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Flashcards in ISCE - Clinical Skills Deck (131):
1

When MUST hands be washed with soap and water rather than alcohol hand gel?

When there is an outbreak of Norovirus, C.diff, other diarrhoeal illness, when the hands are soiled and after gloves are removed

2

What are the 5 moments of hand hygiene?

1. Before patient contact
2. Before an aseptic task
3. After body fluid exposure risk
4. After patient contact
5. After contact with the patient's surroundings (e.g. the bedside)

3

What is the minimum time for which hands must be washed?

10-15 seconds

4

When should HIV PEP ideally be started?

Within an hour

5

When should Hep B immunoglobulin be administered, ideally, after exposure?

Within 48 hours

6

What are the indications for an ABG?

Assessment of oxygenation in:
1. Dyspnoea
2. Acute resp disease
3. Exacerbation of chronic resp disease
4. Suspected resp failure
5. Congestive heart failure
6. Ventilated patients

+ assessment of acid-base balance

7

What are the contraindications to ABG?

1. Patient - consent/condition/co-operation
2. Non-palpable pulse
3. Poor collateral circulation (i.e. failed Modified Allen's test)
4. Underlying skeletal trauma
5. Infection at/around site of puncture
6. Arterial grafts/AV fistula
7. Clotting disorder
8. On anti-coagulation therapy
9. Taking steroids
10. ?extensive vascular disease
11. ?anyeursm at puncture site
12. Previous arterial spasm following puncture

8

What is the depth of the radial artery beneath the skin?

0.5-1cm

9

What are the advantages of using the radial artery for ABG?

Easy access, and pressure is easily applied to arrest bleeding

10

What should you use should the radial artery be contraindicated/unsuccessful?

Femoral artery

11

Whom should not have an ABG taken from the femoral artery + why?

Children - due to the risk of septic arthritis and nerve damage

12

What is the depth of the femoral artery beneath the skin?

2-4cms

13

What are the disadvantages of using the femoral artery for an ABG?

Pressure is not easily applied to arrest bleeding

14

Why is the brachial artery no longer recommended for ABGs?

1. Depth of the artery
2. Risk of damage to median nerve

15

What are the complications of ABGs?

1. Thrombosis
2. Embolization
3. Arterial spasm
4. Bleeding
5. Haematoma
6. Pain
7. Infection
8. Nerve damage/damage to nearby structures
9. Vaso-vagal reaction
10. Venous sample collected

16

How do you perform the Modified Allen's test?

Feel for radial pulse and ulnar pulse, raise the patient's hand and occlude both whilst asking them to make and hold a fist for 20 seconds. After 20 seconds release the ulnar artery. Blanched hand should re-perfuse within 7 seconds

17

What is the Modified Allen's test an assessment of?

Collateral blood flow to the hand on occlusion of the radial artery

18

What is a normal result in a Modified Allen's test?

Re-perfusion within seconds

19

Should the time result of the Modified Allen's test be recorded in the notes?

Yes

20

At what angle should an ABG needle be inserted?

30-45 degrees

21

How much blood should be in a ABG syringe?

1-2mls

22

For how long should pressure be applied to an ABG puncture site?

5 minutes

23

What should you do once you have the ABG sample, and have delegated application of pressure of the puncture site?

1. Invert sample for 30 seconds
2. Ensure bubbles are removed from syringe
3. Drop 1-2 drops onto gauze prior to introduction to check for clots
4. Have read by the ABG analyser within 15 mins of sample collection
5. Do not throw away sample until printed ABG report is in hand

24

What should you do with the printed ABG report?

Sign and date it before putting it in the patient's notes

25

What are the indications for taking blood cultures?

1. Temp <36 or >38.3
2. Focal signs of infection, e.g resp, UTI etc.
3. Tachycardia >90
4. Hypotension
5. Chills or rigors
6. Increased inflammatory markers
7. Raised/low WBC count
8. New/worsening confusion

26

What can cause a false positive result of a blood culture?

1. Improper decontamination of operator
2. Improper decontamination of bottles
3. Improper decontamination of patient
4. Contamination of the patient's skin by re-palpation
5. Contamination of equipment
6. Contamination from other sample bottles

27

For how long should the venepuncture site of a patient be wiped for?

At least 30 seconds

28

From where should you avoid venepuncture?

1. Above IV infusions
2. Sites near AV fistula
3. Sites near previous surgery - e.g with mastectomy/lumpectomy there is an increased risk of lymphoedema in that arm
4. Sites on the side affected by a stroke (avoid where possible)

29

What is the blue blood bottle?

