1. 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)
3. 2
Hand washing
Preparation
Roll sleevesupsoyouare bare fromthe elbows,remove jewelleryandwatch.Turn on
the taps, usingyourforearmsif possible,andadjustthe watertothe right
temperature.Thenwetyourhandsunderrunningwater.Applythe liquidsoapand
latheryourhandsthoroughly.
Step 1
Rub yourpalmstogether.Thenrubyour leftpalmoverthe backof your right hand.
Thenrub your rightpalmoverthe back of yourlefthand.
Step 2 Weave yourfingerstogetherandslide thembackwardsandforwards.
Step 3
Slide yourhandspalmoverpalm, gripthe fingersof one handin the fingersof your
otherhand andrub the backs of yourfingersagainstthe palmsof yourhands.
Step 4
Rub the tipsof the fingersof yourlefthandonthe palmof your righthand.Repeat for
the fingersof the righthand.
Step 5
Rub yourright thumbwithyourlefthandand thenrubyour leftthumbwithyourright
hand.
Step 6
Rub yourright wristwithyourlefthandandthenrub your leftwristwithyourright
hand.
Rinsing
Rinse yourhandsand wristsunderrunningwater,keepingyourhandspointing
upwards,until all the soaphas gone.Turntap off withyour forearmsif possibleor
usinga papertowel.
Drying
Dry all parts of yourhandswithdisposable towels,keepingyourfingerspointing
upwards.Wipe fromyourfingersdownwardstoyourwrist.Dispose of the handtowels
inthe binusingthe footpedal.
4. 3
Setting up for an aseptic procedure
- Wash handswithsoapand water
- Cleantrolleywithsani-clothwipes,topto bottom, back to front
- Gather equipmentonbottomshelf,checkingintegrityandexpirydates
- Take trolleytobedside
- Cleanhandswithalcohol gel andputon apron
- Opensterile packontotopshelf of trolleyusingedgesof paper/plasticwrap
- Opensupplementarypacksontosterile field
- Openglovestoside of sterile field
- Cleanhandswithalcohol gel andputon sterile gloves
6. 5
Vital Signs
Recording the Temperature:Tympanic reading:
- Explainanddiscussthe procedure withthe patient
- Wash yourhands
- Applya newdisposableprobe covertothe probe tipusingthe no-touchtechnique.
- Switchthermometeron
- Insertthermometerintoear, pullingbackwardsonear,withthe pointof the probe directed
towardsthe back of the patient’soppositeeye,ensuringasnugfit.
- Pressand release scanbutton
- Remove probe fromearonce readingistaken(usuallyindicatedbyableep)
- Remove probe coverbypressingreleasebuttonanddispose inclinical waste.
- Recordtemperature onrelevantpaperworkandnote whicheartemperature wastakeninto
ensure continuity. (Normal 36.4⁰-37.3⁰)
Recording the Pulse:
- Explaintothe patientthatyou needtotake theirpulse.
- Cleanhandswithhandgel
- Identifyanappropriate site atwhichtorecordpulse (usuallythe mostaccessible site)
- Palpate the pulse for30 secondsand multiply resultbytwo.If the pulse isirregular,take pulse
for one full minute. (If thisisthe firsttime the patient’spulse hasbeentakenitshouldbe
palpatedfora full minute.)
- Assessforrate and rhythm and record onappropriate paperwork/chart.
Recording Respiration:
- Try to take whilstthe patientisunaware.Thismaybe done withthe pulse, takingthe pulse for
30 secondsandthencountingrespirationsfor30 secondswhilstcontinuingtoholdthe wrist
- Observe forpattern,abnormalities anddepth.
- Recordon relevantchart/paperwork.
Peak expiratoryflow:
- Explaintothe patientthatyou wishtorecord theirpeakflow andwhy.
- Explainanddemonstrate howtoperformapeakflow monitoring
- Askthe patientto stand(ideally) orsitupright.
- Checkthat the peakflowmonitorhasa new,disposable mouthpiece
- Tell patientthatthe gauge on the peakflow monitorismovedtozero.
- Explainthatthe peakflowmonitorshouldbe heldhorizontal,holdingthe meterwithfingers
away fromgauge.The patient’slipsshouldbe sealedaroundthe mouthpieceinorderto
achieve anaccurate reading. The patientshouldtake adeepbreathbefore blowingashard
and fastas possible intothe mouthpiece.
- Demonstrate thistothe patientbefore changingthe mouthpieceandaskingthemtoperform
the same procedure.
- Askthe patientto repeatthe processthree timesandrecordthe bestof these resultsonthe
appropriate charts/paperwork.
- If the patientistorecord theirpeakflow athome,ask themtodo so at the same time of the
day as there isa diurnal variation.
- “Do you have anyquestions?”
- Factors influencingpeakflow:height,age,gender,smoking,COPD,acute respiratoryinfection,
poor technique.
7. 6
Blood pressure
- Checkspatientidentity,gainsconsent,explainsprocedure,ensurespatientcomfort
- Patientshouldrestfor3-5 minutesbefore bloodpressure ismeasured toensure accurate
reading.
- Explaintothe patientwhatyouwill doand whyyouneedto measure theirbloodpressure.
- Wash yourhands andcleanyour stethoscope
- Ensure that tightor restrictive clothingisremovedfromthe arm
- Sitthe patientcomfortablywiththeirarmsupportedatheartlevel,palmfacingupwards.Use
a pilloworsimilartosupportthe arm. Thiswill make itmore comfortable forthe patientso
that theyare lesslikelytomove, whichinturnwill make iteasierforyoutorecord theirblood
pressure.
- Choose correctsizedcuff to reduce riskof falselyhigh/low readings.
- Applythe cuff to the upperarm, ensuringappropriate size isusedandbladderof cuff is
centred overbrachial artery.
- Ensure that the cuff is highenoughupthe arm for youto be able toplace the diaphragmof
the stethoscope overthe brachial arterywithoutitrubbingonthe cuff.(Thiswill create noise
distortionandinterference andmake itmore difficulttoobtainanaccurate reading.)
- Palpate the radial or brachial pulse.
- Close valve of sphygmomanometer
- Inflate the cuff until you canno longerfeel the pulse. Thisgivesanestimated systolicpressure.
(Avoidserrorcausedby auscultatory gap)
- Deflate cuff entirely.
- Place the diaphragmof the stethoscope overthe brachial pulse,closevalve andre-inflate the
cuff to 20-30mmHg above the estimated systolicpulse.
- Slowlydeflate the cuff ata rate of about 2mmHg/second.
- Note the systolicpressure onthe gauge whentwoconsecutiveheartbeatscanbe heard
(phase 1 of the Korotkoff sounds).Readtothe nearest2mmHg.
- Continue todeflate the cuff,listeningforwhensoundsdisappear(phase 5).Thisisthe diastolic
pressure.(Occasionally,especially inchildrenandpregnantwomen,the lastKorotkoff sounds
continue,inwhichcase phase 4 (the muffling) representsthe diastolic.)
- Give measurement
- If you needtotake the BP again(if youmissedthe sounds) thendeflate the cuff completely
and waitat least30sec before tryingagain
- If this isyourfirstconsultationwiththe patient,take abilateral measurement.
- Documentfindings,takingactionasappropriate.
If the patientishypertensiveand/orappearsanxious,repeatthe measurementsome time laterin
orderto rule out ‘white coathypertension’.
