tradition, and the majority of male surgery say that a child is normal when born and
babies are circumcised. According to the CDC, it that circumcision results in loss of a body part, is
is the most commonly performed neonatal surgi- unnecessary, leaves a scar, and removes a func-
cal procedure in the United States. tioning body part in the name of custom or tra-
The practice of circumcision arose during the dition. It is viewed as a nonessential, pathologic
nineteenth century when circumcision was deemed procedure and a violation of basic human rights
necessary for male infants. The belief was that not because infants are too young and helpless to
being circumcised resulted in males who habitually consent or refuse.
masturbated and/or suffered from insanity. How can parents decide what to do? Circum-
Proponents of circumcision say it is impor- cision or not? It is a choice they will make, and it
tant for male babies to have penises that resemble will take courage. Deeply rooted cultural and tra-
their fathers’, for improved hygiene, and for males ditional customs can be difficult to sort through.
to conform socially with peers. With courage, education, and research, parents
Although circumcision is generally safe, it is can gain perspective about whether or not to cir-
not harmless surgery. The infant is restrained in a cumcise their sons. The AAP has information avail-
specially designed device on a table, and the sur- able on its Web site (http://www.aap.org).
gery is performed using sterile technique with anal- Some believe that elective circumcisions of
gesia. (In the nineteenth century it was advocated males and females should not be accepted by con-
that no analgesic be given so that the male would scientious health care providers.
 CHAPTER 15 Pediatrics 399

Procedure 15-1
Administration of a Vaccine
STANDARD PRECAUTIONS: 10. Select the correct needle size (see Figure 15−9).
11. Shake the vial and/or reconstitute powder medi-
cation using all of the diluent. RATIONALE:
Ensures medication is mixed properly.
PURPOSE: 12. Invert the vial and withdraw the correct dose of
To administer a vaccine. vaccine. Recheck the label on the vial and the
medicine note. RATIONALE: Ensures you have
EQUIPMENT/SUPPLIES: the correct vaccine.
Vaccines ordered by provider 13. Wash hands and, if office/clinic policy, put on
Vaccine Information Statement (VIS) disposable gloves. RATIONALE: Gloves must be
Medication note worn if the medical assistant has any openings in
Appropriate syringe needles the skin or on the hands.
Alcohol wipes
Gloves (if office/clinic policy) 14. Restrain the child with parent’s help. RATIO-
Sharps container NALE: Avoids injury to child.
15. Locate the appropriate site for administration.
PROCEDURE STEPS: Cleanse the site with alcohol wipe and let dry.
1. Check the provider’s order. Write out a medica- RATIONALE: The alcohol is an antiseptic and
tion note. RATIONALE: Helps eliminate giving will lower the number of bacteria at the site. Let-
an incorrect medication or dose. Writing the vac- ting the area dry lessens the sting when needle is
cine order on the note prevents giving vaccine to inserted.
the wrong patient.
16. Inject the vaccine quickly and steadily at the
2. Follow the six “rights” (see Chapter 24). appropriate angle.
3. Perform medical asepsis hand washing following 17. Withdraw needle and syringe at angle of inser-
OSHA guidelines. tion. Immediately dispose of needle and syringe
4. Work in a well-lighted, quiet, clean area. in sharps container.
5. Select the appropriate equipment (see Figure 18. Apply gentle pressure to injection site. Rub gen-
15-9). RATIONALE: The appropriate size nee- tly. RATIONALE: Vaccine will be distributed
dle and syringe for the vaccine being given are evenly.
important to prevent patient injury. 19. Wash hands.
6. Give parents/guardians the Vaccine Informa- 20. Fully document each immunization in the
tion Statement (VIS) for the intended vaccine patient’s chart or electronic record and on
and give them time to read the VIS and ask the vaccine administration record. Include lot
questions. number, manufacturer, site, VIS date, and your
7. Select the appropriate vial of vaccine. Check the name and initials.
label three times and check the medication note. 21. Update child’s record of immunizations and
RATIONALE: Safeguards patient from incorrect remind parent or guardian to bring it to each
medication, dose, and route. visit.
8. Check for expiration date on vial. RATIONALE: 22. Be aware of the location of the emergency drugs
Expired medication is not safe to give. (epinephrine and others). RATIONALE: Medi-
9. Maintain sterile techniques throughout. RATIO- cation must be readily available to counteract an
NALE: Compromising the vaccine or syringe allergic reaction.
and needle by poor technique can introduce 23. Remove gloves (if worn) and wash hands.
microorganisms into the patient or vaccine with
serious consequences.
400 UNIT 5 Assisting with Specialty Examinations and Procedures

Procedure 15-2
Maintaining Immunization Records
STANDARD PRECAUTIONS: (Figure 15-27) according to which vaccine you
administered. Note the headings, type of vac-
cine (use generic abbreviations, not the brand
name), date given, month, day, year, dose,
route, site, vaccine lot number and manufac-
PURPOSE: turer, VIS; date on VIS, date given (VIS), and
To establish and maintain a record of preventive your initials as the individual who administered
immunizations against childhood diseases for the the vaccine.
provider and parent or legal guardian. 4. The immunization record is kept by the provider
EQUIPMENT/SUPPLIES: and the parent or legal guardian. NOTE: Remind
Vaccine Administration Record parent or legal guardian to keep immunization
Vial of vaccine as ordered records safe and readily accessible for proof of
immunization for daycare and school.
PROCEDURE STEPS: 5. The data can be entered into the computer man-
1. Give the parent or legal guardian the most recent ually by the medical assistant and provider.
copy of the Vaccine Information Statement
(VIS). The statements explain risks and benefits DOCUMENTATION
of vaccines for each dose of vaccine given. 5/2/20XX DTaP 0.5 mL IM (R) vastus lateralis. Recorded
2. After the administration of a scheduled vaccine on vaccine administration record. Parent given Vaccine
for the child, document in the patient’s chart or Information Statement. W. Slawson CMA (AAMA) _______
electronic medical record and on the Vaccine
Administration Record.
3. Using the medicine note and the vaccine vial,
fill out the Vaccine Administration Record

continues
 CHAPTER 15 Pediatrics 401

Procedure 15-2 (continued)

Figure 15-27 Vaccination Administration Record. (From the Immunization Action Coalition, http://www.
immunize.org.)
402 UNIT 5 Assisting with Specialty Examinations and Procedures

Procedure 15-3
Measuring the Infant: Weight, Length, and Head and Chest
Circumference

STANDARD PRECAUTIONS:

PURPOSE:
To obtain an accurate measurement of an infant’s
weight, length, and head and chest circumference
for medical records and to screen for growth abnor-
malities.

EQUIPMENT/SUPPLIES:
Infant scale Pen
Paper protector Ruler
Flexible measuring Biohazard waste
tape without elasticity container
Growth chart

PROCEDURE STEPS:
Measuring infant weight: Figure 15-28 Infants who are unable to sit erect
1. Wash hands. Explain procedure to parent(s). should be weighed on their back on the scale.
2. Undress infant (including the diaper).
3. Place all weights to left of scale to check
balance.
10. Discard used protective paper towel per Occupa-
4. Place a clean utility towel on scale and check bal- tional Safety and Health Administration (OSHA)
ance scale for accuracy, being sure to compensate guidelines.
for the weight of the towel. RATIONALE: The
protection that the paper utility towel affords 11. Sanitize scale.
helps to reduce transmission of microorganisms 12. Wash hands.
and provides warmth because the scale is cool. 13. Document results according to office policy
5. Gently place small infant on her back on the (pounds and ounces or kilograms) on growth
scale. Larger infants can sit on the scale. Place chart, in patient’s chart or electronic medical
your hand slightly above the infant’s body to record, and parent’s booklet if available. Con-
ensure safety (Figure 15-28). RATIONALE: This nect dot from previous examination with a ruler
will safeguard the infant from falling. to complete graph.
6. Place the bottom weight to its highest measure- Measuring infant length:
ment that will not cause the balance to drop to 1. Wash hands. Explain procedure to parent(s).
the bottom edge. 2. Remove infant’s shoes.
7. Slowly move upper weight until the balance bar 3. Gently place infant on his or her back on the
rests in the center of the indicator. A balanced examination table. If the pediatric table has a
scale will provide an accurate weight. Read the headboard, ask parent to hold infant’s head
infant’s weight while he or she is lying still. against headboard (end) of table at zero mark of
8. Return both weights to their resting position to ruler while you place infant’s heels against foot-
the extreme left. board. Gently straighten infant’s back and legs to
9. Gently remove infant and apply diaper. (Parent line up along ruler. If there is no footboard (to
can help with diapering and holding infant.) place infant’s feet against), use your right hand

continues
 CHAPTER 15 Pediatrics 403

Procedure 15-3 (continued)

as a guide (Figure 15-29). If necessary, gently

place your left hand over the child’s legs at the
knees to secure the child in place and straighten
the legs so you can read the recumbent length
from the head to the heel. RATIONALE: Some-
times it is difficult to straighten the legs.
4. Read length on the measuring device in inches
or centimeters.
5. Give infant to parent to dress.
6. Wash hands.
7. Document measurement on growth chart, in pa-
tient’s chart or electronic medical record, and
parent’s booklet if available. Connect dot from pre-
vious examination with a ruler to complete graph.
Measuring Head Circumference:
1. Wash hands and explain procedure to parent(s).
2. Talk to infant to gain cooperation. Infant may be
held by parent or lie on examination table for Figure 15-30 Measuring infant’s head
procedure. Older children of 2 or 3 years may circumference.
stand or sit if they will remain still.
3. Place the measuring tape snugly around the
head from the occipital protuberance to the 5. Wash hands.
supraorbital prominence. This is the largest part 6. Document results according to office policy on
of the head (Figure 15-30). growth chart, in patient’s chart or electronic
4. Read the measurement, which will be in either medical record, and parent’s booklet if available.
inches (to nearest 1⁄2 inch) or centimeters (to Connect dot from previous examination with a
nearest 0.01 cm). ruler to complete graph.
Measuring infant’s chest circumference:
1. Wash hands and explain procedure to parent(s).
2. Use one thumb to hold tape measure with zero
mark against the infant’s chest at the midsternal
area. With the other hand, bring the tape around/
under the back to meet the zero mark of the tape
in front. Take the measurement of the chest just
above the nipples with the tape fitting around
the child’s chest under the axillary region. If you
need assistance in holding the child still, ask the
parent or another assistant. The measurement
should be taken when the child is breathing nor-
mally and during the resting phase between res-
pirations (Figure 15-31).
3. Read measurement to the nearest 0.01 cm or
one-eighth inch.
4. Wash hands.

Figure 15-29 Measuring the recumbent length of 5. Document results in patient’s chart or electronic
an infant. medical record.

continues
404 UNIT 5 Assisting with Specialty Examinations and Procedures

Procedure 15-3 (continued)

DOCUMENTATION
3/10/20XX 4:00 pm 6 months of age, wt. 15 lbs. Recorded on
growth chart. C. McInnis, RMA __________________
DOCUMENTATION
3/10/20XX 4:00 pm 6 months of age, length 26 inches long.
Recorded on growth chart. C. McInnis, RMA ___________
DOCUMENTATION
3/10/20XX 4:00 pm 6 months of age, head circumference
43 centimeters. Recorded on growth chart. C. McInnis, RMA
DOCUMENTATION
3/10/20XX 4:00 pm 6 months of age, chest circumference
Figure 15-31 Measuring infant’s chest 30 centimeters. Recorded on growth chart. C. McInnis, RMA
circumference.

Procedure 15-4
Taking an Infant’s Rectal Temperature with a Digital Thermometer
STANDARD PRECAUTIONS: 6. Position infant in a prone (Figure 15-32A) or
supine (Figure 15-32B) position having parent
or another medical assistant safeguard infant.
7. Place sheath on thermometer. RATIONALE: Pre-
PURPOSE: vents microorganism cross contamination.
To obtain a rectal temperature using a digital ther- 8. Lubricate with lubricating jelly. (Place lubricant
mometer. on a 4 × 4 gauze sponge and place tip of ther-
mometer in lubricant.) RATIONALE: Easier
EQUIPMENT/SUPPLIES: insertion of thermometer.
Digital thermometer (red probe) and probe cover
9. Apply gloves.
Lubricating jelly
4 × 4 gauze sponges 10. Spread buttocks, insert thermometer gently into
Gloves the rectum past the sphincter; for an infant this
Biohazard waste container is 0.5 inch (Figure 15-32B).
11. Hold buttocks together while holding the ther-
PROCEDURE STEPS: mometer. If necessary, restrain infant movement
1. Wash hands.
by placing your arm across infant’s back. Par-
2. Assemble equipment. ent can immobilize infant’s legs. RATIONALE:
3. Identify patient. Ensure infant’s safety and comfort.
4. Explain procedure to parent(s). RATIONALE: 12. Hold in place until beep is heard. Do not let go
Gain cooperation and assistance in disrobing of the thermometer. RATIONALE: Movement
infant and positioning properly. by infant can cause thermometer to move and
injure the infant.
5. Remove infant’s diaper.

continues
 CHAPTER 15 Pediatrics 405

Procedure 15-4 (continued)

13. Remove from rectum. Have parent attend to infant.

14. Note temperature reading.
15. Remove probe cover by ejecting it into a biohazard
container.
16. Remove gloves, discard in biohazard waste container.
17. Wash hands.
18. Wipe probe with antiseptic wipe. Replace thermom-
eter on holder.
19. Assist parent in dressing infant if necessary.
20. Record result in patient’s chart or electronic medi-
cal record with designation of (R), indicating a rec-
A B
tal temperature.
Figure 15-32 Taking the rectal temperature of
an infant in (A) the prone position and (B) in the DOCUMENTATION
supine position. 5/3/20XX 4:00 PM T 99.8 (R). W. Slawson, CMA (AAMA) _____

Procedure 15-5
Taking an Apical Pulse on an Infant
STANDARD PRECAUTIONS: 8. Locate the fifth intercostal space, midclavicular
line, left of sternum. RATIONALE: Location of
apex of heart.
9. Place warmed stethoscope on the site and listen
PURPOSE: for the lub-dub sound of the heart.
To obtain an apical pulse rate. 10. Count the pulse for 1 minute; each lub-dub
equals one heartbeat or pulse.
EQUIPMENT/SUPPLIES:
11. Wash hands.
Stethoscope
Watch with second hand 12. Assist parent as needed.
Alcohol wipes 13. Clean earpieces and diaphragm of stethoscope
with alcohol wipes. RATIONALE: Prevents cross
PROCEDURE STEPS: contamination of microbes between patients.
1. Wash hands.
14. Record the pulse in the infant’s or chart or elec-
2. Assemble equipment.
tronic medical record with the designation of
3. Identify patient. (AP) to denote method of obtaining the pulse.
4. Explain procedure to parent. RATIONALE: Note any arrhythmias.
Gain co-operation an assistance. 15. Wash hands.
5. Assist in disrobing infant if necessary.
6. Provide a drape for infant’s warmth if necessary.
DOCUMENTATION
3/10/20XX 4:00 PM Pulse 140 (AP). Regular. W. Slawson, CMA
7. Position the infant in a supine position or sitting (AAMA) ________________________________
in the parent’s lap. RATIONALE: The supine
position may offer easier access to apex of heart
if the child is calm.
406 UNIT 5 Assisting with Specialty Examinations and Procedures

Procedure 15-6
Measuring Infant’s Respiratory Rate
STANDARD PRECAUTIONS: 3. Position infant in a supine position.
4. Place hand on the chest to feel the rise and fall
of the chest wall for 1 minute.
5. Note depth, rhythm, and breath sounds while
PURPOSE: counting.
The respiratory rate is normally taken immediately 6. Wash hands.
before or after the pulse rate to obtain an accurate
respiratory rate. 7. Record respiratory rate in patient’s chart or elec-
tronic medical record. Note any irregularities
EQUIPMENT/SUPPLIES: and sounds.
Watch with second hand
DOCUMENTATION
PROCEDURE STEPS: 3/10/20XX 4:00 PM Respirations 22. Regular. W. Slawson,
1. Wash hands. CMA (AAMA) _____________________________
2. Identify the patient and explain the procedure
to the parent. RATIONALE: To gain cooperation
and assistance.

Procedure 15-7
Obtaining a Urine Specimen from an Infant or Young Child
STANDARD PRECAUTIONS: PROCEDURE STEPS:
1. Wash and glove hands following Standard Pre-
cautions.
2. Assemble equipment.
PURPOSE: 3. Identify patient and explain procedure to
To obtain a specimen of urine from an infant or parent(s). RATIONALE: To gain cooperation
young child. and assistance.
EQUIPMENT/SUPPLIES: 4. Instruct parent to remove diaper.
Urine collection bag 5. Wash and dry perineal area. RATIONALE:
Urine cup Cleaning area reduces microorganism level and
Laboratory request form provides better quality urine specimen.
Biohazard transport bag 6. Apply collection bag, secure with adhesive tabs
Gloves (see Figure 15-22).
Cleansing cloth
Towel a. Girls: spread perineum, place bag over labia.
Biohazard waste container b. Boys: place bag over penis and scrotum.

continues
 CHAPTER 15 Pediatrics 407

Procedure 15-7 (continued)

7. Replace diaper carefully. 12. Wash hands.

8. Frequently check bag for urine. 13. Record collection in patient’s chart or electronic
9. Once specimen has been collected, remove bag medical record.
carefully.
DOCUMENTATION
10. Prepare specimen as required. Send to laboratory
3/10/20XX 4:00 PM Urine specimen collected via urine
in an appropriate container with a requisition or
process the specimen in the office laboratory.
collection bag. Specimen sent to Bay Laboratory with requisition
for routine urinalysis. J. Guerro, CMA (AAMA) _________
11. Remove gloves and discard in biohazard waste
container.

Case Study 15-1 Case Study 15-2

Refer to the scenario at the beginning of the chapter. After examining Joey Little, Dr. King confirms the diagnosis
of otitis media.
CASE STUDY REVIEW
CASE STUDY REVIEW
1. In what ways can Bruce learn about new vac-
cines that are required for pediatric patients? 1. Explain otitis media, the most common reason
2. Other than the provider giving information, for its occurrence, and its treatment.
describe two ways in which Bruce can stay cur- 2. How can parents and caregivers be educated to
rent with vaccines and immunizations. help prevent otitis media?

SUMMARY
Caring for the health and well-being of infants and children throughout their various developmental stages
and into adolescence is the responsibility of the pediatric practice.
Careful observation of the parent or caregiver and the child is helpful to the treatment and care
given to the child. The medical assistant is responsible for reporting to the provider any suspicion of child
abuse.
Opportunities abound for educating parents about topics that will keep their children healthy
throughout life and include nutrition, sleep, immunizations, and exercise. Pamphlets, videos, and demon-
strations are available to share with parents and caregivers.
Children need respect and should be treated with empathy, love, and honesty; in doing so, a positive
relationship can be developed with the child.
408 UNIT 5 Assisting with Specialty Examinations and Procedures

STUDY FOR SUCCESS

To reinforce your knowledge and skills of information presented in this chapter:
• Review Key Terms
• Practice the Procedures
• Consider the Case Study and discuss your conclusions
• Answer the Review Questions

˚ Multiple Choice
˚ Critical Thinking
• Navigate the Internet by completing the Web Activities
• Practice the StudyWARE activities on your student CD
• Apply your knowledge in the Student Workbook activities
• Complete the Web Tutor sections
• View and discuss the DVD situations

REVIEW QUESTIONS
Multiple Choice c. Fifth intercostal space on the left side
d. Sixth intercostal space on the left side
1. At what age should the first polio vaccine be given?
a. birth Critical Thinking Questions
b. 1 month
c. 2 months 1. You notice when you undress a 2-year-old child
d. 3 months to prepare for a physical examination that there
e. 6 months are bruises on the buttocks and what appear to be
2. One procedure to treat otitis media is: burns on the feet. What course of action do you
a. suppuration take?
b. tympanostomy 2. Explain the importance of head circumference
c. ear irrigation measurement.
d. otoscopy 3. Explain the importance of growth charts.
e. myringectomy 4. Describe the appropriate positions in which to
3. The pathogen usually responsible for causing place an infant for obtaining a rectal temperature.
tonsillitis is: 5. Describe the appearance of the pediatric urine col-
a. Staphylococcus aureus lector bag. What is the best way to make certain it
b. meningococcus will adhere to the child’s body?
c. beta-hemolytic streptococcus group A 6. Explain the type of chart used to test visual acuity in
d. beta-hemolytic streptococcus group B young children.
4. Head circumference is measured on the child 7. When is it appropriate to use the tympanic ther-
until what age? mometer when taking a child’s temperature?
a. 12 months 8. When taking an infant’s rectal temperature, what
b. 24 months precautions should be taken?
c. 36 months 9. Chest circumference measurements on an infant
d. 72 months are performed for what purpose?
5. An apical pulse is taken over which of the following 10. What do the curved lines printed across growth
sites? charts indicate?
a. Third intercostal space on the left side
b. Fourth intercostal space on the left side
 CHAPTER 15 Pediatrics 409

WEB ACTIVITIES REFERENCES/BIBLIOGRAPHY

Search for the American Academy of Pediat- Ambroz, K. G., & Eilber, W. (2003). An enhanced
rics Web site (http://www.aap.org) to answer method of pediatric urine collection. The Internet
the following: Journal of Emergency Medicine 1(1).
1. What information is available about immunization Clifton, J. C., 2nd. (2007). Mercury exposure and
for hepatitis A, B, and C? public health. In Pediatric clinics of North America
2. What is the most recent recommendation that the (pp. 237–269). The National Library of Medicine
American Academy of Pediatrics has made regarding and the National Institutes of Health. Retrieved
varicella, influenza, and pneumonia immunizations? July 2, 2008, from www.pubmed.gov.
3. Visit the Zero to Three Web site (http://www.zero- Hegner, B. R., Acello, B., & Caldwell, E. (2008). Nursing
tothree.org). Search for “healthy development for assistant: A nursing process approach. Clifton Park, NY:
24- to 36-month-old toddlers.” Describe four to five Delmar Cengage Learning.
ways parents can encourage their 2- to 3-year-old Keir, L., Wise, B., Krebs, C., & Kelley-Arney, C. (2008).
children to express themselves. Medical assisting: Administrative and clinical competen-
4. Visit the National Network for Child Care Web site cies, (6th ed). Clifton Park, NY: Delmar Cengage
(http://www.nncc.org). Search the site for informa- Learning.
tion about fetal alcohol syndrome and birth defects. Mandleco, B. L. (2004). Growth and development hand-
What specific problems can a newborn have if his book: Newborn through adolescent. Clifton Park, NY:
or her mother consumed excessive alcohol during Delmar Cengage Learning.
pregnancy? Potts, N. L., Mandleco, B. L. (2002). Pediatric nursing:
5. Visit the American Academy of Family Physicians Caring for children and their families. Clifton Park, NY:
Web site (http://www.aafp.org). What information Delmar Cengage Learning.
can you find about croup? List five symptoms that Taber’s cyclopedic medical dictionary (20th ed.). (2006).
should alert parents to call their provider. What are Philadelphia: F. A. Davis.
pinworms? How do children get pinworms? How Tamparo, C., & Lewis, M. (2005). Diseases of the human
are pinworms detected? How are pinworms treated? body (4th ed.). Philadelphia: F. A. Davis.

THE DVD HOOK-UP

In this chapter, you learned about the proper techniques for 1. How does the medical assistant know which mark
assisting with pediatric examinations. to use?
The designated scene from today’s program illustrates 2. Is this an accurate reading?
the medical assistant assisting with an infant examina-
tion. In the first scene, the medical assistant asks the DVD Journal Summary
patient’s mother to remove everything but the diaper. Write a paragraph that summarizes what you learned
The mother tells the medical assistant that the diaper is from watching today’s DVD selected scene. How do you
pretty wet; therefore, the medical assistant instructs the feel about working in pediatrics? Do you have children of
mother to change the diaper before she weighs your own? How does having children affect your ability to
the infant. work in pediatrics?

1. Why would removing the diaper altogether as sug-

gested in this chapter be a better method for weighing
the infant?
The medical assistant measures the infant by placing
a mark above the head and below the foot after straight-
ening out the foot and leg. Spencer is quite playful, DVD Series Program Number
Skills Based Series 6
making it difficult for the medical assistant to get an
accurate reading. The marking for the foot actually had Chapter/Scene Reference
two lines. • Infant Examination
Chapter

16 Male Reproductive System

OUTLINE KEY TERMS
Testicular Self-Examination Infertility Cryptorchidism
Disorders of the Male Erectile Dysfunction Foley Catheter
Reproductive System Assisting with the Male Intravenous
Testicular Cancer Reproductive Examination Pyelogram (IVP)
Epididymitis Diagnostic Tests and Procedures Libido
Prostatitis Vasectomy Metastasis
Prostate Cancer Semen Analysis Nocturia
Benign Prostatic Hypertrophy Urodynamic Studies
Orchidectomy
Sexually Transmitted Diseases
Residual Urine
Balanitis
Retention
Spermatogenesis
OBJECTIVES Transilluminator
The student should strive to meet the following performance objectives and Transurethral Resection
demonstrate an understanding of the facts and principles presented in this chapter of the Prostate (TURP)
through written and oral communication.

1. Describe the key terms as presented in the glossary.

2. Describe common disorders and diseases of the male reproduc-
tive system.
3. Explain benign hyperplasia of the prostate.
4. Identify signs and symptoms of the various disorders and diseases
of the male reproductive system.
5. Explain erectile dysfunction, its causes, and its treatments.
6. Describe the common diagnostic tests and procedures used in
the male reproductive system.
7. Explain testicular self-examination to a male patient.
8. Show compassion and empathy.

410
 Scenario
Joe Guerro, CMA (AAMA), finds many situations daily the Internet to obtain the latest information from the
to educate patients because he knows how impor- American Cancer Society about prostate cancer and
tant it is. He keeps abreast of the latest techniques as a resource for people with prostate cancer. With
and procedures about diseases and problems of Dr. Woo’s permission, Joe shares that information
the male reproductive system. He attends lectures, with patients.
workshops, and seminars when possible, and uses

INTRODUCTION
The male reproductive system consists of a pair of testes release a protein into the bloodstream. This protein is an
suspended in the scrotum, in which sperm and hormones antigen called prostate-specific antigen (PSA). Checking
are produced. The scrotum can contract and relax the PSA level can help the provider determine if there is
to help regulate temperature of the testes for optimum some pathology of the prostate gland. It is important that
spermatogenesis. blood be drawn for the PSA test before the digital rectal
A system of tubes (the epididymis) transports the examination of the prostate, which can irritate the prostate
sperm to the outside of the body, and a penis transports gland, thus causing a slight increase of the PSA level.
the sperm into the female reproductive tract through the Diseases, disorders, conditions, diagnostic tests, pro-
urethral opening. There are glands such as the prostate cedures, and treatments common to the male reproductive
that secrete fluid that becomes part of the semen. system are listed in Table 16-1.
The male reproductive system is closely related to the
male urinary system; thus, diseases and disorders of one
system will naturally affect the other. Because the prostate
gland encircles the male urinary urethra, any enlarge-
ment can cause urinary problems. The prostate gland is Spotlight on Certification
located directly next to the rectal wall. This location enables
the provider to palpate the posterior of the prostate gland RMA Content Outline
through the anterior rectal wall and, if necessary, perform • Anatomy and physiology
an ultrasound and biopsy of the prostate using the rec-
• Medical terminology
tal route. It is recommended that men have their prostate
gland routinely evaluated at age 40 years, and then annu- • Patient education
ally after age 50 years. During the annual examination • Physical examinations
of the prostate gland, the provider can assess the gland for • Laboratory procedures
enlargement, nodules, and other abnormalities. When the • Diseases and disorders
prostate becomes inflamed or irritated in any way, it can CMA (AAMA) Content Outline
• Medical terminology
• Anatomy and physiology
• Patient instruction
Patient Education • Patient education
• Examinations
1. Testicular cancer is one of the leading
causes of death in men younger than • Procedures
40 years. • Collecting and processing specimens;
diagnostic testing
2. Risk factors include an undescended
testicle, cryptorchidism, and childhood CMAS Content Outline
mumps. • Medical terminology
3. Prognosis is good when found in the • Anatomy and physiology
early stages. • Examination preparation

411
Table 16-1 Male Reproductive System Diseases and Disorders

412
Radiography and Medical/Surgical
Disease/Disorder Laboratory Diagnostics Technical Diagnostics Diagnostics Treatments

UNIT 5
Complete blood count; urinaly- Urodynamics (if not caused Digital rectal examination Long-term treatment with
Prostatitis (inflammation of
sis and culture; analysis of pros- by a bacterium) antibiotics Increase fluid intake
the prostate gland)
tate secretion

Prostatic-specific antigen (PSA); Intravenous pyelogram Digital rectal examination; Medications; transurethral

Assisting with Specialty Examinations and Procedures

Benign prostatic hypertro- urinalysis (IVP); pelvic ultrasound cystoscopy; ultrasound resection prostatectomy (TURP)
phy/enlargement of (BPH) and biopsy is rare

PSA; urinalysis; acid IVP; pelvic ultrasound Digital rectal examination; Prostatectomy; hormone
Prostate cancer phosphatase (blood) cystoscopy; ultrasound manipulation; chemotherapy,
and biopsy radiation, or both

Complete blood count; Urinaly- IVP; pelvic ultrasound Physical examination Antibiotics, scrotal support
Epididymitis (inflammation
sis and culture and sensitivity;
of the tubes on the testis)
culture and sensitivity of urethra

Testicular ultrasound Physical examination Excision of the testis; radiation

Testicular cancer
(palpation of testis); biopsy therapy; chemotherapy

Erectile dysfunction (ED) Complete blood count; Angiogram, rarely; Physical examination; Oral medications; localized
(inability of male to achieve fasting blood sugar; lipid profile; magnetic resonance neurological examination; injected medication; penile
erection) testosterone level; urinalysis imaging of the brain, rarely psychological evaluation implant; penile pump

Balanitis (inflammation of Culture, rarely Physical examination; skin Localized soaks and frequent
the glans of the penis) culture cleansing; antibiotics

Sexually transmitted diseases (STDs):

Rule out other STDs; culture and Increase fluid intake;

Nonspecific urethritis (NSU) sensitivity of urethral discharge antibiotics; possibly test/treat
partner

Urinalysis; urethral smear Patient education; antibiotics;

Chlamydia
test/treat partner

Genital herpes (type II Culture of lesion Patient education; antiviral

herpes simplex) medications; test/treat partner

Urethral smear Patient education; antibiotics;

Gonorrhea
test/treat partner

Urinalysis with culture; Patient education; antibiotics;

Venereal Disease Research test/treat partner
Syphilis
Laboratory (VDRL) studies;
culture of the lesion
 CHAPTER 16 Male Reproductive System 413

TESTICULAR SELF-EXAMINATION in a testicle. An undescended testicle (cryptorchi-

dism), and a history of mumps are predisposing
Early detection of testicular cancer relies heavily on factors. Diagnosis can be made by performing a
the patient’s willingness to perform self-examination biopsy after palpation of the testicle finds a mass.
of the testes on a regular basis. Patient teaching is Surgery to excise the testicle, orchidectomy, fol-
valuable when used to educate the patient about lowed by radiation and chemotherapy is the usual
self-examination for detection of abnormalities such course of action. If caught early, there is a high
as lumps or thickenings. Figure 16-1 illustrates a tes- cure rate. Monthly testicular examinations are
ticular self-examination, and Procedure 16-1 outlines recommended by the American Cancer Society
steps for instructions usually given to the patient by for all men and are considered the best preventive
the medical assistant. The testicular self-examination measure for testicular cancer.
is best performed in the shower because the warmth Testicular self-examinations (TSEs) are a com-
will cause the scrotum to relax, making the examina- mon patient education topic. Many total practice
tion easier and more effective. management systems have an area for storing
patient education information and forms. These
forms (Figure 16-2) can be printed and given to
DISORDERS OF THE MALE the patient right in the exam room.
REPRODUCTIVE SYSTEM
Table 16-1 gives a summary of male reproductive
Epididymitis
disorders. Epididymitis is an inflammation of the epididymis,
which is a small oblong body resting on and beside
the posterior surfaces of the testes. It consists of a
Testicular Cancer convoluted tube 13 to 20 feet in length. It consti-
Testicular cancer is the most common form of can- tutes the first part of the secretory duct of each tes-
cer in men between 20 and 35 years old; otherwise, tis. The patient’s symptoms are chills, fever, pain in
it is rarely seen. Usually a painless lump is found the inguinal region, and a swollen epididymis that

Figure 16-1 Testicular self-examination

should be performed once a month after a
warm bath or shower. The heat will relax the
scrotum, making it easier to find abnormali-
ties. (A) Stand in front of the mirror. Look
for swelling on the skin of the scrotum.
(B) Examine each testicle with both hands.
Position your index and middle fingers
A B under the testicle with the thumbs on top.
Gently roll the testicle between your thumbs
and fingers (having one testicle larger than
Vas deferens the other is normal). (C) Find the epididymis
(the soft tubelike structure at the back of the
testicle). Do not mistake the epididymis for
an abnormal lump. (D) If you find a lump,
Epididymis
Epididymis notify your provider immediately. Most lumps
are found on the sides of the testicle, but
some are located on the front. Testicular
Testicle cancer is highly curable when detected early
and treated promptly.
Nodule
C D
414 UNIT 5 Assisting with Specialty Examinations and Procedures

Figure 16-2 Testicular self-examination patient teaching forms can be printed in the exam room via the total prac-
tice management system and given to a patient.

can be seen on an ultrasonogram. It is primarily symptoms, if present, are similar to urinary obstruc-
caused by a sexually transmitted disease (STD) such tion, difficulty urinating, frequency of urination,
as chlamydia, gonorrhea, or syphillis. Other causes and inability to urinate. It is of value to check the
are urinary tract infections, trauma, prostatectomy, blood level of PSA. A PSA blood level greater than
and prolonged indwelling Foley catheter. Treatment 2.5 mg/mL is the cutoff for normal values. Younger
consists of antibiotics, scrotal support, and bed rest. men have smaller prostates and lower PSA values.
Any elevation of PSA level greater than 2.5 mg/mL
in younger men is cause for concern.
Prostatitis The PSA is not a perfect test. Most men with
Prostatitis, or inflammation of the prostate, occurs elevated PSA levels have benign prostate enlarge-
primarily in men older than 50 years. The prostate ment, a normal part of aging. Low levels of PSA do
may enlarge and cause pain and discomfort, such not rule out possible prostate cancer.
as burning while urinating. There can be pain in At age 50 years, a PSA level and digital rectal
the back, muscle aches, and urinary frequency. The exams should be done annually, and at age 40 years
cause may be bacterial, such as from gonorrhea, for African-American men with a family history of
or it may be caused by another pathogen that pro- prostate cancer.
duced a urinary tract infection. Urinalysis, urine cul- A new blood test for prostate cancer devel-
ture, and digital rectal examination (to palpate the oped by Johns Hopkins University seems to be
prostate) help in making a diagnosis. Treatment is much more accurate than the PSA. The test mea-
usually medication, such as penicillin and pain med- sures blood levels of the protein and early prostate
ication, and the patient will be told to force fluids by cancer antigen–2 (EPCA-2). According to a report
increasing fluid intake significantly. in the periodical Urology, the new test shows a false-
positive rate of only 3%. The majority of PSA tests
performed show high PSA levels. When biopsies of
Prostate Cancer prostates from these men are done, 80% turn out
Prostate cancer is the third leading cause of can- to be benign. A biopsy is necessary to be certain.
cer death in men, after lung and colon cancer. An ultrasonogram and computed axial tomogra-
Metastasis to the spine or pelvis is not unusual. The phy (CAT) scan can help to determine if metastasis
 CHAPTER 16 Male Reproductive System 415

has occurred. Treatment may consist of prostatec- diminished flow of urine, and difficulty starting
tomy, hormonal therapy, radiation, chemotherapy, to urinate. Hesitancy and nocturia can occur. It is
and brachytherapy (internal radiation “seeds”). thought that the cause is aging and may be related
A prostatic ultrasound consists of a short to hormonal changes. The prostate enlarges and,
probe inserted into the rectum. High-frequency because it surrounds the urethra, it causes con-
sound waves are produced by the probe, and an striction of the urethra and the associated symp-
image (either a photo or a video) of the prostate toms. The provider can palpate the enlarged
is recorded. A biopsy of the prostate can be done prostate gland when performing a rectal examina-
in conjunction with the ultrasound. The provider tion. This helps in making a diagnosis. Other tests
uses the ultrasound to guide a needle through may include the PSA, a urinalysis, and an intrave-
the rectum into areas of the prostate that showed nous pyelogram (IVP); excretory urograph—(a
abnormalities on the ultrasound. The needle col- radiograph of the kidneys, ureters, and bladder
lects cells from the prostate through the rectum using a contrast medium). The enlarged prostate
wall. The specimen is sent to the laboratory for blocks urine flow and if residual urine stays in the
analysis. Medical assistants are responsible for bladder, infections can develop. The kidneys
patient instruction and preparation and assisting may cease functioning because they cannot drain
with an ultrasound and biopsy of the patient. urine properly into the bladder when it is full
A prostatectomy is major surgery done for (Figure 16-3). Catheterization may be necessary
prostate cancer and is performed through the abdo- (see Procedure 18-2).
men or the perineum (the external region between The PSA blood test is used to detect abnormally
the scrotum and the anus). Urinary incontinence, high levels of a protein substance that may indi-
impotence, or both are possible complications. cate prostate cancer. The American Cancer Society
If the cancer has metastasized, orchidectomy recommends that men aged 50 years and older have
may be recommended because the surgery alters an annual PSA blood test.
hormone production (loss of testosterone). Less Ultrasound can be used to view the prostate,
testosterone can slow the metastasis but can lead bladder, or kidneys. A biopsy of the prostate,
to loss of muscle mass, osteoporosis, and sexual done in conjunction with an ultrasound, can help
dysfunction. diagnose either BPH or cancer.
An additional treatment consists of small In some cases, treatment of BPH consists of
pellets (“seeds”) of a radioactive substance that medication that can relax prostate muscles, hor-
are implanted in the prostate tissue through a mones that block prostate growth, or bladder
small incision (brachytherapy). The seeds of relaxants. Transurethral resection of the prostate
radiation are concentrated in the prostate and (TURP), removal of prostate tissue using a device
destroy the prostate without harming surround- inserted through the urethra, is the most com-
ing tissue as external beam radiation does. Vari- mon surgical treatment. Instruments are inserted
ous medications such as those that reduce or through the penis and laser or radio waves can
suppress the production of testosterone may be be used to remove the excess tissue (Figure 16-4).
helpful when combined with radiation or sur- Possible risks of TURP include impotence and uri-
gery, but they have the same possible side effects nary incontinence. BPH does not cause or lead to
as orchidectomy. cancer.
Patients who have been tested for prostate
cancer are monitored for progression of the can-
cer, which includes PSA every 3 months to 1 year,
CAT and bone scans, and monitoring of the signs Critical Thinking
and symptoms that indicate cancer progression
such as bowel and bladder function impairment, Describe brachytherapy. What is it used for?
weight loss, pain, and fatigue.

Benign Prostatic Hypertrophy

Benign hypertrophy of the prostate gland or be- Critical Thinking
nign hypertrophic prostate gland, also known as
benign prostatic hyperplasia (BPH), is common in List several sexually transmitted diseases that
men 50 years or older. Symptoms include retention a male individual can contract.
(the inability to completely empty the bladder), a
416 UNIT 5 Assisting with Specialty Examinations and Procedures

Vas deferens
Urinary bladder

Seminal vesicle
Rectum
Ejaculatory duct Prostate gland
Cowper's glands
Urethra

Glans penis
Epididymis
Prepuce (foreskin)
Testis

A Scrotum

Benign
prostatic
B hypertrophy

Figure 16-3 Normal and enlarged prostate. (A) Normal. (B) Enlarged.

Diagnosis of balanitis may be made by the provider

Sexually Transmitted Diseases through examination of the penis and foreskin,
STDs affect men and women; they can damage skin culture for microorganisms, or both. If the
health and become life-threatening (Table 16-2). cause is bacterial, then antibiotics can be used to
(See Chapter 14 for additional information regard- treat balanitis. In severe cases, circumcision (surgi-
ing STDs.) cal removal of prepuce of penis) may be necessary.

Balanitis Infertility
Balanitis is usually caused by poor hygiene in When couples regularly have unprotected sexual
uncircumcised men. Bacteria, fungi, viruses, intercourse, the majority of them usually conceive
caustic soaps, and improper rinsing of soap while within 1 year. The inability or diminished ability to
bathing also are causes. Symptoms and signs that conceive is known as infertility.
occur include redness of the foreskin or of the An insufficient number or diminished motil-
penis, rashes on the head of the penis, malodor- ity of sperm can cause infertility. Other causes
ous discharge, and pain in the penis and foreskin. include an infection in the genitourinary tract or the
 CHAPTER 16 Male Reproductive System 417

presence of an STD, either of which can block the A complete physical examination and medi-
tract and prohibit sperm from being fully ejaculated. cal history (including childhood illnesses such
An injury to the blood or nerve supply in the area, as parotitis [mumps]), semen analysis for count
radiation exposure, stress, and hormonal imbal- and motility, and tests for endocrine disorders
ances are other factors that can promote infertility. can help determine the cause of infertility.
Treatment of a male patient with infertility
depends on the cause. Treatments include surgery
Bladder
to remove a blockage, antibiotics to treat an infec-
Resectoscope tion, use of artificial insemination, or use of phar-
maceuticals to treat the infertility.
Prevention of the factors that may cause infer-
tility is preferable because the percentage of cou-
ples treated for infertility who successfully become
pregnant is relatively low.

Enlarged prostate Erectile Dysfunction

Cut pieces of Also called impotence, erectile dysfunction (ED)
prostatic tissue
occurs when a man is unable to achieve or to
sustain an erection of the penis during sexual
intercourse. This condition or dysfunction is not
normal at any age and is different from other
Rectum
issues that impede sexual intercourse, such as
lack of libido.
Figure 16-4 Transurethral resection of the prostate Many men, at some point in their lives, can
(TURP). experience the inability to achieve an erection.
This can happen on occasion from consuming too
much alcohol or from extreme fatigue. This is not
Table 16-2 Sexually Transmitted Diseases ED. The inability to achieve an erection more than
50% of the time is generally a reason for seeking
Common in male and female
Chlamydial individuals. A prevalent sexually
treatment and is usually an indication of ED.
infection transmitted disease that often For an erection to occur, certain physiologic
coexists with gonorrhea. conditions must be present. There must be a
stimulus from the brain and adequate circula-
Painful viral disease that is dor- tion and nerve supply to the penis. If any of these
mant and recurs periodically. conditions is impeded, an erection cannot be
There is no cure. Characterized
Genital herpes
by blisters similar to chicken
achieved. Some reasons why ED occurs include
pox. Common in male and conditions or diseases that impair circulation
female individuals. (atherosclerosis) and nerve stimulation (nerve
diseases) and psychological factors such as stress
Caused by a bacterium. Infection and depression. Medications such as those used
can spread, producing a stricture to treat certain conditions such as hypertension
Gonorrhea of the urethra or the vas deferens.
Sterility can result if both vas def-
can cause ED. Diabetes, multiple sclerosis, cere-
erens become involved. bral vascular accident (stroke), surgery on the
prostate or bladder, and brain and spinal cord
Caused by a spirochete. injuries are other causes of ED.
Chancres develop. Can heal. Treatment of the dysfunction is based on the
If untreated, the disease pro- cause. Referral to a urologist, psychologist, or both,
gresses to stages two and three.
Syphilis Severe damage to the cardio-
is made if appropriate. Blood and urine tests will be
vascular system and brain and done after the provider examines the individual for
vision and hearing loss occur. medical problems. Medications the patient may be
General paralysis and death taking will be addressed. Some of the ways ED can
can result. Highly contagious. be treated include oral medications (Viagra, Levitra,
Cialis), penile injections (medication injected into
Hepatitis B and All caused by a virus. There is
C virus and HIV no care for any of the three. the penis), sex therapy, surgery such as penile
implants (device surgically implanted to overcome
418 UNIT 5 Assisting with Specialty Examinations and Procedures

HIPAA ASSISTING WITH THE MALE

REPRODUCTIVE EXAMINATION
Because of the very nature of erectile
HIPAA dysfunction, many men are embar- A female medical assistant usually is not required
rassed if they have the disorder, feeling to assist the provider with the examination of the
they are somehow less “manly” than male reproductive system. The provider exam-
other men. It is of extreme importance ines the penis and the foreskin of the penis in an
to be cautious and sensitive when uncircumcised patient. The penis and testes are
caring for these patients. Confidentiality on the examined for swelling, masses, or discomfort. A
telephone and during conversations must be transilluminator may be used by the provider to
maintained. Protect your patient’s privacy at all check the prostate gland. A lighted instrument
times. This is not only the law, but it is also an used to inspect a cavity or organ, the transillumi-
attribute of a professional medical assistant. nator is passed through the rectum to illuminate
the prostate gland through the walls of the rec-
tum. The provider perform a digital rectal exam-
impotence), and vacuum pumps. A vacuum pump ination to check the size of the prostate and also
device is a pump put over the penis; air is pumped checks for an inguinal hernia.
out of the cylinder, creating a vacuum. This vacuum When working in a total practice management
causes blood to fill the penis, making it erect. Once system, the provider can complete the examina-
the penis is erect, the pump can be removed. tion, orders tests and procedures, charts the find-
Some experts say ED should be considered ings, orders prescriptions as needed, and order a
a possible risk factor for heart disease if arthero- follow-up appointment for the patient—right in
sclerosis is present. the exam room (Figure 16-5).

Inpatient/Outpatient Results from

Admissions Regional/ Results to Outside
Referrals Pharmacy National Labs Providers

RECEPTION CLINICAL CARE LABORATORY

Patient Assessment
Procedures, Diagnoses & Treatment Plans
Scheduling Referrals & Follow-up Appointments
Patient Demographics Prescriptions Test Reports
Insurance Information Orders for Tests Quality Assurance & Controls
Patient Authorizations Patient Medical History Safety Standards

Referrals Test Results Orders for Tests

Follow-up Appointments Schedules and Tickler Files Safety Standards
Coordination of Services Patient Medical History
Medication Administration
Patient Education
Graphical Patient Data Displays

ELECTRONIC RECORDS
Figure 16-5 Clinical care, laboratory, and reception arms of a total practice management system.
 CHAPTER 16 Male Reproductive System 419

DIAGNOSTIC TESTS Critical Thinking

AND PROCEDURES
What test will be done at the first post-operative
Tests and procedures, in addition to those previously clinic visit following a vasectomy?
addressed, include vasectomy, semen analysis, and
urodynamic studies.

who treats infertility. It is also done as part of a

Vasectomy complete fertility workup and to evaluate the effec-
A vasectomy is performed to surgically sterilize tiveness of a vasectomy (see Chapter 32 for exten-
the male individual. The vas deferens extends up sive information about semen analysis).
into the abdomen where it connects to create the
ejaculatory duct that opens into the urethra. By
removing a portion of each vas deferens, sperm
Urodynamic Studies
cannot travel to mix with semen, thereby causing Urodynamic studies are a way of testing the lower
the male to be sterile (Figure 16-6). See Chapter urinary tract. A catheter is used to instill water into
19 for the vasectomy surgical procedure. the bladder and the information is fed into a com-
puter via electrodes. Bladder capacity, strength of
contraction, and the ability to retain urine in the
Semen Analysis bladder can be measured.
Semen testing is frequently performed in the Results from urodynamic studies can be
provider’s office or clinic to determine sperm cell stored electronically for readily accessible com-
counts before referring patients to a specialist parisons.

Vas deferens

Glans penis
Epididymis

Testis

Scrotum
Figure 16-6 Vasectomy (one side).
420 UNIT 5 Assisting with Specialty Examinations and Procedures

Procedure 16-1
Instructing Patient in Testicular Self-Examination
PURPOSE: 5. Locate the epididymis. Provide a chart to the
To provide a patient with information concerning tes- patient that illustrates the testes and epididymis.
ticular screening for the presence of a painless mass RATIONALE: A lump can be similar in size to
in the scrotum. the epididymis and needs to be distinguished
from the epididymis.
EQUIPMENT/SUPPLIES: 6. Look for swelling or changes in the scrotal area.
Testicular self-examination card
Anatomy illustration 7. Encourage the patient to report anything unusual
to the provider.
PROCEDURE STEPS: 8. Document the education provided in the patient’s
1. Identify yourself and explain the procedure. chart or electronic medical record.
2. Instruct patient to examine his testicles in a
warm shower. RATIONALE: The warmth causes DOCUMENTATION
the scrotal skin to relax. 11/4/20XX Patient instructed on how to perform testicu-
3. Examine each testicle separately with both hands. lar self-exam. Patient returned the demonstration and had no
4. Place the index and middle fingers underneath
questions. Joe Guerro, CMA (AAMA) _______________
the testicle and the thumbs on top. Roll the tes-
ticle gently between the fingers.

Case Study 16-1

Refer to the scenario at the beginning of the chapter. CASE STUDY REVIEW
After Dr. Woo examines the patient, John Abbott, he asks
you to schedule a pelvic ultrasound and a CT scan of the 1. What can be determined from these tests?
abdomen for the patient. 2. How will Dr. Woo know if Mr. Abbott’s results show
benign prostatic hypertrophy or prostate cancer?
Will more tests be needed? If so, what are they?

Case Study 16-2

Adam Desmond has an appointment today in the clinic for a CASE STUDY REVIEW
physical examination. His chief complaint is that he has been
having trouble sitting through ball games or movies without 1. How can the provider make a diagnosis of benign
having to go to the bathroom to urinate several times. prostatic hyperplasia?
2 What preliminary tests might the provider order for
Mr. Desmond today?
 CHAPTER 16 Male Reproductive System 421

Case Study 16-3

John Toomey called Dr. King’s office to say that he discov- CASE STUDY REVIEW
ered “something hard in his right testicle, like a marble.”
1. What will Dr. King’s examination consist of?

SUMMARY
A thorough knowledge of the diseases and disorders of the male reproductive system and the diagnostic
tests and procedures that are performed for this specialty will enhance the quality of care given by the
medical assistant.

STUDY FOR SUCCESS

To reinforce your knowledge and skills of information presented in this chapter:
• Review the Key Terms
• Practice the Procedures
• Consider the Case Studies and discuss your conclusions
• Answer the Review Questions

˚ Multiple Choice
˚ Critical Thinking
• Navigate the Internet by completing the Web Activities
• Practice the StudyWARE activities on your student CD
• Apply your knowledge in the Student Workbook activities
• Complete the Web Tutor sections

REVIEW QUESTIONS
Multiple Choice 3. Benign prostatic hypertrophy (BPH) is thought to
be caused by:
1. Cancer of the prostate may be detected early by a. excessive consumption of alcohol
which of the following? b. aging and hormonal changes
a. prostate-specific antigen c. recurrent epididymitis
b. transurethral resection of the prostate d. chronic chlamydia infections
c. semen analysis 4. Which of the following is a symptom of
d. urine culture prostatitis?
2. The best preventive measure for testicular cancer is a. painful urination
which of the following? b. low sperm count
a. yearly physical examination c. eruptions on the scrotum
b. yearly intravenous pyelogram d. high testosterone level
c. monthly self-examination
d. monthly urinalysis with cultures
422 UNIT 5 Assisting with Specialty Examinations and Procedures

5. The most definitive way to diagnose cancer of the 3. Find two other disorders or diseases of the male
prostate is by which of the following? reproductive tract (other than those in the text)
a. ultrasonography and (a) describe what they are, (b) how they are
b. intravenous pyelogram diagnosed, and (c) how they are treated.
c. biopsy of the prostate 4. Discover what contraindications exist for some men
d. semen analysis whose provider is considering prescribing Viagra or
one of the other medications for ED treatment.
Critical Thinking
1. Describe how a testicular self-examination should
be performed. REFERENCES/BIBLIOGRAPHY
2. What is the purpose of severing the vas deferens?
3. List several symptoms of BPH and explain why the Common male sexual problems—erectile dysfunction.
symptoms occur. Retrieved May 26, 2007 from http://www.webmd.
4. Describe the blood test that is helpful to diagnose com/sexual-conditions/guide/mens-sexual-prob-
prostate cancer. lems.
5. At what PSA level does the provider consider the Shuman, T. (ed.). (2006). Sexual conditions guide.
possiblity that the patient may have cancer of the Taber’s cyclopedic medical dictionary (20th ed.). (2005).
prostate? Philadelphia: F. A. Davis.
6. Explain why BPH is more common in men aged Tamparo, C., & Lewis, M. (2005). Diseases of the human
50 years and older. body (4th ed.). Philadelphia: F. A. Davis.
7. What age group is afflicted by testicular cancer, and Warner, J. (Ed.). (2007). Erectile dysfunction. Retrieved
how can the patient take action to detect it? May 29, 2007, from http://www.webmd.com/sexual-
8. How is a rectal examination on a patient useful conditions/guide/mens-sexual-problems.
to the provider in determining a diagnosis for a
patient who has nocturia?

WEB ACTIVITIES
Navigate the Internet to find a medical Web
site, then answer the following questions:

1. Describe two treatment choices for BPH.

2. Search for information about internal radiation or
“seeds” as a treatment choice for cancer of the pros-
tate. What did you find?
 Chapter

Gerontology
17
KEY TERMS OUTLINE
Andropause Societal Bias Prevention of Complications
Arteriosclerosis Facts about Aging Psychological Changes
Cognitive Functioning Physiologic Changes The Medical Assistant and the
Cystitis Senses Geriatric Patient
Dementia Integumentary System Memory-Impaired Older
Nervous System Adults
Empathy
Musculoskeletal System Visually Impaired Older Adults
Geriatrics
Respiratory System Hearing-Impaired Older
Gerontology Adults
Cardiovascular System
Hyperthermia Gastrointestinal System Elder Abuse
Hypothermia Urinary System Healthy and Successful Aging
Incontinence Reproductive System
Macular Degeneration
Nevus
Pernicious Anemia
OBJECTIVES
The student should strive to meet the following performance objectives and
Presbycusis
demonstrate an understanding of the facts and principles presented in this
Residual Urine chapter through written and oral communication.
Senile
Transient Ischemic 1. Define the key terms as presented in the glossary.
Attack (TIA) 2. Identify expected physiologic changes that occur as part of the
aging process.
3. List five common functional changes that can occur.
4. Describe prevention techniques for complications arising from
age-related disorders.
5. Explain two myths about aging.
6. Explain the importance of communication with older adults.
7. Identify several techniques or strategies to communicate with
visually and hearing-impaired older adults.
8. Describe strategies for healthy and successful aging.

423
 Scenario
Mrs. Johnson is an 82-year-old patient of Dr. King, and to medication. She has become a volunteer at the gift
she is scheduled for an appointment in the cardiac shop at St. Louis Hospital. She is an example of an
clinic. She is being evaluated for congestive heart older adult with chronic illnesses who has changed
disease and has had hypertension for many years. Her some long-time behaviors that were harmful to her
condition was difficult to control, but now she responds health.

INTRODUCTION
Gerontology is the scientific study of the problems asso-
ciated with aging. Geriatrics is the branch of medicine
that specializes in all aspects of aging: physiologic, patho-
logic, psychological, economic, and sociologic. The impor- Spotlight on Certification
tance of studying gerontology is becoming more recognized
because the expected life span is increasing. Thousands of RMA Content Outline
people are living to be 100 years old or older. The aging • Conditions of states of health
population is growing rapidly, and according to the U.S. • Health-related syndromes
Census Bureau, by 2030, there will be 60 million people • Patient education
in the United States older than 65 years. The 80 and
o Identify age-group specific responses
above age group is currently the fastest growing group. As
and support
a medical assistant, you will be experiencing the impact
o Understand and properly apply
on the health care system of this growing population of
people. communication methods
Through knowledge of the physical and psychologi- • Employ active listening skills
cal changes that occur as an individual ages, as a medi- CMA (AAMA) Content Outline
cal assistant you will be better able to recognize the special
• Developmental stages of the life cycle
needs of this group of people. You will draw on and use
effective communication skills and provide quality health • Hereditary, cultural, and environmental
care to geriatric patients. influences or behaviors
• Adapting communication to an
individual’s ability to understand
SOCIETAL BIAS (e.g., patients with special needs:
blind, deaf, elderly)
In our culture, there is a deeply ingrained bias • Instructing individuals according to
about aging. Older adults are stereotyped, and their needs
there is much discrimination because of age. Myths • Empathy
and stereotypes are common, and the medical assis- • Evaluating and understanding com-
tant can be an advocate for older adults and can be munication, observation, active listen-
sensitive to these myths and stereotypes. Accurate ing, feedback
information and useful concepts about aging must • Resource information and community
be communicated to the general public. Older services
adults oftentimes are viewed as sick, frail, power- • Patient advocate
less, sexless, and burdensome. As a society, we are
obsessed with the negative, rather than the positive, CMAS Content Outline
aspects of aging. The most popular myth is, “To be • Use human relations skills appropriate
old is to be sick.” Recent studies indicate that older to the health care setting
adults in the United States are generally healthier • Use effective written and oral
than their counterparts of nearly a decade ago. communication
Even in advanced old age, a majority of the older

424
 CHAPTER 17 Gerontology 425

Critical Thinking
What do you consider common myths about
older adults? What are your thoughts about
these myths?

population has little functional disability. Years of

research have debunked this myth. Because of bet-
ter education about the practice of healthier life-
styles, to be old in the United States does not mean
to be sick and frail. Thousands of people are living
to be older than 100 years because of the recog-
nition that healthy lifestyles are the most impor-
tant factor in helping people to live long, healthy,
productive lives. Such factors as good nutrition,
regular exercise, stress reduction, yearly physical
examinations, not smoking, and today’s technol-
ogy help forestall the aging process.

Figure 17-1 Note the many signs of aging.

FACTS ABOUT AGING
Following are general facts about aging:
the ways in which we grow older. Some believe that
• Aging is a progressive, universal, and slow process. the body endures wear and tear and stress during
• There are no diseases specific to aging. life and that because of this, eventually the body
• As people age, not all functional changes are loses its ability to function as well as it had. Oth-
related to disease. Interest, personal and finan- ers believe that as people grow older, the body
cial resources, family structure, genetics, and produces smaller and smaller amounts of various
attitude all play a part. The individual’s lifestyle hormones and other chemicals that keep the body
is a major factor. For example, smoking, misuse functioning. The fewer of these kinds of substances
of chemicals such as alcohol or drugs, type of that are produced, the more susceptible an indi-
diet, and lack of exercise all play a part in how vidual becomes to disease.
people age. Every body system undergoes changes as we
age. The changes are physiologic and psychologi-
• There is a wider range of what is considered
cal. As individuals move into their 60s and beyond,
“normal” function among older adults than
they will show physiologic changes that are part of
among younger people. There is a greater vari-
the aging process. As people age, their body systems
ability among older people in their physical abili-
function less effectively, causing them to have dif-
ties, sizes, and characteristics than among younger
ficulty performing their ordinary, everyday tasks of
groups (Figure 17-1).
living. Also, as people grow older, they can become
• All older ages are not alike. People in their 60s, more susceptible to disorders and diseases. When
70s, 80s, and 90s are all different. taking the medical history of an older patient, it
is evident that many have one or several chronic
illnesses. Heart disease, diabetes, arthritis, hyper-
PHYSIOLOGIC CHANGES tension, and vision and auditory impairments are
common.
Although aging is a normal process, not all indi- Although it is important to be knowledgeable
viduals age in the same way or at the same rate, about the physiologic changes that occur as part
because no two people have exactly the same of aging, it is important to realize that the majority
genetic inheritance, personal lifestyle, or experi- of older adults are free of serious, chronic health
ences in life. All of these factors strongly influence problems.
426 UNIT 5 Assisting with Specialty Examinations and Procedures

Laser surgery may halt the progression of the

Senses degeneration.
Vision. Many changes occur in the eye’s ability Because of failing vision and impaired bal-
to function. Pupil size diminishes, limiting the ance and coordination, older adults should be
amount of light that can go through it to reach cautioned to use handrails whenever possible.
the retina. There is a diminished production of
tears so the eye may be dry, red, and irritated. The Hearing. Loss of hearing in the aging process is
lens may become cloudy, and the cornea thick- not uncommon. It usually occurs over a period of
ens. There is increased sensitivity to glare. Several years, and the older person may not be aware of
problems can occur as a result of these changes. the loss. Loss of the ability to hear begins at about
There is less ability to see clearly at any distance the third decade of life. Many times, individuals
and to discern various shades of colors. Older with hearing loss seem inattentive or confused
people will need eyeglasses to help correct their and are thought to be mentally weak or senile.
vision loss, but reading small print can remain Presbyacusia or presbycusis is the progressive
difficult (Figure 17-2). Glare can be minimized loss of hearing ability caused by the normal aging
by incorporating a process known as polarization process.
into corrective lenses.
Cataracts, macular degeneration, and glau- Taste and Smell. Taste and smell diminish with
coma are common findings in older adults. Cat- age, making food less appealing because it no lon-
aracts can be surgically excised if they are large. ger tastes as good as it once did (Figure 17-3). Taste
Glaucoma can be treated medically or surgically buds decrease in size. Detecting odors becomes
but if left untreated can lead to blindness. Macular difficult and impaired, further lessening the desire
degeneration can lead to vision impairment. The for food. It is not unusual for older adults to lose
macular of the retina is an important area in the weight and even to become malnourished because
visualization of fine details. Macular degeneration of the loss of the ability to taste and smell. Lacking
is the leading cause of visual impairment in adults the sense of smell can be dangerous because of the
older than 50 years, making it difficult to do fine inability to smell smoke or gas and other danger-
work or such activities as threading a needle. ous fumes.

Figure 17-3 Older adults may add more salt and

Figure 17-2 Good lighting and large numbers on a sugar to their food to compensate for their diminished
telephone can help improve vision. sense of taste.
 CHAPTER 17 Gerontology 427

herbals) can cause decreased mental capacity, as

Integumentary System can malnutrition and substance abuse.
Aging individuals’ skin becomes more fragile with Loss of balance can be a problem for
less subcutaneous and connective tissue. Exposure some older adults. Their coordination of
to sunlight is the major cause of wrinkled skin, liver muscles for movement may need more
spots, and leathery looking skin. time for processing than it does with younger indi-
Sweat glands become smaller and the body viduals. Older adults need to be reminded to be
becomes nonsensitive to heat and cold. Hyperther- sure of their balance before starting to walk and to
mia, an unusually high fever, and hypothermia, an do so slowly. There is a general unsteadiness and
unusually low body temperature, are serious prob- lack of coordination not only because of the aging
lems, and exposure to excessive hot or cold tem- process, but also possibly because of medications
peratures should be avoided (see Chapter 21). the older adult takes (Figure 17-4). Older adults
Hair loses color and becomes thinner. The may need to use a cane to help steady their gait.
skin dries and is less elastic. Fingernails and toe-
nails thicken.
The development of skin cancer on the
Musculoskeletal System
exposed skin surfaces is not uncommon in older Musculoskeletal system changes are evident
adults. Basal and squamous cell carcinomas are the because older adults may have less muscle
most common skin cancer types seen in this popu- strength. This results in loss of mobility, and the
lation. Both types of cancer can be serious if left activities of daily living become more difficult.
untreated, but squamous cell cancer can metasta- There is less flexibility and joints can stiffen.
size. A complete skin assessment should be done Loss of height and a stooped appearance can
on a yearly basis. Melanoma, a malignant tumor result. Arthritis and osteoporosis are not unusual,
developing from a nevus, is the least common skin and older adults can suffer fractured bones more
cancer, but it can be serious because it metastasizes easily. Poor nutrition, malnourishment, and lack
readily. It is caused by exposure to the sun. Many of exercise all contribute to these conditions
older adults live in the Sunbelt areas of the and prolong healing time as well (see Chapters
United States and should be cautioned to 21 and 22).
wear sunscreen of at least SPF 15. People Osteoporosis—a thinning of the long bones,
of all ages should protect their skin daily with a pelvic bones, and vertebrae—is a fairly common
sunscreen of at least SPF 15, regardless of where problem in the aging population, with more
they reside. women than men affected. This thinning of bone

Nervous System
The brain shrinks in size as an individual ages
because brain cells do not continue to divide
throughout life as other cells do. Some loss of
memory or delay in memory can be expected in
many, but not all, aging people. Mental compe-
tence is the rule rather than the exception for
older adults. Sudden loss of memory accompanied
by confusion and inability to do tasks once able to
be performed could be an indication of an organic
problem, such as transient ischemic attack (TIA), a
temporary interference of the blood supply to the
brain, or a brain lesion.
Problems with balance, temperature regula-
tion, diminished pain sensation, and insomnia can
occur as part of the physical changes of aging that
affect the nervous system.
Chronic illnesses from which many older
people suffer often require several different med-
ications to keep under control. Side effects of Figure 17-4 Older adults should be instructed to take
medication (over-the-counter, prescription, and their time when sitting, standing, and walking.
428 UNIT 5 Assisting with Specialty Examinations and Procedures

makes these individuals more susceptible to pain adult may be dyspneic, short of breath (SOB), and
and fractures in these and other bones. New medi- more prone to pneumonia.
cations (Fosamax, Actonel, Evista) plus 1500 mg of As people age, there is a gradual decline in
calcium daily helps to slow the progress of osteo- the muscle structure of the respiratory system,
porosis. Vitamin D is essential for utilization of leading to a diminished ability to breathe deeply;
calcium. A deficiency of vitamin D in older adults thus, development of cough and pneumonia is not
occurs either because it is insufficient in their diets uncommon. Regular exercise can help to maintain
or because of insufficient exposure to sunlight. the ability to breathe and cough effectively. In peo-
Vitamin D is added to milk. ple who have been active throughout their lives,
Physical activity and a nutritional diet, includ- there is greater lung capacity.
ing dairy products, can stall the development
of bone and muscle loss; therefore, older adults
should be encouraged to keep active by walking,
Cardiovascular System
gardening, swimming, bicycling, golfing, and so Heart disease and blood vessel disorders are the
on. The pace of these activities should be suited to major cause of death in the United States. Lifestyle
the individual’s level of ability (Figure 17-5). has been implicated as the most significant cause
of cardiovascular disease. Blood vessels lose their
elasticity, become narrower, and build up with
Respiratory System plaque, and the arteries harden. This is known as
Breathing capacity diminishes with age, and oxy- arteriosclerosis. The myocardium loses some of its
gen and carbon dioxide exchange is lessened. The ability to pump effectively. This, together with nar-
rib and chest muscles become smaller and less rowed and plaque-filled arteries, causes the heart
efficient. Lungs lose their elasticity, and the older to pump harder. Hypertension, or sustained high

A B

Figure 17-5 (A) A regular exercise program helps promote successful aging. (B) Gardening is a beneficial form of
exercise.
 CHAPTER 17 Gerontology 429

blood pressure, is a direct result of these factors. pelvic floor, cystitis, hypertrophy of prostate gland,
Hypertension can contribute to the accumulation and diabetes.
of plaque in artery walls. Congestive heart failure
is the inability of the heart to pump effectively to
meet the body’s demand for blood. Myocardial
Reproductive System
infarction, or heart attack, is another result of arte- Women experience menopause at about age
riosclerotic heart disease. Regular exercise and a 55 years. Estrogen produced by the ovaries
healthy diet are the most beneficial activities for ceases, and changes in the female are noticeable
older adults in order to maintain adequate cardiac with shrinking of vulva and genitalia. Hot flashes
output throughout their life spans. are not uncommon because of blood vessel dila-
tion and contraction. Vaginal secretions dimin-
ish, the vagina becomes smaller, and infections
Gastrointestinal System are more likely. Estrogen replacement therapy
Stomach secretions and motility slow as part of helps to lessen symptoms but is used only for
aging. Peristalsis slows, and food moves through short-term therapy in women who experience
the gastrointestinal tract more slowly. Pernicious severe menopausal symptoms. Long-term use of
anemia is a disorder that can occur when cells of estrogen and progesterone has been proved to
the stomach lining fail to secrete the intrinsic fac- increase the risk for heart disease and breast can-
tor. Associated with the absence of hydrochloric cer (see Chapter 14 for information about hor-
acid, pernicious anemia affects the nervous system mone therapy).
and red blood cell formation. Men continue to produce sperm well after
Fewer calories are needed during this time 50 years of age; however, testosterone levels dimin-
because metabolism slows. Many overeat if they are ish and midlife changes occur in men. This is
lonely, gain weight, and may become obese. Eating known as andropause. It is about this time that
is a social as well as a physiologic event, and if they many men older than 50 years experience benign
have no one to eat with, many older adults will not hypertrophy of the prostate (see Chapter 16).
prepare a meal or eat properly to have good nutri- Medication may help in some cases; otherwise, sur-
tion. Loss of vigor and vitality occur. Malnourish- gery, a prostatectomy, may be performed.
ment is not uncommon. Aging men and women maintain their sexual
Poor eating habits, poor nutrition, overeat- desires, and many enjoy sexual intercourse more
ing, or undereating can lead to dental problems. when children are no longer in the home. They
Poor dental hygiene leads to gum disease and loss have more privacy and time to relax.
of teeth, many times making the chewing of food
difficult and discouraging. Sometimes cardiac
problems, such as endocarditis and myocardial PREVENTION
infarction, occur from gum disease due to the inva- OF COMPLICATIONS
sion of pathogens and inflammation.
Older adults are at risk for complications as a result
of changes in the structure and function of their
Urinary System body systems.
With aging, the kidneys decrease in size, resulting Accidents can happen because of impaired
in less urine production and output. With cardio- vision or the inability to hear a warning sound,
vascular arteriosclerosis, blood flow to the kidney such as a fire alarm.
is less. Filtering of waste products from the blood is Malnutrition and anemia can develop because
impaired. Medications are not excreted as quickly of poor nutrition or poor absorption of food. This
as they are in a young, healthy person. Levels of can be caused by lack of interest in food because of
medication may increase to a dangerous level lack of sense of taste or smell.
with impaired kidney filtration. The bladder walls Older adults may have diminished sensi-
become more inelastic, and the ability to empty tivity and lack the ability to feel pain as well as a
the bladder completely becomes difficult. Residual younger person does. Heat and cold applications
urine remains in the bladder, and microorganisms can injure an aging person if not watched care-
can cause an infection. Cystitis is infection and fully. Simple fractured bones may go unnoticed
inflammation of the bladder. Urinary incontinence, for some time. Loss of balance, disorientation,
the uncontrollable loss of urine, can be the result of and confusion may be signs of impaired nervous
many factors, such as relaxed muscles in the female system function.
430 UNIT 5 Assisting with Specialty Examinations and Procedures

Because many older adults suffer from osteo- Dementia affects memory, personality, and cog-
porosis, bones are more easily fractured. Falls nitive functioning (awareness, reasoning, judgment,
are more common because of a loss of vision and intuition) and is permanent. Alzheimer’s disease is
balance. a common form of dementia. Some research has
Respiratory tract infections are not unusual. shown that there may be a genetic, as well as envi-
Pneumonia is a serious complication in this group ronmental, link to the cause of Alzheimer’s disease.
of people. Encourage fluid intake and activity to People who have had a stroke, which inter-
keep the lungs healthy. feres with blood circulation to brain cells, may suf-
Urinary infections are more common. Ade- fer from dementia, impairing brain functioning.
quate fluid intake (eight 8-ounce glasses of liquid Other forms of dementia include Parkinson’s dis-
per day) help keep infections at bay. Incontinence ease, caused by a deficiency of dopamine, a chem-
occurs when pelvic floor muscles are relaxed after ical in the brain; syphilis, caused by a bacterium
childbirth. that causes brain damage (which manifests about
Circulatory problems because of cardiovas- 20 years after initial infection); and Hunting-
cular disease can cause poor circulation to the ton’s disease, a genetic disease. When caring for
extremities, especially the legs. Fluid retention patients with dementia, protect them from injury,
with noticeable edema are a common complica- allow them to be independent if possible, and do
tion, together with hypertension and congestive not be critical or judgmental of their behaviors (it
heart failure. is unintentional) or what they say. Scientists have
Vaginitis is more common because of vaginal not determined what is in the minds of patients
dryness and irritation caused by lack of estrogen. with dementia.
The prostate gland enlarges, making urination dif- Depression in older adults can occur from
ficult for men. loss of a spouse, chronic illness, or financial prob-
It is especially important for older adults to lems. When caring for older adults, look for signs
alert and consult with their providers when con- and symptoms of depression such as poor hygiene,
suming an alternative substance or when consid- insomnia or excessive sleep, crying, depressed mood
ering engaging in an alternative therapy. Many (sad every day, most of the day), inability to concen-
older adults take prescription drugs for a variety trate, and increased alcohol consumption. Personal-
of health problems, and there could be harmful ity seems to help determine how individuals adapt
effects because of the interactions of the prescribed to changes that they experience as they grow older.
medications with the alternative substance. Tai chi,
massage therapy, yoga, art therapy, music therapy,
and meditation are examples of some alternative THE MEDICAL ASSISTANT
or complementary therapies in which as older AND THE GERIATRIC PATIENT
adult patients can participate. Balance, mobility,
strength, creativity, and stress reduction are some Many older adults experience dementia,
of the benefits for older adults who choose to add mental illness, depression, stress, boredom,
these alternatives to enhance their health and fear of the unknown, loss of independence,
well-being. feelings of rejection and worthlessness, low self-
esteem, loneliness, dependence, failed expectations,
and disappointments. All of these factors coupled
PSYCHOLOGICAL CHANGES
There is a great deal of variation in the psycho- HIPAA
logical functioning of older adults. Among the
factors that contribute are the person’s health; Be cautious to limit access to patient
psychosocial history; race; sex; and environmen-
tal aspects, such as education, support system, and
HIPAA health records only to those who need
them to perform their jobs. Be sure to
social class. use passwords to safeguard databases and
The level of decline in an older adult’s intelli- keep computer screens facing away from.
gence can be affected by social factors. People who patients Disclosure of suspected pa-
maintain their intelligence tend to be in better tient abuse is necessary to prevent
health, have had more education, are in a higher serious threats or injuries to older
socioeconomic group, and are involved with oth- adult patients and is required by law.
ers and in their community.
 CHAPTER 17 Gerontology 431

with the physiologic changes that can occur offer a 9. Give clear and simple instructions.
special challenge to the medical assistant caring for 10. Ask the person to do one task at a time.
the health and needs of this group of patients. Allow
11. Listen actively. If you do not understand, apologize
patients time to ventilate and express their con-
to the person by saying that you did not understand
cerns, allow for private and confidential discussion,
exactly what was said. It is extremely important to
and empathize with their situation by being aware
phrase responses in a way that does not damage
of their feelings, emotions, and behavior. Good
the self-esteem of the older adult.
communication is essential for quality care of older
adults. Do not talk to older adults as if they were chil- 12. Avoid asking direct questions that require the per-
dren. Speak slowly and clearly. Face the individual son to remember a fact.
while talking. Write instructions in addition to ver- 13. Focus on well behavior or things that you know the
balizing them. patient can still do.
14. Use humor when appropriate. If expressed naturally,
Memory-Impaired Older Adults humor brings much needed laughter, a dimension
that is often lost in the health care setting.
Geriatric care poses challenges when attempting
15. Let the person know when you leave and if you are
to communicate with impaired older adults. The
returning.
inability to communicate on a meaningful level
can be frustrating and challenging, especially for 16. When discussing a case with another staff
the older person who is struggling to communi- HIPAA member, do so in private to protect patient
cate but cannot find the right words. Following are confidentiality.
some techniques that can be effective in improving
verbal communication with older people experi- Visually Impaired Older Adults
encing memory impairment:
Visually impaired people need to know you are
1. Talk to the person in a nondistracting place. It can present, but do not approach the individual until
be difficult for an older adult to concentrate or to you make your presence known. Help by explain-
sort things out when there are environmental dis- ing his or her location, and identify others who
tractions, such as other conversations, equipment may also be present (Figure 17-6).
noises, or people walking by.
2. Begin conversations with orientating information. Hearing-Impaired Older Adults
Identify yourself, and call older adults by their pre-
ferred names. Explain the purpose of your visit. For the hearing-impaired older adult to communi-
cate and understand instructions, there are some
3. Use short words and short, simple sentences with
techniques the medical assistant should keep in
no pronouns.
mind. These strategies will be beneficial and will
4. Speak slowly and say individual words clearly. facilitate communication and understanding. These
5. Never “talk down” or be condescending. techniques include:
This is demeaning. Speak in an adult man-
1. Face the hearing-impaired person directly and on
ner as you would to a coworker or friend.
the same level when possible. (If he or she is stand-
Provide the dignity and respect you wish
ing, the medical assistant should stand; if the patient
to receive yourself.
is seated, the medical assistant should be seated).
6. Lower the tone (pitch) of your voice. A raised
2. Keep your hands away from your face while talking.
pitch is a signal that one is upset. A lower pitch is
also easier for people with hearing impairments to 3. Reduce background noises when talking. Move to
understand. a quieter room away from extraneous sounds and
activities.
7. Talk to the person in a warm and pleasant manner.
Use nonverbal cues, such as facial expression, tone of
voice, or touch, to show your feelings of affection and
concern. Smiling, taking the older person’s hand, or
touching the person on the arm can vividly commu-
Critical Thinking
nicate that you are interested and really care.
Describe strategies for communicating with
8. When giving instructions, allow plenty of time for hearing-impaired patients.
the information to be absorbed.
432 UNIT 5 Assisting with Specialty Examinations and Procedures

The same procedure should be used when approaching

Making Contact curbs. Point out any changes in the terrain, even small ones.
Introduce yourself. Ask the visually impaired patient if he would
like assistance. If he does, offer your arm by saying so and by Sitting
touching your hand or forearm against his.
When guiding someone to a chair, walk up to it and place your
hand on the back of the chair. Let the patient trail your arm down
Grip to its back. Tell him which way the chair is facing, and he can then
The patient grips your arm just above the elbow. The grip must be seat himself.
firm but not so tight that it becomes uncomfortable. If the chair lacks a back or is very large, bring the patient up
to the chair so that his legs are against the front of it. He can then
Stance reach down to locate the arms and seat of it before he sits.
If the chair is at a table, describe the relationship of the chair,
The patient stands next to you, slightly behind. His arm is bent and
the table and the patient. Place one of his hands on the chair and
held close to his side. Relax your arm and let it hang naturally at
the other hand on the table.
your side.

Pace Doors
When approaching a closed door, tell the patient its position
The pace should be comfortable for both of you. If the patient tight-
when open. For example,“The door opens away and to the left.”
ens his grip or pulls on your arm, slow down; your pace may be too
Or say,“Take the door with your left hand.” After you open the
fast or he may be anxious.You should alert the patient to obstacles
door and begin to walk through, the patient will have his hand
such as curbs, stairs, doors, and thresholds. Be specific, but do not
ready to help hold it open as you walk through together. The
confuse him with too much information.
patient will move his arm across the front of his body to find the
door with the palm of his hand. He should close it behind you if
Stairs it is not a self-closing door. Use the narrow passage technique
When approaching stairs, tell the patient. Let him know whether in addition to this technique if the doorway is narrow.
you are going to go up or down. Be sure you approach the stairs
directly, not at an angle. Have the patient stand next to the hand- Narrow Passage Technique
rail if there is one.
When coming to a narrow passage, tell the patient. Move your
Pause at the top (or bottom) of the stairs and describe any-
guiding arm to the center of your back. Slow your pace. He will
thing unusual about them. The patient will find the handrail and
move behind you and extend his arm, placing you in a single-file
reach forward with his foot to locate the edge of the first step.
position. Once you pass through the narrow passage, bring your
Start down (or up) the stairs, keeping yourself one step ahead.
arm forward and return to the normal stance.
Keep a steady pace.
When you reach a landing, stop immediately. (Do not take an
extra step.) Doing so lets the patient know that there are no more
steps, and he can then match his stride with yours.

Figure 17-6 Sighted guide techniques.

4. Hearing-impaired individuals hear and under-

stand less when they are tired or sick. Elder Abuse
5. Get the person’s attention before beginning to What is elder abuse? Massachusetts law defines
speak and do not talk from another room. elder abuse as the committing or omitting of an act
6. Speak in a normal tone; do not shout. that results in serious physical or emotional injury
to an older adult. All states have elder abuse laws.
7. Be sure that light is not shining in the eyes of the
Abuse includes physical, emotional, and verbal
hearing-impaired individual.
abuse, and neglect. The law protects elders abused
8. If the hearing-impaired patient has trouble under- or neglected by caretakers.
standing, reword what you have said. Do not repeat All persons 60 years and older living in the
the same words again and again. community are protected under the law.
9. Written instructions are useful, but the medical Who must report elder abuse? Providers,
assistant must be certain that what is written is medical interns, dentists, medical assistants, nurses,
understood. family counselors, police officers, psychologists,
 CHAPTER 17 Gerontology 433

homemakers, licensed home health care aides, For information, contact elder protective ser-
and many others may be required to report abuse. vices programs in the Yellow Pages of your phone
Agencies are also liable. Any person required book, or contact the Eldercare Locator toll free at
to report abuse who fails to do so is subject to a (800) 677-1116 or via their Web site (http://www.
fine. Anyone who has reasonable cause to believe eldercare.gov/public/resources/assessment.esp).
an older adult has been abused may report it and
has a moral obligation to protect older adults. In
most states, the department responsible for elder HEALTHY AND SUCCESSFUL
affairs has established an elder abuse hotline to AGING
receive reports of abuse. Reports may also be
made to the designated protective service agency Older adults are enjoying longer, healthier lives.
in your community. Once reports are received by Some reasons for healthy aging are the increase
the elder protective services program, if appropri- in the number of gerontologists (specialists who
ate, a caseworker will assess the situation to deter- provide medical care only to older adult patients),
mine the nature and extent of the abuse. If abuse greater awareness and involvement of older adults
is confirmed, services will be provided to eliminate with their health care, improved nutrition, regular
or alleviate abuse. Many social services are usually exercise, new medications, and advancing medical
available. Mental health, legal, homemaker ser- technology (Figure 17-7).
vices, and alternative living arrangements may be Some tips for healthy aging according to the
provided (see Chapter 7). National Institute on Aging of the National Insti-
Some signs and symptoms of mistreatment or tutes of Health are:
abuse include:
1. Eat a balanced diet.
Psychological Physical 2. Exercise regularly.
Signs and Symptoms Signs and Symptoms
3. Get regular checkups.
• Increasing depression • Lack of personal care 4. Don’t smoke.
• Anxiety • Lack of supervision 5. Wear a seatbelt when in the car.
• Withdrawn/timid • Bruises 6. Practice safety to avoid falls and fractures.
• Hostile • Welts 7. Keep in contact with family and friends and stay
• Unresponsive • Lack of food active through work, community, and recreation.
• Confused • Beatings 8. Avoid overexposure to the sun and cold.

• New poverty • Neglect

• Longing for death • Unsatisfactory living
• Vague health conditions
complaints
• Anxious to please
There are other signs and symptoms, and not
all of those listed by themselves indicate mistreat-
ment, neglect, or abuse. If any seem to increase
in number or severity, it may indicate a problem.
By observing closely, you may be able to initiate
corrective action or reduce or prevent the situa-
tion from deteriorating. Careful documentation
in the patient’s chart or electronic medi-
E HR cal record over time can show continu-
ous signs and symptoms of abuse.
Usually the victim is frail (weak), physically or
emotionally, and dependent on the abuser for basic
survival needs. The victim may be afraid to speak out
for fear of retaliation. Many times the abuser is the Figure 17-7 With improved geriatric care, older
caregiver or a member of the patient’s family. adults can look forward to longer, healthier lives.
434 UNIT 5 Assisting with Specialty Examinations and Procedures

9. Drink alcohol in moderation. Don’t drink and

drive.
10. Keep personal and financial records in order to
simplify budgeting and investing. Plan for long-
term financial needs and housing.
11. Keep a positive attitude toward life and engage in
activities that make you happy.
12. Get vaccines: pneumonia, influenza, and herpes
zoster (Zostavax). Zostavax is approved for people
over age 60. It prevents herpes zoster (shingles).

Successful aging requires that healthy living

and daily activities be combined. To age success-
fully, individuals need to be continually involved,
must pursue what makes them happy, and make an
effort to maintain a positive attitude. These actions
of healthy habits should begin in childhood when Figure 17-9 This woman is celebrating her 100th
they can be formed and encouraged. They become birthday and is surrounded by her family and friends.
the responsibilities of each individual. Some activi-
ties that are important to successful aging are
socialization with friends and family, intimacy, edu-
cation, and employment (for income and social
satisfaction). For successful aging to happen, the
older person must make a commitment to work at
it (Figures 17-8 through 17-10).

Critical Thinking
What are some strategies that older adults
can do to keep mentally and physically
stimulated?

Figure 17-10 Caring for grandchildren is a very satis-

fying social relationship for many older adults.

Case Study 17-1

Refer to the scenario at the beginning of the chapter.

CASE STUDY REVIEW

1. Describe five strategies older adults such as
Mrs. Johnson can use to help slow the aging
Figure 17-8 An exercise class in an assisted-living process.
facility.
 CHAPTER 17 Gerontology 435

Case Study 17-2

Adelaide Robinson, 83 years old, has an appointment CASE STUDY REVIEW
Thursday morning for a recheck of her most recent com- 1. What are the possible causes of Mrs. Robinson’s
plaint. She tells you that she is moving slower than she complaints?
did just 6 months ago, and she has noticed less flexibility
2. What effect will these problems have on Mrs.
as well.
Robinson’s daily routine?
3. What might Dr. King suggest Mrs. Robinson do to
help alleviate symptoms?

Case Study 17-3

Sally Donovan, 92 years old, is in the gerontology clinic today. CASE STUDY REVIEW
Her main concern, problem, and reason for appointment 1. What are some reasons that older adults lose their
is that she “cannot taste or smell much anymore and food sense of taste and smell?
doesn’t taste good.” She wants suggestions from the provider
2. Describe any dangers that can be associated with
about how to improve her taste and smell so she can enjoy
loss of taste and smell.
food more freely.

SUMMARY
Many aging people live well into their 80s, 90s, and even to 100 years of age. They remain physically and
mentally stimulated. They learn a foreign language, learn to play a musical instrument, love to read, gar-
den, and volunteer. Older people are more aware today than ever before of the importance of a healthy
lifestyle and of its significant contribution to their long and healthy life span.
Other older adults, because of genetic inheritance, wear and tear, and stress, and loss of chemicals
and hormones, seem to age quickly and have little control over these factors.
Many others practice poor health habits, some by choice and others by circumstance. These habits
contribute to chronic diseases, disability, and a shorter and unhealthy life span.
Above all, dispel myths about older adults. Be patient, kind, consistent, and thoughtful.

STUDY FOR SUCCESS

To reinforce your knowledge and skills of information presented in this chapter:
• Review Key Terms
• Consider the Case Studies and discuss your conclusions
• Answer the Review Questions

˚ Multiple Choice
˚ Critical Thinking
• Navigate the Internet by completing the Web Activities
• Practice the StudyWARE activities on your student CD
• Apply your knowledge in the Student Workbook activities
• Complete the Web Tutor sections
436 UNIT 5 Assisting with Specialty Examinations and Procedures

REVIEW QUESTIONS WEB ACTIVITIES

1. Visit http://www.gov/aging/saha.htm. “The
Multiple Choice State of Aging and Health in America: 2007
1. The most chronic condition associated with older Report” (pp. 5–6). “Healthy Brain Initiative.”
adults is: Discuss what strategies older adults can adopt to
a. arteriosclerotic heart disease maintain brain function.
b. cystitis 2. The American Psychological Association Web site
c. presbycusis (http://www.apa.org) gives information about psy-
d. pernicious anemia chology. Find information that pertains to older
2. An eye disease common to older adults that is char- adults and their psychological health. What are
acterized by fluid pressure buildup is: some resources for mental health issues that can be
a. macular degeneration helpful for older adults?
b. presbyopia 3. The U.S. government has a Web site (http://www.
c. cataract aoa.gov/) for concerns and information about
d. glaucoma aging. What government agencies can an older
3. Joints in older adults become worn because: adult contact for help with health insurance ques-
a. cartilage erodes in the joints tions?
b. osteoporosis makes bones brittle 4. The National Osteoporosis Foundation Web site
c. muscle fibers decrease (http://www.nof.org) provides information about
d. vertebrae become thinner osteoporosis. Retrieve information about osteo-
4. Inability to cough deeply and raise mucus makes porosis that is useful for all older adults.
older adults more susceptible to which of the 5. Locate a Web site for older adults who have arthri-
following? tis. Find some techniques for these patients to
a. emphysema make their activities of daily living less difficult.
b. asthma
c. pneumonia
d. bronchitis
5. Residual urine refers to: REFERENCES/BIBLIOGRAPHY
a. catheterized urine for urinalysis Cox, H. (2001). Later life: The realities of aging (5th ed.).
b. first-voided specimen Upper Saddle River, NJ: Prentice Hall.
c. amount of urine left in bladder after voiding Hegner, B. R., Accello, B., & Caldwell, E. (2008). Nurs-
d. total amount of urine in the bladder when full ing assistant: A nursing process approach (20th ed.).
Clifton Park, NY: Delmar Cengage Learning.
Critical Thinking Hogstel, M. O. (2001). Gerontology: Nursing care of the
older adult. Clifton Park, NY: Delmar Cengage
1. How can an older adult’s food be made more
Learning.
appealing?
Lodge, H. S. (2007). You can stop “normal” aging.
2. What are some ways that older adults can keep
Parade Magazine, March 6, 2007.
bones from becoming brittle?
Markson, E., & Hollis-Sawyer, G. (2000). Readings in
3. Describe a vision problem that leaves older adults
social gerontology. Los Angeles, CA: Roxbury
with difficulty seeing color intensity.
Publishing Co.
4. What are four causes of urinary incontinence?
Perls, T. (2007). Simple steps may slow aging. Consumer
5. Give three ways to enhance communication with
Reports on Health, 19, 1−4.
older adults.
Simmers, L. (2008). Diversified health occupations (7th ed.).
6. What is the best way to approach a visually impaired
Clifton Park, NY: Delmar Cengage Learning.
person?
Taber’s cyclopedic medical dictionary (21st ed.). (2003).
7. Older adults in the United States are generally
Philadelphia: F. A. Davis.
healthier today than older adults of 30 years ago.
What are some of the reasons for this?
8. How can you encourage older adults to choose a
healthy lifestyle?
Examinations Chapter
and Procedures
of Body Systems 18
KEY TERMS OUTLINE
Amblyopia Urinary System Diagnostic Tests
Amsler Grid Signs and Symptoms of Urinary Spirometry
Appendicular Skeleton Conditions and Disorders Peak Expiratory Flow Rates
Aseptic Diagnostic Tests Pulse Oximetry
Urinary Catheterization Inhalers
Auricle
Digestive System Musculoskeletal System
Axial Skeleton
Signs and Symptoms of Fractures, Casting, and Cast
Bariatrics Digestive Conditions and Removal
Biopsy Disorders Neurologic System
Bronchi Diagnostic Tests Components of a Neurologic
Bronchodilator Bariatrics Screening
Carbuncle Sensory System Circulatory System
Closed Fracture The Eye Blood and Lymph System
Colonoscopy The Ear Integumentary System
The Nose Allergy Skin Testing
Comedone
Respiratory System
Demyelination
Signs and Symptoms of
Dislocation Respiratory Conditions and
Dysuria Disorders
Electrocochleography
Emaciation
Erythema
OBJECTIVES
External Respiration The student should strive to meet the following performance objectives and
demonstrate an understanding of the facts and principles presented in this
Frequency
chapter through written and oral communication.
Furuncle
Hematuria 1. Define the key terms as presented in the glossary.
Hemoptysis 2. Describe how to perform a urinary catheterization.
Immunoglobulin 3. Describe patient preparation for occult blood testing.
Inhaler 4. Differentiate between an instillation and an irrigation.
Internal Respiration 5. Discuss the different types of visual acuity charts and how to use
Lesion them appropriately.
Lithotripsy 6. Explain the medical assistant’s role when assisting with
Malabsorption audiometry.
Malaise 7. Describe the proper use of a metered dose inhaler.
Morbid Obesity 8. Briefly discuss the role of the medical assistant during
Nephrolithotomy spirometry and pulse oximetry.
Nitrogenous

437
OBJECTIVES (continued) KEY TERMS
9. Explain the medical assistant’s role in cast application and cast (continued)
removal and the guidelines for cast care. Nocturia
10. List items required by a provider for a neurologic examination Nystagmus
and explain the medical assistant’s role in the examination. Occluder
11. Explain oxygen administration using a nasal cannula. Oliguria
12. Describe how to perform a nasal irrigation. Opticokinetic Drum Test
13. Identify patient education information for sputum collections. Otoscope
Paresthesia
Phacoemulsification
Polyp
Proteinuria
Pyuria
Rosacea
Salicylates
Spirometry
Strabismus
Urgency

Scenario
At Inner City Health Care, a number of specialty exami- patients. Clinical medical assistants Wanda Slawson,
nations are scheduled for Tuesday the eighth. Admin- CMA (AAMA), and Bruce Goldman, RMA, take respon-
istrative medical assistant Jane O’Hara, who is office sibility to ensure that all supplies and equipment are
manager, is careful to schedule patients requiring spe- assembled, that both provider and patient are comfort-
cialty procedures so that times do not overlap; before able with the physical environment, and that all safety
she schedules, Jane makes certain examination rooms precautions are followed before, during, and after the
are available with an extra margin of time between examination or procedure.

INTRODUCTION
New techniques and developments occur fre- the provider with a multitude of clinical procedures
quently in medicine, and medical assistants that are an integral part of each specialty examination.
must refine existing skills and learn new ones This chapter covers specialty and body system
to be knowledgeable and proficient and to provide the examinations and the appropriate clinical procedures in
most current, up-to-date, quality care to patients. The urology; endoscopy; and the sensory, respiratory, muscu-
medical assistant who works in a specialist’s office or an loskeletal, neurologic, circulatory, blood and lymph, and
ambulatory care setting that treats a variety of patient integumentary systems.
problems needs additional skills when providing spe- Each specialty description includes tables that con-
cialty care to patients. Patients with conditions specific tain information on diseases, disorders, and diagnostic
to a particular body system or body part need special- tests and procedures used to confirm diagnoses. Other
ized care such as urinary catheterization or assisting diseases and disorders and procedures related to each
with a lumbar puncture. The medical assistant assists specialty are addressed in the body of the chapter.

438
 CHAPTER 18 Examinations and Procedures of Body Systems 439

Signs and Symptoms of Urinary

Spotlight on Certification Conditions and Disorders
RMA Content Outline Signs and symptoms of urinary tract diseases
• Anatomy and physiology include any abnormality in urine or in the ability
• Disorders and diseases to urinate. Some common signs and symptoms are
• Patient instruction
dysuria (painful urination), proteinuria (protein in
the urine), hematuria (blood in the urine), pyuria
• Asepsis
(pus in the urine), frequency, urgency, oliguria
• Sterilization (scanty urination), and nocturia (excessive urina-
• Instruments tion at night). Patients may report flank or low back
CMA (AAMA) Content Outline pain or experience fever, nausea, vomiting, general
malaise (general discomfort), and fatigue.
• Anatomy and physiology
Urinary tract infection (UTI) is the most
• Communication common disorder of the urinary system, and it
• Equipment manifests itself with many of the above signs and
• Principles of infection control symptoms. UTI is a broad diagnosis covering any
• Treatment area infection of the urinary tract including the urethra,
• Equipment preparation and ureters, bladder, and kidneys. UTIs may be caused
operation by virus or fungus, but by far the most common
• Patient preparation and assisting the infection is caused by bacteria. The most common
provider area is the bladder (cystitis).
• Collecting and processing specimen; Bacteria may reach the urinary tract through
diagnostic testing the blood (hematogenous infection) or enter the
tract through the urethra (ascending infection).
• Methods of collection
Hematogenous infection is less common and is
CMAS Content Outline usually the result of septicemia. In this case, the uri-
• Anatomy and physiology nary tract is a site of secondary infection. Primary
• Asepsis in the medical office infection of septicemia may begin in the respira-
tory or gastrointestinal tract and is carried to the
• Examination preparation
urinary tract through the blood.

Diagnostic Tests
URINARY SYSTEM The most commonly performed test to diagnose
urinary system disorders is a urinalysis. Many differ-
The urinary system includes the kidneys, ureters, ent disorders of the urinary system can be identified,
and bladder. The main function of the kidneys making this test extremely valuable. A specimen of
is to form and excrete urine, which contains urine can be analyzed for many components such
waste products harmful to body tissues. The kid- as pH, specific gravity, protein, glucose, leukocytes,
neys also regulate water balance in the body and and blood. The specimen can be further analyzed by
help maintain the acid–base balance of body examination under the microscope to look for bac-
fluids. teria, white and red blood cells, crystals, and casts.
Collecting and processing urine for labo- Urine culture and sensitivity can be per-
ratory analysis is covered in Chapter 30. Several formed and will indicate if a UTI is present so the
other clinical and diagnostic procedures of the appropriate antibiotic can be prescribed by the
urinary system are covered in this section, includ- provider. To obtain a urine specimen for culture,
ing urinary catheterization and an overview of there are two ways to collect the specimen: clean
performing a urine drug screen and a diagnostic catch or by catheterization (insertion of sterile
X-ray known as an intravenous pyelogram (IVP) tube into urinary bladder; see Procedures 18-1 and
or excretory urography used to diagnose disor- 18-2 and Chapter 30).
ders of the urinary tract. Blood tests can be done to determine whether
Diagnostic tests, procedures, disorders, and waste products are being adequately filtered out of
conditions common to the urinary system are the circulatory system. A test for kidney function
given in Tables 18-1 and 18-2. confirms the status of glomeruli function.
 440
Table 18-1 Urinary System Disorders

Laboratory/Diagnostic Tests

UNIT 5
Disease/ Medical Tests
Disorder Blood Urine Radiography Surgery or Procedures Treatment

Complete blood Urinalysis Intravenous pyelogram Biopsy of Cystoscopy Resection of cancer

Assisting with Specialty Examinations and Procedures

count Culture and sensitivity of Pelvic ultrasound bladder with (transurethral resection of
Cancer of urine endoscopy a bladder tumor [TURBT])
urinary Computed tomography
scan Cystectomy
bladder
Radium implants
Chemotherapy

Complete blood Urinalysis including micro- Intravenous pyelogram Cystoscopy Appropriate antibiotic
count scopic examination therapy
Cystitis
Culture and sensitivity of
urine

Blood urea nitrogen Urinalysis Intravenous pyelogram Biopsy of Diuretics

Creatinine Culture and sensitivity of Ultrasound of kidneys kidney(s) Antihypertensives
Glomerulo- urine
Blood culture X-ray of kidneys, ureters, Dialysis (if necessary)
nephritis
Sedimentation rate and bladder Kidney transplant
Electrolytes

Blood urea nitrogen Urinalysis Intravenous pyelogram Dialysis

Polycystic Creatinine Ultrasound of kidneys Kidney transplant
kidneys Electrolytes Computerized
tomography scan

Blood urea nitrogen Urinalysis Intravenous pyelogram Appropriate antibiotics

Pyelone- Creatinine Ultrasound of kidneys
phritis Blood culture
Electrolytes

Complete blood Urinalysis X-ray of kidneys, ureters, Cystoscopy Lithotripsy (crushing of a

count and bladder (KUB) kidney stone)
Renal
Uric acid Ultrasound of kidneys, Surgery (nephrolithot-
calculi
ureters, and bladder omy)
Intravenous pyelogram

Urinary Complete blood Urinalysis Cystoscopy Appropriate antibiotics

tract count Culture and sensitivity of
infection urine
 CHAPTER 18 Examinations and Procedures of Body Systems 441

Table 18-2 Description of Urinary Disorders and Conditions

Cancer of urinary bladder. Linked to cigarette smoking, industrial chemicals, and ingested toxins. Microscopic hematu-
ria is one of the first Signs.

Cystitis. Inflammation of the urinary bladder. More common in female patients due to the short length of the urethra. E.coli
may travel from the rectum to the bladder. Infectious organisms can invade the bladder during sexual intercourse. Fre-
quency, burning, dysuria, and urgency are common symptoms.

Glomerulonephritis. Seen in children and young adults after streptococcal infection; strep throat, scarlet fever. Causes
degenerative inflammation of glomeruli. Chills, fever, weakness are common symptoms. Edema and albumin in urine are
common. Hypertension occurs.

Polycystic kidneys. A congenital anomaly. Kidneys contain multiple cysts and greatly dilated tubules do not open into
renal pelvis. Hypertension, kidney failure, and death can result.

Pyelonephritis. Caused by pyogenic bacteria such as E. coli, streptococci, staphylococci, pregnancy, or calculi. May origi-
nate in the bladder and ascend to the kidneys. Pyuria, chills, fever, sudden back pain are symptoms. Dysuria is common.
Tenderness in suprapubic area.

Renal calculi. May be present with or without symptoms. Cause intense pain when they lodge in the ureter(s). Formed by
certain salts (perhaps calcium). Urinary urgency, nausea and vomiting, fever.

Two nitrogenous waste products normally fil- Patient Preparation for IVP. In studies of the
tered from the blood are urea and creatinine. A urinary system, the IVP requires that the patient
blood urea nitrogen (BUN) test checks the levels prepare with laxatives, enemas, and fasting (Table
of these two wastes. High levels of waste products 18-3). The IVP consists of an intravenous injection
can result in uremia (waste products in the blood), of an iodine-based contrast medium that is used to
a toxic condition of the blood that, if not reversed, define the structures of the urinary system. A ret-
leads to death (see Chapter 30). rograde pyelogram is a study of the urinary tract
An IVP, kidney-ureter-bladder (KUB) radio- done by inserting a sterile catheter into the urinary
graph, and cystogram are radiologic examinations meatus. Radiopaque contrast medium then flows
of the urinary tract. upward into the kidneys. This diagnostic test
is usually done in conjunction with cystoscopy.
Intravenous Pyelogram (Excretory Urography). Patients should have iodine-sensitivity tests before
An IVP is used to examine the urinary tract (kid- the examination to determine the possibility of
neys, ureters, and bladder) for blockage, narrowing, an allergic reaction. A voiding cystogram may be
growths, and calculi. This urinary tract diagnostic ordered in conjunction with an IVP. In this case,
radiograph is also used to diagnose disorders such the contrast medium is instilled into the bladder
as lesions, hydronephrosis (collection of urine in by catheter and no special patient preparation is
renal pelvis), and polycystic (many cysts) kidneys. needed (see Chapter 20).

Table 18-3 Intravenous Pyelogram

Purpose Patient Education Precautions

To examine the uri- 1. Light evening meal night before Contrast medium of iodine used for visualization
nary tract—kidneys 2. Cathartic (laxative) (check with patient regarding seafood or iodine
ureters, bladder—for allergies)
3. NPO after 9:00 PM
blockage, narrowing, Warn patients of possible warm flushed sensation
growths, and calculi. 4. Cleansing enema(s) in AM
when dye is injected and that they may experi-
ence a metallic taste.
442 UNIT 5 Assisting with Specialty Examinations and Procedures

Biopsy of the Kidney. Biopsies of the kidney will

Cystoscope
help confirm a diagnosis. Using radiology and
Light cord
(a type of ultrasonography, a fine-gauge needle is inserted
Urinary bladder
endoscope) through the flank to remove a piece of kidney
tissue for analysis and determination of possible
malignancy.

Light
Water cord
Urinary Catheterization
Prostate gland
In some states medical assistants can either
perform or assist with urinary bladder catheter-
ization, which is the introduction of a sterile
catheter (tube) through the urethra into the
bladder for withdrawal of urine. Figure 18-2
Rectum shows male and female anatomy for catheteriza-
tion. There are basically four reasons to cathe-
terize patients:
1. To obtain a sterile urine specimen for analysis
Figure 18-1 Cystoscopy.
2. To relieve urinary retention
3. To instill medication into the bladder, after the
Cystoscopy. Cystoscopy is a sterile procedure that bladder is emptied
uses a lighted scope (cytoscope) to view the ure- 4. To measure the amount of post-void residual urine
thra and bladder. Inflammation, bladder calculi
(stones), polyps, and tumors can be seen using a In some cases, this procedure is done by a
cystoscope. A biopsy of the bladder can be done urologist; however, some providers in obstetrics/
while performing a cystoscopy (Figure 18-1). gynecology and general and family practice

Vas deferens

Bladder

Urethra

Glans penis
Epididymis

Testis

A Scrotum

Figure 18-2 (A) Cross-sectional view of male anatomy showing urethra and bladder for catheterization.
(continues)
 CHAPTER 18 Examinations and Procedures of Body Systems 443

Mons pubis Symphysis pubis

Prepuce of
clitoris Labia majora
Clitoris
Glans of
clitoris
Labia minora

Urethral orifice

Hymen

Anus
Vaginal orifice
Coccyx
B

Uterus

Urinary
bladder

Rectum
Urethral
orifice
Anus

Vaginal
orifice
C

Figure 18-2 (continued) (B) External genitalia of the female. (C) Cross-sectional view of female anatomy showing
urethra and bladder for catheterization.

perform or have the medical assistant perform Procedure 18-1 gives steps for performing a
the catheterization. Catheterizing male patients is urinary catheterization of a female patient and
generally performed by a male provider. The pro- Procedure 18-2 for a male patient.
vider may order a culture and sensitivity of the
urine obtained from catheterization if the patient Catheterization Equipment. Urinary catheters
is experiencing dysuria, frequency, hematura, and are sized according to a system of French sizes.
urgency. This is done to determine if microor- A common size catheter is Fr 12. The higher the
ganisms are present and, if so, what the causative number the larger the diameter of the catheter.
microorganism is and which medication would The provider orders the catheter size when order-
irradicate it, in order to prescribe the appropriate ing the catheterization procedure. Urethral cathe-
antibiotics. ters, sometimes called straight catheters, are used
Sterile technique must be maintained through- when the catheter is removed after the procedure.
out the catheterization. Contamination of any items The Foley catheter is used when the catheter will
during the procedure requires discarding the items remain in the urinary bladder (indwelling cathe-
and obtaining new sterile equipment before con- ter). A suprapubic catheter (indwelling) is placed
tinuing the procedure (Figure 18-3). in the bladder during a surgical procedure. An
444 UNIT 5 Assisting with Specialty Examinations and Procedures

3. Digestion through secretions of digestive enzymes

4. Absorption of nutrients into the bloodstream
5. Defecation of the solid waste products of digestion
When any of these functions is hindered, the
digestive system malfunctions.
The digestive process begins in the mouth
and concludes at the anus. As food passes through
the alimentary canal (gastrointestinal tract), or
digestive tract, it is mixed with gastric juices and
enzymes, allowing it to break down into smaller
nutrients, which allows absorption through the
walls of the small intestine. Contents that have not
been absorbed travel through the large intestine
Figure 18-3 Catheterization kit. and are excreted through the anus. Tables 18-4
and 18-5 list common tests, procedures, disorders,
and conditions of the digestive system. Figure 18-5
incision is made in the suprapubic area. The blad- shows the major organs of the digestive system.
der empties through the catheter.
Sterile, disposable catheterization kits are Signs and Symptoms of Digestive
available that contain all necessary items to per-
form the procedure. Figure 18-4 shows the types
Conditions and Disorders
of urinary catheterizations. Common signs and symptoms of disorders and
diseases of the digestive tract include nausea,
vomiting, stomach cramping, diarrhea, heart-
DIGESTIVE SYSTEM burn, loss of appetite, weight loss, indigestion,
fatigue, hematemesis (vomiting blood), melena
The gastrointestinal system performs the following (blood in feces), and hematochezia (bright red
five functions: blood in feces).
Many disorders and diseases of the diges-
1. Ingestion (taking in) of food and breaking it into tive tract can cause these signs and symptoms.
smaller particles Gastritis, a common ailment of the stomach, can
2. Passage of food through the digestive system be caused by caffeine, aspirin and other medica-
(peristalsis) tions, spicy foods, and alcohol. It is characterized

Pubic bone Abdomen

Pubic bone Bladder Bladder
Pubic bone Bladder
Urethra
Urethra
Urethra

A Rectum B Rectum Vagina Uterus C Rectum Vagina Uterus

Figure 18-4 Types of urinary catheterizations: (A) Straight catheter. (B) Indwelling catheter. (C) Suprapubic
catheter.
Table 18-4 Digestive System Disorders

Laboratory/Diagnostic Tests
Disease/ Medical Tests or
Disorder Blood Urine Other Radiography Surgery Procedures Treatment
Complete blood Urinalysis Electrocardiography Replacement of fluids and
Anorexia count electrolytes if needed
nervosa Electrolytes Psychiatric care
Blood glucose
Complete blood Urinalysis Abdominal ultra- Rectal Appendectomy
Appendicitis count Pregnancy sound examination
test
Complete blood Urinalysis Electrocardiography Replacement of fluids and
count electrolytes if needed

CHAPTER 18
Bulimia Electrolytes Care of esophagus and
teeth erosion
Psychiatric care
Complete blood Urinalysis Cholecystogram Cholecystectomy
count (oral or intravenous)
Cholecystitis
Serum bilirubin Ultrasound of gall
bladder

Examinations and Procedures of Body Systems

Complete blood Radioisotope scan Cholecystectomy
count Ultrasound of gall Asymptomatic—no treat-
Cholelithiasis Serum bilirubin bladder ment other than diet modifi-
Intravenous cholan- cation (low-fat diet)
giogram
Complete blood Barium enema Biopsy of Sigmoidoscopy Colectomy
count Abdominal colon Colonoscopy Resection of colon
Electrolytes ultrasound Radiation
Colon cancer
Computed tomog- Chemotherapy
raphy (CT) scan of
abdomen
Complete blood Abdominal ultra- Biopsy of Sigmoidoscopy Nutritional support
count sound colon Colonoscopy Medication (antibiotics, anti-
Crohn’s Stool culture
Electrolytes Barium enema inflammatories)
disease Abdominal flat plate Pillcam
Surgery of affected portion of
colon (resection)

Complete blood Barium enema Sigmoidoscopy Antibiotics

count Abdominal flat plate Colonoscopy Surgery if bowel perforates
Diverticulitis
Erythrocyte sedi- (colectomy)

445
mentation rate
(continues)
 446
Table 18-4 Digestive System Disorders (continued)

UNIT 5
Laboratory/Diagnostic Tests

Disease/ Medical Tests or

Disorder Blood Urine Other Radiography Surgery Procedures Treatment

Assisting with Specialty Examinations and Procedures

Complete blood Guaiac test Upper gastro- Biopsy of Gastroscopy Cessation of:
count intestinal series stomach • Aspirin
Electrolytes
• Antiinflammatory drugs
(Ibuprofen, Naproxen, etc.)
• Corticosteroids
Drug-induced
ulcer • Iron
• Methotrexate
Treatments
• Histamine H2 blocking
agents (Pepcid, Prilosec,
Tagamet, Zantac)

Complete blood Breath test Upper gastro- Biopsy duo- Upper endoscopy Medication: gastric
count H. pylori intestinal series denum Esophagogastric secretion–blocking agent
duodenoscopy Antibiotics
Duodenal Occult
(EGD)
ulcer blood test Lifestyle changes
Small, frequent meals
Gastrectomy if perforation
Complete blood Stool sample Perianal examination Medication
Enterobiasis count for ova and
parasites

Complete blood Guaiac test Upper gastro- Biopsy stom- Upper endoscopy Medication: gastric
count H. pylori intestinal series ach lining secretion–blocking agent
Serum albumin Abdominal radio- Antibiotics
Culture
Gastric ulcer Transferrin graphs
stomach Lifestyle changes
secretions Small, frequent meals
Breath test Gastrectomy if perforation

Complete blood Stool culture Upper gastro- Upper endoscopy Usually self-limiting
count intestinal series Maintain electrolyte balance
Gastroenteritis Electrolytes Antibiotics if indicated
Infection control

Complete blood Samples of Upper gastro- Biopsy of Gastroscopy Antacid medications (Prilo-
Gastritis count gastric intestinal series stomach sec, Tagamet, Zantac)
content Antibiotics if needed
Gastro- Esophageal ultraso- Medication
esophageal nography Esophageal
reflux disease Diet modification
manometry
Gastroscopy Weight loss
(GERD)

Complete blood Hemorrhoid- Physical Hemorrhoidectomy

count ectomy examination Ligation
Hemorrhoids
Proctoscopy Cryosurgery

Protein Urinalysis Ultrasonography of Liver biopsy Liver scan Hepatitis A

Bilirubin liver • Immunoglobulin
Liver functions Hepatitis B
Hepatitis Alkaline phospha- • No specific treatment
tase Hepatitis C
Gammaglobulin • Medication (alpha-
interferon; ribavirin)

CHAPTER 18
pH studies Upper gastro- Biopsy Gastroscopy Elevate head of bed for sleep
of gastric intestinal series Antacid medications (Prilo-
Hiatal hernia secretions Chest radiograph sec, Tagamet, Zantac)
(Figure 18-6) Avoid foods that irritate stom-
ach and esophagus
Avoid overeating

Examinations and Procedures of Body Systems

Complete blood Ultrasonography Percutaneous Surgical resection (if
count Computerized axial needle aspiration possible)
tomography scan biopsy Radiation therapy
Pancreatic
cancer Endoscopic ret- Chemotherapy
rograde cholan-
giopancreatography
(ERCP)

Serum amylase Ultrasonography Analgesics

Complete blood Computerized axial Diet modification
count tomography scan
Pancreatitis Erythrocyte sedi- Endoscopic ret-
mentation rate rograde cholan-
giopancreatography
(ERCP)

447
448 UNIT 5 Assisting with Specialty Examinations and Procedures

Table 18-5 Description of Digestive Disorders and Conditions

Anorexia nervosa. An eating disorder of psychological origin. The individual does not eat and becomes emaciated
(extremely thin) and malnourished because of the need to avoid weight gain.

Appendicitis. Acute inflammation of the appendix usually caused by infection or obstruction. Characterized by pain, nau-
sea, vomiting, and fever.

Bulimia. A syndrome in which an individual binges on food and then purges by inducing vomiting. Laxative abuse is com-
mon. The reason individuals engage in this behavior is to avoid weight gain; it is of psychological origin.

Cholecystitis. Inflammation of the gallbladder. Usual cause is gall stones, but other causes may be bacteria or chemical
irritants.

Colon cancer. Common malignancy characterized by change in bowel habits, diarrhea or constipation, and abdominal
discomfort as tumor grows.

Crohn’s disease. Chronic disease that exhibits inflammation of the ileum resulting in diarrhea, right lower quadrant pain,
and attacks of diarrhea and frequent blood in the stools.

Diverticulitis. Inflammation of diverticula usually caused by impacted feces or bacteria in the sacs. Pain, cramplike, usu-
ally in left side of abdomen. Obstruction can develop.

Diverticulosis. Diverticula in colon without symptoms.

Drug-induced ulcers. Ulcers of the stomach or duodenum caused by taking salicylates (aspirin), corticosteroids, antiin-
flammatory medications (ibuprofen, naproxen), iron, and Methotrexate.

Duodenal ulcer. Lesion in the mucous membrane of the small intestine usually caused by hyperacidity or
Helicobacter pylori.

Enterobiasis (pinworms). Intestinal parasites causing intestinal and rectal infection. Pruritus of the anus is a symptom.

Gastric ulcer. Caused by Helicobacter pylori, a bactrium, salicylates, smoking, and alcohol.

Gastritis. Inflammation of the stomach lining usually caused by an undefined irritant including alcohol, bacteria, or
viruses. It can result in stomach discomfort, nausea, or vomiting.

Gastroenteritis. Inflammation of the stomach and intestinal tract. Causes nausea, vomiting, and diarrhea. May be caused
by ingestion of pathogen.

Gastroesophageal reflux disease (GERD). A small valve in the lower esophagus (between the stomach and esophagus)
leaks causing stomach acid to back up from the stomach to the esophagus. There is frequent heartburn and discomfort
behind the sternum.

Hepatitis. Inflammation of the liver caused by infection from a virus resulting in hepatomegaly, anorexia, and jaundice.
Hepatitis A. Spread by fecal contamination of food or water.
Hepatitis B. Spread by blood and body fluids contamination through sexual contact, contaminated needles, perinatal
fluids, semen.
Hepatitis C. Spread by blood (i.e., transfusion), contaminated needles, and sexual contact.
Refer to Chapter 10 for more information about hepatitis.

Hiatal hernia. Congenital or traumatic protrusion of stomach through the diaphragm into the chest cavity (Figure 18-6).

Pancreatic cancer. Cancer of the pancreas (usually the head). One of the leading causes of cancer deaths in the United
States. Most commonly seen in the 60- to 70-year age group.

Pancreatitis (acute and chronic). Inflammation of the pancreas. Acute: can be a life-threatening event; pancreatic
enzymes begin to digest the pancreas causing necrosis and hemorrhage. Chronic: a slow, progressive destruction of the
pancreas thought to be from enzymes digesting the pancreas as seen in acute pancreatitis. May be idiopathic or related
to alcoholism. Diabetes can be a complication of pancreatitis.
 CHAPTER 18 Examinations and Procedures of Body Systems 449

water, drug reactions, and allergic reactions to

particular foods. Peptic ulcers found in the stom-
Parotid gland ach are called gastric ulcers and can be caused by
Pharynx
the action of pepsin, an enzyme. It is an erosion
(eating away of tissue) of the mucous lining of the
stomach. Salicylates (such as aspirin), alcohol,
Esophagus smoking, oversecretion of hydrochloric acid, and
stress seem to be implicated in this disease. Some
gastric ulcers may be caused by the bacterium
Diaphragm Helicobacter pylori and require antibiotic treatment.
Ulcers found in the duodenum are called duode-
Liver
Stomach nal ulcers and are similar to gastric ulcers. A duo-
Pancreas
denal ulcer is an erosion of the mucous lining of
the duodenum, a part of the small intestine. If the
Small ulcer is determined to be caused by the bacteria,
intestine Large intestine antibiotics will be prescribed. Both types of ulcers
Rectum
seem to run a chronic course. If they are not con-
Anus
trolled, the ulcerated area can perforate (a hole
Appendix caused by ulceration) and hemorrhage ensues.
Contents of the stomach or intestine can spill
out into the abdominal cavity and cause a serious
complication called peritonitis (infectious organ-
isms enter the membrane covering the internal
Figure 18-5 The digestive system. organs). See Figures 18-7 and 18-8.
Diarrhea is characterized by frequent liquid
bowel movements. Diarrhea and vomiting may
by epigastric pain, nausea, and vomiting of blood have many causes such as allergic reactions, infec-
(hematemesis). Gastroenteritis (inflammation of tions from food or water, or stress. Dehydration
the stomach and small intestine), another com- can become a problem if diarrhea continues for
mon ailment, is also known as food poisoning, several days. Infants, children, and older adults are
intestinal flu, and traveler’s diarrhea. It can be especially vulnerable to dehydration from vomiting
caused by infections from contaminated food or and diarrhea.

Esophagus This part of

the stomach
is normally
located below
Cardiac the diaphragm.
sphincter

Diaphragm
Gastric ulcer

Stomach

Pyloric
sphincter

Duodenal
ulcer

Figure 18-6 Hiatal hernia. Figure 18-7 Peptic ulcers.

450 UNIT 5 Assisting with Specialty Examinations and Procedures

Parotid gland
Pharynx

Perforation 18%

Hemorrhage 25% Esophagus

Diaphragm

Liver
Stomach

Pancreas

Small intestine Large intestine

Figure 18-8 Diverticulosis. Rectum
Anus
Appendix
Diagnostic Tests
Diagnostic tests for the digestive system commonly
include radiography and endoscopy (viewing within
the body with a lighted scope). An upper gastroin-
Figure 18-9 Lower gastrointestinal series; highlighted
testinal (GI) series (barium swallow) is done to visu-
area is visualized.
alize the esophagus, stomach, and upper portion
of the small intestine. A lower GI series (barium
enema) visualizes the large intestine (see Figures
18-9 and 18-10 and Chapter 20).
Endoscopy allows the provider to look directly Parotid gland
into the digestive organs with a lighted scope. Some
examples of endoscopies used in the digestive tract Pharynx
are named by the organ being scoped:
Stomach: gastroscopy
Esophagus
Colon: colonoscopy
Sigmoid colon: sigmoidoscopy
Entire upper GI area: esophagogastroduodenos-
Diaphragm
copy (EGD); see Figure 18-11 Liver
Stomach
Biopsies can be taken during an endoscopic
procedure. Pancreas
Small
Sigmoidoscopy. Sigmoidoscopy is a diagnostic intestine
examination of the interior of the sigmoid colon. Large intestine
It is a useful aid in the diagnosis of cancer of the Rectum
colon, ulcerations, polyps, tumors, bleeding, and Anus
Appendix
other lower intestinal disorders. The sigmoido-
scope is a flexible instrument with a light source
and a magnifying lens, which permits visualization
of the mucous membrane of the sigmoid colon.
Providers commonly use the flexible sigmoid-
oscope. Because it is flexible, it can be inserted Figure 18-10 Upper gastrointestinal series; highlighted
farther into the colon, making it possible to view area is visualized.
 CHAPTER 18 Examinations and Procedures of Body Systems 451

Gastroscope

Esophagus
Stomach

Duodenum

Figure 18-11 Esophagogastroduodenoscopy (EGD)

procedure.

more of the mucous membranes of the intestines

(Figure 18-12).
As with any examination of the pelvic or
abdominal cavity, you should advise the patient
to empty the bladder and evacuate the bowel
before the procedure begins. This will make the
B
examination easier for both patient and exam-
iner. During the procedure the patient should be Figure 18-12 (A) Setup for a proctosigmoidoscopy
instructed to breathe through the mouth deeply with a flexible sigmoidoscope. (B) Control head of
and slowly to relax abdominal muscles. Patients proctosigmoidoscopy.
may feel the urge to defecate during a colon exam-
ination because of the stretching of the intestinal
wall from the instrument passing through and
air being introduced with it. If patients use the products, raw fruits and vegetables, and grains
breathing technique mentioned, this discomfort and cereals from their diet, and encourage them
can be relieved. The procedure should last only to drink plenty of clear liquids and eat lightly the
a few minutes, especially if patients have followed day before the scheduled appointment for the
preparation instructions. sigmoid colon examination. A plain commer-
Air is sometimes introduced into the sigmoid cial enema should be self-administered at home
colon (by the examiner’s use of the inflation bulb approximately 2 hours before the examinations.
attached to the scope with tubing) to distend the The provider may vary the instructions accord-
wall of the colon for easier placement of the lumen ing to the patient’s condition. If patients are not
of the endoscope. Patients find this to be uncom- completely informed about preparations and
fortable and sometimes painful. The provider may the examination is attempted with unsatisfactory
need to use suction to remove mucus, blood, or results, the examination will have to be repeated,
fecal material that is obstructing the view of the sig- which is both costly and inconvenient. Satisfactory
moid colon. results are obtained by giving patients both oral
During these examinations, the medical assis- and written instructions.
tant’s roles are to hand necessary items to the pro- There are occasions when, during an ap-
vider and to give support to the patient. pointment for which the patient was “worked
Most often it is the medical assistant who in” to the schedules, the provider believes that
teaches the patient how to prepare for the the patient’s condition warrants examination of
sigmoidoscopy and explains how the test is per- the sigmoid colon. In this case, the provider will
formed. For successful examination, proper prep- order an enema to be given to the patient in the
aration is essential. Have patients restrict dairy office.
452 UNIT 5 Assisting with Specialty Examinations and Procedures

Administering an enema to a patient in the for the patient’s convenience when you administer
medical office or clinic is not a common proce- an enema. Your patience and understanding are
dure, but it is sometimes necessary for the suc- needed, because many patients are embarrassed to
cessful completion of a sigmoidoscopy or other have an enema administered to them.
rectal examination. Even though a patient may Some examinations, such as diagnostic sig-
have received proper instructions and carried them moidoscopy and X-rays, require the use of laxa-
out before the scheduled appointment, there is no tives by the patient the day before or the morning
guarantee that the patient achieved success. In the of the examination. This may present a problem in
event that the patient comes in for the appoint- the patient’s personal or employment schedule if
ment and the colon is not sufficiently evacuated of instructions are not made clear before the appoint-
feces for a sigmoidoscopy, the physician may order ment is made. Most patients are fearful of what
a cleansing enema so that the examination can the diagnostic examination will disclose. Helping
be completed. It is generally best to proceed with them choose a convenient appointment time and
the planned procedure, even with the delay of the explaining the reasons for the preparations they
enema. Usually this works out well for patient and must undergo is usually appreciated.
staff, because rescheduling presents difficulties for Proper positioning of the patient during the
everyone. sigmoidoscopy is important for both the provider’s
Often the patient did follow the list of instruc- viewing of the rectum and sigmoid colon and the
tions but was not able to retain the enema solu- patient’s comfort. Proctology tables are designed
tion long enough to get satisfactory results. You especially for this procedure (refer back to Fig-
will more likely be able to encourage the patient ure 13-11). They provide support of the patient’s
to retain the contents of the enema longer. You chest and head with the arm resting against the
may want to explain that the longer the contents headboard as the table is tilted to the knee-chest
are retained, the more successful the results will position. Patients who cannot tolerate this position
be. Otherwise, it may have to be repeated, or the are assisted into Sims’ position for the examina-
examination rescheduled. Be certain that you use tion. Many providers find this acceptable and it is
an examination room that is close to the rest room more comfortable for the patient. You should ask

Patient Education
With the provider’s direction, you may discuss 4. Inform patients who are 40 years and older
with your patients the following topics about that they should routinely test their stool for
their digestive health. occult blood every two years for screen-
1. Remind them that laxatives and enemas ing of cancer of the colon, or more often
should only be used by direction of the if advised by the provider (if family history
provider. indicates). All patients older than 50 years
should test annually for occult blood and
2. Constipation may be avoided/relieved by
have a colonoscopy.
including fresh fruits and vegetables, cere-
als, and grains in the diet; drinking plenty 5. Advise patients to include high-fiber foods
of liquids (water); and getting regular exer- in their diets, avoid fat (especially satu-
cise. rated fats) and cholesterol, and eat red
meats sparingly.
3. Instruct them that if they have any of the
following symptoms persistently it could 6. Urge patients to eat a variety of foods
mean that a disease or an abnormal (from the food pyramid) and to eat four
condition is present and consulting the to six small meals rather than one or two
provider is strongly advised: heartburn or large meals daily to promote better utiliza-
indigestion, nausea or vomiting (especially tion of nutrients and more energy.
if coffee grounds consistency), constipa- 7. Suggest to patients that they select snacks
tion or diarrhea, excessive gas or bloating, and beverages wisely such as fruits,
stool that is tarry (black), or other than a vegetables, and juices over coffee/tea/
normal brown color. soda and high-calorie sweets or chips.
 CHAPTER 18 Examinations and Procedures of Body Systems 453

about the provider’s preference for patient posi-

tion because there are many variations. Critical Thinking
The provider may wish to view the intestinal
mucosa after a normal bowel movement. More Phyllis Lomeli, a new patient of Dr. Reynolds,
often, the patient is instructed to eat a light diet has been experiencing gastrointestinal prob-
containing plenty of clear liquids and avoiding lems. Dr. Reynolds has ordered fecal occult
dairy products for 24 hours before the exami- blood tests for the patient. What diet instruc-
nation, and to have a plain cleansing enema the tions does the medical assistant give to the
morning of, or 2 hours before, the examination. patient? What directions and supplies does
Still other provider’s may wish patients to use laxa- the medical assistant give to the patient?
tives the day before and an enema the night before When the guaiac slides are returned by the
and also the morning of the examination. patient, how does the medical assistant
When making a diagnosis of hemorrhoids, fis- develop and interpret them?
sures, and ulcerations, the provider usually begins
investigative procedures by examining the anus
and the interior of the rectum with a proctoscope.
During the sigmoidoscopy, the provider may want type instrument inserted through the colono-
to take a biopsy of questionable tissue from the sig- scope. The tissue is microscopically examined by
moid colon to aid in confirming the diagnosis. It a pathologist to determine whether a malignancy
is a good rule to have all possible necessary items (cancer) is present in the colon (Figure 18-13).
available. When the patient has been prepared and The patient may receive a muscle relaxant/tran-
the provider is ready to begin the examination, the quilizer to facilitate the examination. (See “Endo-
medical assistant hands the necessary instruments scopic Procedures” later in this chapter.)
and supplies to the provider as needed. Remember
to advise patients to report any problems, such as Fecal Occult Blood Test. Patients may be in-
bleeding, discharge, swelling, or any other unusual structed to obtain three stool specimens at home
discomfort, after the procedure. A biopsy labora- for examination of a fecal sample for occult (hid-
tory request form must be completed and accom- den) blood. The patient will be given occult blood
pany the tissue to the laboratory. Containers for slides, applicators, and envelopes to take home
biopsy specimens have a formaldehyde solution to (Figure 18-14). The patient will need to obtain two
preserve the tissue until the analysis is done. small stool samples from each of three separate
Whereas the proctosigmoidoscope exam- bowel movements. Three separate samples are
ines the rectum and sigmoid colon with a flexible used to allow detection of blood from GI lesions
scope, a procedure known as a colonoscopy (view- that exhibit intermittent bleeding. The medi-
ing the colon with a lighted scope) can be sched- cal assistant’s role is to instruct the patient about
uled in the outpatient department of the hospital how to properly collect the stool specimens on the
or endoscopy center or performed in the office or
clinic. A flexible fiberoptic colonoscope is used,
and the entire length of the large intestine (colon)
can be examined for lesions such as tumors, pol- Transverse
yps, fissures, and masses. Biopsies that consist of colon 5%
small tissue pieces can be removed with a snare- Splenic
flexure 3%
Hepatic
flexure 3%

Descending
Patient Education colon 5%

After sigmoidoscopy, patients should drink

plenty of clear fluids to help relieve the Cecum 9%
abdominal discomfort and flatulence. Sigmoid
Patients may also find relief in lying in a colon 21%
prone position with a pillow across their Rectum 54%
midabdominal area to aid in the passage
of gas.
Figure 18-13 Incidence of colorectal cancer by site.
454 UNIT 5 Assisting with Specialty Examinations and Procedures

diagnostic radiographic studies can be performed

in order to study digestive structures and functions
looking for disease. They include the upper GI
series (barium swallow) (Figure 18-15), lower GI
series (barium enema), and the cholecystogram.
Table 18-6 lists the purpose, patient preparation,
and procedures for each of these three studies.

Bariatrics
Millions of people in the United States are obese
A and are ill with or at serious risk for diabetes, heart
READING AND INTERPRETING THE HEMOCCULT ® TEST
disease, hypertension, certain cancers, stroke, sleep
apnea, and many other conditions. Obesity affects
Negative Smears every body system in a negative way. Emotional prob-
Sample report: negative
No detectable blue on or at the edge of lems such as depression, rejection, low self-esteem,
the smears indicates the test is negative
for occult blood.
isolation, and chemical substance abuse are com-
mon. Bariatrics is the field of medicine that treats
obesity and conditions associated with obesity.
Some obese patients decide, with their provid-
Negative and Positive Smears Positive Smears
er’s recommendation, to undergo bariatric surgery
because of the physical and emotional problems
caused by their obesity. Prior to surgery, patients
(with their provider’s guidance) must bring their
Sample report: positive
Any trace of blue on or at the edge of one or more of the smears indicates the test is existing medical problems, such as uncontrolled
B positive for occult blood. diabetes, severe hypertension, hyperlipidemia,
Figure 18-14 (A) Place the required number of and gall bladder disease, under control. Stabiliza-
drops of developing solution on the exposed guiac tion is important to prevent serious complications
paper. (B) A change in color indicates that blood may before, during, and after surgery.
be present in the stool. Bariatric surgery is performed to treat obe-
sity and to help the patient lose weight. It can be

test slides, and then how to care for and store the
slides until they are returned to the office by the
patient (see Procedure 18-3). Biohazardous mate-
rial (feces) cannot be sent through the United
States Postal Service.
For patients who have daily bowel move-
ments, this will not be a problem. For patients who
have difficulty with daily elimination, collecting
the samples may take several days. Patients should
not use laxatives unless directed by the provider.
Positive tests for occult blood require further
testing, because occult blood testing is a screen-
ing tool only. Sigmoidoscopy and/or colonoscopy
help to identify the source of bleeding. If a lesion
is found in either the rectum or colon, a biopsy
can be performed and the sample sent to the labo-
ratory for examination of cells for malignancy (see
Procedure 18-3).

Radiographic Studies of the Digestive System. Figure 18-15 In a barium swallow test, barium sulfate
Endoscopic procedures are done routinely but is swallowed and radiographs are taken of the esopha-
have not replaced the need for radiographic stud- gus, stomach, and small intestine. This is also known as
ies of the gastrointestinal tract. There are several an upper gastrointestinal series.
 CHAPTER 18 Examinations and Procedures of Body Systems 455

Table 18-6 Patient Preparation and Procedure for Radiographic Studies of the Digestive System

Test Purpose Patient Prep Procedure Time

To study the Day before radiograph: 1. The patient is asked to 1 hour
esophagus, 1. Light evening meal drink a flavored barium
stomach, duo- mixture while standing in
2. NPO after midnight
denum of the front of fluoroscope
Barium swallow the small intes- Day of test:
2. The radiologist observes
(upper gastro- tine for disease 1. NPO the passage down the
intestinal [GI] (ulcers, tumors, Postprocedural: digestive tract
series) hiatal hernia,
1. Increase fluid intake 3. The patient is turned to vari-
esophageal
2. Take laxative as prescribed ous positions to allow good
varices)
visualization of the intestine
4. Radiographs are taken

To study the Clear liquid 1 day prior (allowed: 1. The colon is filled with a 1–2
colon for disease non-carbonated beverages, clear barium sulfate mixture hours
(polyps, tumors, gelatin, clear broth, coffee and tea 2. The patient is turned in
lesions) with sugar) various positions to allow
No milk or milk products the barium to fill the colon.
Air is injected to move the
8 oz water every hour until bedtime barium along the colon
3. When the colon is full,
Prep kit: to include bottle of mag- radiographs are taken
nesium citrate, Dulcolax tab(s)
Day before radiograph:
1. Late afternoon drink bottle of
Barium enema magnesium citrate
(lower GI series) 2. Early evening take Dulcolax
tab(s) as prescribed
3. Light evening meal. NPO except
water, after dinner
Morning of procedure:
1. NPO
2. Cleansing enema
Postprocedural instructions:
1. Increase fluid intake and dietary
fiber
2. Report to provider if no bowel
movement within 24 hours of test

To study the 1. Evening before test fat-free dinner 1. A series of radiographs is 1 hour
gall bladder 2. Take dye tablets with 8 oz water taken
for disease 2. A fatty meal may be given
3. Cathartic or cleansing enemas
(stones, duct to stimulate the gall blad-
Cholecystogram may be prescribed
obstruction), der to empty
inflammation 4. NPO after dinner and tablets
3. Other radiographs can
then be taken to check
gall bladder function

accomplished with a standard abdominal inci- abdomen controls the tightness of the band or sta-
sion or laparoscope. Two procedures that can be ples. In gastric bypass surgery, the surgeon creates
performed are “banding” or “stapling” and gas- a pouch out of a small portion of the stomach and
tric bypass surgery (Figure 18-16). With banding attaches it directly to the small intestine, thereby
or stapling, the bottom of the esophagus (where passing the stomach and duodenum. As a result,
it enters the stomach) is banded or stapled, thus absorption, which occurs in the small intestine, is
shrinking the stomach. An adjustable port in the reduced. Before surgery, patients are counseled
456 UNIT 5 Assisting with Specialty Examinations and Procedures

Esophagus

Staples

Surgically
strengthened
outlet

Duodenum

Stomach

Jejunum

Large
intestine

GASTRIC BYPASS STOMACH BANDING

Figure 18-16 Gastric bypass and stomach banding are bariatric surgical procedures.

Patient Education
Follow specific package instructions. bleeding that can mask bleeding from
The following steps should be followed 2 days a lesion.
before the fecal occult blood test and contin- 4. Consume a high-fiber diet. Fiber provides
ued until three slides have been roughage to promote bowel movement
prepared: and encourage bleeding from any lesion
1. Avoid red meats, processed meats, and that may be present.
liver. These release hemoglobin that can 5. Do not begin test during menses, for three
produce a false-positive result. days after menses, or if bleeding from
2. Avoid turnips, broccoli, cauliflower, and hemorrhoids.
melons. These foods may contain a sub- 6. Drink plenty of fluids to help prevent
stance, peroxibase, that will cause a false- constipation.
positive result. 7. Store slides at room temperature and
3. Avoid aspirin, iron supplements, and large protect from heat, sun, and fluorescent
doses of vitamin C for 7 days before the lights.
test. These substances may cause gastric
 CHAPTER 18 Examinations and Procedures of Body Systems 457

about possible side effects, such as malabsorption, organs that contain specialized receptor organs.
anemia, vomiting, diarrhea, hernias, and blood Table 18-7 lists diseases and disorders and diagnos-
clots. tic tests and procedures for eyes and ears.
The surgery is considered for patients who are
morbidly obese who have tried numerous weight
loss and exercise regimens without results and are
The Eye
at serious risk for heart disease, stroke, cancer, The eye is the primary organ for sight and is one
and other conditions. Body mass index (BMI) is of the few organs of the body externally exposed.
another factor considered when providers evaluate Its accessory structures—the eyelids, eyelashes,
patients for surgery. A BMI around 30 to 40 (a gen- lacrimal ducts, and extrinsic muscles—provide
eral guideline) is one of the criteria used to deter- protection for the eye. The anterior portion of the
mine which patients are candidates for the surgery eyeball protrudes outward and the remainder is
(normal BMI is 18.5−24.9). The presence of other protected by the orbit.
diseases is also a factor in the evaluation. The intraocular structures consist of some
Caring for bariatric patients is challeng- parts of the eye visible externally and parts visible
ing. Their emotional health is important. Being only through an ophthalmoscope. The intraocular
nonjudgmental and showing empathy for these structures include the following:
patients is very important. They suffer from dis-
crimination, prejudice, and isolation. Obesity • Sclera: white area covering the outside of the eye
is a chronic illness that requires patience and except over the pupil and iris
understanding. • Cornea: clear tissue covering the pupil and iris
• Iris: round disk of smooth and radial muscles giv-
ing the eye its color
SENSORY SYSTEM • Pupil: round opening in the iris that changes size
as the iris reacts to light and dark
The special senses of vision, hearing, equilibrium
(balance), smell, touch, and taste permit the body • Anterior chamber: space between cornea and iris/
to detect information about the environment. The pupil filled with clear fluid called aqueous humor
eyes, ears, nose, taste buds, and skin are all sense • Posterior chamber: space between the iris and lens
that is filled with aqueous humor
• Lens: clear fibers enclosed in a membrane that
refract and focus light to the retina
Patient Education • Posterior cavity: space in the posterior part of the
eyeball filled with thick, gelatinous material called
Several Web sites (e.g., CDC, Mayo Clinic,
vitreous humor
Weight Watchers) can automatically calcu-
late BMI after inputting the patient’s height • Posterior sclera: white opaque layer covering the
and weight measurements. The following posterior part of the eyeball
are formulas for determining BMI: • Choroid layer: layer between the sclera and retina
1. Multiply weight, in pounds, by 0.45 containing blood vessels
(130 pounds × 0.45 = 58.5). • Retina: inside layer of the posterior part of the eye
2. Multiply height, in inches, by 0.025 (5 feet that receives the light rays (visual stimuli)
6 inches or 66 inches × 0.025 =1.65).
The mechanism of vision occurs after impulses
3. Multiply the answer from step 2 by itself
leave the retina and travel through the optic nerves
(1.65 × 1.65 = 2.72).
to the brain. At the optic chiasm, the nerve fibers
4. Divide the answer from step 1 by the cross and continue to the thalamus. These fibers
answer from step 3 (58.5 ÷ 2.72 = 21.48). synapse with other neurons that send the impulses
5. If the BMI is less than 21, the individual is to the right and left visual area of the occipital lobe
underweight. of the brain. Because the tracts cross at the optic
6. If the BMI is equal to or greater than 25, chasm, the stimuli coming from the right visual
the individual is overweight. fields are translated in the visual area of the left
7. A BMI equal to or greater than 30 indi- occipital area, and the stimuli coming from the left
cates obesity. visual fields are translated in the visual area of the
right occipital lobe. Table 18-8 describes common
458 UNIT 5 Assisting with Specialty Examinations and Procedures

Table 18-7 Sensory System Disorders

Laboratory/Diagnostic Tests

Disease/ Radio- Medical Tests

Disorder Blood Other graphy Surgery or Procedures Treatment

Ophthalmologic Cover the normal eye

Amblyopia examination to force weaker eye to
function

Ophthalmologic Phacoemulsification
Cataract examination Surgical extraction
Slit lamp

Chalazion Excision

Color blind- Ishihara color

ness plates

Culture and Stained Antibiotic drops or

sensitivity smears of antibiotics
Conjunctivitis of eye dis- conjuncti- Ointment
charge val scrap-
ings

Fluorescein stain Antibiotic ointment,

Corneal
dressing over affected
abrasion
eye

Diabetic Laser Fluorescein Laser

retinopathy agiography

Complete Nasal Blood pressure Electrocautery

Epistaxis blood
count

Complete Culture and Otologic exami- Antibiotic therapy

External otitis blood sensitivity of nation Laser (if severe)
count exudate

Vision field testing Medicated eye drops

Ophthalmologic Oral medication
examination includ- Laser surgery
Glaucoma
ing intraocular
Conventional surgery
pressure
or a combination
Tonometry

Impacted Otologic exami- Removal with curette

cearumen nation Irrigation

Ophthalmologic Laser
examination Intraocular injections
Macular Angiography
degeneration Intravenous
Amsler grid medication
Some untreatable

(continues)
 CHAPTER 18 Examinations and Procedures of Body Systems 459

Table 18-7 (continued)

Laboratory/Diagnostic Tests

Disease/ Radio- Medical Tests or

Disorder Blood Other graphy Surgery Procedures Treatment

Audiometry, mag- Medication, surgery

netic resonance only if severe
Ménière’s imaging
disease
Electrocochleo-
graphy

Motion Medication
sickness

Ophthalmologic Radial keratotomy

Myopia
examination

Opticokinetic Directed at cause

drum test (inner ear or central
Nystagmus nervous system)
Neurologic
examination

Hyperopia Astigmatoscopy Corrective lenses

Presbyopia Snellen chart Corrective lenses

Astigmatism Ophthalmic exam Corrective lenses

Biopsy Nasal examination Electrosurgery

Nasal polyps of polyp
(lesion)

Complete Culture and Myringot- Tympanography Antibiotics

blood count sensitivity of omy Myringotomy
Otitis media exudate Tympanos-
tomy

Audiometry Stapedectomy
Otosclerosis
Rinne test

Laser or Ophthalmologic Laser

Retinal
surgery to examination
detachment
reattach

Complete Culture and Sinus Antibiotics for bacte-

Sinusitis blood sensitivity of X-rays rial infection
count exudate

Ophthalmologic Cover the normal eye

examination to force weaker eye to
Strabismus function
Neurologic
examination

Culture and Incision Antibiotic ointment

Stye sensitivity and
(hordeolum) if exudate drainage
present
460 UNIT 5 Assisting with Specialty Examinations and Procedures

eye disorders. Figures 18-17 and 18-18 illustrate the

Table 18-8 Description of Eye Disorders anatomy of the eye.
Signs and symptoms that are common to
Refraction and Other Disorders: eye diseases and disorders are pain or burning in
the eye (conjunctivitis) or around the eye (hor-
• Astigmatism. Irregular lens curvature or cornea shape deolum), decreased visual acuity, and any visual
causing improper focusing of objects.
changes such as seeing sudden flashes of light,
which may indicate retinal detachment (see Fig-
• Cataract. Lens loses its transparent nature caused by
changes in its proteins. Usually brought on by aging or
ures 18-19 to 18-21).
sunlight.
Measuring Visual Acuity. A procedure com-
• Color blindness. Inability to distinguish among colors. monly performed by the medical assistant is the
Caused by an absence of a cone photopigment, a measuring of a patient’s visual acuity. This is only
genetic disorder. a screening process used when errors in refrac-
tion are suspected. The procedure must be per-
• Conjunctivitis. Caused by a bacterial infection or formed in a well-lit, quiet area. While performing
irritant resulting in irritated and reddened con- the procedure, the medical assistant must ob-
junctiva. If caused by bacteria, conjunctivitis.
serve the patient for any action that may indi-
cate difficulty with vision. These actions include
• Corneal abrasion. Caused by an injury to the cornea squinting, wiping of the eyes, or leaning toward
by a foreign body resulting in pain, tearing, redness,
and possible infection.
the chart. In near-vision acuity, these actions
include holding the card nearer or farther than
• Diabetic retinopathy. Diabetes mellitus causes dam-
the stated position. The commonly used chart for
age to the retina because the disease causes vascu- distance visual acuity is the Snellen chart for the
lar changes. This is the leading cause of blindness in adult. Near-vision is commonly checked by using
the United States. the Jaeger card.
The Jaeger chart used for checking clear
• Glaucoma. Condition caused by increased intraocu- vision is a small card that the patient holds between
lar pressure due to a buildup of aqueous humor. This 14 and 16 inches from the eye. The medical assis-
results in mild visual disturbances with little or no pain
but can lead to severe visual impairment if untreated.
tant measures the distance for accuracy. This is the
distance from which a person with normal vision is
• Nearsightedness (myopia). Caused by an elongated
able to read printed material such as a newspaper.
(shaped) eyeball and the image is focused in the The Jaeger test consists of a series of reading mate-
front of the retina resulting in the inability to focus on rial, the letters of which gradually become smaller.
objects at a distance. Record the last line number that the patient can
easily read. The patient is checked with and with-
• Farsightedness (hyperopia). Caused when the eyeball out corrective lenses, and each eye is checked
is irregularly shaped (shortened) and the image is separately.
focused behind the retina causing distance vision to
be unclear.
Errors in refraction is the term used to desig-
nate visual acuity abnormalities. The common visual
abnormalities include myopia (nearsightedness),
• Presbyopia. Attributed to the aging process when the
lens loses its elasticity and the ability to accommo- the ability to see only near objects clearly; hypero-
date. Vision is hampered when items are close. pia (farsightedness), the ability to see only distant
objects clearly; and astigmatism, uneven curvature
• Retinal detachment. Complete or partial separation of of the cornea resulting in a scattering of light rays
the retina from the choroid layer of the eye, leading to producing blurry vision. Presbyopia (associated
possible blindness. with the aging process) is an increase in farsighted-
ness and a loss of lens elasticity that is necessary to
• Stye (hordeolum). Inflamed sebaceous gland of accommodate for near vision (Figure 18-22).
the eyelid caused by bacterial infection. Erythema The Snellen chart consists of the alphabet
and tenderness at site are common symptoms.
letters in various combinations starting at the top
with a large E, and letters of descending size by
line toward the bottom. Each line is labeled with
the visual acuity measurement. The Snellen chart
for children has pictures. Non–English-speaking
patients may use a directional chart.
 CHAPTER 18 Examinations and Procedures of Body Systems 461

Conjunctiva

Cornea
Retina
Iris

Pupil Retinal arteries

and veins
Path of light

Lens Fovea centralis

Anterior chamber
(aqueous humor)

Posterior chamber
(aqueous humor) Optic
nerve
Suspensory ligament
Choroid coat
Ciliary body and muscle
Vitreous body Sclera

Figure 18-17 The eyeball—cross-sectional view.

Retinal
tear
LEFT VISUAL FIELD RIGHT VISUAL FIELD (detachment)

Temporal Nasal Nasal Temporal Subretinal

fluid

Detached
retina

Left eye Right eye

Optic
Vitreous nerve
Optic nerve
humor Sclera
Frontal lobe

Figure 18-19 Detachment of the retina.

Optic chiasm Temporal

lobe
Optic tract

Optic
radiation

Occipital lobe

Visual cortex

Figure 18-18 The visual pathways of the eye. Figure 18-20 Conjunctivitis.
462 UNIT 5 Assisting with Specialty Examinations and Procedures

Recording Visual Acuity. Visual acuity, both

near and far, is recorded in a fraction format. The
numerator indicates the 20-foot distance between
the patient and the chart. The denominator indi-
cates the visual acuity of the patient in relationship
to the normal seeing eye. Normal vision is 20/20.
This means that at 20 feet the eye is seeing what the
normal eye would see at 20 feet. Should the vision
be 20/30, this indicates that the eye is seeing at 20
feet what the normal eye would see at 30 feet away. A
visual acuity of 20/15 indicates that the eye is seeing
at 20 feet what the person with normal visual acuity
would be able to see at 15 feet. Vision is recorded on
the patient chart as right eye, left eye, and both eyes.
Figure 18-21 Stye (hordeolum). Example: Right 20/20 Left 20/20
Both 20/20

Patients should be screened with and without

their corrective lenses and the results recorded in
Normal eye patients’ charts or electronic medical records.
Light rays focus
on the retina
Color Vision. Checking color vision is not part of
a routine examination. This procedure is usually
A
performed on people who must distinguish color
as part of their occupation (e.g., truck drivers,
Myopia (near- pilots, and salespeople). A commonly used color
sightedness) vision test is the Ishihara color graph. The Ishihara
Light rays
focus in front
test chart book contains pages composed of vary-
of the retina ing sized and colored circles. Inside the circles are
numbers or lines that can be traced. The patient
B is seated for the procedure with the book held
14 to 16 inches away and is instructed to identify
the numbers as the page is turned or is instructed
Hyperopia
(farsightedness)
to trace the line from the indicated starting point
Light rays focus to the end. Inability to see the number or to follow
beyond the retina the line may indicate color blindness. Should this
occur, the medical assistant must inform the pro-
C vider as to what number(s) could not be seen. The
patient is referred to an ophthalmologist.
The medical assistant will be responsible for
Presbyopia assisting the provider in ophthalmologic exami-
Light rays focus nations and performing the tests for visual acu-
behind the retina
ity. Diagnostic procedures for the special senses
involve the use of specialized instruments. The use
D of the ophthalmoscope (lighted instrument used
to view inside patient’s eye; Figure 18-23) assists in

Astigmatism
Light rays focus
on multiple areas Critical Thinking
of the retina
List the steps the medical assistant must follow
E
when performing a visual acuity test on a
Figure 18-22 (A) Normal eye vision. (B) Myopia. 9-year-old child and on a 3-year-old toddler.
(C) Hyperopia. (D) Presbyopia. (E) Astigmatism.
 CHAPTER 18 Examinations and Procedures of Body Systems 463

A B

Figure 18-23 (A) The ophthalmoscope is used to identify eye disorders. (B) The provider uses the ophthalmoscope
to view the interior of the patient’s eye.

identifying disease-related problems. The interior ment of the head. The semicircular canals assist
of the eye can be examined. the body to adjust to changes in direction. The
Procedures 18-4 though 18-9 list the steps for movement of fluid in this area can cause symptoms
specialty procedures for the eye. of dizziness. The cochlea is the organ of hearing.
The outer ear (auricle/pinna) picks up sound
waves that are sent through the external auditory
The Ear canal to the tympanic membrane. The membrane
The structures of hearing and equilibrium are vibrates in reaction to the sound striking it. These
divided into the external ear, the middle ear, vibrations pass through the three tiny middle ear
and the inner ear. The external ear includes the bones through the oval window and into the fluid
pinna (auricle) and the external auditory canal. in the cochlea. Receptor cells respond and trans-
The pinna is mostly cartilaginous tissue with a fer the sounds into electrical impulses that travel
small amount of adipose tissue in the earlobe. to the brain via the acoustic nerve. The receiving
The external auditory canal is about 1 inch in area of the brain for auditory impulses is in the
length and contains hair and wax (cerumen)- temporal lobe (Figure 18-24).
producing glands. The external ear and middle Diseases or conditions of the ear, if left
ear are separated by the tympanic membrane untreated, can cause damage to nerves and tissues
(eardrum). and can result in some degree of hearing impair-
The middle ear, also called the tympanic cav- ment, from mild to deafness. Table 18-9 describes
ity, is a small space containing three bones, the mal- common diseases of the ear.
leus (hammer), incus (anvil), and stapes (stirrup).
Next to the stapes is the oval window that leads to Measuring Auditory Ability. The simple methods
the inner ear. The eustachian tube connects the of measuring hearing (gross hearing) are usually
middle ear to the throat. performed by the provider. The patient may be
The inner ear is the most sophisticated part instructed to place a finger in one ear while the
of the ear. It is responsible for both hearing and provider whispers one or two words in the other.
equilibrium (balance). The inner ear consists of a The patient is then asked to repeat the words. A
fluid-filled sterile space housing the vestibule, the ticking watch may be placed by the patient’s ear
semicircular canals, the round window, and the to ascertain hearing. A vibrating tuning fork may
cochlea. The structures in the vestibule are respon- be placed on the mastoid process behind the ear
sible for maintaining equilibrium during move- and then on top of the head. The patient is asked
464 UNIT 5 Assisting with Specialty Examinations and Procedures

Incus

Malleus Semicircular
canals

Branches of
vestibulocochlear
Auricle nerve
(pinna)

Cochlea

External Oval window

auditory canal

Round window

Auditory
(eustachian) tube

Tympanic membrane Stapes

Figure 18-24 The ear.

if the sound vibrations could be heard or felt. This the canal and become impacted (pressed firmly
procedure will identify nerve or conduction deaf- against the tympanic membrane). The sound
ness (Figure 18-25). Conduction deafness occurs waves cannot pass through the hardened cerumen
when the sound wave is not transmitted to the mid- to the middle ear, and hearing loss (conduction
dle ear. This type of deafness may be a result of the hearing loss) results.
presence of impacted ear wax (cerumen) in the To remove impacted cerumen, the provider
ear canal or a scarred tympanic membrane. may use a curette. The patient may have had ear
Cerumen, or ear wax, is a substance secreted drops prescribed before the physical removal of
by glands at the outer third of the ear canal. In the impacted cerumen. The drops are instilled
some individuals it can accumulate and block in an effort to soften the cerumen to facilitate its
removal. An ear irrigation may be performed by
flushing the ear canal with warm water or a solu-
Table 18-9 Ear Disorders tion ordered by the provider. Commercial solu-
tions are available for patients to use at home (see
External otitis (swimmer’s ear). Inflammation of ear Procedure 18-11).
canal. Symptoms are itchiness and crusting of
ear canal.
A scarred tympanic membrane can occur
from a ruptured or perforated tympanic mem-
Otitis media. Acute infection of the middle ear usually
brane. This can occur from untreated acute oti-
caused by bacteria. Symptoms are pain, fever, dis- tis media or traumatic rupture. With acute otitis
charge, and decreased hearing acuity. media, the tympanic membrane is red and bulges
from accumulation of serous or purulent fluid
Otosclerosis. Conduction deafness caused by hard- behind it. The pressure of the fluid on the tym-
ening of the stapes. panic membrane may be so great that the mem-
brane ruptures and drainage can be seen in the
Ménière’s disease. Characterized by deafness, ver- ear canal. The perforation or rupture will prob-
tigo, nausea, and tinnitus. Probable cause is edema ably heal, but a small scar on the membrane will
of the labyrinth. remain. Repeated ruptures from acute otitis
media will cause repeated scarring and dimin-
Impacted cerumen. Caused by accumulation of ished hearing function (conduction hearing loss).
hardened cerumen that has built up against the
tympanic membrane. Impaired hearing and
A culture and sensitivity of the drainage (purulent
tinnitus can result. or serous) will indicate the antibiotic to which the
microorganism is sensitive.
 CHAPTER 18 Examinations and Procedures of Body Systems 465

A B C

Figure 18-25 (A) The provider holds the tuning fork against the crown of the patient’s head to determine which
ear can hear the sound. (B) To check air conduction of sound, the provider holds the tuning fork 1 inch from the
patient’s auditory meatus. (C) The provider places the tuning fork on the bony prominence (mastoid bone) behind
the patient’s ear to check bone conduction of sound.

A myringotomy is a surgical incision into the tested in an alternating fashion to ensure accuracy
tympanic membrane made to remove accumulated (see Procedure 18-10 and Figure 18-26).
fluid caused by infection. Because the procedure is The medical assistant employed in an indus-
surgical in nature, the tympanic membrane can be trial medical facility may be required to monitor
incised to allow the fluid to drain. Scarring is mini- hearing of some employees. In this case, care must
mized because the incision is made with a scalpel be taken to have the hearing test performed before
in a controlled location and will heal with less scar- the employee goes to work for the day. Hearing loss
ring. Tubes may be placed in the opening (tympa- may result from the day’s activities in some noisy
nostomy) made by the myringotomy to equalize facilities even when ear plugs are worn.
pressure and prevent fluid from accumulating (see Tympanometry is a procedure used to
Chapter 15). ascertain the ability of the middle ear to trans-
Nerve deafness is a result of injury along the mit sound waves and is commonly performed on
course of the nerves leading from the inner ear to children to diagnose middle ear infections. A
the auditory centers of the brain.
A more complex procedure for measuring
hearing may be performed by the medical assistant
but more often by an audiologist, using an audiom-
eter. A quiet room with no distractions is required
for the procedure to be accurate. The patient is
seated facing away from the medical assistant and
the audiometer, then ear phones are placed over
the ears. The patient is instructed to raise a hand
when a sound is heard. The audiometer has two
dials, one for the various wavelengths and the other
for wave intensity. Starting at the lowest pitch, the
intensity is increased until the patient responds to
the sound. The next pitch is then tested in the same
manner. This process continues until the highest
pitched sound is tested. The results are obtained by
noting the number of intensity at which the sound
was heard. When performing the procedure, the
medical assistant must not develop a pattern that Figure 18-26 Manual audiometer. (Courtesy of
can be detected by the patient. The ears should be Welch-Allyn.)
466 UNIT 5 Assisting with Specialty Examinations and Procedures

probe is inserted into the ear canal to measure

the air pressure of the ear canal in relation to
The Nose
the air pressure found in the middle ear. Tym- The provider inspects the exterior surface of the
panogram is the recording produced by this patient’s nose for skin lesions such as rosacea,
procedure. The waves and peaks are measured squamous or basal cell carcinoma, and other der-
providing an indication of possible middle ear matologic problems. The provider examines and
abnormalities (Figure 18-27). palpates to determine if the nose is patent and for
The medical assistant or the provider may per- the patient’s ability to breathe in and out through
form the audiometry test. Diagnostic procedures the nose (through each nostril). The mucous mem-
for the ear involve the use of specialized instru- brane is checked for polyps, superficial blood ves-
ments, including the otoscope (lighted instru- sels, and foreign bodies. The septum is noted for
ment to examine the tympanic membrane), which deviation. Epistaxis is a common problem and can
assists in identifying disease-related ear problems be treated with electrocautery and/or nasal pack-
(Figure 18-28). ing. Procedures 18-13, 18-14, and 18-15 describe
Procedures 18-10, 18-11, and 18-12 describe steps for specialized procedures and examinations
steps for audiometry, ear irrigation, and ear for the nose.
instillation.

RESPIRATORY SYSTEM
The respiratory process is all important to the life
process. External respiration allows for the exchange
of carbon dioxide and oxygen across the cell walls
into the airspaces of the lungs. Internal respiration
is the exchange of these gases at the cellular levels
of the organs.
The respiratory process begins with air enter-
ing the nose or mouth, where it passes through the
pharynx, down into the trachea, into the bronchi,
and then enters the lungs. Gas exchange takes
place when the blood filters through the alveoli
(smallest air sacs in the lungs) (Figure 18-29).
Table 18-10 lists diagnostic procedures for respira-
tory diseases and disorders. Table 18-11 discribes
respiratory disorders.
Figure 18-27 A portable tympanometric instrument
with charger. A printout of the tympanogram can be Signs and Symptoms
seen. Testing is done in 1 second and is useful for diag-
nosing otitis media and other middle ear conditions, of Respiratory Conditions
such as patency of tympanostomy tubes and otosclero- and Disorders
sis. (Courtesy of Welch-Allyn.)
If a patient’s chief complaint indicates a respira-
tory condition or disorder, medical attention is
essential. Some signs and symptoms include:

• Dyspnea
• Chest pain
• Fatigue
• Hemoptysis
• Chills and fever
• Hoarseness
Figure 18-28 The otoscope is used to examine the • Wheezing
patient’s tympanic membrane. • Cough, productive or nonproductive
 CHAPTER 18 Examinations and Procedures of Body Systems 467

Nose–mouth

Air sucked in
Airways of respiratory tree
(ventilation)
Air blown out

Alveoli

O2

External respiration (gas exchange between air in

alveoli and blood in pulmonary capillaries)
CO2
Blood in Tissue cells
pulmonary capillaries
Blood flow
CO2

O2
Internal respiration
Blood in (gas exchange between tissue cells
systemic capillaries and blood in systemic capillaries)
Blood flow

Figure 18-29 Gas exchange in the lungs and tissues.

Irrigations of the nose, collection of sputum describe specialized respiratory examinations and
specimens, and assisting with pulmonary tests are procedures.
the roles of the medical assistant.
Spirometry
Diagnostic Tests The measurements of air flow, volume, and capac-
A fundamental test, auscultation of the chest, is ity are known as pulmonary function tests (PFTs).
used to check for abnormalities in breathing rate The patient’s height, age, and sex are used in the
and quality. Lung function tests can be done. Chest PFT. Many times the provider requests the PFT be
X-rays are useful in helping to diagnose tuberculo- perfomed before the administration of a broncho-
sis (Figure 18-30), lung lesions, pneumonia, and dilator and again after the bronchodilator. This is
other respiratory conditions. Cultures of sputum useful in evaluating the effectiveness of the medi-
can help diagnose infections in the respiratory cation (see Procedure 18-18).
tract. Bronchoscopy is used to take a sample of A commonly used tool in the medical office
lung tissues (biopsy) for help in the determination or clinic, spirometry (test to measure lung capac-
of lung cancer and for culture of lung abcesses, ity) assists the provider in the evaluation of signs
washing, and irrigation. A spiral CT scan produces and symptoms of pulmonary disease by measuring
a sharper image of the lungs than a conventional the air capacity (air flow and volume) of the lungs
CT scan. (Figure 18-31). Many components of lung func-
Arterial blood gases measure the amount of tions are measured including the following three
oxygen and carbon dioxide in the arterial blood. components:
Higher amounts of carbon dioxide and lower
amounts than normal of oxygen indicate poor 1. Forced virtual capacity (FVC), which represents
lung functions. the volume of air that can be exhaled from the
Pulmonary function tests such as spirom- lung after the lung is filled with air to meet its total
etry are helpful. Procedures 18-16 through 18-19 capacity
 468
Table 18-10 Respiratory System Disorders

UNIT 5
Laboratory/Diagnostic Tests

Disease/ Medical Tests

Disorder Blood Other Radiography Surgery or Procedures Treatment

Assisting with Specialty Examinations and Procedures

Complete blood Electro- Chest radiograph Tracheotomy Thoracentesis Antibiotics
count cardiography Ventilator
Acute or adult Blood chemistry Urinalysis Oxygen
respiratory dis-
Prothrombin time
tress syndrome
(ARDS) Partial thromboplas-
tin time
Arterial blood gases

Complete blood Sputum analysis Chest radiograph Pulmonary func- Medication (bronchodilators)
count Peak expiratory tion tests Metered-dose inhaler
Asthma
Arterial blood gases flow rate Skin testing for Treatment of hypersensitivity
allergies

Complete blood Sputum culture Chest radiograph Bronchoscopy Antibiotics if secondary bacte-
Bronchitis
count and analysis rial infection occurs

Emphysema Complete blood Spirometry Chest radiograph Pulmonary func- Bronchodilators

(chronic count tion tests
obstructive Arterial blood gases Pulse oximetry
pulmonary dis-
ease [COPD])

Complete blood Nasal cauter- Blood pressure Packing of nose, cautery

Epistaxis
count ization

Complete blood Chest radiograph Symptomatic

Influenza count Antibiotics if secondary bacte-
rial infection occurs

Complete blood Throat culture Laryngoscopy Throat lozenges

Laryngitis count Rapid strep test Analgesics

Complete blood Sputum Chest radiograph Biopsy of lung Bronchoscopy Surgery

Lung cancer count cytology CT scan tissue Chemotherapy
Radiation
 Biopsy of Nasal examination Surgical excision
Nasal polyps
lesions

Complete blood Throat culture Lozenges

Pharyngitis count Rapid strep test Gargling

Complete blood Chest Taping of chest

Pleurisy count radiograph Antibiotics if bacterial
Analgesics

Complete blood Blood culture Chest Antibiotics if bacterial

Pneumonia count radiograph
Sputum smear Symptomatic treatment if viral

Complete blood Throat or naso- Chest Antiviral drugs

Severe acute count pharyngeal swab radiograph Steroids
respiratory syn- Blood chemistry Viral culture Symptomatic treatment

CHAPTER 18
drome (SARS) Serum antibodies of
SARS

Complete blood Culture and sen- Sinus Nasal examination Decongestants

Sinusitis count sitivity radiographs Antibiotics

Complete blood Throat culture Tonsillectomy Antibiotics

Examinations and Procedures of Body Systems

count
Tonsillitis
Streptococcal anti-
body test

Complete blood Sputum culture Chest radiograph Biopsy of lung Tuberculin skin Multiple anti-tuberculosis medi-
Tuberculosis count Acid fast smear Bronchoscopy tissue test: Mantoux cations
of sputum intradermal

469
470 UNIT 5 Assisting with Specialty Examinations and Procedures

Table 18-11 Description of Respiratory Disorders

Acute or adult respiratory distress syndrome (ARDS). A life-threatening condition that occurs when there is severe fluid
buildup and hemorrhage in the lungs. ARDS is breathing failure that can occur in critically ill patients with underlying
illnesses. There is a high mortality rate. Patients may be placed on isolation precautions (see Chapter 10).

Asthma. Inflammation and spasm of the smooth muscle of the bronchi brought on by an allergen or emotional upsets.
Characterized by dyspnea and wheezing.

Bronchitis. Inflammation of the bronchi, caused by viral or bacterial infection with a dry, painful cough, progressing to a
productive cough of greenish yellow sputum. Symptoms include cough, slight fever, chills, malaise, and soreness under
the sternum.

Emphysema. Enlargement of the alveoli due to lost elasticity, usually brought on by a long-time irritant, such as cigarette
smoking. Results in dyspnea, chronic cough, weight loss, and the appearance of a “barrel chest.”

Epistaxis. A nosebleed. May be caused by trauma, chronic sinus irritation, drug abuse (esp.“snorting” drugs), hypertension,
blood disorders, and high altitude.

Influenza. A viral infection of various strains of the upper respiratory tract. Sudden onset of chills, fever, cough, sore throat,
gastrointestinal disorders are common. Can range from mild to life-threatening.

Laryngitis. Hoarseness, cough, aphonia caused by infections from nose or throat.

Lung cancer. Cancer that may appear in trachea, air sacs, bronchi, and other lung tissues and cells.

Nasal polyp. A tumor of the nose that can bleed easily. Should be removed surgically.

Pharyngitis. Inflammation of the pharynx caused by a bacteria, virus, or an irritant. Difficulty in swallowing, pain, redness,
and inflammation of the pharynx are some of the symptoms. Streptococcus is the most common bacterial infection;
influenza virus and the common cold virus are the most common viral agents involved. May be accompanied by fever,
malaise, and headache.

Pleurisy. Inflammation of the pleura caused by bacteria or viruses. Symptoms include pain, fever, cough, chills, and
dyspnea.

Pneumonia. Inflammation of the lungs caused by bacteria, fungi, viruses, and chemical irritants. Usually has sudden onset
and is characterized by chills, fever, chest pain, cough, and purulent sputum. Symptoms include sore throat, fever, and
lymphadenopathy.

Severe acute respiratory syndrome (SARS). An acute viral respiratory illness that begins with fever, headache, body aches,
general malaise, and diarrhea. There may be mild respiratory symptoms at the onset. Most patients will develop pneumo-
nia. The virus is spread by close person-to-person contact (i.e., kissing, hugging, sharing eating or drinking utensils, talking
to someone within 3 feet [respiratory droplets], and touching someone directly). The patient will be placed on isolation
precautions (see Chapter 10).

Sinusitis. Inflammation and infection of a sinus or sinuses. May be caused by allergies, bacteria, viruses, or polyps.

Tonsillitis. Inflammation of the tonsils usually caused by streptococcus.Tonsils become red and enlarged causing severe
pharyngitis and fever.

Tuberculosis. Inflammatory infiltrations, formation of tubercles, abscesses, fibrosis, and calcification. Can lead to infection
of other body systems. Is highly infectious. Airborne Precautions necessary to prevent transmission of the disease.
 CHAPTER 18 Examinations and Procedures of Body Systems 471

Tubercules
Patient Education
Instruct Patient on Use of Peak Flow Meter
1. Slide the indicator to the bottom of the
scale (may be done by the medical
assistant).
2. Sit up straight or stand.
Figure 18-30 Tuberculosis. 3. Hold the peak flow meter upright.
4. Inhale as deeply as you possibly can.
5. Form a tight seal around the mouth-
piece with your lips.
6. Blow out as quickly and as hard as you
can to exhale all of the air out of your
lungs.
7. The force of your exhalation will cause
the indicator to rise in the meter.
8. The medical assistant will have you use
the peak flow meter twice more and will
record the highest number.
NOTE: For accurate results, it is very impor-
tant to inhale and exhale as completely as
possible.
Figure 18-31 The spirometer is used to measure pul-
monary function.

2. Forced expiration volume at 1 second (FEV), which

Pulse Oximetry
is the volume of gas forcibly exhaled from the lungs Pulse oximetry is test that uses a small probe with
after the first second and third second of expiration an infrared light. The probe is placed on the ear-
3. Mean expiration flow (MEF) rate, which is a mea- lobe, toe, finger, or bridge of the nose. It evaluates
sure on a volume–time curve halfway through an the amount of oxygen saturation in the blood. This
exhalation is helpful because cyanosis is not manifested until
the saturation of oxygen is less than 85%. Pulse
There are other measurements done after oximetry is useful in the diagnosis and evaluation
exhaling with force, after a normal exhalation, of impaired respiratory and cardiac functions. A
and how quickly the patient can exhale after a reading less than 95% indicates hypoxemia. It is not
slow inhalation and others. unusual for a patient being tested for sleep apnea
Most spirometers are computerized, and thus to experience a pulse oximetry of under 75%.
automatically calculate the lung functions. Results The appropriate body part is selected, and a
are stored in the electronic health record and read- clip (sensor) is placed on it (typically the finger).
ily accessible for comparison. One side of the sensor is an infrared light, and the
other side is a photo detector. The infrared light
passes through the tissues and blood vessels, and the
Peak Expiratory Flow Rates detection measures the amount of light absorbed by
Peak expiratory flow rates (PEFRs), as part of hemoglobulin. This noninvasive procedure measures
pulmonary function studies, help determine the the amount of hemoglobin and can be performed
extent of a patient’s asthma or other pulmonary on any patient, but especially those with impaired
disorder. The PEFR is the measurement of the heart and lung function. Postoperative patients
fastest rate of the flow of air that is exhaled from are attached to an oxygen pulse oximeter in the
the lungs. It is measured with a peak flow meter. recovery room. The patient is likely to have shallow,
The PEFR is lower in an individual experiencing less effective respirations because of the anesthesia or
an asthma attack caused by impaired expiration narcotics. The patient must not be wearing nail pol-
and trapped air in the lungs. ish (see Procedure 18-19 and Figure 18-32).
472 UNIT 5 Assisting with Specialty Examinations and Procedures

The patient puts the mouthpiece into the mouth

and exhales, and then breathes through the mouth
until all the medication is used, about 10 to 15 min-
utes. Alternatively, the nebulizer can be used with a
mask. The mask must fit well to prevent medication
from getting in the eyes. The medicine cup and
mouthpiece are washed with water and allowed to
air dry (see Procedure 18-17).

MUSCULOSKELETAL SYSTEM
The muscular and skeletal systems interact to coor-
dinate the supporting framework and movements
of the body. The musculoskeletal system includes
bones, joints, muscles, and surrounding tissue. The
Figure 18-32 Apply the sensor to the selected site—in skeletal system provides support; protects vital
this case, the finger. organs; and allows for the attachment of ligaments,
tendons, and muscles. The muscular system gives
the body form and shape and is responsible for the
coordination of movement.
Inhalers Bones of the skeletal system store minerals for
Inhalers are devices that are used to deliver medi- later use by the body. They are classified according
cation into the lungs and are most often used to to their shape. Bones provide for the attachment of
treat asthma. A number of different types of inhal- muscles and joining of another bone, which allows
ers are available: metered dose inhaler (MDI), for the passage of nerves and blood vessels. The skel-
metered dose inhaler with spacer (MDIS), dry etal system is divided into two parts: the appendicu-
powder inhaler (DPI), and nebulizer. lar skeleton (126 bones) and the axial skeleton (80
The MDIS is the preferred method. A tube bones).
that attaches to the inhaler and holds the medi- One of the top four reasons a patient visits a
cation until the patient can breathe it in is called provider is for back pain. During the visit, the pro-
the spacer. It makes the MDI easier to use and helps vider evaluates the patient for contributory factors
get the medication into the lungs better. A mask for the pain by assessing the patient for deformi-
can be attached to the spacer for children or for ties, asymmetry, and signs of restricted motion.
an individual who has difficulty inhaling correctly The provider performs a functional assessment
with a conventional spacer. However, an MDI can by observing the patient’s gait (manner of walk-
be used without a spacer. ing) for indications of decreased mobility and
Some medications for asthma are in the form postural changes associated with aging or injury.
of a powder and can be taken with a handheld Flexion tests with a goniometer detect the degree
device known as a DPI. This device delivers medica- of resistance applied to a given force, thus defin-
tion to the lungs when the patient inhales through ing restricted motion and the amount of discom-
the device. However, some patients cannot inhale fort associated with movement. Supine straight leg
through the device with sufficient force to breathe raising (SLR) tests detect the amount of hamstring
in the medication well. flexibility and can assess sciatic nerve damage.
A nebulizer is an apparatus that changes the There are more than 600 muscles in the body.
medication for asthma from a liquid form into a Muscles are composed of bundles of muscle fibers,
mist for ease of inhaling the medication into the each with the ability to contract and relax. Any dis-
lungs. Nebulizers work well for infants and young ease process that disrupts the balance between the
children and for any person who is unable to use muscular and skeletal systems severely hampers a
an MDIS. The different types of nebulizers all work person’s ability to move effectively and painlessly
in essentially the same way. The nebulizer hose is (Tables 18-12, 18-13, and 18-14).
connected to an air compressor. The medicine cup Diagnostic procedures involving the skeletal
is filled with the appropriate dose of liquid along system involve the extensive use of various forms of
with saline. If a single dose, the contents of the vial radiographs and visual examination techniques. A
the are squeezed into the medicine cup. The hose bone biopsy may be ordered when additional diag-
and mouthpiece are attached to the medicine cup. nostic data are required.
 CHAPTER 18 Examinations and Procedures of Body Systems 473

Table 18-12 Musculoskeletal System Disorders

Laboratory/Diagnostic Tests

Medical
Disease/ Tests or
Disorder Blood Other Radiography Surgery Procedures Treatment

Erythrocyte Surgical Electromyog- Cortisone injection

sedimentation repair raphy Physical therapy
Carpal rate
tunnel Antiinflammatory drugs
Uric acid
syndrome Splinting
Complete
Surgery
blood count

X-ray of affected Reduction Reduction with anesthe-

joint sia if necessary
Dislocation
Surgical tightening of
ligaments

Uric acid Synovial fluid Skeletal x-rays Bed rest when severe
Complete analysis Ice to affected joint(s)
blood count Urinalysis Antiinflammatory
Gout Erythrocyte agents
sedimentation Analgesics
rate
Corticosteroids
Antigout drugs

Myelogram Muscle relaxants

Computerized Analgesics
tomography Brace for affected disk
Herniated (CT)
disk Epidural injection(s) of
Magnetic reso- corticosteroids
nance imaging
Surgical incision and
(MRI)
release

Complete Skeletal Physical therapy

blood count X-rays including Antiinflammatory drugs
Sedimentation vertebrae
Analgesics
Osteoar- rate CT scan
Muscle relaxants
thritis MRI
Corticosteroid injection
into affected joint
Surgery to replace knee,
hip, or shoulder

Serum Urine Bone scan Bone Calcium supplements

calcium calcium biopsy Vitamin D supplements
Alkaline phos- Urine and sunshine
Osteopo- phatase creatinine Drug therapy
rosis
Estrogen level Weight-bearing
Total protein exercises
Creatinine (continues)
474 UNIT 5 Assisting with Specialty Examinations and Procedures

Table 18-12 Musculoskeletal System Disorders (continued)

Laboratory/Diagnostic Tests

Medical
Disease/ Tests or
Disorder Blood Other Radiography Surgery Procedures Treatment

Rheumatoid Synovial fluid Skeletal To correct Antiinflammatory drugs

factor analysis X-rays deformity Corticosteroids
Antinuclear Immunosuppression
antibody test drugs
Rheu- Lupus erythe- Splinting of affected
matoid matosis test joints
arthritis Erythrocyte Exercises
sedimentation
Replacement of joint
rate
with artificial joint
Complete
blood count

Serum phos- Urine Skeletal bone Bone Vitamin D and calcium

phorus calcium scan biopsy supplements
Vitamin D Urine phos- Sunlight exposure
Rickets
Creatinine phorus
Urine
creatinine

Spinal X-rays of spine Exercise

curvatures Brace
• Scoliosis Spinal fusion
• Lordosis Body cast
• Kypho-
sis

Muscular system diseases and disorders can ambulatory care setting. Table 18-15 lists types of
be treated by electromyostimulation (EMS). Elec- fractures (see Chapter 9).
trical current directly stimulates motor nerves. Types of casting materials used are the plaster
A low frequency charge of electricity is given to (the mainstay for casting), synthetic or plastic cast,
muscle(s) through electrodes placed on the skin and the air cast. Plaster casts are formed by wetting
to elicit muscle contraction. The therapy improves bandage rolls impregnated with calcium sulfate and
muscle strength and is used to help strengthen molding them to the injured body part. Synthetic casts
atrophied muscles caused by surgery or injuries. are formed by using tape embedded with a polyester/
EMS therapy can re-educate muscles that have cotton combination, fiberglass, or plastic resin. Air
become paralyzed. It can be used in sports training casts are a type of inflatable immobilizer and are used
to improve muscle strength. for sprains and postcast support. The type of casting
Therapeutic treatment of muscular system material used is dependent on provider preference
injuries caused by trauma is clinically handled by and the body part to which a cast is being applied.
the use of cold and hot therapy and physical ther- Synthetic casts are lighter, stronger, and more water
apy including ultrasound therapy. These proce- resistant, but they have less room for swelling.
dures are discussed in Chapter 21.
• Short arm cast (SAC): extends from the fingers to
just below the elbow (fracture or dislocation of
Fractures, Casting, and Cast wrist and forearm)
Removal • Long arm cast (LAC): extends from the fingers to
Closed fractures of the wrist, forearm, fingers, the axilla, with a bend at the elbow (fracture of the
lower legs, or upper arm are often treated in the upper arm)
 CHAPTER 18 Examinations and Procedures of Body Systems 475

Table 18-13 Muscular/Connective Tissue Disorders

Laboratory/Diagnostic Tests

Disease/ Medical Tests

Disorder Blood Other Radiography Surgery or Procedures Treatment

Urinalysis X-ray of May be Computerized Treatment depends on

vertebrae neces- tomography diagnosis
sary (CT) Analgesics
Magnetic reso- Antiinflammatory
Back pain nance imaging medications
(MRI)
Exercise
Epidural corticosteroids
Electronic stimulation
device

MRI Excision Moist heat

X-ray of of bursa Immobilization
affected joint wall
Bursitis Antiinflammatory
for calcium medications
deposits
Local injection of
corticosteroids

Rheu- Skeletal Electromyogra- Antiinflammatory medi-

matoid X-rays phy cations may be useful
arthritis Physical therapy
antibody
Fibromyal- Medication for sleep
gia disturbances (antide-
pressants)
Counseling
Exercise

X-rays of May be Cold wet packs to area

affected body neces- for 24 hours; follow with
part to rule out sary warm packs
fracture Antiinflammatory medi-
cations
Strain, Elevate and rest
sprain affected part
Immobilization or move-
ment of affected part
(per provider’s recom-
mendation)
Physical therapy

Arthrogram Moist heat

Antiinflammatory medi-
cations
Tendonitis
Local injection of corti-
costeroids
Physical therapy

Note: Physical therapy should be encouraged from the onset. Patient can prevent further damage. Provide patient education.
476 UNIT 5 Assisting with Specialty Examinations and Procedures

Table 18-14 Description of Skeletal and Muscular Disorders

Bone

Carpal tunnel syndrome. Causes pain and weakness of hand and fingers. May cause paresthesia of hand and fingers.
Caused by compression of the median nerve against the carpal bones. Usually results from repetitive tasks (such as using
computer keyboard or mouse or rolling hair).

Cleft palate. Congenital disorder caused by nonunion of the maxillary bones. Surgical repair needed to close palate.

Fractures. Break in a bone classified according to angle, usually caused by trauma or pathology.

Herniated disk. A rupture of the cushioning mass between two intervertebral disks of the spine most often caused by injury
or osteoarthritis. Causes back pain that may radiate into buttock(s) and down leg.

Osteoporosis. Diminished bone mass caused by lack of calcium deposits in the bone, predisposing patients to fracture.

Paget’s disease. Chronic disease marked by a high rate of bone destruction and irregular bone repair. The new bone frac-
tures easily. Cause unknown but may be hereditary.

Rickets. Abnormal bone softening caused by inadequate utilization of vitamin D, inadequate intake or loss of calcium. One
symptom is night fever (known as osteomalacia in adults).

Spinal curvatures. Spinal defects with exaggerated curves caused by diseases of the spine, faulty posture, or congenital
malformations.
Scoliosis: right or left sideway curvature of the spine
Lordosis: inward curvature of the lower spine (swayback)
Kyphosis: outward curvature of the upper spine (hunchback)

Joints

Dislocation. A bone forcibly displaced from its joint usually caused by trauma.

Gout. Form of arthritis caused by metabolic disturbances in purine metabolism resulting in uric acid crystal deposits in the
joints. Causes periodic attacks of arthritis pain and joint inflammation.

Osteoarthritis. Common, chronic inflammatory process of the joints, with overgrowth of bone and spur formation. Accom-
panies aging. Causes swollen joints and pain.

Rheumatoid arthritis. More serious and crippling form caused by inflammation of the synovial tissues of several joints,
may be caused by antigen–antibody reaction. Systemic symptoms include fatigue, temperature elevation, sensory distur-
bances, pain, and joint deformities.

Muscle Disorders

Back pain. Localized discomfort usually in the lumbar area caused by stretching or straining of muscles.

Bursitis. Inflammation of the cavity found in connective tissue of a joint that is lined with synovial fluid usually caused
by trauma.

Fibromyagia. Discomfort of muscles, tendons, ligaments, and soft tissues brought on by trauma, strain, and emotional stress.

Spasm. Sudden involuntary muscle contraction; can cause pain.

Sprains. Caused by trauma to a joint with torn ligament if severe.

Strain. Trauma to a muscle from violent contraction.

Tendonitis. Inflammation of tendons and attachments caused by trauma such as strain.

 CHAPTER 18 Examinations and Procedures of Body Systems 477

Table 18-15 Types of Fractures • Long and short leg casts: extend from the thigh to
the toes (LLC) or from below the knee to the toes
Fractures can be simple, or closed, so called because (SLC) and usually include a walking heel
the bone is broken with no penetration of the skin; or
they can be compound, or open, so called because the The medical assistant’s role in cast applica-
broken bone has protruded through the skin and there tion and removal consists of setting up supplies
is an open wound in addition to the fracture. and assisting the provider. Patient teaching of cast
care is also a primary function of the medical assis-
Two of the most common fractures are both simple frac- tant. Procedures 18-20 and 18-21 outline steps in
tures: Colles fracture and Potts fracture. Colles fracture
applying a plaster cast and assisting in cast removal
is a fracture of the lower end of the radius. Potts fracture
is a fracture of the lower part of the fibula and the mal- (Figures 18-33, 18-34, and 18-35).
leolus of the tibia.

Fractures are described by their characteristics:

Greenstick. The bone is bent on one side and frac-
tured on the other.
Oblique. The bone is fractured and runs obliquely to
the axis of the bone.
Transverse. The bone is fractured at a right angle to
the axis of the bone.
Comminuted. The bone is splintered into fragments.
Impacted. The bone is fractured into fragments
and the fragments have been driven into the inte-
rior of another bone. See Chapter 9.

Figure 18-34 If the cast is on a lower extremity, and

the patient will be ambulating, provide a cast boot for
transfer.

Figure 18-33 Ask the patient if she can feel you touch- Figure 18-35 Cast cutter, cast splitter, and bandage
ing the extremities distal to the immobilized area. scissors.
478 UNIT 5 Assisting with Specialty Examinations and Procedures

Patient Education
Cast Care Guidelines when bathing. If the cast gets wet, dry it
The medical assistant should instruct the patient with a hair dryer.
on managing and caring for a cast. • Cleaning a cast can be accomplished by
• Allow the casting material to dry by expos- using a damp cloth.
ing it to the air and keeping it uncovered, • When decorating a cast, use only water-
even during the night. Applying pressure to soluble paints or marking pens. This allows
the cast before drying can result in tissue the cast to breathe, thus preventing tissue
damage under the pressure area. damage.
• Elevate the casted extremity to aid in reduc- • Do not cut or trim the cast. Use masking
ing swelling and pain. This allows for a bet- tape if there is a sharp edge, or use a nail
ter fitting cast, and thus less discomfort. file to smooth a rough edge.
• Observe the fingers or toes for changes • Notify the provider if any of the following
in color; temperature changes; and occurs:
decreased sensation, pain, or tingling. This 1. A bad odor coming from the cast. This
is called nerve and circulation assessment may indicate an infection.
and could indicate the cast is too tight.
2. Numbness, tingling, severe pain, difficulty
• Do not place objects into the cast to
moving, severe swelling, or cold fingers or
scratch irritated skin. A break in the skin will
toes. The cast may be too tight.
provide a breeding ground for bacteria. Do
not use powder or creams. 3. A burning sensation over a bony area.
The cast may be too tight.
• Do not get the cast wet. This could lead to
malformation of the cast, resulting in mis- 4. Bleeding or pink to red discoloration on
alignment of the extremity and breakdown the cast. There may be bleeding from a
of the skin. Cover with waterproof covering wound under the cast.

NEUROLOGIC SYSTEM attention to symmetric strength and notes unequal

weakness on either side of the body. A patient’s sex
The nervous system functions to coordinate the and body build are considered when examining
activities of body systems and allows for the body muscle mass and tone. Table 18-16 lists neurologic
to adapt to its internal and external environment. diagnostic procedures. Table 18-17 describes neu-
Diagnosis and treatment of the brain, spinal cord, rologic disorders.
and peripheral nerve (nerves away from spinal cord)
disorders are often difficult because of the interde-
pendence of one part of the system on another.
The provider screens the patient during a phys-
ical examination for neurologic signs and symptoms.
The medical assistant’s role in a neurologic screen-
ing is to observe and evaluate the patient’s mental
status and to assist or perform other tests as directed
by the provider. Most of the examination is per-
formed in conjunction with the complete physical
examination, but it can also be done when a patient
is exhibiting specific signs and symptoms of a neu-
rologic problem such as lack of sensation, seizures,
confusion, paralysis, or aphasia (inability to speak).
The equipment and supplies used in a neu-
rologic screening test the patient’s reflexes, touch,
sense of smell, and degree of coordination to name Figure 18-36 Supplies used in a neurologic
a few (Figure 18-36). The provider pays particular examination.
 CHAPTER 18 Examinations and Procedures of Body Systems 479

Table 18-16 Neurologic System Disorders

Laboratory/Diagnostic Tests

Medical
Disease/ Tests or
Disorder Blood Other Radiography Surgery Procedures Treatment

Complete Magnetic Warm moist heat

blood count resonance Facial exercises
Bell’s palsy imaging (MRI)
Analgesics
of brain
Eye patch if unable to
close eye

Cerebral angi- To remove Electroenceph- Anticoagulant therapy

Cerebral vas- ography clots alography Physical therapy
cular acci- Computerized Lumbar punc- Speech therapy
dent (CVA) tomography ture
Tissue-plasminogen
(stroke) (CT)
activator (TPA)
MRI

CT Electroenceph- Antiepilepsy
Epilepsy alography medication
MRI

Varicella- Culture of cell Analgesics

zoster scrapings from Steroids
Herpes zoster antibody lesion
Antiviral medication
(Acyclovir, Famvir)
Vaccine Zostavax

Bran scan Lumbar Steroids

CT puncture Medications:
Multiple MRI experimental
sclerosis Physical therapy
Muscle relaxants
Assistive devices

Complete Saliva Wash wound immedi-

blood count Cerebral spi- ately with soap and
Blood serum nal fluid for water
Reverse antibodies to Antirabies injections
Rabies
transcription rabies virus Medication for
polymerase convulsions
chain reaction
(RT-PCR)

Complete Liver function Liver Lumbar Supportive

blood count studies biopsy puncture Physical therapy
Reye’s
syndrome Serum Brain Examination of Control of brain
ammonia biopsy cerebrospinal swelling
fluid

Blood serum Myelogram Diskec- Physical therapy

CT tomy (if Massage
caused
MRI Exercise
by herni-
Sciatica ated disk) Analgesics
Antiinflammatory
drugs
Surgery
(continues)
480 UNIT 5 Assisting with Specialty Examinations and Procedures

Table 18-16 Neurologic System Disorders (continued)

Laboratory/Diagnostic Tests

Medical
Disease/ Tests or
Disorder Blood Other Radiography Surgery Procedures Treatment

Biopsy of Analgesics
Tic doulou- trigeminal
reux Surgery to dissect the
nerve trigeminal nerve

Complete Cerebral spi- MRI Neurologic No specific

West Nile blood count nal fluid work-up treatment
virus
Supportive

Table 18-17 Description of Neurologic Disorders

• Bell’s palsy. Paralysis of seventh cranial nerve caused by an acute inflammation. Usually characterized by unilateral
facial paralysis and pain, but it can be bilateral.

• Cerebral vascular accident (CVA). Loss of blood supply to the brain (anoxia). May be caused by a ruptured or
clogged blood vessel or clot in the brain. Symptoms include sudden loss of consciousness and paralysis. Also referred
to as a stroke.

• Epilepsy. Episodes of seizures caused by changes in electrical brain potentials that result in disturbed brain impulses
or function.

• Headache. Diffuse pain in different parts of the head. May be acute or chronic with varying degree of pain and may
be caused by a variety of reasons.

• Herpes zoster. An acute infectious viral disease caused by varicella-zoster virus. Painful vesicular eruptions. Known as
“shingles.”

• Meningitis. Inflammation of the membranes of the spinal cord or brain. Symptoms include a stiff neck, headache,
anorexia, and irregular fever. Caused by either a bacterium or a virus.

• Multiple sclerosis. Chronic progressive disease characterized by demyelination (destruction of nerve covering) of
nerve fibers. The cause is unknown. First symptoms are visual disturbances and muscle weakness.

• Parkinson’s disease. A slowly progressive disease, usually occurring in later life, caused by a degeneration of brain
cells due to lack of dopamine in the brain. Muscle rigidity and akinesia are common symptoms.

• Rabies. Caused by a virus and transmitted to humans by scratches or bites from animals infected with the virus. The
disease infects the brain and spinal cord and causes acute encephalitis. It can be fatal.

• Reye’s syndrome. A neurologic illness usually seen in young children after a viral infection such as influenza, varicella,
Epstein–Barr. There may be a connection between the viral infection and aspirin. Cause is unknown, but characteristic
symptoms include vomiting, rash, lethargy and neurologic involvement, seizures, and coma.

• Sciatica. Severe pain in the leg along the course of the sciatic nerve felt at the back of the thigh and running down
the inside of the leg. Caused by compression of the nerve by a ruptured intervertebral disk or osteoarthritis. Character-
ized by sharp, shooting pain running down back of thigh. Leg movement aggravates the pain.

• Tic douloureux. Degeneration of or pressure on the trigeminal nerve (fifth cranial) causing severe stabs of pain that
radiate from the angle of the jaw along one of the branches. Pain may be felt in the eye, lip, nose, tongue. Pain may
come and go for hours.

• West Nile virus. A potentially serious illness that affects the central nervous system. Symptoms may include headache,
stupor, disorientation, tremors, convulsions, and coma. Spread by bite of infected mosquitoes.
 CHAPTER 18 Examinations and Procedures of Body Systems 481

 Cranial nerve VII: facial expressions, taste

Patient Education  Cranial nerve VIII: ear—hearing and equilibrium
 Cranial nerves IX and X: gag reflex, saliva secre-
Post–Spinal Tap Instructions tion, voice, slowing of heartbeat
1. Remain in a prone position for two to  Cranial nerve XI: neck and shoulder muscle
three hours to allow tissues to close over
the puncture site and minimize cerebro-
 Cranial nerve XII: tongue
spinal fluid (CSF) leakage and to allow
The provider continues with the neurologic examination
CSF to be replenished.
by checking the patient for the following:
2. Increase fluid intake because this helps
to replace fluid loss. • Cerebral function
3. Report any severe headaches or altera-  Memory
tions in neurologic status (paralysis,  Muscle coordination
numbness, and tingling).  Sensory interpretation
 Posture and gait
• Motor function
Procedures performed to confirm a diagnosis  Muscle tone
of a neurologic problem or disease are limited to  Strength
the use of various diagnostic imaging and electri-  Muscle mass
cal impulse studies. The medical assistant assists
the providers during certain procedures. Patient  Twitching
teaching by the medical assistant before a proce- • Sensory function
dure and active reinforcement during a procedure  Touch (pain, light touch, vibration, position
will promote patient cooperation. Procedure 18-22 sense)
outlines steps involved in removing cerebrospinal
• Deep tendon reflexes
fluid from the lumbar area.
Extremities:
Components of a Neurologic  Upper: biceps, triceps
Screening  Lower: quadriceps, achilles
Additional tests:
During the neurologic screening examination, var-
ious functions are observed. Procedure 18-23 out-  Angiography provides visualization of the circu-
lines the steps involved in a neurologic screening lation of the blood throughout the brain.
examination:  Computerized tomography (CT) helps to diag-
nose hemorrhage and tumors (see Chapter 20).
• Mental status  Electroencephalography (EEG) records the elec-

Level of consciousness (alert) trical activity of the brain and helps to diagnose
 Memory (recall of past and present) seizures and tumors.
 Magnetic resonance imaging (MRI) helps
 Cognition (ability to calculate and remember
to diagnose tumors and hemorrhage (see
current events)
Chapter 20).
 Mood (is it appropriate for the conversation)  Electromyography (EMG) nerve conduction test,
 Ideational content (hallucinations) usually of the arms and legs.
• Cranial nerve function

Cranial nerve I: aroma identification
 Cranial nerve II: visual acuity, visual fields, CIRCULATORY SYSTEM
optic disk
The circulatory system is composed of the heart
 Cranial nerves III, IV, and VI: extraocular eye and a complex network of blood vessels. Their func-
muscles tion is to pump and transport the blood to all parts
 Cranial nerve V: sensations of the face, scalp, of the body, thus supplying oxygen and removing
teeth waste products from body tissues. Table 18-18 lists
482 UNIT 5 Assisting with Specialty Examinations and Procedures

Table 18-18 Circulatory System Disorders

Laboratory/Diagnostic Tests

Disease/ Medical Tests

Disorder Blood Other Radiography Surgery or Procedures Treatment

Ultrasonography Coronary Electrocardiog- Nitrogycerin

Angiography artery raphy and other
bypass Stress test medications
Cardiac cath-
eterization Angioplasty Coronary artery
Angina bypass surgery
pectoris
Angioplasty
with stent
Lifestyle
changes

Chemistry panel Chest X-ray Removal of Electrocardiog- Medication

part of myo- raphy Heart trans-
Congestive cardium Venous pressure plant
heart failure
Lifestyle
changes

Electrolytes High Angiography Coronary Electrocardiog- Medication

Chemistry, low- sensitivity Thallium stress artery raphy Coronary artery
density, lipopro- C-reactive test bypass bypass surgery
Coronary protein
artery disease tein, high-density Cardiac cath- Angioplasty Lifestyle
lipoprotein, (hsCRP)
eterization changes
cholesterol,
triglycerides

Electrolytes Urinalysis Chest X-ray Electrocardiog- Medication

Essential raphy
hypertension Chemistry panel Kidney Lifestyle
function Blood pressure changes

Ultrasonography Valvotomy Electrocardiog- Valve replace-

Echocardiog- raphy ment
Mitral valve
raphy Medication
stenosis
Cardiac cath-
eterization

Cardiac enzymes Thallium stress Coronary Electrocardiog- Oxygen

Complete blood test artery raphy Medication
Myocardial bypass
count Cardiac cath- Lifestyle
infarction
eterization Angioplasty changes
Ultrasonography

Complete blood Urinalysis Chest X-ray Electrocardiog- Medication

count Blood raphy Antibiotics
Erythrocyte sedi- culture Pericardiocentesis
Pericarditis mentation rate
Cardiac enzymes
Bacterial
antibodies (continues)
 CHAPTER 18 Examinations and Procedures of Body Systems 483

Table 18-18 Circulatory System Disorders (continued)

Laboratory/Diagnostic Tests

Disease/ Medical Tests

Disorder Blood Other Radiography Surgery or Procedures Treatment

Complete blood Throat Echocardiog- Electrocardiog- Antibiotic

count culture raphy raphy therapy
Streptococcal
antibodies
Rheumatic Erythrocyte sedi-
fever mentation rate
(ESR)
Cardiac enzymes
Kidney function
Liver function

Bleeding and Urinalysis Doppler ultraso- Thrombec- Elevation of

clotting time nography tomy affected limb
Thrombophle- Complete blood Angiography Medication
bitis count Radioactive (anticoagu-
fibrinogen lant)
Support hose

Venography Ligation and Elastic

Doppler ultraso- stripping stockings
Varicose
nography Laser Sclerotherapy
veins
Ligation and
stripping

circulatory system disorders and diagnostic proce- Lymph is important because of its filtering
dures. Table 18-19 describes disorders of the circu- properties. The body’s immune system relies heav-
latory sysem. ily on the fact that the lymph passes through the
The variety of diagnostic procedures used to lymph glands and bacteria and other substances
determine the patient’s diagnosis are necessary are filtered out. Table 18-20 describes diseases and
because of the complexity of the cardiovascular disorders diagnostic procedures for the blood and
system. The medical assistant assists with and per- lymphatic system; Table 18-21 describes certain
forms some of the procedures used for clinical blood and lymph system disorders.
diagnosis. Electrocardiography (ECG) is explained Common laboratory and diagnostic proce-
in Chapter 25. dures requested by the provider include some of
the following:

BLOOD AND LYMPH SYSTEM • Complete blood count (CBC). A routine test that
includes a hemoglobin, hematocrit, and red and
The blood and lymph are excellent indicators of white blood cell count.
many underlying diseases. As blood circulates • Differential. Distinguishes among the various types
through body tissues and organs, it deposits nutri- of white blood cells.
ents and removes wastes. Failure to accomplish
this leaves the body in a disease state. Blood cells • Erythrocyte sedimentation rate (ESR) (sedimentation
include erythrocytes, leukocytes, and platelets, and rate). Done to time the speed of red blood cells
each has its own function. Studying the results of settling to the bottom of a test tube.
laboratory findings assists the provider in making • Platelet count. The number of platelets in a blood
a diagnosis. specimen.
484 UNIT 5 Assisting with Specialty Examinations and Procedures

Table 18-19 Description of Circulatory System Disorders

• Angina pectoris. Chest pain caused by lack of oxygen to the myocardium. Usual cause is coronary arteriosclerosis.

• Congestive heart failure. A syndrome characterized by the heart’s inability to pump blood adequately to the body tissues.
Characterized by congestion in the lungs, or edema of lower extremities, dyspnea on exertion, cough, and related edema.

• Coronary artery disease. Arteriosclerosis of the coronary arteries leading to impaired blood flow to the myocardium.
Complete occlusion leads to myocardial infarction. May also be caused by thrombus in a coronary artery. Angina pec-
toris is the name of the chest pain that occurs due to lack of oxygen to the myocardium.

• Essential hypertension. Consistently high blood pressure of unknown cause.

• Mitral valve stenosis. Narrowing of mitral valve obstructing flow from atrium to ventricle. Usual cause is a rheumatic heart
disease as a result of a streptococcal infection (throat or scarlet fever). Thrombi can form. Atrial fibrillation possible.

• Myocardial infarction. Death of myocardial tissue caused by anoxia to the myocardium. Symptoms include dyspnea,
chest pain, nausea, vomiting, and diaphoresis.

• Pericarditis. Inflammation of the pericardium. Caused by tuberculosis, pyogenic organisms, uremia, and myocardial
infarction. Characterized by fever, dry cough, dyspnea, and palpitations.

• Rheumatic fever. A systemic disease affecting the heart, joints, and central nervous system after a group A beta-
hemolytic streptococcal infection. May occur without symptoms. Symptoms include fever, migratory joint pain,
pericarditis, and heart murmur.

• Thrombophlebitis. An inflammation of a vein with thrombus formation, may be caused by trauma. Symptoms include
pain and swelling in affected vein.

• Varicose veins. Enlarged, twisted, and engorged veins, commonly occurring in the saphenous veins but may occur in
any vein in the body. Caused by conditions that hamper venous return, such as pregnancy, standing for long periods of
time, and obesity. Symptoms include pain in feet and ankles, swelling, and leg ulcers.

• Liver function studies. Measure coagulation factors, • Epidermis is the outer layer of the skin that is com-
prothrombin, and fibrinogen necessary for blood posed of squamous epithelium and produces kera-
coagulation. tin and the pigment melanin.
• Schilling test. Radioactive vitamins B12 and intrinsic • Dermis is the inner layer of the skin made up of con-
factor measured in 24-hour urine specimen. nective tissue and contains blood vessels, nerve end-
ings, and glands. Provides strength and elasticity.
Procedures to collect blood specimens and
• Subcutaneous connective tissue (hypodermis) is
venipuncture are explained in Chapter 28; hema-
the layer on which the skin and muscles lie and
tology is discussed in Chapter 29.
consists of elastic and fibrous connective tissue and
adipose tissue. Guards against heat loss and pro-
vides insulation.
INTEGUMENTARY SYSTEM
Skin disorders frequently produce a lesion
The integumentary system consists of the skin (injury or wound) unique to a specific skin dis-
and its associated structures, such as hair, nails, ease, thus allowing for the diagnosis to be based
nerve endings, and the sebaceous (oil) and on the appearance of the lesion, the patient’s his-
sudoriferous (sweat) glands. This system pro- tory, allergies, emotional well-being, and inher-
vides protection for the body against invasion ited diseases. If the lesion appears suspicious, the
of microorganisms and trauma and helps regu- provider may perform a biopsy for tissue analysis.
late body temperature. Nerve endings sense This procedure aids in the diagnosis and treat-
pressure, touch, and pain. Structurally, the skin ment of specific skin disorders. Table 18-22 lists
consists of two layers (Figure 18-37), which func- integumentary system diseases and diagnostic
tion differently from one another to perform procedures. Table 18-23 describes skin disorders
specific activities. of the integumentary system.
 CHAPTER 18 Examinations and Procedures of Body Systems 485

Table 18-20 Blood and Lymph System Disorders

Laboratory/Diagnostic Tests

Disease/ Medical Tests

Disorder Blood Other Radiography Surgery or Procedures Treatment

Ferritin Gastric Ferrokinetic Bone marrow Depends on

Serum iron analysis studies cause
Complete blood Radioactive B12 Increase dietary
Anemias count intake of iron or
folic acid
Red blood cell
count Vitamin B12 injec-
tions
Serum B12

Complete blood Chest radio- Lymph Bone marrow Radiation

Hodgkin’s count graph node Chemotherapy
disease Liver function Lymphangiog- biopsy
raphy

Complete blood Analgesics

count Rest
Infectious Monoscreen
mononu- Heterophile anti-
cleosis body
Epstein–Barr virus
Liver function

Complete blood Bone mar- Bone marrow Chemotherapy

count row trans- Bone marrow
Leukemia Liver function plant transplant
Platelet count
Bleeding time

Lymphangiog- Antibiotics
Lymph- raphy Surgery
edema Lymphedema
therapy

Table 18-21 Description of Blood and Lymph System Disorders

Anemias. All anemias are manifested by a reduction in circulating red blood cells and the amount of hemoglobin, which is
the volume of packed red blood cells per 100 mL blood. Symptoms include pallor of the skin, nailbeds, and mucous mem-
branes; weakness; vertigo; headache; drowsiness; and general malaise.
• Iron deficiency. Lack of reserve iron in the body and in red blood cells that lack hemoglobin resulting from inadequate
dietary intake of iron, iron malabsorption (poor absorption of nutrients), blood loss, or pregnancy.
• Pernicious anemia. Lack of intrinsic factor in the stomach secretions (hydrochloric acid). Vitamin B12 cannot be absorbed.
Red cells cannot develop properly.
• Sickle cell anemia. A hereditary chronic anemia characterized by abnormal red blood cells causing lysis of the cells and
the formation of clumps in the blood vessels, impairing circulation. Not curable.

Hodgkin’s disease. An idiopathic malignancy of the lymphatic system causing enlargement of lymphatic tissue, spleen, and
liver. Symptoms include fever and night sweats. Often curable.

Leukemia. Overproduction of abnormal and immature white blood cells. Cause is unknown. Symptoms include anemia,
fatigue, fever, and joint pain.

Lymphedema. Abnormal accumulation of lymph in the extremities caused by obstruction of the lymphatics. Symptoms
include edema in arms or legs.
486 UNIT 5 Assisting with Specialty Examinations and Procedures

Sweat pore
Hair shaft

Sensory nerve
ending for touch

Epidermis

Dermis
Arrector pili muscle

Sebaceous (oil) gland

Subcutaneous
Hair follicle fatty tissue
Papilla of hair

Nerve fiber Vein

Vein Artery
Nerve
Artery Sweat gland

Figure 18-37 Cross-section of skin.

Diagnostic procedures involving the skin There can be a broad range of inflammatory
range from the simple to the complex. Simple responses to allergens. Some responses include
observations such as skin color, texture, size and urticaria (hives), swelling at the injection site, pruri-
shape of a lesion, and patient history can lead tus (itchiness), and redness. A response or reaction
to a quick diagnosis. Confirmatory procedures can be immediate, life-threatening, and systemic in
such as clinical studies of urine and blood, cul- nature. The allergen reaches the circulatory system
ture of a purulent lesion, radiographs, and biop- triggering a massive release of substances (hista-
sies of the affected tissues can further delineate mine) that can produce severe airway obstruction,
the disease. vasodilation, hypotension, laryngeal edema, and
The clinical procedures for the skin most shock (anaphylactic). See Chapter 9.
commonly performed by the medical assistant
are obtaining wound cultures, applying a ster- Three Kinds of Skin Tests. The scratch test, the
ile dressings to the wound site, and allergy skin patch test, and intradermal test are the three
testing. skin test procedures the provider can perform on
patients to evaluate for allergies. Together with the
patient’s medical history, laboratory values, physi-
Allergy Skin Testing cal exam, and the skin test results, the provider
Medical assistants often perform allergy skin test- compiles the data to determine the substances to
ing. When performing allergy skin tests, severe which the patient is allergic (Figure 18-38).
allergic reaction is a distinct possibility. Emer-
gency treatment must be available immediately Scratch Test. The back and arms are used for
and consists of the following: (1) notify provider the scratch test. The skin surface is numbered in
immediately; (2) have patient lie down; (3) have rows approximately two inches apart so that they
epinephrine, benadryl, and corticosteroid injec- can be identified. A small scratch is made on the
tions ready to be administered; and (4) check surface of the skin and the allergen (a substance
patient’s vital signs. that causes allergy) is placed on the scratch. As
 CHAPTER 18 Examinations and Procedures of Body Systems 487

Table 18-22 Integumentary System Disorders

Laboratory/Diagnostic Tests

Medical
Disease/ Radio- Tests or
Disorder Blood Other graphy Surgery Procedures Treatment

Complete Culture and Incision and Antibiotics

Abscess
blood count sensitivity of drainage Incision and
(furuncle,
Blood glucose wound exu- drainage
carbuncle)
date

Culture of Antibiotics
Acne skin lesions Steroids
Retin-A

Corn, callus, Excisional Surgical excision

wart (ver- biopsy
ucca), mole Electrocau-
(nevus) tery

Serum IgE Biopsy of Depends of cause

Dermatitis
lesion

Culture Wood’s rays Antifungal

Dermato-
(ultraviolet medication
phytosis
rays)

Complete Gram stain Antibiotics

Impetigo blood count of discharge
from lesion

Chest X-ray Biopsy of Surgical excision

Melanoma lesion Chemotherapy

Skin biopsy Medication

Psoriasis
Light therapy

Sedimentation Urinalysis Gastrointesti- Tissue Medication

rate Kidney func- nal X-ray biopsy
Rheumatoid tion tests Chest X-ray
Scleroderma arthritis
factor
Antinuclear
antibodies

Biopsy of Surgical excision

Skin cancer lesion Laser therapy
Radiation therapy

many as 50 allergens can be used at one time an allergy-free fluid. The provider reads the
(Figure 18-39). A reaction to the allergen usually results, which are graded on a scale from 2 to 4.
occurs within a half-hour. If the patient is allergic A number 2 reaction indicates a wheal larger than
to a substance, a wheal (a hive) will develop at the the control scratch reaction (which is minimal).
scratch site. The site is compared with a scratch A number 3 is given to a larger reaction, and a
test with no allergens introduced into it, but just 4 is given to a reaction in which the wheal extends
488 UNIT 5 Assisting with Specialty Examinations and Procedures

Table 18-23 Description of Skin Disorders

Abscess. Furuncle “Boil.” Acute circumscribed infection of the subcutaneous tissues and surrounding tissues caused by
staphylococci. Carbuncle. A circumscribed inflammation and infection of the skin and deeper tissues accompanied by
fever, leukocytosis, and sometimes prostration. Caused by staphylococcus and common in patients with diabetes.

Acne. Chronic inflammatory disease caused by blocked sebaceous glands, characterized by comedones (blackheads),
papules, and pustules.

Corn and callus. Thickening and hyperplasia of the stratum corneum (outermost skin layer) caused by pressure or friction to
the affected area.

Dermatitis. Caused by a specific irritant characterized by erythema or redness as in inflammation.

Dermatophytosis. A highly contagious infectious fungus infection of the skin. Common on hands and feet. When feet are
infected, it is known as athlete’s foot or tinea pedis.

Herpes zoster. An acute infectious disease caused by varicella-zoster virus. Characterized by inflammation of the ganglia of
the spinal or cranial nerves. Painful, vesicular eruptions occur along the course of the nerves.

Impetigo. Contagious small pustules caused by a staphylococci or streptococci or a combination of both and spread by
direct contact.

Melanoma. A malignant pigmented mole. Virulent and invasive. Can be caused by ultraviolet light exposure.

Nevus. A mole. Usually congenital.

Psoriasis. Chronic, genetically determined dermatitis, characterized by flat, reddened areas with silvery scales.

Scleroderma. Progressive thickening of the skin involving collagen tissue. Systemic involvement occurs. Cause is unknown.

Skin cancer. Malignant lesions on the skin surface caused by exposure to ultraviolet rays.

Verruca. A wart caused by a virus.

Patient Education
beyond the usual circumscribed area of the injec-
tion. The allergen extract should be wiped away Teach patients that the following may be warn-
from the scratch area that is exhibiting a number 4 ings of skin cancer (melanoma, basal cell, and
reaction (see Chapter 10). squamous cell carcinoma):
1. Change in size, shape, or color of mole or
Patch Test. The suspected allergen is placed on wart
the skin and is covered with a square of cellophane 2. Scaliness
and held in place by tape. As many as 25 tests can
be done at one time and results are read in 24 to 3. Oozing or bleeding
96 hours (Figure 18-40). 4. Pain
Teach patients to avoid exposure to the sun and
Intradermal Test. A small dose (0.1 mL) of an to use a high number sunscreen even during
allergen is injected intradermally into the forearm. winter months and overcast days. Early detec-
Ten to fifteen tests can be done simultaneously on tion is necessary for successful treatment. Treat-
each arm, and the patient can experience a severe ment is by surgical excision or electrosurgery
reaction more quickly. This test is always done on (see Chapter 19).
the patient’s forearm.
 CHAPTER 18 Examinations and Procedures of Body Systems 489

Pharmacy

CLINICAL CARE
Patient Assessment
Procedures, Diagnoses & Treatment Plans
Referrals & Follow-up Appointments
Prescriptions
Orders for Tests
Patient Medical History

Adhesive patch
Test Results Cellophane
Schedules and Tickler Files
Patient Medical History Linen or blotting
Medication Administration paper patch
Patient Education
Graphical Patient Data Displays

Single patch

ELECTRONIC test in usual

location

RECORDS Patch Test

Negative
reaction
Positive
reaction

Figure 18-40 Patch test being applied. Tell the

patient to keep the patch clean, dry, and covered until
Figure 18-38 In a total practice management system, the provider reads the results.
data entered during clinical care are available on
demand and accessible for comparisons. It can help
the provider develop a treatment plan.
immediate information about allergies and is less
expensive.
After any type of allergy skin test or injection,
the patient should remain in the office for 20 to
30 minutes to watch for an allergic reaction. If a
reaction occurs, emergency medications and sup-
plies (epinephrine, benadryl, and oxygen) must
be readily available.
Once the allergies have been determined,
the patient may choose to undergo immuno-
therapy. At regularly scheduled intervals (usually
weekly), patients go to the office or ambulatory
center and receive an injection of the substance
(an extract) to which they are allergic. The dose
of the extract given to patients is increased at
each visit as long as the patient has had no reac-
tion to the extract at the previous injection. This
Figure 18-39 Allergy extracts are placed on the skin is done in order to provoke the production of
using a multiple applicator. large quantities of blocking antibody, primarily
immunoglobulin.
Patients may bring their extracts (serum)
Radioallergosorbent Test (RAST). The RAST from the allergist’s office with them to the office or
laboratory test is obtained by venipuncture and ambulatory center for you to administer to them.
uses radioisotopes to measure minute, specific Extreme caution must be used because the sub-
antibodies present in the circulating blood. stances being injected are the substances to which
Scratch, patch, and intradermal testing provide the patient is allergic, and anaphylaxis can occur.
490 UNIT 5 Assisting with Specialty Examinations and Procedures

Anaphylaxis is life-threatening and can be fatal if is attached to the patient’s waist. The patient swal-
emergency measures are not taken immediately. lows a pill about 1 inch long and ½ inch wide that
Urticaria (hives), anxiety, weakness, pruritus, and has a camera within it. The camera takes up to
dyspnea are signs and symptoms of impending 57,000 color images (two photos per second) of the
anaphylaxis. small intestine while the patient goes about normal
activities. The camera “sees” areas overlooked by
Medical Assistant Responsibilities. Common conventional endoscopy and small bowel X-rays. It
procedures with which the medical assistant photographs all 25 to 30 feet of the small intestines
can assist the provider are the cutaneous punch for evaluation of the patient’s unexplained rectal
biopsy and wart and mole removal. The prime bleeding, intermittent abdominal pain, and diar-
responsibilities of the medical assistant are to fol- rhea. It can help diagnose polyps, cancer, Crohn’s
low the principles of surgical aseptic technique, disease, and other disorders and diseases. The
infection control, and standard precautions; PillCam does not view the colon. The patient
provide the required supplies as needed; safely returns after 8 hours and drops off the equipment
handle and transport the biopsy specimen; and and the data receiver.
document in the patient record that the biopsy The data from the recorder are downloaded
was sent to the laboratory. onto a computer, and the photos are compressed
The electronic medical record maintains into a video. The provider views the photographed
E HR patient history, including a list of aller- images on a monitor.
gies, test results, and the times, amount, The FDA approved the capsule endoscopy
and serum extract given. (PillCam) in 2001. The FDA said the PillCam is
safe and has few side effects. The patient excretes
Endoscopic Procedures. An endoscope is an the camera in a bowel movement. A PillCam Colon
instrument or device that is used to observe the is being used in Europe but has not been approved
inside of a hollow organ or cavity (to view within). for use in the United States. A PillCam ESO, which
Using an endoscope, procedures can be done on was approved by the FDA in 2004, is used to look
many internal organs without surgical interven- for abnormalities in the esophagus.
tion. These are known as fiberoptic endoscopic Another type of colonoscopy is known as vir-
procedures or endoscopy, and they can be per- tual colonoscopy. It requires the same preparation
formed through a natural body opening or a small as a conventional colonoscopy and can be used for
incision. A light source (fiberoptics) at the end patients who want a procedure they consider to be
of the endoscope permits the provider to observe quicker and less painful.
within the body cavity for disorders such as polyps, The patient lies on the CT table, first on the
tumors, cysts, stenoses, calculi, and malignancies. back and then on the abdomen. A probe is inserted
Biopsies and cultures can be taken during the through the rectum into the colon. The probe
procedure. Small lesions, such as polyps, can be inflates the colon with air. Computerized tomogra-
totally removed during endoscopy. Photos can be phy and X-rays take three-dimensional pictures of
taken for documentation also. the colon and software provides the radiographer
An endoscopic procedure known as capsule with images on a monitor.
video endoscopy (CVE), wireless capsule endos- According to some gastroenterologists, vir-
copy (WCE), or PillCam (all three are the same tual colonoscopy is not as good as a conventional
type of endoscopy) can be performed. The patient colonoscopy because of the lower quality of images
must fast for 10 hours before the procedure and of the colon.
needs a bowel preparation similar to a colonos- The medical assistant must be certain that the
copy preparation. When the patient arrives at patient has signed a consent form before the pro-
7:30 am at the gastroenterology clinic, sensor-like cedure and that the patient has followed the pre-
wires are attached to the abdominal wall (they paratory instructions. Table 18-24 lists endoscopic
look similar to electrocardiogram sensors) and procedures, their importance in diagnosis, and
an 8-hour battery-operated data recording device patient preparation.
 CHAPTER 18 Examinations and Procedures of Body Systems 491

Table 18-24 Endoscopic Procedures

Endoscopic Procedure Importance in Diagnosis Patient Preparation

Detects torn ligaments, examines for syno- NPO after 10:00 PM

Arthroscopy (examination and repair
vial problems. Surgery can be performed
of joints)
to repair joint.

Bronchoscopy (examines bronchial Detects lesions, obstructions, malignancies. NPO for 12 hours before examination
tree) Can take cultures and biopsies.

Helps diagnose Crohn’s disease, polyps, Laxative

Capsule video endoscopy and cancer of the small intestine. NPO for 10 hours before procedure

Detects polyps, tumors, bleeding, malig- Clear liquids for 2 days before
nancies. NPO after 10:00 PM
Colonoscopy (views entire colon)
Can take biopsies, remove polyps, take Night before bowel preparation:
photos, take cultures. laxatives and enemas

Colposcopy (examines the cervix and Biopsy lesions for abnormal cells. No dietary restrictions
vagina after an abnormal Pap test) Empty bladder

Cystoscopy (examines the urethra Identify lesions in the bladder, urethra; No dietary restrictions
and bladder) enlarged prostate gland. Biopsy

Endoscopic retrograde cholangio- Helps diagnose problems in the liver, gall NPO after 10:00 PM
pancreatography (ERCP) (examines bladder, bile ducts, and pancreas, such as
the liver, gall bladder, bile ducts, and cholelithiasis, stenoses, and malignancies
pancreas) of these organs and structures.

Detects abnormalities in the esophagus, NPO after 10:00 PM

Esophagogastroduodenoscopy
stomach, and duodenum, such as hiatal
(EGD) (examines esophagus, stom-
hernia, stenoses, tumors, ulcers, erosion.
ach, and duodenum)
Biopsies, brushings, photos.

Examines stomach and duodenum for NPO after 10:00 PM

Gastroduodenoscopy lesions, such as tumors, polyps, strictnress,
and ulcers.

Examines stomach for ulcers, lesions, and NPO after 10:00 PM

Gastroscopy
malignancies.

Detects endometriosis, cysts, fibroids, ecto- NPO after 10:00 PM

Laparoscopy (examines the perito- pic pregnancies, and masses. Surgery can
neal cavity, abdomen, and pelvis) be performed, such as oophorectomy,
biopsy, and tubal ligation.

Evaluates unexplained rectal bleeding, Laxative

PillCam intermittent abdominal pain, and diarrhea. NPO for 10 hours before procedure

Detects polyps, rectal abscesses, tumors, Bowel preparation: 3-day special

Proctosigmoidoscopy (views sigmoid fissures, and fistulas. diet
colon and rectum) Laxative and enemas
NPO after midnight the night prior

Camera photographs entire small intestine Laxative

with 57,000 colored images, two photos NPO for 10 hours before procedure
Wireless capsule endoscopy per second. Can photograph areas over-
looked by conventional endoscopy and
small bowel X-rays.
492 UNIT 5 Assisting with Specialty Examinations and Procedures

Procedure 18-1
Urinary Catheterization of a Female Patient
STANDARD PRECAUTIONS: 10. Ask patient to keep knees apart. RATIONALE:
This position provides good visualization of the
urinary meatus.
11. Apply sterile gloves.
PURPOSE: 12. Pour Betadine over three cotton balls in appro-
To obtain a sterile urine specimen for analysis or to priate compartment of the kit or open Betadine
relieve urinary retention. swabs.
13. Open urine specimen container.
EQUIPMENT/SUPPLIES:
Catheter kit (commercially available) containing: 14. Apply sterile lubricant to a gauze sponge and
Sterile gloves place tip of catheter in lubricant.
Betadine® solution or swabs 15. Instruct patient to breathe slowly and deeply
Lubricant during procedure. RATIONALE: This helps the
Sterile fenestrated drape patient relax the abdominal and pelvic muscles
Sterile cotton balls and facilitates easier insertion of the catheter.
Sterile urine container with label
16. Spread labia with nondominant hand. Domi-
Sterile 2 ⫻ 2 gauze sponges
nant hand remains sterile. With dominant hand
Forceps (sterile)
and sterile forceps, wipe genitalia with each of
Sterile absorbent plastic pad
the three antiseptic soaked cotton balls, with a
Additional items needed:
front to back motion. First, wipe the right labia
Sterile catheter (size and type as ordered by provider)
using front to back motion. Discard cotton ball
Biohazard waste container
into waxed paper bag that is placed away from
Laboratory requisition form
sterile area. Second, wipe the left labia repeating
Waxed paper bag
procedure, and last, wipe down the center, dis-
PROCEDURE STEPS: carding cotton ball after each wipe. Discard for-
1. Identify the patient and explain the procedure. ceps. Continue to hold labia apart until catheter
is inserted. RATIONALE: Holding labia open
2. Wash hands and assemble supplies.
will keep urinary meatus from becoming con-
3. Place unopened catheter kit on Mayo stand near taminated from labia while inserting catheter.
the patient.
17. Place sterile catheter tray between the patient’s
4. Provide good lighting. legs, touching only the sterile surfaces of tray.
5. Have patient disrobe below the waist; provide a 18. Using sterile gloved hand, pick up catheter and
drape. hold it about 3 to 4 inches from lubricated end.
6. Position patient into a dorsal lithotomy position The other end of the catheter should go into the
on an examination table. RATIONALE: This sterile catheter tray.
allows for access to the urinary meatus. 19. Gently insert lubricated tip of catheter into uri-
7. Drape patient with sheet exposing only external nary meatus approximately 6 inches or until
genitalia. urine begins to flow.
8. Open outer wrapping of sterile kit. This becomes 20. Interrupt urine flow by clamping or pinching
a sterile field. off. RATIONALE: Stop flow of urine while speci-
men container is positioned.
9. Place sterile absorbent plastic pad under
patient’s buttocks. Touching only the corners, 21. Position end of catheter into urine specimen
empty contents of tray onto sterile field. Drape container.
perineal area with fenestrated drape. Add sterile 22. If analysis is needed, wait until catheterization is
catheter to field. complete and pour urine into sterile container.

continues
 CHAPTER 18 Examinations and Procedures of Body Systems 493

Procedure 18-1 (continued)

23. Collect specimen by releasing clamp and collect- requisition form. Place in biohazard transporta-
ing approximately 60 mL urine. tion bag.
24. Allow remaining urine to flow into basin until 34. Assist patient from examination table.
flow ceases. Pinch catheter closed. 35. Remove gloves. Wash hands.
25. Remove catheter gently and slowly. 36. Don gloves.
26. Dry area with remaining cotton balls. 37. Clean room and table. Remove gloves and dis-
27. Tighten lid on the urine specimen container. card in biohazard waste container.
28. Remove procedure items. 38. Wash hands.
29. Position patient for comfort. 39. Document procedure in patient’s chart or elec-
30. Assist patient in sitting up or relaxing in a hori- tronic medical record, noting the amount of
zontal recumbent position. Offer tissues and sink urine collected. Document that specimen was
for hand cleansing. sent to outside laboratory (if appropriate).
31. Help patient to sit on edge of table. Check DOCUMENTATION
patient’s color and pulse. 9/07/20XX 10:15 AM Catheterized with straight catheter
32. Discard disposable items per Occupational Safety to relieve urinary retention and to obtain specimen for uri-
and Health Administration (OSHA) guidelines. nalysis. 700 mL clear urine obtained. Urine specimen sent to
33. If collecting specimen for analysis, label specimen
laboratory with requisition for urinalysis. W. Slawson, CMA
container and attach to completed laboratory
(AAMA) ______________________________________

Procedure 18-2
Urinary Catheterization of a Male Patient
STANDARD PRECAUTIONS: Additional items needed:
Sterile catheter (size and type as ordered by provider)
Biohazard waste container
Laboratory requisition form
Waxed paper bag
PURPOSE:
To obtain a sterile urine specimen for analysis or to PROCEDURE STEPS:
relieve urinary retention. 1. Identify the patient and explain the procedure.
EQUIPMENT/SUPPLIES: 2. Instruct patient to breathe slowly and deeply
Catheter kit (commercially available) containing: during procedure. RATIONALE: This helps the
Sterile gloves patient relax the abdominal and pelvic muscles
Fenestrated drape (sterile) and facilitates easier insertion of the catheter.
Betadine solution, or Betadine swabs 3. Wash hands and assemble supplies.
Lubricant 4. Place unopened catheter kit on Mayo stand near
Sterile cotton balls the patient.
Sterile urine container with label
Sterile 2 ⫻ 2 gauze sponges 5. Provide good lighting.
Forceps 6. Have patient disrobe below the waist; provide a
Sterile absorbent plastic pad drape. Cover from umbilical area to pubic hairline.

continues

continues
494 UNIT 5 Assisting with Specialty Examinations and Procedures

Procedure 18-2 (continued)

A B

Figure 18-41 (A) First, have patient bend knees and separate legs. Then, place sterile underpad between patient’s
legs. (B) Open fenestrated drape. Be careful not to contaminate sterile underpad or drape. Place over penis.

7. Position patient lying on his back with knees

bent and legs separated on an examination
table. RATIONALE: This allows for access to the
urinary meatus.
8. Open outer wrapping of sterile kit. This becomes
a sterile field.
9. Place sterile underpad between patient’s legs
touching only corners. Empty contents of tray
onto sterile field. Add sterile catheter to field
(Figure 18-41A). RATIONALE: Provides sterile
field.
10. Wash hands. Put on sterile gloves.
11. Open fenestrated drape and, being careful not
to contaminate drape or gloves, position drape
opening over penis (Figure 18-41B).
12. Apply sterile lubricant to a sterile gauze sponge
and place tip of catheter in lubricant.
13. With nondominant hand, hold the penis just
below the glans. In uncircumcised males, Figure 18-42 With dominant hand, take the sterile
the glans must be pulled pack to expose the forceps and a cotton ball dipped in Betadine solution
meatus. This is done entirely with the nondomi- and cleanse around the urinary meatus moving from
nant hand. RATIONALE: The dominant hand the center toward the outside. Use all three cotton
remains sterile so as not to contaminate remain- balls and Betadine.
ing sterile equipment.
14. With the dominant hand, take the betadine Betadine swabs (Figure 18-42). RATIONALE:
swabs or sterile forceps and a cotton ball that Ensures that as many microorganisms as pos-
has been dipped in Betadine, cleanse around sible will be removed from the meatus and
the meatus in a circular motion from center surrounding areas before insertion of sterile
toward outside. Use all three cotton balls or catheter.

continues
 CHAPTER 18 Examinations and Procedures of Body Systems 495

Procedure 18-2 (continued)

A B

Figure 18-43 (A) With the dominant hand, take catheter out of lubricant. With the nondominant hand, hold
the head of the penis so that the penis is in an upright, straight position. Insert the catheter about 6 inches until
urine flows into the sterile kit. (B) Obtain a specimen if ordered.

15. With the dominant hand, take catheter out of 21. Assist patient from examination table.
lubricant; while holding the head of the penis 22. Remove gloves and wash hands.
upright and straight with the nondominant hand,
insert the catheter approximately 6 inches until 23. Don gloves.
the urine flows into the sterile kit (Figure 18-43). 24. Clean room and table. Remove gloves and dis-
RATIONALE: Holding the penis by the head so card in biohazard waste container.
that the penis will be upright and straight facili- 25. Wash hands.
tates insertion of the catheter. CAUTION: Do
26. Document procedure in patient’s chart or elec-
not force catheter. If problems arise attempting
tronic medical record, noting the amount of
insertion, do not continue with procedure. Notify
urine collected. Document that specimen was
provider.
sent to outside laboratory (if appropriate) with a
16. After urine flow ceases, remove catheter gently completed laboratory requistion.
and slowly.
17. Dry penis with remaining cotton ball(s). DOCUMENTATION
9/07/20XX 10:15 AM Catheterized with straight catheter
18. Position patient for comfort. to relieve urinary retention. 700 mL clear urine obtained.
19. Discard disposable items per OSHA guidelines. W. Slawson, CMA (AAMA) _________________________
20. If collecting specimen for analysis, pour urine
from sterile kit into sterile urine container.
496 UNIT 5 Assisting with Specialty Examinations and Procedures

Procedure 18-3
Fecal Occult Blood Test
STANDARD PRECAUTIONS: b. Place date on front flap, then open it.
c. Use one end of the wooden applicator to
apply a thin smear of the stool sample from
the toilet to Box “A.” NOTE: Do not collect dur-
PURPOSE: ing menstrual cycle or if hemorrhoids are present.
To test feces for occult blood. d. Repeat the procedure using the other end of
the applicator, taking a specimen from a dif-
EQUIPMENT/SUPPLIES: ferent section of the same stool and applying
Three occult slide test kits containing three slides, a thin smear to Box “B.” RATIONALE: Occult
applicators, and envelope blood may be distributed differently through-
out a bowel movement.
PROCEDURE STEPS:
1. Check expiration dates on occult slides. RATIO- e. Dispose of the applicator in a waste container.
NALE: Outdated slides can give an inaccurate f. Close the cover after air drying overnight.
reading.
g. Repeat the process with the next two bowel
2. Identify the patient. movements, on subsequent days.
3. Fill out all information on the front flap of all 5. Provide the patient with an envelope to return
three slides (Figure 18-44). the slides to the provider’s office. Review with
4. Explain the stool collection process; the patient patient instructions on diet and medication
will need to: (Figure 18-45). Caution patient not to mail slides
to the office. RATIONALE: Slides are considered
a. Keep slides at room temperature, away from
biohazardous material.
sunlight. RATIONALE: Sunlight destroys ef-
fectiveness of guaiac paper and could result 6. Record that the test kit and instructions were
in an inaccurate result. given to patient.

Figure 18-44 The medical assistant writes the Figure 18-45 The medical assistant explains the
patient’s name, the date, and the specimen number process to the patient.
on each occult slide.

continues
 CHAPTER 18 Examinations and Procedures of Body Systems 497

Procedure 18-3 (continued)

Developing the Fecal Occult Slide

When the patient returns the fecal occult samples
to the office, the medical assistant is responsible
for developing the slides. Although most slides can
be stored for up to 14 days before developing, the
medical assistant should develop them as soon as
possible because the patient may have already stored
them for several days. Test results are important
to ensure prompt treatment should a problem be
discovered.

EQUIPMENT/SUPPLIES:
Prepared fecal slides from patient
Good lighting
Occult blood developer
Reference card that accompanies kit
Gloves
Biohazard waste container
Figure 18-46 The medical assistant places
PROCEDURE STEPS: developing solution on the slides.
1. Wash hands and check the expiration date on
the developer.
9. Remove gloves and dispose in biohazard waste
2. Apply gloves and lay a surface protector (paper
container.
towels).
10. Wash hands.
3. Open the window flap on the back of the slide.
11. Document results in patient’s chart or electronic
4. Apply two drops of the developer to each Box “A”
medical record.
and “B,” directly over each smear (Figure 18-46).
RATIONALE: Paper contains the chemical guaiac,
DOCUMENTATION
which will help identify occult blood.
1/14/20XX 2:00 PM Given 3 occult slides, 3 wooden appli-
5. Interpret the results within 30 to 60 seconds or per cators, and an envelope with instructions. Instructed patient
manufacturer’s instructions. Record the results. on dietary restrictions, collection of the stool specimens, and
6. A positive reaction consists of a blue halo appear- need to keep the slides at room temperature, away from sun-
ing around the perimeter of the specimen. Any light. Patient instructed to bring specimens to office. J. Guerro,
blue color is positive. CMA (AAMA) __________________________________
7. Perform the quality-control procedure by pro-
cessing the positive and negative monitor strip on 5/12/20XX 3:00 PM Three hemoccult slides returned.
each slide to confirm the test system is functional. Results: all three slides negative. Reported to Dr. Woo.
RATIONALE: Failure of the positive strip to turn Dr. Woo wants patient notified of results and to remind
blue or of the negative strip to remain neutral patient to make an appointment with her gastroenterolo-
indicates faulty supplies. Recheck expiration dates gist for a colonoscopy. Spoke to patient. Understands slides
on slide and developer. Repeat test if necessary. were negative for hidden blood in the stool. She will make
an appointment for a colonoscopy. W. Slawson, CMA
8. Dispose of all supplies according to OSHA (AAMA) ______________________________________
guidelines.
498 UNIT 5 Assisting with Specialty Examinations and Procedures

Procedure 18-4
Performing Visual Acuity Testing Using a Snellen Chart
STANDARD PRECAUTIONS: the left eye open under the occluder and not
to apply pressure to the eyeball. RATIONALE:
Closing of the eye not being tested may cause
the person to squint when reading the chart.
PURPOSE: 5. Stand next to the chart, point to row 3, and
To perform a visual screening test to determine a instruct the patient to read each letter with the
patient’s distance visual acuity. left eye, verbally identifying each letter read
(Figure 18-48). If unable to read line 3, go to
EQUIPMENT/SUPPLIES: line 2 or 1. RATIONALE: Pointing to each row
Snellen eye chart placed at eye level (appropriate for helps the patient to focus on one row of letters
age and reading ability of patient) at a time. Beginning at row 3 saves time.
Pointer 6. Record the results at the smallest line the patient
Occluder can read with two or fewer errors. Vision is
Alcohol wipes recorded as right eye, left eye, both eyes.
PROCEDURE STEPS: Examples: Right eye 20/25; Left eye
1. Wash hands and assemble equipment. 20/20; Both eyes 20/20
2. Prepare a well-lit room, free from distractions
and with a distance mark 20 feet from the eye
chart. Be certain there is no glare on the chart.
3. Explain the procedure to the patient. Patients
should be tested with their glasses or contact
lenses, unless otherwise indicated by the provider.
4. Instruct the patient to stand behind the mark
and cover the right eye with the occluder
(Figure 18-47). Instruct the patient to keep

Figure 18-48 The patient uses the left eye to read

Figure 18-47 The patient covers the right eye the letters on the chart. The patient is instructed to
with the occluder, keeping the eye open under the start with row 3. Here she is reading row 4.
occluder.

continues
 CHAPTER 18 Examinations and Procedures of Body Systems 499

Procedure 18-4 (continued)

RATIONALE: Visual acuity is recorded as a frac- 8. When finished with the examination of the left
tion. The number above the line on the chart eye, use the same procedure to test the right eye.
is the distance the patient is standing from the 9. Disinfect occluder. Wash hands. Record the
chart. The number below the line on the chart results in patient’s chart or electronic medical
is the distance from which a person with normal record.
vision can read that row of letters.
7. Record the patient’s reaction during the test. DOCUMENTATION
RATIONALE: Leaning forward, squinting or 4/14/20XX 1:15 PM Visual acuity checked using Snellen
straining, or tearing from the eye may indicate chart. Results: right 20/30; left 20/20; both 20/20. B. Abbott,
eye problems. RMA _________________________________________

Procedure 18-5
Measuring Near Visual Acuity
STANDARD PRECAUTIONS: 7. Have patient read the paragraphs printed on the
card.
8. Once patient has reached a line where more
than two mistakes are made, note the visual acu-
PURPOSE: ity for that eye (allow the patient to repeat the
To measure the near vision of the patient. line to verify acuity).
9. Repeat the process to measure the left eye.
EQUIPMENT/SUPPLIES:
10. Repeat the process to measure both eyes.
Appropriate near visual acuity chart (Jaegar)
3 ⫻ 5 cards or occluder 11. Record the result in the patient chart. Results
are charted 14/14 for normal near visual acuity.
PROCEDURE STEPS: 12. Discard the 3 ⫻ 5 card or disinfect the occluder.
1. Wash hands.
RATIONALE: To prevent microorganism cross-
2. Identify patient. contamination.
3. Explain procedure to patient; provide occluder. 13. Wash hands.
RATIONALE: To obtain patient cooperation.
14. Record results in patient’s chart or electronic
4. Position patient in a comfortable position. medical record.
5. Position the near visual acuity card 14 inches
from the patient by measuring with a tape mea- DOCUMENTATION
sure. RATIONALE: To obtain accurate results. 7/22/20XX 4:00 PM Near visual acuity checked. Results:
6. Have patient lightly (no pressure) cover the left
14/14. J. Guerro, CMA (AAMA) _______________________
eye with the occluder. RATIONALE: Pressure
will cause blurring of the other eye.
500 UNIT 5 Assisting with Specialty Examinations and Procedures

Procedure 18-6
Testing Color Vision Using the Ishihara Plates
STANDARD PRECAUTIONS: PROCEDURE STEPS:
1. Wash hands and assemble the equipment in a
room lighted by daylight. RATIONALE: Direct
sunlight or electric light may produce errors in
the results because of an alteration in the appear-
PURPOSE:
ance of shades of color.
To assess a patient’s ability to distinguish between the
colors red and green. 2. Hold each plate 75 cm or 30 inches from the
Patient education: patient and tilted so that the plane of the plate is
1. Explain that the purpose of the test is to deter- at a right angle to the line of the patient’s vision.
mine if the patient has a color vision deficiency. 3. Record the number given by the patient on each
2. Show patient plate number 12 as an example of plate.
the test process. 4. Assess the patient’s readings and record. RATIO-
NALE: If 10 or more plates are read correctly,
EQUIPMENT/SUPPLIES: the color vision is regarded as normal.
Ishihara plates (1–12) (Figure 18-49) Source for error: Test plates should be kept covered
when not in use. Undue exposure to sunlight
causes a fading of the color plates, thus leading
to inaccurate test interpretation
5. Document results in patient’s chart or electronic
medical record.

DOCUMENTATION
3/12/20XX 11:00 AM Color vision test performed using
Figure 18-49 Ishihara plates are used to assess the Ishihara plates. Twelve plates read correctly. L. Carlson,
patient’s ability to distinguish between the colors red RMA _________________________________________
and green.
 CHAPTER 18 Examinations and Procedures of Body Systems 501

Procedure 18-7
Performing Eye Instillation
STANDARD PRECAUTIONS:

PURPOSE:
To treat eye infections, soothe irritation, anesthetize,
and dilate pupils. Ophthalmic medication is supplied
in liquid or ointment form. Use separate medication
for each eye, if both are affected. Medication is sterile.

