The eight Principles

The Principles of Nursing Practice tell us what all people can expect from nursing practice, whether they are colleagues, patients,
or the families or carers of patients.

Nursing is provided by nursing staff, including ward managers (in hospitals) or team members (in the community), specialist nurses,
community nurses, health visitors, health care assistants or student nurses.

To put it simply, the Principles of Nursing Practice describe what everyone can expect from nursing.

Principle A

Nurses and nursing staff treat everyone in their care with dignity and humanity they understand their individual needs, show
compassion and sensitivity, and provide care in a way that respects all people equally.

Principle B

Nurses and nursing staff take responsibility for the care they provide and answer for their own judgments and actions they carry
out these actions in a way that is agreed with their patients, and the families and carers of their patients, and in a way that meets
the requirements of their professional bodies and the law.

Principle C

Nurses and nursing staff manage risk, are vigilant about risk, and help to keep everyone safe in the places they receive health
care.

Principle D

Nurses and nursing staff provide and promote care that puts people at the centre, involves patients, service users, their families
and their carers in decisions and helps them make informed choices about their treatment and care.

Principle E

Nurses and nursing staff are at the heart of the communication process: they assess, record and report on treatment and care,
handle information sensitively and confidentially, deal with complaints effectively, and are conscientious in reporting the things they
are concerned about.

Principle F

Nurses and nursing staff have up-to-date knowledge and skills, and use these with intelligence, insight and understanding in line
with the needs of each individual in their care.

Principle G

Nurses and nursing staff work closely with their own team and with other professionals, making sure patients care and treatment is
co-ordinated, is of a high standard and has the best possible outcome.

Principle H

Nurses and nursing staff lead by example, develop themselves and other staff, and influence the way care is given in a manner that
is open and responds to individual needs.

Pages for each of the Principles pointing to activities and resources to support their use can be accessed from the left hand menu
of this resource. These will be updated to reflect new developments as they occur.
 The Human Rights Act

The Human Rights Act 1998 (also known as the Act or the HRA) came into force in the United Kingdom in October 2000. It is
composed of a series of sections that have the effect of codifying the protections in the European Convention on Human Rights into
UK law.

All public bodies (such as courts, police, local governments, hospitals, publicly funded schools, and others) and other bodies
carrying out public functions have to comply with the Convention rights.

This means, among other things, that individuals can take human rights cases in domestic courts; they no longer have to go to
Strasbourg to argue their case in the European Court of Human Rights.

The Act sets out the fundamental rights and freedoms that individuals in the UK have access to. They include:

Right to life

Freedom from torture and inhuman or degrading treatment

Right to liberty and security

Freedom from slavery and forced labour

Right to a fair trial

No punishment without law

Respect for your private and family life, home and correspondence

Freedom of thought, belief and religion

Freedom of expression

Freedom of assembly and association

Right to marry and start a family

Protection from discrimination in respect of these rights and freedoms

Right to peaceful enjoyment of your property

Right to education

Right to participate in free elections

Further information

Download a full copy of the Act: Human Rights Act 1998.

 For more information on where your human rights are set out, who the Human Rights Act applies to, and if human rights can be
restricted, see How do human rights work?

The Ministry of Justice has produced a guide to the Act and an Easy-Read booklet explaining what the Act means. Below are links
to these resources as well as copies of the Human Rights Act in other languages:

Human Rights Act - a guide

Human Rights Act (pdf, 56K)

A Guide to the Human Rights Act: a booklet for people with learning disabilities (pdf, 351K)

Human Rights Act - Arabic (pdf, 290K)

Human Rights Act - Cantonese (pdf, 364K)

Human Rights Act - French (pdf, 125K)

Human Rights Act - Gujarati (pdf, 324K)

Human Rights Act - Polish (pdf, 269K)

Human Rights Act - Punjabi (pdf, 335K)

Human Rights Act - Somali (pdf, 120K)

Human Rights Act - Tamil (pdf, 136K)

Human Rights Act - Urdu (pdf, 623K)

Human Rights Act - Welsh (pdf, 183K)

Help with pdf files

Legal and Ethics Guidance

The role of the advanced nurse practitioner is a very welcome and dynamic development that assists in the delivery of quality
patient centred care. There are, however, challenges in establishing these roles. In particular, many advanced practitioners
struggle with the legal and ethical issues associated with their role often perceiving that they are more susceptible to legal action
than other nurses because of their increased autonomy and the extended or expanded range of activities they are undertaking.
There are, however, no distinctions between advanced nurse practitioners and other nurses in the Nursing and Midwifery Council
(NMC) Code of Conduct, Performance and Ethics (NMC, 2008). Advanced nurse practitioners therefore need to be familiar with
the NMC Code and the expectation that they take responsibility and are accountable for their own actions and recognise and act
within the limits of their competence and the boundaries of their own practice. This section aims to raise awareness of the
responsibilities and accountability of the advanced nurse in meeting their ethical and legal obligations.

A wide variety of evidence has been gathered from a range of sources including; acts of parliament, key legal court actions, and
publications from regulatory bodies together with leading texts relating to legal, professional and healthcare issues and advanced
practice. The evidence arising from seminal legal actions over the past 50 years refer to the main practitioner responsible for
 patient care at the centre of the legal action, in many instances a doctor. As such the judgements handed down by the court refer to
the practice of the doctor. It should be noted that the principles of many of these leading court actions continue to have relevance
today and have implications for advanced nurse practitioners.

What is Ethics?

Ethics (sometimes called morals or moral philosopy) is concerned with fundamental principles of right and wrong and what people
ought to do. Ethics inform our judgements and values and help individuals decide on how to act. Guidance on acting ethically is
informed by accepted ethical theories, principles and frameworks.

In everyday practice advanced practitioners are expected to make judgements about what is best for a particular individual. Ethical
theories and principles provide the evidence base to support decision making. Ethics is a vast subject area and only a very brief
summary is presented here with links to supportive resources to help Advanced Practitioners further their understanding of ethics
and the application to their practice.

What is Law?

Law is a system of rules that govern a society with the intention of maintaining social order, upholding justice and preventing harm
to individuals and property. Law systems are often based on ethical or religious principles and are enforced by the police and
criminal justice systems such as the courts. In the UK, two major categories of law apply, criminal and civil law. Healthcare is
governed by legislation intended to protect the public and prevent harm and advanced practitioners require a knowledge of relevant
legislation and their responsibilities to the public and their employer. This section provides a brief overview of the UK legal
system, criminal and civil law and links to additional resources.

Accountability
All nurses and midwives including advanced practitioners hold four main areas of accountability to:
their profession
their employer
society via the laws of the land either criminal or civil
the individual and public in general via their duty of care

Consent
The principle of consent is one of the cornerstones of medical ethics (the principle of autonomy upholds the right of the individual to
make their own decisions). Consent is also enshrined in international human rights law. It is a complex issue with the law offering a
considerable amount of information and guidance on the subject. The following section attempts to demystify this topic by:
Defining Consent
Establishing the requirements for informed consent
Establishing capacity to refuse treatment
Reflecting on the implications for the advanced nurse practitioner

Documentation and Record Keeping

The Nursing and Midwifery Council (2009) highlight good record keeping as an integral part of practice and essential to the
provision of safe and effective care. They acknowledge that good record keeping has a range of important functions including,
improving communication between healthcare professionals, supporting delivery and continuity of patient care, demonstrating
clinical judgements and decision making and identifying risk for patients. See NMC guidance on record keeping for more
information.

Patient health records also have a function in improving accountability and in so doing have a legal purpose in providing evidence
of the practitioners' involvement or interventions in relation to patients or clients. The following information is applicable to all nurses
and midwives with some aspects having particular relevance to the advanced practitioner.
 A model of care for cultural competence

The term culturally competent care refers to nursing care that is sensitive to issues regarding culture, race, gender, and sexual
orientation. Cultural competence is a process in which the nurse strives to achieve the ability to effectively work within the cultural
context of an individual, family, or community from a diverse cultural/ethnic background. Campinha-Bacote proposes a culturally
competent model of care that includes cultural awareness, cultural knowledge, cultural skill, and cultural encounters. The
components of this model are:

Cultural awareness
Cultural knowledge
Cultural skill
Cultural encounter
Cultural awareness is the process by which the nurse becomes aware of, appreciates, and becomes sensitive to the values,
beliefs, life ways, practices, and problem-solving strategies of other cultures. During this process, you examine your own biases
and prejudices toward other cultures as well as explore your own cultural background. Without becoming aware of the influence of
ones own cultural values, we have a tendency to impose our own beliefs, values, and patterns of behavior on other cultures. The
goal of cultural awareness is to help you become aware of how your background and your patients background differ.

Cultural knowledge is the process by which you seek out and obtain education about various worldviews of different cultures. The
goal of cultural knowledge is to become familiar with culturally/ethnically diverse groups, worldviews, beliefs, practices, lifestyles,
and problem-solving strategies. Some of the ways you can acquire knowledge are by reading about different cultures, attending
continuing education courses on cultural competence, and attending cultural diversity conferences. The next step, cultural skill,
involves learning how to do a competent cultural assessment. Nurses who have achieved cultural skill can individually assess each
patients unique cultural values, beliefs, and practices without depending solely on written facts about specific cultural groups. It is
extremely important to remember that each patient you care for, whether born and raised in the United States or not, is a member
of a specific cultural group that affects his or her health care beliefs. Therefore, cultural assessments should not be limited to
specific ethnic groups, but conducted with each individual patient. Cultural encounter involves participating in cross-cultural
interactions with people from culturally diverse backgrounds. Cultural encounter may include attending religious services or
ceremonies and participating in important family events. However, it is important to remember that although we may have several
friends of different cultural groups, we are not necessarily knowledgeable about the group as a whole. In fact, the values, beliefs,
and practices of the few people we encounter on a social basis may not represent that specific cultural group which you provide
nursing care for. Therefore, its important to have as many cultural encounters as possible to avoid cultural stereotyping. Below are
some cultural professional resources for nurses.

Transcultural Nursing Society

Journal of Cultural Diversity
Madeleine Leininger, who has done pioneering work in the influence of culture on health care, suggests two guiding principles that
nurses can use in caring for patients from many diverse cultures. The first is to maintain a broad, objective, and open attitude about
each patient. The second is to avoid seeing all patients alike. By following these principles, we can open ourselves to learning
about the way others view health and illness and form relationships that are therapeutic.

Confidentiality
The code: Standards of conduct, performance and ethics for nurses and midwives (2008) states:
"You must respect people's right to confidentiality."
"You must ensure people are informed about how and why information is shared by those who will be providing their care."
"You must disclose information if you believe someone may be at risk of harm, in line with the law of the country in which you are
practising."
Confidentiality
A duty of confidence arises when one person discloses information to another in circumstances where it is reasonable to expect
that the information will be held in confidence. This duty of confidence is derived from:
common law the decisions of the Courts
statute law which is passed by Parliament.
Confidentiality is a fundamental part of professional practice that protects human rights. This is identified in Article 8 (Right to
respect for private and family life) of the European Convention of Human Rights which states:
1: Everyone has the right to respect for his private and family life, his home and his correspondence.
2: There shall be no interference by a public authority with the exercise of this right except such as is in accordance with the law
and is necessary in a democratic society in the interests of national security, public safety or the economic well-being of the country,
for the prevention of disorder or crime, for the protection of health or morals, or for the protection of the rights and freedoms of
others.
The common law of confidentiality reflects that people have a right to expect that information given to a nurse or midwife is only
used for the purpose for which it was given and will not be disclosed without permission. This covers situations where information is
disclosed directly to the nurse or midwife and also to information that the nurse or midwife obtains from others. One aspect of
privacy is that individuals have the right to control access to their own personal health information.
It is not acceptable for nurses and midwives to:
discuss matters related to the people in their care outside the clinical setting
discuss a case with colleagues in public where they may be overheard
leave records unattended where they may be read by unauthorised persons.
Legislation
All nurses and midwives need to be aware of the following pieces of legislation relating to confidentiality:

The Data Protection Act 1998

This Act governs the processing of information that identifies living individuals. Processing includes holding, obtaining, recording,
using and disclosing of information and the Act applies to all forms of media, including paper and electronic.

The Human Fertilisation and Embryology Act 1990

Regulates the provision of new reproductive technology services and places a statutory ban upon the disclosure of information
concerning gamete donors and people receiving treatment under the Act. Unauthorised disclosure of such information by
healthcare professionals and others has been made a criminal offence.
The National Health Service Venereal Disease Regulations (SI 1974 No.29)
This states that health authorities should take all necessary steps to ensure that identifiable information relating to persons being
treated for sexually transmitted diseases should not be disclosed.

The Mental Capacity Act (2005)

This provides a legal framework to empower and protect people who may lack capacity to make some decisions for themselves.
The assessor of an individuals capacity to make a decision will usually be the person who is directly concerned with the individual
at the time the decision needs to be made this means that different health and social care workers will be involved in different
capacity decisions at different times.

The Freedom of Information Act 2000 and Freedom of Information (Scotland) Act 2002
These Acts grant people rights of access to information that is not covered by the Data Protection Act 1998, e.g. information which
does not contain a persons identifiable details.

The Computer Misuse Act 1990

This Act secures computer programmes and data against unauthorised access or alteration. Authorised users have permission to
use certain programmes and data. If the users go beyond what is permitted, this is a criminal offence.

Disclosure
Disclosure means the giving of information. Disclosure is only lawful and ethical if the individual has given consent to the
information being passed on. Such consent must be freely and fully given. Consent to disclosure of confidential information may be:
explicit
implied
required by law or
capable of justification by reason of the public interest
Disclosure with consent
Explicit consent is obtained when the person in the care of a nurse or midwife agrees to disclosure having been informed of the
reason for that disclosure and with whom the information may or will be shared. Explicit consent can be written or spoken. Implied
consent is obtained when it is assumed that the person in the care of a nurse or midwife understands that their information may be
shared within the healthcare team. Nurses and midwives should make the people in their care aware of this routine sharing of
information, and clearly record any objections.

Disclosure without consent

The term public interest describes the exceptional circumstances that justify overruling the right of an individual to confidentiality in
order to serve a broader social concern. Under common law, staff are permitted to disclose personal information in order to prevent
and support detection, investigation and punishment of serious crime and/or to prevent abuse or serious harm to others. Each case
must be judged on its merits. Examples could include disclosing information in relation to crimes against the person e.g. rape, child
abuse, murder, kidnapping, or as a result of injuries sustained from knife or gun shot wounds. These decisions are complex and
must take account of both the public interest in ensuring confidentiality against the public interest in disclosure. Disclosures should
be proportionate and limited to relevant details.
Nurses and midwives should be aware that it may be necessary to justify disclosures to the courts or to the Nursing & Midwifery
Council and must keep a clear record of the decision making process and advice sought. Courts tend to require disclosure in the
public interest where the information concerns misconduct, illegality and gross immorality.
Disclosure to third parties
This is where information is shared with other people and/or organisations not directly involved in a persons care. Nurses and
midwives must ensure that the people in their care are aware that information about them may be disclosed to third parties involved
in their care. People in the care of a nurse or midwife generally have a right to object to the use and disclosure of confidential
information. They need to be made aware of this right and understand its implications. Information that can identify individual
people in the care of a nurse or midwife must not be used or disclosed for purposes other than healthcare without the individuals
explicit consent, some other legal basis, or where there is a wider public interest.

Information Sharing Protocols

These are documented rules and procedures for the disclosure and use of patient information between two or more organisations
or agencies, in relation to security, confidentiality and data destruction. All organisations should have these in place and nurses and
midwives should follow any established information sharing protocols.

Confidentiality after death

The duty of confidentiality does continue after death of an individual to whom that duty is owed.

Information disclosure to the police

In English law there is no obligation placed upon any citizen to answer questions put to them by the police. However, there are
some exceptional situations in which disclosure is required by statute. These include:
the duty to report notifiable diseases in accordance with the Public Health Act 1984
the duty to inform the Police, when asked, of the name and address of drivers who are allegedly guilty of an offence contrary to the
Road Traffic Act 1998
the duty not to withhold information relating to the commission of acts of terrorism contrary to the Terrorism Act 2000
the duty to report relevant infectious diseases in accordance with the Public Health (Infectious Diseases) Regulations 1998.
Police access to medical records
The police have no automatic right to demand access to a persons medical records. Usually, before the police may examine a
persons records they must obtain a warrant under the Police and Criminal Evidence Act 1984. Before a police constable can gain
access to a hospital, for example, in order to search for information such as medical records or samples of human tissue, he or she
must apply to a circuit judge for a warrant. The police have no duty to inform the person whose confidential information is sought,
but must inform the person holding that information.
The Police and Criminal Evidence Act (1984)
This Act allows nurses and midwives to pass on information to the police if they believe that someone may be seriously harmed or
death may occur if the police are not informed. Before any disclosure is made nurses and midwives should always discuss the
matter fully with other professional colleagues and, if appropriate consult the NMC or their professional body or trade union. It is
important that nurses and midwives are aware of their organisational policies and how to implement them. Wherever possible the
issue of disclosure should be discussed with the individual concerned and consent sought. If disclosure takes place without the
persons consent they should be told of the decision to disclose and a clear record of the discussion and decision should be made
as stated above.

Special considerations to be taken into account when disclosure is being considered

In some circumstances it may not be appropriate to inform the person of the decision to disclose, for example, due to the threat of a
violent response. The nurse or midwife may feel that, because of specific concerns, a supplementary record is required containing
details of the disclosure. The Data Protection Act 1998 does allow for healthcare professionals to restrict access to information they
hold on a person in their care, if that information is likely to cause serious harm to the individual or another person. A
supplementary record should only be made in exceptional circumstances as it limits the access of the person in the care of the
nurse or midwife to information held about them. All members of the health care team should be aware that there is a
supplementary record and this should not compromise the persons confidentiality.

Nurse or midwife acting as a witness in a court case

If a nurse or midwife is summoned as a witness in a court case he/she must give evidence. There is no special rule to entitle the
nurse or midwife to refuse to testify. If a nurse or midwife refuses to disclose any information in response to any question put to
him/her, then a judge may find the nurse or midwife in contempt of court and may ultimately send him/her to prison.