8. 7
Intra-muscular injection
1. Introduction,checkpatientidentity,give explanationandgainconsent
2. Checkprescription (ordrugchart):
- AgainstpatientIDand wristbanddetails
- drug dose
- date/time
- signature
- allergies
3. Checkdrug and equipment:
- drug name
- dose/concentration
- expirydate
- integrityof packet
- dilutingagentneeded?
- debrisorcloudinessinliquiddrug
4. Ensure dignityandprivacyof patientismaintainedatall times.Donot administerIMinjectionin
buttocks (chaperone needed)if itcanbe appropriatelyadministeredin deltoid,forexample.
Ensure patient iscomfortable.
5. Explainprocedure andgainverbal consentafterpatienthashadopportunitytoaskquestions.
6. Wash hands
7. Gather andcheck equipmentandplace intray.
8. Put onnon sterile gloves
9. Attach greenneedle (21G) tosyringe.Holdingneedleanddrugvial vertical ateye level draw up
requiredquantityof medication.
10. DO NOT RESHEATH NEEDLE. Remove needlebyhandand dispose insharpsbin.Donot use needle
removal device onsharpsbinat thispoint
11. Replace with blue needle (23G).(Orasecond greenneedle (21G) forpts withmore considerable
SC tissue.)
12. Expel airfromsyringe andprime the needle,ensuringcorrectamountof drug insyringe
13. Choose andexpose site.Checkforskinintegrity,haematoma,hardenedskin,recentinjection
sites,muscle wasting,increasedskinturgor,infection(eczema,erythema),bruising,oedema,
parastheriae/anaesthesiae.Considerunderlying structuresandanatomy.
14. Prepare skinusingalcohol wipe ineverincreasingcircles. SociallycleanskindoesNOTrequire
additional cleaning.Allow todrycompletely.
15. Warn patientthattheywill feel asharpscratch.
16. Use thumband forefingertoslightly stretchSCtissues.
17. Insertneedle at90°, swiftlybutgently,toapproximately2/3the needle length,ensuringneedle
tipis deliveringdrugtomuscle layer.
18. Aspirate.If bloodisevidentremove needle andapplypressure before continuing procedure with
cleanequipment.
19. If no bloodisvisible,slowlyinjectdrug.The more viscousthe drugis,the more slowly itmustbe
administered.
20. Ensure medicationdoesnotleakfromwoundsite –keepneedleinsituforsecondsafterdrughas
beenadministered. Removeneedleandimmediatelypressonpuncture site withgauze swab.
21. Observe forlocalisedorsystemicreaction.
22. Dispose of equipmentinrelevantclinical waste/sharpsbin.
23. Wash handsand recordprocedure appropriately.
9. 8
Subcutaneous injection
1. Introduction, checkpatientidentity,give explanationandgainconsent
2. Checkprescription (ordrugchart):
- patientID( DO NOT relyonwristbanddetailsalone if patientisalert)
- drug dose
- date/time
- signature
- allergies
3. Checkdrug and equipment:
- drug name
- dose/concentration
- expirydate
- integrityof packet
- dilutingagentneeded?
- debrisorcloudinessinliquiddrug
4. Ensure dignityandprivacyof patientismaintainedatall times.DonotadministerIMinjectionin
buttocksif it can be appropriatelyadministeredindeltoid,forexample.Ensure patientis
comfortable.
5. Explainprocedure andgainverbal consentafterpatienthashadopportunitytoaskquestions.
6. Wash hands
7. Gather andcheck equipmentandplace intray.
8. Put onnon sterile gloves
9. Attach greenneedle (21G) tosyringe.Holdingneedleanddrugvial vertical ateye level draw up
requiredquantityof medication.
10. DO NOT RESHEATH NEEDLE. Remove needlebyhandanddispose insharpsbin.Donot use needle
removal device onsharpsbinat thispoint
11. Replace with orange needle (25G).
12. Expel airfromsyringe andprime the needle,ensuringcorrectamountof drug insyringe
13. Choose andexpose site.Checkforskinintegrity,haematoma,hardenedskin,recentinjectionsites
etc.Considerunderlyingstructuresandanatomy.
14. Prepare skin,sociallycleanskindoesNOTrequire additional cleaning.Allowtodrycompletely.
15. Warn patientthattheywill feel asharpscratch.
16. Use thumband forefingertoslightly pinchup SCtissues.
17. Insertneedle at 45°, swiftlybutgently,toapproximately2/3the needle length,ensuringneedle
tipis deliveringdrugto SClayer.
18. Remove needle andimmediatelypressonpuncture site withgauze swab. DONOTrub area
19. Observe fora localisedorsystemicreaction.
20. Dispose of equipmentinrelevantclinical waste/sharpsbin.
21. Wash handsand recordprocedure appropriately.
NB: some subcutaneousinjectionsare available in pre filledsyringes,includingheparinandinsulin
and should be injectedat 90° to accommodate the short needle.
10. 9
Intra-dermal injection
1. Introduction,checkpatientidentity,give explanationandgainconsent
2. Checkprescription (ordrugchart):
- patientID( DO NOT relyonwristbanddetailsalone if patientisalert)
- drug dose
- date/time
- signature
- allergies
3. Checkdrug and equipment:
- drug name
- dose/concentration
- expirydate
- integrityof packet
- dilutingagentneeded?
- debrisorcloudinessinliquiddrug
4. Ensure dignityandprivacyof patientismaintainedatall times.DonotadministerIMinjectionin
buttocksif it can be appropriatelyadministeredindeltoid,forexample.Ensure patientis
comfortable.
5. Explainprocedure andgainverbal consentafterpatienthashadopportunitytoaskquestions.
6. Wash hands
7. Gather andcheck equipmentandplace intray.
8. Put onnon sterile gloves
9. Attach greenneedle (21G) tosyringe.Holdingneedleanddrugvial vertical ateye level draw up
requiredquantityof medication.
10. DO NOT RESHEATH NEEDLE. Remove needlebyhandanddispose insharpsbin.Donot use needle
removal device onsharpsbinat thispoint
11. Replace with orange needle (25G).
12. Expel airfromsyringe andprime the needle,ensuringcorrectamountof drug insyringe
13. Choose andexpose site.Checkforskinintegrity,haematoma,hardenedskin,recentinjectionsites
etc.Considerunderlyingstructuresandanatomy.
14. Prepare skin,sociallycleanskindoesNOTrequire additional cleaning.Allowtodrycompletely.
15. Warn patientthattheywill feel asharpscratch.
16. Insertneedle at 15°, withbevel uppermost.Donotattemptto stretchor pinchup the
subcutaneoustissues.
17. Depressplungerslowly.The injectedfluidmaycause a blebtoform beneaththe skin.Thisis
normal;do nottry to disperse it.
18. Remove needle.DONOTapplypressure orrubarea
19. Observe fora localisedorsystemicreaction
20. Dispose of equipmentinrelevantclinical waste/sharpsbin.
21. Wash handsand recordprocedure appropriately.
11. 10
Recovery Position
- Remove patient’sglasses,andemptykeys,mobile phoneetcfrompatient’spockets.
- Kneel close beside patientandstraightentheirlimbs.
- If the patientisona bed,remove pillowstoenable patienttolie flat.
- Place the arm nearestto youat right anglestotheirbody,elbow bent,palmuppermost.
