clinical skills guide

PLEASE VISIT THE WEBSITE I HAVE CREATED FOR THIS COMPETITION ON

CLINICAL SKILLS: www.wix.com/leedsstudent/clinicalskills

ATTACHED BELOW, IS A COPY OF THE CLINICAL SKILLS GUIDE I HAVE CREATED (AVAILABLE FOR DOWNLOAD FROM THE

WEBSITE ITSELF)

http://www.wix.com/leedsstudent/clinicalskills

Clinical Skills Guide

Content

Hand washing……………………………………………………………………………………………………………………………….………1Aseptic Technique……………………………………………………………………………………………………………………...………..2Surgical Scrub……………………………………………………………………………………………………………………………………….3Vital signs: Temperature, Pulse, Respiratory Rate, Peak Flow…………………………………………………….………..4Blood Pressure……………………………………………………………………………………………………………………………………..5Intra-muscular injection – 90⁰…………………………………………………………………………………………………..………….6Subcutaneous injection – 45⁰……………………………………………………………………………………………………………….7Intra-dermal injection – 15⁰…………………………………………………………………………………………………………………8Recovery Position………………………………………………………………………………………………………………………………..9Managing the choking patient………………………………………………………………………………………………..…………..10BLS………………………………………………………………………………………………………………………………………………………11Blood Glucose…………………………………………………………………………………………………………………………..…………12Venepuncture (taking blood) …………………………………………………………………………………………………..…………13Cannulation (aseptic) ……………………………………………………………………………………………………………..……….…14Blood Cultures……………………………………………………………………………………………………………………………….……15ABGs………………………………………………………………………………………………………………………………………….……….16Urinalysis…………………………………………………………………………………………………………………………………….……..17ABPI…………………………………………………………………………………………………………………………………………….…....18Allen’s Test…………………………………………………………………………………………………………………………………...…..18Fundoscopy…………………………………………………………………………………………………………………………………...….19Rectal examination…………………………………………………………………………………………………………………..…….….20Breast examination………………………………………………………………………………………………………………………….…21Testicular examination…………………………………………………………………………………………………………………….…22Catheterisation…………………………………………………………………………………………………………………………………..23Performing an ECG……………………………………………………………………………………………………………………………..25Interpreting an ECG…………………………………………………………………………………………………………………………….26Interpreting a CXR………………………………………………………………………………………………………………………………29Giving information: Hypertension, Warfarin, 24hr Urine, Inhalers, Endoscopy………………………..………..30Reading obs charts................................................................................................................................30

RememberWhen being examined, easy marks can be given for:- Introduction, consent, patient identity, age, explanation, wash hands- Effective & empathetic communication with patient- Methodology – logical and fluent approach- Professional conduct – attitude, approach, professional manner- Thanking patient, and ensuring they are left comfortable- Documenting findings/completing all relevant paperwork- “Do you have any questions?” 1

Hand washing

Preparation

Roll sleeves up so you are bare from the elbows, remove jewellery and watch. Turn on the taps, using your forearms if possible, and adjust the water to the right temperature. Then wet your hands under running water. Apply the liquid soap and lather your hands thoroughly.

Step 1 Rub your palms together. Then rub your left palm over the back of your right hand. Then rub your right palm over the back of your left hand.

Step 2 Weave your fingers together and slide them backwards and forwards.

Step 3 Slide your hands palm over palm, grip the fingers of one hand in the fingers of your other hand and rub the backs of your fingers against the palms of your hands.

Step 4 Rub the tips of the fingers of your left hand on the palm of your right hand. Repeat for the fingers of the right hand.

Step 5 Rub your right thumb with your left hand and then rub your left thumb with your right hand.

Step 6 Rub your right wrist with your left hand and then rub your left wrist with your right hand.

RinsingRinse your hands and wrists under running water, keeping your hands pointing upwards, until all the soap has gone. Turn tap off with your forearms if possible or using a paper towel.

DryingDry all parts of your hands with disposable towels, keeping your fingers pointing upwards. Wipe from your fingers downwards to your wrist. Dispose of the hand towels in the bin using the foot pedal.

Setting up for an aseptic procedure

2

- Wash hands with soap and water- Clean trolley with sani-cloth wipes, top to bottom, back to front- Gather equipment on bottom shelf, checking integrity and expiry dates- Take trolley to bedside- Clean hands with alcohol gel and put on apron- Open sterile pack onto top shelf of trolley using edges of paper/plastic wrap- Open supplementary packs onto sterile field- Open gloves to side of sterile field- Clean hands with alcohol gel and put on sterile gloves

Surgical Scrub

3

Vital Signs

Recording the Temperature: Tympanic reading:- Explain and discuss the procedure with the patient- Wash your hands

4

- Apply a new disposable probe cover to the probe tip using the no-touch technique.- Switch thermometer on- Insert thermometer into ear, pulling backwards on ear, with the point of the probe directed

towards the back of the patient’s opposite eye, ensuring a snug fit.- Press and release scan button- Remove probe from ear once reading is taken (usually indicated by a bleep)- Remove probe cover by pressing release button and dispose in clinical waste.- Record temperature on relevant paperwork and note which ear temperature was taken in to

ensure continuity. (Normal 36.4⁰-37.3⁰)

Recording the Pulse:- Explain to the patient that you need to take their pulse.- Clean hands with hand gel- Identify an appropriate site at which to record pulse (usually the most accessible site)- Palpate the pulse for 30 seconds and multiply result by two. If the pulse is irregular, take pulse

for one full minute. (If this is the first time the patient’s pulse has been taken it should be palpated for a full minute.)

- Assess for rate and rhythm and record on appropriate paperwork/chart.

Recording Respiration:- Try to take whilst the patient is unaware. This may be done with the pulse, taking the pulse for

30 seconds and then counting respirations for 30 seconds whilst continuing to hold the wrist- Observe for pattern, abnormalities and depth.- Record on relevant chart/paperwork.

Peak expiratory flow:- Explain to the patient that you wish to record their peak flow and why.- Explain and demonstrate how to perform a peak flow monitoring- Ask the patient to stand (ideally) or sit upright.- Check that the peak flow monitor has a new, disposable mouthpiece- Tell patient that the gauge on the peak flow monitor is moved to zero.- Explain that the peak flow monitor should be held horizontal, holding the meter with fingers

away from gauge. The patient’s lips should be sealed around the mouthpiece in order to achieve an accurate reading. The patient should take a deep breath before blowing as hard and fast as possible into the mouthpiece.

- Demonstrate this to the patient before changing the mouthpiece and asking them to perform the same procedure.

