PRACTICAL SKILLS IN PRIMARY CARE STEP-BY-STEP APPROACH WITH DEMONSTRATION VIDEO Family Medicine Unit Faculty of Medicine Universiti Sultan Zainal Abidin

DR. NUR AIZA IDRIS

DR. NURUL IZZA YUNUS

DR. NORWATI DAUD

DR. NURULHUDA MAT HASSAN

DR. NURUL AZREEN YUSOF

DR. SITI NORAZLINA JUHARI

PRACTICAL SKILLS IN PRIMARY CARE STEP-BY-STEP APPROACH WITH DEMONSTRATION VIDEO

PRACTICAL SKILLS IN PRIMARY CARE STEP-BY-STEP APPROACH WITH DEMONSTRATION VIDEO

First printing 2021.

Published in Malaysia by Unit Pendidikan Profesion Perubatan & Kesihatan Universiti Sultan Zainal Abidin, Kampus Perubatan, Jalan Sultan Mahmud, 20400, Kuala Terengganu, Terengganu Published online at http://www.lifeskillsohoebooks.com.

Dr. Nurulhuda Mat Hassan, Dr. Nur Aiza Idris, Dr. Nurul Azreen Yusof, Dr. Nurul Izza Yunus, Dr. Siti Norazlina Juhari.

All rights reserved. No parts of the articles, illustrations and contents of the book can be reproduced in any way or any form including electronic, photocopy, recording and others before getting written permission from the writers.

Authors admit that the facts in the book are true to their knowledge but are prone to be updated from time to time. Authors are not liable for these changes, any misunderstanding or untoward effects resulting from the usage of the contents of this e-book.

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Table of Contents 01

Preface...........………………………………………… 3

02 Message from lecturers…………..……. 4 03 How to use this book……………….….….. 5

Use of insulin pen…………………………….. 6 04 By: Dr Siti Norazlina Juhari

05 Use of glucometer……………………………. 10 By: Dr Nurul Izza Yunus

06 Use of peak flow meter...……….………. 13 By: Dr Norwati Daud

07 Use of inhaler devices……………………. 18 By: Dr Nurul Azreen Yusof

08 Use of spacer devices……………………. 20 By: Dr Nurulhuda Mat Hassan

09 Performing nebulisation.…………….. 23 By: Dr Nurul Izza Yunus

10 Performing a 12-lead ECG…………… 26 11

By: Dr Nur Aiza Idris

Intramuscular injection…………………. 31 By: Dr Nur Aiza Idris

12 Subcutaneous injection…………………. 36 By: Dr Hassan Basri Mukhali

13 Pap smear………………………………………….… 37 By: Dr Nurul Azreen Yusof

14 IUCD insertion…………………………………….. 42

By: Dr Nur Aiza Idris

Preface



Someone once said to me that a doctor in primary care is “A jack of all trades, but a master of none”. This is definitely not true. True doctors in

primary care are ‘masters’ of all the trades needed to manage the majority of patients, who need to be managed holistically and effectively in primary care.

A primary care doctor is a specialist in family medicine who provides definitive care to the undifferentiated patient at the first point of first contact, and takes continuing responsibility for providing the patient’s comprehensive care. This care may include chronic, preventive and acute

care in outpatient as well as pre-hospital setting. Thus, the importance of mastering the art of clinical examinations and procedures in primary care

should be emphasized.

This book outlines the basic procedures needed to manage primary care cases and the necessary knowledge needed to carry them out and and how to advise patients on them. It is our sincere hope that the knowledge imparted in this book will be translated as skills by our future primary care doctors so that they can be effective, holistic and safe primary care and family doctors for their precious patients and their families.

Our utmost gratitude to Almighty as with His bounty and grace, we are able to complete the book, and we would like to extend our gratefulness to Assoc. Prof. Dr. Norwati Daud as Head of the Medical & Health Professions Education Unit who had reviewed the book and given the platform for us to publish.









PRACTICAL SKILLS IN PRIMARY CARE

Message From Lecturers

Learning and practicing will never end... So, never stop to do so.

Seeking knowledge is a journey towards a competency and successful person. So, be knowledgeable.

Along the journey, we may fail and make mistakes. Do not look back. That is how we learn, improve and become better.

