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ECE 8 - Basic Procedural Skill : 26/5/2022
ECE 8 - Basic Procedural Skill : 26/5/2022
My group mates
My group mates
ANIS FARZANA BINTI AHMAD AZAM
MUHAMMAD HARITH ISKANDAR BIN MOHD NIZAM
AIREEN FATHIHA BINTI RIDZAL
AINUL MARDHIAH BINTI MOHD RIZAL
MUHAMMAD AMIR WAFIY BIN MOHD SHAHMIZAN
NURUL AZRIN BINTI ISMAIL
HAZEL LIM YIN ERN
TAY HUEY MAY
IRFAN HAZIQ BIN AMEROL HAMZAH
PREMNAATH KUMAR
UMAR AL-FARUQ BIN MOHAMMED FARIDZ
KRISHEN MAGAYNDRAN A/L GOPI MAGAYNDRAN
KAYALVILI A/P R.MANOGAR
SOMAGANTH A/L ARMUGUM
NUR KHAYRIN AMALIN BINTI AZAMI PARIDZA
NUR SYAHIRAH ILYANA BINTI NASIR
MELISSA LOO JIA HUI
JEANNE LIM JING WEN
BLOOD PRESSURE MEASUREMENT
Introduction
1. Wash your hands and don PPE if appropriate.
2. Introduce yourself to the patient including your name and role.
3. Confirm the patient’s name and date of birth.
4. Briefly explain what the procedure will involve using patient-friendly language.
5. Gain consent to proceed with blood pressure measurement.
6. Position the patient sitting on a chair, with their arm comfortably placed at approximately heart level.
7. Check if the patient has a preference as to which arm to use. Avoid using an arm that has local pathology such as post-mastectomy lymphoedema.
8. Ask the patient to adequately expose their upper arm on the relevant side by rolling up their sleeve.
9. Check if the patient has any pain before proceeding with blood pressure measurement.
Attaching the blood pressure cuff
1. Check that the blood pressure cuff size is appropriate for the patient’s arm and that it is fully deflated.
2. Confirm the location of the brachial artery by palpating medial to the biceps brachii tendon and lateral to the medial epicondyle of the humerus.
3. Wrap the blood pressure cuff around the patient’s upper arm, lining up the cuff marker with the brachial artery.
4. Ensure the cuff size is appropriate
5. Ensure the cuff marker is aligned with the brachial artery.
Measuring blood pressure
1. Estimate an approximate systolic blood pressure
2. To begin with, you need to determine an approximate systolic blood pressure. This is helpful in preventing over-tightening of the cuff during the accurate measurement of blood pressure.
3. Ensure the valve on the blood pressure cuff is closed.
4. Palpate the patient’s radial pulse, located at the radial side of the wrist, with the tips of your index and middle fingers aligned longitudinally over the course of the artery.
5. Inflate the blood pressure cuff until you can no longer feel the patient’s radial pulse.
6. Note the reading on the sphygmomanometer at the point at which the radial pulse
becomes impalpable. This reading is an approximate estimate of the patient’s systolic blood pressure.
7. Open the valve and deflate the blood pressure cuff.
8. Palpate the radial pulse.
9. Inflate the cuff until the radial pulse is no longer palpable.
10. Note the reading when the radial pulse is no longer palpable.
Measure the blood pressure accurately
1. Now that you have an approximate systolic pressure, you can perform an accurate assessment of systolic and diastolic blood pressure.
2. Close the valve on the blood pressure cuff.
3. Position the diaphragm of your stethoscope over the brachial artery.
4. Re-inflate the cuff 20-30 mmHg above the systolic blood pressure you previously estimated.
5. Then slowly deflate the cuff at around 2-3 mmHg per second.
6. Using your stethoscope, listen carefully for the onset of a pulsatile noise. The first of these pulsatile noises is known as the first Korotkoff sound. The pressure at which the first Korotkoff sound becomes audible represents the patient’s systolic blood pressure.
7. Continue to deflate the cuff, whilst listening through your stethoscope until the pulsatile sound completely disappears. The final pulsatile noise you hear is known as the fifth Korotkoff sound and represents the patient’s diastolic blood pressure.
8. If the patient’s blood pressure is outside of the normal range you should repeat the assessment on the same arm after a few minutes and also consider assessing blood pressure using the patient’s other arm.