- Ask the patient to repeat the process three times and record the best of these results on the appropriate charts/paperwork.

- If the patient is to record their peak flow at home, ask them to do so at the same time of the day as there is a diurnal variation.

- “Do you have any questions?”- Factors influencing peak flow: height, age, gender, smoking, COPD, acute respiratory infection,

poor technique.

Blood pressure

- Checks patient identity, gains consent, explains procedure, ensures patient comfort- Patient should rest for 3-5 minutes before blood pressure is measured to ensure accurate

reading.

5

- Explain to the patient what you will do and why you need to measure their blood pressure.- Wash your hands and clean your stethoscope- Ensure that tight or restrictive clothing is removed from the arm- Sit the patient comfortably with their arm supported at heart level, palm facing upwards. Use a

pillow or similar to support the arm. This will make it more comfortable for the patient so that they are less likely to move, which in turn will make it easier for you to record their blood pressure.

- Choose correct sized cuff to reduce risk of falsely high/low readings.- Apply the cuff to the upper arm, ensuring appropriate size is used and bladder of cuff is

centred over brachial artery.- Ensure that the cuff is high enough up the arm for you to be able to place the diaphragm of the

stethoscope over the brachial artery without it rubbing on the cuff. (This will create noise distortion and interference and make it more difficult to obtain an accurate reading.)

- Palpate the radial or brachial pulse. - Close valve of sphygmomanometer- Inflate the cuff until you can no longer feel the pulse. This gives an estimated systolic pressure.

(Avoids error caused by auscultatory gap)- Deflate cuff entirely.- Place the diaphragm of the stethoscope over the brachial pulse, close valve and re-inflate the

cuff to 20-30mmHg above the estimated systolic pulse.- Slowly deflate the cuff at a rate of about 2mmHg/second. - Note the systolic pressure on the gauge when two consecutive heart beats can be heard

(phase 1 of the Korotkoff sounds). Read to the nearest 2mmHg.- Continue to deflate the cuff, listening for when sounds disappear (phase 5). This is the diastolic

pressure. (Occasionally, especially in children and pregnant women, the last Korotkoff sounds continue, in which case phase 4 (the muffling) represents the diastolic.)

- Give measurement- If you need to take the BP again (if you missed the sounds) then deflate the cuff completely

and wait at least 30sec before trying again- If this is your first consultation with the patient, take a bilateral measurement. - Document findings, taking action as appropriate.

If the patient is hypertensive and /or appears anxious, repeat the measurement some time later in order to rule out ‘white coat hypertension’.

Intra-muscular injection

1. Introduction, check patient identity, give explanation and gain consent2. Check prescription (or drug chart):

- Against patient ID and wristband details

6

- drug dose- date/time- signature- allergies

3. Check drug and equipment:- drug name- dose/concentration- expiry date- integrity of packet- diluting agent needed?- debris or cloudiness in liquid drug

4. Ensure dignity and privacy of patient is maintained at all times. Do not administer IM injection in buttocks (chaperone needed) if it can be appropriately administered in deltoid, for example. Ensure patient is comfortable.

5. Explain procedure and gain verbal consent after patient has had opportunity to ask questions.6. Wash hands7. Gather and check equipment and place in tray.8. Put on non sterile gloves9. Attach green needle (21G) to syringe. Holding needle and drug vial vertical at eye level draw up

required quantity of medication.10. DO NOT RESHEATH NEEDLE. Remove needle by hand and dispose in sharps bin. Do not use needle

removal device on sharps bin at this point11. Replace with blue needle (23G). (Or a second green needle (21G) for pts with more considerable

SC tissue.)12. Expel air from syringe and prime the needle, ensuring correct amount of drug in syringe13. Choose and expose site. Check for skin integrity, haematoma, hardened skin, recent injection

sites, muscle wasting, increased skin turgor, infection (eczema, erythema), bruising, oedema, parastheriae/anaesthesiae. Consider underlying structures and anatomy.

14. Prepare skin using alcohol wipe in ever increasing circles. Socially clean skin does NOT require additional cleaning. Allow to dry completely.

15. Warn patient that they will feel a sharp scratch.16. Use thumb and forefinger to slightly stretch SC tissues.17. Insert needle at 90°, swiftly but gently, to approximately 2/3 the needle length, ensuring needle

tip is delivering drug to muscle layer.18. Aspirate. If blood is evident remove needle and apply pressure before continuing procedure with

clean equipment.19. If no blood is visible, slowly inject drug. The more viscous the drug is, the more slowly it must be

administered.20. Ensure medication does not leak from wound site – keep needle in situ for seconds after drug has

been administered. Remove needle and immediately press on puncture site with gauze swab. 21. Observe for localised or systemic reaction.22. Dispose of equipment in relevant clinical waste/sharps bin.23. Wash hands and record procedure appropriately.

Subcutaneous injection


- patient ID ( DO NOT rely on wristband details alone if patient is alert)

7



4. Ensure dignity and privacy of patient is maintained at all times. Do not administer IM injection in buttocks if it can be appropriately administered in deltoid, for example. Ensure patient is comfortable.



removal device on sharps bin at this point11. Replace with orange needle (25G). 12. Expel air from syringe and prime the needle, ensuring correct amount of drug in syringe13. Choose and expose site. Check for skin integrity, haematoma, hardened skin, recent injection sites

etc. Consider underlying structures and anatomy.14. Prepare skin, socially clean skin does NOT require additional cleaning. Allow to dry completely.15. Warn patient that they will feel a sharp scratch.16. Use thumb and forefinger to slightly pinch up SC tissues.17. Insert needle at 45°, swiftly but gently, to approximately 2/3 the needle length, ensuring needle

tip is delivering drug to SC layer.18. Remove needle and immediately press on puncture site with gauze swab. DO NOT rub area19. Observe for a localised or systemic reaction.20. Dispose of equipment in relevant clinical waste/sharps bin.21. Wash hands and record procedure appropriately.

NB: some subcutaneous injections are available in pre filled syringes, including heparin and insulin and should be injected at 90° to accommodate the short needle.

