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DATA COLLECTION
ASSESSMENT
- Is the process of gathering information about the patients
- Is the systematic and continuous collection, organisation health needs. This information is collected by means of
validation and documentation of information (Berman et interview, observation and physical examination and consist
al. 2010). of both OBJECTIVE and SUBJECTIVE data.
The process of assessment requires nurses to make accurate 1. COGNITIVE AND PERCEPTUAL ABILITY
and relevant observations, to gather, validate and organise
data and to make judgments to determine care and COMMUNICATION
treatment needs. It should have physical, psychological,
spiritual, social and cultural dimensions, and it is vital that The nurses needs to assess the level of sensory functioning with
these are explore with the person being assessed. or without aids/support such as hearing aid(s), speech aid(s),
glasses/contact lenses, and the patient capacity to use and
The purpose of nursing assessment is to get a complete maintain aids/support correctly. Furthermore, it is important to
picture of the patient and how they can be helped. assess whether there are or might be any potential language or
cultural barriers during this part of assessment. Knowing the norm
within the culture will facilitate understanding and lessen
miscommunication (Galanti 2000).
(POINTS FOR CONSIDERATION cont..) 3. ELIMINATION
INFORMATION GASTROINTESTINAL
During this part of assessment, the nurse will assess the patients During this part of the assessment it is important to determine a
to comprehend the present environment without showing level of baseline with regard to independence.
distress. This will help establish whether there are any barriers to Is the patient able to attend to their elimination needs
the patients understanding their condition and treatment. It may independently and is he/she continent?
help them to be in a position to give informed consent. What are patients normal bowel habits?
Are bowel movements within the patients own normal
NEUROLOGICAL pattern and consistency?
Does the patient have any underlying medical conditions
It is important to assess the patients ability to reason logically and such as Crohns disease or irritable bowel syndrome?
decisively, and determine that he or she is able to communicate in How does this affect of patient?
a contextually coherent manner.
GENITOURINARY
PAIN
This assessment is focused on the patients baseline observations with
To provide optimal patient care, the assessor needs to have regard to urinary continence/incontinence. It is also important to note
appropriate knowledge of the patients pain and an ability to identify whether there is any penile or vaginal discharge or bleeding.
the pain type and location. Assessment of a patients experience of
pain is crucial component in providing effective pain management. 4. NUTRITION
The nurse should also evaluate the patients ability to meet 6. CONTROLLING BODY TEMPERATURE
personal hygiene, including oral hygiene, needs. This should
include the patients ability to make arrangements to preserve This assessment is carried out to establish baseline temperature and
standards of hygiene and the ability to dress appropriately for determine if the temperature is within normal range, and whether
climate, environment and their owned standard of self-identity. there might be intrinsic factors for altered body temperature.
(CONTROLLING BODY TEMPERATURE cont.)
12. VALUES AND BELIEFS
It is important to note whether any changes in temperature are in
response to specific therapies (e.g. antipyretic medication, RELIGIOUS, SPIRITUAL AND CULTURAL BELIEFS
immunosuppressive therapies, invasive procedures or infection
(Bickley et al. 2013)). White blood count should be recorded to The aim is to assess the patients spiritual, religious, and cultural
determine whether it is within normal limits. needs to provide culturally and spiritually specific care while
concurrently providing a forum to explore spirituals strengths that
7. SLEEP AND REST might be used to prevent problems or cope with difficulties.
Assessment is focused on the patients values and belief, including
This part of assessment is performed to find out sleep and rest spiritual beliefs, or on the goals that guide his or her choices or
patterns and reasons for variation. Description of sleep patterns, decisions. A patients experience of their stay in hospital may be
routines and interventions applied to achieve a comfortable sleep influenced by their religious beliefs or other strongly held principles,
should be documented. The nurse should also include in the cultural background or ethnic origin. It is important for nurses to have
presence of emotional and/or physical problems that may interfere knowledge and understanding of the diverse cultures of their patients
with sleep. and take their different practices into account.
