Student Clinical Skills Manual

Basic Diagnostic and Therapy

This manual is designed for students enrolled in first semester of academic year 2010-2011

Team
dr. Rini Rachmawarni Bachtiar dr. Citra Rosyidah

Faculty of Medicine Hasanuddin University 2010

Anamnesis and Vital Sign Examination

This manual is designed for students enrolled in first semester of academic year 2010-2011

Team
dr. Rini Rachmawarni Bachtiar dr. Citra Rosyidah

Basic Diagnostic and Therapy Faculty of Medicine Hasanuddin University 2010

Anamnesis and Vital Sign Examination Skills

Definition The taking of the medical history or anamnesis- a communication process between physician and the patient. This process aims to list an account of the symptoms experienced by the patient. Anamnesis is a very important initial step before moving on to physical examination procedures. The clues obtained during the anamnesis will aid the health care provider on performing the physical examination and listing the most likely diagnosis. Anamnesis procedure must be done systematically giving a fact that medical histories could sometimes be more useful than Physical examination in forming a diagnosis, however, please bear in mind that the combination of both procedures are often very helpful in determining the correct diagnosis. After finishing the anamnesis session, a complete physical examination can be started by measuring the Vital Signs first. These include objective assesments of Blood Pressure, Pulse, Respiratory rate, Temperature and Conciousness. Aims 1. Conducting an anamnesis procedure sytematically a. Buliding up a good doctor-patient relationship b. Obtaining a comprehensive medical history from the patient c. Hypothesing the likely organ/body parts that have been damaged d. Formulating clinical problems of the patient 2. Being able to conduct a correctly Vital signs measurements which include Blood pressure, Temperature, Pulse and Respiratory rate using the most appropriate instruments. a. Correctly recording blood pressure using a sphygmomanometer. Being able to perform this procedure systematically according to the standard procedure. b. Correctly recording body temperature c. Correctly counting respiratory rate d. Correctly measuring pulse rate

Learning equipments 1. Student Clinical Skill Manual for Anamnesis and Vital Signs Examination Skills 2. Stethoscope, Thermometer, Sphygmomanometer and Mannequin 3. Patientss medical record, pen and pencil Learning Methods 1. Demonstration using the CSL manual 2. Lectures

3. Discussion 4. Active participation in the lab Skill (simulation) 5. Evaluation using check list with a scoring system

Activities Description I. Anamnesis Activities Time allocated 1. Introduction 5 minutes 2. Role play demonstration 30 minutes 1. Arranging the students seats 2. Instructor demonstrates an example on how to perform a systematic anamnesis. Students are asked to observe 3. Allowing students to ask any questions they have regarding the demos. Instructor Introduction Description

emphazises all important points. 4. Students are given opportunity to observe and ask anything that needs to be clarified. Instructor will provide them with answers 3. Practicing the role play 100 minutes 1. Students are divided into pairs 2. Each couple will perform the role play, one person will act as a physician and the other will play the patient 3. Students are given a specific topic or chief complaint that will be explored by the assesor. 4. Instructor will supervise all the student activities using check list 5. Each students is expected to practice at least once during the day sessions. 4. Brain Storming / Discussion 15 minutes 1. Brain storming/Discussion: students are given the opportunity to raise any issues that

they might have including any difficulties during the sessions. Students are also allowed to mention any good things that they have experienced in the class. Students are also asked their impression of being a patient. What could be done by the doctor to make the patient feeling more comfortable. 2. Instructor concludes the session by

providing answers and feedback to any points that need clarification. Total time allocated 100 minutes

II. Vital Signs Examination

Activities Time allocated 1. Introduction 2. Role play demonstration 5 minutes 30 minutes Introduction 1. Arranging the students seats 2. Instructor demonstrates an example on how to record Vital Signs. This point includes measuring Blood pressure, Pulse rate, Respiratory rate and temperature. Two instructors are performing the procedures, one of them will be playing the doctor and the other will act as the patient. Students are asked to observe 3. Allowing students to ask any questions they have regarding the demos. Instructor Description

emphazises all important points. 4. Students are given opportunity to observe

and ask anything that needs to be clarified. Instructor will provide them with answers 3. Practicing the role play 100 minutes 3. Students are divided into pairs 4. Each couple will perform the role play, one person will act as a physician and the other will play the patient 3. Students are given a specific topic or chief complaint that will be explored by the assesor. 4. Instructor will supervise all the student activities using check list 5. Each students is expected to practice at least once during the day sessions. 4. Storming/Discussion Brain 15 minutes 1. Brain storming/Discussion: students are given the opportunity to raise any issues that they might have including any difficulties during the sessions. Students are also allowed to mention any good things that they have experienced in the class. Students are also asked their impression of being a patient. What could be done by the doctor to make the patient feeling more comfortable. 2. Instructor concludes the session by

providing answers and feedback to any points that need clarification. Total time allocated 100 minutes

Student Clinical Skill Manual for Anamnesis and Physical Examination Skills A. Anamnesis Skill
NO 1. Clinical steps Welcome the patient, standing up and shaking each other hands. Introduce yourself in a warm, friendly manner 2. Ask the patient to have a comfortable sit. It is necessary to sit facing your patient. 3. Give a positive response to build up a good relationship with your patient 4. 5. 6. Ensure comfort and privacy Record the patients identity : name, age, address and occupation Pronounce your words clearly using languange which the patient can easily understand 7. 8. 9. Know and Use the patients name during interviews Ask about the patients chief complaint and try to clarify it. Obtain a history of present illness. Try to ask about all information in a chronological manner up to day of interviews. Events related to the development of the symptoms should be recorded . 10. 11. Perform an anemnesis of the associated system Obtain past medical history focusing on any illnesses that are likely to be in conjuuction with the present complaints. 12. Obtain a family history as well as any environmental concerns. Ask the patient if there any family members who suffer or were suffering from the same illness. 13. Perform a Cross checking Case

