Introduction to Clinical Skills Flashcards
What is the NEWS system?
The National Early Warning Score (NEWS).
- Use information easily available at bedside and already monitored by nurses.
- Predicts critically unwell/deteriorating patients.
- Helps clinicians prioritise cases and respond promptly.
What observations are taken for the NEWS chart- what are the normal ranges
Respiration Rate (12-20 breaths per minute)
SPO2 (>96%)
SPO2 scale 2 (88-92%)- This is for patients with chronic Co2 retention e.g. COPD patients
Air or oxygen- RA (Room air)
Blood Pressure (111-219mmHg SBP)
Pulse (51-90 bpm)
Consciousness (Alert)
Temperature (36.1-38.0)
What is the mechanism of arterial pulses:
Alternate expansion and recoil of an artery.
*A pulse can be felt wherever an artery lies near the surface and over a bone or other firm background.
This depends on:
- Intermittent injections of blood from the heart into the aorta which alternately increases and decreases the pressure.
- Flexibility/elasticity of the arterial wall which allows expansion with each injection of the blood and then recoil.
How is measuring the pulse useful:
- Heart (force of contraction).
- The rate of heart contraction.
- Clue to any outflow problems.
- Circulating blood volume.
- State of blood vessels.
Locations to palpate pulse
Neck:
- Common Carotid Artery- along the anterior edge of the sternocleidomastoid muscle at the level of lower margin of the thyroid cartilage.
-Temporal artery - in front and slightly above the ear (temporal bone).
Arm:
- Brachial
- Radial
Trunk:
- Abdominal aortic
Lower limb:
- Femoral
- Popliteal
- Posterior tibial
- Dorsalis pedis
Examination of the pulse:
Rate
Rhythm
Character
Auscultation (listening).
Examine with tips of 2nd, 3rd, 4th fingers and compare the left with the right.
Pulse rates:
Normal adult range is 60-100bpm.
Bradycardia means slow heart beat.
Tachycardia means fast heart beat.
Normal newborn range is 70-120bpm.
Normal infant range is 80-160bpm.
Normal preschool child range is 75-120bpm.
Normal school child range is 70-100bpm.
How is pulse rate measured?
Rate is measured with the patient at rest for at least 5 minutes.
Over radial artery on the right wrist with the examiner standing on the right of the patient.
For at least 30 seconds.
Pulse character
Pulse - character:
Normal: sharp rise - small plateau - normal fall.
Abnormal:
Rise - rapid rise/slow rise.
Plateau - long/short.
Fall - slow/rapid
Auscultation of pulse
Pulse - auscultation:
Normal/laminar flow in arteries and veins are quiet.
If flow is turbulent, it produces noise over the arteries/veins - BRUIT.
Across a heart valve - MURMUR.
Respiratory rate
Normal is 12-20bpm.
Increases with lung and heart disease, anxiety, some metabolic problems.
Decreases with drugs, brain damage.
Pattern:
Usually regular at rest.
Look for irregular, stopping/starting type patterns.
Other:
Depth/effort, coughing, noises (wheeze/stridor), odour (alcohol/tobacco/ketones).
Method:
Count for 30-60 seconds while patient at rest and unaware or distracted.
Try to do immediately after pulse measurement.
Record as a number or plot on a chart.
Temperature
Normal: 36-37.5.
Fluctuates diurnally.
Exercise and eating.
With menstrual cycle.
Not with environment.
Elderly and young - same range but more prone to extremes of temperature in illness.
Measuring temperature:
Core vs peripheral:
Rectal probe.
Thermometer:
Mercury.
Electronic/digital.
Tympanic.
Sites for measuring temp:
Oral.
Axillary.
Rectal.
Tympanic.
Temporal.
Causes of pyrexia/ hyperthermia:
Infection.
Drugs.
Heat stroke.
Stroke.
Autonomic diseases.
Malignancy.
Gout.
Causes of hypothermia:
Below 35 degrees celcius.
Multifactorial.
Alcohol/drugs.
Hypoglycaemia, hypoadrenalism.
Infections.
Post-operative.
NOT environment alone.
Handwashing technique
Bare below the elbows, no rings except wedding ring and no bracelet.
Rinse hands and add soap.
Rub palm to palm for 15 seconds.
Palm to the back of your hand with fingers interlaced for 15 seconds on both sides.
Palm to palm with fingers interlaced.
Both thumbs.
Tips of fingers against each palm.
Wrists.
5 times hand washing should be carried out:
Always before seeing a patient.
Aseptic procedure.
After body fluid exposure.
After touching a patient.
After touching a patient’s surroundings.
When is it appropriate to use hand sanitiser over soap?
Blue is hand wash, red is hand sanitiser. If hands are not visibly soiled, it’s okay to use hand sanitiser. The only exception is if you’ve just seen a patient with suspected or confirmed Clostridium difficile infection.
PPE technique
Fluid resistant surgical mask on hospital site, including car park, outside areas or corridors.
When working with suspected or confirmed case of covid-19, you are required to wear a plastic apron and disposable gloves when in close contact, within 1 metre.
When wearing surgical masks, metallic strip should be positioned to the bridge of your nose.
Don’t touch the mask after putting it on.
Blood pressure technique
Warm, quiet room.
Patient:
Explanation and consent.
Seated and resting.
Arm supported at heart level (pillow or you).
Equipment ready (at eye level).
Apply the cuff.
Inflate cuff while palpating brachial artery.
Deflate cuff while auscultating artery.
Record systolic and diastolic and debrief patient.
How do you apply the BP cuff?
Expose the arm.
Correct cuff size to cover 80% arm circumference.
Snug but not tight (two fingers).
Centre cuff over brachial artery, 2-3cm above pulse point.
Tubes should be superior or slightly off centre to allow access to pulse.
What are the Korotkov phases and what do they indicate?
Tapping starts - systolic.
Tapping softer and swishing - auscultatory gap.
Tapping louder, sharper, clearer.
Tapping muffled.
Tapping disappears - diastolic.
What are some common reasons why BP reading can be incorrect?
Cuff size (too small overestimates).
Arm position (below heart overestimates).
Poor technique (systematic error).
Terminal digit preference.
Observer prejudice (esp at cut offs for treatment).
Hypertension
High BP - hypertension:
Population has normal distribution.
Arbitrary definition.
Treatment decisions taken by considering other risk factors, e.g. Patients with diabetes - lower threshold for treating.
