MEDICAL ASSISTANT SKILLS - Health Care - ثالث ثانوي

Link to digital lesson CHAPTER www.ien.edu.sa 4 MEDICAL ASSISTANT SKILLS Case Study Investigation Abdullah and Noura are medical assistants at a medical clinic. The team of doctors conduct many examinations, immunizations, procedures, and medication refills. Both Noura and Abdullah like to be busy and assist with a variety of patient needs. Noura has been at the clinic for 15 years and Abdullah just graduated from medical assisting training last year. Noura is glad to work as a team with Abdullah to deliver excellent care for clinic patients. At the end of this chapter, you will be asked what kind of skills Abdullah and Noura will need to know so that they can assist the doctors in providing competent and caring support for clinic patients. LEARNING OBJECTIVES After completing this chapter, you should be able to: • Measure and record height and weight. Position and properly drape a patient in horizontal recumbent, prone, Sims', knee-chest, Fowler's, lithotomy, dorsal recumbent, Trendelenburg, and jackknife positions. • Use a visual acuity chart to screen for vision problems. Prepare for and assist with a general physical examination. Identify and describe instruments/equipment used in minor surgery. Identify and describe instruments/equipment used in suture removal. • Record and mount an electrocardiogram (ECG). • Use reputable sources to find basic information about various drugs. • Identify methods of administering medications and safety rules that must be observed. KEY TERMS auscultation dorsal recumbent drapes forceps Fowler's hemostat horizontal recumbent (supine) hyperopia jackknife (proctologic) 162 التعليم ucation CHAPTER 4 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 162 knee-chest lithotomy myopia node observation palpation percussion prone retractor scalpel Sims' (left lateral) speculum stethoscope sutures Trendelenburg visual acuity 14/06/2023 10:29

4:1 MEASURING/RECORDING HEIGHT, WEIGHT, AND HEAD CIRCUMFERENCE Height and weight measurements are a part of the general physical examination in a physician's office. They are also usually done routinely when a patient is admitted to a hospital, long-term care facility, or other health care agency. In addition, these measurements provide necessary information in performing and evaluating certain laboratory tests and in calculating dosages of certain medications. . • Height and weight measurements are taken in many health care fields and are used to determine whether a patient is overweight or underweight. Either of these conditions can indicate disease. Height and weight charts can be used to determine whether a child is growing well and whether they are underweight or overweight. Height and weight measurements must be accurate. Always recheck your calculations. • The height, weight, head circumference, and, at times, chest circumference measurements of infants and toddlers is monitored frequently because growth is rapid. Infants are checked regularly to detect any changes that may indicate problems with growth and development (Figure 4-1). The measurements are recorded on graphs of weight for age (Figures 4-2A and 4-2B), height for age (Figures 4-2C and 4-2D), head circumference for age (Figures 4-2E and 4-2F), and weight for height (Figures 4-2G and 4-2H) for boys and girls. Different graphs are needed for boys and girls as they grow in different patterns and at different rates. The graphed information allows the physician to check the child's growth and compare it with the average percentiles of other children the same age. Abnormal growth patterns may indicate nutritional deficiencies or genetic diseases. FIGURE 4-1 Infants are checked regularly to detect any changes that may indicate problems with growth and development. وزارة التعليم Ministry of Education 2024-1446 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 163 MEDICAL ASSISTANT SKILLS 163 | 14/06/2023 10:29

Weight (kg) The Growth Charts for Saudi Children and Adolescents Endorsed by The Health Services Council of Saudi Arabia No.29 (24/6/2007) 24 Name: 23 22 21 20 19 18 17 16 15 14 13 12 11 10 9 8 7 6 5 4 3 2 Date of birth: Weight-for-age percentiles: boys, birth to 60 months Record #: Date Age WT 97 95 90 75 50 25 10 5 3 036 9 12 15 18 21 24 27 30 33 36 39 4245 48 51 54 57 60 63 Age (months) Source: Mohammad I. El Mouzan, Abdullah A. Al Salloum, Abdullah S. Al Herbish, Peter J Foster, Mansour M. Qurashi, Ahmad A. Al Omar. The 2005 Growth Charts for Saudi Children and Adolescents (No. AR-20-63). King Abdulaziz City for Science and Technology 2009, Riyadh, KSA. NB: The age is based on the Gregorian calendar. FIGURE 4-2A Weight for age percentiles: boys, birth to 60 months. 164 وژ29 التعليم Ministry of Education 2024-1446 CHAPTER 4 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 164 14/06/2023 10:29

Weight (kg) The Growth Charts for Saudi Children and Adolescents Endorsed by The Health Services Council of Saudi Arabia No. 29 (24/6/2007) 24 Name: 23 22 21 20 19 18 17 16 15 14 13 12 11 10 9 وزارة التعليم Ministry of Education 2024-1446 80 7 6 5 4 3 2 1 Date of birth:...... Weight-for-age percentiles: girls, birth to 60 months Record #:. Date Age WT 97 95 90 75 50 25 10 50 3 0 3 6 9 12 15 18 21 24 27 30 33 36 39 42 45 48 51 54 57 60 63 Age (months) Source: Mohammad I. El Mouzan, Abdullah A. Al Salloum, Abdullah S. Al Herbish, Peter J Foster, Mansour M. Qurashi, Ahmad A. Al Omar. The 2005 Growth Charts for Saudi Children and Adolescents (No. AR-20-63). King Abdulaziz City for Science and Technology 2009, Riyadh, KSA. NB: The age is based on the Gregorian calendar. FIGURE 4-2B Weight for age percentiles: girls, birth to 60 months. GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 165 MEDICAL ASSISTANT SKILLS 165 | 14/06/2023 10:29

Height (cm) The Growth Charts for Saudi Children and Adolescents Endorsed by The Health Services Council of Saudi Arabia No. 29 (24/6/2007) 120 Name:.. 115 Date of birth:........... 110 Height-for-age percentiles: boys, birth to 60 months 105 100 95 90 85 80 75 70 65 60 55 50 45 Record #: Date Age HT 97 95 90 75 50 25 10 53 40 0 3 6 9 12 15 18 21 24 27 30 33 36 39 42 45 48 51 54 57 60 63 Age (months) Source: Mohammad I. El Mouzan, Abdullah A. Al Salloum, Abdullah S. Al Herbish, Peter J Foster, Mansour M. Qurashi, Ahmad A. Al Omar. The 2005 Growth Charts for Saudi Children and Adolescents (No. AR-20-63). King Abdulaziz City for Science and Technology 2009, Riyadh, KSA. NB: The age is based on the Gregorian calendar. FIGURE 4-2C Height for age percentiles: boys, birth to 60 months. 166 و 298 التعليم Ministry of Education 2024-1446 CHAPTER 4 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 166 14/06/2023 10:29

The Growth Charts for Saudi Children and Adolescents Endorsed by The Health Services Council of Saudi Arabia No.29 (24/6/2007) 125 Name:..... 120 Height (cm) 115 110 105 100 95 90 85 80 75 70 وزارة التعليم Ministry of Education 2024-1446 65 60 55 50 45 40 40 Date of birth: Height-for-age percentiles: girls, birth to 60 months Record #:. Date Age HT 97 90 95 75 50 25 10 53 369 12 15 18 21 24 27 30 33 36 39 Age (months) 42 45 48 51 54 57 60 63 Source: Mohammad I. El Mouzan, Abdullah A. Al Salloum, Abdullah S. Al Herbish, Peter J Foster, Mansour M. Qurashi, Ahmad A. Al Omar. The 2005 Growth Charts for Saudi Children and Adolescents (No. AR-20-63). King Abdulaziz City for Science and Technology 2009, Riyadh, KSA. NB: The age is based on the Gregorian calendar. FIGURE 4-2D Height for age percentiles: girls, birth to 60 months. GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 167 MEDICAL ASSISTANT SKILLS 167 | 14/06/2023 10:29

Head circumference (cm) و 168 التعليم Ministry of Education 2024-1446 58 Name: 56 54 52 50 48 46 44 42 40 38 36 34 32 30 The Growth Charts for Saudi Children and Adolescents Endorsed by The Health Services Council of Saudi Arabia No. 29 (24/6/2007) Date of birth: Head circumference-for-age percentiles: boys, birth to 36 months Record #: Date Age HC 97 95 90 75 50 25 10 53 0 3 6 9 12 15 18 21 24 27 30 33 36 39 42 45 48 51 54 57 60 63 Age (months) Source: Mohammad I. El Mouzan, Abdullah A. Al Salloum, Abdullah S. Al Herbish, Peter J Foster, Mansour M. Qurashi, Ahmad A. Al Omar. The 2005 Growth Charts for Saudi Children and Adolescents (No. AR-20-63). King Abdulaziz City for Science and Technology 2009, Riyadh, KSA. NB: The age is based on the Gregorian calendar. FIGURE 4-2E Head circumference for age percentiles: boys, birth to 60 months. CHAPTER 4 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 168 14/06/2023 10:29

