OSCE DOC - Other Q's Flashcards
Nurse Sharps Injury- 6 mins (18 marks)
A new 48-year-old patient is attending your practice for a routine first appointment.
During your examination, you observe an MO restoration on tooth 46 which requires replacement and the patient consents to have this treatment undertaken at the same visit.
Shortly after successful completion of the treatment, your dental nurse sustains a sharps injury from the needle used to deliver the local anaesthetic.
You have supervised the immediate first aid treatment of the injury to the dental nurse and arranged for them to be seen at an occupational health department.
You have now returned to the surgery to discuss the incident with the patient.
Undertake the following
- Explain the incident to the patient
- Outline the risks to the dental nurse and the patient
- Provide background information to the patient in order to achieve informed consent for blood borne virus testing
Explain the nature of the injury sustained by dental nurse to patient
Risks are to nurse and not the patient
2 marks
Hi my name is Amy and one of my colleague nurses has sustained something we call a sharps injury which is where she has accidentally cut herself on an object used on you which has been in contact with your bodily fluids. I want to reassure you that this absolutely does not affect you and there is no risk to yourself however there is a standard procedure we need to follow to assess if the staff member is at risk of any infectious disease e.g hep b, c or HIV. The risk is extremely low, but we can give the staff member treatment to prevent infection from occurring if there is an infectious disease. Their treatment needs to be given quickly.
To assess the risk, we need to ask 2 things of you. 1. We have a list of questions that we ask to see if treatment is required for the colleague, and these questions are sensitive in nature but it is standard procedure we must follow to assess risk. 2. Your permission to take a blood sample to test for the infections
Explanation of risks from BBV to dental nurse
Risks of transmission of a BBV (giving examples, e.g. HIV) to the dental nurse
Estimate of risk (low- e.g. 1:300 if HIV) based on the type of injury, explained in detail
HIV 1 in 300, Hep C 1 in 50, Hep B 1 in 3
2 marks
Explanation of standard procedure for managing sharps injuries which is applied to all patients
Explanation of requirement for a source blood sample and clarify that this is a universal process applied to all patients
2 marks
Explain to the patient the requirement for a blood sample by explaining to the patient that it is a universal process applied to all patients but is voluntary and the patient does not have to consent to having blood taken. The decision to be tested lie directly with you and refusing to be tested will have no effect on your ongoing care. If you do refuse the decision and discussion will however be recorded in your personal notes. The benefits of testing includes access to treatment which is vital.
Explanation that there is no pressure to comply with request to provide a blood sample for source patient testing
Student approaches the request for a blood sample from the patient sensitively and professionally, making it clear that there is no pressure on the patient to agree
2 marks
Undertake review of medical history
Covers all issues relating to BBV risk
Have you been diagnosed with HIV? Hepatitis B? Hepatitis C?
Have you ever injected drugs? Have you ever had sex with someone who has?
Have you ever had sex with another man / paid for sex?
Have you ever had sex with someone from a country outside of the UK, Western Europe, Canada, USA, Australia, New Zealand
Have you ever had a blood transfusion not in a country listed above?
Have you ever received dental treatment in a country not listed above?
Are you from a country that is not listed above?
Have you ever had a tattoo / body piercing done by an unlicenced artist in the UK or in a country outside the UK (or America, Canada, Australia, New Zealand or Europe)?
Yes to any of the above- indicate high risk
2 marks
Consent:
Establishes patient understands options + gives opportunity to ask questions (2 marks)
Confirm patient’s decision- giving bloods YES or NO (2 marks)
Apologise for inconvenience caused and thank them for cooperation
Actor marks
From my understanding of the info given, I felt able to consent to treatment (2 marks)
The student was professional in their attitude and approach (2 marks)
Notes:
Introduce yourself
You need to ask the difficult questions to establish risk
Make clear this is a health service protocol- makes it easier to ask the difficult questions
You need to have the knowledge base to discuss BBVs- not hereditary
Handpiece Safety (6 mins) (22 marks)
Your dental nurse will hand you two dental handpieces, labelled A and B.