Risk or breach of confidentiality

If a nurse or midwife identifies a risk or breach of confidentiality they must raise their concerns with someone in authority if they are
unable to take affirmative action to correct the problem and record that they have done so. A risk or breach of confidentiality may be
due to individual behaviour or as a result of organisational systems or procedures. The Code states You must act without delay if
you believe that you, a colleague or anyone else may be putting someone at risk. Nurses and midwives have a professional duty
to take action to ensure the people in their care are protected and failure to take such action could amount to professional
misconduct on their part.
This information was updated May 2012.
Patient Centricity
The media is full of reports about our aging population and the associated increase in disease prevalence as well as the spread of
unhealthy lifestyles. These and other factors are resulting in spiralling costs of healthcare. Those in charge of health systems are
looking for solutions in a more patient-centred approach and are making patient outcomes the priority. Today there is greater focus
on patient empowerment & shared decision-making (the active patient) and on tackling health inequalities.

Patient centricity is officially defined as the process of designing a service or solution around the patient. Stemming from the UKs
NHS-driven thinking like no decision about me, without me, the idea seems easy to grasp, but as an aim for pharma companies it
is all too often overlooked despite the fact that companies often express their desire to be patient centric organizations; e.g.
inspired by patients, driven by science (UCB); science and patientsthe heart of everything we do (AstraZeneca); or being a
global integrated healthcare leader focused on patients needs (Sanofi).

A lot of people are under the false impression that to be patient centric you have to [spend] every minute of every day thinking
about patients, said Lode Dewulf, Chief Patient Affairs Officer, UCB. The truth is were trying to find value points in a process
whether its writing a protocol, whether its designing a marketing campaign where you really should get patient insight, input, and
connection.

A pharma organization should therefore become a listening ear, engaged in a dialogue with patients. [When you get to the point]
when you cant do anything without getting a discussion with patients, thats when youve embraced the concept, for example, you
cant write a protocol without getting patients input. When you listen to what they think, and take away the core messages, thats
when youve made great progress, Dewulf added.

---------------------------------------------

The literal interpretation of stomatitus is a swelling of the mouth. This includes the cheeks, gums, tongue and lips as well as the
roof of your mouth. There might be small amounts of bleeding, swelling and a red colour to the affected areas.

Types of Stomatitis

-Viral. The stomatitis is caused by some form of virus within the body. Typical cases include glandular fever, herpes and
hand/foot/mouth disease.
-Bacterial. This is an uncommon form but might occur if you already have a sore throat or through disease such as syphilis.
-Fungal. This can occur if you have a very low immune system or other health problems which might require a high use of
antibiotics.
Non infective. The most common reason for stomatitis is recurring mouth ulcers. It is normally unknown as to why these occur but
they normally go within 2 weeks. Stomatitis could also be due to problems within the digestive system, often being a problem with
people who have Crohns disease or colic. Some vitamin deficiencies can cause stomatitis, the main problems being a lack of
riboflavin, miacin and B12.

Causes for Stomatitis

-Bad oral hygiene

-Badly fitting fixtures such as dentures or braces
-Burning due to hot food or drink
-Medical problems such as leukemia or Chrohns disease

Stomatitis Treatment

You need to get to the source of the problem before you can effectively manage and treat stomatitis. Being sensible about the
foods you eat can help. For example it is best to avoid crunchy or sharp foods. Also increasing the amount of oral hygiene can
help to clear up cases where this might be a part of the problem. Use a soft toothbrush and brush your teeth gently. If you wear
braces or dentures then you ought to get the fit checked by your dentist to ensure they arent the problem. Your dentist can
replace these so that they fit, or smooth teeth that are sharp which could also cause a similar response. Minor burns and mouth
ulcers sort themselves out within one or two weeks. For other forms of stomatitis that is there due to illness or infection it will have
to be treated with medication and you ought to seek medical help.

---------------------------------------------------------------

The Waterlow Score

For Hospital Community, Nursing & Residential Home Use

The Waterlow pressure ulcer risk assessment/prevention policy tool is, by far, the most frequently used system in the U.K. and it
is also the most easily understood and used by nurses dealing directly with patient/clients.

Intended for use by nurses, healthcare professionals and carers at the patient/client interface.

It must be remembered that "Waterlow", like all risk assessment scoring systems is a simplistic tool.

Professional judgement must be used in determining the risk status of the patient/client.

All assessments and, just as importantly, reassessments must be documented and the plan of care adjusted as necessary.

The Waterlow Manual provides comprehensive guidance on the use of the Waterlow scoring system.

One side illustrates the risk assessment scoring system. The reverse side provides guidance on nursing care, types of
preventative aids associated with the three levels of risk status, wound assessment and dressings.

When the Waterlow card is being used in the Community or in the Nursing and Residential homes it is vital to recognise that this
environment is markedly different from the one in which the scoring system was developed.

The risk factors are still the same, but can be alleviated by the client having for example:

A) A good quality mattress, duvet for his/her bed.

B) A good quality armchair to sit out in.
C) A caring relative or friend who keeps a constant eye on them and provides good nutritious meals, for example.

These factors raise the risk threshold so that if a person is discharged from Hospital with a stated Waterlow score this score
must be reviewed in the light of the changed circumstances to determine the requirements of the clients.

By working in this manner and using the same assessment system in all areas of care, the patient can receive seamless care as
they move to and fro between Hospital, nursing/residential homes, or their own home.

Applicability

The Waterlow card is applicable to all areas of care, from A&E to Residential Nursing Homes.

It is however a simplistic tool, and it is the responsibility of assessors to use the risk assessment system and the advice on the
selection of preventative aids, in conjunction with their own expertise and their own area of cares specific constraints.
A pressure ulcer is an area of localised damage to the skin and underlying tissue caused by pressure, shear, friction or a
combination of these (EPUAP 1998).

They are most likely to occur when a hard bony area covered by a thin layer of tissue is in contact with a hard surface, such as a
bed, trolley, theatre table, wheelchair etc.

The body can withstand high interface pressures for a very short period of time.

It is when the pressure is not regularly relieved that damage occurs and a pressure ulcer develops.

Elderly patiants, those with a long term medical illness / disease / condition are particularly vulnerable because their skin
usually becomes thinner and more fragile with age. Pressure sores can develop in a matter of hours.

Decubitus ulcers can happen during hospitalization, in a nursing home or in a community setting.

Remember: Unrelieved pressure on a specific area of the body (eg the heels , the hips) will affect the blood supply to the skin
and underlying tissues causing that area to become damaged.

Mild tissue damage results in skin discolouration, giving a brown or purple appearance. This may look darker if the skin is very
fair.

More severe pressure ulcers can expose muscle and even bone. The area around the dead tissue will look red and inflamed and
may become infected.

There are four recognised grades of pressure ulcers in the EPUAP Wound Classification system.

GRADE 1: Discolouration of intact skin not affected by light finger pressure (non blanching
erythema)
This may be difficult to identify in darkly pigmented skin .

GRADE 2: Partial-thickness skin loss or damage involving epidermis and/or dermis.

The pressure ulcer is superficial and presents clinically as an abrasion, blister or shallow
crater.
 GRADE 3: Full thickness skin loss involving damage of subcutaneous tissue but not
extending to the underlying fascia.
The pressure ulcer presents clinically as a deep crater with or without undermining of
adjacent tissue.

GRADE 4: Full thickness skin loss with extensive destruction and necrosis extending to underlying tissue.

The most important factor is to try and prevent them from occurring in the first place. Most Health care settings now have strict
guidelines aimed at preventing pressure ulcers from developing.

If a pressure ulcer has developed special equipment (for example, an alternating pressure mattress or cushion) or wound
dressing will be required. Don't forget that lying in bed spreads the load (except for heels)

Do not rub the affected area as this may cause further tissue damage. Inflatable and material ring-shaped cushions should
never be used as they may further restrict the supply of oxygen to the affected area.

If the sore has become infected, further treatment by a Nurse or Doctor may be required. This will be specific to the grade, type
and location of the ulcer and may be accompanied by irrigation of the wound with a salt-water wash.

Some groups of people are at greater risk from pressure ulcers than others.

Immobility for any reason contributes to the risk of pressure sore, therefore the elderly, wheelchair users and patients who are
bed-ridden are most at risk.

People living with incontinence especially women may also develop pressure ulcers, as prolonged exposure to moisture can
cause breakdown of skin tissue.

Many other conditions such as diabetes and arterial diseasecan also increase the risk of pressure ulcers as the supply of blood
and oxygen to body tissue may be restricted.

In order to prevent pressure ulcers developing, it is important that those who are immobile have pressure relieved frequently
either by manual turning or sophisticated bed systems. However even if a patient is lying on a bed system risk areas still require
regular inspection.

This may need to be more frequent if sitting. A healthy balanced diet and plenty of fluids will also help the condition of the skin.
Those at higher risk of pressure ulcers, such as the elderly and those with existing medical conditions should keep as active and
mobile as possible, taking some form of exercise every day.

It is advisable to take part in exercise that uses a range of motions.

Also important is keeping the skin clean and dry, and checking that bed linen is free from wrinkles.

---------------------------------------------

NICE clinical guidelines are systematically-developed recommendations on how healthcare and other professionals should care
for people with specific conditions. The recommendations are based on the best available evidence. Clinical guidelines are also
important for health service managers and those who commission NHS services.

Our clinical guidelines:

 aim to improve the quality of care for patients

assess how well different treatments and ways of managing a specific condition work

assess whether treatments and ways of managing a condition are good value for money for the NHS

set out the clinical care that is suitable for most patients with a specific condition using the NHS in England and Wales

take account of the views of those who might be affected by the guideline (including healthcare and other professionals,

patients and carers, health service managers, NHS trusts, the public, government bodies and the healthcare industry)

are based on the best available research evidence and expert consensus

are developed using a standard process and standard ways of analysing the evidence, which are respected by the NHS

and other stakeholders, including patients

make it clear how each recommendation was decided on

are advisory rather than compulsory, but should be taken into account by healthcare and other professionals when

planning care for individual patients.

Healthcare and other professionals in the NHS are expected to take our clinical guidelines fully into account when exercising their

professional judgement. However, the guidance does not override the responsibility of healthcare professionals and others to make

decisions appropriate to the circumstances of each patient. These decisions should be made in consultation with, and with the

agreement of, the patient and/or their guardian or carer. Healthcare professionals and others should record their reasons for not

following clinical guideline recommendations.

Our clinical guidelines are developed for the NHS, but they may also be relevant to professionals working outside the NHS, such as

those working in social care.

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Morphine overdose: Morphine is a highly addictive drug used to treat pain. Excessive doses of the drug can result in various
symptoms and even death in severe cases.

The list of signs and symptoms mentioned in various sources for Morphine overdoseincludes the 18 symptoms listed below:

Cold skin
Clammy skin
Nausea
Vomiting
Drowsiness
Constipation
Palpitations
Breathing difficulty
Slowed breathing
Slowed pulse rate
 Reduced blood pressure
Dilated or pinpoint pupils
Flaccid muscles
Fluid in the lungs
Stupor
Bluish skin
Bluish fingernails
Bluish lips

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Anaphylaxis is a severe, potentially life-threatening allergic reaction that can develop rapidly.

It is also known as anaphylactic shock.

Signs of anaphylaxis include:

itchy skin or a raised, red skin rash

swollen eyes, lips, hands and feet

feeling lightheaded or faint

narrowing of the airways which can cause wheezing and breathing difficulties

abdominal pain, nausea and vomiting

collapse and unconsciousness

Read more about the symptoms of anaphylaxis.

What to do

Anaphylaxis should always be treated as a medical emergency.

If you suspect that you or somebody else is experiencing symptoms of anaphylaxis, you should immediately dial 999 for
an ambulance.

If available, an injection of a medicine called adrenaline should be given if someone is having breathing difficulties, feeling faint, or
has lost consciousness due to suspected anaphylaxis.

Some people with a previous history of anaphylaxis will have an auto-injector of adrenaline. This should be injected into their thigh
muscle and held in place for 10 seconds. Instructions for how to use these auto-injectors can be found on the side of each device.

If the person is conscious, you should place them in a position where they are comfortable and able to breathe easily until the
ambulance arrives. If they are feeling faint, they should be laid flat with their legs elevated, if possible.

If the person is unconscious, you should place them in the recovery position (on their side, supported by one leg and one arm, with
the head tilted back and the chin lifted).

If the person's breathing or heart stops, cardiopulmonary resuscitation (CPR) should be performed.
Further treatment and observation will be carried out in hospital.

Read more about treating anaphylaxis.

Causes and triggers

Anaphylaxis is the result of your body's immune system overreacting to a harmless substance, such as food. Substances that
provoke allergic reactions are known as allergens.

Anaphylaxis usually develops within minutes of contact with an allergen, though sometimes the reaction can happen hours later.

The most widely reported triggers of anaphylaxis are:

insect stings, particularly wasp and bee stings

nuts

other types of foods, such as milk and seafood

certain medications, such as some types of antibiotics

Read more about the causes of anaphylaxis.

Preventing further episodes

If you know what has triggered anaphylaxis, it is important to take steps to try to avoid further exposure to similar triggers.

If the cause of the allergic reaction is not known, you should be referred to a specialist allergy clinic where tests can be carried out
to help identify possible triggers.

You may be provided with an adrenaline auto-injector to use during any future episodes of anaphylaxis.

Read more about preventing anaphylaxis.

Peanuts are a common trigger for anaphylaxis

Who is affected?

Anaphylaxis is relatively uncommon, but can affect people of all ages.

People with other allergic conditions, such as asthma or the allergic skin condition atopic eczema, are most at risk of developing
anaphylaxis.

Although the condition is life-threatening, deaths are rare. It is estimated that around 20-30 deaths due to anaphylaxis occur in the
UK each year. With prompt and proper treatment, most people make a full recovery.

The time it takes for symptoms of anaphylaxis to develop depends on the cause.
If it was something you ate, such as peanuts, it can take anything from a few minutes to two hours. If it was something that entered
your skin, such as a sting or an injection, it will usually take between five and 30 minutes.

Read more about the causes of anaphylaxis.

Allergic reactions can vary in severity. Sometimes they only involve mild itching or swelling, but in some people they can be severe
and life-threatening.

Symptoms of anaphylaxis include:

itchy skin or a raised, red skin rash (hives)

swollen eyes, lips, hands and feet (angioedema)
feeling lightheaded or faint

narrowing of the airways which can cause wheezing and breathing difficulties

abdominal (tummy) pain, nausea and vomiting

collapse and unconsciousness

When to seek medical advice

If someone has the symptoms of anaphylaxis, they need urgent medical help, particularly if you know they have allergies.

You should immediately dial 999 for an ambulance.

Anaphylaxis is caused by a problem with the immune system, which is the body's natural defence against illness and
infection.

In the case of anaphylaxis, your immune system overreacts to a harmless substance and releases a number of different chemicals,
such as histamine, to deal with the mistaken threat.

Triggers

Some of the more common triggers for anaphylaxis are outlined below.

Insect stings

While any insect has the potential to trigger anaphylaxis, the vast majority of cases are either caused by bee or wasp stings.

It is estimated that around one in 100 people will experience an allergic reaction after a bee or wasp sting, but only a small minority
of these people will go on to develop severe anaphylaxis.

Foods

Peanuts are the leading cause of food-related anaphylaxis, accounting for more than half of all cases.

Other foods known to trigger anaphylaxis include:

various types of nuts, such as walnuts, cashew nuts, almonds, brazil nuts and hazel nuts

milk
 fish

seafood

eggs

some types of fruit, such as bananas, grapes and strawberries

Medication

Types of medication known to trigger anaphylaxis in a small amount of people include:

antibiotics, particularly penicillin-like antibiotics

medications used to put people to sleep before they have surgery (general anaesthetic)
non-steroidal anti-inflammatory drugs (NSAIDs), a type of painkiller that includes ibuprofen and aspirin

Most people sensitive to these types of medication will usually develop anaphylaxis as soon as they begin treatment, although this
is not the case with NSAIDs.

The risks of these types of medication are very small, so in most cases the benefits of treatment outweigh the potential risk. For
example, the risk of developing anaphylaxis:

after taking a NSAID-type painkiller around one in 1,480

after taking penicillin around one in 5,000

after being given a general anaesthetic around one in 10,000

Contrast agents

Contrast agents are a group of special dyes used in certain medical tests to help certain areas of your body show up clearer on
scans such as X-rays.

For example, a contrast agent injected into a blood vessel will help show up any problems in the vessel, such as a blockage, on the
X-ray. This is known as an angiography.

The risk of developing anaphylaxis after being injected with a contrast agent is thought to be less than one in 10,000.

If you suspect somebody is experiencing symptoms of anaphylaxis, call 999 immediately for an ambulance and tell the
operator you think the person has anaphylaxis.

If you can see a potential trigger, such as a wasp or bee sting embedded in their skin, remove it.

If available, an adrenaline injection should be given as soon as a serious reaction is suspected. This can be done by the person
with anaphylaxis if possible, but in some circumstances (such as cases involving a young child or someone who is unconscious)
you may need to inject them yourself.

Before attempting the injection, make sure you know the correct way to use the specific device available.

There are three types of auto-injectors:

 EpiPen

Jext

Emerade

These auto-injectors release adrenaline when jabbed or pressed against the outer thigh.

Make sure you do not accidentally inject into a fatty part of their leg, as the adrenaline cannot move through fat. Also do not inject
into a vein or artery, as this can cause dangerous side effects. The injector should only be placed firmly into the muscle of the outer
thigh.

Carefully reading the manufacturer's instructions that come with the auto-injector will teach you how to do this. Make sure you read
the instructions as soon as you are first prescribed an auto-injector.

After injecting, the syringe should be held in place for 5-10 seconds. Injections can be given through clothing.

Read MHRA (2014) guidelines on how to use an adrenaline auto-injector(PDF, 188Kb).

Most people should experience a rapid improvement in symptoms once the adrenaline has been used. If there is no improvement
after five minutes, you should inject a second dose of adrenaline, if one is available. This should be injected into the opposite leg.