Intra-dermal injection


- patient ID ( DO NOT rely on wristband details alone if patient is alert)

8



4. Ensure dignity and privacy of patient is maintained at all times. Do not administer IM injection in buttocks if it can be appropriately administered in deltoid, for example. Ensure patient is comfortable.



removal device on sharps bin at this point11. Replace with orange needle (25G). 12. Expel air from syringe and prime the needle, ensuring correct amount of drug in syringe13. Choose and expose site. Check for skin integrity, haematoma, hardened skin, recent injection sites

etc. Consider underlying structures and anatomy.14. Prepare skin, socially clean skin does NOT require additional cleaning. Allow to dry completely.15. Warn patient that they will feel a sharp scratch.16. Insert needle at 15°, with bevel uppermost. Do not attempt to stretch or pinch up the

subcutaneous tissues.17. Depress plunger slowly. The injected fluid may cause a bleb to form beneath the skin. This is

normal; do not try to disperse it.18. Remove needle. DO NOT apply pressure or rub area19. Observe for a localised or systemic reaction20. Dispose of equipment in relevant clinical waste/sharps bin.21. Wash hands and record procedure appropriately.

9

Recovery Position

- Remove patient’s glasses, and empty keys, mobile phone etc from patient’s pockets.- Kneel close beside patient and straighten their limbs.- If the patient is on a bed, remove pillows to enable patient to lie flat.- Place the arm nearest to you at right angles to their body, elbow bent, palm uppermost.- Bring their other arm across their chest and hold the back of their hand against their cheek

nearest to you.- Reach across the patient, and with your other hand pull their furthest away knee up into

flexed position with their foot still on the ground.- Maintaining a hold of their furthest away leg just above the knee and their nearest hand

against their cheek, roll them TOWARDS you, using your own knees as a cushion prop to manage the speed with which they roll.

- Shuffle back from them as they roll onto their side, keeping their knee drawn up.- They should now be propped on their flexed knee (with that hip also flexed) and on the hand

which you held to their cheek.- Carefully tilt the head back to maintain an open airway.- Check their breathing at regular intervals until further assistance arrives and takes over.

N.B. May need to perform ‘DR ABC’ first (danger, response, airways, breathing, circulation); see Basic Life Support

10

Managing the Choking Patient

- Observe for general signs of choking (patient clutching throat, coughing)- Approach patient and ask, ‘are you choking?’- If patient can vocalise a response, this indicates obstruction is partial.

o Partial obstruction: encourage patient to cough whilst leaning forward. If patient is conscious and breathing, DO NOTHING MORE AT THIS STAGE.

- If patient cannot vocalise response, obstruction may be complete.o Complete obstruction, or if patient shows signs of exhaustion or becomes cyanosed,

carry out back slaps +/- abdominal thrusts:1. Remove obvious debris from mouth, including loose dentures2. Stand to side and slightly behind patient3. Support them by placing one arm across their chest and lean them forward4. Give up to five sharp back slaps between their scapulae with heel of your hand.5. After each slap, check their mouth for dislodged obstruction.6. If back slaps are ineffective, carry out up to 5 abdominal thrusts.7. Stand behind patient and put your arms around the upper part of their

abdomen.8. Lean patient forward.9. Clench your fist and place just beneath their sternum. Grasp your fist with your

other hand.10.Pull sharply upwards and inwards in order to expel air from lungs and so

dislodge obstruction.11.If one cycle of abdominal thrusts fails to remove obstruction, call for medical

back up.12.If abdominal thrusts are carried out, patient must be medically assessed to rule

out any trauma.- If obstruction is not relieved, recheck mouth for debris then carry out 5 back slaps alternated

with 5 abdominal thrusts until medical assistance arrives or until patient begins to lose consciousness.

- If patient loses consciousness, begin CPR starting with 30 chest compressions. It is not necessary to first check for signs of life in this instance.

11

Basic Life Support in a Clinical Setting

- Check for sources of DANGER to self, casualty and others (sharps, equipment leads, blood etc)- Approach patient and check for RESPONSE. Shake gently by both shoulders, speak loudly into

each ear.- If they respond, get them an urgent medical referral.- If no response, CALL FOR HELP. Ask for helper to stay in the vicinity whilst you assess for signs

of life.- Open AIRWAY using chin lift/head tilt. If there is a risk of c-spine fracture use jaw thrust to

open airway.- Remove any obvious obstruction from airway using forceps and suction where possible.

Dentures should be left in situ if well fitted as they will help maintain the structure of the face during resuscitation.

- Check for SIGNS OF LIFE by kneeling close by patient and:o Looking for chest rise and fallo Listening for breath soundso Feeling for their breathing on the side of your faceo Looking for signs of perfusion, coughing, limb movement.o Feeling for body warmth

- Palpating carotid pulse for signs of circulation- If patient is breathing normally and has a pulse they may need urgent medical attention. While

waiting for their arrival, assess the patient using ABCDE, give oxygen and insert a cannula, or put in recovery position.

- If there are no signs of life (no breathing, coughing, movement, no pulse), send the helper for the crash team/crash trolley (dial 2222 from the nearest hospital phone).

- Begin CPR at a rate of 30 compressions/ 2 breaths, beginning with compressions:o Compressions at a rate of 100/mino Compressions at a depth of 4-5cm (1/3 of the depth of the pt’s chest)

- Compressions should be carried out in the centre of the chest, fingers locked together and arms locked out. Press evenly and regularly, keeping your body weight over the centre of the patient’s chest.

- Breaths should be delivered slowly over approx 1 second. Always use a pocket mask or other airway adjunct in the clinical setting. Between each breath, turn your face away from the patient in order to inspire the next breath

- Continue until:o Help arrives and is able to take overo The patient shows signs of recoveryo You are too exhausted to continue.

NB: In a clinical setting it is never appropriate to perform mouth-to-mouth resuscitation.

12

Capillary Blood Glucose Measurement

Before the procedure: - Ensure that you understand how to use the monitor and lancets correctly- check that a quality control test has been carried out and recorded that day- check that the test strips are in date- check that the monitor and test strips have been calibrated together

- Explain procedure to patient and gain valid consent- Take test strip from tub and insert into glucometer.- Wash own hands and patient’s finger to be used.- Put gloves on- Prime the pen and attach a clean lancet- Choose site on patient’s finger on lateral side (furthest from their thumb).

o Site should be rotated from previous site to reduce the risk of infection, pain, and toughening of the skin from multiple stabbing

o It is less painful- Warn the patient what to expect and prick side of patient’s finger with lancet. Ask patient to

hang hand downwards and rub hand to increase blood flow if necessary.- “Milk” patient’s finger to extract large drop of blood, sufficient to cover the test pad in one go.

Hold the test strip in the glucometer against the drop of blood. The strip will draw up the appropriate quantity of blood.

- Whilst glucometer calculates a reading, apply pressure to puncture site and elevate patient’s finger. Ensure bleeding has stopped.

- Note the reading.- Dispose of contaminated equipment in relevant sharps/clinical waste bins.- Remove gloves. Wash hands.- Record on appropriate paperwork.- If blood glucose reading is outside normal parameters, act immediately on results. Repeat the

procedure after re-washing the patient’s hand; if still abnormal reading, seek medical help.

