Clinical skills Flashcards
Radio-radio delay
Assess both radial pulses simultaneously, the pulses should be synchronous and of similar volume, could be caused by coarction of the aorta proximal
Radio-femoral delay
Assess radio and femoral pulse at the same time and make sure they are synchronous
Collapsing/ water hammer pulse
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
What is heart rate?
The amount of times the heart beats per minute. It will rise when the person is anxious or exercising
Resting heart rate
Between 60-100bpm
Sinus rhythm
Normal rhythm
Sinus arrhythmia
When the pulse varies with the respiratory cycle, accelerating with inspiration and slowing with expiration
Volume in pulses
The pulse pressure
Character in pulses
The waveform or shape of the arterial pulse
Abnormal heart rhythm
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.
Introduction to a chest examination
Introduce yourself and identify the patient. Wash your hands, check the patient isn’t in any pain. Gain consent and obtain a chaperon
Assessing radial pulse
- 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.
Assessing brachial pulse
- 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.
Assessing carotid pulse
- 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.
Assessing femoral pulse
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.
Sides of the stethoscope
The bigger side is the diaphragm, which is normally used. The smaller side is the bell which is used for low-pitched noices
Popliteal pulse
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
Posterior tribial pulse
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.
Dorsalis pedis pulse
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
Measuring estimated systolic pressure with a sphygmomanometer
- 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
Measuring blood pressure with a sphygmomanometer
- 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
Kortokoff sounds
1- a thud 2- a blowing noise 3- a softer thud 4- a disappearing blowing noise 5- nothing
What should a patient do before having their blood pressure taken
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
Potential difficulties with measuring blood pressure correctly
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
What way should the needle be facing
The bevel should be up
Disposal of clinical waste in venepuncture
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
Health and safety issues relevant to venepuncture
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
Procedures dealing with a blood spill
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.
Procedures dealing with a needle stick injury
Encourage bleeding by applying pressure around the wound. Wash the area with soap and running water for 5 minutes.
How to avoid a needle-stick injury
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
