Clinical Skills Flashcards
How to use a stethoscope
- Insert the earpieces so that they point forward towards the bridge of the nose.
- For a dual-head stethoscope, you will select one side while deselecting the opposite side. Some scopes have an indicator dot, while others have a slight bend in the stem that indicates which side is in action. Gently tapping on the chest piece (first one side then the other) will show you which side is active
- To use the diaphragm, apply sufficient pressure to just slightly deflect its surface. You’ll know when optimum pressure is applied as the sound will be markedly louder and clearer
- To use the bell, you want to apply just enough pressure to make a seal, but no more
What is blood pressure?
The pressure exerted by blood in the arteries
This varies between a maximum at the peak of ventricular contraction (systole) and a minimum at the end of ventricular relaxation (diastole)
The blood pressure cuff is placed on the upper arm and inflated to stop blood flow from the brachial artery to the arm. When the pressure in the cuff exceeds the pressure in the artery, blood flow is occluded, and no pulse will be felt below the cuff.
As you slowly release the pressure cuff, the cuff pressure begins to decrease. When it reaches the peak systolic pressure, the artery opens a little, but the flow is turbulent rather than laminar. This generates tapping sounds called Korotkoff sounds, which can be heard through a stethoscope. When turbulent blood flow is first heard, the cuff pressure approximates systolic pressure.
As the cuff pressure continues to decrease and the artery regains its normal diameter, blood flow becomes laminar, and the sounds become muffled and then disappear. The cuff pressure at the point of the sound muffling approximates the minimum blood pressure (diastolic pressure)
How to find the brachial pulse?
First find the radial pulse (next to veins on same side as thumb). The Brachial pulse is on the opposite side of the arm, on the bend of the forearm.
Ensure arm is completely straight.
Manual blood pressure procedure
- Make sure the patient is sat down and comfortable. Feet should be flat on the floor and arm should be resting at heart level and straight
- Introduce yourself and confirm patient ID (3 identifiers – name, DoB, address)
- Explain the procedure “I’m here to check your blood pressure. Is that okay? I’ll inflate this cuff, and it’ll constrict around your arm. But first I’m going to count your pulse rate. Stop me if you feel too uncomfortable at any point”
- Find the brachial or radial pulse and count for a full 60 seconds
- Find the brachial pulse
- Wrap cuff around upper arm and just above the elbow
- Feel for the brachial or radial pulse, then inflate the cuff until the pulse is no longer detectable. This is the estimated systolic pressure.
- Deflate the cuff.
- Place the stethoscope diaphragm over the brachial artery. Inflate the cuff to 20-30 mmHg higher than the estimated systolic pressure.
- Slowly reduce the pressure in the cuff (~1-2 mmHg/s) while listening through the stethoscope for Korotkoff sounds.
- Systolic pressure is the pressure at which sharp, tapping sounds are first heard.
- Continue to slowly reduce the cuff pressure. The diastolic pressure is defined as the pressure at which the sounds disappear.
- Completely deflate the cuff after diastolic pressure is determined.
In practice would record two measurements of the blood pressure. Allow 2 minutes between measurements for recovery.
What is the normal range for respiratory rate?
12-20 breaths per min
High RR >25 BPM, more energy consumption and can lead to exhaustion
Low RR <8 BPM, Risk of death. Red Flag.
The following breath sounds would indicate what?
1. Soft and low-pitched breeze-like sound
2. Wheeze
3. Crackles
4. Rubs
5. Stridor (high pitched whistling sound)
- Breeze-like sound - normal (vesicular)
- Wheeze – asthma and COPD
- Crackles – pneumonia and pulmonary oedema
- Rubs – pleural effusion (excessive fluid in the pleural space, the space that surrounds each lung)
- Stridor (high pitched whistling sound) – obstruction
Sound travels best through what medium?
