Order of stations?
Obtaining a 12 lead ECG and setting up a cardiac monitor
14 minutes
2a) Administering a nebuliser
2b) Advising a patient on inhaler technique
2c) Administering oxygen
14 minutes
3a) Administering an intramuscular injection
3b) Administering a subcutaneous injection
14 minutes
4a) Peak expiratory flow
4b) Obtaining an arterial blood gas sample
14 minutes
What does WIPER stand for?
Wash hands
Introduce and identify
Permission
Expose appropriately
Reposition if needed
For an ECG where are the limb leads placed?
bony prominence of:
right arm (red)
left arm (yellow)
left leg (green)
right leg (black)
Where are the chest leads placed?
C1- 4TH intercostal space right sternal border
C2- 4th intercostal space left sternal border
C3- half way between C2&C4
C4- 5th intercostal space mid clavicular
C5- anterior axillary line horizontal to C4
C6- mid axillary horizontal to C4 and C5
What do you say to the patient before an ECG?
- Explain the procedure- ‘I’ve been asked to take some recordings of your heart, this will involve me placing some stickers on your chest, arms and legs. I’ll then attach the stickers to some leads which are part of the machine. These will then take a recording of your heart. You shouldn’t feel any pain. The procedure will involve you being exposed down to your waste is that ok? I will also need to have access to your ankles. Would you like a chaperone?’
- Gain consent and check allergies (to stickers)
Process of ECG?
- wash hands
- indicate electrodes on diagram
- attach wires to electrodes
- ask patient to lie still and not talk please
- calibrate machine to 25mm/s and 10mm/mv and press AUTO
- id remove the electrodes, check for artefacts, label the ECG and record in patients notes
Where are the leads placed for cardiac monitoring?
right shoulder: over acromion/ lateral clavicle (red)
left shoulder: over acromium/ lateral clavicle (yellow)
Left lower chest over lower ribs: gr`een or black
What do you say to the patient before cardiac monitoring?
- Explain the procedure-‘this cardiac monitor will continually measure the rate of your heart. I am going to attach 3 little stickers to your chest, these will then attach to some leads which will attach to a monitor. Then we can monitor the trace of your heart. This will remain on for the rest of the day- you don’t have to stay still but if you need to get up and go to the toilet just let us know. If your rate increases then there will be little alarms that will go off which will let the nurses know. Any questions? I will need to expose your chest if that is ok? And would you like a chaperone?’
- Gain consent and check allergies
process of cardiac monitoring?
- “I would prepare patient correctly for electrode placement, by cleaning with an alcohol swab and shaving hair-bearing areas if needed”
- Apply electrodes (stickers) to correct areas on the diagram.
- Attach cardiac monitor lead wires to the electrodes on the patient.
- Switches on the monitor, selects an appropriate monitoring lead and sets the alarms within safe parameters
- Check patient is ok
- ‘I would check the electrode sites for any redness/itching’
- “I would record in the notes that monitoring has commenced and would make a note of the ECG rhythm on commencing monitoring
- Q1: How would you objectively monitor the effectiveness of this treatment?
- Q2: Why did you leave the nasal cannula on when administering the nebuliser?
o Do peak flow 20 mins after nebuliser finishes
o To prevent desaturation
What do you say before administering through a nebuliser?
-‘I’ve been asked today to give you some medication via a nebuliser. This medication will open up your airways and allow O2 to get into your body more easily. The machine will turn the medication into a vapour which goes directly into your lungs. Does that sound ok- do you have any questions?’
- Gain consent and check for allergies
Process of nebuliser
- ‘I would check medication and expiry date against patients prescription chart’
- Select MOUTHPIECE
- Connect tubing to the compressor
- Dispense drug (water) into nebuliser chamber
- “I would ask the patient to sit upright and to hold the nebuliser chamber upright’. Mouth has tight seal around the nebuliser.
- Switch compressor on
- Advise patient to breathe through their mouth
- Checks patients welfare
- “I would document the procedure in the patient’s notes”. (would normally give patient a peak flow test 20 mins after nebuliser)
What would you say before inhaler technique?
‘just wanted to have a chat about your inhaler and just to make sure you are using the correct technique. I have brought along a spacer for you to have to help with this. I am also going to show you how to use it.
- Gain consent and check for allergies
Process of explaining inhaler technique?
- Wash hands with alcohol gel
- ‘I would check medication and expiry date against patients prescription chart’
- Remove cap from metered dose inhaler and cap from spacer if it has one
- Shakes inhaler briskly 4 or 5 times
- Inserts inhaler into spacer
- Explain to patient to;
• Breathe out gently.
• Place the mouthpiece of the spacer into their mouth and create a good seal with their lips.
• Press the canister once to release the dose of the drug.
• Take a slow controlled deep breath in and hold for 10-15 seconds OR take 5 slow controlled breaths in and out.
• Remove the mouthpiece from their mouth and breathe normally. - Inform patient that for second dose- should wait about 30 seconds before repeating process. Removes inhaler from spacer and replaces the caps on the inhaler and the spacer.
