skill 1, 2, 3: hand hygiene/ppe - university of oxford...skill 1, 2, 3: hand hygiene/ppe station...

Skill 1, 2, 3: Hand Hygiene/PPE

Station No.: 1 Description: Length/min.: 10

Scenario: Mr AB has presented himself to the ED with a large cut on his shin that is bleeding-uncomplicated wound, no foreign body

Student Information: You have introduced yourself and identified the patient

Student Instructions: Please demonstrate your hand hygiene behaviour and use of personal protective equipment

Examiner Instructions: Student must observe the 5 moments of hand hygiene and appropriate use of PPE

Item Yes Not done orInadequate

Identifies patient verbally and using ID bracelet (2 point ID)

Ensures sleeves are rolled up, removes watch, dons an apron, ? mask

Cleans hands upon approach, before touching patient

Why? To protect patient from your contaminants

Patient contact

Cleans hands before embarking on examination of the wound with gloves

Why? Clean hands before any aseptic task to prevent contamination

Performs examination

Cleans hands after glove removal

Why? To protect self and environment from harmful microbes from patient

Explains and documents findings

Cleans hands on leaving

Why? To protect self and environment

Discuss hand rub versus hand wash

Notes on exceptional student performance or station design

Skill 7, 8: Vital signs

Station No.: 7 Description: Vital signs Length/min.: 10

Scenario: Mr AB has presented himself to the ED with a history of shortness of breath.

Student Information: You have met him and have taken a history

Student Instructions: Please measure and record his vital signs, and calculate a Modified Early Warning score

Examiner Instructions: Student must record RR, Pulse, BP, Sats, Temperature on the Observation chart andreport the MEWS score

Gloves not required


Introduces self, gains consent and co-operation

Ensures sleeves are rolled up, removes watch, performs hand hygiene

Identifies patient verbally and using ID bracelet (2 point ID)

Positions arm, pulse measurement and

Manual blood pressure measurement (selects appropriate cuff size, palpate,auscultate)

Measures Respiratory rate

Places saturation probe and records reading

Records Temperature with the device supplied

Records all measurements and calculates MEWS

Thank the patient, remove devices and tidies up and apply HH


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Skill 9: Oxygen Therapy

Station No.: 9 Description: Oxygen Therapy Length/min.: 10


Student Information: You have met him, taken a history and recorded his vital signs.

His RR is 20. His sats were 90% on room air.

Student Instructions: Please apply an appropriate oxygen device, measure his sats and prescribe oxygen

Examiner Instructions:

Follow BTS guidance

Nasal cannulae applied (2-4 L/min) - Sats 88% and decreasing

Venturi mask 24-40% - Sats 88% and decreasing

> 40% - Sats 88-90%

Non rebreathe mask - Sats improve to 96% but student must indicate need forcontinuous non-invasive monitoring, ABG and senior advice

Gloves not required

Target sats of 88-92% are NOT appropriate in this clinical scenario




Identifies patient verbally and using ID bracelet

Sits patient up and apply device correctly indicating appropriate flow rate on rotameter

Nasal specs 2 litres

Venturi according to device

Non rebreathe 12 to 15 litres

Applies saturation probe and records reading

Prescribes Oxygen therapy on drug chart, signs, prints name, contact details

Adjusts oxygen therapy until saturations are within the prescribed target range (94-98%) and mentions that inspired oxygen should be regularly reviewed and adjusted

Recognises patient’s high oxygen requirement as a sign of illness severity andmentions monitoring needs, ABG and senior input

Thanks the patient, applies HH


Skill 9: Oxygen Therapy

Name these types of devices

A B C DNasal cannula

Hudson mask

Venturi

Non rebreathemask

State FiO2/% delivered by each device

28% Varies Specific 80%

Nasal cannulaat 2 l/min

Hudson maskat 2l/min

Venturi atflow specified

Non rebreathemask at15l/min

Choose the right mask for the right patient

Venturi 28% Nasal cannula Non Rebreathe

Unwell asthmatic

Unwell COPD

Well but low satse.g. 90%Acute severeLVF

Shock

Skill 11: Airway devices


Bare below the elbows, personal protective equipment and performs hand hygiene

Identifies the patient (2 point)

Identifies suction equipment

Performs head tilt, chin lift and jaw thrust on a model

Identifies Guedel airway, sizes correctly, and demonstrates insertion on model.

Understands that this will not be tolerated by the awake patient

Identifies Nasopharyngeal airway and demonstrates insertion on a model.

Understands that this is better tolerated in alert patients.

Identifies an LMA

Understands that this is not for use in the conscious patient.

Identifies an ETT and laryngoscope.

