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Clinical Procedures - Assisting a Patient to Roll Whilst Lying
Equipment
• 1 (or 2) members of staff.
Procedure
• Ensure the bed/trolley is at waist height and that the brakes are on, to avoid staff injuries
• > If the manoeuvre is being carried out with 1 member of staff, always roll the patient towards you:
• D If 2 members of staff are available, they should stand either side of the bed/trolley
• Ensure adequate explanation is given to the patient
• Ensure the patient's head is facing the way the patient will be moving
• Place the patient's distant arm across their chest, and flex their distant hip and knee
• Place an open-palmed hand on the patient's shoulder, and your other hand on the patient's hip or knee:
• Staff may find it more comfortable to put one of their knees on the bed, to avoid stretching or bending
• On the command 'Ready, Steady, Roll', move back slightly, aiding the patient to roll towards you
• Once the patient is on their side, they can be made comfortable with pillows
• It is also important to ensure the patient is secure, by making use of bedrails.
Procedure Tips
• Before carrying out the procedure ensure the area around the bed trolley is clear of any obstacles
• Ensure there is adequate space on the bed/trolley for the patient to roll onto
• It is important to have the correct number of staff available to carry out the manoeuvre
• Do not rush and leave enough time to explain the procedure to the patient and other members of staff involved
• It is important to have assessed the patient prior to carrying out this technique, to discover any contraindications to the patient lying on their side (e.g. problems with the patient's head and neck control, or any potential difficulties such as the patient's size):
• More members of staff will be required for larger patients.
Risks
• Be aware of any attachments that need to move with the patient, e.g. drains or catheters, to avoid disconnection during the procedure.
Documentation
• All patients should have assessments carried out within 24 hours of admission. Care plan to be maintained/consulted as appropriate.
• Any issues or problems with manoeuvre should be documented in the notes.
Equipment
• 1 (or 2) members of staff.
Procedure
• Ensure the bed/trolley is at waist height and that the brakes are on, to avoid staff injuries
• > If the manoeuvre is being carried out with 1 member of staff, always roll the patient towards you:
• D If 2 members of staff are available, they should stand either side of the bed/trolley
• Ensure adequate explanation is given to the patient
• Ensure the patient's head is facing the way the patient will be moving
• Place the patient's distant arm across their chest, and flex their distant hip and knee
• Place an open-palmed hand on the patient's shoulder, and your other hand on the patient's hip or knee:
• Staff may find it more comfortable to put one of their knees on the bed, to avoid stretching or bending
• On the command 'Ready, Steady, Roll', move back slightly, aiding the patient to roll towards you
• Once the patient is on their side, they can be made comfortable with pillows
• It is also important to ensure the patient is secure, by making use of bedrails.
Procedure Tips
• Before carrying out the procedure ensure the area around the bed trolley is clear of any obstacles
• Ensure there is adequate space on the bed/trolley for the patient to roll onto
• It is important to have the correct number of staff available to carry out the manoeuvre
• Do not rush and leave enough time to explain the procedure to the patient and other members of staff involved
• It is important to have assessed the patient prior to carrying out this technique, to discover any contraindications to the patient lying on their side (e.g. problems with the patient's head and neck control, or any potential difficulties such as the patient's size):
• More members of staff will be required for larger patients.
Risks
• Be aware of any attachments that need to move with the patient, e.g. drains or catheters, to avoid disconnection during the procedure.
Documentation
• All patients should have assessments carried out within 24 hours of admission. Care plan to be maintained/consulted as appropriate.
• Any issues or problems with manoeuvre should be documented in the notes.
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Clinical Procedures - Transferring a Patient Using a Log Roll
Use this technique to transfer patients in whom a cervical spine injury is suspected or confirmed. The following assumes that the patient's neck is immobilized in a brace or blocks.
Equipment
• Minimum 5 members of staff
• Patient transfer board or 'Patslide®
Procedure
• D The most senior member of the team should take charge of the patient's head and neck and initiate commands
• Ensure adequate explanation is given to the patient, and to all members of staff involved
• Place destination bed/trolley alongside origin bed/trolley
• Check bed is at waist height to prevent staff injuries
• 1 member of staff should position themselves at the head-end of the patient; the other 3 should be spread alongside the patient, at the origin side. The final member of staff should be at the destination side
• Check brakes on bed secure
• The person responsible for the patient's head should have one hand either side of the patient's head, supporting the patient's shoulders
• The person responsible for the patient's upper body should have one hand on the patient's distant shoulder, and the other on the lateral aspect of the patient's chest
• The person responsible for the patient's pelvis should have one hand on the lateral aspect of the patient's pelvi and the other under the patient's distant thigh
• The person responsible for the patient's lower legs should have both hands under the distant calf
• On the command 'Ready, Steady, Roll' the 3 members of staff at the side of the patient will slowly move backwards with straight arms, rolling the patient towards them
• The member of staff responsible for the patient's head will move sideways, ensuring alignment of the patients spine is preserved and that the neck is not rotated at all
• Staff at the bed/trolley onto which patient is to be transferred, put transfer board onto patient's bed/trolley
• On the command 'Ready, Steady, Roll' the 4 members of staff at the patient roll the patient back flat, keeping the neck straight
• 1 member of staff should now move around the bed such that there are 2 on each side and 1 at the head.