EQUIPMENT/SUPPLIES:
Sterile eye dropper for single use
Sterile ophthalmic medication, either drops or
ointment, as ordered by the provider Figure 18-50 When medication is being instilled
Sterile cotton balls into the patient’s eye, the patient should look up to
Sterile gloves the ceiling and the medical assistant should pull down
Tissues on the lower lid. Contact with the eyeball should be
avoided.
PROCEDURE STEPS:
1. Wash hands.
2. Assemble supplies using sterile technique. ointment in the lower surface of the eyelid being
3. Check medication carefully as ordered by the careful not to touch the eyelid, eyeball, or eye-
provider, including expiration date. Read lashes with the tip of the medication applicator.
label three times. RATIONALE: Verifies cor- Carefully replace cover on bottle. Discard drop-
rect medication and ensures medication has per. RATIONALE: A new dropper each time pre-
not expired. vents contamination.
4. Identify patient. 11. Have the patient close the eye and roll the eye-
5. Explain procedure to the patient and inform ball. RATIONALE: Movement distributes the
the patient that instillation may temporarily blur medication evenly.
vision. RATIONALE: Blurring may occur due to 12. If drops instilled, gently press on tear duct so
medication. medication will remain.
6. Position the patient in a sitting or lying position. 13. Blot excess medication from eyelids with cotton
7. Instruct the patient to stare at a fixed spot dur- ball from inner to outer canthus. RATIONALE:
ing instillation of the drops. RATIONALE: Wipe from cleaner to dirtier.
Allows for easier instillation. 14. Dispose of supplies.
8. Prepare medication using either drops or 15. Wash hands.
ointment. 16. Record procedure in patient’s chart or elec-
9. Have the patient look up to the ceiling and tronic medical record.
expose the lower conjunctival sac of the affected
eye by using fingers over a tissue to pull down DOCUMENTATION
(Figure 18-50). 9/12/20XX 11:30 AM Ophthalmic drops (two) instilled
10. Place the number of drops ordered in the cen- in right eye. Eye red and swollen. No exudate noted. J. Bloom,
ter of the lower conjunctival sac or a thin line of RMA _________________________________________
502 UNIT 5 Assisting with Specialty Examinations and Procedures

Procedure 18-8
Performing Eye Patch Dressing Application
STANDARD PRECAUTIONS: 5. Instruct the patient to close both eyes during the
application of the patch. Prepare sterile area by
opening the sterile package and using the inside of
the package as a sterile field. Apply sterile gloves.
PURPOSE: 6. Place the patch over the affected eye using ster-
To apply a sterile eye patch. ile gloves.
7. Secure the patch with three to four strips of
EQUIPMENT/SUPPLIES: transparent tape diagonally from mid-forehead
Tape to below the ear.
Sterile eye patch
8. Remove gloves.
Sterile gloves
9. Wash hands.
PROCEDURE STEPS: 10. Document the procedure in patient’s chart or
1. Wash hands and assemble supplies.
electronic medical record and provide verbal
2. Identify patient. and written care instructions to the patient.
3. Explain the procedure. Ascertain if patient has a
ride home. RATIONALE: Monovision is mislead- DOCUMENTATION
ing, and the patient cannot see well enough to 8/1/20XX 2:30 PM Sterile eye patch applied to right
drive. eye. Eye appeared red. No exudate seen. Patient instructed
4. Position the patient in a sitting or supine position.
not to drive with eye patch on. Wife to drive patient home.
RATIONALE: Easier to apply patch.
J. Bloom, RMA ___________________________________

Procedure 18-9
Performing Eye Irrigation
STANDARD PRECAUTIONS: EQUIPMENT/SUPPLIES:
Sterile irrigation solution as ordered by the
physician
Sterile bulb syringe (rubber)
Kidney-shaped basin to catch irrigation solution
PURPOSE:
Sterile cotton balls
To irrigate the patient’s affected eye.
Sterile gloves
a. To cleanse debris
Biohazard waste container
b. To cleanse discharge Towel
c. To remove chemicals Pillow
d. To apply antiseptic
e. To apply warmth for comfort

continues
 CHAPTER 18 Examinations and Procedures of Body Systems 503

Procedure 18-9 (continued)

PROCEDURE STEPS:
1. Wash hands and assemble supplies. NOTE: If
both eyes need to be irrigated, use separate
equipment for each eye. RATIONALE: Prevents
cross contamination.
2. Identify patient.
3. Explain the procedure to the patient.
4. Position the patient in a supine position.
5. Check expiration date on solution bottle.
6. Check label three times. Warm solution to body
temperature (98.6°F). RATIONALE: More com-
fortable for patient.
7. Tilt head toward affected eye. Place towel on
patient’s shoulder. RATIONALE: Avoid cross
contamination of unaffected eye by allowing the
solution to flow from the affected eye into the
kidney basin and away from unaffected eye.
8. Place the basin beside the affected eye. RATIO-
NALE: Allows for the solution to drain into a Figure 18-51 The medical assistant irrigates the
catch receptacle. patient’s eye. Note that the solution will go from inner
to outer canthus. The patient is turned toward the
9. Put on sterile gloves.
affected eye.
10. Moisten two to three cotton balls with irrigation
solution and clean the eyelids and eyelashes of
14. After irrigation, dry the eyelid and eyelashes with
the affected eye from inner to outer canthus.
sterile cotton balls. The provider may add a stain-
Discard after each wipe. RATIONALE: Wipe
ing solution to check for corneal abrasion.
from cleaner to dirtier.
15. Discard supplies in biohazard container.
11. Expose the lower conjunctiva by separating the
eyelid with your index finger and thumb. RATIO- 16. Remove gloves.
NALE: To facilitate flowing of solution. 17. Wash hands and document procedure in patient’s
12. Have the patient stare at a fixed spot. RATIO- chart or electronic medical record.
NALE: More likely patient will blink less.
13. Irrigate the affected eye with sterile solution by DOCUMENTATION
resting the sterile bulb syringe on the bridge of 11/26/20XX 10:00 AM Right eye irrigated with 100 mL
the patient’s nose, being careful not to touch the sterile normal saline (100°F). Eye appears slightly red. No exu-
eye or conjunctival sac with the syringe tip. Allow date noted. Fluorescein stain (stain strip used for diagnosis
the stream to flow from the inside canthus to the and detecting foreign bodies or lesions on the cornea) instilled
outer corner of the eye (Figure 18-51). RATIO- into right eye by Dr. Woo. Patient seemed to tolerate procedure
NALE: Prevents a flow of solution into the unaf- well. Says she has “no discomfort.” K. Bloom, RMA _________
fected eye causing cross contamination.
504 UNIT 5 Assisting with Specialty Examinations and Procedures

Procedure 18-10
Assisting with Audiometry
STANDARD PRECAUTIONS:

PURPOSE:
To assist in testing patient for hearing loss.
Patient education:
1. Explain the use and purpose of the audiometer
and that the test measures frequency of sound
waves and ability of patient to hear various
frequencies of sound waves (one frequency at
a time).
2. When the patient hears a new frequency, signal
the tester.

EQUIPMENT/SUPPLIES:
Audiometer with headphones
Quiet room

PROCEDURE STEPS:
1. Wash hands and assemble equipment and sup- Figure 18-52 The patient raises her hand each time
plies. she hears a sound.
2. Prepare room. Test must be held in a room
without outside noises. RATIONALE: Outside
interference may cause inaccurate test results,
especially in the lower frequencies, which are 7. The frequencies gradually increase until com-
more difficult to hear. pleted.
3. Identify and explain procedure to patient. 8. The other ear is checked in the same manner.
4. Position patient in a comfortable sitting posi- 9. The results are given to the provider for inter-
tion. pretation.
5. Have patient put on headphones. The procedure 10. Equipment is cleaned following manufacturer’s
is done on each ear separately. RATIONALE: To instructions.
test each ear for hearing loss. 11. Wash hands.
6. If the medical assistant has been thoroughly 12. Document procedure in patient’s chart or elec-
trained to do the procedure, the provider will tronic medical record.
authorize the medical assistant to perform the
audiometry. The audiometer is started at low fre- DOCUMENTATION
quency. The patient indicates when the sound is 4/12/20XX 2:00 PM Audiometry performed. Results given
heard and the medical assistant plots it on the to Dr. Woo. B. Abbott, RMA __________________________
graph (the audiogram) (Figure 18-52).
 CHAPTER 18 Examinations and Procedures of Body Systems 505

Procedure 18-11
Performing Ear Irrigation
STANDARD PRECAUTIONS:

PURPOSE:
To remove impacted cerumen, discharge, or foreign
materials from the ear canal as directed by the provider.

EQUIPMENT/SUPPLIES:
Irrigation solution as ordered by the provider, warmed
to 98.6–103°F
Ear irrigation syringe or bulb
Ear basin or emesis (catch) basin
Basin for warmed solution
Towel
Cotton balls
Otoscope

PROCEDURE STEPS:
1. Wash hands and assemble equipment.
2. Identify patient.
3. Explain the procedure and inform the patient
that during the procedure a minimal amount
Figure 18-53 When irrigating the patient’s ear, tip
of discomfort and dizziness may be experienced
the affected ear to facilitate the flow of solution. The
caused by solution coming into contact with the
tip of the syringe does not occlude the opening to
tympanic membrane. Be sure provider has exam-
the external auditory canal.
ined the ear before irrigation. RATIONALE:
Ensures irrigation needed.
4. Place the patient in a sitting position and use 10. Check label of solution three times for correct-
an otoscope to visualize the affected ear. Have ness and also check the expiration date of the
patient tilt head toward affected ear. solution.

5. Cleanse the outer ear with a wet cotton ball 11. Pour the solution into a basin and fill the syringe
moistened with irrigation solution. with the warmed irrigation solution as prescribed
by the physician. Use about 30 to 50 cc solution at
6. Gently pull the auricle upward and back to a time to warm the instrument. (Repeat Step 5.)
straighten the ear canal. RATIONALE: Allows
better access to external ear canal. 12. Straighten the external auditory canal by pulling
back and upward on the auricle for adults.
7. Tilt the patient’s head slightly forward and to
the affected side (Figure 18-53). RATIONALE: 13. Expel air from syringe and gently insert the
This position allows the solution to flow into the syringe tip into the affected ear, being careful
basin by gravity. not to insert too deeply. Do not occlude exter-
nal auditory canal. Direct the flow of the solu-
8. Place towel on the patient’s shoulder of the tion upward toward roof of canal. RATIONALE:
affected side. Avoids injury to the tympanic membrane and
9. Place the ear basin under the affected ear and prevents occlusion of external auditory canal,
have the patient hold the basin in place. allowing solution to drain out.

continues
506 UNIT 5 Assisting with Specialty Examinations and Procedures

Procedure 18-11 (continued)

14. Repeat the irrigation, allowing the solution to 20. Provider will examine the tympanic membrane.
drain from the ear, noting the return. Allow for 21. Dispose of supplies.
free flow of return each time. Check with the
22. Wash hands.
patient about any discomfort or pain. Do not
continue if pain is present. 23. Document the procedure in patient’s chart or
electronic medical record, noting return and
15. Dry the outer ear and visualize the inner ear
amount. Provide postcare instructions:
with the otoscope to verify the procedure has
removed or dislodged the foreign body. a. Report any pain or dizziness to the provider.
16. Notify the provider the procedure has been com- b. Do not insert any foreign object (i.e., cotton
pleted. applicator) into the ear canal.
17. When the procedure is completed, remove the
ear basin and towel. DOCUMENTATION
6/4/20XX 3:30 PM Left ear irrigated with normal saline
18. Have patient lie on affected side on examination (100°F). Three pieces (size of pencil eraser) of cerumen in solu-
table for ear to continue draining. tion returns. No complaints of pain or dizziness. Inner ear and
19. Provide dry cotton balls to the patient to catch tympanic membrane appear clear. Dr. King notified of results.
any further drainage if directed by the provider. Examined by Dr. King. W. Slawson, CMA (AAMA) _________

Procedure 18-12
Performing Ear Instillation
STANDARD PRECAUTIONS: RATIONALE: Facilitates flow of medication.
5. Check otic medication three times against the
provider’s order and check expiration date of
the medication. RATIONALE: Only otic medi-
PURPOSE: cation can be used in the ear. Checking the
To soften impacted cerumen, fight infection with anti- medication three times minimizes medication
biotics, or relieve pain. error.
6. Draw up the prescribed amount of medication.
EQUIPMENT/SUPPLIES:
7. Gently pull the top of the ear upward and back
Otic medication as prescribed by the provider
(adult) or pull earlobe downward and backward
Sterile ear dropper
(child) (Figure 18-54).
Cotton balls
Gloves 8. Instill prescribed dose of medication (number
of drops) by squeezing rubber bulb on dropper
PROCEDURE STEPS: into the affected ear.
1. Wash hands and assemble supplies.
9. Have the patient maintain the position for about
2. Identify patient. 5 minutes to retain medication.
3. Explain procedure to the patient. 10. When instructed by the provider, insert moist-
4. Ask patient either to lie on unaffected side or ened cotton ball into external ear canal for
to sit with head tilted toward unaffected ear. 15 minutes. RATIONALE: Moistened cotton

continues
 CHAPTER 18 Examinations and Procedures of Body Systems 507

Procedure 18-12 (continued)

ball will not absorb medication and will help

retain medication in ear.
11. Dispose of supplies.
12. Wash hands.
13. Document procedure in patient’s chart or elec-
tronic medical record.

DOCUMENTATION
12/10/20XX 4:00 PM Otic solution (four drops) instilled
into patient’s right ear. Moistened cotton ball inserted in ear.
No exudate noted. W. Slawson, CMA (AAMA) ___________

Figure 18-54 When instilling drops into patient’s

ear, have the patient tilt head so that the affected ear
is uppermost.

Procedure 18-13
Assisting with Nasal Examination
STANDARD PRECAUTIONS: PROCEDURE STEPS:
1. Wash hands and assemble supplies.
2. Identify patient.
3. Explain the procedure to the patient.
PURPOSE: 4. Place the patient in a sitting position.
To assist the provider with the nasal examination
5. Reassure the patient.
when looking for polyps and engorged superficial
blood vessels, and to assist in the possible removal of 6. Hand the provider equipment and supplies as
a foreign body. needed.
Patient education: 7. Clean equipment and dispose of supplies per
When a foreign object is involved, instruct the patient OSHA guidelines.
not to blow the nose or to attempt to remove the 8. Wash hands.
object because this could cause tissue damage or push 9. Document procedure in patients’s chart or elec-
the object deeper into the nasal passage. tronic medical record, noting foreign object if
EQUIPMENT/SUPPLIES: applicable.
Nasal speculum
Light source DOCUMENTATION
Gloves 2/4/20XX 4:30 PM Nasal examination done by Dr. Woo. Small
Bayonet forceps polyp noted in left nostril. Arrangements made with Bayside
Kidney basin Surgery for polyp removal on 2/10. B. Abbott, RMA __________
508 UNIT 5 Assisting with Specialty Examinations and Procedures

Procedure 18-14
Cautery Treatment of Epistaxis
STANDARD PRECAUTIONS: 5. Assist the provider by handing the supplies and
instruments as directed.
6. Assist the provider with applying the anesthetic
(a syringe and needle may be used to remove
PURPOSE: Xylocaine from the vial and inject it into the
Patient education: medicine cup). The cotton balls or gauze are
Depending on the location and severity of the nose- then soaked in the anesthetic and applied to the
bleed, the provider will either pack the nasal canal or nasal membranes.
chemically cauterize the vessel. Generally, chemical 7. Assist the provider and the patient after the
cautery is attempted first; if that fails, nasal packing anesthetic has taken effect.
or a nasal balloon is inserted. If cauterization is per- 8. The provider will apply an epinephrine (vaso-
formed, the patient should be instructed to not blow constrictor)-soaked gauze to the site of bleed-
the nose or otherwise irritate/disturb the scab that ing and will use pressure on the outside of the
will form. Cautery will sting, and the patient should nose to try to control the bleeding. This may be
be appropriately prepared. followed with electrocautery or silver nitrate.
If not effective, a nasal packing may be needed
EQUIPMENT/SUPPLIES:
if bleeding is not controlled well. The packing
Patient gown and drapes
must be kept in place for 24 to 48 hours. The
Syringes and needles
patient who has a nasal packing is instructed
Vienna nasal speculum
to make an appointment with an ear, nose,
Light source (hands free)
and throat specialist and to avoid aspirin and
Gloves, and other PPE if bleeding severe
antiinflammatory medications. The provider
Bayonet forceps
will order an antibiotic for the patient.
Epinephrine
Silver nitrate sticks 9. Instruct the patient on postprocedure care.
Cotton balls or gauze 10. Clean the equipment and dispose of contami-
Medicine cups nated supplies according to Standard Precau-
Local anesthetic (such as Xylocaine [lidocaine] with tions and OSHA guidelines.
epinephrine or cocaine 4%)
11. Wash hands.
Antibiotic/antiseptic ointment (such as triamcino-
lone) 12. Document the procedure in the patient’s chart
or electronic medical record.
PROCEDURE STEPS:
1. Wash hands, assemble equipment/supplies, and DOCUMENTATION
apply gloves. 8/6/20XX 2:45 PM Patient treated for epistaxis with epi-
2. Identify the patient and explain the procedure. nephrine and pressure on the exterior of nose and silver nitrate
cautery was also used. Bleeding finally controlled with a nasal
3. Give the patient a kidney basin and tissue and
packing . Instructions given to avoid blowing nose or otherwise
have the patient seated.
irritate/disturb the scab and to call/return immediately if nose
4. Assist the provider to visualize the area of begins to bleed again. J. Guerro, CMA (AAMA) ____________
treatment.
 CHAPTER 18 Examinations and Procedures of Body Systems 509

Patient Education
Nasal Irrigation (1/2 teaspoon to a pint). Use a bulb-type
Advise the patient that commercial nasal syringe for irrigation. Instruct patient not to blow
irrigation kits are available at the pharmacy nose for 5 minutes after the irrigation. This could
or department store, or the patient can make force the solution into the sinuses or ears and
her own solution of salt and warm water possibly cause an infection in either or both.

Procedure 18-15
Performing Nasal Instillation
STANDARD PRECAUTIONS: 6. Place the dropper over the center of the outside
of the affected nostril. Ask patients to inhale us
you administer the drops. Care should be taken
not to touch the inside of the nostril. RATIO-
NALE: Touching the inside of the nostril will
PURPOSE: lead to contamination of the dropper.
To provide medication to the nasal membranes as
ordered by the provider. 7. Repeat the procedure for the other nostril if
Patient education: required. Dispose of dropper; recap medication
1. Instruct the patient to keep the head tilted back container using sterile technique.
slightly during the procedure to allow the medi- 8. Instruct the patient to remain in position for 2 to
cation to cover the nasal tissues. 3 minutes. RATIONALE: Allow time for medica-
2. Do not blow nose immediately after treatment. tion to be absorbed by the nasal membranes.
Medication could be forced out of nose. 9. Provide cotton balls or gauze sponges to the
patient when the patient returns to a sitting posi-
EQUIPMENT/SUPPLIES: tion. RATIONALE: Medication may drain from
Medication, drops or spray, as ordered by provider the nostrils.
Medicine dropper (sterile) 10. Dispose of the supplies per OSHA guidelines.
Tissues
11. Wash hands.
PROCEDURE STEPS: 12. Document the procedure in patient’s chart or
1. Wash hands and assemble equipment. electronic medical record.
2. Identify patient.
3. Explain procedure to the patient.
DOCUMENTATION
4/13/20XX 6:00 PM Neosynephrine nasal drops (three drops)
4. Position the patient with the head tilted back instilled into each nostril. W. Slawson, CMA (AAMA) _______
slightly.
5. Draw medication into dropper after checking
medication three times and checking expira-
tion date.
510 UNIT 5 Assisting with Specialty Examinations and Procedures

Procedure 18-16
Administer Oxygen by Nasal Cannula for Minor Respiratory Distress
STANDARD PRECAUTIONS: 3. Open the cylinder one full turn, counter-
clockwise.
4. Check the pressure gauge. RATIONALE: This
will determine the amount of pressure in the
PURPOSE: cylinder.
To provide a low dose of concentrated oxygen to a
5. Attach the nasal cannula to the tubing, and then
patient during periods of respiratory distress (e.g.,
to the flowmeter.
chronic obstructive pulmonary disease).
Patient education:
1. Demonstrate the position of the nasal prongs of
the cannula into the nose. They face upward and
the tab rests above the upper lip.
2. Describe how to clear the oxygen cylinder valve
by turning it counterclockwise.
3. Oxygen supports combustion and a fire can start
with oxygen in use. Friction, static electricity, a
spark, or a lighted cigarette or cigar can cause
ignition.

EQUIPMENT/SUPPLIES:
Portable oxygen tank with stand
Disposable nasal cannula with connecting tube
Flowmeter Figure 18-56 Adjust tubing.
Pressure regulator

PROCEDURE STEPS:
1. Wash hands.
2. Identify patient, and explain procedure to the
patient.

Figure 18-57 Nasal cannula and oxygen tubing

Figure 18-55 Insert cannula prong into nostrils. attached to a humidifier.

continues
 CHAPTER 18 Examinations and Procedures of Body Systems 511

Procedure 18-16 (continued)

6. Adjust the flow rate according to the provider’s NOTE: Oxygen is usually humidified to prevent dry-
order (oxygen is a medication). ing of respiratory mucosa (Figure 18-57).
7. Check for oxygen flow through the cannula.
8. Place the tips of cannula into the nares no more DOCUMENTATION
than 1 inch (Figure 18-55). 4/19/20XX 2:45 PM Oxygen 3 L/minute by nasal can-
nula. Color slightly improved. Less cyanosis. J. Guerro, CMA
9. Adjust the tubing around the patient’s ears (AAMA) _______________________________________
(Figure 18-56) and secure it under the chin.
10. Answer patient’s questions.
11. Wash hands.
12. Document the procedure in patient’s chart or
electronic medical record.

Procedure 18-17
Instructing Patient in Use of Metered Dose Inhaler
STANDARD PRECAUTIONS: EQUIPMENT/SUPPLIES:
Handheld inhaler with mouth piece, and pressurized
canister of medication as ordered by provider

PROCEDURE STEPS:
PURPOSE: 1. Wash hands and assemble equipment (Figure
To instruct patient on the use of a handheld device 18-58).
known as a metered dose inhaler. The device deliv-
ers medication to the respiratory tract including the 2. Identify patient.
lungs. It is used to treat asthma, COPD, and other 3. Check medication order three times.
respiratory diseases and/or conditions. 4. Demonstrate use of equipment to the patient
Patient education: and then have the patient repeat the demon-
1. Remind the patient to inhale slowly. stration.
2. Close the mouth and lips around the mouth- 5. Remove cap from metered dose inhaler (MDI)
piece. and shake well. RATIONALE: To mix medica-
3. Clean the inhaler by rinsing the mouthpiece in tion thoroughly.
warm water. 6. Instruct patient to sit upright, tilt head back
4. Adhere to prescribed dose. slightly, and exhale fully. RATIONALE: Allows
medication to reach all of the respiratory tract.

continues
512 UNIT 5 Assisting with Specialty Examinations and Procedures

Procedure 18-17 (continued)

12. Wait 1 minute, then repeat steps for each puff of

medication ordered by the provider.
13. Check patient for any unusual effects.
14. Wash hands.
15. Put cap on the MDI when finished. If the patient’s
MDI contains a steroid, instruct the patient to
rinse out mouth with water and mouthwash and
to gargle after each treatment. RATIONALE:
Prevents dry mouth, hoarseness, and microor-
ganism growth.
16. Rinse mouthpiece and cap and let air-dry over-
Figure 18-58 Metered dose inhaler and spacer. night.
17. Document in patient’s chart or electronic medi-
cal record that patient was instructed in the use
of an MDI. Encourage patient to cough. RATIO-
7. While holding the inhaler, instruct the patient to NALE: Medication will loosen phlegm and
open the mouth wide and place the MDI about mucus.
½ to 2 inches in front of mouth. NOTE: The MDI can be used with or without a spacer
8. Inhale and exhale one more time. (a tube that attaches to the inhaler and holds
the medication until it can be breathed in) (see
9. On inhalation of the next breath, instruct patient
Figure 18-58). Spacers are made with masks for
to press down on the metal canister. RATIO-
pediatric patients and for persons unable to
NALE: Releases medication.
breathe correctly through a standard spacer.
10. The patient should inhale slowly and deeply (3−5
seconds). DOCUMENTATION
11. Instruct patient to hold the breath for at least 4/19/20XX 2:45 PM Instructed on use of handheld metered
10 seconds. RATIONALE: Medication can enter dose inhaler. Patient encouraged to cough following procedure.
into lungs well. Performed procedure well. No adverse reactions noted. W. Slawson,
CMA (AAMA) ___________________________________
 CHAPTER 18 Examinations and Procedures of Body Systems 513

Procedure 18-18
Spirometry
STANDARD PRECAUTIONS: 3. Explain the procedure and equipment to the
patient. Allow the patient to breathe into the
machine to become acquainted with the equip-
ment (see Figure 18-31).
PURPOSE: 4. Measure patient’s height and weight. Enter data
To prepare a patient for a spirometry to obtain opti- into spirometer.
mum test results. To assist with diagnosis of asthma 5. Place the patient in a comfortable position
and chronic obstructive pulmonary disease (COPD). (sitting/standing). Loosen tie or collar. RATIO-
Patient education: NALE: Helps patient take as large an inhalation
1. Reinforce the importance of good posture dur- and exhalation as possible.
ing the process. RATIONALE: Good posture 6. Instruct the patient not to bend at the waist when
expands lungs more fully. blowing into the mouthpiece.
2. When blowing into the mouthpiece, the lips 7. Reinforce the inhalation process (deep breaths
must seal tightly around it. to fill the lungs to maximum capacity).
3. Explain the parameters needed for successful 8. Instruct the patient to continue to blow into the
completion of the test. mouthpiece until instructed to stop. RATIO-
Parameters: NALE: Provides more accurate result.
1. Patient must refrain from the use of 9. Be supportive and encouraging throughout the
bronchodilators and tobacco for 24 hours test.
before test. 10. Attend to patient’s needs.
2. Explain to the patient that maximum effort is 11. Discard disposable mouthpiece into biohazard
required for accurate test results. container. Disinfect and sanitize equipment.
3. Patient must inhale deeply and quickly and 12. Wash hands.
exhale quickly and forcibly until no air can
be expelled. 13. Document the test results in the patient’s chart
or electronic medical record after they are
reviewed by the provider.
EQUIPMENT/SUPPLIES:
Spirometer
Disposable mouthpiece DOCUMENTATION
12/22/20XX 4:00 PM Spirometry performed. Results given to
PROCEDURE STEPS: Dr. Woo. J. Guerro, RMA _____________________________
1. Wash hands and assemble equipment.
2. Identify the patient.
514 UNIT 5 Assisting with Specialty Examinations and Procedures

Procedure 18-19
Pulse Oximetry
STANDARD PRECAUTIONS: 7. Apply sensor (finger is placed within a clip) (see
Figure 18-32).
8. Connect sensor to oximeter with a sensor cable.
9. Turn on oximeter. A tone and a pulse fluctuation
PURPOSE: can be heard. Adjust volume.
To measure arterial oxyhemoglobin saturation within 10. Alarms can be set to alert medical assistant to lev-
seconds by using an external sensor. els either too high or too low.
EQUIPMENT/SUPPLIES: 11. Check pulse manually and compare with oxim-
Pulse oximeter eter. They should be the same.
Sensor 12. Note results per manufacturer’s instructions.
Soap and water or alcohol wipe
13. Notify supervisor of abnormal results (less
Nail polish remover, if needed
than 95%).
PROCEDURE STEPS: 14. Document procedure in patient’s chart or elec-
1. Wash hands and assemble equipment. tronic medical record, noting type of sensor
2. Identify the patient. used, site of application, and results.
3. Explain the procedure. 15. Plug in oximeter for recharging when not in use
so that the battery does not get low. NOTE: When
4. Select a site for the sensor (finger commonly
measuring, cover the sensor with a towel to elimi-
used).
nate sensor’s exposure to light. It could interfere
5. If patient has poor circulation, use another site with the sensor and give incorrect results.
(bridge of nose, earlobe, or forehead).
6. Clean site with alcohol wipe. Remove nail polish DOCUMENTATION
if necessary. Wash with soap and water. RATIO- 3/16/20XX 4:00 PM Pulse oximetry 98%. G. Underwood,
NALE: Fingernail polish inhibits infrared light CMA (AAMA) ___________________________________
from passing through the oximeter.
 CHAPTER 18 Examinations and Procedures of Body Systems 515

Procedure 18-20
Assisting with Plaster Cast Application
STANDARD PRECAUTIONS: NALE: A stockinette that is too large will form
creases, thus allowing for injury to tissues.
9. Provide provider with correct width of webril
rolls. RATIONALE: Webril (soft cotton ban-
PURPOSE: dage) provider protection to the patient’s skin,
To assist provider in cast application. preventing pressure sores. Folds in the padding
could lead to irritation of the skin.
EQUIPMENT/SUPPLIES: 10. Place the bandage in the container of warm
Cast material: water for 5 seconds. Remove from water and
Plaster bandage roll or synthetic tape gently squeeze to remove excess water. Do not
Container of warm water, which is lined with plastic or wring.
cloth to catch loose plaster
11. Assist with application of the cast material as
Water
requested by the provider.
Stockinette (3-inch width for arms, 4-inch width for
leg casts) 12. Reassure patient as needed.
Webril (sheet wadding) padding rolls 13. After cast application, clean any plaster off
Bandage scissors patient, review cast care instructions, and pro-
Rubber gloves vide written instructions for cast care and iso-
Sponge rubber for padding metric exercises (if prescribed by the provider).
Reinforce any precautions given by the provider.
PROCEDURE STEPS: RATIONALE: Reviewing possible complications
1. Identify the patient and explain of the proce-
with the patient enhances the immediate report-
dure to patient.
ing of circulatory impairment and infection.
2. Answer any questions about the injury or cast
14. Discard water down the sink drain, being cau-
application.
tious to keep plaster from going down the drain.
3. Wash hands and assemble the equipment and (Allow plaster to settle to bottom of basin first.)
supplies. Discard plaster into trash receptacle.
4. Position the patient in a sitting position or as 15. Clean work area.
required by the provider. Proper alignment must
16. Remove gloves and wash hands.
be maintained. RATIONALE: Proper alignment
ensures fracture heals properly. 17. Schedule patient for next appointment to have
cast checked.
5. Put on gloves and drape patient.
18. Document the procedure in patient’s chart or
6. Clean and dry the area to be casted, as directed
electronic medical record.
by the provider. Chart any areas of bruising, red-
ness, or open areas. RATIONALE: Appropriate
DOCUMENTATION
documentation of skin condition is needed to
12/14/20XX 2:00 PM Plaster cast applied to left arm by
assist in evaluation of the extremity at a later
Dr. King. Fingers warm to touch. Patient says there is no tin-
time.
gling or numbness in her fingers. Instructed about cast care,
7. Pad bony prominence with sponge rubber. exercises, and reporting of circulatory impairment and infec-
RATIONALE: Protects from pressure. tion. Sling applied. Next appointment 12/28/20XX. S. Walsh,
8. Provide the correct width of stockinette for the RMA __________________________________________
area on which cast is being applied. RATIO-
516 UNIT 5 Assisting with Specialty Examinations and Procedures

Procedure 18-21
Assisting with Cast Removal
STANDARD PRECAUTIONS: 4. Reassure the patient that skin color and muscle
tone will improve with therapy.
5. Hand the provider the equipment as requested.
6. After the procedure, provide written instructions
PURPOSE: for postcare.
To assist the provider with removal of a cast. 7. Clean equipment.
EQUIPMENT/SUPPLIES: 8. Wash hands.
Cast cutter 9. Document in patient's chart or electronic medi-
Cast spreader cal record cast removal and appearance of body
Bandage scissors part from which cast was removed. RATIONALE:
Bag for disposing of cast materials Condition of the patient’s arm size, skin appear-
Drape ance, and color are important factors to note for
future evaluation.
PROCEDURE STEPS:
1. Wash hands.
DOCUMENTATION
2. Drape patient and area. 6/12/20XX 2:45 PM Cast removed from left arm by Dr. King.
3. Explain the cast removal process to the patient. The Arm seems slightly atrophied. Skin color good, circulation seems
cutter vibrates and does not spin. Some pressure good. Patient given skin care instructions. Appointment for
and warmth may be experienced. RATIONALE: physical therapy scheduled for 6/14/XX at 3:00 PM. W. Slawson,
Explaining the procedure reduces apprehension CMA (AAMA) ___________________________________
and fears about being cut with the blade.

Procedure 18-22
Assisting the Physician during a Lumbar Puncture or Cerebrospinal
Fluid Aspiration

STANDARD PRECAUTIONS: Disposable sterile lumbar puncture tray (to include):

Skin antiseptic (povidone–iodine) with applicator
Adhesive bandage
Spinal puncture needle
Three or four test tubes with corks or tops
PURPOSE: Drape
To assemble supplies and position the patient for
Manometer
removal of cerebrospinal fluid from the lumbar area,
Laboratory requisition
which will be sent to the laboratory for analysis.
Examination light
EQUIPMENT/SUPPLIES: Gauze sponges
Drape
PROCEDURE STEPS:
Xylocaine 1–2%
1. Reinforce provider’s explanation of the proce-
Syringe and needle for anesthetic
dure and answer questions.
Sterile gloves

continues
 CHAPTER 18 Examinations and Procedures of Body Systems 517

Procedure 18-22 (continued)

2. Verify the patient has signed a consent form.

Dura Mater
3. Patient should be instructed to empty the blad- L4
Subarachnoid Space
der and bowel. RATIONALE: Patient cannot
move during the procedure. L5
(A)
4. Wash hands and set up sterile field for the
provider. (B)
5. Cleanse the puncture site with antiseptic soap
and water. Rinse.
6. Position the patient in a lateral recumbent posi-
tion with the back at the edge of the examina-
tion table and a small pillow under the head.
RATIONALE: Patient’s alignment of the spine is
best achieved in a horizontal position.
7. Drape patient for warmth and privacy.
8. Have the patient draw the knees up to the abdo- Figure 18-59 (A) Have the patient draw up
men and grasp onto knees (Figure 18-59A) and the knees to the abdomen and grasp knees. Chin
flex chin on chest (fetal position). RATIONALE: should flex on chest. (B) The site for the lumbar
Position allows for easier needle insertion into puncture.
the subarachnoid space of the spinal cord
because this position widens the spaces between
the lumbar vertebrae. Procedure is performed the provider. RATIONALE: Helps prevent the
at the fourth intervertebral space of the lumbar possibility of cerebrospinal fluid from leaking
region (Figure 18-59B). through the puncture site.
9. The provider swabs the puncture site with anti- 17. Apply gloves. Cap specimens tightly.
septic such as Betadine®. 18. Label samples with date, patient’s name, and
10. The provider drapes area with sterile fenestrated number CSF (#1, #2, #3).
drape. 19. Send the labeled specimens to the laboratory
11. Assist provider to aspirate anesthetic. in a laboratory biotransfer bag with the appro-
12. Help the patient maintain this position until priate laboratory requisition. Store in incuba-
the needle has been inserted into spinal canal. tor. RATIONALE: An incubator preserves the
RATIONALE: Movement by the patient could specimens until they can be processed by a
produce trauma to the spinal cord area. laboratory technologist.
13. Remind patient to breathe evenly and not to 20. Cleanse area using Standard Precautions.
hold his breath or talk, because this may inter- 21. Remove gloves.
fere with the pressure reading. 22. Wash hands.
14. At the provider’s direction, have the patient 23. Document procedure in patient’s chart or
straighten his legs. RATIONALE: Muscle tension electronic medical record.
can give false pressure reading. The provider
reads manometer to determine the pressure of DOCUMENTATION
the spinal fluid. 6/12/20XX 3:10 PM Lumbar puncture performed by
15. Provider collects spinal fluid into three test tubes. Dr. King. Three samples of cerebrospinal fluid obtained.
16. After the procedure has been completed, the Labeled #1, #2, #3. Taken to laboratory. Appeared to toler-
provider applies a sterile adhesive dressing to ate procedure. BP 142/82, P88. Instructed to remain flat for
the puncture site. The patient is placed in a 3 hours and to drink increased amounts of fluids. J. Guerro,
prone position for 2 to 3 hours, or as directed by CMA (AAMA) ________________________________
518 UNIT 5 Assisting with Specialty Examinations and Procedures

Procedure 18-23
Assisting the Provider with a Neurologic Screening Examination
STANDARD PRECAUTIONS: during the history taking, note if behavior is
appropriate for the circumstances.
3. The provider checks reflexes using the percus-
sion hammer.
PURPOSE: 4. The provider checks the patient’s sensory abili-
To determine a patient’s neurologic status. ties; responses to skin sensations using a safety
pin or sensory wheel and cotton ball; patient’s
EQUIPMENT/SUPPLIES: ability to recognize the form of solid objects by
Percussion hammer touch (key, coin, paper clip); and patient’s abil-
Safety pin or sensory wheel ity to identify specific odor. The provider also
Material for odor identification checks cranial nerves, performs finger to nose
Cotton ball test, and checks patient’s ability to touch heel to
Tuning fork shin and ability to run the heel down opposite
Flashlight shin.
Tongue blade
5. Assist the patient as needed during and after the
Ophthalmoscope
examination.
PROCEDURE STEPS: 6. Document procedure in patient’s chart or elec-
1. Wash hands. tronic medical record.
2. The mental status examination can be done by
the medical assistant when taking the patient’s DOCUMENTATION
medical history by observing the following: 8/22/20XX 3:20 PM Assisted Dr. Woo with neurologic
When taking patient’s history, pay special atten- screening examination. Made appointment for patient to see
tion to level of awareness, memory, cognition, Dr. Sullivan, neurologist, on 9/4/XX at 3:00 PM. J. Backus,
and mood. When the patient answers questions RMA __________________________________________

Case Study 18-1

Refer to the scenario at the beginning of the chapter. CASE STUDY REVIEW
Both medical assistants are responsible for ensuring
that the supplies and equipment needed for the specialty 1. Determine what supplies and equipment should be
examinations are available and that safety precautions are assembled for the following specialty examinations:
followed before, during, and after the examination. fecal occult blood testing, performing an eye instil-
lation, performing an ear irrigation, and performing
color vision testing.
2. Explain four safety precautions that must be in
place when allergy skin testing is being performed.
 CHAPTER 18 Examinations and Procedures of Body Systems 519

Case Study 18-2

Corey Bayer is a 15-year-old patient at City Health Care. He CASE STUDY REVIEW
sustained an injury to his right wrist today during soccer
practice. Dr. Rice examined him and ordered a radiograph of 1. Describe cast application. What are the medical
the right forearm. The results show that Corey has sustained assistant’s responsibilities?
a Colles’ fracture of the right wrist. Dr. Rice asks you to pre- 2. After Corey’s cast application, describe the cast
pare the equipment to apply a cast. care instructions that will be given to him and his
mother.

Case Study 18-3

Dr. Rice has scheduled Anita Blanchette for a spirometry test CASE STUDY REVIEW
and wants you to telephone her the day before the test to
prepare her so that optimal results are obtained. 1. What information do you give to Anita before her
spirometry so that the best test results can be
obtained?

SUMMARY
Medical assistants are a vital link in the health care team. A thorough knowledge and understanding of the
various body system examinations and clinical procedures routinely performed as part of patient care will
enhance the quality of care given.
Some of the specialty procedures are performed on a routine basis in the ambulatory care setting;
others are performed occasionally and perhaps only in larger settings that offer specialized and primary
care. Sometimes, to feel comfortable assisting with the less common procedures, medical assistants may
need to broaden their base of knowledge by conducting independent research. Medical assistants who are
willing to constantly expand their clinical understanding will not only fine-tune their professional skills but
will derive greater satisfaction from their job performance.

STUDY FOR SUCCESS

To reinforce your knowledge and skills of information presented in this chapter:
• Review the Key Terms
• Practice the Procedures
• Consider the Case Studies and discuss your conclusions
• Answer the Review Questions

˚ Multiple Choice
˚ Critical Thinking
• Navigate the Internet by completing the Web Activities
• Practice the StudyWARE activities on your student CD
• Apply your knowledge in the Student Workbook activities
• Complete the Web Tutor sections
• View and discuss the DVD situations
520 UNIT 5 Assisting with Specialty Examinations and Procedures

REVIEW QUESTIONS
Multiple Choice 5. What is the medical assistant’s role when assisting
in spirometry?
1. What is the name of the elevated skin lesions 6. What are the cast care guidelines that the medical
affecting the epidermis caused by the assistant gives to the patient?
papillomaviruses? 7. When a mental status examination is given, what
a. scleroderma five areas are being reviewed?
b. moles 8. Explain the medical assistant’s role when assisting
c. calluses with a lumbar puncture.
d. warts 9. Bariatrics is a relatively new specialty. Explain why
2. What is the disorder that is characterized by dis- obese patients might decide with their provider to
comfort of the muscles, tendons, ligaments, and undergo bariatric surgery. What are some medical
soft tissues brought on by trauma, strain, and emo- problems that must be addressed before surgery?
tional stress? What are physical and emotional difficulties or
a. carpal tunnel syndrome problems bariatric surgical patients may have prior
b. bursitis to surgery?
c. gout
d. fibromyalgia
3. What type of fracture has its bone fragments driven
into each other?
WEB ACTIVITIES
a. greenstick
b. impacted Use the Internet to search for information
c. oblique from a medical site to find answers to the
d. comminuted following:
4. What disease is caused by a degeneration of brain 1. Using a search engine of your choice, go to Web
cells caused by lack of dopamine, bringing about MD and gather information about the following
muscle rigidity and akinesia? conditions:
a. multiple sclerosis kidney stones
b. Bell’s palsy polycystic kidneys
c. Parkinson’s disease Describe the etiology and treatment of each.
d. tic douloureux 2. Search for possible treatments for sleep apnea.
5. An acute circumscribed infection of the subcutane- http://www.breathingdisorders.com
ous tissues caused by staphylococcus is a: http://www.sleepapnea.org
a. comedone 3. What are some long-term harmful effects of ciga-
b. carbuncle rette smoking?
c. verruca Check this Web site for information:
d. psoriasis http://www.tobaccofreekids.org
4. The National Digestive Diseases Clearinghouse is a
Critical Thinking useful source for learning about acute and chronic
pancreatitis.
1. Is there an advantage to catheterizing a patient for
What are the signs and symptoms of acute
urinalysis and culture and sensitivity? Why or why
pancreatitis? How is a diagnosis made by the
not?
provider? What is the most common cause of
2. What is the use and purpose of the audiometer?
chronic pancreatitis?
How is the test administered?
5. Adolescent cases of bacterial meningitis have
3. Explain the rationale when doing an eye irrigation
increased since the 1990s.
that the flow of the irrigating solution is from the
Is a particular group of adolescents at greater
inside canthus to the outer canthus of the eye.
risk than other groups? How can meningitis be
4. Differentiate among bronchitis, emphysema, and
prevented?
asthma.
 CHAPTER 18 Examinations and Procedures of Body Systems 521

REFERENCES/BIBLIOGRAPHY
Altman, G. B. (2004). Delmar’s fundamental and advanced Neighbors, M., & Tannehill-Jones, R. (2006). Human
nursing skills (2nd ed.). Clifton Park, NY: Delmar diseases. Clifton Park, NY: Delmar Cengage
Cengage Learning. Learning.
Asthma guide, overview and facts, treatment and self-care. Roe, S. (2003). Delmar’s clinical nursing skills and concepts.
Retrieved from http://www.webmd.com. Clifton Park, NY: Delmar Cengage Learning.
Chronic obstructive pulmonary disease overview and treatment Section 4, Managing asthma long term overview. (2007).
overview. Retrieved October 4, 2008, from http:// Retrieved October 11, 2008, from http://www.
www.copdfoundation.org. nhlbl.gov/idex.htm (pp. 277−280).
Delaune, S. C., & Ladner, P. K. (2002). Fundamentals Spotlight on John McGuire, mobile spirometry unit. (2008).
of nursing standards and practice (2nd ed.). Clifton Retrieved October 11, 2008, from www.
Park, NY: Delmar Cengage Learning. copdfoundation.org. 2(2).
Examinations and tests for COPD. Retrieved September 7, Taber’s cyclopedic medical dictionary. (2003). (22nd ed.).
2007, from http://www.webmd.com. Philadelphia: F. A. Davis.
Metered dose inhalers and how to use them correctly. Retrieved Tamparo, C., & Lewis, M. (2005). Diseases of the human
October 11, 2008, from http://www.aafp.org/afp/ body (3rd ed.). Philadelphia: F.A. Davis.
20010815/603.html.
Miller-Keane. (1997). Encyclopedia and dictionary of medi-
cine, nursing and allied health. (5th ed.). Philadelphia:
W. B. Saunders.

THE DVD HOOK-UP

This chapter discusses the proper techniques for assist- DVD Journal Summary
ing with specialty examinations. Write a paragraph that summarizes what you learned from
The selected scenes from today’s DVD program illustrated watching today’s DVD selected scene. Imagine that you are
various procedures that are used to test the patient’s vision testing the eyes of a pilot. To pass the flight physical, the
and hearing. pilot has to have perfect eyesight. You notice that the pilot is
really straining to see the eye chart. His acuity test showed
When measuring distant vision, the program featured two less than perfect vision. He tells you his eyes are just
separate charts that can be used to measure distant vision strained from flying all day and asks you to alter the results.
in children. What would you do in this situation?
1. What were the names of the charts?
2. Which chart should be used for younger children?
Which chart should be used for older children?
3. The procedure for measuring visual acuity in this chap-
ter talks about using an occluder to cover the eye when
testing vision. The scene for measuring visual acuity DVD Series Program Number
in the DVD program illustrates a patient using a small Skills Based Series 6
paper cup to cover the eye. Are there any advantages Chapter/Scene Reference
to using a cup versus an occluder? • Vision and Hearing Tests
U NIT
Advanced Techniques
6 and Procedures

Chapter 19
Assisting with Office/Ambulatory Surgery
Chapter 20
Diagnostic Imaging
Chapter 21
Rehabilitation and Therapeutic Modalities
Chapter 22
Nutrition in Health and Disease
Chapter 23
Basic Pharmacology
Chapter 24
Calculation of Medication Dosage and Medication
Administration
Chapter 25
Electrocardiography
 Chapter
Assisting with Office/
Ambulatory Surgery 19
KEY TERMS OUTLINE
Allergy Surgical Asepsis and Sterilization Categories and Uses
Anesthesia Hand Cleansing (Hand Care of Instruments
Antibacterial Hygiene) for Medical and Supplies and Equipment
Approximate Surgical Asepsis Drapes
Sterile Principles Sponges and Wicks
Avascularization
Methods of Sterilization Solutions/Creams/Ointments
Bandage
Gas Sterilization Dressings and Bandages
Betadine®
Dry Heat Sterilization Anesthetics
Caustic Chemical (“Cold”) Sterilization Patient Care and Preparation
Cautery Steam Sterilization Patient Preparation and
Contamination (Autoclave) Education
Dressing Common Surgical Procedures Informed Consent
Epinephrine Performed in Providers’ Offices Medical Assisting
and Clinics Considerations
Exudate
Additional Surgical Methods Postoperative Instructions
Fenestrated
Electrosurgery Wounds, Wound Care, and the
Friable
Cryosurgery Healing Process
Hibeclens® Laser Surgery Basic Surgery Setup
Hydrogen Peroxide Suture Materials and Supplies Basic Rules and Concepts for
Infection Suture/Ligature Setup of Surgical Trays
Inflammation Suture Needles Surgery Process
Informed Consent Staples Preparation for Surgery
Isopropyl Alcohol Staple Removal Using Dry Sterile Transfer
Ligature Instruments Forceps
Liquid Nitrogen Structural Features
Mayo Stand/Instrument
Tray
Ratchets
OBJECTIVES
Silver Nitrate The student should strive to meet the following performance objectives and
demonstrate an understanding of the facts and principles presented in this
Sitz Bath
chapter through written and oral communication.
Sodium Hydroxide
Sterile Field 1. Define the key terms as presented in the glossary.
Strictures 2. Define surgical asepsis and differentiate between surgical asepsis
Suppurant and medical asepsis.
Surgery Cards 3. List eight basic rules to follow to protect sterile areas.
Surgical Asepsis 4. State four methods of sterilization.
Suture 5. List supplies and equipment necessary to achieve surgical asepsis
when using an autoclave.

523
OBJECTIVES (continued) KEY TERMS
6. Explain competent wrapping and operation of the autoclave. (continued)
7. State storage measures and expiration periods for autoclaved Swaged
materials.
Thermolabile
8. Explain the sizing standards of suture material and the criteria
Thermophile
used to select the most appropriate type and size.
Unsterile Field
9. Given a variety of surgical instruments, be able to identify each
Volatile
and describe its intended use.
10. Demonstrate the ability to select the most appropriate type of
dressings for a given situation.
11. State advantages and disadvantages of Betadine®, Hibeclens®,
isopropyl alcohol, and hydrogen peroxide when each is used as
a skin antiseptic.
12. Define anesthesia, and explain the advantages and disadvan-
tages of epinephrine as an additive to injectable anesthetics.
13. List five preoperative concerns to be addressed in patient prep-
aration and education.
14. List five postoperative concerns to be addressed with the patient
and the caregiver.
15. Demonstrate applying sterile gloves.
16. Demonstrate setting up a surgical tray, including laying the
field, applying supplies and instruments, pouring a sterile
solution, using transfer forceps, and covering the sterile tray.
17. Explain what is meant by alternative surgical methods.

Scenario
It might be instructive to compare two different maintains two special rooms for minor surgery and
ambulatory care settings. At the multiprovider Inner has a large selection of instruments. At the smaller
City Health Care, minor surgery is performed on a two-provider practice of Lewis and King, however,
routine basis. Certain days are dedicated to certain minor surgical procedures are less frequent and are
procedures. Because of the high volume of patients conducted in the patient examination rooms.
and different provider preferences, Inner City

INTRODUCTION
Office/ambulatory surgery differs from hospital sur- lar surgical procedure. These particular instruments are
gery not only in complexity, but in the supplies, equip- generally not used by the other providers.
ment, instruments, and personnel needed. Some office/ The equipment and supplies used in office/ambulatory
ambulatory surgery is performed by the provider alone; surgery are usually portable and easily maintained. Larger
some surgeries require the assistance of the medical assis- practices that perform many office/ambulatory surgeries
tant. Most ambulatory care settings do not need a large generally can afford the space and expense of maintaining
variety of surgical instruments but often need more than a special room just for that purpose. Often patient exami-
one of the more frequently used instruments. As a personal nation rooms serve as small surgical suites with portable
preference, special instruments may be purchased and Mayo stands/instrument trays, supplies, and equipment
maintained for a specific provider to use during a particu- brought into the room for the procedure.

524
 CHAPTER 19 Assisting with Office/Ambulatory Surgery 525

Whether assisting with office/ambulatory sur-

gery is a routine or an infrequent event for the medical Spotlight on Certification
assistant, it is nonetheless important to be knowledge-
able about sterile technique, the use and care of instru- RMA Content Outline
ments and the room, as well as patient preparation for • Asepsis
the surgery. Medical assistants should understand the • Universal (Standard) Precautions
preferences of each provider on staff to make the surgical
• Sterilization
procedure comfortable and effective for both patient and
provider. • Instruments, care, and handling
• Minor surgery

SURGICAL ASEPSIS CMA (AAMA) Content Outline

• Principles of infection control
AND STERILIZATION • Surgical asepsis
Surgical asepsis means all microbial life (patho- • Equipment preparation and operation
gens and nonpathogens) is destroyed before an • Autoclave/sterilizer
invasive procedure is performed. Therefore, all • Preparing/maintaining treatment areas
equipment to be used is sterile. The terms surgi- • Instruments, supplies, and equipment
cal asepsis and sterile technique often are used inter-
changeably.
CMAS Content Outline
Regardless of the number and complexity • Asepsis in the medical office
of surgical procedures performed in the office or • Exam preparation
ambulatory care center, surgical asepsis must be • Basic pharmacology
strictly maintained. Surgical asepsis uses practices • Understand concepts of asepsis, saniti-
known as sterile techniques and the technique is zation, disinfection, and sterilization
always used during an invasive procedure. Some • Observe Standard Precautions
examples of invasive procedures include creating
an opening in the skin such as a surgical incision,
suturing a wound such as a laceration, giving an
injection, or inserting a sterile catheter into a ster- tion before applying sterile drapes around the
ile body cavity such as the urinary bladder. intended surgical site.
Because microorganisms are on virtually Refer to Chapter 10 for more complete infor-
every surface such as skin, instruments, surgical mation on the concepts of asepsis and aseptic
instrument trays, clothing, and even in the air, it techniques, including hand cleansing for medical
is necessary to destroy as many as possible before asepsis.
performing any surgical procedure. Surgical The differences between hand cleansing for
asepsis or sterile technique prevents microorgan- medical asepsis as discussed in Chapter 10 (see
ism entry into the body during an invasive proce- Procedure 10-1) and hand cleansing for surgi-
dure and, therefore, helps to protect the patient cal asepsis are addressed in the following section
from infection. Once the items and areas are (Table 19-1).
sterilized, every precaution must be taken to pre-
vent contamination of the sterile items or areas Hand Cleansing (Hand Hygiene)
either by a nonsterile item or surface or from
airborne contamination. In this context, to con-
for Medical and Surgical Asepsis
taminate means to make impure; for example, by Hand cleansing (hygiene) for medical asepsis
introducing microorganisms or infectious mate- is defined as removing pathogenic microorgan-
rial into or onto sterile goods or areas. isms from the hands after they become contami-
Living tissue surfaces such as skin cannot nated. Medical hand cleansing is used many times
be sterilized but can be made as free of patho- throughout the day to cleanse the skin after remov-
gens as possible before the use of a sterile cover- ing contaminated gloves, assisting with patient
ing. One example of this concept is the use of care, and touching unclean surfaces.
the surgical hand cleansing technique before Hand cleansing for surgical asepsis is
applying sterile gloves (see Procedure 19-1). defined as removal of as many microorganisms as
Another example of surgical asepsis is prepar- possible before donning sterile gloves and per-
ing the patient’s skin with a surgical scrub solu- forming surgery or a sterile procedure. Hand
526 UNIT 6 Advanced Techniques and Procedures

Table 19-1 Differences between Medical and Surgical Hand Cleansing (Hygiene)

Medical Hand Cleansing (Hygiene) Surgical Hand Cleansing (Hygiene)

Liquid soap and water sufficient for most rou- Performed before any surgical or invasive procedure.
tine clinical activities.

One-minute duration. Three to six-minute duration.

Wash hands and wrists. Wash hands, wrists, and forearms to the elbows. Brush may be used.

Hands should be held down during rinsing. Hands should be held up during washing and rinsing.

Scrub nails with brush; clean under nails with Scrub nails with brush and clean under each nail with cuticle stick.
cuticle stick.

Alcohol-based preparations are practical Alcohol-based hand wash can be used after pre-washing hands to
alternatives to soap and water on visibly remove debris.
clean hands.

Apply lotion.* Do not apply lotion.*

Glove for sterility.

Higher level of decontamination.

*The use of lotions is encouraged to help prevent chafing of the skin, especially with frequent hand cleansings. Nevertheless, studies have deter-
mined that lotions containing petroleum or mineral oil can break down latex and should be avoided if latex gloves are going to be worn within
1 hour after applying the lotion. If lotions are applied immediately before gloving, the use of water-based lotions is recommended. Of special
interest to persons with latex sensitivities (see Chapter 10) is the fact that using lotions and creams containing petroleum products actually
increases the amount of latex protein that is transferred from the gloves into the skin, thereby increasing the symptoms of latex sensitivity.

cleansing for surgical asepsis consists of meticu- any direct patient contact. See Chapter 10 for
lously scrubbing hands, wrists, and forearms information on medical asepsis and Standard
before applying sterile gloves. Both medical and Precautions.
surgical aseptic hand cleansing techniques are
designed to prevent exposing patients, health
care workers, and the public to potentially harm- STERILE PRINCIPLES
ful microorganisms. A brushless/waterless surgi-
cal hand cleanser can be used after prewashing Sterile principles are a set of guidelines designed
hands to remove debris from hands and nails. to designate what items and areas are considered
The brushless cleansing agent has an antimicro- sterile and what actions cause contamination.
bial additive that contains alcohol. The agent Some areas are logical and clear, some are subtle
must be completely dry before donning gown and less clear. Some surfaces, such as skin, can-
and gloves. not be sterilized. Large items such as instrument
Proper protocol when assisting with surgery stands and their trays cannot fit into an autoclave
requires the use of surgical hand cleansing at for sterilization. To create sterile areas and sur-
the beginning of each workday, as well as before faces where sterility is not possible, sterile barriers
every sterile technique, with the complementary should be used; sterile gloves can be worn over
use of medical hand cleansing before leaving the the hands. Sterile drapes can be applied to trays
office and when returning and between patients once they have been washed, rinsed, dried, and
and procedures. Any opening in the medical disinfected.
assistant’s skin should be covered with a sterile Guidelines to protect sterile items and areas
adhesive dressing, and gloves are worn during include:
 CHAPTER 19 Assisting with Office/Ambulatory Surgery 527

• A sterile object may not touch a nonsterile METHODS OF STERILIZATION

object.
• Sterile objects must not be wet. Moisture can draw
There are four methods of sterilization:
microorganisms into or onto the sterile object. 1. Gas sterilization
• An acceptable border between a sterile area and 2. Dry heat sterilization
a nonsterile area is 1 inch. The portion of a drape
3. Chemical (“cold”) sterilization
that hangs over the edge is considered nonsterile,
no matter what its size. Sterile articles should be 4. Steam sterilization (autoclave)
placed in the center of the sterile field and away
from the edge as much as possible.
Gas Sterilization
• Do not turn your back on a sterile field. If you
cannot see the field, you cannot be aware of what Gas sterilization is accomplished in a gas oven large
touched it. enough for wheelchairs and beds and takes hours
for the extremely toxic gases to permeate and dis-
• Anything below the waist is considered contami-
sipate. These features make the gas oven useful in
nated. In support of this principle, all surgery trays
a large hospital setting but much too costly and
should be positioned above the waist. All articles
impractical for the office.
are to be held above the waist.
• All sterile objects (such as gloved hands) must be
held in front and away from the body and above
Dry Heat Sterilization
waist level. Dry heat sterilization requires higher temperatures
• Do not cough, sneeze, or talk over a sterile field.
than steam sterilization and requires longer expo-
Airborne particles may fall onto the sterile area
sure times as well (at least 1 hour at 320°F). This
and contaminate it.
method can be used for instruments that easily cor-
rode, such as sharp cutting instruments. Powders,
• Do not reach over the sterile area. Contami- oils, ointments, rubber goods, and plastic tubing can
nants may fall onto the area and clothing may be sterilized using the dry heat method. Procedures
touch, thereby contaminating the area. Spend for wrapping are the same as when wrapping for
as little time as possible reaching into the sterile steam sterilization (see Procedure 19-3). Dry heat is
area. seldom used in today’s medical office or clinic.
• Do not pass contaminated dressings or instruments
over the sterile field. Chemical (“Cold”) Sterilization
• Arrange for the provider to place contaminated
instruments into a separate container or area. Chemical sterilization, or cold sterilization, may use
the same chemical agents used to chemically disin-
• Always be aware of actions to determine whether fect instruments or fomites. However, the exposure
the sterile field has been contaminated. When in time for chemical sterilization is achieved through
doubt, err on the side of safety. prolonged immersion. Items must be sanitized
• When opening sterile packages, the outer
first. The handling of instruments after chemical
wrapper is contaminated. It should be opened
sterilization differs from handling procedures for
without touching the inner contents, and
instruments that are steam sterilized in that instru-
the contents are then dropped onto the ster-
ments must be handled with sterile gloves, rinsed
ile field. Double wrapping can be used (see
with sterile water, and dried with sterile towels
Procedure 19-3).
before placement on a sterile surface.
Chemical sterilization is an effective method
• Sterile solutions in bottles should be poured into used in many medical offices when the object being
sterile basins or cups on the sterile field without sterilized is too large or too heat sensitive for auto-
touching the rim of the bottle and without splash- claving (see following section for information on
ing solution onto the sterile field. If the sterile autoclaving). Fiber-optic endoscopes are one of the
field is not polylined and becomes wet, it is con- most common items sterilized with the use of chem-
sidered contaminated because a field that is wet icals. These items are delicate and unable to with-
acts as a wick and draws microorganisms into the stand the high heat of an autoclave. The necessary
article. Using polylined drapes as sterile fields equipment for chemical sterilization is a container
protects against contamination. or basin of adequate size for the intended item (and
528 UNIT 6 Advanced Techniques and Procedures

should be maintained for that purpose only) with a

well-fitting lid and the chemical of choice. A vent
hood is required for safety. Two of the most popu-
lar brands of chemicals available through medical
supply sources are Wavecide and Cidex. Both have
advantages and disadvantages. Offices must make
individual choices based on convenience, expense,
and other personnel preferences.
The effectiveness of any of these products
depends greatly on the strength of the solution.
If the strength is a 1:1 ratio of water to chemical,
effectiveness will be lost if the solution is not mixed
according to that dilution. Any attempt to cut cost
by mixing a weaker solution will greatly compromise
the effectiveness. The item will not be sterile. Some-
times solutions are weakened unintentionally by
placing wet items into them, thereby adding more Figure 19-1 Commonly found in providers’ offices,
water than is intended. For this reason, wet items autoclaves are used for sterilization by steam pressure,
must be carefully dried before chemical sterilization. usually at 270°F (118°C) for a specified length of time.
A well-fitting tight lid is essential to prevent evapora-
tion, which also interferes with the strength of the
solution. The lid also lessens the chance of dust and
airborne microbes from falling into the solution. a maximum temperature of 212°F through boil-
Another factor influencing the effectiveness ing. When under pressure, water is converted to
of the sterilizing chemicals is exposure time. The steam and is then able to reach a temperature of
manufacturer provides specific time charts for each 270°F and higher. Exposing items to this extremely
purpose. Manufacturer’s directions also include a high heat and at least 15 pounds of pressure for a
time frame for replacing the solution. The ability of specific amount of time ensures that all microor-
the solution to kill pathogens is directly related to ganisms and their spores are killed. The autoclave
its freshness or shelf life. Regardless of the chemi- is an inner sterilizing chamber surrounded by a
cal used for sterilization, ventilation is important. metal jacket. This creates a middle steam cham-
When using commercial chemicals, make ber between the inner sterilizing chamber and
certain the lid is placed on the soak basin at the jacket. Inside the jacket is a reservoir for water.
all times except when placing or removing When water is poured into the reservoir, the auto-
items. Care must be taken to avoid contact with clave door closed and secured, and the autoclave
skin, eyes, and mucous membranes. Wear protective turned on, several processes occur. The water in
gloves, goggles, and apron. The effects on skin can the reservoir heats until vapor is produced. The
range from slight irritation to serious caustic burns. vapor enters the middle steam chamber inside the
Before any chemically sterilized items are used jacket. The air in the steam chamber is pushed out
for patient contact, the chemicals must be thoroughly and replaced with steam. Because the air has been
rinsed off using either sterile gloves or sterile transfer pushed out, the pressure increases. The increase of
forceps to remove the item from the container. To pressure causes the steam to then enter the inner
maintain sterility, sterile water must be used for the sterilizing chamber (where the items and instru-
rinsing process. Then dry with a sterile towel, and ments for sterilization are placed), which pushes
place onto a sterile field. This process is performed out the air. With the air being displaced with steam,
just before use of the item (see Procedure 19-2). the pressure increases in the inner chamber. The
steam under pressure is able to reach a much higher
Steam Sterilization (Autoclave) temperature than boiling water. When the steam is
able to reach all surfaces of the items placed in the
Steam sterilization is the most widely used method autoclave and exposure is maintained for adequate
of sterilization used in the medical office. An auto- amounts of time, sterility of those items is ensured.
clave, basically a pressure cooker, is used to achieve The recommended temperature for effective
sterilization. The autoclave uses steam under pres- sterilization in an autoclave is 270°F. Unwrapped
sure to obtain higher temperatures than can be items should be sterilized for 20 minutes, loosely
achieved with boiling (Figure 19-1). Water reaches wrapped items for 30 minutes, and tightly packed
 CHAPTER 19 Assisting with Office/Ambulatory Surgery 529

items for at least 40 minutes. When uncertain about Correct Incorrect

the proper amount of time necessary, the medical
assistant should refer to the manufacturer’s recom-
mendations. The overall effectiveness of the auto-
clave in sterilizing contents is totally dependent on
the medical assistant following proper operating
procedure.
Only distilled water should be used to prevent A B
mineral buildup in the machine. Before every use,
check the water level and add to fill line if nec-
essary. Distilled water is inexpensive and readily
available.

How to Load Packages. It is of extreme impor-

tance that instruments and materials be posi-
tioned properly in the autoclave for the steam
to circulate through and between packs and
penetrate them. Do not overload the autoclave. C
Place items as loosely as possible inside the cham- D
ber. Leave a 1- to 3-inch space between packs
and the walls of the autoclave. Correct position- Figure 19-2 (A) Proper placement of packages in
ing and spacing allows sterilization to take place the autoclave allows steam to circulate and penetrate
provided the medical assistant adheres to proper from all sides. (B) Packages incorrectly loaded in
temperature, pressure, and time requirements autoclave. (C) When placed correctly, the jar should
(Figure 19-2). lay on its side with the cover loosely in place to allow
steam to freely circulate through the jar and properly
Autoclave Maintenance and Cleaning. The auto- sterilize the dressings. (D) Incorrect method.
clave, like any piece of equipment in the medical (Courtesy of Steris Corporation, Mentor, OH.)
office, needs regular cleaning and maintenance.
Frequency of cleaning the autoclave depends
somewhat on its usage. If the autoclave is used
every day, the inner chamber should be washed
with a mild detergent and cloth, rinsed, and dried
General Rules to Ensure Proper on a daily basis. The outer jacket should be wiped
clean of dust and soil. Follow the manufacturer’s
Sterilization Using an Autoclave instructions and recommendations for cleansers.
• Articles placed into the autoclave must have been Omni® cleanser is a well-known brand of autoclave
sanitized, rinsed, and dried. cleanser.
• The articles are wrapped and placed to allow adequate At least once a week or following the man-
exposure of all surfaces (see Figure 19-2). Instruments ufacturer’s instructions, the autoclave should be
inside packages should have hinges open and serrations drained of water and cleaned thoroughly. Clean-
exposed. ing the autoclave requires that it be drained,
• To prevent formation of trapped air pockets, containers filled with cleaning solution, run through a
should be placed on their sides with lids loosely in place. 20-minute heated cycle, drained of solution, filled
• Any wrapping material used must be approved for auto- with distilled rinse water, run through another
clave use. 20-minute heated cycle, drained of rinse solu-
• Timing should not start until the gauges read 15 pounds of
tion, and filled with distilled water again. Then
pressure and 270°F.
• When the cycle is complete, the door must be opened
the inner shelves are removed and scrubbed, and
slightly to allow steam to escape. The sterile wrapped the inner chamber is wiped clean. Because this
articles will be hot and damp and should be left in the process is fairly time-consuming and puts the
autoclave to cool and dry. Microorganisms can contami- autoclave out of use for a while, consideration
nate the sterile articles through the damp wrapping if should be given to scheduling the weekly clean-
the door is opened too wide or if articles are handled ing at a time when personnel can devote the time
while damp. and when the autoclave is not in demand for ster-
ilization processes.
530 UNIT 6 Advanced Techniques and Procedures

During the cleaning process, attention should Autoclave Wrapping Material and Packaging
be given to inspecting the rubber seal for cracks Supplies. Wrapping or otherwise packaging sur-
or wear. An extra replacement rubber seal should gical instruments and other surgical and medical
always be kept on hand. The seals are available articles before placing them in the autoclave will
through medical supply sources. Refer to the man- extend their shelf life. Before these articles are
ufacturer’s instructions for regularly scheduled wrapped, they must first be sanitized, rinsed, and
replacement of the rubber seal and other recom- dried. Several materials are available for wrapping.
mended maintenance procedures. Cost, convenience, visibility, time, space, and ease
of use will help determine which to use. Many
Quality Control and Assurance for Autoclave. offices use a combination of materials.
Quality control when using an autoclave consists
of proper maintenance, proper operation, and • Muslin is a cloth wrap available in several sizes and
observation of the temperature and pressure colors. Even with the cost of the initial purchasing,
gauges. Equally important is the regular use of occasional replacements, autoclave tape, and laun-
sterilization indicators and culture tests. Several dering, muslin is still an economical option. Besides
types of sterilization indicators and culture meth- these cost-effective advantages, many surgical instru-
ods are available: ments can be wrapped together in muslin, making
• Sterilization strips. The strips contain a thermolabile up a convenient surgery/procedure set. One of the
dye that darkens when exposed to steam at the main disadvantages of muslin is the inability to view
proper temperature and pressure for the proper the contents. Another disadvantage is the need for
amount of time. These indicators are placed in the constant examination for holes, tears, and wearing
center of the wrapped article (Figure 19-3). out of the cloth. Patching is not a reasonable option
because iron-on patches impede penetration of
• Culture tests. These are available as a culture strip
steam and sewn-on patches create their own set of
containing heat-resistant spores. The strip is placed
perforations. A defective muslin cloth should be dis-
in the center of a wrapped article and placed in a
carded. Wrapping space and training of personnel
fully loaded autoclave. After processing is complete,
are necessary when using cloth. Special autoclave
the article is unwrapped and the strip is placed into
tape is required to seal the package.
a culture medium. If the autoclave is functioning
properly and the medical assistant has followed • Paper sterilization wrapping squares are available
proper operating procedure, no growth should in many different sizes and types. This disposable
occur. type of material requires that a new paper be used
each time items are sterilized, but it eliminates the
Also available through Becton-Dickinson Mi-
need for laundering. Similar to cloth wrapping,
crobiology Systems is an ampule called the Kilit
paper wraps also lend themselves to larger sets
Ampule. These biological indicators are ampules
of articles being wrapped together for surgery or
that contain spores of the thermophile “Bacillus
procedural packs. As with muslin cloth, wrapping
stearothermophilus.” After being processed through
space and some personnel training are necessary.
the autoclave, the Kilit Ampule is sent to a coop-
Paper wraps are opaque, making viewing of the
erating laboratory for week-long observation for
contents impossible. Autoclave tape is required to
survival of the bacilli spores. A written report of the
seal the package.
results is generated by the laboratory and sent to
the office for its records. The CDC recommends • Sterilization pouches or bags may be plastic, paper,
biological indicators. or a combination (Figure 19-4). They are fairly inex-
pensive and very easy to use. Because no wrapping
is involved, additional work space is not required.
Another advantage of bags is the visibility of the
items inside. Some pouches are packaged on a con-
tinuous roll and are available in a variety of widths.
This allows the medical assistant to cut the bag to
fit the article. Because both ends must to be taped
closed, it is difficult to remove the article while main-
taining its sterility. Probably the best bag-type option
is individual bags with the top end open for instru-
ment placement and the bottom end factory closed
Figure 19-3 Types of sterilization indicators. with a peel-apart seal. The article is inserted into the
 CHAPTER 19 Assisting with Office/Ambulatory Surgery 531

wrapped package is sterile, only that it has been in

a heated autoclave. The tape is placed on the out-
side of the package, so it does not assure that steam
has penetrated to the inner article. It does help to
determine if a package has been in the autoclave
(Figure 19-6).

Labeling Packages for Autoclave. Surgical pack-

ages should be labeled clearly. Clear bags usually
have a designated place for labeling, and muslin-
or paper-wrapped packages may be labeled across
the autoclave tape. Proper labeling should include
the name(s) of the articles in the pack, the date of
sterilization, and the initials of the medical assis-
tant responsible for the wrapping. The name of
the instrument or article should be as specific as
Figure 19-4 Various types and sizes of self-sealing possible, especially when using the opaque cloth
bags for sterilization. or paper wraps. If many instruments have been
wrapped together for a specific surgery or for a spe-
cific provider, the label should clearly state which
top opening, the bag is taped closed, and the pack-
age is sterilized (Figure 19-5). When needed, the
sterile article is removed through the factory-sealed
bottom end in a peel-apart sterile fashion. These
individual bags need to be purchased in several
sizes and are expensive but have the advantages of

TowPels
ease of use and item visibility and are probably the

3-24-XX
preferred method for most medical offices today.

M
Autoclave Tape. Autoclave tape is chemically A
treated to appear “striped” when exposed to heat.
The striped pattern indicates exposure to high
temperature but does not measure pounds of pres-
sure or duration of exposure. Because of these
Tow

limitations, autoclave tape does not assure that the

3-24-XX
MP
els

Figure 19-6 Package of towels (A) before and

(B) after autoclaving. Note that the autoclave tape
has a striped pattern indicating that the package was
exposed to a high temperature. However, this does not
assure sterility.

Critical Thinking
What is the purpose of OSHA’s standards for
Figure 19-5 The medical assistant is placing a sani- bloodborne pathogens and whom does it
tized instrument into a sterilization bag for autoclaving cover?
by inserting the tips of the instrument in first.
532 UNIT 6 Advanced Techniques and Procedures

surgery or surgeon. For example, a “laceration Pharmacy

repair set” could contain all the necessary instru-
ments for repairing a laceration. “Dr. Peterson’s
vasectomy set” would contain all the instruments
Dr. Peterson needs to perform a vasectomy, includ- CLINICAL CARE
ing, perhaps, personal preference instruments.
Patient Assessment
The date of sterilization helps determine the expi- Procedures, Diagnoses & Treatment Plans
ration of sterility and a “pull date” for resterilizing. Referrals & Follow-up Appointments
Prescriptions
Initialing the package allows for accountability if Orders for Tests
necessary. Labels should always be written with a Patient Medical History

permanent marker. Ballpoint pen should never be

used because the ink will smear when wet. Caution
should be taken to avoid puncturing through the
Test Results
package during labeling. Schedules and Tickler Files
Patient Medical History
Wrapping Techniques. Articles must be wrapped Medication Administration
Patient Education
in a specific way to ensure they remain sterile when Graphical Patient Data Displays
opened. Wrapped surgical instruments need to be
double wrapped. Some methods advocate placing
both layers of wrapping material together and dou-
ble wrapping the pack in one process. A much more
ELECTRONIC
useful method is the “wrapping twice” technique
(see Procedure 19-3). The wrapping twice technique RECORDS
allows for additional options at the time of opening.
Wrapping twice allows for a completely wrapped
inner sterile package to be applied to the surgi- Figure 19-7 In a total practice management system,
cal tray. This wrapping twice technique eliminates the provider’s preferences for instruments, supplies,
struggling to control multiple instruments during and equipment are electronically stored and immedi-
the unwrapping process; and, if the inner package ately accessible to the medical assistant when setting up
becomes contaminated during the unwrapping, for various surgical procedures.
the medical assistant has the additional option of
unwrapping the inner package using the same tech-
nique without having to start over. All packs should
be neatly and securely wrapped—firm enough to This section includes a general procedure for
prevent the instruments from movement, but loose assisting with surgery and is followed by specific
enough to permit adequate steam penetration office/ambulatory surgical procedures, including:
(see Procedures 19-3 and 19-4).
• Assisting with Office/Ambulatory Surgery (Proce-
dure 19-8)
COMMON SURGICAL • Dressing Change (Procedure 19-9)
PROCEDURES PERFORMED • Wound Irrigation (Procedure 19-10)
• Preparation of Patient’s Skin before Surgery
IN PROVIDERS’ OFFICES (Procedure 19-11)
AND CLINICS • Suturing of Laceration or Incision Repair (Pro-
cedure 19-12)
All surgery has commonalities as well as specif-
ics. The following on specific surgery or surgical • Sebaceous Cyst Excision (Procedure 19-13)
procedures includes lists of needed instruments, • Incision and Drainage of Localized Infection
supplies, and equipment, as well as basic patient (Procedure 19-14)
preparation and postoperative instructions for • Aspiration of Joint Fluid (Procedure 19-15)
some of the more frequently performed surgeries.
• Hemorrhoid Thrombectomy (Procedure 19-16)
The following procedures are suggested protocol
only because providers will have preferences and • Suture/Staple Removal (Procedure 19-17)
techniques unique to them and their practices • Application of Sterile Adhesive Skin Closure Strips
(Figure 19-7). (Steri-Strips) (Procedure 19-18)
 CHAPTER 19 Assisting with Office/Ambulatory Surgery 533

ADDITIONAL SURGICAL
METHODS
Additional surgical methods are those methods
not requiring the use of a surgical knife or scalpel
but using other methods of cutting or destroying,
such as electric current, heat, freezing, chemicals,
or laser beam. The method used is determined by
the provider’s preference.

Electrosurgery
Electrosurgery uses an electric current in a con-
centrated area to either cut or destroy tissue when-
ever pathologic examination is not required. The
equipment for electrosurgery consists of a power
source, usually a small boxed unit, and a detach-
able handheld applicator with removable tips. The
Figure 19-8 Electrosurgical equipment is used to
tips are available in various sizes and are removable
destroy tissue, such as warts, or to coagulate blood
for cleaning and sterilizing.
vessels to decrease bleeding during surgery.
Electrosurgery is useful in removing benign
skin tags and warts. The main advantage of elec-
trosurgery is that the bleeding is controlled
through the cauterization of the blood vessels Liquid chemical caustic agents such as sodium
as the electric current is applied. The terms elec- hydroxide are used to permanently destroy the
trocoagulation, electrofulguration, electrodessication, growth plates of toenails whenever total and per-
electroscission, electrosection, and eletrocautery all manent removal of the toenail is necessary.
refer to various uses of electric current to either
coagulate blood vessels, destroy tissue either with
a spark or by drying, or cut tissue. Disposable
Cryosurgery
battery-operated units designed for one-time use Cryosurgery refers to the destruction of tissue by
are available. freezing. Some types of tissues react differently
to heat than cold in the rate of healing and level
Cautery. The word cautery comes from the term of scarring. The cryogenic substance most often
caustic and means the application of a caustic chem- used to destructively freeze tissue is liquid nitro-
ical or destructive heat. Electrosurgery, cautery, gen. Liquid nitrogen, often incorrectly referred
and electrocautery are often used interchange- to as dry ice, is extremely volatile (easily evapo-
ably. The burning of tissue, either chemically or rated) and must be kept in a covered insulated
electrically, is known as cauterization. Sometimes canister. Liquid nitrogen is obtained when nitro-
during surgical procedures unnecessary bleeding gen gas is compressed under cold temperatures
can be controlled by use of electrosurgical equip- into a liquid. It is most often used to destructively
ment (Figure 19-8). Tissues that do not need to “freeze” warts. Liquid nitrogen can be applied to
be pathologically examined, such as benign skin cervical erosions to facilitate healing and growth
tags, can be destroyed using cauterization. Some of normal tissue, to remove lesions on the anus,
common chemicals used to destroy tissue and stop and for cataract extraction, retinal detachment,
bleeding are silver nitrate, liquid nitrogen, and prostate gland destruction, and removal of super-
sodium hydroxide. ficial lesions in the nose and throat. Some units
are single purpose use. There is less trauma,
Chemical Tissue Destruction. Silver nitrate is more control of bleeding, and less pain with
available in a solid form, impregnated on the end cryosurgery.
of a wooden applicator stick. Silver nitrate is espe- Many patients experience pain with liquid
cially useful inside the nose to cauterize friable, nitrogen because it is colder than other chemi-
easily broken, blood vessels in the treatment of cal cryosurgery options. Liquid nitrogen is usu-
epistaxis (nosebleed). ally kept in a large canister in a central location
534 UNIT 6 Advanced Techniques and Procedures

in the office and carefully transferred to a small • When the laser beam is focused on the target tis-
thermos for transport into the treatment room. sue, the cells explode and vaporize. Care should be
The medical assistant must take care to keep the taken not to inhale the vapors.
canister and thermos covered because of the vol- • Whenever high levels of electricity are used, care
atile properties (evaporation rate) of the liquid should be taken to avoid burns and to ensure that
nitrogen. the equipment is always in good working order.
The cryogenic properties of solid liquid nitro-
• Safety glasses should be worn by the provider, med-
gen make it useful for freezing warts and nevi.
ical assistant, and, if possible, the patient.
Nitrous oxide is another chemical used in cryo-
surgery. Nitrous oxide requires a gas cylinder, a • If the patient’s skin has been prepared with flam-
regulator, a pressure gauge, and a cryogun with mable products such as alcohol-based antiseptics,
assorted tips. Nitrous oxide is applied in a more the skin must be dry with no pooling of liquid.
direct and controlled pattern because of the pre- Read the product label for alcohol and other flam-
cision of the probes, and nitrous oxide does not mable substances.
evaporate as readily as liquid nitrogen. The tank, • Sterile water should be readily available to extin-
probes, and other supplies can be expensive. guish any fire if the laser beam accidently ignites
Nitrous oxide is not as cold as liquid nitrogen; cloth or paper in the area.
therefore, although it is not so uncomfortable for
the patient, it is not as destructive. It is not appro-
priate for use with cancerous lesions, which must SUTURE MATERIALS
be completely destroyed. Because nitrous oxide is AND SUPPLIES
a carcinogen, the Occupational Safety and Health
Administration (OSHA) requires that all nitrous
oxide systems have outside venting. It is not practi-
Suture/Ligature
cal for most ambulatory clinics. The word suture can be used as a verb to describe
All volatile gases are dangerous to inhale, and the motion of sewing or as a noun to describe the
appropriate ventilation must be used. Refer to the material used to sew. Suturing, or sewing, a wound
Material Safety Data Sheet (MSDS) information is a common procedure in provider’s offices. The
(available in printed form or on the manufactur- purpose is to approximate, or bring together, the
er’s Web sites) for specific cautions. edges of a wound. Suturing hastens healing and
lessens scarring. Whether the wound is an acciden-
tal laceration or a surgical incision, the suturing
Laser Surgery process is basically the same. When suture material
Laser is an acronym for Light Amplification by is used for tying off the ends of tubular structures
Stimulated Emission of Radiation. The laser during surgery, it is termed ligature. The terms
instrument converts light into an intense beam. By suture and ligature both refer to suture material, but
focusing the laser beam onto the target, the appli- they are named according to their uses.
cation can be extremely precise without damag- Most suture material used in office/ambu-
ing surrounding tissue. Over the past 2 decades, latory surgical procedures comes already fused,
laser surgery has become less expensive, more or swaged, to a needle and packaged in vari-
readily available, and consequently much more ous lengths (Figure 19-9). These are also called
widespread as a treatment of choice for surgery in atraumatic. Eighteen inches is a preferred length
dermatology, ophthalmology, nerve surgery, vascu- because it is short enough to be manageable yet
lar surgery, plastic surgery, and others. Most spe- long enough to complete most suturing proce-
cialty surgery uses laser in various ways. Because dures. Combinations of sizes and types of suture
many providers use laser technology in the ambu- materials and sizes and shapes of needles are end-
latory care setting, medical assistants must be less, but most providers use a select few. Selection
familiar with the dangers involved with laser sur- from among the many different suture materi-
gery, and safety precautions must be implemented. als and needles is based on the needs of the tis-
Attending a laser education and safety workshop sue and tissue healing. Suture ranges in size on a
is recommended for all personnel intending to scale from the smallest gauge below 0 (aught) to
work with lasers. the largest gauge above 0. The scale from 6–0 to 4
The following precautions are designed to includes all sizes from the smallest to the largest:
heighten awareness and serve as a safety
guide: 6–0, 5–0, 4–0, 3–0, 2–0, 0, 1, 2, 3, 4
 CHAPTER 19 Assisting with Office/Ambulatory Surgery 535

curved. They are categorized according to size,

shape, radius of curve, and type of point. Needles
may be termed cutting needles, round taper point nee-
dles, or blunt point needles.

Staples
Many surgical incisions can be approximated
using staples (made of stainless steel or titanium)
and a stapler made for this purpose (Figure 19-
10). The length, width, and number of staples
depend on the tissue. They are safe to use, reduce
blood loss, and reduce the length of time of the
surgery. Wound healing is quicker, and there is
Figure 19-9 A variety of pre-packaged suture materials less trauma. Staplers are made for specific types
with needles of various sizes and shapes. of tissues (e.g., blood vessels, skin, gastrointestinal
tract, and so forth). It is more difficult to remedy
Sometimes 2–0 is labeled 00, 3–0 labeled 000, 4–0 incorrectly placed staples than it is for manually
labeled 0000, and so on. Ambulatory care settings placed sutures.
use sizes 6–0 to 3–0.
If the tissue being sutured is delicate, as on the
face or neck, smaller suture material such as 6–0 is
Staple Removal
used; the finer the stitch, the less scarring. Some Staple removal (see Procedure 19-17) is done
sutures are made from materials that dissolve when wearing sterile gloves and using sterile instru-
they come in contact with the tissue enzymes. These ments. The staples are removed using a sterile
are referred to as absorbable sutures. The original prepackaged staple remover (Figure 19-11).
absorbable suture was called surgical gut or “cat The staple remover is carefully positioned under
gut.” It was made from sheep intestinal tissue. Left the staple and, when the handle is squeezed, the
“natural” or uncoated, it is called plain gut suture. staple flattens out and it can be carefully lifted
It dissolves or is absorbed in about 1 to 2 weeks. If out. Cleanse with an antiseptic solution such
more time is needed to heal, surgical gut may be as Betadine® and pat dry. Be certain all staples
coated with chromion salts and is called chromion have been removed by verifying the number
gut. It allows for a longer period of healing before that were inserted with the number you have
dissolving. Absorbable gut suture is used for under- removed.
lying tissues where removal is not reasonable and
areas where suture removal is inconvenient.
Individual body chemistries influence the exact
absorption rate of both plain and treated gut
suture. Surgical gut is rarely used now, having been
replaced by man-made absorbable suture (such as
Vicryl® and PDS® II). Suture is also made of nonab-
sorbable materials such as stainless steel, silk, cot-
ton, nylon, and Dacron. Some are natural (cotton,
silk) and some are synthetic/manmade (Dacron®,
Ethilon®, Prolene®). Each type of suture material A
comes in a variety of options such as different col-
ors for ease of visualization, braiding for additional
elasticity and strength, and coatings for lubrica-
tions and to lessen irritability to tissues.

Suture Needles B
The needles swaged (atraumatic) to the suture
material are also varied (see Figure 19-9). For Figure 19-10 Disposable prepackaged skin stapler
office/ambulatory surgery, the needles are usually (A) in package and (B) out of package.
536 UNIT 6 Advanced Techniques and Procedures

provides strength and aids in the prevention of

warping, most instruments with ratchets also need
the box-lock hinge. Other features include prongs,
hooks, and loops (Figure 19-12).

Categories and Uses

Several companies publish and distribute large pic-
A
toral catalogs of well over 30,000 medical-surgical
instruments. A glance through these references
shows the many choices available. For ease of dis-
cussion, learning, and cataloging, most surgical
instruments are placed according to their uses into
three basic categories.
Instruments designed for specific purposes
within medical specialties often do not readily fit into
any one group and are called specialty instruments.
This group includes long-handled gynecologic in-
struments, as well as other instruments designed to
B meet specific needs within specialty practices.

Figure 19-11 Disposable staple remover (A) in pack- Scissors and Scalpels. Most of the cutting instru-
age and (B) out of package. ments are scissors. Scissors have ring handles and
two blades and vary in size, shape, and function.
Because scissors have two blades, the word scissors is
INSTRUMENTS always plural. Bandage scissors have one rounded
tip to allow insertion under a bandage without
causing injury to the patient. Bandage scissors do
Structural Features not have to be sterile to use. The two most com-
Rarely does the phrase “form determines function” mon styles are the Lister bandage scissors and the
have as much meaning as when discussing surgi- finer finger bandage scissors (Figure 19-13).
cal instruments. One can almost always correctly Operating scissors are used to cut tissues and
imagine function simply by close examination of generally have very sharp blades. The blades may
the instrument’s design. Handles designed to be be curved or straight, and the tips may be sharp,
squeezed between the thumb and finger are called blunt, or a combination of each. They are described
“thumb” handles. “Ring” handles are designed for as sharp/sharp (s/s), blunt/blunt (b/b), or sharp/
the insertion of the thumb and finger into rings. blunt (s/b) (Figure 19-14). A special type of scis-
Ratchets are locking mechanisms located between sors, the Mayo dissecting scissors, may be straight or
the rings of the handles and are used for locking curved, with curved more often used, but are never
the instrument closed. Ratchets are designed to described as sharp or blunt because the tips are spe-
close in varying degrees of tightness. Serrations cifically designed to be neither but have a beveled
are the crevices etched into the surfaces of the jaws edge with slightly rounded points (Figure 19-15).
of hemostats, some forceps, and needle holders. Useful, delicately bladed scissors are iris scissors, orig-
The serrations provide a more secure grip during inally named for usefulness in eye surgery but now
use with slippery tissues without actually punctur- widely used in many procedures. Iris scissors may be
ing the tissue. For the purposes of puncturing tis-
sue, forceps with teeth are an option. Teeth may
be numerous or few but are always sharp and
should approximate tightly when the instrument Categories of Instruments
is closed. To help delicate tips match up properly, Cutting Scissors and scalpels
some thumb instruments have a guide pin built Grasping/Clamping Hemostats, forceps, clamps, and
into the handle. The box-lock is a special type of needle holders
hinge found on most ring-handled instruments, Dilating/Probing Specula, scopes, probes, retractors,
especially grasping instruments such as hemostats, and dilators
forceps, and needle holders. Because the box-lock
 CHAPTER 19 Assisting with Office/Ambulatory Surgery 537

Cross
serrations
Serrations
Longitudinal
Guide pins
serrations

Box-lock

Ring handle

A Ratchet B

Heavy Teeth
teeth Delicate
teeth

C Hook

Serrated
loop

Sharp Loop
prongs

Blunt
prongs

Figure 19-12 Structural features of instruments include (A) ratchets, box-locks, pins, and ring handle; (B) serrations;
(C) teeth; and (D) prongs, hooks, and loops. (Courtesy of Miltex, Inc.)
538 UNIT 6 Advanced Techniques and Procedures

Lister Finger bandage scissors with #11 often referred to as a “stab blade” because
of its sharp point (Figure 19-19A). Handles vary in
size, but the most popular are the sturdy #3 and #3L
(long) and the more delicate #7 (Figure 19-19B).

Hemostats, Forceps, Clamps, and Needle Holders.

Grasping and clamping instruments are the largest
of the instrument categories. They are used for many
different tasks. Included in this category are the
towel clamps or clips, needle holders, and forceps.
Many forceps have locking mechanisms called ratch-
ets. Forceps may have ring handles or use a squeeze
concept like a tweezer. Forceps number in the hun-
A B
dreds, but most offices need only a select few. Like
the word scissors, the word forceps is always plural.
Figure 19-13 Bandage scissors (A) Lister bandage Hemostatic forceps, or hemostats, are used to grasp
scissors, small; (B) Knowles finger bandage scissors, and clamp blood vessels. Their name means literally
straight. (Courtesy of Miltex, Inc.) to “stop blood.” Because blood vessels are slippery,
hemostatic forceps have serrations for grasping and
either curved or straight (Figure 19-16). Suture scis- ratchets for locking tightly. Mosquito hemostatic for-
sors, also called stitch or stitch removal scissors, have ceps have fine tips, with serrations along the entire
a distinctively notched blade to facilitate the inser- length of the tips. The Kelly hemostats have serra-
tion of one tip under a suture (Figure 19-17). All of tions only along partial length of the tips. The Kelly
these scissors must be sterilized before use. hemostatic forceps are sturdier, and some hemo-
The scalpel is the knife used to cut the skin. static forceps have teeth. All types may be straight or
The scalpel is actually a blade secured to a handle curved (Figure 19-20).
that, when combined, becomes a surgical knife or Allis tissue forceps are of a similar design to
scalpel. Disposable one-piece units with a protective hemostatic forceps but have unique angular jaws
retractable blade are available (Figure 19-18). The with teeth. Another type of grasping instrument are
most common blade sizes are #10, #11, and #15, thumb forceps, sometimes referred to as “pick-ups.”

Straight Curved

Sharp/sharp Sharp/blunt Blunt/blunt Sharp/sharp Sharp/blunt Blunt/blunt

Figure 19-14 Standard operating scissors. (Courtesy of Miltex, Inc.)

 CHAPTER 19 Assisting with Office/Ambulatory Surgery 539

Figure 19-18 Disposable scalpels with a protective

retractable blade help prevent sharps injuries.
(Photo reprinted Courtesy of Becton Dickinson.)
Straight Curved

Figure 19-15 Mayo dissecting scissors. (Courtesy of

Miltex, Inc.)

Small

Figure 19-19A Surgical blades: #10, #11, #12, #15.

(Courtesy of Miltex, Inc.)

Straight Curved

Figure 19-16 Iris scissors. (Courtesy of Miltex, Inc.)

Suture removal
scissors B

Figure 19-17 Suture or stitch removal scissors. Figure 19-19B Scalpel handles: #3, #7, #3L. (Courtesy
(Courtesy of Miltex, Inc.) of Miltex, Inc.)
540 UNIT 6 Advanced Techniques and Procedures

Mosquito hemostat forceps Kelly hemostat forceps

A Standard Delicate B

Toothed hemostatic forceps

C Straight Curved

Figure 19-20 Hemostatic forceps include (A) mosquito hemostat forceps; (B) Kelly hemostat forceps; and
(C) toothed hemostatic forceps. (Courtesy of Miltex, Inc.)

Thumb forceps do not have ring handles or ratch- duckbill ear alligator-type forceps, and the Hart-
ets but are more like the common tweezers. Thumb man nasal dressing forceps have ring handles but
forceps with teeth are called tissue forceps because also are bent for ease in ear and nose procedures.
of their ability to grasp tissue. Dressing forceps Figure 19-21 shows examples of each.
(plain) do not have teeth and are useful for dress- Splinter forceps do not have teeth and are
ing wounds and applying sterile skin closure strips. used for pulling splinters. Many splinter forceps
Dressing forceps are also used to insert sterile gauze such as the plain splinter forceps and the Walter
packing strips into wounds to facilitate drainage. are of the thumb-handled style, but the physician’s
The Adson, a special type of thumb forceps, is easily splinter forceps have ring handles and the Virtus
differentiated by the shape. Adsons may have teeth have a spring-type handle (Figure 19-22).
or be plain and have a finer tip. Sponge forceps such as the Foerster may have
The Lucae bayonet-type forceps, used in rings on the tips and, as the name implies, are
nose and ear procedures, have a thumb handle used to hold surgical gauze sponges. Sponge for-
and are curved to allow the simultaneous use of ceps may have long handles, making them useful
other instruments and scopes and to facilitate for gynecologic procedures, and are called uterine
viewing. In contrast, the Hartman ear forceps, sponge forceps. Many medical offices use uterine
 CHAPTER 19 Assisting with Office/Ambulatory Surgery 541

Lucae
Allis tissue forceps ear forceps
Dressing or thumb Tissue forceps
forceps plain with teeth Adson Adson
dressing forceps tissue forceps

Bayonet shape

Hartman Duckbill Hartman nasal dressing forceps

ear forceps ear forceps

Alligator type

Serrated jaws

Delicate Regular

Figure 19-21 Tissue and dressing forceps. (Courtesy of Miltex, Inc.)

sponge forceps as transfer forceps (Figure 19-23). jaw. Often called needle drivers, they are designed
(see Basic Surgery Setup later in this chapter). to hold the needle firmly without crushing it while
Towel clamps are used to attach surgical suturing. Most needle holders have a vertical ditch
field drapes to each other and in some situations, in the center of the jaw to disperse tension and
such as when bisecting the vas deferens in a vasec- help prevent slipping of the needle. Needle hold-
tomy, to clamp onto dissected tissue. In the case ers such as the Crile-Wood may have a special groove
of a vasectomy, the Backhaus towel clamp is used in which to place the needle during suturing. Some
to hold the dissected section of the vas deferens needle holders come in various sizes and some are
(Figure 19-24). equipped with a cutting edge that eliminates the
Needle holders are ratcheted instruments sim- need for a separate scissors to cut the suture mate-
ilar to hemostats but with a wider and more stout rial (Figure 19-25).
542 UNIT 6 Advanced Techniques and Procedures

Plain Walter Physician’s Virtus

splinter forceps splinter forceps splinter forceps splinter forceps

Figure 19-22 Splinter forceps. (Courtesy of Miltex, Inc.)

Foerster uterine sponge forceps Bozeman uterine sponge forceps

Straight Curved Straight Curved

Figure 19-23 Sponge forceps. (Courtesy of Miltex, Inc.)

Specula, Scopes, Probes, Retractors, and Dilators. canal and eardrum, has a small light aimed into
The category of dilators and probes includes spec- an ear speculum. Ear specula may be disposable
ula that are designed for enlarging and exploring or reuseable. If reused, they are sanitized, chemi-
body orifices (Figure 19-26). The vaginal speculum cally disinfected, rinsed, and dried between uses.
is available in various lengths and widths and may Proctoscopes, anoscopes (Figure 19-27), and rigid
be made of metal or disposable plastic. The most sigmoidoscopes are used for viewing the rectum,
common instrument for enlarging the nostril is the anus, and the sigmoid portion on the large intes-
Vienna nasal speculum. This instrument is used with tine and have guides called obturators to ease
the Lucae bayonet forceps to perform procedures insertion. The light source for the proctoscopes
within the nose. and anoscopes is usually a separate lamp. Although
Scopes are lighted instruments used for the light sources cannot be sterilized, they can be
viewing. The otoscope, used to visualize the ear meticulously disinfected. The speculum portion
 CHAPTER 19 Assisting with Office/Ambulatory Surgery 543

Jones Backhaus foreign body. Sounds may be calibrated in centi-

towel clamp towel clamp
meters or inches (Figure 19-28).
Retractors used in office/ambulatory surgery
are often called skin hooks and are used to hook
onto and retract the edges of a wound to facilitate
better viewing. Skin hooks are fine-tipped and deli-
cate. As with all of the finer surgical instruments,
special care should be taken to avoid damaging
the delicate tips (Figure 19-29).
Dilators are double-ended metal rods with
smooth, rounded tips, ranging in calibrated sizes
from small to large. Dilators are inserted into nar-
rowed or constricted ducts and tubes for the pur-
Figure 19-24 Towel clamps. (Courtesy of Miltex, Inc.) pose of gradually dilating or enlarging the opening.
Hegar uterine dilators are used to dilate the cervix
to gain access to the inside of the uterus. Esopha-
that is inserted into the rectum may be made of geal dilators are used to relieve strictures, or nar-
disposable plastic or metal. Both the metal specu- rowing, of the esophagus. Urethral dilators are used
lum and its obturator can sanitized and sterilized to relieve strictures of the urethra (Figure 19-30).
in the autoclave.
Another group of scopes are long, flexible,
and much more complex and use fiber-optic light
Care of Instruments
sources. Fiber-optic scopes are considered medi- Medical/surgical instruments require special care
cal equipment rather than surgical instruments. to prevent excessive wear and tear and unneces-
Although considered to be medical equipment, sary damage. Careful and frequent inspections will
these flexible scopes are inserted into body cavities determine when instruments need to be replaced or
and must be sanitized and sterilized between uses. repaired. Some basic rules and rationales include:
Probes are slender instruments used to probe
into a hidden area, body cavity, or wound. Sounds • Immediately after use, soiled instruments should
are long, slender probing instruments used to be soaked. This prevents blood and other body
determine the size and shape of the area being fluids from drying onto the working surfaces of the
probed or to detect the presence of an unseen instruments.

Crile-Wood needle holder Needle holder with cutting edge Mayo-Hegar needle holder

Figure 19-25 Towel clamps. (Courtesy of Miltex, Inc.)

 544 UNIT 6 Advanced Techniques and Procedures

Vienna
nasal
speculum

Graves
vaginal
speculum

Figure 19-26 Specula and scopes are used to explore body openings by widening for better viewing. (Courtesy of Miltex, Inc.)

Hirschman anoscope

Hirschman proctoscope

Figure 19-27 Scopes and specula are used to expose body orifices by opening for better viewing. (Courtesy of Miltex, Inc.)

• Soak solutions should be about room temperature • Heavy-duty rubber gloves should be worn when
and contain a neutral pH detergent with a pro- cleaning instruments to lessen the likelihood of
tein/blood solvent. The proteins in the body fluids being stuck or cut with the sharp points and edges.
will not coagulate on the instruments in cool water • Goggles should be worn to protect eyes from
and the neutral pH detergent will help prevent splashes.
spotting and corrosion of the metals. Solvents will
help break up the blood and proteins in the body • Delicate instruments should be separated from
fluids. heavier instruments to prevent the delicate instru-
• Soak basins should be plastic to prevent damag- ments from being bent or otherwise damaged.
ing points and edges. If a metal soak basin is used, • Sharp instruments should be carefully separated
placing a towel on the bottom as padding will help from the other instruments and washed with
prevent damage to the instruments. extreme caution. The danger of being cut or
 CHAPTER 19 Assisting with Office/Ambulatory Surgery 545

Sims Volkman Miltex

uterine sound retractors skin hooks
(maleable)

Volkman
Rake Retractor
Figure 19-28 Uterine sound. (Courtesy of Miltex, Inc.) Hand Held

punctured is greater when cleaning sharp instru-

ments than at most other times, and the sharp
instruments are usually the most contaminated.
• A soft bristle brush should be used to scrub hinges,
ratchets, and serrations. The brush should be firm
enough to clean crevices thoroughly yet soft enough
Volkman
to prevent scratching instruments. Instruments with Rake Retractor
Self-retaining
multiple parts must be taken completely apart. Retractor
• Immediately after sanitization, instruments should
be thoroughly rinsed and dried to prevent spotting B
and water damage.
Figure 19-29 Various types of retractors (sharp and
• Carefully inspect all surfaces, edges, and points. blunt). (Courtesy of Miltex, Inc.)
Check for nicks, dulling, and warping. Test blades
for sharpness. Be sure the instrument is not bent or
pitted. Handles should also be checked for nicks that Instruments are placed into an ultrasonic container
may snag and tear surgical gloves, thus disrupting with special cleaning solution. Sound waves vibrate
the protective barrier and causing contamination. to loosen debris and contaminants. Place instru-
ments with ratchets or hinges into the cleaner in
• Damaged or malfunctioning instruments should
an open position. The articles, when finished, are
be repaired or replaced.
rinsed well, dried, and wrapped for sterilization.
The process of sanitizing contaminated instruments
Ultrasonic Cleaning. Surgical instruments can be by ultrasound is safe for all instruments including
cleaned (sanitized) by using an ultrasonic cleaner. delicate instruments. It is preferred for endoscopes.
546 UNIT 6 Advanced Techniques and Procedures

Hegar dilators

Pratt uterine dilators

B
Figure 19-30 Two types of dilators. Hegar dilators arranged smallest to largest. Pratt dilators arranged largest to
smallest. (Courtesy of Miltex, Inc.)

Follow manufacturer’s directions for use and care Chemical “Cold” Sterilization. This type of steriliza-
of the ultrasonic cleaner (see Chapter 10). tion is sometimes referred to as “cold” sterilization,
Sanitization by use of an ultrasonic cleaner which indicates that heat-sensitive items such as fiber-
eliminates cleaning instruments by hand, optic endoscopes and delicate cutting instruments
thereby reducing the risk for contamination can be immersed in a chemical solution. The chemi-
to the medical assistant. cals used are reliable and capable of destroying bac-
teria and their spores and, used in strict accordance
• Instruments should be processed in the cleaner for with the manufacturer’s instructions regarding
the full recommended cycle time, usually 5 to 10 length of immersion time, can ensure sterility.
minutes. Procedure 19-2 gives steps for chemical
• Place instruments in open position into the ultra- (“cold”) sterilization.
sonic cleaner. Make sure that sharps blades and
points do not touch other instruments.
• All instruments must be fully submerged.
SUPPLIES AND EQUIPMENT
• Do not place dissimilar metals (stainless, copper, The supplies necessary for office/ambulatory sur-
chrome plated) in the same cleaning cycle. gery are often disposable and should be replen-
• Change solution frequently—at least as often as ished as needed. Most medical/surgical supply
the manufacturer recommends. companies have catalogs and Web sites available for
ordering, and many companies have sales represen-
• Rinse instruments thoroughly with distilled water tatives who make regular stops or are available by
after ultrasonic cleaning to remove ultrasonic telephone or email to assist in the ordering process.
cleaning solution. Sales representatives are familiar with the products
 CHAPTER 19 Assisting with Office/Ambulatory Surgery 547

marked by their company and are extremely useful

as a resource. Samples of new products are often
available for trial, and optional choices are always
offered. Medical/surgical supply companies fre-
quently offer special prices for larger quantity pur-
chases. If a medical/surgical supply item is being
used frequently and storage space is available, buy-
ing in larger quantities might be more cost-effective.
If a product currently being used is not meeting
expectations, requesting optional trial products is
usually the first step toward finding a better prod-
uct. Following are some of the more commonly used
supplies associated with office/ambulatory surgery.
A

Drapes
Drapes are used during surgery to create a sterile
field over and around the surgical site. They are
applied using sterile technique after the skin prep-
aration.
Drapes are of different sizes and materials. A
fenestrated drape is often used because it has an
opening at the site of the surgery to be performed.

Sponges and Wicks

B
Surgical sponges are prepackaged squares of folded
gauze used in surgery. In the provider’s office, Figure 19-31 (A) Box of sterile gauze sponges.
sponges are most often referred to by their size. These are also referred to as 4 × 4s or, in surgery,
A gauze square measuring 4 inches by 4 inches is as surgical sponges. (B) Peel-apart sterile open
called a 4 × 4 (Figure 19-31). The other most com- package of 4 × 4 gauze.
mon sizes are 3 × 3 and 2 × 2. The gauge sponges are
packaged in individual peel-apart packages of two
or may be purchased in nonsterile bulk packages of
two hundred. The individual packages are conve-
nient, sterile, and useful for most purposes but cost
more per sponge than the nonsterile bulk pack-
ages. For larger surgical needs, the medical assistant
may wrap several bulk sponges together and auto-
clave them for later use. Most sponges are simply
folded gauze, but some have cotton or rayon pads
embedded in them to increase absorption ability
and to create a softer texture. The medical assistant
and the provider using the sponge probably have
a preference among the different types and uses.
Gauze sponges are used in wound cleansing, in skin Figure 19-32 Various sizes of iodoform® gauze:
preparation, as absorbable sponges during surgery, ¼ inch, ½ inch, 1 inch, 2 inches.
as dressings and coverings, and for padding. The
ambulatory care setting may prefer to have different
sizes and types in stock to meet different needs. most recognizable trade name is Iodoform®. The
Sterile surgical wicks or wound packing strips Iodoform® is sterile and packaged in multiple-use
are used when an infected wound must remain bottles. Extreme care should be taken to prevent
open for drainage. The sterile wicking material is contamination during removal of individual lengths.
made of narrow strips of gauze packaged in long The bottle is opened using sterile technique, sterile
lengths in opaque glass bottles (Figure 19-32). The dressing forceps are inserted into the bottle, the strip
548 UNIT 6 Advanced Techniques and Procedures

is cut to the desired length using sterile scissors, and ing out the wound. Sterile tongue blades are handy
the lid is applied without compromising the sterility to apply the Silvadene® cream to large area burns.
of the remaining wicking material in the bottle. Silvadene should be thoroughly removed and reap-
plied fresh with each dressing change. Silvadene is
available by prescription only and comes in small
Solutions/Creams/Ointments tubes for individual use as well as larger jars for
Many different soaps and solutions are available multiple use. Silvadene is fairly expensive. When
and effective as skin cleansers, preoperative scrubs, using a multiple-use jar, as with any multiple-use
paints, soaks, and antiseptics. Betadine® (povidone- container, extreme caution must be taken to avoid
iodine) is a well-known antiseptic and is available contamination of the product.
as a surgical soap called a “scrub” and as a non-
soap solution for preoperative skin preparation/
paint. Betadine® comes in multiple-use bottles,
Dressings and Bandages
in single use, and in individually packaged swabs. Dressings are the sterile material applied directly
Hibeclens® is another effective antiseptic that onto the surface of a wound or surgical site. Ban-
does not have the staining tendencies of iodine. dages are the supportive material applied over the
Medical/surgical supply companies have names top of dressings and are not sterile. A dressing, being
and samples of other products. Consideration sterile, should be handled with care to avoid con-
should be made to cost, effectiveness, ease of use, tamination of the wound. Often a sterile nonstick
shelf life, and personal preferences. Isopropyl alco- pad or topical medication is applied to the wound to
hol, a 70% alcohol solution, is of limited medical/ prevent the dressing from adhering to the wound.
surgical use, although because of its rapid volatility Dressings are usually made of gauze and need
rate and its ability to dissolve oils, it is still preferred to completely cover the wound. Dressings must be
for skin preparation before injections and veni- adequately absorbent for any wound drainage.
puncture. Isopropyl alcohol is available in bottles Bandages are used to keep dressings in place,
for use with cotton/rayon balls or in convenient to provide padding and protection, and to immobi-
individually packaged pledgets. Isopropyl alcohol lize. Bandaging may consist of rolled gauze wrapped
can be irritating and is not effective as a preopera- around the wound area with an additional sturdier
tive skin preparation. Hydrogen peroxide is a non- wrap applied overall. An elastic bandage may pro-
caustic mildly effective skin antiseptic. It bubbles on vide additional support, and a triangular bandage,
contact with mucous membranes and other moist sling, brace, or splint provides even more. A unique
skin surfaces, dissolving blood and proteins, and type of bandage is the tubular gauze bandage.
has a mechanical cleansing action. Hydrogen per- Tubular gauze bandages are used to cover append-
oxide is ineffective as a skin prep before surgery ages such as fingers, arms, toes, and legs and come
but is useful for cleaning after surgery. Many pro- in various sizes according to the size of the body
viders do not recommend using hydrogen per- part being covered. Chapter 9 provides information
oxide on surgical wounds because of its abrasive about wounds and bandages. Figure 19-33 illus-
“scrubbing action,” which can cause increased trates various bandage-wrapping techniques.
scarring and irritations. Do not use or recommend
the use of hydrogen peroxide without consulting
your provider.
Anesthetics
Antibacterial creams and ointments are some- The word anesthesia means the loss of feeling or
times applied topically on wounds to aid healing. sensation. An anesthetic is any mechanism that
Antibacterial creams are usually white, water-based, causes this loss of feeling. The application of
and nongreasy. Antibacterial ointments are usually extreme cold can be an anesthetic because it causes
clear and oil based. If a wound requires thorough numbness to nerve endings and thus the loss of
cleaning between dressing changes, an antibacterial feeling. Anesthetics may be inhaled, topically
cream is preferred because of the ease of removal. applied or sprayed, or injected directly into a vein
Some examples of sterile solutions are sterile (intravenously), the spinal column (intrathecally),
saline, sterile distilled water, and Betadine® solution. or locally (subcutaneously) into the tissues at the
Silvadene® is the brand name of a sterile site of the surgical procedure.
cream used on burns and other abrasion wounds.
It is an excellent antibacterial cream but must be Injectable Anesthetics. Most anesthetics used
applied 1 ⁄8 - to 1 ⁄4 -inch thick to help ensure that the in office/ambulatory surgery are administered
dressing does not absorb all the cream, thus dry- locally through injection into the subcutaneous
 CHAPTER 19 Assisting with Office/Ambulatory Surgery 549

A B C D

Figure 19-33 Bandage-wrapping techniques illustrating the circular, spiral, and figure-eight turns. (A) Circular
turns are wrapped around a body part several times to anchor a bandage or to supply support. (B) Spiral turns begin
with one or two circular turns, then proceed up the body part, with each turn covering two-thirds the width of the
previous turn. (C) Reverse spiral turns begin with a circular turn. Then the bandage is reversed or twisted once each
turn to accommodate a limb that gets larger as the bandaging progresses. (D) Figure-eight turns crisscross in the
shape of a figure eight and are used on a joint that requires movement.

tissues. The nerves exposed to the anesthetic Anesthetics with epinephrine should not be
become temporarily unable to conduct sensations used on fingers, toes, noses, or earlobes because
and feelings to the brain, thereby causing a lack of of their vasoconstriction. Patients with circulatory
pain sensation in the area during the surgery. All complications may have even more restrictions/
synthetic local anesthetics have names that end in cautions on the use of epinephrine. This is one
-caine. Some of the most common are Xylocaine reason why it is important to bring the vial into the
(lidocaine), Novacaine (procaine), Marcaine, and procedure room with the patient.
Carbocaine. Local anesthetics are available in single-
dose vials or ampules of 10 mL, but most medical Drawing Techniques. If the provider plans to
offices prefer the cost-effectiveness of multiple-dose inject the anesthesia before applying sterile
vials containing 30 to 50 mL. Local anesthetics are gloves, either the medical assistant or the provider
also available in varying strengths such as 0.5%, may draw up the medication. The filled syringe is
1%, and 2%. then placed on the side, rather than directly on
Injectable anesthetics may contain an additive the sterile field. This allows the provider to anes-
called epinephrine. It has a red label. Epinephrine thetize the patient before beginning the sterile
causes vasoconstriction and is used when reduced procedure. After the anesthesia has taken effect,
blood flow to the area is desired. The medical the provider performs a surgical hand cleansing,
assistant is often delegated the responsibility of applies sterile gloves, and begins the surgery.
filling the syringe with the prescribed amount and When the provider applies sterile gloves
strength of the ordered anesthesia or may assist the before injecting the anesthesia, the sterile syringe
provider in drawing up the medication. Be sure to may be placed directly on the sterile field either
identify the drug and dose for the provider. empty or filled. One person wearing sterile gloves
Anytime the medical assistant draws up a med- may handle the syringe and draw up the medi-
ication for the provider or pours a solution into a cation while another person not wearing sterile
prep basin on the sterile tray, the original vial or gloves holds the vial. This method requires that
bottle that the medication or solution comes from the syringe and needle either be applied directly
should be brought into the procedure room with to the sterile tray or be handed directly to a
the surgical/procedure tray and other supplies. “sterile” person. The medical assistant may draw
The provider should check the vial and container up the anesthesia under sterile process when
before using the medication or solution to be sure the sterile tray is set up. As stated previously, if
it is exactly what has been ordered. A good practice the tray contains a filled syringe, the vial from
is to set the vial or container on the counter within which it was drawn should accompany the
plain view for the provider to see. Often the pro- tray into the procedure room and be set on the
vider verbally confirms what medication is in the counter for the provider to verify. Chapter 24
syringe or what solution is in the prep basin before discusses the specific techniques for drawing up
using them. medications.
550 UNIT 6 Advanced Techniques and Procedures

Topical Spray Anesthetics. Not all anesthesia is PATIENT CARE

injectable. Topical (applied to the surface) anes-
thetics are available in liquid and spray form. AND PREPARATION
The most common topical anesthetic used in the Patient Preparation
medical office is ethyl chloride spray. Ethyl chlo-
ride freezes the skin to allow for simple piercing and Education
or lancing. The anesthetic action usually only For the patient who will undergo a planned surgi-
lasts for a few seconds; therefore, the procedure cal procedure, there is time for patient prepara-
must be performed quickly. It is highly flamma- tion. Patients may need to modify their diet, adjust
ble. One example for the use of ethyl chloride medication, acquire special supplies, adjust their
spray is to briefly numb an area before an injec- personal home and work situations, obtain prior
tion. A lesion that is infected is extremely pain- approval from their insurance, and prepare for the
ful to inject with a local anesthetic; however, by postoperative period. For the patient undergoing an
using ethyl chloride spray before the injection, unplanned procedure, such as a laceration repair,
the patient is able to remain still. Ethyl chloride there is less time for preparation. In either case, the
spray may also be used before installing intrave- medical assistant needs to follow an established pro-
nous lines. tocol about wound care, patient education, patient
Table 19-2 summarizes supplies and equip- health consideration, and consent. In the case of
ment commonly used in minor surgery. an accidental wound, the medical assistant needs to

Table 19-2 Supplies and Equipment Commonly Used in Minor Surgery

Item Use/Description

A mechanism used to cause the loss of feeling. May be inhaled, topically applied, sprayed, or
Anesthetics injected directly into a vein, the spinal column, or locally into the tissues at the site of the surgical
procedure.

Nonsterile supportive materials applied over dressings to keep the dressing in place. May be rolled
Bandages
gauze, elastic bandage, or tubular gauze bandage.

Creams and Antibacterial. May be used topically on wounds to promote healing. Creams are water-based; oint-
ointments ments are oil-based.

Used to create a sterile field over and around the operation site. They are made in various sizes
Drapes
and different materials. A fenestrated drape is commonly used in surgery.

Sterile material applied directly onto surface of a wound or surgical site. Usually made of gauze. Must
Dressings
be adequately absorbent and completely cover the wound.

Used as skin cleansers, preoperative scrubs, paints, soaks, and antiseptics. Most common are
Betadine®, an antiseptic often used in soap form as a scrub; Hibeclens®, an effective antiseptic with-
Solutions out iodine’s staining properties; isopropyl alcohol, a 70% alcohol solution favored for skin preparation
before injections and venipuncture but not effective as a preoperative skin preparation; and hydro-
gen peroxide, a mildly effective abrasive skin antiseptic.

Used in wound cleansing, skin preparation, as absorbable sponges during surgery, as dressings and
Sponges coverings, and for padding. Also called 4 × 4s. Typically made of folded gauze, though some have
cotton or rayon pads embedded in them to increase absorption.

Used when an infected wound needs to remain open for drainage. Wicking material is made of
Wicks narrow strips of gauze packaged in long lengths in opaque glass bottles, which should be opened
using sterile technique (see Figure 19-32).
 CHAPTER 19 Assisting with Office/Ambulatory Surgery 551

determine the cause of the wound and the date of go above a certain amount. It is always a good idea
the last tetanus injection. Chapters 10 and 23 pro- to discuss financial arrangements with all patients
vide specific information about tetanus and immu- before an elective procedure or surgery. In some
nization schedules. The medical assistant must also offices, the bookkeeper or office manager comes
check to determine whether the patient has aller- into the examination room, sits down with the
gies or sensitivities of any kind, particularly to medi- patient, and goes over the forms and financial
cation and medically related substances. arrangements. Any questions the patient has about
Diet modifications include abstaining from the surgery should be answered completely by
eating and drinking for several hours before the the provider, and an assessment should be made
surgical procedure, as well as restricting the types that the patient understands the answers. Even in
and amounts of certain foods or liquids consumed the best of circumstances, results cannot be guar-
before and directly after the procedure. When anteed. Most of the difficult situations between
patients are aware of special dietary needs after providers’ practices and patients come from mis-
surgery, they can shop early and be prepared. An understandings about unexpected outcomes. If
example of a medication treatment includes pre- patients are informed completely, even unplanned
scribing an antibiotic to be taken as a precaution results are better tolerated.
against acquiring an infection after surgery or
adjusting anticoagulant medications to prevent
excessive bleeding during surgery. Each clinic,
Medical Assisting Considerations
provider, procedure, and patient has individual The general health and condition of the patient
requirements and preferences. The patient might before surgery is important when planning the recov-
be required to obtain special supplies for the ery. A frail, weak man living alone may need home
convalescent period. For instance, immediately health care after even a simple surgical procedure.
after a vasectomy a scrotal support is usually rec- Some people may not be able to follow standard pre-
ommended. Crutches or special foot coverings operative or postoperative instructions. The recovery
might be necessary after foot or leg surgery. Spe- may depend on the availability of supplies beyond
cific wound dressing and bandages might need to what the patient can financially afford. If difficult
be purchased before the surgery in anticipation circumstances can be identified before the surgery,
of the postoperative need. Having another person arrangements can be made with home health care
accompany the patient to the clinic for the surgery services, community assistance services, or friends
is required for the safe return home. Knowing the and family. This can help avoid complications. Prior
planned period for recovery allows the patient to medical history should also be established and ques-
make the necessary arrangements for work, child tions should be asked regarding allergies and sen-
care, and other personal situations. sitivities to medications and medical substances. A
patient who has received a general anesthetic must
be watched carefully for cardiopulmonary problems
Informed Consent that can arise from the anesthesia. An elderly, weak
Before a surgical procedure, the patient’s patient who received a general anesthetic (inhala-
written consent must be obtained. For many tion or intravenous) may experience hypotension or
medical and all surgical procedures, a written, hypoxia. A pulse oximeter is applied to the patient to
informed consent form must be signed. An informed monitor blood oxygen percentage (see Chapter 18).
consent is a document that may be created specifi- Vital signs are watched carefully.
cally for a particular procedure or that may be an
established document available for duplication. An
informed consent document informs the patient of
Postoperative Instructions
the medical or surgical procedure to be performed, Postoperative instructions should be written and
describes the actual procedure in lay terms, cites clearly understood by the patient. If the patient
alternative treatments, and lists the possible undesir- has a caregiver at home, the postoperative instruc-
able outcome and risks involved in the procedure. tions should be clearly understood by the caregiver
Chapter 7 provides additional information about as well. The telephone number of the clinic and an
informed consent and a model consent farm. after-hours number should be written on the post-
The cost of the procedure is important infor- operative instructions and brought to the attention
mation. Some insurances companies and Medicare of the patient and caregiver. It is good practice to
require patients to sign an Advanced Beneficiary plan to call patients within the first postoperative
Notice (ABN) if their out-of-pocket expenses will day to check on their condition.
552 UNIT 6 Advanced Techniques and Procedures

Wounds, Wound Care, Ecchymosis, contusion, and hematoma are

examples of closed wounds. They are caused by a
and the Healing Process blunt trauma that damages underlying tissues but
There are many different types of wounds based on leaves the skin intact (Figure 19-35).
the type of injury incurred. Wounds may be classi- Wounds are classified as superficial if the
fied as open or closed, accidental or intentional injury does not extend deeper than the subcuta-
(surgical). neous tissues. Deep wounds extend beyond the
Lacerations, incisions, avulsions, and punctures subcutaneous layer. The size, location, and depth
are all examples of open wounds (Figure 19-34). of the wound are important descriptors both for

Epidermis Epidermis

Dermis Dermis

Subcutaneous Subcutaneous

A Laceration B Incision

Epidermis Epidermis

Dermis Dermis

Subcutaneous Subcutaneous

C Avulsion D Puncture

Figure 19-34 Open wounds. (A) Lacerations are accidental tearing of the body tissue usually made by sharp
objects. The torn flesh may be smooth or jagged and often is difficult to clean and suture properly. There may be
extensive bleeding. A cut from a sharp knife is an example of a laceration. (B) Incisions are intentional cuts typically
made with a scalpel for surgical procedures. (C) Avulsions are accidental tearing away of a part or structures of the
skin. (D) Punctures are holes or wounds made by a pointed object and can be either accidental or intentional. Punc-
ture wounds have little bleeding because the point of entry is small. These wounds typically are not much larger than
the instrument entering the skin. A puncture wound may also be the result of stepping on a nail.
 CHAPTER 19 Assisting with Office/Ambulatory Surgery 553

tion, and type of wound, but also the causative

factor.
Inflammation is the body’s natural reaction
to trauma. Inflammation is also a normal process
of wound healing. Occasionally, inflamed tissue
will become infected if the trauma is caused by a
pathogen. Although a certain degree of inflam-
mation is expected, prevention of infection is a
Figure 19-35 Closed wounds include contusions, primary goal (see Chapter 10).
ecchymoses, and hematomas. This photograph shows Chapter 9 describes wounds and emergency
an ecchymosis. care of wounds.
The best treatment of infection is prevention.
Instructing the patient about proper wound care
is extremely important. Encourage the patient to
keep the wound clean and dry. In certain circum-
stances, the provider may prescribe a warm soak
Patient Education solution or the application of a topical antibacte-
rial medication. If the wound becomes infected
The basic signs of inflammation are redness,
and a suppurant is present, the provider may order
heat, swelling, pain, and loss of function.
a wound irrigation (see Procedure 19-10). Wound
Any one or more of these may be present in
irrigation removes the accumulation of purulent
varying intensities during an inflammatory
exudate that impairs and delays healing. After the
process. Most wounds will have a mild
irrigation, a dry sterile dressing is applied (see
inflammation described as slightly red or
Procedure 19-9). Protecting the wound from fur-
pink, mild warmth, slightly tender to the
ther trauma and contamination will also aid in the
touch, and mildly swollen. The symptoms are
healing process. Opinions will differ on whether a
caused by increased blood supply to the
wound is best left open to the air or covered with
traumatized area and the infiltration of white
a dressing. Most health care providers will agree
blood cells in reaction to the trauma. Patients
that covering a wound is preferred whenever con-
should be taught to watch for an increase
tamination is likely (Procedure 19-9).
in the intensity of redness, pain, swelling, and
heat or any drainage, fever, or lymph gland
swelling, which can indicate an infection
from invading pathogens. Patients should be
BASIC SURGERY SETUP
given instructions as to what actions to take
Preparing for surgery includes assembling sup-
if these symptoms of infection are noticed.
plies and equipment, setting up the surgery tray,
The instructions should include a name and
getting the patient and room ready, and prepar-
telephone numbers to call during the day or
ing to assist during surgery. The specific instru-
night. The medical assistant should reassure
ments, supplies, and equipment needed for each
the patient not to hesitate to contact the
surgery should be listed on individual surgery
center or physician if infection is suspected.
cards. These cards may be 3 × 5 or 5 × 7 cards
stored in a card file or full sheets of procedures
compiled in a manual or notebook, or procedures
can be found on the computer. Each provider will
have individual instrument sets for each
the medical record and for proper insurance E HR surgical procedure performed. Informa-
reimbursement. A typical description of a patient tion on the surgery card or computer
wound that is an intermediate laceration might should include provider glove size, standing pre-
be, “patient sustained a deep 3.5-cm laceration to operative and postoperative instructions, type of
the anterior surface of the right knee caused by skin preparation, and any additional informa-
a fall onto a rock.” A puncture wound might be tion specific to the provider’s needs or to the sur-
described as, “patient presents with a 2-cm deep gical procedure. The card file, whether manual
puncture wound on the plantar surface of the left or computerized, should be updated whenever
foot obtained from stepping on a rusty nail.” Both chanages are made and may be the responsibility
statements describe not only the size, depth, loca- of the medical assistant.
554 UNIT 6 Advanced Techniques and Procedures

Basic Rules and Concepts list only and does not include all the specific details
necessary for each surgery. Refer to the individual
for Setup of Surgical Trays surgical procedures that follow for more details.
In addition to basic sterile principles, the guide-
lines in Table 19-3 will help ensure the sterile field
remains sterile. PREPARATION FOR SURGERY
The following procedures are used in preparation
SURGERY PROCESS for minor surgery:
• Applying Sterile Gloves (Procedure 19-1)
For ease in understanding the individual tasks
involved in office surgery, Table 19-4 provides generic • Setting Up and Covering a Sterile Field (Proce-
steps for setting up the surgical tray, preparing the dure 19-5)
room, preparing the patient, assisting with the sur- • Opening Sterile Packages of Instruments and
gery, and the terminal care process of the room and Supplies and Applying Them to a Sterile Field
equipment. Table 19-4 is intended as a quick check- (Procedure 19-6)

Table 19-3 Guidelines for Sterile Tray Setups

Set up the sterile surgery tray just before the surgery to minimize the chance of accidental contamination.

Immediately after the tray is set up, cover it with a sterile drape.

Once the tray is prepared and covered, move it directly into the surgery area rather than leaving it in a common area.

Inform the patient and others in the surgery room that the tray is sterile and should not be touched. Patients are often
curious about instruments and may attempt to look under the cover if not cautioned against it.

If the medical assistant is interrupted while preparing the tray and it becomes necessary to leave the tray unattended,
cover the tray and move it out of traffic paths to prevent it from being bumped.

Table 19-4 Preparations for Office/Ambulatory Surgery

Tray Setup
1. Wash hands. 8. Apply sterile gloves or use sterile transfer forceps.
2. Reference surgery card, manual, or computer. 9. Arrange instruments and supplies in an organized and
logical manner.
3. Gather equipment and supplies.
10. Medication may be drawn up with assistance (optional)
4. Sanitize and disinfect Mayo instrument tray.
(Figure 19-36).
5. Wash hands.
11. Recheck tray for accuracy and completeness.
6. Set up sterile field.
12. Remove gloves.
7. Place sterile instruments and supplies on the ster-
13. Cover and transport tray.
ile field.
14. Add sterile solution (skin antiseptic) to tray if required.

Room Preparation
In preparing a room for a surgical procedure, all equipment should be clean and in good working order. Be certain to
have spare parts such as light bulbs and filters readily available. Turn on equipment before the procedure to make sure all
is working properly.

1. Check room equipment (light, stool, equip- 3. Arrange accessory supplies on the side counter in a
ment, examination table, waste receptacle). logical order (pathology specimen bottle containing
2. Check room supplies (tissue, extra gloves, preservative, laboratory requisition, sterile glove package,
and so on) dressings/bandages, postoperative medications, and
instructions).
(continues)
 CHAPTER 19 Assisting with Office/Ambulatory Surgery 555

Table 19-4 (continued)

Patient Preparation
1. Wash hands. 6. Review postoperative instructions.
2. Greet patient and ensure identity. 7. Check for signed informed consent form and financial
forms.
3. Escort the patient to the procedure room and
offer restroom facilities. 8. Have the patient remove appropriate clothing and posi-
tion the patient on the examination table. Offer a drape,
4. Discuss the patient’s compliance to preopera-
gown, pillow, and blanket for comfort.
tive instructions.
9. Prepare the skin for the surgical procedure (see
5. Explain the procedure again and address any
Procedure 19-11).
questions.

Assisting with the Surgery

1. Remove the sterile cover from the surgical tray 5. Assist with drawing up local anesthetic or other medica-
while the provider applies sterile gloves. tion as needed.
2. Assist the provider with stool and lamp adjust- 6. Apply clean gloves for protection or sterile gloves to assist.
ment as needed. 7. Surgery begins.
3. If the medical assistant did not perform the skin 8. The medical assistant either assists with sterile procedure
preparation, assist the provider as needed dur- or supports the patient as needed.
ing skin preparation and draping. The equipment 9. After surgery, assist with or perform dressing of wound.
and supplies for skin preparation are separate
10. Clean patient.
from the surgery tray and equipment (see Proce-
dure 19-11). 11. Dispose of biohazardous waste materials.
4. Adjust the instrument tray and equipment 12. Remove contaminated gloves; wash hands.
around the provider. 13. Assist the patient after surgery.

Assisting the Patient after Surgery

1. Check patient vital signs. 4. Review written postoperative instructions with patient
and caregiver. Dressing should be kept clean and dry.
2. Remain with patient to ensure patient safety.
Patient should report any signs of infection.
Allow patient to rest if necessary.
5. Clarify any medication orders with patient and caregiver.
3. Assist patient off examination table and assist
with clothing as necessary 6. If not previously arranged, schedule follow-up appointment.
7. Document postoperative instructions in patient chart or
electronic medical record.

Terminal Care of the Room and Equipment

1. Apply barrier gloves, gown, and goggles 6. Sanitize Mayo instrument tray and all surfaces (examina-
(if appropriate). tion table, stool, counter, lamp, machinery, and equipment).
2. Dispose of drapes, table cover, pillowcase, and 7. Dispose of contaminated barrier gloves and apply pro-
so on. Use biohazardous waste receptacle when- tective gloves.
ever appropriate. 8. Disinfect all surfaces (examination table, stool, counter,
3. Transfer contaminated surgical tray to cleanup lamp, machinery, and equipment).
area. 9. Allow to air dry.
4. Using forceps, isolate sharps from surgical tray and 10. Sanitize, dry, wrap, and sterilize instruments.
dispose of them into designated sharps container. 11. It is the medical assistant’s responsibility to make certain
5. Place instruments into a soak solution. there are enough of each instrument and surgical set.

NOTE: During most surgical procedures, if tissue is excised, it is placed in a biopsy specimen jar containing formalin (a preservative) and sent to the
pathology laboratory with an appropriately completed requisition (Figure 19-37).

• Pouring a Sterile Solution into a Cup on a Sterile Critical Thinking

Field (Procedure 19-7)
• Preparation of Patient Skin before Surgery (Proce- Dr. Woo asks you to assist him in repairing the
dure 19-11) laceration on Jaime Carrera’s hand. Though
you are unsure, you think you may have
Setting up surgical trays for specific sur- noticed a tiny hole in the palm of your left
geries is addressed in the procedures of this glove. What is your next step?
chapter.
556 UNIT 6 Advanced Techniques and Procedures

Using Dry Sterile Transfer Forceps

Occasionally after a sterile tray has been set up and
sterile gloves removed, an additional item needs to
be applied to or removed from the tray. The use of
dry sterile transfer forceps allows sterile items to be
applied or sterile items on the tray to be rearranged
without the application of another pair of sterile
gloves (Figure 19-38). The practice of using wet
sterile transfer forceps is no longer recommended.
Instead, when the use of sterile transfer forceps is
needed, dry sterile transfer forceps are unwrapped,
Figure 19-36 Hold the anesthetic solution in a used only once, and then reprocessed for steriliza-
convenient position so that the provider can fill the tion and subsequent use.
syringe without contaminating the needle.

Figure 19-37 The provider places biopsy tissue into

specimen jar. The specimen will be sent to the pathology
laboratory for examination.

Critical Thinking
B
You are setting up a sterile surgical tray and
Figure 19-38 (A) If sterile gloves have been removed,
have already applied your sterile gloves
use dry sterile transfer forceps to apply or rearrange
before you realize you forgot to place the
sterile items on the Mayo stand. (B) Instruments and
suture package on the tray. You have several
supplies can be moved around using dry sterile transfer
options. What are they, and what are the
forceps if necessary.
advantages and disadvantages of each?
 CHAPTER 19 Assisting with Office/Ambulatory Surgery 557

Procedure 19-1
Applying Sterile Gloves
STANDARD PRECAUTIONS: 6. With the index finger and thumb of the non-
dominant hand, grasp the inner cuffed edge of
the opposite glove. The glove should be picked
straight up off the package surface without drag-
ging or dangling the fingers over any nonster-
PURPOSE: ile area. RATIONALE: Picking up the glove by
Because hands cannot be sterilized, everyone per-
grasping the inner cuff prevents the outer glove
forming sterile procedures must wear sterile gloves.
from becoming contaminated. Strict adherence
This procedure provides direction on how to apply
must be made to the sterile principles listed in
sterile gloves without compromising sterility.
the beginning of this chapter.
EQUIPMENT/SUPPLIES: 7. With the palm up on the dominant hand, care-
Packaged pair of sterile gloves of appropriate size fully slide the hand into the glove. Do not allow
Flat, clean, dry surface the outside of the glove to come in contact with
anything and stand away from sterile package.
PROCEDURE STEPS: Always hold the hands above the waist and away
1. Remove rings and watch. Wash hands using sur- from the body with palms up (Figure 19-39C).
gical asepsis. RATIONALE: Rings and watches RATIONALE: Keeping the palm up allows the
can snag and tear gloves, and therefore interfere glove to remain sterile in the palm area if it rolls
with barrier protection. slightly on the back of the hand.
2. Inspect glove package for tears or stains (Figure 8. With the gloved hand, pick up the glove for
19-39A). RATIONALE: Tears and stains indicate the remaining hand by slipping four fingers
that the gloves are no longer considered sterile under the outside of the cuff. Lift the second
and must be disposed of or used for a nonsterile glove up, keeping it held above the waist and
purpose. away from the body. Do not allow the glove to
3. Place the glove package on a clean, dry, flat sur- drag across the package or touch nonsterile sur-
face above waist level. RATIONALE: Using a con- faces (Figure 19-39D). RATIONALE: The out-
taminated surface could compromise the sterility side of the second glove is sterile and may only
of the sterile package. be touched by another sterile surface.
4. Peel open the package taking care not to touch 9. With the palm up, slip the second hand into the
the sterile inner surface of the package. Do not glove. Do not allow the outside of the gloves to
allow the gloves to slide beyond the sterile inner touch nonsterile skin and be especially mindful
border (Figure 19-39B). RATIONALE: Care must of the thumb (Figure 19-39E).
be taken to maintain the sterility of the gloves. 10. Adjust the gloves on the hands as needed, but
5. The gloves should be opened with the cuffs toward avoid touching the wrist area. Keep gloved hands
you, the palms up, and the thumbs pointing out- above the waist and away from the body. Do not
ward. If the gloves are not positioned properly, touch nonsterile surfaces with the gloved hands
turn the package around, being careful not to (Figure 19-39F and G).
reach over the sterile area or touch the inner sur-
face or the gloves. RATIONALE: Sterile gloves are
packaged in this position for ease in application.

continues
558 UNIT 6 Advanced Techniques and Procedures

Procedure 19-1 (continued)

A B C

D E F

Figure 19-39 (A) Sterile gloves often are packaged with right and left clearly marked. (B) Using only the
fingertips, reach in from each side and grasp the edges of the paper. Pull out and lay paper flat without touch-
ing any area except the very edges. (C) With the nondominant hand, grasp the inner cuffed edge of the opposite
glove. Pick the glove up and step away from the sterile area, keeping your hands above your waist and away from
your body. With palm up on the dominant hand, slide the hand into the glove. (D) Step back to the sterile area.
With the gloved hand, pick up the glove for the remaining hand by slipping four fingers under the outside of
the cuff. (E) With palm up, slip the second hand into the glove. Keep the gloved thumb in a “hitchhiking” posi-
tion. (F) Keeping hands above the waist and away from the body, pull on the second glove. (G) Adjust gloves if
desired, staying away from the wrist area. Keep gloved hands above the waist and away from the body.
 CHAPTER 19 Assisting with Office/Ambulatory Surgery 559

Procedure 19-2
Chemical “Cold” Sterilization of Endoscopes
STANDARD PRECAUTIONS: and germicidal properties; choose the solution
that best fits the needs of the ambulatory care set-
ting. Keep the solution in its original container to
reduce chances of accidental poisoning.
PURPOSE: 3. Put on gloves. RATIONALE: Heavy-duty gloves
To sterilize heat-sensitive items such as fiber-optic help protect from sharp items puncturing the
endoscopes and delicate cutting instruments using skin. Chemicals are harsh on the skin.
appropriate chemical solution. 4. Prepare solution as indicated by manufacturer;
place the date of opening or preparation on the
EQUIPMENT/SUPPLIES: container and initial it. RATIONALE: Follow-
Chemical solution Timer ing manufacturer’s instructions ensures sterility.
such as Cidex Sterile water Note the expiration date of solution.
Steris System® Gloves (heavy-duty)
5. Pour solution into a container with an airtight lid;
(percacetic acid) Sterile towel
avoid splashing (Figure 19-40A and B). RATIO-
Airtight container Plastic-lined sterile drapes
NALE: Chemicals should not be left exposed
PROCEDURE STEPS: to open air to prevent evaporation and loss of
1. Sanitize items that require chemical sterilization. potency, exposure to environmetal contaminants,
Rinse and dry. RATIONALE: Recall that debris accidental inhalation, or poisoning. Splashing
and body proteins must be scrubbed from items may cause skin or mucous membrane contact and
before sterilization. Ultrasonic cleaning is best. result in injury.
2. Read manufacturer’s instructions on original 6. Place sanitized and dried items into the solution,
container of chemical sterilization solution. completely submerging item(s). Avoid splash-
RATIONALE: Each brand of chemical steriliza- ing when placing items into airtight container.
tion solution has specific preparation instructions RATIONALE: Total immersion is necessary for
sterility to be achieved.

A B

Figure 19-40 (A) Medical assistant pours chemical sterilization solution into a large soaking container. Note
the use of heavy-duty gloves and face shield. (B) Medical assistant adds the endoscope to the chemical steriliza-
tion solution in the container.

continues
560 UNIT 6 Advanced Techniques and Procedures

Procedure 19-2 (continued)

7. Close lid of container, label with name of solu- the container interrupts the sterilization process
tion, date, and time required per manufacturer, and limits the effectiveness of the chemical.
and initial (Figure 19-40C). RATIONALE: Expo- 9. Following the recommended processing time,
sure time is the required time indicated by the lift item(s) from the container using sterile
manufacturer to achieve sterility. Initialing work gloved hands or sterile transfer forceps. Care-
ensures accountability and responsibility. fully hold item above sterile basin and pour
8. Do not open lid or add additional items during copious amounts of sterile water over it and
the processing time. RATIONALE: Adding to through it (endoscopes) until adequately rinsed
of chemical solution. RATIONALE: Item(s)
once processed are sterile and must be handled
appropriately. Using sterile gloved hands or ster-
ile transfer forceps ensures sterile-to-sterile con-
tact and no contamination of the item(s). Sterile
water is poured through the inner channels of
endoscopes to rinse chemicals from the inside,
as well as the outside.
10. Hold item(s) upright for a few seconds to allow
excess sterile water to drip off.
11. Place the sterile item on a sterile towel (which
has been placed on a sterile field) and dry it with
another sterile towel. The towel used for drying
is removed from sterile field. The use of sterile
drapes that have a plastic polylined barrier layer
between two layers of paper is recommended for
the sterile field. RATIONALE: Plastic-lined ster-
C ile drapes create a barrier to prevent moisture
from drawing contaminants from the metal sur-
Figure 19-40 (continued) (C) Medical assistant
gical instrument tray or countertop up into the
secures lid tightly, then records the date, time of
sterile area.
day, and her initials.

Procedure 19-3
Preparing Instruments for Sterilization in Autoclave
PURPOSE: Autoclave wrapping tape
To properly wrap sanitized instruments for sterilization Permanent marker or felt-tip pen (Figure 19-41A)
in an autoclave.
PROCEDURE STEPS:
EQUIPMENT/SUPPLIES: 1. Prepare a clean, dry, flat surface of adequate size
Sanitized instruments to lay the wrapping material. RATIONALE: A
Wrapping material (muslin or disposable wrapping clean area reduces risk for contamination. Ade-
paper) quate space is required for proper wrapping.
Sterilization indicator 2. Select two wraps of adequate size in which to
2 × 2 gauze or cotton balls (if instrument has hinges) wrap instruments.

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 CHAPTER 19 Assisting with Office/Ambulatory Surgery 561

Procedure 19-3 (continued)

3. Place one square of wrapping material at an 7. Fold one side edge toward the center line;
angle in front of you on the dry surface with one fan-fold back to side, and crease (Figure 19-41D).
corner pointed directly toward you. 8. Repeat step 7 for the other side edge (Figure
4. Place the sanitized instrument or articles to be 19-41E).
placed in the autoclave just below the center 9. Fold the package up from the bottom (Figure
of the wrap. Open instruments with hinges as 19-41F).
wide as possible and place a 2 × 2 gauze or cot-
ton ball in the opening (Figure 19-41B). RATIO- 10. Fold the top edge down and over the entire pack-
NALE: Instruments with hinged parts that are age (Figure 19-41G). RATIONALE: Final edge
not spread open before autoclaving may not be should wrap entire package for assurance of ade-
properly sterilized. quate coverage and protection once contents
are sterilized. If wrap does not cover adequately,
5. Place one sterilization indicator with the instru- unwrap and start over with larger wrapping
ment. RATIONALE: Sterilization indicators inside material.
packages ascertain sterilization of each individual
package. Indicators change colors when the 11. To “wrap twice,” place this package into the cen-
required temperature has been reached, docu- ter of a second wrap (Figure 19-41H). Repeat
menting the effectiveness of the sterilization. Steps 7 through 10. RATIONALE: Double wrap-
NOTE: Quality control for autoclave operation ping allows more control of multiple instruments
can be evaluated with sterilization indicators. when setting up a surgical tray.

6. Bring the corner of the wrap closest to you up 12. Tape with autoclave tape across the point left
and over the article toward the center. Bring exposed. RATIONALE: Autoclave tape indicates
the tip of the same corner back toward you whether the package has been through the auto-
until it reaches the folded edge, creating a clave; it is not a form of sterilization indicator or
fan-fold effect. Smooth the edges of the fold. quality control.
The article should remain completely covered 13. Label the tape with the name of the instrument
(Figure 19-41C). or type of pack (i.e., laceration repair pack), date
of sterilization, and your initials (Figure 19-41I).

Autoclave
wrapping tape

Felt tip pen

Sanitized
hemostat
Cotton ball

Permeable
autoclave
wrapping
Sterilization material
A indicator B C

Figure 19-41 (A) Equipment needed to wrap surgical instruments or equipment for sterilization in an
autoclave. (B) Place a cotton ball between the hinge joints of instruments to keep them open. Do not ratchet
instruments closed. Pad the tips of sharp instruments. Put a sterilization indicator in with the instruments to be
wrapped. (C) The wrapping paper is folded toward center. A small corner is turned back on itself.

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562 UNIT 6 Advanced Techniques and Procedures

Procedure 19-3 (continued)

RATIONALE: Proper instrument labeling is re- 14. Place wrapped instruments in autoclave.
quired to identify wrapped sterilized instruments. RATIONALE: If wrapped instruments are not
Instruments wrapped and sterilized in paper or to be immediately autoclaved, do NOT date
cloth wrappers are considered sterile for four the package. Leave the package on a clean, dry
weeks from the date of sterilization. Initialing pack- surface and date the package just before auto-
ages ensures accountability and responsibility. claving.

D E F

G H I

Figure 19-41 (continued) (D) Fold one side toward center, leaving small corner turned back on itself. (E) Fold
other side toward center, leaving small corner turned back on itself. (F) The package is folded up from the bottom
and secured. (G) Fold corner back on itself. (H) Wrap first package in another wrap. Double wrapping allows
more control of multiple instruments when setting up a surgical tray. (I) Wrapped package is secured with heat-
sensitive autoclave tape and labeled with the date, contents, and medical assistant’s initials.
 CHAPTER 19 Assisting with Office/Ambulatory Surgery 563

Procedure 19-4
Sterilization of Instruments (Autoclave)
PURPOSE: 3. Load packages into autoclave tray; allow room for
To rid items of all forms of microbial (microorgan- steam to circulate (Figure 19-42). RATIONALE:
isms) life for use in invasive procedures. Steam circulates in predictable patterns in an
autoclave. When packages are loaded too closely
EQUIPMENT/SUPPLIES: or improperly, proper sterilization will not occur
Steam sterilizer (autoclave) in individual packages.
Autoclave manufacturers instructions
a. Load jars of dressings or cups on their sides,
Wrapped sanitized instrument package(s) with
with tops ajar or loosely in place. RATIO-
sterilization indicators placed inside package (or
NALE: Steam is trapped within a jar when it
unwrapped item if removed with sterile transfer
is right side up; containers and goods will not
forceps)
be sterilized if loaded sitting up vertically.
PROCEDURE STEPS: b. Load unwrapped instruments flat with handles
1. Check water level in the autoclave reservoir opened, exposing all surfaces. RATIONALE:
and add distilled water to fill line if necessary. Steam must reach all surfaces.
RATIONALE: Not enough or too much water 4. Close autoclave door and seal. RATIONALE: Pres-
will impair the efficiency of the autoclave. Dis- sure cannot be achieved without a proper seal.
tilled water will not leave deposits (tap water
leaves deposits) inside the autoclave. Deposits 5. Turn on autoclave. When the temperature dial
can impair the efficiency of the autoclave. indicates 270°F (118°C) and 15 pounds of pres-
sure has been achieved inside the autoclave,
2. Depending on your autoclave, turn the knob to begin necessary exposure time by setting timer.
“fill” line and allow water into the chamber until RATIONALE: Proper heat, pressure levels, and
it reaches the “fill” line. Turn the knob to the exposure time must be achieved to kill all micro-
next position. This stops water from continuing organisms within the autoclave. Careful note
to enter the chamber. should be given to setting exposure time only
after the proper temperature and pressure set-
tings have been achieved.
Required
Item Exposure Time
Wrapped instrument 30 minutes
packages or trays
Unwrapped items 15 minutes
Unwrapped items 20 minutes
covered with cloth

6. After completion of the autoclave cycle, vent

exhaust steam pressure from the autoclave
by following the manufacturer’s instructions.
RATIONALE: Following the manufacturer’s
instructions carefully will ensure safe and proper
use of the autoclave.
7. Open the door approximately 1 inch after the
pressure gauge indicates zero (0) pressure and
Figure 19-42 Load packages into the autoclave so the temperature gauge indicates a decrease to
that steam is able to reach all surfaces, allowing for at least 212°F. RATIONALE: You will not be able
proper sterilization. to open the door until the pressure is zero. Be

continues
564 UNIT 6 Advanced Techniques and Procedures

Procedure 19-4 (continued)

aware that steam burns can occur when opening they are to be used immediately in a sterile pro-
the door. Use caution. cedure. Place onto sterile surface.
8. Allow the contents to completely dry, approxi- 11. Perform quality control on a regular basis, based
mately 30 to 45 minutes; do NOT touch contents on usage. RATIONALE: Quality control and
until completely dry. RATIONALE: If packages maintenance of an autoclave is critical to assur-
are still wet or damp, microorganisms can enter ance of proper operation. Accountability and
a wrapped package, rendering it contaminated. responsibility to monitor quality control should
Liquids travel along paper or cloth by capillary be the responsibility of the medical assistant(s)
action and will be contaminated by microorgan- most often responsible for sterilization.
isms on countertops or from hands. a. Monitor sterilization indicators with each use
9. Remove wrapped contents with dry, clean of sterilized instruments.
hands and store in clean, dry closed cupboard b. Weekly perform quality control by document-
or drawer. RATIONALE: Sterilized wrapped ing sterilization indicator outcome on a log;
packages can be held with clean hands, because date and initial quality-control log entries.
only the interior contents require maintenance
of sterility. If the outer wrapper is required to 12. Clean and service the autoclave regularly accord-
remain sterile, remove with sterile transfer for- ing to the manufacturer’s guidelines. When ster-
ceps and place on a sterile field or in sterile stor- ilization is not being achieved, take equipment
age areas. out of service and contact a service agency for
repair. RATIONALE: It is the responsibility of
10. Remove unwrapped contents with sterile trans- the medical assistant to take out of service any
fer forceps; resanitize and resterilize the transfer equipment that is not operating properly as a
forceps following use. RATIONALE: Sterile trans- component of risk management.
fer forceps must have been sterilized immediately
prior to or along with the unwrapped item if 13. Keep a log of cleaning, services, and quality-
control measures performed.

Procedure 19-5
Setting Up and Covering a Sterile Field
STANDARD PRECAUTIONS: NOTE: A variety of materials, both disposable and
nondisposable, can be used to set up and cover a ster-
ile field. All material has certain criteria to be safe for
use and all have advantages and disadvantages. For
example, woven textile fabrics are moisture retardant
PURPOSE: and are effective barriers to microbial penetration.
Disposable sterile field drapes or sterile towels are Polylined paper disposable drapes are excellent barri-
used to isolate a sterile area or field, as well as to ers against microorganisms and moisture. Many times
cover the sterile field for use in surgery and sterile medical office preference is determined by financial
procedures. They are available in convenient peel- consideration.
apart packages, fanfolded for ease of use, and often
EQUIPMENT/SUPPLIES:
are two-tone in color to aid in differentiating one
Disposable sterile polylined field drapes (two) or
side from the other. Cloth drapes may be packaged
reuseable sterile towels (two) (muslin or linen with
separately and sterilized fanfolded.
water-repellent finish)

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 CHAPTER 19 Assisting with Office/Ambulatory Surgery 565

Procedure 19-5 (continued)

Mayo instrument tray/stand positioned above the 5. With thumb and forefinger of one hand, carefully
waist with stem to the right grasp the top cut corner without touching the rest
Sterile transfer forceps (if needed) of the drape or towel and pick the drape or towel
up high enough to ensure that as it unfolds it does
PROCEDURE STEPS: not drag across a nonsterile area (Figure 19-43B).
1. Wash hands. RATIONALE: The drape or towel will naturally
2. Sanitize and disinfect a Mayo instrument tray. unfold as it is lifted, so care must be taken to ensure
Adjust tray to above waist level and have the stem that it is lifted quickly and allowed to unfold with-
to the right. out touching a nonsterile surface.
3. Select an appropriate disposable sterile field 6. Holding the drape or towel above waist level and
drape and place the drape package on a clean, away from the body, grasp the opposing corner
dry, flat surface. so that both corners along the long edge of the
4. Open the package exposing the fanfolded drape are being held (Figure 19-43C).
drape. Ensure that the cut corners of the drape 7. Keeping the drape or towel above waist level and
are toward you; turn the package if necessary away from the body, reach over the Mayo tray
(Figure 19-43A). RATIONALE: Sterile field with the drape or towel. Take care that the lower
drapes are fanfolded and positioned within the edge of the drape or towel does not drag across
package to facilitate ease of use. the tray (Figure 19-43D). RATIONALE: Sterile

A B

C D

Figure 19-43 (A) Open the sterile drape package onto a flat, dry surface 90 degrees perpendicular to the Mayo
tray. Grasp the corner of the sterile drape. (B) Pull the drape straight up, allowing it to unfold. Do not shake it out.
(C) Carefully grasp another corner of the drape and apply the drape to the Mayo tray by pulling it toward you. Do not
reach over the field; do not allow the “top” surface to touch anything. (D) Continue laying the drape as a sterile field.

continues
566 UNIT 6 Advanced Techniques and Procedures

Procedure 19-5 (continued)

principles state that sterile items should be kept 10. To cover the sterile field with a second sterile
above the waist and not touch other objects. drape or towel, follow Steps 4 through 7; then
8. Gently pull the drape or towel toward you as it is instead of pulling the drape or towel toward
laid onto the tray. If adjustment is needed to cen- you (as described in Step 8), which would
ter the drape or towel, do not touch the center necessitate reaching over the sterile field, apply
of the drape or towel, or reach over the sterile the covering drape or towel by holding it up in
field. Walk around or reach underneath the tray front of the field. Adjust the lower edge so it
to move it or make adjustments. RATIONALE: is even with the lower edge of the field drape
The corners/edges that hang over the tray are or towel (see Figure 19-44H). With a forward
no longer considered sterile. motion, carefully lay the cover over the sterile
field (see Figure 19-44I). RATIONALE: Reach-
9. After setting the instruments and supplies on the ing over the sterile field would contaminate
tray, it must be covered. the tray.

Procedure 19-6
Opening Sterile Packages of Instruments and Supplies
and Applying Them to a Sterile Field
STANDARD PRECAUTIONS: PROCEDURE STEPS:
1. Assemble supplies.
2. Wash hands and set up sterile field (see Proce-
dure 19-5).
NOTE: Sterile instruments and supplies are pack-
aged in a manner that allows them to be opened and 3. Position package of surgical instruments on
accessed without compromising sterility. Refer to palm of nondominant hand with outer envelope
other sections of this chapter for the specific steps of flap on top. (Figure 19-44A). RATIONALE: This
wrapping techniques, sterile gloving, and setting up will facilitate opening the pack while protecting
sterile fields. The “wrapping twice” method of double its sterile contents.
wrapping was used in preparing the surgical packs 4. Grasping the taped end of the top flap, open the
for this procedure. Prepackaged items such as gauze first flap away from you. Do not touch the inside
squares should be in peel-apart packs. of the flap (Figure 19-44B).
PURPOSE: 5. Grasping just the folded back tips of the side
To open sterile packages of surgical instruments and flaps, pull the right-sided flap to the right. Then
supplies and place them onto a sterile field using ster- pull the left-sided flap to the left, taking care
ile technique. not to reach over the package (Figure 19-44C).
RATIONALE: Pulling the tips of the flaps toward
EQUIPMENT/SUPPLIES: each side allows the inner portion of the pack-
Mayo instrument tray draped with sterile field age to be exposed without contamination.
Sterile gloves 6. Pull the last flap toward you by grasping the
Wrapped-twice sterile surgical instruments folded-back tip taking care not to touch the
Prepackaged sterile surgical supplies inner contents of the package (Figure 19-44D).

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 CHAPTER 19 Assisting with Office/Ambulatory Surgery 567

Procedure 19-6 (continued)

RATIONALE: Pulling the last tip toward you 8. Open peel-apart packages using sterile technique
allows you to avoid reaching over the inner con- by grasping both edges of the flaps and pulling
tents of the package. them apart in a rolling down motion, keeping
7. Gather all of the loose edges together to obtain both hands together. The sterile item should be
a snug covering over your nondominant hand. exposed gradually between the two peel-apart
Close your covered hand over the inner package edges (Figure 19-44F). The sterile inner contents
and carefully apply the inner package to the ster- may then be offered to the sterile-gloved provider
ile field (Figure 19-44E). RATIONALE: Gather- or applied to the sterile field using a flipping
ing the loose edges prevents them from being motion, or dropped as shown in Figure 19-44G,
dragged across the sterile field. taking care not to contaminate either the pack-
age contents or the field.

A B C

D E F

Figure 19-44 (A) To open a twice-wrapped pack, grasp the taped end of the top flap and open the first
flap away from you. You should have the Mayo tray at or above waist height. Stand back from the sterile field.
(B) Allow the pack to unroll on your hand. Do not touch the inside of the flap. Notice the medical assistant’s
thumb is under the flap, where she can securely grasp the inner pack. (C) Grasp just the folded back tips of
the side flaps. First pull the right-sided tip to the right, then, reaching around or under, pull the left-sided tip
to the left. Do not reach over the package. (D) Gather the loose edges together to form a snug covering over
your nondominant hand. Securely grasping the wrapped inner pack, step toward your sterile field, and invert
your hand. (E) Release (drop) the inner pack onto the center of the sterile field. Step back. (F) Open peel-
apart packages using sterile technique, exposing sterile items slowly and gradually. Continue to peel back the
sides of the package while securely holding onto the tip of the instrument.

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568 UNIT 6 Advanced Techniques and Procedures

Procedure 19-6 (continued)

9. Apply sterile gloves. Arrange instruments and 10. Apply the sterile field cover (Figure 19-44H, I,
supplies in an organized and logical manner and J) (see Procedure 19-5). RATIONALE: A
according to the provider’s preference. RATIO- sterile cover will need to be applied if the surgi-
NALE: Instruments should be arranged in the cal tray will not be used immediately, needs to
order of use. All handles should be pointed be moved, or if the medical assistant leaves the
toward the user. Instruments should be sepa- tray unattended.
rated as much as possible within the space of
the field so entanglement of instruments is not a
problem.

G H

I J

Figure 19-44 (continued) (G) Hold the sides of the package over your hand, step toward the Mayo tray, and
apply the instrument, handle first, onto the sterile field. Apply other supplies as needed. Arrange instruments
and supplies according to provider’s preference using sterile gloves or sterile transfer forceps. (H) Apply the
sterile drape cover to the surgical tray in a similar manner as the field was set up, except apply drape away from
you. (I) Be sure the edges of the cover align with the edges of the field drape before letting go and applying the
cover. (J) Do not adjust cover after it has been laid.

Critical Thinking
You have removed a double-
wrapped instrument pack from the
autoclave and notice a small tear
in the outermost wrap. The inner-
most wrap appears to be intact.
What would your action be? Why?
 CHAPTER 19 Assisting with Office/Ambulatory Surgery 569

Procedure 19-7
Pouring a Sterile Solution into a Cup on a Sterile Field
STANDARD PRECAUTIONS: RATIONALE: This action will cleanse the lip of
the container.
NOTE: If the surgical tray is set up in a surgical area,
the solution can be poured before covering the surgi-
NOTE: Occasionally, sterile solutions need to be cal tray with a sterile drape or towel.
poured into a sterile cup that has been placed onto 6. Carefully pull back the upper right corner of the
the sterile tray. The solution is sterile, but the outside tray cover to expose the cup. Take care to only
of the container is not; therefore, special precautions touch the corner tip of the cover and not reach
need to be taken to pour the solution into the cup over the exposed field. RATIONALE: Touching
without contaminating the sterile field. The solution the underside of the cover or reaching over the
is always poured after the tray has been moved into exposed sterile field will contaminate the sterile
the surgical area to avoid spilling during transport. surgical tray.
7. Approaching from the corner of the tray and using
PURPOSE: the cleansed side of the lip of the container, pour
To pour a sterile solution into a cup on a sterile tray in the needed amount of solution into the sterile
a sterile manner. cup (Figure 19-45). Precaution should be taken to
avoid splashing, spilling, reaching over the field,
EQUIPMENT/SUPPLIES:
or touching any of the sterile surfaces. RATIO-
Covered sterile surgical tray with a sterile cup in upper
NALE: Splashing or spilling of the solution would
right corner
cause the sterile field drape to become wet, which
Container of sterile solution (as ordered)
may cause contaminants to “wick” from the metal
PROCEDURE STEPS: tray into the sterile field. Use of a polylined sterile
1. Wash hands. field drape will create a barrier to avoid wicking.
2. Transport the surgical tray into the surgical area 8. Replace the corner of the drape cover using sterile
before pouring the solution; or, the surgical tray technique or cover with a sterile drape or towel.
can be set up for immediate use in the surgical 9. Replace the cap of the solution container using
area. RATIONALE: The solution may tip and sterile technique.
spill during transport. 10. Read the label again.
3. Read the label of the solution container three
times and check the expiration date. RATIO-
NALE: To eliminate the possibility of pouring
the wrong solution or an outdated solution.
4. Remove the cap from the solution container,
taking care not to touch the inner surface of the
cap. Place the cap upside down on a nonsterile
surface to avoid touching the inner surface of
the cap with a nonsterile surface. When the cap
is held in the hand, hold it right side up. RATIO-
NALE: Touching the inside of the cap with either
your hand or a nonsterile surface will contami-
nate the inside of an otherwise sterile container.
5. Read the label again to ensure accuracy. Place Figure 19-45 Approaching from the corner of the
palm over the label to protect the label from Mayo stand, pour the needed amount of solution into
stains. Pour a small amount of the solution into a the sterile cup. Use the clean side of the container lip
bowl, cup, or sink that is outside the sterile field. for pouring.
570 UNIT 6 Advanced Techniques and Procedures

Procedure 19-8
Assisting with Office/Ambulatory Surgery
STANDARD PRECAUTIONS: 9. Cover the sterile field with a sterile towel if not
being used immediately.
10. Identify patient, explain the procedure, and pre-
pare the patient. Refer to patient preparation in
Table 19-4.
11. Prepare patient’s skin (see Procedure 19-11).
12. Remove the sterile cover from the sterile setup as
PURPOSE: the provider applies sterile gloves. Lift the towel
To maintain sterility during surgical procedures that by grasping the tips of the corners farthest away
require surgical excision. from you and lifting toward you. Do not allow
arms to pass over sterile field. RATIONALE:
EQUIPMENT/SUPPLIES: Avoids crossing over sterile field.
Mayo stand: Side table (unsterile
Needles and syringe for field): 13. Assist the provider as necessary, being certain to
anesthesia follow the principles of surgical asepsis.
Sterile gloves (in
Prep bowl/cup package) • The medical assistant holds the vial of
Gauze sponges Labeled biopsy con- anesthesia while the provider withdraws the
Scalpel and blade tainers with formalin appropriate dose.
Operating scissors Appropriate laboratory • The provider injects the local anesthetic,
Fenestrated drape requisition applies Betadine® or other antiseptic to the
Hemostats (curved and Anesthesia vial surgical site, applies sterile drapes, and begins
straight) Alcohol wipes the surgery.
Thumb dressing forceps Dressing, tape, • Adjust the instrument tray and equipment
Thumb tissue forceps bandages around the provider.
Needle holder Biohazard container
• Ensure a good light source.
Suture pack Betadine ® solution
• Comfort and support patient emotionally.
Transfer forceps
• Assist with the surgery as directed by the
PROCEDURE STEPS: provider (sterile gloves must be worn).
1. Check room and equipment for readiness and • Hand instruments to the provider and receive
cleanliness. used intruments from the provider and place
2. Wash hands. in a basin or container out of patient’s sight.
3. Set up side table of nonsterile items. RATIO- • If necessary, hold biopsy container to receive
NALE: Nonsterile items cannot be placed onto a specimen being excised. Do not contaminate
sterile field because they will contaminate it. the inside of the container. Hold the cover
4. Perform surgical asepsis hand cleansing. facing down. Tightly place cover on the
container. Assist with or apply sterile dressing
5. Set up sterile field on a sanitized and disinfected
to the operative site.
Mayo stand or on a clean, dry, flat surface (see
Procedure 19-5). 14. Assist patient as necessary. Refer to Assisting the
Patient after Surgery in Table 19-4.
6. Add sterile items (see Procedure 19-6).
15. The specimen container must be tightly cov-
7. Apply sterile gloves or use sterile transfer forceps.
ered; labeled with the patient’s name, date,
Arrange instruments according to use. Remove
type, and source of specimen; and sent to the
gloves and forceps from area.
laboratory accompanied by the appropriate
8. Wash hands. laboratory requisition.
(continues)
continues
 CHAPTER 19 Assisting with Office/Ambulatory Surgery 571

Procedure 19-8 (continued)

16. Wearing appropriate personal protective equip- 17. Wash hands.

ment (PPE), clean surgical or examination room. 18. Document in patient’s chart or electronic medi-
• Dispose of used gauze sponges in biohazard cal record that the specimen was sent to the
container and knife blades and other disposable laboratory.
sharps in puncture-proof sharps container.
• Rinse used surgical intruments; soak, sanitize, DOCUMENTATION
and sterilize for reuse (see Chapter 10). 8/12/20XX 2:30 PM Skin tag from left axilla excised by
• Remove gloves and other PPE and dispose of per
Dr. King. Biopsy specimen in its entiret y sent to laboratory.
Occupational Safety and Health Administration
J. Guerro, CMA (AAMA) ______________________
(OSHA) guidelines.

Procedure 19-9
Dressing Change
STANDARD PRECAUTIONS: Cotton-tipped applicators
Adhesive strips
Antibacterial ointment/cream as ordered
Tape
Sponge forceps
NOTE: After most surgical procedures have been com-
Bandage scissors
pleted, the wound is usually covered with a dry sterile
Waterproof waste bag
dressing (DSD) that may need to be removed periodi-
Biohazard waste container
cally so that the wound can be checked for healing or
for suture removal. Another dry sterile dressing may PROCEDURE STEPS:
then be applied. Burns require daily dressing changes. 1. Check provider’s order.
PURPOSE: 2. Wash hands.
To remove a wound dressing and apply a dry sterile 3. Prepare sterile field. Add gauze sponges, bowl
dressing. with solution, and forceps.

EQUIPMENT/SUPPLIES: 4. Position a waterproof bag away from sterile area.

Sterile field: 5. Pour Betadine® solution into sterile bowl or use
Several sterile gauze sponges and other dressing Betadine swab sticks.
material as needed or prepackaged sterile dress- 6. Identify the patient and explain the procedure.
ing kit
7. Reassure and comfort the patient as needed.
Sterile bowl with Betadine® solution or prepared
sterile Betadine® swab sticks 8. Don nonsterile gloves or use forceps.
Sterile dressing forceps 9. Loosen tape on dressing by pulling tape toward
Sponge forceps wound, or cut off bandage if necessary.
Side area (unsterile field): 10. Carefully remove bandage; place in biohazard
Nonsterile gloves waste container. Do not pass over sterile field.
Sterile gloves RATIONALE: Passing dirty (used) bandage or
Hydrogen peroxide dressing over sterile field contaminates it.
Container of sterile water

continues
572 UNIT 6 Advanced Techniques and Procedures

Procedure 19-9 (continued)

11. Remove dressing, taking care not to cause stress or sterile gloves, apply sterile gauze sponge(s) to
on the wound (Figure 19-46A). wound (Figure 19-46C).
a. If stuck to the wound, pour small amounts of 19. Remove gloves, dispose of in waterproof bag.
sterile water over dressing; allow to soak for Wash hands.
a short time. Remove dressing when loose
20. Secure dressing with roller bandage and adhe-
enough to remove without resistance. Note
sive tape (Figure 19-46D and E) or elastic ban-
type and amount of drainage if present.
dage.
12. Place used dressing in waterproof bag without
21. Dispose of waterproof bag in biohazard
touching inside or outside of bag. RATIONALE:
Dirty (used) dressing can contaminate outside container.
of bag. 22. Wash hands.
13. Assess wound and note any drainage or signs of 23. Document procedure in patient’s chart or
infection. Remove and discard gloves in water- electronic medical record, describing wound
proof bag. appearance (i.e., discharge, signs of infection,
14. Wash hands. healing, and so on).
15. Apply sterile gloves.
DOCUMENTATION
16. Clean the wound with antiseptic solution as 11/24/20XX 10:30 AM Dressing change to laceration left fore-
ordered (Figure 19-46B). Gauze may be held arm. Small amount (dime-size) of serosanguinous discharge
with forceps, or use swabs. noted. No signs of redness or swelling in incisional area. DSD
17. Dispose of used gauze in waterproof bag. applied. Says she “feels fine and that my arm hurts very little.”
18. Using sterile cotton-tipped applicators, apply J. Guerro, CMA (AAMA) _______________________
cream/ointment as ordered. Using sterile forceps

A B

C D E

Figure 19-46 To change a dressing: (A) Gently remove dressing. Do not cause stress on wound. (B) Clean
wound with Betadine® solution using sponge forceps. (C) Using dressing forceps, new sterile sponge forceps, a
hemostat, or sterile gloves, apply sterile gauze sponge(s) to wound. (D, E) Secure dressing with elastic bandage
and adhesive tape or roller bandage.
 CHAPTER 19 Assisting with Office/Ambulatory Surgery 573

Procedure 19-10
Wound Irrigation
STANDARD PRECAUTIONS: 5. Position the patient in such a way that directs the
flow of the solution into the wound. The basin
catches the flow from the wound.
6. Don nonsterile gloves, remove the dressing, and
dispose into waterproof waxed bag.
PURPOSE:
To irrigate a wound to remove the accumulation of 7. Note the wound’s appearance, color, amount of
exudate that impairs and delays healing. discharge, and odor to the discharge. RATIO-
NALE: Allows ongoing assessment of the wound.
EQUIPMENT/SUPPLIES: 8. Remove and discard gloves into biohazard con-
On Mayo tray: tainer.
Sterile gloves in package
9. Wash hands.
Sterile irrigation kit (irrigating syringe, basin, and
container for solution) 10. Maintaining sterile technique, open the sterile
Sterile dressing material in package irrigation tray and the dressings. Use the inner
Side area/unsterile field: kit wrapping as a sterile field.
Waterproof pad 11. Pour the irrigation solution into the sterile solu-
Sterile solution for irrigation (per provider’s order) tion bowl or container. (Should be at least room
Nonsterile gloves temperature.) RATIONALE: Room temperature
Waterproof waste bag solution is more comfortable for the patient.
PROCEDURE STEPS: 12. Don sterile gloves.
1. Check the provider’s order. Select the correct 13. Place the sterile basin against the edge of the
solution and appropriate solution strength. It wound. RATIONALE: The basin will collect the
should be at least body temperature. (Solutions irrigation solution.
kept in warming closet.) 14. Fill the irrigating syringe (or bulb syringe) with
2. Identify the patient and explain the procedure. the solution and carefully wash out the wound
3. Wash hands. with the flow of solution (Figure 19-47A and B).
4. Place the waterproof pad under the body part 15. Continue to fill the syringe and continue to wash
that will be irrigated. out the wound until the solution becomes clear
and there is no drainage noted.

A B

Figure 19-47 (A) Flush the wound gently. (B) Hold the syringe close to the wound, but do not
touch the wound with the syringe.

(continues)
continues
574 UNIT 6 Advanced Techniques and Procedures

Procedure 19-10 (continued)

16. Dry the wound edge with sterile gauze. DOCUMENTATION

17. Reassess the wound. 8/6/20XX 2:30 PM Dressing removed from abdominal
18. Apply a dry sterile dressing. wound. Wound red and filled with serosanguinous exudate.
Irrigated with 500 mL sterile normal saline (fluid returns
19. Remove gloves. Dispose in biohazard container. were clear). Wound slightly red and clean-appearing after
20. Wash hands. irrigation. Wound dried with sterile 4 3 4s. Dry sterile dress-
21. Document in patient’s chart or electronic medi- ing applied. Patient states, “I feel much better now that my
cal record. wound has been cleaned out. That only hurt a little.” Patient
says she does not want anything for pain. W. Slawson, CMA
(AAMA) _______________________________

Procedure 19-11
Preparation of Patient’s Skin before Surgery
STANDARD PRECAUTIONS: PURPOSE:
To remove as many microorganisms as possible from
patient’s skin immediately before surgery.

EQUIPMENT/SUPPLIES:
NOTE: The skin and hair contain many microorgan-
Absorbent pads
isms, and the patient’s skin must be prepared before
Drape
surgery to remove as many of the microorganisms as
Disposable prep kit (includes antiseptic solution,
possible. Wound infection results when microorgan-
several sponges, razor, and a container for water,
isms enter the body. The patient may be told to scrub
or self-contained skin prep unit)
the site of the surgery using antimicrobial soap on
Sterile water
the night before surgery. Because it is impossible to
Sterile bowl
sterilize the skin, the operative site and an area sur-
Sterile gloves for medical assistant and provider
rounding it are scrubbed, shaved (hair harbors micro-
(two pair)
organisms), washed, and painted with an antiseptic
If kit is unavailable, equipment needed is:
such as Betadine® solution. A skin prep self-contained
Sterile bowls (two)
unit is a sponge applicator with a cylinder of antiseptic
Antiseptic solution
solution inside. One brand is known as DuraPrep. It
Sterile gauze sponges
contains iodophor and isoprophyl alcohol. The medi-
Sterile razor
cal assistant can use the unit with nonsterile gloves.
Basin for soiled sponges
The unit is compressed, the seal to the inner cylinder
Sterile transfer forceps
is broken, and the sponge end becomes the applica-
tor. The mixture is thick and should be allowed to PROCEDURE STEPS:
dry and not be blotted. Because it contains alcohol, 1. Wash hands.
which can be a fire hazard, the site must be dry before
2. Assemble equipment.
draping. The chemical action decontaminates the
patient’s skin.

continues
 CHAPTER 19 Assisting with Office/Ambulatory Surgery 575

Procedure 19-11 (continued)

3. Identify patient. pattern. RATIONALE: Prevents accidental nicks.

4. Explain procedure, provide privacy, and drape Nicked skin can cause infection.
patient if appropriate. Before the patient is 14. When hair has been removed, scrub again in a
prepped and draped for the procedure, ask the circular fashion as in Step 11 for about two to
patient to state the location of the surgical site. five minutes.
Some facilities require that the appropriate site 15. Rinse shaved area with sterile water and dry with
be marked with an indelible ink pen to be cer- a sterile 4 × 4 gauze sponge.
tain the correct site is identified.
16. Remove and appropriately discard absorbent
5. Provide good light source. pad, 4 × 4 sponges, disposable prep kit, and
6. Position patient for comfort and exposure of gloves. RATIONALE: This removes used supplies
site. and equipment from prepped skin area and pre-
7. Wash hands. vents contamination.
8. Protect area under preparation site with 17. Wash hands.
absorbent pads. 18. Using sterile transfer forceps, remove a sterile
9. Open kit. towel to place under operative site. RATIONALE:
Placing a sterile towel under the operative area
10. Put on sterile gloves or use sterile transfer keeps site free from contamination.
forceps.
19. Cover with a sterile towel. Instruct patient not to
11. Apply antiseptic soap (Betadine®) with 4 × 4 touch the area.
sponges, beginning at operative site and mov-
ing outward in a circular motion from the center 20. Pour antiseptic solution (Betadine®) into the
to away from center of prepared area. RATIO- sterile bowl. The provider puts on sterile gloves
NALE: Work from cleaner to least clean areas to or uses sterile transfer forceps and, with a sterile
prevent contamination. 4 × 4 gauze sponge, paints the operative site with
the antiseptic solution. Let dry. The provider
12. Discard used sponges as necessary. covers the patient with fenestrated drape and
13. Using razor and holding skin taut, shave hair begins the surgical procedure.
away from operative site, following hair growth

Procedure 19-12
Suturing of Laceration or Incision Repair
STANDARD PRECAUTIONS: face, neck, or a bend of a body part; or extends deep
into underlying tissue. Suturing facilitates healing
by approximating the edges of the wound. Suturing
decreases scarring, helps decrease the likelihood of
infection, and promotes healing. The wound and the
surrounding area must be meticulously cleaned of any
dirt and debris. Many providers have standard orders
for wound cleaning before suture repair of either a
PURPOSE: laceration or incision-type wound such as a 10-minute
Suturing is recommended if a laceration or incision is soak in Hibeclens® solution and sterile water.
gaping; is bleeding uncontrollably; is located on the

continues
576 UNIT 6 Advanced Techniques and Procedures

Procedure 19-12 (continued)

EQUIPMENT/SUPPLIES: 9. Dress/bandage/splint wound following provider’s

Surgical tray: preference.
Syringe and needle for anesthetic 10. Remove gloves.
Hemostats (curved)
11. Wash hands.
Adson tissue forceps
Iris scissors (curved) 12. Check patient’s vital signs.
Suture material and needle 13. Explain wound care to the patient (and care-
Needle holder giver) and provide written instructions including
Gauze sponges symptoms of infection and after-hours phone
Side table (unsterile field): number.
Anesthetic as ordered by the provider 14. Assist the patient with any concerns or questions.
Dressings, bandages, and tape
Splint/brace/sling (optional) 15. Arrange for follow-up appointment and medica-
Sterile gloves in package tion as ordered.
16. Don personal protective equipment.
PROCEDURE STEPS:
17. Dispose of supplies per OSHA guidelines. Clean
1. Wash hands.
room, sanitize instruments, and sterilize for
2. Identify the patient and explain the procedure. reuse.
Check for signed consent forms.
18. Wash hands.
3. Reassure and comfort the patient as needed.
19. Document procedure in patient’s chart or elec-
4. Assess cause of wound and its severity. tronic medical record.
• Determine any known allergies and last
tetanus booster. DOCUMENTATION
• Identify any health concerns to avoid possible 11/17/20XX 10:15 AM Patient sustained a 2 3 1.5-cm
complications. laceration on right elbow. Wound soaked in Hibeclens® solu-
• Soak wound in an antiseptic solution as
tion and water for 10 minutes, and then dried. Dr. King
ordered by provider.
sutured the laceration after injecting xylocaine (1%) into
area around laceration site. Ten nonabsorbable Ethicon
• Clean and dry wound. sutures used to close wound. Dry sterile dressing applied
• Position patient comfortably, lying down. to wound. Given a prescription by Dr. King for Perodan,
5. Assist the provider as needed. 1 tab PO of 4-6h prn for pain, and Amoxicillin 500 mg
6. Support the patient as needed.
PO of 6 h. Postoperative instructions reviewed and she
appears to understand. Last tetanus 12 years ago. Tetanus
Give postoperative care: injection given I.M. right deltoid (0.5 cc). W. Slawson, CMA
7. Apply sterile gloves. (AAMA) _________________________________
8. Clean area around the wound and dry wound
with sterile 4 × 4s or sterile towels.
 CHAPTER 19 Assisting with Office/Ambulatory Surgery 577

Procedure 19-13
Sebaceous Cyst Excision
STANDARD PRECAUTIONS: Fenestrated drape (a drape with an opening) in
package
Antiseptic solution as ordered
Gloves (sterile and nonsterile)
Personal protective equipment (PPE)
Anesthesia as directed
Dressing, bandages, tape
Biohazard waste container
Safety razor (optional)
NOTE: A sebaceous cyst is a benign retention cyst,
Alcohol pledgets
sometimes called a “wen.” Sebaceous cysts are caused
Sterile culture tube (if needed)
by an oil duct becoming “plugged,” which causes the
Biohazard specimen transport bag
sebum (oil) to accumulate in the gland. Eventually
the oil gland becomes distended. Sebaceous cysts that PROCEDURE STEPS:
become inflamed or infected need to be removed. 1. Wash hands.
The patient may also elect to have a noninflamed
2. Identify the patient and explain the procedure.
sebaceous cyst removed if it is unsightly or located in a
bothersome area. Incision and drainage of sebaceous 3. Reassure and comfort the patient as needed.
cysts is usually not the treatment of choice because 4. Determine any known allergies and last tetanus
they tend to recur if the entire cyst is not completely booster.
excised. Ideally, the entire cyst sac is removed intact, 5. Check for signed consent form.
but occasionally the sac ruptures during removal and
large amounts of malodorous biohazardous sebum 6. Identify any health concerns to avoid possible
can be expelled. In preparation for this occurrence, complications.
extra gauze sponges, gloves, and goggles should be 7. Position the patient comfortably, lying down.
available. 8. Perform the skin preparation as directed (see
Procedure 19-11).
PURPOSE:
To remove an inflamed or infected sebaceous cyst. 9. Wear appropriate PPE including goggles if cyst
To remove a sebaceous cyst that is not inflamed or is infected. RATIONALE: Purulent material may
infected but is located on an area of the body where drain out of the wound and splash.
the cyst is unsightly or where it may become irritated 10. Assist provider to inject the anesthesia by holding
from rubbing. the vial while the provider withdraws the appro-
priate amount of anesthesia. Continue to assist
EQUIPMENT/SUPPLIES: while the provider excises the cyst and sutures the
Sterile field: surgical incision.
Syringe/needle for anesthesia
Iris scissors (curved) 11. Support patient during surgery.
Mosquito hemostat (curved) Give postoperative care:
Scalpel blade and handle 12. Apply sterile gloves.
Needle holder 13. Clean area around the wound.
Suture material with needle
14. Dress and bandage as directed.
Tissue forceps (two)
Mayo scissors (curved) 15. Dispose of items per OSHA guidelines. Remove
Side area (unsterile field): gloves.
Skin prep supplies 16. Wash hands.
Gauze sponges (many) (sterile, unopened)
17. Check the patient’s vital signs.

(continues)
continues
578 UNIT 6 Advanced Techniques and Procedures

Procedure 19-13 (continued)

18. Explain wound care to the patient (and care- DOCUMENTATION

giver) and provide written instructions including 5/12/20XX 2:00 PM Sebaceous cyst (0.5 3 0.5 cm) excised
symptoms of infection. by Dr. King. Moderate amount of purulent exudate noted as
19. Assist the patient with any concerns or questions. cyst ruptured during removal. Specimen of exudate obtained
20. Arrange for follow-up appointment and medica- and sent to the laboratory for culture and sensitivity. Five
tion as ordered. nonabsorbable sutures used to close the incision. Wound
cleansed with Betadine®; dry sterile dressing applied. Patient
21. Document procedure in patient’s chart or elec-
tronic medical record, noting that the culture
given verbal and written instructions on caring for the dress-
specimen was sent to laboratory if appropriate.
ing and for watching for signs of infection. BP 118/74, P 88.
Skin color good. Will call office for results of culture and sen-
sitivity and to discuss the need for antibiotic therapy. Will
return on 5/22/20XX or sooner if necessary. W. Slawson,
CMA (AAMA) _____________________________

Procedure 19-14
Incision and Drainage of Localized Infection
STANDARD PRECAUTIONS: under the Johnson & Johnson brand name of Nu
Gauze (see Figure 19-32). Care must be taken when
removing the desired length from the bottle to avoid
contaminating the remaining gauze. To accomplish
this, the medical assistant might hold the bottle and
remove the lid to allow the provider to reach into the
bottle with a sterile thumb dressing forceps and pull
out the desired length. Sterile scissors are then used
NOTE: An abscess is a localized accumulation of pus to cut the strip without contaminating the remaining
surrounded by inflamed tissue. The body attempts to wick. The Iodoform is packed into the wound with
isolate pus into a pocket or abscess as a means of pro- a short length exposed. After several hours or days
tecting itself by walling off the pathogens and pre- of continued draining, the wick may be removed,
venting them from spreading throughout the body. and the wound allowed to heal without sutures. The
Incision and drainage is the procedure of cutting patient may be prescribed an appropriate antibiotic.
into an area (often an abscess) for the purposes of The medical assistant should exercise caution
draining the fluid/material. A culture of the exudate by wearing appropriate PPE including goggles
can be done to identify microorganisms. Rather than when assisting with this procedure because the exu-
suturing or otherwise closing the wound, the provider date can be heavy and contains pathogenic micro-
may place a gauze wick or a latex Penrose drain into organisms.
the wound to facilitate continued drainage. The most
commonly used type of wick is Iodoform. Iodoform is PURPOSE:
available in 5-yard lengths and widths of 1 ⁄4 , 1 ⁄2, 1, and To incise and drain an abscess or other localized
2 inches. Iodoform is packaged sterile in glass bottles infection.

continues
 CHAPTER 19 Assisting with Office/Ambulatory Surgery 579

Procedure 19-14 (continued)

EQUIPMENT/SUPPLIES: amount is aspirated for injection. The provider

Surgical tray: incises the abscess and inserts either Iodoform
Syringe/needle for anesthesia gauze or a latex Penrose drain into the wound to
Scalpel blades and handles encourage drainage. No sutures are used. Speci-
Thumb forceps men taken for culture and sensitivity.
Mosquito hemostat (optional) 11. Support the patient as needed.
Gauze sponges (many) (sterile, unopened)
Give postoperative care:
Fenestrated drape
Tissue forceps (two) 12. Apply sterile gloves.
Mayo scissors 13. Clean area around the wound with sterile 4 × 4s
Iris scissors or sterile towels.
Antiseptic solution such as Betadine® in sterile cup 14. Dress and bandage as directed. Several thick-
Side area (unsterile field): nesses of dressing material will be needed to
Skin prep supplies absorb exudate, or the accumulated fluid in the
Gloves (sterile and nonsterile) cavity.
Personal protective equipment (PPE)
Anesthesia as directed 15. Dispose of items per OSHA guidelines. Remove
Dressing, bandages, and tape gloves.
Specimen container with preservative and requisition 16. Wash hands.
(if culture is taken) 17. Check the patient’s vital signs.
Biohazard specimen transport bag
Biohazard waste container 18. Explain wound care to the patient (and care-
Extra sterile gauze sponges giver) and provide written instructions such as to
Iodoform gauze wick or latex Penrose drain apply warm moist compresses to wound. Explain
Antiseptic solution to watch for symptoms of infection. Stress cau-
Sterile culture tube tion when handling contaminated items.
19. Assist the patient with any concerns or questions.
PROCEDURE STEPS: 20. Arrange for follow-up appointment and medica-
1. Wash hands.
tion as ordered.
2. Identify the patient and explain the procedure.
21. Document procedure in patient’s chart or elec-
3. Reassure and comfort the patient as needed. tronic medical record.
4. Determine any known allergies and last tetanus
booster. DOCUMENTATION
5. Check for signed consent form. 6/20/20XX 10:00 am Incision and drainage of an abscess
(2 × 1 cm) on the left buttock. Large amount purulent exu-
6. Identify any health concerns to avoid possible date noted. Wound packed with 1 inch iodoform gauze and
complications.
DSD applied with large amount of 4 × 4s and abdominal
7. Position the patient comfortably, lying down. dressings. Culture tube with specimen of exudate sent to
8. Put on PPE, including goggles. laboratory with a requisition for C&S. BP 138/92, P 100. Post-
9. Perform the skin preparation as directed (see operative wound care explained to patient and given writ-
Procedure 19-11). ten instructions as well. BP 142/72, P 88. J. Guerro, CMA
(AAMA) _______________________________
10. Assist the provider as needed to inject the anes-
thesia by holding the vial while the appropriate
580 UNIT 6 Advanced Techniques and Procedures

Procedure 19-15
Aspiration of Joint Fluid
STANDARD PRECAUTIONS: 3. Reassure and comfort the patient as needed.
4. Determine any known allergies, last tetanus
booster, and which joint will be aspirated.
5. Check for signed consent form.
6. Identify any health concerns to avoid possible
complications.
7. Position the patient comfortably, lying down.
NOTE: The most common reason for aspirating fluid
8. Put on PPE if needed.
is to remove excess fluid from a joint, often the knee.
A long, sterile, sturdy needle is inserted into the joint 9. Perform the skin preparation as directed (see
capsule and fluid is removed. Often a long-acting anes- Procedure 19-11).
thetic and cortisone are injected at the same time. The 10. Assist the provider by holding the vial as anesthe-
fluid can be diagnostically examined for blood, pus, sia is aspirated. The provider injects anesthesia,
and fatty substances and also cultured for pathogens. inserts a long, sturdy needle into the synovial sac,
After surgery the patient may be placed on antiinflam- and aspirates fluid with a large syringe. The aspi-
matory medications to treat the inflammation and rated fluid is put into a sterile bowl as the syringe
antibiotics if the culture is positive for pathogens. fills with fluid. A hemostat is used to remove the
syringe from the needle, leaving the needle in
PURPOSE: the joint. The syringe is reapplied to the needle,
To remove excess synovial fluid from a joint after injury. and the process continues until excess fluid is
removed.
EQUIPMENT/SUPPLIES:
Surgical tray: 11. Support the patient as needed.
Syringe/needle for anesthesia Give postoperative care:
Gauze sponges 12. Apply sterile gloves.
Sterile basin for aspirated fluid
13. Clean area around the wound with sterile 4 × 4s
Fenestrated drape (optional)
or sterile towels.
Syringe/needle for drainage
Sturdy hemostat or needle driver 14. Dress and bandage as directed.
Side area (unsterile field): 15. Dispose of items per OSHA guidelines. Remove
Skin prep supplies gloves.
Gloves (sterile and nonsterile) 16. Wash hands.
Personal protective equipment (PPE)
Anesthesia as directed 17. Check the patient’s vital signs.
Cortisone medication as directed 18. Explain wound care to the patient (and care-
Culture tube giver) and provide written instructions including
Pathology requisition symptoms of infection.
Specimen container 19. Assist the patient with any concerns or ques-
Biohazard waste container tions.
Extra gauze sponges (sterile, unopened)
20. Arrange for follow-up appointment and medica-
Dressing, bandages, and tape
tion as ordered.
Biohazard specimen transport bag
21. Apply gloves and eye/mouth protection if send-
PROCEDURE STEPS: ing specimen to laboratory. Place aspirated fluid
1. Wash hands. into a sterile container and cover tightly.
2. Identify the patient and explain the procedure.

continues
 CHAPTER 19 Assisting with Office/Ambulatory Surgery 581

Procedure 19-15 (continued)

22. Send labeled specimen container and requisi- DOCUMENTATION

tion to the pathology laboratory after placing 10/12/20XX 11:30 AM Left knee aspirated. 250 mL clear
specimen in biohazard transport bag. fluid withdrawn after injection of anesthetic. Sent to pathol-
23. Document the procedure in patient’s chart or ogy department. Patient says she “feels better.” Dressing applied
electronic medical record. to aspiration site. Postoperative verbal and written directions
given. BP 118/64, P 72. Follow-up appointment made for dis-
cussion about results of analysis of fluid sent to laboratory.
B. Abbott, RMA ____________________________

Procedure 19-16
Hemorrhoid Thrombectomy
STANDARD PRECAUTIONS: PURPOSE:
To incise inflamed hemorrhoids and remove thrombus.
To remove hemorrhoids with laser, electrosurgery, cryo-
surgery, or banding.

EQUIPMENT/SUPPLIES:
Surgical tray:
Syringe/needle for anesthesia
NOTE: Hemorrhoids are dilated or varicose veins in Mosquito hemostat (curved)
the rectum, either internal or external. Sometimes a Sterile basin
blood clot can form in a protruding portion of the Gauze sponges
hemorrhoid and the vessel can become inflamed. Rubber bands
The hemorrhoid is incised with a scalpel blade and Fenestrated drape
the clot removed with a hemostat forceps. Suturing is Side area (unsterile field):
not usually necessary. Soaking the area in a sitz bath Skin prep supplies
can aid in healing. Hemorrhoidectomy can be per- Gloves (sterile and nonsterile)
formed in much the same manner as a hemorrhoid Personal protective equipment (PPE)
thrombectomy, and the supplies and equipment are Anesthesia as directed
similar. The anal sphincter is dilated, the hemor- Biohazard waste container
rhoid pedicle is tied, and then each hemorrhoid is Extra gauze sponges
removed with either laser, electrosurgery, or cryosur- Soft absorbent pad, similar to sanitary napkin
gery. Another alternative is to ligate the internal hem- T-bandage (to hold pad in place)
orrhoids after visualizing the area with an anoscope.
PROCEDURE STEPS:
Two rubber bands are placed around the pedicle of
1. Wash hands.
each hemorrhoid. They will slough off after a week
to 10 days because of the loss of blood supply to them 2. Identify the patient and explain the procedure.
(avascularized hemorrhoid). 3. Reassure and comfort the patient as needed.

continues
582 UNIT 6 Advanced Techniques and Procedures

Procedure 19-16 (continued)

4. Determine any known allergies and last tetanus 17. Explain wound care to the patient (and care-
booster. giver) per provider. Sitting in a tub of warm
5. Check for signed consent form. water is soothing and aids healing. Provide writ-
ten instructions including signs of complications
6. Identify any health concerns to avoid possible such as excessive bleeding or pain.
complications.
18. Assist the patient with any concerns or questions.
7. Position the patient comfortably, according to
provider’s preference; usually on a proctologic 19. Arrange for follow-up appointment and medica-
table. tion as ordered.
8. Assist with adequate draping for patient com- 20. Document procedure in patient’s chart or elec-
fort. tronic medical record.
9. Apply PPE if necessary.
DOCUMENTATION
10. Perform the skin preparation as directed (see 3/17/20XX 1:00 PM
Procedure 19-11). A. Thrombus removed from hemorrhoid. Perineal pad
11. Assist the provider to aspirate the appropriate applied and secured with a T-binder. Patient seemed
amount of local anesthesia. After administer- to tolerate the procedure well. BP 110/70, P 88. Postop-
ing the anesthesia, the provider either bands or erative instructions, verbal and written, given to patient.
excises the hemorrhoids with a scalpel. Suturing Prescription for Percodan, 1 tab PO q 4-6 h prn given
is usually not necessary. to patient. Return appointment made for 4/4/20XX.
12. Support the patient as needed. W. Slawson, CMA (AAMA) ___________________
Give postoperative care: B. Internal hemorrhoids removed with electrosurgical
equipment. Very little bleeding noted. Perineal pad and
13. Assist the provider in placing the soft absorbent T-binder applied. Patient seemed to tolerate the procedure
pad against the wound. It may be held in place
well. BP 110/68, P 72. Postoperative instructions given to
with a T-shaped bandage.
patient (verbal and written). Prescription for Percodan 1
14. Dispose of used items per OSHA guidelines. tab. PO q 4-6 h prn given to patient. Return appointment
Remove gloves and wash hands. made for 4/4/20XX. W. Slawson, CMA (AAMA) ________
15. Assist the patient as needed.
16. Check the patient’s vital signs.

Procedure 19-17
Suture/Staple Removal
STANDARD PRECAUTIONS: promote healing. Because these sutures or staples
are nonabsorbable, they must be removed when the
wound has healed. The patient returns to the office
or clinic to have the sutures or staples removed. The
medical assistant removes the dressing and checks
NOTE: Many minor surgical procedures require that the wound. The provider also checks the wound for
suturing be done to approximate the skin edges to degree of healing and determines that the sutures/
staples can be removed.

continues
 CHAPTER 19 Assisting with Office/Ambulatory Surgery 583

Procedure 19-17 (continued)

PURPOSE:
To remove sutures from a healed surgical wound
(as per provider).

EQUIPMENT/SUPPLIES:
(See Figure 19-48)
Gauze sponges
Bandage scissors
Biohazard waste container
Tape
Forceps
Suture removal kit (suture scissors or staple remover,
thumb forceps, and 4 × 4s)
Sterile latex gloves
Antibiotic cream if ordered Figure 19-48 Equipment and supplies for suture
removal.
PROCEDURE STEPS:
1. Identify patient.
cutting suture as close to skin as possible, the
2. Wash hands.
suture will be pulled out from under the skin,
3. Glove and remove bandage. Dispose in biohaz- avoiding contamination of the wound.
ard container.
8. If removing staples: Gently apply instrument to
4. Wash hands. staple. Gently squeeze handle of staple remover
5. Open suture or staple removal kit. until staple is pinched outward and upward.
6. Apply sterile gloves. Pull up.
7. If removing sutures: Using thumb forceps, gently 9. Remove all sutures/staples in the same man-
pick up one knot of a suture. Gently pull upward ner, noting number of sutures/staples removed.
toward suture line. RATIONALE: Less pressure Dispose of the sutures/staples on a sterile gauze
is exerted on suture line. sponge.
Using suture removal scissors, cut one side of the Examine the wound to be certain all sutures have
suture as close to skin as possible (Figure 19-49). been removed.
RATIONALE: Holding knot with forceps and 10. Apply antibiotic cream to area as ordered.

A B

Figure 19-49 To remove sutures: (A) Grasp suture knot with thumb forceps. Place curved tip of suture removal
scissors right next to the skin under the suture. Clip. (B) Gently pull the suture knot up and toward the incision
with thumb forceps to remove.

continues
584 UNIT 6 Advanced Techniques and Procedures

Procedure 19-17 (continued)

11. Apply dry sterile dressing if ordered by the pro- DOCUMENTATION

vider (see Procedure 19-9). 11/27/20XX 2:30 PM Ten sutures removed from right fore-
12. Dispose of used items per OSHA guidelines. arm. Wound appears clean, well healed. No discharge seen.
13. Remove gloves. Edges of wound well approximated. B. Abbott, RMA ______
14. Wash hands. OR
15. Check patient’s vital signs if indicated. 11/27/20XX 2:30 PM Six staples removed from right forearm.
16. Explain wound care and provide written instruc- Wound appears clean, well healed. No discharge seen. Edges of
tions to patient. wound well approximated. B. Abbott, RMA ____________
17. Arrange follow-up appointment if necessary.
18. Document procedure in patient’s chart or
electronic medical record.

Procedure 19-18
Application of Sterile Adhesive Skin Closure Strips
STANDARD PRECAUTIONS: PROCEDURE STEPS:
1. Identify the patient and explain the procedure.
2. Position patient comfortably.
3. Wash hands and apply gloves.
NOTE: On occasion, a superficial wound does not
4. Remove bandages and dressings (see Proce-
require sutures. However, the edges of the wound can
dure 19-9).
be drawn together and sterile strips of adhesive used
to hold the edges of the wound together to facilitate 5. Dispose in waterproof bag.
healing. 6. Remove gloves.

PURPOSE: 7. Wash hands.

To approximate the edges of a wound after the 8. Clean and dry wound (see Procedure 19-9).
removal of sutures. Sometimes used in lieu of sutures 9. Assess the need for skin closure strips and alert
or to give additional support along with sutures. provider as indicated.
EQUIPMENT/SUPPLIES: 10. Wash hands.
Sterile field: 11. Open container of tincture of benzoin.
Suture removal instruments (as indicated) 12. Pour into sterile cup.
Sterile adhesive skin closure strips
Iris scissors (straight) 13. Apply tincture of benzoin to edges of wound if
Adson dressing forceps directed. Use sterile cotton-tipped applicator, tak-
Tincture of benzoin (optional) ing care not to let it come into contact with the
Sterile cup actual wound. RATIONALE: Tincture of benzoin
Sterile cotton-tipped applicators (for tincture of is applied to the periphery of the wound to pre-
benzoin) pare it for application of the skin closure strips
Side area (unsterile field): and to provide a better sticking surface and aid in
Sterile gloves easier removal with less skin irritation.
Dressings, bandages, and tape 14. Open package of skin strips. Cut to size if
Waterproof bag needed. Remove strips from packaging one at a
time using dressing forceps.

continues
 CHAPTER 19 Assisting with Office/Ambulatory Surgery 585

Procedure 19-18 (continued)

15. Apply one end of a skin closure strip to one side

of the wound. Place the first strip over the center
Tincture
of the wound (Figure 19-50A). of benzoin
16. Secure the end to the skin by carefully pressing. Tincture
17. Stretch the strip across the edge of the wound of benzoin
and secure on the other side in the same man-
ner. This motion should bring the edges together
without puckering the skin.
18. Apply the next two closure strips at halfway
points between the first strip and each end of the
wound (Figure 19-50B). A
19. Continue in this manner until the edges
are approximated. Keep wound edges in
B
alignment.
Give postoperative care: Figure 19-50 To apply skin closure strips: (A) Apply
20. Dress and bandage if necessary. first strip in center of incision. (B) Apply closures to
each side of center.
21. Dispose of used items per OSHA guidelines.
22. Remove gloves and wash hands.
23. Check the patient’s vital signs, if indicated.
24. Explain wound care to the patient (and care- DOCUMENTATION
giver) and provide written instructions including 3/17/20XX 4:00 PM Nine skin closure strips applied to
symptoms of infection. wound on shoulder after tincture of benzoin applied to skin
25. Assist the patient with any concerns or questions. around sutures. Suture line approximated well; no puckering
26. Arrange for follow-up appointment and medica- of skin noted. Wound appears clean and to be healing. No red-
tion as ordered. ness or swelling. Patient says there is “very little discomfort.”
B. McQuestion, RMA _________________________
27. Document procedure in patient’s chart or elec-
tronic medical record.

Case Study 19-1

Refer to the scenario at the beginning of the chapter. CASE STUDY REVIEW
Distinguish between the types of surgery that would be per-
formed in a high-volume patient practice and the surgery 1. List several types of surgery performed for the high-
that would be performed in a smaller practice. volume practice and the lower-volume practice.
2. Are there some surgeries common to both? If so,
what are they?
586 UNIT 6 Advanced Techniques and Procedures

Case Study 19-2

Cele Little, an 84-year-old patient at Inner City Health Care, CASE STUDY REVIEW
is having office surgery performed on Thursday morning. Her
sister, Dottie Tate, also a patient and also in her 80s, will come 1. Where should Wanda begin in her communication
with Cele. A friend from the local senior citizen center has with the two sisters?
offered to drive them to the center and home again. Dottie is 2. What specific advice should Wanda give Cele and
more nervous about the procedure, the removal of a bother- Dottie before the procedure?
some cyst, than Cele. After talking with the sisters about the 3. What instructions should Wanda give the sisters to
procedure, clinical assistant Wanda Slawson, CMA (AAMA), follow after the procedure?
MLT, realizes this and wants to reassure Dottie but also wants
her to be prepared to be caregiver to Cele.

Case Study 19-3

Letisha Brown has been scheduled to have a nevus excised CASE STUDY REVIEW
from her upper back.
1. Explain how you would prepare her for the surgery.
2. Explain how you would care for her after the surgery.
3. What will become of the excised nevus? Explain
your actions.

SUMMARY
In assisting with surgery in the ambulatory care setting, the medical assistant needs to know sterile principles
and understand the difference between medical and surgical asepsis. Knowledge of suture materials, instru-
ments, and other supplies such as dressings and bandages is also critical. In preparing for surgical proce-
dures, the medical assistant’s communication skills will be needed, because patients can be apprehensive
and will require both reassurance and education. In addition to understanding the basic process and prep-
arations for assisting with minor surgery, the medical assistant should be aware of the steps involved in some
of the more common surgical procedures.

STUDY FOR SUCCESS

To reinforce your knowledge and skills of information presented in this chapter:
• Review the Key Terms
• Practice the Procedures
• Consider the Case Studies and discuss your conclusions
• Answer the Review Questions

˚ Multiple Choice
˚ Critical Thinking
• Navigate the Internet by completing the Web Activities
• Practice the StudyWARE activities on your student CD
• Apply your knowledge in the Student Workbook activities
• Complete the Web Tutor sections
• View and discuss the DVD situations
 CHAPTER 19 Assisting with Office/Ambulatory Surgery 587

REVIEW QUESTIONS
Multiple Choice 2. While you are preparing a patient for surgery,
he confides in you that he doesn’t have anyone
1. Which of the following describes the primary pur- to drive him home, but he only lives three miles
pose of surgical asepsis? away and plans to drive himself. How do you
a. to prevent microorganisms from collecting on respond?
the Mayo stand 3. You have thoroughly explained the postopera-
b. to prevent microorganisms from causing tive instructions to the patient and caregiver.
inflammation Are written instructions also necessary? Why or
c. to prevent microorganisms from entering the why not?
body during an invasive procedure 4. While pouring a sterile solution into a bowl on
d. to prevent microorganisms from multiplying the sterile field, you accidentally splash a very tiny
2. A basic rule to follow to protect sterile items is: amount of the solution onto the field. What is your
a. a sterile object can touch a nonsterile object next step? Explain your actions.
under certain circumstances 5. During an incision and drainage of a localized
b. it is safe to turn your back on the sterile field if you infection you notice a large amount of exudate
leave plenty of room between you and the field from the site. What precautions should you take.
c. provide the provider a separate container for
contaminated instruments
d. gloved hands are held at the same height as the
hip bone WEB ACTIVITIES
3. Which of the following is the smallest size suture Search the Internet to explore the most cur-
material? rent ambulatory surgical procedures for vari-
a. 0 cose veins, cataracts, and cholelithiasis.
b. 2–0 1. Using a search engine of your choice, go to a Web
c. 4–0 site about ambulatory care.
d. 1 a. Look for the criteria that the patient must meet
4. Which of the following is an example of absorbable to be discharged after surgery.
suture material? b. What are some common complications that can
a. vicryl occur in the ambulatory center after any surgi-
b. nylon cal procedure?
c. silk c. Name two other surgeries other than those
d. cotton listed in your book that can be performed in an
5. What is the purpose of adding epinephrine to the ambulatory center. Discuss them.
local anesthetic? d. List three to four advantages and disadvantages
a. to prevent an allergic reaction of ambulatory surgery.
b. to reduce blood flow in the operative site
through vasoconstriction
c. to reduce patient discomfort during the proce-
dure REFERENCES/BIBLIOGRAPHY
d. to maintain patient vital signs Association of Surgical Technologists, Inc. (2008).
6. Which of the following actions might the physician Surgical technology for the surgical technologists. Clifton
take if a sebaceous cyst were infected? Park, NY: Delmar Cengage Learning.
a. remove the cyst Diversified health occupations. (6th ed.). (2004). Clifton
b. do a biopsy of the cyst Park, NY: Delmar Cengage Learning.
c. perform cryosurgery on the cyst Phillips, N. (2004). Barry and Kohn’s operating room tech-
d. incise and drain the cyst nique (10th ed.). St. Louis, MO: Mosby.
Taber’s cyclopedic medical dictionary (20th ed.). (2005).
Critical Thinking Philadelphia: F. A. Davis.
1. What would be the rationale behind leaving a
wound open rather than suturing it? On what basis
would the provider make the decision?
588 UNIT 6 Advanced Techniques and Procedures

THE DVD HOOK-UP

This chapter discussed the proper technique for assisting DVD Journal Summary
with minor surgical procedures. Write a paragraph that summarizes what you learned
Today’s DVD program illustrated how to assist with a seba- from watching today’s DVD program. What did you think
ceous cyst removal. Eileen called the patient the day before about the testimony of the other medical assistant named
the procedure to make certain that the patient was going Eileen regarding her first experience assisting the provider
to be there the day of the surgery. Eileen gave the patient with a surgery? Would you have quit after the provider
some important information that he needed to know before raised his voice and scolded you in front of the patient?
having the surgery. The day of the surgery, Eileen escorted What do you need to do now, while you are still in school,
the patient back to the provider’s office so that the provider to ascertain that you do not break sterility when you get
could explain the procedure. Once the provider was fin- into the industry?
ished explaining the procedure, Eileen took over and gave
the patient his prescriptions and home-care instructions.
Eileen had many duties during the procedure and had
additional duties immediately after the procedure.
1. Why is it so important to contact the patient the day
before the surgery?
2. What type of phone instructions did Eileen give the DVD Series Program Number
patient before the surgery date? Skills Based Series 14
3. What type of instructions did Eileen give the patient Chapter/Scene Reference
the day of the surgery, before having the procedure? • Entire program
Why did Eileen give the patient instructions before the
procedure?
 Chapter

Diagnostic Imaging 20
KEY TERMS OUTLINE
Cathode Radiation Safety Computerized Tomography
Claustrophobia X-Ray Machine (CT)
Doppler Contrast Media Magnetic Resonance Imaging
Patient Preparation (MRI)
Dosimeter
Positioning the Patient X-Rays (Flat Plates)
Echocardiogram
Ultrasonography
Esophageal Varices Fluoroscopy
Mammography
Fluoroscope Bone Densitometry
Filing Films and Reports
Implantable Cardioverter- Diagnostic Imaging
Radiation Therapy
Defibrillator (ICD) Positron Emission Tomogra-
Nuclear Medicine
Ionizing Radiation phy (PET)
Isotope
Oscilloscope OBJECTIVES
Palliative The student should strive to meet the following performance objectives and
Radioactive demonstrate an understanding of the facts and principles presented in this
Radiograph chapter through written and oral communication.
Radiolucent
1. Define key terms as presented in the glossary.
Radionuclides
2. Describe safety precautions for personnel and patients as they
Radiopaque relate to ionizing radiation treatments.
Radiopharmaceuticals
3. Explain how fluoroscopy is used and explain its benefits.
Stomatitis
4. Describe the various positions used during X-ray procedures.
Transducer
5. Describe four X-ray procedures that require patient preparation.
6. Discuss the uses of ultrasonography, positron emission tomog-
raphy, computerized tomography, magnetic resonance, and
flat plates.
7. Discuss how radiographs are stored.
8. Explain the differences among radiology, radiation therapy, and
nuclear medicine.
9. Recall four possible side effects of radiation.

589
 Scenario
In the radiology department of Inner City Hospital, tain that Mr. Waite has been properly prepared for the
several patients are waiting to have their procedures procedure. She does not want the procedure to have to
performed. Wanda Slawson, CMA (AAMA), brings Don be repeated because of the inconvenience and anxiety it
Waite to the department for an excretory urogram known may cause Mr. Waite, nor does she want there to be addi-
as an intravenous pyelogram. She is careful to make cer- tional expense and time spent repeating the procedure.

INTRODUCTION
Radiology is a branch of medicine concerned with radio- as an excretory urography (intravenous pyelogram [IVP])
active substances, including radiographs, radioactive or a computerized axial tomography (CAT) scan, require
isotopes, and ionizating radiation. There are three spe- special preparation.
cialties into which radiology can be classified: diagnostic
radiology, radiation therapy, and nuclear medicine. All
the specialties are extremely valuable tools that can be used RADIATION SAFETY
to diagnose and treat diseases.
X-rays were named when a German physicist, X-rays, though invisible to the human
Wilhelm Roentgen, discovered them in 1895. He re- eye, are extremely powerful, and they can
ceived the first Nobel Prize in physics for his discovery. be beneficial or they can be dangerous
Roentgen noticed while working with a cathode ray and harmful. Exposure to radiation can destroy
tube that the rays of energy emitted could pass through tissue and permanently damage the eyes, bone
skin, paper, wood, and other solid materials. Because he marrow, and skin. They are harmful to the devel-
didn’t know what the rays were, he called them X-rays. oping embryo and fetus, causing severe anomalies
Radiologic procedures are not often performed in an and death.
office setting; rather, they are performed in the radiology The benefit of X-rays is the ability to use the
department of a hospital, clinic, or a freestanding facility information obtained from them to diagnose and
outside of the hospital or clinic. manage a patient’s disease. The diagnostic benefits
Some radiographs, such as those looking for a frac- outweigh the risks that may result from X-ray expo-
tured bone, require no preparation, whereas others, such sure. Radiographers are educated to be certain
that patients receive as low a dose of radiation as
possible but still obtain a useful radiograph, and
that they and patients are protected from expo-
Spotlight on Certification sure to radiation that is not necessary. Radiation
is rarely used during pregnancy because of the
RMA Content Outline danger it poses to the fetus and embryo. The first
• Anatomy and physiology trimester is the most critical because severe con-
• Patient education genital anomalies can be the result of the fetus’s or
CMA (AAMA) Content Outline embryo’s exposure to radiation. Women are rou-
tinely asked if there is a possibility of their being
• Anatomy and physiology pregnant. X-rays of fertile women should be taken
• Medicolegal guidelines and legal only when necessary and with a minimal exposure
requirements to the fetus or embryo. If a radiologic examination
• Scheduling and monitoring appointments is necessary, a radiologic physicist calculates the
• Performing selected tests dosage of radiation to estimate how little radiation
to which the fetus or embryo should be exposed.
CMAS Content Outline The past guideline stated that X-rays of fertile
• Anatomy and physiology women should not be taken until 10 days after the
• Legal and ethical considerations onset on their last menstrual period. The thinking
• Examination and preparation was that women were unlikely to be pregnant dur-
• Appointment management and scheduling ing these 10 days. This guideline is now considered
to be outdated because the ovum for the next

590
 CHAPTER 20 Diagnostic Imaging 591

Personnel in the X-ray department and oth-

Critical Thinking ers who are exposed to X-rays must wear a dosim-
eter, a small badge-like device worn above the
What are the effects of radiation on a fetus or waist. The dosimeter contains a strip of film that
an embryo? measures the amount of X-ray to which a person
is exposed. The dosimeter film is read on a regu-
lar basis, and radiation exposure is reported to
a supervisor. Exposure can come from the X-ray
beam itself or from scattered rays that are pro-
Critical Thinking duced when going through the patient’s body.
Patients must wear lead aprons over the
What do some state laws require of personnel reproductive organs, and technicians must shield
who take X-rays? themselves with lead aprons and gloves when they
are assisting. However, shields are not necessary
when technicians are standing behind the lead wall
and working the control panel. In addition, walls
menstrual cycle is its most susceptible during this in rooms where X-rays are taken are lead-lined to
10-day period. absorb scattering rays.
In some states, medical assistants and other
health care professionals who are not licensed to
take radiographs are not allowed by law to take X-RAY MACHINE
or assist with radiologic procedures. Licensure in
those states (about 35 states) is mandated because There are three main parts to an X-ray machine:
of the possibility of severe injury to an unlicensed the table, the X-ray tube, and the control panel.
individual and to patients. In some states, a lim- The tube is where the X-rays are produced and
ited license is required. The medical assistant must then come out as a beam of X-ray. Lead surrounds
undergo additional training and is limited to “skel- the tube except for the area where the beams of
etal films” (arms, legs, and so forth). Education X-ray are sent out. The table on which the patient
and training in radiologic techniques is of utmost lies is movable in several directions, even upright
importance for the safety of the patient and health or angled. The control panel is positioned behind
care worker. Medical assistants must have a basic a lead wall specially designed for shielding the
understanding of radiology and radiology safety radiographer from X-rays when an X-ray is being
to instruct patients in the correct preparation for taken (Figure 20-1).
procedures and to keep patients and themselves Photographic film is placed beneath or
safe. They must protect themselves from radia- behind the patient’s body and a radiograph,
tion exposure by not participating in procedures X-ray film, is produced by sending X-rays from the
for which they have not been adequately educated
and trained.
On March 30, 2007, a bill called the CARE
bill (Consistency, Accuracy, Responsibility
and Excellence in Medical Imaging and
Radiation Therapy) was introduced before the
U.S. Senate. If passed, it would require all persons
who perform medical imaging (including X-rays)
and radiation therapy (excluding ultrasound)
procedures to meet specific federal education
and credentialing standards in order to partici-
pate in Medicare and Medicaid. Presently, the
law in some states requires only voluntary basic
training standards. This situation allows individu-
als without formal education to perform imaging
procedures.
The AAMA supports the legislation that would
require specific educational and certification stan- Figure 20-1 Radiography room prepared for
dards for individuals performing medical imaging. procedure.
592 UNIT 6 Advanced Techniques and Procedures

tube of the machine through the body and onto The process produces excellent images with-
the film. After the film is processed, an image is out film. It makes film storage unnecessary, thereby
created (see Figure 20-4A and B). Bone is denser reducing costs. Transmission of patient data is
than skin and other soft tissues, and therefore can quicker.
absorb more X-rays. The image of the hand bones CR equipment is costly, and technologists
on the X-ray film is white due to absorption of the who use the equipment require training on its
X-rays. operation.
Radiologic procedures can be done without
E HR using X-ray film (Figure 20-2). The tech-
nique, known as computed radiography CONTRAST MEDIA
(CR), uses similar equipment. Computers and
laser technology are used to obtain and process Various body structures are of different densi-
digital images. CR images can be recorded on an ties. Bone is denser than skin and, therefore, can
imaging plate that is put through a computer scan- absorb more X-rays, leaving fewer to be picked up
ner, which reads and digitalizes the images. by the X-ray film. Thus, an X-ray film of bone will
The technique provides clear images that appear white. A lung is less dense, and the X-rays
assist the provider in making a diagnosis. The CR can penetrate lung tissue. The lung appears black
images can be sent to providers on the computer on the radiograph. If X-rays do not penetrate a
network for consultation or referral. Images are structure easily, it is termed radiopaque; if they
accessible in 3 minutes. penetrate readily, it is termed radiolucent. Con-
trast media are radiopaque and help to obtain
a radiographic image of an internal organ or
Pharmacy
structure that ordinarily would be difficult to see
because the contrast media cause the organs or
structures of the body to absorb more radiation
(Figure 20-3A–C).
CLINICAL CARE Some commonly used contrast media are
barium sulfate, iodine compounds, air, and carbon
Patient Assessment dioxide. Barium is a chalky compound and, when
Procedures, Diagnoses & Treatment Plans
Referrals & Follow-up Appointments mixed with water, can be swallowed by the patient
Prescriptions or administered as an enema by a radiologic tech-
Orders for Tests
Patient Medical History nician. It is not absorbed by the body. It is used
for upper and lower gastrointestinal (GI) series of
X-rays (Figure 20-4A and B). The patient is told to
drink extra fluids to flush out barium after the pro-
Test Results cedure. Iodine salts are radiopaque and are used
Schedules and Tickler Files
Patient Medical History
for kidney, gall bladder, and thyroid examinations.
Medication Administration Some individuals are allergic to the iodine salts
Patient Education
Graphical Patient Data Displays
used as contrast media. Patients are asked whether
they have any allergies, particularly allergies to
foods that contain iodine, such as fish.
ELECTRONIC Air and carbon dioxide are used to visualize
the spinal cord and joints but have been replaced

RECORDS by use of the magnetic resonance imaging (MRI)

machine.

PATIENT PREPARATION
Figure 20-2 The clinical care arm of total practice
management system data flow. Data about diagnostic By law, without special education and train-
imaging procedures are stored electronically. Examina- ing about X-rays, the medical assistant’s
tion reports and images are immediately available to role in X-ray procedures in most states is
providers on demand. Images can be sent to providers limited to giving patient preparation informa-
on the same network for consultation or referral. tion and explanations about what the patient
 CHAPTER 20 Diagnostic Imaging 593

A B

Figure 20-3 Angiography. (A) An intra-arterial

catheter is inserted. (B) Radiopaque contrast material
is injected. (C) The arteries are visualized.

A B

Figure 20-4 (A) Barium swallow showing esophageal varices. (B) Barium swallow showing duodenal ulcer.
594 UNIT 6 Advanced Techniques and Procedures

can anticipate. A thorough knowledge of the and the fluoroscope. Fluoroscopy is used for pro-
procedure ordered by the provider is essen- cedures such as cardiac catheterization and for
tial, and the medical assistant must be certain viewing the function of the stomach and intestinal
that patients understand the preparation they structures to detect any abnormalities. A television
are about to undergo. Verbal explanations screen and camera are available so that the radiog-
should be followed up with written instructions. rapher can watch and take photos of the body
Many patients, fearful of what the ordered system(s) in operation (Figure 20-6). Most fluo-
X-ray will show, are anxious and frightened and roscopes have radiographic properties and can be
can easily forget verbal instructions. Proper used for both fluoroscopy and X-rays. X-rays can
preparation is essential for the best results on be taken and recorded during fluoroscopy.
the radiographs. Repeating a procedure because
of inadequate preparation results in increased
patient anxiety, time, expense, and inconven- BONE DENSITOMETRY
ience (Table 20-1).
An enhanced form of X-ray technology (low dose) is
used during bone densitometry. X-rays check areas
POSITIONING THE PATIENT of the body (hip, hand, spine, foot) for signs of min-
eral loss and bone thinning. The test determines
The correct patient position is important for the density of bone and is used to diagnose osteo-
obtaining the best quality radiograph, and the type porosis, often found in women after menopause. It
of examination that is necessary determines patient can occur in men as well. Bone densitometry can
position. Some basic views are: assess an individual’s risk for fractures. It is a pain-
less procedure.
• Anteroposterior view (AP): the anterior surface The patient is told to refrain from taking
of the body faces the X-ray tube and X-rays are calcium supplements for 24 hours prior to the exam-
directed from the front toward the back of the ination, to wear loose clothing without metal zippers
body. or buttons or a belt, and to remove jewelry and any
• Posteroanterior view (PA): the posterior surface of the metal objects. These items can interfere with the
body faces the X-ray tube and X-rays are directed X-ray images.
from back to front (Figure 20-5A and B). Most machines have software that computes
• Lateral view: X-rays pass through the body from one and displays the bone density on a computer moni-
side to the opposite side. tor. The test takes from 10 to 30 minutes. The lower
the density, the greater the risk for fractures.
• Right lateral view (RL): X-rays are directed through
the body from the left to the right side. The right
side of the body is next to the film. DIAGNOSTIC IMAGING
• Left lateral view (LL): X-rays are directed through
the body from the right to the left side. The left Positron Emission Tomography (PET)
side of the body is next to the film. PET is a radiographic procedure that uses a com-
• Oblique view: the body is positioned at an angle. puter and a radioactive substance. The radioactive
• Supine view: the body is lying face up, on the substance is injected into the patient’s body and
back. gives off charged particles. They combine with par-
ticles in the patient’s body to produce color images
• Prone view: the body is lying face down, on the that reveal the amount of metabolic activity in an
abdomen. organ or structure.
PET is primarily a diagnostic medical imaging
modality. It makes use of specialized, intravenously
FLUOROSCOPY injected radiopharmaceuticals that emit positrons,
which can be detected out of the body due to high-
Fluoroscopy is the process of using a fluoroscope energy releases. Specialized detectors arranged
to view internal organs and structures of the body around the patient sense the energy and map the
so that they can be seen in motion immediately by location from which it originated inside the body.
the radiologist. The patient is usually given a con- These radiopharmaceuticals can be chemically
trast medium and placed between the X-ray tube designed to localize in the heart, brain, or certain
 CHAPTER 20 Diagnostic Imaging 595

Table 20-1 Examples of Diagnostic Procedures, their Purpose, Patient Preparation, and the Procedure

Test Purpose Patient Preparation Procedure

To visualize the inside NPO 6 to 8 hours before 1. Contrast medium (iodine)

of blood vessel walls. examination. injected into an artery or vein.
Helps to diagnose 2. Catheter threaded to the
Angiography heart attacks, appropriate site.
stroke, aneurysm
3. Digital angiography can be done
(Figure 20-3).
and stored on computer disk.

To study the esopha- Day prior: Light evening meal. NPO 1. The patient is asked to drink a
gus, stomach, duo- after midnight. Day of test: NPO. flavored barium mixture while
denum, and small Postprocedural: Increase standing in front of the fluoro-
intestine for disease fluid intake. Take laxative as scope.
Barium
(ulcers, tumors, hia- prescribed. 2. The radiologist observes the pas-
swallow (upper
tal hernia, esopha- sage down the digestive tract.
gastrointestinal
geal varices) (see
[GI] series) 3. The patient is turned to various
Figure 20-4).
positions to allow good visualiza-
tion of the intestines.
4. Radiographs are taken.

To study the colon Prep kit (usually supplied by provid- 1. The colon is filled with a barium
for disease (polyps, er’s office), which includes bottle of sulfate mixture.
tumors, lesions). magnesium citrate and Dulcolax 2. The patient is turned in various
tablet(s). Day prior: positions to allow the barium to fill
1. Clear liquid allowed: carbonated the colon. Air is injected to move
beverages, clear gelatin, clear the barium along the colon.
broth, coffee and tea with sugar. 3. When the colon is full,
No milk or milk products. radiographs are taken.
2. 8 oz. of water every hour until
bedtime.
3. Late afternoon, drink bottle of
Barium enema magnesium citrate.
(lower GI series)
4. Early evening, take Dulcolax
tablet(s) as prescribed.
5. Light evening meal. NPO except
water after dinner.
Morning of procedure: NPO,
cleansing enema
Postprocedural:
1. Increase fluid intake and dietary
fiber.
2. Report to provider if no bowel
movement within 24 hours of test.

To view the bile May have cleansing enema 1 hour Contrast medium injected and
Cholangiography ducts for possible before examination. Meal preced- radiograph of bile ducts is taken.
calculi or lesions. ing examination is withheld.

To study the 1. Evening before test, fat-free dinner. 1. A series of radiographs is taken.
gall bladder for 2. Patient takes dye tablets with 2. A fatty meal may be given
disease (stones, 8 oz. of water. to stimulate the gall bladder
Cholecystography duct obstruction), to empty.
3. Cathartic or cleansing enemas
inflammation.
may be prescribed. 3. Other radiographs can then be
4. NPO after dinner and tablets. taken to check gall bladder
function.
(continues)
596 UNIT 6 Advanced Techniques and Procedures

Table 20-1 Examples of Diagnostic Procedures, their Purpose, Patient Preparation,

and the Procedure (continued)

Test Purpose Patient Preparation Procedure

To view the urinary Day prior: Light evening meal. Contrast medium injected and
Cystography bladder for lesions, Laxative in evening. radiograph of the urinary bladder
calculi. NPO after midnight. is taken.

To view the uterus Laxative evening before. Cleansing Contrast medium injected and
and fallopian tubes enema day of exam. Meal prior to radiographs taken of uterus and fal-
Hysterosalpingog-
for blockage and examination is withheld. lopian tubes. Carbon dioxide may
raphy
lesions. To check for also be used.
pelvic masses.

Visualization of Eat a light evening meal and noth- A contrast medium of iodine salts is
Excretory kidneys, ureters, and ing after midnight. A laxative and given intravenously after it has been
urography bladder to detect enema are used to clean out the determined that the patient is not
(intravenous kidney stones, intestines to prevent a blocked view allergic to iodine (see Chapter 18).
pyelogram) [IVP]) lesions, strictures of of the ureters behind the intestines.
urinary tract.

To detect abnormal- Do not wear lotion, deodorant, Breast is positioned on the mammo-
ities in the breast, or powders. graph and compressed to flatten it.
Mammography especially breast Two radiographs are taken of each
Remove clothing from waist up.
cancer. No contrast medium required. breast, from the side and from above.

To view the kidneys Drink four to five glasses of water Contrast medium injected and
Retrograde
and urinary tract for before examination unless sedated, radiographs taken of the kidneys
pyelography
abnormalities. then NPO. and urinary bladder.

A B

Figure 20-5 (A) Posteroanterior (PA) view of a hand. Note the dark spaces between the bones. This is because the
bones (denser) pick up X-rays (absorb them) and appear white. The soft tissue (less dense) does not absorb X-rays
and appears dark. (B) PA hand.
 CHAPTER 20 Diagnostic Imaging 597

Generally, low to moderate doses are used

to diagnose disease in patients. The PET scan
can detect cancer and the effects of chemother-
apy. Certain nuclear medicine treatment studies
use specialized radiopharmaceuticals that iso-
late in the area to be treated. These agents emit
their energy locally, irradiate tissue, and usually
do not leave the body, unlike diagnostic radio-
pharmaceuticals. The properties and intent of
diagnostic radiopharmaceuticals are different
from therapeutic radiopharmaceuticals (Figure
20-7A–C).

Figure 20-6 Fluoroscopy room ready for upper Computerized Tomography (CT)
gastrointestinal study. CT uses a small amount of radiation. The beams
penetrate body tissues to produce a series of cross-
sectional images of the body part being examined.
types of tumors (breast) throughout the body. A It allows images of structures that cannot be seen
clinical image is formed by the accumulation of with regular X-rays. It is a noninvasive test that
positron emissions in a target organ. The patient’s usually requires no preparation.
emission pattern forms a clinical image. This image The CT machine has software and hard-
is compared with the normal distribution by the E HR ware for storing and managing inform-
nuclear medicine provider. ation. The images can be examined on a

A B

Figure 20-7 (A) Position emission tomography

(PET) scanner. (B) Medications ready for injection.
(C) PET scan output images.

C
598 UNIT 6 Advanced Techniques and Procedures

computer monitor, and hard copies of the images rior for visualizing the brain. It shows more detail
can be made. It rotates 360 degrees around the than CT. The examiner can see through fluid-
patient to obtain cross-sectional images that are filled tissue with exceptional detail using an MRI
processed by a computer and can be viewed on a machine. The computer forms the visual image.
monitor and on film. It can also be used to guide A noninvasive test, magnetic resonance an-
biopsies, plan surgery, and identify internal organ giography (MRA), evaluates arteries and veins
injury due to trauma. It is ideal for early detec- throughout the body and is very useful for showing
tion of tissue tumors such as childhood cancers neck and brain blood flow. The computer converts
and abdominal tumors, and it helps in direct- the data into digital images of slices. No catheter-
ing radiation therapy for tumor masses. The car- ization is needed, but a contrast medium may be
diac CT is more useful for diagnosing coronary given intravenously. The procedure helps diagnose
artery disease than cardiac stress testing. On occa- blood vessel and heart disorders as well as strokes.
sion, a contrast medium is injected for a better Another imaging technique, functional MRI, mea-
view of internal structures. If contrast medium sures split-second nerve cell activity of the brain.
is used, the patient must be NPO (have noth- Another application of the technology is
ing by mouth) for 4 hours before being placed breast imaging using an MRI that is linked to the
onto a motorized table that moves the body part computer. Hundreds of detailed pictures of the
to be examined into a scanner that surrounds breast are taken from several angles. The patient
that part of the patient. An entire body can lies on the table on her abdomen, and the breasts
be scanned in 15 to 20 minutes (Figures 20-8A drop into a hollow in the table. Breast MRI is
and B). Newer multislice CT scanners produce not used for routine breast cancer screening. It
thinner slices in a shorter time with greater detail. is primarily used to evaluate breast implants for
leaks and to assess abnormalities seen on a con-
Magnetic Resonance Imaging ventional mammogram. Breast MRI does not
(MRI) take the place of conventional mammography
and ultrasonography and is not routinely used to
Images produced by MRI are of exception- diagnose breast cancer.
E HR ally high quality. No ionizing radiation For MRI, the patient lies on a table. The
is used, and it is a noninvasive, safe, and machine has an electromagnet. Three types of
painless procedure that can produce computer- MRI machines are available: closed MRI, open-
processed images. All body areas can be viewed by air MRI, and open MRI (Figure 20-9).
MRI, but it is especially helpful for soft tissues. It is The conventional closed MRI has high mag-
good for the spine, pelvis, and joints and is supe- netic strength. According to Lexington Medical

A B

Figure 20-8 (A) Computed tomography (CT) scanning. Instruct patient to lie still. (B) This axial CT scan demon-
strates a meningioma surrounded by edema.
 CHAPTER 20 Diagnostic Imaging 599

A B C
Figure 20-9 Three types of MRI machines: (A) closed MRI, (B) open-air MRI, and (C) open MRI.

Center, nine of ten MRI machines used in hospitals damaged during testing. Controlled studies inves-
and clinics are the closed MRI. It produces high- tigating whether patients with implantable devices
quality images. such as a pacemaker and/or an ICD can undergo
The open-air type MRI has open sides and CT and/or MRI are inconclusive. The FDA has
ends. Most open machines have low-strength not approved either procedure for these patients.
magnets and are not as powerful as the closed Some researchers found that newer CTs and
MRI. Images are of lesser quality. MRIs did not cause difficulties for patients with
The open type MRI is an advanced MRI implantable-devices compared with earlier mod-
machine that is completely open on all sides. It els, which did cause minor difficulties in some
eliminates patient claustrophobia and can accom- patients. An MRI is not as useful as conventional
modate obese patients. It has a powerful magnet radiographs or a CT scan for diagnosing fractured
that is much stronger than the magnet used in bones.
open-air type MRIs. Greater image detail results Patients are asked to remove all objects that
in information providers need to make a diagnosis have metal (watches, belts, hairpins, rings, other
(Figure 20-10). metal jewelry) and credit cards because of the
A drawback to MRI and CT is that they strong magnet in the MRI machine. Loose, com-
cannot be used in patients with a pacemaker; fortable clothing without zippers or snaps should
an implantable cardioverter-defibrillator (ICD); or be worn. The procedure takes about 45 minutes to
metal clips, pins, or other permanent hardware left an hour, during which time the patient must remain
in place on an internal organ or structure as part still. The technician, although not in the room with
of a surgical procedure. The metal may become the patient, has a camera and microphone with
which to communicate with the patient. An inter-
mittent tapping sound can be heard throughout
the procedure, and earphones are available if the
patient wants them.

X-Rays (Flat Plates)

Flat plates are also known as “plain” films because
they require no special technique or use of con-
trast medium. This type of X-ray is used on vari-
ous parts of the body and is helpful in diagnosing
problems in the skull, abdomen, chest, sinuses,
and bone.

Ultrasonography
Ultrasonography, CT, and MRI allow for greater
imaging detail than conventional radiographs.
Ultrasonography, or ultrasound, has been avail-
able longer than the other technologies. High-
frequency sound waves (inaudible to the human
Figure 20-10 A sagittal MRI of the head. (Courtesy ear) are used to image internal soft tissues. It can be
of GE Healthcare.) used to help diagnose problems in the abdominal
600 UNIT 6 Advanced Techniques and Procedures

organs, liver, gall bladder, uterus, ovaries, and During ultrasound, a transducer is used with
spleen (Figure 20-11). It cannot be used for skel- a coupling agent, and sound waves are emitted
etal structures or the lungs. from the head of the transducer. The transducer is
Doppler ultrasonography is a noninvasive placed firmly on the patient’s body over the organ
technique used to evaluate blood flow through to be examined. The sound waves pass through
the major arteries and veins of the neck, arms, the skin and bounce off the body’s tissues and are
and legs. It can reveal blockages such as plaque reflected back to the transducer. These echoes are
or thrombi (blood clots). An echocardiogram, an displayed on an oscilloscope, showing a visual pat-
ultrasound of the heart, can view the heart and tern or picture. The image or record produced is
determine its size, shape, and position and the known as a sonogram or echogram. A permanent
motion made by the valves opening and closing film for the patient’s record and videotape can also
(Figure 20-12). Ultrasound has advantages over be made.
other methods of viewing internal organs and Integration of ultrasonography with a com-
structures in that it uses no X-rays and allows for E HR puter stores data and then produces three-
continuous viewing while organs and structures dimensional images. Ultrasonography can
are in motion. be used to guide the provider while performing a
biopsy.
Ultrasonography, because it is noninvasive
(procedure does not puncture skin or enter the
body), is widely accepted for obstetrical use. Gesta-
tional age can be determined, congenital anomalies
detected, multiple fetuses noted, ectopic pregnancy

Patient Education
Magnetic Resonance Imaging (MRI)
1. Determine if the patient has followed the
preparation instructions, if there were
any.
2. Explain the procedure and what the
Figure 20-11 Sonogram of gall bladder with gallstones. patient can expect.
3. Have patient remove all metal objects
(jewelry, watch, and so on). The magnet
in the MRI machine is strong, and metal
can disrupt images.
4. Have patient empty bladder before
the procedure because it takes about
45 minutes and patient cannot move
during that time.
5. Explain to patient that machine makes
humming and tapping noises.
6. Tell patient that the intravenous contrast
medium may be slightly uncomfortable
when injected into vein.
7. Remind patient to lie still and not to
move.
8. Tell patient that there is a microphone
Figure 20-12 Echocardiograph machine. (Photo by for communication between the patient
Marcia Butterfield. Courtesy of W.A. Foote Memorial and technician.
Hospital, Jackson, Michigan.)
 CHAPTER 20 Diagnostic Imaging 601

diagnosed, and fetal size and position determined mogram to see if any of the highlighted areas
(see Chapter 14). were missed on the initial review and require fur-
Ultrasound takes 15 to 45 minutes, and the ther investigation. CAD technology may improve
preparation depends on the body part being the accuracy of a screening mammogram. Re-
examined. An obstetrical ultrasound may require searchers continue to seek ways to reduce the
the patient to have a full bladder to push aside the exposure of X-rays to the patient even further.
intestines. An ultrasound of the gallbladder and Chapter 14 provides more information on mam-
liver requires the patient to have had nothing to eat mography.
or drink for 8 to 12 hours before the examination.
The patient must remain still unless requested to
change positions. Therapeutic ultrasonography is
Filing Films and Reports
discussed in Chapter 21. Because radiographs are part of the patient’s
permanent record, they must be safeguarded
from the environment. Conditions such as heat,
Mammography moisture, light, and radiation can damage them.
More than any other X-ray, the mammogram must Processed films are stored in special envelopes
be of the highest resolution and contrast. High res- with the patient’s name, date, and identification
olution and contrast call for an increase in expo- number marked on the outside. They are stored
sure to radiation, but mammography currently is in a cool, dry place. The films are the property of
safer than ever because of strong regulations (the the hospital or other facility where the films were
only fully regulated radiography examination by taken and usually remain where they were taken.
the federal government) and improved technol- Storage on-site makes them accessible for future
ogy. The machines used for mammography must use for comparison purposes and eliminates the
meet stringent requirements. They are used with possibility of their being lost if they were allowed
special screens, film, and cassettes. Currently, to be taken away from the facility where they
the equipment can produce high-resolution and were processed. Written reports of the findings
extremely high-contrast images with exposures are prepared by the radiologist and sent to the
that are lower than ever. Digitalization helps patient’s provider(s) (Figure 20-13). Com-
improve images. Although some newer mammog- E HR puted radiography eliminates the need for
raphy equipment is digitalized, according to some film storage (hard copy).
experts, it produces images that are only slightly
better than those produced by nondigi-
E HR talized equipment. Imaging techniques RADIATION THERAPY
help providers perform biopsies of the
breast, especially of abnormal areas that cannot Radiation therapy is generally used to treat tumors
be felt but are seen by conventional mammogra- that cannot be surgically removed or are inacces-
phy or with ultrasound. A type of needle biopsy, sible for surgical removal, and for treatment of a
stereotactic-guided biopsy, involves the exact loca- malignant tumor that was surgically excised but
tion of the abnormal area in three dimensions a portion of the tumor remains. It is a specialty
using conventional mammography. (Stereotatic re- within cadiology. When used to treat inaccessible
fers to use of a computer and scanning devices to or inoperable tumors, the treatment is considered
create three-dimensional images.) A sterile needle is palliative treatment. The treatments shrink the
inserted into the precise location, and tissue or cell tumor, thereby lessening the symptoms. The treat-
samples can be obtained. The samples are exam- ments can be either external, with direct radia-
ined by a pathologist who looks for cancer cells. tion aimed through the surface of the skin to an
area within the body, or internal, using various
Computer-Aided Detection (CAD). Computer-
aided detection uses the computer to bring suspi-
cious areas on a mammogram to the radiologist’s
attention. The CAD scans the mammogram with
a laser beam and converts it into a digital signal Critical Thinking
that is processed by the computer. The image is
displayed on a video monitor, with the suspicious Describe how radiation therapy helps to
area highlighted. The radiologist can compare destroy malignant neoplasms.
the digital image with the conventional mam-
602 UNIT 6 Advanced Techniques and Procedures

A
B
Figure 20-13A Radiograph showing patient identifi-
cation information. Figure 20-13B Sample requisition form.

applications of radioactivity such as seeds or beads If the radionuclide is in an area that is abnor-
that are planted inside the body and left there mal, such as a tumor, the area is referred to as
for a certain amount of time. The radiation is the “hot.” If the radionuclide does not concentrate in
same as X-rays, with doses carefully calculated. the abnormality, but surrounds it instead, the area
The aim of radiation therapy is to interfere with is refered to as “cold”. Both hot and cold areas are
cell growth and to disrupt the DNA. The object is suggestive of abnormalities.
to destroy as many of the malignant cells as pos- The provider may order a nuclear medicine
sible without harming healthy cells surrounding E HR scan for the following reasons: to analyze
the tumor. Possible side effects are nausea, vomit- kidney function, image blood flow through
ing, hair loss, anorexia, bone marrow suppression, the heart, scan lungs, measure thyroid function, iden-
and stomatitis. tify bleeding into the colon, determine the spread of
cancer, bone scan, brain scan, and others. Nuclear
imaging techniques use a camera and a nearby com-
NUCLEAR MEDICINE puter to detect emissions of the rays, measure the
amount of radioactivity, and provide a digitalized
Nuclear medicine is the branch of medicine image of the organ (e.g., the thyroid gland).
involved with the use of radioactive (emits rays or Data gathered from all of these diagnostic
particles from nucleus) substances for diagnosis, imaging devices are stored electronically in a hos-
therapy, and research. Specific training is neces- pital information system (HIS). Picture archiving
sary for this speciality. and communication systems (PACS) store all
Radioactive substances are administered to radiologic exam results and are available online
the patient either by mouth or by injection. The to providers on demand. The level of access to the
radioactive compounds, known as radionuclides, data can be defined by each system. The benefits of
travel to an organ or area in the body that attracts these systems are that the examination reports and
them and creates an image of that area. The images will not become lost and no time is spent
gamma rays omitted are detected by camera. waiting for a report.
 CHAPTER 20 Diagnostic Imaging 603

Case Study 20-1

Refer to the scenario at the beginning of the chapter. CASE STUDY REVIEW
1. What is the patient preparation for excretory urog-
raphy (IVP)?
2. What should Wanda tell Mr. Waite about what to
expect as he begins to have his procedure?

