Peak Flow

WIPER

Hi, my name is _______, I'm a doctor here. It's very nice to meet you.

Find the Problem
I understand you have symptoms that might suggest asthma. In order to rule help us to rule in or rule out the diagnosis we do a test called the Peak Flow test. Have you had this test before? Are you happy with your understanding of asthma? Are you happy with doing this test?

This is a peak flow meter. It's just a simple tube that measures how well the air flows out of your lungs, and whether you have any difficulty pushing it out. If you have asthma this shows as being less than normal for a person of your height, sex and age.

Demonstrate
I'll show you how to use it, to help you understand how to do it.
First we reset the pointer to make sure that it's one zero.
We stand up for the test. We put a fresh mouthpiece into the meter.
Breathe in fully deeply, as much as you can. Hold the meter level in front of you making sure your fingers don't cover over the pointer. Make a tight seal with your mouth on the mouthpiece. Blow as hard as you can and as fast as you can, like blowing out the candles on a cake. We're not concerned about how long or how much you blow out. Okay? Like so.

We'll do the test 3 times, and take the highest reading as your score.

General Advice

We record like thus and if we record it in a diary we can keep of track of how your breathing is throughout the day. Asthma tends to vary quite characteristically through the day, and can help us make a diagnosis and see how you are doing on medication.

The best time to take a peak flow are first thing in the morning, and before you go to bed. Also take it when you are experiencing symptoms such as coughing or wheezing.

Repeat Relevant Parts

Would you like to have a go?

ICE
Do you have any questions, concerns or expectations?

We'll need to follow-up to see how you've coped with the medication and if your symptoms have improved.


What factors affect PEFR?
- height
- age
- sex
- acute and chronic resp disease
- smoking

Using Inhalers

Hi, my name is______
I'm a final year student.
How are you today?

Find the Problem
Okay, from your symptoms and peak flow recording we believe you might have asthma. What do you know about asthma? How do you feel about it?

Asthma is a condition of the lung where you can get difficulty breathing. We find sensitive airways, that react by narrowing when they become irritated, making it difficult for air to move in or out. It's this narrowing that causes the chest tightness and wheezing that you've been experienced.

We can do something to help with these symptoms. To help with this condition we can prescribe you salbutamol, which is given in a blue inhaler. It works by opening up the airways so air can move more freely. By being given in an inhaler we can deliver the medicine exactly where it needs to be. Is that okay?

What do you know about inhalers? Have you ever used one before?

Demonstrate
Okay, I'm going to show you how to use the inhaler, because technique is very important in ensuring you get the most out of it and to help your lungs as much as possible. Use it when you art feeling wheezy or tightness of the chest.
First we shake the inhaler with the cap on to mix the medicine properly. We remove the cap from the mouthpiece and hold the inhaler like so, between your thumb and index finger, with your index finger on the canister.
Take a big breath in and fully breathe out. Put the mouthpiece in your mouth. At the same time as you breath in push down on the top of the inhaler. Hold your breath for ten seconds afterwards.

Repeat if necessary after 1 minutes.
Gargle/rinse out your mouth if you are using a steroid inhaler.

Mild side-effects of salbutamol include fast heart rate, shakiness and headaches. If they are worrying you should again come back to us.
Salbutamol can be taken 2 puffs as needed, up to 4 times a day, as the maximum. If you need more than that you should return to us, as we might need to try something else, perhaps combining it with another inhaler.

Does that sound okay to you?

Repeat Relevant Parts
Can you show me know how you would use it?
Can you tell me when should you use it?

General Advice
There may be some leaflets I can give you to help your understanding, and to take home with you.

ICE
Do you have any questions, ideas, concerns, expectations?

We'll review you in a while to see how you are doing with it, and if your symptoms have improved.
Does that sound okay?

Thank you!

Using A Spacer

Hello, my name is....
I'm one of the doctors here.
How are you feeling today?

Find the problem
I understand that you've been having some problems in using an inhaler - tell me a bit about that.
How are your symptoms? You understand that it's important to use - for your asthma? Can you show me you trying to use it?