B. Blood Pressure, Pulse Pressure, Respiratory rate and temperature measurements

A. Blood Pressure Measurements NO 1. 2. Clinical steps Prepare the Sphygnomanometer and the Stethoscope Obtain a concent from the patient or their family to perform the examination 3. 4. 5. 6. Stand at the patients right side Explain the procedure Ideally the patient should be either sitting or laying down Patients arm must be free from any pressures. Uncover the clothes in this area 7. Put on the cuff so that it could be circling around the patients arm with an appropriate pressure. Place it at approximately 2.5-5 cm above the anticubital fold. 8. Locate the brachial artery, it is usually located at the medial side of the biceps 9. Palpate the brachial artery pulse using one finger and inflate the cuff quickly to 30 mmHg above the pressure whereby the pulse of the brachial artery disappears. 10. Release the pressure slowly until you feel the brachial arterys pulse again. This is a rough estimated of (palpatoir) 11. 12. 13. Place the sthetoscope over the brachial artery. Inflate the cuff to 30 mmHg above the estimated systolic pressure Release the pressure slowly no greater than 2-3 mmHg per second. The level at which you constantly hear the beats of the brachial artery is the systolic pressure. Continue to lower the pressure until the sounds muffle and disappear. This is the diastolic pressure 14. Always position the spygnomanometer vertically. Upon reading Systolic pressure Case

the result, always place your view at a horizontal line to the column of the mercury. 15. Be able to report the results of the systolic and diastolic pressure measurements 16. Release the cuff , store it back and close the box

B. Pulse rate measurements NO 1. 2. Clinical steps The patiens could be sitting or laying down The arms should be relaxing, Undo all jewelleries and watches from the wrist 3. Compress the radial artery pulse with your index and middle finger at the lateral flection side of the patients wrist 4. 5. 6. Count the pulse for 30 seconds and multiply by 2 Record the rythim and the pulse quality Write down the results Case

C. Respiratory rate NO 1. 2. Clinical steps Ask the patients to undo their clothes Inspect the movement of the chest during respiration. Sometimes, it would be necessary to place your hands at the both sides of the chest to compare them. 3. During inspiration process, oberserve the chest for the presence of the lateral movement towards the ribs side , the widening of epigastrium space size and the enlargement of anteroposterior diameter of the chest 4. During expiration process, observe the chest for the presence of the inwards movement towards the ribs side, the shortening of both epigatrium space size and the anteroposterior diameter of the Case

chest 5. 6. 7 Note any supporting respiratory muscle usages Count breaths for the minimum of 1 minute Record the rythim, frequency and any abnormal breathing movements. D. Temperature Measurements NO 1. Clinical steps Make sure the thermometer column has been set up at above 35.5 degree celcius 2. Place the tip of the mercury thermometer to the apical side of left axillary fold with a maximum adduction of the shoulder joint 3. 4. Allow 3-5 minutes before reading the results Write down and report the results. Case

A. Basic Physical Examination (Inspection, Palpation, Percussion and Auscultation) A. Inspection: Observe and Record NO 1. Clinical steps Observe the body build of the patient e.g. athletic, cachetic or overwight 2. 3. 4. 5. 6. Compare the ratio of the head size and body length Observe the type of the movement Record any obvious deformities or abnormalities Note hair texture, skin, conjunctivaea, sclerae and nails Apparent state of comfort or distress.e.g. anxious, depressed, shy, moaning in pain etc 7 Additional signs B. Palpation NO 1. Clinical steps Position your self at the patients right side Case Case

2. 3. 4.

Examined areas should be free from clothes Make sure that your hands are not cold Palpation could be conducted in several ways : Using your index finger and thumb for measuring the size Using your index, middle and ring fingers all together for measuring the consistency and quality Using the palmar surface to dectect any pulsations or vibrations/thrills

5.

Apply a little pressure using your fingertip or the palmar. This could help us to detect any anbnormal pain that could be seen through the patients expression. C. Percussion

NO 1.

Clinical steps Preparing the middle finger of the left hand in hyperextension position. Placing this finger on the body surface where percussion is to be performed

Case

2.

Gently apply a pressure using the interphalangeal joint to the body surface and avoid contact between this percussion site and any other parts of your left hand

3.

Put your right hand in an oblique position facing upwards and place it near the percussion site

4.

Setting your middle finger up in a flextion and relaxed position ready to perform the percussion procedure

5.

With a quickly but relaxed movement from your right hand wrist joint, tap the middle finger of your left hand attached to the percussion surface using the middle finger of your right hand

6.

Use your fingertip and tap in a 90-degree angle to the percussion surface

Percuss as light as possible that can produce a clear sound

D. Auscultation NO 1. 2. Clinical steps Use a stethoscope with small hose (25-30cm) Place the earpieces appropriately inside your external ear, make sure it is in a fixed position not being pressed 3. Use the back side of the stethoscope to perform a chest examination. The diafragma side is to be used to perform an abdominal examination. Case

Communication/Anamnesis Skills Check List

NO Competencies evaluated 0 Communication Skills Aspects Ability to Build up a good doctor-patient relationship 1. 2. 3. 4. 5. Greeting the patient at the beginning of the anamnesis process Showing a positive attitude to the patient Offering the patient a seat facing yourself Asking the patients identity : name,age,etc Using a non-verbally language Score 1 2

Ability to collect the necessary information 6. 7. 8. 9. Using a languange than can easily be understood by the patient Avoid suggesting an interrogation List any questions that need to be asked Do the cross-check to ensure the validity of the repondens answers 10. 11. Allow the patient to tell their information Be able to record all information clearly

Ability to maintain a comfortable atmosphere during anamnesis process 12. Be a good listener

13. 14. 15. 16.

Show the empathy Be friendly and Be able to ease up the patient Be polite and dress up appropriately Close the anamnesis session by acknowledging the patient

Medical Aspects 17. Identity: Name, Age, Address, Occupation are to be listed and asked clearly 18. 19. Ask the chief complaint Ask any other complaints

0: not demonstrated 1: Demonstrated, not completely address some points 2: Correctly demonstrated Overall score Score = ---------- X 100% = 38

Makassar, .................2005 Instruktur ..........................................