· Palpate the brachial artery
· Place the stethoscope over the brachial artery
· Re-inflate the blood pressure cuff
· Slowly deflate the cuff
· Listen for first Korotkoff sound and note the systolic blood pressure
· Listen for fifth Korotkoff sound and note the diastolic blood pressure
· Remove the blood pressure cuff
To complete the procedure
1. Once a blood pressure recording has been obtained, remove the blood pressure cuff.
2. Explain to the patient that the procedure is now complete.
3. Discuss the blood pressure results with the patient, including any further steps that may need to occur (e.g. follow-up, further investigations, initiation of treatment).
4. Thank the patient for their time.
5. Dispose of PPE appropriately and wash your hands.
6. Document the lowest blood pressure recording in the patient’s notes.
PULSE RATE AND RESPIRATORY RATE
1. Measuring the pulse can tell us much about what is happening inside the body.
2. When the heart contracts, blood circulates through the blood vessels of the body in pulsating waves. this wave known as the pulse can be felt as a light tap. the pulse can be palpated at several sites, the most common site is the radial pulse which is located on the inner aspect of the wrist just below the thumb.
3. When measuring the pulse rate you should also assess the rhythm and volume of the pulse. alterations in any of these can indicate health problems.
4. Sanitize your hands before proceeding.
5. Greet the patient and introduce yourself.
6. Identify the patient and explain the procedure.
7. Observe the patient for any signs that might affect the pulse or respiratory rate.
8. Position the patient's arm alongside the body in a comfortable position.
9. The forearm should be slightly flexed in order to relax the muscles and tendons over the pulse site. this makes it easier to palpate the pulse.
10. Place the pads of your fingertips over the radial pulse site. The radial pulse is located in a groove on the inner aspect of the wrist just below the thumb. Never use your thumb. It has its own pulse and you may end up measuring your own pulse instead of the patient's.
11. Apply moderate gentle pressure directly over the site until you feel the pulse. if you cannot feel the pulse, you may not be palpating over the correct site. Try moving your fingertips to a slightly different location in the groove of the wrist. Another reason for not being able to feel the pulse is the amount of pressure you are applying with your fingertips. If you are not applying enough pressure, you will not be able to palpate the pulse. On the other hand, you may be applying too much pressure and closing off the artery. Try varying the depth of your hold until you can feel the tap under your fingers.
12. Use a watch with a second hand to count the pulse beats for 30 seconds and make a mental note of that number.
13. Determine if the pulse rhythm is regular or irregular and if the pulse volume is normal or bounding. If you discover abnormalities, continue to count for one full minute this gives you more time to fully assess the abnormalities.
14. After taking the pulse, continue to hold your fingers on the patient's wrist with the same amount of pressure and measure the respirations. This helps to make sure the patient is unaware that you are monitoring her breathing.
15. If the patient is aware that her respirations are being counted, she may change her breathing pattern. This results in an inaccurate measurement.
16. Observe the rise and fall the patient's chest as she inhales and exhales. One complete respiration includes one inhalation and one exhalation.
17. Count the respirations for thirty seconds and make a mental note of this number. Note the rhythm and depth of the respirations. Also observe the patient's color.
18. If abnormalities are noted count the respiratory rate for one full minute. If you counted the pulse and respirations for thirty seconds, multiply each of the numbers counted by two. This will give you the pulse rate and respiratory rate for one full minute.
19. The normal resting pulse rate for an adult, ranges from 60 to 100 beats per minute. In a healthy individual the rhythm should be regular and the volume should be strong. The respiratory rate of a normal healthy adult ranges from 12 to 20 respirations per minute. In a healthy individual the rhythm should be even and regular with a normal depth.
20. Sanitize your hands. Chart the results, include the date the time the pulse rate rhythm and volume and the respiratory rate, rhythm and depth.
