Collection Manual CLINIC & LABORATORY SKILLS TROPICAL MEDICINE

Presented at The Grade VI Student of Medical Faculty Hasanuddin University

MEDICAL FACULTY HASANUDDIN UNIVERSITY 2012

CONTENTS 1. Preface: 2. List authors 3. Order 4. 1st Manual Anamnesis of patches on the skin patient Learning objectives Description of activities Step of activities Examples of patient status Checklist 5. 2nd Manual Physical examination of patches on the skin patients Learning objectives Description of activities Step of activities Examples of patient status Checklist 6. 3rd Manual Skin Scratch Learning objectives Description of activities Step of activities Examples of patient status Checklist 7. 4th Manual Skin Liquid Smear Learning objectives Description of activities Step of activities Examples of patient status Checklist 8. 5th Manual Peripheral Blood Smear Learning objectives Description of activities Step of activities Examples of patient status Checklist 9. 6th Manual Feces Smear Learning objectives Description of activities Step of activities Examples of patient status Checklist

PREFACE Manual collection of clinical and laboratory skills is given to the students who take a course in Tropical Medicine in the sixth semester and the instructors who accompany students on these skill activities. General instructional purposes and specific

instructional objectives are presented in each module intended for students and instructors to know the learning objectives of each manual in order to achieve the expected minimum competencies.

Description of activities to be conducted at each skills training is equipped with time allocation, so that the use of 90 minutes for each exercise can be used as efficiently as possible. Step of activities is a step by step activity that should not be exchanged one another so that the consistency of the flow of skills is chieftained.

Each manual is equipped with work sheet so students can record the activities which are undertaken during the skills training, instructors are expected to check this work sheet at the end of activities. Students Attendance in the skill training will be equipped with assessment column.

Some things related to activities such as orderliness, schedule of activities, division of space, and instructor's name are also attached to this set of manual skills.

This manual collection is still far from perfection, a construction criticism is needed very much

Makassar, April 1th

2010

Tropical Medicine

Editor 1 st Manual Anamnesis patient patches on the skin Editor: Sri Vitayani & Sitti Wahyuni 2nd Manual Anamnesis patient patches on the skin Editor: Sri Vitayani & Sitti Wahyuni 3rd Manual Scratch Skin Editor: Muh. Nasrum Massi, Baedah Madjid & A.R. Sultan 4thManual Skin fluid smear Editor: Muh. Nasrum Massi, Firdaus Hamid & Baedah Madjid 5th Manual Peripheral blood smear Editor: Sitti Wahyuni 6th Manual Faeces smear Editor: Sitti Wahyuni

RULE OF CLINICAL SKILLS & LABORATORIUM Students who follow this activity are required: 1. Reading the manual skills of the previous clinical and laboratory. 2. Attending on time. 3. Can prove his identity during the exercise took place (the entire face visible) 4. Wearing a lab coat and appropriate signage absenteeism 5. Neatly dressed and polite. 6. Actively participate in skills training activities. 7. Do not do activities that have not relation with skills training activities. 8. Do not put other items on the table except manual labor and skills training materials 9. No damage to materials and skills training tools. Any damage must be replaced within a maximum period of one week. 10. Leaving skills training room in neat and clean condition. 11. The above rules are applied since entering the corridor of an integrated laboratory skills lab at the first and second floors.

MANUAL 1 ANAMNESIS SKILL PATIENTS WITH MAJOR COMPLAINTS IN PATCHES ON THE SKIN

LEARNING OBJECTIVES General Instructional Objectives At the end of the exercise of these skills, students are expected to do anamnesis that led to the diagnosis of tropical diseases in patients with major symptoms of patches on the skin. Specific Instructional Objectives 1. Capable and skilled to communication with patients 2. Capable and skilled to foster a sense of connection and provide a sense of empathy. 3. Capable and skilled to get information about patches on the skin is experienced by patients. 4. Capable and skilled to conduct guided anamnesis that lead to the diagnosis of tropical diseases with major complaints of patches on the skin 5. Capable and skilled to provide information to patients regarding further action will be carried out based on the anamnesis has been collected. 6. Capable and skilled to make a resume of all information obtained in the anamnesis with the chief complaint of patches on the skin. INDICATIONS Patients with symptoms of patches on the skin with suspect : - Leprosy - Bacterial infection of non leprosy - Fungal infections - Viral infection - Parasitic infection - Non-specific skin disorders MATERIALS AND TOOLS - Desk - Chair of patient - Chair of doctor - Status Book of patients with anamnesis sheet.

ACTIVITY DESCRIPTION Activity l. Introduction Time 5 minutes Description Introduction - The instructor explained about the objectives of these skills - The instructor show materials and tools for these Skills 1. A student acts as patients 2. Mentor shows how to get information about the patches on the skin experienced by patients 3. Mentor shows how to do anamnesis that lead to diagnosis of tropical diseases with a chief complaint of patches on the skin. 4. Mentor shows how to inform to the patient regarding further action will be done based on the results of anamnesis have been collected. 5. Mentor shows how to create resumes from all information obtained in the anamnesis with the chief complaint of patches on the skin 6. Students are required to ask about the things which are not clear related to the these skills activities

2. Demonstration

20 minutes

3. Practice role 55 minute playing with s feedback

1. Students are divided into pairs, one of them acts as a

doctor and another one has a role as a patient 2. Person who acts as the doctor performed the following activities: get information about the patches on the skin experienced by the patient, performing anamnesis that lead to the diagnosis of tropical disease with a chief complaint of patches on the skin, inform the patient about further action to be performed based on anamnesis results have been collected and make a resume of all information obtained in the anamnesis with the chief complaint of patches on the skin 3. Role exchange 4. Mentor rounds among students and does a supervision 5. Mentor corrects the things which are not perfect

Brainstormig and Discussion Total time

10 minutes Students are given the opportunity to put opinions about the activities undertaken 90 minutes

STEP OF ACTIVITY NO. Activities undertaken Preparation of patients 1 Please let the patient came into the room. 2 Greet patients and their families with great familiarity. 3 Introduce yourself while shaking the patients hand. 4 Please let the patients and their families to sit down. 5 Show empathy for patients. Provide general information on the patient or family about the anamnesis you are going to do, 6 objectives and benefits to the patient anamnesis. Provide assurance to patients and their families about the confidentiality of all information 7 obtained on the anamnesis. Tell us about the patients rights to the patient or his family, for example the right to refuse to 8 answer questions which he considers one does not need to answer. General Anamnesis 9 Ask patient's personal data: name, age, address, and occupation Ask what is causing the patient comes to the doctor (chief complaint). 10 For heteroanamnesis, ask the patient relationship with the people who accompany them introduction. Guided anamnesis Ask any skin abnormalities began to appear, whether arising lost, settled, where a location 11 initially and then where they appear. 12 Ask whether or not accompanied by fever 13 Ask whether or not accompanied by itching. 14 Ask if there are patches on the skin with an insect bite or injury (trauma) 15 Ask whether this was accompanied by cramps, patches on the skin or sore. If there is, ask: - When these things begin to happen, whether or not happen suddenly. - Nature of pain or cramping: mild, moderate, severe; intermittent or continuous; higher in the morning, afternoon or evening; attack with a certain interval; only at one place or feels like ants moving. - Is there pain bones, artralgia, myalgia, anorexia and malaise. - Tenderness in the arms and legs. - Wounds in the palms of the hands or feet 16 Ask whether or not the patient had experienced similar complaints in the past. 17 Ask a history of the same disease in the family or the neighborhood where one lived. 18 19 Ask a history of contact with the victims of the disease with similar symptoms Ask your medical history has ever been received from a doctor and purchased his own medicine by a patient without a prescription Ending anamnesis Explain to patients that this phase is just the beginning phase of a series of checks to know the patient's illness: and physical examination is still needed to refine the diagnosis. Create a resume of the results of anamnesis Divide up all the results obtained in a tabulation Create one chief diagnosis and differential diagnosis of the anamnesis result