- Bringtheirotherarm across theirchestand holdthe back of theirhandagainsttheircheek
nearesttoyou.
- Reach acrossthe patient,andwithyourotherhandpull theirfurthestawayknee upinto
flexedpositionwiththeirfootstillonthe ground.
- Maintainingaholdof theirfurthestawaylegjustabove the knee andtheirnearesthand
againsttheircheek,roll them TOWARDSyou,usingyourown kneesasa cushionpropto
manage the speedwithwhichtheyroll.
- Shuffle backfromthemastheyroll onto theirside,keepingtheirknee drawnup.
- Theyshouldnowbe proppedontheirflexedknee (withthathipalsoflexed) andonthe hand
whichyouheldto theircheek.
- Carefullytiltthe headbacktomaintainanopenairway.
- Checktheirbreathingatregularintervalsuntil furtherassistance arrivesandtakesover.
N.B. May needto perform‘DR ABC’ first(danger, response,airways,breathing,circulation); see
Basic Life Support
12. 11
Managing the Choking Patient
- Observe forgeneral signsof choking (patientclutchingthroat,coughing)
- Approachpatientand ask,‘are youchoking?’
- If patientcan vocalise aresponse,thisindicatesobstructionispartial.
o Partial obstruction: encourage patienttocoughwhilstleaningforward.If patientis
consciousandbreathing,DONOTHINGMORE AT THIS STAGE.
- If patientcannotvocalise response,obstructionmaybe complete.
o Complete obstruction,or if patientshowssignsof exhaustionorbecomes cyanosed,
carry out back slaps+/- abdominal thrusts:
1. Remove obviousdebrisfrommouth,includingloose dentures
2. Standto side and slightlybehindpatient
3. Supportthemby placingone armacross theirchestand leanthemforward
4. Give up to five sharpbackslapsbetweentheirscapulae withheel of yourhand.
5. Aftereachslap,checktheirmouthfor dislodgedobstruction.
6. If back slapsare ineffective,carryoutup to 5 abdominal thrusts.
7. Standbehindpatientandputyourarms around the upperpart of their
abdomen.
8. Lean patientforward.
9. Clenchyourfistand place justbeneaththeirsternum.Graspyourfistwithyour
otherhand.
10.Pull sharplyupwardsandinwardsinorderto expel airfromlungsandso
dislodge obstruction.
11.If one cycle of abdominal thrusts failstoremove obstruction,call formedical
back up.
12.If abdominal thrustsare carriedout, patientmustbe medicallyassessedtorule
out anytrauma.
- If obstructionisnot relieved,recheckmouthfordebristhencarryout 5 backslapsalternated
with5 abdominal thrustsuntil medical assistance arrivesoruntil patientbeginstolose
consciousness.
- If patientlosesconsciousness,beginCPRstartingwith30 chestcompressions.Itisnot
necessarytofirstcheckfor signsof life inthisinstance.
13. 12
Basic Life Support in a Clinical Setting
- Checkfor sourcesof DANGER to self,casualtyandothers(sharps,equipmentleads,blood etc)
- Approachpatientandcheckfor RESPONSE. Shake gentlybybothshoulders,speakloudlyinto
each ear.
- If theyrespond,gettheman urgentmedical referral.
- If no response, CALLFOR HELP. Askfor helpertostayinthe vicinitywhilstyouassessfor signs
of life.
- OpenAIRWAY usingchinlift/headtilt.If there isarisk of c-spine fracture use jaw thrustto
openairway.
- Remove anyobviousobstructionfromairwayusingforcepsandsuctionwhere possible.
Denturesshouldbe leftinsituif well fitted astheywillhelpmaintainthe structure of the face
duringresuscitation.
- Checkfor SIGNSOF LIFE by kneelingclose bypatientand:
o Lookingforchestrise and fall
o Listeningforbreathsounds
o Feelingfortheirbreathingonthe side of yourface
o Lookingforsignsof perfusion,coughing,limbmovement.
o Feelingforbodywarmth
- Palpatingcarotidpulse forsignsof circulation
- If patientisbreathingnormallyandhasa pulse theymayneedurgentmedical attention.While
waitingfortheirarrival,assessthe patientusingABCDE,give oxygenandinsertacannula,or
put inrecoveryposition.
- If there are no signsof life (nobreathing,coughing,movement,nopulse), sendthe helperfor
the crash team/crash trolley(dial 2222 fromthe nearesthospital phone).
- BeginCPR at a rate of 30 compressions/2 breaths, beginningwithcompressions:
o Compressionsatarate of 100/min
o Compressionsatadepthof 4-5cm (1/3 of the depthof the pt’schest)
- Compressionsshouldbe carriedoutinthe centre of the chest,fingerslockedtogetherand
arms lockedout.Pressevenlyandregularly,keepingyourbodyweightoverthe centre of the
patient’schest.
- Breathsshouldbe deliveredslowlyoverapprox 1second.Alwaysuse apocketmask or other
airwayadjunctinthe clinical setting. Betweeneachbreath,turnyourface awayfrom the
patientinorderto inspire the nextbreath
- Continue until:
o Helparrivesandis able totake over
o The patientshowssignsof recovery
o You are tooexhaustedtocontinue.
NB: In a clinical settingit is neverappropriate to perform mouth-to-mouthresuscitation.
14. 13
Capillary Blood Glucose Measurement
Before the procedure:
- Ensure that youunderstandhow to use the monitorandlancetscorrectly
- checkthat a qualitycontrol testhasbeencarriedout and recordedthatday
- checkthat the teststripsare in date
- checkthat the monitorandteststripshave beencalibratedtogether
- Explainprocedure topatientandgainvalid consent
- Take test stripfromtub and insertinto glucometer.
- Wash ownhandsand patient’sfingertobe used.
- Put gloveson
- Prime the penandattach a cleanlancet
- Choose site onpatient’sfingeronlateral side (furthestfromtheirthumb).
o Site shouldbe rotatedfromprevioussite toreduce the riskof infection,pain,and
tougheningof the skinfrommultiple stabbing
o It islesspainful
- Warn the patientwhatto expectandprickside of patient’sfingerwithlancet. Askpatientto
hang handdownwardsandrub handto increase bloodflow if necessary.
- “Milk” patient’sfingertoextractlarge dropof blood,sufficienttocoverthe testpad inone go.
Holdthe teststripinthe glucometeragainstthe dropof blood.The stripwill draw upthe
appropriate quantityof blood.
- Whilstglucometercalculatesareading,applypressure topuncture site andelevate patient’s
finger.Ensure bleedinghasstopped.
- Note the reading.
- Dispose of contaminatedequipmentinrelevantsharps/clinical wastebins.
- Remove gloves.Washhands.
- Recordon appropriate paperwork.
- If bloodglucose readingisoutside normal parameters,actimmediatelyonresults. Repeatthe
procedure afterre-washingthe patient’shand;if still abnormal reading,seek medical help.
15. 14
Venepuncture
- Introduce yourself tothe patient
- CheckpatientID:Askpt theirname and DOB (don’trelyonwristband)
- Explainprocedure andgainconsent.
- Ask/assistpatienttoadjustclothing.