• On command of 'Ready, Steady, Move'
• Handlers should move the patient gently across on transfer board keeping the head and neck immobilized.
Procedures Tips
• Ensure sufficient time available to safely complete the manoeuvre
• Check bed area for any furniture/equipment that could be moved
• Staff should wear suitable (preferably low-heel) footwear and non-restrictive clothing
• D It is vital to have the correct amount of staff available
Do not rush, and leave enough time to explain the procedure to all present
• D It is essential that the patient's body be kept in alignment, and the manoeuvre is carried out in one smooth and controlled movement.
Risks
• Potential injuries to patient or staff arising from trailing leads, drains, etc.
• Disconnection of equipment during manoeuvre:
• Watch out for IV pumps, syringe drivers, catheters.
Documentation
• All patients should have assessments carried out within 24 hours of admission
• Care plan should be maintained/consulted as appropriate
• If there are any issues with equipment or manoeuvre, advise nurse in charge, document in notes, and complete an appropriate incident form.
Use this technique to transfer patients in whom a cervical spine injury is suspected or confirmed. The following assumes that the patient's neck is immobilized in a brace or blocks.
Equipment
• Minimum 5 members of staff
• Patient transfer board or 'Patslide®
Procedure
• D The most senior member of the team should take charge of the patient's head and neck and initiate commands
• Ensure adequate explanation is given to the patient, and to all members of staff involved
• Place destination bed/trolley alongside origin bed/trolley
• Check bed is at waist height to prevent staff injuries
• 1 member of staff should position themselves at the head-end of the patient; the other 3 should be spread alongside the patient, at the origin side. The final member of staff should be at the destination side
• Check brakes on bed secure
• The person responsible for the patient's head should have one hand either side of the patient's head, supporting the patient's shoulders
• The person responsible for the patient's upper body should have one hand on the patient's distant shoulder, and the other on the lateral aspect of the patient's chest
• The person responsible for the patient's pelvis should have one hand on the lateral aspect of the patient's pelvi and the other under the patient's distant thigh
• The person responsible for the patient's lower legs should have both hands under the distant calf
• On the command 'Ready, Steady, Roll' the 3 members of staff at the side of the patient will slowly move backwards with straight arms, rolling the patient towards them
• The member of staff responsible for the patient's head will move sideways, ensuring alignment of the patients spine is preserved and that the neck is not rotated at all
• Staff at the bed/trolley onto which patient is to be transferred, put transfer board onto patient's bed/trolley
• On the command 'Ready, Steady, Roll' the 4 members of staff at the patient roll the patient back flat, keeping the neck straight
• 1 member of staff should now move around the bed such that there are 2 on each side and 1 at the head.
• On command of 'Ready, Steady, Move'
• Handlers should move the patient gently across on transfer board keeping the head and neck immobilized.
Procedures Tips
• Ensure sufficient time available to safely complete the manoeuvre
• Check bed area for any furniture/equipment that could be moved
• Staff should wear suitable (preferably low-heel) footwear and non-restrictive clothing
• D It is vital to have the correct amount of staff available
Do not rush, and leave enough time to explain the procedure to all present
• D It is essential that the patient's body be kept in alignment, and the manoeuvre is carried out in one smooth and controlled movement.
Risks
• Potential injuries to patient or staff arising from trailing leads, drains, etc.
• Disconnection of equipment during manoeuvre:
• Watch out for IV pumps, syringe drivers, catheters.
Documentation
• All patients should have assessments carried out within 24 hours of admission
• Care plan should be maintained/consulted as appropriate
• If there are any issues with equipment or manoeuvre, advise nurse in charge, document in notes, and complete an appropriate incident form.
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Clinical Procedures - Aiding a Falling Patient
• It is essential that if a patient falls, the member of staff must not try to catch the patient, but must allow them to fall. as there is no safe method for this situation
• Allowing the patient to fall may feel contrary to the staff's natural instincts to help but trying to catch a patient will only result in injury to staff
• Instead, every attempt must be made to reduce injury to the patient (e.g. moving objects out of the patient's way if possible).
Procedure
Falling in a forward direction
• If a member of staff is walking with a patient as they fall in a forward direction, the member of staff must allow the patient to fall.
Falling towards a member of staff
• If the fall is towards the member of staff, it may be possible to control the patient's movements safely to minimize injury to them
• The member of staff should move close to the patient, standing directly behind them with their leg closest to the patient flexed. Then they should gently guide the patient's body down their flexed leg to the floor.
Procedure Tips
• The risk of falling should be minimized by only performing tasks appropriate to the patient's ability (e.g. only allow patients to walk if they are fully mobile)
• Use equipment to reduce the risk of falls i.e. Zimmer frames or walking sticks
• A patient falling is an unpredictable and sudden event. However, the member of staff should take every care to maintain a good posture at all times, avoiding twisting or stretching
• D If present when a patient falls, the member of staff should immediately call for assistance, to ensure an adequate number of staff are present if the situation turns into an emergency.
Documentation
• All patients should have assessments carried out within 24 hours of admission and placed in their file
• Any fall or issues should be documented in the patient's notes to ensure other ward staff are aware of problems.
• It is essential that if a patient falls, the member of staff must not try to catch the patient, but must allow them to fall. as there is no safe method for this situation
• Allowing the patient to fall may feel contrary to the staff's natural instincts to help but trying to catch a patient will only result in injury to staff
• Instead, every attempt must be made to reduce injury to the patient (e.g. moving objects out of the patient's way if possible).