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Student activity sheets EXAMPLES OF PATIENT STATUS SHEET No Register: Name: Sex: Age: Ocupation: Address: Date/hour: /

ANAMNESIS (relationships with patients .....................................if heteroanamnesis) Chief complain : Guided Anamnesis:

Student activity sheets

Summary:

Diagnosis anamnesis:

CHECKLIST MANUAL 1 ANAMNESIS SKILL PATIENT WITH MAJOR COMPLAINTS IN PATCHES ON THE SKIN NO. Activities which are appraised Check up Preparation 1 Perform a sense of connection with patients and their families. 2 Make an informed concent to the client and his family. General anamnesis 3 Exploring the client's personal data: name, age, address & occupation 4 Asking four chief reasons to come to the doctor Guided anamnesis 5 Exploring the history of the disease based on five chief complaints. 6 Exploring other symptoms that accompany the chief complaints 7 Exploring the history of similar illness in the family or neighborhood environment. 8 Exploring the history of contact with patients with symptoms of patches on the skin

9 Exploring the history of medicine has ever been received / used Ending the anamnesis and creating a resume 10 Explaining to the client that this phase is just the beginning phase of a series of examinations to be able to know the illnesses is suffered by patients: and physical examination is still needed to refine the diagnosis. Composing the results of anamnesis and make its resume.

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Note: The above list contains activities will be assessed on the skills test in which the instructor was asked for giving assessments to students for eleven checklist above (see sheets of student assessment) Score: 0 if not done 1 if it is done but yet satisfying 2 if satisfactory Examples of student assessment sheets for the manual first No Name Student number 1 2 3 4 5 6 7 1 2 3 4 20 Scoring for the first manual Total value of the lowest 0, highest value 22 Score 0-11: unskilled Score 12-22: skilled (graduate CSL, this value will still be scored to C,B &A ) Aminah 2007000C4 2 3 2 2 1 2 2 2 Activities 10 11 2 2 Total 20

8 1

9 2

MANUAL 2 SKILL OF PHYSICAL EXAMINATION CHIEF COMPLAINT OF PATIENT WITH PATCHES ON THE SKIN LEARNING OBJECTIVES General instructional objectives At the end of this skills exercise, the students are expected to perform physical examinations that led to the diagnosis of tropical diseases with chief complaints of patches on the skin Specific Instructional objectives 7. Capable and skilled to communicate with patients. 8. Capable and skilled to explain the physical examination will be conducted. 9. Capable and skilled to prepare patients before physical examination. 10. Capable and skilled to assess patient status in general and measuring vital signs. 11. Capable and skilled inspection done in a systematic physical examination to diagnose a patient with a chief complaint among other patchess on the skin by checking: a. Skin effloresensi. b. Signs of dryness and cracked skin. c. Sensitivity on the part of skin lesions d. Palpability peripheral nerves in a symmetrical right and left, to see the existence of nerve enlargement, its consistence, there is tenderness and dysfunction nerve. 12. Capable and skilled to inform results found, required investigation and treatment plan to patient / family. 13. Capable and skilled to make a resume for patient records

INDICATIONS Patients with suspect: 1. Leprosy 2. Fungal infection 3. Bacterial infection 4. Viral infection 5. Parasitic infections 6. Non-specific skin disorder

MEDIA AND LEARNING TOOLS Water flow Liquid Soap small towel Thermometer Stethoscope Tensimeter magnifying glass Tape measure height and weight Cotton which is sharpened in one its edge. Sterile needle immersed in alcohol Two reactions tubes, each containing hot water and cold water Video, slides or drawings to show typical clinical signs in some tropical diseases that give a patches on the skin. medical and non-medical tpatches can Status book of the patient to record the results of physical examination ACTIVITY DESCRIPTION
Activity 1. Introduction Time 5 minutes Description Introduction - The instructor explained the purpose of this skill. Instructors demonstrate the materials and tools necessary to perform these skills. 7. A student acts as patients. 8. Mentor shows how to prepare patients before physical examination. 9. Mentor shows how to conduct assessment of patient status and measuring vital signs. 10. Mentor shows how to conduct examination systematically to physical diagnosis to the patient with the chief complaint of patches on the skin such as by examining: - Skin effloresensi. - The signs of dryness and cracked on skin. - Sensitivity on the part of the skin lesions. - Peripheral nerves in a symmetrical right and left, to see the existence of nerves enlargement, its consistency, there is tenderness and neurological dysfunction (mentor shows the audiovisual how examination of peripheral nerves). 11. Mentor shows you how to inform the results found, investigation

2. Demonstration

15 minutes

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required and a treatment plan to patient / family 12. Mentor shows how to create a resume for patient records 13. Students are required to ask the things which are unclear in relation to skill activity. 3. Practice role playing 55 minutes with feedback

6. 7.

8. 9. 10.

Students are divided into some pairs , one person acts as a doctor and one person acts as a patient. Person who acts as the doctor performed the following activities: explains the physical examination will be done, prepare the patient before physical examination, assessing patient status in general, and measuring vital signs, perform physical examination in a systematic physical examination to diagnose patients with complaints of the chief patchess on the skin (skin effloresensi, signs of dryness and cracked skin, sensitivity on the part of the skin lesions, peripheral nerves are symmetrical right and left, to see the existence of nerve enlargement, its consistency, tenderness and neurological dysfunction), inform results are found, the investigation required and a treatment plan to patient / family and make a resume for archives patient Role exchange Mentor walk rounds among students and do a supervision Mentor corrects the things which are not perfect

4.Brainstorming and discussion Total time

10 minutes

Students are given the opportunity to put forward opinions about the activities undertaken.

