CCMA Review Patient Positions - PowerPoint Presentation

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CCMA

Review

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Patient Positions

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Supine

The supine position is a position of the body: lying with the face up, as opposed to the prone position, which is face down, sometimes with the hands behind the head or neck.

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Prone

Prone position is a body position in which one lies flat with the chest down and back up. In anatomical terms of location, the dorsal side is up, and the ventral side is down. The supine position is the 180° contrast.

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SIMS

A position in which the patient lies on the side with the knee and thigh drawn upward toward the chest. The chest and abdomen are allowed to fall forward. Left Sims' is the position of choice for administering enemas or conducting rectal examinations. Also called semi-prone side position.

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Lithotomy

a supine position of the body with the legs separated, flexed, and supported in raised stirrups.

M

edical examinations involving the pelvis and lower abdomen, as well as a common position for childbirth.

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Dorsal Recumbent

The word dorsal refers to the posterior (the back or spine). Recumbent refers to the act of lying down or reclining. The patient lays on his or her back with their knees flexed and feet on flat on the surface of the bed.

If a patient in this position, the medical profession can more easily examine certain areas of the body. These areas include the following body parts:

- Genitals

- Chest

- Lungs and Heart

- Hips and Pelvis

- Head and Neck

- Chest and Abdomen

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Fowler’s

•Fowler’s position, is a bed position wherein the head and trunk are raised 40 to 90 degrees.

•Fowler’s position is used for people who have difficulty breathing because in this position, gravity pulls the diaphragm downward allowing greater chest and lung expansion.

•In low Fowler’s or semi-Fowler’s position, the head and trunk are raised to 15 to 45 degrees; in high Fowler’s, the head and trunk are raised 90 degrees.

•This position is useful for patients who have cardiac, respiratory, or neurological problems and is often optimal for patients who have nasogastric tube in place

.

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Orthopneic

or Tripod

•

Orthopneic

or tripod position places the patients in a sitting position or on the side of the bed with an

overbed

table in front to lean on and several pillows on the table to rest on.

•Patients who are having difficulty breathing are often placed in this position since it allows maximum expansion of the chest.

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Lateral position

•In lateral or side-lying position, the patient lies on one side of the body with the top leg in front of the bottom leg and the hip and knee flexed.

•Flexing the top hip and knee and placing this leg in front of the body creates a wider, triangular base of support and achieves greater stability.

•The greater the flexion of the top hip and knee, the greater the stability and balance in this position. This flexion reduces lordosis and promotes good back alignment.

•Lateral position helps relieve pressure on the sacrum and heels in people who sit for much of the day or confined to bed rest in Fowler’s or dorsal recumbent.

•In this position, most of the body weight is distributed to the lateral aspect of the lower scapula, the lateral aspect of the ilium, and the greater trochanter of the femur.

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Trendelenburg’s

•

Trendelenburg’s

position involves lowering the head of the bed and raising the foot of the bed of the patient.

•Patient’s who have hypotension can benefit from this position because it promotes venous return.

Reverse Trendelenburg

•Reverse Trendelenburg is the opposite of Trendelenburg’s position.

•Here the HOB is elevated with the foot of bed down.

•This is often a position of choice for patients with gastrointestinal problems as it can help minimize esophageal reflux.

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Laboratory

If you do not have lab services at your office you will need to sent the patient to a lab. Labs are out Patient Services.

No appointment is necessary.

They must have a copy of your physician’s orders for your lab work.

Please ask your physician to fax a copy of your laboratory test orders to CRMC Scheduling or to provide you with a written order for lab testing.

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Lipid Profile

Lipid profile or lipid panel is a panel of blood tests that serves as an initial broad medical screening tool for abnormalities in lipids, such as cholesterol and triglycerides.

Patient should be on a stable diet for 2-3 weeks prior to testing. Patient should fast for 12 to 14 hours before blood collection. Fasting should be no food or drink except for water.

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GLUCOSE TOLERANCE TEST (NON-PREGNANT)

The oral glucose tolerance test (OGTT) measures the body's ability to use a type of sugar, called glucose, that is the body's main source of energy. An OGTT can be used to diagnose

prediabetes

and diabetes.

Patient should be fasting for 12 to 14 hours (no food or drink, except for water). A blood specimen will be drawn and tested. You will then be given a special drink. Your blood will be drawn once each hour after you finish the drink. The number of hours may vary from 2 to 6. Your doctor will decide how many hours you will be tested.

Please allow plenty of time for this test to be completed. You will need to allow approximately one hour more than the number of hours your physician requested. For example, if your physician ordered a 3 hour glucose tolerance, please allow 4 hours for the test to be completed.

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CORTISOL

Cortisol is a steroid hormone, in the glucocorticoid class of hormones, and is produced in humans by the zona

fasciculata

of the adrenal cortex within the adrenal gland. It is released in response to stress and low blood-glucose concentration

Cortisol may be tested in blood or urine.