Understands that this is for use by trained experts only

Identifies Bag Valve Mask device (BVM)

Understands that this can be used with or without oxygen

Describes or demonstrates a 2 person technique to ventilate using an BVM

Gives a safe management plan for the patient described

Assess airway patency

Suction secretions

Perform head tilt, chin lift & jaw thrust

Site OPA / NPA as tolerated, if needed

Give oxygen

Recognises that they need to inform their senior

States that after any intervention they will re-assess for effect.


Station No.: 11 Description: Airway devices Length/min.: 10

Scenario: Mrs BH has been admitted following a stroke. Her GCS is 9/15 and you are asked to reviewher as her oxygen saturations are falling.

Student Information: Mrs BH does not respond to you when you speak to her but you note a snoring noise as shebreathes and has secretions around her mouth.

Student Instructions: On the table are a number of airway management devices. Please explain their uses andthen conclude how you might manage this case.

Examiner Instructions: Guide the candidate through the displayed items.

Candidates should be able to name and describe or demonstrate the use of each device.

Understanding of indications and contra-indications should be displayed.

A safe immediate management plan is expected, followed by a call for help.

Skill 11: Airway: Bag:Mask:Valve ventilation


Bare below the elbows, personal protective equipment and performs hand hygiene

Identifies the patient (2 point)

Gives a safe management plan for the patient described

Assess airway patency

Suction secretions

Perform head tilt, chin lift & jaw thrust

Site OPA / NPA as tolerated, if needed

Give oxygen

The patient tolerates a guedel airway

Resp rate is low. Naloxone may be mentioned but not available yet

Proceeds to bag mask ventilation and summons help (2 man technique)

Decision based on

1. Can the patient protect his airway2. Can the patient maintain his airway3. Can the patient generate a tidal volume to maintain oxygenation and eliminate

carbon dioxide

Demonstrates bag:valve mask ventilation


Station No.: 11 Description: Bag:Mask ventilation Length/min.: 10

Scenario: Mr H has been admitted following an overdose of methadone. His GCS is 7/15 and you areasked to review him as his oxygen saturations are falling.

Student Information: Mrs BH does not respond to you when you speak to him but you note a snoring noise as hebreathes and has secretions around his mouth. His respiratory rate is 2

Student Instructions: On the table are a number of airway management devices. Please explain their uses andthen conclude how you might manage this case.

Examiner Instructions: Guide the candidate through the displayed items.

Candidates should be able to name and describe or demonstrate the use of each device.

Understanding of indications and contra-indications should be displayed.

A safe immediate management plan is expected, followed by a call for help.

Skill 12: Respiratory function tests: Peak flow

Station No.: 12 Description: Peak Flow measurement Length/min.: 10




Student Instructions: Please obtain a peak flow value.





Identifies patient verbally and using ID bracelet.

Gather equipment. Single use hand piece

Zero the peak flow meter

Instructs the patient to stand or sit upright and take in as deep a breath as possible

Place the mouthpiece in the mouth with the tongue underneath, close the lips tightly aroundthe mouthpiece and blow out as hard and fast as is possible

Breathe normally and then repeat the process twice

Record the three readings

Thanks the patient, applies HH and disposes of the mouthpiece


Skill 12: Respiratory Function Tests:Spirometry

Station No.: 12 Description: Spirometry: FEV1 and FVC Length/min.: 10




Student Instructions: Please perform a spirometry test on this patient


Follow BTS guidance

NICE





The patient must be seated comfortably and allowed to have some practice attempts (nomore than a total of 8)

Record the patients sex, age and height

Apply a nose clip to the patient

Attach a single use mouthpiece to the device, place this in the patients mouth ensuring thatthe lips are sealed around the device with the tongue underneath

FEV1/FVC

Instruct the patient to breathe in as deep as possible, then blow the breath out as hard andfast as is possible until there is nothing left to expel

Repeat this twice. (at least 2 values within 5% or 100mls of each other.

Record the readings

Vital capacity (May be obtained at the start to familiarise patient with the equipment, whenunable to perform a forced measurement)

As above but breathing out at a comfortable pace.

Record



Skill 13: Nebulisation

Station No.: 13 Description: Nebulisation Length/min.: 10

Scenario: Mr AB has presented himself to the ED with a history of coughing up sticky phlegm


His RR is 20. His sats were 90% on room air. He normally uses inhalers.

