Site Map	Log Book Skills - MBBS 5

Break Bad News to a Patient or Relative

Prepares self and patient

Ensures information correct

Sufficient time available

Ensures privacy

Invites patient to bring friend / carer

Elicits understanding so far

Indicates the serious nature of the interview (gives warning shot)

Paces information carefully in small chunks at a time

Appropriate use of silence

Demonstrates empathic responses

Checks for mutual understanding

Encourages questions

Mutually agrees the next step

Summarises and concludes effectively

Communicate Effectively with another Professional

States the purpose of the interview / meeting

States issue / concern / complaint / problem factually

Elicits and acknowledges colleagues perception of issue

Demonstrates effective listening skills

Demonstrates empathy

Offers or accepts support / advice

Summarises main points

Agrees the next step with colleague

Avoids the following behaviours

Blaming

Judging

Criticising

Culluding

Communicate Effectively with a Person from a Different Culture

Establishes

Level of English

Cultural group or religious implications

Purpose of the consultation

Elicits individuals ideas, concerns and expectations

Demonstrates positive behaviour re: individuals beliefs

Offers accurate clinical advise

Uses visual aids if indicated

Uses alternative words and phrases - avoid repeating words not previously understood

Checks for understanding

Acknowledges a need for advocacy / interpreting support

Checks for mutual agreement

Avoids the following behaviours

Patronising

Judgemental

Coercive

Explain to Patient or Relative a Procedure or Operation

Preparation for the procedure

What the patient is expected to do

What the staff will do

The procedure itself

Risks of the procedure

Risks of not undertaking it

Post intervention

How the patient will feel

Recovery times

Pain control

Likely outcomes

Follow up

Intervention results

Expected outcome

Possible problems

Use language the patient understands

Elicit patients concerns and encourage questions

Demonstrate verbal and non verbal empathic responses

Check patients understanding

Summarise the main points of the discussion

Reach a mutual agreement about the course of action to be taken

Conclude the interview effectively

Negotiate a Mutually Acceptable Management Plan

Elicit patients expectations

Explore the patients main concerns

Acknowledge the patients ideas & beliefs

Demonstrate verbal and non verbal empathic responses

Explain the medical view clearly using language the patient understands

Encourage questions

Discuss options and possible outcomes with the individual

Check for understanding from patient and doctor perspectives

Avoid defensive or intransigent behaviours

Summarise the main points and individuals concerns

Reach mutual agreement about the course of action

Conclude the interview effectively

Report on an Abdo X-Ray

Justify the decision to take a AXR

Check the name of the patient and the date of examination on the X-ray

Quality of film

Supine / erect

Correct way round (left / right)

Correct penetration

Bony skeleton

Identify components of the skeleton

Check integrity of components of the skeleton

Identification of the major structures and organs

Presence of air or fluid levels in

Hollow viscera

Under the diaphragm

Presence of calcification of soft tissues

Able to recognise

Bony abnormalities

Bowel obstruction

Faecal impaction

Calcification in renal tract

Aortic calcification

Report on a Chest X-Ray

Justify the decision to take a CXR

Check the name of the patient and the date of examination on the X-ray

Quality of film

PA / AP

Correct way round (left / right)

Correct penetration

Orientation of patient

Bony skeleton

Identify components of the skeleton

Check integrity of components of the skeleton

Heart and mediastinum

Shape

Size

Position

Trachea

Central / Deviated

Diaphragm

Visible to each side

Shape and position

Cardiophrenic angles

Lung fields

Identification and examination of upper, mid and lower zones

Able to recognise

Rib fractures

Pneumothorax

Effusion

Consolidation

Pulmonary oedema

Cardiomegaly

Complete any Blood Test Form and Label Specimen

Writing must be legible

Fill in relevant patient details including (stickers acceptable)

Patient's name

Hospital ID

Date of birth

Fill in details of requesting doctor / team

Consultant name

Location for results

Give brief relevant clinical summary

What clinical question is this test to help answer?

