Student Manual DDT

7/27/2019 Student Manual DDT

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Student Clinical Skills ManualBasic 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



Teamdr. Rini Rachmawarni Bachtiar

dr. Citra Rosyidah

Basic Diagnostic and Therapy

Faculty of Medicine

Hasanuddin University2010


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Anamnesis and Vital Sign

Examination SkillsDefinition

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 areoften 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


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3. Discussion

4. Active participation in the lab Skill (simulation)

5. Evaluation using check list with a scoring system


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Activities Description

I. Anamnesis

Activities Time Description

allocated

1. Introduction 5 Introduction

minutes

2. Role play demonstration 30 1. Arranging the students seats

minutes 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

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 1. Students are divided into pairs

minutes 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 / 15 1. Brain storming/Discussion: students are

Discussion minutes given the opportunity to raise any issues that


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they might have including an y 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


allocated

1. Introduction 5 minutes Introduction

2. Role play 30 1. Arranging the students seats

demonstration minutes 2. Instructor demonstrates an example on how

to record Vital Signs. This point includes

measuring Blood pressure, Pulse rate,

Respirator y 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






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assesor.





4. Brain 15 1. Brain storming/Discussion: students are

Storming/Discussion minutes given the opportunity to raise any issues that

they might have including any difficulties











minutes


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Student Clinical Skill Manual for Anamnesis and Physical Examination

Skills

A. Anamnesis Skill

NO Clinical steps Case

1. 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. Ensure comfort and privacy

5. Record the patients identity : name, age, address and occupation

6. Pronounce your words clearly using languange which the patient

can easily understand

7. Know and Use the patients name during interviews

8. Ask about the patients chief complaint and try to clarify it.

9. Obtain a history of present illness. Try to ask about all informationin a chronological manner up to day of interviews. Events related

to the development of the symptoms should be recorded .

10. Perform an anemnesis of the associated system

11. 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


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

measurements

A. Blood Pressure Measurements


1. Prepare the Sphygnomanometer and the Stethoscope

2. Obtain a concent from the patient or their family to perform the

examination

3. Stand at the patients right side

4. Explain the procedure

5. Ideally the patient should be either sitting or laying down

6. 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 arter ys

pulse again. This is a rough estimated of Systolic pressure

(palpatoir)

11. Place the sthetoscope over the brachial artery.

12. Inflate the cuff to 30 mmHg above the estimated systolic pressure

13. 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


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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


1. The patiens could be sitting or laying down

2. 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. Count the pulse for 30 seconds and multiply by 2

5. Record the rythim and the pulse quality

6. Write down the results

C. Respiratory rate


1. Ask the patients to undo their clothes

2. 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


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chest

5. Note any supporting respiratory muscle usages

6. Count breaths for the minimum of 1 minute

7 Record the rythim, frequency and any abnormal breathing

movements.

D. Temperature Measurements


1. 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. Allow 3-5 minutes before reading the results

4. Write down and report the results.

Basic Physical Examination (Inspection, Palpation,A.

Percussion and Auscultation )

A. Inspection: Observe and Record


1. Observe the body build of the patient e.g. athletic, cachetic or

overwight

2. Compare the ratio of the head size and body length

3. Observe the type of the movement

4. Record any obvious deformities or abnormalities

5. Note hair texture, skin, conjunctivaea, sclerae and nails

6. Apparent state of comfort or distress.e.g. anxious, depressed, shy,

moaning in pain etc

7 Additional signs

B. Palpation


1. Position your self at the patients right side


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2. Examined areas should be free from clothes

3. Make sure that your hands are not cold

4. 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 an y 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 seenthrough the patients expression.

C. Percussion


1. 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

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 Percuss as light as possible that can produce a clear sound


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D. Auscultation


1. Use a stethoscope with small hose (25-30cm)

2. 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.