If blood cortisol levels are requested by your physician, you may be asked to have your blood drawn once (random cortisol) or multiple times. Your physician will inform you if you are having multiple blood draws for your cortisol testing.

Cortisol blood tests may be drawn at about 8 am, when cortisol should be at its peak, and again at about 4pm, when the level should have dropped. Sometimes a resting sample will be obtained late in the evening.

If your physician requests a urine cortisol, you will be asked to collect either a 24-hour urine or a single first morning specimen.

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VITAMIN B12 AND FOLATE

Vitamin B12 or B9 (commonly called folate) deficiency

anaemia

occurs when a lack of vitamin B12 or folate causes the body to produce abnormally large red blood cells that cannot function properly. Red blood cells carry oxygen around the body using a substance called

haemoglobin

A fasting specimen (no food or drink, except for water) for 12- 14 hours before blood is drawn is preferred. However, your doctor may request that you have your blood drawn when you are not fasting.

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C-PEPTIDE

Patient should be fasting (no food or drink, except for water) for 12-14 hours before blood is drawn.

The following are some purposes of C-peptide testing:

•A C-peptide test is not ordered to help diagnose diabetes, but when a person has been newly diagnosed with diabetes, it may be ordered by itself or along with an insulin level to help determine how much insulin a person's pancreas is still producing (endogenous insulin).

•In type 2 diabetes, the body is resistant to the effects of insulin (insulin resistance) and it compensates by producing and releasing more insulin, which can also lead to beta cell damage. Type 2 diabetics usually are treated with oral drugs to stimulate their body to make more insulin and/or to cause their cells to be more sensitive to the insulin that is already being made. Eventually, because of the beta cell damage, type 2 diabetics may make very little insulin and require injections. Any insulin that the body does make will be reflected in the C-peptide level; therefore, the C-peptide test can be used to monitor beta cell activity and capability over time and to help a health practitioner determine when to begin insulin treatment.

•People who are on insulin therapy,

•C-peptide measurements can also be used in conjunction with insulin and glucose levels to help diagnose the cause of documented hypoglycemia and to monitor its treatment.

•Sometimes a C-peptide test may be used to help evaluate a person diagnosed with metabolic syndrome, a set of risk factors that includes abdominal obesity, increased blood glucose and/or insulin resistance, unhealthy blood lipid levels, and high blood pressure (hypertension).

•Rarely, when someone has had his pancreas removed or has had pancreas islet cell transplants, intended to restore the ability to make insulin, C-peptide levels may be used to verify the effectiveness of treatment and continued success of the procedure.

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DIGOXIN LEVEL

Blood should be drawn 6-8 hours after the last dose of digoxin was taken.

Digoxin is a medication that contains cardiac glycosides, used to treat heart failure and irregular heartbeats. A digoxin test is a blood test that determines the level of the medication in your blood to ensure that you are not receiving too much or too little of the drug.

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24-HOUR URINE SPECIMENS

Please follow these instructions in collecting your 24-hour urine specimen.

You will find it more convenient to void (urinate) into the smaller container provided and transfer the urine into the larger collection container.

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24-HOUR CREATININE CLEARANCE COLLECTION

Creatinine is a chemical waste product that’s normally filtered out of your blood by your kidneys. When your kidneys aren’t functioning properly, creatinine can accumulate in your body. A creatinine urine test evaluates how well your kidneys are working by measuring the amount of creatinine in your urine.

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24-HOUR URINE –TOTAL PROTEIN COLLECTION

When higher-than-normal amounts of protein are in the urine, it is called proteinuria. Proteinuria is often a sign of kidney damage and disease.

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24-HOUR CATECHOLAMINE and/or METANEPHRINE COLLECTION

Abnormal results may be due to:

•A group of diseases in which a protein called amyloid builds up in the organs and tissues (amyloidosis)

•Bladder tumor

•Heart failure

•High blood pressure during pregnancy (preeclampsia)

•Kidney disease caused by diabetes, high blood pressure, autoimmune disorders, a blockage in the kidney system, certain medications, toxins, a blockage of blood vessels, or other causes

•Multiple myeloma

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URINE FOR URINALYSIS AND/OR CULTURE

A urine culture is a test to find and identify germs (usually bacteria) that may be causing a urinary tract infection (UTI). Urine in the bladder normally is sterile-it does not contain any bacteria or other organisms (such as fungi). But bacteria can enter the urethra and cause an infection.

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STOOL FOR OCCULT BLOOD

Diet and drugs may affect results of occult blood testing. Please talk to your physician before making any changes in diet or medications prescribed for you.

For three days before and during stool collection eat a well balanced diet including fiber such as bran cereals, fruits and vegetables. Avoid red meats, including beef, lamb, and liver.

There are also some common over-the-counter drugs that may affect results of the testing. For seven days before and during the stool collection period, avoid non-steroidal anti-inflammatory drugs such as ibuprofen, naproxen, or aspirin.

