BP measurement

Procedure of the pulse rate and blood pressure measurement

1. The radial pulse is palpated and the pulse rate is counted for 30 seconds, measured by a digital wrist watch or one with second hand.Record 30-second pulse count and whether pulse was regular.
2. The manometer should be placed so that the scale is at eye level, and the column perfectly vertical. The subject should not be able to see the column of the manometer.
3. Determining the peak inflation level:
   The mercury column has to be at 0 level.
   The subject's radial pulse is again palpated.
4. The cuff is inflated and the level of the top of the meniscus of the mercury column is noted at the point when the radial pulse disappears. The cuff is immediately deflated by completely opening the valve.
5. The peak inflation level is determined by adding 30 mm to the pressure where the radial pulse disappeared.
   Venous blood pool in the forearm is normalized by waiting at least 30 seconds or by raising the arm for 5-6 seconds.
6. The brachial pulse is located and the bell of the stethoscope is placed immediately below the cuff at the point of maximal pulsation. If it is not possible to feel the brachial pulse, the bell of the stethoscope should be placed over the area of the upper arm immediately inside the biceps muscle tendon.
7. The bell should not touch the cuff, rubber or clothing.
8. The cuff is rapidly inflated to the peak inflation level and then deflated at a rate of 2 mmHg per second.
9. The pressure should be reduced steadily at this rate until the occurrence of the systolic level at the first appearance of a clear, repetitive tapping sound (Korotkoff Phase 1) and diastolic level at disappearance of repetitive sounds (Phase 5) have been observed.
10. Then the cuff should be rapidly deflated by fully opening the valve of the inflation bulb. Note: There may be a brief period (auscultatory gap) between systolic and diastolic pressure, when no Korotkoff sounds are heard. Therefore, the 2mmHg/second deflation should be continued until the diastolic blood pressure is definitely established. If Korotkoff sounds persist until the cuff is completely deflated, a diastolic blood pressure of 0 should be recorded.
11. The measurements should be recorded to the nearest 2 mmHg. If the top of the meniscus falls half way between two markings, the marking immediately above is chosen. The subject is not told the blood pressure values at this point.
12. After one minute of wait to allow redistribution of blood in the forearm a second measurement is made by repeating steps 7 to 9. The subject should not change position during the wait.
13. After another one minute a third measurement is made by repeating steps 7 to 9.
    The subject may now be told the measurement values.

*Before the blood pressure measurement begins the following conditions should be met:
Subjects should abstain from eating, drinking (anything else than water), smoking and taking drugs that affect the blood pressure one hour before measurement.
Because a full bladder affects the blood pressure it should have been emptied.
Painful procedures and exercise should not have occurred within one hour.
Subject should have been sitting quietly for about 5 minutes.
Subject should have removed outer garments and all other tight clothes. The sleeve of shirts, blouses, etc. should have been rolled up so that the upper right arm is bare. The remaining garments should not be constrictive and the blood pressure cuff should not be placed over the garment.
Blood pressure should be measured in a quiet room with comfortable temperature. The room temperature should have been recorded.
The time of day should have been recorded.
The blood pressure measurer should be identified on the blood pressure data recording form.
Position of the subject
Measurements should be taken in sitting position so that the arm and back are supported. Subject's feet should be resting firmly on the floor, not dangling. If the subject's feet do not reach the floor, a platform should be used to support them.

What Should Your LDL Cholesterol Be?