Communication/Anamnesis Skills Check List

NO Competencies evaluated Score

0 1 2

Communication Skills Aspects

Ability to Build up a good doctor-patient relationship

1. Greeting the patient at the beginning of the anamnesis process

2. Showing a positive attitude to the patient

3. Offering the patient a seat facing yourself

4. Asking the patients identity : name,age,etc

5. Using a non-verbally language

Ability to collect the necessary information

6. Using a languange than can easily be understood by the patient

7. Avoid suggesting an interrogation

8. List any questions that need to be asked

9. Do the cross-check to ensure the validity of the repondens

answers

10. Allow the patient to tell their information

11. Be able to record all information clearly

Ability to maintain a comfortable atmosphere during anamnesis process

12. Be a good listener


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13. Show the empathy

14. Be friendly and Be able to ease up the patient

15. Be polite and dress up appropriately

16. Close the anamnesis session by acknowledging the patient

Medical Aspects

17. Identity: Name, Age, Address, Occupation are to be listed and

asked clearly

18. Ask the chief complaint

19. Ask any other complaints

0: not demonstrated 1: Demonstrated, not completely address some points 2: Correctlydemonstrated

Overall score

Score = ---------- X 100% = %

38

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

Instruktur

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

Vital Signs Examination Skills Check List


0 1 2

A. Blood Pressure Measurement

1. The examiner stands at the patients right side

2. Explain the procedure to the patient

3. 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


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the hose and placing the scale vertically

5. Using the stethoscope and making sure the bell is alread y opened

6. 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 arter ys

pulse again. Report this result as a rough estimated of Systolic

pressure (palpatoir)

9. Use the stethoscope and place the bell at the pulsation site

10. Inflate the cuff to 30 mmHF above the estimated systolic pressure

11. 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. Be able to record the blood pressure as systolic over diastolic

14. Undo the cuff and tidy it up

B. Pulse rate measurements

1. Position the patients arm in a relaxing way

16. Use the index and middle finger to palpate the radial artery

17. Count the pulse rate frequency for the minimum of 15 seconds

18. 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


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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


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

Instructor

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


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Student Clinical Skills Manual

Physical Examination Skills




dr. Citra Rosyidah

EditorDr. Baedah Madjid, Sp.Mk


Faculty of Medicine


2010


18/58

Physical Examination SkillsDefinition

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 percussionprocedure.

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


7. Lectures8. Discussion




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Physical Examination


allocated




to perform a comprehensive physical

examination covering all aspects of

Inspection, Palpation, Percussion and

Auscultation. 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













assesor.


20/58





4. Brain 15 1. Brain storming/Discussion: students are

Storming/Discussion minutes given the opportunity to raise any issues that

they might have including any difficulties











minutes

Student Clinical Skill Manual for Physical Examination Skills

A. Inspection: Observe and Record


1. Observe the body build of the patient e.g. athletic, cachetic or

overwight

2. Compare the ratio of the head size and body length

3. Observe the type of the movement

4. Record any obvious deformities or abnormalities

5. Note hair texture, skin, conjunctivaea, sclerae and nails

6. Apparent state of comfort or distress.e.g. anxious, depressed, shy,

moaning in pain etc


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7 Additional signs

B. Palpation


1. Position your self at the patients right side

2. Examined areas should be free from clothes

3. Make sure that your hands are not cold

4. 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 an y 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.

PercussionC. Percussion


1. 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


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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 Percuss as light as possible that can produce a clear sound

iii. Auscultation


1. Use a stethoscope with small hose (25-30cm)

2. 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.

