Objective 3.01
I.Diagnostic and Therapeutic Services
A.Diagnostic services professionals create a picture of the health status of patients at a single point in time.
B.Therapeutic services professionals change the health status of the patient over a period of time.
II.Patient Care Process
A.Plan patient care
B.Implement patient care
C.Evaluate patient care
III.Collect Patient Data
A.Patient interview
1.Demographic data
2.Financial information
3.Privacy Information
4.Release of information
5.Medical history
B.Patient assessment
1.Subjective/objective assessment
2.Using senses
a)See
b)Hear
c)Smell
d)Touch
3.Using medical instruments
a)Ophthalmoscope
b)Otoscope
c)Penlight
d)Reflex hammer
e)Scales
f)Sphygmomanometer
g)Stethoscope
h)Thermometer
IV.Record patient data
A.SOAP notes
B.Subjectiveobservations
C.Objective observations
V.Report patient data
A.Oral reports
B.Written reports
VI.Diagnostic Skills
A.Vital signs
1.Temperature
a)Electronic thermometer
b)Aural/tympanic thermometer
2.Pulse
a)Radial
b)Apical
3.Respirations
4.Blood pressure
5.Combined vital signs TPR BP
6.Height and weight
7.Visual acuity
a)Snellen charts
b)Ishihara method
c)Tonometer
B.Positioning the patient
1.Sitting
2.Horizontal recumbent (supine)
3.Prone
4.Sim’s
5.Fowler’s
6.Lithotomy
7.Trendelenburg
C.Laboratory procedure: Using reagent strips to test urine
VII.Therapeutic Skills
A.Patient movement
1.Ambulationaids
a)Cane
b)Crutches
c)Walker
- Standard
- Folding
- Rolling
- Platform
2.Ambulation with crutches
3.Transfer
a)Chair/wheelchair
b)Stretcher
B.Massage therapy
1.Effleurage
2.Petrissage
C.Optional: Respiratory therapy: Measuring lung capacity
3.01 Diagnostic and Therapeutic Services Name______
Handout Date______
Directions: Record notes and class discussion about the responsibilities of diagnostic and therapeutic services personnel while viewing the PowerPoint presentation. Explain the responsibilities in your own words and give examples.
Diagnostic and Therapeutic ServicesDiagnostic Services / Therapeutic Services
Examples / Examples
Career Responsibilities
Plan patient care / Explain what this means
Implement patient care / Explain what this means
Evaluate patient care / Explain what this means
3.01Key Terms Related to Collecting Patient DataName______
Handout
Patient Interviewassessment
auscultation
objective
observation
ophthalmoscope
otoscope
palpation
penlight
percussion
plan
record
reflex hammer
report
sphygmomanometer
stethoscope
subjective
tonometer
3.01 Using the Senses HandoutName ______
HandoutDate ______
Directions: Work in pairs, as assigned by the teacher. Complete the activity at each sensory center. Record your findings in the space provided.
See (vision) / SmellTouch / Hear
Comments:
______
______
______
______
______
______
______
______
______
3.01 Instruments Used for Patient Assessment Name ______
Handout Date______
Directions: Identify the instruments used for patient assessment by writing the name of the instrument on the appropriate spoke. Answer the questions at the bottom of the page related to when these instruments would be used.
Identify the tool(s) used for:
1. a neurological exam ______
2. measuring the pressure exerted on arterial walls ______
3. weighinga patient ______
4. examine the retina ______
5. evaluate the reaction of the pupil ______
6. measuring temperature ______
7. examine the ear ______
8. auscultate the apical pulse ______
3.01 Terms Related to Interpreting Patient Data Name______
Handout
afebrileapnea
arrhythmia
bradycardia
bradypnea
Cheyne-Stokes
cyanosis
diastolic
dyspnea
febrile
hyperopia
hypertension
hyperthermia
hypotension
hypothermia
myopia
OD
OS
OU
orthopnea
pyrexia
rales
rhythm
systole
tachycardia
tachypnea
volume
wheezing
3.01 Measure and Record TemperatureName ______
Using an Oral Electronic Thermometer
Handout
1. Assembled equipment and supplies ____
2. Washed hands ____
3. Practiced standard precautions throughout procedure ____
4. Greeted and identified patient ____
5. Identified self ____
6. Explained procedure ____
7. Questioned patient about eating, drinking or smoking ____
8. Demonstrated proper use of electronic thermometer
according to manufacturer's instructions ____
9. Removed and disposed of plastic sheath/covering in biohazardous
waste container ____
10. Recorded temperature accurately ____
11. Washed hands ____
Students must safely complete 90% of the steps to pass.
