Tropical Medicine System

2013

Clinical Skills

LEARNING GUIDE
FAKULTAS KEDOKTERAN UNIVERSITAS PADJADJARAN

2013 2014 4th year program Tropical Medicine System

Tropical Medicine System

2013

TABLE OF CONTENT 1. HISTORY TAKING OF FEVER IN ADULT 2 2. CHILD IMMUNIZATION PART 1 8 3. CHILD IMMUNIZATION PART 2 11 4. LUMBAL PUNCTURE 14 5. SLIT SKIN SMEAR AND NERVE EXAMINATION FOR LEPROSY 17 6. BED POSITIONING AND BED TURNING 22 7. SKIN SCRAPING FOR SCABIES AND CUTANEUS MYCOSIS 25

Tropical Medicine System

2013

History Taking of Fever in Adult

GENERAL OBJECTIVE The student will be able to perform history taking of fever cases. SPECIFIC OBJECTIVE The student will be able to - understand the procedure of history taking of fever systematically to standardized patient - analyze and apply the information from the patient as diagnostic approach SYLLABUS DESCRIPTION a. Sub Model Objective The student will be able to perform history taking systematically: - Data identifying - Reliability - Chief complaint - Present Illness (seven attributes) - Past History - Family History - Personal and Social History - Review of system The students will be able to apply their previous knowledge to analyze the fever case b. Expect competencies Student will be able to demonstrate the procedure of history taking of fever to standardized adult patient systematically and shows professionalism

Clinical Skills Program Learning Guide

c. Method - Presentation - Demonstration - Coaching - Self practice d. Laboratory facilities - Skills laboratory - Trainers - Student learning guide - Trainers guide - Role play for standardized patient - References

Tropical Medicine System

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LEARNING GUIDE

No
A 1 2 3 4 5 B 1

Steps

General conditioning, Introduction and Data Identifying Introduce yourself properly ask identity, occupation, politely with empathy Ask name, age, gender, occupation, marital status, source of history , source of referral Give attention to the patient, not writing while listening Use of open question at the beginning and the first 3 questions in anamnesis Provide guidance to the patient and not interrogative Chief Complaint and Present Illness Timing : - Onset of fever was inquired and concluded correctly (sudden vs gradual) - Duration of fever Type of fever (Pattern of fever) a. Remittent fever Daily elevated temperature of more than 38C but return to the baseline (but not normal) b. Intermittent Intermittently elevated temperature of more than 38C but return to baseline and normal c. Sustained or continuous fever Daily elevated temperature of more than 38C with fluctuation of elevated temperature (less than 0.3C) d. Hectic fever Daily elevated temperature of more than 38C with temperature excursion more than 1.4C. It could be either remittent or intermittent Setting (at least 2 events or setting when fever occurred) Associated symptoms (at least three ; chills, headache, sweating, rash etc) Factors that aggravate and relieve the symptoms Past History, Family, Personal and Social History Have acquired at least 3 additional information (history of traveling, previous illness, medicine history and occupational history) Review of the System Conclusion Able to name at least 2 organ system related with disease that is relevant to the type of fever encountered.

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Tropical Medicine System ROLE PLAY FOR HISTORY TAKING OF TROPICAL MEDICINE Problem 1:

2013

This exercise is a role play. One student act as a patient, the other one try to anamnesis and describe his fever type and the important information regarding the complaint or possible disease. Try to use all the description, but besides this, you can also be creative about the additional story to make up. Identity : Adin, 25 years old, male, occupation student of art. Chief complaint: Fever General appearance: Patient look weak, pale, and apathetic Description of complaint: Since 1 week ago patient felt cold and slight fever, this symptom persisted and even increasingly felt worse and become very high. Patient lost his appetite. Every day fever is felt, especially at night, there was only slight rigors, and sweating 1 hour after taking parasetamol tablet. He has been weak actually for 10 days. Before fever is felt, he has the feeling of weakness, dizzy and headache. It was difficult for him to study, so he missed several classes. Since a week he did not go to school. He went to a doctor and was prescribed parasetamol tablet, which was taken for 3 days, but the fever kept on coming. He is a student in Bandung, and actually he came from Jakarta but since childhood never travel outside of Java, the farthest journey was to Cirebon last year.

Tropical Medicine System Problem 2:

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This exercise is a role play. One student act as a patient, the other one try to anamnesis and describe his fever type and the important information regarding the complaint or possible disease. Try to use all the description, but besides this, you can also be creative about the additional story to make up. Identity : Yeni Wunungga, 23 years old, female, occupation student of nursing. Chief complaint: Fever General appearance: Patient look weak, pale, and apathetic. Description of complaint: Since 2 week ago patient felt cold but then followed by fever. This has happened about 3 to 4 times, but several days was without any fever, she couldnt quite remember how many days. But the last fever went since yesterday, and 2 days before this there was no fever for two days. She felt shivering with a lot of weating when the fever subsided. Now patient is becoming weak, lost appetite and nauseated. Headache is felt during the fever, especially the high ones. It was difficult for her to study, so he missed several classes in the last 1 weeks and several days leaving earlier in the week before. She went to a doctor and was prescribed parasetamol tablet and amoxicillin last week, which was taken for 4 days, but the fever kept on reapearing. He is a nursing student in UNPAD Bandung, and came from Jayapura since 6 month ago.