Assessment is focused on the patients perception of stress and on RELEVANT MEDICAL CONDITIONS, SIDE EFFECTS/COMPLICATION
his or her coping strategies. Support system should be evaluated OF TREATMENTS
and symptoms of stress should be noted. It includes the
individuals reserve or capacity to resist challenge to self-integrity, Assessment of the patients perceived pattern of health and well-
being and how health is managed should be documented here.
modes of handling stress. The effectiveness of a persons coping
Any relevant history of previous health problems, including side-
strategies in terms of stress tolerances may be further evaluated effects of medication, should be noted. Examples of other useful
(adapted from Gordon 1994) information that should be documented are compliance with
medication regimen, use of health promotion activities such as
9. ROLES AND RELATIONSHIP regular exercise and if the patient has annual check-ups.
POST-PROCEDURAL CONSIDERATIONS
3
The aim is to establish the patients own perception of the roles
and responsibilities in their current life situation. The patients role
DECISION MAKING AND NURSING DIAGNOSIS
in the world and their relationship with others are important to
understand. Assessment in this area includes finding out about the The purpose of collecting information through the process of
patients perception of the major roles and responsibilities they assessment is to enable the nurse to make a series of clinical
have in life, satisfaction or disturbances in family, work or social judgments, which are known in some circumstances as nursing
relationships. An assessment of home life should be undertaken diagnoses, and subsequently decisions about the nursing care
which should include how they will cope at home post discharge each individual needs. The decision-making process is based upon
the clues observed, analysed and interpreted and it has been
from hospital and how those at home will cope while they are in
suggested that expert nurses assess the situation as a whole and
hospital, for example dependants, children or animals and if there make judgments and decisions intuitively (Hedberg and Satterlund
are any financial worries. Larsson 2003, King and Clark 2002, Peden McAlpine and Clark
2002), reflecting Benners (1984) renowed novice-to-expert theory.
10. PERCEPTION/CONCEPT OF SELF
Nursing diagnosis is a term which describes both a clinical
BODY IMAGE/SELF-ESTEEM judgment that is made about an individuals response to health or
illness, and the process of decision making that leads to that
Body image is highly personal, abstract and difficult to describe. The judgment. The importance of thorough assessment within this
process cannot be overestimated. The gathering of comprehensive
rationale for this section is to assess the patients level of
and appropriate data from patients, including the meanings
understanding and general perception of self. This includes their attributed to events by the patient, is associated with greater
attitudes about self, perception of abilities (cognitive, affective or diagnostic accuracy and thus more timely and effective
physical), body image, identity, general sense of worth and general intervention (Alfaro-LeFevre 2014, Gordon 1994, Hunter 1998).
emotional pattern. An assessment of body posture and movement, eye
contact, voice and speech patterns should also be included. PLANNING AND IMPLEMENTING CARE
11. SEXUALITY AND REPRODUCTION Nursing diagnosis provide a focus for planning and implementing
effective and evidenced-based care. This process consists of
Understanding sexuality as the patients perceptions of their own body identifying nursing-sensitive patient outcomes and determining
image, family roles and functions, relationships and sexual function can appropriate interventions (Alfaro-LeFevre 2014, Shaw 1998, White
help the assessor to improve assessment and diagnosis of actual or 2003).
potential alterations in sexual behavior and activity.
To determine the immediate priorities and recognize
Assessment in this area is vital and should include relevant whether patient problems requiring nursing careor
feelings about the patients own body, their need for touch, whether a referral should be made to someone else.
interest in sexual activity, how they communicate their sexual
needs to a partner, if they have one, and the ability to engage in
To identify the anticipated outcome for the patient,
satisfying sexual activities. noting what the patient will be able to do and within
what time frame. The use of measurable verbs that
This may also be an opportunity to explore with the patient issues describe patient behavior or what the patient says
related to future reproduction if this is relevant to the admission. facilitates the evaluation of patient outcomes.
PHYSICAL ASSESSMENT/EXAMINATION
(PLANNING AND IMPLEMENTING CARE Cont..)
Physical assessment serves a number of purposes (Crouch and
Meurier 2005).
To determine the nursing interventions, that is, what
nursing actions will prevent or manage the patients
problems so that the patients outcomes may be To obtain information on the patients overall health status.
achieved.
To enable additional information to
be obtained about any
symptoms reported by the patient.
To record the care plan for the patient which may be
written or individualized from a standardized/core care To detect changes in a patients condition.
plan or a computerized care plan.
To evaluate how the patient is responding to interventions.
