Mo Sobhy Academy Procedures 2022 Note

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Index
Station Page
I Blood Sample 9
II Blood Culture 15
III IV Cannulation 20
IV ABG 26
V Catheterization 31
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Blood procedures
- Blood Sampling
- Blood Culture
- IV Cannulation
- ABG
Overview of Blood Procedures:

• Remember that in Blood Procedure stations, you are not the first line of
contact with the patient.
• Your task is to do the procedure itself, so take focused history relevant
to the procedure. Do not dwell on the patient’s condition itself.
• Assume you are wearing gloves, not actually wear them.
• Expect a flashback of blood after inserting the needle, and fill up the
tubes, syringes, and bottles with blood.
• If you fail to withdraw blood, do not panic, and repeat the procedure:
- Do not reuse the same equipment
- Select another part of the vein or another vein altogether
• Touch the mannequin only after preparing your equipment

• Tie the torniquet very late and loosen it very early. (Tie it after
preparing your equipment and loosen it once you see a flashback).
• Never collect extra equipment.
• Leave the table very tidy and the mannequin clean. The only thing that
should remain in your tray once you are done is the sample you took.
• Needles are discarded into the sharps bin. Others are discarded into the
waste bin
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IPS
Body language
- Confident, active, and energetic outside. Calm, structured and
organized inside.
- Loud, clear, and articulate.
- Good posture (do not shake or cross your legs or arms)
- Take care of your involuntary hand movements.
Verbal “ICE”
• Remember that picking up on non-verbal cues is of extreme
importance, so comment on any action that you notice from the
patient.
• IPS goes throughout the station even while you are doing the
procedure, so please walk the patient through every step as you are
doing it.
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General Structure of blood procedure stations:
History Taking:
1) Confirm the patient’s identity
2) Start the station well (by showing you have read the stem and know the
patient’s condition, not with “how can I help you”
3) Why? & Why?

- Explain why you are here and why you are taking the blood
sample: (My consultant has asked me to take a blood sample from
you to …...)
4) Take focused History relevant only to your procedure
5) Ask about the pillars of every station (Medical Conditions, Medications

and Allergies)
- Medical Conditions (Always start with an open question and then
specify conditions related to blood procedure specially bleeding
disorders.
- Medications (start with an open question, and then specify any
use of blood thinners)
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6) Explain the PPECC (Procedure, Position, Exposure, Chaperone, Consent)
- Procedure: explain exactly what you are going to do: (I will be

inserting a thin needle into one of the blood vessels (veins/ arteries)
of your (forearm/ wrist). It will feel like a sharp scratch, but I will be
as quick and gentle as possible.
- Position: Can you please straighten your elbow/ wrist for me.
- Exposure: Can you please roll up your sleeves for me.

Please be observant. (Notice whether the patient has short sleeves,
or has rolled up the sleeves already, and comment on it accordingly).
- Chaperone: Blood procedures do not require a chaperone.
- Consent: Do I have your consent to proceed?
7) Ask about any arm soreness and any arm preference.
8) Do not forget to inform the patient that if you fail, you may need to
repeat the procedure.
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Procedure:
❖ Collect your equipment
❖ Prepare your equipment in your clean area.

- Once the equipment is prepared, put them in your tray
❖ Gloves: Assume you are wearing gloves
❖ Feel the vein/ Artery
❖ Torniquet (pay attention to tie the torniquet above the cubital fossa)
❖ Clean Prick Collect

- Clean the area with one single stroke
- Prick with the bevel pointing up and warn the patient about the
sharp scratch.
- Collect the blood.
❖ Cotton and Label

- Put a cotton on the prick site
- Verbalize labeling the sample with the patient’s details and
verbalize sending it to the lab.
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Management
❖ Management
Sit down and discuss with the patient the management details specific
to each station
❖ Safety net
1. about the procedure itself (any bleeding, swelling or soreness)
2. about the patient’s general condition.
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Blood Sampling (Venipuncture)
Who you are