Vital Signs Examination Skills Check List

NO Competencies evaluated 0 A. Blood Pressure Measurement 1. 2. 3. The examiner stands at the patients right side Explain the procedure to the patient Ask the patient to sit down or laying down. Ensuring the patients arm is relaxing, slightly flexed at the elbow and free from clothes 4. Preparing the manometer, opening up the mercury flow, checking Score 1 2

the hose and placing the scale vertically 5. 6. Using the stethoscope and making sure the bell is already opened Put on the cuff so that it could be circling around the patients arm with an appropriate pressure. Place it at approxiamtely 2 cm above the elbow and 7. Being able to palpate the brachial artery pulsation at the medial side of cubital fold 8. Palpate the brachial artery pulse using one finger and inflate the cuff quickly to 30 mmHg above the pressure whereby the pulse of the brachial artery disappears. Release the pressure slowly until you feel the brachial arterys pulse again. Report this result as a rough estimated of Systolic pressure (palpatoir) 9. 10. 11. Use the stethoscope and place the bell at the pulsation site Inflate the cuff to 30 mmHF above the estimated systolic pressure Monitor the beats using a stethoscope and slowly release the pressure (3 mmHg per second). Report the level at which you initially hear beats as the systolic pressure 12. Continue to lower the pressure until the sounds muffle and disappear and report it as the diastolic pressure 13. 14. Be able to record the blood pressure as systolic over diastolic Undo the cuff and tidy it up

B. Pulse rate measurements 1. 16. 17. 18. Position the patients arm in a relaxing way Use the index and middle finger to palpate the radial artery Count the pulse rate frequency for the minimum of 15 seconds Report the result for a full minute

C. Temperature measurements 19. Ensuring the thermometer column has been set up at above 35.5 degree celcius

20

Place the tip of the mercury thermometer to the apical side of left axillary fold with a maximum adduction of the shoulder joint

21

Allow 3-5 minutes before reading the results

D. Respiratory rate measurements 1. Ask the patient to undo their clothes (in either a sitting or laying down position) 2. Perform inspection or palpation using both hands at the back or directly to the chest and count the repiratory rate for a minimum of 15 seconds 3. Report the respiratory rate for a full minute

Ket: 0: not demonstrated 1: Demonstrated, not completely address some points 2: Correctly demonstrated a. Blood Pressure Measurement: Overall score Score = ---------- X 100% = 28 %

b. Pulse Rate Measurement: Overall score Score = ---------- X 100% = 8 %

c. Temperature Measuremerent: Overall score Score = ---------- X 100% = 6 %

d. Respiratory rate Measurement: Overall score Score = ---------- X 100% = 6 %

Makassar, .................2010

Instructor .........................................

Student Clinical Skills Manual Physical Examination Skills

This manual is designed for students enrolled in first semester of academic year 2007-2008

Team
dr. Rini Rachmawarni Bachtiar dr. Citra Rosyidah

Editor
Dr. Baedah Madjid, Sp.Mk

Basic Diagnostic and Therapy Faculty of Medicine Hasanuddin University 2010

Physical Examination Skills

Definition Physical examination or clinical examination that follows the taking of the medical history or anamnesis is the process by which a health care provider investigates the part of human body for signs of abnormalities. This procedure consists of Inspection (observing), Palpation (touching), Percussion (tapping) and Auscultation (listening). A systematic physical examination generally starts from Inspection following by Palpation, Percussion and Ausculatation respectively with an exception to Abdominal examination in which the Auscultation should be performed before conducting Palpation.

Aims Being able to perform a systematic Physical Examination include Inspection, Palpation, Percussion and Auscultation e. Preparing the patient prior to the physical examination f. Conducting a direct Inspection and evaluating general appearance of patients body part g. Performing a palpation using the finger and its top side, hands or both palms to measure Vital signs h. Producing a clear percussion sound by performing a correct percussion procedure. i. Performing a correct Auscultation procedure using a stethoscope Learning equipments 4. Student Clinical Skill Manual for Basic Physical Examination Skills 5. Stethoscope and Mannequin 6. Patientss medical record, pen and pencil Learning Methods 6. Demonstration using the CSL manual 7. Lectures 8. Discussion 9. Active participation in the lab Skill (simulation) 10. Evaluation using check list with a scoring system

Activities Description

Physical Examination
Activities Time allocated 1. Introduction 2. Role play demonstration 5 minutes 30 minutes Introduction 1. Arranging the students seats 2. Instructor demonstrates an example on how to perform a comprehensive all physical of and are Description

examination Inspection, Auscultation.

covering Palpation, Two

aspects

Percussion instructors

performing the procedures, one of them will be playing the doctor and the other will act as the patient. Students are asked to observe 3. Allowing students to ask any questions they have regarding the demos. Instructor

emphazises all important points. 4. Students are given opportunity to observe and ask anything that needs to be clarified. Instructor will provide them with answers 3. Practicing the role play 100 minutes 5. Students are divided into pairs 6. Each couple will perform the role play, one person will act as a physician and the other will play the patient 3. Students are given a specific topic or chief complaint that will be explored by the assesor.

4. Instructor will supervise all the student activities using check list 5. Each students is expected to practice at least once during the day sessions. 4. Storming/Discussion Brain 15 minutes 1. Brain storming/Discussion: students are given the opportunity to raise any issues that they might have including any difficulties during the sessions. Students are also allowed to mention any good things that they have experienced in the class. Students are also asked their impression of being a patient. What could be done by the doctor to make the patient feeling more comfortable. 2. Instructor concludes the session by

providing answers and feedback to any points that need clarification. Total time allocated 100 minutes

Student Clinical Skill Manual for Physical Examination Skills

A. Inspection: Observe and Record NO 1. Clinical steps Observe the body build of the patient e.g. athletic, cachetic or overwight 2. 3. 4. 5. 6. Compare the ratio of the head size and body length Observe the type of the movement Record any obvious deformities or abnormalities Note hair texture, skin, conjunctivaea, sclerae and nails Apparent state of comfort or distress.e.g. anxious, depressed, shy, moaning in pain etc Case

Additional signs

B. Palpation NO 1. 2. 3. 4. Clinical steps Position your self at the patients right side Examined areas should be free from clothes Make sure that your hands are not cold Palpation could be conducted in several ways : Using your index finger and thumb for measuring the size Using your index, middle and ring fingers all together for measuring the consistency and quality Using the palmar surface to dectect any pulsations or vibrations/thrills 5. Apply a little pressure using your fingertip or the palmar. This could help us to detect any anbnormal pain that could be seen through the patients expression. Case

cussion C. Percussion NO 1. Clinical steps Preparing the middle finger of the left hand in hyperextension position. Placing this finger on the body surface where percussion is to be performed 2. Gently apply a pressure using the interphalangeal joint to the body surface and avoid contact between this percussion site and any other parts of your left hand 3. Put your right hand in an oblique position facing upwards and place it near the percussion site 4. Setting your middle finger up in a flextion and relaxed position ready to perform the percussion procedure 5. With a quickly but relaxed movement from your right hand wrist Case

joint, tap the middle finger of your left hand attached to the percussion surface using the middle finger of your right hand 6. Use your fingertip and tap in a 90-degree angle to the percussion surface 7 iii. Percuss as light as possible that can produce a clear sound Auscultation NO 1. 2. Clinical steps Use a stethoscope with small hose (25-30cm) Place the earpieces appropriately inside your external ear, make sure it is in a fixed position not being pressed 3. Use the back side of the stethoscope to perform a chest examination. The diafragma side is to be used to perform an abdominal examination. Case