Student Instructions: Please set up a saline nebuliser


Follow BTS guidance





Collects and ensures that the equipment is clean and in working order

Facemask or mouth piece

Nebuliser chamber

Compressor chamber/power source

Checks the Saline and deposits the appropriate amount in the nebuliser chamber

Assembles the chamber and connects to mask and power source and places on thepatients face, ensuring the correct placement and flow rate

Documents the action and outcome



Skill 14: Inhalers

Station No.: 14 Description: Inhalers Length/min.: 10

Scenario: Mr AB has just recently been diagnosed with asthma. He is still unsure how to use his inhaler



Student Instructions: Please educate and advise him and choose an appropriate device that will suit his needs


Follow BTS guidance





Identifies a pressurised Metered Dose inhaler

Ask the patent to sit comfortably with chin up

Instructions:

Remove the cap and check that mouthpiece is clean

Shake the inhaler and breathe out gently

Place the mouthpiece in the mouth and seal with lips

Breathe in gently and simultaneously press the canister

Keep the inhaler in the mouth and hold breath for 10 seconds

Repeat the procedure after 30 to 60 seconds if required

Limitations:

Requires coordination, 30% of patients are unable to use this, ineffective use may lead todeposition of drug in the oropharynx causing irritation

Identifies a spacer inhaler device

Checks that the MDI and spacer device are compatible and clean

1.Single breath technique

Instructions

Remove the cap of the pMDI, shake and insert into the spacer

Place the mouthpiece of the spacer in the mouth and breathe slowly in and out to check thevalve

Press the pMDI, keeping the inhale in the camber and the spacer in the mouth

Take a slow deep breath, hold the breath for about 10 second and breathe out through themouthpiece

Remove the device and clean. Repeat in 30 to 60 seconds if a further dose is required.

2. Multiple Breath technique

As above but breathe in and out 5 times

Limitations:

Spacers are susceptible to static charge, must be cleaned and wiped dry between use,valves may become damaged

Alternatives

Breath-activated inhalers/dry powder inhalers

E.g. Accuhaler, Turbohaler, Diskhaler

Appropriately documents the session



Skill 15, 16: Venipuncture (vacutainer and needle/butterflytechnique) and management of blood samples

Station No.: 15,16 Description: Phlebotomy Length/min.: 10

Scenario: Mr AB was admitted with an atypical pneumonia, he is on anti hypertensives and warfarin.

Student Information: You have met him and have taken a history and recorded his vital signs, he requires a full setof investigations

Student Instructions: Please perform phlebotomy and manage the samples correctly


National and Trustguidelines

Student must use either a vacutainer and needle/butterfly or vacutainer adaptor to obtainblood cultures/ clotting /LFT/CRP/U’s and E’s/FBC/Group and save/blood glucosespecimen, label, process and document the action

Gloves required

Item yes Not done orInadequate


Ensures sleeves are rolled up, removes watch, mentions hand washing and wearsgloves (PPE)


Selects appropriate equipment, cleans tray, opens and prepares equipment

Positions and exposes arm and equipment appropriately, (Non dominant, antecubitalfossa, rationalises if chooses another site, inco sheet)

Applies single use tourniquet and identifies vein

Anchors vein and cleans with wipe and allow to dry

Penetrates vein and stabilises device.

Avoids re palpation.( Explains rescue techniques if failure and abandons procedure)

Avoids unnecessary movement of needle

Correct order of draw

Cultures, Aerobic, anaerobic, cleans tops, agitate

clotting through to EDTA containing tube, agitate

2 x clotting if using butterfly (unless blood cultures have been taken)

Removes device and applies pressure with swab

Activates needle safety device, disposes of sharp

Disposes of waste, gloves, apply HH, cleans tray

Labels specimens

Documents the venesection with time , date, signature, print, designation and anydifficulties encountered

Thanks the patient.


Skill 17: Blood cultures

Station No.: 17 Description: Blood cultures Length/min.: 10



Student Instructions: Please perform phlebotomy and process the specimens



Student must use either a vacutainer and needle/butterfly or vacutainer adaptor to obtainblood cultures, label, process and document the action

Gloves required





Selects appropriate equipment, cleans tray, opens and prepares equipment

Positions and exposes arm and equipment appropriately, (Non dominant, antecubitalfossa, rationalises if chooses another site, inco sheet)

Applies single use tourniquet and identifies vein

Anchors vein and cleans with wipe and allow to dry

Penetrates vein and stabilises device.



Correct order of draw

Cultures, Aerobic, anaerobic, cleans tops, agitate

May indicate the need for different sites

Removes device and applies pressure with swab

Activates needle safety device, disposes of sharp


Labels specimens

Documents the venesection with time , date, signature, capitals, designation and anydifficulties encountered

Thanks the patient.


