New Medical Assistant
Advance to Medical Assistant Terminology

Medical Patient For purposes of this discussion, the term medical patient applies to any person who is receiving diagnostic, therapeutic, and/or supportive care for a condition that is not managed by surgical, orthopedic, psychiatric, or maternity related therapy. Many surgical, orthopedic, psychiatric, and maternity patients have secondary medical problems that are treated while they are undergoing management for their primary condition. Although many medical problems can be treated on an outpatient basis, this discussion will include inpatient care topics so that medical assistants can better relate to patients undergoing these procedures.

Medical Patient Care and Needs

Patient Teaching

Teaching, when provided by the medical assistant in the context of the medical patient, must consider certain areas of patient needs, particularly as the patient approaches discharge from an inpatient status. Those areas include the following:

1. Follow-up appointments
2. Modification in daily living activities and habits
3. Modification in diet, including fluid intake
4. Medications and treatment to be continued after discharge
5. Measures to be taken to promote health and prevent illness

Laboratory Tests And Diagnostic Procedures

Often the success of the test or procedure is dependent upon the patient's informed cooperation.

A variety of laboratory and diagnostic tests and procedures are commonly ordered for the medical patient. Frequently, it is the medical assistant’s job to prepare the patient for the procedure, collect the specimens, or assist with both the procedure and specimen collection whether in the medical office or on a hospital floor. Whether a specimen is to be collected or a procedure is to be performed, the patient needs a clear, simple explanation about what is to be done, and what the patient can do to assist with the activity. When collecting specimens, the medical assistant must complete the following procedures:

1. Collect the correct kind and amount of specimen at the right time
2. Place the specimen in the correct container
3. Label the container completely and accurately (may differ somewhat, local policies apply)
4. Complete the laboratory request form accurately
5. Record on the patient's record or other forms, as appropriate; the date, time, kind of specimen collected; the disposition of the specimen; and anything unusual about the appearance of the specimen or the patient during the collection.

When assisting with a diagnostic procedure, the medical assistant must understand the sequence of steps of the procedure and exactly how the assistance can best be provided. Since many procedures terminate in the collection of a specimen, the above principles of specimen collecting must be followed. Following the completion of a procedure or specimen collection, it is the responsibility of the medical assistant to ensure that the patient's safety and comfort are attended to, the physician's orders accurately followed, and any supplies or equipment used appropriately discarded.

Medications

A major form of therapy for the treatment of illness is the use of prescribed medications. It is not uncommon for the medical patient to be treated with several mediations at once. As members of the healthcare team, medical assistants assigned to administering medications are given a serious responsibility demanding constant vigilance, integrity, and special knowledge and skills. The preparation and administration of medications are usually addressed in great detail in the medical assistant curriculum in pharmacology class and lab.

Food and Fluid Therapy

It is the responsibility of the medical assistant to convey the importance of a prescribed diet to the patient and to ensure that accurate recording of the patient's dietary intake is made in the patient chart or clinical record.

The following brief discussion covers food and fluid and how it relates specifically to the medical patient. Loss of appetite, food intolerance, digestive disturbances, lack of exercise, and even excessive weight gain influence a medical patient's intake requirements. Regardless of their medical problems, patients have basic nutritional needs that frequently differ from those of the healthy person. As a part of the patient's therapeutic regimen, food is usually prescribed in the form of a special diet. Regardless of the kind of diet prescribed, the patient must understand why certain foods are ordered or eliminated, and how compliance with the regimen will assist in his total care.

In many disease conditions, the patient is unable to tolerate food or fluids or may lose these through vomiting, diarrhea, or both. In these cases, replacement fluids as well as nutrients are an important part of the patient's medical management. On the other hand, there are several disease conditions in which fluid restrictions are important aspects of the patient's therapy. In both of these instances, accurate measurement and recording of fluid intake and output must be carefully performed. Very frequently this becomes a major task of the staff medical assistant.

Rest

The primary reason for prescribing rest as a therapeutic measure for the medical patient is to prevent further damage to the body or a part of the body when the normal demand of use exceeds the ability to respond. However, prolonged or indiscriminate use of rest-particularly bed rest-is potentially hazardous. Some of the common complications occurring as a result of prolonged bed rest are:

1. Circulatory problems - development of thrombi and emboli) and subsequent skin problems (decubiti)
2. Respiratory problems - such as atelectasis and pneumonia
3. Gastrointestinal problems - such as anorexia, constipation, and fecal impactions
4. Urinary tract problems - such as retention, infection, or the formation of calculi
5. Musculoskeletal problems - such as weakness, atrophy, and the development of contractures
6. Psychological problems - such as apathy, depression, and temporary personality changes

The prevention of complications is the key concept in therapeutic management for the patient on prolonged bed rest. Awareness of the potential hazards is the first step in prevention. Alert observations are essential: Skin condition, respirations, food and fluid intake, urinary and bowel habits, evidence of discomfort, range of motion, and mood are all critical elements that provide indications of impending problems. When this data is properly reported, the healthcare team has time to employ measures that will arrest the development of preventable complications.