Basic Physical Examination Skills Check List

NO Competencies evaluated 0 1. 2. The examiner stands at the patients right side Ask the patients to lay down and undo their clothes Score 1 2

Inspection 3 Observe the general appearance of the patients

Palpation 4 5 6. Uncover the palpation site from any clothes Try to warm up both hands before touching the patient Place the index and middle finger at the patients wrist to feel the pulse rate 7 Palpate the patients chest using the whole palmar surface and feel the respiratory movement

Show an ability to compare both side of the chest movement by placing one hand on the right chest and the other hand on the left chest

Percussion 9 Gently apply a pressure using the interphalangeal joint of the left hands middle finger to the body surface and avoid contact between this percussion site and any other parts of your left hand 10 11 Perform the percussion using the middle finger of the right hand The middle finger of the right hand has to be at a 90-degree angle to the middle finger of the left hand 12 The right hand should be relaxing and allocate the movement to the wrist 13. Produce an appropriate sound for the percussed area

Auscultation 14 15 Preparing the stethoscope Allow 2-3 seconds to hear at one site before moving on to the other area 16 Report the auscultation results (e.g. Respiratory sounds, Heart sounds and peristaltic) Ket: 0: not demonstrated 1: Demonstrated, not completely address some points 2: Correctly demonstrated Overall score Score = ---------- X 100% = 32

Makassar, .................2010 Instructor ...........................................

Student Clinical Skills Manual Intramuscular Injection Skill

This manual is designed for students enrolled in first semester of academic year 2010-2011

Team
Prof. Dr. dr. Syakib Bakri, SpPD-KGH dr. Rini Rachmawarni Bachtiar

Editor
Dr. Baedah Madjid, Sp.MK dr. Jimmy R. Masykur, MM

Basic Diagnostic and Therapy

Faculty of Medicine Hasanuddin University 2010

Intramuscular, Subcutaneous, and Intracutaneous Injection Skill

Definition
Injecting medications is an invasive procedure in which drugs are deposited into body tissue using a sterile needle. Drug absorbtion rate and its pharmacodynamic will be very much influenced by the characteristic of body tissue where they are injected. It is imperative to measure the exact dose and uderstand the chemical elements of the medication prescribed, as well as the anatomy of the injection sites before performing an injection. Intramuscular injection provides a more rapid absorption due to muscles vascularitation. Tissue damages could be minimised by administering the medication deep inside the muscle. A subcutaneous injection aims to administer a medication into a subcutaneous layer located just under the skin. Subcutaneous layer lacks of blood vessels, therefore the injected medication is generally absorbed more slowly than that given using an intramuscular injection. Subcutaneus tissue consists of paian receptors, hence only a small-dose, water-soluble and no- irritable medication is allowed to be delivered in this manner. Intracutaneous injection is performed to administer medication inside the skin tissue. This method of injection are often used for: 1. Obtaining local reaction 2. Conducting immunisation, e.g BCG ijnection

Learning Goals
Preparing all instruments needed for intramuscular, subcutaneous, and intracutaneos injection procedure. Locating appropriate intramuscular, subcutaneuos, and intracutaneous injection sites Performing a intramuscular injection according to the standardized procedure.

Learning equipments:
1. Student CSL manual for intramuscular injection 2. Hand washing area with soap and antiseptic liquid 3. Sterile container layered with gauzed pad

4. 1 cc syringe with 18 or 20-gauge needle filled with desired solution 5. Alcohol swab/antiseptic 6. Container for syringe disposal

Learning methods: 1. Demonstration using the manual 2. Lectures/guidance 3. Discussion 4. Active participation in the skill lab (simulation) 5. Evaluation using check list with scoring system

Activities Description
Activities Time allocated 1. Introduction 2. Role play demonstration 5 minutes 30 minutes Introduction 1. Arranging the students seats 2. Instructor demonstrates an example on how to perform intramuscular, subcutaneous, and intracutaneous injection using a mannequin. Students are aske to observe 3. Allowing students to ask any questions they have regarding the demos. Instructor Description

emphazises all important points. 4. Students are given opportunity to observe and ask anything that needs to be clarified. Instructor will provide them with answers 3. Practicing the role play 50 minutes 7. Students are divided into pairs 8. Each couple will perform the role play, one person will act as the injector and the other will play the observer/assistant role 3. Students are allowed to take turn on performing the intramuscular, subcutaneous, and intracutaneous injection using

mannequin 4. Instructor will supervise all the student activities using check list 5. Each students is expected to practice at least once during the day sessions. 4. Storming/Discussion Brain 15 minutes Brain storming/Discussion: students are given the opportunity to raise any issues that they might have including any difficulties during

the sessions. Students are also allowed to mention any good things that they have experienced in the class. Total time allocated 100 minutes

Student Clinical Skill Manual for Intramuscular Injection

A. Intramuscular Injection NO 1. 2. 3. 4. 5. Preparing all instruments Expalining the entire procedures to the patients Arranging an appropriate position for the patient Performing an aseptic handwashing Locating the injection sites : The right and left side of Gluteus Maximus muscle (buttockmuscle). Location : The injection is given at 1/3 length of a line drawn from the anterior superior iliac spine to the iliac crest 6. 7. Quadriceps Femoris muscle (thigh muscle) Deltoideus muscle (upper arm muscle) Clinical steps Case

Uncovering the injection sites from clothes Sterilising the injection sites using alcohol swab. Discarding the

used swab directly to disposal box after being used. Allowing the skin to dry. 8. Stretching the skin at the buttocks area using your left finger OR Pulling up the muscle in Qudariceps femoris/deltoideus areas. 9. Inserting the needle at 90-degree angle straight in to the skin surface. Inserting only of the needle length below the skin surface. 10. Pull back slightly on the plunger to aspirate for blood. If no blood appears, slowly inject the medication into the muscle. 11. Covering the injection site immediately with the alcohol sponge, apply gently pressure. Quickly remove the needle. 12. 13. 14. 15. Massaging the injection site. Tiding up the patient Taking all equipments back to the instrument table to be cleaned Performing an antiseptic hand washing

B. Subcutaneous Injection NO 1. 2. 2. 3. 4. Preparing all instruments Skin testing to asses for the likelihood of allergy Explaining the entire procedures to the patients Arranging an appropriate position for the patient Performing an antiseptic hand washing Clinical steps Case

5.