Procedure
Falling in a forward direction
• If a member of staff is walking with a patient as they fall in a forward direction, the member of staff must allow the patient to fall.
Falling towards a member of staff
• If the fall is towards the member of staff, it may be possible to control the patient's movements safely to minimize injury to them
• The member of staff should move close to the patient, standing directly behind them with their leg closest to the patient flexed. Then they should gently guide the patient's body down their flexed leg to the floor.
Procedure Tips
• The risk of falling should be minimized by only performing tasks appropriate to the patient's ability (e.g. only allow patients to walk if they are fully mobile)
• Use equipment to reduce the risk of falls i.e. Zimmer frames or walking sticks
• A patient falling is an unpredictable and sudden event. However, the member of staff should take every care to maintain a good posture at all times, avoiding twisting or stretching
• D If present when a patient falls, the member of staff should immediately call for assistance, to ensure an adequate number of staff are present if the situation turns into an emergency.
Documentation
• All patients should have assessments carried out within 24 hours of admission and placed in their file
• Any fall or issues should be documented in the patient's notes to ensure other ward staff are aware of problems.
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Clinical Procedures - Aiding a Fallen Patient
• It is important to assess the fallen patient immediately, to establish the cause for the fall and any immediate consequences (e.g. fainting, fractures, or cardiac arrest) so that staff can respond to the situation accordingly.
Equipment
• Minimum of 2 members of staff
• Other equipment dependent on circumstances:
• 2 chairs, trolley, slide sheets, hoist with appropriate sling.
Procedure
If patient is cooperative
• Instructions may be given to help the patient up from the floor. Ask the patient to follow this routine:
• Roll onto their side.
• Push up on their hands until they are in a sitting position..
• Bend their knees up and move onto all fours...
• Place their hands onto the seat of a chair for balance...
• Move one leg forward, so they are in a half kneeling position..
• At this point, the patient should be able to push with their hands to stand up, and sit on a chair placed behind them
• If needed, the patient can now be hoisted onto a trolley for further assessment.
If patient is uncooperative
• A hoist should be used.
If fallen in a confined space
• Place a slide sheet under their body
• With a minimum of 2 members of staff, the patient can then be slid on the floor a short distance to allow better access to assist the patient:
• It is essential that the members of staff maintain a good posture at all times during this procedure.
Procedure Tips
It is essential to establish the cause of the fall and act accordingly
• D It is important that, as the patient is moving up from the floor, their condition is continuously monitored:
If the patient has fainted, they may be at risk of falling again
• It is important to allow the patient time to carry out the manoeuvre, as this will reduce the amount of manual assistance required from staff
• It is extremely important that the patient is NEVER LIFTED
• Lifting a patient is hazardous and may result in staff injury.
Documentation
• All patients should have assessments carried out within 24 hours of admission and placed in their file
• Any fall should be documented in the patient's notes to ensure other ward staff are aware of any problems.
• It is important to assess the fallen patient immediately, to establish the cause for the fall and any immediate consequences (e.g. fainting, fractures, or cardiac arrest) so that staff can respond to the situation accordingly.
Equipment
• Minimum of 2 members of staff
• Other equipment dependent on circumstances:
• 2 chairs, trolley, slide sheets, hoist with appropriate sling.
Procedure
If patient is cooperative
• Instructions may be given to help the patient up from the floor. Ask the patient to follow this routine:
• Roll onto their side.
• Push up on their hands until they are in a sitting position..
• Bend their knees up and move onto all fours...
• Place their hands onto the seat of a chair for balance...
• Move one leg forward, so they are in a half kneeling position..
• At this point, the patient should be able to push with their hands to stand up, and sit on a chair placed behind them
• If needed, the patient can now be hoisted onto a trolley for further assessment.
If patient is uncooperative
• A hoist should be used.
If fallen in a confined space
• Place a slide sheet under their body
• With a minimum of 2 members of staff, the patient can then be slid on the floor a short distance to allow better access to assist the patient:
• It is essential that the members of staff maintain a good posture at all times during this procedure.
Procedure Tips
It is essential to establish the cause of the fall and act accordingly
• D It is important that, as the patient is moving up from the floor, their condition is continuously monitored:
If the patient has fainted, they may be at risk of falling again
• It is important to allow the patient time to carry out the manoeuvre, as this will reduce the amount of manual assistance required from staff
• It is extremely important that the patient is NEVER LIFTED
• Lifting a patient is hazardous and may result in staff injury.
Documentation
• All patients should have assessments carried out within 24 hours of admission and placed in their file
• Any fall should be documented in the patient's notes to ensure other ward staff are aware of any problems.
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Clinical Procedures - Percutaneous Liver Biopsy
The following describes the technique when using a suction (Menghini) liver biopsy needle.
• Increasingly, 'blind' biopsies are being replaced by ultrasound-guided biopsies performed by the Radiology Department. Check your local guidelines.
Equipment
• Dressing pack (including gauze, bowl, drape)
• Antiseptic solution
• Sterile gloves and gown
• Local anaesthetic (e.g. 1% lidocaine)
• 2 x 10 mL syringes
• 2 × 23G (blue) needles
• Liver biopsy needles/pack
• 10mL sterile saline
• Scalpel/blade
• Tissue/biopsy collection pot.
