osces urine dipstick and inhaler

8/2/2019 OSCEs Urine Dipstick and Inhaler

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OSCE notes:

16 stations - 6 minutes

1. Focused history taking

2. Long history taking (asthma, angina, hypertension, stroke)

3. Psychiatric history taking

4. BP measurement

5. Hand hygiene

6. Basic life support

7. Urine or BMI or Asthma: Peak flow and inhaler

8. Blood film or growth chart or histology

9. E-OSCE (information retrival)

10. Movement disorders

11. Exploring

12. Explaining (asthma, Hypertension, Diabetes)

13. Sensory awareness (Lip reading or visual impairment)

14. Skeletal anatomy (pelvis, limbs, skull)

15. Surface anatomy (back, chest, neck limbs)

16. Organ anatomy (lung, heart, female pelvis)


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1: HISTORY TAKING:

Chest pain remember to characterise pain, cardiac risk factors including other medical problems, askabout nausea / vomiting and any recent travel or immobility.

Asthma, characterise admissions, how often, peak flow and what is normal for them, their trigger, whatthey were doing when an attack occurred and their current medication.

Hypertension characterise symptoms if any, cardiac events, medication and cardiac risk factors.

Introduction: Age, Name, Occupation

Presenting complaint (PC): Why did you come in today?

History of PC: When? Sudden? What is it like? Intermittent or constant? How long ago?

Site Onset Character Radiation Association;Timing Severity

Does it wake you at night?

Does it stop you doing what you are doing at the time?

DO YOU KNOW WHAT IT IS?

Past Medical History:Any previous medical problems, admissions or surgeries?

JAM THREADS (Jaundice, Anaemia, MI, TB, Hypertension, Rheumatic fever, Epilepsy, Asthma,Diabetes, Stroke)

Family history: Any illnesses in the family? Are your parents still with us? What did they die of?

Drugs: Are you taking anything? Have you been taking anything else? How about the oral contraceptive pill?Over the counter?

Smoking, drugs, alcohol, allergies:

Social history: Smoke? How many a day? Drink? How many in an average week? Do you take anythingelse? (what, when, how much etc.) Have you travelled recently?

How are things at home?

Summary

2: LONG HISTORY TAKING: SYSTEMIC REVIEW

Respiratory System: Dyspnoea, wheeze, cough, sputum, haemoptysis, chest pain

Cardiovascular system: Chest pain, orthopnoea, paroxysmal nocturnal dyspnoea, ankle swelling,palpitations, and intermittent claudication.

Gastrointestinal System: Abdominal pain, nausea, vomiting, haematemesis,bowel habit, blood P/R,melaena.

Urogenital System: frequency, nocturia, polydypsia, loin pain, haematuria.

Menarche, menopause, cycle, intermenstrual bleeding, post coital bleeding.

Central Nervous System: Headaches, visual disturbances, sleep, hearing, tinnitus, light headedness,blackouts, fits, unsteady gait, weakness, and parasthesiae.

Musculoskeletal: Myalgia, arthralgia, back pain, joint swelling.

Psychiatric: The Mental State Examination will be taught more formally in your Psychiatric attachment.Remember, depression is common and may often coexist with physical ill health.


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Psychiatric history taking (DEPRESSION AND PSYCHOSES)

Introduction

Presenting complaint

(symptoms;


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4. Blood Pressure Measurement

Introduce yourself to the patient. Confirm the name and age of patient

Explain the procedure and ask for his consent to carry it out. Ask if they have taken any stimulants,like coffee in the 2 hours. Also ask about recent exercise did they run here?. This woud give a

elevated reading

Tell him that he might feel some discomfort as the cuff is inflated, and that the blood pressuremeasurement will have to be repeated.

Position the patients right arm so that it is horizontal at the level of the mid-sternum. Check thatthey are sitting comfortably and are not crossing their legs.

Place the vertical column so that it is at eye level

Locate the brachial artery at about 2cm above the antecubitalfossa

Select the appropriate sized cuffand apply it to the arm, ensuring that it fits securely

Find the radial pulse, inflate the cuff until the radial pulse disappeared this is the estimatedsystolic. Release the pressure.

Inflate the cuff to 20-30 mmHg more than the estimated systolic blood pressure.