Locating the injection sites : Arm : Patient may either stand up or sit down Abdomen : patient may either sit or lay down Legs : patient may sit down using a bed or a chair

6. 7.

Uncovering the injection sites from clothes Sterilising the injection sites using alcohol swab. Discarding the used swab directly to disposal box after being used. Allowing the skin to dry.

8.

For normal patient: stretch both side of the skin OR simply grasp the skin at the injection site For Obese patient: grasp the skin at the injection site and administer the medication inside the skin fold.

9. 10. 11. 12.

Inserting the needle with the bevel facing upwards Inserting the needle at 45-degree angle Slowly injecting the medication Quickly removing the needle. apply an antiseptic swab to the injection site

13. 14. 15.

Tiding up the patient Taking all equipments back to the instrument table to be cleaned Performing an antiseptic hand washing

C. Intracutaneous Injection NO 1. 2. 3. 4. 5. Preparing all instruments Explaining the entire procedures to the patients Arranging an appropriate position for the patient Performing an antiseptic hand washing Locating the injection sites : Lower Arm : The ventral side at 1/3 length of the lower arm measured from the elbow (or about 2/3 measured from Clinical steps Case

the wrist area). Only a healthy skin area is allowed to be injected. Blood vessels must be avoided. This is the site for injection of Mantoux test and skin test Upper Arm : Place 3 fingers of your hand from the bone that goes across the top of the upper arm (this is called the acriomion process) untill you reach the median side of detoid muscle. This site of injection is for BCG.

6. 7.

Uncovering the injection sites from clothes Sterilising the injection sites using alcohol swab. Discarding the used swab directly to disposal box after being used. Allowing the skin to dry.

8. 9. 10. 11. 12.

Stretching the skin with your left hand Inserting the needle with the bevel facing upwards Inserting the needle at 15-20-degree angle Slowly injecting the medication, making the wheal under the skin Quickly removing the needle. Pat dry, do not apply pressure and acohol swab to the site.

13. 14. 15.

Tiding up the patient Taking all equipments back to the instrument table to be cleaned Performing an antiseptic hand washing

Intramuscular, Subcutaneous, and Intracutaneous Injection Check List

A. Intramuscular Injection NO Competencies evaluated 0
1. 2. Preparing all instruments Expalining the entire procedures to the patients

Score 1 2

3. 4. 5.

Arranging an appropriate position for the patient Performing an antiseptic hand washing Locating the injection sites : The right and left side of Gluteus Maximus muscle (buttockmuscle). Location : The injection is given at 1/3 length of a line drawn from the anterior superior iliac spine to the iliac crest Quadriceps Femoris muscle (thigh muscle) Deltoideus muscle (upper arm muscle)

6. 7.

Uncovering the injection sites from clothes Sterilising the injection sites using alcohol swab. Discarding the used swab directly to disposal box after being used. Allowing the skin to dry.

8.

Stretching the skin at the buttocks area using your left finger OR Pulling up the muscle in Qudariceps femoris/deltoideus areas.

9.

Inserting the needle at 90-degree angle straight in to the skin surface. Inserting only of the needle length below the skin surface.

10.

Pull back slightly on the plunger to aspirate for blood. If no blood appears, slowly inject the medication into the muscle.

11.

Covering the injection site immediately with the alcohol sponge, apply gently pressure. Quickly remove the needle.

12. 13. 14.

Massaging the injection site. Tiding up the patient Taking all equipments back to the instrument table to be cleaned

15.

Performing an antiseptic hand washing

Ket: 0: not demonstrated 1: Demonstrated, not completely address some points 2: Correctly demonstrated Overall score Score = ---------- X 100% = 30 %

Makassar, .................2010 Instructor ...........................................

B. Subcutaneous Injection NO 1. 2. 3. 4. 5. 6. Preparing all instruments Skin testing to asses for the likelihood of allergy Explaining the entire procedures to the patients Arranging an appropriate position for the patient Performing an antiseptic hand washing Locating the injection sites : 7. 8. Arm : Patient may either stand up or sit down Abdomen : patient may either sit or lay down Legs : patient may sit down using a bed or a chair Clinical steps Case

Uncovering the injection sites from clothes For normal patient: stretch both side of the skin OR simply grasp the skin at the injection site For Obese patient: grasp the skin at the injection site and administer the medication inside the skin fold.

9. 10. 11. 12.

Inserting the needle with the bevel facing upwards Inserting the needle at 45-degree angle Slowly injecting the medication Quickly removing the needle. apply an antiseptic swab to the injection site

13. 14. 15.

Tiding up the patient Taking all equipments back to the instrument table to be cleaned Performing an antiseptic hand washing

Ket: 0: not demonstrated 1: Demonstrated, not completely address some points 2: Correctly demonstrated Overall score Score = ---------- X 100% = 30

Makassar, .................2010 Instructor ........................................... C. Intracutaneous Injection NO 1. 2. 3. 4. 5. Preparing all instruments Explaining the entire procedures to the patients Arranging an appropriate position for the patient Performing an antiseptic hand washing Locating the injection sites : Lower Arm : The ventral side at 1/3 length of the lower arm measured from the elbow (or about 2/3 measured from the wrist area). Only a healthy skin area is allowed to be injected. Blood vessels must be avoided. This is the site for injection of Mantoux test and skin test Upper Arm : Place 3 fingers of your hand from the bone that goes across the top of the upper arm (this is called the acriomion process) untill you reach the median side of detoid muscle. This site of injection is for BCG. Clinical steps Case

6. 7.