- Wash handsand putapron on
- Gather andassemble equipment,checking forintegrityandexpirydates:
o Kidneydish
o Bloodsample bottles
o Gauze swabs
o Nonsterile gloves
o ChloraPrepforskin
o Plaster/micropore/cottonwool.
o Sharpsbin
o Needle
o Vacutainer
o Tourniquet
- Positionthe patientsotheyare comfortable withthe armwell supported
- Identifysuitable siteandvein
- Apply tourniquet
- Cleanskinwithappropriate preparationandallow to drythoroughly. Avoidre-palpatingskinin
cleansedarea.
- Cleanhandswithalcohol gel andputon gloves
- Anchorveinwithnondominantthumb,supportingpatient’sarmwithfingersof same hand.
- Insertneedle intoveinwithbevel uppermost.
- Holdvacutainerstill,insertbottlesasrequired andallow tofill(vacuumeffectwill draw
appropriate amountof blood).Ensure bottlesare filledincorrectorder.
- As lastbottle isfilling,release tourniquet.
- Remove bottle andplace in tray.Withdraw needle gentlywithdominanthandandasthisis
done,pressoverpuncture site withwadof gauze.Place needleimmediatelyintosharpsbin.
- If patientisable to co-operate,askthemtopressfirmlyongauze forseveral minutesto
minimise bruising.DONOTallowthemtoflex elbow asthiswill increase riskof bruising.
- Whenbleedinghasstopped,applysmall dressing if required.Checkpatientfeelswell (not
faint)
- Dispose of waste intosharpsbin/clinical waste/householdwasteasappropriate.
- Label bloodbottlesandfill inbloodformsatthe bedside.
- Ensure bag issealedbefore dispatchingtolab.
- Wash hands.
Bloodsamplestobe takeninthe followingorder:
1. Lightblue (Sodiumcitrate:Coagulationtests,heparin&warfarincontrol)
2. Black (ESR: paediatricESR)
3. Red (Serum:serumtesting,noanti-coagulant)
4. Yellow/Gold (SST11: LFTs, U+Es,TFTs, Endocrinology,Serology,Immuno)
5. Green (Heparin&PST 11: Genetics,homocysteine,ammonia,renin,aldost.)
6. Purple (EDTA: FBC,adultESR)
7. Pink (Crossmatch: Bloodgroup,cross matching)
8. Grey (Fluoride Oxalate:Bloodglucose,lactate)
9. Royal Blue (Trace element:Trace element,toxicology)
16. 15
Aseptic Cannulation
THIS IS A GUIDE ONLY.Variation in technique isacceptable.The important thing to rememberis that
this is a STERILE procedure.Maintainingpatient dignity,safetyand sterilityat all timesis more
important than the precise methodyou use. Practise all the ways you have beenshownand work
out which is bestfor you. The actual contentsof cannulation packs vary across sites.Ensure you are
familiarwith differenttypes
- Checkpatientidentity,explainprocedure andgain consent
- Wash handswithsoapand water
- Cleantrolley,gatherequipmentonbottomshelf,check expirydatesandintegrityof packaging
o cannulationpack,
o saline flush,
o syringe,
o needle,
o connectiondevice,
o tourniquet,
o sharpsbin,
o alcohol gel,
o sterile gloves
- Cleanhandswithalcohol gel andputon apron
- Opencannulationpackontotop of trolley touchingcornersof packonly
- Openrestof sterile equipment(cannula,needle andsyringe,connectiondevice) ontofield
- Checkand opensaline flushandplace toside of sterile field
- Opensterile gloves toside of sterile field
- Cleanhandswith alcohol gel
- Selectanappropriate vein. Applytourniquet.
- Cleanhandswithalcohol gel andputon sterile gloves
- Cleanthe patient’sskinwith ChloraPrepandallow todry,
- Meanwhile,drawupsaline flushusing the syringe.Donottouch the non-sterile ampoule.Do
not place needle backontosterilefield-dispose insharpsbin.Prime connectiondevice and
replace onsterile fieldwithsyringe
- Place sterile towel(aspreferred)
- Applyingskintraction,insertcannula at30° angle lookingforflashbackinchamber.Once
flashbackisseen,lowerinsertionangle,andadvance cannulaanotherfew mm.Holding
cannulasecurely,withdraw innerneedle slightly,thenadvance the cannuladownthe vein
- Release the tourniquet withnondominanthand
- Occlude the veinwithfingertippressure above the cannulatipusingnondominanthand,then
remove the needlefullyandplace insharpsbin
- (Dependinghowyouhave usedthe sterile towel,youmaynow have non-sterile hands.If so,a
nontouch technique shouldbe usedfromthispoint)
- Attach primedconnectiondevice withclockwise turn,usingdominanthand.
- Flushcannulawith5-10mlsof 0.9% normal saline.(Remembertoprescribe thisonthe
prescriptionsheet) If patent,secure cannulawithprovideddressing,ensuringdate labeldoes
not obscure insertionsite.
- Ensure patientiscomfortable
- Dispose of waste appropriately andcleantrolley.
- Remove glovesandapronandwashhands withsoapand water.
- Fill incannuladocumentationrecordand file innotes
17. 16
Blood Cultures
- Introduce yourself tothe patient
- CheckpatientID:Askpt theirname and DOB (don’trelyonwristband)
- Explainprocedure andgainconsent.
- Ask/assistpatienttoadjustclothing.
- Wash handsand putapron on
- Gather and assemble equipment,checking forintegrityandexpirydates:
o Kidney dish
o Gloves (non sterile)
o Tourniquet
o ChloraPrep
o Gauze/plaster/Cotton wool
o Blood culture bottles
o Alcohol wipes
o Closed vacutainer system (butterfly)
o Sharps bin
- Positionthe patientsothey are comfortable withthe armwell supported
- Identifysuitable siteandvein
- Applytourniquet
- 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
- Anchorveinwithnondominantthumb,supportingpatient’sarmwithfingersof same hand.
- Insertbutterfly intoveinwithbevel uppermost.
- Holding butterfly still, insert culture bottles into vacutainer system (aerobic first), holding
bottles upright. Allow to fill.
- As lastbottle isfilling,release tourniquet.
- Remove bottle andplace intray.Withdraw needle gentlywithdominanthandandasthisis
done,pressoverpuncture site withwadof gauze.Place needleimmediatelyintosharpsbin.
- If patientisable to co-operate,askthemtopressfirmlyongauze forseveral minutesto
minimise bruising.DONOTallowthemtoflex elbow asthiswill increase riskof bruising.
- Whenbleedinghasstopped,applysmall dressingif required.Checkpatientfeelswell (not
faint)
- Dispose of waste intosharpsbin/clinical waste/householdwasteasappropriate.
- Remove gloves and wash hands
- Label bloodbottlesandfill inbloodformsatthe bedside.
- Ensure bag issealedbefore dispatchingtolab.
18. 17
Arterial Blood Gases
- Introduce self,andestablishcorrectpatient
- Explainprocedure, getconsent,getanassistant
- Cleanhandswithalcohol gel
- PerformAllen’sTest.Donot proceedif abnormal result.
- Wash handswithsoapand water
- Gather equipment
- Gloves(nonsterile),Sharpsbin,ChloraPrep,Lignocaine(if used), ABGsyringe pack,Heparin
1000u/ml (if heparinisedsyringe notused),Needle (if notinpackor needtodraw up heparin),
Gauze
- Cleanhandswithalcohol gel andputgloveson
- Positionpatient’sarmwithwristextendedandpalpate radial artery
- Cleanthe site withChloraPrepfor30 secand allow todry
- (Injectlignocaineif used.)