Aerobic samples

30

What is the red blood bottle?

Anaerobic samples

31

Which blood bottle should be filled first?

Aerobic

32

What is the mnemonic for order of draw?

Boys Love Ravaging Girls Like Dieters Love Greek Yoghurt

33

What is the order of draw?

B - bottles
L - light blue
R - red
G - gold
L - light green
D - dark green
L - lavender
G - grey
Y - yellow

34

What is the minimum sample volume for blood bottles?

10mls

35

What needs to be recorded on the blood bottle?

1. Patient name
2. Hospital number
3. Date and time of collection

36

What are the indications for NG feeding?

1. Impaired swallow - e.g. MND, Parkinson's, stroke etc.
2. Altered level of consciousness
3. To supplement daily oral intake - e.g. in CF, in hypercatabolic states, in decompensated liver disease, in burns

37

What are the contraindications to NG feeding?

1. Maxillo-facial surgery
2. Skull fracture
3. Facial trauma
4. Oesophageal tumours/surgery

38

Which colour syringe is used to aspirate with an NG tube?

Purple

39

What should be discussed with a patient/how should a patient be prepared prior to NG tube insertion?

1. Informed consent
2. Agree a signal to stop if necessary
3. Warn may make gag/vomit - give bowl and tissues
4. Have them sat up straight with pillows
5. Have them flex their head slightly forward
6. Have them blow their nose

40

In what position should an unconscious patient be placed in to pass an NG tube?

Lying on their left side

41

How should an NG tube be measured?

From the ear lobe, to the nostril, to the xiphisternum

42

What pH on aspirate indicates gastric placement?

5 or less

43

How many mls should be flushed on confirmation of the NG position within the stomach?

30mls

44

If you are unable to get aspirate from an NG tube - what do you try and do to obtain aspirate?

1. Lie the patient on their left side
2. Inject 10-20mls of air in an attempt to dislodge any debris from the NG tube
3. Withdraw and/or advance NG tube 10-20cms
4. Confirm with second-line XR
5. Replace/re-pass NG tube

45

If you get aspirate, but it's pH is >5.5, what should you do?

1. DON'T ENTERAL FEED, wait one hour, re-aspirate and re-check
2. Check prescription - drugs that increase gastric pH = PPIs, antacids and H2 antagonists.
3. Ask patient to sip and coloured drink, if your aspirate is the same colour as the drink you know it's gastric placed
4. Contact your senior
5. Confirm with second-line XR
6. Replace/re-pass NG tube

46

When should pH testing be performed on an NG tube?

1. On insertion
2. Prior to each bolus administration
3. At least once daily with continuous feeding
4. Following evidence of displacement
5. Following vomiting/violet coughing etc.

47

What should be documented in the patient notes regarding the NG tube insertion?

1. Patient consent
2. Date and time of insertion
3. Type of NG tube
4. External length of NG tube
5. Whether aspirate was obtained, and what pH it was

48

What makes NG tube removal more comfortable for the patient?

Rapid removal in one smooth movement

49

Where does the tip of a CVAD sit?

In the lower third of the vena cava (usually superior)

50

What are the indications for a CVAD?

1. Poor peripheral access
2. Need for continual access
3. Peripherally toxic drug administration
4. Need for haemodynamic monitoring
5. TPN

51

What are the three types of CVAD?

1. Direct access central catheter
2. Peripherally inserted central catheter (PICC)
3. Tunneled line (Hickman line)

52

Where is a direct access central catheter inserted?

Internal or external jugular vein

53

For how long should a direct access central catheter be used for?

1-3 weeks

54

Why is a direct access central catheter at increased risk of infection?

Because of oral secretions and hair

55

Which types of CVAD can be removed by a practitioner, and which have to be removed surgically?

Direct access central catheter and PICC. Hickman requires surgical removal

56

Where is a PICC inserted?

Basillic or cephalic vein

57

How long can a PICC be used for?

Up to 1 year

58

What should happen before CVADs (inserted outside the radiology department) are used?

X-ray

59

Which CVADs inserted outside the radiology department do not require XR?

Femoral CVADs, and those inserted in emergency situations for urgent drug administration required

60

When taking a blood sample from a CVAD, how many mls should be aspirated off before retrieving the sample?

5mls

61

When aspirating/taking samples from/flushing a CVAD - what should you remember to do between each disconnection?

Clamp

62

How much flush should be given after a sample has been taken from a CVAD?

10mls 0.9% saline, in an agitated 'start-stop' fashion

63

What are the reasons a CVAD is removed?

