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Medical Terminology and Patient Care Guide

The document contains notes from multiple modules covering various medical topics, including drug scheduling, patient care definitions, vital signs, wound healing stages, and medical procedures. It also discusses risk factors for diseases, methods of medication intake, and the importance of proper data entry in medical records. Additionally, it outlines guidelines for screenings and preventive care for specific age groups and conditions.

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20jda07
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0% found this document useful (0 votes)
15 views8 pages

Medical Terminology and Patient Care Guide

The document contains notes from multiple modules covering various medical topics, including drug scheduling, patient care definitions, vital signs, wound healing stages, and medical procedures. It also discusses risk factors for diseases, methods of medication intake, and the importance of proper data entry in medical records. Additionally, it outlines guidelines for screenings and preventive care for specific age groups and conditions.

Uploaded by

20jda07
Copyright
© All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as TXT, PDF, TXT or read online on Scribd

NHA Notes:

Module 1:
• Kidney disease = limit sodium
• Metabolism is impacted by age
• Honey is a simple carbohydrate/ simple sugar
• Excessive Exercising is a warning sign for anorexia

• Drug Scheduling/ Controlled:


• Schedule I: Weed, Heroin, LSD (The worst stuff, nonprescription)
• Schedule II: Meth, Cocaine, Fentanyl (Almost the worst,
nonprescription)
• Schedule III: Steroids, Ketamine, Testosterone (Mid stuff, 5-6 month
refill)
• Schedule IV: Xanax, Ambien, Ativan (Prescription Drugs, 5-6 month
refill)
• Schedule V: Easily accessible drugs (Year’s worth of refills)

• Patient Care Medical Home Definition: It is a care delivery model


supported by an interdisciplinary team and led by a primary care provider (PCP).

• Antihistamines: Allergies
• Antihypertensives: High Blood Pressure
• Diuretics: Increase Peeing
• Antipyretic: Reduces Fever
• Willow Bark: Pain Relief
• Gingko Bilbo: increases blood flow and helps memory
• Melatonin: Sleep Hormone
• Black Cohosh: Helps Menopause

• Methods of intaking Medicine:


• Subcutaneous: Under the skin
• Oral: Via Mouth
• Topical: applied on skin surface
• Vaginal: self explanatory lol
• Inhalation: Breathing via mouth or nose

• Side Effect: other effects that are known that can happen when taking a
drug
• Adverse Effect: Usually an allergic reaction
• Contradiction: it’s in the name
• Indication: Problems or symptoms the meds are for.

• Anticoagulants: delays blood clotting


• Bronchodilator: relaxes air way muscles.
• Antiemic: reduces nausea and vomiting
• Antipsychotics: controls psychotic symptoms.

Module 2:
• 5 stages of grief in order: Denial, Anger, Bargaining, depression,
acceptance.

• Smoking is a risk factor for COPD


• Aging is a risk factor for Osteoporosis
• High blood pressure is a risk for chronic kidney disease
• Eating high fat foods is a risk for colorectal cancer and inflammation
bowel diseases a risk

• CVA: Cerebrovascular Accident


• BP: Blood Pressure
• PVD: Peripheral Vascular Disease
• MI: Myocardial Infraction

• DO NOT ABBREVIATE MEDICATION NAMES

• Outbreak: Sudden rise of disease


• Endemic: Illness constantly present in a community
• Epidemic: disease that spreads rapids to a large population
• Pandemic: Pandemic World-Wide outbreak

**LOOK AT BASIC SKELETAL TERMS**

• Superior: Above
• Inferior: Below
• Anterior: Front or side (usually front)
• Dorsal: Back

• Lou Gehrig’s disease: AKA Amyotrophic lateral sclerosis disease, is a


fatal neurodegenerative disease. Affects motor neurons in the brain and spinal
cord.