Case Study 20-2

Gloria McDermott is scheduled to have a GI series of X-rays CASE STUDY REVIEW
next week because of persistent episodes of stomach pain
that is unrelieved by the medication Dr. King has prescribed 1. How will you explain to her the purpose of
for her. the test?
2. What will you tell her about how to prepare for the
examination?

Case Study 20-3

Raymond Brunnelle has had a series of X-rays, a GI series, CASE STUDY REVIEW
a cholecystogram, and an MRI of his abdomen. He has
scheduled an appointment with a gastroenterologist and 1. What is your response to his request?
asks you to get all of the films for him. 2. Explain why they should be kept on-site.

SUMMARY
Radiology and diagnostic imaging are helpful in the diagnosis and treatment of diseases and conditions
because procedures can be done to visualize internal structures and their functions. Radiation is not
without its risks to personnel and patients, but by following specific safety precautions, the health and
safety of all involved can be safeguarded.
The three specialty areas are radiology, radiation therapy, and nuclear medicine.

STUDY FOR SUCCESS

To reinforce your knowledge and skills of information presented in this chapter:
• Review the Key Terms
• Consider the Case Studies and discuss your conclusions
• Answer the Review Questions

˚ Multiple Choice
˚ Critical Thinking
• Navigate the Internet by completing the Web Activities
• Practice the StudyWARE activities on your student CD
• Apply your knowledge in the Student Workbook activities
• Complete the Web Tutor sections
604 UNIT 6 Advanced Techniques and Procedures

REVIEW QUESTIONS WEB ACTIVITIES

1. Visit the American Society of Radiologic
Multiple Choice Technicians at http://www.asrt.org. What
1. Which of the following radiologic procedures does is available at this Web site?
not require a contrast medium? 2. Use Google to find a Web site for “The history of
a. hysterosalpingogram MRI.” Describe how long it took for the first MRI to
b. mammogram produce one image.
c. cholecystogram 3. Using a search engine of your choice, locate infor-
d. angiogram mation about how CT scans work. What is the fun-
2. A cholecystogram requires which type of contrast damental concept of how a CT scan operates?
medium? 4. Using a search engine of your choice, find
a. air information about how nuclear medicine works.
b. tablets Name three types of techniques that use nuclear
c. carbon dioxide medicine. How is an image obtained?
d. barium 5. Locate a Web site about medical radiation safety.
3. A cholangiogram will examine: Find a guide about radiation protection for the
a. upper GI tract patient. What are the benefits and risks of a
b. lower GI tract mammogram? Excretory urogram (IVP)?
c. bile ducts
d. kidneys and ureters
4. In which of the following positions does the poste- REFERENCES/BIBLIOGRAPHY
rior aspect of the body face the X-ray tube and the
anterior face the film? Bone mineral density test. MedlinePlus Medical Encyclope-
a. oblique dia. Retrieved February 18, 2008, from http://www.
b. anteroposterior nlm.nih.gov/medlineplus/ency/article/007197.
c. posteroanterior htm.
d. prone Carlton, R. R., & Adler, A. M. (2001). Principles of radio-
e. supine graphic imaging: An art and a science (3rd ed.). Clifton
5. The radiologic procedure of choice for brain imag- Park, NY: Delmar Cengage Learning.
ing is: Cornuelle, A., & Gronefeld, D. (1998). Radiographic
a. computerized tomography anatomy positioning: An integrated approach. Stanford,
b. positron emission tomography CT: Appleton and Lange.
c. magnetic resonance imaging Cowling, C. (1998). Radiographic positioning procedures,
d. ultrasonography Volume II: Advanced imaging procedures. Clifton Park,
e. thermography NY: Delmar Cengage Learning.
Metler, F. A., Jr., & Guiberteau, M. J. (2005). Essentials
Critical Thinking of nuclear medicine imaging (5th ed.). Philadelphia:
W. B. Saunders.
1. Describe the purpose of a lead apron and lead-
Orenstein, B. W. (2006). Hot issues—MRI and implant-
lined walls in the radiology department.
able devices. Radiology Today, 7(4), 8.
2. For what is thermography used?
Taber’s cylopedic medical dictionary. (22nd ed.). (2005).
3. How are X-rays used to diagnose?
Philadelphia: F. A. Davis.
4. How are X-rays used to treat patient diseases or
conditions?
5. What is contrast media? How is it used and why?
6. To whom do X-ray films belong once they are taken
and processed?
7. What special precautions should be taken when
a patient is having excretory urography (IVP),
especially the initial time?
Rehabilitation Chapter
and Therapeutic
Modalities 21
KEY TERMS OUTLINE
Abduction The Role of the Medical Therapeutic Exercises
Activities of Daily Assistant in Rehabilitation Range of Motion
Living (ADL) Principles of Body Mechanics Muscle Testing
Adduction Posture Types of Therapeutic Exercise
Ambulation Using the Body Safely and Electromyography
Body Mechanics Effectively Electrostimulation of Muscle
Circumduction Lifting Techniques Therapeutic Modalities
Transferring Patients Heat and Cold
Diathermy
Assisting Patients to Ambulate Moist and Dry Heat
Dorsiflexion
Assistive Devices Moist and Dry Cold
Effleurage
Walkers Ultrasound
Eversion Massage Therapy
Crutches
Extension Canes
Flexion Wheelchairs
Gait
Gait Belt
Goniometer
OBJECTIVES
Goniometry The student should strive to meet the following performance objectives and
demonstrate an understanding of the facts and principles presented in this chapter
Hemiplegia
through written and oral communication.
Hydrocollator Pack
Hypertension 1. Define the key terms as presented in the glossary.
Inversion 2. Define rehabilitation medicine and explain its importance in
Modalities patient care.
Petrissage 3. Discuss the importance of correct posture and body mechanics,
Plantar Flexion and demonstrate how to safely transfer patients and lift or move
heavy objects using proper body mechanics.
Pronation
4. Describe safety precautions and techniques used when helping a
Range of Motion (ROM)
patient to ambulate and demonstrate how to assist the patient to
Rehabilitation Medicine safely stand and walk.
Rotation
5. Demonstrate how to safely care for the falling patient.
Supination
6. Describe assistive devices and the importance of each in helping
Thermotherapy patients to ambulate.
Ultrasound
7. Demonstrate how to measure patients for a walker, crutches, and
Vasoconstriction a cane and help them ambulate safely with each device.
8. Describe the ambulation gaits used with crutches.
9. Discuss the safety precautions and techniques used when pushing
a wheelchair.

605
OBJECTIVES (continued)
10. Explain the importance of joint range of motion and the
method used to measure joint movement.
11. Explain the importance of therapeutic exercise and the types
of therapeutic exercises used in patient rehabilitation.
12. Describe electromyography and its purpose.
13. Explain the purpose of the electrostimulation of muscle.
14. Explain the body’s physiologic reactions to heat and cold
therapeutic modalities.
15. Be able to identify and describe the various types of hot and
cold modalities, and describe how ultrasound works.
16. Describe various conditions for which massage therapy is used.

Scenario
In a large urgent care center such as Inner City Health tion area to the examination room and from wheelchair
Care, a team of therapists is responsible for providing to examination table. Although acutely aware of the
patients with a high level of rehabilitative care. How- needs and safety of the patient, Wanda and Bruce also
ever, the clinical medical assistants at Inner City also make sure they protect themselves by using proper
are involved on a daily basis in the care of patients who body mechanics, by observing good posture, by using
have experienced injuries such as fractures or severe their arm and leg muscles and not their back muscles,
back pain. Clinical medical assistant Wanda Slawson, and by always bending from the hips and knees, not
CMA (AAMA), MLT, and clinical medical assistant Bruce the waist. Wanda’s and Bruce’s observation of these
Goldman, CMA (AAMA), are often responsible for trans- important principles protects their health and ensures
ferring patients and getting them safely from the recep- the safety of their patients.

INTRODUCTION
Physical disability affects millions of people in the United of ability, it seeks to find practical substitutions for that
States, regardless of age, race, or socioeconomic status. loss, thereby assisting patients to make the most of their
Every year thousands of people survive strokes, head or remaining abilities.
spinal cord injury, or other debilitating illness or injury Most rehabilitation services are prescribed by the pro-
that leaves them unable to perform complete independent vider in charge of a patient’s care and, depending on the
function. Some of these individuals recover completely. patient’s condition, can include a recommendation to one
Others recover to their fullest ability, living the rest of their or several rehabilitation specialists. Most likely, that spe-
lives with some type of disability. Still other patients expe- cialist will be a physical therapist, occupational therapist,
rience chronic conditions such as arthritis or severe back speech therapist, or sports medicine specialist, although the
pain that incapacitates them to the extent they cannot field of rehabilitation medicine is certainly not limited to
work or completely care for themselves. these four areas of specialty.
Rehabilitation medicine is a field of medical dis- Professional rehabilitation therapists, in whichever
ciplines that uses physical and mechanical agents to aid field they practice, are specifically trained and licensed
in the diagnosis, treatment, and prevention of diseases in their field of expertise to assess, plan, and execute the
or bodily injuries. Its goal is to aid in the restoration of patient’s treatment in an overall effort to restore that
those functions that have been affected by the patient’s patient to the highest level of physical and social indepen-
condition. For those who have experienced permanent loss dence possible. The medical assistant, as a member of an

606
 CHAPTER 21 Rehabilitation and Therapeutic Modalities 607

working knowledge of the field is important for

Spotlight on Certification a well-rounded understanding of today’s medical
treatments.
RMA Content Outline Whatever the rehabilitation setting, you will
• Personal and physical safety most likely find that you are a member of an inter-
• Body mechanics disciplinary team of health care professionals
• Treatment and medication who bring a broad knowledge base to patient care
(Table 21-1). However, the provider is respon-
• Patient education
sible for prescribing any type of rehabilitative
• Therapeutic modalities medicine.
CMA (AAMA) Content Outline It is important to remember that patients
• Treatment area seeking rehabilitation treatment may have sub-
stained a tremendous loss of physical ability, leav-
• Equipment preparation and operation
ing them vulnerable to feelings of helplessness.
• Principles of operations They may be able to perform only limited activities
• Physical therapy modalities of daily living (ADL) or normal daily self-care such
• Wheelchair/stretcher as brushing their teeth, getting dressed, and eat-
CMAS Content Outline ing. Perhaps they cannot even do the simple tasks
we take for granted every day, leaving them com-
• Employ effective written and oral pletely dependent on another person for help.
communication Understanding and encouragement are vital
• Prepare patients for clinical examination to the recovery process of these patients. While
• Patient information and community working with disabled persons, remember that cer-
resources tain tasks may be challenging to them. More than
• Process Workers’ Compensation/disabil- likely they are acutely aware of their impairment
ity reports and forms and feel frustrated at their loss of function and
discouraged about the future. Some patients may
suffer some speech impairment, making commu-
nication difficult or impossible. Respect for their
interdisciplinary health team, can use medical assisting dignity will build their self-esteem and have a posi-
skills to enable patients to regain normal or near-normal tive effect on their treatment.
function after an illness or injury. Chapter 7 provides Patients’ safety is essential. Many have a loss
information on legal considerations and the Americans of ability to move and are vulnerable to falls.
with Disabilities Act (ADA).

THE ROLE OF THE MEDICAL Table 21-1 Some of the Specialized Fields
ASSISTANT IN REHABILITATION of Rehabilitation Medicine

As a medical assistant, you may find yourself work- The treatment of disorders
ing in one of the rehabilitation fields. Such oppor- with physical and mechanical
Physical Therapy/
agents and methods to restore
tunities might include an ambulatory care setting Physiotherapy
normal function after injury or
with a specialty in physical therapy or sports medi- illness.
cine, an orthopedic surgeon’s practice, the occu-
pational or speech therapy department of a large The use of activities to help
Occupational
suburban hospital, or other outpatient clinic or restore independent function-
Therapy
medical office. For the more chronically ill, nurs- ing after an injury or illness.
ing homes and rehabilitation hospitals also focus
on restoring patients to as much independence as Speech Therapy
The diagnosis and treatment of
possible. speech disorders.
Even if you do not work in the field of reha-
bilitation and therapeutic modalities, you may A branch of medicine that spe-
cializes in the treatment and
be referring patients for treatments and perhaps Sports Medicine
prevention of injuries caused by
even performing insurance coding or rehabilita- athletic participation.
tive and therapeutic modalities. Either way, a good
608 UNIT 6 Advanced Techniques and Procedures

Glance at yourself sideways in a full-length

PRINCIPLES OF BODY mirror. When standing, does your posture most
MECHANICS resemble that in Figure 21-1A or 21-1B? When the
body’s muscle groups and body parts are in proper
The medical assistant’s work with disabled alignment, as shown in Figure 21-1B, the body is
persons may require great physical effort, said to be in balance. Good balance is important
particularly if patients are incapable of for your body to function at its best. It enables you
lifting or moving themselves. Moving patients or to lift, push, and pull easily and safely.
heavy, awkward objects can be hazardous for the Frequently check your posture by remind-
patient as well as the caregiver if not performed ing yourself to keep your chin and chest up,
correctly. shoulders back, pelvis tilted slightly inward, feet
Body mechanics is the practice of using cer- straight and shoulder-width apart, and weight
tain key muscle groups together with good body evenly distributed to both legs with a slight bend
alignment and proper body positioning to reduce in your knees.
the risk for injury to both patient and caregiver.
Always be conscious of using proper body mechan- Using the Body Safely
ics, not just on the job, but in everything that
requires moving, lifting, pushing, or pulling heavy
and Effectively
or awkward objects. The spine is a flexible rod, designed to
bend in many directions and hold the back
steady. However, the muscles of the back
Posture are small and not meant for lifting heavy loads.
Practicing good body mechanics starts with good They can be easily damaged if called on to work
posture. Good posture protects the entire body, beyond their natural ability. The muscles in the arms
particularly the back, whether standing, sitting, or and legs, however, are large and were designed for
lying down. heavy work. Rely on these muscles when lifting and

A B

Figure 21-1 (A) A medical assistant demonstrating poor posture. (B) Good posture not only looks more profes-
sional but can prevent back injuries.
 CHAPTER 21 Rehabilitation and Therapeutic Modalities 609

carrying heavy objects, bending over or bending • Pivot the entire body instead of twisting it.
down, or moving patients. • Use the body’s weight to push or pull any heavy
It is important to keep several basic rules in object.
mind whenever performing any task:
• Obtain help if unable to move a patient or object
• Keep the back as straight as possible and feet that is too heavy.
shoulder-width apart to provide a good base of • Hold heavy objects close to the body (Figure 21-4).
support (Figure 21-2). • Make sure the path is clear and the area to receive
• Always bend from the hips and knees, which enables the object is ready before lifting or moving it.
the largest muscles of the legs to do the hard work, • Get into the habit of wearing a body support if a
but never bend from the waist (Figure 21-3). job includes much lifting.

Lifting Techniques
When lifting patients or moving or lifting heavy
objects, certain techniques should be used to pre-
vent back injury:

• Get as close as possible to the object or person

being lifted, because this allows the center of grav-
ity to be maintained over the base of support.
• Keep the feet apart, one slightly in front of the
other, and knees slightly bent.
• Use the large muscles of the legs and arms to lift,
not back muscles.
• Keep the back straight to transfer the workload to
larger arm and leg muscles.
• Bend from the hips and knees, squat down, and
push up with leg muscles.

Figure 21-2 Provide a good base of support by keep- TRANSFERRING PATIENTS

ing the back straight and feet apart.
It may be necessary to transfer patients if they can-
not walk or lift themselves. Such patients may have
a wide variety of disabilities, from severe back pain to
hemiplegia, or paralysis of one side of the body result-
ing from a stroke, accident, or other condition. Frail
older adults also require particular care when being
transferred, because they are more prone to bruis-
ing and broken bones, and they may be unsteady on
their feet.
As a safety precaution, it is important to
remember good body mechanics when
transferring patients. The act of lifting and
moving someone can throw off one’s center of
gravity and therefore the base of support. Provide
a wider base of support by moving the feet farther
apart and bending slightly, using strong arm and
leg muscles to lift.
Before beginning any transfer, observe cer-
tain precautions:

• Make sure the equipment is stable and firm. Lock

Figure 21-3 Never bend from the waist. the brakes of the wheelchair and make sure the
610 UNIT 6 Advanced Techniques and Procedures

examination table or other surface will not move

during the transfer.
• Check that there are no obstructions to trip over
when making the transfer.
• Take small shuffling steps, and avoid crossing the
feet.
• It is best if the transfer surfaces being used are close
to the same height. If possible, lower the examina-
tion table or bed to the height of the wheelchair.
• Position the equipment according to the patient’s
physical limitations or disability. If the patient is
stronger on one side, make sure that is the side
on which the transfer will take place. It not only
makes the transfer easier, it gives the patient more
confidence.
• Always use a gait belt, a safety belt worn
around the patient’s waist, when transfer-
ring a patient. Lift the patient by grasping
the belt from underneath and lifting up.
Never lift a patient by the arms, or under the
armpits, because this could cause injury to
you and the patient.
A • Take advantage of any assistance the patient can
provide in lifting and moving.
• Never have patients put their arms around your
neck or on your shoulders, because it could cause
you to be injured.
• Make sure both you and the patient are wearing
footwear that will not slip or hinder the trans-
fer process in any way. If a prosthesis or brace
is involved, make sure it is secure and will not
present a problem.
• Thoroughly explain to the patient what you intend
to do, and make sure the patient understands what
to expect during the transfer. Instructions need to
be simple and repeated when necessary.
• Practice good body mechanics. Get close enough
to the patient so you can lift with your legs
(Figure 21-5). Always bend at the hips instead of
the waist.
• Ascertain beforehand whether assistance will be
needed with the transfer.
• Finally, take sufficient time when completing each
step. Many patients will want to help themselves.
Respect their courage and determination, but
B remember that safety is of the utmost importance.

Figure 21-4 (A) When carrying heavy objects, hold Procedure 21-1 gives the proper steps
them close to the body. (B) Never carry heavy objects for transferring patients from a wheelchair to
out in front. an examination table. Procedure 21-2 outlines
steps for transfer from examination table to
wheelchair.
 CHAPTER 21 Rehabilitation and Therapeutic Modalities 611

at any time. For the patient just starting to walk,

this device should be used and held by the care-
giver throughout the session.
• Monitor the patient when standing and through-
out the ambulation session for signs of fatigue and
vertigo.
• Ambulate only as long as the patient has strength.
Never push the patient beyond endurance.
• Never hurry a patient.
• Be ready should a patient start to fall. Generally,
patients will fall toward their weaker side, but
sometimes their legs lose stability and they go
straight down.

Procedures 21-3 and 21-4 detail the steps

involved in assisting patients to stand and walk and
in caring for a falling patient.

Figure 21-5 When a patient or object is too heavy, get

help if necessary. Consider wearing a body support to ASSISTIVE DEVICES
protect the back if a job requires frequent lifting.
For some patients, the extent of their physical dis-
ability may determine that ambulation is only pos-
sible with the help of an assistive device, or walking
ASSISTING PATIENTS aid such as a walker, crutches, or cane. For others,
TO AMBULATE their physical disability is such that mobility is not
possible at all without the use of a wheelchair.
Despite great strides that have been made in pro- Some assistive devices provide stability and
viding access for disabled persons, ambulation, or support, whereas others require more coordina-
walking, is a functional activity that still provides tion. Depending on the patient’s condition, one
the ultimate level of independence and freedom. assistive device may be used until the patient has
For many patients, being able to ambulate again gained enough strength and coordination to
gives them tremendous satisfaction, because the act move on to another type of assistive device, with
of walking more than anything else signifies their the ultimate goal of walking unaided. The device
return to wellness. Some patients take months to a patient needs depends both on the disability and
walk again by undergoing exercises and treatment the patient’s recuperation curve and is prescribed
designed to strengthen specific muscles. They may after careful evaluation by the attending provider
still need help while in your office or a clinic spe- or other health professional (Table 21-2).
cializing in orthopedics or sports medicine. Whatever device a patient will be using, medi-
Before assisting with any type of ambu- cal assistants may be called on to measure the
lation, there are several safety issues to patient for the correct size and provide instruc-
remember: tion in its proper use and care. Once the patient
has become proficient on level surfaces, provide
• Make sure the patient is ready to walk. If a patient instruction on sitting; standing; turning around;
has trouble sitting well or cannot balance once and negotiating stairs, curbs, ramps, doors, and
standing up, walking should not be attempted. other obstacles. In addition, patients should be
• The patient should be wearing good shoes that are taught how to protect themselves should they fall
flat, supportive, and have a rubber sole. while alone and how to get back up.
• Check to be certain there are plenty of handholds
or railings within easy reach should the patient Walkers
become unstable during walking. Walkers are best used for patients who require
• A gait belt provides a firm hold on the patient maximum assistance with balance and coordina-
should the patient require assistance with stability tion, because walkers provide stability and support
612 UNIT 6 Advanced Techniques and Procedures

Table 21-2 Types of Assistive Devices

Assistive Device Features Patient Requirements

Walkers

• Adjustable • Requires upper body strength

Standard • Rubber tips • Provides maximum stability and support
• Excellent for older adults

• Legs have wheels • Good for patients who need walker only for balance and not
Rolling • Otherwise same as support
regular walker

Crutches

• Wooden or steel • Requires good upper body strength and balance

• Worn under axillae • Not recommended for older adults
Axillary • Best for younger persons with lower extremity or hip fractures
that will heal in a short time
• Provides greatest range of ambulation

• Shorter than axillary • Less stable than axillary crutches

crutches • Best for long-term crutch use
Forearm (Lofstrand • Has metal cuff worn • Reduces stress on axillary vessels and nerves
or Canadian) around forearm
• Requires upper body strength and more stability and coordina-
tion
• Provides most maneuverability of all crutches

• Platform affixed to a • Best for patients with severe arthritis or poor use of hands
crutch • Does not require as much upper body strength
Platform
• Patient bears weight on • Requires good balance
forearm

Canes

• Single leg • Good for patients with only one good arm, lateral instability, or
Standard • Curved handle balance conditions
• Rubber tip

• Single cane resting on a • Better for patients with more severe conditions
Quad (four-point) platform with four legs • Does not require as much coordination, but still requires
• Rubber tips on legs balance and upper body strength in one arm

• Has four legs that come • Provides most stability of all canes
Walkcane or all the way up to a • Best for hemiplegic patients who require extra support on one
Hemiwalker handlebar side
• Rubber tips on all legs

when patients are standing or walking. They pro- tips on the legs (stationary walkers), and those with
vide patients with the ability to ambulate indepen- wheels on the bottom of the legs (rolling walkers).
dently with confidence. To use one, patients must Walkers that have wheels can be easily pushed ahead
be strong enough to be able to hold themselves by the patient while walking and are best for patients
upright while leaning on the walker. who primarily need a walker for balance.
Various styles of walkers are available. The two Most walkers are made of aluminum and are
most widely used walkers are those that have rubber lightweight; most can be easily folded for storage
 CHAPTER 21 Rehabilitation and Therapeutic Modalities 613

Figure 21-7 Types of crutches, from left to right:

platform, forearm (or Lofstrand), and axillary.
Figure 21-6 Proper fit for a walker. Note the patient’s
elbows are flexed at a 30-degree angle.

crutches temporarily while a lower extremity heals.

or transport. The major disadvantage is that they Axillary crutches are ideal for stronger patients and
must be used on level ground and cannot be used pediatric patients who have minor injuries; they are
on stairs. Walkers are also difficult to use when not recommended for frail older adults because
attempting to go through doorways and in small upper body strength and balance are required to
areas around the house. use them (Figure 21-8). These crutches are easily
transported and can be used to maneuver on stairs
Fitting a Walker. Most walkers can be adjusted for or in tight places.
a proper fit. The height of the handgrip should
be adjusted to the individual patient just below
the patient’s waist, or at the top of the femur
so the elbow can be bent at a 30-degree angle when
the patient is standing with hands on the handgrip
(Figure 21-6).
Procedure 21-5 provides steps for assisting a
patient to ambulate with a walker.

Crutches
Crutches provide the ambulating patient with a
great deal more mobility and flexibility. They pro-
vide good stability and support, therefore allowing
for a broad range of gait patterns and ambulating
speeds.
Three basic types of crutches are prescribed,
depending on the patient’s physical limitations
and abilities: axillary crutches, forearm crutches
(also called Lofstrand or Canadian crutches), and
platform crutches (Figure 21-7).
Axillary crutches are made of wood or aluminum
and are used primarily for individuals who need Figure 21-8 Patient using axillary crutches.
614 UNIT 6 Advanced Techniques and Procedures

Figure 21-9 Patient using Lofstrand or forearm

crutches. Figure 21-10 Patient using a platform crutch. This
crutch is an ideal substitute for a cane if the patient
Forearm crutches, or Lofstrand or Canadian cannot bear weight in his upper arm or on his hand.
crutches as they are also known, are shorter and
provide less stability than axillary crutches. Forearm
crutches are fixed with a metal or hard plastic cuff grips so the patient’s elbows are bent at about a
that fits around the patient’s forearm. The weight is 20- to 30-degree angle. Position the crutch tips
borne almost exclusively on the hand grip, requiring about 2 inches lateral and 6 inches anterior to the
a great deal of upper body strength and coordination foot. When the patient is standing correctly, the
to use. This type of crutch is generally recommended crutch tips and patient’s feet should form a trian-
for patients who will need crutches permanently or gle (Figure 21-12).
for a long period because they do not put any pres-
sure on the axillary vessels and nerves (Figure 21-9).
The platform crutch is a third type of crutch
that is recommended for patients who cannot
grip the handles of other types of crutches or bear
weight through their wrists or hands. The crutch
has a platform attached to the top that includes a
hand grip. It is high enough for the patient to use
with the elbow bent at a right angle. The patient
bears his or her weight completely on the forearm,
which requires stability, strength, and coordina-
tion. The platform crutch is an ideal substitute
for a cane when a patient only requires minimal
weight transfer but cannot bear weight on or grip
with the hands (Figure 21-10).

Measuring a Patient for Axillary Crutches.

To determine the right height of the
crutches, the patient should stand tall. Be
sure the patient is wearing good walking shoes.
Adjust the height of the crutch so it is about two Figure 21-11 Measuring for axillary crutches. Note
to three fingers, or 2 inches, below the patient’s the height is about two to three fingers below the
axillae, or armpits (Figure 21-11). Adjust the hand patient’s axillae.
 CHAPTER 21 Rehabilitation and Therapeutic Modalities 615

on both legs. The opposite foot and crutch are

advanced forward at the same time (Figure 21-13).
This gait is a more advanced gait and is used after
the four-point gait has been mastered.

Three-Point Gait. This gait is used when the

patient can only bear partial weight on one leg, or
just touch that foot to the floor. Both the crutches
and the weak leg are advanced at the same time.
The body weight is then transferred forward to
the crutches, and the stronger leg is advanced and
placed slightly in front of the crutches (Figure 21-14).

Four-Point Alternating Gait. This is a slower

gait that is used for patients who can bear weight
on both legs and move each leg separately. The
6"
patient moves one crutch forward, then the oppo-
site foot. The patient then moves the other crutch
2"
forward, then the opposite foot (Figure 21-15).

Swing-To Gait. Patients start with the crutches

at their side. They move both crutches forward,
transfer their weight forward, and swing both feet
together up to the crutches.
Figure 21-12 The distal end of the crutch should
be 2 inches lateral and 6 inches anterior to the foot
Swing-Through Gait. Start with the crutches at
to form a triangle.
the side. Move both crutches forward. Transfer the
weight and swing both feet through the crutches,
stopping slightly in front of the crutches.
Procedure 21-6 gives steps for teaching
patients to ambulate with axillary crutches. Sitting. The patient backs into a straight chair
with armrests until the seat of the chair touches
Crutch-Walking Gaits. The type of gait, or walk, the back of the legs. Crutches are held in the hand
a patient uses depends on the patient’s injury and on the strong side and opposite the weak leg. With
condition and is determined by the provider or the other hand the patient can grasp the armrest
licensed therapist. In crutch-walking gaits, each time of the chair and lower slowly into the chair.
the patient’s foot or crutch touches the ground it is
called a point. There are five gaits that are commonly Standing. The patient holds both crutches in
used in crutch ambulation. The number of points in the hand on the strong side, moves forward in
the gait relates to the number of feet and crutch tips
that are on the ground at the same time.
Common crutch-walking gaits include two- 1 2 3
point, three-point, four-point, swing-to, and swing-
through gaits.

Two-Point Gait. There are two types of two-point

gaits:
1. The first type is a nonweight-bearing gait. Patients
place the crutch tips about 18 inches in front of
them. They push off, taking the weight off their
body and transferring it to their hands, then bring
their strong leg forward past the crutches.
2. The second gait, called the two-point alternat- Figure 21-13 Two-point gait. The patient is bearing
ing gait, is used when the patient can bear weight weight on both legs.
616 UNIT 6 Advanced Techniques and Procedures

Patient Education
When instructing patients in the use of axillary on crutches. Remind them to have such haz-
crutches, impress on them the importance of ards removed. Teach patients to examine
putting all their weight on their hands, not on crutches daily for the following:
the axillae. Many patients using crutches for • Check that the wing nuts that adjust the
the first time mistakenly put the pressure on crutches are tight.
their axillae, which can damage the axillary • Check the crutch tips for wear and tear.
nerve. Also reinforce the need for wearing flat,
nonskid shoes when using crutches. • Check the foam pads of the hand grips and
axilla rests for tears.
Throw rugs and other obstacles in the
home or work area are a danger to patients

1 2 3 4

Figure 21-14 Three-point gait. The left leg is the weaker leg and
bears no weight.

1 2 3 4

Figure 21-15 Four-point gait. The patient is bearing weight on both legs.

the chair, grasps the armrest with the hand on the Canes come in three basic types, are made of
weaker side, then pushes up to a standing posi- either aluminum or wood, and have rubber tips.
tion. Some are adjustable and some are not (Figure
21-16). The first type of cane is called a standard, or
single-tipped, cane (Figure 21-17). It has a curved
Canes handle for gripping, and the newer canes have a
A cane is used when the patient has one weak hand grip attached. The standard cane is used for
side and will need this assistive device for a longer patients with less severe walking conditions who
period than crutches. It is also useful for patients need a small amount of support.
who have a general but minor weakness on one The second type of cane is a four-legged,
side or those who have poor balance. or quad, cane. It is a single cane that rests on a
 CHAPTER 21 Rehabilitation and Therapeutic Modalities 617

it is ideal for hemiplegic patients who need the

extra stability of this wide base. When the cane is
the correct height, the elbow is flexed at a 20- to
30-degree angle.
Procedure 21-7 outlines the steps for teaching
a patient how to walk safely with a cane.

Wheelchairs
Wheelchairs are mobile chairs that enable patients
with severe ambulation conditions, or no ability
to ambulate at all, to otherwise get around. Some
must be moved manually, either by the patient or by
someone else. Others are motorized and can be con-
trolled completely by the patient (Figure 21-18).
With the many advancements in wheel-
Figure 21-16 Types of standard canes: quad canes chair design, patients with chronic conditions
and single-tip canes. no longer are restricted to a home or hospital
environment. Today, all public buildings and
many private ones have handicapped access
ramps as an alternative to stairs, remote-controlled
doors, elevators that can accommodate a wheel-
chair, and other amenities that enable wheelchair
patients to get around almost as well as if they were
ambulating.
Many types of wheelchairs can be modified
to suit a patient’s particular disability and lifestyle.
There are even wheelchairs that enable patients to
participate in sports activities. Many car manufac-
turers can modify a van to accommodate a wheel-
chair, and some are equipped to allow wheelchair
patients to drive.
Patients who will be using a wheelchair for
a long time are taught how to maintain it.
Depending on their abilities, they check it
regularly to make sure all the parts are working
correctly, and, if they are able, to make any neces-
sary repairs. Patients are taught to use the wheel-
chair safely and how to maneuver into and out of
difficult spaces.
If a patient is being pushed by someone else,
that individual must learn basic safety rules for
transporting a patient:
• Make sure that the brakes are locked when trans-
ferring a patient into and out of a wheelchair, and
Figure 21-17 A standard cane being used by a hemi- if a patient must be left alone in the wheelchair
plegic patient. for any length of time, lock the brakes (Figure
21-19).
four-legged platform, provides stability and a wide • Make sure the patient’s feet are placed on the foot-
base of support, and is for patients with more rests when the wheelchair is in use.
severe walking difficulties. • Be certain the patient feels safe.
The third type of cane is a walkcane. It has • Always back into and out of elevators.
four legs and a handlebar for gripping and pro-
vides the best support of all canes. This type of • Stay to the right in corridors.
cane is also referred to as a Hemiwalker because • Back down slanted ramps.
618 UNIT 6 Advanced Techniques and Procedures

A B

Figure 21-18 (A) A manual wheelchair. (B) A motorized wheelchair.

body’s vital organs, it allows for movement so we

can carry out a multitude of activities.
The bones of almost all the joints of the body
are designed to move as well. Each joint has its own
range of motion (ROM), the amount of movement
that is present in a joint.
Normal ROM varies among people and
depends on several factors, such as age, sex, and
whether the motion being performed is passive
(assisted motion) or active (voluntary motion).
There is a standard ROM for all movable joints,
and it is this standard that is used when evaluating
the joint movement of a particular patient.
The measurement of joint motion is called
goniometry. Joint movement is measured with
an instrument called a goniometer and is always
expressed in degrees. For example, the average
Figure 21-19 The patient’s wheelchair should be
person lying flat with arms to the sides can move
locked when transferring a patient in and out of it, or
the elbows from a 20-degree hyperextension
when the patient is left alone in the wheelchair for any
(extending the arm beyond its normal limits) to 0-
length of time.
degree extension, through to 150 degrees of flex-
ion, or bending (Figure 21-20).
ROM evaluation is one of several tools used
THERAPEUTIC EXERCISES when developing a therapeutic program for a
patient (Figure 21-21).
As a medical assistant, you need to be familiar
Range of Motion with ROM exercises (Figure 21-22). ROM exercises
The musculoskeletal system is a complex joining are designed to maintain joint mobility and are per-
of bones, joints, ligaments, and tendons. Not only formed either passively (someone else does the move-
does it give structure to the body and protect the ment) or actively (the patient does the movement).
 CHAPTER 21 Rehabilitation and Therapeutic Modalities 619

Spine

20°-0°-150°

Cervical
Flexion, extension,
Lateral flexion Rotation hyperextension

Trunk
Flexion, extension,
Lateral flexion Rotation hyperextension

Shoulder
Figure 21-20 Joint mobility is measured against Abduction
standard ranges of motion and is always expressed in
degrees.

Rotation:
Adduction Flexion, extension,
outward,
inward hyperextension

Pharmacy Hip
Abduction Rotation:
outward,
inward
CLINICAL CARE
Flexion, extension,
Patient Assessment Adduction hyperextension
Procedures, Diagnoses & Treatment Plans
Referrals & Follow-up Appointments
Prescriptions Elbow Flexion
Orders for Tests
Patient Medical History Pronation

Supination Extension
Test Results
Knee
Schedules and Tickler Files
Patient Medical History Extension
Medication Administration
Patient Education
Graphical Patient Data Displays
Flexion

ELECTRONIC Wrist Flexion

Extension
Ankle
Dorsiflexion

RECORDS Ulnar Radial Hyperextension Plantarflexion

flexion flexion
(adduction) (abduction) Eversion Inversion

Figure 21-21 Clinical care arm of the total practice Fingers Toes Adduction Extension
management system (TPMS). Patient rehabilitative Adduction
procedures and therapeutic modalities treatment plans
ordered by the provider are part of the TPMS data
flow. Treatment plans, progress notes, and follow-up
Flexion
appointments are recorded in the patient’s medical Abduction Extension Abduction Flexion
record and readily accessible to the provider for
continuity of patient care. Figure 21-22 Range of motion (ROM) exercises for
specific joints.
620 UNIT 6 Advanced Techniques and Procedures

Joint movement has a special vocabulary,

and it is helpful to learn the terms and their defi-
Muscle Testing
nitions (Table 21-3). The other tool used for evaluating the movement
Before performing ROM exercises on a abilities of a patient is muscle testing. Whereas goni-
patient, the caregiver will need to observe some ometry focuses on joint movement, muscle testing
general precautions: evaluates the motion, strength, and task potential
of a given muscle. ROM testing for muscles deter-
• Always move the patient’s limbs gently, within pain
mines how flexible and resilient a muscle may be.
tolerance and the flexibility of the limb.
Strength testing shows how hard a muscle can work.
• Use slow, careful movements that allow the muscles Task potential of a muscle means how well a muscle
time to adjust to the movement. can aid in accomplishing a given activity. As a medi-
• Always support the limb above and below the joint. cal assistant, you may assist with testing the patient
• It is best to perform passive ROM with the patient for joint mobility, posture, and strength of muscles.
in the supine position.
• ROM should never cause pain. If the patient reports Types of Therapeutic Exercise
pain at any time, the ROM exercises should be dis-
Without constant exercise, the musculoskeletal sys-
continued until the provider or other health care
tem would deteriorate. Joints would become stiff
professional can determine the source of pain.
and contractures, or deformities, could develop.
• Repeat each movement several times or as Muscles would atrophy, or shrink and lose strength.
prescribed by the provider. Bones would lose vital minerals such as calcium
• Provide for patient privacy. and phosphorus. The body’s overall circulation
would decrease, which in turn would create a sepa-
rate set of unhealthy conditions.
Like drugs, exercise has a powerful and systemic
Table 21-3 Terminology of Joint Movement
effect on the body. It involves the function of joints,
Motion away from the midline of
bones, muscles, nerves, tendons, ligaments, as well as
Abduction the circulatory and respiratory systems. Therapeutic
the body
exercises are prescribed after careful evaluation by
Motion toward the midline of the a trained specialist and are tailored to each patient
Adduction
body depending on that patient’s individual condition
and rehabilitation goals. It is the role of the medical
Circumduction Circular motion of a body part assistant to understand the goals and objectives of
the therapeutic exercise program to better support
Moving the foot upward at the
Dorsiflexion and encourage patients to complete their program.
ankle joint
Whereas an athlete uses exercise to build
Eversion Moving a body part outward strength and endurance to attain a certain level of
performance, therapeutic exercises are prescribed
Extension Straightening of a body part for a variety of therapeutic and preventive effects.
They are used most commonly for therapeutic rea-
Flexion Bending of a body part sons to correct or prevent deformities, regain body
movement after an accident or disease, restore
A position of maximum extension, or joint motion after immobility, improve neuromus-
Hyperextension extending a body part beyond its cular coordination, and improve or develop ADLs.
normal limits Exercise is also used for another important
reason: It can prevent many common problems
Inversion Moving a body part inward
brought on by inactivity, such as those associated
with respiration and circulation.
Moving the foot downward at the
Plantar Flexion
ankle
A variety of exercise programs are used for
therapeutic or preventive purposes:
Pronation Moving the arm so the palm is down
1. Active exercises, which are self-directed and per-
formed by the patient without assistance
Rotation Turning a body part around its axis
2. Passive exercises, which are performed by another
Supination Moving the arm so the palm is up person with no voluntary participation from the
patient
 CHAPTER 21 Rehabilitation and Therapeutic Modalities 621

3. Assisted exercises, which help the patient voluntarily which take advantage of the properties of heat,
move weakened muscles with the use of an assistive cold, electricity, light, and water to improve circu-
device, such as a therapy pool lation, minimize pain, and correct or alleviate mus-
4. Active resistance exercises, which provide volun- cular and joint malfunction.
tary movement against various types of manual Many modalities have been around for cen-
or mechanical pressure to increase muscle turies, and some can easily be performed by the
strength patient or caregiver at home. Modalities can be used
locally to treat a small area at a time or systemically to
Electromyography alter a patient’s temperature or soothe many groups
of painful muscles or joints. The patient’s condi-
Electrical activity of muscles can be recorded on a tion and rehabilitation program both influence the
graph or film to help determine how well muscles modality or combination of modalities used.
contract. An electromyograph is the instrument A provider order is required for any therapeu-
used to test the electrical activity of a muscle. An tic modality.
electrode (using a small gauge needle) is inserted
through skin into the muscle, and measurements
of muscle strength are made.
Heat and Cold
Heat, or thermotherapy, acts on the body by caus-
Electrostimulation of Muscle ing vasodilation (dilation of the blood vessels).
The effect of heat increases circulation to an area
An electric current of low voltage can help stimu- and acts to speed up the repair process. Heat can
late muscles to exercise by innervating the sensory be used to:
and motor nerves for that muscle. It is helpful for
a patient who has nerve damage to the muscle • Relax muscle spasms
and cannot voluntarily move the muscle. The pur- • Relieve pain in a strained muscle or sprained joint
pose is to prevent atrophy of the muscle and help • Relieve localized congestion and swelling
restore muscle function. • Increase drainage from an infected area
The low current of electricity passing through
the patient’s muscle acts similarly to the patient’s • Increase tissue metabolism and repair
own nerves causing the muscle to contract and • Combat local infection
relax. The stimulation is helpful to retrain a patient • Increase circulation
after experiencing an injury to a muscle or muscle • Improve mobility before exercise
group. Disposable gel electrodes are applied, and
low-voltage current stimulates muscles to prevent However, because heat dilates the blood ves-
atrophy of muscle. sels and increases circulation, it also acts to speed
A method of using electric current to stimu- up the inflammatory process, which can lead to
late nerves is known as transcutaneous electric nerve more serious problems, such as increased bleeding
stimulation (TENS). It is used for patients who and swelling. Heat should not be used longer than
have severe pain, for example, chronic lower back its prescribed length of time.
pain from an injury. In this method, electrodes Cold applications, or cryotherapy, are used to
are attached to the patient’s skin over a painful constrict blood vessels and slow or stop the flow of
area. It causes interference with the transmission blood to an area. This process, also called vasocon-
of painful stimuli, thus reducing the patient’s striction, slows down the inflammatory process,
pain sensation. Many patients with chronic severe which can reduce or prevent swelling of inflamed
pain need narcotics to ease the pain. However, tissues, reduce bleeding, numb the pain sensation
TENS can control the pain and lesson the need by acting as a topical anesthetic, and reduce drain-
for addictive drugs. TENS can be used by patients age to an area.
at home. By understanding how heat and cold affect
the body, it is easier to observe whether they are hav-
ing the desired therapeutic effect. Because heat and
THERAPEUTIC MODALITIES cold modalities can be extremely effective, they are
widely used for treating certain physical conditions.
Sometimes, therapeutic exercise is not the best or However, the effects of heat and cold modalities
only way to restore injured or painful joints and depend on several conditions: the type of modality
tissues. A patient’s condition may respond equally used, the length of time it is applied, the patient’s
well to certain physical agents, called modalities, condition, and the area or areas being treated.
622 UNIT 6 Advanced Techniques and Procedures

Precautions for Heat and Cold medicated water no hotter than 110°F (44°C) for a
Applications. When applying either heat short time, usually no more than about 15 minutes.
or cold modalities, you need to take cer- The patient should be positioned to be comfort-
tain precautions to avoid injury. If misused, any able. Observe the patient’s skin for excessive redness
therapeutic modality can actually cause more and, if noticed, remove the limb at once. Always dry
damage to the site it is trying to heal. Before start- the skin carefully by patting, not rubbing, it.
ing any treatment, keep the following precautions Total body immersion in water 104–113°F
in mind: can be administered in a whirlpool bath or special
Hubbard tank. This treatment is often prescribed
• Infants and patients who cannot report a burning
to promote relaxation, circulation, and movement
sensation should be watched carefully. Infants and
of limbs in preparation for exercise. The mechani-
older adults are particularly susceptible to burns.
cal action of agitating water moving over the body
• Heat and cold sensitivity varies with patients; check in a whirlpool is called hydromassage and can both
patients frequently and never leave them alone. relax muscles and stimulate circulation. The Hub-
• Never have a patient lie on a heating pad because bard tank is a bit larger and provides room for
severe burning can result. Place a rubber cover limited body exercise without the effects of gravity.
over the heating pad if using with moist dressings.
• Always wrap appliances, whether warm or cold, Sitz Bath. A sitz bath is a bath of warm water in
with cloth before applying them to the skin. which only the hips and buttocks (perineum) are
immersed for relief of pain and discomfort from
• Only soak or immerse patients in water between
conditions such as rectal surgery and episiotomy.
104°F and 113°F (40–45°C). Temperatures of
It is therapeutic and cleansing and will help relieve
116°F (47°C) or greater can cause burning.
discomfort by reducing swelling and improve heal-
• Never use heat within the first 48 hours of an acute ing by stimulating blood flow.
inflammatory process and never apply heat to
newly burned skin. Warm Wet Compresses and Packs. A warm
• Watch carefully persons with impaired circulation; wet compress is usually applied to a small area. It
cardiovascular, renal, sensorineural, or respiratory is prepared by soaking and wringing out either a
conditions; or osteoporosis. Tell patient to report square of gauze or other absorbent material (such
pain or numbness. as a clean washcloth) and applying it for a limited
• Excessive cold can damage tissues. time to the affected area (Figure 21-23). Warm
compresses can be administered easily at home. A
• Lack of sensation to a therapy may mean impaired
warm pack is used for a larger area and generally
circulation to an area, and the patient may be
involves the use of a professional warm pack (hydro-
unable to report a burning sensation.
collator) administered in the clinical setting. This
• Heat concentrates in metal materials, so have type of warm pack is soaked in water 150–170°F,
patients remove all jewelry and other metal objects, removed with tongs and drained, and placed over
and administer the treatment on nonmetal tables larger areas such as the back or shoulders. Check
and chairs. color of patient’s skin frequently.
• Document in the patient’s chart or elec-
E HR tronic medical record the type of modality,
length of time applied, color of patient’s
Paraffin Wax Bath. This type of treatment is
most often used for chronic joint disease, such as
skin, and any discomfort. rheumatoid arthritis. The bath mixture of seven
parts paraffin to one part mineral oil is heated to
melting (about 127°F) and the body part is dipped
Moist and Dry Heat in the mixture several times until a thick coat of
Moist Heat Therapies. Moist heat refers to heat wax builds up. The body part is then wrapped in
modalities that feel moist against the skin. Moist foil, cloth, or plastic wrap to help insulate the heat,
heat penetrates better than dry heat and aids in then left on for 30 minutes or less. Once peeled
improving circulation, relaxation, and mobility. off, the circulatory effects of this treatment can last
up to several hours. It is an excellent modality for
Warm Soaks. Warm soaks are generally used for warming up joints before ROM or other exercises.
soaking the extremities and can be administered This modality, ordered by the provider, will be car-
easily at home by the patient or caregiver. The ried out in the physical therapy department by a
patient’s body part is gradually immersed in plain or professional therapist (Figure 21-24).
 CHAPTER 21 Rehabilitation and Therapeutic Modalities 623

A
A

Figure 21-24 (A) A body part is dipped into the par-

affin bath three or four times to create a layer of warm
wax on the skin. (B) After the wax has been in place for
20 to 30 minutes, it is peeled off and discarded.

B
be covered with a cloth before applying against
Figure 21-23 (A) Dip warm compresses frequently into the skin. Never let a patient lie directly on a heat-
a basin of warm water to keep them warm. (B) Apply com- ing pad because burns can result. Set the switch
presses directly to the skin. NOTE: Limb will be wrapped on the heating pad to a low or medium setting
in a towel that will then be covered with a blue plastic and observe the proper time of exposure.
wrap. This helps keep the compresses warm. An Aquamatic K-Pad® is a commercial pad
that is safer to use than a heating pad or commer-
cially prepared pack because you can maintain
a constant temperature and regulate that tem-
Dry Heat Therapies. Dry heat applications feel dry perature more carefully. It is a pad with tubes that
against the skin and do not penetrate like moist are filled with distilled water and heated by a
heat. They are used more to improve circulation control unit. The pad must be covered and
for the purposes of relieving swelling and healing left on the patient for no more than about
wounds, as well as to relax muscles and reduce mus- 30 minutes. The temperature usually is set
cle spasms. Most dry heat modalities can be per- between 95 and 100°F.
formed easily by the patient or caregiver at home.

Heating Pads and Packs. Heating

Moist and Dry Cold
pads and commercially prepared packs are Moist Cold Therapies. Moist cold therapies refer
used for smaller areas and should always to cold modalities that feel moist against the
624 UNIT 6 Advanced Techniques and Procedures

skin. Moist cold, as with moist heat, penetrates

better than dry cold and is used to prevent swell-
ing or edema, relieve pain or tenderness, and
reduce body temperature. Most cold therapies
can be performed easily at home by the patient
or caregiver.

Cold Compresses and Packs. Cold com-

presses are used for smaller areas, and cold packs
are used for larger areas. For a cold compress,
immerse the cold cloth, gauze, or other clean
material in a basin filled with ice and cold water
or solution prescribed. Wring out the cloth and
apply it to the affected area. Keep the cloth cold
by immersing it several times throughout the treat-
ment or use a syringe to add cold water to the com-
press. Cold or ice packs are administered in the
same manner. Check patient’s skin frequently.
Figure 21-25 A chemical ice pack. These should be
Dry Cold Therapies. Dry cold treatments are covered with a cloth before applying to the skin.
used for the same reasons as moist cold treatments
but are better for bleeding and acute injuries. Dry
cold is also an excellent therapy for sprains, strains,
Ultrasound
burns, or bruises. Ultrasound is a high-frequency acoustic vibra-
The temperature used depends on the area tion that is part of the electromagnetic spectrum,
being treated and the method used, as well as the and its frequencies are beyond the perception of
patient’s tolerance for cold temperatures. In gen- the human ear. This type of treatment uses high-
eral, the colder the temperature, the shorter the frequency sound waves that are converted to heat
duration of exposure. in the deeper tissues.
Ultrasound is an effective form of treatment
Ice Packs. Dry cold treatments include ice packs for chronic pain or acute injuries such as sprains
and commercially prepared chemical ice packs or strains. It relaxes muscle spasms, increases the
or cold packs. Always cover the pack with cloth elasticity of tissue such as tendons and ligaments,
before applying it to the skin (Figure 21-25). Gen- and stimulates circulation, which, in turn, speeds
erally, ice packs can be kept on the body longer up the healing process.
than heat packs, about 30 minutes. Check color Ultrasound waves travel best in tissue that
of patient’s skin frequently (see Chapter 9). A has a high concentration of water, such
commercial ice pack can be used for smaller areas as muscles. They cannot penetrate and
and can usually be chilled in the freezer. Because move through tissue such as bone that has a low
they do not freeze and become solid, these ice water content. In fact, ultrasound treatment must
packs are pliable, making them ideal for contour- be used carefully near bones, particularly those
ing to the body part being treated. The cold packs
are usually single-use. They must be activated by a
blow to the pack before applying or by squeezing
the pack.
Patient Education
Neither heat nor cold applications should
be left on the skin for prolonged periods,
because both can have counterproductive
effects if not monitored carefully. When apply-
Critical Thinking ing heat or cold, periodically check the skin
for signs of paleness or redness. If the patient
How do heat and cold affect the body’s phys- experiences any numbness or tingling reac-
iology and for what conditions should each tion, discontinue the application. Report the
be used? observations, and document.
 CHAPTER 21 Rehabilitation and Therapeutic Modalities 625

near the surface, because their waves are capable pist to be licensed in order to practice the
of concentrating in one area and causing damage. profession.
Because ultrasound waves cannot be con- History shows massage therapy is one of the
ducted through air, a special gel is applied to the earliest practices for helping the body restore
skin surface that acts as a conduit. The sound waves healthy functioning. It is used to relieve minor aches
are generated through an applicator that is rubbed and pains, thus helping patients feel relaxed and
over the gel. This applicator must be kept moving refreshed. Massage therapy is safe and advantageous
to prevent any internal damage caused by too high for most individuals, from infants to older adults.
a concentration of sound waves. The duration of Some physiologic benefits include increased
treatment lasts anywhere from 5 to 15 minutes, metabolism, promotion of healing, soothing of
depending on the condition being treated and muscles, relief of discomfort and pain, and im-
the recommendation of the physician or other proved circulation. Massage therapy can be used to
health care provider. It is important to note that, manage the pain associated with conditions such as
because of its potential dangers, ultrasound treat- whiplash injury, muscle spasm, sciatic nerve pain,
ment should only be administered if the medical arthritis, and many other health problems.
assistant or other caregiver is specially trained in its Therapists use their hands to handle or touch
safe and effective use. the soft tissues of the patients’ body. The move-
ments stimulate the patients’ circulation, help
relieve discomfort, improve range of motion, and
Massage Therapy relax muscles. Some of the movements include
Massage therapy has become recognized as percussion (tapping), rubbing, pressing, petris-
a modality that is basic to physical therapy. sage (kneading), and effleurage (stroking) of the
The majority of states require a massage thera- soft tissue (Figure 21-26).

A B

C D

Figure 21-26 (A) The therapist applies long strokes up along the muscles on each side of the spine. (B) Effleurage
strokes are used up the back and over the shoulders. Effleurage or gliding strokes are applied in the direction of venous
blood and lymph flow. (C) The muscles of the back are stroked outward. (D) Fan stroking is applied to the back.
626 UNIT 6 Advanced Techniques and Procedures

E F

Figure 21-26 (continued) (E) Vibration movements are applied to the vertebrae, and vibrations go back and forth
as the therapist moves down along the spine. (F) Petrissage is applied to the entire side opposite the therapist.

Massage therapy is inappropriate for patients the patient thereby lessening fatigue; and regener-
with open wounds, neuropathies, shock, severe ates energy.
upper respiratory illnesses, varicose veins, phlebi- Massage therapy has been accepted and
tis, high blood pressure, and often patients with recognized by the medical community and the
osteoporosis (bones can easily break). community-at-large as a complementary or alter-
There are psychological benefits as well. Mas- native form of medicine.
sage therapy relieves stress and tension; refreshes

Procedure 21-1
Transferring Patient from Wheelchair to Examination Table
STANDARD PRECAUTIONS: nearest the examination table should be the
patient’s stronger side to allow the patient to bal-
ance on that leg during the transfer.
4. Place the gait belt snugly around the patient’s
PURPOSE: waist and tuck the excess end under the belt
To move a patient safely from a wheelchair to the (Figure 21-27A).
examination table. 5. Move the footrests up and out of the way. Have
the patient place feet on the floor. Newer wheel-
EQUIPMENT/SUPPLIES:
chairs have removable footrests. Taking them off
Stool with rubber tips and a handle for gripping
enables you to put the wheelchair closer to the
Gait belt
examination table. There is also less chance of
PROCEDURE STEPS: being bumped or bruised by the wheelchair.
1. Wash hands. 6. Position the stool in front of the examina-
2. Identify the patient and introduce yourself. tion table as close to the wheelchair as possible
Explain to the patient what you are going to do. (Figure 21-27B).
3. Place the wheelchair next to the examination 7. Have the patient move to the edge of the wheel-
table and lock the brakes. CAUTION: The side chair.

continues
 CHAPTER 21 Rehabilitation and Therapeutic Modalities 627

Procedure 21-1 (continued)

Long-handled
stool

A B

Figure 21-27 (A) The gait belt is always applied snugly around the patient’s
waist before attempting to move or ambulate with the patient. (B) Position
the long-handled stool in front of the examination table and as close to the
wheelchair as possible.

8. Stand directly in front of the patient with your 13. Position the patient on the examination table as
feet slightly apart. Bending at the hips and knees, necessary.
grasp the gait belt and have the patient place his 14. Move the wheelchair and stool out of the way.
or her hands on the armrests of the wheelchair
so he or she can push up when you give the sig- Modification: Two-Person Transfer
nal (Figure 21-27C). If the patient does not have 1. Place the gait belt snugly around the patient’s
the upper body strength to push off, simply let waist and tuck the excess end under the belt.
the arms rest in front of him or her. 2. Have one person stand in front of the patient
9. Give a signal and lift the gait belt upward, push- and the other to the side.
ing with your knees. If the patient has the 3. Both persons should grasp the gait belt from
strength in the legs, he or she should push underneath. Have the patient place the hands
with the legs in addition to pushing up with on the armrests of the wheelchair.
the arms.
4. On one person’s signal, both persons pull the
10. Still grasping the gait belt, have the patient patient straight up. The patient should also push
step onto the stool with the foot closest to the up with the hands, but if there is little upper
examination table, and pivot so the back is to the body strength to push off, simply let the arms
examination table (Figure 21-27D). Make sure rest in front (Figure 21-28).
the buttocks are lifted slightly higher than the
5. The person nearest the examination table moves
bed. Support the patient’s weaker, outer leg with
the wheelchair out of the way, whereas the other
your leg furthest from the examination table.
pivots the patient and has the patient place his
11. Have the patient grasp the stool handle and or her stronger leg on the stool. If the patient has
place the other hand on the examination table. the upper body strength, he or she should also
12. Gently ease the patient to a sitting position on grasp the handle of the stool.
the examination table.

continues
628 UNIT 6 Advanced Techniques and Procedures

Procedure 21-1 (continued)

6. On one person’s signal, both persons lift the 7. Position the patient on the examination table as
patient onto the examination table. necessary.

C D

Figure 21-27 (continued) (C) Before lifting, observe proper body Figure 21-28 A two-person trans-
mechanics to avoid injuring yourself or the patient. (D) Check that fer is used when the patient does not
the patient’s foot is firmly placed on the stool before completing the have the upper body strength to help
transfer. move himself or herself.

Procedure 21-2
Transferring Patient from Examination Table to Wheelchair
STANDARD PRECAUTIONS: PROCEDURE STEPS:
1. Wash hands.
2. Identify the patient and introduce yourself.
Explain to the patient what you are going to do.
PURPOSE: 3. Position the wheelchair next to the examination
To move a patient safely from the examination table table and lock the brakes. NOTE: Place the
to a wheelchair. wheelchair so it is closest to the patient’s stron-
EQUIPMENT/SUPPLIES: ger side so the patient can transfer weight onto
Stool with rubber tips and a handle for gripping the stronger foot as he or she gets down.
Gait belt 4. Position the stool next to the wheelchair.

continues
 CHAPTER 21 Rehabilitation and Therapeutic Modalities 629

Procedure 21-2 (continued)

5. Assist the patient to rise to a sitting position. 9. On your signal, pull the patient slightly toward
Place the gait belt snugly around the patient’s you so the feet come down onto the stool. The
waist and tuck the excess end under the belt. patient should push off the examination table
6. Place your arm under the patient’s arm and and grasp the stool handle for support.
around the shoulders, and your other arm 10. Still grasping the gait belt, have the patient step
under the knees. Pivot the patient so the legs onto the floor with the strong leg, and pivot at
are dangling over the side of the examination the same time so the back is to the wheelchair.
table. 11. Have the patient grasp the armrests of the wheel-
7. Keeping a hand on the patient, move so you are chair.
directly in front. 12. Bending from your knees and hips, gently lower
8. Grasp the patient by placing your hands under the patient into the wheelchair and make sure
the gait belt. Plant your feet shoulder’s width the patient is comfortably seated.
apart and bend your knees so you will have a 13. Lower the footrests and place the feet on them.
strong base of support.

Procedure 21-3
Assisting the Patient to Stand and Walk
STANDARD PRECAUTIONS: stand on your signal. At the same time, have
the patient push up on the armrests of the
wheelchair.
7. Steady the patient momentarily and watch for
PURPOSE: balance, strength, and skin color. If necessary
To help a patient ambulate safely. have patient sit back in wheelchair and take his
or her pulse and/or blood pressure.
EQUIPMENT/SUPPLIES:
8. If the patient appears steady and has balance,
Gait belt
strength, and good skin color, proceed by stand-
PROCEDURE STEPS: ing slightly behind and to the side of the patient’s
1. Wash hands. weaker side.
2. Identify the patient and introduce yourself. 9. Grasp the gait belt with one hand and place
Explain to the patient what you are going to do. the other hand on the patient’s bent arm for
support. Note the gait belt is grasped with your
3. Lock the brakes on the wheelchair, if the patient
fingers under the belt, palm up and elbow bent
is using one. Place the patient’s feet on the floor
(Figure 21-29).
and move the foot plates out of the way.
10. Start with the same foot as the patient and keep
4. Instruct the patient to slide forward in the chair.
in step with him or her.
5. Place the gait belt around the patient’s waist and
11. Document the procedure in the patient’s chart
tuck the excess end under the belt.
or electronic medical record, including date,
6. Standing directly in front of the patient, grasp time, duration of ambulation, response of
the gait belt from underneath and assist to patient, and instructions given.

continues
630 UNIT 6 Advanced Techniques and Procedures

Procedure 21-3 (continued)

Modification: Two-Person Assist 4. Document the procedure in the patient’s chart

with Ambulation or electronic medical record, including date,
1. Perform the preceding steps 1 through 5. time, duration of ambulation, response of
2. Have a person stand on either side of the patient. patient, and instructions given.
Grasp the gait belt from underneath with one
hand, and place the other hand on the patient’s
back for support.
3. During ambulation, there should be a person
on either side of the patient and slightly behind
(Figure 21-30). Both persons should be grasp-
ing the gait belt throughout the ambulation
session.

Figure 21-29 Firmly grasp the gait belt from under- Figure 21-30 When two persons are assisting with
neath, with the palm up and elbow bent. ambulation, they should stand on either side of the
patient.

DOCUMENTATION DOCUMENTATION
7/14/20XX 2:30 PM Patient states she has been doing 7/14/20XX 2:30 PM Patient has been to physical therapy a
“fairly well” in physical therapy. She says she walks short total of 15 times. Dr. Woo wants patient to ambulate to see her
distances, about 10 feet. Assisted with ambulation. Seems progress. Assisted patient to ambulate with another person
steady on her feet. Says she feels “very good.” W. Slawson, assisting. Did very well. Walked about 100 feet. Color remained
CMA (AAMA) __________________________________ good. P 100. B. Beckus, RMA _________________________
 CHAPTER 21 Rehabilitation and Therapeutic Modalities 631

Procedure 21-4
Care of the Falling Patient
PURPOSE:
To help the patient fall safely to prevent injury.

EQUIPMENT/SUPPLIES:
Gait belt (should already be on patient)

PROCEDURE STEPS:
1. Keep a firm hand on the gait belt. CAUTION:
Never grab clothing, because it can shift and
become unstable.
2. If the patient falls backward, widen your stance
to become a more stable base of support to fall
against (Figure 21-31). Gently guide the patient
to the floor, call for assistance, and take pulse
and blood pressure.
3. If the patient falls to either side, steady back onto Figure 21-32 Ease the falling patient to the floor and
the feet. To do this, you will need to move your try to protect the head.
foot in the direction of the fall. Inquire whether
the patient would like to terminate the ambu-
lation session and check for signs of fatigue. If necessary, call for assistance. Check blood pres-
sure and pulse.
4. Should the patient fall forward, support him or
her around the waist. Step forward with your
outer leg and gently lower to the floor, mak-
ing sure to protect from injury (Figure 21-32).
Call for assistance and take blood pressure and
pulse.
5. Have the patient examined by the provider
before moving patient again.
6. Document the fall in an incident report and
in the patient’s chart or electronic medical
record.

DOCUMENTATION
1/21/20XX 11:30 AM While walking to exam room with
assistance the patient suddenly began to fall forward with
knees buckling. Says she feels “faint.” Eased to the floor gen-
tly. Did not strike any body parts during fall. BP 110/60,
P 108 (lying on floor). BP and pulse rechecked when patient
placed in wheelchair. BP 120/78, P 92. Dr. King notified.
Figure 21-31 Support a falling patient with a wide B. Abbott, RMA __________________________________
base of support.
632 UNIT 6 Advanced Techniques and Procedures

Procedure 21-5
Assisting a Patient to Ambulate with a Walker
STANDARD PRECAUTIONS: 8. Position yourself behind and slightly to the side
of the patient.
9. Have the patient lift the walker and place all four
legs of the walker in front so the back legs are
PURPOSE: even with the patient’s toes.
To allow a patient to ambulate independently and 10. Instruct the patient to lean forward and trans-
safely with a walker. fer the weight and step into the walker, first
with the stronger leg, then the weaker leg.
EQUIPMENT/SUPPLIES:
Make sure the stronger leg is brought past the
Walker
weaker leg.
Gait belt
11. Monitor the patient carefully. Be alert for signs
PROCEDURE STEPS: of fatigue and be ready to assist the patient to fall
1. Wash hands. without injury.
2. Identify the patient and introduce yourself. 12. If the walker has rollers, the patient simply rolls
Explain to the patient what you are going the walker ahead a comfortable distance, then
to do. walks into it. The patient can also walk normally
3. Apply the gait belt snugly around the patient’s with a rolling walker by simply rolling it in front
waist and tuck the excess end under the belt. and leaning into the gait, using the walker for
support.
4. Check the walker to be sure the rubber suction
tips are secure on all the legs. Check the hand- 13. Document the date, time, duration of ambula-
rests for rough or damaged edges that could cut tion, response of patient, and instructions given
or pinch the patient. The adjustments should be in the patient’s chart or electronic medical
tightened so they will not slip. record.
5. Be sure the patient is wearing good walking DOCUMENTATION
shoes with a rubber sole. 2/12/20XX 1:35 PM Patient assisted with ambulation
6. Check the height of the walker. The handrests using a walker for the first time. Walked approximately
should be level with the tip of the patient’s 50 feet. Did well. Walked to reception desk and back. No
femur, and the elbows should be flexed at a change in color. P 100. J. Guerro, CMA (AAMA) _________
30-degree angle.
7. Position the patient inside the walker, and
instruct the patient to hold onto the handles
while keeping the walker in front.
 CHAPTER 21 Rehabilitation and Therapeutic Modalities 633

Procedure 21-6
Teaching the Patient to Ambulate with Crutches
STANDARD PRECAUTIONS: 4. Check the measurement of the crutches. Pedi-
atric crutches must be used for pediatric
patients.
5. Apply the gait belt and assist the patient to stand
PURPOSE: and place the crutches under the axillae.
To teach the patient how to ambulate safely using 6. Instruct the patient to carry the weight com-
crutches. pletely on the hands and not on the axillae.
EQUIPMENT/SUPPLIES: 7. Have the patient put all the weight on the good
Crutches leg, and bend the weak leg slightly so it will not
Gait belt drag on the floor.
8. Assist the patient with the required gait.
PROCEDURE STEPS:
1. Wash hands. 9. Wash hands.
2. Identify the patient and introduce yourself. 10. Document the date, time, duration of ambula-
Explain to the patient what you are going to do. tion, and instructions given in patient’s chart or
electronic medical record.
3. Assemble the crutches and be sure they are in
good working order. Make sure there are rubber DOCUMENTATION
suction tips on the bottom ends, and that they
3/24/20XX 4:45 PM Crutches adjusted to patient’s height.
are not worn or torn. Check the bar and hand-
Three-point gait used. Tolerated well. J. Guerro, CMA
rest to be sure they are covered with padding,
and that the padding is not cracked or worn. Be
(AAMA) _______________________________________
sure the wing nuts are tight.

Procedure 21-7
Assisting a Patient to Ambulate with a Cane
STANDARD PRECAUTIONS: PROCEDURE STEPS:
1. Wash hands.
2. Ascertain what type of cane the provider or
therapist indicates your patient is to use and
PURPOSE: assemble the equipment.
To teach patients how to walk safely with a cane.
3. Identify the patient and introduce yourself.
EQUIPMENT/SUPPLIES: Explain to the patient what you are going to do.
Appropriate cane for patient 4. Check the cane to be sure the bottom has a
Gait belt rubber suction tip that is not worn. If a quad

continues
634 UNIT 6 Advanced Techniques and Procedures

Procedure 21-7 (continued)

or walkcane is to be used, make sure all the

legs have rubber suction tips.
5. Apply the gait belt snugly around the patient’s
waist if needed and tuck the excess end under
the belt. Assist the patient to a standing posi-
tion.
6. Place the cane relatively close to the body to
the side of the foot of the strong leg. Adjust
the cane so the handle is at the level of the
patient’s hip joint (Figure 21-33).
7. During weightbearing, the patient’s elbow
should be flexed 20 to 30 degrees.
8. The cane and the involved leg are advanced
simultaneously.
9. Have the patient move the weak leg forward
while transferring the weight to the cane.
10. Have the patient move the strong leg forward
past the cane.
11. Follow along behind and to the side of the
patient’s weak side.
12. Wash your hands.
13. Document the date, time, duration of ambu-
lation, response of patient, and instructions
Figure 21-33 When placing the cane, be sure the
given in patient’s chart or electronic medical handle comes to the top of the patient’s hip and elbow
record. is flexed 20 to 30 degrees.

DOCUMENTATION
4/17/20XX 10:30 AM Standard cane adjusted to patient’s
hip joint. Ambulated about 100 yards and seemed to tolerate it
well. W. Slawson, CMA (AAMA) ______________________

Case Study 21-1

Refer to the scenario at the beginning of the chapter. CASE STUDY REVIEW
Mrs. Williams comes to Inner City Urgent Care because
she fell when she tripped on a scatter rug at home. Her son 1. What action(s) should you take immediately to help
helped her to the clinic. Her left ankle is swollen and painful. Mrs. Williams?
2. After X-rays, Dr. King determined that Mrs. Williams
has an ankle fracture, and he applied a cast to it.
He wants you to fit Mrs. Williams to crutches and
teach her how to use them. What gait will Dr. King
have you teach the patient? Why?
 CHAPTER 21 Rehabilitation and Therapeutic Modalities 635

Case Study 21-2

It is a mild summer afternoon in the city of Carlton, the home CASE STUDY REVIEW
of Inner City Health Care. The softball season is in full swing,
and Inner City has treated its share of players and spectators 1. What are some of the general principles the
who have had minor injuries. On this particular Tuesday, Bill medical assistant should observe during any
Schwarz, a regular patient, comes in late in the day in obvious transfer?
pain. Bruce Goldman, the clinical medical assistant on duty, 2. Summarize the steps involved in transferring the
quickly gets the patient into a wheelchair. From the patient’s patient from the wheelchair to the examination
description of the situation and the pain, Bruce suspects a table.
sprained ankle. Dr. Woo is on call and is available to examine 3. What are possible treatment choices Dr. Woo
the patient immediately. Dr. Woo asks Bruce to transfer Bill may use?
from the wheelchair to the examination table.

Case Study 21-3

After diagnosing Mr. Schwarz with a sprained left ankle, CASE STUDY REVIEW
Dr. Woo has prescribed an Ace bandage to the ankle, 1. Explain what you would tell Mr. Schwarz about
crutches, and an ice pack to be applied to the ankle. He has applying the ice pack to his ankle at home.
also given Mr. Schwarz a prescription for pain relievers and
2. What patient education can be used in this
has recommended that Mr. Schwarz stay off his feet as much
situation?
as possible. He is to keep the leg elevated with an ice pack
on it.

SUMMARY
Rehabilitation medicine is a field of medical disciplines that specializes in both preventing disease or injury
and restoring physical function. It uses a combination of physical and mechanical agents to aid in the diag-
nosis, treatment, and prevention of diseases or bodily injury, including exercise and a variety of treatment
modalities.
Much of what a medical assistant might do on the job in this field involves some form of lifting or
moving of heavy objects. It is important to remember to use good body mechanics to prevent back or other
injury. When transferring patients, good body mechanics ensures the safety of both caregiver and patient.
If necessary, get someone to help with the transfer.
Helping patients to ambulate safely after a period of sedentary recuperation is an important part of a
rehabilitation program. If they are not able to ambulate on their own, patients can be fitted for a variety of
assistive walking devices, including walkers, crutches, and canes. Crutch walking, by far the most common
use of an assistive device, can be done using one of several walking patterns, or gaits, depending on the
patient’s condition, strength, and stability. Whatever assistive device is used, it is important that the patient
be measured correctly for that device and taught how to periodically check it for safety.
In addition to ambulation, there are a number of other types of therapeutic exercises. Depending on
the patient’s condition, an exercise program can be prescribed after evaluating the patient’s joint ROM
and muscle strength. Joints and muscles must be exercised regularly to prevent muscle atrophy or joint
contractures, as well as improve circulation and maintain or improve overall health. ROM and other exer-
cises can be performed by the caregiver, the patient, or a combination of the two.
In addition to exercise, a variety of therapeutic modalities might be used as part of the patient’s reha-
bilitation program. The various properties of heat, cold, light, electricity, and water act on the body to
improve circulation, minimize pain, or correct or alleviate joint and muscle malfunction. Heat dilates the
blood vessels, thereby increasing circulation to an area and speeding up the repair process. Cold constricts
636 UNIT 6 Advanced Techniques and Procedures

the blood vessels, slowing circulation and therefore the inflammatory process. Ultrasound and other elec-
trical diathermies use an electrical current to create heat in the deeper tissues of the body. It is important
to understand how each modality affects the physiologic functioning of the body and observe certain safety
precautions to avoid injuring the patient.

STUDY FOR SUCCESS

To reinforce your knowledge and skills of information presented in this chapter:
• Review the Key Terms
• Practice the Procedures
• Consider the Case Studies and discuss your conclusions
• Answer the Review Questions

˚ Multiple Choice
˚ Critical Thinking
• Navigate the Internet by completing the Web Activities
• Practice the StudyWARE activities on your student CD
• Apply your knowledge in the Student Workbook activities
• Complete the Web Tutor sections
• View and discuss the DVD situations

REVIEW QUESTIONS
Multiple Choice Critical Thinking
1. Brushing teeth, getting dressed, and eating are 1. Define rehabilitation and explain its importance in
referred to as: patient care.
a. rehabilitation medicine 2. If a patient should fall to the side, what action
b. activities of daily living would you take to ensure safety?
c. assistive behaviors 3. Describe the procedure for measuring for axillary
d. occupational therapy crutches.
2. Hemiplegia is defined as: 4. What kind of patient would need a forearm crutch?
a. inability of the patient to ambulate properly 5. In crutch-walking gaits, what is a point?
b. severe back pain 6. Describe the five different types of crutch gaits.
c. paralysis of one side of the body 7. List the six safety rules for transporting a patient in
d. confinement to a wheelchair a wheelchair.
3. Ambulatory assistive devices include: 8. What is joint range of motion, how is it measured,
a. gait belts and how is the measurement expressed?
b. walkers, canes, and crutches 9. Describe how ultrasound works and identify the
c. wheelchairs patient conditions for which it is an effective
d. stools with handholds treatment.
4. Motion away from the midline of the body is called: 10. Explain how to avoid internal damage to the
a. adduction patient when an ultrasound treatment is being per-
b. pronation formed.
c. extension
d. abduction
5. Supination involves:
a. placing the patient in the supine position
b. moving the arm so the palm is up
c. bending a body part
d. straightening a body part
 CHAPTER 21 Rehabilitation and Therapeutic Modalities 637

WEB ACTIVITIES REFERENCES/BIBLIOGRAPHY

1. Search the Internet for information online Beck, F. (2006). Theory and practice of therapeutic massage
about the Americans with Disabilities Act (4th ed.). Clifton Park, NY: Delmar Cengage
of 1990. Learning.
a. To what group of people does the act apply? Hegner, B., & Caldwell, E. (2008). Nursing assistant:
b. What does the act provide for these individuals? A nursing process approach (10th ed.). Clifton Park,
c. Does the act have any influence over access to NY: Delmar Cengage Learning.
O’Sullivan, S. B., & Schmitz, T. (2000). Physical
physicians’ offices and clinics? Explain.
rehabilitation: Assessment and treatment (4th ed.).
2. Visit the American Physical Therapy Association
Philadelphia: F. A. Davis.
(APTA) Web site to find information about
Taber’s cyclopedic medical dictionary. (22nd ed.). (2003).
(1) repetitive stress injuries, (2) spinal cord
Philadelphia: F. A. Davis.
injuries, and (3) sports injuries. What therapies
Weiss, R. C. (1999). The physical therapy aide: A work text.
can be prescribed for each of these? Clifton Park, NY: Delmar Cengage Learning.

THE DVD HOOK-UP

This chapter discusses the medical assistant’s role in DVD Journal Summary
assisting with various types of modalities and rehabilitation Write a paragraph that summarizes what you learned from
therapy. watching today’s DVD program. Many times when a patient
In the first scene of this program, Carla, the medical assis- has an injury to an extremity, it prohibits him or her from
tant, helped Jerry through the door. She noticed that Jerry being able to shower properly. What will you do if another
was having a difficult time maneuvering the crutches and coworker starts talking to you about the way a patient looks
the door at the same time, so she took that opportunity to or smells?
conduct some patient education.
1. Do you think that Carla should have waited until the
patient was in the examination room to instruct the
patient? Why or why not?
2. In general, what is the public’s attitude about rehabili- DVD Series Program Number
tative therapy? Skills Based Series 7
3. Why does the patient start with the weak leg first, when
Chapter/Scene Reference
using a cane or walker?
• Entire program
Chapter
Nutrition in Health
22 and Disease

OUTLINE KEY TERMS

Nutrition and Digestion Infancy Amino Acid
Types of Nutrients Childhood Antioxidant
Energy Nutrients (Organic) Adolescence Ascorbic Acid
Other Nutrients (Inorganic) Older Adults Basal Metabolic
Reading Food Labels Therapeutic Diets Rate (BMR)
Items on the Nutrition Label Weight Control Beriberi
Comparing Labels Diabetes Mellitus Cachectic
Nutrition at Various Stages Cardiovascular Disease
Calorie
of Life Cancer
Carotene
Pregnancy and Lactation Diet and Culture
Catalyst
Breast-Feeding
Cellulose
Cheilosis
OBJECTIVES Cholecalciferol
The student should strive to meet the following performance objectives and Cobalamin
demonstrate an understanding of the facts and principles presented in this chapter Coenzyme
through written and oral communication. Digestion
1. Define the key terms as presented in the glossary. Diuretic
2. Describe the relation of nutrition to the functioning of the diges- Electrolytes
tive system. Extracellular
3. Identify the seven basic nutrient types. Fat-Soluble
4. Explain the relationship and balance among the three energy Folic Acid
nutrients. Glycogen
5. Distinguish between water-soluble and fat-soluble vitamins. Homeostasis
6. Discuss herbal supplements. Major Mineral
7. Explain the reason for nutrition labels on food packaging. Metabolism
8. Read and interpret nutrition facts and ingredients on three food Niacin
packages. Nutrient
9. Discuss various therapeutic diets, and explain how each can help Nutrition
to control a particular disease state or accommodate a change in Oxidation
the life cycle. Pellagra
Preservative
Processed Food
Pyridoxine
Riboflavin
Saturated Fat
Scurvy

638
638
 KEY TERMS
(continued)
Thiamin
Tocopherol
Trace Mineral
Water-Soluble
Xerophthalmia

Scenario
This morning at Inner City Health Care, clinical medical Corey Boyer, who is in the prime of adolescence and
assistant Wanda Slawson, CMA (AAMA), was conferring capable of eating large quantities of food with little nutri-
with Dr. Rice on three of the center’s patients whose diets tional value; and Annette Samuels, who recently discov-
needed modification. With the help of Dr. Rice, Wanda ered she was pregnant. All these patients have different
was putting together dietary plans for patients Edith nutritional requirements, and Wanda wants to encourage
Leonard, who is in her early 70s and is losing weight all to review and modify their diets.
because she is not eating well enough or often enough;

INTRODUCTION
The human body is in a constant state of fluctuation. The recognize the role of nutrition in maintaining health and
outside environment is constantly changing, and the body will use a knowledge of nutritional principles to encourage
requires homeostasis, or a continual internal environ- patients to adopt a healthy lifestyle.
ment, which, in turn, gives us a requirement for nutri-
ents. The nutrients we take into our bodies replenish the
materials we have used. In this way, homeostasis is main- NUTRITION AND DIGESTION
tained, and our bodies have a relatively balanced inter-
nal environment. Nutrition is the study of the taking of Nutrition includes ingestion, digestion, absorp-
nutrients into the body and how the body uses them. tion, and metabolism of food. Good nutrition
The normal healthy individual will consume and results in longer life spans and healthier individu-
use close to what the body needs to stay healthy. However, als through the control of preventable diseases.
some individuals either do not consume enough nutri-
ents or consume too much of a particular type of nutri-
ent. These are poor diets that can cause particular disease Spotlight on Certification
states, and the diet must be modified to return the patient
to good health. In addition, specific disease states, such as RMA Content Outline
diabetes mellitus, warrant a change from a normal diet to • Disorders and diseases
control the progress of the disease. The human body also • Health and wellness
goes through many changes in a lifetime and with these
• Nutrition
changes come new nutritional needs. Protecting health
requires paying attention to strategies to prevent disease. CMA (AAMA) Content Outline
The choices made regarding foods consumed and the qual- • Developmental stages of the life cycle
ity of nutritional intake have a significant impact on the • Patient instruction
quality and longevity of life. Healthy food choices contrib-
• Basic principles (food pyramid)
ute to living longer and preventing major health issues.
This chapter explores the balance of nutrients required • Special needs (diets)
for good health and examines therapeutic modifications to CMAS Content Outline
the diet that should take place at various life stages or in • Know various disorders and diseases
the presence of disease. The astute medical assistant will

639
640 UNIT 6 Advanced Techniques and Procedures

The food eaten by an individual is used to build Nutrients also provide building blocks so that pro-
and repair cells and tissues of the body. Therefore, teins or phospholipids can be made within the
it is important to have knowledge and informa- body, or they can act as catalysts to help processes
tion about nutrition and to make appropriate food such as the clotting mechanism proceed at a faster
choices for optimum health. A well-nourished indi- rate. Essentially, ingested substances that help the
vidual is less susceptible to infection and disease. body stay in its homeostatic state can be called
Patient education is important especially nutrients.
when the normal diet must be modified to treat the Nutrients can be divided into two groups:
patient’s illness. The medical assistant can answer those that provide energy and those that do
patient questions only through a knowledge of not. Both groups are necessary for good health.
good nutrition and what constitutes the therapeu- Table 22-1 lists examples of each of these two
tic diets prescribed by the provider. groups. Those that provide energy are composed
Digestion involves the physical and chemical of three types: carbohydrates, fats (lipids), and
changes to food that the body makes to make it proteins. Each of these three substances is used
absorbable. Absorption is the transfer of the nutri- in ways other than making energy, but it is impor-
ents from the gastrointestinal tract into the blood- tant to remember that these are the only sub-
stream. Without absorption, the body would not stances from which the body can derive energy.
receive the nutrients. Figure 22-1 shows the diges- Nutrients that do not provide energy are also
tive system and its basic functions. important and perform other vital functions as
described previously. These nutrients include
vitamins, minerals, water, and fiber.
TYPES OF NUTRIENTS
Nutrients serve many purposes in the body. Some
Energy Nutrients (Organic)
nutrients provide energy for the body to perform The three energy nutrients—carbohydrates, fats,
activities such as the pumping of the heart, the and proteins—have one thing in common: all can
division of cells, or the contraction of muscles. be converted into energy.

1. Mouth: Teeth and tongue begin 2. Salivary Glands: Begin chemical

mechanical digestion by digestion as salivary amylase
breaking apart food. begins to change starch to
maltose.

4. Stomach: Hydrochloric acid

3. Esophagus: Peristalsis and prepares the gastric area for
gravity move food along. enzyme action. Pepsin breaks
down protein into smaller
proteins. In children,
rennin breaks down milk
5. Liver: Produces bile. proteins. Lipase acts on
emulsified fats.

8. Small Intestine: Produces

enzymes, prepares foods for
6. Gallbladder: Stores bile and absorption, lactase converts
releases it into small intestine lactose, maltase converts
to emulsify fats. maltose, sucrase converts
sucrose to simple sugars.
Peptidases further reduce
proteins to amino acids.
7. Pancreas: Enzymes are
released into the small
intestine. Amylase breaks 9. Large Intestine: Absorbs water
down starch. Lipase breaks and some other nutrients and
down fats. Pancreatic proteases collects food residue for
break down proteins. excretion.

Figure 22-1 The digestive system.

 CHAPTER 22 Nutrition in Health and Disease 641

Starches are the most important dietary complex

Table 22-1 Types of Nutrients
carbohydrate. Glycogen is only ingested in small
quantities, but is an important carbohydrate form
Energy Nutrients for storage of glucose in the body. Fiber is a special
(Organic) Function
polysaccharide because it cannot be digested.
Carbohydrates Provide energy
Because the simple sugars are composed of only
(CHO) one or two units of sugar, their digestion takes little
time, and absorption occurs soon after ingestion.
Fats (lipids) Provide energy The body initially experiences a large increase in
sugar concentration in the blood, which is brought
Proteins Build and repair tissues down to within a normal range by the release of insu-
lin. The complex carbohydrates require more time
Other Nutrients Function
to digest, and as a result there is a slow absorption
of the single-carbohydrate units as the larger starch
Vitamins Regulate body processes
molecule is broken down. This is demonstrated in
Figure 22-2. In this case, there would be a moder-
Minerals Regulate body processes
ate increase in the sugar levels in the blood, and this
would continue for a longer period. A continuous
Water Regulate body processes
level of sugar in the bloodstream is necessary for a
constant energy supply (Figure 22-3). The principle
Fiber Regulate body processes
sources of carbohydrates are fruits, vegetables, cereal
grains, and sugar.

Carbohydrates. Carbohydrates provide the major

source of energy and are made up of carbon, hydro-
gen, and oxygen. Although many compounds are 300
made up of these three elements, it is the ratio of
Plasma glucose mg/dL

these elements that is important. Carbohydrates

are made up of units called sugars. The scientific
term for sugar is saccharide, and carbohydrates can 200

exist as monosaccharides, disaccharides, or poly-

saccharides.
A monosaccharide is composed of a single
100
unit of sugar, whereas disaccharides have two units
of sugar. Together, monosaccharides and disac-
charides are known as simple sugars. Examples of
monosaccharides are glucose, fructose, and galac-
tose. Glucose is the sugar that the body uses most 60 120 180 240

efficiently, thus most ingested sugar is broken down Minutes after glucose ingestion
in the intestines and converted to glucose in the
liver. Fructose is found largely in fruits, whereas
Complex carbohydrate
galactose is a product of lactose digestion. Examples
of disaccharides are lactose, maltose, and sucrose. Simple sugar
Lactose is found primarily in milk or milk products.
Maltose is a product of starch breakdown. Sucrose Figure 22-2 This graph shows how complex carbo-
is one of the sweetest sugars and is what we com- hydrates (red broken line) and simple sugar (black
monly refer to as table sugar. It occurs naturally in line) are used by the body (in minutes) after glucose
many fruits and vegetables, as well as sugar cane ingestion. Simple sugar peaks to approximately
and the sugar beet, which are commercial sources 120 to 160 mg/dL in 60 minutes and returns to a
of refined sugar. normal level within 120 minutes. Complex carbohy-
Polysaccharides are also known as complex drates (red broken line) never increase to more than
carbohydrates. They are made up of many units approximately 130 to 140 mg/dL during a 60-minute
of sugar connected together. The most common period; that level is maintained for the next
polysaccharides are starches, glycogen, and fiber. 180 minutes and then returns to normal.
642 UNIT 6 Advanced Techniques and Procedures

A B

Figure 22-3 The need for carbohydrates is constant whether you are (A) active or (B) at rest.

Fats. Fats, also called lipids, are also composed

of carbon, hydrogen, and oxygen, but in a ratio ero
l
c
different from carbohydrates. They exist as triglyc- Gly
erides in the body. A triglyceride has three fatty
acids attached to a glycerol molecule (Figure 22-4).
The fatty acid component of a triglyceride has sev-
eral important characteristics. The first is whether
it is essential to the diet. The only true essential
fatty acid in the human diet is linoleic acid, and all
other fatty acids the body requires can be derived
from this. Another important characteristic of fatty
acids is saturation. When a fatty acid is saturated, Fatty Acids
every carbon molecule on the fatty acid holds as
many hydrogens as possible. If it does not hold all
the hydrogens possible, it is called unsaturated.
The more unsaturated the fatty acid, the more liq-
uid the fat. For example, lard has saturated fatty
acids and a thick consistency compared with corn Figure 22-4 A triglyceride has three fatty acids
oil, which has relatively unsaturated fatty acids and attached to a glycerol molecule.
a thin consistency. If an unsaturated fat is hydroge-
nated, combined with hydrogen, it becomes more
saturated. Saturated fats are more common in
foods from animal sources than from plant sources. and hydrogen is added to it. This makes the prod-
Generally, saturated fatty acids tend to increase the uct solid at room temperature. It gives certain
level of fats and cholesterol in the blood. foods a longer shelf life (stays fresh longer) and
Trans unsaturated fatty acids (trans fats) are un- a better taste. The process, however, turns healthy
healthy fats because they increase low-density lipo- fat (vegetable oil) into unhealthy fat, trans fats.
proteins (LDL), bad cholesterol, and decrease Trans fats are found in meat and dairy prod-
high-density lipoproteins (HDL), good cholesterol. ucts, as well as stick margarine, solid shortening,
Trans fats are produced by a process known and many commercially prepared foods. Foods that
as hydrogenation. Vegetable oil (liquid) is heated are considered convenience foods such as snacks,
 CHAPTER 22 Nutrition in Health and Disease 643

potato chips, cookies, crackers, and cakes are high quantities. A complete protein is so named because
in trans fats. Margarine, fast foods, cereal, dough- it has all eight of the essential amino acids. An incom-
nuts, and french fries are also examples. Experts plete protein does not contain all of these. The best
recommend that the daily amount of trans fats be sources for complete proteins are meats and animal
as close to zero as possible. The FDA requires that products such as milk and eggs. Most plants provide
all food packaging labels show the amount of trans only incomplete proteins and must be combined
fats per serving in the product. Table 22-2 lists with complementary incomplete proteins to obtain
some common foods and their grams of total fat all eight amino acids (Figure 22-5).
and trans fat per serving. Although protein is described as an energy
nutrient, its main function is not to provide energy
Proteins. Although protein is also composed of car- but to provide amino acids to be used as building
bon, hydrogen, and oxygen, it contains one more components of body proteins, which can be used
important element: nitrogen. The basic structural as enzymes, hormones, and as the basic structural
unit of protein is the amino acid. There are 22 amino unit in all body tissues and cells. The body uses car-
acids in proteins. Eight of these are needed in the bohydrates and fats as its primary energy sources;
diet for the body to function normally. One more, however, when these are in short supply, the body
histidine, is essential only during childhood. The diverts its use of protein for structural purposes to
rest of the amino acids can be synthesized from the use it as an energy source. This has detrimental
eight, provided that they are present in adequate effects on the body.

Table 22-2 Grams of Fat per Serving of Some Common Foods

Product Serving Size Total Fat Saturated Fat Trans Fat

Butter 1 tbsp 10.8 7.2 0.3

Cake (pound) 1 slice 16.4 3.4 4.3

Cookies (filled with cream) 3 6.1 1.2 1.9

Doughnut 1 18.2 4.7 5.0

French fries (fast food) Medium 26.9 6.7 7.8

Granola bar 1 bar 7.1 4.4 0.4

Margarine (stick) 1 tbsp 11.0 2.1 2.8

Margarine (tub container) 1 tbsp 6.7 1.2 0.6

Mayonnaise 1 tbsp 10.8 1.6 0.0

Milk (whole) 1 cup 6.6 4.3 0.2

Potato chips Small bag 11.2 1.9 3.2

Ramen noodle soup 42 g 7.2 3.2 0.9

Shortening (solid) 1 tbsp 13.0 3.4 4.2

Wheat crackers 50 g 10.0 2.0 4.0

Source: Food and Drug Administration Center for Food Safety and Applied Nutrition; U.S. Department of Agriculture National Nutritional Database.
644 UNIT 6 Advanced Techniques and Procedures

Patient Education
Trans Unsaturated Fatty Acids • Make foods from scratch to avoid trans
• Use a margarine that is soft at room tem- fats. Foods such as breads, dips, salad
perature; it is lower in trans fat. Some mar- dressings, cereals, and soups can be
garines are available that are entirely trans made without hydrogenated fats.
fat free. If a food label lists hydrogenated oil or
• Olive oil is a wise choice for salads and for shortening as one of its main ingredients
dipping bread, and butter is a better option (usually one of the first listed ingredients), it
than margarine. has a large amount of trans fats in it. Avoid
the product altogether, or eat only small
• Olive oil and canola oil are best for sauté-
amounts.
ing and frying.

Similarly, if 10 g protein were used for energy, it would

yield 40 Calories.

+ 10 g 4 Calories
= × = 40 Calories
protein 1 gram of protein
Fats, in comparison, yield nine Calories for
Amino acids Amino acids from All essential
dairy products amino acids for
every gram of fat. Fats, therefore, are a more energy-
from grains
complete protein rich food source than carbohydrates or proteins
because they give more Calories for every gram used.
Figure 22-5 Some foods, such as grains and dairy If 10 g fat were used, it would yield 90 Calories.
products, may not have all the essential amino acids
when considered separately. Combined, however, these 10 g × 9 Calories = 90 Calories
form a complete protein and therefore are considered fat 1 gram of fat
complementary. The total of all changes, chemical and physi-
cal, that take place in the body is called metabolism.
The metabolic rate concerns itself with the changes
Deficiencies in protein usually occur together in the body with respect to energy. It is the balance
with deficiencies in total Calories. Failure to thrive between the energy that is brought into the body and
is caused by a lack of protein in infants and young the energy used by the body. Energy is used during
children. every action of the body, including voluntary activi-
ties such as walking or riding a bicycle and involun-
Energy Balance. Although all of the energy tary activities such as breathing and cellular repair.
nutrients are capable of supplying energy to The level of energy required for activities
the body, they do so in different ways and in vary- that occur when the body is at rest is called basal
ing amounts. The amount of energy that a sub- metabolism. The basal metabolic rate (BMR) var-
stance is able to supply can be measured in large ies according to several factors. For example, the
Calories. Nutrition is discussed in terms of the BMR is higher in individuals with leaner body mass
large Calorie, which is always capitalized to dis- (muscle) because more energy is needed to fuel
tinguish it from the small calorie. The large Calo- the muscles than to store fat. BMR also is higher
rie (abbreviation: C or Cal) is also expressed as in individuals during periods of high growth rate,
a kilocalorie (abbreviation: kcal). One thousand such as in children and pregnant women.
small calories equal one large Calorie or one Ideally, an individual will take in as many
kilocalorie. Calories as the body will use each day. When a per-
Carbohydrates and proteins both give four Cal- son takes in more Calories than will be used, the
ories for each respective gram. So, if 10 g pure carbo- body will store the excess energy in the form of fat.
hydrate were ingested, it would yield 40 Calories. When a person uses more energy than is brought
into the body, the body breaks down these stores.
10 g × 4 Calories = 40 Calories When the stores of fat are depleted, the body will
carbohydrate 1 gram of carbohydrate start to break down its protein structures.
 CHAPTER 22 Nutrition in Health and Disease 645

For an optimal energy balance in the body, the have available great amounts of food from the dairy
largest percentage of Calories in the diet should and meat groups. Unfortunately, dairy products
come from carbohydrates. Ideally, the percentage and meats, although containing many good nutri-
should be 50% to 60% of total calories consumed. ents, also contain a great deal of fat. Studies have
The percentage of Calories attributable to fat shown that many Americans are obese (as defined
should not be greater than 30%, with a percent- as weight being at least 20% greater than what their
age closer to 20% being preferred. Proteins should ideal weight should be). The U.S. diet is too high
make up 10% to 20% of Calories in the diet. in fat, has too many calories, has too much salt and
Take note that these values are the percent- cholesterol; and has insufficient amounts of com-
age of the total Calories derived from each energy plex carbohydrates and fiber. As a result, many ill-
nutrient—not the percentage of grams. This dis- nesses and diseases occur, such as heart disease,
tinction is important because of the difference in high blood pressure, diabetes, and cancer.
Calories derived from each energy nutrient. Figure Because obesity in the United States has become
22-6 gives an example of these calculations. Note such a serious problem, there has been much interest
the percentages of fat, carbohydrate, and protein in modifying the U.S. Department of Agriculture’s
found in the “mystery” food. All fall outside of the pyramid for ideal weight. Health experts believe that
recommended percentages for each. the emphasis on 6 to 11 servings from the bread,
In many cultures outside of the United cereal, rice, and pasta groups (carbohydrates) is a
States, rice, bread, and noodles are the contributing factor to obesity. Ongoing studies and
basis of the diet. In the United States, we research has led to redesign of the pyramid with
less emphasis on the carbohydrate group and more
emphasis placed on the fruits, vegetables, whole
grains, legumes, and nuts (Figure 22-7).
The new food pyramid has specific information
about portions and calories. It can help individuals
Label for Mystery Food: Amount Per Serving
get individualized nutrition and exercise advice.
Calories 149 Each color on the pyramid represents a food
Total Fat 9g group:
Total Carbohydrate 14g
Total Protein 3g • Orange represents grains. The recommendation
is to eat 5–8 ounces of grain per day, 3 of which
should be from whole grain breads, pasta, rice,
The first calculation to make is one that converts grams to cereal, or crackers.
Calories.
• Green represents vegetables. For a low calorie per
9 Calories day intake, 21⁄2 cups of vegetables should come
9 grams of fat × = 81 Calories due to fat
gram from all five vegetable groups several times a week.
14 grams of 4 Calories 56 Calories due to • Red represents fruits. Two cups daily is the recom-
× = mended intake.
carbohydrate gram carbohydrate
• Yellow represents oils. Most oil should come from
3 grams of 4 Calories 12 Calories due to nuts, fish, and vegetable oil, while limiting butter,
× =
protein gram protein lard, stick margarine, and shortening.
The next calculation is to find the percentage of total Calories • Blue represents milk. Three cups per day of fat-free
due to each of the energy nutrients. or low fat milk or milk products is recommended.
• Purple represents beans and meat. Choose lean
81 Calories due to fat
= 54% meat and poultry and use fish, beans, nuts, seeds,
149 total Calories
and peas.
56 Calories due to carbohydrate • The action figure represents physical activity
= 38%
149 total Calories (Table 22-3).
12 Calories due to protein The new government Web site (http://www.
= 8%
149 total Calories mypyramid.gov) allows individuals to input their
age, gender, and activity level. By doing so, they
Figure 22-6 Calculations of percentages of total get a recommendation about their personal daily
calories from fat, carbohydrate, and protein. calorie intake and physical activity level.
646 UNIT 6 Advanced Techniques and Procedures

Figure 22-7 The U.S. Department of Agriculture’s guide to a balanced diet takes the shape of a pyramid. The
foundation of a good diet is made up of a balance between food and physical activity. (Courtesy of U.S. Depart-
ment of Agriculture.)

Other Nutrients (Inorganic) Vitamins. Vitamins are a class of nutrient in which

Many other nutrients are essential to maintain- each specific vitamin has a function entirely its own.
ing good health. Although they do not provide They are complex molecules and are required by
the body with energy, they perform a variety the body in minute quantities. Vitamins were first
of necessary functions. They include vitamins, named as letters of the alphabet. These names have
antioxidants, herbal supplements, minerals, water, been supplemented with chemical names and both
and fiber. should be learned. Vitamins generally have one of
 CHAPTER 22 Nutrition in Health and Disease 647

two functions: to facilitate cellular metabolism by

Table 22-3 Health Benefits of Regular
acting as a coenzyme with a catalyst, and to act as
Physical Activity
a component of tissue structure. A catalyst allows
Increase physical fitness a chemical reaction to proceed at a much quicker
rate and without as much energy input, and the
Helps build and maintain healthy bones, muscles, coenzyme is the nonprotein part that acts with it.
and joints Neither a catalyst nor its coenzyme is used in the
reaction, thus each can be used again and again.
Builds endurance and muscular strength Vitamins that work with catalysts are only needed
in minute quantities.
Helps manage weight
Vitamins are divided into two classes based
Lowers risk factors for cardiovascular diseases, colon
on solubility. The vitamins that are not soluble in
cancer, and type 2 diabetes water are said to be fat soluble. This is important
because the fat-soluble vitamins are not carried
Helps control blood pressure into the bloodstream easily and are stored in fatty
tissue, especially the liver. The water-soluble vita-
Promotes psychological well-being and self-esteem mins are not so easily stored, and blood levels must
be maintained by constant dietary intake. Toxicity
Reduces feelings of depression and anxiety can occur with high doses of either type of vitamin
but is more likely to occur with the fat-soluble vita-
Source: Nutrition and Your Health: Dietary Guidelines for Americans
(6th ed.), 2005 mins because they are stored in the body. The vita-
mins are listed in Table 22-4.

Table 22-4 Vitamin Sources and Functions

Name Food Sources Functions Deficiency/Toxicity

Fat-Soluble Vitamins

Animal Antioxidant Deficiency

Liver Dim light vision Night blindness
Whole milk Maintenance of Xerophthalmia
Butter mucous membranes Respiratory infections
Vitamin A Cream Growth and develop- Bone growth ceases
ment of bones
(carotene or retinol) Cod liver oil Toxicity
Plants Cessation of menstruation
Dark green leafy vegetables Joint pain
Deep yellow or orange fruit Stunted growth
Fortified margarine Enlargement of liver

Animal Bone growth Deficiency

Eggs Rickets
Liver Osteomalacia
Fortified milk Osteoporosis
Vitamin D
Plants Poorly developed teeth
(cholecalciferol)
None Muscle spasms
Toxicity
Kidney stones
Calcification of soft tissues
(continues)

Vitamins are divided into two classes based on water solubility: fat soluble and water-soluble vitamins.
648 UNIT 6 Advanced Techniques and Procedures

Table 22-4 Vitamin Sources and Functions (continued)

Name Food Sources Functions Deficiency/Toxicity

Animal Antioxidant Deficiency

Vitamin E None Neurologic defects
(alphatocopherol, Plant Destruction of red blood cells
betatocopherol, Wheat germ (RBCs)
deltatocopherol, Margarines Toxicity
gammatocopherol) Salad dressing Hypertension
Nuts

Animal Blood clotting Deficiency

Egg yolk Prolonged blood clotting
Liver Toxicity
Vitamin K
Milk Hemolytic anemia
(phytonadione)
Plant Jaundice
Green leafy vegetables
Cabbage

Water-Soluble Vitamins

Animal Coenzyme in oxidation Deficiency

Liver of glucose Beriberi
Eggs Gastrointestinal tract, nervous
Fish and cardiovascular system
Thiamin
Pork problems
(vitamin B1)
Beef Toxicity
Plants None
Whole and enriched grains
Legumes

Animal Metabolism of Deficiency

Pork carbohydrates Cardiovascular system, nervous
Beef Maintains normal system and gastrointestinal
appetite and nervous
Liver system disorders
system function
Eggs Toxicity
Thiamin
Fish None
Plants
Whole and enriched grains
Legumes
Brewer’s yeast

Animal Aids release of energy Deficiency

Poultry from food Cheilosis
Milk Glossitis
Riboflavin Fish Photophobia
(vitamin B2) Plants Toxicity
Green vegetables None
Cereals
Enriched bread
(continues)
 CHAPTER 22 Nutrition in Health and Disease 649

Table 22-4 (continued)

Name Food Sources Functions Deficiency/Toxicity

Animal Synthesis of nonessential Deficiency

Pork amino acids Irritability
Milk Conversion of Depression
Pyridoxine tryptophan to niacin
Eggs Dermatitis
(vitamin B6) Antibody production
Plants Toxicity
Whole grain cereals Liver disease
Legumes Rare

Animal Synthesis of RBCs Deficiency

Seafood Maintenance of myelin Degeneration of myelin sheaths
Meat sheaths Pernicious anemia
Vitamin B12
Eggs Toxicity
(cobalamin)
Milk None
Plants
None

Animal Transfers hydrogen Deficiency

Milk atoms for synthesis of Pellagra
Niacin (vitamin B3, adenosine triphosphate
Eggs Toxicity
nicotinic acid)
Fish Vasodilation of blood vessels
Poultry

Animal DNA synthesis Deficiency

Liver Synthesis of RBCs Anemia
Plants Protein metabolism Glossitis
Folate (folic acid) Spinach Macrocytic anemia
Asparagus Neural tube defects
Broccoli Toxicity
Kidney beans None

Animal Coenzyme in carbohy- Deficiency

Milk drate and amino acid None
metabolism
Liver Toxicity
Biotin Niacin synthesis from
Plants None
tryptophan
Legumes
Mushrooms

Animal Metabolism of carbo- Deficiency

Eggs hydrates, lipids, and None
proteins
Liver Toxicity
Synthesis of
Salmon None
Pantothenic acid acetylcholine
Plants
(vitamin B5)
Mushrooms
Cauliflower
Peanuts
Yeast
(continues)
650 UNIT 6 Advanced Techniques and Procedures

Table 22-4 Vitamin Sources and Functions (continued)

Name Food Sources Functions Deficiency/Toxicity

Fruits Prevention of scurvy Deficiency

All citrus Formation of collagen Scurvy
Plants Healing of wounds Muscle cramps
Vitamin C Broccoli Release of stress Ulcerated gums
(ascorbic acid) Tomatoes hormones Toxicity
Brussel sprouts Absorption of iron Increase uric acid level
Potatoes Antioxidant Hemolytic anemia
Kidney stones

There are four fat-soluble vitamins, which of vitamin K include fats, fishmeal, oats, alfalfa,
include vitamins A, D, E, and K. The first one, vita- wheat, and rye.
min A, has two forms. The form that is used by the
body is retinol, which is found in animal foods. The Antioxidants. Antioxidants are an important topic
form found in plants is carotene. Carotene is con- in nutrition. Some think they are as important as
verted into retinol in the body. Vitamin A is part the discussion about fats. Antioxidants are pow-
of the pigment rhodopsin found in the eye and erful and beneficial to us. The four primary anti-
is responsible in part for vision, especially night oxidants are betacarotene (vitamin A), vitamin C,
vision. Vitamin A also gives strength to epithelial vitamin E, and selenium.
tissue and is required for healthy skin and mucous When our bodies use oxygen to burn (oxi-
membranes. It is also an antioxidant. Sources of dize) food for energy, the process results in the for-
vitamin A include animal fats, butter, and cheese. mation of free radicals. Most times our bodies take
Vitamin D, also called cholecalciferol, is care of the free radicals by producing enzymes to
the fat-soluble vitamin involved in the metab- fight them.
olism of calcium in the body. It not only helps If free radicals are excessive, health can be
with absorption of this important mineral, but seriously impaired. Evidence has shown that excess
also with formation and maintenance of bone free radicals cannot be fought successfully and the
tissue. Vitamin D can be made in the body with body cannot get rid of them.
exposure to sunlight. Rickets, osteomalacia, and The radicals attack the cells’ DNA and blood
osteoporosis are diseases caused by a deficiency vessel cells, contributing to cardiovascular disease,
in vitamin D. When deficiencies occur, especially strokes, arthritis, cataracts, and other diseases that
during childhood, malformation of the skeleton may be degenerative in nature. These are seen in
is seen. Sources of vitamin D include milk, cod older adults.
liver oil, and egg yolk. Free radicals are not only a by-product of oxi-
Another fat-soluble vitamin is vitamin E, or dation, they form with exposure to environmental
tocopherol. It too is an antioxidant, possibly reduc- influences such as water and air pollution, ciga-
ing the likelihood of oxidation of substances. This rette smoke, and certain foods, like fried foods.
ability to reduce oxidation has recently led to sug- Antioxidants fight free radicals through those
gestions that vitamin E may slow the aging process, enzymes in our bodies, those we ingest in food,
but its true effectiveness is yet to be demonstrated. and those we take as supplements. Vitamins A (as
Vitamin E is found in lettuce and other green leafy betacarotene), C, E, and selenium provide power-
vegetables, wheat germ, and rice. ful benefits because they fight against oxidation
Vitamin K is a fat-soluble vitamin required that produces free radicals.
for the production of prothrombin. Prothrombin Vitamin C, or ascorbic acid, is a water-soluble
is one agent responsible for the clotting of blood. vitamin. Vitamin C is a constituent of connective
Deficiencies can result in prolonged blood clotting tissue and acts to hold cells together. A deficiency
time and hemorrhage. Vitamin K is synthesized of vitamin C causes scurvy, in which the walls of the
by intestinal bacteria, and bile is required for capillaries become so weakened that they burst.
its absorption. About half of the body’s require- Vitamin C also helps with wound healing and with
ment for vitamin K is fulfilled in this way. Sources the absorption of iron. Sources include most fresh
 CHAPTER 22 Nutrition in Health and Disease 651

fruits (especially citrus fruits) and vegetables (espe- Most patients who are healthy and eat a nutri-
cially tomatoes). tious diet do not need a supplement in the form of
The last group of water-soluble vitamins is a multivitamin. A balanced diet is the best overall
the B-complex vitamin. It is important to remem- source of nutrients. Some people may need a sup-
ber that each vitamin in the B-complex is a sepa- plement because they are at risk for disease such
rate vitamin with distinct functions. Vitamin B1, as cancer and heart disease. Examples of people
or thiamin, helps in the conversion of glucose to at high risk are patients who have a chronic illness
energy. The disease beriberi is caused by thiamin such as AIDS or cancer; who have gastrointestinal
deficiency and is characterized by neuritis, edema, problems that impair digestion or absorption; who
and cardiovascular changes. Sources include whole are dieting; who are vegans or vegetarians; preg-
grain cereals, peas, beans, vegetables, and brewer’s nant and breast-feeding women; and patients older
yeast. Vitamin B2, or riboflavin, is also involved than 50 years (many older than 50 years have dif-
in energy production. It is important in the pro- ficulty absorbing B vitamins from food, and their
duction of proteins and is necessary for normal level of vitamin D may be low because of lack of
growth. Sources include eggs, liver, milk, brewer’s sunshine and eating poorly).
yeast, and green vegetables. A third B-complex Patients should check with their provider
vitamin, niacin, works with both thiamin and ribo- before beginning to take multivitamin supplements.
flavin in the production of energy. Lack of niacin
results in gastrointestinal and central nervous sys- Herbal Supplements. Herbs are medicinal plants
tem disturbances. All three of these vitamins are and are also known as botanicals or phytomedi-
important throughout the body. cines. Many have been used as far back as Roman
Vitamin B6, or pyridoxine, has an important times and used as traditional herbal medicine.
role in protein metabolism, especially the synthe- Many patients use herbs for the treatment of ill-
sis of proteins. It is also important in the metabo- nesses and diseases and to maintain health. It is part
lism of fats and carbohydrates. Vitamin B6 is found of a movement toward alternative or complementary
in rice, beans, and yeast. Another B-complex vita- therapy. The herbal supplements can be found in
min, folic acid, is involved in the formation of health food stores, pharmacies, supermarkets, large
DNA and the formation of red blood cells. Folic outlet stores, through the mail, and on the Internet.
acid is found in liver, yeast, and green leafy vegeta- Herbs are made from dried plants and plant
bles. Vitamin B12, or cobalamin, is another vitamin juices. Herbal teas are made by placing the herb
important to the functioning of red blood cells. into boiling water. Natural hormones can be found
This vitamin is responsible for the synthesis of the in soy products.
heme portion of hemoglobin, and deficiencies in Some supplements are helpful; other supple-
vitamin B12 result in the disease pernicious ane- ments are harmful and are banned in several coun-
mia. Because vitamin B12 is only found in animal tries but may be available in the United States. The
foods such as liver, kidney, and dairy products, Food and Drug Administration (FDA) is exempt
pernicious anemia may be a problem for some from having authority over dietary supplements,
vegetarians. Pernicious anemia may also occur although under the Dietary Supplement Health
when there is decreased production of a factor and Education Act of 1994, the FDA must prove
within the stomach that is required for vitamin a product is unsafe before it can order its removal
B12 absorption. Other B-complex vitamins, panto- from store shelves. An example of a potentially
thenic acid, vitamin B5, and biotin, are generally unsafe herbal supplement that the FDA removed
responsible for energy metabolism. from the shelves in 2004 is ephedra. It was used as
Multivitamin supplements may help reduce the an anorectic and a bronchodilator, acts as a stimu-
risk for certain diseases, especially in individuals who lant, and can increase blood pressure and pulse to
do not eat nutritionally sound diets. Individuals who dangerous levels. In 2005, a federal judge struck
may be more likely to suffer vitamin deficiencies down the FDA’s year-long ban on ephedra and sup-
because of poor nutrition include the elderly, men- plements containing ephedra. A Utah supplement
tally challenged individuals, young children without company challenged the ban that prompted the
proper care, alcoholics, and patients with chronic judge’s ruling. In 2006, the ruling was appealed to
diseases such as Crohn’s disease, cystic fibrosis, and the U.S. Court of Appeals for the Tenth Circuit in
celiac disease. Some studies show a reduced risk for Denver, Colorado, and the Appeals Court upheld
coronary artery disease in patients who take a multi- the FDA’s ban on ephedra. Sale of ephedra or
vitamin coupled with antioxidants. Researchers supplements containing ephedra are illegal in the
believe that B vitamins and antioxidants may help United States. Although ephedra is an illegal and
keep plaque from forming in arteries. banned substance, it is widely used by athletes.
652 UNIT 6 Advanced Techniques and Procedures

Be sure to ask patients about all substances 2002, estrogen has not been given as a preventive
or remedies they may be using, including herbs, measure because a large study by the Women’s Health
vitamins, teas, or others. Most patients do not con- Initiative showed an increased risk for heart disease,
sider supplements to be medicines and may not stroke, cancer, and breast cancer in postmenopausal
think to mention them when asked what medica- women who took estrogen.
tions they are taking. Herbs can interact unfavor- Phosphorus (P) is another mineral important
ably with certain prescription and over-the-counter in bone formation. Phosphorus also is involved in
medications. numerous activities associated with energy metab-
olism, as well as maintaining a proper pH balance
Minerals. Minerals differ from vitamins in two in the blood.
distinct ways. Whereas vitamins are complex mole- Sodium (Na) and potassium (K) are two min-
cules, minerals are singular elements. Another way erals that act as electrolytes. Together they work
that minerals differ from vitamins is that although to maintain proper water balance. They also help
vitamins are only required in minute quantities, in maintenance of proper pH balance and are
some minerals are required in larger amounts. involved in nerve and muscular conduction and
The foundation of the classification of minerals excitability. In addition, potassium is involved in
falls into two groups: major and trace minerals. No protein synthesis and release of insulin from the
matter how small the quantity required of either a pancreas.
mineral or vitamin, all are vital to a healthy body. Magnesium (Mg) is another mineral that is
Some minerals are considered electrolytes, in that involved with energy metabolism. It also functions in
they become ionized and carry a positive or nega- nerve and muscle excitability and is stored in bone.
tive charge. The levels of these minerals in the Chloride (Cl) is important in pH balance and
bloodstream must be carefully balanced for the is the major extracellular (outside the cell) anion.
body to function in a healthy state. It is also a major component of gastric secretions
There are seven major minerals (Table 22-5). in the form of hydrochloric acid.
They are calcium, phosphorus, sodium, potassium, The last major mineral is sulfur (S). It is a
magnesium, chloride, and sulfur. component of one of the amino acids, and there-
Calcium (Ca) is the mineral present in the fore is found in protein. It is also involved in energy
largest quantity in the body because of its involve- metabolism.
ment in the structure of bone and teeth. It is also The trace minerals are required in smaller
important in blood clotting, muscle contraction, quantities but are as important as the major minerals.
and nerve conduction. Its levels in the blood must Some of the more important trace minerals include
be kept at narrow limits to ensure that the nervous iron, copper, chromium, molybdenum, selenium,
and muscular tissues can function. This is espe- manganese, iodine, zinc, cobalt, and fluorine.
cially important for the beating heart tissue. When Iron is vital to life because of its role in the
there is a deficiency of calcium in the diet, calcium heme molecule, which carries oxygen to every cell
is taken from the bones to keep the blood calcium in the body. Iron-deficiency anemia results when
levels constant. The resulting deficient peak bone the diet is low in iron and is characterized by small,
mass may put a person at risk for osteoporosis. This pale red blood cells. Iron is also part of the mol-
condition develops when there is not enough cal- ecule myoglobin, found in muscle cells, and is
cium in the bones and the bones become porous involved in a number of metabolic reactions.
and easily broken. Copper, chromium, molybdenum, selenium,
Women older than 60 years are at greater risk and manganese are trace minerals important as
for osteoporosis than are men. There are no symp- factors in a number of metabolic reactions. Sele-
toms of the disease, and the first indication for the nium acts as an antioxidant and has been receiving
patient is when he or she sustains a fracture caused much of the recent publicity that vitamin E has.
by weakened bones. Iodine is also involved in metabolism but is unique
Most adults in the United States older than in that the only place that iodine is found is in the
60 years do not consume enough calcium in their thyroid hormone produced by the thyroid gland.
diets and risk development of osteoporosis. Dairy Without it, the thyroid gland would be unable to
products contain high amounts of calcium, as regulate the overall metabolism of the body.
do sardines, figs, oranges, almonds, greens, and Zinc is an important constituent of many parts
beans. of the body but most notable is its involvement with
Supplemental estrogen for menopausal women the immune system and growth of tissues. Deficien-
was once a common preventative for bone loss. Since cies lead to decreased ability to heal and reduced
 CHAPTER 22 Nutrition in Health and Disease 653

Table 22-5 The Seven Major Minerals and Their Food Sources

Name Food Sources Functions Deficiency/Toxicity

Milk exchanges Development of bones and teeth Deficiency

Milk, cheese Permeability of cell membranes Osteoporosis
Meat exchanges Transmission of nerve impulses Osteomalacia
Calcium
Sardines Blood clotting Rickets
(Ca)
Salmon Normal heart action Poor bone and teeth formation
Vegetable exchanges
Green vegetables

Milk exchanges Development of bones and teeth Deficiency

Phosphorus Milk, cheese Transfer of energy (Same as calcium)
(P) Meat exchanges Component of phospholipids Anorexia
Lean meat Buffer system Weakness

Fruit exchanges Contraction of muscles Deficiency

Potassium Oranges, bananas Maintaining water balance Hypokalemia
(K) Dried fruits Transmission of nerve impulses Toxicity
Legumes Carbohydrate and protein metabolism Hyperkalemia

Table salt Maintaining fluid balance in blood Toxicity

Meat exchanges Transmission of nerve impulses Increase in blood pressure
Sodium (Na) Beef, eggs
Milk exchanges
Milk, cheese

Table salt Gastric acidity Deficiency

Chloride
Meat exchanges Regulation of osmotic pressure Imbalance in gastric acidity
(Cl)
Eggs Activation of salivary amylase Imbalance in blood pH

Vegetable exchanges Synthesis of adenosine triphosphate Unknown, perhaps mental and

Magnesium Green vegetables Transmission of nerve impulses emotional disorders
(Mg) Bread exchanges Activator of metabolic enzymes
Whole grains Relaxation of skeletal muscles

Meat exchanges Maintaining protein structure Unknown

Sulfur (S)
Eggs, poultry, fish Formation of high-energy compounds

immune resistance. Cobalt is part of vitamin B12 medium in which most biochemical reactions of the
and is therefore important for the functioning of body take place. As a solvent, water is essential for
red blood cells. Fluorine is involved in calcified tis- the removal of toxic waste from the body. In addi-
sues. Its involvement in strengthening teeth has led tion, it is an important component of many struc-
to the fluoridation of most public water supplies. tures; the body is composed of 50% to 60% water.
Its role in the prevention of osteoporosis has been Being the major component of blood, water serves as
suggested but is still under investigation. a transporter. Another function of water is its lubri-
cating role, especially in joints and in the digestive
Water. Water is an important nutrient. The human system. In addition, water helps control temperature
body can go far longer without food than it can with- within the body by eliminating excess heat through
out water. Water has a multitude of functions in the the evaporation of water secreted in the form of
body. It is the major solvent of the body and is the perspiration.
654 UNIT 6 Advanced Techniques and Procedures

Because the body cannot efficiently store water, The government also wants to prevent food
water that is lost daily must continually be replen- companies from fooling people into thinking
ished. Water is lost through perspiration, feces, something has good nutrition when it really does
urine, and respiration. Water can be replenished not. Food companies often put words on their
in part from foods that are ingested, but additional labels to make people believe a product is healthy.
water should also be consumed. It is suggested that Words like “healthy” and “light” or “lite” are not
six to eight glasses of water be taken in per day. adequately descriptive. To discover what is in the
Although other beverages are important sources package and if it is healthy, it is important to read
of water, it should be considered that caffeine and the nutrition label (Figure 22-8).
alcohol are diuretics and may cause the body to lose
water through increased urinary output.
Items on the Nutrition Label
Fiber. Although most fiber is carbohydrate in com- Serving Size. The nutrition information given is
position, it is included in its own section because for one serving of the food. In this case, one serving
of its special characteristics. Fiber comes only from is one-half cup of the food. The package contains
plant sources. An adequate supply of fruits, vegeta- four servings.
bles, and grains is necessary to ensure enough fiber
in the diet. Fiber cannot be digested and therefore Calories. The label lists the number of calories
is not absorbed into the body. Although fiber is not per serving, as well as the number of calories
digested, it is important for the proper functioning from fat per serving. This number should be less
of the gastrointestinal tract because it adds bulk to than 30% of the total calories. For example, if the
feces as it is passed through the intestines; there- total calories is 100, the calories from fat should
fore, it gives the muscles of the tract something be 30 or less.
against which to work. Lack of fiber in the diet has
been implicated in such gastrointestinal disorders The Percentage (%) Daily Value. The percent-
as diverticulitis, constipation, and colorectal cancer. age (%) daily value is the amount of a nutrient
There are several types of fiber. Most are car- obtained by eating one serving of the product. The
bohydrates and include cellulose, gums, mucilages, amount is given in a percentage based on a diet of
algal polysaccharides, pectins, and hemicellulose. 2,000 calories a day. For example, if the packaged
Another important fiber, lignin, is not a carbo- food has 3 g fat, the total fat from eating one serv-
hydrate. It is recommended that the diet contain ing is 5% of the total fat that should be ingested in
20 to 35 g of fiber per day. The U.S. diet tends to an entire day.
be far below this recommendation (approximately
11 g), in part because of the consumption of pro- Fat and Cholesterol. Because it is important to
cessed foods. During processing, fiber is often eat a low-fat diet, nutrition labels list both the
removed. Fiber levels should be increased gradu- total amount of fat and the amount of saturated
ally to prevent gastrointestinal distress, which can
include diarrhea or flatulence.
Nutrition Facts
Serving Size ½ cup (130g)
Servings Per Container About 4
READING FOOD LABELS
Amount Per Serving

When assisting patients to change or modify their Calories 110

Calories from Fat 0
diets, the medical assistant must be knowledgeable % Daily Value*
not only about types of nutrients, but about how Total Fat 0g 0%
these nutrients are expressed in the foods we eat. Sodium 340mg 14%
The nutritional analysis presented on a package’s Total Carbohydrate 20g 7%
food label is a helpful guide to understanding lev- Dietary Fiber 6g 25%
els of fat, cholesterol, sodium, carbohydrate, pro- Sugars 2g
Protein 8g
tein, and vitamins contained in a particular food.
Many of the foods we eat are processed foods, Calcium 6% • Iron 10%
Not a significant source of saturated fat, trans fat,
which are cooked or packaged with parts removed cholesterol, vitamin A and vitamin C.

or ingredients added. We rely on the labels on the *Percent Daily Values are based on a
2,000 calorie diet.
cans, bottles, and boxes to tell us what nutrients
are inside. The government wants to make it easier Figure 22-8 Labels on food packages give facts about
for people to understand the labels. the ingredients and nutrition of the food in the package.
 CHAPTER 22 Nutrition in Health and Disease 655

fat and trans fat per serving. Saturated fat comes

from an animal source and contains more cho- Critical Thinking
lesterol than unsaturated fats, which come from
vegetable sources. The cholesterol content is also Following is information from a label for peanut
listed. butter. Calculate the percentage of calories
from fat, protein, and carbohydrate.
Sodium. The amount of sodium per serving is Serving size 2 tbsp
listed. This category is especially important for Calories 204
patients on a sodium-restricted diet, such as those Protein 9g
with cardiac disease and hypertension. Carbohydrates 6g
Fat 16 g
Carbohydrates. The total amounts of carbo-
hydrates per serving is listed together with the
amount of carbohydrates that come from simple
sugar. These two types of carbohydrates are sepa- be high in fat. It may be surprising that the snack
rated for individuals who are trying to eat more crackers have high fat content. Pretzels are the
complex carbohydrates and less simple sugar. clear winner for a low-fat snack.
Although the labels show total fat and satu-
Other Information. The amounts of fiber, protein, rated fat, the amount of trans fatty acids (TFA) is
and some vitamins and minerals are listed. not listed. Previously, food labels included trans
fats within the total fat amount. The FDA now
Ingredients. The ingredients contained in a pack- requires the amount of TFAs be listed in the label.
aged food are listed on the label. The item that is All three snack items contain TFAs. These snacks
in the largest quantity is listed first. For example, if should be avoided or used sparingly.
a product lists flour first and water second, there is In terms of sodium, calories, and sugar, pret-
more flour than water in the product. Preservatives, zels have the most sodium, but all three are high in
or chemicals added to food to keep it fresh longer, sodium.
and artificial flavors and colors are often added to All three are low in sugar. Their calories are
processed foods. nearly the same as are the amounts of fiber and
protein. The pretzels have the most carbohydrates,
and the crackers have the most artificial flavors,
Comparing Labels colors, and preservatives.
Look at some labels from snack foods that people
eat when they want something crunchy and salty.
Figure 22-9 shows labels from potato chips, pret- NUTRITION AT VARIOUS
zels, and snack crackers. When comparing prod- STAGES OF LIFE
ucts, compare equal amounts. These products list
the serving as 30 or 28 g. That is close enough to For the nutrients discussed in the preceding sec-
compare the labels. tions, ranges of suggested normal requirements
In reviewing these labels, note the amount were given. These ranges should be used as a guide,
of fat and saturated fat in each item. It might be remembering that each individual is unique, and
assumed that potato chips, which are fried, would requirements will vary.

Patient Education
Encourage patients to read and evaluate food • Low sodium content. Total sodium should
labels.Typically, they should look for: be less than 2,400 mg per day.
• The lowest amount of fat, saturated fat, and • High fiber. Fiber intake should be as high as
trans fat. Calories from fat should not be possible.
more than 30% of total calories. • Vitamins and minerals. Some vitamins and
• No cholesterol or low cholesterol. Total minerals occur naturally and sometimes
cholesterol should be less than they are added to food during processing.
300 milligrams (mg) per day.
656 UNIT 6 Advanced Techniques and Procedures

Nutrition Facts
Serving Size 1 oz. (28g/About 15 chips)
Servings Per Container About 12

Amount Per Serving

Calories 140 Calories from Fat 60
% Daily Value* Nutrition Facts
Total Fat 6g 10% Serving Size 6 Crackers (15g)
Saturated Fat 1g 5% Servings Per Container About 24
Polyunsaturated Fat 2g
Monounsaturated Fat 3.5g Amount Per Serving Nutrition Facts
Trans Fat 0g Calories 60 Calories from Fat 15 Serving Size 18 Pretzels (30g)
Cholesterol 0mg 0% Servings Per Container about 8
% Daily Value*
Sodium 130mg 5% Total Fat 1.5g 2%
Potassium 75mg 2% Saturated Fat 0.5g 3% Amount Per Serving
Total Carbohydrate 18g 6% Trans Fat 0g Calories 120 Calories from Fat 0
Dietary Fiber 2g 9% Polyunsaturated Fat 0.5g % Daily Value*
Sugars 3g Monounsaturated Fat 0.5g Total Fat 0g 0%
Protein 2g Cholesterol 0mg 0% Saturated Fat 0g 0%
Sodium 160mg 7% Trans Fat 0g
Vitamin A 0% • Vitamin C 0% Total Carbohydrate 11g 4% Cholesterol 0mg 0%
Calcium 0% • Iron 2% Dietary Fiber less than 1g 1% Sodium 320mg 13%
Vitamin E 8% • Thiamin 2% Sugars 1g Total Carbohydrate 25g 8%
Niacin 2% • Vitamin B6 4% Protein 1g Dietary Fiber 2g 8%
Phosphorus 6% • Magnesium 4% Sugars 3g
Zinc 2% Protein 3g
* Percent Daily Values are based on a 2,000 calorie Vitamin A 0% • Vitamin C 0%
diet. Your Daily Values may be higher or lower
depending on your calorie needs:
Calcium 0% • Iron 2% Vitamin A 0% • Vitamin C 0%
Calories: 2,000 2,500 * Percent Daily Values are based on a 2,000 calorie Calcium 0% • Iron 2%
diet. Your Daily Values may be higher or lower * Percent Daily Values are based on a 2,000 calorie
Total Fat Less than 65g 80g
Sat Fat Less than 20g 25g depending on your calorie needs: diet. Your Daily Values may be higher or lower
Cholesterol Less than 300mg 300mg Calories: 2,000 2,500 depending on your calorie needs:
Sodium Less than 2,400mg 2,400mg Total Fat Less than 65g 80g Calories: 2,000 2,500
Potassium 3,500mg 3,500mg Sat. Fat Less than 20g 25g Total Fat Less than 65g 80g
Total Carbohydrate 300g 375g Cholesterol Less than 300mg 300mg Sat Fat Less than 20g 25g
Dietary Fiber 25g 30g Sodium Less than 2,400mg 2,400mg Cholesterol Less than 300mg 300mg
Calories per gram: Total Carbohydrate 300g 375g Sodium Less than 2,400mg 2,400mg
Fat 9 • Carbohydrate 4 • Protein 4 Dietary Fiber 25g 30g Total Carbohydrate 300g 375g
Ingredients: Whole Corn, Sunflower Oil, Whole Wheat, Rice Flour, Ingredients: Enriched flour (wheat flour, niacin, reduced iron, Dietary Fiber 25g 30g
Whole Oat Flour, Sugar, Salt, Whey Protein Concentrate, Dry thiamin mononitrate [vitamin B1], riboflavin [vitamin B2], folic Calories per gram:
Buttermilk, Whey, Sour Cream (Cultured Cream, Nonfat Dry Milk), acid), partially hydrogenated soybean and/or cottonseed oil† Fat 9 • Carbohydrate 4 • Protein 4
Onion Powder, Natural Flavors, Hydrolyzed Soy Protein, Cultured with TBHQ for freshness, sugar, contains two percent or less of
Whey, Corn Starch, Autolyzed Yeast Extract, Mozzarella Cheese salt, leavening (baking soda, sodium acid pyrophosphate, Ingredients: Organic wheat flour, water, organic
(Pasteurized Part Skim Milk, Cheese Cultures, Salt, Enzymes), Citric monocalcium phosphate), corn syrup, high fructose corn syrup, oat flour and oat bran, organic evaporated cane
Acid, Garlic Powder, Gum Arabic, Glycerol, Disodium Phosphate, sodium stearoyl lactylate, sodium sulfite, soy lecithin. juice, salt, yeast, sodium bicarbonate.
Spice, and Artificial Color (Including Red 40, Blue 1).
†
Less than 0.5g trans fat per serving Allergy information: Produced in a facility that
A CONTAINS WHEAT, MILK, AND SOY INGREDIENTS. B CONTAINS WHEAT, AND SOY INGREDIENTS. C handles peanut butter.

Figure 22-9 Examples of food label from (A) potato chips, (B) wheat crackers, and (C) pretzels.

tional nutrients, but the growth of the placenta,

Critical Thinking the increase in adipose tissue in the mother, the
increased volume of blood, and the growth of
Evaluate your own diet. Write down every item breast tissue also require additional nutrients.
you eat in a day and find the values of the The increased demand for nutrients is not just
nutrients contained in the foods. A medical a demand for Calories, but also for other specific
dictionary is a good source for listing the nutri- nutrients to be increased, most notably protein.
ent value of selected foods. If you are eating Protein requirements are nearly double during
prepared foods, read the package food label. pregnancy. Because of the role vitamins play in
Remember, you are trying to get an idea of metabolism and structure, they are needed in
your average daily diet, so do not change greater quantities than usual. In addition, calcium,
your diet for your analysis unless you plan to phosphorus, and iron are needed in such high
maintain it. What is the balance of your energy amounts that usually a vitamin supplement is pre-
nutrients? Are you getting enough vitamins scribed. It is important that diet modifications are
and minerals? Are you getting adequate not simply an increase in Calories but include qual-
fiber? What modifications could you make? ity foods high in minerals, vitamins, and protein.
Pregnancy is an important time for both fetus
and mother. It is normal and healthy for the mother
Pregnancy and Lactation to gain weight. Her provider will determine the
appropriate amount of weight gain based on the
Pregnancy and lactation both cause marked individual. During lactation, the requirement for
changes in a woman’s body and both require an higher levels of nutrients continues; however, over-
increase in various nutrients. During pregnancy, all, it is not as high as during pregnancy. A baby is
not only does the growth of the fetus require addi- more likely to be healthy and develop normally if
 CHAPTER 22 Nutrition in Health and Disease 657

the mother has good nutritional habits during preg- why pediatricians prescribe infant liquid iron sup-
nancy and breast-feeding. A baby born to a mother plement. Because of the high rate of growth, espe-
who is malnourished may suffer from mental retar- cially of the nervous system, infancy is an important
dation and be of lower birth weight. Lower birth time to be sure nutritional requirements are met.
weight babies (less than 5.5 pounds) have a greater However, according to some pedintricians, over-
mortality rate than do babies of normal weight. feeding in infancy might lead to childhood doesity.

Breast-Feeding Childhood
There are several reasons why breast-feeding is Good eating habits develop during childhood. One
encouraged. The nutrition the infant receives from way parents who have good eating habits can teach
breast milk is a perfect combination of water, lac- their children how to eat healthfully is by example.
tose (sugar), fat, and protein. There are more than Family eating habits, physical activity, and lifestyle
100 ingredients in breast milk that are not found help children to adopt healthy habits. Poor habits
in formula milk. There are no allergic reactions to are established during childhood and are often dif-
mother’s milk. (On occasion, if the mother eats a ficult to alter. This can lead to lifelong health prob-
particular food, the infant may react by being fussy.) lems, such as obesity, diabetes, and cardiovascular
Breast-feeding is nutritionally sound, economical, diseases. The affects of poor nutrition not only are
and sterile. Breast milk is easily digested and does physical but can be emotional as well. When an
not easily cause gastrointestinal upsets. Breast-fed obese child is “picked on” in school, anxiety, low
babies receive temporary antibodies to many dis- self-esteem, depression, and irritability can result.
eases from their mothers. Mother and infant bond Childhood obesity is a serious problem, lead-
during breast-feeding. Breast-feeding helps con- ing to type 2 diabetes because the disease is related
tract the uterus and bring it back to its nonpregnant to being overweight and having a poor diet. Obese
state, thus helping to control postpartum bleeding. children have a greatly increased chance of becom-
While breast-feeding, the mother will con- ing obese as adults if they are obese before becom-
tinue to require nutritious foods taken from the ing a preteen (around age 11 years). Osteoporosis
food pyramid and will need to increase her intake and cardiovascular diseases are other problems
of Calories. If she consumes inadequate Calories, obesity can cause.
the amount of milk produced will be decreased. The availability of electronic devices, such as
When the mother terminates the period of breast- computers, video games, and television, contrib-
feeding (6 months is recommended for the great- ute greatly to a child’s reluctance to be active. Bike
est benefit to the infant), caloric intake should be riding, jumping rope, swimming, and running are
reduced to avoid gaining weight. activities that most children enjoy if encouraged to
engage in them.
Fast foods and carbonated sodas contribute
Infancy to obesity because of their high fat and Calorie
Infancy is a time of continuous growth, and many of content. They are even banned from some schools
the mother’s nutritional requirements during preg- because they are consumed readily and are poor
nancy are still required by the baby after birth. In choices at any age.
the first year of life, the baby will triple birth weight. Clearly, parental education (and therefore
The infant will need two to three times more Calo- of their children) about exercise and good nutri-
ries per kilogram (kg) of body weight than the nor- tion is an excellent way to stop childhood obesity
mal adult. This is true for protein as well, and most and type 2 diabetes. By following MyPyramid for Kids
of the vitamins and minerals are required at greater and MyPyramid for Adults, parents and children can
levels per kilogram. Most of these can be furnished learn to be active every day and to make healthy
with breast milk or formula; however, once iron food choices. The government Web site (http://
stores have been used up, usually in 3 to 6 months, www.MyPyramid.gov) gives ideas on how everyone
the infant will require an iron supplement, which is in the family can eat better and exercise more (Fig-
ures 22-10 and 22-11).

Critical Thinking Adolescence

Write a response to a teenage girl who refuses During adolescence, individuals experience the
to gain weight during her pregnancy. greatest levels of growth. The period of growth
varies from person to person but generally begins
658 UNIT 6 Advanced Techniques and Procedures

Figure 22-10 The U.S. Department of Agriculture’s MyPyramid for Kids reminds children to be physically active
every day, or most days, and to make healthy food choices. (Courtesy of the U.S. Department of Agriculture.)
 CHAPTER 22
Nutrition in Health and Disease
Figure 22-11 The U.S. Department of Agriculture’s Guide to a balanced diet for children. It takes the shape of a pyramid. A good diet is made up of a
balance between food and physical activity. (Courtesy of the U.S. Department of Agriculture.)

659
660 UNIT 6 Advanced Techniques and Procedures

sooner with girls. Except for times of pregnancy

and lactation, the need for total nutrients is great-
Older Adults
est at this stage of growth. At the end of the growth Aging is a natural process of the body. Although
spurt, nutrient requirements decrease, and young aging occurs in different stages and at different
adults must then also decrease the amount of food rates for each individual, some generalities can be
they consume and exercise regularly. made. As we age, our cellular metabolism tends to
Two particular nutrients that especially need to slow and, coupled with a general decline in physi-
be altered during adolescence are iron and calcium. cal activity, results in a decreased requirement for
Iron requirements increase for the female individual Calories. At the same time, there may be an
as she begins menstruation. Calcium requirements increase in nutrient requirement in special circum-
increase for both male and female individuals as stances. There is always an increased requirement
bone development is occurring at a rapid rate. for nutrients, vitamins, and protein in particular
during illness, especially the prolonged illness that
Bulimia and Anorexia Nervosa. Two eating dis- may occur in older adults. With aging, there may
orders that may occur at any age are bulimia and be increased breakdown of cells; as a result, there is
anorexia nervosa, and they are serious in all individ- an increased requirement for nutrients that repair
uals. Girls are more likely than boys to suffer from and build cells and tissues. There is also a need to
these problems. The diets of adolescent girls in gen- ingest more nutrients because of decreased absorp-
eral are deficient in Calories, vitamins, protein, and, tion within the digestive tract. Thus, although there
as previously mentioned, iron and calcium. Many is less need for Calories, there is more need for
girls have concerns about their weight and, coupled nutrient-rich foods. Less need for Calories along
with poor eating habits; when taken to extreme, with less physical activity may lead to weight gain if
can result in bulimia or anorexia nervosa. When a Calorie requirement is not reduced.
patient is diagnosed with bulimia or anorexia ner- This may become difficult for older adults for
vosa, the provider monitors the patient’s weight several reasons. One may be an individual’s psy-
gain or loss, orders laboratory tests at each office chological state. Loneliness and depression affect
visit, and makes an appropriate treatment plan. many older adults, especially after the loss of a
These tasks are facilitated in a total practice spouse. Older adults may not like the idea of eat-
E HR management system, as the patient’s weight ing alone. The economic status of the individual
pattern can be viewed graphically and test also may present problems, as after retirement
results can be easily accessed (Figure 22-12). income generally decreases. Physiologically, taste
tends to diminish with age and interest in food may
Bulimia. Bulimia, although not usually life decrease. In addition, problems with teeth and a
threatening, can result in electrolyte imbalance, decrease in salivary gland secretions may make eat-
dental caries, malnutrition, dehydration, and ing painful. Many medications cause a decrease in
eroded mouth and esophagus. Individuals with saliva production. Also, decreased motility in the
bulimia binge on food and then purge (vomit). gastrointestinal tract may lead to constipation,
Use of laxatives is common. Girls fear becoming making eating uncomfortable. All these factors, as
overweight and usually binge on high-Calorie well as a general unwillingness to break old habits,
dessert-type foods, then self-induce vomiting. may make it difficult to change the diet to keep up
Psychological therapy may help. with the body’s aging process.

Anorexia Nervosa. Anorexia nervosa can be

life threatening. It is characterized by the individ- THERAPEUTIC DIETS
ual severely restricting caloric intake and exercis-
ing excessively. Problems that occur are low blood Thus far this chapter has examined the nutrient
pressure, alopecia, altered metabolism, amenor- requirements of the body under normal condi-
rhea, brain damage, and death. tions. There are times, however, when the body
Both bulimia and anorexia nervosa seem to becomes diseased and nutrient requirements
have some basis in U.S. culture, with teenagers change. These changes may be necessitated by dis-
(mostly women) wanting to look like the slim super ease states such as diabetes mellitus or conditions
models and fashion models (with distorted body resulting from a poor diet such as obesity. Thera-
images) seen in movies and in magazines. peutic diets are designed to overcome or control
These eating disorders are serious, and relapses these conditions.
are not unusual. Sometimes it becomes a lifelong The diet can be modified in a number of ways.
struggle, and repeated therapy sessions are needed. The number of overall Calories can be adjusted, or
 CHAPTER 22 Nutrition in Health and Disease 661

Results from
Regional/ Results to Outside
Pharmacy National Labs Providers

CLINICAL CARE LABORATORY

Patient Assessment
Procedures, Diagnoses & Treatment Plans
Referrals & Follow-up Appointments
Prescriptions Test Reports
Orders for Tests Quality Assurance & Controls
Patient Medical History Safety Standards

Test Results Orders for Tests

Schedules and Tickler Files Safety Standards
Patient Medical History
Medication Administration
Patient Education
Graphical Patient Data Displays

ELECTRONIC
RECORDS
Figure 22-12 The clinical care and laboratory arms of the total practice management system (TPMS). Laboratory
test results and mensurations are tracked in the patient’s electronic medical record and are accessible to providers
when determining an appropriate treatment plan.

one type of nutrient can be restricted or encouraged. Individuals will gain weight if they consume
The consistency, texture, and spiciness of food can more Calories than they need. Conversely, indi-
be varied. The frequency of eating can be increased viduals will lose weight if they use more Calories
or decreased. When counseling patients, remember than they ingest. In either case, the individual
that habits are hard to change. The medical assistant must bring the amount of Calories ingested into
should be supportive and encouraging. balance with the amount used. For the overweight
individual, this means either decreasing Calorie
consumption or increasing Calorie usage, or both.
Weight Control For the underweight individual, it usually entirely
Overweight and underweight are both weight dis- involves increasing Calorie consumption.
orders. The problem in defining overweight or Weight loss has become a big business. How-
underweight stems from the fact that there is no ever, individuals do not need to spend tremendous
ideal weight for an entire population. There is only amounts of money to lose weight; patient education
an ideal weight for the individual. Ideal weight can about low-Calorie, low-salt foods and a moderate
depend on many factors including age, sex, lean exercise program are basic starting points for weight
muscle mass, bone structure, and physical activity. loss. Because losing more than 1 to 2 pounds a week
Obesity is generally considered more than 20% can put an individual into nutritional deficiency,
overweight. Underweight is weight 10% to 15% goals should not be set higher than this. Modifica-
below average. Height–weight tables now generally tions made to the diet should then be maintained
give ranges that vary more than 20 pounds. The even after the weight is lost and should be continued
ratio of fat tissue to lean muscle mass is a better throughout life. Losing weight takes much effort,
indicator of whether individuals are at their ideal and the patient needs constant encouragement and
weight than a specific weight. support from medical personnel and family.
662 UNIT 6 Advanced Techniques and Procedures

Obesity has become a serious health prob- imately 5% of the population has diabetes mellitus
lem. It is defined as severely overweight and having (type 1 or type 2) in some form. Most patients with
a body mass index (BMI) of 30 or above. BMI uses this disease are not dependent on insulin and can
height and weight to calculate an individual’s total control their condition by monitoring diet, exer-
amount of body fat. cise, and weight (type 2 diabetes).
Genetics may play a role in obesity. Several Normally, after a meal, the body secretes the
genes affect the rate at which the body burns calo- hormone insulin, which makes its way to all cells of
ries. Playing a major role in obesity are family eat- the body. Insulin signals the cells that the glucose
ing habits, other lifestyle habits, physical activity is available and should be brought in so that it can
levels, and psychological factors such as stress and be converted to energy. If the cells do not receive
depression. Major causes are lack of physical exer- this signal, or do not respond to it, their ability to
cise, oversized portions of high-fat foods, and the use glucose is markedly reduced. Because the body
accessibility of fast foods. Many people eat more uses glucose as its main energy source, the ramifica-
food than their bodies need. tions of this affect almost every tissue of the body.
Obesity causes increased risk for hyperten- In addition, the high levels of glucose that remain
sion, heart and lung disease, hip and knee prob- in the bloodstream put a tremendous strain on
lems, certain cancers, and diabetes, and it shortens the kidneys and other major body organs, causing
the life span. problems such as myocardial infarction, vascular
Parents can be role models and teach their diseases, neuropathy, and infections.
children to eat nutritious foods and not to con- The effects of diabetes mellitus can be con-
sume more calories than their bodies need. Parents trolled with a general goal of maintaining a regular
should provide nourishing foods, limit inactiv- level of glucose in the bloodstream, avoiding large
ity such as television and computer time, engage fluctuations between high and low levels. There
the entire family in regular exercise, eat at regular are several ways suggested to accomplish this. Total
mealtimes at the table, and encourage the family Calories need not be altered, unless the diabetic
to drink plenty (six to eight glasses) of water daily. patient is overweight. However, the ratio of car-
By parents setting good examples when their chil- bohydrate, fat, and protein must be closely moni-
dren are young, the children will learn that healthy tored. Total carbohydrates should be increased, but
eating habits and regular exercise will improve the simple sugars should be avoided. Because of the
quality of life (fewer illnesses) and prolong the longer rate of digestion and absorption of complex
length of life. carbohydrates, these will be released over a longer
The American Heart Association and the period and prevent a sudden high level of glucose
American Cancer Society are community resources in the bloodstream, and these are the type of car-
available with information about reducing the bohydrates diabetics need. Increasing fiber content
risk for heart disease and cancer. Keeping weight also increases the time of absorption and decreases
under control and regular exercise helps prevent the likelihood of sudden increases in glucose levels
heart attacks, hypertension, and certain cancers. in the bloodstream. Regular snacks may be added
Because there has been a great deal of media between meals to maintain levels of glucose. The
attention given to the problem of obesity and the trend is for patients to take charge of their own
diseases it can cause, many people are looking for care. The role of educator for the medical assistant
a quick fix to lose weight. There are many claims will be an important one to facilitate patient self-
that people can lose weight without exercising or management.
eating healthy foods. Most claims about weight loss
products are deceptive or false. Type 2 Diabetes and Obesity. Obesity has become
Individuals who want to lose weight must epidemic in the last 10 years and is the most signif-
strive to eat a healthful diet over time. A health- icant factor in the increase in diabetes. Children
ful diet together with regular exercise can reduce and young people who are obese are being diag-
their risk for hypertension, coronary artery disease, nosed with type 2 diabetes at an extremely high
and certain cancers (colon and breast). rate. The longer individuals have diabetes, the
greater their risk for development of the complica-
tions of the disease, heart disease, stroke, kidney
Diabetes Mellitus disease, blindness, and infections. Diabetes is a
Diabetes mellitus is a disease in which there is either major cause of death.
reduced or no production of insulin, or in which Prevention of type 2 diabetes is of utmost
there is reduced or no response to insulin. Approx- importance. Changes in lifestyle such as weight loss,
 CHAPTER 22 Nutrition in Health and Disease 663

regular exercise, and a nutritious diet can prevent although it should be started slowly and under a
type 2 diabetes. If a patient has type 2 diabetes, it physician’s guidance. Atherosclerosis and arte-
can be controlled by diet and exercise and by medi- riosclerosis often occur together. Smoking and
cation (see Chapter 24 for more information about hypertension will increase the likelihood of devel-
diabetes and insulin). opment of both of these conditions.
The conditions of atherosclerosis and arte-
riosclerosis facilitate each other. The fatty depos-
Cardiovascular Disease its associated with atherosclerosis tend to occur at
Cardiovascular disease is currently the leading points of damage to the inner walls of the artery.
cause of death in the United States. The unfortu- One of the causes of this damage is high pressure
nate aspect is that much of it is preventable. Cardio- at points where there may be narrowing because
vascular disease encompasses a variety of problems. of deposits that are already there, or because of
Two of these problems, hypertension and athero- the constriction of blood vessels due to nicotine.
sclerosis, often work hand in hand to perpetuate Carbon monoxide brought into the bloodstream
one another until a myocardial infarction occurs. during smoking also causes damage to the arterial
It is important to remember that the conditions walls. The deposits and hardening increase the
leading up to a myocardial infarction do not occur blood pressure, which, in turn, causes more dam-
overnight. They have been developing slowly over age and more deposits. It is a cycle that is difficult
many years, often asymptomatically. These condi- to stop. The best solution is prevention.
tions can be reduced or prevented with lifestyle Fats and cholesterol in the diet have been
modifications such as a healthy diet, moderate strongly implicated in atherosclerosis. It is not
exercise, cessation of smoking, and weight man- only total fat that is important, but also types of
agement. This section focuses on a healthy diet to fat ingested. The effect of high levels of fats and
prevent cardiovascular disease. cholesterol in the diet will vary among individu-
Hypertension, or increased blood pressure, is als, and the factor in atherosclerosis is the levels
often of unknown cause. Sometimes it has a famil- of these substances in the bloodstream. Some
ial connection. When the blood pressure is only individuals are able to ingest high amounts of
moderately increased, certain diet modifications fat and cholesterol without the body maintain-
can be used to reduce it. If it is severe, drug therapy ing high levels of it in the blood. Unfortunately,
may be used in conjunction with diet therapy. One this is not the case for everyone, and fat and cho-
of the largest diet factors in controlling increased lesterol levels in the bloodstream must be closely
blood pressure is restricting sodium, because it monitored. Fat levels are measured by looking at
can play such an important role in maintenance triglycerides and lipoproteins. Lipoproteins are
of water levels in the body. Some individuals are a complex made of fatty acids and proteins and
salt sensitive. An increased volume of blood and are used to carry fat and cholesterol in the blood-
water will increase the pressure on the blood ves- stream. LDLs are used by the body to transport
sel walls. Eliminating sodium includes more than fats and cholesterol to the body tissues. These are
simply eliminating use of table salt. Foods that are the lipoproteins more likely to deposit choles-
particularly high in sodium include smoked meats, terol and fat into the arterial wall. HDLs carry fats
luncheon meats, olives, pickles, chips, crackers, cat- and cholesterol to the liver to be broken down
sup, and cheese. In some cases, eliminating foods and used. These lipoproteins are more likely to
with only moderate salt levels may be indicated. remove fats and cholesterol from the deposits in
These may include certain meats, breads contain- the arterial walls. HDL levels can be increased by
ing baking powder or baking soda, shellfish, and exercise.
some vegetables. The Nurses’ Health Study, done by Harvard
Atherosclerosis is another condition that University, showed an association between the
can lead to a myocardial infarction. Atherosclero- intake of hydrogenated fats (trans fats) and heart
sis is hardening of the arteries because of depos- disease. The women who consumed high levels of
its of fatty substance. It should not be confused foods that contained hydrogenated fats experi-
with arteriosclerosis, which is a hardening of the enced a much greater risk for having a heart attack
arteries because of loss of the elasticity of the arte- than did the women who consumed few hydro-
rial wall. Atherosclerosis leads to arteriosclerosis, genated fats. Harvard School of Public Health
which generally occurs because of a lack of exer- researchers have found that hydrogenated fats are
cise and increased blood cholesterol levels. The responsible for the thousands of premature heart
elasticity can be regained by increasing activity, disease deaths in the United States every year.
664 UNIT 6 Advanced Techniques and Procedures

Trans fats have also been implicated in increasing the new growth has the ability to divert nutrients to
the risk for type 2 diabetes. itself, the result is the body receives fewer nutrients.
If total serum cholesterol and LDL levels are It will then break down its own tissue. In addition,
found to be increased, the individual must modify there is an increased need for nutrients to supply
the diet, and, if severe enough, drug therapy may the immune system with energy and nutrients in its
be indicated. The percentage of Calories from fat attempt to destroy the cancerous cells.
should be kept to less than 20% to 30% of total The patient who is receiving chemother-
daily dietary intake, with less than a third of these apy or radiation treatment has an even greater
coming from saturated fats. Cholesterol consump- need for increased nutrients. These therapies
tion should be less than 200 mg per day. are directed at killing cells that are rapidly divid-
If a person experiences a myocardial infarc- ing. This includes not only the cancerous cell but
tion, it is important that the heart muscle be also healthy cells such as those of the lining of the
allowed to rest to facilitate proper healing. This gastrointestinal tract and hair follicles. Increased
includes bed rest, initially with a gradual progres- nutrients are needed for repair and replacement
sion to limited activity over about a 2-week period. of the lost cells, and protein levels in particular
Then the patient is allowed to resume full activity. should be increased. Because of the disturbance of
Rehabilitation consists of cessation of smoking; the gastrointestinal lining, digestion and absorp-
control of hypertension; weight reduction through tion may also be decreased. It is important that the
a low-fat, low-calorie diet; and a program of exer- patient maintain as healthy a nutritional status as is
cise. All help to improve myocardial function. possible rather than having to make up for nutri-
tional deficiencies.
The patient may experience loss of appetite,
Cancer as well as nausea and vomiting. There are several
Some substances ingested or inhaled are thought ways to cope with this. First, food should be made
to be carcinogenic. For example, nitrites that are as appealing as possible. If the patient has difficulty
found in foods such as smoked ham or bacon are swallowing, food can be liquefied in a food proces-
thought to cause cancer of the stomach and esoph- sor. Generally, food will be better tolerated if it is
agus. Smoking tobacco, although not a food, has slightly chilled; extremes of temperature should
been implicated in cancers of the mouth, larynx, be avoided. Several smaller meals may be easier to
esophagus, and lungs. High fat in the diet has been eat than three large meals.
shown to be associated with cancer of the breast, If patients lose large amounts of weight
uterus, and colon. because of worry or concern or as a result of che-
High fiber in the diet may protect from colon motherapy and/or radiation, they may become
cancer. Foods with vitamins A and C protect from cachectic. In such cases, a tube is passed into
cancer of the stomach, lung, and bladder. Fruits the patient’s stomach or duodenum through the
and vegetables, legumes, and foods with soy may nose, and liquid feedings are given through the
protect from certain cancers. tube. Another method for providing nutrition
Wise choices of foods from the food pyramid, to a patient who is unable to take in necessary
avoiding foods with known carcinogens, keeping amounts of food is through a catheter (sterile
weight under control, and practicing a healthy life- tube) inserted into the subclavian vein to the
style will improve the quality and length of life. superior vena cava, known as total parenteral
Cancer is a disease that comes in a variety of nutrition (TPN). Feedings via the catheter pro-
forms. It generally means that normal regulatory vide very good nutrition and can be given for pro-
mechanisms within a cell have broken down. The longed periods.
result is that cells continue to grow in an unre-
strained manner, diverting energy and nutrients
from the patient’s body to the cells’ uncontrolled DIET AND CULTURE
growth. There are many stages through which these
cells may go, and they will go through them at vary- Medical assistants are likely to come into
ing rates. The ramifications of this new growth will contact with patients from many different
vary depending on what types of cells are affected. ethnic groups. Many of these patients will
For these reasons, each cancer patient will have have diets based on traditional cultures, and some
varying nutritional requirements. However, there of the foods they eat, or the way they combine
are some generalities that can be made. First, there foods, may be unfamiliar to the medical assistant.
is definitely a need for increased Calories. Because Often, diets in other cultures are sensible, with
 CHAPTER 22 Nutrition in Health and Disease 665

foods chosen or combined to make up a com- sometimes associated with vegetarian diets that do
plete protein. The medical assistant who has some not contain enough animal product (see the section
knowledge of ethnic food choices can help reas- on vitamins in this chapter). One type of vegetarian,
sure patients that the dietary changes they need to vegan, does not eat any product associated with ani-
make are within the parameters of their own cul- mals, including milk or eggs. This type of diet is par-
tures. Table 22-6 presents some highlights of the ticularly susceptible to nutritional deficiencies.
food choices of different ethnic groups. In speaking with patients about diet and
Vegetarian diets are fairly common around the dietary changes, it is important to remember that
globe, including in the United States. With a good patients choose their diets for a variety of reasons,
variety of grains, vegetables, fruits, and dairy prod- including cultural, religious, or ethical beliefs. The
ucts, a vegetarian diet can supply an individual with medical assistant should respect the patient’s rea-
all the required nutrients. Pernicious anemia, a dis- sons for following a certain diet while encouraging
ease caused by lack of cobalamin (vitamin B12), is any modifications.

Table 22-6 Sample Food Choices of Various Cultural, Religious, and Ethnic Groups

Culture/Region/
Group Diet and Food Choices

It is thought that approximately half of the edible plants commonly eaten in the United States
today originated with the Native Americans. Examples are corn, potatoes, squash, cranber-
ries, pumpkins, peppers, beans, wild rice, and cocoa beans. In addition, they used wild fruits,
game, and fish. Foods were commonly prepared as soups and stews, and dried. The original
Native American
Native American diets were probably more nutritionally adequate than their current diets,
which frequently consist of too high a proportion of sweet and salty, snack-type, empty
calorie foods. Native American diets today may be deficient in calcium, vitamins A and C,
and riboflavin.

Hot breads such as corn bread and baking powder biscuits are common in the U.S. South
because the wheat grown in the area does not make good quality yeast breads. Grits and
rice are also popular carbohydrate foods. Favorite vegetables include sweet potatoes,
squash, green beans, and lima beans. Green beans cooked with pork are commonly served.
U.S. Southern
Watermelon, oranges, and peaches are popular fruits. Fried fish is served often, as are barbe-
cued and stewed meats and poultry. There is a great deal of carbohydrate and fat in these
diets and limited amounts of protein in some cases. Iron, calcium, and vitamins A and C may
sometimes be deficient.

Mexican food is a combination of Spanish and Native American foods. Beans, rice, chili pep-
pers, tomatoes, and corn meal are favorites. Meat is often cooked with the vegetable as in
chili con carne. Corn meal is used in a variety of ways to make tortillas and tamales, which
Mexican serve as bread. The combination of beans and corn makes a complete protein. Although tor-
tillas filled with cheese (called enchiladas) provide some calcium, the use of milk should be
encouraged. Additional green and yellow vegetables and vitamin C–rich foods would also
improve these diets.

Rice is the basic carbohydrate food in Puerto Rican diets. Vegetables commonly used
include beans, plantains, tomatoes, and peppers. Bananas, pineapple, mangoes, and papa-
Puerto Rican
yas are popular fruits. Favorite meats are chicken, beef, and pork. Milk is not used as much as
would be desirable from the nutritional point of view.

Pastas with various tomato or fish sauces and cheese are popular Italian foods. Fish and
highly seasoned foods are common to Southern Italian cuisine, whereas meat and root veg-
Italian etables are common to northern Italy. The eggs, cheese, tomatoes, green vegetables, and
fruits common to Italian diets provide excellent sources of many nutrients, but additional milk
and meat would improve the diet.

Northern and Western European diets are similar to those of the U.S. Midwest, but with a
Northern and Western greater use of dark breads, potatoes, and fish, and fewer green vegetable salads. Beef and
European pork are popular, as are various cooked vegetables, breads, cakes, and dairy products.
(continues)
666 UNIT 6 Advanced Techniques and Procedures

Table 22-6 Sample Food Choices of Various Cultural, Religious, and Ethnic Groups (continued)

Culture/Region/
Group Diet and Food Choices

Citizens of Central Europe obtain the greatest portion of their calories from potatoes and
grain, especially rye and buckwheat. Pork is a popular meat. Cabbage cooked in many
Central European
ways is a popular vegetable, as are carrots, onions, and turnips. Eggs and dairy products are
used abundantly.

Grains, wheat, and rice provide energy in these diets. Chickpeas in the form of hummus are
Middle Eastern popular. Lamb and yogurt are commonly used, as are cabbage, grape leaves, eggplant,
tomatoes, dates, olives, and figs. Black, very sweet (Turkish) coffee is a popular beverage.

The Chinese diet is varied. Rice is the primary energy food and is used in place of bread. Foods
are generally cut into small pieces.Vegetables are lightly cooked, and the cooking water is
Chinese saved for future use. Soybeans are used in many ways, and eggs and pork are commonly
served. Soy sauce is extensively used, but it is salty and could present a problem with patients
on low-salt diets.Tea is a common beverage, but milk is not.This diet may be low in fat.

Japanese diets include rice, soybean paste and curd, vegetables, fruits, and fish. Food is fre-
Japanese quently served tempura style, which means fried. Soy sauce (shoyu) and tea are commonly
used. Current Japanese diets have been greatly influenced by Western culture.

Many Indians are vegetarians who use eggs and dairy products. Rice, peas, and beans are
Southeast Asian frequently served. Spices, especially curry, are popular. Indian meals are not typically served
in courses as Western meals are. They generally consist of one course with many dishes.

Rice, curries, vegetables, and fruit are popular in Thailand, Vietnam, Laos, and Cambodia.
Thailandese,
Meat, chicken, and fish are used in small amounts. The wok (a deep, round fry pan) is used
Vietnamese, Laos, and
for sautéing many foods.
Cambodian
A salty sauce made from fermented fish is commonly used.

Interpretations of the Jewish dietary laws vary. Those who adhere to the Orthodox view con-
sider tradition important and always observe the dietary laws. Foods prepared according
to these laws are called kosher. Conservative Jews are inclined to observe the rules only at
home. Reform Jews consider their dietary laws to be essentially ceremonial and thus mini-
mize their significance. Essentially the laws require the following:
• Slaughtering must be done by a qualified person, in a prescribed manner. The meat or
poultry must be drained of blood, first by severing the jugular vein and carotid artery, then
by soaking in brine before cooking.
• Meat or meat products may not be prepared with milk or milk products.
• The dishes used in the preparation and serving of meat dishes must be kept separate from
those used for dairy foods.
• A specified time, 6 hours, must elapse between consumption of meat and milk.
• The mouth must be rinsed after eating fish and before eating meat.
Jewish
• There are prescribed fast days—Passover Week, Yom Kippur, and Feast of Purim.
• No cooking is done on the Sabbath—from sundown Friday to sundown Saturday.
These laws forbid the eating of:
• The flesh of animals without cloven (split) hooves or that do not chew their cud
• Hind quarters of any animal
• Shellfish or fish without scales or fins
• Fowl that are birds of prey
• Creeping things and insects
• Leavened (contains ingredients that cause it to rise) bread during the Passover
Generally, the food served is rich. Fresh smoked and salted fish and chicken are popular, as
are noodles, egg, and flour dishes. These diets can be deficient in fresh vegetables and milk.
(continues)
 CHAPTER 22 Nutrition in Health and Disease 667

Table 22-6 (continued)

Culture/Region/
Group Diet and Food Choices

Although the dietary restrictions of the Roman Catholic religion have been liberalized, meat
Roman Catholic
is not allowed its adherents on Ash Wednesday and Fridays during Lent.

Followers of this religion include Christians from the Middle East, Russia, and Greece.
Eastern Orthodox Although interpretations of the dietary laws vary, meat, poultry, fish, and dairy products are
restricted on Wednesdays and Fridays and during Lent and Advent.

Generally, Seventh Day Adventists are ovolacto-vegetarians, which means they use milk
products and eggs, but no meat, fish, or poultry. They may also use nuts, legumes, and
Seventh Day Adventist
meat analogues (substitutes) made from soybeans. They consider coffee, tea, and alco-
hol to be harmful.

Mormon (Latter Day The only dietary restriction observed by Mormons is the prohibition of coffee, tea, and
Saints) alcoholic beverages.

Adherents of Islam are called Muslims. Their dietary laws prohibit the use of pork and alco-
Islamic hol, and other meats must be slaughtered according to specific laws. During the month of
Ramadan, Muslims do not eat or drink during daylight hours.

To the Hindus, all life is sacred, and small animals contain the souls of ancestors. Consequently,
Hindu
Hindus are usually vegetarians. They do not use eggs because they represent life.

There are several vegetarian diets. The common factor among them is that they do not
include red meat. Some include eggs, some fish, some milk, and some even poultry. When
carefully planned, these diets can be nutritious. They can contribute to a reduction of obesity,
Vegetarians high blood pressure, heart disease, some cancers, and possibly diabetes. They must be
carefully planned so they include all needed nutrients.
Lacto-ovo vegetarians use dairy products and eggs but no meat, poultry, or fish.
Lacto-vegetarians use dairy products but no meat, poultry, or eggs.

Vegans avoid all animal foods. They use soybeans, chickpeas, and meat analogues made
from soybeans. It is important that their meals be carefully planned to include appropri-
ate combinations of the nonessential amino acids to provide the needed amino acids. For
Vegans
example, beans served with corn or rice, or peanuts eaten with wheat, are better in such
combinations than any of them would be if eaten alone. Vegans can show deficiencies of
calcium; zinc; vitamins A, D, and B12; and, of course, proteins.

The macrobiotic diet is a system of 10 diet plans developed from Zen Buddhism. Adherents
progress from the lower number diet to the higher, gradually giving up foods in the follow-
ing order: desserts, salads, fruits, animal foods, soups, and ultimately vegetables, until only
cereals—usually brown rice—are consumed. Beverages are kept to a minimum, and only
organic foods are used. Foods are grouped as Yang (male) or Yin (female). A ratio of 5:1
Zen macrobiotic diets
Yang to Yin is considered important. Most macrobiotic diets are nutritionally inadequate.
As the adherents give up foods according to plans, their diets become increasingly inad-
equate. These diets can be especially dangerous because avid adherents promise medical
cures from the diets that cannot be attained, and thus medical treatment may be delayed
when needed.
668 UNIT 6 Advanced Techniques and Procedures

Procedure 22-1
Provide Instruction for Health Maintenance and Disease Prevention
PURPOSE: examination, Pap smear, mammogram,
To instruct patients about how to exercise more occult blood testing, colonoscopy, urinalysis,
responsibly and take control of their health in order electrocardiogram, chest X-ray, blood tests
to extend their lives and enjoy healthy years. for anemia, chemistry profiles, hearing and
With the provider’s permission, medical assistants vision tests.
have many opportunities on a daily basis to educate • Avoid tobacco.
patients about ways to stay healthy and r educe the
• Get regular exercise at least 30 minutes
risk of disease. Patient education boxes throughout
most days (walk dog, bicycle, rake leaves, do
the textbook relate specific behaviors patients can
housework, swim).
adopt to prevent diseases and measures they can take
to preserve health. • Eat a balanced diet (see myPyramid worksheet at
http://www.mypyramidtrackerworksheet.gov)
EQUIPMENT/SUPPLIES • Practice safety to prevent injuries (make sure
Discussion smoke detectors work, wear seat belts, don’t
DVDs drink and drive).
Videos
Print material • Control weight, blood pressure, and cho-
Authentic Web-based interactive information lesterol.
Community resources directories • Watch sun exposure and use a sun block
Seminars factor of at least SPF 30 all year.
Classes (self-directed and self-paced) • Keep vaccine immunizations current.
PROCEDURE STEPS: • Practice food safety by preparing food with
1. Gather materials being used for guidelines for clean hands and on clean surfaces.
health and disease prevention. 6. Instruct patients who do not have a computer that
2. Arrange a quiet area for patient and medical they may be able to gain online access at a pub-
assistant. lic library. Some Web sites they can visit to learn
more about strategies to prevent disease are:
3. Assess patient’s learning style and preference.
RATIONALE: The patient’s age, physical limita- • General health: http://www.healthfinder. gov
tions, and learning preferences need to be taken • Cancer: http://www.cancer.gov
into consideration by the medical assistant. It is • Osteoporosis: http://www.osteo.org
important to communicate clearly and at the level
of the patient’s understanding and knowledge. • Nutrition: http://www.usda.gov
4. Include the patient’s family if appropriate. • Nutrition: http://www.fda.gov
RATIONALE: The patient’s family will learn • Alcohol and drug abuse: http://www.niaa.
along with the patient and provide instruction nih.gov
and encouragement to the patient at home. • Depression:http://www.nimh.nih.gov/health/
5. Teach patients to take an active role in their topics/depression/index.html
health. Tell them that prevention is an impor- • Heart and lung: http://www.nhlbi.nih.gov
tant aspect in maintaining health. Instruct
them to: • Product safety: http://www.cpsc.gov

• Get regular screenings for cancer when 7. Document the education session in the patient’s
age appropriate, such as yearly physical chart or electronic medical record.
 CHAPTER 22 Nutrition in Health and Disease 669

Case Study 22-1

Review the scenario at the beginning of the chapter.

CASE STUDY REVIEW

1. List and explain four possible reasons for 3. Annette Samuels is pregnant and has particular needs.
Mrs. Leonard’s not eating enough. Search online for dietary/nutritional requirements for
2. What strategies might you use to educate the teen- pregnant women. Name five of the most important
ager Corey Boyer about his consuming “fast” food? nutrients that Annette needs during pregnancy.

Case Study 22-2

Anita Ferguson is a new patient at Inner City Health Care. She CASE STUDY REVIEW
is a 16-year-old girl who is 4 months pregnant and came
to the urgent care center only a couple of weeks ago. After 1. What patient education can Wanda provide to alert
Wanda Slawson, CMA (AAMA), took Anita’s medical history, Anita to the importance of diet and weight gain dur-
and after Anita was examined by the provider, Wanda set ing pregnancy?
aside time to answer any questions Anita might have about 2. What foods should Wanda encourage Anita to eat?
her pregnancy. Anita is obviously scared; she wants the baby, 3. If Anita resists Wanda’s suggestions and has not
but she does not want her life to change. According to the gained any weight by the next visit, how should
history, Anita has lost a few pounds in the last 2 weeks. Wanda proceed?

Case Study 22-3

Dr. Lewis prescribed a diabetic diet for Mrs. Johnson. CASE STUDY REVIEW
1. Describe what is included in a diabetic diet.
2. Describe the patient education you would use to
help Mrs. Lewis understand the diet and to help her
reach her goal of improved health.
670 UNIT 6 Advanced Techniques and Procedures

SUMMARY
Seven types of nutrients are required by the body for maintenance of good health. Carbohydrates, fats, and
proteins provide energy for the body. Vitamins, minerals, fiber, and water cannot provide energy but are
responsible for many vital processes within the body.
Some individuals take herbal supplements. Making the provider aware of which supplements is an
important responsibility of the medical assistant.
Nutritional needs change at various points in the life cycle. During pregnancy, lack of nutrients can
be detrimental to the development of the fetus and the health of the expectant mother. The need for
nutrients is great during infancy and childhood, with the greatest need for total nutrients occurring dur-
ing adolescence. During adulthood, the requirement for Calories decreases. With the decrease in basal
metabolism that occurs with aging, the requirement for Calories decreases even more.
At times of disease, the diet of the individual must be modified to help relieve stress put on the body
by the disease, to give energy to fight the disease, and, in cases where the disease is diet related, to decrease
the severity of the disease.
It is important to have adequate nutritional intake during every stage of life. The healthier one is, the
better one feels and enjoys a good quality of lfe. Nutritional status should be examined and adjustments
made if necessary with the goal of helping patients maintain a healthy body.

STUDY FOR SUCCESS

To reinforce your knowledge and skills of information presented in this chapter:
• Review the Key Terms
• Consider the Case Studies and discuss your conclusions
• Answer the Review Questions

˚ Multiple Choice
˚ Critical Thinking
• Navigate the Internet by completing the Web Activities
• Practice the StudyWARE activities on your student CD
• Apply your knowledge in the Student Workbook activities
• Complete the Web Tutor sections

REVIEW QUESTIONS
Multiple Choice c. a catalyst
d. an antioxidant
1. The transfer of nutrients from the gastrointestinal 4. What is the significance for the provider in deter-
tract into the bloodstream is: mining the patient’s use of herbal supplements?
a. ingestion a. The FDA has authority over these dietary supple-
b. digestion ments, therefore they are safe.
c. absorption b. They are unsafe if bought in a supermarket.
d. elimination c. They may interact with over-the-counter and
2. Fats are considered a(n): prescription medications.
a. mineral d. They are not considered medicines. It is not
b. vitamin significant to inform the provider.
c. energy nutrient 5. Another name for vitamin C is:
d. fiber a. tocopherol
3. The total of all chemical and physical changes that b. carotene
take place in the body is called: c. biotin
a. homeostatis d. ascorbic acid
b. metabolism
 CHAPTER 22 Nutrition in Health and Disease 671

Critical Thinking 2. Explore the FDA’s site and find the amount of trans
1. For each of the following vitamins and minerals, fats in one serving of:
suggest some symptoms that might appear if there a. apple pie
were a deficiency: b. a jelly doughnut
vitamin A c. shredded wheat
vitamin K d. ice cream
vitamin C 3. Explore the National Center for Chronic Disease
thiamin Prevention and Health Promotion and Physical
riboflavin Activity at Web site (http://www.cdc.gov/nccdphp/
cobalamin (vitamin B12) dnpa/index.htm) and discuss with your classmates
calcium four diseases that can be prevented through nutri-
2. Consider the functions of the various regions of the tion and exercise. Explain how and why.
digestive system, and look up in a medical diction- 4. Using a search engine, find a site for discussion
ary each of the following procedures. Describe the about anorexia nervosa and bulimia. Describe
problems that might exist with the following proce- these eating disorders. Is there any treatment for
dures if diet modifications do not take place: them?
colostomy 5. Visit http://www.healthmonitor.com to calculate
gastrectomy your body mass index (BMI) and decide if it is
3. Explain why a breakfast high in complex carbohy- within a healthy range.
drates is an important goal. 6. Use the government Web site (http://www.
4. Figure 22-6 shows calculations of percentages of mypyramid.gov) to help you determine how your
total calories from fat, carbohydrate, or protein. dietary habits rate according to the food pyramid.
Are the percentages healthy or unhealthy? What 7. Use www.cfscan.fda.gov/~dms/Foodlabel/html
are the recommended percentages of total calories to access information on how to use food labels
from fat, carbohydrate, and protein? of pasta. How much cholesterol and saturated fat
5. What are some things to consider when assessing is there? Look at nutrition facts on a box.
the diet of an older adult?
6. Find five things a person can do to decrease the
risk for heart disease. Compile a list from the class. REFERENCES/BIBLIOGRAPHY
How many of the items are associated with diet?
How many of the items involve you? Centers for Disease Control and Prevention. (2007).
7. Describe how the diet can be used to control dia- Overweight and obesity. Retrived May 24, 2007, from
betes mellitus. When a person becomes dependent http://www.cdc.gov.
on insulin, should the diet continue to be used? Ephedra. (2007). Retrieved May 25, 2007, from http://
www.wikipedia.org/wiki/ephedra.
Richardson, M. (2004). Calcium absorption in post-
WEB ACTIVITIES menopausal women. Harvard Women’s Health Watch,
5, 1–3.
1. Search community agencies on the Web Roth, R. A. (2007). Nutrition and diet therapy. (9th ed.).
for information about the following dis- Clifton Park, NY: Delmar Cengage Learning.
eases and the role nutrition plays in pre- Spratto, G. R., & Woods, A. L. (2004). PDR nurses
vention of the disease: drug handbook. Clifton Park, NY: Delmar Cengage
a. diabetes mellitus Learning.
b. arteriosclerotic heart disease Taber’s cyclopedic medical dictionary. (20th ed.). (2006).
c. hypertension Philadelphia: F. A. Davis.
Chapter

23 Basic Pharmacology

OUTLINE KEY TERMS

Medical Uses of Drugs Drug References and Standards Abuse
Drug Names How to Use the PDR Administer
History and Sources of Drugs Other Reference Sources Anaphylaxis
Plant Sources Classification of Drugs Contraindication
Animal Sources Principal Actions of Drugs Dispense
Mineral Sources Factors That Affect Drug Action Pharmacology
Herbal Supplements Undesirable Actions of Drugs
Prescribe
Synthetic Drugs Drug Routes
Pruritus
Genetically Engineered Forms of Drugs
Pharmaceuticals Urticaria
Liquid Preparations
Drug Regulations and Legal Solid and Semisolid
Classifications of Drugs Preparations
Controlled Substance Act of 1970 Other Drug Delivery Systems
Prescription Drugs Storage and Handling of
Nonprescription Drugs Medications
Proper Disposal of Drugs Emergency Drugs and Supplies
Administer, Prescribe, Bioterrorism
Dispense Drug Abuse

OBJECTIVES
The student should strive to meet the following performance objectives and
demonstrate an understanding of the facts and principles presented in this
chapter through written and oral communication.

1. Define the key terms as presented in the glossary.

2. Recall five medical uses for drugs.
3. Describe three types of drug names and give an example, for one
drug, of all three names.
4. List five sources of drugs.
5. Describe the Federal Foods, Drug, and Cosmetic Act and the
Controlled Substance Act of 1970.
6. Name the five controlled substances schedules and describe
appropriate storage of the substances.
7. Define the law in terms of administering, prescribing,
and dispensing drugs.
8. Describe how to use the four most commonly used sections of
the Physician’s Desk Reference (PDR).

672
OBJECTIVES (continued)
9. Describe the principal actions of drugs and three undesirable reactions.
10. Describe routes of drug administration and drug forms.
11. Describe handling and storing of drugs.
12. List emergency drugs and supplies.
13. Recall commonly abused drugs and describe their physical and emo-
tional effects.
14. Critique the legal role and responsibilities of the medical assistant.

Scenario
Policy at Drs. Lewis and King dictates that a patient container) that they are currently using. When taking
medication history is taken on the first appointment, or updating a patient history, clinical medical assis-
routinely updated, and reviewed whenever medica- tants Audrey Jones, CMA (AAMA),and Joe Guerrero,
tion is prescribed, dispensed, or administered. Both CMA (AAMA), ask a number of questions of patients
administrative and clinical medical assistants work regarding medications, prescription, over-the-
together to ensure that this policy is carried out. counter, and herbal supplements, and gently probe
When making a patient appointment, administra- to ensure that patients include all medications in
tive medical assistants ask patients to bring with the history and describe any allergy or hypersensi-
them any medications (keeping them in the labeled tivity they may have to certain drugs.

INTRODUCTION
Spotlight on Certification
Pharmacology is the study of drugs, the science that is RMA Content Outline
concerned with the history, origin, sources, physical and • Anatomy and physiology
chemical properties, uses, and effects of drugs on living
• Medical law
organisms. Medical assistants in the ambulatory care
setting need to understand basic pharmacology includ- • Medical ethics
ing the uses, sources, forms, and delivery routes of drugs; • Patient education
must know and be able to implement the intent of the • Asepsis
law regarding controlled substances and other medica- • Clinical pharmacology
tions; and must have a knowledge of drug classifications
CMA (AAMA) Content Outline
and actions to be able to caution patients when taking
prescription or nonprescription drugs. In addition, the • Anatomy and physiology
medical assistant must be able to educate patients about • Medicolegal guidelines
a drug’s intended purpose and the correct way to take the and requirements
drug for maximum effectiveness. • Principles of infection control
This chapter provides an overview of pharmacol- • Pharmacology
ogy; it is considered a review for medical assistants who • Emergencies
have had a formal course in the subject. Information on
dosage, calculation, and medication administration can CMAS Content Outline
be found in Chapter 24. • Anatomy and physiology
• Apply principles of medical law
and ethics to the health care setting
MEDICAL USES OF DRUGS • Asepsis in the medical office
• Recognize and respond to emergencies
A drug is defined as a medicinal substance that may
• Understand basic pharmacological
alter or modify the functions of a living organism.
concepts and terminology
There are five medical uses for drugs:

673
674 UNIT 6 Advanced Techniques and Procedures

• Therapeutic. Used in the treatment of a condition to the patient. To reduce costs, some insurance com-
relieve symptoms. An example is an antihistamine panies pay for only generic brands. Sometimes,
that may be used in the treatment of an allergy. providers specify drugs by their trade names.
• Diagnostic. Used in conjunction with radiology Some states allow patients to request that their
and other diagnostic imaging procedures to allow pharmacist dispense the generic drug equivalent
the physician to pinpoint the location of a disease unless the provider has specified that the drug be
process. An example is dye tablets used in the dispensed by its trade name. Also, in some states, a
X-ray study of the gallbladder. pharmacist may select a generic form of a drug if
not specifically directed otherwise by the provider.
• Curative. Used to kill or remove the causative agent
Generic and trade name drugs have the same
of a disease. An example is an antibiotic.
chemical composition and must adhere to identi-
• Replacement. Used to replace substances normally cal FDA standards; therefore, according to most
found in the body. Hormones and vitamins are state laws, they can be used interchangeably. The
examples of replacement drugs. drug label reflects the drug products dispensed.
• Preventive or Prophylactic. Used to ward off or lessen
the severity of a disease. Examples are immunizing
agents such as vaccines. HISTORY AND SOURCES
OF DRUGS
DRUG NAMES Drugs prepared from roots, herbs, bark,
and other forms of plant life are among
Most drugs have three types of names: chemical, the earliest known pharmaceuticals. Their
generic, and trade or brand name. origin can be traced back to primitive cultures
where they were first used to evoke magical pow-
• The chemical name describes the drug’s molecular ers and to drive out evil spirits. Having discovered
structure and identifies its chemical structure. that certain plants were pharmacologically useful,
• The generic name is the drug’s official name and is a search was begun for sources of drugs.
assigned to the drug by the U.S. Adopted Names Today this search continues. In addition to
Council. A generic drug can be manufactured by plants, drugs are derived from animals and miner-
more than one pharmaceutical company. When als and are produced in laboratories using chemi-
this is the case, each company markets the drug cal, biochemical, and biotechnologic processes.
under its own unique trade or brand name. Generic
names begin with a lowercase letter.
Plant Sources
• A trade or brand name is registered by the U.S.
Patent and Trademark Office and is approved by The leaves, roots, stems, or fruit of certain plants
the U.S. Food and Drug Administration (FDA). may contain medicinal properties. For example, the
The ® symbol following a drug’s trade or brand dried leaf of the foxglove plant (Digitalis purpurea) is
name indicates that the name is registered and a source of digitalis, a cardiac glycoside used in the
protected for 17 years. No other manufacturer can treatment of certain heart conditions.
make or sell the drug during that time. Once the Herbals fit into this plant source category. The
patent expires, any manufacturer can sell the drug disadvantage of many natural herbals on the mar-
under its generic name or a new trade name. The ket today is that some drugs derived from plants
original trade name cannot be reused. The brand may not be standardized. In any given crop, there
name begins with a capital letter. may be plants that are more or less potent than
their neighboring plants. This lack of consistency
Example: is related to the amount of sunshine and water a
particular plant receives, as well as the nutrients
Chemical name: 1, 4, 3, 6-dian hydrosorbitol-2, 5 dinitrate in the soil. Another disadvantage of natural plant
Generic name: isosorbide dinitrate drugs is the pesticides that may be present. These
Trade/Brand name: Sorbitrate® may be man-made pesticides applied to the plants
or taken up by the plant through the environment
When providers prescribe a drug, they may (soil, water, and air); they may also be natural pes-
use either the generic or trade name. It is not ticides originating from the plant itself to defend
uncommon for providers to prescribe the generic itself from molds, insects, and other threats. These
form of a drug because it is usually less costly for pesticides all pose biologic threats to our chemical
 CHAPTER 23 Basic Pharmacology 675

and biologic functions. These foreign chemicals The DSHEA gathers and thoroughly reviews
can be interpreted by our bodies as irritants, free evidence about the pharmacology of a product,
radicals, antigens, and antagonists. Patients should uses peer-review scientific literature on safety and
be cautioned to purchase only reputable, standard- effectiveness, examines adverse event reports, and
ized, natural herbal products for these reasons. includes public comments for information about
associated health risks.
Self-medication with herbal products is less in
Animal Sources the United States than worldwide, but sales in the
A few drugs are obtained from tissues such as the United States have been increasing yearly. There
adrenal glands of animals. Examples of drugs has been an abundance of interest by the public
obtained from animals are adrenaline and corti- in herbal products because of the media attention
sone, extracted from the adrenal glands of animals. given to them and their benefits.
Adrenaline is used for allergic reactions and corti- Many providers combine herbal products
sone is an antiinflammatory. Premarin® is another (together with nutrition) in their practice(s), and
example. It is derived from urine produced by certain herbal treatments have become part of the
pregnant mares. It is used for treating menopausal practitioner’s treatment regimen.
symptoms in some women. Some examples of herbs and their uses are as
follows: cascara—laxative; feverfew—headaches;
garlic—antibacterial; licorice—gastritis, cough,
Mineral Sources menopause; St. John’s wort—depression and anxi-
Some naturally occurring mineral substances are ety; and saw palmetto—prostate health.
used in medicine in a highly purified form. One There are risks associated with self-
such mineral is sulfur, which has been used as a key medication with herbal products. Patients
ingredient in certain bacteriostatic drugs. It is now need to be informed that taking certain
prepared synthetically and used in the treatment medications together with herbal products can pro-
of urinary and intestinal tract infections. duce dangerous interactions. It is important for you
as the medical assistant to gather information about
all medications, prescriptions, over-the-counter
Herbal Supplements medications, and herbals. Pregnant patients should
With the increased interest in alternative or com- inform their provider about what they are taking
plementary medicine, many patients and some and should be cautioned about possible harm to the
practitioners use herbal products for treatment, fetus (see Chapter 14). It is important to remem-
prophylaxis, and maintenance of health and ber that any medication and any herb can cause an
care of disease. Phytomedicine is the term used to allergic reaction and have side effects.
describe the use of plants to promote optimum The dietary supplement ephedra, also known
health. as Ma huang, had been prohibited from being sold
Native cultures since ancient times had great since April 2004 because, according to DSHEA
respect for their medicine men and women of 1994, ephedra presented an unreasonable risk
because they knew about plants and herbs for for illness and injury. The herbal supplement had
medicinal purposes. Such diseases and conditions as been promoted for use in weight loss and control
cardiac arrhythmia, pain, blood thinning, digestive and for enhancing performance in sports activities.
upsets, and increased urinary output (diuresis) have Evidence showed modest effectiveness for weight
been treated with success with herbal medicine. loss with no clear health benefit. It was confirmed
European providers use herbal medicines that, in many instances, the substance increased
routinely in their practices and have had classes on blood pressure and caused tachycardia, chest pain,
the topic throughout medical school. myocardial infarction (MI), cerebral vascular acci-
In the United States, it was not until dents (CVA), seizures, psychosis, and death.
1974 that the FDA passed an act known In 2005, the ban on ephedra was lifted
as the Dietary Supplement Health and because it had been challenged in court, and the
Education Act (DSHEA). The act examines any judge ruled for the company that manufactures
dietary supplement such as herbal products and ephedra. During 2005 and 2006, ephedra was sold
may remove it from the market if it presents a sig- again. In August 2006, the FDA’s ban on all ephe-
nificant or unreasonable risk for illness or injury dra and ephedra-like drugs was upheld. It now is
when used according to its labeling or under illegal in the United States. In October 2006, the
ordinary conditions of use. manufacturing company filed a petition for a
676 UNIT 6 Advanced Techniques and Procedures

DRUG REGULATIONS
Patient Education AND LEGAL CLASSIFICATIONS
If you want to use herbal therapy, you should OF DRUGS
find a qualified herbalist and work with him or
her and your practitioner. Herbal products are Qualified medical practitioners
not regulated or standardized by an agency who prescribe, dispense, or admin-
or organization (see earlier for information ister drugs must comply with
about DSHEA). Report at once symptoms that federal and state laws. The laws govern the manu-
seem unusual. Herbal products should be facture, sale, possession, administration, dispens-
used for the shortest amount of time needed ing, and prescribing of drugs. All drugs available
to obtain results. Keeping track of herbs taken, for legal use are controlled by the Federal Food,
for what purpose they are being taken, and Drug, and Cosmetic Act. The law protects the
the effect on symptom control is important public by ensuring the purity, strength, and com-
and provides information about which position of foods, drugs, and cosmetics. It also
products are helpful and those that are not. prohibits the movement in interstate commerce of
Journals, newsletters, and the Internet can altered and misbranded food, drugs, devices, and
provide information about herbal medicine. cosmetics. Enforcement of the act is the responsi-
These publications can be explored for bility of the FDA, which is part of the Department
information and are a valuable resource. of Health and Human Services (DHHS).
Relevent publications include Herbalgram,
Phytomedicine, Alternative Medicine Alert, and Controlled Substance Act of 1970
Alternative and Complementary Medicine.
One category of drugs—those with potential for
abuse or addiction—is regulated by the Controlled
Substance Act of 1970. It controls the manufacture,
rehearing on the issue. Ephedra remains illegal importation, compounding, selling, dealing in,
and is likely to remain so. Congress is rewriting and giving away of drugs that have the potential for
laws so it will be easier for the FDA to take action abuse and addiction. The drugs are known as con-
and ban substances they believe are harmful. trolled substances and include heroin and cocaine
and their derivatives, other narcotics, stimulants,
and depressants. The Drug Enforcement Agency
Synthetic Drugs (DEA) of the U.S. Justice Department monitors and
Synthetic drugs are artificially prepared in phar- enforces the act, which is also known as the Com-
maceutical laboratories. By combining various prehensive Drug Abuse Prevention and Control
chemicals, scientists can produce compounds that Act. Under federal law, providers who prescribe,
are identical to a natural drug or create entirely administer, or dispense controlled substances must
new substances. An advantage of synthetic drugs register with the DEA and renew their registration
over natural is the ability to standardize doses. as required by state law (Form DEA 224).
Thousands of drugs are now produced syntheti- Applications for registration are available
cally. Examples are Motrin® (ibuprofen), Feldene® online (http://www.deadiversion.usdoj.gov). A
(piroxician), and Prilosec® (omeprazole). licensed provider is issued a registration that must
be renewed at regular intervals (Figure 23-1).
Genetically Engineered The renewal form is sent approximately 2 months
before the expiration date.
Pharmaceuticals
Scientists are now capable of creating new strains Controlled Substances Schedules. Controlled sub-
of bacteria using a technique known as gene splic- stances are classified according to five schedules:
ing. Through this process, hybrid forms of life have
been created that benefit human beings by provid- • Schedule I specifies drugs that have a high poten-
ing an alternative source of drugs, such as Humu- tial for abuse and are not accepted for medical use
lin® (insulin) for the diabetic patient and interferon within the United States. Examples are heroin,
for use in treatment of cancer. These drugs can be lysergic acid diethylamide (LSD), and marijuana.
manufactured in large quantities; thus, they are less • Schedule II drugs include those that also have a high
expensive than natural substances. abuse potential but have an accepted medical use
 CHAPTER 23 Basic Pharmacology 677

APPROVED OMB NO 1117-0014

Form-224 APPLICATION FOR REGISTRATION FORM DEA-224 (10-06)
Under the Controlled Substances Act Previous editions are obsolete

INSTRUCTIONS Save time - apply on-line at www.deadiversion.usdoj.gov DEA OFFICIAL USE :

1. To apply by mail complete this application. Keep a copy for your records.
2. Print clearly, using black or blue ink, or use a typewriter.
3. Mail this form to the address provided in Section 7 or use enclosed envelope.
4. Include the correct payment amount. FEE IS NON-REFUNDABLE. Do you have other DEA registration numbers?
5. If you have any questions call 800-882-9539 prior to submitting your application.
IMPORTANT: DO NOT SEND THIS APPLICATION AND APPLY ON-LINE. NO YES

MAIL-TO ADDRESS Please print mailing address changes to the right of the address in this box.
FEE FOR THREE (3) YEARS IS $551
FEE IS NON-REFUNDABLE

SECTION 1 APPLICANT IDENTIFICATIION Individual Registration Business Registration

Name 1 (Last Name of individual -OR- Business or Facility Name)

Name 2 (First Name and Middle Name of individual - OR- Continuation of business name)

Street Address Line 1 (if applying for fee exemption, this must be address of the fee exempt institution)

Address Line 2

City State Zip Code

Business Phone Number Point of Contact

Business Fax Number Email Address

DEBT COLLECTION
INFORMATION Social Security Number (if registration is for individual) Tax Identification Number (if registration is for business)

Mandatory pursuant Provide SSN or TIN.

to Debt Collection See additional information
Improvements Act note #3 on page 4.

Professional Professional Year of

Degree : School : Graduation :
FOR select from
Practitioner list only
or
MLP National Provider Identification: Date of Birth (MM-DD-YYYY):
ONLY:
M M D D Y Y Y Y

SECTION 2 Central Fill Pharmacy

Practitioner
Ambulance Service
BUSINESS ACTIVITY (DDS, DMD, DO, DPM, DVM, MD or PHD)
Practitioner Military
Check one Retail Pharmacy (DDS, DMD, DO, DPM, DVM, MD or PHD) Animal Shelter
business activity
box only Mid-level Practitioner (MLP)
Nursing Home (DOM, HMD, MP, ND, NP, OD, PA, or RPH) Hospital/Clinic

Automated Dispensing System Euthanasia Technician Teaching Institution

FOR Automated Dispensing System DEA Registration # An ADS is automatically fee-exempt.

(ADS) ONLY: of Retail Pharmacy Skip Section 6 and Section 7 on page 2.
for this ADS You must attach a notorized affidavit.

SECTION 3 Schedule II Narcotic Schedule III Narcotic Schedule IV

DRUG SCHEDULES

Check all that apply Schedule II Non-Narcotic Schedule III Non-Narcotic Schedule V

Check this box if you require official order forms - for purchase or transfer of schedule 2 narcotic and/or schedule 2 non-narcotic controlled substances.
NEW - Page 1

Figure 23-1 Licensed providers who prescribe, administer, or dispense controlled substances must register with
the Drug Enforcement Agency (DEA) of the U.S. Justice Department. The registration must be renewed at regular
intervals. Shown here is Form 224 for a new application for registration with the DEA. Form 224(A) is for registration
renewal.
678 UNIT 6 Advanced Techniques and Procedures

SECTION 4 You MUST be currently authorized to prescribe, distribute, dispense, conduct research, or otherwise handle the controlled substances
in the schedules for which you are applying under the laws of the state or jurisdiction in which you are operating or propose to operate.
STATE LICENSE(S)
Be sure to include both State Expiration
state license numbers License Number Date / /
if applicable (required) (required)
MM - DD - YYYY
What state was this license issued in?

State Controlled Substance Expiration

License Number Date / /
(if required)
MM - DD - YYYY
What state was this license issued in?

SECTION 5 YES NO
1. Has the applicant ever been convicted of a crime in connection with controlled substance(s) under state or federal law,
LIABILITY or is any such action pending?
Date(s) of incident MM-DD-YYYY:
YES NO
IMPORTANT
2. Has the applicant ever surrendered (for cause) or had a federal controlled substance registration revoked, suspended,
All questions in restricted, or denied, or is any such action pending?
this section must
be answered. Date(s) of incident MM-DD-YYYY:
YES NO
3. Has the applicant ever surrendered (for cause) or had a state professional license or controlled substance registration
revoked, suspended, denied, restricted, or placed on probation, or is any such action pending?
Date(s) of incident MM-DD-YYYY:
YES NO
4. If the applicant is a corporation (other than a corporation whose stock is owned and traded by the public), association,
partnership, or pharmacy, has any officer, partner, stockholder, or proprietor been convicted of a crime in connection with
controlled substance(s) under state or federal law, or ever surrendered, for cause, or had a federal controlled substance
registration revoked, suspended, restricted, denied, or ever had a state professional license or controlled substance
registration revoked, suspended, denied, restricted or placed on probation, or is any such action pending?
Date(s) of incident MM-DD-YYYY: Note: If question 4 does not apply to you, be sure to mark 'NO'.
It will slow down processing of your application if you leave it blank.
EXPLANATION OF
"YES" ANSWERS Liability question # Location(s) of incident:
Applicants who have
answered "YES" to Nature of incident:
any of the four questions
above must provide
a statement to explain
each "YES" answer.

Use this space or attach

a separate sheet and Disposition of incident:
return with application

SECTION 6 EXEMPTION FROM APPLICATION FEE

Check this box if the applicant is a federal, state, or local government official or institution. Does not apply to contractor-operated institutions.
Business or Facility Name of Fee Exempt Institution. Be sure to enter the address of this exempt institution in Section 1.

The undersigned hereby certifies that the applicant named hereon is a federal, state or local government official or institution,
and is exempt from payment of the application fee.
FEE EXEMPT
CERTIFIER
Signature of certifying official (other than applicant) Date
Provide the name and
phone number of the
certifying official Print or type name and title of certifying official Telephone No. (required for verification)

SECTION 7 Make check payable to: Drug Enforcement Administration

Check See page 4 of instructions for important information. Mail this form with payment to:
METHOD OF
PAYMENT
American Express Discover Master Card Visa
Check one form of U.S. Department of Justice
payment only Credit Card Number Expiration Date Drug Enforcement Administration
P.O. Box 28083
Washington, DC 20038-8083

FEE IS NON-REFUNDABLE
Sign if paying by Signature of Card Holder
credit card

Printed Name of Card Holder

SECTION 8 I certify that the foregoing information furnished on this application is true and correct.
APPLICANT'S
SIGNATURE
Signature of applicant (sign in ink) Date
Sign in ink

Print or type name and title of applicant

WARNING: Section 843(a)(4)(A) of Title 21, United States Code states that any person who knowingly or intentionally furnishes false or
fraudulent information in the application is subject to imprisonment for not more than four years, a fine of not more than $30,000, or both.
NEW - Page 2

Figure 23-1 (continued)

 CHAPTER 23 Basic Pharmacology 679

within the United States. Examples are amphet- Record keeping applies only to persons
amines and cocaine. Because of their high poten- E HR who administer or dispense controlled
tial for abuse, a special DEA form must be used to substances. Record-keeping data can be
order these drugs. The form is not necessary for stored electronically.
Schedule III and IV drugs. A written prescription is Controlled substances (Schedule II) stored
required for Schedule II drugs and the prescription and used on the premises must be counted at the
cannot be renewed. Examples of Schedule II drugs end of each workday, verified by two individuals for
are morphine, codeine, Ritalin, and Percocet. accuracy of count, and recorded on an audit sheet.
• Schedule III drugs have a low-to-moderate potential An inventory record of Schedule II drugs must be
for physical dependence, yet have a high potential submitted to the DEA every 2 years.
for psychological dependency. Some examples are Because of the increase in office and clinic
barbiturates and various drug combinations con- drug theft and substance abuse, as well as the
taining codeine and paregoric. Prescriptions for stringent federal laws that apply to storing, dispens-
Schedule III drugs can be either written or oral. ing, and administration of controlled substances,
They can be refilled, but only five times within 6 many offices and clinics do not keep controlled
months. Schedule III drugs are accepted for medi- substances on the premises. However, agencies
cal use in the United States. that do have controlled substances on the prem-
ises must comply with the DEA disposal policy.
• Schedule IV drugs have a lower potential for abuse
and have an accepted use in the United States.
Examples of these drugs include chloral hydrate
Controlled Substance Disposal Policy (per DEA).
The DEA Disposal Policy for Controlled Substances
and diazepam. Prescriptions for Schedule IV drugs
requires that controlled substances be accounted for
may include refills, but refills are limited to five
when they are disposed of. One option is the com-
times within 6 months.
pany Universal Solutions, which is contracted with
• Schedule V drugs have the lowest abuse potential of the DEA and will dispose of expired or unused con-
controlled substances. Some examples from this trolled substances. Certain forms (DEA Form 41)
schedule are Lomotil® and Donnagel®. Some drugs must be completed, and the provider must have cur-
from Schedule V may include refills, but refills are rent certificate of registration (DEA Form 222) with
limited to five times within 6 months. the DEA. Records of disposed controlled substances
must be kept for 2 years. Application forms are com-
On occasion, the DEA will reclassify drugs pleted and signed by the provider. A copy of the pro-
and move them from one schedule to another. vider’s DEA certificate of registration is included and
So that they can be readily identified, con- sent to Universal Solutions (controlled substances
trolled substances are labeled with a large C with are not sent at this time). Shipping instructions from
a Roman numeral inside it to indicate from which Universal Solutions will be sent along with a label.
schedule the drug has come; for example, C II
repre- Follow the instructions provided and ship to Uni-
sents a Schedule II drug. versal Solutions. The company will confirm receipt
The provider’s DEA number must appear on of the material and its eventual destruction. Cop-
each prescription for controlled substances. ies of application and confirmation of destruction
A copy of the federal law and a complete list must be sent to the DEA. Applications for forms for
of controlled substances and their schedules are disposal of controlled substances are available from
available from any DEA office or online. the nearest DEA office or online (http://www.usdoj.
gov/dea).
Storage of Controlled Substances. Federal law
requires that all controlled substances be kept sepa- Medical Assistant Role and Responsibilities.
rate from other drugs. They must be stored in a well- Medical assistants are required to know the le-
constructed metal box or compartment that has a galities that surround controlled sub-
double lock. Controlled substances must be pro- stances. Medical assistant responsibilities
tected from possible misuse and abuse, and persons may include:
who administer controlled substances must record
them in a separate record book. The record must be 1. Monitor the provider’s DEA registration renewal
maintained on a daily basis and kept for a minimum date.
of 2 to 3 years, depending on state laws. Patient name, 2. Maintain legally designated records and
address, date of administration of the controlled sub- E HR inventories of all drugs (Figure 23-2),
stance, drug name, dose, and route and method of including samples. This can be done
administration must be included in the record. electronically.
680 UNIT 6 Advanced Techniques and Procedures

Figure 23-2 It is important to maintain patient medication records both for the safety of the patient and to
protect the practice. (A) A paper-based patient medication record. (B) The patient medication record as part
of the patient’s electronic medical record.
 CHAPTER 23 Basic Pharmacology 681

3. Provide security for all drugs, in particular con- Medical assistants need to advise patients after
trolled substances (Schedule II). the provider prescribes a drug. Patients should also
4. Provide security for prescription pads. read warning labels on medication containers (Figure
23-3). Prescription drugs are also called legend drugs.
5. Properly destroy expired drugs and document.
The July 20, 2007, issue of Medical Econom-
6. Know and understand federal and state laws that
regulate drugs, including all controlled substances
E HR ics, a periodical for providers and other
medical professionals, reported the results
and samples. of a survey they conducted, which showed physicians
ranked computer systems high on timely access to
The computer and its software have the records, better quality of care, and better documen-
E HR capability of storing information regard- tation. E-prescribing is a feature many providers
ing the due date for the provider’s DEA appreciated (Figure 23-4). Providers have instanta-
registration renewal, maintaining legal records and neous and remote access to records, in addition to
inventories on all drugs including samples, keep- many other capabilities. Some are:
ing track of expiration dates of drugs and when
• Automatically alerts to allergies and drug
they are destroyed, accessing the latest informa-
interactions
tion regarding new DEA laws, and e-prescribing.
• Automatically calculates doses of medication
Since 2006, the DEA has been reluctant to
according to the patient’s age and weight
approve regulations covering e-prescribing of con-
trolled substances. The reluctance and lack of DEA • Recommends brand and/or generic drug sub-
policies have been a hurdle to widespread adop- stitutions
tion of e-prescribing. Presently, some providers • Prints prescriptions and faxes them to the patient’s
can e-prescribe medications other than controlled pharmacy
substances (which require handwritten and signed
prescriptions). This requires two separate systems,
e-prescribing and handwritten prescriptions, and
providers object, viewing this as time-consuming.
A proposal known as the Medicare Electronic
Medication and Safety Protection Act, if approved,
would penalize providers who write prescriptions
by hand after 2011. The government is offering a
one-time grant to help offset the costs to providers
who implement e-prescribing technology.
The DEA is preparing to allow e-prescribing
of controlled substances as of 2008. It has sent a
proposed rule to the Department of Justice (DOJ).
The rule requires review from the DOJ and the
Office of Management and Budget (OMB) before
the rule can be enacted.
E-prescribing of medications is safe, efficient,
and effective. It can improve patient safety. The
next section on Prescription Drugs discusses how
e-prescribing is beneficial to providers and patients.

Prescription Drugs
State laws require that licensed practitioners who
prescribe drugs must write and sign an order for
the dispensing of drugs. This process is known as
writing a prescription. Some examples of drugs
that require a prescription are all of the controlled
substances, except for Schedule I, which is not
accepted for medical use in the United States, and Figure 23-3 Warning labels are placed on prescription
other categories such as digoxin, a cardiac drug, medication containers, and patients should be advised to
and epinephrine, a vasoconstrictor. read and adhere to the precautions or instructions.
682 UNIT 6 Advanced Techniques and Procedures

Pharmacy
Patient Education
Guidelines for patients who take prescription
CLINICAL CARE medications include:
Patient Assessment 1. Take exactly as directed.
Procedures, Diagnoses & Treatment Plans
Referrals & Follow-up Appointments 2. Inform the provider or the medical
Prescriptions assistant of unusual or adverse
Orders for Tests
Patient Medical History reactions.
3. Continue to take the medication for the
duration of the prescribed number of
days, weeks, and so on.
Test Results 4. If you want to discontinue the
Schedules and Tickler Files
Patient Medical History medication, inform your provider or the
Medication Administration medical assistant.
Patient Education
Graphical Patient Data Displays 5. Do not take other medications or herbs
concurrently without checking with your

ELECTRONIC provider or medical assistant.

6. Do not take someone else’s prescribed
medication.
RECORDS 7. Store all medications away from
children.
8. Discard unused medication properly.
Many states require that unused
Figure 23-4 The clinical care arm of the total prac- medications be turned into a
tice management system (TPMS). E-prescribing sends community’s biohazard waste collection.
prescriptions and prescription refills directly to the Medication substances have been
patient’s pharmacy. found in some water supplies.
9. Heed warning labels on medication
• Integrates with a drug reference such as the Physi- containers.
cian’s Desk Reference (PDR)
• Contains and upgrades patient’s demographics
• Automatically processes renewals or refills
An expired drug cannot be dispensed or
administered because it could be harmful.
Nonprescription Drugs When disposing of expired drugs, it is no lon-
Drugs that are frequently referred to as over-the- ger recommended that expired and unused medica-
counter (OTC) drugs fall into the category of tions, prescriptions or over-the-counter, be released
nonprescription drugs. These drugs are readily into the sewage system. Various antibiotics and hor-
accessible to the public. They do not require a pre- mones have been discovered in the water supplies.
scription because the FDA considers them safe to Pharmacists have been asked to allow patients to
use without a provider’s advice. Examples of OTC take their expired and unused medications to their
drugs are aspirin, ibuprofen, and vitamins such as pharmacies. Pharmacists can arrange to have the
vitamin C. Although OTC drugs are considered medications incinerated. Some communities have
safe, it is useful for the medical assistant to offer 1 day a year set aside for disposal of biohazard sub-
patients some guidelines (Figure 23-5). stances, including these medications.
If a medication is removed from its original
container, it should not be used (for example, the
Proper Disposal of Drugs patient refused the medication); do not replace it
All drug labels contain an expiration date (Figure in the container. Dispose of it as outlined earlier.
23-6). When that date has been reached, the drug Outdated and expired controlled substances
must be removed from the shelf and destroyed (Schedule II) are handled differently. They must be
(see Procedure 23-1). returned to the pharmacy (as required by law). If a
 CHAPTER 23 Basic Pharmacology 683

means that the licensed practitioner with prescrip-

Because patients are more aware and better tive authority (provider, physician assistant, or nurse
informed about their health care needs, they are practitioner) gives a written order to be taken to the
becoming more involved in making choices and
pharmacist to be filled. To dispense a drug means
decisions about their health care. When they choose to take
over-the-counter (OTC) drugs, they need information and
to give (hand over) the medication as ordered by
guidance. Over the past few years, some previous prescrip- the provider to the patient to be taken at another
tion drugs have been changed to OTC drugs. The safety of time. To administer a drug means to give it to the
these drugs can only be ensured if patients take them as patient by mouth or injection or any other method
directed. of administration as ordered by the provider.
Patients need to realize that OTC medications: Although state laws vary, some states allow
1. Can interact with other drugs (either prescribed, herbal, or
certain professionals, including medi-
other OTCs) and cause undesirable or adverse reactions or cal assistants, to prepare and administer
complications medications under the licensed practitioner’s
2. May be used in lieu of seeking professional help and supervision. Usually, it is the provider and phar-
thereby interfere with the need for medical care macist who dispense medications. However, med-
3. Can mask symptoms and exacerbate an existing condition ical assistants can also dispense samples of drugs
4. May have several active ingredients, which may be found under the provider’s direction. Although medical
to be undesirable assistants act as the provider’s agent when they
5. Have a safe minimum dose, which may not have the prepare and administer medication, they are eth-
desired therapeutic effect ically and legally responsible for their own actions
and can be subject to legal action should harm
Figure 23-5 Guidelines for patients when taking non- come to a patient. The law requires that individu-
prescription (over-the-counter) medications. als who prepare and administer medications know
the medications and their side effects.

controlled substance (Schedule II) has been either

dropped onto the floor (and is thus unfit to be DRUG REFERENCES
given to a patient) or has spilled (if in liquid form), AND STANDARDS
a witness should verify the action and proper docu-
mentation must take place. The strength, purity, and quality of drugs differ
The local DEA office and local police must be depending on how they are manufactured. To con-
notified and the appropriate paperwork completed trol the differences, standards have been set. By
if there has been a loss or theft of a controlled sub- law, the various drug products must meet standards
stance (Schedule II). that are set forth by the FDA. A special reference
book, United States Pharmacopeia/National Formulary,
and Web site list the drugs for which standards have
Administer, Prescribe, Dispense been established. These resources are recognized
There are three ways to handle drugs in the by the U.S. government as the official list of drug
provider’s office or clinic: by prescribing, dispens- standards, which are enforced by the FDA. Every 5
ing, or administering them. To prescribe a drug years the information is updated in an attempt to
include all drug products in the United States. Nat-
urals and herbals are not regulated.
Patient Education Other useful books used as references
include the Compendium of Drug Therapy, the Desk
Many patients keep unused medications Reference for Nonprescription Drugs, and the Physi-
past their expiration date. This presents a cian’s Desk Reference (PDR), which is published
potential health hazard, because some annually by Thomson Healthcare in coopera-
medications lose their potency after a tion with pharmaceutical companies. The PDR is
period, whereas others become toxic. It is published annually and supplements to the PDR
best to inform patients to discard any unused are available two times a year. The supplements
portion of medication by the stated date. contain the newest drugs that were not yet avail-
Encourage patients to check their medicine able when the PDR was printed; thus, the supple-
cabinets at the same time every year so it ments contain the most current information. The
becomes a routine practice. supplements are organized in the the same way
as the PDR. The PDR is available in print, on the
684 UNIT 6 Advanced Techniques and Procedures

EXPIRES 5/09 Expiration date

ENTERIC COATED

ASPIRIN Product name

Statement of identity

81mg Product dose

ENTERIC COATED
400 TABLETS 81mg EACH Net quantity of contents

Manufactured by Clark Name and address of

Pharmaceuticals manufacturer
49 Pleasant Way
Austin, TX. XXXX

Front of label
DRUG FACTS
ACTIVE INGREDIENTS: (in each tablet) List of active
Aspirin 81mg.................................................... Pain reliever ingredients

USES: Temporary relief of minor aches and pains or as Indications

recommended by provider. for use

WARNINGS: Reye’s Syndrome. Children and teens who Warning and

have or are recovering from chicken pox or flu-like cautionary statments
symptoms should not use product. When using, if nausea
and vomiting occur, or there are behavior changes consult
a provider. These may be early signs of Reye’s Syndrome.
ALLERGY ALERT: May cause hives, swelling, asthma or
shock.
ALCOHOL WARNING: If you consume alcohol (3 or more
drinks every day), consult provider about whether you
should take aspirin. May cause stomach bleeding.
NOT RECOMMENDED DURING PREGNANCY:
Especially last trimester.
KEEP OUT OF CHILDREN’S REACH: In case of
overdose, contact a poison control center or seek
medical help.

DIRECTIONS: Directions and

• Drink a full glass of water with each dose dosage instructions
• Adults and children 12 years and over, take 4 to 8
tablets every 4 hours. Do not exceed 48 tablets in 24
hours
• Children under 12 years, consult provider

Back of label OTHER INFORMATION: Tamper-resistant

• Store at room temperature (59-86°F) feature and other
• Use by expiration date information
• Tamper resistant feature: Do not use if imprinted safety
seal under cap is missing or broken.

Figure 23-6 Medication labels contain valuable information essential to the safe and effective use of the drug.

Web, and for PDAs. The PDR is one of the most tants (PDAs), hand-held electronic devices that
widely used reference books and is found in most give them the information they need. The PDR
offices and clinics. It is divided into sections of comes with a CD-ROM, and an individual can
drug information, which are followed by other register online to access medications information
useful drug information such as a list of products, (http://www.PDR.net).
poison control 800 telephone numbers, conver-
sion tables, and a guide to management of drug
overdose (Figure 23-7).
How to Use the PDR
Providers use electronic technology to The five most commonly used sections of the PDR
assist them when they need references list drugs according to:
to drugs, their interactions, brand and
generic names, and doses according to patient’s • Brand name and generic name index, section 2
needs. Some providers use personal digital assis- • Classification or category, section 3
 CHAPTER 23 Basic Pharmacology 685

tion page number, section 4. The second number is

the product information, section 5.
Example:
Look up Zithromax® capsules in a current PDR.

Zithromax (Pfizer)
Note all the information provided for a drug.
• Description. Gives the origin and chemical composi-
tion of the drug.
• Clinical Pharmacology. Indicates the effect of the
drug on the body and the process by which the
drug exerts this effect.
• Indications and Uses. States the various conditions,
diseases, types of microorganisms, and so on, for
which the drug is used.
• Contraindications. States when the drug should not
be given to a specified person.
• Warnings. Gives the potential dangers of the drug.
• Precautions. States the possible unfavorable effects
Figure 23-7 The Physician’s Desk Reference (PDR) is a
that the drug may have on a patient.
valuable resource for the medical assistant who wishes
to obtain information about a specific medication. • Adverse Reactions. Lists the undesired side effects or
toxicity of the drug.
• Dosage and Administration. States the amount
(usual daily dose for adults and children) and
• Product identification guide, section 4 time sequence of administration.
• Product information and alphabetical arrange- • How Supplied. Lists the various forms of the drug
ment by manufacturers, section 5 and their dosages.
Section 2 of the PDR is the alphabetized section 2. If you know the classification of the drug, turn to
used for finding the page numbers for generic and section 3 and locate the category of the drug.
brand name drugs. Each drug, whether generic
Example:
or brand, has a page number listed to enable you
to locate a specific drug. Each time a brand name Antibiotics
appears, it is followed by the manufacturer’s name Macrolide
and page number to check for more information. Zithromax® capsules (Pfizer)
When more than one page number appears, the
first number refers to the photo section (Product NOTE: All controlled substances listed in the PDR
Identification Guide), section 4; the last num- are indicated with the symbol C with the Roman
ber refers to the prescribing category, section 3 numeral II, III, IV, or V printed inside the C to
(Product Category Index). Generic named drugs designate the schedule in which the substance is
are underlined; brand names are not. classified.
The PDR has many other sections within it,
such as the Key to Controlled Substances category, Example:
the U.S. Food and Drug Administration telephone Duramorph® C, morphine sulfate USP
II

directory, telephone numbers for poison control

centers, and herb and drug interactions.
The following guidelines will assist you as you Other Reference Sources
learn to use the PDR. On occasion, you may not find the drug that you are
looking for listed in the PDR. When this happens:
1. If you know the brand or generic name of the drug,
turn to section 2 and locate the drug in the alpha- • Refer to another drug reference book, or go online
betical listing. The manufacturer’s name will be in • Ask a pharmacist about the drug
parentheses, followed by a page number or two page • Refer to the packet insert that comes in the drug
numbers. The first number is the product identifica- package
686 UNIT 6 Advanced Techniques and Procedures

The package insert that most manufacturers Other drugs may have what is known as:
provide with their products is an important source
of information about a particular drug. This is a • Local action. The drug acts on the area to which it is
brief description of the drug, including its clini- administered.
cal pharmacology, indications and usage, contra- • Remote action. A drug affects a part of the body that
indications (any symptom or circumstance that is distant from the site of administration.
indicates that the use of a particular drug is inap-
propriate when it would otherwise be advisable), • Systemic action. The drug is carried via the blood-
warnings, precautions, drug interactions, adverse stream throughout the body.
reactions, overdose, dosage, and administration. • Synergistic action. One drug increases or counter-
The package insert can be a valuable source of acts the action of another.
information about drugs that might not be listed
elsewhere, or if a PDR is unavailable.
Information about some older medications, Factors That Affect Drug Action
such as digoxin, can be found in the package insert The four principal factors that affect drug action
because they may have been deleted from the cur- are: absorption, distribution, biotransformation,
rent PDR. You or your employer can become reg- and elimination. These factors depend on the indi-
istered to use the PDR. A version of the PDR is vidual patient, the form and chemical composition
available. of the drug, and the method of administration.
1. Absorption is the process whereby the drug passes
CLASSIFICATION OF DRUGS into the body fluids and tissues.
2. Distribution is the process whereby the drug is
Drugs can be classified (arranged in groups) in a transported from the blood to the intended site
number of ways. Some examples are: of action, site of biotransformation, site of storage,
and site of elimination.
• Drugs used to treat or prevent disease (examples
are hormones and vaccines) (see Chapter 10) 3. Biotransformation is the chemical alteration that a
drug undergoes in the body, usually in the liver.
• Drugs that have a principal action on the body (ex-
amples are analgesics and antiinflammatory 4. Elimination is the process whereby the drug is
drugs) excreted from the body. Elimination occurs via
the gastrointestinal tract, respiratory tract, skin,
• Drugs that act on specific body systems or organs
mucous membranes, and mammary glands.
(examples are respiratory and cardiovascular
drugs)
• Drug preparation (examples are suppository, Undesirable Actions of Drugs
liquid)
Most drugs have the potential for causing an action
Table 23-1 lists common drug classifications. other than their intended action. For example:
See Appendix B for the 50 top prescribed brand
name medications, or visit the following Web site: 1. Side effect. An undesirable action of the drug that
http://www.drugtopics.modernmedicine.com. may limit the usefulness of the drug.
Look under facts and figures for the top 200 brand 2. Drug interaction. Occurs when one drug potentiates—
name drugs for 2007. increases or diminishes the action of another drug.
These actions may be desirable or undesirable. Drugs
may also interact with various foods, alcohol, tobacco,
PRINCIPAL ACTIONS and other substances.
OF DRUGS 3. Adverse reaction. An unfavorable or harmful unin-
tended action of a drug, such as an allergic reaction.
In general, drugs can be grouped as follows: those
that act directly on one or more tissues of the body; A patient may experience an allergic reaction
those that act on microorganisms; and those that to a drug after administration. It is often mild and
replace body chemicals. may exhibit itself in the form of a rash, urticaria, or
Certain drugs have selective action, such as pruritus. On occasion, a severe reaction or anaphy-
stimulants, which increase cell activity, and depres- laxis can occur, which is hypersensitivity to a drug
sants, which decrease cell activity. or other foreign protein. It is the least common
 CHAPTER 23 Basic Pharmacology 687

Table 23-1 Common Classifications of Drugs and Their Actions

Classification Examples of Drugs Commonly Used

(with Phonetic Spelling) Action in Ambulatory Care Setting

An agent that relieves pain Acetaminophen (Tylenol), acetylsalicylic

Analgesic (an"al-je'sik) without causing loss of acid (aspirin), ibuprofen (Advil, Motrin)
consciousness

An agent that produces lidocaine HCl (Xylocaine) Both are local

numbness procaine HCl (Novacaine) anesthetics
Anesthetic (an"es-thet'ik) May be local or general
depending on the type and how
administered

Antacid (ant-as'id) An agent that neutralizes acid Amphojel, Gelusil, Mylanta, Milk of Magnesia

Antianemic (an"ti-an-em'ic) An agent that replaces iron Iron, ferrous sulfate

An agent that relieves anxiety Benzodiazepines: diazepam (Valium), chlordi-

Antianxiety (an"ti-ang-zi'e-te)
and muscle tension azepoxide HCl (Librium), alprazolam (Xanax)

Antiarrhythmic An agent that controls cardiac Lidocaine HCl (Xylocaine), propranolol HCl
(an"te-a-rith'mik) arrhythmias (Inderal)

An agent that is destructive to or Penicillins (Pentids, Duracillin, Polycillin,

Antibiotic (an"ti-bi-ot'ik)
inhibits growth of microorganisms Pipracil, Augmentin) and others

Anticholesterol or An agent that reduces cholesterol Zocor, Lipitor, Crestor, Mevacor

antihyperlipidemic
(an”ti-ko”less;ter-ol)

Anticholinergic An agent that blocks parasym- Atropine, scopolamine, trihexyphenidyl HCl

(an"ti-ko"lin-er'jik) pathetic nerve impulses (Artane)

Anticoagulant An agent that prevents or Heparin sodium, Dicumarol, warfarin sodium

(an"ti-ko-ag'u-lant) delays blood clotting (Coumadin)

Anticonvulsant An agent that prevents or Carbamazepine (Tegretol), Phenytoin

(an"ti-kon-vul'sant) relieves convulsions (Dilantin), Ethosuximide (Zarontin)

An agent that prevents or Monoamine oxidase (MAO) inhibitors:

relieves the symptoms of isocarboxazid (Marplan), phenelzine sulfate
Antidepressant depression (Nardil), tricyclic: amitriptyline HCl (Elavil),
(an"ti-dep-res'ant) imipramine HCl (Tofranil), sertraline HCl
(Zoloft), paroxetine HCl (Paxil), trazodone
(Desyrel), fluoxentine (Prozac)

An agent that prevents or Pepto-Bismol, Kaopectate, Diphenoxylate HCl

Antidiarrheal (an"ti-di-a-re'al)
relieves diarrhea (Lomotil)

An agent that counteracts Naloxone (Narcan)

Antidote (an-ti'dot)
poisons and their effects

An agent that prevents or Tigan, Dramamine, Phenergan, Reglan,

Antiemetic (an"ti-e-met'ik)
relieves nausea and vomiting Marinol, Compazine
(continues)
688 UNIT 6 Advanced Techniques and Procedures

Table 23-1 Common Classifications of Drugs and Their Actions (continued)

Classification Examples of Drugs Commonly Used

(with Phonetic Spelling) Action in Ambulatory Care Setting

An agent that counteracts Dimetane, Benadryl, Seldane, Allegra

Antihistamine (an"ti-his'ta-min)
histamine

Antihypertensive An agent that prevents or Methyldopa (Aldomet),

(an"ti-hi"per-ten'siv) controls high blood pressure clonidine HCl (Catapres),
metoprolol tartrate (Lopressor)

Antiinflammatory An agent that counteracts Naproxen (Naprosyn),

(an"ti-in-flam'a-to-re) inflammation aspirin, ibuprofen (Advil, Motrin)

An agent used for the treatment Lithium

Antimanic (an"ti-man'ik) of the manic episode of manic-
depressive disorder

Antineoplastic An agent that kills or destroys Busuflan (Myleran), cyclophosphamide

(an"ti-ne"o-plas'tik) malignant cells (Cytoxan)

An agent that helps in Haloperdol (Haldol), chlorpromazine

Antipsychotic schizophrenia and chronic (Thorazine)
brain syndrome

Antipyretic (an"ti-pi-ret'ik) An agent that reduces fever Aspirin, acetaminophen (Tylenol)

An agent that prevents or Codeine, dextromethorphan (Pertussin,

Antitussive (an"ti-tus'iv)
relieves cough Romilar)

An agent that relieves and heals Cimetidine (Tagamet), anitidine (Zantac),

Antiulcer (an"ti-ul'ser)
ulcers by blocking hydrochloric omeprazole (Prilosec)
(H2 blockers)
acid

An agent that fights a specific Zovirax, Retrovir, Denavir

Antiviral (an”ti-viral)
virus

Bronchodilator An agent that dilates the bronchi Isoproterenol HCl (Isuprel), albuterol (Proventil)
(brong"ko-dil-a'tor)

Any device, method, or agent Envid-E 21, Ortho-Novum 10/11-21; 10/11-28

Contraceptive (kon"tra-sep'tiv)
that prevents conception Triphasil-21, Ovral 28, Alesse, Levlen

An agent that inhibits COX-2 (an Celebrex

COX-2 Inhibitor (kox-2 in-hib-it-or) enzyme) found in joints or other
body parts that are inflamed

An agent that reduces nasal Oxymetazoline (Afrin), phenylephrine HCl

Decongestant (de"con-gest'ant) congestion or swelling (Neo-Synephrine), pseudoephedrine HCl
(Sudafed)

An agent that increases the Chlorothiazide (Diuril), furosemide (Lasix),

Diuretic (di"u-ret'ik)
excretion of urine mannitol (Osmitrol)
(continues)
 CHAPTER 23 Basic Pharmacology 689

Table 23-1 (continued)

Classification Examples of Drugs Commonly Used

(with Phonetic Spelling) Action in Ambulatory Care Setting

An agent that facilitates removal Gualifenesin (Robitussin)

Expectorant (ek-spek’to-rant) of secretion from bronchopul-
monary mucous membrane

An agent that controls or stops Humafac, Amicar, vitamin K

Hemostatic (he"mo-stat'ik)
bleeding

An agent that produces sleep or Secobarbital (Seconal), chloral hydrate,

Hypnotic (hip-not'ik)
hypnosis ethchlorvynol (Placidyl)

An agent that reduces blood Insulin, chlorpropamide (Diabinese),

Hypoglycemic (hi"po-gli-se'mik)
glucose level tolbutamide (Orinsase)

An agent that loosens and pro- Metamucil powder, Dulcolax, Docusate

Laxative (lak'sa-tiv)
motes normal bowel elimination sodium (Colace)

Muscle relaxant An agent that produces Robaxin, Norflex, Paraflex, Skelaxin, Valium
(mus'el re-lak'sant) relaxation of skeletal muscle

An agent that relieves mild to Aspirin (Bufferin, Ecotrin), ibruprofen (Advil,

Nonsteroidal antiinflammatory moderate pain due to head- Excedrin, Motrin), naproxen (Aleve, Anaprox,
drug (NSAID) ache, toothache, dysmenorrhea, Naprosyn), ketorofex (Orudis)
backache

Proton-pump inhibitor An agent that suppresses gastric Acifex, Nexium, Protonix

(pro
ˉto
ˉn pump in-hib-it-or) acid (GERD) ulcers

An agent that produces a calm- Amobarbital (Amytal), butabarbital sodium

Sedative (sed'a-tiv)
ing effect without causing sleep (Buticaps), phenobarbital

An agent that reduces mental Diazapem (Valium), Alprazolam (Xanax),

Tranquilizer (tran"kwi-liz'er)
tension and anxiety chlordiazepoxide (Librium)

An agent that produces relax- Isorbide dinitrate (Isordil), atenolol

Vasodilator (vas"o-di-la'tor) ation of blood vessels; reduces (Tenormin), nitroglycerin, diltiazem
blood pressure (Cardizem)

An agent that produces con- Metaraminol (Aramine), norepinephrine

traction of muscles of capillaries (Levophed)
Vasopressor (vas"o-pres'or)
and arteries; increases blood
pressure

allergic reaction but can become severe quickly and the provider immediately so that appropriate emer-
result in dyspnea and shock. Loss of consciousness gency treatment can be given. One or two injections
and death can result. To help prevent an allergic of epinephrine usually reverses the life-threatening
reaction or minimize its risk, the medical assistant symptoms of anaphylaxis and is followed by admin-
should attempt to ascertain before administration istration of an antihistamine such as Benadryl®. In
of every drug whether the patient has any known severe cases that do not respond to this treatment,
allergies. The medical assistant should be aware of oxygen and immediate transfer to the emergency
signs and symptoms of allergic reaction and notify department is necessary.
690 UNIT 6 Advanced Techniques and Procedures

DRUG ROUTES The method for administering a drug

depends on its form, its properties, and the effects
Drugs are manufactured in a variety of forms and desired. When given orally, a drug may be in the
for various purposes. The route of a drug refers to form of a liquid, powder, tablet, capsule, or caplet.
how it is administered to the patient, and thereby If it is to be injected, it must be in the form of a liq-
transported into the patient’s body. Certain medi- uid. For topical use, the drug may be in the form
cations can be administered by more than one of a liquid, powder, or semisolid. Oral and injec-
route, whereas others must be administered via a table medications are examples of preparations
specific route. designed for internal use.
The route of administration is determined by
a number of factors. One factor is the action of the Liquid Preparations
medication on the body, either local or systemic.
Intravenous medication reaches the systemic cir- Liquid preparations contain a drug that has been
culation rapidly via the bloodstream and quickly dissolved or suspended. Depending on the sol-
becomes effective. Injections of medication and vent used, the drug may be further classified as an
medications absorbed through mucous mem- aqueous (water) or alcohol preparation or as an
branes such as suppositories and sublingual nitro- aerosol or mist. When prescribed for internal use,
glycerine are absorbed quickly. Oral medications liquid preparations other than emulsions are rap-
take longer to act because they must be digested idly absorbed through the stomach, intestinal walls,
by the stomach and then be absorbed into the or lungs.
bloodstream.
Another factor in route selection is the physi- Solid and Semisolid Preparations
cal and emotional state of the patient. The patient’s
consciousness level, emotional status, and physical Tablets, capsules, caplets, troches or lozenges, sup-
restrictions are considered when selecting a route positories, and ointments are examples of solid and
to administer medication. semisolid preparations. These products offer great
A third factor to consider is the characteris- flexibility as a means of dispensing different dos-
tics of the drug. An example is insulin. Insulin is ages of drugs. Figure 23-8 shows types of tablets
destroyed by digestive enzymes; therefore, the and capsules.
route of administration must be by injection.
The most frequently used routes of admin- Other Drug Delivery Systems
istering medication to the patient are oral and
parenteral routes: oral medications are taken by Technologic advances have introduced new ways
mouth, parenteral generally by injection. Other by which drugs can be introduced into the patient.
routes of administration include: In addition to the conventional preparations, the
following therapeutic systems offer special delivery
• Direct application to the skin—topical (lotions, of medication to targeted areas.
creams, liniments, ointments, transdermal [patch]
systems) Transdermal System. The transdermal system of
• Sublingual (tablets, liquid, drops) medication delivery consists of a small adhesive patch
• Buccal (tablets) that may be applied to intact skin near the treatment
site. For example, Transderm Scop®, used for pre-
• Rectal (suppositories, ointments)
venting motion sickness, may be applied behind the
• Vaginal (suppositories, creams, applications) ear; Nitro-Dur® (Figure 23-9), used for preventing
• Inhalation (sprays, aerosols) angina pectoris, may be applied to the chest; Estra-
• Instillation (liquid, drops) derm®, used to treat menopausal symptoms, may be
applied to the trunk; and Nicoderm®, used to relieve
the body’s craving for nicotine, may be applied to
FORMS OF DRUGS any area above the waist. A transdermal system gen-
erally consists of four layers (Figure 23-10):
Drugs are compounded in three basic types of prep- 1. An impermeable backing that keeps the drug from
arations: liquids, solids, and semisolids. The ease with leaking out of the system
which a drug’s ingredients can be dissolved largely
determines the variety of forms manufactured. Some 2. A reservoir containing the drug
drug agents are soluble in water, others in alcohol, 3. A membrane with tiny holes that controls the rate
and others in a mixture of several solvents. of drug release
 CHAPTER 23 Basic Pharmacology 691

Backing layer
Drug reservoir
Microporous
rate-limiting
membrane
Adhesive
formulation
Skin
surface

Blood
vessel

A
A B

B
C D
Figure 23-10 (A) The multilayer unit comprising
Figure 23-8 Drugs are manufactured in various TransdermNitro® delivers nitroglycerin into the blood-
forms, including solid preparations such as tablets stream in a consistent, controlled manner for 24 hours.
and capsules. (A) Tablets, scored and unscored. The thin unit contains a backing layer, a reservoir of
(B) Enteric-coated tablets. (C) Capsules and nitroglycerin, a unique rate-limiting membrane, and
gelatin-coated capsules. (D) Timed-release capsules. an adhesive layer that has a priming dose of nitroglyc-
erin. (B) The patch is applied to the skin. (Courtesy
of Novartis.)

bronchi), bronchitis, and others may require treat-

ment with inhalation medication from an aerosol-
ized inhaler or a nebulizer. Some of the commonly
prescribed medications are bronchodilators such
as aminophylline, albuterol, isuprel, epinephrine,
and cortisone-type medications. Oxygen may be
Figure 23-9 Nitro-Dur® is a transdermal system of prescribed for hypoxia caused by respiratory dis-
delivering medication used for prevention and for eases. Oxygen may be prescribed for cardiovascular
long-term management of angina pectoris. It can be collapse, congestive heart failure, and pneumonia
applied to the chest. among other examples. (See Chapter 18 for infor-
mation about nebulizers, inhalers, and oxygen
4. An adhesive layer or gel that keeps the device in administration.)
place
Eye-Curing Lens. Another innovative drug delivery
Inhalation Medications. Medication for respira- system is one in which a drug, contained between
tory diseases and conditions such as asthma, bron- two ultrathin plastic membranes, is placed inside
chiectasis (permanent dilation of one or more the lower eyelid. It appears to cause little or no
692 UNIT 6 Advanced Techniques and Procedures

discomfort and provides a controlled release of the

Table 23-2 Examples of Common Emergency
medication for an extended period. Pilocarpine, a
Drugs
miotic that causes contraction of the pupils, is being
used in this method for the treatment of glaucoma. Adrenaline (a-dren'a-lin) or epinephrine (ep-i-nef-rin)
A vasoconstrictor. Relieves anaphylactic shock.
Implantable Devices. Implantable devices are Albuterol (al-bú-ter-ol)
available in several shapes and sizes and are posi- A bronchodilator. Relaxes smooth muscle of the
tioned just beneath the skin near blood vessels that respiratory tract.
lead directly to the area to be medicated. For exam-
Atropine (a- t́rō-peen)
ple, an infusion pump that is about the size of a
Helps restore heart rate.
hockey puck can be implanted below the skin near
the waist to provide continuous delivery of chemo- Benadryl (ben'a-dril)
therapy to patients with liver cancer or insulin to An antihistamine that relieves allergic symptoms.
a diabetic. This device, which has a refillable drug Compazine (com-pa'zeen)
reservoir, is connected by an outlet catheter to the An antiemetic. Relieves symptoms of nausea and
patient’s blood vessel. In addition to providing a vomiting.
continuous supply of medication, these devices
Dextrose (deks'trose) 50%
have the advantage of delivering greater doses with Used for hypoglycemia to counteract
fewer side effects than can be realized through the hyperinsulinism.
systemic route.
Diazepam (d ī-az’-e-pam)
Helps control seizures. Antianxiety.
STORAGE AND HANDLING Digoxin (di-jox'in)
OF MEDICATIONS Cardiac drug. Used for congestive heart failure,
arryhthmias. Slows and strengthens heartbeat.
Certain precautions should be followed if Diuril (di'ur-il)
the ambulatory care setting keeps medi- Promotes excretion of urine.
cations on the premises. The goal should
Hydrocortisone (hi"dro-cort'i-zon)
be to store all medications in their original contain-
An antiinflammatory. Used to suppress swelling
ers in a separate room in a locked cabinet. Many and shock.
medications require storage in a certain manner,
such as a dark area or in a dark container (to keep Insulin (in'sah-lin)
light away from them) or in the refrigerator. Some Diabetic coma.
must be kept in glass containers only because plas- Isuprel ( īcé-ū-prel)
tic may react with the medication’s chemical com- Heart block.
position. The drug label indicates proper storage
Lidocaine (l ī’-dō-kāne)
and handling for each medication. Controls ventricular arrhythmia.
Keep medications that are for internal use
separated from those intended for external use. Narcan (nar'can)
Access to medications is simplified if they Antidote. Used in narcotic overdose.
are organized in the storage area either accord- Nitroglycerin (ni"tro-glis'er-in)
ing to their classification (diuretic, hormones) or Vasodilator. Dilates coronary arteries. Used in
according to the alphabet. Always check expira- treatment of angina pectoris.
tion dates. Valium (val'e-um)
Antianxiety, muscle relaxant. Used to calm anxious
patients and to relax muscles. Valium is a Schedule
EMERGENCY DRUGS IV drug, and therefore must be kept in a locked
AND SUPPLIES cabinet.