- (Heparinise syringe if applicable andchange needle)
- (Expel liquidheparinthroughcleanneedle)
- DO NOT REPALPATEARTERY AT PUNCTURE SITE. Fix arterybetweenindex andmiddlefingers
of nondominanthand
- Warn patienttoexpecta scratch
- Insertneedle at60⁰, inopposite directiontobloodflow,untilyouobtainpulsatileflashback.
- Allowsyringe tofill with2ml blood(gentleaspirationmaysometimesbe required).
- Withdrawneedle,placinggauze oversite.
- Applyfirmpressure forat least5 minutes(longerif coagulopathyoronanticoagulants);can
ask assistanttodo this
- Dispose of needle,replacewithfiltercapandexpel anyairfromsyringe HOLDINGTHE
SYRINGE VERTICALLY.
- Take/sendimmediatelyforanalysis.(Label samplewithpatientdetails,date,time,inspiredO2
and temperature)
19. 18
Urinalysis
Urine samplesshouldbe collectedina cleandry container. The sample shouldnotbe more than4
hoursoldat the time of testing.
- Provide patientwithacleanurine pot.Explainthatyouneedamidstreamsample of urine.
- Wash ownhandsand put nonsterile glovesandanapronon.
- Note forclarity, transparency, particles,andcolourbefore removinglidof container.
- Remove lidof containerandcheck any obvious odour.
- Checkmultistix containerisintactandindate.DO NOT use if storedinhumidenvironmentor
if out of date as accuracy of resultscannotbe guaranteed.
- Remove astripfrom the containerandreplace lid(toavoiddegenerationof teststrips)
- Diptest stripintourine towetall the testzones.Donot leave inthe urine formore than one
second.
- Remove stripfromurine anddrag the edge of the strip alongthe rimof sample bottle to
remove excessurine.
- Replace lid.
- Take note of the time and compare testzonesonstripagainstthose on the multistix container
at the appropriate time.BEACCURATEIN YOUR TIMING.
- Commentonfindingsandnote anyabnormalities.
- Dispose of waste appropriately.(Urine downsluice ortoilet,containerintoclinical waste bag,
foldteststripinside glovesasyouremove them)
- Wash hands.
- Recordresults.
Othertests:microscopy,culture andsensitivity,cystoscopy,rectal examinationof prostate
Substance Name of
Condition
PossibleCauses
Glucose Glycosuria Diabetes Mellitus
Ketones Ketonuria Starvation,untreated diabetes mellitus
Specific gravity Ranges from 1.001-1.035 accordingto how concentrated the urineis
Blood/Erythrocytes Haematuria Bleeding in urinary tract,kidney stones, UTI, trauma
PH Normally urineslightly acidic (pH6) Vomiting and bacterial infection
can causeurineto become alkaline
Protein Proteinuria Severe hypertension, UTI, asymptomatic renal disease,may be seen
in high protein diets and pregnancy, vaginal discharge.
Nitrites Bacteriuria UTI
Leucocytes Pyuria UTI
Bilepigments Bilirubinuria Liver disease,obstruction of bileducts
Haemoglobin Haemoglobinuria Transfusion reaction,haemolytic anaemia,severeburns
20. 19
Ankle- Brachial Pressure Index (ABPI)
- Introduce yourself
- Explainprocedure andgetconsent
- Wash handsand cleanthe Dopplerprobe
- Positionpatientat45°
withsleeves andtrousersrolledup,allowingthem20-25 minutesrest
before startingthe procedure.Roomshouldbe warm.
- Place appropriate sizedbloodpressure cuff aroundarm
- Locate brachial pulse bypalpationandapplycontactgel at thissite
- Angle dopplerat45° to skinand locate bestpossible signal
- Inflate the bloodpressure cuff untilthe signal disappears
- Slowlydeflate the cuff until the signal reappears.Recordthispressure
- Repeatonthe opposite arm
- Retainthe highestreading
- Place appropriate sizedcuff aroundankle
- Locate dorsalispedispulse bypalpation,applygel andlocate bestsignal withDoppler
- Inflate cuff till signal disappears
- Deflate cuff,recordingpressure atwhichsignal reappears
- Repeatprocedure forposteriortibial pulse onthe same leg
- Retainthe higherreadingfromthe twopulses
- Repeatonthe opposite leg
- Cleanthe gel off the patientandallow themtoredress.Ensure theyare comfortable.
- Cleanthe gel off the Dopplerprobe
- Wash hands
- Calculate the ABPIforbothlegs:
RightABPI = highestof rightankle pressures(dorsalispedisORposteriortibial)
highestof arm pressures
LeftABPI = highestof leftankle pressures (dorsalispedisORposteriortibial)
highestof arm pressures
Normallythe systolicBPinlegs≥ armsso a normal ABPIshouldbe ≥1 in the supine position.
ABPIisa sensitivemarkerof arterial insufficiency. Typical valuesof ABPIare:
≥1 = Normal
<0.9 = Abnormal
0.5 – 0.9 = Claudication
<0.5 = Critical Ischaemia
NB: Indiabetics,systolicBPinlowerlimbsissometimesnotmeasurable asarteriesare calcifiedand
difficulttocompress(falsenormal result?).Pole testcanbe used
Allen’s Test
- Patientelevateshandandmakesfistfor20 sec,
- Firmpressure appliedtoradial andulnararteries,
- Patientopenshandwhichshouldblanchwhite,
- Release ulnarcompressionandhandshouldregainnormal colourwithin5-7sec
- Abnormal result: handremainswhiteuntil radial pressure released.
- Repeatforcheckingradial arterypatencybyreleasingcompressedradial artery.
21. 20
Fundoscopy
- Introduce yourself,checkpatientID,explainprocedure,gainconsent
- Checkthat ophthalmoscope isworking;checkbatteries, bulbandsettings.
- Askpatientif theywearcontact lensesorglasses.Patientshouldremove glassesbutleave
contact lensesinsitu. If the patientisextremelyshortsightedit maybe easiertoview the
funduswhilsttheyare wearingtheirglasses.
- Ensure optimal lightingconditions –dim lightsto dilate patient’spupils.
- Positionpatient(sitting,lookingstraightahead).Askpatienttofocus on somethingbehind
examiner’sheadand tell themto blinkand breathe normally.Examinerpositionsself face to
face withpatientat eye level,onside tobe examined.
- Place yourfree handagainstpatient’sforehead soatarm’s lengthfrom patient.You can then
use thumbof thishandto liftpatient’seyelidwhennecessary.
- Whilstexamining,examinershould attempttokeepbotheyesopenasthiswill reduce eye
fatigue. Holdophthalmoscope toyourrighteye in right hand to examine pt’srighteye and
vice versafor lefteye.
- Turn ophthalmoscope on,adjustto largest (NOTbrightest) lightsource andrack lensesto 0.
- Holdophthalmoscope with indexfingerrestingonfocusingwheel andthumbon on/off
switch.
- Use thumbto adjustbrightnessof beam.Toobrighta beamisuncomfortable.
- Directbeamof lightontopt’seye fromarms length awayand froman angle of 15-20° towards
the nose.Move slowlyin towardspt’seye.
- Thisdirectsbeamtowardsopticdisc.