Skill 19: Asepsis and wound care

Station No.: 19 Description: Asepsis Length/min.: 10

Scenario: Mr AB has presented himself to the ED with a large wound on his leg


Student Instructions: Please proceed to dress the wound

Examiner Instructions: Aseptic technique

Wound dressing


Introduces self, gains consent and co-operation. Ensures the patient is in a comfortableposition

Ensures sleeves are rolled up, removes watch, performs appropriate hand hygiene at allstages

Appropriate Personal Protective Equipment


Gathers equipment and cleans trolley

Wound Care Pack, cleaning solution, sterile gloves, waste disposal equipment

Appropriate dressings

Prepares equipment

Aseptic non touch technique: Due care with Key sites, Key parts

Performs the procedure

Aseptic non touch technique: Due care with Key sites, Key parts

Disposes of waste appropriately, applies HH

Documents the procedure, (date, signature, designation, contact details)

Thanks the patient,


Skill 18: Blood glucose/ketone measurement

Station No.: 18 Description: Blood glucose/ketone Length/min.: 10

Scenario: Mr AB has presented himself to the ED with a history of polyuria and polydipsia

Student Information: You have met him, taken a history and recorded his vital signs

Student Instructions: Please perform a capillary blood glucose/ketone measurement

Examiner Instructions: Student must perform and record the above measurement with the equipment provided.Various devices available.

Gloves required



Ensures sleeves are rolled up, removes watch, mentions hand washing and wearsgloves

Identifies patient verbally and using ID bracelet (may require scanning)

Ensures that the patient has clean hands (soap and water wash)

Collects appropriate equipment and container, waste and sharps disposal

Prepares strip and device for specimen collection without touching reagent part of strip

Lances side of pulp space of either ring or little finger of non-dominant hand,

Warns the patient that it may hurt

Obtains specimen and offers swab to staunch blood flow

Records measurement with time, date, signature, print and contact details

Thanks the patient, tidies up, disposes of waste and sharp and apply HH

Column Total:


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Skill : 20, 21: MSU and urinalysis

Station No.: 20,21 Description: MSU, Urinalysis Length/min.: 10

Scenario: Mr(s) AB presented to the ED with a suspected urinary tract infection

Student Information: You have met the patient, taken a history and recorded vital signs.

Student Instructions: Please explain how to produce a midstream urine sample and perform urinalysis

Examiner Instructions: Specimen bottle

Urine analysis sticks

performed with gloves


Introduces self, gains consent and co-operation. Ensures the patient has a full bladder.

Ensures sleeves are rolled up, removes watch, performs appropriate hand hygiene at allstages

Appropriate Personal Protective Equipment


Instruct the patient to

Wash their hands and remove the cap from the sterile container

Begin to pass urine into the toilet whilst keeping the foreskin retracted or the labia parted

Catch the middle portion of urine flow , without interrupting the flow

Fill the container to approx. ¾ full, finish voiding.

Wash hands and replace the cap

Complete details on the container: name, date, time etc.

Retain some urine for urinalysis in a separate container

Student should familiarise themselves with test strips and check expiry date

Wear gloves

Inspect the urine for colour, odour and turbidity

Dip/cover testing strip in urine without touching the testing zone

Time accurately and note results

Disposes of waste appropriately

Documents the procedure, record the results and dispatch the MSU (date,time, signature,designation, contact details)



Skill 24: Inserting a cannula into peripheral veins

Station No.: 24 Description: Insertion of a Cannula Length/min.: 10

Scenario: Mr BC has been admitted with left lower lobe pneumonia. IV antibiotics have been prescribedfor him. Please insert a cannula for his antibiotics to be administered.

Student Information: Mr BC knows you and understands the procedure that is to be performed

Student Instructions: Please insert a cannula into the manikin. Demonstrate the ANTT method. Tell the examinerwhat you are doing as you go along.


ANTT

CQC/NHSLA/CNST

Pay special attention to the observance of key parts, key sites and Critical moments

ItemYes

Not done orInadequate

Identifies patient verbally and using ID bracelet and gains cooperation

Prepares tray for cannulation to include cannula, dressing, swabs, flush (saline notwater) 5ml syringe, tourniquet, drawing up needle,Chlorhexidine wipe , needle freebung, sharps bin

Prepares Flush

Draws up flush using needle

Disposes of needle into sharps bin,

places syringe back into its packet to maintain sterility of syringe

(All three =essential)

Prepares Needle free bung

Uses aseptic no touch technique to open pack and flushes through needle freebung/octopus, keeping key areas sterile

Places Bung/Octopus back into the packaging to maintain its sterility

(both = essential)

Ensures BBE, mentions hand washing and protective sheet and gloves

Places tourniquet on arm, identifies appropriate vein, stabilises skin

Cleans with Chlorhex wipe and wears gloves after HH

Holds cannula correctly (not touching key parts)

Avoids repalpation

(may request sterile gloves if re palpation is required)

Passes the cannula into the vein at an angle of 15-25 degrees and observes for flashback

Gently advances the cannula a few millimetres beyond the point of flash back

Slides the cannula over the needle maintaining traction to the skin

Releases tourniquet

Removes the needle and immediately puts into sharps bin, places bung onto cannula.