Verapamil (ver-ap'a-mil)
The ambulatory care setting should maintain a For cardiac arrhythmia, stable and unstable
tray, box, cabinet, or crash cart (see Chapter 9 angina.
for contents of crash cart) especially and solely
NOTE: Ipecac syrup, no longer used to induce vomiting, has proven to
for drugs and supplies needed in an emergency be cardiotoxic, and several cases of aspiration have occurred.
such as anaphylaxis or other form of shock.
The drugs listed in Table 23-2 are a sample of
 CHAPTER 23 Basic Pharmacology 693

some general drugs to keep readily available for for infectious diseases, and Chapter 24 for infor-
emergencies. mation on antibiotics.)
Other supplies and equipment to keep together
with the drugs on the emergency cart are:
DRUG ABUSE
• Intravenous (IV) materials such as IV fluids, nee-
dles, tubing, syringes, alcohol, swabs, constriction There has been an enormous
band, and tape increase in the abuse, or misuse,
• Sphygmomanometer of legal and illegal drugs. Any
drug can be abused, whether it is penicillin, alco-
• Stethoscope
hol, or a controlled substance such as cocaine.
• Oxygen and mask Medical assistants, while caring for patients, may
• Airways unexpectedly come in contact with patients who
• Defibrillator abuse or misuse drugs.
• Suction equipment (nasopharyngeal) Medical assistants must be able to recog-
nize the symptoms of drug abuse in a patient or
• Personal protective equipment
coworker and report it to the provider. Health pro-
Check the tray on a regular basis (weekly, fessionals, including providers, are among individ-
monthly, depending on use) according to need. uals who can have a problem with drug or alcohol
Check the oxygen tank and gauge. Replace items abuse, and it must be reported to the proper pro-
that have been used as soon as possible, and dis- fessional association (see Chapter 7 for more infor-
card drugs and supplies that have reached their mation on drug abuse).
expiration dates. Document that the tray has been There are many programs available for treat-
checked and updated. (See Chapter 9 for more ment of drug abuse. Detoxification and rehabili-
information about emergencies and emergency tation are examples of treatment programs. The
drugs used in the office and other ambulatory National Institute on Drug Abuse, which is part
areas.) of the National Institutes of Health of the U.S.
Department of Health and Human Services,
provides information, treatment options, and
Bioterrorism specific programs for drug abuse on their Web site
Bioterrorism is the name given to the use of biologic (http://www.nida.nih.gov/podat/podatindex.
weapons (pathogenic microorganisms) to create html).
fear in people. There are many biologic agents that Table 23-3 gives examples of drug types most
can be used in an attempt to cause serious diseases. commonly abused.
Most diseases can be treated with pharmaceutical In addition to the drugs of abuse listed in
agents such as antibiotics and antitoxoids. Table 23-3, another drug of abuse is dextrometho-
The most dangerous disease threats are rphan. It is an antitussive (cough suppressant)
anthrax, botulism, pneumonic/bubonic plague, that has been an over-the-counter medication for
smallpox, and tularemia. more than 30 years and is a component of several
Anthrax, pneumonic/bubonic plague, and cough medications. One of the drugs is coricidin
tularemia can all be treated with antibiotics. Botu- HBP (cough and cold tablets), also known as “ccc,”
lism is treated with botulism antioxides supplied “robo,” or “red devils.” Primarily it is used by youths
by public health authorities. Smallpox is treated as a recreational drug for its euphoric effects, but an
by early vaccination (within four days). The Cen- overdose can result in coma and death. The cough
ters for Disease Control and Prevention has the and cold medications are easily available and often
vaccine. are shoplifted by persons who abuse them.
Education plays a vital role in raising aware- The same social pressures that influence
ness and increasing the knowledge of health care young people to try alcohol are responsible for
professionals to aid them in being better prepared introducing people of all ages to the previously
for threats to the public health. The World Health mentioned drugs and other chemical substances.
Organization, the Centers for Disease Control Because it is easier to prevent drug abuse than it is
and Prevention, and state and local public health to break an established habit, most efforts to com-
departments are excellent resources for more bat drug abuse are directed at the young. However,
information about bioterrorism. (See Chapter 9 people of all ages, including older people, may be
for information about emergencies, Chapter 10 or become abusers.
694 UNIT 6 Advanced Techniques and Procedures

Table 23-3 Drugs of Abuse—Uses and Effects

Dependence

Controlled Sub- Trade or Other

Drugs stance Schedule Names Medical Uses Physical Psychological

Narcotics

Substance I Diamorphine, Horse, None in High High

Smack, Black tar, United States,
Chiva, Negra analgesic,
Heroin
(black tar) antitussive

Substance II MS-Contin, Roxanol, Analgesic High High

Morphine
Oramorph SR, MSIR

Substance II, Prod- Hydrocodone with Analgesic, High High

uct III, V acetaminophen, antitussive
Hydrocodone
Vicodin, Vicoprofen,
Tussionex, Lortab

Hydromorphone Substance II Dilaudid Analgesic High High

Substance II Roxicet, Oxycodone Analgesic High High

with acetamino-
Oxycodone phen, OxyContin,
Endocet, Percocet,
Percodan

Substance II, Prod- Acetaminophen, Analgesic, Moderate Moderate

uct III,V Guaifenesin or antitussive
Promethazine with
Codeine
Codeine, Fiorinal,
Fioricet or Tylenol
with Codeine

Substance II, III, IV Fentanyl, Demerol, Analgesic, High-Low High-Low

Methadone, Darvon, antidiarrheal,
Other Narcotics
Stadol, Talwin, Par- antitussive
egoric, Buprenex

Depressants

Substance I, Prod- GHB, Liquid Ecstasy, None in United Moderate Moderate

Gamma uct III Liquid X, Sodium States,
Hydroxybutyric Oxybate, Xyrem® anesthetic
Acid

Substance IV Valium, Xanax, Hal- Antianxiety, Moderate Moderate

cion, Ativan, Restoril, sedative, anti-
Benzodiazepines Rohypnol (Roofies, convulsant,
R-2), Klonopin hypnotic, muscle
relaxant
 CHAPTER 23 Basic Pharmacology 695

Duration Usual Withdrawal

Tolerance (hours) Method Possible Effects Effects of Overdose Syndrome

Yes 3−4 Injected, Euphoria, drowsiness, Slow and shallow Watery eyes, runny
snorted, respiratory depression, breathing, clammy nose, yawning, loss
smoked constricted pupils, nausea skin, convulsions, of appetite, irritabil-
coma, possible ity, tremors, panic,
death cramps, nausea,
chills, sweating

Yes 3−12 Oral, injected Same as above Same as above Same as above

Yes 3−6 Oral Same as above Same as above Same as above

Yes 3−4 Oral, injected Same as above Same as above Same as above

Yes 3−12 Oral Same as above Same as above Same as above

Yes 3−4 Oral, injected Same as above Same as above Same as above

Yes Variable Oral, injected, Same as above Same as above Same as above
snorted,
smoked

Yes 3−6 Oral Slurred speech, disorien- Shallow respiration, Anxiety, insomnia,
tation, drunken behavior clammy skin, dilated tremors, delirium,
without odor of alcohol, pupils, weak and convulsions, possible
impaired memory of events, rapid pulse, coma, death
interacts with alcohol possible death

Yes 1−8 Oral, injected Same as above Same as above Same as above

(continues)
696 UNIT 6 Advanced Techniques and Procedures

Table 23-3 Drugs of Abuse—Uses and Effects (continued)

Dependence

Controlled Sub- Trade or Other

Drugs stance Schedule Names Medical Uses Physical Psychological

Substance I, II, III, IV Ambien, Sonata, Antianxiety, Moderate Moderate

Meprobamate, Chlo- sedative,
Other Depressants ral Hydrate, Barbitu- hypnotic
rates, Methaqualone
(Quaalude)

Stimulants

Substance II Coke, Flake, Snow, Local anesthetic Possible High

Crack, Coca, Blanca,
Cocaine
Perico, Nieve, Soda

Substance II Crank, Ice, Cristal, Attention deficit/ Possible High

Amphetamine/ Krystal Meth, Speed, hyperactivity
Methampheta- Adderall, Dexedrine, disorder,
mine Desoxyn narcolepsy,
weight control

Substance II Ritalin, Concerta, Attention deficit/ Possible High

Methylphenidate Focalin, Metadate hyperactivity
disorder

Substance III, IV Adipex P, Ionamin, Vasoconstriction Possible Moderate

Other Stimulants Prelu-2, Didrex,
Provigil

Hallucinogens

Substance I (Ecstasy, XTC, None None Moderate

MDMA and Adam), MDA (Love
Analogs Drug), MDEA (Eve),
MBDB

Substance I Acid, Microdot, None None Unknown

LSD Sunshine, Boomers

Substance I, II, III PCP, Angel Dust, Hog, Anesthetic Possible High
Phencyclidine Loveboat, Ketamine (ketamine)
and Analogs (Special K), PCE,
PCPy, TCP

Substance I Psilocybe mushrooms, None None None

Mescaline, Peyote
Other
cactus, Ayahausca, DMT,
Hallucinogens
Dextromethorphan
(DXM)

Cannibis

Substance I Pot, Grass, Sinsemilla, None Unknown Moderate

Blunts, Mota, Yerba,
Marijuana Grifa

*Not regulated
 CHAPTER 23 Basic Pharmacology 697

Duration Usual Withdrawal

Tolerance (hours) Method Possible Effects Effects of Overdose Syndrome

Yes 2−6 Oral Slurred speech, disorien- Shallow respiration, Anxiety, insomnia,
tation, drunken behavior clammy skin, dilated tremors, delirium,
without odor of alcohol, pupils, weak and convulsions, possible
impaired memory of events, rapid pulse, coma, death
interacts with alcohol possible death

Yes 1−2 Snorted, Increased alertness, excita- Agitation, increased Apathy, long periods
smoked, tion, euphoria, increased body temperature, of sleep, irritability,
injected pulse rate and blood pressure, hallucinations, convul- depression,
insomnia, loss of appetite sions, possible death disorientation

Yes 2−4 Oral, injected, Same as above Same as above Same as above
smoked

Yes 2−4 Oral, injected, Same as above Same as above Same as above
snorted,
smoked

Yes 2−4 Oral Same as above Same as above Same as above

Yes 4−6 Oral, snorted, Heightened senses, teeth Increased body Muscle aches,
smoked grinding, dehydration temperature, drowsiness,
electrolyte imbalance, depression, acne
cardiac arrest

Yes 8−12 Oral Illusions and hallucinations, Longer, more intense None
altered perception of time “trip” episodes
and distance

Yes 1−12 Smoked, oral, Illusions and hallucinations, Unable to direct Drug-seeking
injected, altered perception of time movement, feel pain, behavior*
snorted and distance remember

Possible 4−8 Oral Illusions and hallucinations, Unable to direct Drug-seeking

altered perception of time movement, feel pain, behavior*
and distance remember

Yes 2−4 Smoked, oral Euphoria, relaxed inhibitions, Fatigue, paranoia, Occasional reports
increased appetite, possible psychosis of insomnia,
disorientation hyperactivity,
decreased appetite

(continues)
698 UNIT 6 Advanced Techniques and Procedures

Table 23-3 Drugs of Abuse—Uses and Effects (continued)

Dependence

Controlled Sub- Trade or Other

Drugs stance Schedule Names Medical Uses Physical Psychological

Substance I, THC, Marinol Antinauseant, Yes Moderate

Tetrahydrocanna- Product III appetite
binol stimulant

Hashish and Substance I Hash, Hash oil None Unknown Moderate

Hashish Oil

Anabolic Steroids

Substance III Depo Testosterone, Hypogonadism Unknown Unknown

Testosterone Sustanon, Sten, Cypt

Substance III Parabolan, Anemia, breast Unknown Yes

Winstrol, Equipose, cancer
Other Anabolic
Anadrol, Dianabol,
Steroids
Primabolin-Depo,
D-Ball

Inhalants

Amyl and Butyl Pearls, Poppers, Rush, Angina (amyl) Unknown Unknown
Nitrite Locker Room

Laughing gas, Anesthetic Unknown Low

balloons, Whippets
Nitrous Oxide

Adhesives, spray None Unknown High

paint, hair spray, dry
Other Inhalants cleaning fluid, spot
remover, lighter fluid

Alcohol

Beer, wine, liquor None High High

Alcohol
 CHAPTER 23 Basic Pharmacology 699

Duration Usual Withdrawal

Tolerance (hours) Method Possible Effects Effects of Overdose Syndrome

Yes 2−4 Smoked, oral Euphoria, relaxed inhibitions, Fatigue, paranoia, Occasional reports
increased appetite, possible psychosis of insomnia,
disorientation hyperactivity,
decreased appetite

Yes 2−4 Smoked, oral Same as above Same as above Same as above

Unknown 14−28 Injected Virilization, edema, testicular Unknown Possible depression

days atrophy, gynecomastia,
acne, aggressive behavior

Unknown Variable Oral, injected Same as above Same as above Same as above

No 1 Inhaled Flushing, hypotension, Methemoglobinemia Agitation

headache

No 0.5 Inhaled Impaired memory, slurred Vomiting, respiratory Trembling, anxiety,

speech, drunken behavior, depression, loss of insomnia, vitamin
slow-onset vitamin defi- consciousness, pos- deficiency, confusion,
ciency, organ damage sible death hallucinations, con-
vulsions

No 0.5−2 Inhaled Impaired memory, slurred Vomiting, respiratory Trembling, anxiety,

speech, drunken behavior, depression, loss insomnia, vitamin
slow-onset vitamin defi- of consciousness, deficiency, confusion,
ciency, organ damage possible death hallucinations,
convulsions

Yes 1−3 Oral Impaired judgments, uncoor- Motor vehicle acci- Anxiety, shakiness,
dinated movements, slurred dents, gastritis, liver depression, hal-
speech, blurred vision damage, brain lucinations, sweats,
damage, domestic increased blood
violence pressure, seizures
700 UNIT 6 Advanced Techniques and Procedures

Procedure 23-1
Proper Disposal of Drugs
STANDARD PRECAUTIONS: 3. Only if the label or accompanying patient infor-
mation specifically instructs flushing drugs
down the toilet or sink can you do so. RATIO-
NALE: The FDA advises that only a certain few
PURPOSE: drugs can be flushed or thrown into the trash.
To properly dispose of drugs that have reached their The label or accompanying information will give
expiration dates. instructions.
EQUIPMENT/SUPPLIES: 4. Wash hands.
Drugs (oral and parenteral) that have reached their 5. Document instructions in the computer that the
expiration dates drugs with expired use by dates were disposed of
either by returning them to the pharmacy or by
PROCEDURE STEPS: having the contracted agency incinerate them.
1. Gather expired drugs, either prescription or Be sure to save receipts.
over-the-counter. RATIONALE: Expired drugs
NOTE: Patients can be instructed to determine
cannot be dispensed nor administered because
if their communities have pharmaceutical
they can be harmful to patients.
take-back programs or hazardous waste dis-
2. According to agency policy and state law, the posal programs that allow them to bring
drugs can be taken to the pharmacy or drug sup- unused drugs to a central location for proper
ply company from which they were ordered, and disposal.
the pharmacist can make arrangements to have
expired drugs incinerated. Another option is for DOCUMENTATION
the provider to contract with an outside company 2/17/XX Drugs from the crash cart, drugs in the medica-
to incinerate the expired drugs. RATIONALE: tion closet, and drug samples all checked for expiration dates.
Disposal of drugs into the sewage system, either Expired medications were removed and returned to the phar-
by flushing down the toilet or down the sink, is
macy for incineration. Drugs inventoried and restocked with
discouraged and is prohibited in some states
new replacements. C. McInnis, RMA __________________
(medication substances have been found in some
municipal water supplies).
 CHAPTER 23 Basic Pharmacology 701

Case Study 23-1

Refer to the scenario at the beginning of the chapter. opportunity to educate Mrs. Anderson about unfinished pre-
Mrs. Anderson has an appointment to see Dr. Lewis. While scribed medication.
Audrey Jones is updating data in the patient’s electronic
medical records, Mrs. Anderson, tells Audrey that she has CASE STUDY REVIEW
brought in with her a bag of medications. She tells Audrey
that she cleaned out her medicine cabinet and found some 1. What should Audrey tell her, and what can Audrey
expired prescription medications. Audrey recognizes an do with the expired medications?

Case Study 23-2

Maria Jover reports vaginal discharge and discomfort. 2. Maria tells Audrey that the last time she had a vagi-
Dr. King confirms the diagnosis of a yeast infection by per- nal yeast infection she only used part of the rec-
forming a smear and identifying the microorganism. Dr. King ommended number of suppositories because the
prescribes over-the-counter vaginal suppositories. After ask- infection cleared up. How should Audrey respond?
ing Maria if she has any questions, clinical medical assistant 3. Maria does not really like using suppositories.
Audrey Jones proceeds to help Maria understand the self- Should Audrey ask Dr. King to prescribe another
administration of this particular medication. form of medication for the yeast infection? What
other forms might be available?
CASE STUDY REVIEW
1. The patient, Maria, asks Audrey Jones whether she
can use some vaginal suppositories she bought
last year. How should Audrey respond?

Case Study 23-3

Dr. Lewis keeps a small quantity of various controlled CASE STUDY REVIEW
substances on the premises for use in an emergency
situation. 1. What are the legalities that surround controlled
substances as Joe Guerrero, the clinical medical
assistant, is concerned?
2. What are his responsibilities?

SUMMARY
Medical assistants must know state and federal laws that govern the distribution and administration of medi-
cations and understand their role and responsibilities in light of these laws. Knowledge of drug regulations;
the legal classifications of drugs, including controlled substances; and prescribing, administering, and dis-
pensing of drugs is essential to ensure compliance with the law.
Available resources and reference books will provide valuable information about pharmaceutical
products, their classifications, routes, forms, storage and handling, and side effects.
Emergency drugs and supplies should be available on a crash cart or a tray or cabinet for the sole use
in an office emergency.
With the increase of drug abuse and misuse, it is important for medical assistants to recognize the
signs of drug abuse in patients and coworkers and to report abuse to the provider or supervisor.
702 UNIT 6 Advanced Techniques and Procedures

STUDY FOR SUCCESS

To reinforce your knowledge and skills of information presented in this chapter:
• Review the Key Terms
• Practice the Procedure
• Consider the Case Studies and discuss your conclusions
• Answer the Review Questions

˚ Multiple Choice
˚ Critical Thinking
• Navigate the Internet by completing the Web Activities
• Practice the StudyWARE activities on your student CD
• Apply your knowledge in the Student Workbook activities
• Complete the Web Tutor sections

REVIEW QUESTIONS
Multiple Choice Critical Thinking
1. Which of the following drugs is commonly used in 1. Drugs are derived from various sources. List five
an emergency such as anaphylactic shock? sources of drugs.
a. lomotil 2. How does the Federal Food, Drug, and Cosmetic
b. interferon Act protect the public?
c. cytoxan 3. The _________ is recognized by the U.S. govern-
d. epinephrine ment as the official list of standardized drugs.
2. Which of the following types of drugs do providers 4. Describe the principal factors that affect drug action.
prescribe most frequently? 5. While preparing an injection of Demerol® (meperi-
a. generic dine), you accidentally drop and break the ampule,
b. official spilling its contents. Describe what actions you would
c. chemical take.
d. brand 6. Name five emergency drugs that may be found on a
3. An example of a drug that can be obtained from crash cart or emergency tray. Describe the use and
an animal is: actions of each.
a. digitalis 7. Under what circumstances can a medical assistant
b. cortisone dispense stock medication?
c. imferon 8. Audrey Jones is considering taking a new position
d. sulfur with a provider who is opening an office in another
4. Which of the following is an example of a state. Audrey will be responsible for the clinical
controlled substance? aspect of the practice. Where can Audrey find infor-
a. Nembutal mation about laws that apply to her in regard to
b. Keflin administering medications? Where can she get in-
c. Inderal formation about the storage and handling on the
d. Aldomet premises of narcotics?
5. After you have poured a medication and taken it to 9. List several drug references and briefly describe the
the patient, he refuses to take it. You should: contents of the PDR.
a. give it to another patient who has the same 10. After lunch, a newly hired medical assistant is help-
medication prescribed ing you get Lenore McDonell back into her wheel-
b. return the refused medication to its original chair after her physical examination. You strongly
container suspect that the medical assistant has been drinking
c. save it for the next time the patient is due for alcohol, because she is uncoordinated in her move-
another dose ments and there is a strong odor of what seems to be
d. dispose of it by returning it to the pharmacist to alcohol on her breath. Describe your next action.
dispose of. Document.
 CHAPTER 23 Basic Pharmacology 703

WEB ACTIVITIES Facts & figures. (2007). Retrieved October 15, 2008,
from http://www.drugtopics.modernmedicine.
Explore on the Internet for information regard- com.
ing the Drug Enforcement Agency. Rice, J. (2006). Principles of pharmacology for medical
assisting (4th ed.). Clifton Park, NY: Delmar
1. Print a copy of Schedules I–V of the controlled Cengage Learning.
substances. Spratto, G. R., & Woods, A. L. (2007). Physician’s desk
2. Find to which schedule the following controlled reference—nurses drug handbook. Clifton Park,
substances belong: phencyclidine (PCP), amphet- NY: Cengage Delmar Learning.
amines, cocaine, and heroin. Taber’s cyclopedic medical dictionary (22nd ed.). (2003).
3. Using a search engine of your choice, gather infor- Philadelphia: F. A. Davis.
mation about over-the-counter (OTC) analgesics United States Drug Enforcement Agency (DEA).
such as aspirin and nonsteroidal antiinflammatory (2007). Drugs of abuse publication chart. Retrieved
drugs (NSAIDs). February 16, 2008, from http://www.usdoj.gov/
a. What risks can be associated with taking these dea/pubs/abuse/chart.htm.
drugs? U.S. Food and Drug Administration, Department of
b. Look for surveys that have been done by the Health and Human Services. (2004, February 6).
National Consumers League on adults who used FDA issues regulations prohibiting sale of dietary supple-
an OTC pain reliever in the past year. ments containing ephedrine alkaloids and reiterates—it
c. What percentage exceeded the recommended advises that consumers stop using these products. Retrieved
dose? September 11, 2007, from http://www.cfisan.fda.
d. What percentage had not spoken to a health gov/~lrd/fpephed6.html.
care professional about possible risks associated WebMD Health. (2006). Crash carts and their typical con-
with these products? tents and indications. Retrieved October 15, 2008,
from http://vcdmc.vcdavis.edu/cne/resources/
clinical_skills_refreshed/crash_cart.
REFERENCES/BIBLIOGRAPHY Wooten, J. M. (2003, April). Medicine cabinet staples
Broderick, M. (2003, September). Spotting drug abuse. are not without risks. RN Magazine, 66(4), 96.
RN Magazine, 66(9), pp. 48–53. World Health Organization. (n.d.). Health aspects
Centers for Disease Control and Prevention. (2007). of biological and chemical weapons. Retrieved
Public emergency preparedness and response. Retrieved September 10, 2007, from http://www.who.int.
September 11, 2007, from http://www.bt.cdc.gov.
Chapter
Calculation of Medication
Dosage and Medication
24 Administration
OUTLINE KEY TERMS
Legal and Ethical Implications Medication Errors Administering
of Medication Administration Patient Assessment Apnea
Ethical Considerations Administration of Oral Body Surface Area (BSA)
The Medication Order Medications Compounding
The Prescription Equipment and Supplies for
Dispensing
Drug Dosage Oral Medications
Hypoxemia
Age Administration of Parenteral
Medications Meniscus
Weight
Sex Hazards Associated with Nomogram
Other Factors Parenteral Medications Parenteral
The Medication Label Reasons for Parenteral Route Phytomedicines
Calculation of Drug Dosages Selection Port
Understanding Ratio Parenteral Equipment and Precipitate
Supplies
Understanding Proportion Retrolental Fibroplasia
Principles of Intravenous Therapy
Weights and Measures Status Asthmaticus
Medications Measured in Units Site Selection and Injection
Angle Taut
How to Calculate Unit
Marking the Correct Site for Unit Dose
Dosages
Intramuscular Injection
Insulin
Basic Guidelines for Administra-
Diabetes
tion of Injections
Calculating Adult Dosages
Z-Track Method of Intramuscular
The Proportional Method
Injection
The Formula Method
Administration of Allergenic
Calculating Children’s Dosages
Extracts
Body Surface Area
Administration of Inhaled
Kilogram of Body Weight
Medications
Administration of Medications
Implications for Patient Care
The “Six Rights” of Proper
Administration of Oxygen
Drug Administration

OBJECTIVES
The student should strive to meet the following performance objectives and
demonstrate an understanding of the facts and principles presented in this
chapter through written and oral communication.

1. Define the key terms as presented in the glossary.

2. Discuss the legal and ethical implications of medication
administration.

704
OBJECTIVES (continued)
3. Describe the medication order.
4. Describe the parts of a prescription.
5. Define drug dosage.
6. State what information is found on a medication label.
7. Understand ratio and proportion.
8. Use the metric, household, and apothecary systems of
measurement and convert between metric and apothecary
systems.
9. Understand units of medication dosage.
10. Correctly calculate dosages for adults and children.
11. List the guidelines to follow when preparing and administering
medications.
12. Describe safe disposal of syringes, needles, and biohazard
materials.
13. Understand intravenous therapy.
14. Describe site selection for administration of injections.
15. Understand allergenic extracts.
16. Describe inhalation medication and its administration.

Scenario
At Drs. Lewis and King’s practice, office policy card contains the patient’s name, the provider’s
dictates that a medicine card must be written out order, and the date, time, and route the medication
before the administration of any medication to a is to be administered. After giving the medication
patient. Clinical medical assistant Joe Guerrero, to the patient, Joe documents the fact in the patient
CMA (AAMA), is careful to check the provider’s order, file, and then, according to procedure, tears and dis-
then prepare the medicine card before preparing cards the medicine card.
and administering medication. He notes that the

INTRODUCTION LEGAL AND ETHICAL

IMPLICATIONS OF MEDICATION
Despite the fact that many ambulatory care centers ADMINISTRATION
use what is known as the unit dose type of medication
preparation, there remains a responsibility for medical Members of the health care profession who
assistants to know and understand how to calculate prepare and administer medications are
dosages of medication and to safely administer them to ethically and legally responsible for their
patients. own actions. Under law, these individuals are
This chapter addresses calculation of adult and required to be licensed, registered, or otherwise
pediatric dosages of medication using the metric and authorized by a physician.
household systems. It also emphasizes the legal aspects of Each state has enacted laws governing the prac-
medication administration and discusses oral and paren- tice of medicine, nursing, and pharmacy. These laws
teral medication administration. vary from state to state; therefore, it is essential that

705
706 UNIT 6 Advanced Techniques and Procedures

administer and the effects the drug(s) may or

Spotlight on Certification will have on the patient. Many states have uni-
form disciplinary acts. Never administer a medi-
RMA Content Outline cation without thorough knowledge of the drug.
• Medical law It is the medical assistant’s responsibility to
• Patient education know the information about a medication listed
in Figure 24-1 before administering it to a patient.
• Asepsis
You are an agent of the provider and accountable
• Sterilization for your actions.
• Specialty examinations
• Allergy
• Clinical pharmacology
Ethical Considerations
• First aid and emergency response Anyone who has access to medications
may be tempted to use them for personal
CMA (AAMA) Content Outline benefit. To do so not only is unethical, it is
• Legislation considered to be illegal. The conversion to per-
• State compliance sonal use of medications intended for another is
• Documentation/reporting unethical and may cause harm to the patient. It
• Drug Enforcement Administration (DEA) is also unethical and illegal to take any medica-
• Principles of infection control tion that belongs to your employer, even aspirin
• Principles of asepsis
or drug samples, without proper authorization.
• Preparing and administering medications
• Pharmacology The Medication Order
• Emergencies The medication order is given by the provider. It
• First aid is for a specific patient and denotes the drug to be
CMAS Content Outline given, the dosage, the form of the drug, the time
for or frequency of administration, and the route
• Medical office emergencies by which the drug is to be given.
• Asepsis in the medical office
• Pharmacology
• Understand basic pharmacological con-
The Prescription
cepts and terminology The prescription is a written legal document
• Risk management and quality assurance that gives directions for compounding, dis-
pensing, and administering a medication to
a patient. There are nine parts to a prescription
(Figure 24-2).
medical assistants become familiar with the laws of
the state in which they are employed before admin-
istering any medication. In some states, the only
health professional authorized to give injections, 1. Drug name (generic and brand)
other than a physician, is a registered nurse. In other 2. Action
states, legislation gives physicians broad authority to 3. Uses
delegate responsibility for administering medication 4. Contraindications
to other health care workers such as medical assis- 5. Warnings when indicated
tants. Laws have been passed in some states speci- 6. Adverse reactions
fying which qualified and properly educated and 7. Dosage and route
trained persons may perform certain medical acts. 8. Implications for patient care
Regardless of the differences in state 9. Patient teaching
authorization laws, the courts will not permit 10. Special considerations
the careless action of health care workers to go
unpunished, especially when such actions result Figure 24-1 Medical assistants should have a thor-
in harm or death to the patient. Under the law, ough knowledge of any medication they administer
those administering medications are expected to a patient and should consult references such as the
to be knowledgeable about the drugs that they Physician’s Desk Reference (PDR).
 CHAPTER 24 Calculation of Medication Dosage and Medication Administration 707

DEA# 8669046
Parts of a Prescription lewis & king, md

1. The physician’s name, address, telephone [1] L&K 2501 center street
northborough, oh 12345
and fax numbers, and DEA registration number. PHONE:
413-682-8591 FAX: 413-682-7330
2. The patient’s name, date of birth, address, and the date on
which the prescription is written.
[2] Name Juanita Hansen DOB 7/8/XX
3. The superscription that includes the symbol Rx (“take
Address 143 Gregory Lane, Apt. 43 Date 4/7/XX
thou”).
4. The inscription that states the names and quantities of [3]
ingredients to be included in the medication.
5. The subscription that gives directions to the pharmacist [4] Furadantin 50 mg Tabs
for filling the prescription. [5] #56
6. The signature (Sig) that gives the directions for the
patient. [6] Sig 50 mg p.o. qid 14 days
7. The physician’s signature blanks. Where signed,
indicates if a generic substitute is allowed or if the [7] Generic Substitution Allowed Susan Rice M.D.
medication is to be dispensed as written. Dispense As Written
8. REFILL 0 1 2 3 p.r.n. This is where the physician [8] REFILL 0 1 2 3 p.r.n. M.D.

indicates whether or not the prescription can be refilled.

Figure 24-2 Prescriptions are written legal documents that give directions for compounding, dispensing, and
administering a medication. Prescriptions have eight distinct elements.

The purpose of a prescription is to control the the-counter (OTC) medicines. The prescription is
sale and use of drugs that can be safely and effectively written by the provider and signed with an ink pen
used only under the supervision of a licensed pro- or e-prescribed. The pharmacist fills the prescrip-
vider. Federal law divides medicines into two main tion according to the provider’s order. Once the pre-
classes: prescription or legend medicines and over- scription has been filled, the assigned prescription
number and all other information can be entered
into a computer. The hard copy of the prescription
HIPAA is filed and kept for a minimum of 7 years. Schedule
II controlled substances prescriptions (see Chap-
E-prescribing is the process of elec- ter 23 for a description of schedule II medications)
HIPAA tronically accessing the patient’s med- are kept separate from other prescriptions and are
ical history, prescribing a medication, stamped with a red C (C for controlled) and filed
and selecting a pharmacy. separately. Schedule III through V prescriptions are
The Medicare Prescription Drug, Im- stamped with a red C and filed.
E HR provement and Modernization Act
(MMA) of 2003 and the Health Insur- Prescriptions for Controlled Substances. Federal
ance Portability and Accountability Act laws require that the provider follows specific pro-
(HIPAA) of 1996 have recommended e- cedures when prescribing controlled substances
prescribing standards. Medications han- (Table 24-1).
dled electronically have reduced the prob- All prescriptions for controlled substances
lems of medication errors. Patients enjoy the must be dated and signed on the date issued, bear-
ease of e-prescriptions because they do not ing the full name and address of the patient and the
have to drop off the prescription and then name, address, and Drug Enforcement Administra-
return to pick it up. Some states already tion (DEA) number (see Chapter 23) of the pro-
have e-prescriptions in patients’ electronic vider. The prescription must be written in ink or
medical records. However, the possibility of typewritten and signed by the provider’s own hand.
a breach in confidentiality exists whenever
electronic medical records are used. Prescription Abbreviations and Symbols. It is im-
portant to be knowledgeable of the most common
708 UNIT 6 Advanced Techniques and Procedures

Table 24-1 Requirements for Prescriptions Table 24-2 Common Prescription

for Controlled Substances Abbreviations and Symbols

Verbal Abbreviation
Order or Written or Symbol Meaning
Prescription Prescription Refills
aa of each
Schedule I NOT FOR MEDICINAL USE
ac before meals
Schedule II No Yes No
ad lib as desired
Yes Yes 5 × within
Schedule III aq water
6 months
bid twice a day
Yes Yes 5 × within
Schedule IV –
6 months c with

Schedule V Yes Yes Yes cap capsule

dil dilute

abbreviations used by the provider when an order elix elixir

for a prescription drug is given. The abbreviations
are a clear and concise means of writing orders. This g gram
medical shorthand is an international language gr grain
used by professional and nonprofessional people
involved with patient care. Medical assistants should gt or gtt drop (drops)
memorize all abbreviations in Table 24-2 so that they
can prepare medications safely and accurately for h hour
administration. IM intramuscular
The Joint Commission requires that facili-
ties comply with the Joint Commission’s mini- IV intravenous
mum requirement for the banning of certain
kg kilogram
abbreviations, acronyms, symbols, and their do
not use list. This ban, as part of the Joint Commis- L liter
sion’s 2004 patient safety goals, has been applied
to protect patients from errors during documen- liq liquid
tation. The ban was reaffirmed in 2005 by the
m or min minim
Joint Commission.
Table 24-3 lists abbreviations no longer mg milligram
allowed by the Joint Commission. Table 24-4 lists
abbreviations and symbols that can be misinter- mL milliliter
preted and are under consideration for possible
mm millimeter
inclusion on the “Do Not Use” list in the future.
Patients should be inquisitive when at the NPO nothing by mouth
provider’s office, clinic, pharmacy, or hospital and
should ask questions about the medications they non rep do not repeat
are prescribed or being given (see Patient Educa- –
p after
tion box).
Many medications sound alike and look alike, pc after meals
which can cause confusion and errors. The Joint
Commission recommends that pharmaceutical per by or with
manufacturers examine their practices in naming
po by mouth
their medications and make changes to alleviate
confusion and errors. Table 24-5 lists a few sound- prn as needed
alike, look-alike medications. The United States (continues)
Pharmacopeia regularly updates a complete list of
 CHAPTER 24 Calculation of Medication Dosage and Medication Administration 709

sound-alike, look-alike medications on their Web

Table 24-2 (continued)
site (http:// www.USP.org).
Abbreviation
or Symbol Meaning
DRUG DOSAGE
pt patient
The dosage or dose is the amount of medicine that
q every
is prescribed for administration. It is determined by
qh every hour the provider or qualified practitioner who considers
the following important factors: age, weight, sex, and
q (2, 3, 4) h every (2, 3, 4) hours other factors as well.
qid four times a day
Age
qs of sufficient quantity
The usual adult dose is generally suitable for the
Rx take 20- to 60-year age group. Infants, young children,
–s adolescents, and older adults require an individu-
without
alized dosage regimen.
sol solution

ss one-half Weight
The average adult dosage is based on 150 pounds
stat at once
(about 68 kilograms). Individuals who weigh less
tab tablet or more than this should have the dosage based
on body surface area (BSA) or kilogram of body
Tbs tablespoon weight.
tsp teaspoon
Sex
tid three times a day
Many medications are contraindicated during preg-
tr tincture nancy and breast-feeding. It is important that these
ung ointment
two factors be known before any dose of medication
is prescribed.

Table 24-3 Dangerous Abbreviations No Longer Allowed

Do Not Use Possible Misinterpretation How to Avoid Problem

U (for unit) Mistaken for a four (4), zero (0), or cc Write out the word “unit”

IU (for international unit) Mistaken for IV or ten (10) Write out “international unit”

Q.D., every day; Mistaken for one another Write “daily”

Q.O.D, (every other day) Write “every other day”

Decimal point is missed and dose is Do not write a zero by itself after the
Trailing zero (X.0 mg)
either too much or not enough decimal point (X mg)
Lack of preceding zero
Always use zero before a decimal point
(.X mg)
(0.X mg)

mS Can be interpreted to mean morphine Write out “morphine sulfate”

mSO4 sulfate or magnesium sulfate Write out “magnesium sulfate”
MgSO4
710 UNIT 6 Advanced Techniques and Procedures

Table 24-4 Additional Abbreviations, Acronyms and Symbols that May Be Misinterpreted
(for Possible Future Inclusion in the Official “Do Not Use” List)

Do Not Use Possible Misinterpretation How to Avoid Problem

> (greater than) Can be misinterpreted as number seven (7) or the letter “L” Write out “greater than” and “less
< (less than) Confused for one another than”

Apothecary Unfamiliar to many practitioners Use metric units

units Confused with metric units

@ Mistaken for number two (2) Write “at”

cc Mistaken for U (units) when written poorly Write out “mL” or “milliliters”

μg Mistaken for mg (milligrams) causing 1,000 × overdose Write out “mcg” or micrograms

Table 24-5 Sound-alike, Look-alike 5. Patient’s medical history, allergies, and idiosyn-
Medications crasies
Aciphex (heartburn, 6. Safest method, route, time, and amount to effect
Accupril (hypertension)
ulcers) the desired maximum result

Rimantidine (flu) Ranitidine (heartburn)

THE MEDICATION LABEL
Oxybutynin (urinary
Oxycontin (pain)
incontinence)
The medication label can be a source of valu-
Plavix (prevent heart able information to the medical assistant and the
Paxil (depression)
attack and stroke) patient. Regardless of whether administering a
prescription drug or taking a nonprescription
Pravachol (high Propranolol (hypertension) product, an understanding of the information pro-
cholesterol)
vided on the label is essential to the safe and effec-
Sinequan (depression, tive use of any medicine. In addition to the name
Singulair (asthma)
anxiety) and address of the manufacturer, other impor-
tant items of information on a medication label
Clonazepam (anticon- Chlorazepate (anti- include:
vulsant) anxiety)
• The trade or brand name for the medication
Darvon (analgesic) Diovan (hypertension)
• The generic name (or listing of active and inactive
Clonazepam Lorazepam (anti-anxiety) ingredients)
(anticonvulsant) • The National Drug Code (NDC) numbers that can
be used to identify the manufacturer, the product,
and the size of the container
Other Factors • The dosage strength in a given amount of the med-
ication
Other factors that determine the dosage of a medi-
• The usual dosage and frequency of administration
cation include the following:
• The route of administration
1. Physical and emotional condition of patient • Precautions and warnings
2. Disease process, especially kidney disease because • The expiration date for the medication
of impaired excretion
Other information that may be on a medi-
3. Presence of more than one disease process cation label includes directions for storage and
4. Causative microorganism(s) and the severity of the directions for mixing or reconstituting a powdered
infection form of the drug (see Figure 23-6).
 CHAPTER 24 Calculation of Medication Dosage and Medication Administration 711

Pharmacy
CALCULATION OF DRUG
DOSAGES
The preparation and administration of CLINICAL CARE
medications is one of the most important
Patient Assessment
and critical tasks that medical assistants Procedures, Diagnoses & Treatment Plans
perform. Today, drugs are more potent and more Referrals & Follow-up Appointments
Prescriptions
likely to cause physiologic changes in the body; Orders for Tests
therefore, anyone who administers medications Patient Medical History
must do so with extreme care.
Incorrectly calculated or measured dosages
are the leading cause of error in the administra-
tion of medications. A drug error is a violation of Test Results
Schedules and Tickler Files
a patient’s rights. It is important that medical assis- Patient Medical History
tants develop a working knowledge of mathemat- Medication Administration
Patient Education
ics to calculate or measure accurately a medication Graphical Patient Data Displays
that is to be administered to a patient.

E HR
According to the Institute of Medicine
(IOM), each year medications kill several
thousands of hospital patients and injure
ELECTRONIC
another 1.5 million. About half of these deaths
and injuries result from side effects; the other RECORDS
half result from errors. Because the majority of
prescriptions are written in the provider’s offices,
the figures are likely to be proportionately higher. Figure 24-3 The clinical care arm of the total prac-
E-prescribing will reduce the number of errors. tice management system (TPMS). Medication errors
Hospital prescriptions and all OTC medications, can be minimized when prescriptions are written elec-
vaccines, and blood will require standardized and tronically. The computer calculates the dose according
universal bar codes to help prevent medication to the patient’s height and weight and can send the
errors. Reading the bar code with a scanner can prescription to the pharmacy.
correlate the medication bar code with a patient
identification bar code.
The IOM states that only a small percent of
Understanding Ratio
health care agencies use a bar code medication Ratio is a method of expressing the relation-
system. Studies have shown that use of bar codes ship of a number, quantity, substance, or degree
(bar code on medication matches bar code on between two similar components. For example,
patient’s wrist) results in far fewer errors. the relationship of one to five is written 1:5. Note
The IOM wants health care agencies, that numbers are side by side and separated by a
E HR especially hospitals, to computerize their
prescription systems by 2008 and to begin
colon.
In mathematics, a ratio may be expressed as a
using them by 2010. According to the IOM, quotient, a fraction, or a decimal.
fewer than 10% of hospitals have computerized
prescriptions systems. The system works when a Ratio Expressed as a Quotient. A quotient is the
provider inputs data on the computer. For exam- number found when one number is divided by
ple, the patient’s height and weight and medica- another number. The ratio one to five written as a
tion are entered and the computer calculates the quotient is 1  5.
dose. There is no paper, illegible handwriting,
or miscalculation of the dose. The computer fills Ratio Expressed as a Fraction. A fraction is the
in the correct dose as part of the prescription process of dividing or breaking a whole number
(Figure 24-3). into parts. The ratio one to five written as a frac-
Additionally, the IOM recommended to the tion is 1⁄5 or 51 .
FDA that they lessen the confusion about sound-
alike medications and simplify look-alike labels Ratio Expressed as a Decimal. A decimal is
and packaging. a linear array of numbers based on 10 or any
712 UNIT 6 Advanced Techniques and Procedures

Patient Education
Patients should: 5. Have the provider or pharmacist explain
1. Question the provider, pharmacist, and the name and purpose of each new medi-
staff administering the drug about the cation that is being prescribed. Be sure you
drug and its possible side effects. understand.
2. Be sure the prescription has been writ- 6. Keep an updated list of all medications,
ten legibly. Many drugs sound alike prescriptions, OTC vitamins, minerals, and
(e.g., Ambien® for insomnia and Amen® phytomedicines.
for menstrual cycle control; Xanax® for 7. Take medications as directed, and do not
anxiety and Xantac® for heartburn and discontinue use until the appropriate date
ulcers; Fosamax® for osteoporosis and as indicated by the provider.
Flomax® for enlarged prostate). 8. Store medicines away from heat and
3. Always check the label at the pharmacy to humidity in their original containers.
make sure it is clearly written. 9. Ask the provider or pharmacist what you
4. Always check your medication at the should do if you miss a dose.
pharmacy to be certain that the medica-
tion and directions are what you expect.

multiple of 10. To express the ratio one to five as Example:

a decimal, divide the denominator (5) into the
numerator (1). 6 :4  3 :2 (4) (3)
means
0.2
4 × 3  12 (means)
(denominator) 5)1.0 (numerator)
6 × 2  12 (extremes)
The ratio may be expressed as:
The extremes are the outer numbers or the first
A quotient A fraction A decimal
1
and fourth terms of the proportion.
1÷5 1
⁄5 ( 5 ) 0.2
Example:

Understanding Proportion 6 :4 3 :2 (6) (2)

Proportion is a process of expressing the compar- extremes
ative relationship between a part, share, or por-
tion with regard to size, amount, or number. In In a true proportion, the product of the
mathematics, a proportion expresses the relation- means equals the product of the extremes.
ship between two ratios. In setting up a propor-
Example:
tion, the ratios are separated by : or an  sign. In
this text, the equal sign () is used to separate means (16) (1)
ratios. 8 : 16  1 : 2

Example:
extremes (8) (2)
6 :4  3 :2 16 × 1  16 (means)
8 × 2  16 (extremes)

Read:
Six is to four equals three is to two.
Solving for ×. The proportion is a useful math-
ematical tool. When a part, share, or portion of
The four terms of a proportion are given the problem is unknown, then x represents the
special names. The means are the inner num- unknown factor. You can determine the unknown
bers or the second and third terms of the by solving for x. The unknown factor x may appear
proportion. any place in the proportion.
 CHAPTER 24 Calculation of Medication Dosage and Medication Administration 713

Now solve for x in the problem: 3 : 4  x : 12. 5. The abbreviation for gram should be capital-
ized (Gm) or written as (g) to distinguish it from
1. Multiply the term that contains the x and place the grain (gr).
product to the left of the equal sign (4x). 6. The abbreviation for liter is capitalized (L).
2. Multiply the other terms and place the product to 7. Prefixes are written in lowercase letters, e.g., milli,
the right of the equal sign (36). centi, deci, deka.
3. To find x, divide the product of x into the product 8. Capitalize the measurement and symbol when it is
of the other terms. named after a person, e.g., Celsius (C).
4 x  36 9. Periods are no longer used with most abbreviations
or symbols.
x  36 or 36  4
4 10. Abbreviations for units are the same for singular
x9 and plural. An s is not added to an abbreviation to
indicate a plural.
After finding the unknown factor, check your
mathematical skills by determining if you have a The Seven Common Metric Prefixes. It is im-
true proportion. This technique is called proof or portant to know common metric prefixes to have
proving your answer. To prove your answer: a solid foundation for determining metric equiva-
lents. When a metric prefix is combined with a root
1. Place the answer you found for x back into the for- of physical quantity, you arrive at multiples or sub-
mula where x was. multiples of the metric system.
3 : 4  9 : 12 Example:
2. Now multiply the means by the means, and the • milli (prefix): one-thousandth of a unit
extremes by the extremes. meter (root): a measure of length
3. The results will equal each other. millimeter: one-thousandth of a meter
• kilo (prefix): one thousand units
liter (root): a measure of volume
Formula: 3 : 4  x : 12
kiloliter: one thousand liters
Proof: 3 : 4  9 : 12 • micro (prefix): one-millionth of a unit
gram (root): a measure of mass and/or weight
microgram: one-millionth of a gram
4  9  36
3  12  36
Prefixes:
micro (mi’kro)  one millionth of a unit written
Weights and Measures as 0.000001
milli (mil’i)  one-thousandth of a unit
Two systems of measurement are used in pharma-
written as 0.001
cology to calculate dosages: metric and household.
centi (sen’ti)  one-hundredth of a unit
The metric system is used throughout the world as
written as 0.01
the official language of communication in scien-
deci (des’i)  one-tenth of a unit written as 0.1
tific and technical fields. It is based on the decimal
deka (dek’a)  ten units written as 10
system: the number 10 or multiples of 10.
hecto (hek’to)  one hundred units written as 100
kilo (kil’o)  one thousand units written as
Metric System Guidelines. The following guide- 1000
lines are helpful when learning basic facts about
the metric system: Fundamental Units:
1. Arabic numbers are used to designate whole num- Following are the fundamental units of the metric
bers, e.g., 1, 250, 500, 1,000. system:
2. Decimal fractions are used for quantities less than meter (m) length
one, e.g., 0.1, 0.01, 0.001, 0.0001. liter (L) volume
3. To ensure accuracy, place a zero before the deci-
gram (Gm, g) mass and/or weight
mal point, e.g., 0.1, 0.001, 0.0001.
4. The Arabic number precedes the metric unit of The meter is the fundamental unit of length
measurement, e.g., 10 grams, 2 millimeters, 5 liters. in the metric system and originally formed the
714 UNIT 6 Advanced Techniques and Procedures

foundation for the entire system. A meter is equal Weight

to 39.37 inches, which is slightly more than a yard, 1,000 micrograms (mcg)  1 milligram (mg)
or 3.28 feet. 1000 milligrams (mg)  1 gram (Gm, g)
A millimeter is about the width of the head of 1000 grams (g)  1 kilogram (kg)
a pin. It takes approximately 21⁄2 centimeters to make 1 kilogram  2.2 pounds (lb)
an inch; a decimeter is approximately 4 inches.
Meter (m)  Length
Household Measurements. Household measure-
ments are approximate measurements. They are
1 millimeter (mm)  0.001 meter
more frequently used in the home than in the
1 centimeter (cm)  0.01 meter
medical field, but the medical assistant should be
1 decimeter (dm)  0.1 meter
familiar with the common household measure-
1 meter (m)  1 meter
ments listed in Table 24-6.
1 dekameter (dam)  10 meters
Because medications can be prescribed in
1 hectometer (hm)  100 meters
either metric or household measurements, it
1 kilometer (km)  1,000 meters
is important to know equivalents between both
The liter is the metric unit of volume. A liter to calculate the dose of prescribed medication
is equal to 1.056 quarts, which is 0.26 gallon or (Table 24-7).
2.1 pints.
A milliliter is equivalent to one cubic centi- Metric System Conversion. The process of chang-
meter (cc), because the amount of space occupied ing into another form, state, substance, or product
by a milliliter is equal to one cubic centimeter. The is known as conversion. In the metric system, chang-
weight of one milliliter of water equals approximately ing from one unit to another involves multiplying
one gram. It takes approximately 15 milliliters to or dividing by 10, 100, 1,000, and so forth. This can
make 1 tablespoon. It takes 15 or 16 minims to make be done by the proportional method or by moving
one milliliter. the decimal in the correct direction.
Liter (L) Volume
Proportional Method for Converting Metric
1 milliliter (mL)  0.001 liter
Equivalents. There are six basic steps in the pro-
1 centiliter (cL)  0.01 liter
portional method, plus an additional step to prove
1 deciliter (dL)  0.1 liter
the answer. The following example will serve as a
1 liter (L)  1 liter
model for future applications of the proportional
1 dekaliter (daL)  10 liters
method of converting metric equivalents.
1 hectoliter (hL)  100 liters
1 kiloliter (kL)  1,000 liters
The gram is the metric unit of mass and
weight. It equals approximately the weight of Table 24-6 Common Household Measures
1 cubic centimeter or 1 milliliter of water. A gram is
equal to approximately 15 grains or 0.035 ounce. 60 drops (gtt) is equal to: 1 teaspoon (t or tsp)

Gram (Gm, g) Mass and Weight 3 teaspoons is equal to: 1 tablespoon (T or tbsp)
1 microgram (mcg)  0.000001 gram (tsp)
1 milligram (mg)  0.001 gram 2 tablespoons is equal to: 1 ounce (oz)
1 centigram (cg)  0.01 gram (tbsp)
1 decigram (dg)  0.1 gram
1 gram (Gm, g)  1 gram 8 ounces (oz) is equal to: 1 measuring cup (c)
1 dekagram (dag)  10 grams
16 tablespoons is equal to: 1 measuring cup (c)
1 hectogram (hg)  100 grams or 8 ounces
1 kilogram (kg)  1,000 grams
2 cups (c) is equal to: 1 pint (pt)
The metric equivalents most frequently used
in the medical field are: 2 pints (pt) is equal to: 1 quart (qt)
Length 4 quarts (qt) is equal to: 1 gallon (gal)
21⁄2 centimeters (cm) = 1 inch
Drop (gt) = approximate liquid measure depending on kind
Volume of liquid measured and the size of the opening from which it is
1,000 milliliters (mL)= 1 liter (L) dropped.
 CHAPTER 24 Calculation of Medication Dosage and Medication Administration 715

Step 4.
Table 24-7 Approximate Equivalents Among
Metric and Household Systems Now that you have the left side of the equation, set up the
right side by using the designated metric value 1,500 mg :
Metric Household x g. Always write the smallest equivalent as to the largest
equivalent, for example, mg : g. By being consistent, it is less
DRY likely errors will occur.
1,000 mg : 1 g  1,500 mg : x g
60 mg
Step 5.
1 Gm 1
⁄4 tsp
Note that you have an equal equation:
15 Gm 1 tbsp (3 tsp)
mg : g  mg : g
1 oz (2 tbsp)
30 Gm The first values on either side of the equal sign are milligrams,
1 lb (16 oz) and the second values on either side are grams.
1 kg 2.2 lb Step 6.
LIQUID Now solve for the unknown (x) by multiplication and division.
Multiply the means by the means and the extremes by the
1 gt extremes. NOTE: Once the proportion is correctly set up, simply
use the numbers as you multiply and divide.
1 mL 15 gtt
1,000 : 1  1,500 : x
5 mL 1 tsp

15 mL 1 tbsp (3 tsp)
1,000x 5 1,500 1.5
30 mL 1 fl oz (2 tbs) x 5 1,500 4 1,000 1,000)1,500.0
x 5 1.5 1,000
500 mL (1 pt or 2 cups) 500.0
500
1,000 mL 4 cups (1 qt)

LENGTH Step 7.
2.5 cm 1 in To make sure the answer is correct, prove the work: Place the
answer 1.5 g into the formula where x once was. Now multiply
1m 39.37 in the means by the means and the extremes by the extremes.

1,000 mg : 1 g 5 1,500 mg : 1.5 g

1,500 5 1,500
Example:

Convert 1,500 milligrams to grams.

1,500 mg  ______ g

Step 1. MEDICATIONS MEASURED

Because the unknown factor in the given formula is the num- IN UNITS
ber of grams contained in 1,500 milligrams, substitute the sym-
bol x for grams in the equation. Medications such as insulin, heparin, some antibiot-
ics, hormones, vitamins, and vaccines are measured
Step 2.
in units. These medications are standardized in units
Setting up the proportion requires that you know metric equiv- based on their strengths. The strength varies from
alents. For example, in this problem you have to know that one medicine to another, depending on the source,
1,000 milligrams (mg)  1 gram (g). condition, and method by which it is obtained.
Step 3.
Since you know that 1,000 mg is equal to 1 g, you can create
How to Calculate Unit Dosages
one-half of the equation. Write the equivalent and place it When calculating medications that are ordered in
on the left of the equal sign.
units, use either the proportional method or the
1,000 mg : 1 g  formula method.
716 UNIT 6 Advanced Techniques and Procedures

The Proportional Method olism of blood glucose and maintenance of the

correct blood sugar level. Inadequate secretion or
Example:
no secretion of insulin, as in the disease diabetes
The provider orders 4,000 USP units of heparin given deep sub- mellitus, results in hyperglycemia and subsequent
cutaneously. On hand is heparin 5,000 USP units per milliliter. excessive production of ketone bodies. Eventual
Step 1.
coma can occur.
Patients’ needs are individualized according to
Use the following proportion to calculate the dose: the severity of their disease; treatment includes tak-
Known Known Unknown ing insulin, controlling diet, and exercise. The diet
unit : dosage  Dose : amount to is well-balanced and consists of the correct number
on hand form ordered be given of calories distributed among carbohydrates, fats,
5,000 Units: 1 mL  4,000 Units: x mL and proteins. Patients are taught to monitor blood
5,000x  4,000 and urine glucose levels at home throughout the
4 4
x  ⁄5  ⁄5 mL or 0.8 mL day, because the dosage of insulin taken depends
4
Use a tuberculin syringe to draw up 0.8 mL, or convert ⁄5 mL on the amounts of glucose detected. Uncontrolled
to minims. diabetes mellitus can result in serious complications
Step 2. such as circulatory problems, especially in the feet
and legs; kidney disease; loss of vision; bedsores;
4
Convert ⁄5 mL to minims. NOTE: There are 15 or 16 minims per infection; and gangrene. Special care of the feet is
milliliter. essential. The mouth and teeth require excellent
Multiply:
3
oral hygiene.
4 15 4 3
/

5  1  1  1  12 minims
/

1
Diabetes
Administer 12 minims (of 5,000 Units/mL for correct dose of
4,000 Units) to the patient.
The National Diabetes Data Group of the National
Institutes of Health organized the various forms of
diabetes into the following categories:
The Formula Method
Type 1 Insulin-dependent diabetes mellitus
Example: (IDDM)
The provider orders 450,000 Units of Bicillin 1M. On hand is Type 2 Noninsulin-dependent diabetes
Bicillin 600,000 Units per milliliter. mellitus (NIDDM)
Type 3 Women who developed glucose
Step 1. intolerance in association with
Use the following formula to calculate the dose: pregnancy (gestational)
Dose ordered
Type 4 Other types of diabetes associated
(desired) Quantity with pancreatic disease, hormonal
  Amount to give changes, adverse effects of drugs, or
Dose on hand (per mL)
450,000 units / / / 0/ units 45 3
450,00 genetic or other anomalies
1 mL   
600,000 units / / / / units 60 4
600,000
3 3
Individuals with type 1 diabetes (IDDM) must
1 mL  mL take insulin on a regular basis to maintain life.
4 4
Other insulin delivery devices besides the syringe
Step 2.
and the needle can be used for injection. With
You may convert to minims. If you do, multiply 3⁄4 by 16. an insulin pen, the patient can turn a dial on the
4 top until the correct dose of insulin is displayed
3

16
 12 minims
through a small window. Once the correct dose is
4 1 chosen, the dial “locks” itself to prevent the pen
1
from losing insulin or from the dial moving for-
The patient will receive 12 minims of Bicillin 600,000 ward to give an unintended larger dose. The pen
Units for the ordered dose of 450,000 Units. has a needle similar to the insulin syringe, and the
patient presses the plunger and the dose of insulin
is delivered under the skin.
Insulin Another delivery device is a jet injector. High-
Insulin is a chemical substance (hormone) secreted pressure air sends a fine mist of insulin through
by the beta cells of the islets of Langerhans in the the skin. No needles are required. This device may
pancreas. Insulin is necessary for the proper metab- be suitable for patients who dislike needles.
 CHAPTER 24 Calculation of Medication Dosage and Medication Administration 717

Table 24-8 Insulin Preparation Units 100

Patient Education
Type of
Encourage patients with diabetes to enroll Insulin Onset Appearance
in diabetic education classes, which are
offered at most local hospitals. Patients also Rapid- 5 minutes after injec- Clear, colorless
Acting tion
need to realize that treatment of diabetes
Humalog Peaks in 1 hour
is a lifelong commitment and that they
must abide by everything that the hospital Lispro Works for 2−4 hours
teaches. Regular or 30 minutes after Clear, colorless
short-acting injection
Humulin R Peaks in 2−3 hours
The insulin pump is a small device outside Novolin Works for 3−6 hours
of the body that pumps insulin through a flex-
Actrapid
ible tubing that is connected to a catheter that is
under the skin of the abdomen, thigh, or buttocks. 2−4 hours after Cloudy
Intermediate
The pump is programmed to deliver a steady flow injection
Lente L
of the correct dose of insulin 24 hours a day. The Peaks in 4−12 hours
Humulin NPH
pump can allow the patient to add insulin in a Effective 12−18 hours
short time if needed. Although it is convenient
and helps keep the patient’s blood glucose under Long-lasting 6−10 hours after Clear, colorless
Ultralente injection
control, the pump can be damaged if the patient
Lantus Effective 20−24 hours
engages in certain physical activities. Patients still
must regularly monitor their blood glucose levels. 5 minutes after Clear, colorless
Premixed
Other devices not yet approved but being Humalog injection
worked on for approval are an insulin patch and a Mix 75/25 Duration 1−24 hours
dry powder that is inhaled into the lungs through
the mouth, then from the lungs into the blood- 1−2.5 hours after Clear, colorless
stream. The dosage of insulin is expressed in units Humulin injection
and is individualized by the provider for each 70/30 Peak 7−15 hours
patient. The amount of insulin that a person must Duration 24 hours
take is based on blood and urine glucose levels, diet,
15−20 minutes after Clear, colorless
exercise, and the individual’s needs (Table 24-8). injection
Humulin
It is extremely important that the exact dosage of 50/50 Peak 1−4 hours
insulin be given to the patient. Too little or too much
Duration 1−24 hours
insulin can cause serious problems ranging from
a blood sugar level too low or too high, to coma,
and even death. It may be the medical assistant’s • Do not substitute one insulin for another.
responsibility to administer insulin and to teach
• Use the correct syringe, U-100.
patients or their families how to administer insulin.
When administering insulin, the U-100 • Dosage of insulin is always measured in units and is
syringe (1 mL) is preferred. U-100 means there individualized for each patient.
are 100 units of insulin per milliliter. Insulin dos- • Check the label for the name and type of insulin,
age should always be expressed in units rather strength, and expiration date.
than in milliliters. For example, if the provider • Make sure the insulin has the proper appearance.
orders 30 units of U-100 NPH insulin, use a U- Refer to Table 24-8 for proper appearance of vari-
100 syringe and draw up 30 units of U-100 NPH ous insulins.
insulin.
• When insulin is not in use, store it in a cool place
and avoid freezing.
Precautions to Observe When Administer-
ing Insulin. The following precautions must be • When mixing insulins in one syringe, be certain
observed when administering insulin: they are compatible. NPH and Regular are com-
patible. Regular and lente are not compatible.
• Be sure to use the proper insulin, the one ordered • Avoid shaking the insulin bottle. Roll gently in
by the provider. Refer to Table 24-8 for various palms of hand to mix. This method prevents bub-
insulin preparations. bles in the medication.
 718 UNIT 6 Advanced Techniques and Procedures

• Use a subcutaneous needle, but inject at a 90-degree

angle. CALCULATING ADULT
• Insulin pens are available prefilled with 300 units DOSAGES
of insulin.
Two measures, weight and volume, are used to
• Use a site rotation system and select an appro-
determine the amount of medication that is to be
priate site. Insulin injection sites must be rotated
administered. The weight of a medication may be
to prevent tissue damage. Record site used
expressed as any of the following:
(Figure 24-4).
• Do not massage after injection. • milliequivalent (mEq)
• Always follow the provider’s order and office policy • microgram (mcg)
when mixing insulins. • milligram (mg)
• gram (Gm, g)
Oral Hypoglycemic Medication. Persons with type
2 diabetes mellitus are known to have noninsulin- • unit
dependent diabetes mellitus (NIDDM). Type 2
The volume of a medication may be expressed as a:
diabetes has a gradual onset, usually seen in adults
over 40 years of age. With the obesity epidemic in • milliliter (mL)
the United States, individuals are contracting type
• minim (m)
2 diabetes at earlier ages (obesity contributes to and
can cause type 2 diabetes). The pancreas in patients • dram (dr)
with type 1 diabetes secretes no insulin; in type 2, • ounce (oz)
the pancreas has some ability to secrete insulin. • by a variety of household measures, such as the tea-
Most individuals with type 2 diabetes do not have to spoon (tsp)
inject insulin, although a few do. Exercise and diet
management may be sufficient for type 2 diabetics Many different methods can be used when
to lose enough weight and not require oral hypo- calculating the dosage to be administered. Two
glycemic medication. For the majority, however, of the most useful methods—the proportional
exercise and diet are not enough to bring the blood method and the formula method—are described
sugar to an acceptable level. Medication works by next.
stimulating the pancreas to secrete more insulin, by
making cells more receptive to insulin, and by slow-
ing the body’s carbohydrate absorption. Some oral The Proportional Method
hypoglycemics are Orinase, Tolinase, Micronase, Example:
Glucotrol, Glucophage, and Starlix.
The provider orders 0.2 g of Equanil tabs. The dose on hand is
400 mg tabs.
FRONT BACK
Step 1.
Determine whether the medication ordered and the medica-
tion on hand are available in the same unit of measure.
2 2 1 1
4 4 3 3 Step 2.
6 6 5 5
8 8 7 7 If the medication ordered and the medication on hand are
not in the same unit of measure, convert so that both mea-
1 2 1 2
3 4 3 4
1 2 3 4 1 2 3 4 sures are expressed using the same unit of measure.
5 67 8
5 6 5 6 5 67 8 Conversion: To change 0.2 g to mg
7 8 7 8
1,000 mg : 1 g  x mg : 0.2 g
x  200 mg
1 2 1 2 or
3 4 3 4
5 6 5 6 multiply 0.2  1,000  200
7 8 7 8

Step 3.
Now use the following proportion to calculate the dosage.
Figure 24-4 Sites and rotation for insulin administration. Remember that 0.2 g was converted to 200 mg.
 CHAPTER 24 Calculation of Medication Dosage and Medication Administration 719

Known Known Unknown

unit : dosage  Dose : amount to CALCULATING CHILDREN’S
on hand form ordered be given DOSAGES
400 mg : 1 tab  200 mg : x tab

400 : 1  200 : x Each child is an individual with differences in

age, size, and weight. In the past, formulas such as
Young’s, Clark’s, and Fried’s rules were used to calcu-
400x  200
1
late pediatric dosages. These formulas determined
200 what fraction of an adult dose was appropriate for
x= 400 (Reduce fraction to lowest terms) a child. Because each child does not develop in the
2
same way during a given time span, these formulas
x = 1⁄2 tab of 400 mg have been replaced by more exact methods of deter-
mining the correct dosage of medication for a child.
Step 4
Today, there are two basic methods used to
Prove your answer. Place your answer in the original formula in calculate children’s dosages:
the x position.
• According to kilogram of body weight
400 mg : 1 tab  200 mg : 1⁄2 tab
200  1⁄2 of 400 • According to BSA
200  200 The body weight method is generally the
method of choice, because most medications are
The Formula Method ordered in this way and it is easier to calculate. The
BSA is an exact method, but one must use a for-
Example: mula and a nomogram (a device-graph that shows
The provider orders 0.2 g of Equanil tabs. The dose on hand is
relation among numeric values) to determine a
400-mg tabs. correct dosage (Figure 24-5).
Step 1.
Body Surface Area
Determine whether the medication ordered and the medica-
tion on hand are available in the same unit of measure.
The BSA is considered to be one of the most accu-
rate methods of calculating medication dosages
Step 2. for infants and children up to 12 years of age. This
method requires the use of a nomogram that esti-
If the medication ordered and the medication on hand are mates the BSA of the patient according to height
not in the same unit of measure, convert so that both mea-
sures are expressed using the same unit of measure.
and weight.
Conversion: To change 0.2 g to mg The body surface area is determined by draw-
1,000 mg : 1 g  x mg : 0.2 g ing a straight line from the patient’s height to the
x  200 mg patient’s weight. Intersection of the line with the
or surface area column is the estimated BSA. This
multiply 0.2  1,000  200 figure is then placed in the following formula:
Step 3. BSA of child (m2)
 adult dose  child dose
1.7 (m2)
Now use the following formula to calculate the dosage.
Dose ordered (desired) Quantity (Amount to give This formula is based on the average adult
  form of drug) who weighs 140 pounds and has a body surface
Dose on hand 1
area of 1.7 square meters (1.7 m2).
D
H 3 Q 5 Amount to give Example:
Marion Carrera is a 4-year-old child who is 40 inches tall and
The provider ordered 0.2 g of Equanil tabs (0.2 g converts to
weighs 38 pounds (BSA 0.7). The provider has ordered Dem-
200 mg). The dose on hand is 400 mg tabs.
erol for pain. The average adult dose of Demerol is 50 mg per
mL. What dosage will be given to Marion according to the
200 mg 200 BSA method?
3 1 tab 5 or 1⁄2 tab
400 mg 400 0.7 (m2) 50 mg
  child’s dose
Give 1⁄2 tab of 400 mg. 1.7 (m )
2
1
720 UNIT 6 Advanced Techniques and Procedures

WEST NOMOGRAM

Nomogram

Height SA Weight
cm in For children of M2 lb kg
normal height
for weight
90 180 80
1.30 160
80 1.20 70
2.0 140
240 70 1.10 1.9 130 60
90 1.8 120
220 60 1.00 1.7 110 50
85
1.6 100
200 80 0.90 1.5 90
50 40
190 75 1.4
0.80 80
180 70 1.3
170 40 1.2 70
65 0.70 30
1.1 60
160
60 1.0 25
150 30 0.60 50
140 55 0.9
0.55 45 20
0.8 40

Surface area (square meters)

130 50 0.50
120 0.45 0.7 35
20 15
110
45
0.40
30 2
0.6
Weight (lb)

25
100 40 15 0.35
3
0.5 10
20 9.0
90 35 18
0.30 8.0
1 0.4
16
7.0
80 10 14
30 6.0
9 0.25
28 12
70 8 5.0
26 0.3 10
7
24 9 4.0
60 6 0.20 8
22 7
5 3.0
50 20 0.2 6
19 2.5
4 0.15 5
18
17 2.0
16 4
40 3
15 1.5
3
14
13 0.10
2 0.1
12 1.0
30

Figure 24-5 Body surface area (BSA) is determined by drawing a straight line from the patient’s height (1) in
the far left column to his or her weight (2) in the far right column. Intersection of the line with BSA column (3) is
the estimated BSA (m2). For infants and children of normal height and weight, BSA may be estimated from weight
alone by referring to the enclosed area. (From Behrman, R. E., Kleigman, R. M., & Arvin, A. M. (1996). Nelson
textbook of pediatrics (15th ed.). Philadelphia: W. B Saunders, Reprinted with permission from Elsevier.)

0.7 (m2) 50 35
1.7 (m2)

1

1.7
 20.5 mg  20.5 or 21 mg Kilogram of Body Weight
Now use the formula
Desired
 Quantity to convert mg
It may be the responsibility of the medical assis-
to mL.
Have tant to calculate the amount of dosage ordered
by the provider according to the patient’s body
21 mg
 1  x mL weight. Today, many medications are ordered
50 mg
in this manner; therefore, it is essential that you
21 learn how to calculate dosage according to this
0.42 mL administered in a tuberculin syringe
50
method. The following example will guide you
 CHAPTER 24 Calculation of Medication Dosage and Medication Administration 721

step by step through the mathematical process of

calculating dosage according to kilogram of body ADMINISTRATION
weight. OF MEDICATIONS
There are 2.2 pounds in 1 kg.
Regardless of a medication’s form or the route by
Example: which it is administered, certain basic guidelines
must be followed. These guidelines are:
The provider ordered the antiepileptic agent Depakene (val-
proic acid) 15 mg/kg/day capsules for Clark Kipperley, who 1. Practice medical asepsis (see Chapter 10
weighs 110 pounds. The medication is to be given in three for specific medical asepsis rules.) Wash
divided doses. your hands before and after administering
Step 1. a medication. Remember Occupational
Safety and Health Administration (OSHA)
To express pounds in kilograms, divide the weight in pounds guidelines and Standard Precautions (see
by 2.2. Convert the patient’s weight to kilograms: Chapter 10 for Standard Precautions.)
110  2.2  50 kilograms
2. Work in a well-lighted area that is free from dis-
tractions.
Step 2.
3. Follow the “Six Rights” of proper drug adminis-
Now, calculate the prescribed dosage by placing 50 in the tration (see following section).
appropriate place:
4. Always check for allergies before administering
15 mg/50/day
any medication.
15  50  750 mg/day
5. Give only drugs ordered by a licensed practitioner
Step 3. who is authorized to prescribe medications.
To determine the amount of each dose, divide 750 by 3
6. Never give a medication if there is any question
(divided doses). about the order.
750 mg  3  250 mg 7. Be completely familiar with the drug that you are
administering before giving it to the patient. Look
Depakene is available in 250-mg capsules and 250-mg/5 mL
syrup. The provider ordered the medication in capsules, so it up in the PDR or online.
Clark will receive a 250-mg capsule every 8 hours for a total of 8. Always check the expiration date on the medica-
3 doses a day. tion label.
In the same example, use the proportional method to
9. Never give a drug if its normal appearance has
calculate kilogram of body weight.
been altered in any way (color, structure, consis-
Step 1. tency, or odor); it may be outdated, contaminated,
or stored incorrectly.
To convert 110 pounds to kilograms, set up the proportion as
follows:
10. Make out a medication note (Figure 24-6) for med-
ications, dose, route, and time exactly as ordered
2.2 lb : 1 kg  110 lb : x kg
by the provider using the provider’s order from the
Step 2. patient’s record as a guide. Do not rely on memory.
11. Give only those medications that you have actually
Now, solve for x. prepared for administration. Trust only your own
2.2 : 1  110 : x actions.
2.2x  110
12. Do not allow someone else to give a medication
x  50 that you have prepared. Depend on yourself to
Step 3. give the correct medication.
13. Once you have prepared a medication for admin-
Now, calculate the prescribed dosage by placing 50 in the istration, do not leave it unattended; it could be
appropriate place: mg/50 kg/day
misplaced or spilled.
15  50  750 mg/day
14. Be careful in transporting the medication to the
Step 4. patient. Do not spill or drop.
15. When administering oral medications, stay with
To determine the amount of each dose, divide 750 by 3
the patient until you are certain that the medica-
(divided doses).
tion has been taken, to be sure patient swallowed
750  3  250 mg per dose
medication.
722 UNIT 6 Advanced Techniques and Procedures

19. Keep all drugs not being administered in a safe

A medication note is written out prior to administration of
storage place.
any medication to the patient in the ambulatory care set-
ting. The information is taken directly from the provider’s 20. Carefully follow the procedural steps for the type
order sheet of the patient’s record. An example follows. of medication that you are giving or the type of
procedure you are performing.
Information needed:
Patient name: Abigail Johnson 21. Always keep safety precautions in mind.
Provider’s order: Cardizem (diltiazem hydrochloride) 180 The United States Department of Health
mg po stat. Winston Lewis, MD. and Human Services, Public Health Ser-
vice, and Centers for Disease Control and
The medicine note is then used to be certain you have the
Prevention recommend following Standard
correct patient, and to document the information on Mrs.
Precautions for prevention of hepatitis B
Johnson’s record. Following documentation, tear up the
and C viruses and human immunodefi-
medication note and discard.
ciency virus and other bloodborne diseases
(see Chapter 10 for specifics about Stan-
dard Precautions).
Room 3
Johnson, Abigail The “Six Rights” of Proper Drug
Administration
Cardizem The “Six Rights” have been developed as a check-
list of activities to be followed by those who give
180 mg medications. This easy-to-remember list should
po always be followed to ensure the proper adminis-
tration of any drug:
stat 1. Right drug. To be sure that the correct drug has
been selected, compare the medication order with
10/24/XX – 10 A.M. the label on the medication bottle. A frequent
check of the medication label is a good way to
avoid a medication error. One should make a prac-
tice of reading the label on each of the following
Figure 24-6 A medication note is used to prepare, three occasions:
administer, and record medications, dose, route, and
time as ordered by the provider. First: When the medication is taken from the
storage area.
Second: Just before removing it from its con-
tainer.
16. Shake (to mix) all liquid medications that con- Third: On returning the medication con-
tain a precipitate before pouring. A precipitate tainer to storage or before discarding
is a substance that separates from a solution if the empty container.
allowed to stand. This mixes the liquid for the
proper medication. 2. Right dose. It is essential that the patient receive
17. When pouring a liquid medication, hold the mea- the right dose. If the dose ordered and the dose
suring device at eye level or place it on a flat sur- on hand are not the same, carefully determine the
face and squat down so you can observe it at eye correct dose through mathematical calculation.
level. Read the correct amount at the lowest level When calculating dosage, it is advisable to have
of the meniscus, which is the top surface of the col- another qualified person verify the accuracy
umn of liquid. of your calculations before the medication is
18. Do not contaminate the cap of a bottle while pour- administered.
ing a medication. Place the cap with the rim pointed 3. Right route. Check the medication order to be sure
upward to prevent contamination of that portion that you have the right route of administration
that comes into contact with the medication. (Figure 24-7A).
 CHAPTER 24 Calculation of Medication Dosage and Medication Administration 723

4. Right time. You are responsible for medicating the

patient at the proper time. Check the medica- When a medication error occurs, follow standard procedure:
tion order to ensure that a drug is administered a. Recognize that an error has been made.
according to the time interval prescribed. For a b. Stay calm. Assess the patient’s condition and reactions to
drug to be maintained at the proper blood level, the medication.
care must be taken to administer it at the right c. Report the error immediately to the provider. Give the
time (Figure 24-7B). details of the mistake and the patient’s reactions.
d. Follow the provider’s order for correcting the error.
5. Right patient. Before administering any medi- e. Document the error in the patient’s chart or electronic
cation, always be sure that you have the right medical record or the facility’s record form:
patient. A good safety practice is to correctly • Describe the type of error.
identify the patient on each occasion when • Describe the patient’s reactions.
you administer a medication. In a hospital, the • Describe the steps taken to correct the error.
patient’s identification bracelet is always checked. • State date, time, and your name.
In the ambulatory care facility, call the patient by
name or ask the patient to state his or her name
(Figure 24-7C).
odically. A medication error occurs when any of
6. Right documentation: The recording pro-
E HR
the following happen:
cess is the vital link between provider,
patient, and medical assistant. It is an 1. A drug is given to the wrong patient
account of the essential data that are collected
2. The incorrect drug is given
and preserved. The patient’s chart is a legal docu-
ment; therefore, all data should be recorded in 3. The drug is given via an incorrect route
ink or entered into the computer. The data should 4. The drug is given at the incorrect time
be accurate and clearly stated. It is important that 5. The incorrect dose is administered
certain data about drug administration be entered
6. Incorrect data are entered on the patient’s chart
into the patient’s chart (Figure 24-7D):
or electronic medical record
• Patient’s name
• Date and time of administration Patient Assessment
• Name of the medication and the amount (dos- Before administering any medication, carefully
age) administered assess the patient’s condition. An assessment
• Route by which the medication was adminis- should include, but is not limited to, the following
tered conditions:
• Any unusual reactions experienced by the 1. Age. Is the medication and route suitable for the
patient patient at a particular stage in life? The stages of
• Any complications in administering the drug life include infancy, childhood, adolescence, adult-
(patient refusing to take the medication, diffi- hood, and old age. During infancy, early child-
culty in swallowing) hood, and old age, a smaller dose of medication
• If the medication was not given, state may be required than would be appropriate for
why and dispose of the medication the other stages in life.
according to agency policy and federal 2. Physical conditions. Potential problems associated
and state laws with the patient’s physical condition must be con-
• Patient data, such as blood pressure, pulse, res- sidered. Female patients during pregnancy or
pirations, when appropriate while breast-feeding should not be given certain
medications because they may be contraindicated.
• Your name or initials and title
3. Body size. The amount of medication given and size
of the needle used are directly related to the size
Medication Errors of the patient. Pediatric and geriatric patients usu-
Medication errors should not happen when per- ally have less subcutaneous and muscular tissue
sonnel follow the “Six Rights” of proper drug per BSA than the average adult (see Figure 24-5).
administration and the essential medication guide- Small, thin patients usually require less medica-
lines; however, honest mistakes will be made peri- tion, and a shorter needle may be used to reach
724 UNIT 6 Advanced Techniques and Procedures

A B

Figure 24-7 (A) Medical assistant checks the right

drug, the right route, and the right dose of medica-
tion to administer. (B) Medical assistant checks for the
right time to administer medication to the patient.
(C) Medical assistant assesses patient before ad-
ministering the medication. The medical assistant
ascertains he has the right patient and asks the patient
if she has any allergies. (D) Medical assistant docu-
ments administration of medication in patient’s chart.
D

the appropriate tissue level. On the other hand,

the large or obese patient may or may not require
more tone than that of an older adult. Slightly
more medication than the average adult and a lon-
more force is required to penetrate skin that is
ger needle to reach the appropriate tissue level.
tough or lacking in tone.
4. Sex. Consider differences that are related to the sex
5. Injection site. Always inspect and palpate the skin
of the patient.
before administering an injection. The following
• Build. Muscular patients generally have more mus- body areas should be avoided when choosing the
cular tissue. Obese patients have more adipose tis- site for an injection:
sue. Always inspect and palpate muscle tissue with
• Any type of skin lesion
this in mind when determining the appropriate
needle length to reach muscle tissue. • Burned areas
• Skin texture. Some patients have tougher skin • Inflamed areas
than others. A young person’s skin might have • Previous injection sites
 CHAPTER 24 Calculation of Medication Dosage and Medication Administration 725

• Any traumatized area

• Scar tissue (vaccination, keloid)
• Moles, warts, birthmarks, tumors, lumps, hard
nodules
• Nerves, large blood vessels, bones
• Cyanotic areas
• Edematous areas
• Paralyzed areas
• Arm on same side as mastectomy, or other lym-
A B
phatic compromise

Correct injection sites are illustrated later in Figure 24-8 Medicine cups: (A) glass; (B) plastic.
this chapter.

The medicine dropper (Figure 24-9) may be

ADMINISTRATION OF ORAL calibrated in milliliters, minims, or drops. Medi-
MEDICATIONS cine droppers are often included with the bottle
of medication. Uncalibrated droppers may be pro-
Oral medications are easily and economically vided when the medicine is administered only in
administered. There are, however, several disadvan- drops. The size of the drop varies with the size of
tages associated with the oral route. For instance, the dropper opening, the angle at which it is held,
the drug may: the force exerted on the rubber bulb, and the vis-
cosity of the medication.
• Have an objectionable odor/taste It is important that the appropriate measur-
• Cause discoloration of the teeth, mouth, and ing device be selected for a medication and the
tongue prescribed dosage accurately measured. The selec-
• Irritate the gastric mucosa tion of the measuring device depends on the physi-
cal structure of the medication (solid or liquid),
• Be altered by digestive enzymes
the amount of medication prescribed, the size of
• Be poorly absorbed from the digestive system the measuring device, and the calibrations on the
because of illness or nature of the medication container.
• Not be taken by the patient Procedure 24-1 give steps for administration
• Have less predictable effects on the body when of oral medications.
given orally than when given by the parenteral
route (by injection)
• Not be able to be swallowed if in tablet, capsule, or
caplet form

Equipment and Supplies for Oral

Medications
Three measuring devices commonly used in the
administration of oral medications are the medi-
cine cup, the water cup, and the medicine drop- A
per. The medicine cup (Figure 24-8) comes in
various sizes and shapes, depending on its manu- B
facturer and its intended use. Cups may be cali-
brated in fluid ounces, fluidrams, milliliters (mL), C
and tablespoons.
The water cup is a small plastic or paper cup
that is disposable. The average water cup holds Figure 24-9 Various types of medicine droppers:
three ounces of liquid. (A) glass; (B) plastic; (C) plastic calibrated.
726 UNIT 6 Advanced Techniques and Procedures

• Cartridge-needle unit. A disposable sterile cartridge

ADMINISTRATION containing a premeasured amount of medication.
OF PARENTERAL MEDICATIONS This unit is designed for use in a nondisposable
cartridge-holder syringe such as the Tubex® or
The term parenteral is used to describe the injec- Carpuject®.
tion of a substance into the body via a route other • Vial. A small, sterile, prefilled glass bottle with rub-
than the alimentary canal/digestive system. The ber stopper containing a hypodermic solution.
most frequently used parenteral routes are:
• Subcutaneous. Just below the surface of the skin.
A subcutaneous injection is usually given at a Hazards Associated
45-degree angle. with Parenteral Medications
• Intramuscular. Within the muscle. An intramuscu- Injections of medications must be done
lar injection is given at a 90-degree angle, passing with extreme care. Sterile technique must
through the skin and subcutaneous tissue, and be used because the needle and medication
penetrating deep into muscle tissue. are being introduced into the patient’s body and
• Intradermal. Within the dermal layer of the skin. An microorganisms must not be transmitted. Appropri-
intradermal injection is given at an angle between ate site selection and proper technique ensure effec-
10 and 15 degrees. tiveness of the medication.
• Intravenous. Within or into a vein. Additional dangers to be aware of when
administering medications parenterally (by injec-
Medications that have been prepared for tion) include:
use by injection are available in multiple-dose
form (vials) and in unit dose form (ampules and • Allergic reaction (if present) will be swift
cartridge-needle units) (Figure 24-10.) Unit dose • Injury to bone, nerve, or blood vessel
forms are premeasured amounts, packaged on a • Breaking of needle in tissue (rare)
per-dose basis.
• Injecting into a blood vessel instead of tissue
• Ampule. A small, sterile, prefilled glass container (this is avoided by checking for blood return, on
that usually holds a single dose of a hypodermic aspiration).
solution.
Reasons for Parenteral Route
Selection
The parenteral route is selected because of:
• Rapid response time to medication
• Accuracy of dosage
• Need to concentrate medication in a specific body
part or area (into a joint or local anesthetic)
• Inability to administer orally because the medica-
tion is destroyed by gastric juices, or the patient is
incapable of taking medication orally
Because parenteral medications are intended
for use by injection, they must be injected as liq-
uids. Some medications are supplied in powder
form and must be reconstituted to a liquid form
for injection (see Procedure 24-8).
Because they must be in liquid form, the
A B C
amount of parenteral medications is expressed in
terms of volume (milliliters, minims, or ounces).
Figure 24-10 Medications given parenterally. The strength of the drug contained in the liquid is
(A) Ampule. (B) Sterile cartridge with premeasured usually expressed in terms of its weight (milliequiv-
medication. (C) Vial of powder for reconstitution. alents, micrograms, milligrams, grams, or units).
 CHAPTER 24 Calculation of Medication Dosage and Medication Administration 727

Therefore, medications ordered for parenteral use Nondisposable glass and plastic syringes are
are often ordered by both weight and volume. available in sizes from 1 to 50 milliters. They may
The parenteral route of drug administration be used by providers to perform special procedures
offers an effective mode of delivering medication to such as paracentesis, thoracentesis, thoracotomy,
a patient when a rapid and direct result is desired. and tracheotomy.
The effect of a parenteral medication is faster than
one given by the oral route; however, the accuracy Combination Disposable/Nondisposable Car-
of dosage calculation for both is important. tridge-Injection Syringes. A cartridge-injection
system, such as the plastic Carpuject® (Figure
Parenteral Equipment 24-11) or the metal Tubex®, consists of a dispos-
able cartridge-needle unit and a nondisposable
and Supplies cartridge-holder syringe. The cartridge-needle
Syringes. Syringes are classified as disposable, unit is factory sealed and sterile and contains a
nondisposable, or a combination of these two precisely measured unit dose of medicine. The
types. Most syringes used are plastic. They also cartridge-holder syringe may be made of durable
may be classified according to their intended use. chrome-plated brass or of plastic. These reusable
In addition to the standard hypodermic syringes syringes are designed for quick and safe loading
that are in general use, there are special-purpose and unloading of cartridge-needle units, which
syringes for irrigations or oral feedings, tuberculin are manufactured in various sizes and dosage
syringes, and insulin syringes. capacities and contain a wide range of medica-
tions (Figure 24-12).
Disposable Syringes. Disposable syringes are The combination of disposable/nondispos-
those that are sterilized, prepackaged, nontoxic, able syringe system is easy to use and convenient.
nonpyrogenic, and ready for use. They are available When using this system, be careful to read the
as a syringe-needle unit and are generally enclosed label and compare the medication order with the
in individual peel-apart packages of durable paper label. For example, the provider may order Dem-
or clear plastic. They are available in sizes from 1 erol® 25 mg and the cartridge is 50 mg/mL. Give
to 60 milliters. The 1-, 3-, and 5-mL syringes are the 1
⁄2 mL and properly discard the other 1⁄2 mL
ones most often used when parenteral medications according to office policy. Another person must
are administered. witness the disposal of the Demerol®, which is a
A disposable syringe-needle unit consists controlled substance.
of a syringe with an attached needle. The
needle is covered by a hard plastic sheath Parts of a Syringe. The component parts of a
to prevent it from accidentally penetrating the syringe consist of a barrel, plunger, flange, tip
package or sticking the user. The unit may be (Figure 24-13), and a safety shield on a safety
sealed within a peel-apart package or encased in syringe.
a rigid plastic container that has been heat sealed
to ensure sterility. Labeling usually includes the • The barrel is the part that holds the medication and
manufacturer’s name, type and size of the syringe, has graduated markings (calibrations) on its sur-
gauge and length of the needle, and a reorder face for use in measuring medications.
number. Packages are usually color coded for ease
of identification. Always read the label. Disposable
syringes are generally preferred for the administra-
tion of parenteral medications because they ensure
sterility and sharp needles. Also, disposable syringes
eliminate the need for resterilizaton, which is costly,
time-consuming, and possibly unsafe if not done
properly.

Nondisposable Syringes. Nondisposable sy-

ringes are usually made of specially strengthened
glass resistant to thermal shock. These units, con-
sisting of round glass barrels with individually Figure 24-11 The Carpuject® is a type of cartridge-
fitted plungers, are manufactured to exacting injection system with a click-lock mechanism for safety.
specifications. (Courtesy of Hospira, Inc.)
728 UNIT 6 Advanced Techniques and Procedures

Plunger rod
Plunger

Rubber collar

Disposable sterile
cartridge-needle
unit

A B

C D E

Figure 24-12 (A) Reusable cartridge holder with disposable sterile cartridge needle unit. (B) Turn ribbed collar
to open position. (C) Insert the sterile cartridge-needle unit into the open end of the injector. The ribbed collar is
firmly tightened. The plunger of the injector and the plunger of the cartridge-needle unit are tightened and ready
for use. (D) The medical assistant prepares to dispose of the cartridge-needle unit. The needle is not recapped.
The plunger rod is disengaged by unscrewing. The ribbed collar is loosened. (E) The medical assistant holds the
cartridge-needle unit over a sharps container, and the unit drops into the container.

• The plunger is a movable cylinder designed for • The tip is at the end of the barrel where the needle
insertion within the barrel; it provides the mecha- is attached.
nism by which a medication (or other substance) is • The safety shield is pulled over the needle while
drawn into or pushed out of the barrel. withdrawing it. Safety needles have a mechanism
• The flange is at the end of the barrel where the to either sheath the needle, retract it, or blunt it.
plunger is inserted. It forms a rim around the end (Figure 24-14).
of the barrel where the plunger is inserted and has
appendages against which one places the index The parts of a syringe that must remain ster-
and middle fingers when drawing up solution for ile during the preparation and administration of
injection. The flange also prevents the syringe a parenteral medication are the inside of the bar-
from rolling when laid on a flat surface. rel, the section of the plunger that fits inside the
 CHAPTER 24 Calculation of Medication Dosage and Medication Administration 729

Luer-Lok tip
Plain
tip
Barrel
Rubber
stopper Rubber
stopper

Plunger

Plunger

Flange Flange

5 mL syringe separated 3 mL syringe

and together (A) separated (B)

Figure 24-13 Parts of a syringe. (A) A 5-mL syringe separated and unseparated with
Luer-Lok® tip. (B) A 3-mL syringe separated with plain tip.

barrel, and the syringe tip to which the needle is

to be attached.
A
Types of Syringes and Uses. Syringes are
named according to their sizes and uses. Table
24-9 lists the types, sizes, calibrations, and uses of
syringes used in the administration of parenteral
medications. Figure 24-14 shows various sizes of
safety syringes.
One should always choose a needle with suf-
ficient length to reach the desired tissue level
(Table 24-10). A large person may require a longer
needle to reach the correct body tissue than would
be required for a smaller person. The delivery of
medication to the proper tissue level is important.
A concentrated or irritating medication that is
B
intended for deep intramuscular injection could
be delivered instead into the subcutaneous tissue
of an obese patient if one selects a needle that is
too short. Such an inappropriate injection may
cause a sterile abscess and necrosis. This unneces-
C sary complication can be avoided by considering
the size of the patient when choosing the length of
the needle.

D Needles. Both disposable and nondisposable nee-

dles are available for use with syringes. Of these, the
Figure 24-14 Types of safety syringes. (A) Hypodermic most frequently used are disposable needles, which
safety syringe, 3 mL with protective needle guard. (B) Tuber- are individually packaged in sterile paper or plastic
culin syringe 1 mL. (C) Lo-dose unit 100 insulin syringe. containers. Disposable needles and syringe-needle
(D) Standard units 100 insulin syringe. (Courtesy of BD.) units are available with a color-coded sheath. The
730 UNIT 6 Advanced Techniques and Procedures

Table 24-9 The Most Frequently Used Table 24-10 Syringe-Needle Combinations for
Syringes for Parenteral Various Parenteral Routes
Medications
Subcutaneous Intramuscular Intradermal
Type of Size and Injection Injection Injection
Syringes Calibration Typical Uses
3-mL syringe/ 3-mL syringe/ 1-mL syringe/25G,
3 milliliter Intramuscular and 25G, 5⁄8 inch 23G, 1 inch 5
⁄8 inch needle
Calibrated 0.1 subcutaneous needle needle
Hypodermic injections
15/16 minims/
milliliters 3-mL syringe/ 3-mL syringe/ 1-mL syringe/26G,
26G, 3⁄8 inch 22G, 11⁄2 inch 3
⁄8 inch needle
5 milliliter Venipuncture and needle needle
Hypodermic Calibrated 0.2 intramuscular
injections 3-mL syringe/ 3-mL syringe/ 1-mL syringe/27G,
27G, 1⁄2 inch 21G, 11⁄2 to 2 inch 1
⁄2 inch needle
Larger sizes Medical/surgical needle needle
(10, 30, and treatments, aspira-
60 milliliter) tions, irrigations, U-100 (1 mL)/26G,
Hypodermic 1
⁄2 inch needle
venipunctures,
gavage (tube-to- for insulin
stomach) feedings

1 milliliter To inject minute

Calibrated 0.1 amounts for intrader-
Tuberculin and 0.01 mal injections, allergy
testing, allergy injec-
16 minims/
tions
milliliters Intramuscular Subcutaneous
Intradermal
U-100 (0.5 milliliter) Lo-Dose® administra-
Insulin U-100 (1 milliliter) tion of insulin
Insulin administration

sheath protects the needle and identifies its gauge

and length. Common needle gauges (G) range
from 16 to 32, and their lengths vary from 3⁄8 to 2
inches. The needle’s gauge is determined by the Intracatheters
diameter of the lumen or opening at its beveled for intravenous
tip. The larger the gauge, the smaller the diameter use Butterfly needle and tubing for
infusions of medications i.v.
of its lumen. For example, a 32-gauge needle is over a period of time
much smaller than a 16-gauge needle.
Nondisposable needles are made of high- Figure 24-15 Various sizes and types of needles. Dif-
quality stainless steel. They are equipped with ferent colored hubs denote needle gauges.
a mounting hub that has a cylindrical opening
designed to slip over the lock onto the tip of a
syringe, such as a Luer-Lok®. See Figure 24-15 for • The lumen, the hollow core of the needle, forms an
various sizes and types of needles. oval-shaped opening when exposed at the beveled
point.
Parts of a Needle. Figure 24-16 shows the
• The hollow steel tube through which the medica-
parts of a needle used to administer parenteral
tion passes is the shaft.
medications.
• The other end of the shaft attaches to the hub,
• The point is the sharpened end of the needle. which is part of the needle unit that is designed to
The point is formed when the end of the shaft is mount onto the syringe.
ground away to form a flat, slanted surface called • The point at which the shaft attaches to the hub is
the bevel. called the hilt.
 CHAPTER 24 Calculation of Medication Dosage and Medication Administration 731

Lumen Shaft medications is at risk for an injury. Other types of

sharps-related injuries besides disposable needles
include suture needles, butterfly needles, scal-
Point
pel blades, phlebotomy needles, and IV catheter
stylets.
A number of pathogens can enter the body
Plastic sheath during a sharps-related injury, but of greatest
concern are hepatitis B and C viruses and HIV
(see Chapter 10 for details about these and other
bloodborne pathogens).
Point Shaft Hub
The National Alliance for the Primary Preven-
Lumen Hilt
tion of Sharps Injuries (NAPPSI) consists of medical
device makers, health organizations, and health care
providers whose goal is the prevention of sharps-
related injuries. Besides safety needles (see infor-
mation on retractable needles in Chapter 10), laser
Figure 24-16 Parts of a needle and needle sheath. scalpels, and needleless drug delivery systems such
Inset shows point, lumen, and shaft. as patches and inhaled medications, a needleless
injection system is available (fluid under pressure).
There are glues and adhesives available to approxi-
mate surgical incisions. These alternative methods
The Safe Disposal of Needles and are helpful in reducing sharps-related injuries; how-
Syringes. The careless disposal of used ever, phlebotomy and IV therapy still require a nee-
needles and syringes may present a health dle. Legal regulations (CDC and OSHA) require
risk to any person coming into contact with the use of the safest needle available.
used equipment. An accidental stick by a con- Proper use and disposal of sharps is the utmost
taminated needle could transmit diseases such as importance to health care workers and others.
hepatitis B, hepatitis C, syphilis, Rocky Mountain Avoid needles if there are other methods available,
spotted fever, tuberculosis, malaria, varicella zos- and never recap used needles. Engage the safety
ter, and human immunodeficiency virus (HIV). mechanism and dispose of needles and syringes
Used needles and syringes should be discarded in immediately after use.
a rigid, puncture-proof container (Figure 24-17).
Never recap a needle after giving an injection. Sharps Collectors. Sharps collector systems
Do engage safety feature. Most needlesticks occur eliminate the need to reshield the needle, thereby
while recapping. Refer to Chapter 10 for OSHA reducing the risk for an accidental needlestick.
regulations. Needles are placed into the container as a
Most sharps-related injuries (needlesticks) whole unit after safety mechanisms are engaged.
occur in the hospital with inpatients. However, any Sharps containers need to be within reach any time
health care worker who administers parenteral injections are given.

PRINCIPLES OF INTRAVENOUS
THERAPY
Patients who are unconscious, uncooperative,
experiencing severe nausea and vomiting, have
had severe burns, or have a significant amount
of blood loss may need an intravenous infusion.
All of these situations result in the patient losing
body fluids, resulting in loss of homeostasis. The
provider will order the fluids to be replaced by
intravenous infusion according to the patient’s
condition or disease. The fluids will be specific
Figure 24-17 Place used needles, point down, in for the needs of a particular patient. Some infu-
puncture-proof sharps containers. sions maintain the patient’s water (fluids) and
732 UNIT 6 Advanced Techniques and Procedures

electrolyte needs. For example, some elderly be programmed to a specific drop per minute rate.
people who live alone and do not feel well, per- The device has an alarm that signals if there is a
haps have pneumonia, may not eat well or drink problem and signals when the infusion is finished.
enough liquid to maintain the body’s balance of Equipment for an IV comes in a sterile kit.
fluids and electrolytes. If the situation goes on for Within the kit are the needle and cannula for enter-
a few days, during which time the patient becomes ing the vein, the tubing to attach to the needle and
dehydrated, the patient will need IV fluids. Symp- cannula (shielded), and a plastic (usually) or glass
toms of dehydration are dry mouth, dark urine, container of the prescribed fluid. The equipment
and lightheadedness. It can lead to changes in the institutes a “basic” administrating set and is what is
body’s chemistry and become life-threatening. generally seen in ambulatory care (Figure 24-18).
Severe nausea and vomiting can quickly dehy- The tubing has a roller-type clamp for adjusting the
drate an individual and eventually can lead to drop rate. Some tubing is made with a port that gives
kidney failure. The patient needs replacement of ready access for addition of other fluids by using
fluids and electrolytes through an intravenous infu- another infusion set simultaneously. The tubing can
sion. (If a patient is vomiting, any attempt at taking become kinked and slow down the flow of fluid. If
in fluids orally is not likely to be successful.) the needle is not securely attached to the tubing,
When a patient is prescribed intravenous the fluid may leak out at the attachment site.
fluids, the provider takes into consideration the IV therapy or infusion is ordered by the pro-
patient’s age, weight, height, and clinical labora- vider for a variety of patient conditions. It provides
tory results. for medication to be given for a rapid response,
When patients are receiving an intravenous replaces fluids and electrolytes, helps to raise blood
infusion, they must be watched carefully. The flow pressure when the patient suffers from shock due to
rate is ordered by the provider. Blood pressure blood or fluid loss, and can be used for nutritional
should be monitored. Breathing and chest tight- supplements. Access to a vein when needed will have
ness should be reported. Excessive volume (too
much fluid too quickly) can result in overhydra-
tion and possible serious adverse cardiac and pul-
Piercing pin
monary consequences.
Inserting a needle or cannula into a vein for Flange
purposes of an infusion is an invasive procedure,
and the possibility exists for microorganisms to Drip chamber Drop orifice
enter the patient’s body. Everything must be sterile
because microorganisms can enter the bloodstream Luer
and cause serious problems. Infection at the site of slip
needle entry is possible. Phlebitis (inflammation of
the vein) can occur from the patient moving about Close Open
and causing the needle to irritate the vein. The IV Slide clamp
fluid can infiltrate the tissues around the needle
site, causing pain, swelling, and possibly tissue dam-
age. The IV must be terminated and a new site used
to restart it. Monitor the skin around the injection
site for swelling and redness. Standard Precautions
must be used to avoid exposure to the patient’s
blood and/or body fluids. The fluid is infused into
the patient drop by drop. The flow of the solution is Injection port
Flow control
carefully monitored. The rate of the IV flow is cru- clamp
cial, and the number of drops per minute must be
accurate. Other essential factors for IV infusion are
that the prescribed fluid amount and the amount
of time required for the infusion to finish are cor-
rect, and that the drop factor is calculated using a
mathematical formula.
Electronic devices for IV infusion are battery
operated, electronically operated, or a combination
of both. The devices are safe and accurate and can Figure 24-18A Basic IV administration set.
 CHAPTER 24 Calculation of Medication Dosage and Medication Administration 733

All persons providing health care to

Open patients are legally responsible for their
Open own actions. See Chapter 28 for informa-
Close tion regarding phlebotomy.
Close Open
It is important to realize that IV infusion is an
Close invasive procedure much like the phlebotomy pro-
cedure. The veins for IV infusion are similar to those
used for venipuncture in the hands and arms.
Figure 24-18B Administration set tubing clamps.
SITE SELECTION
AND INJECTION ANGLE
The selection of a proper site for a subcutaneous,
intramuscular, or intradermal injection and the
correct angle of insertion for each will ensure that
Straight adapter the medication is delivered to the correct tissue
type (Figure 24-19).
A subcutaneous injection is given at an angle
of 45 degrees just below the surface of the skin
wherever there is subcutaneous tissue. The shaded
areas shown in Figure 24-20A are the usual sites for
subcutaneous injections because they are located
Luer-Lok® adapter away from bones, joints, nerves, and large blood
vessels.
Figure 24-18C Straight and Luer-Lok® cannula hub
An intramuscular injection is given at a
adapters.
90-degree angle, passing through the skin and sub-
cutaneous tissue and penetrating deep into muscle
a systemic effect in a short period of time. The vein tissue. Body areas normally used for intramuscular
is accessible for emergencies. The route is useful for injections are the dorsogluteal area, ventrogluteal
unconscious patients and provides a rapid route for area, deltoid muscle, and vastus lateralis.
countering poisonous substances or inappropriate After locating an appropriate vein, an IV
medication response. injection is given at a 25-degree angle penetrating
Veins may “collapse” (very difficult to find) the skin and introducing the needle into the vein.
as a result of the patient’s condition (dehydra- The antecubital, median cephalic, median basilic,
tion, hypotension, blood loss), and locating an and median cubital veins are common sites appro-
accessible vein may be difficult. The provider may priate for IV injections (see Chapter 28 for more
order that the vein be kept opened (by continuous information about vein selection).
IV infusion). This is abbreviated KVO (keep vein Intradermal injections are given at an angle
open) or TKO (to be kept open) for immediate between 10 and 15 degrees into the dermal layer
accessibility. of the skin. The body areas used for intradermal
Some IV solutions commonly used for infu- injections are the inner forearm and the middle of
sions in ambulatory settings are: the back (Figure 24-20B). These two sites are used
because the skin in these areas is thin and contain
• 5% dextrose in water
little hair.
• Saline solutions
• Dextrose in normal saline Marking the Correct Site
• Lactated Ringer’s solution for Intramuscular Injection
Although IV therapy is not a procedure medi- To give a safe injection, it is necessary to become
cal assistants perform, they must be knowledgeable familiar with the anatomic structures associated
about the procedure, understand the purpose for with the injection site. With knowledge of where
IV infusions, recognize the precautions concerning such structures are located, it is easier to mark
this invasive procedure, and realize that state laws injection sites that avoid bones, nerves, and large
vary regarding IV infusion. blood vessels.
734 UNIT 6 Advanced Techniques and Procedures

Intramuscular Subcutaneous Intravenous Intradermal

90-degree 45-degree 25-degree 10–15-degree

angle angle angle angle
Epidermis
Dermis
Subcutaneous
tissue
Muscle

Intramuscular Subcutaneous Intravenous Intradermal

(IM) (SC) (IV) (ID)
Figure 24-19 Angles of injection for intramuscular, subcutaneous, intravenous, and intradermal injections.

and result in an injection into the inappropriate

area. To locate the correct site for a dorsogluteal
injection, locate the superior posterior iliac spine
and place a small x on this spot. Then locate the
greater trochanter of the femur and mark this spot.
Draw (or imagine) a diagonal line between the two
locations. The area above and outside this line and
about 3 inches below the iliac crest is the correct
location of the dorsogluteal site.
Extreme caution should be used when giv-
ing intramuscular injections in the dorsogluteal
A area. Improper site selection can result in dam-
age to the sciatic nerve or injection into the
superior gluteal artery or vein. This site is con-
traindicated for infants and is used only as a site
of last resort in children because of less muscle
development. This muscle mass may be degener-
ated in older adults, the nonwalking, or the ema-
ciated patient.

Ventrogluteal Site. The ventrogluteal site (glu-

teus medius muscle) can generally accommodate
the majority of medications ordered for intra-
B muscular injection. It may be used for individu-
als from infancy to adulthood. The ventrogluteal
Figure 24-20 Injection sites: (A) subcutaneous; site is relatively free of major nerves and vessels,
(B) intradermal. thereby making it a choice site for intramuscular
injections. To locate the ventrogluteal injection
site, palpate to find the greater trochanter, the
Dorsogluteal Site. The dorsogluteal site is the tra- anterior superior iliac spine, and the bony ridge
ditional location for giving most (adult) deep intra- of the iliac crest (Figure 24-21B). With these
muscular injections (Figure 24-21A). Commonly three locations identified, place the palm of your
referred to as the “upper outer quadrant of the but- hand against the greater trochanter with the
tocks,” this description can be easily misinterpreted tip of your index finger on the anterior superior
 CHAPTER 24 Calculation of Medication Dosage and Medication Administration 735

• Volume of drug administered:

Iliac crest
Usual 1.0 mL to 2.0 mL
Gluteus medius muscle
• Needle sizes frequently used:
Posterior superior
20G to 23G. 1inch to 1½ inches iliac spine
(greater length needed for very obese
individuals) Gluteus minimus
muscle
• Acceptable patient position:
Prone
• Angle of injection:
90° angle to flat surface upon which prone patient is
Greater trochanter of
lying femur
• Advantages of site: Sciatic nerve
Large muscle mass accommodates deep IM/Z-track Gluteus maximus
injections. muscle
Injection not visible to patient. Iliotibial tract
• Disadvantages of site:
Boundaries of the upper, outer quadrant are often arbi-
trarily selected and may exceed margin of safety. • Additional considerations:
Danger of injury to major nerves and vascular structures IM injection using the dorsogluteal site requires strict
if incorrect site or technique is used. adherence to proper anatomical site location and injec-
Subcutaneous fat in area is often very thick; an injection tion technique.
intended for muscle may in fact be subcutaneous.

Figure 24-21A Injection technique for dorsogluteal site, adult and pediatric (2 years and older).

• Volume of drug administered:

Usual 1.0 mL to 2.0 mL
Adult 1.0 mL (2 years and older)
• Needle sizes frequently used:
20G to 23G. 1 inch to 1½ inches Tubercle of iliac crest
• Acceptable patient positions: Gluteus medius
muscle
Supine, lateral
Anterior superior
• Angle of injection: iliac spine
Angle the needle slightly toward the iliac crest Gluteus minimus
• Advantages of site: muscle
Relatively free of major nerves and vascular branches. Tensor fasciae latae
Well localized by bony anatomic landmarks. muscle
Thinner layer of subcutaneous fat than
dorsogluteal site. Gluteus maximus
Sufficient muscle mass for deep muscle Greater trochanter
of femur
IM/Z-track injections.
Readily accessible from several patient positions.
• Disadvantages of site:
Health professional’s unfamiliarity with site.
• Additional considerations:
Serves as alternative to dorsogluteal and vastus lateralis
for deep IM/Z-track injections.

Figure 24-21B Injection technique for ventrogluteal site, adult and pediatric (2 years and older).

iliac spine. Then spread your middle finger as Deltoid Muscle. The deltoid muscle is a small but
far from the index finger as possible. Place an adequate site for certain intramuscular injections.
x in the center of the triangle formed by the These intramuscular preparations include vac-
middle and index fingers to mark the correct cines, narcotics, sedatives, and vitamin prepara-
injection site. tions. The site should not be used for an infant. To
736 UNIT 6 Advanced Techniques and Procedures

locate the deltoid injection site, place your fingers Vastus Lateralis Site. The vastus lateralis is the pre-
on the shoulder and find the acromion (lateral ferred site for intramuscular injections in infants
triangular projection of the spine of the scapula and children. It is also used for intramuscular injec-
forming the point of the shoulder) and the del- tions in adults (Figure 24-21D). This site generally
toid tuberosity that lies lateral to the side of the accommodates the majority of intramuscular injec-
arm, opposite the axilla (Figure 24-21C). The cor- tions ordered and is a relatively safe site because the
rect injection site is 1 to 2 inches (about the width nerves and vessels supplying the area are not gener-
of three fingers) below the acromion. ally endangered. The vastus lateralis is a part of the
CAUTION: Do not inject medicine into the quadriceps femoris. The muscle is located on the
upper and lower aspects of the deltoid muscle. anterolateral aspect of the patient. For infants and
Care should be taken to avoid brachial and axillary children, the site lies below the greater trochanter
nerves and blood vessels, the radial nerve, acro- of the femur and within the upper lateral quadrant
mion, and the humerus. of the thigh (Figure 24-21E).

• Volume of drug administered:

Acromion
Usual 0.5 mL to 1.0 mL
Clavicle
• Needle sizes frequently used:
23G to 25G. 5⁄8 inch to 11⁄2 inches
• Acceptable patient positions: Deltoid muscle
Sitting, prone, supine, lateral Brachial artery
• Angle of injection: and vein
90° angle to the skin surface (or angled very slightly
upward toward acromion) Cephalic vein
• Advantages of site:
Humerus
Easily accessible.
General patient acceptance of site.

Figure 24-21C Injection technique for deltoid site, adult and pediatric (15 months and older).

• Volume of drug administered:

Usual 1.0 mL to 2.0 mL Femoral
• Needle sizes frequently used: nerve
20G to 23G. 11⁄4 inch to 1 1⁄2 inches Anterior
• Acceptable patient positions: superior
iliac spine
Supine, sitting
Tensor
• Angle of injection: fasciae
90° angle to the skin surface (for small or thin adults the latae muscle
technique used for pediatric injections may be prefer- Femoral
artery and
able) vein
• Advantages of site: Sartorius
Large muscle mass can tolerate relatively large quanti- muscle
ties of medication.
Surface area provides sufficient space for several injec-
tions.
Free of major nerves and vascular branches. Vastus
lateralis
muscle

Patella

Figure 24-21D Injection technique for vastus lateralis site, adult and pediatric (2 years and older).
 CHAPTER 24 Calculation of Medication Dosage and Medication Administration 737

• Volume of drug administered:

Usual < 0.5 mL (infants);
1.0 mL (pediatric) Anterior superior
iliac spine
• Needle sizes frequently used:
Greater trochanter
22G to 25G. 1⁄2 inch to 1 inch of femur
• Acceptable patient positions: Femoral artery and
Supine, sitting vein
• Angle of injection: Aponeurosis of vastus
lateralis muscle
45° angle to the frontal, sagittal, and horizontal planes of
the thigh (directed toward the knee) Femoral nerve
• Advantages of site:
Relatively large muscle mass at birth.
Suitable site for infants. Vastus lateralis
Surface area provides sufficient space for several muscle

injections.
Free of major nerves and vascular branches.

Patella

Figure 24-21E Injection technique for vastus lateralis site, pediatric (newborn to 2 years of age).

For the adult patient, the correct injection 8. Once the needle is inserted, gently pull back on
site is within the middle third of the muscle. the plunger (aspirate) to ensure that the needle is
not in a blood vessel.
BASIC GUIDELINES CAUTION: If blood appears in the syringe on aspi-
ration, smoothly withdraw the needle, properly dis-
FOR ADMINISTRATION card the used unit, and prepare another injection
OF INJECTIONS for administration. Repeat the preceding steps.
9. Slowly inject the medication into the patient.
Regardless of the type of injection, basic
guidelines must be followed to safeguard 10. With a quick, smooth motion, remove the needle
the patient. These guidelines are presented from the injection site. Immediately activate the
according to the sequence of the events to which safety mechanism and discard the syringe–needle
they relate: unit in a puncture-proof container. Cover the injec-
tion site with a dry, sterile cotton swab and gently
1. Adhere to the “Six Rights” of proper drug massage the site.
administration. CAUTION: Do not massage the site when adminis-
2. Always evaluate each patient as an individual. tering insulin, Imferon, or heparin.
3. Select a needle–syringe unit that is the appropriate 11. Remove the cotton swab and check for bleeding.
size for the proper administration of a parenteral If bleeding occurs after applying pressure for
medication. 30 seconds, apply a sterile adhesive strip to the
4. Correctly prepare the appropriate parenteral injection site.
equipment and supplies for use. Wash hands and 12. Remove gloves.
put on gloves. Always use OSHA guidelines and 13. Observe the patient for any signs of hypersensitiv-
follow standard precautions. ity. Take precautions to ensure the patient’s safety.
5. Select the correct site for the intended injection. 14. Properly and immediately discard the used equip-
6. Prepare the patient properly for the injection. ment and supplies.
7. For subcutaneous and intramuscular injections, 15. Wash hands.
use a smooth, quick, dartlike motion to insert the 16. Follow documentation procedures in patient’s
needle into the patient’s skin. Use the correct angle chart or electronic medical record, noting admin-
of insertion (45 or 90 degrees) for the injection. istration of the medication (Figure 24-22).
738 UNIT 6 Advanced Techniques and Procedures

Figure 24-22 Document all injections. This screen shows the medication documented in the patient’s electronic
medical record. (Synapse EHR screen shot courtesy of E. S. Butler).

17. Before releasing the patient, wait the appropriate is a good reference source for help in determining
amount of time and make sure the patient is given the correct route technique for injections.)
proper instructions and is not experiencing any The Z-track technique is similar to an intramus-
unusual effects. cular injection, except that the skin is pulled to the
18. Return medications to shelf/storage. side before needle insertion. This causes a displace-
ment of the tissues and the medication enters in a
Procedures 24-1 through 24-9 provide steps manner that will not allow it to seep back into the
as follows: subcutaneous tissues and up to the skin’s surface.
Because the medications are irritating, for the com-
• Procedure 24-1: Administration of Oral Medications
fort of the patient, change the needle on the syringe
• Procedure 24-2: Withdrawing Medication from after aspirating the medication from the ampule or
a Vial vial before injecting the patient with the medication
• Procedure 24-3: Withdrawing Medication from an (see Procedure 24-9).
Ampule
• Procedure 24-4: Administration of Subcutaneous,
Intramuscular, and Intradermal Injections
ADMINISTRATION
• Procedure 24-5: Administering a Subcutaneous OF ALLERGENIC EXTRACTS
Injection
It may be the responsibility of the medical assistant
• Procedure 24-6: Administering an Intramuscular
to administer allergenic extracts. It is important to
Injection
observe the following:
• Procedure 24-7: Administering an Intradermal
Injection of Purified Protein Derivative (PPD). • Allergic extracts are always given in subcutaneous
tissue, never in the muscle.
• Procedure 24-8: Reconstituting a Powder Medica-
tion for Administration • Use a tuberculin syringe with a 25G, 5⁄8-inch needle,
26G, 3⁄8-inch needle, or 27G, 1⁄2-inch needle or 1-mL
• Procedure 24-9: Z-Track Intramuscular Injection
allergist syringe (Figure 24-23).
Technique
• Use a site rotation system for each injected extract.
• Correctly document the procedure and dosage.
Z-TRACK METHOD • Allergenic extracts should be refrigerated; they
OF INTRAMUSCULAR should retain potency for 10 to 12 weeks.
INJECTION • Adverse reactions such as itching, swelling, and red-
ness should be reported immediately to the provider.
Imferon is an example of a medication that is • Severe reactions such as anaphylactic shock have
administered using the Z-track method. This medi- occurred; therefore, emergency equipment and
cation and others that are irritating to the subcuta- supplies must be available for use. Epinephrine
neous tissues and may discolor the skin are given in and Benadryl must be readily accessible. (See
this manner. (The Physician’s Desk Reference [PDR] Chapters 9 and 23 for emergency supplies.)
 CHAPTER 24 Calculation of Medication Dosage and Medication Administration 739

that contains a microcrystalline suspension of med-

ication. When activated, it produces a fine mist or
spray containing the medication. This suspension is
then drawn into the respiratory tract, settling deep
into the lungs and alveoli. See Chapter 18 for infor-
mation about pulmonary diseases and procedures.

Implications for Patient Care

Patients should be instructed to follow the pre-
scribed medication regimen. The prescribed
medicine and the type of inhaler to be used will
determine the method of administration. A hand-
held inhaler may be used for oral or nasal inha-
Figure 24-23 Allergist syringes. lation, depending on the type ordered by the
provider.
Inhalation therapy may be contraindicated
• Allergy testing is done when the provider is present. in patients with delicate fluid balance, cardiac
• Patient must wait 20 to 30 minutes after injection arrhythmias, status asthmaticus, and hypersensitiv-
to be certain there has been no reaction. ity to the medication. As with any medication, the
provider will determine the treatment regimen
Example: for each patient. See Chapter 18 for information
about pulmonary diseases and procedures.
Patient’s Name:
Date Dose Site
Administration of Oxygen
6/24/XX 1st 0.01 mL SC Lt. arm
6/27/XX 2nd 0.02 mL SC Rt. arm
Oxygen is a colorless, odorless, tasteless gas that is
essential for life. When the body does not have an
6/30/XX 3rd 0.03 mL SC Lt. arm
adequate supply of oxygen, a state of hypoxemia
(lack of oxygen in the blood) develops, and irre-
The patient should be observed for 20 to versible damage to vital organs is possible. When
30 minutes after the injection of an aller-
genic extract.
Susceptible individuals can experience devel-
opment of allergic reactions to many foreign sub- Patient Education
stances. It is wise for the patient with allergies to be
aware of those substances and others that are known • Patients should be advised to avoid over-
allergens. use of the inhaler. Tolerance, rebound
bronchospasm, and adverse cardiac
effects can occur from overuse. Instruct
ADMINISTRATION OF INHALED the patient to notify the provider should
MEDICATIONS the prescribed dose of medication fail to
produce the desired effect.
The act of drawing breath, vapor, or gas into the • Instruct the patient to perform good oral
lungs is known as inhalation. Inhalation therapy hygiene, including rinsing of the mouth
may involve the administration of medicines; water and mouthpiece of equipment, after the
vapor; and such gases as oxygen, carbon dioxide, inhalation treatment (to prevent the pos-
and helium. sible growth of fungi).
An inhaler may be used to deliver medications • Caution the patient against the contin-
to the lungs. Medications that use an inhaler include ued use of a metered-dose canister after
bronchodilators, mucolytic agents, and steroids. the stated number of actuations. If the
Inhalers are useful in the delivery of treatment for medication contains adrenaline, fatali-
chronic obstructive pulmonary disease (COPD) and ties can occur if heart rate and blood
reversible obstructive airway disease. An inhaler is a pressure increase significantly.
small, handheld apparatus, usually an aerosol unit,
740 UNIT 6 Advanced Techniques and Procedures

a lack of oxygen threatens a person’s survival, sup-

plemental oxygen must be prescribed and admin-
istered immediately, and arterial blood gas analysis Gauge
will be necessary after oxygen administration has
been started. If the situation is not an emergency
or life threatening, arterial blood gas analysis can
be performed before the provider prescribes the
dosage and method of administration. The normal
range for oxygen in the arterial blood is 80 to 100
mm Hg (millimeters mercury). Oxygen is supplied
Gauge
in tanks (Figure 24-24) for use in the ambulatory
care setting, but in a hospital setting, oxygen is Large
tank in
piped in through a wall pipe system. carrier

Dosage. When oxygen is to be administered, dos-

age is based on individual needs. Because oxygen
is a drug, the provider will prescribe the flow rate,
concentration, method of delivery, and length of
time for administration. Oxygen is ordered as liters
per minute (LPM) or L/min and as percentage of Small
portable
oxygen concentration (%). tank
It is the medical assistant’s responsibility to
follow provider orders and adhere to the guide-
lines for proper drug administration. Always assess
the patient as an individual, explain the proce-
dure, and carefully observe the patient for signs of
improvement or symptoms of oxygen toxicity.
CAUTION: Oxygen toxicity may develop Figure 24-24 Oxygen tanks. Note gauge at top of tanks.
when 100% oxygen is breathed for a prolonged
period. As with any other drug, toxicity depends
on dose, time, and the patient’s response. The which oxygen passes, and a strap or other device to
higher the dose, the shorter the time required to secure it to the patient’s head (Figure 24-26). Do not
develop toxicity. Symptoms of oxygen toxicity are place the direct flow of oxygen against the patient’s
substernal pain, nausea, vomiting, malaise, fatigue, nasal mucosa, because this causes tissue dehydra-
numbness, and a tingling of the extremities. tion. Flow rates greater than 2 to 4 L/min require
High concentrations of inhaled oxygen cause humidification.
alveolar collapse, intraalveolar hemorrhage, hyaline
membrane formation, disturbance of the central ner-
vous system, and retrolental fibroplasia in newborns.
NOTE: Apnea (absence of breathing) can
result when giving oxygen at a flow rate greater B
than 2 liters per minute to patients with COPD,
especially those with emphysema.

Methods of Oxygen Delivery. Many methods are

available today for the delivery of oxygen. The
more commonly prescribed methods include the
use of nasal cannulas, nasal catheters, and masks.
Other methods of delivery involve the use of iso-
lettes, hoods, and tents.

Nasal Cannula. When a low concentration of

oxygen is desired, the nasal cannula (Figure 24-25)
A
is the simplest and most convenient method for the
administration of oxygen. Made of plastic, the nasal
cannula consists of two hollow prongs through Figure 24-25 (A) Oxygen cannula. (B) Tubing.
 CHAPTER 24 Calculation of Medication Dosage and Medication Administration 741

Figure 24-26 Medical assistant adjusts nasal cannula Figure 24-27 Oxygen masks: (A) without tubing;
around patient’s ears for oxygen administration. (B) with tubing.

Nasal Catheter. The nasal catheter is a

disposable plastic tube that has small holes
at the inserted end. These holes diffuse the flow
of oxygen for better distribution to lung tissue
with minimum dehydration. The nasal catheter
is seldom used today because it causes mucous
membrane irritation and has to be changed
every 8 hours. Because of the discomfort caused
to the patient by the catheter, the nasal can-
nula is the preferred method for the delivery of
oxygen.

Mask. The common types of masks used for inha-

lation therapy include plastic disposable, partial
rebreather, nonrebreather, and Venturi (Figure
24-27). These devices are used when the patient
requires high humidity and a precise amount of
oxygen. To be effective, the mask must be fitted
snugly to the patient (Figure 24-28). Figure 24-28 Medical assistant adjusts oxygen mask
CAUTION: Oxygen must be humidified around patient’s head.
before delivery to the patient to prevent drying of
the respiratory mucosa.

Oxygen Safety Precautions. Oxygen sup-

ports combustion; thus, there is the dan-
ger of a fire being started when oxygen is Patient Education
in use. Extreme caution should be exercised when
oxygen is being administered because ignition can Explain safety measures to the patient who
be caused by friction, static electricity, or a lighted uses oxygen at home. Cigarettes, lighters,
cigar or cigarette. In the provider’s office, oxygen candles, and other smoking materials should
is generally stored in tanks. These tanks must be not be used in the room where oxygen is
checked on a regular basis and replaced as neces- used. Instruct the patient to wear nonstatic-
sary. See Chapter 18 for information about pulmo- producing clothing, such as cotton.
nary diseases and procedures.
742 UNIT 6 Advanced Techniques and Procedures

Procedure 24-1
Administration of Oral Medications
STANDARD PRECAUTIONS: 7. Compare the medication label with the medi-
cation note (first time). RATIONALE: Reading
from a medicine note helps prevent errors while
pouring the medication.
PURPOSE: 8. Check the expiration date. RATIONALE: Out-
Correctly administer an oral medication after receiv- dated medication may be deteriorated or altered
ing the provider’s order and assembling the necessary in some way and be harmful to the patient.
equipment and supplies. 9. Calculate dosage if necessary.
10. Correctly prepare (a, b, or c) (Figure 24-29B
EQUIPMENT/SUPPLIES:
and C).
Proper medication
Medication note a. Multiple-dose solid medication
Medicine cup b. Unit dose medication
Water, milk, or juice for patient
c. Liquid medication
PROCEDURE STEPS: 11. Compare medicine label with medication note
1. Verify the provider’s order. (second time).
2. Follow the “Six Rights” (Figure 24-29A). 12. Properly transport the medicine.
3. Perform medical asepsis handwash. 13. Identify the patient. Explain the procedure.
4. Work in a well-lighted, quiet, clean area. 14. Assess patient. Take vital signs if indicated.
5. Assemble equipment and supplies. RATIONALE: RATIONALE: Always assess the patient for body
A well-lighted area for preparing medications is size, physical condition, age, and gender to be
important because you must be able to see well certain the dose and route are appropriate prior
to accurately pour medications. A quiet area is to administration of certain medications. BP or
free from distractions, and medical asepsis helps pulse may need to be taken to ascertain if the
fight transmission of microorganisms. vital signs are within normal limits.
6. Obtain the correct medication using the medi- 15. Assist patient to a comfortable position.
cine note. 16. Check medication label a third time.

A B C

Figure 24-29 (A) Medical assistant checks for right drug, right dose, right route, and expiration date before
pouring medication. (B) Medical assistant pours capsules from the cover of the medicine container into a medi-
cine cup before administering medicine to patient. The medication is poured into cover to avoid contamination
of medicine. (C) Medical assistant administers the medication, being certain that patient takes the medicine.

continues
 CHAPTER 24 Calculation of Medication Dosage and Medication Administration 743

Procedure 24-1 (continued)

17. Administer the medication. Provide water. Be 19. Care for equipment and supplies according to
certain that the patient takes the medicine. OSHA guidelines.
RATIONALE: Some patients, for various reasons, 20. Document administration of the medication
may deliberately not swallow their medication. in patient’s chart or electronic medical record.
18. Provide for the patient’s safety: Observe the (Figure 24-29D and 24-29E).
patient for any adverse reactions. 21. Return the medication to the shelf/storage area.

Figure 24-29 (continued) (D) Example of medication administration record for patient’s chart.

continues
744 UNIT 6 Advanced Techniques and Procedures

Procedure 24-1 (continued)

Figure 24-29 (continued) (E) The computer makes a graph when the appropriate patient data is input. The
patient’s white blood cell count (WBC), temperature (in Celsius), and antibiotic (Vancomycin) are shown. The
patient has an infection, and the computer-generated graphic shows the patient’s response to the antibiotic.
The WBC and temperature climb over a period of 4 days, then began to drop in response to the antibiotic.
The provider has access to the information on demand.

Procedure 24-2
Withdrawing Medication from a Vial
STANDARD PRECAUTIONS: 5. Remove the metal or plastic cap from the vial.
If the vial has been opened previously, clean the
rubber stopper by applying an alcohol wipe in a
circular motion (Figure 24-30A).
PURPOSE: 6. Remove the needle cover by pulling it straight off.
Medication is supplied in a variety of packaging. Med- 7. Inject air into the vial as follows:
ication from a vial must be drawn into a syringe for a. Hold the syringe pointed upward at eye level.
parenteral injection. Pull back the plunger to take in a quantity
of air that is equal to the ordered dose of
EQUIPMENT/SUPPLIES:
medication.
Medication order Vial of medication
Medication note Alcohol wipes b. Leave vial on tabletop/countertop.
Appropriate syringe Disposable gloves c. Insert the needle through center of the rub-
and needle with cover Sharps container ber stopper of the vial. Inject the air by push-
ing in the plunger (Figure 24-30B).
PROCEDURE STEPS:
1. Read the medication order and assemble equip- 8. Invert the vial. Hold the vial and the syringe
ment. Check for the “Six Rights.” Read the vial steady. Pull back on the plunger to withdraw the
label by holding it next to the medicine card measured dose of medication. Measure accu-
(first time). rately. Keep the tip of the needle below the surface
of the liquid; otherwise, air will enter the syringe.
2. Wash hands. Apply gloves.
Keep syringe at eye level (Figure 24-30C).
3. Select the proper size needle and syringe for the
9. Check the syringe for air bubbles. Remove them
medication and the route (e.g., for subcutane-
by tapping sharply on the syringe. Push the
ous injection of insulin, 100-U insulin syringe
air bubbles back into the vial (Figure 24-30D).
and 25G, 5⁄8-inch needle). If necessary, attach the
Check measurement for accuracy, and draw
needle to the syringe.
more medication if needed.
4. Check the vial label against the medication note
10. Remove the needle from the vial. Replace the
(second time).
sterile needle cover (Figure 24-30E) using “scoop”

continues
 CHAPTER 24 Calculation of Medication Dosage and Medication Administration 745

Procedure 24-2 (continued)

A B

C D E

Figure 24-30 (A) Disinfect the rubber stopper on the medication vial with an alcohol wipe. (B) Keeping
the bevel of the needle above the fluid level, inject an amount of air equal to medication quantity to be with-
drawn. (C) Hold syringe pointed upward at eye level and with the bevel of the needle in the medication. Pull
back plunger and aspirate the quantity to be withdrawn. (C) Hold syringe pointed upward at eye level and
with the bevel of the needle in the medication. Pull back plunger and aspirate the quantity of medication
ordered. (D) Tap syringe to eliminate air bubbles. Hand should hold syringe while tapping it. (E) After the
correct dose has been withdrawn, recover the sterile needle using “scoop” method. Place medicine on a tray
with medication note, the medication vial, and an alcohol wipe and safely transport to the patient.

method. RATIONALE: The needle cover can be 13. If medication is a tissue irritant, change to another
replaced because it is sterile and has not been sterile needle. RATIONALE: Tissue irritants can
used on a patient. cause tissue necrosis. Activate safety mechanism.
11. Check the vial label against the medication note 14. Immediately after the injection, activate the
(third time). safety mechanism. Discard the syringe-needle
unit into a sharps container.
12. Place the filled syringe and medication vial on a
medicine tray with an alcohol wipe and the medi- 15. Remove gloves and dispose in biohazard waste
cation note. The dose is now ready for injection. container.

continues
746 UNIT 6 Advanced Techniques and Procedures

Procedure 24-2 (continued)

16. Wash hands. DOCUMENTATION

17. Document procedure in patient’s chart or elec- 8/9/20XX 2:30 PM Vitamin B12 (Cyanocobalamin) 100 mcg
tronic medical record. IM (R) deltoid area. W. Slawson, CMA (AAMA) __________
18. Return the vial to the proper storage area.
Destroy medication note.

Procedure 24-3
Withdrawing Medication from an Ampule
STANDARD PRECAUTIONS: cation remains trapped above the neck in the
top of the ampule, some medication will not be
available for use and it is possible to give an incor-
rect dose, especially if the patient is to receive the
entire contents of the ampule.
PURPOSE:
Medication is supplied in a variety of packaging. An 5. Thoroughly disinfect the neck with an alcohol
ampule is a sterile, glass, single-dose container of liquid swab. Check label (second time). RATIONALE:
medication. It is aspirated into a syringe for injection. The needle will enter the opening of the ampule
and wiping the neck of the ampule before
EQUIPMENT/SUPPLIES: removal of the top ensures disinfection of the
Medicine tray and medication note neck or opening of the ampule.
Ampule of medication 6. With a sterile gauze, wipe dry the neck of
Alcohol wipes the ampule. Completely surround the ampule
Sterile gauze sponges with the gauze and forcefully snap off the top of
Sharps container the ampule by pulling the top toward you
Sterile filter needle and syringe (Figure 24-31B). RATIONALE: Ensure medical
Gloves assistant safety from possible injury from bro-
ken glass. Discard top in sharps container.
PROCEDURE STEPS:
1. Check the provider’s order. Write out medica- 7. Place opened ampule down on medicine tray.
tion note. Check label (third time).
2. Wash hands and gather equipment. Put on 8. With a prepared sterile syringe-needle unit that
gloves. has a filter on the needle, aspirate the required
dose into the syringe (Figure 24-31C). Cover
3. Select ampule of medication. Read label and needle with sheath using scoop method and
check medication note for correct medication, transport it with medication ampule to patient
dose, route, and time (first time). Check medica- on the medicine tray. RATIONALE: Filtered
tion expiration date. needles prevent glass particles from being aspi-
4. Flick ampule of medication (medication will often rated with medication.
get “trapped” above the neck of the ampule). A a. There is another method used to aspirate
sharp flick of the wrist will help force all of the the contents of an ampule. The needle and
medication down below the neck of the ampule syringe unit can be inserted into the open
into the body of the ampule (Figure 24-31A). ampule and then inverted. The medication
RATIONALE: This is important to ensure all can be drawn into the syringe because sur-
medication is available in the body of the ampule face tension prevents the medication from
to calculate the correct dose. If some of the medi- leaking out of the ampule.

continues
 CHAPTER 24 Calculation of Medication Dosage and Medication Administration 747

Procedure 24-3 (continued)

A B C

Figure 24-31 (A) Hold ampule by the top and force all the medication into the bottom of the ampule by
a snap of the arm and wrist. (B) Remove top from ampule. Snap away from you by pulling top toward you.
(C) Draw the required dose into syringe.

9. Change needles. RATIONALE: The filter needle 14. Wash hands.

may contain glass particles. 15. Document procedure in patient’s chart or
10. Identify the patient. electronic medical record. Destroy medication
11. Administer medication. note.
12. Discard syringe–needle unit into sharps con- DOCUMENTATION
tainer. Alcohol wipes and gauze are discarded in
5/12/20XX 11:20 AM Phenergan 25 mg IM (R) dorsogluteal
biohazard waste container if there is any blood
area. B. Abbott, RMA ______________________________
on them.
13. Remove gloves and dispose in biohazard waste con-
tainer. Dispose of ampule into sharps container.

Procedure 24-4
Administration of Subcutaneous, Intramuscular, and Intradermal Injections
STANDARD PRECAUTIONS: EQUIPMENT/SUPPLIES:
Medicine tray
Medication as ordered by the provider and medication
note
Appropriately sized needle and syringe
PURPOSE:
Alcohol wipes
To properly administer subcutaneous, intramuscular,
Disposable gloves
and intradermal injections.
Sharps container
Cotton ball

continues
748 UNIT 6 Advanced Techniques and Procedures

Procedure 24-4 (continued)

PROCEDURE STEPS: 15. Identify the patient. Explain the procedure.

1. Verify the provider’s order. Write out medication 16. Assess the patient. Put on gloves.
note taking information from provider’s order
17. Prepare the patient for the injection (drape,
sheet from patient record.
position, allay apprehension).
2. Follow the “Six Rights.”
18. Select an appropriate injection site. Follow a
3. Perform medical asepsis hand cleansing. Adhere rotating schedule if appropriate.
to OSHA guidelines.
19. Cleanse the injection site with a sterile alcohol
4. Work in a well-lighted, quiet, clean area. wipe. Use a circular motion, working from the
5. Select the appropriate syringe and needle and center out to about 2 inches beyond the planned
alcohol wipe. injection site.
6. Select the correct medication. 20. Allow the skin to dry.
7. Compare the medication label with the medica- 21. Inject medication after first aspirating to be cer-
tion note (first time). tain needle is not in a blood vessel (except for
intradermal injection). Immediately activate
8. Check expiration date on medicine.
safety mechanism and dispose of syringe and
9. Calculate dosage, if necessary. needle in a puncture-proof container.
10. Prepare syringe and needle for use (Figure 22. Massage injection site with an alcohol wipe
24-32A–D). unless contraindicated (such as insulin, Imferon,
11. Withdraw medication from vial. heparin).
12. Compare medicine label with the medication 23. Observe the patient for signs of difficulty.
note (second time). 24. Inspect the injection site for bleeding, apply
13. Place filled syringe and needle on the medi- adhesive strip if necessary.
cine tray with medication note and vial. Check 25. Properly dispose of used equipment and sup-
the medication label with the medicine note plies. Remove gloves.
(third time).
26. Perform medical asepsis handwash.
14. Transport the medicine to the patient with medi-
cation note.

A B C

Figure 24-32 Preparing syringe–needle unit for use. (A) Assemble the equipment and supplies needed to
draw up medication from a vial. (B) Open the sterile syringe and needle from packages. (C) Secure the needle
by twisting it clockwise.

continues
 CHAPTER 24 Calculation of Medication Dosage and Medication Administration 749

Procedure 24-4 (continued)

27. Correctly document procedure in patient’s chart

or electronic medical record. Return the vial to
storage. Destroy medication note.
Procedure to follow should the medical
assistant sustain an accidental needle-
stick after the injection:
• Thoroughly wash the site where the stick
occurred.
• Cleanse the skin with an antiseptic.
• Report the incident to your supervisor and
manager.
• Document the incident and retain a copy for
yourself.
D
• Obtain medical attention. Be tested for hepatitis B
Figure 24-32 (Continued)(D) Pull the plunger to and C viruses and HIV.
check for ease of gliding operation. • Fill out appropriate OSHA paperwork (200
form).

Procedure 24-5
Administering a Subcutaneous Injection
STANDARD PRECAUTIONS: 4. Work in a well-lighted, quiet, clean area.
5. Select the appropriate equipment and supplies.
6. Select the correct medication.
7. Compare the medication label with the medica-
PURPOSE: tion note (first time).
Correctly administer a subcutaneous injection after
checking the provider’s order and assembling the 8. Check expiration date on medicine.
necessary equipment and supplies. 9. Calculate dosage, if necessary.
10. Correctly prepare the parenteral medication.
EQUIPMENT/SUPPLIES:
Medication ordered Alcohol wipes 11. Compare medication label with the medication
by provider Gloves note (second time).
Medication note Sharps container 12. Correctly transport the medicine to the patient
Appropriately sized Adhesive strip on the tray, with the vial and medication
needle and syringe Medicine tray note.

PROCEDURE STEPS: 13. Identify the patient. Explain the procedure.

1. Verify the provider’s order. Write out a medica- 14. Assess the patient. Put on gloves.
tion note. 15. Prepare the patient for the injection (drape,
2. Follow the “Six Rights.” position, allay apprehension).
3. Perform medical asepsis handwash. Adhere to 16. Check syringe with the medication note (third
OSHA guidelines. time).

continues
750 UNIT 6 Advanced Techniques and Procedures

Procedure 24-5 (continued)

17. Select an appropriate injection site.

18. Correctly cleanse the site with an alcohol wipe
using a circular motion starting with the injec-
tion site and moving outward to a 2-inch diam-
eter. Allow skin to dry.
19. Remove needle guard.
20. Grasp skin to form a 1-inch fold.
21. Insert needle quickly at a 45-degree angle
(Figure 24-33).
22. Aspirate to be certain needle is not in a blood
vessel.
23. Slowly inject the medicine.
24. Quickly remove the needle and syringe and acti-
vate the safety mechanism. Release the skin.
25. Immediately dispose of needle and syringe in a
sharps container.
26. Cover site. Massage (unless contraindicated as
with insulin, Imferon, and heparin).
27. Provide for patient’s safety.
28. Properly dispose of used supplies. Remove Figure 24-33 Insert needle at 45-degree angle into
gloves and wash hands. Return medication vial upper arm.
to storage.
29. Document procedure in patient’s chart or elec- DOCUMENTATION
tronic medical record. Destroy the medication 12/16/20XX 10:00 AM Sandostatin 100 mcg subcutaneously
note. (L) deltoid. S. Jones, CMA (AAMA) ____________________

Procedure 24-6
Administering an Intramuscular Injection
STANDARD PRECAUTIONS: EQUIPMENT/SUPPLIES:
Medication ordered by provider with medication
note
Appropriately sized needle and syringe
Alcohol wipes
PURPOSE:
Gloves
Correctly administer an intramuscular injection after
Sharps container
receiving a provider’s order and assembling the nec-
Medicine tray
essary equipment and supplies.
Adhesive strip

continues
 CHAPTER 24 Calculation of Medication Dosage and Medication Administration 751

Procedure 24-6 (continued)

PROCEDURE STEPS:
1. Verify the provider’s order. Write out a medica-
tion note.
2. Follow the “Six Rights.”
3. Perform medical asepsis handwash. Adhere to
OSHA guidelines.
4. Work in a well-lighted, quiet, clean area.
5. Obtain the appropriate equipment and sup-
plies.
6. Obtain the correct medication.
7. Compare the medication label with the medica-
tion note (first time).
8. Check expiration date.
9. Calculate dosage, if necessary.
10. Correctly prepare the parenteral medication.
11. Compare medicine label with the medication
note (second time). Figure 24-34 Using deltoid muscle, insert needle to
12. Transport the medicine to the patient on tray, the hub at a 90-degree angle.
with the vial.
13. Identify the patient. Explain the procedure. 25. Quickly remove the needle and syringe and acti-
14. Assess the patient. Put on gloves. vate safety mechanism.
15. Prepare the patient for the injection (drape, 26. Immediately dispose of needle and syringe in a
position, allay apprehension). sharps container.
16. Compare the medication note with the medica- 27. Cover site. Massage (unless contraindicated as
tion (third time). with insulin, Imferon, and heparin).
17. Select an appropriate injection site. 28. Dispose of equipment. Remove gloves.
18. Correctly cleanse the site with an alcohol wipe 29. Wash hands.
using a circular motion and covering a 2-inch 30. Observe the patient for signs of difficulty.
diameter. Allow the skin to dry.
31. Provide for patient’s safety. Return medication
19. Remove needle guard. vial to storage.
20. Stretch the skin taut, pulling it tight. 32. Document procedure in patient’s chart or elec-
21. Using a dartlike motion, insert needle to the hub tronic medical record. Destroy the medication
at a 90-degree angle (Figure 24-34). note.
22. Release the skin.
DOCUMENTATION
23. Aspirate to check for blood.
12/16/20XX 10:00 AM Demerol 75 mg IM (L) deltoid.
24. Slowly inject the medication. S. Jones, CMA (AAMA) ____________________________
752 UNIT 6 Advanced Techniques and Procedures

Procedure 24-7
Administering an Intradermal Injection of Purified Protein Derivative (PPD)
STANDARD PRECAUTIONS: 8. Check expiration date.
9. Calculate dosage, if necessary.
10. Correctly prepare the parenteral medication.
11. Compare medication label with the medication
PURPOSE: note (second time).
Correctly administer an intradermal injection of PPD
after receiving a provider’s order and assembling the 12. Correctly transport the medication to the patient
necessary equipment and supplies. on tray with medication vial.
13. Identify the patient. Explain the procedure.
EQUIPMENT/SUPPLIES:
14. Assess the patient. Put on gloves.
Medication as ordered by provider with medication
note 15. Prepare the patient for the injection (drape,
Appropriately sized needle and syringe position, allay apprehension).
Alcohol wipes 16. Check medication note with medication (third
Disposable gloves time).
Sharps container 17. Select an appropriate injection site (see Figure
Medicine tray 24-19B).
Adhesive strip
18. Correctly cleanse the site with an alcohol wipe
PROCEDURE STEPS: using a circular motion and covering a 2-inch
1. Verify the provider’s order. Write out a medica- diameter. Allow the skin to dry (Figure 24-35A).
tion note. 19. Remove needle guard.
2. Follow the “Six Rights.” 20. Pull the skin tissue taut.
3. Perform medical asepsis handwash. Adhere to 21. Carefully insert the needle at a 10–15-degree
OSHA guidelines. angle, bevel upward to about 1⁄8 inch (Figure
4. Work in a well-lighted, quiet, clean area. 24-35B). Do not aspirate. Release skin.
5. Organize the appropriate equipment and 22. Steadily inject PPD to form a wheal (Figure
supplies. 24-35C).
6. Select the correct medication (PPD). 23. Correctly remove the needle after a brief delay.
7. Compare the medication label with the medica- RATIONALE: Minimizes leakage.
tion note (first time). 24. Activate safety mechanism.

A B C

Figure 24-35 (A) Cleanse the injection site with alcohol and allow area to air-dry. (B) Insert the needle at a
10 to 15–degree angle, bevel upward about 1⁄8 inch. (C) Steadily inject the medicine, allowing a wheal to form.

continues
 CHAPTER 24 Calculation of Medication Dosage and Medication Administration 753

Procedure 24-7 (continued)

25. Immediately dispose of needle and syringe in a 32. The injected area should be read in 48 to 72 hours
sharps container. for the amount of induration (hardness) to deter-
26. Blot site. Do not massage. Remove gloves. mine tuberculosis exposure. Measure the indura-
tion. If injection area is hardened and elevated
27. Wash hands. 10 mm or larger, the test is positive and the pro-
28. Observe the patient for signs of difficulty. vider should be notified.
29. Provide for patient’s safety.
DOCUMENTATION
30. Caution patient not to rub wheal.
10/14/20XX 10:00 AM 0.1 mL PPD intradermallY (L) forearm.
31. Return vial to storage and document procedure Pt given appointment to return 10/16/20XX to have PPT read.
in patient’s chart or electronic medical record. S. Jones, CMA (AAMA) ____________________________
Destroy the medication note.

Procedure 24-8
Reconstituting a Powder Medication for Administration
STANDARD PRECAUTIONS: amount of air in it equal to the amount of dilu-
ent to be withdrawn (Figure 24-36B).
4. Withdraw the appropriate amount of diluent
to be added to the powder medication (Figure
PURPOSE: 24-36C).
Drugs for injection may be supplied in a powdered 5. Inject the diluent into the powder medication
(dry) form and must be reconstituted to a liquid for vial (Figure 24-36D).
injection. A diluent (usually sterile water) is added to 6. Remove needle from vial and discard into sharps
the powder, mixed well, and the appropriate dose is container (Figure 24-36E).
drawn up to be administered.
7. Roll the vial between the palms of the hands to
EQUIPMENT/SUPPLIES: completely mix together the powder and dilu-
Medication as ordered by the provider and medication ent (Figure 24-36F). Label the multiple-dose vial
note with the dilution or strength of the medication
Diluent prepared, the date and time, your initials, and
Two appropriately sized needles and syringes the expiration date.
Alcohol wipes 8. With a second sterile needle and syringe, with-
Disposable gloves draw the desired amount of medication (Figure
Sharps container 24-36G).
PROCEDURE STEPS: 9. Flick away any air bubbles that cling to side of
1. Prepare the needle–syringe unit in preparation syringe (Figure 24-36H).
for reconstituting powder medication. 10. The medicine tray with reconstituted medica-
2. Remove tops from diluent and powder medica- tion and medication note are ready for transport
tion containers and wipe with alcohol swabs to the patient.
(Figure 24-36A). 11. Proceed as in Steps 11 to 32 of Procedure 24-6,
3. Insert the needle through the rubber stopper on Administering an Intramuscular Injection.
the vial of diluent. The syringe should have an

continues
754 UNIT 6 Advanced Techniques and Procedures

Procedure 24-8 (continued)

A B C D

E F G H

Figure 24-36 (A) Remove top from diluent and powdered medication. Wipe top of each with an alcohol
wipe. (B) Inject air in an equal amount to diluent being removed from the vial. (C) Prepare to remove the
needle from the vial after withdrawing diluent. (D) Inject diluent into vial containing powdered medication.
(E) Discard safety needle–syringe unit. (F) Roll vial of solution medication between palms of hands to mix
well. Label vial with date, amount of diluent added, strength of dilution, time mixed, and your initials. (G) Use
a second sterile needle–syringe unit to draw the prescribed dose of medication ordered by the provider. (H)
Flick away any air bubbles that cling to the side of the syringe. Withdraw more medication if needed. Labeled,
reconstituted medication will be taken to the room with the syringe and placed on the shelf or in the refrigera-
tor according to the manufacturer’s instructions after the injection is given.
 Procedure 24-9
Z-Track Intramuscular Injection Technique
STANDARD PRECAUTIONS: 20. Pull the skin laterally 11⁄2 inch away from the
injection site. RATIONALE: Prevents medica-
tion from leaking.
21. Insert needle quickly, using a dartlike motion
PURPOSE: at a 90-degree angle. Maintain Z position
Correctly administer a Z-track intramuscular injection (Figure 24-37).
after receiving a provider’s order and assembling the 22. Aspirate to check for blood.
necessary equipment and supplies. 23. Slowly inject medication.
EQUIPMENT/SUPPLIES: 24. Wait 10 seconds before removing needle to allow
Medication ordered by provider and medication note medication to begin to be absorbed.
Appropriately sized needle and syringe 25. Remove needle and syringe at same angle of
Alcohol wipes insertion.
Disposable gloves 26. Immediately release traction of the Z position to
Sharps container seal off the needle track. This prevents medica-
Medicine tray tion from reaching the subcutaneous tissues and
Adhesive strip the surface of the skin.
PROCEDURE STEPS: 27. Immediately activate safety mechanism and
1. Verify the provider’s order. Write out a medica- dispose of needle–syringe unit in a sharps con-
tion note. tainer.
2. Follow the “Six Rights.” 28. Cover site. Do not massage.
3. Perform medical asepsis hand cleansing. Adhere 29. Remove gloves. Wash hands.
to OSHA guidelines. 30. Observe patient for signs of difficulty.
4. Work in a well-lighted, quiet, clean area. 31. Provide for patient safety.
5. Organize the appropriate equipment and supplies. 32. Return medication vial to storage.
6. Select the correct medication. 33. Document procedure in patient’s chart or elec-
7. Compare the medication label with the medica- tronic medical record.
tion note (first time).
DOCUMENTATION
8. Check expiration date.
12/01/20XX 2:00 PM Interferon 1,000,000 International
9. Calculate dosage, if necessary. units IM (R) Dorsogluteal muscle using Z-track technique.
10. Correctly prepare the parenteral medication. J. Guerro, CMA (AAMA) ___________________________
11. Compare medicine label with the medication
note (second time).
12. Correctly transport the medicine to the patient.
13. Identify the patient. Explain the procedure.
Skin pulled taut Skin released
14. Assess the patient. Put on gloves.
15. Prepare the patient for the injection (drape,
position, allay apprehension).
16. Recheck medication note with the order and the
syringe (third time).
17. Select an appropriate injection site.
18. Correctly cleanse the site with an alcohol wipe
Figure 24-37 With client supine, grasp and pull the
using a circular motion and covering a 6-inch
muscle laterally before injecting medication. Inject med-
diameter. Allow the skin to dry.
ication. Keep skin pulled taut for 10 seconds. Quickly
19. Remove needle guard. withdraw the needle and release the skin to seal the site.
756 UNIT 6 Advanced Techniques and Procedures

Case Study 24-1

Refer to the scenario at the beginning of the chapter.

CASE STUDY REVIEW

1. Explain the consequences of preparing and 2. Is it possible under normal circumstances to com-
administering a medication without a medicine mit to memory the medication, dose, route, patient,
card. and documentation?

Case Study 24-2

Abigail Johnson, a patient of Dr. Lewis, has been unable to CASE STUDY REVIEW
keep her type 2 noninsulin-dependent diabetes mellitus
under control with oral hypoglycemics, and Dr. Lewis has 1. What size insulin syringe should be used?
decided that Abigail needs to begin to take insulin injections. 2. What does the medication label state are the num-
Today in the clinic, her fasting blood glucose level is 190 mg/ ber of units per milliliter? Show how to calculate
mL. Dr. Lewis prescribes Humulin® insulin 10 units subcuta- the correct dosage.
neously stat. 3. Discuss the route of administration and the specif-
ics about insulin administration that require it to be
given slightly differently from other subcutaneous
injections.
4. Describe several topics of discussion in which you
would engage Abigail to help her learn how to bet-
ter control her disease.

Case Study 24-3

Alice Chambers weighs 28 pounds and is 33 inches tall. CASE STUDY REVIEW
The adult dose of erythromycin is 400 mg every 6 hours by
mouth. 1. Calculate the dose of erythromycin Alice needs.
2. If the provider ordered erythromycin by injection
rather than by mouth, how would the dose be cal-
culated if the erythromycin adult dose is 400 mg/
mL?
3. What size needle and syringe are appropriate for
giving Alice the injection?

SUMMARY
Administering medications is one of the most important and essential responsibilities that the medical
assistant performs. This chapter reviewed of some of the fundamental elements of pharmacology, dosage
calculations, and medication administration.
Each state has enacted laws governing the practice of medicine, nursing, and pharmacy. These laws vary
from state to state; therefore, it is essential that medical assistants become familiar with the laws of the state in
which they are employed before administering any medication.
Under the law, those administering medications are expected to be knowledgeable about the drugs
that they administer and the effects the drug may or will have on the patient. They are responsible for their
own actions.
 CHAPTER 24 Calculation of Medication Dosage and Medication Administration 757

STUDY FOR SUCCESS

To reinforce your knowledge and skills of information presented in this chapter:
• Review the Key Terms
• Practice the Procedures
• Consider the Case Studies and discuss your conclusions
• Answer the Review Questions

˚ Multiple Choice
˚ Critical Thinking
• Navigate the Internet by completing the Web Activities
• Practice the StudyWARE activities on your student CD
• Apply your knowledge in the Student Workbook activities
• Complete the Web Tutor sections
• View and discuss the DVD situations

REVIEW QUESTIONS
Multiple Choice Critical Thinking
1. A written legal document that gives directions for 1. Describe the process to follow to determine the
compounding, dispensing, and administering med- state law regarding a medical assistant administer-
ication to a patient is a: ing medications.
a. medication note 2. What is a medication order? Describe its purpose.
b. prescription 3. List nine parts of a prescription and define each
c. medication order part.
d. subscription 4. Name and describe factors that can affect medica-
2. An abbreviation symbol that means nothing by tion dosage. Explain why and how the dosage is
mouth is: affected.
a. non rep 5. List the fundamental units of the metric system.
b. NPO 6. Name two methods used to calculate children’s
c. IM dosages of medication.
d. mm 7. List and describe the “Six Rights.”
3. Insulin-dependent diabetes mellitus is: 8. A fellow student tells you that she accidentally gave
a. Type 1 a patient the incorrect dose of medication. Explain
b. Type 2 in detail what should be done.
c. Type 3 9. You accidentally stick yourself with a used needle.
d. Type 4 What are the steps to take?
4. Body surface area is used: 10. Discuss allergenic extracts. What are they? What
a. when calculating children’s dosages safeguards are needed after administration?
b. when calculating adult dosages 11. List two reasons for the provider to prescribe
c. when determining an injection site oxygen for a patient. Describe how oxygen is
d. when selecting an appropriately sized needle administered and oxygen safety.
5. An injection given just below the surface of the skin
at a 15-degree angle is called a(n):
a. intramuscular injection
b. intradermal injection
c. subcutaneous injection
d. parenteral injection
758 UNIT 6 Advanced Techniques and Procedures

Calculation Problems WEB ACTIVITIES

1. Calculate the following dosages according to body
1. Search for a Web site to explore the various
surface area (BSA):
types of safety needles available for injec-
If the adult dose of E.E.S. tabs is 400 mg every
tion and venipuncture. What is the most
6 hours, what is the dosage for a child who is
recent ruling by OSHA in regard to these
35 inches tall and weighs 28 pounds (BSA 0.57)?
types of needles?
If the adult dose of penicillin V potassium, USP,
2. Check the Web site http://www.cerner.com and
is 250 mg every 6 to 8 hours, what is the dosage for
search for the following:
a child who is 24 inches tall and weighs 35 pounds
a. What is the most common medication error?
(BSA 0.56)?
2. Calculate the following dosages according to kilo- b. Which group of medical professionals makes the
gram of body weight: most medication errors?
The provider orders Augmentin 20 mg/kg/day c. How can medication errors be prevented?
for Sally Whitney, who weighs 72 pounds. The dose
is to be divided and given every 8 hours. What is the
total dose? What is the amount to be given every REFERENCES/BIBLIOGRAPHY
8 hours? Centers for Disease Control and Prevention, Division of
The provider orders Cefadyl 40 mg/kg for Health Care Quality Promotion (2004, February).
George Kipperley, who weighs 78 pounds. The dose Workbook for designing, implementing, and evaluating
is to be divided into four equal doses. What is the a sharps injury prevention program. Retrieved August
total dose? What is the amount to be given in four 9, 2004, from http://cdc.gov/sharpsafety/wk_info.
equal doses? html.
The provider orders Garamycin 2.0 mg/kg every Centers for Disease Control and Prevention. (2006).
8 hours for a child who weighs 86 pounds. What is Health care workers and regulations regarding safety
the correct dosage? needles. Retrieved October 15, 2008, from http://
3. The provider ordered 64 units of U-100 Humulin www.cdc.gov/features/medicationsafety.
insulin. Shade the correct dosage on the U-100 Josephson, D. (2004). Intravenous infusion therapy for
syringe pictured. nurses principle and practice. (2nd ed.). Clifton Park,
NY: Delmar Cengage Learning.
UNITS

Keir, L., Wise, B., Krebs, C., & Kelley-Arney, C. (2008).

100

90
80
70
60
50
40
30
20
10

Medical assisting administrative and clinical com-

petencies (6th ed.). Clifton Park, NY: Delmar
Cengage Learning.
Using the proportional or formula method, calculate the Prescription for drug safety. (2003, March). Consumer
following dosages. Reports on Health, 15(3), 1, 4–6.
4. The provider orders 125 mg of Diamox. On hand Rice, J., (2006). Principles of pharmacology for medical
you have 250-mg tablets. You will give ____ tablets assisting (4th ed.). Clifton Park, NY: Delmar
to your patient. Cengage Learning.
5. The provider orders 250 mg of Tagamet liquid. On Spratto, G., & Woods, A. (2009). Delmar Nurse’s Drug
hand you have 300 mg/5 mL. How many milliliters Handbook 2009 Edition. Clifton Park, NY: Delmar
will you give? Cengage Learning.
Taber’s cyclopedic medical dictionary (22nd ed.). (2005).
Philadelphia: F. A. Davis.
To the point. (2004, August 2). Advance for nursing
serving RN’s in New England, 4(17), 30–31.
 CHAPTER 24 Calculation of Medication Dosage and Medication Administration 759

THE DVD HOOK-UP

This chapter discussed the medical assistant’s role in pre- 2. The medical assistant in the DVD program allowed the
scription writing, administering nonparenteral medications, alcohol to dry before administering the injection. Is this
and administering parenteral medications. acceptable with your teacher? What is the purpose of
In one of the first scenes in Program 9, the provider gave allowing the alcohol to dry before injecting the patient?
Tyrah verbal medication orders for two separate patients.
In cases where the provider dictates his or her notes, he or DVD Journal Summary
she may not have anything written in the chart so he or she Write a paragraph that summarizes what you learned from
may give a verbal order to save time. watching today’s DVD programs. Making a medication error
could result in a negative reaction or even death to the
1. What did Tyrah do as soon as the provider gave her the patient. Write a paragraph that will reassure your instructors
verbal orders? that you will be cautious when drawing up and administer-
2. You will notice that the provider used common pre- ing medications.
scription abbreviations when talking to Tyrah. Do
you think that was wise? What are some of the
abbreviations that the provider used that are no
longer considered acceptable with certain govern-
mental agencies?
3. What did you think of Tyrah’s nails when she demon-
strated the inhaler?
4. Do you think there was a more sanitary way of dem-
onstrating the inhaler instead of using the patient’s DVD Series Program Number
inhaler? Should Tyrah have observed Mrs. Edmonson Skills Based Series 9
Skills Based Series 10
when she practiced her inhaler?
Chapter/Scene Reference
You will notice that the book illustrates the medical assis- • Entire program
tant wearing gloves when withdrawing medications; how-
ever, Program 10 of the DVD program showed the medical
assistant without gloves drawing up medication.
1. Why might it be a bit more sanitary to wear gloves
when drawing up medications?
Chapter

25 Electrocardiography

OUTLINE KEY TERMS

Anatomy of the Heart Standardization and Adjustment Amplified
Electrical Conduction System of of the Electrocardiograph Amplitude
the Heart Standard Resting Angiogram
The Cardiac Cycle and the ECG Electrocardiography Arrhythmia
Cycle Mounting the ECG Tracing
Artifact
Calculation of Heart Rate on Interference or Artifacts
Augment
ECG Graph Paper Somatic Tremor Artifacts
Types of Electrocardiographs Baseline
AC Interference
Single-Channel Electro- Wandering Baseline Artifacts Bipolar
cardiograph Interrupted Baseline Artifacts Bradycardia, Sinus
Multichannel Electro- Patients with Unique Problems Calibration
cardiograph Myocardial Infarctions Cardiac Catheterization
Automatic Electrocardiograph (Heart Attacks) Cardiac Cycle
Machines Cardiac Arrhythmias Cardioversion
Electrocardiograph Telephone Atrial Arrhythmias Countershock
Transmissions Ventricular Arrhythmias
Facsimile Electrocardiograph Defibrillation
Defibrillation
Interpretive Electrocardio- Defibrillator
Other Cardiac Diagnostic Tests
graph Deoxygenated
Holter Monitor (Portable
ECG Equipment Depolarization
Ambulatory Electro-
Electrocardiograph Paper cardiograph) Diastole
Electrolyte Loop ECG Electrocardiogram
Sensors or Electrodes Treadmill Stress Test or Electrocardiograph
Lead Wires Exercise Tolerance ECG Electrocardiography
Electrocardiograph Machine Thallium Stress Test Electrodes
Care of Equipment Echocardiography/
Lead Coding Electrolyte
Ultrasonography
The Electrocardiograph and Galvanometer
Cardiac Procedures
Sensor Placement Implantable Cardioverter
Procedures for Heart Disease
Standard Limb or Bipolar Defibrillator (ICD)
Procedures for Arrhythmias
Leads Infarction
Augmented Leads Ischemia
Chest Leads or Precordial Isoelectric
Leads Lead Wires
Mounting
Noninvasive
Normal Sinus Rhythm

760
OBJECTIVES KEY TERMS
The student should strive to meet the following performance objectives and (continued)
demonstrate an understanding of the facts and principles presented in this
Oscilloscope
chapter through written and oral communication.
Precordial
1. Define the key terms as presented in the glossary. Repolarization
2. Follow the circulation of blood through the heart starting at the Rhythm Strip
vena cavae. Sensor
3. Describe the electrical conduction system of the heart. Sonographer
4. State three reasons why patients may need an electrocardiogram Stylus
(ECG). Syncope
5. Identify the various positive and negative deflections and Systole
describe what each represents in the cardiac cycle. Tachycardia, Sinus
6. Explain the purpose of standardization of the ECG. Test Cable
7. Identify the 12 leads of an ECG and describe what area of the Thallium Scan
heart each lead represents. Tracing
8. State the function of ECG graph paper, electrodes (sensors), and Transducer
electrolyte.
Ultrasonography
9. Describe various types of ECGs and their capabilities. Unipolar
10. Explain each type of artifact and how each can be eliminated.
11. Name and describe the purposes of the various cardiac diagnos-
tic tests and procedures as outlined in this chapter.
12. Identify the placement of Holter monitor electrodes.
13. Describe the reason for a patient activity diary during ambulatory
electrocardiography.
14. Identify six arrhythmias and explain the cause of each.
15. Explain how to calculate heart rates from an ECG tracing.
16. Identify a common coding system used to code each lead on an
ECG tracing.
17. Describe the procedure for mounting an ECG tracing.

Scenario
Wanda Slawson, CMA (AAMA), clinical medical assis- ing an ECG. These included feelings of fear that the test
tant at Inner City Health Care, recently had her own may be abnormal; a cold feeling because even though
physical examination that included her first electro- the room temperature was normal, she was partially
cardiogram (ECG). This is now Wanda’s baseline ECG, uncovered and the pads were cold when applied; and
which provides a basis for future ECG readings to be anxiousness because she found it difficult to stay
compared. Because Wanda currently has no heart completely still through the entire tracing. Wanda could
problems, future tests will indicate differences from her empathize more with her patients after she had the
normal baseline ECG. It was different for Wanda to be test than she did before her test. Wanda now makes a
the patient versus the person performing the ECG. Hav- more concerted effort to allay patient fears and make
ing the test performed on her, Wanda can now relate to patients comfortable during ECGs.
feelings many of her patients must have felt when hav-

761
762 UNIT 6 Advanced Techniques and Procedures

INTRODUCTION
Many providers include an electrocardiogram (ECG or mounting, and labeling the ECG; and maintenance and
EKG) as part of a complete physical examination, especially care of the instrument.
for patients who are 40 years or older, for patients with a
family history of cardiac disease, or for patients who have
experienced chest pain. It is a noninvasive, safe, and pain- ANATOMY OF THE HEART
less procedure that can provide valuable information about
the health of the patient’s heart or suspected cardiac symp- The heart has four chambers: two upper chambers
toms. A graphic representation of the heart’s electrical activ- known as atria, and two lower chambers known
ity, an ECG measures the amount of the electrical activity as ventricles. Deoxygenated blood enters the
produced by the heart and the time necessary for the electrical right atrium from the superior and inferior vena
impulses to travel through the heart during each heartbeat. cavae and passes through the tricuspid valve into
Some reasons for electrocardiography are to: the right ventricle. In a healthy heart, the blood
(1) detect myocardial ischemia, (2) estimate damage between right and left sides cannot mix together.
to the myocardium caused by a myocardial infarction, It then travels to the lungs via the pulmonary arter-
(3) detect and evaluate cardiac arrhythmia, (4) assess ies. The deoxygenated blood gives off the carbon
effects of cardiac medication on the heart, and (5) deter- dioxide and picks up oxygen in the capillary bed
mine if electrolyte imbalance is present. An ECG cannot of the lungs. Oxygenated blood is pumped through
always detect impending heart disease or cardiovascular the pulmonary vein into the left atrium, through
disease. The ECG is used in conjunction with other labo- the mitral valve, into the left ventricle. The oxygen-
ratory and diagnostic tests to assess total cardiac health. ated blood then passes through the aortic valve
An ECG alone cannot diagnose disease. into the aorta and from the aorta to all cells, tis-
In a medical office or ambulatory care set- sues, and organs of the body (Figure 25-1). The
ting, it is the medical assistant who records the cycle begins with each heartbeat.
ECG; therefore, special knowledge and skills On its external surface, the heart is sur-
are necessary and include these aspects of the correct elec- rounded by coronary arteries that supply the myo-
trocardiography procedures: patient preparation; opera- cardium with its blood supply, from which oxygen
tion of the electrocardiograph; elimination of artifacts, and nutrients are obtained (see the section on the
circulatory system in Chapter 18).

Spotlight on Certification ELECTRICAL CONDUCTION

SYSTEM OF THE HEART
RMA Content Outline
There are basically two kinds of cardiac cells: elec-
• Body systems
trical cardiac cells and myocardial cells. The elec-
• Disorders and diseases
trical cells, which are located in distinct pathways
• Patient education around and through the heart, are sensitive to
• Vital signs and mensurations electrical impulses. Their pathways are referred
• Electrocardiography to as the conduction system of the heart and have
CMA (AAMA) Content Outline specific names.
The body’s natural pacemaker, the sino-
• Anatomy and physiology atrial (SA) node, is located in the upper part of
• Communication the right atrium. It sends out an electrical impulse
• Equipment preparation and operation that begins and regulates the heartbeat. When the
• Performing selected tests electrical impulses are sent along the pathways or
conduction system of the heart (via the electrical
CMAS Content Outline cells), the myocardial cells contract, causing the
• Anatomy and physiology heart muscle to pump the blood from chamber to
• Vital signs and measurements chamber and through the lungs. The contraction
• Examination preparation of the cardiac cells is called depolarization (from
• Medical office emergencies the electrical “discharge”). The first chambers
affected (contracted) by the electrical discharge
 CHAPTER 25 Electrocardiography 763

Right pulmonary artery Aorta (to general circulation)

(carries deoxygenated blood) Pulmonary trunk
Superior vena cavae Left pulmonary trunk

Right lung Left lung

Pulmonary
veins Pulmonary veins
(carry oxygenated blood)
Right
Left
atrium
atrium

Inferior vena cavae Left ventricle

Right ventricle

Figure 25-1 Oxygenated blood passing through the heart and then to the rest of the body.

from the SA node are the atria. From the atria, the are either deflecting upward, known as positive
electrical impulses travel along the conduction deflection, or deflecting downward, known as nega-
system toward the ventricles, to the atrioventricular tive deflection from the baseline.
(AV) node, located at the base of the right atrium. The P, QRS, and T waves, recorded during the
From here, the electrical impulses are transmitted ECG, represent the depolarization (contraction)
to the bundle of His. The bundle of His divides and repolarization (recovery) of the myocardial
into right and left bundle branches that continue cells. The P wave represents atrial depolarization
the electrical impulses on to the Purkinje fibers. and is recorded as a positive deflection. The QRS
These fibers disperse the electrical impulses to the complex represents ventricular depolarization and
right and left ventricles, causing them to contract. is measured from the beginning of the first wave
The heart recovers electrically (repolarization), of the QRS to the end of the last wave of the QRS
then relaxes briefly (polarization), and then a new complex (see Figure 25-2). The T wave represents
impulse is begun by the SA node and the cycle ventricular repolarization and is a positive deflec-
begins again (Figure 25-2). This cycle is known as tion. The recovery of the atria is so slight, it is lost
the cardiac cycle and it represents one heartbeat. behind the QRS complex.
The electrocardiograph records the electrical Each complete cardiac cycle takes about
activity that causes the contraction (systole) and 0.8 second, with each wave taking an appropriate
the relaxation (diastole) of the atria and ventricles. amount of time if the heart is healthy. By observ-
The ECG cycle is the recording or the graphic rep- ing and measuring the size, shape, and location of
resentation of the cardiac cycle. These electrical each wave on an ECG recording, the provider can
impulses can be recorded on special ECG paper analyze and interpret the conduction of electricity
or displayed on an oscilloscope. through the cardiac cells, the heart’s rhythm and
rate, and the health of the heart in general.
THE CARDIAC CYCLE Calculation of Heart Rate
AND THE ECG CYCLE on ECG Graph Paper
The baseline, or isoelectric, line is the flat line ECG graph paper is divided into 1-mm squares
that separates the various waves. It is present when (small squares) and 5-mm squares (large squares).
there is no current flowing in the heart. The waves Each large square consists of 25 small squares and is
764 UNIT 6 Advanced Techniques and Procedures

Q wave is a negative deflection or wave.

Represents
ventricular
R wave is a positive deflection or wave.
contraction
or systole.
S wave is a negative wave.

T wave is a positive wave and represents

ventricular repolarization or diastole.

U wave (occasionally seen in some patients)

is a positive deflection and associated with
repolarization.

Sinoatrial
(SA) node

Atrioventricular
(AV) node Bundle of His

(AV) Bundle Right and left

bundle branches

Purkinje fibers

Atrial Ventricle
depolarization repolarization Cycle
V begins
(contraction systole) (recovery diastole)
O again
L T
P U P
T
T
A P
G U-wave
Q occurs in
E
S some patients
Ventricle
depolarization
(contraction systole)

TIME

Figure 25-2 The heartbeat is controlled by electrical impulses that comprise the continuous
cardiac cycle.

5 mm high and 5 mm wide. On the horizontal line, time of each deflection on the horizontal line and
one small square represents 0.04 second. On the ver- cardiac electrical activity (voltage) on the vertical
tical line, one small square represents 1 mm of volt- line to help determine cardiac health.
age. Because a large square is five small squares wide Because all cardiac complexes consist of P,
and five deep, each small square represents 0.2 sec- QRS, and T waves, and the electrocardiograph
ond horizontal and 5 mm vertical. NOTE: Every fifth paper measures time on the horizontal line, it is
line, both horizontally and vertically, is darker than possible to calculate heart rate. Count the num-
the other lines, making squares that are 5 ⫻ 5 mm ber of 5-mm boxes (number within the dark lines)
(Figure 25-3). These measurements are accepted between two R waves. Divide this number into 300.
worldwide and enable the provider to interpret the The result is the heart rate in beats per minute.
 CHAPTER 25 Electrocardiography 765

3 sec 3 sec

V
O Small square
L
T
A
G Large square
E

0.2 sec

1 mm
TIME

0.5 mV 5 mm

0.04 sec

Figure 25-3 Electrocardiogram graph paper measurements allow medical professionals to determine the time
and voltage of heartbeats. (A) The small square is 1 mm wide and 1 mm high. One small square ⫽ 0.04 second.
(B) The large square consists of 25 small squares and measures 5 mm wide and 5 mm high. One large square ⫽
0.04 second ⫻ 5, or 0.2 second.

Example: TYPES
One small square (1 mm) ⫽ OF ELECTROCARDIOGRAPHS
0.04 second in time
One large square (5 mm) ⫽ Single-Channel
0.04 ⫻ 5 ⫽ 0.2 second
Divide 60 seconds (1 minute) by
Electrocardiograph
0.2 second 60 ⫼ 0.2 ⫽ 300 A conventional 12-lead single-channel electro-
Example: cardiograph can be used in either manual mode
or automatic mode. When using automatic mode,
There are three large squares between two R waves. the 12-lead ECG tracing is complete in less than
300 ⫼ 3 ⫽ 100 40 seconds. With a single-channel machine, only
The heartrate is 100 beats per minute. one lead can be recorded at a time. If not automatic,
the single-channel ECG requires manually turning
the lead selector on and off between each of the 12
leads. It may also require the leads to be coded so that
Critical Thinking they can be identified later and properly mounted.
Lead coding and mounting are explained more fully
Explain the significance of the small and later in this chapter. The ECG tracing from a single-
large boxes on ECG paper. There are 2.5 large channel machine will need to be cut and mounted
boxes between each cardiac cycle. What is onto special forms for filing into the patient record.
the heart rate in beats per minute?
Figure 25-4 shows a sample of a single-channel elec-
trocardiograph machine and tracing.
766 UNIT 6 Advanced Techniques and Procedures

A B

PATIENT Charles Williams NO. DATE 11–1–20XX

SEX AGE HEIGHT WEIGHT B/P POSITION
DRUGS RATE:ATRIAL VENT. AXIS
INTERVAL: PR QRS QT RHYTHM
INTERPRETATION

INTERPRETED BY Dr. T. Winston Lewis

LEAD I LEAD II LEAD III

AVR AVL AVF

aVR aVL aVF

V1 V2 V3

V1 V2 V3

V4 V5 V6

V4 V5 V6

C
Figure 25-4 (A) Single-channel 12-lead electrocardiograph machine. (B) Supplies for single-channel 12 lead
electrocardiograph. (C) Mounted single ECG tracing or recording.
 CHAPTER 25 Electrocardiography 767

multichannel tracing. Other multichannel elec-

Multichannel Electrocardiograph trocardiograph machines are available, such as
An electrocardiograph that can simultaneously 6- and 12-channel machines. Some have a built-in
record several different leads is known as a mul- rechargeable battery, an interpretation software
tichannel electrocardiograph. The conventional program, a spirometery module, and transmis-
electrocardiograph records one lead at a time. A sion capability.
three-channel machine, one type of multichan-
nel electrocardiograph, records three channels Automatic Electrocardiograph
at one time. It records lead I, II, and III, followed
by aVR, aVL, and aVF, followed by V1, V2, and
Machines
V3, followed by V4, V5, and V6. The advantage of When using an automatic electrocardiograph, the
the multichannel machine is its speed. The most lead length and switching of leads are done auto-
common multichannel machine used in the matically by the electrocardiograph and there is
provider’s office is the three-channel machine. no need to advance the control knob. For these
This type of machine requires three-channel reasons, both time and paper can be saved with the
recording paper that is 81⁄2 ⫻ 11 inches and automatic machine. The automatic machine also
fits into the patient record with no cutting or comes equipped with a manual control that can be
mounting. Figure 25-5 shows an example of a used if a longer tracing is necessary.

Figure 25-5 Example of three-channel electrocardiogram recording in which three leads are recorded simultane-
ously. (Courtesy of Quinton Cardiology, Inc.)
768 UNIT 6 Advanced Techniques and Procedures

Electrocardiograph Telephone the electrical current. The impulses are transmit-

ted to the electrocardiograph by metal tips on the
Transmissions patient lead wires or cables that are attached to the
An electrocardiogram can be transmitted via a tele- sensors. Because electrolyte substances must con-
phone line to an ECG interpretation site when tain moisture to properly conduct impulses, they
using an electrocardiograph with such capabilities. are manufactured in the forms of gels, lotions,
A recording printout and interpretation (many pastes, presaturated pads, or, more commonly,
times interpretation is done by a cardiologist or are contained within adhesive sensors. For our
by a computer) are transmitted automatically on purposes here, we use the disposable self-adhesive
the electrocardiograph. Results of the ECG can be electropads/sensors.
transmitted verbally as well.
Sensors or Electrodes
Facsimile Electrocardiograph There are various types of sensors or electrodes
The provider may need a rapid, expert ECG inter- made of metal or other conductive material. The
pretation from an off-site diagnostician. Direct sensors detect the electrical impulses on the body
ECG fax transmits from the electrocardiograph to surface and relay them through cables, or lead,
a fax machine, and a high-quality facsimile is pro- wires to the ECG machine.
duced and sent to a diagnostician, who calls back
with a reading. This saves time by eliminating the Disposable Electrodes. Disposable sensors (elec-
step of copying the report and sending it via the trodes) contain a layer of electrolyte gel on their
traditional fax machine. adhesive surface and can be used on both the limbs
and chest. They do not require additional electro-
lytes. These sensors are applied to the skin of the
Interpretive Electrocardiograph limbs and chest and held in place by the adhesive.
The interpretive electrocardiograph has a built-in The self-adhesive electrodes are discarded after
computer program that interprets the ECG tracing use. They should be kept in an airtight bag because
while it is being recorded, allowing for faster diag- they dry out and will not stick well.
nosis and treatment. The provider in charge will
review the tracing before a diagnosis is confirmed
and treatment is begun.
Lead Wires
Once the self-adhesive sensors are placed, a series
of lead wires coming from the machine will be con-
ECG EQUIPMENT nected to them. Small clips, sometimes referred to
as alligator clips, will grasp the tabs on the sensors
(Figure 25-6). This completes the circuit from the
Electrocardiograph Paper patient to the machine.
ECG paper can be either black or dark blue and is
wax or plastic coated with a white or pink background
and color lines. The paper is heat and pressure sensi-
tive. As the heated stylus of the electrocardiograph
moves across the paper, the background coating is
melted away, revealing the black or blue color of the
paper, and the ECG cycles are recorded or traced.
The heat of the stylus can be adjusted to obtain a
sharp, clear recording, or tracing. Medical assistants
should learn how to adjust the proper control using
the specific manual or instructions that accompany
the electrocardiograph in their facility.

Electrolyte
Because the skin is a poor conductor of electric-
ity, there are various types of conductive electrolyte
substances applied with each electrode to pick up Figure 25-6 Alligator clip and disposable sensor.
 CHAPTER 25 Electrocardiography 769

mounting purposes. Newer electrocardiographs

THE PROCESS OF RECORDING automatically mark (code) each lead in the upper
margin of the ECG paper during the recording.
CARDIAC ELECTRICITY Older electrocardiographs must be manually coded
Skin—Poor conductor by depressing the lead marker button. Figure 25-7
Electrolyte—Must contain moisture to conduct current shows an example of a common coding system.
Electrodes—Must contain metal to conduct current
Metal clips or tips—To connect the electrodes to the lead
wires THE ELECTROCARDIOGRAPH
Lead wires—To conduct the current from the patient to the
machine AND SENSOR PLACEMENT
Amplifier in the machine—To amplify the electricity enough to
measure it The standard ECG consists of 10 sensors that
Stylus—An instrument to record the electrical pattern record 12 leads of the heart’s electrical activity
ECG paper—On which the stylus can record the pattern from different angles, allowing for a thorough
three-dimensional interpretation of its activity.
The electrical impulses given off by the heart are
picked up by the electrodes and conducted into
the machine through lead wires.
The electrodes are placed on the patient’s
Older electrocardiographs may have plain lead wire tips for
four limbs and chest. The four limb leads are right
use with the older metal plates and suction cups. They can
easily and inexpensively be converted to use the current self-
arm (RA), left arm (LA), right leg (RL), and left
adhesive sensor electrodes. The only conversion equipment leg (LL). The right leg electrode is not used as
necessary is a set of “alligator” clips that will fit over the end part of the recording. It is an electrical reference
of the lead wire tips. Contact the manufacturer or a medical point only. The limb leads are placed on the fleshy,
supplier for conversion sets. nonmuscular area of upper arms and lower legs.
The chest leads are known as precordial leads,
V leads, or C leads, and use an electrode for each
of six areas on the chest wall or one electrode that
is moved to six different positions on the chest
Electrocardiograph Machine wall. (This depends on the type of electrocardio-
Because the electrical activity that comes from the graph being used.)
body is small, it is made larger, or amplified, by
the amplifier of the electrocardiograph machine.
The voltage is changed into a mechanical motion
Standard Limb or Bipolar Leads
by the galvanometer and recorded on the paper by The first three leads that are recorded on
the heated stylus. a standard ECG are called leads I, II, and III
(Figure 25-8A). These are known as bipolar leads
because each of them uses two limb electrodes
Care of Equipment that record simultaneously. Lead I records elec-
Once the ECG tracing is complete, remove the trical activity between the right arm (RA) and
lead wires from the sensors, then remove the left arm (LA); lead II records electrical activity
sensors from the patient. Dispose of the sensors. between the right arm (RA) and left leg (LL);
Check supplies on machine so it is ready for next and lead III records activity between the left arm
use. Neatly and loosely place the lead wires on (LA) and left leg (LL). Lead II is used as a rhythm
top of or beside the machine. Change the ECG strip because it portrays the heart’s rhythm bet-
paper when necessary according to manufacturer’s ter than the other leads. The rhythm strip is usu-
suggestions. ally a separate longer recording approximately
6 to 12 inches.

LEAD CODING Augmented Leads

There are a number of codes used to identify each The next three leads are augmented (added
lead recorded on the ECG reading. There are to) leads and are designated aVR, aVL, and aVF
12 leads recorded using the 10 lead wires. These (Figure 25-8B). The aV stands for augmented
codes are necessary for later identification and for voltage; the R, L, and F stand for right, left, and
770 UNIT 6 Advanced Techniques and Procedures

Standard
or bipolar Electrodes Marking Recommended positions for
limb leads connected code multiple chest leads
(Line art illustration of chest positions)

Lead I RA & LA 1 dot

Lead II RA & LL 2 dots

1 2
Lead III LA & LL 3 dots 3
4 5 6

Augmented
unipolar Dash—1 dot
1 dash V1 Fourth intercostal
limb leads
space at right
aVR RA & (LA-LL) margin of sternum
V2 Fourth intercostal
2 dashes space at left
margin of sternum
aVL LA & (RA-LL) V3 Midway between
position 2 and
3 dashes
position 4
aVF LL & (RA-LA) V4 Fifth intercostal space
at junction of left
midclavicular line
V5 At horizontal level of
Chest or position 4 at left anterior
precordial axillary line
leads V6 At horizontal level of
position 4 at left
V C & (LA-RA-LL) (See data on right) midaxillary line

Figure 25-7 Example of a common coding system for electrocardiogram leads that must be manually coded on
older electrocardiographs. Accurate coding is accomplished by pressing the lead marker button appropriately.
(Courtesy of Quinton Cardiology, Inc.)

foot (or leg). These are unipolar leads. Lead record the heart’s electrical impulse from a central
aVR records electrical activity from the mid- point within the heart to one of six predesignated
point between the left arm added to the left leg, positions on the chest wall where an electrode is
directed to the right arm. Lead aVL records elec- attached. The correct position must be used for
trical activity from the midpoint between the each lead recording.
right arm added to the left leg, directed to the left The anatomic positions for placement of the
arm. Lead aVF records electrical activity from the chest or precordial leads are:
midpoint between the right arm added to the left V1: fourth intercostal space at right margin of
arm, directed to the left leg. Because these three sternum
leads produce such small electrical impulses, V2: fourth intercostal space at left margin of sternum
the electrocardiograph machine augments, or V4: fifth intercostal space on left midclavicular line
increases, their size to record them. Figure 25-8B V3: midway between V2 and V4 (NOTE: This is correct
will help you visualize the augmented process. order, V3 after V4.)
V5: horizontal to V4 at left anterior axillary line
V6: horizontal to V4 at left midaxillary line
Chest Leads or Precordial Leads When using an electrocardiograph with one
The remaining six leads of the standard 12-lead chest wire, the chest electrode must be moved
ECG are the chest leads or precordial leads (Fig- manually one by one to each of the six chest lead
ure 25-8C). These are unipolar leads and are positions. This necessitates stopping the instrument
designated V1, V2, V3, V4, V5, and V6. These leads between each chest lead to move the electrode to the
 CHAPTER 25 Electrocardiography 771

(A) Standard limb or bipolar leads

Electrodes Connected

Lead I LA and RA

Lead II* LL and RA

Lead III LL and LA Lead I Lead II Lead III

* Also used for rhythm strip

(B) Augmented limb leads

aVR RA and (LA-LL)

aVL LA and (RA-LL)

aVF LL and (RA-LA) Lead aVR Lead aVL Lead aVF

(C) Precordial or chest leads Electrodes connected Placement

V1 V1 and (LA-RA-LL) Fourth intercostal space at right margin of sternum

V2 V2 and (LA-RA-LL) Fourth intercostal space at left margin of sternum
V4 V4 and (LA-RA-LL) Fifth intercostal space at junction of left
midclavicular line
V3 V3 and (LA-RA-LL) Midway between position 2 and position 4
V5 V5 and (LA-RA-LL) At horizontal level of position 4 at left anterior
axillary line
V6 V6 and (LA-RA-LL) At horizontal level of position 4 at left midaxillary
line

V6
V1 V2 V3
V5 V4 V5 V6
V1 V2 V3 V4

Precordial leads

Figure 25-8 Lead types, connections, and placement. (A) Standard limb or bipolar leads. (B) Aug-
mented limb leads. (C) Precordial or chest leads.
772 UNIT 6 Advanced Techniques and Procedures

next appropriate position on the chest wall. Some the 10-mm standardization at the beginning of
electrocardiographs have six lead wires allowing all each row.
six chest leads to be applied at one time; therefore, On occasion, R waves may be large and go off
there is no interruption between chest lead record- the paper. Repositioning the stylus may not correct
ings (see Figure 25-18C in Procedure 25-1). the situation. In such instances, the medical assis-
tant can record the lead(s) in which the R wave is
STANDARDIZATION large at one-half sensitivity. This action will record
all ECG cycles at half their normal amplitude.
AND ADJUSTMENT OF THE Conversely, the waves of the ECG cycles may
ELECTROCARDIOGRAPH be small, making it difficult to interpret. In this
circumstance, the medical assistant can record the
The value of an ECG recording depends on it ECG cycles at twice the normal standard. This action
being performed accurately. To ensure a precise will record ECG cycles at twice their normal ampli-
and reliable recording, you must standardize the tude. Whenever a change is made from a normal
ECG instrument before every ECG performed. standardization (10 mm high) to either a one-half
The standardization of the machine is a quality- standardization (5 mm high) or a double standard-
assurance check to determine if the machine is ization (20 mm high), the medical assistant must
set and working properly. Standardization mea- include the adjusted standardization mark with that
surements have been adopted internationally particular lead to alert the provider to the change in
as a means of accurate calibration according to standard. The standard must be returned to normal
universal measurements. The universal standard to prevent accidentally running the next
is that 1 mV (millivolt) of cardiac electrical activ- lead at a standard other than normal.
ity will deflect the stylus exactly 10 mm high. The paper is usually run at a speed of
This is the equivalent of 10 small squares on 25 mm/second. If cycles are too close together, the
the ECG paper. Figure 25-9 shows an example of paper speed can be adjusted to 50 mm/second.

Standard limb or Bipolar leads Augmented leads Chest (Precordial) leads

Standardization quality
checks 10 mm

Rhythm strip
Standard speed

Figure 25-9 An electrocardiogram showing all 12 leads recorded in minutes at one time with no interruption.
(Courtesy of Quinton Cardiology, Inc.)
 CHAPTER 25 Electrocardiography 773

Make a note on the ECG paper if paper speed or baseline, and interrupted baseline. The medical
amplitude is changed. assistant should understand the causes of each type
of artifact and know how to eliminate them. The
newer machines have filters, which will automati-
STANDARD RESTING cally filter out the artifact.
ELECTROCARDIOGRAPHY
Regardless of the type of electrocardiograph used,
Somatic Tremor Artifacts
the basic components of the standard electrocar- Somatic tremor artifact is also known as muscle
diography procedure remain the same. Patient tremor. It is characterized by unnatural baseline
preparation, placement of limb and chest leads, deflections such as jagged peaks or irregularity
attachment of lead wires, and elimination of arti- of spacing and height. The tracing appears fuzzy
facts vary little from one electrocardiograph to (Figure 25-10A). Somatic tremor occurs when the
another. Procedure 25-1 explains a 12-lead ECG patient is apprehensive or uncomfortable, result-
using a multiple-lead channel electrocardiograph. ing in involuntary muscle movement. Voluntary
Before performing the procedure, medical assis- muscle movement occurs when the patient moves,
tants must be familiar with the electrocardiograph talks, coughs, and so on. Parkinson’s disease, a ner-
machine in their facility and should thoroughly vous system disorder, is an example of involuntary
review the manufacturer’s instruction manual that somatic tremor. It is not possible for the patient to
accompanies the machine. Knowledge of the basic control the muscle tremors. (Often, involuntary
procedures included here can be adapted for all somatic tremor can be minimized somewhat by
other electrocardiographs. having the patient slide the hands under the but-
tocks during the recording.)
It is natural for the patient to feel apprehen-
MOUNTING THE ECG sive before and during the ECG tracing. Reassur-
TRACING ance and an explanation of the procedure will
allay apprehension and relax muscles. Be certain
Commercially prepared mounting forms are avail- the patient is comfortable. Use pillows for the head
able, and the medical assistant should mount the and under the knees; be sure the temperature of
completed tracing after the provider has reviewed the room is comfortable. These simple techniques
the entire recording. The mounting of the ECG will help to minimize somatic tremor.
recording depends on the machine. Some machines
produce a strip already printed on a durable paper
record. Some machines produce a long strip that
AC Interference
will need to be cut apart and adhered to a mount- The AC interference artifact is caused by electrical
ing paper or card. There are many options within interference and appears as a series of small reg-
these two varieties. Included with any ECG record- ular peaks (Figure 25-10B). Electricity present in
ing should be the patient’s name, date, address, medical equipment or wires in the area can leak a
age, sex, blood pressure, height and weight, and small amount of energy into the room in which the
cardiac medications on the mounting form. ECG is being recorded. The current can be picked
up by the patient’s body and it will be detected by
the ECG tracing as an AC artifact.
INTERFERENCE OR ARTIFACTS
Common Causes of AC Interference Artifacts.
The ECG is a valuable diagnostic aid to the provider Some common causes of AC interferences are:
and must be performed accurately. The medical
assistant is responsible for obtaining a recording that 1. Improper grounding of electrocardiograph. The
can be easily read and interpreted by the provider. three-pronged plugs in the newer electrocar-
There can be unusual and unwanted activity diographs should be inserted into a properly
in the tracing not caused by the electrical activity grounded three-receptacle outlet. This reduces
of the heart. These defects in the ECG tracing are AC interference from improper grounding.
known as artifacts, and their appearance can make 2. Presence of other electrical equipment in the
the ECG tracing difficult to read and interpret. Four room. Unplug other electrical equipment in the
of the more common artifacts are somatic tremor, room (electrical examination tables, lamps, auto-
alternating current (AC) interference, wandering claves, and so on).
774 UNIT 6 Advanced Techniques and Procedures

Wandering Baseline Artifacts

A wandering baseline occurs when the stylus
moves from the center of the ECG paper, result-
ing in the complexes “wandering” across the ECG
paper; for example, from the top of the paper to
the bottom, or bottom to top (Figure 25-10C).
This makes it difficult to follow the complexes
when the provider reads and interprets the
A recording.

Common Causes of Wandering Baseline

Artifacts. Wandering baseline artifacts can be
caused by the following conditions:
1. Electrodes applied too loosely or too tightly. There
should be equal tension on all four limb leads,
metal tips should be firmly attached to the elec-
trodes, and the cable attached to patient should
not have tension on it nor be dangling to cause
B pulling on the electrode.
2. Corroded or dirty electrodes or metal tips of the
lead wires. Clean and rinse after each use.
3. Inappropriate amount or poor-quality electrolyte
gel or paste. Each electrode should have the same
amount of electrolyte gel or paste on it.
4. Lotions, oils, or creams on the patient’s skin that
interfere with the adhesive sticking well. Remove
any of these substances before applying the elec-
trode by cleansing the area with an alcohol wipe.
C Wandering baseline artifacts are more often
seen in older ECG machines that use metal
electrodes and electrolyte. Newer machines use
electrodes (sensors) that are disposable and self-
adhesive, thereby eliminating the four causes of
wandering baseline artifacts.

Interrupted Baseline Artifacts

On occasion, the baseline is interrupted and a
break is seen between waves (Figure 25-10D). Pos-
D sible causes are a broken cable, a lead wire that
became detached from an electrode, or an elec-
Figure 25-10 Electrocardiogram artifacts. (A) Somatic trode that came completely off.
tremor. (B) Alternating current. (C) Wandering base-
line. (D) Interrupted baseline. (Courtesy of Quinton
Cardiology, Inc.) Patients with Unique Problems
On occasion, the medical assistant performs
3. Electrical wiring in the floor, ceiling, or walls. Move an ECG on a patient who has unique medical
the ECG table away from walls. problems. An obese patient, a woman with large
4. Crossed lead wires and lead wires not following breasts, or a patient with thick chest muscles will
body contour. Straighten lead wires and be sure make it difficult to palpate the intercostal spaces.
they are positioned to follow the patient’s body Place the chest leads on the chest as accurately as
contour. you can.
 CHAPTER 25 Electrocardiography 775

cal assistants are in an excellent position to offer

Critical Thinking healthy tips and suggestions from which patients
can benefit. For instance, they can offer patient
Mr. Williams has a diagnosis of Parkinson’s health tips regarding diet and exercise while apply-
disease. The provider requests an ECG. What ing the ECG equipment and provide handouts and
strategies can you use to ensure an ade- informational Web sites for patients to research
quate tracing? (Table 25-1).

For a patient with a limb amputation or a cast, Table 25-1 Behaviors to Adopt for
the medical assistant should apply the sensors as a Healthy Heart
close to the preferred site as possible, higher on
the limb. Place the sensor in a similar position on The provider may want the medical assistant to
remind patients of the following healthy behaviors:
the other limb.
Do not place sensors on wounds, open areas,
1. Avoid tobacco
sutures, or staples. Try to situate the sensors as
close as possible to the preferred site.
2. Take medications as prescribed
If the patient has dyspnea, the ECG can be
taken with the patient in semi-Fowler’s position
3. Report any unusual symptoms or problems to the
(see Chapter 13 for positions). provider
If you have difficulty performing an ECG
on patients with certain medical problems or con- 4. Eat a low-fat, low-cholesterol, low-sodium diet
ditions, ask for assistance from your supervisor/
delegator. 5. Exercise regularly with provider’s permission

MYOCARDIAL INFARCTIONS 6. Get adequate rest

(HEART ATTACKS) 7. Keep weight under control and at an acceptable

level
Myocardial infarctions (heart attacks) are the num-
ber one cause of death in the United States today. 8. Practice stress reduction behaviors
With the approval of the employer–provider, medi-

Patient Education
Atherosclerosis is the buildup of fatty depos- Treatment of angina consists of rest and
its on the lining of coronary arteries causing medication. Nitroglycerin may be prescribed
narrowing and obstruction of the arteries. in tablet or patch form. Change in lifestyle
Blood flow to the heart muscle is diminished and other suggestions (Table 25-1) may be
particularly when the heart is called on to recommended. Tests that the provider may
work harder, for example, during increased order include a 12-lead ECG, a stress ECG
physical activity, emotional stress, exposure to (stress test), blood tests, chest radiograph,
cold temperatures, and after a heavy meal. and coronary angiogram.
The heart’s muscle tissue responds to these Pain that does not subside after rest may
conditions by symptoms of pain or discomfort indicate a more serious condition such as a
beneath the sternum, into the neck, jaw, left complete obstruction of the coronary arteries
arm and shoulder, and throat. Rest usually and no blood flow to the heart muscle, a myo-
relieves the pain. This condition is known as cardial infarction, or heart attack. Seek imme-
angina pectoris. diate medical attention if pain persists.
776 UNIT 6 Advanced Techniques and Procedures

feine, but they can forewarn of more serious cardiac

CARDIAC ARRHYTHMIAS problems. This type of arrhythmia is characterized
by a cardiac cycle that occurs before the next cycle
The medical assistant should recognize cardiac is due. The P wave is shaped differently from the
arrhythmias that occur during the ECG recording P wave of the normal cycle (Figure 25-12A).
and without alarming the patient make the pro-
vider aware of them as soon as they are noticed. The Paroxysmal Atrial Tachycardia (PAT). This ar-
normal, healthy ECG cycle consists of P, QRS, and rhythmia can be seen in healthy individuals; and
T waves in a regularly appearing sequence or pat- in persons with cardiac disease. PAT is character-
tern. The term normal sinus rhythm refers to an ized by its unprovoked sudden onset and abrupt
ECG that is within normal limits (WNL). The nor- termination. The heart rate is regular and ranges
mal adult heart rate is 60 to 100 beats/min. A rate between 160 to 250 beats/min. The episode usually
less than 60 beats/min is known as sinus bradycar- lasts only a few seconds; the heart rate then returns
dia (Figure 25-11A); a rate greater than 100 beats/ to its original rate (Figure 25-12B). The patient may
min is known as sinus tachycardia (Figure 25-11B). describe a fluttering in the chest, apprehension,
These two heart rates, although regular in rhythm, shortness of breath, and, on occasion, dizziness.
are considered cardiac arrhythmias.
Atrial Fibrillation. This arrhythmia can be seen in
healthy individuals or in those with cardiac disease.
Atrial Arrhythmias In younger patients, common causes can be congen-
Premature Atrial Contractions (PACs). Healthy ital heart disease and mitral valve damage caused
individuals can experience PACs. They are seen in by rheumatic heart disease. In older patients, the
patients who use tobacco and stimulants such as caf- arrhythmia can be caused by hypertension, coronary

B
Figure 25-11 (A) Heart rate shown is 50 beats/min, known as sinus bradycardia because it is less
than 60 beats/min. One large square ⫽ 0.2 second; 1 minute (60 seconds) ⫼ 0.2 ⫽ 300. There are
six large squares between R waves: 300 ⫼ 6 ⫽ 50 beats/min. (B) Sinus tachycardia is a heart rate
faster than 100 beats/min. There are three large squares between R waves: 300 ⫼ 3 ⫽ 100 beats/min.
 CHAPTER 25 Electrocardiography 777

P wave
R wave

Figure 25-12 Atrial arrhythmias. (A) Premature atrial contractions. (B) Paroxysmal atrial tachycardia.
(C) Atrial fibrillation.

artery disease, or mitral valve prolapse. It is charac- in patients with hypertension, coronary artery dis-
terized by extremely rapid, incomplete contractions ease, and lung disease. In healthy individuals, PVCs
400 to 500 beats/min resulting in small, irregular, can be caused by tobacco, anxiety, alcohol, and med-
and uncoordinated complexes that are difficult to ications that contain epinephrine (Figure 25-13A).
measure accurately because the P waves cannot be PVCs are seen on ECG tracings fairly frequently
distinguished (Figure 25-12C). and are considered common disturbances in the
rhythm. They are characterized by a beat that comes
early in the cycle, has no P wave, a wide QRS com-
Ventricular Arrhythmias plex, and a different T wave. The PVC is followed by
Premature Ventricular Contractions (PVCs). This a pause before the occurrence of the next normal
arrhythmia can be seen in healthy individuals and cycle.
778 UNIT 6 Advanced Techniques and Procedures

Normal
Normal

PVC
PVC
A

Figure 25-13 Ventricular arrhythmias. (A) Premature ventricular contractions (PVCs). (B) Ventricular tachycardia.
(C) Ventricular fibrillation.

Ventricular Tachycardia. This arrhythmia is seen cardia is life threatening and can rapidly deterio-
in patients with cardiac disease, both acute and rate into fibrillation and cardiac standstill.
chronic. It is common in patients with coronary
artery disease, and frequently the patient experi- Ventricular Fibrillation. This arrhythmia is seen
encing a myocardial infarction will have ventricu- in patients experiencing a myocardial infarction
lar tachycardia as a result of the infarction (Figure or in patients with existing cardiac disease. It
25-13B). The arrhythmia is manifested by three or may be preceded by PVCs or ventricular tachy-
more PVCs that occur at a rate ranging from 150 to cardia, or it may begin as ventricular fibrilla-
250 beats/min. There are no P waves, and the tion. It is a life-threatening arrhythmia (Figure
QRS complexes are distorted. Ventricular tachy- 25-13C).
 CHAPTER 25 Electrocardiography 779

DEFIBRILLATION OTHER CARDIAC

DIAGNOSTIC TESTS
A defibrillator is an electrical device
that applies countershocks to the heart Holter Monitor (Portable
through electrodes or pads placed on
the chest wall (Figure 25-14). The purpose is to con-
Ambulatory Electrocardiograph)
vert cardiac arrhythmia into normal sinus rhythm. The Holter monitor is a portable continuous record-
This is known as defibrillation or cardioversion. In ing of cardiac activity for a 24-hour period (Figure
most offices and clinics, a defibrillator is kept on a 25-15). The patient is monitored while going about
crash cart for quick access in emergency situations. the usual daily activities with no restrictions. This
The medical assistant should regularly check the noninvasive test helps to diagnose cardiac arrhyth-
equipment for proper operation and prepared- mias by correlating them with the patient’s symp-
ness and assist the provider as needed. toms. Some symptoms are syncope, fatigue, chest
Automated external defibrillators (AEDs) are pain, and vertigo. This type of monitoring is useful
widely used and are found in places where many for patients whose arrhythmias are sporadic and are
people congregate, such as airports and the work- not found on a 12-lead ECG tracing. Also, ambu-
place, and in private homes of individuals at risk for latory monitoring helps assess the function of an
cardiac arrest. artificial pacemaker and the effectiveness of antiar-
The devices are portable, small, and battery rhythmic medications.
operated. Emergency medical technicians, police, Special electrodes attached to lead wires are
and firefighters trained in defibrillation techniques placed in the appropriate areas of the patient’s
and who are the first to respond in an emergency chest. A special portable tape recorder, either digi-
were primarily the individuals who used these tal or magnetic, computer or magnetic, continually
devices. Now, many citizens are certified to use records, the heart’s electrical activity for a 24-hour
AEDs (see Figure 25-14). period. The monitor is a battery-operated recorder
In an individual experiencing a myocardial that is placed in a leather pouch or bag and is worn
infarction, ventricular fibrillation is not uncom- by the patient either on a belt around the waist or
mon. If the fibrillation can be stopped within the by a strap over the patient’s shoulder. Table 25-2 lists
first 5 minutes using a defibrillator, the life can locations for placement of electrodes.
be saved (see Chapter 9 for more about AEDs). One kind of digital Holter monitor is a three-
channel (five-lead) ECG that has Windows-based
software technology. A keypad is used to enter the
patient’s information, such as date of recording,
patient identification number, etc. There is no need
to check the effectiveness of the monitor by attach-
ing it to a test cable and an ECG machine. Some
monitors have a removable flash memory card and a

Figure 25-14 The CardioVive DM AED. (Courtesy of Figure 25-15 Holter monitor and supplies needed
Quinton Cardiology, Inc.) for application.
780 UNIT 6 Advanced Techniques and Procedures

have routine scheduled checks of their devices over

Table 25-2 Holter Monitor Electrode
the phone.
Placement
Some cardiac monitoring devices are sent
directly to the patient from the supplier, com-
Electrode Lead Location
plete with printed or telephone directions for the
patient. When the specific time period has elapsed
mV1 Fourth intercostal space
A (black) at right of the sternal
for the particular monitor being used, the patient is
edge responsible for returning the device to the supplier.

mV5 Right clavicle, just lat- Medical Assistant’s Role. The medical assistant is
B (white)
eral to sternum responsible for preparing the patient, instructing
the patient, checking and replacing the battery,
C (brown)
mV1 Left clavicle, just lateral and applying and removing the monitor.
to the sternum
Holter Monitor Electrode Placement. Special
mV5 Fifth intercostal space at disposable electrodes, which are round plastic and
D (red)
left axillary line have a strong adhesive backing, are available for the
Holter monitor. These disposable electrodes con-
E (green) Ground Lower right chest wall tain an electrolyte gel. There may be either four or
five electrodes depending on whether the monitor
has a built-in ground. Notice that the leads for the
Holter monitor are applied to different locations
flash card reader that can download information in from the electrodes of a resting ECG. Table 25-2 lists
90 seconds. It can hold up to 48 hours of ECG infor- the locations for lead placement.
mation. The tracing is interpreted and sent back
by computer. It can be accessed and printed. The Holter Monitor Attachment. Once the Holter
electrode placement is the same for a digital Holter monitor has been attached to the patient, the mon-
monitor as it is for a magnetic tape Holter monitor, itor should be checked for effectiveness by attach-
but both digital and magnetic tape electrode place- ing the test cable to the monitor and the other
ment is not the same as it is for a standard 12-lead end to an ECG instrument. A baseline strip can
resting ECG. be recorded to verify the correct wave activity and
Other computerized continuous cardiac mon- lack of artifact. If there are inaccurate readings,
itoring devices are available and are prescribed for the monitor may not have been applied properly.
patients according to the patient’s symptoms and The medical assistant can reconnect the leads to
the practitioner’s preference. The tracing can be the electrodes or reposition the electrodes and
read over the telephone or is computerized. Trans- reconnect the leads (see Procedure 25-2). The
telephone monitor devices are frequently used skin should be cleansed with an alcohol wipe and
by patients with a pacemaker and or implantable rubbed with gauze to roughen it. Males should be
cardioverter-defibrillator (ICD). These patients shaved so that the electrodes adhere well.

Patient Education
When preparing patients to wear a 24-hour 3. Do not shower, bathe, or swim while
Holter monitor, instruct them in the following: wearing the monitor because the
1. Keep a diary of daily activities, symptoms, recording could be interrupted or the
and emotions, and note the time of monitor could be damaged.
occurrence. 4. Do not handle the electrodes. Doing so
2. Depress the event marker only briefly and could cause artifacts.
only when experiencing a significant 5. Do not remove the recorder from its case.
symptom. Overuse of the marker can 6. Do not use an electric blanket. This can
mask the ECG tracing. cause interference.
 CHAPTER 25 Electrocardiography 781

The following are examples of some of the daily activities

Loop ECG
that should be recorded by the patient in the patient activ- Another type of ambulatory electrocardiography
ity diary: is called loop ECG. It uses only two electrodes. It
• Eating meals records a few minutes of the ECG at a time on a
• Ascending and descending stairs computer chip. It constantly records new informa-
• Sexual activity tion and discards the oldest information. Thus,
• Medications taken the memory contains only the last few minutes of
• Times of sleep the ECG recording. When a patient has an “epi-
• Smoking sode or event” (symptoms), the patient pushes the
• Bowel movements “record” button and the recording remains in the
• Physical exercise
device’s memory. The recorded event is transmit-
ted (played back) by telephone to the provider.
The device then erases the event.
The recorder constantly refreshes its memory.
Patient Activity Diary. The patient activity diary It is suitable for capturing brief events and can be car-
is an important component of the monitoring ried for long periods of time. Other types of record-
procedures. As noted in the Patient Education ers take a longer period of time, and if a patient is
box, all activities and emotional states, and the experiencing dizziness, it takes too long to apply a
time of their occurrence, should be noted during recorder. This may result in not being able to cap-
the 24-hour monitoring time. Symptoms such as ture episodes associated with syncope.
chest pain, shortness of breath, dizziness, palpita-
tions, and so on, and the time the event occurred Treadmill Stress Test or Exercise
should also be noted. Patient symptoms recorded
while being monitored can be compared with the
Tolerance ECG
patient’s notations in the activity diary and cor- On occasion patients have symptoms of cardiac
related to the heart’s activity. Symptoms can be problems that do not appear as abnormalities on
further noted by the patient briefly depressing a resting ECG. The provider may prescribe a tread-
an event marker button located at one end of the mill stress test or exercise tolerance test to aid in
monitor. This places an electronic “tag” on the the determination of the patient’s diagnosis and
tape. This signal can alert the person interpreting prognosis. The test is done to diagnose heart disor-
the ECG to look for a significant event or abnor- ders, to diagnose the probable cause of the patient’s
mality on the tape. chest pain, and to assess the patient’s cardiac ability
after cardiac surgery. The treadmill stress test is a
Holter Monitor Removal. The patient is instructed noninvasive ECG tracing taken under controlled
to return to the office or ambulatory care center 24 conditions while the patient is closely monitored
hours later to have the monitor removed. Usually by the medical assistant and the provider. Frequent
no appointment is necessary. The tape is analyzed blood pressure readings are taken. The patient
by a Holter monitor scanner or by a computer. This wears comfortable clothing and flat shoes such as
is usually done in the ECG department of a nearby sneakers with rubber soles and exercises on a tread-
hospital. The provider can access the report from mill at prescribed rates of speed (Figure 25-16).
the computer with samples of any abnormalities Electrodes are applied to the chest only.
that were picked up during the monitoring period. As with the Holter monitor, the patient’s
A follow-up appointment is scheduled with the skin should be cleansed with an alcohol wipe and
provider to discuss the results. rubbed with gauze to roughen it. Male patients
should be shaved at the site of the electrodes to
ensure electrode adherence.
The myocardium requires extra oxygen dur-
Critical Thinking ing exercise and in the presence of narrowed or
obstructed coronary arteries; the additional work-
State three purposes for using a Holter moni- load on the myocardium will often be demonstrated
tor and give the instructions that the patient as an abnormality on the ECG recording. The
will need to know while wearing patient should have no pain, shortness of breath,
the monitor.
or excess fatigue. If any of these or other unusual
symptoms occur, the provider may terminate the
test because this could indicate cardiac disease.
782 UNIT 6 Advanced Techniques and Procedures

blockage, the cause of a patient’s chest pain, cardiac

function, post myocardial infarction, and to check
the level of exercise a patient can safely engage in.
The thallium is injected intravenously while
the patient is being monitored on the treadmill
and is exercising. After the stress test, the patient is
“scanned” under a machine in the diagnostic imaging
department. The patient leaves the department for
3 or 4 hours (rests), then returns, and another scan is
done. Therefore, the patient has been “scanned” dur-
ing exercise and after a rest period of a few hours.
The thallium intravenous injection mixes
with blood in the bloodstream and in the arteries
and enters the heart muscle cells. If a portion of
the heart does not receive a normal blood supply,
than a less amount of thallium will be present in
the heart muscle cells. To the cardiologist this find-
ing indicates a degree of block in the heart’s blood
supply. The patient most likely has ischemia of the
Figure 25-16 The Quest Exercise Stress System. heart muscle or an infarct of the heart muscle.
(Courtesy of Quinton Cardiology, Inc.) Patients who can not tolerate an exercise
stress test because of serious heart disease or
patients with special needs, such as wheelchair-
At the conclusion of the test, the patient is bound patients, can be given a vasodilator and
told to rest. Monitoring continues until the the undergo ECG test seated in a chair or wheel-
vital signs and heart rate return to normal. chair. The medication will cause an increase in
Prior to the patient leaving the office, the patient heart rate, thus simulating the stress of walking
should be instructed to rest, refrain from a hot bath on a treadmill. The thallium stress test is per-
or shower, avoid stimulants such as caffeine, and avoid formed in the outpatient department of the hos-
extreme temperature changes for several hours. pital or in a cardiology office or clinic.
Complications such as a myocardial infarction
or a serious arrhythmia can occur during testing. Echocardiography/
Although these events are unusual, appropriate Ultrasonography
emergency equipment must be readily available,
and the medical assistant should check them fre- Echocardiography is a noninvasive, diagnostic test
quently for proper functioning. Some equipment that uses ultrasound (ultrahigh-frequency sound
to have available on a crash cart for cardiac emer- waves) to image the internal structures of the heart.
gencies include oxygen, antiarrhythmic drugs, X-rays are not useful. General anatomy, myocardial
an Ambu-bag™, a defibrillator, an endotracheal function, valve function, and heart chamber size
tube, and a laryngoscope. The medical assistant can be evaluated. Echocardiography may be per-
is responsible for checking the supplies and plug- formed in a cardiologist’s office.
ging in the defibrillator. During ultrasonography, a handheld trans-
Further diagnostic tests such as cardiac cath- ducer acts as a transmitter and receiver of the high-
eterization (angiogram) may be necessary to diag- frequency sound waves as it is held against the chest
nose the extent of the atherosclerosis buildup and wall and moved over the heart area. As the sound
obstruction of the coronary arteries. waves go through the skin and hit internal structures,
echoes are sent back to the transducer. A machine
converts the images when the various structures pro-
Thallium Stress Test vide different echoes. The images can then be exam-
Thallium stress test is similar to a treadmill stress ined by a computer and converted into photographs
test in that the patient has an ECG tracing while and films of structures and blood flow.
exercising on the treadmill after having been given There is little patient preparation other than
an injection of a radioactive substance such as thal- to have the patient lie on the examination table
lium. The test shows how well blood flows to the with the four-limb leads of a 12-lead electrocardio-
heart muscle. It can help diagnose coronary artery graph attached. The test is usually performed by a
 CHAPTER 25 Electrocardiography 783

sonographer. The provider views the results later Other cardiac procedures that can be per-
and informs the patient. formed for heart disease are atherectomy and laser
angioplasty. In atherectomy, the provider uses a
very small device on the end of the catheter to cut
CARDIAC PROCEDURES away the blocked area inside the coronary artery.
In laser angioplasty, the provider uses a laser beam
The following section discusses cardiac procedures to destroy the blockage in the artery.
performed for heart disease and arrhythmias. Some Coronary artery bypass is a procedure in
cardiac procedures for diagnosing diseases of the which a portion of a vein (typically the saphenous)
heart are computerized (Figure 25-17), and the transplanted into one or more of the heart’s coro-
results are stored in the patient’s electronic medi- nary arteries. The transplanted vein circumvents or
cal record. The data are accessible on demand. bypasses the blocked coronary artery, thus reestab-
lishing blood supply to that portion of the heart.
A catheter with a large balloon can be used
Procedures for Heart Disease to open a standard (normal) valve. The balloon is
Percutaneous transluminal coronary angioplasty inflated and, as in the angioplasty, the valve can be
(PTCA) is a procedure that widens a narrowed loosened. The catheter with balloon is removed
or blocked coronary artery. One type of PTCA is after the procedure.
balloon angioplasty. A catheter with a deflated bal- A heart valve can be repaired or replaced. In
loon is inserted into the patient’s femoral artery a replacement procedure, a tissue or mechanical
and threaded up into the heart. The small balloon valve replaces the heart’s damaged valve.
is inflated inside the blocked coronary artery and
opens the blocked area. A stent is often placed
within the artery to increase blood flow to the myo-
Procedures for Arrhythmias
cardium. The stent remains in the artery perma- A cardiac electrophysiologist is a specialist who
nently, keeping the artery open. provides care to patients with arrhythmias. After a
study by the cardiac electrophysiologist determines
the source of the patient’s arrhythmia within the
Pharmacy
electrical conduction system of the heart, a cathe-
ter is inserted into the femoral artery and a special
device with radio waves is “aimed” at the source of
the abnormal heart rhythm. This is known as cardiac
CLINICAL CARE ablation. The tiny scar produced prevents the elec-
Patient Assessment trical conduction system from traveling through the
Procedures, Diagnoses & Treatment Plans
Referrals & Follow-up Appointments
scarred area, resulting in normal rhythm.
Prescriptions A permanent battery-operated pacemaker
Orders for Tests
Patient Medical History
can be surgically implanted into the patient’s chest
wall for treatment of certain types of arrhythmias.
Wires from the pacemaker are inserted into the
heart to provide a steady, regular heartbeat.
Test Results An implantable cardioverter defibrillator
Schedules and Tickler Files (ICD) is a device surgically implanted into the
Patient Medical History
Medication Administration patient’s chest wall with wires leading into the
Patient Education heart. When the patient’s heart rate is extremely
Graphical Patient Data Displays
low or the patient’s heart stops beating, the defi-
brillator delivers a small electric shock to jar the
ELECTRONIC heart back into a normal rhythm (works like the
AED; see section on defibrillation and Chapter 9).

RECORDS Two other diagnostic tools for cardiac disease

are cardiac computerized tomography (CCT) and
cardiac magnetic resonance (CMR). Both are very
useful tools, but they expose the patient to radia-
tion and they are very expensive. Some cardiologists
Figure 25-17 Total practice management system believe echocardiography (no radiation exposure)
(TPMS) data flow. is just as useful in diagnosing heart disease.
784 UNIT 6 Advanced Techniques and Procedures

Procedure 25-1
Perform Single-Channel or Multichannel Electrocardiogram
STANDARD PRECAUTIONS: tion table with arms and legs supported. Pillows
can be used under the knees and head. RATIO-
NALE: All four limbs and chest must be uncov-
ered for proper electrode placement.
PURPOSE: 4. Explain that the procedure is painless and why
To obtain an accurate, graphic, artifact-free reading it is necessary not to move or talk during the
of the electrical activity of the patient’s heart to iden- procedure. RATIONALE: Patient cooperation
tify arrhythmias, estimate damage caused by myocar- ensures good quality tracing.
dial infarction, assess effects of cardiac medication, 5. Place the electrocardiograph with the power
determine if electrolyte imbalance is present, identify cord pointing away from the patient. Do not
cardiac ischemia, and determine the effects of hyper- allow the cable to go underneath the table.
tension or other disorders on the heart. RATIONALE: Helps reduce AC inter ference.
6. Apply the limb electropads (sensors) first. Apply
EQUIPMENT/SUPPLIES:
the sensors to the fleshy parts of the four limbs.
Examination or ECG table with pillow and sheet or
If the sensor does not adhere well, use an alcohol
blanket
wipe on the skin, let it dry, and apply a new sen-
Patient gown (open in front)
sor. Shave sites if necessary. RATIONALE: Skin
Automated electrocardiograph with patient cable
oils can be removed by alcohol, thus improving
wires
the adherence of the sensor. By removing excess
Alligator clips
hair on the chest, the sensor will adhere bet-
Electropads (sensors)
ter. Place sensors on a nonbony, nonmuscular
ECG paper
(fleshy) area of the upper arms and lower legs.
Alcohol wipes
Arm sensors should have tab pointing down, leg
Gauze squares
sensors point upward. RATIONALE: Artifact can
Mounting form/card
be reduced if sensors are placed on nonbony,
Razor
nonmuscular areas of the limbs. Directing tabs
PROCEDURE STEPS: properly reduces tension on the electrodes.
1. Perform tracing in a quiet, warm, and comfort- 7. Place the sensors on the chest wall on the appro-
able room away from electrical equipment that priate intercostal spaces with sensors pointing
may cause artifacts. RATIONALE: Patient is less downward. Shave chest sites if necessary.
apprehensive in a quiet atmosphere. AC inter-
8. Attach lead wires from the ECG machine to each
ference is minimized when ECG is performed
sensor using alligator clips, special clips applied
away from other electrical equipment.
to the ends of the lead wires (Figure 25-18 A and
2. Wash hands, gather equipment, identify the B). Be sure to connect lead wires to the correct
patient, and explain the procedure to the sensors. Lead wires are labeled with abbreviations
patient. RATIONALE: Following these universal (RA, LA, RL, LL, and V or C) and are color-coded
steps minimizes transmission of microorganisms as follows: RA ⫽ white; LA ⫽ black; RL ⫽ green;
and reassures patient. LL ⫽ red, V or C ⫽ (chest) ⫽ brown or multicol-
3. Have the patient remove clothing from the waist ored depending on machine model. The lead
up and uncover lower legs; nylon stockings must wires should follow the patient’s body contour
be removed; socks can be worn. RATIONALE: (Figure 25-18C–D). RATIONALE: Following body
Electropads must be placed on bare skin for contour prevents sensors from being pulled off.
optimum conductivity of electricity. Provide a 9. The patient cable is supported either on the
sheet or blanket for privacy and warmth. Place table or on the patient’s abdomen. Plug the
the patient in supine position on the examina- patient cable into the electrocardiograph.

continues
 CHAPTER 25 Electrocardiography 785

Procedure 25-1 (continued)

B
D

C
E

Figure 25-18 (A) Lead wires with nothing attached. (B) Alligator clip attached to top of lead wires. (C) Lead
wires attached to the patient’s chest and arms. (D) Lead wires attached to the patient’s legs. (E) The machine
prints each lead sequentially on a strip of ECG paper.

10. Turn the instrument to ON. Somatic tremor artifact may be lessened when
11. Enter information (patient name, date of birth, the patient’s hands are slid under the buttocks.
age, height, weight, sex, identification number, 13. Press AUTO and the machine will automatically
and cardiac medications the patient is presently record and standardize the tracing. RATIO-
taking). RATIONALE: The ECG machine auto- NALE: Standardization ensures a dependable
matically prints the information entered onto and accurate ECG.
the ECG printout. 14. The single-channel machine prints each lead
12. Remind the patient not to talk and to try not to sequentially on a strip of ECG paper (Figure
move. (If the patient has a neuromuscular con- 25-18E). A multichannel machine prints the
dition such as Parkinson’s disease and cannot tracing on an 8 1⁄2- ⫻ 11-inch sheet of paper.
remain still, try having the patient slide his or 15. Check the quality of the tracing (artifacts, low
her hands under the buttocks.) RATIONALE: voltage) before disconnecting lead wires. If it

continues
786 UNIT 6 Advanced Techniques and Procedures

Procedure 25-1 (continued)

is necessary to repeat the tracing, first correct 19. If the tracing is a single-channel tracing, cut and
the problem that is causing a poor quality trac- mount it, remembering to handle it carefully.
ing. RATIONALE: Checking the tracing before Place in patient’s record.
removing the electropad sensors will save time if 20. Document procedure in patient’s chart or elec-
the ECG must be repeated. tronic medical record.
16. Disconnect lead wires and remove the electro-
pad sensor from the patient. DOCUMENTATION
17. Assist patient as needed. 4/19/20XX 2:00 PM Twelve-lead ECG completed. Tracing
given to Dr. Woo. Patient cooperative and seemed comfortable
18. Be certain the patient information is on the trac- throughout procedure and says she “feels fine” after tracing.
ing before giving it to the provider to read.
W. Slawson, CMA (AAMA) _________________________

Procedure 25-2
Holter Monitor Application (Cassette and Digital)
STANDARD PRECAUTIONS: 3. Wash hands.
4. Identify the patient and explain the procedure.
RATIONALE: Adherence to patient guidelines
helps ensure an accurate tracing.
PURPOSE: 5. Have patient remove clothing from the waist up.
To detect sporadic cardiac arrhythmias, to determine 6. Have patient sit on the examination table or
correlation of symptoms with activity, and to evaluate chair. RATIONALE: This allows for patient com-
chest pain and cardiac status after pacemaker implan- fort and relaxation and for the medical assistant
tation or after acute myocardial infarction. to place the electrodes appropriately.
EQUIPMENT/SUPPLIES: 7. Locate the correct electrode placement sites.
Holter monitor Alcohol wipes The skin must be prepared in the following way:
Patient activity diary Gauze a. Dry shave patient’s chest at each electrode
Blank magnetic tape or Carrying case site if chest is hairy.
flash memory card Belt or shoulder strap
b. Cleanse the shaved area with an alcohol wipe.
Disposable electrodes
Let area dry.
Razor
c. Abrade the skin slightly with a dry 4 ⫻ 4 gauze.
PROCEDURE STEPS: Areas should be red. RATIONALE: Shaved
1. Wash hands and assemble equipment. site and abraded skin help the electrodes to
2. Prepare the equipment by removing old (used) adhere better to the skin and facilitate easier
battery from the monitor and replacing it with a removal.
new battery. Insert a blank magnetic tape or flash 8. Take the electrodes from the package and peel
card into the monitor. RATIONALE: Installing a away the backing from one of them (electrode
new battery each 24-hour period will ensure the should be moist). Continue to remove elec-
monitor will function because it will have suffi- trodes one by one and attach as in Step 9.
cient power.

continues
 CHAPTER 25 Electrocardiography 787

Procedure 25-2 (continued)

9. Apply adhesive-backed electrode to the appro-

priate sites by applying firm pressure at the cen-
ter of the electrode and moving outward toward
the edges. Run your fingers along the outer rim
to ensure firm attachment. Avoid moving from
one side of electrode to the other. Gel could be
forced out and could cause interference. RATIO-
NALE: Firmly attached electrodes ensure a good
quality tracing.
10. Attach the lead wires to the electrodes. Connect
them to the patient cable.
11. Plug the monitor into the electrocardiograph
with the test cable. Run a baseline tracing (not
necessary with digital monitor). RATIONALE:
Running a baseline tracing will validate proper
setup of electrodes and confirm there is no mal-
function of the leads or cable.
12. Place the electrode cable so that it extends from
between the buttons of the patient’s shirt or from
below the bottom of the shirt. Figure 25-19 Correct placement of Holter monitor
on patient.
13. Place the recorder into its carrying case and either
attach it to the patient’s belt or over the patient’s
shoulder. Be certain there is no pulling on the lead
wires (Figure 25-19). RATIONALE: Pulling on 20. Upon the patient’s return 24 hours later, take
electrodes could cause them to become detached. the patient’s electrodes off, remove flash mem-
14. Plug the electrode cable into the monitor. ory card, accept cassette, remove battery.
Record the starting time in the patient activity log 21. Document patient returned with equipment.
(diary). These data will already be recorded in a
digital monitor. RATIONALE: The beginning DOCUMENTATION
time is noted to correlate cardiac activity with the 3/2/20XX 10:00 AM Holter monitor applied. Patient given
patient activity log. complete written instructions and restrictions and seems to
15. Help patient get dressed. understand them well. Time and date noted on activity log.
16. Give the activity log to the patient, being cer- Patient reminded to return to cardiac clinic at the same time
tain that the patient information is completed. tomorrow (10:15 AM) to have monitor removed and also to
RATIONALE: The activity log helps correlate bring the activity diary. Patient given after-hours number if he
cardiac activity with patient symptoms. needs assistance. J. Guerro, CMA (AAMA) ______________
17. Inform patient what time the following day the
3/3/20XX 10:00 AM Holter monitor electrodes removed from
monitor will be removed. Remind the patient to
bring along the activity log/diary.
patient. Cassette and activity log returned/or flash memory
card removed for later analysis on the computer analysis sys-
18. Wash hands. tem. J. Guerro, CMA (AAMA) ________________________
19. Document procedure in patient’s record or elec-
tronic medical record.
788 UNIT 6 Advanced Techniques and Procedures

Case Study 25-1

Refer to the scenario at the beginning of the chapter. CASE STUDY REVIEW
Wanda can empathize better with her patients now that she
herself has had a baseline ECG. 1. The feelings Wanda had while having her tracing
are experienced by many patients. Explain what
you can do for your patients to allay their fears
when they are getting ready for an ECG and dur-

Case Study 25-2

Abigail Johnson, who is in her mid-70s, arrives at the urgent CASE STUDY REVIEW
care center reporting chest pain. She has been seen on
two other occasions for similar pain and has a history of 1. What immediate action could Wanda have taken if
diabetes, hypertension, arteriosclerotic heart disease, and Mrs. Johnson’s pain had not subsided?
angina pectoris. Medical assistant Wanda Slawson imme- 2. Mrs. Johnson tells Wanda that Dr. Rice explained
diately alerts Dr. Rice of Mrs. Johnson’s chest pain and arteriosclerotic heart disease and angina pectoris
then takes her into the cardiac examination and treatment to her, but that she was nervous and understood
room. Dr. Rice tells Wanda to have Mrs. Johnson take one little and that she is embarrassed to admit that to
of her nitroglycerin tablets and to perform an ECG on her. Dr. Rice. How can Wanda explain, in language that
Mrs. Johnson is restless and anxious as Wanda prepares the patient can comprehend, what causes arte-
for the ECG and while the tracing is in progress. There is riosclerotic heart disease and angina, and what
significant somatic tremor. Wanda attempts to allay Mrs. Mrs. Johnson experiences during an attack of
Johnson’s apprehension to obtain a good quality ECG. angina? What strategies can Wanda teach Mrs.
The patient’s pain subsides within a few minutes and she Johnson to promote healthier habits and prevent
begins to feel better. more serious heart problems?
3. Research community resources are available
for persons with Mrs. Johnson’s heart condition.
Explain how Mrs. Johnson can locate them and
how she could benefit from them.

Case Study 25-3

George Matthews, a 79-year-old patient of Dr. Abbott, has a CASE STUDY REVIEW
history of cardiovascular heart disease. He tells Dr. Abbott
that today he has been experiencing “palpitations and slow 1. Describe why Dr. Abbott ordered Holter monitor
and fast heartbeats and sometimes dizziness.” Dr. Abbott electrocardiography for Mr. Matthews.
orders a resting ECG that shows no evidence of arrhyth- 2. What instructions will you give to Mr. Matthews
mia and decides that a Holter monitor electrocardiograph about wearing the monitor?
for Mr. Matthews might be helpful in diagnosing a cardiac 3. Mr. Matthews says he is not certain what activities
arrhythmia. should be recorded in the patient activity diary.
Explain what they are and the reason for their
importance.
 CHAPTER 25 Electrocardiography 789

SUMMARY
Electrocardiography is a noninvasive, painless procedure that is helpful in diagnosing heart arrhythmias,
ischemia, and effects of cardiac medications. Wires with sensors are attached to the patient’s arms, legs,
and chest. The electrocardiograph amplifies the electrical currents generated by the electrical cells of
the heart. A series of deflections (waves) is recorded on special ECG paper when a heated stylus on the
electrocardiograph moves across the paper. The cardiac cycles that appear are then interpreted by the
provider. The recording or tracing, known as an ECG, represents the heart’s rate, rhythm, and other myo-
cardial actions. Each of the 12 leads of the recording becomes part of the patient’s permanent record.
In addition to a resting ECG, other types of electrocardiography can be done. Cardiac stress testing
is done while the patient is physically challenged to perform increasingly strenuous exercises. The heart’s
tolerance to the increased demands placed on it during exercise can be observed and recorded while the
patient is being closely monitored. This type of electrocardiography helps determine cardiac health and
arrhythmias that would not be evident if a resting ECG were done.
Holter electrocardiography or ambulatory cardiac monitoring is an ECG test done as the patient goes
about normal daily activities. The patient wears chest leads and carries a small recording device on a belt or
on a strap over the shoulder for a period of 24 hours and documents activities in the patient activity diary.
This type of electrocardiography helps diagnose cardiac arrhythmias that occur sporadically and may be
difficult to capture on a resting ECG because of their unpredictability. Echocardiography is a diagnostic
test that uses ultrasound to image the internal structures of the heart. Myocardial function, valvular func-
tion or defects, and chamber size can be determined.
In most cases, the medical assistant is responsible for patient preparation; patient education; opera-
tion of the electrocardiograph; elimination of artifacts; mounting, labeling, and placing ECG readings into
the patient’s file; and maintenance and care of the equipment. The diagnostic value of the test depends on
the medical assistant’s accuracy and skill.

STUDY FOR SUCCESS

To reinforce your knowledge and skills of information presented in this chapter:
• Review the Key Terms • Practice the StudyWARE activities on your
• Practice the Procedures student CD

• Consider the Case Studies and discuss • Apply your knowledge in the Student Work-
your conclusions book activities

• Answer the Review Questions • Complete the Web Tutor sections

• View and discuss the DVD situations
˚ Multiple Choice
˚ Critical Thinking
• Navigate the Internet by completing the
Web Activities

REVIEW QUESTIONS
Multiple Choice 2. Which of the following may cause somatic tremor?
a. too much electrolyte
1. Which of the following is the most common type of b. cable across patient’s lap
artifact? c. corroded sensors
a. somatic tremor d. Parkinson’s disease
b. AC interference
c. wandering baseline
d. interrupted baseline
790 UNIT 6 Advanced Techniques and Procedures

3. One cardiac cycle (heartbeat) takes approximately WEB ACTIVITIES

how long?
Search on the Internet for a national organi-
a. 0.2 second
zation that focuses on heart and blood vessel
b. 0.4 second
disorders such as the American Heart Asso-
c. 0.6 second
ciation or the American College of Cardiology.
d. 0.8 second
4. Which of the following indicates ventricular 1. Print information about risk factors for cardiovas-
depolarization? cular heart disease.
a. QRS complex 2. What is the mortality rate for first-time myocardial
b. P wave infarctions for men versus women? Is there any
c. T wave
difference in the mortality rate?
d. S-T segment
3. Are the symptoms identical in male and female
5. Another name for V leads is:
patients when they are experiencing a myocardial
a. precordial
infarction? Explain the similarities/differences
b. augmented
c. standard between them.
d. limb 4. Determine if there are newer types of 24-hour car-
diac monitoring devices. How are they the same as
Critical Thinking or different from the Holter monitor?
1. The provider wants you to explain to Mrs. Johnson
(see Case Study 2) what behaviors she can adopt to
have a healthy heart. With a partner, role-play med-
REFERENCES/BIBLIOGRAPHY
ical assistant and patient and explain to the patient Delaune, S. C., & Ladner, P. (2002). Fundamentals of
what she can do to improve her heart’s health. nursing standards and practice (2nd ed.). Clifton
2. During the ECG, the equipment malfunctions. Park, NY: Delmar Cengage Learning.
What options are available to the medical assistant? Heartsaver AED. Retrieved September 18, 2009, from
3. Name four cardiac abnormalities that can be http://www.americanheart.org.
detected on an ECG. Passanisi, C. (2001). Electrocardiology essentials. Clifton
4. Identify the placement of the 12 leads of the ECG. Park, NY: Delmar Cengage Learning.
5. The patient coughs and moves during the ECG. Taber’s cyclopedic medical dictionary. (20th ed.). (2005).
How can this affect the ECG tracing? Philadelphia: F. A. Davis.
6. Explain standardization and why it is important.
7. What causes AC interference, wandering baseline,
and interrupted baseline and how can they be
eliminated?

THE DVD HOOK-UP

This chapter discusses the proper techniques for perform- DVD Journal Summary
ing electrocardiographic procedures. Write a paragraph that summarizes what you learned
In the first scene, the student extern prepared Mr. Byrne for from watching today’s DVD program. What steps could
his ECG. Typically, men do not wear gowns when exposing you take to help a patient relax who is anxious about
only the chest. Mr. Byrne, however, has a little more breast having an ECG?
tissue than most men.
1. Do you think that the extern should have offered him
a gown for modesty purposes?
Things do not always go as planned. In the majority of
cases, the patient is placed in a supine position for an ECG.
DVD Series Program Number
In today’s program, the patient was unable to lie down for
Skills Based Series 13
the ECG because of a neck and back injury.
Chapter/Scene Reference
1. What are some other obstacles that may interfere with • Entire program
the way you would normally attach or run an ECG?
 UNIT

Laboratory Procedures 7
Chapter 26
Safety and Regulatory Guidelines
in the Medical Laboratory
Chapter 27
Introduction to the Medical Laboratory
Chapter 28
Phlebotomy: Venipuncture
and Capillary Puncture
Chapter 29
Hematology
Chapter 30
Urinalysis
Chapter 31
Basic Microbiology
Chapter 32
Specialty Laboratory Tests
Chapter Safety and Regulatory
Guidelines in the Medical
26 Laboratory

OUTLINE KEY TERMS

Clinical Laboratory Improvement Where to Find More Informa- Acetone
Amendments of 1988 tion Regarding CLIA ’88 Aegis
The Intention of CLIA ’88 OSHA Regulations Body Fluid
General Program Description The Standard for Occupational Calibration
Categories of Testing Exposure to Hazardous
Chemotherapeutic
Contents of the Law Chemicals in the Laboratory
Agents
Criteria for PPMP Chemical Hygiene Plan
Communicable
Criteria for CLIA Waived Tests OSHA Regulations and Students
Ethyl Alcohol
CLIA ’88 Regulation for Avoiding Exposure to
Quality Control in Chemicals Excretion
Automated Hematology Cumulative Trauma Disorders Formaldehyde
Aftermath of CLIA ’88 Fume Hood
Impact of CLIA on Medical Mandate
Assistants Medical Asepsis
Proficiency Testing
OBJECTIVES Provider Performed
Microscopy
The student should strive to meet the following performance objectives and dem- Procedure (PPMP)
onstrate an understanding of the facts and principles presented in this chapter Pulmonary Edema
through written and oral communication.
Quality Assurance
1. Define the key terms as presented in the glossary. Quality Control
2. Identify the governmental agency that regulates procedures per- Reimbursement
formed on patients and describe the agency’s main concerns. Requisition
3. List the types of human specimens that CLIA regulates. Secretion
4. Name two performance requirements CLIA imposes on all Suppressed
laboratories. Immune System
5. Describe how CLIA ’88 regulates the use of quality control in Waived
automated hematology instruments.
6. Recall the three categories of testing and list several from the
waived category.
7. Discuss the importance of CLIA to the medical assistant.
8. Identify and discuss the contents of the law of CLIA ’88.
9. Describe CMS form 116 and explain its purpose.
10. Identify two OSHA standards that seek to safeguard employees.
11. Describe MSDS manuals and their purpose.
12. Differentiate among the four colors and five numbers of the
National Fire Protection Association.

792
 Scenario
At Inner City Health Care, Dr. Susan Rice ordered a for Dr. Rice to examine under the microscope. While
complete urinalysis for patient May Pankey. Dr. Rice’s Wanda is waiting for the doctor, she examines the slide
medical assistant, Wanda Slawson, CMA (AAMA), has to see if she can identify any abnormalities. She will
obtained the specimen from the patient, has performed compare her findings with Dr. Rice’s findings to see how
the physical examination and the chemical examination closely she comes to correctly identifying the cellular
of the urine, and has documented her findings on the components in the urine sediment.This is one way for
lab report form. She has also spun a test tube of urine in Wanda to continue her education on a daily basis while
the centrifuge and has prepared a slide of the sediment performing her clinical duties.

INTRODUCTION
Laboratory safety is a concern for all—management, States Public Health Service, is an agency that investi-
staff, and patients. An unsafe work environment and gates various diseases in an attempt to control them and
work practices can threaten the emotional and physical makes recommendations on how to prevent the spread
health of the health care worker, as well as the patient. of disease. The CDC issued the system of seven isolation
Injuries are costly on many levels: personally to the categories for patients with infectious diseases and rec-
injured individual, lost work days, workers’ compen- ommended the guidelines known as Universal Precau-
sation, medical treatment, potential legal action, and tions. In 1996, the CDC released Standard Precautions,
potential fines from regulatory agencies. These situa- which represent the most current and comprehensive
tions have a direct effect on the individuals involved, approach to infection control. The CDC Guidelines for
but they also have an indirect effect by lowering staff Standard Precautions and Universal Precautions are
morale, ultimately resulting in less productivity. Man- covered thoroughly in Chapter 10. This chapter focuses
agement’s response to safety is the key. Appropriate ori- on the federal regulations of the Clinical Laboratory
entation, annual reviews, periodic drills, and consistent Improvement Amendments of 1988 (CLIA ’88) and
enforcement of staff adherence to policy are all part of a the Occupational Safety and Health Administration
successful laboratory safety program. (OSHA) in relation to the providers’ office laboratory
All health care providers continually come into (POL).
contact with patients who are ill. Some patients have CLIA ’88 and OSHA, together with the CDC, regu-
communicable or contagious diseases; others may have late the safety of patients and health care workers. CLIA
a suppressed immune system that does not protect them ’88 comes under the aegis, or protection, of the Centers for
from infection. In the course of performing your duties Medicare & Medicaid Services (CMS), formerly known
as a medical assistant, you will be in contact with blood as the Health Care Financing Administration (HCFA)
and body fluids that may be highly infectious. It is of of the U.S. Department of Health and Human Services
extreme importance that your health and safety, as well as (DHHS) of the federal government. OSHA comes under
the health and safety of your patients, be protected. the U.S. Department of Labor. Both agencies require
There are a number of infection control measures that health care settings, including clinical laboratories,
that can be used to reduce the transmission of bloodborne adhere to the strict regulations that they set forth.
and other pathogens. Medical asepsis, also known as The purpose of CLIA ’88 is to safeguard the pub-
infection control, consists of procedures and practices lic by regulating all testing of specimens taken from the
that health care professionals use to prevent the spread human body. The purpose of OSHA is to require employ-
of infection (see Chapter 10). State and federal agencies ers to ensure employee safety in regard to occupational
also have established policies, procedures, and guide- exposure to potentially harmful substances.
lines for health care providers and employers to follow CLIA ’88 and OSHA guidelines are discussed sepa-
to reduce the risk for transmission of infectious diseases. rately in this chapter. Keep in mind as you go through
This chapter, as well as Chapter 10, examines the major this chapter that CLIA ’88 is designed to protect patients,
guidelines. and OSHA regulations are designed to protect workers.
The Centers for Disease Control and Prevention Table 26-1 summarizes the guidelines and purposes of
(CDC) in Atlanta, Georgia, a division of the United CDC, CLIA ’88, and OSHA.
793
794 UNIT 7 Laboratory Procedures

Table 26-1 Federal Health and Safety Guidelines

Guidelines Issuing Agency Purpose

Centers for Disease Control Issued in 1996 to augment and synthesize Universal
and Prevention (CDC), U.S. Precautions and techniques known as body substance
Standard Precautions Public Health Service isolation (BSI). Standard Precautions contain measures
intended to protect all health care providers, patients, and
visitors from infectious diseases.

CDC Designed to reduce the risk for airborne, droplet, and con-
Transmission-Based tact transmission of pathogens. These are used in addi-
Precautions tion to Standard Precautions and are intended for specific
categories of patients.

Universal Blood and CDC Released in 1985 to assist health care providers to greatly
Body Fluid Precautions reduce the risk for contracting or transmitting infectious
(Universal Precautions) diseases, particularly AIDS and hepatitis B.

Centers for Medicare & Safeguards the public by regulating all testing of speci-
Clinical Laboratory Medicaid Services (CMS), mens taken from the body.
Improvement Amend- U.S. Department of Health
ments of 1988 (CLIA ‘88) and Human Services
(DHHS)

Occupational Safety OSHA, U.S. Department of Requires employers to ensure employee safety in regard
and Health Administra- Labor to occupational exposure to potentially harmful sub-
tion (OSHA) Guidelines stances.

