Vital signs 2

Question 1

How do you measure core body temperature using a tympanic thermometer?

Answer 1

Method;

1) . Introduce self
2) . Identify patient
3) . Explain the procedure
4) . Seek consent to perform the procedure
5) . Undertake hand hygiene
6) . Visually inspect the ear canal for any obvious obstructions
7) . Remove the thermometer from the base and inspect the prober lens. If any debris is present, clean the probe tip with a detergent wipe and allow to dry.
8) . Press the scan button to verify functionality and mode selection on the LCD screen display (EAR and *C)
9) . Instal a probe cover by firmly inserting the probe tip into a probe cover (stored in base). After the probe cover is installed, the thermometer will perform a system reset. The thermometer will then display dashes, EAR, and the thermometer icon.
10. Pull auricle gently backwards and upwards, align the probe tip with the ear canal and gently advance into the ear canal until the probe lightly seals the opening, ensuring a snug fit.
11. Once the thermometer is positioned lightly in the ear canal, press and release the scan button. Wait for the triple beep before removing the thermometer.
12. As soon as the triple beep is heard, gently remove the thermometer from ear canal, read temperature result and eject the cover into clinical waste bin using the eject button.
13. Thank patient.
14. Undertake hand hygiene.
15. Record temperature on the observation chart using a cross.

Question 2

How do you measure oxygen saturation using a pulse oximeter?

Answer 2

1. Introduce self.
2. Identify patient.
3. Explain the procedure.
4. Seek consent to perform the procedure.
5. Undertake hand hygiene.
6. Switch the monitor on.
7. Place the pulse oximeter probe on to a digit.
8. After a few seconds, note the reading on the digital display and then remove the pulse
   oximeter.
9. Thank patient.
10. Undertake hand hygiene.
11. Record the SpO2 reading on the observation chart.

Question 3

How do you measure respiratory rate ?

Answer 3

1. Having assessed the radial pulse rate, continue to give the impression you are examining it by keeping your fingers over the radial pulse.
2. Indirectly observe the patient’s chest and count the breaths over 30 seconds then multiply total by 2 to give the number of breaths in 60 seconds.
3. Record the rate in breaths per minute on the observation chart.

Question 4

How do you measure blood glucose level?

Answer 4

1. Gather your equipment:
   a. Tray
   b. Glucometer (Accu-Chek Advantage)
   c. Test strips (Accu-Chek)
   Safety lancets (Unistik 3)
   d. Swabs
   e. Sharps container box
   f. Gloves and an apron
   g. ABHR and detergent wipes.
2. Introduce yourself.
3. Identify patient.
4. Explain the procedure.
5. Seek consent to perform the procedure.
6. Undertake hand hygiene.
7. Put on a disposable apron.
8. Check expiry date on Test Strip container. Remove a new test strip from the container. Be sure
   to tightly replace container cap after removing test strip. Insert test strip into meter with silver
   bars facing up and towards meter.
9. The monitor will display a 3-digit code that should match the code on the test strip container
   and a flashing ‘blood drop’ signal will then appear on the digital display.
10. Put on disposable gloves (whenever there is exposure to blood, gloves must be worn).
11. The patient’s finger should be warm, CLEAN and dry. The side of the finger should be used as
    they are less sensitive than the tip.
12. Spring loaded safety lancets are single use only. Hold the sides of the lancet device. Twist the grey cap twice and pull cap off. Discard cap into the tray (it will be disposed of into the black
    Domestic Waste Disposal Bin at the end of the process).
13. Hold patient’s finger with your non-dominant hand and place the lancet device firmly against
    the side of patient’s fingertip.
14. Press trigger to release lancet.
15. Dispose of the lancet device immediately into the yellow Sharps container box.
16. Hold the finger tightly at the distal phalanx for 3 seconds.
17. The blood should be allowed to form naturally. Place the edge of the strip against the drop of
    blood on finger within the curve. The blood will be drawn into the strip.
18. Ensure the yellow square is fully filled with blood. The monitor will ‘bleep’ to acknowledge
    that enough blood has been obtained.
19. Apply a swab to the patient’s bleeding finger and ask them to hold the swab firmly in place.
20. Read the digital display and record the glucose result in mmol/L on the observation chart.
21. Ensure that finger has stopped bleeding.
22. Place contaminated swab in yellow Clinical Waste Disposal Bin.
23. Remove and place test strip in yellow Clinical Waste Disposal Bin.
24. Remove and place gloves and apron in yellow Clinical Waste Disposal Bin.
25. Place cap from lancet in black Domestic Waste Disposal Bin.
26. If required, ensure that any spillage or contamination is cleaned with a detergent wipe.
27. Undertake hand hygiene.
28. Record the blood glucose result on the observation chart in section marked ‘BM’ or ‘BLOOD
    SUGAR’.