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SEMEN ANALYSIS

A semen analysis (plural: semen analyses), also called "

seminogram

" evaluates certain characteristics of a male's semen and the sperm contained therein. It is done to help evaluate male fertility, whether for those seeking pregnancy or verifying the success of vasectomy.

1. Refrain from sexual intercourse or masturbation for between 2 and7 days.

2. Produce the sample by masturbation without artificial lubricants. Do not use a condom, as condoms contain spermicidal agents.

3. Collect the sample into the clean, wide mouth container supplied. It is important that the whole ejaculate is collected. If not, the specimen should be labeled as incomplete.

4. Within 1 hour of collection, bring the sample to Outpatient services or to the laboratory. Keep the specimen warm in a pocket near your body.

5. Label the specimen with name, date, and time of the collection.

6. Complete the patient questionnaire and return to Outpatient services or laboratory with the specimen.

7. Samples may also be produced in a room at the laboratory.

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SPUTUM FOR CULTURE AND ACID FAST MYCOBACTERIUM (AFB)

AFB testing may be used to detect several different types of acid-fast bacilli, but it is most commonly used to identify an active tuberculosis (TB) infection caused by the most medically important AFB, Mycobacterium tuberculosis.

Mycobacteria are called acid-fast bacilli because they are rod-shaped bacteria (bacilli) that can be seen under the microscope following a staining procedure in which the bacteria retain the color of the stain after an acid wash (acid-fast).

1. Patient should rinse mouth and gargle with water immediately prior to collection.

2. Collect specimen from deep cough into a sterile container.

3. Patient should avoid any contamination with saliva.

4. Return specimen as soon as possible. If there is a delay, specimen should be refrigerated. Please label the specimen container with patient’s name, date and time.

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Types of Blood Tests

Some of the most common blood tests are:

•A complete blood count (CBC)

•Blood chemistry tests

•Blood enzyme tests

•Blood tests to assess heart disease risk

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Complete Blood Count

The CBC is one of the most common blood tests. It's often done as part of a routine checkup.

The CBC can help detect blood diseases and disorders, such as anemia, infections, clotting problems, blood cancers, and immune system disorders. This test measures many different parts of your blood, as discussed in the following paragraphs.

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Red Blood Cells

Red blood cells carry oxygen from your lungs to the rest of your body. Abnormal red blood cell levels may be a sign of anemia, dehydration (too little fluid in the body), bleeding, or another disorder.

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White Blood Cells

White blood cells are part of your immune system, which fights infections and diseases. Abnormal white blood cell levels may be a sign of infection, blood cancer, or an immune system disorder.

A CBC measures the overall number of white blood cells in your blood. A CBC with differential looks at the amounts of different types of white blood cells in your blood.

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Platelets

Platelets (PLATE-lets) are blood cell fragments that help your blood clot. They stick together to seal cuts or breaks on blood vessel walls and stop bleeding.

Abnormal platelet levels may be a sign of a bleeding disorder (not enough clotting) or a thrombotic disorder (too much clotting).

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Hemoglobin

Hemoglobin (HEE-

muh

-glow-bin) is an iron-rich protein in red blood cells that carries oxygen. Abnormal hemoglobin levels may be a sign of anemia, sickle cell anemia, thalassemia (

thal

-a-SE-me-ah), or other blood disorders.

If you have diabetes, excess glucose in your blood can attach to hemoglobin and raise the level of hemoglobin A1c.

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Hematocrit

Hematocrit (

hee

-MAT-oh-

crit

) is a measure of how much space red blood cells take up in your blood. A high hematocrit level might mean you're dehydrated. A low hematocrit level might mean you have anemia. Abnormal hematocrit levels also may be a sign of a blood or bone marrow disorder.

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Blood Chemistry Tests/Basic Metabolic Panel

The basic metabolic panel (BMP) is a group of tests that measures different chemicals in the blood. These tests usually are done on the fluid (plasma) part of blood. The tests can give doctors information about your muscles (including the heart), bones, and organs, such as the kidneys and liver.

The BMP includes blood glucose, calcium, and electrolyte tests, as well as blood tests that measure kidney function. Some of these tests require you to fast (not eat any food) before the test, and others don't. Your doctor will tell you how to prepare for the test(s) you're having.

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Blood Glucose

Glucose is a type of sugar that the body uses for energy. Abnormal glucose levels in your blood may be a sign of diabetes.

For some blood glucose tests, you have to fast before your blood is drawn. Other blood glucose tests are done after a meal or at any time with no preparation.

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Calcium

Calcium is an important mineral in the body. Abnormal calcium levels in the blood may be a sign of kidney problems, bone disease, thyroid disease, cancer, malnutrition, or another disorder.

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Electrolytes

Electrolytes are minerals that help maintain fluid levels and acid-base balance in the body. They include sodium, potassium, bicarbonate, and chloride.