CLINICAL LABORATORY
Spotlight on Certification IMPROVEMENT AMENDMENTS
RMA Content Outline OF 1988
• Medical law
CLIA ’88 was designed to set safety policies
• Asepsis
and procedures that protect patients.
• Laboratory procedures (safety) In 1988, there was a public outcry as a
• First aid result of articles published in the Washington Post
CMA (AAMA) Content Outline and the Wall Street Journal and televised reports of
deaths that were attributed to misread Pap smears.
• Medicolegal guidelines and
The public wanted action taken to ensure its
requirements
safety, particularly in regard to laboratory testing.
• Principles of infection control The outcry prompted the federal government to
• Processing specimens become more involved in regulating laboratories.
• Quality control Although CLIA had been enacted into law
• Preplanned action in 1967, the issue of the misread Pap
CMAS Content Outline smears caused Congress to reexamine the
regulations it had set forth in 1967. Thus, CLIA ’88
• Legal and ethical considerations was passed and included amendments to the origi-
• Asepsis in the medical office nal law. The amended regulations took effect on
• Medical office emergencies September 1, 1992.
• Safety States can seek exemptions from the CLIA
• Supplies and equipment standards if they have regulations that are com-
parable to those imposed by CLIA. If the federal
 CHAPTER 26 Safety and Regulatory Guidelines in the Medical Laboratory 795

government grants the state an exemption, labo- ity of the test method; thus, the more complicated
ratories in that state are under the control of state the test, the more stringent the requirements.
standards and applicable fees, not federal stan- Three categories of tests have been established:
dards and fees. Few states have exempt status. waived; moderate complexity, including the sub-
category of Provider-Performed Microscopy Proce-
dure (PPMP); and high complexity. CLIA specifies
The Intention of CLIA ’88 quality standards for proficiency testing (PT),
The intent of CLIA ’88 is to protect the pub- patient test management, quality control, person-
lic by regulating all laboratory tests performed nel qualifications, and quality assurance as appli-
on specimens taken from the human body, that cable. Because problems in cytology laboratories
is, tissue, blood, and body secretions and excre- were the impetus for CLIA, there are also specific
tions, which are used in the diagnosis, treatment, cytology requirements.
and prevention of disease. Previous regulations CMS is charged with the implementation of
(Medicare, Medicaid, and CLIA ’67) were based CLIA, including laboratory registration, fee col-
on the site and scope of the laboratory testing. lection, surveys, surveyor guidelines and training,
CLIA ’88 regulates laboratory testing regardless enforcement, approvals of PT providers, accrediting
of site, scope, volume, or frequency. As of June organizations, and exempt states. The CDC is respon-
2007, registered CLIA laboratories total more sible for test categorization and CLIA studies.
than 200,600, with POL making up more than To enroll in the CLIA program, laboratories
50% of the total. The regulations require that must first register by completing an application,
all laboratories in the United States and its ter- pay fees, be surveyed if applicable, and become
ritories meet performance requirements that are certified. CLIA fees are based on the certificate
based on how complex a test is and the risk fac- requested by the laboratory (i.e., waived, PPMP,
tors that are associated with incorrect test results. accreditation, or compliance) and the annual vol-
Laboratories must comply with the requirements ume and types of testing performed. Waived and
to be certified by the DHHS. PPMP laboratories may apply directly for their
It is necessary to understand what the certificate because they are not subject to routine
CLIA ’88 regulations encompass and how inspections. Those laboratories that must be sur-
they impact medical assistants and other veyed routinely—that is, those performing mod-
health care workers who participate in testing erate- or high-complexity testing—can choose
human specimens. It is important because all labo- whether they wish to be surveyed by CMS or by a
ratories, including POLs, must abide by the CLIA private accrediting organization. The CMS survey
law. process is outcome-oriented and uses a quality
CLIA ’88 regulations are based on the com- assurance focus and an educational approach to
plexity of tests performed and they affect all aspects assess compliance (Table 26-2).
of the laboratory. They specify the type of test per-
formed, personnel involved in testing, and quality
control.
Table 26-2 How to Tell What Level of CLIA Is
Required
General Program Description
Congress passed CLIA in 1988, establishing quality If these tests This type of certificate
standards for all laboratory testing to ensure the are performed and/or survey is needed
accuracy, reliability, and timeliness of patient test
results regardless of where the test was performed. Waived tests only Certificate of Waiver
A laboratory is defined as any facility that performs
laboratory testing on specimens derived from PPMP Certificate of PPMP
humans for the purpose of providing information
for the diagnosis, prevention, or treatment of dis- Certificate of Registration, CLIA
Tests of moderate
ease, or impairment or assessment of health. CLIA survey, and Certificate of Com-
complexity
pliance
is user-fee funded; therefore, all costs of adminis-
tering the program must be covered by the regu-
Certificate of Registration, sur-
lated facilities. Tests of high com-
vey by an accrediting agency,
The final CLIA regulations were published on plexity
and Certificate of Accreditation
February 28, 1992, and are based on the complex-
796 UNIT 7 Laboratory Procedures

Data indicate that CLIA has helped to improve Contents of the Law
the quality of testing in the United States. The 1. All laboratories are required to register with
total number of quality deficiencies has decreased CLIA ’88 even if just one test is performed,
significantly from the first laboratory survey to the regardless of whether there is Medicare and
second. Medicaid reimbursement and regardless in
Work is currently in progress with the CDC and which of the categories the test is found.
CMS to develop a final CLIA rule that will reflect all
2. The regulations apply to all laboratories.
comments received and new technologies.
3. The regulations are specific to the complexity of
the test. The waived tests are the simplest with the
Categories of Testing fewest regulations. Standards become more strin-
CLIA ’88, under the aegis of the CMS of the DHHS, gent as the complexity of the test increases.
has designated three categories of testing: 4. A laboratory must obtain a certificate to perform tests.
An initial filing for a certificate is made on CMS form
1. Waived tests 116. One of five certificates can be obtained. (There
2. Moderate-complexity tests, including PPMP can be a state exemption as previously mentioned.)
3. High-complexity tests a. Certificate of Waiver. This certificate is issued to a
laboratory to perform only waived tests.
Each of these categories has different require- b. Certificate for PPMP. This certificate is issued to
ments for personnel and quality control. a laboratory in which a provider, midlevel prac-
Waived tests are simple, are unvarying, and titioner, or dentist performs no moderate com-
require a minimum of judgment and interpre- plexity tests other than the PPMP procedures
tation. Test error carries minimal hazard to the (Table 26-3). This certificate permits the labo-
patient. Waived tests represent the lowest percent- ratory to also perform waived tests.
age of the total number of tests performed. c. Certificate of Registration. This certificate enables
PPMP tests are moderate-complexity tests the entity to conduct moderate- and high-
but represent a subcategory that was added at the complexity laboratory testing until the entity is
request of providers. determined by survey to be in compliance with
The following criteria are used to categorize CLIA regulations.
moderate- and high-complexity tests.
d. Certificate of Compliance. This certificate is issued
• The degree of operator intervention needed to a laboratory after an inspection finds the lab-
oratory to be in compliance with all applicable
• The necessary knowledge and experience the
CLIA requirements.
operator possesses
• The degree of maintenance and troubleshooting
needed to perform the tests
Table 26-3 Examples of Provider-Performed
Even though most of the tests medical assis- Microscopy Procedures
tants perform fall into the waived category, POLs All direct wet-mount preparations for the presence or
will often perform moderate tests, including the absence of bacteria, fungi, parasites, and human cellular
PPMP tests. POLs are not limited to any category elements
as long as they have sufficiently trained and cre-
All potassium hydroxide (KOH) preparations
dentialed personnel, equipment, and approval.
Manufacturers of self-contained test kits apply Pinworm examinations
for and receive Food and Drug Administration
Fern tests
(FDA) approval for their particular test to be on
the CLIA waived list. To find out if your particu- Postcoital direct, qualitative examinations of vaginal or
lar brand of self-contained test kit is on the CLIA cervical mucus
waived list, access an up-to-date listing at the FDA Urine sediment examinations
Web site http://www.fda.gov and use the key search
term “currently waived analytes” (be forewarned, Nasal smears for granulocytes

though, the list is very long). You can obtain a list Fecal leukocyte examinations
of categories and the complete CLIA ’88 guide-
lines from the CDC Web site (http://www.cdc.gov Qualitative semen analysis (limited to the presence or
absence of sperm and detection of motility)
and use key search term “CLIA”).
 CHAPTER 26 Safety and Regulatory Guidelines in the Medical Laboratory 797

e. Certificate of Accreditation. This is a certificate be undertaken and appropriate action taken

that is issued to a laboratory on the basis of the and recorded. It is a requirement that quality-
laboratory’s accreditation by an organization assurance records be maintained.
approved by CMS. 9. The law mandates quality control for nonwaived
To date, more than 200,600 CLIA certifications tests. Laboratories are required to have an ade-
have been issued, more than half being Certifi- quate supply of equipment to perform the num-
cates of Waiver or PPMP. ber and types of tests that they offer. A procedures
5. All five certificates require renewal every 2 years. manual must be available in the testing area and
must include complete testing instructions. Docu-
6. After a laboratory has been certified, it must notify
mentation of maintenance programs for instru-
CMS within 6 months if it changes the type of tests
ments, equipment, and test systems must be
it performs. Changing the tests performed may
evident.
change the laboratory’s classification.
10. The law establishes requirements for the correct
7. Some examples of sanctions or penalties imposed
collection, transportation, and storage of speci-
by CMS for noncompliance with CLIA law are:
mens and the reporting of results (see No. 16,
Infraction Penalty Patient Test Management).
Failure to enroll Denial or revocation 11. The law mandates maintenance of records, equip-
with CMS of certificate ment, and facilities of laboratories performing
Nonparticipation in A score of zero (a score nonwaived tests (see No. 17, Documentation).
proficiency testing of 80% is required) 12. The law mandates personnel standards. There are
Failure to return the A score of zero requirements for personnel who perform non-
proficiency testing result waived tests and they spell out the necessary quali-
In addition, Medicare and Medicaid payments fications and responsibilities required of them.
may be suspended or terminated and civil penal- Each person who takes the tests must be licensed
ties of up to a $10,000 fine per violation or per day by the state if required, have a high school diploma
of noncompliance may be imposed. or equivalent, have adequate training, and be able
For CLIA ’88 conditions other than proficiency to demonstrate an understanding of laboratory
testing, newly regulated laboratories will not be procedures; calibration, or standardization of
subjected to penalties during the first inspection instruments; specimen collection; and quality con-
cycle unless it is determined that the laboratories’ trol. Personnel must report test results accurately
inadequacies pose immediate patient danger. and with dependability. All high-complexity tests
must be done by technologists and technicians
8. The law mandates quality assurance for non-
except for cytology, which requires more stringent
waived tests. Laboratories are required to establish
qualifications.
policies and procedures through programs that
assess test quality; identify problems and correct 13. The law mandates proficiency testing for non-
them; ensure precise, dependable, and punctual waived tests. The procedures and tests found in the
reporting of test results; and guarantee sufficient waived category are exempt from proficiency test-
competent staff. In addition, laboratories must ing, regardless of the type of laboratory in which
ensure that all quality-control data are studied, the tests are performed. Moderate- and high-
and if there is a complaint, an investigation must complexity test laboratories must enroll in pro-
ficiency testing programs that are approved by
the DHHS. The proficiency testing samples are
checked in the same manner as patient specimens.
CMS FORM 116 Unsatisfactory performance on a proficiency test-
ing check can result in various penalties rang-
CMS form 116 for the clinical laboratory application for CLIA,
ing from termination of the laboratory’s license
CMS-116, must be completed and returned to the CMS within
to operate to the termination of reimbursement
30 days of receipt. The form collects information regarding
a laboratory’s operation and is needed to evaluate fees, to from Medicare and Medicaid.
determine baseline data, to update existing data, and to fulfill 14. The law mandates unannounced on-site inspec-
legal requirements. The information obtained from the appli- tion. All laboratories in the moderate- and high-
cation will give the surveyor of the laboratory a perspective of complexity category are subject to unannounced
the laboratory’s operation and if it will be subject to an on-site inspections by DHHS or an agency assigned to
inspection. the task by DHHS. Laboratories that perform
only waived tests must prove that tests are being
798 UNIT 7 Laboratory Procedures

done according to the manufacturer’s directions. Patient identification number

Inspections can involve interviewing employees, Specimen identification
observation of employees performing tests, analy- Date
sis of data, and documentation of results. Viola-
Time specimen is received in laboratory
tions of requirements by any laboratory can result
in penalties. The cost of inspection will be billed Specimen rejection log maintained
to the laboratory. Records and dates of all tests done
15. The law mandates an annual listing of laboratories
that have had action taken against them. Criteria for PPMP
16. The law mandates patient test management. All lab-
To be categorized as a PPMP, the procedure must
oratories must have a strategy for properly receiving
meet the following criteria:
and processing specimens and for the precise report-
ing of the results. Written instructions regarding 1. The examination must be personally performed
collection, safeguarding of specimens, and labeling by one of the following practitioners:
of specimens must be available for patients. There
a. A provider during the patient’s visit on a speci-
must be a specific procedure for the reporting of
men obtained from his or her own patient
life-threatening results and a follow-through to the
or from a patient of a group medical prac-
person requesting the test. Test records must be kept
tice of which the provider is a member or an
for 2 years after the reporting of results.
employee
17. The law mandates documentation. The following
b. A midlevel practitioner, under the supervision
documentation must be done and be available:
of the provider or in independent practice only
• Specimen if authorized by the state, during the patient’s
Patient preparation visit on a specimen obtained from his or her
own patient or from a patient of a clinic, group
Specimen collection procedure
medical practice, or other health care provider
Proper labeling technique of which the midlevel practitioner is a member
Preservation of specimen if applicable or an employee
• Proficiency testing c. A dentist during the patient’s visit on a speci-
Corrective action taken men obtained from his or her own patient or
• Quality control and quality assurance from a patient of a group dental practice of
which the dentist is a member or an employee
Any corrective action taken
2. The procedure must be categorized as moderately
• Problem and complaint log
complex.
• Requisitions or written requests
3. The primary instrument for performing the test
Patient name is the microscope, limited to bright-field or phase-
Name and address of laboratory contrast microscopy.
Date and time of collection 4. The specimen is labile, or a delay in performing
Name of test requested the test could compromise the accuracy of the test
Diagnosis result.
• Results 5. Control materials are not available to monitor the
entire testing process.
Name and address of laboratory where test is
done 6. Limited specimen handling or processing is
required.
Test name
Test results, including normal ranges listed
on test results
Criteria for CLIA Waived Tests
Disposition of unacceptable specimens must To be categorized as a laboratory performing
be released to authorized person waived tests, the procedures must meet the follow-
• Log of Results ing criteria:
Printouts from instruments report must be 1. The tests must be simple laboratory examinations
kept and procedures that are cleared by the FDA for
Identification of person performing test home use, use methods that are simple and accu-
 CHAPTER 26 Safety and Regulatory Guidelines in the Medical Laboratory 799

rate so errors are negligible, or pose no reason- The findings of errors in processes at Certificate of Waiver
able risk for harm to the patient if performed (COW) laboratories and PPMP certificate laboratories are of
incorrectly. concern. Both COW and PPMP laboratories currently have
2. The tests performed must be on CLIA’s waived virtually no oversight. Results of studies indicate that, even
test list. though COW laboratories have the least amount of complexity
to their tests, there are huge gaps in quality of the tests per-
3. The manufacturer’s instructions for performing formed. It was discovered that POLs are lacking in the areas of
the tests must be followed. following instructions, quality assurance, and quality control.
4. Minimal scientific and technical knowledge PPMP laboratories were lacking in the areas of inappropriate
is required to perform the test, or knowledge certificates, not documenting personnel competency, and
required to perform the test may be obtained not evaluating test accuracy. Although these findings are
through on-the-job instruction. of concern to the CLIA program, no patient harm has been
documented as a result of these errors. Personnel performing
5. Minimal training is required for preanalytic, analytic, the tests at COW laboratories surveyed were mostly nurses
and postanalytic phases of the testing process, or lim- and physicians. The Centers for Medicare & Medicaid Services
ited experience is required to perform the test. (CMS) confirmed that lack of routine oversight in COW and
6. Reagents and materials are generally stable and PPMP laboratories continues to be a significant challenge to
reliable, or reagents and materials are prepack- ensuring quality testing. They recommend the following:
aged; premeasured; or require no special han- • Institute educational programs for COW and PPMP
dling, precautions, or storage conditions. laboratories
7. Operational steps are either automatically exe- • Validate the effectiveness of this educational program
cuted (such as pipetting, temperature monitor- • Survey a percentage of COW and PPMP laboratories
ing, or timing of steps) or are easily controlled. annually
8. Calibration quality-control materials are stable • Develop a self-assessment for PPMP laboratories
and readily available, and external proficiency • Provide educational material as part of the CLIA enrollment
testing materials, when available, are stable. process
9. Test system troubleshooting is automatic or self- • Have state survey agencies contact COW and PPMP
correcting, clearly described, or requires minimal laboratories to verify test menus
judgment, and equipment maintenance is pro-
vided by the manufacturer, is seldom needed, or
can be performed easily.
eter that will be performed on a patient’s sample.
10. Minimal interpretation and judgment are required These quality-control checks must be performed
to perfom preanalytic, analytic, and postanalytic before the patient’s sample is tested. The results for
processes, and resolution of problems requires lim- quality-control samples must fall within two stan-
ited independent interpretation and judgment. dard deviations of the expected mean value for that
sample.
In addition to calibrations and control sam-
CLIA ’88 Regulation ple testing, an ambulatory care setting that uses
for Quality Control in automated hematology instruments must enroll
Automated Hematology in a proficiency testing program with a reference
laboratory that is CLIA ’88 approved.
CLIA ’88 regulations require that three different
procedures be performed in the quality-control
protocol for automated hematology instruments.
Aftermath of CLIA ’88
The procedures are calibration, control sample There are many individuals who have serious con-
testing, and proficiency testing. CLIA’s regulations cerns about whether CLIA has led to improved
require that the automated hematology instru- testing as was intended, or if the law has just pro-
ment be calibrated at regularly scheduled intervals duced an overload of paperwork and problems.
with either a calibrator sample or a normal con- Some question if the law will be fully implemented
trol sample testing. Many manufacturers of auto- or even eliminated altogether.
mated hematology instruments recommend or Important developments help to put the
may require that the instrument be recalibrated law into perspective. CMS has postponed
at shorter intervals than are required by CLIA the date that Medicare payments would be
’88. CLIA ’88 mandates that two levels of control cut off for failure to register. The deadline has been
samples be tested first each day on any param- postponed at least three times. The American Medical
800 UNIT 7 Laboratory Procedures

Association (AMA) complained that unannounced Medical assistants are the only health care
inspections of POLs would disrupt patient office vis- professionals trained specifically for the ambula-
its. As a result, the Secretary of DHHS declared that tory setting, including the POL procedures. Lack-
POL inspections would be announced. ing a medical laboratory technician or medical
The category of PPMP was added as another technologist in the POL, the burden of quality
certificate and testing category because providers performance of the waived tests falls to the person
argued that the microscopic tests were essential to specifically trained in that area, the medical assis-
their practice. Already the PPMP has expanded to tant. Because laboratory training of the medical
include midlevel practitioners such as nurse practi- assistant focuses primarily on CLIA waived tests,
tioners, nurse midwives, and physician assistants. it is of major concern that medical assisting pro-
The law states that CLIA must be self- grams offer the best training possible in the areas
supporting. However, far fewer laboratories reg- of quality assurance, quality control, and following
istered than was originally anticipated, and the manufacturer’s instructions. Keep in mind that
result is a significantly lower amount of revenue the medical assistant may be the only health care
than had been expected. professional in the POL who has formal training
It is interesting to note that the CDC has pro- in the performance of the waived laboratory tests.
posed easing CLIA regulations by adding another Add that to the received findings of errors in pro-
category of testing. It would fall between the waived cesses at COW and PPMP laboratories and medical
tests and the moderately complex tests. The tests assistants are definitely on the front lines of ensur-
within this new category would be subject to mini- ing the best quality for test results performed in
mal regulation. This proposal is under consider- the POLs.
ation. Many question whether CLIA will have any Because CMS has received only a fraction of
value if this event occurs. the money that they expected to collect from appli-
cation fees, there is little money to carry the CLIA
Impact of CLIA ’88 program forward. Medical assistants must real-
ize that CLIA ’88 is the law even though a number
on Medical Assistants of laboratories have not seen inspectors nor felt
CLIA ’88 requires every facility that tests human any impact from the CLIA ’88 regulations. Some
specimens for diagnosis, treatment, and preven- laboratories are delaying concern about CLIA ’88
tion of disease to meet specific federal require- rules and do not understand the law and, there-
ments. The law applies to any facility that performs fore, have not fully implemented the regulations.
tests for the preceding purposes. This includes Medical assistants must know and comply with the
any POLs and ambulatory care setting, two typical law and be prepared for a CLIA inspection. Pen-
areas where medical assistants are employed. The alties are imposed on laboratories that are not in
law covers all facilities even if only one test or a few compliance with the law.
basic tests are done and even if there is no charge Medical assistants who perform clinical labo-
for the testing. ratory procedures must keep up with government
Medical assistants may be responsible not changes.
only for performing the tests but also for
maintaining personnel records, including Where to Find More Information
such information as workers’ college diplomas,
state licenses, national certifications, employ-
Regarding CLIA ’88
ees’ continuing education, and recredentialing. The original CLIA ’88 guidelines and updates are
Employee hepatitis B status must also be on file. available from the Federal Register for a fee. See
Medical assistants may be involved with compil- the appendices for ordering information or visit the
ing a procedures manual on how to perform every CMS Web site (http://www.cms.hhs.gov/CLIA).
test done; these must be reviewed every year. An
instrument log must be available for each piece of
equipment. Systems must be in place for calibra- OSHA REGULATIONS
tion, quality control, quality assurance test record-
ing, and proficiency testing (if higher than waived OSHA regulations are intended to ensure employ-
category tests are performed). Documentation ers have a safe and healthy work environment for
by medical assistants is of utmost importance; for their employees. This applies to all workers, not
instance, a quality-control plan may be in action, just health care workers. Some of the regulations
but it may not be written down in detail. include hard hats and steel-toed shoes for con-
 CHAPTER 26 Safety and Regulatory Guidelines in the Medical Laboratory 801

struction workers, safety switches for machinery, included. OSHA standards are not optional, and
fire prevention equipment in restaurants, and, of penalties are imposed for noncompliance with the
course, safety equipment and supplies for health standard. Employers must meet the requirements
care workers. Two OSHA standards have the great- not only to be in compliance with the law but to
est impact: The Occupational Exposure to Hazardous protect employees as well.
Chemicals (revised from The Hazard Communication All laboratories and ambulatory care set-
Standard) and The Bloodborne Pathogen Standard. tings, including providers’ offices, must
The Bloodborne Pathogen Standards is reviewed in comply with a chemical hygiene plan to
Chapter 10. This chapter discusses the standard meet the OSHA regulations. The only laboratories
for Occupational Exposure to Hazardous Chemicals. exempt from compliance are those that exclusively
It is important to note that states have their own use methods that do not place employees at risk
worker safety standards. Those state standards are for exposure to chemicals that are hazardous. For
required to be as strict or greater than the federal example, some POLs perform only dipstick tests
OSHA standards. or use other commercially prepared kits in which
reagents are not exposed and, as a result, they are
exempt from compliance. The primary compo-
The Standard for Occupational nent of the OSHA standard is that a written chemi-
Exposure to Hazardous cal hygiene plan and program must be operational
Chemicals in the Laboratory if chemicals are stored in a facility and handled by
employees. Some examples of chemicals include,
In an effort to reduce the number of chemically
but are not limited to, stains, ethyl alcohol, sodium
related illnesses and injuries in the workplace,
hypochlorite (household bleach), formaldehyde,
OSHA published its Hazard Communications Stan-
fixatives, preservatives, injectables such as chemo-
dard in 1983. This led many states to develop right-
therapeutic agents, and acetone. Many laboratory
to-know laws. In 1992, OSHA expanded the Hazard
accidents result in chemical-related illnesses rang-
Communications Standard, and published The Occu-
ing from eye irritations to pulmonary edema.
pational Exposure to Hazardous Chemicals in the Labo-
There are three primary goals that an employer
ratory Standard, which specifically addressed clinical
must accomplish to be in compliance with the
laboratories.
OSHA standard for chemical exposure. The first
The intention of this law is to heighten
is that there must be an inventory taken and a list
employee awareness of risks linked with chemi-
compiled of all chemicals considered hazardous.
cal dangers. It serves to improve work practices
The following information must be documented
through employee training and identification of
(Figure 26-1): the quantity of chemical stored per
hazardous chemicals that exist in the workplace.
month or year; whether the substance is gas, liquid,
The use of protective equipment is utilized to pro-
or solid; the manufacturer’s name and address; and
tect employees from harmful chemicals.
the chemical hazard classification.
Second, a Material Safety Data Sheet (MSDS)
Chemical Hygiene Plan (Figure 26-2) manual must be assembled. The
MSDS statements are provided by the manufacturer
The Chemical Hygiene Plan (CHP) on hazard-
when the chemicals are purchased and give detailed
ous chemicals is the core of the OSHA safety stan-
information about the chemicals and whether they
dard on hazardous chemicals. A written plan must
are a health hazard. The MSDS statements should
specify the training and information requirements
be organized into a notebook for employee use and
of the standard. Certain specific control mea-
located in an area of immediate access by employ-
sures such as fume hoods and glove boxes must be
ees. Every employee who is exposed to or works with
included in the plan. A designated employee is the
chemicals must read the MSDS about those chemi-
chemical hygiene or safety officer. Provisions for
cals and know where the manual is kept. The vari-
housekeeping and maintenance of the facility are
ous chemicals are labeled using the National Fire
Protection Association’s color and number method
(Figure 26-3). There are four colors, each signifying
Critical Thinking a warning to the person handling the chemical(s)
(Figure 26-4). They are:
Compare whom CLIA protects with whom
• Blue signifies a health hazard
OSHA protects. Do they have similar missions?
• Red signifies a flammability hazard
802 UNIT 7 Laboratory Procedures

SAMPLE
CHEMICAL INVENTORY FORM

Office of ____________________________________________________

Date _______________________________________________________

Chemical Name Catalog # Quantity Stores Physical Hazard Class Manufacturer Comments
L./gm. (monthly) State
H F R P

(H) Health (F) Fire Hazard (R) Reactivity (P) Protection

0 - Minimal 0 - Will not burn 0 - Stable is not reactive A. - Goggles
1 - Slightly 1 - Slight with water B. - Goggles/Gloves
2 - Moderate 2 - Moderate 1 - Slight C. - Goggles/Gloves/Apron
3 - Serious 3 - Serious 2 - Moderate D. - Face Shield/Gloves/Apron
4 - Extreme 4 - Extreme 3 - Serious E. - Goggles/Gloves/Mask
4 - Extreme F. - Goggles/Gloves/Apron/Mask
X. - Gloves

Figure 26-1 Sample chemical inventory form for listing chemicals on the premises, including quantity, physical
state, hazard class, manufacturer, and comments. (Courtesy of POL Consultants, 2 Russ Farm, Delanco, NJ 08075.)

• Yellow signifies reactivity or instability hazard cals, how to read and understand the labels on the
• White signifies a special hazard and the use of per- chemicals, where the MSDS manual is kept, when
sonal protective equipment (PPE) to use PPE, and procedures to follow for chemical
spills. The training sessions must be documented,
The numbers 0 to 4 are used in conjunction signed by the employer, and permanently retained
with the colors to indicate the level of risk for each in the employee record (Figure 26-6B).
product and are assigned by the manufacturer
using the rating system. The numbers can be found Requirements of Chemical Hygiene Plan (CHP).
on the MSDS (Figure 26-5). The requirements for a CHP include:
Third, the employer is required to provide a
hazard communication educational program to the • Employers must have an operational written plan
employee within 30 days of employment and before (a manual) relevant to the safety and health of
the employee handles any hazardous chemicals (Fig- employees.
ure 26-6A). The training program should consist of • Written instructions on the use of PPE must be
the location and identification of hazardous chemi- available.
 CHAPTER 26 Safety and Regulatory Guidelines in the Medical Laboratory 803

MATERIAL SAFETY DATA SHEET

I – PRODUCT IDENTIFICATION

COMPANY NAME: We Wash Inc.

Tel No: (314) 621-1818

ADDRESS: 5035 Manchester Avenue Nights: (314) 621-1399
Freedom, Texas 79430 CHEMTREC: (800) 424-9343

PRODUCT NAME: Spotfree Product No.: 2190

Synonyms: Warewashing Detergent

II – HAZARDOUS INGREDIENTS OF MIXTURES

MATERIAL: (CAS#) % By Wt. TLV PEL

According to the OSHA Hazard Communication Standard, 29CFR 1910.1200, N/A N/A N/A
this product contains no hazardous ingredients.

III – PHYSICAL DATA

Vapor Pressure, mm Hg: N/A Vapor Density (Air=1) 60–90F: N/A

Evaporation Rate (ether=1): N/A % Volatile by wt N/A
Solubility in H2O: Complete pH @ 1% Solution 9.3–9.8
Freezing Point F: N/A pH as Distributed: N/A
Boiling Point F: N/A Appearance: Off-White granular powder
Specific Gravity H2O=1 @25C: N/A Odor: Mild Chemical Odor

IV – FIRE AND EXPLOSION

Flash Point F: N/AV Flammable Limits: N/A

Extinguishing Media: The product is not flammable or combustible. Use media appropriate for the primary source of fire.
Special Fire Fighting Procedures: Use caution when fighting any fire involving chemicals. A self-contained breathing
apparatus is essential.
Unusual Fire and Explosion Hazards: None Known

V – REACTIVITY DATA

Stability - Conditions to avoid: None Known

Incompatibility: Contact of carbonates or bicarbonates with acids can release large quantities of carbon dioxide and heat.

Hazardous Decomposition Products: In fire situations heat decomposition may result in the release of sulfur oxides.

Conditions Contributing to Hazardous Polymerization: N/ A

Figure 26-2 Example of a Material Safety Data Sheet (MSDS) listing product name, hazardous ingredients, physi-
cal data, fire and explosion data, reactivity data, health hazard data, emergency and first aid procedures, spill or leak
procedures, protection information/control measures, and special precautions. (Courtesy of POL Consultants,
2 Russ Farm, Delanco, NJ 08075.)
804 UNIT 7 Laboratory Procedures

Spotfree
VI – HEALTH HAZARD DATA

EFFECTS OF OVEREXPOSURE (Medical Conditions Aggravated/Target Organ Effects)

A. ACUTE (Primary Route of Exposure) EYES: Product granules may cause mechanical irritation to eyes.
SKIN (Primary Route of Exposure): Prolonged repeated contact with skin may result in drying of skin.
INGESTION: Not expected to be toxic if swallowed, however, gastrointestinal discomfort may occur.
B. SUBCHRONIC, CHRONIC, OTHER: None known.

VII – EMERGENCY AND FIRST AID PROCEDURES

EYES: In case of contact, flush thoroughly with water for 15 minutes. Get medical attention if irritation persists.
SKIN: Flush any dry Spotfree from skin with flowing water. Always wash hands after use.
INGESTION: If swallowed, drink large quantities of water and call a physician.

VIII – SPILL OR LEAK PROCEDURES

Spill Management: Sweep up material and repackage if possible.

Spill residue may be flushed to the sewer with water.

Waste Disposal Methods: Dispose of in accordance with federal, state and local regulations.

IX – PROTECTION INFORMATION/CONTROL MEASURES

Respiratory: None needed Eye: Safety Glove: Not

glasses required

Other Clothing and Equipment: None required

Ventilation: Normal

X – SPECIAL PRECAUTIONS

Precautions to be taken in Handling and Storing: Avoid contact with eyes. Avoid prolonged or repeated contact with skin.
Wash thoroughly after handling. Keep container closed when not in use.
Additional Information: Store away from acids.

Prepared by: D. Martinez Revision Date: 04/11/XX

Seller makes no warranty, expressed or implied, concerning the use of this product other than indicated on the label. Buyer
assumes all risk of use and/or handling of this material when such use and/or handling is contrary to label instructions.
While Seller believes that the information contained herein is accurate, such information is offered solely for its customers’
consideration and verification under their specific use conditions. This information is not to be deemed a warranty or repre-
sentation of any kind for which Seller assumes legal responsibility.

Figure 26-2 (continued)

 CHAPTER 26 Safety and Regulatory Guidelines in the Medical Laboratory 805

CHEMICAL WARNING LABEL DETERMINATION

The Hazard Communication Act contains specific labeling requirements. Labels must be on all hazardous chemicals that are
shipped to and used in the workplace. Labels must not be removed. Material safety data sheets for all chemicals will be available
to employees.

Manufacturer Requirements: Chemical manufacturers are required to evaluate chemicals, determine status as hazards, provide
material safety data sheets (MSDS), and label all shipped chemicals properly. Manufacturer labels must never be removed. The best
way to determine the hazards of the chemical is to read the MSDS, obtain an OSHA designated list or State Hazardous Substance list.
For most mixed chemicals, it is necessary to contact the manufacturer for MSDS.

Office Chemicals: Search through your office and write down all chemicals you have in the office. Most pharmaceuticals and com-
mon household products do not come under this standard. Ingredients can then be compared to a list of regulated substances or
MSDS sheets will provide necessary information.

Employer’s Responsibility: Any hazardous chemical used in the workplace that is not in its original container must be labeled with
the identity of the chemical and hazards. “Target Organ” chemical labels may be used. The label must include the chemical and com-
mon name, warnings about physical and health hazards, and the name and address of the manufacturer. The employer is to compile
a chemical inventory list that is to be updated as needed. MSDS information should be located in a place where it is accessible to all
employees. Label and MSDS information should be provided during the safety training program.

Identity: The term identity can refer to any chemical or common name des-
ignation for the individual chemical or mixture, as long as the term used is also Chemical Name
used on the list of hazardous chemicals and the MSDS.
Common Name
NOTE: If a chemical is poured into another container for immediate use, it
Manufacturer
does not need to be labeled.

Figure 26-3 Chemical warning label determination indicates necessary information for labels, including manu-
facturer’s requirements, office chemicals, employer’s responsibility, and identity of chemical or its common name.
(Courtesy of POL Consultants, 2 Russ Farm, Delanco, NJ 08075.)

• Fume hoods or biohazard hoods must be checked • Instruction must be provided regarding disposal of
regularly. hazardous waste produced in the workplace. (Usu-
• Training sessions must be held for employees ally a hazardous waste company is contracted by
regarding their right to know what hazardous the employer.)
chemicals are in their work environment. • Each employee’s record must have a written state-
• It is the employer’s legal responsibility to provide ment, signed by the employer, stating the employ-
medical attention for an employee should an acci- er’s responsibility to arrange for employee training
dental chemical spill occur. and a safe work environment.
• The responsibility for executing training sessions,
keeping manuals current, and documentation is Importance of Chemical Standard to
designated to an employer. Medical Assistants. Meeting the require-
ments set forth by OSHA is not optional.
All must comply or face penalties. All employees,
Critical Thinking including medical assistants, have the right to know
and be given information and be educated regard-
Name three other professions beside health ing chemical hazards that they are exposed to in
care that should abide by OSHA regulations. their place of employment. Medical assistants can
For each profession, list four rules that should be exposed to hazardous chemicals through skin
be in place. Do you think they are in place? contact, injection, or inhalation. Because many
laboratory accidents result in chemical-related
806 UNIT 7 Laboratory Procedures

BLUE: HEALTH HAZARD A B C D

4 Danger: May be fatal
3 Warning: Corrosive or toxic
2 Warning: Harmful if inhaled
1 Caution: May cause irritation
0 No unusual hazard

RED: FLAMMABILITY
4 Danger: Flammable gas or extremely flammable liquid
3 Warning: Flammable liquid
2 Caution: Combustible liquid
1 Caution: Combustible if heated Figure 26-5 Four containers are marked using the
0 Noncombustible National Fire Protection Association’s color and num-
ber method for identifying and warning of chemical
hazards. (A) Distilled water: Presents no health, flam-
mability, or reactivity/instability hazard and requires
YELLOW: REACTIVITY/INSTABILITY no PPE when used (all areas are zero). (B) Sodium
hypochlorite: Does not promote a flammability hazard
4 Danger: Explosive at room temperature
(red is zero), is harmful if inhaled (blue is 2), and may
3 Danger: May be explosive if spark occurs or if heated
react or become unstable if heated or mixed with water
under confinement
(yellow is 1). (C) Acetone: Flammable (red is 3), may
2 Warning: Unstable or may react if mixed with water
cause irritation (blue is 1), and is stable/nonreactive
1 Caution: May react if heated or mixed with water
when mixed with water (yellow is zero). (D) Ethyl alco-
0 Stable: Nonreactive when mixed with water
hol: Flammable (red is 3), no unusual health hazards
(blue is zero), and is stable/nonreactive when mixed
with water (yellow is zero).
WHITE: SPECIAL HAZARD/PROTECTION
A Goggles
B Goggles, gloves
C Goggles, gloves, apron
D Face shields, gloves, apron OSHA REGULATIONS
E Goggles, gloves, mask AND STUDENTS
F Goggles, gloves, apron, mask
X Gloves With the passage of the OSHA laws, all students
with potential exposure to chemicals and blood-
Figure 26-4 National Fire Protection Association’s borne pathogens should follow all safety proce-
color and number method. dures as outlined by OSHA. Because students are
not considered employees of a health care facil-
ity and are attending an educational institution,
they do not fall under the OSHA guidelines. They
should, however, take precautions to avoid con-
illnesses, it is important for medical assistants to tact with potentially infectious materials and toxic
understand how the law affects them, their place chemicals wherever learning is taking place.
of employment, and their employer. Medical
assistants and other health care providers should
know what hazards they face, and know the proper
Avoiding Exposure to Chemicals
technique for handling, storing, and disposing of Students may come into contact with harmful
hazardous chemicals. Medical assistants in admin- chemicals when doing procedures that can cause
istrative positions must use their knowledge and such problems as burns to the skin and eyes. Stu-
skills to provide a safe work environment for them- dents will be made aware of these through infor-
selves and their staff. mation packaged with kits and the MSDS. As a
 CHAPTER 26 Safety and Regulatory Guidelines in the Medical Laboratory 807

SAFETY TRAINING CRITERIA SAMPLE

Safety training will be offered to all employees within 30 CERTIFICATE OF TRAINING
days of employment or before the employee assumes
responsibilities that involve exposure to body fluids or
chemicals. First Name Middle Initial Last Name
Items to be covered in training session:
• General explanation of OSHA laws
has completed the
• General explanation of the epidemiology and symptoms
of HBV and HIV
OSHA HAZARD COMMUNICATION
• Who is at risk in office
INFORMATION TRAINING PROGRAM
• Modes of transmission of HBV and HIV
• Method of control in workplace
This certificate indicates your successful participation in a
• Universal Precautions
program instructing you of your rights as a worker and the
• Handwashing
proper handling of hazardous substances in the workplace.
• Personal protective equipment
• How to clean up spills
_____________________ _______________________
• What to do after a needlestick injury
• Medical follow-up after an exposure Date Employee Signature
• Cleaning protocol for office
• Hazardous Communication Standard _______________________
• Types of chemical labels Instructor’s Signature
• How to read MSDS and NFPA signs
• Warning signs _______________________
• How to get MSDS Employer’s Signature
• Location of MSDS
• How to store chemicals Figure 26-6B Sample Certificate of Training shows
• How to record chemical inventory that the employee has completed an OSHA Hazard
• Hazardous Waste laws Communication Information Training Program. (Cour-
• How to comply with laws tesy of POL Consultants, 2 Russ Farm Way, Delanco, NJ
• How to use and label bio-bins and sharps containers 08075.)
• How to keep records
• Who keeps the records
• Medical consent forms
• HBV forms
• Safety training certificate Chemical spills should be carefully cleaned
• Engineering control records following the procedure for the particular chemi-
cal. The same chemical biohazard spill cleanup
kits used in POLs can be used in school laborato-
Figure 26-6A Safety Training Form lists the items to ries. Students should familiarize themselves with
be covered by the employer during OSHA training ses- the contents of the kits and the instructions for use
sions. (Courtesy of POL Consultants, 2 Russ Farm Way, before an actual spill occurs.
Delanco, NJ 08075.) Toxic fumes can occur with certain chemi-
cals and certain tests can cause lung irritation and
damage. This type of chemical should be handled
general rule, if the chemical comes in contact with under a fume hood that will take the fumes away
the skin, it must be flushed with water immediately by means of a ventilation mechanism.
and continued for five minutes. Chemicals that get A student safety laboratory manual outlining
into the eye must be flushed for 15 minutes (unless an exposure control plan with emphasis on Stan-
contradicted on the label). Refer to the MSDS for dard Precautions, PPE, work practice controls,
specific postexposure procotol. Eyewash stations lists of hazardous chemicals, and MSDS should
and showers should be available in case of acciden- be compiled and accessible. Students should be
tal exposure to hazardous chemicals with a follow- thoroughly familiar with its contents. In addition,
up in the emergency department. students should be educated as to the location
808 UNIT 7 Laboratory Procedures

and identification of hazardous chemicals just as published its first standard, Ergonomic Hazards,
employees are. in 1991. At the heart of these guidelines is the
It is of utmost importance that students learn prevention of cumulative trauma disorders.
about and understand the OSHA standards and Cumulative trauma disorders are injuries involv-
comply with them. In so doing, they will safeguard ing the musculoskeletal or nervous system, such
themselves from harmful chemicals and blood- as carpal tunnel syndrome and trigger finger.
borne pathogens. They are the result of long-term, repetitive work
actions, such as gripping, keyboard use, pipet-
ting, and microscopy. Limiting or preventing
CUMULATIVE TRAUMA repetitive work actions is the key to minimizing
DISORDERS cumulative trauma disorders. Use of ergonomi-
cally correct equipment and supplies, proper
OHSA has been focusing its attention on a new work site design, staff training, and job rotation
threat to the workplace: ergonomic hazards. are essential in creating an ergonomically sound
Ergonomics is the study of the workplace. OSHA workplace.

Case Study 26-1 Case Study 26-2

Refer to the scenario at the beginning of the chapter. Marie Tyndall is a student in the Jackson Heights Commu-
Wanda performs the microscopic examination of the urine nity College Medical Assisting Program. She and two other
slide even though the procedure is not a waived test. She classmates have been assigned the project of creating a
compares her findings to Dr. Rice’s assessment. plan for cleaning up spills that might occur in the class-
room laboratory and ensuring that all students using the
CASE STUDY REVIEW laboratory have been trained in the proper procedure.

1. Besides learning more about urine components CASE STUDY REVIEW

and continuing her education, what benefit does
Wanda obtain by putting forth this extra effort? 1. What materials would her group need?
2. Do you think Dr. Rice will appreciate her extra 2. How would her group go about learning the
effort? proper steps in the clean-up process?
3. How would her group ensure that all other students
in the laboratory also have the proper training?

SUMMARY
Infectious diseases and accidents occur through lack of education and carelessness. Medical assistants must
understand the importance of the regulations and guidelines set forth by the federal government and
follow through by helping employers implement them. In doing so, the health and safety of patients and
health care workers will be protected, the spread of infectious diseases can be kept under control, and the
risk for contracting an infectious disease such as AIDS or hepatitis B will be greatly minimized.
Every medical office and ambulatory care setting must, by law, have clearly written and readily avail-
able manuals containing information about Standard Precautions, CLIA ’88, and OSHA for the safe han-
dling, storage, and disposal of blood, body fluids, and chemicals.
Through consistent use of Standard Precautions and adherence to the CLIA and OSHA laws, health
care providers can acquire the behaviors and techniques needed to safeguard themselves and their
patients.
Because of frequent changes in the laws, it is necessary for medical assistants and all other health care
providers to keep abreast of the government mandates.
 CHAPTER 26 Safety and Regulatory Guidelines in the Medical Laboratory 809

STUDY FOR SUCCESS

To reinforce your knowledge and skills of information presented in this chapter:
• Review the Key Terms
• Consider the Case Study and discuss your conclusions
• Answer the Review Questions

° Multiple Choice
° Critical Thinking
• Navigate the Internet by completing the Web Activities
• Practice the StudyWARE activities on the CD
• Apply your knowledge in the Student Workbook activities
• Complete the Web Tutor sections
• View and discuss the DVD situations

REVIEW QUESTIONS
Multiple Choice c. orientation, periodic drills, and consistent
1. Standard Precautions were issued by: enforcement of policy
a. DHHS d. potential fines from regulatory agencies
b. CDC 6. CLIA regulations specify all the following except:
c. CMS a. the type of test performed
d. OSHA b. the personnel involved in testing
2. CLIA ’88 was made law to regulate: c. quality control
a. the disposal of infectious waste d. the methods used in testing
b. the use of chemicals in the workplace 7. The agency charged with implementing CLIA is:
c. laboratory tests performed on specimens taken a. CDC
from the human body b. United States Public Health Service
d. the transmission of the human immuno- c. CMS
deficiency virus (HIV) d. OSHA
3. The core of the OSHA safety standard for chemical 8. Which is not an approved provider for PPMP?
exposure is: a. a physician
a. the dipstick test b. a nurse practitioner
b. the chemical hygiene plan c. a dentist
c. the quantity of chemical stored per month d. a medical assistant
d. the MSDS manual 9. The standard published by OSHA to prevent cumu-
4. The agency that requires employers to ensure lative trauma disorders is:
employee safety concerning occupational exposure a. Workplace Standard
to potentially harmful substances is: b. Standard for Prevention of Cumulative Trauma
a. CDC c. Ergonomic Hazards
b. U.S. Public Health Service d. Ergonomic Standard
c. CMS 10. Match the chemical warning color with the hazard
d. OSHA represented.
5. Successful laboratory safety programs include: 1. Blue a. Reactivity or instability
a. threats to the emotional and physical health of 2. Red b. Use PPE
health care workers 3. Yellow c. Health
b. lost workdays and increased workers’ compen- 4. White d. Flammability
sation claims e. Disaster
810 UNIT 7 Laboratory Procedures

Critical Thinking 2. Go into the FDA’s Web site at http://www.fda.gov

and see if the list of CLIA waived tests on that site
1. Explain the purpose of CLIA ’88 and why the law
differs. What do you think is the reason for the lists
was amended.
being different or the same?
2. Name three categories of testing and explain each
3. While you are searching those two Web sites, find
category.
out what language(s) is acceptable for labels on
3. Discuss the 17 major components of CLIA ’88.
hazardous chemicals.
4. Describe quality control and quality assurance. Why
4. Go to the CDC Web site at http://www.cdc.gov/
are they important?
mmwr and find the report on Good Laboratory
5. What is CMS Form 116? Explain its use.
Practices. Find the seven important criteria to be
6. You have been asked to develop a manual for
considered before introducing a new waived test.
your provider–employer. The manual is to detail a
chemical hygiene plan (CHP) for all employees in
the office. How would you proceed? What should REFERENCES/BIBLIOGRAPHY
be included in the plan? In the CHP include three
major goals that will ensure the provider–employer’s Centers for Disease Control and Prevention. (2007).
compliance with the hazard standard. You have Good laboratory practices for waived testing report.
been asked to compile a manual of the MSDSs. Retrieved December 2008, from http://www.cdc.
What must be included in the manual and from gov/mmwr.
where does the information come? Centers for Medicare & Medicaid Services. Retrieved
October 2008, from http://www.cms.hhs.gov.
U.S. Food and Drug Administration. (2004). Databases
WEB ACTIVITIES on the FDA web site. Retrieved October 2008, from
http://www.fda.gov/search/databases.html.
1. Using the Internet, go to http://www.cms.
hhs.gov and search for the list of CLIA
waived tests. Is this list extensive/brand spe-
cific or general?

THE DVD HOOK-UP

This chapter discusses safety and regulatory guidelines for What would you do if you found out that your employer was
the medical office. running tests that he should not, based on the office’s CLIA
Both the chapter and selected DVD scene discuss the three classification?
major categories for testing.
1. What is the most common category that medical
offices fall into for laboratory testing? Why?
2. In a waived laboratory, which personnel have the
authority to perform microscopy? DVD Series Program Number
3. What does CLIA stand for and who oversees CLIA? Skills Based Series 11
Chapter/Scene Reference
DVD Journal Summary
• Introduction to Venipuncture, Hematology,
Write a paragraph that summarizes what you learned from and Immunology Procedures
watching the selected scene from today’s DVD program.
 Chapter
Introduction to the
Medical Laboratory 27
KEY TERMS OUTLINE
Assay The Laboratory Instrument Validations
Asymptomatic Purposes of Laboratory The Medical Assistant’s Role
Baseline Values Testing Laboratory Requisitions and
Biopsy Types of Laboratories Reports
Laboratory Personnel Specimen Collection
Clinical Chemistry
Laboratory Departments Proper Procurement, Storage,
Clinical Diagnosis
Panels of Laboratory Tests and Handling
Condenser Billing for Laboratory Services Processing and Sending
Control Test Quality Controls/Assurances in Specimens to a Laboratory
Culture and the Laboratory Microscopes
Sensitivity (C&S) Control Tests Types of Microscopes
Cytology Proficiency Testing How to Use a Microscope
Diagnosis Preventative Maintenance How to Care for a Microscope
Diaphragm
Differential Diagnosis
DNA
Electrolyte OBJECTIVES
Glucose The student should strive to meet the following performance objectives and dem-
Hematology onstrate an understanding of the facts and principles presented in this chapter
Histology through written and oral communication.
Hormone Replace- 1. Define the key terms as presented in the glossary.
ment Therapy
(HRT) 2. Explain the purposes of laboratory testing.
Hospital-Based 3. Describe the main similarities and differences between indepen-
Laboratories dent laboratories and physicians’ office laboratories.
Immunohematology 4. Explain the levels of laboratory personnel in relation to their
Immunology education, skills, and duties.
Invasive 5. List eight different departments within the medical laboratory
Microbiology and list at least two types of testing performed within each of
Mycology those departments.
Objective 6. Name nine of the most common laboratory panels and explain
the body system or function being surveyed.
Panel
Parasitology 7. Explain the concepts of quality control and quality assurance in
the medical laboratory.
Patient Service
Centers 8. Describe at least three methods of ensuring quality in the medi-
Peak cal laboratory.
Physician’s Office 9. Demonstrate how to correctly complete a laboratory requisition.
Laboratory (POL)

811
OBJECTIVES (continued) KEY TERMS
10. List 10 pieces of information required on a written laboratory
(continued)
requisition. Qualitative Test
11. Explain the rationale behind proper patient preparation before Quantitative Test
laboratory testing. Reagent
12. Explain where accurate and reliable information might be Reference Laboratories
obtained about proper procurement, storage, and handling of
Reference Values
laboratory specimens.
Requisition
13. On a diagram, label the parts of a compound microscope.
Serum
14. Explain the function of a compound microscope.
Therapeutic Drug
15. Demonstrate the proper use of a compound microscope. Monitoring (TDM)
16. List six rules to ensure proper care of a compound microscope. Toxicology
Trough
Urinalysis
Virology

Scenario
Dr. Susan Rice’s patient, Annette Samuels, has come it, transfers a portion of the urine into a urine transport
into the Inner City Health Care clinic complaining of tube, places the tube into a biohazard transport bag,
lower abdominal cramps and burning when she uri- and completes a lab requisition for a culture and sen-
nates. After discussion of her symptoms and a brief sitivity test. The requisition and lab specimen are then
examination, Dr. Rice’s clinical diagnosis is urinary ready to be sent to the outside lab for testing. Wanda
tract infection. She asks Wanda Slawson, CMA (AAMA), performs a urinalysis on the remaining urine sample,
to obtain a urine sample for a urinalysis and culture and the test confirms Dr. Rice’s clinical diagnosis of
with sensitivity. The urinalysis is to be performed in the a urinary tract infection. Dr. Rice is able to prescribe
physician’s office laboratory (POL) within the Inner City an antibiotic for Annette while waiting for the culture
Health Care clinic, and a portion of the sample will results. The culture will determine what type of bacteria
be sent to an outside independent lab for the culture is in the urine, and the sensitivity will assure Dr. Rice
and sensitivity testing. Wanda gives Annette specific that the proper antibiotic was prescribed. The culture
instructions on how to prepare for the urine test and will take 24 to 48 hours, so Wanda assures Annette
how to collect the urine. She asks Annette if she has that she will contact her the next day when the report
any questions and she has Annette repeat the instruc- is received. A return appointment is made for Annette
tions to be sure she understands them. When Annette for a follow-up check and urinalysis in about 10 days.
returns with the specimen, Wanda immediately labels

INTRODUCTION
Providers use laboratory tests to diagnose illnesses, assess patient preparation, obtaining specimens, and testing
patients’ health, and manage chronic diseases such as or sending specimens to an independent laboratory. It is
diabetes and arthritis. Medical assistants in providers’ important for medical assistants to be aware of laboratory
offices, clinics, and laboratories may be responsible for procedures to ensure accurate testing.

812
 CHAPTER 27 Introduction to the Medical Laboratory 813

To Record an Individual’s State of Health.

Spotlight on Certification Blood tests may be performed periodi-
cally, usually during a routine physical
RMA Content Outline examination, to be assured of healthy normal
• Medical law ranges, also known as reference values. Then in
• Laboratory procedures the future, if illness occurs, the baseline values are
available for comparison.
CMA (AAMA) Content Outline
• Medicolegal guidelines and To Satisfy Employment, Insurance, or Legal
requirements Requirements. If an accident occurs, quite often
• Principles of infection control blood is tested for the presence of drugs and alco-
• Principles of operation hol. Such a determination can prove a person
• Processing specimens guilty or innocent of a crime. Sometimes, places of
• Quality control employment or life insurance companies request
laboratory tests to be assured that their employees
CMAS Content Outline or clients are free of illegal or dangerous drugs.
• Legal and ethical considerations Employment-required drug and alcohol testing is
• Asepsis in the medical office a classic example of this reason for testing.
• Supplies and equipment
To Gain Statistics for Research and Clinical
Trials. Laboratory tests are sometimes a part of
the data gathered for research and for clinical
THE LABORATORY trials information. When we read about the rela-
tion between osteoporosis and hormone replace-
The current health care environment offers ment therapy (HRT), the information is gathered
numerous options in the methods used to process through research. Clinical trials might address the
laboratory tests. efficacy of certain medications, vitamins, and min-
erals on osteoporosis in women receiving HRT.
• The specimen may be obtained and the test per-
formed within the physician’s office laboratory To Detect Asymptomatic Conditions or Dis-
(POL). eases. Occasionally, a patient has no complaints
of illness and is asymptomatic—that is, exhibits no
• The specimen may be procured and packaged for
symptoms that might be associated with a disease
transport to a separate laboratory.
process—but during routine screening or testing
• The patient may be referred to a separate labora- in another, perhaps unrelated, area, a disorder may
tory for collection and testing of the specimen. be discovered. An example is a young man present-
ing at the office for an athletic physical. Routine
Each laboratory setting has specific urinalysis reveals he has a mild bladder infection.
requirements for the training and quali-
fications of the health care personnel To Confirm a Clinical Diagnosis. When a patient
who work in that setting. The equipment, supplies, reports specific symptoms and describes a par-
and paperwork, as well as the instructions given to the ticular condition (subjective information), and
patient, are also determined by the type of laboratory. data are compiled through a clinical examina-
Whichever laboratory setting is selected, the focus tion (objective information), the provider may
should be on the safety of the public, the patient, and be able to determine a diagnosis without the aid
the health care personnel, while always maintaining of laboratory tests. This is referred to as a clini-
quality testing to ensure accurate results. cal diagnosis. To confirm a clinical diagnosis, the
provider orders laboratory tests. For example, a
child has symptoms of a strep throat infection
Purposes of Laboratory Testing such as sudden onset of sore throat, fever, head-
Physicians depend on the ability of medical labo- ache, and upset stomach. On visual examination,
ratories to help in determining a patient’s state the provider discovers small abscesses on the
of health or disease in some of the following child’s tonsils. The provider is almost certain that
ways. the diagnosis will be strep throat, but a quick and
814 UNIT 7 Laboratory Procedures

simple strep test is performed to confirm the clin- To Prevent Diseases/Disorders. Protection of the
ical diagnosis. public, families, and coworkers can warrant labo-
ratory tests. An example is protecting an unborn
To Differentiate between Two or More Diseases. child from contracting genital herpes through the
Sometimes, a patient presents with a combination birthing process. A culture of the mother’s cervi-
of symptoms that can be related to more than cal and vaginal mucosa helps to determine if the
one condition. For the provider to diagnose accu- child is at risk. If the culture is positive, perform-
rately, a laboratory test is performed. In situations ing a caesarean section is the treatment of choice
such as these, the provider chooses to perform to protect the newborn from contracting herpes.
the simplest and least invasive laboratory test to Because a newborn’s immune system is not fully
rule out a particular disease before requiring developed, contracting herpes can cause serious
more extensive testing. This is known as a differ- illness and even death.
ential diagnosis. For example, if the child in the
preceding case had a negative strep test but per- To Prevent the Exacerbation of Diseases.
haps exhibited other more systemic symptoms, Patients with chronic conditions require regular
a blood test might confirm mononucleosis or blood tests to prevent exacerbation of the disease.
another condition. The provider is then able to When the results of the blood test are obtained,
differentiate between the two diagnoses—strep the provider or patient determines whether it is
throat and mononucleosis. necessary to adjust the diet or medication. For
example, a patient with diabetes tests his or her
To Diagnose. If symptoms are vague, thereby mak- blood regularly to measure the blood sugar, or glu-
ing the clinical diagnosis difficult for the provider, cose, level. If the blood sugar level is too high or
a series of laboratory tests may be required. Some- too low, the patient may adjust the insulin dosage
times a panel, or group of related tests, is ordered. or have something to eat to return the blood sugar
This helps narrow the field for diagnosis. For level to normal.
example, a patient presents with reports of severe
fatigue, but preliminary testing does not indicate
a diagnosis. Further testing will eventually either
Types of Laboratories
lead the provider in a specific direction or at least There are many different types and locations of
eliminate a wide variety of conditions. medical laboratories. They are identified by their
size, capabilities, and affiliations. Independent lab-
To Determine the Effectiveness of Treatments. oratories may be located within medical centers or
After a patient has been diagnosed and has begun large clinics. They often have small satellite patient
treatment, the provider monitors the patient’s service centers located near more isolated medi-
health to be sure that the treatment is therapeu- cal facilities or in areas of convenience to patients.
tic. For example, a patient diagnosed with epi- Satellite laboratories facilitate patients’ specimens
lepsy must take an effective amount of antiseizure being obtained closer to their neighborhoods and
medication. A blood test is used to check the level ambulatory care settings. The specimens are usu-
of medication in the patient’s system. Sometimes ally couriered back to the independent central
the provider wants to know the highest and low- laboratory for processing.
est ranges of medication in the patient’s blood to Hospital-based laboratories perform most of
determine if the levels are within a therapeutic the tests required by that hospital area, but even
range, called therapeutic drug monitoring (TDM), large hospitals use reference laboratories for spe-
and to check for drug toxicity (if the drug level is cialized testing. Reference laboratories are indepen-
too high). To measure the highest level of medi- dent, regionally located laboratories that service
cation in the patient’s blood serum (called the larger areas. Reference laboratories are used by
peak), the specimen is taken about a half hour hospitals and providers for complex, expensive, or
after the patient has taken his or her regular dose specialized tests.
of medicine. To measure the lowest level (called In a business sense, medical laboratories
the trough), the specimen is taken just before the are quickly becoming more and more
patient takes his or her next scheduled dose of competitive. Growth and profitability
medicine. A periodic blood test can also be used to depend on community relations and service,
determine the effectiveness of dietary and lifestyle convenience, efficiency, cost, location, and even
changes in reducing blood cholesterol levels. reputation. Competition often places the medi-
 CHAPTER 27 Introduction to the Medical Laboratory 815

cal assistant and other medical personnel in a contained kits, tests for strep throat, pregnancy,
position of being asked to recommend a particu- blood sugar (serum glucose) levels, and hidden
lar medical laboratory over another. Unless the (occult) blood in stool can be performed quickly.
provider has a valid reason for using a particular Other kits are being developed daily. Patients may
laboratory or not referring to a particular labo- use a kit that can be purchased without a prescrip-
ratory, the patient should choose the laboratory. tion at home. Some of the home kits available to
The patient’s insurance plan may also be a factor the general public are “just as accurate” as the kits
in determining which laboratory is used. Many used in medical offices. The major difference is
insurance plans require the patient to use a par- that the person performing the test may not be
ticular laboratory or to choose a laboratory from trained, which may affect the accuracy of the test
those participating in the plan to guarantee pay- results. Consistent quality control measures might
ment for the tests. The medical assistant is then not be used by the nonmedical person (see Qual-
a resource for options rather than a referral ser- ity Control/Assurances in the Laboratory section).
vice. The law is clear that a provider may not have For example, a pregnancy test kit may be exposed
a financial interest in the laboratory to which he to extreme temperatures while in the patient’s care,
or she refers patients. on a grocer’s shelf, or in the patient’s home. These
extreme temperatures may invalidate the chemical
Point-of-Care Testing (POCT). With the many reaction in the test kit. More training, education,
changes in health care delivery and managed care, and credentialing are required as the complexity
the clinical laboratory is also experiencing changes of the testing and equipment increases. (See CLIA
to improve clinical services in the laboratory area. ’88 in Chapter 26 for specific testing parameters.)
On the forefront of change in the laboratory is If the results are not within normal limits, the pro-
POCT, also referred to as near-patient testing or vider needs to be consulted for confirmation and
bedside testing. Medical conditions, location of diagnosis/treatment.
the patient, and treatment methods often require
laboratory results as quickly as possible so proper Laboratory Personnel
medical care can be administered without delay.
POCT uses small instruments that provide rapid, All independent medical laboratories must be
accurate results when used correctly. managed by a pathologist, a physician who special-
Medical personnel can be trained to do lab- izes in disease processes. Additional staffing con-
oratory tests of moderate complexity (as defined sists of clinical laboratory scientists, technicians,
by CLIA ’88) during POCT. The laboratory staff, clinical laboratory assistants, phlebotomists, and
because of their education, knowledge, and expe- medical assistants. Many agencies certify labora-
rience in this area, are responsible for advice and tory personnel.
management of the quality control and various Table 27-1 gives specific information about
aspects of this new area of testing. The extension laboratory personnel, their titles, training required,
of this laboratory service demands cooperation and duties performed within the clinical lab.
and cross-departmental efforts from all nontradi-
tional personnel in the health care facility. POCT
also has provided new career tracks for the labora-
Laboratory Departments
torian, together with multiple skills for several dis- Laboratories are usually divided into departments
ciplines of health care providers. and may even be subdivided, depending on the size
and specialties within the laboratory (Figure 27-1).
POLs. POLs are those laboratories physically set The various departments perform special tests cat-
within the office. Some of the more commonly per- egorized within their expertise (Table 27-2). Cat-
formed medical laboratory tests can easily and inex- egorization becomes evident when test results are
pensively be performed in the office by the medical requested over the telephone or whenever there
assistant. With a simple fingerstick and a few read- is a need to converse with laboratory personnel.
ily available medical supplies, a patient’s blood glu- Through knowledge of the various departments
cose levels can be determined. Another commonly within the laboratory, information can be more
performed test in the ambulatory care setting is readily obtained.
urinalysis, in which urine is physically, chemically,
and microscopically examined for irregularities. Hematology Department. The hematology depart-
With the availability of the many varieties of self- ment tests the formed (cellular) elements of the
816 UNIT 7 Laboratory Procedures

Table 27-1 Laboratory Personnel

Credential/Title Education Required Duties Performed

Board-certified medical doctor or Director of the lab

Physician Pathologist (MD) PhD scientist (either must be CAP Manages the laboratory
or Scientist (PhD) accredited)
Interprets biology results, Pap smears, and
other cytology samples

Bachelor’s degree in life sciences or Qualified to perform analysis testing in all

medical technology, including 3 years departments of the lab
of course work and 1 year of clinical Has leadership role; often trains, manages,
experience. and supervises other lab personnel
Clinical Laboratory Scientist Must be certified by ASCP, AMT, DHHS, May perform routine lab tests as well as
(CLS) or Medical Technolo- ISCLT, NCA, or NRM highly specialized lab tests
gist (MT) or Registered Medi- Troubleshoots problems with results, speci-
cal Technologist (RMT) mens, and/or instruments
Clinical Laboratory Works directly with the lab director/manager
Technologist (CLT)
Performs quality control checks
Evaluates new instruments
Implements new test procedures
Often specializes in one area within the lab

Medical Laboratory Techni- Usually has associate’s degree or cer- Performs routine tests
cian (MLT) tificate from an accredited MLT/CLT Performs microscopic exams and utilizes
Clinical Laboratory Techni- program other lab equipment
cian (CLT) May be certified by ASCP or NCA May specialize in one area in the lab

Phlebotomist/Phlebotomy High school and additional phle- Performs venipuncture and skin puncture
Technician (PBT)–ASCP botomy training through a certificate May perform CLIA waived testing
Registered Phlebotomy program or on-the-job training
Collects specimens
Technician (RPT)–AMT May be certified through ASCP, AMT,
Processes specimens for transport
Certified Phlebotomy ASPT, or NCA, and registered under
Technician (CPT)–ASPT state law
Clinical Laboratory
Phlebotomist (CLP)–AMT

Generally an associate’s degree or May perform routine specimen procurement

certificate from an ABHES- or CAAHEP- and waived testing as well as administrative
Certified Medical Assistant accredited program in a community duties, receptioning, computerized record
(CMA)–AAMA college, technical school, or propri- keeping, and billing
Registered Medical Assistant etary school Often works in POL
(RMA)–AMT May be certified through AAMA or AMT
May be registered under state law

Credentialing Associations: AAMA: American Association of Medical Assistants; ABHES: Accrediting Bureau of Health Education Schools; ASCP:
American Society of Clinical Pathologists; ASPT: American Society for Phlebotomy Technicians; AMT: American Medical Technologists; CAAHEP:
Commission on Accreditation of Allied Health Education Programs; CAP: College of American Pathologists; DHHS: Department of Health and Human
Services; ISCLT: International Society of Clinical Laboratory Technology; NCA: National Credentialing Agency for Medical Laboratory Personnel; NRM:
National Registry of Microbiologists.

blood. These tests may be quantitative or qualitative. the components, such as the size, shape, and maturity
The quantitative tests involve actual number counts of the cells. In addition, the hematology department
such as counting the number of white blood cells tests the ability of the blood components to perform
(WBC), red blood cells (RBC), or platelets. The qual- their individual tasks correctly. An example is testing
itative tests focus on the quality or characteristics of the coagulation ability of clotting factors in blood.
 CHAPTER 27 Introduction to the Medical Laboratory 817

Administrator

Pathologist

Laboratory Manager
or
Chief Technologist

Assistant
Laboratory Manager

Anatomic Hematology Chemistry Immunohematology Microbiology Specimen Collecting DNA

Pathology Immunology and Processing
Toxicology

Phlebotomy
Cytology Histology Routine Routine Immunohematology Bacteriology
Hematology Chemistry (Blood Bank) Processing
Mycology

Coagulation Special Immunology Parasitology

Chemistry (Serology)
Virology
Urinalysis

Figure 27-1 Departments of a typical medical laboratory.

Urinalysis Department. Urinalysis is the physical, against one’s own body (autoimmune), as in rheu-
chemical, and microscopic examination of urine. matic diseases such as rheumatoid arthritis and
Required cultures are sent to the microbiology or lupus erythematosus. Diseases such as AIDS have
bacteriology department. In a large laboratory, helped move laboratory evaluation of the cellular
the urinalysis department is often located under immune system out of the research setting and into
hematology because of the microscopic examina- the diagnostic setting of the medical laboratory.
tions performed on urine (Figure 27-2). Molecular biology and flow cytometry are becom-
ing commonplace in today’s medical laboratory.
Clinical Chemistry Department. The clinical Traditionally, serology has been an area within the
chemistry department analyzes the chemical com- microbiology department, but with the introduc-
position of blood, cerebrospinal fluid, and joint tion of many new immunologic techniques, most
fluid. Some of the procedures within this depart- medical laboratories now include a separate immu-
ment include assay of enzymes in the serum, serum nology department.
glucose, or electrolyte levels. Toxicology, including
TDM and identification of drugs of abuse, is also Toxicology. The toxicology department tests for
performed in this department. toxic substances in a person’s blood and monitors
any drug usage, therapeutic levels of medication
Immunohematology (Blood Bank) Department. prescribed, or toxicity to the drugs being used.
Immunohematology is a special area that deals with Medications commonly monitored for toxicity are
blood typing procedures, cross-matching, and the digoxin, phenobarbital, lithium, and pain manage-
separation and storage of blood components for ment drugs. Blood tests also determine levels of
transfusion, as well as antibody-antigen reactions. occupational exposure to metals and chemicals in
the course of one’s employment. Testing for drug
Serology (Immunology) Department. The serol- usage/toxicity is now required in a growing num-
ogy (immunology) department is the area of the lab- ber of pre-employment physical examinations.
oratory that performs tests to evaluate the body’s Toxicity levels for chemicals and metals include
immune response, both production of antibodies lead, zinc, iron, copper, arsenic, and carbon diox-
and the cellular immune response. Procedures ide. The Department of Social and Health Services
in this area include the detection of antibodies to requires toxicology tests in child protection cases.
bacteria and viruses, as well as antibodies produced Drug testing is often required for special assistance
818 UNIT 7 Laboratory Procedures

Table 27-2 Categories of Laboratory Tests

HEMATOLOGY

White blood cell (WBC) count Hematocrit (Hct)

Red blood cell (RBC) count Prothrombin time (PT)
Differential white blood cell count (Diff) Erythrocyte sedimentation rate (ESR)
RBC indices Platelet count
Hemoglobin (Hgb)

CLINICAL CHEMISTRY

Glucose Potassium
Blood urea nitrogen (BUN) Bilirubin
Creatinine Cholesterol
Total protein Triglycerides
Albumin Uric acid
Globulin Lactate dehydrogenase, LD (LDH)
Calcium Aspartate aminotransferase, AST (SGOT)
Inorganic phosphorus Alanine aminotransferase, ALT (SGPT)
Chloride Alkaline phosphatase
Sodium Phospholipids

SEROLOGY (IMMUNOLOGY/IMMUNOHEMATOLOGY) AND BLOOD BANKING

Syphilis detection tests (VDRL, RPR) Rheumatoid Arthritis factor (RA factor)
C-reactive protein test (CRP) Mono test
ABO blood typing Heterophil antibody titer test
Rh typing Hepatitis tests
Rh antibody titer test HIV tests: ELISA and Western blot
Cross-match Antistreptolysin O (ASO) titer
Direct Coombs’ test Pregnancy tests
Cold agglutinins

URINALYSIS

Physical analysis of urine: Bilirubin

Color Urobilinogen
Clarity Nitrite
Specific gravity Leukocyte esterase
Chemical analysis of urine: Microscopic analysis of urine:
pH Red blood cells
Glucose White blood cells
Protein Epithelial cells
Ketones Casts
Blood Crystals
(continues)
 CHAPTER 27 Introduction to the Medical Laboratory 819

Table 27-2 (continued)

MICROBIOLOGY

Candidiasis Pneumonia
Chlamydia Streptococcal sore throat
Diphtheria Tetanus
Gonorrhea Tonsillitis
Meningitis Tuberculosis
Pertussis Urinary tract infection
Pharyngitis

PARASITOLOGY

Amebiasis Scabies
Ascariasis Tapeworm disease (cestodiasis)
Hookworm disease Toxoplasmosis
Malaria Trichinosis
Pinworm disease (enterobiasis) Trichomoniasis

CYTOLOGY

Chromosome studies
Pap test

HISTOLOGY

Tissue analysis
Biopsy studies

DNA

DNA tests compare individuals according to their indi-

vidual genotype

TOXICOLOGY

Tests for chemicals, specifically for drugs and other tox-

ins in blood

in low-income housing and other public financial Microbiology Department. The microbiology
assistance programs. The reasons for drug testing department is the area in the laboratory where
are wide and varied and are growing every year, microorganisms such as bacteria and fungi are
making this department larger than in the past. grown in an appropriate medium, cultured, and
then identified. Sensitivity tests are then performed
DNA. The second area within the medical laboratory to identify which antibiotics can effectively eradi-
growing larger each year is the DNA department. cate the pathogenic organisms. The combination
With the advent of DNA tests for proving paternity of culturing and identifying the best antibiotic is
and maternity of children and the growing use of called culture and sensitivity (C&S). Mycology is an
DNA testing for criminal cases, DNA testing is quickly area within the microbiology department where
becoming a major focus in many laboratories. fungi are studied. Virology is an area within the
820 UNIT 7 Laboratory Procedures

current list of CMS-approved organ- and disease-

oriented panels, see Table 27-3.
Medicare requires that providers order tests
under their approved panels. Providers may not
refer to panels under other names such as the
previously named Chem Screen, SMAC, Chem 7,
and so on. The panels listed in Table 27-3 are the
only panels allowed. If a provider would like a spe-
cific series or combinations of tests under a special
panel, he or she must apply to the CMS for the
approval to design their own panel.

BILLING FOR LABORATORY

SERVICES
Figure 27-2 Clinical reference laboratories may have
a separate urinalysis department where the laboratory Providers must justify which lab tests are ordered
professional tests urine for physical, chemical, and by using the correct diagnosis code. For example,
microbiological properties. if the diagnosis is pneumonia, a urinalysis would
not be justified and would not be covered. If a pro-
vider wants to order a test that probably will not
be covered by insurance under CMS guidelines,
microbiology department where viruses are stud- the patient should sign a waiver. Medicare patients
ied. would sign an Advance Beneficiary Notice (ABN).
The waiver/ABN notifies the patient that the test
Parasitology Department. Parasitology is a sub- might not be covered and that the patient will have
division of the microbiology department where to pay for it. If the clinic fails to notify the patient,
ova and parasite (O&P) tests are performed the patient does not have to pay for the test, and
on specimens such as feces. The specimens are the provider is liable for the charges.
examined for the presence of parasites or their
eggs.

Cytology Department. The cytology department

QUALITY CONTROLS/
is the area in which microscopic examinations of ASSURANCES IN THE
cells are performed to detect early signs of cancer LABORATORY
and other diseases. The Papanicolaou test, known
as the Pap smear, for irregular cervical cells is an The accuracy of any laboratory test result
example of a test performed in the cytology depart- depends on all safeguards being followed. These
ment. standards ensure the quality of the testing equip-
ment, supplies, personnel, and the accuracy of
Histology Department. Histology is the study of the test results. Many factors can compromise
tissue sample biopsies for the determination of dis- the accuracy of laboratory test results. Among
ease. Frozen samples or biopsies are sliced/stained these factors are collection of specimen, temper-
and then microscopically examined for cancer and ature, amount or age of specimen, time limits of
other anomalies. test, and using chemicals or reagents past their
expiration dates. Even when laboratory guide-
lines are strictly followed, inaccurate results
Panels of Laboratory Tests may be obtained by using test kits that have
Laboratory tests are often categorized into related been exposed to extreme heat or cold, or using
groups to provide information about a particu- chemicals or reagents after their expiration. It is
lar body system or related bodily function. The important to follow all laboratory guidelines, but
groups are usually referred to as panels, formerly the medical assistant must also confirm that the
called “profiles.” In addition, laboratory tests are specimen, chemicals, and test kits are handled
organized into panels for ease of ordering. For a and processed properly.
 CHAPTER 27 Introduction to the Medical Laboratory 821

Table 27-3 Centers for Medicare and Medicaid Services (CMS) Approved Organ- and Disease-
Oriented Panels (with Current Procedural Terminology [CPT] Codes), Updated October 2008

BASIC METABOLIC PANEL (CPT CODE 80048)

BUN (84520) Creatinine (82565)
Calcium, total (82310) Glucose (82947)
Carbon dioxide (82374) Potassium (84132)
Chloride (82435) Sodium (84295)

GENERAL HEALTH PANEL (CPT CODE 80050)

Comprehensive metabolic panel (CPT code 80053) CBC w/manual differential (80054) or CBC w/automated
TSH (84443) differential (85025)

ELECTROLYTE PANEL (CPT CODE 80051)

Carbon dioxide (82374) Chloride (82435)

Potassium (84132) Sodium (84295)

COMPREHENSIVE METABOLIC PANEL (CPT CODE 80053)

Albumin (82040) Creatinine (82565)
Alkaline phosphatase (84075) Glucose (82947)
Bilirubin, total (82247) Potassium (84132)
BUN (84520) Protein, total (84155)
Calcium, total (82310) Sodium (84295)
Carbon dioxide (82374) SGOT (AST) (84450)
Chloride (82435) SGPT (ALT) (84460)

OBSTETRIC PANEL (CPT CODE 80055)

CBC w/manual differential (80054) or CBC w/automated Syphilis test, qualitative (e.g., VDRL, RPR) (86592)
differential (85025) Antibody screen, RBC (86850)
Hepatitis B surface antigen (87340) Blood typing, ABO (86900) and Rh (D) (86901)
Rubella antibody (86762)

LIPID PANEL (CPT CODE 80061)

Cholesterol (82465) Triglyceride (84478)

HDL cholesterol (83718) and LDL cholesterol, calculated

RENAL FUNCTION PANEL (CPT CODE 80069)

ALBUMIN (82040) Creatinine (82565)

BUN (84520) Glucose (82947)
Calcium, total (82310) Phosphorous (84100)
Carbon dioxide (82374) Potassium (84132)
Chloride (82435) Sodium (84295)

ARTHRITIS PANEL (CPT CODE 80072)

Uric acid (84550) Fluorescent noninfectious agent, screen (86255)

ESR, erythrocyte sedimentation rate (85651) Rheumatoid factor, qualitative (86430)

ACUTE HEPATITIS PANEL (CPT CODE 80074)

Hepatitis A antibody, IgM (86709) Hepatitis B surface antigen (87340)

Hepatitis B core antibody, IgM (86705) Hepatitis C antibody (86803)

HEPATIC FUNCTION PANEL (CPT CODE 80076)

Albumin (82040) Protein, total (84155)

Alkaline phosphatase (84075) SGOT (AST) (84450)
Bilirubin, direct (82248) SGPT (ALT) (84460)
Bilirubin, total (82247)

TORCH ANTIBODY PANEL (CPT CODE 80090)

Cytomegalovirus antibody, IgG (86644) Rubella antibody, IgG (86762)

Herpes simplex (1 & 2) antibody, IgG (86694/86695) Toxoplasmosis antibody (86677)
822 UNIT 7 Laboratory Procedures

Control Tests The Medical Assistant’s Role

To further ensure accurate test results, control Medical assistants are educated to perform admin-
test samples are tested together with the patient’s istrative office duties, prepare patients, collect
sample. The control samples have a known value, specimens, and perform waived tests in such a
negative or positive result, or abnormal or normal manner that patients and health care person-
result, which is compared with the results of the nel are safe from contamination, patients are not
patient’s test. One of the purposes of this control harmed, samples are reliable, and tests are accu-
measure is to minimize human error. By being able rate. These four aspects of quality laboratory test-
to compare a sample of known value or positive ing are critical for accuracy. When the patient is
or negative test result with the patient’s test, the prepared properly, the specimen is obtained as
health care worker performing the test can accu- expertly as possible, the reagents and equipment
rately determine the result. An error in the testing are in the best condition and calibration possible,
method may be discovered if the control sample and the test is performed by a trained professional,
does not test accurately. the test results will be accurate.
Another purpose of the control test is to
check the reagents or chemicals. If the control sam-
ple is not showing accurate results, it may be deter- LABORATORY REQUISITIONS
mined that the chemicals (reagents) are faulty or AND REPORTS
have expired. On receiving any test in the POL,
the person responsible for quality assurance and A written requisition for laboratory work must
quality control (probably the medical assistant per- be sent to the laboratory with the patient or with
forming the tests) should perform the calibration the specimen (Figure 27-3). These forms are pre-
or control test provided by and as directed by the printed with the most commonly requested tests
manufacturer. This ensures proper test function. separated into logical categories. Additional space
is provided for writing special requests. The labo-
ratories that patients use can provide your medical
Proficiency Testing agency with these forms. Laboratory requisition
CLIA ’88 requires laboratories to participate in an forms are computer generated, and the provider’s
accredited proficiency program for certain iden- name, address, and other information necessary
tified tests (see Chapter 26 for CLIA ’88 require- for proper reporting and recordkeeping are often
ments). Proficiency testing is similar to quality pre-printed on the forms. If the requisitions are
control in that “known” proficiency samples are not preprinted, spaces are provided for the infor-
tested the same as patient samples. The difference mation to be written in. The information must be
is an approved outside agency evaluates the accu- complete, accurate, and clearly legible. A properly
racy of the testing and submits the performance completed requisition contains the following data:
records to CMS for CLIA ’88 compliance.
• Provider’s name, account number, address, and telephone
number. This information is necessary to contact
Preventative Maintenance the office for any clarification or further informa-
tion and to report the results.
Preventative maintenance helps identify potential
problems before they actually occur. Procedures • Patient’s name, address, and telephone number. Be sure
include manufacturer-recommended maintenance the name is complete and spelled correctly. Avoid
on equipment; daily temperature checks on refrig- using alternate versions of the patient’s name with-
erators, freezers, and incubators; daily checks on out also including the proper, legal name. Make
expiration dates of reagents and supplies; and certain to include apartment numbers and zip
instrument log and centrifuge checks. codes. This information will be used for billing
purposes, as well as medical records. Social Secu-
rity numbers and middle initials are helpful when
Instrument Validations it is necessary to differentiate between patients.
The quality of test results can be ensured by consis- • Patient’s billing information, insurance, and identi-
tently checking the calibration and linear range of fication number. Because the patient is often not
the instruments and machines. If the equipment is the person who is the subscriber to the insur-
not maintained or is functioning improperly, accu- ance, the subscriber’s name, address, telephone
rate test results cannot be ensured. number, and insurance identification numbers
 CHAPTER 27 Introduction to the Medical Laboratory 823
Requested By

Courtesy Copy/Comments

Chart Number Pre-Op? Surgery Date Insurance Company (Name/Billing Address)

Insurance Information
Y N
Patient Information

Social Security Number Sex Date of Birth (required)

Patient Name Guarantor (Responsible Party)

State
REQUIRED
Mailing Address

Zip Patient Phone

City
REQUIRED
Insurance Number

Medicare Number

ICD.9 Diagnosis Code(s) Physician Notice: For reimbursement, Medicare requires ABN signature
review (see reverse side) be made for the following tests in bold, that may NOT
REQUIRED be covered under “Medical Necessity”.
STAT Phone Results # Fasting Last Dose Collected By Date
ASAP
ROUTINE
Comments/Additional Tests
FAX Report # hrs
Medication
Date/Time ID REQUIRED Time

SS = SST L = LAV B = BLUE R = RED G = GRAY GN = GREEN PK = PINK U = URINE C = CULTURE S = SERUM FROZEN BIOPSY SLIDES
COLL COLL COLL COLL
Alphabetical Test Listing CODE Alphabetical Test Listing CODE Alphabetical Test Listing CODE Alphabetical Test Listing CODE Microbiology
ABO 50100 Rh 50200 R Creatinine 30570 S Hepatitis Panel, Acute 40781 S Prolactin 40450 S Indicate Exact Specimen Source
Albumin 30590 S Creatinine, Urine, 24hr 32100 U • Hep A Ab (IgM) • HBcAb (IgM) Protein, Urine U
Alkaline Phosphatase 30670 S Creatinine, Urine, Ran 32081 U • HBsAg • Hep C Ab RAN 32180 24hr 32200 AFB Culture with Smear 64450
Alpha-fetoprotein 41150 S Creatinine Clearance 32240 S,U HIV-1 & -2 Antibody 42007 S PSA, Diagnostic 42158 S C. difficile Toxin 68016
ALT (SGPT) 30680 S C-Reactive Protein (CRP) 58200 S HIV-1 RNA, PCR, Quant 42015 L PSA, Screen 41954 S Chlamydia Only, Amplified 68361
Amylase 31710 S CRP, Cardiac Risk 43575 S Homocysteine 43600 L PSA Ratio, Free & Total 42147 S Chlamydia/GC, Amplified 68395
ANA (with Reflex) 69107 S Digoxin 33060 S Iron 30720 S PT (Protime w/INR) 25000 B Fungal Culture 64300
Anitbody Screen 50500 R Electrolytes 31310 S Iron, TRF Sat., (TIBC) 44210 S PTH (Whole Molecule) 40571 L Giardia Antigen 67031
AST (SGOT) 30700 S • Na • K • Cl • CO2 LDH 30710 S PTT, Activated 25100 B Gram Stain, Direct 60050
B12 41250 S Electrophoresis, Serum 48010 S LDL Direct 43571 S Reticulocyte Count 21150 L Herpes simplex Virus Culture 68263
B12/Folate 41311 S Electrophoresis, Urine 48310 U LH 40500 S Rheumatoid Factor 44480 S Herpes/Varicella Virus Culture 68277
Basic Metabolic Panel 31307 S ESR (Sed Rate) 21050 L Lipase 31740 S RPR 58800 S Influenza A & B, Direct Exam 65092
• Na • K • Cl • CO2 Estradiol 41600 S Lipid Panel 1 43560 S Rubella 58681 S KOH Prep 64200
• BUN • Creat • Gluc • Ca Ferritin 41350 S • Chol • HDL • Trig • LDL Semen, Post Vasectomy 23540 Se Ova & Parasite 67002
BNP 31379 L Folate 41300 S • Chol/HDL • LDL/HDL T3, Free 40070 S Pinworm Prep 67200
BUN 30560 S FSH 40400 S Rflx Direct LDL, Trig> 400 43562 T3, Total 40200 S Polys (WBC’s) 67455
Bilirubin, Total 30640 S GGT 30690 S Lithium 33320 S T4 (Thyroxine) 40000 S Rapid Strep-A Antigen,
Bilirubin, Direct 30650 S Glucose 30550 S Lymphocyte T-Cell Subsets 29100 LGN T4, Free 40050 S Culture if Negative 65100
CA 125 41050 S Glucose Tolerance Test hrs S Lymphocytes, T-Helper 29150 LGN Free Thyroxine Index, S Rotavirus 68073
CA 19.9 42900 S Glucose 2hr PP 31820 S Magnesium 31280 SS FTI (T4 + TU) 40025 Trichomonas Wet Mount 60103
CA 27.29 41061 S hCG-beta, Quantitative 41100 S Microalbumin, Urine U Thyroid Peroxidase Ab 34720 S Culture, Bacterial
Calcium 30610 S hCG-beta, Tumor Marker 41110 S Ran 43980 24hr 42101 Theophylline 33430 S Anaerobic 61653
Carbamazepine (Tegretol) 33050 S HCV RNA, PCR, Quant 40738 L Timed hrs min 42100 Total Protein 30580 S Blood 60250
Cardiolipin Abs, IgG, IgM 27500 S H. pylori, lgG 58322 S Microalbumin/Creat Ratio 43985 U Triglycerides 30730 S CSF 60450
CBC w/auto differential 20000 L Hemoglobin AIC (Glycol) 42550 L Monotest 58550 S Troponin I 31378 S Catheter Tip 60420
Hemogram Only 20150 Hepatic Function Panel 31306 S Occult Blood Screen 67100 F TSH 40250 S E. coli – 0157, Only 61227
CEA 41000 S • Alk Phos • Alb • DBil • TBil • TP Occult Blood Diagnostic 67105 F TSH with Reflex 40012 S GC Only 60750
Cholesterol 30740 S • ALT (SGPT) • AST (SGOT) Phenytoin (Dilantin) 33360 S Testosterone 40550 S Genital, Full Culture 60800
CK, Total 31350 S Hep A Ab, IgM 42114 S Phenytoin, Free & Total 87060 R Uric Acid 30630 S Group-B Strep Only, Genital 60217
Comp Metabolic Panel 31305 S Hep B Core Ab, IgM 42141 S Phosphorus 30620 S UA & Microscopic 24080 U MRSA Screen, Nares 60867
• Na • K • Cl • CO2 • Gluc Hep C Ab 40711 S Potassium/NA 30510 S UA & Microscopic, Reflex U Sputum/Trach/Bronch 61100
• BUN • Creat • Ca • AST • ALT Hepatitis B Immunity Scrn 40770 S Prealbumin 44470 S with C&S if Indicated 11850 Stool, Full Culture 61150
• TP • Alb • A/G • Alk Phos • TBil HBsAg 42127 S Progesterone 41750 S Strep-A Screen, Throat 60207
Throat Culture 61350
Urine Culture 61500
Lab Use Only Wound, 61657
source:
Veni A 95370 C 95372
NH 99561
Hfee 1 2 3

Many payors (including Medicare and Medicaid) have a necessity requirement for the diagnosis and treatment of the patient,
therefore, only those tests which are medically necessary should be ordered.

Figure 27-3 Sample laboratory requisition form.

824 UNIT 7 Laboratory Procedures

are extremely important, especially if the patient The clinical diagnosis may also alert the labora-
does not live with the subscriber. Some patients tory personnel to any possible special consid-
have secondary insurance coverage. Be sure to erations of which to be aware. For example, if
include that data also. The laboratory would pre- diabetes is suspected, the laboratory will give
fer to receive an additional sheet of information special consideration to the glucose value. The
than to have incomplete insurance records in its diagnosis or preferably the ICD-9 code is also nec-
business office. essary for billing.
• Unique patient identifier. This can be an identifica- • Urgency of results. Sometimes the provider needs
tion number that is hospital or laboratory gener- a test to be performed immediately (STAT) or
ated. In the outpatient setting, this can be the would like a result as soon as possible (ASAP). The
patient’s Social Security number or date of birth. provider’s orders need to be clearly stated on the
requisition. Additional space is also provided for
• Patient’s age/date of birth and sex. Age and sex both
other special instructions if necessary.
influence the results of some tests and should not
be assumed. • Special collection/patient instructions. Examples in-
clude fasting specimens, timed collections, and
• Source of specimen. This information is especially
“do not collect from a specific area” instructions.
important when dealing with tests such as cultures
and biopsies. In the case of cultures, knowing the • If copies of the results are to be sent to a second pro-
source of the specimen aids the laboratory in vider, the medical assistant must include the provid-
determining whether the specimen contains nor- er’s full name, address, and fax number. Be careful
mal flora or is abnormal for that area of the body. to print the fax number clearly so that the patient’s
results are not sent to the wrong place in error.
• Time and date of the specimen collection. Some tests
require that the specimen be tested fairly quickly
after leaving the body; other tests must be per- The laboratory will send back a written
formed after a certain period has elapsed. The time report (Figure 27-4) that will contain the follow-
and date of the specimen collection are important ing information:
because accuracy can be compromised if the speci-
men is not sent to the laboratory in a reasonable • Name, address, and telephone number of the lab-
amount of time. oratory
• Test requested. This is usually a matter of putting a • Referring provider’s name, address, and identifica-
check mark in the appropriate box on the requi- tion numbers
sition, but it is surprising how often laboratories • Patient’s name, identification number, age, and
receive specimens with nicely completed requisi- sex
tions and no indication of the test desired.
• Date the specimen was received by the laboratory
• Medications the patient is taking. Because medica-
• Date and time the specimen was collected
tion can influence some test results, it is important
that the laboratory be provided this information. • Date the laboratory reported the results
Patients are often asked to refrain from taking • The test name, results, and normal reference
certain medications before testing. Be sure to ranges if applicable
consult with the provider to verify orders. If a
medication is not discontinued before testing, Lab requisitions may be electronically gen-
the type of medication, the dosage amount, and
the time of the last dose must be included on the E HR erated using an electronic health record
(EHR) program and completed on screen
requisition.
and then either printed for the patient to take to
• Clinical diagnosis. The provider’s tentative diagno- the outside lab or sent electronically to the lab.
sis is useful to the laboratory in helping to differ- Occasionally a requisition will be faxed to a lab
entiate between diagnoses or confirm a diagnosis. if the EHR is not available. Interestingly, today’s
medical clinic staff may perform a combination
of electronic and manual communication with
Many offices copy both sides of the patient’s insurance card and
outside labs. Eventually the electronic format will
attach the copies to the laboratory requisition. This ensures the replace all manual methods.
laboratory will have all the insurance information it needs to bill Reports are sent to the provider by fax (Fig-
for its services. ure 27-5), manually delivered to the clinic, or sent
electronically using EHR software (Figure 27-6).
 CHAPTER 27 Introduction to the Medical Laboratory 825

Figure 27-4 Sample computerized laboratory report.

Abnormal test results are always flagged in tories often send results via computer-generated
some way, either in a different color, a different col- reports directly to the provider’s office or hospital.
umn, or perhaps designated by a star or simply by H
(for high) or L (for low). Critical values (results that
may indicate serious medical conditions) are alerted
to the provider by a phone call from the laboratory.
When the results are received, the medical
assistant should attach them to the patient’s chart
for the provider to review and initial before fil-
ing them. The provider should be alerted to any
abnormal test results as soon as possible. Labora-

HIPAA
If a patient wants a copy of the results
HIPAA for his or her own records, the provider
must send permission or the patient
will need to sign a release form.This is required Figure 27-5 The computerized laboratory report
by HIPAA. is transmitted directly from the reference lab to the
provider’s office.
826 UNIT 7 Laboratory Procedures

Results from • Instruct the patient to ingest special food or take

Regional/ Results to Outside
National Labs Providers other substances if required.
• Select or provide to the patient appropriate con-
tainers with the proper preservatives in them, if
required.
LABORATORY • Be certain to label the specimen with the patient’s
name, identification number, date, type of speci-
Test Reports men, time of collection, and provider’s name.
Quality Assurance & Controls
Safety Standards Label the container, not the lid, because the lid will
be removed during testing. Label the container,
not the wrapping, because the wrapping will be
separated from the container when testing is per-
Orders for Tests
Safety Standards
formed, for example, throat swabs.
• Obtain the specimen or instruct the patient to
provide the specimen according to the directions

ELECTRONIC given by the laboratory.

• Follow applicable OSHA bloodborne pathogens
guidelines (see Chapter 10) when packaging the
RECORDS specimen for transport so it will not leak or con-
taminate the courier or other office staff and so
that it will safely arrive at the laboratory without
being damaged or destroyed (Figure 27-7).
Figure 27-6 The laboratory arm of the total practice
management system (TPMS). Lab requisitions may • Place any biological specimen to be sent to an out-
be electronically generated and completed on screen, side laboratory into an approved biological trans-
then sent directly to an outside lab. port bag (Figure 27-8A–C). These bags, which
have the universal symbol for biohazard caution
stamped on them, contain two sections: one for the
specimen and one for the requisition. The requisi-
tion and specimen are placed in the proper areas
SPECIMEN COLLECTION within the transport bag, and the bag is sealed.
When the testing laboratory receives the bag, the
Proper Procurement, Storage, other end is torn open so that the specimen and
and Handling requisitions can be removed without contaminat-
ing the receiver.
Instructions for procuring, storing, and handling
and transporting laboratory specimens properly
can be obtained from the independent laborato-
ries. Most laboratories will provide the office/clinic
with a step-by-step instruction manual, sometimes
called a compendium, a laboratory manual, or a
user manual and will also be available to answer
any additional questions by telephone.
Obtaining the specimen in the proper man-
ner and using the right equipment will ensure that
a high-quality specimen is submitted to the labora-
tory. Some guidelines are as follows:
• Check the provider’s orders and identify the
patient.
• Refer to the laboratory instruction manual or con-
sult the laboratory for specific collection instruc-
tions.
• Instruct the patient on any necessary dietary restric- Figure 27-7 Various types of collection and transpor-
tion. tation containers for laboratory specimens.
 CHAPTER 27 Introduction to the Medical Laboratory 827

• Document in the patient’s chart or electronic med-

ical record the type of specimen collected, the tests
ordered, which laboratory the specimen is being
sent to (even if it is being tested in your POL), how
the patient tolerated the procedure (including
any complications), and other pertinent informa-
tion according to your office policy. Many offices
also keep a copy of the laboratory requisition in
the patient’s chart for later reference. If the testing
is performed in your POL, the results of the test
should be recorded on a laboratory report form
and, after the provider has initialed it, filed in the
A
laboratory section of the chart.

If the clinic is using EHRs, lab requisitions

E HR often stay in a “pending” file until the
results are reported from the laboratory.
The medical assistant may be responsible for
tracking pending lab tests until the reports are
received.
If the medical clinic and lab both are using
EHRs, they may share an interface software pro-
gram that allows the report to be imported onto
the provider’s desktop as an “unsigned” document.
Many clinics have policies in place that require the
provider to electronically “sign” lab reports within
36 or 48 hours of receipt.

Processing and Sending

B Specimens to a Laboratory
Specimens collected by the medical assistant are
often sent from the office to a laboratory many
miles away or are picked up by a courier repre-
senting the outside laboratory. These are often
large commercial laboratories that are not associ-
ated with a local hospital laboratory. The patient’s
insurance often dictates the laboratory contracted
to perform the patient’s testing. It is not unusual
for several different laboratories to pick up at one
location. A situation could be that the blood work
from patient Jones would go to laboratory A, the
blood work from patient Smith would go to labora-
tory B, and a urine sample from patient Doe would
be tested in the laboratory within the building. It
sometimes can be confusing as to where to send
the specimen.
C All laboratory test results are dependent on
the quality of the specimen submitted. The quality
Figure 27-8 Preparing a biological specimen to be of the specimen depends on patient preparation,
sent to an outside laboratory. (A) Laboratory specimen proper collection, correct patient identification,
transport bag. (B) The medical assistant places the and transportation of the specimen. If there is any
specimen into the transport bag and seals that part of doubt or question regarding the type of specimen
the bag. (C) The medical assistant places the requisi- to be collected, it is imperative that the appropri-
tion into a separate compartment of the bag. ate laboratory be called to clarify the specimen
828 UNIT 7 Laboratory Procedures

Patient Education
The patient will often need to be instructed
on a specific preparation before a specimen
is taken. Because food and medication
can greatly influence test results, a patient
may need to be instructed not to eat for
several hours before having the specimen
taken or drawn. Fasting means the patient
may not have anything except water for
the 12 hours before the test. NPO means
the patient may not have even water. The
patient may need to refrain from taking a
routine dosage of medication before the
test is performed. Sometimes the patient
preparation instructions will include a special
diet for a few days. Regardless of how simple
instructions may seem, it is important to give
the patient clear, written directions. Take
the time to go over any instructions with
the patient (and sometimes other family
members). Your patients will welcome the
opportunity to ask questions and to have a
written set of instructions to take home.

Figure 27-9 Basic compound microscope.

needed. There are often differences between labo-

ratories; the type of specimen acceptable for one or image, is then reflected by the condenser onto
laboratory is not necessarily the acceptable speci- the specimen to the ocular lenses for visualization.
men for another laboratory. The eyepiece may have a single (monocular)
lens, or there may be two (binocular) lenses. This
lens is not adjustable or changeable. The magnifi-
MICROSCOPES cation in the eyepiece is usually 10 times (10x) the
normal size of the object being viewed.
One of the most used pieces of equipment in the The objective lenses are adjustable between
medical laboratory is the microscope. Consisting low power, high power, and oil immersion. When
of a light source, eyepieces, objectives, condenser, viewing through the microscope under low power,
and diaphragm, the microscope enables us to see more of the slide can be seen but with less detail
bacteria and other microorganisms that are much than when using high power. When viewing under
too small to be seen without magnification. high power, a smaller portion of the field can be
seen but with greater detail. The low-power objec-
tive lens allows the item being viewed to be magni-
Types of Microscopes fied 10 times larger than life. This magnification
The most commonly used microscope in the clinic combined with the 10 times magnification of the
is the compound microscope (Figure 27-9). As the ocular lens gives the ability to see microscopically
name indicates, the image is compounded by the 100 times the normal size (10x ⫻ 10x ⫽ 100x).
use of two different lenses. One lens compounds or Combining the 10-power (10x) ocular lens
increases the magnification produced by the other with the high-power objective lens, which has
lens. The first lens system is located in the objec- the magnification power of forty times life (40x),
tives, and the second lens system is in the eyepiece increases magnification vision to 400 times the
(ocular). The light source is a bulb in the base. normal size (10x ⫻ 40x ⫽ 400x). This is enough
The light is directed up through the specimen on magnification to see large microorganisms but is
the slide and into the objective lenses. The light, still not enough to see smaller organisms, such as
 CHAPTER 27 Introduction to the Medical Laboratory 829

bacteria, clearly. An oil-immersion lens is needed Another type of microscope is the electron
to view bacteria closely. microscope (Figure 27-10). Special training is
The oil-immersion lens give the ability to mul- required to operate this sophisticated instrument.
tiply the ocular lens magnification (10x) by one The electron microscope is large (several feet tall)
hundred (100x) to reach a possible total magnifi- and expensive; therefore, it is only found in larger
cation of one thousand times normal life size (10x regional and hospital laboratories. An electronic
⫻ 100x ⫽ 1,000x). Because more light is needed to beam, rather than light, is passed through the
actually see this amount of magnification, the lens specimen. The image is projected onto a fluores-
is immersed in oil. This prevents the scattering and cent screen and may then be photographed and
loss of light rays, which naturally occurs when light enlarged. The electron microscope provides views
travels through air, consequently increasing the of extremely small organisms, such as viruses, in
efficiency of the magnification. great detail and in three dimensions. Figure 27-11
Other types of microscopes have been shows blood cells seen using an electron micro-
developed especially for specific uses. The phase- scope.
contrast microscope is specifically designed
for viewing specimens that are transparent and
unstained. Some microscopic specimens must be
How to Use a Microscope
stained with a fluorescent dye to be examined in Besides being able to adjust a microscope’s mag-
detail (e.g., when detecting specific bacteria). A nification, it may be necessary to adjust focus. The
fluorescent microscope is the instrument best microscope contains a coarse adjustment and a
suited for viewing those specimens. In dark-field fine adjustment. The coarse adjustment is to be
microscopy, the light is reflected from an angle, used with the low-power (short) objective only.
which causes the specimen to appear as a bright The coarse adjustment is used to bring the object
object on a dark field. into view. The fine adjustment may then be used to
sharpen the image. Depending on the individual
microscope, the coarse and fine adjustments may
raise and lower the nosepiece, which houses the
objectives, or they may raise and lower the stage, or
platform, on which the slide rests.
It is important always to remember to raise
the platform of the lower objectives using the
coarse adjustment and the low-power objective
while viewing the slide from the side. This allows the
lens to come close to the slide without actually
touching it. If the slide is not viewed from the side

Figure 27-11 Blood cells as seen under an electron

Figure 27-10 S440 scanning electron microscope. microscope.
830 UNIT 7 Laboratory Procedures

for the coarse adjustment, there is the possibility of

running the objective through the slide and seri-
ously damaging the lens and the microscope, or
of breaking the slide. After bringing the slide and
objective together, the adjustments may be made
through the ocular, always moving away from the
slide. Once the item is in view, the fine adjustment
may be used for clarity.
The bulb in the base directs light through the
slide. The light first goes through a condenser and
then through an iris diaphragm. The condenser
is used to control the intensity of the light, and
the iris diaphragm may be adjusted to control the
amount of light.
To use the oil-immersion lens, place a drop of
cedar or mineral oil on top of the coverslip directly
over the specimen on the slide. Then carefully
lower the oil-immersion lens into the oil, making
sure that the lens never actually touches the slide.

How to Care for a Microscope Figure 27-12 The proper way to carry a microscope.

Microscopes can be expensive and, like any preci-

sion instrument, should be treated with care. Some
practices that will extend the life of a microscope • Clean the lenses with special lens paper and lens
and maintain the quality of its performance are: cleaner after each use. Using standard tissue can
scratch the lenses.
• Always follow the manufacturer’s and clinic’s rules
for the care and maintenance of the microscope. • When looking through the eyepiece and focusing,
always move the platform away from, never toward,
• Carry the microscope with one hand securely sup- the eyepiece to prevent the objective from coming
porting the base and the other hand holding the into contact with the slide. If you are actually looking
arm (Figure 27-12). at the platform, then you can move it closer to the
• Keep the microscope covered when it is not being eyepiece without coming into contact with the slide.
used. • Use oil only with the oil-immersion lens.

Procedure 27-1
Using the Microscope
STANDARD PRECAUTIONS: EQUIPMENT/SUPPLIES:
Hand disinfectant
Microscope (monocular or binocular)
Lens paper
Lens cleaner
PURPOSE: Prepared slides (commercially available)
To properly use a microscope to view microscopic Immersion oil
organisms using the coarse and fine adjustments, as Surface disinfectant
well as the low- and high-power and oil-immersion NOTE: Procedure will vary slightly according to micro-
objectives. scope design. Consult the operating procedure in
the microscope manual for specific instructions.

continues
 CHAPTER 27 Introduction to the Medical Laboratory 831

Procedure 27-1 (continued)

PROCEDURE STEPS: 14. Scan the slide by either method:

1. Wash hands. a. Use the stage knobs to move the slide left and
2. Assemble equipment and materials. right and backward and forward while look-
3. Clean the ocular(s) and objectives with lens ing through the ocular(s),
paper. or
4. Use the coarse adjustment to raise the eyepiece b. Move the slide with the fingers while looking
or lens unit. through the ocular(s) (for microscope with-
5. Rotate the 10x, or low-power, objective into posi- out movable stage).
tion so that it is directly over the opening in the 15. Rotate the high-power (40x) objective into posi-
stage. tion while observing the objective and the slide
6. Turn on the microscope light. to see that the objective does not strike the slide.
7. Open the diaphragm until maximum light 16. Look through the ocular(s) to view the object on
comes up through the condenser. the slide; it should be almost in focus.
8. Place the slide on the stage (specimen side up). 17. Locate the fine adjustment.
9. Locate the coarse adjustment. 18. Look through the ocular(s) and turn the fine
adjustment until the object is in focus. Do not
10. Look directly at the stage and 10x objective and use the coarse adjustment.
turn the coarse adjustment until the objective is
as close to the slide as it will go. 19. Adjust the amount of light. This can be done by
closing the diaphragm, lowering the condenser,
NOTE: Do not lower any objective toward a slide or adjusting the light at the source.
while looking through the ocular(s).
20. Scan the slide as in Step 14, using the fine adjust-
11. Look into the ocular(s) and slowly turn the ment if necessary to keep the object in focus.
coarse adjustment in the opposite direction (as
in Step 10) to raise the objective (or lower the 21. Rotate the oil-immersion objective to the side
stage) until the object on the slide comes into slightly (so that no objective is in position).
view. 22. Place one drop of immersion oil on the portion
12. Locate the fine adjustment. of the slide that is directly over the condenser.
13. Turn the fine adjustment to sharpen the image. 23. Rotate the oil-immersion objective into position,
being careful not to rotate the 40x objective
NOTE: If a binocular microscope is used, the through the oil.
oculars must be adjusted for each individual’s
eyes. 24. Look to see that the oil-immersion objective is
touching the drop of oil.
a. Adjust the distance between the oculars so
that one image is seen (as when using binocu- 25. Look through the ocular(s) and slowly turn the
lars). fine adjustment until the image is clear. Use only
the fine adjustment to focus the oil-immersion
b. Use the coarse and fine adjustments to bring objective.
the object into focus while looking through
the right ocular with the right eye. 26. Adjust the amount of light using the procedure
in Step 19.
c. Close the right eye, look into the left ocular
with the left eye, and use the knurled collar on the 27. Scan the slide using the procedure in Step 14.
left ocular to bring the object into sharp focus. 28. Rotate the 10x objective into position (do not
(Do not turn the coarse or fine adjustment at allow the 40x objective to touch the oil).
this time.) 29. Remove the slide from the microscope stage and
d. Look into the oculars with both eyes to gently clean the oil from the slide with lens paper.
observe that the object is in clear focus. If it is A copeland jar containing a solvent cleaner, such
not, repeat the procedure. as xylene, can be used to remove excess oil from
the slide.

continues
832 UNIT 7 Laboratory Procedures

Procedure 27-1 (continued)

30. Clean the oculars, 10x objective, and 403 objec- 34. Position the eyepiece in the lowest position using
tive with clean lens paper and lens cleaner. the coarse adjustment.
31. Clean the 100x objective with lens paper and 35. Center the stage so that it does not project from
lens cleaner to remove all oil. either side of the microscope.
32. Clean any oil from the microscope stage and - 36. Cover the microscope and return it to storage.
condenser. 37. Clean the work area; return slides to storage.
33. Turn off the microscope light and disconnect. 38. Wash hands.

Case Study 27-1 Case Study 27-2

Refer to the scenario at the beginning of the chapter. Edith Leonard came to Inner City Health Care because
Now imagine that Wanda sent Annette to the lab for the she was experiencing sight disturbances, constant thirst,
urinalysis rather than performing the test in the POL. and fainting spells. After examining Edith, Dr. Ray Reynolds
ordered a glucose tolerance test. Certified medical assis-
CASE STUDY REVIEW tant Wanda Slawson gave Edith a special diet that she was
to follow for the 3 days preceding the test and instructions
1. What was the advantage of Wanda performing regarding fasting before the test.
the urinalysis in the POL rather than sending Edith has returned to the clinic to have the test.“Did
Annette to the lab for the urinalysis? you follow the diet I gave you, Mrs. Leonard?” Wanda asks.
2. What would have been an advantage of sending “Yes, I did.” “Did you have anything to eat this morning?”
Annette to the outside lab for the urinalysis? “No, but I did have a cup of coffee. I thought it would be all
right because I drink it black. I can’t start the day without
my coffee.”

CASE STUDY REVIEW

1. Should Wanda perform the test? Explain your
answer.
2. How can Wanda emphasize the importance of
following the diet, fasting, and test instructions?
3. What can Wanda do to try to ensure Edith’s
cooperation?

SUMMARY
If disease did not exist, we would have little need for clinical laboratories. If we were not susceptible to viral
illnesses, if bacteria never infected our bodies, if our bodies always operated in their healthiest state regard-
less of what we did to them, and, perhaps most important of all, if we chose our parents wisely, there would
be little that a clinical laboratory would be asked to do. The fact that our bodies are susceptible to disease
necessitates the existence of clinical laboratories.
Together with clinical laboratory personnel, medical assistants play an important role in laboratory
testing. They prepare patients for tests, obtain specimens, and perform simple, routine tests or send speci-
mens to the appropriate laboratory. Medical assistants are educated to perform these tasks in a manner
that ensures the accuracy of the test and safeguards the health of patients and health care personnel.
 CHAPTER 27 Introduction to the Medical Laboratory 833

STUDY FOR SUCCESS

To reinforce your knowledge and skills of information presented in this chapter:
• Review the Key Terms
• Practice the Procedure
• Consider the Case Study and discuss your conclusions
• Answer the Review Questions

° Multiple Choice
° Critical Thinking
• Navigate the Internet by completing the Web Activities
• Practice the StudyWARE activities on the textbook CD
• Apply your knowledge in the Student Workbook activities
• Complete the Web Tutor sections

REVIEW QUESTIONS
Multiple Choice c. the patient’s file
1. All of the following statements concerning point-of- d. an insurance form
care testing are true except: 6. The most commonly used microscope in the clinic
a. performed at the patient’s bedside is the:
b. must be performed by certified laboratory a. fluorescent microscope
professionals b. electron microscope
c. provides for rapid, accurate results c. phase-contrast microscope
d. the medical laboratory’s role includes training d. compound microscope
and management of quality control
2. Independent medical laboratories must be man- Critical Thinking
aged by a: 1. A patient asks you to recommend a laboratory for
a. clinical laboratory technologist the tests ordered by the provider. How will you
b. pathologist respond to the request? What are some factors that
c. clinical laboratory technician will influence your response?
d. medical assistant 2. A patient performed a pregnancy test at home, but
3. The hematology department of a laboratory: her provider has requested a pregnancy test in the
a. studies microorganisms and their activities office. Explain to the patient why the home test
b. studies blood and blood-forming tissues may not be as accurate as the test performed in the
c. detects the presence of disease-producing office.
human parasites or eggs present in specimens 3. The provider has ordered a metabolic panel for a
taken from the body patient. What is a panel, and how will it help the
d. detects the presence of abnormal tissues provider to diagnose the patient’s condition?
4. The quality of patient test results is maintained by: 4. Explain why it is important to handle and process
a. instrument calibration procedures specimens, test kits, and chemicals properly.
b. preventative maintenance procedures 5. The time and date of specimen collection were not
c. quality control testing included on the requisition form. Why are these
d. all of the above data always important to the laboratory?
5. When a patient or specimen is sent to a laboratory 6. Explain how a compound microscope is able to
for testing, the medical assistant also sends: magnify.
a. a written requisition
b. a report
834 UNIT 7 Laboratory Procedures

WEB ACTIVITIES REFERENCES/BIBLIOGRAPHY

1. For each group of laboratory personnel dis- American Medical Technologists. (2004). Retrieved
cussed in this chapter, search the Internet October 2008, from http://www.amt1.com.
for a Web site that pertains to it. What kind American Society for Clinical Laboratory Science.
of information does it offer? Retrieved October 2008, from http://www.ascls.org.
2. Locate a local hospital’s Web site. Does it outline all American Society for Clinical Pathology. Retrieved
the specialty departments described in this chap- October 2008, from http://www.ascp.org.
ter? What unique services do they offer? National Accrediting Agency for Clinical Laboratory
3. Visit your insurance company’s Web site. Does it Sciences. Retrieved October 2008, from
specify which laboratories must be used? http://www.naacls.org.
National Credentialing Agency for Laboratory
Personnel. Retrieved October 2008, from
http://www.nca-info.org.
 Chapter
Phlebotomy: Venipuncture
and Capillary Puncture 28
KEY TERMS OUTLINE
Additive Why Collect Blood? Selecting the Appropriate
Aliquot The Medical Assistant’s Role in Venipuncture Site
Anticoagulant Phlebotomy Applying the Tourniquet
Buffy Coat Anatomy and Physiology of the Performing a Safe Venipunc-
Circulatory System ture
Cannula
Blood Collection Specimen Collection
Centrifuge The Syringe Technique
Plasma and Whole-Blood
Constrict Vacuum Tube Specimen
Collection
Dilate Collection of Blood Specimens Collection
Edematous Venipuncture Equipment Butterfly Needle Collection
Erythrocyte Syringes and Needles System
Hematology Safety Needles and Blood Blood Cultures
Hematoma Collection Systems Patient Reactions
Vacuum Tubes and Adapters/ The Unsuccessful
Hemoconcentration
Holders Venipuncture
Hemolysis Criteria for Rejection of a
Anticoagulants, Additives,
Hypoglycemia Specimen
and Gels
Leukocyte Order of Draw Factors Affecting Laboratory
Lipemia Tourniquets Values
Luer-Lok Specimen Collection Trays Capillary Puncture
Oxygenated Venipuncture Technique Composition of Capillary
Approaching the Patient Blood
Palpate
Preparing Supplies and Capillary Puncture Sites
Phlebotomy
Greeting the Patient Preparing the Capillary
Plasma Puncture Site
Patient and Specimen
Primary Container Performing the Puncture
Identification
Serum Positioning the Patient Collecting the Blood Sample
Thixotropic
Separator Gel
Thrombocyte
Tourniquet
OBJECTIVES
The student should strive to meet the following performance objectives and dem-
Venipuncture
onstrate an understanding of the facts and principles presented in this chapter
Viscosity through written and oral communication.

1. Define the key terms as presented in the glossary.

2. Explain the medical assistant’s responsibility to the patient in
terms of quality of care and respect for the patient as a human
being.

835
OBJECTIVES (continued)
3. Explain why the medical assistant has a special responsibility to
present a neat, pleasant, and competent demeanor.
4. Differentiate between serum and plasma.
5. State the relationship between diameter and the gauge of the
needle.
6. Explain the principle of the vacuum tube system.
7. State the manner in which anticoagulants prevent coagulation.
8. Name the anticoagulant associated with the various color-coded
vacuum tubes.
9. State the purpose of additives to vacuum tubes.
10. Explain the three skills used in collecting blood specimens.
11. Explain the importance of correct patient identification; com-
plete specimen labeling; and proper handling, storage, and
delivery.
12. Describe the step-by-step procedure for drawing blood with a
syringe, vacuum tube system, butterfly, or capillary puncture.
13. Explain how to handle the various reactions a patient might
have to venipuncture.
14. List two items commonly used in phlebotomy that may cause a
problem with a patient who has a latex sensitivity or allergy.

Scenario
At Inner City Health Care, medical assistant Bruce dent and professional in his interactions with patients.
Goldman often performs venipunctures. Bruce is per- He is always well-groomed, and he treats patients with
sonable and has an easy-going manner that makes respect. Using his social, technical, and administrative
patients feel comfortable with him. He takes time to skills, Bruce is usually able to collect the necessary
talk to patients before performing a venipuncture to blood samples while providing a positive experience
determine their feelings about the procedure and to for patients.
learn about their previous experiences. Bruce is confi-

INTRODUCTION
The task of collecting blood samples from patients for cross trained to do phlebotomy and other tasks. Many
diagnostic testing is known as phlebotomy. The health health care settings do not have enough patients to jus-
care professional who performs this duty varies at tify having a phlebotomist available at all times. There-
each health care setting. The task of phlebotomy is not fore, the medical assistant may be designated to perform
restricted to one individual. A variety of individuals are phlebotomy procedures.

836
 CHAPTER 28 Phlebotomy: Venipuncture and Capillary Puncture 837

collect blood as efficiently as possible for accurate

Spotlight on Certification and reliable test results. How the medical assistant
will be involved in phlebotomy will vary greatly
RMA Content Outline from one health care environment to another. The
• Anatomy and physiology medical assistant performing venipuncture will
• Human relations have direct contact with the patient and perform
• Asepsis tasks that are critical to the patient’s diagnosis and
• Laboratory procedures care. During the direct contact with the patient,
the medical assistant will leave an impression with
CMA (AAMA) Content Outline the patient. It can be positive or negative depend-
• Systems, including structure, function ing on the skill with which the medical assistant
related conditions, and diseases performs the venipuncture.
• Maintaining confidentiality It is the medical assistant’s responsibility to
• Medical records provide high-quality care to patients. The medi-
cal assistant must act professionally when working
• Principles of infection control
with patients. Professionalism is displayed by per-
• Equipment preparation and operation forming tasks in an efficient, competent manner;
• Safety precautions wearing clean, neat attire; and showing concern
• Collecting and processing specimens; for patients and their feelings.
diagnostic testing Patients will not tell family and friends that
CMAS Content Outline their blood was run through expensive state-of-the-
art instruments but rather that the person draw-
• Anatomy and physiology
ing their blood sample was friendly and skilled. A
• Professionalism smile and a kind word can allay a patient’s fear and
• Asepsis in the medical office ensure a more satisfied and loyal patient.
• Communication

ANATOMY AND PHYSIOLOGY

WHY COLLECT BLOOD? OF THE CIRCULATORY SYSTEM
To be prepared to collect blood, the medical assis-
Hematology is the study of blood and its components, tant must understand the system that carries the
fluids, and cells. Hematology also includes the study blood and the composition of the blood. The sys-
of blood- forming organs and blood diseases. tem in which the blood is transported is the cir-
Phlebotomy is the process of collecting blood culatory system. Blood forms in the organs of the
for diagnostic purposes or bloodletting as a ther- body. The bone marrow is the primary factory for
apeutic measure. The history of bloodletting production of blood cells. The lymph nodes, thy-
dates back to the early Egyptians and continues mus, and spleen are also sites for the production
into modern times. Phlebotomy in the past was a of blood cells. The function of blood is to carry
method to cure individuals with “bad” blood. The oxygen to body tissues and to remove the waste
blood was drained out of individuals as a treat- product, carbon dioxide. The blood also carries
ment, thereby alleviating the patient’s symptoms. nutrients to all parts of the body and moves the
Phlebotomy, also called venipuncture, is now used waste products to the lungs, kidneys, liver, and skin
to help determine the disease process taking place for elimination.
and to determine the method of treatment. Test- The circulatory system consists of the heart,
ing blood samples give the provider more tools for which pumps blood through the body by way of
gathering diagnostic information. tubing called arteries, veins, and capillaries. When
blood flows away from the heart, it flows in arteries;
blood flowing back to the heart flows through the
THE MEDICAL ASSISTANT’S veins. Connecting most of the arteries and veins
ROLE IN PHLEBOTOMY are the capillaries (Figure 28-1).
Arteries have a thick wall that helps them
A phlebotomist is a person trained to obtain blood withstand the pressure of the pumping action of
specimens by venipuncture and capillary puncture the heart. The arteries branch to form arterioles,
techniques. The phlebotomist’s primary role is to which branch again to become capillaries. The
838 UNIT 7 Laboratory Procedures

The liquid portion of uncoagulated blood is known

ARTERIES TO VEINS
as plasma. Plasma is the fluid that provides a matrix
for blood cells, electrolytes, proteins, and chemi-
Arteries Veins
cals to travel throughout the body via the blood
vessels. Blood flowing through the body contains
1. Carry blood from the 1. Carry blood to the heart,
heart, carry oxygenated carry deoxygenated
a substance called fibrinogen. The clotting process
blood (except blood (except converts the fibrinogen into fibrin. The fibrin is like
pulmonary artery) pulmonary vein) a sticky spider web that traps the formed elements
into the fibrin mass called a clot. The clot then con-
2. Normally bright red 2. Normally dark red
in color in color tracts and the liquid (serum) portion is extracted.
The serum is a clear, straw-colored liquid that is
3. Elastic walls that expand 3. Thin walls/less elastic used for many of the tests done in the laboratory.
with surge of blood
The main difference between serum and plasma is
4. No valves 4. Valves that plasma contains fibrinogen, and serum does
not.
5. Can feel a pulse 5. No pulse
The formed elements and the liquid portion
of the blood are often separated for laboratory
testing. To speed the removal of the serum from
To
a tube of blood, an instrument called a centrifuge
From spins the blood. A carrier holds the tubes of blood,
Heart
Heart
and when the centrifuge is activated, the carrier spins.
The spinning action of the carrier pushes the blood
cells to the bottom of the tube. The blood separates
according to weight. The clot goes to the bottom of
the tube and the serum goes to the top.
To produce a plasma specimen, the blood must
Artery Arteriole Capillaries Venule Vein be prevented from clotting by the use of a chemical
anticoagulant. Blood collected in a tube containing
an anticoagulant can be centrifuged to separate the
Figure 28-1 Blood flows from the heart through the formed elements (cells) from the plasma. The bot-
larger arteries to arterioles to arterial capillary beds at tom layer will contain the erythrocytes, then there
the cellular level, then back to the heart through venous will be a thin layer called the buffy coat. The buffy
capillary beds into venules and finally larger veins. coat contains a mixture of leukocytes and thrombo-
cytes, which are lighter and less numerous than the
red blood cells (RBCs). On top of all these layers
capillaries then begin coming together to form is the plasma layer. The plasma will contain fibrino-
venules, and the venules then become veins. As gen and usually is slightly hazy (Figure 28-3).
blood flows through the body, it follows this path
of artery-arteriole-capillary-venule-vein. Oxygenated
arterial blood, which contains a high level of oxy-
gen, leaves the heart and carries the oxygen to the BLOOD COLLECTION
tissue by releasing the oxygen through the cell walls
of the capillaries. At the same time, carbon dioxide Most laboratory tests are performed on serum,
is being absorbed by the blood, and then is trans- plasma, or whole blood. Generally, when a serum
ported to the lungs to be exhaled as a waste product. sample is needed, a serum separator vacuum tube
The flow of the blood also regulates body tempera- with thixotropic gel is used. The purpose of the
ture. When the body gets warm, the capillaries in thixotropic gel is to create a barrier between the
the extremities dilate and let off heat. This process clotted cells and the serum during centrifuga-
then cools the body. If the body becomes cold, the tion. This protects the serum from contamination
capillaries constrict and less blood flows through, from any hemolyzed RBCs. There will be certain
thereby conserving heat for the rest of the body. restrictions in some cases; refer to the laboratory
The body contains approximately 6 liters (L) user manual to verify tube requirements. When a
of blood, 45% of which is formed elements. The serum separator tube is used, several steps must be
formed cellular elements consist of erythrocytes, followed:
leukocytes, and thrombocytes (Figure 28-2). The
remaining 55% of the blood is liquid. Generally 2.5 1. Perform venipuncture by the preferred method.
milliliters (mL) blood will yield about 1 mL serum. 2. Invert the tube five times to activate the clotting.
 CHAPTER 28 Phlebotomy: Venipuncture and Capillary Puncture 839

White Blood Cell Red Blood Cells Platelets

(Leukocyte) (Erythrocytes) (Thrombocytes)

Function Body defense Transport of Stoppage of

(extravascular) oxygen and carbon bleeding
dioxide (intravascular)

Formation Bone marrow, Bone marrow Bone marrow

lymphatic tissue

Size/shape 9–16 micrometers; 6–7 micrometers; 1–4 micrometers;

different size, bioconcave disc; fragments of
shape, color, normally no nucleus megakaryocytes
nucleus (core) in circulatory blood

Life cycle Varies, 100–120 days 9–12 days

24 hours–years

Numbers 5–10,000/ 4.5–5.5 million/ 250–450,000/

cubic millimeter cubic millimeter cubic millimeter

Removal Bone marrow, Bone marrow, Spleen

liver, spleen spleen

Figure 28-2 Cellular components of blood.

3. Allow the specimen to clot with the tube in the be specified by the laboratory or testing require-
upright position in a rack for at least 30 minutes ments. Preparing the plasma specimen for trans-
but no longer than an hour. port or testing is similar to serum preparation:
4. Centrifuge the tube at 2,500 g for 15 minutes. 1. Perform venipuncture by the preferred method.
5. Store the tube upright or transfer the serum to a 2. Invert the tube 8 to 10 times to mix the blood with
plastic transport vial for pickup by the laboratory. the anticoagulant.
These are usually frozen specimens and require a
3. Centrifuge the tube at 2,500 g for 10 minutes.
stat pickup. Check the manual to see indications.
4. Transfer the plasma to a plastic transport vial for
There will be different requirements for differ- pickup by the laboratory. Do not allow any blood
ent laboratories. NOTE: Do not use serum separa- cells to mix with the plasma specimen. Indicate
tor tubes for therapeutic drug monitoring (TDM)
or toxicology studies. The gel has a tendency to
absorb the drugs, thereby decreasing the accuracy Uncoagulated Clotted
of the test results. Collect these samples in a plain Blood Blood
red-top vacuum tube. Remove the serum immedi-
ately (if indicated in the test requirements) after
centrifugation and place it in a plastic transport
vial. Indicate if the specimen is a serum specimen
Plasma
or for type and cross match. (Usually Hazy) Serum
(Contains Fibrinogen)

Plasma and Whole-Blood “Buffy Coat”

White Blood Cells
Collection Platelets
Cellular
Portion
Formed
Elements Clot
Tubes containing anticoagulants are used to col- Red Blood Cells
lect plasma and whole-blood samples. There are
a variety of different anticoagulant tubes that can Figure 28-3 Vacuum collection tubes showing serum
be used. The anticoagulant needed in the tube will and plasma.
840 UNIT 7 Laboratory Procedures

the specimen as a plasma specimen and what type for venipuncture is the antecubital space, which is
of anticoagulant was used. There will be different located anterior to the elbow on the inside of the
requirements for different laboratories. Refer to arm. The veins are near the surface and are large
your laboratory user manual for the appropriate enough to give access to the blood (Figure 28-4).
test requirements. The median cubital vein is the vein that is used the
majority of the time. When this vein is not avail-
To prepare whole blood specimens for trans- able, any of the other veins that can be felt may be
port or testing: used. These veins include the basilic, cephalic, and
1. Perform venipuncture by the preferred method. median veins. When necessary, veins on the dorsal
surface of the hand or wrist may be used for veni-
2. Invert the tube 8 to 10 times to mix the blood with
puncture, but they are more painful for the patient
the anticoagulant.
and may require a smaller needle or the use of a
3. Maintain the tube at room temperature unless butterfly apparatus.
otherwise instructed. Never freeze a whole-blood The veins of the feet are an alternative when
sample unless specifically instructed to do so. the arms are not available. The provider’s permis-
sion is needed before drawing blood from the veins
of the legs and feet. The provider may not want
Collection of Blood Specimens the patient’s leg or foot veins punctured because
The most commonly used method for blood col- the act of drawing blood may cause clots to form.
lection is venipuncture. To obtain a blood sample, These clots then have the possibility of dislodging
the medical assistant must locate a vein that is and causing a blockage elsewhere in the body. It
acceptable for blood collection. The preferred site would be extremely rare for a medical assistant

Basilic

Cephalic

Median Cubital Brachial Artery

Median

Radial Artery

Ulnar Artery

Figure 28-4 Superficial veins of the arm. Figure 28-5 Arteries of the arm.
 CHAPTER 28 Phlebotomy: Venipuncture and Capillary Puncture 841

to use this location. The provider should be con- a blood sample. The three methods used to per-
sulted before a foot puncture is considered. The form venipuncture are the syringe method, the
person performing a foot draw must be specially vacuum tube method, and the butterfly method.
trained for that procedure. Each method has advantages and disadvantages
The arteries in the arm consist of the brachial (Table 28-1). It is important that the well-trained
artery in the brachial region of the arm and the medical assistant have options when attempting
radial and ulnar arteries in the wrist (Figure 28-5). to draw blood from a wide range of patients in a
Special techniques are necessary to puncture arter- variety of situations. There will be times in one’s
ies to obtain a blood specimen for the examination career when one method will be preferred over
of gases absorbed by the blood. Arterial punctures another. Regardless of which method is chosen to
and the techniques used to draw blood from these perform the blood draw, the blood will probably
locations for blood gas testing are not generally be transferred into a vacuum tube eventually. This
done by a medical assistant. Refer to individual is because vacuum tubes contain the chemicals
state laws for specific training and certification/ and substances necessary for the blood tests to be
registration requirements. performed.

VENIPUNCTURE EQUIPMENT Syringes and Needles

Syringes used in venipuncture are usually made
All methods of venipuncture require the inva- of plastic (Figure 28-6). They come in a variety of
sive procedure of punturing into a vein to obtain sizes. Each manufacturer has their own packaging

Table 28-1 Comparison of Blood Collection Methods

Method Indications for Use Advantages Disadvantages

Routine collection Fast May not work with:

Multiple tubes are Relatively safe Small veins
needed Best specimen quality Fragile veins
Vacuum tube Whenever possible Large collection amount possible Difficult draws
Small children
Hand or feet draws

Small or fragile veins Least likely to collapse vein Syringe not as safe because tube
Difficult draws Less painful to patient transfer is necessary
Small children or older Can attach syringe Specimen may be hemolyzed
Butterfly adult patients Not good for large amounts of
assembly Can attach tube adapter
blood
Least likely to pass through small
veins
Good specimen quality

Children Easier to perform Not good for dehydrated patients

Infants Allows for smaller amount Not good for patient with poor
Older adult patients of specimen circulation
Onocology patients Cannot be used for:
Severely burned patients Blood cultures
Syringe Obese patients Erythrocyte sedimentation rate
Inaccessible veins
Extremely fragile veins
Home testing by patient
Procedure requires
capillary specimen

Source: Courtesy of Sheri R. Greimes, CMA (AAMA), PBT (ASCP).

842 UNIT 7 Laboratory Procedures

Table 28-2 Needle Gauges Used in

Phlebotomy

Gauge
Size Comments

Often considered too small, can cause

A 23 hemolysis of blood cells; used sometimes
with butterfly system

Preferred for pediatric phlebotomy or

22
very small veins of the hands or feet

Most common size used with vacuum

21
tubes

B Appropriate, but large for common phle-

20
botomy

Not used for phlebotomy, but sometimes

18
used in blood banking/donations

Most commonly used in blood banking/

16
donations

C
Another type of needle used in venipuncture is
Figure 28-6 (A) Safety syringes with needles, before the special needle, designed for use with the vacuum
and after safety mechanisms are engaged. (B) Pull tube method. This needle has a double end—the
entire casing over the needle to engage this type of longer needle to puncture the vein and the shorter
safety mechanism. Once engaged, it is locked into needle to puncture into the vacuum tube (Figure
place. (C) With the thumb and forefinger, press the 28-7). These needles also come in a variety of gauges
safety mechanism over the needle; or, an even safer and lengths; the most common is the same as the
technique is to press it against a hard surface such as standard needle described previously: 20, 21, and
the edge of the counter. Be sure to listen for the click. 22 gauge, 1 to 1.5 inches in length. When selecting a
Once engaged, the safety mechanism should be firmly double-ended needle for use with the vacuum tube,
locked in place. you will use a multidraw needle, which enables draw-
ing of more than one tube of blood. The multidraw
needles come with a rubber sheath over the shorter
and coloring, thus there is really no significance needle, which goes into the vacuum tube. This rub-
related to the color and design of syringes. Most ber sheath prevents blood from leaking out of the
syringes used in venipuncture will be 5 and 10 mL needle during tube changes. Multidraw needles are
in size. Some syringes are designed with a Luer- sometimes referred to as multisample or multiple
Lok tip. This tip allows the needle to be securely sample needles.
twisted onto the syringe. The Luer-Lok tip may be
preferred to the push-on tip for additional safety
for the user. Vein puncturing Tube puncturing
Needles attached to syringes and used for end end
venipuncture do not necessarily differ in function
and design from needles used for injections (Fig-
ure 28-6). They come in a wide variety of lengths
and gauges. Most common sizes for venipuncture Bevel Shaft Hub Rubber sleeve
covering needle
are 20, 21, and 22 gauges and about 1 or 1.5 inches
in length (Table 28-2). Sixteen-gauge needles are
often used for blood banking procedures. Remem- Figure 28-7 Multidraw needle for vacuum tube
ber, the larger the number, the smaller the gauge. blood collection system.
 CHAPTER 28 Phlebotomy: Venipuncture and Capillary Puncture 843

Figure 28-8 (A) Winged infusion set (butterfly) with Figure 28-9 Puncture Guard is one type of safety
safety needle. (B) Butterfly attached to syringe. needle. (Courtesy of BioPlexus, Inc., Tolland, CT)

Another type of needle used in venipuncture Guard system (Figure 28-9). Before withdrawing the
is on a “winged” infusion set called the butterfly needle from the patient’s vein, a cannula is clicked
collection system (Figure 28-8). Because of the rea- into place. The cannula fills the inside of the nee-
sons for using the butterfly collection system, the dle, virtually blunting the tip. Another option is the
needles are smaller, usually 21 or 23 gauge. Eclipse system by Becton-Dickinson (Figure 28-10),
More details about each collection method which requires the medical assistant to snap a cover
are discussed later in this chapter. over the needle after it is removed from the vein.
A third option, called the Safety-Lok, also manu-
factured by Becton-Dickinson, requires the medi-
Safety Needles and Blood cal assistant to slide the cover over the needle until
Collection Systems it locks into place. Whichever system you choose,
The Occupational Safety and Health Administra- always combine the safest equipment with the saf-
tion (OSHA) requires that safety needles be made est practices for the best all-around benefit for you,
available to employees to prevent on-the-job needle- your coworkers, and your patients. Many accidents
stick injuries. The huge variety of safety needles and occur when we become distracted or hurried in our
blood collection systems currently available greatly tasks.
reduces the risks for accidental needlesticks. The
main issue is deciding which to select for use in Vacuum Tubes and Adapters/
your clinic based on personal preferences. OSHA
requires that employers make purchasing decisions
Holders
based on formal feedback from front-line employ- The vacuum tube system is often called the Vacu-
ees rather than costs and administrative contracts. tainer system. Vacutainer can be a misnomer
This means that you have a great deal of choice because the term Vacutainer ® is a brand name for
about what systems you select to use. It is recom- the vacuum tube system manufactured by Becton-
mended that you examine a variety of safety systems Dickinson. Medical assistants often say Vacutainer
on a regular basis to determine which one gives you when they are using another company’s product.
the greatest protection from accidental needlestick Vacuum tubes are vacuum-packed test tubes
injury. These systems are often referred to as needle- with rubber stoppers. The safest ones are made
stick prevention devices (NPDs). Among the avail- of plastic and have screw-on caps. They are avail-
able systems are passive systems in which the needle able in a variety of sizes for a variety of uses (Figure
is automatically covered when withdrawn and sys- 28-11). Vacuum tubes come plain or with added
tems that require the medical assistant to activate chemicals or substances necessary for the appropri-
a mechanism of covering the needle. Within each ate test to be run. The color of the rubber stopper
type are many options and brands. This chapter dis- designates the additive inside the tube. Although
cusses and shows a few currently available options in most colors are universal regardless of manufac-
no particular order. The first is the Plexus Puncture turer, the shades may vary and can be confusing
844 UNIT 7 Laboratory Procedures

A
A B C D

Figure 28-11 Standard anticoagulant tubes with

conventional rubber stopper and Hemogard twist off
closures. (A) Gray top, tube contains antiglycocytic
agent; left tube with rubber stopper, right tube with
twist off Hemogard top. (B) Green top, tube contains
heparin anticoagulant; left tube with rubber stopper,
right tube with twist off Hemogard top. (C) Lavender
top, tube contains EDTA anticoagulant; left tube with
B
rubber stopper, right tube with twist off Hemogard top.
(D) Light blue top, tube contains sodium citrate; left
tube with twist off Hemogard top, right tube with rub-
ber stopper.

Anticoagulants, Additives,
and Gels
Different tests require different types of blood
C specimens. Some specimens require a serum
sample and need to be drawn in a tube that allows
Figure 28-10 Three Eclipse safety needles for use the blood to clot. Others require a whole-blood
with vacuum tubes. (A) Needle capped, safety mecha- or plasma specimen and need to be drawn in a
nism not engaged. (B) Needle exposed, safety mecha- tube that does not allow the blood to clot. Addi-
nism not engaged. (C) Safety mechanism engaged. tives are put into the tubes during manufacturing.

to beginners. It is always best to read the label to

determine the additive if the shade is different.
Plastic holders or tube adapters (Figure B
28-12) are used in conjunction with the vacuum
tubes. Figure 28-13 shows safety holders devel- A
oped to minimize the risk for accidental needle-
sticks. Some plastic holders are reusable, but
there is much debate about the appropriateness
of reusing them, even after disinfection. They
are fairly inexpensive and the inner threads will
eventually wear out, therefore replacing them fre-
quently is always good practice. The holders with
the safety mechanisms shown in Figure 28-13 are Figure 28-12 Holders for vacuum tube system. (A)
not reusable. Adult holder. (B) Pediatric tube using an adapter.
 CHAPTER 28 Phlebotomy: Venipuncture and Capillary Puncture 845

Table 28-3 Steps to Blood Clotting

1. Uncoagulated blood

2. Calcium utilized

3. Prothrombin converts to thrombin

A B 4. Fibrinogen converts to fibrin

5. Clot forms

vents the clotting by removing calcium in the form

of calcium salts or by inhibiting the conversion of
prothrombin to thrombin. Coagulation occurs
naturally according to the steps in Table 28-3. If a
Figure 28-13 Safety tube holders. (A) Safety needle step is prevented, the blood does not clot.
and holder. (B) Locking cover. A tube containing an anticoagulant removes
one of the steps in the process, preventing the blood
The additive may be an anticoagulant to prevent from clotting. The step removed depends on the
clotting of the blood, a chemical to help preserve anticoagulant used. The basic anticoagulants used
the blood, or a substance to accelerate the clotting consist of oxalates, citrates, ethylenediaminetetraace-
process (called a clot activator). Some tubes also tic acid (EDTA), or heparin (Figure 28-14). Antico-
contain gel plugs, which act as separators between agulants are identified by tube color. It is important
the blood cells/clot and the serum/plasma. An to use the correct anticoagulant for the test because
anticoagulant is a chemical substance that pre- the improper anticoagulant can alter test results.

Red Top Light Green Top

Contains: None Contains: Plasma Separating Tube (Na Heparin)

Effects on Blood clots, and the serum is separated by Anticoagulants with lithium heparin:
Effects on
Specimen: centrifugation plasma is separated with PST gel at the
Specimen:
bottom of the tube
Chemistries, Immunology and Serology,
Uses:
Blood Bank (Crossmatch) Uses: Chemistries

Red-Gray Mottled Top (“Tiger top”) Lavender/Purple Top

Serum Separating Tube (SST) with clot Contains: EDTA (liquid form)
Contains:
activator
Effects on
Forms calcium salts to remove calcium
Effects on Forms clot quickly and separates the serum Specimen:
Specimen: with SST gel at the bottom of the tube
Hematology (CBC) and Blood Bank
Uses: Blood type screening and chemistries (Crossmatch); requires a full draw—invert 8
Uses:
times to prevent clotting and platelet
clumping

Gold Top
Light Blue Top
Contains: Separating gel and clot activator
Contains: Sodium citrate (Na Citrate)
Serum separator tube (SST) contains a gel
Effects on Effects on
at the bottom to separate the blood from
Specimen: Forms calcium salts to remove calcium
serum on centrifugation Specimen:

Serology, endocrine, immunology, including Uses: Coagulation tests (PT, PTT, TCT, CMV),
Uses:
HIV tube must be filled 100%

Figure 28-14 Collection tubes and their additives for phlebotomy (continues).
846 UNIT 7 Laboratory Procedures

Dark Green Top Yellow Top

Contains: Sodium heparin or lithium heparin Contains: ACD (acid-citrate-dextose)

Effects on Effects on
Inactivates thrombin and thromboplastin Complement inactivation
Specimen: Specimen:

Ammonia, lactate, HLA typing Uses: Paternity testing, DNA studies

For lithium level, use sodium heparin
Uses:
For ammonia level, use sodium or lithium
heparin Tan/Brown Top
Contains: Sodium heparin
Dark Blue/Royal Blue Top
Effects on
Contains: Sodium heparin or Na2 EDTA Inactivates thrombin and thromboplastin
Specimen:

Forms calcium salts Uses: Serum lead determination

Effects on
Tube is designed to contain no
Specimen:
contaminating metals
Black Top
Toxicology and trace element testing (zinc,
Uses: copper, lead, mercury) and drug level Contains: Sodium citrate (buffered)
testing
Effects on
Forms calcium salts to remove calcium
Specimen:
Light Gray Top
Uses: Westergren Sedimentation Rate; requires
Contains: Sodium fluoride and potassium oxalate a full draw

Effects on Antiglycolytic agent preserves glucose up

Specimen: to 5 days Orange Top
For lithium level, use sodium heparin Contains: Thrombin
Uses: Glucoses requires a full draw (may cause
hemolysis if short draw) Effects on
Quickly clots blood
Specimen:

Uses: STAT serum chemistries

Figure 28-14 (continued)

Clot activators consists of silica (small glass) tops have clot activators in them. The glass red top
particles on the sides of the tubes that initiate the vacuum tubes do not.
clotting process. The silica particles work as a cata- Serum and plasma tubes can also be pur-
lyst for the clotting process by promoting the clot- chased with a thixotropic separator gel (Figure 28-
ting process. The plastic vacuum tubes with the red 15). The gel is an inert material that undergoes a
temporary change in viscosity during centrifuga-
tion. When centrifuged, the gel changes to a liquid
and moves up the sides of the tube to create a bar-
rier between the blood cells or clot and the liquid
Actions of Additives portion of the blood. The gel then forms a solid
Potassium oxalate Binds calcium plug and separates the cells/clot from the plasma/
Sodium fluoride Inhibits glycolysis serum (Figure 28-16).
Sodium citrate Binds calcium
EDTA Binds calcium
Lithium heparin Inhibits prothrombin to thrombin Order of Draw
No additive Clot naturally forms
Sodium Binds calcium The order in which blood is drawn or mixed with
polyanetholesulfonate the additives is important. Sterile collection bottles
(SPS) (for blood cultures) need to be filled first to prevent
Glass particles/silica Promotes clotting any contamination. After the sterile culture tubes
Ammonium heparin Inhibits prothrombin to thrombin are drawn, the order for the other tubes is related
to the additives in them. It does not matter whether
 CHAPTER 28 Phlebotomy: Venipuncture and Capillary Puncture 847

Table 28-4 Standard Order of Draw—CLSI

Guidelines as of December 2008

Blood culture Yellow top or culture bottles

tubes or vials

A B Sodium citrate Light blue top

Serum tubes Red top and red/gray top (SST)

Heparin tubes Green tops, light and dark

Figure 28-15 Standard vacuum tubes. (A) SST (red/ Lavender top, then pink, white,
EDTA tubes
gray or “speckled top”) top tube contains clot activa- or royal blue
tors and thixotropic gel. (B) Standard red top (glass)
tube contains no anticoagulant but might contain glass Glycolytic inhibitor Gray top
particles/silica on the inside walls to irritate the throm-
bocytes to promote clotting. FDP Dark blue

the blood is drawn directly into a vacuum tube or

into a syringe, then transferred to the vacuum tube.
be discarded into biohazard waste. If a patient has
The order of the tubes remains the same for either
been identified as having a latex hypersensitivity,
method. Table 28-4 also lists the order of draw.
you must use a nonlatex tourniquet. Latex-free
tourniquets are readily available and inexpensive,
Tourniquets so they can be used for all patients regardless of
latex allergy or hypersensitivity.
The tourniquet, when applied to the arm, constricts
A blood pressure cuff can also be used as a
the flow of blood in the arm and makes the veins
tourniquet. Its use is primarily for veins that are
more prominent. The tourniquet is a soft, pliable,
difficult to locate using a standard tourniquet. The
rubber or elastic strip approximately 1 inch wide
by 15 to 18 inches long (Figure 28-17). The elastic
strip serves as the best tourniquet for all conditions.
The elastic strip can easily be released with one Critical Thinking
hand. Being about 1 inch wide, it does not cut into
the patient’s arm but distributes the pressure. The Which vacuum tube would you use to draw
tourniquet can easily be disinfected but is inexpen- a serum specimen: lavender or red top? Why
sive enough that it should be replaced often. If the did you choose that tube? What differentiates
tourniquet is obviously contaminated, it should the two tubes?

Serum or Serum or
Plasma Serum or
Plasma Plasma
Blood
Cells
Gel Gel
Gel Cells Cells
Gel

Before During Plug After

Centrifugation Centrifugation Formation Centrifugation

Figure 28-16 Separator thixotropic gel tube showing

how the centrifugation process works. Figure 28-17 One kind of tourniquet.
848 UNIT 7 Laboratory Procedures

blood pressure should be taken first, and then the Table 28-5 Steps in Venipuncture
cuff should be maintained slightly below the dia-
stolic pressure (average: 40 mm Hg). 1. Identify the patient.

2. Verify test ordered.

Specimen Collection Trays 3. Verify diet/drug restrictions, e.g., fasting vs. nonfasting.
The medical assistant may need a specimen collec- 4. Wash hands. Put on gloves, as well as safety glasses .
tion tray to hold all the equipment necessary for and mask, if there is a potential for blood splatter
proper specimen collection. The tray can be taken
5. Assemble supplies and inspect equipment.
to the patient in the examination room so that
whatever procedure is performed the phlebotomy 6. Reassure the patient and explain the procedure.
can be conducted without searching for the proper 7. Position the patient.
equipment. The trays vary depending on the type
of collections done. Because the tray is also used to 8. Verify paperwork and tubes.
transport blood specimens, the OSHA Bloodborne 9. Perform venipuncture .
Pathogen Standard requires the tray be all red or
10. Fill the tubes.
prominently labeled with an approved biohazard
symbol. The tray is usually preferred because it is 11. Bandage the patient’s arm.
more portable and can easily be taken to the patient. 12. Dispose of sharps in the proper container.
The trays come in a variety of sizes and shapes to
better fit the preference and needs of the individual 13. Label the tubes.
collecting the blood sample (Figure 28-18). Some- 14. Remove gloves and other PPE. Dispose of properly.
times the equipment is stored in a special drawer Wash hands.
for venipuncture equipment in each examination 15. Chill specimen (only for certain tests).
room or in a central laboratory area.
16. Process paperwork. Complete laboratory
requisition.
VENIPUNCTURE TECHNIQUE 17. Send correctly labeled tubes to the office laboratory
or prepare them to be sent to a reference laboratory.
Venipuncture is a detailed process that consists of 18. Document procedure.
many steps (Table 28-5).

Figure 28-18 Two types of well-stocked phlebotomy trays.

 CHAPTER 28 Phlebotomy: Venipuncture and Capillary Puncture 849

Approaching the Patient stitutes the greatest number of errors in phlebotomy.

All patient specimens must be positively identified on
The first step to a successful venipuncture is to
the primary container, the container that holds the
put the patient at ease. The medical assistant uses
specimen, to avoid any errors in reporting of results,
many skills when interacting with patients during
thereby affecting patient diagnosis or treatment.
phlebotomy. Three of the skills used are:
1. Social skills
Preparing Supplies and
2. Technical skills
Greeting the Patient
3. Administrative skills
Prepare all supplies and equipment before the
Social skills are used by the medical assis- venipuncture. Place all tubes within easy reach to
tant to obtain cooperation from the patient. avoid crossing over the patient and possibly mov-
Some patients will be calm, whereas others may ing the needle after it is in the patient. Remember
be extremely frightened. The nicest patient may that occasionally a tube will not fill completely;
be irritable and may even become physically or therefore, it is best to keep a few spare tubes or
emotionally abusive when placed in the unfamil- have the phlebotomy tray within reach.
iar health care setting. The medical assistant uses
social skills to put the patient at ease, allay the
patient’s fears, and persuade the patient to allow Patient and Specimen
blood to be drawn. Identification
After calming the patient and explaining
the procedure, the medical assistant uses techni- Proper patient and specimen identification is essen-
cal skills to perform the phlebotomy with a mini- tial to accurate patient testing. The results of speci-
mum of pain to the patient. As important as it is men testing will be incorrect if the specimen is not
to obtain a good specimen, it is equally important accurately identified. When entering the room, do
to treat the patient with empathy. Using social and not say, “Mr. Jones, I’m here to draw your blood,”
technical skills, the medical assistant can provide a assuming if the patient says “Yes” this is Mr. Jones.
positive experience for the patient. A patient who The patient may not have been paying attention
has had a positive experience will talk with friends and may answer yes even if it is not his name. Ask
and neighbors about that experience, which could the patient to state his or her full name. If the
result in new patients for the physician’s office, the patient is unable to communicate with you, or if you
clinic, or the laboratory. are in an inpatient environment such as a hospital
For the medical assistant, administrative skills or extended care facility, always check the patient’s
involve drawing the correct patient’s blood and cor- identification wristband or check with the caretaker.
rectly labeling the specimen. Incorrect labeling con- In the ambulatory setting, a good policy is to ask for
picture identification from non-English-speaking
patients.
Once the medical assistant has identified
the patient and the blood is drawn, the specimen
Greeting the Patient needs proper identification. The patient’s first and
1. Reassure the patient that the procedure is going to be last name, middle initial, date of birth, any assigned
simple and there will only be a slight inconvenience. identification number, the date, the time, and the
2. Be friendly and outgoing and talk to the patient, explaining initials of the person collecting the specimen must
the procedure. Polite conversation with all patients gives be written on the tube immediately after drawing
them the feeling someone cares about them. the patient’s blood. Label the tubes clearly, using
3. Do not tell the patient that the procedure will not be pain- a permanent marker, before leaving the patient’s
ful. Explain that the procedure can be slightly uncomfort- presence. By doing so, if the tubes are taken to the
able but you will take care to cause the least discomfort
physician’s office laboratory or an outside refer-
possible. If the patient seems overly concerned about pain,
check frequently with him or her to see how he or she is
ence laboratory, the specimens will be properly
doing. If the patient seems extremely apprehensive, ask if identified. Any paperwork or forms accompany-
he or she would prefer to lie down during the procedure. ing the specimens must be checked with the blood
This may prevent further problems if the patient faints. tubes to verify that names and numbers match.
4. Exhibit concern for patients, because this will result in more Many offices are using various types of com-
satisfied patients who will return in the future for care from
the same provider.
E HR puter systems for test ordering and result
reporting (Figure 28-19). The computer
label has several advantages in that it lists the
850 UNIT 7 Laboratory Procedures

Results from

6 mL
Regional/ Results to Outside
National Labs Providers
244866 3857748 2005-12
REF./Best Nr: LOT/Ch.-8: Exp./Verw bis:
A

LABORATORY

Test Reports
Quality Assurance & Controls
Safety Standards

Orders for Tests

Safety Standards

ELECTRONIC Figure 28-20 (A) Adhesive computer-generated

RECORDS
labels for identifying specimen tubes from one patient.
(B) The medical assistant applies a computer-
generated label to the patient’s specimen tube.

Figure 28-19 Laboratory arm of a total practice

patient will make the patient feel more at ease and
management system (TPMS). Test ordering and result
facilitate the performance of the venipuncture.
reporting are capabilities of a TPMS.

Selecting the Appropriate

Venipuncture Site
specific tests that are ordered and the required The appropriate venipuncture site can vary
specimen and specimen requirements. The label depending on the patient. The usual site that is
can also be adhesive so it can be attached directly first checked is the antecubital region of the arm.
to the tube. Smaller labels can also be printed at
the same time for smaller aliquot specimens. An
aliquot specimen is a portion of a specimen that
has been taken for use or storage. The computer Positioning the Patient
has multiple advantages in timing the printing of Before a patient’s blood is drawn, discuss with the patient any
orders, sorting lists of orders for one patient at one previous problems with blood being taken. Usually one of two
time, and speeding entry of draw times and test situations must be addressed:
results. The computer labels print off in a roll with 1. Patients who do not have a problem with having blood drawn.
one label following the other. Two attached labels a. The patient must be in a seated or reclining position
(Figure 28-20A and B) require special attention. before any attempt is made to draw blood.
One label must be checked carefully with the other b. Do not allow the patient to sit on a tall stool or stand
to ensure that each label is for the same person, while drawing blood. There is always the possibility that
the patient will faint (syncope) and be injured.
date, and time. Labels may also contain bar codes
c. The sitting position requires a chair with adequate arm
to assist in electronic patient and specimen identi- supports that are adjustable for the best venipuncture
fication. With computerized systems, the medical position.
assistant will verify by entering information into 2. Patients who will faint (syncope).
the computer when the blood is drawn. a. Apprehensive patients and patients who indicate they
have fainted in the past when having blood drawn
should be instructed to lie down.
Positioning the Patient b. The reclining position is the ideal position from which
The position of the patient is critical for proper to draw a blood sample from the patient.
patient blood collection. The best position is the c. A pillow may be required to help support the patient’s
position that is comfortable for the patient and the arm by keeping it straight for easier venous access.
health care professional. Proper positioning of the
 CHAPTER 28 Phlebotomy: Venipuncture and Capillary Puncture 851

3 to 4 inches above the intended puncture site. It

Patient Safety is applied tightly enough to slow the flow of blood
• Question the patient about his or her past experi- in the veins but not so tightly as to prevent the flow
ences with venipuncture. of blood in the arteries (Figures 28-21A–D). This is
• Position the patient properly to avoid injury. similar to damming a small stream. When a stream
is dammed, the water forms a pond in front of the
• Do not attempt to draw blood from a combative patient.
dam. With the tourniquet applied, the veins fill
• Restrain uncooperative children. with blood, pooling in the veins below the tourni-
• Note allergies or sensitivities to latex, alcohol, and tape quet. This pooling of blood makes the veins more
adhesives. prominent. The veins can then be palpated (exam-
ined with the fingertips) to determine their direc-
tion, depth, and size. The tourniquet should be on
the arm no longer than one minute. A stream will
become stagnant when it no longer flows. A tourni-
The primary vein used in the antecubital region of quet that is left on too long will cause hemoconcen-
the arm is the median cubital vein. This is usually tration of the blood, an increased concentration of
the prominent vein in the middle of the bend of constituents in the blood sample that may lead to
the arm (see Figure 28-4). The basilic or cephalic inaccurate test results. If the patient has sensitive
vein can be used as an alternative. These veins may skin or a skin problem, the tourniquet should be
not be accessible or may not be prominent enough applied over the patient’s upper arm clothing or a
to obtain a blood sample. The next step is to go piece of gauze pad. This will minimize the discom-
to the back of the hand to determine other possi- fort felt by the patient.
bilities. The veins in the back of the hand have the The tourniquet often causes greater discom-
tendency to “roll” more than the arm veins because fort for patients than the venipuncture itself. The
they are not supported by as much tissue and are tourniquet should ideally be removed as soon as
closer to the surface. To avoid this, the vein will blood flow is established. This is not practical for
have to be held in place securely while a smaller the novice medical assistant. The act of removing
gauge needle or a butterfly is used. The hand veins the tourniquet may move the needle or vein just
are ideal for a 3- to 5-cc syringe with a 22 gauge enough so that no more blood can be obtained
needle. Careful, slow pulling on the syringe will and a second venipuncture must be performed.
obtain the blood sample without collapsing the It is recommended to wait until just before the
vein or hemolyzing the blood. The veins at the needle is removed from the patient to remove the
back of the wrist are also an alternative, but they tourniquet. If the tourniquet is not removed before
are generally much more painful than the other the needle is removed, the patient will bleed heav-
sites. The foot and ankle veins may also be used ily. Blood will be forced out of the needle hole and
if the patient’s provider gives permission to use into the surrounding tissue, resulting in a hema-
them and the medical assistant is properly trained toma (an accumulation of blood around the veni-
to perform venipuncture on the lower extremities. puncture site).
The veins in the foot or ankle will also have the
tendency to “roll.” The medical assistant will in all Performing a Safe Venipuncture
likelihood never draw from the foot or ankle, but
this is an area that will give an acceptable blood The first step in actual collection of a venous blood
sample when all other attempts have failed. specimen is to find the site that will give the best
The order for checking for the best available blood return. The vein must be palpated with the
site is: (1) antecubital region of the arm, (2) back tip of the index finger. Feel for and trace the path
of hand, (3) back of wrist, and (4) ankle or foot.
The next alternative is to have a more experienced
medical assistant check. If venous access is not pos- Critical Thinking
sible, draw the sample by capillary puncture if the
test can be performed on a capillary specimen. You are having a difficult time getting the
Check the laboratory manual for criteria. needle to cooperate when putting together
a butterfly system and you accidentally
Applying the Tourniquet contaminate it. The patient has the tourniquet
already on her arm. What do you do? Why? Is
A tourniquet must be used to assist the medical there something else you could have done?
assistant in feeling a vein. The tourniquet is applied
852 UNIT 7 Laboratory Procedures

of the vein several times. Avoid using the thumb

because it has a pulse and is not as sensitive as
the rest of the fingers. The vein will feel soft and
bouncy to the touch. The roundness of the vein
and the direction it follows may be determined.
All veins are not straight up and down the arm.
If no veins become prominent, retie the tourni-
quet tighter but not so tightly as to stop the flow
of arterial blood into the arm. If the tourniquet is
A tied tightly enough to stop arterial blood flow, the
patient will no longer have a pulse in the wrist. If
this occurs, immediately remove the tourniquet
because this indicates that blood has ceased flow-
ing below the tourniquet.
If the “vein” that is felt has a pulsing action to
it, it is an artery, not a vein, and the vessel should
not be punctured (see safety box). Tendons can be
deceptive and give the appearance of veins. They
do not have the soft, bouncy feel and will be hard to
the touch. Puncturing a tendon will give no blood
return and will be painful to the patient. Nerves
B
also run the length of the arm. The nerves cannot
be seen or felt, but by avoiding deep, probing veni-
punctures, the chance of puncturing a nerve will
be diminished. If the patient complains that the
venipuncture is extremely painful, it is best to stop
and try another site.
Veins of edematous arms, which are swollen
because of fluid in the tissue, will not be prominent
and the tourniquet will not be effective because of
the swelling. Using the tourniquet in this instance
may cause tissue damage. Areas of scarring should
C also be avoided because of possible injury or exces-
sive pain to the patient. Specimens collected from
an area of a hematoma may cause erroneous test
results. If another vein site is not available, the
specimen is collected distal from the hematoma.
Because of the potential for harm to the patient
due to lymphostasis (the stoppage of the flow of
lymph), the arm on the side of a mastectomy or any

Safety Box
D
If you accidentally puncture an artery, you will see
Figure 28-21 Applying a tourniquet. (A) Wrap the that the blood is a brighter color. This is due to the
oxygenation of arterial blood versus venous blood.
tourniquet around the arm 3 to 4 inches above the veni-
Go ahead and calmly fill the tubes. Often the laboratory can run
puncture site. Keeping the tourniquet flat to the skin the blood tests on arterial blood just as with venous blood. After
will help minimize the discomfort felt by the patient. the needle is removed, pressure needs to be held for a full 3
(B) Stretch the tourniquet tight and cross the ends. minutes (longer if the patient is taking a blood thinner such as
(C) While holding the ends tight, tuck one portion of Coumadin). As with any phlebotomy procedure, make sure the
the tourniquet under the other. (D) The tourniquet bleeding has stopped before the patient leaves your care. While
should not be loose and the ends should be secure. The the patient is still there, check with the lab. If the test requires
ends of the tourniquet should be pointed upward and venous blood, you will need to repeat the procedure.
not hanging into the intended venipuncture site.
 CHAPTER 28 Phlebotomy: Venipuncture and Capillary Puncture 853

be used. Wipe the skin firmly with an alcohol pad.

Correct Hand Position to Hold a This removes any oil, sweat, perfume, lotions, and
Syringe skin contaminations. This process is often referred
to as “defatting” the skin. Allow the area to air dry,
1. The needle is attached to the syringe.
2. Hold the syringe and needle system in your dominant
or you may dry it with a clean cotton ball or gauze
hand, cradling it on your four fingers. A right-handed person pad. Puncturing the skin through wet alcohol
would hold the syringe in the right hand, leaving the left can cause hemolysis of the specimen and give the
hand to pull on the plunger. A left-handed person would do patient a stinging sensation. Residual alcohol can
the opposite. also contaminate the specimen.
3. Place the thumb on top of the syringe (Figure 28-22). Some authorities suggest putting on gloves
4. With the syringe held in this position, turn it slightly so the first and then palpating for the vein. This tech-
bevel of the needle is facing up. nique is required for the patient who is isolated
5. Hold the hand in such a position that by tilting the point of because of a communicable disease and is good
the needle down slightly the needle will enter the skin at a practice for all patients. Standard Precautions
15-degree angle and about 0.5 cm below the point where
require that personal protective equipment be
the vein was felt.
worn when there is a chance of coming in con-
tact with blood and body fluid. If the patient has
veins that are difficult to palpate, the gloves can be
put on after the site has been palpated and before
the cleansing. To avoid forgetting where the col-
lection site is, palpate the vein 1 to 2 inches above
and below the intended puncture site. It helps the
medical assistant feel that the vein is located in a
straight line and these points can be used to “reset”
the mental crosshairs without contaminating the
venipuncture site. Safety glasses and a mask must
Figure 28-22 Proper hand position to hold a syringe be worn if there is a potential for blood spatter.
for blood collection.
The Syringe Technique
lymphatic compromise should be avoided. If the The syringe technique is used less often than the
patient has had a double mastectomy, a physician vacuum tube method. The syringe is ideal for col-
should be consulted before drawing the blood. lecting small volumes of blood from fragile, thin,
or “rolling” veins or veins on the back of the hand
or from the foot. Pulling on the plunger of the
SPECIMEN COLLECTION syringe creates suction; the larger the syringe, the
greater the suction that can be obtained. Too great
The patient has been identified, paperwork and a suction might cause the vein to collapse. Vein col-
tubes have been verified, equipment has been lapse can be avoided by pulling the plunger slowly
assembled, and the patient is in a comfortable posi- and by resting between pulls to allow the vein to
tion. Hand washing is the most critical step to pre- refill. Because pediatric and geriatric patients
venting the spread of infection. Before touching often have thin and fragile veins, the syringe is the
the patient, medical assistants should wash their preferred method of venipuncture for them. The
hands. It is good practice to wash your hands in use of a syringe larger than 15 mL is not recom-
view of the patient to give the patient confidence mended. If more than 12 mL is needed, the but-
in your technique. The next step is to tie the tour- terfly collection method should be considered.
niquet. Have the patient close the hand, and then Syringe draws are also ideal in special procedures
select a vein. If possible, place the patient’s arm in when the blood must be transferred to a different
a downward position. After locating an acceptable container. Procedure 28-2 gives detailed instruc-
vein, mentally map the location. Set mental sites tions for venipuncture with syringe.
on the vein by visualizing the puncture site as the When a syringe is used, the blood obtained
target for an accurate puncture. Cleanse the site must be placed in appropriate containers. The
with a gauze pad wet with 70% isopropyl alcohol order of filling the tubes is important.
solution. A commercially prepared alcohol pad or The use of a needle to transfer blood from a
one with 0.5% chlorhexidine in alcohol may also syringe to a vacuum tube or culture bottle is unsafe
854 UNIT 7 Laboratory Procedures

Correct Needle Position

The patient will experience the least amount of pain if the
bevel of the needle is facing upward when the needle is
inserted into the vein. The bevel of the needle is upward when
the opening in the needle is visible when you look straight
down on the needle as it is inserted. This position also helps
prevent the suction from causing the inside wall of the vein to
adhere to the needle bevel, thus occluding the needle.
The needle should be inserted at a 15-degree angle to the
surface of the skin (Figure 28-23).
The skin should be held taut until the needle has been A
inserted. This technique allows the point of the needle to enter
the skin with little drag or bunching of the skin, thereby reduc-
ing the discomfort of the puncture.

10°

Figure 28-23 Proper angle of needle insertion for B

venipuncture.
Figure 28-24 (A) The medical assistant attaches the
BD Vacutainer Blood Transfer Device. (B) The device is
and prohibited by OSHA. The use of a safety system used to safely transfer blood from a syringe to a vacuum
such as the BD Vacutainer Blood Transfer Device is tube.
recommended (Figure 28-24). After drawing the
blood into the syringe, activate the needle’s safety
mechanism, then remove the needle and dispose syringe plunger or force the blood into the tube.
of it. Connect the needleless syringe to the trans- This could cause the tube’s stopper to pop off.
fer device. Insert a vacuum tube to the device and When the appropriate tubes have been filled, dis-
allow the blood to transfer from the syringe to the pose of the entire syringe and transfer assembly as
tube using the tube’s vacuum. Never push on the one unit according to your clinic policies.
Immediately after filling, mix any tubes con-
taining additives (Figure 28-25).
When transferring blood from a syringe to a
vacuum tube, keep these safety features in Vacuum Tube Specimen
mind:
• Never transfer to a vacuum tube using a needle. When Collection
transferring from a syringe to a vacuum tube, use a The vacuum tube system is an improvement over
needleless transfer device. the syringe method yet maintains many similari-
• Never push the blood into the vacuum tube. It will fill on ties. When the syringe method is used, a vacuum
its own. is created as the medical assistant pulls on the
• Always wear gloves, goggles, and face guard when perform- syringe plunger. The vacuum tube method has the
ing this procedure. vacuum already in the tube. Another advantage of
the vacuum tube system is that with multiple blood
 CHAPTER 28 Phlebotomy: Venipuncture and Capillary Puncture 855

BD Vacutainer™ Closure Number of

Tube Type Color Inversions
EDTA Lavender 8–10

Sodium citrate Light Blue 3–4

SST with gel Tiger (Red Gray) or Gold 5

Serum Red 5

Sodium fluoride Gray 8–10

Heparin Green 8–10

Figure 28-25 Vacuum tubes should be inverted several times (not shaken) to mix the addi-
tives well.

samples, syringes do not need to be changed; only wings. Six or twelve inches of tubing leads from the
the tubes need to be changed. needle. On the other end of this tubing is a hub
The similarity between the vacuum tube sys- that can attach to a syringe. A needle covered by a
tem and the syringe system is that the holder and rubber sleeve can also be attached to the tubing.
needle are held in the same manner (Figure 28- The covered needle screws into an evacuated tube
26). The syringe is held in a manner that allows holder (Figure 28-27).
the medical assistant access to pull on the plunger. The butterfly system is used for small veins
Access must be left in the vacuum tube system for that are difficult to puncture with the vacuum
one tube to be pulled out and another inserted. tube system and standard vacuum tube system
The hand that pulled on the plunger of the syringe needle. The system also facilitates drawing from
is the hand that changes tubes with the vacuum veins that have a tendency to collapse. The winged
tube system. needle of the butterfly needle will slide into a
The procedure for venipuncture with the small surface vein in the back of the hand, wrist,
vacuum tube system follows the same steps as the or foot. Instead of entering the vein at the usual
syringe method with only slight variations. 15-degree angle, the winged needle is inserted at
a 5- to 10-degree angle, and then threaded into
the vein. This procedure anchors the needle in
Butterfly Needle Collection the center of a small vein that is inaccessible by
System other methods. If the patient moves, the tubing
The butterfly collection system combines the ben- gives flexibility so the needle will stay anchored
efits of the syringe system and the vacuum tube
system. The butterfly collection system has on one
end a 21- or 23-gauge needle with attached plastic

A B

Figure 28-27 Butterfly needle sets with connections

Figure 28-26 Proper hand position to hold a vacuum for either a (A) vacuum tube or (B) a Luer-Lok tipped
tube system. syringe.
856 UNIT 7 Laboratory Procedures

and not pull out of the vein. The butterfly collec-

tion set works well on children who have small Critical Thinking
veins and the tendency to move while blood is
being collected. You are preparing to perform a venipuncture
The system also gives the adaptability of ini- on a geriatric patient who has fragile veins.
tiating a draw with a syringe and then finishing it Which system would you use: a syringe or
with the evacuated tube system. A syringe can be a vacuum tube system? What makes one
filled for procedures that require a syringe sample. technique more successful in this case?
It can then be removed, and the vacuum tube sys-
tem can be attached for multiple tube collection.
Remember to draw into or transfer into the vac-
uum tubes in the proper order (see Table 28-4). Patient Reactions
Although the butterfly collection system has many
benefits, it is not used for all collections. It is more Patients can have a variety of reactions to having
expensive than the needle system. The additional their blood drawn. The medical assistant must
expense is unnecessary for the majority of veni- anticipate these reactions and respond appropri-
punctures. ately as quickly as possible. The most common
patient reaction is pain. The patient will indicate
that the venipuncture is painful. Slightly reposi-
Blood Cultures tion the needle, and then loosen the tourniquet.
Occasionally a patient will need to have blood col- Loosening the tourniquet often helps because the
lected for culture. The culture will determine if tourniquet may be pinching the arm and causing
the patient has pathogens in the blood. Normally discomfort rather than the needle. Avoid deep,
blood is sterile. When drawing blood for cultures, probing venipunctures because they may go deeply
use a surgical solution (often Betadine) rather into the arm and get too close to the nerves. If the
than alcohol and sterile rather than clean proce- pain persists, discontinue the venipuncture.
dure. This means using sterile gloves; do not wipe Other possible patient reactions and the
away the surgical solution, touch the puncture site, medical assistant’s appropriate responses are listed
or in any way compromise the sterile process. The in Table 28-6.
blood is collected into special transport bottles,
which are like vacuum tubes but shaped differently
(Figure 28-28). The blood culture bottle contains
The Unsuccessful Venipuncture
transport media to preserve any microorganisms Methods of vein stimulation are shown in Table
present while they are transported to the labora- 28-7. When a blood sample cannot be obtained,
tory for culture. Because it is unknown whether it may be necessary to change the position of the
the pathogen is anaerobic (living without oxygen) needle. Rotate the needle half a turn. The bevel of
or aerobic (living with oxygen), blood is collected the needle may be against the wall of the vein. If
to test for both. The aerobic bottle is filled first, the needle has not penetrated the vein far enough,
then the anaerobic bottle is filled. advance it further into the vein. Advance it only
slightly; a small change may mean the difference
between a failed and a successful venipuncture.
If the needle has penetrated too far into the vein,
pull back a little. Always withdraw the needle slowly
when the venipuncture has been unsuccessful. The
blood often may start coming just as it seems the
needle is ready to come out of the skin. The tube
used may not have sufficient vacuum. Try another
tube before withdrawing the needle.
Probing the site is not recommended. Prob-
ing is painful to the patient and may cause a hema-
toma. Never attempt a venipuncture more than
two times. If a blood sample cannot be obtained
after two attempts, have another person attempt
the draw. Notify the patient’s provider if two medi-
Figure 28-28 Blood being drawn for cultures. cal assistants have been unsuccessful.
 CHAPTER 28 Phlebotomy: Venipuncture and Capillary Puncture 857

Table 28-6 Patient Reactions to Blood Draws

Patient Reaction Medical Assistant Response

Immediately remove the tourniquet, then the needle, and stop the patient from falling. Lower
the patient’s head and arms. Wipe the patient’s forehead and back of the neck with a cold
Syncope (fainting)
compress if necessary. If the patient does not respond, notify the provider, move the patient to
the floor, and place a pillow under the patient’s legs

If a patient becomes nauseated, apply cold compresses to the patient’s forehead. Give the
Nausea patient an emesis basin, and have facial tissues ready if the nausea does not diminish. Deep,
slow breathing through the mouth may help

The first signs of insulin shock are a cold sweat and pallor similar to the signs of syncope. The
Insulin shock or patient becomes weak and shaky, sudden mental confusion may follow, and it appears as
hypoglycemia though the patient’s personality changes instantly. Call the provider if the patient loses con-
sciousness. This can happen especially to patients having a fasting blood sugar test

The patient loses consciousness and exhibits violent or mild convulsive motions. Do not try to
restrain the patient. Move objects or furniture out of the way to prevent the patient from striking
Convulsions objects and being hurt. Help the patient to the floor and into a reclining position. The patient
usually recovers within a few minutes. Notify the provider about the patient’s reaction. The pro-
vider will determine when to release the patient

Criteria for Rejection all inclusive. The type of specimen that is accept-
of a Specimen able and the volume required are determined by
the procedure ordered. The quality-control checks
The primary goal of the medical assistant is to pro- done by the laboratory may indicate the results are
vide an acceptable specimen for laboratory testing as valid. If the results do not agree with what the pro-
required by the provider. Certain general criteria must vider believes is the patient’s diagnosis, the blood
be met for a specimen to be acceptable. If the crite- specimen may need to be redrawn to confirm the
ria are not met, the specimen is rejected and another results. This is accomplished by either retesting
venipuncture of the patient must be performed. the specimen or collecting another sample. This
Table 28-8 lists quality-assurance controls for will either reconfirm that blood was drawn from
specimen collection and processing. The list is not the correct patient or that the patient’s test results
changed significantly.

Table 28-7 Methods of Vein Stimulation

Factors Affecting Laboratory
1. Position the patient’s arm lower than his or her heart. Values
Table
2. 28-7
Reapply Methods of
the tourniquet; Veinnot
it may Stimulation
be tight enough. Numerous variables can affect laboratory test
results. The specimens are tested by analytic in-
3. Massage the arm from the wrist to the elbow to
struments that give accurate and precise results.
encourage venous return.
These results will accurately reflect what is wrong
4. Tap sharply at the venipuncture site with your finger- with the patient only if the specimen is collected
tips. This can cause the veins to dilate. correctly. The medical assistant is responsible for
collecting and caring for the specimen properly.
5. Use a blood pressure cuff in place of the tourniquet.
When in doubt of how to care for a specimen,
Pump it to about 40–60 mm Hg.
refer to the manual supplied by the laboratory or
6. Warm the venipuncture site with a warming device contact the laboratory for specific instructions. It
or a warm washcloth (not hotter than 100°F.) is always better to ask the question and perform
the proper procedure than not to ask and have
7. Have the patient make a fist. Do not have the
patient pump his or her fist; that can cause a false
to repeat the venipuncture. In addition, if you
high level of potassium in the specimen. ever do need to repeat a venipuncture because of
improper collection or handling of the specimen,
858 UNIT 7 Laboratory Procedures

Table 28-8 Quality Assurance for Specimen Table 28-9 Factors Affecting Laboratory
Collection and Processing Results

1. Each specimen must have its own label attached to Factor Effect
the specimen’s primary container.

2. Each specimen must have a laboratory requisition label. When drawing a specimen for
blood alcohol testing, a nonalco-
3. Labels must have the patient’s complete name and hol-based antiseptic should be
Blood alcohol
identification number, date of birth, date and time, and used to clean the venipuncture site.
your signature. The cleansing alcohol may falsely
elevate the test result.
4. Specimens in syringes with needles still attached are
unacceptable. Some specimens must be drawn at
timed intervals because of medica-
5. All specimens must be in the appropriate anticoagu- Diurnal
tion or diurnal (daily) rhythm. The
lant. rhythm
exact time of collection must be
noted on the specimen.
6. Blood collection tubes with anticoagulant must be at
least 75% full. All blood collection tubes for coagula-
tion testing must be at least 90% full. Strenuous short-term exercise can
make the heart work harder and
7. Uncoagulated blood specimens must be free of clots. increase the heart enzymes. Long-
Exercise term exercise such as that per-
8. Certain tests require specimens to be free of hemolysis formed by highly trained runners
and lipemia, a milky appearance due to lipids. can cause erroneous results due to
runner’s anemia.
9. The specimen may need to be recollected if the results
do not agree with what the provider believes is the
diagnosis of the patient.
Patient not in fasting state when
Fasting fasting is required. Results of tests
10. Do not combine partially filled tubes. will not be accurate.

11. Do not mix tubes of different additives. Destruction of red blood cell mem-
brane and release of intercellular
12 As soon as possible, invert tubes 8 to 10 times to pre- contents into serum/plasma can
vent microclots from forming (see Figure 28-25). be caused by not allowing alco-
hol to air-dry at venipuncture site,
13. Mix tubes gently to prevent hemolysis of specimen. using a needle that is too small
Hemolysis
(less than 22 gauge), forcing the
blood into a vacutainer tube from
a syringe, or shaking the vacutainer
the patient should not be billed for the second col- tube instead of mixing by gentle
lection. Patient physiologic factors may also con- inversion when mixing tubes with
additives.
tribute to inaccurate results. Other factors that can
alter results are listed in Table 28-9.
Incorrect heparin used that
Occasionally, a specimen requires protection Heparin interferes with tests being run on
from light, incubation, refrigeration, or chilling patient.
immediately after collection. Any delay in these
requirements will alter the results. The laboratory In children, violent crying before a
manual will direct you as to which specimens need Stress specimen is collected can increase
to be chilled. See Table 28-10 for examples of spe- the white blood cell count.
cial handling requirements.
The medical assistant is not the only person Tourniquet on Hemoconcentration, change in
who can affect test results. The patient can know- too long chemical concentration.
ingly or unknowingly alter the results by certain
Not enough blood will cause a dilu-
actions. For example, a patient has consumed a
tion factor, which can change the
cup of coffee but claims not to have had anything Volume
size of the cells and therefore pro-
to eat or drink. The patient is often under the mis- duce a variation in test results.
conception that black coffee without sugar will
not be a problem. Caffeine and smoking affect the
metabolism and can affect the test results.
 CHAPTER 28 Phlebotomy: Venipuncture and Capillary Puncture 859

Table 28-10 Common Laboratory Tests that Require Special Handling

Laboratory Test Special Handling

A, vitamin Protect from light by wrapping tube in foil

Acid phosphatase Deliver to laboratory within 1 hour. Separate, freeze serum after clotting

Adrenocorticotropic hormone (ACTH) Place in ice slurry

Alcohol, blood Do NOT use alcohol pad to clean site

Ammonia Place in ice slurry

B6, vitamin Protect from light by wrapping tube in foil

B12, vitamin Protect from light by wrapping tube in foil

Beta-carotene Protect from light by wrapping tube in foil

Bilirubin, total or direct Protect from light by wrapping tube in foil

Catecholamines Place in ice slurry

Clot retraction Incubate in 37°C until clotted

Cold agglutinins Warm tube, incubate in 37°C

Complement C4 Separate and freeze serum after clotting

Complement, total (CH50) Let clot in refrigerator, separate immediately and freeze immediately

Complement, total (CH100) Let clot in refrigerator, separate immediately and freeze immediately

Cryofibrinogen Warm tube, incubate in 37°C

Gastrin Place in ice slurry

Gentamicin Label peak or trough and time of last medication

Glucose tolerance Label tubes with time intervals of draw specimens

Human leukocyte antigen (HLA-B27) Do NOT refrigerate or freeze, record date and time collected

Lactic acid Place in ice slurry

Parathyroid hormone (PTH) Place in ice slurry

Partial thromboplastin time (PTT) Refrigerate, test within 4 hours of drawing specimen

pH / blood gas Place in ice slurry

Porphyrins Protect from light by wrapping tube in foil

Prostate-specific antigen Deliver to laboratory within 1 hour, separate, freeze serum after clotting

Prostatic acid phosphatase Deliver to laboratory within 1 hour, separate, freeze serum after clotting

Prothrombin time (PT) Refrigerate

Pyruvate Place in ice slurry

Red cell folate Protect from light by wrapping tube in foil

Renin Place in ice slurry

Thioridazine (Mellaril) Protect from light by wrapping tube in foil

Tobramycin Label peak or trough and time of last medication

Source: Courtesy of Sheri R. Greimes, CMA (AAMA), PBT (ASCP).

860 UNIT 7 Laboratory Procedures

Great
CAPILLARY PUNCTURE Ring
Not this
This
Venipuncture is the most frequently performed
phlebotomy procedure, but it is not the procedure
of choice in all circumstances. An alternative to
venipuncture is capillary puncture, also known as
dermal puncture or skin puncture. B
Capillary puncture is a method of obtaining
one to several drops of blood for a variety of tests.
With proper instruments, tests such as a complete
blood count, RBC count, white blood cell (WBC)
count, hemoglobin, and hematocrit can be run.
One drop of blood can be used to test glucose A
blood levels, a few drops of blood can fill capillary
tubes, and several drops can complete a phenylke- Figure 28-29 (A) Capillary blood collection sites. (B)
tonuria (PKU) test card. Tests that cannot be run Correct direction of capillary puncture.
on capillary blood specimens are sedimentation
rates, blood cultures, coagulation studies, and any
other tests requiring large amounts of serum or Preparing the Capillary
plasma. Puncture Site
Capillary puncture is the method of choice The area selected for a capillary puncture must be
with two types of patients: when patient blood vol- carefully prepared. The puncture site will be warm
ume is a concern, such as with infants, and when if blood circulation is adequate. Coolness of the
vein access is difficult, such as with burned or skin indicates decreased circulation. To increase
scarred patients. Capillary puncture should not be circulation, the site can be gently massaged, or a
used when a patient is edematous, dehydrated, or warm, moist towel, face cloth, or warm pack (at a
has poor peripheral circulation. temperature not higher than 100°F) can be placed
on the site for 3 to 5 minutes.
Alcohol-soaked gauze or cotton should be
Composition of Capillary Blood used to cleanse and disinfect the puncture site. The
Blood obtained via capillary puncture is a mix- site should then be allowed to air-dry, or dry with
ture of blood from arterioles, venules, capillaries, a gauze pad. A cotton ball is not recommended
and interstitial fluid. In most instances, a capillary because the tiny cotton fibers can stay on the punc-
puncture specimen most resembles arterial blood. ture site, assisting in clotting, which is not desirable
There may be significant differences between at this point. When the puncture is complete, a cot-
specimens obtained by capillary puncture and ton ball can be used as a compress. Residual alco-
those collected by venipuncture. For example, the hol at the puncture site results in hemolysis of the
glucose level may be increased in capillary blood, specimen, which may affect test results, as well as
whereas the potassium, calcium, and total protein cause a burning sensation to the patient. Betadine®
levels may be decreased. It is therefore important (povidone-iodine) should not be used to clean the
to always note on the specimen when capillary puncture site. Blood contaminated with iodine may
blood has been obtained. falsely increase certain blood chemistries.

Performing the Puncture

Capillary Puncture Sites Safety glasses, a mask, and gloves should be worn
The usual site for capillary puncture in adults by the medical assistant while performing capillary
and children is the fingertip (Figure 28-29). In puncture. Some patients bleed quite readily from the
adults, the ring finger is often selected because puncture, so be sure to have extra gauze on hand.
it usually is not callused. In infants, the lateral The patient’s hand and finger should be held so the
or medial plantar surface of the heel pad is usu- puncture site is readily accessible. The puncture is
ally used, and the procedure is often called a made at the tip of the fleshy pad and slightly to the
heelstick. The heelstick is most often performed side (see Figure 28-29). The skin near the chosen
when testing for PKU, which is covered in detail site should be pulled taut. If the tips of the fingers
in Chapter 32. are heavily callused or thickened, a lancet with a
 CHAPTER 28 Phlebotomy: Venipuncture and Capillary Puncture 861

longer point may be used. Capillary punctures are tubes to check hematocrit levels. When capillary
performed using semiautomated devices such as the tubes are used for hematocrit tests, they are called
disposable Microtainer ® Brand Safety Flow Lancet ®. microhematocrit tubes.
The BD Microtainer ® Genie Lancet is shown It may be necessary to massage the finger to
in Figure 28-30. After cleansing the puncture site, increase the blood flow. It is best to massage the
twist off the indicator as directed on the tab. Press whole hand, taking care not to apply direct pres-
the safety lancet firmly against the puncture site. sure near the puncture site. Squeezing the fingertip
Hold the lancet between your fingers and press the should be avoided; this forces tissue fluid into the
white button with your thumb. The lancet should blood sample and dilutes it or may cause hemolysis.
not bounce off the skin. The puncture should be Do not use a scooping technique when collecting
performed in one quick, steady movement. Once blood from the puncture site. Scooping can break
you have depressed the plunger, the button will the RBC membranes, leading to hemolysis.
lock into the housing and the needle will be per- Figure 28-31 shows the basic steps to follow
manently encapsulated. Practice working the lan- when filling a capillary tube. Allow well-rounded
cets until you are comfortable with the action. drops of blood to form at the puncture site. Hold-
ing the capillary tube at a horizontal position, gen-
Collecting the Blood Sample tly touch the tip of tube to the top of the blood
drop. The blood will enter the tube through “capil-
The first drop of blood is wiped away with dry, ster- lary action” caused by surface tension. Take care to
ile gauze because it contains tissue fluid, which not tilt the tube downward, which can cause air to
dilutes the blood drop and can also activate clot- enter the tube, nor upward, which can cause blood
ting. The second and following drops of blood are to come out of the tube. Continue to fill the tube
used for test samples. Depending on the tests to until it is two-thirds to three-quarters full. When the
be performed, the blood may be collected in cap- tube is sufficiently filled, remove it from the drop
illary tubes or other capillary collecting devices. and, at the same time, place your gloved finger
Capillary tubes are small-diameter glass or plastic over the opposite end of the tube. This will prevent
tubes that are open at both ends. Capillary tubes the blood from flowing out of the tube. Keep your
are extremely fragile and care should be taken to gloved finger over the end of the tube and, using
prevent breakage. The tubes have a colored line your other hand, wipe off any residue blood from
around one end. A red or black line indicates the outside of the tube with a gauze pad. Gently
that the tube contains heparin, an anticoagulant, place the end of the tube into the sealing clay. Seal-
and will yield a nonclotted specimen. A blue line ing clay trays are specially made for this purpose.
indicates that the tube contains no anticoagu- They have numbered sections to help identify the
lant and will yield a clotted specimen. When tak- samples. Some capillary tubes have plastic caps.
ing the blood sample directly from the puncture Carefully follow the manufacturer’s instructions
site, a capillary tube that contains anticoagulant for the type of tube you are using.
would be used; when taking blood from a vacuum During the filling of the tubes, if the flow
tube that already has anticoagulant in it, the plain of blood begins to slow, rewipe the puncture site
capillary tube would be used. Capillary tubes are firmly with dry gauze (not a cotton ball). This
used for many tests, depending on the equipment action will dislodge the platelet plug and allow the
available. Chapter 29 explains how to use capillary blood to flow freely. Be sure the patient is relaxed.
Have the patient take a deep breath. After filling
the required number of tubes, apply a cotton ball
compress to the puncture site. The patient can
usually help hold the compress. The compression
should be held in place for 1 to 3 minutes, depend-
ing on the patient. If the patient is taking aspirin,
Coumadin, or other anticoagulants, compression
should be for at least 5 minutes.
In many ways the procedure for capillary
puncture is similar to the other collection proce-
dures discussed in this chapter (e.g., patient iden-
Figure 28-30 Microtainer brand lancets are available tification, safety precautions, specimen labeling).
in different types for various purposes. They are color Procedure 28-5 provides a detailed description of
coded and have specific information on their packaging. capillary puncture.
862 UNIT 7 Laboratory Procedures

A
E

D H

Figure 28-31 Collecting a specimen into a capillary tube through capillary puncture. (A) Assemble the necessary
equipment and supplies and examine the finger for the best puncture site. (B) Clean the site with alcohol and allow
the area to dry. (C) Perform the puncture. (D) Discard the lancet into a nearby sharps container. (E) Wipe off the
first drop (not shown) and allow a well-rounded drop to form. (F) Holding the capillary tube horizontally, touch
the end to the drop and allow the tube to fill. (G) Carefully wipe the residue blood off the tube. (H) Gently place
the end of the tube into the sealing clay. Repeat to collect a second tube. Draw at least two tubes; some laboratories
require three. Follow your laboratory manual instructions.
 CHAPTER 28 Phlebotomy: Venipuncture and Capillary Puncture 863

Procedure 28-1
Palpating a Vein and Preparing a Patient for Venipuncture
STANDARD PRECAUTIONS: allow the patient to pump his or her hand.
RATIONALE: Having the patient close his or her
hand and positioning the arm below the heart
causes enlargement of the vein, allowing for an
PURPOSE: easier, more successful puncture. Pumping of
To palpate a vein and assess patient preparation prior the hand can lead to excessive engorgement of
to performing venipuncture. the vein, causing blood to leak into surrounding
tissue during the puncture, which will cause a
EQUIPMENT/SUPPLIES: hematoma to occur.
Gloves 5. Palpate the antecubital space of the arm, feel-
Tourniquet ing for the basilic or cephalic vein with the tip of
your middle or ring finger. Feel for a soft bounce
PROCEDURE STEPS: and a roundness to the vein. RATIONALE: The
1. Identify the patient and explain the procedure. Ask
tip of the middle or ring finger is less callused
the patient’s name and verify it with the computer
and more sensitive than the tip of the index fin-
label or identification number. If a fasting speci-
ger. Veins will have a soft round feel.
men is required, verify that the patient has not had
anything to eat or drink except water for 12 hours. 6. After locating an acceptable vein, mentally map
RATIONALE: Proper identification of the patient the location. Visualize the puncture site. Follow
and specimen and ensuring that the patient has the direction of the vein with your finger tip,
properly prepared for the blood tests are quality- making a mental note of any turns, dips, and
control and quality-assurance measures. twists. RATIONALE: Mentally mapping the loca-
tion and visualizing the puncture site will help in
2. Wash hands. Put on gloves.
planning a successful direction.
3. Apply tourniquet 3 to 4 inches above the veni-
7. If a vein cannot be found in the antecubital
puncture site. Apply tightly enough to slow
space of either arm, then the hand veins must
venous blood flow but not so tight that blood
be checked following the same procedure. The
flow in arteries is stopped (see Figure 28-21).
butterfly technique is more successful for hand
RATIONALE: Applying the tourniquet too
venipuncture. RATIONALE: Butterfly is more
tightly can lead to excessive engorgement of the
successful because the hand veins have a greater
veins, causing blood to enter the tissues during
tendency to roll and are smaller than the veins in
puncture, further causing a hematoma.
the arm.
4. Have the patient close the hand and place the
patient’s arm in a downward position. Do not
864 UNIT 7 Laboratory Procedures

Procedure 28-2
Venipuncture by Syringe
STANDARD PRECAUTIONS: agulants and check the expiration dates. Arrange
them in a holding rack in proper order. RATIO-
NALE: Having the supplies ready and in the rack
saves confusion later. The rack is a safety item so
PURPOSE: you are not holding the tube while transferring
To obtain venous blood acceptable for laboratory test- the specimen. Tapping the tubes ensures that all
ing as requested by the provider. the additive is dislodged from the stopper and
wall of the tubes. Checking expiration dates is a
EQUIPMENT/SUPPLIES: quality-assurance measure.
Gloves Cotton balls 6. Apply the tourniquet (Figure 28-32A) and select
Goggles and mask Adhesive bandage or a site. See Procedure 28-1. RATIONALE: Apply-
10 mL syringe, tape ing the tourniquet causes the vein to enlarge for
21-gauge needle Sharps container and easier venipuncture.
Vacuum tube(s) or biohazard red bag
7. Ask the patient to close the hand. The patient
special collection Test tube rack
must not pump the hand. Place the hand in a
tube(s) Biohazard transport
downward position. RATIONALE: Closing the
Tourniquet bag (optional)
hand and placing the arm in a downward posi-
70% isopropyl alcohol Lab requisition
tion further enlarges the vein, allowing for easier
swab (optional)
venipuncture. Pumping the hand can damage
PROCEDURE STEPS: the quality of the specimen collected.
1. Assemble the supplies. RATIONALE: Organizing 8. Select a vein, noting the location and direction
supplies before the procedure ensures a more of the vein. RATIONALE: This allows you to pre-
timely and professional process. pare mentally for the venipuncture.
2. Position and identify the patient. Ask the 9. Cleanse the site with an alcohol swab with one
patient’s name and verify it with the tests firm swipe (Figure 28-32B). Avoid touching
ordered and the computer label or identifica- the site after cleansing. RATIONALE: Alcohol
tion number. If a fasting specimen is required, removes body oils, sweat, and other contami-
verify that the patient has not had anything to nants. The site should stay as clean as possible.
eat or drink except water for 12 hours. RATIO- 10. Draw the skin taut with your thumb by placing
NALE: Proper identification of the patient and it 1 to 2 inches below the puncture site. RATIO-
the tests ordered and ensuring that the patient NALE: This will anchor the vein.
is properly prepared for the blood tests are all
quality-control and quality-assurance measures. 11. With the bevel up, line up the needle with the direc-
tion of the vein and perform the puncture (Figure
3. Wash hands and apply gloves and goggles/mask. 28-32C). The point of the needle should enter the
RATIONALE: Clean hands further protect the skin about 1⁄4 inch below where the vein was pal-
patient. Gloves protect you. Goggles/mask should pated. With experience, a sensation of entering the
be worn if there is a possibility of blood splatter. vein can be felt. Once the vein has been entered,
4. Open the sterile needle and sterile syringe packages do not move the needle from side to side. Do not
and assemble if necessary. Pull the plunger halfway push down or pull up the needle. The needle can
out and push it all the way in again. RATIONALE: be moved in or out gently if needed to locate the
Preparing the equipment ahead of time ensures a vein. RATIONALE: Lining up the needle with the
smoother process. Syringes can stick when new, so vein is a mental exercise to help enter the vein in
pulling once on the plunger prevents it from stick- the proper direction. Entering the skin a fraction
ing during the venipuncture. of an inch below the palpated site will aid in enter-
5. Select the proper vacuum tubes for later transfer ing the vein at the correct site. This will align the
of the specimen; tap all tubes containing antico- needle so that it will enter the vein.

continues
 CHAPTER 28 Phlebotomy: Venipuncture and Capillary Puncture 865

Procedure 28-2 (continued)

A B C

D E F

G H I

Figure 28-32 Performing a venipuncture with the syringe method. (A) Apply tourniquet and find vein. (B)
Apply alcohol in one with motion and allow with to dry. Area can be wiped with a clean 2 ⫻ 2 gauze (do not use
a cotton ball). (C) Draw skin taut (not shown) and insert needle. (D) Let go of skin and use that hand to pull
back on the plunger. (E) Withdraw blood slowly, until the syringe is full. (F) Release tourniquet. (G) Apply a
clean cotton ball immediately after withdrawing needle. (H) Have patient apply pressure to the site until a clot
forms. (I) Apply a bandage over the site.

12. Let go of the skin and use that hand to pull Holding the cotton ball above the site allows for
back on the plunger (Figure 28-32D). Pull gen- immediate pressure to be applied once the nee-
tly and only as fast as the syringe fills (Figure 28- dle is removed.
32E). If the vein collapses, stop pulling on the 15. Apply pressure to the site for 2 to 3 minutes, or lon-
plunger and let the vein refill. RATIONALE: ger if the patient is taking prescribed anticoagulants
Pulling too rapidly or too hard can cause the (blood thinners) such as warfarin (Coumadin) or
vein to collapse. is taking aspirin or an herbal blood thinner such as
13. When the syringe is full, have the patient open ginkgo biloba. Let the patient assist by holding the
the hand. Remove the tourniquet (Figure 28- pressure if desired (Figure 28-32H). The patient
32F). RATIONALE: Opening the hand and can elevate the arm but should be instructed not
removing the tourniquet releases the pressure so to bend the elbow. RATIONALE: Two to three
the needle can be removed. minutes is usually enough time for the bleeding
14. Lightly place a cotton ball above the puncture to stop. Elevating the arm while holding pressure
site and remove the needle in the same direc- aids in the clotting. Bending the elbow can cause a
tion as inserted (Figure 28-32G). RATIONALE: hematoma to form.

continues
866 UNIT 7 Laboratory Procedures

Procedure 28-2 (continued)

16. Aliquot blood into the appropriate tubes in the 23. When sufficient pressure has been applied to
rack in the proper order (see Table 28-4). During stop the bleeding, apply a small pressure ban-
transfer, hold each tube at the base only. RATIO- dage by pulling a cotton ball in half, applying
NALE: Having the tubes in the rack and holding it to the puncture site, and placing an adhesive
the tubes at the base protects your hand from acci- bandage or tape over it (Figure 28-32I). Instruct
dental needlestick during the transfer process. the patient to remove the bandage in 20 min-
17. Puncture the vacuum tube through the rub- utes. If the patient is sensitive or allergic to latex,
ber stopper with the syringe needle and allow be sure to use nonlatex paper tape. If the bleed-
the blood to enter the tube until the flow stops. ing has not stopped after 2 to 3 minutes, have
Never push on the plunger or force blood into the patient continue to hold direct pressure on
the tube. RATIONALE: Pushing on the plunger the site for another 5 minutes with his or her
and forcing blood into the vacuum tube can arm elevated above the heart. He or she can
cause the rubber stopper to pop off, splashing do this by lying down with his or her arm on a
blood. pillow. Recheck after 5 minutes. RATIONALE:
The patient should not leave your care until the
18. Implement safety mechanism or devices on the bleeding has stopped.
needle immediately. RATIONALE: Immediate
implementation of safety mechanisms will pro- 24. Disinfect tray and supplies and dispose of all
tect from accidental needlesticks. contaminated items properly. Remove gloves
using proper technique. RATIONALE: Proper
19. Mix any anticoagulant tubes immediately. disposal and disinfection of all contaminated
RATIONALE: Mixing the anticoagulants right supplies and equipment protects from exposure
away minimizes the chance of miniclots forming. to biohazardous substances.
20. Discard the syringe and needle into a sharps 25. Wash hands, record the procedure, and com-
container and the contaminated cotton ball and plete the laboratory requisition. RATIONALE:
other contaminated waste into a red biohazard Washing hands after removing gloves further pro-
bag. RATIONALE: Proper disposal of sharps and tects from biohazardous substances and lessens
biohazard waste protects all personnel. the chance of cross contamination to the patient’s
21. Label all tubes before leaving the room. If any chart and the laboratory requisition. Completing
special treatment is required for the specimens, the documentation and requisition as soon as pos-
institute the handling protocol right away. sible after the procedure improves accuracy.
RATIONALE: Labeling the tubes right away less-
ens the chances of a mix-up error. Proper handling DOCUMENTATION
of specimens ensures an accurate test result. 11/13/XX 2:54 PM Venipuncture performed right arm
22. Check the patient. Observe him or her for signs for CBC and sed rate. Specimen sent to Inner City Lab. Identi-
of stress. RATIONALE: Venipuncture can be fication #987654321. Patient tolerated the procedure well and
stressful for some patients. will call back tomorrow for the test results. Joe Guerrero, CMA
(AAMA) ________________________________
 CHAPTER 28 Phlebotomy: Venipuncture and Capillary Puncture 867

Procedure 28-3
Venipuncture by Vacuum Tube System
STANDARD PRECAUTIONS: 6. Select a site and apply the tourniquet (see Pro-
cedure 28-1). RATIONALE: Applying the tour-
niquet causes the vein to enlarge for easier
venipuncture.
PURPOSE: 7. Ask the patient to close the hand. The patient
To obtain venous blood acceptable for laboratory test- must not pump the hand. Place the hand in a
ing as requested by a provider. downward position. RATIONALE: Closing the
hand and placing the arm in a downward posi-
EQUIPMENT/SUPPLIES: tion further enlarges the vein, allowing for easier
Gloves 21-gauge multidraw venipuncture. Pumping the hand can damage
Goggles and mask needle the quality of the specimen collected.
Vacuum tube Vacuum tube(s) or special
8. Select a vein, noting the location and direction
adapter/holder collection tube(s)
of the vein. RATIONALE: This allows you to pre-
Lab requisition (optional) Tourniquet
pare mentally for the venipuncture (Figure 28-
70% isopropyl Adhesive bandage or tape
33A).
alcohol swab Sharps container and
Cotton balls biohazard red bag 9. Cleanse the site with an alcohol swab with one
Biohazard transport bag firm swipe. RATIONALE: Alcohol removes body
(optional) oils and contamination (Figure 28-33B).
10. Avoid touching the site after cleansing. RATIO-
PROCEDURE STEPS: NALE: The site should stay as clean as possible.
1. Place specimen and requisition into biohazard
transfer bag. 11. Draw the skin taut with your thumb by placing
it 1 to 2 inches below the puncture site. RATIO-
2. Position and identify the patient. Ask the NALE: This will anchor the vein.
patient’s name and verify it with the tests
ordered and the computer label or identifica- 12. With the bevel up, line up the needle with the
tion number. If a fasting specimen is required, direction of the vein and perform the puncture.
verify that the patient has not had anything to The point of the needle should enter the skin
eat or drink except water for 12 hours. RATIO- about 1⁄4 inch below where the vein was palpated.
NALE: Proper identification of the patient and With experience, a sensation of entering the
the tests ordered and ensuring that the patient vein can be felt. Once the vein has been entered,
is properly prepared for the blood tests are all do not move the needle. RATIONALE: Lining
quality-control and quality-assurance measures. up the needle with the vein is a mental exercise
to help enter the vein in the proper direction.
3. Wash hands and apply gloves and goggles/mask. Entering the skin a fraction of an inch below the
RATIONALE: Clean hands further protect the palpated site will aid in entering the vein at the
patient. Gloves protect you. Goggles/mask should palpated site (Figure 28-33C).
be worn if there is a possibility of blood splatter.
13. Let go of the skin and use that hand to grasp the
4. Break the seal on the shorter needle; thread the flange of the vacuum tube holder and push the
shorter needle into the holder/adapter. Select tube forward until the needle has completely
the first tube and gently place it into the holder/ entered the tube (Figure 28-33D). Do not change
adapter (do not puncture the tube yet). RATIO- hands while performing venipuncture. The hand
NALE: Preparing the equipment ahead of time performing the venipuncture is the hand that is
ensures a smoother process. holding the vacuum tube holder. The other hand
5. Tap all tubes containing anticoagulants and check is free for tube insertion and removal. RATIO-
the expiration dates. RATIONALE: Tapping the NALE: Using the flange of the adapter helps you
tubes ensures that all the additive is dislodged hold the needle steady while changing tubes.
from the stopper and wall of the tubes. Checking Changing hands while performing venipuncture
expiration dates is a quality-assurance measure. could cause the needle to move.

continues
868 UNIT 7 Laboratory Procedures

Procedure 28-3 (continued)

14. Fill the tube until the vacuum is exhausted and 16. Immediately mix the blood in the anticoagulant
the blood flow stops. Rotate tubes so the label tubes by gently inverting them several times.
is down. RATIONALE: Letting the tubes com- RATIONALE: Mixing the anticoagulant tubes
pletely fill will ensure the right ratio of blood to right away minimizes the chance of miniclots
additive. Positioning the label down enables you forming.
to see the tube filling. 17. Insert the second tube onto the needle by using
15. When the blood ceases, gently remove the vac- the same motion as the first tube (Figure 28-33F).
uum tube from the needle and holder. Do this Let it fill; then remove it with the same motion as
by grasping the tube with the fingers and palm the first tube. Invert it several times if it contains
of your spare hand and using your thumb to anticoagulants. RATIONALE: Mixing the addi-
push off from the flange of the holder (Figure tives prevents the blood from coagulating.
28-33E). RATIONALE: Using the flange will help 18. When the last tube has filled, remove it from
steady the needle. the needle. Ask the patient to open his or her

A B C

F
D E

G
I
H

Figure 28-33 Performing a venipuncture with a vacuum tube assembly. (A) After tying the tourniquet, pal-
pate the vein. (B) Cleanse the site with alcohol. Allow area to dry or wipe with a clean 2 ⫻ 2 gauze. (C) While
holding the skin taut, hold needle with bevel up and penetrate the vein with a smooth rapid movement. (D)
Grasp the flange of the vacuum tube holder to push the vacuum tube onto the needle. (E) When the tube has
stopped filling, remove it gently from the needle and holder using the flange to push from. Invert it several
times to mix the additives. (F) Place another tube onto the needle and let it fill. (G) When the last tube has
filled, gently remove it from the holder. Release the tourniquet (not shown) and smoothly remove the needle
from the vein, immediately applying pressure with the cotton ball. Mix well by inverting several times. (H) Dis-
pose of the needle and holder into a nearby sharps container. (I) Properly label the tubes.

continues
 CHAPTER 28 Phlebotomy: Venipuncture and Capillary Puncture 869

Procedure 28-3 (continued)

Figure 28-33 (continued) (J) Check the patient, apply a bandage. (K) Package the specimens properly for
transport (be aware of special storage or treatment needed, such as centrifugation or refrigeration). (L) Com-
plete the laboratory requsition and document the procedure in the patient’s chart or electronic medical record.

hand and release the tourniquet. RATIONALE: RATIONALE: Proper disposal of sharps and bio-
Removing the last tube from the needle pre- hazard waste protects all personnel.
vents any residual suction from drawing blood 23. Label all the tubes before leaving the patient
through the tissues when the needle is removed (Figure 28-33I). If any special treatment is
from the vein. Opening the hand and removing required for the specimens, institute the han-
the tourniquet relieves pressure so the needle dling protocol right away. RATIONALE: Label-
can be removed without causing excessive blood ing the tubes right away lessens the chances of a
loss through the puncture site. mix-up error. Proper handling of the specimens
19. Lightly place the cotton ball above the puncture ensures accurate test results.
site and smoothly remove the needle from the 24. Check the patient. Observe him or her for signs
arm in the same direction of insertion. RATIO- of stress. He or she should stop bleeding within
NALE: Holding the cotton ball above the site 2 to 3 minutes. If the bleeding has stopped,
allows for immediate pressure to be applied once apply a small pressure bandage by pulling a cot-
the needle is removed. ton ball in half, applying it to the site, and plac-
ing an adhesive bandage or tape over it (Figure
20. Immediately activate the safety device. RATIO-
28-33J). The patient should be instructed to
NALE: Activating the safety device protects you
remove the bandage in about 20 minutes. If
from accidental needlesticks (Figure 28-33H).
the patient is sensitive to latex, be sure to use
21. Apply pressure on the site for 2 to 3 minutes. Let a nonlatex paper tape. If the bleeding has not
the patient assist by holding the pressure. Ask him stopped, have the patient continue to hold
or her not the bend his or her arm, but he or she direct pressure another 5 minutes with his or
can elevate his or her arm while applying pressure. her arm elevated above his or her heart level.
RATIONALE: Two to three minutes is usually Have him or her lie down with his or her arm
enough time for bleeding to stop. Hold pres- up on a pillow. Recheck the site after 5 minutes
sure for longer if the patient is taking prescribed of additional direct pressure. RATIONALE:
anticoagulants (blood thinners) such as warfarin Check the patient for signs of distress because
(Coumadin) or taking aspirin or an herbal blood venipuncture can be stressful for some people.
thinner such as ginkgo biloba. Elevating the arm The patient should not leave your care until the
while holding pressure aids in the clotting. Bend- bleeding has stopped.
ing the elbow can cause a hematoma to form. 25. Disinfect all surfaces and supplies/equipment.
22. Dispose of the needle into a sharps container Remove gloves using proper technique. Dispose
and the contaminated cotton ball and other of contaminated items appropriately. RATIO-
contaminated waste into a biohazard red bag. NALE: Proper disposal and disinfection of all

continues
870 UNIT 7 Laboratory Procedures

Procedure 28-3 (continued)

contaminated supplies and equipment protects tion and requisition as soon as possible after the
from exposure to dangerous biohazard substances. procedure improves accuracy.
26. Wash hands, record the procedure, and complete
the laboratory requisition. Place specimen and DOCUMENTATION
requisition into biohazard transport bag (Figures 4/27/XX 8:36 AM Venipuncture performed left arm for
28-33K and L). RATIONALE: Washing hands CBC, Hgb & Hct, and thyroid panel. Specimen sent to Inner
after removing gloves further protects from bio- City Lab. Patient ID # 56776523. Patient tolerated the pro-
hazard substances and lessens the chance of cross cedure well and will return on 4/30/XX for a recheck. Joe
contamination to the patient’s chart and the labo- Guerrero, CMA (AAMA) ______________________
ratory requisition. Completing the documenta-

Procedure 28-4
Venipuncture by Butterfly Needle System
STANDARD PRECAUTIONS: 2. Position and identify the patient. Ask the
patient’s name and verify it with the computer
label or identification number. If a fasting speci-
men is required, verify that the patient has not
PURPOSE: had anything to eat or drink except water for 12
To obtain venous blood acceptable for laboratory test- hours. RATIONALE: Proper identification of
ing as requested by a provider. the patient and the tests ordered and verifying
that the patient is properly prepared are quality-
EQUIPMENT/SUPPLIES: control and quality-assurance measures.
Gloves
3. Wash hands. Put on gloves, as well as goggles and
Goggles and mask
mask if there is a potential for blood splatter.
Vacuum tube holder if using a vacuum tube
RATIONALE: Clean hands further protect the
connection
patient. Gloves and goggles/face shield protect
A 10- to 15-mL/cc syringe if using a syringe
you from any potential splatters.
connection
Butterfly needle system with 21-gauge needle (use 4. Open the package of butterfly needle system. If
a multisample needle system with a Luer-lok using the multisample needle, connect the nee-
adapter for attaching to the vacuum tube and a dle to the vacuum tube holder/adapter. If using
hypodermic needle for syringe attachment) the hypodermic needle and syringe, connect the
Vacuum tubes if appropriate needle to the syringe (Figure 28-34A). If using a
Tourniquet syringe, set the vacuum tubes in a rack for later
70% isopropyl alcohol swab use. RATIONALE: The more organized you are
Gauze before the venipuncture; the smoother the pro-
Adhesive bandage or tape cedure will go.
Sharps container and biohazard red bag 5. Tap the vacuum tubes to be sure any additive
Lab requisition (optional) is dislodged from the stopper and sides of the
tube. Check the expiration dates. RATIONALE:
PROCEDURE STEPS: Dislodging the additive will ensure proper ratio
1. Assemble the supplies. RATIONALE: Organizing in the specimen. The tubes should not be older
supplies before the procedure ensures a more than their expiration date.
timely and professional process.

continues
 CHAPTER 28 Phlebotomy: Venipuncture and Capillary Puncture 871

Procedure 28-4 (continued)

6. Apply the tourniquet. Select a vein. RATIONALE: and removing the vacuum tubes. RATIONALE:
Applying a tourniquet enlarges the vein, making Changing hands can cause the needle to change
it more accessible. position.
7. Ask the patient to close his or her hand (Figure 17. If you are collecting directly into vacuum tubes,
28-34B). The patient should not pump his or her remove and replace the vacuum tubes as explained
hand. If possible, place the arm in a downward in Procedure 28-3 until you have drawn the nec-
position. RATIONALE: Pumping of hand can essary amounts. If you are drawing into a syringe,
lead to excessive engorgement of the vein, which you will be limited to the size of the syringe being
can cause blood to enter the tissues during the used. RATIONALE: You do not have the option of
puncture, causing a hematoma. removing and replacing the syringe during a draw.
8. Select the vein, noting the direction and location 18. When the syringe is filled, ask the patient to
of the vein. RATIONALE: You will want to enter open his or her hand and release the tourniquet.
the vein in the same direction it is going. RATIONALE: Opening of the hand and releasing
9. Cleanse the site with an alcohol swab using one the tourniquet takes the pressure off the vein and
swift firm swipe and allow to dry (Figure 28- allows the blood to flow freely through the arm.
34C). RATIONALE: Alcohol removes body oils 19. Lightly place a cotton ball above the puncture site
and other contaminations. Puncturing the skin and smoothly remove the needle from the arm in
through wet alcohol can cause stinging and the same direction of insertion (Figure 28-34F).
hemolysis of the specimen and will contaminate RATIONALE: You are getting the cotton ball
the specimen. ready so you can apply pressure on the puncture
10. Avoid touching the site after cleansing. RATIO- site immediately on removing the needle.
NALE: Touching the skin will recontaminate it. 20. Activate the safety device of the butterfly needle
11. Draw the skin taut by placing your thumb 1 to immediately (Figure 28-34G). RATIONALE: The
2 inches below the site and pulling down firmly. safety devices are better able to protect if activated
RATIONALE: This will anchor the vein. immediately.
12. Hold the wings of the butterfly together with the 21. Apply pressure on the site. Let the patient assist
bevel up, line up the needle with the vein, and by holding the pressure (Figure 28-34H). Ask
smoothly insert it into the vein at about a 5- to him or her not the bend his or her arm. He or
10-degree angle (Figure 28-34D). RATIONALE: she can elevate his or her arm while applying
This process will cause the least amount of dis- pressure though. RATIONALE: Applying pres-
comfort and provide the greatest success. sure and elevating the arm lessens the chance of
bruising, whereas bending the elbow increases
13. Remove your hand from holding the skin taut. the chance of the patient forming a hematoma.
RATIONALE: You will need one hand free to
handle the other equipment. 22. If using a syringe, aliquot blood into the appro-
priate tubes as outlined in Procedure 28-2.
14. If you are connected to a vacuum tube holder, RATIONALE: Following proper procedure when
grasp the flange of the vacuum tube holder and transferring blood from the syringe into the vac-
push the tube forward until the needle has com- uum tubes ensures the best specimens for testing.
pletely entered the tube. RATIONALE: Using
the flange when inserting and removing vacuum 23. Dispose of the needle into a sharps container (Fig-
tubes will help the needle stay in position. ure 28-34I). RATIONALE: Immediate disposal of
contaminated needles is the safest practice.
15. If you are connected to a syringe, pull gently on
the syringe (Figure 28-34E). RATIONALE: Pull- 24. Label all the tubes. RATIONALE: Not labeling
ing too rapidly can cause the vein to collapse. the tubes right away increases the likelihood of a
mix-up error.
16. Do not change hands while performing veni-
puncture. The hand performing the venipunc- 25. Check the patient. Observe him or her for signs
ture is the hand that is holding the vacuum of stress. RATIONALE: Patient safety is a primary
tube holder. The other hand is for inserting concern. Venipuncture can be difficult for some
patients.

continues
872 UNIT 7 Laboratory Procedures

Procedure 28-4 (continued)

C
A B

D E F

Figure 28-34 Performing a venipuncture with the butterfly needle system. (A) Open the package with the but-
terfly needle system and assemble the needle. In this case, the needle is connected to the syringe. (B) Apply the
tourniquet and ask the patient to close his hand. (C) Cleanse the site with using one swift wipe and allow to air dry.
(D) Draw skin taut. While holding the wings of the butterly together, line up the needle with the vein, and insert at
a 5- to 10-degree angle. (E) Pull gently on the syringe, allowing it to fill. (F) When filled, have the patient open his
hand, and release the tourniquet. Place a cotton ball above the puncture site and remove the needle. (G) Activate
the safety device of the butterfly needle. (H) Apply pressure on the site, and ask the patient to continue holding
the pressure. (I) Dispose of the needle into a sharps container. (J) Apply a bandage to the site.

continues
 CHAPTER 28 Phlebotomy: Venipuncture and Capillary Puncture 873

Procedure 28-4 (continued)

26. The patient should stop bleeding within 2 to 3 nated supplies and equipment protects from
minutes. If the bleeding has stopped, apply a exposure to biohazard substances.
small pressure bandage by pulling a cotton ball 28. Wash hands, record the procedure, and com-
in half, applying it to the site, and placing an plete the laboratory requisition. Place speci-
adhesive bandage or tape over it (Figure 28-34J). men and requisition into biohazard transfer
The patient should be instructed to remove the bag. RATIONALE: Washing hands after remov-
bandage in about 20 minutes. If the patient is ing the gloves further protects from biohazard
sensitive to latex, be sure to use a nonlatex paper substances and lessens the chance of cross con-
tape. If the bleeding has not stopped, have the tamination to the patient’s chart and laboratory
patient continue to hold pressure another 5 requisition. Completing the documentation and
minutes with his or her arm elevated above his requisition as soon as possible after the proce-
or her heart level, then recheck. RATIONALE: dure improves accuracy.
The patient should not be released from your
care until the bleeding has stopped. DOCUMENTATION
27. Clean up tray and supplies; dispose of contami- 11/13/XX 2:54 PM Venipuncture performed right arm for
nated cotton ball. Remove gloves using proper CBC and sed rate. Specimen sent to Inner City Lab. Identifi-
technique. Discard gloves into biohazard con- cation #987654321. Patient tolerated the procedure well and
tainer and disinfect goggles. RATIONALE: will call back tomorrow for the test results. Joe Guerrero, CMA
Proper disposal and disinfection of contami- (AAMA) ________________________________

Procedure 28-5
Capillary Puncture
STANDARD PRECAUTIONS: PROCEDURE STEPS:
1. Assemble the supplies. RATIONALE: Organiz-
ing the supplies before the procedure ensures a
more timely and professional process.
PURPOSE: 2. Identify the patient, introduce yourself, explain
To obtain capillary blood acceptable for laboratory the procedure, and recheck the provider’s
testing as requested by a provider. orders. RATIONALE: Introducing yourself and
explaining the procedure will establish a profes-
EQUIPMENT/SUPPLIES: sional relationship with the patient and might
Gloves help put him or her at ease. Identifying the
70% isopropyl alcohol swab patient and rechecking the provider’s orders will
Microcollection tubes or capillary tubes ensure the proper tests will be performed on the
Safety lancet right patient.
Gauze 2 ⫻ 2
Adhesive bandage or tape 3. Wash hands and apply gloves. RATIONALE:
Sharps container Washing your hands protects the patient, and
Cotton balls applying gloves protects you.
Biohazard red bag 4. Select the puncture site on the fleshy part of the
Laboratory requisition (optional) ring or middle finger, avoiding the very tip and
Biohazard transport bag (optional) the extreme sides. RATIONALE: The ring and

continues
874 UNIT 7 Laboratory Procedures

Procedure 28-5 (continued)

middle fingers generally will have fewer calluses hematocrit; see Chapter 32 for PKU, glucose,
and less scarring. The tip and sides are more sen- and other specialty tests performed on capillary
sitive than the fleshy part. blood).
5. Have the patient wash his or her hands in very 10. Have patient hold firm, direct pressure on the
warm water; if necessary, apply a warming pack site with a cotton ball for at least 2 minutes. If
to the fingertip, encourage the patient to relax, the bleeding has stopped, an adhesive strip can
and provide a comfortable, professional atmo- be applied. If the bleeding has not stopped yet,
sphere. RATIONALE: The patient washing his hold firm, direct pressure on the site for another
or her hands in very warm water provides two 5 minutes and then recheck. Adhesive strips
benefits: his or her hands will be cleaner and are not recommended for patients younger
warmer, which encourages better blood to the than 2 years. RATIONALE: A cotton ball is used
area. Appling a warming pack to the fingertips because the cotton fibers further encourage clot-
will further encourage blood flow. A relaxed ting at the puncture site. The bleeding should
patient in a comfortable, professional atmo- be stopped before the patient leaves your care.
sphere is more likely to provide a better sample. Adhesive strips for children younger than 2 years
6. Clean the selected puncture site with alcohol are not recommended because they are a chok-
swab and allow it to air dry or dry it with a gauze ing hazard.
pad. RATIONALE: Alcohol will remove any resi- 11. Disinfect the area and equipment, remove gloves,
due soap or debris. Allowing the alcohol to dry and dispose of them into a biohazard waste con-
will prevent irritation and stinging. If the site is tainer/red bag. Wash hands. RATIONALE: Bio-
wiped dry, the irritation of the gauze pad will fur- hazard waste should be controlled for everyone’s
ther encourage blood to the area. protection. Hand washing after removing gloves
7. Holding the distal phalange firmly, perform the further protects you.
puncture across the lines of the fingerprint rather 12. Record the procedure and complete the labora-
than along the lines. RATIONALE: Holding the tory requisition or test. The laboratory requisi-
distal phalange firmly will add support to the fin- tion is completed in the presence of the patient
ger and prevent the patient from pulling back on if possible. RATIONALE: Documentation is criti-
the finger during the puncture. Puncturing across cal for good patient records. Completing the lab-
the fingerprint will assist the blood to form a drop oratory requisition in the presence of the patient
rather than flow across the fingertip. provides accurate insurance and personal infor-
8. Using a gauze pad, wipe away the first drop. mation if needed for the insurance forms and
RATIONALE: The first drop usually contains for your medical records.
contamination from the alcohol and tissue fluid
and would not be a good representation of the DOCUMENTATION
blood sample needed. Using gauze rather than 4/27/XX 8:15 AM Capillary puncture performed left ring
cotton to wipe it away lessens the likelihood of it finger for Hgb A1c. Patient tolerated the procedure well. Dr.
clotting too quickly. Lewis is scheduled to see the patient today to discuss progress.
9. Collect the specimen according to the test being Joe Guerrero, CMA (AAMA) ____________________
performed (see Chapter 29 for hemoglobin and
 CHAPTER 28 Phlebotomy: Venipuncture and Capillary Puncture 875

Procedure 28-6
Obtaining a Capillary Specimen for Transport
Using a Microtainer Transport Unit

STANDARD PRECAUTIONS: 5. Discard the first drop of blood. Wipe it away with
a gauze square. RATIONALE: The first drop can
contain mostly alcohol residue and tissue fluid
and would not be a good representation of the
PURPOSE: blood sample needed. Using gauze rather than
To obtain a specimen of capillary blood for transport cotton to wipe it away lessens the likelihood of it
to a laboratory for testing, using a Microtainer. clotting too quickly.
6. Allow a good size drop to form. RATIONALE:
EQUIPMENT/SUPPLIES: Allowing a good size drop to form is a good idea
Capillary puncture supplies: with any capillary specimen; the blood is more
Gloves likely to stay in a drop and not flow over the finger.
70% isopropyl alcohol swab 7. Scoop the drop into the Microtainer (Figure 28-
Gauze 35A). RATIONALE: This is the method used to
Safety lancet get the specimen into the tip of the Microtainer.
Cotton balls
Adhesive bandage 8. Tip the Microtainer, allowing the drop to slide
Sharps container and biohazard waste receptacle into the tube (Figure 28-35B). RATIONALE: As
Microtainer transport unit soon as a drop is obtained on the scoop it should
Laboratory requisition be moved into the tube where it can mix with the
Small sturdy container with a tightly fitting lid (such additive.
as a urine specimen cup or red top vacuum tube) 9. Gently agitate the tube. RATIONALE: Agitat-
Biohazard specimen transport bag ing the tube allows the additive to mix with the
blood.
PROCEDURE STEPS: 10. Continue collection of blood until the tube is
1. Determine the appropriateness of submitting a filled (Figure 28-35C). RATIONALE: The tube
capillary specimen for the specific test you are must be filled to the fill line to ensure the proper
performing. RATIONALE: Not all tests can be ratio of blood to additive.
performed on capillary specimens.
11. Provide the patient with a cotton ball and ask
2. Assemble the supplies. RATIONALE: Organiz- him or her to hold pressure on the puncture
ing the supplies before the procedure ensures a site. RATIONALE: The pressure with a cotton
more timely and professional process. ball will encourage the wound to clot.
3. Identify the patient, introduce yourself, explain 12. Remove the scoop from the Microtainer and dis-
the procedure, and recheck the provider’s card the scoop into the sharps container (Figure
orders. RATIONALE: Introducing yourself and 28-35D). RATIONALE: The scoop is contami-
explaining the procedure will establish a profes- nated with blood and therefore is considered to
sional relationship with the patient and might be biohazard waste. Being hard plastic, it is capa-
help put him or her at ease. Identifying the ble of scratching someone, so the sharps con-
patient and rechecking the provider’s orders will tainer is safer than the red bag waste receptacle.
ensure the proper tests will be performed on the
13. Remove the colored cap from the back of the
right patient.
Microtainer and place it securely onto the open-
4. Wash hands, apply gloves, and perform the cap- ing. RATIONALE: Placing the cap securely onto
illary puncture according to Procedure 28-5. the Microtainer will ensure the specimen will
RATIONALE: Washing your hands protects the stay in the Microtainer during handling and
patient, and applying gloves protects you. transport.

continues
876 UNIT 7 Laboratory Procedures

Procedure 28-6 (continued)

A
B

Figure 28-35 Collecting a capillary specimen for transport. (A) After wiping away the first drop (not shown),
allow drop to form. Touch the scoop on the collection Microtainer tube to the blood droplet. (B) Tip the col-
lection Microtainer tube up so that the blood flows into the tube. Agitate it gently to mix the anticoagulant
with the blood. (C) Continue collecting the blood until the collection Microtainer tube is filled to the marked
level. (D) Remove the scoop from the collection Microtainer tube and dispose of the scoop into a nearby
sharps container.

14. Place the capped Microtainer into a small sturdy any questions the patient has, and release the
container with a tight-fitting lid. RATIONALE: patient. RATIONALE: Caring for the patient
Placing the Microtainer in another container both physically and emotionally shows a profes-
protects it from being uncapped and (because of sional dedication to your job.
its small size) lost in transport. The Microtainer 18. Document procedure in patient’s chart or elec-
is also not large enough for adequate labeling. tronic medical record. RATIONALE: Documen-
15. Label the container. RATIONALE: Proper label- tation ensures that the proper information is
ing ensures the proper tests on the right speci- recorded into the patient’s chart or electronic
men. medical record.
16. Fill out the laboratory requisition while the
patient is present. Place the specimen and the DOCUMENTATION
requisition into the biohazard transport bag in 3/3/XX 4:15 PM Capillary puncture was performed for
their separate compartments. RATIONALE: Any a CBC. Specimen (Microtainer) sent to Inner City Laboratory.
questions about the patient’s address and insur- Patient tolerated the procedure well and will call in on Friday
ance can be answered immediately if the patient (3/6/XX) for the results. No return appointment scheduled.
is present while you complete the form. W. Slawson, CMA (AAMA) _____________________
17. Check the patient’s puncture site. If bleeding
has stopped, apply an adhesive strip, answer
 CHAPTER 28 Phlebotomy: Venipuncture and Capillary Puncture 877

Procedure 28-7
Obtaining Blood for Blood Culture
STANDARD PRECAUTIONS: one anaerobe) from each site. Occasionally,
three sites will be necessary. Expired supplies
and culture bottles must not be used.
5. Place the culture bottles on a flat surface within
PURPOSE: reach during the procedure. Mark the correct fill
While performing venipuncture from two separate line on both bottles at 10 mL per bottle (1–3 mL
sites, prepare two culture bottles of blood from each per bottle for pediatric patients). RATIONALE:
site for culture (four total). Marking the fill line helps in viewing the proper
amount during the procedure.
EQUIPMENT/SUPPLIES: 6. Prepare the venipuncture site with isopropyl
Nonsterile gloves for use with povidone-iodine alcohol and allow to dry, then apply povidone-
solution iodine in progressively larger concentric circles
Sterile gloves from the inside outward (Figure 28-36B). The
Laboratory requisition iodine must remain on the skin for 1 full minute
Blood culture bottles, anaerobic and aerobic (usually and be allowed to dry naturally. The venipunc-
four: two bottles each for two sets of cultures) ture site should not be touched after the skin is
70% isopropyl alcohol disinfected. RATIONALE: Alcohol removes oils
Povidone-iodine solution swabs or towelettes and other debris, the povidone-iodine is a more
Venipuncture supplies (according to method used) thorough antiseptic. One full minute is required
for two separate sites to ensure antisepsis. Touching the site may
Biohazard red bag recontaminate it.
Sharps container 7. Cleanse the bottle tops with alcohol and povi-
Labeling pen done-iodine solution. RATIONALE: The bottle
tops need to be disinfected to remove contami-
PROCEDURE STEPS: nation. NOTE: Some laboratory guidelines state
1. Identify the patient, introduce yourself, and that iodine can disintegrate the rubber stopper
explain the procedure. and therefore should not be used. Follow your
2. Ensure that the patient has not initiated anti- laboratory guidelines as stated in your laboratory
microbial therapy. RATIONALE: Antibiotic manual.
therapy can interfere with the culture results. If 8. Remove the preparation gloves and apply the
the patient has started antibiotics, the name and sterile gloves using sterile procedure. RATIO-
strength of the antibiotic, dosage, duration, and NALE: Sterile gloves will ensure the procedure
last dose must be documented clearly on the lab- will be as sterile as possible.
oratory report.
9. Perform venipuncture according to method
3. Wash hands and put on gloves. RATIONALE: used. Insert the aerobic culture bottle onto the
Washing hands before any laboratory process needle (Figure 28-36C). Fill to the appropriate
prevents contamination of the specimen. Glov- line, usually 10 mL per bottle (1–3 for pediatric
ing provides personal protection. patients). Remove the first bottle, invert 8 to 10
4. Assemble equipment and supplies according to times, and apply the second (anaerobic) bottle.
the venipuncture procedure being used and the Fill. Remove the second bottle and invert 8 to
laboratory requirements (Figure 28-36A). Check 10 times. RATIONALE: Follow your laboratory
expiration dates on all collection and culture manual guidelines. The aerobic bottle should be
supplies. RATIONALE: Organizing your work filled first because there will be some residual air
area prevents confusion and error due to miss- in the needle. The anaerobic bottle will then col-
ing supplies. Usually two separate sites are used lect only blood. Inverting the bottles ensures the
for collection, with two bottles (one aerobe and culture media will be well mixed with the blood.

continues
878 UNIT 7 Laboratory Procedures

Procedure 28-7 (continued)

transient bacteria coming into the blood (such

as through teeth brushing or scratching a skin
lesion, and so on).
12. The culture bottles should be stored at room
temperature and not refrigerated. RATIONALE:
Room temperature is ideal for the cultures so
organisms are not destroyed.
A 13. Label the bottles with the patient’s name, date,
time, and other required information. RATIO-
NALE: Labeling with the required information
prevents mix-ups of specimens and ensures a
quality timeline. Specimens will be rejected if
not labeled properly.
14. Dispose of all contaminated supplies, disinfect
all surfaces, remove gloves, and wash hands.
RATIONALE: Using appropriate disposal tech-
B niques and disinfecting all surfaces according to
Standard Precautions safely control biohazard
substances.
15. Complete the laboratory requisition including
the date and time of each specimen collected, any
antibiotic therapy the patient is on, the name and
strength of the antibiotic, as well as the dosage,
duration, and the last dose taken. Include the
clinical diagnosis and any special organisms sus-
pected or to rule out. The laboratory requisition
C must indicate if the culture is for brucella or fran-
cisella. The information on the laboratory requisi-
Figure 28-36 Obtaining blood for blood culture. tion should match exactly the information given
(A) Assemble equipment and supplies (only one cul- on the bottles. RATIONALE: Labeling with the
ture bottle shown). (B) Prepare the venipuncture site required information prevents mix-ups of speci-
with alcohol and allow to dry, then apply povidone- mens, ensures a quality timeline, and ensures the
iodine in concentric circles from the inside outward. laboratory will have the necessary information.
Allow the iodine to dry naturally. (C) Perform veni- Specimens will be rejected if there is a discrep-
puncture. Insert the aerobic culture bottle onto the ancy between the information on the bottle and
needle and fill to the appropriate line. the information on the laboratory requisition.
16. Document the procedure in the laboratory sec-
tion of the patient’s chart or electronic medical
10. Complete the venipuncture procedure as deter-
record. RATIONALE: Necessary information
mined by the method used. Remove the remain-
and the patient’s chart or electronic medical
ing iodine from the skin with isopropyl alcohol.
record will be accurate and complete.
RATIONALE: The next two bottles will be filled
from a different site. The iodine solution can
DOCUMENTATION
irritate the skin and should be removed.
08/06/20XX Venipuncture performed left arm for blood
11. Perform venipuncture at the second site, repeat- culture. Specimen sent to Inner City Lab. Patient ID #56776533.
ing the process as stated above. The second and Patient tolerated procedure well and instructed to call us on
subsequent culture bottles must be collected Wednesday for the results. Joe Guerrero, CMA (AAMA) ____
within 30 minutes of the first. RATIONALE: The
30-minute time frame rules out the possibility of
 CHAPTER 28 Phlebotomy: Venipuncture and Capillary Puncture 879

Case Study 28-1

Refer to the scenario at the beginning of the chapter. 2. How can Bruce use that information to better serve
the patients?
CASE STUDY REVIEW
3. Do you think patients are a good source of informa-
1. What types of information will patients be able to tion about their bodies and their reactions to past
share with Bruce about their previous venipuncture experiences?
experiences?

Case Study 28-2

Inner City Health Care is short-staffed today, and medical CASE STUDY REVIEW
assistant Liz Corbin is feeling pressed for time. She has many
tasks to complete, but first she must perform a venipunc- 1. What should Liz do now?
ture. She greets the patient, Wayne Elder, in a perfunctory 2. What could Liz have done to prevent this situation
manner, discouraging time-wasting conversation. Although from occurring?
Wayne appears apprehensive, he is not resistant, so Liz 3. In the future, what are some steps Liz can take to
quickly assembles the necessary supplies, applies the tourni- provide a positive experience for venipuncture
quet, and inserts the needle. While she is drawing his blood, patients?
Wayne faints.

SUMMARY
With a little practice, the medical assistant will become an expert at phlebotomy. The skills of phlebotomy
cannot be learned primarily from a textbook; continuous practice will develop the skill to perfection. It
may take months before the medical assistant feels comfortable and is able to obtain a sample without dif-
ficulty.
In all phlebotomy, safety is of the utmost consideration. Dispose of all sharps properly and separately
from the noncontaminated trash. Proper hand cleansing between patients and wearing gloves, goggles,
and masks with each phlebotomy will ensure safety for both the patient and the medical assistant.
Proper specimen collection and handling of the specimen after collection by the medical assistant
will ensure that the patient obtains the most accurate result. The specimen must be treated in such a way
that the integrity of the specimen is maintained. The quality of the sample must be the same when col-
lected as when tested. Correct method of draw, order of draw, and the correct handling of the sample
after collection will reduce the number of factors affecting the sample and give the most accurate result
possible.
880 UNIT 7 Laboratory Procedures

STUDY FOR SUCCESS

To reinforce your knowledge and skills of information presented in this chapter:
• Review the Key Terms
• Practice the Procedures
• Consider the Case Study and discuss your conclusions
• Answer the Review Questions

° Multiple Choice
° Critical Thinking
• Navigate the Internet by completing the Web Activities
• Practice the StudyWARE activities on the CD
• Apply your knowledge in the Student Workbook activities
• Complete the Web Tutor sections
• View and discuss the DVD situations

REVIEW QUESTIONS
Multiple Choice b. hand washing
1. Drawing blood with a 25-gauge needle increases c. always wearing masks
the chance for: d. avoid breathing on clients
a. vein collapse 6. Under Standard Precautions, all used needles are
b. hematomas to be disposed of in the following manner:
c. hemoconcentration a. recapped
d. hemolysis b. discarded intact in a sharps container
2. An anticoagulant is an additive placed in vacuum c. bent
tubes to: d. broken or cut off
a. dilute the blood before testing 7. When drawing multiple specimens in vacuum
b. ensure the sterility of the tube tubes, it is important to fill which of the following
c. make the blood clot faster color-stoppered tubes first?
d. prevent the blood from clotting a. light blue
3. When collecting a blood sample with a vacuum b. green
tube system, the last tube drawn is withdrawn from c. lavender
the holder before removing the needle from the d. red
patient to: 8. The anticoagulant of choice when drawing coagula-
a. avoid hematoma at the venipuncture site tion studies such as PT and APTT is:
b. avoid dripping blood out the end of the needle a. (red) no anticoagulant
c. prevent clotting of the blood b. (light blue) sodium citrate
d. cause the blood to clot c. (lavender) EDTA
4. Leaving the tourniquet on a patient’s arm for an d. (green) heparin
extended length of time before drawing blood may 9. When the medical assistant cannot perform a veni-
cause: puncture successfully after two attempts, the medi-
a. hemoconcentration cal assistant should:
b. specimen hemolysis a. try at least two more times
c. stress b. notify the provider
d. bruising c. ask another medical assistant to try
5. The single most important way to prevent the d. request the test for the next day
spread of infection from patient to patient is:
a. gowning and gloving
 CHAPTER 28 Phlebotomy: Venipuncture and Capillary Puncture 881

10. If the blood is drawn too quickly from a small vein, 4. Discuss how clots are formed and what can be done
the vein has a tendency to: to stop the clotting process.
a. collapse 5. You have calmed the crying patient and successfully
b. bruise drawn the patient’s blood. What will you do next?
c. disintegrate Why is this step important? Describe the skills you
d. roll have used.
11. What is OSHA’s policy about choosing the safest 6. The patient cries out in pain when you insert the
needle systems to prevent accidental needlestick needle into the vein. What will you do to make
injuries? the patient more comfortable? If you decide to try
a. The clinic administrators can choose whatever is another site, how will you locate it?
most cost effective.
b. The clinic administrators should carefully
choose the safest system for their staff.
WEB ACTIVITIES
c. The clinic administrators must select the safest 1. Visit the CDC and other government Web
equipment based on feedback from the people sites for the most current information on
who are using the needles. Standard Precautions and proper protection
d. OSHA is not interfering with the clinics’ rights during blood draws.
to use any system they choose. 2. Search the keywords “phlebotomy” and “puncture”
on the Web. What organizations can you find that
Critical Thinking offer information for medical assistants?
1. A frightened patient begins crying when you enter 3. Search the Internet for the laws in your state gov-
the room to perform a venipuncture. How will you erning phlebotomy training.
handle the situation? What is your responsibility to
the patient? Why are your demeanor and appear-
ance important in this type of situation?
REFERENCES/BIBLIOGRAPHY
2. Explain the difference between serum and plasma. Walters, N. J., Estridge, B. H., & Reynold, A. P. (2008).
Describe how serum and plasma samples are col- Basic medical laboratory techniques (5th ed.). Clifton
lected. Park, NY: Delmar Cengage Learning.
3. How can vein collapse be avoided in a geriatric
patient?
882 UNIT 7 Laboratory Procedures

THE DVD HOOK-UP

This chapter
In this discusses
chapter, the various
you learned abouttechniques
the medicalforassistant’s
obtaining DVD Journal
2. Did Summary
the medical assistant use a therapeutic approach
blood specimenswhen
responsibilities from handling
patients. phone calls. Working the Write when she spoke
a paragraph that to the patient?
summarizes what you learned from
phonesdesignated
Today’s in a medical officeillustrate
scenes is hard work.
three The medical
various methods watching the selected scenes from today’s DVD program.
assistant must become familiar with the telephone
that are used to collect blood samples. The first method system, DVD
Lori, the Journal Summary
medical assistant, spoke about a patient who had a
as well as office protocol for handling various
was the vacuum tube system. There was a special order types of Write a episode
syncope paragraph thatperforming
while summarizes what you learned
a phlebotomy. The patient
phone calls. Patience is extremely important when
for filling the blood tubes. The order of draw was slightly working from
fell back,watching the head
hitting his designated
on the scenes from
floor, and he today’s DVD
immediately
the telephones.
different between the DVD program and the text in this program.
went In the last scene,
into convulsions. the medical
The convulsions assistantstopped
eventually tries to
chapter. This is because
The designated DVD clips both projects two
presented wereseparate
written at assist
and thean olderunderwent
patient adult patient whoFortunately,
X-rays. is having problems
the patientwith
had
different
scenarios. timeIn intervals and the tube
the first scenario, order changed
we observed the medical thedamage
no telephoneas amenu.
result How
of thedofall.
you feelwill
How about
you telephone
ascertain that
between
assistantthe projects.
talking TheMorgan
to Pat information in this
regarding anchapter
order for has menus
your and older
patients adult
are safe patients?
during Would
and after you ever
a blood give
draw? out
What
the latest information
a possible prescription.for The
the medical
correct order of draw.
assistant checked your
are someextension to an
signs that olderindicate
could adult patient
that thewho was may
patient struggling
to see if the provider leftdraw
any according
orders in the chartchapter?
for the with the
faint? Howphone
wouldmenu?
you feelWhyif theorpatient
why not?did injure himself or
1. What is the order of to this herself while under your care?
patient’s refill prescription. When the
Does the order change when using a syringe? Howmedical assistant
sawabout
that there was no method?
the capillary order, sheWhat
wrotewill
down
you the
do to patient’s
make
message and current symptoms so that she
certain that you stay up to date with the latest informa-could share
thetion
information
regardingwith tubetheorders
doctor.
andBefore
otherending
importantthe labora-
phone
call,tory
theinformation
medical assistant told the
once you graduate? patient that if the doctor
2. This chapter states that you should label the tubes the
approved the prescription, she would call it directly to
DVD Series Program Number
pharmacy,
immediately and that
afterifthe
there weredraw,
blood any but
problems
the DVD sheprogram
would
callstates
her back; Skills Based Series 11
that you should label the tube before drawing up
otherwise, she could pick the prescription
at the pharmacy aftertechnique
3:00 PM. does your instructor want Chapter/Scene Reference
the blood. Which
• Administer Venipuncture, Vacuum Tube, and
1.you
Do to youfollow?
think that it was wise for the medical assistant Syringe Method
3. Why is itthe
to tell important to determine
patient that she wouldif only
the patient
call herfollowed
back if • Preparing Slides for a Differential
allthe
theprovider
fasting did
instructions before
not approve the taking the patient’s
prescription? Why or • Administering Capillary Puncture and
blood?
why not? Performing Hematocrit Testing
 Chapter

Hematology 29
KEY TERMS OUTLINE
Anisocytosis Hematologic Tests Using Erythrocyte Indices to
Basophil Hemoglobin and Hematocrit Diagnose
C-Reactive Tests Erythrocyte Sedimentation Rates
Protein (CRP) Hemoglobin (ESR or SED Rate)
Complete Blood Hematocrit Wintrobe Method
Count (CBC) White and Red Blood Cell Counts Westergren Method
Eosinophil (ESP) White Blood Cells and Using the ESR to Screen
Erythrocyte Differential C-Reactive Proteins
Erythrocyte Indices Red Blood Cells Coagulation Studies
Erythrocyte Platelets Automated Hematology
Sedimentation Erythrocyte Indices
Rate (ESR) Understanding RBC Indices
Erythropoietin
Hematocrit
Hematology
OBJECTIVES
The student should strive to meet the following performance objectives and dem-
Hematopoiesis
onstrate an understanding of the facts and principles presented in this chapter
Hemoglobin through written and oral communication.
Hemoglobinopathy
Hypochromic 1. Define the key terms as presented in the glossary.
Leukocyte 2. Describe the process of hematopoiesis.
Lymphocyte 3. Discuss how the clinical science of hematology and the complete
Macrocytic blood count (CBC) are used in the diagnosis and treatment of
disease.
Microcytic
4. Compare the normal versus abnormal values of the CBC param-
Monocyte
eters.
Neutrophil
5. Describe which blood tests and methods are within the scope of
Normochromic
practice and training of the medical assistant performing under
Normocytic a CLIA Waived Test Certificate.
Protime 6. Discuss how the hemoglobin and hematocrit are used to diag-
Reticulocyte (Retic) nose anemia.
Thrombocyte 7. Describe how the erythrocyte indices are used in the differential
diagnosis of anemias.
8. Perform the calculations necessary to derive the erythrocyte indi-
ces mean corpuscular cell volume, mean corpuscular hemoglo-
bin, and mean corpuscular hemoglobin concentration.
9. List the five types of normal white blood cells and give the identi-
fying characteristics of each.

