Flashcards in Phase 2a DOCSS Deck (67):
In a 12-lead ECG, what are the 4 colours of limb leads and which limbs do they go on?
Over bone where possible. Right arm - red lead
Left arm - yellow lead
Left leg - green lead
Right leg - black lead
'ride your green bike'
In a 12-lead ECG, where do the chest leads go?
C1: 4th intercostal space, right sternal border
C2: 4th intercostal space, left sternal border
C3: halfway between C2 and C4
C4: 5th intercostal space, midclavicular line
C5: anterior axillary line at the same horizontal level as C4
C6: mid-axillary line at the same horizontal level as C4 and 5.
What should you do before any procedure?
Wash hands (or use gel)
Introduce, identify and inform
Expose patient appropriately
Re-position patient as necessary.
What does preparing for an ECG involve?
Wash hands/use gel
Position patient appropriately (remember moving and handling)
Indicate electrode sites on diagram
Attach lead wires to patient skin - ensure good skin contact
Attach lead wires on electrodes to pt chest wall.
How would you objectively monitor the effectiveness of treatment with a salbutamol inhaler?
Do a peak flow measurement 20 minutes after the nebuliser finishes.
Why should you leave the nasal cannulae on the patient when administering a nebuliser?
To prevent desaturation.
What is the normal range for blood pH?
Normal range for pCO2?
4.5-6.0 kPa/ 34-45 mmHg
Normal range for pO2?
10-13 kPa/ 75-98 mmHg
Normal range for HCO3?
Normal range for SpO2?
What is SpO2?
A measure of the fraction of saturated to total haemoglobin in the peripheral capillaries.
What two things would you do to monitor the patient's response to oxygen therapy?
1. Use pulse oximetry to measure oxygen saturation levels.
2. Repeat the arterial blood gas analysis within one hour.
What is the target range of oxygen saturation when treating someone with type 2 resp failure?
How would you explain peak flow to the patient?
Peak flow measures how quickly you can blow air out of your lungs. Peak flow can be compared with normal values for your age, height, gender.
What times of day does peak flow need to be checked?
Morning and evening. Morning reading often lower.
How many exhalations are needed, and which result should be recorded?
3 - the best one should be recorded.
What is Allen's test for and why would you do it?
Allen's test is used to determine whether the palmar arches are intact and patent, so either the radial or ulnar artery can perfuse all the digits if the other artery becomes occluded. It is used prior to obtaining arterial blood samples in case the procedure causes occlusion of the punctured artery.
How is Allen's test performed?
1. Ask the pt to make a fist.
2. Using your fingertips, occlude blood flow through radial and ulnar arteries at the wrist.
3. Pt releases fist. Observed blanched hand while maintaining pressure on arteries.
4. Remove pressure from ulnar artery while maintaining pressure on radial artery. Are all 5 digits perfused?
5. Repeat with radial artery.
Explain what spirometry is to a patient.
Spirometry is a common lung function test measuring how much air you can breathe out in one forced breath. Your breathing can be affected by asthma as well as other diseases. We are checking your lung function to make sure you are OK to go ahead for your surgery (in the scenario).
Explain how to use a spirometer to a patient.
A spirometer has a mouthpiece that you use to blow into the device. You blow into it and will be given the results at the end of the procedure.
Why is it important to offer a chaperone in an ECG or cardiac monitoring?
The patient has to be exposed to their waist.
Why do you need to tell the patient to not talk in an ECG?
This could cause electrical signals which would interfere with the ECG reading.
What should the ECG machine be calibrated to?
Speed 25mm/sec, calibration 10mm/mv.
In cardiac monitoring, where do the red, yellow and green leads go?
Red- right shoulder over the acromion, yellow - left shoulder over the acromion, green (or black) - lower left chest wall
How do you administer a nebuliser?
Ensure nebuliser diffuser is inside base of nebuliser. Put medication in the base.
Connect tubing to the base of the nebuliser and the compressor, keeping the nebuliser upright.
Switch compressor on so it starts to nebulise. Mouthpiece should emit cool steam.
Patient breathes normally and inhales the mist.
What is nebuliser therapy?
