CLINICAL MEDICINE

Procedure Manual

Third Edition 2009

NAME

COLLEGE

STUDENT NUMBER

YEAR OF ENTRY

Clinical Medicine Procedure Manual – edition 2009	1

Clinical Medicine Procedure Manual

Kenya Medical Training College

Nairobi, Kenya

© SkillsLab National Coordination Centre 2009

Third edition 2009

Printed and bound in Kenya by English Press,

Nairobi.

Clinical Medicine Procedure Manual – edition 2009	2

TABLE OF CONTENT
Table of content	3
Preface to the 3rd Edition	7
Preface to the 2nd Edition	7
YEAR 1	9
CHAPTER 1: BASIC COMMUNICATION SKILLS	11
Basic communication skills	12
The communication process & Observing	13
Active Listening & Non-verbal Communication	21
Giving and receiving feedback	27
Expressing feelings and exploration of feelings	32
Asking questions	36
Summarizing	39
CHAPTER 2 COMPUTER SKILLS	43
Introduction to basic computer use	44
Getting started	47
Word processing	50
Windows explorer	53
Internet and E-mail	55
Software for medical professions	60
Annex: Useful keys and key combinations	64
CHAPTER 3: BASIC PATIENT CARE SKILLS	67
Scrubbing, gowning and gloving	68
Aseptic techniques and surgical wound dressing	71
Administration of oral drugs	73
Administration of drugs: Injection techniques	75
Vene-puncture and collection of blood specimen	84
Insertion of intravenous canula’s and IV-infusion	85
Nasogastric tube: Insertion and feeding	87
Stomach wash-out / Gastric lavage	89
CHAPTER 4: FIRST AID & BASIC LIFE SUPPORT	91
Bandaging	92
Splinting	98
Introduction to basic life support and resuscitation	105
Assessment of the victim for response	106
Positioning and moving the victim	107
Management of foreign body airway obstruction (FBAO)	111
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Assessment of breathing and performing artificial ventilation	113
Assessment of circulation and circulatory support	115
CHAPTER 5: HISTORY TAKING & BASIC PHYSICAL EXAMINATION SKILLS ...	119
General history taking	120
Examination techniques and instruments	123
Physical examination: Approach and overview	129
General examination	134
Vital signs	141
The respiratory system	146
Cardiovascular (CVS) system examination	155
Examination of the heart	156
Measurement of jugular venous pressure (JVP)	162
Examination of the peripheral vascular system	164
Abdominal examination	170
YEAR 2	183
CHAPTER 6: INTERNAL MEDICINE ROTATION SKILLS	185
History taking in internal medicine	186
Ano-rectal examination	187
Examination of the male genitalia	189
Neurological system examination	191
Blood transfusion management	207
Giving enema	209
Passing flatus tube	212
Catheterization	214
Specimen collection	217
Lumbar puncture	222
CHAPTER 7: SKILLS IN PAEDIATRICS	227
Paediatric history taking	228
Paediatric physical examination	230
Resuscitation of the newborn	234
CHAPTER 8: SURGICAL ROTATION SKILLS	239
Surgical history taking	240
Examination of the female breasts and axilla	242
Examination of the back	247
Examination of the pelvis and hip joint	252
Examination of the knee joint	260
Local examination	263
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Assessment of burns	267
Introduction to wound care	269
Administration of local anaesthesia	270
Wound toilet	273
Simple wound closure	275
Local treatment of burns	280
Incision and drainage	285
Bladder irrigation	287
Pre-operative care	289
Post-operative care	291
Interpretation of X-rays	293
CHAPTER 9: BASIC OBSTETRIC & GYNAECOLOGICAL SKILLS	297
Obstetric history taking	298
Gynaecological history taking	301
Gynaecological pelvic examination	302
Obstetric abdominal examination	305
Obstetric vaginal examination	313
Partograph – Monitoring first stage of labour	316
Second stage of labour – Spontaneous vaginal delivery (SVD)	320
APGAR score system	322
Examination of the newborn	324
Third stage of labour – Delivery of the placenta	329
Examination of the placenta	331
Performing episiotomy	332
Suturing of perineal tears / episiotomy	334
YEAR 3	337
Chapter 10: Advanced communication skills	339
Health education	340
Basics of counselling skills	345
Communicating bad news	354
CHAPTER 11: ADVANCED SKILLS IN INTERNAL MEDICINE	365
Administration of oxygen	366
CHAPTER 12: ADVANCED SKILLS IN SURGERY	369
Ear Nose and throat examination	370
Examination of the thyroid gland	374
Eye examination	376
Ear syringing / ear irrigation	380
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Traction Application	382
CHAPTER 13: ADVANCED SKILLS IN OBSTETRICS AND GYNAECOLOGY	387
IUCD insertion	388
Manual vacuum aspiration (MVA)	392
Delivery of the baby in POPP (persistent occipito posterior position)	394
Vaginal delivery of the baby in breech presentation	397
References	403

Clinical Medicine Procedure Manual – edition 2009	6

PREFACE TO THE 3RD EDITION

This is the third edition of the clinical medicine procedure manual. The text in this manual and the organization are similar to the 2nd edition. The improvements in this manual lie in the illustrations - almost all pictures and photographs have been replaced by what we hope are clearer and better quality illustrations. In addition the lay-out has been adjusted to make the manual more user-friendly.

We hope you find it a helpful and easy to use document. If you have any suggestions, please forward your comments to our office to improve the next edition even more.

SkillsLab National Coordination Centre

P.O. Box 2384

00202 Nairobi

PREFACE TO THE 2ND EDITION

This manual has been developed to enable clinical officers in training and post-training to correctly perform procedures when practising in the SkillsLab or when attending to patients.

The main difference with the preceding edition is that 23 extra procedures have been included. These extra procedures include specific history taking, different procedures in basic life support, several procedures related to wound care and some individual procedures. The second change is that the order of the procedures has changed to be better aligned with the clinical medicine curriculum. This resulted in this manual being organized in 13 chapters. The procedures are organized in relation to the 13 units in which these procedures are supposed to be covered.

We hope the order chosen will guide the students and teachers to ensure that all necessary procedures are mastered at the end of the three years. Their ordering in certain units is not meant to be a rule but to be a guideline as sometimes procedures are not exclusively carried out in one department. This applies especially for several procedures in the second year Surgery and Internal Medicine as well as the advanced communication skills in chapter 10.

The overall ordering of the manual is as follows:

∙1st Year:

oChapter 1: Basic Communication Skills (6 procedures)

oChapter 2: Computer Skills (7 procedures)

oChapter 3: Basic Patient Care Skills (8 procedures)

oChapter 4: First Aid and Basic Life Support (7 procedures)

oChapter 5: History Taking & Basic Physical Examination Skills (112 procedures)

∙2nd Year:

oChapter 6: Internal Medicine Rotation Skills (10 procedures)

oChapter 7: Skills in Paediatrics (3 procedures)

oChapter 8: Surgery Rotation Skills (17 procedures)

oChapter 9: Basic Obstetric & Gynaecological Skills (13 procedures)

Clinical Medicine Procedure Manual – edition 2009	7

∙3rd Year:

oChapter 10: Advanced Communication Skills (3 procedures)

oChapter 11: Advanced Skills in Internal Medicine (1 procedure) o Chapter 12: Advanced Skills in Surgery (5 procedures)

o Chapter 13: Advanced Skills in Obstetrics & Gynaecology (4 procedures)

The selection of the procedures follows directly from the Curriculum for Diploma in Clinical Medicine and Surgery and includes all those skills considered essential for a clinical officer to function well as a first line health care provider. Nevertheless, that does not mean that this manual is exhaustive. Trainers are free to assist students to acquire any other skill they consider essential. But believe that this manual will aid a long way in guiding the clinical officers in their practical training.

We anticipate that this manual will be used in a variety of settings; in the Skills Laboratory, in the practice area, in the classroom and in private study. We also expect that as you and we continue to use this manual, we will at the same time review it. Please, inform us about your experiences and comments as you are using the manual.

Developing this manual did not mean we had to start from scratch. There was work of many people on whose shoulders we could stand. Staff of the SkillsLab, Nursing and Clinical Medicine in Nairobi developed the first procedure manuals in SkillsLab in 2001- 2004. In 2005 and 2006 a selection of them was reviewed and bound together in the first and second edition of the Nursing Procedure Manual KRCHN by staff from the SkillsLab Department Nairobi and Nursing Department Nairobi, Embu, Mombasa Nakuru and Kakamega MTC.

We would like to thank the following persons in particular for their contributions to the afore mentioned manuals: Agnes Mwaluko, Agnes Muendo, Charles Mwangi, Edwin Wambari, Elizabeth Mweha, Janet Wesonga, John Aswani, Karolien Haeck, Mary Mwalunda, Margaret Chege, Margaret Kinyanzwii, Margaret Njoroge, Mary Kioko, Millicent Kabiru, Mirjam Heinsbroek, Mwangi Kirubi, Mwololo Kumbu, Nicholas Ochieng’, Norbert Boruett, Paul Ketele, Peter Gachau, Reuben Waswa, Rosemary Andedo, Ruth Mworia.

Furthermore, we wish to thank the following people for their contributions in reviewing existing procedure manuals and developing new ones which made the development of the first and second edition of this Clinical Medicine Procedure Manual possible: Alloys Musuya, Benedict Nzovo, Carey Francis Okinda, Carolyn Tanui, Daniel Kimwetich, Harun Chemjor, , Josephine Muia, Julius Maina, Kijungu Kishasha, Raphael Soli, David Wafula, Juma Okoth, Ben Simiyu, Kumbu Mwololo, Carolyne Meme, Florence Wachira, Zack Rwanda, Daniel Lai, Ruth Mwea Jackson Chemjor, Lucy Nziu Reuben Waswa, Marianne Darwinkel (final editing).

SkillsLab National Coordination Centre

P.O. Box 2384

00202 Nairobi

Clinical Medicine Procedure Manual – edition 2009	8

YEAR 1

of the Diploma in Clinical Medicine & Surgery

(DCMS) course

Clinical Medicine Procedure Manual – edition 2009	9

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CHAPTER 1: BASIC

COMMUNICATION SKILLS

Annex to CMS 111: Communication Skills and Critical & Creative Thinking

Communication Process & Observing

Active Listening & Non-Verbal Communication Giving & Receiving Feedback

Expressing & Exploring Feelings

Asking Questions

Summarizing

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BASIC COMMUNICATION SKILLS

Objective of basic communication skills

To relate theoretical knowledge and effective communication process to clinical communication behaviours.

Requirements

Felt pens, chalks

Flip chart with 4 markers (two different colours)

Board

Video-player and television

Simulated patients

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THE COMMUNICATION PROCESS

&OBSERVING

Objectives

The ability to:

∙Explain the effective communication process model

∙Explain the difference between observations and inferences

∙To use the 5 senses in observation

The Communication Process

What is Communication

∙The process of understanding and sharing meaning;

∙The skills that we need in our contacts with other people

Figure 1.1: The communication process – message, sender & receiver

Exercise:

Explain your views on what you perceive from the picture in the above diagram

Communication is a process, an activity, an exchange or a set of behaviours.

Communication is a process that requires understanding – a process that does not have a beginning, an end and is not static. The ingredients within a process interact, each affecting all the others.

There are different components in the process

Clinical Medicine Procedure Manual – edition 2009	13

Referent	SOURCE - ENCODER	MESSAGE	CHANNELS	RECEIVER - DECODER	Feedback
	Communication skills	Code	Touch	Communication skills
	Knowledge levels	Content	Hearing	Knowledge levels
	Attitudes	Treatment	Sight	Attitudes
	Socio-cultural		Smell	Socio-cultural influences
	influences		Taste

Figure 1.3: S-M-C-R model

The process of communication requires certain attributes so that perceiving, interpretation and comprehending the meaning of verbal and non-verbal behaviour can take place.