Demonstrate; perform and the examination should seek to confirm, refute or further
Will lose; will gain; has an absence of establish that a differential diagnosis is a possibility (Douglas and
Walk; stand; sit Bevan 2013). There are four aspects of physical examination:
NON-MEASURABLE VERBS (do not use) 1. Inspection simply observing the patient.
2. Palpation requires the use the whole hand including
Know the palm and the full length of the fingers to feel and
AIRBORNE TRANSMISSION involves droplets or particles In England, the Health and Safety at Work etc. Act 1974 is the
containing infectious agents, but on a small enough scale that the primary piece of Legislation relating to the safety of people in the
particles can remain suspended in the air for long periods of time. workplace. It applies to all employees and employers, and requires
Infections spread via this route include measles and chickenpox. them to do everything that is reasonable and practicable to
Prevention is as for droplet transmission. prevent harm coming to anyone in the workplace. It requires
employers to provide training and appropriate protective
PARENTERAL TRANSMISSION this is a form of contact equipment and employees to follow the training that they have
transmission, where blood or body fluids containing infectious received, use the protective equipment provided, and report any
agents, come into contact with mucous membranes or exposed situations where they believe inadequate precautions are putting
tissue. In healthcare, this can occur through transplantation or anyones health and safety at serious risk. This dovetails with the
infusion (which is why blood and organs for transplantation are requirements of the Nursing and Midwifery Council (NMC 2015) for
screened for blood borne viruses such as HIV). Transmission is nurses to promote and protect the well-being of those in their care
prevented by good practice in handling and disposing of sharps and to report concerns in writing if problems in the environment of
and the appropriate use of protective equipment, including eye care are putting people at risk.
protection (UK Health Departments 1998). A European Union
directive recently incorporated into UK Legislation requires the use The NMC Code (NMC 2015) states that all nurses must work within
of safe needle-free devices wherever possible in order to reduce the limits of their competence. This means, for example, not
the risk of inoculation injury (Health and safety Executive 2013) . carrying out aseptic procedures without being competent nad
confident that they can be carried out without increasing the risk
FAECAL-ORAL TRANSMISSION this occurs when an infectious of introducing infection through lack of knowledge or technique.
agent present in the faces of an infected person is subsequently
ingested by someone else and enters their gastrointestinal tract. COMMUNICATION
Transmission is prevented through isolating any patient with
symptoms of gastroenteritis; effective hand hygiene by both staff Communication is a universal word with many definition, many of
and patients with soap and water (as many of these organism are which describe it as a transfer of information between a source
less susceptible to alcohol); appropriate use of gloves and aprons; and a receiver (Kennedy Sheldon 2009); that is, the sending and
and good food hygiene (DH/HPA 2008). receiving of verbal and non-verbal messages between two or more 5
people (de Vito 2013). In nursing, this communication primarily
VECTOR TRANSMISSION many diseases are spread through the interpersonal; the process by which compassion and support are
action of a vector, most often an insect that travels from one offered and information, decisions and feelings are shared
person to another to feed. This route is not currently a concern in (McCabe and Timmins 2013).
healthcare in England, but in some areas of the world, for example
where malaria is endemic, protecting patients from vectors such as EVIDENCE-BASED APPROACHES
mosquitoes is an important element of nursing care.
Effective communication is widely regarded to be a key determinant of
SYMPTOMS OF INFECTION patient satisfaction, compliance and recovery (Dwamena et al. 2012,
Webster and Bryan 2009), yet poor communication is one of the most
HEAT the site of the infection may feel warm to the common causes of complaints in healthcare (DH 2013, Strachan 2004).
touch, and the patient may have a raised temperature. Nurses need to communicate effectively with patients in order to
PAIN at the site of the infection. deliver individualized safe care and treatment and to manage
SWELLING at the site of the infection. psychosocial concerns appropriately.
REDNESS at the site of the infection.
FEELING of general malaise. LISTENING is a skill often assumed to be natural. Rarely would
In GASTROINTESTINAL INFECTION abdominal pain and we consider that we were physically unable to listen and perhaps
tenderness; nausea; diarrhea and/or vomiting (Goering this makes us pay little attention to this crucial skill area.
et al. 2012).
In URINARY TRACT INFECTION frequency of How to let someone know you are listening to them?
micturition; often confusion in the elderly; loin pain
and/or abdominal discomfort (Goering et al. 2012). Non-verbal encouragement e.g. head nodding, body
position, eye contact.