VENEPUNCTURE
Introduction
1. Introduce yourself to the patient including your name and role
2. Confirm the patient's name and date of birth
3. Briefly explain what the procedure will involve using patient-friendly language
4. Gain consent to proceed with venepuncture
5. Check if the patient has any allergies
6. Adequately expose the patient's arms for the procedure
7. Position the patient so that they are sitting comfortably
8. Ask the patient if they have any pain before continuing with the clinical procedure
9. Wash your hands using alcohol gel. If your hands are visibly soiled, wash them with soap and water.
10. Gather equipment
Preparation
1. Choose an arm you to perform venepuncture on and place a pillow under it.
2. Choosing a vein.
3. Inspect the patient’s arm for an appropriate venepuncture site.
4. Apply the tourniquet approximately 4-5 finger-widths above the planned venepuncture site.
5. Palpate the vein you have identified to assess if it is suitable.
6. Once you have identified a suitable vein you may need to temporarily release the tourniquet.
7. Wash your hands again.
8. Wear gloves.
9. Clean the site with an alcohol swab for 30 seconds and then allow to dry completely for 30 seconds.
10. Insertion of the needle.
11. Re-apply the tourniquet if removed previously and attach the needle to the barrel.
12. Unsheathe the needle.
13. Anchor the vein from below with your non-dominant hand by gently pulling on the skin distal to the insertion site.
14. Warn the patient that they will experience a sharp scratch.
15. Insert the needle through the skin at a 30-degree angle or less, with the bevel facing upwards.
16. Advance the needle a further 1-2 mm into the vein after flashback is noted to ensure you are within the lumen.
17. Lower and anchor the needle to the patient’s skin using the wings of the butterfly needle.
18. Attach each blood bottle, in the correct order of draw, to the barrel and allow them to fill to the appropriate level.
19. Release the tourniquet.
20. Withdraw the needle and then apply gentle pressure to the site with some gauze or cotton wool.
21. Ask the patient to hold the gauze or cotton wool in place whilst you dispose of the needle into a sharps container.
22. Apply a dressing to the patient’s arm.
23. Invert each of the blood bottles the suggested number of times based on its color.
24. Discard the used equipment into the appropriate clinical waste bin.
To complete the procedure…
25. Explain to the patient that the procedure is now complete and that they should seek review if the venepuncture site becomes painful or inflamed.
26. Thank the patient for their time.
27. Wash your hands.
Video : https://youtu.be/fpAhoSrKYNM
Written protocol
COMMENTS
COMMENTS
I think this is the first class of basic procedural skills. So, Dr Safuraa had asked us earlier to watch the video given before coming to this session. As we start, Dr asked two students to be patient and doctor and act out for each part. From there, Dr will asked us to explain we were doing and what did we get from the video earlier. So as each of us have watch the video, we actually try to act like what the video show but actually understand nothing. Hence, Dr Safuraa point out all of our mistake and guide us step by step of the basic procedural skills. After all of us understand and saw everything in big picture, Dr Safuraa allow us to practice them freely among us. When I practiced with my friends to measure blood pressure using the sphygmomanometer, all of us didn't find the Korotkoff sound. As we asked Dr Safuraa's help, she tried to measure the blood pressure on one of us as she thought if there any appliance that broke but actually she manage to hear the Korotkoff sound. From then on, Dr point out what did we do wrong and we able to realize our mistake and
MY REFLECTION
MY REFLECTION
PROS: We are able to practice the real method of checking blood pressure and also the correct method of doing the venepuncture. Dr Azmah taught us the trick on how to hear the Korotkoff sound and also the way to insert the needle while slowing withdrawing the blood in the syringe.
CONS: There was only one venepuncture provided during the session, so some of us was unable to experience the skill. Besides, some of us unable to hear the first Korotkoff sound and was struggling to deflate the blood pressure cuff. Moreover, finding the brachial pulse was also quite challenging.
IMPROVEMENT: Number of medical appliances could be increased so that all the students could experience the clinical skills.
ECE 11 - Basic Procedural Skill : 22/6/2022
ECE 11 - Basic Procedural Skill : 22/6/2022
measuring blood pressure using the sphygmomanometer
measuring blood pressure using the sphygmomanometer
venepuncture
venepuncture
measuring heart rate and pulse rate
measuring heart rate and pulse rate
Video : https://youtu.be/XWh07skwS7g
Written protocol
COMMENTS
COMMENTS
This session firstly divide my batch into some big groups where each of us free to practice our basic procedural skill in the clinical skill lab. There were many rooms which each of the room have all the appliance needed such as stethoscope, sphygmomanometer, and all the device for venepuncture procedure. Dr Safuraa allow all of us to do the basic procedural skill within the 2 hours to practice among us. This was an opportunity to test our skill whether we had mastered them or not. In addition, from here also each of us could point out which part that we miss and that actually would help us to improve in future. Dr also walk around each room to observe us and also sometimes correct us when we do them wrongly or miss something out. This last session was the most important as it gave us the chance to practice and allow us to know where does we stand right now, where did we lack at and what we need to improve. Of course we could book the clinical skill lab whenever we want to practice but not all people available anytime. So, don't waste this session by doing nothing.
MY REFLECTION
MY REFLECTION
During this session, I had the chance to practice the history taking, pulse and respiratory rate measurement, blood pressure measurement and also venepuncture. I could identify my weakness while practicing those clinical skills. This help me to manage and correct all the mistakes. It was a fun and relaxing session where lots of skills learned as I was practicing the skills together with my friends. We practiced on the live commentaries as well. It was like a recap session for all the ECE classes before. I can guarantee that this session will definitely help me to perform correct clinical skills during OSCE examination and also in the future. I look forward to more session like this in the future.