Cleans port with chlorhex wipe and allow to dry

Flushes through the cannula (checks contents)

Fixes the cannula using dressing and writes/mentions drug chart documentation andVIP score


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SAVING LIVES CAMPAIGN

Intra venous cannulation care bundle

Hand hygiene PPE Skin preparation Dressing Documentation

Skill 25, 27: Setting up an IV infusion; use ofinfusion devices, prescription of fluids

Station No.: 25 Description: Setting up an IV infusion Length/min.: 10

Scenario: Mr BC has been admitted with left lower lobe pneumonia. IV fluids and antibiotics have beenprescribed for him. He has a cannula in situ.

Student Information: You have met him, taken a history and recorded his vital signs. He understands theprocedure

Student Instructions: Please prime an infusion set with saline, attach and set to run at 120mls/hour


ANTT

Set up an iv infusion, set a flow rate either manually or by Infusion device





Select the prescribed fluid and check expiry date

Remove from packaging and remove the port cover taking care not to touch the key part

Remove the giving set from packaging and turn the roller/wheel clamp off

Insert the sharp end of the giving set into the port of the IV fluid bag.

Do not touch key parts

Hang fluid bag on drip stand and squeeze drip chamber until half filled with fluid

Release the roller/wheel clamp gradually and run the fluid through the tubing (ensure all airis removed)

Close the roller/wheel clamp

Hang giving set over drip stand or attach to roller/wheel clamp to help reduce contamination

Clean hands

Wipe the needle free bung on the cannula, allow 30 seconds to dry

Remove the cap from the end of the giving set

Attach to the needle free bung, slowly open the roller/wheel clamp

(the cannula may need to be flushed with saline first to check integrity if not newly inserted)

Check that the drip runs freely when fully opened, and then adjust the drip rate according tothe prescription.

With a standard set 20 drops is 1 ml (found on back of giving set package)

mls/hour x no. of drops/ml of giving/60 mins = drops per minute

Manually count drops and adjust roller clamp over a minute

Best practice is for fluids to be infused through a pump

Document on the fluid chart, including batch number, pump number and starting time



Skill 26: Making up drugs for parenteraladministration

Station No.: 26 Description: Parenteral administration ofdrugs

Length/min.: 10

Scenario: Mr BC has been admitted with left lower lobe pneumonia. IV antibiotics have been prescribedfor him. He has a cannula in situ. He has an iv infusion running


He requires iv antibiotics. He has been consented.

Student Instructions: Please prepare appropriate antibiotics e.g. Co Amoxiclav(vial, by iv infusion) or gentamycin(ampoule, push iv injection)


ANTT/COSH/WHO



Ensures sleeves are rolled up, removes watch, performs hand hygiene and uses gloves atappropriate times


Checks the prescription chart for patient dose, drug, route and time of administration.

Prep of parenteral drugs generally requires 2 practitioners

Basic principles

Gather equipment and place in clean tray with key parts protected

Wear gloves if handling a noxious substance

Check the drug to be prepared and expiry date

Reconstitute drug to be administered from (vial) / Draw up from ampoule

Use a syringe appropriate to the volume of drug to be injected

Use a filter needle or < 21 G if drawing from a glass ampoule

Prepares a flush

Label the syringe or infusion

Administer the drug (see iv administration sheet)

Institute appropriate monitoring

Document the procedure: date, time, route, dose, name, signature, designation, contactdetails



Skill 28: Giving intravenous injectionsStation No.: 28 Description: IV injections Length/min.: 10

Scenario: Mr BC has been admitted with left lower lobe pneumonia. IV antibiotics have been prescribedfor him. Please administer Co amoxiclav by push in IV injection.

Student Information: Mr BC knows you and understands the procedure that is to be performed. He has a cannulain place

Student Instructions: Please perform a push in intravenous injection. Demonstrate the ANTT method. Tell theexaminer what you are doing as you go along.

Examiner Instructions: Prepared IV drug.


Identifies patient verbally and using ID bracelet and gains cooperation

HH

Prepares tray for injection.

Includes Chlorhexidine wipes x2

Flush x2

Pre prepared drug (protected key part), labelled

Prepares Flush (normal saline 5 to 10 mls)

Draws up flush using appropriately sized needle/drawing up needle

Disposes of needle into sharps bin,

places syringe back into its packet to maintain sterility of syringe, or covers key partwith sheathed needle or bung

(All three =essential)

Prepares Needle free bung

Uses aseptic no touch technique to clean with wipe

Inspects and Flushes cannula to check integrity/swelling or pain

Delivers IV antibiotic over a few minutes, monitors for adverse reactions

Cleans with Chlorhex wipe, re flushes cannula

Tidies, applies HH and thanks patient

Documents the administration with time , date, signature, capitals, designation on the drugchart