Passage of air or oxygen through a solution of a drug creating a fine mist that is inhaled through a mouthpiece or mask. Used to deliver drugs to the lungs to treat respiratory conditions such as COPD.
What medications can be administered using nebuliser therapy?
Bronchodilators, steroids and antibiotics.
What equipment is needed to administer drugs via a nebuliser?
Electric air compressor
Nebuliser chamber consisting of base, lid and diffuser
Mouthpiece or mask
Describe good inhaler technique with a spacer.
Remove the cap from the metered dose inhaler and the cap from the spacer if it has one.
Shake inhaler briskly 4-5 times.
Insert inhaler into spacer
Breathe out gently
Place mouthpiece of spacer into your mouth and create a good seal with your lips.
Press the canister once to release one dose of the drug.
EITHER: Take one deep breath in and hold for 10 seconds OR take 5 normal breaths.
Remove mouthpiece from mouth and breathe normally.
Wait 30 seconds before repeating for next dose.
Remove inhaler from spacer and replace both caps.
How can the patient maintain good oral hygiene when using a spacer?
Rinse mouth out with water and spit out after use,
never share inhaler/ spacer.
rinse inhaler once a week by rinsing the plastic container under warm running water, ensuring it is visibly clean and air-drying.
What equipment is needed for an intramuscular injection?
Gloves and apron
Green needle for drawing up drug
Blue needle for injecting drug
'Drug' - 90% NaCl instead of Stemetil.
How would you administer a drug by intramuscular injection?
Ensure door is closed/ curtain shut to maintain patient dignity. Patient should lie on their side. Ensure safety rails are up to stop patient falling out.
Identify outer upper quadrant of buttock by using the greater trochanter of the femur as a landmark. Assess the site for any contraindications.
Clean skin using wipe.
Draw up drug - 1ml needed.
Stretch skin around injection site. Warn of sharp scratch. Insert needle quickly and gently at 90 degrees, until 1/3 of the needle can be seen.
Check needle is not in a blood vessel by pulling back plunger and looking for blood. If this occurs, pull out, ensure no bleeding, and start again.
Inject drug at a rate of 1ml/5s.
Remove needle, apply pressure, dispose of sharps
Update pt notes and check welfare.
Why should you stretch the skin when doing an IM injection?
Stretching the skin helps with absorption of the drug into the muscle.
Why do you leave 1/3 of the needle visible when injecting IM?
So that if the needle breaks, it can still be removed.
Why apply pressure after any injection?
To reduce risk of haematoma and bruising.
Why do you need to keep monitoring a patient for at least 15 minutes after the drug has been administered?
To check for adverse effects.
What are possible complications of IM injections?
Local infection or abscess formation (sterile technique reduces risk)
Sciatic nerve injury (shouldn't happen if you inject in the right region)
Local fibrosis (repeated injections at the same site)
Drug adverse effects
What are the properties of medications that can be injected IM?
They must be soluble, used in small amounts and do not irritate soft tissues.
What medications can be administered IM?
Antiemetics (eg Stemetil)
What are the 5 main sites for intramuscular injection?
1. Upper arm (deltoid)
2. Upper outer quadrant of buttock (dorsogluteal site)
- most popular but lowest drug absorption rate.
3. Lateral aspect of thigh (vastus lateralis)
4. Anterior aspect of thigh (rectus femoris)
5. Ventogluteal site (gluteus medius).
What is a subcutaneous injection?
Injecting a drug into the fatty vascular layer below the dermis. It allows slow, sustained absorption of the drug as there is less blood flow to fatty tissue.
What kind of drugs can be administered using SC injection?
Up to 2ml of highly soluble medications - otherwise they may irritate tissues. This includes low molecular weight heparin (like clexane) and insulin.
What are the common sites for SC injection?
Umbilical region of abdomen
Thighs, under the greater trochanter
Why should diabetics rotate their insulin injection sites?
To decrease the risk of irritation and ensure the insulin is absorbed.
What equipment do you need for a SC injection?
Apron and gloves
Green needle to draw up
Orange needle to inject (think orange -> fat)
Why do you change the needle between drawing up the drug and administering the drug?
To avoid trauma to the patient if the needle is barbed and avoids tracking of medication through superficial tissues.
How would you inject a drug SC?