Question 5

How do you perform urinalysis?

Answer 5

Method
1. Explain and discuss the procedure with the patient and ask patient to return the sample to you.

2. Undertake hand hygiene.
3. Put on a disposable apron and gloves.
4. Check the expiry date on the urine dipsticks container. Remove a new test strip from the container and replace the lid.
5. Observe appearance of specimen, noting the colour and evidence of cloudiness or sediment.
6. Dip the reagent stick into the urine, making sure that it is completely immersed.
7. Take the strip out immediately, removing excess urine by tapping it gently on the side of the container.
8. After the prescribed time [this varies depending on the brand of stick, check the instructions
   beforehand] compare the colour of the test area to the chart provided. Ensure that you do not contaminate the dipstick container when comparing the dipstick test area to the chart by keeping the strip a short distance from the container.
9. Dispose of the dipstick in the yellow Clinical Waste Disposal Bin.
10. Ensure that any spillage or contamination is cleaned with a detergent wipe.
11. Remove gloves and apron and dispose of in yellow Clinical Waste Disposal Bin.
12. Undertake hand hygiene.
13. Record results below adding patient identification details i.e. name and DOB/hospital number.

Note carefully the different units used.

Question 6

How do you record vital signs on an observation chart?

Answer 6

You plot the results of the patients conditions and connect the dots to form a line-graph to show trends in their condition.

Question 7

What do the abbreviations found on the observation chart mean? What are their normal values ?

Answer 7

Temp - Temperature

• Normal; 37C
• 38+ means fever
• <35C means hypothermia

SpO2 - Peripheral oxygen saturation

• Normal 96-99%
• <95% means hypoxia

BM - Blood sugar

• 4.0-5.4 mol/L when fasting
• Up to 7.8 mol/L 2 hours after eating
• Over these values means diabetes
• Under 2.8-3 mol/L means hypoglycaemia

Question 8

What is the normal respiratory rate range for an adult?

Answer 8

12-20 breaths per minute

• Over 25 breaths per minute means Lung disease (Asthma, COPD, Pneumonia)
• Under 12 means hypoxemia, or low blood oxygen.

respiratory acidosis - a condition in which your blood becomes too acidic.

Question 9

Give some reasons for performing urinalysis

Answer 9

To detect UTI (urinary tract infection), Kidney disease and diabetes.

Question 10

What results may be observed in a dipstick sample of infected urine?

Answer 10

Blood;

• May be present if there is an infection.
• Can be due to significant underlying disease, such as cancer, in the bladder or kidney (and the prostate gland in men).
• In women, it may be contamination if you are on your period at the time of doing the sample.
• Will always need to be confirmed by sending the sample for a full laboratory tes

Protein;

• Protein is normally found in the urine in tiny amounts but these tiny amounts aren’t usually picked up on a urine dipstick test.
• Protein may be found in larger amounts if there is an infection or if you’re pregnant and are developing pre-eclampsia.
• Can be the first sign of kidney disease.