Tropical Medicine System Problem 3:

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This exercise is a role play. One student act as a patient, the other one try to anamnesis and describe his fever type and the important information regarding the complaint or possible disease. Try to use all the description, but besides this, you can also be creative about the additional story to make up. Identity : Dina, 32 years old, female, occupation secretary of a factory. Chief complaint: Fever General appearance: Patient look weak Description of complaint: Four days ago patient felt cold and then fever is felt. It was a high fever, especially at night time. Her friends told that his skin felt like fire. Actually in the morning before, she felt OK and still went to work in the factory until the afternoon. This symptom persisted for the next two days even increasingly felt worse and become very high. There was no shivering or sweating, however she felt thirsty and nauseated. She also felt dizzy and have a headache every-time fever is felt. Fever subsided this morning. There is a reddish rash in her arms and lower leg / foot. Her room mate observed this only today. She has not come to the doctor He is a secretary in Bandung, and never went traveling too far, except Bali in the last year.

Tropical Medicine System Problem 4:

2013

This exercise is a role play. One student act as a patient, the other one try to conduct anamnesis and describe his fever type and the important information regarding the complaint or possible disease. Try to use all the description, but besides this, you can also be creative about the additional story to make up. Identity : Abdulah, 67 years old, male, retired office clerk. Chief complaint: Fever General appearance: Patient look weak, pale, and apathetic. Description of complaint: Since 1 month ago patient felt fever which comes and go. This has happened often almost every day there is fever. Sometimes it subsides in the morning, but never felt normal, because he still felt cold and weak. At night usually is higher. He has no appetite and loose his weight. Headache is felt during the fever, especially the high ones. It was difficult for him to work in the garden where he usually like to spent his time. He went to a doctor 3 times and was prescribed parasetamol tablet and antibiotic for 3 times. Has his blood checked but he never felt better. If he takes parasetamol, fever only normalized for 2-3 hours and then it comes back. He has no history of traveling. Smoke 1 box per day until he felt sick.

Tropical Medicine System

2013

Clinical Skills Program Learning Guide

Child Immunization part 1 : Before Session (Cold Chain)

GENERAL OBJECTIVE The student will be able to perform cold chain regarding immunization. SPECIFIC OBJECTIVE The student will be able to Perform the cold chain procedures at health provider setting - Perform the cold chain procedures at rural area using vaccine carrier SYLLABUS DESCRIPTION a. Sub Model Objective The student will be able to perform cold chain procedures appropriately using refrigerator, cold boxes and vaccine carrier The student perform procedures to determine the quality of vaccine e the fever case b. Expect competencies Student will be able to demonstrate the application of cold chain procedure as a part of immunization

c. Method - Presentation - Demonstration - Coaching - Self practice d. Laboratory facilities - Skills laboratory - Trainers - Student learning guide - Trainers guide - Refrigerator - Basic immunization Vaccine - Cold boxes, vaccine carrier - Ice pack - Temperature monitor - References

Tropical Medicine System

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LEARNING GUIDE

BEFORE SESSION
STEPS
LOADING COLD-CHAIN EQUIPMENT Refrigerators Load a vaccine into refrigerator: 1. Freeze and store frozen ice packs in the freezer compartment 2. All the vaccines and diluents have to be stored in the refrigerator compartment. 3. Arrange the boxes of vaccine in stacks between which the air can move between them. 4. Keep opened vials of OPV, DTP, Td, TT, Liquid Hib, hepatitis B and DTP-HepB vaccines in the use first box for first use during the next session. 5. Keep vials with VVMs showing more heat exposure than other in the box labelled use first. Use these vials first in the next session. 6. Only keep vials that are good for use in the refrigerator. 7. Keep ice-packs filled with water on the bottom shelf and in the door of the refrigerator. 8. Store vaccines in locations appropriate to the refrigerator you use. Load front-loading refrigerator with freezer on top 1. Measles, MR, MMR, BCG and OPV on the top shelf. 2. DTP, DT, Td, TT, HepB, DTP-HepB, Hib, DTP-HepB+Hib, meningococcal, yellow fever, and JE vaccines on the middle shelves; and 3. Diluents next to the vaccine with which they were supplied. Loading ice-lined refrigerators 1. Measles, MR, MMR, BCG and OPV in the bottom only; and 2. Freeze sensitive vaccines (DTP; TT; HepB, Hib, DTP-HepB, Hib; DTP-HepB+Hib, meningococcal, yellow fever, and JE vaccines) in the top only. Cold boxes and vaccine carriers Load vaccine into cold boxes and vaccine carriers : 1. At the beginning or the day of the session, take all the frozen ice-packs you need from the freezer and close the door. 2. Condition frozen ice-packs properly, by allowing ice-packs to sit at room temperature until ice begins to melt and water starts to form. 3. Put conditioned ice-packs against each of the four sides of the cold box or vaccine carrier and on the bottom of the cold box if required. 4. Put the vaccines and diluents in the middle of the cold box or carrier. 5. Include a freeze indicator in the packing with the vaccines 6. In vaccine carriers, place a foam pad on top of the conditioned ice-packs. In cold boxes, place conditioned icepacks on top of the vaccines. 7. Close the cold box or carrier lid tightly. MONITOR AND ADJUST THE TEMPERATURE

