Medical Terminology and Procedures, Exams of Nursing

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Certified Clinical Medical Assistant

Exam

Define: Tort - Wrongful act that results in injury to one person by another (intentional/unintentional) Define: Battery - Unprivileged touching (ex. Taking arm of patient for blood pressure without consent) Define: Invasion of Privacy - Records released without consent Define: Defamation of Character - injury to person's reputation, name, or character Define: Negligence - unintentional tort; failing to do what a "careful and reasonable" person would do.

Define: Standard of Care -

• Damage (wrongful activity causing injury)
• Derelict (breach of duty of care)
• Direct cause (recognizable injury)
• Duty (duty of care) Define: Good Samaritan Law - Can't be sued when in scope of practice; encourages heath care workers to render care. Define: OSHA - (Occupational Safety and Health Administration) Safety for health care worker, NOT the patient; identification of hazards present in the workplace and creates rules to minimize exposure to these hazards. Define: Hazards - Biological, sharps, chemical, electrical, fire/explosive, physical, allergic (ex. Latex sensitivity) Define: Chain of Infection: -

Agent (virus, bacteria, fungus, etc.) → portal of exit→ mode of transmission - through contact, droplet, airborne... (Fomite- doorknob, $, clothes, etc.) → portal of entry→ susceptible host. Ex. Common cold ***Hand washing #1 way to stop cycle!!!! Define: Nosocomial Infections - Health care acquired infection (ex. A doctor leaves the hospital in scrubs infected with MRSA and his family gets sick) Define: Universal Precautions - Assume that all people/blood and most bodily fluids are potentially infectious. Define: Medical Asepsis - By hand washing with soap, warm water, & friction (internet) state of being free from disease causing microorganisms. Define: Needle-Stick Prevention Act - Engineering controls; self-sheathing needles; sharps injury log, exposure control plan (ECP) Define: CLIA -

Waved laboratory procedures- tests are simple with a low risk of error (blood glucose, fecal occult blood, spun micro hematocrit, urine chemical screening, and urine tests for pregnancy) Define: POCT - Point Of Care Testing; testing done @ patient's bedside- immediate results. Define: Subjective - Subjective: chief complaint in patient's words; ask open-ended Qs. location of pain/discomfort, quality of pain, severity (1-10), timing, context, modifying factors (what relieves, helps?), associated signs & symptoms. Ex. 12 y.o. male c/o persistent cough x 4 wks. Child's mother reports that he has a decrease in energy & appetite. He has hx of allergies and asthma. No fever was noted. ------------------------ ----------------------Initials (notes) Statement by patient describing the most significant symptoms or signs of illness aka what the patient says. Define: Objective - Measurable info (vitals) BP, T, P, R, Wt., Ht. ----------------------------------------------------------Initials Berry Pie Tastes Pretty Ripe When it's Hot Define: Assessment - Diagnosis or impression of problem (Docs only...we don't diagnose or give an opinion)

Define: Plan of Action - Options for treatment, meds, tests, consults, patient education, follow-up BPM of Adult BP (mmHg) of Adult (systolic/diastolic) R (breaths per minute) of Adult -

• 60 - 100 bpm
• 90 - 130 / 60 - 90 (systolic/diastolic)
• 12 - 20 breaths per minute Child = 1 - 8 yrs. BPM of Child BP (mmHg) of Child (systolic) R (breaths per minute) of Child -
• 80 - 100 bpm
• 80 - 110 systolic
• 15 - 30 breaths per minute

Infant = 1 - 12 months BPM of Infant BP (mmHg) of Infant (systolic) R (breaths per minute) of Infant -

• 100 - 140 bpm
• 70 - 95 systolic
• 25 - 50 breaths per minute Neonatal = ≤ 28 days BPM of Neonatal BP (mmHg) of Neonatal (systolic) R (breaths per minute) of Neonatal -
• 120 - 160 bpm

• 60 systolic

• 40 - 60 breaths per minute Irregular BP

120 - 139 / 80-89 is? - Pre-Hypertension Irregular BP 140 - 159 / 90-99 is? - Hypertension Stage 1 Irregular BP 160+/100+ is? - Hypertension Stage 2 Irregular BP 180+/110+ is? - Hypertensive Crisis Irregular BP <90/<60 - Hypotensive Irregular Pulse <60 bpm - Bradycardia Irregular Pulse