Head circumference (cm) وزارة التعليم Ministry of Education 2024-1446 58 Name: 56 54 52 50 48 46 44 42 40 38 36 34 32 The Growth Charts for Saudi Children and Adolescents Endorsed by The Health Services Council of Saudi Arabia No 29 (24/6/2007) Date of birth: Head circumference-for-age percentiles: girls, birth to 60 months Record #: Date Age HC 97 95 90 75 50 25 10 ام 3 30 0 3 69 12 15 18 21 24 27 30 33 36 39 Age (months) 42 45 48 51 54 57 60 63 Source: Mohammad I. El Mouzan, Abdullah A. Al Salloum, Abdullah S. Al Herbish, Peter J Foster, Mansour M. Qurashi, Ahmad A. Al Omar. The 2005 Growth Charts for Saudi Children and Adolescents (No. AR-20-63). King Abdulaziz City for Science and Technology 2009, Riyadh, KSA. NB: The age is based on the Gregorian calendar. FIGURE 4-2F Head circumference for age percentiles: girls, birth to 60 months. GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 169 MEDICAL ASSISTANT SKILLS 169 | 14/06/2023 10:29

28 27 26 27 Name: 26 Weight (kg) 25 25 24 23 21 20 22222 19 18 17 16 15 14 14 13 12 11 10 9 8 7 16 50 4 3 2 1 و270 التعليم Ministry of Education 2024-1446 The Growth Charts for Saudi Children and Adolescents Endorsed by The Health Services Council of Saudi Arabia No. 29 (24/6/2007) Date of birth: Weight-for-height percentiles: boys, birth to 60 months Record #: Date Age W/H 97 95 90 75 50 50 25 10 5 3 50 55 60 65 70 75 80 85 90 Height (cm) 95 100 105 110 115 120 125 Source: Mohammad I. El Mouzan, Abdullah A. Al Salloum, Abdullah S. Al Herbish, Peter J Foster, Mansour M. Qurashi, Ahmad A. Al Omar. The 2005 Growth Charts for Saudi Children and Adolescents (No. AR-20-63). King Abdulaziz City for Science and Technology 2009, Riyadh, KSA. NB: The age is based on the Gregorian calendar. FIGURE 4-2G Weight for height percentiles: boys, birth to 60 months. CHAPTER 4 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 170 14/06/2023 10:29

The Growth Charts for Saudi Children and Adolescents Endorsed by The Health Services Council of Saudi Arabia No. 29 (24/6/2007) 30 29 Name:..... Date of birth:. 28 27 26 Weight-for-height percentiles: girls, birth to 60 months 25 24 23 22 22 Weight (kg) 21 20 19 18 17 16 15 14 13 12 11 10 9 80 Record #:. 97 95 90 75 50 25 10 7 Date Age WT/HT 16 5 4 3 2 1 53 50 55 60 65 70 75 80 85 90 95 100 105 110 115 120 125 Height (cm) وزارة التعليم Source: Mohammad I. El Mouzan, Abdullah A. Al Salloum, Abdullah S. Al Herbish, Peter J Foster, Mansour M. Qurashi, Ahmad A. Al Omar. The 2005 Growth Charts for Saudi Children and Adolescents (No. AR-20-63). King Abdulaziz City for Science and Technology 2009, Riyadh, KSA. NB: The age is based on the Gregorian calendar. Ministry of Education 2024-1446 FIGURE 4-2H Weight for height percentiles: girls, birth to 60 months. GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 171 MEDICAL ASSISTANT SKILLS 171 | 14/06/2023 10:29

و273 التعليم Ministry of Education 2024-1446 CHAPTER 4 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 172 HEAD AND CHEST CIRCUMFERENCE Head circumference in infants can be an early indication of abnormal development of the brain. Any head circumference above the 95th percentile usually indicates hydrocephalus, an accumulation of fluid around the brain. This leads to increased intracranial pressure and brain damage. Hydrocephalus can be caused by abnormal development of the ventricles in the brain, bacterial meningitis, or tumors. • A below-normal value for head circumference can be an indication of microencephaly, or a small brain. This too can lead to mental restriction. Microencephaly can be caused by a congenital defect, infections during pregnancy, a premature closure of the fontanels in the brain, or genetic defects. Chest circumference is also measured in infants, especially if suspicion exists of overdevelopment or underdevelopment of the heart or lungs, or a calcification of the rib cartilage. • From birth to 1 year of age, the head circumference is usually greater than the chest circumference. • At about 1-2 years, the head and chest circumferences are equal. • After that, the chest circumference is larger than the head circumference. Chest circumferences may also be measured in adults with chronic obstructive pulmonary diseases such as emphysema to determine the progression of the disease. WEIGHT Weight is measured frequently in adults to monitor excessive weight loss or gain with hormone disorders such as diabetes, thyroid disease, digestive disorders, and hypertension (high blood pressure) with fluid retention. Patients with cancer or patients receiving chemotherapy are weighed frequently to monitor weight loss. Daily weights are often ordered for patients with edema (swelling) due to heart, kidney, or other diseases. When taking daily weights, note the following points: • Use the same scale each day. • Make sure the scale is balanced before weighing the patient. • Weigh the patient at the same time each day. If possible, weigh the patient early in the morning, before any food or liquids have been consumed. • Make sure the patient is wearing similar clothing each day. • Ask the patient to void to empty the bladder. 14/06/2023 10:29

Comm Most patients are very weight conscious. Parents may also worry about the weight of their children. Therefore, it is very important for the health care provider to make only positive statements while weighing a patient. In addition, privacy must be provided while weighing a patient and care should be taken so other individuals cannot see the patient's weight on the scale. HEIGHT Height measurements are performed more frequently in older adults to check for osteoporosis, a degeneration of the spinal column caused by a deterioration of cartilage and bone. As the intervertebral disks between the vertebrae deteriorate, the individual will become shorter. Safety Careful consideration must be given to the safety of the patient while weight and height are being measured. Observe the patient closely at all times. Prevent falls from the scale and possible injury from the protruding height lever. SCALES • A wide variety of scales are used to obtain height and weight measurements. • Some clinical scales contain a balance beam for measuring weight and a measuring rod for determining height (Figure 4-3A). Infant scales provide an area for placing the infant in a lying- down, or flat, position. Some facilities have digital scales that show the weight automatically. Institutions, such as hospitals or long- term care facilities, may have special scales for patients who are unable to stand. Such scales include the wheelchair scale (Figure 4-3B) and the bed scale with a mechanical lift. • Some hospitals and long-term care facilities have beds with a built-in scale (Figure 4-3C) that can be used to weigh comatose or paralyzed patients. It is important to follow the manufacturer's instructions while using any special scale to obtain accurate weight measurements. FIGURE 4-3A A beam-balance scale. FIGURE 4-3B A wheelchair scale. Fill-Ren 000 FIGURE 4-3C A bed with a built-in scale. وزارة التعليم Ministry of Education 2024-1446 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 173 MEDICAL ASSISTANT SKILLS 173 | 14/06/2023 10:29

• Math + Weight is recorded as kilograms (kg). Metric scales measure in kg and have 0.1-kg increments. Height is recorded as centimeters (cm). The measuring bar has 1-cm increments. HOW TO MEASURE AND RECORD THE HEIGHT AND WEIGHT OF AN ADULT OR CHILD . Assemble the equipment. FIGURE 4-4A Raise the height bar of the scale higher than the height of the patient. FIGURE 4-4B Move the bar of the height measuring scale down until it just touches the top of the patient's head. • . . Always wash your hands before beginning the procedure. Introduce yourself and identify the patient. Explain the procedure. Ask the patient to remove shoes, heavy outer clothing, purses, and heavy objects that may be in the pockets of clothing. In a hospital or long-term care facility, the patient is usually weighed in a gown. • Raise the height bar higher than the height of the patient (Figure 4-4A). • Assist the patient onto the scale. The patient should stand unassisted, with their feet centered on the platform and slightly apart. Safety Caution: Watch the patient closely at all times to prevent falls. Move the bar of the height measuring scale down until it just touches the top of the patient's head (Figure 4-4B). Safety Caution: Move slowly. Do not hit the patient with the bar. • Instruct the patient to stand as erect as possible. Ask them to look straight ahead to keep the head level. • Wait until the digital display is stationary and record the numbers shown. • Recheck your reading. Record the weight correctly. • If the height scale is not recorded digitally, read the height from the scale bar. Recheck your reading. Record the height correctly. P174 CHAPTER 4 Ministry of Education 2024-1446 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 174 14/06/2023 10:29

