Clinical skills

Question 1

Radio-radio delay

Answer 1

Assess both radial pulses simultaneously, the pulses should be synchronous and of similar volume, could be caused by coarction of the aorta proximal

Question 2

Radio-femoral delay

Answer 2

Assess radio and femoral pulse at the same time and make sure they are synchronous

Question 3

Collapsing/ water hammer pulse

Answer 3

You fell the radio pulse and the raise their hand above their head. It is a large volume pulse of a short duration with a rapid ascent and descent, caused by aortic regurgitation

Question 4

What is heart rate?

Answer 4

The amount of times the heart beats per minute. It will rise when the person is anxious or exercising

Question 5

Resting heart rate

Answer 5

Between 60-100bpm

Question 6

Sinus rhythm

Answer 6

Normal rhythm

Question 7

Sinus arrhythmia

Answer 7

When the pulse varies with the respiratory cycle, accelerating with inspiration and slowing with expiration

Question 8

Volume in pulses

Answer 8

The pulse pressure

Question 9

Character in pulses

Answer 9

The waveform or shape of the arterial pulse

Question 10

Abnormal heart rhythm

Answer 10

You can have irregular rhythm and regularly irregular rhythm, when the ‘extra’ or ‘missed’ beat happens regularly, this may be due to ectopic beats. An irregularly irregular rhythm is when there is no pattern at all.

Question 11

Introduction to a chest examination

Answer 11

Introduce yourself and identify the patient. Wash your hands, check the patient isn’t in any pain. Gain consent and obtain a chaperon

Question 12

Assessing radial pulse

Answer 12

• Place the pads of two or three of your middle fingers over the right radial artery.
• Assess the rate and rhythm.
• Count the pulse rate over 15s and multiply by 4 to obtain the beats per minutes. If the pulse is in anyway irregular then you must feel and time for the full minute.

Question 13

Assessing brachial pulse

Answer 13

• Place the pads of 2 or 3 of your middle fingers over the right brachial artery, its deeper then the radial artery, medial to the bicep tendon.
• Character and volume can be more reliably assessed using a central pulse, rate can be confirmed.
• If its hard for you to find get the patient to flex their elbow and then fully extend (straighten) their arm and then find the bicep tendon, the pulse is just medial to it.
• Check for a slow rising pulse which feels like a pulse which is taking longer to reach its peak, this is causes by aortic stenosis.

Question 14

Assessing carotid pulse

Answer 14

• Don’t assess both carotid pulses simultaneously
• The patient should be lying in a semi-recumbent position, place the tips of your two middle fingers between the larynx and the anterior border of the sternocleidomastoid muscle.
• Listen for bruits over both carotid arteries, using the diaphragm of your stethoscope whilst the patient holds their breath.
• Assesses character and volume
• Bruits are a whooshing sound due to turbulent blood flow, caused by atherosclerosis plaques.

Question 15

Assessing femoral pulse

Answer 15

Not routinely done but you have to mention it. Ask the patient to lie down and put two or three of your fingers over the femoral pulse. Check for the radio-femoral delay. Palpate and ausculate each femoral. Halfway between the pubic symphysis and anterior superior iliac spine (ASIS). Listen for bruits over both femoral arteries using the diaphragm of your stethoscope.

Question 16

Sides of the stethoscope

Answer 16

The bigger side is the diaphragm, which is normally used. The smaller side is the bell which is used for low-pitched noices

Question 17

Popliteal pulse

Answer 17

Lie the patient down in a semi-recumbent position, flex their knee to 30 degrees, it is behind the knee, feel the pulse on both sides. It can be over the popliteal artery or against the back of the tibia. If its really easy to find there may be an aneurysm

Question 18

Posterior tribial pulse

Answer 18

With the pads of your fingers, feel 2cm below and 2cm behind the medial malleolus, assess both sides. It is on the ankle, make sure you feel the pulse in both legs.