883
OBJECTIVES (continued)
10. Describe the differences in the procedures for the Wintrobe
and Westergren erythrocyte sedimentation rates.
11. Recognize the physiologic reasons why the erythrocyte sedi-
mentation rate varies with different states of health and disease.
12. Describe CRP and its uses as a screening test for general infec-
tion and inflammation.
13. List the two general types of automated hematology instru-
ments used in the ambulatory care setting and describe their
technology.
14. Perform the laboratory procedures included in this chapter in a
manner acceptable for entry-level employment.

Scenario
The providers in the office of Drs. Lewis and King often ogy analyzer or performing tests manually because
order hematologic tests to assist them in diagnosing she understands the purposes and procedures of the
and treating patients. As she performs the tests in the tests. She always follows all safety and quality-control
physician’s office laboratory, medical assistant Audrey guidelines to protect herself and others and to ensure
Jones uses her knowledge of hematology every day. the accuracy of test results.
Audrey is comfortable using an automated hematol-

INTRODUCTION
Hematology is the study of the blood cells and coagula- in the yolk sac, liver, and spleen. After we are born, the
tion in both normal and diseased states. The two main primary site for the production of erythrocytes, granulo-
components of the blood are plasma (the liquid portion) cytes, and platelets is the bone marrow. Lymphocytes are
and cells. Cells of the blood are also known as the formed also produced in the bone marrow, as well as in the lymph
elements of the blood. The study of hematology is usually nodes. At birth, most of the bone marrow in the body is
limited to the cellular components of the blood and does capable of producing blood cells. This process is confined
not include the chemistry of the blood. See Chapter 32 for
the chemistry of blood and tests related to blood chemistry.
The cellular components of blood include erythro-
cytes (red blood cells [RBCs]), leukocytes (white blood Spotlight on Certification
cells [WBCs]), and thrombocytes (platelets). Blood has
many different functions. RBCs are responsible for sup- RMA Content Outline
plying oxygen to all the cells of the body and removing • Asepsis
the waste products of the cells: carbon dioxide. WBCs are • Laboratory procedures
involved in fighting infection, as well as producing anti-
bodies for the immune system to defend against foreign CMA (AAMA) Content Outline
antigens. There are five basic types of WBCs and they • Principles of infection control
all have specific disease-fighting functions. Platelets are • Processing specimens
involved in homeostasis, the control of bleeding. Figure • Quality control
28-2 shows the cellular elements of blood. • Performing selected tests
Hematopoiesis is defined as the formation of blood
cells (Figure 29-1). The process of hematopoiesis, as well CMAS Content Outline
as the blood-forming tissues of the body, is included in the • Asepsis in the medical office
study of hematology. In the embryo, hematopoiesis occurs
884
 CHAPTER 29 Hematology 885

Figure 29-1 Hematopoiesis showing blood cells and platelet formation starting with
hematopoietic stem cell.

to the bone marrow of the ribs, vertebrae, sternum, and

iliac crest by the age of 20 years. Bone marrow that is
producing cells is known as red marrow. As the area for Critical Thinking
hematopoiesis is reduced, the red bone marrow is replaced
by yellow marrow, which is stored fat. When a provider What do you think would happen if you did
collects a bone marrow sample in an adult, the site chosen not have any leukocytes? What would your
for sampling is the sternum or the iliac crest because this symptoms be?
is where the blood cells are still being produced.
886 UNIT 7 Laboratory Procedures

HEMATOLOGIC TESTS • Erythrocyte sedimentation rate (ESR)

• Prothrombin time (PT)
Hematologic tests are the second most common tests
performed in the physician’s office laboratory (POL). The results of these hematologic tests provide
The most common test is the urinalysis. The cellular valuable information used by the provider in mak-
components of the blood may be affected by changes ing a diagnosis, evaluating a patient’s progress, and
in either the blood-forming organs or in other tissues regulating further treatment.
of the body. The study of these changes forms the basis The laboratory test ordered most frequently
of hematologic tests performed in the POL. on blood in the ambulatory care setting is the
Hematologic tests performed in the clinical complete blood count (CBC). The exact number
laboratory include: of parameters included in the CBC will vary from
• Hemoglobin laboratory to laboratory (Figure 29-2). The CBC
generally includes:
• Hematocrit
• WBC count • Hemoglobin determination
• Differential WBC count • Hematocrit determination
• RBC count • RBC count (and indices)
• RBC indices • WBC count (and differential)
• Platelet count • Platelet count

Figure 29-2 Hematology report form.

 CHAPTER 29 Hematology 887

All these tests can be performed by manual testing HEMOGLOBIN AND

procedures or with an automated hematology ana- HEMATOCRIT TESTS
lyzer. Manual blood cell counts are considered by
the Clinical Laboratory Improvement Act (CLIA) Hemoglobin and hematocrit tests are part of the
to be of moderate to high complexity, whereas the CBC; however, they are frequently individually
automated tests are considered to be moderately ordered by the provider rather than a CBC. The
complex; therefore, neither are within the medi- abbreviations for hemoglobin and hematocrit are
cal assistant’s scope of practice. The manual blood Hgb and Hct, respectively. Although they are sepa-
cell counts are performed only at reference labora- rate tests, they have a unique relationship with each
tories by medical technicians. The automated ana- other but may be performed individually. Both the
lyzers may be located in the POL, but the testing hemoglobin and the hematocrit are performed to
and interpretation of the tests, the maintenance of obtain similar information about RBCs in relation
the analyzers, as well as training and supervision of to the rest of the blood sample, but they also give
laboratory personnel is performed by the medical decidedly different information. In normal results,
technician. the hemoglobin often will be about one third the
Test results are recorded in the patient’s number of the hematocrit.
medical record in the progress notes section and
a lab report is completed. The lab report is filed
in the lab section of the patient record. Accurate Hemoglobin
and timely documentation are important in medi- Hemoglobin is the major component of the RBC
cal laboratory procedures. and serves to transport oxygen and carbon dioxide
A total practice management system (TPMS) through the body. Hemoglobin, which is respon-
allows test results to be recorded in the patient’s sible for about 85% of the dry weight of the RBC,
medical record as well as documentation of qual- is a conjugated (combined) protein composed of
ity controls performed prior to patient test results heme and globin. A single hemoglobin molecule
(Figure 29-3). consists of four globin chains with a heme group
attached to each globin (Figure 29-4). The central
component of each heme group is an iron mole-
cule. One oxygen molecule can be transported to
Results from each heme group; therefore, each RBC can carry
Regional/ Results to Outside four oxygen molecules.
National Labs Providers
Synthesis of the heme portion of the hemo-
globin molecule requires iron, which is usu-
ally obtained through our diets. The daily iron
LABORATORY

Test Reports e
H

m
em

Quality Assurance & Controls

He
e

Safety Standards
G
n

lo
bi

bi
lo

n
G

Orders for Tests

Safety Standards

ELECTRONIC
n
G

bi

RECORDS
lo

lo
bi

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Figure 29-4 A normal hemoglobin molecule contain-

Figure 29-3 The laboratory arm of the total practice ing four globin chains with a heme group attached to
management system (TPMS). Quality controls and test each globin. One oxygen molecule can be transported
results are easily recorded in a TPMS. by each heme group.
888 UNIT 7 Laboratory Procedures

requirement for an adult man is about 0.5 mg/day,

whereas a menstruating woman requires about
four times that much, or 2 mg/day.
Hemoglobin carries about 95% of the oxy-
gen to the body cells and carries away about 27%
of the carbon dioxide. The RBCs pick up the oxy-
gen in the lungs from when we breathe in, and
they drop off the carbon dioxide in the lungs to be
expelled when we breathe out. The rest of the car-
bon dioxide is removed through other processes.
Oxygenated hemoglobin is bright red, and hemo-
globin unbound to oxygen is darker. This explains
the bright red color of arterial blood (going from
the lungs and to the cells) and the darker color of
venous blood (going back to the lungs). Figure 29-5 HemoCue instrument used for auto-
A second function of hemoglobin is as a mated test.
blood buffer; that is, hemoglobin helps maintain
the proper pH balance of the blood as it picks up
and drops off oxygen and carbon dioxide. Hemoglobin is measured in the POL using
The production of new RBCs and consequently an automated device called the HemoCue (Figure
the formation of new hemoglobin is triggered by a 29-5). The HemoCue is an infrared analyzer that
hormone called erythropoietin, which is produced measures the density of the hemoglobin pigment
in the kidney. The erythropoietin process is acti- by light refraction. The more hemoglobin present
vated when the body cells sense a low oxygen level. in the sample, the more light is refracted. This is a
There are several forms of hemoglobin. Hemo- quick method, uses only a small drop of blood, and
globin A (Hgb A) is the most common form found gives immediate results (see Procedure 29-1).
in adults. The other hemoglobin types are abnormal CAUTION: The solution within the
and are responsible for a group of diseases known HemoCue is poisonous. Precautions to
as hemoglobinopathies. These abnormal forms of observe when working with any reagents
hemoglobin include hemoglobin S (Hgb S), hemo- includes wearing gloves, working in a well-ventilated
globin C, and hemoglobin E. Hgb S is the most com- area, properly disposing of used reagents, wiping
mon abnormal form of hemoglobin observed in the up all spills, and hand washing.
laboratory. It is the form of hemoglobin that causes The normal reference values for hemoglobin
sickle cell anemia. When Hgb S molecules are sub- vary according to both the age and sex of the indi-
jected to certain conditions, they alter the physical vidual (Table 29-1).
structure of the RBCs. The RBCs assume a sickle
shape, which makes it difficult, if not impossible, for
the cell to pass through a capillary bed.
Hematocrit
The most frequent hemoglobin disease seen Hematocrit (packed RBC volume) is the ratio of
in the ambulatory care setting is anemia, with iron the volume of packed RBCs to that of the whole-
deficiency anemia being the most common type. A blood specimen. Packed RBC volume is expressed
decrease of available iron in the body is the most com- as a percentage of the whole specimen. This is
mon cause of this type of anemia. Lack of available achieved manually or by automated methods. Most
iron can be caused by insufficient intake through the medical assistants working in ambulatory care set-
diet (called nutritional anemia); losing iron because tings use the manual microhematocrit method
of a bleeding problem (called hemorrhagic anemia); (see Procedure 29-2) It requires only a few drops
or less common, congenital defects, industrial toxins, of blood either directly into a microhematocrit
diseases of bone marrow (aplastic anemia), and a tube obtained by capillary draw, or the sample can
variety of other disorders. In nutritional anemia, the be taken from a vacuum tube containing ethylene-
laboratory finding usually shows a normal or near- diaminetetraacetic acid (EDTA) after a venipunc-
normal hematocrit (because these patients have the ture. Chapter 28 explains both capillary draw and
right percentage of RBCs) but a low hemoglobin. venipuncture.
Their RBCs are hypochromic (pale) because they The cellular components of the blood sample
lack oxygen. The main symptom of anemia, fatigue, separate into layers when they are centrifuged at high
is also caused by lack of oxygen. speeds (Figures 29-6 and 29-7). The cellular layers
 CHAPTER 29 Hematology 889

Table 29-1 Normal Hemoglobin Values Table 29-2 Normal Hematocrit Values
or Reference Ranges by Age or Reference Ranges by Age
and/or Sex and/or Sex
Newborn 15–20 g/dL Newborn 45–60%
Age 3 months 9–14 g/dL 1-year-old child 27–44%
Age 10 months 12–14.5 g/dL Adult female 36–46%
Adult woman 12–16 g/dL Adult male 40–55%
Adult man 13–18 g/dL

Table 29-4 Normal Values for a Differential

Leukocyte Count in Adults

Neutrophil Bands: 3–5%

Neutrophil bands increase in appendicitis and many
Table 29-3 Normal Leukocyte Counts
other diseases.

Leukocyte Count (cells/mm3) Neutrophil Segs: 54–62%

Segmented neutrophils increase in appendicitis and
Age Average Reference Range many other diseases. An elevation in neutrophils usu-
Newborn 18,000 9,000–30,000 ally is indicative of an infectious disease.

1-year-old toddler 11,000 6,000–14,000 Lymphocytes: 25–33%

Lymphocytes increase with infectious mononucleosis,
6-year-old child 8,000 4,500–12,000 lymphocytic leukemia, and many diseases of viral origin.

Adult 7,000 4,500–11,000 Monocytes: 3–7%

Monocytes increase in tuberculosis and monocytic
leukemia.

Eosinophils: 1–3%
Eosinophils increase with allergic reactions, hay fever,
and parasitic infections.
Table 29-5 Normal Erythrocyte Counts
Basophils: 0–1%
Age Reference Range Basophils increase in polycythemia vera, chicken pox,
and ulcerative colitis.
Newborn 5.0–6.5  106/mm3

1-year-old child 4.0–5.0  106/mm3

Adult woman 4.0–5.5  106/mm3 Table 29-6 Normal Values for the Erythrocyte
Indices
Adult man 4.5–6.0  106/mm3
MCV 80–100 fL

MCH 27–33 pg

MCHC 32–36 g/dL

Table 29-8 Normal Values for the Westergren

Table 29-7 Normal Values for the Wintrobe
Method of ESR
Method of ESR
Male patients younger than 50 years 0–15 mm/hr
Male patients 0–9 mm/hr
Male patients older than 50 years 0–20 mm/hr
Female patients 0–20 mm/hr
Female patients younger than 50 years 0–20 mm/hr

Female patients older than 50 years 0–30 mm/hr

890 UNIT 7 Laboratory Procedures

Capillary tube

Plasma

Buffy coat

Figure 29-6 Microhematocrit centrifuge. Red blood cells

arrange themselves with the RBCs at the bottom of

the tube. RBCs are the most numerous and the heavi-
est of the cellular components. WBCs and platelets
form a thin layer called the buffy coat on top of the Sealing clay
erythrocytes. The buffy coat has a whitish tan appear-
ance. The plasma often is so clear it is difficult to see. Figure 29-7 Diagram of packed cell column in the
The WBC count of the sample can be esti- hematocrit tube showing separation of cellular compo-
mated by measuring the buffy coat thickness. Each nents after centrifugation.
0.1 mm of the buffy coat equals approximately
1,000 WBC/mm3. Therefore, a buffy coat of 1 mm
would equal a leukocyte count of approximately neither method is considered CLIA waived, neither
10,000 WBCs/mm3, and a 0.5 mm reading would is within the scope of practice for the medical assis-
equal 5,000 WBCs/mm3. The cell counts may be tant. The Introduction discusses the functions of
reported in units of microliters (mcL), which are blood cells, and you will learn much more in your
equivalent to cubic millimeters. anatomy and physiology course. The formation
The normal values of hematocrit vary according of blood cells was shown in Figure 29-1. Because
to the age and sex of the individual (Table 29-2). blood cell counts are not performed by medical
Sources of error associated with the micro- assistants, this section does not discuss the test pro-
hematocrit method include improper centrifuga- cess itself but rather the diagnostic implications of
tion, resulting in increased trapped plasma, and the leukocyte count with the differential.
improper reading of the packed RBC volume, such
as including the buffy coat layer.
Procedure 29-2 explains the microhematocrit
White Blood Cells and Differential
method of determining blood hematocrit levels. WBCs do not necessarily remain within the
Review Chapter 28 sections on capillary tubes and blood vessels like RBCs do. They leave the blood
capillary draw together with Procedure 28-5. vessels and travel to the tissues of the body to
find and destroy pathogens. When a “bacterial
battle” is fought in an area and many WBCs have
WHITE AND RED BLOOD died, the “battlefield” may be too large for the
CELL COUNTS body to clean up. In these cases, pus can occur.
A localized accumulation of pus is called an
WBC and RBC counts can be performed using abscess and often must be incised (lanced) to aid
either a manual or automated method. Because in the removal of the pus. Chapter 19 discusses
 CHAPTER 29 Hematology 891

incision and drainage surgery for the purpose die if our leukocytes lost their ability to perform
of incising and draining an abscess. Antibiotics this process.
are useful in some cases to help the leukocytes Detoxification is a neutralizing process that
fight off the bacteria and remove the infection. is effective against poisons and other harmful sub-
When leukocytes travel into the tissues, most stances. Eosinophils use detoxification to control
of them do not return to the bloodstream. The allergic reactions and histamine production.
lymphocyte is the only type that does; it travels Inflammation is a general process that occurs
to the lymphatic system where it is specialized as a sequence of events. Chapter 10 explains the
and matured (hence, its name), then returns to inflammatory process in more detail. The leuko-
the bloodstream to await a mission. The normal cyte most actively involved in inflammation is the
values for white blood cells vary with age. Babies basophil, which releases histamine into injured tis-
need more, because they have not yet built up sue to increase inflammation (antihistamines work
antibody protections (Table 29-3). to reduce inflammation). Basophils also contain
WBCs or leukocytes can be divided into two the anticoagulant heparin. The basophil synchro-
basic groups: granulocytes, which contain granules nizes the entire inflammatory process; thus, the
within their cytoplasm, and agranulocytes, which poison is rendered harmless, the offending agents
do not contain granules. The presence of granules are eliminated, and the area is cleaned up of all
can be visualized by the trained eye after a staining the necrotic tissue and is ready for repair.
process during the manual WBC count. Even dur- Immune response is a series of complicated
ing the automated method, the leukocyte is identi- and involved specific antigen–antibody reactions.
fied by the contents of the cytoplasm and the shape Simply stated, when a harmful substance enters
of their nuclei. The granulocytes are the neutro- the human body, the adaptive immune response
phils, basophils, and eosinophils (notice they all provided by the lymphocyte destroys the harm-
end in -phil, which will help you remember their ful substance. A “memory” is created so that the
cytoplasm is “filled” with granules). The agranulo- next time the body is exposed, it recognizes the
cytes are the lymphocytes and the monocytes. intruder and is better able to prevent the illness
The nuclei of the leukocytes differ from each again. This is called immunity. Immunity can be
other, as well as the cytoplasm. All three of the permanent or temporary, passively acquired or
granulocytes contain nuclei that are multilobed or actively acquired. Passively acquired immunity is
segmented (sometimes they are even called segs).
They are described as being polymorphonuclear
cells (poly means “many,” morpho means “shape,”
and nuclear means “nucleus”). The immature neu- LEUKOCYTE IDENTIFICATION GUIDE
trophil has a nucleus that has not yet formed lobes Cell Types Functions
and is called a band cell (or stab cell) because its
Granulocytes
nucleus looks sort of like a comma. The agranu-
locytes do not form lobed nuclei; their nuclei are Neutrophils Phagocytosis of bacteria
rounded in a single mass. Because of their single Mature are segmented cells/segs Destruction by enzymes
nuclei, the aganulocytes are sometimes called Immature are bands or stabs
mononuclear (meaning one nucleus). Because so Eosinophils Detoxification of toxins
many different names can be confusing, this chap- and harmful substances
ter provides an identification guide and pictures
Neutralize histamine
for you (see Table 29-4, Leukocyte Identification
Guide box, and Figure 29-8). Destroy parasitic worms
Each of the five types provide specialized pro- Basophils Mediate inflammation
tection. Some of their methods include phagocy- Release histamine to
tosis, detoxification, inflammation, and immune increase inflammation
response. Release heparin to inhibit
Phagocytosis is an engulfing process per- blood clotting
formed by all leukocytes, but especially the neu- Agranulocytes
trophils and the monocytes. Once the bacteria or
Monocytes Phagocytosis to clean up
particles are engulfed, the material is destroyed by
enzymes present in the leukocyte. Phagocytosis is Lymphocytes Destruction of viruses
so important as a means of protection, we would Immune response
892 UNIT 7 Laboratory Procedures

(A) Neutrophilic bands (B) Segmented neutrophils

(C) Lymphocytes (D) Monocytes

(E) Eosinophils (F) Basophilis

Figure 29-8 Various types of leukocytes from a stained blood smear.

gifted to us either in utero (congenital or natu- This is what can happen in an allergic reaction.
ral) or through an injection (artificial). Actively Eosinophils are especially well suited to battle the
acquired immunity requires us to actively fight off inflammation accompanying allergic-type reactions
a disease, and because we take active part in creat-
ing the immunity, it is usually permanent. Passively
acquired immunities do not make us sick, but they
Some examples of blood cell changes associated with disease
usually do not last longer than 6 months. states are:
Not only do the leukocytes fight off patho-
gens/toxins in a variety of ways, they also are fairly 1. When a patient is experiencing an acute appendicitis,
specific in the types of pathogens they do battle the white blood cell count increases rapidly with a high
with (see Table 29-4). Neutrophils are the most percentage of neutrophils. There is also an increase in the
numerous of all leukocytes and for good reason. number of early or younger forms of these cells.
They are there to destroy bacteria, which is our 2. Patients who are suffering from a viral infection, especially
most common enemy. The second largest group is adults, frequently experience a reduction in white blood
cells and an increase in the percentage of lymphocytes.
the lymphocytes, and they fight our second most
Patients with infectious mononucleosis have increased
common enemy: viruses. Lymphocytes are also numbers of lymphocytes, many of which are atypical.
involved in immune responses, which explains why 3. When patients have iron deficiency anemia, their indices
we have immunity to viruses and not to other sub- demonstrate red blood cells that show marked reduction in
stances or microbes. Basophils release histamine to hemoglobin content. Their erythrocytes appear hypochro-
increase inflammation into injured tissues. Inflam- mic, lacking or low in color, because they lack the normal
mation usually is our friend, but sometimes the amount of hemoglobin in the red blood cells.
inflammation is too severe.
 CHAPTER 29 Hematology 893

because they neutralize the histamines. Monocytes

can be likened to the “cleanup crew” because these Clinical Laboratory Improvement
“big eaters” come in later to clean up the battlefield Amendment, 1988 (CLIA ’88)
of the cellular debris and other substances.
Regulation Regarding WBC
Differential Counts
Red Blood Cells
• Laboratories that are certified for waiver-level testing only
RBCs (erythrocytes) are very different from WBCs are not permitted to perform manual WBC differential
in composition, function, and numbers (Table 29- counts.
5). Remember from the Introduction that eryth- • Laboratories with a moderate-complexity certification can
rocytes are responsible for carrying oxygen to the perform a manual differential WBC count but may only
body’s cells and bringing back the carbon dioxide. identify and report normal cells.
To have room to carry the oxygen and carbon diox- • Laboratories certified to perform tests of high complexity can
ide molecules, the erythrocyte leaves its nucleus in perform a manual differential WBC count and are permitted
the bone marrow where it is formed. The nucleus is to identify and report both abnormal and normal cells.
used again and again to create other erythrocytes.
• Laboratories with moderate to complex certification can
Our bodies are efficient at recycling raw materials. perform automated WBC counts including the reporting of
If an erythrocyte is released from the bone mar- abnormal results. Only qualified medical technicians and
row before it is mature, it may retain some of its higher personnel may use and maintain the machines.
nucleus material. It is then called a reticulocyte See Chapter 26 for details on CLIA ’88 regulations.
(retic). About 1% of the circulating erythrocytes
are reticulocytes, and an increase in the number
of circulating reticulocytes is an indication that the
body needs more erythrocytes. This can occur in
cases of hemorrhage and anemia. Erythrocytes can from injured tissues and plasma proteins and fac-
be of varying sizes. When erythrocytes are of nor- tors released from platelets. These chemicals form
mal size, they are called normocytic. Those that prothrombin activator. Prothrombin activator
are larger are called macrocytic, and those that are (with calcium) converts (activates) a blood pro-
smaller are called microcytic. When the erythro- tein called prothrombin into thrombin. Thrombin
cytes show marked variation in size, the condition converts another blood protein called fibrinogen
is called anisocytosis. The normal erythrocyte has into fibrin. Fibrin is stringy and traps the sticky
a round or slightly oval shape. If the shape of the blood cells in a web at the site of injury, forming a
erythrocytes show marked variation, the condition plug of sorts. Eventually, the plug starts drying up,
is known as poikilocytosis. shrinks (pulling the edges of a wound together),
The RBC should contain hemoglobin that and forms a scab.
fills about half of the cell. The RBC is biconcave, so What is really fascinating about the clot-
most of the hemoglobin is seen around the outer ting of blood is why blood does not normally clot
part of the cell. The central area of the RBC is inside the blood vessels. Two chemicals made in
pale. RBCs with the proper amount of hemoglobin the human body prevent that from happening.
are called normochromic. Those that do not have One is heparin, which is released from basophils
enough hemoglobin, that demonstrate too large and endothelial cells, and the other is antithrom-
of a pale central area, are called hypochromic. bin, which is released by the liver. The body needs
blood to clot to stop bleeding, but it is important
that blood not clot inside the body where it can
PLATELETS cause problems and even death.

The normal number of platelets (thrombocytes)

is 140,000 to 400,000 per microliter of blood. ERYTHROCYTE INDICES
Thrombocytes are actually fragments of cells.
Like mature erythrocytes, thrombocytes have no The erythrocyte indices include the mean corpus-
nuclei. Thrombocytes are involved in the clot- cular (cell) volume (MCV), the mean corpuscular
ting of blood, or coagulation. Coagulation is a hemoglobin (MCH), and the mean corpuscular
complex series of events that contains 13 distinct hemoglobin concentration (MCHC). These indi-
steps. A brief overview is provided here. When the ces (plural for index) are calculations that pro-
body is physically injured, chemicals are released. vide information about the size of the RBCs and
Included in these chemicals are thromboplastin the hemoglobin content. The blood parameters
894 UNIT 7 Laboratory Procedures

needed to calculate all three indices are the RBC of all the balloons in our basket, then divide that
count, the hematocrit, and the hemoglobin. The number by the number of balloons in the basket.
erythrocyte indices values are important in the This gives us the average (mean) mass (volume),
diagnosis or classification and treatment of differ- or MCV.
ent types of anemia. Table 29-6 shows normal val- If we use MCH in the above example, we are
ues for the erythrocyte indices. measuring the average amount/concentration of
Before the automated hematology instrument water in the balloons. To measure this, we would
became commonly used in the ambulatory care pop each balloon, measure the total amount of
setting, the erythrocyte indices were not included water, and then divide by how many balloons
as a part of the CBC because the RBC count was there were. This would give us the average (mean)
not an accurate measurement. amount of red water (hemoglobin), or MCH.
The following formulas are used to calculate Using the same water balloon comparison for
the erythrocyte indices: explaining the MCHC, it would be the intensity
of the red water within all the balloons. Some of
MCV  Hematocrit
RBC (in millions)  10
the balloons might contain light red water, some
might contain dark red water. The average of the
The result is reported in femtoliters (f L), a intensity would give us the average (mean) inten-
unit of volume 1015 L, formerly reported in cubic sity (concentration), or the MCHC.
microns (m3). This index gives the average vol- All of these numbers together tell us about
ume of RBCs in the sample. how many balloons (RBC) there are in the basket/
sample, their average size (volume), how much
Hemoglobin (in grams)
MCH   10 they contain (amount hemoglobin/water), and
RBC (in millions) the average concentration/intensity of the red
The result is expressed in picograms (pg), a water (hemoglobin) within all of them.
micro microgram, or 1  1012 g. This index esti- Understanding the relationship between the
mates the weight of hemoglobin in RBCs of the MCV, MCH, and MCHC helps to better understand
sample. what is happening when a patient is anemic due to
low hemoglobin within each RBC versus a patient
Hemoglobin (in grams) who is anemic due to low RBC count and so forth.
MCHC   10
Hematocrit
This result is expressed in grams/deciliter Using Erythrocyte Indices
(g/dL). The MCHC is the average concentration to Diagnose
of hemoglobin in a given volume of packed RBCs
(hematocrit). The MCH and MCV are increased in megaloblas-
tic anemias such as vitamin B12 and folate deficiency
anemias. They also are increased in acute blood
Understanding RBC Indices loss anemia, chronic hemolytic anemias, aplastic ane-
If we think of the red blood cells as water bal- mias, hypothyroidism, and liver disease. The MCH
loons filled with red-colored water, we might bet- and MCV are decreased in hypochromic and micro-
ter understand the indices: The red-colored water cytic anemias, including iron deficiency anemia, thal-
signifies the hemoglobin inside the red blood cell. assemias, and occasionally in hyperthyroidism.
We have a basket of water balloons to signify our The MCHC is increased in hereditary sphero-
blood sample. cytosis. It is normal in macrocytosis. The MCHC is
Because each water balloon is a different size decreased in iron deficiency anemia. The stained
(as are our red blood cells), we would need to mea- blood smear of a person with iron deficiency ane-
sure the size of all of them to get the average vol- mia demonstrates RBCs that are both hypochro-
ume or mass. We would add together the size/mass mic and microcytic.

ERYTHROCYTE
Critical Thinking SEDIMENTATION RATES
(ESR OR SED RATE)
If the patient’s hematocrit is 37 and the RBC
count is 5 million, what would the MCV be? The erythrocyte sedimentation rate (ESR), as
the name implies, is a measurement of the rate
 CHAPTER 29 Hematology 895

at which the RBCs in a well-mixed, anticoagu- Two ways to perform an ESR test are the
lated blood sample will fall, or settle, toward the Wintrobe method and the Westergren method.
bottom when it is placed in a vertical tube. This Both methods will provide the same information.
test is commonly referred to in the laboratory as Because of the simplicity in setting up the Wester-
a “sed rate” (see Procedure 29-3). The ESR has gren ESR, it has become the more widely used
been used for many years in the diagnosis and method in the ambulatory care setting’s POL.
treatment of many disease states of the body.
It is an inexpensive, accurate, and easy test to
perform. Two factors that influence the sedi- Wintrobe Method
mentation rate are the condition of the surface
An EDTA venous blood sample is thoroughly
membrane of the RBC and changes in the level
mixed. With the use of a Pasteur pipette, the blood
of fibrinogen in the plasma of the blood. During
is transferred to a Wintrobe tube. The blood is
disease conditions in the body, the surface mem-
added to the left zero mark at the top of the tube.
brane of the RBC is altered, as well as the levels
It is important that no air bubbles are present in
of fibrinogen, and this affects the rate at which
the blood column. The tube is placed exactly ver-
the RBCs fall in the tube. RBCs will demonstrate
tical in a rack and allowed to stand for exactly 60
this change even after the disease has subsided
minutes. The test is read by determining the num-
because RBCs have an average life of 120 days.
ber of millimeters (mm) the red cells have settled.
For this reason, the ESR is a more accurate tool
The tube has a total capacity of 100 mm. The test
in diagnosing the onset of a disease than in
is reported in millimeters per hour (Figure 29-9).
checking the progress of treatment.
Table 29-7 lists normal values for the Wintrobe
method of ESR.

Westergren Method
0 10
0 10 The Westergren method differs from the Win-
Plasma Distance
trobe method in that the blood sample is mixed
1 9 erythrocytes with 3.8% sodium citrate solution before the tube
have fallen is filled. The blood and sodium citrate are mixed
and the tube is filled to the zero mark and placed
2 8 exactly vertical in a rack. The tube is read after
1 9
exactly 60 minutes, and the test is reported in mil-
3 7 limeters per hour. Table 29-8 gives normal values
for the Westergren method of ESR.
The Polymedco company produces a
4 6
Sediplast® system to perform a Westergren ESR
that is self-filling. It is a completely closed system
5 5 that protects laboratory personnel from the risks
Blood associated with blood handling. The Sediplast®
ESR System is shown in Figure 29-10.
6 4
The following guidelines should be followed
when performing Wintrobe and Westergren ESR
7 3 procedures to ensure accurate test results:

8 2 1. The tube must remain exactly vertical during the

1-hour test time.
2. The test must be read at exactly 60 minutes
9 1
(1 hour).
3. The counter on which the rack is placed must be
free of vibrations.
Figure 29-9 Wintrobe sedimentation tube showing 4. The test should be set up within 2 hours after the
settling of cells. The example shows a sedimentation of blood is drawn.
8 mm. 5. The test should be conducted at room temperature.
896 UNIT 7 Laboratory Procedures

Figure 29-11 Erythrocytes forming rouleaux.

The ESR may be normal in osteoarthritis and

in some cases of cirrhosis and malaria. ESR values
are decreased in polycythemia, spherocytosis, and
sickle cell anemia.
Figure 29-10 Westergren method using Sediplast®
ESR System. Three filled tubes are standing in the rack.
Note the diluting vials with sodium citrate solution (right). C-REACTIVE PROTEINS
(Courtesy of Polymedco, Inc., Cortlandt Manor, NY.)
Another screening blood test for inflammation is
C-reactive protein or CRP. The CRP level will rise
6. The tube should not be placed in a draft, and it and drop quicker than the ESR, giving the pro-
should not be exposed to direct sunlight. vider more timely information about the effective-
ness of treatment.
7. The column of blood must be free of bubbles.
Like the ESR, CRP is helpful in determining
The erythrocytes in normal, nondiseased systemic inflammatory conditions such as autoim-
blood tend to remain suspended in the plasma. mune diseases, inflammatory bowel conditions,
They do not aggregate (clump) together to form and some forms of arthritis. While it is not specifi-
rouleaux. Rouleaux is a phenomenon where RBCs cally diagnostic for any one disease, it can serve as
form aggregates that look like rolls or stacks of a marker for general infection and inflammation,
coins (Figure 29-11). and, once the disease or condition is diagnosed, it
This aggregate form causes the rate of sedimen- can help determine the effectiveness of treatment.
tation to increase. RBCs have membrane properties CRP is made by the liver and released into
that tend to make them remain separated in the the bloodstream. It increases when infection and
plasma. During certain diseased states, this repelling inflammation are present. It has been used for
property is lost and the RBCs tend to aggregate. many years as an indicator of bacterial and viral
infections.
Due to the more recent studies showing the
Using the ESR to Screen correlation between vascular inflammation and
ESRs are increased in infections, acute stress, and heart disease, a more sensitive CRP-related test
inflammatory diseases, tissue destruction, and called hsCRP (highly sensitive C-reactive protein)
other conditions that lead to an increase in plasma has gained popularity in detecting vascular inflam-
fibrinogen. They are also increased with menstrua- mation that can indicate coronary artery disease
tion, pregnancy, lupus, malignant neoplasms, and and cardiovascular disease. The hsCRP is used in
multiple myeloma. With anemia, the ESR increases conjunction with the traditional lipid profile and
according to the severity of the condition. cardiac risk assessment.
 CHAPTER 29 Hematology 897

COAGULATION STUDIES
Persons prone to forming blood clots often are
medicated with anticoagulants (blood thinners)
such as Coumadin or heparin. While a patient is
taking an anticoagulant, it is important to deter-
mine the blood is able to clot within a reasonable
amount of time, which ensures that the patient is
taking the correct dosage. The method of monitor-
ing coagulation time is called the prothrombin time
(PT), or, more commonly the protime. The pro-
time is reported in the time (seconds) it takes for
the patient’s blood to clot and in the international
normalized ratio (INR). We still refer to both tests as Figure 29-12 ProTime coagulation analyzer. (Cour-
protime. Currently the INR is more useful because it tesy of ITC, Edison, NJ.)
is standardized, that is, it can be universally applied,
in contrast to the timing test, which can vary quite a
bit from facility to facility. Normal blood will clot in
about 11 to 13 seconds. The provider will want the testing under CLIA and therefore is not within
patient taking anticoagulant medication to have a the medical assistant’s scope of practice without
protime of approximately 16 to 18 seconds and INR further education and training. Many medical
of 2.0 to 2.6 (sometimes higher). If blood clots too assistants have obtained additional education and
soon, the anticoagulant medication is not at a ther- training and are performing moderately complex
apeutic level. If the blood clotting takes too long tests under additional credentials. All procedures
(prolonged clotting), then the patient is taking too performed with automated instrumentation are
much medication. An INR of 1.0 is considered inef- modifications of manual methods. Automated
fective; 5.0 is considered dangerous. hematology procedures have many advantages
Because activities of daily living, such as diet, over the manual methods. They are faster, less
can interfere with clotting factors, the protime usu- expensive, simple to operate, and accurate. The
ally is tested on a regular basis, weekly at the begin- instruments can be calibrated and lend them-
ning of treatment, then monthly or less frequently selves to control testing. Most are equipped with
as treatment progresses. If the patient experiences printers that produce hard copy results. Many can
frequent unusual bruising or bleeding that might store quality-control results and print out quality-
indicate an imbalance in clotting ability, then the control data summary sheets.
protime test can be run “on demand.” Some foods In addition to performing a wide variety of
rich in vitamin K (e.g., dark leafy vegetables), alco- hematologic tests, many automated hematology
hol, vitamins and supplements, aspirin, and many instruments also calculate part or all of the RBC
other medications can interfere with anticoagulant indices and print the results. Some automated
therapy. Health care professionals must interview hematology instruments can be connected to other
the patient carefully about what is being taken. computers in the medical facility.
Patient education and patient compliance both The hematologic parameters that are avail-
are important components of effective treatment able on different automated office hematology
with anticoagulants. instruments are:
The protime test is also used as a screening
test for people who have liver disease or clotting • RBC count
factor disease or who are vitamin K deficient. • WBC count
The protime is a simple CLIA waived test that
• Hemoglobin
is performed on a drop of blood (Figure 29-12).
Procedure 29-4 describes the step-by-step process. • Hematocrit
• Platelet count
• MCV
AUTOMATED HEMATOLOGY • MCH
Use of the automated or semiautomated hema- • MCHC
tology instruments is not categorized as waived • Percentage of granulocytes
898 UNIT 7 Laboratory Procedures

• Granulocyte count (neutrophils, eosinophils, baso- • Percentage of mid-cells

phils) • Lymphocyte count
• Percentage of lymphocytes/monocytes • Percentage of lymphocytes
• Non granulocyte count (lymphocytes and mono- • RBC distribution width (RDW)
cytes)
• Mid-cell count (monocytes and band neutrophils)

Procedure 29-1
Hemoglobin Determination Using a CLIA Waived Hemoglobin Analyzer
STANDARD PRECAUTIONS that you have the right patient. Explaining the
procedure reassures the patient and gains his or
her cooperation with the procedure.
5. Select the site, prepare the site, and perform
PURPOSE the capillary puncture (see Chapter 28). Wipe
Properly and safely perform an automated hemoglo- away the first drop with gauze. RATIONALE:
bin determination to evaluate the oxygen-carrying The first drop may be contaminated with tissue
capacity of the blood. fluid. Using gauze rather than a cotton ball will
discourage a clot from forming.
EQUIPMENT/SUPPLIES
6. Apply the second drop of blood into the slide
Gloves
reservoir using the appropriate technique for
Biohazard container
the analyzer (Figure 29-13B). RATIONALE:
Sharps container
Each machine has a slightly different applicator
Capillary puncture equipment
device and technique.
70% isopropyl alcohol
Safety lancet 7. Apply a cotton ball to the puncture site and
Cotton ball ask the patient to hold pressure for 2 minutes.
Gauze 2  2 RATIONALE: Cotton will assist the site to clot
Adhesive bandage during the 2 minutes the pressure is held.
CLIA waived hemoglobin analyzer with test slides 8. Place the slide into the analyzer and perform
appropriate steps as required by the manufactur-
PROCEDURE STEPS er’s instructions. RATIONALE: Each manufacturer
1. Assemble and organize equipment and supplies. has specific processes for use with its analyzer.
RATIONALE: Being organized helps the process
go more smoothly and professionally. 9. Read and make a note of the test results (Figure
29-13C). RATIONALE: Making a note helps you
2. Wash hands and put on gloves. RATIONALE: retain the results until they can be charted in the
Hand washing and gloving protects the patient patient’s medical record.
and you.
10. Assess the patient and apply a bandage strip to
3. Turn on the analyzer and calibrate or standard- the puncture site. RATIONALE: The patient
ize according to the manufacturer’s instructions should not leave your care until the bleeding
(Figure 29-13A). RATIONALE: Turn on analyzer has stopped. Do not apply a fingertip bandage to
to warm machine up, calibrate to maintain qual- an infant or young child because it could pose a
ity controls. choking hazard.
4. Identify the patient and explain the procedure. 11. Disinfect analyzer according to manufacturer’s
RATIONALE: Identifying the patient ensures instructions. Discard all contaminated equip-

continues
 CHAPTER 29 Hematology 899

Procedure 29-1 (continued)

A B C

Figure 29-13 (A) Turn on the machine and perform control testing if necessary. Always follow the manu-
facturer’s instructions. (B) Place the patient’s drop of blood into the slide reservoir. (C) Read and record the
hemoglobin value.

ment and supplies into appropriate biohaz- Accurate and timely documentation are impor-
ard waste receptacles. Disinfect counter space. tant in medical laboratory procedures.
RATIONALE: Using disinfectants not recom-
mended by the manufacturer could harm the DOCUMENTATION
analyzer. Use sharps containers for sharp sup- 08/06/20XX Capillary puncture performed for hemoglo-
plies and red bags for contaminated cotton ball bin determination. Specimen tested in our lab. Results lab
and gloves. report filed. Patient tolerated the procedure well and Dr.
12. Discard note, remove gloves and discard into Rice discussed results with her. Joe Guerrero, CMA (AAMA)
biohazard container, and wash hands. RATIO-
NALE: Washing hands removes residual contam- Laboratory Report
ination.
Patient Name Diane Pankey Date 08-06-20XX
13. Document the procedure in the patient’s medical
record in the progress notes charting section and Hematocrit — % Hemoglobin 14.5 gm/dL
complete a lab report. File the lab report in the
lab section of the patient record. RATIONALE: Joe Guerrero, CMA (AAMA)
MA signature

Procedure 29-2
Microhematocrit Determination
STANDARD PRECAUTIONS Sharps container
Capillary puncture equipment
70% isopropyl alcohol
Safety lancet
PURPOSE Cotton ball
Properly and safely perform a microhematocrit deter- Gauze 2  2
mination. Adhesive bandage
Microhematocrit tubes (heparinized, plastic, self-
EQUIPMENT/SUPPLIES sealing or use sealing clay)
Gloves Microhematocrit centrifuge and reader
Biohazard container

continues
900 UNIT 7 Laboratory Procedures

Procedure 29-2 (continued)

PROCEDURE STEPS Sealing the tube prevents the specimen from

1. Assemble and organize equipment and supplies. being forced out during centrifugation.
RATIONALE: Being organized helps the process 7. Repeat the procedure with one more tube.
go more smoothly and professionally. RATIONALE: The two tubes balance one
2. Wash hands and put on gloves. RATIONALE: another in the centrifuge and the amounts are
Hand washing and gloving protects the patient averaged to get the hemotocrit results.
and you. 8. Apply a cotton ball to the puncture site and
3. Identify the patient and explain the procedure. ask the patient to hold pressure for 2 minutes.
RATIONALE: Identifying the patient ensures RATIONALE: Cotton will assist the site to clot
that you have the right patient. Explaining the during the 2 minutes the pressure is held.
procedure reassures the patient and gains his or 9. Place the tubes into the centrifuge with sealed
her cooperation with the procedure. ends outward against the gasket. Make certain the
4. Select the site, prepare the site, and perform tubes balance each other across the centrifuge.
the capillary puncture (see Chapter 28). Wipe Fasten the lid securely, lock into place, and turn
away the first drop with gauze. RATIONALE: the centrifuge on. Set the timer and spin for the
The first drop may be contaminated with tissue appropriate amount of time as required by the
fluid. Using gauze rather than a cotton ball will manufacturer’s instructions. RATIONALE: Cen-
discourage a clot from forming. trifugal force requires that the outside ends of the
5. Allow the second drop of blood to form on the tubes be plugged to prevent the specimen from
patient’s finger. Holding the microhematocrit leaking out. Balancing the tubes and locking the
tube horizontally, touch the end onto the top of lid ensure laboratory safety and prevents breakage.
the blood drop and let the tube fill by capillary 10. Assess the patient and apply a bandage strip to
action until the tube is approximately 3⁄4 full (Fig- the puncture site. RATIONALE: The patient
ures 29-14A and B). should not leave your care until the bleeding
6. With a 2  2 gauze, wipe off the end of the tube. has stopped. Do not apply a fingertip bandage to
Gently place the tube into clay until a plug is an infant or young child because it could pose a
formed or use self-sealing tube (Figure 29-14C). choking hazard.
RATIONALE: Wiping the end of the tube of 11. Allow the centrifuge to come to a complete stop
blood lessens contamination to the clay holder. before touching it. Remove the tubes. Using a

A B C

Figure 29-14 (A) Perform the capillary puncture, and wipe away the first drop
with gauze. Allow the second drop of blood to form on the patient’s finger. (B)
Holding the microhematocrit tube horizontally, touch the end onto the top of
the blood drop and let the tube fill by capillary action until it is approximately
3
⁄4 full. (C) Seal the microhematocrit tube with sealing clay.

continues
 CHAPTER 29 Hematology 901

Procedure 29-2 (continued)

reader or accompanying graph, determine the 14. Document the procedure in the patient’s medi-
hematocrit level. Read and make a note of the cal record in the progress notes charting section
test results. RATIONALE: A spinning centrifuge and complete a lab report. File the lab report
is very dangerous and can cause a friction burn in the lab section of the patient record. RATIO-
if touched. Making a note helps you retain the NALE: Accurate and timely documentation are
results until they can be charted in the patient’s important in medical laboratory procedures.
medical record.
12. Discard all contaminated equipment and sup- DOCUMENTATION
plies into appropriate biohazard waste recep- 08/06/20XX Capillary puncture performed for hemato-
tacles. Disinfect counter space and centrifuge crit determination. Specimen tested in our labs. Results in lab
according to manufacturer’s instructions. report filed. Patient tolerated the procedure well and Dr. Rice
RATIONALE: Using disinfectants not recom- discussed results with her. Joe Guerrero, CMA (AAMA) ___
mended by the manufacturer could harm the
analyzer. Use sharps containers for sharp sup-
Laboratory Report
plies and red bags for contaminated cotton ball Patient Name Diane Pankey Date 08-06-20XX
and gloves.
Hematocrit 38 % Hemoglobin — gm/dL
13. Discard note, remove gloves and discard into
biohazard container, and wash hands. RATIO- Joe Guerrero, CMA (AAMA)
NALE: Washing hands removes residual contam- MA signature
ination.

Procedure 29-3
Erythrocyte Sedimentation Rate
STANDARD PRECAUTIONS: Long-stem Pasteur-type pipette with rubber bulb
Timer
Disinfectant
Biohazard disposal container
PURPOSE: Acrylic face shield or goggles and mask
Properly and safely examine a blood sample by using Sharps container
either the Sediplast® (Westergren) or Wintrobe NOTE: Consult the manufacturer’s package insert for
method to record the ESR. specific instructions for the ESR kit being used.

EQUIPMENT/SUPPLIES: PROCEDURE STEPS:

Gloves 1. Wash hands and put on gloves.
Sample of venous blood collected in EDTA 2. Assemble equipment and materials.
Sediplast® kit (or other ESR kit): 3. Gently mix blood sample for 2 minutes.
Sedivial and sedirack
4. Perform either method a (Sediplast® ESR) or
Sediplast® autozeroing pipette
method b (Wintrobe):
Pipette capable of delivering up to 1.0 mL
Wintrobe method: a. Sediplast® ESR (modified Westergren)
Wintrobe sedimentation tube (disposable or method:
reusable) (1) Remove stopper on sedivial and fill to
Wintrobe sedimentation rack the indicated mark with 0.8 mL blood.

continues
902 UNIT 7 Laboratory Procedures

Procedure 29-3 (continued)

Replace stopper and invert vial several (5) Return blood sample to proper storage.
times to mix (or mix using pipette). (If no other laboratory work is scheduled,
(2) Place sedivial in Sediplast® rack on a level remove gloves, discard appropriately, and
surface. wash hands. Reglove before handling test
materials.)
(3) Gently insert the disposable Sediplast®
pipette through the pierceable stopper (6) Measure the distance the erythrocytes
with a twisting motion and push down have fallen (in mm): after exactly 1 hour,
until the pipette rests on the bottom of use the scale on the tube to measure the
the vial. The pipette will autozero the distance from the top of the plasma to
blood and any excess will flow into the the top of the RBCs.
sealed reservoir compartment. (7) Record the sedimentation rate:
(4) Set timer for 1 hour. ESR (Wintrobe, 1 hr)  ___ mm
(5) Return blood sample to proper storage. (8) Disinfect and clean equipment and
(If no laboratory work will be performed return to storage.
during the incubation, remove gloves, NOTE: If disposable equipment is used, dis-
discard appropriately, and wash hands. pose of in biohazard container.
Reglove before handling test materials.) 5. Clean work area with surface disinfectant.
(6) Let the pipette stand undisturbed for 6. Remove gloves and discard into biohazard con-
exactly 1 hour, and then read the results tainer.
of the ESR: Use the scale on the tube to
measure the distance from the top of the 7. Wash hands.
plasma to the top of the RBCs. 8. Document the procedure in the patient’s medi-
(7) Record the sedimentation rate: cal record in the progress notes charting section
ESR (Mod. Westergren, 1 hr)  ___ mm and complete a lab report. File the lab report
in the lab section of the patient record. RATIO-
(8) Dispose of tube and vial in appropriate NALE: Accurate and timely documentation are
biohazard container. important in medical laboratory procedures.
b. Wintrobe method:
(1) Place tube in Wintrobe sedimentation DOCUMENTATION
rack. 08/06/20XX ESR performed. Results filed in patient’s chart.
(2) Check the leveling bubble to ensure that
Patient tolerated the procedure well and Dr. Rice discussed
the Wintrobe rack is level.
results with him. Joe Guerrero, CMA (AAMA) _________
(3) Fill Wintrobe tube to the zero mark
with well-mixed blood using the Pasteur Laboratory Report
pipette and being careful not to overfill.
NOTE: Tube must be filled from the bot-
Patient Name George Pankey Date 08-06-20XX
tom to avoid getting air bubbles in the Erythrocyte Sedimentation Rate 17 mm/hr
tube.
(4) Set timer for 1 hour. Be certain the tube Joe Guerrero, CMA (AAMA)
is vertical and left undisturbed for the MA signature
entire hour.
 CHAPTER 29 Hematology 903

Procedure 29-4
Prothrombin Time (Using CLIA Waived ProTime Analyzer)
STANDARD PRECAUTIONS 6. Fill the Tenderlett lancet cup to the fill line then
place it onto the cuvette, which was placed into
the machine in Step 3. Be sure it is snapped into
place. Press the start button. RATIONALE: The
PURPOSE Tenderlett cup is calibrated for the analyzer and
Properly and safely perform an automated prothrom- must be properly placed for the test to run cor-
bin time determination to evaluate the clotting time rectly.
of a drop of blood. 7. Apply a cotton ball and ask the patient to hold
pressure for 3 to 5 minutes. RATIONALE: A
EQUIPMENT/SUPPLIES patient having this test performed usually has a
Gloves delayed clotting time. Assess that the bleeding
Biohazard container has stopped and apply bandage. RATIONALE:
Sharps container A patient should never leave your care until the
Capillary puncture equipment bleeding has stopped.
70% isopropyl alcohol
8. Stay by the analyzer and await a prompt to
Safety lancet
remove the Tenderlett lancet device. When
Cotton ball
prompted, immediately remove the device and
Gauze 2  2
discard it into a nearby sharps container. RATIO-
Adhesive bandage
NALE: The device must be removed as soon as
CLIA Waived ProTime Analyzer (ITC ProTime-3)
the clot has formed. This must be done very
with accessories
quickly, within seconds. The Tenderlett device
PROCEDURE STEPS contains a lancet and must be discarded into a
1. Assemble and organize equipment and supplies. sharps container.
Check expiration dates. RATIONALE: Being 9. Read the clotting time in seconds and the INR.
organized helps the process go more smoothly Record the results. RATIONALE: Results should
and professionally. be recorded as soon as possible to decrease the
2. Wash hands and put on gloves. RATIONALE: chance of error.
Hand washing and gloving protects the patient 10. Notify the provider immediately if the results
and you. fall within a critical range. RATIONALE: If the
3. Turn on the ProTime-3 and follow the prompts. patient has a seriously delayed clotting time, the
Insert the test cuvette into the analyzer. RATIO- risk of serious event occurring (such as a stroke)
NALE: Turn on analyzer to warm up machine, is greater. The provider must be notified imme-
calibrate to maintain quality controls. diately in order to adjust the anticoagulant dos-
age and/or prescribe other treatment.
4. Identify the patient and explain the procedure.
RATIONALE: Identifying the patient ensures 11. Disinfect analyzer according to manufacturer’s
that you have the right patient. Explaining the instructions, discard all contaminated equip-
procedure reassures the patient and gains his or ment and supplies into appropriate biohazard
her cooperation with the procedure. waste receptacles, and disinfect counter space.
Remove gloves and wash hands. RATIONALE:
5. Select the site, prepare the site, and perform the
Using disinfectants not recommended by the
capillary puncture using the Tenderlett lancet.
manufacturer could harm the analyzer. Use
Remember to use gauze to wipe away the first
sharps containers for sharp supplies and red bags
drop. RATIONALE: The Tenderlett lancet con-
for contaminated cotton ball and gloves. Wash-
tains the reservoir required for use with the Pro-
ing hands removes residual contamination.
Time-3.

continues
904 UNIT 7 Laboratory Procedures

Procedure 29-4 (continued)

12. Document the procedure in the patient’s medi- lab report filed. Patient tolerated the procedure well and
cal record in the progress notes charting section Dr. Rice discussed results with her. Joe Guerrero, CMA (AAMA)
and complete a lab report. File the lab report
in the lab section of the patient record. RATIO-
NALE: Accurate and timely documentation are
Laboratory Report
important in medical laboratory procedures. Patient Name Cynthia Januszewski Date 08-06-20XX
Protime 16 seconds INR 2.0
DOCUMENTATION
08/06/20XX Capillary puncture performed for pro- Joe Guerrero, CMA (AAMA)
time determination. Specimen tested in our lab. Results in MA signature

Case Study 29-1 Case Study 29-2

Refer to the scenario at the beginning of the chapter. Today is busier than usual at Drs. Lewis and King. While she
is performing an ESR for Jim Marshal, a patient in his late
CASE STUDY REVIEW 30s, medical assistant Audrey Jones is called on to help
with another patient. She hurriedly places the sedimenta-
1. What should Audrey do if the clinic buys a new tion rack on top of an incubator in the sunlight by an open
machine for laboratory analysis that she is not window and leaves to assist Dr. King.
familiar with?
2. How can Audrey be sure that she is using the CASE STUDY REVIEW
laboratory analyzers properly and that the patient
test results are accurate? 1. List two ways in which the test results may be
affected.
3. Who should Audrey consult if she has questions
about how to perform a test using an analyzer? 2. What are the normal Westergren ESR values
for male and female patients younger than 50
years?
3. What are the best conditions for an accurate
test?

SUMMARY
Hematology tests are the second most frequently performed tests in the ambulatory care setting. Only uri-
nalysis is performed more frequently. Medical assistants must have a knowledge of hematology to accurately
and efficiently perform the tests. The study of hematology includes hematopoiesis, which is the formation of
the blood elements, as well as the hematologic tests and their relation to the pathology of the body.
This chapter introduced the more common hematologic tests that are performed in the ambulatory
care setting, including all the parts of the CBC, the ESR methods, and the erythrocyte indices. All of these
tests are used by the provider in the diagnosis and treatment of disease.
Most of the hematology procedures performed in today’s ambulatory care setting use some type of
automated instrumentation. Some automated hematology instruments require a diluted blood sample,
whereas others do not. Both methods of automated instrumentation are discussed in this chapter.
Blood specimens used in the sampling of hematologic procedures are biohazardous material.
Be sure to follow Universal and Standard Precautions when you work with these specimens (see
Chapter 10).
 CHAPTER 29 Hematology 905

STUDY FOR SUCCESS

To reinforce your knowledge and skills of information presented in this chapter:
• Review the Key Terms
• Practice the Procedures
• Consider the Case Studies and discuss your conclusions
• Answer the Review Questions
• Multiple Choice
• Critical Thinking
• Navigate the Internet by completing the Web Activities
• Practice the StudyWARE activities on the CD
• Apply your knowledge in the Student Workbook activities
• Complete the Web Tutor sections
• View and discuss the DVD situations

REVIEW QUESTIONS
Multiple Choice 6. The erythrocyte indices are used for the diagnosis,
1. Which of the following is not a cellular component classification, and treatment of different:
of blood? a. infections
a. erythrocytes b. anemias
b. leukocytes c. inflammatory diseases
c. thrombocytes d. neoplasms
d. erythropoietin 7. Which hematologic test result shows an increase
2. The formation of blood cells is defined as: with infections, inflammatory disease, acute stress,
a. erythropoietin and tissue destruction?
b. hematopoiesis a. hemoglobin
c. mean corpuscular volume b. MCV
d. hemoglobinopathy c. hematocrit
3. Sickle cell anemia, a hereditary disease, has which d. ESR
type of hemoglobin? 8. The most frequent hemoglobin disease seen in the
a. hemoglobin S ambulatory care setting is:
b. hemoglobin A a. iron deficiency anemia
c. hemoglobin E b. sickle cell anemia
d. hemoglobin C c. leukemia
4. The volume of packed red cells compared with the d. anisocytosis
total volume of the sample is calculated for which 9. Which test within a CBC is within the scope of prac-
test? tice of a medical assistant under CLIA’s waived test
a. hematocrit category?
b. hemoglobin a. Using a HemoCue® to determine a hemoglobin
c. MCH level
d. MCV b. Using a hemacytometer to count WBCs manu-
5. The most common white cell type found in the ally
granulocytic series is the: c. Using the Unopette system to count RBCs man-
a. lymphocyte ually
b. monocyte d. Using an automated blood analyzer that requires
c. neutrophil calculations and mixing of reagents
d. basophil
906 UNIT 7 Laboratory Procedures

10. The highly sensitive C-reactive protein (hsCRP) test 4. How does aspirin interfere with clotting?
is used for detecting: 5. What test would have elevated results if a patient
a. any type of protein in the blood had systemic arthritis? Why?
b. vascular inflammation
c. very specific diseases such as lupus
d. anemia and leukemia
WEB ACTIVITIES
1. Visit the CDC’s Web site to review Standard
Critical Thinking Precautions required during blood
1. What hematologic factors do the erythrocyte indi- collection.
ces provide information about? List one example 2. Does the American Heart Association’s Web site
for each index in which a disease causes an eleva- offer parameters for different blood counts and
tion or decrease. hematology values? Are guidelines and tips on
2. You are serving your practicum in a local clinic. A specimen collection outlined?
provider has made a tentative diagnosis of appendi-
citis for a patient. In addition to the urinalysis, what
single hematologic test is most likely to confirm the
REFERENCE/BIBLIOGRAPHY
diagnosis? Walters, N. J., Estridge, B. H., & Reynolds, A. P. (2008).
3. List the guidelines that must be followed to ensure Basic medical laboratory techniques (5th ed.). Clifton
accurate sed rate results. Park, NY: Delmar Cengage Learning.

THE DVD HOOK-UP

This chapter discusses common hematologic procedures is important to make certain that test results are accurate.
that are performed in the medical office. What would you do if your controls do not match what is
The selected scenes in this program taught you how listed on the control bottle and the office supervisor tells
to perform a hematocrit, hemoglobin, and ESR test. you to ignore the control values?
Procedures will vary depending on the equipment used.
1. The selected clip for performing a hematocrit test
stated that you may test one or two tubes, depending
on equipment used and the policy of your office. Why
is it best to run two tubes when measuring a patient’s
hematocrit?
2. How can you make certain that you are performing DVD Series Program Number
Skills Based Series 11
waived tests when working in a waived laboratory?
3. What tube color should you use for hematologic test- Chapter/Scene Reference
ing? Is the ESR considered a hematologic test? • Administering Capillary Puncture and
Performing Hematocrit Test
• Performing Automated Hemoglobin
DVD Journal Summary • Performing ESR Test
Write a paragraph that summarizes what you learned from
watching the selected scenes from today’s DVD program. It
 Chapter

Urinalysis 30
KEY TERMS OUTLINE
Acid/Base Balance Urine Formation Urine Collection
Amorphous Filtration Urine Specimen Types
Bilirubin Reabsorption Collection Methods
Bilirubinuria Secretion Examination of Urine
Casts Urine Composition Physical Examination of Urine
Chain of Custody Safety Chemical Examination of
Circadian Rhythm Quality Control Urine
Creatinine Clinical Laboratory Improvement Microscopic Examination of
Amendments of 1988 Urine Sediment
Critical Values
(CLIA ’88) Urinalysis Report
Crystals
Urine Containers Drug Screening
Culture and
Sensitivity (C&S)
Cultures
Glucose OBJECTIVES
Glucosuria The student should strive to meet the following performance objectives and dem-
Hematuria onstrate an understanding of the facts and principles presented in this chapter
Hyaline through written and oral communication.
Ketoacidosis 1. Define the key terms as presented in the glossary.
Ketone
2. Explain the process of urine formation.
Ketonuria
3. Discuss the importance of safety procedures and quality control
Ketosis
when working with urine.
Leukocyte Esterase
4. Describe the importance of proper collection and preservation
Midstream Collection
of 24-hour urine specimens.
pH
5. Identify the proper technique for examining the physical charac-
Quality Control (QC)
teristics of a urine specimen.
Reagent
6. Explain pathologic and nonpathologic causes of abnormal physi-
Reagent Test Strip
cal characteristics of urine.
Refractometer
7. Describe methods for chemical examination of a urine speci-
Sediment
men.
Specific Gravity
8. Identify the proper method of preparing urine sediment for
Supernatant
microscopic examination.
Turbid
9. Identify normal and abnormal structures found during the
Urea
microscopic examination of urine sediment.
Urinalysis
Urinary Tract
Infection (UTI)
Urobilinogen

907
 Scenario
At Inner City Health Care, clinical medical assistant before collecting the urine sample, and she provides
Wanda Slawson performs many urinalyses. Although written instructions for easy reference. When she per-
urinalysis is a routine procedure, Wanda recognizes forms the urinalysis,Wanda follows safety and quality-
its importance as a diagnostic tool, and she performs control guidelines. By paying attention to the details
each test carefully to ensure accurate results. Wanda of the procedure, Wanda does her best to ensure the
takes time to instruct patients in the proper collection quality of the urinalysis results.
procedures. She encourages patients to ask questions

INTRODUCTION
Examination of the urine (urinalysis) as a diagnostic fluid volume, acidity and alkalinity (acid/base bal-
tool for many diseases has been performed for centuries ance), composition, and pressure.
by medical practitioners. Urinalysis refers to the study There are two kidneys, one on each side of
of urine as an aid in patient diagnosis or to follow the the body. They are about 11 to 12 cm long and 5
course of disease. The urine examination is a routine part to 6 cm wide. Kidneys are shaped like a lima bean
of most physical examinations. with their concave border directed toward the mid-
The routine urinalysis is one of the most frequently line of the body. The left kidney is slightly higher
performed procedures in the medical office laboratory. than the right.
Many tests can be performed on one urine sample. This
procedure is often ordered because urine is easily obtained,
and much information about the body’s metabolism may
Filtration
be gained from the results of this testing. The kidney filters waste products, salts, and excess
When providers order a “routine urinalysis,” they fluid from the blood. The filtering unit of the kid-
expect timely and accurate results. Results can indicate a ney is called the glomerulus. The part of the kidney
systemic disease process or renal (kidney) or urinary tract
disease.
Practice, experience, and attention to detail are the
most important tools in achieving quality results. Follow-
ing Standard Precautions when working with any body
Spotlight on Certification
fluid is mandatory. RMA Content Outline
• Anatomy and physiology
URINE FORMATION • Patient education
• Asepsis
Before discussing the analysis of urine, it is helpful • Laboratory procedures
to understand how urine is formed in the human
body. The formation and excretion of urine is the CMA (AAMA) Content Outline
principal way the body excretes water and gets rid • Systems, including structure, function,
of waste. These waste products, if not removed, related conditions and diseases
rapidly can become toxic. • Patient instruction
The kidney is a highly specialized organ that • Legislation
eliminates soluble (dissolved in water) waste prod- • Principles of infection control
ucts of metabolism. Urine is formed in the kidney • Collecting and processing specimens;
and is excreted from the body by way of the urinary diagnostic testing
tract system (Figure 30-1). The kidney also regulates
the fluid outside the cells of the body by eliminating CMAS Content Outline
certain fluids and returning other fluids, maintain- • Asepsis in the medical office
ing a careful balance (homeostasis). In this man- • Communication
ner, the body is protected from dramatic changes in
908
 CHAPTER 30 Urinalysis 909

To From Bowman’s capsule

inferior aorta Glomerulus
vena Proximal
cava convoluted
tubule
Afferent
arteriole
Cortex

Distal
Medulla Efferent
convoluted
arteriole
tubule

Left kidney
Right kidney Collecting Interlobular
Ureter tubule vein
Peritubular
capillaries
Henle’s loop
Descending (ascending
limb of loop limb)

Figure 30-2 Parts of the nephron, including the

Urinary bladder glomerulus.

Reabsorption
Urethra While passing through the kidney, some substances
may need to be reabsorbed by the blood. Approx-
imately 180 L of filtrate is produced daily by the
body, but only 1 to 2 L of urine is eliminated from
the normally functioning human body. Therefore,
Figure 30-1 The urinary system. much of the filtrate, including water, sodium, chlo-
ride, potassium, bicarbonate, glucose, calcium,
and amino acids, is reabsorbed into the body.
Under normal conditions, blood cells and most
that concentrates the filtered material is called the proteins stay in the blood plasma because they are
tubule. Together, the glomerulus and the tubule too large to pass through the walls of the capillaries
combine to form the nephron (Figure 30-2). of the glomerulus. If blood cells and excess protein
Most of the work of the kidney is done by the are found in the urine, the provider is alerted that
nephrons. There are approximately one million the kidney is not filtering properly due to an irregu-
nephrons in each kidney. Each minute, more than lar condition affecting the urinary tract.
1,000 mL of blood flows through the kidney to be As long as the concentration of glucose in the
cleansed. In the glomerulus, certain substances are blood is less than 180 mg/dL (milligrams per deci-
filtered out of the blood. The remaining filtrate liter), the glucose will be completely reabsorbed.
then passes into the tubule where various changes If the level increases to more than 180 mg/dL,
occur. Substances filtered out from the body can the glucose is not reabsorbed. Substances such as
include water, ammonia, electrolytes, glucose, glucose that are reabsorbed in relation to their
amino acids, creatinine, and urea. These wastes concentration in the blood are known as thresh-
leave the body in the eliminated urine. old substances. The needs of homeostasis call for
For example, when diabetics have excess sugar sugar and protein to be almost completely reab-
in their blood, the body attempts to eliminate the sorbed, whereas other threshold substances such
excess glucose through the urine. Routine urinaly- as creatinine, amino acids, potassium, sodium, and
sis testing will reveal the excess glucose, alerting chloride are only partially reabsorbed.
the provider to the presence of too much glucose.
In this manner, diabetes can be diagnosed, and it
can be determined that a patient with diabetes is
Secretion
not taking enough insulin to control the glucose Near the end of the blood’s journey through the
in the blood. kidney, specifically in the distal convoluted tubule,
910 UNIT 7 Laboratory Procedures

• Urine color can change

Critical Thinking • Urine appearance can vary
1. What are the three actions that take place • Urine odor can change
in the formation of urine? • Cells can be present in urine
2. Why do you suppose we test for sugar in • Chemical constituents in urine can change
urine but not salt/sodium? • Urine concentration (specific gravity) may vary

other substances that have not already been fil- SAFETY

tered are secreted into the urine. Such substances
as hydrogen and ammonium ions may be secreted Chapter 26 discusses the guidelines set
into the urine in exchange for sodium. Cer- up by government agencies to ensure the
tain drugs in the blood at this point may also be safety of everyone working in the health
secreted into the urine. care field and for the protection of our environ-
ment. These guidelines are now referred to as Stan-
dard Precautions. Other terms used to describe care
URINE COMPOSITION when handling infectious materials are Transmis-
sion-Based Precautions and biohazard precautions.
After urine progresses through a healthy kidney, it
is approximately 96% water and 4% dissolved sub-
stances, most of which come from either dietary QUALITY CONTROL
intake or metabolic waste products. These sub-
stances are primarily urea, salt, sulfates, and phos- As in every area of the laboratory, every effort must
phates. Abnormal constituents of urine include be made by health care professionals to produce
red and white blood cells, fat, glucose, casts, bile, test results free from error. Much pressure is placed
acetone, and hemoglobin (Table 30-1). by regulatory agencies on facilities that perform lab-
When certain disease processes occur in the oratory tests such as urinalysis to maintain standards
human body, the following changes in urine pro- that will ensure reliable results. Quality control
duction and composition can occur: (QC) programs are an important part of urine test-
• The amount of urine excreted can increase or ing to ensure accurate and reliable results for the
decrease patient. QC programs must be incorporated into
every urine testing procedure. Because many of the
tests are interpreted by visual examination, the QC
Table 30-1 Normal and Abnormal procedures are dependent on the expertise of the
Substances in Urine person performing the examination.
Testing protocols must be written out and
Normal Abnormal available to personnel. Records of testing must

Urea Bile
Precautions To Use When Handling
Uric acid Blood
Urine Specimens
Creatinine Fat • Treat all specimens as if they were infectious, handling
them with gloved hands.
Sodium Glucose • Avoid splashes or creation of aerosols when handling or
disposing of urine specimens. Wearing face shields will
Potassium Protein prevent splashes from getting into the eyes, nose, or mouth.
• Process urine specimens as soon as possible.
Ammonium White blood cells
• Store urine specimens appropriately in a designated refrig-
erator that contains no food or drink items.
Sulfate Urobilinogen
• Dispose of urine appropriately, possibly in a designated sink
(run water to wash the specimen into the drain) or toilet.
Chloride Microorganisms (bacteria, parasites)
 CHAPTER 30 Urinalysis 911

be maintained. Equipment and instruments used

for urine testing must be maintained and checked Critical Thinking
daily for proper calibration. If the instrument
should require recalibration, the manufacturer’s 1. Is there any test that can be performed on
instructions are provided with the instrument. urine that is not in a sterile container?
Always be careful to perform the QC pro- 2. If a patient brings in a urine specimen
cedures exactly as you perform the procedures from home in a clean baby food jar, can
on actual patient samples. Documentation of it be used for any testing or any part of a
the performance of daily control testing must be urinalysis?
kept for at least 3 years. With computer storage,
the data can be stored indefinitely. Commercially
available urine control samples can be purchased
from a number of manufacturers. Positive and take the opportunity to view the slide and discuss
negative controls should be run each day on all the finding with the provider as part of professional
tests to be performed. Control results should be development and continued education.
recorded on a daily log for easy access. The con-
trol samples should be stored as directed by the
manufacturer. URINE CONTAINERS
The first step toward achieving proper results dur-
CLINICAL LABORATORY ing laboratory testing is proper collection of the
specimen to be tested. There are a variety of contain-
IMPROVEMENT AMENDMENTS ers (Figure 30-3) used for urine collection, includ-
OF 1988 (CLIA ’88) ing nonsterile containers for random specimens
(urinalysis), sterile containers for cultures (testing
The regulations under the new CLIA are specimens for growth of bacteria), and 24-hour col-
discussed in Chapter 26. Several CLIA ’88 lection containers with added preservatives.
regulations apply to the medical assistant Just before handing the urine specimen cup
performing urine testing. They include: to the patient, label the cup with the patient’s
name, the date, and the time. Some facilities
• Appropriate training in the methodology of the require more information, so follow the protocol
test being performed of your facility. Always use a permanent marker so
• Understanding of urine-testing QC procedures the information stays clear. Always label the cup,
• Proficiency in the use of instrumentation, being not the lid. This practice ensures that the speci-
able to troubleshoot problems men will not be separated from the label if the lid is
• Knowledge of the stability and proper storage of removed. If the patient is unable to procure a spec-
reagents (substances involved in urine testing) imen, discard the cup and give the patient a new
cup if the patient is later able to give a specimen.
• Awareness of factors that influence test results
• Knowledge of how to verify test results
• The microscopic examination of urine is designated
by CLIA to be a PPMP (provider-performed micros-
copy procedure) and therefore must be performed
by a provider. The medical assistant is trained and
able to prepare the slide for viewing and reading by
the provider. The medical assistant should always

Critical Thinking
1. What criteria does CLIA use to determine
which tests are in each category?
2. In a urinalysis, which part is not in CLIA’s
waived category? Figure 30-3 Urine collection containers should be
calibrated, clear, and have a secure lid.
912 UNIT 7 Laboratory Procedures

When using electronic medical records, viders may require an overnight fast. Others may
E HR computer-generated labels can be ask the patient to have a meal and then urinate
four hours later.
printed. One label can be applied
to the cup and other labels used for additional It is up to the medical assistant to give the
tests ordered, if appropriate. An example of an patient proper instruction as to how to collect a
additional lab test is a culture and sensitivity of the fasting, or timed, specimen. Written directions
urine as explained later in this chapter. given to the patient in addition to oral instructions
Occasionally, a patient will bring a sample are best. A regular urinalysis container can be used
with him or her in a generic container from home. for a fasting specimen. It does not require a sterile
General recommendations are to provide the container.
patient with a new urine specimen cup and request
a fresh sample. The exception to this rule would Twenty-Four-Hour Specimen. Urine varies in its
be if the patient has brought a “first morning void” concentration of certain substances at different
specimen in an appropriate container. times during any 24-hour period because of circa-
dian rhythm and the intake of food and water. For
instance, the amount of water excreted is greatest
URINE COLLECTION from 10 am to noon and 4 to 6 pm. Chloride is in its
highest concentration from noon to 2 pm. There-
fore, a 24-hour specimen is sometimes requested
Urine Specimen Types when quantitative tests (measuring the amount)
Patients may have questions about how a specimen for different substances are desired. The results
should be collected. The medical assistant must of this type of collection then will be expressed
be able to give proper instructions using common in units per 24 hours. Some commonly tested sub-
terms that the patient will be able to understand. stances include sodium, potassium, calcium, and
Following are common types of urine specimens creatinine.
that might be ordered frequently by providers. The container used to collect this amount of
urine should be of adequate size. Usually a one-
Random (Spot) Specimen. Random (spot) urine gallon, dark-colored plastic bottle is used. For
samples are specimens that can be obtained at any measuring urine constituents, preservatives need
time and are the most common collection per- to be added to the bottle before the collection
formed in the outpatient setting. Random simply begins. Without the preservative, these substances
means that there is no particular time placed on the may break down and be impossible to quantify.
collection. Patients are requested to give a specimen Preservatives include thymol, toluene, and cer-
whenever they are present for their appointment. If tain acids.
the patient has already voided, not knowing a speci- Urine collected over a 24-hour period may be
men would be required, the medical assistant may refrigerated between collections. After the collec-
offer the patient several cups of water in an attempt tion is complete, it must be returned to the medi-
to procure another specimen. Because the kidneys cal laboratory as soon as possible.
constantly produce urine, the patient should be Many 24-hour urine bottles contain pre-
able to provide another specimen within 15 to 20 servatives. Some preservatives are strong
minutes of drinking several cups of water. acids or bases. As with all laboratory
chemicals, the medical assistant and the patient
First Morning Void Specimen. The first morning should avoid contact between the preservative
void is typically the most concentrated specimen and the skin. The urine specimen should be col-
and has a higher acid pH (which helps preserve lected into a smaller container and then poured
the cellular components). It is preferred, but carefully into the main container. Vapors must not
because it is less convenient, it is seldom ordered be inhaled when adding the specimen to the con-
unless the patient is an inpatient or is in a con- tainer. The patient’s written instructions should
trolled setting. contain a warning about avoiding contact with pre-
servatives.
Fasting/Timed Specimens. A fasting (going with- Providers sometimes choose to have a 2-hour
out food and drink except water) urine specimen or a 12-hour specimen instead of the usual 24-
is ordered less often than a random specimen. The hour collection. All of the collection steps for a 24-
provider may want to measure a urinary substance hour specimen apply. Recording the time of day is
without interference from food intake. Some pro- important.
 CHAPTER 30 Urinalysis 913

Collection Methods
In addition to ordering the type of urine speci-
Patient Education
men desired (random, fasting, 24-hour), the pro- 24-Hour Urine Collection
vider might also order a certain type of collection
method to collect the specific sample. These meth- 1. When giving a patient any type of
ods include clean-catch midstream and catheter- instructions, make sure that the patient
ized collection. understands the importance of each
step. Always provide written instructions
Clean-Catch Midstream Collection. To avoid as well. Emphasize that failing to follow
as much contamination as possible when collect- the instructions will cause the results to be
ing a specimen, providers prefer that the patient invalid, requiring another collection.
cleanse the genital area before collection. The 2. The patient begins a 24-hour collection by
clean-catch order means that cleansing towelettes emptying the bladder and not keeping the
are provided in addition to a urine container. Male specimen. The container is then labeled
patients are directed to cleanse the urethral open- with the time of bladder emptying. Patients
ing twice with cleansing towelettes, and female generally start the collection between
patients are directed to cleanse the urethral area 6 and 8 PM, but any 24-hour period is
with three swipes, using three separate towelettes. acceptable.
(See Patient Education box and Procedure 30-7
for complete instructions.) Female patients should 3. Explain that each time the patient urinates
also be instructed to notify the medical assistant if within the 24-hour period, the urine is
they are menstruating during the collection. transferred into the collection container.
After cleansing, the patient should begin to 4. Instruct the patient to refrigerate the
urinate into the toilet. The patient begins urinat- container between urinations if required.
ing, pulls the cup into the urine stream and col- 5. Explain that at the end of the 24-hour
lects the sample, then removes the cup from the period, the patient should urinate and
stream and voids the rest of the urine into the toi- transfer the urine into the container. The
let. This is called a midstream specimen. The mid- exact time should be written on the label
stream urine should be as free of contamination as as the “ended” or “completed” time.
possible. 6. The most common errors in the 24-hour
urine specimen collection are the inclusion
Catheterized Collection. Urinary catheterization of the first voided specimen and the
involves insertion of a sterile flexible tube into the discarding of one or more of the voided
urinary bladder through the urethra. Although specimens during the 24-hour period. Be
urinary catheterization is performed for many rea- sure the patient understands these steps.
sons, this section discusses only the use of cathe-
terization as a way to obtain a urinary sample (see
Procedures 18-2 and 18-3).
Obtaining a urine specimen by catheteriza- introduced into the patient’s bladder, which can
tion is required when a completely sterile speci- cause a bladder infection.
men is needed or when the patient is unable to
follow cleansing instructions. The patient may not Culture and Sensitivity of Urine. Occasionally, the
understand the language, may be mentally unable provider orders a culture and sensitivity (C&S) of
to comprehend the instructions, or may be physi- a urine specimen. The medical assistant is respon-
cally unable to perform the process. It is the medi- sible for preparing the sample for transport. A
cal assistant’s responsibility to determine if the commonly used system is the Urine Culture and
patient understands the instructions for obtaining Sensitivity Transport kit (see Procedure 30-6).
a clean-catch midstream urine sample and is able
to perform the process.
Catheterization is a sterile procedure and EXAMINATION OF URINE
is only performed under a provider’s order and
only by health care professionals who have been Urine should be examined in a fresh state, prefer-
adequately trained. Because the urinary bladder is ably while still warm if possible. However, on rare
considered a sterile environment, if the catheter- occasion the urine sample cannot be tested imme-
ization is not performed properly, bacteria may be diately. If immediate testing is not possible, the
914 UNIT 7 Laboratory Procedures

urine should be refrigerated at about 4°C (39°F) or tals and casts begin to break down after 2 hours.
stored on ice. The urinalysis should be performed Any time delay allows bacteria to multiply and can
as soon as possible, preferably within 2 hours. Crys- lead to inaccurate microbiology results.

Patient Education
Clean-Catch, Midstream Urine Specimen Collection Instructions
1. The patient should be provided with a clean or sterile covered urine cup, a pair of gloves, and
adequate cleansing towelettes (three for female patients, two for male patients). The cup should
be labeled with the patient’s name and the date. Caution the patient not to contaminate the
inside of the cup. A shelf near the toilet is extremely helpful for patients, allowing them to have the
towelettes and cup within reach during collection of the specimen.
2. Instruct the patient in proper cleansing of the genital area. It is best to give the patient written
instructions as well. Men and women should have separate instructions. The written instructions
should be posted next to the toilet for reference by the patient during the procedure. Logically,
the female instructions should be posted on the wall beside the toilet at reading level while she is
sitting, and the male instructions should be posted on the wall behind the toilet at reading level
while he is standing. Laminating the instruction documents protects the writing from any sprays or
splashes.
• Men: After thoroughly washing his hands, the male patient should retract the foreskin on the
penis (if not circumcised). A cleansing towelette should be used to cleanse the urethral
opening with a single stroke directed from the tip of the penis toward the ring of the glans. The
cleansing procedure should be repeated again using a new towelette.
• Women: After thoroughly washing her hands, the female patient should position herself
comfortably on the toilet seat and spread her knees as far apart as she can. She should spread
the outer vulval folds and hold them open with one hand. With the other hand, using the first
towelette, the patient should cleanse on one side from front to back with one swipe, disposing
of the towelette into the toilet. With the second towelette, she should wipe on the other side front
to back with one swipe, disposing of that towelette into the toilet. While still holding the vulval
folds open, she should use the third towelette to wipe the urethral opening front to back with
one swipe. She may dispose of that towelette into the toilet, too. She should continue to hold the
vulval folds open until she has completed the collection of the urine specimen.
3. Instruct the patient also about the midstream collection technique. Explain why it is necessary.
These instructions should also be written and included with the clean-catch written directions.
• After cleansing the area using the clean-catch directions, the patient should begin to void
into the toilet. The specimen cup should then be held into the stream until it is about half full,
then the cup should be removed from the stream. Assure the patient that urinalysis can be
performed on a small amount of urine if they are unable to give half a cup. The patient may
finish urinating into the toilet. Only the middle portion of the urine flow is included in the sample.
After the specimen has been collected, the container should be capped. After securely
capping the urine cup, the patient may cleanse the outside of the cup if desired. The patient
should always avoid touching the inside of both the container and the lid.
4. The patient should be instructed on where/how to return the specimen to the medical assistant.
Some physicians’ office laboratories (POLs) have a special shelf with a small door opening into the
laboratory, whereas other offices prefer the patient actually hand the specimen to the medical
assistant directly. Either way, the specimen should be taken immediately into the laboratory by the
medical assistant.
5. All surface areas in the restroom should be immediately decontaminated in preparation for the
next patient.
 CHAPTER 30 Urinalysis 915

The routine urinalysis procedure is composed bladder infection, is requested, then a full test tube
of three parts: is needed as well as some extra urine for a culture.
These tests are thoroughly discussed later in this
• Physical examination of the urine chapter.
• Chemical examination of the urine The provider should be consulted for further
• Microscopic examination of urine sediment direction if the amount of urine submitted is less
than needed for the complete urinalysis. The uri-
The medical assistant should wash hands, nalysis report should reflect that the quantity was
put on gloves, and follow all the safety not sufficient for complete testing. The medical
guidelines when performing any of the fol- assistant should write “QNS” (quantity not suffi-
lowing procedures. Some facilities require eye cient) where applicable or follow clinic protocol.
protection when pouring urine or performing If the patient is able to give less than 10 mL of
any procedure where splashing of urine into the urine for the test tube, the medical assistant should
eye could occur. All surface areas in the restroom make a note of the amount of urine used. For
should be decontaminated immediately after pro- example, if the patient provides 5 mL, the medical
curing or testing urine specimens. assistant may go ahead with the microscopic exam-
ination of urine but should note on the report that
Physical Examination of Urine the specimen was only 5 mL. The rationale for this
notation becomes clear when you understand that
When the medical assistant begins the process of the amount of a substance found in 10 mL of urine
performing a urinalysis, the first step is perform- will be less in a smaller sample. In other words, if
ing the physical examination. This examination the patient has five white blood cells in 10 mL of
consists of: urine, he or she might only have two to three white
blood cells in 5 mL of urine. Unless the notation
• Assessing the volume of the urine specimen, mak- is made that the sample was smaller, the provider
ing sure that the amount is sufficient for testing may diagnose incorrectly.
• Observing and recording the color, appearance, Most clinics/POLs do not require that the
and transparency of the specimen urine volume be noted unless it is less than ade-
• Noting any unusual urine odor quate for a complete urinalysis.
• Measuring the specific gravity of the specimen
Urine Color. There is a wide range of color in nor-
Procedure 30-1 describes how to assess the mal urine, usually ranging from a pale yellow to
volume, color, appearance, transparency, and odor a dark yellow or amber (Figure 30-4). The range
of urine. Procedure 30-2 discribes testing for the of color usually is the result of the concentration
specific gravity. of the urine. A darker color generally indicates
a more concentrated urine. The color of urine
Specimen Volume. The first step in performing a
urinalysis is to determine if the sample’s volume is
adequate for testing.
The medical assistant must have enough
urine to fill a test tube with at least 10 mL (about
two teaspoons) of urine with enough leftover in
the specimen cup to completely insert and wet a
chemical reagent strip and to culture if ordered.
The volume usually requested of the patient is
a half cup, but patients should be assured that sam-
ples of much less volume can be tested. If the patient
is only able to submit a small volume of urine, which
tests can be performed are determined, depending
on the priority set by the provider according to the
patient’s suspected diagnosis. For example, if only a
test for protein and glucose is requested, then only Figure 30-4 Normal urine can range in color from
enough urine to process the chemical reagent strip straw and yellow, to amber. Abnormal urine (depend-
portion is needed. However, if a test for microscopic ing on it constituents) can be red, brown, fluorescent
examination of the urine, such as to diagnose a orange, and more.
916 UNIT 7 Laboratory Procedures

comes from normal metabolic processes, the end be contributed to contamination from vaginal dis-
products of which are deposited in the urine. charges, white blood cells, bacteria, or yeast. As
After assessing the adequacy of the urine urine cools, sometimes crystals form that may give
volume, the medical assistant then observes and urine a cloudy appearance.
records the color of the urine (see Procedure 30-1).
The diet and certain drugs can add sub- Urine Odor. With experience, the medical assistant
stances to the urine that give it a specific color. The will recognize certain odors in the urine that can
medical assistant should be familiar with common indicate specific conditions. Odors, though not
reasons for abnormally colored urine and whether recorded on the final laboratory urinalysis report,
they are pathologic (due to a disease process) or should not be disregarded. For example, the
nonpathologic abnormalities. For example, the urine of a diabetic patient who may have a condi-
most common pathologic cause of red urine is the tion known as ketoacidosis may have a sweet odor.
presence of red blood cells, known as hematuria. Urine full of bacteria will have a foul odor that is
Red blood cells in urine may indicate bleeding in easily recognized.
the urinary tract either because of a bladder infec-
tion or a kidney stone. A nonpathologic example Urine Specific Gravity. Specific gravity is defined
of abnormally colored urine is the medication as the ratio of the weight of a given volume of a sub-
phenazopyridine (Pyridium), which can turn the stance to the weight of the same volume of distilled
urine bright orange. Table 30-2 lists several urine water at the same temperature. Distilled water used
color variations and possible causes. as the reference point has been given the specific
gravity value of 1.000. The specific gravity of urine
Urine Transparency. In order to assess transpar- indicates the concentrations of solids such as phos-
ency, the urine should be viewed through a clear phates, chlorides, proteins, sugars, and urea that
cup or tube. Urine is considered clear if a line are dissolved in urine.
of print can be read through it. Urine transpar- Variations in urine specific gravity can give the
ency normally is not significant by itself. However, provider diagnostic information. In uncontrolled
it may be helpful when included with the rest of diabetes, glucose in released into the patient’s
the urinalysis information. Transparency of urine urine. Glucose molecules are dense and may give
usually is recorded as clear, cloudy, hazy, or tur- the urine a high specific gravity. Another reason
bid (opaque) (Procedure 30-1). These descriptive for high specific gravity readings is dehydration,
terms may vary in different facilities. because less fluid is being released by the body in
There are many causes of cloudy urine, most relation to whatever chemicals are in the urine. The
of which are considered normal. Cloudiness could color of this urine will also probably be darker. In
a well-hydrated patient, the specific gravity is low,
meaning that the urine is mostly water. The normal
Table 30-2 Urine Colors and Possible Causes range of specific gravity for urine is from 1.005 to
1.030. Specific gravity is highest in the first morning
Color Possible Cause samples because the urine is more concentrated.
Specific gravity is often tested by using either
Straw to yellow Normal
a test strip, urinometer, or refractometer. A uri-
Orange to amber Concentrated urine nometer is a calibrated, floating device. A refrac-
tometer measures the amount of light that is bent
Colorless Dilute urine by particles suspended in a liquid. A specific gravity
reading is also available in conjunction with chem-
Deep yellow Vitamin intake
ical testing on some reagent strips. The urinom-
Drugs, usually eter is the least accurate method and perhaps the
Bright orange most difficult; therefore, it is being replaced by the
phenazopyridine (Pyridium)
refractometer or reagent test strips in most POLs.
Orange-brown Urobilin

Greenish orange Bilirubin

Urinometer. A urinometer is made from a small
glass tube weighted to float in a sample of urine
Smokey Red blood cells (usually 15 mL). The glass tube has been cali-
brated, and the stem of the tube has been marked
Wine red/reddish brown Hemoglobin pigments accordingly to read 1.000 at the bottom of the
Green or blue Methylene blue
meniscus in distilled water at room temperature.
The meniscus is the curvature that appears in a
 CHAPTER 30 Urinalysis 917

liquid’s upper surface when the liquid is placed ability. This instrument only needs a drop or two of
in a container. The medical assistant reads the urine, and the result does not have to be adjusted
specific gravity of the urine from the stem at the for temperature as long as the temperature is
meniscus. However, the temperature of the urine between 60° and 100°F (see Procedure 30-2).
must be taken into account if it differs from 70°F,
which is normal room temperature. The buoyancy Reagent Test Strips. Reagent test strips that
of a liquid changes with the temperature. If the include specific gravity are available through many
urine is allowed to come to room temperature, the medical laboratory supply companies. Look for
medical assistant risks the physical and chemical SG in the name, such as brands MultiStix 10 SG
changes that can occur to urine when left for more or Chemstrip 10 SG (the “10” designates there are
than 20 minutes. It is because of these and other 10 tests included on those particular test strips).
conflicting processes (such as human error) that Keep in mind that the more tests available on the
the urinometer is not recommended as the best reagent test strips, the more expensive the product
option for measuring the weight (specific gravity) will be.
of urine.

Refractometer. The most common tool for

Chemical Examination of Urine
determining the specific gravity of liquids is the After the physical testing of a urine specimen, the
refractometer (Figures 30-5A and B). This instru- next step in urinalysis testing is chemical testing.
ment measures the refractive index of urine, which This procedure once was complex, but today many
is the speed at which light travels through the manufacturers have made the task simple through
air as compared with the speed at which it passes a wide range of ready-to-use reagents and the
through urine. Light is slowed, and therefore bent, reagent test strip (Figure 30-6).
as it encounters particles—the more particles, the A reagent test strip is a narrow strip of plas-
more bend. The bend can be used to determine tic on which pads containing reagents for differ-
the total number of particles and is not affected by ent reactions are attached. The pads have reagents
the weight of the particles. to test for many metabolic processes, including
The refractometer reading is about 0.002 less kidney and liver functions, urinary tract infection
than that of the true specific gravity. This slight (UTI), and pH balance. The reagent test strip is
difference is more than made up for by the ease the primary tool used for chemical examination of
of using the instrument and the instrument’s reli- urine. Specific confirmatory tests or methods may

320
310
15
300
290
14
280
270
13
260
250
12
240
230
11
220
210
10
SERUM OR PLASMA 200
PROTEIN 190
9
GMS/100 ml 180
T/C 8
170
PR/N RATIO 6.54 160
150
7
140
130 REFRACTION
6
1.035 120 (N-No) ⫻ 104

1.030
5
110
T/C
100
90
1.025 4
80
URINE 70
1.020 3
SPECIFIC GRAVITY
60
T/C 1.015 50
40
1.010
30

1.005 20
10
1.000 0

A B
Figure 30-5 (A) Refractometers. (B) Specific gravity as viewed through a refractometer.
918 UNIT 7 Laboratory Procedures

ing is required before a diagnosis of diabetes can

be made.
• pH is the abbreviation for potential hydrogen ion
concentration. The pH test determines if the urine
is alkaline or acidic. The scale for pH runs from 0
for the most acidic to 14 for the most alkaline or
base. Neutral pH, of course, is 7. The pH of urine
varies from 4.5 to 8. The kidneys and lungs are
responsible for helping the blood stay at its perfect
pH (7.35 to 7.45). The kidneys do this by adjust-
Figure 30-6 Chemical reagent test strips with color- ing the substances they secrete. A person can die
coded chart. if the blood is too acidic (acidosis) or too alkaline
(alkalosis). Because there is so little room for devi-
ation in the pH of blood, the kidneys and lungs are
be necessary based on the result of the reagent test constantly adjusting secretions. Many things affect
strip. Table 30-3 lists some tests available on urine the pH of the urine, from medication and diets
reagent strips. to pathological conditions. Diets high in protein,
some medications, renal tuberculosis, high fevers,
Specific Reagent Test Strips. Glucose is the sugar and uncontrolled diabetes can cause acidic urine,
most commonly found in urine. Glycosuria and whereas alkaline urine can be caused by diets high
glucosuria both are terms that describe the condi- in vegetables, citrus fruits, dairy products, some
tion of having glucose in urine. Sugar is normally medications, and UTIs. Letting a urine specimen
filtered out of urine in the glomerulus of the kid- sit at room temperature for too long can cause a
ney and is reabsorbed in the renal tubules. If the false high-pH reading.
body has too much glucose in the blood, the extra
• Protein (albumin) may be secreted in very small
will not be reabsorbed and instead will “spill” into
(trace) amounts by the kidneys. The presence of
the urine. Reagent test strips are embedded with
protein in urine (proteinuria) occasionally has a
an enzyme called glucose oxidase, which detects
nonpathological basis such as excessive exercise,
glucose. Of course the first pathological condition
exposure to extreme heat or cold, or acute emo-
we think of for glucosuria is diabetes, but other
tional stress. Any substantial and/or consistent
nonpathological conditions can cause some glu-
presence of protein in urine is of concern for
cose to spill into the urine. Glucose is stored by
renal disease. Proteins are large compounds and
the liver and used for energy. Although unusual,
can only get through the filtering system (glom-
conditions such as extreme physical or emotional
erulus) of the kidney if there has been damage
stress can cause the liver to put a lot of glucose into
to the glomeruli. Think of a volleyball net that a
the blood. Eating an unusual amount of sugar can
small golf ball could pass through but not a larger
also cause high amounts of glucose in the blood
basketball, unless there are holes (damage) to the
and either of these conditions can cause excess
net. Damage can be caused by many things: dis-
glucose to be lost in the urine. These nonpatho-
eases, toxins, or systemic conditions, such as diabe-
logical causes are some of the reasons further test-
tes and uncontrolled hypertension. Any condition
that causes the blood pressure to increase in the
nephron can also cause damage to the glomeruli.
Table 30-3 Chemical Testing Available on A false high-protein reading can occur when large
Urine Reagent Test Strips
amounts of WBCs, RBCs, epithelial cells, or bacte-
ria are present in the urine. When these four types
pH Blood
of cells rupture in urine, they can release protein,
causing a false-positive reading. It is important to
Protein Urobilinogen
note, too, that any protein reading in dilute urine
is of concern because a normal SG in the same
Glucose Nitrite
patient would show a much higher level of protein-
uria. Thus, it is important to look at the SG of the
Ketones Leukocyte esterase
specimen whenever protein is found in urine.
Bilirubin Specific gravity • Ketones are formed whenever the body uses fat/
fatty acids for energy rather than carbohydrates/
 CHAPTER 30 Urinalysis 919

sugars. This can happen whenever there is a low infection [UTI]), irritation of the urinary tract from
intake of carbohydrates/sugars such as in dieting a kidney stone, or, rarely, a neoplasm. Many chemi-
and in certain metabolic disorders such as diabe- cal reagent test strips differentiate between hemo-
tes. In diabetes, the body lacks insulin or is unable globin and intact red blood cells. Hemoglobin
to use sugar properly for energy, so it uses fatty in urine is called hemoglobinuria and can indicate
acids. Insulin is a chemical that helps the body use pathogenic conditions such as severe infectious
sugar for energy, so some diabetics replace their diseases, transfusion reactions, and hemolytic ane-
insulin. As fats are broken down, ketone bodies mias. A nonpathogenic cause of hemoglobinuria
form and “spill” into the urine. The presence of occurs when the urine is allowed to sit too long, so
ketones in urine is called ketonuria. The burning any RBCs present start breaking down, thus releas-
of fats for energy is called ketosis or sometimes lipoly- ing their hemoglobin. Sometimes the chemical
sis. Persons on carbohydrate-careful diets often use reagent test strips indicate the presence of blood
chemical reagent test strips to check if their urine in the urine, but no blood cells are seen during the
contains ketones, thus indicating that their bodies microscopic examination. This is an example of
are burning fats. Ketosis should not be confused hemoglobin being present rather than the intact
with ketoacidosis, which is a dangerous condition RBCs. The presence of blood in urine is combined
for diabetics and alcoholics. with the patient symptoms and other tests to arrive
• Bilirubin is a yellow-orange substance that comes at a diagnosis.
from the breakdown of hemoglobin. Hemoglobin • Urobilinogen is a substance formed when bacteria
is contained within the red blood cells. Because in the digestive tract breaks down bilirubin. A very
individual RBCs live for only 120 days, they are con- small percentage is excreted in the urine and is
stantly breaking down and being replaced. When increased in liver disease. Urobilinogen gives color
the RBCs “die,” the “heme” part of the hemoglobin to feces.
circulates in the blood until the liver filters it out. • Nitrite forms in urine when certain pathogenic bac-
The liver is responsible for changing the heme into teria are present. These specific bacteria convert
a water-soluble substance called bilirubin. Before it normal nitrate in urine to abnormal nitrite; thus,
gets to the liver, it is called “indirect” or “free” biliru- nitrite in urine is always indicative of the presence
bin. After it leaves the liver, it is called direct or con- of these pathogenic bacteria in sufficient quanti-
jugated bilirubin. The liver sends the conjugated ties to cause a bladder infection. Whenever nitrite
bilirubin to the gall bladder where it is released with is positive in a urine sample, white blood cells, bac-
bile into the small intestine. When there is a block- teria, and often red blood cells also will be seen.
age in the liver or gall bladder ducts or when there The provider often orders a urine culture to deter-
is a disorder or disease of the liver, the bilirubin can- mine the type of bacteria and the best medication
not get past the gall bladder to the small intestine, to eradicate it.
so it continues to circulate in the blood. This excess • Leukocytes are white blood cells. They may be either
of bilirubin in the blood can lead to yellow-orange granulocytes or agranulocytes. Either type can fight
skin called jaundice. The body will try to get rid of urinary tract infectious bacteria, and either type
extra bilirubin through the urine. Hence, any detec- may be present in infected urine. You will learn
tion of bilirubin in the urine (bilirubinuria) can more about specific WBCs in another chapter. The
be indicative of a problem in the liver and/or gall chemical reagent test strips will only detect esterase
bladder. Newborn babies can be jaundiced because from granulocytes and will not detect the presence
their systems are not mature enough to rid the bile. of agranulocytes, so a microscopic examination is
Because bilirubin breaks down in sunlight, we treat still important as well as a urine culture and sensitiv-
jaundiced babies with special “bili-lights” to help ity. These results along with the patient’s symptoms
them break down the bilirubin in their skin. Know- will help the provider diagnose and treat the UTI.
ing that bilirubin is so unstable, we need to protect
• Specific gravity (SG) has been discussed previously
it from light in our urine samples, another good
in this chapter and is available as a test option on
reason to test urine samples immediately. Keep in
many brands of chemical reagent test strips. The
mind that further testing is required before a diag-
normal SG for urine is between 1.005 (very dilute
nosis can be made, because bilirubinuria is a symp-
urine) to 1.030 (concentrated urine).
tom, not a disease.
• Blood in urine is called hematuria. If the blood in the
urine is not from a nonpathogenic source, such as Reagent Test Strip Quality Control. Reagent
a contaminate from menstruation, it is indicative test strips are easy to use, but the complexity of the
of a bladder infection (often called a urinary tract chemical testing should not be overlooked. As with
920 UNIT 7 Laboratory Procedures

any chemical reaction, each test involves multiple test strip container. Employees performing this test
steps that are sensitive to temperature, time, dilu- should be tested for color blindness as many of the
tion, and other factors. Outdated strips or reagents color changes are subtle.
should never be used, so be sure to check the expi- Reagent test strips are ready to use directly
ration date every time. To get optimum results, a from their container. Correct QC procedures
certain amount of care must be taken when han- should be followed as required by CLIA ’88 and
dling and storing the reagent strips. They must not the facility where the testing is performed. This
be exposed to moisture, volatile substances, direct usually includes using a QC urine sample (with
sunlight, or excess heat. The strips should not be predetermined results). All that is needed for this
removed from their original container except at testing are the strips, QC specimen, and patient
the time of use. Always follow the manufacturer’s specimens. Procedure 30-5 explains how to per-
instructions for storage. Test results are repre- form a urinalysis chemical examination.
sented by a color change. The test result is com- Automated urine analyzers (Figure 30-7)
pared with a color chart on the label of the reagent capable of timing and reading the test strip are

A B

C D

Figure 30-7 Automated urine analyzers are used frequently because of their accuracy. (A) The reagent strip is
immersed in the urine specimen and then tapped lightly on a paper towel to remove excess urine. (B) The strip is
placed into the machine. (C, D) The test is selected, and the machine pulls the strip into the machine to be ana-
lyzed.
 CHAPTER 30 Urinalysis 921

Table 30-4 Reagent Strip Sensitivity

Normal
Test Range Value

pH 5–9 5–8

Protein Negative to positive* Negative

Negative to Negative
Glucose
⬎1,000 mg/dL

Negative to Negative
Ketone
⬎80 mg/dL

Bilirubin Negative to large Negative

Blood Negative to large Negative

Leukocyte Negative to large Negative

esterase

Nitrites Negative to positive Negative

E
Urobilinogen 0.2–8.0 mg/dL 2.0 mg/dL
Figure 30-7 (continued) (E) Results are printed
from the machine. Specific gravity 1.000–1.035 Varies greatly

*Note that positive results in a newborn for glucose, ketone,

available. These instruments can be expensive and protein are considered critical values and should be
and are not available in small laboratories. Cur- reported to the provider immediately.
rently, automated urine analyzers are used more
frequently because they are more accurate and
reduce human error. must be able to properly centrifuge the specimen
When reporting results, it is important to use and set up a slide of the urine sediment for the
the proper units and terms as directed by your provider to examine. It is recommended that the
laboratory. An example of the sensitivity of the medical assistant have a working knowledge of all
reagent strips is shown in Table 30-4 (there is varia- urine sediment, the pathologic significance of the
tion in sensitivity among manufacturers). components, and how to report the presence of
sediment components. The sediment (insoluble
Microscopic Examination material) at the bottom of the centrifuge tube is
used for the microscopic examination (see Chap-
of Urine Sediment ter 27 for proper use of the microscope). The
In addition to the physical and chemical examina- microscopic examination is helpful in determin-
tion of urine, the medical assistant should be famil- ing kidney disease, disorders of the urinary tract,
iar with the microscopic examination of urine. and systemic disease. It is particularly important
CLIA ’88 considers the microscopic examination that urine be freshly voided and examined as soon
of urine to be a PPMP and not within the category as possible to prevent deterioration of sediment
of waived tests. Nevertheless, the medical assistant components.
One of the most important items to have on
hand when performing a microscopic urine exam-
ination is a urine color atlas. It takes years to be
Critical Thinking able to correctly identify abnormal components of
urine. A color atlas should always be available to
If a medical assistant is color blind, does the medical assistant to help with identification.
that mean she/he cannot perform the Some laboratories make use of urine stains to
chemical testing of urine? What (if any) add color to certain structures in the urine sedi-
accommodations can be made for her/him? ment. Sedi-Stain® is an example of such a stain
(Figure 30-8).
922 UNIT 7 Laboratory Procedures

cells in the urine specimen, it is indicative that the

specimen is contaminated with skin cells. Better
education of the patient of the reasons for and the
technique of a clean-catch midstream collection
should result in a less contaminated specimen.

Abnormal Urine Sediment Cells and

Microorganisms. The methods of reporting
abnormal urine sediment may vary among health
facilities. Microscopic examination of the urine
sediment may show one or more of the following
cells and microorganisms:

• Red blood cells. Red blood cells appear as pale,

light-refractive disks when seen under high power.
Large amounts of red blood cells in urine (hema-
turia) indicate disease or trauma. These cells are
Figure 30-8 Sedi-Stain® is an example of a stain used counted in a microscopic field (high-power field,
in laboratories. or HPF) and reported as cells counted per HPF
(e.g., 10/HPF).
• White blood cells. A few white blood cells can appear
Sediment Components. Sediment is obtained by in normal urine. More than four white blood cells
centrifugation of 10 to 15 mL of urine. The solid
in urine often indicate a UTI. White blood cells
substances, such as cells and crystals, are forced
are slightly larger than red blood cells, may appear
to the bottom of the test tube, leaving clear fluid
granular, and have a visible nucleus (the red blood
called supernatant on the top. The supernatant
cell has no nucleus). Figure 30-9B shows white
urine is carefully poured off. Most urine test tubes
blood cells in urine. White blood cells are reported
are specifically formed to assist in the process of
in the same manner as red blood cells.
pouring off all but 1 mL of the supernatant fluid.
This is accomplished by quickly inverting the tube • Renal tubular epithelial cells. Renal tubular epithe-
completely upside down (do not shake the tube in lial cells (Figure 30-9C) can indicate kidney dis-
this position). When returned to the upright posi- ease if they are present in large numbers. They
tion, the 1 mL of fluid will be present in the bot- can be confused with both white blood cells and
tom of the tube, together with the urine sediment. other epithelial cells. Renal and vaginal epithelial
This is the perfect amount of supernatant fluid cells are smaller than squamous epithelial cells.
needed to resuspend the sediment. Try the inver- Renal epithelia are rounder and vaginal epithelia
sion process first with plain water until you are able are more oblong with pointed ends. They are also
to perform it easily. After the supernatant has been reported in the same manner as white and red
poured off, the sediment needs to be resuspended blood cells.
or mixed back into the 1 mL of fluid. This mixing • Bacteria. Bacteria can appear as tiny round or rod-
can be accomplished by gently tapping the tube on shaped objects (Figure 30-9D). Rod-shaped bac-
the counter or flicking it with your finger until the teria are generally easier to see because round
sediment and cellular components have all been bacteria may appear as amorphous, or shapeless,
mixed and resupended in the fluid. A drop of material. Bacteria often seem to be shaking or
sediment is then placed on a slide and examined vibrating. This is called Brownian movement and is
microscopically. caused by the molecules of water bumping against
When viewing a normal urine specimen, the the bacteria. Bacteria can be very active, actually
medical assistant may see very little under the moving across the microscopic field. If many bac-
microscope. Squamous epithelial cells (Figure teria are seen and the specimen is not an obviously
30-9A) may be seen, especially in women. These contaminated specimen, the indication is usually a
cells have no medical significance because they UTI. The provider will consider the patient’s symp-
are skin cells continuously sloughed off into the toms in addition to the results of the urinalysis to
urine. They are generally reported as few, moder- make a diagnosis and will often order a C&S of
ate, or many. If the provider sees many epithelial the urine. Bacteria can be reported as few, moder-
 CHAPTER 30 Urinalysis 923

A B C

D E

Figure 30-9 (A) Squamous epithelial cells. (B) White blood cells. (C) Renal epithelial
cells. (D)Bacteria in urine sediment. (E) Yeasts and squamous epithelial cells. (Courtesy of
Bayer Healthcare.)

ate, or many. If both rod-shaped and round bac- atlas will show illustrations of artifacts. If in doubt,
teria are seen in the same specimen, they may be get an expert opinion (Figures 30-11B and C).
reported as mixed bacteria. Mixed bacteria more
often indicate a contaminated specimen rather Crystals in Urinary Sediment. Crystals make
than an infection. up unorganized urine sediment. Because crystals
• Yeast. Yeast cells (Figure 30-9E) may be present are big, the tendency of the novice examiner is
in urine, possibly indicating a yeast infection
in the urinary tract. Yeast cells are smaller than
red blood cells but may appear similar to them.
Yeasts are round and can be observed to be bud-
ding. To distinguish between yeast and red blood
cells, a drop of dilute acetic acid is added to the
urine sediment. The red blood cells will lyse, but
the yeast will not. The most common yeast found
is Candida albicans. Yeasts are reported as the
amount per HPF.
• Parasites. The most frequently seen parasite in
urine is Trichomonas vaginalis (Figure 30-10). Tricho-
monas is a parasite that can infect the urinary tract.
It is often recognized by the movement of its tail
(flagella). Always check with a provider or some-
one more familiar with these organisms before
reporting this organism.
• Sperm. Sperm is reported when seen in male and
female urine. Sperm have oval bodies with one
long, thin flagella (Figure 30-11A).
• Artifacts. Hair, fibers, powder, and oil are among
the substances that may appear in urine sediment
as a result of contamination during collection or
later. If a structure cannot be identified using a
good urine atlas, it probably is an artifact. A urine Figure 30-10 Trichomonas in stained urine sediment.
924 UNIT 7 Laboratory Procedures

B C
A

D E F

Figure 30-11 Crystals and miscellaneous structures that can appear in urine. (A) Spermatazoa. (B) Starch gran-
ules. (C) Cotton fibers. (D) Triple phosphate. (E) Calcium oxalate. (F) Ammonium biurate. (Courtesy of Bayer
Healthcare.)

to pay attention to them. However, they are the stances observed inside them. Some casts include
most insignificant part of the urinary sediment. debris as they are forming and may appear cellular
These crystals include calcium phosphate, triple or granular.
phosphate, calcium oxalate, amorphous phos- The most common cast seen in urine sedi-
phates and urates, and calcium carbonate. These ment is the hyaline cast. Rare hyaline casts can be
crystals generally form as urine specimens stand, seen in normal urine but increase with any kidney
especially when refrigerated. Many laboratories disease. They can also be seen as a result of fever,
do report these crystals. Refer to a urine color emotional stress, or strenuous exercise. Hyaline
atlas to identify crystals. Figures 30-11D–F illus- casts are nearly transparent and can be difficult
trates several kinds of crystals that can be found to see under the microscope without some light
in urine. adjustment.
Some specific crystals in urine that should be Other types of casts include granular casts,
particularly noted if seen because they may indi- containing remnants of disintegrated cells that
cate disease states are uric acid, cystine, and sulfa appear as fine or coarse granules. Cellular casts
drug crystals. Refer to a urine atlas for the shape of may contain epithelial cells, red blood cells, or
these crystals. white blood cells. Figure 30-12 illustrates hyaline,
granular, and cellular casts.
Casts in Urinary Sediment. Casts are impor- Identification of casts in urine requires an
tant to see and identify in urine sediment. It takes experienced eye (see Procedures 30-4 and 30-5).
a great deal of experience and expertise to recog-
nize the many different kinds of casts that can be
in sediment.
Urinalysis Report
Casts are formed when protein accumu- When reporting the results of a urinalysis, you may
lates and precipitates in the kidney tubules. The use a ready-made form, or your clinic may create
casts are then washed into the urine. Most casts a form specifically for your practice. When using
are made from a particular type of protein called electronic medical records, test results are entered
Tamm-Horsfall mucoprotein. Other proteins can directly into the patient’s medical record on the
also form casts. Serum proteins can form waxy computer (Figure 30-13). No printed report is
casts. The presence of casts in the urine may indi- needed unless the patient requires a hard copy
cate kidney disease. (printed document). The report should contain the
Casts are cylindrical with rounded or flat patient’s name, the type of urine specimen (voided
ends. They are classified according to the sub- or catheterized and if it was a clean-catch midstream
 CHAPTER 30 Urinalysis 925

A B C

Figure 30-12 Casts in urine sediment. (A) Hyaline. (B) Granular. (C) Cellular. (Courtesy of Hycor Biomedical
Inc., Garden Grove, CA.)

specimen), the provider who ordered the urinalysis,

Results from the medical assistant performing the physical and
Regional/ Results to Outside chemical portions of the urinalysis, the date and
National Labs Providers
time the specimen was obtained and the date and
time it was tested, and the findings (see Figure 30-14
for an example of a urinalysis report).
LABORATORY

Test Reports
DRUG SCREENING
Quality Assurance & Controls
Safety Standards Testing for drugs is becoming more common
during the job interview process. Some clinics
specialize in occupational health, offering pre-
Orders for Tests
employment physicals including drug screening.
Safety Standards The actual test is simple and is CLIA waived, but
there are detailed protocols and legal documenta-
tions that need to be strictly adhered to. The POL
should be certified to perform drug testing, and all
ELECTRONIC clinical personnel should receive special training.
A chain of custody must take place so that the spec-
RECORDS imen is guarded against tampering and to guaran-
tee the integrity of the specimen.
Some basic criteria in the process are as fol-
lows:
Figure 30-13 The laboratory arm of the total practice
management system (TPMS). The patient’s urinalysis • When the patient arrives, he or she must show
results are entered directly into the electronic medical photo ID, which is copied. The copy is signed
record, which automatically compares the data to nor- • The patient signs a consent form for the testing
mal values. and completes a questionnaire.

Patient: May Pankey Chart # 567-89 MA: W. Slawson, CMA (AAMA) URINALYSIS
City Health Care

Date/Time Date
Req. by: Dr. Rice Spec. Rec’d: 3-3-XX 10:15 AM Test Completed: 3-3-XX 10:18 AM
VOID TEST NORM RESULT TEST NORM RESULT TEST NORM RESULT TEST NORM RESULT

CC
Color Yellow It yellow Protein Neg neg. WBC 0–2 Bact. Trace tr.
MICRO

Glucose Neg neg. Nitrite Neg neg. RBC 0–2 Mucus None
CATH
Ketone Neg neg. Leuk Neg neg. Epith. Few rare Casts Occ
TURBID
Sp. Gr. 1.005-1.030 1.010 Cryst. None
HAZY Blood Neg neg. OTHER:
CLEAR Ph 5–8 6.0
Figure 30-14 A sample of a completed urinalysis report.
926 UNIT 7 Laboratory Procedures

• The urine collection cup has a built in thermom- • After the sample is collected, the temperature is
eter to ensure the urine is fresh and is at body tem- recorded and the sample is sealed and secured for
perature. transport to a testing facility. The patient signs to
verify that the sample is his or hers.
• The patient is asked to leave coats and bags with
the clinic personnel, and these items should be • If a CLIA waived test kit is used in the POL, a test
secured. strip is dipped into the urine, and the reagent will
react qualitatively (positive, negative, or sometimes
• The bathroom and patient are inspected for chem-
inconclusive) for various substances during a spe-
icals and/or urine samples that do not belong to
cific amount of time. Inconclusive samples must be
the patient.
tested further.
• In the case of a legal court ordered drug test, the
donation of the urine is monitored. Monitoring
may occur in all drug testing, depending on clinic
policy.

Procedure 30-1
Assessing Urine Volume, Color, and Clarity
STANDARD PRECAUTIONS: 4. Examine the specimen for proper labeling. Any
unlabeled specimen is not to be tested. If the
missing, unlabeled specimen cannot be identi-
fied, the patient should be notified to submit
PURPOSE: a new specimen. The provider ordering the
Determine and document the volume of a urine sample. test should be notified of the delay. The speci-
men should be labeled on the cup, not the lid.
EQUIPMENT/SUPPLIES: RATIONALE: An unlabeled specimen cannot
Gloves Biohazard container be proven to come from any particular patient
Urine container Disinfectant cleaner and we should never guess or assume whose
Laboratory report form specimen it is. The provider should be noti-
fied so that he or she is kept informed about
PROCEDURE STEPS: the processing of laboratory tests he or she
1. Wash hands and put on gloves. RATIONALE: orders. The specimen should be labeled on the
Washing hands before any laboratory process cup rather than the lid, because the lid can be
prevents contamination of the specimen. Glov- removed from the specimen and mixed up with
ing provides personal protection. other lids.
2. Assemble equipment and supplies. RATIO- 5. Ensure the lid is securely tightened and mix the
NALE: Organizing your work area prevents con- urine thoroughly. RATIONALE: Securing the lid
fusion and error caused by missing supplies. will prevent leaking of urine while mixing. Mix-
3. Follow all safety guidelines, being careful not ing the specimen will suspend all particles and
to splash the urine specimen. Wipe up all spills cellular components in the specimen so that the
immediately with disinfectant cleaner. RATIO- urine that is poured into the centrifuge tube
NALE: Preventing splashes and spills will prevent contains a good sampling of the specimen.
exposure to biohazardous substances. Cleaning 6. Measure and note the amount of urine in the spec-
any spill immediately prevents further contami- imen if it is less than 10 mL. The amount of the
nation and risk for exposure. specimen does not have to be noted if it is more

continues
 CHAPTER 30 Urinalysis 927

Procedure 30-1 (continued)

than 10 mL. RATIONALE: If the sample is less than color names should come only from accepted
10 mL, the sample is considered an inadequate color descriptors, not from arbitrary names.
amount. If unable to obtain an adequate amount, 8. After the volume and color have been assessed
the testing may still be run on the sample, but and recorded, assess the clarity of the urine. Hold-
the exact amount of the specimen should be well ing the urine against a white background with
noted on the laboratory report form, and the test good lighting, observe it for cloudiness. If you
should be run according to the priority set by the can clearly see print through the urine, it is said
provider. For example, he or she may request only to be clear. If the urine appears cloudy, it is said
a C&S be performed or only chemical testing using to be slightly cloudy, cloudy, or very cloudy/tur-
chemical reagent test strips rather than a complete bid. Record the description on the report form.
urinalysis. Samples that are not of adequate quan- RATIONALE: The clarity of the urine is useful in
tity to perform the test ordered should be marked predicting the presence of contaminants such as
as QNS (quantity not sufficient). skin cells, mucus, and other debris.
7. Note and assess the urine color. Many medi- 9. Dispose of the specimen into the toilet or des-
cal assistants find it helpful to assess the color ignated sink and all supplies into appropriate
against a white background. Be sure to have biohazard containers. Disinfect all reusable
good lighting. In the practice setting, comparing equipment and all surfaces. RATIONALE: Using
a variety of urine specimens with each other will appropriate disposal techniques and disinfecting
help with learning about color assessment (see all surfaces according to Standard Precautions
Table 30-2 for appropriate urine color descrip- safely controls all biohazard substances.
tors). RATIONALE: The color of urine is helpful
in predicting the concentration of the specimen. 10. Remove gloves. Wash hands.
The white background helps with assessment of 11. Document procedure in patient’s chart or elec-
the color; good lighting also is helpful. Urine tonic medical record.

Procedure 30-2
Using the Refractometer to Measure Specific Gravity
STANDARD PRECAUTIONS: PROCEDURE STEPS:
1. Wash hands and put on gloves. RATIONALE:
Washing hands before any laboratory process
prevents contamination of the specimen. Glov-
PURPOSE: ing provides personal protection.
Measure and record the specific gravity of a urine 2. Assemble equipment and supplies. RATIO-
specimen. NALE: Organizing your work area prevents con-
fusion and error caused by missing supplies.
EQUIPMENT/SUPPLIES:
Refractometer Lint-free tissues 3. Follow all safety guidelines, being careful not
Urine sample Biohazard container to splash the urine specimen. Wipe up all spills
Gloves Disinfectant cleaners immediately with disinfectant cleaner. RATIO-
Pipettes Laboratory report form NALE: Preventing splashes and spills will prevent
Distilled water exposure to biohazardous substances. Cleaning
any spill immediately prevents further contami-
nation and risk for exposure.

continues
928 UNIT 7 Laboratory Procedures

Procedure 30-2 (continued)

4. QC must be performed on the refractometer results on your QC sheet and proceed to test
before every use. This is accomplished by check- the urine specimen (Step 5). If the QC test
ing the specific gravity of a drop of distilled water: shows the refractometer to be inaccurate
a. Clean the surface of the prism and the cover with (the refractometer does not measure the sec-
lint-free tissue and distilled water. Wipe dry. ond sample of distilled water accurately), the
instrument is not calibrated properly. Use the
b. Depending on the type of refractometer used, small screwdriver to adjust the calibration. Do
you may either apply the drop and then close this adjustment using distilled water until the
the cover, or close the cover and apply the drop gauge reads 1.000.
of distilled water to the notched portion of the
cover so it flows over the prism. (Figure 30-15A). 5. Test the urine specimen exactly as the distilled
water was tested and record the specific gravity
c. With the instrument tilted to allow light to on the urinalysis report form (Figure 30-15C).
enter, view the scale and read the specific
gravity number (Figure 30-15B). It should be 6. Dispose of the specimen into the toilet or des-
exactly 1.000. ignated sink and all supplies into appropriate
biohazard containers. Disinfect all reusable
d. If the QC test shows the refractometer to equipment and all surfaces. RATIONALE: Using
be calibrated properly, you may record the appropriate disposal techniques and disinfecting
all surfaces according to Standard Precautions
safely controls all biohazard substances.
7. Remove gloves. Wash hands.
8. Document procedure in patient’s chart or elec-
tronic medical record.

1.035

1.030

1.025

URINE
1.020
A SPECIFIC GRAVITY
T/C 1.015
320
310
15
300
1.010 290
14
280
270
1.005 13
260
250
12
1.000 240
230
11
220
210
10
SERUM OR PLASMA 200
PROTEIN 190
9
GMS/100 ml 180
T/C 8
170
PR/N RATIO 6.54 160
150
7
140
130 REFRACTION
6
1.035 120 (N-No) ⫻ 104

1.030
5
110
T/C
100
90
1.025 4
80
URINE 70
1.020 3
SPECIFIC GRAVITY
60
T/C 1.015 50
40
1.010
30

1.005 20
10
1.000 0
B
C
Figure 30-15 (A) A pipette or dropper may be used to fill the refractometer with urine. (B) The medical assistant
looks through the refractometer. The instrument is held toward a light source. (C) The specific gravity readout.
 CHAPTER 30 Urinalysis 929

Procedure 30-3
Performing a Urinalysis Chemical Examination
STANDARD PRECAUTIONS: because the lid can be removed from the speci-
men and mixed up with other lids.
5. Ensure the lid is securely tightened and mix the
urine thoroughly. RATIONALE: Securing the lid
PURPOSE: will prevent leaking of urine while mixing. Mix-
Detect any abnormal chemical constituents of a urine ing the specimen will suspend all particles and
specimen. cellular components in the specimen so that the
urine that is poured into the centrifuge tube
EQUIPMENT/SUPPLIES: contains a good sampling of the specimen.
Gloves
6. If you are planning to perform a complete uri-
Urine test strips
nalysis, label a urine centrifuge tube with the
Urine specimen
patient’s name and pour 10 mL into the tube for
Biohazard container
the microscopic examination. Set aside in the
Disinfectant cleaner
centrifuge. RATIONALE: Setting this portion of
Laboratory report form
the sample aside ensures that it is not contami-
PROCEDURE STEPS: nated by the chemicals of the test strips or the
1. Wash hands and put on gloves. RATIONALE: process of the chemical examination.
Washing hands before any laboratory process 7. Read and follow the manufacturer’s instruc-
prevents contamination of the specimen. Glov- tions exactly. The following procedure is a basic
ing provides personal protection. guideline. RATIONALE: Each manufacturer
2. Assemble equipment and supplies. RATIO- will provide specific instructions related to their
NALE: Organizing your work area prevents con- product. Even manufacturers whose test strips
fusion and error caused by missing supplies. you are already familiar with could change their
instructions. The package insert should be read
3. Follow all safety guidelines, being careful not
carefully every time a new package is used.
to splash the urine specimen. Wipe up all spills
immediately with disinfectant cleaner. RATIO- 8. Remove a test strip from the container and
NALE: Preventing splashes and spills will prevent replace the cap tightly. RATIONALE: Strips are
exposure to biohazardous substances. Cleaning adversely affected by light and moisture and
any spill immediately prevents further contami- should always be kept sterile in the original con-
nation and risk for exposure. tainer with the lid securely on.
4. Examine the specimen for proper labeling. Any 9. Immerse the test strip completely in the well-mixed
unlabeled specimen is not to be tested. If the urine and remove it immediately (Figure 30-16A).
missing, unlabeled specimen cannot be iden- While removing the test strip from the cup, tap it
tified, the patient should be notified to submit gently onto a paper towel to remove excess urine
a new specimen. The provider ordering the (Figure 30-16B). RATIONALE: Removing the
test should be notified of the delay. The speci- excess urine prevents the specimen from cross con-
men should be labeled on the cup, not the lid. tamination of adjacent chemical pads on the strip,
RATIONALE: An unlabeled specimen cannot be which can cause inaccurate results.
proven to come from any particular patient and 10. Properly time the test for each test pad. RATIO-
we should never guess or assume whose speci- NALE: Proper timing is essential for accurate
men it is. The provider should be notified so that results. The manufacturer’s instructions will
he or she is kept informed about the process- clearly list the proper time for each test.
ing of laboratory tests he or she orders. The cup 11. Holding the test strip close to the container (or
should be labeled on the cup rather than the lid, chart) but not touching it, compare the color of

continues
930 UNIT 7 Laboratory Procedures

Procedure 30-3 (continued)

the pads on the test strip with the color guides 15. Document procedure in patient’s chart or elec-
on the container (or chart) (Figure 30-16C). tronic medical record.
RATIONALE: Touching the chart or container
with the wet test strip will contaminate the
chart/container with urine. If this accidentally
happens, be sure to disinfect the surface well.
12. Record the results on the laboratory report
form.
13. Dispose of the specimen into the toilet or des-
ignated sink and all supplies into appropriate
biohazard containers. Disinfect all reusable
equipment and all surfaces. RATIONALE: Using
appropriate disposal techniques and disinfecting
all surfaces according to Standard Precautions
safely controls all biohazard substances.
14. Remove gloves. Wash hands. A

B C

Figure 30-16 Performing a chemical examination of urine. (A) Immerse the reagent strip into the urine. (B)
Remove the strip and tap it lightly on a paper towel to remove excess urine. (C) Read the strip by matching the
color on the strip to the color chart. Take care not to touch the strip onto the color chart.
 CHAPTER 30 Urinalysis 931

Procedure 30-4
Preparing Slide for Microscopic Examination of Urine Sediment
STANDARD PRECAUTIONS: 5. Ensure the lid is securely tightened and mix the
urine thoroughly. RATIONALE: Securing the lid
will prevent leaking of urine while mixing. Mix-
ing the specimen will suspend all particles and
PURPOSE: cellular components in the specimen so that the
Prepare slide for a microscopic examination of urine urine poured into the centrifuge tube contains a
sediment. good sampling of the specimen.
6. Label a urine centrifuge tube with the patient’s
EQUIPMENT/SUPPLIES: name and pour 10 mL into the tube. Set into the
Gloves Sharps container centrifuge. Balance the centrifuge, securely close
Microscope Centrifuge tubes and holder and lock the lid, and spin at 1,500 g (revolutions
Centrifuge Urine atlas guide per minute) for 5 minutes. RATIONALE: The
Microscope slides Disinfectant cleaner urine sediment will be forced to the bottom of
Coverslips Biohazard container the test tube and then will be placed on a slide
Disposable pipettes Sedi-Stain® (optional) for microscopic examination.
PROCEDURE STEPS: 7. After centrifugation, pour off the supernatant,
1. Wash hands and put on gloves. RATIONALE: leaving about 1 mL in the bottom of the tube.
Washing hands before any laboratory process Add two drops of Sedi-Stain® if desired. Remix
prevents contamination of the specimen. Glov- the sediment by tapping gently on the counter or
ing provides personal protection. with your fingernail. RATIONALE: The test will
be performed on the sediment only so the excess
2. Assemble equipment and supplies. RATIO-
supernatant is not needed. Sedi-Stain® colors the
NALE: Organizing your work area prevents con-
cells and other elements for easier viewing.
fusion and error caused by missing supplies.
8. Place a drop of the well-mixed sediment onto
3. Follow all safety guidelines, being careful not
a clean microscope slide. Cover with a cover-
to splash the urine specimen. Wipe up all spills
slip by holding the coverslip at an angle to the
immediately with disinfectant cleaner. RATIO-
drop, bringing the edge close to the drop until
NALE: Preventing splashes and spills will prevent
the urine spreads along the edge of the cover-
exposure to biohazardous substances. Cleaning
slip, and then gently lower the coverslip onto the
any spill immediately prevents further contami-
drop. Keep the tube. RATIONALE: Using this
nation and risk for exposure.
technique to place the coverslip onto the speci-
4. Examine the specimen for proper labeling. Any men will prevent air pockets from forming. Keep
unlabeled specimen is not to be tested. If the miss- the tube in the event that a fresh slide needs to
ing, unlabeled specimen cannot be identified, be prepared.
the patient should be notified to submit a new
9. Place the slide onto the microscope stage but
specimen. The provider ordering the test should
do not leave the light on. RATIONALE: Do not
be notified of the delay. The specimen should be
leave the light on because this will heat the slide
labeled on the cup, not the lid. RATIONALE: An
and destroy the specimen.
unlabeled specimen cannot be proven to come
from any particular patient and we should never 10. Alert the provider that the slide is ready for
guess or assume whose specimen it is. The pro- viewing. RATIONALE: The microscopic exam-
vider should be notified so that he or she is kept ination is considered by CLIA to be in the
informed about the processing of laboratory tests moderately complex test category of PPMP.
she or he orders. The cup should be labeled on You are encouraged to view and discuss the
the cup rather than the lid, because the lid can be microscopic examination with the provider
removed from the specimen and mixed up with as part of your professional development and
other lids. continuing education. If you do view the slide

continues
932 UNIT 7 Laboratory Procedures

Procedure 30-4 (continued)

before the provider views it, do not leave on the objective (400⫻ magnification) to identify
light. If the slide dries before the provider can the casts.
view it, prepare a fresh slide. d. Scan the slide using the 40⫻ objective (400⫻
11. NOTE: The following steps are included so the 5 high magnification) for other cells and
medical assistant can learn to examine urine formed elements. The count is obtained by
microscopically even though the provider must averaging the number of each formed ele-
perform the actual assessment. ment or cell in 10 to 15 visualized fields.
a. When examining urine sediment, it is impor- 12. After the provider is finished with the speci-
tant to keep the light subdued by lowering men and the patient has left the clinic, dispose
the condenser and to constantly vary the fine of the specimen into the toilet or designated
focus adjustment to view the structures that sink and all used supplies into appropriate bio-
are faint. Proper lighting and focus adjust- hazard containers. Disinfect all reusable equip-
ments take a great deal of practice. ment and all surfaces. Remove gloves and wash
b. Scan the sediment using a 100⫻ (low-power) hands. RATIONALE: Using appropriate disposal
magnification. A 100⫻ magnification is achieved techniques and disinfecting all surfaces accord-
by using the 10⫻ objective lens (10⫻ ⫻ 10⫻ ⫽ ing to Standard Precautions safely controls all
100⫻). biohazard substances. Remember that micro-
scopic slides and coverslips are glass and should
c. View 10 to 15 fields and around the edges of
be placed into an appropriate biohazard sharps
the slide for casts. Casts are often forced to
container.
the edges. It may be necessary to use the 40⫻

Procedure 30-5
Performing a Complete Urinalysis
STANDARD PRECAUTIONS: PROCEDURE STEPS:
NOTE: The following procedure is a compilation and
summary of the physical, chemical, and microscopic
examination of urine (see Procedures 30-1, 30-2, 30-
PURPOSE: 3, and 30-4). For details within each step, refer to the
Perform a complete urinalysis, including the physi- specific procedure as referenced.
cal, chemical, and microscopic examination within 30 1. Wash hands and put on gloves.
minutes of obtaining the specimen. 2. Assemble equipment and supplies.

EQUIPMENT/SUPPLIES: 3. Follow all safety guidelines.

Gloves Reagent test strips 4. Examine the specimen for proper labeling.
Urine specimen Urine atlas 5. Ensure the lid is securely tightened and mix the
Pipettes Refractometer urine thoroughly.
Centrifuge tube Distilled water
6. Label a urine centrifuge tube with the patient’s
Centrifuge Lint-free tissues
name, pour 10 mL into the tube and set it into
Microscope Biohazard container
the centrifuge. Balance the centrifuge, securely
Microscope slides Sharps container
close and lock the lid, and spin at 1,500 g (revo-
Coverslip Disinfectant cleaner
lutions per minute) for 5 minutes.
Permanent marker Laboratory report form
Sedi-Stain® (optional)

continues
 CHAPTER 30 Urinalysis 933

Procedure 30-5 (continued)

7. While the sample is being centrifuged, assess and 13. Dispose of the specimen into the toilet or des-
record the color and clarity. ignated sink and all supplies into appropriate
8. Perform the specific gravity test using a refrac- biohazard containers. Disinfect all reusable
tometer if specific gravity is not included in the equipment and all surfaces. Remember that
chemical test strip. microscopic slides and coverslips are glass and
should be placed into an appropriate biohaz-
9. Perform the chemical examination following the ard sharps container. Remove gloves and wash
manufacturer’s instructions. Record the results. hands.
10. After centrifugation, pour off the supernatant, 14. File the completed laboratory report form into
leaving about 1 mL in the bottom of the tube. the laboratory section of the patient’s chart or
Add two drops of Sedi-Stain® if desired. Remix electronic medical record and document the
the sediment by tapping gently on the counter procedure.
or with your fingernail.
11. Place a drop of the well-mixed sediment onto a DOCUMENTATION
clean microscope slide. Cover with a coverslip. 11/13/XX 4:15 PM Complete urinalysis performed on random
12. Place the slide onto the microscope stage and alert voided specimen. Report filed. Joe Guerrero, CMA (AAMA) _
the provider that the slide is ready for viewing.

Procedure 30-6
Utilizing a Urine Transport System for C&S
STANDARD PRECAUTIONS: 3. Follow all safety guidelines, being careful not
to splash the urine specimen. Wipe up all spills
immediately with disinfectant cleaner. RATIO-
NALE: Preventing splashes and spills will prevent
PURPOSE: exposure to biohazardous substances. Cleaning
Prepare a urine specimen for transport using a Cul- any spill immediately prevents further contami-
ture and Sensitivity Transport Kit. nation and risk for exposure.
4. Examine the specimen for proper labeling.
EQUIPMENT/SUPPLIES: RATIONALE: The specimen cup must be prop-
Gloves erly labeled to ensure QC.
Sterile urine cup and specimen
5. Check the urine C&S Transport kit expiration
Urine Culture and Sensitivity Transport kit
date. RATIONALE: If the kit has expired, the
Laboratory requisition
contents cannot be guaranteed sterile.
Paper towel
6. Open the urine C&S Transport kit package (Fig-
PROCEDURE STEPS: ure 30-17B). Remove the cap from the specimen
1. Wash hands and put on gloves. RATIONALE: cup, placing the lid upside down on the paper
Washing hands before any laboratory process towel. RATIONALE: The cap must be placed
prevents contamination of the specimen. Glov- upside down to maintain the sterile inner sur-
ing provides personal protection. face.
2. Assemble equipment and supplies (Figure 30- 7. Follow the manufacturer’s instructions exactly:
17A shows one type of system). RATIONALE: a. Place the urine tube in the tube adapter (Fig-
Organizing your work area prevents confusion ure 30-17C) and the specimen straw into the
and error caused by missing supplies.

continues
934 UNIT 7 Laboratory Procedures

Procedure 30-6 (continued)

B C

D E

Figure 30-17 The urine transport kit for culture and sensitivity. (A) Packaged as a kit. (B) The components
of the kit. (C) The tube is connected to the straw and adapter. (D) The end of the straw is placed in the urine
(the vacuum tube is not pushed completely onto the adapter until the straw is submerged in the urine). (E) The
vacuum in the tube draws up the urine.

continues
 CHAPTER 30 Urinalysis 935

Procedure 30-6 (continued)

urine within the specimen cup (Figure 30- Labeling with the required information prevents
17D). mix-ups of specimens and ensures a quality time-
b. Advance urine tube into the adapter, pushing line.
the tube onto the needle while keeping the 9. Dispose of all contaminated supplies, disinfect
specimen straw submerged in the urine. all surfaces, remove gloves, and wash hands.
c. Allow the vacuum in the urine tube to draw RATIONALE: Using appropriate disposal tech-
up the urine. Fill to the exhaustion of the vac- niques and disinfecting all surfaces according to
uum within the tube (Figure 30-17E). Standard Precautions safely controls biohazard
substances.
d. Remove the tube and the specimen straw/
adapter unit and dispose of it into a biohaz- 10. Complete the laboratory requisition and docu-
ard container. ment procedure in patient’s chart or electronic
medical record. RATIONALE: Proper docu-
e. Gently invert the tube 8 to 10 times to mix the mentation ensures the laboratory will have the
preservative within the tube. necessary information and the patient’s medical
8. Label the tube with patient’s name, date, time, record will be accurate and complete.
and other required information. RATIONALE:

Procedure 30-7
Instructing a Patient in the Collection of a Clean-Catch,
Midstream Urine Specimen
PURPOSE: RATIONALE: Identifying the patient ensures
To instruct a patient on the proper technique of col- that the right patient will have the right proce-
lecting a urine specimen suitable for urinalysis testing. dure. Intoducing yourself provides for a profes-
sional rapport with the patient. Providing for a
EQUIPMENT/SUPPLIES: private area ensures that the patient will have the
Gloves freedom to ask questions and that confidentiality
Urine cup with a secure lid will be maintained. Being in an area that is free
Cleansing towelettes (two for males, three for from distractions allows you to use a moderate
females) voice volume and still be heard and understood
Marking pen by the patient.
PROCEDURE STEPS: 3. Provide the patient with a capped urine cup
1. Wash hands and assemble the supplies. RATIO- labeled with his/her name, a pair of gloves, and
NALE: Always wash hands before working with the cleansing towelettes. RATIONALE: The
each patient as a means of preventing disease cup should be labeled (not the cap) prior to
transmission. Being organized ensures that the giving it to the patient so there is not a chance
procedure will be performed in a professional of a mixup. Gloves will protect the patient’s
manner. hand from contamination from the urine and
from the genital area. The towelettes will be
2. Identify the patient, introduce yourself, and used for cleansing the area prior to obtaining
provide for a private area free from distractions. the sample.

continues
936 UNIT 7 Laboratory Procedures

Procedure 30-7 (continued)

4. Show the patient the written instructions posted 8. Explain the process of obtaining the midstream
in the bathroom. RATIONALE: The patient specimen: For both the male and the female
should always have written instructions in case he patient, he or she is to bring the cup into the
or she forgets a step. The instructions should be stream and obtain about half a cup before remov-
posted at a level that can be read by the female ing the cup from the stream. RATIONALE: The
patient while sitting and by the male patient mid-stream catch is used to further prevent epi-
while standing. thelial cells from entering the sample. If the
5. Explain to the patient why the urine sample patient were to stop and start the urine flow, the
should be a clean-catch midstream sample and chances of epithelial contamination increases.
what that means. RATIONALE: When the patient 9. Explain to the patient that he or she should
understands the reasons behind the instructions, secure the cap onto the cup. RATIONALE: The
he or she is much more likely to follow the steps secure lid will prevent spillage.
completely. 10. The patient may rinse the outside of the capped
6. Ask the patient to first wash his or her hands and cup if needed and towel dry it. RATIONALE:
apply the gloves. RATIONALE: Gloves are worn Rinsing and drying the outside of the cup will
to protect the patient’s hands from contamina- remove any urine that may be present.
tion. 11. The patient is to then remove the gloves, dis-
7. Explain the cleansing process for a clean-catch: pose of them into the red bag waste recepticle,
For the male patient, explain that he is to cleanse and wash his or her hands. RATIONALE: Con-
the urethral opening twice, using two separate taminated waste should always go into red bag
towelettes before he begins to urinate. For the recepticles. Hands should be washed to remove
female patient, explain that she will need to any residual powder from the gloves and/or con-
spread her labia and cleanse from front to back tamination that may have touched the hands.
first on one side, then the other, and lastly, in the 12. Using a paper towel as a barrier, the cup may be
middle. Explain that she is to hold her labia apart returned to the medical assistant or placed in
until the urine sample is obtained. RATIONALE: the lab recepticle as directed. RATIONALE: The
Cleansing the urethral opening ensures that the POL often has a shelf or designated area for the
sample will have no or few epithelial cells from patient to place the urine sample onto. If not,
the skin. Epithelial cells are quite large and can the sample may be handed to the medical assis-
make the urine difficult to evaluate microscopi- tant. The paper towel creates a barrier between
cally because the bacteria and other cells can be the specimen and the hand.
hidden behind them.
 CHAPTER 30 Urinalysis 937

Case Study 30-1 Case Study 30-2

Refer to the scenario at the beginning of the chapter. Annette Samuels came to Inner City Health Care today
Wanda is careful to prepare her patient properly, so she because she is experiencing frequent urination, itching,
gets a good sample, she pays attention to the details so and burning when urinating. Dr. Rice ordered a urinalysis,
that the test is run properly, and she cares about the quality which clinical medical assistant Wanda Slawson is perform-
of the results. ing. Wanda notes that the urine has a cloudy appearance
and the chemical reagent test strip tests positive for nitrites.
CASE STUDY REVIEW Wanda confers with Dr. Rice, who instructs her to prepare a
slide for a microscopic examination of the specimen.
1. What is the worst that can happen if the patient
does not give a good clean-catch midstream CASE STUDY REVIEW
urine sample?
2. What might happen if the reagents Wanda uses 1. Why might Dr. Rice want to examine this speci-
are outdated or have not been stored properly? men microscopically?
3. If Wanda does not care about the quality of the 2. How would the findings be reported?
urine tests, how does that reflect on the rest of
Wanda’s work?

SUMMARY
This chapter summarizes the basics of the urinalysis. Providers order a variety of tests on urine to help them
determine or rule out certain abnormalities to make a correct diagnosis and prescribe treatment.
Urine is formed as blood is filtered through the kidney. Substances such as by-products of metabo-
lism, mineral excesses, cells, bacteria, parasites, crystals, and casts can be found in the urine during exami-
nation.
It is important for the medical assistant to:
• Understand the proper collection techniques for urine specimens. Medical assistants often are called on to
instruct patients on the proper collection procedures.
• Understand the safety guidelines involved with collecting and handling specimens, preservatives, and reagents.
These guidelines must always be observed.
• Understand the importance of and the procedures for maintaining a consistent quality-control program.
• Understand how to properly perform the urinalysis, following up with proper confirmatory tests when neces-
sary.
• Understand and be constantly aware of factors that may interfere with the accuracy of a urinalysis.
938 UNIT 7 Laboratory Procedures

STUDY FOR SUCCESS

To reinforce your knowledge and skills of information presented in this chapter:
• Review the Key Terms
• Practice the Procedures
• Consider the Case Study and discuss your conclusions
• Answer the Review Questions

˚ Multiple Choice
˚ Critical Thinking
• Navigate the Internet by completing the Web Activities
• Practice the StudyWARE activities on the CD
• Apply your knowledge in the Student Workbook activities
• Complete the Web Tutor sections
• View and discuss the DVD situations

REVIEW QUESTIONS
Multiple Choice 5. What is the most common way of doing a chemical
analysis of urine in a provider’s office?
1. What safety guideline is important to follow during
a. reagent test strip
a routine urinalysis?
b. microscopic examination
a. use the same pipette for all patients’ urine sam-
c. culture test
ples
6. Which substance or structure is automatically con-
b. allow urine to sit at room temperature to fer-
sidered abnormal when found in urine?
ment the urine properties
a. phosphates
c. once tested, urine can be disposed of by the jani-
b. urea
torial service
c. blood
d. treat all specimens as if they were infectious
d. salt
2. What are the three basic parts of a typical urine
examination?
a. volumetric, chemical, and macroscopic
Critical Thinking
b. pathologic, chemical, and confirmatory 1. What is the importance of proper urine collection?
c. physical, chemical, and microscopic 2. When is a urine preservative necessary?
d. random, 24-hour, and catheterized 3. Why is the first morning specimen preferred for
3. What is the specimen of choice for routine urinaly- routine urinalysis?
sis? 4. What would give a urine sample a cloudy appear-
a. sterile ance?
b. clean-catch
c. catheterized
d. timed
WEB ACTIVITIES
4. A diabetic patient will normally have an excess of 1. Search for CLIA information on the Inter-
what substance in the urine? net. Are guidelines posted for specimen
a. hemoglobin collection? When were these guidelines last
b. glucose updated?
c. insulin 2. According to CLIA, which tests are waived in
d. sodium regard to urinalysis and which tests are not?
 CHAPTER 30 Urinalysis 939

3. Visit the CDC’s Web site and review the Standard REFERENCE/BIBLIOGRAPHY
Precautions that apply to urine collection and anal-
ysis. Walters, N. J., Estridge, B. H., & Reynold, A. P. (2008).
4. Using your favorite search engine, search for Basic medical laboratory techniques (5th ed.). Clifton
images that show specific cells and bacteria in Park, NY: Delmar Cengage Learning.
urine. You might even find some video clips that
show cells or bacteria in action.

THE DVD HOOK-UP

This chapter discusses common urologic procedures that Mr. Bean and Shannon really struggled to connect. What
are performed in the medical office. could Shannon have done differently to improve her
In one of the first scenes, Dr. Rao’s medical assistant encounter with Mr. Bean? Do you think that Mr. Bean was
Shannon explains to Mr. Bean how to collect a clean-catch trying to hide something?
urine sample.
1. What do you think about the chemistry between
Shannon and Mr. Bean?
2. This chapter states that you should not touch the test
strip against the bottle when performing a chemical
analysis of the urine. Did Shannon follow those guide-
lines? What should you do if you accidentally touch the DVD Series Program Number
Skills Based Series 12
bottle with the contaminated test strip?
3. Today’s program stated that you should not insert the Chapter/Scene Reference
test strip into the original specimen container. Why? • Introduction to Specimen Collection and
Processing Procedures
• Administering and Performing Urinalysis
DVD Journal Summary • Administering 24-Hour Urine Test
Write a paragraph that summarizes what you learned from
watching the selected scenes from today’s DVD program.
Chapter

31 Basic Microbiology

OUTLINE KEY TERMS

The Medical Assistant’s Role in Microscopic Examination of Aerobic
the Microbiology Laboratory Bacteria Aerosols
Microbiology Bacterial Shapes Agar
Classification Dyes (Stains) Anaerobic
Nomenclature Simple Stain
Biochemical Tests
Cell Structure Differential Stain
Broth Tubes
Equipment Acid-Fast Stain
Special Techniques Culture
Autoclave
Microscope Potassium Hydroxide Dermatophytes
Safety Hood Preparation DNA
Incubator Culture Media Expectorate
Anaerobic Equipment Media Classification Genus
Inoculating Equipment Microbiology Culture Gram Stain
Incinerator Inoculating the Media Holding Media
Media Other Types of Streaking Immunosuppressed
Refrigerator Primary Culture
Inoculate
Safety When Handling Subculture
Lumbar Puncture
Microbiology Specimens Rapid Identification Systems
Personal Protective Equip- Streptococcus Screening (Rapid Microbiology
ment Strep Testing) Mordant
Work Area Sensitivity Testing Morphology
Specimen Handling Parasitology Mycology
Disposal of Waste and Spills Examination Methods Nematode
Quality Control Specimen Collection Normal Flora
Collection Procedures Common Parasites Nosocomial
Specific Collection Mycology Ova
Requirements for Cultures
Parasitology
Pathogen
Petri Dish
OBJECTIVES Potassium
The student should strive to meet the following performance objectives and dem- Hydroxide (KOH)
onstrate an understanding of the facts and principles presented in this chapter Protozoa
through written and oral communication.
Quality Control
1. Define the key terms as presented in the glossary. Reagents
2. Define microbiology, discussing classifications and nomenclature Sensitivity
relevant to the microbiology laboratory. Species
3. Describe bacterial cell structure. Spores

940
OBJECTIVES (continued) KEY TERMS
4. List and describe the equipment used in the physicians’ office
(continued)
laboratory (POL). Stab Culture
5. Explain how to safely handle microbiology specimens. Taxonomy
6. Describe the importance of and steps involved in quality con- Virology
trol in the POL. Wet Mount
7. Explain the types of microbiology specimens collected in the Wood’s Lamp
POL and how they are collected.
8. List different types of stains used to microscopically observe
microorganisms.
9. List the different classifications of media used in the POL and
microbiology laboratory.
10. Describe how organisms are inoculated onto various media.
11. Describe the significance of sensitivity testing.
12. List two parasites and two fungi that can be observed in the
POL.

Scenario
To aid in diagnosing and treating patients, the provid- medical assistant Joe Guerrero follows all Safety
ers at Drs. Lewis and King’s office order tests to identify Precautions when handling specimens. He checks the
disease-causing bacteria, fungi, viruses, and parasites. test manufacturer’s or laboratory’s procedures and
Some of these tests, such as the quick tests for group carefully completes each step. By following all safety
A Streptococcus, are performed in the office laboratory, guidelines and test procedures, Joe ensures his and
whereas other tests are sent to a reference labora- others’ safety. He also obtains a high-quality specimen
tory. Regardless of where the test will be performed, for testing.

INTRODUCTION
The field of microbiology encompasses the study of all THE MEDICAL ASSISTANT’S
microorganisms, living structures that can be seen only
with the powerful magnification of a microscope. The ROLE IN THE MICROBIOLOGY
word microbiology comes from the Greek words micro LABORATORY
(“small”) and bios (“living”). The field of microbiology
includes the study of such organisms as bacteria, fungi, The role of the medical assistant in microbiology
viruses, parasites, and algae (Table 31-1). within the physicians’ office laboratory (POL) is to
Many medical textbooks in microbiology include obtain specimens, test specimens within the Clini-
extensive study of all of the preceding organisms, includ- cal Laboratory Improvement Act (CLIA) waived
ing lesser known species in each category. It is the goal of categories, and prepare slides and cultures for
this chapter to introduce the student to the field of micro- microscopic examination by the provider or for
biology with emphasis on bacteria, fungi, and parasites. transport to an outside laboratory.
Safety while working with microorganisms in the labora- This chapter discusses cultures in detail. Sim-
tory is emphasized. The relation of bacteria to diseases ply put, a culture is a sample of a body secretion that
also is explored. is placed on special media to allow the bacteria to
941
942 UNIT 7 Laboratory Procedures

kill the microorganism identified as causing the

Spotlight on Certification infection.
In healthy individuals, several types of bacte-
RMA Content Outline ria are found naturally in various parts of the body.
• Medical law These natural bacteria are called normal flora.
• Asepsis These organisms are always present and help with
• Laboratory procedures the body’s immune system. In disease, the caus-
ative microorganism is called a pathogen because
CMA (AAMA) Content Outline it causes harm to the body.
• Equipment preparation and operation The medical assistant’s technique must be
• Principles of operation exact to avoid laboratory error. The medical assis-
• Principles of infection control tant also must ensure that the specimen for cul-
• Collecting and processing specimens ture was taken with sterile supplies and delivered
and diagnostic testing to the laboratory in a reasonable amount of time.
Delivery time of the specimen or culture may vary
CMAS Content Outline depending on the type of specimen collected for
• Legal considerations culture. Some specimens may be refrigerated with-
• Asepsis in the medical office out harm. Some may be kept in holding media—
media that will keep a specimen on a swab moist
until it is cultured. These variations are discussed
later in specimen processing.
grow. Some samples of cultures discussed in this By doing the smear, culture, and identification
chapter are throat, sputum, urine, blood, vaginal through biochemical tests, the microbiologist can
and penile, and wound cultures. Cultures are usu- identify the organism and aid the provider in diag-
ally allowed to grow in optimum temperatures and nosing and treating the patient. Most identification
environments for at least 12 hours before they are of organisms can be done successfully within 12 to
examined for identification. 24 hours. Some organisms may take longer to grow.
In certain situations, a provider may request Many test kits are currently available to test
a sensitivity in addition to the culture. This test for microbiologic pathogens; these kits are quick
will identify which antibiotic(s) will effectively and fairly simple to perform. CLIA has identified

Table 31-1 Biologic Sciences

BIOLOGICAL SCIENCES

BOTANY MICROBIOLOGY ZOOLOGY

(study of plants) (study of microorganisms) (study of animals)

VIROLOGY PROTOZOOLOGY
(study of viruses) (study of protozoa)

BACTERIOLOGY PHYCOLOGY
(study of bacteria) (study of algae)

IMMUNOLOGY MYCOLOGY
(study of resistance) (study of fungus)
 CHAPTER 31 Basic Microbiology 943

which test kits are within their waived category and talized. The second name is the species name,
therefore appropriate for the medical assistant which is not capitalized. These names may reflect
and other nonlaboratory medical personnel to a characteristic of a bacterium or names of places
perform. What used to take days and required the or persons associated with the discovery of the
expertise of a laboratory technologist now takes microorganism. For example, Salmonella typhi was
minutes and can be performed within the POL discovered by an American microbiologist named
and sometimes even within patients’ homes. The Salmon. The bacterium causes typhoid fever.
at-home pregnancy tests were probably the first test Individuals who study bacteria are referred to as
kits available over the counter, but now there are bacteriologists or microbiologists. These individuals
literally hundreds. The test kits range from urine have taken extensive courses in the field of microbiol-
testing for cocaine and other drugs to cholesterol ogy. In most laboratories, clinical laboratory scientists
and cancer screening tests. or assistants help perform microbiology procedures.
The job of these individuals is to quickly and effi-
ciently identify the organism in a given culture that
MICROBIOLOGY has been properly obtained and brought to the labo-
ratory within a reasonable time frame.
Classification Together with routine bacteriologic cultures,
many microbiology departments, especially in
Taxonomy deals with the classification of living larger health care facilities, perform parasitology
organisms. procedures for the identification of parasites; virol-
A common system divides living organisms ogy procedures for the identification of viruses;
into kingdoms. Before the discovery of the micro- and mycology procedures for the identification of
scope in the sixteenth century, there were two fungi. If an institution such as a clinic or POL is too
known kingdoms, animal and plant. A new king- small to properly identify many microorganisms,
dom of microscopic organisms, the Protista, was cultures often are sent to a reference laboratory.
developed because most microbes are neither These laboratories are specialized laboratories with
plant nor animal. The members of this kingdom up-to-date equipment to handle large amounts of
are called protists and are one-celled organisms complex tests. In today’s health care environment,
(Table 31-2). it is cost-effective to centralize expensive and com-
The microorganisms of importance in medi- plex procedures. Instead of 10 small laboratories
cal microbiology are divided into two groups: the each having their own specialized equipment, one
lower protists, or prokaryotes (including blue-green laboratory buys the equipment and runs the spe-
algae and bacteria), and the higher protists, or cialized test for all 10 laboratories.
eukaryotes (including protozoa, algae, and fungi). The microbiology department works closely
with the infection control department of a hospi-
Nomenclature tal to determine if certain organisms are causing
infections throughout the hospital. These infec-
The system used for naming bacteria is a two-part tions can be acquired by an immunosuppressed
system of names. Two Greek or Latin names are patient and become a serious problem. Infections
used, the first name being a genus, which is capi- acquired in hospitals are referred to as nosoco-
mial infections and should be closely monitored.
Some common nosocomial infections are caused
Table 31-2 Kingdom Protista by bacteria such as Staphylococcus, Serratia, and
Candida (a yeast).
I. Lower protists Certain types of bacteria and yeasts that
1. Prokaryotic—nuclear material not organized are identified and grown in the laboratory
A. Bacteria must be reported to the Department of
B. Blue-green algae Public Health in your county or state because they
are communicable diseases. These diseases vary
II. Higher protists from city to city and state to state. Some of the com-
1. Eukaryotic—true nucleus mon bacteria that are reported are Salmonella;
A. Algae Shigella; and those organisms that cause sexually
B. Slime molds transmitted diseases (STDs), such as gonorrhea,
C. Fungus syphilis, chlamydia, and herpes. The state and
D. Protozoa county you work in will have a list of reportable dis-
eases that the clinic or POL will have posted.
944 UNIT 7 Laboratory Procedures

Cell Structure spores are so resistant they can live 150,000 years
and can survive in dust. Tetanus is an example of
All living forms are alike in that their cells contain
bacteria that create spores.
a nuclear material referred to as DNA (deoxy-
ribonucleic acid), which carries special genetic
information. The main structural difference of
eukaryotes and prokaryotes is the arrangement of EQUIPMENT
the nucleus. A eukaryote has a well-defined or true
nucleus and is a higher form of microorganism. Basic equipment needed in a microbiology depart-
The prokaryote is a lower form of microorganism ment of a clinic or a POL varies depending on the
and has a simple nucleus that is not well-defined. size of the facility. Most laboratories have some of
The bacterial cell, classified as a lower protist, the following equipment.
is a single-celled organism with a cytoplasmic cell
membrane, cell wall, and nucleus. The nucleus is
not well-defined. The cell grows by taking in mate-
Autoclave
rials from the environment. After a certain amount An autoclave (Figure 31-2) is used in the laboratory
of growth, the bacteria reproduce by division of to sterilize equipment that may have been contam-
the cell. Certain conditions are required for this inated while processing specimens. It can be used
reproduction to take place. to sterilize contaminated materials as well. The set-
Figure 31-1 illustrates a basic bacterial cell. ting of 15 pounds per square inch and a tempera-
Not all bacteria possess flagella for motility, as some ture of 121°C for 15 to 20 minutes is sufficient to
are not motile. Some bacteria can encapsulate kill infectious agents, spores, viruses, and contami-
themselves in protein, providing protection from nants. Many laboratories no longer use autoclaves
antibiotic penetration and white blood cell attack. because of the use of presterilized and disposable
Once encapsulated they are called spores, an inac- equipment. (See Chapter 10 for more information
tive state that can help bacteria resist chemicals, on the autoclave.)
freezing, drying, radiation, and heating. Bacterial
Microscope
An important piece of equipment for the POL
Capsule or clinic is the microscope. This instrument is
used to view organisms that cannot be seen with
Cell wall the naked eye on a prepared slide. Skill in using
the microscope is necessary to gain information
Cytoplasmic membrane from studying the slide. The microscope is a deli-
cate instrument and should be cared for properly
Nucleoid material
as stated by the manufacturer (see Chapter 27 for
more information on the microscope).

Ribosomes

Flagellum

Figure 31-1 Basic bacterial cell. Figure 31-2 Small laboratory autoclave.
 CHAPTER 31 Basic Microbiology 945

Safety Hood oratories post lists of cultures that need an anaero-

bic setup.
Some laboratories, especially if they are
To grow anaerobic bacteria, the absence of
culturing specimens with aerosols, will
oxygen is achieved by using something as simple as
have a safety hood (Figure 31-3). Aerosols
a candle jar (Figure 31-4) containing a lighted can-
are airborne particles that can be released into the
dle into which the inoculated petri dish is placed.
air when culturing. They are potentially danger-
When the cover is put on the jar, the burning of the
ous if inhaled. By using the safety hood, the health
candle will use up the available oxygen and gen-
care worker is separated from the specimen by a
erate carbon dioxide. Organisms such as Neisseria
glass in front of the face, with fumes and aerosols
gonorrhoeae, which causes gonorrhea, need a high
suctioned into the hood. The use of a safety hood
carbon dioxide atmosphere to survive. The use of
is mandatory when performing a culture on a spec-
a candle jar allows an easy collection and transport
imen with a potential aerosol. Aerosols are par-
system that maximizes the recovery rate of certain
ticularly dangerous in fungus and mycobacterium
microorganisms.
cultures. It is a good idea to use the safety hood
Another method of maintaining an anaero-
with foul-smelling specimens to minimize odors.
bic condition is a specialized jar called a gas pack
Tuberculosis is an example of bacteria that travels
jar (Figure 31-5). This jar contains a foil pack that,
by aerosol from person to person.
when activated, gives off carbon dioxide, decreas-
ing the oxygen in the jar. Extensive culturing of
Incubator anaerobes often is not performed by smaller lab-
The incubator is a cabinet that has a constant tem- oratories. Anaerobic specimens are sent to refer-
perature of 35 to 37°C. Most organisms, whether ence laboratories better equipped to process them.
aerobic (grow well in oxygen) or anaerobic (will Some small laboratories will perform a Gram stain
not grow well or at all in oxygen), grow at these tem- on the suspected anaerobic cultures. The Gram
peratures. Some bacteria, such as Yersina, grow at a stain is the most common stain used to observe the
lower temperature (26°C). A bacterium called Cam- gross morphologic features of bacteria and is dis-
pylobacter requires a higher temperature (42°C). cussed later in this chapter.
When working with these organisms, temperature
requirements must be met for adequate growth. Inoculating Equipment
An inoculating loop (Figure 31-6) is a piece of wire
Anaerobic Equipment with a rounded end and a handle at the other end.
Certain types of cultures, such as deep-wound cul- The loop is used to inoculate organisms onto a
tures, could contain anaerobic pathogens. At the
time of culturing, the medical assistant sets up
some cultures in an oxygenated environment, as
well as an oxygen-reduced environment. Most lab-

Figure 31-4 Candle jar with media for high CO2

Figure 31-3 Laboratory safety hood. conditions.
946 UNIT 7 Laboratory Procedures

as “deep” inoculation. The needle is flamed, and

the culture material is “stabbed” on the needle
into medium in a tube. This technique is used for
certain biochemical tests used for identification.

Incinerator
Incineration is the quickest method of steriliz-
ing the inoculating loop and needle. This can be
accomplished by using an electrical incinerator
(Figure 31-8) or a Bunsen burner (less popular
today because of the open flame danger). When
doing cultures, the inoculating needle or loop
must be sterilized before and after it is used. This
is done by placing the loop in the incinerator or
passing through the flame of the Bunsen burner.

Figure 31-5 Gas pack anaerobic system. Media

Media in the microbiology laboratory refers to a
host of substances used to foster the growth of bac-
culture medium in a plate or broth. If it is made of teria. It is listed in this section of basic equipment
wire, the loop can be flamed to sterilize it before (Figure 31-9) but is explained in detail in the sec-
and after use. As an alternative, sterile plastic dis- tion about media.
posable loops can be used. These are one-time use
and are disposed of in the biohazardous waste.
An inoculating needle (Figure 31-7) is similar Refrigerator
to the loop but has a straight end. The needle is A refrigerator is needed to store certain materials,
used when performing a stab culture, also known such as media and testing kits that need a tempera-
ture of 2 to 8°C. Food or drink should never be
stored in the refrigerator with any specimens, kits,
or media.

Figure 31-6 Inoculating Figure 31-7 Inoculating

loop. needle. Figure 31-8 Electrical incinerator.
 CHAPTER 31 Basic Microbiology 947

before and after daily use or immediately after a

spill. Pathogens could be present where microbiol-
ogy specimens are cultivated. This area should be
dust-free and clean at all times.
Care should be taken not to have a cluttered
work area. If using burners or incinerators, caution
should be practiced to avoid body burns or fires.

Specimen Handling
Some microbiology specimens will be brought to
the POL or clinic to be processed, so the medical
assistant should look for leaks and contamination
on the outside of the transporting containers. It is
a good practice always to wear gloves when receiv-
Figure 31-9 Various types of media tubes and plates. ing specimens. Most specimens will arrive in an
“outside” plastic bag to avoid danger to laboratory
personnel. When sending specimens to an outside
laboratory to be cultured, it is important to use
SAFETY WHEN HANDLING the appropriate container to avoid contamination
MICROBIOLOGY SPECIMENS of others. Remember, if there is a possibility of an
aerosol specimen, the specimen must be cultured
Safety should be practiced in every area of under a safety hood. All specimens should be han-
the clinical laboratory at all times. Micro- dled as if they were contaminated (see Chapter 10
biology specimens can be dangerous for more information on Standard Precautions).
because of potential pathogens. Following safety
rules will reduce danger to all personnel con-
cerned. Some important safety measures follow. Disposal of Waste and Spills
Detailed discussions can be found in Chapters 10 Most facilities have a plan for disposal of danger-
and 26. ous biohazardous waste that should be strictly fol-
lowed. Biohazardous waste generally is placed in
Personal Protective Equipment red bags marked with the universal biohazard sym-
bol (Figure 31-10). Most clinics or POLs employ an
Personal protective equipment should be worn outside agency to dispose of waste. It is extremely
at all times when processing microbiology speci- important that biohazardous waste is not placed
mens. It should be removed when leaving the work with the regular waste and disposal guidelines are
area. When processing microbiology specimens, followed.
the medical assistant wears a buttoned laboratory
coat or apron, safety goggles, and gloves. At times,
personnel performing microbiology testing work
behind a shield or use a safety hood to avoid inha-
lation of aerosol pathogens and to avoid splashes BIOHAZARD
and spatters of blood and body fluids.
There is never any eating, smoking, drinking,
or putting objects into the mouth while working
with microbiology specimens or in the laboratory
area itself. Contact lenses should not be touched,
nor should makeup be applied. The practice of
washing hands several times should be a habit.
Washing hands after glove removal is important.

INFECTIOUS WASTE
Work Area
The counters where specimens are processed and
set up should be cleaned with a strong germicide Figure 31-10 Biohazard symbol.
948 UNIT 7 Laboratory Procedures

Figure 31-11A In a total practice management system (TPMS), quality control docu-
mentation can be entered into electronic logs. (SynapseEHR screen shot courtesy of E.S.
Butler.)

If a spill should occur, follow the agency’s or COLLECTION PROCEDURES

employer’s rules. Remember to disinfect with a 5%
phenol or a 10% bleach solution. When a provider needs identification of an organ-
ism that is causing infection, he or she orders a cul-
ture from that site. The culture specimen should be
QUALITY CONTROL collected properly, delivered within a reasonable
period, and collected in sufficient quantity. The
Although quality control is practiced in all areas of results of the culture will depend on the quality
the clinical laboratory, the microbiology depart- of the original specimen. All specimens obtained
ment has equipment, media, and reagents that for identification of infectious organisms must be
need quality-control checks with almost every test.
The following list details some measures that are a
part of a quality-control program in microbiology:
Results from
• All equipment with temperature controls should Regional/ Results to Outside
National Labs Providers
be monitored daily.
• The microscopes should be cleaned and kept dust-
free.
• Testing for microorganism identification is often LABORATORY
accomplished with the use of a special kit. When
using kits for different tests, the positive and nega- Test Reports
tive controls must be run at all times. Before use, Quality Assurance & Controls
Safety Standards
the expiration date should be checked.
• Media of all types should not be used past the shelf
life and should be stored at the proper tempera-
Orders for Tests
tures. Your POL should have a specific list of bacte- Safety Standards
ria to use on various media to test for growth. This
list can be found in your laboratory manual.
• The laboratory manual should be updated periodi-
cally.
• All chemicals or reagents with Material Safety Data
ELECTRONIC
Sheets (MSDSs) should be available to reference
when working with a chemical that is not familiar B
RECORDS
to you.
• Document all quality control testing in proper lab- Figure 31-11B The laboratory arm of the total prac-
oratory logs (Figure 31-11). tice management system (TPMS).
 CHAPTER 31 Basic Microbiology 949

taken from the site of the infection, not the sur- 8. Specimen collected before the administration of
rounding area. antibiotics
Once the specimen is collected correctly, it 9. Specimen inoculated onto proper media and
should be placed in the appropriate container and placed in correct atmosphere to ensure growth
delivered to the laboratory soon after collection.
Many organisms will die if not kept moist. Trans- When collecting specimens, it is important that
port media can have a moistening agent to keep the medical assistant carefully follow the instruc-
the specimen from drying out. tions as designated in the laboratory manual. Stan-
If a specimen comes into the laboratory in dard Precautions must be strictly adhered to while
an improper container or has not been delivered obtaining and processing specimens and everyone
within a reasonable period soon after collec- (including couriers, receptionists, and laboratory
tion, it must be rejected and another specimen assistants) handling specimens should wear gloves
obtained. The container in which the specimen to protect themselves from leakage of the container
has been placed should be sterile, and the right and contamination with a pathogenic organism.
type should be used for a specific culture (Figure
31-12). Sterile containers are used for most collec- Specific Collection Requirements
tions, with the exception of stool collection con-
tainers, which do not have to be sterile. Culturette for Cultures
cultures are from swabs and should be kept moist. Urine. Patients should be instructed to obtain a
This system is a plastic tube that has a sterile swab clean-catch urine specimen in a sterile container.
used to collect the specimen and then is placed A clean-catch midstream specimen is obtained by
back into the tube. The tube contains a medium first cleaning the genital area and then urinating
which keeps the swab moist and preserves the midstream into a specimen container. Details of
specimen. this procedure are found in Chapter 30. Patients
The laboratory’s success in isolating the caus- should be given strict instructions so that a quality
ative pathogens depends on the following factors: specimen for culturing can be obtained.
Sometimes a catheterization is done to col-
1. Proper collection from infection site
lect a sterile urine specimen for culture. The urine
2. Collection of specimen during infectious period must be collected into a sterile container.
3. Sufficient amount of specimen
4. Appropriate specimen container Throat. When taking a throat specimen for cul-
ture, explain to the patient that a throat culture is
5. Appropriate transport medium
necessary to identify certain organisms. Be sure to
6. Specimen labeled properly tell the patient that there may be some momentary
7. Specimen delivered to the laboratory in a minimal discomfort in obtaining the specimen, especially if
amount of time his or her throat is sore. Answer all questions about
the process of obtaining the specimen. Throat cul-
ture specimens are taken using the culturette. As
mentioned in the previous section, the culturette
contains a sterile swab and growth medium for
moisture to keep the bacteria viable.
Once you have gathered all the necessary sup-
plies (see Procedure 31-1) and put on gloves and a
face shield, have the patient open his or her mouth
and say “ah.” This will lower the back of the tongue
for better viewing (Figure 31-13A). Be sure to have
a good light source available. Use a sterile tongue
depressor to help hold the tongue down. While
avoiding the tongue and inside of the cheeks, take
the specimen directly from the affected area with
the sterile swab. Once the specimen is obtained on
the swab, place the swab back into the culturette
(Figure 31-13B). The culturette is now ready for
Figure 31-12 Various collection and transport con- labeling and transport to the laboratory for testing
tainers for bacteriologic specimens. (Figure 31-13C). As with any culture test ordered,
950 UNIT 7 Laboratory Procedures

Patient Education
As you obtain throat cultures from patients,
you may want to give them some helpful
advice concerning their condition. Generally
when a person has a sore throat, it is
associated with other respiratory symptoms
as well. The following suggestions may
provide some relief from discomfort and help
patients toward better health.
1. Advise patients to drink plenty of liquids,
especially water, and to eat sensibly from
the basic food groups. A
2. Urge patients to get extra rest and dress
comfortably (according to the weather/
temperature outside).
3. Suggest use of gargles or throat lozenges
(or both) to relieve painful sore throat.
4. Remind patients to avoid tobacco/
smoking.
5. Instruct patients to cough/sneeze into
tissue and discard into proper waste
container wherever they are to prevent the
spread of microorganisms. Because sewer
waste is treated and disinfected, flushing
a contaminated tissue is an effective
method of disposal.
6. Remind patients to refrain from sharing
drinking glasses and tableware and from B
intimate contact such as kissing while they
are infected and still contagious. All eating
utensils should be sanitized in hot water
after use to avoid the spread of contagious
diseases. Perhaps the most important
educational advice is reminding patients
to wash their hands frequently.

a requisition stating the site from which the speci-

men was obtained is required.
Throat swabs for the detection of group A
Streptococcus infection (strep throat) usually are
tested in the POL using a self-contained kit that C
produces quick results (see Procedure 31-3). Per-
forming the rapid strep tests are well within the Figure 31-13 (A) The medical assistant obtains a
medical assistant’s scope under CLIA’s waived test throat culture using a culturette, taking care to not
category. More information about performing touch the cheeks or tongue. (B) After swabbing the
rapid strep tests is provided later in this chapter in patient’s throat, the medical assistant returns the swab
the section on Streptococcus Screening. to the culturette, which contains the moist media.
(C) The culturette is labeled, and a requisition is
Nose. A nasopharyngeal swab may be requested completed in preparation for transport to the regional
with a throat culture. This is collected with a swab laboratory for testing.
 CHAPTER 31 Basic Microbiology 951

on a thin wire. A separate swab may be used for 18-22). The fluid generally is dispersed in several
each nostril. The patient tilts back the head, and departments of the clinical laboratory. Generally,
each swab is gently inserted into each of the nos- the fluid goes first to the microbiology laboratory
trils. The swab is then placed into a sterile tube for a culture before it becomes contaminated by
and kept at room temperature for transport to the doing other tests. Before the culture set up, the
laboratory. tube should be placed in an incubator or left at
room temperature. Refrigeration of spinal fluid
Wound. When culturing a wound, a sterile needle can kill two common meningitis-causing bacteria,
might be used to aspirate pus-filled fluid from the Haemophilus influenzae and Neisseria meningitidis.
wound, or a swab is used. It is important to get the CSF culture is a STAT order for processing, and
swab deep into the wound without touching the the medical assistant is responsible for calling the
surrounding skin. Specimens for wound cultures laboratory for immediate pickup.
often are placed in anaerobic transport medium,
especially if the wound is not superficial. Blood. Human blood is free from bacteria in a
healthy human. If blood does become contami-
Sputum. To collect this specimen correctly, the nated with bacteria, septicemia (septic blood infec-
patient should cough deeply and expectorate into tion) can result. Blood cultures are collected by
the sterile container (Figure 31-14). The specimen the same means as regular blood collection, with
should be a first morning specimen and placed special considerations to avoid any contamination
into a sterile container designed to protect all who of the blood. A variety of collection devices are
handle the specimen from contamination. available for collecting blood cultures, all requir-
ing careful sterile techniques (see Procedure 29-4
Stool. Stool specimens are brought to the labora- for blood culture).
tory for various tests. If the stool is to be examined
for ova (eggs) or parasites, the specimen should
be as fresh as possible. Special containers often are MICROSCOPIC EXAMINATION
used for ova and parasites. Stool specimens must OF BACTERIA
be kept at between room temperature and body
temperature. Refrigeration may destroy the para- There are usually two procedures involved in prop-
sites within the specimen. erly identifying bacteria: the microscopic examina-
For bacterial cultures of stool (as well as for tion and the culture. The microscopic examination
ova and parasites), several different specimens involves viewing stained or unstained bacteria
may be sent for testing at different times. The col- through the microscope.
lection containers for stool cultures do not have to Culturing is a means of isolating a disease-
be sterile, but they must be clean and have a tight- causing microorganism for identification. A speci-
fitting lid (see Procedure 31-4). men is obtained and placed in a culture medium,
which contains nutrients comparable to human tis-
Cerebrospinal Fluid (CSF). The provider obtains sue to encourage growth of microorganisms. The
CSF by doing a lumbar puncture (see Procedure medium is agar, a gelatin-like substance, mixed
with nutrients. The nutrients mixed in the agar
will vary according to what each particular bacte-
rium prefers. The section on Culture Media later
discusses in detail the types of nutrients each type
of bacterium prefers. Table 31-4 lists the more com-
mon bacteria and their growth requirements.
Microscopically identifying bacteria is not in
CLIA’s waived categories; therefore, although the
medical assistant will not actually perform these
tests, the staining information is included here to
aid in understanding the staining and examination
processes that culture specimens go through. It is
important for medical assistants to be familiar with
the processes and the terminology related to stain-
ing and microscopic identification of bacteria to bet-
Figure 31-14 A patient gives a sputum sample. ter serve their patients, employer, and colleagues.
952 UNIT 7 Laboratory Procedures

Bacterial Shapes The microscopic examination produces infor-

mation that is often needed to identify bacteria.
Each genus of bacteria has a characteristic shape. A However, biochemical reactions and the sensitivity
knowledge of the shapes of bacteria helps in iden- pattern (how the organisms respond to antibiotics)
tification. Bacteria have three basic shapes: are also needed to make the full identification.
1. Cocci. Cocci (Figure 31-15) are round in shape,
occurring in clusters, pairs, singles, and tetrads Dyes (Stains)
(groups of three). They are nonmotile micro-
organisms. (They do not move on their own The dyes used in microbiology are derived
accord.) from coal tar. These dyes are acidic or basic and
impart a color to the microorganism. Basic dyes
2. Bacilli. Bacilli are rod-shaped and can have carry a positive ion and stain structures that are
rounded, straight, or pointed ends (Figure 31-16). acidic in nature. An acid dye carries a negative
Some bacilli have flagella that give bacteria motil- ion and stains structures that are basic (alkaline)
ity (movement). Most bacteria are the shape of in nature such as cytoplasmic structures. Several
bacilli. different types of stains are used depending on
3. Spirilla. Spirilla are spiral-shaped bacteria that what test is ordered. (Table 31-3 lists stains and
have one too many turns (Figure 31-17). Most spi- their uses.)
rilla are motile.

Bacilli (rod)
Cocci (round)

Flagella

Bacillus (flagellated) Diplobacillus

Diplococcus Staphylococcus

Streptobacillus

Streptococcus
A
A

B B

Figure 31-15 (A) Cocci (round). (B) Cocci, as seen Figure 31-16 (A) Bacilli (rod). (B) Bacilli, as seen
through a microscope. through a microscope.
 CHAPTER 31 Basic Microbiology 953

Spirilla (spiral)
Differential Stain
A differential stain is more complex than a simple
stain. It is known as a differential stain because the
stain result varies. A common differential stain is
the Gram stain.
The Gram stain was developed in 1884 by Dr.
Hans Christian Gram. More than 100 years later,
Spirilla Spirochete this famous stain is still in use with little variation.
A This staining procedure differentiates bacteria by
their Gram stain ability of being either negative
or positive. A bacterium is Gram negative or posi-
tive by the nature of the cell wall and the ability
of it either to retain or lose color through decol-
orization. This identification of Gram-positive or
Gram-negative bacteria aids in identification of an
organism. Gram-positive bacteria have a lower lipid
(fat) content and are not decolorized as compared
with Gram-negative bacteria, which have a higher
lipid content and are readily decolorized.
The reagents used in the Gram stain are gen-
tian or crystal violet, a purple stain that is the pri-
mary stain. Iodine, which acts as a mordant, holds
B the purple stain. Alcohol-acetone is the decolor-
izer that removes the purple color. Safranin is the
Figure 31-17 (A) Spirilla (spiral). (B) Spirilla, as seen
red counterstain. When stained according to the
through a microscope.
manufacturer’s directions, the Gram-positive bac-
teria stain purple, and the Gram-negative bacteria
stain pink. Sometimes an organism will appear
Simple Stain Gram-variable. This is found with Gram-positive
A simple stain uses a single stain on a fixed slide organisms that have been exposed to acidic media,
for a given period of time. A simple stain shows the that are often old and lose their ability to retain
arrangement and structure of the bacterial cell. It the gentian violet, or the proper procedure has
is fast, taking no more than 3 minutes to stain, but not been followed (Figure 31-18).
it does not give much information. The Gram stain is one of the most important
procedures in the microbiology laboratory, giving
valuable information by identifying Gram-positive
bacteria such as Staphylococcus and Streptococcus or
Gram-negative bacteria such as Escherichia coli and
Table 31-3 Stains and Their Uses
Proteus.
The morphologic arrangement, shape, and
Stain Example Gram stain characteristic will begin to help iden-
tify the bacteria. Sometimes this is all the physician
Carbolfuchsin
needs to know to start treatment for a pathogenic
Gentian violet organism. For example, the bacteria causing gon-
Simple
Methylene blue orrhea (Neisseria gonorrhoeae) is a distinctive organ-
Safranin ism, having a characteristic diplococci shape that
resembles a coffee or kidney bean. These organ-
Gram isms are found in and outside of white blood cells
Differential
Acid-fast (Ziehl-Neelsen, Kinyoun) and can be identified by a Gram stain.
Capsule (Welch negative)
Acid-Fast Stain
Flagella (Leifson)
Special Another differential stain, which is often referred
Nuclei (Feulgen)
Spore (Doerner) to as a specific stain, is the acid-fast stain. This stain
is either differential or specific in that it allows
954 UNIT 7 Laboratory Procedures

Step Time Procedure Result

1 1 minute Primary stain: Apply crystal All bacteria stain purple

violet stain (purple)

↓
Rinse slide

2 1 minute Mordant: Apply Gram’s iodine All bacteria remain purple

↓
Rinse slide

3 3 to 5 seconds Decolorize: Apply alcohol Purple stain is removed

from Gram-negative cells

↓
Rinse slide

4 1 minute Counterstain: Apply safranin Gram-negative cells appear pink-red;

stain (red) Gram-positive cells appear purple

↓
Rinse slide

Figure 31-18 Steps in the Gram stain procedure.

microscopic examination of acid-fast organisms. Characteristics that can be studied by this method
This group of organisms does not respond well to include motility, shape, and arrangement of organ-
the Gram stain and is difficult to stain under ordi- isms. This technique requires the microorganisms
nary circumstances because of a waxy capsule cell to be in a liquid suspension. The medical assis-
wall that resists staining. tant often is responsible for setting up the slide
To stain these organisms, heat or a powerful for microscopic examination by the provider.
dye is used in the procedure to stain the bacteria. Although microscopy is not a CLIA waived test,
The bacteria, once stained, resist decolorization the medical assistant can certainly view the slides
with an acid alcohol, giving them the acid-fast microscopically and discuss the finding with the
name. The bacteria that causes tuberculosis is an provider as a learning exercise.
acid-fast organism. For vaginal secretions, a swab of the vaginal
Two methods commonly used to stain acid- discharge is placed in a sterile tube containing 1
fast organisms are the Ziehl–Neelsen stain, which mL normal saline and mixed. Then the suspension
uses heat, and the Kinyoun stain, a cold method is viewed under a microscope. For stool or other
that does not include a heating process. Either of bacterial specimens, a small amount of specimen
these stains is satisfactory. is mixed with a drop of normal saline, then viewed
under a microscope. These methods are known as
the wet-mount preparation and the hanging drop
Special Techniques preparation (see Procedure 31-2).
There are several special situations when more The wet-mount preparation is a valuable diag-
than the Gram stain or the shape and arrangement nostic tool in determining the cause of vaginosis.
of an organism is needed to aid in the identifica- Bacterial vaginosis is identified by the presence of
tion. Such situations would be the demonstration “clue cells,” epithelial cells covered by coccobacil-
of the presence of flagella, spore, capsule, or nuclei lary bacteria. Motile trichomonads are seen with
of cells. Trichomonas vaginalis. The presence of pseudohy-
There also are microscopic examinations phae indicates a yeast infection. In many cases,
of organisms in a living state, without staining. an accurate diagnosis can be made from the wet-
 CHAPTER 31 Basic Microbiology 955

mount preparation, thus making more complex bility. Some bacteria require a specialized medium
techniques unnecessary. to grow and multiply. Aerobic bacteria grow only
in the presence of oxygen. Anaerobic bacteria live
and grow in the absence of oxygen. Examples of
Potassium Hydroxide Preparation common bacteria and their growth requirements
Another type of wet preparation is using 10% solu- are listed in Table 31-4.
tion of potassium hydroxide (KOH) in a wet prepa- When specimens are collected for the labo-
ration for the study of fungi and spores. The slide is ratory, the microorganism’s growth requirements
prepared by using fragments of human hair, skin, must be considered. No matter how good the
or nails that could have fungus. KOH wet mounts specimen, if an anaerobic organism is kept in an
are also useful for examining other body fluids aerobic atmosphere while being transported to
such as vaginal swabs. These specimens are placed the reference laboratory, it will probably not sur-
on a slide with a drop of 10% KOH and a cover- vive. Special anaerobic transport systems must be
slip on top. The KOH will clear debris. The slide used.
should sit at room temperature for about a half Neisseria gonorrhoeae, the causative agent of
hour before examination for debris settlement. the STD gonorrhea, requires special media and an
The direct examination of specimens is best atmosphere of reduced oxygen and increased car-
viewed with a phase or dark-field microscope bon dioxide. Therefore, the specimen must be col-
rather than a bright-field microscope because of lected from the patient and immediately placed on
reduced illumination. If using a bright-field micro- a special media in a reduced oxygen atmosphere.
scope, lower the condenser to reduce transmitted Medical assistants who send bacterial speci-
light. Proper disposal of these specimens is impor- mens to a reference laboratory must be familiar
tant because the organisms are alive and possibly with the transport media the reference laboratory
pathogenic. provides. Your laboratory manual explains how
and when to use the various microbiology trans-
port systems.
CULTURE MEDIA Media can be a solid, liquid, or semisolid sub-
stance that has the required nutrients to support
After the proper collection of the specimen, the the growth of bacteria. Such ingredients include
material collected must be inoculated on a proper vitamins, sugar, salt, minerals, and amino acids.
culture medium. This is necessary for growth and Some media have the addition of special products
eventual identification of an organism. such as egg, potato, meat, milk, blood, and dyes.
The results of culture, the growing of an The solid form of media is called agar. Agar
organism on special media in the laboratory, are has an appearance similar to gelatin and is made
only as reliable as the method used in collecting of seaweed. When heated, agar is a liquid; when
the specimen. In addition, growth requirements cooled, it solidifies. Agar is poured into a petri dish
of different organisms must be considered, such (a plastic dish used to grow bacteria) so the bacte-
as moisture, temperature, oxygen, carbon dioxide, ria can be studied for gross morphology (form and
and essential nutrients. Organisms that are sensi- structure). Agar can also be placed in tubes.
tive to drying must be put into transport medium Semisolid media is made by adding less agar.
immediately after collection to prevent loss of via- Media in a liquid broth form is stored in tubes

Table 31-4 Common Bacteria and Their Growth Requirements

Oxygen
Organism Disease Medium Requirements

Streptococcus Strep throat Blood agar ↓O2, ↑CO2

Neisseria Gonorrhea Chocolate agar, modified Thayer-Martin (MTM) ↓O2, ↑CO2

gonorrhoeae

Staphylococcus Infections, boils Blood agar O2

Escherichia coli Urinary tract infection Blood agar, eosin methylene blue (EMB), MacConkey O2
956 UNIT 7 Laboratory Procedures

called broth tubes and allows for the observation • Enriched. This type of medium contains substances
of gas production, change in pH, and odor. Fig- that inhibit certain bacteria from growing. These
ure 31-9 shows many different types of media that media work well with cultures from sites that pos-
can be used to identify bacteria. Media can be pur- sess normal flora, such as the throat. The normal
chased already prepared, or it can be produced flora is inhibited and pathogenic bacteria are
from ingredients in the laboratory. Charts listing encouraged to grow. Blood agar and chocolate
the proper media to set up for specific types of cul- agar are examples of enriched media.
tures generally are prominently displayed in the All media that are used should first be
setup area of most microbiology laboratories. checked with known organisms for quality control
and for contaminants. The manufacturer will usu-
Media Classification ally suggest a list of organisms for a quality-control
There are several classifications of media, including: check. A check for contaminants involves a thor-
ough visual check of the plate before using it. It
• Basic. Basic media are used for general purposes is also important to store media according to the
and do not contain added nutrients. They will sup- manufacturer’s direction. Never use outdated media.
port the growth of many Gram-negative and Gram- Table 31-5 lists common media by classifica-
positive organisms. tion and use. Table 31-6 lists media that might be
• Differential. Differential media contain substances selected for specific sources. All laboratories vary
that alter the appearance of some types of organ- slightly in their recommendations of media to set
isms and not other types. An eosin methylene blue up on specimens.
(EMB) plate for lactose and nonlactose fermenters
is an example of differential media. The lactose
fermenter can use lactose and looks different on
MICROBIOLOGY CULTURE
the agar.
• Selective. Selective media support the growth of one
Inoculating the Media
type of organism while inhibiting the growth of After selecting the correct medium for the culture
another. This is done by the addition of a salt, dye, and observing the specimen to make sure it is prop-
chemical, or antibiotic. A hektoen enteric (HE) erly collected, the specimen is inoculated onto the
plate for the growth of salmonella and shigella is a medium. If the specimen is on a swab, the swab is
selective type of medium. rolled directly onto the upper quadrant of the agar

Table 31-5 Common Microbiology Media by Classification and Use

Type Name Use

Trypticase agar Supports the growth of most organisms

Basic
Trypticase broth

Blood agar Supports the growth of Streptococcus and Staphylococcus; demonstrates

MacConkey hemolysis
Differential
Eosin methylene blue (EMB) Certain Gram-negative organisms
Escherichia coli

Salmonella and Shigella (SS) Gram-negative Salmonella and Shigella

Hektoen Enteric organisms
Phenylethyl alcohol Inhibits Gram-negative growth
Selective Mannitol salt Promotes growth of Staphylococcus
Selenite (GN) broth Promotes growth of enteric organisms
Thayer-Martin Promotes growth of Neisseria species
Thioglycollate broth Promotes growth of anaerobes

Loefflers Promotes growth of Corynebacterium

Enriched Chocolate Promotes growth of Haemophilus species
Lowenstein-Jensen Promotes growth of mycobacteria
 CHAPTER 31 Basic Microbiology 957

Table 31-6 Common Specimens, Suspected Pathogens, and Media Recommendations

Hektoen Enteric
Methylene Blue

Thayer–Martin

Thioglycollate
and Shigella
MacConkey

Salmonella
Blood agar

Chocolate

Selenite
Eosin

CO2
Specimen Source Potential Pathogens

Neisseria gonorrhoeae x x x x x x x
Haemophilus species
Staphylococcus aureus
Eye/Ear
Streptococcus pyogenes
Pseudomonas aeruginosa
Moraxella species

Neisseria meningitidis x x x x
Cerebrospinal fluid Streptococcus pneumoniae
Haemophilus influenzae

Throat Streptococcus pyogenes x x

Sputum Streptococcus pneumoniae x

Escherichia coli x x x
Klebsiella
Urine Proteus
Pseudomonas aeruginosa
Enterococcus

Staphylococcus x x x x x x
Streptococcus
Wounds
Enterobactericae
Anaerobic bacteria

Salmonella x x x x
Stool
Shigella

Pathogenic E. coli
Stool
Yersinia species

Vaginal Neisseria gonorrhoeae x x x x

plate. If the specimen is a sputum or liquid, it is because of gas production by some organisms that
inoculated onto the plate with a loop. can break the tube.
The inoculum is spread back and forth in a
sweeping motion with a flamed loop or needle.
After the agar plate has been inoculated and
Other Types of Streaking
properly labeled, it should be turned upside down Other types of streaking include the lawn streak.
and placed in the proper environment for growth. This streaking technique is used to place an organ-
By turning the agar upside down, any condensa- ism over an entire area of an agar plate for sensi-
tion that forms from bacterial growth will be on tivity testing. The bacteria is spread over the entire
the inside lid. plate using a swab (Figure 31-19), streaking over the
Liquid broths and agar slant tubes have screw entire area several times from different angles. After
caps. These caps must not be screwed on too tightly the streaking has been completed, disks saturated
958 UNIT 7 Laboratory Procedures

Primary Culture
After the media has been incubated for 24 to 48
hours, the initial or primary culture is read.

Subculture
When working with bacterial cultures, there can
be more than one pathogen growing in the cul-
ture. For instance, a wound culture may have both
Gram-positive and Gram-negative organisms grow-
ing. To identify each organism, you must separate
these bacteria to other media (Figure 31-21). It is
also necessary at times to separate the pathogenic
bacteria from the normal flora, as in the throat and
sputum cultures. Some initial cultures do achieve
Figure 31-19 Lawn or spread streak.
excellent isolation without having to subculture.

with different antibiotics are placed equidistant RAPID IDENTIFICATION

throughout the streaked area (Figure 31-20B). SYSTEMS
The colony count is a streaking technique
much like the lawn technique. This technique is The age of high technology and computerized
used to plate urine cultures. A special calibrated equipment has also made inroads into microbiol-
urine loop is used to make the first streak, followed ogy laboratories, clinics, and POLs. Many tradi-
by a second streak that goes across the entire length tional methods of identifying bacteria have been
of the initial streak. Then another complete streak- replaced by rapid identification test kits.
ing is placed over the original streaks after rotating Rapid test systems, which are CLIA waived,
the plate (Figure 31-20A). This method of using a give a quick identification, are economical, and
calibrated loop to get a more accurate inoculation allow the provider to start treatment sooner. Rapid
gives the provider an idea of how many colonies of tests allow the provider to receive results while the
bacteria are present. patient is still in the office.
Every laboratory will use slightly different
ways of performing the basic streaks. The impor- Streptococcus Screening
tant factor is to use good aseptic techniques so
there is no contamination from outside organisms,
(Rapid Strep Testing)
and all organisms that are streaked out are isolated A number of instant or rapid test kits identify group
enough to test further if necessary. A Streptococcus (also known as beta-hemolytic Strepto-

Culture swab Inoculating loop Same loop

(sterile before (do not resterilize)
pass begins)
A B

Figure 31-20 Colony count streak.

 CHAPTER 31 Basic Microbiology 959

Figure 31-21 Stages of spreading out the bacteria to isolate colonies.

coccus group A), the causative agent of a serious sore sure there is no infection present. Latex aggluti-
(strep) throat. It is important to identify this Gram- nation kits can give false readings, and it is best to
positive Streptococcus as soon as possible because the follow up with the throat culture. A list of all the
bacteria can cause serious damage (i.e., kidney and CLIA waived rapid tests is available at the CDC
heart valve damage) if not treated immediately with Web site (http://www.cdc.gov) using the search
antibiotics. words Waived Tests.
This test is sensitive and eliminates false-
positive results. The directions should be fol-
lowed strictly to produce an accurate test result. SENSITIVITY TESTING
The results are based on color development of a
spot on the test filter. Test results are available in Antibiotic sensitivity testing often is ordered on the
minutes. pathogenic organisms recovered from the cultur-
A latex agglutination test for group A Strepto- ing process. By setting up an antibiotic sensitivity
coccus is based on an antigen and antibody agglu- test, the laboratory can identify which antibiotics
tination. A throat swab is placed directly on the destroy the pathogen, and the provider will be
antibody-coated slide, and the presence of a posi- able to set up antibiotic treatment for the patient.
tive test is seen by the appearance of agglutination Today’s health care environment demands that
(clumping). Although these tests are quick and this information be made available to the provider
convenient, the following rules should be followed as soon as possible.
strictly: When a patient has had multiple bacterial
infections and the provider is concerned with pre-
• Read and understand the manufacturer’s instruc- scribing an ineffective antibiotic, or when the bac-
tions and directions before starting the test. terial infection is not responding to the currently
• Never use outdated materials. prescribed antibiotic, the provider will order a cul-
ture and sensitivity (C&S). The antibiotic that is
• Observe all safety guidelines and precautions.
effective against the culture bacteria is reported as
• Use the correct swab in taking the throat culture. “sensitive to,” and the antibiotics that are not effec-
Some cottons and chemicals on swab will interfere tive will be reported as “resistant to,” meaning that
with the test reagents. If possible, use the swabs the bacteria will be sensitive to some antibiotics
provided with the kit. and resistant to others.
• Always run the positive and negative control To determine which antibiotic will destroy
together with the patient’s actual test. the culture bacteria, the technician places small
discs on the culture plate. The discs contain vari-
If a patient has symptoms of an infected ous antibiotics. The antibiotic to which the bacte-
throat and the slide test is negative, the provider ria is sensitive will eventually become surrounded
will also order a regular throat culture to make by an area of no growth (Figure 31-22).
960 UNIT 7 Laboratory Procedures

erly, understands how and where to transport the

specimen, how to maintain the proper tempera-
ture of the specimen, and even how quickly the
specimen must be returned to the laboratory.

Examination Methods
The most common methods of fecal specimen
examination for parasitic identification in a clinic
or POL is the direct wet-mount slide.

Specimen Collection
Fecal specimens for identification of ova and para-
sites should be collected in wide-mouth containers
with a tight lid to prevent leakage. The container
should be put in a biohazard transport bag to
avoid contamination and sent for examination
immediately. The patient should be instructed not
to contaminate the specimen with urine because it
Figure 31-22 Culture plate showing antibiotic discs could interfere with testing. Special vials contain-
on bacteria. Note the one antibiotic disc in the top left ing formalin are also available for ova and parasite
area that the bacteria are totally “resistant to.” Most of testing that are preferred by some laboratories.
the other antibiotics have carrying degrees of effective- Refer to the laboratory user’s manual for specific
ness and would be labeled “sensitive to.” The one just instructions.
right of the center area is barely effective and would be The laboratory procedure for collection and
reported as “intermediate.” processing of the parasite specimen should be
strictly followed to provide an accurate testing of
the specimen. The collection time of the specimen
PARASITOLOGY should be followed as directed by the provider.
Three specimens may be ordered over a speci-
With the age of travel and more public aware- fied period. Provider’s offices will have specific
ness, we are beginning to see more parasitic infec- instructions and containers with a preservative
tions. The field of parasitology is a vast one with in them when an ova and parasite examination is
many different types of parasites. They range from requested.
extremely small microscopic ones to those that When the specimen is sent for testing, it
are large and macroscopic in size. Parasites have should be labeled correctly with the patient’s name,
varying life cycles. The degree of severity of illness date, and time of the specimen. It is important to
depends on which parasite enters the human body know if the patient has been traveling, to what area
and infects it. Parasites can be found in the blood, of the world, and what is suspected by the provider
urine, or feces. The more common ones are found to help aid in identification (see Procedure 31-4).
in the feces.
Different geographic areas have different
types of parasites that are seen. Resettled immi-
Common Parasites
grant populations may be infected with a parasite Some of the more common parasites identified in
previously unseen in a geographic area. World trav- the POL are Enterobius vermicularis, the causative
elers can also bring back rare parasitic infections organism of pinworm infection, and Trichomonas
from their adventures. vaginalis, a parasite that infects the urogenital
Even though parasitology tests are performed tracts of men and women.
by medical technologists rather than medical assis-
tants, the medical assistant must be able to prop- Enterobius vermicularis. This nematode (round
erly obtain the sample (such as a throat culture worm) is found worldwide, predominantly in chil-
or wound culture), instruct the patient on how to dren. The adult worm is shaped like a pin, wide at
properly obtain the sample (such as a stool sam- one end and pointed at the other end. The female
ple), and make sure the patient is prepared prop- worm is larger than the male. Infection with pin-
 CHAPTER 31 Basic Microbiology 961

worm can cause severe itching, irritability, and

Name
insomnia, depending on the severity of the infec-
tion. The adult female worm migrates to the anus
at night, depositing ova (eggs) that cause itching A
during hatching. At times, the adult worm can be Slide with tape and label
found around the anus and on the stool. The adult
worm measures approximately 7 to 12 mm long.
The egg is the infectious stage of the parasite (Fig-
ure 31-23).
To diagnose the presence of the parasite,
either the adult worm or ova has to be located in
the specimen. A negative test should be confirmed
by as many as six negative tests performed. The test
is performed by taking a cellophane tape swab and
Loop tape over end of
placing the sticky side down to the skin around the tongue depressor to
anal area. The tape is placed on a slide and brought expose sticky surface
to the laboratory for examination (Figure 31-24).
B
Trichomonas vaginalis. This parasite is found
in both men and women, but its presence is five
times higher in women (men can harbor the
organism for years without symptoms). Because
men can harbor this parasite and have no symp-
toms, it is recommended that both partners be
treated. This will prevent the ongoing reinfection
of the female patient. The organism belongs to the
flagellate (possesses flagella) class and is extremely
motile. Infection with this flagellate causes a puru-
lent yellowish green discharge and dysuria. The C
organism is recovered from the discharge or urine Press sticky surfaces against perianal areas
and is transmitted sexually.
Name

The trichomonad is recovered in a wet prep-

aration slide of spun urine or vaginal secretion
mixed with a drop of saline (see Procedure 31-2.)
The specimen should not be contaminated with
fecal material, which could contain Trichomonas
D
hominis, another flagellate. The prepared slide is
Replace tape

Figure 31-24 Technique for preparing and using a

cellophane tape swab.

Online Images and Information

about Parasites
The Centers for Disease Control and Prevention (CDC) has an
extensive Web site with a wealth of information about many
health issues. Of particular interest to medical assistants and
other health care professionals interested in parasites is the
DPDx, a Web site that is maintained by the CDC’s Division of
Parasitic Diseases. Go to http://www.dpd.cdc.gov/dpdx and
click on Image Library for a great college-level epidemiology
Figure 31-23 Pinworm ova, as seen through a micro- image library.
scope. (From CDC, Atlanta, GA.)
962 UNIT 7 Laboratory Procedures

larger laboratories and specific reference labora-

tories. Identification of two of the common fun-
gal infections can be made quickly in the clinic or
POL.
The genus Candida has several species that
cause yeast infections in the body. Candida species
are also present in the environment around us.
They present a particular problem in the health
care setting where they can cause serious nosoco-
mial infections. Equipment can be easily contami-
nated with Candida organisms.
Yeast infections commonly are found on the
moist areas of the body and in the subcutaneous
tissue. An infection with yeast can range from mild
to serious. Candida albicans is the causative agent of
vaginal yeast infections. The specimen is examined
microscopically for the characteristic budding
yeast forms (see Procedure 31-2). If the specimen
is fluid and clear, it is placed on a slide with a drop
of saline. If the specimen is thick, it should be
mixed with 10% KOH (one drop) on the slide to
clear away debris. Once the specimen is prepared,
Figure 31-25 Trichomonas in stained urine sediment. it is examined microscopically.
Another group of significant fungi that some-
examined under the low and high objectives of the times can be generally identified are the dermato-
microscope to observe the motility and morphol- phytes. These fungi cause infections on the hair,
ogy of the parasite (Figure 31-25). There are also skin, and nails. The microscopic structure of these
test kits and fluorescent stains used to diagnose fungi is detailed. Some of the fungi that cause
this parasite. dermatophytic infections can be diagnosed using
a Wood’s lamp. This is a lamp with an ultraviolet
light. Some dermatophytes will fluoresce (glow
MYCOLOGY brightly) under this light.
Mycotic infections can also be identified
The field of mycology and the infections that cause through culture and kit identification systems.
fungi are extensive. Most identification and sensi- Fungi can produce heavy aerosols and should be
tivities testing for fungal organisms take place in processed and observed under a safety hood.

Procedure 31-1
Procedure for Obtaining a Throat Specimen for Culture
STANDARD PRECAUTIONS: EQUIPMENT/SUPPLIES:
Tongue depressor
Culture tube with applicator stick or commercially
prepared culture collection system (culturette)
PURPOSE: Label and requisition form
To obtain secretions from the nasopharnyx and tonsil- Gloves and face shield
lar area for means of identifying a pathogenic micro- Good light source
organism.

continues
 CHAPTER 31 Basic Microbiology 963

Procedure 31-1 (continued)

PROCEDURE STEPS: 8. Place the swab back into the culturette using
1. Identify yourself and explain the procedure to sterile technique and crush the glass capsule
the patient. RATIONALE: Identifying yourself containing the culture media. (NOTE: Some cul-
helps establish professional trust and rapport turettes require a puncturing action to release
with the patient. Explaining the procedure the media. Follow the manufacturer’s instruc-
allows the patient to understand the process and tions.) RATIONALE: Using sterile technique
encourages cooperation. avoids contaminating the specimen and hav-
2. Have an emesis basin and tissues ready. RATIO- ing the specimen contaminate any other area.
NALE: You will want to be prepared in case the Crushing the glass capsule (or piercing the cul-
patient spits up or vomits. ture membrane) releases the culture medium,
which will maintain the optimum environment
3. Have the patient in a sitting position. RATIO- for the specimen until it is tested at the regional
NALE: The patient in a sitting position will facili- laboratory.
tate better visualization of the throat area.
9. Label the culturette according to the POL policy
4. Wash hands, gather supplies, and apply gloves and requirements. RATIONALE: Proper and timely
and face shield. RATIONALE: Washing hands labeling of all specimens ensures that samples will
before any patient contact will eliminate con- not be mixed up with other patient samples.
tamination. Gathering equipment before begin-
ning the procedure ensures less chance of errors 10. Ensure patient comfort and answer any ques-
caused by missing supplies. Gloves and a face tions related to the testing. RATIONALE: Ensur-
shield will offer personal protection in case the ing patient comfort and answering questions will
patient coughs, spits up, or vomits. establish professional rapport.

5. Ask the patient to open his or her mouth wide 11. Discard contaminated supplies into a biohaz-
and then adjust the light source. RATIONALE: ard waste container. Disinfect all work surfaces.
A widely opened mouth and properly adjusted Remove gloves and face shield and discard
light source will facilitate better visualization of appropriately. RATIONALE: Following Standard
the throat area. Precautions when disposing of contaminated
supplies and disinfecting work surfaces will elim-
6. Remove the swab from the culturette using ster- inate biohazard contaminations.
ile technique. RATIONALE: Using sterile tech-
nique maintains the sterility of the swab, which 12. Wash hands. RATIONALE: Gloves protect hands
results in a quality specimen for culture. from most but not all infectious microorganisms.
Washing hands will remove residual powders and
7. Ask the patient to say “ah.” Depress the tongue latex.
with the tongue depressor and swab the back of
the throat and tonsillar area. Concentrate pri- 13. Complete the laboratory requisition and record
marily on any red, raw areas and pustules. Take procedure in patient’s chart or electronic medi-
care to not touch the swab on the inside of the cal record. RATIONALE: Completing the labora-
cheeks or on the tongue. RATIONALE: Hav- tory requisition properly and in a timely manner
ing the patient say “ah” lowers the back of the will give the regional laboratory accurate infor-
tongue. Depressing the tongue reminds the mation regarding the patient and the specimen.
patient to keep the mouth opened and assists in Charting the procedure will establish a timeline
keeping the back of the tongue down. Swabbing and document the procedure.
only the tonsillar area and the back of the throat
without touching the inside of the cheeks or the DOCUMENTATION
tongue ensures that the specimen will contain 1/12/20XX 10:11 AM Throat culture specimen obtained
mostly the bacterial infectious agent (strepto- and sent to Inner City Laboratory for C&S. Patient tolerated
cocci), if present, and not normal mouth flora the procedure well and will return for a follow-up visit and
or other contaminants. The red, raw areas and medication reevaluation in 2 days per Dr. King’s request. Appt
pustules will most likely contain the greatest con- scheduled 1/14 at 3:30 PM. Joe Guerrero, CMA (AAMA) ___
centration of streptococci.
964 UNIT 7 Laboratory Procedures

Procedure 31-2
Wet Mount and Hanging Drop Slide Preparations
STANDARD PRECAUTIONS: 3. For wet-mount slide preparation:
a. Place a drop of the bacterial suspension onto
a clean glass slide (Figure 31-26A). RATIO-
NALE: The suspension of bacteria in a drop
PURPOSE: facilitates viewing.
Prepare a slide for viewing live organisms for motility b. Place petroleum jelly around the edges of
and identifying characteristics. the coverslip (Figure 31-26B) and place the
coverslip on top of the bacterial suspension
EQUIPMENT/SUPPLIES: (Figure 31-26C). RATIONALE: The petro-
Gloves Coverslips leum jelly cuts down on air currents and
Laboratory coat Petroleum jelly keeps the slide from drying out.
Clean glass slide Dropper 4. For hanging drop slide preparation:
Glass slide with concave well Bacterial suspension a. Place the bacterial specimen (in suspension)
in the center of the coverslip with petroleum
PROCEDURE STEPS: jelly around the edges (Figure 31-27A).
1. Wash hands and apply gloves. RATIONALE: RATIONALE: For the suspended drop to be
Washing hands before any procedure helps to formed properly, this technique is used.
eliminate contamination. Gloves will offer per- b. Invert the slide and place the concave well of the
sonal protection. slide over the specimen drop on the cover slip
2. Assemble equipment and supplies. RATIONALE: (Figure 31-27B). RATIONALE: This method
Gathering equipment before beginning the pro- allows the slide well to protect the drop.
cedure ensures less chance of errors caused by c. The slide is then carefully turned right side up
missing supplies. for microscopic examination (Figure 31-27C).
RATIONALE: The slide must be handled care-
fully to avoid slippage and disruption of the
drop.
NOTE: After the smear is prepared properly, it can
be observed microscopically at any power. Viewing
the slide is considered by CLIA to be a provider-
performed microscopy procedure.
A

A
B

B
C
C
Figure 31-26 Wet-mount slide. (A) Specimen
placed on a glass slide. (B) Coverslip with petroleum Figure 31-27 Hanging drop slide. (A) Specimen
jelly on edges. (C) Coverslip placed directly on top of placed on coverslip. (B) Slide placed over coverslip.
slide with specimen. (C) Slide turned right side up for examination.
 CHAPTER 31 Basic Microbiology 965

Procedure 31-3
Performing Strep Throat Testing
STANDARD PRECAUTIONS: cotton-tipped applicator. RATIONALE: The
tongue blade will assist in keeping the mouth
opened for ease in obtaining the specimen with-
out contaminating it on the tongue, cheek, or
PURPOSE: roof of the mouth.
To test for streptococcus infection of the throat for 5. Follow the manufacturer’s instructions exactly to
diagnostic purposes. The following steps are inten- perform the strep throat test. Be sure to also run
tionally general, so a variety of kits can be used. the controls tests. RATIONALE: Each manufac-
turer’s kit varies slightly in the method used. The
EQUIPMENT/SUPPLIES: controls are to ensure quality results.
Gloves
6. Properly dispose of all waste in biohazard con-
Commercial (CLIA waived) strep throat testing kit:
tainer. Disinfect the equipment and the area.
Controls and reagents
RATIONALE: Standard precautions are used to
Sterile cotton-tipped swabs
prevent disease transmission.
Test tubes and holder or receptacles (depending
on the kit used) 7. Complete the laboratory report form and notify
Tongue blade the provider of the results. RATIONALE: The
Adjustable light source provider will treat the disease as soon as it is con-
firmed.
PROCEDURE STEPS: 8. Document procedure in patient’s chart or elec-
1. Wash hands and apply personal protective equip- tronic medical record. RATIONALE: Proper
ment (PPE). RATIONALE: Hands should always documentation ensures good recordkeeping.
be washed prior to working with patients to avoid
transferring pathogens. PPEs protects you from DOCUMENTATION
the patient in case he or she coughs or vomits
04/27/20XX Strep throat test performed in office. Patient
during the procedure.
tolerated procedure well. Dr. Lewis notified of results. Ini-
2. Assemble and organize equipment and supplies. tialed report on file. Joe Guerrero, CMA (AAMA) _______
RATIONALE: Organization presents a more
professional image.
3. Introduce yourself, identify the patient, and Laboratory Report
explain the procedure. RATIONALE: Introduc- Patient Name Lisa Car ter Date 04-27-20XX
ing yourself and explaining the procedure to
the patient will gain his or her cooperation and Strep Throat Test negative
establish a good rapport. Identifying the patient
ensures that the right patient will receive the test. Joe Guerrero, CMA (AAMA)
4. Using the tongue blade and light source, obtain MA signature
the specimen from the patient’s throat on the
966 UNIT 7 Laboratory Procedures

Procedure 31-4
Instructing a Patient on Obtaining a Fecal Specimen
STANDARD PRECAUTIONS: onto it. RATIONALE: Labeling the container
rather than the lid will ensure that the specimen
will not be mixed up with another patient’s sam-
ple in the laboratory. The sturdy lid will prevent
PURPOSE: leakage of the specimen during transport.
To instruct a patient in the correct collection of a 4. Caution the patient to avoid contaminating the
fecal sample. stool specimen with urine. RATIONALE: Urine
may interfere with the test.
EQUIPMENT/SUPPLIES:
5. Give the patient a biohazard transport bag and
Gloves
instructions on which pocket to put the speci-
Biohazard container
men into and how to secure the bag. The medi-
Sturdy, opaque, waterproof specimen container with
cal assistant can place the laboratory requisition
a securely fitting lid
into the other pocket. RATIONALE: Using a bio-
Special laboratory manual instructions if needed
hazard transport bag and properly sealing it will
(depending on the test being performed)
prevent contamination during transport to the
PROCEDURE STEPS: laboratory. Keeping the requisition in a separate
1. Assemble and organize equipment and supplies. pocket from the specimen further prevents con-
RATIONALE: Being organized helps the process tamination of the paperwork.
go more smoothly and professionally. 6. The patient should be prepared to transport the
2. Identify the patient and explain the procedure. specimen to the laboratory as soon as possible
Give the patient written instructions as well. while keeping the specimen at or just below body
RATIONALE: Identifying the patient ensures that temperature. RATIONALE: If the stool is being
you have the right patient. Explaining the proce- tested for parasites and their eggs (ova and para-
dures reassures the patient and gains his or her site, commonly called O&P), the laboratory will
cooperation with the procedure. Written instruc- want to test the parasites while they are still viable.
tions helps the patient to remember better. 7. Document that the instructions were given to the
3. Hand the patient the labeled specimen con- patient, both orally and written. RATIONALE:
tainer, instructing him or her to deposit a sam- Proper documentation serves as a record for future
ple of stool into the cup then securely set the lid reference.

Case Study 31-1 Case Study 31-2

Refer to the scenario at the beginning of the chapter. You Mary O’Keefe has brought her 3-year-old son Chris to the
can see that Joe is very careful with all safety precautions office of Drs. Lewis and King with a temperature of 102°F and
when handling specimens. an extremely sore and red throat. He is irritable and crying.
After examining Chris, Dr. King orders a quick test for group A
CASE STUDY REVEIW Streptococcus. Medical assistant Joe Guerrero has a difficult
time acquiring the throat swab for the test because of Chris’s
1. Name a few diseases Joe could contract from the condition.The test is run, and the results are negative.
specimens he handles.
CASE STUDY REVIEW
2. Discuss the methods of transfer those diseases
would take during transmission. 1. What could be some reasons the test result is negative?
2. What other procedure can be done to diagnose strep
throat?
3. How would the test in question 2 be set up?
 CHAPTER 31 Basic Microbiology 967

SUMMARY
The field of microbiology is vast. Many microorganisms are pathogenic and can cause serious infection in
patients. The successful culturing and identification of such organisms is an important aspect of the suc-
cessful treatment of patients. All specimens that are processed in the POL should be handled carefully, and
all safety guidelines should be followed.
For the pathogen to be identified correctly, the utmost care must be taken in obtaining the culture.
Sterile equipment must be used. When the culture is processed, the correct microscopic examination,
media, incubation, and confirmatory tests must be used correctly to identify the pathogen.
Often a sensitivity test will be requested together with the culture. The information from this test will
guide the physician in selecting the appropriate treatment for the patient.
POLs vary in the type and number of cultures that are performed on the premises and those that are
sent out to be performed in a reference laboratory. It is important to provide the best care for the patient
by doing only those tests that a POL can reasonably handle given equipment, personnel limitations, and
CLIA regulations.
In addition to performing bacterial identification, some POLs perform parasitology and mycology
tests on a limited basis. When performing parasitology tests, it is important to obtain the proper specimen
in the correct manner. When performing mycology tests, it is important to work under a safety hood to
minimize the risk for exposure to spores from the fungal specimens.
Of utmost importance is the careful adherence to Quality Control guidelines. These procedures
ensure the integrity of test results.

STUDY FOR SUCCESS

To reinforce your knowledge and skills of information presented in this chapter:
• Review the Key Terms
• Practice the Procedures
• Consider the Case Study and discuss your conclusions
• Answer the Review Questions

° Multiple Choice
° Critical Thinking
• Navigate the Internet by completing the Web Activities
• Practice the StudyWARE activities on the CD
• Apply your knowledge in the Student Workbook activities
• Complete the Web Tutor sections
• View and discuss the DVD situations

REVIEW QUESTIONS
Multiple Choice 2. An example of nonselective media would be media
1. A structure that is not part of all bacterial cells is that:
the: a. contain a substance that alters the appearance of
a. nucleus some organisms
b. ribosome b. will support the growth of all organisms and
c. spore does not alter their appearance
d. cell wall c. support the growth of one type of organism and
inhibit the growth of other types of organisms
d. identify the biochemical activity of some
organisms
968 UNIT 7 Laboratory Procedures

3. When a CSF culture cannot be set up immediately, 4. A patient is given a requisition slip for a stool cul-
it should be placed in the incubator or remain at ture, ova, and parasite examination. How would
room temperature as opposed to being placed you instruct this patient to collect the specimen?
in the refrigerator because some organisms are 5. Explain why pinworm specimens are collected at a
affected by a low temperature. An example of this certain time of the day.
type of organism would be:
a. Beta streptococci
b. Neisseria meningitidis
WEB ACTIVITIES
c. Streptococcus pneumoniae Visit the Centers for Disease Control and Pre-
d. Staphylococcus aureus vention’s Web site and other Web sites to review
4. The best method of taking a specimen for the guidelines on reportable diseases for your state.
recovery of anaerobic organisms is to:
a. swab deep and place into an anaerobic con-
tainer REFERENCES/BIBLIOGRAPHY
b. aspirate purulent fluid and place into a test tube
Department of Health and Human Services, Centers
c. swab around the wound and place into an anaer-
for Disease Control and Prevention. (2008). Dis-
obic container
eases and Conditions. Retrieved October 2008,
d. take as any other specimen for culture
from http://www.cdc.gov.
U.S. Food and Drug Administration. (2008). Databases
Critical Thinking on the FDA Website. Retrieved October 2008, from
1. Name two ways to identify whether an organism is http://www.fda.gov/search/databases.html.
motile. Walters, N. J., Estridge, B. H., & Reynold, A. P. (2008).
2. Define an aerosol and explain how protection is Basic medical laboratory techniques (5th ed.). Clifton
provided when working with an aerosol. Park, NY: Delmar Cengage Learning.
3. Identify one potential pathogen and list the
specimen source, media for culture, microscopic
appearance, and the disease it causes.

THE DVD HOOK-UP

This chapter discusses basic microbiology procedures. Are you worried about collecting specimens that may cause
The selected scenes in this program demonstrate how to you or the patient to gag? What if you suddenly become
educate patients in collecting more sensitive specimens. sick yourself and have to run out of the patient’s room? How
1. Do you think that Mr. Turell was a little embarrassed would you handle such an episode with the patient?
about discussing the proper technique for collecting a
stool sample with the medical assistant? Why?
2. In the scene about collecting a sputum specimen, the
medical assistant waited in the room while the patient
collected the specimen. Did that scene bother you? Do
you think that you will be able to stay in the room with
DVD Series Program Number
the patient when you are responsible for collecting a
Skills Based Series 12
sputum sample?
3. Why should you not touch the tongue when collecting Chapter/Scene Reference
• Administer Fecal Collection and Performing
a throat specimen? Occult Blood Test
• Administering Sputum Collection
DVD Journal Summary • Administering Throat Culture and
Write a paragraph that summarizes what you learned from Performing Rapid Strep Test
watching the selected scenes from today’s DVD program.
 Chapter

Specialty Laboratory Tests 32

KEY TERMS OUTLINE
ABO Blood Group Urine Pregnancy Tests Glucose Tolerance Test
Agglutination Commercial/Home Urine Automated Methods of
Antibody Pregnancy Tests Glucose Analysis
Antigen Testing Methods Testing Panels
Slide Test or Agglutination Glycosylated Hemoglobin
Antiserum
Inhibition Test Cholesterol and Lipids
Bilirubin Enzyme Immunoassay Test The Chemistry of
Blood Urea Infectious Mononucleosis Cholesterol
Nitrogen (BUN)
Transmission of EBV Functions of Cholesterol
Cholesterol Lipoproteins and Cholesterol
Symptoms of IM
Choriocarcinoma Treatment of IM Transport
Cushing’s Syndrome Diagnosis of IM Triglycerides
Diabetes Mellitus CLIA Waived IM Tests Blood Chemistry Tests
Ectopic Pregnancy Prothrombin Time/ProTime/ Alanine Aminotransferase
Enzyme Immunoassay INR (ALT)
Epstein–Barr Blood Typing Albumin
Virus (EBV) ABO Blood Typing Alkaline Phosphatase (ALP)
Guthrie Screen- Rh Blood Typing Aspartate Aminotransferase
ing Test Semen Analysis (AST)
Heterophile Semen Composition Bilirubin, Total and Direct
Antibodies Altering Factors in Semen Blood Urea Nitrogen Test
High-Density Analysis Calcium
Lipoprotein (HDL) Phenylketonuria Test Chloride
Human Chori- Blood Testing for PKU Carbon Dioxide (CO2)
onic Gonado- Tuberculosis Creatinine
tropin (hCG) Gamma Glutamyltransferase
Cause of TB
Hydatidiform Mole Resistance in Mycobacteria (GGT)
Hyperglycemia Transmission of Infectious TB Lactate Dehydrogenase
Hypoglycemia (LDH)
Diagnosis of TB
Infectious Mono- Phosphorus (Phosphate)
Screening for TB: Skin Testing
nucleosis Potassium (K)
The Mantoux Test
Insulin Sodium
Blood Glucose
Latex Beads Total Protein
Fasting Blood Glucose
Uric Acid
Low-Density Two-Hour Postprandial Blood
Lipoprotein (LDL) Glucose
Mantoux Test
Phenylketonuria
(PKU)
Purified Protein
Derivative (PPD)

969
OBJECTIVES KEY TERMS
The student should strive to meet the following performance objectives and dem-
(continued)
onstrate an understanding of the facts and principles presented in this chapter Rh Factor
through written and oral communication. Semen
1. Define the key terms as presented in the glossary. Triglycerides
2. List the three main precautions to be observed during all tests Tuberculosis (TB)
and the collection of samples included in this chapter. Wheal
3. Collect samples and perform and interpret all tests included in
this chapter.
4. Discuss factors to be considered when evaluating test results.
5. Discuss transmission, incubation period, and symptoms of
Epstein–Barr virus/infectious mononucleosis.
6. List the blood group antigens and antibodies found in each of
the four ABO groups and the Rh factors.
7. Explain the cause of phenylketonuria (PKU) and the symptoms
caused by untreated PKU.
8. Indicate normal and increased levels of phenylalanine and the
dietary restrictions to be observed by PKU patients.
9. Discuss the cause of tuberculosis and some major characteristics
of Mycobacterium tuberculosis.
10. Discuss the role of insulin in the regulation of blood glucose
levels.
11. List and discuss differences among the normal values for fasting
blood glucose, 2-hour postprandial glucose, and the glucose tol-
erance test.
12. Explain the importance of cholesterol and triglyceride testing
to identify patients at high risk for coronary heart disease.
13. Give the desirable values of cholesterol for adults.
14. Give the acceptable level of low-density lipoprotein (LDL) in
persons with or without coronary heart disease, and discuss the
role of high-density lipoprotein and LDL in coronary heart dis-
ease.
15. Give the normal values of urea nitrogen for adults, children,
infants, and newborns, and discuss the significance of increased
blood urea levels.

Scenario
Audrey Jones, CMA (AAMA), has worked at Drs. Lewis for testing is just as important as being skillful in col-
and King’s office for more than 5 years. In that time, lecting and testing the specimens. Audrey has found
Audrey has become proficient in obtaining specimens that when she explains the reason the specimen is
from patients for various laboratory tests. Audrey needed in terms patients can understand, they are
enjoys the work and finds it extremely challenging. She often less fearful, which helps them relax. This can be
also realizes that communicating with patients to help especially helpful when collecting blood specimens.
them understand why their specimens are necessary

970
 CHAPTER 32 Specialty Laboratory Tests 971

INTRODUCTION
Spotlight on Certification
An increasing number of tests are performed in the ambu- RMA Content Outline
latory care setting, many of them by the medical assistant.
• Medical law
To meet these new demands, the medical assistant must
have a strong background in a variety of areas includ- • Patient education
ing medical terminology, Clinical Laboratory Improve- • Laboratory procedures
ment Amendments (CLIA) regulations, laboratory safety CMA (AAMA) Content Outline
procedures, and specimen collection. Because many pro-
• Patient instruction
cedures require collection of a blood specimen, the medi-
cal assistant must also be an excellent phlebotomist. Good • Medicolegal guidelines and
recordkeeping and communications skills round out the requirements
requirements. A quality-control program is necessary to • Collecting and processing specimens;
ensure that the results are accurate and reliable (Figure diagnostic testing
32-1). This will require a commitment on the part of CMAS Content Outline
the medical assistant to maintain the highest standards
• Legal and ethical considerations
throughout the process.
A variety of specialty tests are covered in this chapter, • Communication
including testing for pregnancy, infectious mononucleosis,
tuberculosis (TB), and phenylketonuria (PKU), as well as
blood types, hemoglobin A1c, and protime. This chapter
also discusses the chemistry of blood, including chemistry Results from
Regional/ Results to Outside
panels, blood glucose, cholesterol, triglycerides, and other National Labs Providers
specialty laboratory tests such as semen analysis.

URINE PREGNANCY TESTS LABORATORY

Pregnancy tests are used when pregnancy is sus-
pected. Pregnancy tests may also be used to rule Test Reports
Quality Assurance & Controls
out pregnancy before prescribing birth control Safety Standards
pills, radiograph studies, certain antibiotics or
other drugs, and for female patients who are to
undergo surgery.
Orders for Tests
Pregnancy testing is based on detection of Safety Standards
human chorionic gonadotropin (hCG), a hormone
secreted by the placenta that can be detected in the
serum or urine of pregnant women as early as 5 days
after conception. During pregnancy, hCG levels peak
at about 8 weeks, then decrease to lower but detect-
ELECTRONIC
able levels for the remainder of the pregnancy.
RECORDS
Commercial/Home Urine
Pregnancy Tests Figure 32-1 The laboratory arm of the total practice
A variety of accurate and easy-to-use commercial management system (TPMS). When tests are ordered,
tests are available for use in the medical office. the medical assistant performs these procedures and
Manufacturers of pregnancy test kits have designed records the results directly in the lab and progress
them to be sensitive, to be easy to perform and notes sections of the patient’s electronic medical
interpret, and to give rapid results. Pregnancy tests record. The medical assistant can check to see whether
are one of many tests available for purchase as an controls have been performed in the lab’s global elec-
over-the-counter product. However, results of tests tronic log to ensure the highest degree of patient care.
performed at home should be confirmed by a lab- Finally, the medical assistant can print patient educa-
oratory test using appropriate quality-control mea- tion materials and follow-up instructions contained in
sures and properly trained personnel. CLIA has the TPMS.
972 UNIT 7 Laboratory Procedures

granted waived status to all urine pregnancy tests

that use visual color comparison and specifically to Precautions for Pregnancy Testing
the Bayer Corporations Clinitek 50 Urine Chem- 1. Use a clean container for collection of the urine specimen.
istry Analyzer for hCG in urine. Medical assistants Disposable containers are preferred. Detergent residue on
qualify for the waived test category within the phy- nondisposable containers may interfere with test results.
sicians’ office laboratory (POL). 2. The first-voided morning urine has the highest concentra-
tion of hCG and is the preferred specimen. If this is not
available, a urine specimen with a specific gravity of at
Testing Methods least 1.010 is acceptable.
3. Although it is always best to run tests on fresh specimens,
Two testing methods using urine are discussed in if the urine specimen cannot be tested immediately, it may
this section: the slide test or agglutination inhibi- be stored at 4°C for up to 24 hours. Both urine and serum
tion test and the modified enzyme immunoassay. specimens may be used with some test kits; other kits use
Diagnosis of pregnancy is made using these test only one or the other.
results in conjunction with a physical examination 4. Allow refrigerated urine specimens and test reagents to
including a pelvic examination by the provider. come to room temperature before starting test procedures.
A positive reaction to any pregnancy test 5. If using the slide test procedure:
does not necessarily indicate a normal pregnancy. a. Avoid cross contamination with other urine specimens.
Detection of hCG can also indicate such abnormal b. Use a new stirrer for each test.
conditions as an ectopic pregnancy, a developing
hydatidiform mole of the uterus, choriocarcinoma,
or cancer of the lung, stomach, pancreas, colon, or
breast. gen, and a second antibody. The test may be designed
to detect a particular antibody in a patient’s serum or
Quality Control. Kits must be stored and used at to detect an antigen in a patient specimen.
the temperature directed by the manufacturer. Numerous tests are based on variations of
Most kits contain a built-in control; however, the EIA. New technologies have been developed
appropriate positive and negative urine controls called membrane EIAs. In these tests, most of the
must always be run with patient specimens. Kits reagents are incorporated into an absorbent mem-
and reagents must not be used after the expiration brane, which is enclosed in plastic. When the sam-
date. Manufacturer’s instructions must be followed ple (serum or urine) is added, it migrates through
precisely for the particular test used. the membrane, reacting with the reagents and
forming a color. Many of these tests are simple to
Slide Test or Agglutination set up and interpret even though the technology
is complex. Examples of membrane EIAs include
Inhibition Test over-the-counter pregnancy test kits and tests for
The slide test is based on inhibition of agglutina- group A Streptococcus.
tion (clumping) of hCG-coated latex beads. The Enzyme immunoassays for hCG vary in design
hCG antiserum (antibody against hCG) is added but have some features in common. Most have the
to urine on a microscope slide. If hCG is present reagents incorporated into an absorbent mem-
in the urine, an hCG/anti-hCG complex forms brane within a self-contained test unit, which may
between the antiserum and the patient’s hCG. look like a plastic slide, a reagent strip, or a test cyl-
Next, an antigen reagent containing latex beads inder. Tests may require the addition of the sample
coated with hCG is added to the mixture. If the only or the addition of the sample and reagents to
hcG/anti-hCG complex formed, then there is no the test unit. Procedure 32-1 describes the general
hCG antiserum available to react with the latex steps for pregnancy testing.
beads, and agglutination will not occur. No aggluti-
nation indicates positive pregnancy. Agglutination
of the latex beads indicates negative pregnancy. INFECTIOUS
MONONUCLEOSIS
Enzyme Immunoassay Test Infectious mononucleosis (IM) is a contagious dis-
The enzyme immunoassay (EIA) is a more com- ease that may have vague clinical symptoms and can
plex procedure than agglutination. The test can mimic other diseases. Serologic tests are often the
be designed in several different ways, but it always basis for an early diagnosis of the disease and may
involves an antigen, an antibody specific for the anti- also be used to follow the course of the disease.
 CHAPTER 32 Specialty Laboratory Tests 973

IM is commonly called “mono” or “kissing available, some important work in that direction is
disease.” The disease is a result of infection of the ongoing.
lymphocytes by the Epstein-Barr virus (EBV). EBV
is common in our population. By 5 years of age,
approximately 50% of the population is infected, Diagnosis of IM
increasing to 90% to 95% in adults. After the pri- To properly diagnose IM, the provider must con-
mary infection, the virus establishes a lifelong sider blood and serology test results together with
latency. The infectious virus may be isolated from the patient’s symptoms.
saliva for several months, whereas antigens may be
detected for life. In addition to causing IM, EBV Blood Test for IM. The hematologic tests for IM
has been implicated in other diseases such as naso- include white blood cell count and evaluation of
pharyngeal carcinoma (NPC) and chronic fatigue the patient’s lymphocytes. In IM, lymphocytosis, or
syndrome. increase in lymphocytes, usually occurs, and large
numbers of lymphocytes (greater than 20%) have
Transmission of EBV an unusual or atypical appearance.
Transmission of EBV IM is primarily by saliva, Serologic Test for IM. Persons with IM produce
which is why it is often referred to as “the kissing antibodies called heterophile antibodies by the
disease.” EBV may also be spread by the sharing of sixth to tenth day of the illness. Heterophile anti-
drinking glasses and less often by blood transfu- bodies are antibodies that react with similar anti-
sion. The disease is moderately contagious and is gens in more than one species. They are usually of
transmitted approximately 10% to 38% of the time the IgM class.
in close social groups. In the home or in the hos- Detection of heterophile antibodies com-
pital, careful handwashing will help prevent trans- bined with the blood tests and patient symptoms
mission of the virus. provide the basis for the diagnosis of IM. The sero-
logic test is usually positive after the first week of
Symptoms of IM illness. However, if test results are negative, the test
should be repeated after 1 week if clinical symp-
Mononucleosis is seen most often in children and toms are still present.
young adults. Incubation may vary from 4 to 50
days; however, 7 to 14 days is the average. Infec-
tion in younger children is usually asymptomatic CLIA Waived IM Tests
or manifests minor symptoms such as pharyngitis,
otitis media, bronchitis, and other upper respira- Several manufacturers have produced CLIA waived
tory discomforts. test kits suitable for use by the medical assistant in
Classic symptoms usually occur when the pri- the POL.
mary infection is delayed until the second decade Kits for IM usually provide all the necessary
of life. IM is most often observed in the 15- to 25- reagents, materials, and controls. The laboratory
year-old age group. Symptoms usually begin with must obtain only the specimen to be tested, which
a fever and swollen glands lasting for 3 to 5 days. is usually a small sample of the patient’s plasma or
Over the next 7 to 20 days, the patient may develop serum or a drop of capillary blood.
a headache; malaise; chest pain; a cough; tonsilli-
tis; a rash; soft, swollen lymph nodes; and a swollen
spleen. While the spleen is enlarged, the patient is
Prothrombin Time/ProTime/INR
advised to curtail activity, especially contact sports Prothrombin time, which is also called protime, PT,
and rough activities, to prevent the rare, but seri- and international normalized ratio (INR), is a test
ous, rupture of the spleen. Symptoms usually per- for blood’s clotting ability. It is used often for peo-
sist for 2 to 4 weeks and in more serious cases may ple who are taking anticoagulant medications such
last for more than 1 month. as Coumadin (warfarin). Monitoring is needed
to maintain a careful balance that must be moni-
tored between the blood clotting too readily and
Treatment of IM the blood being so thin it will not clot. The desired
Because there are currently no effective drugs levels of INR are 2.0 to 3.0. Refer to Chapter 28 for
available for EBV IM, treatment is primarily pala- more information on coagulation tests and Proce-
tive, or supportive. Although a vaccine is not yet dure 28-4 for the process of running a protime test.
974 UNIT 7 Laboratory Procedures

BLOOD TYPING
Blood typing is based on the presence or absence
of certain antigens on the surface of red blood cells
(RBCs). These antigens are carbohydrate molecules
A NTI-B
that react with antibodies specific to them to cause A NTI-A Red blood cells SE RUM
SE RUM to be tested
agglutination of the RBCs. Antibodies are protein
molecules that are found in serum; they are also
referred to as immunoglobulins (Ig). When RBC
antigens and antibodies react, they cause the RBCs
to agglutinate. This process is called hemagglutina-
tion. Hemagglutination reactions are used in the ANTI-B
typing of blood. The two major categories of blood ANTI-A
typing are for the ABO blood group and the Rh fac-
tor. The ABO blood group consists of type A, type B,
type AB, and type O. Within each of these types are
the Rh factors, either Rh-positive (factor present) or
Rh-negative (no factor). Figure 32-2 illustrates how
RBCs are tested for blood type. In the example, type
O blood would have no reaction to either anti-A or Type O
anti-B, whereas type AB blood would have a reaction
to both. By process of elimination, one can deter- No agglutination No agglutination
mine which type the specimen is.
The ABO and Rh systems place certain
restrictions on how blood can be transfused from
Type A
one individual to another. Depending on their
blood type, individuals with a particular RBC anti-
gen may have antibodies against the other types Agglutination No agglutination
(Table 32-1). An incompatible blood transfusion
results when the antigens of the donor RBCs react
with the antibodies of the recipient RBCs. This is a Type B
potentially life-threatening situation that varies in
severity from mild fever to anaphylaxis with severe
No agglutination Agglutination
intravascular hemolysis. Although ABO and Rh
typing does not completely rule out the possibility
of reaction, it greatly reduces the chances.
Type AB

ABO Blood Typing Agglutination Agglutination

ABO blood typing is determined by the presence
Figure 32-2 Blood typing the ABO groups.
or absence of two major antigens, A and B. All peo-
ple have one of the four blood group categories:
A, B, AB, or O. People with group A RBCs have A
antigens, group B RBCs have B antigens, group AB
RBCs have antigens for both A and B, and group the patient’s blood will be retested as a precaution.
O RBCs lack both A and B antigens. Naturally This is called a “blood cross and match” test. Nev-
occurring antibodies to the other antigen types are ertheless, it is a good idea to know your individual
found in the serum. blood type and Rh factor.
ABO type can be determined by the slide or
tube method. The tube method is now most often
used for blood typing. Because neither method is
Rh Blood Typing
considered in the waived category by CLIA, they Rh typing is routinely performed together with
usually are not performed in the POL. Even if the ABO typing. The Rh system is named for the rhe-
patient carries a card listing his or her blood type, sus monkey used in experiments that led to its dis-
 CHAPTER 32 Specialty Laboratory Tests 975

Table 32-1 Antigens and Antibodies in ABO the amount of oxygen to his or her tissues and
and Rh Blood Systems organs. The baby responds by trying to make
more RBCs in his or her liver and spleen. This
Blood Antigen Serum overuse can cause these two organs to become
Group/Type on RBC Antibodies enlarged. The new RBCs are usually immature
(called erythroblasts) and are not able to do the
None Anti-A and work of the mature RBC. Also, when the RBCs
O (universal donor)
Anti-B are destroyed, bilirubin is formed. Babies cannot
rid the body of bilirubin, which can builds up in
A A Anti-B the blood, tissues, and body fluids of the baby.
This condition is called hyperbilirubinuremia
B B Anti-A (too much bilirubin in the blood). Bilirubin is
pigmented and causes a yellowing or jaundice of
AB A and B None the newborn’s skin and tissues.
This jaundice is not to be confused with the
Rh⫹ D No anti-D* jaundice many newborns have, which is caused by
a similar process but to a much less degree and
Rh⫺ None No anti-D* with mild consequences. Hemolytic disease can
be determined by evaluating the quantity of bili-
*There are no naturally occurring antibodies to the Rh system. rubin in the amniotic fluid and in the newborn’s
blood.
HDN can cause severe complications for the
newborn, ranging from the enlarged liver and ane-
covery. The Rh factor is found on the surface of mia to seizures, brain damage, and even death.
RBCs. People possessing the Rh factor are said to Treatment before the baby is born can include
have Rh-positive (Rh⫹) blood. Those without the intrauterine blood transfusions and early delivery
Rh factor have Rh-negative (Rh⫺) blood. if the baby is mature enough to survive. After the
About 85% of North Americans are Rh-posi- baby is born, blood transfusions, intravenous flu-
tive; 15% are Rh-negative. Neither Rh-negative ids, and help with respiration and oxygen intake
nor Rh-positive people have naturally occuring Rh may be necessary.
antibodies in their blood. However, if an Rh-nega-
tive individual receives a transfusion of Rh-positive
blood, he or she will develop antibodies to it. The
antibodies take 2 weeks to develop. Both blood
type and Rh factor must be taken into account for Patient Education
safe and successful transfusions.
Rh blood typing is also performed on preg- When a woman gives birth (or has a
nant women to determine the mother’s Rh blood miscarriage or abortion), some of the fetal
type. During the patient’s initial prenatal care blood can mix with the mother’s as the
examination, blood typing is usually performed placenta tears away from the uterus. When
as part of the prenatal panel. In situations where the Rh-negative woman is exposed to the
the mother is Rh-negative, the mother’s blood is baby’s Rh-positive blood (there is an 85%
tested for the presence of Rh antibodies. If the chance that the baby is Rh-positive), she
test is negative, then there is no risk to the fetus. builds antibodies against the Rh factor.
A negative test should be repeated at weeks 30 Consequently, during the next pregnancy,
and 36. If the test is positive, then the mother has her antibodies (which cross the placental
been exposed to Rh-positive blood and has pro- barrier) would attack the next Rh-positive
duced antibodies. A positive reaction also means baby’s RBCs. Giving the woman an injection
that maternal hemolysis of fetal RBCs can occur. of RhoGAM after each exposure to the Rh
This condition is also called hemolytic disease antigens prevents her from building the
of the newborn (HDN, also known as erythro- antibodies. Rh-negative women will need
blastosis fetalis). When the mother’s antibodies RhoGAM each time they are exposed to the
attack the baby’s RBCs, the RBCs are destroyed. Rh factor.
This will make the baby anemic, which limits
976 UNIT 7 Laboratory Procedures

Fortunately, most cases of HDN can be pre-

vented by administering RhoGAM to the Rh- Table 32-2 Reference Values for Semen
negative mother. When injected into the mother, Analysis
RhoGAM will prevent her from producing the
RhD antibody. The injection must be administered Parameter Normal Range
at the 28th week of pregnancy and within 72 hours
after delivery of an Rh-positive baby, miscarriage, Appearance White, viscid, opaque
or termination of pregnancy.
Volume 1.5–5 mL

SEMEN ANALYSIS pH 7.12–8.00

With the progression of managed health care, Total count 50–200 million
more primary care providers are performing
semen analysis in their offices to determine sperm % normal sperm At least 80%
cell counts before referring patients to fertility spe-
cialists. Examination of semen is also performed as % motility At least 60%
part of a complete fertility work-up, to evaluate the
effectiveness of a vasectomy, to determine pater-
nity, and to substantiate rape cases. for instructions to give to the male patient before
When semen analysis is performed as part semen analysis.
of a fertility work-up, the procedure involves
macroscopic and microscopic analysis of semi- Altering Factors in Semen
nal fluid for determination of total sperm count,
percentage of motility, presence of agglutina- Analysis
tion, and percentage of normally formed sperm Many factors can alter the results of semen analysis.
cells (Table 32-2). All male individuals will have Several drugs such as cyclophosphamide (Cytoxan)
variable sperm counts; therefore, a single analy- and nitrogen mustard reduce sperm count, as well
sis is insufficient. To achieve a reasonable esti- as certain conditions such as orchitis (inflammation
mate of these factors, the seminal analysis should of the testes), testicular atrophy, testicular failure,
be repeated at least three times over a 2-month and obstruction of the vas deferens. Cigarette smok-
period. A complete analysis will also include an ing is associated with a decrease in the volume of
evaluation of the partner’s cervical secretions semen, whereas coffee drinking results in increased
and sperm survival. This involves determining sperm density and an increase in the percentage of
the ability of sperm to penetrate the mucus and cells with abnormal morphology. Fever may tempo-
maintain motility. rarily suppress the count. Although research sug-
Postvasectomy semen analysis is evaluated gests that consumption of alcohol does not affect
a few weeks after surgery. If sperm are seen at sperm function as measured by semen analysis, the
that time, then follow-up analysis is required. patient is instructed to avoid alcohol for several days
The patient is not considered sterile until he has before testing as a precaution.
returned two samples, at least 1 week apart, that Although research suggests that fertility is
demonstrate no sperm, viable or dead. This typi- most closely correlated with motility and morphol-
cally will take several weeks. Until that time, an ogy, men with very high (⬎200 million/mL) or
alternative method of birth control must be used. very low (ⱕ20 million/mL) counts are likely to
be infertile. Patients with aspermia (no sperm) or
Semen Composition oligospermia (low sperm count, ⱕ20 million/mL)
should be endocrinologically evaluated for pitu-
Semen is a composite solution produced by the itary, testicular, adrenal, or thyroid abnormalities.
testes and the accessory male reproductive organs.
It consists primarily of spermatozoa suspended in
seminal plasma. Because there is considerable vari- PHENYLKETONURIA TEST
ation in composition between different portions of
the fluid as ejaculated, it is important to collect the Phenylketonuria (PKU) is an inherited condi-
entire sample. Refer to the Patient Education box tion in which the baby cannot metabolize protein
 CHAPTER 32 Specialty Laboratory Tests 977

Many other tests can be performed using the

Patient Education blood sample sent on the PKU card, including
tests for congenital hypothyroidism (CH), con-
The following instructions should be given genital adrenal hyperplasia (CAH), galactosemia,
to male patients when a semen sample is sickle cell disease, and others. The tests that are
required for analysis: performed depend on individual state require-
1. Advise the patient to avoid consumption ments.
of alcohol for several days before the test. Excess phenylalanine can be detected in blood
He should also avoid ejaculation for 3 days or in urine. Normal levels of phenylalanine are less
before collection of the semen sample. than 2 mg/deciliter (dL); more than 4 mg/dL is
2. Provide the patient with instructions and considered elevated. The Guthrie screening test
a container. The entire sample should is used to evaluate blood and is considered more
be collected in a clean, dry, glass bottle accurate than urine tests. Phenylalanine can be
that has been labeled, dated, and timed. detected in the blood of infants with PKU after
The sample is collected by masturbation 3 to 4 days on a breast milk or formula milk diet.
or interrupted coitus at home, or it may Testing of breast-fed infants is delayed a few days
be collected at the medical office of the because of the lack of phenylalanine in colostrum,
laboratory. A condom should never be the first breast milk. Colostrum is produced for the
used to collect a semen specimen due to first 2 to 3 days after birth and is rich in antibodies,
the spermide content. protein, and calories. True breast milk production
begins after this time. Positive results from blood
3. Specimens for complete fertility analysis
testing are confirmed by measuring serum phenyl-
collected outside the laboratory must
alanine and tyrosine levels. Infants with PKU have
be brought to the laboratory within 30
increasing phenylalanine levels (⬎4 mg/dL) and
minutes. Postvasectomy specimens should
decreasing tyrosine levels (⬍0.6 mg/dL).
be brought to the laboratory within 1 hour
of collection.
4. The sample must be transported to Blood Testing for PKU
the laboratory at 37°C (98.6°F). Low The Guthrie test was developed to screen for phe-
temperature during transport will decrease nylalanine in the blood, and the first test is usually
the motility of sperm. Temperature that performed before the discharge of infants from
is too warm could destroy the sperm. the hospital. However, with managed care and
Keeping the sample close to his body the trend toward very short hospital stays for new-
during transport might be the best advice. borns, many pediatrician offices are now perform-
ing this first test. Capillary blood is collected from

properly. Phenylalanine is present in milk and

other dairy proteins. If the baby has PKU, phe-
nylalanine can build up in his or her brain and Patient Education
other organs and cause irreversible mental retar-
dation, loss of muscle coordination, and other Infants who test positive for PKU require a
serious disorders. Diagnosis should be made restricted phenylalanine diet for normal
early so that the baby can be put on a diet low development to occur. Parents will need
in proteins. The baby should be tested at about 2 to have an appointment with a dietician
days old and again at 7 to 14 days old. Although a to understand fully what foods the baby
phenylalanine-restricted diet will prevent mental can and cannot eat. The diet will include a
retardation, it will not cure the underlying con- suitable milk substitute such as Lofenalac.
dition. Routine screening of newborns for PKU Blood and urine tests will be necessary
is mandatory in all states and may be performed periodically to monitor the special diet.
in the hospital or the medical office. The medi- Women who have PKU and become
cal assistant’s role is to properly explain the pro- pregnant must be especially careful to avoid
cedure to the infant’s parents and to collect the phenylalanines during pregnancy.
blood specimen for analysis.
978 UNIT 7 Laboratory Procedures

a heel stick onto a “filter paper” test card and sent

to the laboratory for testing. Patient, provider, and
test information, together with the blood samples,
are placed directly on the laboratory test card,
which is typically provided by most state Depart-
ments of Health (Figure 32-3). (See Procedure
32-3 and Chapter 28 for proper capillary puncture
technique.)