13

Venepuncture

- Introduce yourself to the patient- Check patient ID: Ask pt their name and DOB (don’t rely on wrist band)- Explain procedure and gain consent.- Ask/ assist patient to adjust clothing.- Wash hands and put apron on- Gather and assemble equipment, checking for integrity and expiry dates:

o Kidney disho Blood sample bottleso Gauze swabso Non sterile gloveso ChloraPrep for skino Plaster/micropore/cotton wool.o Sharps bino Needle o Vacutainero Tourniquet

- Position the patient so they are comfortable with the arm well supported- Identify suitable site and vein- Apply tourniquet- Clean skin with appropriate preparation and allow to dry thoroughly. Avoid re-palpating skin in

cleansed area.- Clean hands with alcohol gel and put on gloves- Anchor vein with non dominant thumb, supporting patient’s arm with fingers of same hand.- Insert needle into vein with bevel uppermost.- Hold vacutainer still, insert bottles as required and allow to fill (vacuum effect will draw

appropriate amount of blood). Ensure bottles are filled in correct order.- As last bottle is filling, release tourniquet.- Remove bottle and place in tray. Withdraw needle gently with dominant hand and as this is

done, press over puncture site with wad of gauze. Place needle immediately into sharps bin.- If patient is able to co-operate, ask them to press firmly on gauze for several minutes to

minimise bruising. DO NOT allow them to flex elbow as this will increase risk of bruising.- When bleeding has stopped, apply small dressing if required. Check patient feels well (not

faint)- Dispose of waste into sharps bin/ clinical waste/household waste as appropriate.- Label blood bottles and fill in blood forms at the bedside. - Ensure bag is sealed before dispatching to lab.- Wash hands.

14

Blood samples to be taken in the following order:1. Light blue (Sodium citrate: Coagulation tests, heparin & warfarin control)2. Black (ESR: paediatric ESR)3. Red (Serum: serum testing, no anti-coagulant)4. Yellow/Gold (SST 11: LFTs, U+Es, TFTs, Endocrinology, Serology, Immuno)5. Green (Heparin & PST 11: Genetics, homocysteine, ammonia, renin, aldost.)6. Purple (EDTA: FBC, adult ESR)7. Pink (Cross match: Blood group, cross matching)8. Grey (Fluoride Oxalate: Blood glucose, lactate)9. Royal Blue (Trace element: Trace element, toxicology)

Aseptic Cannulation

THIS IS A GUIDE ONLY. Variation in technique is acceptable. The important thing to remember is that this is a STERILE procedure. Maintaining patient dignity, safety and sterility at all times is more important than the precise method you use. Practise all the ways you have been shown and work out which is best for you. The actual contents of cannulation packs vary across sites. Ensure you are familiar with different types

- Check patient identity, explain procedure and gain consent- Wash hands with soap and water- Clean trolley, gather equipment on bottom shelf, check expiry dates and integrity of packaging

o cannulation pack, o saline flush, o syringe, o needle,o connection device,o tourniquet, o sharps bin, o alcohol gel, o sterile gloves

- Clean hands with alcohol gel and put on apron- Open cannulation pack onto top of trolley touching corners of pack only- Open rest of sterile equipment (cannula, needle and syringe, connection device) onto field- Check and open saline flush and place to side of sterile field- Open sterile gloves to side of sterile field- Clean hands with alcohol gel- Select an appropriate vein. Apply tourniquet.- Clean hands with alcohol gel and put on sterile gloves- Clean the patient’s skin with ChloraPrep and allow to dry,- Meanwhile, draw up saline flush using the syringe. Do not touch the non-sterile ampoule. Do

not place needle back onto sterile field- dispose in sharps bin. Prime connection device and replace on sterile field with syringe

- Place sterile towel (as preferred)- Applying skin traction, insert cannula at 30° angle looking for flashback in chamber. Once

flashback is seen, lower insertion angle, and advance cannula another few mm. Holding cannula securely, withdraw inner needle slightly, then advance the cannula down the vein

- Release the tourniquet with non dominant hand- Occlude the vein with fingertip pressure above the cannula tip using non dominant hand, then

remove the needle fully and place in sharps bin- (Depending how you have used the sterile towel, you may now have non-sterile hands. If so, a

non touch technique should be used from this point)

15

- Attach primed connection device with clockwise turn, using dominant hand.- Flush cannula with 5-10mls of 0.9% normal saline. (Remember to prescribe this on the

prescription sheet) If patent, secure cannula with provided dressing, ensuring date label does not obscure insertion site.

- Ensure patient is comfortable- Dispose of waste appropriately and clean trolley.- Remove gloves and apron and wash hands with soap and water. - Fill in cannula documentation record and file in notes

Blood Cultures

- Introduce yourself to the patient- Check patient ID: Ask pt their name and DOB (don’t rely on wrist band)- Explain procedure and gain consent.- Ask/ assist patient to adjust clothing.- Wash hands and put apron on- Gather and assemble equipment, checking for integrity and expiry dates:

o Kidney disho Gloves (non sterile)o Tourniqueto ChloraPrepo Gauze/plaster/Cotton woolo Blood culture bottleso Alcohol wipeso Closed vacutainer system (butterfly)o Sharps bin

- Position the patient so they are comfortable with the arm well supported- Identify suitable site and vein- Apply tourniquet- Clean skin over appropriate vein. Allow to dry. DO NOT REPALPATE.- Gel hands and put on gloves- Remove caps from blood culture bottles and clean rubber tops- Anchor vein with non dominant thumb, supporting patient’s arm with fingers of same hand.- Insert butterfly into vein with bevel uppermost.- Holding butterfly still, insert culture bottles into vacutainer system (aerobic first), holding

bottles upright. Allow to fill. - As last bottle is filling, release tourniquet.- Remove bottle and place in tray. Withdraw needle gently with dominant hand and as this is

done, press over puncture site with wad of gauze. Place needle immediately into sharps bin.- If patient is able to co-operate, ask them to press firmly on gauze for several minutes to

minimise bruising. DO NOT allow them to flex elbow as this will increase risk of bruising.- When bleeding has stopped, apply small dressing if required. Check patient feels well (not

faint)- Dispose of waste into sharps bin/ clinical waste/household waste as appropriate.- Remove gloves and wash hands- Label blood bottles and fill in blood forms at the bedside. - Ensure bag is sealed before dispatching to lab.