Some of the factors affecting effective the communication process to the sender:

1.Sender wants to keep information back

2.Sender does not know exactly what to say

3.Sender is very much involved in his own affairs (exam, tired, ill)

4.Sender speaks another language than the receiver

5.Intensity, movements, repetition

6.Non-verbal communication is not according to the words

Some of the factors affecting the communication process to the receiver:

1.Knowledge and experience

2.Feelings

3.Attention

4.Views, norms, values, culture

5.Motivation

6.Mood

7.Physical condition

8.Defence mechanisms

Advantages of good communication

1.Patients are more satisfied with the service which they receive

2.Patients are more inclined to comply with medical regimes and procedures. Poor communication is a major cause of patient dissatisfaction.

3.Good communication increase comprehension and recall of info received

4.Outcomes appear to be not only psychological (e.g. feelings of satisfaction) and behavioural (e.g. compliance) but somatic, measured by improved health indices and recovery rates

5.Good communication amongst the health care team is vital for the effective care of patients.

Clinical Medicine Procedure Manual – edition 2009	15

Figure 1.5: Expressions

Exercise:

Observation is subjective.

What is expressed in the pictures above?

Why observing is subjective:

1.You know what you are observing already (someone shy)

2.You have a self-image

3.You have a certain mood (also moment of the day, own health)

4.You have more or less experience with observing (essentials and details)

5.You have a certain ideal or vision (e.g. on abortion)

Conditions for good observation:

1.At regular times and in different manners observing

2.As objective as possible

3.As much as possible inconspicuous

4.As accurate as possible

Summary

Communication is a process where a source sends a message through certain channels to a receiver (SMCR-Model). It takes place in a situation where the message is observed, interpreted and followed by a behaviour choice. It is a process of action and reaction. There are a lot of factors that can disturb the communication process.

Training communication skills is learning and training essential techniques for interacting effectively. In your profession it is important to be able to surpass the level of instinctively, to dissociate yourself from your own frame of references and to be able to put yourself in another person’s position. It is proven that good communication offers a lot of advantages.

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Exercises

Exercise: observation

Introduction: When you look at someone you can see everything and you are open for all kind of information. When you observe, you especially look to some specific item of the total information. So, observing is looking to specific things. This exercise is also to learn to know each other.

Form pairs by taking a number out of the pot. Look for the person with the same number. This will be your partner to observe. Fill in the list after a first impression. After observing the other person during the session you fill in the second column.

Behaviour	First view	Observation
Way of sitting
Position of the head
Way of listening
Eye contact
Making contact
Asking attention

Discussion:

Per pair talk through the observations you wrote down. Try to find the reasons for eventual differences e.g. at first view, I had the impression that you make few contacts but after observation, I discovered you do make contacts but only for short times. Possible cause for the difference can be that I saw you standing alone very often and you did not talk with anybody. Maybe I only saw those moments and that was why I wrote you make few contact. After this discussion the whole group can discuss together a few differences and the causes, the way real observation is influencing your attitude towards the other person, advantages and disadvantages of observation, influence of your own frame of references...

Exercise: action and reaction

Group A are students who try to imagine how health workers would react in reality Group B are students who try to imagine how patients would react in reality.

Each group tries to make an inventory of all possible behaviours that could have a negative influence on the other group, either by purpose or not.

Group A: Write on a paper: column 1 behaviour of the nurse, column 2 emotional effect on the patient and column 3 reaction of the patient

Group B: write on a paper: colon 1 behaviour of the patient, column 2 emotional effect on the nurse and column 3 reaction of the nurse

Discuss the results

Start the game again by giving column 3 to the other group

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Exercise: Use of the 5 senses

Exercise: give an example of the use of 5 senses from your experience on the wards. e.g. Listening to the heart sounds; feeling the pulse in resuscitation, looking to the thorax to see respiration movements, smelling alcohol with an unconscious patient, in the past urine was tasted to measure the amount of sugar.

Exercise: factors influencing the communication process

Preparation:

Give a task to someone (something simple like put 5 chairs on a row or go three times in and out the room). Describe also the way to give the task (e.g. Hurry up otherwise you are disqualified, don’t make noise...)

Let everyone pick a number on a small paper and let everyone choose. Two persons should get the same number.

Exercise:

∙Let corresponding numbers give the task to each other the way they described it.

∙Observe your own reaction and feeling when you heard your task.

∙How was your reaction when you received your task?

∙How did others react when they got their task?

Discussion:

For the receiver:

∙What was your first reaction when you heard your task?

∙What was your feeling about the way the task was given to you?

∙Did you fulfil the task? If no, why; if you did, why?

For the sender:

∙How did it feel to give the task the way you described?

∙Was the reaction of the receiver the way you had given the task?

Exercise: sending versus receiving

Observation is subjective. You observe with different senses e.g. Hearing. Sometimes you don’t hear what you have to hear. The result is that some things can be unclear; even more people might not be able to understand each other.

Exercise:

Two people A and B have each a pen and paper. Person A draws a picture that cannot be seen by person B. Then, person A tells person B what to draw. The purpose is that person B draws the same as person A. Person B draws what person A told him (e.g. A straight line from the middle, starting on top of the paper; a small circle on the bottom of the paper at the right side...) B is not allowed to see the drawing of person A during the exercise. A can see the activities of B, but cannot correct B. B is not allowed to ask questions to A.

Discussion:

Compare the two drawings and discuss differences and similarities. Discuss why there are differences. Is it because the instruction from person A was not clear? Was it because person B had a different size of dog in his mind when person A was thinking about a big dog …?

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Exercise: everybody says the truth

Everybody says the truth. The truth is not what is said, but what you hear. Observing is subjective and the observations are different depending on the observer. It is good to discuss the differences and the reasons.

Exercise:

∙Person A tells a story about something she encountered. It is taking on cassette or video.

∙The others listen to the story and they talk to each other.

∙After that each of the observers writes down briefly what they heard.

∙Thereafter the different observations are compared. Discuss the differences and what made the observations different.

∙Repeat the exercise with a different person telling the story

More exercises:

∙Look through a telescope and describe what you see so that another person can draw and interpret it

∙Discuss advertisements and the way the situation guides the interpretation

∙Boggle-game: you find different words with the same letter blocks

∙2 persons with umbrella’s who must pass each other on a small path

Clinical Medicine Procedure Manual – edition 2009	20

ACTIVE LISTENING & NON- VERBAL COMMUNICATION

Objectives

The ability to:

1.Explain and demonstrate principles of active listening

2.Interpret the non-verbal communication (body language) and respond appropriately

3.Determine the importance of active listening

4.Apply active listening and non-verbal communication in practice

Introduction to active listening

Active listening is a, strenuous activity, which involves:

1.Conscious reception of auditory stimuli

2.Self awareness of the sender and receiver of the message

3.Comprehension of the message

4.Interpretation and correlation of the message and other data

2									Good	listening encourages
									talking, coding, and decoding
									of the information
						3
		4							Stimuli:
								1.	The ears bear stimuli
							5
								2.	Nerves transmit sensation to
									the brain
								3.	The brain attends to the
			1
								4.	stimuli
									The	stimuli are assigned
									meaning
								5.	The Stimuli are placed in
									short term or long term recall
									and affect how future sounds
									will be treated

		You hear with your ears but
		you listen with your brain!
	Figure 1.6: Hearing versus listening

To understand the process of listening we need to distinguish between hearing and listening.

Hearing is the act of receiving sound. It is not the same as listening.

Important to note:

1.Both the sender and receiver should be aware of themselves (self-awareness) e.g. are you ready? Can we start?

2.The channel of communication should be appropriate e.g. appropriate language, tone of the voice

3.The distance between sender and receiver should be appropriated (close enough)

4.A conducive environment – interruption free (if it is room, lock the door or engage it)

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Core elements of active listening:

1.Approach the client in a purposeful and unhurried manner e.g. introduction, of self the topic, the role, time available

2.Remember SOLER

a.Sit squarely

b.Observe non-verbal communication and maintain open posture

c.Lean forward towards the client

d.Eye contact much as possible

e.Repeat/paraphrase/revise as often as possible

3.Put aside your own needs (e.g. smoking, taking tea, reading a magazine) and focus on the client’s needs

4.Avoid interruption in the middle of the discussion e.g. telephone calls, talking to friends)

5.Demonstrate acceptance and understanding of the client

6.Encourage the client by using verbal and non-verbal indicator e.g. mmm, yes or nodding of the head …

7.Clarify or ask for clarification of unclear message e.g. when the client starts crying or in the middle of the discussion

Areas for attention to the health worker:

∙Observe the client’s non-verbal behaviour e.g. smiling, restlessness on the chair, yawning

∙Indicate to the client that you are about to end the discussion, for example by summarizing and giving feedback to the client

Importance of active listening

1.Eliminates barriers to effective communication

2.The sender is encouraged to talk more

3.Both the sender and receiver feel respected and expected

4.Avoids a lot of repetition thus saves time

5.Avoids wrong conclusions

6.Enhances mutual relationship

7.Fosters an atmosphere of trust between the sender and receiver

8.Use to evaluate the communication process or instruments

9.Clarity of the message is ensured

10.Avoids being judgmental

Special considerations during the conversations

1.As a health worker you are not always emotionally the same

2.Clients are of different emotional status and personality e.g. shy, introvert or extrovert

3.Every client is an individual, thus similar problems are perceived differently

4.The client has come to you desperate for a solution

5.The environment should be sufficient state to accommodate all clients

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Environment				Sender/Receiver			Channel			Message
Conducive		environment		Emotionally stable e.g.:			Stimulating e.g.:			∙	Timely
e.g.:				∙	not anxious		∙	Sender comfortable		∙	Meaningful
∙	Non threatening			∙ Not in a hurry				with channel		∙	Applicable to
∙	Interruption free			∙	Not biased		∙	Receiver			the situation
∙	Free		from	A good communicator e.g.:				comfortable	with	∙	Short and clear
∙	destructors			∙	always relevant		∙	channel
	Appropriate facilities			∙	aware of elements of			Enhances
	e.g.	chairs	and		communication		∙	communication
∙	tables				process:			Enhances
	Distance			o	Paraphrasing			communication	and
				o	Asking questions			retention of the facts
				o	Giving feedback
				o	Summarizing
Table: Motivators of active listening

Sender / Receiver		Channel			Message
∙	Biasness	∙	Inappropriate	e.g.	∙	Untimely
∙ Hearing or talking deficits (lack of eloquence,		∙	loud or low		∙	Not meaningful
∙	partially deaf)		Unclear writing	or	∙ Not applicable to the
	Time limitation		words			situation
∙ Opposite sex (can be a strong point at times)					∙ Too much at a short
∙	Age					given time

∙Poor listener / personality e.g. introvert

∙Health status

Table: Barriers to Active listening

Introduction to Non-Verbal Communication

People learn more when seeing and listening simultaneously.

Psychologists say that:

∙We learn:

o11% through hearing

o83% through sight

∙We retain

o20% of what we hear

o50% of what we see and hear

Messages can be transmitted by means of body language more than what one says. One is usually more honest in non-verbal behaviour as it is not easy to watch the tongue than “watch” facial expression or body language.

Non-verbal signal can have strong effects: A comforting gesture, a hand on someone’s arm, a hug, smile etc is much more meaningful than the words.

It is important to listen “between the lines, i.e. pay attention to the other person’s behaviour

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Functions of Non-Verbal Behaviour

1.Gives indications of qualities, attitudes and identity:

a.People’s emotions and moods. Can be observed through his facial expression, posture, sounds of his voice and gestures

b.A person’s status, age & gender can be observed from appearance, and clothing

c.Qualities like dominance, self-assurance, submissiveness and uncertainty are expressed in body postures and gestures.