ECE 3 - Practical Male Catheterisation: 27/12/2022
ECE 3 - Practical Male Catheterisation: 27/12/2022
My Group Members :
Nor Afiqah Binti Ahmad
Tan Tze Chian
Shanu Devi A/P Kumareson
Nor Eliza Chew Binti Ahmad Syukri Chew
Gajavadanen A/L Thirugnana Seluan
Ainul Mardhiah Binti Mohd Rizal
Nur Ain Syamimie Binti Ahmad Yaakub
Sabella Emalien
Farhan Ali Bin Misbah
Faris Hazreen Bin Jaysri
Harith Iskandar
Tay Huey May
Zulaikha Binti Mohamad Nasron
Tan Jian Qi
Kauthar Binti Mohd Fitri
Muhammad Nabil Najmi Bin Ahmad Sabri
Nuralya Tasnim Binti Mohd Zaki
Amir Yusuf Bin Mohd Haizad
Muhammad Zulhakimi Bin Mohd Samsul
Goh Jun Hui
Mohammad Shahril Bin Mohd Sanip
Janani A/P Thanadurai
Jaiyadeepan A/L Ganesh
Kuganesh Gunaseelan
Sritharan A/L Nagendran
Nurul Amira Binti Harun
Nur A'isyah Binti Rosli
Mellisa Loo Jia Hui
Chua Cai Jun
Gather equipment
1. Clean the top of a procedure trolley using a disinfectant wipe.
2. Collect the equipment required for the procedure and place it within reach on the clean trolley:
Plastic apron
Two pairs of sterile gloves
Sterile water-filled syringe (10ml) for inflation of the catheter balloon.
0.9% sodium chloride (10mls)
Lidocaine (1%) anaesthetic lubricating gel for insertion into the urethra.
Male urinary catheter (12/14 french)
Catheter pack: including cotton wool balls, sterile gauze, sterile drapes, absorbent pad and gallipot (a.k.a. a small pot).
Catheter bag
Urine collection bowl (a.k.a. a receiver)
3. Check the expiry date on the catheter, sterile water, normal saline and lidocaine gel.
4. Ensure a clinical waste bin is placed nearby
Introduction
Wash your hands using alcohol gel. If your hands are visibly soiled, wash them with soap and water.
Don PPE if appropriate.
Introduce yourself to the patient including your name and role. Confirm the patient’s name and date of birth.
Explain the need for a chaperone
Gain consent to proceed with catheterisation. Check if the patient has any allergies (e.g. latex).
Ask the patient if they have any pain before continuing with the clinical procedure.
Explain to the patient that they’ll need to remove their underwear and lie on the clinical examination couch, covering themselves with the sheet provided. Provide the patient with privacy to undress and check it is ok to re-enter the room before doing so.
Equipment preparation
Setting up the sterile field
Setting up the sterile field
1. Set up the sterile field by first removing the outer packaging from the catheter pack and then opening the catheter pack from the corners without touching the inner surface of the field. Make sure to keep the catheter packaging, as you’ll need to transfer the sticky label containing the details of the catheter into the patient’s notes.
2. Using aseptic non-touch technique (ANTT) place the catheter, lidocaine gel syringe, sterile water syringe and sterile gloves onto the field.
3. Pour the 0.9% sodium chloride solution over the cotton balls which should already be located within the gallipot of the catheter pack.
Wash your hands
Don apron
Remove the outer wrapping of the catheter pack
Open the catheter pack using ANTT to create a sterile field
Remove packaging and place all single-use equipment onto the sterile field using ANTT
Pour NaCl 0.9% into the gallipot
Positioning the patient
1. With the patient lying supine, ensure the bed is at an appropriate height for you to comfortably carry out the procedure.
2. Wash your hands again and don a pair of sterile gloves.
3. Ask your chaperone to remove the sheet covering the patient’s genitals to allow you to maintain sterility.
4. Place a sterile absorbent pad underneath the patient’s genital region, ensuring you maintain sterility.
Wash your hands
Don a pair of sterile gloves
Expose the patient's genitals
Place an absorbent pad beneath the patient
Cleaning the penis
1. Hold the penis with your non-dominant hand using some sterile gauze and ensure the patient’s foreskin is retracted (if present).
2. With your dominant hand, pick up a cotton ball and use a single stroke moving away from the urethral meatus to clean an area of the glans. Dispose of the first cotton ball into the clinical waste bin and continue to repeat this process with a new cotton ball each time until all areas of the glans have been cleaned.