• Elevate the height bar and help the patient get off the scale. . A Safety Caution: Watch the patient closely to prevent falls. Replace all equipment and wash your hands. Comm Record all required information on the patient record and enter it into the computer; for example: date, time, Wt: 60 kg, Ht: 163 cm, and your signature and title. • In offices with electronic health records (EHRs), information is entered directly into the patient's record on a computer. HOW TO MEASURE AND RECORD THE WEIGHT OF AN INFANT • • Assemble the equipment. Wash your hands. Prepare the scales. Place a towel or scale paper on the scale pan to protect the infant from the shock of the cold metal and from pathogens. • Introduce yourself. Explain the procedure to the parent/carer. Identify the infant by asking the parent/carer for the infant's name. Ask the parent/carer to undress the infant. An undershirt or pajama is sometimes left on the infant. • Place the infant on the scales and wait for the digital display to show the weight. Safety Watch closely at all times. To prevent falls, keep one hand over the infant (Figure 4-5). FIGURE 4-5 Always keep one hand close to the infant to prevent them from falling off the scale. وزارة التعليم Ministry of Education 2024-1446 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 175 MEDICAL ASSISTANT SKILLS 175 | 14/06/2023 10:29

176 CHAPTER 4 و 276 التعليم Ministry of Education 2024-1446 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 176 • Record the weight in kilograms. Check your reading for accuracy. خخ Comm Record all required information on the patient record and/or enter it into the computer; for example: date, time, Wt: 4.3 kg, and your signature and title. • In offices with electronic health records (EHRs), information is entered directly into the patient's record on a computer. • Clean and replace all equipment. Turn off the scales and use a disinfectant to wipe them. HOW TO MEASURE AND RECORD THE HEIGHT OF AN INFANT • Assemble the equipment (a tape measure). • Wash your hands. • Pick up and place the infant on a flat surface. Safety Watch closely at all times. Do not leave the infant unattended. If it is necessary to reach for anything nearby, use one hand to hold the infant and the other hand to reach. FIGURE 4-6A Position the infant's head against the zero mark bar and gently straighten the legs to measure the infant's height. FIGURE 4-6B Hold the tape measure in a straight line to measure an infant's height. 14/06/2023 10:29

49 50 51 52 9 10 11 12 13 14 FIGURE 4-7 To measure head circumference, bring the tape around the infant's head, just above the ears, and back to the forehead. • Place the zero mark of the measuring tape or rod at the infant's head. If the measuring bar is a part of the examination table, position the infant so that their head is at the zero mark (Figure 4-6A). Ask the parent/carer or an assistant to hold the head at this mark. Gently straighten the infant's legs. If a tape measure is used, measure to the infant's heel (Figure 4-6B). If a bar is used, position the heel on the bar while holding the leg straight. •If the infant is lying on examining table paper, mark the paper at the infant's head and heel. Then measure the marked area. • Record the height correctly in centimeters. Recheck your reading. Comm Record all required information on the patient record and enter it into the computer; for example: date, time, Ht: 60 cm, and your signature and title. • In offices with electronic health records (EHRs), information is entered directly into the patient's record on a computer. • Clean and replace all equipment. Fold up the tape measure. HOW TO MEASURE AND RECORD THE HEAD CIRCUMFERENCE OF AN INFANT • Assemble the equipment (a tape measure). . Wash your hands. Position the infant on the examination table or ask the parent/carer to hold the infant. • Use a thumb or finger to hold the zero mark of the tape measure against the infant's forehead just above the eyebrows. Use your other hand to bring the tape around the infant's head, just above the ears, over the occipital bone at the back of the head, and back to the forehead to meet the zero mark on the tape (Figure 4-7). وزارة التعليم Ministry of Education 2024-1446 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 177 MEDICAL ASSISTANT SKILLS 177 | 14/06/2023 10:29

و278 التعليم Ministry of Education 2024-1446 CHAPTER 4 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 178 • Pull the tape snug to compress the hair, but not too tight. • Read the tape measure to the nearest 0.1 cm. • Record the reading. • Return the infant to the parent/carer. Clean and replace all equipment. Fold up the tape measure. HOW TO MEASURE AND RECORD THE CHEST CIRCUMFERENCE OF AN INFANT • Assemble the equipment (a tape measure). • Wash your hands. • Use the thumb of one hand to hold the zero mark of the tape at the middle of the sternum. • Use your other hand to wrap the tape snugly under the axillary area and around the back to meet at the midsternal area (Figure 4-8). • Make sure that the tape is at the nipple level of the chest and that it is not twisted. Read the measurement after the infant has exhaled or during the resting phase between respirations. • Read the tape measure to the nearest 0.1 cm. • Record the reading. FIGURE 4-8 To measure chest circumference, wrap the tape snugly around the chest and back at the nipple line. 14/06/2023 10:29

Comm Record all required information on the patient record and enter it into the computer; for example: date, time, chest circumference: 43.8 cm, and your signature and title. • In offices with electronic health records (EHRs), information is entered directly into the patient's record on a computer. • Clean and replace all equipment. Fold up the tape measure. . checkpoint 1. What three measurements are taken regularly for an infant? 2. What brain condition does an infant head circumference above the 95th percentile indicate? 4:2 POSITIONING A PATIENT A wide variety of positions are used for different procedures and examinations. The patient may need to be positioned on a medical examination table or a surgical table. It is important to know how to operate the table before attempting to position a patient. Obtain instruction or read the manufacturer's directions carefully. After use, medical examination tables and surgical tables are usually cleaned with an antiseptic soap or a disinfectant solution. In addition, table paper is frequently used to cover an examination table prior to the examination and is removed and replaced after the examination. * During any procedure or examination, reassure the patient. Make Comm sure that the patient understands what is being done and grants permission for the procedure. At all times, watch the patient closely for signs of distress. Safety Observe all safety factors to prevent falls and injuries. Use correct body mechanics at all times to prevent injury to yourself. It is also essential to make sure that the patient is not exposed during any examination or procedure. The door should be closed and the curtains, if present, should be drawn. Care must be taken to properly drape or cover the patient to avoid unnecessary exposure. At the same time, the drape must be applied so that the physician or technician has ready access to the area to be examined or treated. Some of the most common examination positions are listed and described below. • Horizontal recumbent (supine) position: - This position is used for examination or treatment of the front, or anterior, part of the body (Figure 4–9). وزارة التعليم Ministry of Education 2024-1446 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 179 MEDICAL ASSISTANT SKILLS 179 | 14/06/2023 10:29

180 و 230 التعليم Ministry of Education 2024-1446 CHAPTER 4 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 180 - - The patient lies flat on their back with the legs slightly apart. One small pillow is allowed under the head. The arms lie flat at the side of the body. The drape is placed over the patient but left loose on all sides to facilitate examination or treatment. • Prone position: . - - - - This position is used for examination or treatment of the back or spine (Figure 4-10). The patient lies on their abdomen and turns their head to either side. A small pillow may be placed under the head. The arms may be flexed at the elbows and positioned on either side of the head or positioned along the side of the body. One sheet or drape is placed over the patient but left loose on all sides to facilitate examination or treatment. Sims' (left lateral) position: - - - - - - - - This position is used for simple rectal and sigmoidoscopic examinations, enemas, rectal temperatures, and rectal treatments (Figure 4-11). - The patient lies on their left side. - The left arm is extended behind the back. - The head is turned to the side. A small pillow may be used. - The right arm is in front of the patient, and the elbow is bent. The left leg is bent, or flexed, slightly. The right leg is bent sharply at the knee and brought up to the abdomen. - Draping can be done with one large sheet or two small sheets that meet at the rectal area. A sheet with a hole at the examination site may also be used. All sheets hang free at the sides. ⚫ Knee-chest position: - This position is used for rectal examinations, usually a sigmoidoscopic examination (Figure 4-12). It is only used in rare circumstances when proctologic tables are not available. - - - The patient rests the body weight on the knees and chest. The arms are flexed slightly at the elbows and are extended above the head. 14/06/2023 10:29