Procedure
• Introduce yourself, confirm the patient's identity, explain the procedure, and obtain informed consent
• Review the patient's clotting profile and platelet count:
• If platelets <60 × 10°/L or prothrombin time >3 seconds prolonged, consider transjugular approach or clotting factor support
• D Ensure antiplatelets and anticoagulants are stopped at least 3 days prior to procedure to minimize risk of bleeding
• Ensure the patient has IV access
• Position the patient supine with the right arm abducted
• Examine the patient and percuss the borders of the liver before choosing a biopsy site. This is usually at the 7th or 8th intercostal space in the midaxillary line
• Confirm the site with ultrasonography:
• Confirm the direction the needle will take and a safe depth for the biopsy. Ensure that there are no major vessels within the liver at this point and that no bowel lies between the liver and abdominal wall
• Clean the area with antiseptic solution
• Administer local anaesthetic using both a 23G (blue) and
21G (green) needle down to the depth of the liver capsule
• Make a small incision at the point of insertion with the blade
• Half-fill a syringe with saline and attach to the biopsy needle
• Introduce the biopsy needle just above a rib
• As the needle is advanced, flush small amounts of saline until resistance is encountered (the liver surface)
• Pull back the plunger to apply suction and ask the patient to exhale completely and hold the breath in exhalation
• Whilst maintaining suction on the syringe, push the needle into the liver to the depth and direction estimated previously and then quickly remove the needle
• This should be a quick, fluid movement taking 1 second
• The biopsy now lies either within the needle or the syringe
• Deposit the sample in a suitable collection container:
• Judging an 'adequate' biopsy is controversial, but 2.5 cm is the ideal
• If the sample lies within the syringe, don't try to expel it through the needle, this will damage the tissue. Instead, remove the plunger from the syringe completely and pour the contents into the collection pot
• Apply pressure to the biopsy site for a couple of minutes and then cover with a suitable dressing.
Documentation
• Date, time, indication, informed consent obtained
• How was liver position confirmed?
• Type and volume of local anaesthetic used
• How many passes?
• No more than 2 passes should be made (British
Society of Gastroenterology (BS) guidelines 2004)
• Size and nature of the sample obtained
• Any immediate complications
• Instructions for monitoring and discharge if day-case
• Signature, printed name, and contact details.
Indications
• Staging of chronic hepatitis B and C
• Non-alcoholic liver disease (NAFLD)
• Diagnosis of other chronic liver diseases such as Wilson's, haemochromatosis, primary biliary cirrhosis, and sclerosing cholangitis:
• A 4mm portion can be analysed by some clinical chemistry departments for iron or copper index. The sample should be sent on saline-soaked filter paper in a plain universal tube
• Unexplained altered liver function tests
• Suspected malignant lesion
• To exclude rejection in a previous liver transplant patient.
Contraindications
• Uncooperative patient
• Dilated biliary system (risk of biliary peritonitis)
• Thrombocytopenia or coagulopathy
• Ascites
• Vascular or cystic lesions
• Amyloidosis (risk of haemorrhage increased).
Risks
• Haemo- or pneumothorax, intraperitoneal hemorrhage
• Pain, hypotension, sepsis
•Biliary leak due to gallbladder puncture, injury to other organs.
Procedure Tips
• Check the patient's clotting profile and platelet count. Do not perform if INR >1.3 or platelets <50 x 10°/L
• Ensure blood is group and saved prior to the procedure
• The biopsy sample should have clear clinical information on the request form for the Pathologist.
Post-procedure monitoring
Practice varies and you should consult your local guidelines. Most bleeding complications arise within the first 2 hours post-procedure.
A reasonable strategy (based on guidelines from the BS) is:
• Patient to be monitored for total 6 hours
• Monitor vital signs every 15 minutes for first 2 hours
• Monitor vital signs every 30 minutes for next 2 hours
• Monitor vital signs hourly for remaining time.
The following describes the technique when using a suction (Menghini) liver biopsy needle.
• Increasingly, 'blind' biopsies are being replaced by ultrasound-guided biopsies performed by the Radiology Department. Check your local guidelines.
Equipment
• Dressing pack (including gauze, bowl, drape)
• Antiseptic solution
• Sterile gloves and gown
• Local anaesthetic (e.g. 1% lidocaine)
• 2 x 10 mL syringes
• 2 × 23G (blue) needles
• Liver biopsy needles/pack
• 10mL sterile saline
• Scalpel/blade
• Tissue/biopsy collection pot.