Record any hazards to lab staff

Indicate urgency

Sign form indicating status

Print name and bleep number

Label specimen container

Dispatch to lab in sealed plastic bag

Complete a Blood Transfusion Request and Label Specimen

Wash hands

Introduce yourself and check the patient's identity

Discuss procedure with the patient

Venesect 10ml into correct container (clotted sample)

Label bottle with a minimum of

Patient's name

Date of birth

Hospital number

Complete full details on request form

Place sample in transport bag & dispatch to lab

Write a Discharge Notification

Fill in patient details including (stickers acceptable)

Patient's name

Date of birth

Address

Hospital ID

GP's details

Admission and discharge dates

Reason for admisson

Outcome of admission

Outstanding problems and plan to deal with these

Home care arrangements

Follow up arrangements

Drugs - this is a prescription

Duration of drug treatment (most trusts prescribe for 2 weeks only)

Write a GP or Outpatient Prescription

All writing must be legible and in ink

Fill in patient details including

Patient's name

Address

Age (legal requirement if under 12 years)

Name of drug (generic normally)

Formulation

Dose

Usually gram (g), milligram (mg) or microgram

Spell microgram & nanogram in full

Always include 0 proceding decimal point

Give full dose as a weight

Frequency

Number of times / day

Number of hours between doses

Latin abbreviations inside the back cover of BNF (English better practice)

Total quantity

Special instructions

Total number of items - Avoid > 3 or 4 on a form

Sign and date the prescription

Complete an Inpatient Prescription Form

All writing must be legible and in ink

Fill in patient details including (stickers acceptable)

Patient's name

Date of birth

Hospital ID

Address

Location in hospital (ward)

Fill in details of consultant (including hospital code if appropriate)

Identify and list known allergies

Regular medication

Date of entry

Generic name of drug

Dose

Route of administration

Frequency and time of administration

Duration of course

Signature

As required medication

Date of entry

Generic name of drug

Dose

Route of administration

Maximum frequency of adminstration

Signature

Intravenous fluids

Date of entry

Name and description of fluid

Volume of fluid

Rate of administration

Duration of course

Signature

Oxygen administration

Date of entry

Percentage concentration of oxygen

Route

Rate of delivery

Signature

Write an Outpatient Referral Letter

Fill in patient details including (stickers acceptable)

Patient's name

Date of birth

Address & phone number

Hospital ID

Fill in GP details (usually on headed paper)

Description of clinical problem

Reason for referral

Urgency

Summary of presenting complaint & examination findings

Relevant histories

Relevant investigations (including negatives)

Medication and drug sensitivities

What the patient has been told and patients understanding of the problem

Write a Ward Referral

Fill in relevant patient details including (stickers acceptable)

Patient's name

Hospital ID

Date of birth

Patients location (ward and bed number)

Consultant name and address to whom referral is being made

Discription of clinical problem

Reason for referral

Urgency

Summary of presenting complaint and examination findings

Relevant histories

Relevant investigations (including negatives)

Medication and drug sensitivities

What the patient has been told and patients understanding of the problem

Sign form indicating status

Print name, bleep number & referring consultant name

Complete X-Ray Request Form / Nuclear Medicine Request Form

Writing must be legible

Fill in relevant patient details including (stickers acceptable)

Patient's name

Hospital ID

Date of birth

Fill in details of requesting doctor / team

Consultant name

Location for results

Identify:

Transport requirements

Interpreter requirements

Mobility status of patient

Oxygen requirements

Known allergies

Known asthmatic

Infection risk if present (eg MRSA)

Urgency of request

Date of patients next visit (if appropriate)

Confirm patient is not pregnant (ionising radiation only)

Contact department if patient is pregnant

Confirm patient not breast feeding if nuclear medicine study or contrast to be used

Contact department if patient is breast feeding

Confirm patient does not have aneurysm clips or pacemaker (MRI only)

Give brief relevent clinical history

Identify clinical question to be answered by investigation

Give dates and details of other relevant investigations

Sign form indicating status

Print name and bleep number

Measure Doppler Index of Foot Pulses

Introduce yourself and check the patient's identity

Discuss procedure with the patient

Position patient supine with no pressure on the proximal vessels

Allow the patient to rest 10-20 minutes

Arms

Place an appropriate cuff around the arm

Locate the brachial pulse & apply ultrasound contact gel

Angle the Doppler probe at 40° and locate the best signal

Inflate the cuff untill signal is abolished

Deflate slowly and record the pressure at which the signal returns

Record this pressure (brachial systolic)