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Tropical Medicine System Monitoring the temperature in vaccine refrigerators If the temperature is too LOW (below +2 C) 1. Turn the thermostat knob so that the arrow points to a LOWER number. This will make the refrigerator warmer. 2. Check whether the door of the freezer closes properly. The seal may be broken. 3. Check freeze-sensitive vaccines (DTP; DT; Td: TT; HepB; DTP-HepB, liquid Hib and DTP-HepB+Hib vaccines) to see whether they have been damaged by freezing by using the shake test. If the temperature is too HIGH (above +8 C) : 1. Make sure that the refrigerator is working; If not, check if kerosene, gas or power supply is present. 2. Check whether the door of refrigerator or the freezing compartment closes properly. 3. Check whether frost is preventing cold air in the freezing compartment from entering the refrigerator compartment. 4. Turn the thermostat knob so that the arrow points to a HIGHER number. 5. If the temperature cannot be maintained between +2 C and +8 C, store vaccines in another place until the refrigerator is repaired. Maintaining the correct temperature in cold boxes and vaccine carriers 1. Place the adequate number of conditioned ice pack in the cold box or vaccine carrier. 2. Keep the cold box or vaccine carrier in the shade 3. Keep the lid tightly closed. 4. Use the foam pad to hold vials during immunization sessions. 5. SHAKE TEST (to determine whether vaccine has been frozen ) 1. Prepare a frozen control sample 2. Choose a test sample 3. Shake the control and test samples for 10-15 seconds 4. Allow to rest 5. Compare the vials, If the sedimentation rate is similar, the vial has probably been damaged by freezing and should not be used.

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Tropical Medicine System

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Clinical Skills Program Learning Guide

Child Immunization part 2 : During Session (Giving Vaccine)

GENERAL OBJECTIVE The student will be able to perform giving basic immunization for pediatric SPECIFIC OBJECTIVE The student will be able to - Perform patient preparation before vaccination - Perform vaccine preparation - Perform the procedure of vaccine injection : intracutaneous, intramuscular, oral. SYLLABUS DESCRIPTION a. Sub Model Objective The student will be able to perform: - Registering, assessing and giving information to the the patient - Determining the appropriate vaccine - Vaccine preparation - Vaccine reconstitution - Giving BCG vaccine to the mannequin (intracutaneous) - Giving OPV to the mannequin (oral) - Giving DPT/Hep-B vaccine to the mannequin (intramuscular) - Measles (subcutaneous) - Disposing the syringe and needles - Closing remarks b. Expect competencies Student will be able to demonstrate the appropriate vaccination procedures to the mannequin

c. Method - Presentation - Demonstration - Coaching - Self practice d. Laboratory facilities - Skills laboratory - Trainers - Student learning guide - Trainers guide - Baby mannequin - Intracutan injection mannequin - Model - Vaccines and diluents - Spuit - Alcohol swab - Gloves - Cold boxes, vaccine carrier

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Tropical Medicine System

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LEARNING GUIDE

DURING SESSION
N o A
1

STEPS PATIENT PREPARATION

COMPLETING THE PATIENT REGISTER A patient register should include at least the following information: a. date, month and year of visit; b. name of client; c. client's address and, if applicable, telephone number; d. client's age or birth date; e. client's sex; f. services provided, e.g., OPV1, DPT1. ASSESSING THE CLIENT a. Is this the right time to give a child an immunization? b. How many doses has the child already had? c. Has sufficient time elapsed since the last dose? d. Can I give different vaccines at the same time? e. Should I give a booster dose? f. Is there a contraindication to immunization? INFORMING CLIENTS a. What vaccines are required on the day of the assessment and when to return b. Describe possible side-effects and explain what to do about them.

