Examination and Treatment Areas 9 Examination and Treatment Areas

Learning Outcomes (cont.) 9.1 Describe the layout and features of a typical examination room. 9.2 Differentiate between sanitization and disinfection. 9.3 List steps to prevent the spread of infection in the exam and treatment rooms.

Learning Outcomes (cont.) 9.4 Describe the importance of temperature, lighting, and ventilation in the exam room. 9.5 Identify instruments and supplies used in a general physical exam and tell how to arrange and prepare them.

Introduction Care and maintenance of exam room Equipment Supplies Infection control practices The care and maintenance of the medical office’s examination and treatment areas are duties of the medical assistant. The medical assistant must perform specific tasks to prepare and maintain the rooms, equipment, and supplies. These tasks include knowing the equipment and supplies and practicing infection control at all times.

The Exam Room Number and size of rooms Two per physician Accommodate the physician, patient, and one assistant Supplies and equipment must be in reach Learning Outcome: 9.1 Describe the layout and features of a typical examination room. Number and Size of Rooms The number of exam rooms in a medical office depends on the number of physicians who work there and on each physician’s patient load. Ideally, each physician in a medical office has at least two exam rooms for her or his exclusive use. This enables the medical assistant to prepare one room while the physician examines a patient in the other room. The customary size for an exam room is 8 by 12 feet. It needs to be large enough to accommodate the physician, the patient, and one assistant comfortably, yet small enough that instruments and supplies are within easy reach. Rooms should be soundproofed to ensure privacy for patients. A rack for the patient’s medical records usually hangs on the wall outside the exam room or on the outside of the door. A light or other device may be used to signal that the room is occupied.

Furnishings Arrangement Examining table Efficiency Patient comfort Physician convenience Examining table Step Drawers Adjustable positioning Learning Outcome: 9.1 Describe the layout and features of a typical examination room. The examining table is the exam room’s key piece of equipment and should be positioned in the center of the room or extending out from the wall. This arrangement allows the physician and an assistant to attend to the patient on at least three sides. The table has a pullout step for the patient to use when getting onto the table and may also have drawers for storing instruments and table coverings. Examining tables are usually adjustable to enable the patient to assume the various positions the physical exam may require. Key equipment found in exam room Examining table Sink Countertop Writing surface Shelves, cupboards, drawers for routine supplies

Furnishings Items commonly found in exam rooms One or more chairs A rolling stool Weight scale Biohazard container Wastebasket with lid Puncture-proof containers Wall brackets High-intensity lamp Learning Outcome: 9.1 Describe the layout and features of a typical examination room. Key equipment found in exam room Examining table Sink Countertop Writing surface Shelves, cupboards, drawers for routine supplies

Special Features The 1990 Americans with Disabilities Act (ADA) Requires “reasonable accommodations” Accessibility Guidelines Learning Outcome: 9.1 Describe the layout and features of a typical examination room. To comply with this act, at least one exam room in a medical office must have features that make the area accessible to patients who use wheelchairs or who have visual or other types of physical impairments. Accessibility refers to the ease with which people can move in and out of a space. Guidelines: A doorway at least 36 inches (915 mm) wide to allow a person in a wheelchair to pass through. A clearance space in rooms and hallways that is 60 inches (1525 mm) in diameter to allow a person in a wheelchair to make a 180-degree turn. Stable, firm, slip-resistant flooring. Door-opening hardware that can be grasped with one hand and does not require the twisting of the wrist to use. Door closers adjusted to allow time for a person in a wheelchair to enter or exit through the door. Grab bars in the lavatory.

Right! Apply Your Knowledge When arranging an examination room, what three things should you consider? ANSWER: You need to consider efficiency, patient comfort, and physician convenience when arranging an examination room. Learning Outcome: 9.1 Describe the layout and features of a typical examination room. Right!