100 bpm - Tachycardia When you have Irregular Respirations, you must observe for? - Pale, ashen, or cyanotic (blue/purple) skin that may be cold to the touch. Define Blood Pressure - Measures the pressure of the blood against the walls of the artery (systole- heart contracts, diastole- heart relaxes). Measured using a sphygmomanometer (aka blood pressure cuff) and the brachial artery. Define Temperature - Measure of the body's ability to generate and lose heat. Can be taken orally (most common), via tympanic membrane (aurally), on the temporal artery, rectal, or axillary. Either in Fahrenheit or Celsius. Normal adult T: 98.6° F or 37° C Factors that affect...anything to eat/drink? Smoked a cigarette? Exercised in past 30 min.? Inches to Centimeters, multiple by...? -

1 lb =? kg -

Define

Supine - Patient laid flat on back, facing upwards Define Dorsal Recumbent - Patient laid face-up, knees bent Define Fowler's Position - Patient laid on table with head of table elevated 90° Define Semi-Fowlers - Table elevated 45° Define Sim's Position - Patient lies on his or her left side with right leg sharply bent with knee on exam table Define Knee-Chest Position - Patient rests knees and the chest on the ground with head turned to one side

Define Trendelenburg - Patient is supine and the bottom of the table is raised about 30° Define Anatomical Position - Erect, facing forward, palms facing forward; medial- midline (pinky, big toe), lateral- outside (thumb, pinky toe) Describe the Administration of Meds: Oral - Liquid, tablet, capsule (give patient medication cup & provide water to drink) Describe the Administration of Meds: Parenteral - Meds given that are not ingested Define Topical Transdermal Intramuscular Intradermal Subcutaneous - Topical: Lotions, liniments, ointments, transdermal patch

Transdermal: An adhesive patch placed on skin to administer a specific dose of meds through the skin and into the bloodstream. (may not shower with patch on; previous patch kept in place 30 min. to ensure correct blood levels of meds are maintained) Intramuscular: Goes directly into the muscle at 90° like a dart (Deltoid Site - muscle forming the rounded contour of the shoulder) (Aspirate and observe for blood- if NO blood, dispense injection) Intradermal: Injection within or between layers of skin. (Volar forearm, 15°. Ex. TB test) Subcutaneous: Injection below the skin, into subcutaneous tissue at 45° (Aspirate to observe for blood- if NO blood, dispense injection) Define Pulmonary Function Test (PFT) - When patients' lung volume is in question; help diagnose lung diseases and their progression (check that patient refrained from smoking and using nebulizers or bronchodilators for 6 hrs)

• Use spirometer, a device that measures the volume of air inhaled and exhaled from lungs
• Repeat until 3 acceptable tests have been performed Define Vision Test - Snellen chart used to determine visual acuity (*remove contacts/glasses and don't squint, patient stand 20 ft. from chart, cover one eye, start with 20/70 row, if completes bottom row pt. has 20/ vision) Define

Suture Removal - Taking out stitches used to hold skin together (some dissolve) Define Urinalysis - Detects disorders and infection of the kidney and urinary tract; detects disorders such as diabetes; also used in drug testing (for collection of bodily fluids, label specimen in front of the patient (name, date, time, initials) on the container, not the lid; menstruating women should not undergo urine tests until cycle complete

• Physical examination- color, clarity/turbidity, odor
• Microscopic examination- casts (kidney stones), bacteria, yeast, parasites, epithelial cells, WBC&RBC
• Chemical examination
• pH (acid/base), glucose (diabetes), ketones (calorie deprivation), protein, specific gravity (above=dehydrated), blood (hematuria), bilirubin (liver disease or bile obstruction, jaundice), urobilinogen (rel. to conditions that cause increase such as liver disease), nitrites (bacteria), leukocytes (UTI) Give Types of Urine Collections - Routine/random specimens (most common), clean-catch midstream specimen (mid urination, genital area clean; culture/sensitivity test), morning (pregnancy, culturing, microscopic examination), timed, 24-hour specimen, catheterization, suprapubic specimen (microbial analysis or cytology) or fasting. Define Sputum Testing - To detect lower respiratory tract infections (tuberculosis); pt. must cough deeply and material that is expelled is collected. First morning specimens preferred.