Basic Physical Examination Skills Check List


0 1 2

1. The examiner stands at the patients right side

2. Ask the patients to lay down and undo their clothes

Inspection

3 Observe the general appearance of the patients

Palpation

4 Uncover the palpation site from any clothes

5 Try to warm up both hands before touching the patient

6. 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


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8 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 Perform the percussion using the middle finger of the right hand

11 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 Preparing the stethoscope

15 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)



Overall score

Score = ---------- X 100% = %

32

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

Instructor

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


24/58


Intramuscular Injection Skill



TeamProf. Dr. dr. Syakib Bakri, SpPD-KGH


EditorDr. Baedah Madjid, Sp.MK

dr. Jimmy R. Masykur, MM



25/58

Faculty of Medicine


2010


26/58

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 medicationdeep 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


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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


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allocated




to perform intramuscular, subcutaneous, and

intracutaneous injection using a mannequin.

Students are aske to observe








minutes 8. Each couple will perform the role play, oneperson 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. Brain 15 Brain storming/Discussion: students are given

Storming/Discussion minutes the opportunity to raise any issues that they

might have including any difficulties during


31/58

the sessions. Students are also allowed to

mention any good things that they have

experienced in the class.


minutes

Student Clinical Skill Manual for Intramuscular Injection

A. Intramuscular Injection


1. Preparing all instruments

2. Expalining the entire procedures to the patients

3. Arranging an appropriate position for the patient

4. Performing an aseptic handwashing

5. 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. Uncovering the injection sites from clothes

7. Sterilising the injection sites using alcohol swab. Discarding the


32/58

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. Massaging the injection site.

13. Tiding up the patient

14. Taking all equipments back to the instrument table to be cleaned

15. Performing an antiseptic hand washing

B. Subcutaneous Injection



2. Skin testing to asses for the likelihood of allergy

2. Explaining the entire procedures to the patients




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- 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




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. Inserting the needle with the bevel facing upwards

10. Inserting the needle at 45-degree angle

11. Slowly injecting the medication

12. Quickly removing the needle. apply an antiseptic swab to the

injection site




C. Intracutaneous Injection







- Lower Arm : The ventral side at 1/3 length of the lower

arm measured from the elbow (or about 2/3 measured from


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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.




skin to dry.

8. Stretching the skin with your left hand


10. Inserting the needle at 15-20-degree angle

11. Slowly injecting the medication, making the wheal under the skin

12. Quickly removing the needle. Pat dry, do not apply pressure and

acohol swab to the site.




Intramuscular, Subcutaneous, and Intracutaneous

Injection Check List

A. Intramuscular Injection


0 1 2


2. Expalining the entire procedures to the patients


35/58



5. Locating the injecti on sites :

- The right and left side of Gluteus Maxi mus 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)


7. Sterilising the injection sites using al cohol 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. Pul l back sli ghtly on the plunger to aspirate for blood. If no blood

appears, slowl y inject the medication into the muscle.

11. Covering the injection site immediately with the alcohol sponge, appl y

gently pressure. Quickly remove the needle.

12. Massaging the injection site.






Overall score

Score = ---------- X 100% = %

30

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

Instructor

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


36/58

B. Subcutaneous Injection



2. Skin testing to asses for the likelihood of allergy





- 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


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.


10. Inserting the needle at 45-degree angle

11. Slowly injecting the medication

12. Quickly removing the needle. apply an antiseptic swab to the

injection site






Overall score

Score = ---------- X 100% = %

30


37/58

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

Instructor

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

C. Intracutaneous Injection







- 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.




skin to dry.

8. Stretching the skin with your left hand


10. Inserting the needle at 15-20-degree angle

11. 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.


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Overall score

Score = ---------- X 100% = %

30

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

Instructor

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


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MANUAL BOOK OF

CHANGING BANDAGE SKILL

stGiven to 1 Semester Medical Students Of


Created By


Editor

Dr. Baedah Madjid, Sp.MK

BASIC DIAGNOSTIC AND THERAPY

MEDICAL FACULTY

HASANUDDIN UNIVERSITY

2010


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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


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4. some tape, plaster (depends on the need)

5. biodegradable bin

6. extra gauze and surgipad or ABD pad

7. patients own robe8. tape lifter (optional)

9. measuring tool

LEARNING METHOD

1. Skill demonstration based on the manual

2. Lecture

3. Discussion

4. Active participation in conducting the skill (simulation)

5. 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 TIME DESCRIPTION

1. Introduction 5 minutes Introduction Speech

2. Role Play: asking and 30 minutes 1. Arranging students seat


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answering question 2. Two instructors (an instructor and co-

instructor) giving examples on ho to

change 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.