وزارة التعليم Ministry of Education 2024-1446 - The knees are slightly separated, and the thighs are at right angles to the table. Draping can be done with one large sheet or two small sheets that meet at the rectal area. A large sheet with a hole at the rectal area can also be used. Sheets hang loose with no tucks. Safety Safety Caution: Do not place the patient in this position until the physician is ready to begin the examination. Caution: Never leave a patient alone in this position. This is a difficult position for the patient to maintain and should be used only as long as absolutely necessary. • Fowler's positions: - - - These positions are used to facilitate breathing, to relieve distress, to encourage drainage, and to examine the head, neck, and chest. The patient lies on the back. The head is elevated to one of three main positions: • Low Fowler's: the head is elevated to a 25-degree angle. • Semi-Fowler's (or mid-Fowler's): the head is elevated to a 45-degree angle (the most frequently used position) (Figure 4-13A). High Fowler's: the head is elevated to a 90-degree angle (Figure 4-13B). The legs lie flat on the table but the knees are bent slightly and are sometimes supported on a pillow. A sheet is used to drape the patient, which is left hanging loose. ⚫ Lithotomy position: • - - - This position is used for vaginal examinations, urinary catheterization, cystoscopic examinations, and surgery of the pelvic area (Figure 4-14). The patient is positioned on their back. - The knees are separated and flexed, and the feet are placed in stirrups. The arms rest at the sides. - The buttocks are at the lower end of the table. - The lower end of the table is dropped down or pushed in depending on the model of the examination table. GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 181 MEDICAL ASSISTANT SKILLS 181 | 14/06/2023 10:29

182 و233 التعليم Ministry of Education 2024-1446 CHAPTER 4 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 182 - Draping is done with one large sheet placed over the body in a diamond shape. One corner is at the upper chest, and one corner hangs loose between legs. Each of the other two corners is wrapped around a foot. ⚫ Dorsal recumbent position: • • - This position is similar to the lithotomy position, but the patient is in bed or on a table without stirrups (Figure 4-15). The feet are separated but flat on the table or bed. - The knees are bent. - Draping and other points are the same as for the lithotomy position. Trendelenburg position: - - This position increases circulation of blood to the head and brain, and can be used for circulatory shock. The entire bed or table is elevated at the feet. The patient lies in the horizontal recumbent position, with the head lower than the feet. The surgical Trendelenburg position (Figure 4-16) can be used for surgery on pelvic organs and for pelvic treatments. The patient is flat on their back. The table is lowered at a 45-degree angle to lower the head, and the feet and lower legs are inclined downward. Straps are frequently used to hold the patient in position. - Draping for this position depends on the treatment being performed; usually, one large sheet is used and left hanging loose. For surgical procedures, the patient is draped with a sheet that has a hole to expose the surgical area. Jackknife (proctologic) position: - This position is used mainly for rectal surgery or examinations and for back surgery or treatments. - The patient is in the prone position. - - The table is elevated at the center so that the rectal area is at a higher elevation. A special surgical table is required for this position (Figure 4-17). The head and chest point downward. The feet and legs hang down at the opposite end of the table. The patient must be supported to prevent injury. Straps are used to hold the patient in position. 14/06/2023 10:29

- Draping is done with a surgical sheet that has a hole to expose the surgical or treatment area. Two small sheets that meet at the surgical or treatment area can also be used. Safety Caution: It is important to use good body mechanics while positioning the patient. This will protect both yourself and the patient. checkpoint 1. When positioning a patient, what should you do to prevent injury to yourself? 2. What are Fowler's positions used for? FIGURE 4-9 Horizontal recumbent (supine) position. FIGURE 4-10 Prone position. FIGURE 4-11 Sims' (left lateral) position. FIGURE 4-12 Knee-chest position. وزارة التعليم Ministry of Education 2024-1446 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 183 MEDICAL ASSISTANT SKILLS 183 | 14/06/2023 10:29

FIGURE 4-13A Semi-Fowler's (mid-Fowler's) position. FIGURE 4-13B High Fowler's position. FIGURE 4-14 Lithotomy position. FIGURE 4-15 Dorsal recumbent position. FIGURE 4-16 Surgical Trendelenburg position. FIGURE 4-17 A special surgical table is required for the jackknife (proctologic) position. و184 التعليم Ministry of Education 2024-1446 CHAPTER 4 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 184 14/06/2023 10:29

4:3 SCREENING FOR VISION PROBLEMS Vision screening tests are given to measure an individual's visual acuity, or ability to perceive and comprehend the sense of sight. They are often given as part of a physical examination or to detect eye disease. Any test for visual acuity should be conducted in a well-lit room. Natural daylight, with no direct sunlight, is preferred. During any test, it is important to watch the patient for squinting, leaning toward the eye chart, closing one eye when both eyes are being tested, excessive blinking, and watering of the eyes. If defects are noted on any test, the patient should be referred to an ophthalmologist for a more extensive examination. One method of vision screening involves the use of visual acuity charts. These charts are used to test distant vision. They come in a variety of types. Some contain pictures for use with small children. Characters (letters or pictures) on the chart have specific heights, ranging from small, on the bottom of the chart, to large, on the top. When standing 6 meters from the chart, a person with normal visual acuity should be able to see characters that are 20 millimeters (mm) high. Visual acuity charts test only for defects in distant vision, or for nearsightedness (myopia). Defects in close vision (problems with reading small print and seeing up close), known as farsightedness (hyperopia), are tested by a different system. This system uses a printed card with different short paragraphs. Each paragraph is printed in a different size type, ranging from 0.37 to 2.5 millimeters (mm) high. A card with different characters or pictures is available for use with small children or individuals who cannot read. The patient holds the card approximately 35-40 cm away from the eyes. The patient then reads printed text or identifies pictures that gradually become smaller. The smallest print or character that the patient can read or identify without error is recorded. Defects in color vision, or color blindness, are tested by using a series of numbers printed in colored dots against a background of dots in contrasting color (Figure 4-18). Patients with normal color vision are able to identify the numbers. Patients with color blindness either are unable to see the numbers or identify incorrect numbers. This test is usually conducted in a room illuminated by natural daylight but not bright sunlight. When screening for visual acuity, there are special terms to remember: وزارة التعليم Ministry of Education 2024-1446 • Myopia: Nearsightedness; defect in distant vision. . Hyperopia: Farsightedness; defect in close vision. Ophthalmoscope: An instrument for checking the eye. • Tonometer: An instrument for measuring intraocular tension or pressure; increased pressure often indicates glaucoma. FIGURE 4-18 People with color blindness are not able to see the numbers in these Ishihara color plates. GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 185 MEDICAL ASSISTANT SKILLS 185 | 14/06/2023 10:29

و 186 التعليم Ministry of Education 2024-1446 CHAPTER 4 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 186 checkpoint 1. Where should a test for visual acuity take place? 2. What is an ophthalmoscope used for? 4:4 ASSISTING WITH PHYSICAL EXAMINATIONS A large variety of physical examinations are performed. The methods used and the equipment available vary from physician to physician. However, there are some basic principles that apply to all examinations. Four main techniques used during the examination are observation, palpation, percussion, and auscultation. • Observation (inspection): The physician looks at the patient carefully to observe things such as skin color, rash, growths, swelling, scars, deformities, body movements, condition of hair and nails, and general appearance. Palpation: The physician uses the hands and fingers to feel various parts of the body (Figure 4-19) and determine whether a part of the body is enlarged, hard, out of place, or painful to the touch. • Percussion: The physician taps and listens for sounds coming from various body organs (Figure 4-20). The physician may place one or several fingers of one hand on a part of the body, then use the fingers FIGURE 4-19 For palpation, the physician uses the hands and fingers to feel various parts of the body. 14/06/2023 10:29

of the other hand to tap the body part. The sounds emitted allow a trained individual to determine the size, density, and position of underlying organs. Auscultation: The physician listens to sounds coming from within the patient's body (Figure 4-21). A stethoscope is used in most cases. The physician listens to sounds produced by the heart, lungs, intestines, and other body organs. FIGURE 4-20 Percussion involves tapping on body parts and listening to sounds coming from body organs. O FIGURE 4-21 The physician is using a stethoscope and auscultation to listen to posterior lung and heart sounds. وزارة التعليم Ministry of Education 2024-1446 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 187 MEDICAL ASSISTANT SKILLS 187 | 14/06/2023 10:29

و 183 التعليم Ministry of Education 2024-1446 CHAPTER 4 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 188 EQUIPMENT All necessary equipment should be assembled prior to the examination (Figure 4-22). The equipment needed will vary depending on the body areas to be examined. Some of the equipment and instruments used for different examinations include: . • Laryngeal mirror: An instrument with a mirror at one end; used to examine the larynx, or voice box, in the throat. Ophthalmoscope: A lighted instrument used to examine the eyes (Figure 4-23). Otoscope: A lighted instrument used to examine the ears (Figures 4-24A and 4-24B). • Percussion (reflex) hammer: An instrument used to test tendon reflexes. . • Sigmoidoscope: A lighted instrument used to examine the sigmoid colon (the inside of the lower part of the large intestine); used during sigmoidoscopic examinations. Speculum: An instrument used to examine internal canals of the body. Sphygmomanometer: An instrument used to measure blood pressure. Stethoscope: An instrument used for listening to internal body sounds. X FIGURE 4-22 All necessary equipment should be assembled prior to the examination. 14/06/2023 10:29