16

Arterial Blood Gases

- Introduce self, and establish correct patient- Explain procedure, get consent, get an assistant- Clean hands with alcohol gel- Perform Allen’s Test. Do not proceed if abnormal result.- Wash hands with soap and water- Gather equipment - Gloves (non sterile), Sharps bin, ChloraPrep, Lignocaine (if used), ABG syringe pack, Heparin

1000u/ml (if heparinised syringe not used), Needle (if not in pack or need to draw up heparin), Gauze

- Clean hands with alcohol gel and put gloves on- Position patient’s arm with wrist extended and palpate radial artery- Clean the site with ChloraPrep for 30 sec and allow to dry- (Inject lignocaine if used.) - (Heparinise syringe if applicable and change needle)- (Expel liquid heparin through clean needle)- DO NOT REPALPATE ARTERY AT PUNCTURE SITE. Fix artery between index and middle fingers

of non dominant hand- Warn patient to expect a scratch- Insert needle at 60⁰, in opposite direction to blood flow, until you obtain pulsatile flashback.- Allow syringe to fill with 2ml blood (gentle aspiration may sometimes be required).- Withdraw needle, placing gauze over site.- Apply firm pressure for at least 5 minutes (longer if coagulopathy or on anticoagulants); can

ask assistant to do this- Dispose of needle, replace with filter cap and expel any air from syringe HOLDING THE

SYRINGE VERTICALLY.- Take/send immediately for analysis. (Label sample with patient details, date, time, inspired O2

and temperature)

17

Urinalysis

Urine samples should be collected in a clean dry container. The sample should not be more than 4 hours old at the time of testing.

- Provide patient with a clean urine pot. Explain that you need a mid stream sample of urine.- Wash own hands and put non sterile gloves and an apron on.- Note for clarity, transparency, particles, and colour before removing lid of container.- Remove lid of container and check any obvious odour.- Check multistix container is intact and in date. DO NOT use if stored in humid environment or

if out of date as accuracy of results cannot be guaranteed.- Remove a strip from the container and replace lid (to avoid degeneration of test strips)- Dip test strip into urine to wet all the test zones. Do not leave in the urine for more than one

second.- Remove strip from urine and drag the edge of the strip along the rim of sample bottle to

remove excess urine.- Replace lid.- Take note of the time and compare test zones on strip against those on the multistix container

at the appropriate time. BE ACCURATE IN YOUR TIMING.- Comment on findings and note any abnormalities.- Dispose of waste appropriately. (Urine down sluice or toilet, container into clinical waste bag,

fold test strip inside gloves as you remove them)- Wash hands.- Record results.

Other tests: microscopy, culture and sensitivity, cystoscopy, rectal examination of prostate

18

Substance Name of Condition

Possible Causes

Glucose Glycosuria Diabetes MellitusKetones Ketonuria Starvation, untreated diabetes mellitusSpecific gravity Ranges from 1.001-1.035 according to how concentrated the urine isBlood/Erythrocytes Haematuria Bleeding in urinary tract, kidney stones, UTI, traumaPH Normally urine slightly acidic (pH 6) Vomiting and bacterial infection

can cause urine to become alkalineProtein Proteinuria Severe hypertension, UTI, asymptomatic renal disease, may be seen

in high protein diets and pregnancy, vaginal discharge. Nitrites Bacteriuria UTI Leucocytes Pyuria UTIBile pigments Bilirubinuria Liver disease, obstruction of bile ductsHaemoglobin Haemoglobinuria Transfusion reaction, haemolytic anaemia, severe burns

Ankle- Brachial Pressure Index (ABPI)- Introduce yourself- Explain procedure and get consent- Wash hands and clean the Doppler probe - Position patient at 45° with sleeves and trousers rolled up, allowing them 20-25 minutes rest

before starting the procedure. Room should be warm.- Place appropriate sized blood pressure cuff around arm- Locate brachial pulse by palpation and apply contact gel at this site- Angle doppler at 45° to skin and locate best possible signal- Inflate the blood pressure cuff until the signal disappears- Slowly deflate the cuff until the signal reappears. Record this pressure- Repeat on the opposite arm- Retain the highest reading- Place appropriate sized cuff around ankle- Locate dorsalis pedis pulse by palpation, apply gel and locate best signal with Doppler- Inflate cuff till signal disappears- Deflate cuff, recording pressure at which signal reappears- Repeat procedure for posterior tibial pulse on the same leg- Retain the higher reading from the two pulses- Repeat on the opposite leg- Clean the gel off the patient and allow them to redress. Ensure they are comfortable.- Clean the gel off the Doppler probe- Wash hands- Calculate the ABPI for both legs:

Right ABPI = highest of right ankle pressures (dorsalis pedis OR posterior tibial) highest of arm pressures

Left ABPI = highest of left ankle pressures (dorsalis pedis OR posterior tibial) highest of arm pressures

Normally the systolic BP in legs ≥ arms so a normal ABPI should be ≥1 in the supine position.ABPI is a sensitive marker of arterial insufficiency. Typical values of ABPI are:

≥1 = Normal<0.9 = Abnormal0.5 – 0.9 = Claudication<0.5 = Critical Ischaemia

19

NB: In diabetics, systolic BP in lower limbs is sometimes not measurable as arteries are calcified and difficult to compress (false normal result?). Pole test can be used

Allen’s Test- Patient elevates hand and makes fist for 20 sec,- Firm pressure applied to radial and ulnar arteries,- Patient opens hand which should blanch white, - Release ulnar compression and hand should regain normal colour within 5-7 sec- Abnormal result: hand remains white until radial pressure released. - Repeat for checking radial artery patency by releasing compressed radial artery.

Fundoscopy

- Introduce yourself, check patient ID, explain procedure, gain consent

- Check that ophthalmoscope is working; check batteries, bulb and settings.

- Ask patient if they wear contact lenses or glasses. Patient should remove glasses but leave contact lenses in situ. If the patient is extremely short sighted it may be easier to view the fundus whilst they are wearing their glasses.

- Ensure optimal lighting conditions – dim lights to dilate patient’s pupils.- Position patient (sitting, looking straight ahead). Ask patient to focus on something behind

examiner’s head and tell them to blink and breathe normally. Examiner positions self face to face with patient at eye level, on side to be examined.

- Place your free hand against patient’s forehead so at arm’s length from patient. You can then use thumb of this hand to lift patient’s eyelid when necessary.

- Whilst examining, examiner should attempt to keep both eyes open as this will reduce eye fatigue. Hold ophthalmoscope to your right eye in right hand to examine pt’s right eye and vice versa for left eye.

