Cbt Review Manual_source Royal Marsden Clinical Nursing Procedures_part 1 3638f

REVIEW

MANUAL

Source: The Royal Marsden Ninth Edition (Part 1)

NMC COMPUTER BASED TEST (CBT) CLINICAL NURSING PROCEDURES ASSESSMENT AND DISCHARGE

EVIDENCE-BASED APPROACHES DATA COLLECTION

ASSESSMENT -

Is the systematic and continuous collection, organisation validation and documentation of information (Berman et al. 2010).

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It is a deliberate and interactive process that underpins every aspect of nursing care (Heaven and Maguire 1996).

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It is the process by which the nurse and patient together identify needs and concerns. It is seen as the corner-stone of individualised care, a way in which the uniqueness of each patient can be recognised and considered in the care process (Holt 1995).

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OBJECTIVE DATA -

2. 3. 4.

5. 6. 7. 8. 9.

Patient assessment is patient focused, being govern by the notion of an individual‟s actual, potential and perceived needs. It provides baseline information on which to plan the interventions and outcomes of care to be achieved. It facilitates evaluation of the care given and is a dimension of care that influences a patient‟s outcome and potential survival. It is a dynamic process that starts when problems or symptoms develop, and continues throughout the care process, accommodating continual changes in the patient‟s condition and circumstances. It is essentially an interactive processing which the patient actively participates. Optimal functioning, quality of life and the promotion of independence should be primary concerned. The process include observation, data collection, clinical judgment and validation of perceptions. Data used for the assessment process are collected from several sources by a variety of methods, depending on the healthcare setting. To be effective, the process must be structured and clearly documented.

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An effective assessment will provide the nurse with information on the patient‟s background, lifestyle, family history and the presence of illness or injury (Crouch and Meurier 2005).

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The nursing assessment should focus on the patient‟s response to a health need rather than disease process and pathology (Wilkinson 2007).

The process of assessment requires nurses to make accurate and relevant observations, to gather, validate and organise data and to make judgments to determine care and treatment needs. It should have physical, psychological, spiritual, social and cultural dimensions, and it is vital that these are explore with the person being assessed. The purpose of nursing assessment is to get a complete picture of the patient and how they can be helped.

Are measurable and can be detected by someone other than the patient. They include vital signs, physical signs and symptoms, and laboratory results.

SUBJECTIVE DATA -

PRINCIPLES OF ASSESSMENT 1.

Is the process of gathering information about the patient‟s health needs. This information is collected by means of interview, observation and physical examination and consist of both OBJECTIVE and SUBJECTIVE data.

Are based on what the patient perceives and may include descriptions of their concerns, network, their awareness and knowledge of their abilities/disabilities, their understanding of their illness and attitude to and readiness for learning (Wilkinson 2007).

Nurses working in different settings rely on different observational and physical data. A variety of methods have been developed to facilitate nurses in eliciting both objective and subjective assessment data on the assumption that, if assessment is not accurate, all other nursing activity will also be inaccurate. LEGAL AND PROFESSIONAL ISSUES NHS Knowledge and Skills Framework (DH 2004a) -

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States that the specific dimensions of assessment and care planning to meet people‟s health and wellbeing needs and assessment and treatment planning related to the structure and function of physiological and psychological system are core to nursing posts in all settings. Staff will need to be aware of their legal obligations and responsibilities, the rights of the different people involved, and the diversity of the people they are working with. Nurses have an obligation to record details of any assessments and reviews undertaken and provide clear evidence of the arrangements that have been made for future and on-going care (NMC 2010). This should also include details of information given about care and treatment.

POINTS FOR CONSIDERATION 1. COGNITIVE AND PERCEPTUAL ABILITY COMMUNICATION The nurses needs to assess the level of sensory functioning with or without aids/ such as hearing aid(s), speech aid(s), glasses/ lenses, and the patient capacity to use and maintain aids/ correctly. Furthermore, it is important to assess whether there are or might be any potential language or cultural barriers during this part of assessment. Knowing the norm within the culture will facilitate understanding and lessen miscommunication (Galanti 2000).

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(POINTS FOR CONSIDERATION cont…..)

3. ELIMINATION

INFORMATION

GASTROINTESTINAL

During this part of assessment, the nurse will assess the patient‟s to comprehend the present environment without showing level of distress. This will help establish whether there are any barriers to the patients understanding their condition and treatment. It may help them to be in a position to give informed consent.

During this part of the assessment it is important to determine a baseline with regard to independence.  Is the patient able to attend to their elimination needs independently and is he/she continent?   What are patient‟s normal bowel habits?   Are bowel movements within the patient‟s own normal pattern and consistency?   Does the patient have any underlying medical conditions such as Crohn‟s disease or irritable bowel syndrome?   How does this affect of patient?

NEUROLOGICAL It is important to assess the patient‟s ability to reason logically and decisively, and determine that he or she is able to communicate in a contextually coherent manner. PAIN To provide optimal patient care, the assessor needs to have appropriate knowledge of the patient‟s pain and an ability to identify the pain type and location. Assessment of a patient‟s experience of pain is crucial component in providing effective pain management.

Dimond (2002) asserts that it is un acceptable for patients to experience unmanaged pain or for nurses to have inadequate knowledge about pain. Pain should be measured using an assessment tool that identifies the quality and/or quality of one or more of the dimensions of the patient‟s experience of pain. Australian and New Zealand College of Anaesthetists 2005, Jensen et al. 2003, Rowbotham and Macintyre 2003 Assessment should also observe for signs for neuropathic pain, including descriptions such as shooting, burning, stabbing, allodynia (pain associated with gentle touch). 2. ACTIVITY AND EXERCISE RESPIRATORY Respiratory pattern monitoring addresses the patient‟s breathing pattern, rate and depth. In this section it is also important to assess and monitor smoking habits. It is helpful to document the smoking habit in the format of pack-years. A pack-year is a term used to describe the number of cigarettes a person has smoked over time. One pack- year is defined 20 manufactured cigarettes (one-pack) smoked per day for 1 year. At this point in the assessment, it would be a good opportunity, if appropriate, to discuss smoking cessation. A recent meta-analysis indicates that if interventions are given by nurses to their patients with regard to smoking cessation the benefits are greater (Rice and Stead 2008). CARDIOVASCULAR A basic assessment is carried out and vital signs such as pulse (rhythm, rate and intensity) and blood pressure should be noted. Details of cardiac history should be taken for this part of the assessment. Medical conditions and experience of previous surgery should be noted. PHYSICAL ABILITIES, PERSONAL HYGIENE/ MOBILITY/ TOILETING, INDEPENDENCE WITH ACTIVITIES OF DAILY LIVING The aim during this part of assessment is to establish the level of assistance required by the person to tackle activities of daily living such as walking steps/stairs. An awareness of obstacles to safe mobility and dangers to personal safety is an important factor and part of the assessment. The nurse should also evaluate the patient‟s ability to meet personal hygiene, including oral hygiene, needs. This should include the patient‟s ability to make arrangements to preserve standards of hygiene and the ability to dress appropriately for climate, environment and their owned standard of self-identity.

GENITOURINARY This assessment is focused on the patient‟s baseline observations with regard to urinary continence/incontinence. It is also important to note whether there is any penile or vaginal discharge or bleeding.

4. NUTRITION ORAL CARE As part of inpatient ission assessment, the nurse should obtain an oral health history that include oral hygiene beliefs, practices and current state of oral health. During this assessment it is important to be aware of treatments and medications that affect the oral health of the patient. HYDRATION An in-depth assessment of hydration and nutritional status will provide the information needed for nursing interventions aimed at maximising wellness and identifying problems for treatment. The assessment should ascertain whether the patient has any difficulty eating or drinking. During the assessment the nurse should observe signs of dehydration, for example dry mouth, dry skin, thirst or whether the patient shows any signs of altered mental state.