FIGURE 4-23 An ophthalmoscope is used to examine the patient's eye. . Tongue blade/depressor: A wood or plastic stick used to depress (hold down) the tongue so that the throat can be examined. PREPARE YOURSELF Precaution Standard precautions must be followed at all times while assisting with physical examinations. Any instruments or equipment contaminated by blood or body fluids must be correctly cleaned and disinfected or sterilized after use. The medical assistant must always be aware of and take steps to prevent the spread of infection. • Hands must be washed frequently. Precaution Gloves must be worn if any contact with blood or body fluids is possible. If splashing of fluids is possible, wear a gown, mask or face shield, and eye protection. Observe standard precautions at all times. وزارة التعليم Ministry of Education 2024-1446 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 189 MEDICAL ASSISTANT SKILLS 189 | 14/06/2023 10:29

FIGURE 4-24A An otoscope is used to examine the interior of the patient's ear. PREPARE THE PATIENT • Introduce yourself and identify the patient. Explain the procedure. Remember that this procedure has multiple steps. Comm Preparation of the patient must include carefully explaining all procedures. Thorough explanations can help alleviate some fear. Patients often are apprehensive and need reassurance. Ask the patient to void their bladder before the examination so that the bladder will be empty and internal organs in the area of the bladder can be palpated. If a urinalysis is ordered, the urine specimen can be obtained at this time. Some tests frequently done prior to the physical examination might include: - - - - Record height and weight. Take and record vital signs, including temperature, pulse, respiration, and blood pressure. Check visual acuity and record results. - Perform an audiometric screening (a special FIGURE 4-24B An otoscopic examination may reveal a bulging tympanic membrane, a sign of otitis media or middle ear infection. - - hearing test requiring additional training to administer) and record results. Obtain blood samples for tests ordered (various tests may be ordered by the physician). - Run an ECG (electrocardiogram; a test to check the electrical conduction pattern in the heart) if ordered by the physician. • Seat the patient on the examination table. Drape the patient correctly. . Notify the physician that the patient is ready. DURING THE EXAMINATION • Be prepared to assist as necessary. • Hand equipment to the physician as needed. • Position the patient correctly for each part of the examination. • Be ready to help with each procedure. و290 التعليم Ministry of Education 2024-1446 CHAPTER 4 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 190 14/06/2023 10:29

AFTER THE EXAMINATION • When the examination is complete, assist the patient into a sitting position. Allow the patient to rest for a few minutes. . If no signs of weakness or dizziness are noted, help the patient to get off the table. Inform the patient how and when they will be notified of test results. • Ask the patient to get dressed or assist with dressing if necessary. • Label all specimens and cultures with the patient's name, identification number, and physician's name. Print all information on the laboratory requisition form(s) or use a computer-generated form. This might include date, time, patient's name, address, identification number, physician's name and identification number, type or site of specimen, and test ordered. Send specimens to the laboratory as soon as possible. • Wear gloves while cleaning and sterilizing any contaminated equipment. Put all contaminated disposable supplies in the infectious- waste bag. Use a disinfectant to wipe any contaminated areas. • Remove the gloves and discard them in an infectious-waste bag. Wash your hands. . Record all required information on the patient record or enter it into the patient's electronic health record. For example: date, time, physical examination, throat culture sent to laboratory, and your signature and title. Place a copy of any laboratory requisition forms in the patient's chart. The physician sometimes records the required information. checkpoint 1. What four main techniques are used during an examination? 2. List five tests that are frequently done prior to the physical examination. 4:5 ASSISTING WITH MINOR SURGERY AND SUTURE REMOVAL As a health care provider, you may be required to prepare for and assist with minor surgery or suture removal in a medical, dental, or health care facility. Minor surgery includes removing warts, cysts, tumors, growths, or foreign objects; performing biopsies of skin growths or tumors; suturing wounds; incising and draining body areas; and other similar procedures. وزارة التعليم Ministry of Education 2024-1446 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 191 MEDICAL ASSISTANT SKILLS 191 | 14/06/2023 10:29

192 و233 التعليم Ministry of Education 2024-1446 CHAPTER 4 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 192 INSTRUMENTS AND EQUIPMENT Instruments and equipment used depend on the type of surgery or procedure being done. Some basic instruments and supplies that may be used (Figure 4-25) include: Scalpels: Instruments with a handle attached to knife blades; used to incise (cut) skin and tissue. Disposable scalpels with a protective retractable blade to prevent sharps injuries are also available for use. Surgical scissors: Special scissors with blunt ends or sharp points or a combination; identified as sharp-sharp, sharp-blunt, or blunt-blunt; used to cut tissue. • Hemostats: Special group of curved or straight instruments, usually striated at the ends; used to compress (clamp) blood vessels to stop bleeding or to grasp tissue. ⚫ Tissue forceps: Instruments with one or more fine points (or teeth) at the tip of the blades; used to grasp tissue. Splinter forceps: Instruments with fine-pointed ends and no teeth; used to remove foreign objects from the skin or tissues. • Towel clamps: Instruments with sharp points at the end that lock together; used to attach surgical drapes to each other; also used to clamp onto tissue that has been dissected (separated or cut into pieces). • Retractors: Instruments used to hold or draw back the lips, or sides, of a wound or incision; also called skin hooks. • Suture materials: Special materials used for stitches (sutures); applied to hold a wound or incision closed. Absorbable suture materials such as surgical gut or vicryl is digested by tissue enzymes and absorbed by the body. Nonabsorbable suture materials such as silk, nylon, Dacron, stainless steel, and metal skin clips or staples are removed after the tissue or skin has healed (Figure 4-26). Needle holders: Special instruments used to hold or support the needle while sutures are being inserted. • Needles: Pointed, slender instruments with an eye at one end; used to hold suture material while sutures are being inserted into an incision or wound; usually curved for easier insertion into the skin. Swaged • needles have the suture material attached to the needle as one unit. Bandage scissors: Special scissors with blunt lower ends; used to remove dressings and bandages. The blunt ends prevent injury to the skin directly next to the dressing material. 14/06/2023 10:29

Surgical scissors Volkman retractors dododo Sharp/Sharp kni Sharp/Blunt Scalpel blades and handles kai 100 10 11 Blunt/Blunt Jones towel clamp 12 15 Needle holder Bandage scissors 1/2 Plain splinter forceps Backhaus towel clamp Tissue forceps with teeth MILTES 360 6~ 3 Physician's splinter forceps Ꮕ. Hemostatic forceps (curved or straight) Allis tissue forceps о O FIGURE 4-25 Some sample surgical instruments. وزارة التعليم Ministry of Education 2024-1446 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 193 MEDICAL ASSISTANT SKILLS 193 | 14/06/2023 10:29

194 و299 التعليم Ministry of Education 2024-1446 CHAPTER 4 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 194 ETHLON BENTICON ET 662 ETRICON S-O PL TORRINGTON stainles sant REXILES SURGEONS NEEDLES 50x3 4-0 CHROMIC GUT 1:2 3030-St 853 ETHICON. TEE Plain 00 2-0 SURGILENE 7-0 DEXONAS CV-305 99 TA CHROMIC GUT 583-21 4-0 CHROMIC GUT T-S ETHICON 828 ETHE STHILL ETHICON CHROMIC GUT FIGURE 4-26 A wide variety of suture materials and needles are available for minor surgeries. Preparation of the surgical tray requires the use of strict sterile technique to prevent infection. Instruments and supplies must be sterilized. Care must be taken to avoid contaminating the instruments and supplies when they are placed on the tray. Complete sterile setups are also available in commercially prepared, disposable packages. Examples include setups for insertion of sutures and for removal of sutures. It is important to follow sterile technique while opening the packages to maintain sterility of all materials in the package. PREPARING THE PATIENT Before any minor surgery, the patient must sign a written consent form. The consent form must describe the procedure, cite alternative treatments, and list possible complications or risks of the surgery. If the patient is a minor or lacks competence, an authorized person must sign the form. Most offices also provide written preoperative and postoperative instructions. Patients who are undergoing minor surgery or suture removal are often fearful and apprehensive. Reassure the patient to the best of your ability. Refer specific questions regarding the surgery or procedure to the physician. Comm 14/06/2023 10:29