Having good values in you; attitude, respect, responsible and honesty will make you amazingly different from others.

Wishing you great success. Keep up the good work and never stop aspiring to be the best in life.

Good luck in your brightest future!

PRACTICAL SKILLS IN PRIMARY CARE

How to use this book This book is designed to help medical students and primary care doctors learn to perform common procedures safely and correctly. In this book, you will find essential information that every medical professional should have under his/her belts.

Each procedure is explained in detail in the accompanying notes. There is a list of homework assignments to complete if you want to learn more about the subject. It is always a good idea to stay up to date on the latest news and information.

You will get more out of this book if you use the QR code in the book to watch the video rather than reading it cover to cover. You should practise the procedures with your peers to ensure that you understand them. Our recommendation is that you practise the procedures in groups of two or three, and the more you practise, the more you will benefit from them.

PRACTICAL SKILLS IN PRIMARY CARE

Use of insulin pen COMPONENT OF INSULIN PEN

needle

needle attachment point

insulin cartridge /reservoir

injection button

inner needle cap dose adjustment dial

pen cap

PREPARING THE PEN

Wash your hands before handling insulin pen devices. Make sure you have a clean site and clean hands. Remove the pen cap and unscrew the pen .

Insert the insulin cartridge into the cartridge holder, colourcoded cap end first.

Reassemble the pen and twist it until you feel or hear a click.

Use of insulin pen PREPARING THE PEN (CONT.)

Cloudy insulin (e.g. NPH and premixed insulin) must be

resuspended prior to each injection to ensure the suspension has a consistently milky white appearance

1. Gently roll in between your palms for 10 times (for cold insulin only). 2. Tip up and down for 10 cycles. 3. Visually check for milky white appearance.

Note!

Vigorous shaking should be avoided since this produces bubbles which reduce dose accuracy. Inadequate resuspension of cloudy insulin before pen injection may lead to varying concentration of medication dosage that can cause unpredictable clinical responses.

B) CHECKING THE INSULIN FLOW (PRIMING) Before injection, always attach a new needle. Remove both the outer and inner needle caps, and dispose of the inner needle cap. Keep the outer needle cap to remove the needle from the pen after injection. Prime insulin pen device with the needle pointing upwards. Pull out the dose button. Turn the dose button to select 2 units. Keep the pen upright and tap the cartridge holder gently to raise any air bubbles. Press the dose button all the way in until it clicks and the dial returns to 0. Observe at least a drop of insulin at the needle tip.

Use of insulin pen SETTING YOUR DOSE

Pull out the dose button and turn the dial until the white indicator line is level with the required number of units you need to inject. Adjust the dose by dialling up or down, if necessary. No insulin will be released until the dose button is pressed.

INJECTING YOUR DOSE Insert gently the pen needle into the skin at 90°. Press the dose button until you feel or hear a click and the dose indicator lines up with 0. Leave the needle under the skin for at least 10 seconds (keeping the button pushed down), and then slowly pull the pen out Recap the used pen needle using the outer cap. Remove pen needle and dispose it safely. Used pen needle should not be left attached to the pen. This allows the entry of air and other contaminants into the cartridge, or leakage of insulin from the cartridge, which can affect subsequent dose accuracy. References: 1. http://www.myhealth.gov.my/en/insulin-injection-technique/ 2. http://insidepatientcare.com/issues/2013/december-2013-vol-1-no-2/14-counseling-patients-on-theuse-of-insulin-pen-devices 3. FORUM FOR INJECTION TECHNIQUE – MALAYSIA (FIT–MY)

Homework!!! 1.

Sites of injections

2.

Insulin storage

3.

Side effects of insulin

Scan / click on the QR code below to watch demonstration video

Use of glucometer EQUIPMENTS

lancet needle

glucometer test strips

dry cotton

lancet pen

STEP TO MEASURE CAPILLARY BLOOD GLUCOSE Wash your hands. Introduce yourself and confirm patient details. Ensure the patient has washed their hands before the procedure. Alcohol wipes can also disrupt readings. Turn on the blood glucose monitor, and make sure it is calibrated. Check the test strip expiry date and insert it into the glucose monitor.