One was due to be sent for repair but has been mixed up with a working handpiece.
Please perform all the appropriate dental handpiece checks on these two handpieces. Identify the handpiece in need of repair and hand it to your nurse. You can attach the handpiece to the dental unit and run it as required.
Your nurse will hand you three more handpieces (labelled 1, 2 and 3). They are all in need of repair but need a description of their fault recorded prior to sending to the technician for repair. You can attach the handpiece to the dental unit and run it as required. Each handpiece has one major fault.
Please identify the major fault for each handpiece and tell your nurse. They will write this on the engineers request form for you.
Back cap checked
Gripped and turned anti-clockwise
2 marks
Bur security checked
Suitable force applied to remove bur
2 marks
Tension applied to handpiece when fitted to coupling
Suitable force applied to assess if handpiece is attached safely
2 marks
Bur rotated laterally with fingers
Attempts to spin bur, rolls along finger
2 marks
Attempts to move bur laterally
Pushes bur from side to side a few times
2 marks
Handpiece sound tested when running
Runs for 5 secs or more, views bur movement
2 marks
Gives defective handpiece to nurse
4 marks
Major fault handpiece 1
2 marks
Major fault handpiece 2
2 marks
Major fault handpiece 3
2 marks
Notes:
Apply tension to handpiece once connected to air cable
Don’t run a handpiece with no bur
Use enough force when trying to turn backcap
Charting (6 mins)
Please work with your nurse to chart the dentition present (in the mannequin head)
Communication with nurse whilst charting and checking her charting
Look carefully for buccal restorations!
- Go through in a systematic way
- Charting missing teeth first
- Then going through each tooth one by one checking for restorations, mobility, drifting, rotations, over-eruption, crowns, bridges.
Cleanliness Champions / Cross Infection (6 mins)
What is wrong with this bay? Identify dangers and how to rectify.
Know waste streams- disposal of amalgam and sharps. Cleaning up blood spillage.
Identify dangers and how to rectify
* Bracket table- LA needle unsheathed, scalpel, tooth in forceps, endo files
* Surgery- sharp box on floor, gloves in sink, blood spillage
Know waste streams
* Black- household waste- packaging, hand towels
* Orange- low risk clinical waste- swabs, dressings and other non-sharp clinical waste e.g., dam, micro brush, PPE
* Yellow- high risk clinical waste (we don’t have this on clinic)- body parts including teeth
* Red- specialist, hazardous waste- dispose of amalgam in white box with red lid; spill / leak proof (mercury vapour suppressant in lid); amalgam waste, amalgam capsules, amalgam filled teeth
* Blue lid yellow box- sharps including vials with medication or pharmaceuticals remaining (LA that hasn’t been fully used)
* Orange lid yellow box- sharps box
* Brown waste- confidential- any paper with patient details on it
Disposal
* Disposal of sharps in sharps bin (orange stream)- 3 As, 2 Ns
* Always dispose of sharps in the sharps box immediately after use
* Always keep out of reach of children and non-authorised personnel
* Always close sharps box between use using temporary closing mechanism
* Never retrieve anything from the sharps box
* Never fill more than ¾ full
* - place sharps box at waist height on a flat surface- sharps box on floor here
Blood spillage and how to deal with it
* Stop what you’re doing
* Apply appropriate PPE- apron, mask, visor, gloves
* Cover spill with disposable paper towels
* Apply sodium hypochlorite / sodium dichloroisocyanurate- liquid / powder / granules (10,000ppm)
* Leave for 3-5 mins, use scoop to take up the gross contamination and put into orange waste
* Clean with water and general-purpose neutral detergent disinfectant wipes
Decontamination- Sterilisers (6 mins)
Difference between type N and type B, cycle, type of water used, tests for sterilisers
Instruments on top of steriliser- how do you know if sterilised? What do you do?