2.Supports and regulates verbal communication

3.Replaces verbal communication e.g. in case of loud noise, distance or language barrier sign language is used

4.Regulates interpersonal relations

The Relationship between Verbal and Non-Verbal Communication

1.The non-verbal behaviour is clear in itself:

a.When actions are clearer than words in agreeing or disagreeing in a conversation: words are not always necessary to express approval or disapproval - shaking the head or using hands to regulate are strong non-verbal alternatives.

b.One cannot smile to mean disapproval and shaking head to mean is agreeing with the point.

2.The non-verbal behaviour supports the verbal behaviour:

a.When you like something you say it and accompany with a smile. A dislike of a person the face is dull and does not go near him.

3.The non-verbal behaviour is in contrast with the verbal –behaviour:

a.A person says he is alright but looks gloomy. The verbal communication and non- verbal should not contradict each other if it happens then the person emitting this is not understood.

Aspects of Non-Verbal Behaviour

∙The way the person speaks:

oVolume, vocabulary, melody etc.

∙Appearance (one forms first impression):

oPhysical characteristics e.g. slender, bald, short, tall

oPhysical hygiene/appearance e.g. clothing, jewellery, make up, clean

∙Body posture and movement:

oCan show whether one is confident or not, peaceful or angry, thinking hard or relaxed etc.

∙Gestures:

oScratching head, rub skin, jerk corners of the mouth. Some gestures are obsessive and occur frequently – “tics” involuntary gestures

∙Facial expression:

oExpresses mood and change of moods or feelings. E.g. smile, frown, yawn, flaring of nostrils in anger can be noticed.

There are four zones of distance that people can keep to determine their relationship and the topic of conversation:

Closeness of both the sender and the receiver shows more intimacy and promotes effective communication. The longer the distance creates a barrier and shows rejection.

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Exercises

Exercise active listening

Aim:

To become aware that active listening is built on concentration and attention.

Exercise:

Give someone a text to read. One reads 5 sentences slowly and clear. The next one tries to repeat what was read. The first one corrects where necessary. After that another person reads 5 sentences of the text.

Discussion:

Was it difficult to listen to the other? Why, why not? How could you listen more actively?

Exercise on active listening

Aim:

To become aware of your own way of listening.

Exercise:

While you have a conversation with some one else you record it on cassette or video. Afterwards you look back or listen to the conversation. Try to find out how you were listening. How could you eventually improve your way of listening?

Exercise active listening: “prohibited to listen”

Aim:

To become aware of your feelings when one is not listening to you or you don’t listen.

Exercise:

Make pairs. Tell a story to each other. You can choose the subject. While the other is talking you are not allowed to listen, you cannot run away but show in your behaviour that you are not listening.

Discussion: how it feels when someone doesn’t listen to you and how does it feel not to listen to the other:

Exercise non –verbal communication: Video example

Discuss the non-verbal communication on the video examples first without the sound; afterwards look another time with the sound on.

Exercise non-verbal behaviour: Eye contact

The group is walking slowly in the room. When the lecturer gives a sign, everybody stops and you look to the eyes of the one, which is most close to you. Don’t speak. Repeat this several times.

Discussion: describe how it feels when someone was looking in your eyes. How did you react? Were you aware of the reaction of the other?

Were there differences in the reactions? Why?

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Exercise non-verbal behaviour: Interpretation of body language of emotions

Sitting in a circle, the lecturer says an emotion and everybody tries to express it with his body. Look for differences and similarities. Discuss this.

Exercise non-verbal behaviour: Interpretation of body language

Give a photograph of a person or persons. Describe what you can see and what the person tries to express. e.g. what profession the person can have; how old is the person; is he rich or poor; is the person happy;…

Discussion:

Are there different results, why, how does the different interpretations of the body- language influence the communication?

Exercise non-verbal communication: The use of silence

Start a conversation in small groups. Everybody can join the conversation but after 3 sentences you should stop talking and someone else should take over the conversation. The person who takes over the conversation can be any one in the group. Try between the different persons to have a silence as long as possible. Only start talking when you feel you should react.

Discussion: How does it feel?

If you could videotape it: how are your non-verbal reactions during the silence. How did you feel?

Exercise on non- verbal communication

Exercise:

One person out of the group takes a paper with a feeling on it. The person tries to express it with body language and the others have to guess. On the paper can be written a feeling or a profession.

Exercise:

Give a paper to two persons with 5 words on it that compose a small story. The others have to describe what those two persons act so that they use in their description the 5 words, which were on the paper, e.g.:

∙Car, road, policeman, driving license, to pay.

∙shop, computer, explanation, expensive, pay with a VISA card

∙Pregnant women, contractions, matatu driver, drives to the hospital, go to emergency department.

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Exercises on giving and receiving feedback

Exercise 1: Giving positive feedback

Make pairs and give positive feedback to each other. To start, one person gives feedback about a good thing in the behaviour of the other. Use the rules of feedback while giving the feedback.

Discuss afterwards how he/she used the rules to give feedback and what effect the feedback has on the receiver. Then change positions.

Exercise 2: Giving and receiving feedback

Use the training situations given on the next page.

Group work:

Make groups of three students.

Person A is given a certain situation and gives feedback to person B.

Person C observes how the feedback is given and what the reactions of the person receiving the feedback are. Person C can also interrupt the talk when the rules of feedback are no longer observed.

Rotate positions so that everybody takes every position.

Discuss how the rules of feedback were used and what difficulties emerged.

Plenary discussion:

Discuss afterwards how it feels to get feedback. What are the advantages and disadvantages of giving and receiving feedback?

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Situations for feedback exercises

Situation 1:

You come on your duty in your ward. Your colleague from the night shift putted an infusion and did not clean the place afterwards. This is already the third time that this happens. You have a lot of work to do and before you can start, you must clean the rubbish she made. You want to talk with her about this.

Situation 2:

You are a health worker. A second year student of KMTC is under your supervision and he / she is prepared to give an injection of Benzyl penicillin to a patient. You observe that the student is too close to the Sciatic nerve in the lower medial quadrant of the buttock. You know the danger associated with injury to the sciatic nerve and you take respond appropriately.

Situation 3:

You have told your sister about a quarrel with your boyfriend. One week later, open as she is, she says in front of a group of her friends: “O don’t worry, last week my sister also had a quarrel with her boyfriend but now everything is okay”. You don’t like it that everybody knows about it now and you try to tell this to your sister.

Situation 4:

You have an appointment with a friend in town. After one hour waiting, he doesn’t come. Your first reaction is one of anger and disappointment. You know he is often distracted and maybe he just forgot it. You feel very upset about it and you want to end your relationship. Nevertheless, you decide to give him another chance. You want to speak with him about this.

Situation 5:

You are sharing a room with another student and you are happy with each other. The only thing is that she doesn’t clean the bathroom after washing herself. You always have to do it before you start using it for yourself. You get irritated about it and you want her to talk about this.

Situation 6:

You are a student and a friend borrowed your bicycle. He is not back and you need it to be in time for your exam. You are very nervous and decide to go to school by foot. When you leave the house, you see your bike. You are upset because he did not inform you he returned it. Give him feedback about this.

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EXPRESSING FEELINGS AND EXPLORATION OF FEELINGS

Objective

Understanding aspects and importance of expressing feelings and the ability to explore other people’s feelings in an appropriate way

Introduction of expressing feelings

Figure 1.8: Expressing emotions

Exercise:

Which feelings are expressed in the pictures above?

Feelings can be expressed both in a verbal and non-verbal manner. Expressing feelings verbally is something most of us find very difficult. But even when not expressed verbally, our feelings are often still visible to others in our non-verbal behaviour.

Examples of situations where we might non-verbally show what we feel:

∙Getting annoyed with others during a group discussion but not saying anything about it.

∙Disagreeing with decisions taken, without saying so.

∙Meeting somebody you like, without showing it?

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What it takes to express feelings

1.Courage It takes courage to put your feelings into words. People sometimes fear unkind / negative reactions from their surroundings, e.g.: In some cultures it is considered a sign of weakness when men express their feelings

2.Honesty Balance between being dishonest and being blunt.

There are people who think honesty is essential and tell others right to their faces what they think about them. There are also people, who are so careful (afraid) not to hurt others, that they never make clear what the situation means to themselves.

Feelings are very relevant to your behaviour and if they are visible to others in most circumstances, it is important to find out why you are trying to disguise them and whether that reason is valid.

In most instances, you do not blame a person for his/her feelings of grief, joy, anger, affection or fear. Most likely, others will also accept such feelings from you.

Importance of expressing feelings

1.	Show more of	If you keep your feelings hidden, others can see only half of
	yourself to others	you, your rational side. So it is only this half they can take
		into account. But is this your essential half? Conversations
		tend to gain in depth when important feelings are expressed.
2.	Reduce	You might control yourself verbally in not translating your
	misunderstanding	feelings into words, but controlling your non-verbal
		behaviour is very difficult. Without verbalizing, others are

forced to interpret your non-verbal behaviour, with all possible consequent misunderstandings.

Non-verbal expression of feelings can be very clear, but in some cases it can be necessary to explain in words what a certain situation means to you. For example, in a situation where the other person does not see your non-verbal behaviour or ignores it, you will then have to express your feelings verbally in order to intensify the non-verbal and to stand up for yourself.

Efficient and clear ways of expressing feelings

Presentation Use an I-message

Many people put their feelings into words in an indirect manner, as if they were not exclusively theirs e.g. “I feel very disappointed” is much clearer than “No one would like something like that”

Construction The message always contains 2 elements:

1.How you feel

2.On what this feeling is based

In relation to construction:

Accompany the feelings with information on the occurrence or fact to which they relate: “I am very disappointed; I really studied hard and now I still have only a grade C”.

When you do not accompany your verbal expression of feelings with telling anything about the cause or circumstances the other person lacks the information she / he needs to determine how to react. For example “I feel depressed”. He / she may ask for further information but more often than not this is not done. A statement like “too bad” then dismisses the matter.

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Figure 1.9: More expressing feelings

There are people who spontaneously without introduction put their feelings to the fore, others introduce first, apologizing for their feelings as it were.

What is your attitude on expressing feelings is and what considerations are decisive?

Introduction to exploration of feelings

Feelings largely determine our behaviour; therefore to understand someone’s behaviour you have to be acquainted with his/her feelings.

We often find it difficult to react to someone’s feelings and tend to quickly change the subject instead. By doing so we miss an opportunity to really gain any deeper contact with other people. For we ignore the very thing that makes them behave the way they behave.

Remember someone’s “character may be manifested in great moments but it is made in many small ones”

In a caring profession it will be impossible not to include the aspect of exploration when faced with an emotionally loaded situation. The client’s experience in these situations will often be information indispensable for making a problem diagnosis.

Exploratory questioning for feelings is a skill you cannot apply easily as a trick. It is a technique you need to acquire through practice in order to master it and for it to become a natural part of your everyday behaviour.

Guidelines on how to explore feelings

1.	Observe the	non-	Pay special attention to the congruency to what someone says.
	verbal behaviour		Say what you observe when you think the verbal and non-
			verbal are not in accordance with each other, e.g.: “You say
			that you are glad yet you look gloomy”.
2.	Give feedback	to	Say what you observe if the other person does not speak about
	non-verbal		his/her feelings, e.g. if he looks sad, jerks the mouth “I can see
	behaviour observed		you are moved”.
3.	Ask for details		Preferably use open questions, for example “What does this
			mean to you”?

4.Avoid escaping into Have courage to ask for details about feelings facts

5.Know when to stop

You use the I –message and encourage the other person to do the same

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Mistakes frequently made

Unjust reassurance

Reassuring a person is only correct if the reassurance is justified. When it is not justified it only discourages talking about feelings because you create the impression that you do not want to hear that the other person feels bad.