Procedure
• Introduce yourself, confirm the patient's identity, explain the procedure, and obtain informed consent
• Review the patient's clotting profile and platelet count:
• If platelets <60 × 10°/L or prothrombin time >3 seconds prolonged, consider transjugular approach or clotting factor support
• D Ensure antiplatelets and anticoagulants are stopped at least 3 days prior to procedure to minimize risk of bleeding
• Ensure the patient has IV access
• Position the patient supine with the right arm abducted
• Examine the patient and percuss the borders of the liver before choosing a biopsy site. This is usually at the 7th or 8th intercostal space in the midaxillary line
• Confirm the site with ultrasonography:
• Confirm the direction the needle will take and a safe depth for the biopsy. Ensure that there are no major vessels within the liver at this point and that no bowel lies between the liver and abdominal wall
• Clean the area with antiseptic solution
• Administer local anaesthetic using both a 23G (blue) and
21G (green) needle down to the depth of the liver capsule
• Make a small incision at the point of insertion with the blade
• Half-fill a syringe with saline and attach to the biopsy needle
• Introduce the biopsy needle just above a rib
• As the needle is advanced, flush small amounts of saline until resistance is encountered (the liver surface)
• Pull back the plunger to apply suction and ask the patient to exhale completely and hold the breath in exhalation
• Whilst maintaining suction on the syringe, push the needle into the liver to the depth and direction estimated previously and then quickly remove the needle
• This should be a quick, fluid movement taking 1 second
• The biopsy now lies either within the needle or the syringe
• Deposit the sample in a suitable collection container:
• Judging an 'adequate' biopsy is controversial, but 2.5 cm is the ideal
• If the sample lies within the syringe, don't try to expel it through the needle, this will damage the tissue. Instead, remove the plunger from the syringe completely and pour the contents into the collection pot
• Apply pressure to the biopsy site for a couple of minutes and then cover with a suitable dressing.
Documentation
• Date, time, indication, informed consent obtained
• How was liver position confirmed?
• Type and volume of local anaesthetic used
• How many passes?
• No more than 2 passes should be made (British
Society of Gastroenterology (BS) guidelines 2004)
• Size and nature of the sample obtained
• Any immediate complications
• Instructions for monitoring and discharge if day-case
• Signature, printed name, and contact details.
Indications
• Staging of chronic hepatitis B and C
• Non-alcoholic liver disease (NAFLD)
• Diagnosis of other chronic liver diseases such as Wilson's, haemochromatosis, primary biliary cirrhosis, and sclerosing cholangitis:
• A 4mm portion can be analysed by some clinical chemistry departments for iron or copper index. The sample should be sent on saline-soaked filter paper in a plain universal tube
• Unexplained altered liver function tests
• Suspected malignant lesion
• To exclude rejection in a previous liver transplant patient.
Contraindications
• Uncooperative patient
• Dilated biliary system (risk of biliary peritonitis)
• Thrombocytopenia or coagulopathy
• Ascites
• Vascular or cystic lesions
• Amyloidosis (risk of haemorrhage increased).
Risks
• Haemo- or pneumothorax, intraperitoneal hemorrhage
• Pain, hypotension, sepsis
•Biliary leak due to gallbladder puncture, injury to other organs.
Procedure Tips
• Check the patient's clotting profile and platelet count. Do not perform if INR >1.3 or platelets <50 x 10°/L
• Ensure blood is group and saved prior to the procedure
• The biopsy sample should have clear clinical information on the request form for the Pathologist.
Post-procedure monitoring
Practice varies and you should consult your local guidelines. Most bleeding complications arise within the first 2 hours post-procedure.
A reasonable strategy (based on guidelines from the BS) is:
• Patient to be monitored for total 6 hours
• Monitor vital signs every 15 minutes for first 2 hours
• Monitor vital signs every 30 minutes for next 2 hours
• Monitor vital signs hourly for remaining time.
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Clinical Procedures - Proctoscopy
Indications
• Rectal bleeding
• Altered bowel habit
• To assess for perianal fistula
• Assessing patient with proctitis.
Contraindications
• Anal stenosis
• Painful perianal area on digital examination
• Pregnancy (relative).
Risks
• Bleeding
• Pain.
Procedure Tips
• Take care while assessing patients with pain (e.g. anal fissure, ischiorectal abscess, fistula):
• Presence of a fissure might prevent further examination due to pain
• Optimal views are obtained if patient has an enema prior to exam but it might not be feasible in all outpatient settings
• Do not biopsy from anal canal lesions as anus is pain-sensitive.
Equipment
• Gloves and other suitable protection (e.g. apron)
• Water-based lubricant gel
• Dry gauze
• Disposable proctoscope set with bellows
• Light source.
Procedure
• Introduce yourself, confirm the patient's identity, explain the procedure, and obtain informed consent
• Ensure a chaperone is available during the examination
• Ask the patient to lie on their left side, flexed at the hips and knees (the Sims position) such that their body lies diagonally across the couch or bed and their buttocks are at the edge of the bed towards you
• Ensure the instrument is assembled (connect the bellows tubing, light source, scope, and eyepiece). Ensure that the tip of the obturator (stylet) protrudes slightly from the end of the scope
• Inspect the anus and perform a digital rectal examination:
• If the rectum is faecally-loaded, this should be emptied (with the use of suppository or enema) before continuing
• Apply lubricant to the tip of the scope
• Insert the scope gently, directed towards the umbilicus
• After insertion, remove the obturator and gently inflate the rectum using the bellows
• With direct visualization, advance slowly as much as possible towards the direction of the lumen, insufflating as you advance
• Remove the scope slowly, examining the mucosa as you do so
• Finally, ask the patient to bear down and look for haemorrhoids or mucosal prolapse
• Once the scope is removed, wipe the perianal area and allow the patient to move to a more comfortable position.
Documentation
• Date, time, informed consent taken.
• Chaperone present.
• Indication (s).
• Depth examined.
• Any abnormalities identified and distance from anal verge.
• Any immediate complications.
• Signature, printed name and contact details.
Indications
• Rectal bleeding
• Altered bowel habit
• To assess for perianal fistula
• Assessing patient with proctitis.
Contraindications
• Anal stenosis
• Painful perianal area on digital examination
• Pregnancy (relative).