3. Discard your used gloves, wash your hands again and don a new pair of sterile gloves.
4. Place the sterile drape over the patient’s penis, positioned such that the penis remains visible through the central aperture of the drape. Some drapes come with a hole already present for this purpose, whereas others will require you to create one.
5. Place the sterile urine collection bowl below the penis but on top of the sterile drape.
Clean the penis
Discard gloves and wash your hands
Don a new pair of sterile gloves
Place a sterile drape over the penis
Place a sterile receiver below the penis
Inserting the local anaesthetic
1. Hold the penis vertically with your non-dominant hand using a piece of sterile gauze.
2. Warn the patient that the anaesthetic gel might initially sting, but then should quickly cause things to become numb.
3. With your dominant hand place the nozzle of the syringe of anaesthetic gel into the urethral meatus.
4. Empty the entire 10mls of anaesthetic gel into the urethra at a slow but steady pace.
5. Continue to hold to the penis in the vertical position to ensure the gel remains within the urethra and allow 3 to 5 minutes for the lidocaine gel to reach its maximum effect.
Inject local anaesthetic into the penis
Inserting the catheter
Preparation
Preparation
1. Pick up the catheter which should be on your sterile field in its wrapper.
1. Pick up the catheter which should be on your sterile field in its wrapper.
2. Remove the tear-away portion of the wrapper near the catheter tip, making sure not to touch the catheter.
2. Remove the tear-away portion of the wrapper near the catheter tip, making sure not to touch the catheter.
3. Hold the penis again using sterile gauze with your non-dominant ‘dirty hand’.
Insertion
4. Warn the patient you are about to insert the catheter.
5. Insert the exposed catheter tip into the urethral meatus using your dominant ‘clean hand’.
6. Advance the catheter slowly whilst gradually removing more of the wrapper to expose more of the catheter. The key to removing the wrapper without also pulling the catheter back out is to ensure you have a good grip on the penis as you gently pull back on the wrapper. As you pass the prostate you may note some resistance and the patient may experience some discomfort. If the resistance is significant and the patient appears very uncomfortable you should remove the catheter and consider a repeat attempt or specialist input from urology.
7. You should continue to advance the catheter until it is fully inserted into the penis. As you enter the bladder urine should begin to drain from the catheter.
Balloon inflation
8. Once the catheter is fully inserted, inflate the catheter balloon with the 10ml syringe of sterile water to secure it within the bladder. Before doing this, ask the patient to let you know immediately if they experience any discomfort as you inject the water. If the patient begins to experience discomfort during the injection of the water stop immediately as this may indicate the tip of the catheter is within the urethra.
9. Once the balloon is fully inflated, remove the syringe and gently withdraw the catheter until resistance is noted, confirming the catheter is held securely within the bladder.
Attaching the catheter bag
10. Attach the catheter bag tubing to the end of the catheter securely.
11. Position the catheter bag below the level of the patient to facilitate effective drainage of urine.
Final steps
12. Replace the patient’s retracted foreskin (if present) as failure to do so can result in the development of paraphimosis.
13. Clean away any urine spillage or excess lubricating gel and cover the patient with the sheet.
14. Dispose of your equipment into a clinical waste bin.
15. Provide the patient with privacy to get dressed.
Open the catheter wrapper
Gently insert the catheter into the urethra
Grip the penis once you have inserted part of the catheter to prevent it sliding back out.
Pull back on the wrapper to expose more of the catheter whilst gripping the penis
Loosen your grip and continue to insert the catheter
Fully insert the catheter and observe urine draining
Inflate the catheter balloon with the water-filled syringe
Gently retract the catheter to confirm it is secure within the bladder
Attach the catheter bag
Place the catheter below the level of the patient
Clean up the patient and dispose of your equipment into the clinical waste bin
Re-cover the patient
Wash your hand
COMMENTS
COMMENTS
This session was conducted by Prof Bahariah where she demonstrates to us the right technique of male catheterization. She also points out the angle of how the catheter should be inserted and states that we also can use water as a lubricant as during this session, the olive oil that has been prepared had run out. Prof also said that in actual cases, there's no need to insert anesthesia.
MY REFLECTION
MY REFLECTION
During this session, my group only had the opportunity to observe how Prof Bahariah simulate to us catheterization as we have too many people if each person wants to do it. She also adds several important things that are actually not listed in the step list. She states that we should not follow exactly all the long and complicated steps. Prof also explained very well whenever we have questions. I love how she handles this session as she creates a lively atmosphere in this session. I guarantee all of us had fun in this session. I look forward to more sessions like this in the future.
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