Sanitization and Disinfection For cleaning items that touch only healthy, intact skin First step in disinfection and sterilization for other equipment Learning Outcome: 9.2 Differentiate between sanitization and disinfection. In addition to the basic measures outlined in Basic Safety and Infection Control, sanitation and disinfection must be performed. Items that can be sanitized and reused without further disinfection or sterilization Blood pressure cuff Ophthalmoscope Otoscope Penlight Reflex hammer Stethoscope Tape measure Tuning fork

Sanitization (cont.) Collect items for sanitization Scrub items PPE Separate sharps from other equipment Scrub items Small brush Neutral pH detergent Dry Learning Outcome: 9.2 Differentiate between sanitization and disinfection. Sanitize instruments as soon as possible after use. If you cannot sanitize them immediately, place them in a container filled with water and a neutral-pH detergent solution so that blood and tissue will not dry on the instruments. Take care when placing instruments in sinks or basin. Nicks or scratches can affect their function and can provide opportunities for bacterial contamination. Put on properly fitting, intact utility gloves which act as a barrier between your skin and any infectious material on the instruments and equipment to be cleaned. You may also need to use the additional protection of a mask, eye protection, or protective clothing. Separate the sharp instruments from all other equipment to reduce the risk of blunting sharp edges or points, damaging other equipment, and injuring yourself. Scrub each item using hot, soapy water and a small plastic scrub brush using a low- sudsing, neutral pH detergent specially formulated to dissolve blood and blood products for medical instruments and equipment. Rinse instruments individually, and place each one on a clean towel. Instruments that need only to be sanitized can be returned to trays or bins for storage. Wrap items that require disinfection and sterilization in a clean covering, and set them aside for those processes.

Sanitization (cont.) Rubber and plastic items Ultrasonic cleaning For delicate instruments and those with moving parts Sound waves generated through a cleaning solution to loosen contaminants Learning Outcome: 9.2 Differentiate between sanitization and disinfection. Rubber and plastic items Soak for a short time or not at all as these items will fade or discolor if left in a detergent solution. Follow manufacturers’ guidelines. Ultrasonic cleaning – metals Separate different types of metal. Ultrasonic cleaning can cause one metal to disintegrate and fuse with another metal, rendering all instruments useless.

Disinfection Adequate for some instruments For others, it is the second step prior to sterilization Sterilization is necessary for visible contamination with blood Learning Outcome: 9.2 Differentiate between sanitization and disinfection. After sanitization, some instruments and equipment require only disinfection before being used again. Disinfection of other items is only the second step in infection control, performed before the sterilization process. Disinfection is a process that destroys most microorganisms. It cannot kill all microorganisms. Bacterial spores and certain viruses have been known to survive disinfection with strong chemicals and boiling water. To destroy microorganisms, a disinfectant solution must reach every surface of an instrument. Gloves must be worn when handling instruments during disinfection procedures because instruments requiring disinfection are considered to be contaminated. Items that can be disinfected and reused without sterilization Enamelware Endotracheal tubes Glassware Laryngoscopes Nasal specula However, these must be sterilized if there is visible contamination with blood or blood products. Sterilization is the only reliable measure you can take to eliminate bloodborne pathogens.

Disinfection (cont.) Using disinfectants Cleaning products for inanimate materials Reduce or eliminate infectious organisms Manufacturer’s guidelines Effectiveness Learning Outcome: 9.2 Differentiate between sanitization and disinfection. Disinfectants are cleaning products used primarily on inanimate materials. They are applied to instruments and equipment to reduce or eliminate infectious organisms. Antiseptics are cleaning products used on human tissues as anti-infection agents. To ensure the optimum effectiveness of disinfectants, follow manufacturers’ guidelines carefully when using them. Other factors also may have an impact on a disinfectant’s effectiveness. Number of times solution is used Wet items – surface moisture may dilute solution Traces of soap left from sanitization – alters chemical composition Evaporation