B
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PREPARING VACCINES
Washing hand Checking the vaccine and diluents vial labels a. Is the label still attached to the vial? b. Is it the right vaccine or diluents? c. Has the vaccine or diluents passed its expiry date? Checking the vaccine vial monitor (VVM) (if a vaccine has a VVM attached, check whether the vaccine has been exposed to excessive heat) Cleaning the skin before an injection Drawing vaccine from a vaccine vial a. Assemble a sterile syringe and needle of the correct size. b. Turn the needle adaptor with forceps to make sure that the needle is fixed firmly to the syringe. c. Draw air into the syringe by pulling back on the plunger. You need the same amount of air in the syringe as the amount of fluid to be taken out of the vial. d. Push the needle through the rubber stopper into the vaccine vial. e. Inject the air into the vial by pushing in the plunger. f. Draw the vaccine out of the vial by pulling back the plunger. The vaccine comes out easily because the air you have injected takes its place. g. Point the needle upwards and press in the plunger to get rid of air bubbles and excess vaccine. h. Read the scale on the barrel of the syringe to make sure that you have the correct amount of vaccine. i. Ready to inject the vaccine Reconstituting Vaccines a. Insert the mixing needle into the vaccine vial or ampoule. b. Hold the plunger end of the mixing syringe between your index and middle fingers and push the plunger in with your thumb. This empties the diluents into the vaccine. c. To mix the diluents and vaccine, draw them slowly up into the syringe and inject them slowly back into the ampoule. Repeat this several times. d. If you think you may need to reconstitute more of the same kind of vaccine during the session.
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Tropical Medicine System e. You can put the mixing syringe and needle on the sterilizer rack lid for use later in the session. f. Wrap the reconstituted vaccine in foil to protect it from dirt and sunlight. Keep it in the shade. g. Put the vaccine on the foam pad of your vaccine carrier. h. When you no longer need an empty diluents ampoule, dispose of it in a safety box. C 1. GIVING IMMUNIZATIONS BCG a. Positioning the patient sideways on mothers and removes clothing from the arm and shoulder. b. The mother should hold the infant close to her body, supporting his or her head and holding the arms close to the body. c. Hold the syringe in your right hand with the bevel of the needle facing upwards. d. Stretch the skin out flat with your left thumb and forefinger. e. Lay the syringe and needle almost flat along the infants skin. f. Insert the tip of the needle just under the surface but in the thickness of the skin just past the bevel. g. Keep the needle FLAT along the skin, so that it goes into the top layer of the skin only. Keep the bevel of the needle facing up. h. Do not push too far and do not point down or the needle will go under the skin. Then it will be subcutaneous instead of the intradermal injection. i. To hold the needle in position, put your thumb on the lower end of the syringe near the needle, but do not touch the needle. j. Hold the plunger end of the syringe between the index and middle finger of your right hand. Press the plunger in with your right thumb. k. Inject 0.05 ml of vaccine and remove the needle. OPV administration a. Ask the parent to hold the infant with the head supported and tilted slightly back. b. The chin and cheeks should be dry: OPV is less likely to spill out. c. Open the infants mouth gently, either with your thumb on the chin (for small infants) or by squeezing the infants cheeks gently between your fingers. d. Let 2 drops of vaccine fall from the dropper onto the tongue. Do not let the dropper touch the infants. DTP or DTP-HepB or HepB, Hib vaccine: intramuscular (IM) injection in thigh a. Position the infant sideways on the mothers lap with the infants whole leg bare. b. The parent should hold the infants legs. c. Gently stretch the skin flat between your thumb and forefinger. d. Insert the needle at a 900 angle. e. Quickly push the entire needle straight down through the skin and into the muscle. Inject slowly to reduce pain. MEASLES vaccine, YELLOW FEVER, JE: subcutaneous (SC) injection a. Position infant sideways on mothers lap with the whole arm bare. b. The parent should hold the infants legs. c. Reach your fingers around the pinch up the skin. d. Quickly push the needle into the pinch up skin the needle should point towards the shoulder. e. To control the needle, support the end of the syringe with your thumb and forefinger but do not touch the needle. DISPOSING OF SYRINGES AND NEEDLES 1. Place syringes and needles in a disposal box Single-use syringe and needle: after a single use, place the used syringe and needle directly in a disposal box. To avoid needle-stick injuries, do not attempt to recap the needle or to separate the syringe and needle. 2. When the box is full, dispose of it by burning. 3. Bury the remaining debris CLOSING REMARKS Tell the 5 essential messages :

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Tropical Medicine System Date and time of next immunization Place of next immunization Number of visits the client still needs in order to be fully immunized or protected What side effect may occur How side effect can be treated

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Tropical Medicine System

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Clinical Skills Program Learning Guide

Lumbal Puncture
GENERAL OBJECTIVE After completing this skill lab program, student will be able to perform lumbar puncture (LP). SPECIFIC OBJECTIVE By the end of this skill lab program, student will be able to master the procedure of lumbar puncture. SYLLABUS DESCRIPTION a. Expected Competence Student will be able to demonstrate his/her skill in performing Lumbal Puncture to the mannequin b. Method - Presentation - Demonstration - Coaching - Self practice c. Tools - Lumbar puncture manequin set - Spinal needle #18 or 19 - Gloves - Perforated drape - Lidocaine, povidone iodine, ethyl alcohol - Sterile gauze - Tubes (3 pieces) - Bandage d. Venue Laboratory of Skills Lab e. Evaluation - Self assessment sheet - OSCE