- Turn ophthalmoscope on, adjust to largest (NOT brightest) light source and rack lenses to 0.- Hold ophthalmoscope with index finger resting on focusing wheel and thumb on on/off

switch.- Use thumb to adjust brightness of beam. Too bright a beam is uncomfortable.- Direct beam of light onto pt’s eye from arms length away and from an angle of 15-20° towards

the nose. Move slowly in towards pt’s eye.- This directs beam towards optic disc.- Look for red reflex and use it to guide you closer to pupil. Observe shape and opacity (eg

advanced cataract)/transparency of red reflex. Should be round and clear- Move in close to pt’s eye. If both you and the patient have an eye prescription, add these

together and use the focusing wheel to adjust the lenses accordingly (EG: Patient prescription = +1, your prescription = -1, set dial at 0)

- Observe disc:o Contour (margin, size and shape)o Colour and clarityo Cup (optic cup to disc ratio): Cup is in centre of optic disc, should be < ½ diameter of

the disco Elevation of obscuring vessels at disc margino Papilloedema

20

- In order to facilitate observation of quadrants of eye for features of vessels and spaces, ask patient to look up/down/side to side.

o Observe vessels and comment: AV ratio 2:3, AV crossing/nipping – indentations? Arterial light reflex? - Copper/silver wiring? Arteries/veins: how many? Straight/tortuous? Normal calibre? Narrowing of arteries? New vessel formation? Venous pulsation

o Observe spaces and comment: Micro aneurysms? Dot, blot or flame haemorrhages? Cotton wool spots, Hard exudates?

- Fundus background: Exudates? Haemorrhages? Colour- red/purple?- Observe macula (which is temporal to the disc). Ask patient to look directly at the light source

to bring fovea into view and adjust it to the smallest setting: Colour? Any vessels around macula? Pigmented? Any degenerative changes? Can you see the foveal reflex? Haemorrhages? Hard exudates?

- Complete process on one eye and repeat on other eye (your left eye to examine patient’s left eye. Adjust seating accordingly).

- Document and discuss findings as appropriate.

- Pathologies: papilloedema, hypertensive retinopathy, diabetic retinopathyDigital Rectal Examination

- Introduce yourself- Explain procedure, gain consent, reassure patient. Provide chaperone.- Ensure privacy, dignity and comfort. Advise patient which clothing they need to remove. Allow

them time and privacy to do so.- Gather equipment:

o Lubricanto Non sterile gloves and aprono Gauze/tissueso Disposable continence pad.

- Wash hands and put on gloves and apron- Position patient- left, lateral position with knees and hips flexed and place disposable

continence pad beneath patient’s hips.- Inspect general area of buttocks, observing for pressure sores, indications of personal hygiene,

muscle wasting etc.- Part buttocks and inspect perianal area for:

o Warts, Threadwormso Anal fissureso Ulcerso Excoriation (surface injury – from itching?)o Haemorrhoidso Fistulaeo Pressure soreso Dischargeo Polyps, Skin tagso Prolapse (incomplete, complete or concealed)o General hygiene

- DO NOT proceed with digital rectal examination if patient has fistulae, excessive rectal bleeding, history of 3rd degree heart block or autonomic dysreflexia.

- Apply lubricant to gloved index finger. Warn patient they may feel rectal fullness so feel the urge to defaecate.

- Ask patient to take a deep breath and place finger into rectum to first joint of finger, asking patient to bear down if necessary to relax sphincter.

21

- Test sphincter tone: “can you squeeze my finger with your back passage?”- Advance finger further into rectum.- Perform 180° posterior sweep of rectum and describe findings:

o Smooth/pliableo Lymph nodeso Abscesseso Polypso Faeceso Does patient experience any pain? Tenderness?

- Turn arm to perform 180° sweep of anterior aspect of rectum and describe findings. - In a male patient: Prostate (benign hypertrophy? Nodules – cancerous?)

o Pliability of prostate, location, tenderness, size, regularity of shape, consistency – smooth, rubbery, nodularity, symmetry, presence/absence of medial sulcus.

- Slowly withdraw finger and examine for blood, mucus, faeces or pus.- Clean patient using wipes then cover the patient. Allow them time to redress. - Remove apron and gloves and wash hands- Discuss findings as appropriate and document

Breast Examination

- Introduce yourself, patient ID- Explain procedure and gain consent, reassure patient- Ensure dignity, privacy and comfort at all times.- Advise patient which clothes they need to remove and allow time to do so in privacy. Provide

them with sheet or blanket with which to preserve their modesty.- Provide chaperone.- Wash your hands- Position patient sitting on edge of bed or chair, naked to waist. - Observe for:

o symmetry of breast tissue, o altered pigmentation, skin changeso venous pattern or localised hypervascular areas, o nipple discharge or bleeding,o nipple retraction or deviation, o rash on areola or nipple, o changes in breast size or shape, o oedema of the skin with dimpling - peau d’orange o obvious lumps/swellingso inflammation, paino Abnormal reddening, thickening or ulceration of the areola (Paget’s disease)o Ask if any pain or ‘tugging’ sensation is experienced.

- Consider the list above. Certain features may be present in some positions and not others. o At rest - Ask patient to place hands resting on thighso Ask patient to raise arms above head.o Ask patient to place hands on hips and press inwards. o Ask patient to lean forwardo Ask patient to lie in supine position with arms flat along sides.

- Explain you will first examine the ‘normal’ breast in order to determine breast tissue changes. - Ask patient to place hand behind head on side you wish to examine if this is the preferred

procedure of the consultant. - Ask the patient to tell you if they have any pain or discomfort

22

- Palpate with palmar surface of middle three fingers. Use rotary movement to compress tissue gently against chest wall.

- Observe for lumps:o Estimate its sizeo Describe texture/consistencyo Describe shapeo Is it tethered to underlying tissue?o Is it tender?o Comment on mobilityo Describe location in relation to clock face, using nipple as the centre

- Examine:o Quadrantso Areolar areao Tail of Spence (between finger and thumb)o Lymph nodes: Anterior axillary, posterior axillary, apical, supra-clavicular, infra-

clavicular, nodes on medial aspect of humerus- Examine other breast and compare/contrast findings- Wash hands.- Describe/document findings.- End pieces: Check liver and spine for mets, Triple assessment incl mammogram, FNA

Testicular Examination

- Introduce yourself- Explain the procedure, Reassure the patient, Obtain verbal consent - Identify the need for a chaperone- Wear gloves- Inspect for:

o Skin changes (pigmentation, ulceration, erythema)o Symmetry o Lie of testeso Oedema/swelling