Skill 29: Intramuscular injections

Station No.: 29 Description: Intramuscular injection Length/min.: 10

Scenario: Mr AB has presented himself for his flu vaccination

Student Information: You have met him and explained the procedure

Student Instructions: Please choose an appropriate site and administer an im injection


WHO

Student chooses either deltoid/ventro gluteal or vastis lateralis

Administers injection

WHO guidance: gloves not required

Alternative scenario: IM Adrenaline for anaphylaxis





Sits patient up and exposes an appropriate site

Deltoid (1 ml)

Ventrogluteal (up to 4 ml)

Vastus Lateralis (up to 4 ml)

Dorsogluteal (controversial)

Chooses appropriate equipment and sets out tray using ANTT

Correct needle length and syringe (21 or 23 G, (green or Blue hub) length dependant onpatient, Luer lock/slip, pre filled: choose appropriate size)

Checks drug and expiry date

Checks for allergies

Skin prep. Socially clean (local policy)

Injection technique: May use z tracking

Pulls skin taut

Insert needle at 90 degree angle

Aspirates (particularly ventrogluteal)

Injects 1ml every 10 seconds

Remove and dispose of sharp

Documents the administration with time , date, signature, capitals, designation on the drugchart/notes

Records lot number

Thanks the patient, observes for adverse effects (patient and site), applies HH


Skill 30: Subcutaneous injections

Station No.: 30 Description: Subcutaneous injection Length/min.: 10

Scenario: Mr AB has presented himself for his insulin/heparin injection

Student Information: You have met him and explained the procedure

Student Instructions: Please choose an appropriate site and administer an sub cut injection

Examiner Instructions: Student chooses either thigh/arm/abdomen or buttock

WHO Administers injection

WHO guidance: gloves not required



Ensures sleeves are rolled up, removes watch, mentions hand washing


Sits patient up and exposes an appropriate site

Arm, thigh, abdomen, buttock

Alternating sites may be appropriate


Chooses the pre filled syringe/8mm/27G needle

Checks drug and expiry date


Skin prep. Socially clean (local policy)

Injection technique:

May bunch up skin, particularly in thin individuals

Insert needle at 90 degree angle

Aspiration is not required

Injects 1ml every 10 seconds

Remove and dispose of sharp


Records lot number



Skill 31: intra dermal injections and localanesthetics

Station No.: 31 Description: Intradermal injection Length/min.: 10

Scenario: Mr AB has presented himself to the ED with a history of shortness of breath. He requires andarterial blood gas and requests that local anaesthetic is administered prior to the test

(alternative scenario: allergy testing)

Student Information: You acknowledge his request and confirm that this is now standard practice according to BTSguidance

You have explained the procedure

Student Instructions: Please perform and intradermal injection at the wrist


Follow BTS guidance



Ensures sleeves are rolled up, removes watch, performs hand washing




Checks drug and expiry date, lot number (preferably with another practitioner)

Opens the ampoule with the recommended technique

Prepares a 1 or 2 ml syringe with 1% Lidocaine. Draws up using ANTT technique and a filter

or 21G needle

Change the needle: 25G

Ensures the patient is comfortable

Prepares the site

Cleans the site

Performs the injection

Insert the needle and syringe at a 10 to 15 degree angle

Bevel up

Just under the epidermis

Warns the patient that it will sting

Injects up to 0.5 ml until a wheal appears

Disposes of the sharp

Proceed to perform an ABG (different skill sheet)


Records lot number



Skill 32: Carry out arterial blood sampling

Station No.: 10 Description: Arterial blood sample Length/min.: 10



Student Instructions: Please perform an arterial blood sample



BTS guidelines

Student must have knowledge of preferred sites, Allen’s test and use of local anaestheticinfiltration by intra dermal injection

Gloves required





Selects appropriate equipment, cleans tray, opens and prepares equipment.

23 G needle, heparinised syringe, chlorhex wipe, swab

Positions and exposes arm and equipment appropriately, (Non dominant, radial artery)

Performs Allens test

Mentions use of local anaesthetic infiltration

Palpates artery and stabilises to avoid needle stick

Penetrates artery, waits for flush and fills syringe to 1 to 2 mls



Places swab and applies pressure for 3 to 5 minutes (longer in warfarinised patients)

Agitates syringe and disposes of sharp appropriately


Labels specimen

Documents the procedure with time , date, signature, capitals, designation and anydifficulties encountered

Thanks the patient.