90 minutes

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STEP OF ACTIVITIESS No. 1 2 3 4 5 6 7 8 9 Activities undertaken Preparation of patients Explains the physical examination will be conducted, its purpose and benefits Giving assurance to patients and their families about the confidentiality of all information obtained on the physical examination. Explaining about the rights of patients or their families, for example concerning the right to refuse to be examined. Please the patient to put off all the clothes and make sure the patient gets good light during the physical examination. Standing on the right side of patient. Assessment of overall patient status and vital signs View and record the general condition of patients: mild pain, moderate pain or severe pain. Determine the nutritional status: height and weight measurement (in accordance with the manual to determine the status of a nutrient). Measure and assess patient vital signs: blood pressure, pulse, respiration and temperature. Look at the entire patient body from top to toe: - whether there is thinning of scalp hair and eyebrows. - whether there lagophthalmia in the eyelid. - whether the patient's nose dropped (sadle nose). - areas where patchess are located Check there is any enlargement of the liver, edema of the legs, wounds in the legs Examination of patches on the skin Where these patchess location are Look at the effloresence type: erythema, hypopigmentation, hyperpigmentation, vesicles nodules, blister, macular papules, squama, urtika, ulceration, crusting If the entire surface of lesions is flat, note whether the skin surface is dry or wet, and the presence of fine hair. Sensitivity test Using a sharpened tip of cotton: - Touch the skin of normal patients with a sharpened tip of the cotton, and a little bent. Allow the patient to see what and where you do it. - Ask the patient to see to another direction and do the touch with cotton at first on a normal region, and in the regions are alternating patches. Ask whether or not the patient felt the touch. - Ask patients to showed part of her body touched. Record whether or not in accordance with section which is touched. - Take the assessment test results of the touches. Doing lightly puncture with the tip of the needle: - Do the same test with lightly puncture by using a sterile needle, firstly on normal skin area. Allow the patient to see what and where you do it. - Close the patients eye and do lightly puncture in normal area first , then in alternating patches area. - Do the assessment results of puncture tests. Using hot and cold tubes: - Do the same test using two tubes where each using two tube contain cold and warm water. Doing first at normal skin area and ask for the patient to see what and where you do it

10 11 12 13

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close the patients eyes and put alternating both tubes to normal area first, then at patches area. - Doing result assessment of tube test you have done. Examination of peripheral nerves 17 N. Auricularis magnum: Ask the patient to turn his face into the direction opposite from the side which will be checked, while looking toward the shoulder. - Keep a notice whether visible or absence of enlargement of N. Auricular magnum. - If the enlargement of the nerve is not visible, do remain palpation by maintaining a position like that, scan the area with palpability upper neck of the patient, from craniolateral to caudomedial direction. - Feel the presence or absence of this nerve thickening. Inspection N. Radialis: - Ask the patient to bend his arm so as to form an angle of 60 C at the elbow. - Calm the patient down and instruct him to relax his muscles. - Touch and trace the lateral third of the upper arm area roughly between meeting area. Triceps brachii caput longum and lateral. - Feel the presence or absence of this nerve enlargement. Look at the expression on the patient to know the sensitivity of this nerve Inspection N. Ulnaris: - Hold the bottom of the right arm of patient with your right hand. - Put elbows slightly bent so that the patient's arm will be relaxed. - Use the index finger and middle finger left hand to search while touching N. ulnaris in nervi ulnaris sulcus (indentation between the bones bulge elbow and a small bulge in the medial = medial epicondylus) - Feel whether or not there is nerve enlargement. - Give a little light pressure on N. Ulnar while tracing it to top direction smoothly, see the expression whether or not looks pain. . Inspection N. Medianus - Ask for the patient to clench his hands (not too tight), while slightly difleksikan. - Scan the area between the tendo m. Palmaris longus tendon and m. Flexor carpi radialis longus with your fingertips. - Feel if there is enlargement. While touchinglook at the patients expression

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Inspection N. Peroneus communis (lateral popliteal nerve) - Have the patient sit on the edge of the bed with legs dangling relaxed. - Sit in front of the patient with a right hand checks the left foot of the patient and left hand checks the right foot of the patients. - Put middle finger and your index finger on the outside of the mid-calf patients. - Touch slowly upward until it finds a lump of bone, (caput fibula). - After that Touch peroneus nerve approximately 1 cm from the lump into bones the rear top. - Rolling the nerve with mild pressure to the left and right are interchangeably. - Feel the absence of enlargement. - While touching look at the expression of the patient. - Patients were asked to sit idly dangling. - Touch N. Posterior tibial artery at the bottom of the rear side of ankle deep. - Feel the absence of enlargement. - While touching look at the expression of the patient. Mapping neural disorders: Make a picture in the paper that has been provided, all found in nerve abnormalities. Examination of nerve function impairment: - Inspect the patient's eyelids to see any disruption of motor N. Facialis -Check the feet to see the motor and sensory disturbances. Helping the patient to wake up, to put on clothing and to allow one to re-sit. Informing results found, investigation and treatment plan Explain to the patient's family about the patient's examination results found. Explain that for a definite diagnosis some supporting investigation are required. Explain about the disease diagnosis, treatment plan, prognosis and complications. Doing counseling by explaining about the disease (according to diagnosis), especially the one about the success of therapy. Explain the rules of treatment and make sure the patient or his preface to comply with a rule that will be receiving treatment. Say goodbye to the patient by giving hope to patients Creating a resume for patient records Write your resume in its entirety (the anamnesis, physical examination, a temporary treatment given and the requested investigation) as patient records.

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Student activity sheets EXAMPLES OF PATIENT STATUS

No Register: Name: Sex: Age: Occupation: Address: Date / hour: /

ANAMNESIS (the relationship with the patient.......................... if heteroanamnesis) The main complaint: The guided Anamnesis: Resume: GENERAL CONDITIONS: Vital signs: Blood pressure......mmHg; Nadi....../min, Respiratory:.... minutes; Temperature.......oC General conditions: pain mild / moderate / heavy Nutritional status: height.......cm; weight.......kg; nutrition less/better/more PHYSICAL EXAMINATION: 1. Skin patches: Effloresensi Type: Surface: Student activities sheets 2. Sensitivity test Cotton test: Needle puncture test: Test tube: 3. Nerve circumstances: Thickening N. Auricularis magnum: Thickening N. Radialis: Thickening N. Ulnaris: Thickening N. Medianus: Thickening N. Peroneus communis (lateral popliteal nerve):

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Map of neurological disorders:

Nerve facialis

Nerve auricularis magnus

Nefrve medianus

Nerve radialis

Nerve peroneus Nerve tiabialis

Disfunction of nerve :

Summary : Student activity sheets

Diagnosis:

Differential diagnosis :

Management: Th/

Editional examination :