NUTRITION A detailed diet history provides insight into a patient‟s baseline nutritional status. Assessment includes questions regarding chewing or swallowing problems, avoidance of eating related to abdominal pain, changes in appetite, taste or intake, as well as use of a special diet or nutritional supplements. A review of past medical history should identify any relevant conditions and highlight increased metabolic needs, altered gastrointestinal function and the patient‟s capacity to absorb nutrients. NAUSEA AND VOMITING During this part of assessment you want to ascertain whether the patient has any history of nausea and/or vomiting. Nausea and vomiting can cause dehydration, electrolyte imbalance and nutritional deficiencies (Marek 2003), and can also affect the patient‟s psychosocial well-being. They may become withdrawn, isolated and unable to perform their usual activities of daily living. 5. SKIN A detailed assessment of a patient‟s skin may provide clues to diagnosis, management and nursing care of the existing problem. A careful skin assessment can alert the nurse to cutaneous probles as well as systematic diseases. In addition, a great deal can be observed in a person‟s face, which may give insight to his or her state of mind. 6. CONTROLLING BODY TEMPERATURE This assessment is carried out to establish baseline temperature and determine if the temperature is within normal range, and whether there might be intrinsic factors for altered body temperature.

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(CONTROLLING BODY TEMPERATURE cont….) It is important to note whether any changes in temperature are in response to specific therapies (e.g. antipyretic medication, immunosuppressive therapies, invasive procedures or infection (Bickley et al. 2013)). White blood count should be recorded to determine whether it is within normal limits.

12. VALUES AND BELIEFS RELIGIOUS, SPIRITUAL AND CULTURAL BELIEFS

7. SLEEP AND REST

The aim is to assess the patient‟s spiritual, religious, and cultural needs to provide culturally and spiritually specific care while concurrently providing a forum to explore spirituals strengths that might be used to prevent problems or cope with difficulties.

This part of assessment is performed to find out sleep and rest patterns and reasons for variation. Description of sleep patterns, routines and interventions applied to achieve a comfortable sleep should be documented. The nurse should also include in the presence of emotional and/or physical problems that may interfere with sleep.

Assessment is focused on the patient‟s values and belief, including spiritual beliefs, or on the goals that guide his or her choices or decisions. A patient‟s experience of their stay in hospital may be influenced by their religious beliefs or other strongly held principles, cultural background or ethnic origin. It is important for nurses to have knowledge and understanding of the diverse cultures of their patients and take their different practices into .

8. STRESS AND COPING

13. HEALTH PERCEPTION AND MANAGEMENT

Assessment is focused on the patient‟s perception of stress and on his or her coping strategies. system should be evaluated and symptoms of stress should be noted. It includes the individual‟s reserve or capacity to resist challenge to self-integrity, modes of handling stress. The effectiveness of a person‟s coping strategies in of stress tolerances may be further evaluated (adapted from Gordon 1994)

RELEVANT MEDICAL CONDITIONS, SIDE EFFECTS/COMPLICATION

9. ROLES AND RELATIONSHIP The aim is to establish the patient‟s own perception of the roles and responsibilities in their current life situation. The patient‟s role in the world and their relationship with others are important to understand. Assessment in this area includes finding out about the patient‟s perception of the major roles and responsibilities they have in life, satisfaction or disturbances in family, work or social relationships. An assessment of home life should be undertaken which should include how they will cope at home post discharge from hospital and how those at home will cope while they are in hospital, for example dependants, children or animals and if there are any financial worries. 10. PERCEPTION/CONCEPT OF SELF BODY IMAGE/SELF-ESTEEM Body image is highly personal, abstract and difficult to describe. The rationale for this section is to assess the patient‟s level of understanding and general perception of self. This includes their attitudes about self, perception of abilities (cognitive, affective or physical), body image, identity, general sense of worth and general emotional pattern. An assessment of body posture and movement, eye , voice and speech patterns should also be included.

11. SEXUALITY AND REPRODUCTION Understanding sexuality as the patient‟s perceptions of their own body image, family roles and functions, relationships and sexual function can help the assessor to improve assessment and diagnosis of actual or potential alterations in sexual behavior and activity.

Assessment in this area is vital and should include relevant feelings about the patient‟s own body, their need for touch, interest in sexual activity, how they communicate their sexual needs to a partner, if they have one, and the ability to engage in satisfying sexual activities. This may also be an opportunity to explore with the patient issues related to future reproduction if this is relevant to the ission.

OF TREATMENTS Assessment of the patient‟s perceived pattern of health and wellbeing and how health is managed should be documented here. Any relevant history of previous health problems, including sideeffects of medication, should be noted. Examples of other useful information that should be documented are compliance with medication regimen, use of health promotion activities such as regular exercise and if the patient has annual check-ups. POST-PROCEDURAL CONSIDERATIONS DECISION MAKING AND NURSING DIAGNOSIS The purpose of collecting information through the process of assessment is to enable the nurse to make a series of clinical judgments, which are known in some circumstances as nursing diagnoses, and subsequently decisions about the nursing care each individual needs. The decision-making process is based upon the clues observed, analysed and interpreted and it has been suggested that expert nurses assess the situation as a whole and make judgments and decisions intuitively (Hedberg and Satterlund Larsson 2003, King and Clark 2002, Peden McAlpine and Clark 2002), reflecting Benner‟s (1984) renowed novice-to-expert theory.

Nursing diagnosis is a term which describes both a clinical judgment that is made about an individual‟s response to health or illness, and the process of decision making that leads to that judgment. The importance of thorough assessment within this process cannot be overestimated. The gathering of comprehensive and appropriate data from patients, including the meanings attributed to events by the patient, is associated with greater diagnostic accuracy and thus more timely and effective intervention (Alfaro-LeFevre 2014, Gordon 1994, Hunter 1998). PLANNING AND IMPLEMENTING CARE Nursing diagnosis provide a focus for planning and implementing effective and evidenced-based care. This process consists of identifying nursing-sensitive patient outcomes and determining appropriate interventions (Alfaro-LeFevre 2014, Shaw 1998, White 2003).

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To determine the immediate priorities and recognize whether patient problems requiring nursing careor whether a referral should be made to someone else. To identify the anticipated outcome for the patient, noting what the patient will be able to do and within what time frame. The use of “measurable” verbs that describe patient behavior or what the patient says  facilitates the evaluation of patient outcomes.

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(PLANNING AND IMPLEMENTING CARE Cont…..)

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To determine the nursing interventions, that is, what nursing actions will prevent or manage the patient‟s problems so that the patient‟s outcomes may be achieved.

MEASURABLE VERBS (use these to be specific)    

State; verbalize; communicate; list; describe; identify Demonstrate; perform Will lose; will gain; has an absence of Walk; stand; sit

NON-MEASURABLE VERBS (do not use)   

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Know Understand Think Feel

EVALUATING CARE Effective evaluation of care requires the nurse to critically analyse the patient‟s health status to determine whether the patient‟s condition is stable, has deteriorated or improved. Seeking the patient‟s and family‟s views in the evaluation process will facilitate decision making. By evaluating the patient‟s outcomes, the nurse is able to decide whether changes need to be made to the care planned. Evaluation of care should take place in a structured manner and on a regular basis by a ed Nurse. The frequency of the evaluation depends on the clinical environment within which the individual is being cared for as well as the nature of the nursing diagnosis (problem) to which the care relates. DOCUMENTING Nurses have a professional responsibility to ensure that healthcare records provide an accurate of treatment, care planning and delivery, and are viewed as a tool of communication within the team. There should be a “clear evidence of the care planned, the decision made, the care delivered and the information shared” (NMC

2010, p.8). The content and quality of record keeping are a measure of standards of practice relating to the skills and judgment of the nurse (NMC 2010). OBSERVATION Observation is the conscious, deliberate use of the physical senses to gather data from the patient and the environment. It occurs whenever the nurse is in with the patient. At each patient , it is important to try and develop a sequence of observations. These might include the following: 1. 2. 3. 4. 5.