Just a year ago, people bragged if their LDL cholesterol (the "bad" cholesterol) was under 100 milligrams per deciliter (mg/dL). However, the publication of two major trials (PROVE-IT and REVERSAL) showed that patients with diagnosed coronary artery disease had fewer heart attacks and deaths and not as many fatty deposits in their arteries when their LDL levels were much lower — about 60 mg/dL. Those studies have kindled a surge of activity and discussion among cardiology experts and between doctors and patients. The debate boils down to a simple question: How low should your LDL cholesterol be?
Getting a simple answer to a simple question is not always as easy as one might expect, but there seems to be growing momentum for defining "optimal" LDL cholesterol as 50 to 70 mg/dL. This target is not "official" — at least not yet. The American Heart Association (AHA) has lowered the LDL goal to less than 70 mg/dL for people at very high risk of a heart attack or sudden death. The goal for everyone else is less than 100 mg/dL. The American College of Cardiology and the National Heart, Lung, and Blood Institute endorse the AHA recommendations.
However, ask most physicians, even those at average risk, what they want their LDL to be, and they will give you a number lower than 100. The evidence to support this belief goes beyond PROVE-IT and REVERSAL. If you study "hunter-gatherer" populations still living their indigenous lifestyles, you find LDLs of 50 to 75 mg/dL, and you find no atherosclerosis. Healthy gorillas and other primates in the wild have LDL levels of 40 to 80 mg/dL, and no atherosclerosis. In fact, modern humans are the only adult mammals with mean LDL levels over 80 mg/dL, and they are the only animals that keel over on a regular basis with heart attacks.
The lower, the better
Plenty of research studies show that the lower your LDL level, the less atherosclerosis you have and the lower your heart-attack risk. Most studies only studied people with an LDL of 90 mg/dL or higher, because until recently it was nearly impossible to find humans in the Western world with lower LDLs, and available drugs couldn't get LDL down to lower levels. Now, however, there are drugs and combinations of drugs that can get LDL to that 50 to 70 mg/dL range in most people. Since it is unlikely that many of us are ready to go back to the hunter-gatherer lifestyle, the real question becomes whether we should be taking these medications with a goal of getting our LDL down to those low ranges.
Physicians counsel people based on their risk profile. For patients with a high risk of a heart attack — such as those with known coronary disease, diabetes, or multiple heart-disease risk factors — the doctor will often prescribe a statin (such as Lipitor, Mevacor, Pravachol, Zocor, and others). The physician will likely push up the statin dose until the LDL is well below 100 mg/dL. Occasionally, he or she will recommend combining statins with other drugs to get their LDL even lower, or to raise their HDL (the "good" cholesterol). For example, niacin can lower LDL and raise HDL. It is inexpensive and available without a prescription. However, you should only take niacin and a statin together in collaboration with your doctor. Niacin has significant side effects, especially when combined with other cholesterol-lowering drugs.
It is trickier to advise people on whether to take a statin when they do not have risk factors for heart disease and do not have any signs of atherosclerosis. Statins do have side effects, some of them potentially serious, and they are not cheap. Over the course of a year, they cost patients and society a pretty penny. So for lower-risk people, is the small potential benefit of getting their LDL down greater than the risks of the drug? And is that difference worth the cost of the drugs? The answers to these questions are not completely clear.
Given current available knowledge, medications are usually not necessary for low-risk patients unless their LDL is over 160 mg/dL. Medications are sometimes necessary when LDL is 130 to 159 mg/dL, depending on factors like family history and C-reactive protein levels (despite the lack of clear evidence about how best to use this blood test result). When LDL is below 130 mg/dL, doctors encourage patients to live a healthy lifestyle, but do not generally recommend drug treatment.
*Today's answers are likely to change as new research results provide doctors better evidence to guide recommendations.

courtesy of Harvard Medical Publications

INSERTION OF PERIPHERAL IV LINE

Aims

To gain peripheral venous access in order to:

• administer fluids

• administer blood products, medications and nutritional components.