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EXAMINATION REFERENCE OF LEPROSY SUSPECT PATIENTS A. Basic diagnosis of leprosy (leprosy) Leprosy or leprosy diagnosis can only be enforced if found in one of the cardinal sign (major symptoms). The main symptoms of leprosy are: 1. Numbness of skin lesions Abnormalities of the skin in leprosy can be in the shape of patches of hypopigmentation or reddish (eritrematous), which was numb. May be less flavor (hipestesi) or do not feel at all (anesthesia). 2. Significant thickening of nerve is followed by nerve function impairment Thickening of the nerve occurs as a result of peripheral nerve inflammation (peripheral neuritis). Neuritis in leprosy can be accompanied with or without a neurological dysfunction. Functions nerve disorders that can occur: a. Sensory dysfunction: anesthesia / hipestesi, b. Motor dysfunction: parese or paralise, c. autonomic function disorders: dry skin, cracking, edema, etc.. Neuritis in leprosy can be symptomatic pain, but sometimes there is no pain, known as silent neuritis. 3. Positive acid resistant bacillus Examination materials to notice a smear taken from a liquid preparation made by direct skin (skin smear). This material is usually taken from the ear lobe or from the active part (edge) of a lesion on the skin. Sometimes the material was taken with a skin or nerve biopsy. B. Diagnosis For the diagnosis of leprosy was found in a person must be at least one of the cardinal sign above. If one cardinal sign is not found, it should only be diagnosed as a suspected leprosy = leprosy. Such patients should be observed and reexamined after 3-6 months until the diagnosis of leprosy can be enforced or removed. C. Clinical symptoms a. Early Signs of Leprosy Disease (leprosy) 1. Skin disorders Changes in skin color such as white spot like white blotches, Can be infiltrates shape Can be nodules shape 2. Nerve Disorders Edge Real nerve enlargement accompanied by numbness, and / or muscle weakness in areas that are supplied (eyes, hands, feet), or sometimes in the form of tender. b. Signs of Leprosy Disease (Leprosy) Continue. If untreated leprosy early is not medicated or found lately, it will be found a more severe clinical symptoms.
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1. Skin disorders The number of patches on the skin grow much, much thicker and red spots. The skin becomes more dry. 2. Nerve Disorders Thickened nerves with nerve function impairment, and tenderness, may occur on one or more peripheral nerves. Therefore, peripheral nerve function is disrupted, the skin is numb when taxable collision will cause wounds (ulcers on the palms of the hands or feet), dry skin can crack. Further disruption muscles moving the fingers and toes (kiting / clawing). Symptoms continued: Nose to collapse, gynecomasty madarosis and lagophthalmus. \ PHYSICAL EXAMINATION OF LEPROSY SUSPECTED PATIENTS Doing an examination in a room that gets enough sunlight lighting. Examination must be done systematically in which the patient sits facing the examiner. Beginyour examination from head to toe, then the rear body start from neck, shoulders, rear body, arms and legs. Examination of skin on the entire surface of the client body by paying attention to the client privacy. Inspection numb Inspection of anesthesia (numbness), or sensitivity testing using the following: - Cotton and patients were asked for indicating the direction of movement of cotton. - Pick a light sterile needle to determine the pain experienced by patients. - Hot and cold reaction Tubes to determine the response to temperature. - Compare between one lesion with other lesions. Sensitivity test conducted alternately in the area of normal skin and skin lesions Make sure the patient does not see the area is touched or punctured. Sensitivity test used to assess how much nerve damage that occurs in patients. While the enlargement of the nerve test to assess how much of the peripheral nerve fibers involved and damaged in the disease. Both these tests are often performed in patients suspected of leprosy. Ballpoin or bike bars, can be used to assess peripheral nerve disorders based on its nerves area. Examination of peripheral nerve enlargement Peripheral nerve examination should be conducted systematically and carried out on the right limb and left. Feeling nervous or palpation should be conducted in such a way that does not hurt patient or not a good impression on patients. Fingernail examiner should not be long.

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In this examination the patient should be in calm condition with attenuated muscle. Find a place that will be examined peripheral nerves. Then rubbed and Taste referred to the enlargement of peripheral nerves. Check as many as possible peripheral nerves are frequently involved in leprosy. Make the picture on the paper has been provided. 1. Inspection N.Auricular magnus In addition to the palpability, in most cases, the enlargement N. Auricular magnus can be found by inspection. 2. Inspection N.Radialis Is the most difficult Nerve to be touched because it was not superficial palpable as other nerves that are often involved in leprosy. To feel it browse the lateral third of the upper arm about a meeting between regional m. Tricep brachii caput longum and lateral. 3. Inspection N. Ulnaris This nerve is difficult to touch from the outside, because it required proficiency of the examiner to be able to feel it. 4. N. Median Inspection This nerves is rather difficult to Palpated because lie between the deep and two tendon (M.Palmaris longus and M.Flexor carpi radialis longus). To be able to distinguish easily the thickened / enlarged nerve, it is required a normal nerve palpation experience on healthy people.
CHECKLIST MANUAL 2 PHYSICAL EXAMINATION SYSTEMATIC COMPLAINTS OF PATIENTS WITH SKIN SPOT ON NO. 1 2 3 4 5 6 7 8 9 10 Activities that are considered Preparatory examination Do connect with patients and their families feel. Take through the informed concent to patients and their families. Assessment of general condition and skin Perform thorough skin examination. Examination of other organs such as eyes, nose and heart patients. Verifying the existence of thinning hair and eyebrows. Examination of skin patches Location and type of effloresensi. How is lesions surface: dry, wet, presence or absence of fine hair. Sensitivity test With a cotton tip With the tip of the needle With tube

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MANUAL 3 SKILLS OF TAKING, MAKING AND CHECKING WET PREPARATION AND PREPARING SKIN SCRATCH DELIVERY LEARNING OBJECTIVES General instructional objectives After completing this training, students are expected to perform retrieval and delivery of skin scratch properly, correctly and efficiently. Specific instructional objectives After doing the exercises these skills, students are expected to be able to: 1. Do preparation of patients correctly 2. Prepare equipment / materials correctly 3. Make good relation with patients 4. Give inform concent to patients correctly. 5. conduct regular hand washing and asepsis correctly 6. Install sterile gloves correctly, and release them after the work is completed. 7. Perform capture of the scratch skin correctly 8. Make preparation and delivery of skin scratch correctly INDICATIONS Patients with skin lesions which is suspected to suffer dermatomikosis. TOOLS AND MATERIALS REQUIRED Flow water Spiritus Lights Liquid Soap Paper sterile Petri dish or is a minimum size 10 x 10 cm Antiseptic solution small towel or tissue in a folded state. Cotton Sterile gloves Scalpel (knife handles size 2 pcs Lisol solution containing 5% No.3 and the blade no. 15) Medical trash Alkohol70% Non-medical trash REFERENCE Scratch up ward with a slope of 30 - 45 using a sterile scalpel. Locations scraped the edge of the lesion which is part of the most active part and covered with scales. TOOLS AND MATERIALS ARE REQUIRED FOR MAKING & EXAMINING DIRECT BLOOD SMEAR OF SKIN SCRATCH Flow water Inoculated Needles Liquid Soap 10% KOH solution Antiseptic solution Pipette Small towel or tissue Fold the paper sterile / sterile petri dish Cotton Binocular microscope 70% Alcohol 2 pcs khlorin0 basin containing solution 5% Lights spiritus Cover glass Glass Objects permanent markers Medical trash Non-medical trash
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ACTIVITY DESCRIPTION ACTIVITY 1.Introduction 2. Demonstration Time 5 minutes 20 minutes DESCRIPTION Introduction 1. Organize students seated position 2. Two instructors give examples how to retrieve, create and examining wet preparat (blood smear), and preparing skin scratch delivery. Students pay attention / watched a demonstration by using learning manual. 3. Give opportunities for students to ask questions and instructors give explanations about important aspects 2. Students are divided into pairs. An Instructor is needed to observe every step taken by each spouse. 3. Simultaneously, each pair of practices take steps to capture and scratch delivery skin preparation 4. Instructors around between pairs of students who are doing practice to conduct supervision and use a checklist to assess student work. 5. If there are errors instructor, immediately work procedures shows again pass up the right way. 6. Instructors provide questions and feedback back to each pair 1. Brainstorming / Discussion: Which one is easy? Which one is difficult? Ask about students feelings at the time of scratching the skin. What can be done by doctor to patient feel more comfortable? 2. Instructors make conclusions by answering the last question and clarify things are still not understood.