Uncovering the injection sites from clothes Sterilising the injection sites using alcohol swab. Discarding the used swab directly to disposal box after being used. Allowing the skin to dry.

8. 9. 10. 11.

Stretching the skin with your left hand Inserting the needle with the bevel facing upwards Inserting the needle at 15-20-degree angle Slowly injecting the medication, making a tiny bubble under the skin

12.

Quickly removing the needle. Pat dry, do not apply pressure and acohol swab to the site.

13. 14. 15.

Tiding up the patient Taking all equipments back to the instrument table to be cleaned Performing an antiseptic hand washing

Ket: 0: not demonstrated 1: Demonstrated, not completely address some points 2: Correctly demonstrated Overall score Score = ---------- X 100% = 30

Makassar, .................2010 Instructor ...........................................

MANUAL BOOK OF

CHANGING BANDAGE SKILL

Given to 1st Semester Medical Students Of Hasanuddin University

Created By dr. Rini Rachmawarni Bachtiar Editor Dr. Baedah Madjid, Sp.MK

BASIC DIAGNOSTIC AND THERAPY MEDICAL FACULTY HASANUDDIN UNIVERSITY 2010

CHANGING DRY BANDAGE SKILL

INTRODUCTION
Dry Bandages protecting wound by providing minimal drainage of microorganism contamination. A bandage can be made either from gauze pad which is not attach to the incision or wound site, hence leading to lesser irritation, or from tefla pad, which is also not attach to the incision or wound site but much better in allowing drainage process through the un-shield surface of wound under the soft gauze. If the incision or wound site remains opened, dry bandage positioning has to be performed in sterile condition.

STUDY GOAL OBJECTIVE

After completing this skill training, students are expected to have the ability of changing dry bandage

STUDY OBJECTIVES
After completing this skill training, students are expected to be able in: 1. preparing materials and instruments needed in changing dry bandage 2. performing a correct and efficient procedure in changing dry bandage

MATERIALS AND INSTRUMENTS

1. a properly sterilized bandage set or the following materials: a pair of sterilized gloves a bandage set (scissors and forceps) a some gauze and gauze pads a basin for antiseptic and cleaning solution antiseptic ointment 2. antiseptic solution 3. a pair of disposable gloves

4. 5. 6. 7. 8. 9.

some tape, plaster (depends on the need) biodegradable bin extra gauze and surgipad or ABD pad patients own robe tape lifter (optional) measuring tool

LEARNING METHOD
1. 2. 3. 4. 5. Skill demonstration based on the manual Lecture Discussion Active participation in conducting the skill (simulation) Evaluation using provided check list with scoring system

MEDICS/PARAMEDICS CONCERN
During process of removing or placing a bandage, be very careful not to displace the wound drain (if any). If the wound is complete and dry, it is possible to achieve optimal recovery without bandaging. The medical officer has to wear gloves and place the used gauze and bandage in the biodegradable bin. In the case of possible ocular contamination, e.g. blood burst, wearing specific spectacles is highly recommended.

EDUCATION FOR PATIENTS

Most frequently, patients are discharged with dry bandage. It is important to educate the patients and their family about correct hand washing technique, appropriate wound cleaning and proper used bandage disposal. These techniques do not require sterile procedures.

GERIATRIC CONSIDERATION
Older peoples skin texture is generally much thinner and un-elastic. Therefore, it requires thorough care when removing the tape.

ACTIVITIES DESCRIPTION
ACTIVITIES 1. Introduction 2. Role Play: asking and TIME 5 minutes 30 minutes DESCRIPTION Introduction Speech 1. Arranging students seat

answering question

2.

3.

4. 3. Role play with feed 100 minutes back 1. 2.

3. 4. 4. Brain storming and 15 minutes discussion 1.

2.

Two instructors (an instructor and coinstructor) giving examples on ho to change bandage. One instructor acts as a doctor and the other as the patient. Students thoroughly observe. Students are given opportunity to ask questions; instructors explain important aspects related to the topic Students observe and ask questions; instructors replay. Students are grouped in pairs. A mentor is required to observe every 2 pairs In each role play, one student acts as a doctor who is changing the bandage and the other as the patient Mentors supervise the performed procedures using check list Every student should at least has one chance Brain storming/discussion: Which part that is easy to perform?, what are the difficult parts?, What are the patients-act students feel? What can a doctor improve to make the patients more comfortable? Instructors summarize by explaining the last question and giving necessary enlightenment

Total allocated time

150 minutes

CHANGING DRY BANDAGE SKILL

(Provided for the students) Mark every clinical step using the following scoring categories: 1. Need to be improved: Steps that are not correctly performed, un-organized chronologically, or for some missed/left over steps 2. Able: Steps that are performed correctly, chronologically based, but not efficiently conducted 3. Master: Steps that are performed correctly, chronologically based, and efficiently conducted NS (Not suitable): Steps that are unnecessarily conducted due to the situation

No. ACTIVITIES
1. 2. 3. 4. 5. Explain the procedure to the patient by describing the overall wound caring steps Organize all the needed instruments and materials on the table beside the patients bed (do not open yet) Get a disposable paper bag, fold the upper lid, and place it somewhere within your hands reach Close the assessment rooms door or curtain, or organize the curtain to surround the bed. Close all open windows Position the patient in a comfortable setting, place the patients bath robe supporting the wound. Instruct the patient not to touch the wound site or the sterilized instruments. Wash hands thoroughly Wear a pair of clean disposable gloves, remove any tapes, straps or bandages Remove the tape by peeling from side then carefully pulling it parallel to the skin toward the bandage (in case of any tape remnants, it can be cleaned with acetone) Using gloved hands or forceps, lift the bandage while at the same time maintain the used dirty surface out of the patients sight Should the bandage stuck to the wound, easy the peeling process with sterile solution or water Observe character and drainage volume of the bandage Dispose the used bandage in the provided bin; avoid contaminating outer surface of the bin. Release the gloves, by start pulling from inside out. Dispose in the proper bin Uncover the sterilized bandage tray. Place the tray on the table beside patients bed. Bandages, scissors and forceps must always be

SCORE 1 2 3

6. 7. 8.

9. 10. 11. 12.

13.

14. 15. 16.

17.

18. 19. 20.