Define Semen Collection - Don't expose to light or extreme temps (must be kept at body temperature); must reach lab within 1 hour. Define Fecal/stool Specimens - To detect parasites, occult blood, and colorectal cancer Tubes needed for culture sensitivity tests may be kept at room temperature for up to ___ hours - 72 Stress testing complications? - SOB, nausea, syncope, heart attack. Room should have: routine monitoring equipment, O2, defibrillator, intubation tray, artificial breathing barrier/bag valve mask, emerg. cardiac meds. HIPPA - Health Insurance Portability and Accountability Act; patient confidentiality; keep personal info to yourself (applies to verbal, observed, or written); regulates who has the right to one's medical records & sets standards on storing and transmitting records & must have signed consent to release records. - Must desensitize the case- minimum necessary. ROI= release of information. Chain of Command, define what is a...

• Office Manager
• Supervisor - Office Manager: responsible for day-to day operation; acts as physician's representative; relays/enforces policies; arranges trainings; fix errors & complications.

Supervisor- in charge of a particular dept. or facility. Reports to OM and assists in running the facility; supervises subordinates. Routine letters such as appointments, orders for office supplies, collection of delinquent accounts, and general notifications to patients may be signed by the ___. - Medical Assistant (MA) Define Form Letter - Document with info that can be tailored to individual needs Define Electronic medical records (EMR) / Electronic health records (EHR) - Store info on pt. demographics, notes on progress, problems or issues, meds, vital signs, past medical hx, immunizations, and laboratory, radiology, & other testing results. (Save time cause all pt. info in one place) Define Practice Management Software - Stores patient info to use in billing, scheduling, patient calls, and registration Define Electronic Communication - Have a confidentiality notice stating who the email is intended for. For a bulk email, use blind carbon copies (BCC) to avoid release of personal info.

Fax must have a cover sheet explaining to whom fax is directed and that info in confidential...HIPPA permits faxes between who? - A lab and a physician regarding patient test results. Who must explain consent form? - Doctor (NOT MA) Define Inpatient and Outpatient - Inpatient: someone who has been admitted to a hospital or other health care facility; in order to schedule a patient for admission, an oral or written order by the physician is required...COPE (computerized provider order entry) systems allow physicians who have the appropriate admitting rights and hospital privileges to write admission orders for their patients through the computer. Outpatient: patient who has received a procedure, treatment or test that does not require an overnight stay *when scheduling, inform the patient of any prep needed for the procedure (fasting, meds, smoke restrictions) Define the 5 types of Scheduling -

1. Open office scheduling: no appointment; used in urgent care; convenience to the pt.; office may be very busy or slow
2. Self-Scheduling: patients electronically schedule their own appointments; reduces calls; complicated/longer visits must still be scheduled by medical facility
3. Wave scheduling: patients scheduled to arrive at the top of the hour, then seen in order of arrival; pt. who comes late doesn't delay schedule; issues if all arrive @ same time
4. Cluster scheduling: patients with similar problems or procedures book consecutively; used in offices that have specialized equipment @ limited times
5. Advance booking: scheduled months in advance (routine physicals, follow-ups, etc.); cards given- 24 hour notice if unable to make apt. HIPPA regulations for Insurance, define the...

Privacy Rule Security Rule - Privacy Rule: Minimum necessary standard to protect patient info (pt. must be informed and sign a release when complete med records are forwarded to the insurance company) Security Rule: Specific technical precautions be taken to insure that patient information stored or transmitted in an electronic format remains confidential, accessible, and of high quality Patient's Bill of Rights (18+) - <18 requires refusal from a parent/guardian unless 12+ being treated for substance abuse, pregnancy, or in danger physical/sexual abuse OR a minor who is emancipated. Define CEU - Continuing Education Unit (must be completed to maintain certification) Define Inventory: Durable Supplies - Expensive and not easily replaced (fax machine, computers, EKG machine, etc.) Define Inventory: Non-durable Supplies - Inexpensive, used & replaced (gauze, tongue depressors, tape, etc.)