Too hasty identification / Attributing to another person

Some people feel such a pity for people who have a rough time that they start complaining with them even before they know why the other person feels that way. It also cuts of the route to real understanding of the other person’s feelings.

Both mistakes arise from an insufficiently suppressed urge to take the lead in a conversation - a tendency which is very common in communication.

Exercises on expressing and exploring feelings

Exercise 1: Expressing negative feelings

A friend walks into your office when you are very busy and while you watch with growing irritation he/she turns the light switch on/off 10 times.

What determines whether you have the courage to express your feelings? How would you express your feelings (practical situation)?

Exercise 2: Expressing negative feelings

Snoring sounds are more disturbing to sleeping partners than to the snorers themselves, who are usually unaware of the problem until someone complains.

Your partner is a snorer and you have complained severally but he/she denies this vehemently and you are not happy about it. Express you feelings to this situation

Exercise 3: Exploration of feelings

Form groups of four (4)

Let each member remember a recent occurrence that evoked strong positive or negative feelings.

Each in turn tells the facts around the occurrence.

One of the others next tries to obtain information, tries to explore, about the feelings connected to this occurrence.

Two other observe and give a feedback about the exploration. Roles are then swapped.

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ASKING QUESTIONS

Objective

The ability to use the art of asking questions efficiently while communicating with patients, relatives or colleagues

Specific objectives

While communicating with patients, relatives or colleagues, the health worker is able to:

1.Use specific types of questions – open or closed – as the situation requires

2.Ask clear and concrete questions

3.Ask questions relevant to the situation

Introduction to asking questions

As a health worker, asking the right questions at the right time is a core skill to get the correct information from the patient and central to your management of the patient.

The way questions are asked is an important factor determining the process and the outcome of any communication.

The way health workers ask for information, either from clients / patients, from relatives or from their colleagues will influence their assessment of a medical situation and their consequent actions.

Open- and closed-ended questions:

Two basic types of questions can be distinguished:

1.Open-ended questions:

a.They do not exclude any answer-category

b.They give minimal structure and direction to the answer so that the client has the freedom to answer in his / her own way

2.Closed-ended questions:

c.They provide limited options for answers which are often short (frequently either “Yes” or “No”)

d.They are easily suggestive / leading (“Was the discharge smelling?”)

Examples
Open-ended	Can you say something more about the abdominal
	discomfort?
	Did you notice anything while urinating?
	When you are unable to fall asleep, what are you thinking
	about?
Closed-	Do you feel the abdominal discomfort left or right?
ended	Does your urine look dark?
	When you are unable to fall asleep, are you thinking about
	your job

Probing

Probing refers to a questioning technique whereby you try to encourage the receiver (patient) to give more specific information (“What happened next?” “How did you feel after you completed the course of antibiotics?”)

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Conducting the interview

Open-ended questions are useful in exploring a problem. Probing is used to dig deeper into a certain problem. Closed-ended questions are useful to clarify the relation between the problems experienced and a certain disease. Furthermore, questions can be used to confirm whether the information you have obtained is correct. This can be done by delivering a summary of the information in a questioning way. Sometimes it can also be useful to repeat some questions in a slightly different way.

After the identity of the patient has been established or confirmed, an interview with a patient usually starts with an open-ended question like “What can I do for you?” or “Why have you come to see me?” Several more open-ended questions are normally asked (“What can you tell me about the cough?” “What other problems do you experience?”) to establish the scope of the problems and its effects on the patient. Closed-ended questioning technique can be used to clarify some information (“You said the sputum is green?”) or get specific details (“Does the sputum contain any red or brown spots”?) relevant to diagnosing and managing the patient. Repeating your question slightly differently might help the patient if you think she / he has not understood or if the answer was not clear to you.

Interviewing styles

During medical interviewing, different styles of interviewing are possible. Commonly distinguished are the “health worker-centred style” and the “patient-centred style”. In terms of communication skills being used, the latter is characterized by more open- ended questions and more probing where the health worker-centred style is characterized by a tendency to use closed ended questioning. Also, active listening and observing the patient are more prominent in a patient centred approach. All techniques tend to encourage the patient to talk freely.

Health worker centred	Patient centred
Questions focused on getting answers to questions	Questions focused on getting information on the
arising from the medical technical references of the	references of the patient
health worker
Objective: collecting information about facts	Objective: collecting information about the facts in
	relation to the patient
Advantage:	Advantage:
∙ Control over the discussion	∙ Clarifies the problem of the patient
∙ Only covering areas which the health worker is	∙ Focus on solution of the problem of the
comfortable with	patient
∙ Many questions can be asked in a short while
Disadvantage:	Disadvantage:
∙ Easy to miss the real problem	∙ Health worker can feel uncomfortable with
∙ Easy to give solutions which are not suitable for	not leading the conversation
the patient	∙ Issues the health worker does not feel
	competent to handle, might arise
Commonly used communication techniques:	Commonly used communication techniques:
∙ Health worker talks a lot	∙ Health worker talks less and listens more
∙ Use of closed-ended questions	∙ Use of open-ended questions
∙ Use of suggestive questions	∙ Use of probing techniques
∙ Little encouragement, reflection or silence	∙ Use of reflective questions
	∙ Summaries are given in a reflective manner
	∙ Encouragement and use of silence
Table: Interviewing styles

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SUMMARIZING

Objective

The ability to use the different forms of summarizing effectively

Introduction of summarizing

Summarizing is pulling together the main ideas or suggestions from a more elaborate communication, for example from a conversation, a text or a small group discussion.

Summarizing can be used as a tool to give feedback to the other person and to receive feedback in return.

Functions of summarizing						Explanation
1.	Brings	order		to	a	People often jump from one subject to the other. A summary should
	conversation					distinguish the major from the minor points of discussion.
2.	Stimulates			further		Hearing again in brief can assist the other person to elaborate more on certain
	exploration					issues
3.	Brings		emotional			When somebody is emotionally affected, emotions tend to be more prominent
	statements		back	to	the	than facts. A summary can assist to separate the emotions from the facts:
	point					“You think that your insufficient mark was not justified and you feel cheated”
						“I understand that you are very angry about it. You have told me so far that...”.
4.	Gives a rest					It gives the partner in the conversation some breathing space and time to
						reflect on what has been discussed and what to add
5.	Shows interest					A correct summary gives evidence of active listening behaviour
6.	Check	the	information			Summarizing is a means of auditing whether you have really understood the
	obtained					other person. It gives the other person insight in how his information was
						understood. To enhance this effect, a summary should be ended with a
						question like “Is that right?”
7.	Discourage		talkative			A short summary of content can assist to bring the conversation back to the
	people					relevant problems to be discussed and in case of a group conversation can
						create opportunities for less talkative people to contribute
8.	Give a clear picture of					In a group discussion, a summary can assist in arranging similarities and
similarities and differences						differences of opinions given.
	Table: Functions of summarizing

Forms of summarizing	Clarification
Repeating	Repeat part of what has been said, using the other persons words – used as an
	encouragement to continue talking
Paraphrasing	Restate what the other person has said – can be used as a clarification.
	Generally includes an emotional component which makes it more challenging
	and confronting than summary
Summarizing	Either at the end of a certain line of enquiry or after the whole conversation or
	discussion
Table: Forms of summarizing

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A good summary…:

1.… is very clear

2.… is brief but complete

A summary should contain the main points and relationship between them e.g. (content vs. feelings; similarities vs. differences; pros vs. cons).

3.… separates facts from feelings

4.… is timely, not too frequent, not too late

5.… is given in your own words

This will prevent the parroting effect. Make sure the words used are understandable to

other people.

6. ... is restricted to the topic of the conversation

A summary always follows conversation. No new elements should be added in a summary - if you do that, it is no longer a summary.

7.… is without judgment, valuation of the person summarizing and without conclusion

The person summarizing should leave his own opinion out of a summary, for example: “I think you take a negative view of it” is not summarizing.

8.… is sometimes done by the other person

You can invite the other person to give a summary instead. For example, when you have given information so that you can confirm whether she / he has understood or as a clarification.

Box: A good summary

Mistakes frequently made when summarizing

1.Summarizing too much, too brief

2.Failing to distinguish between content and feelings

3.Parroting

4.Presuming your summary will be correct

5.Using your own presuppositions (instead of paraphrasing)

6.Adding your own conclusions or valuations

7.Summarizing too selectively and thus directing too much, for example:

a.Limiting your summary to that which you agree with

b.Only summarizing what you yourself contributed to the conversation

Box: Mistakes in summarizing

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Exercises in summarizing

All of the following exercises should be followed by a discussion on the following:

∙Which forms of summarizing were used? (when applicable)

∙Did the summaries demonstrate the elements of a good summary?

∙Which mistakes were made?

∙How did the summaries contribute to the conversation (when applicable?)

Exercise 1: Summarizing a video or text

The group watches a video fragment and several group members are asked to summarize it.

OR

One group member reads a fragment from the newspaper and several group members are asked to summarize it.

Exercise 2: Summarizing a conversation with different views

The trainees divide in groups of 3 or 4. They discuss on a topic on which people have many different views (e.g. politics; abortion; wild life protection). They discuss the topic for several minutes. One of them is appointed the role of summarizing (parts of) the conversation.

Exercise 3: Summarizing a complaint

Two students role-play a patient and a health worker. The student role-playing the patients demonstrates a common complaint or problem. The health worker uses the art of summarizing while exploring the problem. Others observe.

After discussing the summarizing skills, trainees exchange roles.

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CHAPTER 2 COMPUTER

SKILLS

Annex to CMS 112: Introduction to Computing

Introduction to Basic Computer Use

Getting Started

Word Processing

Windows Explorer

Internet & Email

Software for Medical Professions

Annex: Useful Keys and Key Combinations

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INTRODUCTION TO BASIC

COMPUTER USE

Introduction

As you know or you will later learn the computer world is really dynamic. With this introduction in computer use we wish to equip you with the basic skills to use a computer as a learning devise throughout your training at KMTC.

Within this first part we will provide you with the objectives and requirements of the computer sessions and some basic concepts that you will encounter while interacting with the computer. In the following parts we will take you through different procedures and exercises. We will use the following format:

∙A text that appears on your screen will be displayed as: text on screen

∙	If want you to type something it looks like:		type this
∙	Menu commands are shown like:	Choose File
	Combinations of keys at the same time look like:				Ctrl+S
	A procedure or exercise will appear in a box:			procedure

Objectives

After completing the SkillsLab sessions on computer use you will be able to:

1.Start your computer and log on

2.Use Windows to start and quit programs

3.Use Windows explorer

4.Use Windows to store and organize documents

5.Use MS-word to create and edit a document

6.To send and receive e-mail

7.To use internet to search for medical information

8.Use medical programs as learning tools

Requirements

A personal computer (PC) with the following programs:

∙Windows (1998 or above)

∙MS Word (1998 or above)

∙Outlook (1998 or above)

∙Internet Explorer (1998 or above)

∙Adam Interactive Anatomy

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Basic concepts

PC (Personal Computer)

A Personal Computer is a tool that can help you with your work with words, numbers, graphics, and communication. Also laptops and notebooks are types of personal computers, they look different but they perform the same jobs.

The main components of a PC are Software and Hardware.

Software

Software is the brain of the computer. The software tells the hardware what to do, without software your computer has nothing to do, like a car without a driver. Two important types of software are:

System software (or operating system): The basic software that makes everything else run. Most computers run on system software called Microsoft Windows.

Application software: The software doing the work for you, like: word processing, games, send and receive your e-mail etc.

Hardware components of the computer

Hardware is the physical part of the computer, anything you can touch or see.