Disinfection (cont.) Choose the correct disinfectant Handling disinfected supplies Prevent contamination with other surfaces Use sterile transfer forceps Wear gloves Store in clean, moisture-free environment Learning Outcome: 9.2 Differentiate between sanitization and disinfection. Follow manufacturers' guidelines for use. Types of disinfectants Germicidal soap products Alcohol Acid products Formaldehyde Glutaraldehyde – “cold disinfection” Bleach Iodine and iodine compounds Each of these disinfectants has advantages and disadvantages. Before using any disinfectant product or procedure, it is important to understand some general guidelines about disinfectant use as well as specific concerns with each approach. Refer to Table 9-1 Disinfectants.

Nice Job! Apply Your Knowledge What is sanitation and for what items is sanitation adequate for cleaning? ANSWER: Sanitation is scrubbing with a brush and detergent to remove blood, mucus, and other contaminants or media where pathogens can grow. It is adequate for cleaning items that touch only healthy, intact skin. Learning Outcome: 9.2 Differentiate between sanitization and disinfection. Nice Job!

Preparation of the Exam and Treatment Areas Clean and well organized Safeguards Making hand hygiene a priority; Keeping the examining table clean; and Disinfecting all work surfaces. Learning Outcome: 9.3 List steps to prevent the spread of infection in the exam and treatment rooms. All areas of the medical office should be clean and well-organized. A clean exam and treatment area is extremely important in preventing the spread of infectious diseases to patients and healthcare workers. The potential for the spread of infection is higher in medical offices than in most other places so you must be especially careful to follow infection-control procedures at work.

Infection Control Hand hygiene Examining Table Handwashing Alcohol-based hand cleaners Examining Table Paper cover Linens Learning Outcome: 9.3 List steps to prevent the spread of infection in the exam and treatment rooms. Clean hands are the first step in preventing infection transmission. Refer to Table 9-2 Hand Hygiene. After performing hand hygiene, use a clean paper towel to handle faucets or doorknobs to help you avoid contaminating your clean hands with microorganisms. Examining Table The disposable paper that covers the examining table provides a barrier to infection during an exam. Change the covering after each use by rolling it up quickly and carefully with the contaminated side on the inside. Dispose of paper and place linens in the appropriate containers

Infection Control (cont.) Disinfect surfaces Visibly contaminated with tissue, blood or other body fluids At end of shift Per office schedule Learning Outcome: 9.3 List steps to prevent the spread of infection in the exam and treatment rooms. The medical assistant is responsible for disinfecting work surfaces in the exam room, including the examining table, sink, and countertop. As discussed earlier, disinfection involves exposing all parts of a surface to a disinfectant. Surfaces must be disinfected After an exam or treatment during which surfaces have become visibly contaminated with tissue, blood, or other body fluids. Immediately following accidental blood or body fluid spills or splatter. At the end of your work shift. In addition, routinely clean and disinfect the patient lavatory toilet and sink, and inspect and disinfect reusable receptacles like wastebaskets. Follow the schedule established by your office. Refer to Procedure 9-2 Guidelines for Disinfecting Exam Room Surfaces Refer to CONNECT to see a video on Guidelines for Disinfecting Exam Room Surfaces.

Infection Control (cont.) Storage Store biohazardous specimens properly Work practice controls Store testing kits properly Learning Outcome: 9.3 List steps to prevent the spread of infection in the exam and treatment rooms. Specimens must be handled and stored properly because they have the potential to be biohazards. Occupational Safety and Health Administration (OSHA) regulations require storing biohazardous materials separately from food and beverages. OSHA regulations also require that a warning label containing the biohazard symbol be clearly and securely posted on the outside of refrigerators, freezers, and cabinets where biohazardous materials are stored. Work practice controls represent safeguards to protect workers against the health hazards of bloodborne pathogens. They prohibit doing the following in a location where infectious materials are present: Eating Drinking Smoking Chewing gum Applying cosmetics Handling contact lenses Chewing pencils or pens Rubbing eyes Testing kit and specimen storage often involves refrigeration as a means of preservation. Adequate preservation requires maintaining careful temperature control in a refrigerator.