Type N
* Non-vacuum
* Passive air removal
* Unwrapped solid products
* Non-hollow
* Non-lumened
Type B
* Vacuum
* Active air removal
* Packaged instruments
* Lumened
* Hollow canulated or porous
Cycle
* Stages- air removal, sterilising, drying, cooling
* Parameters- 134-137 degrees, 2-2.3bar for a minimum holding time of 3 mins
* Type of water used- reverse osmosis / distilled / sterile / de-ionised
Steriliser tests
* Daily- wipe clean, change water, automatic control test (ACT), steam penetration test (Bowie-Dick / Helix)
* Weekly- ACT, steam penetration test, vacuum leak test, automatic air detector function test
* Quarterly- validation report (taking loads of data for effectiveness of steriliser)
* Yearly- annual report- by insurance company for safety (e.g., check pressure release valves)
* PAT testing, pressure vessel test????? (2012)
* How do you know if steriliser has been on?- test strip changes colour
Instruments found on top of steriliser
* Should be set out non-overlapping with hinged instruments open
* Check for recent printout from steriliser
* Check if colour change of packaged instruments
* - Instrument packaging- brown to pink
* - Helix / Bowie Dick- yellow to blue
* If unsure- take tray of instruments back to beginning- cleaning in AWD or manual cleaning
*
Cleanliness Champions- Cleaning Station (6 mins)
How would you completely clean down a unit from the point of finishing treatment with one patient to starting with the next?
- Wear appropriate PPE
- Dispose all sharps, then clinical wastes and domestic wastes
- Wipe down bay for the next patient
- Start from the top- dental light, control surfaces, full length of all cables
- Then change to new wipes- dental chair, spittoon
- New wipes again- bench top surfaces, computer keyboard and mouse
What are all these instruments on the surgical trolley? 1- 32
- Black safety plus handle- for LA injection
- Mouth mirror- soft tissue retraction, indirect vision
- Straight probe- test LA before XLA, test surface
- College tweezers- handle cotton pledget (with cross pattern), remove sequestrae
- Swann Morton scalpel handle with no.15 blade- incision to raise flap or biopsy
- ‘S’ shaped cheek retractor- retract the cheek, retract soft tissue
- Howarth periosteal elevator- raise mucoperiosteal flaps, flap retraction
- Howarth periosteal elevator
- Ash periosteal elevator- elevate soft tissue flaps, flap retraction
- Couplands osteo chisel no1- elevate root and tooth, create space for insertion of forceps
- Couplands osteo chisel no2- elevate root and tooth, create space for insertion of forceps
- Couplands osteo chisel no3- elevate root and tooth, create space for insertion of forceps
- Warwick James elevator right- elevator for removing teeth and roots, especially upper 8s
- Warwick James elevator straight- elevator for removing teeth and roots, especially upper 8s
- Warwick James elevator left- elevator for removing teeth and roots, especially upper 8s
- Cryers elevator right- elevator used to elevate roots and remove interradicular bone
- Cryers elevator left- elevator used to elevate roots and remove interradicular bone
- Curved mosquito forceps- picking up sequestrae or fractured instruments or posts, artery clips
- Bone rongeurs- also known as bone nibblers, used to trim bone, remove spicules and septae
- Rake retractor- flap deflection
- Bone file- smooth down rough bit of bone by pull stroke
- Victoria curette- remove granuloma or cyst from periapical tissue, remove granulation tissue from socket
- Mitchell’s osteo trimmer- removing sharp bone spicules, exposing canines, apicectomy
- Straight Spencer Wells forceps- picking up teeth, removing sharp bone spicules
- Alice tissue forceps- used to hold soft tissues, can be used to pick up teeth
- Kilner needle forceps- holding needle for suturing
- Fickling forceps- holding needle for suturing
- Gillies needle holders- holding needle for suturing
- Gillies toothed tissue forceps- manipulation of suture
- Curved iris scissors- cutting suture
- Lack’s tongue depressor- depressing tongue, retracting tissue
- Towel clips- clipping things on tray table
Local Anaesthetic (extra Q)
Common formulations and doses. Assembly. Side effects. Anaesthesia check.