- Look forred reflex anduse it to guide youclosertopupil. Observe shape and opacity (eg
advanced cataract)/transparency of redreflex. Shouldbe roundandclear
- Move in close to pt’seye.If bothyouand the patienthave an eye prescription,addthese
togetheranduse the focusingwheel to adjust the lensesaccordingly (EG: Patientprescription
= +1, your prescription=-1, setdial at 0)
- Observe disc:
o Contour(margin,size andshape)
o Colour andclarity
o Cup (opticcupto disc ratio):Cupisin centre of opticdisc,shouldbe < ½ diameterof
the disc
o Elevationof obscuringvesselsatdiscmargin
o Papilloedema
- In orderto facilitate observationof quadrantsof eye forfeaturesof vesselsandspaces,ask
patienttolookup/down/side toside.
o Observe vessels andcomment:AV ratio 2:3, AV crossing/nipping–indentations?
Arterial lightreflex? - Copper/silverwiring?Arteries/veins:how many?
Straight/tortuous?Normalcalibre? Narrowingofarteries? New vessel formation?
Venouspulsation
o Observe spaces andcomment:Microaneurysms?Dot,blot or flamehaemorrhages?
Cotton woolspots,Hard exudates?
- Fundusbackground:Exudates?Haemorrhages?Colour- red/purple?
- Observe macula(whichis temporal tothe disc).Askpatienttolookdirectlyatthe lightsource
to bringfoveaintoview andadjustitto the smallestsetting:Colour?Any vesselsaround
macula?Pigmented? Any degenerativechanges? Can you seethefovealreflex?
Haemorrhages?Hard exudates?
- Complete processonone eye andrepeatonothereye (yourlefteye toexaminepatient’sleft
eye.Adjustseatingaccordingly).
- Documentanddiscuss findingsasappropriate.
- Pathologies:papilloedema,hypertensive retinopathy,diabeticretinopathy
22. 21
Digital Rectal Examination
- Introduce yourself
- Explainprocedure, gainconsent,reassure patient. Provide chaperone.
- Ensure privacy,dignityandcomfort.Advise patientwhich clothingtheyneedtoremove.Allow
themtime andprivacyto do so.
- Gather equipment:
o Lubricant
o Nonsterile glovesandapron
o Gauze/tissues
o Disposable continence pad.
- Wash handsand puton glovesandapron
- Positionpatient- left,lateral positionwithknees andhipsflexedandplace disposable
continence padbeneathpatient’ships.
- Inspectgeneral areaof buttocks,observingforpressure sores,indicationsof personal hygiene,
muscle wastingetc.
- Part buttocksand inspectperianal areafor:
o Warts, Threadworms
o Anal fissures
o Ulcers
o Excoriation (surface injury –fromitching?)
o Haemorrhoids
o Fistulae
o Pressure sores
o Discharge
o Polyps, Skintags
o Prolapse (incomplete,completeorconcealed)
o General hygiene
- DO NOT proceedwithdigital rectal examinationif patienthasfistulae,excessive rectal
bleeding,historyof 3rddegree heartblockor autonomicdysreflexia.
- Applylubricanttoglovedindexfinger. Warnpatienttheymayfeel rectal fullnesssofeel the
urge to defaecate.
- Askpatienttotake a deepbreathandplace fingerintorectumto firstjointof finger,asking
patienttobear downif necessarytorelax sphincter.
- Testsphinctertone:“can yousqueeze myfingerwithyourbackpassage?”
- Advance fingerfurtherintorectum.
- Perform180° posteriorsweepof rectumanddescribe findings:
o Smooth/pliable
o Lymphnodes
o Abscesses
o Polyps
o Faeces
o Doespatientexperienceanypain? Tenderness?
- Turn arm to perform180° sweepof anterioraspectof rectum and describe findings.
- In a male patient:Prostate (benignhypertrophy?Nodules –cancerous?)
o Pliabilityof prostate, location,tenderness,size, regularityof shape,consistency –
smooth,rubbery,nodularity,symmetry,presence/absence of medial sulcus.
- Slowlywithdraw fingerandexamine forblood,mucus,faecesorpus.
- Cleanpatientusingwipesthencoverthe patient.Allow themtimetoredress.
- Remove apronandglovesandwashhands
- Discussfindingsasappropriate anddocument
23. 22
Breast Examination
- Introduce yourself,patientID
- Explainprocedure andgain consent,reassure patient
- Ensure dignity,privacyandcomfortat all times.
- Advise patient whichclothestheyneedto remove andallow time todo so inprivacy.Provide
themwith sheetor blanket withwhichtopreserve theirmodesty.
- Provide chaperone.
- Wash yourhands
- Positionpatientsitting on edge of bedor chair, naked to waist.
- Observe for:
o symmetry of breasttissue,
o alteredpigmentation, skinchanges
o venouspattern orlocalised hypervascularareas,
o nipple discharge orbleeding,
o nipple retractionordeviation,
o rash on areolaor nipple,
o changesinbreastsize or shape,
o oedemaof the skinwithdimpling - peaud’orange
o obviouslumps/swellings
o inflammation,pain
o Abnormal reddening,thickeningorulcerationof the areola(Paget’sdisease)
o Askif any painor ‘tugging’sensationisexperienced.
- Considerthe listabove. Certainfeaturesmaybe presentinsome positionsandnotothers.
o At rest- Askpatienttoplace hands restingonthighs
o Askpatienttoraise arms above head.
o Askpatienttoplace hands onhipsand pressinwards.
o Askpatienttoleanforward
o Askpatienttolie insupine positionwitharmsflatalongsides.
- Explainyouwill firstexaminethe ‘normal’breastinorder to determinebreasttissue changes.
- Askpatienttoplace hand behindheadonside youwishtoexamine if thisisthe preferred
procedure of the consultant.
- Askthe patientto tell youif theyhave anypainor discomfort
- Palpate with palmarsurface of middle three fingers.Use rotarymovementtocompresstissue
gentlyagainstchestwall.
- Observe forlumps:
o Estimate itssize
o Describe texture/consistency
o Describe shape
o Is ittetheredtounderlyingtissue?
o Is ittender?
o Commentonmobility
o Describe locationinrelationtoclockface,usingnippleasthe centre
- Examine:
o Quadrants
o Areolar area
o Tail of Spence (betweenfingerandthumb)
o Lymph nodes:Anterior axillary,posterior axillary,apical, supra-clavicular,infra-
clavicular, nodeson medial aspect of humerus
- Examine otherbreastandcompare/contrastfindings
- Wash hands.
- Describe/documentfindings.
- End pieces:Checkliverandspine formets,Triple assessmentincl mammogram, FNA
24. 23
Testicular Examination
- Introduce yourself
- Explainthe procedure,Reassurethe patient,Obtainverbal consent
- Identifythe needforachaperone
- Wear gloves
- Inspectfor:
o Skinchanges(pigmentation,ulceration,erythema)
o Symmetry
o Lie of testes
o Oedema/swelling
- Checkwhetherpatienthasanypainbefore proceedingwithpalpation
- Palpate:
o Testes
o Epididymis
o Spermaticcord
- Identifywhattheyare lookingfor/describe findings
o Observe forsignsof discomfort
o Is the testispalpable asadiscrete organ?(Wouldnotbe withhydrocele)
o Size andconsistencyof testes
o Describe locationof massor lump
o Estimate size of anymass incentimetres
o Describe the texture
o Describe the shape
o Is ittetheredtounderlyingtissue?
o Is ittender?
o Commentonmobility
o Can youget above the swelling?(It ispossible to‘getabove’atesticularswellingbut
not a scrotal hernia)
- Performtransilluminationof bothsidesof the scrotuminthe presence of aswelling
o Place pentorch lightupagainstthe swelling
o Cysticswellingwillspreadbrightredglow into scrotum, asolidtumourwill not
- Checkfor coughimpulse
o Place twofingersonthe mass and determinewhetheranimpulseistransmittedtothe
fingertipswhenthe patientcoughs(wouldbe presentwithahernia)
- Describe findings
- Coverpatient
- Remove glovesandwashhands
- Maintainpatientsdignitythroughout
- Attemptdiagnosis
25. 24
Urinary Catheterisation
Catheterpacks and actual insertiontechnique mayvary across sites.The important thing to
rememberisthat this is a STERILE procedure.Maintaining patientdignity,safety and sterilityat all
timesis more important than the methodyou use. Practise all the ways you have beenshownand
work out whichis best for you.