Abnormal electrolyte levels may be a sign of dehydration, kidney disease, liver disease, heart failure, high blood pressure, or other disorders.

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Kidneys

Blood tests for kidney function measure levels of blood urea nitrogen (BUN) and creatinine (

kre

-AT-

ih

-

neen

). Both of these are waste products that the kidneys filter out of the body. Abnormal BUN and creatinine levels may be signs of a kidney disease or disorder.

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Blood Enzyme Tests

Enzymes are chemicals that help control chemical reactions in your body. There are many blood enzyme tests. This section focuses on blood enzyme tests used to check for heart attack. These include troponin and

creatine

(KRE-ah-teen) kinase (CK) tests.

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Troponin

Troponin is a muscle protein that helps your muscles contract. When muscle or heart cells are injured, troponin leaks out, and its levels in your blood rise.

For example, blood levels of troponin rise when you have a heart attack. For this reason, doctors often order troponin tests when patients have chest pain or other heart attack signs and symptoms.

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Creatine

Kinase

A blood product called CK-MB is released when the heart muscle is damaged. High levels of CK-MB in the blood can mean that you've had a heart attack.

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Blood Tests To Assess Heart Disease Risk

A lipoprotein panel is a blood test that can help show whether you're at risk for coronary heart disease (CHD). This test looks at substances in your blood that carry cholesterol.

A lipoprotein panel gives information about your:

•Total cholesterol.

•LDL ("bad") cholesterol. This is the main source of cholesterol buildup and blockages in the arteries. (For more information about blockages in the arteries, go to the Diseases and Conditions Index Atherosclerosis article.)

•HDL ("good") cholesterol. This type of cholesterol helps decrease blockages in the arteries.

•Triglycerides. Triglycerides are a type of fat in your blood.

A lipoprotein panel measures the levels of LDL and HDL cholesterol and triglycerides in your blood. Abnormal cholesterol and triglyceride levels may be signs of increased risk for CHD.

Most people will need to fast for 9 to 12 hours before a lipoprotein panel.

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Blood Clotting Tests

Blood clotting tests sometimes are called a coagulation (KO-

ag

-

yu

-LA-shun) panel. These tests check proteins in your blood that affect the blood clotting process. Abnormal test results might suggest that you're at risk of bleeding or developing clots in your blood vessels.

Your doctor may recommend these tests if he or she thinks you have a disorder or disease related to blood clotting.

Blood clotting tests also are used to monitor people who are taking medicines to lower the risk of blood clots. Warfarin and heparin are two examples of such medicines.

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Intramuscular injection

An intramuscular injection is a technique used to deliver a medication deep into the muscles. This allows the medication to be absorbed into the bloodstream quickly. You may have received an intramuscular injection at a doctor’s office the last time you got a vaccine, like the flu shot.

In some cases, a person may also self-administer an intramuscular injection. For example, certain drugs that treat multiple sclerosis or rheumatoid arthritis may require self-injection.

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What are IM used for?

Intramuscular injections are used when other types of delivery methods are not recommended. These include oral (swallowed into the stomach), intravenous (injected into the vein), and subcutaneous (injected into the fatty tissue just under the layer of skin). Intramuscular injection may be used instead of intravenous injection because some drugs are irritating to veins or because a suitable vein cannot be located.

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Intramuscular Injection Sites

Deltoid muscle-

The deltoid muscle is the site most typically used for vaccines. However, this site is not common for self-injection, because its small muscle mass limits the volume of medication that can be injected (typically no more than 1ml). It’s also difficult to use this site for self-injection.

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How to give Deltoid shot

To locate this site, feel for the bone (acromion process) that is located at the top of the upper arm. The correct area to give the injection is two finger widths below the acromion process. At the bottom of the two fingers, will be an upside down triangle. Give the injection in the center of the triangle.

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Vastus

lateralis

M

uscle of the thigh

The thigh may be used when the other sites are not available or if you need to administer the medication on your own.

Divide the upper thigh into three equal parts. Located the middle of these three sections. The injection should go into the outer top portion of this section.

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Injection site

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Ventrogluteal

M

uscle of the hip

The

ventrogluteal

muscle is the safest site for adults and children older than seven months. It’s deep and not close to any major blood vessels and nerves. This site is difficult for self-injection, and may require the help of a friend, family member or caregiver.

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Ventrogluteal

Place the heel of your hand on the hip of the person receiving the injection, with the fingers pointing towards their head. Position the fingers so the thumb points towards the groin and you feel the pelvis under your pinky finger. Spread your index and middle fingers in a slight “V” shape, and inject the needle into the middle of that “V”.

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Ventrogluteal

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Dorsogluteal

M

uscles of the buttocks

The

dorsogluteal

muscle of the buttocks is the site most commonly selected by healthcare providers. It’s difficult to use this site for self-injection.