21. 22. 23. 24. 25.

placed in the sterilized tray, or on the inner surface of the tray cover (additional sterile area). Open the antiseptic bottle or package; and pour some amount of the solution in to the provided basin, or on gauze Should the gauze package become wet by antiseptic solution, then the preparation process has to repeated all over again Wear a sterile pair of gloves (Picture 125) Inspect the wound. Thoroughly observe the condition, stitches integration or newly developed skin flap, and drainage character. (if required, palpate the wound site with the non dominant part of the hands, which will not have any direct contact with the sterile materials Clean the wound with prescribed antiseptic solution or with physiologic saline solution. Hold the antiseptic dipped gauze with forceps. Use different gauze for each cleaning. Starts from the poorly contaminated to the heavily contaminated area, away from the incision line or the wound edge Use new gauze for wound drying or incision purpose. Clean based on step 17 description Apply antiseptic ointment; similar way to the cleaning technique. Do not apply the ointment on the drainage site. Apply dry sterile bandages on the incision or wound site: Apply one bandage each time (Picture 127) Apply thinly crafted gauze (4x4) or tefla as contact layer In case with drainage placement, apply 4x4 gauze on the drainage surrounding insertion site Apply the second layer of gauze Apply a thicker surgipad or ABD pad (blue line in the middle of the pad indicates outer surface) (Picture 128) Secure the bandage with tapes or Montgomery straps, or bandages Remove the gloves and dispose in the provided bin Dispose all used materials, then help the patient regain his/her comfortable position Wash hands Make some notes on wound, bandage and drainage observation and caring section. Record bandage replacement procedure along with patients responds.

CHANGING WET TO DRY BANDAGE SKILL

INTRODUCTION
Changing wet to dry bandage is a preference when dealing with debridement-required wound. The wet part of the bandage effectively cleans the wound from infection and necrotic tissue. Moist gauze will directly absorb wound debris and exudates. By similar to capillary action, the dry outer part of the bandage helps retrieve and distribute wound moisture into the bandage.

After completing this skill training, students are expected to have the ability of changing wet bandage

STUDY GOAL OBJECTIVE

STUDY OBJECTIVES
After completing this skill training, students are expected to be able in: 1 preparing materials and instruments needed in changing wet bandage 2. performing a correct and efficient procedure in changing wet bandage

MATERIALS AND INSTRUMENTS

1. a properly sterilized bandage set or the following materials: a pair of sterilized gloves a bandage set scissors and forceps some thinly crafted 4x4 gauze and gauze pads a basin for antiseptic and cleaning solution antiseptic ointment 2. 3. 4. 5. 6. 7. 8. antiseptic solution sterile physiologic saline solution or boiled water a pair of disposable gloves some tape (depends on the need) a biodegradable bin extra gauze and surgipad or ABD pad patients own robe

9. a water proof pad

ACTIVITIES DESCRIPTION
ACTIVITIES 1. Introduction 2. Role Play: asking and answering question TIME 5 minutes 30 minutes DESCRIPTION Introduction Speech 1. Arranging students seat 2. Two instructors (an instructor and coinstructor) giving examples on ho to change wet to dry bandage. One instructor acts as a doctor and the other as the patient. Students thoroughly observe. 3. Students are given opportunity to ask questions; instructors explain important aspects related to the topic 4. Students observe and ask questions; instructors replay. 1. Students are grouped in pairs. A mentor is required to observe every 2 pairs 2. In each role play, one student acts as a doctor who is changing the bandage and the other as the patient 3. Mentors supervise the performed procedures using check list 4. Every student should at least has one chance 1. Brain storming/discussion: Which part that is easy to perform?, what are the difficult parts?, What are the patients-act students feel? What can a doctor improve to make the patients more comfortable? 2. Instructors summarize by explaining the last question and giving necessary enlightenment

3. Role play with feed 100 minutes back

4. Brain storming and 15 minutes discussion

Total allocated time

150 minutes

CHANGING WET TO DRY BANDAGE SKILL

(Provided for the students) Mark every clinical step using the following scoring categories: 1. Need to be improved: Steps that are not correctly performed, un-organized chronologically, or for some missed/left over steps 2. Able: Steps that are performed correctly, chronologically based, but not efficiently conducted 3. Master: Steps that are performed correctly, chronologically based, and efficiently conducted NS (Not suitable): Steps that are unnecessarily conducted due to the situation

No. ACTIVITIES
1. 2. 3. 4. 5. Explain the procedure to the patient by describing the overall wound caring steps Organize all the needed instruments and materials on the table beside the patients bed (do not open yet) Get a disposable paper bag, fold the upper lid, and place it somewhere within your hands reach Close the assessment rooms door or curtain, or organize the curtain to surround the bed. Close all open windows Position the patient in a comfortable setting, place the patients bath robe supporting the wound. Instruct the patient not to touch the wound site or the sterilized instruments. Wash hands thoroughly Place a water proof pad underneath the patient Wear a pair of clean disposable gloves, remove any tapes, straps or bandages Remove the tape by peeling from side then carefully pulling it parallel to the skin toward the bandage (in case of any tape remnants, it can be cleaned with acetone) Using gloved hands or forceps, lift the bandage while at the same time maintain the used dirty surface out of the patients sight Should the bandage stuck to the wound, do not easy the peeling process by wetting. Slowly, peel the bandage by releasing the dryclotted exudates. Inform the possibility of pain and other uncomfortable feelings that might be induced by this procedure Observe character and drainage volume of the bandage Dispose the used bandage in the provided bin; avoid contaminating outer surface of the bin. Release the gloves, by start pulling from inside out. Dispose in the proper bin

SCORE 1 2 3

6. 7. 8. 9.

10. 11.

12. 13.

14.

15. 16.

17.

18.

19. 20. 21. 22. 23. 24. 25.