- Introduce yourself
- Explainprocedure topatient(includingpatienteducation) andgainverbal consent. Identify
needforchaperone.
- Encourage patienttohave a showerorbath before catheterisationif possible.
- Wash handswithsoapand waterand cleantrolleyusingappropriate technique
- Place all necessaryequipmentonbottomshelf,checkingintegrity andexpirydates
o Sterile catheterpack
o Disposable pad
o Sterile gloves (x2pairs)
o Catheter
o Lubricating/anaestheticgel
o Specimencontainerif specimenisrequired.
o 0.9% sodiumchloride orantisepticsolution
o 10mls waterfor injectionand syringe (ifnotprovidedwithcatheter)
o Hand gel
o Apron
o Drainage bag and stand.
o Clinical waste bag
- Screenbed, assistpatientintosupineposition.DONOTexpose orpositionpatientatthis
stage.
- Wash hands.
- Openoutercoverof catheterisationpackandslide contentsontotopshelf of trolleyusing
aseptictechnique.Openinnercoverof catheterisationpackholdingonlythe edgesof the
paperor plasticwrap.This isnowyour sterile field.
- Opensupplementarypacketsontosterile field.Retaincatheterpacketfornotes.
- Pourcleaningsolutionintogallipotfromaheightof several cms.
- Place a disposable padbeneathpatient’sbuttocks.
- Wash hands.
- Opensterile glovesontoanothertrolleyandputgloveson.
- Arrange equipmentonsterile field. Tearendoff innerwrappingof cathetertoexpose tipand
place catheterinreceiver
- Nowask chaperone toexpose the patient
- Refertomale/female proceduresasfollows:
FROM THIS POINT,MAINTAIN YOURDOMINANT HAND AS THE UNCONTAMINATEDONE
THROUGHOUT THE PROCEUDRE.
26. 25
Male CatheterisationProcedure
- Use sterile swabtowraparoundpenisandretract foreskin.
- Positiondrape onpatientsothaturethra isaccessible.
- Cleanglanspeniswithsalinesolution. Workawayfromurethraandavoidgoingback over
same area twice.Discard usedswabsintoclinical waste.
- Ensure dominant handdoesnotmake contact withpatientor bedlinen.
- Usinga swabto holdthe penis,holdthe penisinaraisedpositionandDROP small amountof
anaesthetic/lubricantgel aroundurethral openingbefore administering 11mlsof the gel into
urethra. Ensure that tipof nozzle doesnottouchpenis. Discardintoclinical waste.
- Wait 3-5 minutesforanaesthetictowork,continuingtoholdpenis sothatitis almost
completelyextended.
- Change gloves
- Place the receivercontainingthe catheterbetweenpatient’slegs.
- You can noweitherremove catheterfromblue wrappingandcoil itwithinpalmof dominant
handwithtip protruding,orinsertcatheterintourethradirectlyfrominnerwrapping.
- Insertcatheterfor15-20cm alongurethra.If resistance isfeltatthe external sphincter,askthe
patienttogentlystrainas if passingurine.If thisispainful orineffective,seekexpert
assistance.
- Whenurine beginstoflowfromcatheter,advance almosttoitsbifurcation.
- Inflate balloonusing10mls(orspecifiedamount)of sterilewater. There shouldbe no
resistance.
- Withdrawcatheterslightlyuntilitisevidentthatthe balloonisinflatedwithinthe bladder.
- Repositionforeskin.
- Connectto catheterbagand supportbag usingcatheterstandor legstraps.
- If requested,take urine samplefromcatheterviaportusing greenneedle andsyringe.
- Tidyarea and dispose of waste appropriately.
- Remove glovesandwashhands.
- Recordrelevantinformationandguidance foraftercare innotes.
Female CatheterisationProcedure
- Positiondrape toexpose urethra.
- Withpatientinsupine position, separate labiaminorausingaswab so thatthe urethral
meatuscan be seen
- Use sterile swabsand0.9%sodiumchloride tocleanurethral orifice,workinginsingle strokes
down.
- Discard swabsinclinical waste.
- Drop small amountof anaesthetic/lubricationgel aroundurethraandthenadminister6ml of
it intourethra.
- Wait 3-5 minutes.
- Change gloves
- Place receivercontainingcatheterbetweenpatient’slegs
- Introduce tipof catheterintourethrain an upwardand backwarddirection.
- If catheteris wronglyinsertedintovagina,leaveitthere whilstintroducingasecond,clean
catheterintothe urethra,and thenremove the wronglysituatedone.
- Advance the catheteruntil 5-6cmhas beeninsertedandurine beginstoflow.
- Advance a little furtherandinflatethe balloon. There shouldbe noresistance.
- Withdrawthe catheterslightlytocheckitisin situ.
- Connectto catheterbag.
- Supportthe catheterbag eitherona stand or usinglegbagstraps.
- Cleanthe patientandthe area, disposingof clinical waste appropriately.
- Take urine sample forlaboratoryspecimenviathe specimenport.
- Remove glovesandwashhands
- Recordrelevantdetail inpatient’snotes
27. 26
Performing an ECG
- Introduce self andensure correctpatient.
- Explainprocedure andgain verbal consent.
- Prepare ptensuringcomfort,dignityandprivacy.Provide chaperone where appropriate.
- Advise ptwhatclothingandjewellerytheyare requiredtoremove. Washhands.
- Askpt to lie flat on couch andadvise themtokeeplimbsrelaxed.Prepare skin:bodylotions
and oilsmayneedtobe removedtoallow adhesionof electrodepads.Itmaybe necessaryto
shave chesthair.
- Plug ECG machine in.Checkthat the machine is correctly calibrated (25mm/s, 10mm/mV).
- Apply electrode pads to limbsona bonyprominence andapplylimb leads:
o rightwrist= RED
o leftwrist= YELLOW
o leftankle =GREEN
o rightankle = BLACK (Thisisthe anti-staticorearth electrode)
o (Inamputees,place onthe mostdistal bonyprominence)
- Apply chestelectrode padsand apply chestleads;
o V1: 4th intercostal space, rightsternal edge
o V2: 4th
intercostal space,leftsternal edge
o V3: MidwaybetweenV2& V4
o V4: 5th
intercostal space,midclavicularline
o V5: MidwaybetweenV4& V6
o V6: 5th
intercostal space,midaxillarline
- Start machine.Remembertoaskthe patienttolie asstill aspossible.
- Accurately record 12 lead ECG.