Use of glucometer STEP TO MEASURE CAPILLARY BLOOD GLUCOSE Wear gloves. Remove lancet’s cap. Prick the patient. Ideally, the finger's side, as this is less painful. Squeeze the finger to produce a blood droplet. Touch the test strip to the blood droplet. Stop bleeding with gauze at the puncture site. Record the blood glucose metre reading. Dispose lancet in sharps bin. Dispose gloves and cotton wool in a clinical waste bin.

Homework!!! 1. Interpret the blood glucose results 2.

Target glucose level for fasting and post meal in diabetic patient

Scan QR code below to watch demonstration video

Use of peak flow meter COMPONENT OF PEAK FLOW METER

marker/dial

mouth piece

PREPARING THE PEAK FLOW METER

Wash your hands before handling the devices. Obtain the peak flow meter and mouthpiece. The mouthpiece will fit onto the end of one side. Ensure the red dial is set to zero. Sit up straight or stand.

Use of peak flow meter USING THE PEAK FLOW METER Keep hands on either side, being careful not to obstruct the red dial. Make sure that the peak flow meter is exactly horizontal, parallel to the floor. This is to avoid any confounding effects of gravity. Take in a deep breath (as deep as you can possibly manage) Place your mouth around the mouthpiece of the PEFR meter, ensuring a tight seal with your lips Exhale forcefully (as hard and as fast as possible). The red dial will move up from 0 to a value given on the side of the meter, giving the PEFR (measured in L/min). Note the PEFR reading Rest and repeat this process a further 2 times The highest reading of the 3 should be taken as the PEFR reading

References: 1. lung.org/lung-health-diseases/lung-disease-lookup/asthma/living-with-asthma/managingasthma/measuring-your-peak-flow-rate 2. https://simpleosce.com/procedures/peak-expiratory-flow.php 3. Asthma book primary health care MOH

Homework!!! 1. How to estimate PEFR value? 2. How to use PEFR in diagnosing bronchial asthma? 3.

How to use PEFR to monitor asthma control?

4.

What is the value of PEFR in assessing severity of asthma?

Scan QR code below to watch demonstration video

USE OF INHALER DEVICE TYPE OF INHALER DEVICES

Metered dose inhaler (MDI)

Accuhaler (dry powder inhaler)

Handihaler (dry powder inhaler)

Soft mist inhaler

Turbohaler (dry powder inhaler)

Ellipta inhaler (dry powder inhaler)

USE OF INHALER DEVICE HOW TO USE INHALER DEVICE 1. Prepare the inhaler Take off the lid Shake 3-5 times if MDI Insert capsule if handihaler

2. Load the dose Press button to puncture capsule if handihaler Press lever once if accuhaler Twist bottom if turbohaler

3. Breathe out gently as much as comfortable. 4. Tightly seal lips around the mouthpiece. 5. Breathe in

Dry powder inhalers (DPI) need to be breathed in quick and deep Metered dose inhalers (MDI) need to be breathed in slow and deep Soft mist inhalers (SMI) need to be breathed in slow and deep

6. Remove inhaler from your mouth 7. Hold your breath for 10 seconds or as long as comfortable. 8. Wait for 30 seconds to take another dose if needed. (During acute asthma attack, take reliever first followed by controller)

USE OF SPACER DEVICES INTRODUCTION ON SPACER What is a spacer?

A spacer chamber is a polycarbonate or plastic reservoir in which a pressured meter dose inhaler (MDI) is inserted at one end and an adapter for mask/ direct breathing at the other end. It can be used with or without a mask.

Why a spacer is needed?

A spacer helps with coordination problems when using an inhaler, for example in small children or elderly. Another benefit is it reduces the deposition of medication on the throat, thereby reducing possibility of local side-effects.

COMPONENT OF SPACER

mask valve

adapter

spacer body

USE OF SPACER DEVICES HOW TO USE SPACER DEVICE 1. Prepare inhaler (shake aerosol inhaler five times and remove cap). 2. Attach adapter part of spacer to mask. 3. Attach inhaler mouthpiece to spacer with inhaler canister upright. Hold spacer horizontal, one hand holding inhaler between thumb and index finger and the other hand supporting the mask. 4. Sit or stand up straight with chin up. 5. Breath out gently as much as comfortable. 6. Place mask gently over nose and lips with a tight seal. 7. Release 1 dose into spacer device. 8. Breath in and out several times (up to 10 times) 9. Administer a second dose if needed.