EVIDENCE-BASED APPROACHES Verbal responses
Questioning
The principle of all infection prevention and control is preventing Paraphrasing
the transmission of infectious agents. Clarifying
Summarizing
The infection prevention and control policies of health and social care Empathy
providers are based on generic risk assessments of their usual client or
patient group and should be adhered to unless there are strong LEGAL AND PROFESSIONAL ISSUES
reasons to alter procedures for a particular individuals care.
In such circumstances, the advice of the infection prevention and There are number of legal and professional concepts and issues
control team (IPCT) should be sought first. Nurses working in that impact on effective communication and psychological support.
organizations without an IPCT should identify the most appropriate These include:
source from which to seek advice, preferably before it is needed.
(LEGAL AND PROFESSIONAL ISSUES Cont) DEPRESSION
Denial is a complex phenomenon (Vos and Haes 2010) and can be Pharmacological Support there are four main types of
considered a mechanism for slowing down and filtering the antidepressant: tricyclic, monoamine oxidase inhibitors (MAOI),
absorption of traumatic information, allowing for avoidance of selective serotonin reuptake inhibitors, (SSRI) and serotonin-
painful or distressing information (Goldbeck 1997). norepinephrine reuptake inhibitors (SNRI) (RCPsych 2013).
Collusion is when two or more parties develop a shared,
sometimes secret understanding that may involve withholding Non-pharmacological Support Nurses can be involved in assessing
information from another person. depression in patients with physical illness. NICE guidance sets out a
Related theory step model for managing a patient with depression.
The End of Life Care Strategy (DH 2008) set guidance aimed at Advance decisions to refuse treatment must be in writing, be signed
improving care and choices for all people regardless of their and witnessed, and must expressly state that the decisions stands
diagnosis and place of care. The principal aims are to improve the even if the persons life is at risk (DH 2012). They can be withdrawn
quality of care for those approaching the end of their life and to verbally or in writing and are not considered valid if the person has
enable greater choices and control about their place of care and conferred Lasting Power of Attorney on another person.
death. The strategy, which focuses on the role of health and social
care, states that high-quality EOLC should be available wherever Post-procedural considerations
the person maybe: at home, in a care home, in hospital, in a
hospice or elsewhere (DH 2008). Nursing care does not end when the death of the patient occurs; it
extends beyond death to provide care for the deceased person
The National End of Life Care Programme (NEoLCP 2010) was and support to their family and cares (NNCG 2011). This physical
developed to implement the strategy. care given by nurses following death in hospitals has been
traditionally referred to as last offices (Care after death).
PULSE (HEART RATE)
CARE AFTER DEATH
A persons pulse rate can be influenced by several factors
The term last offices only applies to the physical care of the including ae, gender, exercise, pyrexia, medications,
deceased body. Care after death is a broader term that better hypovolaemia, stress, positioning, pathology, hormones and
reflects a multicultural society and also embraces all the differing electrolytes (Field 2008, Kozier et al. 2008).
nursing task involved, including the outgoing support of the family
and carers (NNCG 2011). Even though they have die, patients are Normal pulse rate per minute at various ages
still referred to as patients or people throughout this section.
Age Approximate range
LEGAL AND PROFESSIONAL ISSUES
1 week-3 months 100-160
3 months-2 years 80-150
Nurses should be aware of the legal requirements for care of
patients after death as it is essential that correct procedures are 2-10 years 70-110
followed (Green and Green 2006). It is particularly important that 10 years-adult 55-90
nurses are aware of deaths that require referral to the coroner as
this will facilitate the correct personal care and enable nurses to BLOOD PRESSURE
prepare the family for both a potential delay in the processing of
the MCCD and also the possibility of a post-mortem examination Blood pressure may be defined as the force of blood inside the
(NNCG 2011). blood vessels against the vessel walls (Marieb and Hoehn 2010).