Risks
• Bleeding
• Pain.
Procedure Tips
• Take care while assessing patients with pain (e.g. anal fissure, ischiorectal abscess, fistula):
• Presence of a fissure might prevent further examination due to pain
• Optimal views are obtained if patient has an enema prior to exam but it might not be feasible in all outpatient settings
• Do not biopsy from anal canal lesions as anus is pain-sensitive.
Equipment
• Gloves and other suitable protection (e.g. apron)
• Water-based lubricant gel
• Dry gauze
• Disposable proctoscope set with bellows
• Light source.
Procedure
• Introduce yourself, confirm the patient's identity, explain the procedure, and obtain informed consent
• Ensure a chaperone is available during the examination
• Ask the patient to lie on their left side, flexed at the hips and knees (the Sims position) such that their body lies diagonally across the couch or bed and their buttocks are at the edge of the bed towards you
• Ensure the instrument is assembled (connect the bellows tubing, light source, scope, and eyepiece). Ensure that the tip of the obturator (stylet) protrudes slightly from the end of the scope
• Inspect the anus and perform a digital rectal examination:
• If the rectum is faecally-loaded, this should be emptied (with the use of suppository or enema) before continuing
• Apply lubricant to the tip of the scope
• Insert the scope gently, directed towards the umbilicus
• After insertion, remove the obturator and gently inflate the rectum using the bellows
• With direct visualization, advance slowly as much as possible towards the direction of the lumen, insufflating as you advance
• Remove the scope slowly, examining the mucosa as you do so
• Finally, ask the patient to bear down and look for haemorrhoids or mucosal prolapse
• Once the scope is removed, wipe the perianal area and allow the patient to move to a more comfortable position.
Documentation
• Date, time, informed consent taken.
• Chaperone present.
• Indication (s).
• Depth examined.
• Any abnormalities identified and distance from anal verge.
• Any immediate complications.
• Signature, printed name and contact details.
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Clinical Procedures - Recording a 12-lead ECG
The term '12-lead' relates to the number of directions that the electrical activity is recorded from and is not the number of electrical wires attached to the patient!
Equipment
• An ECG machine capable of recording 12 leads
• 10 ECG leads (4 limb leads, 6 chest leads):
• These should be attached to machine
• Conducting sticky pads ('ECG stickers*).
Procedure
• Introduce yourself, confirm the identity of the patient, explain the procedure, and obtain verbal consent
• Position the patient so that they are sitting or lying comfortably with their upper body, wrists, and ankles exposed
• Position the stickers on the patient's body
• The chest leads:
• V1: 4th intercostal space at the right sternal border
• V2: 4th intercostal space at the left sternal border
• V3: midway between V2 and V4
• V4: 5th intercostal space in the mid-clavicular line on the left
• V5: left anterior axillary line, level with V4
• V6: left mid-axillary line, level with V4
• The limb leads are often colour-coded:
• Red: Right arm. (Red: Right)
• Yellow: Left arm. (YeLLow: Left
• Green: right leg
• Black: left leg
• Attach the leads to the appropriate stickers
• Turn on the ECG machine
• Ask the patient to lie still and not speak for approximately 10 seconds whilst the machine records
• Press the button to record, usually marked 'analyse' or 'record'
Check the calibration and paper speed:
• 1mV should cause a vertical deflection of 10mm
• Paper speed should be 25mm/s (5 large squares per second)
• Ensure the patient's name, date of birth, as well as the date and time of the recording are clearly recorded on the trace
• Remove the leads, discard the sticky electrode pads. Correct positioning of the chest electrodes for a standard 12-lead ECG
Procedure Tips
• Encourage the patient to relax otherwise muscle contraction will cause interference
• If unable to relax, or access to the peripheries is difficult, the 'arm' leads can be placed at the shoulders and the leg leads at the groins
• Breathing may cause a wandering baseline; breath holding for 6 seconds whilst recording may alleviate this
• Ensure that you cleanse the area gently with an alcohol swab before attaching an electrode to ensure a good connection
• It may be necessary to cut chest hair to allow good contact and adhesion with the chest leads
• The AC mains electricity may cause interference. If this is the case, try turning off nearby fluorescent lights.
The term '12-lead' relates to the number of directions that the electrical activity is recorded from and is not the number of electrical wires attached to the patient!
Equipment
• An ECG machine capable of recording 12 leads
• 10 ECG leads (4 limb leads, 6 chest leads):
• These should be attached to machine
• Conducting sticky pads ('ECG stickers*).