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LEARNING GUIDE NEUROLOGIC EXAMINATION LUMBAR PUNCTURE STEPS 1 1 Great the patient. Explain the LP procedure to the patient, its advantages and disadvantages. Ask his/her consent. Prepare the equipments needed for the procedure. Ask the patient to lay on his left side of the body (left lateral decubitus). Place the patient near the edge of the bed. Flex the neck, trunk, hips, and knees; the patients body should be perpendicular to the bed Locate the site of puncture (L3 L4 interspace in adult patient) by drawing an imaginary line between the highest points of the iliac crests (crista iliaca). The site is in the intersection of the imaginary line and vertebral axis Wash your hand and put on a pair of sterile gloves Apply alcohol swab to the puncture site and surrounding area with circular movement, followed by applying povidone-iodine solution with the same manner Wipe with alcohol to remove all traces of the antiseptic to prevent it from entering the subarachnoid space; and wipe it once more using a dry gauze Cover the LP area with perforated drape Infiltrate the site of lumbar puncture with 2 mL of 2% lidocaine HCl for local anesthesia. Start with injecting up to 1 mL of lidocaine to the interspinous ligament and infiltrate the adjacent subcutaneous area with the remaining lidocaine. Wait several moments to let the anesthesia works Take a sterile spinal needle. Make sure that the needle is equipped with stylet, lock the stylet inside the needle, and then insert it slowly with the bevel faces up (parallel to the long axis of the body) until it enters the subarachnoid space. (You will feel a sudden lost of resistance when the tip of the needle reaches subarachnoid space; sometimes reffered to as pop feling) Turn the needle counterclockwise to 9 oclock position, partially wihdraw the sylet and see if there is some CSF comes out. If there is no fluid coming out from the needle, reinsert the stylet, turn the needle back to 12 oclock position and oush tge needle further in. Redo the procedure above until you can get the CSF, and withdraw the stylet wholly. Withdraw the stylet and collect the CSF in three sterile tubes: - Tube 1: 10 15 drops for cell count and differentiation - Tube 2: up to 5 mL for bacteriological workups - Tube 3: up to 2 mL for chemistry (protein, glucose) Reinsert the stylet, turn the needle back to 12 oclock and the withdraw the needle Apply some pressure to the puncture site, and then cover it with sterile gauze soaked by povidoneiodine Ask the patient to lay flat for at least 6 hours to prevent post-LP headache 2

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Tropical Medicine System Clinical Skills Program

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SLIT SKIN SMEAR FOR LEPROSY-NERVE EXAMINATION FOR LEPROSY

GENERAL OBJECTIVE After completing this skill practice, the students will be able to perform clinical procedures for leprosy patient diagnostic approach SPECIFIC OBJECTIVE At the end of skill practice, the student will be able to: Conduct skin smears for the examination of leprosy Perform nerve examination for leprosy (enlargement peripheral nerves in specific sites and skin sensibility) METHOD 1. Presentation 2. Demonstration 3. Coaching EQUIPMENT 1. Presentation: Audiovisual aids 2. Demonstration: Video film 3. Coaching: anatomical model bunsen burner or alcohol lamp matches 70% alcohol cotton wool wooden plate forceps scalpel holder scalpel blade glass slides gloves steril gauze standardized patient cotton wool/cotton bud

Learning Guide

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Tropical Medicine System LEARNING GUIDE: SLIT SKIN SMEARS FOR LEPROSY

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Tropical Medicine System No . Client assessment 1. 2. Greet the patient respectfully and with kindness Ask the patient to sit down. Give an adequate explanation about the test that will be carried out, and explain the goals or the expected result of the test. Ask the patient to sign the informed consent form, and then sign it yourself. STEP PERFORMANCE SCALE 1 2 3 4