Passing date: ______
Evaluator ______
Comments:
3.01Measure and Record Temperature Name______
Using an Aural (Tympanic) Thermometer
Handout
1. Assembled equipment and supplies ____
2. Washed hands ____
3. Practiced standard precautions throughout procedure ____
4. Greeted and identified patient ____
5. Identified self ____
6. Explained procedure ____
7. Removed thermometer from base and set to proper mode ____
8. Installed probe cover assured thermometer was “ready” ____
9. Positioned patient ____
10. Holding the thermometer in the proper hand, pulled he pinna up and back ____
11. Inserted the covered probe into the ear far enough to seal the canal ____
12. Accurately measured the temperature ____
13. Removed thermometer. Read and recorded temperature ____
14. Ejected probe, disposed of it properly and returned thermometer to base ____
15. Repositioned patient, observing safety checkpoints. ____
16. Recorded temperature accurately. ____
17. Washed hands. ____
Students must safely complete 90% of the steps to pass.
Passing date: ______
Evaluator ______
Comments:
3.01 Measure and Record Radial Pulse Name______
Handout
1. Assembled equipment and supplies ____
2. Washed hands ____
3. Practiced standard precautions throughout procedure ____
4. Greeted and identified patient ____
5. Identified self ____
6. Explained procedure ____
7.Positioned patient's hand and arm so they were well supported and rested
comfortably with palm of hand turned downward ____
8. Placed fingers properly on thumb side of wrist ____
9. Assessed quality of pulse and described accurately to teacher ____
10. By exerting light pressure, counted regular pulse for 30 seconds times 2;
if irregular, counted for full minute ____
11. Counted pulse accurately within + or - 2 of teacher ____
12. Recorded pulse accurately ____
13. Washed hands ____
Students must safely complete 90% of the steps to pass.
Passing date: ______
Evaluator ______
Comments:
3.01 Measure and Record Apical Pulse Name______
Handout
1. Assembled equipment and supplies ____
2. Cleaned earpieces and bell/diaphragm with alcohol____
3. Washed hands ____
4. Practiced standard precautions throughout procedure ____
5. Greeted and identified patient ____
6. Identified self ____
7. Explained procedure ____
8. Placed stethoscope in ears properly ____
9. Placed stethoscope on apical area, avoiding unnecessary exposure of patient ____
10. Counted pulse for one full minute ____
11. Counted pulse accurately within + or - 2 of teacher ____
12. Assessed quality of pulse and described accurately to teacher ____
13. Recorded pulse accurately ____
14. Cleaned and replaced equipment ____
15. Washed hands ____
Students must safely complete 90% of the steps to pass.
Passing date: ______
Evaluator ______
Comments:
3.01 Measure and Record Respirations Name ______
Handout
1. Assembled equipment and supplies ____
2. Washed hands ____
3. Practiced standard precautions throughout procedure ____
4. Greeted and identified patient ____
5. Identified self ____
6. Explained procedure ____
7. Placed hand in pulse position, or continued pulse position, to keep patient
unaware of counting ____
8. Assessed quality of respirations and described accurately to instructor ____
9. Counted regular respirations for 30 seconds times 2; if irregular,
counted for full minute ____
10. Counted respirations accurately within + or - 2 of teacher ____
11. Recorded respirations accurately ____
12. Washed hands ____
Students must safely complete 90% of the steps to pass.
Passing date: ______
Evaluator ______
Comments:
3.01 Measure and Record Blood Pressure Name ______
Handout
1. Assembled equipment and supplies ____
2. Cleaned earpieces and bell/diaphragm with alcohol____
3. Washed hands ____
4. Practiced standard precautions throughout procedure ____
5. Greeted and identified patient ____
6. Identified self and explained procedure ____
7. Measured blood pressure:
a. Exposed patient's arm, extending arm with palm up ____
b. Wrapped deflated cuff around patient's arm above the elbow,
snugly and smoothly ____
c. Centered the bladder over the brachial artery, 1 - 1 1/2" above the elbow ____
d. With one hand, closed valve on bulb, clockwise ____
e. Palpated radial pulse ____
f. Inflated cuff to 30mm Hg above pulse disappearance ____
g. Opened valve slowly until radial pulse detected ____
h. Reported palpated pressure and maximum inflation level to teacher ____
i. Deflated cuff completely and waited 15-30 seconds ____
j. Positioned earpieces of stethoscope in ears ____
k. Palpated brachial artery ____
l. Placed bell of stethoscope over brachial artery ____
m. Rapidly inflated cuff to the maximum inflation level ____
n. Released the air in the cuff at a rate of 2-3 mm Hg/second, silently noting
systolic/diastolic pressures ____
o. Listened for 10-20 mm Hg below the last sound heard to confirm
disappearance, then deflated cuff rapidly ____
p. Removed cuff from patient's arm, made pt. comfortable____
8. Recorded blood pressure accurately ____
9. Obtained accurate systolic and diastolic readings within + or - 2 of teacher ____
10. Cleaned earpieces of stethoscope and replaced equipment ____
11. Washed hands ____
12. Recorded results. ____
Students must safely complete 90% of the steps to pass.
