Observations

Why do observations need to be repeated?

• Baseline observations pain a picture of your patient’s health on arrival

• Continued monitoring indicates whether your treatment is working or whether you’ve missed something

How do you measure body temperature, what is the normal range, and what are some challenges that may need to be addressed?

Normal Range

• 35.8 - 38.2*C (37 is good average)

Approach

• Using thermoscan tympanic (can detect changes to core body temperature quickest measuring tympanic membrane), and less invasive

• Attach single use cover on end of tympanic device

• Pull er backwards and upwards and insert in ear

• Press button and wait for beep, discard single use cover in clinical waste

• Note temperature and report findings

• Clean probe

• Always use same ear for repeat readings

Challenges

• Hearing aid: can generate heat for up to 30mins, remove before

How do you measure levels of consciousness, what is the normal values, and what are some challenges that may need to be addressed?

Normal range

• A on AVPU

• GCS 15

Approach

• Use AVPU to assess (check eyes tracking, responding with voice, trap squeeze)

Challenges

How do you measure severity of pain and what are some challenges that may need to be addressed?

Approach

• SOCRATES

  • Severity - 0-10

  • Timescale - 5/60 5mins, 5/24 5 hours, 5/7 5 days

  • Character and radiation - description of crushing, squeezing, stabbing

Challenges

• Pain is subjective, can be exacerbating and alleviating factors

How do you attach ECG nodes for a 4 lead and 12 lead, what is the normal values, and what are some challenges that may need to be addressed?

Approach

• Consent, chaperone, dry the skin, shave hairy skin, move metal out of way of dots, position comfortably, ensure electrodes sealed and in date

• 4 lead (Lead 2) electrode placement - (limb leads)

  • Ride Your Green Bike (clockwise on anatomical model for limb placement)

  • Red on right arm, Yellow on left arm, Green on left leg, Black on right leg

• 12 lead electrode placement

  • V1, V2, V3, V4, V5, V6 along chest in straight, down, up pattern

  • V7, V8, V9 tracking along back under scapula

  • V4 can be moves to other side of chest to look at inferior view

Challenges

• Sweaty chest, chest hair, jewellery and clothing

How do you measure pupils, what is the normal values, and what are some challenges that may need to be addressed?

Normal value

• Pupils equal and reactive to light (PEARL)

• 3-4mm

Approach

• Prior to pen torch visually check pupils to check for equal size and or abnormal changes in shape

• Use pupil gauge on pen torch to determine size

• Shine pen touch on eye for three seconds - Prompt constriction should be observed - repeat on other eye

• Document pupil size and reactivity

Challenges

• False eyes

How do you measure respiratory rate, sounds and rise/fall, what are the normal values, and what are some challenges that may need to be addressed?

Normal values

• 12-20 for adults

• Equal chest rise and fall

• Normal breath sounds

Approach

• Respiratory rate: count over 30 seconds while taking pulse

• Breath sounds: Listen with stethoscope 6 points back and front, ladder pattern left to right

• Chest rise and fall: Back of hands or palms spread butterfly while taking deep breath

Challenges

• Heavy clothing

• Heavy tissue

How do you measure blood glucose, what are the normal values, and what are some challenges that may need to be addressed?

Normal values

• Non diabetic

  • 3.0-5.6 mmol/L

• Diabetics

  • 4.0-7.0 mmol/L before meals

  • Less than 10 mmol/L 1.5 hours after meal

  • Around 8 mmol/L at end of day towards sleep

How do you measure capnogrpahy (end tidal CO2), what are the normal values, and what are some challenges that may need to be addressed?

Normal values:

• Measures asthma, bronchospasm, COPD CO2 retention

• 4.67 - 6.00 kPa (35-45 mmHg)

• Good box waveform - (A-B insipratory baseline, B-C expiratory upstroke, C-V alveolar plateau, D end-tidal amount of CO2 [end of expiration], D-E waveform starts as inspiration starts

• Bronchospasm can show show ‘shark fin’ shape sharper higher C-D incline

Application:

• Must be used if iGel, intubated, receiving assisted ventilation, to ascertain quality of CPR. Advised to be used in acute/severe resp distress, acutely unwell patients

How do you measure blood oxygen saturations (SPO2), what are the normal values, and what are some challenges that may need to be addressed?

Normal values:

• 94-98% in normal patients

• 88-92% in COPD patients

Application:

• Ensure finger is clean, free of heavily applied nail polish, ensure patient sitting still

• Place says probe on patient’s finger

Challenges

• Heavily applied nail varnish

• Cold skin/poor circulation

• Moving patient

How do you measure pulse rate, what are the normal values, and what are some challenges that may need to be addressed?

Normal values:

• 60-100bpm in normal adults (higher in children)

• Regular, strong pulse in normal adults

Application:

• Pulse can be felt at:

  • Carotid

  • Brachial (crook of elbow)

  • Radial

  • Femoral

  • Posterior tibial (between ankle and Achilles)

  • Dorsalis Pedis (tendon in line with large toe)

• Count for 30 secondS

Challenges

• Recent exercise

• Anxiety

• Cardiac arrhythmias

How do you measure capillary refill, what are the normal values, and what are some challenges that may need to be addressed?

Normal values:

• Return to normal skin colour in under 2 seconds

Application:

• Apply pressure to patient’s finger for 5 seconds, then release

• Time to refill

Challenges:

• Cold

• Poor circulation

How do you measure capillary refill, what are the normal values, and what are some challenges that may need to be addressed?

Normal values:

• Return to normal skin colour in under 2 seconds

Application:

• Apply pressure to patient’s finger for 5 seconds, then release

• Time to refill

Challenges:

• Cold

• Poor circulation

How do you measure blood pressure, what are the normal values, and what are some challenges that may need to be addressed?

Normal values:

• Systolic 120 for normal patients (as a guide, 100 + patient’s age)

  • Hypertension numbers may be >140 systolic and/or >90 diastolic

  • Hypotension numbers may be <90 systolic

• Diastole 60-90 for normal patients

• Systole is squeezing contraction part, disastole is relaxing

Application:

• Ensure arm is free of restrictive clothing and bare

• Wrap cuff around arm, align ‘artery’ indicator on cuff to align with brachial artery

• Pump up to 200 - put stethoscope over brachial pulse, slowly deflate and watch needle fall

• As falls, listen for

  • Phase 1: sharp tapping sounds indicated systolic blood pressure

  • Phase 2: swishing sound as blood flows through the blood vessels

  • Phase 3: Softer thump as blood flows through vessels

  • Phase 4: a muffled thump

  • Phase 5: sounds ceases, indicating diastolic blood pressure

• Deflate cuff