Homework!!! 1. How to clean the spacer?

Scan QR code below to watch demonstration video

PREPARING NEBULISATION EQUIPMENTS

facemask nebuliser cup/ medication chamber Oxygen supply or air compressor oxygen tube

Medications: ie. B2 agonist with proper dilution Syringe and needle DILUTION (e.g.Salbutamol) Adult: 1 mL Salbutamol + 4 mL Normal saline (NS) Paediatric : • < 2yrs old: 0.5 mL Salbutamol + 3.5 mL NS • >2 yrs old : 1 mL Salbutamol+ 3 mL NS



PREPARING NEBULISATION STEPS Wash your hands and dry with paper towel. Syringe out prescribed medication (i.e. Salbutamol and normal saline with correct dilution) and put into nebulizer cup. Attach the nebulizer cup to the facemask. Attach the facemask to the oxygen tube and another end of the tube to the oxygen supply/ air compressor. Put the facemask on the patient. Patient should be in upright position/ propped up. Turn on the oxygen 5-6L/min / turn on the air compressor until the aerosol generated. Continue inhaling the aerosolised medications for about 15-20 minutes until the mists stop. Turn off the oxygen, unplug it and review back the patient in 10-15minutes.

Homework!!! 1.

When is nebulized medication indicated?

2. What other medications can be given through the nebulizer machine? 3.

How to clean the nebulizer?

Scan QR code below to watch demonstration video

Performing a 12-lead ECG EQUIPEMENTS

electrocardiogram machine

lead wire

limb clamp and electrodes

lead wire

cardio cream/gel

precordial/ chest electrodes

STEPS PRIOR TO THE PROCEDURE

Wash your hands before the procedure. Check your electrocardiogram machine. Confirm patient's details and explain the procedure. Position the patient ; lie down at 45 degree. Adequate exposure (chest and limbs).

Performing a 12-lead ECG PREPARE THE SKIN Before placing your electrodes, gently clean the area of skin with a paper towel to remove any oil or dirt. If necessary, with the patient’s consent, shave the local area. Once the skin is clean, find and mark the placements for the electrodes.

FIND AND MARK THE PLACEMENTS FOR CHEST ELECTRODES

V1

4th intercostal space to the right of the sternum

V2

4th intercostal space to the left of the sternum

V3

Directly between the leads V2 and V4

V4

5th intercostal space at left midclavicular line

V5

Level with V4 & V6 at left anterior axillary line

V6

Level with V4 & V5 at left midaxillary line

Performing a 12-lead ECG FIND AND MARK THE PLACEMENTS FOR PRECORDIAL LEAD

APPLY LIMB LEADS Attach the four limb electrodes at the following locations: Right wrist - Red electrode. Left wrist - Yellow electrode. Left ankle - Green electrode. Right ankle - Black electrode.

Tips!STOP LOOK GO References: 1. https://litfl.com/ecg-lead-positioning/ 2. https://www.adinstruments.com/blog/correctly-place-electrodes-12-lead-ecg 3. https://simpleosce.com/procedures/ECG.php

Performing a 12-lead ECG RECORD YOUR ECG TRACE After applying all the electrodes correctly, switch on the electrocardiogram machine. Ensure the ECG paper has been loaded into the machine. Press the button on the ECG machine to record the ECG trace. If the ECG trace is poor, double-check the connections to ensure there is good skin contact.

EXAMPLE OF PRINTED ECG

References: 1. https://litfl.com/ecg-lead-positioning/ 2. https://www.adinstruments.com/blog/correctly-place-electrodes-12-lead-ecg 3. https://simpleosce.com/procedures/ECG.php

Homework!!!

1.

Label the printed ECG with patient's details

2.

Interpret the ECG finding

Scan QR code below to watch demonstration video

INTRAMUSCULAR INJECTION EQUIPMENTS

Kidney dish or tray to carry the drug Dry cotton swab Gloves Alcohol swab

Syringe

Needles – proper size

Drug for administration

PROCEDURES

Explain the procedure. Before drug administration, make sure the patient’s name, drug and indication are correct. Check whether the patient has any allergies. Make sure the prescription is correct, following the ‘five rights’ of drug administration. Wash and dry hands to reduce the risk of infection. Wear gloves.

