DOCSS

Question 1

Order of stations?

Answer 1

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

Question 2

What does WIPER stand for?

Answer 2

Wash hands
Introduce and identify
Permission
Expose appropriately
Reposition if needed

Question 3

For an ECG where are the limb leads placed?

Answer 3

bony prominence of:
right arm (red)
left arm (yellow)
left leg (green)
right leg (black)

Question 4

Where are the chest leads placed?

Answer 4

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

Question 5

What do you say to the patient before an ECG?

Answer 5

• 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)

Question 6

Process of ECG?

Answer 6

• 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

Question 7

Where are the leads placed for cardiac monitoring?

Answer 7

right shoulder: over acromion/ lateral clavicle (red)
left shoulder: over acromium/ lateral clavicle (yellow)
Left lower chest over lower ribs: gr`een or black

Question 8

What do you say to the patient before cardiac monitoring?

Answer 8

• 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

Question 9

process of cardiac monitoring?

Answer 9

• “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

Question 10

• Q1: How would you objectively monitor the effectiveness of this treatment?
• Q2: Why did you leave the nasal cannula on when administering the nebuliser?

Answer 10

o Do peak flow 20 mins after nebuliser finishes

o To prevent desaturation

Question 11

What do you say before administering through a nebuliser?

Answer 11

-‘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

Question 12

Process of nebuliser

Answer 12

• ‘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)

Question 13

What would you say before inhaler technique?

Answer 13

‘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

Question 14

Process of explaining inhaler technique?

Answer 14

• 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”

Question 15

Equipment needed for IM injection

Answer 15

• drug and drug chart
• gloves and apron
• syringe
• two BLUE needles
• wipe to clean the skin
• sharps bin

Question 16

What do you say before an IM injection

Answer 16

• ‘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”

Question 17

Process of IM injection

Answer 17

• 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

Question 18

How do you inject subcutaneously?

Answer 18

Pinch the skin into a fold and inject at 45 degrees

Question 19

Equipment needed for SC injection?

Answer 19

• gloves and apron
• drug and drug chart
• syringe
• two orange needles
• wipe
  -sharps bin

Question 20

What do you say before an SC injection?

Answer 20

• 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. ‘

Question 21

Process of SC injection

Answer 21

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

Question 22

How would you explain what a peak flow is, why and when it should be done

Answer 22

• 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

Question 23

What do you say before showing the patient how to do a peak flow?

Answer 23

• ‘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?’

Question 24

Process of Peak flow

Answer 24

• 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

Question 25

What do you say before performing the allens test?

Answer 25

• so now im going to do a test on you which involves squeezing lightly on your wrist to check whether either of your two arteries area this wont be painful but let me know if you’re in any pain, am I okay to continue?

Question 26

Process of Allens Test

Answer 26

• Ask the patient to make a fist.
• Find pulse on both sides
• Using your fingertips, occlude the blood flow through the radial and ulnar arteries at the wrist.
• Ask the patient to release the fist and observe the blanched appearance to the hand, while maintaining pressure on the arteries.
• Remove pressure from the ulnar artery whilst maintaining pressure on the radial artery and observe the reperfusion of the patient’s hand. Observe whether all five digits are reperfused.
• Repeat the process with the radial artery.

Question 27

what do you say before performing an ABG?

Answer 27

‘today I need to do a blood test which tells us about O2 levels in your blood. This is a bit different to blood tests you might have had before- it is taken from artery and not vein and also it is taken from your wrist and not further up your arm. It might be a bit painful but I’ll try and be as gentle and quick as possible. Also we will have to press on it for a lot longer afterwards too.’
- Gain consent

Question 28

equipment needed for ABG?

Answer 28

• wipe
• ABG needle
• cotton wool

Question 29

process of ABG?

Answer 29

o Identify site and check for CI e.g. broken skin, no surgery on that arm? Preferred arm? No swelling or fistula in that arm?
o Clean skin and dry
oPunctures the radial artery at either 45 or 90 degrees and slowly advances the needle until it is sited intra-arterial (i.e. until you get flashback)

o Allows the syringe to fill with blood.
o Carefully withdraws needle and applies firm pressure to the puncture site
o Checks allergy status and secures cotton wool with tape
o Asks the patient to press firmly for a minimum of five minutes
o Ensures that air bubbles are expelled from the syringe and caps the sample
o Rolls or inverts the syringe immediately to mix contents with heparin
o States “I would analyse this sample immediately, or if there is any delay, I would put the sample in ice
o Dispose of sharp
- Check patient is ok
- Document results in notes- inc conc of flow rate of inspired O2, site used, result of Allen’s test, any complications, results of blood gas test etc.

Question 30

• Q1) What two things would you do to monitor this patient’s response?

Q2) What range of oxygen saturation would you ideally aim to achieve?

Answer 30

A. Monitor oxygen saturation levels with pulse oximetry and
o B. Repeat the arterial blood gas analysis within one hour

o 88% – 92%

Question 31

what do you say before administering oxygen?

Answer 31

• Introduce myself
• Identifies patient correctly
• ‘I’m here today to give you some O2 to try and reduce your breathlessness, I will also try and raise O2 levels in the blood because they are just a little bit low.’
• consent

Question 32

Process of administering O2

Answer 32

• select venturi mask
• Identifies correct valve- the correct oxygen percentage (accept 24% (blue) OR 28% (white) as correct) (the white bit that attaches to the mask)
• Identifies correct oxygen flow rate- the correct flow rate for the valve they have selected (24% = 2 l/min; 28% = 4l/min). (the ball thing on the wall)
• Prescribes oxygen correctly on the prescription chart
• Connect tubing to oxygen source and turn it on
• Check patency/flow before applying mask to patient.
• Make sure there is a snug fit for mask/apply it correctly
• Check patients welfare
• ‘I would document the procedure in the patients notes’

Question 33

Why would you use a Venturi mask over a rebreath

Answer 33

Rebreathe would lower the amount of oxygen so you’re not always sure the amount they’re breathing

Question 34

Why wouldn’t you want a pulse oximetry above 92% with a patient with COPD

Answer 34

They are physiologically compensated for lower O2 eg renal compensation so if you went above they would be alkalotic