If the person has asthma and they have a reliever inhaler (usually blue), this should be used if they are wheezing.

Positioning and resuscitation

If the person is unconscious, check their airways are open and clear and also check their breathing. Then put them in the recovery
position (see below) to ensure they do not choke on their vomit.

Place the person on their side, ensuring they are supported by one leg and one arm. Open the airway by tilting the head and lifting
the chin.

If the person is conscious but experiencing trouble breathing, they may prefer to sit up as this will make breathing easier.

If the person is conscious but feels faint, they should lie flat with their legs elevated, if possible. They should not sit or stand as this
could potentially lead to a heart attack.

If a woman is pregnant, they should lie down on their left side to avoid putting too much pressure on one of the large veins that
leads to the heart.

If the person's breathing or heart stops, cardiopulmonary resuscitation (CPR) should be performed.

Admission to hospital

Even if adrenaline is given, the person will need to be admitted to hospital for observation (usually for six to 12 hours) as
occasionally symptoms can return during this period.

While in hospital, an oxygen mask can be used to help breathing and you may be given fluids via an intravenous drip (directly into a
vein) to help increase your blood pressure.
As well as adrenaline, additional medications such as antihistaminesand corticosteroids can be used to help relieve symptoms.

Blood tests may also be carried out while you are in hospital to confirm a diagnosis of anaphylaxis.

You should be able to leave hospital when the symptoms are under control and it is felt they will not quickly return. In some
cases, this may be after a few hours, but there is a chance you will have to stay in hospital for a few days if the symptoms were
severe.

You may be asked to take antihistamines and corticosteroid tablets two to three days after leaving hospital to help prevent a return
of symptoms.

It is likely you will be asked to attend a follow-up appointment so you can be given advice about how you can avoid further
episodes of anaphylaxis. You may also be given an adrenaline auto-injector for emergency use between leaving hospital and
attending the follow-up appointment.

What does adrenaline do?

Adrenaline causes the blood vessels to constrict (become narrower), which raises your blood pressure and reduces swelling. It also
causes the airways to open, relieving breathing difficulties.

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What is dementia?

Dementia is a common condition that affects about 800,000 people in the UK. Your risk of developing dementia increases as you
get older, and the condition usually occurs in people over the age of 65.

Dementia is a syndrome (a group of related symptoms) associated with an ongoing decline of the brain and its abilities. This
includes problems with:

memory loss

thinking speed

mental agility

language

understanding

judgement

People with dementia can become apathetic or uninterested in their usual activities, and have problems controlling their emotions.
They may also find social situations challenging, lose interest in socialising, and aspects of their personality may change.

A person with dementia may lose empathy (understanding and compassion), they may see or hear things that other people do not
(hallucinations), or they may make false claims or statements.
As dementia affects a person's mental abilities, they may find planning and organising difficult.Maintaining their independence may
also become a problem. A person with dementia will therefore usually need help from friends or relatives, including help
with decision making.

Your GP will discuss the possible causes of memory loss with you, including dementia. Other symptoms can include:

increasing difficulties with tasks and activities that require concentration and planning

depression

changes in personality and mood

periods of mental confusion

difficulty finding the right words

Most types of dementia can't be cured, but if it is detected early there are ways you can slow it down and maintain mental function.

Read more about the symptoms of dementia.

Why is it important to get a diagnosis?

An early diagnosis can help people with dementia get the right treatment and support, and help those close to them to prepare and
plan for the future. With treatment and support, many people are able to lead active, fulfilled lives.

Dementia is not a disease but a collection of symptoms that result from damage to the brain. These symptoms can be caused by a
number of conditions. The most common cause of dementia is Alzheimer's disease.

Common symptoms of Alzheimer's disease and other forms of dementia include:

memory loss, especially problems with memory for recent events, such as forgetting messages, remembering routes or
names, and asking questions repetitively

increasing difficulties with tasks and activities that require organisation and planning

becoming confused in unfamiliar environments

difficulty finding the right words

difficulty with numbers and/or handling money in shops

changes in personality and mood

depression

Symptoms of vascular dementia

The symptoms of vascular dementia can sometimes develop suddenly and quickly get worse, although they can also develop
gradually over many months or years. People with vascular dementia may also experience stroke-like symptoms, including muscle
weakness or paralysis on one side of their body.

Symptoms of dementia with Lewy bodies

Dementia with Lewy bodies shares many of the symptoms of Alzheimer's disease and people with the condition typically also
experience the following:
 periods of alertness and drowsiness or fluctuating levels of confusion

visual hallucinations

becoming slower in their physical movements

Symptoms of frontotemporal dementia

Early symptoms of frontotemporal dementia typically include changes in emotion, personality and behaviour. For example,
someone with this type of dementia may become less sensitive to other peoples emotions, perhaps making them seem cold and
unfeeling.

They may also lose some of their inhibitions, leading to behaviour that is out of character, such as making tactless or inappropriate
comments.

Some people with frontotemporal dementia also have language problems. This may include not speaking, speaking less than usual
or having problems finding the right words.

Symptoms in the later stages of dementia

As dementia progresses, memory loss and difficulties with communication often become very severe. In the later stages, the
person is likely to neglect their own health and require constant care and attention.

Memory symptoms in dementia

People with advanced dementia may not recognise close family and friends, they may not remember where they live or know
where they are. They may find it impossible to understand simple pieces of information, carry out basic tasks or follow instructions.

Communication problems in dementia

It is common for people with dementia to have increasing difficulty speaking and they may eventually lose the ability to speak
altogether. It is important to keep trying to communicate with them and to recognise and use other, non-verbal means of
communication, such as expression, touch and gestures.

Problems with mobility in dementia

Many people with dementia gradually become less able to move about unaided and may appear increasingly clumsy when carrying
out everyday tasks. Some people may eventually be unable to walk and may become bedbound.

Incontinence

Bladder incontinence is common in the later stages of dementia and some people will also experience bowel incontinence.

Eating, appetite and weight loss

Loss of appetite and weight loss are common in the later stages of dementia. It's important that people with dementia get help at
mealtimes to ensure they eat enough. Many people have trouble eating or swallowing and this can lead to choking, chest infections
and other problems.
Causes of dementia

Dementia is caused by damage in the brain. The most common causes of dementia are called neurodegenerative diseases, and
include Alzheimer's disease, frontotemporal dementia, and dementia with Lewy bodies. With these diseases, the brain cells
degenerate and die more quickly than is part of the normal ageing process. This leads to a decline in a person's mental and,
sometimes, physical abilities. The gradual changes and damage to brain cells are caused by a build-up of abnormal proteins in the
brain.

These abnormal proteins are different in each type of neurodegenerative dementia. In most cases, dementia is not inherited directly
from family members. However, a small number of cases of Alzheimer's disease and frontotemporal dementia can run in families.

Vascular dementia is caused when the brain's blood supply is interrupted. If the blood supply is restricted or stopped, brain cells
begin to die, resulting in brain damage.

The causes of the different types of dementia are listed below.

Causes of Alzheimer's disease

Alzheimer's disease is the most common form of dementia. In Alzheimer's disease, the loss of brain cells leads to the brain
shrinking. The medical name for this is atrophy.

An area of the brain known as the cerebral cortex is particularly affected by atrophy. The cerebral cortex is the layer of grey matter
covering the brain. Grey matter is responsible for processing thoughts and many of the complex functions of our brains, such as
storing and retrieving memories, calculation, spelling, planning and organising.

Clumps of protein, known as "plaques" and "tangles", progressively form in the brain. The plaques and tangles are thought to be
responsible for the increasing loss of brain cells. Connections between brain cells are lost and there are less neurotransmitter
chemicals available to carry messages from one brain cell to another. They also affect the chemicals that carry messages between
brain cells.

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Antibiotics are medications used to treat, and in some cases prevent, bacterial infections.

They can be used to treat relatively mild conditions such as acne as well as potentially life-threatening conditions such
as pneumonia.

However, antibiotics often have no benefit for many other types of infection and using them unnecessarily would only increase the
risk ofantibiotic resistance, so they are not routinely used.

Read more about when antibiotics are used.

How do I take antibiotics?

Take antibiotics as directed on the packet or the patient information leaflet that comes with the medicine, or as instructed by your
GP or pharmacist.

Doses of antibiotics can be provided in several ways:

oral antibiotics tablets, pills and capsules or a liquid that you drink which can be used to treat most types of mild to
moderate infections in the body
topical antibiotics creams, lotions, sprays or drops, which are often used to treat skin infections
injections of antibiotics these can be given as an injection or infusion through a drip directly into the blood or muscle,
and are usually reserved for more serious infections

It is essential to finish taking a prescribed course of antibiotics, even if you feel better, unless a healthcare professional tells you
otherwise. If you stop taking an antibiotic part way through a course, the bacteria can become resistant to the antibiotic.

Missing a dose of antibiotics

If you forget to take a dose of your antibiotics, take that dose as soon as you remember and then continue to take your course of
antibiotics as normal.

However, if it is almost time for the next dose, skip the missed dose and continue your regular dosing schedule. Do not take a
double dose to make up for a missed one.

If you have to take two doses closer together than normal, there is an increased risk of side effects.

Accidentally taking an extra dose

Accidentally taking one extra dose of your antibiotic is unlikely to cause you any serious harm.

However, it will increase your chances of experiencing side effects such as pain in your stomach, diarrhoea and feeling or being
sick.

If you accidentally take more than one extra dose of your antibiotic, or if you are worried or are experiencing severe side effects,
speak to your GP or call NHS 111 as soon as possible.

Types of antibiotics

There are now hundreds of different types of antibiotics but most of them can be broadly classified into six groups. These are
outlined below.

Penicillins are widely used to treat a variety of infections, including skin infections, chest infections and urinary tract
infections.
Cephalosporins can be used to treat a wide range of infections but are also effective in treating more serious infections
such assepticaemia and meningitis.
Aminoglycosides tend to be used only to treat very serious illnesses such as septicaemia as they can cause serious side
effects, including hearing loss and kidney damage. They break down quickly inside the digestive system so they have to
be given by injection. They are also used as drops for some ear or eye infections.
 Tetracyclines can be used to treat a wide range of infections. They are commonly used to treat moderate to severe acne
and a condition called rosacea, which causes flushing of the skin and spots.
Macrolides can be particularly useful in treating lung and chest infections. They can also be a useful alternative for people
with a penicillin allergy or to treat penicillin-resistant strains of bacteria.
Fluoroquinolones are broad-spectrum antibiotics that can be used to treat a wide range of infections.

For detailed information about a specific antibiotic, see our antibiotic medicine guide page.

Side effects

Antibiotics, as with any medication, can cause side effects. Most antibiotics, if used properly, don't cause problems for people who
take them and serious side effects are rare.

The most common side effects of antibiotics include:

being sick

feeling sick

bloating and indigestion

diarrhoea

Around one person in 15 has an allergic reaction to antibiotics, especially penicillin and cephalosporins. In very rare cases, this can
lead to a serious allergic reaction (anaphylaxis), which is a medical emergency.

Read more about the side effects of antibiotics.

Considerations and interactions

Some antibiotics are not suitable for people with certain medical conditions, or for women who are pregnant or breastfeeding. You
should only ever take antibiotics that are prescribed to you never 'borrow' them from a friend of family member.

Some antibiotics can also react unpredictably with other medications, for example, the oral contraceptive pill and alcohol. It is
therefore important to read the information leaflet that comes with your medication carefully.

Read more information about:

things to consider before taking antibiotics

how antibiotics interact with other medicines

Antibiotic resistance

Both the NHS and health organisations across the world are trying to reduce the use of antibiotics, especially for conditions that are
not serious. This is to try to combat the problem of antibiotic resistance, which is when a strain of bacteria no longer responds to
treatment with one or more types of antibiotics.

Antibiotic resistance can occur in several ways.

Strains of bacteria can mutate (change) and, over time, become resistant to a specific antibiotic. The chance of this increases if a
person does not finish the course of antibiotics as some bacteria may be left to develop resistance.
Also, antibiotics can destroy many of the harmless strains of bacteria that live in and on the body. This allows resistant bacteria to
multiply quickly and replace them.

The overuse of antibiotics in recent years has played a major part in antibiotic resistance. This includes using antibiotics to treat
minor conditions that would have got better anyway.

It has led to the emergence of 'superbugs'. These are strains of bacteria that have developed resistance to many different types of
antibiotics. They include:

meticillin-resistant Staphylococcus aureus (MRSA)

Clostridium difficile (C. diff)
the bacteria that cause multi-drug-resistant tuberculosis (MDR-TB)
CPE (Carbapenemase-producing Enterobacteriaceae)

These types of infections can be serious and challenging to treat, and are becoming an increasing cause of disability and death
across the world. For example, the World Health Organization (WHO) estimates that there are around 170,000 deaths due to MDR-
TB each year.

The biggest worry is that there may emerge new strains of bacteria that are effectively untreatable by any existing antibiotics.

Carbapenemase-producing Enterobacteriaceae are one such emerging group of bacteria, with several types. These bacteria are
widespread in some parts of the world, including parts of Europe, and are beginning to be seen in the UK.

Antibiotics help fight infection caused by bacteria. In this animation the Tokkels learn that antibiotics do not help against viral
infections such as cold and flu.

How do antibiotics work?

Antibiotics work in one of two ways:

they kill bacteria by disrupting one of the processes that they need to survive, such as turning glucose into energy

they prevent bacteria from reproducing and spreading, for example by disrupting the processes bacteria use to produce
new cells, such as growing new proteins
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A Clostridium difficile infection is a type of bacterial infection that can affect the digestive system. It most commonly
affects people who have been treated with antibiotics.

The symptoms of a C. difficile infection can range from mild to severe and include:

diarrhoea
a high temperature (fever) of above 38C (100.4F)

painful abdominal cramps

A C. difficile infection can also lead to life-threatening complications such as severe swelling of the bowel from a build-up of gas
(toxic megacolon).

Read more about the symptoms of Clostridium difficile and complications of a Clostridium difficile infection.
Causes

Spores of the C. difficile bacteria can be passed out of the human body in faeces (stools) and can survive for many weeks, and
sometimes months, on objects and surfaces.

If you touch a contaminated object or surface and then touch your nose or mouth, you can ingest the bacteria.

The C. difficile bacteria do not usually cause any problems in healthy people. However, some antibiotics can interfere with the
natural balance of normal bacteria in the gut that protects against C. difficile infection.

When this happens, C. difficile bacteria can multiply and produce toxins (poisons) that cause symptoms such as diarrhoea.

Read more about the causes of a Clostridium difficile infection.

Treatment

A mild C. difficile infection can usually be controlled by withdrawing treatment with the antibiotics causing the infection.

More severe cases can be treated using the following antibiotics:

vancomycin

metronidazole

The condition usually responds well to treatment, with symptoms improving in two to three days and clearing up completely within 7
to 10 days.

However, relapse is common, occurring in around one in four cases, and requires further treatment. Some people have two or more
relapses.

Life-threatening cases may need surgery to remove a damaged section of the bowel. This is needed in less than 1% of cases.

Severe cases of C. difficile infection can be fatal, especially when they occur in people who are already very ill.

Read more about treating a Clostridium difficile infection.

Prevention

C. difficile bacteria spread very easily. Despite this, C. difficile infections can usually be prevented by practising good hygiene in
healthcare environments, such as washing hands regularly and cleaning surfaces using products containing bleach.

If you are visiting someone in hospital with C. difficile, you can reduce the risk of spreading infection by washing your hands before
and after entering the bed space. Alcohol hand gel is not effective against C. difficile spores, so the use of soap and water is
essential.

Who is affected?

The majority of C. difficile cases occur in people who have had antibiotics. This may be in a healthcare setting, such as a hospital
or care home, but can also occur at home without ever going to hospital.
Older people are most at risk from infection, especially those who are frail or with medical conditions. People over the age of 65
account for three-quarters of all cases.

In recent years, the number of C. difficile infections has fallen rapidly. There were 14,687 reported cases in England from April 2012
to March 2013, compared with 52,988 in 2007.

However, a new strain of the C. difficile bacteria called NAP1/027 has emerged in recent years. This new strain tends to cause
more severe infection.

There has also been an increase in the number of C. difficile infections occurring outside a healthcare setting (known as
community-acquired Clostridium difficile infection).

C difficile

The symptoms of C difficile range from mild to very severe diarrhoea. Get expert advice on how to avoid it, how it spreads and
treatments that can control the disease.

Antibiotics

Antibiotics are medications that are used to treat, and in some cases prevent, bacterial infections

--------------------------------------------------------------------------------

An aneurysm is a bulge in a blood vessel caused by a weakness in the blood vessel wall, usually where it branches.

As blood passes through the weakened blood vessel, the blood pressure causes a small area to bulge outwards like a balloon.

Aneurysms can develop in any blood vessel anywhere in the body, but the two most common places for them to form are in the
abdominal aorta (the artery that transports blood away from the heart to the rest of the body) and the brain.

This topic is about brain aneurysms. Read the separate topic on abdominal aortic aneurysm.

About brain aneurysms

The medical term for an aneurysm that develops inside the brain is an intracranial or cerebral aneurysm.

Most brain aneurysms will only cause noticeable symptoms if they burst (rupture).

This will then lead to an extremely serious condition known as asubarachnoid haemorrhage, where bleeding caused by the
ruptured aneurysm can cause extensive brain damage and symptoms such as:

a sudden agonising headache it has been described as a thunderclap headache, similar to a sudden hit on the head,
resulting in a blinding pain unlike anything experienced before

stiff neck

sickness and vomiting

pain on looking at light

About three in five people who have a subarachnoid haemorrhage will die within two weeks and half of those who survive are left
with severe brain damage and disability.

Read more about the symptoms of a brain aneurysm.

A ruptured brain aneurysm is a medical emergency. If you suspect that you or someone in your care has had a ruptured
brain aneurysm, call 999 immediately and ask for an ambulance.