Repeat on other arm

Use the higher of these two values to calculate the abPI

Legs

Place an appropriate cuff around the ankle immediately above the malleoli (protect any ulcers)

Locate the dorsalis pedis pulse

Measure and record as with arm

Locate the posterior tibial pulse

Use the highest reading to calculate the abPI for the ankle

abPI = Highest ankle pressure (for each leg) / highest brachial pressure

Wipe up ultrasound contact gel & clean the Doppler probe

Encourage & answer questions from the patient

Take, Analyse and Interpret a Radial Blood Gas

Equipment

Select appropriate equipment

2ml syringes

Smallest bore needle practical:

• Orange for radial
• Green for femoral

Heparin 100u/ml

Dressing pack

Antiseptic

Local anaesthetic

Sterile gloves

Lay up a sterile trolley with

Drapes

Antiseptic

Cotton Wool

Syringe & needle

Procedure

Introduce yourself and check the patient's identity

Discuss procedure with the patient

Identify artery and select site for sampling

Position patient correctly for access to site

Clean skin & Give intradermal bleb of local anaesthetic

Wash hands & glove up

Clean site & drape area

Heparinise syringe

Squirt out excess heparin

Locate & fix artery between 1st & 2nd fingers of non-dominant hand

Introduce needle vertically throught the skin & aspirate approx 2ml blood

Request assistant to press firmly on wound site for 5 minutes

Inspect site for signs of enlarging haemotoma

Expel any air bubbles from syringe, cap and take to auto-analyser

Follow instruction for use and cleaning of anto-analyser

Dispose of sample and sharps safely

Check patient's wellbeing

Clean up trolley and equipment

Discuss results with superviser

Able to recognise

Metabolic acidosis

Respiratory acidosis

Respiratory alkalosis

Take a Swab for Bacteriological Examination

Introduce yourself and check the patient's identity

Discuss procedure with the patient

Consider analgesia

Wash hands and put on non-sterile gloves

Remove the cotton swab from its tube & roll in areas to be examined

Replace swab in the tube with culture medium in its base & shut firmly

Redress the wound if required

Label the swab and complete microbiological form, give details of antibiotic therapy

Take Blood Cultures

Introduce yourself and check the patient's identity

Discuss procedure with the patient

Label set of 2 blood culture bottles

Wash hands and put on gloves

Cleanse venepuncture site with swab

Attach green needle to 20ml syringe and venesect 20ml blood

Discard used green needle safely & replace with a sterile green needle

Remove caps from blood culture bottles and inject 5-10ml of blood into each

Discard used needle and syringe safely

Send bottles and completed request forrm to microbiology

Setup a Blood Transfusion and Write Instructions to Ward Staff

Wash hands

Introduce yourself and check the patient's identity

Discuss procedure with the patient

Set up a trolley with

Cannula (large if rapid transfusion likely)

Giving set set up with normal saline

First unit of blood

Insert cannula and set up saline infusion

Double check label of blood bag with nurse

Re-check patient ID against blood details

Replace saline with blood bag

Adjust drip rate

Write up instructions specifying

Rate of infusion

Total number of units to be given

Ensure nursing observations commenced for adverse reactions to blood

Ensure patient is comfortable and answer any questions they may have

Measure Height & Weight and Calculate BMI

Introduce yourself and check the patient's identity

Discuss procedure with the patient

Height

Position patient correctly on stadiometer

• Stand erect
• No footware
• Facing away from wall
• Heels to wall
• Head such that external auditory meatus is on same horizontal as lateral canthus

Move reading arm or stadiometer to touch patients head

Read & record height

Weight

Check with patient in indoor clothing with shoes removed

Check balance correctly zeroed (use steelyard type)

Adjust weights with patient on platform to achieve balance

Read & record weight

Calculate BMI (weight / height²)

Appreciate & explain acceptable ranges of values

Measure & Interpret a CVP Reading

Introduce yourself and check the patient's identity

Discuss procedure with the patient

Identify mid-axillary reference point

Using the spirit level, place the zero level of the manometer horizontal with the mid-axillary point

Open three-way tap and fill the manometer to a level above the anticipated CVP

Turn three-way tap to connect manometer directly to the central venous line

The fluid level in the manometer will change and then stabilize at the level of the CVP.