Inventory required when controlled substances are kept in office- check daily and submit every? to the DEA (drug enforcement agency) - 2 years Define Coding - The use of #s and letters to describe illnesses, diseases, & med procedures; insurance companies want a numeric code; how physicians get paid What is the coding book that MA use to used? -

• ICD- 9 - CM: international classification of diseases.
• Volume 1: Tabular list- organized according to etiology and organ systems; diseases and conditions listed in numerical order; chapters are divided into section, category, subcategory, and sub- classification. Hyperlipidemia, unspecified: 272.40 (272=category, 272.4=subcategory, 272.40=sub-classification) *more # = more specific Ex. Acute myocardial infarction 410.90 or benign hypertension due to brain tumor 405.
• Volume 2: Alphabetic index- contains the same diseases and conditions in alpha order and is divided into 3 sections; an index of diseases, poison and external causes of adverse effects of drugs and other chemical substances; and an alphabetic index of external causes of injury and poisoning
• Volume 3: contains an alphabetic and tabular index of procedures primarily used in hospitals Define Current Procedural Terminology (CPT) - Codes used for services and procedures on claim forms for payment from Medicare and many other insurance companies; also used to ensure medical necessity of services and procedures and to measure physician productivity; published by AMA; a 5 digit code is used to describe medical, surgical, radiology, laboratory, and anesthesiology
• Category 1: current procedure codes- developed by AMA
• Category II: designed for physicians to track services that have been determined to assist with quality care

• Category III: temporary codes used to identify new technologies
• 6 Sections: Evaluation and Management (physician encounters for all pt. visits, transports, case management services, preventative medicine services, & prolonged services), Anesthesia (rank patients by level of complexity), Surgery (global periods- all services that are part of the procedure), Medicine (immunizations), Pathology & Laboratory, and Radiology (ultrasound, nuclear medicine)
• Further divided into subsections, subheadings, categories, and subcategories Name the Universal Claim Form - CMS Define Blood Borne Pathogen Standard - To protect/limit exposure to microorganisms; covers any employee that may be exposed to serious, life-threatening infections (Hepatitis B, Hepatitis C, and HIV) Define The Joint Commission (TJC) - Recommends health-care professional be immunized against influenza Define The Clinical Laboratory and Standards Institute (CLSI) - Provides guidelines for fire prevention, electrical and radiation safety, and other potential laboratory hazards Define Center for Disease Control (CDC) -

est. standard precautions (formerly "universal precautions") - advise health care practitioners about safe handling of blood and bodily fluids...all blood, tissue, secretions, and excretions (not sweat) are considered potentially infectious Explain Chain of Custody - A method of handling specimens that may be used in a legal setting (suspected SA, DNA testing for paternity, cases of rape) everyone who received the specimen must initial and date the chain of custody form Explain Substance Abuse Test - Test performed within a certain period of time, rubbing alcohol must NOT be used to clean the site for a blood draw- instead use benzalkonium chloride or chlorhexidine → Rape: within * hours* of the attack; use the Sexual Assault Evidence Kit Types of Fire (Know the classes) -

• In case of a fire, activate fire alarm, call 911, and attempt to extinguish a small fire. Types: Class A: from ordinary combustible materials, which require water to extinguish; Class B: includes flammable liquids and vapors and requires an extinguisher or method of stopping the fire that removes O2; Class C: an electrical fire- requires a method of extinguishing that is non-conductive; Class K: in the kitchen Heart Coverings What does the Pericardium cover? Visceral Pericardium?

Parietal Pericardium? - Covers heart and large blood vessels attached to the heart.

1. Visceral pericardium- innermost layer; directly on the heart
2. Parietal pericardium- layer on top of the visceral pericardium Heart Walls What does the Epicardium cover? Myocardium? Endocardium? -
   1. Epicardium: Outermost layer; fat to cushion heart
3. Myocardium: Middle layer; primary cardiac muscle (contract/relax)
4. Endocardium: Innermost layer; thin and smooth; stretches as the heart pumps Four Chambers FYI - Two Atria- upper chambers; right & left, separated by interatrial septum; Two ventricles- lower chambers; left and right; separated by interventricular septum Name the 4 types of Valves - Tricuspid valve, bicuspid/mitral valve, pulmonary valve, aortic valve