Passing date: ______
Evaluator ______
Comments:
3.01 Measure and Record Height and Weight Name ______Handout
1. Assembled equipment and supplies ____
2. Washed hands ____
3. Balanced scales at zero ____
4. Placed paper towel on foot platform of scale if appropriate____
5. Greeted and identified patient ____
6. Identified self and explained procedure ____
7. Told patient to remove shoes or slippers if appropriate ____
8. Positioned patient on scale
a. Assisted as needed ____
b. Positioned in center of platform ____
c. Positioned feet slightly apart ____
9. Balanced scale correctly ____
10. Recorded weight accurately ____
11. Assisted patient off scale and raises height bar ____
12. Assisted patient back on scale with back toward scale ____
13. Asked patient to stand erect while positioning bar correctly, just touching top
of head ____
14. Accurately read measurement ____
15. Assisted patient off scale after raising height bar ____
16. Recorded height accurately ____
17. Replaced all equipment with weight beams to zero and height bar lowered ____
18. Washed hands ____
Students must safely complete 90% of the steps to pass.
Passing date: ______
Evaluator ______
Comments:
3.01 Measure and Record Visual AcuityName ______
Handout
1. Assured that chart is at patient's eye level, and tape is 20 feet from chart ____
2. Washed hands ____
3. Greeted and identified patient ____
4. Identified self ____
5. Explained procedure ____
6. Had patient stand with heels on 20 foot mark ____
7. Asked patient to remove corrective lenses if needed ____
8. Had patient cover left eye gently with occluder ____
9. Instructed patient to keep both eyes open during testing ____
10. Instructed patient to verbally identify letters/pictures on chart, beginning with
the smallest line the patient could read comfortably ____
11. Recorded smallest line patient could read comfortably ____
12. Used correct charting abbreviations to record results____
13. Properly repeated procedure for the left eye ____
14. Used correct charting abbreviations to record results ____
15. Noted any observations such as squinting or turning head to see ____
16. Cleaned occluder with alcohol ____
17. Washed hands ____
Students must safely complete 90% of the steps to pass.
Passing Date: ______
Evaluator ______
Comments:
3.01 Record VitalPatient Data Name ______
Handout Date______
Directions: Record the vital signs of classmates on the chart below.
Patient Name ______ / Patient Name ______Temperature ______/ Temperature ______
Pulse ______/ Pulse ______
Blood Pressure ______/ Blood Pressure ______
Height ______/ Height ______
Weight ______/ Weight ______
Vision ______/ Vision ______
Patient Name ______ / Patient Name ______
Temperature ______/ Temperature ______
Pulse ______/ Pulse ______
Blood Pressure ______/ Blood Pressure ______
Height ______/ Height ______
Weight ______/ Weight ______
Vision ______/ Vision ______
3.01 Positioning a Patient for AssessmentName ______
Handout
1. Assembled equipment and supplies ____
2. Washed hands ____
3. Greeted and identified patient ____
4. Identified self and explained procedure ____
5. Assisted patient with gown and onto table ____
6. Horizontal recumbent (supine)
a. Assisted patient to lie on back with arms at side ____
b. Used small pillow for head ____
c. Draped with one sheet/drape, hung loosely ____
7. Prone
a. Turned patient toward self ____
b. Positioned patient on abdomen with arms flexed by head ____
c. Positioned head to side on small pillow ____
d. Draped with one sheet/drape, hung loosely ____
8. Sim's or left lateral
a. Turned patient onto left side ____
b. Positioned left arm behind back, right arm bent at elbow in front of body ____
c. Turned head to side on small pillow ____
d. Flexed left leg slightly, right leg to abdomen ____
e. Draped with one sheet/drape, hung loosely ____
9. Fowler's
a. Positioned patient on back with small pillow under head ____
b. Elevated head and back 25 degrees for low-Fowler's ____
c. Elevated head and back 45 degrees for semi-Fowler's ____
d. Elevated head and back 90 degrees for high-Fowler's ____
e. Flexed knees slightly and supports with pillow ____
f. Draped with one sheet/drape, hung loosely ____
10. Lithotomy
a. Patient positioned on back, arms at sides, buttocks at end of table____
b. Placed pillow under head ____
c. Flexed and separated knees and placed feet in stirrups ____
d. Used diamond shaped draping procedure ____
e. Dropped lower end of table ____
11. Trendelenburg
a. Positioned patient on back ____
b. Inclined table/bed with head lower than body ____
c. Draped correctly with one sheet/drape ____
d. Remained with patient at all times ____
12. Assisted patient off table and to dress ____
13. Cleaned and replaced all equipment ____
14. Washed hands ____
Students must safely complete 90% of the steps to pass.