All patients in hospital should have their observations IMMEDIATE CARE notify medical staff of an abnormal blood pressure
taken at least once every 12 hours, unless specified
result. As the treatment will depend on what is causing the
otherwise by senior staff (NICE 2007a).
abnormality, and its severity, it is important that practitioners try to
ascertain the possible cause for the physiological change in blood
LEGAL AND PROFESSIONAL ISSUES
pressure (Kisiel and Perkins 2006). Hypovolaemia will require fluid
replacement and, if persistent, then inotropes and other cardiovascular
Nurses are accountable and responsible fpr providing optimum
drugs may be necessary (Hinds and Watson 2009).
care for their patients. The Nursing and Midwifery Council (NMC)
The Code provides the main source of professional accountability
ONGOING CARE if the patient is hypertensive and in primary
for nurses (NMC 2015). It is essential that nursing staff objectively
care, they will require at least monthly blood pressure
examine the information gathered from assessments and
measurement and more frequently if it is accelerated hypertension
observations, including the patients baseline, as well as any
or there are any further concerns (NICE 2011a). Additionally, it will
information previously recorded (Crounch and Meurier 2005).
be necessary to give lifestyle advice on, for example, eating
Pre-procedural considerations healthily and smoking cessation (NICE 2011a). If the hypotension
is orthostatic then advise the patient to change position slowly so
Equipment all practitioners need to be aware of the strengths and the baroreceptors and sympathetic nervous system have time to
limitations of the devices they are using and need to have adequate adapt the blood pressure to each stage (Marieb and Hoehn 2010).
training on the use of all equipment. They must ensure that the
devices are validated, checked, maintained and recalibrated regularly
according to the manufacturers instructions (NICE
2011a).
RESPIRATION AND PULSE OXIMETRY PULSE OXIMETRY is an effective method of monitoring for
hypoxaemia and will immediately alert the practitioner to a fall in
The major function of the respiratory system is to supply the cells arterial oxygen saturation, often even before any obvious
of the human body with oxygen and to remove carbon dioxide, in symptoms are displayed(Higginson and Jones 2009), Moore 2007).
order that they can continue to function effectively (Tortora and
It also provides useful information about heart rate (Jevon and
Derrickson 2011). Respiration is composed of four processes:
Ewens 2000). Pulse oximetry provides continuous and non-
invasive monitoring of the oxygen saturation from haemoglobin in
PULMONARY VENTILATION the movement of air into
and out of the lungs to continually arterial blood (Moore 2007).
refresh the gases
there, commonly called breathing.
METHODS OF ASSESSING RESPIRATION
TRANSPORT OF RESPIRATORY GASES transport of
oxygen from the lungs to the cells, and of carbon Airway assessment
dioxide from the cells to
the lungs, accomplished by the Breathing assessment
cardiovascular system.
Skin colour
Use of accessory muscles
INTERNAL RESPIRATION movement of oxygen from
blood to the cells and of carbon dioxide Rhythm, rate and depth of respiration
from the cells to
the blood (Marieb and Hoehn 2010). Shape and expansion of the chest
General condition or distress of the patient
Pulse oximetry
HYPOXIA AND HYPERCAPNIA
TEMPERATURE
HYPOXIA is defined as inadequate oxygen delivery to the tissues.
Signs of hypoxia include tachypnea, dyspnea, tachycardia, Body temperature represents the balance between heat
restlessness and confusion, headache, mild hypertension and production and heat loss (Marieb and Hoehn 2010). If the rate of
pallor; irregular breathing, cyanosis, hypotension, altered level of heat generated equates to the rate of heat lost, the core body
consciousness, blurred vision and eventual respiratory arrest temperature will be stable (Tortora and Derrickson 2011). All body
(Beachery 2012). tissues produce heat depending on how metabolically active they
are. When the body is resting, most heat is generated by the
Hypoxia can have various causes, and based on this, can be
classified into four types (Marieb and Hoehn 2010, Tortora and
heart, liver, brain and endocrine organs (Marieb and Hoehn 2010). 9
Derrickson 2011). HYPOTHERMIA (lowered body temperature) is defined as a core
temperature of 35C (Frink et al. 2012) that causes the metabolic rate
1. Hypoxaemic hypoxia caused by a low PO2 in arterial to decrease (Trim 2005). Hypothermia may be classified as mild (32-
blood as a result of breathing air with inadequate 35C), moderate (28-32C) and severe (less than 28C) (Cuddy 2004).
oxygen (such as at high altitude) or abnormal Hypothermia occurs when the body loses more heat and is
ventilation/perfusion matching in the lungs (due to subsequently unable to maintain homestasis (Neno 2005).
airway obstruction or fluid in the lungs). Carbom
monoxide poisoning can also cause this. HYPERTHERMIA sudden temperature elevations usually indicate
2. Anaemic hypoxia caused by too little functioning infection, making it prudent to perform a directed physical
haemoglobin being present in the blood which reduces examination and, if indicated, obtain appropriate cultures and
the transport of oxygen to the cells (such as institute antibiotics.
haemorrhage or anaemia).