3. Role play with feed 100 minutes 1. Students are grouped in pairs. A mentor

back 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 patient3. Mentors supervise the performed

procedures using check list

4. Ever y student should at least has one

chance

4. Brain storming and 15 minutes 1. Brain storming/discussion: Which part

discussion 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 thelast question and giving necessary

enlightenment

Total allocated time 150 minutes


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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 SCORE

1 2 3

1. Explain the procedure to the patient by describing the overall wound

caring steps

2. Organize all the needed instruments and materials on the table

beside the patients bed (do not open yet)

3. Get a disposable paper bag, fold the upper lid, and place it

somewhere within your hands reach

4. Close the assessment rooms door or curtain, or organize the curtainto surround the bed. Close all open windows

5. 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.

6. Wash hands thoroughly

7. Wear a pair of clean disposable gloves, remove any tapes, straps or

bandages

8. 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)

9. Using gloved hands or forceps, lift the bandage while at the sametime maintain the used dirty surface out of the patients sight

10. Should the bandage stuck to the wound, easy the peeling process

with sterile solution or water

11. Observe character and drainage volume of the bandage

12. 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

13. Uncover the sterilized bandage tray. Place the tray on the table

beside patients bed. Bandages, scissors and forceps must always be


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placed in the sterilized tray, or on the inner surf ace 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

gauze14. Should the gauze package become wet by antiseptic solution, then

the preparation process has to repeated all over again

15. Wear a sterile pair of gloves (Picture 125)

16. 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

17. 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 thepoorly contaminated to the heavily contaminated area, away from

the incision line or the wound edge

18. Use new gauze for wound drying or incision purpose. Clean based

on step 17 description

19. Apply antiseptic ointment; similar way to the cleaning technique.

Do not apply the ointment on the drainage site.

20. 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)

21. Secure the bandage with tapes or Montgomery straps, or bandages

22. Remove the gloves and dispose in the provided bin

23. Dispose all used materials, then help the patient regain his/her

comfortable position

24. Wash hands

25. Make some notes on wound, bandage and drainage observation and

caring section. Record bandage replacement procedure along with

patients responds.


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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.

STUDY GOALOBJECTIVE

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

wet bandage

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. antiseptic solution

3. sterile physiologic saline solution or boiled water

4. a pair of disposable gloves

5. some tape (depends on the need)

6. a biodegradable bin

7. extra gauze and surgipad or ABD pad

8. patients own robe


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9. a water proof pad

ACTIVITIES DESCRIPTION

ACTIVITIES TIME DESCRIPTION

1. Introduction 5 minutes Introduction Speech

2. Role Play: asking and 30 minutes 1. Arranging students seat

answering question 2. Two instructors (an instructor and co-

instructor) 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.

3. Role play with feed 100 minutes 1. Students are grouped in pairs. A mentor

back 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. Ever y student should at least has one

chance

4. Brain storming and 15 minutes 1. Brain storming/discussion: Which part

discussion 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

Total allocated time 150 minutes


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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 SCORE

1 2 3

1. Explain the procedure to the patient by describing the overall wound

caring steps

2. Organize all the needed instruments and materials on the table

beside the patients bed (do not open yet)

3. Get a disposable paper bag, fold the upper lid, and place it

somewhere within your hands reach

4. Close the assessment rooms door or curtain, or organize the curtain

to surround the bed. Close all open windows5. 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.