INTRAMUSCULAR INJECTION PROCEDURES (CONT.)

Assemble the syringe and needle (ensure correct size), and withdraw the required amount of drug from the ampoule/vial. Disperse air bubbles from the syringe. Change the needle. (Doing so will ensure that the needle used for the injection is sharp, thereby reducing pain) Position the patient comfortably with the injection site exposed. (The site is influenced by the assessment of the patient, the drug and the volume to be injected ) Swab for 30 seconds with isopropyl alcohol and allow to dry for 30 seconds Hold the syringe and needle in your dominant hand and gently stretch the skin around the injection site using the nondominant hand. This displaces the subcutaneous tissue and aids needle entry A Z-track technique can be used to prevent backtracking and leakage from the injection site

INTRAMUSCULAR INJECTION PROCEDURES (CONT.)

Z-track technique 1. Identify injection site 2. Pull skin to one side

3. 4. 5. 6.

Insert needle intramuscularly Inject medication Withdraw needle Release skin injection site

Medication is prevented from oozing out

medication

Needle should be inserted at 90 degrees skin layer (epidermis & dermis) subcutaneous muscle

90o

INTRAMUSCULAR INJECTION PROCEDURES (CONT.)

Insert the needle at a 90-degree angle using a dart-like action. Aspiration to check whether the needle is in a blood vessel is not usually necessary Press the plunger slowly at a rate of 1ml/10 seconds - this aids absorption of the drug and reduces pain Wait for 10 seconds - allow the drug to diffuse into the tissue and then quickly withdraw the needle at the same insertion angle Dispose of the sharps directly into the sharps bin and the syringe according to local policy Ensure the patient is comfortable and wash your hands. Record administration on the prescription chart Monitor the patient for any effects of the prescribed medicine and any problems with the injection site.

Homework!!! 1. What is the five rights’ of medicines administration? 2.

List four (4) muscle sites that are recommended for IM administration

Scan QR code below to watch demonstration video

SUBCUTANEOUS INJECTION PROCEDURES 1. Perform proper hand hygiene. 2. Cleanse the skin with a sterile alcohol swab and allow it to dry. 3. Pinch up the skin and underlying fatty tissue. 4. Insert the needle at a 45-degree angle into the subcutaneous tissue and inject the vaccine/ medication. Avoid reaching the muscle. 5. Withdraw the needle. 6. Apply an adhesive bandage to the injection site if there is any bleeding. 7. Ensure correct disposal of equipments and observe for any allergic reactions. Always educate patient/parents to observe for possible adverse effects post injection/vaccination and report to health centre immediately.

skin layer (epidermis & dermis) subcutaneous muscle

Pap smear BEFORE PAP SMEAR Prepare equipments Ensure sterile technique Prepare swab for HVS C&S (if needed) Explain to patient regarding procedure Position: dorsal

EQUIPMENTS 1. Bowl with cotton balls

6. Sponge holder

3. Sterile gloves

8. Cytobrush with/out Ayre spatula

2. Light source

4. Drape/cloth to cover

5. Kidney dish & gallipot

7. Cusco Speculum

9. 95% alcohol solution 10. Slides

Kidney dish, gallipots and cotton balls Sterile gloves Slides Drape

95% alcohol

Sponge holder

Speculum

Cytobrush and Ayre spatula

Pap smear PROCEDURES 1. Ensure correct position and good lighting. 2. Wash hands and wear gloves and facemask. 3. Clean the introitus with normal saline (NS) dan drape. 4. Inspect external genitalia for any abnormality. 5. Lubricate the speculum with NS. 6. Insert speculum into the vagina. Avoid touching the cervix to avoid bleeding. 7. Visualise the cervix and observe for any abnormality. 8. If vaginal discharge is present, take a sterile swab and send for gram stain/ C&S.

TECHNIQUE 1 : USING CYTOBRUSH ONLY Insert the endocervical brush into the os and rotate 360 degree clockwise for 5 times Take the brush out gently without touching the speculum Separate the brush from the handle and put into the container filled with 95% alcohol solution.