Place the stethoscope over the brachial artery pulse, ensuring that it does tightly on the skin

Reduce the pressure in the cuff at a rate of 2-3 mmHg (DO NOT REINFLATE)

The first consistent Korotkoff sounds indicate the systolic BP

The muffling and disappearance of the Korotkoff sounds indicate the diastolic BP

Record the blood pressure as the systolic reading over the diastolic reading. Do not attempt to roundoff your readings

If the BP is higher than 140/90, indicate that you might take a second reading after giving the patient aone minute rest.

If the patient has a history ofpostural hypotension, you must also record the standing BP

Tell the patient his BP and explain its significance. Hypertension can only be confirmed throughseveral BP measurements taken over time.

Thank the patient

5. HAND HYGIENE


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6: BASIC LIFE SUPPORT

1 HAZARDS, HYGEINE

2 RESPONSE Gently shake his shoulders and ask loudly, Are you all right?

3 HELP

Turn the victim onto his back and then open the airway using head tilt and chin lift:

Place your hand on his forehead and gently tilt his head back. With your fingertips under the point of thevictim's chin, lift the chin to open the airway.

4 Keeping the airway open, look, listen, and feel for normal breathing.

(chest movement, breath sounds, air)

5 B If he is not breathing normally:

Kneel by the side of the victim.

Place the heel of one hand in the centre of the victims chest.

Place the heel of your other hand on top of the first hand.

o Interlock the fingers of your hands and ensure that pressure is not applied over the victim's ribs. Do not applyany pressure over the upper abdomen or the bottom end of the bony sternum (breastbone).

o Position yourself vertically above the victim's chest and, with your arms straight, press down on the sternum4 - 5 cm.

o After each compression, release all the pressure on the chest without losing contact between your handsand the sternum.

Repeat at a rate of about 100 times a minute (a little less than 2 compressions a second).

o Compression and release should take an equal amount of time.

6 After 30 compressions open the airway again using head tilt and chin lift.

Pinch the soft part of the victims nose closed, using the index finger and thumb of your hand on his

forehead.

Allow his mouth to open, but maintain chin lift.

Take a normal breath and place your lips around his mouth, making sure that you have a good seal.

Blow steadily into his mouth whilst watching for his chest to rise; take about one second to make his chestrise as in normal breathing; this is an effective rescue breath.

Maintaining head tilt and chin lift, take your mouth away from the victim and watch for his chest to fall as aircomes out.

Take another normal breath and blow into the victims mouth once more to give a total of two effective rescue

breaths. Then return your hands without delay to the correct position on the sternum and give a further 30chest compressions.

Continue with chest compressions and rescue breaths in a ratio of 30:2.


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Stop to recheck the victim only if he starts breathing normally; otherwise do not interrupt

7 Continue resuscitation until:

qualified help arrives and takes over,

the victim starts breathing normally, or

you become exhausted.


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OSCE skill - urine dipstick

Either explain to the examiner or actually introduce yourself to the patient.

-Ask theirname, check it correlates with the sample and date of birth matches, confidentiality

-Ask for a brief history of why the test was ordered, then explain what it would be for

-Check sample was correctly collected e.g. midstream or less than 4 hours after last urination

BEFORE TOUCHING THE SAMPLE- put on gloves. Get some paper towel and put it down on table to catchdrips.

Then check date on sample- whether it is fresh and if it is not fresh, whether it has been in the refrigerator(


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OSCE - Inhaler technique peak flow

-Introduce yourself to the patient, explain who you are, explain confidentiality.

-Ask the patient whether they understand what asthma is and whether they have any questions about it.

-Check what type of inhalerthey have been prescribed (probably a reliever).

-Explain that the inhaler device delivers aerosolised bronchodilator medication for inhalation. If this is used

correctly, it should provide fast and effective relief from airway irritation or narrowing. If it is a preventer,

explain it will not relieve the symptoms of an asthma attack but if it is taken regularly as prescribed, it will

reduce the frequency and severity of asthma attacks.

-Explain the drugs, because they are inhaled have relatively few side effects, although for salbutamol, they

might experience muscle tremors and heart palpitations whilst with preventers like beclomethasone they

may experience cough and sore throat. They should also rinse out their mouth afterwards to prevent against

oral thrush. A good way to ensure that this occurs and that they take it regularly is to take their preventer

before they brush their teeth morning and evening.

-Demonstrate the following steps to the patient, then ask them to repeat them.

1. If the inhaler has not been used before, remove it from the plastic canister and check the expiry date.

Replace it, and remove the cap, giving it a tester spray to ensure the canister has locked back into place.

