Clinical Skills Exam

Infection Control and Bloodborne Pathogens: ● Spread of infection

• ○  2 Types of Pathogens ■ Bacteria

  • ●  Live single cell

  • ●  Cells multiply quickly

  • ●  Treatable → antibiotics

    ■ Virus

  • ●  Capsules

  • ●  Contents inside use patient’s cells to multiply

  • ●  Host

  • ●  Not treatable → treat symptoms

• ○  3 Types of Transmission Routes

  • Surface → Contact

  • Droplet

■ Respiration → airborne s a m e ○ Tuberculosis - uber-together

■ System Infected: s p o t ● Respiratory

■ Route of Transmission:
● Being in the same room as someone infected

■ Signs & Symptoms:

• ●  Coughing

• ●  Sweating

• ●  Red

• ●  Feels cold → cold sweats

  ○ COVID-19

• System Infected:

  ● Respiratory

• Route of Transmission:

● Breathing → airborne ■ Signs & Symptoms:

● No taste ■ Testing:

● Two-types: ○ Viral

■ Determines if you currently have the virus

• ●  This may be done via nasal swab or saliva

• ●  Antigen results in minutes

• ●  PCR/Nucleic acid amplification test

  (NAATS) - hours to days ○ Serology/Antibody

• Determines if you previously had the virus

• This is done via blood sample

  ○ Influenza

■ System Infected:

● Respiratory

● Upper airway
■ Route of Transmission:

● Droplet - Loughing , sneezing , e t c

• Signs & Symptoms:

  ● Everything felt when sick

• Most Affected:

  ● Old
  ● Young
  ● Immunocompromised

• Has been around for hundreds of years

● 1918 - pandemic killed 30-50 million worldwide

○ Hepatitis B & C

• System Infected:

  ● Liver

• Route of Transmission:

  • ●  Bloodborne pathogens

  • ●  Bodily fluids

• Signs & Symptoms:

  • ●  Jaundice

  • ●  Fever

  • ●  Feel like shit

• Hepatitis B:

  • ●  Has a vaccines

  • ●  People of all ages get HBV

  • ●  1982 - AICP recommended vaccine to high risk groups

  • ●  1991 - AICP recommends national HBV childhood vaccination

    program

●

●

● ●

○ HIV/AIDS
■ Human Immunodeficiency Virus

● Attack immune system, leaving patient unable to fight off infection ■ Acquired Immunodeficiency Syndrome

● Set of conditions that results when the immune system has been attacked by HIV

• Lower risk for health care workers than hepatitis or TB

• Contact with blood usual route of infection

  Infection control strategies, cleaning/disinfecting/sterilizing

○ Infection control strategies primarily focus on cleaning, disinfecting, and sterilizing surfaces and medical equipment to eliminate harmful microorganisms, including bacteria, viruses, and fungi, by following a tiered approach depending on the level of contamination required: cleaning removes dirt and debris, disinfection kills most germs, and sterilization destroys all microorganisms on a surface or object; each process should be performed according to specific guidelines and with appropriate personal protective equipment (PPE)

Body substance isolation

○ Body substance isolation (BSI) is a system of infection precautions intended to reduce nosocomial transmission of infectious agents among patients

• Wearing exam gloves, face masks, gowns, and other things separating you from patient’s pathogens

• Remove gloves properly

● Flip gloves inside out to assure you only come in contact with

clean surfaces or surfaces only you have touched ■ Dispose of gloves immediately

Use of gloves, gowns, masks and additional protection

○ Gloves, gowns, masks, and other personal protective equipment (PPE) are used to prevent the spread of infection and protect healthcare workers and patients

Handwashing and alcohol rubs

• ○  Turn the hot water on and lather hands with soap

• ○  Wash hands for at least 30 seconds

• ○  Washe front, back, palms, individual finger, wrists, between fingers, underneath

  nail beds

• ○  Be aware of jewelry

blood

● ●

●

No vaccine
Average risk for infection after a needlestick or cut exposure to HCV infected blood is 1.8%
There are no exact estimates on the number of healthcare personnel occupationally infected with HCV