Glucose;

• Glucose, a type of sugar, is never normally found in the urine.
• Glucose in the urine may be the first sign of diabetes.

Ketones;

• Ketones are chemicals made by the body when it’s breaking down fat for energy, which is what we do when we are starving and have used up all, or nearly all, of our stores of sugar (glucose). This is normal.
• Ketones are not usually found in the urine.
• Ketones may be present if you have diabetes and it’s out of control and the levels of sugar in the blood are very high.
• Ketones may also be present in women who are pregnant.

Bilirubin and urobilinogen;

• Bilirubin and urobilinogen are chemicals produced by the liver. - They are not normally found in the urine.
• If bilirubin is found in the urine it usually means there’s a problem with the liver.
• Small amounts of urobilinogen may be found in the urine but large amounts suggest a problem with the liver or with red blood cells being destroyed too quickly.

Leukocyte esterase and nitrite;
These are both tests for the presence of infection.
- Leukocyte esterase test looks for a reaction that only happens if there are lots of white cells in the urine. White cells get into the urine when there is an infection.
- Nitrite is not normally found in the urine but will appear there if there are lots of germs (bacteria) in the urine.
- Nitrite test can be negative even if there are lots of bacteria in the urine if the urine hasn’t been in the bladder for long. For example it will be negative if you do your urine sample soon after having passed urine.
- Ideally you should wait at least four hours from the last time you had a pee before doing your urine sample.
- The urine dipstick test also measures how concentrated the urine is and how acidic it is.

Question 11

Why is temperature taken from the ear?

Answer 11

Because the tympanic membrane and hypothalamus shares and atrial blood supply originating from the carotid artery; therefore the tympanic membrane is considered to directly reflect core temperature.

Question 12

How to tympanic thermometers work?

Answer 12

Tympanic thermometers use infra-red light to detect thermal radiation.

Question 13

What are the advantages of using Tympanic Thermometers ?

Answer 13

Tympanic thermometers are a non-invasive, hygienic, simple to use, comfortable for the patient and quick to register.

Question 14

Why must you practice your technique of using Tympanic thermometers ?

Answer 14

Poor technique can give inaccurate readings. The opening of the ear canal and the tympanic membrane can differ in as much as 2.8C

Question 15

How should the Tympanic thermometer be placed in the ear canal and why?

Answer 15

The Tympanic thermometer should be gently placed in the ear canal and allowed to fit snugly. This will prevent ambient air at the opening of the ear canal from entering it, resulting in the prevention of a false low temperature measurement.

Question 16

What are causes of false low readings?

Answer 16

False low readings can occur due to;

• A dirty or cracked lens
• Improper technique
• Incorrect installation of the probe cover
• Short time intervals (less than 2-3 minutes) between consecutive measurements

Question 17

What does respiratory rate measure and what can its observation be used as an indicator for?

Answer 17

The respiratory rate (RR) is the number of breaths per minute.

RR is the most sensitive marker of deteriorating patient and the first observation to indicate a problem.

Research has shown that abnormalities in RR predict serious adverse events including Cardiac arrest and ICU admission

Question 18

Why should you try to be subtle when measuring a patients respiratory rate?

Answer 18

If a patient is aware that their respiratory rate is being monitored their breathing pattern may alter.

Question 19

What is peripheral oxygen saturation?

Answer 19

Peripheral oxygen saturation (SpO2) is an estimation of the oxygen saturation level and is usually measured with a pulse oximeter.

Question 20

How does a pulse oximeter work?

Answer 20

A pulse oximeter is a point-of-care testing device that uses the different absorption spectra of oxygenated haemoglobin and deoxygenated haemoglobin to provide an estimation of the percentage of haemoglobin saturated with oxygen.

Question 21

What factors can affect the accuracy of a pulse oximeter?

Answer 21

The pulse oximeter can be affected by;
- Movement of artefact
- Poor tissue perfusion
- Hypothermia 
- Rapid irregular pulse
(E.g - Atrial fibrillation can lead to an inadequate waveform)

Question 22

What factors can result in a falsely low SpO2?