2. Before using it at any point, shake it vigorously with the cap still on.

3. Remove the cap from the inhaler and then hold the inhaler between index finger (the top of the inhaler) and

the thumb (base). If the patient has weak hands, they can use both and if they still cannot manage, they can

try Haleraid or another device that turns the push down action into a lever action.

4. Sit orstand up straight to increase lung capacity.

5. Place the inhalerupright about 3-5cm from the mouth.

6. Breathe out completely.

7. Put the inhaler in between the lips (which should form a tight seal aroundthe inhaler).

8. Breathe in deeply. As the inhalation begins, activate the inhaler, and continue breathing in.

9. Close the mouth and hold in the breath for 10 seconds then breathe out.

-Explain to the patient that he can repeat the procedure after one minute if relief is insufficient. If there is still

no relief, he should continue this once a minute for 5 minutes. At 5 minutes, if there is no improvement, he

should call 999 for an ambulance (explain that if he then feels better he can cancel it).

-Explain it is important not to run out of the blue inhaler, so periodically shake it to check the amount left,

and dont forget to collect repeat prescriptions.

-Ask the patient if they have any questions or concerns.

-Thank the patient.


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PEFR meter explanation

Introduce yourself to the patient

Check his understanding of asthma

Explain the importance of using a PEFR (peak expiratory flow rate) meter and the importance of usingit correctly

Explain that the PEFR is to be used first thing in the morning and at any time he has symptoms ofasthma

Attach a clean mouthpiece to the meter

Slide the marker to the bottom of the numbered scale

Stand or sit up straight

Hold the peak flow meter horizontal, keeping the fingers away from the marker

Take as deep a breath as possible and hold it

Insert the mouthpiece into his mouth, sealing his lips around the mouthpiece

Exhale as hard as possible into the meter

Read and record the meter reading

Repeat the procedure three times, keeping only the highest score

Check this score against the peak flow chart or his previous readings

Check the patients understanding by asking him to carry out the procedure

Ask him if he has any questions or concerns


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Adult BLS sequence

Basic life support consists of the following sequence of actions:

1 Make sure the victim, any bystanders, and you are safe.

2 Check the victim for a response.

Gently shake his shoulders and ask loudly, Are you all right?

3 A If he responds:

Leave him in the position in which you find him provided there is no further danger.

Try to find out what is wrong with him and get help if needed.

Reassess him regularly.

3 B If he does not respond:

Shout for help.

Turn the victim onto his back and then open the airway using head tilt and chin lift:

o Place your hand on his forehead and gently tilt his head back.

o With your fingertips under the point of the victim's chin, lift the chin to open the airway.

4 Keeping the airway open, look, listen, and feel for normal breathing.

Look for chest movement.

Listen at the victim's mouth for breath sounds.

Feel for air on your cheek.

In the first few minutes after cardiac arrest, a victim may be barely breathing, or taking infrequent, noisy,gasps. Do not confuse this with normal breathing.

Look, listen, and feel for no more than 10 sec to determine if the victim is breathing normally. If you have anydoubt whether breathing is normal, act as if it is not normal.

5 A If he is breathing normally:

Turn him into the recovery position (see below).

Send or go for help, or call for an ambulance.


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Check for continued breathing.

5 B If he is not breathing normally:

Ask someone to call for an ambulance or, if you are on your own, do this yourself; you may need to leave thevictim. Start chest compression as follows:

o Kneel by the side of the victim.

o Place the heel of one hand in the centre of the victims chest.

o Place the heel of your other hand on top of the first hand.

o Interlock the fingers of your hands and ensure that pressure is not applied over the victim's ribs. Do not applyany pressure over the upper abdomen or the bottom end of the bony sternum (breastbone).

o Position yourself vertically above the victim's chest and, with your arms straight, press down on the sternum4 - 5 cm.

o After each compression, release all the pressure on the chest without losing contact between your handsand the sternum.

Repeat at a rate of about 100 times a minute (a little less than 2 compressions a second).

o Compression and release should take an equal amount of time.

6 A Combine chest compression with rescue breaths.

After 30 compressions open the airway again using head tilt and chin lift.

Pinch the soft part of the victims nose closed, using the index finger and thumb of your hand on hisforehead.

Allow his mouth to open, but maintain chin lift.

Take a normal breath and place your lips around his mouth, making sure that you have a good seal.

Blow steadily into his mouth whilst watching for his chest to rise; take about one second to make his chestrise as in normal breathing; this is an effective rescue breath.