Physical assessment serves a number of purposes (Crouch and Meurier 2005).

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To record the care plan for the patient which may be written or individualized from a  standardized/core care plan or a computerized care plan.

EXAMPLES OF MEASURABLE AND NON-MEASURABLE VERBS FOR USE IN OUTCOME STATEMENTS

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PHYSICAL ASSESSMENT/EXAMINATION

As you enter the room, observe the patient for signs of distress. Scan for safety hazards. Look at the equipment. Scan the room-who is there and how do these people interact with the patient. Observe patient more closely for data such as skin temperature, breath sounds, drainage/dressing odours, condition of dressing, drains, need for repositioning (Wilkinson 2007).

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To obtain information on the patient‟s overall health status.

To enable additional information to be obtained about any symptoms reported by the patient. To detect changes in a patient‟s condition.

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To evaluate how the patient is responding to interventions.

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EVIDENCE-BASED APPROACHES The patient‟s health history and the nurse‟s knowledge of anatomy and physiology will help guide when it is appropriate to do a physical examination and which system is to examine. From the history, a list of differential diagnoses will have been generated and the examination should seek to confirm, refute or further establish that a differential diagnosis is a possibility (Douglas and Bevan 2013). There are four aspects of physical examination: 1. 2. 3. 4.

Inspection – simply observing the patient. Palpation – requires the use the whole hand including the palm and the full length of the fingers to feel and assess (Bickleyet al. 2013, Rushforth 2009). Percussion – helps to identify organs, allowing assessment of size and shape. Auscultation – involves listening to various sounds in the body using a stethoscope (Bickley et al. 2013, Rushforth 2009).

LEGAL AND PROFESSIONAL ISSUES As in all aspects of care, nurses must be aware of their ethical and legal responsibilities when assessing patients. Issues of honesty and confidentiality are frequently encountered during assessment (Wilkinson 2007). INFECTION PREVENTION AND CONTROL MECHANISMS OF INFECTION Whether or not a particular infectious agent will cause an infection in any given circumstance is dependent on many different factors, including how easily that agent can be transmitted, its pathogenicity (which is its ability to cause disease) and its virulence (which determine the severity of the infection produced ) (Gillespie and Bamford 2012). It is generally accepted that for infection to occur, certain linked requirements need to be met; these links are often referred to as the chain of infection (Damani 2011).

MODES OF TRANSMISSION DIRECT – person-to-person spread of infectious agents through physical between people. It can be prevented through good hand hygiene, the use of barriers such as aprons and gloves and non-touch technique for aseptic procedures (Loveday et al. 2014). INDIRECT – occurs when someone comes into with a contaminated object. Transmission is prevented by effective cleaning, decontamination and good hand hygiene (DH/HPA 2008).

DROPLET TRANSMISSION – when people cough, sneeze or even talk, they expel droplets of respiratory secretions and saliva. Transmission is prevented through isolating the affected patient and using masks, aprons and gloves to provide a barrier. May also be reduced through good hand hygiene.

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(MODES OF TRANSMISSION Cont…)

LEGAL AND PROFESSIONAL ISSUES

AIRBORNE TRANSMISSION – involves droplets or particles containing infectious agents, but on a small enough scale that the particles can remain suspended in the air for long periods of time. Infections spread via this route include measles and chickenpox. Prevention is as for droplet transmission.

In England, the Health and Safety at Work etc. Act 1974 is the primary piece of Legislation relating to the safety of people in the workplace. It applies to all employees and employers, and requires them to do everything that is reasonable and practicable to prevent harm coming to anyone in the workplace. It requires employers to provide training and appropriate protective equipment and employees to follow the training that they have received, use the protective equipment provided, and report any situations where they believe inadequate precautions are putting anyone‟s health and safety at serious risk. This dovetails with the requirements of the Nursing and Midwifery Council (NMC 2015) for nurses to promote and protect the well-being of those in their care and to report concerns in writing if problems in the environment of care are putting people at risk.

PARENTERAL TRANSMISSION – this is a form of transmission, where blood or body fluids containing infectious agents, come into with mucous membranes or exposed tissue. In healthcare, this can occur through transplantation or infusion (which is why blood and organs for transplantation are screened for blood borne viruses such as HIV). Transmission is prevented by good practice in handling and disposing of sharps and the appropriate use of protective equipment, including eye protection (UK Health Departments 1998). A European Union directive recently incorporated into UK Legislation requires the use of “safe” needle-free devices wherever possible in order to reduce the risk of inoculation injury (Health and safety Executive 2013) . FAECAL-ORAL TRANSMISSION – this occurs when an infectious agent present in the faces of an infected person is subsequently ingested by someone else and enters their gastrointestinal tract. Transmission is prevented through isolating any patient with symptoms of gastroenteritis; effective hand hygiene by both staff and patients with soap and water (as many of these organism are less susceptible to alcohol); appropriate use of gloves and aprons; and good food hygiene (DH/HPA 2008). VECTOR TRANSMISSION – many diseases are spread through the action of a vector, most often an insect that travels from one person to another to feed. This route is not currently a concern in healthcare in England, but in some areas of the world, for example where malaria is endemic, protecting patients from vectors such as mosquitoes is an important element of nursing care. SYMPTOMS OF INFECTION      

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HEAT – the site of the infection may feel warm to the touch, and the patient may have a raised temperature. PAIN at the site of the infection. SWELLING at the site of the infection. REDNESS at the site of the infection. FEELING of general malaise. In GASTROINTESTINAL INFECTION abdominal pain and tenderness; nausea; diarrhea and/or vomiting (Goering et al. 2012). In URINARY TRACT INFECTION frequency of micturition; often confusion in the elderly; loin pain and/or abdominal discomfort (Goering et al. 2012).

EVIDENCE-BASED APPROACHES The principle of all infection prevention and control is preventing the transmission of infectious agents. The infection prevention and control policies of health and social care providers are based on generic risk assessments of their usual client or patient group and should be adhered to unless there are strong reasons to alter procedures for a particular individual‟s care.

In such circumstances, the advice of the infection prevention and control team (IPCT) should be sought first. Nurses working in organizations without an IPCT should identify the most appropriate source from which to seek advice, preferably before it is needed.

The NMC Code (NMC 2015) states that all nurses must work within the limits of their competence. This means, for example, not carrying out aseptic procedures without being competent nad confident that they can be carried out without increasing the risk of introducing infection through lack of knowledge or technique. COMMUNICATION Communication is a universal word with many definition, many of which describe it as a transfer of information between a source and a receiver (Kennedy Sheldon 2009); that is, the sending and receiving of verbal and non-verbal messages between two or more people (de Vito 2013). In nursing, this communication primarily interpersonal; the process by which comion and are offered and information, decisions and feelings are shared (McCabe and Timmins 2013). EVIDENCE-BASED APPROACHES Effective communication is widely regarded to be a key determinant of patient satisfaction, compliance and recovery (Dwamena et al. 2012, Webster and Bryan 2009), yet poor communication is one of the most common causes of complaints in healthcare (DH 2013, Strachan 2004). Nurses need to communicate effectively with patients in order to deliver individualized safe care and treatment and to manage psychosocial concerns appropriately.

LISTENING – is a skill often assumed to be natural. Rarely would we consider that we were physically unable to listen and perhaps this makes us pay little attention to this crucial skill area. How to let someone know you are listening to them?       