How brain aneurysms are treated

If a brain aneurysm is detected before it ruptures, treatment may be recommended to prevent it from rupturing in future. Most
aneurysms, however, will not rupture so treatment is only carried out if the risk of a rupture is particularly high.

Factors that affect whether treatment is recommended include your age, the size and position of the aneurysm, your family medical
history and any other health conditions you have.

If treatment is recommended, this will usually involve either filling the aneurysm with tiny metal coils, or an open operation to seal it
shut with a tiny metal clip.

If your risk of a rupture is low, you will have regular check-ups to monitor your aneurysm. You may also be given medication to
reduce your blood pressure and advice about ways you can reduce your chances of a rupture, such as stopping smoking if you
smoke.

The same techniques used to prevent ruptures are also used to treat brain aneurysms that have already ruptured.

Read more about diagnosing brain aneurysms and treating brain aneurysms.

Why brain aneurysms develop

Exactly what causes the wall of affected blood vessels to weaken is still unclear, although risk factors have been identified,
including:

smoking

high blood pressure

a family history of brain aneurysms

In some cases, an aneurysm may develop because there was a weakness in the walls of the blood vessels at birth.

Read more about the causes of brain aneurysms.

Who is affected

It's difficult to estimate exactly how many people are affected by brain aneurysms because in most cases they cause no symptoms
and pass undetected. Some experts believe it could be as high as one in 20 people, while others think the figure is much lower at
around one in a 100 people.

The number of aneurysms that actually rupture is much smaller. Only around one in 12,500 people will have a ruptured brain
aneurysm in any given year in England.
Brain aneurysms can develop in anyone at any age, but are more common in people over 40 years of age and women tend to be
affected more commonly than men.

Preventing brain aneurysms

The best way to prevent getting an aneurysm, or reduce the risk of an aneurysm growing bigger and possibly rupturing, is to avoid
activities that could damage your blood vessels, such as:

smoking

eating a high-fat diet

not exercising regularly

being overweight or obese

A brain aneurysm rarely causes any symptoms unless it bursts (ruptures).

However, unruptured brain aneurysms occasionally cause symptoms if they are particularly large or press against tissues or nerves
inside the brain.

Symptoms of an unruptured brain aneurysm can include:

visual disturbances such as loss of vision or double vision

difficulties moving one of your eyes

pain on one side of your face or around your eye

inability to move some of your facial muscles (usually only affecting one side of your face), which may make it difficult to
speak

headaches
seizures (fits)

You should see your GP as soon as possible if you experience symptoms of an unruptured brain aneurysm. Although most
aneurysms won't rupture, it is important to get it checked in case treatment is necessary.

Ruptured brain aneurysm

Symptoms of a ruptured brain aneurysm usually begin with a sudden agonising headache. It's been likened to being hit on the
head, resulting in a blinding pain unlike anything experienced before.

Other symptoms include:

stiff neck

feeling or being sick

sensitivity to light

enlarged (dilated) pupils

blurred or double vision

confusion
 loss of consciousness

Treatment for aneurysm is difficult due to problems accessing parts of the brain, but generally involves surgical clipping, where a
section of skull is removed and a clip placed over the neck of the aneurysm to stop blood flowing into it, or coiling, where a series
of platinum coils are threaded from the patient's lower body up into the brain aneurysm, filling it with the platinum and stopping
blood flow.

An abdominal aortic aneurysm is a dilation (ballooning) of part of the aorta that is within the abdomen. An abdominal aortic

aneurysm (AAA) usually causes no symptoms unless it ruptures (bursts). A ruptured AAA is often fatal. An AAA less than 55 mm

wide has a low chance of rupture. An operation to repair the aneurysm may be advised if it is larger than 55 mm, as above this size

the risk of rupture increases significantly. Men aged 65 and over are to be offered a routine scan to screen for AAA.

What is the aorta?

The aorta is the largest artery (blood vessel) in the body. It carries blood from the heart and descends through the chest and the

abdomen. Many arteries come off the aorta to supply blood to all parts of the body. At about the level of the pelvis the aorta divides

into two arteries, one going to each leg.

What is an aneurysm and an abdominal aortic aneurysm?

An aneurysm is where a section of an artery widens (balloons out). The wall of an aneurysm is weaker than a normal artery wall.

The pressure of the blood inside the artery causes the weaker section of wall to balloon.
Aneurysms can occur in any artery, but they most commonly occur in the aorta. Most aortic aneurysms occur in the section of the

aorta that passes through the abdomen. These are known as abdominal aortic aneurysms (AAAs). Sometimes they occur in the

section going through the chest. These are known as thoracic aortic aneurysms.

The rest of this leaflet is only about AAAs.

The normal diameter of the aorta in the abdomen is about 20 mm. An AAA is said to be present if a section of the aorta within the

abdomen is 30 mm or more in diameter.

AAAs vary in size. As a rule, once you develop an AAA, it tends gradually to get larger. The speed at which it gets larger varies from

person to person. However, on average, an AAA tends to get larger by about 10% per year.

Related discussions
E

What causes an abdominal aortic aneurysm?

In most cases

The exact reason why an aneurysm forms in the aorta in most cases is not clear. Most instances occur in older people. An AAA is

rare in people under the age of 60. So, ageing has a major role to play.

The wall of the aorta normally has layers of smooth muscle, and layers made from tissues called elastin and collagen. Elastin and

collagen are strong supporting tissues. What seems to happen is that a part of the aorta loses its normal strength and elasticity in

some people as they become older. Research suggests that this is due to changes in the elastin, collagen and smooth muscle

tissues. There seem to be complicated biochemical processes that cause these changes. Some people are more prone than others

to these changes.

Your genetic make-up plays a part, as you have a much higher chance of developing an AAA if one of your parents has, or had,

one.
Atheroma may also play a part. Atheroma is a fatty substance that deposits within the inside lining of arteries. Atheroma is

sometimes called furring of the arteries. Most AAAs are lined with some atheroma. Anyone can develop atheroma, but it develops

more commonly with increasing age. Certain risk factors also increase the chance of atheroma forming. They

include: smoking, high blood pressure, diabetes, raised cholesterol level, taking littleexercise, and obesity. These are the same risk

factors that increase the chance of atheroma forming in the heart (coronary) arteries, which can cause angina and heart attacks.

In a minority of cases

Rare causes of AAAs include injury or infection of the aorta. Also, certain uncommon hereditary conditions can affect the artery

structure. In these uncommon situations an aneurysm may develop at a relatively young age.

How common are abdominal aortic aneurysms?

About 4 in 100 men and about 1 in 100 women over the age of 65 have an AAA. It becomes more common with increasing age.

However, most people with an AAA are not aware that they have one (see below in the section on symptoms). An AAA is rare in

people under the age of 60.

What is the concern about an abdominal aortic aneurysm?

The main concern is that the aneurysm might rupture (burst). The wall of the aneurysm is weaker than a normal artery wall and

may not be able to withstand the pressure of blood inside. If it ruptures then severe internal bleeding occurs which is often fatal.

Most AAAs do not rupture - only a certain proportion (see below).

What are the symptoms of an abdominal aortic aneurysm?

Often there are no symptoms. At the time of diagnosis, 7 in 10 people with an AAA will not have had any symptoms due to the

aneurysm. The ballooning of the aneurysm does not cause any symptoms unless it becomes large enough to put pressure on

nearby structures. If symptoms do occur, they are likely to be mild abdominal or back pains. There are many causes of mild

abdominal and back pain. Therefore, the diagnosis may be delayed unless the aneurysm is large enough to be felt by a doctor

when he or she examines your abdomen.

Sometimes small blood clots form on the inside lining of an AAA. These may break off and be carried down the aorta and block a

smaller artery further on. These blood clots are called emboli and can be dangerous. For instance, complete blockage of an artery

that supplies a foot may lead to loss of blood to part of the foot, which can cause pain in the foot and gangrene if left untreated.

If the aneurysm does rupture then you are likely to have sudden severe abdominal and/or back pain. This is commonly soon

followed by collapse as the internal bleeding causes a sharp drop in blood pressure.

How is an abdominal aortic aneurysm diagnosed?

Sometimes a doctor feels the bulge of an aneurysm during a routine examination of the abdomen. However, many AAAs

are too small to feel.

An X-ray of the abdomen (often done for other reasons) will show calcium deposits lining the wall of an AAA in some, but

not all, cases.

 An ultrasound scan is the easiest way to detect an AAA. This is a painless test. It is the same type of scan that pregnant

women have to look at the baby in the womb. The size of the aneurysm can also be measured by ultrasound. As discussed

later, it is important to know the size.

A more detailed scan, such as a CT scan, is sometimes done. This may be done if your doctor needs to know whether the

aneurysm is affecting any of the arteries that come off the aorta. For instance, if the aneurysm involves the section of the

aorta where the arteries to the kidneys branch off, surgeons need to know this information if they plan to operate.

What is the chance of an abdominal aortic aneurysm rupturing?

The chance of rupture is low if an AAA is small. As a rule, the risk of rupture increases with increasing size. This is much like a

balloon - the larger you blow it up, the greater the pressure, and the greater the chance it will burst. The diameter of an AAA can be

measured by an ultrasound scan. The following gives overall risk figures for the size (diameter) of the aneurysm:

40 mm-55 mm: about a 1 in 100 chance of rupture per year.

55 mm-60 mm: about a 10 in 100 chance of rupture per year.

60 mm-69 mm: about a 15 in 100 chance of rupture per year.

70 mm-79 mm: about a 35 in 100 chance of rupture per year.

80 mm or more: about a 50 in 100 chance of rupture per year.

As a rule, for any given size, the risk of rupture is increased in smokers, females, those with high blood pressure, and those with a

family history of an AAA.

Should everyone with an abdominal aortic aneurysm have surgery?

The short answer is no. Surgical repair of an AAA is a major operation and carries risks. A small number of people will die during, or

shortly after, the operation. If you have a small AAA, the risk of death caused by surgery is higher than the risk of rupture.

Therefore, surgery is usually not advised if you have an AAA less than 55 mm wide. However, regular ultrasound scans will

normally be advised to see if it gets larger over time.

Surgery is commonly advised if you develop an AAA larger than 55 mm. For these larger aneurysms the risk of rupture is usually

higher than the risk of surgery. However, if your general state of health is poor, or if you have certain other medical conditions, this

may increase the risk if you have surgery. So, in some cases the decision to operate may be a difficult one.

Emergency surgery is needed if an AAA ruptures. On average, about 8 in 10 people who have a ruptured aortic aneurysm will die

due to the sudden severe bleeding. However, emergency surgery is life-saving in some cases.

What operations are performed?

There are two types of surgical operation to repair an AAA.

The traditional operation is to cut out the bad piece of aorta and replace it with an artificial piece of artery (a graft). This is a major

operation and, as mentioned, carries some risk. Some people die during this operation. However, it is successful in most cases and

the aneurysm is totally fixed. The long-term outlook is good. The graft usually works well for the rest of your life.

A newer technique allows the aorta to be repaired by a method called endovascular repair. This has become a popular option in

recent years. In this method a tube is passed up from inside one of the leg arteries into the area of the aneurysm. This tube is then

passed across the widened aneurysm and fixed to the good aorta wall using metal clips. The advantage to this type of repair is that

there is no abdominal surgery. This technique is therefore safer than the traditional operation, and you need to spend less time in

hospital. A disadvantage is that some people have to undergo a further operation at a later stage to refine the initial procedure.

Surgical techniques continue to develop and improve. Your surgeon will advise about the pros and cons of surgery, the different

types of operation, and the best option for you.

Other treatments may be important

If you have an AAA, you are likely to have a significant amount of atheroma that lines the artery. Therefore, you are at risk of having

significant atheroma formation in other arteries, such as the coronary (heart) arteries and brain arteries. Therefore, you are likely to

be at increased risk of developing heart disease (angina, heart attack, etc) and stroke.

In fact, most people who develop an aortic AAA do not die of the aneurysm but die from other vascular conditions, such as a heart

attack or stroke.

Therefore, you should consider doing what you can to reduce the risk of these conditions by other means. For example:

Eat a healthy diet which includes keeping a low salt intake.

If you are able, exercise regularly.

Lose weight if you are overweight.

Do not smoke.

If you drink alcohol, do so in moderation.

If you have high blood pressure, diabetes, or a high cholesterol level, they should be well controlled on treatment.

You may be prescribed a statin drug to lower your cholesterol level and low-dose aspirin to help to prevent blood clots

from forming.

See separate leaflet called Preventing Cardiovascular Diseases for more details.

Screening for abdominal aortic aneurysm

 Decision aids

Research studies suggest that a routine ultrasound scan is worthwhile for all men aged 65. This is because most people with an

AAA do not have symptoms. Following a routine scan, surgery can be offered to men found to have an aneurysm over 55 mm wide.

Follow-up scans can be offered to monitor those with smaller aneurysms between 30 mm and 54 mm wide.

In early 2008, the Government announced that a national screening programme should be rolled out for men aged 65, while men

aged over 65 should be able to self-refer. Implementation of the NHS AAA Screening Programme in England began in Spring 2009

and screening covered the whole of England by March 2013. Screening was also introduced in Scotland, Wales and Northern

Ireland in 2013. Screening for AAA is offered only to men, as the condition is much more common in men than in women.

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The Yellow Card Scheme is vital in helping the MHRA monitor the safety of all healthcare products in the UK to ensure they are
acceptably safe for patients and those that use them. Reports can be made for all medicines including vaccines, blood factors and
immunoglobulins, herbal medicines and homeopathic remedies, and all medical devices available on the UK market.

The Scheme collects information on suspected problems or incidents involving

1. side effects (also known as adverse drug reactions or ADRs)

2. medical device adverse incidents
3. defective medicines (those that are not of an acceptable quality)
4. counterfeit or fake medicines or medical devices

It is important for people to report problems experienced with medicine or medical devices as these are used to identify issues
which might not have been previously known about. The MHRA will review the product if necessary, and take action to minimise
risk and maximise benefit to the patients. The MHRA is also able to investigate counterfeit or fake medicines or devices and if
necessary take action to protect public health.

Side effects to a medicine, vaccine, herbal or complementary remedy

All medicines can cause side effects (commonly referred to as adverse drug reactions or ADRs by healthcare professionals).

Side effects reported on Yellow Card are evaluated, together with additional sources of information such as clinical trial data,
medical literature or data from international medicines regulators, to identify previously unknown safety issues. These reports are
assessed by a team of medicine safety experts made up of doctors, pharmacists and scientists who study the benefits and risks of
medicines. If a new side effect is identified, the safety profile of the medicine in question is carefully looked at, as well as the side
effects of other medicines used to treat the same condition. The MHRA takes action, whenever necessary, to ensure that medicines
are used in a way that minimises risk, while maximising patient benefit.

More information about the reporting of suspected side effects or adverse drug reactions are available on the MHRA website:

general information for patients and healthcare professionals

black triangle (additional monitored) medicines ()
what happens to my Yellow Card after reporting a side effect?
looking for potential drug safety issues in Yellow Card data
impact of reporting side effects to the Yellow Card scheme
drug analysis prints - numbers of side effects reported to the MHRA
case studies: reporting side effects to the Yellow Card Scheme
other languages: Information about reporting side effects
 Medical device adverse incidents

The term 'medical device' covers almost all products, except medicines, that are used in healthcare. They can be used for the
diagnosis, prevention, monitoring or treatment of illness or disability.

The range of products is very wide: it includes contact lenses and condoms; heart valves and hospital beds; resuscitators and
radiotherapy machines; surgical instruments and syringes; wheelchairs and walking frames.

An adverse incident is an event that caused, or almost caused, an injury to a patient or other person or a wrong or delayed
diagnosis and treatment of a patient.

Examples of problems:

faulty brakes on a wheelchair

a faulty ear thermometer giving a low reading
a faulty batch of test strips for a blood glucose meter giving wrong readings.

If your equipment has a fault you should let us know as soon as you can. If possible, keep the faulty equipment until you have
contacted us.

For more information go to the adverse incidents page involving medical devices on the MHRA website

Defective medicines (those that are not of an acceptable quality)

Defects in medicines may relate to quality issues with the product itself, the packaging, e.g. carton and blister or other packaging
components such as the patient information leaflet. Yellow Card reports of defective medicines are submitted to the defective
medicines report centre (DMRC). The role of the DMRC is to minimise the hazard to patients arising from the distribution of
defective medicines by providing an emergency assessment and communication system between manufacturers, distributors,
regulatory authorities and users.

Where a defective medicine is considered to present a risk to public health, the company or manufacturer as appropriate, is
responsible for recalling any affected batch(es) or, in extreme cases, removing all batches of the product from the market. DMRC
normally supports this action by issuing a drug alert notification to healthcare professionals. Other regulators and countries may be
notified of a recall by the issue of a Rapid Alert notification.

If a member of the public has reason to believe that their medicine is not of an acceptable quality they should, in the first instance,
consult with their doctor or a pharmacist who may then decide to refer the matter to the MHRA.

Further information about defective medicines can be found on the defective medicines pages on the MHRA website

Counterfeit healthcare products

The MHRA makes sure that the UK has systems in place to prevent counterfeit or fake healthcare products entering the supply
chain. If counterfeit products become available, we make sure we detect counterfeits early and take action to protect the public.

When medicines and medical devices are bought on the internet the source of these products is sometimes difficult to trace and it
is highly unlikely that the manufacturers of these products conform to European standards of safety and effectiveness. This means
there can be a significant risk of harm to the patient or person using the product.

Yellow Card counterfeit reports are investigated in accordance with the terms of the Human Medicines Regulations 2012 and
Consumer Protection Act 1987, and associated legislation.

The MHRA has statutory powers to enter business and private property to seize products suspected of being in breach of the
Human Medicines Regulations. Investigations concerning counterfeits can be complex, involving networks of companies and
countries, banks, international law enforcement agencies, solicitors, financial investigators, crime analysts, internet investigators,
disclosure officers, test purchasers, and specialists in the use of the Regulation of Investigatory Powers Act 2000.

The MHRA can work with manufacturers to resolve any potential issues and problems. However, where necessary, the MHRA has
the powers to take formal enforcement action against individuals and organisations. Offenders can be prosecuted under various
regulations and Acts which can result in fines and often imprisonment. Civil injunctions are also given, where appropriate.