6. Wash hands thoroughly

7. Place a water proof pad underneath the patient

8. Wear a pair of clean disposable gloves, remove any tapes, straps or

bandages

9. 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)

10. Using gloved hands or forceps, lift the bandage while at the same

time maintain the used dirty surface out of the patients sight

11. Should the bandage stuck to the wound, do not easy the peeling

process by wetting. Slowly, peel the bandage by releasing the dry-

clotted exudates. Inform the possibility of pain and other

uncomfortable feelings that might be induced by this procedure

12. Observe character and drainage volume of the bandage

13. 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


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14. 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 surf ace of the tray cover

(additional sterile area). Open the antiseptic bottle or package; andpour some amount of the solution in to the provided basin. And add

some small holed-gauze.

15. Wear a sterile pair of gloves (Picture 125)

16. 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

17. 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 thepoorly contaminated to the heavily contaminated area, away from

the incision line or the wound edge

18. 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.

19. Apply dry sterile 4x4 gauze on top of the previous wet gauze

20. Finally, apply a thicker surgipad or ABD pad

21. Secure the bandage with tapes or Montgomery straps, or bandages

22. Remove the gloves and dispose in the provided bin

23. Dispose all used materials, then help the patient regain his/hercomfortable position

24. Wash hands

25. Make some notes on wound, bandage and drainage observation and

caring section. Record bandage replacement procedure along with

patients responds.


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Hand Washing

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

2010-2011

DDT Teamdr. Rini Rachmawarni Bachtiar

dr. Citra Rosyidah


Faculty of Medicine


2010


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HAND WASHING

CLINICAL SKILL MANUALDefinition

Hand washing is defined as a process to dispose all the waste and dust mechanicall y from

both of hands using soap and water.

From the point of view of infect ion 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:

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

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 preparattegak dari spec properly.

Learning equipment

- Flowing water

- Liquid soap

- Antiseptic solution

- Hand napkin or tissue


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CLINICAL SKILL MANUAL

Routine and Aseptic Hand Washing

NO. Clinical Activity Case

A. Routine Hand Washing 1 2 3

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 partof 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.


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B. Aseptic Hand Washing 1 2 3

1. Perform routine hand washing

2. Rinse both of the arm until the elbow by using the flowing water.

3. 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.


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Clinical Skill Lab Manual

RADIOLOGY




dr. Citra Rosyidah


Faculty of Medicine


2010


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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


12. Lectures

13. Discussion




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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

Set the photoes in the di light box. Consider that the patient is in3.

front of the examiner.

PA, AP, Lateral (R/L), Lateral4. Determine the position of the photo:

decubitus (R/L) atau oblique

5. Identify the kinds of the radiology examination :

- X-ray (thorax, extremities,BNO dll)

- Colon in Loop

- MD

- Foto Oesofagography

- IVP

- Mammography

- USG

- CT Scan

- MRI6. Identif y the densities in each examination:

Conventional photo( x-ray and contrast photo):

- Radioopaque

- Hiperradioopaque (metal density)

- Intermediate


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The densities of ultrasonography:

- Hiperechoic

- Hipoechoic

- Normoechoic (isoechoic)

CT-Scan:

- Hiperdense

- Hipodense

- Isodenes

MRI (T1 & T2):

- Hiperintense

- Hipointense

- Isointense


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SKILL CHECKLIST

INTRODUCTION TO THE BASICS OF RADIOLOGY

Score

No Evaluated Frequency

0 1 2

1 Examine the identities of the patient and the photo marker

2 Set the photo properly

3 Determine the photo position

4 Mention the kinds of radiology examinations (case)

5 Identify the density of these examination (above)

6 Mention the kinds of nonconventional radiology examination

(case)

7 Identify the density of these examination (above)

0: not demonstrated 1: Demonstrated, not completely address some points 2: Correctly

demonstrated

Overall score

Score = ---------- X 100% = %

38

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

Instructor

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


58/58

Student Manual DDT

Documents

Transcript of Student Manual DDT