Putting the Room in Order Straighten and put items away Contributes to physical safety Housekeeping Learning Outcome: 9.3 List steps to prevent the spread of infection in the exam and treatment rooms. After ensuring that the examining table is clean, all surfaces are properly disinfected, and all necessary items are stored, take time to straighten the exam room and put things in order. This supports the impression of a well-run office and contributes to the physical safety of patients and staff. Tasks include the following: Putting the rolling stool in its place Pushing in the examining-table step Returning supplies to containers Securing sample medications and solutions, prescription pads if used, and other items that may have been left out Housekeeping Medical offices usually contract with a janitorial service for after-hours cleaning. Be sure the service cleans and sanitizes all areas adequately. Monitor their work and let the service know if there are any lapses in cleanliness. You may need to damp dust an open shelf to remove dust that harbors bacteria and allergens. It is important to keep the exam rooms as dust-free as possible.

Apply Your Knowledge Other than at the end of your shift, when should you disinfect the surfaces in the examination rooms? ANSWER: Whenever there is visible contamination with blood, body fluid, or body tissue. Learning Outcome: 9.3 List steps to prevent the spread of infection in the exam and treatment rooms.

Room Temperature, Lighting, and Ventilation Maintain examination room temperature at about 72°F Eliminate drafts Temperature Learning Outcome: 9.4 Describe the importance of temperature, lighting, and ventilation in the exam room. Adjusting the temperature, lighting, and ventilation is part of keeping the exam room in good order and fit for use. Be sure the exam room is warm enough. A warm room can help an anxious patient relax.

Lighting Accurate diagnoses Perform medical procedures Read orders and instructions Prevent accidents Learning Outcome: 9.4 Describe the importance of temperature, lighting, and ventilation in the exam room. If room has exam lamp with movable arm, be sure the arm is positioned appropriately. Replace all burned-out light bulbs as soon as possible.

Ventilation Examination area should smell clean and fresh Eliminate source of odors If opening windows, monitor room temperature Room deodorizer or spray Learning Outcome: 9.4 Describe the importance of temperature, lighting, and ventilation in the exam room. The air in the exam area should smell fresh and clean. If offensive odors develop, you must first eliminate the source of the odor. Some exam rooms have a ventilation system with an odor-absorbing filter. If not, you may be able to turn on a high-speed blower to vent room air to the outside. If necessary, you can temporarily mask unpleasant odors with a room deodorizer or spray which may also help kill germs. Be careful that the room deodorizer you choose does not have a strong odor.

Excellent! Apply Your Knowledge Why is it important to have good lighting in the examination room? ANSWER: Good lighting is needed for making accurate diagnoses, performing medical procedures, reading orders and instructions, and preventing accidents. Learning Outcome: 9.4 Describe the importance of temperature, lighting, and ventilation in the exam room. Excellent!

Medical Instruments and Supplies Maintain instruments and supplies Order and stock all needed supplies Sanitize, disinfect, and/or sterilize instruments as needed Instruments and supplies should be placed within easy reach for the physician Learning Outcome: 9.5 Identify instruments and supplies used in a general physical exam and tell how to arrange and prepare them. The medical assistant must maintain all instruments and supplies needed in the exam room. This responsibility involves the following three tasks: Ordering and stocking all supplies needed for exams and treatment procedures. Keeping the instruments sanitized, disinfected, or sterilized (as appropriate) and in working order. Ensuring all instruments and supplies are placed where the physician can easily reach them. Most instruments are either fine-grade stainless steel or disposable. Some stainless steel instruments have disposable parts. Discard disposable instruments and supplies according to OSHA guidelines.