Further information about counterfeits can be found on the counterfeit medicines and devices pages on the MHRA website.

Blood factors and immunoglobulin products

Blood factor and immunoglobulin products, such as factors I to XIII or Anti-D (RHO) immunoglobulin, are considered medicines.
Suspected side effects to these products should be reported using the Yellow Card side effect form.

What are cerebrovascular diseases?

------------------------------------------------------------------------------

Cerebrovascular diseases are conditions that develop as a result of problems with the blood vessels that supply the
brain.

Cerebrovascular disease is also a type of cardiovascular disease that affects the brain's blood vessels.

Types of cerebrovascular disease

There are a number of different types of cerebrovascular disease. The four most common types are:

stroke a serious medical condition where the blood supply to the brain is interrupted
transient ischaemic attack (TIA) a temporary fall in the brain's blood supply, resulting in a lack of oxygen to the brain
subarachnoid haemorrhage an uncommon cause of stroke where blood leaks out of the brain's blood vessels
vascular dementia problems with the blood circulation, leading to parts of the brain not receiving enough blood and
oxygen

These are discussed in more detail below.

Stroke

To function properly, the brain needs oxygen and nutrients that are provided by the blood. However, if the blood supply is restricted
or stopped, brain cells will begin to die. This can lead to brain damage and possibly death.

A stroke occurs when the brain's blood supply is blocked or interrupted for example, by a blood clot, where the blood thickens and
becomes solid. This is the most common cause of stroke.

The main symptoms of a stroke can be remembered using the acronym FAST, which stands for Face-Arms-Speech-Time. Each
symptom is explained below.

Face the person's face may have fallen on one side, they may be unable to smile, or their mouth or eye may have
drooped
Arms they may be unable to raise both arms and keep them there due to weakness or numbness
 Speech they may have slurred speech
Time it is time to dial 999 immediately if you see any of these signs or symptoms

A stroke is a medical emergency. Prompt treatment is essential as the sooner treatment is received, the less damage is likely to
occur.

Read more about stroke.

Transient ischaemic attack (TIA)

A TIA or "mini-stroke" is caused by temporary disruption in the blood supply to part of the brain. This results in a lack of oxygen to
the brain.

This can cause symptoms that are similar to a stroke, although they tend to last for a short time (less than 24 hours).

A TIA should be taken seriously, as it's an early warning sign of further TIAs or a stroke.

If you or someone you know has had a TIA, you should contact your GP, local hospital or out-of-hours service immediately to
arrange for a specialist assessment.

Read more about TIAs.

Subarachnoid haemorrhage

A subarachnoid haemorrhage is a less common cause of stroke. It occurs when blood leaks from blood vessels onto the surface of
the brain.

The bleeding occurs in the arteries that run underneath a membrane in the brain known as the arachnoid, which is located just
below the surface of the skull.

A subarachnoid haemorrhage is a medical emergency that requires immediate medical treatment to prevent serious complications,
brain damage and death.

Three quarters of all subarachnoid haemorrhages are the result of an aneurysm rupturing (bursting). An aneurysm is a bulge in a
blood vessel caused by a weakness in the blood vessel wall.

Other causes of a subarachnoid haemorrhage include:

severe head injury

arteriovenous malformations a rare type of birth defect that affects normal blood vessel formation

Read more about subarachnoid haemorrhage.

Vascular dementia

Vascular dementia is a common form of dementia that affects more than 111,000 people in the UK.

The term "dementia" describes a loss of mental ability associated with gradual death of brain cells.
It is caused by reduced blood flow to the brain as a result of a problem with the blood vessels that supply it. Parts of the brain
become damaged and eventually die from a lack of oxygen and nutrients.

Children

Cerebrovascular diseases are much less common in children than they are in adults. However, stroke can sometimes affect
children.

The Stroke Association estimate that each week, childhood stroke affects around five out of every 100,000 children in the UK.

Abnormalities in the brain's blood vessels, resulting in bleeding in the brain, are the leading cause of childhood stroke. The classic
warning signs of a stroke are the same in adults and children (see above).

Children may also experience additional symptoms, including:

a high temperature (fever) of 38C (100.4F) or above

fits (seizures)

nausea and vomiting

vision loss

Cerebrovascular diseases affect the blood vessels inside the brain

The world's biggest killer

Globally, cardiovascular diseases which include cerebrovascular diseases are responsible for more deaths than any other
cause.

In the UK, about a third of all deaths are caused by cardiovascular disease. Overall, coronary heart disease is the UK's biggest
killer cancer claims the second highest number of lives, with stroke third.

The risks of cerebrovascular disease and how to prevent them

There are nine risk factors for cerebrovascular disease.

They are:

high blood pressure (hypertension)

smoking

poor diet

high blood cholesterol

lack of exercise

being overweight or obese

diabetes

excessive alcohol consumption

stress
Many of the risk factors for cerebrovascular disease are linked, which means that if you have one it is likely you will also have
others.

For example, people who drink excessive amounts of alcohol often have poor diets and are more likely to smoke. Also, someone
who is overweight or obese is more likely to have high blood pressure, diabetes and high cholesterol.

Addressing one risk factor, such as giving up smoking, will bring important health benefits. However, to significantly reduce the risk
posed by cerebrovascular disease you need to look at your lifestyle as a whole. In particular, you need to consider:

your weight

your diet

how active you are and the amount of regular exercise you do

whether you need to stop smoking

how much alcohol you drink

your stress levels

As well as reducing your risk of developing cerebrovascular disease, making changes to your lifestyle will also lower your risk of
having other serious health conditions, such as coronary heart disease, heart attackand cancer.

High blood pressure

High blood pressure is one of the most significant risk factors for cerebrovascular disease. This is because the increase in blood
pressure damages the walls of the brain's blood vessels, increasing the risk of a blood clot forming or an artery rupturing (splitting).
Both of these can trigger a stroke.

If you have high blood pressure, you are four times more likely to have a stroke than someone with healthy blood pressure.

Not taking enough regular exercise increases your chances of developing high blood pressure and high cholesterol (see below for
advice about how much exercise you should be doing each week).

You can also prevent high blood pressure by eating healthily, maintaining a healthy weight, not smoking and drinking alcohol in
moderation.

Smoking

Smoking is also a major risk factor for cerebrovascular disease because the toxins in tobacco can damage and narrow the blood
vessels that supply the brain. Smoking also causes high blood pressure.

It is estimated that a person who smokes 20 cigarettes a day is six times more likely to have a stroke than someone who does not
smoke.

Therefore, if you smoke it is strongly recommended that you give up as soon as possible. Your GP will be able to provide you with
helpful advice, and they can prescribe medication to help you stop smoking.

The NHS Smokefree service also provides useful information, advice and support. You can speak to an adviser by calling their free
helpline on 0800 022 4 332 (Monday to Friday, 9am-8pm and Saturday and Sunday, 11am-4pm).
Diet

A diet that contains a high amount of saturated fat and salt can lead to high blood pressure, high cholesterol and narrowing of the
arteries, which are all risk factors for cerebrovascular disease.

A low-fat, high-fibre diet that includes whole grains and at least five portions of fresh fruit and vegetables a day is recommended for
a healthy heart.

You should limit the amount of salt in your diet to no more than 6g (0.2oz or 1 teaspoon) a day. Too much salt will increase your
blood pressure.

Also, avoid eating foods that are high in saturated fat as these foods will increase your cholesterol level. Foods that contain high
levels of saturated fat include:

meat pies

sausages and fatty cuts of meat

butter

ghee a type of butter that is often used in Indian cooking

lard

cream

hard cheese

cakes and biscuits

foods that contain coconut or palm oil

Foods high in unsaturated fat can help decrease your cholesterol level. These foods include:

oily fish

avocados

nuts and seeds

sunflower oil

rapeseed

olive oil

High blood cholesterol

High blood cholesterol can cause your arteries to narrow, increasing your risk of developing a blood clot.

Not exercising regularly puts you at risk of getting high blood pressure and high cholesterol. Being physically inactive
also increases your chances of becoming overweight (see below).

Exercise

To maintain a good level of health, the Department of Health recommends that you do at least:

150 minutes (2 hours and 30 minutes) of moderate-intensity aerobic activity, such as cycling or fast walking, every
week, and
 muscle-strengthening activities on two or more days a week that work all major muscle groups (the legs, hips, back,
abdomen, chest, shoulders and arms)

Alternatively, you could do:

75 minutes (1 hour and 15 minutes) of vigorous-intensity aerobic activity, such as running or a game of singles tennis
every week, and
muscle-strengthening activities on two or more days a week that work all major muscle groups (the legs, hips, back,
abdomen, chest, shoulders and arms)

Another alternative would be to do:

a equivalent mix of moderate- and vigorous-intensity aerobic activity every week, for example two 30-minute runs plus 30
minutes of fast walking, and
muscle-strengthening activities on two or more days a week that work all major muscle groups (the legs, hips, back,
abdomen, chest, shoulders and arms)

Weight

Being overweight or obese increases your risk of developing a number of serious health conditions, such as diabetes and high
blood pressure.

To lose weight, you need to combine regular exercise with a calorie-controlled diet. After you have reached your ideal weight, you
should aim to maintain it by eating healthily and exercising regularly.

You can use the healthy weight calculator to calculate your body mass index (BMI) and get tips about how to lose weight. You can
also read more about losing weight.

Diabetes

The high blood sugar levels associated with diabetes can damage the body's organs and arteries.

If you have type 1 diabetes, you will need regular insulin treatment to keep your blood sugar levels normal. You will also need to
look after your health very carefully and, if necessary, make changes to your lifestyle.

If you have type 2 diabetes, it may be possible to control your symptoms by making some simple lifestyle changes, such as
exercising regularly and eating healthily. However, you may eventually need medication (tablets or injections) to keep your blood
glucose normal.

Alcohol

Drinking excessive amounts of alcohol can increase your cholesterol and blood pressure levels.

If you drink, you should not exceed the recommended daily alcohol limits. These are:

3-4 units a day for men

2-3 units a day for women

One pint of ordinary strength beer, lager or cider contains two units of alcohol, and a small glass of wine (125ml) or a single pub
measure (25ml) of spirits contains one unit.

You should visit your GP if you are finding it difficult to moderate your drinking. Treatments such as counselling and medication are
available to help you reduce your alcohol intake.

Read more about alcohol units and alcohol misuse.

Stress

Reducing the amount of stress in your life may help you control your blood pressure more effectively, as well as keeping your blood
sugar levels under control. Both of these will help reduce your risk of getting cerebrovascular disease.

Regular exercise has been shown to reduce stress levels, as have relaxation techniques such as deep breathing and yoga.

Read more about managing stress.

Medication

If your risk of getting cerebrovascular disease is thought to be particularly high, medication may be prescribed to help reduce your
risk.

For example, you may be prescribed:

statins to help lower blood cholesterol levels

anticoagulants (blood-thinning medication) such as warfarin or low-dose aspirin, to help prevent blood clots
angiotensin-converting enzyme (ACE) inhibitors to treat high blood pressure
Preventing malnutrition

Over 3 million people across the UK are either malnourished or at risk of malnourishment. Over 1 million are over the age of 65.

Age UK is a founding member of The Malnutrition Task Force, an independent group of experts across health, social care and local
government united to address avoidable and preventable malnutrition in older people. The Task Force is chaired by Age UKs
Chairman Dianne Jeffrey CBE DL.

The Malnutrition Task Force is currently piloting a prevention programme, funded by The Department of Health, to help the 1 million
older people in England who are suffering from or are at risk of malnutrition.

About the programme

The programme sees whole communities including local NHS trusts, hospitals, GP practices, care homes and community groups
coming together to tackle malnutrition. The aim is to significantly reduce the number of people aged 65 and over in these areas
who are malnourished.

This whole community approach is currently being piloted in five different areas across England, with the learning and results from
these to be disseminated nationally. The pilot areas are Gateshead, Salford, Purbeck in Dorset, Keny and Lambeth and Southwark.

The Programme is part of the Governments response to the Francis Report into the failings at the Mid Staffordshire Foundation
Trust (see Recommendation 241 on the Department of Health website).

The report revealed that patients, many of them older, had been unable to eat or drink properly and that nutrition was not treated as
a priority.

5 key principles

The Programme is based on 5 principles, identified by the Malnutrition Task Force, that are key to providing good nutrition and
hydration care:

1. Raise awareness of malnutrition

2. Work together
3. Identify older people who are malnourished or at risk
4. Provide support, care and treatment and monitor progress;
5. Monitor and evaluate your activities

All organisations participating in the whole communities approach will implement the five principles above in a way that reflects the
locally agreed vision and objectives.

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 Controlled drugs

Categories:

Organisations we regulate

This section provides information about our role and the legal responsibilities of healthcare providers that handle controlled drugs.

You can also download the Self assessment tools for primary care providers/commissioners and acute NHS trusts or independent
hospitals.

Our work to oversee the safer management of controlled drugs

Our work involves:

providing external scrutiny on how other regulators and agencies work together following the Government's response on
the management of controlled drugs after the fourth report of the Shipman inquiry.
leading a national group of the regulators and agencies involved in different aspects of the management and use of
controlled drugs, to look at national trends in their use.
reporting to Government on how partner organisations work together.
assessing and overseeing how health and social care providers manage controlled drugs.
taking part in local intelligence networks led by primary care trusts. These networks bring together organisations from the
NHS and independent health, and other responsible bodies, regulators and agencies including the Royal Pharmaceutical Society of
Great Britain, NHS counter fraud and security management services and police services.

The tools have now been revised and the previous numerical scoring system replaced with a RAG (red, amber, green) rating.

We will run the tools as a pilot for the next six months (until 31st March 2015) and would welcome your comments and feedback
during this time. We will then consider what changes need to be made, based on comments received.

Please send your feedback to medicines.enquiries@cqc.org.uk.

Annual reports

Our latest annual report on the safe management of controlled drugs 2013.

We found the prescribing trends for controlled drugs were:

In 2013, the total number of controlled drugs items prescribed in NHS primary care was 47,044,814, which is a decrease
of 1% compared with 2012. The cost of this was 498,942,743 representing an increase of 10% compared with 452,761,855 in
2012.
The prescribing of temazepam a benzodiazepine hypnotic (sleeping agent) has continued to fall steadily since 2007.
Between 2012 and 2013, prescriptions fell by 355,357.However, it is likely that the non-benzodiazepine hypnotics, zolpidem,
zopiclone and zaleplon, are now being prescribed instead.
At the same time (since 2007) there have been increases in prescribing of morphine sulphate, oxycodone, fentanyl,
methylphenidate and midazolam.
Private prescribing of controlled drugs decreased by 6% in 2013 (36,935 items), compared with 2012 (39,203 items).
Private prescribing accounts for about 0.1% of overall controlled drug prescribing.
The use of drugs to provide relief for severe and long term pain management has increased, with use of Morphine up by
223,838 between 2012 to 2013 and use of Fentanyl up by 42,155 between from 2012 to 2013.
 Attention Deficit Hyperactivity Disorder (ADHD) drug, methylphenidate continues to rise steadily in use from last year by
68,458. Private prescriptions for this drug increased by 7% in 2013.

The following seven recommendations have been made.

1. NHS England controlled drug accountable officers must be adequately resourced to carry out their roles and
responsibilities with regard to controlled drugs.
2. NHS England controlled drug accountable officers must be clear about their responsibilities for controlled drug governance
arrangements and strengthen their relationships with clinical commissioning groups (CCGs) and commissioning support units
(CSUs) so that these organisations are clear as to how they can support them.
3. NHS England controlled drug accountable officers should consider organising learning events for controlled drug
accountable officer colleagues and controlled drug leads, to enable them to share learning and best practice.
4. NHS England controlled drug accountable officers should consider extending membership of the controlled drug local
intelligence network to other relevant local organisations (such as social enterprise organisations or community interest
companies) either on a permanent or as required basis.
5. A formal process should be put in place by NHS England controlled drug accountable officers to ensure controlled drug
concerns and good practice are shared nationally where appropriate.
6. Healthcare providers must determine whether they are required to appoint a controlled drug accountable officer or whether
they meet the criteria for an exemption.
7. The Care Quality Commission should summarise the key messages from the Controlled Drugs National Group meetings
and circulate them to NHS England controlled drug accountable officers to pass on to members of their controlled drug local
intelligence networks.
----------------------------------------------------------------------

The 6Cs
1. Care Care is our core business and that of our organisations and the care we deliver helps the individual person
and improves the health of the whole community. Caring defines us and our work. People receiving care expect it
to be right for them consistently throughout every stage of their life.
2. Compassion Compassion is how care is given through relationships based on empathy, respect and dignity. It
can also be described as intelligent kindness and is central to how people perceive their care.
3. Competence Competence means all those in caring roles must have the ability to understand an individuals
health and social needs. It is also about having the expertise, clinical and technical knowledge to deliver effective
care and treatments based on research and evidence.
4. Communication Communication is central to successful caring relationships and to effective team working.
Listening is as important as what we say and do. It is essential for no decision about me without me.
Communication is the key to a good workplace with benefits for those in our care and staff alike.
5. Courage Courage enables us to do the right thing for the people we care for, to speak up when we have
concerns. It means we have the personal strength and vision to innovate and to embrace new ways of working.
6. Commitment A commitment to our patients and populations is a cornerstone of what we do. We need to build on
our commitment to improve the care and experience of our patients. We need to take action to make this vision
and strategy a reality for all and meet the health and social care challenges ahead.

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What is dehydration?

Dehydration occurs when the body loses more water than is taken in. It is often accompanied by disturbances in the
bodys mineral salt or electrolyte balance especially disturbances in the concentrations of sodium and potassium.

Under typical circumstances the body loses and needs to replace approximately 2 to 3 litres of water daily. Breathing, urinating,
defecating, and perspiring all cause water losses that need to be replaced on a daily basis. If water is lost from the bloodstream,
the body can compensate somewhat by shifting water from cells into the blood vessels, but this is a very short-term solution. If the
lost water is not replenished, the body may suffer serious consequences.