Procedure
• Introduce yourself, confirm the identity of the patient, explain the procedure, and obtain verbal consent
• Position the patient so that they are sitting or lying comfortably with their upper body, wrists, and ankles exposed
• Position the stickers on the patient's body
• The chest leads:
• V1: 4th intercostal space at the right sternal border
• V2: 4th intercostal space at the left sternal border
• V3: midway between V2 and V4
• V4: 5th intercostal space in the mid-clavicular line on the left
• V5: left anterior axillary line, level with V4
• V6: left mid-axillary line, level with V4
• The limb leads are often colour-coded:
• Red: Right arm. (Red: Right)
• Yellow: Left arm. (YeLLow: Left
• Green: right leg
• Black: left leg
• Attach the leads to the appropriate stickers
• Turn on the ECG machine
• Ask the patient to lie still and not speak for approximately 10 seconds whilst the machine records
• Press the button to record, usually marked 'analyse' or 'record'
Check the calibration and paper speed:
• 1mV should cause a vertical deflection of 10mm
• Paper speed should be 25mm/s (5 large squares per second)
• Ensure the patient's name, date of birth, as well as the date and time of the recording are clearly recorded on the trace
• Remove the leads, discard the sticky electrode pads. Correct positioning of the chest electrodes for a standard 12-lead ECG
Procedure Tips
• Encourage the patient to relax otherwise muscle contraction will cause interference
• If unable to relax, or access to the peripheries is difficult, the 'arm' leads can be placed at the shoulders and the leg leads at the groins
• Breathing may cause a wandering baseline; breath holding for 6 seconds whilst recording may alleviate this
• Ensure that you cleanse the area gently with an alcohol swab before attaching an electrode to ensure a good connection
• It may be necessary to cut chest hair to allow good contact and adhesion with the chest leads
• The AC mains electricity may cause interference. If this is the case, try turning off nearby fluorescent lights.
- Published on
Clinical Procedures - Carotid Sinus Massage
Anatomy and physiology
• The carotid sinus is located at the bifurcation of the common carotid artery. It lies just under the angle of the jaw at the level of the thyroid cartilage and contains numerous baroreceptors which coordinate homeostatic mechanisms responsible for maintaining blood pressure
• These baroreceptors are innervated by a branch of the glossopharyngeal nerve (CN IX), which relays back to the medulla and modulates autonomic control of the heart and blood vessels.
Carotid sinus hypersensitivity
• The carotid sinus can be oversensitive to manual stimulation, a condition known as carotid sinus hypersensitivity (also 'carotid sinus syndrome' or 'carotid sinus syncope')
• In this condition, manual stimulation of the carotid sinus provokes significant changes in heart rate and/or blood pressure due to an exaggerated response to carotid sinus baroreceptor stimulation. This may result in marked bradycardia, vasodilation, and subsequent hypotension
• The patient may complain of episodes of dizziness or syncope related to pressure on the neck (e.g. wearing a tight collar or turning the head quickly)
• The underlying mechanism behind this exaggerated response is not fully understood.
Carotid sinus massage
• Carotid sinus massage is a diagnostic technique used to confirm carotid sinus hypersensitivity and is sometimes useful for determining the underlying rhythm disturbance in supraventricular tachycardia (SVT)
• The procedure acts in a similar way to the Valsalva manoeuvre, increasing vagal tone and, therefore, reducing the heart rate
Carotid massage is less effective than pharmaceutical management of SVT (verapamil or adenosine) though is still the preferable choice in the young haemodynamically stable patient
• This procedure should be performed with caution in the elderly as it may cause disruption of atheromatous plaque disease in the carotid artery and result in stroke.
Procedure
• Explain the procedure in full to the patient and obtain written consent
• If the test is to confirm carotid sinus hypersensitivity, then warn the patient that they may feel like they are going to faint but reassure them it is a controlled procedure
• If the test is to determine the underlying rhythm in SVT, explain that they may feel a bit peculiar as the heart rate slows down transiently
• Auscultate over the carotids for any bruits:
•If present, the procedure will have to be abandoned as the risk of stroke is significant
• D Document discussion of risks including failure, arrhythmias, stroke, faint, cardiac arrest
• • Secure intravenous access
• Ensure that you have ECG monitoring with a recordable rhythm strip
• I Ensure access to full resuscitation equipment, including emergency drugs such as atropine and adrenaline
• Position the patient supine on a bed with the neck extended and head turned away from the side to be massaged
• Whilst watching the ECG monitor (recording on a rhythm strip) gently massage the carotid sinus for 10-15 seconds using circular motions of your hand
• If there is no response, switch to the opposite side
• I Never massage both carotid sinuses simultaneously
• If successful (or 'positive' in the case of sinus hypersensitivity), the heart rate will slow:
• This may allow you to determine the underlying rhythm in SVT
• Ensure that the patient feels back to normal afterwards.
Anatomy and physiology
• The carotid sinus is located at the bifurcation of the common carotid artery. It lies just under the angle of the jaw at the level of the thyroid cartilage and contains numerous baroreceptors which coordinate homeostatic mechanisms responsible for maintaining blood pressure
• These baroreceptors are innervated by a branch of the glossopharyngeal nerve (CN IX), which relays back to the medulla and modulates autonomic control of the heart and blood vessels.
Carotid sinus hypersensitivity
• The carotid sinus can be oversensitive to manual stimulation, a condition known as carotid sinus hypersensitivity (also 'carotid sinus syndrome' or 'carotid sinus syncope')
• In this condition, manual stimulation of the carotid sinus provokes significant changes in heart rate and/or blood pressure due to an exaggerated response to carotid sinus baroreceptor stimulation. This may result in marked bradycardia, vasodilation, and subsequent hypotension
• The patient may complain of episodes of dizziness or syncope related to pressure on the neck (e.g. wearing a tight collar or turning the head quickly)
• The underlying mechanism behind this exaggerated response is not fully understood.