• Homeostasis: the body keeping stability


• Anatomical Position standing up right

• GERN: detected via endoscopy and is acid reflux


• Diverticulosis: detected via colonoscopy, the muscular wall in the
colon
• Celiac Disease: Detected via upper endoscopy into biopsy, small
intestine
• UTI: detected via urine tests, urinary tract

• Spinal Cavity: Midline of back


• Thoracic Cavity: Chest Cavity
• Abdominal Cavity: Abdomen
• Pelvic Cavity: Pelvis

• Rheumatoid Arthritis: messes with connective tissue mainly in joints.


• Gout: accumulation of uric acid in joints, typically ankles
• Muscular dystrophy: inherited gene that affects muscle fibers.
• Myalgia: Term for general muscle pain

Module 3:
• BMI Levels:
• Underweight: 18.5 & below
• Normal: 18.5-24.9
• Overweight: 25-29.9
• Obese: 30+
• Obese I: 30-34.9
• Obese II: 35-39.9
• Obese III: 40+

• Different ways to check for temp:


• Auxiliary: Under the armpit and not very accurate
• Oral: Mouth, not for young children
• Tympanic: Ear
• Temporal Artery: on the “temples” least invasive and very accurate
• Rectal: most accurate mainly for infants
• respiration rates:
• Adult: 12-20 a minute
• Newborn: 30-60

• pulse oxidation 95% or higher


• Can use the earlobe or big toes if the finger isn’t available

• Any heart rate over 100 UNLESS IF THEY ARE 3 OR YOUNGER, is not normal

• Brady- : Slow
• Tachy- : Fast
• -Tension: blood pressure
• -Cardia: heart (rate)
• -Pnea: respirations
• Hypo- : Below
• Hyper- : Above
• Ortho- : Straight or Vertical

• Vital Signs: Body Temperature, Pulse Rate, Respiratory rate, and Blood
Pressure.
• Orthostatic Vital Signs: are different methods on taking vital signs in
different positions to check for things.

• Different Arteries:
• Femoral: Upper-Inner thigh, used for determined circulation on lower
extremities
• Brachial: Inner upper arm, used for blood pressure readings
• Radial: lower-inner arm, used for palpatory method for blood pressure
if brachial isn’t an option
• Carotid: Side of the neck, or for emergencies

• Blood Pressure ranges/ levels:


• Systolic (aka top number *#*/#): less than 120
• Diastolic (aka bottom number #/*#*): less than 80
• Normal: Top is below 120 and Bottom is below 80
• Elevated: Top is 120-129 and bottom is below 80
• Stage 1 Hypertension: top is 130-139 and bottom is 80-89
• Stage 2 Hypertension: Top is 140+ and bottom is 90+
• Hypertensive Crisis: 180/120+

• 98.6°F (37°C) is common known as the “average” body temp

• Auscultated: the act of listening to the body for signs

Module 4:
• Needle info:
• 18-22 gauge needles are larger and used for thicker medications or
drawing blood.
• 23-25 gauge needles are commonly used for intramuscular and
subcutaneous injections.
• 26-30 gauge needles are used for intradermal injections, insulin
administration, and other subcutaneous injections where minimal tissue damage is
desired.
• 5°-15° Intadermal
• 15°-35° intravenous
• 45°-89° Subcutaneous
• 90° IM aka intramuscular

• A month in medical terms is 30 days


• Multidose vials are only good for 28 days

• Clinical Decision support system (CDSS): Checks for medication


interactions and allergies
• Computerized provider order entry system (CPOE): it’s in the name
• Electronic health record system (EHR): digitalization of paper copies
• Electronic Medication administration record (eMAR): digital report
system for medication administration to someone by someone

• Prone: Whole body facing down


• Supine: Whole body facing up
• Left and right lateral: laying on the depicted side
• Semi-Fowlers: Sitting halfway-upright 45°
• Fowler’s: sitting upright 90°
• Trendelenberg: Laying on back at a slight backwards angle
• Lithotomy: on back with legs suspended upwards
• Sim’s: between lateral and prone

• Loratadine: a type of allergy medication


• Automated External Defibrillator: is for patients without a pulse and
who aren’t breathing
• CPR: is for lack of breathing and is unconscious