- You are FY2 in A&E department
Who the patient is
- Adam Elkady, 26-year-old male has taken some paracetamol tablets
Other information
- Your consultant has asked you to take a blood sample from the patient to
test for the level of paracetamol in her blood
Special Note
- None
What you must do
- Take focused history, do the relevant procedure, and manage the patient
accordingly
History Taking:
2) Start the station well (I can see from my notes that you are here as you
have taken some PCM tablets)
• IPS:
- Pick up on non-verbal cues (if the patient is looking at the ground
or avoiding eye contact)
- Build Rapport. Show sympathy and empathy
- Reassure by giving confidentiality
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3) Why? & Why?
- My consultant has asked me to take a blood sample from you to
test for the level of PCM in your blood

1. Ask if he took anything else. With water or alcohol?
2. How many?
3. When? All together or separately?
4. Any symptoms? Tummy pain? Vomiting?

and Allergies)
- Medical Conditions (specify any bleeding disorder, Liver or kidney
conditions)
- Medications (specify any blood thinner)
- Procedure: I will be inserting a thin needle into one of the blood

vessels veins of your forearm. It will feel like a sharp scratch, but I
will be as quick and gentle as possible.
- Position: Can you please straighten your elbow for me.

- Chaperone: No need for a chaperone.
10 | P a g e
Procedure:
❖ Collect your equipment:

- Tourniquet Yellow tube is the first choice for toxicology
- 1 Alcohol swab
Second choice is the red tube
- Vacutainer and needle
- Blood Tube
- Cotton piece
❖ Prepare your equipment in your clean area, then put them on your
tray:
- Partially open the alcohol swab
- Remove the grey (white) cap from the needle and discard it. Then
attach the needle to the vacutainer.
- Loosen up the other cap (The green cap) slightly and keep it aside ready
for the procedure.
❖ Feel the vein

11 | P a g e
❖ Torniquet (Tie the torniquet above the cubital fossa)

- Remove the green cap to reveal the needle, and discard the cap.
Then warn the patient and prick with the bevel pointing up.
- Keep the needle fixed and secure all the time.
- Loosen the tourniquet as soon as you see the flashback.
- Once in the vein, while holding the vacutainer holder firm and
still with your left hand, attach the vacutainer and let it fill.
- Once blood is collected, turn the tubes upside down and swill it
around a bit to ensure full mixing.

- Withdraw the needle carefully. Once the needle is out, press the
cotton down on the puncture site.
- Dispose the needle attached to the vacutainer holder into the
sharps bin.
12 | P a g e
Management
❖ Management
Sit down and discuss with the patient the management details:
• Keep in the observation unit
• Investigations
- FBC, LFT, RFT
- Coagulation profile
- Plasma PCM concentration (81mg/l)
• Treatment
Interpret the results of the PCM concentration on the PCM chart
➢ If above the t.t line: N-acetyl cysteine- takes about 21 hours
After medical fitness, refer to Psychiatry colleagues for support, relief

of stress and improving mood
❖ Safety net
3. about the procedure itself (any bleeding, swelling or soreness)
4. about the patient’s general condition (Tummy pain, vomiting,
confusion, drowsiness, yellowish discoloration...)
13 | P a g e
14 | P a g e
Blood Culture
Who you are

- You are FY2 in Surgery Department
Who the patient is
- Tom Henderson, 35-year-old male has had an appendectomy 3 days ago.
He has now developed a fever.
Other information
- Your consultant has asked you to take a blood culture sample from the
patient
Special Note
- None
What you must do
- Take focused history, do the relevant procedure, and address the patient’s
concerns
History Taking:
2) Start the station well (I can see from my notes that you have been
admitted here for an operation to remove your appendix 3 days ago)
• IPS:
- Pick up on non-verbal cues (if the patient is in pain or looking
unwell)
- Build Rapport. Ask about the hospital stay.
15 | P a g e
3) Why? & Why?
- My consultant has asked me to take a blood sample from you to
send it for culture to test for the specific bug causing your
symptoms.