Divide the buttock into four equal quadrants, halfway down from top to bottom and halfway across. The injection should always go into the upper, outer quadrant of the buttock, towards the hip bone.

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Dorsogluteal

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How to Administer an Intramuscular Injection

Any person who administers intramuscular injections should receive training and education on proper injection technique. The needle size and injection site will depend on many factors. These include the age and size of the person receiving the medication, and the volume and type of medication. Your doctor or pharmacist will give you specific guidelines about which needle and syringe are appropriate to administer your medication.

The needle should be long enough to reach the muscle without penetrating the nerves and blood vessels underneath. Generally, needles should be one inch to one and a half inches for an adult, and will be smaller for a child. They will be 22 gauge to 25 gauge thick (noted as 22g on the packaging).

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S

teps for a safe intramuscular injection

1) Wash your hands. Wash your hands with soap and warm water to prevent potential infection. Be sure to thoroughly scrub between fingers, on the backs of hands, and under fingernails. The Centers for Disease Control and Prevention (CDC) recommends lathering for 20 seconds – the time it takes to sing the “Happy Birthday” song twice.

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Steps for a safe intramuscular injection

2) Gather all needed supplies. Assemble the following supplies:

•needle and syringe with medication

•alcohol pads

•gauze

•puncture-resistant container to discard the used needles and syringe (typically a red, plastic “sharp’s container”)

•bandages

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Steps for a safe intramuscular injection

3) Locate injection site. To isolate the muscle and target where you will place the injection, spread the skin at the injection site between two fingers The person receiving the injection should get into a position that’s comfortable, provides easy access to the location, and keeps the muscles relaxed.

4) Clean injection site. Clean the site selected for injection with an alcohol swab and allow the skin to air dry.

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Steps for a safe intramuscular injection

5) Prepare syringe with medication.

Remove the cap. If the vial or pen is multi-dose, take a note about when the vial was first opened. The rubber stopper should be cleaned with an alcohol swab.

Draw air into the syringe. Draw back the plunger to fill the syringe with air up to the dose that you’ll be injecting. This is done because the vial is a vacuum and you need to add an equal amount of air to regulate the pressure. This also makes it easier to draw the medication into the syringe. Don’t worry; if you forget this step, you can still get the medication out of the vial.

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Steps for a safe intramuscular injection

Insert air into the vial. Remove the cap from the needle and push the needle through the rubber stopper at the top of the vial. Inject all of the air into the vial. Be careful to not touch the needle to keep it clean.

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Withdraw medication.

Turn the vial and syringe upside down so the needle points upward and pull back on the plunger to withdraw the correct amount of medication.

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Self-injection with a syringe:

Insert needle. Hold the needle like a dart and insert it into the muscle at a 90-degree angle. You should insert the needle in a quick, but controlled manner. Do not push the plunger in.

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Check for blood/blood vessel.

Using the hand that is holding the skin at the injection site, pick up your index finger and thumb to stabilize the needle. Use your dominant hand (the one that did the injection) to pull back on the plunger slightly to look for blood in the syringe.

•If you see blood going into the syringe, it means the tip of the needle is in a blood vessel. If this happens, withdraw the needle and begin again with a new needle, syringe with medication, and injection site. It’s rare to have this happen.

•If you don’t see blood going into the syringe, the needle is in the correct place and you can inject the medicine.

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7) Inject medication. Push the plunger slowly to inject the medication into the muscle.

8) Remove needle. Withdraw the needle quickly and discard it into a puncture-resistant sharps container. Do not recap the needle. A sharps container is a red container that you can purchase at any pharmacy. It is used to collect medical waste, like needles and syringes. You should not put any of these materials into the regular garbage, as needles can be hazardous to anyone who handles the trash.

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Steps

9) Apply pressure to the injection site. Use a piece of gauze to apply light pressure to the injection site. You can even massage the area to help the medicine be absorbed into the muscle. It is normal to see slight bleeding. Use a bandage if necessary.

Video

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To minimize possible discomfort before your injection:

•Apply ice or an over-the-counter topical numbing cream to the injection site before cleaning it with the alcohol pad.

•Allow the alcohol to dry completely before the injection. Otherwise, it might cause stinging.

•Warm the vial of medication by rubbing it between your hands prior to drawing the medication into the syringe.

•Have someone you trust give you the injection. Some people find it difficult to inject themselves.

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What Are the Complications of Intramuscular Injections?

•severe pain at the injection site

•tingling or numbness

•redness, swelling or warmth at the injection site

•drainage at the injection site

•prolonged bleeding

•signs of an allergic reaction, such as difficulty breathing or facial swelling

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Subcutaneous injection

A subcutaneous injection is a method of administering medication. Subcutaneous means under the skin. In this type of injection, a short needle is used to inject a drug into the tissue layer between the skin and the muscle. Medication given this way is usually absorbed more slowly than if injected into a vein, sometimes over a period of 24 hours.