Instruments Used in a General Physical Exam Purpose Anoscope Used to open the anus for examination Exam light Provides additional lighting Laryngeal mirror Reflects inside of mouth and throat Nasal speculum Used to enlarge the opening of the nose Ophthalmoscope Used to examine the inner eye surfaces Learning Outcome: 9.5 Identify instruments and supplies used in a general physical exam and tell how to arrange and prepare them. An anoscope is used to open the anus for an exam. An exam light provides an additional source of light during the exam. It is usually on a flexible arm to permit light to be directed to the area being examined. A laryngeal mirror reflects the inside of the mouth and throat for exam purposes. A nasal speculum is used to enlarge the opening of the nose to permit viewing. This type of speculum may consist of a reusable handle with a disposable speculum tip, or it may be a disposable one-piece unit. An ophthalmoscope is a lighted instrument used to examine the inner structures of the eye.

Instruments for a General Physical Exam (cont.) Purpose Otoscope Used to examine the inner ear Penlight Small flashlight used to view a small area Reflex hammer Used to check patient’s reflexes Sphygmomanometer Used to measure blood pressure Learning Outcome: 9.5 Identify instruments and supplies used in a general physical exam and tell how to arrange and prepare them. An otoscope is used to examine the ear canal and the tympanic membrane. The otoscope consists of a light source, a magnifying lens, and an ear speculum. An otoscope also may be used to examine the nostrils and the anterior sinuses. Like a nasal speculum, an otoscope has disposable tips. A penlight is a small flashlight used when additional light is necessary in a small area. It may also be used to check pupil response in the eye. A reflex hammer – used to check a patient’s reflexes and has a hard-rubber triangular head. A sphygmomanometer, or blood pressure cuff, is a piece of equipment used to measure blood pressure.

Instruments for a General Physical Exam (cont.) Purpose Stethoscope Used to listen to body sounds Tape measure Used to measure size or development of an area Thermometer Used to measure body temperature Tuning fork Used to test hearing Vaginal speculum Used to enlarge the vagina for specimens from cervix and vagina Learning Outcome: 9.5 Identify instruments and supplies used in a general physical exam and tell how to arrange and prepare them. A stethoscope is used to listen to body sounds. A tape measure is a long, narrow strip of fabric, marked off in inches and /or in centimeters. It is used to measure size or development of an area or part of the body. A thermometer is used to measure body temperature. A tuning fork tests hearing. A vaginal speculum is used to enlarge the vagina to make the vagina and the cervix accessible for visual exam and specimen collection.

Instruments for a General Physical Exam (cont.) Inspecting and maintaining instruments Arranging instruments Mounted on wall Out on countertop Set on a clean towel or tray Learning Outcome: 9.5 Identify instruments and supplies used in a general physical exam and tell how to arrange and prepare them. Inspecting and Maintaining Instruments Prior to the exam, make sure all instruments are sanitized, disinfected, or sterilized and in good working order. Medical instruments are expensive and are designed to work in precise ways. Read the manufacturers’ directions so you are familiar with the care and maintenance of various instruments. Arranging Instruments You can assist by placing instruments in the same place for every exam or by arranging them in the order used. Instruments are kept in one of three places during an exam: Mounted on the wall (sphygmomanometer, some otoscopes and ophthalmoscopes). Set out on the countertop (penlight, reflex hammer, tape measure, tuning fork, thermometer, some otoscopes and ophthalmoscopes). Set on a clean (or sterile, if appropriate) towel or tray (anoscope, laryngeal mirror, nasal speculum, vaginal speculum).

Instruments for a General Physical Exam (cont.) Preparing instruments Cleaning instruments Dispose of supplies in the appropriate containers Use approved procedures for sanitizing, disinfecting, and sterilizing Learning Outcome: 9.5 Identify instruments and supplies used in a general physical exam and tell how to arrange and prepare them. Preparing Instruments. You must prepare some instruments before they can be used. Any time you will be handling instruments, you must first wash your hands. If the instruments are sterile, you also must wear sterile gloves. Cleaning Instruments. After the exam, put used instruments in a container and take them to the cleaning area. Always handle instruments carefully because mishandling can alter their precision. Dispose of supplies in the appropriate containers, and use approved procedures for sanitizing, disinfecting, and sterilizing reusable instruments and equipment. Refer Table 9-3 General Guidelines for Cleaning Instruments.