3. Practice role playing 55 minutes with feedback

4. discussion

10 minutes

Total time

90 minutes

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LEARNING GUIDE

SKILLS OF TAKING, MAKING AND CHECKING WET PREFARAT, AND PREPARING DELIVERY OF SKIN SCRATCH

NO. STEP / ACTIVITY PATIENT PREPARATION 1. Greet clients or their families friendly and introduce yourself, and ask their conditon. 2. Please clients and their families to sit 3. Give general information on the client or his family about making scratch, purpose and the benefit to the client circumstances. 4. Give assurance to the client or his family about the security checks performed 5. 6. 7. Give assurance to the client or his family about the confidentiality required by the client Explain to the client about the rights of clients or their families, for example the right to refuse taking skin scratch. Ask your client's willingness to oral examination of skin scratch

PREPARATION OF MAKING SKIN SCRATCH 8. Prepare all the necessary tools and materials on a table near the patient 9. Write the register number / patient data on the back of the glass objects, petri dish or on the outside of the sterile paper folds. 10. Ask the patient to sit or lie down (depending on the location of specimen collection) 11. Wash your hands regularly 12. Put sterile gloves MAKING SKIN SCRATCH 13. Check the location of specimens well 14. Do disinfection of the skin defect with alcohol 70% starting from the middle of an abnormal area in a circle to the edge of the skin disorder that would be scratched. 15. Take a new alcohol cotton and do skin disinfection in the area around the lesion started from the outside to the inside. 16. Making scratch with a sterile scalpel lesion edges upward with a slope of 30 - 45 17. Open the folded paper cup or lid 18. Knock scalpel at the base of the Petri dish or on the surface of sterile paper that had been prepared until all the scales and the flake of skin scratch falls on the surface of paper or a petri dish . 19. Insert a scalpel which has been used in the basin contains 50-10% lisol

MAKE AND CHECK WET TABLET FROM SKIN SCRATCH 20. Put one glass flat objects with Register number / patient data on the back. 21. Drop 1-2 drops of 10% KOH solution 22. Dampen the tip of the needle inoculation with KOH solution and then take one or more bits of skin on the bottom plate dish, and insert in KOH solution on the surface of glass objects 23. Cover a glass cover on the liquid droplets with caution, so that no air between the glass objects and glass cover.

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Fit horizontally on the microscope table. Close the microscope diaphragm as small as possible and derive the microscope condenser (if any) as low as possible. Look under the microscope with an objective lens 10 times. Rotate macrometer to obtain a clear image. Find the object by looking at the edge of the liquid droplets. After finding the object, change the object lens to 45 times magnification. Record what you see: epithelial skin, spores, hyphae.

AFTER WORK OUT 30. Wipe the desk with a cloth dampened with a solution of 50-10% lisol 31. Take inventory and write this directly in a bowl lisol 32. Wash hands who still wear gloves with a solution of 5% lisol 33. 34. 35. Open up the gloves and throw into medical trash. Do wash your hands asepsis. Say thank you and goodbye to patients with good wishes recovery soon

PREPARATION SKIN SCRATCH DELIVERY 36. Check the security of the skin scratch: stick cap with a folded paper tape Sello. 37. Write the introduction of the skin scratch delivery for laboratory containing: Personal data of patients, Examination request: microscopic or / and culture An explanation of the local use of anti-fungal or other drugs: what drugs are used and when to stop. The folding of paper inserted in an envelope and sent in room temperature together with a letter envelope of introduction to the laboratory.

38.

Student activity sheets EXAMPLES OF SKIN SCRATCH EXAMINATION SHEET RESULTS

No: Date: Name: Sex: Age: Address: Occupation: The main complaints:

The result of skin scratch examination:

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Student activity sheets

EXAMPLE REFERENCE GAZETTE Dr. Sanusi Perangin Angin Praktice permission No. 1234567 Practice address: Kebangkitan street no. 27 Telephone No.: 0411-275634

Makassar, Designation: At........................

In Sincerely, Sent patient's skin scratch: Name: Sex: Age: Address: Occupation: The main complaints:

Thank you,

Dr. Sanusi Perangin Angin

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CHECK LIST TAKE, MAKE AND CHECK WET PREPARAT AND PREPARE SKIN SCRATCH DELIVERY Instructions : Put an (V) in the appropriate box.

Give Score : (0) if not done, (1) if it is done but still not satisfactory, (2) if satisfactory NO. ASSESSED ASPECTS PREPARATION 1. Capable of connecting with patients and their families feel. 2. 3. 4. 5. 6. Able to give informed concent well. Able to prepare the patient for retrieval and examination of skin sctrach Able to adjust lighting Prepare all the necessary tools Perform routine hand washing and wear gloves correctly 0 1 2 SCORE 1 2

MAKE & CHECK SKIN SCTRACH 7. Conduct any skin sctrach 8. Saving the skin sctrach on the right folded paper 9. Doing the manufacture of wet preparat skin sctrach 10. Checking the wet prefarat in the microscope correctly MAKING OUT AFTER SKIN SCTRACH 11. Conducting medical garbage disposal properly 12. Perform cleaning and disinfeksi job field correctly 13. Making a delivery preparation examination material correctly. 14. Separate well with the Patients .

Commment / Summary :

Recommendation:

Instructor Signature ..........................................

Date:..

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MANUAL 4 SKILLS OF TAKING AND MAKING SKIN SMEAR PREFARAT

LEARNING OBJECTIVES General Instruction Objectives After having this training, students are expected to be able to perform skin fluid intake and make prefarat skin liquid (skin smears) well, correct and efficient. Specific Instructional Objectives After doing these exercises skills, students are expected to be able to: 1. Prepare equipment / materials properly. 2. Make sense of connection with the patient and or family well. 3. Make inform concent to patients and / or their families properly. 4. Conduct regular hand washing and asepsis correctly. 5. Wearing sterile gloves correctly, and put it out after the work is completed. 6. Perform skin fluid intake. 7. Making and store prefarat liquid of the skin (skin smears) correctly. 8. Prepare a prefarat skin liquid delivery properly.

TOOLS AND MATERIALS REQUIRED Water flow Liquid soap Antiseptic solution to clean Small towel or tissue Cotton scalpel (knife handle No.3 and blade no.15) 70% Alcohol Lights spiritus Objects glass The basin contains a 5% solution Lisol Plasters medical trash non-medical trash

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INDICATIONS Patients who have anaestesi skin patches (numbness) or with enlargement of one peripheral nerves.