PREPARING THE SITE The patient's skin is usually prepared before minor surgery. To do this: . Wash your hands and put on gloves. Wash the site thoroughly with an antiseptic soap. • If the surgical area has excessive hair, the area may be shaved. If a skin shave has been ordered, hold the skin taut and use a disposable razor to shave in the direction of hair growth. Shaving the surgical area is controversial because shaving increases the risk for abrasions leaving open areas that are prone to infection. It is important to avoid nicking the patient with the razor. Discard long hairs on a gauze pad or paper towel. Rinse the Precaution area and then pat it dry with gauze. Before minor surgery, a local anesthetic is often administered by the physician. This numbs the surgical site and decreases pain. Before the injection of local anesthesia, the physician may apply a liquid or spray topical anesthetic to the surface of the skin to decrease the pain of the injection. Anesthetics must be available for use. They are usually placed on the side of the sterile tray. DURING SURGERY During surgery, the medical assistant will be expected to assist as needed. The procedure will depend on the physician doing the surgery. Be alert to all points of the procedure and be ready to help as needed. • Sterile dressings must be available for use. These are usually placed directly on the surgical tray so that they are readily accessible. Some physicians prefer that sterile dressings be left in the original sterile wrappers and placed in the immediate area. • The physician will apply sterile drapes. Have towel clamps ready for the physician to use to hold the drapes in position. The physician may cleanse the surgical site with an antiseptic. . • When the physician is ready to inject the anesthetic, use a gauze pad saturated with alcohol to clean the top of the anesthetic solution vial. Hold the vial in a convenient position so the physician can fill the syringe without contaminating the needle (Figure 4-27). The physician will then inject the anesthetic. The needle and syringe should be discarded immediately into a sharps container. . If required, put on sterile gloves and assist as needed. Hold retractors, hand instruments, and assist with the procedure. وزارة التعليم Ministry of Education 2024-1446 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 195 MEDICAL ASSISTANT SKILLS 195 | 14/06/2023 10:29

196 و138 التعليم Ministry of Education 2024-1446 XYLE CAINE FIGURE 4-27 Hold the anesthetic solution vial in a convenient position so the physician can fill the syringe without contaminating the needle. FIGURE 4-28 Tissue or biopsy specimens removed during minor surgery must be placed in the correct type of specimen container so they can be examined by a pathologist. CHAPTER 4 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 196 • Body tissues, abnormal growths, and other specimens removed during surgery are usually sent to a laboratory for examination. Each specimen must be placed in an appropriate container immediately to avoid loss. A biopsy specimen is usually placed in a formalin solution that preserves the specimen until it can be examined. Most laboratories will provide a health care facility with the required specimen containers. • If tissue or a biopsy specimen is removed, open the lid of the specimen container. Hold the container close to the physician so the specimen can be placed into the container (Figure 4-28). Label the containers correctly and complete the laboratory requisition form. Many laboratories use computer-generated forms. The specimens should be sent to the laboratory as soon as possible. If the physician is going to insert sutures, have the suture material and suture needles ready for use. • Get additional supplies or equipment as needed. AFTER THE SURGERY • After the surgery, assist with placement of dressings and bandages. • Observe for any signs of distress. If no signs of weakness or dizziness are noted, help the patient get off the table. Review postoperative orders with the patient. • Provide the patient with a written copy of postoperative orders if this is office policy. Inform the patient how and when they will be notified of test results. 14/06/2023 10:29

Label all specimens correctly with the patient's name, identification number, and the physician's name or use a computer-generated label. Print all information on the lab requisition form. This might include date, time, patient's name, address, identification number, physician's name and identification number, type or site of specimen, and test ordered. Make sure each specimen is in the correct specimen container or bottle. Check the lids on the containers to make sure they are closed securely. Send specimens to the laboratory as soon as possible. Pathologists will provide special containers for most health care facilities. • Wear gloves to clean and sterilize all instruments and equipment. Put sharp objects such as the needle and syringe and scalpel blade (or disposable scalpel) in the sharps container immediately after use. Put contaminated disposable supplies in the infectious-waste container. Use a disinfectant to wipe any contaminated areas. • Put all equipment in its correct place. • Remove gloves and discard in an infectious-waste bag. Wash hands. Record all required information on the patient's chart or enter it into the electronic health record. For example: date, time, surgical removal of tumor on right forearm, specimen sent to pathology laboratory, verbal and written postoperative instructions given to patient, and your signature and title. Place a copy of any laboratory requisitions in the patient's chart. The physician sometimes records the required information. Precaution Because contamination from blood and body fluids is possible during minor surgical procedures, standard precautions must be observed at all times. Hands must be washed frequently, and gloves must be wiped with a disinfectant. Contaminated disposable supplies must be placed in an infectious-waste bag before disposal. Sharp objects such as scalpel blades (or disposable scalpels) and needles must be placed in a leakproof puncture-resistant sharps container immediately after use. The medical assistant must always be aware of and take steps to prevent the spread of infection. TRAVENOL TRIFLEX db FIGURE 4-29 A sample suture removal tray setup. FIGURE 4-30 A suture removal set consists of suture scissors and thumb forceps. وزارة التعليم Ministry of Education 2024-1446 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 197 MEDICAL ASSISTANT SKILLS 197 | 14/06/2023 10:29

FIGURE 4-31A Use dressing forceps or wear sterile gloves to apply a sterile dressing to the site. FIGURE 4-31B Anchor the dressing in place with roller gauze or tape. SUTURE REMOVAL Suture removal (removal of stitches) also requires that sterile technique be followed. Infection is an ever-present threat and must be prevented. • Instruments and supplies (Figure 4-29) will vary according to the physician. The main instruments used for this procedure are suture scissors and thumb forceps. The two instruments are frequently packaged in sterilized, disposable kits called suture removal sets (Figure 4-30). The thumb forceps are used to grasp and hold the suture. It is compressed with the thumb and forefinger. The suture scissors have a curved blade that is inserted under the suture material so that the stitch can be cut and removed. • When the sutures have been removed, place a clean dressing and bandages on the wound. Use dressing forceps or wear sterile gloves to apply a sterile dressing to the site (Figure 4-31A). Then apply roller gauze or tape to anchor the dressing in place (Figure 4-31B). · Instruct the patient on wound care and provide written instructions if this is office policy. Watch closely for signs of distress. If no signs of weakness or dizziness are noted, help the patient get off the table. • Wear gloves to clean and sterilize all instruments. If the suture set is disposable, place it in a sharps container. • Put all contaminated disposable supplies in the infectious-waste bag. Use a disinfectant to wipe any contaminated areas. • Remove gloves and discard in an infectious-waste bag. Wash your hands. . Record all required information on the patient's chart or enter it into the electronic health record. For example: date, time, sutures removed from right forearm, sterile dressing applied, and your signature and title. The physician sometimes records the required information. checkpoint 1. List four basic instruments or pieces of equipment that may be used for surgery or a procedure. 2. Is a sterile technique required for suture removal? Justify your answer. و 198 التعليم Ministry of Education 2024-1446 CHAPTER 4 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 198 14/06/2023 10:29

4:6 RECORDING AND MOUNTING AN ECG Science To understand an ECG, it is essential to understand the electrical conduction pattern in the muscles of the heart (Figure 4-32). The contraction of the heart muscles is controlled by electrical impulses within the heart. The electrical impulse originates in the sinoatrial (SA) node, an area of heart muscle near the top of the right atrium. The impulse moves through the atria, causing the muscles of the atria to contract. The impulse next travels to the atrioventricular (AV) node, through a band of fibers called the bundle of His, and then through the right and left bundle branches to the final branches, called the Purkinje fibers. The Purkinje fibers distribute the impulse to the muscles of the right and left ventricles, which then contract. Sinoatrial (SA) node Atrioventricular (AV) node (AV) Bundle VOLTAGE Q wave is a negative deflection or wave. R wave is a positive deflection or wave. S wave is a negative wave. T wave is a positive wave and represents ventricular repolarization. U wave (occasionally seen in some patients) is a positive deflection and associated with repolarization. Bundle of His Right and left bundle branches Purkinje fibers R Atrial depolarization (contraction systole) Ventricle repolarization Cycle (relaxation → diastole) begins again Ventricle depolarization (contraction → systole) T TIME U-wave occurs in some patients FIGURE 4-32 As the electrical impulse passes through the conduction pathway in the heart, it creates a pattern recorded as an electrocardiogram. وزارة التعليم Ministry of Education 2024-1446 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 199 MEDICAL ASSISTANT SKILLS 199 | 14/06/2023 10:29