Supplies for a General Physical Exam Needles and Syringes Curettes Cervical scraper Sterile and clean gloves Cotton balls Cotton-tipped applicators Gauze, dressings, and bandages Learning Outcome: 9.5 Identify instruments and supplies used in a general physical exam, and tell how to arrange and prepare them. Disposable supplies Specimen containers Paper tissues Glass slides Occult blood test slides Tongue depressors

Supplies for a General Physical Exam (cont.) Consumable supplies Fixative Isopropyl alcohol Lubricant Be sure patients do not have access to Prescription blanks Drugs Needles Learning Outcome: 9.5 Identify instruments and supplies used in a general physical exam and tell how to arrange and prepare them. Consumable supplies are items that can be emptied or used up in an exam. Fixative – a chemical spray used for preserving a specimen obtained from the body for pathologic exam Isopropyl alcohol – for cleansing skin Lubricant Certain supplies, like needles, medications, and prescription blanks, if used, should be kept in a locked cabinet away from patient access.

Supplies for a General Physical Exam (cont.) Store supplies Label drawers Put items back in correct place Routinely straighten and clean Restocking supplies Learning Outcome: 9.5 Identify instruments and supplies used in a general physical exam and tell how to arrange and prepare them. Storing Supplies – store every item in its own place so you can find it quickly. Restocking Supplies – be sure you have a sufficient quantity of items on hand, order new supplies well in advance of needing them. A record-keeping system will help you determine which supplies you need to restock most frequently and how long it takes for new supplies to arrive. Information needed for tracking supplies Types of supplies your office uses Quantities of each type of supply you use in a given amount of time Frequency with which you must reorder particular supplies Names of various suppliers, along with the amount of time it takes to receive your orders

Apply Your Knowledge Good Choices! A medical assistant is preparing the treatment room for a local ENT specialist. Which of the following instruments might be used in this office to assess patient ear, nose, and throat functioning? ANSWER: stethoscope nasal speculum reflex hammer otoscope penlight laryngeal mirror ophthalmoscope tape measure sphygmomanometer tuning fork anoscope *penlight *nasal speculum *laryngeal mirror *tuning fork Learning Outcome: 9.5 Identify instruments and supplies used in a general physical exam and tell how to arrange and prepare them. *ophthalmoscope *otoscope Good Choices!

In Summary 9.1 A typical examination room is about 8 by 12 feet, large enough to accommodate the physician, the patient, and one assistant. Instruments and equipment in the room should be easily accessible. 9.2 Sanitization is the scrubbing of instruments and equipment with special brushes and detergent to remove blood, mucus, and other contaminants or media where pathogens can grow. Disinfection uses special cleaning products applied to instruments and equipment to reduce or eliminate infectious organisms.

In Summary (cont.) 9.3 Steps involved in preventing the spread of infection in the examination room include covering the examination table with a paper cover and changing the cover between each patient. It is also important to disinfect all surfaces that come in contact with blood or body fluids after each patient, and at the beginning and end of the day. 9.4 It is important that patients feel comfortable in the examination room. A comfortably warm, well lit, and properly ventilated room will help the patient feel comfortable during his examination.

In Summary (cont.) 9.5 A variety of instruments and supplies are used in a general physical examination. To ensure the examination room always has the necessary instruments and supplies, the medical assistant should order and stock all supplies needed for examinations and treatment procedures; keep the instruments sanitized, disinfected, or sterilized and in working order; and place all instruments and supplies where the physician can easily reach them.

End of Chapter 9 As a general thing, an individual who is neat in his person is neat in his morals ~Henry Wheeler Shaw