Carotid sinus massage
• Carotid sinus massage is a diagnostic technique used to confirm carotid sinus hypersensitivity and is sometimes useful for determining the underlying rhythm disturbance in supraventricular tachycardia (SVT)
• The procedure acts in a similar way to the Valsalva manoeuvre, increasing vagal tone and, therefore, reducing the heart rate
Carotid massage is less effective than pharmaceutical management of SVT (verapamil or adenosine) though is still the preferable choice in the young haemodynamically stable patient
• This procedure should be performed with caution in the elderly as it may cause disruption of atheromatous plaque disease in the carotid artery and result in stroke.
Procedure
• Explain the procedure in full to the patient and obtain written consent
• If the test is to confirm carotid sinus hypersensitivity, then warn the patient that they may feel like they are going to faint but reassure them it is a controlled procedure
• If the test is to determine the underlying rhythm in SVT, explain that they may feel a bit peculiar as the heart rate slows down transiently
• Auscultate over the carotids for any bruits:
•If present, the procedure will have to be abandoned as the risk of stroke is significant
• D Document discussion of risks including failure, arrhythmias, stroke, faint, cardiac arrest
• • Secure intravenous access
• Ensure that you have ECG monitoring with a recordable rhythm strip
• I Ensure access to full resuscitation equipment, including emergency drugs such as atropine and adrenaline
• Position the patient supine on a bed with the neck extended and head turned away from the side to be massaged
• Whilst watching the ECG monitor (recording on a rhythm strip) gently massage the carotid sinus for 10-15 seconds using circular motions of your hand
• If there is no response, switch to the opposite side
• I Never massage both carotid sinuses simultaneously
• If successful (or 'positive' in the case of sinus hypersensitivity), the heart rate will slow:
• This may allow you to determine the underlying rhythm in SVT
• Ensure that the patient feels back to normal afterwards.
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Clinical Procedures - Vagal Maneouvres
Background
The Purpose
• Vagal manoeuvres can be used to determine the underlying rhythm or terminate SVT in haemodynamically stable patients. If the underlying rhythm is atrial flutter, slowing of the ventricular response by increasing vagal tone will reveal flutter waves
• Vagal manoeuvres are part of the adult peri-arrest algorithm for management of narrow complex tachycardia. They can be performed in a controlled clinical situation (i.e. attached to an ECG machine), or taught to the patient to perform at home if the sensation of the arrhythmia reoccurs.
Physiology
• Vagal manoeuvres increase vagal tone by activation of the parasympathetic nervous system, conducted to the heart by the vagus nerve
• Increasing vagal tone impedes the AV node and so slows transmission of the electrical impulse from the atria to the ventricle. In this way any SVT that relies upon the AV node will be modified by an increase in vagal tone.
Background
The Purpose
• Vagal manoeuvres can be used to determine the underlying rhythm or terminate SVT in haemodynamically stable patients. If the underlying rhythm is atrial flutter, slowing of the ventricular response by increasing vagal tone will reveal flutter waves
• Vagal manoeuvres are part of the adult peri-arrest algorithm for management of narrow complex tachycardia. They can be performed in a controlled clinical situation (i.e. attached to an ECG machine), or taught to the patient to perform at home if the sensation of the arrhythmia reoccurs.
Physiology
• Vagal manoeuvres increase vagal tone by activation of the parasympathetic nervous system, conducted to the heart by the vagus nerve
• Increasing vagal tone impedes the AV node and so slows transmission of the electrical impulse from the atria to the ventricle. In this way any SVT that relies upon the AV node will be modified by an increase in vagal tone.
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Clinical Procedures - The Valsalva manoeuvre
• This is forced expiration against a closed glottis. Increasing intrathoracic pressure stimulates baroreceptors in the aortic arch and results in increased vagal stimulation
• This can be successful in 25-50% of cases.
Procedure
• Ask the patient to take a deep breath in and then 'bear down' as if they are trying to open their bowels (or for women, as if they are in labour)
Some patients may struggle with this concept and so alternatively:
• Give them a 10mL syringe and ask them to blow into the tip, in an attempt to expel the plunger.
Showing off
The technique is named after Antonio Maria Valsalva a 17th-century physician from Bologna, who was mainly interested in the workings of the ear. He first described the manoeuvre with regard to testing the patency of the Eustachian tubes.
The Diving Reflex
• This involves either submerging the face in ice cold water (not very practical or covering the face with a towel soaked in ice cold water.
Carotid Sinus Massage
• This is described separately (see topic).
Eyeball Pressure
•This is not recommended as a clinical procedure as it can be both painful and damaging. Do NOT perform.
• This is forced expiration against a closed glottis. Increasing intrathoracic pressure stimulates baroreceptors in the aortic arch and results in increased vagal stimulation
• This can be successful in 25-50% of cases.
Procedure
• Ask the patient to take a deep breath in and then 'bear down' as if they are trying to open their bowels (or for women, as if they are in labour)
Some patients may struggle with this concept and so alternatively:
• Give them a 10mL syringe and ask them to blow into the tip, in an attempt to expel the plunger.
Showing off
The technique is named after Antonio Maria Valsalva a 17th-century physician from Bologna, who was mainly interested in the workings of the ear. He first described the manoeuvre with regard to testing the patency of the Eustachian tubes.
The Diving Reflex
• This involves either submerging the face in ice cold water (not very practical or covering the face with a towel soaked in ice cold water.
Carotid Sinus Massage
• This is described separately (see topic).
Eyeball Pressure
•This is not recommended as a clinical procedure as it can be both painful and damaging. Do NOT perform.