Observe for variation in CVP with respiration

Identify the CVP in cm H2O. Likley to be positive

Document the reading in the patients records

Turn three-way tap to close off the manometer line, re-connecting the infusion

Discuss the result with supervisor

State the value of the reading

Record and Interpret a 12 Lead ECG

Introduce yourself and check the patient's identity

Discuss procedure with the patient

Read the instructions and familiarise yourself with the machine being used

Attach the limb leads

AVR - Right wrist | Red

AVL - Left wrist | Yellow

AVF - Left ankle | Green

Neutral - Right ankle | Black

Attach the chest leads

V1 - 4th intercostal, right sternal border

V2 - 4th intercostal, left sternal border

V3 - Midway between V2 & V4

V4 - 5th intercostal, mid clavicular line

V5 - 5th intercostal, anterior axilary line

V6 - 5th intercostal, mid axillary line

Ensure the machine is set to the correct speed (25ccm/sec) & amplitude (test should be 1 cm)

Ensure the patient is relaxed & resting comfortably

Record & evaluate quality of recording

Discuss interpretation with superviser

Able to recognise

Ischaemia

Infarction

Bundle branch block

1st, 2nd & 3rd degree heart block

Atrial fibrillation

Common tachyarrythmias

Give the First Dose of a Drug by IV Injection

Introduce yourself and check the patient's identity

Read the drug dosage instructions on the patient's drug chart

Check the drug and dose are appropriate (BNF or formulary)

Discuss procedure with the patient

Check for a history of drug reactions

Check on drug ampoule with a nurse / staff member

Name

Strength

Expiry date

Dilute according to the manufacturers instructions

Tighten tourniquet on patients arm & identify vein

Prepare to give injection using appropriate sterile technique

Insert needle into vein and draw back blood to ensure venous access

Loosen tourniquet & inject drug

Withdraw needle and apply pressure to site

Check patients comfort & absence of immediate side effects

Dispose of sharps safely

Write up and sign drug chart

Insert a Naso-Gastric Tube

Wash hands

Introduce yourself and check the patient's identity

Discuss procedure with the patient

Set up a trolley including

Ryle's tube of appropriate size

Sterile water / K-Y jelly / Aqua gel

Disposable gloves

Spigot / bag to attach to the Ryle's tube

Tape

Vomit bowl

Sit the patient upright

Measure the anticipated lenght of insertion of the tube (cumulative distance)

The nose to the patients ear

From the ear to 2 finger-breadths above the umbilicus

Moisten the end of the tube

Slowly pass the tube down the nose

Ask the patient to start swallowing, with or without the use of water

If the patient coughs stop advancing and withdraw the tube until coughing stops before proceeding

Stop inserting the tube at the desired length

Tape the tube to the nose and side of the face

Test correct placement of the tube

Pass 50ml of air down the tube while listening for bowel sounds over the epigastrium

Attempt to aspirate liquid stomach contents and confirm acidity using litmus paper

Discuss the requisition of a chest x-ray to confirm the placement of the tube

Administer a Drug Via a Nebuliser

Ensure you understand how to assemble and use equipment (reads instructions / asks)

Introduce yourself and check the patient's identity

Discuss procedure with the patient

Assemble nebuliser correctly and attach to air / oxygen supply

Consult prescription sheet to:

Check validity of prescription

Ascertain drug, dose, diluent, time and route of administration

Measure drug and diluent into nebuliser with a syringe, checking drug with a colleague