1. End of treatment
2. Suspected/proven line infection
3. Device fracture/faulty
4. Proven thrombus/irremovable occlusion
5. Has exceeded duration for which it can remain in-situ

64

What are the complications that can arise from CVAD?

1. Haemorrhage
2. Haematoma
3. Infection
4. Kinking
5. Cathter fracture
6. Displacement
7. Phlebitis/extravasation
8. Thrombus/embolus (including air)
9. Haemo-/pneumothorax
10. Cardiac tamponade

65

How do you troubleshoot when you can't aspirate from a CVAD?

1. Patient - ask to sit up, raise arms, breath deeply, or cough
2. Ensure clamp off
3. Check for kinks
4. Consider changing dressing (dressing may be compressing line)
5. Use 10ml of larger syringe to introduce 1ml of saline, withdrawing back quickly
6. Contact senior

66

How do you troubleshoot when you can't flush a CVAD?

1. Patient - ask to sit up, raise arms, breath deeply, or cough
2. Ensure clamp off
3. Check for kinks
4. Consider changing dressing (dressing may be compressing line)
5. Use 10ml of larger syringe to introduce 1ml of saline, withdrawing back quickly
6. Contact senior

67

What do you do if there is pain on drug administration through a CVAD?

Stop infusion, observe for visible leakage, contact senior

68

What do you do if the CVAD fractures?

Clamp proximal to fracture, stop infusion, contact senior

69

What are the contraindications to suturing?

1. Presence of foreign bodies
2. Wounds older than 8 hours
3. Poor blood supply
4. Grossly contaminated - ground-in dirt, human/animal bite, infected
5. Surgical debridement needed

70

What are the 3 stages of wound healing?

1. Inflammation - first 2-5 days
2. Proliferation - 12 hours - 3 weeks
3. Re-modelling - 6-12 months

71

What foreign bodies in a wound will show up on XR?

1. Glass
2. Metal
3. Gravel
4. Some types of plastic

72

How long do sutures remain in place on the face?

5-7 days

73

What properties influence your choice of suture?

1. Elasticity
2. Memory
3. Tensile strength
4. Knot strength
5. Absorb-able vs. non-absorb-able
6. Mono-filament vs. multi-filament
7. Tissue reaction
8. Suture size and nature of repair

74

What size suture is used in opthalmic surgery?

7-O

75

What size suture is used on the face?

5-O - 6-O

76

When is a suture considered absorbable?

If it is absorbed within 60 days

77

How long does it take lidocaine to take effect?

5-10 mins

78

What are the side effects of lidocaine?

1. Arrhythmia
2. CNS toxicity
3. Problems arising from injection site - e.g. bleeding, infection, pain etc.

79

What are the two methods of administration of lidocaine?

1. Direct wound infiltration
2. Parallel margin infiltration

80

What is the advantage of direct would infiltration?

Less painful than piercing the skin

81

What is the advantage of parallel margin infiltration?

Appropriate for contaminated wounds

82

What is the advantage of tissue forceps?

Prevent crushing injury to the wound edges and maintain tissue viability for best healing outcome

83

At what degree should the needle enter the skin when taking a bite?

90 degrees

84

In interrupted suturing, how far should you begin from the wound edge?

0.5cm

85

What is the advantage of a vertical mattress suture?

More useful for deep wounds as they prevent dead space (where abscesses may otherwise form)

86

What are the suture-alternative forms of wound closure?

1. Steri-strips
2. Surgical glue

87

What wound care advice can you give a patient?

1. Wound care leaflet
2. Use analgesia where necessary
3. Keep dry and covered for at least 24 hours
4. Look out for these (X) signs of infection
5. Any problems go see a HCP
6. Go and have the sutures removed on (X) day by (X) HCP

88

What sort of patients require a tetanus vaccination?

1. Those where their primary immunization is incomplete
2. Those that are not immunized, or those whom are unsure of their immunization status (treat as not immunized)

89

What are most cases of anaphylaxis caused by?

Wasp and bee stings

90

What strength of adrenaline is given in anaphylaxis?

1:1000

91

What dose of adrenaline should be given to adults in anaphylactic shock?

500 micrograms 1:1000 IM (0.5ml)

92

What dose of adrenaline should be given to children older than 12 in anaphylactic shock?

500 micrograms 1:1000 IM (0.5ml)

93

What dose of adrenaline should be given to children 6-12 years old in anaphylactic shock?