It's really important that you're able to take your inhaler if you need it but I can see that you're having problems with it. This isn't an uncommon issue for people, it can be fiddly, so there is a device we can use to help you called a spacer. The spacer makes it easier to deliver the medicine to your lungs.

Demonstrate
I'll demonstrate what to do...

The spacer is made up of two parts which slot together easily.

On one end you can attach the inhaler, and on the other side you have the mouthpiece
Shake your inhaler well and attach it to the far end
Release 1 puff into the spacer
Don't worry the medicine stays inside
Make tight with your mouth on the mouthpiece
Breathe deeply in and hold for 10s
Breathe out slowly all the while keeping your mouth attached

Wait 30s before next dose
Do this for three or four times
This should be enough to get the medicine into your lungs

Repeat Relevant Parts
Can you show me how you would use this?

General Advice
In caring for the spacer wash it once a week warm water, and leave it to drip dry
Don't use any detergents as this can cause static inside the spacer, which makes it less effective
Store the device in its box in a cool area to prevent scratches
We should relace the device every 6-12months of use to make sure you have optimum delivery of the drugs

ICE
How does that sound?
Do you have any ideas? concerns? expectations?

We'll follow you up to see how you're doing

Thank you!

Cannulation

WIPERNA

Hello my name is _______
I'm a __________
How are you doing?

Is it alright if I put a cannula in your arm? Have you ever had one before?
It's a small plastic sterile tube that we insert into a vein, that acts like a port, that we leave there.
We use it to transport the fluids through.it's not painful, but you probably feel a small scratch. Do you have a problem with needles? Are you fine with me to go ahead?

Checks:
Nameband/dob/name/hospital number

I'm just going to get my equipment.

Equipment
Tray

Gloves

Tourniquet

Alco swab

Cannula (16G grey - 18G green - 20G pink)

10ml syringe

Saline 0.9%
Green needle

Bung
Tegiderm
Sharps bin

Prepare Equipment
Clean tray inside & out
Wash hands
Open cannula
Open bung
Draw up saline

CT/WH/Eq/Flu

Prepare Patient
Roll up sleeve
Pt comfortable?
Tourniquet (clench fist - promote venous filling)
Select vein and direction (distal to proximal)
Clean area with swab

Put on gloves/alcohol gel gloves/change gloves

Tq/V/Alc/W+G

Cannula Bit
Stabilise vein
'sharp scratch'!!!
Cannula - shallow angle 25-35
Flashback?
Lower cannula
Advance by 2mm
Withdraw needle slightly watch blood track along cannula
Advance plastic sheathing
Take off tourniquet
Press over vein above cannula
Remove needle
Bung over cannula

SS!/25-35/FBl/AdvPl/xTq/OutN/Bung/Flush

Secure
Needle into sharps bin
Apply tegiderm over cannula
Flush!

Sec/Sharps/Saline

Finishing Off
Thank pt, make sure they're comfortable

Document:
Cannula gauge
Location
Operator
Site

Dispose waste

Resite immed if signs of inf/phlebitis
Otherwise ev. 72hrs

T/Doc/Disp/Resite

MSK Cases

X-ray

Normal

OA
- narrow joint space
- subchondral sclerosis
- subchondral cysts
- osteophytes

RA
- soft-tissue swelling
- ill-defined marginal erosions
- loss of joint space
- periarticular osteoporosis

Gout
- assymetrical soft tissue swelling
- well-defined periarticular erosions
- bony 'hooks'

MSK Investigations

Ix

Bloods
ESR
CRP
Serum uric
Autoantibodies
Blood cultures

Synovial Fluid Aspirate

Imaging
XR
MRI
CT
Bone Scans
DEXA

Spine Examination - Revision Card

WIPER

... Standing...
Look
Sides, behind - asymmetry, wasting, scoliosis, lordosis, kyphosis

Feel
Spinal processes
Paraspinal muscles

Move
Lumbar
- Flexion - fingers in spinous processes
- Extension
- Lateral flexion - arm down sides
Cervical
- Flexion, extension, lateral flexion, rotation

... Sit on couch, arms crossed...
Thoracic
- rotation

... Lying on couch...
Straight leg raise
Dorsiflexion of foot, and big toe
Limb reflexes