• Adipose means fat, insulin gets injected subcutaneously at 45°

Module 5:
• Money comes first on all things big, aka insurance

• 4 stages of wound healing & more info:


• Stage 1: Hemostasis, body tries to stop bleeding
• Stage 2: Inflammation, occurs at day 1-3. Pain, swelling, etc
• Stage 3: Proliferative, on day 3-21, the healing process
• Stage 4: Remodeling, New healthy skin takes place
• Dehiscence: Wound complication were edges don’t meet
• Evisceration: A wound complication and your abdomen guts are protruding
• Hemorrhaging: bleeding wound
• Infection: the wound is infected

• Mayo stand general info:


• Should be above the waist
• Stays 12 inches away
• The 1 inch edge of a sterile instrument package is considered non
sterile, including the outside of the packaging
• Everything makes a stop to the mayo stand when unpacking something

• Colposcopy: To examine inside the vagina and cervix

• Staples: For high tension


• Non absorbable Suture: used on skin that can be easily removed
• Sterile tape: used for not much tension
• Cyanoacrylate: used to make a strong bond flexible bond.

Module 6:
• Autoclave general info:
• Minimum temp of 121.1
• Unwrapped items stay for 20 minutes

• Exposure control plans get updated annually if nothing happens


• Staff gets reminded of blood borne pathogens annually
• If you touch something like blood, always wash yourself first then
report
• OSHA requires employees to have a Hepatitis B vaccine.

• Different precautions:
• Droplet: coughing or sneezing
• Airborne: SOL
• Contact: touch
• General term: Transmission-based precautions

• Common Infectious Disease Symptoms:


• Fever, headache, cough, runny nose, malaise, and sleepiness.

• 8 hours for Chemical Sterilization


• Asepsis = Eliminate & wash hands
• 15-20 minimum hand washing
• Alcohol based hand sanitizer minimum of 60% alcohol
• You can return to work after being fever-free for 24 hours without meds

Module 7:
• adult normal hearing can hear tones at 25 decibels
• Chain of custody is mandatory for some drug transportation
• Abnormal Tympanogram shows a flat line, normal shows peaks
• HbA1c (hemoglobin A1c): normal range is less than 5.7% to have diabetes
under control
• Don’t consume vitamin c or iron supplements before a fecal occult blood
testing for 3 days
• ^^^Same thing with antihistamines and skin tests
• Analytical phase is when things get maintained and calibrated
• 5-minute minimum time for an accurate pregnancy test
• Times & and collectors initials on collections

• Urine Collection Methods:


• 24-hour-urine: checks for sporadic substances
• Clean-catch: UTI, more chemical stuff
• Random: more like professional drug screening
• First void: first pee of the day

• Normal Total Cholesterol Levels: 130 to 200 mg/dL


• Order Entry is important
• 3 breathing tests for spirometry testing
• 15 minutes for scratch allergen testing for seeing wheels (skin
swelling)

Module 8:
• Characteristics of collecting timed specimens: They monitor therapeutic
medication levels
• EDTA tubes should be inverted 8 to 10 times
• 70% alcohol for skin disinfection prior to a phlebotomy test
• IMPROPER DATA ENTRIES ARE IMPORTANT
• Butterfly needle system info: 22-gauge, 1/2 inch
• Stop everything and alert provider if they’re an emergency
• HALF AND HOUR 30 min prior time before centrifugation
• Antecubital Vein first

• Color of blood tubes:


• Light Blue: Sodium Citrate
• Red: Clot Activator
• Green: Lithium Heparin
• Tiger: Serum Separator Gel
• Lavender: EDTA
• Gray and red marbled: clot activator & serum separator gel
• Gray: Sodium fluoride
• Gold: SST
• Yellow: ACD Solution
• Order: Blue, red, gold, green, lavender, gray, yellow

• 15 minutes minimum for leaving the bandage after a phlebotomy or


capillary puncture
• Ask about past events involving a phlebotomy if patient seems anxious
• Diagnosis code on a laboratory requisition form