Maintaining head tilt and chin lift, take your mouth away from the victim and watch for his chest to fall as aircomes out.

Take another normal breath and blow into the victims mouth once more to give a total of two effective rescuebreaths. Then return your hands without delay to the correct position on the sternum and give a further 30chest compressions.

Continue with chest compressions and rescue breaths in a ratio of 30:2.

Stop to recheck the victim only if he starts breathing normally; otherwise do not interrupt resuscitation.

If your rescue breaths do not make the chest rise as in normal breathing, then before your next attempt:

Check the victim's mouth and remove any visible obstruction.

Recheck that there is adequate head tilt and chin lift.

Do not attempt more than two breaths each time before returning to chest compressions.


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If there is more than one rescuer present, another should take over CPR about every 2 min to prevent fatigue.Ensure the minimum of delay during the changeover of rescuers.

6 B Chest-compression-only CPR.

If you are not able, or are unwilling, to give rescue breaths, give chest compressions only.

If chest compressions only are given, these should be continuous at a rate of 100 a minute.

Stop to recheck the victim only if he starts breathing normally; otherwise do not interrupt resuscitation.

7 Continue resuscitation until:

qualified help arrives and takes over,

the victim starts breathing normally, or

you become exhausted.


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OSCE Explaining- Diabetes

Introduce yourself.

Explain confidentiality.

Ask consent.

Ask the patient how much they know about their condition.

Ask if they have any specific questions they would like you to answer. Give most important information

first and check their understanding of that before moving on.

What is Type 1 diabetes

Is where the body stops making insulin. When we eat food, it is broken up into (amongst other things)

sugars in our gut that are absorbed. The most common one is called glucose. When blood glucose

levels rise, insulin is released to help our cells take in this glucose. The cells then use glucose for

energy and covert the rest into glycogen and fat- energy stores for when we havent just eaten. When

insulin falls, these energy stores and broken back down into glucose and used for energy.

Normally insulin is made in the pancreas by specialised cells called cells which are found in mixed

clusters of cells called the Islets of Langerhans. In Type 1 diabetes, these cells are damaged and

dont produce enough insulin

It tends to occur in children and young adults, where it develops rather quickly. About 1 in 250 people

is affected.

cells are damaged because the body starts attacking them. Normally the body makes antibodies to

fight viruses, bacteria and other infections. But sometimes it starts making antibodies against its own

cells, leading to autoimmune disease. In Type 1 diabetes, the body starts making antibodies against

cells. They are damaged or killed so they can no longer produce enough insulin.

Symptoms of diabetes include being tired, very thirsty and needing to pass urine a lot more than usual.

It is diagnosed by looking for glucose in the urine and if this is found, a fasting blood test is done to

confirm the diagnosis.

If it is untreated, blood glucose gets very high and acids start to be formed in the blood leading to a

condition called ketoacidosis. People with ketoacidosis can slip into a coma and die.

Role of genetics: if you have a parent or sibling with Type I diabetes, the risk is raised from 1 in 250 toabout 6 in 100. There is also been a proposed role for infection in developing the disease.

Complications

A raised blood glucose level over a prolonged period of time, even if it is only slightly elevated, can lead

to damaged blood vessels. This can lead to eyesight problems, heart disease, high blood pressure,

kidney damage (which can lead to kidney failure), nerve damage, foot problems (due to nerve and

blood vessel damage) which may end up in amputation and impotence. These problems are generally

the consequence of diabetes being poorly controlled over a number of years and do not appear

immediately. If diabetes is well controlled, and side effects such as high blood pressure, are treated,

then the risk of complications are massively reduced.

-If too much insulin is taken, the blood glucose level can drop too low leading to confusion, feeling

sweaty, feeling unwell, collapse and even coma. This is easily reversed with sugar, sweet drinks or a


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glucagon injection (glucagon has the reverse effect to insulin). It is recommended a starch filled meal,

such as a sandwich, should then be eaten.

Treatment

-The aims of treatment are thus to keep blood glucose as close as possible to normal, to treat other risk

factors, like high blood pressure and to recognise and treat complications as soon as possible.

-Blood glucose is controlled by regular insulin injections. To stay healthy and alive, these will have to

be taken every day for the rest of your life. Insulin is not absorbed by the gut, so it must be taken as

injection instead of tablets. Most people need between 2 and 4 injections a day. There are several

types of insulin and the doctor will tailor the type of insulin and injection plan to your needs. As a Type I

diabetic, you do not need to pay for your insulin or any other medications you are on. You do have to

fill in an exemption form. You also get free eye tests.