Skill 33: Performing a 12 lead ECG

Station No.: 33 Description: 12 lead ECG Length/min.: 10

Scenario: Mr AB has presented himself to the ED with sudden onset chest pain


You have explained the procedure and obtained verbal consent

Student Instructions: Please obtain a 12 lead ECG






Ensures the patient is comfortable

Prepare skin surface if required and ensure surface is clean and dry prior to placing

Electrodes

Razor / Scissors for preparation of skin surface

Gauze swabs / tissues

Position ECG Machine close to patient’s chest

Check power cable and patient lead cable are fitted into power sockets

Press “on” button and check machine does self-test analysis

Follow the instructions on the machine (each machine has variations on how to STARTthem)

Apply electrodes to appropriate anatomical sites;

Outer aspect of each forearm (RA, LA) (red, yellow)

Medial aspect of each lower leg (LL, RL) (black, green)

Appropriate anatomical chest locations ( V1 - V6)

V1: 4th

Intercostal space to the right of the sternum

V2: 4th

Intercostal space to the left of the sternum

V3: Between V2 and V4

V4: 5th

intercostal space, left mid clavicular line

V5: Anterior axillary line level with V4

V6: Mid axillary line level with V4

Connect leads to electrodes these are labelled or colour coded for the sites

• Push auto button to start recording

• Observe recording as paper emerges

Before disconnecting the leads ensure the recording is:

� Free from artefact

� Paper speed is at 25mm/sec

� Normal standardisation of 1mv, 10mm

� Lead placement is correct

Turn off ECG machine

Disconnect leads form electrodes

Carefully peel off electrode and wipe off any gel from patient’s skin with gauze or tissue

Ensure ECG is labelled with all patient details, time, date and signed



Skill 35: Blood Transfusion

Station No.: 35 Description: Blood Transfusion Length/min.: 10

Scenario: Mr AB requires a blood transfusion

Student Information: You have met him, taken a history and explained the procedure to him

Student Instructions: Please obtain a blood sample, order blood and set up the transfusion


FollowSHOT/BloodTrackTx/local policies

Set a scenario





Performs venepuncture and obtains a specimen Vacutainer/butterfly/syringe technique

Documents the procedure, labels the sample and orders blood products

Group and save/cross match/type specific

Performs cannulation using ANTT and documentation as required

Sets up an IV infusion using a blood giving set , primes the set with saline and attaches thisto the patient

Receives and checks the blood according to policy and prescribes the products

Institutes appropriate monitoring.

Documents the procedure: Sign, print, date, time, designation, contact details as well as anyproblems encountered



Skill 36: Suturing

Station No.: 36 Description: Suturing Length/min.: 10

Scenario: Ms DT has a laceration on her leg

Student Information: You have met her and have taken a history and recorded her vital signs.

She requires suturing of the wound. You have explained the procedure and she hasconsented

Student Instructions: Please suture this wound



NPSA guidance

ItemYes



Ensures sleeves are rolled up, removes watch, performs hand hygiene and wearsgloves and apron (PPE) at appropriate times


Selects appropriate equipment, opens and prepares equipment

Positions patient and places a protective sheet under the leg

Opens packs and chooses gloves and suture material

Mentions the use of Lidocaine and allows time for this to be effective (10 to 15 minutes)(DO NOT DO)

Aseptic clean

Correctly mounts needle in needle holder

Holds instruments correctly Forceps/needle holder/scissors

Manages to tie at least one quality suture

Size/tension/spacing

Applies a dressing

Disposes of waste, gloves, apply HH


Thanks the patient.


Skill 37: Nasogastric tube insertion/ enteral feeding

tube and perform a nutritional assessment

Station No.: 37 Description: NG tube Length/min.: 10

Scenario: Mrs DE is admitted with severe nausea and vomiting and possible small bowel obstruction

OR post stroke with a positive SALT and requires enteral feeding

Student Information: You have met her and have taken a history and recorded her vital signs, she requires a nasogastric tube

Student Instructions: Please perform a nasogastric tube insertion



NPSA guidance

ItemYes



Ensures sleeves are rolled up, removes watch, mentions hand washing and wearsgloves and apron (PPE)


Selects appropriate equipment,, opens and prepares equipment

Positions patient and examines nostrils/nasal passages

Measures the length of tube required

(nostril to ear to xiphisternum)

Applies lubricant to tube

(Water for feeding tube, KY for Ryles)

Gently advances tube, allowing patient to swallow small sips of water, to the measuredlength

Aspirates and checks for gastric content by measuring pH on indicator strip

(pH below 5)

Removes guide wire and discusses rescue techniques if negative aspirate

Applies securing device and attaches to bag for free drainage or spigots

Disposes of waste, gloves, apply HH


Thanks the patient.


Skill 38: Perform bladder catheterization

(Male/Female)Station No.: 38 Description: Catheterisation Length/min.: 10

Scenario: Mr AB was admitted with acute urinary retention


Student Instructions: Please perform a bladder catheterisation on this patient that is socially clean



Student must use aseptic non touch technique as required by Saving Lives Campaign

Sterile equipment, gloves and apron





Selects appropriate equipment, cleans trolley, opens and prepares equipment

Positions and exposes patient and equipment appropriately.