Passing date: ______
Evaluator ______
Comments:
3.01 Positions for Patient Assessment Name______
Handout Date______
Directions: Record the name of the proper position for the patient to be examined for each symptom listed.
1. abdominal pain ______
2. becomes dizzy during procedure ______
3. breast exam______
4. chest pain ______
5. hemorrhoids ______
6. rectal exam ______
7. removal of abdominal stitches ______
8. shortness of breath ______
9. vaginal exam ______
10. wheezing ______
3.01 Ambulation with Crutches Name______
Handout
Note: The gait used for the purpose of providing this checklist for competency evaluation is the swing-to-gait.
1. Obtained instructions or checked authorization____
2. Assembled equipment – checked crutches, rubber suction tips, axillary
bar and hand rest padding____
3.Washed hands ____
4.Greeted and identified patient ____
5. Identified self ____
6. Explained procedure ____
7. Put shoes/slippers on patient as appropriate ____
8. Assisted patient to standing position with crutches at each side ____
9. Checked the measurement of the crutches and notified the physical therapist
if adjustments needed ____
10. Instructed patient to balance weight on foot or feet.
Moved both crutches forward ____
11. Instructed patient to transfer weight forward ____
12. Instructed patient to swing body forward using shoulder and arm strength ____
13. Repeated steps 10-12 as instructed and tolerated by patient ____
14. Monitored progress and provided feedback to patient on gait performance and
avoidance of resting weight on axillary bar rest ____
15. Assisted patient back to bed/chair ____
16. Replaced equipment ____
17. Washed hands ____
18. Reported/recorded procedure accurately ____
Students must safely complete 90% of the steps to pass.
Date passing: ______
Evaluator ______
Comments:
3.01 Transfer to Chair/Wheelchair Name ______
Handout
1.Assemble equipment_____ . Washed hands _____
3.Practiced standard precautions throughout procedure_____
4.Greeted and identified patient_____
5.Introduced self_____
6.Explained procedure and provided privacy_____
7.Determined which side of bed to use and placed chair at
head of bed_____
8.Locked wheels of wheelchair and folded up foot rest_____
9.Lowered bed and locked wheels_____
10.Elevated the head of the bed_____
11.Lowered the side rails on the exit side of the bed_____
12.Fanfolded the bed linen to the foot_____
13.Assisted patient to dangle feet and maintained patient safety_____
14.Put robe and slippers on patient_____
15.Transferred patient into chair / wheelchair
a.Assisted patient to stand at bedside_____
b.Assisted patient pivot and sit down in chair_____
c.Adjusted footrest to wheelchair as needed_____
16.Draped patient with blanket / sheet_____
17.Attached safety belt / took safety measures for chair_____
18.Checked to assure patient comfort with call bell and supplies
within reach_____
19.Recorded / reported information accurately_____
Students must safely complete 90% of the steps to pass.
Passing date: ______
Evaluator ______
Comments:
3.01 Transfer to Stretcher Name ______
Handout
1.Checked order or obtained authorization_____
2.Assembled equipment and supplies_____
3.Washed hands and put on gloves if indicated_____
4.Identified patient and explained procedure_____
5.Screened unit_____
6.Elevated bed to level of stretcher_____
7.Locked bed to prevent movement_____
8.Lowered siderails on side of transfer_____
9.Draped patient with bath blanket_____
10.Positioned stretcher parallel to bed_____
11.Locked wheels on stretcher_____
12.Held stretcher against bed with weight of body_____
13.Held up bath blanket while patient slid across to stretcher_____
14.Assisted patient as needed_____
15.Positioned patient in correct alignment_____
16.Locked safety belt (s) across patient_____
17.Elevated siderails on stretcher_____
18.Transported with two team members:
19.a.One at head and one at foot_____
b.Moved slowly on right side of hall_____
c.Moved patient feet forward_____
19.Returned patient to bed correctly by reversing transfer procedure_____
20.Positioned patient in proper alignment_____
21.Elevated siderails and lowered bed to lowest level_____
22.Positioned call signal and supplies within reach_____
23.Replaced equipment and leaves area neat and clean _____
24.Washed hands_____
25.Recorded or reported information accurately_____
Students must safely complete 90% of the steps to pass.
Passing date: ______
Evaluator ______
Comments:
3.01Patient Movement Case Scenarios Name______
Handout Date______
Directions: Determine the appropriate device and gait to be used in the following scenarios.
1. Eighty-five-year-old patient with total hip replacement on right
Order: weight bearing as tolerated on right leg
______
2. Sixty-three-year-old male status post CVA with right hemiparesis
Order: needs ambulation aid to walk
______
3. Ten-year-old child with spastic diplegic cerebral palsy
Order: full weight bearing but needs assistive device
______
4. Fifteen-year-old with fractured right ankle
Order: non-weight bearing right leg
______
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