1. Ask about any bleeding, pain, or discharge from the operation
site.
2. Ask about bowel motion since after the operation.

and Allergies)
- Medical Conditions (specify any bleeding disorder)


16 | P a g e
Procedure:

- Tourniquet
- Alcohol swab
- Vacutainer and needle
- Blood culture bottles
- 2 (2% Chlorhexidine 70% ispropyl) alcohol wipes
- Cotton piece.
tray:
- Partially open the alcohol swabs
- Remove the grey (white) cap from the needle and discard it. Then
attach the needle to the vacutainer.
- Loosen up the other cap (The green cap) slightly and keep it aside ready
for the procedure.
- Culture Bottles: * Check the expiry date
* Flip off the caps
*Clean the tops of the bottles each with a different
chlorhexidine wipes
17 | P a g e
❖ Feel the vein

- Remove the green cap to reveal the needle, and discard the cap.
Then warn the patient and prick with the bevel pointing up.
- Loosen the tourniquet as soon as you see the flashback.
- Once in the vein, while holding the vacutainer holder firm and
still with your left hand, attach the vacutainer and let it fill.
- Once blood is collected, swirl the bottles 180 degrees and put
them on the tray.

cotton down on the puncture site.
- Dispose the needle attached to the vacutainer holder into the
sharps bin.
18 | P a g e
Management
❖ Management
• Investigations
- FBC, LFT, RFT
- Lactate level
- Monitor Urine output
• Treatment
- PCM for the fever
- Start on Broad Spectrum Antibiotic and change it once the
results of the culture come back.
❖ Safety net
- about the procedure itself (any bleeding, swelling or soreness)
- about the patient’s general condition (Tummy pain, discharge,
bleeding from the operation site, constipation, if fever does not
resolve…)
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IV Cannulation
Who you are

- You are FY2 in Surgery Department
Who the patient is
- Jamie Smith, 28-year-old male has had an appendectomy few hours ago.
His cannula is blocked
Other information
- Your consultant has asked you to change his IV cannula
Special Note
- The patient is on 5mg IV morphine 4 hourly. His last dose was 1 hour ago
What you must do
- Take focused history, do the relevant procedure, and address the patient’s
concerns
History Taking:
2) Start the station well (I can see from my notes that you have been
undergone an operation to remove your appendix a few hours ago)
• IPS:
- Pick up on non-verbal cues (the patient will be in pain)
- Build Rapport.
- Ask how the operation went.
20 | P a g e
3) Why? & Why?
- My consultant has asked me to change your blocked cannula to
give medications and fluids

1. Explore the Pain (SOCRATES)
2. Ask about any bleeding, pain, or discharge from the operation
site.
3. Ask about bowel motion since after the operation.
4. Ask about the pillars of every station (Medical Conditions,

Medications and Allergies)
5. Explain the PPECC (Procedure, Position, Exposure, Chaperone,

Consent)


21 | P a g e
6. Ask about any arm soreness and tell him as he has a blocked
cannula, you will be inserting the cannula in the other arm.
7. Do not forget to inform the patient that if you fail, you may
need to repeat the procedure.
Procedure:
❖ Remove the blocked cannula, discard it into the waste bin and ask the
patient to press the cotton down.

- Tourniquet
- Alcohol swab
- Cannula
- Tegaderm
The syringe will be already
- 2 cc syringe filled with saline
prefilled with saline
- Gauze piece
- Cotton piece.
❖ Prepare your equipment in your clean area, then put them in your tray:
- Partially open the alcohol swabs
- Make cannula ready to use, remove the stopper, loosen the cap on top
and loosed the cap covering the needle and place in your tray.
- Prepare the Tegaderm: Take the 3 stickers off and stick them on the
side of the tray.
22 | P a g e
❖ Feel the vein

- Insert the cannula with the bevel facing upwards. Flashback of
blood is seen in the hub at the back of the cannula- advance the
needle into the vein at 15 degrees (Lower) and progress the
entire cannula a further 2mm to ensure it is in the vein.
- Fix the needle by holding the end of the needle steady with your
non-dominant hand and slide the rest of the cannula forwards
slightly.
- Withdraw (Retract) the needle slightly so that its sharp point is
inside of the plastic tubing.
- Advance cannula fully into vein – The needle still inside the
tubing will stop the plastic from kinking.
- Loosen the tourniquet
- Place some gauze directly underneath the cannula. Then remove
the needle fully and dispose it into the sharps bin.
- Put the stopper back to the cannula.
- Put two of the stickers on both sides of the cannula. Then flush
the cannula and close the cannula port.
23 | P a g e
❖ Label
- Fix the Tegaderm on securely and verbalize labeling the date and
time and discard your waste.
Management
❖ Management
Examination:
Vitals- respiratory depression (because of Morphine)
GPE- shock/dehydration
Operation site
Abdominal examination- internal bleeding
• Investigations
- FBC, LFT, RFT
- Coagulation profile
- Monitor Urine output
• Treatment
➢ For the pain: according to the patient’s charts and the last dose of
morphine
o If he is on 5 mg IV morphine 4 hourly and his last dose was 1 hour
ago, then no morphine but we give instead 1g IV PCM
o Check vitals- RR before giving morphine
24 | P a g e
➢ If still in pain:
o Encourage to wait for some time- reassess in 10-15 mins
o PRN Naloxone (100-200microgram)
➢ For the Nausea: IV Metoclopramide 10mg
❖ Safety net
- about the patient’s general condition (Tummy pain, discharge,
bleeding from the operation site, constipation, if pain does not
resolve…)
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Arterial Blood Gases
Who you are