The body is able to monitor the amount of water it needs to function. The thirst mechanism signals the body to drink when the body
water content is reduced. Hormones, including anti-diuretic hormone (ADH), work with the kidney to limit the amount of water lost in
the urine when the body needs to conserve water. Water intake and output are highly variable but closely matched to less than
0.1% over an extended period through homeostatic control. Electrolyte intake and output are also closely linked, both to each other
and to the hydration status.

Failure to match intake and loss of water and minerals, especially sodium and potassium, may lead to dehydration. Depending on
the ratio of water to electrolyte loss, dehydration can be classified as isotonic, hypertonic or hypotonic:

Isotonic dehydration

Is characterised by isotonic loss of both water and solutes from the extracellular fluid, that is when both water and sodium are lost
in equivalent amounts, e.g. through vomiting, diarrhoea or through inadequate intake. There is no osmotic shift of water from the
intracellular space to the extracellular space. This type of dehydration accounts for cases of dehydration in young children.

Hypertonic dehydration

In hypertonic dehydration water loss exceeds salt loss, that is when more water than sodium is lost (e.g. through inadequate water
intake, excessive sweating, osmotic diuresis and diuretic drugs). This is characterised by an osmotic shift of water from the
intracellular fluid to the extracellular fluid. This type of dehydration is more common in people who have diabetes, and it accounts
for approximately 10 to 20 percent of all paediatric cases of dehydration with diarrhoea.

Hypotonic dehydration

In hypotonic dehydration more sodium than water is lost, e.g. in some instances of high sweat or gastro-intestinal water losses or
when water and electrolyte deficits are treated with water replacement only, it is characterised by an osmotic shift of fluid from the
extracellular area to the intracellular. It also occurs with excessive intakes of plain water or other liquids with little or no sodium
content. This type of dehydration accounts for approximately 10 to 15 percent of all paediatric cases of dehydration with diarrhoea.
This complication can be life-threatening if swelling causes pressure on the brain (cerebral oedema). This is called hyponatraemia.

How is dehydration caused?

Mild dehydration is common and usually caused by not drinking enough fluids throughout the day. In children, diarrhoea is a
common cause.

Fluids are continuously lost through normal body functions such as sweating, breathing and urinating. Common causes of
dehydration include gastrointestinal water loss caused by diarrhoea and vomiting, excessive urination, excessive water loss
through the skin (sweating) and lungs (breathing) due to heat and/or humidity, physical activity and fever or burns.

Diarrhoea

One of the most common reasons a person loses excess water is an infection that causes diarrhoea. Diarrhoea may be caused by
bacteria, viruses or parasites. A significant amount of water can be lost with each bowel movement up to 1 litre per hour in
extreme cases. Worldwide, more than four million children die each year because of dehydration from diarrhoea.

Vomiting

The rapid loss of water that occurs with severe and sustained vomiting makes dehydration more likely to occur, as it is difficult to
restore hydration status by drinking. The risk of dehydration due to vomiting is higher in infants and children, in the elderly, in
people with eating disorders (e.g. bulimia) and anyone taking medications that can cause vomiting.

Excessive urination

There are certain medications that increase urination beyond normal levels (e.g. diuretics), and there are conditions that affect
kidney function, leading to the loss of body water through urine. Conditions that may affect urine production include diabetes and
kidney cancer. Diabetes is characterised by elevated blood sugar levels causing sugar to spill into the urine and excessive urination
which can lead to significant dehydration.

Sweating
 Sweating or perspiration is the mechanism used by the body to cool itself in conditions of heat, humidity and physical activity.
Humidity can play a greater role in dehydration than heat, because the sweat drips from the body rather than evaporating, and thus
does not cause a loss of heat from the body. However, high rates of sweating can also occur during sports or other vigorous
physical activity in cool and dry conditions, contributing to the risk of dehydration. Heavy clothing limits sweat evaporation meaning
that body heat is not dissipated causing the body to lose even more water as it attempts to lose more heat.

Fever or burns

These conditions, including sunburn, increase body temperature, requiring more fluid for proper body functioning. Fever is present
due to an infection and the body uses a significant amount of water in the form of sweat to cool itself. Burn victims become
dehydrated because water seeps into the damaged skin and is lost by evaporation.

Inadequate intake of liquids during hot weather or exercise may also deplete the bodys water stores. Anyone may
become dehydrated, but young children, older adults and people with chronic illnesses are most at risk.

Consequences

A loss of body water equivalent to about 1% of body weight is normally compensated within 24 hours. Thirst stimulates drinking, so
intake is increased and there is also a reduction in water loss by the kidneys. If losses are greater than this, reductions in physical
and cognitive performance may occur and there may be some impairment of thermoregulation and cardiovascular function

Mild dehydration can cause symptoms such as thirst, headache, weakness, dizziness and fatigue and generally makes people feel
tired and lethargic. Symptoms of moderate dehydration may include dry mouth, little or no urine, sluggishness, a rapid heartbeat
and lack of skin elasticity. Severe dehydration is a life-threatening medical emergency, and is characterized by extreme thirst, no
urine, rapid breathing, altered mental state and cold, clammy skin.

Increasing levels of dehydration with fluid losses of more than 1% of body weight can lead successively to reduction in exercise
performance and in the ability to control body temperature. With fluid deficits of 4% and more, severe performance decrements
may be observed as well as difficulties in concentration, headaches, irritability and sleepiness, and increases in body temperature
and in respiratory rates. Dehydration that causes a loss of 10% or more of body weight can be fatal.

As dehydration progresses, the volume of water in the blood stream decreases, and blood pressure may fall. Cardiovascular
function is impaired with increasing levels of dehydration, with a rise in heart rate and difficulties in maintaining the volume of blood
that the heart delivers to the tissues. The heart pumps harder to maintain blood flow to the organs, but blood pressure may fall as
the blood volume falls. Reduced blood flow to the skin and reduced levels of hydration keep the body from sweating and dissipating
heat.

Chronic dehydration can increase the risk of infection, particularly of the urinary tract. The kidneys and other major organs that
receive a decreased blood flow may begin to fail. Kidney failure is a common occurrence, although it is reversible if it is due to
dehydration and is treated early. Decreased blood supply to the brain may cause confusion, impairing both cognitive function and
coordination.

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What are blood-borne viruses?

Blood-borne viruses (BBVs) are viruses that some people carry in their blood and can be spread from one person to another.
Those infected with a BBV may show little or no symptoms of serious disease, but other infected people may be severely ill. You
can become infected with a virus whether the person who infects you appears to be ill or not indeed, they may be unaware they
are ill as some persistent viral infections do not cause symptoms. An infected person can transmit (spread) blood-borne virsuses
from one person to another by various routes and over a prolonged time period.

The most prevalent BBVs are:

human immunodeficiency virus (HIV)- a virus which causes accuired immunodeficiency virus (AIDS), a
disease affecting the body's immune system;
 hepatitis B (HBV) and hepatitis C; BBVs causing hepatitis, a disease affecting the liver.
As well as through blood, these viruses can also be found and transmitted through other body fluids,
for example:
vaginal secretions;
semen; and
breast milk.
Unless contaminated with blood, minimal risk of BBV infection is carried by:
urine;
saliva;
sweat;
tears;
sputum;
vomit; and
faeces.
The presence of blood in these bodily fluids and materials isn't always obvious, so care should still always be taken to avoid
infection.

Blood-borne viruses that cause hepatitis include the hepatitis B virus (HBV) and hepatitis C virus (HCV). Other viruses that cause
hepatitis (such as hepatitis A and E) are not usually passed on by blood-to-blood contact and hence do not present a significant risk
of blood-borne infection. The hepatitis D virus, previously known as the 'delta agent', is a defective virus, which can only infect and
replicate in the presence of HBV.

The number of occupational exposure incidents relating to blood or other high-risk body fluids are collated and reported bi-annually
by the Health Protection Agency (HPA) in their Eye of the Needle report.

Human immunodeficiency viruses (HIV-1 and HIV-2)

There are two types of HIV virus; HIV-1 and HIV-2. [Move next text to line below]
HIV-1 is responsible for the majority of global HIV infections and cases of acquired immune deficiency syndrome (AIDS), while the
relatively less common HIV-2 is mainly restricted to West Africa.

HIV-1 and HIV-2 are very similar in almost every respect, although growing evidence indicates that progression of disease is slower
in HIV-2 infection. Unless specifically highlighted, the properties of these viruses are presented under the generic term 'HIV'.

Pathogenesis of HIV infection

HIV infects certain types of white blood cell; specifically helper T-lymphocytes, monocytes and some other cells that are key
elements of the human immune system. This usually results in the death of these cells. The hallmark of HIV infection is the gradual
loss of helper T-lymphocytes from an infected person. This ultimately leads to a state of generalised immunodeficiency and AIDS.
In some cases, infection of the central nervous system occurs, often leading to progressive brain damage (encephalopathy).

Several different conditions may occur as a result of HIV infection that precedes the development of AIDS. Most infected individuals
generate antibodies to HIV within a few weeks after infection and, during this period, may develop a self-limiting illness resembling
glandular fever (infectious mononucleosis). After a longer period, some develop a long-lasting generalised enlargement of the
lymph glands. Other non-specific symptoms (including fever, night sweats and swollen lymph glands) are associated with
progressive immune dysfunction. When AIDS develops fully, which often takes several years, it is characterised by the appearance
of secondary opportunistic infections and tumours.

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Developing a culture of compassionate care
October 8, 2012

Care, compassion, competence, communication, courage and commitment. These are the six Cs set out in the Chief
Nursing Officer's recent consultation paper Developing the culture of compassionate care: Creating a new vision and
strategy for nurses, midwives and care-givers.

The paper aims to 'set out a shared purpose' for staff in those roles, with six key areas for action. But why do we need a new vision
for nurses, midwives and care-givers? And what difference will this vision make?

Two years ago, the Prime Minister's Commission on the Future of Nursing and Midwifery in England published a vision for
nursing and midwifery called Front Line Care, which seems to have disappeared into oblivion. And only five months ago, the
Nursing and Care Quality Forum (NCQF) published a letter to this Prime Minister with perfectly sensiblerecommendations about
what to do about nursing. The Chief Nursing Officer is working with the NCQF but the vision does not refer to its
recommendations.

The new vision differs a little from the earlier ones. It focuses much more on nurses' and midwives' roles in prevention and health
promotion and on making every contact count'. Strangely, given the focus on care and compassion, it does not mention nurses'
contribution to caring for the half a million people who die each year, fifty percent of whom die in hospital. The NCQF has been
explicit that quality of care is linked to staffing, skill mix, and nurses and midwives being able to spend time with individual patients.
This new paper acknowledges that lack of time, lack of support, long shift patterns and expanded roles contribute to the apparent
lack of empathy in some areas of nursing. However it defers tackling these challenges until the next stage of the work, without
saying when that will start or how many stages will follow.

Fundamentally however, what is troubling about this vision and the others is the attempt to create an independent vision for
nursing, midwifery, and care-giving separate from the rest of the health care system. All the visions acknowledge that nurses and
midwives are members of a 'wider team', but they are not co-produced with health professionals and managers or with patients and
relatives. Of course the professions have their own cultures, their own bodies of knowledge and practice, and their own hierarchies
and ways of working. And values and behaviours in nursing and midwifery are critically important. But nurses, midwives and care-
givers look after patients in the context of organisations, not in isolation. It's simply not possible to deliver reliable, compassionate
care 24/7 unless the system as a whole makes it a priority and the most powerful people in the system actively demonstrate their
commitment to the values and behaviours that support caring. Read the excellent 'Preventing Abuse and Neglect in Institutional
Care of Older Adults' (PANICOA) Dignity in Care report, or the hundreds of pages of testimony to the Mid-Staffordshire
Inquiry, or the report of the investigation into Winterbourne View and then ask yourself how much change nurses, midwives
and care assistants can achieve on their own, and without the active support of others in the system.

In the USA a growing number of organisations are appointing Board-level Chief Experience Officers. In the absence of such a role
on the NHS Commissioning Board, I would like to see a vision for care for patients and their relatives, jointly written by the Chief
Executive, the Chief Nursing Officer, the Chief Medical Officer, the Director of Patient Experience and the Chief Financial Officer
and signed off by the whole Board. The Board, by virtue of its position, will shape the wider culture of care and working practices
across the whole of the health care system. How good it would be to see those at the top modelling the collaborative leadership
and close working that patients and relatives need between the nurses, doctors, therapists, managers and support staff who look
after them.

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Religion and food

Many of the features that shape dietary habits are derived from religious laws. All over the world many people
choose to eat or avoid certain foods according to their religious beliefs. When a dietary practice is preserved by
religious dogma it is given additional force. Dietary differences linked to religion should be considered when
planning a balanced diet. While not all religions have specific guidance regarding food, here are some of the major
religions and a brief look at how they impact eating habits:

Buddhism
Buddhism considers living beings to be sacred, a belief that has translated into widely practiced vegetarianism and
veganism. Violence towards animals is considered to translate into human aggression; hence most Buddhists will
keep to the principle of ahimsa (non-violence or harmlessness) and avoid all foods related to processes where
harm was done. Some Buddhists avoid meat and dairy products while others avoid only meat. Buddhists also
avoid the consumption of alcohol. Monks of this religion fast in the afternoon and rely on alms or donations of
food as they, along with Buddhist nuns, are not allowed to cultivate, store or cook their own food.
Christianity
Food regulations differ from one Christian denomination or group to another, with some groups not observing any
restrictions at all. Some fasting days are observed by Catholic and Orthodox Christians on certain days such as
Good Friday or during Lent. In earlier centuries, meat and dairy products were avoided during a substantial portion
of the year, but today it often just means eating fish on a Friday. The ritual of consuming bread and wine (Holy
Communion or the Eucharist) is regularly celebrated but its symbolic or actual meaning in relation to the body and
blood of Jesus Christ depends on the denomination.
Hinduism
Hinduism is one of the most ancient religions in the world and, although meat was not originally prohibited, many
Hindus today regard vegetarianism as a way to maintain the respect observed for life. Hinduism is characterized
by the avoidance of the killing of any animal, the cleansing of those involved in food preparation, which is a
reflection on previously existing caste-restricted practices, and the symbolism of certain foods. The cow is held in
high regard as a symbol of abundance and so it is not eaten by Hindus, yet products such as milk, butter and
yogurt may be eaten. Some Hindus fast on selected days as a mark of respect to certain gods.
Islam
The main food practices in Islam involve specific ritual slaughtering procedures for animals of consumption
(haram practices), fasting during the month of Ramadan, the avoidance of pork and of intoxicating liquor. Foods
are categorised as halal (those than may be eaten) and haram (those that should be avoided), as are other
aspects of life. Most foods arehalal while the list of haram foods includes pork, alcohol and any products that may
contain emulsifiers made from animal fats (such as gelatines and margarines). Bread and bread products
fermented by yeast may contain traces of alcohol and in some cases may be considered haram. Moderation in all
things, including eating and dietary habits, are an integral part of Islam.
Rastafari movement
Most Rastafarians are vegetarian or vegan. Foods that may be consumed by people practicing this religion are
called ital; these foods are characterised by having no artificial colours, flavours or preservatives, hence being
considered pure or natural. Rastafarians also avoid the consumption of alcohol and in some cases also tea, coffee
and other caffeinated drinks as it is considered that these foods confuse the soul.
Judaism
In this religion foods are divided into kosher (allowed) or trefa (forbidden). Characteristics of kosher foods include
animals that have a completely split hoof and chew cud (such as cows, goats and sheep), while kosher fish must
have fins and scales. In general all plant foods are kosher. In addition, a specific slaughtering process must be
followed for meat to be considered kosher. Meat and dairy products must not be prepared, stored or eaten
together and certain fasting days are observed (especially Yom Kippur). During the celebration of Passover, food
helps to tell the story of the Exodus from Egypt.

Food selection is due to different reasons, with religion being one of the strongest principles on which diets are
based. Sacred space and time (altars, shrines, feast and fasting days), as well as symbolism and myth (what foods
represent or the stories they recall) are all part of religious rituals linked to food. Regardless of religious views, it is
important to follow a balanced diet and favourable lifestyle for optimum health.

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10Exemptions for pharmacists.

(1)Subject to the next following subsection, the restrictions imposed by sections 7 and 8 of this Act do not apply to anything which is
done in a registered pharmacy, a hospital [F1, a care home service] or a health centre and is done there by or under the
supervision of a pharmacist and consists of

(a)preparing or dispensing a medicinal product in accordance with a prescription given by a practitioner, or

(b)assembling a medicinal product [F2provided that where the assembling takes place in a registered pharmacy

(i)it shall be in a registered pharmacy at which the business in medicinal products carried on is restricted to retail sale or to supply
in circumstances corresponding to retail sale and the assembling is done with a view to such sale or supply either at that registered
pharmacy or at any other such registered pharmacy forming part of the same retail pharmacy business, and

(ii)the medicinal product has not been the subject of an advertisement]; and those restrictions do not apply to anything done by or
under the supervision of a pharmacist which consists of procuring the preparation or dispensing of a medicinal product in
accordance with a prescription given by a practitioner, or of procuring the assembly of a medicinal product.

(2)The exemption conferred by the preceding subsection does not apply to a vaccine specially prepared for administration to
poultry, and does not apply to any other vaccine or any plasma or serum prepared or dispensed for administration to an animal or
herd unless

(a)in the case of a vaccine, it is specially prepared for administration to the animal from which it is derived, or

(b)in the case of plasma or a serum, it is specially prepared for administration to one or more animals in the herd from which it is
derived,

and (in either case) it is so prepared in accordance with a prescription given by a veterinary surgeon or veterinary practitioner.

(3)Those restrictions do not apply to the preparation or dispensing in a registered pharmacy of a medicinal product by or under the
supervision of a pharmacist in accordance with a specification furnished by the person to whom the product is or is to be sold or
supplied, where

(a)the product is prepared or dispensed for administration to that person or to a person under his care, or

(b)the product, not being a vaccine, plasma or serum, is prepared or dispensed for administration to an animal or herd which is in
the possession or under the control of that person.