و200 التعليم Ministry of Education 2024-1446 CHAPTER 4 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 200 The movement of the electrical impulse is recorded by an electrocardiograph machine as a series of waves known as a PQRST complex: • The P wave occurs as the impulse originates in the SA node and travels through the atria. • The QRS wave represents the movement of the impulse through the AV node, bundle of His, bundle branches, and Purkinje fibers. • The T wave represents the repolarization of the ventricles, or the period of recovery in the ventricles before another contraction occurs. The pattern of electrical current in the heart is recorded by an electrocardiograph machine as an ECG. Each PQRST pattern represents the electrical activity that occurs during each contraction of the heart muscle, so each PQRST complex represents one heartbeat. Because an abnormal pattern of the electrical impulses will be evident on an ECG, the ECG can be used to diagnose disease or damage to the muscles of the heart. Comm Many patients are frightened or apprehensive about having an ECG taken. It is important to explain this procedure to the patient. Stress that it is not a painful or uncomfortable test. Position the patient comfortably with all body parts supported. Encourage the patient to relax and to avoid moving while the ECG is being taken. Muscle movement can cause electrical interference and will be displayed on the ECG recording. Nervous tension can also interfere with the recording. RECORDING AN ECG Using special electrodes, the electrical activity is recorded from different angles, called leads. The different leads give the physician a more complete picture of the heart. By noting an electrical disturbance in any of the leads, the physician can determine which parts of the heart are diseased or malfunctioning. A complete ECG normally consists of 12 leads. Electrodes are placed at specific locations on the body to pick up the voltage present. Connections between the various electrodes create the various leads. There are three classifications: standard, augmented, and chest leads (Figure 4-33). • Standard, or limb, leads include leads 1 (I), 2 (II), and 3 (III) (Figure 4-34). Each records the voltage between two extremities. Augmented voltage leads (see Figure 4-34) are different angles of the standard leads. "aVR" stands for "augmented voltage right arm", "aVL” stands for “augmented voltage left arm”, and “aVF" stands for "augmented voltage left foot". 14/06/2023 10:29

Standard or bipolar limb leads Electrodes connected Marking code Lead I RA & LA .1 dot 2 dots Lead II RA & LL Lead III LA & LL Augmented 3 dots Recommended positions for multiple chest leads (Line art illustration of chest positions) unipolar 1 dash limb leads aVR RA & (LA-LL) 2 dashes aVL LA & (RA-LL) 3 dashes aVF LL & (RA-LA) Chest or precordial leads V C & (LA-RA-LL) (See data on right) V₁ Fourth intercostal space at right margin of sternum V2 Fourth intercostal space at left margin of sternum V3 Midway between position 2 and position 4 V4 Fifth intercostal space at junction of left midclavicular line V5 At horizontal level of position 4 at left anterior axillary line V6 At horizontal level of position 4 at left midaxillary line FIGURE 4-33 The lead arrangement and coding for a standard electrocardiogram. • The six chest, or precordial, leads record angles of the electrical impulse from a central point within the heart to specific sites on the front of the chest (see Figure 4-34). Chest electrodes are placed at six specific locations on the chest to obtain these angles (see Figure 4-33): - - - - ·V₁ fourth intercostal (between ribs) space on the right side of the sternum (breastbone). V₁: fourth intercostal space on the left side of the sternum. V3: midway between the V2 and V positions. 4 V: fifth intercostal space at the junction of the midclavicular line 4 (line drawn from the middle of the clavicle). - V: same level as 4 but at left anterior axillary line. V: same level as 4 but at left midaxillary line. Disposable electrodes are placed on various parts of the body to record these 12 leads. The leads have an alligator clip to attach them to the electrodes (Figure 4-35). The leads are coded so that each is put in the proper place: وزارة التعليم Ministry of Education 2024-1446 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 201 . Dash-Dot THA .. ..... MEDICAL ASSISTANT SKILLS 201 | 14/06/2023 10:29

(A) (B) Lead I Lead II Lead III (C) Lead aVR Precordial leads m Lead aVL V5 V₁ V2 V3 V₁ 4 6 Lead aVF 5 FIGURE 4-34 Lead types, connections, and placement. (A) Standard limb leads. (B) Augmented voltage (aV) leads. (C) Precordial or chest leads. FIGURE 4-35 An alligator clip on the end of the electrocardiograph cable wire attaches to the disposable electrode. "RA" for "right arm"; placed on the fleshy outer area of the upper part of the right arm. • "LA" for "left arm"; placed on the fleshy outer area of the upper part of the left arm. • "RL" for "right leg"; placed on the fleshy part of the lower right leg; does not record a lead but serves as a ground for electrical interference. • "LL" for "left leg"; placed on the fleshy part of the lower left leg. و203 التعليم Ministry of Education 2024-1446 CHAPTER 4 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 202 14/06/2023 10:29

• “C” or “V” for "chest”; placed at six different locations on the chest (see Figure 4-33). The lead wires should follow body contour (Figures 4-36A and 4-36B). If there is excess wire, coil it in a loop and fasten with tape or a band. Pay particular attention to the labels and color codes to connect the cable ends to the correct electrodes. Make sure all connections are tight and in the same direction. Electrocardiograph machines vary slightly, but most have the same basic parts. It is important to read the specific manufacturer's instructions with each machine. There are two main classes of electrocardiographs: single- channel and multiple-channel. The single-channel electrocardiograph produces a narrow strip of paper showing one lead at a time. Most facilities use a multiple-channel electrocardiograph that produces a full sheet of paper showing all 12 leads, with each lead labeled with its name (Figure 4-37). (A) (B) FIGURE 4-36 The lead wires should follow body contour when they are connected to the electrodes: (A) chest and arm leads; (B) leg leads. € ARTH 00000 INTER AUTO FIGURE 4-37 A multiple-channel electrocardiograph produces a full sheet of paper showing all 12 leads. وزارة التعليم Ministry of Education 2024-1446 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 203 MEDICAL ASSISTANT SKILLS 203 | 14/06/2023 10:29

و200 التعليم Ministry of Education 2024-1446 CHAPTER 4 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 204 PATIENT Nasser Al-Ahmed NO. SEX _AGE HEIGHT WEIGHT B/P DRUGS RATE:ATRIAL VENT. INTERVAL: PR QRS. QT. RHYTHM. INTERPRETATION aVR LEAD I DATE 11-1-20-- POSITION AXIS INTERPRETED BY LEAD II Dr. T. Winston Lewis LEAD III AVR AVL AVF V1 V2 V3 V4 V5 V6 FIGURE 4-38 A mounted ECG. MOUNTING AN ECG After all the ECG leads have been recorded, a section of each recorded lead is mounted. Multiple-channel machines produce complete mounts. These mounts are sometimes attached to firmer backings using self-stick tape. The final mount should be neat, with each lead in the correct area on the mount. The mount should be labeled with the patient's name and address, physician's name, date, and any other pertinent information (Figure 4-38). Computerized ECG machines will retain the ECG in the computer memory so it can be viewed on the screen. Most computerized ECG machines will also provide a printed copy of an ECG. Follow the manufacturer's instructions to save the ECG correctly in the patient's electronic health record. 14/06/2023 10:29

checkpoint 1. What node does the electrical pulse of the heart originate from? Where is that node located? 2. What are the two main classes of electrocardiographs? 4:7 WORKING WITH MEDICATIONS AYLIN A medication is a drug used to treat or prevent a disease or condition. The following discussion provides only basic information about the preparation and administration of medications. Even so, it should make you aware of the need for extreme care in handling all medications. It is important to remember that only authorized persons can administer medications. Medications are available in various forms, usually liquids, solids, or semi-solids. • • Liquids: - - Aqueous suspension: A medication dissolved in water. Suspension: The solid form of a medication is mixed with a solution. Usually, it must be shaken well before use to resuspend the medication in the solution. Syrup: A concentrated solution of sugar, water, and medication. - Tincture: A medication dissolved in alcohol. Precaution Liquid medications must be poured at eye level to ensure that the dosage is exact (Figure 4-39). Solids (Figure 4-40): - - - - Capsule: A gelatin-like shell with medication inside. Pill: A powdered medication mixed with a cohesive substance and molded into shape. Tablet: Compressed or molded preparation. Troche or lozenge: A large, flat disc that is dissolved in the mouth. Enteric coated: A medication with a special coating that does not dissolve until the substance reaches the small intestine. FIGURE 4-39 Liquid medications must be poured at eye level to ensure that the dosage is exact. Caplet Tablet- 2010 Capsule FIGURE 4-40 Types of solid medications. وزارة التعليم Ministry of Education 2024-1446 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 205 MEDICAL ASSISTANT SKILLS 205 | 14/06/2023 10:29