Who the patient is
- Peter Fey, 49-year-old male who has been previously diagnosed with COPD
has now presented with shortness of breath.
Other information
- Your consultant has asked you to take an ABG sample from the patient
Special Note
- None
What you must do
- Take focused history, do the relevant procedure, and manage the patient
accordingly
History Taking:
have been having some shortness of breath.)
* Check if the patient is on oxygen already
• IPS:
- Pick up on non-verbal cues (if the patient is looking is SOB)
- Build Rapport.
26 | P a g e
3) Why? & Why?
- My consultant has asked me to take a sample to test for the level
of gases of your blood.

1. Ask about any chest pain.
2. Ask about fever.
3. Any cough.
4. Ask about compliance to medications for COPD.

and Allergies)
- Procedure: I will be inserting a thin needle into one of the arteries of

your wrist. It will feel like a sharp scratch, but I will be as quick and
gentle as possible.
- Position: Straighten your wrist for me.

- Exposure: Roll up your sleeves for me or remove your watch for me.
27 | P a g e
Procedure:
❖ Perform the modified Allen’s test: This test involves the assessment of
the arterial supply to the hand.
If the reperfusion time is less than 7 seconds, I will continue with the
procedure.

- 1 Alcohol swab
- ABG Needle (with the stopper)
- Cotton piece
tray:
- Partially open the alcohol swab
- Loosen up the cap slightly and keep it aside ready for the procedure.
- Keep the green stopper in the tray.
❖ Feel the artery
28 | P a g e
- Locate the Radial pulse by palpating over the artery using 3
fingers of your left hand (index, middle and ring fingers).
If you do not feel the pulse inform the examiner, as the
mannequin has a palpable pulse in the exam. Simply say: “I can’t
feel the Radial pulse.”
- Sterilize the area: Put 3 fingers of your left hand over the Radial
artery. Then remove only your middle finger (backwards) and
clean the area using an alcohol swab with a single stroke. Keep
that hand fixed.
- With the other hand, remove the cap to reveal the needle, and
discard the cap. Then warn the patient and prick at a degree
between 45 to 90 degrees holding the needle like a pen.
- Once inside the artery, the syringe should begin to self-fill. The
arterial pressure will cause the blood to fill the syringe
automatically.
- Withdraw about 1cc of Blood.

cotton down firmly on the puncture site, and ask the patient to
do so for 5 minutes.
- Lock the protective needle sleeve by pushing it down against the
table. Do not use your hand to lock the protective needle sleeve.
Remove the needle from the syringe and discard it into the
sharps bin.
- Apply the stopper onto the syringe.
29 | P a g e
- Verbalize labeling the sample with the patient’s details (Mention
oxygen saturation) and verbalize sending it to the lab by yourself
immediately.
Management
❖ Management
Take the patient’s observations including the O2 saturation
• Treatment
➢ Oxygen
❖ Safety net
- about the patient’s general condition (chest pain, cough, fever,...)
30 | P a g e
Male Urethral Catheterization
Who you are
Who the patient is
- Tony Samson, 41-year-old male who has presented with an abdominal
discomfort
Other information
- None
Special Note
- None
What you must do
- Take focused history, perform the emergency management, and address
the patient’s concerns
History talking
are having some abdominal discomfort.)
• IPS:
- Pick up on non-verbal cues (if the patient is holding his tummy in
pain)
- Build Rapport.
31 | P a g e
P1 Explore the main complaint
1) Pain: SOCRATES
2) Ask about waterworks (and when was the last time he has passed
urine)
** Exclude the Contraindications of catheterization:

• Bleeding from down below
• Discharge (UTI)
• Any trauma or recent instrumentation
P2 (start with an open question, then specify)

- Medical Conditions (specify any history of stones, problems in
the male gland, and bleeding disorders)
- Medications (specify any blood thinners)
- Allergies (ask about any allergy to latex)
Examination
▪ Vitals
▪ GPE- blood on the meatus
▪ Abdominal examination
Provisional Diagnosis
From the information you have given me and according to my examinations
(Always briefly mention the positive findings you have found in history and
Examination), I am suspecting that you have a urinary retention.
32 | P a g e
Procedure
Explain that in order to relieve the patient’s pain or discomfort, you will need
to insert a catheter
Explain PPECC:
- Procedure: I will be inserting a thin rubber tube into your penis. It
will be a bit uncomfortable, but I will be as quick and gentle as
possible.
- Position: lie flat on your back with your legs slightly separated
- Exposure: uncover from the waist down
- Chaperone: I will ensure your privacy by having a chaperone
❖ Collect your equipment

- 2 kidney trays
- Sterile gauze
- 3 cotton pieces
- Sterile forceps
- Antiseptic solution / Normal saline
- Anesthetic jelly filled syringe (1%)
- Normal distilled water filled syringe (10mls)
- Urine bag
- Male Foley catheter – 12-14 French size
33 | P a g e
❖ Prepare your equipment
- Keep the catheter ready for insertion: Remove outer packaging
and take the tip of catheter few centimeters out from the inner
packaging using non-touch technique.
- Place the kidney tray between the patient’s thighs.
❖ Assume you are wearing double sterile gloves
❖ Cleaning:
- With the help of a sterile forceps place a piece of gauze over the
shaft of the penis. Dispose the plastic forceps into clinical waste
bin.
- Hold the penis with your left (non-dominant) hand and make
sure that you do not leave it until you have fully inserted the
catheter. This hand is contaminated and should now not touch
the aseptic trolley.
- Using your right hand and with the help of a sterile forceps pick
up a cotton piece, soak it into normal saline/antiseptic solution
and clean the penis in concentric circles beginning at the glans
penis, and moving progressively outwards (Use 3 cotton pieces,
make each circle with one swab to clean the glans and the whole
area around the glans). Dispose the plastic forceps and cotton
pieces into the clinical waste bin.
**Assume to take one pair of the sterile gloves off.
34 | P a g e
❖ Insert the anesthetic gel
- Explain to the patient that you are going to insert some
anesthetic gel to make the procedure more comfortable
- Pick up the syringe labelled as anesthetic jelly. Holding the glans,

pull firmly upward and place the nozzle of the syringe of
anesthetic gel into the urethral meatus. Slowly expel the
contents into the urethra. Verbalize giving the gel 3-5 minutes to
take full effect.
❖ Inserting the catheter:

- Place the draining end of the catheter in the kidney tray.
- Warn the patient that you are going to insert the catheter.
- While you are holding the base of the glans with your left hand,
apply gentle upward traction to the penis and insert the exposed
catheter tip into the urethral meatus with your right hand.
- Advance the catheter by slowly removing the wrapper to expose

more catheter, using a non-touch technique by touching only the
packaging i.e. insert without taking the catheter completely out
of the packaging.
- To remove the wrapper without also pulling the catheter back