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Subcutaneous injection

Medications administered by subcutaneous injection include drugs that can be given in small volumes (less than 2 mL). Insulin and some hormones are commonly administered as subcutaneous injections.

Other drugs that need to be given very quickly can also be administered via subcutaneous injection. Epinephrine comes in an automated injector or “

EpiPen

” form that is used to quickly treat severe allergic reactions. Some pain medications like morphine and

hydromorphone

can be given this way as well. Drugs that prevent nausea and vomiting like metoclopramide or dexamethasone can also be given via subcutaneous injection.

Some vaccines and allergy shots are administered as a subcutaneous injection. Many other vaccines are administered as an intramuscular injection (into muscle tissue rather than subcutaneously).

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Preparing for a Subcutaneous Injection

The location of injection is important for subcutaneous injections. The drug needs to be injected into the fatty tissue just below the skin. Some areas of the body have a more easily accessible layer of tissue, where a needle injected under the skin will not hit muscle, bone, or blood vessels.

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The most common injection sites are:

•Abdomen: at or under the level of the belly button, about two inches away from the navel

•Arm: back or side of the upper arm

•Thigh: front of the thigh

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Equipment used for subcutaneous injections includes:

1.Medication: Vials of liquid medication can be single-use or multi-use. Vials can also be filled with a powder to which liquid needs to be added.

2.Syringes: Syringes with short 5/8-inch-long needles. The thickness of the needle is usually 25 or 27 gauge. There may be other options for doses more than 1 mL or for children or visually impaired patients.

3. Auto-injector pen: Some medications are available in a “pen” with a short single-use needle screwed onto the end of a pen-shaped, multi-use vial. The amount of medication needed is then dialed in at the end. As mentioned earlier, emergency medications like epinephrine can also come in a “pen” form.

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How to Administer a Subcutaneous Injection

Wash your hands

Gather supplies

Clean and inspect the injection site

Prepare the syringe with medication

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Preparing a syringe

Remove the cap from the vial. If the vial is multi-dose, make a note about when the vial was first opened. The rubber stopper should be cleaned with an alcohol swab.

Draw air into the syringe. Draw back the plunger to fill the syringe with air up to the dose that you will be injecting. This is done because the vial is a vacuum, and you need to add an equal amount of air to regulate the pressure. This makes it easier to draw the medication into the syringe. Don’t worry; if you forget this step, you can still get the medication out of the vial.

Insert air into the vial. Remove the cap from the needle and push the needle through the rubber stopper at the top of the vial. Inject all the air into the vial. Be careful to not touch the needle to keep it clean.

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Preparing a syringe

Withdraw the medication. Turn the vial and syringe upside down so the needle points upward. Then pull back on the plunger to withdraw the correct amount of medication.

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Remove any air bubbles.

Tap the syringe to push any bubbles to the top and gently depress the plunger to push the air bubbles out.

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Preparing an auto-injector:

•If you are using a pen delivery system, attach the needle to the pen.

•The first time that you use the pen, you will need to prime it to push out extra air in the delivery system.

•Dial a small dose (usually 2 units or 0.02 mL, or as indicated by the package instructions) and push the button to expel the primer.

•Dial the correct dose and prepare for your injection.

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Inject the medication.

Pinch your skin. Take a big pinch of skin between your thumb and index finger and hold it. (Your thumb and forefinger should be about an inch and a half apart.) This pulls the fatty tissue away from the muscle and makes the injection easier.

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Inject the medication.

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Insert the medication.

Slowly push the plunger to inject the medication. You should inject the entire amount of medication.

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Withdraw the needle. Let go of the pinched skin and withdraw the needle. Discard the used needle in a puncture-resistant sharp’s container.

Apply pressure to the site. Use gauze to apply light pressure to the injection site. If there is any bleeding, it should be very minor. You may notice a little bruising later. This is common and nothing to be concerned about.

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Complications of Subcutaneous Injection

If you’ll be doing this type of injection for more than one dose or for multiple days, you’ll need to rotate the injection sites. This means that you shouldn’t inject medicine into the same spot twice in a row. For example, if you injected medicine into your left thigh this morning, use your right thigh this afternoon. Using the same injection site over and over again can cause discomfort and even tissue damage.

As with any injection procedure, infection at the site of injection is a possibility. Signs of infection include severe pain, redness, swelling, warmth or drainage at the injection site. These symptoms should be reported to your physician immediately.

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Intradermal PPD test

PPD Tuberculin Skin Testing. Test Administration: Give 0.1 ml of 5 Tuberculin Units PPD

intradermally

. (Administration examples below.) All tests should be read between 48 and 72 hours

Video

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Venipuncture

Venipuncture is the method by which blood is drawn in most cases, and it may also be called phlebotomy or a blood draw. It refers to using a needle to pierce the skin and to access a vein so that a small amount of blood can be removed for various studies.