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Non-verbal encouragement – e.g. head nodding, body position, eye . Verbal responses Questioning Paraphrasing Clarifying Summarizing Empathy

LEGAL AND PROFESSIONAL ISSUES There are number of legal and professional concepts and issues that impact on effective communication and psychological . These include:

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(LEGAL AND PROFESSIONAL ISSUES Cont…)

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DEPRESSION

Professional responsibility for effective communication.

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Confidentiality andappropriate disclosure of information about the patient. Consent communicating about a procedure and ensuring that a patient is fully cognizant of what it involves.

Assessment of an individual‟s mental capacity to engage  in care and treatment.

Depression is a broad and heterogeneous diagnosis. Central to it is a depressed mood and/or loss of pleasure in most activities (NICE 2009b). Depression is often accompanied by symptoms of anxiety, and can be short-lived (sometimes dependent upon physical symptoms) or chronic. SYMPTOMS THAT DEPRESSION

INDICATE

A

DIAGNOSIS

OF

CLINICAL

MENTAL CAPACITY ACT 2005 BEHAVIOURAL The Mental Capacity Act (2005) sets out clear guidance and has produced a code of practice to professionals working weith people who may have impairment in their capacity. COMMUNICATING WITH THOSE DISTRESSED

WHO ARE WORRIED

OR

Interpersonal communication is the process of discussion between healthcare professionals and patients and carers, which allows patients and carers to explore issues and arrive at decisions (NICE 2004). Related Theory Patients will naturally have an emotional response to serious illness. At its most mild, this is seen as sadness and worry. At its most serious, however, patients experience severe psychological responses such as adjustment reactions, anxiety states or depression (NICE 2004). EVIDENCE-BASED APPROACHES Research evidence suggests that nurses and other healthcares should listen to all of the concerns, even those that have no resolution (Booth et al. 1999, Pennebaker 1993). Nurses should inquire about the resources (help) that patients have around themselves what would help, before the health worker offers advice, information or reassurance (Booth et al. 1999, Tate 2010).

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Tearfulness Irritability Social withdrawn Changes to sleep patterns Lowered appetite Lack of libido Fatigue Diminished activity Attempts at self-harm or suicide

PHYSICAL   

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Exacerbation of pre-existing pains Pains secondary to increased muscle tension Agitation and restlessness Changes in weight

COGNITIVE   

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Poor concentration Reduced attention Pessimistic thoughts Recurring negative thoughts about oneself, past and future Mental slowing Rumination

EMOTIONAL Pre-procedural consideration Patients need privacy to discuss emotions and worries: they also need time. Nurses, therefore, should create the conditions for patients to describe their worries. COMMUNICATING WITH THOSE WITH SPECIFIC PSYCHOLOGICAL NEEDS

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Feelings of guilt Worthlessness Deserving of punishment Lowered self-esteem Loss of confidence Feeling of helplessness Suicidal ideation

DENIAL AND COLLUSION

Pre-procedural considerations

Denial is a complex phenomenon (Vos and Haes 2010) and can be considered a mechanism for slowing down and filtering the absorption of traumatic information, “allowing for avoidance of painful or distressing information” (Goldbeck 1997). Collusion is when two or more parties develop a shared, sometimes secret understanding that may involve withholding information from another person. Related theory

Pharmacological – there are four main types of antidepressant: tricyclic, monoamine oxidase inhibitors (MAOI), selective serotonin reuptake inhibitors, (SSRI) and serotoninnorepinephrine reuptake inhibitors (SNRI) (Rsych 2013).

Diagnosis of any potentially life-threatening illness is experience in many different ways and can cause strong emotional responses. Patients are likely to feel a degree of distress and experience a wide range of emotions that may be lessened if healthcare professionals (Hs) are truthful and open with patients about their diagnosis and prognosis.

Non-pharmacological – Nurses can be involved in assessing depression in patients with physical illness. NICE guidance sets out a step model for managing a patient with depression.

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Initiate the conversation, develop rapport. Develop a person-centred communication style.

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Show understanding, caring  and acceptance of behavior, including tears or anger.

Encourage patient to identify their  own abilities or strategies for coping with the situation.

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PATIENT COMPORT AND END-OF-LIFE CARE

The programme advocates the following core principles for delivery of EOLC.

PERSONAL HYGIENE

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Maintaining levels of good personal hygiene is essential for all patients during their stay in hospital (Massa 2010). Hygiene is the science of health and its maintenance. Personal hygiene is the self-care by which people attend to such functions as bathing, toileting, general body hygiene and grooming. Hygiene is a highly personal matter determined by individual values and practices. It involves care of the skin, hair, nails, teeth, oral and nasal activities, eyes, ears, and perianal and perianal-genital areas (Berman et al. 2010).

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Treat individuals with dignity and respect. Provide information and to families and cares.

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Recognize andrespect an individual‟s spiritual and religious needs.  Provide effective pain and symptom management. Provide care after death.

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Ensure care is person centred and integrated.

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Provide a safe, comfortable environment for care.

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CARE BEFORE DEATH END-OF-LIFE CARE There is considerable ambiguity surrounding the end-of- life care, palliative care and terminal care and they are often used interchangeably but are not synonymous. PALLIATIVE CARE – is the active, total care of the patient whose disease is not responsive to curative treatment. Control of pain, of other symptoms and of social, psychological and spiritual problems is paramount. Palliative care affirms life and regards dying as a normal process: it neither hastens nor postpones death (European Association for Palliative Care 2014). END-OF-LIFE CARE (EOLC) – encomes the holistic assessment and management of physical care, pain and other symptoms which includes the provision of psychological, social, financial, spiritual and practical for both the patient and their family/cares in their place of choice, during the last year of life and includes care given after bereavement (National Council for Palliative Care 2008).

A component of palliative care has been defined as care that helps all those with advanced, progressive, incurable conditions to live as well as possible until they die. It enables the ive and palliative care needs of both patient and family to be identified and met throughout the last phase of life and into bereavement. TERMINAL CARE – care that is given during the terminal phase. This is an ill-defined period of irreversible declines that signifies imminent death. This is usually a period of several days but may be as short as a few hours; occasionally this can be as long as a couple of weeks (Maltoni and Amadori 2001). Related Theory Enabling people to die in comport and with dignity is hugely important for the patient, their families and cares and is a core function of the NHS (NEoL 2011). The End of Life Care Strategy (DH 2008) set guidance aimed at improving care and choices for all people regardless of their diagnosis and place of care. The principal aims are to improve the quality of care for those approaching the end of their life and to enable greater choices and control about their place of care and death. The strategy, which focuses on the role of health and social care, states that high-quality EOLC should be available wherever the person maybe: at home, in a care home, in hospital, in a hospice or elsewhere (DH 2008). The National End of Life Care Programme (NEoL 2010) was developed to implement the strategy.

Recognition of the dying phase – care of the dying patient starts with a recognition from the multi-professional team that the terminal phase has begun. This has been cited as perhaps the single most important factor in enabling the achievement of all the factors associated with a “good death‟ (Faull and Nyatanga 2012). It has been suggested that the following characteristics are central to a good death from medical, nursing and patient perspectives.

  













 

Control Comfort Closure







Trust in healthcare providers

 

Recognition of impending death

An honouring of personal beliefs and values (Kehl 2006)



Four basic criteria for recognizing the terminal phase are widely acknowledged. The presence of two or more of the following, commonly preceded by a progressive period of decline and where no other reversible cause is present, is said to denote the terminal phase of life.   

   

The The The The

patient patient patient patient

is is is is

unable to get out of bed. semi-comatose. only able to take sips of fluid. no longer able to take tablets.