Places inco sheet (and ensures foreskin is retracted)

HH, gloves and performs an aseptic clean, places drapes

Inserts Instillagel

11 mls for males

6 mls for females

Changes gloves and applies HH appropriately

Attaches drainage bag to catheter to ensure a closed system and inserts the catheterusing non touch technique

Fills balloon appropriately, checks that urine is draining

Tidies up and Secures the catheter,


Has some knowledge of rescue techniques/ appropriate sizes

Documents the aseptic catheterisation with time , date, signature, capitals, designation,residual volume, and any difficulties encountered

Thanks the patient.


Skill 40: Work out a drug dosage

Station No.: 40 Description: Work out drug dosage Length/min.: 10 hahaha

Calculate mg/ml in the following solutions:

1. 2%2. 0.5%3. 0.2%4. 10%

Answers

20mg/ml5mg/ml2mg/ml100mg/ml

5. 8.4%6. 1:10007. 1:10000

84mg/ml1mg/ml0.1mg/ml

How many ml of each is required?

1. 10% CaCl, 750mg dose required2. 1mg/ml Atropine, 600 microgram3. 1:1000 adrenaline, 5 mg4. 1:10000 adrenaline, 750 microgram

Answers

7.5 ml0.6 ml5 ml7.5 ml

How many mg in 1 g?

How many micrograms in 1 g?How many micrograms in 1 mg?

1000

10000001000

Gentamycin 80mg/2ml

Give 120 mg, how many ml?

3 ml

Lidocaine 2%

Give 100mg, how many ml?

5 ml

Bupivacaine 0.25%

Give 150 mg, how many ml?

60 ml

KCL 20 mmol/10 ml

Give 7.5 mmol, how many ml

3.75 ml

Mannitol 20%, how many ml for

1. 12.5mg stat dose2. 2g/hr infusion

Answers

62.5 ml10 ml

Digoxin 0.25mg/ml

Give 62.5 microgram, how many ml

Answer

0.25ml

Frusemide infusion: 500mg/50 ml

How many milliliters/hr should the pump be set at to give 4 mg/min?

Answer

24ml/hr

Heparin infusion: 10000units/50 ml

How many ml/hr should the pump be set at to give 1300units/hr?

Answer

6.5ml/hr

Adrenaline infusion: 3mg/50ml. running at 4.6ml/hr

What is the dose in microgram/minute?

Answer

4.6mcg/min

Magnesium

Vancomycin

GTN

Skill 41: Write a safe prescription

Station No.: 41 Description: Prescription Length/min.: 10

Oxygen prescription

Fluid prescription

Drug chart prescriptions

Once only dosage

prn “As Required” drug prescription

Regular drug prescription

Skill 43: Ophthalmoscopy

Station No.: 43 Description: Ophthalmoscopy Length/min.: 10

Scenario: Mr AB has presented with a new diagnosis of diabetes/hypertension

Student Information: You have met him, taken a history and recorded his vital signs. He understands that herequires an examination of his eyes

Student Instructions: Please perform ophthalmoscopy

Examiner Instructions: Gloves are not required



Ensures sleeves are rolled up, removes watch, performs hand washing


Checks the equipment: battery and controls

Ask subject to fix vision on distant object

Dim lights

Hold instrument to eye with index finger on lens dial

Approach from shallow angle (15-20 degrees)

Approach on the same level as the equator of subject’s eye

Note & comment on red reflex

Note & comment on anterior structures of the eye

Focus on retina

Identify optic disc

Follow blood vessels into 4 quadrants

Seek to identify the macula and fovea



Skill 44: Otoscopy

Station No.: 44 Description: Auroscopy Length/min.: 10

Scenario: Mr AB complains of ear ache


He understands the procedure

Student Instructions: Please perform otoscopy

Examiner Instructions: Gloves are not required





Checks equipment: battery, light and appropriately sized single use ear piece

Performs the procedure with care

Commenting on

Pinna and surrounding structures

Canal

drum

Documents the procedure



Skill 45: Digital rectal examination

Station No.: 45 Description: DRE Length/min.: 10

Scenario: Mr AB has presented with symptoms of prostatism


He understands and has consented to a rectal examination

Student Instructions: Please perform a digital rectal examination






Positions the patient (left lateral) ensuring maintenance of dignity, considers a chaperone

Dons gloves and applies lubricant

Warns the patient before insertion of finger

Inspect and report findings that can be seen

Comments on anal tone

Rotates anticlockwise to examine left side of the pelvis and anteriorly. Comments onfindings.

Rotates the finger to examine the right side of the pelvis. Comments.

Performs a bimanual examination

Documents the procedure

Answers patients questions and ensure that all lubricant is cleaned up