Console (or system unit): The box in which all files and software are stored. It is the main component of hardware and any other hardware component is connected tot this console. If you look at the outside of the console you will see various buttons, lights and holes into which you plug in the rest of the system. Some of these holes are:

∙Slot for floppy disc drive– usually called A: drive

∙CD ROM or DVD drive – usually called D: drive

∙USB port – often called E: drive

These drives can read information from a floppy, CD, DVD or memory stick (also called flash disk).

Monitor: The TV-screen on which information stored in your computer can be displayed.

Mouse: It is one of the devices that allow you to communicate with the computer. When the mouse is moved, the computer responds by moving a mouse pointer or cursor on the display screen. When you click on one of the buttons on the mouse your computer will perform an action depending on the place of the mouse pointer on your screen.

Key board: Is the thing you type on like a typewriter but with Ctrl keys, Arrows (for taking you up, down, right or left), and special Function keys. It is another device to communicate with your computer.

	Figure 2.1 Mouse and keyboard
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UPS (Uninterruptible Power Supply): It is a battery that keeps your computer running for a short while when the power goes out. It will allow you to safe your work and turn the computer off properly.

Network

A computer network is a collection of computers that are physically connected by network cables. Networks are used for sharing resources such as files, programs, and printers.

Server

The server is the unit that controls the network. This unit can be seen as a computer with an enormous memory (storage) capacity which enables each user of the network to share the network resources.

User account

A user account provides you entry to the computer resources. Each user account consists of a unique user name (to identify you as a user) and password (to prevent unauthorized persons to use your account).

Internet

Internet is composed of hundreds of thousands computers all over the world. The computers send and receive information, and most important, they store information. You can access the Internet by using a web browser.

Internet Service Provider (ISP)

An ISP is a company that sells access to the Internet. You pay such a provider to get access to Internet.

Web Browser

A Web Browser is software that helps you to get access to Internet. A common one is Internet Explorer.

Search engine

A search engine is software that helps you search information on the Internet. The most commonly used web browser is called Google.

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GETTING STARTED

Starting the Computer and Logging on

Procedure: Starting the computer and logging on

Step 1	Turn on the UPS by pressing the switch on the UPS to the digit 1
Step 2	Turn on the computer by pressing the start button on both the console and the
	monitor. Both buttons have a similar image with a circle cut by a vertical line
	on the top.
	WAIT until he logon information dialog box appears
Step 3	Press Ctrl+Alt+Del to log on
	Figure 2.2 appears:
Step 4	Type in your User name and your Password and click OK

Figure 2.2: getting started – Log on screen

After starting your computer, the operating system named Windows will come to life. You will see the basic screen of Windows which is called the Desktop as shown on the following page.

The basic things you can see on your desktop are:

Background: It is possible to change this picture for your favourite picture but that is something you can try out later.

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Icons: These little pictures are actually short cuts to programs, folders or files. So it is not the thing itself but when you activate it, it will bring you there.

Taskbar: At the bottom of your desktop, the taskbar is your tool to control the Windows operating system. One important thing on the taskbar is the Start button on the left side. It is your entry to the Start panel from where you visit various important places and start most of the programs you use in Windows.

Figure 2.3: Background, icons and taskbar on desktop

Exercise 1: Warming up with basic mouse operation

There are several operations you can perform with your mouse, let’s start with the basic ones. Hold your mouse with a gentle grip while it is placed on the mouse pad. Make sure your index finger rests on the left mouse button. Now let’s try some basic mouse operations:

Point the mouse

When you are told to “point the mouse” you move the mouse around by rolling it on your mouse pad. Simultaneously you will see a mouse pointer moving around your screen and you can actually point at something.

Try out what happens when you point at the small icons on the right side of the task bar at the bottom of your screen. What does it tell you?

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Exercise 1 continued: Warming up with basic mouse operation

Click the mouse

Once you have pointed something you can click one of the buttons on your mouse. Most operations take place with your left mouse button. Unless we tell you explicitly to click the right mouse button, expect to click the left button when you are asked to click. Clicking the mouse will activate different type of operations, e.g.:

∙Selecting something: click once at one of the icons on your desktop and describe how you can see that you have selected it

∙Opening a menu: click once on the Start button and see what kind of menu pops up

∙Closing a menu: just click next to the popup menu and it will close again

Double click the mouse

Opening a program or folder: click twice (rapid clicks in a row at the same spot). Try double clicking some of the icons on your desktop. Close whatever you have opened by clicking once on the white cross in the red box on the right top of the window or program you have opened.

Drag the mouse

Dragging with the mouse is used to:

1.Select a group of items on your screen

2.Pick up and move an item on your screen

To drag with the mouse, follow the steps below:

1.Point the mouse at the icon you want to drag (choose any from your desktop)

2.Press and hold the mouse button down

3.Move the mouse until your item is at the location of your choice

4.Release the mouse button.

If you want to drag to select a group of items follow these steps:

1.Point the mouse just left of the group of items you want to select

2.Press and hold the mouse button down

3.Move the mouse to the right and down and draw a rectangle around the items you want to select

4.Release the mouse button and you will see the colour of the selected items turn dark

5.Try to drag this group of selected items like explained before, just start pointing at one of the selected items

Shutting down

Procedure: Shutting down

When you have finished using your computer, you must shut it down before turning off the power to the computer. This enables the Windows program to perform some important housekeeping activities.

Step 1: Open Start and click the shut down icon.

Step 2: A dialogue box opens and asks you if you want to shut down. Click OK Alternatively a dialogue box might open with several options. Select turn off

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WORD PROCESSING

Introduction

Word processing is one of the most common uses of computers. The computer can help you type and edit texts in far more sophisticated ways than the traditional type writer does. The most important advantage is that you can keep changing your document until you are satisfied. Below are some exercises to introduce you in the basics of MS-Word, which is the most commonly used software package for word processing.

Loading MS-Word

Procedure: Loading MS-Word

There is always more than one way to load a program. This also applies to MS-Word, which is one of the MS Office applications. We will show you two ways:

Step 1	Open Start
Step 2a	Most probably you will see the icon of Microsoft Office Word in the list of
	favourites on the left side of your Start panel (see figure below).
	Click the Word icon to load.
Step 2b	Another route is to point at All Programs and then Microsoft Office from the list
	that appears.
	Another list will appear: choose Microsoft Office Word to load

Once you have loaded the program, MS-Word will automatically start with a new empty document (see figures 2.4 & 2.5 below)

Figure 2.4: Loading MS Word
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Menu / Tool bar

Scroll bar

Cursor

Figure 2.5: Empty MS Word document

Some important features of the screen

(See figure 2.5)

Tool or Menu bar:

The tool or menu bar is located under the title bar, and displays the names of all available menu lists with command options.

Scroll bar:

Two scroll bars on the right and the bottom of your screen can be used to view information that does not fit inside the window.

You can click the arrows or the scroll bar to move around from top to bottom or from left to right within your document.

Cursor:

The cursor is the small vertical line that shows you where you are. Any typing action you undertake will appear there.

Saving a Document

Procedure: Saving a Document

After loading MS Word automatically creates a document called document 1 (see title bar on top of your screen). It is important to safe this document under a new name in a folder where you can retrace and reopen it later.

Step 1: Click File on the menu bar below the title bar

Step 2: Click Save As on the menu list that appears

Step 3: Choose the folder My Documents from the menu list on the left of the screen that appears

Step 4: Give your document a name (e.g. my first document) by typing the name in box right of the words File name

Step 5: Click Save to actually save your file in the folder My Documents

You will see the new name appearing in the title bar at the top of your screen

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Exercise 2: Creating and editing a document

Let’s try to make something of your first document:

1.Type a short health message on prevention of HIV and AIDS

2.Format the text by using different font sizes, bold text and other relevant formatting tools from the menu bar

3.Do not forget to save your document: The first time you save a document you have to use the procedure as described above. You can use the floppy disk icon on the menu bar or Ctrl+S to save the document more quickly once you have named it

4.Compare your document lay-out with that of your fellow students and exchange the different format tools you have used

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WINDOWS EXPLORER

Introduction

In the previous paragraph you have created your first document or file. For sure you will create more files in the future. To handle all the files you must organize them so that you will be able to retrace them when the number of files increases. Windows explorer can help you organize and find your files. Let’s find them first by using the tools to view and search for files.

Viewing and Searching to Locate Files and Folders

Procedure: viewing and searching files and folders

View when you know where to go

Step 1: To open Windows Explorer you can press the E + Win key (the key next to the Ctrl key on your keyboard).

Another way to open it is to open the Start panel and find the program under All Programs

>Accessories > Windows Explorer

Windows Explorer will open as displayed in the figure below. What you see on the left side of the screen is the Folder tree. It shows you the organization of folders and drives.

Step 2: By clicking the folder of your choice the content of this folder will be displayed on the right sight of the screen.

Step 3: Clicking the + sign right of the folder or driver you can reveal the subfolders.

Step 4: Clicking the – sign right of the folder or driver you can hide the subfolders again.

Search when you don’t know where to go

Step 1: Open Windows explorer as explained above

Step 2: Click the Search icon on the menu bar on top of your screen

Step 3: Click the item you are searching for from the screen that appears (usually a file or folder)

Step 4: Enter a relevant search key in one of the empty boxes that appear in your screen.

Step 5: Start the search by clicking the Search button at the bottom of this screen. All documents matching your search key will appear on the right side of your screen. You can open them by double clicking.

Figure 2.6: Viewing files and folders
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Organizing Data: Creating Folders and Sub- Folders

As you have seen Windows has organized files in folders and subfolders. Maybe you have also noticed that there is some logic in the structure of folders e.g. documents and programs are stored in different folders.

You can create folders yourself to organize your data in a logical way. One golden rule is that you don’t change anything in the structure others have made. The best place to create your own folders for your data is within the folder My Documents.

Procedure: Creating a folder and replacing documents

Step 1: To open Windows Explorer you can press the E + Win key (the key next to the Ctrl key on your keyboard).

Another way to open it is to open the Start panel and find the program under All Programs than Accessories.

Windows Explorer will open as displayed in the figure below. What you see on the left side of the screen is the Folder tree. It shows you the organization of folders and drives.

Step 2: By clicking the folder of your choice (e.g. My documents) the content of this folder will be displayed on the right sight of the screen.

Step 3: To create a new folder within this folder you click File than New than Folder.

Step 4: A folder with the name “new folder” will appear on your screen. Just type the name of your choice to give the folder a new name.

Step 5: To move your document to the new folder you can use several options:

∙Click and drag the document to the folder (it looks like disappearing but when you open the folder you will find your document in it).

∙Another method is by selecting the document (click once), cut it (Ctrl+X), than open the folder (double click the folder) and paste your document (Ctrl+V)

∙Similarly you can use the Cut and Paste options under the Edit menu

Exercise 3: Using Windows Explorer to find and organize files

1.Find your document created in paragraph 3 by using the search procedure

2.View the folder that contains the document you created in paragraph 3 by using the view procedure as described above

3.Create a new sub-folder in the folder My Documents and name it with your own name

4.Place the document you created in paragraph 3 in this new sub-folder

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INTERNET AND E-MAIL

Internet

Internet is composed of hundreds of thousands of computers all over the world. Those computers send and receive information, but most important, they store information.

The whole idea behind using Internet is to get access to all that information and to take advantage of the Internet’s communication abilities.

Within Windows you use a so-called web browser called Internet Explorer to access the Internet.

You just click the Internet Explorer icon in the Start panel of your computer and it will load with a screen like in the figure below. Some important features of this screen are:

Web page

The figure below shows a page of information displayed by the web browser from the data stored on the Internet here.

The page shown in the figure below is the home page of Yahoo but any other information you search for will be displayed here.