(4)Without prejudice to the preceding subsections, the restrictions imposed by sections 7 and 8 of this Act do not apply to anything
which is done in a registered pharmacy by or under the supervision of a pharmacist and consists of

(a)preparing or dispensing a medicinal product for administration to a person where the pharmacist is requested by or on behalf of
that person to do so in accordance with the pharmacists own judgment as to the treatment required, and that person is present in
the pharmacy at the time of the request in pursuance of which that product is prepared or dispensed, or

(b)preparing a stock of medicinal products with a view to dispensing them as mentioned in subsection (1)(a) or subsection (3) of
this section or in paragraph (a) of this subsection [F3provided that such stock is prepared with a view to retail sale or to supply in
circumstances corresponding to retail sale and the preparation is done with a view to such sale or supply either at that registered
pharmacy or at any other registered pharmacy forming part of the same retail pharmacy business];

and those restrictions do not apply to anything which is done in a hospital or a health centre by or under the supervision of a
pharmacist and consists of preparing a stock of medicinal products with a view to dispensing them as mentioned in subsection (1)
(a) of this section.

[F4(5)Without prejudice to the preceding subsections, the restrictions imposed by section 7 of this Act do not apply to the
preparation or dispensing in a registered pharmacy of a medicinal product by or under the supervision of a pharmacist where

(a)the medicinal product is prepared or dispensed otherwise than in pursuance of an order from any other person, and

(b)the medicinal product is prepared with a view to retail sale or supply in circumstances corresponding to retail sale at the
registered pharmacy at which it is prepared, and

(c)the medicinal product has not been the subject of an advertisement.

(6)Without prejudice to the preceding subsections, the restrictions imposed by section 8(2) of this Act do not apply to anything
which is done in a registered pharmacy by or under the supervision of a pharmacist and consists of preparing a medicinal product
with a view to retail sale or to supply in circumstances corresponding to retail sale at that registered pharmacy.

[F5(6A)The preceding provisions of this section shall not have effect so as to exempt from the restrictions imposed by sections 7
and 8 of this Act anything done in a registered pharmacy by or under the supervision of a pharmacist in relation to a ready-made
veterinary medicinal product as defined in Article 1.2 of the 1981 Directive.]

(7)Without prejudice to the preceding subsections, the restrictions imposed by section 8(3) [F6or (3A)] of this Act do not apply to
anything which is done in a registered pharmacy by or under the supervision of a pharmacist and amounts to wholesale dealing,
where such dealing constitutes no more than an inconsiderable part of the business carried on by the pharmacist at that pharmacy.

(8)For the purposes of this section advertisement" shall have the meaning assigned to it by section 92 of this Act, except that it
shall not include words inscribed on the medicinal product, or on its container or package.]

[F7(9)In subsection (1) of this section, care home service" has the meaning given by section 2(3) of the Regulation of Care
(Scotland) Act 2001 (asp 8).]

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What is a care plan?

Everyone with a long-term condition can have a care plan if they want one.

A care plan is an agreement between you and your health professional (or social services) to help you manage your health day to
day. It can be a written document or something recorded in your patient notes.

Everyone who has a long-term condition can take part in making their care plan. It helps to assess what care you need and how it
will be provided.

If you think a care plan could help you, talk to your GP, nurse or social worker about the support you need to manage your
condition better. Mention things that are important to you and any goals you want to work towards. These can range from losing
weight or stopping smoking, to going out more or getting back to work.

Also, try to talk about anything that might be worrying you. For example, some people want to talk about how lonely or anxious they
feel.

By talking about your care plan with your GP, nurse or social worker, you can say how you want to manage your health and choose
what's best for you. The care plan will be based on what you want so you're in control.

The care plan is designed to help you, rather than the GP and other healthcare workers that look after you. It will cover areas
including:

the goals you want to work towards, such as getting out of the house more, returning to work, or starting a hobby

the support services you want, who is in charge of providing these services, what the support services have agreed to
do, and when they will do it

emergency numbers, such as who you should contact if you become very unwell and your doctor's surgery is closed

medicines

an eating plan

an exercise plan
Make sure you say what's important to you and that you're happy with any decisions that are put into the plan. Unless health and
social care workers know what you want, they can't put it in.

Usually your care plan will be printed out for you to take home. If you're not given a paper copy, ask for one. Your care plan may
also be stored in your GP practice's computer system.

All the information in the care plan is private, seen only by you and the people who give you care or support. If you want someone
else to be allowed to see the care plan, you can say so.

Your plan will be looked over at fixed times as part of a care plan review. You can have a care plan review at least once a year. You
can also ask for one if you feel the care plan isn't working or if other things in your life change.

---------------------------------------------

Introduction

Suicide is the act of intentionally ending your life.

If you are reading this because you have, or have had, thoughts about taking your own life, it's important you ask someone for help.
It's probably difficult for you to see at this time, but you're not alone and not beyond help.

Many people who have had suicidal thoughts say they were so overwhelmed by negative feelings they felt they had no other
option. However, with support and treatment they were able to allow the negative feelings to pass.

Getting help

If you are feeling suicidal, there are people you can talk to who want to help:

speak to a friend, family member or someone you trust as they may be able to help you calm down and find some
breathing space

call the Samaritans 24-hour support service on 08457 90 90 90

go to, or call, your nearest accident and emergency (A&E) department and tell the staff how you are feeling

contact NHS 111

make an urgent appointment to see your GP

Read more about getting help if you're feeling suicidal.

Worried someone else is suicidal

If you are worried that someone you know may be considering suicide, try to encourage them to talk about how they are
feeling. Listening is the best way to help. Try to avoid offering solutions and try not to judge.

If they have previously been diagnosed with a mental health condition, such as depression, you can speak to a member of their
care team for help and advice.

Read more about suicide warning signs and how you can help someone with suicidal thoughts.
Why do some people take their own life?

There is no single reason why someone may try to take their own life, but certain things can increase the risk.

A person may be more likely to have suicidal thoughts if they have a mental health condition, such as depression, bipolar
disorder orschizophrenia. Misusing alcohol or drugs and having poor job security can also make a person more vulnerable.

It is not always possible to prevent suicidal thoughts, but keeping your mind healthy with regular exercise, healthy eating
and maintaining friendships can help you cope better with stressful or upsetting situations.

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Metric BMI Formula

BMI = ( Weight in Kilograms / ( Height in Meters x Height in Meters ) )

Category BMI range kg/m2 BMI Prime

Very severely underweight less than 15 less than 0.60

Severely underweight from 15.0 to 16.0 from 0.60 to 0.64

Underweight from 16.0 to 18.5 from 0.64 to 0.74

Normal (healthy weight) from 18.5 to 25 from 0.74 to 1.0

Overweight from 25 to 30 from 1.0 to 1.2

Obese Class I (Moderately obese) from 30 to 35 from 1.2 to 1.4

Obese Class II (Severely obese) from 35 to 40 from 1.4 to 1.6

Obese Class III (Very severely obese) over 40 over 1.6

New NICE guidance for the longer-term management of self-harm

NICE, the healthcare guidance body, has today published a new clinical guideline on the longer-term care of adults,
children and young people who self-harm.

This new guideline follows on from the NICE guideline on the short-term physical and psychological management
and secondary prevention of self-harm in primary and secondary care (NICE clinical guideline 16). The new
recommendations focus on the longer-term psychological treatment and management of self-harm.

Dr Fergus Macbeth, Director of the Centre for Clinical Practice at NICE, said: "Self-harm is a very broad term for a
behaviour that can be expressed by those affected in very individual ways, which is why it is so important that
each person receives the right care plan for them. The previous NICE guideline on the short-term treatment of self-
harm focused on the first 48 hours of an episode and the care they received in the Emergency Department. This
new guideline aims to help healthcare professionals support, in the longer term, people who are known to self-
harm in reducing and then stopping the behaviour."

Key recommendations include:

Working with people who self-harm: Health and social care professionals working with people who self-harm should
aim to develop a trusting, supportive and engaging relationship with them, be aware of the stigma and
discrimination sometimes associated with self-harm and ensure that people are fully involved in decision-making
about their treatment and care.

Risk assessment: When assessing the risks of repetition of self-harm or suicide, identify and agree with the person
who self-harms the specific risks for them, taking into account:

- methods and patterns of current and past self-harm

- specific risk factors and protective factors (social, psychological, pharmacological and motivational) that may
increase or decrease the risks associated with self-harm

- coping strategies that the person has used to either successfully limit or avert self-harm or to contain the impact
of personal, social or other antecedents
Do not use risk assessment tools and scales to predict future suicide or repetition of self-harm.

Care plans: Care plans should be multidisciplinary and developed collaboratively with the person who self-harms
and, provided the person agrees, with their family, carers or significant others. The care plan should identify
realistic and optimistic long-term goals, including employment and occupation and identify short-term treatment
goals (linked to the long-term goals) and steps to achieve them

Interventions for self-harm: Consider offering 3 to 12 sessions of a psychological intervention that is specifically
structured for people who self-harm, with the aim of reducing self-harm. The intervention should be tailored to
individual need and could include cognitive-behavioural, psychodynamic or problem-solving elements. Therapists
should be trained and supervised in the therapy they are offering to people who self-harm. Therapists should also
be able to work collaboratively with the person to identify the problems causing distress or leading to self-harm.

Treating associated mental health conditions: Provide psychological, pharmacological and psychosocial interventions
for any associated conditions as described in the relevant NICE guidelines, for example, borderline personality
disorder (NICE clinical guideline 78), depression (NICE clinical guideline 90), bipolar disorder (NICE clinical guideline
38).

Professor Tim Kendall, Director, National Collaborating Centre for Mental Health (NCCMH) Medical Director, Sheffield
Health and Social Care Trust; Consultant Adult Psychiatrist, said: "Self-harm is very common and involves a wide
range of methods, the most common being self-poisoning with prescribed or over the counter medicines, or by
cutting. People self-harm for numerous reasons, and although self harm is not usually an attempt at committing
suicide, it is a way of expressing deeper emotional feelings, such as low self-esteem, the emotional results of
previous abuse and hurts. However, people who self harm are much more likely to die by suicide, and many suffer
from long term physical effects of self injury and self poisoning, as well as psychiatric problems such as depression.
It is very important that we help identify people who self harm sooner and to help them come to terms with the
underlying problems and access treatment when they need it. This guideline is a really important step to achieving
this".

Professor Navneet Kapur, Professor of Psychiatry and Population Health, University of Manchester. Honorary Consultant
Psychiatrist, Manchester Mental Health and Social Care Trust and Chair of the Guideline Development Group,
said: "People may keep self-harm a secret which means it is difficult to know how widespread it is. Many cases are
unreported unless medical treatment is required. However, it is thought to be common, especially amongst young
people, with one UK study finding that 1 in 10 girls aged 15-16 had self-harmed in the previous year. This new
guideline is an important step in improving health professionals' understanding of self-harm and thereby helping to
ensure people receive the treatment and support they need."
Dr Suzanne Kearney, GP in Aylesbury and guideline developer, said: "Although most people who self-harm do not wish
to end their lives, it does increase the likelihood that the person will eventually die by suicide by between 50- and
100-fold. NICE has already published guidance on what services should be offered to people immediately after an
episode of self-harm; with this new guideline on the longer term management, we hope to provide healthcare
professionals with clear recommendations on how to work with people who self-harm and enable them to choose
the right treatment for their individual needs."

Mr Gareth Allen, guideline developer representing service user and carer interests, said: "Every person who self-harms
is different; they do it for individual reasons and have their own individual needs. It is hoped the recommendations
made in this new guideline will help healthcare professionals identify the needs and risks that should be considered
when assessing a person who has self-harmed and the types of treatment available."

Ends
Notes to Editors
About the guidance
1. The guidance will be available on the NICE website (www.nice.org.uk/guidance/CG133) from 23 November, 2011.
2. The focus of this new guidance is the longer-term psychological treatment and management of self-harm, and
does not include recommendations for the physicaltreatment of self-harm.
About NICE
1. The National Institute for Health and Care Excellence (NICE) is the independent organisation responsible for
providing national guidance and standards on the promotion of good health and the prevention and treatment of ill
health
2. NICE produces guidance in three areas of health:
public health - guidance on the promotion of good health and the prevention of ill health for those working in the
NHS, local authorities and the wider public and voluntary sector
health technologies - guidance on the use of new and existing medicines, treatments, medical technologies
(including devices and diagnostics) and procedures within the NHS
clinical practice - guidance on the appropriate treatment and care of people with specific diseases and conditions
within the NHS.
3. NICE produces standards for patient care:
quality standards - these reflect the very best in high quality patient care, to help healthcare practitioners and
commissioners of care deliver excellent services
Quality and Outcomes Framework - NICE develops the clinical and health improvement indicators in the QOF, the
Department of Health scheme which rewards GPs for how well they care for patients
4. NICE provides advice and support on putting NICE guidance and standards into practice through
its implementation programme, and it collates and accredits high quality health guidance, research and information
to help health professionals deliver the best patient care through NHS Evidence.

----------------------------------------------------

Infection: Patient-centred care

This guideline offers best practice advice on the care of adults, young people and children following emergency treatment for
suspected anaphylaxis. For the purpose of this guideline all patients under 16 are classed as children. Those aged 16 and 17 are
classed as young people and those aged 18 and over as adults.

Treatment and care should take into account patients' needs and preferences. People with suspected anaphylaxis should have the
opportunity to make informed decisions about their care and treatment, in partnership with their healthcare professionals. If patients
do not have the capacity to make decisions, healthcare professionals should follow the Department of Health's advice on
consent and the code of practice that accompanies the Mental Capacity Act. In Wales, healthcare professionals should
follow advice on consent from the Welsh Government.

If the patient is under 16, healthcare professionals should follow the guidelines in Seeking consent: working with children.
Good communication between healthcare professionals and patients is essential. It should be supported by evidence-based written
information tailored to the patient's needs. Treatment and care, and the information patients are given about it, should be culturally
appropriate. It should also be accessible to people with additional needs such as physical, sensory or learning disabilities, and to
people who do not speak or read English.

Families and carers should be given the information and support they need.

Care of young people in transition between paediatric and adult services should be planned and managed according to the best
practice guidance described in Transition: getting it right for young people.
Adult and paediatric healthcare teams should work jointly to provide assessment and services to young people with suspected
anaphylaxis. Diagnosis and management should be reviewed throughout the transition process, and there should be clarity about
who is the lead clinician to ensure continuity of care.

-------------------------------------

Patient experience in adult NHS services: improving the experience of care for people using adult NHS services

Over the past few years, several documents and initiatives have highlighted the importance of the patient's
experience and the need to focus on improving these experiences where possible.

Lord Darzi's report High quality care for all (2008) highlighted the importance of the entire patient experience within the NHS,
ensuring people are treated with compassion, dignity and respect within a clean, safe and well-managed environment.
The development of the NHS Constitution (20092010) was one of several recommendations from Lord Darzi's report. The
Constitution describes the purpose, principles and values of the NHS and illustrates what staff, patients and the public can expect
from the service. Since the Health Act came into force in January 2010, service providers and commissioners of NHS care have
had a legal obligation to take the Constitution into account in all their decisions and actions.

The Equality Act 2010 replaces all previous anti-discrimination legislation, and includes a public sector equality duty requiring public
bodies to have due regard to the need to eliminate discrimination and to advance equality of opportunity and foster good relations
between people who share certain protected characteristics and those who do not. The protected characteristics are age, disability,
gender reassignment, pregnancy and maternity, race, religion or belief, sex and sexual orientation. The Act provides an important
legal framework which should improve the experience of all patients using NHS services.

Despite these policy initiatives, there is evidence to suggest that further work is needed to deliver the best possible experience for
users of NHS services. The Government signalled in its White Paper Equity and excellence: liberating the NHS(2010) that more
emphasis needs to be placed on improving patients' experience of NHS care.

This guidance is a direct referral from the Department of Health. It focuses on generic patient experiences and is relevant for all
people who use adult NHS services in England and Wales. The aim of the guidance is to provide the NHS with clear guidance on
the components of a good patient experience. This guidance provides the evidence and the direction for creating sustainable
change that will result in an 'NHS cultural shift' towards a truly patient-centred service.

A NICE quality standard for patient experience in adult NHS services has been developed alongside this guidance. NICE quality
standards are a set of specific, concise statements and associated measures. They set out aspirational, but achievable, markers of
high-quality, cost-effective care. Quality standards are derived from the best available evidence and address three dimensions of
quality: clinical effectiveness, patient safety and patient experience. The quality statements for patient experience in adult NHS
services are listed in the next section.

NICE clinical guidelines are usually shaped around both clinical and economic evidence, and include recommendations concerned
with ensuring a good patient experience, with the recognition that such advice should sit alongside evidence of clinical and cost
effectiveness. The recommendations in the current guidance have been informed by research evidence, recommendations in
previously published NICE clinical guidelines, national survey data and consensus processes that have identified the key elements
that are important to patients and how these can be improved to ensure a good experience of care. The guidance draws on multiple
evidence and data sources in developing the recommendations, which are further distilled into commissioning guidance in the
quality standard.

The recommendations in this guidance are directed primarily at clinical staff, but patient experience is also significantly affected by
contacts with non-clinical staff such as receptionists, clerical staff and domestic staff. Services need to ensure that non-clinical staff
are adequately trained and supported to engage with patients in ways that enhance the patient experience.
Taken together, the recommendations in this guidance capture the essence of a good patient experience. Their implementation will
help to ensure that healthcare services are acceptable and appropriate, and that all people using the NHS have the best possible
experience of care.

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Nutrition support in adults: Oral nutrition support, enteral tube feeding and parenteral nutrition
Malnutrition is a state in which a deficiency of nutrients such as energy, protein, vitamins and minerals causes
measurable adverse effects on body composition, function or clinical outcome. In this guideline we do not use the
term to cover excess nutrient provision.