■

↑

• ●  2013 - estimated 700,000 - 1.4 million people were infected with chronic HBV

• ●  Annual number of infection has decreased by 95% since vaccine in 1982

  Hepatitis C:

○ Use elbows or paper towel to touch faucet, paper towel dispenser, and door knob ● Sharps and hazardous waste disposal

• ○  Marked by a bright red/orange color and biohazard symbol

• ○  Announce sharps after use, and immediately dispose

• ○  Notify supervisor when container is 3⁄4 full

• ○  Never attempt to push down or remove items in a sharps container

• ●  Safety systems for needles

  • ○  Avoid using sharps if safe alternative devices are available

  • ○  Always wear gloves

  • ○  Needles and sharps should be handled with care, and handling kept to a

    minimum

  • ○  Users of needles or other sharps are responsible for their disposal

  • ○  Never re-sheath, bend or break needles before disposal

  • ○  Dispose of syringes and needles as a unit

  • ○  Never carry used sharps or re-use equipment

  • ○  Sharps disposal containers must be available at the point of use

  • ○  Discard sharps containers when three-quarters full

  • ○  Never clear areas where sharps may be present without hand protection

  • ○  Wear goggles if there is a risk of splashing

• ●  OSHA and what it is/stands for > ○ Occupational safety and hazard association ALL -

■ Covers and creates safety regulations for all American workers ● Anyone who has a job in America, has a size portion to it ● I They say there has to be x amount of fire exits S

doesnthealthcare o r not

Vital Signs/Heart and Lungs:
● Vital signs (temp, respiration, pulse and blood pressure) – how to obtain, what is

normal and abnormal, and why they are assessed

○ Height/ Weight

○ Pulse ■

t

■ ■

Direct patient to remove shoes and stand facing away from the scale Remember to measure in constant units, as most scales are lb/kg

● They are used to determine whether a patient is overweight or underweight- either of these can indicate a disease. Measurements provide necessary information in performing and evaluating certain lab tests and in calculating dosages of certain medications. Abnormal growth patterns may indicate nutritional deficiencies or genetic disease. Height measurements taken for adults to check for osteoporosis.

○ Normal and abnormal are dependent on each person

• ●  Carotid - side of the neck below the jaw

• ●  Brachial - near bicep/ inner elbow

Different types
● Apical - felt at the apex (bottom) of the heat

• ●  Radial - wrist

• ●  Pedal - thigh

■ Check pulse for full 30 secs and multiply by 2, making it per minute

• ●  Normal pulse is 60-100

• ●  Bradycardia is <60

• ●  Tachycardia is >100

  ○ Respirations

• Do not tell patient when monitoring respiratory rate

• Instruct patient to grab their shoulders or lie down to help visualize chest

  rise

  • ●  Normal respiratory rate is 12-20

  • ●  Tachypnea is >20

  • ●  Bradypnea <12

○ Blood Pressure

• Stethoscope is on diaphragm side and knob on the cuff is closed

• Select appropriate sized cuff and align it with brachial artery

• Place stethoscope slightly medial to the antecubital space (elbow crease)

• Slowly release knob and listen for first “thud”

  • ●  Korotkoff sound: The thudding/whooshing sounds caused by turbulent blood flow when auscultating a blood pressure

  • ●  Systolic: The top blood pressure measurement referring to the pressure during the contraction of the ventricles

• Keep listening until the rhythmic “thud” fades away

● Diastolic: The bottom blood pressure measurement referring to the

pressure during ventricular rest
■ Record the value as systolic/diastolic. Avoid saying things like “I think it

was...” or “Ummmm I got...” to ensure confidence in the patient. ○ Temperature

• Pull the probe out from the device, this will turn on the thermometer

• Insert probe into temperature sheath, apply pressure until it is solidly on

  probe

• Insert probe into the patient’s mouth going under the tongue to either side

  and have patient close their mouth

• Wait until thermometer beeps or number stabilizes before interpreting

  number

• Discard temperature sheath into garbage by pressing on the back of the

  probe

● Most accurate as rectal

○ There is also temporal

• ●  Normal temp depends on the person

• ●  100.4 F is a fever

• ●  95 F is considered hypothermic

● Auscultation techniques

○ Auscultation is a technique that involves listening to the sounds of the body using a stethoscope. It's used to assess the lungs, heart, and bowels.