Uncover the sterilized bandage tray. Place the tray on the table beside patients bed. Bandages, scissors and forceps must always be placed in the sterilized tray, or on the inner surface of the tray cover (additional sterile area). Open the antiseptic bottle or package; and pour some amount of the solution in to the provided basin. And add some small holed-gauze. Wear a sterile pair of gloves (Picture 125) Inspect the wound. Thoroughly observe the condition, stitches integration or newly developed skin flap, and drainage character. (if required, palpate the wound site with the non dominant part of the hands, which will not have any direct contact with the sterile materials Clean the wound with prescribed antiseptic solution or with physiologic saline solution. Hold the antiseptic dipped gauze with forceps. Use different gauze for each cleaning. Starts from the poorly contaminated to the heavily contaminated area, away from the incision line or the wound edge Apply wet softly-crafted gauze exactly covering the wound site. For deeper wound, apply a bundle/package of gauze by folding the gauze edge with forceps. Slowly insert the gauze in to the wound until all wound surfaces have direct contact with the gauze. Apply dry sterile 4x4 gauze on top of the previous wet gauze Finally, apply a thicker surgipad or ABD pad Secure the bandage with tapes or Montgomery straps, or bandages Remove the gloves and dispose in the provided bin Dispose all used materials, then help the patient regain his/her comfortable position Wash hands Make some notes on wound, bandage and drainage observation and caring section. Record bandage replacement procedure along with patients responds.

Student Clinical Skills Manual Hand Washing

This manual is designed for students enrolled in first semester of academic year 2010-2011

DDT Team
dr. Rini Rachmawarni Bachtiar dr. Citra Rosyidah

Basic Diagnostic and Therapy Faculty of Medicine Hasanuddin University 2010

HAND WASHING CLINICAL SKILL MANUAL

Definition Hand washing is defined as a process to dispose all the waste and dust mechanically from both of hands using soap and water. From the point of view of infection prevention, hand washing is planned to prevent infection that spread throught the hands, by disposing waste and dust aand inhibits the growth of microorganisms. By hand washing, we will able to eliminate microorganisms which are not only by the contact to the patient and environment, but also but also in the deeper of the skin.

Indication 1. Routine hand washing: Aim After participating in this activitity, the students are able to perform routine and aseptic hand washingiswa harus sudah mampu melakukan cuci tangan rutin, pembuatan preparat tegak dari spec properly. Before beginning a routine work and before going home Before and after performing examination to a patient When go out of a toilet Before wearing gloves After releasing gloves

2. Aseptic hand washing: Before performing an invasive intervention Any possibility that the hand is contaminated

Learning equipment Flowing water Liquid soap Antiseptic solution Hand napkin or tissue

CLINICAL SKILL MANUAL

Routine and Aseptic Hand Washing
NO. Clinical Activity A. Routine Hand Washing 1. Release all of the rings, watches, and bracelets, and all of the things that attached in the hand. Keep them in a safety place. 2. Roll the arm of the shirt till the elbow. 3. Damp the hands with flowing water, then decrease the flow. 4. Pour 3 ml of liquid soap, and spread it over the hands 5. Rub both of the palms of the hands. 6. Rub the palm of the right hand with the dorsal part of the left hand, reciprocally. 7. Rub the fingers by inserting the fingers or right hand between the fingers of the left hand. Do it reciprocally. 8. Grub the thumb and the surrounding area. 9. Clean the nail by rubbing the nails of right hand to the palm of the left hand. Do it reciprocally. 10. Rub the circle of the hand reciprocally. 11. Rinse both of the hands with the flowing water, from the end part of the fingers to the elbow. The water may not flow to the end part of the fingers 12. Discontinue the flowing water without touching with the washed hand, by using elbow, tissue, or clean napkin. 13. Dry them with clear napkin or tissue. 1 Case 2 3

B. Aseptic Hand Washing 1. 2. 3. Perform routine hand washing Rinse both of the arm until the elbow by using the flowing water. Pour 3 mL of antiseptic to the palm of the hands, spread them until the circle of the hands, fingers, and between the fingers. 4. Dry them with the air.

Clinical Skill Lab Manual RADIOLOGY

This manual is designed for students enrolled in first semester of academic year 2010-2011

Team
dr. Rini Rachmawarni Bachtiar dr. Citra Rosyidah

Basic Diagnostic and Therapy Faculty of Medicine Hasanuddin University 2010

BASICS OF RADIOLOGY EXAMINATION

The radiology examination is one of the important examinations for diagnosing a disease, so we should properly know the appropriate examinations for each organ, the procedures, and the possible finding of the examinations.

General Aim: After participating in this activity, the students are able to differentiate the kinds of radiology examination and know the densities ithat occur in eash examination.

Spesific Aim: 1. Know the positions for radiology examinations.. 2. Able to identify the density in the x-ray. 3. Able to identify the density in the photo with contrast (IVP, Colon in Loop, MD photo, Oesophagography,Arteriography, dan Cor Analisis) 4. Able to identify the density in the mammography 5. Able to identify the density in the ultrasonography 6. Able to identify the density in the CT-scan 7. Able to identify the density in the MRI

Learning media and equipments 1. Manual skills lab for radiology 2. Light box 3. Radiology photo

Learning Methods 11. Demonstration using the CSL manual 12. Lectures 13. Discussion 14. Active participation in the lab Skill (simulation) 15. Evaluation using check list with a scoring system

CLINICAL ACTIVITY 1. Perform the examination for patient identites (according to the
registration number) :

Name Age Sex Date

2. Perform the examination for photo identities Photo number Photo marker as R L or D S

3. Set the photoes in the di light box. Consider that the patient is in

front of the examiner.

4. Determine the position of the photo: PA, AP, Lateral (R/L), Lateral

decubitus (R/L) atau oblique 5. Identify the kinds of the radiology examination : 6. X-ray (thorax, extremities,BNO dll) Colon in Loop MD Foto Oesofagography IVP Mammography USG CT Scan MRI

Identify the densities in each examination: Conventional photo( x-ray and contrast photo): Radioopaque Hiperradioopaque (metal density) Intermediate

The densities of ultrasonography: CT-Scan: Hiperdense Hipodense Isodenes Hiperechoic Hipoechoic Normoechoic (isoechoic)

MRI (T1 & T2): Hiperintense Hipointense Isointense

SKILL CHECKLIST INTRODUCTION TO THE BASICS OF RADIOLOGY Score No 1 2 3 4 5 6 7 Evaluated Frequency 0 Examine the identities of the patient and the photo marker Set the photo properly Determine the photo position Mention the kinds of radiology examinations (case) Identify the density of these examination (above) Mention the kinds of nonconventional radiology examination (case) Identify the density of these examination (above) 1 2

0: not demonstrated 1: Demonstrated, not completely address some points 2: Correctly demonstrated Overall score Score = ---------- X 100% = 38

Makassar, .................2010 Instructor

..........................................