Module 9:
• Somatic Tremors (aka involuntary muscle movement) produce irregular
spikes on a 60-cycle interference in EKG tracing
• Wandering baseline is from breathing or patient wearing lotion or cream
on their skin
• Interrupted baseline is from breaks in EKG tracing
• Frequency spikes can be from near by electrical equipment

• EKG 12 Lead placement, 10 electrodes, 6 chest, 4 limb:


• V1 is placed in the 4th intercostal space, right sternal border, Red
• V2 in the 4th intercostal space, left sternal border, Yellow
• V3 midway between V2 and V4, Green
• V4 in the 5th intercostal space, mid-clavicular line, Blue
• V5 in the 5th intercostal space, anterior axillary line, Orange
• V6 in the 5th intercostal space, mid-axillary line, Purple
• RA: right arm, mid upper, White
• LA: Left arm, mid upper, Black
• RL: Right Leg, any part above ankle, green
• LL: Left leg, any part above ankle, red

• Atrial Fibrillation: characterized by irregular rhythms, no P wave, and


narrow QRS complexes
• Semi-fowlers assists breathing
• Electrolyte gel is a conductor

• Wave meanings
• P Wave: atrial depolarization
• T Wave: Ventricular repolarization
• Q Wave: early Ventricular depolarization
• U Wave: late ventricular repolarization

• Sinus has narrow QRS complexes


• Ventricular has wide QRS complexes
• The duration of a standard calibration box is 0.2 seconds, the height
is 10mm
• Supine is the best position for a EKG
• Have the patient sit on their hands if there are too many somatic
tremors

Module 10:
• Female Patient need to start annual mammograms at 45 years of age
• Live Video substitutes in-person
• Colorectal cancer screenings start at 45 years old
• Long-term care facilities are for people who can no longer take care of
themselves
• A 65-year-old who has a history of smoking should get screenings to
check for Abdominal Aortic Aneurysm

Module 11:
• Clearinghouse: cleans outs claims from third-party payers
• A/R aging report: Accounts Receivable, money owed
• A/P aging report: Accounts Paid, money paid out
• Health Care Facilities give out usernames and access codes to log into
patient portals
• Elective and costly medical services can require preauthorizations
• Medical Equipment Inspection logs document timelines of scheduled
maintenance
• Interoperability: really important documentation
• Reconciliation: making sure patients have the proper amount in their
account
• Practice management software includes patient medical records and the
encounter form
• Diagnosis codes (ICD-10-CM): reason for patient visits
• ICD-10-PCS: for hospital or inpatient only
• Procedure codes (CPT): treatment or services rendered by provider
• HCPCS: for admin of medication and durable medical equipment
• Drop down menus = greater accuracy
• Provider Preferences = change duration
• Medical Necessity should be supported with code selections
• Advance Beneficiary Notice of Non coverage may not be covered by a fee-
for-service Medicare plan

Module 12:
• Virtual Visits are mainly communication based
• Active Listening includes paraphrasing
• Communication between medical professionals can use more complex words,
not with patients
• All types of communication must be documented period.
• When situations escalate always get a higher-up
• Therapeutic communication can encourage and support the patient
• If the patient is upset in any sense, let them get through it and
support them
• Kinetic, Kin-, or Kine-, pertains to hands on. Touch, using hands, etc.
• Closed Ended questions: direct and get a simple answer

Module 13:
• Be aware of possible domestic abuse. If someone is bruised and hurt all
over and/or all at different stages it could be abuse
• Some states don’t allow a health care provider or health care employees
to be a patient’s health care proxy
• Employers are NOT covered entities under HIPAA
• Patients with a DNR can receive chemotherapy, antibiotics, dialysis, or
any life-sustaining treatments
• If a patient is seeing a different health care provider, they need to
sign the information release form
• OSHA = Work place safety
• HIPAA = Patient Privacy
• Duty of care: think about it
• Patient’s bill of rights: the right for all information regarding
treatment and procedures
• CLIA (Clinical Laboratory Improvement Amendments): a group of laws that
handle testing and specimens
• Health Information Technology for Economic and Clinical Health
(HITECH): prohibits the sale of a PHI (protected health information)

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