Apply mask

Set airflow according to manufacturers instructions

Ensure patient is comfortable and using equipment effectively

Sign up administration on drug chart

Clean and store equipment after use

Give Oxygen & Write on the Prescription Chart

Introduce yourself and check the patient's identity

Discuss procedure with the patient

Assess the patient's oxygen requirements

Assess the requirement for further information from arterial blood gases

Perform arterial blood gases if appropriate

Decide the percentage inspired oxygen to be prescribed

Select appropriate mask and fittings

Connect via tubing to oxygen source

Adjust correct flow rate of oxygen delivery

Apply mask

Determine the time at which oxygenation of the patient will be reassessed and whether to repeat ABG's

Write instructions on appropriate chart

Perform Pulse Oximetry

Introduce yourself and check the patient's identity

Discuss procedure with the patient

Select fingernail

Ensure that it is unobliterated by nail varnish

Apply finger probe & turn on machine

Ensure calibration has occurred

Record oximetry reading of Hb oxygen saturation

Remove probe and turn off machine

Remove Skin Sutures or Wound Closure Staples

Equipment

Dressing pack containing:

Gallipots

Cotton Wool

Disposable forceps

Dressing towel

Rubbish bag

Tape

Antiseptic solution

Plastic apron

Culture swab for microbiology (optional)

Sterile field paper drape

Suture cutter or staple remover

Procedure

Check that the sutures should be removed & are non-absorbable

Introduce yourself and check the patient's identity

Discuss procedure with the patient

Screen the patient from onlookers

Wash hands (soap and water) & put the apron on

Place the equipment required (unopened) on the bottom shelf of a clean dressing trolley

Place the sterile field drape on the top shelf of the trolley and open it

Remove the outher packageing of the dressing pack and slide the contents of the pack onto the sterile field

Attach the disposal bag to the side of the trolley

Arrange the pack's contents using one of the pairs of forcepts

Discard forceps

Fill the gallipots with saline or antiseptic

Put on the sterile gloves

If there is a dressing, remove it

Inspect the wound for signs of infection or inflammation

Take a swab if necessary

Using forcepts, cotton wool and antiseptic / saline clean the wound working from the inside to the outside of the wound

Remove Sutures

Interrupted

• Pick up one knot and cut the suture flush with the skin on one side
• Gentle upward traction on the suture will free it from the wound

Continuous

• Cut one end flush with the skin
• Gentle traction on the other end will pull the suture through the wound

Remove Staples using staple remover

Apply new dressing and secure with micropore tape

Fold up the sterile field drape and discard contents

Spray trolley with disinfectant

Setup and Operate a Syringe Driver to Deliver a Drug

Introduce yourself and check the patient's identity

Discuss procedure with the patient

Select the correct device (hourly or daily rate) and consult manual

Check the battery

Select the correct brand and size syringe for the infusion to be given

Calculate the appropriate dilution of the drug

Draw it up with the correct diluent (usually sterile water / saline)

Fill the syringe and the extension tubing with the drug at the correct dilution

Attach the syringe to the pump and secure

Calculate the correct rate

Set it on the syring driver

Fit the cover

Test the apparatus

Connect to the patient & start the infusion

Change a Simple Dressing & Perform Wound Care

Equipment

Dressing pack containing:

Gallipots

Cotton Wool

Disposable forceps

Dressing towel

Rubbish bag

Tape

Antiseptic solution

Plastic apron

Culture swab for microbiology (optional)

Sterile field paper drape

Procedure

Introduce yourself and check the patient's identity

Discuss procedure with the patient

Consider analgesia

Screen the patient from onlookers

Wash hands (soap and water) & put the apron on

Place the equipment required (unopened) on the bottom shelf of a clean dressing trolley

Place the sterile field drape on the top shelf of the trolley and open it

Remove the outher packageing of the dressing pack and slide the contents of the pack onto the sterile field

Attach the disposal bag to the side of the trolley

Arrange the pack's contents using one of the pairs of forcepts

Discard forceps

Fill the gallipots with saline or antiseptic

Put on the sterile gloves

Inspect and palpate the wound for signs of infection or inflammation

Decide if a new dressing is required

Take a swab if necessary

Using forcepts, cotton wool and antiseptic / saline clean the wound working from the inside to the outside of the wound

Apply new dressing and secure with micropore tape

Fold up the sterile field drape and discard contents

Spray trolley with disinfectant