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Types of Needles Used for Venipuncture

To puncture a vein, only a small variety of needles are used because of their diameter – as larger needles could cause venial tear and or hemorrhage.

The most commonly used needles include:

A 21g green top needle,

A 22 g black top needle,

A 21g green label butterfly needle, and

A 25 g orange label butterfly needle (typically only used with very small veins in infants and children).

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Determining Needle size

• the type and viscosity of the medication

• the size and age of the patient

• the mobility status of the patient

• the desired absorption rate for the medication

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Intramuscular

IM (intramuscular) injections you would use a 21 to 23 gauge needle 1 to 1.5 inches long for an adult. In a child you use a 1 inch long, 25 to 27 gauge needle. In obese patients, 1.5 to 2 inch needles may be necessary.**

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Subcutaneous

SQ (subcutaneous) injections you would typically use a 25 to 27 gauge needle 3/8 to 5/8 inches long for adults and children alike. Some newer medications such as

Byetta

for diabetes recommends using 30 or 31 gauge 1/3 inch needles which are ultra fine.

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Venipunture basics

Brush Up Venipuncture Skills With These Videos

video

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Tubes

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Medical Billing & Coding

What is ICD-9, ICD10 & CPT?

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Current Procedural Terminology (CPT)

Current Procedural Terminology (CPT) is a medical code set that is used to report medical, surgical, and diagnostic procedures and services to entities such as physicians, health insurance companies and accreditation organizations. CPT codes are used in conjunction with ICD-9-CM or ICD-10-CM numerical diagnostic coding during the electronic medical billing process.

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CPT codes: Category 1, Category 2 and Category 3.

Category 1 covers procedures and contemporary medical practices that are widely performed.

Category 1 codes are broken down into six sections:

•Evaluation and management

•Anesthesiology

•Surgery

•Radiology

•Pathology and laboratory

•Medicine

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The Category 2

CPT medical code set consists of the supplementary tracking codes that are used for performance measures and are intended to help collect information about the quality of care delivered.

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The Category 3

CPT code list consists of temporary codes that cover emerging technologies, services and procedures. They differ from the Category 1 medical CPT codes list in that they identify services that may not be widely performed by healthcare professionals, may not have FDA approval, and also may not have proven clinical efficacy.

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ICD-9-CM

ICD-9-CM contains a list of codes corresponding to diagnoses and procedures recorded in conjunction with hospital care in the United States. These codes may be entered onto a patient's electronic health record and used for diagnostic, billing and reporting purposes. Related information also classified and codified in the system includes symptoms, patient complaints, causes of injury, and mental disorders.

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ICD-10-CM

Like its predecessor ICD-9-CM, ICD-10-CM is based upon the International Classification of Diseases, which is published by the World Health Organization (WHO) and which uses unique alphanumeric codes to identify known diseases and other health problems. According to WHO, physicians, coders, health information managers, nurses and other healthcare professionals also use ICD-10-CM to assist them in the storage and retrieval of diagnostic information. ICD records are also used in the compilation of national mortality and morbidity statistics.

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ICD-10-CM Code Structure

ICD-10 diagnosis codes have between 3 and 7 characters: Graphic illustrating ICD-10-CM Code Structure of 3-7 characters. First 3 characters are the category; character 4 to 6 describe the etiology, anatomical site and severity; and the final character is an extension. The first character is alpha (not U) and the second is numeric, while characters 3 to 7 can be any combination of alpha or numeric characters.

•Codes with three characters are included in ICD-10-CM as the heading of a category of codes that may be further subdivided by the use of any or all of the 4th, 5th, and 6th characters. Digits 4-6 provide greater detail of etiology, anatomical site, and severity. A code using only the first three digits is to be used only if it is not further subdivided.

•A code is invalid if it has not been coded to the full number of characters required. This does not mean that all ICD-10 codes must have 7 characters. The 7th character is only used in certain chapters to provide data about the characteristic of the encounter.

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Electronic medical billing

Electronic medical billing is the process by which a health care provider electronically submits a bill, or claim, to a health insurance company, or payer, for the rendering of medical services.

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CMS

The Centers for Medicare & Medicaid Services (CMS) is an agency within the US Department of Health & Human Services responsible for administration of several key federal health care programs.

In addition to Medicare (the federal health insurance program for seniors) and Medicaid (the federal needs-based program), CMS oversees the Children’s Health Insurance Program (CHIP), the Health Insurance Portability and Accountability Act (HIPAA) and the Clinical Laboratory Improvement Amendments (CLIA), among other services.

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What is Medicare

Medicare is the federal health insurance program for people who are 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant, sometimes called ESRD).

The different parts of Medicare help cover specific services:

Medicare Part A (Hospital Insurance)

Part A covers inpatient hospital stays, care in a skilled nursing facility, hospice care, and some home health care.