REFERENCE Abnormalities of skin disorders in leprosy is usually a skin spot that can be red or whiter than normal skin (hypopigmentation). This defect usually experienced anesthesia. Good taking area is skin defect on the ear lobe or lobes nose. Or on the skin in other places that show signs of leprosy. Skin incision with a scalpel on the skin defect is only efforted up to the layer of dermis, in case achieve coating subdermis because there are many blood vessels and nerve fibers in that area. Blood on the stocks is very difficult to the discovery of acid resistant bacillus. Leprosy bacillus usually gathered a lot at the ends of sensory nerves in the lining dermis.

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ACTIVITY DESCRIPTION Activity l.Introduction 2. Role playing & answer question Time 5 minutes 20 minutes Description Introduction 4. Organize students seated position 5. Two instructors give example of how to retrieve and made directly from a liquid dosage form skin. Students pay attention to demonstration by using Learning manual. 6. Give opportunities to students to ask questions and instructors provide an explanation about important aspects 7. Students are divided into pairs, couples. An instructor is required to observe every step is taken by each couples. 8. Simultaneously, each pair practice these steps taking and making skin liquid prefarat (skin smear). 9. Instructors walk around between couple of students who practice to conduct supervision and use a checklist to assess students work 10. If there are errors work procedures instructor shows again pass up the right ways soon. 11.The instructor gives questions and feedback to each pair 3. Brainstorming / Discussion: What is perceived easy? What is difficult? Asking how the students feel when they slice skin. What can be done by doctor so that the patient feels more comfortable? 4. Instructors make conclusions by answering the last question and clarify the things are not yet understood

3. Role playing practice with feedback

55 minutes

4. Brainstorming / Discussion

10 minutes

Total times

90 minutes

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LEARNING GUIDE SKILL OF TAKING AND MAKING SKIN SMEAR PREFARAT NO. STEPS / ACTIVITIES PATIENT PREPARATION 1. Greet clients or their families with friendly and introduce yourself, and ask their condition 2. Please clients and their families to sit 3. Give general information to the client or his family about making the skin liquid, objectives and benefits for client condition. 4. Give assurance to the client or his family about the security check up performed. 5. Provide assurance to the client or his family about the confidentiality required by the client. 6. Explain to the client about the rights of clients or their families, for example the right to refuse taking action skin liquid 7. Ask your client's willingness orally to take skin fluids PREPARATION OF TAKING SKIN LIQUID 8. Prepare all the necessary tools and materials on a table near the patient. 9. Wipe the glass objects and write the lab number / patient data on the back of the glass object 10. Ask the patient to sit in bright locations 11. Wash your hands regularly 12. Wear gloves DDT . MAKING SKIN SMEAR 13. Choose the area for suspicious skin lesion, for example on the ear lobes or nostrils 14. Take asepsis action by brushing cotton with alcohol 70% in the area to be used as place-making, ranging from local to regional play edges. 15. Pinch the area strongly between finger and left thumb, so that the surface of the skin becomes pale. 16. Make incisions with a sterile scalpel along the 0.5 cm with a depth of 1 2 mm (top layer only reaches the dermis). 17. Rotate the scalpel 90 with curry base side and wound up a kind of pulp tissue obtained from the epidermis and dermis to be attached to the surface of the scalpel. 18. Make a smear prefarat, with drops of examination material evenly on the surface of glass objects. 19. Dry prefarat and then fication with the flame 20. Press the cut wound with cotton and cover it with plaster alcohol AFTER FINISHING TO MAKING PREPARAT 21. Put off your gloves and throw into medical trash can 22. Do wash hand asepsis. 23. Put a rack of preparations in preparations or wrap the preparations with tissue paper and put in envelope. 24. Write a letter reference to the laboratory

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Student activity sheets

EXAMPLES OF RESULTS SKIN SMEAR PREFARAT

No Date Name Sex Age Address Occupation

: : : : : : :

The main complaints :

The result of skin smear examination

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Student activity sheets EXAMPLE REFERENCE GAZETTE

Dr. Sanusi Perangin Angin Practice permission no. 1234567 Address practice: Kebangkitan street No. 27 No. Phone: 0411-275634 _______________________________________________________________________ ___ Makassar, Designation: At..................

Sincerely, Sent liquid of skin smear ..................

From a patient: Name Sex Age Address Occupation The main complaints

: : : : : :

Thank you

Dr. Sanusi Perangin Angin

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CHECKLIST SKILLS OF TAKING AND MAKING SKIN SMEAR PREFARAT Instructions: Put an (V) in the appropriate box. Give Score: (0) if not done, (a) if it is done but still not satisfactory, (2) if satisfactory

NO. ASSESSED ASPECTS SCORE PREPARATION 0 1 2 1. Capable of connecting with patients and their families feel. 2. Able to give good informed concent. 3. Able to prepare patients for making skin smear 4. Able to regulate lighting 5. Prepare all the necessary equipment 6. routinely hands properly MAKING SKIN LIQUID 7.. Determining the location of the specimen and disinfection 8. Perform specimen collection correctly . 9. Doing the manufacture of liquid dosage form of skin (skinsmear) 10. Perform decontamination of equipment which has been used AFTER TAKING 11. Making a preparation of delivering apus stocks.

Comment / Summary :

Recommendation :

Coordinator signature/Instructure .............................

Date:..

Student Name :

Stambuk number :

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SKILL DOING PERIPHERAL BLOOD TAKING, MAKE A PERIPHERAL BLOOD SMEAR, MAKE GIEMSA STAIN FOR PERIPHERAL BLOOD SMEAR AND MICROSCOPIC EXAMINATION FOR PERIPHERAL BLOOD SMEAR

EDITORS: SITTI WAHYUNI

PRESENTED IN SEMESTER 6 TROPICAL MEDICINE SUBJECT MEDICAL FACULTY HASANUDDIN UNIVERSITY 2012

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SKILL DOING PERIPHERAL BLOOD TAKING, MAKE A PERIPHERAL BLOOD SMEAR, MAKE GIEMSA STAIN FOR PERIPHERAL BLOOD SMEAR AND MICROSCOPIC EXAMINATION FOR PERIPHERAL BLOOD SMEAR LEARNING OBJECTIVES General instructional objectives After completion of this skills training, students are expected to be capable and skilled bleeding edge, making the peripheral blood smear (thin and thick), made for Giemsa staining peripheral blood smear and microscopic examination for peripheral blood smear well and right.