• Lung auscultation ● Sit upright

  ● Place the stethoscope's diaphragm on the chest
  ● Instruct the patient to take a deep breath through their mouth
  ● Listen to the lungs from the top down, moving from side to side ● Listen to a full breath cycle at each location
  ● Compare the sounds between the front and back of the lungs

• Heart auscultation

  • ●  Listen for the heart's S1 and S2 sounds

  • ●  Note the timing of the sounds

  • ●  Listen for murmurs, which are extra heart sounds

• Bowel auscultation

● Listen to the abdomen for bowel sounds

■ Tips for auscultation

• ●  Warm the stethoscope in your hands before using it

• ●  Listen in a quiet, warm, private environment

• ●  Ask the patient not to speak or move

• ●  Clean the stethoscope with an alcohol pad before and after use

● What are normal and abnormal breath sounds and where they can be found

• ○  Fine : Rales/Crackles

  • Fluid in the lugs

  • Heard at the bases

  • Classically end of inhalation

  • Sounds like velcro

  • Common causes: J

    ● CHF/Chronic Bronchitis

• ○  Coarse : Rales/Crackles

  • Fluid in the lungs

  • Heard throughout lungs

  • Ealy inhalation (but can be through all phases)

  • Sounds like bubbling

  • Common causes: J

    ● Severe pulmonary edema

    ○ Wheezing

  • Bronchial constriction

  • Starts on exhalation

● Worse if on inhalation too

■ Sounds high pitched
● Often described as musical

■ Common causes: ● Asthma

● Immune response

○ Rhonchi

• Secretions in large airways

• Can be heard wherever secretions are located

• Rattling junky sounds

• Common causes:

  • ●  Lung infection

  • ●  Severe Asthma

    ○ Stridor

• Upper airway swelling

• Heard in trachea

• High pitched whistling

• Common causes:

  • ●  Foreign body

  • ●  Anaphylaxis

  • ●  Croup

● What is cardiac auscultation and how to perform
○ Cardiac auscultation is the medical practice of listening to the sounds of a

patient's heart using a stethoscope, allowing a healthcare provider to assess the heart's rhythm, rate, and identify potential abnormalities like murmurs by carefully listening to the sounds produced by the heart valves at specific points on the chest wall

■ Preform: - quizletth is ● Aortic valve:

stuff

!

LV-left ventrical

RV-right ventrical

○ Controls the flow of blood from the LV to the aorta ■ 2nd intercostal L sternal border

● Tricuspid valve:
○ Controls blood flow between RA and RV

■ 2nd intercostal R sternal border ● Pulmonary valve:

○ Controls the flow of oxygen-poor blood from heart to lungs ■ 4th/5th intercostal L sternal border

● Mitral valve:
○ Controls flow of oxygenated blood from LA to the LV

■ 5th intercostal midclavicular line

● Heart sounds

○ Normal: -F-1st letter of Alphabet

• S1: “lub” closing of the tri and bicuspid valve

  • ●  Atrioventricular valves closing

  • ●  Loudest at apex of heart

    ○ Ticupid

    ○ Mitral

  • ●  Occurs at start of systole

  • ●  Can be timed with pulse

• S2: “dub” closing of the semilunar (Pulmonary/aortic) valves

  ↓

base

• ●  Semilunar valves closing

• ●  Loudest at base of heart

  ○ Aortic

  ○ Pulmonic

• ●  Occurs at start of diastole

• ●  “Split” occurs during inhalation

  ○ Abnormal:

• S3: The “Y” of Kentucky. Indicates congestive heart failure

  • ●  Ventricular vibration from filling distended ventricles

  • ●  Heard just after S2

  • ●  Best heard with the bell

• S4: The “ten” of Tennessee. Indicates aortic stenosis

  • ●  Ventricular filling of stiff ventricles

  • ●  Heard before S1

  • ●  Best heard with the bell

• Murmurs

  • ●  Turbulent blood flow through damaged heart valves

  • ●  Can occur during systole & diastole

  • ●  Can vary in location based on valve involved

○ Grading system

• Grade I - Barely audible

• Grade II - Audible, but quiet and soft

• Grade III - Moderately loud without thrust or thrill (palpable vibration)