Formulations and max doses:
* Lidocaine 2% 1:80000 adrenaline 4mg/kg
* Articaine 4% 1:100000 adrenaline 6mg/kg
* Prilocaine with felypressin 0.03IU/ml 8mg/kg
Assembly:
* Remember to check expiry date and that bung is on the right way round
Side effects:
* Allergic reaction (rash, tingling, breathing problems)
* Seizure, cardiac arrest
* Nausea, vomiting, dizziness, headache, blurred vision
* Twitching muscles
* Nerve damage, continuing numbness, weakness or pins and needles
* Haematoma
* Tachycardia
Checking anaesthesia:
* Question patient
* Check by percussion to tooth
* Probe to gingivae / palate
SIRS (extra Q)
4 criteria (National Early Warning Score)
Systemic inflammatory response syndrome (SIRS) is an exaggerated defense response of the body to a noxious stressor (infection, trauma, surgery, acute inflammation, ischemia or reperfusion, or malignancy, to name a few)
- Temperature <36 or >38
- White blood cell count <4 or >12 thousand cells per mm3
- Pulse >90bpm
- Respiratory rate >20bpm
If a patient has SIRS how many of the 4 definition of sepsis does the patient need to have before you refer?
2 out of 4 required for definition of sepsis syndrome
Requires urgent referral
Always refer urgently if
* Spread of infection to pharyngeal or submandibular space
* Systemic manifestations and immunocompromised
* Trouble swallowing or breathing
* Rapidly progressing infection
For dental abscess with systemic involvement what would you do AB wise for the patient?
Antibiotics
* For dental abscess if systemic manifestations or immunocompromised
* Always try local measures first- drain by extraction, through canal or by soft tissue incision
* Phenoxymethylpenicillin 250mg tablet 2 4x daily for 5 days
* Amoxicillin 500mg capsule 3x daily for 5 days
* Metronidazole 400mg tablet 3x daily for 5 days
SIRS (Systemic Inflammatory Immune Syndrome)
Actor – patient attends with swelling, ask for radiograph, and go through history including temp, HR etc and then diagnose sirs and how this is managed.
Radiograph shows an abscess relating to a specific tooth
Abscess is pus enclosed in the tissues of the jawbone at the apex of an infected tooth root/s. Usually the abscess originates from a bacterial infection that has accumulated in the soft, often dead, pulp of the tooth
Ask patients symptoms
* Swelling, trismus, dysphonia, dysphagia, drooling, poor neck flexion, inability to stick tongue out or swallow, pain, pyrexia, tachycardia, tachypnoea
* Colour, size and duration of swelling
* Ask about temperature, pulse rate, Respiratory rate, colour and temperature
Criteria for SIRS (National early warning score NEWS)
* Temperature <36o or >38o
* WCC <4 or >12x109/L
* Heart rate >90/min (tachycardia)
* Respiratory rate >20/min (tachypnoea)
* 2 out of 4 positive SIRS – sepsis syndrome and requires urgent referral To OMFS or A&E
SIRS is an inflammatory state affecting the whole body, frequently a response of the immune system to infection. It is related to sepsis a condition in which individuals both meet criteria for sirs and have a known or highly suspected infection.
Always refer if:
* Spread of infection to pharyngeal or submandibular space
* Systemic manifestations and patient is immunocompromised
* Trouble swallowing or breathing – drooling
* Rapidly progressing infection
Antibiotics for dental abscess if systemic manifestations or immunocompromised
* Always try local measures first: incision and drainage, extraction and drainage, drainage through retraction of the socket or instrumentation
* Amoxicillin 500mg 3x daily for 5 days (send 15)
* Metronidazole 400mg 3x daily for 5 days (send 15)
*