Malnutrition is both a cause and a consequence of ill health. It is common and increases a patient's vulnerability to
disease. Methods to improve or maintain nutritional intake are known as nutrition support. These include:
oral nutrition support for example, fortified food, additional snacks and/or sip feeds
enteral tube feeding the delivery of a nutritionally complete feed directly into the gut via a tube
parenteral nutrition the delivery of nutrition intravenously.

These methods can improve outcomes, but decisions on the most effective and safe methods are complex.
Currently, knowledge of the causes, effects and treatment of malnutrition among healthcare professionals in the
UK is poor. This guideline aims to help healthcare professionals correctly identify people in hospital and the
community who need nutrition support, and enable them to choose and deliver the most appropriate nutrition
support at the most appropriate time.

The recommendations in this guideline were graded according to the quality of the evidence they were based on.
The gradings are available in the NICE guideline and are not shown in this web version.

Key clinical priorities

Screening for malnutrition and the risk of malnutrition should be carried out by healthcare professionals with
appropriate skills and training.
All hospital inpatients on admission and all outpatients at their first clinic appointment should be screened.
Screening should be repeated weekly for inpatients and when there is clinical concern for outpatients. People in
care homes should be screened on admission and when there is clinical concern.

Hospital departments who identify groups of patients with low risk of malnutrition may opt out of screening these
groups. Opt-out decisions should follow an explicit process via the local clinical governance structure involving
experts in nutrition support.

Nutrition support should be considered in people who are malnourished, as defined by any of the following:
a body mass index (BMI) of less than 18.5 kg/m 2
unintentional weight loss greater than 10% within the last 36 months
a BMI of less than 20 kg/m2 and unintentional weight loss greater than 5% within the last 36 months.

Nutrition support should be considered in people at risk of malnutrition, defined as those who have:
eaten little or nothing for more than 5 days and/or are likely to eat little or nothing for 5 days or longer
a poor absorptive capacity and/or high nutrient losses and/or increased nutritional needs from causes such as
catabolism.
Healthcare professionals should consider using oral, enteral or parenteral nutrition support, alone or in
combination, for people who are either malnourished or at risk of malnutrition, as defined above. Potential
swallowing problems should be taken into account.

------------------------------------

--------------------------------------
Nursing Directorates

Nursing
Nursing (AHP) is part of the Nursing and Allied Health Professionals Directorate, led by Mary Hinds.
Pat Cullen is the Assistant Director of Nursing, Safety Quality and Patient Experience.

Areas of responsibility
Public health, community nursing, primary care, child protection.
Acute and childrens services, cancer and palliative care, quality and standards.
Mental health, elderly care, learning disability and physical disability.
Professional regulation, education, workforce planning and development, research and development activities.
Providing advice on all matters relating to midwifery services; professional input into the development, monitoring
and review of policy with regards to midwifery services; promoting the midwifery agenda in relation to policy,
practice and education, and liaising closely with colleagues in developing midwifery services.
Providing advice on all matters relating to children's services; professional input into the development, monitoring
and review of policy with regards to children's services; promoting the agenda for children across Northern Ireland
in relation to policy, practice and education, and liaising closely with colleagues in developing children's services.
Provision of health facility planning/nursing advice on all major capital/Priorities for Action (PfA) schemes in
Northern Ireland.
Business case analysis.
Decontamination.
Healthcare associated infections (HCAIs) in relation to the estate, clinical waste management and management of
medical devices.
Monitoring and investigation of adverse incidents reported to the Northern Ireland Adverse Incident Centre (NIAIC).
Chair of GAIN Medical Devices Committee.
Emergency planning.

Nursing leads
Molly Kane
Regional Lead Nurse Consultant, Mental Health and Learning Disability

Siobhan McIntyre
Regional Lead Nurse Consultant, Commissioning

Rose McHugh
Lead Primary Care Nurse

Verena Wallace
Lead Midwife

Deirdre Webb
Lead Childrens Nurse

Oriel Brown
Nurse Consultant, Service Development and Service Improvement (Prescribing)

Mary McElroy
Safety, Quality and Patient Experience Lead
-----------------------------------------------------------------------
The Visual Infusion Phlebitis score is a very popular tool for monitoring infusion sites. It is the tool recommended by the RCN for
monitoring infusion sites. In 2006 Paulette Gallant and Alyce Schultz completed an evaluation of the VIP score as a tool that
determines the appropriate discontinuation of peripheral intravenous catheters. The authors state that The VIP scale, as evaluated
in this study, was considered to be a valid and reliable measure for determining when a PIV catheter should be removed Gallant
and Schultz (2006).

VIP score now recommended in the Infusion Nursing Standards of Practice (INS 2011). The Visual Infusion Phlebitis (VIP) scale
has content validity, inter-rater reliability, and is clinically feasible. This scale includes suggested actions matched to each scale
score (INS 2011). The VIP score is also recommended by the English Department of Health and Health Protection Scotland.

Infusion phlebitis originates from two main sources. One is mechanical the other is chemical. By far the most prevalent cause of
infusion phlebitis is chemical in origin. Early recognition of phlebitis will help to maintain patient safety and comfort. Consideration of
blood flow past the tip of the catheter must be viewed in association with the chemical composition of the drug to be infused. A pH
between 5 and 9 is considered appropriate for safe peripheral administration. However, Stranz and Kastango (2002) describe how a
phlebitic episode depends upon the type of tissue that the drug is coming into contact with. They further describe In vitro
experiments have demonstrated that solution pH values of 2.3 and 11 kill venous endothelium cells on contact.

Kennedys-Law.com report on Case Law Kettlety v The Queen Elizabeth Hospital Kings Lynn NHS Trust [2009] LTLPI 27.1.10
Claimant aged 50 years, who had previously undergone aortic and mitral valve replacement, was admitted to Defendant Trust on
16.04.05 with acute coronary syndrome. In course of treatment an IV cannula was inserted into Claimants right elbow. He was
discharged on 19.04.05 with oral antibiotics for cannula site phlebitis. Claimant was readmitted to the Defendant Trust nine days
later with suspected infective endocarditis. Treatment with IV antibiotics failed to prevent damage to mitral valve requiring repeat
double valve replacement surgery on 08.06.05 due to cardiac failure. Claimant suffered severe heart failure affecting function and
longevity. Trust admitted breach of duty in failing to manage the Claimants phlebitis appropriately between 16.04.05 and 19.04.05
and administer intravenous antibiotics earlier which caused or materially contributed to the Claimants endocarditis and the need for
surgery on 08.06.05.

----------------------------------------------------------------------

Clean Care is Safer Care

First Global Patient Safety Challenge

The goal of Clean Care is Safer Care is to ensure that infection control is acknowledged universally as a solid and essential basis
towards patient safety and supports the reduction of health care-associated infections and their consequences.

As a global campaign to improve hand hygiene among health-care workers, SAVE LIVES: Clean Your Hands is a major component
 of Clean Care is Safer Care. It advocates the need to improve and sustain hand hygiene practices of health-care workers at the
right times and in the right way to help reduce the spread of potentially life-threatening infections in health-care facilities.

Announcing the 5 May 2015 Campaign theme!

Strengthening healthcare systems and delivery hand hygiene is your entrance door

What are you doing to be part of a life-saving social epidemic? Some of our collaborators around the globe are already actively
supporting 5 May 2015, including Private Organisations for Patient Safety (POPS).

After 10 years of the WHO Clean is Safer Care programme, here are 10 reasonswhy you should be part of it:

1. Hand hygiene at the right times saves lives.

2. Hand hygiene in health care has saved millions of lives in the last years.
3. Hand hygiene is a quality indicator of safe healthcare systems.
4. Health-care problems, like HAIs which are often invisible but nevertheless still occur, are political and social challenges
that we must address now.
5. Infections can be stopped through good hand hygiene, and patient and health worker harm prevented for less than
$10.
6. Affordable life-saving technology is available! Alcohol-based handrub, which costs approximately $3 per bottle, can
prevent HAI and millions of deaths every year.
7. #handhygiene exists in the media, which means it exists as an important topic, whether due to HAI or outbreaks of
deadly diseases like Ebola.
8. Embedding specific moments for hand hygiene action into health worker workflow makes it easier to do the right thing
every minute, every hour, every day.
9. Infection prevention is at the heart of strengthening health-care systems. Hand hygiene is core to all interventions,
whether inserting an invasive device, managing a surgical wound, or giving an injection.
10. The social epidemic has already begun to spread with SAVE LIVES: Clean Your Hands, a successful global campaign
promoting hand hygiene action at the point of patient care.

-----------------------------------------------------------------------------------

Intravenous fluid therapy in adults in hospital

This guideline contains recommendations about general principles for managing intravenous (IV) fluids, and applies to a ra
conditions and different settings. It does not include recommendations relating to specific conditions.

Many adult hospital inpatients need intravenous (IV) fluid therapy to prevent or correct problems with their fluid
and/or electrolyte status. Deciding on the optimal amount and composition of IV fluids to be administered and the
best rate at which to give them can be a difficult and complex task, and decisions must be based on careful
assessment of the patient's individual needs.

Errors in prescribing IV fluids and electrolytes are particularly likely in emergency departments, acute admission
units, and general medical and surgical wards rather than in operating theatres and critical care units. Surveys
have shown that many staff who prescribe IV fluids know neither the likely fluid and electrolyte needs of individual
patients, nor the specific composition of the many choices of IV fluids available to them. Standards of recording
and monitoring IV fluid and electrolyte therapy may also be poor in these settings. IV fluid management in hospital
is often delegated to the most junior medical staff who frequently lack the relevant experience and may have
received little or no specific training on the subject.

The National Confidential Enquiry into Perioperative Deaths report in 1999 highlighted that a significant number of
hospitalised patients were dying as a result of infusion of too much or too little fluid. The report recommended that
fluid prescribing should be given the same status as drug prescribing. Although mismanagement of fluid therapy is
rarely reported as being responsible for patient harm, it is likely that as many as 1 in 5 patients on IV fluids and
electrolytes suffer complications or morbidity due to their inappropriate administration.

There is also considerable debate about the best IV fluids to use (particularly for more seriously ill or injured
patients), resulting in wide variation in clinical practice. Many reasons underlie the ongoing debate, but most
revolve around difficulties in interpretation of both trial evidence and clinical experience, including the following
factors:
-Many accepted practices of IV fluid prescribing were developed for historical reasons rather than through clinical
trials.
-Trials cannot easily be included in meta-analyses because they examine varied outcome measures in
heterogeneous groups, comparing not only different types of fluid with different electrolyte content, but also
different volumes and rates of administration and, in some cases, the additional use of inotropes or vasopressors.
-Most trials have been undertaken in operating theatres and critical care units rather than admission units or
general and elderly care settings.
-Trials claiming to examine best early therapy for fluid resuscitation have actually evaluated therapy choices made
after initial fluid resuscitation, with patients already in critical care or operating theatres.
-Many trials inferring best therapy for fluid resuscitation after acute fluid loss have actually examined situations of
hypovolaemia induced by anaesthesia.

There is a clear need for guidance on IV fluid therapy for general areas of hospital practice, covering both the
prescription and monitoring of IV fluid and electrolyte therapy, and the training and educational needs of all
hospital staff involved in IV fluid management.

The aim of this NICE guideline is to help prescribers understand the:

-physiological principles that underpin fluid prescribing
-pathophysiological changes that affect fluid balance in disease states
-indications for IV fluid therapy
-reasons for the choice of the various fluids available and
-principles of assessing fluid balance.

In developing the guideline, it was necessary to limit the scope by excluding patient groups with more specialised
fluid prescribing needs. It is important to emphasise that the recommendations do not apply to patients under
16 years, pregnant women, and those with severe liver or renal disease, diabetes or burns. They also do not apply
to patients needing inotropes and those on intensive monitoring, and so they have less relevance to intensive care
settings and patients during surgical anaesthesia. Patients with traumatic brain injury (including patients needing
neurosurgery) are also excluded. The scope of the guideline does not cover the practical aspects of administration
(as opposed to the prescription) of IV fluids.

It is hoped that this guideline will lead to better fluid prescribing in hospitalised patients, reduce morbidity and
mortality, and lead to better patient outcomes.

Strategies for further research into the subject have also been proposed.

The guideline will assume that prescribers will use a drug's summary of product characteristics to inform decisions
made with individual patients.
-------------------------------------------------------------------------------
Healthcare Waste

Overview

Some wastes from healthcare (also called clinical waste) may prove hazardous to those that come into contact with them and are
subject to stringent controls.

Controls on the disposal of healthcare waste

Under the Environmental Protection Act 1990 it is unlawful to deposit, recover or dispose of controlled (including clinical) waste
without a waste management licence, contrary to the conditions of a licence or the terms of an exemption, or in a way which
causes pollution of the environment or harm to human health. Contravention of waste controls is a criminal offence. Section 34 of
the act, places people concerned with controlled (including clinical) waste under a duty of care to ensure that the waste is managed
properly, recovered or disposed of safely and is only transferred to someone who is authorised to keep it. Householders are exempt
for their own household waste.

Hazardous healthcare waste is subject to the requirements of the Hazardous Waste Regulations 2005 (PDF, 83.3KB, 11 pages) .

The Environment Agency is responsible for administering the hazardous waste regime. Again, householders are not subject to the
requirements of these regulations.

The Department of Health published a best practice guide to the management of healthcare waste:

Safe management of healthcare waste

Healthcare waste produced in a private household

Hypodermic needles and other hazardous healthcare wastes should never be disposed of in the domestic waste stream.

If patients are treated in their home by a community nurse or a member of the NHS profession, any waste produced as a result is
considered to be the healthcare professionals waste. If the waste is non-hazardous, and as long as it is appropriately bagged and
sealed, it is acceptable for the waste to be disposed of with household waste. This is usually the case with sanitary towels, nappies
and incontinence pads (known collectively as sanpro waste) which are not considered to be hazardous when they originate from a
healthy population. If the waste is classified as hazardous, the healthcare professional can remove that waste and transport it in
approved containers (ie rigid, leak proof, sealed, secured etc) and take it back to the trust base for appropriate disposal.

If patients treat themselves in their own home, any waste produced as a result is considered to be their own. Only where a
particular risk has been identified (based on medical diagnosis) does such waste need to be treated as hazardous clinical waste.
Local authorities have a duty to collect household waste including healthcare waste from domestic properties. Under the controlled
waste regulations, the authority may charge for the collection of specific waste streams, including clinical waste.

Where hypodermic needles are produced in the home, on no account should soft drink cans, plastic bottles or similar containers be
used for the disposal of needles, since these could present serious hazards to staff if they were disposed of in domestic waste.
Sharps bins can be obtained on prescription (FP10 prescription form) and can be returned to your doctor for disposal when full. The
duty on local authorities to collect and dispose of clinical waste generated by households also applies to sharps waste and again
the local authority may make a charge to cover the cost of collection.

In the case of pharmaceuticals (medicines etc), the recommended means of disposal is to return them to a pharmacist. If this is not
possible, again local authorities are obliged to collect the waste separately when asked to do so by the waste holder, but may make
a charge to cover the cost of collection.

Human hygiene waste

Human hygiene or sanpro waste can sometimes be produced in large quantities in places such as schools, nurseries and
motorway service areas. Although such wastes from these sources may be non-hazardous, in quantity they can be offensive and
cause handling problems. In these cases, where the premises generate more than one standard bag or container of human
hygiene waste over the usual collection interval, it is considered appropriate to package it separately from other waste streams.

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What is speech and language therapy?

Speech and language therapy provides life-changing treatment, support and care for children and adults who have
difficulties with communication, or with eating, drinking and swallowing.

Speech and language therapists (SLTs) are allied health professionals. They work closely with parents, carers and other
professionals, such as teachers, nurses, occupational therapists and doctors. There are around 14,000 practising SLTs in the UK.

Find out how to become an SLT

Our careers guide contains information about what speech and language therapists do, how to become an SLT and recognised
speech and language therapy courses in the UK.

You can also find out about pay scales, becoming a support worker and obtaining work experience.

Visit our Career in SLT web page.

Giving Voice

Our Giving Voice campaign provides a platform and resources to demonstrate SLTs unique value to national and local decision
makers. Visit the Giving Voice website to see campaign messages, find out about our campaign supporters, and more information
about how you can get involved.
Giving Voice factsheets

You can download the following factsheets with case studies and peoples' stories showing how Speech and Language Therapy
changes lives:

Supporting people with dementia

Dementia can cause a range of difficulties in relation to communication, safe eating and drinking. Speech and language therapists
support people with dementia and their carers by assessing their needs and delivering direct interventions to manage their
problems.

Children and young people

Communication difficulties put children at greater risk of poor literacy, mental health issues and poorer employment outcomes in
adulthood. Speech and language therapy is a vital service that improves childrens language and communication skills, and aids
their personal development.

Young offenders
Improving the communication skills of young offenders by providing speech and language therapy significantly reduces the risk of
reoffending, increases access to rehabilitation and treatment programmes, and can improve an individuals chances of gaining
employment.

Supporting stroke survivors

Speech and language therapy plays an important role in the rehabilitation and reablement of stroke survivors by assessing their
needs and providing appropriate strategies to support their speech, language, communication and swallowing needs.

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Public health

Welcome to this Royal College of Nursing (RCN) resource on public health. Nurses with an interest improving the
publics health can join the RCN Public Health Forum by following the links on the RCN Join a forum page.
Visit: RCN forums.

It is an exciting time for nurses working in public health as all four countries of the UK seek to address the
underlying causes of ill health such as unhealthy lifestyles and social inequalities. Public health deals with and
supports measures at an individual level, within organisations and at a wider society level to tackle the causes of
disease and preventable mortality and disability. These approaches can be broadly grouped into three categories.

Prevention (for example, immunisation and screening).

Protection (for example, safety and protection from abuse).

Promotion (such as health education and supporting evidence based commissioning about health needs).

Nursing's presence at almost every stage and setting of care means that nurses are engaged across a whole
spectrum of public health interventions (RCN Policy and International Department 2012, p.7). The RCN is an
advocate for the nursing contribution to minimising the impact of illness and promoting health and function so that
people can maintain roles at home, at work and at leisure in their communities. Maximising the role that all nurses
have in supporting health and wellbeing is essential.

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