-Diabetics do not need to eat a special diet, but they should like everyone else, eat a high fibre, low fat

diet. However the amount of insulin injected needs to balance out what has been eaten that day, so

you should go to the dietician to learn how to work out how much insulin you need after a particular

meal.

-Blood glucose levels can be monitored at home with a skin prick device and testing strips. This allows

you to see how well the condition is controlled. You should aim for a blood glucose before meals of

about 4mM-7mM and no more than 10mM two hours after a meal.

-In the doctors they can do a blood test called the HbA1c, which shows how well blood glucose has

been controlled over the previous 2-3 months. A good test result to have here is less than 7%. This

should be done about once or twice a year.

-Because people with Type I diabetes have an elevated risk of cardiovascular disease, they should be

especially careful to avoid other risk factors such as high blood pressure, smoking, too little physicalexercise and trying to lose weight (with help from the dietician).

-Detecting and treating any complications can be done at the GPs or in a specialist diabetic clinic. They

will perform regular eye checks to make sure there are no problems with the blood vessels in the retina

(or glaucoma as people with diabetes have an elevated risk of this), do urine checks to look for protein

in the urine (which can be a sign of kidney damage), do foot checks to make sure no ulcers form and

blood tests to check kidney function, HbA1c and for some other autoimmune disorders that are more

common in diabetics like Coeliacs disease and thyroid problems.

-Because infections can change blood glucose demands and therefore being diabetic can make some

illnesses more serious, diabetics should have yearly flu vaccines and have a one-off pneumococcal

vaccine. If you do get ill, measure blood glucose regularly, consume sugary drinks and milk if there is

appetite loss and contact your GP if you have vomiting or diarrhoea or are unsure of what to do.

Concerns

Diabetes and drinking: alcohol increases the risk of becoming hypoglycaemic (blood sugar dropping

too low). If you want to go out drinking, make sure you eat a big meal of carbohydrates before and

snack on starchy snacks like crisps and nuts. Take some glucose tablets out with you so if you do get

hypoglycaemic, you dont have to wait in a queue at the bar to buy a sugary drink/food. Make sure your

friends know you are diabetic and know the symptoms of hypoglycaemia. Always wear a medic alert

bracelet or an ID card so people know you are diabetic if something goes wrong. Because alcohol is

processed quite slowly by the liver, it is possible to get hypoglycaemic several hours after stopping

drinking. So make sure you eat something starchy before bed like toast or cereal. In the morning, if you


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feel shaky, unwell and have a headache, it may be a hangover or it may be hypoglycaemia, so check

your blood sugar.

It is discrimination under the Disabilities Discrimination Act to be refused entry somewhere because of

carrying an insulin pen/blood glucose testing kit.

Driving: as long as diabetes is controlled you can drive. You have to fill in an extra form and will be

issued with a one, two or three year license depending on the doctors report. You legally have to tellthe DVLA you have diabetes and you have to tell your insurer too or cover isnt valid. Try not to drive

for more than two hours without food, if you feel a hypo coming on, stop the car, remove the keys from

the ignition, check your blood glucose and treat it before moving on again and make sure to keep

glucose tablets/crisps in the car in case of traffic jams/hypo attacks.

Travelling: make sure you have enough insulin (the same type may not always be available where you

are going) and some way of keeping it cold. If you are going away for a long time, check insulin

availability where you are going and if it is not available talk to your doctor about an alternative. Bring a

spare blood glucose monitor and ID that clearly shows you are diabetic. Make sure travel insurance

covers diabetes and its complications. Diabetes UK produces special booklets for a variety of countries

with information about facilities and useful phrases. You can still take insulin onto aeroplanes despite

new security restrictions but you need a letter from your GP explaining about the need to carry

syringes, insulin etc. Avoid storing insulin in the baggage hold because the temperature drops and it

could damage the insulin.

Exercise: increased activity can cause you to use up more glucose than normal. You might have to

reduce insulin doses otherwise you might get hypoglycaemia. This can happen up to 36 hours

afterwards as your muscles are refuelling. There is also a risk of hyperglycaemia because adrenaline

can cancel out the effects of insulin. Always check blood glucose levels before and after exercise and

talk to your doctor before taking up new sports so they can draw up a new plan with you. There is a

special website about diabetes and sport called runsweet.com.