ADVANCE DECISIONS TO REFUSE TREATMENT (ADRT) These allow people who are 18+ years to make a legal decision to refuse, in advance, a proposed treatment or the continuation of that treatment, if at the relevant time the person lacks the capacity to consent to it. ADRTs can only be made by those who are deemed to have the mental capacity to do so, and allow only for the refusal of treatments – they cannot enforce the provision of specified treatments in the same circumstances (DH 2012). Advance decisions to refuse treatment must be in writing, be signed and witnessed, and must expressly state that the decisions stands even if the person‟s life is at risk (DH 2012). They can be withdrawn verbally or in writing and are not considered valid if the person has conferred Lasting Power of Attorney on another person.

Post-procedural considerations Nursing care does not end when the death of the patient occurs; it extends beyond death to provide care for the deceased person and to their family and cares (NNCG 2011). This physical care given by nurses following death in hospitals has been traditionally referred to as “last offices” (Care after death).

7

PULSE (HEART RATE) CARE AFTER DEATH The term “last offices” only applies to the physical care of the deceased body. “Care after death” is a broader term that better reflects a multicultural society and also embraces all the differing nursing task involved, including the outgoing of the family and carers (NNCG 2011). Even though they have die, patients are still referred to as patients or people throughout this section. LEGAL AND PROFESSIONAL ISSUES Nurses should be aware of the legal requirements for care of patients after death as it is essential that correct procedures are followed (Green and Green 2006). It is particularly important that nurses are aware of deaths that require referral to the coroner as this will facilitate the correct personal care and enable nurses to prepare the family for both a potential delay in the processing of the MCCD and also the possibility of a post-mortem examination (NNCG 2011). OBSERVATION The term “observation” refers to the physical assessment of a patient, including assessment of wounds, intravenous therapy, wound drains, pain and vital signs collection and specializes assessments such as neurological observations (Zietz and McCutcheon 2006). “Vital signs” are traditionally used in the context of the collection of a cluster of physical measures, such as pulse, respiration, temperature and blood pressure, and more recently pulse oximetry. PRINCIPLES OF CARE

A person‟s pulse rate can be influenced by several factors including ae, gender, exercise, pyrexia, medications, hypovolaemia, stress, positioning, pathology, hormones and electrolytes (Field 2008, Kozier et al. 2008). Normal pulse rate per minute at various ages Age

Approximate range

1 week-3 months 3 months-2 years 2-10 years 10 years-adult

100-160 80-150 70-110 55-90

BLOOD PRESSURE Blood pressure may be defined as the force of blood inside the blood vessels against the vessel walls (Marieb and Hoehn 2010). SYSTOLIC PRESSURE – is the peak pressure of the left ventricle contracting and blood entering the aorta, causing it to stretch and therefore in part reflects the function of the left ventricle (Marieb and Hoehn 2010). DIASTOLIC PRESSURE – is when the aortic valve closes, blood flows from the aorta into the smaller vessels and the aorta recoils back. This is when the aortic pressure is at its lowest and tends to reflect the resistance of the blood vessels (Marieb and Hoehn 2010).

NORMAL BLOOD PRESSURE – Normal blood pressure ranges between 110-140 mmhg systolic and 70-80 mmhg diastolic at rest (Marieb and Hoehn 2010).

Adult patients in acute hospital setting should have:

   

Observations taken when they are itted or initially assessed (Including on transfer to a ward setting from critical care or transfer from one ward to another). A clearly documented plan which identifies which observations should be taken and how frequently subsequent observations should  be done. This plan should take into consideration: The diagnosis Plan for patient‟s treatment Any co-morbidities which may affect their health (NICE 2007a). All patients in hospital should have their observations taken at least once every 12 hours, unless specified otherwise by senior staff (NICE 2007a).

LEGAL AND PROFESSIONAL ISSUES Nurses are able and responsible fpr providing optimum care for their patients. The Nursing and Midwifery Council (NMC) The Code provides the main source of professional ability for nurses (NMC 2015). It is essential that nursing staff objectively examine the information gathered from assessments and observations, including the patient‟s baseline, as well as any information previously recorded (Crounch and Meurier 2005). Pre-procedural considerations Equipment – all practitioners need to be aware of the strengths and limitations of the devices they are using and need to have adequate training on the use of all equipment. They must ensure that the devices are validated, checked, maintained and recalibrated regularly according to the manufacturer‟s instructions (NICE

2011a).

HYPOTENSION – is generally in adults as a systolic blood pressure below 100mmhg (Marieb and Hoehn 2010). A low blood pressure may indicate orthostatic hypotension, that is, sudden drop in blood pressure when the patient rises from a supine or sitting position. HYPERTENSION – is defined as blood pressure of 140/90mmhg or greater. Factors leading to hypertension include gender, genetic factors and age, alongside risk factors such as obesity, lack of exercise, smoking and high caffeine and alcohol intake (Patton and Thibodeau 2009). Post-procedural considerations IMMEDIATE CARE – notify medical staff of an abnormal blood pressure result. As the treatment will depend on what is causing the abnormality, and its severity, it is important that practitioners try to ascertain the possible cause for the physiological change in blood pressure (Kisiel and Perkins 2006). Hypovolaemia will require fluid replacement and, if persistent, then inotropes and other cardiovascular drugs may be necessary (Hinds and Watson 2009).

ONGOING CARE – if the patient is hypertensive and in primary care, they will require at least monthly blood pressure measurement and more frequently if it is accelerated hypertension or there are any further concerns (NICE 2011a). Additionally, it will be necessary to give lifestyle advice on, for example, eating healthily and smoking cessation (NICE 2011a). If the hypotension is orthostatic then advise the patient to change position slowly so the baroreceptors and sympathetic nervous system have time to adapt the blood pressure to each stage (Marieb and Hoehn 2010).

8

RESPIRATION AND PULSE OXIMETRY The major function of the respiratory system is to supply the cells of the human body with oxygen and to remove carbon dioxide, in order that they can continue to function effectively (Tortora and Derrickson 2011). Respiration is composed of four processes:

    

PULMONARY VENTILATION – the movement of air into and out of the lungs to continually refresh the gases there, commonly called “breathing”.

PULSE OXIMETRY – is an effective method of monitoring for hypoxaemia and will immediately alert the practitioner to a fall in arterial oxygen saturation, often even before any obvious symptoms are displayed(Higginson and Jones 2009), Moore 2007). It also provides useful information about heart rate (Jevon and Ewens 2000). Pulse oximetry provides continuous and noninvasive monitoring of the oxygen saturation from haemoglobin in arterial blood (Moore 2007). METHODS OF ASSESSING RESPIRATION

TRANSPORT OF RESPIRATORY GASES – transport of oxygen from the lungs to the cells, and of carbon dioxide from the cells to the lungs, accomplished by the cardiovascular system. INTERNAL RESPIRATION – movement of oxygen from blood to the cells and of carbon dioxide  from the cells to the blood (Marieb and Hoehn 2010).

      

HYPOXIA AND HYPERCAPNIA HYPOXIA is defined as inadequate oxygen delivery to the tissues. Signs of hypoxia include tachypnea, dyspnea, tachycardia, restlessness and confusion, headache, mild hypertension and pallor; irregular breathing, cyanosis, hypotension, altered level of consciousness, blurred vision and eventual respiratory arrest (Beachery 2012). Hypoxia can have various causes, and based on this, can be classified into four types (Marieb and Hoehn 2010, Tortora and Derrickson 2011). 1.

2.

3.

4.