Pinch skin, inject at 45 degrees, 90 if insulin. RELEASE the skin and administer the drug slowly.
Why do you pinch the skin in SC injections?
To elevate the SC tissue away from the underlying muscle.
Describe peak flow meter technique.
1. put new mouthpiece on
2. set reader to zero.
3. hold so that not in the way of the meter.
4. tight seal
5. sit up straight, shoulders back
6. deep breath in
7. expel air as fast as you can, like blowing out the candles on a birthday cake, keeping the meter horizontal.
8. note reading.
Repeat 2 more times and take the best reading.
Explain to the patient why they need to monitor their peak flow.
(In scenario, pt has asthma)
You have been having trouble with your asthma. In asthma, the airways become narrower so it is difficult to expel air quickly. The peak flow helps us to monitor the severity of the condition, and the effectiveness of your treatment. This helps us to see how well the medication is working and whether it needs to be changed.
How would you explain an ABG to a patient?
I need to do a blood test which tells us about the oxygen levels in your blood. This might be different to blood tests you have had before because is taken from an artery in your wrist, instead of a vein further up your arm. Because it's an artery, we will apply pressure for longer afterwards to prevent bruising and bleeding.
What equipment do you need for an ABG?
Gloves and apron
ABG syringe with heparin
Why is an ABG carried out?
It is used to assess the pH, paO2, PaCO2, HCO3 and base excess. This gives information about oxygenation, acid-base balance and adequacy of lung ventilation. It helps diagnose hypoxaemia, hyper/hypocapnia and metabolic compensation.
This would be used for patients with organ failure, sepsis, acute poisoning and those on the ICU.
Normal range for base excess?
-2 to +2
Why should you advance the needle slowly when doing an ABG?
It reduces the risk of double-punturing the artery which can cause bleeding and haematoma.
What must you do when you have obtained the ABG sample?
Update the notes, expel any air bubbles, invert the syringe to mix with heparin, deliver to the lab straight away or put in ice. Make sure pt is applying pressure for 5 minutes.
What would you document in the patient notes after doing an ABG?
Result of Allen test; site used; result of ABG analysis; inspired oxygen percentage when measured; any complications.
What are the benefits of oxygen therapy?
Correct hypoxaemia to prevent hypoxic tissue damage.
For critically ill patients, it can reduce organ failure and length of stay in ICU and increases survival
Increase wound healing - surgical/chronic
Relieve breathlessness and work of breathing
Treating carbon monoxide poisoning
How much oxygen should be given to critically ill patients, eg those with sepsis?
What is hypoxaemia and how should it be treated?
Hypoxaemia is when there is not enough oxygen in the blood (PaO2 < 8kPa or 60mmhg. It is treated with oxygen therapy to achieve target saturation 94-98%.
How would you administer oxygen therapy to someone with type 2 respiratory failure?
A venturi or 'fixed performance' mask delivers a fixed concentration of oxygen (FiO2). It is used for patients with Type 2 respiratory failure because uncontrolled high-dose oxygen therapy can be dangerous for them. Use the blue valve for 24% oxygen and set it to the corresponding flow rate, in this case 2L/min. Check patency before putting mask on patient, and say you would ensure there is a snug fit.
What is a flowmeter?
The oxygen tubing of the mask or cannula is connected to the flowmeter. The flowmeter is used to regulate the flow of oxygen from the oxygen source. Some flowmeters work with pre-set values while standard flowmeters allow a gradual change of oxygen flow.
How should you reduce/stop oxygen therapy?
Oxygen flow should be reduced when the target saturation is exceeded. Use the mark escalator. Monitor O2 sats for 10 minutes, ensuring that target saturation are still met. Once stopped, if pt remains within target range for 1 hour, they can stay off oxygen.
What are some adverse effects of oxygen therapy?
Formation of free radicals which can cause ischaemic damage and reperfusion injury;
coronary and cerebral vasoconstriction - don't use in normoxaemic stroke/ ACS patients if possible.
What defines type 2 respiratory failure?
Hypoxaemia (PaO2 <8kPa/60mmHg), Hypercapnia (PaCO2 >50mmhg), resulting in acidosis (pH <7.35). It often occurs in COPD.