- Check whether patient has any pain before proceeding with palpation- Palpate:

o Testes o Epididymiso Spermatic cord

- Identify what they are looking for/describe findingso Observe for signs of discomfort o Is the testis palpable as a discrete organ? (Would not be with hydrocele)o Size and consistency of testeso Describe location of mass or lumpo Estimate size of any mass in centimetreso Describe the textureo Describe the shapeo Is it tethered to underlying tissue?o Is it tender? o Comment on mobilityo Can you get above the swelling? (It is possible to ‘get above’ a testicular swelling but

not a scrotal hernia)- Perform trans illumination of both sides of the scrotum in the presence of a swelling

o Place pen torch light up against the swellingo Cystic swelling will spread bright red glow into scrotum, a solid tumour will not

23

- Check for cough impulseo Place two fingers on the mass and determine whether an impulse is transmitted to the

fingertips when the patient coughs (would be present with a hernia)- Describe findings ---------

- Cover patient- Remove gloves and wash hands- Maintain patients dignity throughout - Attempt diagnosis

Urinary Catheterisation

Catheter packs and actual insertion technique may vary across sites. The important thing to remember is that this is a STERILE procedure. Maintaining patient dignity, safety and sterility at all times is more important than the method you use. Practise all the ways you have been shown and work out which is best for you.

- Introduce yourself- Explain procedure to patient (including patient education) and gain verbal consent. Identify

need for chaperone.- Encourage patient to have a shower or bath before catheterisation if possible.- Wash hands with soap and water and clean trolley using appropriate technique- Place all necessary equipment on bottom shelf, checking integrity and expiry dates

o Sterile catheter packo Disposable pado Sterile gloves (x2 pairs)o Cathetero Lubricating/ anaesthetic gelo Specimen container if specimen is required.o 0.9% sodium chloride or antiseptic solutiono 10mls water for injection and syringe (if not provided with catheter)

24

o Hand gelo Aprono Drainage bag and stand.o Clinical waste bag

- Screen bed, assist patient into supine position. DO NOT expose or position patient at this stage.

- Wash hands.- Open outer cover of catheterisation pack and slide contents onto top shelf of trolley using

aseptic technique. Open inner cover of catheterisation pack holding only the edges of the paper or plastic wrap. This is now your sterile field.

- Open supplementary packets onto sterile field. Retain catheter packet for notes.- Pour cleaning solution into gallipot from a height of several cms.- Place a disposable pad beneath patient’s buttocks.- Wash hands.- Open sterile gloves onto another trolley and put gloves on.- Arrange equipment on sterile field. Tear end off inner wrapping of catheter to expose tip and

place catheter in receiver- Now ask chaperone to expose the patient- Refer to male/female procedures as follows:

FROM THIS POINT, MAINTAIN YOUR DOMINANT HAND AS THE UNCONTAMINATED ONE THROUGHOUT THE PROCEUDRE.

Male Catheterisation Procedure- Use sterile swab to wrap around penis and retract foreskin.- Position drape on patient so that urethra is accessible.- Clean glans penis with saline solution. Work away from urethra and avoid going back over

same area twice. Discard used swabs into clinical waste.- Ensure dominant hand does not make contact with patient or bed linen.- Using a swab to hold the penis, hold the penis in a raised position and DROP small amount of

anaesthetic /lubricant gel around urethral opening before administering 11mls of the gel into urethra. Ensure that tip of nozzle does not touch penis. Discard into clinical waste.

- Wait 3-5 minutes for anaesthetic to work, continuing to hold penis so that it is almost completely extended.

- Change gloves- Place the receiver containing the catheter between patient’s legs.- You can now either remove catheter from blue wrapping and coil it within palm of dominant

hand with tip protruding, or insert catheter into urethra directly from inner wrapping.- Insert catheter for 15-20cm along urethra. If resistance is felt at the external sphincter, ask the

patient to gently strain as if passing urine. If this is painful or ineffective, seek expert assistance.

- When urine begins to flow from catheter, advance almost to its bifurcation.- Inflate balloon using 10mls (or specified amount) of sterile water. There should be no

resistance.- Withdraw catheter slightly until it is evident that the balloon is inflated within the bladder.

25

- Reposition foreskin.- Connect to catheter bag and support bag using catheter stand or leg straps.- If requested, take urine sample from catheter via port using green needle and syringe.- Tidy area and dispose of waste appropriately.- Remove gloves and wash hands. - Record relevant information and guidance for aftercare in notes.

Female Catheterisation Procedure- Position drape to expose urethra.- With patient in supine position, separate labia minora using a swab so that the urethral

meatus can be seen- Use sterile swabs and 0.9% sodium chloride to clean urethral orifice, working in single strokes

down.- Discard swabs in clinical waste.- Drop small amount of anaesthetic /lubrication gel around urethra and then administer 6ml of

it into urethra.- Wait 3-5 minutes.- Change gloves- Place receiver containing catheter between patient’s legs- Introduce tip of catheter into urethra in an upward and backward direction. - If catheter is wrongly inserted into vagina, leave it there whilst introducing a second, clean

catheter into the urethra, and then remove the wrongly situated one.- Advance the catheter until 5-6cm has been inserted and urine begins to flow.- Advance a little further and inflate the balloon. There should be no resistance.- Withdraw the catheter slightly to check it is in situ.- Connect to catheter bag.- Support the catheter bag either on a stand or using leg bag straps.- Clean the patient and the area, disposing of clinical waste appropriately.- Take urine sample for laboratory specimen via the specimen port.- Remove gloves and wash hands- Record relevant detail in patient’s notes

Performing an ECG

- Introduce self and ensure correct patient.- Explain procedure and gain verbal consent.- Prepare pt ensuring comfort, dignity and privacy. Provide chaperone where appropriate.- Advise pt what clothing and jewellery they are required to remove. Wash hands.- Ask pt to lie flat on couch and advise them to keep limbs relaxed. Prepare skin: body lotions

and oils may need to be removed to allow adhesion of electrode pads. It may be necessary to shave chest hair.

- Plug ECG machine in. Check that the machine is correctly calibrated (25mm/s, 10mm/mV).- Apply electrode pads to limbs on a bony prominence and apply limb leads:

o right wrist = REDo left wrist = YELLOWo left ankle = GREENo right ankle = BLACK (This is the anti-static or earth electrode)o (In amputees, place on the most distal bony prominence)

- Apply chest electrode pads and apply chest leads;o V1: 4th intercostal space, right sternal edgeo V2: 4th intercostal space, left sternal edgeo V3: Midway between V2 & V4o V4: 5th intercostal space, mid clavicular line o V5: Midway between V4 & V6

26

o V6: 5th intercostal space, mid axillar line- Start machine. Remember to ask the patient to lie as still as possible.- Accurately record 12 lead ECG.- Remove wires from pt’s limbs and chest. Remove pads from patient, taking care not to pull

skin/hair.- Give patient privacy to dress before advising them where to go/what to do for results.- Write patients details onto print out if not already on.- Accurately complete all relevant documentation- Thank patient, ensure they are left comfortably.