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Preparation 3. 4. Check the appropriate equipment. Select the smear sites: 3 sites routine for taking smears are: - The right earlobe - The left earlobe - The lesion If there is no lesion, please take the third smear from the upper knee or the back of the hand. Skin lesions can be very different: a. A well defined lesion: take the smear from the edge b. In ill defined lesion : take the smear from the centre c. A raised lesion : take the smear from the centre. Prepare glass slides: Clean the slide with cotton wool soaked in 70% alcohol. Thereafter, avoid to touch the glass slide with your fingers. Put the clean glass slide on the table where it is easy to reach, with its marked side upwards Light the alcohol lamp/Bunsen burner. Clean the scalpel blade by wiping it with a piece of cotton wool soaked in 70% alcohol. Pass the scalpel blade trough the flame, but do not let it become red hot. Allow the scalpel blade to cool in such a way that it does not touch anything. Wash your hands thoroughly using antiseptic hand soap. Put on gloves on your both hands. Soak a piece of cotton wool with 70% alcohol and clean the site before making the smear. Allow the site to dry before making the cut. Pinch the skin into a fold with your forefinger and thumb, or with artery clamp. Apply enough pressure to minimize bleeding. Wait for a view seconds before making the cut. Make a cut of approximately 5 mm long and at least 2 mm deep. Make the cut into the infiltrated layer of the dermis. After the cut, turn the blade 90o through a right angle and scrape to get tissue material from the edge and the bottom of the cut. Pinch firmly during the whole procedure. Transfer material to the one third first part of the glass slide and spread it evenly in a circular manner. The smear should be 5-7mm in diameter. If this is done carefully the reading of the smear will be easier. The material should appear colorless to pink. If the cut bleeds, apply a dry piece of cotton wool and press for a few minutes. Repeat the cleaning of the scalpel blade before making the second cut. Perform the same procedure on the left earlobe and the lesion, and place the material on the same glass slide. Specimen from the left earlobe is placed on the middle one third of glass slide, and specimen from the lesion is placed on the one third last of glass slide. Leave the slide to dry in a plate, for at least five minutes, but not more than a few hours. After drying, the smear is ready to be fixed. Pass the slide three times through the flame. Hold it either with your fingers or with a forceps. The slide is now ready to be stained Fill out the request form, send the specimen and request form to a laboratory for identifying Mycobacterium leprae and count bacterial index (BI) and Morphological index (MI)

5.

6.

7. 8. 9.

10. 11.

12.

13. 14.

15. 16. 17.

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LEARNING GUIDE NERVE EXAMINATION IN LEPROSY

No

STEP

PERFORMANCE SCALE 1 2 3

A. CLIENT ASSESMENT 1. 2. 3. Greet the patient respect fully and with kindness, introduce your self Give the patient an adequat explanation about the nerve examination Explain the goals or the espected result of nerve examination

B. EXAMINATION OF ENLARGEMENT OF PERIPHERAL NERVES IN SPECIFIC SITES The nerves commonly involved in leprosy lie close to the skin and thereore can be easily felt. The finding of an enlarged nerve means that the patient definitely has leprosy. A number of nerves must be routinely examined in every suspected leprosy patient. Get into the habit of examining them in the same order every time so that none is forgotten. 1 - Ask the patient to sitdown facing the examiner. - Notice the important nerves that should be examined in leprosy patient. They are: 1. Great Auricular Nerve (N. Aurikularis Magnus) 2. Ulnar Nerve (N. Ulnaris) 3. Median Nerve (N. Medianus) 4. Radial Nerve (N. Radialis) 5. Peroneal Nerve (N. Peroneus) 6. Posterior Tibial Nerve (N. Tibialis Posterior) (All of them except the Great Auricular nerve run over bone in the positions where they can be felt) - To feel the nerves, use two or three fingers, and try to roll the nerve on the surface of the bone. - Compare the right and left side, and notice the tenderness. Examination of the right and left great auricular nerve: For the left side, turn the head to the right and palpate along the sternomastoid muscle. For the right side, turn the head to the left. This neve can often be seen and felt in normal person. Examination of the right and left ulnar nerve : Feel for the nerve in the bony groove medial to the point of the elbow. Trace it further up the arm. (It can often be palpated for 10 cm or more up the arm, and may be more enlarged at this level) This nerve is always palpable in normal persons. Examination of the right and left median nerve: - Keep the wrist straight and feel for the nerve in the middle part of the wrist. It lies deep to the tendons, and only a very large nerve can be felt. But this test should always be done, because a nerve that cannot be felt may prove to be tender. Examination of the right and left radial nerve (dorsal cutaneous branch): - Keep the wrist straight with the thumb upwards. - The nerve runs just behind the lower end of the radius
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Tropical Medicine System and can be rolled against the bone. This nerve can almost be felt in normal persons. 7 Examination of the right and left peroneal nerve (sometimes called the Lateral Popliteal nerve). Ask the patient to sit down with knee joint in relax position. - For the left side, put your right hand on the knee with the tumb above the patella and fingers round the outside of the knee Place the little finger on the head of the fibula and palpate the nerve with the other fingers. - For the right side use yout left hand. This nerve can almost always be felt in both positions in normal persons. Examination of the right and left posterior tibial nerve: - Let the patient sit facing you, his feet resting on the floor. - Palpate for the nerve just below and behind the medial maleolus, Because there are other structures-a tendon, an artery and two small veins between the nerve and the underlying bone this nerve can only be felt if it is markedly enlarged; but tenderness can be recognised in a nerve that is too small to palpate