3. Ischaemic hypoxia caused when blood flow to a Non-infectious causes of hyperthermia
specific area is inadequate to supply enough oxygen,
even though PO2 and Hb-O2 levels are normal (due to Alcohol withdrawal
embolism or thrombosis). Anticholinergic drugs
4. Histotoxic hypoxia caused by the cells being unable to Allergic drug or transfusion reaction
use the oxygen that has been delivered; this can ccur as Autonomic insufficiency
aresult of poisons such as cyanide. Crystalline arthritis (gout)
Drug allergy
HYPERCAPNIA is an elevated level of carbon dioxide level in the Heat stroke
blood. Signs include tacypnoea (eventually becoming bradyypnoea
as it worsens), dyspnea, tachycardia, hypertension, headaches, BLOOD GLUCOSE
vasodilation, drowsiness, sweating and a red colouration (Beachey
2012). Blood glucose is the amount of glucose in the blood (Brooker
2010). Normally blood glucose levels stay within narrow limits
Patients with hypercapnia will require urgent medical attention and throughout the day: 4-8 mmol/L (millimoles per litre) (NICE 2004).
close monitoring as hypercapnia will cause respiratory acidosis
(Beachey 2012). Patients with chronic hypercapnia, such as those Normal target blood glucose ranges
who have chronic obstructive pulmonary disease (COPD), will have
at least partially adapted to the chronically high levels of carbon Children and young people Adults >18 years of age
dioxide; oxygen therapy needs to be administered with caution in <18 years of age
these patients as they are at risk of hypercapnic respiratory failure Preprandial blood glucose Preprandial blood glucose
(ODriscoll et al. 2008). Levels 4-8 mmo/L level 4-7 mmo/L
HYPERGLYCAEMIA it is defined as a random blood glucose of The NMC (2010a) clearly states that a verbal order is not acceptable on
more than 11.1 mmol/L (WHO/IDF 2006). its own. n exceptional circumstances, where the medication (NOT
including controlled drugs) has been previously prescribed and the
HYPOGLYCAEMIA is described as ablood glucose level that is prescriber is unable to issue a new prescription, but where changes to
unable to meet the metabolic needs of the body (Marini and the dose are considered necessary, the use of information technology
Wheeler 2012), normally lower than 4 mmol/L (Wallymahmed (such as fax or email) may be used but the prescriber must confirm
2007). Hypoglycaemia is an acute complication of diabetes that any changes to the original prescription(NMC 2010a, p.28). This
increases morbidity, mortality and economic costs of diabetes and should be followed up by a new prescription, signed by the prescriber
can decrease quality of life (Fidler et al. 2011, Liu et al. 2012). confirming the changes, within a maximum of 24 hours. The changes
must be authorized before the new dosage is administered (NMC
MEDICINES MANAGEMENT 2010a).
The Medicines and Healthcare products Regulatory Agency (MHRA MEDICINES RECONCILIATION
2004) defines medicines management as the clinical, cost-effective
and safe use of medicines to ensure patients get the maximum benefit It has been defined by the Institute for Healthcare Improvement as
from the medicines they need, while at the same time minimizing the process of creating the most accurate list possible of all
potential harm. All Registered Nurses have a professional responsibility medications the patient is taking-including drug name, dosage,
with regard to procurement, prescription, supply and disposal of frequency and route-and comparing that list against the
medicines as defined in the NMC Standards for Medicines Management physicians admission, transfer, and/or discharge orders, with the
(NMC 2010a). They must ensure the patient understands what goal of providing correct medications to the patient at all transition
medicines they are taking, the indication for the medication and any points within the hospital (www.ihi.org).
likely side-effects.