- Remove wiresfrom pt’slimbsandchest.Remove padsfrompatient,takingcare notto pull
skin/hair.
- Give patientprivacytodressbefore advisingthemwhere togo/whattodofor results.
- Write patientsdetails onto printoutif notalreadyon.
- Accurately complete all relevantdocumentation
- Thank patient,ensure theyare leftcomfortably.
28. 27
InterpretingECGs
10 physical leadswithattachedelectrodes,but12 leadreadings:
- Peripheral limbelectrodes:
RightArm Red Ride
LeftArm Yellow Your
LeftLeg Green Green
RightLeg Black Bike
- Electrode positionsonthe heart:
V1 4th
intercostal space,rightsternal border Rightventricle
V2 4th
intercostal space,leftsternalborder Rightventricle
V3 InbetweenV2andV4 InterventricularSeptum
V4 5th
intercostal space,mid-clavicularline InterventricularSeptum
V5 InbetweenV4andV6 Leftventricle
V6 5th
intercostal space,mid-axillaryline Leftventricle
ECG Axis–showsthe directionof the readingstaken,egfromleftarmto right arm.These
readingsare shownonECG printouts as shownbelow.
29. 28
INTERPRETATION
1. Demographics:
- Name,DOB,date and time of ECG, indicationforECG,any symptoms
- Checkthere iselectrical activityineveryleadandthatcalibrationiscorrect:25mm/s
paperspeed,10mm/mvamplitude reference
2. Rate:
- 300/no of big squaresbetweeneachRpeak=... bpm
- (300 is workedoutfrom5 bigsquaresbeingwrittenpersecond,therefore 300 big
squaresare writtenin1 minute).Eg300/4 = 75 bpm
3. Rhythm:
- Mark outon a piece of paperthe peaksof a few QRS complexesfromleadII,and
compare to the rhythmstrip to see if regularorirregular
- Regular
- Irregular
o Regularlyirregular→ Heartblock
o Irregularlyirregular→ AF(noPwaveswill be visible)
30. 29
4. Axis
Representsthe generaldirectioninwhichelectrical activityspreadsacrossthe heart:
- If both leadI andaVF are positive,the axisisnormal.
- If leadI is positive andaVFisnegative,the axisisdeviatedtothe LEFT
- If leadI is negative andaVFispositive,the axisisdeviatedtothe RIGHT
5. P-waves:
Are theypresent?
- Yes?Before everyQRS?Patientisinsinusrhythm
- No?→ AF
Is there a P-wave before eachQRS?Nomeansheartblock
P-wavesshouldbe uprightinleadsI,IIandV2-V6.
BifidP-waves=leftatrial hypertrophy
PeakedP-waves=rightatrial hypertrophy
6. P-R interval:
Shouldbe 120-200ms (<1 bigsquare or 3-5 small sqs)
How longdoesitlast?
- If >200ms thenitis 1st
degree heartblock
- If <120 thenaccessorypathwayproblemsegWolf-Parkinson-Whitesyndrome
Is itthe same eachtime?
7. QRS complex:
Shouldbe <120ms (3 small squares)
Is it<120?
- If >120 thenbundle branchblock(BBB),or a depolarisationoriginatinginthe
ventricles.
How bigisthe QRS complex?If itisbig,leftventricularhypertrophy
8. ST segment:
Is ST segmentisoelectricwiththe baseline (before P-wave)?
- ST segmentelevation?→ ischaemia?Infarct?MI
- ST segmentdepression?→ ischaemia?Angina
9. T-wave:
Shouldbe uprightinleadsI,II andV2-V6
Doesit go up?Doesit go down?
- T-wave inversionisasignof an oldMI/ischaemia
Is itpointy/”tented”?→ hyperkalaemia
Is itflat?→ hypokalaemia
10. QT interval:
Measuredfromstart of QRS,to endof T-wave.Varieswithrate.
Shouldbe 380-420ms (2 large squares)
How longisQT duration?
- If >420ms, thenLongQT Syndrome orpropensitytodevelopventriculartachycardia
whichcan cause suddendeath
31. 30
Interpreting Chest X-Rays/Radiographs
- Patientcredentials,name, gender, DOB,age;date of CXR,whichhospital
- Posterioranterior(PA) orAnteriorposterior(AP)?
- Supine orerect?
- Commentonqualityof the film:
o Are claviclesvisible and equidistantfromthe spinousprocess?(rotation)
o Are five anterior ribs visible?(expansion)
o Are all the lungedgesare visible?(centering)
o Are the vertebral bodies of the dorsal spine visibleandalsothe lefthemi diaphragm?
(exposure/penetration)
- Is trachea central?
- Is the mediastinumnot displaced?
o Cardiothoracic ratio<1:2?
o Is twothirdsof the heartare visible onthe lefthandside?
o Are right atriumandleftventricle are visible?
- Are the hila normal?
o Are the hila concave and bothsymmetrical inappearance?
o Is the lefthilaisno more than 1.5cms higherthan the right?
o No signof lymphadenopathy athila?
- Mediastinal contoursnormal?Egaorticknuckle
- Do the lungs appear clear?
o Any opacities?Homogenous?Heterogenous?
o Is there nodistortion of the lungor lungfields?
o Is there nosignof depressedhemi diaphragm?
o Are Costophrenicangles and cardiophrenicangles nice and crisp?
o Is there nofluidtrapped beneaththe lungs/diaphragm?
- Do the pleura appearnormal?
o No pneumothorax or pleural effusion?
o Thickening?
o Calcifications?
- Is there nofree air underthe diaphragm? (if free airwaspresentthiswouldbe indicative of
perforatedbowel) Howeverthere isavisibleairbubble- gastricbubble.
- Do the bones andsoft tissue appearnormal?
o Any fractured ribs/clavicles?
o Both breast shadowsare present(female)?Mastectomy?
o Do bonesdoappear destroyedortissuessclerotic?
- Reviewareas if noabnormalitiesfound:
o Softtissue
o Bones
o Trachea
o Mediastinum
o Pleura/Apices
o Diaphragm
o Behindthe Heart
32. 31
Giving Information
- Possible topics: anewdiagnosis,explainingaprocedure,explainingamedicationregime,
teaching(eghypertension,warfarin,24hrurine collection,inhalers,endoscopy)
- Establishpatient’spresentunderstandingandideas: “Whatdoyouknow about… before we
begin?”
- “Sign-post”/structure:introduction,establishesthe purposeof the interview
- “Feel free tostopme if youhave any questions”
- Explain+/- demonstrate:givesaccurate andappropriate information,explainsinawaythe
patientcan understand(language,vocab,drawings),atthe correctpace.
- Clarifiespatientsunderstanding:“Didthatmake sense/doyouunderstand?”
- Checksforconcernsand addressesthem: “Doyouhave any questions?”
Reading Obs Charts
- Patientcredentials
- Checkhowfrequentlyobsshouldbe taken(4houristhe standard butDrs can increase this)
- Time of day
- Temperature (anyspiking? Septic?)
- Bloodpressure (anydrops?Bleed?Septic?) (markedwithadottedline between2crosses)
- Pulse
- RespiratoryRate
- O2 sats (normal- 94-98, COPD 88-92)
- Consciousness
- MEWS – what isthe trend?Whatare theypreviouslymewsingat?
- Extras: egurine
- Are obs stable/withinnormal parameters?
- FOLLOW THE PATTERN OF EACH