Hypoxaemic hypoxia – caused by a low PO2 in arterial blood as a result of breathing air with inadequate oxygen (such as at high altitude) or abnormal ventilation/perfusion matching in the lungs (due to airway obstruction or fluid in the lungs). Carbom monoxide poisoning can also cause this. Anaemic hypoxia – caused by too little functioning haemoglobin being present in the blood which reduces the transport of oxygen to the cells (such as haemorrhage or anaemia). Ischaemic hypoxia – caused when blood flow to a specific area is inadequate to supply enough oxygen, even though PO2 and Hb-O2 levels are normal (due to embolism or thrombosis). Histotoxic hypoxia – caused by the cells being unable to use the oxygen that has been delivered; this can ccur as aresult of poisons such as cyanide.

HYPERCAPNIA is an elevated level of carbon dioxide level in the blood. Signs include tacypnoea (eventually becoming bradyypnoea as it worsens), dyspnea, tachycardia, hypertension, headaches, vasodilation, drowsiness, sweating and a red colouration (Beachey 2012). Patients with hypercapnia will require urgent medical attention and close monitoring as hypercapnia will cause respiratory acidosis (Beachey 2012). Patients with chronic hypercapnia, such as those who have chronic obstructive pulmonary disease (COPD), will have at least partially adapted to the chronically high levels of carbon dioxide; oxygen therapy needs to be istered with caution in these patients as they are at risk of hypercapnic respiratory failure (O‟Driscoll et al. 2008).

       

Airway assessment Breathing assessment Skin colour Use of accessory muscles Rhythm, rate and depth of respiration Shape and expansion of the chest General condition or distress of the patient Pulse oximetry

TEMPERATURE Body temperature represents the balance between heat production and heat loss (Marieb and Hoehn 2010). If the rate of heat generated equates to the rate of heat lost, the core body temperature will be stable (Tortora and Derrickson 2011). All body tissues produce heat depending on how metabolically active they are. When the body is resting, most heat is generated by the heart, liver, brain and endocrine organs (Marieb and Hoehn 2010). HYPOTHERMIA – (lowered body temperature) is defined as a core temperature of 35˚C (Frink et al. 2012) that causes the metabolic rate to decrease (Trim 2005). Hypothermia may be classified as mild (3235˚C), moderate (28-32˚C) and severe (less than 28˚C) (Cuddy 2004). Hypothermia occurs when the body loses more heat and is subsequently unable to maintain homestasis (Neno 2005).

HYPERTHERMIA – sudden temperature elevations usually indicate infection, making it prudent to perform a directed physical examination and, if indicated, obtain appropriate cultures and institute antibiotics. Non-infectious causes of hyperthermia      

      

Alcohol withdrawal Anticholinergic drugs Allergic drug or transfusion reaction Autonomic insufficiency Crystalline arthritis (gout) Drug allergy Heat stroke

BLOOD GLUCOSE Blood glucose is the amount of glucose in the blood (Brooker 2010). Normally blood glucose levels stay within narrow limits throughout the day: 4-8 mmol/L (millimoles per litre) (NICE 2004). Normal target blood glucose ranges Children and young people <18 years of age Preprandial blood glucose Levels 4-8 mmo/L Postprandial blood glucose Levels of less than 10 mmo/L

Adults >18 years of age Preprandial blood glucose level 4-7 mmo/L Postprandial blood glucose Levels of less than 9 mmo/L

9

(BLOOD GLUCOSE Cont…)

VERBAL ORDERS

HYPERGLYCAEMIA – it is defined as a random blood glucose of more than 11.1 mmol/L (WHO/IDF 2006).

The NMC (2010a) clearly states that a verbal order is not acceptable on its own. Ín exceptional circumstances, where the medication (NOT including controlled drugs) has been previously prescribed and the prescriber is unable to issue a new prescription, but where changes to the dose are considered necessary, the use of information technology (such as fax or email) may be used but the prescriber must confirm any changes to the original prescription‟(NMC 2010a, p.28). This should be followed up by a new prescription, signed by the prescriber confirming the changes, within a maximum of 24 hours. The changes must be authorized before the new dosage is istered (NMC 2010a).

HYPOGLYCAEMIA – is described as ablood glucose level that is unable to meet the metabolic needs of the body (Marini and Wheeler 2012), normally lower than 4 mmol/L (Wallymahmed 2007). Hypoglycaemia is an acute complication of diabetes that increases morbidity, mortality and economic costs of diabetes and can decrease quality of life (Fidler et al. 2011, Liu et al. 2012). MEDICINES MANAGEMENT The Medicines and Healthcare products Regulatory Agency (MHRA 2004) defines medicines management as „the clinical, cost-effective and safe use of medicines to ensure patients get the maximum benefit from the medicines they need, while at the same time minimizing potential harm‟. All ed Nurses have a professional responsibility with regard to procurement, prescription, supply and disposal of medicines as defined in the NMC Standards for Medicines Management (NMC 2010a). They must ensure the patient understands what medicines they are taking, the indication for the medication and any likely side-effects.

MEDICINES RECONCILIATION It has been defined by the Institute for Healthcare Improvement as

„the process of creating the most accurate list possible of all medications the patient is taking-including drug name, dosage, frequency and route-and comparing that list against the physician‟s ission, transfer, and/or discharge orders, with the goal of providing correct medications to the patient at all transition points within the hospital‟ (www.ihi.org). SAFE STORAGE OF MEDICINES

EVIDENCE BASE FOR MEDICINES MANAGEMENT IN PRACTICE Good medicines management is essential to assure high standards in the clinical care of patients. When delivered effectively, it can reduce the risk of medication errors and serious adverse drug reactions and prevent unnecessary delays for the patient at the point of discharge. All aspects of a medicine‟s use must be managed with a multidisciplinary approach to ensure it is ed by a strong evidence base and that safety and well-being of the patient remain paramount (NMC 2015, Shepherd 2002a). LEGAL METHODS FOR PRESCRIBING MEDICINES The medicines Act 1968 states that only authorized healthcare practitioners can legally prescribe medicines in the UK. It provides all prescribers with a framework for which medicines require a prescription and which medicines can be available to the public without a prescription and under what circumstances. All medicines istered in hospital must be considered prescription only. This is because istration, whether by a nurse or by a patient to themselves, may only take place in accordance with one or more of the following processes:

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











 

Patient-specific direction

SECURITY All drugs should be stored in locked cupboards with separate storage for internal medicines, external medicines, controlled drugs and medicines needing refrigeration or storage in a freezer. Diagnostic reagents, intravenous and topical agents should also be kept separately in individual storage. STABILITY No medical preparation should be stored where it may be subject to substantial variations in temperature, for example not in direct sunlight. The normal temperature ranges for storage are as follows:



Patient medicines istration chart(also called a medicines istration record [MAR])  Patient Group Direction (PGD) Medicines Act exemplar

The report The Safe Secure Handling of Medicines: A Team Approach (RPSGB 2005) details that the responsibility for establishing and maintaining a system for the security of medicines should that of the senior pharmacist in the hospital. They should do this in consultation with senior nursing staff and appropriate medical staff. The appointed nurse in charge of the area will have the responsibility of ensuring that the system is followed and that the security of medicines is maintained.



COLD STORAGE – products to be stored between 2˚C and 8˚C. COOL STORAGE – products that need to be stored in a cool place or between 8˚C and 15˚C.



Standing orders



Homely remedy protocol

Prescription form (NMC 2010a, pp.13-19)



ROOM TEMPERATURE – for products that need to be stored at room temperature or not above 25˚C (MHRA 2001).

NURSE PRESCRIBING AND PATIENT GROUP DIRECTIONS

SAFE ISTRATION OF MEDICINES

As nurses have undertaken increasingly specialized roles, the need for them to have powers to prescribe has become more apparent. The report of the Advisory Committee on Nurse Prescribing (DH 1989) initially recommended a limited nurses‟ formulary for community nurses and health visitors.