Solids
A consolidated space will transmit sounds more and sound louder
Chest exam procedure
- Introduce yourself
- Confirm patient ID (3 identifiers - name, DoB, address)
- Explain procedure (“I’m here to take your pulse. Then I’ll listen to your chest using my stethoscope. Just to see if there’s anything concerning. This is best done with direct skin contact, but I won’t be doing that today. Is that okay?”)
- Ask if they want a chaperone
Respiratory rate
5. Ensure the patient’s feet are flat on the floor; sitting with legs suspended can reduce venous return, which may increase heart rate and subsequently RR.
6. Pretend to take pulse whilst measuring respiratory rate (Measure for full 60 seconds, normal range = 12-20 breaths per min)
Chest auscultation
7. “Next I’m going to listen to your chest using my stethoscope. Please take some deep breaths in and out through your mouth every time the stethoscope touches you”
8. Using the diaphragm side, start above the collarbone and end at the bottom of the ribs (5 at the front). Listen high, wide and systematically - for a full inhalation and exhalation at each point.
9. Repeat on the back. Listen to more areas at the back – at least 6 sections, ensure you come wide at the end.
10. Feedback to patient
a. Respirate rate? Equal distribution? Added sounds? Patient visual appearance?
b. “Thank you for that. So, your respiratory rate was normal at –. Your chest also sounded clear on both sides, I didn’t hear any added sounds such as crackles or wheezes. You didn’t look like you were using a lot of effort to breathe”
When is urinalysis using a dipstick required?
- <65, female, 1 key symptom= REQUIRED
- <65, female, 2+key symptoms= NOT NEEDED as UTI likely
Aged over 65 years — dipsticks become more unreliable with increasing age over 65 years.
An MSU instead of a dipstick should be arranged for women who satisfy what conditions?
- Is pregnant
- Is aged over 65 years
- Has symptoms that are persistent, not resolving with antibiotic treatment, or recurring within four weeks after antibiotic treatment
- Has a history of recurrent UTI
- Has a urinary catheter in situ or has been catheterised within the previous 48 hours
What results on a dipstick would make a UTI likely/less likely?
- Positive for nitrite and leukocytes = UTI is likely
- Negative for nitrite and positive for leukocytes = UTI is equally as likely as an alternative cause for symptoms.
* Send a mid-stream urine (MSU) sample for culture and sensitivities to confirm the diagnosis. - Negative for both nitrites and leukocytes = UTI is less likely and suggests an alternative cause for symptoms
Potential causes of the following UTI symptoms?
* Cloudy
* Colour change
* Unpleasant smell
Urinalysis procedure
- Wash hands
- Check reagent sticks are in date
- Put on gloves (+/- apron)
- Dip the reagent strip into the urine for 1-2 seconds (DO NOT SOAK)
- Strip should be completely immersed and then removed, wiping any excess urine on the side of the pot
- Start the timer
- Hold the dipstick sideways/horizontal against the tube to read the results (read from the bottom up)
- Read results out loud and mark on sheet
- Dispose of your waste correctly. The test strip and container should be placed in a clinical waste bag. The urine should be disposed of in a sluice in a hospital setting.
- Feedback to patient
a. Introduce yourself and confirm ID (3 identifiers – name, DoB, address)
b. If negative for infection “The sample is negative for infection. I would recommend keeping hydrated and monitoring your symptoms. If they don’t improve in the next few days or if they get worse/you get new symptoms then please come back”
c. If positive for infection “Your urine sample had some…which suggests a urine infection. I will write you a prescription for some antibiotics. Fo you have any allergies? If the infection doesn’t clear up following the antibiotics, please come back, and we can consider an alternative antibiotic”
What do the presence or absence of the following indicate for urinalysis?