To minimise the risk of complications when initiating IV therapy through:

• judicious choice of equipment

• careful choice of IV site

• good insertion technique

• aseptic preparation of infusions

Key points
In the case of two unsuccessful attempts at insertion, the operator will seek the assistance of another experienced nurse for one additional attempt. After a total three unsuccessful attempts the assistance of a medical practitioner will be sought.
PROCEDURE & ADDITIONAL INFORMATION

1. Explain procedure to patient/parent


2. Wash hands with antiseptic soap.


3. Don gloves
   (Strict adherence to hand washing and
   aseptic technique remains the
   cornerstone of prevention of cannula
   related infections)


4. Apply the tourniquet above insertion site(For paediatric patient, an assistant's hand used both as a tourniquet and restraint is
   often more acceptable to a child than a
   tourniquet)


5. Disinfect the selected site with skin prep
   and allow to dry.
   (Do not touch the skin with the fingers after
   preparation solution has been applied)


6. If infiltration of local analgesia is
   required, inject lignocaine 1% at the
   proposed site of entry of cannula.
   (Lignocaine may only be injected by a
   Medical Officer)


7. Inspect the cannula before insertion to
   ensure that the needle is fully inserted
   into the plastic cannula and that the
   cannula tip is not damaged.
   (Do not touch the shaft or tip of the
   cannula)


8. Ensure the bevel of the cannula is
   facing upwards.
   (Facilitates the piercing of the skin by the
   bevel)


9. Insert the needle and the cannula into
   the vein.
   (Gentle traction on skin may stabilise the
   vein under the skin)


10. Partially withdraw the needle and
    advance the cannula.


11. Release the tourniquet


12. Secure the hub of the cannula with
    clean adhesive tape.
    (Do not cover the puncture site. Cut tape
    immediately prior to use only)


13. Flush the cannula with normal saline (Ensures the line is patent and accessible )


14. Cover the intravenous and surrounding
    area with a sterile transparent dressing.
    (Ensure that the insertion site and the area
    proximal to the site are visible for
    inspection purposes)


15. If infusion ordered, prime the line and
    connect the intravenous giving set to the
    cannula


16. Note the date and time of insertion in
    the patient's medical record.
    Record date of line change and secure
    to IV line
    (Intravenous lines used for intermittent
    infusions must be labelled with the
    patient’s name, and the date and time of
    commencement)


17. If the site needs to be immobilised, use
    a well padded splint and strapping if
    necessary.
    (For infants <12>)


18. Dispose of equipment safely

Osteoarthritis: Causes and Risk Factors

Until recently, doctors blamed OA on “wear and tear,” implying that simple overuse causes the cartilage to wear away. It’s a logical theory, but it’s wrong. Time and mechanical stress do contribute to OA, but the process is really much more complex. In fact, scientists still don’t understand all the mechanisms involved, but they have identified the major OA risk factors, including:

1. 
   Age. Time takes a toll on the whole body, and joints are no exception. In fact, age is the strongest risk factor for OA. Although the disease can sometimes start in the 30s, it usually surfaces between the ages of 50 and 65, becoming more prevalent (and more prominent) with each passing year. Advancing age does mean more cumulative wear and tear, but age-related changes in the body’s metabolism, circulation, and elastic tissue may be even more important.



2. Heredity. OA tends to run in families. Heredity is particularly important in early-onset OA, in OA of the hands (shown in the figure below) or hips, and in an uncommon form of the disease that strikes many joints at once.



3. Obesity. It’s an important risk factor, and it’s one of the few that’s correctable. Extra weight makes joints work harder; every 10 pounds of excess weight, for example, produces about 40 pounds of extra stress on the knee with each step. A study of young men suggested that each 18 pounds of extra weight increases the lifetime risk of painful knee OA by 70%.



4. Mechanical abnormalities. Neurological or orthopedic problems that produce faulty body mechanics, such as an abnormal gait, increase the stress on joints. The joints that bear the brunt of such stress are the most likely to develop OA.



5. Injury. It’s the reason retired football players appear in advertisements for arthritis medication. A joint injury can seem to heal completely, but residual damage can slowly progress to produce OA later in life. A study of 1,321 Johns Hopkins Medical School graduates proves the point. Nearly 14% of doctors who suffered hip injuries during their student years developed hip OA by age 65, while only 6% of those without hip injuries developed OA. A knee injury in youth was even more significant, producing a fivefold increase in the risk of OA of the knee in maturity.