Help

Diabetes UK has a special section of their website (diabetes.org.uk) called My Life about dealing with

diabetes as a child/teenager/young adult with lots of advice.


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OSCE Explaining Hypertension

-Introduce yourself/explain confidentiality/check for consent.

-Find out how much the patient already knows about the condition.

-Ask if they have any specific questions about the condition. If they feel unclear at any stage about

what you are saying, or they have a question, dont hesitate to ask.

-Give the most important information first. Tell them to make notes if they want as they

What is hypertension?

-Blood pressure is a measurement of the pressure of the blood in your arteries. If this is high, it

means you might be at risk of a heart attack, stroke or other serious complications as it is one of

several risk factors for this condition. Having high blood pressure does not necessarily mean you

will get any of these conditions, but it is safer to try and lower blood pressure to reduce the risk.

-Blood pressure is given as two figures. The top one is the systolic pressure. This is the pressure in

the arteries when the heart contracts. The bottom number is the diastolic pressure. This is thepressure in the arteries when the heart is resting between beats. Blood pressure is determined by

how hard your heart beats and how much resistance there is in the arteries.

-If it is below 140/90 (but above 120/80) the doctor will generally just keep an eye on your blood

pressure unless you have specific cardiovascular risk factors.

-High blood pressure is when, each time the blood pressure is taken, the figure is significantly

above normal. This is generally taken to be 140/90, although it is possible to have just a high

systolic pressure (e.g. 150/80) or just a high diastolic pressure (e.g. 120/100). The reason why the

criteria says every time it is measured is because if you are nervous, or have just exercise, it is

possible for your blood pressure to be elevated. Therefore to diagnose hypertension, severalreadings are generally taken over several weeks/months to check it is always elevated.

-If your blood pressure is less than 160/100 (but above 140/90), this is known as mild high blood

pressure. You may not need medication if you do not have other cardiovascular risk factors (such

as diabetes, kidney disease, family history of heart disease or high cholesterol). In these cases the

doctor may recommend just lifestyle changes.

-Lifestyle changes include weight loss,regular exercise, cutting back on caffeine, drinking alcohol in

moderation and limiting your salt intake.

Medication

-If your BP is above 160/100 or you have other cardiovascular risk factors, the doctor may

prescribe medication in addition to lifestyle changes.

-The aim of medication is to lower BP to 140/90 or below (lower if you have diabetes/kidney

disease/cardiovascular disease). There are a variety of drugs that do this (ACE inhibitors, diuretics,

calcium channel blockers and blockers). Different people require different drugs depending on

age, ethnicity and other health factors.

-All medications have side effects, but if yours are troublesome see your doctor as there are lots of

other drugs available that act in different ways. In most cases, medication is required for lifealthough if significant lifestyle changes have been made and blood pressure has been well-

controlled for three years, then the doctor may agree to stop the drugs. The doctor should always

be consulted before stopping medications.


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What causes hypertension?

-In most cases, there is no obvious cause for hypertension (this is known as primary hypertension).

It is very common- half of people over 65 and 1 in middle aged people have hypertension. It is less

common in younger people. It has no symptoms so it is important to have blood pressure checked

regularly (every 3-5 years). High blood pressure is more common in people with diabetes, of Afro-

Carribean or South Asian origin, people with a family history of high BP, those who are overweight,

eat a lot of salt, dont eat much fruit or vegetables, dont take enough exercise, drink a lot ofcaffeinated drinks or drink a lot of alcohol.

-Sometimes hypertension is caused by other conditions (then it is called secondary hypertension).

This is less common but conditions that cause it include kidney problems and some hormone

problems.

-Ask the patient if they smoke. If so advise they give up smoking. Whilst smoking has no effect on

blood pressure, it is a cardiovascular risk factor (as is hypertension).

-Summarise what you have discussed with the patient, ask if they have any questions and check

they have understood the key points.

-Tell the patient if they have any more queries dont hesitate to ask the doctor or nurse.

-Thank them.


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HAND HYGIENE:

18 Check the infection control CAL exercise for full details on how to wash your

hands. Remember to use the right bottle of soap and know the differences.

18 Also learn the difference between cleaning, disinfecting and sterilization.

BMI

Weight / height sq

Blood film

Growth chart?

Movement disorders

Sensory awareness (blind or deaf)

osces urine dipstick and inhaler

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