SAFE STORAGE OF MEDICINES
EVIDENCE BASE FOR MEDICINES MANAGEMENT IN PRACTICE
The report The Safe Secure Handling of Medicines: A Team
Good medicines management is essential to assure high standards Approach (RPSGB 2005) details that the responsibility for
in the clinical care of patients. When delivered effectively, it can establishing and maintaining a system for the security of 10
reduce the risk of medication errors and serious adverse drug medicines should that of the senior pharmacist in the hospital.
reactions and prevent unnecessary delays for the patient at the They should do this in consultation with senior nursing staff and
point of discharge. appropriate medical staff. The appointed nurse in charge of the
area will have the responsibility of ensuring that the system is
All aspects of a medicines use must be managed with a followed and that the security of medicines is maintained.
multidisciplinary approach to ensure it is supported by a strong
evidence base and that safety and well-being of the patient remain SECURITY
paramount (NMC 2015, Shepherd 2002a).
All drugs should be stored in locked cupboards with separate
LEGAL METHODS FOR PRESCRIBING MEDICINES storage for internal medicines, external medicines, controlled
drugs and medicines needing refrigeration or storage in a freezer.
The medicines Act 1968 states that only authorized healthcare Diagnostic reagents, intravenous and topical agents should also be
practitioners can legally prescribe medicines in the UK. It provides kept separately in individual storage.
all prescribers with a framework for which medicines require a
prescription and which medicines can be available to the public STABILITY
without a prescription and under what circumstances. All
medicines administered in hospital must be considered prescription No medical preparation should be stored where it may be subject
only. This is because administration, whether by a nurse or by a to substantial variations in temperature, for example not in direct
patient to themselves, may only take place in accordance with one sunlight.
or more of the following processes:
The normal temperature ranges for storage are as follows:
Patient-specific direction
COLD STORAGE products to be stored between 2C and 8C.
Patient medicines administration chart(also called a
medicines administration record [MAR])
COOL STORAGE products that need to be stored in a cool place
Patient Group Direction (PGD)
Medicines Act exemplar
or between 8C and 15C.
Standing orders
Homely remedy protocol
ROOM TEMPERATURE for products that need to be stored at
Prescription form (NMC 2010a, pp.13-19)
room temperature or not above 25C (MHRA 2001).
As nurses have undertaken increasingly specialized roles, the need All nurses who administer medicines must be familiar with and
for them to have powers to prescribe has become more apparent. adhere to the Standards for Medicines Management (NMC 2010a).
The report of the Advisory Committee on Nurse Prescribing (DH To achieve safe administration the nurse must have a sound
1989) initially recommended a limited nurses formulary for knowledge of the therapeutic use, usual dose, side-effects,
community nurses and health visitors. precautions and contradictions of the drug being administered. If
the nurse lacks knowledge of particular medicines, she/he must
not administer the medicine and must seek advice from a senior
colleague.
(Medicines Management Cont) Controlled Drugs (Supervision of Management and Use)
Regulations 2006 these regulations set out the requirements
RECORD OF ADMINSTRATION for certain NHS bodies and independent hospitals to appoint an
accountable officer. The duties and responsibilities of the
The nurse must document a clear, accurate and immediate record accountable officer are to improve the management and use of
of all medicines administered, intentionally withheld or refused by controlled drugs. These regulations also allow the periodic
the patient, ensuring all written entries and signatures are clear inspection of premises.
and legible (NMC 201b). If any medication is withheld or refused
by a patient, the reasons must be documented. Misuse of Drugs and Misuse of Drugs (safe Custody)
(Amendment) regulations 2007 these regulations give
SINGLE OR DOUBLE CHECKING OF MEDICINES accountable officers authority to nominate persons to witness the
destruction of controlled drugs within their organization. They also
Medicines can be prepared and administered by a single qualified nurse allow operating department practitioners to order, possess and
or by two nurses checking (known as double checking). There are supply controlled drugs. In addition, they set out changes to the
certain times when double or second checking is required. It is record keeping for controlled drugs, with requirements for
recommended that for the administration of controlled drugs, a recording in the controlled drug register the person (the patient),
secondary signature is required (NMC 2010a). The NMC Standards for patients representative or a healthcare professional) collecting the
Medicines Management also states that wherever possible two Schedule 2 controlled drug. If it is a healthcare professional, there
registrants should check medication to be administered intravenously, is a requirement for the name and address of that person.
one of whom should also be the registrant who the administer the
intravenous medication (NMC2010a, p.34). CONSENT
SEVEN KEY ACTIONS TO IMPROVE MEDICATION SAFETY NHS Choices (2012) defines consent as: the principle that a
person must give their permission before they receive any type of
1. Increase reporting and learning from medication medical treatment.
incidents.