Blood Vessels What are Arteries & Arterioles? - Strongest, carry blood away from the heart; under high pressure (vasoconstriction, vasodialation); Arterioles- small branches of arteries; Aorta- blood heart→ body; Coronary arteries- supply blood to heart muscle (nourish heart) Blood Vessels What are Veins & Venules? - Blood under no pressure in veins so blood doesn't move very easily; skeletal muscle contractions help move blood; sympathetic nervous system also influences pressure; valves prevent backflow; venules- small vessels formed when capillaries merge; superior and inferior vena cava- largest veins- carry blood into right atrium Blood Vessels What are Capillaries? - Branches of arterioles, smallest type of blood vessel, connect arterioles to venules, only about 1 cell layer thick, O2 and nutrients can pass out of a capillary into a body cell, CO2 and other wastes pass out of a body cell into a capillary Blood FYI - A type of connective tissue: 1. RBC (erythrocytes) 2. WBC (leukocytes) 3. Platelets (thrombocytes)- cell fragments 4. Plasma- fluid part of blood

• WBC: 1. Granulocytes: Neutrophils- (55%) destroy bacteria, viruses, and toxins in the bloodstream (phagocytes); Eosinophils- (3%) get rid of parasitic infections such as worm infections and increase in allergies or skin infections; Basophils- (1%) control inflammation and allergic reactions. 2. Agranulocytes (no grain/texture): Monocytes- (8%) destroy bacteria, viruses, and toxins in the blood; Lymphocytes- (33%) provide immunity for the body

• Platelets aka Thrombocytes- fragments of cells found in the bloodstream; important in the clotting process of blood Hemostasis - The control of bleeding 1. Blood vessel spasm (spiderlike/sticky) 2. Platelet plug formation 3. Blood coagulation 4. Fibrinolysis- breakdown and removal of clot Average sized adult has __ liters of blood. - 5 - 6
• Depends on size of person, amt. of adipose tissue, concentrations of ions, males >females (we only remove about 6 tsp of blood when performing a venipuncture) Location of? Median cubital Cephalic Basilic - Median cubital: In middle Cephalic: Outermost Basilic: Innermost (brachial artery is below) Describe the types of complications: - Hematoma: most common; inadequate pressure after needle withdraw (bruising) Hemoconcentration:relative ↑ in # of RBC due to ↓ in volume of plasma; duration of tourniquet Phlebitis: inflammation of the veins; repeated venipuncture on same vein

Petachiae: small red spots on skin; duration of tourniquet Thrombus: blood clot; inadequate pressure Thrombophlebitis clot + inflammation Septicemia: bacteria in blood; not cleaning properly Trauma: nerve damage; needle probing Syncope: fainting Cyanosis: skin turns bluish; lack of oxygen Ecchymosis: blood that has pooled in the skin; trauma from phlebotomy or bleeding disorder Hemolysis: Cells are ruptured What are the Limb Leads? - RL, LL, LA, RA What are the Precordial Leads? - V1, V2, V4, V3, V6, V5 The calibration mark is __? The running speed is __? - The calibration mark is 10 mm

The running speed is 25 mm/sec Myocardial cells have _____? (4 things) -

1. Automaticity (can produce electrical activity without outside nerve stimulation; pacemaker cells)
2. Excitability (ability to respond to an electrical stimulus; electrical conducting cells)
3. Conductivity (ability to transmit an electrical stimulus from cell to cell throughout myocardium; electrical conducting cells)
4. Contractility (Ability of myocardial cell to contract when stimulated by an electrical impulse; myocytes) ________ is the primary pacemaker site of the heart. - Sinoatrial Node How long is the P wave? How long is the PR Interval? How long is the QRS complex? - P wave: 0.06 - 0.1 sec PR Interval: 0.12 - 0.2 sec QRS complex: 0.06 - 0.12 sec QT Interval: 0.36 - 0.44 sec

Define Angina Pectoris - Sensation of pain/discomfort in the chest What is Ambulatory EKG Monitoring - Allows to monitor a patient's HR, rhythm, and QRST morphology during their normal daily activities What is a Holter Monitor - 3/5 lead EKG; usually worn for 24 hours; used to rule out intermittent arrhythmias; portable machine; records a continuous EKG on a magnetic tape, keeps a dairy of changes throughout the day. Name the corresponding color of the Holter Placement R clavicle close to manubrium L clavicle close to manubrium 5th intercostal, L midaxillary 4th intercostal, R side sternal border 9th or 10th intercostal, R midaxiallary - white = R clavicle close to manubrium brown = L clavicle close to manubrium red = 5th intercostal, L midaxillary