BASIC PATIENT ASSESSMENTS

Station 1: HEART RATE AND RESPIRATORY RATE

Mrs Bradbury has pelvic pain and has just been transferred to your ward from the Emergency Department. Please record Mrs Bradbury's heart rate and respiratory rate.

Objectives

• Measuring and interpreting the radial pulse

• Measuring and interpreting the respiratory rate

General Advice

• Always wash your hands before and after patient contact and be sure to obtain consent before starting the procedure

• At the end of the procedure, discuss your findings with the patient and record them appropriately in the notes

Measuring Heart Rate

1. Check that the patient is in a comfortable position with the arm supported and the lower arm exposed

2. Place your index and middle finger pads over the lateral aspect of the wrist at the site of the radial pulse (Fig 1.1)

3. Once identified, assess the rate and rhythm of the radial pulse for 1 minute (in practice, this is usually assessed over 15 seconds and multiplied by four)

Measuring Respiratory Rate

1. Check that the patient is in a comfortable position with the chest exposed

2. Watch the chest for movement; if this is subtle, explain to the patient that you are going to place your hand on his/her chest to feel for chest wall movement

3. Assess the respiratory rate and regularity for 1 minute

4. Document your findings in the patient notes

Questions and Answers for Candidate

What are the commonest physiological causes of bradycardia?

• Athletes

• Sleep

Name two pathological causes of bradycardia

• Pharmacological: any negative chronotrope, e.g. beta (ß) blockers

• Acute myocardial infarction (particularly an inferior myocardial infarction leading to a heart block)

• Cushing's reflex: a systemic reaction to raised intracranial pressure (bradycardia, erratic breathing and widened pulse pressure)

• Hypoxia

• Hypothermia

• Hypothyroidism

Name three causes of tachypnoea

• Physiological: exercise, anxiety, excitement

• Circulatory shock: septic shock, anaphylactic shock, hypovolemic shock

• Lung pathology: pneumonia, asthma, pneumothorax

• Other pathology: heart failure, anaemia, myocardial infarction

Additional Questions to Consider

1. What medication can cause tachycardia?

2. What medication can cause bradycardia?

3. How would you assess a patient with tachypnoea?

4. Why is it important to take the heart rate manually rather than relying on a machine?

5. What signs of respiratory distress might you see in a patient with tachypnoea?

Station 2: OXYGEN SATURATION

Mr Michael has just walked back from the toilet and now feels breathless. Please record Mr Michael's oxygen saturation.

Objectives

• Measuring and interpreting oxygen saturation

General Advice

• Always wash your hands before and after patient contact and obtain consent before starting the procedure

• At the end of the procedure, discuss your findings with the patient and record them appropriately in the notes

Measuring Oxygen Saturation

1. Ensure that the patient is comfortable and select a forefinger that is clean and without nail polish (Fig 1.2)

2. Correctly position the oxygen saturation probe onto the end of the forefinger and ensure the machine is turned on

3. Read off the oxygen saturation

4. Note whether the patient is breathing room air or is receiving supplementary oxygen

Questions and Answers for Candidate

Where can an oxygen probe be placed?

• Finger

• Toe

• Ear lobe

Name two causes of hypoxaemia

• Low concentration of inspired oxygen, e.g. breathing at high altitude

• Right to left shunting (blood bypasses the lungs), e.g. Eisenmenger's syndrome

• Ventilation-perfusion mismatch, e.g. pneumonia, pulmonary oedema

• Diffusion impairment, e.g. interstitial lung disease

• Hypoventilation, e.g. brain stem tumour, intracerebral haemorrhage, Guillain-Barré syndrome

Additional Questions to Consider

1. How would you assess a patient found to be hypoxaemic?

2. What other investigations would you undertake in a patient found to be hypoxaemic?

3. What are the different ways you might deliver oxygen to a patient?

4. When would you perform an arterial blood gas in a patient with low oxygen saturations?

5. What is the normal range of oxygen saturations, and how would you determine a patient's oxygen saturation target?

Station 3: BLOOD PRESSURE

Mrs Space has recently stopped her anti-hypertensive medication. Please check her blood pressure (BP).

Objectives

• Measuring and interpreting BP using manual and electronic techniques

General Advice

• Always wash your hands before and after patient contact and obtain valid consent before performing the procedure

• At the end of the procedure, discuss your findings with the patient and record them appropriately in the notes

• Ensure that the patient is comfortable and adequately expose the right arm

• Correctly position the arm so it is supported. The point at which you will measure the BP in the arm should be approximately level with the heart

• Select an appropriately sized cuff

For the Manual Technique

1. Correctly place the BP cuff on the patient's arm (Fig 1.3)

2. Locate the brachial artery (usually found at the medial border of the antecubital fossa, medial to the biceps tendon)

3. Inflate the cuff until the pulse becomes impalpable

4. Note the pressure on the manometer

5. Deflate the cuff and place the stethoscope over the brachial artery (Fig 1.4)

6. Re-inflate the cuff to a pressure 20 millimeters of mercury (mmHg) higher than that noted previously

7. Deflate the cuff by 2mmHg per second

8. Note the pressure at which you hear the first heart sounds (systolic blood pressure)

9. Continue to deflate the cuff and note the pressure at which the heart sounds completely disappear (diastolic blood pressure)

For an Automatic Electronic Device

1. Correctly place the blood pressure cuff on the patient's arm

2. Switch on the blood pressure device and press the start button

3. Note the blood pressure reading and document your findings on the patient's observation chart

Questions and Answers for Candidate

What can make a BP...