All nurses who ister medicines must be familiar with and adhere to the Standards for Medicines Management (NMC 2010a). To achieve safe istration the nurse must have a sound knowledge of the therapeutic use, usual dose, side-effects, precautions and contradictions of the drug being istered. If the nurse lacks knowledge of particular medicines, she/he must not ister the medicine and must seek advice from a senior colleague.

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(Medicines Management Cont…) RECORD OF STRATION The nurse must document a clear, accurate and immediate record of all medicines istered, intentionally withheld or refused by the patient, ensuring all written entries and signatures are clear and legible (NMC 201b). If any medication is withheld or refused by a patient, the reasons must be documented. SINGLE OR DOUBLE CHECKING OF MEDICINES Medicines can be prepared and istered by a single qualified nurse or by two nurses checking (known as double checking). There are certain times when double or second checking is required. It is recommended that for the istration of controlled drugs, a secondary signature is required (NMC 2010a). The NMC Standards for Medicines Management also states that „wherever possible two registrants should check medication to be istered intravenously, one of whom should also be the registrant who the ister the intravenous medication‟ (NMC2010a, p.34).

SEVEN KEY ACTIONS TO IMPROVE MEDICATION SAFETY 1. 2. 3. 4. 5. 6.

 

7.   

Increase reporting and learning from medication incidents. Implement NPSA safer medication practice recommendations. Improve staff skills and competencies. Minimize dosing errors. Ensure medicines are not omitted. Ensure the correct medicines are given to the correct patients. Document patient‟s medicine allergy status. Consent must be given willingly. Consent must be informed. The person must have the capacity to consent to the procedure in question.

CONTROLLED DRUGS

Controlled Drugs (Supervision of Management and Use) Regulations 2006 – these regulations set out the requirements for certain NHS bodies and independent hospitals to appoint an able officer. The duties and responsibilities of the able officer are to improve the management and use of controlled drugs. These regulations also allow the periodic inspection of premises. Misuse of Drugs and Misuse of Drugs (safe Custody) (Amendment) regulations 2007 – these regulations give able officers authority to nominate persons to witness the destruction of controlled drugs within their organization. They also allow operating department practitioners to order, possess and supply controlled drugs. In addition, they set out changes to the record keeping for controlled drugs, with requirements for recording in the controlled drug the person (the patient), patient‟s representative or a healthcare professional) collecting the Schedule 2 controlled drug. If it is a healthcare professional, there is a requirement for the name and address of that person. CONSENT NHS Choices (2012) defines consent as: „the principle that a person must give their permission before they receive any type of medical treatment‟. EVIDENCE-BASED APPROACH There are different types of consent in healthcare: written, verbal (explicit) and non-verbal (implied or implicit) (DH 2009b). The Department of Health (DH 2009b) and professional bodies including the Nursing and Midwifery Council (NMC) and General Medical Council (GMC) have produced comprehensive guidance about consent (GMC 2008, NMC 2013). The DH guidance (DH 2009) includes information about what consent is, by whom and in what circumstances. PRINCIPLE OF CARE

Controlled drugs are those drugs that are listed in Schedule 2 of the Misuse of Drugs Act 1971 and are subject to the controls stipulated in the Act, for example diamorphine, morphine, amphetamines, benzodiazepines, The use of controlled drugs in medicine is permitted by the Misuse of Drugs Regulations and related regulations.

Unless it is emergency, the gaining of consent should be treated as a process rather than a one-off event (DH 2009b). For major operations, it should be considered good practice to gain a person‟s consent to the proposed procedure well in advance ideally prior to pre-assessment when there is time to respond to the person‟s questions and provide adequate information so that the person has time to develop an understanding to allow an informed decision to be made (Hughes 2011).

LEGISLATION

LEGAL AND PROFESSIONAL ISSUES

Medicines Act 1968 – The Act and the regulations made under the Act set out the requirements for the legal sale, supply and istration of medicines.

It is accepted that when a patient gives valid consent, this is valid indefinitely unless withdrawn by the patient; therefore no specific time limit is designated from signature to procedure (Hughes 2011).

Misuse of Drugs Act 1971 – for reasons of public safety, the Misuse of Drugs Act controls the export, import, supply and possession of dangerous or otherwise harmful drugs to prevent abuse as most are potentially addictive or habit forming as well as harmful.

For consent to be valid, it must encom several factors.

Misuse of Drugs (safe Custody) Regulations 1973 – these regulations control the storage of controlled drugs. The level of control of storage depends on the premises in which they are being stored and the schedule of the drug. Misuse of Drugs Regulations 2001 – under these regulations controlled drugs are classified into five schedules, each representing a different level of control.

 

  

Consent must be given willingly. Consent must be informed. The person must have the capacity to consent to the procedure in question.

All healthcare professionals should be aware of the different types of consent and the importance of ensuring that the person understands what is going to happen to them and what is involved. Healthcare professionals should also be familiar with their local hospital consent policy and be aware of and understand what to do if people refuse care or treatment or when consent is not valid or is no longer valid.

11

Q&A Q. You are a ed nurse in a community giving health education to a patient and you notice that the student nurse is using his cell phone to text, what should you do? A.

Politely signal the student and encourage him by actively including him in the discussion.

Q. A nurse is having trouble with doing care plans. Her team are already noticing this problem and are worried of the consequences this may bring to the quality of nursing care delivered. The problem is already brought to the attention of the nurse. The nurse should: A.

Q. What would make you suspect that a patient in your care had a urinary tract infection? A.

The patient has spiked a temperature, has a raised white cell count (WCC), has new-onset confusion and the urine in his catheter bag is cloudy.

Q. What steps would you take if you had sustained a needle stick injury? A.

Accept her weakness and take this challenge as an opportunity to improve her skills by requesting lectures from her manager.

Gently make the wound bleed, place under running water and wash thoroughly with soap and water. Complete an incident form and inform your manager. Co-operate with any action to test yourself or the patient for infection with a blood borne virus but do not obtain blood or consent for testing from the patient yourself; this should be done by someone not involved in the incident.

Q. If you were told by a nurse at handover to take „standard

Q. Why is it essential to humidify oxygen used during respiratory therapy? A.

Oxygen is a dry gas which can cause evaporation of water from the respiratory tract and lead to thickened mucus in the airways, reduction of the movement of cilia and increased susceptibility to respiratory infection.

Q. When using nasal cannulae, the maximum oxygen flow rate that should be used is 6 litres/min. Why? A.

Observe the patient‟s breathing for ease and comfort, rate and pattern.

Q. Why should healthcare professionals take extra care when washing and drying an elderly patient‟s skin? A.

A.

what

would

you

expect

to

be

doing?

Using appropriate hand hygiene, wearing gloves and aprons when necessary, disposing of used sharp instruments safely and providing care in a suitably clean environment to protect yourself and the patients.

Q. You believe that an adult you know and has been a victim of physical abuse that might be considered a criminal offence. What

should you do to the police in an investigation? A.

Higher rates can cause nasal mucosal drying and may lead to epistaxis.

Q. What should be included in your initial assessment of your patient‟s respiratory status? A.

precautions‟

Make an accurate record of what the person has said to you.

Q. A young mother who delivered 48hrs ago comes back to the emergency department with post partum haemorrhage. What type of PPH is it? A.

Secondary post partum haemorrhage.

Q. What do you mean by MRSA? A.

Methicillin-resistant staphyloccocus aureus

As the skin of an elder person has reduced blood supply, is thinner, less elastic and has less natural oil. This means the skin is less resistant to shearing forces and wound healing can be delayed.

Q. Who will you inform first if there is a shortage in supplies in your shift?

Q. What is the best way to prevent a patient who is receiving an enteral feed from aspirating?

Q. You are to take charge of the next shift of nurses. Few minutes before your shift, the in charge of the current shift informed you that two of your nurses will be absent. Since there is a shortage of staff in your shift, what will you do?