6. Occupation and sports. Does running cause arthritis of the knees and hips? Most nonrunners would answer yes, but most studies of runners say no. Repetitive use, such as long-distance running, has been linked to a slight increase in x-ray abnormalities but not to an increase in clinical OA (unless a significant injury has occurred along the way). Contrary to expectations, long-distance runners have fewer musculoskeletal complaints over the years than sedentary folks. But occupations that involve frequent knee bending increase the risk of knee OA, and those that require frequent lifting appear linked to hip OA.



7. Nutritional factors. Diet affects the metabolism of many tissues. The Framingham Knee Osteoarthritis Study linked low levels of vitamins C and D to an increased risk of OA. Unfortunately, there is no evidence that vitamin supplements can relieve the symptoms of OA or slow its progression. Still, a good diet is important for health, and weight control is particularly important for OA.

courtesy of Harvard Health Publications

Lung Auscultation

Listening to the Lungs
The lungs are auscultated with the diaphragm on the chest piece of a stethoscope with the patient breathing slowly and deeply thorugh their mouth. The anatomical sites for lung auscultation are illustrated in below.













There are some common errors to avoid:
Listening to breath sounds through a patients gown or clothes.
Allowing tubing to rub against bed rails or patient’s clothes.
Interpreting chest hair sounds as adventitious* sounds.
Auscultating on the convenient places only

*Adventitious sounds: added sounds, or those superimposed on a patient's underlying breath sounds that usually indicate disease.

Normal breath sounds consist of those heard over the entire lung field and consist of an inspiratory and expiratory phase. They are classified as:

1. Tracheal: These breath sounds are high-pitched and loud, with a harsh and hollow (or "tubular) quality. The inspiratory and expiratory phases are of equal duration, and there is a definite pause between phases. Tracheal breath sounds usually have very little clinical usefulness.



2. Bronchial: Normally heard over the upper manubrium, these breath sounds directly reflect turbulent airflow in the main-stem bronchi. They are loud and high-pitched but not quite as harsh and hollow as tracheal breath sounds, the expiratory phase is generally longer than the inspiratory phase, and there is usually a pause between the phases.



3. Bronchovesicular: These breath sounds are normally heard in the anterior first and second intercostal spaces and posteriorly between the scapulas, where the main-stem bronchi lie. The inspiratory and expiratory phases are about equal in duration, with no pause between phases. Bronchovesicular sounds are soft and less harsh than bronchial breath sounds and have a higher pitch than vesicular sounds.



4. Vesicular: Audible over peripheral lung fields, these breath sounds are soft and low-pitched, without the harsh, tubular quality of bronchial and tracheal breath sounds. The inspiratory phase is about three times longer than the expiratory, with no pause between phases .

Breath sounds are considered abnormal if they are heard outside their usual location in the chest or if they are qualitatively different from normal breath sounds (e.g. decreased or absent). They are divided into two categories: (1) continuous; and (2) non-continuous lung sounds.

Continuous adventitious sounds are referred to as wheezes and described as either high-pitched or low pitched.Wheezes represent airway obstruction which can be caused by broncho-constriction of smooth muscle or the presence of mucus. When a wheezes occur, it is significant. They are most common with expiration. However, they can occur during inspiration and this indicates that a severe airway obstruction is present.

Discontinuous adventitious sounds are classified as either:
1. Crackles(rales) sound like brief bursts of popping bubbles. They are most commonly associated with the sudden opening of closed airways.

2. Pleural Rubs are an indication of pleural inflammation and sounds like two pieces of sandpaper rubbing together throughout each inspiration and expiration

Click here to test your auscultation skills

Nasogastric Intubation

Indications
By inserting a nasogastric tube, you are gaining access to the stomach and its contents. This enables you to drain gastric contents, decompress the stomach, obtain a specimen of the gastric contents, or introduce a passage into the GI tract. This will allow you to treat gastric immobility, and bowel obstruction. It will also allow for drainage and/or lavage in drug overdosage or poisoning. In trauma settings, NG tubes can be used to aid in the prevention of vomiting and aspiration, as well as for assessment of GI bleeding. NG tubes can also be used for enteral feeding initially.
*Contraindications
Nasogastric tubes are contraindicated in the presence of severe facial trauma (cribriform plate disruption), due to the possibility of inserting the tube intracranially. In this instance, an orogastric tube may be inserted.