Button bar

The button bar is displayed just below the menu bar on top of your screen and contains a series of useful tools like:

∙Arrow icons to move back and forward to and from previous actions you took

∙The red-cross icon to stop an action

∙The refresh button (two green arrows going round) to tell Internet to update the Web page you are viewing e.g. when a page is not found or when graphics are not appearing well on your screen

∙The home icon takes you back to the first page you saw when connecting with Internet

Button Bar

Adress box

Web page

Figure 2.7: Information on a website on the Internet

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Address box

This box holds the address of the page you visit and it is also an input box where you can type Web addresses you want to go to.

Once you are on Internet, search engines can help you find the information you are looking for. There are different search engines available but one of the most commonly used is called Google.

Loading Internet Explorer and Performing Basic Search with Google

Procedure: Loading Internet Explorer and performing a basic search with Google

1.Load Internet Explorer by opening the Start panel and click the Internet Explorer icon.

2.Type www.google.co.ke in the address box and click Enter. The home page of Google will appear as in figure 2.8 below.

3.Type one or more keywords in the text box in the middle of this screen (e.g. drug information) and click Google Search.

After a few moments Google will display a page (or more) full of links to web pages that match more or less with your keyword(s).

4.Click any link you would like to give a further look and it will direct you to the page concerned.

Figure 2.8: Search Engine – Google – start page

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Figure 2.9: Search results Google

Tips on conducting searches

If you have too many results or results are not relevant then:

∙Narrow down by using the tool search within results or advanced search

∙Add or change keywords

∙Use vocabulary that is specific

∙Use Boolean logical operators: and, not to keep out records you don’t want.

If you have too few results:

∙Drop the least important keyword(s) to broaden your subject

∙Add alternative terms or spelling for individual concepts and connect with the Boolean logical operator, or

Exercise: Use of search engine

As you have seen with the search for drug information, Google can overload you with an enormous amount of findings (hits or results). It is important to be selective and critical when you search the Internet.

Narrow down a search on drug information to a small number of relevant web sites. Explain:

1.Which keys or steps you used to narrow down the list of results?

2.List the most relevant websites you have found and explain what is the relevance for you as a health professional?

3.Compare your findings with your neighbour students?

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E-mail

E-mail is the digital way of sending and receiving mail. In fact it is quickly replacing the written mail we used to send and receive through the post office. You can use different programs to send and receive e-mail. Most commonly used office applications to send and receive e-mail are Outlook and Outlook express. If you don’t have access to Outlook you can also use one of the (free) Internet services that supply e-mail, like Hotmail and Yahoo. We will explore the possibilities of Yahoo as this is most used by students in Kenya.

Procedure: Sending and receiving e-mail with Yahoo

1.Load Internet Explorer by opening the Start panel and clicking Internet Explorer icon

2.Type www.yahoo.com in the address box and click Enter.

The home page of Yahoo will appear as shown earlier when loading Internet Explorer

3.Click the e-mail icon (envelope) next to the Yahoo title on your screen. The Yahoo e-mail log on screen will appear as on the next page.

4.Enter your e-mail ID and password as it has been given to you in the boxes and click sign in.

5.Yahoo will welcome you with the screen as displayed in figure 2.10 below. From this screen you have several options:

-Click the button Inbox to view new mail that you have received. To open a message you double click the message

-Click Reply to answer the message.

To close it, click the cross in the upper right corner of your screen.

-Click the button Sent to view any mail you have send before

-Click Compose to compose a new message: start with typing the e-mail address of the receiver in the address box, than type your message in the message box

-End by clicking Send

Figure 2.10: Email – log on screen for Yahoo

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Adress box

Message box

Figure 2.11: Email – writing a message

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SOFTWARE FOR MEDICAL

PROFESSIONS

Introduction

Different types of software are available for medical education. The content and quality of these applications varies a lot. Some applications are not much more than a digital copy of a traditional text book; others are more interactive and give you options to follow your own route through the content. Also the use of audiovisual aids differs from application to application.

Within this introduction course in computer use we would like to take you through an example of medical software. From there we hope you will have developed enough interest to go and search for more.

ADAM Interactive Anatomy

As the title says, ADAM Interactive Anatomy enhances the study of human anatomy in quite a different way than a normal text book does. The program is highly visual as it contains over 20000 pictures of anatomical structures from different view points.

Another difference with the traditional text book is that ADAM allows you as a student to decide on the route to follow and the possibilities are numerous. As much as this is an advantage it is also one of the difficulties within the program because you easily get lost. To help you getting familiar with the possibilities of ADAM this section gives a general introduction, followed by some exercises.

Basically ADAM consists of the following four functions:

1.Dissectible Anatomy: Within this tool you can identify, highlight and extract structures in four views of a male or female body.

2.Atlas Anatomy: This tool allows you to identify pinned structures in illustrations, cadaver photographs and radiographs.

3.3D Anatomy: This tool provides several 3D models to identify structures from different views

4.Slide Shows: This tool allows you to create your own slide show with images from

ADAM the way you create presentations in applications like Microsoft Power Point Let us start the program and move around through the different functions of ADAM.

Procedure: Start ADAM

Step 1: Click the Start button

Step 2: Point All Programs

Step 3: Point ADAM interactive anatomy in the menu popping up

Step 4: Select ADAM Interactive anatomy in the pop up menu and click once

Step 5: Click Continue on the introduction screen that shows

Step 6: Open one of the four functions by clicking File in the menu bar

Step 7: Then point Open from the pop up menu and click Content. See figure 2.12

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Figure 2.12: Starting Adam Anatomy

Procedure: Working with Atlas Anatomy

Once you have started ADAM as described in the procedure above:

Step 1: Click on Atlas Anatomy in the menu that appears (see figure below)

Step 2: Select the region, system, view or type of picture you are looking for

Step 3: Select specific picture you would like to see in the menu, the preview shows you the picture you have selected.

Step 4: Click Open to activate the picture you have selected

Figure 2.13: Going around in Adam Anatomy
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Procedure: Working with 3D Anatomy

Once you have started ADAM as described in the procedure above: Step 1: Choose Content

Step 2: Click on 3D Anatomy in the menu that appears

Step 3: Choose a model from the list by clicking on the model name

Step 4: The preview shows the model you have chosen, click Open to activate it

Step 5: Once the model shows on your screen you can use the arrow buttons and magnifying glass button from the toolbar left of the model, to rotate or enlarge the model

Exercise: Comparison of Atlas and 3D pictures

To understand the differences between the 3D models and the Atlas pictures it is useful to compare similar images:

1.Search for an image of the cardiac veins both in the Atlas Anatomy and the 3D Anatomy

2.Compare the two images and explain what you can learn from each of the images

3.Give one advantage and one disadvantage of both the Atlas and the 3D image

Procedure: Working with Dissectible Anatomy

Once you have started ADAM as described in the procedure above: Step 1: Choose Content

Step 2: Click on Dissectible Anatomy in the menu that appears

Step 3: Choose a gender and view from the lists shown by clicking the appropriate button

Step 4: The preview shows you the options you have chosen, click Open to activate the model (see picture below)

Step 5: Once the model shows on your screen you can use a number of options to explore the anatomy of the body, like:

-Structure list: click the arrow to switch to another structure

-Navigator: point to orient in which part of the body you are

-Zoom tool: click the magnifying glass to zoom in or out

-Identify tool: click the arrow and then point at any structure you would like to identify

-Transparency tool: allows you to define an area for dissection while keeping the surrounding anatomy intact. Click the tool and then click and drag the area you want to dissect.

-Depth bar: to dissect or restore anatomy layers click and drag the button up and down through the bar.

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Structure list

Navigator

Zoom tool

Identify tool

Transparency tool

Depth bar

Figure 2.14: Example of images in Adam Anatomy

Exercise: Explore Adam Dissective Anatomy

We have explained to you just a few of the buttons available on your screen.

1.Find out and describe the functions of the 5 other buttons

2.Discuss in your group which functions are most useful for you

Other Medical Software

ADAM is just one example of software available for medical education. As the world of ICT is very dynamic, software changes constantly and it is important to keep up dated with new development. The way you have explored ADAM you can explore any program. Programs differ in content but also in quality. As a life long learner it is important to be aware of the possibilities of ICT but also of the weaknesses you may encounter.

Exercise: Exploring Medical Software

Ask your teacher which other medical software is installed on your system. Explore at least two programs and answer the following questions:

1.How can the program be used to enhance your learning?

2.Describe at least two advantages and two disadvantages of the program

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ANNEX: USEFUL KEYS AND KEY COMBINATIONS

Useful key combinations in Window Programs

	Key Combo	Function
	Ctrl + A	Select all
	Ctrl + B	Make text bold
	Ctrl + C	Copy selected items
	Ctrl + F	Summon search / find command
	Ctrl + I	Make text italic
	Ctrl + N	Start a new document
	Ctrl + O	Open a document or display Open dialog box
	Ctrl + P	Print or display Print dialog box
	Ctrl + S	Save document
	Ctrl + U	Underline text
	Ctrl + V	Paste copied or cut items
	Ctrl + W	Close window
	Ctrl + X	Cut selected items
	Ctrl + Y	Repeat command
	Ctrl + Z	Undo last action
Useful text editing keys
	Key Combo	Function
	←↑→↓ (cursor key)	Move the cursor: left, up, right or down
	End	Move the cursor to the end of the line
	Home	Move the cursor to the start of the line
	Delete	Deletes a character right of the cursor
	Back space	Delete a character left of the cursor
	Insert	Switch between insert and overtype mode
	Shift + cursor key	Selects text in the direction of the cursor key

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Useful key combinations in Windows

Key Combo	Function
Alt + Tab	Switch to next window / program
Alt+ Shift+Tab	Switch back to preceding window / program
Alt + Esc	Cycle through running programs
Ctrl+ Esc	Display the Start Panel
Alt + F4	Close the current window
Alt + ↓	Display a drop down list
F10	Activate the menu bar
Alt+Enter	Display a Windows Control Menu

Using the Win key

On the bottom of your key board you will find a key with the Windows logo, this is the Win key.

Key Combo	Function
Win	Pops up the Start Panel
Win + D	Displays the desktop (minimizes all windows)
Win + E	Starts Windows explorer
Win + F	Display the Find Files /Search Results in the dialog
	box
Win + L	Lock windows or displays logon screen
Win + M	Minimize open windows
Win + R	Display the Run dialog box
Win + Break	Display the System properties dialog box

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CHAPTER 3: BASIC

PATIENT CARE SKILLS

Annex to CMS 153: Nursing Skills & Patient Care

Scrubbing, Gowning and Gloving

Aseptic Technique and Surgical Dressing

Administration of Oral Drugs

Injection techniques (IM & SC & Intra-dermal) Vena Puncture for Collection of Blood Specimen

Insertion of Intra-Venous Cannula’s and I.V. infusion

NG-Tube Insertion and Feeding

Gastric Lavage / Stomach Wash-Out

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SCRUBBING, GOWNING AND

GLOVING

Objectives

To remove as many micro-organisms as possible from the forearms and hands To ensure hands and clothes do not contaminate sterile instruments / field

Indications

Performing and assisting in sterile operation / procedures.