و206 التعليم Ministry of Education 2024-1446 Intramuscular Subcutaneous Intravenous 90-degree angle 45-degree angle 25-degree angle CHAPTER 4 H Intradermal 10- to 15- Edegree angle -Epidermis Dermis Subcutaneous tissue Muscle Intramuscular (IM) Subcutaneous (SC) Intravenous (IV) Intradermal (ID) Angle of Injection for Parenteral Administration of Medications FIGURE 4-41 Types of injections and the correct angles for administration of parenteral medications. • Semi-solids: - Ointment: A medication in a fatty base. - Paste: Ointment with an adhesive substance. Cream: A medication with a water-soluble base. - Suppository: A cone-shaped object that usually has a base material of cocoa butter or glycerin mixed with the medication. It is usually inserted into the rectum, where it melts as a result of body heat and dispenses the medication. It is used rectally to stimulate peristalsis and aid in expelling feces, relieve pain, decrease body temperature (aspirin suppositories), and stop vomiting (antiemetics). Medications may be given in a variety of ways. Some of the routes of administration are: . Oral: Given by mouth; for liquid and solid forms. • Rectal: Given in the rectum; liquids and suppositories. Injection: Given with a needle and syringe. It is often called parenteral, which means any route other than the alimentary canal (digestive tract) (Figure 4-41). Routes for injection are: - - Subcutaneous (SQ): Injected into the layer of tissue just under the skin. - Intramuscular (IM): Injected into a muscle. - Intravenous (IV): Injected into a vein. - Intradermal: Injected just under the top layer of the skin. The skin tests for allergies and tuberculosis are examples. GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 206 14/06/2023 10:29

Topical (or local): Applied directly to the top of the skin. - - Ointments, sprays, liquids, and adhesive patches. Transdermal adhesive patches applied to the skin can be used to provide a continuous dosage of medication for motion sickness, heart disease, hormonal imbalance, and nicotine withdrawal (for individuals who are trying to stop smoking) (Figures 4-42A and 4-42B). • Inhalation: Inhaled, or breathed in, by way of special machines. sprays, inhalers, or Sublingual: Given under the tongue. Backing layer Drug reservoir Microporous rate-limiting membrane Adhesive formulation Skin surface Blood vessel FIGURE 4-42A The layers of a transdermal patch allow the medication to be absorbed into the bloodstream over a period of time, frequently 24 hours. FIGURE 4-42B A transdermal patch. وزارة التعليم Ministry of Education 2024-1446 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 207 s MEDICAL ASSISTANT SKILLS 207 | 14/06/2023 10:29

و308 التعليم Ministry of Education 2024-1446 CHAPTER 4 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 208 SOURCES OF INFORMATION Before administering any medication, it is essential to check for complete information about the medication. When you are looking for information, it is important to know that drugs have two names: a generic name and a proprietary (trade or brand) name. The same generic medicine can have several different brand names, which may be different in different countries. For example, the generic analgesic aspirin (acetyl salicylic acid) has many trade names, such as Anadin, Fevadol, Disprin, and Ecotrin, as it is manufactured by different companies in many countries. Some useful sources of accurate information about drugs include: • The Saudi Arabia Ministry of Health (MOH) Drug Formulary, which is divided into three sections: - A directory of policies, guidelines, and medical supplies. - A listing of all medications approved for use in MOH hospitals. An appendix of approved abbreviations, MOH forms, and indexes. The MOH Drugh Formulary is available as an app for Smartphone users), which delivers frequently updated information on over 1,500 generic and over 2,000 branded medicines. • The Saudi Food and Drug Authority (www.sfda.gov.sa) provides lists of drugs that are available in Saudi Arabia and internationally, drugs being studied, pharmacies, safety alerts, and much more. • In addition to websites, the packet inserts provided in medication packages also provide valuable information. INFORMATION NEEDED BEFORE ADMINISTERING A DRUG Information that must be obtained from a reliable source about any medication or drug before administering the drug includes the following: • Action of the drug: Tells how the drug works and what it should do. • Uses of the drug: Provides all approved reasons why the drug is used to treat specific conditions, and also frequently provides information on conditions that the drug treats that are unlabeled uses. Availability or how supplied: Lists all forms of the drug, or routes of administration, such as capsules, pills, injectables, or liquids. Dosage: Indicates correct dose (the specific amount of medication taken at one time) for each form of the medication and for the specific condition for which it is being used; how to take the medication as prescribed (a specific amount, number, and frequency of doses over 14/06/2023 10:29

a specific period); categorizes the dosages according to the age of the person taking the drug. • Administration: Provides information on correct storage, special precautions such as capsules not being chewed or crushed, taking the medication with food, drinking large amounts of fluid with medication, and similar factors. Adverse effects (or side effects): Indicates all effects other than those intended that may be experienced, from minor to major. • Contraindications: Lists diseases or reasons why the medication should not be taken. . Cautions for use: Emphasizes times it may be dangerous to administer this medication. • Interactions: Provides a list of other medications that may interact with this drug and how its use would interfere with the action of other medications or decrease in effectiveness. There are six main points to watch each time a medication is given. These can be called the "six rights": Right medication. Right dose or amount. Right patient. • Right time. . Right method or mode of administration. • Right documentation. SAFETY Certain safety rules must be observed when giving medication. • Read the order carefully. Note all "six rights". • Check for patient allergies before administering any medication. • Check the label at least three times to be sure it is the correct medication (Figure 4-43). The label must be read when the bottle is taken from the shelf, as the medication is poured, and when the bottle is replaced on the shelf. • Prepare or administer a medication only on the order of a physician. • Never administer a medication that you did not personally prepare. وزارة التعليم Ministry of Education 2024-1446 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 209 MEDICAL ASSISTANT SKILLS 209 | 14/06/2023 10:29

و210 التعليم Ministry of Education 2024-1446 CHAPTER 4 GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 210 EXVO FIGURE 4-43 Check the label of any medication at least three times. • Know the action of the drug, the usual dosage, the route of administration, and the adverse effects. Store medications in a safe, cool, dry area. Make sure they are out of the reach of children. • Check expiration dates on all medications. Medications must never be used beyond the expiration date, and expired medications must be destroyed. Record all required information regarding the destruction of the medication according to agency policy. Never use medication from an unmarked bottle. Make sure the label is clear. If in doubt, throw it out. • Do not return any medication to a bottle. This can lead to serious errors. Discard any medication that is not used. • Report all mistakes immediately. Math IIII Legal Concentrate while handling any medication. Avoid distractions. Use a calculator or paper and pencil to calculate dosages. Avoid "mental" math because it can cause errors. Only legally authorized health care providers can administer medications. Administering medications is a major responsibility and every effort must be made to make sure the correct drug and dosage is given to the patient. Always use the literature that comes with each medication to learn the basic information about the medication. Question dosages or uses that do not seem correct. It is your responsibility to determine what you are legally permitted to do. 14/06/2023 10:29

وزارة التعليم Ministry of Education 2024-1446 checkpoint 1. List the four routes for injections. 2. What are the "six rights"? Today's Research Tomorrow's Health Care The Nose Knows Cancer? Even though treatment for cancer has improved and many lives have been saved, some types of cancers are extremely difficult to detect at an early stage when a cure is most likely. Examples include stomach, bone, kidney, pancreatic, and ovarian cancers. Scientists all over the world are researching the possibility of a “smell test” for cancer using dogs. Initially, researchers in California trained five different dogs to smell breast and lung cancer on a patient's breath. Since then, dogs have been used to identify breast cancer, lung cancer, colorectal cancer, and prostate cancer with accuracy rates approaching 100% (Figure 4-44). Researchers think the dogs were able to smell the cancers by sensing minute amounts of volatile organic compounds (VOCs) that are end products of metabolism, which are excreted in breath, urine, and feces. Some researchers are isolating polyamines, molecules linked to cell growth and differentiation, because cancer raises polyamine levels and they have a distinct odor. Estimates are that a dog's sense of smell can be 10,000 to 100,000 times superior to a human's sense of smell, so the dogs can detect minute quantities of the VOCs. Currently, many researchers are working to identify and isolate the chemical compounds associated with different types of cancers. This is very challenging because the smell of cancer is probably made up of many different chemicals. In fact, each type of cancer might have a unique chemical combination. At the same time, researchers are trying to develop artificial noses that will be able to detect specific chemical FIGURE 4-44 Dogs have been used to identify different types of cancer with accuracy rates approaching 100%. compounds. Recently, several electronic noses (e-noses) have been produced and are being used in trial studies. Initial studies have had some success. One e-nose was able to distinguish between lung cancer patients and high-risk smoking patients without cancer 80% of the time. Another model was able to identify prostate cancer from the scent of urine 78% of the time. A third e-nose checking fecal gas identified 73-85% of patients with colorectal cancer. Once the compounds associated with cancer are identified, it may be possible to modify the e-nose to detect them by inserting sensors to detect the specific compounds. Eventually, it is very possible that a simple noninvasive test using scents from breathing, urine, feces, and even blood could lead to early detection of cancer. This research could save many lives. Case Study Investigation Conclusion What skills should Abdullah and Noura have to be a part of the health care team at the clinic? If Abdullah is unfamiliar with a procedure or skill, what should he do? How can Noura help him? GE45.PATHWAYS.G03.S1-2.HC.ENG.SB.indb 211 MEDICAL ASSISTANT SKILLS 211 | 14/06/2023 10:29