300 micrograms 1:1000 IM (0.3ml)

94

What dose of adrenaline should be given to children less than 6 years old in anaphylactic shock?

150 micrograms 1:1000 IM (0.15ml)

95

What are the causes of extravasation?

1) PVC displacement - from patient pulling, accidental pulling, or ineffective dressing
2) Vein spasm from venous irritation - the vasoconstriction results in back pressure at the puncture site (and thus extravasation)
3) Unsuitable, small, vein
4) Fragile veins as a result of anti-coagulation, corticosteroids or chronic conditions

96

What are the acute signs of extravasation?

1) Pain
2) Redness
3) Swelling

97

What other signs of extravasation may become clear?

1) Unable to aspirate blood
2) Increased resistance notes
3) Drip rate slows
4) High pressure alarms on infusion device

98

How should an extravasation injury be managed?

1) Stop drug administration
2) Only remove cannula when aspiration of the drug (by means of a syringe in the cannula) has been attempted
3) Notify medical and pharmacy team
4) ABCDE approach
5) Elevation, analgesia, cold pack
6) Ongoing observation, consider serial photography
7) Incident reporting

99

What level constitutes hyponatraemia?

<135mmol/L

100

What level constitutes hypernatraemia?

>145mmol/L

101

What are the common causes of hyponatraemia?

1. Renal failure
2. CCF
3. SIADH
4. Excessive IV fluids

102

What are the common causes of hypernatraemia?

1. DI
2. Excessive fluid output
3. Poor fluid input
4. Excessive salt administration

103

What level constitutes hypokalaemia?

<3.5mmol/L

104

What level constitutes hyperkalaemia?

>5.3mmol/L

105

What are the common causes of hypokalaemia?

1. Poor dietary intake
2. Diuretics
3. D&V

106

What are the common causes of hyperkalaemia?

1. Chronic renal failure
2. Trauma and burns
3. Potassium sparing diuretics

107

What level constitutes hypocalcaemia?

<2.2mmol/L

108

What level constitutes hypercalcaemia?

>2.6mmol/L

109

What are the common causes of hypocalcaemia?

1. Vit D deficiency
2. PTH deficiency/malfunction

110

What are the common causes of hypercalcaemia?

1. Hyperparathyroidism

111

What level constitutes hypophosphataemia?

<0.8mmol/L

112

What level constitutes hyperphosphataemia?

>1.5mmol/L

113

What are the common causes of hypophosphataemia?

1. DKA
2. Re-feeding/malnutrition
3. Alcoholic liver disease
4. Renal disease

114

What are the common causes of hyperphosphataemia?

1. Burns and trauma

115

What level constitutes hypomagnesaemia?

<0.7mmol/L

116

What level constitutes hypermagnesaemia?

>1.0mmol/L

117

What are the common causes of hypomanesaemia?

1. Malnutrition
2. Alcoholism
3. Chronic diarrhoea

118

What are the common causes of hypermagnesaemia?

1. Renal failure
2. Hypothyroidism

119

What level constitutes hypochloraemia?

<95mmol/L

120

What level constitutes hyperchloraemia?

>108mmol/L

121

What are the common causes of hypochloraemia?

1. Sweating and vomiting
2. Renal disease

122

What are the common causes of hyperchloraemia?

1. Diarrhoea
2. Hypernatraemia

123

What is the definition of sensible losses?

Measurable fluid outputs - include urine, D&V, suction and drains

124

What is the approx. estimate of insensible losses?

5-800mls/day

125

What are the causes of hypovolaemia?

1. Haemorrhage
2. D&V
3. Burns
4. Decreased fluid intake
5. Diuretics
6. Diabetes

126

What are the indications for a 12-lead ECG?

1. Chest pain
2. Pre-surgery
3. SOB
4. Irregular pulse
5. Syncope
6. (?Cardiac arrest)

127

What are the considerations for NOT performing a 12-lead ECG?

1. Patient refusal/non-cooperation
2. Tremor, trauma, burns etc.

128

When may there need to be alterations in lead placement on an ECG?

1. Dextrocardia
2. Posterior myocardial infarction
3. Trauma, burns
4. Uncontrollable tremor, e.g. in Parkinson's

129

Which needle is required to penetrate the muscle in IM injections?

Green - 21g

130

What are the indications for a PVC?

1. Intermittent or continual drug therapy
2. Continual fluid infusion
3. Administration of blood/blood products
4. Urgent/emergency situation

131

What are the complications of PVC?

1. Phlebitis
2. Thrombus/embolus
3. Infection
4. Infiltration
5. Extravasation
6. Haematoma