Contra-indications

A health worker with the following should preferably not carry out aseptic procedures:

1.Cut wounds on fingers

2.Respiratory tract infections

3.Gastro-enteritis

Requirements

1.Wall clock

2.Sterile hand brush in a dispenser

3.Antiseptic soap in a soap dish or soap dispenser

4.Running water (hot and cold)

5.Mackintosh apron

6.Sterile gown

7.Sterile gloves in a pack

8.Sterile hand towel

9.Trolley draped with sterile towel

10.Kick about basin

Procedure

Preparation

Environment

1.Ensure the scrub area is spacious, clean and well organized

2.Get all the supplies required ready, and place them at convenient places

Equipment

1.Arrange the equipment appropriately before starting to scrub (i.e.) gloves, gowns, hand brushes etc

2.Using chittel forceps drape the trolley with a sterile towel

3.Place a pack of sterile gowns at the centre of the trolley

4.Place the set trolley at a place where it cannot be splashed with water while scrubbing

5.Place the kick about basin at a convenient place for use after scrubbing (i.e.) next to the trolley

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Health Worker

1.Finger nails trimmed short and clean and without nail varnish

2.Remove all jewellery e.g. wide rings

3.Request another nurse to assist

4.Tuck in tidily the top / shirt

5.Roll the sleeves up to at least 5 inches above the elbow

6.Wear the cap and mask correctly

7.Cap should be covering all the hair

8.Mask – the short side should be above the nose and long side under the chin

9.The tapes of the mask should be tied at the back, then adjust to suit

Method: Complete Scrubbing

1.Wear the Mackintosh apron to protect your scrub suit

2.Run the cold and hot water taps until the temperature feels comfortable and the force does not splash all over

3.Use the clock to time yourself during the procedure

4.Wet the hands and arms to the elbows

5.Pick soap / swizz soap from the dispenser and lather well on the hands and arms

6.Wash hands and arms for one minute, lathering and rinsing under running water at least 3 times

7.Keeping the fingertips upper most all the time, rinse the hands to the elbow

8.Using elbow, press clutch of dispenser and pick one sterile brush

9.Wet and lather the brush, and keep the piece of soap at the back of the brush

10.Starting with one hand, put the fingers together and scrub the fingernails, then the fingers, wet the hand and the palm up to the wrist

11.Use a circular movement inside the palm, paying attention to the folds of the wrist. Rinse the soap from fingertips to wrist and repeat the process 3 times, spending about 1 ½ – 2 minutes on one hand

12.Rinse brush and soap

13.Change to the other hand and repeat the procedure

14.Drop brush in the correct receiver provided (basin) without contaminating the hands

15.Lather hands and wash up to elbow for another one minute, rinsing and lathering frequently, about 3 times

16.Rinse the soap and drop it back in the soap dish if a piece of soap was used without touching any surface

17.Rinse the hands and arms from fingers tips to elbows

18.Hold hands together and let water drain out

19.Use elbow to close the taps with hands still together

20.Keep hands together and arms away from the body, and let them drip until there is no more water dripping

21.Request assistant nurse to remove the mackintosh apron and dry it for the next use

22.Move to the gowning trolley without letting the hands go below level of trolley

Method: Drying of Hands

1.The assistant nurse opens the top flap of the sterile gowns and there you find a sterile towel

2.Pick the towel and step back

3.Blot dry fingers, webs of hands and palm well.

4.Repeat the same procedure on the other hand.

5.Dry the back of hand and forearm, using a rotating movements from wrist to elbow

6.Reverse the used part of towel, wet part inside, and using the dry part, repeat same procedure on the other arm.

7.Drop the towel in the receiver basin.

8.Keep arms above the waist-line and in front of the chest throughout the procedure.

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Method: Gowning

1.Standing in front of the trolley with gowns, pick a gown and step back to prevent contamination as it rolls out

2.Hold firmly the neckband (collar) and let the bottom hem drop

3.Open the gown at the neckband and slide both hands in through the armholes taking care not to touch outside of gown with your clothes or hands

4.Ask the assistant to tie the tapes at the back starting the neck, chest then waist

Method: Gloving

1.Ask the assistant to open the outside packing of a sterile pack of gloves and drop the inside, sterile packing on a sterile field on the trolley

2.Open the glove pack, touching the lower part of the pack only

3.Arrange the gloves on the top, picking them on the folded cuff

4.Bring fingertips of the left hand together and slide in to the left glove, while holding the folded cuff with the right hand

5.Pull the glove to the wrist

6.Slip the fingers of the gloved hand in to the folded cuff of the right glove

7.Bring fingertips of the right hand together and slide into the right glove to the wrist

8.Pull the folded cuff well up over the thumb, and hold it with the thumb

9.Fold the sleeve of the gown firmly with thumb of the left gloved hand at the wrist and keep in the fold in place by the thumb

10.Fingers of the same hand pulls the cuff of the glove over the sleeve

11.Repeat the same procedure on the left hand

12.Smooth any wrinkles ensuring that the gloves are comfortable

13.Avoid touching any other un-sterile area

14.Keep hands above elbow and away from the gown to avoid contamination

Method: glove removal

1.Bring the fingertips of right hand and insert them into the proximal turn-up of the gloved left hand

2.Grasp the glove of the left hand from the outside and pull distally

3.To avoid contaminating your hand, dispose the glove in the receiver

4.Slip the fingers of your un-gloved left hand into the gloved right hand

5.Slip off the contaminated right glove slowly while removing it from the inside and by pulling the right hand until you drop it in the receiver

Figure 3.1: How to put on gloves

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ASEPTIC TECHNIQUES AND SURGICAL WOUND DRESSING

Introduction

The purposes of surgical dressings are multiple. First of all they help to prevent wound infection through absorption of secretions from the wound and through preventing the wound from further damage through trauma or infection. Secondly, they provide comfort to the patient, physical as well as psychological by covering the disfigured areas.

Objective

The ability to perform surgical dressings with the use of aseptic technique Specific objectives:

1.To have practical knowledge in order to prevent wound infection

2.To use aseptic technique

3.To cover a wound

4.To keep the wound clean

Indications

1.Open wounds.

2.Infected wounds

3.Removal of stitches/clips

4.Shortening or removing drains

Requirements

Clean trolley

Top Shelf					Bottom Shelf
∙	Sterile	dressing	pack	containing	∙ Non-sterile articles on a large tray
	the following:				like:
	o 2 pairs of dressing forceps.				o	Pair of scissors
	o 2 pairs of dissecting forceps				o	Adhesive tape/bandage
	o	2 gallipots			o	Antiseptic	solutions	as
	o	10 cotton swabs				required
	o	5 gauze swabs			o	1 kidney dish or jar with
	o	1 kidney dish				disinfectant (e.g. Jik)
	o	1 hand towel			o Topical drugs if required
∙	Additional if required.				o Extra sterile swabs			and
	o	Sterile	stitch	remover		gauze
		scissors			o 1 pair of sterile gloves
	o	Sterile clip remover			∙ Receiver for used hand towel
	o	Sterile	pin	for drain
		shortening			Accessories:
	o	Sterile scissors			∙ Pedal bin or plastic bags for soiled
					dressings
					∙ Dressing Mackintosh

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Procedure

1st Health Worker

1.Greet the patient and establish rapport

2.Explain the procedure to the patient

Assistant

1.Assist the patient to lie in the most comfortable position while exposing the side of the wound

2.Fold the bed clothes and expose the area to be dressed

1st Health Worker

1.Disinfect the top shelf of the clean trolley with methylated spirit

2.Place the sterile dressing pack on the top shelf

3.Set the bottom shelf with equipment required and wheel the trolley to the bedside

4.Scrub hands vigorously with soap and water for at least 5 minutes

Assistant

1.Remove tape from sterile pack and open it to expose sterile towel.

1st Health Worker

1.Pick the sterile hand towel and dry hands then discard

2.Using dissecting forceps, arrange instruments appropriately for easy use

Assistant

1.Pour antiseptic lotion in the gallipot carefully after reading the label together with the first health worker

2.Loosen and remove outer dressing and discard it in the pedal bin

1st Health Worker

1.Remove inner dressing using a dissecting forceps and drop it in the pedal bin.

2.Discard dissecting forceps into the jar containing disinfectant on the bottom shelf

3.Holding a pair of dressing forceps in one hand (right hand if right handed) and the second dissecting forceps in the other

4.Pick a cotton wool swab using the dressing forceps

5.Dip the cotton swab in the antiseptic lotion and use the dissecting forceps to squeeze off excess lotion from the swab

6.Swab the wound from inside outwards using a swab only once and discard

7.Repeat until the wound is clean

8.Remove any loose dead tissue

9.Dry the wound with a gauze swab

10.Discard the dressing forceps into the decontaminant / disinfectant

11.Pick the 2nd dressing forceps to apply sterile dressing

12.Discard the forceps into the jar on the bottom shelf

Assistant

1.Secure the dressing with adhesive tape / bandage

1st Health Worker

1.Thank the patient for cooperation and leave him/her comfortable

2.Clear the bedside

3.Wheel the trolley and pedal bin to the sluice room

4.Decontaminate the equipment in Jik 1.6 for ten minutes the clean

5.Discard the mackintosh and green towels into linen bag

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ADMINISTRATION OF ORAL

DRUGS

Objective

The ability to administer oral drugs safely

Indications

1.Treatment of conditions whereby a patient is able to take medicine orally

2.Prevention of disease / conditions

3.Promotion of health by boosting defence mechanism.

Requirements

A clean trolley containing the following:

1.Top Shelf

a.A tray containing labelled containers with drugs in use

b.Two (2) medicine measures

c.Two (2) spoons (for picking capsules, tablets, pills): 5 ml (teaspoon), and 10 ml (table spoon)

d.Two (2) special spoons for holding liquid drugs in drug container

e.Two (2) small plates / saucers

f.One (1) Medicine cloth

g.Bottle / carafe / jug of water

h.Plain clean paper for crushing tablets

i.Hand towel

j.Damp bottle cloth

k.Paper for recording antibiotics and missing drugs as well as recording injections

l.Milk in a jar or packet if required

2.Bottom Shelf Trolley

a.A bowl of warm soapy water

b.A bowl of clean water

c.Receiver for contaminated items

d.Receiver for waste materials

NOTE: In case of a patient with nasogastric tube on oral drugs, include:

e.A small tray containing syringes

f.Medicine measure with plain water

g.Blue litmus paper

Procedure

Preparation

1.Ensure all patients are in their beds

2.Clean trolley with soapy water, rinse and dry

3.Assemble all items on the trolley appropriately

4.Ensure environment is conducive to safe drug administration

5.Get an assistant

6.Prepare paper for recording antibiotics, injections and missing drugs

7.Place the clean plain paper under the saucers / plates

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Method

1.Begin from one end of the ward and move systematically from one patient to the next; in between patients wash hands and dry them

2.Greet and explain the procedure to the patient

3.With the help of the assistant, take the patient’s treatment sheet

4.The two of you read the patient’s name and confirm by asking the name to ensure he is the right patient in the right bed

5.Check for allergies in the patient

6.Read the whole treatment sheet, noting the drugs that are due to be given and confirming this with the assistant

7.Together with the other nurse, read the prescription against the drug container noting the dosage and expiry date for that particular drug (NB: Note any contra- indication of the drug)

8.If tablets, pick the correct dose from the drug container, using a spoon

9.Place the tablet on a saucer

10.If patient is to get more than one drug repeat No. 15, 16 and 17

11.Take the medicine to the patient

12.Re-check the right patient, right drug, dose time against the treatment sheet

13.Give drug to the patient and offer him a drink

14.Ensure patient swallows drug in your presence

15.Record time drug(s) was given and sign treatment sheet

16.If mixtures, shake the container lightly by turning up and down, until the drug is well mixed

17.Make sure the label on the container is held uppermost to avoid soiling label

18.Remove the cork

19.Pour drug into the medicine measure ensuring that the meniscus of the dose required in the medicine measure, is at the level of your eye

20.Replace the cork / cup

21.If patient is getting more than one mixture use a separate measure for each drug / mixture

22.Continue as per tablet

23.Wash rinse and dry medicine measure between patients

24.If the patient is on drug by injection write this on the sheet of paper you had prepared. If a drug is missing do the same

25.Record all the antibiotic drugs you gave in the antibiotic register and sign

26.Clear the equipment

27.Report

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ADMINISTRATION OF DRUGS:

INJECTION TECHNIQUES

Includes

Withdrawal of solution from containers

General procedure for injection

Specific steps: Subcutaneous administration

Specific steps: Intramuscular administration

Specific steps: Intra-dermal injection

Introduction

The safe preparation and administration of injections is a routine clinical responsibility that requires dexterity, sterile technique, knowledge of: actions, usual dosage, desired effect, and side–effects of the drug being given and knowledge of HOW and WHERE to give the drug.