Factors That May Influence the Guthrie Test. The

following factors may influence the Guthrie test:
• Feeding problems such as vomiting may result in a A
false-negative reaction.
• Failure to ingest sufficient phenylalanine—testing
before 3 to 4 days of the beginning of a milk diet—
will result in a false-negative reaction.
• Premature infants may give false-positive test
results because of a delay in the development of
certain liver enzymes.
• Drugs such as salicylates, aspirin, or antibiotics
taken by the mother (if breast-feeding) or the child
may interfere with test results.

TUBERCULOSIS B

Despite efforts to control its spread, tubercu-

losis (TB) infections are on the increase in the
United States and around the world. Because
tuberculosis morbidity is on the rise, increas-
ing 14% from 1985 to 1997, more patients are
screened now for the disease than ever before.
The Advisory Council for Elimination of Tuber-
culosis, an independent group of TB-control
experts, recommends screening all patients who
fall into high-risk groups, or those who associate
with high-risk groups, such as health care work- C
ers, including medical assistants. See the Cur-
Figure 32-3 (A) Pediatric-sized safety lancets are
rent Family Practice Recommendations for TB
available to vary the depth of the puncture. (B) The
Testing for a more complete list.
back of the PKU test card provides detailed instructions
on performing the test and completing the card cor-
rectly. (C) Patient information and permission forms
Cause of TB are available in a variety of languages.
Infectious TB is caused by the small, rod-shaped
bacterium Mycobacterium tuberculosis. This aerobic
bacterium is nonmotile and has a high content
of lipid in its cell wall, making it difficult to stain
Resistance in Mycobacteria
using basic aniline dyes. For this reason, the Ziehl- Mycobacteria exhibit an unusual degree of resis-
Neelsen method was developed and is used as a tance on many fronts. They are able to toler-
tool for identification of mycobacteria. Mycobacte- ate drying and the effects of many disinfectants.
ria will retain the red stain in the presence of acid Mycobacteria also show resistance to most antibi-
alcohol and are therefore referred to as acid-fast. otics, making these infections difficult to treat. To
Other bacterial species stain blue. help overcome bacterial resistance to antimicro-
 CHAPTER 32 Specialty Laboratory Tests 979

Diagnosis of TB
Patient Education TB diagnosis differentiates between active and
Current Family Practice inactive TB, and the treatments differ. Active TB
is a serious and contagious condition that requires
Recommendations for TB Testing
isolation of the patient and aggressive treatment
TB screening is recommended for: with several drugs over several months.
• Close contacts of those with known or Patients exhibiting a positive or questionable
suspected TB. purified protein derivative (PPD) reaction should
• Persons infected with HIV. have a chest X-ray to examine for tubercles, and
• Intravenous drug users or users of other a sputum sample should be stained to search for
illicit drugs. acid-fast rods. The presence of acid-fast rods in the
sputum confirms active TB. Reasons for a positive
• Chronically ill patients with conditions
reaction to PPD are varied. First and most obvious
or diseases that increase the risk for
is that the patient has been exposed to TB or has
progressing from latent to active TB. Risk
an active case of TB. Persons with an old, inactive
factors include diabetes, high-dose steroids,
case will also give a positive skin test, as will per-
immunosuppressive therapy, chronic
sons who have been vaccinated with BCG. BCG
renal failure, lymphoma, leukemia, other
(the bacille of Calmette and Guerin) is a vaccine
cancer, weight loss to more than 10% below
made from live, avirulent Mycobacterium bovis. The
ideal weight, silicosis, gastrectomy, and
vaccine is used in Europe and South America to
jejunoileal bypass.
help prevent childhood cases of TB. Persons who
• Foreign-born persons and those arriving receive BCG will give a positive skin reaction for
within the last 5 years from countries that a minimum of 4 years and much longer in many
have had a high incidence of TB. cases. Many immigrants will show positive PPD
• Residents and employees of high-risk because of a BCG vaccination. The chest X-ray is
institutions, such as correctional facilities, an important second step for those individuals.
nursing homes, mental institutions, and
homeless shelters.
• Health care workers, especially those Screening for TB: Skin Testing
caring for patients at high risk.
Screening for TB may be performed as part of a
• Medically underserved and low-income routine medical examination or as a prerequisite
populations. for school or employment. In states where medical
• Infants, children, and adolescents exposed assistants can legally perform injections, they may
to adults at high risk. be responsible for administration and interpreta-
tion of the skin test. The most accurate method
used is the Mantoux test. The tine test, which is a
multiple-puncture test, may still be used in some
bial agents, patients take two or three drugs for a areas but is no longer recommended by the Ameri-
period of 6 to 9 months. The most common drug can Academy of Pediatrics. Both the Mantoux and
used to fight TB is isoniazid (INH). Other drugs the tine methods use tuberculin, also referred to
used are rifampin, pyrazinamide, ethambutol, and as PPD, which is a filtrate of tuberculin cultures
streptomycin. that are used for skin testing. Persons who have
been exposed to TB will develop a hypersensitive
response to PPD resulting in the formation of an
Transmission of Infectious TB induration. An induration is a hard, red spot on
Infectious TB is highly contagious. Seventy-five the skin that is the result of sensitized lymphocytes
percent of new cases occur by inhalation of cough- migrating to the site of the injection. It is important
produced airborne droplets from symptomatic or to keep in mind that a positive skin test does not
asymptomatic persons. Crowded conditions con- distinguish between active or inactive cases of TB.
tribute to this transmission. TB often is associated Again, a positive skin test will require further diag-
with poverty, poor nutrition, and crowded con- nostic testing including an X-ray for lung lesions
ditions such as what is often seen in prisons and and an acid-fast stain of sputum to examine for the
mental health hospitals. A recent increase in TB is presence of Mycobacterium tuberculosis. Because of
related to the increase in AIDS cases. the severity of the reaction, do not administer the
980 UNIT 7 Laboratory Procedures

skin test to persons who have had a positive reac- allowed to dry before administering the PPD. The
tion in the past. left arm is the standard arm.

Reading the Results of the Mantoux TB Test. Have

The Mantoux Test the patient return in 48 to 72 hours for examination
In the Mantoux test, 0.1 mL of 5 TU (toxin unit) of the injection site. Gently feel the induration—the
strength PPD is injected intradermally using a 1 mL hard, raised area. Do not include the area of red-
tuberculin syringe. A short (3⁄8–1⁄2 inch), 26 or 27 ness or erythema in your assessment. See Procedure
gauge needle is used. Care must be taken to inject 24-7 for the complete injection procedure and Fig-
the PPD so that a wheal forms (Figure 32-4). If the ures 32-5 and 32-6 for measuring the induration.
injection is too deep, it will be impossible to form Proper patient instructions should be given
the wheal. If the injection is too shallow, the PPD both verbally and in written form to help ensure
may leak onto the skin. Either of these two errors patient compliance. If the patient delays more
would invalidate the test results. It is also impor-
tant to draw exactly 0.1 mL of the PPD, because
too much or too little will lead to erroneous test
results.

Choosing a Site to Administer the Mantoux Test.

To select a site for the Mantoux test, locate a site
approximately 3 to 4 inches down from the bend
of the arm on the anterior side. Avoid areas with
excess hair, visible blood vessels, or scar tissue. The
chosen site should be cleaned with alcohol and

A
0m
c

4
5

B
Figure 32-5 Gently inspect and measure the indura-
Figure 32-4 (A) Gently insert the needle just under tion (the elevated firm area, not the area of redness
the skin surface at about a 5-degree angle. Imbed the or erythema) in response to the tuberculin test within
entire bevel. Slowly and carefully inject the medication. 48 to 72 hours after administration. Some patients will
(B) A wheal should appear as a whitish raised bump. have no induration.
 CHAPTER 32 Specialty Laboratory Tests 981

Induration

Positive reaction for past or present infection: 10 mm or more induration

Doubtful reaction: 5–10 mm induration: (considered positive among persons who have
had recent contact with active TB; HIV-positive persons; persons with a chest X-ray con-
sistent with healed TB)

Negative reaction: without induration or less than 5 mm.

Figure 32-6 The size of the induration (raised and firm area, not the redness) is measured and recorded as shown.

than 72 hours in returning to the clinic for the test Blood glucose concentrations rise after a
reading, the test cannot be accepted. meal and are regulated by the action of several hor-
Some patients may show swelling, itching, or mones including insulin and glucagon. Both insu-
localized, raised hives when injected with the PPD. lin and glucagon are produced by the pancreas.
This is not a true induration but rather an aller- Insulin is secreted by pancreatic cells in response
gic reaction to the protein derivative, and should to increased glucose levels and aids with the entry
not be misinterpreted as a positive response. Do of glucose into cells for conversion into energy.
not repeat the Mantoux test if an allergic reaction Insulin is also required for proper storage of glu-
occurs. If you are unable to get a wheal, repeat the cose (which is first converted into glycogen) in
test at least 2 inches from the first attempt. the liver and in muscle cells. Glucagon is secreted
by the pancreas when blood sugar levels decrease
and triggers the breakdown of glycogen to help
BLOOD GLUCOSE increase and regulate blood sugar levels.

Glucose is the principal and almost exclusive car-

bohydrate found circulating in blood. It may also Fasting Blood Glucose
be detected in urine, cerebrospinal fluid, and Evaluation of FBG levels is commonly used to
semen. Glucose serves as an energy source for screen for diabetes mellitus. Diabetes mellitus
the body. Excess glucose is converted into glyco- is a type of carbohydrate disorder characterized
gen for short-term storage in the liver and muscle
cells, and as adipose tissue for long-term storage.
Tests for blood glucose levels are commonly per-
formed in the medical office. The results are used Patient Education
to screen for carbohydrate disorders such as hypo-
glycemia (low blood glucose level), hyperglycemia In preparation for the test, the patient
(high blood glucose level, which occurs in diabe- should be instructed to fast for 12 hours
tes mellitus), and liver dysfunction. A variety of (except for water). A fasting blood sample is
testing methods have been developed to diagnose, usually collected in the morning to minimize
evaluate, and monitor abnormalities in carbohy- inconvenience to the patient. Certain drugs
drate metabolism. They include the fasting blood such as oral contraceptives, salicylates,
glucose (FBG), the 2-hour postprandial blood diuretics, and steroids may alter the results,
glucose, and the glucose tolerance test (GTT). All so the provider may restrict their use for 2
tests are discussed here, but the FBG is preferred to 3 days before the test. The patient should
as the first step in the clinical setting because it is receive both verbal and written instructions
easier and faster to perform, more convenient and for the testing requirements and preparation.
acceptable to patients, and less expensive.
982 UNIT 7 Laboratory Procedures

by insulin deficiency (or no insulin) and a state Table 32-3 Reference Values For Blood
of hyperglycemia (hyper means “too much,” glyc Glucose Level
means “sugar,” and emia means “blood”).
The normal fasting value of glucose ranges Glucose
from 70 to 110 mg/100 mL (mg/dL). Table 32-3 Test Concentration (mg/dL)
lists reference glucose values. A value of 120 mg/
dL glucose is the dividing point between healthy Fasting
and hyperglycemic individuals. Generally, truly Serum 70–110
increased glucose levels indicate diabetes mellitus. Whole blood 60–100
Other causes of hyperglycemia include Cushing’s
syndrome and acute stress response. Increased Two-hour postprandial ⱕ110
blood glucose levels should be further evaluated
using the glucose tolerance test. Glucose tolerance
(oral, serum)
Fasting 70–110
Two-Hour Postprandial Blood
1 hour 20–50 above fasting
Glucose 2 hour 5–15 above fasting
The 2-hour postprandial (after eating) evaluation 3 hour Fasting level or below
of blood glucose levels is used to screen for dia-
betes and to monitor insulin dosage. After fasting Values vary slightly between laboratories depending on
from midnight the night before, the patient eats a testing method used.
prescribed meal containing 75 to 100 g carbohy-

Patient Education
Let your patient know there are more than 25 glucose meters available for them to choose from. All
of them use the typical process of a drop of blood applied to a disposable “test strip” and inserted
into the meter. The unit measures how much glucose is in the sample. All the meters display the
result. Some meters allow a much smaller sample to be used and allow the sample to be taken from
sites other than the fingertip (alternate site testing). Some meters record and store a number of test
results, and some meters can connect to a personal computer to store results and print them out.
Some new models have automatic timing, error codes and signals, or barcode readers to help with
calibration. Some meters have a large display screen or spoken instructions for people with visual
impairments. In choosing a meter, the patient should consider the following:
• Cost per strip
• Number of tests required per day
• Amount of blood needed for testing
• Testing speed
• Overall size and portability
• Cost of the meter
• Ability to store test results in memory
• Ability to test sites other than fingertip
• Other personal preferences
Many manufacturers offer free meters with the purchase of the test strips. Your clinic may be
given free meters to give to patients together with a few sample strips in hopes the patient will
continue to use that meter and purchase the strips. Unfortunately, the meters given to patients might
not be the best choice for them, but they will continue to use it because their doctor gave it to them.
Be sure to let patients know that there are many choices, and that the free meter you are giving
them is not necessarily an endorsement of one meter over another.
 CHAPTER 32 Specialty Laboratory Tests 983

drate or consumes a 75 to 100-gram glucose test sometimes 6 hours) after ingestion of the glucose
load solution such as Glucola®. Two hours later, a solution and are tested for glucose level. These
blood specimen is collected and tested for glucose measurements help determine the patient’s abil-
concentration. Glucose levels will return to or fall ity to deal with increased glucose. During the test,
below the fasting level within 2 hours in individuals the patient must not ingest anything (other than
without diabetes. Increased glucose levels should the solution) except water. The patient must also
be further examined using the GTT. abstain from smoking, because smoking acts as a
According to the standards of the American stimulant and increases blood glucose levels. The
Diabetes Association, a normal blood glucose is patient must also refrain from chewing gum, which
defined as less than 100 mg/dL in a fasting plasma stimulates the digestive process and also may add
glucose test and a 2-hour postload (75 g glucose sugar to his or her system. Physical activity should
load solution) value of less than 140 mg/dL. be strongly discouraged because activity can acti-
A fasting plasma glucose test of 126 mg/dL vate sugar utilization in the body and affect the test
or greater indicates a need for further testing, and results. Sedentary activity level is suggested.
a 2-hour postload value of 140 mg/dL or greater During the second and third hours of the
is a diagnosis of having “prediabetes” indicating a test, the patient may experience weakness, slight
relatively high risk for development of diabetes. faintness, and perspire. These are all normal
A 2-hour postload value of 200 mg/dL or symptoms. If, however, the patient develops a
greater is a positive test for diabetes and should be headache, faints, or displays irrational speech or
confirmed on another day. behavior, he or she may be experiencing hypogly-
cemic shock and the provider should be notified
immediately.
Glucose Tolerance Test The blood glucose level of patients without
The GTT provides more detailed information used diabetes usually peaks 30 to 60 minutes after con-
to assess insulin response to glucose and to diag- sumption of the test load at 160 to 180 mg/dL
nose diabetes. and returns to the fasting level after 2 to 3 hours.
When the patient arrives, he or she should be Patients with diabetes will still have increased glu-
fasting (nothing but water) for at least 10 hours. cose levels at the end of the test.
A capillary specimen is drawn to determine the
fasting blood sugar (FBS) level. If the FBS level is Automated Methods of Glucose
less than 200 mg/dL, then a venous specimen and
urine specimen are obtained. These are labeled as
Analysis
fasting specimens with the date and time noted. If Several types of glucose analyzers are available that
the results of the capillary test shows the FBS level are suitable for POLs or small clinical laboratories.
greater than 200 mg/dL, the provider should be Many of these operate on the principle of reflec-
notified immediately. Hyperglycemia after fasting tance photometry and use adaptations of the enzy-
is abnormal and not an appropriate condition for matic methods of glucose analysis. One example of
further loading with additional glucose and may an instrument suitable for small laboratories is the
be dangerous to the patient. HemoCue® blood glucose analyzer.
After providing the fasting urine and blood Dozens of small, inexpensive, handheld glucose
specimens, the patient consumes a glucose test meters are also made and are designed for home use
solution containing 1.75 g glucose/kilogram of by patients with diabetes. See the Patient Education
body weight, or the standard adult dose of 75 to box for some criteria for patients to consider when
100 g. The patient must consume the entire glu- purchasing an at-home testing method. Most of these
cose solution within a 5-minute time frame. The are suitable for use in point-of-care (POC) testing or
test timing starts immediately after the patient in the provider’s office (Figure 32-7).
has finished drinking the solution. If the patient Glucose controls can be purchased to check
should vomit within the first 30 minutes after instrument performance. It is always necessary to
drinking the solution, the test will be stopped and use test materials that are made for a particular
rescheduled on a different day. It is probably best instrument only with that instrument.
not to mention this to the patient, though, because All of these analyzers are designed to be easy
it is a rare occurrence and it is best not to have the to use and to give rapid results. With all instru-
patient worried about the possibility of vomiting. ments, it is necessary to use consistent proper spec-
Blood and urine specimens are typically collected imen collection and testing technique to avoid
at 30 minutes, 1 hour, 2 hours, and 3 hours (and variations in results.
984 UNIT 7 Laboratory Procedures

Reflectance Photometry Analyzers. Several glu-

cose analyzers are available that are based on
reflectance photometry. Blood from a fingerstick,
serum, or plasma is applied to the reagent area of a
test strip. The glucose in the sample reacts with the
reagents in the pad(s), causing a color to form. The
more glucose present in the sample, the darker or
more intense the color. At the appropriate time,
the strip is inserted into the test chamber and light
is directed onto the test area. The amount of light
reflected from the colored test area is measured by
Figure 32-7 A variety of hand-held glucose analyzers the photometer and converted to a digital readout
(commonly called glucometers) are available for home showing the glucose concentration in milligrams
or clinic use. per deciliter (or mmol/L). Most instruments give
results in 1 to 3 minutes. Instructions included
with the test strips must be followed carefully for
The medical assistant often is responsible for reliable test results (see Procedure 32-5).
providing education to patients on how to use glu-
cometers, including maintenance and calibration Testing Panels
of the meter. It is important that the medical assis-
tant who works with patients with diabetes become Glucose testing may be part of a general chemistry
familiar with a variety of meters and their differ- panel test that can be useful in giving an overall
ences and similarities. view of an individual’s state of health, especially
when used in conjunction with other tests. Glucose
Photometry Analyzers. The HemoCue® blood glu- testing may also be performed as part of a specific
cose system is a compact glucose analyzer based on chemistry panel such as a glucose panel. Glucose
the principle of photometry. The system consists of a serum levels are included in both the Basic Meta-
compact photometer and disposable microcuvettes. bolic Panel (BMP) and the Comprehensive Meta-
The self-filling microcuvette automatically draws up bolic Panel (CMP).
5 mcL blood from a capillary puncture into its reac-
tion chamber. The microcuvette is then placed into Glycosylated Hemoglobin
the holder and pushed into the photometer. The
glucose concentration in milligrams per deciliter Glycosylated hemoglobin or hemoglobin A1c (Hb
(mg/dL) is displayed within 45 to 240 seconds (Fig- A1c) determination is a blood test that measures
ure 32-8). This system is ideal for POLs and POC how well the glucose level has been controlled
testing because of the stability of calibration and the over the past 2 to 3 months versus the conventional
minimum operator training required. blood test that shows only current day status. Pro-

A B C

Figure 32-8 The HemoCue Blood Glucose System. (A) The patient’s blood specimen in placed on the microcu-
vette. The microcuvette is inserted into its holder and pushed into the photometer. (B) Specimen is allowed to
remain in the analyzer until test is completed. (C) When the analyzer has completed the testing, the results are dis-
played and recorded.
 CHAPTER 32
Specialty Laboratory Tests
Figure 32-9 Laboratory panels are combinations of tests related to a specific function, body organ, or organ system.

985
986 UNIT 7 Laboratory Procedures

viders can use this test to determine if patients with cies such as the American Heart Association and the
diabetes are consistently adhering to their diet and National Cholesterol Education Program advise that
health guidelines or are adhering to their diet only fats make up no more than 30% of the total intake of
for a day before their office visit. calories daily, and that the concentration of choles-
Glycosylated hemoglobin is a stable molecule terol in blood not exceed 200 mg/dL. Cholesterol of
formed when sugar and hemoglobin bind together 240 mg/dL or greater is considered to present a high
on the RBC. An increased finding of glycosylated risk for heart disease. Cholesterol levels between 200
hemoglobin indicates poor glucose control in the and 239 mg/dL are considered borderline (see Pro-
assessment of the diabetic patient. cedure 32-6).
When the RBC is first formed, it contains
no glucose. If glucose is present at increased The Chemistry of Cholesterol
levels in the blood, the excess enters the RBC
and attaches (glycates) to the hemoglobin. The The cholesterol molecule consists of carbon,
more glucose is present, the more hemoglobin hydrogen, and oxygen. Cholesterol is a saturated,
becomes glycated. fatty acid. Saturated refers to the number of hydro-
The A1c measures the percentage of the gly- gen atoms attached to the molecule. The more
cated hemoglobin. This offers us an average of the saturated the fat, the harder it is at room tempera-
glucose in the blood over about 3 months. Most ture. Fats of animal origin, for example, butter and
RBCs live about 120 days and maintain the glycated animal fat, are saturated and are solid at room tem-
state. perature. Monounsaturated and polyunsaturated
What hemoglobin A1c does not do is indicate fats are liquid at room temperature. Research into
whether the patient has experienced hyperglyce- coronary artery disease has shown that saturated
mia or hypoglycemia over that time frame because fats tend to increase levels of blood cholesterol.
day-to-day readings of glucose levels are not pro- Monounsaturated fats (olive and peanut oils) do
vided; thus, it is not useful in adjusting insulin. not change blood cholesterol levels, and poly-
Having the patient monitor his or her blood glu- unsaturated fats (corn, safflower, sunflower, and
cose level with a meter and keep a daily diary is a many fish oils) tend to reduce those levels.
good way to look at his or her day-to-day blood glu-
cose levels. Both tests are useful tools in helping Functions of Cholesterol
manage diabetes.
The advantage of hemoglobin A1c not being The human body is efficient at manufacturing cho-
affected by day-to-day variations in blood glucose lesterol. Most cells are capable of doing so, espe-
levels is that the patient does not need to be fasting
for this test.

Patient Education
CHOLESTEROL AND LIPIDS
Let your patients know that several factors
Cholesterol is a fatty compound that is essential for can influence their blood cholesterol levels:
many vital life functions and is a normal constituent
• Age and sex: Cholesterol levels naturally
of blood. Although it is required for life, excess cho-
increase as we age, and women
lesterol is not a necessary part of the diet, except in
experiencing menopause often will
babies and children. Sufficient quantities are manu-
experience an increase in their LDL levels.
factured by the body from carbohydrates and other
fats. Cholesterol has been linked to coronary artery • Heredity and family history: High cholesterol
disease. According to the American Heart Associa- often runs in families. Studies are still in
tion and the National Institutes of Health, cholesterol process about the role genetics play in
should not be restricted in babies and toddlers. Fats cholesterol levels.
and cholesterol are important for normal growth and • Weight: Gaining weight increases
development. Babies and very young children should cholesterol levels in the blood, and losing
be on healthy diets, though, containing unsaturated weight helps to reduce cholesterol levels.
and polyunsaturated oils and fats. From about 4 or • Exercise: Regular physical exercise may
5 years old, they can be transitioned to heart-healthy reduce the LDL level, as well as increase
foods such as nonfat milk. To help reduce the risk the HDL levels.
for coronary artery disease, nutritionists and agen-
 CHAPTER 32 Specialty Laboratory Tests 987

cially the liver, the adrenal cortex, the testes, and

the ovaries. All of the preceding cells, with the
exception of the liver, use cholesterol to manufac-
ture steroid hormones. In addition, cholesterol
is an important component of bile and cellular
membranes. Although the body is efficient at
making cholesterol, it is not as easily degraded
and may accumulate in the body and reach dan-
gerous levels.
In addition to what the body produces,
humans take in additional cholesterol through the
ingestion of meat, eggs, and dairy products (Fig-
ure 32-10). The liver metabolizes cholesterol to
its free form, which is then bound to lipoprotein CHOLESTEROL
and transported through the blood. Over time,
excess cholesterol in the diet can result in a grad- Figure 32-10 Cholesterol is created by the liver or
ual increase of cholesterol concentration in the obtained through animal sources of food such as meat,
plasma. Increased concentrations of cholesterol in eggs, and dairy products.
the plasma can increase to pathogenic levels. Some
of the excess is stored in the liver, whereas some Lipoproteins and Cholesterol
is deposited on the walls of blood vessels (athero-
sclerosis). Atherosclerosis of the coronary arter-
Transport
ies is the most common cause of acute myocardial Two kinds of lipoprotein are involved in the trans-
infarction (heart attack). port of cholesterol through the body: high-density

Patient Education
The Simple Scoop on Cholesterol
Cholesterol can be a confusing subject to try to explain to patients. Here is a very basic explanation
that may help them:
Our bodies need cholesterol and we get it in two ways. We eat it and our liver manufactures it.
Our liver manufactures plenty of cholesterol, so we do not need to eat it (except as babies and young
children). There is only one source of cholesterol in our food: animal products (meat, eggs, and dairy).
Vegetables, fruits, and grains naturally contain no cholesterol, although they may contain oils.
Our bodies have cholesterol transporters called high-density lipoproteins (HDLs) and low-
density lipoproteins (LDLs).
HDLs (sometimes called “healthy lipoprotein”) carry cholesterol to the liver where it can be
released into the stool as bile. We want high levels of HDLs so we can get rid of excess cholesterol.
LDLs (sometimes referred to as the “lousy lipoprotein”) carry cholesterol to our tissues and blood
vessels where it is stored and can cause problems such as blocked arteries, fatty liver, and obesity.
We want low levels of the LDLs so we can have less risk for heart disease and arterial disease.
Fats and oils can also be confusing. Saturated fats are solid at room temperature and come from
animal fats and butter and from manufactured products such as hydrogenated fats.These are the worst
fats. Unsaturated fats, which are liquid at room temperature, may be in two forms: monounsaturated fats
(mono means “single”) and polyunsaturated fats (poly means “many”). Monounsaturated fats such as
olive and peanut oils do not affect blood cholesterol levels, whereas polyunsaturated fats such as corn,
safflower, sunflower, and fish oils will actually reduce blood cholesterol levels.
Triglycerides are a type of lipid found in our blood that provides energy. If we have too much in
our blood, it is also stored in our tissues as fat. The liver converts some of our foods (fatty acids and
glycerol) into triglycerides.
988 UNIT 7 Laboratory Procedures

lipoprotein (HDL) and low-density lipoprotein erides by the liver. When triglyceride levels in the
(LDL). Cholesterol bound to HDL is transported blood are excessive, they are deposited in tissues as
to the liver where it is excreted in the form of bile. adipose tissue. Triglycerides are transported within
HDL is sometimes referred to as good cholesterol. the bloodstream by LDL and very low-density lipo-
LDL cholesterol is deposited in the tissues as fat and proteins (VLDLs).
inside the walls of blood vessels, and it is referred to Many factors influence serum triglyceride lev-
as bad cholesterol. High levels of LDL are associated els. Serum triglyceride concentration will increase
with an increased risk for coronary artery disease. moderately after ingesting a meal containing fat,
Persons with coronary artery disease should have peaking 4 to 5 hours later. Increased concen-
levels of less than 100 mg/dL LDL, whereas those trations of triglycerides are associated with an
without the disease should have levels of less than increased risk for coronary and vascular disease.
160 mg/dL. Desirable values for HDL and LDL
are shown in Table 32-4. Levels of HDL and LDL
are influenced by many factors, both genetic and BLOOD CHEMISTRY TESTS
environmental. It is possible to increase HDL levels
through a combination of weight loss, a diet low in There are many natural chemicals in blood. The
saturated fats, exercise, and cessation of smoking. amounts of those chemicals are controlled by the
Blood cholesterol may be reported as total cho- efficiency of the body’s organs and organ systems
lesterol or as total cholesterol and the HDL and LDL and certainly by environmental factors such as
fractions. Cholesterol screening is used to help iden- diet, smoking, drugs, and activity, as well as genetic
tify patients who are at a high risk for heart disease. composition.
Cholesterol testing is part of a lipid profile The provider can order a general chemistry
that also evaluates lipoproteins and triglycerides to panel (BMP or CMP) or specific panels. A panel
help identify patients at a high risk for heart dis- is a series of tests related to a body system, organ,
ease. Figure 32-9 shows tests performed for lipid or function. In interpreting a chemistry panel,
profiles on the laboratory form. the provider can determine pathology within the
organ or malfunctions.
Triglycerides This chapter discusses each of the compo-
nents briefly and explains some of the conditions
Triglycerides are a type of lipid found in the blood and diseases that can cause these chemical tests
that serve as a source of energy. Fatty acids and to be abnormal. Keep in mind that all laboratory
glycerol from the diet are converted into triglyc- chemistry tests can vary slightly from laboratory
to laboratory. Also remember that no one test,
just like no one symptom, will make a diagnosis
Table 32-4 Values for Cholesterol, HDL, LDL, independent of other clues. The provider is con-
and Triglycerides sidering laboratory tests together with the clinical
picture, patient symptoms, and many other data in
Total finalizing a diagnosis or diagnoses.
Cholesterol (with no other risk factors
such as hypertension and/or diabetes) Alanine Aminotransferase (ALT)
Desirable ⬍200 ALT is an enzyme found in liver tissue. A high level
Less desirable 200–239 indicates liver damage. A normal ALT level is less
At risk ⬎240 than 45 units/L.
HDL (good cholesterol)
Desirable ⬎60 Albumin
At risk for women ⬍50 Most of the protein in plasma is albumin. It is
At risk for men ⬍40 responsible for transporting many small molecules
(such as calcium, drugs, and bilirubin). It is synthe-
LDL (bad cholesterol)
sized in the liver; thus, low levels of albumin may
Optimal ⬍100
indicate liver disease. It may also result from kidney
Borderline risk 130–160
disease, because the kidney is allowing too much
High risk ⬎190
albumin to spill into the urine. Low albumin may
All values are measured in milligrams per deciliter also be caused by malnutrition or a low-protein diet.
(mg/dL). A normal albumin level is 3.4 to 5.4 mg/dL.
 CHAPTER 32 Specialty Laboratory Tests 989

Alkaline Phosphatase (ALP) is part of the hepatic panel. Some types of general
blood problems can cause high levels of bilirubin
ALP is an enzyme. It is present in all our body tis-
because more blood cells are breaking down than
sues but mostly in the liver and bone. When levels
usual. Normal bilirubin ranges are as follows:
are high in the blood, liver or bone disease must be
suspected. A normal ALP level is 44 to 147 Interna- Total bilirubin 0.1–0.2 mg/dL
tional Units/L. Indirect bilirubin 0.1–0.7 mg/dL
Direct bilirubin 0.1–0.3 mg/dL
Newborn total bilirubin 1–12 mg/dL
Aspartate Aminotransferase (AST)
AST is found in the muscle cells (heart and skeletal Blood Urea Nitrogen Test
muscles) and in the liver. High levels cannot indi-
cate specifically liver disease, but it is considered The blood urea nitrogen (BUN) test measures the
together with other liver enzymes. It is also used to concentration of urea in blood. The amount of
monitor patients who have had heart muscle dam- urea in blood reflects the metabolic function of
age (such as heart attacks), but it is not the best the liver and the excretory function of the kidneys.
or only enzyme tested for that purpose. A normal Most renal diseases result in inadequate excretion
AST level is 10 to 34 International Units/L. of urea from the body; therefore, increased con-
centrations of urea appear in the blood. BUN is
one of several tests, including creatinine, that are
Bilirubin, Total and Direct used to screen for renal disease and is especially
useful for evaluating glomerular function.
Bilirubin is a yellow-orange substance that comes Excess protein in the diet is not stored in the
from the breakdown of hemoglobin. Hemoglobin body but is metabolized (catalyzed) for energy pro-
is contained within the RBCs. Because individual duction. Urea is the nitrogenous end product of
RBCs live for only 120 days, they are constantly protein catabolism and is produced in the liver. It is
breaking down and being replaced. When the deposited in the blood and carried to the kidneys for
RBCs “die,” the “heme” part of the hemoglobin excretion. Surplus urea is measured as BUN. Normal
circulates in the blood until the liver filters it out. values of urea vary but in adults range between 8 and
The liver is responsible for changing the “heme” 25 mg/dL; concentrations greater than 100 mg/dL
into a water-soluble substance called bilirubin. indicate serious impairment of renal function. A
Before it reaches the liver, it is called “indirect” or slightly elevated BUN can indicate dehydration.
“free” bilirubin. After it leaves the liver, it is called
“direct” or “conjugated” bilirubin. The liver sends
the conjugated bilirubin to the gall bladder where Calcium
it is released with bile into the small intestine. All the cells in the human body need calcium for
When there is a blockage in the liver/gall bladder many functions. It is a critical element for bones,
ducts or a disorder/disease of the liver, the biliru- muscles, and the nervous system. Too much cal-
bin cannot get past the gall bladder to the small cium can cause the muscles and nerves to become
intestine, so it continues to circulate in the blood. hyperactive, whereas too little calcium can cause
This excess of bilirubin in the blood can lead to the muscles and nerves not to function at all.
a yellow-orange coloring of the skin called jaun- Muscle cramps (Charlie Horses) are often
dice. The body will try to get rid of extra bilirubin caused by low calcium. Calcium needs to be main-
through the urine. Hence, any detection of biliru- tained within certain levels in the blood. If we eat
bin in the urine (bilirubinuria) can be indicative more calcium than we need, the excess is stored in
of a problem in the liver or gall bladder. When the bones. If our diets are low in calcium, the needed
the bilirubin level increases, it causes the skin and amount is pulled from the bones. The storage of
whites of the eyes to become yellow. This change to excess calcium becomes less efficient as women lose
yellow is called jaundice. Newborn babies can be estrogen, hence the need to take in adequate daily
jaundiced because their systems are not sophisti- calcium to prevent osteoporosis as we age. A normal
cated enough to get rid of the bile. Because biliru- calcium level is 8.5 to 10.2 mg/dL.
bin breaks down in sunlight, babies with jaundice
are treated with special “bili-lights” to help them
break down the bilirubin in their skin. The total
Chloride
bilirubin test will indicate problems in the liver and Chloride is an electrolyte. Its main function is to
the hepatic system. Notice the total bilirubin test is help with the electrical impulses of the cells. Chlo-
in the general panel and the direct bilirubin test ride works closely with sodium. Changes in either
990 UNIT 7 Laboratory Procedures

sodium or chloride levels usually affect each other. ment of calcium levels and to detect endocrine
A normal chloride level is 96 to 106 mEq/L. and kidney disorders. Phosphorus levels are
related to uncontrolled diabetes and malnour-
ished conditions. A normal phosphorus level is
Carbon Dioxide (CO2) 2.4 to 4.1 mg/dL.
Measuring CO2 actually is measuring bicarbonate.
This test is part of an arterial blood gas analysis. Potassium (K)
The kidneys are the main organs responsible for
balancing CO2. Anything that throws off the body’s K is an electrolyte and is critical to muscle and
metabolic balance (excessive vomiting and diar- nerve function and for the transportation of nutri-
rhea) can affect the CO2 levels. The CO2 levels in ents and cellular wastes across cellular membranes.
the blood are influenced by kidney and lung func- Abnormal levels of K can cause heart muscle irreg-
tion. Normal CO2 is 20 to 29 mEq/L. ularities and, if severe, can lead to cardiac arrest. K
is controlled by aldosterone, a hormone. Uncon-
trolled diabetes or excessive vomiting/diarrhea
Creatinine can cause abnormal K levels. Patients taking cer-
Creatinine forms when muscle (creatine) breaks tain diuretics (such as Lasix) should be observed
down. Logically, these levels will vary depending for low K. A normal K level is 3.7 to 5.2 mEq/L.
on the patient’s size and muscularity. This test is
used to determine kidney function, and is espe- Sodium
cially important for patients on diabetic or hyper-
tension medications. A normal creatinine level is Sodium is an electrolyte and works closely with
0.8 to 1.4 mg/dL. chloride. Dietary intake of sodium is usually suf-
ficient, and the kidney can excrete the excess.
Sodium is closely related to fluid balance and
Gamma Glutamyltransferase retention. Normal sodium is 135 to 145 mEq/L.
(GGT)
The highest concentrations of GGT are in the Total Protein
liver and kidney. Abnormal levels usually indicate
diseases of the liver, kidney, or bone. It is used in Total protein is a measurement of protein in the
conjunction with other enzymes, especially ALP, to blood serum and can reflect the nutritional state
diagnose diseases. A normal GGT level is 0 to 51 of the body, liver, kidneys, and many other condi-
International Units/L. tions. If the total protein is abnormal, then fur-
ther, more specific tests will need to be performed
to find out exactly the source of the problem. Of
Lactate Dehydrogenase (LDH) course, if the total protein is abnormal, other tests
LDH is an enzyme found in many organs, espe- might show some abnormal levels, too. A normal
cially the liver, heart, kidneys, brain, skeletal mus- total protein level is 6.0 to 8.3 mg/dL.
cles, and lungs. Abnormal levels indicate tissue
damage but are not specific by themselves. Like Uric Acid
all enzymes, LDH is examined in conjunction with
other tests. A normal LDH level is 105 to 133 Inter- Uric acid is created when purine is metabolized.
national Units/L. It is usually secreted by the kidneys, but too much
can build up as crystals in the body and seem to
settle in the largest dependent joint, the great toe.
Phosphorus (Phosphate) This is known as gout. A normal uric acid level is
Phosphorus works closely with calcium, another 3.0 to 7.0 mg/dL.
electrolyte. It is used to assist in the proper assess-
 CHAPTER 32 Specialty Laboratory Tests 991

Procedure 32-1
Pregnancy Test
STANDARD PRECAUTIONS: general so a variety of kits can be used. RATIO-
NALE: The manufacturer’s instructions will
differ from kit to kit. It is important, as a quality-
assurance measure, for the instructions to be
PURPOSE: read and understood thoroughly. Any questions
To perform the enzyme immunoassay or agglutina- must be directed to the manufacturer.
tion inhibition test to detect hCG in urine to deter- a. Determine materials are at room tempera-
mine positive or negative pregnancy results. ture.
b. Apply urine to the test unit using dispenser
EQUIPMENT/SUPPLIES:
provided (Figure 32-11A ).
Gloves
Urine specimen c. Wait appropriate time interval (use stopwatch
Stopwatch to time test).
Disinfectant (10% chlorine bleach solution) d. Apply first reagent/antibody to test unit using
Biohazard container dispenser provided.
hCG negative and positive urine control e. Observe color development after appropriate
Pregnancy test kit time interval.
PROCEDURE STEPS: f. Stop reaction.
1. Wash hands and put on gloves. RATIONALE: g. Consult manufacturer’s package insert to
While working with body fluids, such as urine, interpret test results (Figure 32-11B).
gloves should be worn as personal protection.
4. Record the results of the test on a laboratory report
2. Assemble all equipment and supplies. RATIO- form following laboratory policy. RATIONALE:
NALE: Organizing all equipment and supplies Interpretation of results may differ from kit to
before running the test will eliminate errors kit according to the manufacturer’s design, and
caused by missing supplies. even though laboratory processes are the same,
3. Perform the test following the manufacturer’s policies and forms will differ from laboratory to
instructions. The following steps are intentionally laboratory.

A B

Figure 32-11 (A) Urine is place in the test unit according to the manufacturer’s instructions.
(B) The package instructions specify how the test is to be interpreted. A common interpretation
is with a negative sign (left) and a positive sign (right).

continues
992 UNIT 7 Laboratory Procedures

Procedure 32-1 (continued)

disposal of biohazard substances and disinfec-

tion of supplies/equipment.
7. Remove gloves and discard into biohazard con-
tainer. Wash hands. RATIONALE: Gloves protect
hands from most but not all microorganisms.
Hands should always be washed after removal
of gloves to ensure complete protection and to
remove glove powders and latex residue.
C 8. Document procedure in patient’s chart in the
progress notes. Complete a lab report. After the
Figure 32-11 (C) Control tests must be performed provider has initialed the report, it should be
according to the manufacturer’s instructions. The filed in the lab section of the patient’s chart..
results of the positive and negative controls test are RATIONALE: Documentation should refer the
shown. reader to the test result in the laboratory section
of patient’s chart.

DOCUMENTATION
5. Repeat steps with both positive and negative 08/06/20XX Urine HCG test performed for pregnancy deter-
urine controls (Figure 32-11C). RATIONALE: mination. Specimen tested in our lab. Results filed in lab
Controls are performed to ensure the quality section. Patient tolerated the procedure well and Dr. Rice dis-
of the reagents and testing supplies. If a positive cussed results with her. Audrey Jones, CMA (AAMA) _____
control test does not show a positive result, then
something is wrong with the reagent or the test-
ing supplies. If the control test is not accurate, Laboratory Report
the patient’s test will not be accurate either. Patient Name Lynn Engle Date 08-06-20XX
6. Disinfect reusable equipment. Discard dispos-
able supplies into biohazard container. Dispose Urine Pregnancy Test negative
of specimen per laboratory policy. Clean work
Audrey Jones, CMA (AAMA)
area with disinfectant. RATIONALE: Follow
Standard Precautions and laboratory policies for MA signature

Procedure 32-2
Performing Infectious Mononucleosis Test
STANDARD PRECAUTIONS: EQUIPMENT/SUPPLIES:
Gloves
Serum or plasma specimen
Stopwatch or lab timer
PURPOSE: Surface disinfectant (10% chlorine bleach solution)
To perform an accurate test of serum or plasma to Test kit for IM
detect the presence or absence of antibodies of infec- Biohazard container
tious mononucleosis (IM).

continues
 CHAPTER 32 Specialty Laboratory Tests 993

Procedure 32-2 (continued)

PROCEDURE STEPS: with disinfectant. RATIONALE: Follow Standard

NOTE: These instructions are intentionally general so Precautions and laboratory policies for disposal
a variety of test kits may be used. The manufacturer’s of biohazard substances and disinfection of sup-
instructions will differ from kit to kit. It is important, plies/equipment.
as a quality-assurance measure, for the instructions to 7. Remove gloves and discard into biohazard con-
be thoroughly read and understood before perform- tainer. Wash hands. RATIONALE: Gloves protect
ing the test. Any instructions not clearly understood hands from most but not all microorganisms.
should be clarified with the manufacturer. Hands should always be washed after removal
1. Wash hands and put on gloves. RATIONALE: of gloves to ensure complete protection and to
While working with body fluids, such as urine, remove glove powders and latex residue.
gloves should be worn as personal protection.
8. Document results in the progress notes. Com-
2. Assemble all equipment and supplies. RATIO- plete a lab report. After the provider has initialed
NALE: Organizing all equipment and supplies the report, it should be filed in the lab section of
before running the test will eliminate errors patient’s chart. RATIONALE: Documentation
caused by missing supplies. should refer the reader to the test result in the
3. Perform the test according to the manufacturer’s laboratory section of patient’s chart .
instructions exactly. RATIONALE: The manufac-
turer’s instructions will vary with each specific DOCUMENTATION
kit. Quality results are assured only when instruc- 4/27/20XX 2:54 PM Mononucleosis test performed. Results
tions are followed precisely. forwarded to provider and initialed. Form filed in laboratory
4. Record the results on a laboratory report form section of medical record. Joe Guerrero, CMA (AAMA) ____
following laboratory policy. RATIONALE: Even
though laboratory processes are the same, poli-
cies and forms will differ from laboratory to labo-
DOCUMENTATION
ratory. 08/06/20XX Venipuncture performed for infectious mono-
nucleosis test. Specimen tested in our lab. Results in lab report
5. Repeat the test procedure using positive and filed. Patient tolerated the procedure well and Dr. Rice dis-
negative controls. RATIONALE: Controls are
cussed results with her. Audrey Jones, CMA (AAMA) _____
performed to ensure the quality of the reagents
and testing supplies. If a positive control test
does not show a positive result, then something Laboratory Report
is wrong with the reagent or the testing supplies.
If the control test is not accurate, the patient’s Patient Name Carolyn Siderland Date 08-06-20XX
test will not be accurate either.
Infectious Mononucleosesis Test negative
6. Discard contaminated materials into biohazard
container. Dispose of specimen appropriately Audrey Jones, CMA (AAMA)
and disinfect reusable materials. Clean work area MA signature

Procedure 32-3
Obtaining Blood Specimen for Phenylketonuria (PKU) Test
STANDARD PRECAUTIONS: PURPOSE:
To obtain a blood specimen using a PKU test card or
“filter paper” to determine phenylalanine levels in
newborns who are at least 3 days old.

continues
994 UNIT 7 Laboratory Procedures

Procedure 32-3 (continued)

EQUIPMENT/SUPPLIES: 3. Select and clean an appropriate puncture site

Gloves (Figure 32-12A). Allow the alcohol to dry before
PKU filter paper test card and mailing envelope the puncture. RATIONALE: Cleaning the site
Alcohol swabs before puncture will remove any powders, oils,
Cotton balls/gauze pad lotions, and contaminates. Allowing the alcohol
Sterile pediatric-sized lancet to dry prevents the stick from stinging.
Biohazard waste container 4. Grasp the infant’s foot, taking care not to touch
the cleansed area. Make a puncture approxi-
PROCEDURE STEPS: mately 2 to 3 mm deep in the infant’s heel, mak-
1. Wash hands and put on gloves. RATIONALE:
ing sure the infant’s lateral, or side, portion of
While working with body fluids, gloves should be
the heel pad is used. A pediatric-sized lancet,
worn as personal protection.
which limits the depth of puncture, should be
2. Identify the infant. Explain the purpose of the used (Figure 32-12B). If possible, recent punc-
test and the procedure to the parents. Discuss ture sites should always be avoided (see Proce-
the current health of the infant before begin- dure 28-5, Capillary Puncture).
ning the procedure. RATIONALE: Certain anti-
5. Wipe away the first drop of blood with a gauze
biotics, medications, or vomiting problems may
pad. RATIONALE: The first drop is diluted with
cause false results.
alcohol and should not be collected for the test.
Using a gauze pad rather than a cotton ball is
preferred because the cotton ball may leave
tiny fibers on the puncture site. The fibers may
encourage clotting, which will interfere with
obtaining sufficient specimen for the test.
6. To collect blood for the test, press the back side
of the filter paper test card against the infant’s

B C

Figure 32-12 (A) Capillary blood collections sites on an infant’s heel. (B) The infant’s foot should be held
securely with the nondominant hand while the dominant hand uses the pediatric lancet to perform the capillary
heelstick. (C) Drops of blood are transferred from the capillary heelstick puncture site to the PKU filter card,
completely filling all the circles.

continues
 CHAPTER 32 Specialty Laboratory Tests 995

Procedure 32-3 (continued)

heel while exerting gentle pressure on the heel 11. After the test card is dry, complete the PKU test
(Figure 32-12C). The drop of blood should be card with all patient and provider information.
large enough to completely fill and soak through RATIONALE: Allowing the blood to dry thor-
the circle. Do not layer the multiple blood drops oughly before further handling lessens the chances
within a single circle. Completely fill all of the of contaminating other parts of the form.
circles on the test card. RATIONALE: Failure to 12. Place the test card in the mailer envelope and
do so will require a retest. send it to the laboratory within 2 days. RATIO-
7. Hold a cotton ball over the puncture and apply NALE: It is important that the completed card
gentle pressure until the bleeding stops. Do not be mailed as soon as possible to eliminate the
apply a bandage. RATIONALE: The bleeding breakdown of the contents within the specimen
should be stopped before the patient is released and to obtain the results as soon as possible to
from your care. Bandages are discouraged begin treatment if necessary.
because they can be a choking hazard for infants 13. Document the procedure in patient’s chart. When
and toddlers. test results are returned, they should be initialed
8. Properly dispose of all waste in biohazard con- by the provider and be placed in the lab section
tainer. RATIONALE: Follow Standard Precau- of patient’s chart. RATIONALE: Documentation
tions and laboratory policies for disposal of should refer the reader to the test result in the
biohazard substances and disinfection of sup- laboratory section of patient’s chart.
plies/equipment.
DOCUMENTATION
9. Remove the gloves and wash hands. RATIO- 6/27/20XX 10:54 AM Capillary puncture performed on lat-
NALE: Gloves protect hands from most but not eral aspect of left heel for PKU testing. Patient is 12 days old,
all microorganisms. Hands should always be currently taking no medication, and is not ill. Patient toler-
washed after removal of gloves to ensure com- ated the procedure well and adequate specimen was obtained.
plete protection and to remove glove powders PKU card completed and mailed. Audrey Jones, CMA (AAMA)
and latex residue.
10. Allow the PKU test card to completely dry on
a nonabsorbent surface at room temperature. 7/10/20XX PKU test results received and initialed by Dr.
This will take about 2 hours. If collecting more King and filed in the laboratory section of the patient’s medi-
than one card, do not lay one card on another cal record. The patient’s parents were notified of the nega-
when drying. RATIONALE: This could cause tive results per Dr. King’s instructions. Audrey Jones, CMA
cross contamination of blood between the cards. (AAMA) ________________________________

Procedure 32-4
Screening Test for PKU
STANDARD PRECAUTIONS: newborns who are at least 6 weeks old. This is a quick
screening test only.

EQUIPMENT/SUPPLIES:
Gloves
PURPOSE: 10% ferric chloride for the diaper test
Test a urine specimen using the diaper test or the or
Phenistik test to determine phenylalanine levels in Phenistik for the Phenistik Method Test
Biohazard waste container

continues
996 UNIT 7 Laboratory Procedures

Procedure 32-4 (continued)

PROCEDURE STEPS: 6. Properly dispose of all waste in a biohazard waste

1. Assemble and organize equipment and supplies. container. RATIONALE: Follow Standard Pre-
RATIONALE: Being organized helps the process cautions and laboratory policies for disposal of
go more smoothly and professionally. biohazard substances and disinfection of sup-
plies/equipment.
2. Identify the infant. Verify that the infant is at
least 6 weeks of age. Explain the purpose of the 7. Remove gloves and wash hands. RATIONALE:
test and the procedure to the parents. RATIO- Gloves protect hands from most but not all
NALE: Explaining the procedure helps the par- microorganisms. Hands should always be washed
ents understand and the process usually goes after removal of glove to ensure complete pro-
more smoothly. tection and to remove glove powders and latex
residue.
3. Wash hands and apply gloves. RATIONALE:
Because biohazard body fluids will be tested, per- 8. Document the procedure in the progress notes.
sonal protective equipment is required for safety. Complete a lab report. After the provider has
initialed the report, it should be filed in the lab
4. Follow one of the two following procedures
section of patient’s chart. RATIONALE: The
after removing the diaper away from the infant.
documentation should refer the reader to the
RATIONALE: Always follow manufacturer’s
laboratory section of patient’s chart.
instructions for assuring test accuracy. The dia-
per is remove away from the infant to ensure that
DOCUMENTATION
no chemical comes in contact with the infant.
08/06/20XX Phenistik test performed in urine for PKU
a. Diaper test: Apply several drops of 10% ferric screening. Specimen tested in our lab. Results filed in lab sec-
chloride to a diaper that contains fresh urine. tion. Dr. Rice discussed results with the patient’s parents.
Development of a green color indicates a pos- Audrey Jones, CMA (AAMA) ____________________
itive test.
b. Phenistik test: Dip the Phenistik test strip into Laboratory Report
fresh urine or press it against a diaper con-
taining fresh urine. Development of a green Patient Name Pedro Gonzalas Date 08-06-20XX
color indicates a positive test.
Screening PKU (Urine) negative
5. A positive urine test should be followed up with a
blood test. RATIONALE: This is a screening test Audrey Jones, CMA (AAMA)
only and should be followed up with the more MA signature
accurate blood test.

Procedure 32-5
Measurement of Blood Glucose Using an Automated Analyzer
STANDARD PRECAUTIONS: EQUIPMENT/SUPPLIES:
Gloves Control solutions for
Goggles glucose analyzer
Safety lancet Test strips for glucose
PURPOSE: Alcohol swabs analyzer
To measure blood glucose. Glucose analyzer Laboratory tissue
Adhesive strip Cotton balls
Gauze

continues
 CHAPTER 32 Specialty Laboratory Tests 997

Procedure 32-5 (continued)

PROCEDURE STEPS: 4. Apply a large drop of blood to the test strip.

1. Review the manufacturer’s manual for the spe- RATIONALE: The test requires a large drop of
cific glucose analyzer being used. Turn on the blood for accurate results. Let a large drop form
analyzer. RATIONALE: Always read and follow before applying it to the test device.
the manufacturer’s instructions exactly for your 5. While the test is running, check the puncture
particular analyzer to ensure accurate results. site. If the bleeding has stopped, apply an adhe-
2. Clean the work area and assemble all materi- sive strip. RATIONALE: The test will take time to
als and supplies. RATIONALE: Organizing all compute, allowing you time to treat the patient.
equipment and supplies before running the test 6. After the appropriate time interval has passed,
will eliminate errors caused by missing supplies. read the glucose concentration. RATIONALE:
3. Wash hands. Put on gloves and goggles. RATIO- The test requires an appropriate amount of time
NALE: Washing your hands ensures that your for accurate results.
skin is clean before gloving and decreases con- 7. Properly dispose of all waste in a biohazard waste
taminants. Applying personal protection equip- container. RATIONALE: Follow Standard Pre-
ment when working with body fluids will lessen cautions and laboratory policies for disposal of
the chances of exposure to dangerous biohazard biohazard substances and disinfection of sup-
substances. plies/equipment.
4. Record the control ranges, control lot num- 8. Remove gloves and wash hands. RATIONALE:
ber, and test strip lot number. RATIONALE: Gloves protect hands from most but not all
Recording the lot numbers and control ranges is microorganisms. Hands should always be washed
another type of quality-assurance measure and is after removal of gloves to ensure complete pro-
required by CLIA for many automated tests. tection and to remove glove powders and latex
5. Perform the check test and the control test residue.
according to the manufacturer’s instructions. 9. Document the procedure in the progress notes.
If both tests are within range, proceed to the Complete a lab report. After the provider has
glucose test. Repeat both tests if either is out of initialed the report, it should be filed in the lab
acceptable range. RATIONALE: Controls are section of patient’s chart. RATIONALE: The
performed to ensure the quality of the reagents documentation should refer the reader to the
and testing supplies. If a positive control test laboratory section of patient’s chart.
does not show a positive result, then something
is wrong with the reagent or the testing supplies. DOCUMENTATION
If the control test is not accurate, the patient’s 08/06/20XX Fingerstick performed for blood glucose. Speci-
test will not be accurate either. men tested in our lab. Results filed in lab section. Patient tol-
To perform the glucose test: erated the procedure well and Dr. Rice discussed results with
1. Remove a test strip from the bottle and replace her. Audrey Jones, CMA (AAMA) _________________
the lid. RATIONALE: Replacing the lid securely
ensures that the reagents are protected from Laboratory Report
light and moisture. Patient Name Veronica Hernandez Date 08-06-20XX
2. Insert the test strip into the test chamber. RATIO-
NALE: Follow the manufacturer’s instructions Blood Glucose 108 mg/dL
for proper use of test kits.
Audrey Jones, CMA (AAMA)
3. Perform a capillary puncture (see Procedure
28-5). Wipe first drop with gauze. RATIONALE:
MA signature
Wiping the first drop away lessens the amount of
tissue fluid in the specimen.
998 UNIT 7 Laboratory Procedures

Procedure 32-6
Cholesterol Testing
STANDARD PRECAUTIONS: 28). RATIONALE: Always read and follow the
manufacturer’s instructions to ensure accurate
results.
4. Follow the manufacturer’s instructions to per-
PURPOSE: form the cholesterol test. Be sure to run the
To measure cholesterol and triglyceride for monitor- controls also. RATIONALE: Following all man-
ing purposes. For cholesterol, HDL, LDL, or triglyc- ufacturer’s instructions will assure accurate test
eride monitoring. NOTE: The following steps are results. Controls are performed to ensure the
intentionally general so a variety of kits can be used. quality of the reagents and testing supplies. If
The manufacturer’s instructions will differ from kit the control test is not accurate, the patient’s test
to kit. It is important, as a quality-assurance measure, will not be accurate either.
for the instructions to be read and understood thor- 5. Properly dispose of all waste in biohazard con-
oughly. Any questions must be directed to the manu- tainer. RATIONALE: Follow Standard Precau-
facturer. tions when disposing of sharps and biohazard
and contaminated waste.
EQUIPMENT/SUPPLIES:
Gloves 6. Record the results of the test on a laboratory
Blood collecting equipment report form and document the procedure in the
Pipettes with disposable tips patient’s chart. After the provider has initialed
Chlorine bleach the report, file it in the patient’s chart. RATIO-
Commercial kit for manual determination of NALE: The chart note should refer the reader to
cholesterol the laboratory section of the patient’s chart.
Controls and standards
Marking pen DOCUMENTATION
Biohazard container 08/06/20XX Fingerstick performed for serum cholesterol.
Specimen tested in our lab. Initialed results filed in the lab
PROCEDURE STEPS: section of the chart. Dr. Rice discussed the results with the
1. Assemble all necessary equipment and materi- patient. Audrey Jones, CMA (AAMA) _______________
als. RATIONALE: Organizing all equipment and
supplies before running the test will eliminate Laboratory Report
errors caused by missing supplies and will show
the patient a more professional process.
Patient Name Jennifer Yu Date 08-06-20XX
2. Wash hands; apply gloves. RATIONALE: Wash- Serum Cholesterol 150 mg/dL
ing your hands ensures that your skin is clean
before gloving and decreases contaminants. Audrey Jones, CMA (AAMA)
Applying personal protection equipment when MA signature
working with body fluids will lessen the chances
of exposure to dangerous biohazard substances.
3. Obtain a blood sample from the patient, either
by fingerstick or venipuncture, depending on
the manufacturer’s instructions (see Chapter
 CHAPTER 32 Specialty Laboratory Tests 999

Case Study 32-1

Refer to the scenario at the beginning of the chapter. CASE STUDY REVIEW
Audrey takes pride in paying attention to every detail
when performing lab tests. She is also committed to explain- 1. What are some key points to adhere to when
ing processes to her patients and increasing their comfort performing testing using a CLIA waived test kit to
level. ensure accuracy?
2. What are some specific ways you can reassure a
patient to have confidence in your ability?

Case Study 32-2

Anna Preciado, CMA (AAMA), a clinical medical assistant with CASE STUDY REVIEW
Drs. Lewis and King, has performed many venipunctures dur-
ing her training at college, throughout her practicum, and 1. What course of action should Anna take to prepare
since her employment with Drs. Lewis and King. She has not, herself for performing a procedure that she has not
however, performed a heelstick capillary draw since she was done in several years?
in college and even then she practiced on a doll. Until now 2. Once Anna feels she is technically ready to perform
another medical assistant in the clinic was doing all the heel- the PKU blood test, what should she do to ensure
stick capillary draws for PKU testing, but Anna is ready to start that the procedure goes well?
performing them herself. She is concerned and understand-
ably nervous about performing this procedure on an infant.

SUMMARY
CLIA has identified many rapid test kits and automated methods for use in the ambulatory care setting in
the waived category. For all of the tests discussed in this chapter, it is important for the medical assistant
to have a basic understanding of the principles involved and the proper sampling procedures required.
Safety procedures and Standard Precautions must be observed at all times and include the proper disposal
of infectious materials and reagents. Gloves and goggles are always used when obtaining samples and while
performing the actual test. Careful documentation by the medical assistant will help the provider in the
diagnosis of the patient.
1000 UNIT 7 Laboratory Procedures

STUDY FOR SUCCESS

To reinforce your knowledge and skills of information presented in this chapter:
• Review the Key Terms
• Practice the Procedures
• Consider the Case Studies and discuss your conclusions
• Answer the Review Questions

˚ Multiple Choice
˚ Critical Thinking
• Navigate the Internet by completing the Web Activities
• Practice the StudyWARE activities on the CD
• Apply your knowledge in the Student Workbook activities
• Complete the Web Tutor sections
• View and discuss the DVD situations

REVIEW QUESTIONS
Multiple Choice d. Type AB RBCs have both A and B antigens on
1. In addition to pregnancy, a positive hCG test can be the cell.
found in the following pathologic conditions except: 6. Which of the following is a true statement about the
a. ectopic pregnancy Rh factor?
b. hydatidiform mole of the uterus a. Rh factor is a rare blood type.
c. pelvic inflammatory disease b. Rh factor is present on all RBCs.
d. cancer of the lung c. Rh factor was discovered by experiments on rhe-
2. If a urine sample for a pregnancy test cannot be sus monkeys.
tested immediately, it may be stored in the follow- d. People without the Rh factor on their RBCs have
ing way for 24 hours: naturally occurring antibodies called anti-D in
a. room temperature, 25°C their plasma.
b. body temperature, 37°C 7. When instructing a patient in the correct collection
c. frozen of a specimen for semen analysis, all of the follow-
d. refrigerated at 4°C ing should be considered except:
3. The kissing disease is synonymous with the disease: a. avoid the consumption of alcohol several days
a. tuberculosis before the test
b. infectious mononucleosis b. collection of semen into a condom is unacceptable
c. hemolytic anemia c. specimen should be transported to the labora-
d. hypoglycemia tory at 37°C within 30 minutes of collection
4. Serum or blood would be the specimen for all but d. avoid the consumption of fats several days before
the following test: the test
a. ABO typing 8. Testing for PKU is done on:
b. testing for EBV a. newborns
c. cholesterol b. children 1 to 3 years of age
d. hCG hormone c. teenagers
e. all of the above d. adults older than 40 years
5. Which of the following statements is incorrect 9. The best site location for a tuberculin Mantoux
regarding blood type: test is:
a. Type A RBCs have A antigens on the cell. a. back of the hand
b. Type B RBCs have B antigens on the cell. b. forearm 3 to 4 inches from bend of arm
c. Type O RBCs have A and B antigens on the cell. c. 1⁄2 inch above the back of the knee
d. upper part of the arm in the deltoid muscle
 CHAPTER 32 Specialty Laboratory Tests 1001

10. A patient with hypoglycemia would have a blood WEB ACTIVITIES

glucose level of:
a. 50–70 mg/dL 1. Search the CDC’s and other government
b. 70–110 mg/dL Web sites for information on infectious
c. 110–150 mg/dL diseases such as mononucleosis.
d. 150–200 mg/dL 2. Use search engines to research some of the
conditions discussed in this chapter, such as
Critical Thinking PKU and TB.
1. Why is the first-voided morning urine the preferred
specimen for a pregnancy test? REFERENCES/BIBLIOGRAPHY
2. Why is it necessary to repeat the seminal sperm
count analysis three times over a 2-month period? Department of Health and Human Services, Centers for
3. What factors may alter the results of a blood glu- Disease Control and Prevention. (2008). Epstein-
cose measurement? Barr virus and infectious mononucleosis. Retrieved
4. How can you distinguish between the diabetic and November 2008, from http://www.cdc.gov.
nondiabetic patient based on the results of the 2- U.S. Food and Drug Administration. (2007). Databases
hour postprandial glucose evaluation? on the FDA Website. Retrieved October 2008, from
5. Discuss the relation between saturated fats and http://www.fda.gov/search/databases.html.
coronary artery disease. Walters, N. J., Estridge, B. H., & Reynold, A. P. (2008).
6. What is the function of triglycerides in the body? Basic medical laboratory techniques (5th ed.). Clifton
7. What instructions should the patient be given in Park, NY: Delmar Cengage Learning.
preparation for a triglyceride evaluation?
8. What is the source of urea in the blood?

THE DVD HOOK-UP

This chapter discusses specialty tests that may be checking with him first. Why is it best for the provider
performed in the medical office. to communicate test results to the patient? Is it ever
1. This program illustrated the technique for performing a acceptable for the medical assistant to communicate test
blood glucose test. The medical assistant ran a control results to a patient?
before performing the test. Why is it important to run a
control before performing the test?
2. What should you do if a patient asks you for his or her
laboratory results before the doctor has had a chance
to review them?

DVD Journal Summary DVD Series Program Number

Write a paragraph that summarizes what you learned from Skills Based Series 11, 12
watching the selected scenes from today’s DVD programs. Chapter/Scene Reference
When viewing the scene from program 12, you saw a • Performing Blood Sugar Test
medical assistant give a testimonial about giving out a test • Performing Mononucleosis Test
result without checking with the provider first. The patient • Performing Pregnancy Test
was traumatized and the provider was furious with the
medical assistant for giving out the test results without
This page intentionally left blank
SEC TI ON
Professional
III Procedures
UNIT
Office and Human
8 Resources Management

Chapter 33
The Medical Assistant as Office
Manager
Chapter 34
The Medical Assistant as Human
Resources Manager

1004
 Chapter
The Medical Assistant as
Office Manager 33
KEY TERMS OUTLINE
Agenda The Medical Assistant as Office Procedure Manual
Ancillary Services Manager Organization of the Procedure
Authoritarian Qualities of a Manager Manual
Manager Office Manager Attitude Updating and Reviewing the
Benchmark Professionalism Procedure Manual
Benefit Management Styles HIPAA Implications
Bond Authoritarian Style Travel Arrangements
Participatory Style Itinerary
Brainstorming
Management by Walking Time Management
Conflict Resolution
Around Marketing Functions
Embezzle Risk Management Seminars
Fringe Benefit Importance of Teamwork Brochures
“Going Bare” Getting the Team Started Newsletters
Itinerary Using a Team to Solve a Press Releases
Liability Problem Special Events
Malpractice Planning and Implementing a Records and Financial
Management by Walk- Solution Management
ing Around (MBWA) Recognition Electronic Health Records and
Marketing Supervising Personnel the Office Manager
Mentor Staff and Team Meetings Payroll Processing
Minutes Conflict Resolution Facility and Equipment
Harassment in the Workplace Management
Negligence
Assimilating New Personnel Administrative and Clinical
Participatory Inventory of Supplies and
Manager Employees with Chemical
Dependencies or Emotional Equipment
Practicum Administrative and Clinical
Problems
Procedure Manual Evaluating Employees and Equipment Calibration and
Professional Liabil- Planning Salary Review Maintenance
ity Insurance Dismissing Employees Liability Coverage and Bonding
Profit Sharing Legal Issues
Risk Management
Salary Review
Self-actualization OBJECTIVES
Shadow The student should strive to meet the following performance objectives and dem-
Subordinate onstrate an understanding of the facts and principles presented in this chapter
Teamwork through written and oral communication.
Work Statement
1. Define the key terms as presented in the glossary.
2. Describe the qualities of a manager.

1005
OBJECTIVES (continued)
3. Discuss characteristics of managers and leaders.
4. Differentiate between authoritarian and participatory manage-
ment styles.
5. Describe management by walking around and its usefulness in
ambulatory care settings.
6. Recall a minimum of four common risks and risk-control measures.
7. List three benefits of a teamwork approach.
8. Discuss the importance of a meeting agenda.
9. Describe appropriate evaluation tools for employees.
10. Recall effective methods of resolving conflict.
11. Identify the steps required to make travel arrangements.
12. Define the term itinerary and list important information the
itinerary should contain.
13. List three methods of increasing productivity and efficient time
management.
14. Describe the purpose of a procedure manual.
15. Discuss the impact of HIPAA’s privacy policy in ambulatory care
settings.
16. Describe the general concept of marketing and recall at least
three marketing tools.
17. Describe the purpose and benefit of marketing.
18. Discuss the steps involved in the inventory of administrative and
clinical supplies and equipment.
19. Discuss the steps involved in administrative and clinical equip-
ment calibration and maintenance.

Scenario
Marilyn Johnson has been employed by Drs. Lewis and a nearby suburb. Marilyn has a baccalaureate degree
King’s office for the past 8 years. Three years ago, she in business administration. Her responsibilities at Drs.
was promoted to the position of office manager when Lewis and King’s office include various duties involving
the facility added the second office for its associates in personnel, finances, and office efficiency.

INTRODUCTION
The drive to improve the productivity of the medical medical assistants to advance to the position of office
office, precipitated by managed care, Medicare, and manager.
insurance limits placed on fees, have broadened the In small offices, the position of office manager may
scope of employment options and job marketability for include the duties of the human resources (HR) repre-
medical assistants. This has created an opportunity for sentative; in larger clinics, these positions will be inde-

1006
 CHAPTER 33 The Medical Assistant as Office Manager 1007

3. Supervise office personnel

Spotlight on Certification 4. Approve financial transactions and account dispo-
sition; generate financial reports as needed
RMA Content Outline
5. Supervise the purchase and storage of office sup-
• Medical law plies
• Medical ethics
6. Prepare staff meeting agenda, conduct the meet-
• Human relations ing, and record minutes
CMA (AAMA) Content Outline 7. Supervise the purchase, repair, and maintenance
• Basic principles (psychology) of office equipment
• Working as a team member to achieve 8. Assist in improving work flow and office efficien-
goals cies (time management)
• Evaluating and understanding 9. Create and update the office procedure manual,
communication Material Safety Data Sheets (MSDSs), and Health
• Medicolegal guidelines & requirements Insurance Portability and Accountability Act
• Computer applications (HIPAA) manual.
• Records management 10. Prepare patient education materials and arrange
• Resource information and community patient/community education workshops as needed
services
• Managing physician’s professional
schedule and travel QUALITIES OF A MANAGER
• Managing the office
• Office policies and procedures An office manager should not feel the need to be
• Manage practice finances superior to employees but should strive to develop
• Employee payroll a synergistic organization. The best manager is like
an orchestra conductor. He or she constructively
CMAS Content Outline blends together the skills and abilities of diverse
• Legal and ethical considerations people to produce a smooth and efficient team.
• Professionalism The result is an organization having greater capa-
• Patient information and community bility than would be achievable by the individuals
resources acting independently.
• Medical records management
The office manager should have two over-
arching goals:
• Medical office financial management
• Medical office management • Get the job done.
• Make the process enjoyable.

pendent. This book treats them as separate positions (see This does not mean work should be one big
Chapter 34). In the larger facilities, the office manager party. It means developing ownership for the work,
and HR representative must coordinate their personnel- pride in doing the job well, and a sense of teamwork.
related functions into a seamless organization. There will be times when employees will not like
having to stay late to meet important deadlines, but
through developed self-actualization, they will take
THE MEDICAL ASSISTANT enjoyment from even the most undesirable task.
AS OFFICE MANAGER A good office manager needs to be two persons
in one body: leader and manager. The two functions
The manager of a medical office or ambulatory are different, and the good manager will use some
care facility can have vast and diverse responsibili- of each characteristic in meeting objectives. Table
ties. This chapter covers the following office man- 33-1 lists the differences between an authoritarian
ager duties: style manager and a leader/manager.
Good managers are leaders, providing their
1. Make travel arrangements and prepare an itinerary coworkers with vision, guidance, and a feeling of
2. Arrange and maintain practice insurance and ownership in the process. They do these things
develop risk management strategies without threats, usually through the power of their
1008 UNIT 8 Office and Human Resources Management

to one employee will be granted to others in similar

Table 33-1 Differences Between an
Authoritarian Style Manager situations. This approach will decrease the risk for
and a Leader/Manager being accused of playing favorites or being unfair.
• Objectivity. The office manager must be able to view
Authoritarian Leader challenges without bias or prejudice. For example,
when promotions are made, the office manager
• Establishes and adheres • Empower people
must be able to focus on the job description crite-
to written procedures • Inspires by example ria and individual qualifications without introduc-
• Focused on short-range • Vision and long range
goals
ing personal preference.
goals
• Authoritarian style of • Consensus or team
• Organizational skills. Being organized includes
management style of management being able to prioritize tasks, working efficiently
• Bottom line all important • Does the right thing and methodically. Know when and be willing to
• Does things right • Pay for performance delegate tasks when others have the expertise and
• Annual raises • Not afraid of change time to complete the task within the time lines.
• Reluctant to change • People skills. The office manager must like people in
general and enjoy working with them. Building con-
fidence and self-esteem in others and being inter-
ested in promoting constructive relationships are
personal charisma. It is also important that man- essential qualities of the office manager. The abil-
agers clearly convey their expectations to their ity to function as an effective team leader provides a
employees. Possibly nothing leads to ill feeling role model for other staff members to emulate.
between the manager and an employee more than
• Problem-solving skills. The office manager must be
failure to let the employee know what is expected
a problem solver. This may include being creative
of him or her. Furthermore, a lack of expectations
and doing away with old paradigms and traditional
stifles career growth and organizational vitality.
approaches to solving a problem. When difficult
Good leaders need to blend many admirable per-
issues arise, focus on the situation, issue, or behav-
sonality traits of leadership to be successful and
ior, not on the person. A discussion about solving
still control the resources entrusted to them.
the problem without laying blame is much more
Before proceeding with a listing of qualities
productive. Positive solutions may be more readily
of a leader/manager, a rule that defines almost
attained when discussing what was observed rather
all of the ethical qualities needs to be mentioned
than what was told by someone else.
(Figure 33-1). Some texts call it the Golden Rule;
this rule will make the difference between a man- • Technical expertise. Have a working knowledge of
ager who is successful and one who fails miserably. each procedure performed in the office, although
The rule needs no explanation and will serve any it is not necessary to be the acknowledged techni-
manager well in any circumstance. cal expert. A good office manager is continually
Qualities needed by a leader/manager include learning and encourages subordinates to seek
the following: opportunities to continue their education and
advance their technical skills.
• Effective communication skills. Communication skills • Truthfulness. Lead by example! If an honest mistake
include written and oral methods. The manager is made, be the first to admit to the error and seek
must communicate clearly, diplomatically, tactfully, the best solution for preventing it from happening
and with respect for the feelings of others. again. Respond honestly to requests. For example,
• Fairmindedness. It is important to always be fair two staff members ask for the same day off. The
with coworkers. Decisions that impact one fellow office manager will make the decision that only
employee create a ripple effect. That is, you may have one member may have the day off and will review
to make the same decision for another employee at the policy manual to determine the appropriate
another time. Decisions should be based, as much criteria for designating who will have the request
as possible, on the assumption that what is granted granted.

TREAT OTHERS AS YOU WOULD LIKE TO BE TREATED!

Figure 33-1 The Golden Rule.

 CHAPTER 33 The Medical Assistant as Office Manager 1009

Office Manager Attitude

Critical Thinking
Many managers share a common enemy—them-
selves. The part of ourselves that is our enemy is How does the office manager begin to
our mind and the outlook we have on the world. develop good working relationships with
People who succeed attribute positive results to other community service organizations to
their own actions. People who underachieve or better serve and provide for the patient’s
fail usually attribute negative results to someone
health care needs? How would this improve
else or to chance, over which they have no con-
the quality of public relations?
trol. Because underachievers feel helpless to affect
results, psychologists conclude that their moti-
vation to succeed is diminished. A low achiever
would be unlikely to have a personal risk manage- The office manager serves as a liaison between
ment system in place. They would feel they could the provider, patient, and other professionals.
not affect events. The more positive person could Therefore, professional demeanor in all respects
easily take steps to avoid these problems. must be followed. It is not uncommon to be called
The effect of a negative mindset does not stop on to locate community resources and informa-
with failure to accept responsibility for the things tion for patients and employers. A good working
that happen to each of us, it continues on. Unless relationship with other community service orga-
we change our outlook, we lower our expectations nizations fosters the sharing of information vital
and begin accepting the mediocre. Individuals to your patient’s health care needs and promotes
who feel they are helpless to affect events become quality public relations. Review Procedure 4-1 for
afraid of success as well as failure, and they subcon- specific information on how this is done.
sciously find a way to fail to avoid the challenges
success will bring.
How do you change your mindset? The fol- MANAGEMENT STYLES
lowing are a few suggestions considered helpful:
There are many books written on management
• Come to terms with what you would have to change styles; however, it is possible to break all of them
if you are to be successful and be ready for the down into only two basic styles, each with an infi-
change. nite number of variations. Because this is not a
• Identify what you really want to achieve. management text, we take a simplistic view and
• Put your goals in writing using positive terms (say
look at only the fundamental styles: authoritar-
“I will” not “I’ll try”).
ian and participatory. We also examine a third
management style, managing by walking around,
• Begin with small, achievable goals. which, although not a people interaction style, is
• Eliminate poor habits such as procrastination. an effective management technique for keeping
• Tune out negative thoughts and focus on positive abreast of what is going on in an organization.
thoughts.

We are what we think we are. Be careful of your

mindset, it can derail you and your job as a manager. HIPAA
In many offices, the office manager is
Professionalism HIPAA also designated to fill the role of Secu-
The medical assistant as office manager rity Officer. The responsibilities of the
must exhibit professional behavior at all Security Officer include coordinating and over-
times. He or she must be courteous and seeing the various impacts of HIPAA on each
diplomatic and demonstrate a responsible and department and assisting with compliance
positive attitude. All verbal and written communi- issues related to HIPAA regulations. The Security
cations should be accurate and correct and should Officer must also keep abreast of any changes
follow appropriate guidelines. The office manager and rulings and how they may apply to their par-
should demonstrate knowledge of federal and state ticular office environment.Some online resources
health care legislation and regulations and must are available at http://www.cms.hhs.gov; or
perform within legal and ethical boundaries. All e-mail questions to [email protected].
documentation must be performed appropriately.
1010 UNIT 8 Office and Human Resources Management

Authoritarian Style Workers engaged in a participatory management

style are motivated by much more than monetary
Authoritarian managers operate on the premise that
reward and develop an ownership for the work in
most workers cannot make a contribution without
which they are involved. Although the carrot is still
being directed, sometimes in the minutest detail,
important, their reward comes from teamwork,
and even if they could, they would not be inclined
peer recognition, and self-actualization, that is, the
to do so. This type of manager believes in the carrot
pleasure derived from doing a job well and being
and stick approach to motivate people to work. The
recognized for it. Competition between teams is
carrot is monetary reward, and the stick is docked
sometimes used as a motivation technique.
pay or being reprimanded or fired. The personality
of the manager tends to influence natural tenden-
cies of style. Individuals who are task or procedure Management by Walking Around
oriented tend to be authoritarian. Authority control
Management by walking around (MBWA) is not
is easily accomplished in the case of simple tasks that
really a management style but rather a technique
can readily be structured and defined. Authoritar-
for keeping the manager informed about the
ian managers try to control work to the maximum
health of his or her organization. This style con-
extent possible, for example, micro-management.
sists of just what the title says, the manager walks
Complex jobs, however, are difficult for the authori-
around looking at what is going on in the organiza-
tarian manager to control.
tion and talks with employees to get their opinion
Sometimes a manager needs to use the
on how things could be done better. The manager
authoritarian style. It should be used quite spar-
collects data on new ideas; in a participatory sys-
ingly because it may destroy morale and personal
tem, a team is assigned to study and come up with
incentive. An assumption regarding the character
a better way of doing the work. The manager must
of an employee frequently becomes a self-fulfilling
be careful to make sure his or her motives are not
prophecy. Workers with an authoritarian manager
to micromanage and to convey this to the workers.
either give up and quit, or they become mindless
robots asking “how high” when told to jump. As
a manager, you use the authoritarian style in the
case of new employees until you have a chance to
determine their capabilities, in the case of a worker Critical Thinking
who has proved to be without self-motivation, or in
supervising short-term temporary labor. How would you make the medical office
Can an authoritarian manager style work in (front- and back-office space) safe for
the twenty-first century? Yes. It has worked for a employees and nonemployees (e.g., patients,
few well-respected, large companies in the United venders, visitors)? List as many considerations
States, but this occurred only because manage- as possible.
ment had unlimited resources to use as a carrot for
rewarding employees. Most managers will not have
these resources.
RISK MANAGEMENT
Participatory Style The office manager should formulate a risk man-
The participatory management style is based on the agement procedure that assesses risks to which he
premise that the worker is capable and wants to do or she and the organization is exposed and takes
a good job. The best known form of participatory steps to develop contingencies that minimize prob-
management is the use of teams to do work tasks. able risks. Some common risks and risk-control
This type of management is well suited to complex measures are:
tasks where each member can contribute his spe-
cialty to the job at hand. The manager’s function • Loss of a critical employee. Have cross training of
in this type of system is communicating direction employees to permit them to assume the duties
and vision to the team and selling the team on the of an employee who is ill or terminates his or her
importance of the task. Providing the team with employment.
the necessary resources required is an important • Failure of a supplier or contractor. Maintain sufficient
managerial function. Managers using this type inventory to permit contracting with a secondary
of style need to be comfortable teaching, coach- supplier before critical shortages occur. Monitor
ing, communicating, inspiring, and motivating. the status of orders so that you are aware of any
 CHAPTER 33 The Medical Assistant as Office Manager 1011

failures in delivery before they have a negative Efficiency of a team results from collectively
impact and supplies can be obtained from a sec- working together to plan how to “work smarter”
ond source. Have a list of secondary sources. and how to dovetail tasks and support each other so
• Accidental disclosure of confidential information through that wasted effort is avoided. To achieve all of these
error or unauthorized entry. Have protocols in place things, a team not only must be given the respon-
regarding breach of confidentiality and defin- sibility and the authority to plan and execute their
ing steps to be taken in the event information is plan to solve a problem, but they must know your
compromised. Define protocols to patients alert- expectations for them. Sometimes this means that
ing them to the unlikely but potential possibility of you, the office manager, must stick your neck out
accidental disclosure. Notify patients immediately for them. They will reward you handsomely for
if confidential information is compromised and doing so.
work with them for resolution.
• Computer failure. Back up the system regularly. Have Getting the Team Started
a secondary system that permits the office to oper-
ate until repairs are effected. Have a maintenance A successful teamwork approach is not a myste-
contract in place with a reputable firm permitting rious event that just happens; it is the result of
overnight repair. clear vision, specific goals, and a well-planned
strategy on the part of the team leader. For team-
• Injury to a staff member or nonemployee. Continually
work to be successful, individual team members
review safety procedures and conduct safety sur-
must understand and support the specifics of
veys. Have adequate liability insurance for the
the problem they are being asked to solve. This
medical office.
is probably the most significant task of the team
• Managerial position change. Continuously network leader or the office manager. It is helpful in tak-
with friends and associates to permit you to rapidly ing this important step to let the team develop its
seek a new position before experiencing a job loss. own work statement, for in this way they assume
It’s always easier to get a job while you still have a job. ownership of the goals and objectives you want
them to achieve. The work statement frequently
Incident reports are required to notify manag- outlines specific tasks and their sequential order
ers of events involving injuries to patients, visitors, of accomplishment. Its purpose is to ensure that
or staff, medical errors or omissions, breech of con- everyone is working toward the team goals and
fidential information, and potentially dangerous objectives.
conditions associated with facilities or equipment. A major pitfall at this stage may be diverse
This report signals the risk manager to implement opinions that can lead to a work statement that
existing protocols to minimize risk. Medical inci- does not meet the manager’s goals and objectives
dent reports are confidential and cannot be released for the team. It is your job as office manager to try
to anyone without a signed release of information to direct the team back to what you want them to
agreement. The medical incident report form is work on without undermining their team spirit.
an administrative document and is not considered Take care at this stage not to begin making assign-
part of the medical record. Procedure 33-1 provides ments or to let team members start solving the
steps for completing a medical incident report. problem until the work statement is complete.
Under some circumstances, it may be necessary for
you, the office manager, to exercise your author-
IMPORTANCE OF TEAMWORK ity in defining the work statement, but be careful,
because this approach could harm the team’s col-
The use of teamwork to improve the efficiency lective spirit.
of the office at first may seem incongruent to The next step in team development is to
your desire to improve office efficiency, because establish a timetable for achieving results and
it seems that several people are now involved in identifying the standards that must be main-
solving a problem that you as the manager should tained. Without a timetable a team feels no sense
solve and explain. Teamwork builds morale and of urgency and tends to lose direction. You also
actually results in getting more accomplished with have to paint a clear picture of the standards that
the resources you have because the team members must be maintained as you attempt to solve the
develop ownership of the solution to a problem problem. You should let the team develop both the
and want to make it work. When it works, it flatters standards and the timetable, but with your leader-
them and builds their esteem. ship and support.
1012 UNIT 8 Office and Human Resources Management

Using a Team to Solve a Problem SUPERVISING PERSONNEL

Problem solution is the next step in team develop-
ment. Some people call this stage brainstorming a Creating an atmosphere in which open and honest
solution. Brainstorming is fun, but unless it is con- communication can take place is critical to super-
trolled by the leader, it will bog down into need- vising personnel. This type of communication may
less arguments and hurt feelings. In a successful be encouraged through the establishment of regu-
brainstorming session, everyone feels free to con- lar staff meetings, with each staff member sharing
tribute solutions to the problem without any con- ideas for improvement and areas of concern. Elic-
sideration for practicality or flaws in the proposal. iting the help of others in problem-solving strate-
Only after everyone has had a chance to speak are gies promotes harmony (Figure 33-2).
the solutions looked at in terms of practicality and
for technical correctness. At this point the team Staff and Team Meetings
should not look at what is wrong with the solution,
but what needs to be done to make it a workable The office manager usually initiates the staff and
solution. team meeting idea and should officiate at such
Prioritization of the solutions comes next. To meetings. Failure of the office manager to be pres-
do this, it is helpful to assign scores for impact on ent may convey a message that the meeting is an
solving the problem and for changeability, or the event not worthy of attention. It is important that
difficulty in implementing a particular solution in the office manager be familiar with basic parlia-
your office environment. The result is a list of solu- mentary procedures. The purchase of books such
tions to the problem in descending order from the as Robert’s Rules of Order or Parliamentary Procedure at
greatest impact on the problem with the least cost a Glance is an excellent investment.
or difficulty in implementation. Do a needs assess- Successful staff and team meetings are
ment, remove yourself from the issue, and look at announced well in advance or on established time
it from a different perspective. Benchmark (com- lines to enable the majority of office personnel to
pare) your facility to other facilities and organiza- attend. An agenda identifying the subjects to be
tions to see how they accomplish tasks, compensate covered during a given meeting should be issued
employees, and so on. before the meeting so that each attendee arrives
prepared with input or questions relevant to the
topics. Procedure 33-2 outlines the procedural
Planning and Implementing steps for creating a meeting agenda. Figure 33-3
a Solution shows a sample agenda. Each meeting should end
The team should work out a detailed plan for with opportunity for nonagenda items to be dis-
implementation of the solution selected, includ- cussed or suggested for inclusion in the next meet-
ing a schedule. Assignments should be made, ing. The meeting should have a fixed time to end.
resources of equipment and funds available to the
team should be defined, and any remaining prob-
lems should be assigned to subteams that will func-
tion just as the primary team did in solving them.
The team should continue to meet to discuss prog-
ress and to resolve additional problems that may
occur.

Recognition
A successful team should not be disbanded until
it is acknowledged for its efforts and physical rec-
ognition is given in the case of an important prob-
lem that was solved. In some cases, a dinner or
luncheon is in order. This is the most important
phase of team development, because it is respon-
sible for developing a team spirit or sense of
self-actualization within the organization. Once Figure 33-2 Consistently scheduled staff meetings
this spirit is implanted into an organization, it promote communication and harmony among the
becomes infectious. health care team.
 CHAPTER 33 The Medical Assistant as Office Manager 1013

Conflict Resolution
AGENDA A good human resources manager is a master at
conflict resolution, solving problems between any
STAFF MEETING Wednesday, February 16, 20XX
two parties. The most difficult task is to prevent
2:00 PM — Conference Room
or solve conflicts that occur between employees
1. Read and approve minutes of last meeting and supervisors or providers. Most conflict occurs
because of poor communication or a misunder-
2. Reports standing; thus effective communication is a goal
A. Satellite facility — Marilyn Johnson for any manager.
Volumes of materials have been written about
B. Patient flow — Joe Guerrero
successful conflict management. One can probably
C. never get enough material on the subject. Some
3. Discussion of new telephone system guidelines that may be helpful in preventing con-
flicts include the following:
4. Unfinished Business
A. Review new procedure manual pages • Listen to your employees. What do they say? What
do they communicate nonverbally?
B.
• Manage by walking around and talking to your
5. New Business employees.
A. Appoint committee for design of new marketing • Do not tolerate negative comments or actions
brochure among employees.
B. • Encourage an open-door policy for concerns and
complaints.
6. Open discussion and/or topics for next meeting’s
• Be a role model for all employees.
agenda
• Keep confidences.
7. Set next meeting time
8. Adjourn An office manager who cares about each
employee, who “carries water for the workers in
the trenches,” and who administers fairly and hon-
Figure 33-3 Sample meeting agenda. estly creates an environment where conflict is at a
minimum.
When conflicts arise, do not avoid taking
immediate action to resolve the issue even if it
appears to be superficially resolved. It will resur-
face at the first instance of stress between the
A written record in the form of minutes individuals. Conflicts usually are the result of
should be maintained and sent to all team mem- misunderstanding. In some cases the manager
bers regardless of whether they attended the can mediate the issue and resolve the conten-
meeting. This policy keeps all members informed tious behavior, but this places you with the role
about policy changes and decisions that impact of judge and jury, and one party will feel injured
the office operations. The minutes also trigger a or abused regardless of the outcome. Mediation
reminder for any new procedures or revisions to is the only approach when the conflict is between
be made in the procedure manual. a provider or supervisor and an employee. In
The minutes for a staff and team meeting all other instances the best approach is to use a
should record action plans under each agenda confrontational approach. The two persons hav-
topic. Summarize all action items agreed to in ing a conflict are brought together and asked to
the meeting in one section of the minutes. This express their conflicting opinions without inter-
facilitates easy access to information at a later date ruption. The purpose is to communicate what
should it be required. each perceives to be the problem. If an obvious
The date, time, and place of the next meet- solution that is acceptable to both parties does
ing should be included. The person preparing the not appear, the manager must insist that the par-
minutes should always sign them. A copy of the ties come up with an acceptable solution to the
minutes should always be maintained in a book for conflict. (This latter step is not appropriate for
easy reference. conflicts between an employee and a superior in
1014 UNIT 8 Office and Human Resources Management

the organization.) In doing so both parties have sentative usually assume this task jointly, with the
ownership of the resolution. office manager being responsible for orientation
in medical protocols and procedures, and the HR
representative handling orientation regarding
HARASSMENT IN THE medical practice rules and regulations and any
WORKPLACE legal implications.

Harassment consists of verbal or physical behav- New Personnel Orientation. The new personnel
ior/conduct that is (a) unwelcome, (b) based on a orientation process consists of orienting and train-
protected class (e.g., race, sex, age, national origin, ing new employees in the medical protocols and
veteran status, or sexual orientation), (c) severe or procedures unique to the practice. If the proce-
pervasive, and (d) has a negative impact or cre- dure manual is detailed and accurate, this manual
ates a hostile environment. As a manager, you are now becomes a guide for new employees.
legally responsible for ensuring nondiscrimination It is important to introduce new employees to
and preventing harassment. You, as a manager, other staff members and to assign a mentor who
may be innocent of any kind of sexual harassment can respond to questions that new employees may
yourself, but if the workplace you manage is con- raise. Sometimes the individual leaving a position
strued as hostile by any one of your employees and still is present and is asked to assist in the orienta-
you do not take appropriate action, you and your tion process. This is especially beneficial if there is
company can be held liable in a court of law. a good working relationship between the employee
When an employee contacts you or you who is leaving and the management of the prac-
become aware of harassment, you should tice. Depending on the responsibilities of the new
immediately contact your Human Re- employee, a supervisor may be asked to monitor
sources Equal Opportunity Office (EOO). If your all procedures for a period for accuracy, safety, and
facility does not have an EOO, you should collect facts patient protection.
and confront the offending individuals or group, The orientation should clearly present what
clearly notifying them that the offensive behavior must is expected of new employees and explain that, at
stop immediately. A report of the incident should be the end of their probationary period, their perfor-
placed in the file of the offending individuals, with a mance will be evaluated to determine if full-time
written warning that a future incident will result in employment will be offered. The same procedures
termination. followed for new employees should be followed for
The manager must carefully evaluate the facts student practicums, with the exception that expec-
surrounding an incident. It is not uncommon for tations and the evaluation process may vary.
innocent events to be perceived as harassment.
When there is conflict between people who are in Probation and Evaluation. It is common for a new
some way different from each other, simple misun- employee to be placed on probation for 60 to 90
derstandings can be perceived as harassment. Bla- days. During this period, both the employee and
tant harassment is far less common than this kind supervisory personnel determine if the position is
of muddled interaction. Although some situations a suitable match for both employer and employee.
do involve malicious intent, many are largely the Near the end of the probation period, the employee
result of poor communication, and it is the manag- should be officially evaluated to determine how
er’s responsibility to differentiate between the two. competently he or she is performing the assigned
Every employer needs a comprehensive policy tasks/duties. The employee should also be given
that prohibits all types of harassment. The policy an opportunity to express their personal thoughts
needs to include a definition of what could con- relative to job satisfaction. Figure 33-4 shows a sam-
stitute harassment or create a hostile work envi- ple probationary employee evaluation form. The
ronment, information on who to report to, and a evaluation becomes part of the employee’s person-
nonretaliation provision. This policy must be made nel record at the end of the probation period.
available to all employees.
Supervising Student Practicums. The student
practicum is a transitional stage that provides
Assimilating New Personnel opportunity for the student to apply theory learned
The goal in the assimilation of new personnel into in the classroom to a health care setting through
the workplace is to make it happen as seamlessly practical, hands-on experience. Some institutions
as possible. The office manager and HR repre- use the term externship or internship, and still oth-
 CHAPTER 33 The Medical Assistant as Office Manager 1015

of 10 commonly used medical terms or verbally

PROBATIONARY EMPLOYEE stating five telephone numbers for the student to
EVALUATION FORM write down, an immediate evaluation is attained.
The office manager should directly supervise
Name ______________________________________ or identify someone else to supervise the student.
During the first few days of the practicum, the stu-
Hire Date ___________________________________ dent may simply shadow the supervisor, learning
Job Title ____________________________________ the routine, provider preference, and protocols
Pay Rate____________ Supervisor ______________ for that particular office. As the student begins to
feel comfortable in the new environment, minimal
Do you recommend the employee continue in employment? tasks should be assigned. Based on the student’s
________ Yes ________ No ability to follow directions and perform tasks,
Please state your reasons for whatever action you recom- increased skill-level tasks may be added.
mend. Use the guidelines below to make your decision. The supervisor will direct and evaluate the
student’s progress; schedule activities that will
1. Has the employee required more training than is nor- provide experience in all aspects of medical assist-
mally needed for the job? ing, including administrative, clinical, and labo-
2. Has the employee grasped this job with very little ratory procedures; maintain accurate records of
training? attendance and hours “worked”; and communi-
3. Is the employee performing at, above, or below (circle cate the student’s progress to the medical assist-
one) the standard for this job? ing supervisor from the educational institution.
Procedure 33-3 provides steps for supervising a
4. If below, when do you expect the employee to reach student practicum.
the standard? When working with students, it is important
5. Does the employee get along well with all staff to remember that they still have much to learn and
members? will need lots of reassuring guidance. When you
6. Has the employee maintained a good attendance take time to explain each step and to provide the
record and a good work attitude? rationale for each, students will learn more quickly.
Demonstrating new or different techniques and
7. Has the employee expressed any dissatisfactions? approaches helps students by providing them with
options that they may find more comfortable.
___________________________ ___________ Remember that this type of learning is stress-
Supervisor’s Signature Date ful. The student is not yet accustomed to commu-
nication with a “real” patient, let alone working
with a provider. Your role as office manager is to
Figure 33-4 Sample probationary employee reduce as much stress as possible for everyone con-
evaluation. cerned. Introduce the student to the patient and
ask the patient’s permission to allow the student to
perform a procedure. Many patients will be toler-
ers operate through a cooperative education pro- ant when they realize the circumstances and will
gram. The number of hours for the practicum are be quite cooperative.
predetermined together with criteria for site selec-
tion and tasks to be performed by the student. Employees with Chemical
The office manager should schedule an Dependencies or Emotional
information interview with the student before the
practicum begins. During this time, the expecta-
Problems
tions of the office manager and the student may be Employees with chemical dependencies or emo-
established. A tour of the facility and introductions tional problems are ill and are to be treated as such.
to key personnel aid the student in feeling more Approach the situation constructively rather than
comfortable the first day of “work.” punitively. Make a commitment to the employee,
Because the student will be writing in medi- to the rest of the staff, and to the patients that at
cal records where correct spelling is mandatory or no time will patient care be put at risk. Help an
may be scheduling appointments and must write employee with a problem to find the support and
telephone numbers without transposition, some counseling necessary. No staff member should be
pretesting may be offered. By giving a spelling test permitted to remain on the premise with impaired
1016 UNIT 8 Office and Human Resources Management

judgment while under the influence of alcohol or The evaluation may take many forms; it can
controlled substances. If chemical dependency be formal or informal; it may involve more than
treatment is necessary, make accommodation as one person. The results of the evaluation, how-
seems appropriate or is warranted. Everyone occa- ever, must be a part of the employee’s personnel
sionally feels discouraged and distressed. Hope- record. For that reason, a formal evaluation is pre-
fully, the provider–employer and the manager are ferred. Many practices use a written evaluation that
able to recognize problems before they become requires that the employee evaluate himself before
too serious. meeting with the office manager (Figure 33-5).
It has been said that one in four individu- The office manager uses the same form for evalu-
als will experience some form of mental health ation. During the meeting, notes are compared as
problem during the course of a year. Work- the evaluation is conducted.
related stress is the base cause of a significant The climate of the performance evaluation
degree of mental ill health. Plan for and create should be comfortable and provide privacy (Fig-
a work environment that reduces as much stress ure 33-6). The meeting should be friendly, but the
as possible. Actions to consider may include the employee must sense the importance of the evalua-
following: tion. Do not allow any disagreements to escalate into
arguments during the evaluation. Without reading
1. Properly educate and train all employees for their the employee’s self-evaluation, ask the employee
positions. to tell about the self-assessment. Acknowledge the
2. Encourage teamwork and reward those who help employee’s point of view and identify when you
each other. agree or differ from the self-assessment. Be pre-
3. Mandate “break periods” in the day for each pared to describe specific examples of positive per-
employee. formance and negative performance.
When negative performance is identified,
4. Create a pleasant work environment (plants,
ask the employee for possible solutions. Then
water, music, and so on).
a plan can be determined to alter the negative
5. Establish a blowing off steam place for when performance. In this way, a trusting atmosphere
employees are especially frustrated. is established in that both of you are working
6. Take everyone out for lunch at least once a quar- together for a solution that will benefit the medi-
ter. cal practice. Always look for and seek a win-win
7. Have regular staff meetings to discuss employee situation whenever possible. The action plan
concerns and office improvements. determined should then be evaluated at the next
performance evaluation.
8. Celebrate birthdays and special occasions (i.e.,
At the close of the evaluation, always express
length of service).
your confidence in the individual to make any
Keep in mind that a happy employee who changes necessary, offer assistance where needed,
feels valued in his or her position will stay much and thank the employee for participating. End any
longer than someone who is unhappy and does evaluation with a positive statement about some
not feel valued. portion of the employee’s performance.
There are occasions when reviews are per-
formed more frequently than annually. A review
Evaluating Employees and would occur 2 to 3 months after a significant pro-
Planning Salary Review motion to measure how things are progressing.
It is important that all employees know whether Reviews occur more often when general perfor-
they are performing their job as expected and mance falls well short of past efforts or a serious
know how they can improve their performance if error in judgment has been made. This type of
necessary. review may end with a reprimand, a warning to
correct the problem by a given date, or possibly,
Performance Evaluation. Not only is evaluation of immediate dismissal. Document any steps to be
employees necessary during the probation period, taken to correct a problem and any reason that is
but it is necessary for current employees as well. cause for dismissal.
Evaluations should be performed no less than once
a year on the anniversary of the hire date. Some Salary Review. Although the practice is common in
office managers may wish to evaluate an employee some areas, it may be better not to tie salary increases
more often, especially if a problem has surfaced in or bonuses with the annual performance evalua-
an evaluation. tion. Conduct the salary review at the beginning
 CHAPTER 33 The Medical Assistant as Office Manager 1017

PERFORMANCE REVIEW FORM

_____________________________________________ ________________________________________________
Employee Name Title
_____________________________________________ ________________________________________________
Supervisor Department
TYPE OF REVIEW (Check One)
_______ Quarterly
_______ Annual
_______ Probation
_______ Other ______________
Review Period Covered ____________ to ____________
PERFORMANCE DEFINITIONS
5 = Outstanding Performance that is clearly superior, beyond the call of duty, or substantially above standard level. Seldom
attained level of performance but achievable.
4 = Above Standard Very commendable performance; exceeds the norm for the job.
3 = Standard Competent and consistent performance; expected level of activity and performance for the job. Most often rating
received.
2 = Below Standard Performance needs improvement. This level of performance is unacceptable; needs improvement to meet the
standards for the job.
Employee new to the job: Performance might receive below standard rating due to lack of job knowledge and
is expected to improve with experience.
Experienced Employee: Performance is below acceptable level and requires direction and/or counsel.
1 = Unsatisfactory Performance is unacceptable. Job activity is clearly and substantially lacking in quality, quantity, or timeliness.
May also not be meeting cost or budget constraints. Needs much improvement to meet the standards for the job.

(office use only) FINAL RATING: CHECK ONE (office use only)
EVALUATION SUMMARY ______ Merit Increase Recommended
Total I ______ ______ No Merit Increase—Satisfactory Performance/No Growth
+ Total II _____ ______ No Merit Increase (Probationary/Special Evaluation)
______ No Merit Increase (Performance Probation)
Re-evaluate in 90 Days for Unsatisfactory or in 180 Days for Needed Improvement

GENERAL PERFORMANCE RATING (PART I)

General Criteria Rating Comments Supporting Rating
1. Patient Relations: How well does the em-
ployee communicate a “we care” image to
the patients, visitors, providers, and fellow
employees?
2. Work Responsibilities: What is the quality
of the employee’s work relative to quality,
quantity, and timeliness?
3. Teamwork: Does the employee have a team
spirit? Does the employee interact well with
co-workers/supervisor/manager? (continues)

Figure 33-5 Sample performance review form.

1018 UNIT 8 Office and Human Resources Management

General Criteria Rating Comments Supporting Rating

4. Adaptability: Is the employee open to
change and new ideas? Does the employee
remain flexible to changes in routine, work-
load, and assignments?
5. Personal Appearance: How well does the
employee maintain appropriate personal
appearance, including proper attire, hygiene?
6. Communication: Does the employee com-
municate well? Is information given and
received clearly? Does he/she have good
verbal and written skills?
7. Dependability: Can the employee be relied
upon for good attendance? Does the
employee perform and follow through on
work without supervisory intervention or
assistance?

Subtotal I ____________ + 7 General Criteria = ____________

JOB-SPECIFIC CRITERIA RATING (PART II) (To be used with Job Description attached)
Responsibility and Standard Rating Comments Supporting Rating
Complete a section for each responsibility
listed on the employee’s job description.
Subtotal II ____________ + ____________ = ____________
# job duties
Contributions made since last review:

Education or training received since last review:

Action to be taken based on performance:

Comments:

Employee Signature Date

Supervisor Signature Date

Provider Signature Date

Figure 33-5 (continued)

 CHAPTER 33 The Medical Assistant as Office Manager 1019

tory care setting tell the story. A consideration

worth mentioning is that often the salary does
not match the education, experience, and spe-
cial training required of someone working in
the health care field. Educators often hear,
“Why would I spend a year or more in educa-
tion to be paid what I would make working in a
fast food restaurant?” Because it is costly in time
and resources to replace employees, it is best to
invest that cost into a fair and just salary increase
for valued employees.

Dismissing Employees
Figure 33-6 A comfortable, private setting encour- Most human resources managers do not enjoy rat-
ages discussions during an employee performance ing the performance of other employees, particu-
review. larly when difficult topics are involved and it may
be necessary to dismiss an employee. However,
the written performance evaluation actually estab-
of the new year separate from performance evalua- lishes the format for such a dismissal when neces-
tions. sary and is more likely to remove the emotion from
Salary review is important. Unfortunately, in the situation. Involuntary dismissal is still difficult
smaller medical offices and ambulatory care set- when it is necessary.
tings, the review of salary may have to be raised by
the employee. Provider–employers tend to forget Involuntary Dismissal. Involuntary dismissal results
that their employees have been with them for over from two primary causes: poor performance or
a year without a raise or a discussion of financial serious violation of office policies or job descrip-
reimbursement. If this is the case, it is perfectly tions. When it becomes apparent to the office
acceptable for the employee to raise the issue on manager that the effectiveness of an employee is
a yearly basis. However, the best approach is for dropping well below expectations, it will be known
the office manager to conduct salary reviews at the in the review or a performance review may be called.
beginning or end of each calendar year. The review allows the employee to be informed
Data should be collected before a salary of the shortcomings, to explain any reasons for
review. The office manager should network with the present situation, and to determine a plan to
other office managers to determine wages and alleviate the problem. If the problem is a serious
salaries for comparable individuals with compa- one, probation is usually invoked and any lack of sig-
rable skills. Remember, also, that it is far more nificant improvement in the time provided results
cost-effective to reward good employees with a in immediate dismissal.
salary increase than it is to train a new employee When the problem is a violation of either
who commands a lesser salary than current office policy or procedures, both a verbal and a
employees. Reward employees well and provide written warning are given to the employee. Invol-
benefits that encourage them to stay with the untary dismissal follows if the situation persists. Dis-
practice. Employees who stay with the practice missal may be immediate if the action is a serious
for a long time not only fully understand how violation of policy. Serious violations depend on
best to serve their provider–employers, they the office practice, but some causes for immediate
have established a relationship with patients that dismissal include theft, making fraudulent claims
is beneficial. against insurance, placing the patient in jeopardy
How much of a raise is to be awarded at the by not practicing safe techniques, and breach of
time of salary review is difficult to determine and patient confidentiality.
depends on many factors that might include the Some key points to keep in mind when dis-
profits of the year, the patient load, the workload, missal is necessary are:
and the current cost of living.
1. The dismissal should be made in privacy.
The critical shortage of health care employ-
ees today is reflected in the shortage of medical 2. Take no longer than 10 minutes for the dismissal.
assistants across the country. Newspapers adver- 3. Be direct, firm, and to the point in identifying
tising for individuals to work in the ambula- reasons.
1020 UNIT 8 Office and Human Resources Management

4. Do not engage in an in-depth discussion of perfor- istrative and clinical sections with subdivisions for
mance. each primary task performed (Figure 33-7).
5. Explain terms of dismissal (keys, clearing out area To facilitate using the procedure manual, a
of personal items, final paperwork). consistent format should be developed and used
throughout the manual. Each procedure should
6. Listen to employee’s opinion and emotions; it is
be a step-by-step outline or list of steps to be taken
not necessary to agree.
to complete a task as desired in that facility. Pro-
7. Accompany the employee to his or her desk to viding the rationale for a step, when appropri-
pack his or her belongings. ate, enhances the learning process, especially for
8. Escort the employee out of the facility; do not new staff members. Material Safety Data Sheets
allow him or her to finish the work of the day. (MSDSs) are required to be maintained in the
clinic and available for personnel to reference at
Voluntary Dismissal. Other reasons for dismissal any time. MSDS must be compiled for all chemi-
may be more pleasant. Changes in personnel occur cals considered hazardous and maintained in an
for many good reasons, and people voluntarily appropriate manual. Some offices opt to maintain
leave their jobs. They may relocate, seek advance- these records in a separate tabbed section of the
ment in another facility, or simply have personal procedure manual. Others choose to maintain a
reasons for leaving. These employees will give separate MSDS manual. The information must be
their manager proper notice and will be able to reviewed and updated on a regular basis. See Chap-
turn their current projects and duties over to their ter 26 for detailed information regarding MSDS.
replacements. They have time to say good-bye to Procedure 33-4 provides steps for developing and
their friends and leave with a good feeling about maintaining a procedure manual.
their employment.
Updating and Reviewing
the Procedure Manual
PROCEDURE MANUAL
When new procedures are added to the office rou-
The procedure manual provides detailed informa- tine, a new procedure page should be developed
tion relative to the performance of tasks within the immediately. The new page is useful as an edu-
facility in which one is employed. Each procedure cational tool or job aid while team members are
manual should be designed for that specific office learning new techniques.
setting and should satisfy its requirements. An annual page-by-page review should be
The procedure manual serves as a guide to the done to ascertain if each procedure is still being
employee assigned a specific task and may also be used and to ensure that each page is correct in
useful in evaluating the employee’s performance. each detail and satisfies all criteria established by
If a temporary employee is assigned the task, the the staff personnel. This contributes to an efficient
procedure manual will be invaluable in assuring
that each procedure is completed as outlined.
The provider(s) and the office manager Administrative Section Clinical Section
should have copies of the procedure manual, and
all employees should have access to the proce- Personnel Management Physical Examinations
dure manual. Copies of individual sections may be Communication Infection Control
given to the employee responsible for the task; the (oral and written) Collecting Specimens
employee should be instructed to follow these guide- Patient Scheduling Laboratory Procedures
lines and told that they may be used as employee Records Management Surgical Asepsis
evaluation tools. If all employees have access to the Financial Management Emergencies
office computer system, the procedures manual can Facility and Equipment Material Safety Data Sheets
be made available in electronic format. Management (MSDS)
OSHA
CLIA ’88
Organization of the
Procedure Manual Figure 33-7 Many offices find that dividing the pro-
It is best to use a loose-leaf binder with separator cedure manual into tabular sections helps organize the
pages denoting each procedure. Many office man- material. A table of contents with page numbers helps
agers find it helpful to divide the binder into admin- locate information easily.
 CHAPTER 33 The Medical Assistant as Office Manager 1021

office and gives all employees a sense of pride and • Name of travel agents used in the past (ranked by
satisfaction that they are performing within the reputation and recommendation)
scope of their training and to their greatest poten- • Provider’s or office credit card numbers
tial. The procedure manual should be reviewed by
• Car rental preference
personnel performing the various tasks, and their
suggestions should be evaluated and incorporated • Preferred airline, class of travel, seating choice
into the revisions when appropriate. All new pro- • Hotel/motel accommodations (bed size, suite, stu-
cedure pages and revisions should be dated (Rev. dio, connecting rooms, price range, amenities)
02/15/XX). • Shuttle service

HIPAA IMPLICATIONS Next, contact the travel agent and identify

the destination, date and time for departure and
HIPAA regulations require each office to return, number traveling in party, and seating
HIPAA develop a separate HIPAA manual that is preference. A travel agent can assist with rental
in either an electronic form or a paper car and hotel accommodations if needed. Take
manual. The manual spells out all policies and pro- your time and pay attention to details. When tick-
cedures of the practice and security management ets are received, always check to see that all depar-
measures; identifies the security officer; addresses ture and arrival times match what is needed and
workforce security issues, information access con- that a confirmation number has been provided
cerns, security awareness and training, security for car rentals and hotel arrangements. Proce-
incidents, and contingency plans; evaluates secu- dure 33-5 outlines the procedural steps involved
rity effectiveness; and contains copies of all busi- in making travel arrangements through a travel
ness associate contracts. agent.
The HIPAA manual must be available to all The Internet can be used to search for
employees and updated on a regular basis. During the lowest-cost air, auto, and lodging res-
an audit, the office manager will be asked to pro- ervations. The procedures do not require
duce the HIPAA manual for review and to establish extensive knowledge of travel and airline reserva-
compliance with all regulations. All documenta- tion protocols. Searching for information on the
tion of policies and procedures are to be kept for Internet requires the use of a search engine if you
6 years even though the wording has changed or do not already have a list of favorite travel Web
been eliminated. If an incident is under investiga- sites. A search engine is a special computer pro-
tion, this allows an investigator to go back to what a gram available through your Internet service pro-
policy said 6 years ago. vider. With a search engine, you enter only the
subject of your search, and the Web provides a
list of Web sites related to your subject. For exam-
TRAVEL ARRANGEMENTS ple, if you are making travel arrangements, you
might access a search engine such as Google.com
The office manager may be asked to make travel and enter the key words “air fares.” The engine
arrangements for providers going on vacation or to returns either a list of Web sites or asks you to
conventions, symposiums, or out-of-town seminars further refine your subject, with suggestions such
and continuing medical education (CME) courses. as cheap air fares, international travel, and so
If the providers do a fair amount of travel or if they on. Once you refine your search, you may have
live in a metropolitan area, they may use the services choices such as Travelocity.com, Expedia.com, or
of a travel agent. Attention to detail is extremely Priceline.com. Select the appropriate Web site
important in preventing travel disruptions. and follow its instructions.
Read carefully the instructions for complet- Priceline.com and similar Web sites are ser-
ing registration forms, complete them, and mail vices that allow you to name the price you want to
them as quickly as possible to secure reservations pay; Priceline finds a major airline willing to release
to conventions and so forth. Next make hotel and seats on flights where they have unsold space. You
travel arrangements. General information regard- need to have a reasonable idea of the price of the
ing the provider’s travel preferences should be service you are trying to purchase; unreasonably
maintained in a file folder and referred to when low bids will just waste your time and effort. Pro-
making travel arrangements. Helpful information cedure 33-6 outlines the steps for making travel
to maintain in this file includes: arrangements via the Internet.
1022 UNIT 8 Office and Human Resources Management

Itinerary Important information to be included on any

itinerary includes:
If you have used a travel agent in making the
travel arrangements, the agency most likely will • Air travel: departure and arrival date and time,
provide several copies of the itinerary. An itiner- meals, airline name and telephone number, air-
ary is a detailed plan for a proposed trip. The port
office should maintain one copy of the itinerary in • Car rental: name of provider, telephone number,
case the provider must be reached for emergencies. confirmation number
The provider should have one copy to carry with
• Hotel/motel: name, confirmation number, dates,
him or her and a copy to leave with family mem-
telephone number
bers. You may need to develop the itinerary if you
have made the travel arrangements via computer. • Meeting location: name, address, room number, tele-
Figure 33-8 shows a sample travel itinerary. phone number

TRAVEL ITINERARY
James Whitney, MD
Inner City Health Care
400 Inner City Way
Seattle, WA 98400

15 Sept 20XX INVOICE: 880133795

29 Sept Friday
USAIR 630 Coach Class Equip-Boeing 757 Jet
LV: Seattle 11:55P Nonstop Miles-2125 Confirmed
AR: Pittsburgh 7:23A Elapsed time-4:28 Arrival Date-30Sept
Seat-31C

30 Sept-Saturday
Alamo 1 Compact 2/4 DR Drop-101CT Confirmed
Pickup-Pittsburgh Pittsburgh Airport Chg-USD .00
Rate- 59.98 Baserate Guaranteed Extra Hr 10.00-UN
Phone-412-472-5060
Confirmation-1870649

01 Oct Sunday
USAIR 1419 Coach Class Equip-Boeing 737 Jet
LV: Pittsburgh 3:05P Nonstop Miles-2125 Confirmed
AR: Seattle 5:27P Elapsed time-5:22
Lunch Seat-20A

Ticket Number/s:
Whitney/James 3570933 BA Card $461.00
Air Transportation $416.36 Tax 44.64 TOTAL $461.00
Sub Total $461.00
Credit Card Payment $461.00-
Amount Due 0.00

TICKET IS NON REFUNDABLE. TRIP INSURANCE IS AVAILABLE. RECONFIRM ALL FLTS 24 HRS PRIOR TO DEPARTURE

Figure 33-8 Sample travel itinerary.

 CHAPTER 33 The Medical Assistant as Office Manager 1023

TIME MANAGEMENT external audiences, such as other organizations,

potential new patients, and community members.
Time management is an item of critical impor- Developing relationships outside the office is often
tance to the manager. You may have upward of 20 called marketing, a concept that office managers
staff members putting demands on your time, and may use to enhance the image and visibility of an
added to this are vendors, your superiors, business ambulatory care setting while also providing ben-
associates, and a host of others. A manager has not efits to patients, potential patients, and the neigh-
a moment to lose in the day, so managing time boring community.
makes the difference between a normal 8- or 10- In its broadest sense, marketing can be
hour day and a 15-hour or more day. The following defined as the process by which the provider of
suggestions are some proven means of managing services makes the consumer aware of the scope
your time whether in management or as a salaried and quality of these services. Although marketing
employee. is a tool traditionally used by for-profit organiza-
tions to promote and sell products and services, it
• Handle items once. Once the mail is opened, sorted, has become increasingly acceptable among health
and prioritized, try to handle it only once more, care organizations, whether they are for- or not-
when action is taken with it. Picking it up, reading for-profit.
it, and setting it down again without taking action Marketing functions and materials are diverse
is a real waste of time. and can include seminars and workshops, patient
• Develop a to-do list. At the end of each day prepare education brochures, brochures that describe the
a list of things you plan to complete the next day ambulatory care setting and its scope of services,
and try to work down this list. Prioritize the list by HIPAA policies, newsletters, press releases, and
importance or by practical order. special events such as open houses or participa-
• Guard your time. Schedule meetings with person- tion in community health care events. Depending
nel and vendors so that they do not fragment your on the size and resources of the medical office, the
time, making you have to restart a task and get up manager may choose to use all or some of these
to speed over and over again. Although modern tools (Figure 33-9).
management practice is to have an open-door pol- When producing written mate-
icy with employees, this does not mean you should rial and organizing events, it is
allow them to come into your office whenever they essential that ethical guidelines
think about it. Have them schedule time with you. be respected at all times. Marketing tools should
Make them think about what they want to discuss be appropriate, in good taste, and designed to qui-
and do not let them monopolize your time. This is etly enhance the reputation of the office. Cultural
also true of meeting with vendors; require vendors issues should always be considered. For example,
to schedule ahead a time to meet with you. patient education brochures for a practice with
many Spanish-speaking patients should be pro-
• Delegate work. Assign others or a team to perform
duced in bilingual editions, with English on one
some of the functions discussed in this chapter.
side and Spanish on the other. Legal issues are
Having a team prepare weekly work schedules
important as well; when presenting material of
and vacation schedules results in less bickering
a medical nature, it is extremely important that
and feelings of favoritism that you would have to
information be accurate and up to date.
spend time defusing if you made the schedules
Effective marketing is a valuable tool for the
yourself. This does not mean that you do not have
office manager, especially as managed care calls on
to approve them and, in some instances, make the
all health care professionals to become more com-
hard decisions, but it results in your people having
petitive to survive. Marketing can increase visibility
ownership in the decisions.
and credibility. The effective manager enlists the
talents and skills of the entire team in developing a
MARKETING FUNCTIONS marketing plan.

Effective communication skills are essential in the

management of the ambulatory care setting. These
Seminars
skills are used by the office manager inside the As consumers become increasingly aware of lifestyle
ambulatory care setting to establish friendly, profes- choices, they look to health care professionals for
sional relationships with colleagues and patients. information and guidance. Seminars and workshops
Communication is just as critical when relating to are useful vehicles for presenting health-related
1024 UNIT 8 Office and Human Resources Management

Seminars can be organized to meet patient

Marketing
and community needs. Some popular seminar top-
Tool Potential Uses and Value
ics include hypertension, diabetes, eating disorders,
Seminars Can educate patients and provide good will and exercise and weight management programs.
in the community. All staff—administrative No matter what the topic area, the content
and clinical—can work as a team to orga- should be oriented to the lay person’s level of
nize, publicize, and deliver the seminars. understanding, with a focused message and a deliv-
Brochures Brochures are typically of two types: patient ery designed to maintain attention. Interactive sem-
education brochures and brochures on inars, which encourage audience participation, can
office services. Can be simple 8-1/2" x 11" be productive and enjoyable. Audiovisuals, such as
fact sheets, with text only, or more elaborate PowerPoint™ slides, provide visual reinforcement.
brochures folded to 4" x 9" that incorporate Handouts, either from professional organizations
both text and graphics or photos. Both types or those produced by office staff, can elaborate on
of brochures are informative for patients seminar content and help the participant review
and present a professional image of the and remember what was said.
ambulatory care setting.
Practice The practice Web site is an excellent means Brochures
Web site and of promoting the practice. Personnel can
E-zines be introduced, and procedures and tech- Despite the promise of a paperless society, bro-
nologies can be discussed. The E-zine chures continue to be valuable sources of informa-
approach is rapidly catching on as a promo- tion. In the health care setting, patients welcome a
tional tool. It can be e-mailed to patients so rack of brochures as a source of current, accurate
it saves time and money. The patient may background on medical issues. New patients also
choose to view, delete, or save to read at a find that a brochure on office services answers many
later time. questions about the practice, its philosophy, and its
scope of services and gives provider profiles.
Newsletters Newsletters can be produced on a biannual Today, it is possible to produce a profes-
or quarterly basis and can form the nucleus sional-looking brochure in the office
of a marketing program. Because they are using a computer program that integrates
versatile tools, they can include a wide text and graphics. If a brochure is produced in-
range of information from health-related house, it is important to consider writing, design,
articles to staff introductions to insurance and production. Writing should be clear, to the
updates. They should be sent to individuals point, and grammatically correct. Always proof-
on the office’s mailing list and be available read carefully before printing. Design should be
in the reception area. kept simple. Avoid the use of too many typefaces;
Press Periodic press releases on new equipment, choose a typeface and size for readability, and, if
Releases new staff, and expanded or remodeled using artwork or photography, consider its repro-
office space can be a vital link to the local duction qualities. Black or another dark ink against
community. a light background is best for readability.
Special Special events are an effective way to Often, a local printer can advise the office
Events join with other community organizations manager on how to prepare a brochure or hand-
to promote wellness. They can include out for printing. The simplest handouts can be
participation in health fairs, cosponsorship quick-copied (a high-speed photocopy) on a white
of a charity event, or an open house on the or lightly colored or textured stock. After printing,
premises to acquaint the community with brochures should be made accessible to patients
new services or equipment. and other visitors in a rack or neatly arranged in
piles (Figure 33-10). Occasionally, a brochure is
mailed; one that folds to 4 × 9 inches fits into a
Figure 33-9 Marketing tools and their use in a medi- standard #10 business envelope.
cal environment.
Patient Education Brochures. Like seminars,
information; while expert advice can be given, there patient education brochures can address a variety
is also the opportunity for patients and health care of topics, including hypertension, diabetes, eating
professionals to interact. disorders, and exercise and weight management
 CHAPTER 33 The Medical Assistant as Office Manager 1025

Newsletters
Newsletters are effective communication tools
because they encourage regular contact with
patients and other readers. Newsletters are a ver-
satile medium; they can contain patient education
articles, updates on staff changes, awards, informa-
tion on insurance carriers, calendars of events, and
even recipes that are consistent with a healthful
lifestyle.
Most newsletters can be written and pro-
duced in the office. Like brochures, they should
be simple in design and format. An additional
factor in newsletter production is mailing; an
up-to-date database must be maintained, postal
regulations followed, and costs of mailing consid-
ered.

Press Releases
Figure 33-10 Brochures and handouts should be Press releases are simple, inexpensive marketing
accessible and inviting to patients and office visitors. tools. Use them to announce new staff, promote
a new service, or publicize a series of seminars. If
a professional, courteous relationship is developed
programs. When writing these brochures, always with the local press, most will be happy to receive
research material carefully, request permission for and publish releases. When writing releases, always
copyrighted materials, and present the informa- follow proper format, which includes a date of
tion in a manner that is accessible to your patient release, a contact person’s name and telephone
population. number, and a short headline. Releases are best
kept to one double-spaced typed page. At the end
Office Brochures. A brochure on the practice can of the release, type “30” or a number sign (#).
provide a wide range of information and orient the Maintain an active list of local newspapers and edi-
new patient to the practice. One way to determine tors’ names so that you can mail or fax the release
what information to include is to develop a list of to the appropriate editor.
frequently asked patient questions. Once this list is
compiled, it can serve as the beginning of the bro-
chure outline. Issues to consider might include:
Special Events
• Brief history of the practice
Although they can be time-consuming to organize
• Brief résumés or credentials of providers and participate in, special events are rewarding
• Philosophy of the practice because they present an opportunity to interact
• Scope of services with the community. They have high visibility; often
a group of community organizations collaborate to
• How to reach the practice in case of emergency
cosponsor an event such as a walk-a-thon, blood
• Insurances accepted pressure clinic, health fair for seniors, or wellness
• Rights of patients day for children and families. Sponsorship can be
• Policies regarding the release of information as simple as a donation to the cause; other times,
staffing a booth or offering a service such as blood
• Scheduling information: how to schedule an
pressure checks is appropriate.
appointment, cancellation policies
Like all marketing efforts, special events
• Amenities on the premises, such as parking, phar- require organizational skills and teamwork, but
macy, laboratory they often result in heightened communication
• Location, map if necessary, and location of satellite with the community and provide an educational
offices service to patients and their families.
1026 UNIT 8 Office and Human Resources Management

adjustments to income, or two-earner/multiple payments using Form 1040-ES, Estimated Tax

Form W-4 (2008) job situations. Complete all worksheets that for Individuals. Otherwise, you may owe
apply. However, you may claim fewer (or zero) additional tax. If you have pension or annuity
Purpose. Complete Form W-4 so that your allowances. income, see Pub. 919 to find out if you should
employer can withhold the correct federal income Head of household. Generally, you may claim adjust your withholding on Form W-4 or W-4P.
tax from your pay. Consider completing a new head of household filing status on your tax Two earners or multiple jobs. If you have a
Form W-4 each year and when your personal or return only if you are unmarried and pay more working spouse or more than one job, figure
financial situation changes. than 50% of the costs of keeping up a home the total number of allowances you are entitled
Exemption from withholding. If you are for yourself and your dependent(s) or other to claim on all jobs using worksheets from only
exempt, complete only lines 1, 2, 3, 4, and 7 qualifying individuals. See Pub. 501, one Form W-4. Your withholding usually will
and sign the form to validate it. Your exemption Exemptions, Standard Deduction, and Filing be most accurate when all allowances are
for 2008 expires February 16, 2009. See Information, for information. claimed on the Form W-4 for the highest
Pub. 505, Tax Withholding and Estimated Tax. Tax credits. You can take projected tax paying job and zero allowances are claimed on
credits into account in figuring your allowable the others. See Pub. 919 for details.
Note. You cannot claim exemption from
withholding if (a) your income exceeds $900 number of withholding allowances. Credits for Nonresident alien. If you are a nonresident
and includes more than $300 of unearned child or dependent care expenses and the alien, see the Instructions for Form 8233
income (for example, interest and dividends) child tax credit may be claimed using the before completing this Form W-4.
and (b) another person can claim you as a Personal Allowances Worksheet below. See Check your withholding. After your Form W-4
dependent on their tax return. Pub. 919, How Do I Adjust My Tax takes effect, use Pub. 919 to see how the
Basic instructions. If you are not exempt, Withholding, for information on converting dollar amount you are having withheld
complete the Personal Allowances your other credits into withholding allowances. compares to your projected total tax for 2008.
Worksheet below. The worksheets on page 2 Nonwage income. If you have a large amount See Pub. 919, especially if your earnings
adjust your withholding allowances based on of nonwage income, such as interest or exceed $130,000 (Single) or $180,000
itemized deductions, certain credits, dividends, consider making estimated tax (Married).
Personal Allowances Worksheet (Keep for your records.)
A Enter “1” for yourself if no one else can claim you as a dependent A
● You are single and have only one job; or
B Enter “1” if: ● You are married, have only one job, and your spouse does not work; or B
● Your wages from a second job or your spouse’s wages (or the total of both) are $1,500 or less.
C Enter “1” for your spouse. But, you may choose to enter “-0-” if you are married and have either a working spouse or
more than one job. (Entering “-0-” may help you avoid having too little tax withheld.) C
D Enter number of dependents (other than your spouse or yourself) you will claim on your tax return D
E Enter “1” if you will file as head of household on your tax return (see conditions under Head of household above) E
F Enter “1” if you have at least $1,500 of child or dependent care expenses for which you plan to claim a credit F
(Note. Do not include child support payments. See Pub. 503, Child and Dependent Care Expenses, for details.)
G Child Tax Credit (including additional child tax credit). See Pub. 972, Child Tax Credit, for more information.
● If your total income will be less than $58,000 ($86,000 if married), enter “2” for each eligible child.
● If your total income will be between $58,000 and $84,000 ($86,000 and $119,000 if married), enter “1” for each eligible
child plus “1” additional if you have 4 or more eligible children. G
H Add lines A through G and enter total here. (Note. This may be different from the number of exemptions you claim on your tax return.) H
For accuracy, ● If you plan to itemize or claim adjustments to income and want to reduce your withholding, see the Deductions
complete all and Adjustments Worksheet on page 2.
worksheets ● If you have more than one job or are married and you and your spouse both work and the combined earnings from all jobs exceed
that apply. $40,000 ($25,000 if married), see the Two-Earners/Multiple Jobs Worksheet on page 2 to avoid having too little tax withheld.
● If neither of the above situations applies, stop here and enter the number from line H on line 5 of Form W-4 below.

Cut here and give Form W-4 to your employer. Keep the top part for your records.

Form W-4 Employee’s Withholding Allowance Certificate OMB No. 1545-0074

Department of the Treasury

Internal Revenue Service
Whether you are entitled to claim a certain number of allowances or exemption from withholding is
subject to review by the IRS. Your employer may be required to send a copy of this form to the IRS.
2008
1 Type or print your first name and middle initial. Last name 2 Your social security number

Home address (number and street or rural route) 3

Single Married Married, but withhold at higher Single rate.
Note. If married, but legally separated, or spouse is a nonresident alien, check the “Single” box.
City or town, state, and ZIP code 4 If your last name differs from that shown on your social security card,
check here. You must call 1-800-772-1213 for a replacement card.

5 Total number of allowances you are claiming (from line H above or from the applicable worksheet on page 2) 5
6 Additional amount, if any, you want withheld from each paycheck 6 $
7 I claim exemption from withholding for 2008, and I certify that I meet both of the following conditions for exemption.
● Last year I had a right to a refund of all federal income tax withheld because I had no tax liability and
● This year I expect a refund of all federal income tax withheld because I expect to have no tax liability.
If you meet both conditions, write “Exempt” here 7
Under penalties of perjury, I declare that I have examined this certificate and to the best of my knowledge and belief, it is true, correct, and complete.
Employee’s signature
(Form is not valid
unless you sign it.) Date
8 Employer’s name and address (Employer: Complete lines 8 and 10 only if sending to the IRS.) 9 Office code (optional) 10 Employer identification number (EIN)

For Privacy Act and Paperwork Reduction Act Notice, see page 2. Cat. No. 10220Q Form W-4 (2008)

Figure 33-11 Form W-4 indicates the number of exemptions claimed by the employee for income tax purposes.
 CHAPTER 33 The Medical Assistant as Office Manager 1027

RECORDS AND FINANCIAL a mouse or a few keystrokes. Figure 33-12 graphi-

cally shows the most significant types of data flow-
MANAGEMENT ing between the TPMS and the office manager.
Table 33-2 lists sample data types and the resulting
Providers entrust a great deal of responsibility to
actions by the manager.
their medical office managers. The daily payments
received through the mail and office visits must
be processed and prepared for banking. Office Payroll Processing
expenses must be processed and paid in a timely
In some cases, it is the office manager’s responsi-
fashion to capitalize on any discounts available.
bility to prepare payroll checks for each employee
Employee requirements and records such as Social
and record all deductions withheld. A W-2 form
Security records; Withholding Allowance Certificates
(Figure 33-13) summarizing all earnings and
(W-4 forms) (Figure 33-11) indicating the number
deductions for the year must be prepared for each
of exemptions claimed; and Employment Eligibil-
employee by January 31 of each year. The Social
ity Verification Forms (I-9) ensuring that all persons
Security Administration must receive a summary
employed are either United States citizens, lawfully
report of W-2 forms each year.
admitted aliens, or aliens authorized to work in the
To comply with all governmental regulations,
United States must be completed and filed with the
federal, state, and local, it is important that the
appropriate federal agencies. Also, state and local tax
office manager who processes payroll maintain com-
records must be maintained for each employee.
plete, up-to-date records on every employee. This
information should be gathered from new employ-
Electronic Health Records ees and updated every year and with any change
and the Office Manager in employee status. For more specific information
The Total Practice Management Sys-
E HR tem (TPMS) is the nerve center for the
Table 33-2 Office Manager Actions in
office manager as he or she orchestrates a Response to TPMS Data
smooth-running organization. It provides all of the
data needed by the office manager at the click of
Data Action by Office Manager

Staffing require- Hire or terminate employees,

ments and obtain additional office space
ELECTRONIC appointment
schedules
and equipment, adjust vaca-
tion schedules

RECORDS Equipment
and supplies
Issue purchase orders, autho-
rize payment of invoices, secure
Financial & Billing Reports requests, and vendors and suppliers, negoti-
Staffing Requirements and Reports inventory data ate maintenance contracts
Equipment & Supply Requests

Practice financial status reports,

instructions for coding and
Personnel Data Financial and
Payroll billing on past due accounts,
billing reports
Approved Vendors actions on billing denied due to
Incident Reports coding errors
Collections Policies
Inventory Received
Employee time Payroll authorization, corrective
OFFICE MANAGER & sheets actions for missed work
HUMAN RESOURCES
Review if patient demograph-
Medical records ics and HIPAA requirements are
current

Receiving Hiring
Purchasing
Progress reviews, salary reviews,
W-4 forms, corrective actions,
Personnel data
licenses, malpractice insurance
Figure 33-12 Data flow between the total practice contracts
management system and the office manager.
1028 UNIT 8 Office and Human Resources Management

a Employee’s social security number For Official Use Only

22222 Void
OMB No. 1545-0008
b Employer identification number (EIN) 1 Wages, tips, other compensation 2 Federal income tax withheld

c Employer’s name, address, and ZIP code 3 Social security wages 4 Social security tax withheld

5 Medicare wages and tips 6 Medicare tax withheld

7 Social security tips 8 Allocated tips

d Control number 9 Advance EIC payment 10 Dependent care benefits

e Employee’s first name and initial Last name Suff. 11 Nonqualified plans 12a See instructions for box 12
C
o
d
e

13 Statutory Retirement Third-party 12b

employee plan sick pay C
o
d
e

14 Other 12c
C
o
d
e

12d
C
o
d
e

f Employee’s address and ZIP code

15 State Employer’s state ID number 16 State wages, tips, etc. 17 State income tax 18 Local wages, tips, etc. 19 Local income tax 20 Locality name

W-2 Wage and Tax

2008
Department of the Treasury—Internal Revenue Service
Form Statement For Privacy Act and Paperwork Reduction
Act Notice, see back of Copy D.
Copy A For Social Security Administration — Send this entire page with
Form W-3 to the Social Security Administration; photocopies are not acceptable. Cat. No. 10134D

Do Not Cut, Fold, or Staple Forms on This Page — Do Not Cut, Fold, or Staple Forms on This Page
Figure 33-13 Form W-2 summarizes all earnings and deductions for the year and must be prepared for each
employee by January 31.

regarding printed and electronic filing forms, go to ee’s earnings. Many ambulatory care settings that
the Internal Revenue Service Web site (http://www. operate on a manual bookkeeping system find that
irs.gov) for detailed instructions. It is a good idea to the write-it-once system is the most efficient way to
have employees update their W-4 form each year in accurately maintain these records. Payroll records
case they want to adjust their deductions or make should include:
any other change. To accomplish this, many payroll
managers include a new W-4 form with the first pay- • Employee name, address, and telephone number
check at the beginning of each year. Every employee • Social Security number
file should contain Social Security number, number • Date of employment
of exemptions claimed on the W-4 Form, employ-
ee’s gross salary, and all deductions withheld for all Each paycheck stub should contain:
taxes, including Social Security, federal, state, local,
and unemployment tax (where applicable), and dis- • Number of hours worked, including regular and
ability insurance (where applicable). overtime (if hourly)
To process payroll, the provider’s office must • Dates of pay period
have a federal tax reporting number, obtained • Date of check
from the Internal Revenue Service. In some states,
• Gross salary
a state employer number also is needed.
• Itemized deductions for federal income tax, Social
Preparing Payroll Checks. When preparing payroll Security (FICA) tax, state tax, city or local tax
checks, it is important to keep a record of all tax • Itemized deductions for health insurance and dis-
and insurance amounts deducted from an employ- ability insurance
 CHAPTER 33 The Medical Assistant as Office Manager 1029

• Other deductions such as uniforms, loan pay- sibility of each staff member to report to the office
ments, and so on manager any facility repairs that require atten-
• Net salary (gross earnings minus taxes and deduc- tion and suggest replacement or recommend new
tions) pieces of equipment as required by the practice to
support the health care needs of its population.
Procedure 33-7 provides steps for processing The office manager usually is responsible for
payroll. maintenance of the office and may hire ancillary
services to provide janitorial and laundry services,
Figuring Employee Taxes. When figuring federal dispose of hazardous materials, and maintain
income taxes and Social Security taxes, use the “Cir- aquariums or plants that may enhance the environ-
cular E” tables provided by the Internal Revenue ment of the facility. The office manager must be
Service. Federal tax is based on amount earned, cognitive of the importance of patient confidenti-
marital status, number of exemptions claimed, and ality when ancillary services are present. Ancillary
length of pay period. State and city or local taxes are services must not view confidential material. A
typically a percentage of the gross earnings. signed Business Associate agreement must be on
All federal and state taxes withheld must be file for each ancillary service contracted.
paid on a quarterly basis to the appropriate govern- Magazine subscriptions and health-related
ment offices. These monies should be accompanied literature for the reception area are the responsi-
by the required reporting forms. It is important to bility of the office manager. Selections should be
observe deposit requirements for withheld income made carefully, keeping in mind the interests of
tax and Social Security and Medicare taxes. These the patients and their cultures. These materials
requirements, which change frequently, are listed should not be kept once they become dog-eared,
in the Federal Employer’s Tax Guide, available from torn, and outdated. The use of plastic protectors
the U.S. Government Printing Office, Internal Rev- and appropriate storage shelving aid in keeping
enue Service (or online at http://www.irs.gov). the area and materials tidy.
The office manager, together with the pro-
Managing Benefits and Other Responsibilities. vider, is responsible for facility improvements,
Benefits, or additional remuneration to the salary including any necessary repairs, decorating and
earned by full-time employees, must be man- color scheme, and floor plan suggestions. The
aged and records maintained for each employee. wise office manager does not make these deci-
Examples of benefits include paid vacation, paid sions independently but asks for suggestions from
holidays, health/dental insurance, disability, staff members. Remember, the team-building
profit-sharing options, and complimentary health approach adds a cohesive element to any office
care. Some ambulatory care settings may refer to environment.
all or some of these benefits as fringe benefits.
Other responsibilities of the office man-
ager include maintaining a personnel file for each Administrative and Clinical
employee providing his or her history with the facility, Inventory of Supplies and
application for the current position, evaluations, pro- Equipment
motions, problems, awards, entitlements, legal forms
required by state and federal agencies, and so on. All administrative and clinical supplies and equip-
All Occupational Safety and Health Administration ment in the facility must be inventoried. Maintain-
(OSHA) data, hazard material training and documen- ing a sufficient inventory of administrative and
tation, HIPAA training documentation, cardiopulmo- medical supplies requires implementation of a
nary resuscitation (CPR) certifications, immunization system for taking inventory of supplies frequently
records, AIDS education, and confidentiality agree- enough to permit placing and receiving an order
ment must be recorded and maintained. before a shortage occurs. Large facilities frequently
use the TPMS to inventory items that normally
would be billed as part of a procedure, but this will
FACILITY AND EQUIPMENT not identify routinely used medical and adminis-
MANAGEMENT trative supplies.
Medical offices operate on a budget, so com-
The physical plant or building must be parison shopping is prudent. Many companies
observed and maintained with safety being have online catalogs with full descriptions and
a key ingredient. It should be the respon- prices of their products. The cost of an item is not
1030 UNIT 8 Office and Human Resources Management

the only consideration when purchasing inventory. • Date last serviced

Consider the following: • Routine maintenance or calibration information

• Warranties The steps for inventorying supplies and

• Bulk orders equipment for administrative and clinical needs
• Maintenance agreements are given in Procedure 33-8.
• Quality and durability
• Personal preferences
• Cost factors
Administrative and Clinical
Equipment Calibration and
Online ordering via the Internet can save
Maintenance
time and money. When placing orders, select Administrative and clinical equipment must be
those with secure Web sites; it is generally safe cleaned, calibrated, and maintained on a regular
to use credit cards with these vendors. Supplies basis. Most offices use a computer spreadsheet or
also can be ordered through hardcopy catalogs. relational-type database, depending on the size of
Benchmarking with other medical offices nets the facility. The database identifies the equipment
valuable information in determining reputable by name or type, its assigned facility identification
vendors. number, location in the facility, warranty expira-
When an order is received, it must be opened tion date, service period, dates when service and
and checked properly. Look first for the packing calibration were last performed, and when the
slip, which lists the items ordered and the items next service or calibration will be required. The
shipped. Verify that no items have been substi- database also may identify service contracts for
tuted or backordered. Each item unpacked must equipment not maintained or calibrated by facility
be checked with the packing slip to be sure there personnel and information on service contractors
are no discrepancies. Write the date the shipment of equipment, such as contacts, phone numbers,
was received, who verified it, and any follow-up and addresses. The database is backed up by a
information. The new stock should be stored paper file containing operation manuals, warranty
appropriately. information, and service contracts.
Some items purchased come with a warranty. Administrative equipment such as the com-
A warranty usually is activated online at the ven- puter should be cleaned and maintained regu-
dor’s Web site or by using a warranty card pack- larly. Telephones as well as any other pieces of
aged with the purchased item. Warranty cards are equipment should be cleaned and working order
similar to postcards and establish the purchase checked.
date and name and address of the purchaser. The Laboratory and clinical equipment must be
returned warranty information provides the ven- maintained and quality-control measures utilized.
dor with information should it be necessary to Calibration checks are required for a number of
notify the buyer of recalls or defective parts. It is pieces of equipment: sphygmomanometers and
also proof of purchase and gives the length of time centrifuges to name two. Microscopes and various
the warranty is in effect. types of scopes used during physical examinations
It is important to create a file for each piece and specialty procedures contain light sources that
of equipment in the medical office. Information in must be checked before each use. A replacement
this file should include: supply of bulbs should be available. See Chapter
26 for more information on quality control and
• Date of purchase and original receipt safety in the medical laboratory. Assigning a clini-
• Manufacturer name, address, and telephone num- cal laboratory manager to oversee the equipment
ber is a good idea. Procedure 33-9 provides steps for
• Model number and owner’s manual routine maintenance or calibration of administra-
tive and clinical equipment.
• Technical support information and telephone
The office storage areas should be well main-
number
tained, and each item should always be put back
• Warranty information in its place with lids replaced properly to prevent
• Service agreement any accidents. Medication storage requires special
 CHAPTER 33 The Medical Assistant as Office Manager 1031

attention. Many medications must be stored at option of purchasing personal and professional
certain temperatures, kept dry, or stored in dark, insurance through the organization at corporate
airtight containers. All medications, including rates.
samples, must be kept out of patient access areas. Some providers carry the names of their
Narcotics should always be stored in a separate employees on their policies. If this is the case,
locked cabinet. Dispensing requires two individu- always ask to see the policy and verify that your
als to sign off when narcotic supplies are used. A name is printed on the policy—no name indi-
daily inventory should be maintained. cates no coverage. The manager may need to see
that professional liability insurance has been pur-
chased, all appropriate names are listed, and the
LIABILITY COVERAGE premiums are paid in a timely fashion.
AND BONDING Professional liability insurance is important if
the provider–employer is sued. In this event, the
Negligence is performing an act that a rea- provider and the medical assistant could be named
sonable and prudent provider would not in the suit. If the case were lost, both the provider
perform or failure to perform an act and the medical assistant could be liable.
that a reasonable and prudent provider would Individuals who are responsible for handling
perform. The common term used to describe pro- financial records and money in the medical office
fessional liability or legal responsibility today is mal- may be bonded. A bond is purchased for a cash
practice. It is much easier to prevent malpractice value in an employee’s name that ensures that the
than to defend it in litigation; therefore every effort provider will recover the amount of loss in the event
should be taken to prevent negligence. Events that that an employee embezzles funds. It is the office
could result in a malpractice litigation invariably will manager or the HR manager’s responsibility to ask
occur from time to time in even the best of medical prospective employees if they are bondable. Indi-
offices. When such an incident occurs, complete viduals who are not bondable may not be the best
honesty with the patient and insurance carrier is candidates for the position.
the best policy. Protocols should be implemented
or existing ones revised to prevent any future occur-
rences, and all steps necessary to minimize risk to LEGAL ISSUES
the patient should be taken.
Insurance policies specifically designed to The office manager must be aware of
protect the provider’s assets in the event a liabil- and follow all state and federal regulations
ity claim is filed and awarded in the patient’s favor impacting the practice. Information related
are available. Any provider not carrying such insur- to Clinical Laboratory Improvement Amendments
ance is said to be “going bare” and would person- of 1988 (CLIA ‘88) and Occupational Safety and
ally be responsible for any court costs, damages, Health Administration (OSHA) can be found in
and attorney fees if a malpractice suit were lost. Chapter 26. Federal regulations related to pro-
Practicing medical assistants should carry pro- vider office laboratories (POLs) are discussed in
fessional liability insurance for protection. Medi- Chapter 26. The Centers for Medicare and Med-
cal assistants who are members of the American icaid Services Web site also is helpful (http://www.
Association of Medical Assistants (AAMA) have the cms.hhs.gov).
1032 UNIT 8 Office and Human Resources Management

Procedure 33-1
Completing a Medical Incident Report
PURPOSE: This ensures the most accurate recording of the
To complete a medical incident report and submit it incident.
in a timely manner. 3. Each section of the form must be completed.
The incident description should be a brief nar-
EQUIPMENT/SUPPLIES: rative consisting of an objective description
Appropriate medical incident report form
of the facts but should not draw any conclu-
Computer with Incident Report Software
sions. Quotes should be used when appropriate
PROCEDURE STEPS: with any unwitnessed incidents (e.g., “Patient
1. Complete the office-approved Medical Inci- states...”). The name(s) of any witnesses should
dent Report form. A single-sheet, multiple-copy be included on the report as well as employees
form is best. The form should contain basic directly involved in the incident. RATIONALE:
patient identification data, a checklist of differ- To provide unbiased information without mak-
ent incidents, and a space for written comments. ing judgments.
RATIONALE: Ensures that all information 4. Incident reports must be submitted in a timely
needed is documented. manner to the appropriate administrator or
2. The person completing the incident report office following protocol identified in the Pro-
form should be the individual who witnessed cedure Manual for the office. RATIONALE:
the incident, first discovered the incident, or is Ensures that appropriate documentation and
most familiar with the incident. RATIONALE: action is taken for follow-up.

Procedure 33-2
Preparing a Meeting Agenda
PURPOSE: 2. Collect information for meeting agenda by pre-
To prepare a meeting agenda, a list of specific items viewing the previous meeting’s minutes for old
to be discussed or acted on, to maintain the focus of business items, checking with others for report
the group and allow business to be transacted in a items, and determining any new business items.
timely fashion. RATIONALE: Ensures that all old and new busi-
ness items have been identified.
EQUIPMENT/SUPPLIES: 3. Prepare a hard copy of the agenda and have it
List of participants
approved by chair of the meeting. RATIONALE:
Order of business
Confirmation by the chair of the agenda content
Names of individuals giving reports
ensures that agenda is correct and complete.
Names of any guest speakers
Computer and paper to print agendas 4. Send agenda to meeting participants a few days
in advance of the meeting. RATIONALE: Per-
PROCEDURE STEPS: mits participants to prepare for the meeting by
1. Reserve proposed date, time, and place of meet- completing any tasks required and preparing
ing. RATIONALE: Ensures that the facilities are any necessary documentation.
available for the meeting.
 CHAPTER 33 The Medical Assistant as Office Manager 1033

Procedure 33-3
Supervising a Student Practicum
PURPOSE: 6. Begin orientation for the student as soon as he
To prepare a training path for a student extern being or she arrives at the office. Include a tour of the
assigned to the office. To make the involved office office and introduction to the staff. RATIONALE:
personnel aware of their responsibilities. To preplan Orients student and staff to each other and estab-
which jobs the student extern performs and in what lishes guidelines for procedures.
sequence they will be assigned. To make the practi- 7. Give the student a copy of the Office Policy
cum successful by providing as much supervision and Manual and the work schedule for the entire
assistance as necessary. practicum. Answer any questions the student
might have. RATIONALE: Orients student and
EQUIPMENT/SUPPLIES: staff to each other and establishes guidelines
None needed
for procedures.
PROCEDURE STEPS: 8. Maintain an accurate record of the hours the
1. Review the clinical practicum contract or agree- student works. Also log the date and reason for
ment between your agency and the educational any missed days, late arrivals, or early dismissals.
institution. RATIONALE: Guidelines and proce- RATIONALE: Provides necessary documenta-
dures are reviewed and refreshed in your mind. tion for the hours completed by the student.
2. Determine the amount of supervision the stu- 9. Check with the student frequently to be sure the
dent will require. RATIONALE: Prepares you student is receiving meaningful training from
to speak with the student and site supervisor the work experience. RATIONALE: Verifies that
regarding supervision. necessary training is being provided.
3. Identify the supervisor who will be immedi- 10. Consult providers and staff members with whom
ately responsible for the student. RATIONALE: the student has worked for their opinion of the
Establishes a person who knows he or she is to student’s capabilities. Follow up on any problems
supervise the student and be responsible for the that might be identified. RATIONALE: Verifies
practicum procedures. that necessary training is being provided.
4. Plan what tasks the student will be allowed or 11. Report the student’s progress to the medical
encouraged to perform. RATIONALE: The assisting supervisor from the educational institu-
office may or may not permit the student to per- tion. This person usually visits once or twice each
form invasive procedures. Determining tasks the rotation. RATIONALE: Verifies that necessary
student can and cannot perform beforehand training is being provided.
promotes a better relationship. 12. Prepare the student evaluation report from com-
5. Create a schedule outlining the time the student ments provided by the supervisor assigned and
will be assigned to each unit. RATIONALE: Estab- each employee who worked with the student.
lishing a schedule keeps everyone appraised of RATIONALE: Provides necessary documenta-
what is happening and when. tion for the practicum experience.
1034 UNIT 8 Office and Human Resources Management

Procedure 33-4
Developing and Maintaining a Procedure Manual
PURPOSE: ers, and patients. Provide a listing in each area
To develop and maintain a comprehensive, up-to-date with contact information and services provided.
procedure manual covering each medical, technical, RATIONALE: The procedures and instruc-
and administrative procedure in the office, with step- tions listed in the Procedure Manual should
by-step directions and rationale for performing each provide supporting documentation needed for
task. accomplishing each task. For example, if the
clinic requires that local public transportation
EQUIPMENT/SUPPLIES: resources be given to each patient who needs
Computer or electronic typewriter (electronic storage transportation, the Procedure Manual has a list-
allows changes and revisions to be made easily) ing of all transportation available in the area
Binder, such as a three-ring binder with telephone numbers and schedules. This
Paper document could either be printed from the
Standard procedure manual format computer or photocopied from the manual and
provided to the patient.
PROCEDURE STEPS:
1. Write detailed, step-by-step procedures and 5. Include basic rules and regulations, state and
rationales for each medical, technical, and federal, which are related to processes per-
administrative function. Each procedure is formed in both clinical and office/business
written by experienced employees close to areas. RATIONALE: Having a listing of the rules
the function and then reviewed by a super- and regulations assists in performing those regu-
visor and office manager. Rationales help lated duties correctly and legally.
employees understand why something is done. 6. Include the clinic procedures and flow sheets for
RATIONALE: Establishes consistent guidelines taking inventory in each of the areas and instruc-
to be followed. tions on ordering procedures. RATIONALE:
2. Include regular maintenance instructions and When a clinic has processes clearly written for
flow sheets for cleaning, servicing, and cali- managing inventory and ordering of equip-
brating of all office equipment, both in the ment and supplies, the clinic is less likely to run
clinical area and in the office/business areas. out of needed items and may even be able to
RATIONALE: Equipment needs to be cleaned take advantage of discounts offered by manu-
and maintained on a regular basis to ensure it facturers.
is working properly and that it lasts as long as 7. Collect the procedures into the Office Proce-
needed. Some manufacturer guarantees and dure Manual. RATIONALE: Provides a refer-
service contracts require regular cleaning and ence guide with step-by-step instructions and
maintenance, especially on new and leased examples where appropriate.
equipment. Instructions are necessary so that 8. Store one complete manual in a common library
the task can be performed properly. The flow area. Provide a completed copy to the provider–
sheets provide documentation of dates the employer and the office manager. Distribute
equipment was cleaned, serviced, and/or cali- appropriate sections to the various departments.
brated and the person who performed the task. RATIONALE: Provides a reference guide with
3. Include step-by-step instructions on how to step-by-step instructions and examples where
accomplish each task in the office/clinic in both appropriate.
the clinical area and in the office/business areas. 9. Review the procedure manual annually and add
RATIONALE: Clear and concise instructions any new procedures, delete or modify as neces-
ensure that each task is consistently performed sary, and indicate the revision date (Rev. 10/12/
to the clinic standards. XX). RATIONALE: Maintains current office
4. Include local and out-of-the-area resources protocols.
for clinical staff, office/business staff, provid-
 CHAPTER 33 The Medical Assistant as Office Manager 1035

Procedure 33-5
Making Travel Arrangements with a Travel Agent
PURPOSE: 3. Pick up tickets or arrange for their delivery.
To make travel arrangements for the provider. 4. Check to see that ticket arrangements are accu-
rate (dates, times, places).
EQUIPMENT/SUPPLIES:
5. Check to see that car rental and lodging
Travel plan
accommodations are accurate and confirmed.
Telephone and telephone directory
RATIONALE: Avoid inaccuracies and confusion
Computer
with schedule.
Provider’s or office credit card to pay for reservations
6. Make additional copies of the itinerary or create
PROCEDURE STEPS: the itinerary if making arrangements via com-
1. Confirm the details of the planned trip: dates, puter. The itinerary should list date and time of
time, and place for departure and arrival; pre- departures and arrivals, including flight numbers
ferred mode of transportation (plane, train, bus, and seat assignments. Note mode of transporta-
car); number of travelers; preferred lodging type tion to lodging (shuttle, bus, car, taxi). Include
and price range; and whether travelers checks name, address, and telephone number of lodg-
are required. RATIONALE: Confirming perti- ings and meeting places.
nent travel details ensures that correct arrange- 7. Maintain one copy of the itinerary in the office
ments will be made. file.
2. Make travel and lodging reservations by calling 8. Give several copies of the itinerary to the pro-
travel agent or using the computer for online vider. RATIONALE: Ensure that a copy is on file
ticket services. RATIONALE: Ensure that space with the office and that there are sufficient cop-
for provider is reserved at desired times. ies for the traveler(s) and their families.

Procedure 33-6
Making Travel Arrangements via the Internet
PURPOSE: are required. RATIONALE: Confirming perti-
To make travel arrangements for the provider using nent travel details ensures that correct arrange-
the Internet. ments will be made.
2. Go to the computer and access the Internet.
EQUIPMENT/SUPPLIES:
3. Select a search engine to locate Web pages using
Travel plan
the key term “air fares.” Web pages may provide
Computer
links to air fares, auto reservations, and hotel/
Provider’s or office credit card to pay for reservations.
motel reservations. Follow Web page instruc-
PROCEDURE STEPS: tions for making arrangements. Review and copy
1. Confirm the details of the planned trip: dates, confirmation of your transaction. RATIONALE:
time, and place for departure and arrival; pre- The Internet can be a time saver and a cost-
ferred mode of transportation (plane, train, bus, effective way of securing travel arrangements.
car); number of travelers; preferred lodging type 4. Pick up tickets or arrange for their delivery, if
and price range; and whether travelers checks necessary. Tickets purchased on the Internet can

continues
1036 UNIT 8 Office and Human Resources Management

Procedure 33-6 (continued)

be mailed or picked up at an airport, or they can taxi). Include name, address, and telephone
be electronic tickets. number of lodgings and meeting places.
5. Make additional copies of the itinerary or create 6. Maintain one copy of the itinerary in the office file.
the itinerary. The itinerary should list date and 7. Give several copies of the itinerary to the pro-
time of departures and arrivals, including flight vider. RATIONALE: Ensure that a copy is on file
numbers and seat assignments. Note the mode with the office and that there are sufficient cop-
of transportation to lodging (shuttle, bus, car, ies for the traveler(s) and their families.

Procedure 33-7
Processing Employee Payroll
PURPOSE: tion. Be sure to document any that may be found
To process payroll compensating employees, calculat- and action taken.
ing all deductions accurately. 3. Calculate the salary or hourly wages due the
employee for the work period. RATIONALE: To
EQUIPMENT/SUPPLIES: determine the amount owed each employee.
Computer and payroll software or checkbook
4. Calculate any deductions that must be withheld
Tax withholding tables
from the paycheck. These may include federal,
Federal Employers Tax Guide
state, and local taxes; Social Security withhold-
PROCEDURE STEPS: ings; Medicare withholdings; insurance; savings;
1. Verify copies of the employee’s Social Security or donations. RATIONALE: To ensure compli-
card and current I-9 and W-4 forms are in each ance with all federal, state, and local laws and sat-
employee file. RATIONALE: Provides verification isfy all proper deductions are made.
that employee is eligible to work in the United 5. Use computer and payroll software or hand write
States and to calculate withholding amounts that the payroll check and explanation of deductions.
should be deducted from paychecks. 6. Distribute individual payroll checks in envelopes
2. Review time cards looking for any tardiness, according to office protocol. RATIONALE:
early dismissals, or absences. RATIONALE: To Ensures compliance and confidentiality issues
access any problems that could lead to termina- are maintained.
 CHAPTER 33 The Medical Assistant as Office Manager 1037

Procedure 33-8
Perform an Inventory of Equipment and Supplies
PURPOSE: 3. Repeat the previous step for each storage loca-
To develop an inventory of expendable administrative tion on the inventory printout sheet.
and clinical supplies in a medical office. 4. After completing the inventory, enter the new
inventory information, including date of inven-
EQUIPMENT/SUPPLIES: tory, quantity, and date of reorder request, into
Printout of most recent inventory spreadsheet,
the computer database. RATIONALE: To deter-
listing items by storage location, name and
mine what needs to be ordered.
identification code, number of items, minimum
quantity requiring reorder, date and quantity of 5. Forward the reorder forms to the person respon-
last reorder, and expiration date of items if any. sible for purchasing. RATIONALE: To forward
Clipboard, pad of reorder forms, pen or pencil. information to the person responsible for reor-
dering supplies and equipment.
PROCEDURE STEPS:
1. Compare number of items on hand corresponding NOTE: If the office or clinic uses handheld computers
to each name or code identification number with on a wireless network, all of the printouts and reor-
the printout, and write in the new inventory num- der forms can be entered directly into the computer
ber on the printout. RATIONALE: To determine record while doing the inventory, making unneces-
what is on hand and what needs to be ordered. sary the reentry and preparation of reorder forms. If
2. If the number of any item is less than the mini- the handheld computer is not networked, it will be
mum quantity, fill out a reorder form listing necessary to download or sync the data after complet-
completely the name, identification number, ing the inventory.
and quantity required.

Procedure 33-9
Perform Routine Maintenance or Calibration of Administrative
and Clinical Equipment
PURPOSE: 2. Check equipment for cleanliness and clean thor-
To ensure the operability and calibration of adminis- oughly if required. RATIONALE: Equipment
trative and clinical equipment. works more efficiently when clean; this is a safety
issue as well.
EQUIPMENT/SUPPLIES: 3. Perform visual safety check for electrical and
Equipment list with maintenance or calibration
mechanical integrity. RATIONALE: Visual
requirements
inspection quickly determines deficiencies.
Clipboard, pen, maintenance record sheets, and
deficiency tags 4. Tag any equipment with safety hazards and
Access to operation and service manuals of equipment report the deficiency. RATIONALE: Equipment
to be serviced with safety hazards should not be used until
Access to any necessary maintenance tools and supplies repaired to protect operators.
5. Check for operability using procedures defined
PROCEDURE STEPS: in the operation manual.
1. Date the maintenance record. RATIONALE:
Documents when equipment was last checked 6. Check to ensure the equipment meets opera-
and serviced. tional/calibration standards as defined in the

continues
1038 UNIT 8 Office and Human Resources Management

Procedure 33-9 (continued)

operation and service manual. Recalibrate the 8. Fill out and sign the maintenance record sheet
equipment following the instructions in the man- if the equipment meets operations standards.
ual if required. RATIONALE: Calibration stan- RATIONALE: Documents routine maintenance
dards must be maintained for correct results. was performed.
7. Tag any equipment not meeting operational stan- NOTE: The equipment list, maintenance records, and
dards and report the deficiency. RATIONALE: deficiency reports may be included in the TPMS of
Equipment must be either replaced or repaired many practices.
to ensure proper results.

Case Study 33-1

Review the scenario at the beginning of the chapter. CASE STUDY REVIEW
Drs. Lewis and King have requested sigmoidoscopy
procedures to be scheduled for two different patients. The 1. Divide the class into two groups to discuss problem-
patients are scheduled. Both patients are put on a strict solving solutions. Assume that rescheduling a
diet and pretest protocol for several days to prepare for the patient is not an acceptable solution because of
procedures. The day of the appointments, Marilyn Johnson, the patient’s pretest protocol. The patients would be
CMA (AAMA), and office manager, discovers that the two upset if the procedure could not be performed due
sigmoidoscopy procedures have been scheduled at the to a scheduling problem.
same time. The problem is that the office has only one sig- 2. How could this problem have been avoided?
moidoscope available. 3. Both patients have been told about the schedul-
ing problem and one is upset and argumentative.
What role should the office manager assume in this
predicament?

Case Study 33-2

Anita Juarez, the office administrative medical assistant, CASE STUDY REVIEW
speaks privately with Jane O’Hara, the office manager and
the person responsible for personnel. Anita has a suspicious 1. Identify the first and immediate concerns to be
lump in her breast. She has seen both her internist and a addressed.
surgeon for evaluation. Next week, she will have the lump 2. What action might be taken to help both Anita and
removed, perhaps even a complete mastectomy. Anita is the office manager address these concerns?
concerned about the time she will need to be away from the 3. Is it helpful to plan for the best results, the worst
office. results, or both?

SUMMARY
The office manager is the glue that holds the office together and keeps it running smoothly. When the
manager sets a positive example for others and is considerate and aware of the diversity of others, a positive
environment is created for teamwork. A teamwork approach enables the entire office to be more produc-
tive, provide the best health care, and foster an enjoyable work relationship.
 CHAPTER 33 The Medical Assistant as Office Manager 1039

The role of office manager varies greatly depending on the size of the medical practice, the provider’s
trust in the manager’s competency level, and the provider’s comfort in delegating authority to others. An
effective office manager is a tremendous asset to providers. The personal and financial rewards are worth-
while to the medical assistant who desires a new dimension to explore and enjoys a challenge.

STUDY FOR SUCCESS

To reinforce your knowledge and skills of information presented in this chapter:
• Review the Key Terms
• Practice the Procedures
• Consider the Case Studies and discuss your conclusions
• Answer the Review Questions

˚ Multiple Choice
˚ Critical Thinking
• Navigate the Internet by completing the Web Activities
• Practice the StudyWARE activities on the textbook CD
• Apply your knowledge in the Student Workbook activities
• Complete the Web Tutor sections

REVIEW QUESTIONS
Multiple Choice b. they do not need supervision when working with
1. For teamwork to be successful, individual team a patient
members must: c. they are experienced with working on real
a. do as they are told by the office manager patients
b. not ask why they are doing something a certain d. they have much to learn
way 4. Which of the following statements is not correct
regarding a student practicum?
c. understand and support the task
a. It is a transitional stage that provides oppor-
d. think independently and solve the problem on
tunity for students to apply theory learned in
their own
the classroom to a health care setting through
2. Meeting minutes:
hands-on experience.
a. should address each agenda topic and include
b. It assumes that the student is an employee who
a brief summary of discussions, actions taken,
does not need to be introduced to patients.
name of each person making a motion, the exact
c. It may require the student to shadow another
wording of motions, and motion approval or
medical assistant for a few days.
defeat
d. It involves an evaluation of the student’s
b. are a detailed plan for a proposed trip progress.
c. include information regarding mode of trans- 5. The procedure manual:
portation and lodging reservations a. is a detailed plan for a proposed trip
d. must follow parliamentary procedures b. provides detailed information regarding mode
3. When working with practicum students, it is impor- of transportation and lodging reservations
tant to remember that: c. provides detailed information relative to the per-
a. they should have expert knowledge about their formance of tasks within the health care facility
field d. summarizes action details of staff meetings
1040 UNIT 8 Office and Human Resources Management

6. Developing relationships outside the office is often 4. Describe how a procedure manual for a single-
called: provider practice would differ from a procedure
a. marketing manual for a multiprovider practice.
b. benchmarking 5. Describe how a procedure manual could become
c. advertising outdated and need revision.
d. sales
7. Record and financial management involves all of
the following except:
WEB ACTIVITIES
a. payroll processing Use the Web sites given in the text or alterna-
b. preparing payroll checks tive sites you know about to plan a trip between
c. figuring taxes two cities within the United States. Compare
d. equipment and supplies maintenance the fares for Sunday departure and Friday return dates
8. Controlled substances must: with the fares for low-volume days as obtained from
a. be kept separate from other drugs the Priceline.com site. Also compare fares on flights
b. be stored in a separate locked cabinet purchased within 1 week of departure with fares on
c. be recorded in a book that is maintained daily flights purchased 1 month before departure. Follow the
d. all of the above instructor’s instructions on completing and turning in
your results.
Critical Thinking
1. How would you, as the office manager, handle
someone who is spreading a harmful rumor about
REFERENCES/BIBLIOGRAPHY
another employee in the office? Colbert, B. J. (2000). Workplace readiness for health occupa-
2. How can the office manager promote open and tions. Clifton Park, NY: Delmar Cengage Learning.
honest communication? ingenix. (2003). HIPAA tool kit. Salt Lake City, UT:
3. The student practicum can be a stressful time for St. Anthony Publishing/Medicode.
the extern. As an office manager, how can you help Krager, D., & Krager, C. (2005). HIPAA for medical office per-
the extern feel more at ease the first day of “work”? sonnel. Clifton Park, NY: Delmar Cengage Learning.
The Medical Assistant Chapter

as Human Resources
Manager 34
KEY TERMS OUTLINE
Exit Interview Tasks Performed by the Human Orienting New Personnel
Involuntary Dismissal Resources Manager Dismissing Employees
Job Description The Office Policy Manual Exit Interview
Letter of Reference Recruiting and Hiring Office Maintaining Personnel Records
Personnel Complying with Personnel Laws
Letter of Resignation
Job Descriptions Special Policy Considerations
Overtime
Recruiting Temporary Employees
Probation
Preparing to Interview Smoking Policy
Applicants Discrimination
The Employment Interview Providing/Planning Employee
Selecting the Finalists Training and Education

OBJECTIVES
The student should strive to meet the following performance objectives and dem-
onstrate an understanding of the facts and principles presented in this chapter
through written and oral communication.

1. Define the key terms as presented in the glossary.

2. Describe the role of the human resources manager.
3. Explain the function of the office policy manual.
4. Identify methods of recruiting employees for a medical practice.
5. Discuss the interview process.
6. Identify items to keep in an employee’s personnel record.
7. List and define a minimum of four laws related to personnel
management.
8. Compare and contrast voluntary and involuntary separations.
9. Recall continuing education possibilities for employees.

1041
 Scenario
Jane O’Hara, CMA (AAMA), is the office manager at for a new medical assistant; welcome a new pro-
Inner City Health Care. She also functions in the role of vider to the practice, being sure she completes all
the human resources manager. Part of her responsibili- the necessary employment forms; and meet with
ties includes recruiting, hiring, and orienting employees. another staff member to evaluate her continuing
In one day Jane may meet with Dr. Rice to education.
update the policy manual; begin the hiring process

INTRODUCTION
The medical assistant’s employment responsibilities are climate in which there are too few persons for
many and varied. As you learned in Chapter 33, often the positions to be filled and the delivery meth-
they become office managers and assume a quite dif- ods for health care are changing almost daily,
ferent function in the medical setting. The size of the productivity, service, and quality are essential to
ambulatory care setting and the number of employees a successful practice. It becomes the responsibil-
likely determines if a human resources (HR) manager is ity of the HR manager to see that every employ-
a part of the practice. Whether the HR manager heads ee’s productivity level is high, that the service
an HR department in a large, corporate medical set- is A+, and that quality is at the highest level.
ting with the title Human Resources Manager or is a Today’s customers, the patients, often choose
medical assistant/office manager who serves as the HR their health care provider on the basis of service
representative, there are some common tasks assigned as and quality.
specific HR duties. The position of HR manager now requires
a higher level of education and experi-
ence to better grasp the legal and regula-
TASKS PERFORMED tory aspects of personnel management. The HR
BY THE HUMAN manager also must have excellent people skills, a
RESOURCES MANAGER
Tasks usually assigned to the HR manager include
Spotlight on Certification
determining job descriptions for, hiring, and ori-
RMA Content Outline
enting employees; maintaining employee person-
nel records that include credentials and continuing • Medical law
education units (CEUs); and managing employee • Medical ethics
separations. With today’s quest for greater office • Human relations
efficiency and the tremendous increase in fed- CMA (AAMA) Content Outline
eral and state regulatory requirements, the skills
required of an HR manager have greatly broad- • Basic principles (psychology)
ened. Former responsibilities have been expanded • Interview techniques
to include preparing the policy manual, schedul- • Medicolegal guidelines and
ing employee evaluations, preventing and investi- requirements
gating discrimination and harassment claims, and • Maintaining the physical plant
complying with regulatory agencies. The HR man- • Office policies and procedures
ager also assists in providing training and educa-
tional opportunities for employees so they are up CMAS Content Outline
to date in all aspects of quality patient care. • Legal and ethical considerations
Increasingly, HR managers are expected to • Professionalism
be able to support the organization’s efforts that • Human resources
focus on productivity, service, and quality. In a

1042
 CHAPTER 34 The Medical Assistant as Human Resources Manager 1043

strong sense of fairness, and the ability to resolve The policy manual identifies clear guidelines
conflicts. None of this is accomplished in a vac- and directions required of all employees. It also
uum. It requires working in close cooperation with defines appropriate expectations and boundaries of
the office manager and the employer(s). the employment relationship. Having written poli-
This chapter discusses these responsibilities in cies means not having to determine a policy on a
the following separate but overlapping functions: case-by-case basis. Policy manuals will vary by the
size of the practice or problems to be addressed, but
1. Creating and updating the office policy manual some topics include the mission statement of the
2. Recruiting and hiring office personnel practice, biographic data on each provider, employ-
3. Orienting new personnel ment policies, wage and salary policies, benefits to
4. Scheduling salary reviews be awarded, and employee conduct expectations.
Establishing and stating the mission of the
5. Conducting exit interviews practice clearly identifies the goals and objectives
6. Maintaining personnel records to be sought by each employee. Having biographic
7. Complying with all state and federal regulations data of each provider helps employees to respond
regarding personnel to queries from patients about a provider’s experi-
8. Planning/providing employee training and edu- ence, education, and interests.
cation Employment policies might include statements
on equal employment opportunity, job requirements
9. Maintaining records of credentials, licensure, cer- for particular positions and to whom the person
tifications, and CEUs such as cardiopulmonary reports, recruitment and selection procedures, ori-
resuscitation (CPR) entation of new employees, probation, and dismissal.
Wage and salary policies should be in writing. How
are employees classified, what are the working
THE OFFICE POLICY MANUAL hours, how is overtime compensated, how are sal-
ary increases determined, what benefits (medical,
The procedure manual described in Chapter 33 retirement, vacation, holidays, sick leave, profit shar-
identifies specific methods of performing tasks. ing) does the practice have? The answers to such
The policy manual provides more general guide- questions are part of the policy manual. Employee
lines for office practices (Table 34-1). conduct is another piece of the policy manual. A state-
ment regarding the confidentiality of all information
received in the practice is essential in this area of
Table 34-1 Possible Content of Policy the policy manual. Guidelines should be established
and Procedure Manuals about uniforms, dress codes, appearance, and per-
sonal hygiene. Can an employee hold a second job
Policy Manual Procedure Manual outside the practice? Is smoking allowed? Are staff
members responsible for housekeeping duties?
Details of procedures When the policy manual is computerized,
Mission statement
performed changes and updates are easily made (Figure 34-1).
Any changes made are to be shared with employees so
Employer(s) biographic Administrative proce- that everyone is up to date on policies. Having a policy
data dures manual with clearly written directives helps employ-
ees understand the expectations and boundaries of
Employment issues Clinical procedures the employment relationship. The policy manual is
reviewed with each new employee and updated on a
Wages, salaries, and Safety issues regular basis. Procedure 34-1 provides details on devel-
benefits
oping and maintaining a policy manual.
Employee conduct Asepsis
RECRUITING AND HIRING
Material Safety Data
Confidentiality guidelines
Sheets OFFICE PERSONNEL
HIPAA compliance Emergency protocol The majority of employees in the ambulatory
care center are full-time, part-time, or occasional
1044 UNIT 8 Office and Human Resources Management

expanded office, a complete set of job descrip-

ELECTRONIC tions is needed before recruiting can begin. Even

when a written description is on file, it should be
reviewed when a new employee is to be hired. The
RECORDS person who is leaving the position is often an excel-
lent resource for the accuracy of the current job
Financial & Billing Reports description and any changes that should be made.
Staffing Requirements and Reports The job description must include basic
Equipment & Supply Requests
qualifications for the position and have enough
information to provide both the supervisor and
Personnel Data the employee with a clear outline of what the job
Payroll entails (Figure 34-2). Necessary work experience,
Approved Vendors
Incident Reports skills, education, and any special certification or
Collections Policies licensure that is expected is to be identified in the
Inventory Received
job description. Procedure 34-2 provides details on
OFFICE MANAGER & preparing job descriptions.
HUMAN RESOURCES Another important point with respect to the
job description is that a review and update of the
description should be done every year. Most jobs
change constantly whether from a minor shift-
Receiving Hiring
ing of duties or the addition of some new techni-
Purchasing cal procedure or device. Without updating a job
description, a person with the wrong qualifications
Figure 34-1 A total practice management system may be recruited to fill a vacancy.
(TPMS) includes management and human resources
functions.
Recruiting
independent contracted employees. Full-time A major challenge facing the HR manager today
employees generally work 30 hours or more per is recruitment. Medical assistants are listed in
week; part-time employees work less than 30 hours the top 10 occupations with employment growth
per week. Either may be paid by the hour. Full-time much faster than average through 2014 according
employees may be salaried and are exempt from to the U.S. Department of Labor, Bureau of Labor
overtime regulations. Most part-time employees Statistics. One reason for this demand is the aging
are paid by the hour. Benefits are often different of the U.S. population. It is estimated that more
between full- and part-time employees. Indepen- than 80% of jobs are in the service industry, and all
dent contractors usually work with the facility to health care positions fit into that category. When
perform specific predetermined tasks at a prede- employers have been unsuccessful in recruiting
termined rate of pay for the services provided. qualified medical assistants, they have turned to
Before recruiting and hiring personnel to fill contracting out some work, such as transcription
positions within the medical facility, the HR man- and billing.
ager and employers must understand exactly what Once the hiring need is determined, the HR
the role and responsibilities of the position are by manager begins the recruitment process. Often
having a current job description for the position and a process called networking is a highly effective
following a recruiting policy that is effective, fair, and
observes all appropriate laws and regulations.

Job Descriptions Critical Thinking

Before any position is filled, a job description must be Identify proper qualifications for an
in place. This usually is created cooperatively by the administrative medical assistant in a fairly
office manager and the employer(s). Once the job large ambulatory care setting. Determine
qualifications are defined, the lead personnel and what work experience might qualify versus
HR manager can begin efforts to fill the position. what work experience is preferred. Would
In daily operations most job descriptions are certification be helpful? Explain.
on file, but if the situation involves a new or greatly
 CHAPTER 34 The Medical Assistant as Human Resources Manager 1045

JOB DESCRIPTION Critical Thinking

POSITION TITLE:
Administrative Medical Assistant Is there ever a time when providers are con-
REPORTS TO: sidered recruiters for their medical practice’s
Office Manager and Provider–Employer(s) personnel? When and how?
RESPONSIBILITIES AND DUTIES:
• Being a therapeutic and helpful receptionist
1. Answer telephone as quickly as possible, hopefully Checking with nearby colleges’ medical assis-
by the second ring tant departments is another good resource.
2. Greet all patients warmly and with a helpful attitude Employing a private or state placement agency is
• Manage time efficiently with appropriate scheduling another possibility. Although newspaper advertise-
for patients and professional staff ments may generate many résumés, they are only
1. Schedule patients according to their needs, marginally effective as a search tool. It is often far
scheduling guidelines, staff availability, and equip- too time consuming to review the large volume of
ment readiness applications generated by this approach. Online
2. Call to remind patients of their visit the day before options may be beneficial. There are a number of
appointment medical employment Internet sites that identify
• Responding to patient requests on the telephone and in positions for medical assistant personnel, often in
person specific localities.
1. Ascertain reason for request
2. Satisfy patient request or refer patient to one who
can Preparing to Interview Applicants
• Preparing patient charts for professional staff
1. Print schedules and encounter forms Once several applicants have expressed interest in
2. Pull patient charts late afternoon the day before the position, preparation for the interview begins.
appointment; print as necessary The HR manager should have a number of résu-
3. Check charts for completeness més to consider. Some may have already filled out
4. Attach encounter form when patient arrives to a job application when they dropped off a résumé.
check in The résumés and applications can be reviewed
together. Some important points to remember in
AUTHORITY BOUNDARIES: reading résumés and applications follow.
The office manager will assist in answering questions. When considering education, look beyond
Remember that it is better to ask than to make an error. the degree earned. Look for a good performance
Screening concerns not identified in a policy/procedure manual record at school and the kinds of supplemental
also can be directed to the clinical medical assisting staff. education achieved. Does attendance at seminars
POSITION REQUIREMENTS: and short-course training programs relate to your
Two years experience and/or graduate of a medical assis- position needs? When reading a person’s work his-
tant program. CMA (AAMA), RMA, or CMAS preferred. tory, make note of unexplained gaps in employ-
ment. You may want to ask specific questions in
Figure 34-2 Sample job description for administra- the interview. Has advancement been gained in
tive medical assistant. each new position? Are the responsibilities and
duties of the applicant’s positions explained, or
will questions need to be asked of the prospective
employee?
method of finding employees. Networking is a pro- Look for information that indicates if this
cess in which people of similar interests exchange candidate really enjoys the kind of work setting
information in social, business, or pro- you have. Is the applicant comfortable serving the
fessional relationships. For instance, the infirm? Can you truly identify the level of skill from
HR manager may network with members the descriptions, or are the skills vague? The cover
of the American Association of Medical Assistants letter, if one is included, should address the spe-
and express an interest in a new employee for an cifics required of your position. Does the person
open position. Current employees are often an display a negative or a positive attitude? Do not
excellent resource because they may know of a excuse any errors or unprofessional appearance in
qualified person who is looking for a position. the job application or the résumé. Each should be
1046 UNIT 8 Office and Human Resources Management

letter perfect. An individual who is careless in this Suggested items for the interview worksheet
respect is likely to be careless on the job. are:
Some applications will be discarded when
• Applicant’s name
compared to the preceding guidelines. With the
remaining candidates, determine who is to be • Telephone number
interviewed and make telephone calls to estab- • Education and training
lish interviews. You may make note of the quality • Work experience
of speaking skills, especially if this person will be
• Special skills
using the telephone on the job. Make an interview
appointment date with only those who seem truly • Professional demeanor
interested in the position during your telephone • Voice and mannerisms specific to position
conversation. • Questions and responses
• Ability to problem solve when given a scenario
The Employment Interview • Any health-related or work-related problems appli-
The employment interview is usually conducted cant discloses
by only one person if second interviews are antici- • Interviewer’s personal impressions and recom-
pated. The provider–employer, office manager, mendations
or another employee may be present in either
the first or the second interview, however (Figure Conduct interviews in a quiet and private set-
34-3). The interviewer(s) will want to review the ting. Do not schedule interviews back to back with-
application and résumé before the interview for out time to collect your thoughts or to allow you
particular points to ask the candidate. Before the to compare notes with others participating in the
interview, those doing the interviews should estab- interview. Ask job-related questions. For example,
lish a set of questions for the applicants. These Describe your last job. What did you like best about
predetermined questions will help alleviate one it? What did you like least? What is most important
applicant being given privileges over another and to you about a job? Describe your administrative
will help ensure continuity throughout all the and clinical skills. Figure 34-4 shows some sample
interviews. An interview worksheet is an excellent questions. Let the applicant do the most of the
tool to use to make certain that you are fair and talking.
equitable with each candidate. The worksheet Any questions related to age, sex, race,
should provide enough room for notes taken dur- religion, or national origin are inappropri-
ing the interview. ate. Inquiries about medical history,
drug use, or arrest records may not be made (see
Chapter 7). Keep your questions related to per-
formance on the job. If you may want to bond this
employee, you may ask candidates if they have
been bonded before or are willing to be bonded. It
may be best to leave salary discussions for a second
interview, but it can also be helpful to determine
if applicants’ salary expectations are in line with
what you can offer. A question such as “What salary
are you expecting?” is appropriate. Do not make a
job offer until all the candidates selected for inter-
view have been interviewed, and do not prejudge
someone on any factor during or after the inter-
view, except the person’s qualifications.
At the close of the interview, let the applicant
know when a decision will be made or whether a
second interview will be conducted and how notifi-
cation will be made. A tour of the facility and intro-
Figure 34-3 The interview can be conducted on a duction to key staff members may be offered but
one-to-one basis with only the applicant and one staff are not necessary at the time of the first interview.
member or with several staff members meeting with the Finally, thank the applicant for participating in the
applicant at once. interview and being interested in the position.
 CHAPTER 34 The Medical Assistant as Human Resources Manager 1047

General Questions TELEPHONE REFERENCE

• What are your strengths and weaknesses? Name of Applicant ___________________________
• Why did you leave your last job?
• Identify what is most important to you in a job. Person Contacted ____________________________
Position and Name of Business _________________
Questions Related to Work Relationships
• Describe an individual you have enjoyed working with. _________________________________________________
• Explain how a conflict with a coworker was resolved. Telephone Number ___________________________
• How would a coworker describe you? Relationship to Applicant ______________________
Questions Related to Problem Solving • May I verify the employment history of (applicant’s name)
• Describe a work-related decision that made you very who is applying for a position with our medical clinic?
proud. ____________, 20____ to ____________, 20____
• Identify a task/procedure/assignment you could not do,
and explain why. • Describe the responsibilities held by this individual.
• How do you approach a task when it seems mundane or
boring? • Identify the salary ___________________________
Questions Related to Integrity
• If asked to do something you believe is illegal or unethical, • What are this individual’s strong points?
what would you do?
• Tell us about a time when you broke a confidence. • What are this individual’s weak points?
• If you saw a coworker put a patient at risk, what would
you do? • Describe this individual’s overall attitude toward the job
and toward patients.
Figure 34-4 Common interview questions.
• Please comment on dependability and attendance.

Selecting the Finalists • Given the opportunity, would you rehire? Why or why
Shortly after the final interview is completed, the not?
HR manager should compare notes with all the
others involved in the interviews to select the top • Why did this individual leave the job?
candidates. This is done by comparing notes and
impressions from the interviews and by taking • Describe personal and professional growth this indi-
into consideration the ability of a candidate to vidual made while in your firm.
work with patients and colleagues who might have
a variety of problems and cultural backgrounds.
The next step is to check references from former • Is there anything else you would like to tell us?
employers, supervisors, coworkers, and instructors.
A large corporate medical practice may even have Reference call made by ________________________
a consent form each candidate is asked to sign that Date ______________________
gives permission to check references and call for-
mer employers and instructors. You may need to
recognize, however, that even with a release from Figure 34-5 Sample form to use for telephone
a potential new employee, many organizations references.
and businesses restrict the release of reference
information to only name, dates of employment,
and title of position served. Telephone checks for assessment of the candidate. All reference informa-
references are an excellent strategy before you tion is to be kept confidential. A sample telephone
receive an immediate response. If you stress con- reference check form is shown in Figure 34-5.
fidentiality when you make the contact, it will be A checklist of questions to ask might include:
easier for the person to respond to your questions.
When possible, always check with more than one 1. What were the dates of employment of (name of
reference and former employer to get an accurate applicant) in your firm?
1048 UNIT 8 Office and Human Resources Management

2. Describe the job performed. staff members, assigning a mentor who can
3. Reason for leaving the job? respond to questions, and making the employee
aware of the procedures to be performed in this
4. Strong points of the employee? new position. If the procedure manual is detailed
5. Limitations of the employee? and accurate, this manual now becomes the daily
6. Can you comment on attendance and depend- guide for the new employee. Sometimes the indi-
ability? vidual leaving a position may still be present and
7. Would you rehire? is asked to assist in the orientation process. This
is especially beneficial if there is a good working
8. Anything else we should know about this candi- relationship between the employee who is leaving
date? and the management of the practice. Depend-
ing on the responsibilities of the new employee,
Offer the position when a first-choice can- a supervisor may be asked to monitor all proce-
didate has been determined and indicate when a dures for a period for accuracy, safety, and patient
response is needed. Be prepared with a second- protection. During the probation period, the
choice candidate should the preferred candidate employee should be officially evaluated by the
respond negatively. At the time of the offer, the office manager.
candidate should understand the salary offered,
the starting date, the practice policies, and the
benefits. When a candidate has accepted the posi-
tion, a confirmation letter should be written that
DISMISSING EMPLOYEES
clearly spells out details discussed earlier. Give
The function of employee dismissal or separation
specific instructions on when and where the new
falls mostly to the office manager; however, in a
employee should report the first day on the job. If
large facility with an HR representative, discuss-
practical, the employee should be given the policy
ing dismissal or separation with that individual can
and procedure manuals to read. Employers are
be quite beneficial. Such a discussion ensures that
required by federal law to verify that all employees
all the information necessary is in place before a
are authorized to work. This is done by having the
separation. There are voluntary and involuntary
candidate complete an Eligibility Verification (I-9)
dismissals or separations.
form (see Case Study 34-2).
Voluntary separations usually occur when an
For the unsuccessful applicants, send a letter
employee is relocating, advancing to another posi-
explaining that “we have selected another candi-
tion elsewhere, retiring, or leaving for personal
date whose qualifications and experience more
reasons. A letter of resignation is usually submit-
closely meet our needs at this time. We would like
ted to both the office manager and the HR repre-
to keep your résumé on file should another suit-
sentative. These employees will give their manager
able position become available.” Copies of these
proper notice and may be able to turn current proj-
letters, as well as the interview checklists, should be
ects and duties over to their replacement. There is
kept for a minimum of 6 months should any ques-
also time to say good-bye to their colleagues and
tions arise regarding your choice of candidates.
have a good feeling about their employment.
Procedure 34-3 provides details on interviewing.
Involuntary dismissals or separations usually
occur when an employee’s performance is poor
or there has been a serious violation of the office
ORIENTING NEW PERSONNEL policies or job description. The office manager is
aware of poor performance through the proba-
Orienting new employees is usually the responsibil- tionary reviews. Verbal and written warnings must
ity of both the office manager and lead personnel be given to the employee and are to be well docu-
who are most likely to work the closest with the new mented. Dismissal can be immediate if there is a
employee. It is common for a new employee to be serious breach of office policy. The HR director
placed on probation for 60 to 90 days, during which can provide necessary detail to the office man-
time both the employee and supervisory personnel ager regarding when and if immediate dismissal is
may determine if the environment and the position recommended. If an office manager expects any
are satisfactory for the employee. Procedure 34-4 serious difficulties with an employee during an
outlines how to orient personnel. immediate dismissal, the HR director should be
Important elements to orientation include present when the employee is notified. (see Chap-
the introduction of the new employee to other ter 33 for a more detailed discussion).
 CHAPTER 34 The Medical Assistant as Human Resources Manager 1049

Exit Interview Employers should always be informed of

any dismissal as quickly as possible. Some may be
An exit interview is an excellent opportunity for
involved in the actual dismissal process.
the employee who voluntarily leaves a practice and
the HR manager to discuss the positive and nega-
tive aspects of the job and what changes might be MAINTAINING
made for a new person coming into the facility. A
sample exit interview form is shown in Figure 34-6. PERSONNEL RECORDS
It also allows the opportunity for the employee to
ask for a letter of reference or to view the personnel An important aspect of the responsibilities of the
file before leaving. In a voluntary dismissal, a letter HR manager is maintaining personnel records.
of resignation for the personnel file is necessary. All documentation and correspondence related to
Any dismissal process, voluntary or involun- each employee from application to dismissal, from
tary, must include a statement in the personnel awards to reprimands including the for-
file. For involuntary dismissal, be certain that the mal reviews, must be kept in the confiden-
reasons for the dismissal are well documented in tial personnel file. Access to this file
an honest, nonjudgmental statement. State only is limited to certain management personnel and
the facts in the personnel file; do not state opin- the employee. Not all of these people are allowed
ion. Remember that employees have the right to to see the entire file. These files are usually kept
view their personnel file at any time. for a period of 3 to 5 years after employees leave
the practice. Some of the personnel files may be
maintained electronically on the computer. How-
ever, access to those files must be protected so that
EXIT INTERVIEW FORM only those with authorized access are able to open
1. What did you like and dislike about the work you have the files or make changes to them.
been doing? This file also includes the kind of informa-
(Including: support on the job; opportunity for per- tion normally maintained for payroll and busi-
sonal growth; recognition and rewards) ness practices. That information includes name,
address, and sex of employee. The position
2. What kind of people have you found the providers, your title, date of beginning employment, rate of pay
immediate supervisor, and co-workers to be? (hourly or otherwise), total overtime pay, deduc-
(Including: attitude; fairness; scheduling and assign- tions or additions to wages, wages paid each pay
ment of work; work expectations; technical com- period, and date employee leaves the practice
petence; assistance and guidance available; team also are included.
spirit)
3. What is your view of our management practices and
policies? COMPLYING WITH
(Including: clarity and fairness of practice policies; PERSONNEL LAWS
communications; management and staff)
4. How have you felt about performance appraisals, your This text is not meant to be a legal guide
salary and benefits? for an HR manager. The practice attorney
(Including: adequacy of salary; regularity and fair- should always be contacted if there
ness of appraisals) is any question regarding personnel laws, which
may vary in some states depending on the size
5. What are your principal reasons for leaving the practice? of the practice. Only a brief introduction of the
(Including: primary dissatisfactions; job or personal laws related to the ambulatory care setting are
changes) given.
6. In what areas do you feel we need to improve? Overtime must be addressed in each prac-
Interviewer signature: ______________ Date ________ tice. Who is reimbursed for overtime and how
is that reimbursement determined? Typically,
Employee signature: _______________ Date ________ administrative medical assistants, insurance bill-
ers, medical transcriptionists, and clinical medical
Figure 34-6 Sample exit interview form. (From assistants are likely to be paid overtime. Overtime
Ricardo, M. (1992). Personnel management handbook pay at a rate of not less than one and one-half
[2nd ed.]. New York: The McGraw-Hill Companies, times the regular rate of pay after a 40-hour work
Inc. Copyright 1992. Reprinted with permission.) week is standard. Each week stands alone and
1050 UNIT 8 Office and Human Resources Management

one week cannot compensate for another. If the SPECIAL POLICY

practice does not want to be involved in overtime CONSIDERATIONS
situations, require that any overtime be preautho-
rized in advance. Several other managerial issues may arise in a med-
The Equal Pay Act of 1963 prevents wage dis- ical setting for which the office manager and the
crimination for jobs that require equal skill, effort, HR manager will have to plan. These can include
and responsibility. The Civil Rights Act of 1964 policies for temporary employees, rules of conduct,
prevents employers from discriminating against avoiding discrimination, and having a support sys-
individuals on the basis of race, color, religion, sex, tem in place for employees who need physical or
age, or national origin (see Chapter 7). emotional help.
Sexual harassment violates Title VII of the
Civil Rights Act. Steps must be taken to ensure
that all employees are working in an atmo- Temporary Employees
sphere that is not hostile, where sexual gestures, Temporary employees who may be employed for
the presence of pornographic or offensive mate- 90 days or less include students who are serving an
rials, or obscene language are not allowed (see internship or externship from a local college prac-
Chapter 7). ticing their skills for when they will be on the job.
Employees have a right to expect safe working They should be reviewed on a regular basis in coop-
conditions. The Occupational Safety and Health eration with their college supervisor. Give them as
Act (OSHA) was established to prevent injuries much actual hands-on experience as possible; they
and illnesses resulting from unsafe or unhealthy are future employees. Accommodating students
working conditions (see Chapter 10 for detailed in the practice is a two-way benefit. Students learn
discussion of the standards and requirements, what reality is in the ambulatory care setting and
especially the section on bloodborne pathogens, are able to practice newly developed skills. Cur-
which went into effect in 1992.) Compliance with rent staff members in the facility are “sharpened”
this law requires that each employee be aware of by the students’ presence. Teaching and monitor-
possible risks associated with chemical hazards and ing someone’s actions always results in sharpening
how to protect themselves. Because there are many and rethinking the skills of the current staff. Many
of these hazards in a medical practice, compli- HR directors and managers depend on these pro-
ance and protection for employees are extremely grams for future job applicants.
important, and training sessions should be held in
this area.
The Immigration Reform Act requires Smoking Policy
employers to verify the right of employees to work Smoking on the premises, especially a health
in the United States. Documentation acceptable care facility, is a concern. Many places of employ-
for verification is a Social Security card or birth ment do not allow smoking at all. Additionally,
certificate. The U.S. Department of Justice Immi- some states and cities have laws that govern this
gration and Naturalization Service will provide issue. When a policy is established, it should cover
instructions and a form for employees and employ- everyone—employers, employees, and patients.
ers to complete, commonly referred to as the I-9 or The objective is to have a policy that is workable
Employment Eligibility Verification form. and enforceable, promotes health, encourages
Employers cannot discriminate against or con- employee morale and productivity, and sets exam-
demn any full-time employee for jury duty. Although ples for patients.
the employer does not have to continue pay during
jury duty, the employee cannot lose seniority, insur-
ance, or other benefits. Many employers continue
Discrimination
an employee’s full pay during the time of service on The Americans with Disabilities Act (ADA)
a jury because the reimbursement for jury service prohibits discrimination by all private
is minimal. This is a way to benefit employees and employers with 15 or more employees.
encourage good citizenship. Some states may further prohibit discrimination
This list is by no means comprehensive but in facilities regardless of the size of their work-
does include personnel regulations most likely to force. All public entities are prohibited from
affect the medical practice. Any concerns should discrimination against qualified individuals with
be directed to the practice’s attorney. disabilities. The ADA establishes guidelines pro-
 CHAPTER 34 The Medical Assistant as Human Resources Manager 1051

hibiting discrimination against a “qualified indi- that employees receive a continuing and constant
vidual with a disability” in regard to employment. update in their area of employment.
Someone with a disability who satisfies the skills Training and education may be accomplished
necessary for the job; has the experience, educa- within the practice or outside the practice. When
tion, and any other job requirements; and who, an employee is a member of a professional organi-
with reasonable accommodation, can perform zation such as the American Association of Medical
the job cannot be discriminated against. Employ- Assistants, many monthly meetings include con-
ers often find that persons with disabilities are tinuing education opportunities. Numerous semi-
their finest employees. nars and conferences held throughout the country
Persons who are HIV-positive or have AIDS may be beneficial to employees. Local hospitals
are included in the guidelines set forth by the often have continuing education opportunities
ADA. Persons with HIV/AIDS cannot be discrimi- that may be beneficial. Managers will keep abreast
nated against. It can be assumed that if a safe work- of these opportunities and encourage employees
ing environment is provided when all employees to attend. Any continuing education opportunity
follow the rules for Standard Precautions; then that may benefit the employee on the job and
reasonable accommodation has been made for the the medical practice itself should ideally be paid
person with HIV or AIDS. for by the employer(s). Credentialed employees
An employer cannot refuse the job to a qual- will always need to update skills and earn CEUs
ified person based on the belief that in the future to maintain their credentials in active status. An
the employee may become too ill to work. The important function of HR is to make CEU oppor-
hiring decision must be based on the individual’s tunities available to employees.
ability to perform the functions of the position at It is often best to provide training and educa-
the present time. If a current employee reveals tion within the facility when the training necessary
to the manager that he or she is HIV positive or is specific to the medical practice. For instance,
has AIDS, that information must be kept confi- training on new computer software is apt to be spe-
dential and must be kept apart from the general cific to the particular setting. When sophisticated
personnel file. The manager may choose to hold new equipment is purchased, companies often
a discussion at that time of what accommodations provide in-house training for the individuals who
might be needed in the future. will be using the equipment. Take advantage of as
many of those opportunities as are available and
PROVIDING/PLANNING for as many of your employees as possible. When
the training is quite expensive or time consum-
EMPLOYEE TRAINING ing, make certain one person receives the training.
AND EDUCATION Then have that individual train others. Whenever
possible, provide training outside of regular hours
Health care changes daily; new procedures are when patients are not being seen—before the
established, a better technique is discovered for office opens or after the office closes or during a
performing a particular task. Major changes reg- lunch period. Always pay employees for any time
ularly occur in medical insurance. Computer sys- served over their regular working hours. Offer cer-
tems are updated or new software is added. A more tificates for any inservices.
sophisticated telephone system is installed to make Careful attention to continuing education
certain patients are responded to promptly. New and training for employees will pay for itself many
state or federal regulations mandate additional times over again. The more confident and secure
training or compliance in safety. New medications employees feel in the skills they are expected to
become available that providers may prescribe perform, the more satisfied the practice’s patients
and employees must understand. All this demands will be.
1052 UNIT 8 Office and Human Resources Management

Procedure 34-1
Develop and Maintain a Policy Manual
PURPOSE: 2. Identify procedures for reimbursing overtime,
To develop and maintain a comprehensive, up- preventing discrimination and harassment, cre-
to-date policy manual of all office policies relating ating a safe working environment, and allowing
to employee practices, benefits, office conduct, and for jury duty.
so on. 3. Include a policy statement related to rules of
conduct.
EQUIPMENT/SUPPLIES:
Computer 4. Identify steps to follow should an employee be-
Binder, such as a three-ring come disabled during employment.
Paper 5. Determine what employee opportunities for
Standard policy manual format continuing education, if any, will be reimbursed;
include requirements for recertification or licen-
PROCEDURE STEPS: sure.
1. Develop precise, written office policies detailing
all necessary information pertaining to the staff 6. Provide a copy of the policy manual for each
and their positions. The information should employee. RATIONALE: Each employee is made
include benefits, vacation, sick leave, hours, dress aware of facility policies.
codes, evaluations, rules of conduct, and grounds 7. Review and update the policy manual regularly.
for dismissal. RATIONALE: Well-defined policies Add or delete items as necessary, dating each
clearly outlined for each employee are necessary revised page. RATIONALE: Policy manual will
for efficient and effective staff operations. always be current.

Procedure 34-2
Prepare a Job Description
PURPOSE: 2. List special medical, technical, or clerical skills
To provide a precise definition of the tasks assigned to a required.
job, to determine the expectations and level of compe- 3. Determine the level of education, training, and
tency required, and to specify the experience, training, experience required for the position.
and education needed to perform the job for purposes
4. Determine where the job fits in the overall struc-
of recruiting and performance evaluation.
ture of the practice.
EQUIPMENT/SUPPLIES: 5. Specify any unusual working conditions (hours,
Computer locations, and so on) that may apply.
Paper 6. Describe career path opportunities.
Standard job description format

PROCEDURE STEPS:
1. Detail each task that creates the job. RATIO-
NALE: A detailed job description identifies clear
expectations for each employee.
 CHAPTER 34 The Medical Assistant as Human Resources Manager 1053

Procedure 34-3
Conduct Interviews
PURPOSE: 9. Ask questions about the applicant’s work expe-
To screen applicants for training, experience, and rience and educational background using the
characteristics to select the best candidate to fill the résumé and interview worksheet as a guide.
position vacancy. 10. Provide the most promising applicants addi-
tional information on benefits and a tour of the
PROCEDURE STEPS: office if practical.
1. Review résumés and applications received.
11. Applicant’s general salary requirements may be
2. Select candidates who most closely match the
discussed, but avoid discussion of a specific sal-
education and experience being sought.
ary until a formal offer is tendered.
3. Create an interview worksheet for each candi-
12. Inform the applicants when a decision will be
date listing points to cover.
made and thank each for participating in the
4. Select an interview team; this team should always interview.
include the HR or office manager and the imme-
13. Do not make a job offer until all the candidates
diate supervisor to whom the candidate will
have been interviewed.
report.
14. Check references of all prospective employees.
5. Call personally to schedule interviews. RATIO-
NALE: This allows you to judge the applicant’s 15. Establish a second interview between the pro-
telephone manners and voice. vider–employer(s) and the qualified candidate if
necessary.
6. Remind the interviewers of various legal restric-
tions concerning questions to be asked. 16. Confirm accepted job offers in writing, specify-
ing details of the offer and acceptance. RATIO-
7. Conduct interviews in a private, quiet setting.
NALE: Written document provides proof of
RATIONALE: Careful interviewing of potential
hiring and employment details.
employees is an important step in hiring the best
candidate for the position. 17. Notify all unsuccessful applicants by letter when
the position has been filled. RATIONALE:
8. Put the applicant at ease by beginning with an
Makes a positive statement to those not hired
overview about the practice and staff, briefly
and keeps the doors open for future employ-
describing the job, and answering preliminary
ment possibilities.
questions.

Procedure 34-4
Orient Personnel
PURPOSE: 2. Complete employee-related documents and ex-
To acquaint new employees with office policies, staff, plain their purpose.
what the job encompasses, procedures to be per- 3. Explain the benefits programs.
formed, and job performance expectations.
4. Present the office policy manual and discuss its
PROCEDURE STEPS: key elements.
1. Tour the facilities and introduce the office 5. Review federal and state regulatory precautions
staff. for medical facilities.

continues
1054 UNIT 8 Office and Human Resources Management

Procedure 34-4 (continued)

6. Review the job description. 9. Assign a mentor from the staff to help with the
7. Explain and demonstrate procedures to be per- orientation. RATIONALE: Without proper ori-
formed and the use of procedure manuals sup- entation and training, the best new employee
porting these procedures. can fail.
8. Demonstrate the use of any specialized equipment.

Case Study 34-1

Refer to the scenario at the beginning of the chapter. CASE STUDY REVIEW
It is sometimes difficult for Jane O’Hara to complete
her responsibilities as both the office manager and the 1. What steps might Jane take to manage her many
human resources manager. and time-consuming tasks comfortably?
2. What responsibilities, if any, that normally fall to the
human resources manager could be assigned to
other staff members?

Case Study 34-2

Daly Jacobsen, RMA, is an administrative medical assistant CASE STUDY REVIEW
at Inner City Health Care. The HR manager has suggested
that she might expand her skills and learn some of the proce- 1. Daly knows that the I-9 is a government form veri-
dures in the hiring process. A new medical assistant who spe- fying employment eligibility. What keywords might
cializes in nutrition is coming on board. Daly has been asked she use in her Internet search to find the form?
to make certain the I-9 form is completed appropriately. The 2. Once the form has been located, identify the spe-
HR manager tells Daly that she will need to download the lat- cific rules necessary in completion of the form.
est form before completion. What document in List A might a number of pro-
spective employees likely have?
3. In what area of the office might you post the lists of
acceptable documents for the I-9 form?
4. With what agency is the form filed on successful
completion?

Case Study 34-3

Charles Kensington has just been hired as the HR manager in a CASE STUDY REVIEW
large metropolitan clinic. In studying the policy manual, he notes
that there is no defined policy for sick leave or bereavement 1. To whom should he speak regarding what currently
leave. Describe the steps he might take to write such a policy. occurs when an employee is ill or when there is a
death in the family?
2. What might Charles consider in writing this policy?
3. How should a policy be approved once it is written?
4. What parameters would you suggest for the policy?
 CHAPTER 34 The Medical Assistant as Human Resources Manager 1055

SUMMARY
As shown in this discussion, HR management is a challenge. It is, however, a rewarding one. While provider–
employers are responsible for patients’ physical care, the management team is responsible for hiring and
maintaining the employees in the organization. The HR manager who is successful will hire the right peo-
ple for the jobs and monitor employees in a way that enables and encourages them to give the best patient
care possible. The medical assistant who has good communication skills and acquires additional training in
HR management will always have variety on the job and will have the satisfaction of watching a health care
team run smoothly and efficiently.

STUDY FOR SUCCESS

To reinforce your knowledge and skills of information presented in this chapter:
• Review the Key Terms
• Practice the Procedures
• Consider the Case Studies and discuss your conclusions
• Answer the Review Questions

° Multiple Choice
° Critical Thinking
• Navigate the Internet and complete the Web Activities
• Practice the StudyWARE activities on the textbook CD
• Apply your knowledge in the Student Workbook activities
• Complete the Web Tutor sections

REVIEW QUESTIONS
Multiple Choice 4. Overtime hours in the medical facility:
1. HR managers: a. are to be expected as part of the job
a. need no special training for the job b. do not require prior authorization
b. are responsible for hiring and orienting personnel c. are usually paid at no less than one and one-half
c. often work longer hours than other employees times the regular pay rate
d. both b and c d. are paid only to managers
2. The following questions may be asked in an inter- 5. The HR manager will work closely with:
view: a. the provider–employer(s)
a. How old are you? b. the office manager
b. Have you ever been arrested? c. all employees
c. Can you supply a birth certificate or a Social d. all of the above
Security card? 6. OSHA:
d. Do you plan to start a family soon? a. requires employers to verify an employee’s right
3. When a candidate has been accepted for a position, to work in the United States
the HR manager should: b. protects employees who have disabilities from
a. call the candidate to determine what salary is employment discrimination
preferred c. protects employees with chemical dependencies
b. write a letter defining the position details or emotional problems
c. check references listed by the candidate d. protects employees from unsafe or unhealthy
d. notify patients of a staff change working conditions
1056 UNIT 8 Office and Human Resources Management

7. The best area for hiring medical employees comes C stands for “change.” What would you recommend
from: we change? Discuss the merits of both forms for an
a. students in a business college exit interview.
b. newspaper advertisements 4. Do a simple comparison of salaries in your com-
c. networking sources munity. Compare the hourly wages of a secretary,
d. the state’s unemployment office a medical assistant, a plumber, your automobile
8. Employees receiving training or education neces- mechanic, and a person working in a fast-food
sary to the job: restaurant. How might you use this material when
a. will seek that training after hours and not expect seeking salary increases?
reimbursement 5. What might employers and HR managers do to
b. will be current and up to date in the health care make certain they keep valued employees? Is salary
field really the most important issue?
c. should always be paid for any time served over
regular working hours
d. both b and c
WEB ACTIVITIES
9. Personnel records: 1. Research the Centers for Medicare &
a. are usually kept for 3 to 5 years after employ- Medicaid Services Web site (http://www.
ment ends and may include payroll data cms.hhs.gov) for information related to
b. are not available for everyone to view and must the prohibition of discrimination on the basis of
be kept confidential sexual orientation. What do you find? Are there
c. include all papers related to employment and other sources on this subject that are helpful? Can
personal data the manager choose not to hire a person who is
d. all of the above otherwise qualified on the basis that he or she is
10. Dismissal: gay? Why or why not?
a. may be voluntary or involuntary 2. “NOLO Law for All” has a helpful Web site with
b. should always be documented many topics in their directory. Research the area
c. is a good time for an exit interview related to personnel policies and practices. What
d. all of the above suggestions do they make for establishing goals and
standards for employee evaluations? Do they iden-
Critical Thinking tify any helpful evaluation tips? If so, outline them
1. You have just accepted a position to work in a for your instructor.
larger, more specialized clinic where you will be 3. Research the ADA Web site to determine if there
able to use skills you are not currently able to exer- are any examples of accommodations made in
cise. Identify two or three main points for a letter of the medical setting. If yes, describe them. Are all
resignation you will prepare. provider–employers covered by the ADA? If not,
2. An employee approaches you, the HR manager, how might discrimination be prevented?
identifying that he or she has just become responsi-
ble for the care of an aging parent and may require
occasional time away from work. You have no policy
REFERENCES/BIBLIOGRAPHY
about how this absence should be treated. What Fallon, Jr., F. L. (2007). Human resource management in
kind of policy might be helpful? Where would you health care: Principles and practice. Bowling Green,
look for suggestions? OH: Bowling Green State University.
3. An exit interview form has been introduced in this Mathis, R. L., & Jackson, J. H. (2004). Healthcare human
chapter. Another simple form for an exit interview resource management (10th ed.). Cincinnati, OH:
is to use the ABCs. A stands for “awesome.” What South-Western College Publishing.
do we do that is awesome? B stands for “better.” McWay, D. C. (2008). Today’s health information manage-
What could we do better in our organization? ment. Clifton Park, NY: Delmar Cengage Learning.
 UNIT
Entry into the
Profession 9
Chapter 35
Preparing for Medical Assisting
Credentials
Chapter 36
Employment Strategies
Chapter
Preparing for Medical
35 Assisting Credentials

OUTLINE KEY TERMS

Purpose of Certification National Healthcareer Accrediting Bureau
Certification Agencies Association (NHA) of Health Education
Preparing for Certification Exam- Certified Clinical Medical Schools (ABHES)
inations Assistant and Certified American Association
Medical Administrative of Medical Assis-
American Association of Medical tants (AAMA)
Assistants (AAMA) Assistant Examination
Format and Content American Medical
Certified Medical Assistant Technologists
(AAMA) Examination Certified Clinical Medical
(AMT)
Format and Content Assistant and Certified
Medical Administrative Certification
Certified Medical Assistant Examination
(AAMA) Application Process Assistant Application
Process Certified Clinical
Certified Medical Assistant Medical Assistant
(AAMA) Examination Certified Clinical Medical (CCMA)
Scheduling and Assistant and Certified
Certified Medical
Administration Medical Administrative Administrative
Certified Medical Assistant Assistant Examination Assistant (CMAA)
(AAMA) Recertification Scheduling and
Certified Medical
Administration Administrative
American Medical Technologists
(AMT) Certified Clinical Medical Specialist (CMAS)
Assistant and Certified Certified Medical
Registered Medical Assistant
Medical Administrative Assistant (CMA
(RMA) Examination Format
Assistant Recertification [AAMA])
and Content
Professional Organizations Commission on
Registered Medical Assistant
(RMA) Application Process American Association of Accreditation of
Medical Assistants (AAMA) Allied Health
Registered Medical Assistant Education Programs
(RMA) Examination American Medical
(CAAHEP)
Scheduling and Technologists (AMT)
National Healthcareer Continuing
Administration Education Units
Registered Medical Assistant Association (CEUs)
(RMA) Recertification National Healthcareer
Association (NHA)
Recertification
OBJECTIVES Registered Medical
The student should strive to meet the following performance objectives and dem- Assistant (RMA)
onstrate an understanding of the facts and principles presented in this chapter Task Force for Test
through written and oral communication. Construction
(TFTC)
1. Define the key terms as presented in the glossary.
2. List the necessary qualifications to sit for the certified medical
assistant (AAMA) certification examination.

1058
OBJECTIVES (continued)
3. State when the certified medical assistant (AAMA) certification
examination is offered and the registration deadlines.
4. List the necessary qualifications to sit for the registered medical
assistant examination.
5. State when the registered medical assistant examination is
offered and the registration protocols.
6. Differentiate between being certified and being registered.
7. Discuss the National Healthcareer Association and its options
for medical assisting certification.
8. Identify the benefits of certification and registration.
9. Describe several methods for continuing education opportunities.
10. Explain when recertification must take place for the CMA
(AAMA).
11. Describe the procedure for recertification for the registered
medical assistant.

Scenario
Dr. Ray Reynolds currently is the senior provider at came with experience from another medical office, the
Inner City Health Care, a multiprovider urgent care cen- procedures still required retraining.
ter. When he began his practice 32 years ago, however, Dr. Reynolds finds that when he needs to replace
he had a private practice and employed one full-time a medical assistant now, he looks at the applicants’
and two part-time medical assistants. Dr. Reynolds felt résumés and interviews only those candidates who
the office ran smoothly, except when an assistant had are Certified Medical Assistants or Registered Medical
to be replaced. Retraining a new person consumed a Assistants. The office is too busy to spend time training
great deal of valuable time. Even if the new employee and retraining new people.

INTRODUCTION
Forty years ago, medical assistants were trained on the job ing numbers of career-oriented candidates enter
by the practitioner with whom they were employed. Qual- this profession annually. Certification acknowledges
ity control of training varied because there were no estab- the professional has standard entry-level knowledge
lished criteria for evaluating such training. This chapter and skills. Successfully passing a certification exami-
will present the purpose of certification, certifying agen- nation also builds personal self-esteem and confi-
cies, and preparation for certification examinations. dence in performing the responsibilities assigned.
Other reasons for certification include help in
your career advancement and compensation. Hir-
PURPOSE OF CERTIFICATION ing providers view these credentials as professional
and an indication of proficiency in entry-level skills.
Certification is intended to set a consistent mini- Individuals who are competent and interested in
mum standard for evaluating an individual’s pro- continued learning experiences are more apt to
fessional competence as a medical assistant. The be rewarded with promotions and salary increases.
medical assisting profession continues to be one of Maintaining the credential demonstrates a life-long
the fastest growing in the U.S. economy. Because of commitment to professional development. The
the demand for skilled medical assistants, increas- graduate medical assistant has a goal and challenge
1059
1060 UNIT 9 Entry into the Profession

Critical Thinking Spotlight on Certification

Take time to think through your personal RMA Content Outline
medical assisting career goals. Will • Medical law
credentialing be an important consideration? • Oral and written communication
Why or why not?
CMA (AAMA) Content Outline
• Displaying a professional attitude
to which to aspire, first by earning the credential • Professional communication and
and second by maintaining the credential through behavior
continued education and recertification.
Some certifying agencies offer membership CMAS Content Outline
into their organizations. This avenue provides • Legal and ethical considerations
excellent opportunities to network and be men- • Professionalism
tored by fellow professionals, to enroll in continu- • Communication
ing education programs, and to receive many other
membership perks.
tified Clinical Medical Assistant (CCMA) and the
Certification Agencies Certified Medical Administrative Assistant (CMAA).
Agencies such as the Commission of Accreditation Figure 35-1 illustrates a comparison of agencies
of Allied Health Education Programs (CAAHEP) providing certification for medical assistants.
certifies the Certified Medical Assistant (CMA Effective January 1, 2008, medical assis-
[AAMA]). The American Medical Technologists tants certified through AAMA use the title Certi-
(AMT) offers examinations to certify the Reg- fied Medical Assistant or the abbreviation CMA
istered Medical Assistant (RMA) and the Certi- (AAMA). This title indicates that a person whose
fied Medical Administrative Specialist (CMAS). services are competent, having graduated from
The National Healthcareer Association (NHA) is a Commission of Accreditation of Allied Health
another agency offering certification to healthcare Education Programs (CAAHEP) or an Accredit-
professionals. These professionals include the Cer- ing Bureau of Health Education Schools (ABHES)

Certification Details

Certifying American Association of Medical American Medical National Healthcareer

Agency Assistants (AAMA) Technologists (AMT) Association (NHA)

Credential CMA (AAMA) RMA or CMAS CCMA or CMAA

Computer-based national exam, Computer-based national National exam taken by online or

offered at Prometric testing centers exam offered at PearsonVue paper exam
Certification (www.prometric.com) testing centers
Exam (www.pearsonvue.com),
or paper exam by
appointment
Number of 200 multiple choice questions 200–210 multiple choice 200 mutiple choice questions
Questions Topics from the Content Outline for questions Separate tests for CCMA and
and the CMA (AAMA) Clinical, Administrative, CMAA (exam completing time
Make-up and General questions approximately 90 minutes)
of Exam
AAMA Approved CEUs Certification Continuation Continuing education (CE)
60 points every 5 years Program (CCP) program
10 Clinical 30 points every 3 years 5 credits per year
Continuing 10 Administrative AMT and AMTIE* Home study program taken online,
Education 10 General offer several CE options downloaded, or using printed
30 Discretionary for credits copies
*American Technologists Institute For Education

Figure 35-1 Comparison of agencies providing certification.

 CHAPTER 35 Preparing for Medical Assisting Credentials 1061

accredited program and having successfully passed Outline accompanying the application. Other
the AAMA certification examination, will perform groups review/study only those areas in which they
medical assisting services. feel less confident. A plan that meets the needs
RMA certificants may use the term “certified of each group member and that all can agree to
medical assistant” in a descriptive sense to describe works best.
the credentialing services offered by AMT’s Reg- Meeting once or twice a week helps the group
istered Medical Assistant program or to describe stay focused and on task. Independent study
individuals who have been awarded the RMA cer- should be done throughout the week. During the
tification. When responding to advertisements or independent study time, each group member may
during the interview process, “certified medical be asked to write 10 multiple choice questions rel-
assistants” who are AMT certificants must make evant to the weeks’ study topic. Answers to these
clear to the prospective employer that they are cer- questions should be on a separate page. Some find
tified by AMT as a Registered Medical Assistant. it helpful to also provide the rationale or textbook
page number that supports their answer. When the
group meets, a discussion of the study topic could
take place and copies of the questions could be dis-
PREPARING FOR tributed for answering. The questions could then
CERTIFICATION be corrected and discussion of any questionable or
EXAMINATIONS missed answers could take place.
Once a schedule has been established and
Preparation for the examination requires plan- agreed on, discipline is required. It is critical that
ning, scheduling, and discipline. It is important each group member spend time individually prepar-
to plan well in advance to ensure confidence and ing for the next group meeting. Someone should
a passing score to earn your credential. If you are be put in charge of each group meeting to keep the
sitting for the examination immediately on gradu- event from turning into a social time. To help with
ation, your preparation time for the examination this, it is a good idea to set a specific time limit for
may only allow 2 to 3 months. If you have been out the study/review session. If individuals want to visit
of school for some time or your work experience after the session, they are free to do that without
has been very specialized, you may need longer to disrupting the purpose of the session. All members
prepare for the examination. should be committed to being prepared and attend-
During the planning stage, determine the ing each scheduled review/study session.
date you want to sit for the examination. Check
with the appropriate Web site or call the appro- AMERICAN ASSOCIATION
priate examination department to obtain the
current application form. The application form OF MEDICAL ASSISTANTS
contains information such as dates, times, and (AAMA)
locations of test sites; policies regarding dead-
lines; incomplete applications; examination veri- The AAMA is an organization whose objective is
fication information; and information regarding to promote skills and professionalism, protect the
study guides. medical assistants’ right to practice, and encour-
It is important to consider having a study age consistent health care delivery through pro-
group or partner. The right study environment can fessional certification. The AAMA is a sponsoring
be invaluable to your success for several reasons. member of the Commission on Accreditation of
First, it is important to select a study partner or Allied Health Education Programs (CAAHEP).
group who shares your commitment to a successful CAAHEP establishes the standards for medical
outcome and who plans to sit for the examination assisting programs and is the issuing body of the
on or near the same date you have selected. A study accreditation for AAMA.
partner can also give you some accountability for Only graduates of CAAHEP- and Allied
keeping to the planned schedule. Bureau of Health Education Schools (ABHES)-
Once it has been determined when and where accredited medical assistant programs may sit for
you will sit for the examination and who your study the Certified Medical Assistant exam. To locate
partner(s), if any, will be, a meeting should be either CAAHEP or ABHES medical assisting pro-
scheduled to discuss the review/study approach. It grams, go to http://www.aama-ntl.org and click
may be that your group will decide to review/study on About AAMA. Follow the drop-down menu for
each subject provided in the Curriculum Content specific information.
1062 UNIT 9 Entry into the Profession

Eligibility categories and documentation re- medical assistants, providers, and medical assist-
quirements to sit for the Certified Medical Assis- ing educators from across the United States. The
tant exam include the following: TFTC updates the examination annually to reflect
changes in medical assistants’ day-to-day responsi-
• Category 1: The candidate must be a CAAHEP or bilities, as well as the latest developments in medi-
ABHES graduating student or recent graduate. cal knowledge and technology.
A transcript-to-date with the institution’s seal or The three major areas tested include:
registrar’s signature, or an official transcript and
verification of graduation date, are required as 1. General: Medical Terminology, Anatomy and
documentation. Physiology, Psychology, Professionalism, Com-
• Category 2: The candidate may be a CAAHEP or munication, and Medicolegal Guidelines and
ABHES nonrecent graduate. A nonrecent gradu- Requirements
ate is one with a graduation date more than 12 2. Administrative: Data Entry, Equipment, Records
months prior to the examination date. An official Management, Screening and Processing Mail,
transcript and verification of graduation date are Scheduling and Monitoring Appointments,
required documentation. Resource Information and Community Services,
• Category 3: The candidate may be a recertificant, a Managing the Office, Office Policies and Proce-
Certified Medical Assistant® applying for the CMA dures, and Practice Finances
Examination to recertify his or her credential. 3. Clinical: Principles of Infection Control, Treat-
ment Area, Patient Preparation and Assisting the
The AAMA Endowment is a not-for-profit cor- Provider, Patient History Interview, Collecting and
poration that provides funding for two purposes: Processing Specimens; Diagnostic Testing, Prepar-
ing and Administering Medications, Emergencies,
• Awarding of scholarships to students in CAAHEP-
First Aid, and Nutrition
accredited medical assisting education programs
• Accreditation of medical assisting education pro- Students must enroll as an AAMA member
grams through CAAHEP
before their graduation date to be eligible for the
reduced student rate. Once they are a student
The Medical Assisting Education Review member they may stay at the student rate for 1
Board (MAERB) operates under the authority of year after graduation if they do not choose to be
the endowment and evaluates medical assisting an active or associate member and pay the higher
programs according to standards adopted by the dues amount. The additional year of member-
endowment and the CAAHEP. The MAERB recom- ship at the reduced rate helps the recent gradu-
mends programs to CAAHEP for accreditation. The ate maintain membership while finding a job and
MAERB also reviews standards for medical assisting becoming established in a career.
curricula, conducts accreditation workshops for
educators, and provides medical assisting educators
with current information about CAAHEP, accredi- Certified Medical Assistant
tation laws, policies, and practices. CAAHEP’s (AAMA) Application Process
purpose is to accredit entry-level, allied health edu-
cation programs. Candidates should read all instructions carefully
before completing the application form. Incom-
plete or incorrect applications will not be processed
Certified Medical Assistant and will be returned to the candidate. Postmark
(AAMA) Examination Format deadlines for applications, cancellations, and exam-
ination location changes are strictly enforced.
and Content Applications are available from the AAMA
The AAMA certification examination is a com- Certification Department, 7999 Eagle Way, Chi-
prehensive test of the knowledge actually used in cago, IL 60678-1079. The application may also be
today’s medical office. The content is drawn from downloaded from the AAMA Web site (http://
an in-depth analysis of the numerous tasks medical www.aama-ntl.org).
assistants perform on a daily basis. It is recommended that the application be
Examination questions are formulated by the sent by certified mail, return receipt requested to
Certifying Board’s Task Force for Test Construc- verify delivery. The application must be typewritten
tion (TFTC). This group is composed of practicing or printed using black ink only. Be sure the appli-
 CHAPTER 35 Preparing for Medical Assisting Credentials 1063

cation is signed and dated properly and the eligi- Photo identification is required for admission
bility category section is completed appropriately. to the examination. Candidates are not permit-
Applications take up to 45 days after the postmark ted to bring any items except identification in the
date to process. examination area. Candidates are allowed 3 hours
Tear off the application page from the instruc- and 15 minutes to complete the exam, which
tion pamphlet. Do not mail the instructions back includes a 15 minute tutorial.
with the application. Keep this information for All exam candidates will receive an unofficial
future reference together with a copy of everything pass/fail result immediately upon completion of
submitted, including a copy of your completed pay- the exam. An official report of your scores will be
ment check or money order. If you are paying by mailed within 6 to 10 weeks after the exam date.
VISA or MasterCard, provide the requested infor-
mation at the top of the application.
A guide for the certification examination enti-
Certified Medical Assistant
tled A Candidate’s Guide to the AAMA Certification Exam- (AAMA) Recertification
ination provides explanations of how to approach the Effective January 2005, all newly certified and
types of questions used on the examination and tips recertifying CMAs (AAMA) will be current through
on how to study for the content that will be tested. A the last day of their birth month in the sixth calen-
sample 120-question examination is included to help dar year following their last certification/recertifi-
assess your knowledge of the categories tested and cation. In other words, if you were born on August
the format used to formulate the questions. 6th and certified in June 2004, you would be due
to recertify by the end of August 2010.
Certified Medical Assistant Recertification can be achieved either by
reexamination or by the continuing education
(AAMA) Examination Scheduling method. Recertification credits are evaluated on
and Administration supportive documentation and on their relevancy
The AAMA certification examination is made up of to medical assisting as defined by the AAMA Med-
200 multiple choice questions, covering topics listed ical Assistant Role Delineation Study or the Con-
on the Content Outline for the CMA (AAMA) Certi- tent Outline for the Certification/Recertification
fication/Recertification Examination. As of January Examination.
2009, the CMA (AAMA) certification examination A total of 60 points is necessary to recertify the
is now offered via computer-based testing (CBT). CMA (AAMA) credential. A minimum of 10 points
Candidates whose applications are accepted will is required in each category: general, administra-
receive a Scheduling Permit containing instructions tive, and clinical. The remaining 30 points can be
for making a testing appointment, and are able to accumulated in any of the three content areas or
select locations and flexible testing times at Promet- from any combination of the three categories. At
ric test centers throughout the United States. To least 30 of the required 60 recertification points
schedule examination appointments, candidates must be accumulated from AAMA-approved con-
may call 800-853-6761 or go to www.prometric. tinuing education units (CEUs). If desired, all 60
com and select a test center and appointment test points may be AAMA CEUs.
time. Centers are open 9:00 am to 5:00 pm Mon- CMAs (AAMA) applying for recertification
day through Saturday. An email confirming your must also provide documentation of current
appointment will be sent to you.
On successfully passing the Certification Examination and
earning the CMA (AAMA) credential, one should begin to
Critical Thinking document all CEUs earned. It is important to have the follow-
ing information for CEU documentation:
• Complete date of the activity
You will graduate from a CAAHEP-accredited
• Sponsor (group or organization issuing the credit for the
program in June and want to sit for the CMA continuing education activity)
examination the last Saturday of June (the • Program title
same month in which you graduate). Go • Amount and type of credit earned (e.g., CEU, CME, contact
to the AAMA web site and determine when hour or college credit)
your application must be postmarked for • Recertification points (AAMA CEUs or other credit)
acceptance for this test date. • Points per content area (general, administrative, clinical)
1064 UNIT 9 Entry into the Profession

cardiopulmonary resuscitation (CPR) certifica- formed in health care settings. Each individual
tion for health care professionals or providers. state decides the scope of practice for the CMAS,
Acceptable courses of CPR include the American with most states not requiring licensure.
Red Cross and the American Heart Association. Additional information regarding CMAS edu-
The components of certification must include cation requirements, duties performed, working
adult and pediatric CPR and obstructed airway conditions, employment outlook, and estimated
training and Automated External Defibrillator earnings can be found online at http://www.amt1.
(AED) instruction. com. Simply click on Certified Medical Adminis-
Applicants who accumulate all 60 points trative Specialist to access the information.
through AAMA CEUs, and in the correct con-
tent areas, can order a recertification over the
telephone. Application fees still apply; however, Registered Medical Assistant
an application form is not required. All CMAs (RMA) Examination Format
employed or seeking employment must have and Content
current certified status to use the CMA (AAMA)
credential. AMT certification examinations are intended to
Continuing education courses are offered by evaluate the competence of entry-level practitio-
local, state, and national AAMA groups. Guided ners. The Education, Qualifications, and Standards
study programs are also available through AAMA’s Committee of American Medical Technologists
“Quest for Excellence” program. CMA Today, the develop registered medical assistant (RMA) exami-
official bimonthly publication of AAMA, provides nations. The medical assistant committee writes
articles designated for CEUs. test questions and reviews questions submitted
A CMA (AAMA) need not be a member of from other sources (e.g., instructors, experts, prac-
the AAMA nor currently employed to recertify. titioners, and other individuals associated with
The entire recertification by continuing education the medical assistant profession). The medical
instructions and application can be downloaded assistant committee also determines certification
from AAMA’s Web site (http://www.aama-ntl.org). requirements and addresses standard-setting issues
Review of recertification applications can take up related to the credential. Once test construction
to 90 days. If all criteria are met, recertification has been completed, the examination is reviewed
is granted. The date that the application is post- and approved by the AMT Board of Directors.
marked to the AAMA Executive Office will be the The AMT registration examination consists
date of recertification. of 200 to 210 four-option multiple-choice ques-
On meeting recertification requirements, the tions. Examinees are required to select the single
applicant receives an identification card, which best answer; multiple answers for a single item are
indicate the year of recertification and the expira- scored as incorrect. Test questions may require
tion date. examinees to recall facts, interpret graphic illus-
trations, interpret information presented in case
studies, analyze situations, or solve problems. The
AMERICAN MEDICAL approximate percentages of questions in content
TECHNOLOGISTS (AMT) areas are as follows:
1. General Medical Assisting Knowledge—41.0%
The American Medical Technologists (AMT) awards
the registered medical assistant (RMA) credential to • Anatomy and physiology
individuals graduating from an ABHES-accredited • Medical terminology
medical assisting program who successfully passes • Medical law
their examination. ABHES is recognized by the U.S.
• Medical ethics
Department of Education for accreditation of post-
secondary schools offering traditional instruction as • Human relations
well as instruction by distance delivery. • Patient education
The AMT also offers certification for the certi- 2. Administrative Medical Assisting—24.0%
fied medical administrative specialist (CMAS). The
• Insurance
CMAS is employed primarily in the “front office”
of provider offices, clinics, or hospitals. They must • Financial bookkeeping
understand and use medical terminology prop- • Medical secretarial-administrative medical assis-
erly and be skilled in all administrative tasks per- tant
 CHAPTER 35 Preparing for Medical Assisting Credentials 1065

3. Clinical Medical Assisting—35.0% 5. The AMT Board of Directors has further deter-
• Asepsis mined that applicants who have passed generalist
medical assistant certification examination offered
• Sterilization by another medical assisting certification body
• Instruments (provided that examination has been approved
• Vital signs for this purpose by the AMT Board of Directors),
• Physical examinations who have been working in the medical assisting
field for the past 3 of 5 years, and who meet all
• Clinical pharmacology other AMT training and experience requirements
• Minor surgery may be considered for RMA (AMT) certification
• Therapeutic modalities without further examination.
• Laboratory procedures Applications can be downloaded from AMT’s
• Electrocardiography Web site (http://www.amt1.com) either in print
• First aid and fill-in format or as online fill-in format.