  (murmurs)

• Grade IV Loud with a thrill

• Grade V - Very loud with thrill

• Grade VI - Loud enough to be heard before stethoscope comes into

  contact with chest

● Lung Sounds

• ○  Each location is assessing a different area in the respiratory tract. Certain sounds

• ○  will only be heard at specific locations and/or only during exhalation or inhalation

■

■ ■ ■

Patient Positioning:

Stridor: Trachea. High-pitched whistling. Caused by obstruction (foreign body/choking) or anaphylactic constriction. Can also be caused by croup in children.

Rhonchi: Bronchi (easy to remember). Coarse, expiratory, rattling sounds. Caused by thick mucous secretions, or asthma/allergic reactions Wheezing: Bronchiole constriction, often from COPD, emphysema, or asthma.
Rales/Crackles: Bases. Sounds like rice crispies, caused by alveoli popping due to loss of surfactant

○

● Body mechanics – describe and why important

• ○  Body mechanics refers to the coordinated movement and alignment of your body

  while performing daily activities, like sitting, standing, lifting, or bending

• ○  Helps prevent injuries, reduce muscle strain, and maintain good posture by

  minimizing stress on joints and muscles, especially in the back and spine

■ Essentially, it's about moving your body efficiently and safely to avoid pain

and discomfort.
● Patient positions (High/Full Fowlers, semi-fowlers, Trendelenburg, reverse

quiket Trendelenburg, prone, supine, recumbent)
○ Supine: Patient positioned lying down flat on their back.

• ○  Prone: Patient positioned lying down face down.

• ○  High- or Full-Fowlers: Patient is lying on their back, and the bed is adjusted to

  raise the head at least 80 degrees upwards so the patient is sitting upright.

• ○  Semi-Fowlers: Patient is lying on their back, and the bed is adjusted to raise the

  head 30-45 degrees upwards so the patient is sitting upright.

• ○  Trendelenberg: Patient is lying supine, and their legs are raised above their

  heads.

• ○  Reverse Trendelenberg: Patient is lying supine, and the feet are lowered below

  the head.

• ○  Left Lateral Recumbant/Recovery: Patient lies on their left side, resting their head

  on their elbow. ○

● Use and purpose of safety devices- restraints, call buttons, rails, etc.

• ○  Call Button: A device given that requests the staff attention. It should be within your patient’s reach at all times.

• ○  Code Button: A button usually located on the wall behind the hospital bed, sometimes labeled “Emergency Button.” Hit in the event of a cardiac or respiratory arrest. Note other wall buttons, like “Code Green” buttons.

• ○  Brakes: All wheels are locked and the bed is immobilized.

• ○  Steer: All but one wheel are free moving. One wheel remains fixed on a straight

  angle. This is best used for moving a patient down a hallway.

• ○  Float: All wheels are free moving. This is best used for maneuvering small

  spaces and rotating the bed.

• ○  Restraints: Materials used to restraint a patients in order to provide them with

  care

• ○  Rails: Always are up when provider is not in the room

  Patient Interaction:

● Stages of interaction

○ Introductory Stage

• Enter room and introduce yourself

• Social space; 4-12 ft

• Use formal name: (Mr./Ms.) even if unresponsive

● If patient introduces by first name, generally OK to use it

● Always safe to ask what the patient prefers to be called

• Describe purpose of visit, your role in care

• Confirm correct patient with ID bracelet

  • ●  ALWAYS ASK

  • ●  Shows respect and commitment to quality care

  • ●  Confirm both name and another detail (i.e. DOB)

• Important stage to develop rapport

• Be friendly, but avoid extremes

• Look for signs of resistive behavior:

● Crossed arms, no eye contact, brief responses ■ If so, make extra effort to establish rapport

• ○  Initial

  • Note general appearance, attitude, responses

  • Formal assessment with brief interview to determine CC

  • Followed by exam to determine patient condition

  • Goal: determine condition and make sure prescribed treatment is

    appropriate

  • If change is indicated, advise the care team

• ○  Treatment and Monitoring Stage:

  • Continue with assent skills to evaluate treatment

  • Note side effects and response

  • Document +/- effects

  • Stop treatment if side effects occur

  • Notify appropriate personnel (RN, PA)

• ○  Follow-up Stage:

  • Change to communicate with patient about treatment

  • Let patient know that you will return if necessary

  • Ensure patient comfort

  • “Is there anything else I can do to help you?”