Specific Instructional objectives After doing the exercises these skills, students: 1. Capable and skilled to give explanations on the patient or family about what will be done, tools are used, how to do, what are the benefits, and what possible risks & the right of patients to refuse. 2. Capable and skilled to make a preparation of patients correctly. 3. Capable and skilled bleeding edge by using the Lancet. 4. Capable and skilled to do a thick blood smear. 5. Capable and skilled to do thin blood smear. 6. Capable and skilled to make Giemsa colouring. 7. Capable and skilled to do microscope inspection to identify parasites found on blood smear prefarat. 8. Capable and skilled to calculate the intensity of Plasmodium infection 9. Capable and skilled to clean laboratory after completion of these skills. INDICATIONS 1. Patients with suspected malaria fever, dengue infection or infection of filaria 2. Patients with symptoms of lethargic / weak

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DESCRIPTION OF ACTIVITIES Activities 1. Introduction Time 10 minutes Description Introduction - Instructor explain about the skill objectives - Instructor shows material and tools needed to perform this skill. 1. A student acts as patients. 2. Instructors demonstrate how to perform peripheral blood taking by using the Lancet. 3. Instructors demonstrate how to create thick and thin blood smear. 4. Instructors demonstrate how to create Giemsa Stain 5. The instructor shows way of microscope examination to identify parasites found on blood smear preparations. 6. The instructor explains how to calculate the intensity of infection Plasmodium. 7. Students are required to ask for things are unclear in connection with the activities of these skills 1. Students were divided into four groups 2. Each group engaged in activities of peripheral blood taking, make thick and thin blood smear, making Giemsa Stain for blood smear and microscopic examination for simultaneous blood smear 3. Mentors walk around among students and do a supervision 4. Mentor corrects things which are not perfect yet Students are given the opportunity to express opinions about the activities undertaken

2. Demonstration

20 minutes

3. Practice of role playing with feedback

60 minutes

4.Brainstorming and discussion Total time

10 minutes 100 minutes

MATERIALS AND EQUIPMENT (for each student) - 2 pieces of glass objects - Lancet or sterile needles - Gloves - Permanent markers/ markers - Cotton alcohol - Dry Cotton - Methanol Solution - 3% Giemsa solution in phosphate buffer solution (pH 7.2) - Bottled water containing - glass objects Rack - medical trash can - Oil emersi binocular microscope - Tissue lens

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STEPS / ACTIVITIES A 1 2 B 3 Preparation Explaining to patients about the purpose of inspection and asked for approval. Prepare all the necessary tools. Peripheral blood-making activities With a marker, write the patient's identity on the first glass objects
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C 4

How to perform the peripheral blood sampling Clean the ring finger or middle finger with cotton alcohol, let it dry.

Puncture the clean Finger with sterile Lancet

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6 7 8

Wipe the first drop with sterile dry cotton. Press the fingers gently until blood came out In a glass object which has been given an identity, drops blood approximately 1 cm from the left edge of the glass object the size of 3 mm for a thick blood smear and a drop more of the same dimensions for a thin blood smear of about 1 cm adjacent to the thin trickle of blood

D 9 10

Making a thin blood smear Place the glass object of blood on the table Tap the blood on the surface of a glass object with the tip of the other glass objects that has a function as the catalyst so that the blood spread to all the tip of a glass object Make a 45 degree angle between the object glasses containing the droplets of blood and glass objects booster.

11

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12

Push the second glass object towards the front while maintaining a 45 degree angle and the driving end of the object glass is never separated from the glass object containing a droplet of blood

A good smear is a smear-shaped tip of the tongue are more narrowed Let the smear is dry Reference Thin blood smear can be used for: Identification of Plasmodium and the degree of parasitemia See cell and the morphology of cells are in blood for example to view hipokrom microcytic anemia due to hookworm infestation. Calculating the platelet count in patients with DHF
E 13

Making a thick blood smear Place the glass objects that are filled with approximately equal to , Take another glass object which has a function as a spreader, and spread out the blood on an object glass by using sharp angles of the spreader object glass until approximately

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And let dry Reference Thick blood smear can be used for: Identification of Plasmodium and the degree of parasitemia/mm3 blood Identification of filaria

Giemsa staining activity

14

Put a glass object containing a dried blood smear on a glass shelf object

15

Dipping into the thin blood smear methanol solution, be careful not to come thick blood smear fixed. Allow to dry. Drop the water above the thick blood smear for hemolysis of erythrocytes, let

16

a few minutes Drops two object glasses with Giemsa solution 3% and let stand for 30 minutes.

17

18

Flush with running water until clean.

19

After it is clean place in slanting condition and let it dry.

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G 20 21

The identification of parasites on thin blood smear Put binocular microscope on a flat work table Check the cleanliness of the microscope. if it is dirty, clean it with xylol and wipe lightly with lens tissue

22 23

Put dawn preparat on the object table. First look at the object with the objective lens 10 until you can see the red blood Cells clearly.

24 25

If the object has been focus, drop to preparat with a drop of oil emersi Replace the lens objective lens with 100 times and turn the micrometer to focus.

26

Find erithrocyt containing schizont, trophozoit, gametocytes at all field of view, do a zigzag way, record what you get Identification reference for thin blood smear Parasite Plasmodium which can be found located within erithrocyt Plasmodium will appear with a red chromatin and pale bluish purple-stained cytoplasm. Normal erithrosit grayed somewhat pale purple Neuthrophil same color but with a core of dark purple and have granules in their cytoplasm Erithrocyt containing Plasmodium will be different in shape and size. Wall of normal erythrocytes. Chromatin from Plasmodium reddish purple with purple-blue cytoplasm. Spot of Schiiffher's is seen in erythrocytes containing P. vivax or P. Ovale Maurer spots visible on the large rings erythrocytes containing P.falciparum. In P.vivax and P.ovale Schuffher's spots can be seen Preparations declared negative if no plasmodium was found in 100 field of view

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Seeing the thick blood smear (Erythrocyte lysis was so red blood cells did not appear anymore Look at the object with the objective lens 10 times. If the object has been focus, drop to the preparat with a drop of oil emersi

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30

Replace the lens objective lens with 100 times and turn the micrometer until the focus of which will show the background looks clean and Plasmodium will appear with a red chromatin and cytoplasm pale bluish purple

31

Perform inspection at the 100 field of view and take note of what was found

Reference to identify parasites in thick blood smear Plasmodium will appear with a red chromatin and cytoplasm pale bluish purple. In P.vivax and P.ovale Schuffher's spots can be seen Microfilaria can also appear with thick blood tests 10 x magnification Calculating the intensity of infection (parasitemia) For each field of view (LP) count the amount of leukocyte and Plasmodium until the amount of leukocyt achieves 200 For example:

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field of view 1 2 3 4 5 6 7 8 9 10 11 Total

Amount eritrocyt/ field of view 23 27 16 17 15 23 15 20 17 15 12 200

Amount Plasmodium/ field of view 0 2 0 1 0 0 0 0 0 1 1 5

After 11 field of view, 200 leukocyt and five Plasmodium are found. In 1 mm3 blood there are 5000-10000 leukocyt, or taken as many as 8000 the average Then the intensity of infection are: 8000 x 5 = 200 parasit/mm3 200 The results stated above there are a number of 200 parasit/mm3 blood

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CHECKLIST

No 1 2 3 4 5 6 7 8

Assesced Aspect Knowledge of these skills training purposes. Ability and skills to act in patients asepsis Ability and skills to do the blood sampling using the Lancet Ability and skills to make a thin blood smear Skills Ability to make a thick blood smear. Ability and skills to make Giemsa staining Ability and skill to determine the intensity of infection in a thick blood smear. Ability to answer a question from the examiner

Check list above contains the activities which will be assessed on the skills test in which the instructor was asked for giving assessments to students for twelve checklist above (see sheets of student assessment) Score: 0 if not done 1 if it is done but unsatisfying yet 2 if satisfactory Examples of student assessment sheets for manual 8 No 1 2 6 7 8 9 10 Scoring for the manual 8 Total value of the lowest 0, highest value 16 Value <12 : unskilled Value > = 12: ski Name Stambuk 1 2 3 4 5 Activities 6 7 Total 8