Answer 22

• Severe Anemia
• Severe skin pigmentation
• Nail varnish
• Dirty fingers

Question 23

What factors can result in a falsely high SpO2?

Answer 23

Raised levels of carboxyhaemoglobin (carbon monoxide poisoning).

Question 24

What saturations is pulse oximetry less accurate with?

Answer 24

Pulse oximetry is less accurate with saturations <75%.

Question 25

What are the advantages of using a finger prick capillary blood glucose measurement ?

Answer 25

The advantages of using a finger prick capillary blood glucose measurement is;
- It provides a rapid accurate estimation of blood glucose

Question 26

What does urinalysis reveal?

Answer 26

Urinalysis can reveal abnormalities in urine that can be important warning signs of illness.

Question 27

How can urinalysis be inaccurate and what can this lead to?

Answer 27

If contamination has occurred in the sample incorrect results may be produced.

Contamination rates of urine samples are high, especially from women.

This sample contamination may lead to diagnostic ambiguity or incorrect diagnosis and inappropriate treatment.

This may lead to poorer patient outcomes and increase the miss use of antibiotics and overall resistance.

Question 28

How can some of these inaccuracies in Urinary analysis be removed?

Answer 28

Inaccuracies can be reduced by repeating samples and getting patients to obtain a mid-stream urine sample

Question 29

What are the disadvantages of repeating urine samples?

Answer 29

Disadvantages of repeating urine samples;

• Additional cost
• Prolongs diagnosis and treatment
• Increase patient anxiety

Question 30

How should you instruct a patient to obtain a mid-stream urine sample?

Answer 30

1) . You should emphasise to the patient the importance of obtaining a sample which is as free from contamination as possible.
2) . This can be achieved by asking the patient to clean their external genitalia and wash their hands before micturition (urinating) prior to collecting the sample.
3) . You should ask male patients to retract their foreskin and female patients to separate the labia before collecting an MSU.

4). You may wish to advise the patient:
“Because of the symptoms you have described to me, I would like to perform a urine dipstick test. In order to prevent contamination of the sample that may give us inaccurate results, it is important that you collect the urine in a certain way. A midstream sample is best as the first bit of urine that you pass may be contaminated with bacteria from the skin. Prior to giving the sample, please ensure your genital area and hands are clean. Start by passing urine into the toilet. After a second or two, and without stopping the flow of urine, catch some urine in the sterile container. Once you have enough urine in the container, finish off passing the rest of your urine into the toilet.
Do not open the sterile container until you are ready to take the sample. You do not need to fill the bottle to the top, halfway will do. Some specimen containers contain a preservative. If this is the case, a mark on the bottle will indicate the ideal amount of urine. However, if that is difficult, any amount is better than none. Once you have finished, screw the lid onto the container and return it to me please.”

Question 31

What timeframe should the urine analysis be carried out after urination?

Answer 31

Urination using the dipstick should be performed within an hour of urination.

Question 32

How does a urine dipstick work?

Answer 32

A urine dipstick is a long, thin plastic strip with square test areas impregnated with chemical reagents. These reagents react to different molecules in a urine sample and change colour depending on the presence and concentration of, for example, protein, glucose, ketones, blood and leukocytes.

They also indicate pH and specific gravity however not all dipsticks are the same, so it is important to check the container to ensure that you are using the correct dipstick for the test you wish to undertake.

Question 33

How can a urine dipstick test be used in making a diagnosis?

Answer 33

Urine dipstick is only used as an investigatory tool and should not be relied upon when making a diagnosis. An abnormal result should always be accompanied by a relevant detailed history and appropriate further investigations as necessary.

Question 34

What must you be wary of when marking the results of a Urine dipstick during an OSCE?

Answer 34

Different units are used on the side of the bottle and on the sheet, make sure you use the results in the correct units