- Check patients welfare
- “I would document the procedure in the patient’s notes”
Equipment needed for IM injection
- drug and drug chart
- gloves and apron
- syringe
- two BLUE needles
- wipe to clean the skin
- sharps bin
What do you say before an IM injection
- ‘today I am going to give you a little injection in buttock and as this is a deep muscle so it won’t be too painful and will make you feel better soon’
- tell patient to lie in lateral position
- Gain consent and check for allergies to any medication
- “I would check the name, dose and route of administration of the drug against the prescription chart”
- “I would check the expiry date of the drug”
Process of IM injection
- Washes hands using alcohol gel
- Don gloves and apron
- Sterile technique to open the packaging
- Draw up and administer drug by IM route into buttock of the manikin (draw up 1ml of NaCl). Change needle before administering the injection.
o Sharps bin!
o Clean skin with wipe and leave to dry
o Injection goes into upper outer quadrant (make it obvious that you are dividing into 4 using the greater trochanter of femur as the landmark)
o Assess site for any lesions or inflammation
o Stretch skin around injection site
o Insert needle 90degrees to skin surface (‘just going to be a sharp scratch’)
o Leaves one third of needle visible
o Checks needle is not in blood vessel by pulling back plunger (if blood is seen the remove needle and syringe and apply pressure to site until haemostasis has been achieved then start again with new equipment).
o Inject meds slowly
o Remove needle and apply pressure at site
o Needle in sharps bin - ‘I would sign the prescription chart at patient’s bedside’
- Check patient welfare
How do you inject subcutaneously?
Pinch the skin into a fold and inject at 45 degrees
Equipment needed for SC injection?
- gloves and apron
- drug and drug chart
- syringe
- two orange needles
- wipe
-sharps bin
What do you say before an SC injection?
- Introduce self
- Identify patient and check with drug chart etc
- Explain procedure and then get consent and check for allergies. ‘So today I’ve been asked just to give you a little injection just to make sure you aren’t going to develop any little clots in your body whilst you’re in having to stay in bed here in the hospital. It is a very routine procedure. It will be given in the skin of your tummy and it is a small and not very painful injection. ‘
Process of SC injection
o “I would check the name, dose and route of administration of the drug against the prescription chart” and “I would check the expiry date of the drug”
o Wash hand with alc gel
o Dons apron and gloves
o Sterile technique
o Draw up drug (actually 1ml of NaCl)
o Change needle between drawing up and admin
o Sharps bin
- Identify site (‘can I ask you just to expose your tummy area’) and clean skin and leave to dry
- Pinch skin and warn of ‘sharp scratch’
- Insert needle at 45 degrees to skin surface
- Insert needle into SC tissue and release skin
- Administer drug slowly
- Removes needle and apply pressure at puncture site
- Dispose of sharps
- Sign prescription chart
- Check patient is ok
How would you explain what a peak flow is, why and when it should be done
• What is peak flow;
o a peak flow meter measures the maximum speed that a patient can exhale air from their lungs in litres per minute. A patient’s peak flow can be compared with normal expected values for someone of their age, sex and height and there are charts that can be used to work out normal values.
• Why they need to monitor their peak flow;
o In asthma, the airways become narrowed and this reduces the speed that air can move through them. Changes in a patient’s peak flow over time reflect changes in the severity of their disease and the effectiveness of their treatment. A peak flow diary is useful to guide doctors as to whether current asthma medication is working or whether a change in treatment regimen is needed. In this patient’s case, the GP wishes to see if there is any improvement in Peak Flow once the patient starts using a salbutamol inhaler, indicating that this treatment is effective in increasing air flow.
• When they should check their peak flow i.e. what times of day; How many exhalations are needed, and which result should be recorded?
o The student should explain to the patient that three readings should be taken every morning and every evening, before using their inhaler. The best of the three readings should be recorded in the Peak Flow Diary. It is common for morning readings to be lower than evening readings
What do you say before showing the patient how to do a peak flow?
- ‘today we will be doing a peak flow test on your lungs due to the problems you have been having with your asthma. We use it to assess the severity of your asthma and also to monitor the progress of your treatment and to see how it has been working. We need the best technique for the correct results. I will demonstrate and then let you have a go- does that sound ok?’
Process of Peak flow
- Peak flow meter;
o Set pointer to 0
o Use a disposable mouthpiece
o Sit upright and hold meter horizontally
o Make sure pointer moves smoothly along the scale
o Take deep breath
o Form tight seal around with mouthpiece with lips
o Blow as hard and fast as you can
o Note reading and reset pointer
o Do 3 times and record highest value - Get patient to do it (change mouthpiece) and check technique and show them how to record on flow chart
- Check patient is ok and ask if any questions
-
Introductory Clinical Sciences480
-
Public Health319
-
Microbiology359
-
Respiratory482
-
Cardiovascular466
-
Haematology198
-
GI and Liver380
-
Rheumatology289
-
Neurology321
-
Dermatology and Endocrine409
-
DOCSS34
-
IACSS18
-
Catheters7
-
Miscellaneous12
-
Genitourinary172
-
Microbiology and Pathology (before Xmas)198
-
Peer Teaching Exam Questions141
-
Introduction to Clinical Sciences558
-
Drugs62