1. Glucose
2. Bilirubin/Urobilinogen
3. Ketones
4. Specific gravity
5. Blood
6. pH
7. Protein
8. Nitrites
9. Leukocytes
- Glucose - elevated blood glucose levels (diabetes) or reduced renal absorption (renal glycosuria, if plasma glucose concentration is normal)
- Bilirubin/Urobilinogen - gallbladder/liver impairment
- Ketones – products of fat metabolism and are a sign of the body using an alternative source of energy (instead of insulin or carbohydrates). Diabetic ketoacidosis (if associated with raised glucose) or starvation/fasting (if not associated with raised glucose)
- Specific gravity – measures the concentrating and diluting power of the kidney, measure of hydration. Dilute urine in absence of water intake indicates diabetes insipidus or chronic renal disease
- Blood – infection, cancer, trauma, period
- pH – average urine is slightly more acidic and usually within a pH of 5 – 6, but may vary from 4.6 – 8.0. Strongly alkaline urine may indicate infection with bacteria that metabolize urea
- Protein – normal urine contains small amounts of albumin and globulin, but generally in amounts low enough not to give positive readings. Infection marker. If markedly raised – nephrotic syndrome
-
Nitrites – not normally found in urine, potential infection marker
i. NiTRATEs present all the time in urine
ii. Gram negative bacteria in the urinary tract turn nitrates into nitrites. If absent however, it does not exclude infection as not all bacteria are able to perform the reaction. - Leukocytes – White blood cells, indicates infection
The following needle colours are used for what?
Orange, pink or red, blue, green
- Orange - 1ml insulin needles, increments in units rather than mililitres
- Pink or red- drawing up needles, MUST NOT BE USED FOR ADMINISTRATION (blunt tip)
- Blue - IM deltoid injections or in larger muscles for those slight in build
- Green - typically selected for adult IM injections in larger muscles
How should IM deltoid injections be administered?
- Blue needle
- Use the smallest syringe (excluding 1ml syringe) allowing for dose and removal of air (usually 2.5ml)
- Volume for this site is up to 1ml
- Inject at 90 degrees
- Aspiration and z-track are not required
Mouth examination procedure
Use pen torch/tongue depressor to inspect:
* Lips and buccal mucosa
* Teeth and gums
* Tongue/floor of mouth
* Salivary glands
* Palates and uvula
* Oropharynx and tonsils
Looking for white plaques, thrush, ulcers, swelling etc.
Anatomy of outer ear (pinna)?
How Cute, Thanks Love (descending order)
Ear examination procedure
- Introduce yourself
- Identify the patient (3 identifiers)
- Ask which ear the symptoms are present in - “I believe that you’ve been having some problems with one of your ears. Which one is the issue?”. Examine normal ear first then affected ear
- Explain the procedure and gain consent - “I’ll first look outside the ear, to see if there’s any redness, swelling or discharge. Then I’ll look inside using the otoscope. Is that okay? Stop me if you feel uncomfortable at any point”
- External examination first (both ears). Red? Swollen? Mastoids? Discharge?
- Then examine inside the ear (normal ear first)
a. Gently pull the ear helix up and outwards, and look inside using otoscope. Hold otoscope with the same side as the ear (right hand for right ear), hold like a pen, and rest your pinkie on the patient’s skin.
b. Looking for discharge (otorrhoea), redness, swelling
c. Tympanic membrane - Is it visible? Is there a hole? Bulging/retracted? - Then check lymph nodes - “I’m now going to have a feel of the lymph nodes around your jawline and neck area. Please let me know if you feel any pain or feel uncomfortable at any point”
- Name areas outloud whilst feeling for them
a. If forget names – name the general area e.g. jawline, back of the head, clavical, nape
b. Feel behind the ear, round the jawline, down the neck and across the clavical - Feedback to patient - The inside and outside of your ears all look normal and I didn’t feel anything concerning when I felt your lymph nodes. I would recommend taking some paracetamol if you’re in pain, keep in eye on your symptoms and come back if they don’t improve or get worse.”
Name the different lymph node areas
What are red flag ear symptoms/conditions?
- Otorrhoea (discharge)
- Mastoiditis (otitis media infection spreading to mastoid bone)
- Sudden onset unilateral hearing loss
- Cholesteatoma (abnormal collection of skin cells)