Medicare Part B (Medical Insurance)

Part B covers certain doctors' services, outpatient care, medical supplies, and preventive services.

Medicare Part C (Medicare Advantage Plans)

A type of Medicare health plan offered by a private company that contracts with Medicare to provide you with all your Part A and Part B benefits.

Medicare Part D (prescription drug coverage)

Part D adds prescription drug coverage to Original Medicare, some Medicare Cost Plans, some Medicare Private-Fee-for-Service Plans, and Medicare Medical Savings Account Plans. These plans are offered by insurance companies and other private companies approved by Medicare. Medicare Advantage Plans may also offer prescription drug coverage that follows the same rules as Medicare Prescription Drug Plans.

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What is Medicaid

Medicaid in the United States is a social health care program for families and individuals with low income and limited resources. The Health Insurance Association of America describes Medicaid as a "government insurance program for persons of all ages whose income and resources are insufficient to pay for health care".[1] Medicaid is the largest source of funding for medical and health-related services for people with low income in the United States.

States are not required to participate in the program, although all currently do. Medicaid recipients must be U.S. citizens or legal permanent residents, and may include low-income adults, their children, and people with certain disabilities.

Poverty alone does not necessarily qualify someone for Medicaid.

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Employer Group Health Plan

A group health insurance policy is purchased by an employer (or employee organization) and is offered to eligible participants, and to eligible dependents of participants. With group health insurance, the risk is spread over the company -- the number of participants covered. There are several types of group health insurance plans including HMO, PPO, etc.

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HMO

A health maintenance organization (HMO) is an organization that provides health coverage with providers under contract. A Health Maintenance Organization (HMO) differs from traditional health insurance by the contracts it has with its providers

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PPO

A preferred provider organization (PPO) is a type of health insurance arrangement that allows plan participants relative freedom to choose the doctors and hospitals they want to visit.

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The Basics

First and foremost, your health insurance card contains some straightforward identification information:

•The name of your health insurance company and possibly contact information (website, phone numbers, etc.)

•Your name

•The name of the subscriber or policyholder, if it’s not you. This may appear if you get your health insurance through another family member’s employer (e.g., spouse, parent)

•The names of other covered family members (e.g., spouse, children) may also appear here

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Member ID

Each member of a health plan is assigned a unique ID number, which allows doctors and other health care providers to verify your health insurance coverage and eligibility. If you have a question for your health insurer, this information will allow their customer service department to bring up your account to view your claims and benefits, and to answer any questions you may have.

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Group Number

A health insurer also assigns a unique ID number to each employer that purchases one of its plans. This is called the group number, and you’ll see it on your ID card if you receive your health insurance through an employer. It identifies the benefits of your specific plan and your doctor’s office will use it, along with your member ID, to submit claims.

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Plan Type

There are many different types of health insurance. The most common plan types you’ll see listed on your ID card are HMO insurance plans (health maintenance organizations), PPO insurance plans (preferred provider organizations), EPO insurance plans (exclusive provider organizations), and HDHPs (high deductible health plans). Each plan type is defined by its specific requirements regarding referrals, in- and out-of-network providers, and how out-of-pocket costs are calculated.

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Payment Information

Most health insurance cards will show how much you will be expected to pay (your out-of-pocket costs) for common services like visits with your primary care physician (PCP), specialist visits and urgent care and emergency room visits. This may be listed as a flat rate (a copay) or a percentage of the total cost of the service (coinsurance). If two numbers are listed, the first represents your cost at an in-network provider, and the second is your cost at an out-of-network provider.

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Prescription Costs

Formularies are commonly divided into three tiers. Your card may list the price you’ll pay at each tier level when you use a participating pharmacy.

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Rx BIN (banking identification number)

Your pharmacist will use this number to process your prescription. It indicates which company will reimburse the pharmacy for the cost of the prescription and where to send the claim for reimbursement.

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Medical Network

Your insurance company may provide out-of-area coverage through a different health care provider network. If so, this will be listed here.

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The Back of the Card

The back of your health insurance ID card is where you’ll be likely to find additional information, like important telephone numbers and addresses for doctors and hospitals so that they can verify eligibility, file claims, get pre-authorizations, etc. It might also provide hotlines and other resources for a variety of specific situations (e.g., chemical dependency services number, fraud hotline).

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Types of Scheduling

Open-hours scheduling:

patients arrive at the office at their convenience and are seen on a first-come, first-served basis.

Time-specified scheduling:

patients arrive at regular, specified intervals, assuring the practice has a steady stream of patients throughout the day.

Wave scheduling:

the number of patients seen each hour is determined by dividing the hour by the length of the average visit and then giving the number of patient’s appointments with the doctor at the beginning of each hour.

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Scheduling

Modified-Wave scheduling: system similar to wave scheduling, with patients arriving at planned intervals during the hour, allowing time to catch up before the next hour begins.

Cluster scheduling: scheduling similar appointments together at a certain time of the day or week.

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