A.

Sit them at least at a 45° angle.

A.

A. Q. What specifically do you need to monitor to avoid complications and ensure optimal nutritional status in patients being enterally fed?

A.

Blood glucose levels, full blood count, stoma site and bodyweight.

Q. What factors are essential in demonstrating ive communication to patients? A.

Listening, clarifying the concerns and feelings of the patient using open questions.

Q. NMC requires in the UK how many units of continuing education units a nurse should have in 3 years? A.

35 units

Immediate nurse manager

Ask from your manager if there are qualified staff from the previous shift that can cover the lacking number for your shift while you try to replace new nurses to cover.

Q. As you visit your patient during rounds, you notice a thin child who is shy and not mingling with the group who seemed to be visitors of the patient. You offered him food but his mother told you not to mind him as he is not eating much while all of them are eating during that time. As a nurse, what will you do? A.

Raise the situation to your head nurse and discuss with her what intervention might be done to help the child.

Q. What could be the reason why you instruct your patient to retain on its original container and discard nitroglycerine meds after 8

weeks? A.

Removing from its darkened container exposes the medicine to the light and its potency will decrease after 8 weeks.

12

Q. Who is responsible in disposing sharps? A.

Whoever used the sharps.

Q. Where will you put infectious linen? A.

Red plastic bag designed to disintegrate when exposed to heat.

Q. What does AVPU mean? A.

Alert voice pain unresponsive.

Q. When will you consider giving out information of the patient to a police officer? A.

If safety of the public is at risk.

Q. For an average person from Uk who has non-insulin dependent diabetes, how many servings of fruits and vegetables per day should they take? A.

Q. The degree of injection when giving subcutaneous insulin injection on a site where you can grasp 1 inch of tissue? A.

45 degrees

Q. What is the best position in applying eye medications? A.

Sitting position with head tilt backwards

Q. The worst advice you can give a student nurse with regards to the use of social networking sites like Facebook? A.

Do not identify yourself as a nurse; Rely on the sites privacy settings

Q. Which bag do you place infected linen? A.

Water-soluble alginate polythene bag before being placed in the appropriate linen bag, no more than ¾ full.

Q. In the News observation system, what is AVUP? A.

Assessment for the level of consciousness.

5 servings Q. Normal heart rate for 1 to 2 years old?

Q. A relative of the patient was experiencing vomiting and diarrhea and wished to visit her mother who was itted. As a nurse, what

A.

80 - 110 beats per minute

13

will you advise to the patient's relative? A.

There should be 48 hours after active symptoms should disappear prior to visiting patient.

Q. What advice do you need to give to a patient taking Allopurinol?

A.

Q. As a nurse, what health teachings will you give to a COPD patient? A.

Encourage to stop smoking; ister oxygen inhalation as prescribed; Enroll in a pulmonary rehabilitation programme.

Q. In a community hospital, an elderly man approaches you and tells you that his neighbour has been stealing his money, saying "sometimes I give him money to buy groceries but he didn't buy groceries and he kept the money" what is your best course of action

for this? A.

Raise a safeguarding alert

Q. Safeguarding is the responsibility of: A.

A.

Self-induced vomiting and she likely has bulimia nervosa

Q. Patients with gastric ulcers typically exhibit this symptom: A.

Epigastric pains worsens after eating and weight loss

Health care assistants; ed nurses; Doctors

Q. Hypoglycaemia in patients with diabetes is more likely to occur when the patients take: A.

Insulin; Sulphonylureas; Prandial glucose regulators

Q. Enteral feeding patient checks patency of tube placement by: A.

Q. On physical examination of a 16 year old female patient, you notice partial erosion of her tooth enamel and callus formation on the posterior aspect of the knuckles of her hand. This is indicative of:

Drink 8 to 10 full glasses of fluid every day, unless your doctor tells you otherwise; Store allopurinol at room temperature away from moisture and heat; Avoid being near people who are sick or have infections

Aspirating gastric juice and then checking for ph <4 X-ray

Q. A doctor prescribes an injection of 200 micrograms of drug. The stock bottle contains 1mg/ml. How many ml will you ister? A.

0.2 ml

Q. The doctor prescribes 25mg of a drug to be given by injection. It is a drug dispensed in a solution of strength 50mg/ml. How many ml should you ister? A.

0.5 ml – Dose Prescribed: Dose /ml - 25:50=0.5

Q. Commonly aneurysms can develop on? A.

Abdominal aorta; Circle of Willis

Q. A patient suffered from stroke and is unable to read and write. This is called: A.

Dysphasia

Q. The doctor prescribes a dose of 9 mg of an anticoagulant for a patient being treated for thrombosis. The drug is being supplied in 3mg tablets. How many tablets should you ister? A.

3 tablets

Q. Patient has next dose of Digoxin but has a CR=58 A.

Q. A patient is assessed as lacking capacity to give consent if they are unable to:

Omit dose, record why, and inform the doctor

Q. Patient is post op liver biopsy which is a sign of serious complication A.

Nausea and vomiting; Bleeding

Q. A suicidal Patient is itted to psychiatric facility for 3 days when suddenly he is showing signs of cheerfulness and motivation.

The nurse should see this as: A.

That she has finalize suicide plan.

Call the doctor; Consider this as an emergency and prioritize abc

Q. What position should you prepare the patient in preop for abdominal Paracentesis? A.

Understand information about the decision and that information; Use that information to make a decision; Communicate their decision by talking, using sign language or by any other means

Q. Hospital discharge planning for a patient should start: A.

On the ission assessment

Q. Recommended preoperative fasting times are:

Q. You are monitoring a patient in the ICU when suddenly his consciousness drops and the size of one his pupil becomes smaller what should you do? A.

A.

Supine with head of bed elevated to 40-50cm

A.

6-12 hours

Q. The following are signs of a speed shock: A.

Flushed face; Headache and dizziness; Tachycardia and fall in blood pressure

Q. Comion in Practice – the culture of comionate care encomes: A.

Care, Comion, Competence, Courage, Commitment

Communication,

Q. Wound proliferation starts after? A.

Q. In a patient with hourly monitoring, when does a nurse formally document the monitoring?

3-24 days

Q. What do you expect to manifest with fluid volume deficit? A.

A.

High Pulse, low BP

Q. You can delegate medication istration to a student if: A.

Q. Patient usually urinates at night Nurse identifies this as: A.

Nocturia

A.

Vaginal bleeding; Positive pregnancy test; Shoulder tip pain

Q. What medications would most likely increase the risk for fall? A.

Only if a patient has the mental capacity to give consent.

Hypnotics Q. Adequate record keeping for a medical device should provide evidence of:

Increasing blood flow velocity in the compression of the deep venous system.

legs

by

A.

Q. An overall risk of malnutrition of 2 or higher signifies: A.

Evaluation

Q. When do you gain consent from a patient and consider it valid? A.

Q. In DVT TEDS stockings affect circulation by: A.

Only under close, direct supervision

Q. At what stage of the nursing process does the revision of the care plan occur?

Q. The signs and symptoms of ectopic pregnancy: A.

Every hour

High risk of malnutrition

A unique identifier for the device, where appropriate; A full history, including date of purchase and where appropriate when it was put into use, deployed or installed; Any specific legal requirements and whether these have been met; Proper installation and where it was deployed; Schedule and details of maintenance and repairs; The end-of-life date, if specified

Q. It is unsafe for a spinal tap to be undertaken if the patient: Q. What is the purpose of The Code? A.

It is a tool for educating prospective nurses and midwives.

A.

Has bacterial meningitis; Papilloedema; Intracranial mass is suspected; Site skin infection

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