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SKILL TABLET MAKING DIRECT FECES, IDENTIFYING PARASITES CONTAINED IN THE FECES AND WAY OF PRESERVATION AND DELIVERY OF FECES SAMPLES

Created by SITTI WAHYUNI

PRESENTED IN GRADE 6 TROPICAL MEDICINE SUBJECT MEDICAL FACULTY HASANUDDIN UNIVERSITY 2012

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SKILL TABLET MAKING DIRECT FECES, PARASITES IDENTIFYING CONTAINED IN FECES AND WAY OF PRESERVATION AND FECES SAMPLES DELIVERY LEARNING OBJECTIVES General instructional objectives After completion of this skills training, students are expected to be capable and skilled to make feces direct preparations, identified the parasites found in stool specimens as well as preserving and delivering specimens of faeces properly and correctly. Special Instructional objectives After doing the exercises these skills, students: 1. Capable and skilled to give explanations to the patient or family about what to do, tools are used, how to do, what the benefits are, risks and what might happen. And the right to refuse 2. Capable and skilled in preparing patients correctly. 3. Capable and skilled to prepare equipment / materials properly. 4. Capable and skilled to make smear feces on a glass object 5. Capable and skilled to color feces samples for direct examination. 6. Capable and skilled to identify the parasites contained in stool samples. 7. Capable and skilled to perform preservation of feces samples to be sent to reference laboratories. 8. Capable and skilled to clean laboratory after finishing skill exercise. INDICATIONS 1. Patients with diarrhea. 2. Patients with a dysentery. 3. Patients with gastrointestinal complaints without diarrhea or dysentery. 4. Patients with symptoms of fever complaint or weakness with a suspected infection of the gastrointestinal tract.

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ACTIVITY DESCRIPTION Activity 1. Introduction Time 10 minutes Description The instructor explained the purpose of this skills training Instructors show materials and tools required

2. Demonstration

20 minutes

1. Instructors demonstrate how to make preparations Feces direct. 2. Instructors demonstrate how to identify parasite found in stool specimens. 3. Instructors demonstrate how to preserve Feces specimens and how to refer. 4. Students were asked for asking about unclear things related to this activity 11.Students were divided into four groups 12. Being supervised by instructors, each group of students make direct preparations feces, dentify parasites found on feces specimens and stool specimens preserved for reference laboratory simultaneously 13. Instructors walk around among students and do a supervision 14. The instructor corrects the things which are not perfect

3. Practice of role playing with feedback

60 minutes

4. Disscusion

10 minutes 100 minutes

Students are given the opportunity to express their opinion about the activities undertaken

Total times

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TOOLS AND MATERIALS 1. Gloves 2. glass Object and the glass cover 3. Disinfection solution 4. Pots containing feces 5. Solution and saline solution and Lugol's iodine solution (1% solution) 6. Tissue paper 7. Microscope 8. Wooden applicators 9. Marker pen 10. Pots with a volume of 20 ml of feces that have a tight lid 11. Formalin (formaldehyde) 10% 12. Scotch tape 13. Paper labels 14. Preparat to remove faeces 15. Reference letter STEP/ACTIVITY

A 1 2 B 3

Preparation Prepare all the necessary tools. Explaining to patients about the purpose of inspection Make a direct preparations feces With a marker, write the patient's identity on a glass object

224 10/04/84

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4 5

Place the glass objects are flat on the table Drop a drop of saline solution on the middle left glass and 1 drop of lugol iodine solution on the right middle of the glass object

Take a little faeces (part slimy) using a wooden applicator, put on drop saline solution, mix until blended Note: - Hard Faeces: take a part that is located outside and inside the specimen. - Mixed Faeces or blood: taken from the slimy or bloody area Dilute Faeces: take a section anywhere.

Same as the third step: Take a little faeces, put on lugol iodine drop, mix until evenly distributed

Close the two drops each with a glass cover

50

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9 10 C 11 12 13

Suction with blotting paper and which is outside the glass cover Put the stocks on the microscope object table, ready for inspection Identifying parasites which are found on fecal preparations Place the glass object on an objective table under the microscope Lower the condenser and arrange the light through the diaphragm. Look at the object by using an objective lens 10 times, turn macrometer until the object is visible Clear the focus by turning the micrometer slowly Increase the magnification to 45 times if necessary Perform the systematic examination with zigzag method.

14 15 16

17

Perform identification of parasites: Protozoa worm eggs and larvae: the form of trophozoites and cysts amoebae and flagella

Reference

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Eggs and larvae of worm in a saline solution and iodine lugol Worm eggs and larvae can be identified easily in the saline solution. They look colorless and easily seen with magnification 10 x Protozoa in saline solution - Forms of trophozoites and cysts of amoebae and flagellate may be seen - Cysts look round or oval with a clear wall - Trophozoit will look round or oval with irreguler wall. - In fresh faeces (faeces of no more than two hours after being expelled), trophozoit movement can be seen especially in the flagella. - At first look at the object with the enlargement of an Ox, to see more clearly a part of parasites such as the nucleus, chromatoid bodies, sucking discs, spirals grooves, or filaments of the parasite, increase gradually enlarged. Protozoa in Lugol Iodine - Trophozoit or cytoplasm of the cyst will look yellow or brown and the nucleus will look dark brown. - In Entamoeba cysts karyosome peripheral chromatin and the position can be seen (if not visible, not Entamoeba). Peripheral chromatin look pale yellow. Sometimes the young cysts still contain glycogen, glycogen will look dark brown. - Cysts and flagella filaments are also visible with iodine staining lugol. D 18 19 20 Preserve Feces Label the pot with the patient's identity Fill the pot with 10% formalin until the middle of pot With a wooden applicator take feces approximately as much as a teaspoon, put into pots that are filled with preservatives, stir until feces and its preservative mixed properly. E 21 22 23 Send to a reference laboratory Cover pot well and use masking tape to prevent leakage at the mouth of the pot. Write the introduction of these specimens include: name, age and sex of patients, a major complaint and the date of delivery Clean the table after the completion of this activity

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CHECK LIST

No.
1 2

Aspects assessed Knowledge of these skills training purposes. Abilities and skills of doing preparation materials and tools are used correctly.

Ability and skills to make smear feces on an object glass for immediate inspection.

Ability & skill to identify the parasites contained in stool samples. Ability and skills to do the stool sample preservation

Ability & skill to send stool samples to a reference laboratory check list above contains the activities that will be assessed on the skills test where the instructor was asked for giving assessments to students for eight checklist above (see sheets of student assessment) Score: 0 if not done 1 if it is done but unsatisfying yet 2 if satisfactory Examples of student assessment sheets for manual 9 No 1 2 3 4 5 6 7 Name Stambuk 1 Activities 2 3 4 Total 5

Scoring for manual 9 Total value of the lowest 0, highest value 10 Score 0-6: unskilled Score 60-10: skilled53 53

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