Question 19

Dorsalis pedis pulse

Answer 19

With the pad of your index, middle and ring finger place them in the middle of the dorsum of the foot. It is located between the tendons of the big toe and second toe about halfway down the foot. Some people don’t have it. Press lightly as a firm pressure can occlude the artery, assess both side

Question 20

Measuring estimated systolic pressure with a sphygmomanometer

Answer 20

• The patient should be sitting with both feet on the floor and their arm should be at the level of their heart, usually using a table or pillow.
• Remove tight clothing from arm.
• Apply cuff with the arrow aligned over the brachial artery.
• Position the dial of the sphygmomanometer at eye level.
• Inflate cuff whilst feeling the radial pulse, inflate until you can no longer feel the pulse.
• Ensure valve is closed before trying to inflate cuff.
• The reading on the sphygmomanometer is the estimated systolic blood pressure.
• Deflate cuff

Question 21

Measuring blood pressure with a sphygmomanometer

Answer 21

• Place the diaphragm of the stethoscope correctly over the distal brachial artery.
• Close the valve and inflate rapidly (within 5 sec.) the cuff pressure to 30 mmHg above the estimated systolic pressure.
• Listen while slowly and smoothly reducing cuff pressure at a rate of about 2 mmHg per second (or per heartbeat).
• Note the systolic pressure when you hear the tapping sound (phase 1 Korotkoff sound)
• Note the diastolic pressure when the sound disappears (phase 5 Korotkoff sound)
• Record measurement in patient notes as Systolic/Diastolic for example 120/80 mmHg.
• Record where and how the reading was taken i.e. right arm, patient supine

Question 22

Kortokoff sounds

Answer 22

1- a thud
2- a blowing noise
3- a softer thud
4- a disappearing blowing noise
5- nothing

Question 23

What should a patient do before having their blood pressure taken

Answer 23

Avoid smoking or caffeine, rest for 5 minutes before their blood pressure is taken. May vary according to the time of day, meals, exercise, anxiety and temperature. It is lowest when sleeping

Question 24

Potential difficulties with measuring blood pressure correctly

Answer 24

Cuff could be on inside out.
Valve not fully closed
Valve screwed closed too tight, resulting in pressure being release too quickly
Wrong stethoscope side being used
Stethoscope moving when on artery which will cause other noises

Question 25

What way should the needle be facing

Answer 25

The bevel should be up

Question 26

Disposal of clinical waste in venepuncture

Answer 26

Syringe disposed in clinical waste bin, needles in sharps bin. The needle and vacutainer go in the sharps bin, you don’t have to disassemble it

Question 27

Health and safety issues relevant to venepuncture

Answer 27

1) Bruising/Ecchymosis- can be extensive is the patient is on anticoagulants. To reduce bruising release the tourniquet prior to withdrawing the needle and ensure sufficent pressure in applied to the puncture site after withdrawing the needle.
2) Cross infection- to reduce the risk you should clean the skin with chlorhexidine and alcohol wipes, use the aseptic no-touch technique when assembling the needle and syringe. Do not re-palpate the vein

Question 28

Procedures dealing with a blood spill

Answer 28

Inform your peers and colleagues working nearby. Let a tutor or technician in the lab know. Clean up while wearing gloves. In a clinical setting immediately inform those working nearby and find an appropriate member of staff so that the correct procures can be followed.

Question 29

Procedures dealing with a needle stick injury

Answer 29

Encourage bleeding by applying pressure around the wound. Wash the area with soap and running water for 5 minutes.

Question 30

How to avoid a needle-stick injury

Answer 30

Keep the tip of the needle in direct vision at all times, never attempt to re-sheath the needle, don’t leave an exposed needle lying around and dispose in sharps bins immediately after use. With your supervising tutor inform the appropriate staff that an accident form needs to be completed and appropriate action taken. In a clinical setting always report it to your supervisor, consult either the occupational health department or the A&E department