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C. EXAMINATION OF SKIN SENSIBILITY 1 Prepare the piece of cotton wool. The test must be done with one end of the cotton wool rolled into a fine point. The skin should be touched with this point, so that it bends. A stroking movements must be avoided, because this is a stronger stimulus and may not detect slight loss of sensation. Explain the patient about the test The patient must be carefully and clearly told what the examiner is going to do and what he wants the patient to do. This should be demonstrated first on your own arm; eg i am going to touch you with this piece of cotton wool and i want you to point with one finger to exactly the place on the skin where it touches. Perform the preliminary test or trial test After the explanation and demonstration on your own skin, you do a trial test by touching the patient on normal skin with the patients eyes open so that he sees exactly what you are doing. Explain again that he must touch the skin at the point where the bristle touched it (but never ask, Did you feel that?). Go on touching different places till the patient immediately put his finger tip where you touch him with the cotton wool. Perform the real test Ask the patient to close his eyes so he cannot see what you are doing. Ask the patient to touch the skin everytime he feels you touched him with cotton wool, but do not tell him when you touch him. First test in normal skin close to a lesion.When he can point the location correctly, try testing in the skin patches. If he fails to point in the skin patches correctly, it proved loss of sensation . Every second or third time you touch the skin, touch an area where he can feel; this gives both you and the patient confidents in the test. Summaries the results of examination of skin sensibility

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Clinical Skills Program Learning Guide

BED POSITIONING AND BED TURNING

GENERAL OBJECTIVE After finishing skill practice of proper bed positioning and bed turning, the student will be able to perform bed positioning in supine, lying and prone positions in the good manner to prevent complication of prolong bed rest. SPESIFIC OBJECTIVE At the end of skill practices, the student will be able to : - Demonstrate proper bed positioning in supine position with three upper extremities position, using hand rolling, trochanter rolling and foot board. - Demonstrate proper bed positioning in side lying postion, using pillow in between lower extremities and pillow for positioning upper extremities. - Demonstrate proper bed positioning in prone position using some pillows - Make the program for bed turning. METHODS Presentation Demonstration Coaching Self practice EQUIPMENT - Bed with firm mattress - Shoulder roll - Hand Roll, - Trochanter Roll - Foot Board - Pillows - Hand Splint VENUE Skills Laboratory at A5.1.1 Building, University of Padjadjaran Jatinangor

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LEARNING GUIDE PROPER BED POSITIONING AND BED TURNING PROCEDURE

No
A. 1. 2. 3. 4. B. 1. 2. C 1

Procedure
Client Assessment Greeting the patient respectfully and with kindness, introduce yourself Give an adequate explanation about what will you perform Explain the aim Check the instruments and materials Preparation Wash your hands with antiseptic soap and dry it with paper tissue Put on hand gloves and masker for universal precautions Procedure Supine Position a. Lower extremities in neutral position, hip and knee extension, contact with the posterior heel is avoided, the feet dorsoflexion, using the footboard and the trochanter roll b. Upper extremities can perform in three position c. the shoulder is abducted to 90 degrees, slightly internally rotated, the elbow is flexed at 90 degrees and the forearm is partially pronated d. The shoulder is abducted to 90 degrees, externally rotated to the greatest degree compatible with comfort, the elbow is flexed at 90 degrees, and the forearm is pronated e. The shoulder is in slight abduction, the elbow is extended, and the forearm is supinated, wrist and hand can perform in two position. : - The wrist is extended, the finger are partially flexed at the interphalangeal and metacarpophalangeal joints, and the thumb is abducted, opposed, and slightly flexed at he interphalangeal joints, use a hand roll. - Similar to the position no 1) except that the finger are extended at the interphalangeal and metacarpophalangeal joints. - A palmar positioning splint can be used to maintain this position Side lying position The top leg is placed in a position of flexion at the hip and knee. Through use of pillow, Contact with the under leg is avoided. The inner (bottom) arm is externally rotated and partially extended. The outer (top) arm is kept away from the patients chest. Prone position a. The prone position is ordered when pulmonary, cardiac, and skeletal status permit. Many patient do not tolerate it well at first b. Hip and knee extended, toes should not be allowed to touch the

Performance Scale 1 2 3 4

Comment

3.

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Tropical Medicine System bed board (footboard). The feet can be elevated slightly using a trochanter roll under the anterior ankle. The arm is abducted slightly, extended at the elbow, extended and supinated at the wrist. Finger flexion and wrist extension are achieved through the use of a hand roll. Shoulder roll are placed lengthwise under each shoulder Turning Position a. Turning the patient every two hours is usually a safe routine to follow until the patients skin sensitivity and tolerance of the position have been determined. Generally it best to order the more prolonged positioning periods for the night hours b. The physician should frequently check the skin in vulnerable areas to make certain that no decubiti are developing and to emphasize to the attending staff the importance of a proper turning schedule

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4.