out, ensure a good grip on the penis as you pull back on the
wrapper.
- Continue to advance the catheter until it is fully inserted up to
the Y- junction.
35 | P a g e
❖ Inflating the catheter balloon:
- Once fully inserted, attach the distilled water syringe to the
balloon port of the catheter. Insert about 5ml of distilled water
slowly while looking at the patient’s face to check for any pain or
resistance. Then inject the rest of distilled water, ensuring that it
does not cause any pain.
- Dispose the syringe into the clinical waste bin. Once the balloon
is fully inflated, gently pull on the catheter until resistance is felt.
- If the mannequin had foreskin, replace/reposition the patient’s
retracted foreskin and discard the gauze you were using to hold
the shaft of the penis into the clinical waste bin. Hold the Y
junction with your left hand.
❖ Attaching the urine bag:
- Remove the cap from the tubing and plug the plastic tube end into
the catheter, ensuring a tight seal.
- Place the urine bag below the level of the patient. “Ideally I would
place the urine bag below the level of my patient and I will stick the
catheter on the thigh.”
❖ Ensure area and patient is clean:
- Tear the drape and dispose it into the clinical waste bin. However, in
the exam you will be asked not to do so.
- Dispose of equipment into the clinical waste bin.
- Clean the patient and ensure his dignity by making sure that he is
comfortable and covered: Thank the patient and ask him to dress up.
36 | P a g e
❖ Label:
- Record the date and time of insertion, size of catheter and volume
and color of urine drained.
After evacuating the urine,
the Blood pressure may fall
** Take the patient’s observations again after the procedure
Management
• Shift to the observation unit
• Senior
• Investigations:
- Bloods , RFT
- Ultrasound
- Monitor urinary output
• Symptomatic treatment:
- PCM if still in pain after the procedure
- IV fluids if blood pressure after the procedure is low
- Medication to relax the neck of bladder
- Antibiotics if there is a UTI
• Specialist (Urologist)
• Safety net:
- Any pain, burning sensation or fever
- Blockage of the catheter
- If blood is noticed in the catheter.
- If the catheter is full.
37 | P a g e

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1|Page

Overview of Blood Procedures:

• Touch the mannequin only after preparing your equipment

1) Confirm the patient’s identity

3) Why? & Why?

4) Take focused History relevant only to your procedure

5) Ask about the pillars of every station (Medical Conditions, Medications

- Procedure: explain exactly what you are going to do: (I will be

- Exposure: Can you please roll up your sleeves for me.

- Chaperone: Blood procedures do not require a chaperone.

- Consent: Do I have your consent to proceed?

7) Ask about any arm soreness and any arm preference.

❖ Collect your equipment

❖ Prepare your equipment in your clean area.

❖ Gloves: Assume you are wearing gloves

❖ Feel the vein/ Artery

❖ Clean Prick Collect

❖ Cotton and Label

Who you are

1) Confirm the patient’s identity

4) Take focused History relevant only to your procedure

5) Ask about the pillars of every station (Medical Conditions, Medications

6) Explain the PPECC (Procedure, Position, Exposure, Chaperone, Consent)

- Procedure: I will be inserting a thin needle into one of the blood

- Position: Can you please straighten your elbow for me.

❖ Collect your equipment:

❖ Gloves: Assume you are wearing gloves

❖ Feel the vein

❖ Clean Prick Collect

❖ Cotton and Label

After medical fitness, refer to Psychiatry colleagues for support, relief

Who you are

1) Confirm the patient’s identity

4) Take focused History relevant only to your procedure

5) Ask about the pillars of every station (Medical Conditions, Medications

6) Explain the PPECC (Procedure, Position, Exposure, Chaperone, Consent)

- Procedure: I will be inserting a thin needle into one of the blood

- Position: Can you please straighten your elbow for me.

❖ Collect your equipment:

❖ Feel the vein

❖ Torniquet (Tie the torniquet above the cubital fossa)

❖ Clean Prick Collect

❖ Cotton and Label

Who you are

1) Confirm the patient’s identity

4) Take focused History relevant only to your procedure

4. Ask about the pillars of every station (Medical Conditions,

5. Explain the PPECC (Procedure, Position, Exposure, Chaperone,

- Procedure: I will be inserting a thin needle into one of the blood

- Position: Can you please straighten your elbow for me.

❖ Collect your equipment:

❖ Feel the vein

❖ Torniquet (Tie the torniquet above the cubital fossa)

❖ Clean Prick Collect

➢ For the Nausea: IV Metoclopramide 10mg

Who you are

1) Confirm the patient’s identity

4) Take focused History relevant only to your procedure

5) Ask about the pillars of every station (Medical Conditions, Medications

6) Explain the PPECC (Procedure, Position, Exposure, Chaperone, Consent)

- Procedure: I will be inserting a thin needle into one of the arteries of

- Position: Straighten your wrist for me.

❖ Collect your equipment:

❖ Gloves: Assume you are wearing gloves