Pap smear TECHNIQUE 2: USING AYRE SPATULA AND CYTOBRUSH

Repeat procedure 1-7. To take the cervical specimen, insert the longer end of spatula into the os and rotate 360 degree gently. Then smear on the slide (refer image). Next, to take endocervical sample, use cytobrush and insert into the os ~2cm, rotate 360 degree gently to avoid bleeding. Roll the brush on the slide (refer image). Fixed the slide with alcohol spray and put into the slide container OR directly put the slide into 95% alcohol solution. Ensure correct label.

Patient's details

smear using Ayre spatula Patient's details

roll the cytobrush

Pap smear PROCEDURE AFTER PAP SMEAR Clean the vulvae and make the patient comfortable Explain findings and referral if needed Explain when the result will be available and give appointment for review Ensure correct equipment disposal Fill in the pap smear request form with correct patient’s details and clinical indications.

References: 1. Modul Pengajar Teknik Pengambilan Pap Smear Bahagian Pembangunan Kesihatan KKM Disember 2009

Homework!!! What is your advice to patient before doing the pap smear?

Scan QR code below to watch demonstration video

IUCD insertion COMPONENTS OF IUCD ( multiload copper )

flange insertion tube

wing

strings/threads

vertical stem with copper wire

EQUIPMENTS FOR IUCD INSERTION 1. Bowl with cotton balls

6. Speculum

3. Sterile gloves

8. Uterine sound

2. Light source

4. Drape/cloth to cover

5. Sponge holder

Sterile gloves

Tenaculum

7. Tenaculum 9. Scissors 10. IUCD

Kidney dish, gallipots and cotton balls

IUCD Drape

Sponge holder

Uterine sound

Speculum

Scissors

IUCD insertion IUCD PLACEMENT - TECHNIQUE Before procedure Explain to patient that the procedure may be slightly uncomfortable but would not hurt. Tell her to relax. Check IUCD expiry date and sterility. Prepare the patient (lie in dorsal or lithotomy position). Prepare and check the instruments. Wear mask and apron. Wash hands then wear gloves.

IUCD procedure Clean the genital area - use saline (one way, from front to back) and drape. Inspect the genitalia externally - look for wart, ulcers, discharged. Do bimanual examination (insert right hand in the cervix while left hand on patient's suprapubic region) - feel for mass, position of uterus, size of uterus, tenderness. Insert the speculum. Position the light source. Clean the cervix with an antiseptic solution. (Use iodine or Chlorhexidine). Stabilised cervix using tenaculum. Gently pull the tenaculum to align the uterus and cervical opening.

IUCD insertion IUCD PLACEMENT - TECHNIQUE Insert the uterine sound to measure dimension of uterine cavity. Assess the level of mucus/blood to determine the uterine depth (average is 6-9 cm). No IUCD should be inserted if the uterus is less than 6 cm deep.

Withdrawn the uterine sound. Adjust the IUCD length according to the uterine sound measurement.

Insert the IUCD into the uterus until the flange reaches the cervical opening. Pull back the inserter tube. Cut the string about 2-3 cm from the os. Remove the tenaculum and check for any bleeding. Remove the speculum. Safe disposal of waste.

Homework!!! Pre-insertion - Patient selection - Contraindications - Risks/ Adverse effects - Informed consent

Post IUCD insertion - advice to patient - Check string - Follow up - Safety net

Scan QR code below to watch demonstration video

References: 1. https://www.aafp.org/afp/2005/0101/p95.html 2. https://fpnotebook.com/gyn/procedure/IntrtrnDvcInsrtn.htm 3. https://slideplayer.com/slide/15114945/

Now that you have watched the videos and learnt the notes, it is time to do & teach your friends.

See One, Do One & Teach One!

Thank you and best wishes for the future!

from lecturers in unisza Family Medicine Unit

PRACTICAL SKILLS IN PRIMARY CARE

Published by Unit Pendidikan Profesion Perubatan & Kesihatan Universiti Sultan Zainal Abidin, Kampus Perubatan, Jalan Sultan Mahmud, 20400, Kuala Terengganu, Terengganu