Drugs given by these routes are not only absorbed more quickly than by mouth but are irretrievable once injected. Therefore, perfection of this art of giving injections is mandatory for clinicians.

Routes for injections: intra-dermal, subcutaneous, intra-muscular and intravenous.

Objective

To prepare and administer intramuscular, subcutaneous and intra-dermal medications safely to patients

Specific objectives:

1.Use aseptic technique to assemble equipment for giving injections

2.Select the appropriate needle and syringe for giving an injection

3.Prepare solutions and withdraw a specified amount from vials and ampoules without contamination

4.Identify various sites for giving injections

5.Correctly adapt steps for giving injections

6.Administer IV, subcutaneous, intra-dermal and intramuscular injections

Indications

1.Treatment of diseases / conditions whereby the appropriate route is by injection

2.Administration of immunization

3.Diagnostic allergic tests

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Requirements

To give any injection, a syringe, a needle, a swab, and disinfectant to clean the skin, and of course the medication are needed.

Clean trolley

Top Shelf		Bottom Shelf
∙	Disposable plastic syringes-various	∙ Receiver for used swabs
	sizes	∙ Disposable gloves
∙ Tray with vials and ampoules of		∙ Clinician’s order sheet or cardex
	relevant medication	∙ Medication sheet / card
∙ Container with sterile water
∙	File
∙	Needles (gauges 18-25)
∙ Insulin and tuberculin syringes
∙ Cotton wool swabs in bowl
∙	Container of antiseptic

Syringes

Syringes are available in various sizes, shapes, and materials:

1. Glass syringes

2. Disposable plastic syringes

3. Insulin syringes

4. Tuberculin syringes

5. Pre-filled syringes and cartridges

Figure 3.2: Syringe + needle

Plunger
		Inside of barrel		Needle

Figure 3.3: Parts of a syringe to be kept sterile

Needles

Needles for use with syringes come in standardized lengths (3/8 to 5 inches) and with standard diameters, measured in Gauges (13 to 27): the higher the Gauge of a needle, the smaller the lumen.

The needles most commonly used are ½ to 2 inches in length and 18 to 25 gauges. Disposable needles have plastic hubs and metal shafts, and the length and gauge are indicated on the outside of the packaging.

A needle with a small lumen is less painful to the patient when it is inserted.

The choice of a needle is based on the relative viscosity or thickness of the medication. Larger needles are used primarily for blood donation and for injecting special intravenous fluids.

Medication containers
VIAL	AMPOULE
Small bottle with sterile entry, can	Glass container you break to
be multiple dose or single dose	access, always single dose

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Procedure: Withdrawing solution from containers

Vials

1.Wash your hands.

2.Using antiseptic swab, clean the rubber top of the vial in firm circular motion

3.Discard the swab

4.Allow the alcohol to dry to obtain maximum antibacterial action

5.Prepare the syringe and needle. Be careful to keep the needle, the syringe tip, the inside of the barrel, and the side of the plunger sterile

6.If drug is to be diluted (reconstitute) use the correct amount of sterile water for dilution and mix well

7.Draw as much air into syringe as the necessary volume of solution you’ve calculated

8.With the vial resting on the countertop remove needle guard and insert the needle through the rubber top of vial.

9.Inject air into the vial by pushing the plunger of the syringe into the barrel. This prevents a vacuum when you withdraw the medication.

10.Pick up the vial in your non-dominant hand and hold it upside down at eye level. Pull the plunger down to withdraw the necessary amount of medication

11.Make sure the tip of the needle is beneath the level of the fluid in the inverted vial and that you do not touch the sides of the plunger as you withdraw the medication.

12.Examine the medication for air bubbles and remove any that are present:

a.Keep syringe vertical and flick your index finger against the side of the syringe over the air bubble

b.Once bubbles reach the top, push on the plunger and expel the air into the vial

13.Once all air is removed from the syringe make sure you have the exact volume needed. (Modern needles and syringes are marked so that the volume in the needle and hub is considered dead space. This means that this space is full of medication when you begin injection and it is still full when the injection is completed. Therefore exact dosage in the syringe is given)

14.Remove the needle from the vial

15.Replace the needle guard. Be careful: do not hold the guard but direct the needle inside the guard holding the syringe-needle

Ampoules

1.Wash your hands

2.If medication is in the upper part of ampoule, move it down into the lower part by flicking the tip of ampoule using the index finger

3.Swab the narrowest part of the ampoule

4.Prepare syringe and needle

5.Wrap gauze around the neck to protect your hand from cuts and break the top of the ampoule away from yourself (or use file). Discard the top in a sharps container.

6.Hold the ampoule firmly in your non-dominant hand, insert needle being careful to touch the inside only

7.Pull the plunger of the syringe back

8.Withdraw the needle from the ampoule after drawing the amount of solution needed

9.With the needle pointing vertically, pull back slightly to aspirate the fluid from the needle into the syringe

10.Push the plunger gently into the barrel until the medication appears at the point of the needle. This prevents medication from being on the outside of the needle and thus irritating the tissues as the needle is inserted

11.Make sure you have the exact volume needed

12.Replace the needle guard

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General procedure for giving injections

Preparation

1.Assess the type and amount of drug to be injected as well as the size and build of the patient to select the correct size of needle and syringe for the injection

2.Confirm the 5 rights: right patient, right drug, right dose, right time, right route

3.Assess whether you will need assistance to turn or restrain the patient during the injection

4.Include in the equipment the appropriate needle, syringe and alcohol swabs to be used

5.Check the medication label for a second time and calculate the volume of medication needed

6.Draw the correct dosage, using the technique described previously

7.Ensure privacy and adequate light in the injection room

Method

1.Recheck your calculation of dosage

2.Place the syringe and alcohol swab on a tray (in a child you might consider hiding the syringe in your hand to avoid frightening the patient when you enter the room)

3.Confirm patient’s name (call by name; check identification band, check name on patient card)

4.Check the patient’s identification band, check patient’s name on the medication card

5.When explaining the procedure to the patient, check which site was used for any previous injection, and select a different site and avoid excessive use of one site

6.Select the appropriate injection site

7.Position the patient and expose the injection site

8.Clean site with a swab, using circular motion and moving from the middle of the site outwards

9.Allow the skin to air-dry

10.Place swab between the third and fourth fingers of your non-dominant hand.

11.Remove needle guard, be careful to pull it straight off and away from needle

12.Insert the needle on the syringe

13.As soon as the needle is inserted, transfer your non-dominant hand to the syringe’s barrel to steady it and transfer your dominant hand to the plunger

14.Using your non-dominant hand, make the skin taut in an appropriate manner for route chosen (an injection is less painful if the skin is taut when pierced, also tautness allows the needle to enter skin more easily)

15.Hold the syringe like a dart (barrel between the thumb and index finger of your dominant hand) and insert needle with a quick dart like thrust

16.Pull plunger back gently (aspiration) to be sure the needle is not in a blood vessel

17.If blood appears in the syringe, the needle is in a blood vessel. Withdraw the needle, discard the needle and syringe, and start all over

18.If no blood appears in the syringe inject the medication by pushing the plunger into the barrel with slow, even pressure

19.Use the non-dominant hand to steady the tissue immediately adjacent to the puncture site and quickly remove the needle

20.Place an alcohol swab firmly on the injection side

21.Gently massage the injection site with the alcohol swab and discard it

22.Discard the syringe and needle in the appropriate sharps container

23.Specific sharps-only container in the room: Do not re-cap the needle guard before you discard and discard the needle only

24.General sharps container: Discard syringe and needle as a whole unit

25.Sharps container elsewhere: Re-covering the needle during transport unless you carry it in another tray, e.g. kidney dish

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SUBCUTANEOUS INJECTIONS

Advantages		Disadvantages
1.	Rapid almost complete absorption (in	1.	Penetrates the body’s first line of defence, the
	presence of adequate circulation)		skin
2.	Gastric disturbances do not affect the	2.	Patient teaching necessary for those continuing
	medication.		injections at home
3.	Patient does not need to be conscious	3.	Total amount of fluid that can be given is limited

Specific steps: Intramuscular administration

INTRAMUSCULAR INJECTIONS

Advantages		Disadvantages
1.	Medication is almost completely absorbed and even more	1.	Penetration of skin
	rapidly than through subcutaneous administration (better	2.	Possibility of nerve damage
	vascularisation of muscle)	3.	Pain lingers long after injection
2.	Gastric disturbances do not affect the medication	4.	Abscess formation
3.	The patient does not need to be conscious
4.	Irritating drugs are commonly given intramuscularly,
	because of few nerve endings in the deep muscle tissue

Follow the steps for general injection with the following modifications

1.Select the equipment

a.The needle: 20 to 22 Gauge (according to thickness of medication) and ½

-2 inches length (depending on the size of patient and the site)

b.The syringe: The maximum amount of solution that can be comfortably given intramuscular is about 3 ml so a 2-3 ml syringe (calibrated in tenths of millilitres) is generally sufficient.

2.Select the injection site:

a.Varies with individual patients and circumstances

b.Four sites are generally available (see below for specific considerations):

i.Dorso-gluteal site: upper outer quadrant of the buttock

ii.Rectus femoris and vastus lateralis site

iii.Deltoideus muscle

iv.Ventro-gluteal site

b.Landmark the injection site

3.Select angle of injection: normally a 90° angle to the skin surface is used

a)For intra muscular injection

“Z-track” technique

Sometimes used for intramuscular injection.

The main difference with the normal procedure is the aspiration and release of air together with the mediation. Follow the standard steps for injection, but adjust the following:

1.While preparing the medication, draw 0.5 ml of air into the syringe after aspirating the correct dose

2.Change needle, and attach a 2-inch (5 cm) needle to the syringe

3.Remove needle cover but do not express air bubbles

4.At injection site, pull the skin in a lateral direction, moving it at least 1 inch ( 2.5 cm)

5.Inject the medication slowly; then wait 10 seconds. Along with the air bubble, this delay aids in sealing solution in tissues before the needle is removed

6.Remove needle and release the skin

7.Do not massage the injection site

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Ventrogluteal site

The landmarks of the site are the greater trochanter, the crest of the ileum, and the anterior superior iliac spine. To identify the site, first locate these landmarks on the patient. Then place the heel of your palm on the greater trochanter, point one finger towards the anterior superior iliac spine and adjacent finger towards the finger towards the iliac crest, forming a triangle with the iliac bone. Use your non-dominant hand to locate the site. The injection site is near the middle of this triangle. Point the needle slightly towards the iliac bone as you insert it.

Iliac crest

Ventrogluteal site

Anterior superior(in triangle) iliac spine

Greater trochanter of femur

Figure 3.10: Ventrogluteal site for IM injection

Specific procedure: Intra-dermal administration

Commonly used for diagnostic procedures:

1. Diagnosing allergies and sensitivities

2.Administration of tuberculin test

It has the longest absorption time of all parenteral routes.

Follow the steps for general injections, with the following modifications:

1.Select the equipment

a.The needle: 26-27 Gauge of ½ inch length

b.The syringe: small, calibrated

	in tenths of millilitres
			Figure 3.11: Intradermal injection technique
2.	Select the injection site:
	a. Normally the fore-arm
	b. Landmark the injection site
3.	Select angle of injection: 10° - 15° angle with the bevel (eye of the needle) directed
	upward, the needle should 1-2 mm inside, just below the outer skin
4.	Stretch the skin before penetrating it (so, this is different compared to the other
	injections where you taut the skin
5.	Inject the solution slowly until wheal appears
6.	Gently wipe site with an antiseptic swab.
7.	Do not massage site

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