Procedure

1. Gather equipment


2. Don non-sterile gloves


3. Explain the procedure to the patient and show equipment


4. If possible, sit patient upright for optimal neck/stomach alignment


5. Examine nostrils for deformity/obstructions to determine best side for insertion


6. Measure tubing from bridge of nose to earlobe, then to the point halfway between the end of the sternum and the navel


7. Mark measured length with a marker or note the distance


8. Lubricate 2-4 inches of tube with lubricant (preferably 2% Xylocaine). This procedure is very uncomfortable for many patients, so a squirt of Xylocaine jelly in the nostril, and a spray of Xylocaine to the back of the throat will help alleviate the discomfort.


9. Pass tube via either nare posteriorly, past the pharynx into the esophagus and then the stomach.Instruct the patient to swallow (you may offer ice chips/water) and advance the tube as the patient swallows. Swallowing of small sips of water may enhance passage of tube into esophagus.If resistance is met, rotate tube slowly with downward advancement toward closes ear. Do not force.


10. Withdraw tube immediately if changes occur in patient's respiratory status, if tube coils in mouth, if the patient begins to cough or turns pretty colours


11. Advance tube until mark is reached


12. Check for placement by attaching syringe to free end of the tube, aspirate sample of gastric contents. Do not inject an air bolus, as the best practice is to test the pH of the aspirated contents to ensure that the contents are acidic. The pH should be below 6. Obtain an x-ray to verify placement before instilling any feedings/medications or if you have concerns about the placement of the tube.


13. Secure tube with tape or commercially prepared tube holder


14. If for suction, remove syringe from free end of tube; connect to suction; set machine on type of suction and pressure as prescribed.


15. 
    Document the reason for the tube insertion, type & size of tube, the nature and amount of aspirate, the type of suction and pressure setting if for suction, the nature and amount of drainage, and the effectiveness of the intervention.

Complications
The main complications of NG tube insertion include aspiration and tissue trauma. Placement of the catheter can induce gagging or vomiting, therefore suction should always be ready to use in the case of this happening.

Universal precautions:
The potential for contact with a patient's blood/body fluids while starting an NG is present and increases with the inexperience of the operator. Gloves must be worn while starting an NG; and if the risk of vomiting is high, the operator should consider face and eye protection as well as a gown. Trauma protocol calls for all team members to wear gloves, face and eye protection and gowns.

Recovery Position

Adult Recovery Position
This position helps a semiconscious or unconscious person breathe and permits fluids to drain from the nose and throat so they are not breathed in. If the person is unconscious or semiconscious after you have done everything on the Emergency Checklist, move the person into the recovery position while waiting for help to arrive.

*Do not use the recovery position if the person has a major injury, such as a back or neck injury

1. Kneel next to the person. Place the arm closest to you straight out from the body. Position the far arm with the back of the hand against the near cheek.

2. Grab and bend the person's far knee.

3. Protecting the head with one hand, gently roll the person toward you by pulling the far knee over and to the ground.

4. Tilt the head up slightly so that the airway is open. Make sure that the hand is under the cheek. Place a blanket or coat over the person (unless he or she has a heat illness or fever) and stay close until help arrives.

Infant Recovery Position
Place the infant face down over your arm with the head slightly lower than the body. Support the head and neck with your hand, keeping the mouth and nose clear. Wait for help to arrive.

Courtesy of BLS(Basic Life Support) by Dr.George made possible thanks to RMT(Russian Medical Team), spiced up with a little Indran touch.Enjoy