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Clinical Skills Program Learning Guide

SKIN SCRAPING FOR SCABIES AND CUTANEUS MYCOSIS

GENERAL OBJECTIVE After completing this skill practice, the students will be able to take skin specimens for the examination of skin infections in tropical medicine. SPECIFIC OBJECTIVE At the end of skill practice, the student will be able to: Conduct skin scraping for the examination of scabies Conduct skin scraping for the examination of cutaneous mycosis METHOD - Presentation - Demonstration - Coaching EQUIPMENT 1. Presentation: - Audiovisual aids 2. Demonstration: - Video film 3. Coaching: Skin scraping for scabies: - anatomical model - 70% alcohol - cotton wool - scalpel blade - Imerse oil - glass slides - cover slips - vaselin album - tooth pick/cotton buds - pipette - gloves Skin scraping for cutaneous mycosis anatomical model bunsen burner or alcohol lamp 70% alcohol cotton wool scalpel blade adhessive tape + dispenser 10% KOH or 20% KOH + Blue-black ink Parker aa glass slides cover slips forceps pipette gloves

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SKIN SCRAPING FOR SCABIES & SKIN SCRAPING FOR CUTANEOUS MYCOSIS No . PROCEDURES PERFORMANCE SCALE 1 2 3 4

SKIN SCRAPING FOR SCABIES Client assessment 1. 2. 3. 4. Greet the patient respectfully and with kindness Give an adequate explanation about the test that will be carried out Explain the goals or the expected result of the test. Ask the patient to sign the informed concent form, and then sign it yourself.

Preparation 5, 6 Check the apropriate equipment. The scraping is performed with a No 21 blunt scalpel Prepare glass slides: Clean the slide with cotton wool soaked in 70% alcohol. Thereafter, avoid to touch the glass slide with your fingers. Put the clean glass slide on the table where it is easy to reach, with its marked side upwards Light the alcohol lamp/Bunsen burner. Clean the scalpel blade by wiping it with a piece of cotton wool soaked in 70% alcohol. Pass the scalpel blade trough the flame, but do not let it become red hot. Allow the scalpel blade to cool in such a way that it does not touch anything. Determine the papular eruption or tiny vesicles at the finger web spaces Clean the papular eruption or tiny vesicles gently with 70% alcohol, being careful to leave the papular eruption or tiny vesicles intact. Wash your hands thoroughly using antiseptic hand soap Put on gloves on both hands

8 9

10 11

Taking specimen 12 13 14 15 A papular eruption or a tiny vesicle are dropped with immerse oil and then gently scraped off with a No 21 blunt scalpel. Place the material on a glass slide, cover it with a cover slip. Seal the edge of the cover slip with vaselin album. Fill out the request form, send the specimen and request form laboratory The presence of mites, eggs, larvae, nimphae, fragment of egg shell or/and scibala confirm the diagnosis

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SKIN SCRAPING FOR CUTANEOUS MYCOSIS Client assessment 1. 2. 3. 4. Greet the patient respectfully and with kindness Give an adequate explanation about the test to be carried out Explain the goals or the expected result of the test. Ask the patient to sign the informed consent form, and then sign it yourself.

Preparation 5 6 Check the appropriate equipment. Determine the skin lesions to be examined: Choose a skin lession with an active border and which is characterized by erythematous papules or plaque with scales, mainly at the border of the lesions. Clean a slide with cotton wool or clean cloth soaked in 70% alcohol. Thereafter, avoid to touch the glass slide with your fingers. Put the clean glass slide, marked side upward, on the table where it is easy to reach Light the alcohol lamp/Bunsen burner. Clean the scalpel blade by wiping it with a piece of cotton wool soaked in 70% alcohol. Pass the scalpel blade trough the flame, but do not let it become red hot. Allow the scalpel blade to cool in such a way that it does not touch anything. Clean the skin lesions with 70% alcohol to remove surface contaminants such as dirt, crusts or airbone micro-organisms so as to facilitate reading of direct preparations. Wash your hands thoroughly using antiseptic hand soap Put on gloves on both hands

10 11

Taking specimen - Method 1. 12 Scrape off carefully the scales from the center part of the lesion to the edge with a blunt scalpel or a sharp curette. The scales are best taken from the leading edge of the rash. Place the material on a glass slide, add a drop of 10% KOH or a mixture of the same amounts of 20%KOH and Blue-black Ink Parker, and cover it with a cover slip. For faster dissolution of the horny substance, warm the slide slightly by passing it three times over a flame. Fill out the request form, and send the specimen slides and request form to a laboratory. The presence of hyphae and spores confirm the diagnosis. The preparation should be examined initially at low magnification to obtain a general impression. If this reveals hyphae, increase the magnification to x100-400.

13 14 15 16

Taking specimen -Method 2 17 18 Strip off the skin with adhesive tape, Stick the tape on a glass slide on which a drop of 10% KOH has been placed

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For faster dissolution of the horny substance, warm the slide slightly by passing it three times over a flame. Fill out the request form, and send the specimen slides and request form to a laboratory.

NOTES

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