  • Important for rapport

● Zones of interaction ○ Public Space

■ 12-25feet

■ An impersonal interaction ○ Social Space:

Assessment Stage

■ ■ ■ ■ ■

4-12 feet

Formality

Introduction and establishing rapport

Ability to see big picture and appreciate environment

14

Avid personal questions

○ Personal Space:

• 18 inches - 4 feet

• Used for interviewing and personal questions

• Provide privacy-pull curtain or close door to ensure patient comfort

• Rapport becomes more important in this space

• Use eye contact

○ Intimate Space:

• 0-18 inches

• Done after introduction and interview

• Always ask to invade intimate space

• Used with exam and procedures

• Minimal or no eye contact

• Use simple questions and brief commands

• Be ready for poor response to invasion

● Patient Assessment

○ There are several acronyms that we use to help us navigate the task of assessing our patients. These can be used as a blueprint for how you frame your assessment, or they can be used as a review that you use to ensure you haven’t forgotten anything during your assessment. Remember to keep assessments fluid and conversational, we are not training robots here!!!

■ Important Medical Assessment acronyms ● SAMPLE

• ○  SAMPLE is used when your patient is conscious, and generates a good patient history.

• ○  Signs/symptoms

• ○  Allergies

• ○  Medications

• ○  Past pertinent medical history

• ○  Last oral intake

• ○  Events leading up ● A&O

• ○  Alert &

• ○  Oriented

  • Used to determine patient’s cognitive awareness

  • Ranked out of 4 questions-

● Person, Place, Time, Event ■ Both acronyms are used in trauma assessments as well!

• ●  AVPU is a scale used to determine our patient’s responsiveness. ○ Alert

  ○ Verbal
  ○ Painful
  ○ Unresponsive

• ●  OPQRST is used when your patient is conscious, and it dives deeper into their complaint or complaints.

  • ○  Onset- Did this come on abruptly or slowly

  • ○  Provocation/Palliation- Does anything make it better or

    worse

  • ○  Quality- Describe how this sensation feels

• ○  Radiation/Region- Where is the sensation and does it occur elsewhere

• ○  Severity- Scale of 1-10 with 10 as the worst pain

• ○  Time- When did this happen/start or how long did it occur

  Medical Documentation and HIPAA: ● HIPAA

• ○  Health Insurance Portability and Accountability Act of 1966

  • “P” - Portability: gives certain protection when an individual's health care

    coverage changes

  • “A” - Accountability: privacy of patient’s information

• ○  Under HIPAA, those that use or disclose individually identifiable health information, known as protected health information, are subject to the HIPAA privacy rules

• ○  Before HIPAA, no national standard existed for the protection of a person’s medical information. With the implementation of these privacy rules on April 14, 2003, a minimum level of protection was created nationwide.

  ● TJC

• ○  Standards for documentation

  • Content charted

  • Level of detail

  • Frequency

    ● Communication

○ Using SOAP and Stages & Zones of Interaction ○ Influences:

■ Internal Factors
● Experiences, attitudes, culture, religion

■ Environmental
● Lighting, noise, privacy, distance, temp

■ Verbal Expression
● Language, jargon, word choice, voice tone

■ Nonverbal Expression
● Body movement, facial expression, dress

■ Emotional/ Sensory
● Fear, stress, pain, mental acuity, sight, hearing, speech

● Health History
○ Using SOAP

■ Subjective

• ●  What patient tells you about how they feel

• ●  Past Medical and Social History

• ●  Chief complaint

  ■ Objective

● Everything you see, hear, feel, smell, and learn from tests and

procedures