Registered Medical Assistant

Registered Medical Assistant
(RMA) Examination Scheduling
(RMA) Application Process
and Administration
The following criteria have been established for
applicants sitting for the RMA examination: All applications must be completed online or printed
clearly except for the signatures required. All ancil-
1. Applicant shall be of good moral character and at lary documentation must also be submitted (e.g.,
least 18 years of age. application fee; proof of high school graduation or
2. Applicant shall be a graduate of an accredited equivalent; official final transcripts stating gradua-
high school or acceptable equivalent. tion from medical assistant school, college, or train-
ing program [with school seal affixed or notarized]).
3. Applicant must meet one of the following require-
When the AMT Registrar has received the
ments:
application and all required information, an
a. Applicant shall be a graduate of a(n): authorization letter containing a toll-free number
• Medical assisting program that holds pro- is mailed to you. You can then contact Pearson Vue
grammatic accreditation by (or is in a post- locations at http://www.pearsonvue.com/amt to
secondary school or college that holds insti- schedule a date and time to take the examination.
tutional accredition by) the ABHES or the Two forms of valid identification are required,
CAAHEP. both bearing your signature and at least one bear-
• Medical assisting program in a postsecond- ing your photo. Photo identification is limited to
ary school or college that has institutional a driver’s license, state-issued identification card,
accreditation by a Regional Accrediting Com- military identification, or passport.
mission or by a national accrediting organi- All AMT registration examination tests are
zation approved by the U.S. Department of available in paper-and-pencil format or in comput-
Education. That program must include a erized formats at over 200 locations in the United
minimum of 720 clock hours (or equivalent) States, its territories, and Canada. Tests can be
of training in medical assisting skills (includ- scheduled daily except Sundays and holidays. Both
ing a clinical externship). formats are identical in length; however, experi-
ence has shown the computerized test takes less
• Formal medical services training program of
time to complete. Your computerized test score is
the U.S. Armed Forces.
displayed moments after you complete your test. A
b. Applicant shall have been employed in the pro- paper copy of your result letter is provided to you
fession of medical assisting for a minimum of before you leave the testing center.
five years, no more than two years of which may
have been as an instructor in a postsecondary
medical assisting program.
Registered Medical Assistant
4. Applicants applying under 3 A or B must take
(RMA) Recertification
and pass the AMT certification examination for The AMT has established the Certification Contin-
RMA. uation Program (CCP) for continuing education
1066 UNIT 9 Entry into the Profession

points. Certification will be suspended following tification examination receive NHA Study Guides.
a 30-day grace period if proper documentation is Separate tests are taken for each healthcareer
not submitted. certification. The CCMA and the CMAA test is
Each RMA is required to accumulate 30 composed of multiple choice questions and takes
points, which must be turned in every 3 years for approximately 90 minutes to complete.
recertification. A Compliance Evaluation Work- The examination is offered in traditional
sheet and Attestation will be mailed close to the pencil-and-paper formats or can be taken online at
3-year mark. This worksheet must be completed, any of the specified approved locations. For details
signed, and returned to AMT by the due date. regarding testing, contact the NHA by telephone
Retaking the RMA examination is not an option at 1-800-499-9092 or email them at http://www.
for reinstatement or recertification. nhanow.com. You will receive a confirmation
notice of your seating including the date and loca-
tion of the examination.
NATIONAL HEALTHCAREER
ASSOCIATION (NHA) Certified Clinical Medical
The National Healthcareer Association (NHA) Assistant and Certified Medical
also offers national certification examinations for Administrative Assistant
health care professionals. NHA works with educa- Application Process
tional institutions throughout the country on cur-
riculum development, competency testing, and There are four ways to apply or register for the
preparation and administration of their examina- NHA national certification examination.
tion and offers a continuing education (CE) pro-
gram. The NHA is dedicated to the following: • Online using http://www.nhanow.com. Go directly
to the secured registration page and submit the
• Set guidelines for national certification competen- registration form using Visa, MasterCard, Discover,
cies/standards American Express, or school voucher.
• Ensure a high level of performance among health- • The registration form can be downloaded and
care professionals printed. Once it is filled out completely, it can be
• Establish educational/continuing education require- mailed along with payment. Address and mail to:
ments National Healthcareer Association
• Adhere to the highest ethical standards 7 Ridgedale Ave, Suite 203
Cedar Knolls, NJ 07927
Certified Clinical Medical • The completed registration form can be faxed
Assistant and Certified Medical to NHA with credit card information or school
voucher. The fax number is 1-973-644-4797.
Administrative Assistant
• Telephone the Customer Service Department at 1-
Examination Format and Content 800-449-9092. You can then complete the registra-
The NHA certifies the Certified Clinical Medi- tion over the phone. You will need your credit card
cal Assistant (CCMA) and the Certified Medical number and expiration date or school voucher
Administrative Assistant (CMAA) among other accessible for payment information.
health career professions. Criteria for taking the
NHA certification examinations include one of the
following: The applicant must have a high school Certified Clinical Medical
diploma and have recently successfully completed Assistant and Certified
an NHA-approved training program, or the appli- Medical Administrative Assistant
cant must have either a high school diploma or
equivalency and have recently worked in the field of
Examination Scheduling
certification for a minimum of 1 year as a full-time and Administration
employee. Work experience must be documented The NHA examination can be scheduled at any of
in writing and signed by the director or employer. the specified approved locations:
The NHA offers several methods to help pre-
pare candidates for their national certification • Training Schools/Colleges—Check with your school
examination. All students applying for NHA cer- for details
 CHAPTER 35 Preparing for Medical Assisting Credentials 1067

• Testing Sites—Over 950 NHA testing sites nation- American Association of Medical
wide Assistants (AAMA)
• Experienced individuals can take examinations at The AAMA was instrumental in defining the scope
their place of employment of training required for the profession and devel-
NOTE: All examinations are required to have oped standards and guidelines by which programs
an exam proctor present. could become accredited and the medical assistant
credentialed. Membership in the AAMA offers
Certified Clinical Medical many benefits, which include, but are not limited
Assistant and Certified to, the following:
Medical Administrative • Medical assisting news and health care informa-
Assistant Recertification tion through the bimonthly magazine CMA Today
NHA offers a Continuing Education (CE) Pro- • CEUs for AAMA activities entered in the Continu-
gram to make the process of continuing education ing Education Registry and access to your tran-
more convenient for the health care professional. script online
Courses in this program can be taken at your con- • Educational events provided by local chapters,
venience at home. state societies, and national meetings
New industry standards require that each • Answers to legal questions regarding job-related
NHA-certified health care professional complete issues
at least 5.0 CE credits per year to keep certifica-
• If eligible, application for the prestigious CMA
tion current. These CE credits are obtained by
examination at a reduced fee
completing three of the six minor topics at 1.0
credit each and one of two major topics worth • Discounts on car rentals, conventions, workshop
2.0 credits each from the NHA curriculum, which and seminar fees, and self-study courses
is updated annually. • Opportunity to network with other practicing
If certification has expired, the entire pro- medical assistants
gram must be completed; all six CE minor topics
and two CE major topics. Candidates are required
to pay the cost of the 10 credits plus a reinstate- American Medical
ment fee. Technologists (AMT)
Applicants who pass the examination will
be nationally certified as recognized by the NHA. The AMT is another nonprofit certification agency
They will receive a certification certificate suitable and professional membership association repre-
for framing and a wallet-size ID certification card senting allied health care individuals. It certifies
containing their national certification number. CE medical assistants by awarding the RMA national
credits will be reviewed by NHA, and a sticker to credential to those candidates successfully satisfy-
apply to the certification ID card will be mailed if ing requirements. AMT has many local chapters,
the credits are accepted. 38 state societies, and a Uniform Services Com-
mittee. Each of these societies meets regularly and
annually for a national convention.
PROFESSIONAL AMT benefits and services include:
ORGANIZATIONS • Continuing education through the Journal of Con-
tinuing Education Topics & Issues published three
Professional organizations have evolved times a year
to establish standards by which medical
• AMT’s Institute for Education (AMTIE), which
assistants and medical assisting programs
monitors continued education credits and sends a
are evaluated. Programs accredited by agencies
“report card” each year
must meet certain criteria, and students must pass
national examinations to become certified. Medi- • Four scholarships available to members who want
cal assistants are not licensed and need not be cer- to return to school and five scholarships for cur-
tified to meet employment requirements; however, rent students enrolled in allied health care pro-
those certified are viewed as professionals with grams
entry-level skills and a commitment to continued • State societies that offer opportunities for contin-
education. ued education, activities, and networking
1068 UNIT 9 Entry into the Profession

• Peer recognition through AMT’s prestigious RMA NHA benefits and services include:
credential
• National certification
• Personal discount programs
• Continuing education opportunities
• Collaboration with educational institutions in cur-
National Healthcareer riculum development and competency testing
Association • Annual Continuing Education Program
The NHA serves as a reliable resource for up-to- • Elite Membership Program that puts you in touch
date information on health career opportunities, with a team of placement specialists to expand job
training programs, education opportunities, and opportunities
industry forecasts. The NHA newsletter The NHA
Today is well respected and provides current trends
and information regarding the health care field.

Case Study 35-1

Review the scenario at the beginning of the chapter. 2. Discuss the advantages of certification to the pro-
vider.
CASE STUDY REVIEW 3. How does certification set a consistent minimum
standard for evaluating professional competence
1. Discuss the advantages of certification to the medi-
as a medical assistant?
cal assistant.

Case Study 35-2

It is May, and Nancy McFarland, who graduated from an CASE STUDY REVIEW
ABHES-accredited program 4.5 years ago, is beginning
to research the procedures and requirements for taking 1. If Nancy wants to take the examination in January,
the RMA examination. Nancy completed her internship at what is the procedure for applying?
Inner City Health Care and was hired to work there full time 2. Nancy is setting up a study schedule. She plans to
(35 hours per week) when she graduated. review course textbooks and tests, purchase a study
guide, and set up a study group. Develop a simple
study schedule.
3. What criteria should Nancy use when asking peo-
ple to join her study group?

SUMMARY
Many advantages for certification/recertification and registration have been discussed in this chapter.
Although certification examinations are not legally required for practicing medical assistants, it is the goal
of CAAHEP- and ABHES-accredited institutions to encourage graduates to sit for and maintain their cre-
dentials. Membership in the AAMA or in the AMT is also encouraged.
With nearly 400 local AAMA chapters and 51 affiliate state societies, there is the benefit of networking
with others in the profession. As an information source for both professional and association issues, the
executive staff at the AAMA’s national headquarters is available to answer questions at a toll-free number
(1-800-228-2262).
AMT currently has 38 chapters that meet regularly and allow networking with other RMAs plus other
allied health professionals registered through the AMT, including phlebotomists, medical laboratory tech-
nicians, and dental assistants.
The NHA offers national certification examinations for CMAAs and CCMAs among other health care
professionals. NHA offers CE programs and encourages recertification.
 CHAPTER 35 Preparing for Medical Assisting Credentials 1069

STUDY FOR SUCCESS

To reinforce your knowledge and skills of information presented in this chapter:
• Review the Key Terms
• Consider the Case Studies and discuss your conclusions
• Answer the Review Questions

° Multiple Choice
° Critical Thinking
• Navigate the Internet and complete the Web Activities
• Practice the StudyWARE activities on the textbook CD
• Apply your knowledge in the Student Workbook activities
• Complete the Web Tutor sections
• View and discuss the DVD situations

REVIEW QUESTIONS
Multiple Choice 6. The RMA was established by the:
1. The goal and challenge of each graduating medical a. ABHES
assistant should be to: b. CAAHEP
a. find employment c. AMT
b. have a good benefit package d. AAMA
c. possess entry-level skills 7. The NHA offers medical assisting certification for
d. earn the CMA/RMA credential and maintain it which of the following:
2. The certification examination is: a. CMA
a. a comprehensive test based on tasks medical b. RMA
assistants perform daily c. CCMA and CMAA
b. all true/false questions d. CMAS
c. developed by the AMTIE 8. RMA examinations:
d. developed by the NBME a. are offered at Pearson Vue locations
3. Benefits of membership in a professional organi- b. are offered twice a year
zation such as AAMA or AMT include all of the fol- c. are offered three times a year
lowing except: d. are offered six times a year
a. discounted rates on legal representation
b. legal advice
c. nationwide networking opportunities Critical Thinking
d. professional journal publications 1. You are a recent high school graduate and have
4. Recertification of the CMA (AAMA) credential decided to pursue medical assisting as a career.
options include: What will you do to find a school offering an
a. submit work experience accredited program? Is accreditation important?
b. reexamination or CEU method How might your school selection impact your
c. submit on-the-job training future as a professional medical assistant?
d. submit military training 2. After graduation you plan to sit for the certification
5. To keep the RMA credential current, an individual examination. How will you prepare for the exami-
must earn: nation to ensure a positive outcome and earn your
a. 5 credits each year CMA/RMA credential?
b. 30 points every three years 3. After graduating from an accredited program, you
c. 30 points every five years immediately went to work as an medical assistant.
d. 60 points every five years Now that you have been working several years
1070 UNIT 9 Entry into the Profession

you decide to become credentialed. How will you cal assistants. Retrieved February 10, 2008, from
achieve this? http://www.aama-ntl.org.
American Association of Medical Assistants. (n.d.).
FAQs on CMA (AAMA) certification. Retrieved Janu-
WEB ACTIVITIES ary 29, 2009, from http://www.aama-ntl.org.
Using the Internet, search your local and state American Medical Technologists. Allied Health Profes-
AAMA or AMT Web sites. Print and turn in to sionals Association for Certification as a Registered
your instructor the location, meeting sched- Medical Assistant. (n.d.). Retrieved February 10,
ules, and any upcoming events planned for your state. 2008, from http://www.amt1.com.
Review the certification process that applies to your National Healthcareer Association. (n.d.). NHA
program. national certification examination. Retrieved Septem-
ber 9, 2007, from http://www.NHAnow.com.
Simmers, L. (2004). Diversified health occupations (6th
REFERENCES/BIBLIOGRAPHY ed.). Clifton Park: NY: Delmar Cengage Learning.
American Association of Medical Assistants. (2008).
AAMA certification/recertification examination for medi-

THE DVD HOOK-UP

This chapter discussed credentialing opportunities for the credentialed an important goal for you? What will you do to
medical assistant. stay current once you graduate from your medical assistant
This program discussed the importance of critical thinking program?
when working in the medical industry.
1. How does good critical thinking apply to your goal of
becoming a Certified or Registered Medical Assistant?
2. What credentials are you able to attain as a graduate
of your Medical Assistant institution?
DVD Series Program Number
DVD Journal Summary Critical Thinking 1
Write a paragraph that summarizes what you learned Chapter/Scene Reference
from watching today’s DVD program. Why is becoming • Introduction
 Chapter

Employment Strategies 36
KEY TERMS OUTLINE
Accomplishment Developing a Strategy The Interview Process
Statements Attitude and Mindset The Look of Success
Application/ Self-Assessment Preparing for the Interview
Cover Letter Job Search Analysis and Research The Actual Interview
Application Form Résumé Preparation Interviewing the Employer
Benefits Résumé Specifications Closing the Interview
Bullet Point Clear and Concise Résumés Interview Follow-Up
Career Objective Accomplishments Follow-Up Letter
Chronologic Résumé References Follow Up by Telephone
Contact Tracker Accuracy After You Are Employed
Direct Skills Résumé Styles Dealing with Difficult People
Vital Résumé Information Getting a Raise
E-résumé
Application/Cover Letters Professionalism
Functional Résumé
Completing the Application
Interview Form
Keywords
Power Verbs
References OBJECTIVES
Résumé The student should strive to meet the following performance objectives and dem-
Targeted Résumé onstrate an understanding of the facts and principles presented in this chapter
Transferable Skills through written and oral communication.

1. Define the key terms as presented in the glossary.

2. List the steps involved in job analysis and research.
3. Describe a contact tracker and its usefulness.
4. Give three examples of accomplishment statements.
5. Differentiate chronologic, functional, and targeted résumés.
6. Identify the purpose and content of a cover letter.
7. Demonstrate effective ways to anticipate and respond to an
interviewer’s questions.
8. Describe appropriate overall appearance and dress for an
interview.
9. Identify the benefits of writing a follow-up letter.
10. Discuss professionalism as it relates to employment strategies.

1071
 Scenario
Eun Mee Soo is a graduate of an accredited medical and beginning her job search. Eun Mee plans to move
assisting program and recently passed the certification out of state (she always dreamed of moving north),
examination. While attending school, Eun Mee was so she will also be looking for a new apartment. All of
employed part-time as a sales representative (clerk) in these changes are a bit unsettling for Eun Mee. She is
one of the city’s prestigious clothing stores. She has no beginning to wonder if she should defer relocating at
medical work experience except her practicum at Inner this time and stay close to home until she feels more
City Health Care. She is now preparing her résumé secure.

INTRODUCTION
So you are about to graduate from the medical assistant 1. Taking direction
program! This time is often unsettling because many 2. Seeking excellence or doing just enough to get by
changes are occurring; the loss of security the classroom
3. Meeting employer’s needs, not just looking for-
environment provided, loss of contact with fellow class-
ward to payday
mates, and loss of a structured schedule are just a few
changes. Questions such as: Am I ready for my first job? 4. Assuming responsibility for your actions versus con-
How do I find a job? What do I say at the interview? sidering your problems to be someone else’s fault
begin to surface. If you find yourself having a negative attitude
The focus on employment may represent apprehen- in any of the ways mentioned in the preceding list,
sion and doubt or be sparked with anticipation and a you need to make an effort to change while you
sense of fulfillment. This chapter provides direction and are still in training. An employer will zero in on a
answers some of the questions related to the job search. negative attitude and eliminate you as a candidate
almost immediately. Your formal training is impor-
tant and you can be retrained to do things the way
DEVELOPING A STRATEGY a new employer desires, but your attitude takes
time to change and requires a willingness to make
It is best to begin developing your job search strat- the change. Develop a strategy to evolve a positive
egy early in your training as a medical assistant. If attitude while you are still in school because this is
you have not started this phase, determine to begin a time when you will have professional guidance
today. and resources, as well as excellent models.
The first step in developing a strategy is to look
at reality. You and maybe a hundred other medical
assistants may be applying for the same job posi- Spotlight on Certification
tion. How are you different from every other person
applying for this job? The following sections will RMA Content Outline
help make you stand out, be different, and hopefully • Medical law
be successful in your job search.
• Human relations
• Oral and written communications
Attitude and Mindset CMA (AAMA) Content Outline
One important quality an employer looks for in • Displaying professional attitude
employees is their attitude. Your attitude is not • Job readiness and seeking employment
something you turn on and off or learn in school.
It is the result of your innate personality combined CMAS Content Outline
with the events that mold you during your life. Your • Legal and ethical considerations
instructors and acquaintances have a significant • Professionalism
impact over who you are. Your attitude is reflected • Communication
by how you react to:
1072
 CHAPTER 36 Employment Strategies 1073

Beyond a positive attitude, being successful Self-Assessment

in your search for a job requires positive thinking
As you begin your job search campaign, you
on your part. There is a good position out there for
should identify what you want in a job. It is always
you. Finding it is your first job. Those individuals
better to do work you enjoy in the type of practice
who are successful at finding that first job devote
you find most interesting. Take a moment now to
many hours per week at job strategy tactics. You
complete the self-evaluation work sheet shown
should not become discouraged by rejection but
in Figure 36-1. When you have finished, you will
learn from it and apply what you have learned to
have some idea of the type of practice you would
the next interview opportunity.

SELF-EVALUATION WORK SHEET

Respond to the following questions honestly and sincerely. They are meant to assist you in self-assessment.
1. List your three strongest attributes as related to people, data, or things.
i.e., Interpersonal skills related to people
Accuracy related to data
Mechanical ability related to things
__________________________________ related to __________________________________
__________________________________ related to __________________________________
__________________________________ related to __________________________________
2. List your three weakest attributes as related to people, data, or things.
__________________________________ related to __________________________________
__________________________________ related to __________________________________
__________________________________ related to __________________________________
3. How do you express yourself? Excellent, Good, Fair, Poor
Orally ______________________________ In writing _______________________________
4. Do you work well as a leader of a group or team? Yes _____ No _____
5. Do you prefer to work alone? Yes _____ No _____
6. Can you work under stress/pressure? Yes _____ No _____
7. Do you enjoy new ideas and situations? Yes _____ No _____
8. Are you comfortable with routines/schedules? Yes _____ No _____
9. Which work environment do you prefer?
Single-provider setting _____ Multiple-provider setting _____
Small clinic setting _____ Large clinic setting _____
10. Which type of practice do you prefer?
Pediatrics _____ Obstetrics/Gynecology _____
Geriatrics _____ General Medicine _____
Internal Medicine _____ Other _______________________
11. Which work setting do you prefer?
Front office (reception) _____ Back office (assisting provider) _____
Laboratory (phlebotomy) _____ Administrative (coding/billing) _____

Figure 36-1 Self-evaluation work sheets can help determine a person’s strengths, weaknesses,
and preferences before the job search begins.
1074 UNIT 9 Entry into the Profession

like to work in and what position you would find JOB SEARCH ANALYSIS
most satisfying. AND RESEARCH
Before you begin a self-assessment, review
what a medical assistant does, determine what level The job analysis and research phase of your job
pay can be expected, and compare that with your search should start before graduation. Telephon-
personal skills and financial requirements. In some ing or visiting various clinics and asking questions
practices you may specialize in administrative or to determine what the duties of a medical assis-
clinical duties: in others you may be expected to tant are in different types of practices will help to
function in both specialties. further clarify where you would like to work and
A medical assistant is salaried, with yearly will help you become acquainted with a potential
earnings varying between $20,160 and $38,800, employer or identify a possible site for practicum
inflation adjusted to 2008. Entry-level salaries will experience. If you visit the facility, dress appropri-
be closer to the lower figure but will vary depend- ately just as you would for an interview. You want to
ing on credentials, practicum performance, and impress the clinic personnel just as if it were a for-
geographic location. Medical assistants who can mal interview. Remember to send a letter thanking
show proficiency in both administrative and clini- the person taking time on the telephone or autho-
cal capability command higher salaries in some rizing the visit.
medical settings. Based on the self-assessment you completed
As part of the self-assessment you should evalu- and the preliminary job analysis, you know what
ate what direct and transferable skills you have that type of clinic or practice you want to work in,
will make you a contributing member of the medi- so now is the time to compile a list of potential
cal team. Direct skills are the medical procedures employers in the geographic area where you want
you have acquired in school and in which you are to work. Begin your job search by networking with
proficient. Transferable skills are those skills that students who have graduated before you and are
would be useful in a wide variety of professions and successfully employed. Statistics tell us that 80% of
may have been perfected during the education positions are filled through networking contacts.
process or learned in other employment settings. Next compile a list from the Yellow Pages, Job
Leadership, communication, writing, computer Expositions, the Internet, Want Ads for your spe-
literacy, keyboarding, linguistics, and spelling are cialty in the local papers, American Association of
some examples of transferable skills. Medical Assistants (AAMA) or American Medical
When you have completed this portion of the Technologists (AMT) publications, and contacts
self-assessment, you will be in a better position to acquired through attending state and local meet-
determine what type of job to seek. You will also ings. Other sources are your program director and
have identified the skills that you can highlight instructors and the network of contacts at the site
as you prepare your application/cover letter and where you did your practicum. A practicum site
résumé. is frequently your best prospect because they will
The final part of your self-assessment is con- know your capabilities and your attitude and have
ducting a budgetary need analysis to determine expended time and resources in your training. If
how much income you need to make per month to the site is hiring and you performed well, experi-
meet your living expenses. ence has shown that most sites will frequently hire
The budgetary analysis should include a list the extern.
of the benefits you find necessary, such as medi- Candidate job sites can also be found through
cal, dental, and vision insurance, 401k program, employment agencies. These agencies usually
and stock options. You also might need to consider charge a fee, although sometimes the employer
work schedule, location/travel, and childcare leave pays the fee. Extreme caution should be exercised
policies. in dealing with agencies because fees are some-
To accomplish this, begin to keep a diary of times excessive. Fees should only be paid after suc-
all purchases and payments. By reviewing your cessfully obtaining a job and never for getting an
checkbook register, you should be able to item- interview.
ize basic expenditures, such as rent, utilities, pay- Prioritize the list based on your assessment
ments (car, credit card), food, clothing, insurance, of chances of employment. Sites where you have
and taxes. Once a monthly expenditure record is personal contacts or where you have done your
established the amount of money needed to meet practicum should be at the top of the list, with sites
living expenses can be calculated. advertising for help wanted next. Further down the
 CHAPTER 36 Employment Strategies 1075

list should be sites that, in sales parlance, would be

called cold prospecting. You can further prioritize Copy or design your own contact tracker form and document all
pertinent information regarding your job search contacts.
the list by putting your personal choices at the top
each category.
Now is the time to complete detailed home-
work or research on each prospective employer. describe your education, what you have done, and
Start collecting information on each prospective what you can do, and it lists those who can vouch
site, identifying their services, policies, fees and for your integrity and experience. A résumé that is
insurance protocol, hours of service, number of well thought out and written in such a way as to cre-
providers, and very importantly their mission state- ate interest in what you have to contribute to the
ment and philosophy of practice criteria. Brochures employer may reward you with many interviews.
may be available in their offices, on the Internet, During the interview your résumé serves as a refer-
and in wellness publications for patients. Pamphlets ence from which the interviewer may be prompted
on new procedures are other sources of this infor- to ask questions.
mation. You can use this information to prepare the
cover letter for your résumé and to brief yourself
should you be invited for an interview.
Résumé Specifications
As part of a serious job search, you should con- The résumé should be limited to one page in
tact many individuals and will need some means of length whenever possible. Each page should con-
recording the contacts, their responses, and your tain your name and the page number. Keep a 1-
actions. Figure 36-2 shows a helpful sample contact to 11⁄2-inch margin on all four sides of the page
tracker. It should be used to prevent confusion and to create a picture-like frame. Capitalize major
to keep track of valuable information and action headings and single space between lines. Double
items. space between sections. The use of bullet point
lists instead of paragraphs aids the interviewer in
gleaning key points quickly.
RÉSUMÉ PREPARATION Select a high-quality bond stationery that is
standard 81⁄2 × 11 inches with a weight between 16
A résumé is a summary data sheet or a brief and 25 pounds. This paper weight provides aes-
account of your qualifications and progress in the thetic benefit and accepts the ink better, result-
career you have chosen and should include both ing in a clean, sharp print resolution. Buff or ivory
direct and transferable skills. The purpose of your paper with matching envelope has great eye appeal
résumé is to sell you. It provides an opportunity to and helps distinguish your résumé from others.

Figure 36-2 A simple contact tracker such as this can help organize all communi-
cation you have with potential employers.
1076 UNIT 9 Entry into the Profession

Use a word processing program to produce plishment statements begin with power verbs and
your résumé. It allows you the freedom to experi- give a brief description of what you did and the
ment with placement and create a picture-perfect demonstrable results that were produced. Figure
résumé or to individualize the résumé for a partic- 36-3 provides a list of sample power verbs. Some
ular position or facility. accomplishment statement examples are “Uti-
lized computer skills to schedule and reschedule
patient appointments” and “Demonstrated skills
Clear and Concise Résumés in setting up sterile trays and assisting with sterile
Your résumé must be concise and easy to read procedures.”
and understand. Use statements that are positive,
reflect confidence, and portray you as a problem References
solver. Be sure that any information given within
your résumé or application form is not misleading Select a variety of references to be included with
or exaggerated. Leave out the word I when writing your résumé. References should be listed on a
your résumé. This is your personal résumé, and it separate sheet of paper that matches your résumé.
is understood that you are referring to yourself. Remember to include the same letterhead as on
your résumé on the references page. An individ-
ual who knows you or has worked with you long
Accomplishments enough to make an honest assessment and recom-
Use accomplishment statements if you have them mendation regarding your background history is
from your practicum or work experience. Accom- an excellent reference person. Use only nonre-

Accompanied Changed Corrected Entertained Implemented Listed

Accumulated Charged Corresponded Enumerated Improved Listened
Achieved Charted Counseled Established Improvised Loaded
Acquired Classified Created Estimated Increased Located
Administered Cleaned Debated Evaluated Indexed Logged
Admitted Cleared Decided Examined Indicated Mailed
Advised Closed Delegated Exchanged Influenced Maintained
Allowed Coded Delivered Exhibited Informed Managed
Analyzed Collated Demonstrated Expanded Initiated Manufactured
Answered Collected Deposited Expedited Inspected Marked
Applied Commanded Described Experienced Installed Marketed
Appointed Communicated Detailed Fabricated Instructed Measured
Appraised Compiled Determined Facilitated Insured Met
Arranged Completed Developed Figured Integrated Modified
Assembled Composed Devised Filled Interpreted Monitored
Assessed Computed Diagnosed Financed Interviewed Motivated
Assigned Conducted Directed Finished Introduced Negotiated
Attached Conferred Discovered Fitted Inspected Nominated
Attained Constructed Dismantled Fixed Inventoried Noted
Attended Consulted Dispatched Formalized Investigated Notified
Authorized Contacted Distributed Formulated Invoiced Observed
Balanced Contracted Documented Fulfilled Issued Obtained
Billed Contrasted Drew Generated Judged Opened
Bought Contributed Drove Graded Justified Operated
Budgeted Controlled Earned Graphed Kept Ordered
Built Converted Educated Greeted Learned Organized
Calculated Convinced Employed Headed Lectured Outlined
Cashed Coordinated Encouraged Hired Led
Catalogued Copied Engineered Identified Licensed (continues)

Figure 36-3 These sample power verbs may help you define your previous job responsibilities.
 CHAPTER 36 Employment Strategies 1077

Overcame Priced Ran Related Secured Summarized

Packaged Printed Rated Relayed Selected Supervised
Packed Processed Read Renewed Sent Supplied
Paid Procured Rearranged Reorganized Separated Taught
Participated Produced Rebuilt Repaired Served as Telephoned
Patrolled Programmed Recalled Replaced Serviced Tested
Perfected Promoted Received Reported Set up Trained
Piloted Prompted Recommended Requested Showed Transferred
Placed Proofread Reconciled Researched Sold Transported
Planned Proposed Recorded Responsible for Solicited Typed
Posted Proved Reduced Retrieved Sorted Verified
Prepared Provided Referred Revised Stocked
Prescribed Published Registered Routed Stored
Presented Purchased Regulated Scheduled Straightened

Figure 36-3 (continued)

lated persons as references unless the work rela- Accuracy

tionship has been formalized.
Proofread, proofread, and proofread your résumé.
Choose references who are well respected
Ask someone who is a good speller or one of your
and are clear speakers and writers. No matter how
references to edit your résumé. Then proofread it
much someone likes you and your work, they may
again yourself. Do not rely on your computer spell
not be helpful to you if they cannot convey the
check; it does not differentiate between words such
information in a business-like manner. Profes-
as to, too, two or here and hear. Eliminate repeti-
sional references such as a former instructor, pro-
tion of information such as task descriptions. Sum-
vider, practicum supervisor, or fellow coworker are
marize employment before 10 years ago or leave it
excellent choices.
off entirely if not relevant to the position you are
Always ask permission to use someone as a ref-
seeking.
erence before the name is printed on the reference
list. Verify the correct spelling of the reference’s
name, title, place of employment and position, Résumé Styles
and telephone number for prospective employers.
Help your references aid you in obtaining an Various résumé styles have been developed, each
interview and employment. A personal visit or tele- having specific advantages and disadvantages.
phone call to discuss your career objectives and Choose the style or combination of styles that best
how you plan to conduct your job search will be describes your strengths and ability to do the job.
helpful. Ask for any suggestions they may have to It may be advantageous to check with the human
offer. Provide them with a copy of your résumé and resources department of the facility to which you
cover letter. This helps them visualize the position are applying to determine if they have a résumé
for which you are applying and picture how you style preference.
may benefit that employer.
Keep in touch with references. Check back Chronologic Résumé. Your chronologic résumé
to see who has called and how things went. Know- should be organized so that the most important
ing what employers ask may produce some valu- information you want to share is the first thing the
able pointers for your next letter, résumé, or reader sees. If your job experience is your greatest
interview. asset and may set you apart from other applicants,
Finally, thank your references. They will put your work history and job skills first. If your
appreciate knowing how you are doing and that education and training is your best professional
you value their assistance. feature, put your education and training first.
Leave out “References Upon Request” if Some medical managers and human resources
necessary to shorten your résumé to save space. directors take only 10 seconds to scan a résumé.
Employers know they can ask for references at a You want them to see clearly and quickly what you
later date. have to offer.
1078 UNIT 9 Entry into the Profession

ASHLEY JACKSON, CMA (AAMA)

2031 Craig Street ~ Renton, Washington 98055
Work: 206-878-1545 Cell: 206-835-9879
Home: 253-838-6690 email: [email protected]

WORK EXPERIENCE
September, 1999-Present GROUP HEALTH COOPERATIVE
Directed support for a dermatology/surgery practice.
Patient preparation.
Medical and surgical asepsis.
Assist with sterile procedures.
Patient follow-up.
June, 1997-August, 1999 VALLEY INTERNAL MEDICINE
Clinical responsibilities.
Assisted with surgeries in ambulatory care setting.
Patient preparation.
Medical and surgical asepsis.
Assisted with sterile procedures.
March, 1997-June, 1997 VALLEY INTERNAL MEDICINE
Medical Assistant Practicum
Administrative duties and clinical responsibilities utilizing all medi-
cal assisting skills, including patient induction, chief complaint, vital
signs, patient preparation, EKGs, medical and surgical asepsis, and
sterile procedures.

EDUCATION/CERTIFICATION
Associate in Applied Science degree, June, 1997, Highline Community College,
Des Moines, Washington, 98198-9800.
Certified Medical Assistant (AAMA), June, 1997.

Figure 36-4 Sample chronologic résumé.

The chronologic résumé is advantageous • You have been in the same job for many years
when: • You are looking for your first job

• The position is in a highly traditional field, such

as teaching, law, or health care, where specific em- Figure 36-4 illustrates a chronologic résumé.
ployers are of paramount interest
• You are staying in the same field as prior jobs Functional Résumé. The functional résumé
• Job history shows real growth and development highlights specialty areas of accomplishment and
• Prior titles are impressive strengths. It allows you to organize them in an
order that supports your work objective.
The chronologic résumé is not advantageous The functional résumé is advantageous when:
when:
• Your experience can be sorted into areas of func-
• Your work history is spotty tion, i.e., administrative, clinical, supervisory
• You are changing career goals • You are changing careers
 CHAPTER 36 Employment Strategies 1079

• You are reentering the job market after an absence The functional résumé is not advantageous
• Your career path or growth is not clear from a when:
chronologic listing
• You want to emphasize a management growth
• You have had a variety of different, apparently
pattern
unconnected work experiences
• Your most recent employers are highly prestigious
• Much of your work has been volunteer, freelance,
and the specific employers are of paramount
or temporary
interest
• You want to eliminate repetition of descriptions of
job duties A sample of a functional résumé for a person
• You have extensive specialized experience reentering the job market is shown in Figure 36-5.

JOAN BISHOP, RMA

4320 Sprig Street
Renton, Washington 98055
Work: 206-878-1545 Cell: 206-835-9879
Home: 253-838-6690 email: [email protected]

TEACHING:
Instructed community groups on issues related to child abuse.
Taught volunteers how to set up community program for victims of domestic violence.
Conducted workshops for parents of abused children.
Instructed public school teachers on signs and symptoms of potential and actual
child abuse.
COUNSELING:
Consulted with parents for probable child abuse and suggested courses of action.
Worked with social workers on individual cases, in both urban and suburban settings.
Counseled single parents on appropriate coping behaviors.
Handled pre-take interviewing of many individual abused children.
ORGANIZATION/COORDINATION:
Coordinated transition of children between original home and foster home.
Served as liaison between community health agencies and schools.
Wrote proposal to state for county funds to educate single parents and teachers.
WORK HISTORY:
1998–2000 Community Mental Health Center, Tacoma, Washington
Volunteer Coordinator—Child Abuse Program
2000–2003 C.A.R.E.—Child-Abuse Rescue-Education, Trenton, New Jersey
County Representative
EDUCATION:
1998 B.S. Sociology, Douglass College, New Brunswick, New Jersey

Figure 36-5 Sample functional résumé. This style is useful for a person
reentering the job market.
1080 UNIT 9 Entry into the Profession

Targeted Résumé. The targeted résumé is best • The text résumé is not vulnerable to viruses and
for focusing on a clear, specific job target. It is compatible across computer programs and plat-
should contain a career objective and list your forms.
skills, capabilities, and any supporting accomplish- • The text résumé is versatile and can be used for:
ments related to that objective. This résumé style • Posting on job boards
enables graduating students to list classes related
• Pasting piece-by-piece into the profile forms of
to their career objective, grade point average, stu-
job boards, such as Monster.com
dent awards, and achievements. This information
adds substance to a résumé when work experience • Pasting into the body of an email to be sent to
is minimal and should be at the beginning of the prospective employers
résumé because it is your most significant asset. • Converting to a Web-based HTML résumé
The targeted résumé is advantageous when: • Sending as an attachment to prospective
• You are very clear about your job target employers
• You have had a variety of experiences that appear • Conversion to a scannable résumé
unrelated to each other but that include skills that Employers are often inundated with résumés
you can use in a skills list related to your job target
from job seekers each time they advertise a position
• You can go in several directions and want a differ- opening. Therefore, in an effort to save time and to
ent résumé for each determine the best-qualified candidates for the posi-
• You are just starting your career and have little tion, employers digitize the résumés to create an elec-
experience but know what you want and are clear tronic résumé. Using software to search for specific
about your capabilities keywords that relate to the position, the numbers of
• You are able to keep your résumé on a computer candidates can quickly be narrowed. If you apply for
disk a job with a company that searches databases for key-
words and your résumé does not conform, you may
The targeted résumé is not advantageous when: not be considered for the position.
How do you determine keywords? Begin
• You want to use one résumé for several different scrutinizing employment ads and list keywords
applications repeatedly mentioned in association with jobs that
• You are not clear about your abilities and accom- interest you. Nouns that relate to the skills and
plishments experience the employer is looking for will quickly
surface. Keywords may include:
Figure 36-6 shows a sample targeted résumé.
• Job-specific skills/profession-specific words (e.g.,
E-Résumé. An electronic résumé, also known as specialty experience, bilingual, scheduling, data
an e-résumé, is electronically delivered via email, entry, insurance verification, telephone and com-
submitted to Internet job boards, or placed on munication skills, laboratory/X-ray experience)
Web pages. When employers post jobs on their
• Technologic terms and descriptions of technical
own Web sites, they generally expect job seekers to
expertise (including hardware and software in which
respond electronically.
you are proficient, e.g., PRISM, DEXA experience)
Special care must be taken when preparing
the e-résumé because many employers place résu- • Job titles, certifications (e.g., MA, CMA [AAMA],
més directly into searchable databases. The follow- RMA, CMAS, Biller, Coder)
ing points should be considered: • Types of degrees, names of colleges (e.g., AAS, BA)
• Formatting must be removed before the résumé • Awards received, professional organization mem-
can be placed in a database. Submitting a format- berships (e.g., Dean’s list, scholarships, certificates,
ted résumé may cause it to be eliminated. AAMA or AMT member)
• Submit a text résumé, also known as a text-based Keywords should be used throughout the
résumé, plain-text résumé, or ASCII text résumé. résumé, but they should be front loaded. Front
These variations are preferred when submitting loaded means to use as many keywords as possible
résumés electronically. in the first 100 words of the résumé. A good goal is
• The e-résumé is not visually appealing. Eye appeal to aim for 25 to 35 keywords. This may be achieved
is not required because its main purpose is to be by using synonyms, various forms of the keyword,
placed into one of the keyword-searchable data- and using both the spelled-out and acronym ver-
bases. sions of common terms. If a person reviews the
 CHAPTER 36 Employment Strategies 1081

ASHLEY JACKSON, CMA (AAMA)

2031 Craig Street ~ Renton, Washington 98055
Work: 206-878-1545 Cell: 206-835-9879
Home: 253-838-6690 email: [email protected]

CAREER OBJECTIVES: To obtain a position as a medical assistant in an ambulatory

care/surgery facility that allows use and development of
clinical skills.
ACHIEVEMENTS:
Certified Medical Assistant.
Graduate of an Accredited Medical Assistant Program accredited by the
Commission on Accreditation of Allied Health Education Programs (CAAHEP).
Experienced in providing assistance with surgeries in an ambulatory care setting.
Excellent communication and interpersonal skills.
SKILLS AND CAPABILITIES:
Post-surgery patient follow-up.
Patient induction.
Vital signs.
Patient preparation.
EKGs.
Medical and surgical asepsis.
Sterile procedures.
WORK HISTORY:
September, 1996 to present Group Health Cooperative, Seattle, WA
Surgical Medical Assistant.
June, 1994-August, 1996 Valley Internal Medicine, Renton, WA
Clinical Medical Assistant.
March 1994-June, 1994 Valley Internal Medicine, Renton, WA
Practicum Student/Trainee.
EDUCATION/CERTIFICATION:
Associate in Applied Science Degree, Highline Community College.
Certified Medical Assistant (AAMA).
AFFILIATIONS:
American Association of Medical Assistants.

Figure 36-6 Sample targeted résumé. This style is useful when focusing on
a specific job target.

résumé, he or she will see enough keywords to pro- one you are confident will be answered in a profes-
cess it through the software search. sional manner. Always include the area code with
the number.
Vital Résumé Information • Your email address.
All résumé styles must contain certain vital infor- • Your education. Begin with the most recent school
mation about the job applicant. Essential informa- attended and include the name, address, and grad-
tion includes: uation date with the diploma, certificate, or degree
earned.
• Your full name and credential, address including • Work experience. List company name and ad-
street number, city, state, and zip code. dress. Do not underestimate the value of any
• Your telephone number or a number where a mes- job; relate transferable skills to your career
sage can be left. The telephone selected should be objective.
1082 UNIT 9 Entry into the Profession

• Skills that are necessary for the job. The list can should not give as a reason “in response to a
be completed from your program curriculum. Be help wanted ad.”
careful not to list course titles that have no mean- 4. The second paragraph should identify how your
ing to the reader. It is much better to list the skills education, experience, and qualifications relate
obtained in courses. to the job and refer to the enclosed résumé.
The following are the top errors found in 5. The last paragraph should close with a request for
résumés: an interview.
6. Have someone with management experience
• Typographical and grammatical errors review your cover letter. This could be your practi-
• Lack of specifics on work training or history cum supervisor, an instructor, a friend, or an
• Use of same résumé for all job applications (résumé acquaintance who is in a supervisory position.
should be tailored to specific job) 7. Do not reproduce cover letters. An original letter
• Emphasizing what you did instead of highlighting should be sent to each individual.
your accomplishments 8. The cover letter should be placed on top of the
• Stating objectives that do not focus on the needs of résumé and mailed in a business size envelope
the employer that matches its contents or in an 81⁄2 ⫻ 11 manila
envelope containing your return address.
• Lack of power verbs and keywords
9. Do not staple the cover letter to the résumé.
• Not mentioning jobs that gave you transferable
skills A sample of an application/cover letter is
• Lying or exaggerating about skills and experience shown in Figure 36-7A.
• Eliminating key accomplishments in order to meet An alternate example of an application/
a one-page goal cover letter using Information Mapping® to high-
light and draw attention to specific information in
your letter is shown in Figure 36-7B. This format
APPLICATION/COVER LETTERS is considered easier to read because the focus is
on specific blocks of information. In addition, its
The application/cover letter is a means of intro- uniqueness draws attention to your letter and may
ducing yourself and submitting your résumé to a result in your being selected when competition is
potential employer with the goal of obtaining an keen.
interview. A well-written cover letter highlights your
qualifications and experience for employment and
enhances the information contained within your COMPLETING THE
résumé. It should reflect how your skills satisfy the APPLICATION FORM
employer’s needs. The letter should follow a stan-
dard business style and should not be more than Sooner or later during the job search you will
one page in length. It should be printed on the be asked to complete an application form. How
same paper as the résumé. well you complete this task may be a key factor in
Because this may be your first contact with a obtaining an interview and that first job.
potential employer, the letter should sell you and Reading through the application form ques-
describe your intentions regarding employment, tions, you may be tempted to write in “See résumé”
display your personality, and create an interest in rather than repeat pertinent information already
reading your enclosed résumé. contained within your résumé. Do not fall into this
Some guidelines to follow in writing the appli- pitfall. Answer every item completely. The appli-
cation/cover letter include: cation is organized in the manner that suits the
clinic, whereas individual résumés are organized
1. Address your letter to a specific individual when-
in a variety of ways. Finding specific information
ever possible. You may need to make a telephone
on a résumé is more time consuming for the clinic,
call to obtain the name, title, and correct spelling.
whereas finding the same information on the job
2. Keep the letter concise, use correct grammar and application is easy and quick because they know
spelling, and follow standard business letter format where to look for it. Read all the directions care-
(formality is key). fully. Look for seemingly insignificant directions
3. The first paragraph should state your reason placed at the top or bottom of the page that state
for writing and focus the reader’s attention. It “Print Carefully,” “Complete in Your Own Hand-
 CHAPTER 36 Employment Strategies 1083

2031 Craig Street

Renton, Washington 98055
August 22, 20XX

Sarah Molles, Manager

Seattle Group Health Cooperative
304 Fourth Avenue
Seattle, Washington 98124-1716

Dear Ms. Molles:

I am interested in the medical assistant position to assist in a dermatology surgery

practice. I meet the qualifications and would like to be considered for the position.

I am currently a certified medical assistant certified through the National Healthcareer

Association (NHA). I have experience as a clinical assistant in an internal medicine
clinic and have excellent communication and interpersonal skills.

I will be available Tuesday and Thursday afternoon from 1:00 p.m. to 4:00 p.m. I will
call you next Thursday to set up an appointment for an interview.

Yours truly,

Porscha Dolan, CMA (AAMA)

Enclosure, Résumé

Figure 36-7A Sample application/cover letter.

writing,” or “Please Type.” Employers may use this increasingly the preferred method. All of the con-
to assess your ability to read and follow directions cerns relative to care in following instructions, pro-
and pay attention to detail. viding complete and accurate information, and
If the application is to be handwritten, use proofreading the application for any errors before
black ink to complete the form. Black ink is consid- sending are applicable.
ered legal and often is an indelible (permanent) If you are asked to list experience but the
ink and is more legible if the form must be dupli- application does not specify “paid experience,” be
cated. Concentrate when completing the form and sure to list any volunteer or practicum experience
be sure to print clearly and make no errors. When that relates to the position you are seeking. Part-
possible, copy the application before beginning in time employment can be important as an indicator
case an error is made. of your willingness to work, your ability to serve the
The current trend is toward online applica- public, and your organizational skills.
tion forms. These forms are prepared by keying You may be asked to complete the applica-
information into the appropriate spaces or blocks tion form “on the spot.” Plan ahead for this event
by using a computer. The completed forms are and carry a completed copy of your résumé, ref-
printed and mailed to the perspective employer erence list, and application/cover letter with you.
or sent electronically. Sending electronically is Also carry with you information not included in
1084 UNIT 9 Entry into the Profession

2031 Craig Street

Renton, Washington 98055
August 22, 20XX

Sarah Molles, Manager

Seattle Group Health Cooperative
304 Fourth Avenue
Seattle, Washington 98124-1716

SUBJECT: SURGICAL MEDICAL ASSISTANT POSITION

Background I am interested in the medical assistant position to assist in

a dermatology surgery practice. I meet the qualifications and
would like to be considered for the position.

Qualifications I am currently a certified medical assistant graduated from a

2-year program accredited by the Commission on Accreditation
of Allied Health Education Programs (CAAHEP). I have
experience as a clinical assistant in an internal medicine clinic
and have excellent communication and interpersonal skills.

Requested Action I will be available Tuesday and Thursday afternoon from

1:00 p.m. to 4:00 p.m. I will call you next Thursday to set
up an appointment for an interview.

Yours truly,

Ashley Jackson, CMA (AAMA)

Enclosure, Résumé

Figure 36-7B Sample information mapped letter.

your résumé, such as which years you attended an interview. An interview is a meeting in which
high school and your salary history. A pocket spell- you and the interviewer discuss the employment
ing wordbook or dictionary may be a useful tool opportunities within that particular organization.
to carry for those who find spelling challenging. It is the interviewer’s responsibility to determine if
These documents should provide all the informa- you have the personality, education, and skills to
tion needed to complete the application form and perform the job. The interviewer uses the inter-
may be submitted with the application form. This view process to assess appearance, attitude, and
demonstrates to the potential employer your seri- dependability. The interviewer also tries to verify
ousness and preparedness for finding a job. that you have been honest in the skills you claim to
have mastered. You, on the other hand, are selling
your qualifications and assessing if this is an orga-
THE INTERVIEW PROCESS nization in which you want to be employed.
Being well prepared for the interview will
If your application/cover letter, résumé, and increase your self-confidence and ability to focus
application form have made a favorable impres- during the actual interview. Knowing that your
sion with the organization, you may be invited for application/cover letter, résumé, and references
 CHAPTER 36 Employment Strategies 1085

all support your career goal and objectives allows

you time to concentrate on interview preparation
and presentation.

The Look of Success

The look of success begins with the outward
appearance. First impressions are lasting,
so strive for a favorable, professional look
from head to toe. Appropriate conservative attire
is important. Remember, your goal is to sell your
professional abilities.
Hair should be clean and healthy looking,
and worn in an appropriate style for the ambula-
tory care setting. Long hair should be worn off the
collar in perhaps a French braid or twist. Strive for
a neat, professional style.
The skin should have a healthy glow. Con-
sultation with a cosmetician may prove helpful in
solving skin problems or provide opportunity for
trying new products. A basic understanding of your
personal skin type and selection of cosmetics that Figure 36-8 Medical assistant appropriately dressed
complement your skin tone aid in the presentation and prepared for the interview.
of a professional appearance. The natural look is
most appropriate for the medical office.
A daily shower and use of personal hygiene not plan to search in either a purse or a portfolio
products is advised. Remember to use caution for a pen or papers, keys, and so forth. Be sure that
where perfumes and scents are concerned because your cell phone is turned off before entering the
many magnify when the body is under stress and the clinic.
scent may be offensive or cause allergic reactions in When you feel well and know that you look
others. Smokers should be aware that smoke odor good, you project a confident and professional
carries in their hair, skin, and clothing. This odor appearance. In other words, you are professionally
may not be acceptable in health care settings. poised. Webster’s Dictionary defines poise as balance
Fingernails should be short and oval shaped and stability; ease and dignity of manner. Personal
or have rounded corners. Only clear nail polish poise combines all of the previously mentioned
should be worn in the ambulatory care setting if body appearances plus smoothness of movement
you are not working in the clinical area. Nail pol- and physical flexibility.
ish that is chipped or cracked must be removed or
replaced immediately because it creates crevices in Preparing for the Interview
which pathogens may hide, multiply, and spread.
First impressions are lasting, so make yours Before the interview takes place, carefully research
professional in all respects. Conservative business the organization offering the position. Study the
attire is appropriate. Smart casual attire is appro- organization’s mission statement, financial reports,
priate for both men and women. This consists of a future projections, and any other information avail-
skirt and blouse or a tailored pantsuit for women able. Be prepared to relate your skills and interests
and slacks and dress shirt with or without a tie for
men. Pay attention to details such as your accesso-
ries and shoe selection. Accessories should be small Critical Thinking
and tasteful. Shoes should be clean, polished, and
in good repair. They should fit properly and be If you are a smoker, how can you minimize the
comfortable and easy to walk in (Figure 36-8). smoke odor carried on your person before
Women may carry a small purse if necessary. you go on a job interview? Make a list and
A portfolio is recommended in which to keep an prioritize each suggestion into a plan of
extra copy of your résumé, reference list, applica- action.
tion, and cover letter. A pen should be handy. Do
1086 UNIT 9 Entry into the Profession

to the needs of this organization. In other words,

what can you contribute and why should they hire REASONS FOR EMPLOYERS
you? The interview is your opportunity to sell your- NOT HIRING
self and identify ways in which you can benefit the
employer. Employers in business were asked to list reasons for
Bring a copy of your résumé and cover letter not hiring a job seeker. Given in rank order (from most
to the interview just in case the interviewer can- unwanted to least unwanted), the 15 biggest gripes are
not locate the original or wants another copy. You as follows:
should also have copies of letters of recommenda- 1. Poor appearance (not dressed properly, poorly
tion, a list of references, a copy of your transcript groomed).
from the schools you attended, and copies of any 2. Acting like a know-it-all.
certificates such as AIDS training, First Aid, and 3. Cannot express self clearly; poor voice, diction,
CPR. These items should not be presented unless grammar.
dictated by events that take place during the inter- 4. Lack of planning for work—no purpose or goals.
view. You might also have with you the name of the 5. Lack of confidence or poise.
interviewer and a copy of any questions you plan to 6. No interest in or enthusiasm for the job.
ask the interviewer. A last-minute review will refo- 7. Not active in school extracurricular programs.
cus your thoughts before you go into the interview. 8. Interested only in the best dollar offer.
Keep your list available for quick reference in the 9. Poor school record (academic, attendance).
event your mind goes blank when you are asked if 10. Unwilling to start at the bottom.
you have questions. 11. Making excuses, hedges on unfavorable record.
To arrive 5 to 10 minutes early, check a map 12. No tact.
for directions or make a trip the day before your 13. Not mature.
interview. Try to travel about the same time as you 14. No curiosity about the job.
would for the interview so you have an idea of 15. Critical of past employers.
the time it takes, traffic flow, construction areas
encountered, and parking availability. Plan for
Figure 36-9 Reasons for employers not hiring. (Cour-
inclement weather (raincoat, umbrella, shoes).
tesy of Highline Community College, Counseling/
It is a good idea to make a quick trip to the rest-
Career Center, Des Moines, WA.)
room on arrival to change shoes or recheck your
appearance.
Introduce yourself confidently to the admin-
istrative medical assistant and identify by name
the person you wish to see and the time of your the floor near your chair. Do not invade the inter-
appointment. Always arrive alone. The employer viewer’s territory by placing your things on the
wants to see you and sense your self-reliance and desk.
responsibility. While you wait, try to relax and Sit erect in the chair with your feet flat on
observe the office setting, other employees, what the floor or cross only your ankles. Avoid ner-
they are wearing, and their manner of conduct- vous mannerisms while you speak and maintain
ing business. This may be helpful to you during good eye contact, but do not stare the interviewer
the interview and in making a decision to work down. Be natural and positive about the posi-
there. tion, organization, and yourself. Present a profes-
Figure 36-9 lists reasons why employers do not sional image by using medical terminology when
hire applicants. responding to questions or providing informa-
tion. Observe the interviewer carefully for cues.
Respond to questions completely, trying not to
The Actual Interview repeat yourself or give more information than
When you enter an interviewer’s office, think of was requested.
yourself as a guest and take your cues from him or Be prepared for the kinds of questions that
her. Most interviewers will introduce themselves may be asked during the interview process. Ask
and extend a hand. A firm handshake, responding yourself, “If I were the employer, what would I want
by introducing yourself, and smiling confidently to know about the applicant?” Figure 36-10 gives
convey a positive professional image. Remain examples of standard questions asked by most
standing until you are invited to be seated. Keep employers. Consider how you would respond to
your personal items on your lap or place them on each question.
 CHAPTER 36 Employment Strategies 1087

Interviewing the Employer

TYPICAL QUESTIONS ASKED DURING
The worst thing that can happen to an entry-level
AN INTERVIEW employee is to be hired and then have to quit or be
fired because of a conflict with the employer. The
1. I see from your résumé you graduated from interview process is a two-way street. You, the inter-
______________ college. What did that college viewee, should also interview the potential employer.
have to offer that others didn’t? The following are danger signs of an employer who
2. What subjects did you enjoy the most and why? could make your work life very difficult:
3. What do you see yourself doing 5 years from now?
4. What salary do you expect and what do you think it • Disrespectful behavior during the interview toward
will be in 5 or 10 years? other staff members or to you
5. What do you consider to be your greatest strengths • Signs of insecurity by the manager
and weaknesses?
6. How do you think a friend or professor who knows • Lack of enthusiasm toward the organization
you well would describe you? • Shows signs of being highly stressed
7. What qualifications do you have that make you think • Negative attitude in statements
you would be successful in this position? • Arrogance or answers own questions
8. In what ways do you think you can make a contribu-
tion to our organization? • Uses the pronoun “I” excessively
9. What two or three accomplishments have given you You have to read the interviewer because
the most satisfaction? some of the signs listed could be attributed to a
10. What didn’t you like about your last employer? “bad day.” If too many signals are showing or, after
11. How well do you work under pressure? prudent questioning on your part, you still have
12. Will you be able to work overtime occasionally? concerns, perhaps you should look for employ-
13. How do you respond to criticism? ment elsewhere to avoid the possibility of damag-
14. How would you respond if a patient or coworker ing your future career.
made advances toward you? Following are a few questions you might ask
15. How would you handle following procedures with the interviewer to resolve some of these concerns
which you do not agree? raised by observations:
16. Describe a specific medical procedure.
17. Do you have any questions you would like to ask? • How would you describe the clinic culture?
18. How would you establish credibility quickly • How do you handle differing opinions on how best
with our team? to accomplish tasks?
19. What attracted you to this clinic?
20. What is the last book you read? • How are employee accomplishments recognized?
21. Why should we hire you? • What is the leadership style at the clinic?
22. What is your personal mission statement? • What is the attitude toward professional growth
and educational opportunities?
Figure 36-10 Knowing how you would answer some
of these typical questions can prepare you for your Answers to these questions will help you deter-
interview. mine if the clinic culture is one you can embrace.

Closing the Interview

Remember that the interviewer is asking ques- By observing the interviewer and listening care-
tions to determine if you are qualified for the posi- fully, you will be able to determine when the inter-
tion and if you are the kind of person who will fit viewer feels he or she has enough information
into the organization. Think before answering ques- about you to make a decision. Usually during the
tions; try to provide the information requested in a closing the interviewer asks if you have any addi-
positive and professional manner. Do not respond tional questions. This is your opportunity to col-
with slang terms. Listen carefully so that you under- lect information helpful in making a decision to
stand what information the question is requesting. accept or decline an offer. Your questions provide
Ask for clarification if you are uncertain. This dem- another opportunity to sell yourself, show that you
onstrates your ability to be open enough to ask have done your homework about the organization,
questions when in doubt. and have listened carefully during the interview.
1088 UNIT 9 Entry into the Profession

Select three or four questions that will help you interviewing you. The letter should be written in
the most. standard business format and printed on the same
Questions about the organization are excel- paper as your application/cover letter and résumé.
lent choices. Examples are: Be sure that all spelling and grammar are correct.
The follow-up letter provides another opportu-
• “What are the opportunities for advancement with nity to express your interest in the organization and
this organization?” the position. You can briefly emphasize the experi-
• “I read that your organization has educational ben- ence and skills you have to offer and again request
efits. Could you explain briefly how that program being considered a candidate for the position.
works?” Record the mailing date on your contact
• “You mentioned in-house training programs for tracker and keep a copy of the letter in a file with
employees. Could you give one or two examples?” other information about the organization. Figure
36-11 shows a sample follow-up letter.
You may also have some questions about the
job itself. Examples of these types of questions are:
Follow Up by Telephone
• “Is this a newly created position? If so, what results
are you hoping to see?”
Allow a few days for your follow-up letter to reach
the interviewer. If you do not hear from the inter-
• “Was the last person in this position promoted? viewer within a week or by the designated time
What contributed to their advancement?” established during the interview, you may call to
• “What do you consider the most difficult task on ask if you are still being considered for the position
this job?” or if a decision has been made.
• “What are the lines of authority for this position?” Speak directly into the mouthpiece of the tele-
phone using good diction and voice volume. Iden-
Do not use this question time to ask about sal- tify yourself and provide some information to aid
ary, sick leave, vacations, or retirement benefits. At the interviewer in recalling who you are. Perhaps
this point, your focus should be on the value and mentioning the date you interviewed will suffice. Be
skills you can contribute to the organization. These polite and professional, and remember to thank the
questions may be asked during a second interview individual for speaking with you. At the end of the
or when a position is offered. conversation say good-bye and wait until the other
Before you leave, thank the interviewer for person hangs up before you break the connection.
taking time to discuss the position with you. If Log the telephone call and its response on your
you definitely are interested in the position, ask contact tracker for future reference.
to be considered as a candidate for the position.
If follow-up procedures have not been explained,
now is the time to ask when the final selection AFTER YOU ARE EMPLOYED
will be made and how you will be notified. A firm
handshake as you leave, a pleasant smile, and You are now a newly employed medical assistant.
confidence as you exit will leave a professional What do you do now to advance your career? Fol-
picture in the interviewer’s mind. lowing are some suggestions:
• Make sure your workstation is set up and you have
INTERVIEW FOLLOW-UP what you need to do the job
• Practice good time management skills
Following up after the interview is essential. This is
the time to telephone your references to let them • Try to allow time for emergencies, which will occur
know the name of the organization and the per- • Do not be a know-it-all; ask other employees how
son’s name with whom you interviewed, something they do things around here
about the position, and your qualifications. Share • Get to know colleagues and be part of the team
any information that will help your references sup-
• Seek feedback on how you are doing your job
port you in obtaining the position.
• Create a professional image
Follow-Up Letter
Take time to write a follow-up letter or handwrit-
Dealing with Difficult People
ten note to the interviewer a day or two after your Sooner or later you will encounter coworkers who
interview to thank him or her for the time spent could be described as just plain “jerks.” Jerks may
 CHAPTER 36 Employment Strategies 1089

2031 Craig Street

Renton, Washington 98055
August 28, 20XX

Sarah Molles, Manager

Seattle Group Health Cooperative
304 Fourth Avenue
Seattle, Washington 98124-1716

Dear Ms. Molles,

Thank you for scheduling a personal interview with me last Wednesday, August 26,
at 9:45 AM. I enjoyed discussing the medical assistant position open in one of your
dermatology surgery practices. I would like to be considered for the position.

After talking with you, I feel my qualifications match closely with those you
requested. My communication and interpersonal skills are excellent and a neces-
sary ingredient for any medical assistant.

I look forward to hearing from you September 5 as you mentioned during the inter-
view. If there are any questions I may answer, please telephone me.

Sincerely,

Ashley Jackson
Ashley Jackson, CMA (AAMA)
(206) 255-1365

Figure 36-11 Sample follow-up letter.

be defined as persons who use power to belittle three quarters received a raise or promotion. After
and ridicule people who work under them. These taking into consideration the wages of persons
people may be foul-mouthed, power hungry, bul- with similar job descriptions and experience, if
lies, uncouth, or unethical. There are several ways your salary appears to be lagging you should not
to free yourself from jerks. feel uncomfortable asking for a raise at your next
favorable performance review.
• Check out emotionally (attempt to ignore the com-
ments); indifference is an underrated virtue
• Try to move to a different position within the orga- Critical Thinking
nization
• If all else fails, change jobs As you begin to prepare for a job interview,
how can you prepare yourself to reflect a
professional image, attitude, demeanor,
Getting a Raise verbal and nonverbal communication skills,
One of the main reasons people do not get a raise as well as articulately describe your skills
is because they do not ask. This is particularly true and abilities to fit the position to which you
of professional women. It has been reported that are applying? Develop a complete written
less than half ask for a raise or promotion within checklist and review it before each interview.
a 12-month period. Of those that did ask, almost
1090 UNIT 9 Entry into the Profession

PROFESSIONALISM • Promote your CMA (AAMA), RMA, CMAS, or

other credential. On graduation from an accred-
Areas of professionalism directly related to ited school, you will be ready to sit for the national
the medical office may include: certification examination. On notification of
passing the examination, you will be awarded
• Display a professional manner and image. The the appropriate credential. When signing your
chapter content stresses the importance of having name, include your credential and educate oth-
a positive attitude, taking pride in doing the best ers regarding its significance.
you can, being prepared, and dressing appropri-
ately for job interviews.

Case Study 36-1

Review the scenario at the beginning of the chapter. 3. What is the purpose of an accomplishment state-
ment? Provide examples Eun Mee might use.
CASE STUDY REVIEW
1. Which résumé style represents Eun Mee best and
why?
2. List transferable skills that Eun Mee may want to
include in her résumé.

Case Study 36-2

Drs. Lewis and King maintain a two-provider family practitio- CASE STUDY REVIEW
ner office.They are in need of a new medical assistant to take
the place of one who will be leaving at the end of the month. 1. Eun Mee enters the interview with some papers in
They have scheduled interviews with five applicants. Eun Mee her hand. What paperwork should she have brought
Soo is the first candidate to be interviewed. with her?
2. Why should Eun Mee arrive 5 to 10 minutes early
for the interview?
3. How should Eun Mee enter the room?

SUMMARY
Finding your first job is your first job. How well you research, plan, prepare, and implement your tasks will
make the difference between being hired and not being hired. Learn from each interview session. Recall
the questions that were asked and formulate answers that you feel would be appropriate for your next
interview. Tell everyone you are looking for a job and solicit their help. Follow up on all leads and do not
become discouraged.
Once you have been hired at that first job, continue your learning experience. Ask appropriate ques-
tions and try not to ask the same question a second or third time. Pay attention to details and learn indi-
vidual preferences. Become a team player and look for ways you can help others. Carry your share of
responsibility and do not be afraid to admit you are unfamiliar with certain aspects of the office. Employ-
ers need to know you can be trusted to work within the scope of your education and not beyond. Practice
being an asset to your employer.
 CHAPTER 36 Employment Strategies 1091

STUDY FOR SUCCESS

To reinforce your knowledge and skills of information presented in this chapter:
• Review the Key Terms
• Consider the Case Studies and discuss your conclusions
• Answer the Review Questions

° Multiple Choice
° Critical Thinking
• Navigate the Internet by completing the Web Activities
• Practice the StudyWARE activities on the textbook CD
• Apply your knowledge in the Student Workbook activities
• Complete the Web Tutor sections
• View and discuss the DVD situations

REVIEW QUESTIONS
Multiple Choice b. requires you to think before answering ques-
1. The résumé: tions, listen carefully, and ask for clarification if
a. is a summary data sheet or brief account of your uncertain of the question
qualifications and progress in your career c. provides time to ask questions about salary, vaca-
b. is also known as a contact tracker tion, and benefits
c. always includes references d. does not require any follow-up
d. is used to introduce yourself and identify 6. Preparing for the interview:
qualifications a. bathe yourself, groom your hair and fingernails,
2. References: and wear clean and pressed conservative busi-
a. must always be listed on the résumé ness attire
b. should be a relative b. allow adequate time to get to the interview
c. should be someone who likes you and your work c. prepare a packet to give the interviewer contain-
but may not be a good communicator ing certificates, letters of recommendation, a list
d. should be someone who knows you or has of references, and your list of questions
worked with you long enough to make an honest d. all of the above
assessment of your capabilities and integrity 7. Job analysis should include:
3. The targeted résumé is advantageous: a. compiling a list of potential employers
a. when prior titles are impressive b. gathering information about employers in
b. when reentering the job market after an absence whom you have interest
c. when you are just starting your career and have c. preparing a budgetary needs analysis
little experience d. all of the above
d. when you have extensive specialized experience 8. The best source for job search data is:
4. The application/cover letter: a. the Internet
a. is a detailed data sheet describing your vital b. friends and acquaintances
information, education, and experience c. the Yellow Pages and classified ads
b. introduces you to a prospective employer and d. all of the above
captures their interest in you as a candidate for
the position Critical Thinking
c. lists individuals who can vouch for you 1. Discuss the various résumé styles with a class-
d. should be lengthy and detailed mate and how to determine which style best pre-
5. The interview: sents your knowledge and skills to a prospective
a. does not require much thought or preparation employer.
1092 UNIT 9 Entry into the Profession

2. After reading the section discussing methods of questions that specifically discriminate against you
researching a prospective employer, how will you on the basis of:
proceed with your research? • Age
3. Review Figure 36-9, which lists reasons for employ- • Color
ers not hiring, with a classmate. How will you • Disability
prevent the 15 biggest gripes from being an • Sex
employment stumbling block for you personally? • National origin
4. How will you prepare a budget for living expenses • Race, religion, or creed
to determine job salary requirements? Using your favorite search engine, research these inap-
5. Sometimes employers may ask illegal or inappro- propriate questions and ways in which you might han-
priate questions during an interview in true inno- dle them appropriately. Compile a list of questions and
cence, or true ignorance. Give a legal reason why your personal appropriate response to each. Discuss
an employer might need the following information these with a classmate and role-play responding to the
once you have been hired. questions.
a. Are you married?
b. How many kids do you have?
c. How old are you? REFERENCES/BIBLIOGRAPHY
d. Where were you born? Farr, M. (2000). Quick resume & cover letter book.
Indianapolis, IN: JIST Works, Inc.
WEB ACTIVITIES Keir, L., Wise, B. A., Krebs, C., Kelley-Arney, C. (2008).
Medical assisting: Administrative and clinical competen-
1. Being prepared to answer and discuss inter- cies (6th ed.). Clifton Park, NY: Delmar Cengage
view questions is critical in the selection for Learning.
the position opening. Using Google.com, or Nobel, D. F. (2000). Gallary of best resumes for people with-
your favorite search engine, search job interview out a four-year degree. Indianapolis, IN: JIST Works,
questions. Many sites provide sample questions and Inc.
appropriate answers. Study them and prepare a list Sindell, M., & Sindell, T. (2006). Sink or swim. Avon,
of questions with personal responses you feel are MA: Adams Media Publishing.
appropriate. Washington, T. (2000). Resume power selling yourself on
2. There are some illegal interview questions based on paper in the new millennium. Indianapolis, IN: JIST
Federal Discrimination Laws enforced by the Equal Works, Inc.
Employment Opportunity Commission. They are Zedlitz, R. H. (2003). How to get a job in health care.
Clifton Park, NY: Delmar Cengage Learning.

THE DVD HOOK-UP

This chapter discusses strategies that you can use to help Using a scale of 1 to 10, how would you have rated your
gain employment. professionalism skills when you started the program? How
One of the first testimonials in this scene showed Paula would you rate your professional skills now that you have
talking about the fact that she can determine a person’s almost completed with the program? What improvements
professionalism within 5 minutes of the interview. do you need to make to be the best possible medical
assistant you can be?
1. Do you really think that it is possible to gauge a per-
son’s professionalism within 5 minutes of an interview?
2. What do you think about the outfit that Dee was wear-
ing for her interview? Do you think it was professional?
3. What will you wear for your interviews when you apply
for a medical assisting position? DVD Series Program Number
Critical Thinking 1
DVD Journal Summary
Chapter/Scene Reference
Write a paragraph that summarizes what you learned from
• Preparing for a Job
watching the selected scenes from today’s DVD program.
 Appendix A Common Medical Abbreviations and Symbols 1093
Appendix
Common Medical
Abbreviations and Symbols A
āa
¯¯ of each APC ambulatory payment classifications
AAMA American Association of Medical Assistants aq water
AAP American Academy of Pediatricians A/R accounts receivable
AAPC American Academy of Professional Coders ARDS acute (or adult) respiratory distress syndrome
ab abortion ARU automated routing unit
abd abdomen ASA acetylsalicylic acid
ABE acute bacterial endocarditis ASAP as soon as possible
ABG arterial blood gases ASC atypical squamous cell
ABHES Accrediting Bureau of Health Education ASCAD arteriosclerotic coronary artery disease
Schools ASC US atypical squamous cell of uncertain
ABO blood groups significance
abs absent ASCVD arteriosclerotic cardiovascular disease
ac before meals (ante cibum) atherosclerotic cardiovascular disease
acute A&W alive and well
ACAP Alliance of Claims Assistance Professionals
ACIP Advisory Committee on Immunization Practices Ba barium
ACOG American College of Obstetricians and BaE barium enema
Gynecologists BBB bundle branch block
ACTH adrenocorticotropic hormone BC birth control
ADA Americans with Disabilities Act BCP birth control pills
ADHD attention deficit hyperactivity disorder BC/BS Blue Cross/Blue Shield
ADL activities of daily living BE bacterial endocarditis
ad lib as desired bid twice a day
adm admission bil bilateral
AED automated external defibrillator BM basal metabolism
AFP alpha fetal protein bowel movement
AHD arteriosclerotic heart disease BMI body mass index
atherosclerotic heart disease BMR basal metabolism rate
AHDI Association for Healthcare Documentation BNA budget neutrality adjuster
Integrity BP blood pressure
AHIMA American Health Information Management BPH benign prostatic hypertrophy
Association BS blood sugar
AIDS acquired immunodeficiency syndrome bowel sounds
alb albumin breath sounds
AM before noon (ante meridiem) BSA body surface area
AMA against medical advice BSL blood sugar level
American Medical Association BSN bowel sounds normal
AMBA American Medical Billing Association BSO bilateral salpingo-oophorectomy
AMI acute myocardial infarction BSR blood sedimentation rate
amt amount BUN blood urea nitrogen
AMT American Medical Technologists BW below waist
AMTIE American Medical Technologists Institute for birth weight
Education body weight
ant anterior Bx biopsy
ante before
A&P anterior and posterior C Celsius
auscultation and palpation centigrade
auscultation and percussion c̄ with
1094 Appendix A Common Medical Abbreviations and Symbols

C1 first cervical vertebra C/O complains of

CA cancer CO2 carbon dioxide
carcinoma COB coordination of benefits
Ca calcium COPD chronic obstructive pulmonary disease
CAAHEP Commission on Accreditation of Allied Health CPC Certified Professional Coders
Education Programs CPC-A Certified Professional Coders-Apprentice
CAD coronary artery disease CPC-H Certified Professional Coders-Hospital
CAHD coronary arteriosclerotic heart disease CPC-HA Certified Professional Coders-Hospital
caps capsules Apprentice
CAM complementary and alternative medicine CPR cardiopulmonary resuscitation
CAT computerized axial tomography CPT Current Procedural Terminology
CBC complete blood count CPU central processing unit
CC chief complaint CRB Curriculum Review Board
CCA Certified Coding Associate crit hematocrit
CCMA Certified Clinical Medical Assistant CS cerebrospinal
CCP Certification Continuation Program cesarean section
CCR continuity of care record C&S culture and sensitivity
CCS Certified Coding Specialist CSF cerebrospinal fluid
CCS-P Certified Coding Specialist-Physician-Based CT computerized tomography
CCT cardiac computerized tomography CVA cerebrovascular accident
CCU coronary care unit CVE capsule video endoscopy
C&D cystoscopy and dilation CVP central venous pressure
CDC U.S. Centers for Disease Control and CVS chorionic villus sampling
Prevention cx cervix
CE continuing education CXR chest X-ray
cerv cervical cysto cystoscopic examination
cervix cystoscopy
CEU continuing education unit
CF conversion factor DACUM developing a curriculum
CHAMPVA Civilian Health and Medical Program of the DC doctor of chiropracty
Veterans Administration D&C dilation and curettage
CHD childhood disease DDS doctor of dentistry
congenital heart disease DEA U.S. Drug Enforcement Agency
congestive heart disease dec decrease
coronary heart disease DEERS Defense Enrollment Eligible Reporting
CHEDDAR chief complaint, history, examination, details System
of problems, drugs and dosages, assessment, del delivery
return visit if applicable DES diethylstilbestrol
CHF congestive heart failure DHHS U.S. Department of Health and Human
CHO carbohydrate Services
CIN cervical intraepithelial neoplasia diab diabetic
ck check diag diagnosis
Cl chlorine diff differential white blood cell count
cldy cloudy dil dilute
CLIA Clinical Laboratory Improvement disc discontinue
Amendments disp dispense
cm centimeter DM diabetes mellitus
CMA Certified Medical Assistant through the DNA deoxyribonucleic acid
(AAMA) American Association of Medical Assistants does not apply
CMAA Certified Medical Administrative Assistant DNR do not resuscitate
CMAS Certified Medical Administrative Specialist DO doctor of osteopathy
CME continuing medical education DOA dead on arrival
CMR cardiac magnetic resonance DOB date of birth
CMS Centers for Medicare and Medicaid DOD date of death
Services DOE dyspnea on exertion
CMT Certified Medical Transcriptionist dos dosage
CNS central nervous system DPI dry powder inhaler
 Appendix A Common Medical Abbreviations and Symbols 1095

DPM doctor of podiatric medicine FECA Federal Employees Compensation Act

DPT diphtheria, pertussis, and tetanus Program
DR delivery room FH family history
Dr doctor FHR fetal heart rate
DRGs diagnosis-related groups FHS fetal heart sound
DS discharge summary fl fluid
DSD dry sterile dressing fl oz fluid ounce
dsg dressing FMP first menstrual period
DT delirium tremens FP family practice
DTR deep tendon reflex freq frequent
D&V diarrhea and vomiting FSH follicle-stimulating hormone
DW distilled water ft foot
D/W dextrose in water FTA fluorescent treponemal antibody
dx diagnosis FTP file transfer protocol
fx fracture
ea each
EBV Epstein–Barr virus G gravida
ECG electrocardiogram g gram
echo echocardiogram GB gallbladder
echoencephalogram GC gonococcus
E. coli Escherichia coli gonorrhea
ECT electroconvulsive therapy GERD gastroesophageal reflux disease
electronic claims transmission GI gastrointestinal
EDC estimated date of confinement or expected gm gram
date of confinement GP general practice
EDD estimated date of delivery or expected date GPCI Geographic Practice Cost Index
of delivery gr grain
EEG electroencephalogram grav pregnancy
EENT eyes, ears, nose, and throat GTH gonadotropic hormone
e.g. for example GTT glucose tolerance test
EHR electronic health record gtt(s) drop (drops)
EKG electrocardiogram GU genitourinary
elix elixir GYN gynecology
Email electronic mail
EMG electromyography h hour
EMR electronic medical record HAI healthcare–associated infection
EMS emergency medical service HBP high blood pressure
ENT ear, nose, and throat HCFA U.S. Health Care Financing Administration
EOB explanation of benefits hCG human chorionic gonadotropin
eos eosinophil HCl hydrochloric acid
EPA Environmental Protection Agency HCPCS Healthcare Common Procedure Coding System
EPCA-2 early prostate cancer antigen-2 Hct hematocrit
EPO exclusive provider organization HCVD hypertensive cardiovascular disease
eq equivalent HEENT head, eyes, ears, nose, and throat
ER emergency room HEPA high-efficiency particulate air
ERT estrogen replacement therapy Hgb hemoglobin
ESR erythrocyte sedimentation rate H&H hemoglobin and hematocrit
EST electroshock therapy HIPAA Health Insurance Portability and
exam examination Accountability Act
ext extract HMO health maintenance organization
H/O history of
F Fahrenheit H2O water
female H&P history and physical
FAS fetal alcohol syndrome HPI history of present illness
fax facsimile HPV human papillomavirus
FBS fasting blood sugar HR human resources
FDA U.S. Food and Drug Administration HRS Healthcare Reimbursement Specialist
1096 Appendix A Common Medical Abbreviations and Symbols

HRT hormone replacement therapy LE lupus erythematosus

HSV1 herpes simplex virus 1 LEEP loop electrosurgical excision procedure
HSV2 herpes simplex virus 2 liq liquid
HT hormone therapy LLQ lower left quadrant
ht height LMP last menstrual period
hx history LP lumbar puncture
Hz hertz LRQ lower right quadrant
LUQ left upper quadrant
ICCU intensive coronary care unit L&W living and well
ICD-9-CM International Classification of Diseases, lymphs lymphocytes
9th revision, Clinical Modification
ICU intensive care unit M male
ID intradermal m meter
I&D incision and drainage MA medical allowable
IDS integrated delivery system MBCD management by coaching and development
IM internal medicine MBCE management by competitive edge
intramuscular MBDM management by decision models
imp impression MBP management by performance
inf infusion MBS management by styles
inj injection MBWA management by wandering around
I&O intake and output MBWS management by work simplification
IOM Institute of Medicine MCHC mean corpuscular hemoglobin and red cell
IPA independent physician association indices
IPV intimate partner violence MCO managed care organization
IPPB intermittent positive pressure breathing MCV mean corpuscular volume and red cell indices
IPPS inpatient prospective payment systems MD doctor of medicine
ISP Internet service provider muscular dystrophy
IUD intrauterine device MDI metered dose inhaler
IV intravenous MDR minimum daily requirement
IVF in vitro fertilization med medicine
IVP intravenous pyelogram mEq/L milliequivalents per liter
MFS Medicare fee schedule
JAAMT Journal of the American Association for Medical mg milligram
Transcription MH marital history
JAMA Journal of the American Medical Association medical history
jt joint menstrual history
MHx medical history
K potassium MI maturation index
kg kilogram myocardial infarction
KOH potassium hydroxide mL milliliter
KUB kidney, ureter, and bladder mm millimeter
kV kilovolt mm3 cubic millimeter
mm Hg millimeters of mercury
L left MMR measles, mumps, and rubella
liter MOM milk of magnesia
l length mono mononucleosis
LA left atrium MP menstrual period
lactic acid MRC Medical Reserve Corps
L&A light and accommodation MRI magnetic resonance imaging
lab laboratory MRIA magnetic resonance imaging angiography
lac laceration MRSA methicillin resistant Staphylococcus aureus
LAN local area network MS mitral stenosis
lap laparotomy multiple sclerosis
lat lateral MSDS material safety data sheets
lb pound MSHA Mine Safety and Health Administration
LBBB left bundle branch block MT medical technologist
LDL low-density lipoprotein medical transcriptionist
 Appendix A Common Medical Abbreviations and Symbols 1097

multip multipara OR operating room

MVP mitral valve prolapse operative report
ortho orthopedics
NA not applicable os mouth
NaCl sodium chloride OSHA U.S. Occupational Safety and Health
NACP National Association of Claims Assistance Administration
Professionals OT occupational therapist
narc narcotic occupational therapy
NB newborn OTC over the counter
NCAI National Coalition for Adult Immunization OURQ outer upper right quadrant
N/C no complaints OV office visit
ND doctor of naturopathy OWCP Office Workers’ Compensation Programs
NEBA National Electronic Billers Alliance oz ounce
NEC not elsewhere classified
neg negative P phosphorus
NG nasogastric pulse
NGU nongonococcal urethritis P&A percussion and auscultation
NHA National Healthcareer Association PA physician’s assistant
NIDDM noninsulin–dependent diabetes mellitus posteroanterior
NL normal limits PAC phenacetin, aspirin, and codeine
NMP normal menstrual period premature atrial contraction
noct at night PACS picture archiving and communications
Non-PAR nonparticipating provider systems
non rep do not repeat Pap Papanicolaou (smear, test)
NOS not otherwise specified PAR participating provider
NPI national provider identification para number of pregnancies
NPO nothing by mouth para I primipara
NR no refill PAT paroxysmal atrial tachycardia
nonreactive path pathology
normal range PBI protein-bound iodine
NS nonspecific pc after meals
normal saline PC personal computer
not significant PCA patient-controlled analgesic
not sufficient PCC Poison Control Center
N&T nose and throat PCN penicillin
N&V nausea and vomiting PCP primary care physician
NVD nausea, vomiting, and diarrhea PCR polymerase chain reaction
PCV packed cell volume
O oral PDA personal digital assistant
oxygen PDR Physician’s Desk Reference
O2 oxygen PE physical examination
OB obstetrics peds pediatrics
OB-GYN obstetrics-gynecology PEG pneumoencephalography
OC office call PERRLA pupils equal, round, regular, react to light, and
on call accommodation
oral contraceptive PET positron emission transmission or
occ occasionally tomography
OCR Office of Civil Rights PH past history
optical character reader personal history
OGTT oral glucose tolerance test public health
OM office manager pH hydrogen in concentration
OOB out of bed PHI protected health information
OP outpatient PHO physician-hospital organization
O&P ova and parasites PI present illness
OPIM other potentially infectious material pulmonary infarction
OPPS outpatient prospective payment systems PID pelvic inflammatory disease
OPV oral poliovaccine PKU phenylketonuria
1098 Appendix A Common Medical Abbreviations and Symbols

PM after noon (post meridiem) RBC/hpf red blood cells per high power field
post mortem (after death) RBCM red blood cell mass
PMN polymorphonuclear neutrophils RBCV red blood cell volume
PMP past menstrual period RBRVS Resource-Based Relative Value Scale
PMS premenstrual syndrome REM rapid eye movement
PNC penicillin resp respiration
PO postoperative Rh rhesus (factor)
po by mouth Rh- rhesus negative
POB place of birth Rh+ rhesus positive
POLST physician orders for life-sustaining treatment RHD rheumatic heart disease
POMR problem-oriented medical record RLQ right lower quadrant
POS point-of-service plan RMA Registered Medical Assistant
pos positive RNA ribonucleic acid
poss possible R/O rule out
postop postoperative ROA received on account
PP present problem ROM range of motion
postprandial read-only memory
PPB positive pressure breathing ROS review of systems
PPBS postprandial blood sugar ROTA rotavirus
PPD purified protein derivative RT radiation therapy
PPO preferred provider organization RUQ right upper quadrant
preop preoperative RVUs relative value units
primip woman bearing first child Rx prescription
prn as the occasion arises, as necessary
procto proctoscopy S subjective data (POMR)
prog prognosis s̄ without
PROM premature rupture of membranes S&A sugar and acetone (urine)
pro-time prothrombin time SA sinoatrial
PRSP penicillin-resistant Streptococcus pneumonia SARS severe acute respiratory syndrome
PSA prostate-specific antigen SBE shortness of breath on exertion
PSRO Professional Standards Review Organization subacute bacterial endocarditis
PT physical therapy SE standard error
prothrombin time sed rate sedimentation rate
pt patient segs segmented neutrophils
PTA prior to admission seq sequela
PTT partial thromboplastin time SF scarlet fever
pulv powder spinal fluid
PVC premature ventricular contraction SG specific gravity
px physical examination SH social history
prognosis SIDS sudden infant death syndrome
sig instructions, directions
q each; every sigmoid sigmoidoscopy
q AM every morning SIL squamous interepithelial lesion
QA quality assurance SMA 12/60 Sequential Multiple Analyzer (12-test serum
qh every hour profile)
q (2, 3, 4)h every 2, 3, or 4 hours SOAP subjective data, objective data, assessment, and
qid four times a day plan
QISMC Quality Improvement System for Managed SOAPER subjective, objective, assessment, plan, educa-
Care tion, response
qns quantity not sufficient SOB shortness of breath
qs of sufficient quantity SOF signature on file
qt quart sol solution
solv solvent
R registration SOMR source-oriented medical record
right SOP standard operating procedure
RAM random access memory SOS if necessary
RBC red blood cell spec specimen
 Appendix A Common Medical Abbreviations and Symbols 1099

sp gr secific gravity UA urinalysis

spont ab spontaneous abortion UB04 Uniform Bill 04
SR sedimentation rate UCG urinary chorionic gonadotropin
SS signs and symptoms UCHD usual childhood diseases
s̄s
¯¯ one-half UCR usual, customary, reasonable
SSI Supplemental Security Income ULQ upper left quadrant
Staph Staphylococcus ung ointment
stat immediately UNICEF United Nations International Children’s
STD sexually transmitted disease Emergency Fund
Strep Streptococcus UR utilization review
subq subcutaneous urg urgent
supp suppository URI upper respiratory infection
surg surgery URL Uniform Resource Locator
sx signs urol urology
symptoms URQ upper right quadrant
sym symptoms URT upper respiratory tract
syr syrup URTI upper respiratory tract infection
USB universal system bus port
T temperature USMLE United States Medical Licensing
T3 tri-iodothyronine Examination
T4 thyroxine USP United States Pharmacopoeia
T&A tonsillectomy and adenoidectomy UT urinary tract
tab tablet UTI urinary tract infection
TAT temporal artery thermometer UV ultraviolet
TB tuberculin
tuberculosis vac vaccine
TBS The Bethesda System vag vagina
tbs tablespoon vaginal
TC throat culture VD venereal disease
tissue culture VDRL Venereal Disease Research Laboratory
total capacity VIS vaccine information statement
total cholesterol vit vitamin
TENS transcutaneous electrical nerve stimulator vit cap vital capacity
TFTC Task Force for Test Construction vol volume
ther therapy VoIP voice over Internet protocol
therap therapeutic VRE vancomycin-resistant enterococcus
TIA transient ischemic attack VRS voice recognition software
tid three times a day VS vital signs
tinct tincture
TLC tender loving care WAN wide area network
TMJ temporomandibular joint WBC white blood cell
top topically WC white cell
TOPV trivalent oral poliovirus vaccine WDWN well developed, well nourished
TP total protein WHO World Health Organization
TPI treponema pallidum immobilization test WN well nourished
TPMS Total Practice Management System WNF well-nourished female
TPN total parenteral nutrition WNL within normal limits
TPR temperature, pulse, and respiration WNM well-nourished male
tr tincture WO written order
trig triglycerides w/o without
TSH thyroid-stimulating hormone wt weight
tsp teaspoon WVE wireless video endoscopy
TSS toxic shock syndrome
TUR transurethral resection x multiply by
tus cough XDR TB extensively drug-resistant tuberculosis
T&X type and cross match XR X-ray
1100 Appendix A Common Medical Abbreviations and Symbols

YOB year of birth – negative

yr year Ⳳ positive or negative, indefinite
⳰ divide by
= equal to
Symbols > greater than
* birth < less than
† death ⫻ multiply by
么 male 噜 number, pound
乆 female ⴕ foot, minute
+ positive ⴖ inch, second
Top 50 Brand Drugs Appendix

for 2007 by Number of U.S.

Prescriptions Dispensed B
1. Lipitor 18. Zyprexa 35. Coreg
2. Nexium 19. Levaquin 36. Flomax
3. Advair Diskus 20. Celebrex 37. Lyrica
4. Prevacid 21. Zetia 38. Wellbutrin XL
5. Plavix 22. Valtrex 39. Aricept 9
6. Singulair 23. Crestor 40. Imitrex Oral
7. Seroquel 24. Fosamax 41. Ambien
8. Effexor 25. Zyrtec 42. Lotrel
9. Lexapro 26. Lantus 43. Nasonex
10. Actos 27. Adderall XR 44. Toprol XL
11. Protonix 28. Diovan 45. Ambien CR
12. Vytorin 29. Avandia 46. Enbrel
13. Topamax 30. Tricor 47. Spiriva
14. Risperdal 31. AcipHex 48. Viagra
15. Abilify 32. Diovan HCT 49. Lidoderm
16. Cymbalta 33. OxyContin 50. Actonel
17. Lamictal 34. Concerta

Drug Topics. (2008). Top 200 brand-name drugs by retail dollars in 2007. Retrieved July 24, 2008, from http://
drugtopics.modernmedicine.com/drugtopics/data/articlestandard//drugtopics/102008/500221/
article.pdf.
Text not available due to copyright restrictions
Appendix C AAMA 2007–2008 Occupational Analysis of the CMA (AAMA)* 1103

Text not available due to copyright restrictions

Text not available due to copyright restrictions
 Appendix D Medical Assisting Task List 1105
Appendix

Medical Assisting Task List D

The various tasks that medical assistants perform include, but are not necessarily limited to, those on the
following list.
The tasks presented in this inventory are considered by American Medical Technologists to be representa-
tive of the medical assisting job role. This document should be considered dynamic, to reflect the medical
assistant’s evolving role with respect to contemporary health care. Therefore, tasks may be added, removed,
or modified on an on-going basis.
Medical Assistants that meet AMT’s qualifications and pass a certification examination are certified as a
Registered Medical Assistant (RMA).

I. GENERAL MEDICAL ASSISTING KNOWLEDGE

A. Anatomy and Physiology D. Medical Ethics
1. Body systems 1. Principles of medical ethics
2. Disorders and diseases of the body 2. Ethical conduct
B. Medical Terminology 3. Professional development
1. Word parts E. Human Relations
2. Medical terms 1. Patient relations
3. Common abbreviations and symbols 2. Interpersonal skills
4. Spelling 3. Cultural diversity
C. Medical Law F. Patient Education
1. Medical law 1. Identify and apply proper communication
2. Licensure, certification, and registration methods in patient instruction
2. Develop, assemble, and maintain patient
resource materials

II. ADMINISTRATIVE MEDICAL ASSISTING

A. Insurance 4. Electronic insurance claims
1. Medical insurance terminology 5. ICD-9CM/CPT Coding applications
2. Various insurance plans 6. HIPAA mandated coding systems
3. Claim forms 7. Financial applications of medical insurance
1106 Appendix D Medical Assisting Task List

B. Financial Bookkeeping 3. Appointment scheduling systems

1. Medical finance terminology 4. Oral and written communications
2. Patient billing procedures 5. Medical records management
3. Collection procedures 6. Charting guidelines and regulations
4. Fundamental medical office accounting 7. Protect, store, and retain medical records
procedures according to HIPAA regulations
5. Office banking procedures 8. Release of protected health information
6. Employee payroll adhering to HIPAA regulations
7. Financial calculations and accounting 9. Transcription of dictation
procedures 10. Supplies and equipment management
C. Medical Secretarial—Receptionist 11. Medical office computer applications
1. Medical terminology associated with recep- 12. Compliance with OSHA guidelines and
tionist duties regulations of office safety
2. General reception of patients and visitors

III. CLINICAL MEDICAL ASSISTING

A. Asepsis 4. Methods of examinations
1. Medical terminology 5. Specialty examinations
2. State/Federal universal bloodborne 6. Visual acuity/Ishihara (color blindness)
pathogen/body fluid precautions measurements
3. Medical/surgical asepsis procedure 7. Allergy testing procedures
B. Sterilization 8. Normal/abnormal results
1. Medical terminology associated with steril- F. Clinical Pharmacology
ization 1. Medical terminology associated with phar-
2. Sanitization, disinfection, and sterilization macology
procedures 2. Commonly used drugs and their categories
3. Record keeping procedures 3. Various routes of medication administration
C. Instruments 4. Parenteral administration of medications
1. Specialty instruments and parts (subcutaneous, intramuscular, intradermal,
2. Usage of common instruments ZTract)
3. Care and handling of disposable and 5. Classes or drug schedules and legal pre-
reusable instruments scriptions requirements for each
D. Vital Signs/Mensurations 6. Drug Enforcement Agency regulations for
1. Blood pressure, pulse, respiration measure- ordering, dispensing, storage, and docu-
ments mentation of medication use
2. Height, weight, circumference measure- 7. Drug Reference books (PDR, Pharma-
ments copeia, Facts and Comparisons, Nurses
Handbook)
3. Various temperature measurements
G. Minor Surgery
4. Recognize normal and abnormal measure-
ment results 1. Surgical supplies and instruments
E. Physical Examinations 2. Asepsis in surgical procedures
1. Patient history information 3. Surgical tray preparation and sterile field
respect
2. Proper charting procedures
4. Prevention of pathogen transmission
3. Patient positions for examinations
 Appendix D Medical Assisting Task List 1107

5. Patient surgical preparation procedures 6. Capillary, dermal, and venipuncture proce-

6. Assisting physician with minor surgery dures
including set-up 7. Office specimen collection such as: urine,
7. Dressing and bandaging techniques throat, vaginal, wound cultures – stool,
8. Suture and staple removal sputum, etc
9. Biohazard waste disposal procedures 8. Specimen handling and preparation
10. Instruct patient in pre- and postsurgical 9. Laboratory recording according to state
care and federal guidelines
H. Therapeutic Modalities 10. Adhere to the MA Scope of Practice in the
1. Various standard therapeutic modalities laboratory
2. Alternative/complementary therapies J. Electrocardiography
3. Instruct patient in assistive devices, body 1. Standard, 12 lead ECG testing
mechanics, and home care 2. Mounting techniques for permanent record
I. Laboratory Procedures 3. Rhythm strip ECG monitoring on lead II
1. Medical laboratory terminology K. First Aid
2. OSHA safety guidelines 1. Emergencies and first aid procedures
3. Quality control and assessment regulations 2. Emergency crash cart supplies
4. Operate and maintain laboratory equipment 3. Legal responsibilities as a first responder
5. CLIA waived laboratory testing procedures
Appendix
Software Support:
E The Critical Thinking Challenge

TECHNICAL SUPPORT INFORMATION

Technical Support at Delmar Cengage Learning is available from 8:30 am to 6:30 pm, Eastern Standard
Time.

• Telephone: 1-800-648-7450
• Email: [email protected]

ABOUT THE CRITICAL THINKING CHALLENGE 2.0

The new Critical Thinking Challenge (CTC) 2.0 is a game that simulates a 3-month practicum in Dr. Con-
nor’s medical office. In this game, you’ll be confronted with a series of situations in which you have to
use critical thinking skills to select the most correct action in response to the situation. Your actions will
be evaluated by how the decision has affected the practice, the patient, and your career. You will also be
awarded points for your overall decision-making. The 2.0 version includes 10 all-new video-based scenarios
that include more follow-on scenarios, depending on the decisions made. After successfully completing
the program, print out a Certification of Completion.

Setup and Time Requirements

The program automatically starts when you put the
CD into your computer. Completion of the game
requires about 30 minutes of your time.
After watching the Overview video, you must
set up your character as male or female by clicking
the appropriate button. You can turn on Subtitles
by clicking the buttons in the bottom left corner of
the game window. You can turn Subtitles on or off
at any point in the game.
To adjust the volume level, click on the Vol-
ume button at the lower right side of the game
window. Then, move the fader to the desired set-
ting. Click Close in the volume window to return
to the game.
To exit the Critical Thinking Challenge, click
on the Quit button in the bottom right corner of
the game window. Your score will not be saved. The
next time you enter the Critical Thinking Chal-
lenge, you will have to start from the beginning.
 Appendix E Software Support: The Critical Thinking Challenge 1109

Playing the Game

You are a character in each situation in the game.
Each situation is a video presented from your point
of view. In some cases, you will be directly involved
in the situation, interacting with other staff mem-
bers or patients; in other instances, you will be a
witness to the situation. However, in every situa-
tion presented, you must use your critical thinking
skills to respond.
The object of the game is to receive an offer
of employment from the medical practice.

The Situations. You will need to view each video

situation to determine the best action to take. To
control the pace of the narrative, use the video
buttons at the bottom of the game window. These
allow you to play, pause, forward, and reverse the
narration. After you view the video scenario, you
are presented with three possible actions that you
can take.

Using Resources. To help you choose the most

correct action, you may consult your Resources
Panel by clicking the Resources button on the
lower left side of the game window. The Resources
Panel allows you to access People and Documents
resources and the Available Time clock.
The People resources allow you to interact
with individuals in the medical office who may
be able to assist you in choosing the appropriate
action. Click on the staff member with whom you
would like to speak.
The Documents resources represent files that
would be found in the medical office and that may
be able to help you. Keep in mind that not all the
resources may be available when you need them or
helpful to you, depending on the situation. Always
use your critical thinking skills!

Available Time Clock. Each time you consult with

a resource, you use up 5 minutes of the scenario
clock. Most of the time you’ll be able to check with
up to four resources; however, some situations are
more time-sensitive than others, so you’ll have to
choose your resources carefully. Don’t worry about
using up time while you’re thinking about what to
do; the clock only moves ahead each time you con-
sult a resource.
1110 Appendix E Software Support: The Critical Thinking Challenge

Evaluation and Points Awarded

When you have finished consulting your resources,
select one of the actions presented. Your decisions
are then evaluated in three categories: practice,
patient, and career.
• Practice means how your decisions affect the
medical office—reputation, patient retention, eth-
ical and legal compliance, or medical malpractice
liability.
• Patient means how your decision affects the
patient—sensitivity, privacy, health, convenience,
and satisfaction.
• Career means how your decisions affect your
career as a medical assistant—employability, pro-
fessionalism, effectiveness, reputation, ethical and
legal compliance, or medical malpractice liability.

You will receive positive and negative feedback

discussing the merits of your decision and the out-
come of the situation, and then you are awarded
points for your overall decision-making skills.
You will receive points according to the merits
of the action chosen:
• You will receive 10 points for selecting the best
action.
• You will receive 5 points for selecting a good action
to take, but not the best action.
• You will not receive any points for selecting the
least desirable action.

Follow-on Situations
In some cases, if you do not select the best decision
in the first instance, you will be presented with a
follow-on situation that directly resulted from the
action (or lack of action) that you chose.
In these situations, the maximum point value
you are awarded is less than what you would have
received in the original scenario. Remember, these
situations could have been avoided if you had
taken the most appropriate action at first, even if it
seemed difficult to do.
Points are awarded in follow-on situations as
follows:
• You will receive 7 points for selecting the best action.
• You will receive 3 points for selecting the next-best
action.
• You will not receive any points for selecting the
least desirable solution.
 Appendix E Software Support: The Critical Thinking Challenge 1111

Scoring the Game • If you score between 70 and 85 points, you

will receive a letter of recommendation from
Your goal is to be hired by Dr. Connor’s office as
Dr. Connor’s office. At the end of game play, you
a full-time medical assistant. On the other hand,
will receive a Certificate of Completion that you
if you show a serious lack of critical thinking skills
can print out.
that threatens the well-being of the medical office
or the patients, Dr. Connor’s office will terminate • If you score below 70 points, your practicum is ter-
your practicum and you’ll have to start over. minated, and you’ll need to start over.
• Your practicum also can be terminated early if you
• You will receive a job offer to work in the office if choose the least desirable action three times in a
you score above 85 points in the game. At the end row at any point during game play.
of game play, you will receive a Certificate of Com-
pletion that you can print out.
This page intentionally left blank
 Glossary of Terms 1113

Glossary of Terms

Note: The equivalent Spanish word follows in parentheses in acetone (acetona) colorless, inflammable liquid. Found in
green. the blood and urine of diabetics as a result of the breakdown
of fatty acids (Ch. 38).
A acid/base balance (equilibrio ácido-básico) condition that
occurs when the net rate at which the body produces acids or
abduction (abducción) motion away from the midline of the bases is equal to the net rate at which acids or bases are excre-
body (Ch. 33). ted (Ch. 42).
ABO blood group (grupo sanguíneo ABO) genetically deter- acquired immunodeficiency syndrome (AIDS) (síndrome
mined system of antigens found on the surface of erythrocytes. de inmunodeficiencia adquirida [SIDA]) disorder of the
The population can be divided into four ABO blood groups: A, immune system caused by a human immunodeficiency virus
B, AB, and O (Ch. 44). (HIV), a retrovirus that destroys the body’s ability to fight
abortion (aborto) expulsion of the products of conception infection. As the disease progresses, the individual becomes
before viability (Ch. 26). overcome by disorders, including cancers and opportunistic
abuse (abuso) misuse; excessive or improper use, especially infections. There is no known cure for AIDS (Ch. 22).
of narcotics or psychoactive drugs (Ch. 17, 35). active listening (escucha activa) received message is para-
accession record (numeric system) (registro de entrada [sis- phrased back to the sender to verify the correct message was
tema de ordenación por número]) logbook used to assign decoded (Ch. 4).
numbers to correspondence or patients (Ch. 14). activities of daily living (ADL) (actividades de la vida diaria
accomplishment statements (declaraciones de logros) state- [AVD]) activities usually performed during a typical day that
ments that begin with a power verb and give a brief descrip- involve caring for oneself, such as eating and brushing teeth
tion of what you did, and the demonstrable results that were (Ch. 33).
produced (Ch. 48). acupuncture (acupuntura) treatment to relieve pain and
accounting (contabilidad) system of monitoring the finan- disease by puncturing the skin with thin needles at specific
cial status of a facility and the financial results of its activities, points (Ch. 2).
providing information for decision making (Ch. 21). acyclovir (aciclovir) antiviral drug used in some herpes
accounts payable (cuentas por pagar) sum owed by a busi- infections (Ch. 22).
ness for services or goods received (Ch. 19); also unwritten additive (aditivo) any material placed in a tube that maintains
promise to pay a supplier for property or merchandise pur- or facilitates the integrity and function of the specimen (Ch. 40).
chased on credit or for a service rendered (Ch. 21). adduction (aducción) motion toward the midline of the
accounts receivable (cuentas por cobrar) amount owed to a body (Ch. 33).
business for services or goods supplied (Ch. 19). adjustments (ajustes) increases or decreases to patient
accounts receivable (A/R) ratio assets (relación de cuentas por accounts not due to charges incurred or payments received
cobrar a activos) outstanding accounts receivable divided (Ch. 17, 19).
by the average monthly gross income for the past 12 months administer (administrar) to give a medication (Ch. 7, 35, 36).
(Ch. 20, 21).
administrative law (derecho administrativo) establishes agen-
accreditation (acreditación) process whereby recognition cies that are given the power to make laws and enact regulations
is granted to an educational program for maintaining stan- (Ch. 7).
dards that qualify its graduates for professional practice; to
provide with credentials (Ch. 1). aegis (auspicio) sponsorship or protection (Ch. 38).
Accrediting Bureau of Health Education Schools (ABHES) aerobic (aerobio) organism that requires oxygen for growth
(Junta de Acreditación de Escuelas de Educación en Salud (Ch. 43).
[ABHES]) entity accrediting private, postsecondary institu- aerosolyzed (aerosolizado) dispensed by means of a mist
tions in the U.S. which offer allied health education programs (Ch. 27).
as well as programmatic accreditation of medical assistant, aerosols (aerosoles) particles from potentially infectious
medical laboratory technician and surgical technology pro- materials that may be released in the air (Ch. 22, 43).
grams (Ch. 1, 47).
afebrile (afebril) without fever (Ch. 24).
accrual basis accounting (contabilidad según el principio del
devengo) reports income at the time charges are generated agar (agar) a gelatin-like substance extracted from red algae
(Ch. 21). that contains nutrients and moisture for bacteria growth
(Ch. 43).
1114 Glossary of Terms

agenda (orden del día) printed list of topics to be discussed amplified (amplificado) made larger or enlarged. The
during a meeting, sometimes giving time allocation (Ch. 15, 45). amplifier of the electrocardiograph enlarges the electrical
agent (agente) person representing another (Ch. 7). impulse activity and the recording can be read more easily
(Ch. 37).
agglutination (aglutinación) antigen–antibody reaction in
which a solid antigen clumps with a solid antibody (Ch. 44). amplitude (amplitud) amount, extent, size, abundance, or
fullness (Ch. 37).
airborne transmission (transmisión por aire) spread of
disease-causing microorganisms over long distances through Amsler grid (cuadrícula de Amsler) a grid of lines used in
the air (Ch. 22). testing for macular degeneration (Ch. 30).
algorithm (algoritmo) a special method for solving a specific anaerobic (anaerobio) organism that needs little or no oxy-
kind of problem (Ch. 11). gen for growth (Ch. 43).
aliquot (alícuota) part of the whole specimen that has been anaphylaxis (anafilaxia) hypersensitive state of the body to a
taken off for use or storage (Ch. 40). foreign protein or drug (Ch. 9, 35).
allergen (alérgeno) any substance that causes signs of allergy; ancillary services (servicios auxiliares) professional occupa-
examples are inhalants such as dust and pollen, foods such as tional companies hired to complete a specific job (Ch. 45).
wheat and strawberries, drugs, penicillin, chemicals, heat, bac- andropause (andropausia) midlife changes in a male (Ch. 29).
teria (Ch. 30). anesthesia (anestesia) loss of feeling or sensation; an anes-
allergy (alergia) acquired hypersensitivity to a substance (aller- thetic is any mechanism that causes anesthesia (Ch. 31).
gen) that does not normally cause a reaction (Ch. 23, 31). angiogram (angiograma) series of X-rays of a blood vessel(s)
allopathic (alopático) method of treating disease with reme- after injection of a radiopaque substance (Ch. 37).
dies that produce effects different from those caused by the anisocytosis (anisocitosis) marked variation in the size of
disease itself. Most traditional practitioners today are conside- cells (Ch. 41).
red allopathic practitioners (Ch. 3).
anorexia (anorexia) loss of appetite (Ch. 22).
alternative dispute resolution (ADR) (resolución alternativa de
conflictos [RAC]) an alternative to trial that encourages the answering services (servicios de respuesta) services emplo-
parties to settle their differences out of court (Ch. 7). yed to answer the calls of an ambulatory care setting after
hours; unlike an answering machine, a live operator answers
amblyopia (ambliopía) disorder of the eye characterized by the call and forwards it appropriately (Ch. 12).
dimness of vision (Ch. 30).
antibacterial (antibacteriano) capable of destroying bacte-
Ambu Bag™ (Ambu Bag™) a brand name for a bag placed ria, often applied to a wound in the form of an ointment or
over nose and mouth to assist in providing artificial ventila- cream (Ch. 31).
tion to the lungs (Ch. 9).
antibody (anticuerpo) specific chemical produced by
ambulation (ambulación) ability to walk (Ch. 33). B cells of the immune system in response to an antigen
ambulatory care setting (entorno de atención ambulatoria) (Ch. 22, 44).
health care environment where services are provided on anticoagulant (anticoagulante) chemical in a blood tube that
an outpatient basis. Ambulatory is from the Latin and means prevents the clotting of the blood by removing the calcium from
“capable of walking.” Examples include the solo-provider’s the blood or by stopping the formation of thrombin (Ch. 40).
office, the group practice, the urgent care center, and the
health maintenance organization (Ch. 1, 2). antigen (antígeno) substance such as bacteria or other agents
that the body recognizes as foreign; the stimulus for antibody
American Association of Medical Assistants (AAMA) (Asocia- production (Ch. 22, 44).
ción Estadounidense de Asistentes Médicos [AAMA]) pro-
fessional organization dedicated to serving the interests of antiglare screen (pantalla antirreflejo) a filter put over the
Certified Medical Assistants (Ch. 47). screen of a computer monitor to reduce glare (Ch. 11).
American Medical Technologists (AMT) (Tecnólogos Médi- antioxidant (antioxidante) something that prevents oxida-
cos Estadounidenses [AMT]) national organization which tion (Ch. 34).
credentials health care professionals, including Registered antiserum (antisuero) serum containing antibodies (Ch. 44).
Medical Assistants (RMA) and Certified Medical Administra- apical (apical) pertaining to the apex of the heart. A site for
tive Specialists (CMAS)(Ch. 1, 47). measuring heart rate with a stethoscope (Ch. 24).
amino acid (aminoácido) basic structural unit of protein apnea (apnea) cessation or absence of normal spontaneous
(Ch. 34). breathing (Ch. 24, 36).
amniocentesis (amniocentesis) surgical puncture of the amnio- appendicular skeleton (esqueleto apendicular) skeleton that
tic sac to remove fluid for laboratory analysis (Ch. 22, 26). consists of the pectoral and pelvic girdles and the upper and
amniotomy (amniotomía) artificial rupture of the amniotic lower extremities. The pelvic girdle attaches the upper extre-
sac (Ch. 26). mities to the trunk (Ch. 30).
amoebic dysentery (disentería amébica) infectious intestinal application/cover letter (solicitud/carta de presentación)
disease caused by amoebas and characterized by inflammation letter used to introduce yourself and your résumé to a pros-
of the mucous membrane of the colon (Ch. 22). pective employer with the goal of obtaining an interview
amorphous (amorfo) shapeless; possessing no definite form (Ch. 48).
(Ch. 42).
 Glossary of Terms 1115

application form (formulario de solicitud) form devised automated external defibrillator (AED) (desfibrilador externo
by a prospective employer to collect information relative to automatizado [DEA]) portable, self-contained, automatic
qualifications, education, and experience in employment device with voice instructions on use for individuals in cardiac
(Ch. 48). arrest. It is used externally to electronically “shock” the myocar-
application software (software de aplicación) software that dium into contracting again. Same as cardioversion (Ch. 9).
performs a specific data-processing function (Ch. 11). automated routing unit (ARU) (enrutador automático
approximate (aproximar) to bring together the edges of a [ARU]) telephone system that answers a call and uses a
wound (Ch. 31). recorded voice to identify departments or services (Ch. 12).
arbitration (arbitraje) a form of dispute resolution that autopsy report (informe de autopsia) also called an autopsy
allows a neutral party to settle the dispute (Ch. 7). protocol, a necropsy report, or a medical examiner report.
Autopsies are performed to determine the cause of death or
arrhythmia (arritmia) deviation from the normal pattern or to ascertain and confirm disease presence (Ch. 16).
rhythm of the heartbeat (Ch. 24, 37).
avascularization (avascularización) expulsions of blood from
arteriosclerosis (arteriosclerosis) hardening of the arteries tissues. Leaves the tissues with no blood supply (Ch. 31).
caused by buildup of plaque, a deposit of fatty substances on
the artery lining (Ch. 29). axial skeleton (esqueleto axial) consists of bones that lie
around the center of the body (Ch. 30).
articulating (elocuente) expressing oneself clearly and dis-
tinctly (Ch. 12).
B
artifact (artefacto) anything artificially produced (Ch. 37).
bachelor’s degree (licenciatura) four-year academic degree
ascorbic acid (ácido ascórbico) vitamin C (Ch. 34). conferred by colleges and universities (Ch. 1).
asepsis (asepsia) protecting against infection caused by backup (hacer una copia de seguridad) copying or saving
pathogenic microorganisms (Ch. 3). data to a secure location to prevent loss of data in the event of
aseptic (aséptico) freedom from any infectious material; a disaster (Ch. 11).
absence of microorganisms (Ch. 22, 30). balance (balancear) amount owed (N); to verify posting accu-
aspirate (aséptico) to remove by suction (Ch. 22). racy (V); records difference between debit and credit columns
assay (ensayo) analysis of a substance to determine consti- (Ch. 19).
tuents and relative proportion of each (Ch. 39). balance sheet (balance general) itemized statement of assets, lia-
assets (activos) properties of value that are owned by a busi- bilities, and equity; a statement of financial condition (Ch. 21).
ness entity (Ch. 21). bandage (venda) nonsterile gauze or other material applied
assignment of benefits (asignación de beneficios) sig- over a sterile dressing to protect and immobilize (Ch. 9, 31).
ning over of benefits by the beneficiary to another party bariatrics (bariátrica) the branch of medicine that deals with
(Ch. 17). prevention, control, and treatment of obesity (Ch. 30).
Association for Healthcare Documentation Integrity (AHDI) barrier (barrera) obstacle that exists to protect an indivi-
(Asociación para la Integridad de la Documentación del Cui- dual from contact with blood or other potentially infected
dado de la Salud [AHDI]) professional organization in the materials. Called personal protective equipment (PPE),
field of medical transcription/editing (Ch. 16). barriers include gloves, masks, face shields, laboratory coats,
asymptomatic (asintomático) without symptoms (Ch. 39). protective eyewear, and gowns (Ch. 22).
ataxia (ataxia) defective muscular coordination, primarily seen Bartholin gland (glándula de Bartolino) one of two small
when attempting voluntary muscular movements (Ch. 25). mucous glands located at the vaginal opening at the base of
the labia majora (Ch. 26).
atherosclerosis (aterosclerosis) a form of arteriosclerosis
marked by calcium deposits in the arterial linings (ch. 24). basal metabolic rate (BMR) (índice metabólico basal [IMB])
level of energy required when the body is at rest (Ch. 34).
attribute (atributo) inherent characteristic (Ch. 1).
baseline (valor de referencia) known or initial measurement
auditor (auditor) a person responsible for determining the against which future measurements are compared (Ch. 24,
final content of a document and the document’s correctness 39); also, flat, horizontal line that separates the various waves
in every aspect (Ch. 16). of the ECG cycle (Ch. 37).
augment (aumentar) to add or increase (Ch. 37). basophil (basófilo) granulocytic white blood cell with dark
auscultatory gap (brecha auscultatoria) while measuring purple cytoplasmic granules. It is the least common of the
blood pressure, the tapping sounds heard may disappear bet- white blood cells (Ch. 41).
ween the Korotkoff phases of sound (Ch. 24). benchmark (comparador de rendimiento) making a com-
auricle (aurícula) the external ear, also called pinna (Ch. 30). parison among different organizations relative to how they
authentication (autenticación) dictating provider signs or accomplish tasks, such as office computerization, organizing
authenticates the document indicating that the information file systems, and employee remuneration (Ch. 11, 45).
was accurate and complete at the time of signing (Ch. 16). beneficiary (beneficiario) person under a policy eligible to
authoritarian manager (gerente autoritario) operates on receive benefits (Ch. 17).
the premise that most workers cannot make a contribution benefit (beneficio) remuneration that is in addition to the
without being directed (Ch. 45). salary (Ch. 45, 48).
1116 Glossary of Terms

benefit period (período de beneficios) the specified time of nitrogen in the blood is an indicator of kidney function
during which benefits will be paid under certain types of (Ch. 44).
health insurance coverages (Ch. 17). Bluetooth® (Bluetooth®) a technical industry standard that
beriberi (beriberi) disease caused by a deficiency in vitamin B facilitates communication between wireless devices such as
(thiamin), characterized by headaches, depression, anorexia, personal digital assistants, handheld computers, and wireless-
constipation, tachycardia, edema, and heart failure (Ch. 34). enabled laptop computers or desktop computers (Ch. 11).
Betadine® (Betadine®) brand of povidone-iodine solution body fluid (líquido corporal) any secretion or excretion
used as a skin antiseptic. Betadine® is also available in a scrub from the human body such as vaginal, cerebrospinal, synovial,
(soap) solution (Ch. 31). pleural, pericardial, peritoneal, amniotic, sputum, and saliva
bias (sesgo) slant toward a particular belief (Ch. 4). (Ch. 38).
bilirubin (bilirrubina) orange–yellow pigment that forms body language (lenguaje corporal) nonverbal communica-
from the breakdown of hemoglobin in damaged red blood tion that includes unconscious body movements, gestures, and
cells. Bilirubin usually travels in the bloodstream to the liver, facial expressions that accompany verbal messages (Ch. 4).
where it is converted to a water-soluble form and is excreted body mechanics (mecánica corporal) practice of using cer-
into the bile (Ch. 42, 44). tain key muscle groups together with correct body alignment
bilirubinuria (bilirrubinuria) the presence of bilirubin in to avoid injury when lifting or moving heavy or awkward
urine (Ch. 42). objects (Ch. 33).
bimanual examination (examen bimanual) an examination body surface area (BSA) (área de superficie corporal
performed by the provider using two hands to examine the [ASC]) a highly accurate method for calculating medica-
internal pelvic organs. Two fingers of one hand are inserted tion dosages for infants and children up to 12 years of age
into the vagina and the other hand presses on the outside of (Ch. 36).
the abdominal wall. Shape, consistency, and position of the bond (fianza) binding agreement with an employee ensuring
pelvic organs can be determined (Ch. 26). recovery of financial loss should funds be stolen or embezzled
biochemical tests (análisis bioquímicos) tests that show bio- (Ch. 45).
chemical properties and reactions of bacteria to achieve iden- bond paper (papel bond) durable, strong paper usually used
tification of microorganisms; often performed in solid and for correspondence (Ch. 15).
liquid media (Ch. 43). booting (arranque) everything that happens between the
bioethics (bioética) branch of medical ethics concerned with time the computer is turned on, performs the operations
moral issues resulting from high technology and sophisticated necessary to get all components functioning, and the opera-
medical research. Social issues such as genetic engineering, ting system loaded (Ch. 11).
abortion, and fetal tissue research raise important bioethical bradycardia (sinus) (bradicardia [sinusal]) slow (less than 60
questions (Ch. 8). beats per minute), but regular heartbeat (Ch. 24, 37).
biohazard (riesgo biológico) material that has been in con- bradypnea (bradipnea) abnormally slowed respiratory rate
tact with body fluid and is capable of transmitting disease (Ch. 24).
(Ch. 22).
brainstorming (tormenta de ideas) process of developing
biometric (biometría) a type of electronic signature that ideas through a synergistic interaction among participants in
may use alphanumeric computer key entries as identification; an environment free of criticism (Ch. 45).
an electronic writing device; or a biometric system using voice,
fingerprints, or the retina of the eye (Ch. 16). Braxton–Hicks (Braxton–Hicks) irregular, intermittent,
and painless uterine contractions; also known as false labor
biopsy (biopsia) removal of a small piece of living tissue (Ch. 26).
from an organ or other part of the body for microscopic exa-
mination to confirm or establish a diagnosis (Ch. 30, 39). bronchi (bronquios) bifurcates from the trachea into each
lung that terminate in the bronchial tubes (Ch. 30).
bipolar (bipolar) having two poles or processes (Ch. 37).
bronchodilator (broncodilatador) a drug that expands the
birthday rule (regla del cumpleaños) method to determine bronchial tubes (Ch. 30).
which of two or more policies covering a dependent child will
be primary; that parent with the birthday falling first in the broth tubes (tubos de caldo) tubes filled with a broth subs-
calendar year has the primary policy (Ch. 17). tance that will support the growth of certain microorganisms
(Ch. 43).
blind copy (copia oculta) protects the privacy of email.
Other recipients cannot identify who else may have received bruits (ruidos) sound of venous or arterial origin heard on
the transmitted message (Ch. 15). auscultation (Ch. 25).
bloodborne (transmisión sanguínea) means of transmission bubonic plague (peste bubónica) infectious disease with a
of an infectious disease (such as HIV and HBV) via human high fatality rate transmitted to humans from infected rats
blood (Ch. 22). and ground squirrels by the bite of the rat flea (Ch. 3).
bloodborne pathogen (patógeno transmitido por la sangre) buffer words (palabras de relleno) expendable words used
microorganism capable of causing disease found in blood or while answering the telephone (Ch. 12).
components of blood (Ch. 22). buffy coat (capa leucocitaria) layer of white blood cells and
blood urea nitrogen (BUN) (nitrógeno ureico en sangre platelets that forms at the interface between the plasma and
[BUN]) nitrogen in the blood in the form of urea. The level
 Glossary of Terms 1117

red blood cells in a tube of blood containing an anticoagulant career objective (objetivo profesional) expresses your career
(Ch. 40). goal and the position for which you are applying (Ch. 48).
bullet point (viñeta) asterisk or dot followed by a descrip- carotene (caroteno) vitamin A (Ch. 34).
tive phrase; helps the reader identify important points easily carrier (portador) person who harbors a pathogenic orga-
(Ch. 48). nism and who is capable of transmitting the organism to
bundled codes (códigos agrupados) a grouping of several others (Ch. 22).
services that are directly related to a specific procedure and cash basis accounting (contabilidad de caja) reports income
are paid as one (Ch. 18). at the time money is collected (Ch. 21).
burnout (agotamiento profesional) a state of fatigue or frustra- cashier’s check (cheque de caja) bank’s own check drawn
tion brought about by a devotion to a cause, a way of life, or a against the bank’s account (Ch. 19).
relationship that failed to produce the expected reward (Ch. 5).
casts (cilindros) tiny structures usually formed by deposits of
protein or other substances on the walls of renal tubules; in
C urine, they can indicate kidney disease (Ch. 42).
cachectic (caquéctico) describes a state of ill health, malnu- catalyst (catalizador) substance that allows a chemical reac-
trition, and wasting (Ch. 34). tion to proceed at a much quicker rate and without as much
calibration (calibración) determination of the accuracy of energy input (Ch. 34).
an instrument by comparing the information provided with catheterization (cateterismo) insertion of a catheter tube
an accepted standard known to be accurate (Ch. 37, 38). into the body for evacuating fluids or injecting fluids into
calorie (caloría) unit of heat. The large Calorie (which is body cavities. In urinary catheterization, the tube is inserted
always capitalized) is used in discussion of human nutrition. through the urethra into the bladder for withdrawal of urine
The large Calorie is also expressed as the kilogram calorie (Ch. 25).
(kcal), equal to 1,000 small calories (Ch. 34). cathode (cátodo) a negative electrode from which electrons
candidiasis (candidiasis) infection of the skin or mucous are emitted (Ch. 32).
membrane with any species of Candida (Ch. 26). caustic (cáustico) corrosive and burning; destructive to
cannula (nasal) tubing (cánula) used to deliver oxygen living tissue (Ch. 22, 31).
(Ch. 36); also, the blunting member in a Bio-Plexus Punctur- cauterize (cauterizar) to destroy tissue through application
Guard® needle (Ch. 40). of a caustic agent, a hot instrument, an electric current, or
capitation (capitación) use of the number of members enro- other agent (Ch. 9).
lled in a plan to determine salary of the provider; the provider cautery (cauterio) destruction of tissue by burning (Ch. 31).
is paid a fixed fee for each member no matter how many times
that member is seen by the provider (Ch. 17). cell-mediated immunity (inmunidad mediada por células) the
regulatory activities of T cells during the specific immune res-
caption (leyenda) method of designation used on file guides ponse (Ch. 22).
(Ch. 14).
cellular telephones (teléfonos celulares) a short range
carbuncle (ántrax) necrotizing infection of skin and tissue portable device used for voice or data communication over
composed of a cluster of boils (Ch. 30). a network of base stations known as cell sites. The cell sites
carcinoma in situ (carcinoma in situ) cancer that does not are interconnected to the public switched telephone network
extend beyond the basement membrane (Ch. 26). (Ch. 12).
cardiac catheterization (cateterismo cardíaco) passage of a cellulose (celulosa) type of indigestible fiber made of carbo-
catheter into the heart through an arm or leg vein and blood hydrates found in plants (Ch. 34).
vessels leading into the heart. The purpose is to obtain car- Centers for Medicare and Medicaid Services (CMS) (Centros
diac blood samples, detect abnormalities, and determine de Servicios de Medicare y Medicaid [CMS]) formerly known
intracardiac pressure. Contrast medium can be injected and as HCFA. CMS is a federal agency within the U.S. Department
a coronary artery angiogram can be performed (Ch. 37). of Health and Human Services (DHHS). The agency admi-
cardiac cycle (ciclo cardíaco) period from the beginning of one nisters Medicare, Medicaid, and the State Children’s Health
heartbeat to the beginning of the next succeeding beat, inclu- Insurance Program (SCHIP). CMS also administers the
ding systole and diastole. One complete heartbeat (Ch. 37). Health Insurance Portability and Accountability Act of 1996
cardiopulmonary resuscitation (CPR) (reanimación cardio- (HIPAA) and Clinical Laboratory Improvement Act of 1988
pulmonar [RCP]) combination of rescue breathing and (CLIA ’88) (Ch. 17).
chest compressions performed by a trained individual on a central processing unit (CPU) (unidad de procesamiento cen-
patient experiencing cardiac arrest (Ch. 9). tral [CPU]) brain of the computer that performs instruc-
cardioversion (cardioversión) conversion of a pathological tions defined by software (Ch. 11).
cardiac rhythm (arrhythmia), such as ventricular fibrillation, centrifuge (centrifugador) device that spins tubes using cen-
to normal sinus rhythm (Ch. 9, 37). trifugal force to separate the fluid portion of blood from the
cardioverter/defibrillator (cardioversor/desfibrilador) an formed elements (Ch. 40).
implantable device used for life-threatening arrhythmias.Its certification (certificación) guarantees as being true or as
purpose is to shock the heart out of the arrhythmia and into a represented by or as meeting a standard (Ch. 1).
more normal sinus rhythm (Ch. 37).
1118 Glossary of Terms

certification examination (examen de certificación) stan- choriocarcinoma (coriocarcinoma) rare malignant neo-
dardized means of evaluating medical assistant competency plasm, usually of the uterus or of an ectopic pregnancy. The
(Ch. 47). exact cause is unknown (Ch. 34, 37, 44).
certified check (cheque certificado) depositor’s own check chronologic résumé (curriculum vitae cronológico) ré-
that the bank has indicated with a date and signature to be sumé format used when you have employment experience
good for the amount written (Ch. 19). (Ch. 48).
Certified Clinical Medical Assistant (CCMA) (Asistente Clín- circadian rhythm (ritmo circadiano) pattern based on a 24-
ico Médico Certificado [CCMA]) an NHA certification for a hour cycle emphasizing the repetition of certain physiologic
clinical medical assistant. (Ch. 47). phenomena such as eating and sleeping (Ch. 42).
Certified Medical Administrative Assistant (CMAA) (Asistente circumduction (circunducción) circular motion of a body
Administrativo Médico Certificado [CMAA]) an NHA certi- part (Ch. 33).
fication for a medical administrative assistant (Ch. 47). cirrhosis (cirrosis) a chronic liver disease in which normal
Certified Medical Administrative Specialist (CMAS) (Espe- functioning liver tissue is replaced with nonfunctioning scar
cialista Administrativo Médico Certificado [CMAS]) an tissue (Ch. 22).
AMT certification for a medical administrative specialist civil law (derecho civil) law related to actions between indi-
(Ch. 47). viduals (Ch. 7).
Certified Medical Assistant (CMA [AAMA]) (Asistente Médico clinical email (correo electrónico clínico) type of email esta-
Certificado [CMA (AAMA)]) a certified medical assistant blished using defined protocols as a means of communication
who has successfully completed the AAMA’s national certifica- between providers and established patients (Ch. 12).
tion examination (Ch. 1, 47).
claim register (registro de reclamaciones) diary or register
Certified Medical Transcriptionist (CMT) (Transcriptor of claims submitted to each insurance carrier. When payment
Médico Certificado [CMT]) completion of a two-part cer- is received, the date and amount of payment is entered in the
tification examination administered by the Association for register (Ch. 18).
Healthcare Documentation Integrity (AHDI) (Ch. 16).
claustrophobia (claustrofobia) fear of being confined in any
cervical punch biopsy (biopsia cervical en sacabocados) a space (Ch. 32).
biopsy of the uterine cervix using an instrument, the end of
which is a punch (Ch. 26). clinical chemistry (química clínica) analysis and study of
blood, body fluids, excreta, and tissues in the diagnosis and
cesarean section (operación cesárea) delivery of fetus treatment of disease (Ch. 39).
through surgical incision into the uterus (Ch. 26).
clinical diagnosis (diagnóstico clínico) identification of
chart notes (notas clínicas) (also called progress notes) a disease by history, laboratory studies, and symptoms
provider’s formal or informal notes about presenting pro- (Ch. 23, 39).
blem, physical findings, and plan for treatment for a patient
examined in the office, clinic, acute care center, or emergency closed fracture (fractura cerrada) uncomplicated fracture
department (Ch. 16). in which the bone does not break the skin (Ch. 30).
check register (registro de cheques) record of checks closed questions (preguntas cerradas) questions answered
written; categorized into separate and identified columns with a yes or no (Ch. 4).
(Ch. 21). clustering (agrupación) a grouping together of nonverbal
cheilosis (queilosis) caused by a deficiency of vitamin B2 messages into statements or conclusions. Can also be used
(riboflavin) and characterized by sores on the lips and cracks to describe a scheduling system where patients with similar
in the corners of the mouth (Ch. 34). complaint/conditions are scheduled consecutively (example
is scheduling all the allergy injections for 3:00 pm to 4:00 pm
chemotherapeutic agents (agentes quimioterapéuticos) every Tuesday and Thursday) (Ch. 4).
agents used in the treatment of diseases; the application of che-
mical reagents that are toxic to pathogenic microorganisms. CMS 1500 (08/05) (CMS 1500 [08/05]) formerly known as
Commonly used to describe agents (chemicals) used in the the HCFA 1500 form that is the office health insurance claim
treatment of certain malignancies (Ch. 38). form for Medicare and Medicaid (Ch. 18).
Cheyne–Stokes (Cheyne–Stoke) regular pattern of irregular cobalamina (cobalamina) vitamin B12 (Ch. 34).
breathing rate often seen in children and that may be seen in cochlear implantation (implante coclear) an electrical
brain dysfunction (Ch. 24). device that receives sounds and transmits the resulting signal
chief complaint (CC) (queja principal [QP]) specific to electrodes implanted in the cochlea. The signal stimula-
symptom or problem for which the patient is seeing the provi- tes the cochlea and the individual is able to perceive sound
der today (Ch. 16, 23). (Ch. 27).
chlamydia (clamidia) a bacterium that causes one of the coenzyme (coenzima) substance that enhances a catalyst
most prevalent sexually transmitted diseases (Ch. 26). (Ch. 34).
cholecalciferol (colecalciferol) vitamin D (Ch. 34). cognitive functioning (funcionamiento cognitivo) awareness
with perception, reasoning, judgment, intuition, and memory
cholesterol (colesterol) sterol lipid that is widely distributed (Ch. 29).
in animal tissues. Cholesterol is produced in the liver and is a
component of bile (Ch. 44). coinsurance (coseguro) that percentage paid by the com-
pany or that paid by the insured (Ch. 17).
 Glossary of Terms 1119

collection ratio (relación de cobranza) gross income divided constitutional law (derecho constitucional) consists of laws
by the amount that could have been collected less disallowan- that are made by constitutions of the United States or indivi-
ces (Ch. 20, 21). dual states (Ch. 7).
colonoscopy (colonoscopia) visual examination of the colon constrict (constreñirse) to become smaller in diameter
with a lighted scope (Ch. 30). (Ch. 40).
colposcopy (colposcopia) visual examination of vaginal and constriction band (banda de constricción) term used to
cervical tissues using a colposcope following abnormal Pap replace tourniquet (no longer used) in emergencies. A band
smear. A magnifying lens and powerful lights are used (Ch. 26). of material used to control severe bleeding in an extremity
comedone (comedón) blackhead; usually the result of bloc- that has been injured due to trauma. The band is applied
ked sebaceous glands caused by acne (Ch. 30). above the source of bleeding, but not so tight that it restricts
the flow of blood completely. Some slight trickling of blood
Commission on Accreditation of Allied Health Education Pro- should be evident. This action avoids loss of an extremity
grams (CAAHEP) (Comisión de Acreditación de Programas because of complete blood flow restriction. Complete blood
Educativos Asociados a la Salud [CAAHEP]) entity accre- flow restriction results in no blood flow to the extremity’s cells
diting over 2,000 educational programs in 20 health sciences and tissues; therefore, the cells, tissues and body part receive
professions (Ch. 1, 47). no oxygen and die (Ch. 9).
common law (derecho consuetudinario) refers to laws deve- consultation report (informe de consulta) document that
loped in England and France and brought to the United Sta- reports the findings and advice of another provider requested
tes by the early settlers; sometimes referred to as judge-made to see a patient by the attending provider (Ch. 16).
law (Ch. 7).
contact tracker (seguidor de contactos) form used to keep
communicable (transmisible) contagious. Capable of being track of employment contact information such as name of
transmitted from one person to another either directly or employer, name of contact person, address and telephone
indirectly (Ch. 22, 38). number, date of first contact, résumé sent, interview date,
compact disk (CD) (disco compacto [CD]) see optical disk follow-up information, and dates (Ch. 48).
(Ch. 11). contact transmission (transmisión por contacto) spread
compensation (compensación) overemphasizing of charac- of disease-causing microorganisms by directly or indirectly
teristics to make up for a real or imagined failure or handicap touching the source of the infection or by touching an object
(Ch. 4). or environmental surface (Ch. 22).
competency (competencia) legally qualified or adequate contaminate (contaminar) to make something unclean;
(Ch. 1). often used to describe a sterile area being made “unsterile” or
complete blood count (CBC) (recuento sanguíneo completo exposing a clean area to a pathogenic substance (Ch. 22, 31).
[RSC]) battery of hematologic tests consisting of hemo- continuing education units (CEU) (unidades de educación
globin, hematocrit, total white blood cell count including continua [UEC]) method for earning points toward recerti-
differential, total red blood cell count, including indices, and fication (Ch. 47).
platelets (Ch. 41). contract law (derecho contractual) law that refers to agree-
compliance (cumplimiento) conformity in fulfilling official ments between individuals and entities that are binding (Ch. 7).
requirements (Ch. 1). contracting (contraer) acquiring an infection from patho-
compounding (composición) combining two or more subs- gens (Ch. 22).
tances in definite proportions (Ch. 36). contraindication (contraindicación) any symptom or cir-
condenser (condensador) in a microscope, directs a beam cumstance indicating that the use of a particular drug is
of light from the source to the specimen (Ch. 39). inappropriate when it would otherwise be advisable. For
condylomata (condiloma) a wartlike lesion of viral origin example, the use of alcoholic beverages is a contraindication
found on external genitalia or perianal region (Ch. 26). when the drug Flagyl® is prescribed (Ch. 35).
confidentiality (confidencialidad) ethical and legal rules in control test (prueba de control) test of a sample of known
regard to patient privacy (Ch. 16). results used to compare with the results of a patient’s sample
(Ch. 39).
confidentiality agreement (acuerdo de confidencialidad)
when signed, the agreement signifies that the medical coordination of benefits (COB) (coordinación de beneficios
transcriptionist is committed to keep all patient informa- [COB]) the provision of an insurance contract that limits
tion confidential (Ch. 16). benefits to 100% of the cost (Ch. 17).
conflict resolution (resolución de conflictos) solving pro- co-payment (copago) payment required when seen by the
blems between coworkers or any two parties (Ch. 45). provider (Ch. 17).
congenital anomalies (anomalías congénitas) being born coryza (coriza) acute inflammation of the membranes of the
with; existing at time of birth (Ch. 26). nose accompanied by profuse drainage (Ch. 22).
congruency (congruencia) the verbal message and the non- cost analysis (análisis de costos) procedure that determines
verbal message must agree (Ch. 4). the costs of each service (Ch. 21).
consecutive or serial filing (archivado consecutivo o en cost ratio (relación de costos) formula that shows the cost
serie) numeric filing method where numbers are considered of a procedure or service and helps determine the financial
in ascending order using the entire set of figures (Ch. 14). value of maintaining certain services (Ch. 21).
1120 Glossary of Terms

cough etiquette (protocolo de manejo de la tos) coughing/ cultures (cultivos) microorganisms cultivated in a nutrient
sneezing into a tissue to prevent microorganisms from sprea- medium (Ch. 42, 43).
ding to others. Includes properly disposing of tissue into a waste Current Procedural Terminology (CPT) (Terminología Actual
receptacle and washing hands as soon as possible (Ch. 22). sobre Procedimientos [TAP]) standard codes for procedu-
countershock (contrachoque) application of an electric res and services. Used by most ambulatory care settings in
current to the heart directly or indirectly to alter a disturbance encoding the claim form and recognized by most insurance
in cardiac rhythm (Ch. 37). carriers (Ch. 19).
coupling agent (agente de acoplamiento) an agent used current reports (informes actuales) reports such as history
when ultrasonography is used; enhances penetration of sound and physical examinations that should be complete within
waves through tissue (Ch. 26). 24 hours (Ch. 16).
crash tray or cart (bandeja o carro de parada) tray or por- Cushing’s syndrome (síndrome de Cushing) hypersecretion
table cart that contains medications and supplies needed for of the adrenal cortex producing excessive glucocorticoids.
emergency and first aid procedures (Ch. 9). The condition may be caused by a tumor or hyperfunction of
creatinine (creatinina) waste product formed in muscle that the anterior pituitary (Ch. 44).
is excreted by the kidneys; increased in blood and urine when cyanosis (cianosis) discoloration of the skin due to abnor-
kidney function is abnormal (Ch. 42). mal amounts of reduced hemoglobin in the blood caused by
credentialed (acreditado) testimonials showing that a per- decreased oxygen and increased carbon dioxide in the blood
son is entitled to credit or has a right to exercise official (Ch. 25).
power (Ch. 1). cyberspace (ciberespacio) reference to the nonphysical
credit (crédito) decreases balance due; column used for space of binary computer communication (Ch. 11).
entering payments (Ch. 19). cystitis (cistitis) inflammation of the bladder (Ch. 29).
crepitation (crepitación) grating sound heard on movement cytology (citología) science that deals with the formation,
of ends of a broken bone (Ch. 9). structure, and function of cells (Ch. 39).
criminal law (derecho penal) law related to wrongs commit-
ted against the welfare and safety of society as a whole (Ch. 7). D
critical values (valores críticos) test results that indicate data storage device (dispositivo de almacenamiento de datos)
a potentially life-threatening or greatly debilitating situa- device capable of permanently or temporarily storing digital
tion that must be reported to the provider immediately data (Ch. 11).
(Ch. 42). data storage memory (memoria de almacenamiento de
cross-reference (referencia cruzada) notation in a file to datos) permanent memory not part of the motherboard.
direct the reader to a specific record that may be filed under Uses any suitable data storage device. Can be read-only or
more than one name/subject (e.g., married name/maiden read-write type of memory (Ch. 11).
name or foreign names) where the surname is not easily day sheet (hoja diaria) form used with pegboard system to
recognizable (Ch. 14). record daily patient transactions (Ch. 19).
cryopreservation (crioconservación) storage of biologic debit (debe) used for entering charges and description of
materials (sperm, embryo, tissue, plasma) at extremely cold services; column is on the left (Ch. 19).
temperature for use at a later time (Ch. 8).
debris (detritos) remains of broken down or damaged cells
cryosurgery (criocirugía) the destruction of tissue by appli- or tissues (Ch. 22).
cation of extreme cold, silver nitrate, and carbon dioxide
declination form (formulario de rechazo) written formal
(Ch. 26).
refusal (Ch. 22).
cryotherapy (crioterapia) use of cold to treat a physical
decode (decodificar) to translate into language that is easily
condition (Ch. 33).
understood; to interpret (Ch. 4).
cryptorchidism (criptorquidia) undescended testicle (Ch. 28).
deductible (deducible) that amount of incurred medical
crystals (crystals) found in normal urine sediment having expenses that must be met before the insurance policy will
no particular significance; should be noted because they may begin to pay (Ch. 17).
indicate disease states (Ch. 42).
defendant (demandado) person who defends action brought
cultivate (cultivar) to foster the growth of (Ch. 1). in litigation (Ch. 7).
cultural brokering (intermediación cultural) the act of Defense Enrollment Eligible Reporting System (DEERS)
bridging, linking, or mediating between groups or persons (Sistema de Informes de Elegibilidad para la Inscripción en
through the process of reducing conflict or producing change Defensa [DEERS]) a system operated by the Department of
(Ch. 4). Defense and used by TRICARE contractors to determine and
culture (cultura) the attitudes and behavior that are charac- confirm the eligibility of beneficiaries (Ch. 17).
teristic of a particular social group or organization (Ch. 4). defense mechanism (mecanismo de defensa) behavior that
culture and sensitivity (cultivo y sensibilidad) often referred protects the psyche from guilt, anxiety, or shame (Ch. 4).
to as C&S. The sample is cultured for bacteria and then is defibrillation (desfibrilación) stopping fibrillation of the
exposed to various antibiotics to determine what the bacteria heart by use of drugs or by physical means (Ch. 37).
is sensitive (and resistant) to (Ch. 39, 42).
 Glossary of Terms 1121

defibrillator (desfibrilador) a machine that delivers an elec- digital video disk/digital versatile disk (DVD) (disco de
tric current to alter a disturbance in cardiac rhythm (Ch. 37). video digital/disco versátil digital [DVD]) an optical disk
defragmentation (desfragmentación) reorganization of infor- that holds 4.7 to 9.0 gigabytes of data depending on format
mation on a hard disk to store files as continuous units rather (Ch. 11).
than as small packets. A computer with little fragmentation of dilate (dilatarse) to enlarge in diameter (Ch. 40).
files will operate at a higher speed (Ch. 11). dilation (dilatación) expansion of an orifice or organ
dementia (demencia) impairment of intellectual func- (Ch. 26).
tion that is progressive and interferes with normal activities diploma (diploma) a document bearing record of gradua-
(Ch. 29). tion from or of a degree conferred by an educational institu-
demyelination (desmielinización) destruction of the myelin tion (Ch. 1).
sheath; often a factor in multiple sclerosis (Ch. 30). direct skills (habilidades directas) skills that are job specific.
denial (rechazo) rejection of or refusal to acknowledge Skill in taking a blood pressure reading would be specific to the
(Ch. 4). medical field (Ch. 48).
deoxygenated (desoxigenada) blood that is high in carbon discharge summary (DS) (resumen de alta médica [DS]) me-
dioxide, low in oxygen, and pumped through the heart to dical reports that document the hospitalization history of a
the lungs where the carbon dioxide is exchanged for oxygen patient (Ch. 16).
(Ch. 37). discovery (exhibición de pruebas) the time in which both
depolarize (despolarizar) process of reducing to a nonpola- parties are allowed access to all information and evidence
rized condition. Generation of an electrical current is enhan- related to a case; follows the subpoena process (Ch. 7).
ced. Electrical activity generated when the atria or ventricles disinfection (desinfección) use of chemicals or boiling water
contract (Ch. 37). to free an item from infectious materials but not its spores
deposition (declaración) oral testimony given by an indivi- (Ch. 22).
dual with a court reporter and attorneys for both sides pre- dislocation (luxación) displacement of a bone or joint from
sent; often used as part of the discovery process (Ch. 7). its normal position (Ch. 30).
dermatophytes (dermatofitos) category of fungi causing dispense (dosificar) prepare and give out a medication to be
infections of hair, skin, and nails (Ch. 43). taken at a later time (Ch. 7, 35, 36).
dexterity (destreza) skill and ease in using the hands (Ch. 1). displacement (desplazamiento) displacing negative feelings
diabetes mellitus (diabetes mellitus) chronic disorder of car- onto something or someone else with no significance to the
bohydrate metabolism characterized by hyperglycemia and situation (Ch. 4).
resulting from inadequate production or utilization of insulin disposition (temperamento) temperament, character, per-
(Ch. 44). sonality (Ch. 1).
diagnosis (diagnóstico) determination of disease or condi- diuretic (diurético) substance that causes less water to be
tion (Ch. 39). reabsorbed by the kidney and therefore causes water to be
diaphragm (diafragma) a lens or other object that opens excreted from the body (Ch. 34).
and closes to increase or decrease the amount of light on the DNA (ADN) deoxyribonucleic acid; important nuclear
object being illuminated. This refers to optic diaphragm such material that carries genetic codes (Ch. 39, 43).
as in a microscope (diaphragms are used in birth control and
also the large respiratory muscle) (Ch. 39). doctrine (doctrina) principle of law established through past
decisions (Ch. 7).
diastole (diástole) one component of blood pressure mea-
surement representing the lowest amount of pressure exerted documentation (documentación) written material that
during the cardiac cycle; the force exerted on the arterial walls accompanies purchased software containing the information
during cardiac relaxation (Ch. 24, 37). necessary for using the software appropriately; sometimes
known as the manual (Ch. 11, 22); also, providing factual
diathermy (diatermia) the therapeutic use of high-frequency support through written information (Ch. 22).
current to generate heat within some part of the body without
damaging tissues (Ch. 33). Doppler (doppler) a noninvasive technique used with ultra-
sonography to evaluate blood flow through major arteries and
diethylstilbestrol (DES) (dietilestilbestrol [DES]) a synthetic veins of the arms, legs, and neck. It can reveal blood clots or
hormone used therapeutically in menopausal disturbances. blockages (Ch. 32).
It should not be given during pregnancy. It has been related
to cervicovaginal malignances in daughters of mothers who dorsiflexion (dorsiflexión) moving the foot upward at the
had it prescribed for them to treat a threatened abortion. DES ankle joint (Ch. 33).
has been related to reproductive disorders in males whose dosimeter (dosímetro) a device for measuring X-ray output
mothers took it during pregnancy (Ch. 26). (Ch. 32).
differential diagnosis (diagnóstico diferencial) diagno- down-coding (baja de codificación) insurance carriers down-
sis based on comparison of symptoms of similar diseases code if documentation or codes are ambiguous and reimburse
(Ch. 39). for the lowest possible fee (Ch. 18).
digestion (digestión) breaking down of food into smaller donut hole (período sin cobertura) within the Medicare Part
particles. It can be either physical or chemical (Ch. 34). D prescription drug program, the donut hole is the phase of
1122 Glossary of Terms

coverage in which all costs are covered by the enrollee rather electrolyte (electrolito) substances that conduct electricity
than CMS (Ch. 17). whose components are important in maintaining fluid and
dressing (apósito) sterile gauze or other material applied acid–base balance (Ch. 34, 37, 39).
directly to a wound to absorb secretions and to protect electrocochleography (electrococleografía) diagnostic
(Ch. 9, 31). tool used to help diagnose Meniere’s disease. It records
driver (controlador) computer program designed to convert the electrical activity of the inner ear in response to sound
data output from one device to a format compatible with ano- (Ch. 30).
ther device (Ch. 11). electronic health record (EHR) (registro de salud electrónico
droplet transmission (transmisión por gotitas) method of [RSE]) a patients’ electronic medical records from multiple
spreading disease from respiratory secretions through the sources combined into one master database (Ch. 11).
air. Spread is usually confined to within 3 feet of the infected electronic medical record (EMR) (registro médico electrónico
patient (Ch. 22). [RME]) patient medical record from a single medical prac-
durable power of attorney for health care (poder legal dura- tice, hospital, or pharmacy (Ch. 11, 16).
dero para atención médica) legal form that allows a designa- emaciation (emaciación) state of being extremely lean
ted person to act on another’s behalf in regard to health care (Ch. 30).
choices (Ch. 6, 7). emancipated minor (menor emancipado) persons under
dysmenorrhea (dismenorrea) painful menses (Ch. 26). age 18 years who are financially responsible for themselves
dyspareunia (dispareunia) painful intercourse (Ch. 26). and free of parental care (Ch. 7).
dysplasia (displasia) abnormal development of tissue embezzle (malversar) to appropriate fraudulently to one’s
(Ch. 26). own use (Ch. 45).
dyspnea (disnea) shortness of breath or labored/difficult Emergency Medical Services (EMS) (Servicios Médicos de
breathing (Ch. 24). Emergencia [SME]) a local network of police, fire, and
medical personnel trained to respond to emergency situa-
dysuria (disuria) painful or difficult urination (Ch. 30). tions. In many communities, the system is activated by calling
911 (Ch. 9).
E empathy (empatía) ability to be objectively aware of and
E codes (códigos E) ICD-9-CM codes for the external causes have insight into another’s feelings, emotions, and beha-
of injury, poisoning, or other adverse reactions that explain viors, and to be aware of the significance and meaning of
how the injury occurred (Ch. 18). these to the other person (Ch. 1, 29).
echocardiogram (ecocardiograma) noninvasive diagnostic emphysema (enfisema) chronic pulmonary disease charac-
method that uses ultrasound to visualize internal cardiac terized by dilated and damaged alveoli (Ch. 24).
structure, including valves (Ch. 32).
EMR (RME) see electronic medical record (Ch. 11).
eclampsia (eclampsia) complication of pregnancy that inclu-
encode (encoding) (codificar [codificación]) creating a mes-
des general edema, hypertension, proteinuria, and convulsions
sage to be sent (Ch. 4).
(Ch. 26).
encounter form (formulario de visita) formerly known as a
ectopic pregnancy (embarazo ectópico) implementation of
charge slip or superbill. A copy of the encounter form is given
the fertilized ovum outside of the uterine cavity (Ch. 26, 44).
to the patient after seeing the provider. It identifies the pro-
edematous (edematoso) abnormal accumulation of fluid in cedures performed, diagnoses, charges, and when to return
the tissues resulting in swelling (Ch. 40). (Ch. 18, 19).
editing (corrección) the process of manipulating text to avoid encrypted email (correo electrónico cifrado) the process
inaccuracies and inconsistencies within a document (Ch. 16). of coding email to render the transmission essentially secure
editor (corrector) see auditor (Ch. 16). (Ch. 12).
effacement (borramiento) thinning and shortening of encryption technology (tecnología de cifrado) converts
the cervical canal during labor to permit passage of fetus information into code; used to protect privacy and confiden-
(Ch. 26). tiality of individuals in computer software (Ch. 13).
effleurage (effleurage) deep or gentle stroking massage endemic (enfermedad endémica) disease that occurs conti-
(Ch. 33). nuously or in cycles with a certain number of cases expected
EHR (RSE) see electronic health record (Ch. 11). for a given period (Ch. 22).
electrocardiogram (electrocardiograma) record of the electri- endometriosis (endometriosis) tissue that resembles the
cal activity of the heart; showing P, QRS, and T waves (Ch. 37). endometrium invades various locations in the pelvic cavity
and elsewhere (Ch. 26).
electrocardiograph (electrocardiografío) instrument for
recording the electrical activity of the heart (Ch. 37). endoscopy (endoscopia) visual examination of body cavities
with a lighted scope (Ch. 22).
electrocardiography (electrocardiografía) process of recor-
ding the electrical activity originating in the heart (Ch. 37). engineering controls (controles de ingeniería) physical or
mechanical devices that isolate or remove health hazards from
electrode (electrodo) also known as a sensor. Used to con- the workplace (Ch. 22).
duct electricity from the body to the electrocardiograph
(Ch. 37).
 Glossary of Terms 1123

enunciation (dicción) speaking clearly; articulating (Ch. 12). eupnea (eupnea) normal breathing (Ch. 24).
enzyme immunoassay (inmunoensayo enzimático) measure- evaluation (evaluación) assessment of an employee’s job
ment of reaction of antigen with specific antibody (Ch. 44). performance (Ch. 46).
eosinophil (eosinófilos) granulocytic white blood cell with eversion (eversión) moving a body part outward (Ch. 33).
red eosin-stained granules in the cytoplasm. It is elevated in exclusion (exclusión) specific disease or condition listed in
cases of allergies (Ch. 41). an insurance policy for which the policy will not pay (Ch. 17).
epidemic (epidemia) an infectious disease that attacks many exclusive provider organization (EPO) (organización de pro-
persons at the same time in the same location (Ch. 22). veedor exclusivo [EPO]) a closed-panel preferred organiza-
epidemiology (epidemiología) field of science that stu- tion (PPO) plan where enrollees receive no benefits if they
dies the history, cause, and patterns of infectious diseases opt to receive care from a provider who is not in the EPO
(Ch. 22). (Ch. 17).
epinephrine (epinefrina) used to treat allergic reactions excoriated (excoriación) abrasion of the epidermis by
(Ch. 9); also, hormone also known as adrenaline. Epinephrine trauma, chemicals, burns, or other causes (Ch. 22).
is manufactured as a chemical (pharmaceutical preparation) excretion (excreción) waste matter. The elimination of waste
and is often mixed with local anesthetics for use as a vasocons- products from the body (Ch. 22, 38).
trictor in minor surgery (Ch. 31).
exfoliated (exfoliación) the shedding of something such as
epistaxis (epistaxis) nosebleed (Ch. 22). cervical cells (Ch. 26).
Epstein–Barr virus (EBV) (virus de Epstein-Barr [VEB]) virus exit interview (entrevista de salida) opportunity for depar-
that is believed to be the cause of infectious mononucleosis and ting employees to provide their positive and negative opinions
is implicated in such conditions as African Burkitt’s lymphoma of the position and facility (Ch. 46).
and nasopharyngeal carcinoma (Ch. 44).
expectorate (expectorar) act of coughing up material from
e-résumé (curriculum vitae electrónico) electronic résumés airways that lead to the lungs (Ch. 22, 43).
may be delivered electronically via e-mail, submitted to Inter-
net job boards, or placed on Web pages (Ch. 48). expert witness (testigo experto) individual with highly spe-
cialized knowledge and skills in a particular area who testifies
ergonomics (ergonomía) scientific study of work and space, to a standard of care (Ch. 7).
including factors that influence worker productivity and that
affect workers’ health (Ch. 11). explanation of benefits (EOB) (explicación de beneficios
[EDB]) insurance report that is sent with claim payments
erythema (eritema) redness or inflammation of the skin or explaining the reimbursement of the insurance carrier
mucous membranes that is the result of dilatation and conges- (Ch. 18).
tion of superficial capillaries (Ch. 30).
explicit (explícito) fully revealed or expressed without ambi-
erythrocyte (eritrocito) red blood cell, one of the formed guity or vagueness, leaving no question as to intent (Ch. 9).
elements of the blood (Ch. 40, 41).
expressed contract (contrato explícito) written or verbal
erythrocyte indices (índices de eritrocitos) three equations contract that specifically describes what each party in the con-
that provide information about the sizes and hemoglobin con- tract will do (Ch. 7).
tent of red blood cells. These include the mean corpuscular
cell volume, mean corpuscular hemoglobin, and mean cor- extension (extensión) straightening of a body part (Ch. 33).
puscular hemoglobin volume (Ch. 41). external respiration (respiración externa) ventilation of the
erythrocyte sedimentation rate (velocidad de eritrosedimen- lungs when the exchange of oxygen and carbon dioxide takes
tación) measurement of how far the red cells in a sample of place (Ch. 30).
blood settle in one hour (Ch. 41). externship (práctica laboral) transition stage between the
erythropoietin (eritropoyetina) hormone that causes pro- classroom and actual employment; may also be referred to as
duction of new red blood cells (Ch. 41). internship or practicum (Ch. 1, 24, 45).
esophageal varices (várices esofágicas) tortuous dilation of extracellular (extracelular) pertaining to the environment
the esophageal vein associated with any condition that causes outside of a body cell (Ch. 34).
obstruction of drainage from the esophageal veins into the exudate (exudado) accumulated fluid in a cavity; an oozing
portal vein of the liver. Seen in cirrhosis of the liver and alco- of pus; matter that penetrates through vessel walls into adjo-
holism (Ch. 32). ining tissue (Ch. 22, 27, 31).
Ethernet (Ethernet) references the networking of compu-
ters using metallic conductors or hard wires (Ch. 11). F
ethics (ética) defined in terms of what is morally right and facilitate (facilitar) to make an action or process easier
wrong; ethics will differ from person to person; often defined (Ch. 1).
by a code or creed as in the Code of Ethics from the American Fair Debt Collection Practice Act (Ley sobre Prácticas Justas
Association of Medical Assistants (AAMA) (Ch. 8). para el Cobro de Deudas) 1977 federal law that outlines
ethyl alcohol (alcohol etílico) alcohol, used to make a solu- collection practices (Ch. 20).
tion (Ch. 38). fat-soluble (soluble en lípidos) pertaining to substances
etiquette (etiqueta) manners, politeness, proper behavior that are hydrophobic and therefore dissolve better in fat
(Ch. 12). (Ch. 34).
1124 Glossary of Terms

fax (facsimile) (fax [facsímilx]) machine that sends docu- fracture (fractura) break in a bone. There are several types
ments from one location to another by way of telephone lines of fractures, but all are classified as either open or closed frac-
(Ch. 12). tures (Ch. 9).
febrile (febril) having a fever (Ch. 24). fraud (fraude) deliberate misrepresentation of facts (Ch. 17).
Federal Register (Registro Federal) federal government frenulum (frenillo) of the tongue, a fold of mucous mem-
agency from which written CLIA ’88 documents may be ob- brane located under the tongue attaching the tongue to the
tained (Ch. 38). floor of the mouth (Ch. 24).
felony (delito mayor) a serious crime such as murder, frequency (frecuencia) urinating frequently (Ch. 30).
larceny (thefts of large sums of money), assault, and rape friable (friable) easily broken (Ch. 31).
(Ch. 7).
fringe benefit (beneficio complementario) benefit above
fenestrated (fenestrado) having openings. A sterile, fenes- and beyond salary to which an employee may be entitled.
trated drape is used in surgery. It has an opening (round) in it Examples include health and life insurance, paid vacation,
to expose only the operative site. The remainder of the drape sick days, personal days, and tuition reimbursement for cour-
covers the patient and is a sterile area (Ch. 31). ses related to employment (Ch. 2, 45).
fenestrated drape (paño fenestrado) a type of drape with an fulgarated (fulgurado) destroyed by electric current
opening, usually round, that can be placed with the opening (Ch. 26).
over a particular body area; used in surgery and for proctolo-
gic examinations (Ch. 25). full block letter (carta de bloque completo) major letter
style in which all lines begin flush with the left margin. This
firewall (cortafuegos) hardware device or software program style is suggested for offices desiring a contemporary-looking,
designed to prevent unauthorized access to a computer sys- efficient letter (Ch. 15).
tem (Ch. 11).
fume hood (campana de humo) type of hood or barrier
first aid (primeros auxilios) immediate (or first) care pro- used in the laboratory to capture chemical vapors and fumes
vided to persons who are suddenly ill or injured; first aid is and move them away from health care workers and into a
typically followed by more comprehensive care and treatment building’s exhaust fan system (Ch. 38).
(Ch. 9).
functional résumé (curriculum vitae funcional) résumé for-
fiscal intermediary (intermediario fiscal) local administra- mat used to highlight specialty areas of accomplishment and
tor for Medicare (Ch. 17). strengths (Ch. 48).
fixed cost (costo fijo) cost that does not vary in total as the furuncle (forúnculo) localized, suppurative staphylococcal
number of patients vary (Ch. 21). skin infection originating in a gland or hair follicle (Ch. 30).
flag (indicador de mensaje) method of identifying a blank
space or a question regarding dictator’s meaning by attaching G
a note or marker to indicate the question (Ch. 16).
gait (marcha) manner or style of walking including rhythm
flash drive (unidad flash) solid-state data storage device and speed (Ch. 33).
(Ch. 11).
gait belt (cinturón de marcha) safety belt worn by the patient
flexion (flexión) bending of a body part (Ch. 33). around the waist that provides a firm handhold for the caregi-
fluent (fluido) able to write or speak easily or flowing smoo- ver when transferring the patient or when assisting in ambula-
thly (Ch. 12). tion (Ch. 33).
fluoroscope (fluoroscope) a device consisting of a screen; gallium (galio) a nontoxic metal, similar to mercury
mounts separately or with an X-ray tube that shows the ima- in appearance, that can be used in place of mercury for
ges of objects interposed between the table and the screen fever thermometers. It is not yet widely available for use
(Ch. 32). (Ch. 24).
folic acid (ácido fólico) one of the B-complex vitamins galvanometer (galvanómetro) mechanism in the electrocar-
(Ch. 34). diograph that changes the voltage into a mechanical motion
fomite (fómite) substance that absorbs and transmits infec- for recording purposes (Ch. 37).
tious material; for example, contaminated items such as equip- genetic engineering (ingeniería genética) alteration, mani-
ment (Ch. 22). pulation, replacement, or repair of genetic material (Ch. 8).
fontanel (fontanela) soft spot lying between the cranial genitalia (genitales) the reproductive organs, internal and
bones of the skull of a fetus, newborn, and infant (Ch. 27). external (Ch. 26).
forensic (forense) applying scientific knowledge to legal genus (género) first Greek or Latin name given to a microor-
issues (Ch. 38). ganism; always capitalized (Ch. 43).
form letter (carta tipo) letter containing the same content geriatrics (geriatría) the branch of medicine concerned with
in the body but sent to different individuals (Ch. 15). the problems of aging (Ch. 29).
formaldehyde (formaldehído) colorless gas combined with gerontology (gerontología) the scientific study of the pro-
methanol and used as a solution, such as a disinfectant, astrin- blems associated with aging (Ch. 29).
gent, or a preservative for histologic specimen (Ch. 38). gestation (gestación) period of development from fertiliza-
formalin (formalina) an aqueous solution of 37% formalde- tion to birth (Ch. 26).
hyde (Ch. 26).
 Glossary of Terms 1125

gestational diabetes (diabetes gestacional) diabetes that first [HIPAA]) government rules, regulations, and procedures
manifests clinically during pregnancy. It usually subsides after resulting from legislation designed to protect the confidentia-
delivery (Ch. 26). lity of patient information (Ch. 16).
gestures/mannerisms (gestos/ademanes) movement of health maintenance organization (HMO) (organización de
various body parts while communicating (Ch. 4). mantenimiento de la salud [HMO]) type of managed care
glucose (glucosa) simple sugar that is a major source of operation that is typically set up as a for-profit corporation
energy in the human body; monitoring of blood glucose levels with salaried employees. HMOs “with walls” offer a range of
in urine and blood is a vital diagnostic test in diabetes and medical services under one roof; HMOs “without walls” typi-
other disorders; also a test on a reagent strip (Ch. 39, 42). cally contract with providers in the community to provide
patient services for an agreed-upon fee (Ch. 2, 17).
glucosuria (glucosuria) the presence of glucose in urine
(also correct is glycosuria) (Ch. 42). Healthcare Common Procedure Coding System (HCPCS)
(Sistema de Códigos de Procedimientos Comunes de la Aten-
glycogen (glicógeno) carbohydrate form used for storage of ción Médica [HCPCS]) a coding system consisting of the CPT,
sugar in the body (Ch. 34). national codes (level II), and local codes (level III); previously
goal (meta) result or achievement toward which effort is direc- known as HCFA Common Procedure Coding System (Ch. 18).
ted (Ch. 5). Heimlich maneuver (maniobra de Heimlich) abdominal
“going bare” (“estar desprotegido”) said of a provider who thrusts designed to overcome breathing difficulties in indivi-
does not carry professional liability insurance (Ch. 45). duals who are choking (Ch. 9).
goniometer (goniómetro) instrument used to measure the hematocrit (hematocrito) percentage of red blood cells
angle of a joint’s range of motion (Ch. 33). within a specimen of anticoagulated whole blood (Ch. 41).
goniometry (goniometría) measurement of joint motion hematology (hematología) study of blood and the blood-
(Ch. 33). forming tissues (Ch. 39, 41).
Good Samaritan laws (leyes del Buen Samaritano) laws hematoma (hematoma) a large bruise, accumulation of
designed to protect individuals from legal action when rende- blood around the venipuncture site during or after venipunc-
ring emergency medical aid, without compensation, within the ture caused by the leakage of blood from where the needle
areas of their training and expertise (Ch. 12). punctured the vein (Ch. 31, 40).
Gram stain (tinción de Gram) named for its inventor, Hans hematopoiesis (hematopoyesis) formation of blood cells
Christian Gram, and is, therefore, always capitalized; most (Ch. 41).
common stain used in microbiology to observe gross mor- hematuria (hematuria) abnormal presence of blood in
phologic features of bacteria; a differential stain, allowing urine, symptomatic of many disorders of the genitourinary
differentiation between Gram-negative and Gram-positive system and renal diseases (Ch. 30, 42).
organisms (Ch. 43).
hemiplegia (hemiplejía) paralysis of one side of the body
gravidity (gravidez) total number of pregnancies a woman (Ch. 33).
has had regardless of duration, including a present one
(Ch. 26). hemoconcentration (hemoconcentración) pooling of blood
at the location of the venipuncture caused by leaving the tour-
gross contamination (contaminación importante) highly niquet on the arm longer than one minute, resulting in inac-
infectious material present (Ch. 22). curate blood samples (Ch. 40).
gross examination (examen macroscópico) viewing speci- hemoglobin (hemoglobina) molecule within the red blood
mens with the naked eye (Ch. 16). cell that transports oxygen (Ch. 41).
guarantor (garante) the person identified as responsible for hemoglobinopathy (hemoglobinopatía) inherited disease
payment of the bill (Ch. 19). resulting from the formation of an abnormal hemoglobin
Guthrie screening test (prueba de detección de Guthrie) molecule (Ch. 41).
also known as newborn screening test; diagnostic test for the hemolysis (hemólisis) rupturing of the red blood cells
detection of phenylketonuria (PKU) (Ch. 44). during the process of blood collection. The serum or plasma
becomes contaminated and has a reddish color (Ch. 40).
H hemoptysis (hemoptisis) spitting up of blood arising from
hard drive (disco duro) a nonvolatile storage device that sto- the mouth, larynx, trachea, bronchi, or lungs characterized by
res digitally encoded data on rapidly rotating rigid disks with a sudden attack of coughing with production of bloody spu-
magnetic surfaces. The capacity is approximately 100 GB. The tum (Ch. 30).
device is either permanently installed within the computer
heterophile antibody (anticuerpo heterófilo) antibody that
case or can be portable (Ch. 11).
reacts with other than the specific antigens as seen in infec-
hardware (hardware) physical equipment used by the com- tious mononucleosis (Ch. 44).
puter system to process data (Ch. 11).
Hibeclens® (Hibeclens®) brand of antiseptic soap solution
hard-wired networks (redes con cableado físico) networks (Ch. 31).
connected by metallic conductors or cables; under some cir-
hierarchy of needs (jerarquía de necesidades) needs that are
cumstances, optical cables could be used (Ch. 11).
arranged in a specific order or rank; sequential arrangement.
Health Insurance Portability and Accountability Act (HIPAA) Associated with Abraham Maslow (Ch. 4).
(Ley de Portabilidad y Responsabilidad de Seguros de Salud
1126 Glossary of Terms

high-context communication (comunicación de alto contexto) hyperextension (hiperextensión) position of maximum

communication style that involves great reliance on body lan- extension, or extending a body part beyond its normal limits
guage, reference to objects in the environment, and culturally (Ch. 33).
relevant phraseology to convey an idea. Relies on the listener hyperglycemia (hiperglucemia) increased levels of blood glu-
knowing related events through close association with the cose. Hyperglycemia does not necessarily mean that the patient
speaker or culture (Ch. 4). is diabetic but may be an indication of prediabetes (Ch. 44).
high-density lipoprotein (HDL) (lipoproteína de alta densidad hyperpnea (hiperpnea) increased respiratory rate and depth
[HDL]) lipoprotein in the blood composed primarily of pro- as seen in exercise, pain, fever, and hysteria (Ch. 24).
tein; removes cholesterol from peripheral tissues and trans-
ports them to the liver for excretion (Ch. 44). hypertension (hipertensión) blood pressure that is consis-
tently greater than 140/90 mm Hg (Ch. 24).
histology (histología) study of a tissue biopsy sample for the
determination of disease (Ch. 39). hyperthermia (hipertermia) body temperature above nor-
mal range; an unusually high fever (Ch. 29).
history and physical examination report (H&P) (informe de
historia clínica y examen físico [H&P]) report of patient’s hyperventilation (hiperventilación) ventilation rate that is
history and physical examination to document reason for visit greater than metabolically necessary, potentially leading to
(Ch. 16). alkalosis (Ch. 24).
history of present illness (HPI) (antecedentes de enfermedad hypochromic (hipocrómico) less color than normal (Ch. 41).
actual [AEA]) the chronologic description of the develop- hypoglycemia (hipoglucemia) state of having a lower than
ment of the patient’s illness (Ch. 16). normal blood glucose level (Ch. 40, 44).
holding media (medios de sostén) specific media used in the hypotension (hipotensión) abnormally low blood pressure
transport of microorganisms to support the life of the orga- resulting in inadequate tissue profusion and oxygenation
nisms until they can be put on nutrient medium in the labora- (Ch. 24).
tory (Ch. 43). hypothermia (hipotermia) extremely dangerous cold-related
homeopathy (homeopatía) a healing modality that uses dilu- condition that can result in death if the individual does not
ted doses of certain substances to create an “energy imprint” receive care and if the progression of hypothermia is not rever-
in the body to bring about a cure (Ch. 2). sed. Symptoms include shivering, cold skin, and confusion
homeostasis (homeostasia) state of equilibrium of internal (Ch. 9, 29).
environment (Ch. 34). hypoventilation (hipoventilación) decrease in respiration
hormone replacement therapy (HRT) (terapia de reemplazo rate with shallow depth of respiration (Ch. 24).
hormonal [TRH]) the replacement of hormones lacking hypoxemia (hipoxemia) lack of oxygen in the blood (Ch. 36).
from the patient’s system. In this case, HRT refers to the hypoxia (hypoxia) oxygen deficiency (Ch. 26).
replacement of varying levels of estrogen and progesterone
hysterosalpingogram (histerosalpingograma) X-ray of uterus
in perimenopausal or postmenopausal women (Ch. 26, 39).
and fallopian tubes using a contrast medium (Ch. 26).
hospital-based laboratories (laboratorios con base en el
hospital) hospital-owned laboratories that perform most tests
required by the hospital and local communities (Ch. 39).
I
immune system (sistema inmunitario) body’s strong line of
human chorionic gonadotropin (hCG) (gonadotropina corió- defense against invading microorganisms. The body recogni-
nica humana [hCG]) hormone secreted by the trophoblast zes foreign substances such as microorganisms and produces
after fertilization of the ovum. It may be detected in the blood substances to fight them off. Antibodies, white blood cells,
and urine of pregnant women (Ch. 26, 44). digestive enzymes, and resistance of the skin are some exam-
human immunodeficiency virus (HIV) (virus de la inmunode- ples (Ch. 22).
ficiencia humana [VIH]) virus causing AIDS; it is a retrovirus immunity (inmunidad) ability of the body to resist specific
that ultimately destroys immune system cells (Ch. 22). pathogens and their toxins (Ch. 22).
humoral immunity (inmunidad humoral) immunity media- immunoglobulins (inmunoglobulinas) family of proteins
ted by antibodies in body fluids such as plasma and lymph capable of acting as antibodies, thereby protecting indivi-
(Ch. 22). duals from pathogenic microorganisms; also, antibodies
hyaline (hialino) transparent, clear; hyaline casts consist of produced by the cells of the immune response system
mucuprotein, they are transparent and often difficult to see (Ch. 22, 30).
in urine (Ch. 42). immunohematology (inmunohematología) study of blood
hydatidiform mole (mola hidatidiforme) development of group antigens and antibodies; blood banking (Ch. 39).
cysts and rapid growth of the uterus with bleeding (Ch. 44). immunology (inmunología) the study of the components of
hydrocollator pack (paquete de hidrocolator) pack filled the immune system and their function (Ch. 39).
with gel that is warmed in a water bath (Ch. 33). immunomodulator (inmunomodulador) a substance that
hydrogen peroxide (peróxido de hidrógeno) antibacterial has the ability to change immune responses (Ch. 22, 43).
solution that has a mechanical cleansing action (Ch. 31). immunosuppressed (inmunosuprimido) referring to a
hyperemesis gravidarum (hiperemesis gravídica) severe nau- patient whose immune system is unhealthy because of disease,
sea and vomiting during pregnancy with inability to eat; may medication, and genetics; these patients can be particularly
lead to severe dehydration (Ch. 26). susceptible to attack by microorganisms (Ch. 22, 43).
 Glossary of Terms 1127

implicit (implícito) capable of being understood from some- inner-directed people (personas con autodeterminación)
thing else though unexpressed; implied (Ch. 9). people who decide for themselves what they want to do with
implied consent (consentimiento implícito) consent assu- their lives (Ch. 5).
med by the health care provider, typically in an emergency inoculate (inocular) to place colonies of microorganisms
that threatens the patient’s life. Implied consent also occurs onto nutrient media (Ch. 43).
in more subtle ways in the health care environment; for exam- inoculation (inoculación) injection (Ch. 22).
ple, when a patient willingly rolls up the sleeve to receive an
injection (Ch. 7). input device (dispositivo de entrada) a device used to input
data into a computer (Ch. 11).
implied contract (contrato implícito) contract indicated by
actions rather than words (Ch. 7). instrument tray (bandeja de instrumentos) see Mayo stand
(Ch. 31).
improvise (improvisar) to make, invent, or arrange in an
unplanned or spontaneous manner (Ch. 1). insulin (insulina) hormone secreted by beta cells of the islets
of Langerhans of the pancreas essential for the proper meta-
incinerate (incinerar) to destroy by fire (Ch. 22). bolism of glucose (Ch. 44).
income statement (estado de resultados) financial statement integrate (integrar) to incorporate into a larger unit; to form
showing net profit or loss (Ch. 21). or blend into a whole (Ch. 1).
incompetence (incompetencia) legally, a person who is integrated delivery system (IDS) (sistema de prestación de
insane, inadequate, or not an adult (Ch. 7). servicios médicos integrado [IDS]) a health care organi-
incontinence (incontinencia) uncontrollable loss of urine or zation of affiliated provider sites combined under a single
feces (Ch. 29). ownership that offers the full spectrum of managed health
increment (incremento) an increase or addition in number, care (Ch. 17).
size, or extent (Ch. 24). integrative medicine (medicina integradora) bringing toge-
independent physician association (IPA) (Asociación Inde- ther of two or more treatment modalities so they function as a
pendiente de Médicos [IPA]) independent network of phy- harmonious whole, as seen in alternative forms of health care
sicians in private practice who contract with the association to (Ch. 2).
treat patients for an agreed-upon fee (Ch. 2). internal respiration (respiración interna) passage of oxygen
indexing (indexar) selecting the name, subject, or number from the blood into the cells (Ch. 30).
under which to file a record and determining the order in International Classification of Diseases, 9th Revision, Clinical
which the units should be considered (Ch. 14). Modification (ICD-9-CM) (Clasificación Internacional de Enfer-
indirect statements (declaraciones indirectas) means of eli- medades, 9.ª Revisión, Modificación Clínica [CIE-9-MC]) stan-
citing a response from a patient by turning a question into a dard diagnosis codes used to identify a patient’s medical
statement of interest (Ch. 4). problem. Used by most ambulatory care settings in encoding
the claim form and recognized by most insurance carriers
infarction (infarto) area of tissue in an organ or part that (Ch. 18).
becomes necrotic (dead) after cessation of blood supply
(Ch. 37). internship (pasantía) transition stage between classroom
and employment (Ch. 1).
infection (infección) invasion of pathogens into living tissue
(Ch. 31). interrogatory (interrogatorio) a written set of questions that
must be answered, under oath, within a specific time period;
infection control (control de infecciones) methods to elimi- part of the discovery process (Ch. 7).
nate or reduce the transmission of infectious microorganisms
(Ch. 22). interview (entrevista) meeting in which you and the inter-
viewer discuss employment opportunities and strengths you
infectious agent (agente infeccioso) pathogen responsible can contribute to the organization (Ch. 48).
for a specific infectious disease (Ch. 22).
interview techniques (técnicas de entrevista) methods of
infectious mononucleosis (mononucleosis infecciosa) acute encouraging the best communication between the applicant
infectious disease primarily affecting the lymphoid tissue, cau- and the interviewer (Ch. 4).
sed by the Epstein–Barr virus (Ch. 44).
intraepithelium (intraepitelial) within the epithelium
infectious waste (residuos patógenos) items that have come (Ch. 26).
in contact with patient blood or body fluids. Contaminated
items (Ch. 22). intravenous pyelogram (pielograma intravenoso) radiogra-
phic studies of the kidneys, ureters, and bladder using a con-
inflammation (inflamación) the normal nonspecific immune trast medium (Ch. 28).
response by the body to any type of injury (trauma, bacterial,
viral, and temperature extremes) (Ch. 31). invasive procedure (procedimiento invasivo) surgical techni-
que or a procedure that requires penetration of the skin or a
inflammatory response (respuesta inflamatoria) body’s body opening. The potential for pathogenic microorganisms
defense against the threat of infection or trauma. Characteri- to enter the body exists (Ch. 22, 39).
zed by redness, pain, heat, and swelling (Ch. 22).
inversion (inversión) moving a body part inward (Ch. 33).
informed consent (consentimiento informado) consent
given by the patient who is made aware of any procedure to involuntary dismissal (despido involuntario) termination of
be performed, its risks, expected outcomes, and alternatives employment based on poor job performance or violation of
(Ch. 7, 31). office policies (Ch. 46).
1128 Glossary of Terms

involution (involución) return of the uterus to normal size keywords (palabras clave) words that relate to a job-specific
and shape after childbirth (Ch. 26). position. Keywords may be job-specific skills or profession-
ionizing radiation (radiación ionizante) X-ray beams (Ch. 32). specific words (Ch. 48).
ischemia (isquemia) local and temporary lack of blood to an kinesics (cinésica) study of body language (Ch. 4).
organ or part caused by obstruction of circulation (Ch. 37).
isoelectric (isoeléctrico) having equal electrical potentials.
L
It is represented on the ECG as the flat horizontal line, the labyrinthitis (laberintitis) inflammation of inner ear or
baseline (Ch. 37). labyrinth (Ch. 25).
isolation (aislamiento) separating a patient with certain lackluster (deslucido) dull, lacking in sheen (Ch. 9).
infections or communicable diseases from other individuals Lamaze (Lamaze) technique consisting of breathing exerci-
(Ch. 22). ses to facilitate delivery (Ch. 26).
isolation categories (categorías de aislamiento) system of latex beads (perlas de látex) tiny latex beads coated with
seven categories developed by the Centers for Disease Control antibodies or antigens that react with antigens or antibodies
(CDC) that isolates patients according to known infections. in the test sample in an agglutination reaction. The latex
These categories have been condensed into three Transmission- beads may be colored to make the reaction easier to visualize
Based Precautions based on air, contact, and droplet routes of (Ch. 44).
transmission (Ch. 22).
lead wire (alambre guía) a conductor attached to an electro-
isopropyl alcohol (alcohol isopropílico) commonly called cardiograph. Consists of limb leads and chest leads (Ch. 37).
rubbing alcohol; 70% alcohol solution commonly used as a
ledger (libro mayor) record of charges, payments, and
cleaner (Ch. 31).
adjustments for individual patient or family (Ch. 19).
isotope (isótopo) a chemical element (Ch. 32).
lesion (lesión) injury or wound. A circumscribed area of
itinerary (itinerario) detailed written plan of a proposed trip tissue that has been altered pathologically (Ch. 22, 30).
(Ch. 45).
letter of reference (carta de referencia) letter usually writ-
ten by an employee’s past employer describing the employee’s
J performance, attitude, or qualifications. This letter is pre-
jargon (jerga) words, phrases, or terminology specific to a sented to a potential employer when applying for a new job
profession (Ch. 12). (Ch. 46).
jaundice (ictericia) yellow discolorization of the skin and letter of resignation (carta de renuncia) letter informing the
sclera caused by excess bilirubin in the blood (Ch. 22, 25). current employer of the employee’s decision to resign from a
jet injection (inyección a chorro) an injection given under current position (Ch. 46).
the skin without a needle, using the force of the liquid under leukocyte (leucocito) white blood cell, one of the formed
pressure to pierce the skin (Ch. 22). elements of blood (Ch. 40, 41).
job description (descripción del trabajo) outline of tasks, leukocyte esterase (esterasa leucocitaria) test on a reagent
duties, and responsibilities for every position in the office strip that indicates the presence of white blood cells in the
(Ch. 46). urinary tract (Ch. 42).
Joint Commission (Comisión Conjunta) formerly the Joint leukorrhea (leucorrea) whitish or yellowish mucus dischar-
Commision on Accreditation of Healthcare Organizations, ged from the cervical canal or vagina. Usually normal unless
a commission established to improve the quality of care and there is an increase in amount or variation in color (Ch. 22).
services provided in organized health care setting, through liability (pasivo) debts and financial obligations for which
a voluntary accreditation process (Ch. 16). one is responsible (Ch. 21); legal responsibility (Ch. 45).
libel (calumnia) false and malicious writing about another
K constituting a defamation of character (Ch. 7).
keratitis (queratitis) inflammation of the cornea (Ch.22). libido (libido) sexual drive (Ch. 28).
ketoacidosis (cetoacidosis) accumulation of ketones in the license (licencia) permission by competent authority (the
body, occurring primarily as a complication of diabetes melli- state) to engage in a profession; permission to act (Ch. 1);
tus; if left untreated, it could cause coma (Ch. 42). permission statement authorizing the use of copyrighted com-
ketone (cetona) chemical compound produced during puter software (Ch. 11).
an increased metabolism of fat; also, test on a reagent strip license (matrícula) granting of licenses to practice a profes-
(Ch. 42). sion (Ch. 1).
ketonuria (cetonuria) having ketones in urine (Ch. 42). ligature (ligadura) length of suture thread without a needle,
ketosis (cetosis) a condition of the body burning fatty acids for used for tying off vessels during surgery (Ch. 31).
energy in the absence of appropriate glucose/carbohydrates; lipemia (lipemia) excessive amount of fat (lipids) in the
may be referred to as lipolysis (Ch. 42). blood, resulting in a blood sample that has a milky appea-
key (keyed) (mecanografiar) to input data by keystrokes on a rance (Ch. 40).
computer keyboard (Ch. 15). liquid nitrogen (nitrógeno líquido) commonly and incor-
key unit (unidad clave) first indexing unit of the filing seg- rectly referred to as dry ice, liquid nitrogen is a volatile
ment (Ch. 14).
 Glossary of Terms 1129

freezing agent used to destroy unwanted tissue such as warts magnetic drive (disco magnético) memory storage device
(Ch. 31). that uses the magnetic state of a ferrous coating to record data
lithotripsy (litotricia) procedure using shock waves directed (Ch. 11).
at calculi to crush them (Ch. 30). mainframe computer (computadora central) large com-
litigation (litigio) court action (Ch. 7). puter system capable of processing massive volumes of
data (Ch. 11).
litigious (pleiteador) prone to engage in lawsuits (Ch. 1).
major mineral (mineral principal) mineral that is required
living will (testamento en vida) document allowing a person in large amounts by the body (Ch. 34).
to make choices related to treatment in a life-threatening ill-
ness (Ch. 6). malabsorption (malabsorción) inadequate absorption of
nutrients from the intestinal tract (Ch. 30).
local area network (LAN) (red de área local [LAN]) network
of computers usually in one office or building (Ch. 11). malaise (malestar) discomfort, uneasiness, or indisposition,
often indicative of infection (Ch. 22, 30).
lochia (loquios) discharge from the uterus of blood, mucus,
and tissue during the period after childbirth (Ch. 22, 26). malaria (paludismo) acute infectious disease caused by the
presence of protozoan parasites within the red blood cells;
long-range goals (metas a largo plazo) achievements that usually comes from the bite of a female mosquito (Ch. 3, 22).
may take three to five years to accomplish (Ch. 5).
malfeasance (fechoría) conduct that is illegal or contrary to
low-context communication (comunicación de bajo contexto) an official’s obligations (Ch. 7).
communication style that uses few environmental or cultural
idioms to convey an idea or concept. Ideas are spelled out malpractice (mala praxis) professional negligence (Ch. 7, 45).
explicitly (Ch. 4). managed care operation (establecimiento de atención
low-density lipoprotein (LDL) (lipoproteína de baja densidad administrada) any health care setting or delivery system
[LDL]) lipoprotein in the blood composed primarily of cho- that is designed to reduce the cost of care while still providing
lesterol. The cholesterol carried by LDL may be deposited in access to care (Ch. 2).
peripheral tissues and is associated with an increased risk for managed care organization (MCO) (organización de atención
heart disease (Ch. 44). administrada [MCO]) a health insurance organization that
lumbar puncture (punción lumbar) surgical puncture of the adheres to the principles of strong dependence on selective
lumbar area of the intervertebral spaces to aspirate cerebro- contracting with providers, the use of primary care physicians,
spinal fluid for laboratory analysis (Ch. 22, 43). prospective and retrospective utilization management, use
of treatment guidelines for high cost chronic disorders, and
lumen (luz) the space within an artery, vein, intestine, nee- an emphasis on preventive care, education, and patient com-
dles, and catheter or tube (Ch. 24). pliance with treatment plans (Ch. 17).
lymphadenopathy (linfadenopatía) a disease of the lymph management by walking around (MBWA) (gestión itinerante
nodes (Ch. 22). [MBWA]) a technique for keeping managers informed
lymphocyte (linfocito) white blood cell with a dense non- about the health of their organization (Ch. 45).
segmented nucleus and lacking granules in the cytoplasm mandate (mandato) formal order to obey certain rules and
(Ch. 41). regulations (Ch. 38).
lyophilized (liofilizado) the process of rapidly freezing manifest (manifestar) to reveal in an obvious way (Ch. 22).
a substance at extremely low temperatures and then
dehydrating the substance in a high vacuum (freeze drying) manometer (manómetro) device for measuring a liquid or
(Ch. 27). gaseous pressure. The measurement is expressed in millime-
ters of mercury or water (Ch. 24).
M Mantoux test (prueba de Mantoux) test for tuberculosis
involving the intracutaneous injection of purified protein
M codes (morphology codes) (códigos M [códigos mor-
derivative (see PPD) (Ch. 44).
fológicos]) found in the ICD-9-CM and used primarily
with cancer registries. M codes further identify behavior marketing (comercialización) process by which the provider
and the cell type of a neoplasm (Ch. 18). of services makes the consumer aware of the scope and quality
of those services. Marketing tools might include public rela-
macroallocation (macroasignación) of scarce medical re-
tions, brochures, patient education seminars, and newsletters
sources; decisions are made by Congress, health systems
(Ch. 45).
agencies, and insurance companies (Ch. 8).
masking (ocultamiento) attempt to conceal or repress true
macrocytic (macrocítico) term that describes a larger than
feelings or the message (Ch. 4).
normal cell (Ch. 41).
matrix (matriz) to establish an appointment matrix, a
macular (macular) pertaining to a discoloration of a patch
provider’s unavailable time slots are marked with an X.
of skin, neither elevated nor depressed, of various colors, sizes,
Patients are not scheduled during those times (Ch. 13).
and shapes (Ch. 22).
mature minor (menor maduro) a person, usually younger
macular degeneration (degeneración macular) degenera-
than 18 years, who is able to understand and appreciate
tion of the macula area of the retina caused by aging; a lea-
the consequences of treatment despite their young age
ding cause of visual impairment in people older than 50 years,
(Ch. 7).
making it difficult to do fine work (Ch. 29).
1130 Glossary of Terms

Mayo stand (mesa de Mayo) portable metal tray table used microorganism (microorganismo) microscopic living crea-
for setting up small sterile fields for minor surgery and proce- ture capable of transmission and reproduction in specific cir-
dures (Ch. 31). cumstances (Ch. 22).
meconium (meconio) first feces of newborn (Ch. 26). microscopic examination (examen microscópico) viewing a
mediation (mediación) dispute resolution that allows a faci- specimen with the aid of a microscope (Ch. 16).
litator to help the two parties settle their differences and come microscopy (microscopia) inspection with a microscope
to an acceptable solution (Ch. 7). (Ch. 38).
medical asepsis (asepsia médica) clean and free from infec- midstream collection (recolección de mitad de micción)
tion (Ch. 22, 38). urine sample collected in the middle of a flow of urine
medically indigent (médicamente indigente) refers to those (Ch. 42).
individuals unable to pay for their own medical coverage minicomputer (minicomputadora) one of the four catego-
(Ch. 7). ries of computers based on size: larger than a microcomputer
Medicare Part A (Medicare Parte A) benefits covering inpa- and smaller than a mainframe (Ch. 11).
tient hospital and skilled nursing facilities, hospice care, and minor (menor) person who has not reached the age of majo-
blood transfusion (Ch. 17). rity, usually 18 years (Ch. 7).
Medicare Part B (Medicare Parte B) benefits covering out- minutes (actas) written record of topics discussed and
patient hospital and health care provider services (Ch. 17). actions taken during meeting sessions (Ch. 15, 45).
Medicare Part C (Medicare Parte C) commonly referred to misdemeanor (contravención) a lesser crime; misdemeanors
as Medicare advantage plans. These plans are approved by vary from state to state in their definition. Punishment is usua-
Medicare and are run by private companies (Ch. 17). lly probation or a time of public service and a fine (Ch. 7).
Medicare Part D (Medicare Parte D) prescription drug cove- misfeasance (irregularidad) a civil law term referring to a
rage by Medicare (Ch. 17). lawful act that is improperly or unlawfully executed (Ch. 7).
Medigap policy (póliza de Medigap) an individual plan modalities (modalidades) physical agents such as heat, cold,
covering the patient’s Medicare deductible and co-pay obli- light, water, and electricity used to treat muscular or joint mal-
gations that fulfills the federal government standards for function (Ch. 33).
Medicare supplemental insurance (Ch. 17). modified block letter, indented (carta estilo bloque modi-
memorandum (memorándum) interoffice correspondence, ficado, con sangría) modified letter style with indented
usually referred to as a memo (Ch. 15). paragraphs. Paragraphs in this style of letter may be indented
memory (memoria) refers to storage of computer data. five spaces (Ch. 15).
Memory can be volatile (lost when computer is turned off) modified block letter, standard (carta estilo bloque modi-
or nonvolatile (permanently written to storage device) ficado, estándar) major letter style where all lines begin at
(Ch. 11). the left margin with the exception of the date line, compli-
meniscus (menisco) curvature appearing in a liquid’s upper mentary closure, and keyed signature. The exceptions usual-
surface when a liquid is placed in a container (Ch. 24, 36). ly begin at the center position or a few spaces to the right of
center (Ch. 15).
menses (menstruación) menstruation (Ch. 22).
modified wave scheduling (planificación en olas modificada)
mentor (mentor) person assigned or requested to assist in system where multiple patients are scheduled at the beginning
training, guiding, or coaching another (Ch. 45). of each hour, followed by single appointments every 10 to 20
metabolism (metabolismo) total of all changes, chemical minutes the rest of the hour (Ch. 13).
and physical, that take place in the body (Ch. 34). modifier (modificador) an additional code that may be
metastasis (metástasis) in cancer, malignant cells spread added to a five-digit CPT code to further explain the service
from the primary growth to a new location (Ch. 28). provided (Ch. 18).
metered dose inhaler (inhalador de dosis medida) a device modulated (modulado) speech that varies in pitch and
used to deliver a prescribed amount of medication to the res- intensity (Ch. 12).
piratory tract, especially the lungs (Ch. 30). money market savings accounts (cuentas de ahorro del mer-
metrorrhagia (metrorragia) uterine bleeding at irregular cado monetario) bank accounts that pay a higher interest
intervals (Ch. 26). rate (money market rate) than standard savings accounts and
microallocation (microasignación) of scarce medical resour- permit writing a limited number of checks (Ch. 17).
ces; decisions are made by providers and individual members monocyte (monocito) white blood cell without cytoplasmic
of the health care team (Ch. 8). granules that has a large convoluted nonsegmented nucleus
microbiology (microbiología) branch of biology dealing with (Ch. 41).
the study of microscopic forms of life (Ch. 39, 43). morbid obesity (obesidad mórbida) obesity so severe that it
microcomputer (microcomputadora) personal or desktop can result in serious diseases (Ch. 30).
computer. Also, a handheld or laptop model (Ch. 11). morbidity (morbilidad) number of cases of disease in a spe-
microcytic (microcítico) term describing a smaller than nor- cific population (Ch. 22).
mal cell (Ch. 41). mordant (mordiente) substance that causes dye to adhere to
an object; iodine is a mordant in Gram stain (Ch. 43).
 Glossary of Terms 1131

morphology (morfología) form and structure of an orga- nonconsecutive filing (archivado no consecutivo) numeric
nism (Ch. 22, 43). filing method where numbers are considered in ascending
mortality (mortalidad) the ratio of the number of deaths to order using subsets of figures within a number; for example,
a given population (Ch. 22). in the number 574 19 2863: 2863 is unit 1, 19 is unit 2, 574 is
unit 3 (Ch. 14).
motherboard (placa madre) printed circuit board on which
the CPU, ROM, and RAM chips and other electronic circuit ele- nonfeasance (omisión) a civil law term referring to the
ments of a digital computer are frequently located (Ch. 11). failure to perform an act, official duty, or legal requirement
(Ch. 7).
mounting (montaje) process of applying in sequence a por-
tion of each of the 12 leads of the ECG recording onto a com- noninvasive procedure (procedimiento no invasivo) a proce-
mercially prepared mounting form or plain sheet of paper as dure that does require penetrating the skin or a body opening
part of the patient’s permanent record (Ch. 37). (Ch. 37).
moxibustion (moxibustión) ancient Chinese method of normal flora (flora normal) microorganisms that are normal-
treatment that uses a powdered plant substance on the skin to ly present in a specific site (Ch. 22, 43).
raise a blister (Ch. 3). normal saline (solución salina normal) a solution of sodium
multigravida (multigrávida) a woman who has been preg- chloride (salt) and distilled water. It has the same osmotic
nant more than once (Ch. 26). pressure as blood serum. It is also known as isotonic or physio-
logic saline (Ch. 9).
mycology (micología) study of fungi (Ch. 39, 43).
normal sinus rhythm (ritmo sinusal normal) term used to
myringotomy (miringotomía) incision into the tympanic describe the heart’s rhythm when it is within the normal range
membrane; part of the treatment for otitis media (Ch. 27). (Ch. 37).
N normochromic (normocrómico) of normal color, in this
case, when referring to red blood cells (Ch. 41).
Nägele’s rule (regla de Nägele) usual method for calculating
normocytic (normocítico) term that describes a normal-
expected date of birth (Ch. 26).
sized cell (Ch. 41).
National Healthcareer Association (NHA) (Asociación Nacio-
nosocomial (intrahospitalaria) infection acquired in a health
nal de Profesiones de Salud [NHA]) an association that
care setting (hospital, clinic, nursing home) (Ch. 22).
offers national certification examinations for health care pro-
fessionals. NHA works with educational institutions on curri- notary (notary public) (escribano público) someone with
culum development, competency testing, and preparation and the legal capacity to witness and certify documents; can take
administration of their examination for certification (Ch. 47). depositions (Ch. 19).
negligence (negligencia) failure to exercise a certain stan- nullipara (nulípara) a woman who has not carried a preg-
dard of care (Ch. 7, 45). nancy to the stage of viability (Ch. 26).
nematode (nematodo) round worm (Ch. 43). nutrient (nutriente) ingested substance that helps the body
stay in its homeostatic state (Ch. 34).
neonatal (neonatal) pertaining to newborn (Ch. 26).
nutrition (nutrición) study of the bringing of nutrients into
neonate (neonato) newborn.
the body and how the body uses these nutrients (Ch. 34).
nephrolithotomy (nefrolitotomía) incision into the kidney
nystagmus (nistagmo) continuous involuntary movement of
to remove stones (Ch. 30).
the eyes (Ch. 30).
network interface (interfaz de red) software, servers, and
cable connections used to link computers (Ch. 11). O
networking (conexión en red) connecting two or more com- obfuscation (ofuscación) making things clouded or confu-
puters together to share files and hardware. The system is sed (Ch. 12).
called a network (Ch. 11); process in which people of similar
interests exchange information in social, business, or profes- objective (objetivo) a patient sign that is visible, palpable,
sional relationships (Ch. 46). or measurable by an observer (Ch. 23); also, magnifying lens
that is closest to the object being viewed with a microscope
neutrophil (neutrófilo) the most common type of granulocy- (Ch. 39).
tic white blood cell (Ch. 41).
obturator (obturador) tool that obstructs or closes a cavity or
nevus (nevo) a mole (Ch. 29). opening. The internal portion of an examination instrument
niacin (niacina) one of the B-complex vitamins (Ch. 34). that facilitates the entry of the instrument into the body; it is
nitrogenous (nitrogenoso) pertaining to waste products in then withdrawn, permitting visualization of the internal area
the blood indicating kidney disease (Ch. 30). (Ch. 30).
nocturia (nocturia) excessive urination during the night occluder (oclusor) instrument used to obstruct or close off
(Ch. 28, 30). vision or light (Ch. 30).
nomogram (nomograma) graph that shows the relation occlusion (oclusión) closure of a passage (Ch. 9).
among numeric values. Body surface area (BSA) of a patient old reports (informes anteriores) reports such as a discharge
can be estimated by its use (Ch. 36). summary that should be completed within 71 hours (Ch. 16).
noncompliant (inobservancia) failure to follow a required oliguria (oliguria) decrease in urine output (Ch. 30).
command or instruction (Ch. 7).
1132 Glossary of Terms

open-ended questions (preguntas abiertas) questions that oxytocin (oxitocina) a pituitary hormone that stimulates
encourage verbalization and response; questions that seek a the muscles of the uterus to contract, thus inducing labor
response beyond a simple yes or no (Ch. 4). (Ch. 26).
operating system (OS) (sistema operativo [SO]) software
used to control the computer and its peripheral equipment. P
Also referred to as system software (Ch. 11). pagers (localizadores) also known as beepers. One-way
operative report (OR) (informe quirúrgico [OR]) medical paging systems often used inside hospitals and by providers on
report that chronicles the details of a surgical procedure call. Pagers only receive signals (Ch. 12).
(Ch. 16). palliative (paliativa) measures taken to relieve symptoms of
opportunistic infection (infección oportunista) an infec- disease (Ch. 22, 32).
tion that results from a defective immune system that cannot pallor (palidez) lack of color, paleness (Ch. 25).
defend itself from pathogens normally found in the environ-
palpate (palpar) to feel with fingertips, to search for a vein
ment (Ch. 22).
with a pressure and release touch (Ch. 40).
optical character reader (OCR) (lector óptico de caracteres
pandemic (pandemia) a disease affecting the majority of the
[OCR]) U.S. Postal Service’s computerized scanner that
population of a large region; is epidemic at same time in many
reads addresses printed on letter mail. If the information
parts of the world (Ch. 22).
is properly formatted, then the OCR will find a match in its
address files and print a bar code on the lower right edge of panel (panel) a series of tests related to a particular organ
the envelope (Ch. 15). or organ system of body function. For example, a liver panel
would check many different functions of the liver. Previously
optical disk (disco óptico) portable and transferable read-
called a “profile” (Ch. 39).
write or read-only data storage device. Sometimes called a
CD-ROM, CD-RW, or compact disk. Capacity is 1 to 8 gigabytes papular (papular) pertaining to a small, red, elevated area of
of data. Optical drive unit is required to read-write data from the skin, solid and circumscribed (Ch. 22).
the disk (Ch. 11). paracentesis (paracentesis) puncture of a cavity for removal
opticokinetic drum test (prueba del tambor optocinético) of fluid (Ch. 22).
test used to help diagnose nystagmus (Ch. 30). parasitology (parasitología) study of organisms (parasites
orchidectomy (orquidectomía) surgical excision of a testicle and their eggs) that live within or on another organism and at
(Ch. 28). the expense of that organism (Ch. 39, 43).
organomercurial (compuestos organomercuriales) any parasympathetic nervous system (sistema nervioso para-
mercury-containing organic compound (Ch. 27). simpático) part of the autonomic nervous system that
returns the body to its normal state after stress has subsided
orthopnea (ortopnea) difficulty breathing in any position
(Ch. 5).
other than an upright position (Ch. 24).
parenteral (parenteral) injection of a liquid substance
oscilloscope (osciloscopio) an electronic device used for
into the body via a route other than the alimentary canal
recording electrical activity of the heart, brain, and muscular
(Ch. 22, 36).
tissues (Ch. 32, 37).
paresthesia (parestesia) a sensation of numbness, prickling,
otoscope (otoscopio) instrument used to examine the exter-
or heightened sensitivity (Ch. 30).
nal ear canal and tympanic membrane (Ch. 30).
parity (paridad) carrying a pregnancy to the point of viabi-
out guide or sheet (señalador o marcador) card, folder,
lity regardless of the outcome (Ch. 26).
or slip of paper inserted temporarily in the files to replace a
record that has been retrieved from the files (Ch. 14). participatory manager (gerente participativo) operates on
the premise that the worker is capable and wants to do a good
outer-directed people (personas influenciables) people who
job (Ch. 45).
let events, other people, or environmental factors dictate their
behavior (Ch. 5). parturition (parir) the process of giving birth (Ch. 26).
output device (dispositivo de salida) a device used to output patch (parche) modification to software to fix deficiencies
data from a computer. Includes printers, faxes, data storage in the software. Frequently downloaded from the software
drivers, screens, and plotters (Ch. 11). supplier’s Web site or from floppy disks provided by the
supplier (Ch. 11).
ova (óvulos) eggs, in this case, eggs of a parasite (Ch. 43).
patent (permeable) open, not blocked (Ch. 26).
overtime (horas extra) money paid at a rate of not less than
one and one-half times the regular rate of pay after a 40-hour pathogen (patógeno) disease-producing microorganism
work week is completed (Ch. 46). (Ch. 22, 43).
owner’s equity (patrimonio neto) amount by which business pathology report (informe de patología) medical reports
assets exceed business liabilities. Also called net worth, pro- generated to describe the gross and microscopic examina-
prietorship, and capital (Ch. 21). tions performed during a surgical procedure (Ch. 16, 31).
oxidation (oxidación) process of a substance combining Patient Self-Determination Act (PSDA) (Ley de Autodeter-
with oxygen (Ch. 34). minación del Paciente [PSDA]) the Act that includes the
Advance Directive giving patients the right to be involved in
oxygenated (oxigenado) containing high levels of oxygen
their health care decisions (Ch. 7).
(Ch. 40).
 Glossary of Terms 1133

patient service centers (centros de servicio al paciente) sate- amino acid phenylalanine. If not discovered and treated
llite laboratory facilities located in convenient areas for patients early, brain damage can occur, causing severe mental retar-
where specimens can be collected or dropped off (Ch. 39). dation (Ch. 27, 44).
payee (beneficiario) person named on check who is to phlebotomy (flebotomía) process of collecting blood
receive the amount indicated (Ch. 19). (Ch. 22, 40).
peak (pico) the opposite of “trough,” this is the point at physician’s directive (directiva a los médicos) another name
which a drug is at its highest level in the body, usually about for a living will (Ch. 6).
30 minutes after administration. In lab tests, the peak would physicians’ office laboratories (POL) (laboratorios del consul-
tell the provider the strongest influence the drug would have torio de los médicos [POL]) laboratories within physicians’
on the body at that particular dose (Ch. 39). offices where common office laboratory tests are performed
pegboard system (sistema de tablero de clavijas) most (Ch. 39).
commonly used manual medical accounts receivable system phytomedicines (fitomedicinas) herbs used as medicinal
(Ch. 19). plants. They contain plant material as their active ingredient
pellagra (pelagra) disease caused by a deficiency in vitamin (Ch. 36).
B3 (nicotinic acid) characterized by sores on the skin, diarr- placenta abruptio (desprendimiento de la placenta) sudden
hea, anxiety, confusion, and death if not treated (Ch. 34). and abrupt separation of the placenta from uterine wall
pelvic inflammatory disease (enfermedad inflamatoria pélvica) (Ch. 26).
infection of uterus, fallopian tubes, and adjacent pelvic structu- placenta previa (placenta previa) placenta lies low in uterus
res; most common causes are gonorrhea and chlamydia, spread and can partially or completely cover the cervical os (Ch. 26).
as sexually transmitted diseases (Ch. 26).
plaintiff (demandante) person bringing charges in litigation
perception (percepción) conscious awareness of one’s own (Ch. 7).
feelings and the feelings of others (Ch. 4).
plantar flexion (flexión plantar) moving the foot downward
peripheral (periférico) away from the center of the body at the ankle (Ch. 33).
(Ch. 24).
plasma (plasma) fluid portion of blood from a tube contai-
pernicious anemia (anemia perniciosa) chronic anemia cau- ning anticoagulant. This fluid contains fibrinogen (Ch. 40).
sed by lack of hydrochloric acid in the stomach; weakness, fati-
gue, tingling of extremities, and even heart failure can result; pluralistic (pluralism) (pluralista [pluralismo]) society where
vitamin B12 injections are the treatment for this condition there are several distinct ethnic, religious, or cultural groups
(Ch. 29). that coexist with one another (Ch. 3).
personal computer (PC) (computadora personal [PC]) any point-of-service (POS) device (dispositivo de punto de servi-
computer whose price, size, and capabilities make it useful cio [POS]) device allowing direct communication between a
for individuals to use with no intervening computer operator. medical office and the health care plan’s computer (Ch. 18).
Also known as a microcomputer (Ch. 11). point-of-service (POS) plan (plan de punto de servicio
personal digital assistant (PDA) (asistente personal digital [POS]) a plan that allows direct communication between a
[PDA]) an electronic tool for organizing data, a handheld medical office and the health insurance company (Ch. 17).
computerized personal organizer device (Ch. 11). polyp (pólipo) tumor with a stem found in nose, uterus,
petri dish (placa de Petri) plastic dish into which agar is pla- bladder, colon, or rectum (Ch. 30).
ced for the purpose of growing bacteria (Ch. 43). port (puerto) shortened term for portal—an entry way.
petrissage (petrissage) a kneading movement in massage When related to intravenous therapy, it is a type of adapter
(Ch. 33). that can serve as additional means for infusing fluids or medi-
cations. The port can be attached to the primary tubing. The
petty cash (caja chica) small sum kept on hand for minor or port has a needleless entry site (Ch. 36).
unexpected expenses (Ch. 19).
portfolio (cartera) notebook or file containing examples of
pH (pH) scale that indicates the relative alkalinity or acidity materials commonly used (Ch. 15).
of a solution; measurement of hydrogen ion concentration
(Ch. 42). postcoital (poscoital) period of time following (after) inter-
course (Ch. 26).
phacoemulsification (facoemulsificación) treatment for
cataracts. An ultrasonic device is used to disintegrate the cata- posting (asiento) recording financial transactions into a
ract of the lens of the eye, which is then aspirated and remo- bookkeeping or accounting system (Ch. 19).
ved (Ch. 30). potassium hydroxide (KOH) (hidróxido de potasio [KOH])
pharmacology (farmacología) study of drugs; the science 10% solution placed on vaginal smears, as well as skin scra-
concerned with the history, origin, sources, physical and che- pings, hair, and other dry substances, to dissolve excess debris.
mical properties, and uses of drugs and their effects on living This clears the vision field for better viewing of fungi and
organisms (Ch. 35). spores (Ch. 26, 43).
pharmacopoeia (farmacopea) book describing drugs and power verbs (verbos de acción) action words used to des-
their preparation or a collection or stock of drugs (Ch. 3). cribe your attributes and strengths (Ch. 48).
phenylketonuria (PKU) (fenilcetonuria [FCU]) a here- practicum (práctica) transitional stage providing oppor-
ditary disease caused by the body’s inability to oxidize the tunity to apply theory learned in the classroom to a health
1134 Glossary of Terms

care setting through practical, hands-on experience (Ch. charting; for example, bronchitis is #1, a broken wrist is #2,
1, 45). and so forth (Ch. 14, 23).
preauthorization (autorización previa) obtaining an insu- procedure manual (manual de procedimientos) manual
rance carrier’s consent to proceed with patient care and treat- providing detailed information relative to the performance of
ment. Unless authorization is obtained, insurance carriers tasks within the job description (Ch. 45).
may not pay benefits for specific problems (Ch. 17). processed food (alimentos procesados) food that is no lon-
precedents (precedentes) refers to rulings made at an ear- ger in a whole, natural state; cooked or packaged with parts
lier time and include decisions made in a court, interpreta- removed or ingredients added (Ch. 34).
tions of a constitution, and statutory law decisions (Ch. 7). professional liability insurance (seguro de responsabilidad
precipitate (precipitado) substance in the form of fine par- profesional) insurance policy designed to protect assets in
ticles that separates from a solution if allowed to stand for a the event a claim for damages resulting from negligence is
time (Ch. 36). filed and awarded (Ch. 45).
precordial (precordial) pertaining to the area on the professionalism (profesionalismo) the qualities that cha-
anterior surface of the body overlying the heart (Ch. 37). racterize or distinguish a professional person who conforms
preeclampsia (preeclampsia) a complication of pregnancy to the technical and ethical standards of the profession
characterized by generalized edema, hypertension, and pro- (Ch. 1).
teinuria (Ch. 26). proficiency testing (prueba de aptitud) sample tests perfor-
preexisting (preexistente) injury or disease that occurs med in a clinical laboratory to determine with what degree of
before a certain date (Ch. 22). accuracy tests are being performed. Testing samples are chec-
ked in the same manner as patient specimens (Ch. 38).
preferred provider organization (PPO) (organización de pro-
veedor preferido [PPO]) organization of providers who net- profit sharing (participación en las ganancias) sharing in
work together to offer discounts to purchasers of heath care the financial profits, gains, and benefits of an organization
insurance (Ch. 2, 17). (Ch. 45).
prejudice (prejuicio) opinion or judgment that is formed progress notes (notas de evolución) also called chart notes.
before all the facts are known (Ch. 4). Provider’s formal or informal notes about presenting pro-
blem, physical findings, and plan for treatment for a patient
prenatal (prenatal) time period between fertilization and examined in the office, clinic, acute care center, or emergency
birth (Ch. 26). department (Ch. 16).
presbycusis (presbiacusia) progressive loss of hearing cau- projection (proyección) act of placing one’s own feelings on
sed by the normal aging process (Ch. 29). another (Ch. 4).
present problem (PP) (problema presente [PP]) see chief pronation (pronación) moving the arm so the palm is down
complaint (CC) (Ch. 16). (Ch. 33).
prescribe (recetar) to order or recommend the use of a pronunciation (pronunciación) saying words correctly
drug, diet, or other form of therapy (Ch. 7, 35). (Ch. 12).
preservative (conservante) chemical added to food to keep proofread (revisar) to read a document to verify the accu-
it fresh longer or added to urine to preserve it for testing racy of content and that correct grammar, spelling, punctua-
(Ch. 34, 42). tion, and capitalization were used (Ch. 15, 16).
primary care physician (PCP) (médico de atención primaria proprietary (empresa de propiedad privada) privately owned
[PCP]) primary care physician for a patient; all care is coor- and managed facility, a profit-making organization (Ch. 1).
dinated through the PCP (Ch. 17).
prostaglandin (prostaglandina) modulator of biochemical
primary container (recipiente principal) container that activity in tissues (Ch. 26).
directly contains the specimen (Ch. 40).
proteinuria (proteinuria) protein in the urine (Ch. 30).
primigravida (primigrávida) a woman pregnant for the first
time (Ch. 26). protozoa (protozoos) one-celled animals divided into four
groups: amoebae, flagellates, ciliates, and coccidia (Ch. 43).
privileged (privilegiada) confidential information that may
only be communicated with the patient’s permission or by provider performed microscopy procedure (PPMP) (procedi-
court order (Ch. 16). miento de microscopia realizada por el proveedor [PPM]) a
CLIA term for those microscopic examinations that require
probate court (tribunal sucesorio) court that administers the expertise of a physician or mid-level provider qualified in
estates and validates wills (Ch. 20). microscopic examinations. The PPMP is part of the CLIA’s
probation (período de prueba) period during which the moderately complex category of tests (Ch. 38).
employee and supervisory personnel may determine if both pruritus (prurito) itchiness (Ch. 22, 35).
the environment and the position are satisfactory for the
employee (Ch. 46). psychomotor retardation (retraso psicomotor) slowing of
physical and mental responses; may be seen in depression
problem-oriented medical record (POMR) (historia clínica (Ch. 6).
orientada al problema [POMR]) a type of patient chart
recordkeeping that uses a sheet at a prominent location in puerperium (puerperio) the period from the end of the
the chart to list vital identification data. Patient medical pro- third stage of labor until involution of uterus is complete,
blems are identified by a number that corresponds to the usually three to six weeks (Ch. 26).
 Glossary of Terms 1135

pulmonary edema (edema pulmonar) accumulation of random access memory (RAM) (memoria de acceso aleatorio
serous fluid in the air vesicles and interstitial tissues of the [RAM]) a type of computer memory that can be written to
lungs (Ch. 38). and read from. The word random means that any one location
pulse oximeter (oxímetro de pulso) a device (similar to a can be read at any time. RAM commonly refers to the inter-
clip) that can be attached to a finger or bridge of the nose. It nal memory of a computer. RAM is usually a fast, temporary
measures oxygen concentration in the blood (Ch. 24). memory area where data and programs reside until saved or
until the power is turned off (Ch. 11).
purging (purga) method of maintaining order in the files by
separating active from inactive and closed files (Ch. 14). range of motion (ROM) (amplitud de movimiento
[ROM]) amount of movement that is present in a joint
purified protein derivative (PPD) (derivado proteico purifi- (Ch. 33).
cado [DPP]) filtrate obtained from Mycobacterium cultures
used for intradermal testing for tuberculosis (Ch. 44). ratchets (trinquetes) locking mechanisms on the handles of
many surgical instruments (Ch. 31).
purulent (purulento) forming or containing pus (Ch. 22).
rationalization (racionalización) act of justification, usually
pyorrhea (piorrea) discharge of pus from the gums, around illogically, that one uses to keep from facing the truth of the
the teeth (Ch. 25). situation (Ch. 4).
pyrexia (pirexia) fever (Ch. 24). read-only memory (ROM) (memoria de sólo lectura
pyridoxine (piridoxina) vitamin B6 (Ch. 34). [ROM]) permanently stored computer data that cannot be
pyuria (piuria) pus in the urine (Ch. 30). overwritten without special devices. Stores instructions requi-
red to start up the computer. Located on the motherboard
Q (Ch. 11).
qualitative test (prueba cualitativa) analysis to identify qua- reagent (reactivo) chemical substance that detects or syn-
lity or characteristics of components, such as size, shape, and thesizes other substances in a chemical reaction; used in labo-
maturity of cells (Ch. 39). ratory analyses because it is known to react in a specific way
(Ch. 39, 42, 43).
quality assurance (QA) (aseguramiento de calidad [QA]) pro-
cess to provide accurate, complete, consistent health care reagent test strip (tira de prueba reactiva) narrow strip of
documentation in a timely manner while making every rea- plastic on which pads containing reagents are attached; used
sonable effort to resolve inconsistencies, inaccuracies, risk in the urinalysis chemical examination to detect glucose,
management issues, and other problems (Ch. 16, 38). bilirubin, ketones, specific gravity, blood, pH, urobilinogen,
nitrites, and leukocyte esterase (Ch. 42).
quality control (control de calidad) measures used to moni-
tor the processing of laboratory specimens. Includes proper recertification (nueva certificación) documentation admit-
use, storage, handling, stability, expiration dates, and indica- ted to support continued education for maintaining a profes-
tions for measuring precision and accuracy of analytic proces- sional credential (Ch. 47).
ses (Ch. 38, 42, 43). redundant array of independent disk (RAID) (matriz redun-
quantitative test (prueba cuantitativa) analysis that can iden- dante de discos independientes [RAID]) a data storage scheme
tify quantity or actual number counts such as counting the that uses multiple hard drives to share or replicate data among
number of blood cells (Ch. 39). the drives (Ch. 11).
reference laboratories (laboratorios de referencia) indepen-
R dent, regionally located laboratories used by hospitals for com-
plex, expensive, or specialized tests (Ch. 39).
radioactive (radioactivo) emits rays or particles from nucleus
(Ch. 32). reference values (valores de referencia) also referred to
as normal value, normal range, or reference range; range of
radiograph (radiografía) the film on which an image is pro- values that includes 95% of test results for a normal healthy
duced through exposure to X-rays (Ch. 32). population (Ch. 39).
radiology and imaging reports (informes de radiología y de references (referencias) individuals who have known or
diagnóstico por imágenes) medical reports that describe the worked with a person long enough to make an honest assess-
findings and interpretations of the radiologist (Ch. 16). ment and recommendation regarding the person’s back-
radiolucent (radiolúcido) allowing X-rays to pass through. A ground history (Ch. 48).
dark area appears on the radiograph (Ch. 32). referral (remisión) term used by managed care facilities for
radionuclides (radionúclidos) atoms that disintegrate by authorization for someone other than the patient’s primary
emitting electromagnetic radiation (Ch. 32). care provider to treat the patient (Ch. 17).
radiopaque (radiopaco) impenetrable to X-rays. A light area refractometer (refractómetro) instrument that measures
appears on the radiograph (Ch. 32). the refractive index of a substance or solution; used in the uri-
radiopharmaceuticals (sustancias radiofarmacéuticas) radio- nalysis physical examination to measure the urine specimen’s
active chemicals used in testing the location, size, outline, or specific gravity (Ch. 42).
function of tissue, organs, vessels, or body fluids (Ch. 32). Registered Medical Assistant (RMA) (Asistente Médico Matri-
rales (estertores) abnormal bubbling or crackling sound culado [RMA]) credential awarded for successfully passing
heard by auscultation during the inspiratory phase of respira- the AMT examination (Ch. 1, 47).
tion (Ch. 24).
1136 Glossary of Terms

regression (regresión) moving back to a former stage to rosacea (rosácea) a chronic skin condition characterized by
escape conflict or fear (Ch. 4). pustules, papules, erythema, and hyperplasia. Its cause is un-
regulated waste (residuos regulados) any waste that contains known (Ch. 30).
infectious material that would pose a threat due to possible rotation (rotación) turning a body part around its axis
transmission of pathogenic microorganisms (Ch. 22). (Ch. 33); also, opportunity to spend 2 or 3 weeks in a variety
rehabilitation medicine (medicina de rehabilitación) field of health care settings (Ch. 40).
of medical disciplines that seeks to restore an individual or
body part to normal or near-normal function after an illness S
or injury using physical and mechanical agents (Ch. 33). salary review (revisión de salario) informing the employee
reimbursement (reembolso) payment (Ch. 38). of his or her revised base pay rate (Ch. 45).
repolarization (repolarización) reestablishment of a polari- salicylates (salicilatos) aspirin-type drugs that can cause
zed state in a muscle after contraction (Ch. 37). ulcers because of their irritation to the gastrointestinal tract
repression (represión) coping with an overwhelming situa- (Ch. 30).
tion by temporarily forgetting it; temporary amnesia (Ch. 4). sanitization (higienización) cleaning or scrubbing conta-
requisition (solicitud) request form sent with a specimen minated instruments or fomites to remove tissue, debris, or
specifying tests to be performed on the specimen; most com- other contaminants (Ch. 22).
mon tests are separated into logical categories with additional saturated fat (grasa saturada) fats that are typically solid
space for writing special requests (Ch. 38, 39). at room temperature, most commonly found in animal pro-
rescue breathing (respiración de rescate) performed on ducts, such as butter, milk, cream, and eggs as well as coconut
individuals in respiratory arrest, rescue breathing is a mouth- and palm oils (Ch. 34).
to-mouth (using appropriate protective equipment) or scabies (sarna) infectious skin disease caused by the itch
mouth-to-nose procedure that provides oxygen to the patient mite (Sarcoptes scabiei), which is transmitted by direct contact
until emergency personnel arrive (Ch. 9). with infected persons (Ch. 22).
residual urine (orina residual) amount of urine remaining scleroderma (esclerodermia) slowly progressing disease
in bladder immediately after voiding; seen with hyperplasia of characterized by deposition of fibrous connective tissue in the
prostate (Ch. 28, 29). skin and in internal organs (Ch. 25).
resistance (resistencia) ability of the immune system to resist scoop technique (técnica de una sola mano) a one-handed
or withstand an infectious disease (Ch. 22). technique used to “scoop” up and cover a used needle only if
resource-based relative value scale (RBRVS) (escala de valores a sharp’s container is not immediately available, the covering
relativos basada en recursos [RBRVS]) basis for the Medi- (cap) over the needle is not manipulated in any way; it is
care fee schedule (Ch. 17). then disposed of in the nearest sharps container (Ch. 22).
résumé (curriculum vitae) written summary data sheet or scope of practice (ámbito de práctica) the range of clinical
brief account of qualifications and progress in your chosen procedures and activities that are allowed by law for a profes-
career (Ch. 48). sion (Ch. 1).
retention (retención) urine held in the bladder; inability to screening (prueba de detección) evaluating patient
empty the bladder (Ch. 28). symptoms to determine emergent needs. Sometimes used to
determine the next best course of action when assisting a pro-
retrolental fibroplasia (fibroplasia retrolenticular) disease of vider in giving appropriate patient care (Ch. 42).
blood vessels of retina in newborns (Ch. 36).
scurvy (escorbuto) a deficiency in vitamin C characterized
review of systems (ROS) (revisión de sistemas [ROS]) inqui- by the abnormal formation of bones and teeth. Signs of hemor-
res about the system directly related to the problems identi- rhage can appear, such as bruising (Ch. 34).
fied in the history of the present illness (Ch. 16).
secretion (secreción) substance produced by the cells of
Rh factor (factor Rh) blood factor indicating the presence glandular organs from materials in the blood (Ch. 22, 38).
or absence of the Rh antigen on the surface of human erythro-
cytes (Ch. 44). sediment (sedimento) insoluble material that settles to the
bottom of a liquid; material examined in the urinalysis micro-
rhythm strip (tira de ritmo) ECG recording of a single lead, scopic examination (Ch. 42).
usually lead II, that is used to determine the rhythm of the
heart beat. An arrhythmia can more easily be seen in a rhythm self-actualization (autorealización) being all that you can be;
strip because it is run longer per provider’s request (Ch. 37). developing your full potential and experiencing fulfillment
(Ch. 5, 45).
riboflavin (riboflavina) vitamin B2 (Ch. 34).
self-insurance (autoseguro) insurance carried by large com-
risk management (gestión de riesgos) techniques adhered panies, nonprofit organizations, and government to reduce
to in the ambulatory care setting that keep the practice, its costs and gain more control of their finances. Each plan differs
environment, and its procedures as safe for the patient as pos- in coverage and claim filing requirements (Ch. 17).
sible. Proper risk management also reduces the possibility of
negligence that leads to torts and malpractice suits (Ch. 7, 9, semen (semen) thick, viscid secretion discharged from the
16, 45). urethra of males at orgasm. It is a mixed product containing
various fluids and spermatozoa. In postvasectomy males, sper-
roadblocks (obstáculos) verbal or nonverbal messages that matozoa is absent in semen (Ch. 44).
block communication (Ch. 4).
 Glossary of Terms 1137

senile (senil) mental and physical weakness sometimes asso- slander (calumnia) false and malicious words about another
ciated with aging (Ch. 29). constituting a defamation of character (Ch. 7).
sensitivity (sensibilidad) test in which an organism is placed SOAP (SOAP) acronym for patient progress notes based on
with antibiotics to determine which antibiotic will effectively subjective impressions (S), objective clinical evidence (O),
kill the organism with the smallest dose (see also culture and assessment or diagnosis (A), and plans for further studies (P)
sensitivity) (Ch. 43). (Ch. 14, 23).
sensor (sensor) term used to describe a metallic-coated sodium hydroxide (hidróxido de sodio) chemical used to
paper tab that is applied to the patient’s body in preparation chemically burn and destroy tissue; usually in a liquid state
for an ECG (also known as electrode). Sensors are placed on when used in minor surgery (Ch. 31).
specific locations on the skin, then attached to the ECG with sodium hypochlorite (hipoclorito de sodio) household
wires. The sensors conduct electricity from the patient to the bleach (Ch. 22).
ECG machine (Ch. 37).
software (software) equivalent of a computer program or
sensorineural (neurosensorial) permanent hearing loss that programs (Ch. 11).
results from damage or malformation of the middle ear and
auditory nerve (Ch. 27). solvent (solvente) producing a solution, dissolving (Ch. 22).
septicemia (septicemia) invasion of pathogenic bacteria into sonographer (ecografista) professionally trained individual
the bloodstream (Ch. 3). capable of performing the ultrasound examination (Ch. 37).
serum (suero) liquid portion of blood obtained after blood source-oriented medical record (SOMR) (historia clínica
has been allowed to clot (Ch. 39, 40). orientada a la fuente [SOMR]) a type of patient chart record
keeping that includes separate sections for different sources
server (servidor) computer with massive hard drive capacity of patient information, such as laboratory reports, pathology
that is used to link other computers together so that data can reports, and progress notes (Ch. 14, 23).
be shared by multiple users. A computer system in an ambu-
latory care facility is likely to be linked or networked with a species (especie) second Greek or Latin name given to
central server (Ch. 11). microorganisms; the species name is not capitalized (Ch. 43).
severe acute respiratory syndrome (SARS) (síndrome respira- specific gravity (densidad específica) ratio of weight of a
torio agudo y grave [SARS]) a viral outbreak of a respiratory given volume of a substance to the weight of the same volume
illness first reported in Asia in 2003; spread by close person- of distilled water at the same temperature; test often perfor-
to-person contact and characterized by fever and respiratory med during the urinalysis physical examination (can also
symptoms (Ch. 22). appear on the reagent strip) (Ch. 42).
shadow (aprendizaje por observación) follow a supervisor spermatogenesis (espermatogénesis) the formation of
or delegated subordinate to learn facility protocol (Ch. 45). mature sperm (Ch. 28).
sharps (objetos filosos) needles or scalpels or other sharp spill kit (kit para derrames) commercially packaged mate-
instruments that are capable of causing a penetrating or punc- rials containing supplies and equipment needed to clean up a
ture wound of the skin (Ch. 22). spill of a biohazardous substance (Ch. 22).
shock (shock) potentially serious condition in which the spirometry (espirometría) test to measure the air capacity of
circulatory system is not providing enough blood to all parts the lungs (Ch. 30).
of the body, causing the body’s organs to fail to function pro- splint (férula) any device used to immobilize a body part.
perly (Ch. 9). Often used by EMS personnel (Ch. 9).
short-range goals (metas a corto plazo) long-range goals are spores (esporas) an inactive state of some bacteria in which
dissected and reassembled into smaller, more manageable they are capsulated in protein. The encapsulation protects
time segments (Ch. 5). them from heat, chemicals, freezing, desiccation, and radia-
sickle cell anemia (anemia drepanocítica) an inherited tion. Spores can live for tens of thousands of years with no
blood disorder that may shorten life span (Ch. 26). nutrient. When they are placed onto fertile soil (such as
human tissue), they can become activated and grow. Tetanus
silver nitrate (nitrato de plata) caustic astringent antiseptic. is one type of bacteria that creates spores (Ch. 43).
As a weak liquid, it is applied to the eyes of newborns to prevent
infections at birth. In the medical office, it is most often seen sprain (esguince) injury to a joint, often an ankle, knee, or
as a solid substance impregnated onto the end of a wooden wrist, that involves a tearing of the ligaments. Most sprains are
applicator. Silver nitrate applicator sticks contain hydrochloric minor and heal quickly; others are more severe, include swel-
acid and other chemicals and are commonly used to cauterize ling, and may not heal properly if the patient continues to put
small blood vessels in the nose or other mucous membranes stress on the sprained joint (Ch. 9).
(Ch. 31). sputum (esputo) substance from the respiratory tract expel-
simplified letter (carta simplificada) major letter style led by coughing (Ch. 22).
recommended by the Administrative Management Society stab culture (cultivo por punción) culture where the micro-
that omits the salutation and complimentary closure. All lines organism is stabbed for deep penetration into tubed solid
are keyed flush with the left margin. In medical offices, this media (Ch. 43).
style is most often used when sending a form letter (Ch. 15). standard (patrón) rules established to measure quality,
sitz bath (baño de asiento) a warm water bath, in which only weight, extent, or value (Ch. 22, 38).
the hips and buttocks are immersed (Ch. 31).
1138 Glossary of Terms

Standard Precautions (Precauciones Estándar) precautions subpoena (citación) written command designating a per-
developed in 1996 by the Centers for Disease Control and Pre- son to appear in court under penalty for failure to appear
vention (CDC) that augment universal precautions and body (Ch. 7).
substance isolation practices. They provide a wider range of supercomputer (supercomputadora) fastest, largest, and
protection and are used any time there is contact with blood, most expensive of the four classes of computers currently
moist body fluid (except perspiration), mucous membranes, being manufactured (Ch. 11).
or nonintact skin. They are designed to protect all health care
providers, patients, and visitors (Ch. 9, 22). supernatant (sobrenadante) urine that appears above the
sediment when centrifuged; poured off before sediment is exa-
status asthmaticus (estado asmático) severe episode of mined in the urinalysis microscopic examination (Ch. 42).
asthma that does not respond to ordinary treatment (Ch. 36).
supination (supinación) moving the arm so the palm is up
statute of limitations (ley de prescripción) statute that (Ch. 33).
defines the period in which legal action can take place
(Ch. 20). suppressed immune system (sistema inmunitario con
inmunosupresión) term used to describe an immune sys-
statutory law (derecho estatutario) refers to the body of laws tem unable to function normally due to the presence of a
established by states (Ch. 7). disease such as AIDS (Ch. 38).
sterile field (campo estéril) an area that is considered ste- suppurant (supurante) an agent causing pus formation
rile, usually designated by a sterile drape. The area contains (Ch. 31).
sterile supplies and instruments needed for a particular sterile
procedure or surgery (Ch. 31). suppurative (supurativo) producing or associated with the
generation of pus (Ch. 27).
stertorous (estertoroso) snoring sound heard with labored
breathing (Ch. 24). surge protection (protección contra sobretensiones) protec-
tion of the fragile electronics from spikes in electrical voltage
stigma (estigma) a social condition marked by attitudinal that occur on electric distribution lines (Ch. 11).
devaluing or demeaning of persons who, because of disfigure-
ment or disability, are not viewed as being capable of fulfilling surgery cards (tarjetas de cirugía) written reference for sur-
valued social roles (Ch. 26). geries and procedures (Ch. 31).
stomatitis (estomatitis) inflammation of the mouth associa- surgical asepsis (asepsia quirúrgica) procedures that ren-
ted with chemotherapy. Can include swelling, redness, halito- der objects sterile; techniques to maintain sterile conditions
sis, ulcerations (Ch. 32). during invasive procedures (Ch. 22, 31).
strabismus (estrabismo) disorder of the eye in which surrogate (sustituto) substitute; someone who substitutes for
optic axes cannot be directed to the same object (cross-eye) another (Ch. 8).
(Ch. 30). suture (sutura) surgical material or thread; may describe the
strain (distensión) injury to the soft tissue between joints act of sewing with the surgical thread and needle (Ch. 31).
that involves the tearing of muscles or tendons. Strains often swaged (estampada) a surgical needle attached, during
occur in the neck, back, or thigh muscles (Ch. 9). manufacturing, to a length of suture material (Ch. 31).
stream scheduling (programación ininterrumpida) system symmetry (simetría) correspondence in shape, size, and
where patients are seen on a continuous basis throughout position of body parts on opposite sides of the body
the day; for example, at 15-, 30-, or 60-minute intervals, each (Ch. 25).
patient having a distinct appointment time (Ch. 13). sympathetic nervous system (sistema nervioso simpático)
stress (estrés) body’s response to change; can be manifested large part of the autonomic nervous system that prepares the
in a variety of ways, including changes in blood pressure, heart body for fight-or-flight (Ch. 5).
rate, and onset of headache (Ch. 5). syncope (síncope) fainting (Ch. 9, 37).
stressors (factores estresantes) demands to change that system software (software de sistema) see operating system
cause stress (Ch. 5). (Ch. 11).
strictures (estenosis) narrowing of a tubelike structure such systemic (sistémico) pertaining to the whole body (Ch. 9).
as the esophagus or urethra (Ch. 31).
systole (sístole) one component of blood pressure measure-
stridor (estridor) crowing sound heard on inspiration, the ment representing the highest amount of pressure exerted
result of an upper airway obstruction (Ch. 24). during the cardiac cycle; the force exerted on the arterial
stylus (estilete) heated slender wire of the electrocardio- walls during cardiac contraction (Ch. 24, 37).
graph that melts the wax off of the ECG paper during the
recording (Ch. 37). T
subjective (subjetivo) symptom that is felt by the patient but tachycardia, sinus (taquicardia sinusal) abnormally rapid
not observable by others (Ch. 23). heartbeat greater than 100 beats/minute. A type of cardiac
sublimation (sublimación) redirecting a socially unaccepta- arrhythmia (Ch. 24, 37).
ble impulse into one that is socially acceptable (Ch. 4). tachypnea (taquipnea) abnormal increased rate of breathing
subordinate (subordinado) in an organization, a person (Ch. 24).
under the direction of (reporting to) a person of greater tape drive (unidad de cinta) data storage device that uses
authority (Ch. 45). magnetic tape as the storage media (Ch. 11).
 Glossary of Terms 1139

targeted résumé (curriculum vitae dirigido al objetivo) ré- time focus (enfoque en el tiempo) defines the period of
sumé format utilized when focusing on a clear, specific job time that is important and to which an individual’s actions are
target (Ch. 48). directed or oriented (Ch. 4).
Task Force for Test Construction (TFTC) (Fuerza de Tareas tinnitus (tinnitus) ringing or buzzing sound in the ear
para la Elaboración de Exámenes [TFTC]) committee of (Ch. 25).
professionals whose responsibility is to update the CMA exa- titer (título) measurement of amount of antibody present
mination annually to reflect changes in medical assistants’ against a particular antigen (Ch. 26).
responsibilities and to include new developments in medical tocopherol (tocoferol) vitamin E (Ch. 34).
knowledge and technology (Ch. 47).
tort (agravio) wrongful act that results in injury to one per-
taut (tirante) to pull or draw tight a surface, such as skin son by another (Ch. 7).
(Ch. 36).
tort law (derecho de responsabilidad civil) laws that stem
taxonomy (taxonomía) classification of organisms into from torts, or wrongful acts that cause harm to one person, by
appropriate categories (Ch. 43). another (Ch. 7).
Tay–Sachs (Tay–Sachs) an inherited disease that is usually Total Practice Management System (TPMS) (Sistema de Ges-
fatal (Ch. 26). tión de Prácticas Total [TPMS]) a category of software that
teamwork (trabajo en equipo) persons synergistically wor- deals with all the day-to-day operations of a medical practice
king together (Ch. 45). (Ch. 11).
test cable (cable de prueba) accessory device that attaches tourniquet (torniquete) device used to facilitate vein promi-
between the Holter monitor and the electrocardiograph to nence (Ch. 40).
check for correct waveform and lack of artifact (Ch. 37). toxicity (toxicidad) the level at which a drug or chemical
thalassemia (talasemia) a hereditary anemia that may be becomes poisonous or toxic. Some substances, such as certain
fatal (Ch. 26). metals, are considered toxic at any level of accidental expo-
thallium scan (gammagrafía con talio) chemical element sure (Ch. 39).
given intravenously and used in cardiac stress tests. The radio- trace mineral (oligomineral) mineral required by the body
isotope localizes in the myocardium, and a scanning device in small amounts (Ch. 34).
picks up the distribution of the thallium and can identify bloc- tracing (trazado) graphic record usually of an event that
kages in the coronary arteries. An accurate test for coronary changes with time, as with the electrical activity of the heart
artery disease (Ch. 37). (Ch. 37).
therapeutic communication (comunicación terapéutica) use transcriber (transcriptor) device that makes it possible to
of specific and well-defined professional communication skills transform voice recordings into a transcript or printed docu-
to create a feeling of comfort for patients even when difficult ments (Ch. 16).
or unpleasant information must be exchanged (Ch. 4).
transducer (transductor) device that converts one form of
therapeutic drug monitoring (TDM) (monitoreo de fármacos energy to another. During an ultrasound procedure, the trans-
terapéuticos [TDM]) periodic blood tests to determine the ducer picks up echoes and converts them to electrical energy.
effectiveness of a particular drug. Drugs will have a therapeu- The energy is transformed into digitalized images that can be
tic level that must be attained in order for the drug to be the- viewed and printed. Photographs of the image can be taken
rapeutic or effective. If the blood level of the drug is below the (Ch. 32, 37).
range of therapeutic effectiveness, the provider will probably
increase the dosage. Likewise, if the drug is above the thera- transferable skills (habilidades transferibles) skills that
peutic range, the provider will probably lower it (Ch. 39). would be used in a host of different and unrelated occupa-
tions. Keyboarding skill is an example of a transferable skill.
thermolabile (termolábil) easily affected by heat (Ch. 22). It could be used by a secretary, data entry clerk, medical assis-
thermophile (termófilo) resistant to destruction by heat. tant, or clothing manufacturer (Ch. 48).
Characteristic of some bacteria (Ch. 31). transient ischemic attack (ataque isquémico transitorio) tem-
thermotherapy (termoterapia) use of heat to treat a physical porary interference with blood flow to brain; may last only a
condition (Ch. 33). few moments or several hours; neurologic symptoms occur
thiamin (tiamina) vitamin B1 (Ch. 34). (Ch. 29).
thixotropic separator gel (gel separador tixotrópico) gel transilluminator (transiluminador) instrument used to inspect
material capable of forming an interface between the cells a cavity or organ by passing a light through the walls (Ch. 28).
and fluid portion of the blood as a result of centrifugation transmission (transmisión) spread of infectious disease by
(Ch. 40). direct contact, indirect contact, inhalation, ingestion, or blood-
thoracentesis (toracentesis) surgical puncture of the thora- borne contact (Ch. 22).
cic cavity to aspirate fluid (Ch. 22). Transmission-Based Precautions (Precauciones Basadas en la
thrombocyte (trombocito) (platelet) cellular fragment of Transmisión) second tier of Centers for Disease Control and
megataryocyte; plays an important role in blood coagulation, Prevention (CDC) guidelines that applies to specific catego-
hemostasis, and clot formation (Ch. 40, 41). ries of patients and that include air, contact, and droplet pre-
cautions. Transmission-Based Precautions are always used in
tickler file (archivo de recordatorios) system to remind of
addition to Standard Precautions (Ch. 22).
action to be taken on a certain date (Ch. 14).
1140 Glossary of Terms

transurethral resection (resección transuretral) removal of transformed into a picture on a monitor or printed on paper.
prostate tissue using a device inserted through the urethra Photographs of the images can be taken and become part of
(Ch. 28). the patient’s permanent record (Ch. 26, 37).
traveler’s check (cheque de viajero) often used in place of ultrasound (ultrasonido) use of high-frequency sound
cash when traveling; available in denominations of $20 to waves for therapeutic reasons to generate heat in deep
$100; requires a signature at place of purchase as well as signa- tissue (Ch. 33).
ture at the time the check is used (Ch. 19). unbundling codes (códigos de desagregación) refers to sepa-
TRICARE (TRICARE) formerly the Civilian Health and rating the components of a procedure and reporting them as
Medical Program for Uniformed Services (CHAMPUS). billable codes with charges to increase reimbursement rates
TRICARE offers HMO, PPO, and fee-for-service medical (Ch. 18).
insurance for dependents of active duty and retired military undifferentiated (no diferenciada) a change in the charac-
personnel and dependents of personnel who died while on ter of a cell(s) toward a malignant state (Ch. 22).
active duty (Ch. 17).
undoing (reparación) actions designed to make amends to
trichomoniasis (tricomoniasis) infestation with a Trichomo- cancel out inappropriate behavior (Ch. 4).
nas parasite, which may be transmitted through sexual inte