27

- Interpreting ECGs

10 physical leads with attached electrodes, but 12 lead readings:- Peripheral limb electrodes:

Right Arm Red RideLeft Arm Yellow YourLeft Leg Green GreenRight Leg Black Bike

- Electrode positions on the heart: V1 4th intercostal space, right sternal border Right ventricleV2 4th intercostal space, left sternal border Right ventricleV3 Inbetween V2 and V4 Interventricular SeptumV4 5th intercostal space, mid-clavicular line Interventricular SeptumV5 Inbetween V4 and V6 Left ventricleV6 5th intercostal space, mid-axillary line Left ventricle

ECG Axis – shows the direction of the readings taken, eg from left arm to right arm. These readings are shown on ECG print outs as shown below.

INTERPRETATION

28

1.

Demographics: - Name, DOB, date and time of ECG, indication for ECG, any symptoms- Check there is electrical activity in every lead and that calibration is correct: 25mm/s

paper speed, 10mm/mv amplitude reference

2. Rate: - 300/no of big squares between each R peak= ... bpm- (300 is worked out from 5 big squares being written per second, therefore 300 big

squares are written in 1 minute). Eg 300/4 = 75 bpm

3. Rhythm: - Mark out on a piece of paper the peaks of a few QRS complexes from lead II, and

compare to the rhythm strip to see if regular or irregular- Regular- Irregular

o Regularly irregular → Heart blocko Irregularly irregular → AF (no P waves will be visible)

4. Axis

29

Represents the general direction in which electrical activity spreads across the heart:- If both lead I and aVF are positive, the axis is normal.- If lead I is positive and aVF is negative, the axis is deviated to the LEFT- If lead I is negative and aVF is positive, the axis is deviated to the RIGHT

5. P-waves:Are they present?- Yes? Before every QRS? Patient is in sinus rhythm- No? → AF

Is there a P-wave before each QRS? No means heart blockP-waves should be upright in leads I, II and V2-V6.Bifid P-waves = left atrial hypertrophyPeaked P-waves = right atrial hypertrophy

6. P-R interval:Should be 120-200ms (<1 big square or 3-5 small sqs)How long does it last?- If >200ms then it is 1st degree heart block- If <120 then accessory pathway problems eg Wolf-Parkinson-White syndrome

Is it the same each time?

7. QRS complex:Should be <120ms (3 small squares)Is it <120? - If >120 then bundle branch block (BBB), or a depolarisation originating in the

ventricles.How big is the QRS complex? If it is big, left ventricular hypertrophy

8. ST segment:Is ST segment isoelectric with the baseline (before P-wave)?- ST segment elevation? → ischaemia? Infarct? MI- ST segment depression? → ischaemia? Angina

9. T-wave:Should be upright in leads I, II and V2-V6Does it go up? Does it go down?- T-wave inversion is a sign of an old MI/ischaemia

Is it pointy/”tented”? → hyperkalaemiaIs it flat? → hypokalaemia

10. QT interval: Measured from start of QRS, to end of T-wave. Varies with rate.Should be 380-420ms (2 large squares)How long is QT duration? - If >420ms, then Long QT Syndrome or propensity to develop ventricular tachycardia

which can cause sudden death

Interpreting Chest X-Rays/Radiographs

30

- Patient credentials, name, gender, DOB, age; date of CXR, which hospital- Posterior anterior (PA) or Anterior posterior (AP)?- Supine or erect?- Comment on quality of the film:

o Are clavicles visible and equidistant from the spinous process? (rotation)o Are five anterior ribs visible? (expansion)o Are all the lung edges are visible? (centering)o Are the vertebral bodies of the dorsal spine visible and also the left hemi diaphragm?

(exposure/penetration)- Is trachea central?- Is the mediastinum not displaced?

o Cardio thoracic ratio <1:2?o Is two thirds of the heart are visible on the left hand side?o Are right atrium and left ventricle are visible?

- Are the hila normal?o Are the hila concave and both symmetrical in appearance?o Is the left hila is no more than 1.5cms higher than the right?o No sign of lymphadenopathy at hila?

- Mediastinal contours normal? Eg aortic knuckle- Do the lungs appear clear?

o Any opacities? Homogenous? Heterogenous?o Is there no distortion of the lung or lung fields?o Is there no sign of depressed hemi diaphragm?o Are Costophrenic angles and cardiophrenic angles nice and crisp?o Is there no fluid trapped beneath the lungs/diaphragm?

- Do the pleura appear normal?o No pneumothorax or pleural effusion?o Thickening?o Calcifications?

- Is there no free air under the diaphragm? (if free air was present this would be indicative of perforated bowel) However there is a visible air bubble- gastric bubble.

- Do the bones and soft tissue appear normal?o Any fractured ribs/clavicles?o Both breast shadows are present (female)? Mastectomy?o Do bones do appear destroyed or tissues sclerotic?

- Review areas if no abnormalities found:o Soft tissueo Bones o Tracheao Mediastinumo Pleura/Apiceso Diaphragmo Behind the Heart

31

Giving Information

- Possible topics: a new diagnosis, explaining a procedure, explaining a medication regime, teaching (eg hypertension, warfarin, 24hr urine collection, inhalers, endoscopy)

- Establish patient’s present understanding and ideas: “What do you know about… before we begin?”

- “Sign-post”/structure: introduction, establishes the purpose of the interview- “Feel free to stop me if you have any questions”- Explain +/- demonstrate: gives accurate and appropriate information, explains in a way the

patient can understand (language, vocab, drawings), at the correct pace.- Clarifies patients understanding: “Did that make sense/do you understand?” - Checks for concerns and addresses them: “Do you have any questions?”

Reading Obs Charts

- Patient credentials- Check how frequently obs should be taken (4 hour is the standard but Drs can increase this)- Time of day- Temperature (any spiking? Septic?)- Blood pressure (any drops? Bleed? Septic?) (marked with a dotted line between 2 crosses)- Pulse- Respiratory Rate- O2 sats (normal- 94-98, COPD 88-92)- Consciousness- MEWS – what is the trend? What are they previously mewsing at?- Extras: eg urine - Are obs stable/within normal parameters?- FOLLOW THE PATTERN OF EACH

32

clinical skills guide

Documents