2. Implement NPSA safer medication practice EVIDENCE-BASED APPROACH
recommendations.
3. Improve staff skills and competencies. There are different types of consent in healthcare: written, verbal 11
4. Minimize dosing errors. (explicit) and non-verbal (implied or implicit) (DH 2009b). The
5. Ensure medicines are not omitted. Department of Health (DH 2009b) and professional bodies
6. Ensure the correct medicines are given to the correct including the Nursing and Midwifery Council (NMC) and General
patients. Medical Council (GMC) have produced comprehensive guidance
7. Document patients medicine allergy status. about consent (GMC 2008, NMC 2013). The DH guidance (DH
Consent must be given willingly. 2009) includes information about what consent is, by whom and in
Consent must be informed. what circumstances.
The person must have the capacity to consent to the
procedure in question. PRINCIPLE OF CARE
Medicines Act 1968 The Act and the regulations made under It is accepted that when a patient gives valid consent, this is valid
the Act set out the requirements for the legal sale, supply and indefinitely unless withdrawn by the patient; therefore no specific time
administration of medicines. limit is designated from signature to procedure (Hughes 2011).
Misuse of Drugs Act 1971 for reasons of public safety, the For consent to be valid, it must encompass several factors.
Misuse of Drugs Act controls the export, import, supply and
possession of dangerous or otherwise harmful drugs to prevent Consent must be given willingly.
abuse as most are potentially addictive or habit forming as well as Consent must be informed.
harmful. The person must have the capacity to consent to the
procedure in question.
Misuse of Drugs (safe Custody) Regulations 1973 these
regulations control the storage of controlled drugs. The level of All healthcare professionals should be aware of the different types
control of storage depends on the premises in which they are of consent and the importance of ensuring that the person
being stored and the schedule of the drug. understands what is going to happen to them and what is
involved. Healthcare professionals should also be familiar with
Misuse of Drugs Regulations 2001 under these regulations their local hospital consent policy and be aware of and understand
controlled drugs are classified into five schedules, each what to do if people refuse care or treatment or when consent is
representing a different level of control. not valid or is no longer valid.
Q&A Q. What would make you suspect that a patient in your care had a
urinary tract infection?
Q. You are a registered nurse in a community giving health
education to a patient and you notice that the student nurse is A. The patient has spiked a temperature, has a raised
using his cell phone to text, what should you do? white cell count (WCC), has new-onset confusion and
the urine in his catheter bag is cloudy.
A. Politely signal the student and encourage him by
actively including him in the discussion. Q. What steps would you take if you had sustained a needle stick
injury?
Q. A nurse is having trouble with doing care plans. Her team
members are already noticing this problem and are worried of the A. Gently make the wound bleed, place under running water
consequences this may bring to the quality of nursing care and wash thoroughly with soap and water. Complete an
delivered. The problem is already brought to the attention of the incident form and inform your manager. Co-operate with
nurse. The nurse should: any action to test yourself or the patient for infection with a
blood borne virus but do not obtain blood or consent for
A. Accept her weakness and take this challenge as an testing from the patient yourself; this should be done by
opportunity to improve her skills by requesting lectures someone not involved in the incident.
from her manager.
A. As the skin of an elder person has reduced blood supply, Q. Who will you inform first if there is a shortage in supplies in
is thinner, less elastic and has less natural oil. This your shift?
means the skin is less resistant to shearing forces and
wound healing can be delayed. A. Immediate nurse manager
Q. What is the best way to prevent a patient who is receiving an Q. You are to take charge of the next shift of nurses. Few minutes
enteral feed from aspirating? before your shift, the in charge of the current shift informed you
that two of your nurses will be absent. Since there is a shortage of
A. Sit them at least at a 45 angle. staff in your shift, what will you do?
A. Listening, clarifying the concerns and feelings of the A. Raise the situation to your head nurse and discuss with
patient using open questions. her what intervention might be done to help the child.
Q. What could be the reason why you instruct your patient to retain on
its original container and discard nitroglycerine meds after 8
Q. NMC requires in the UK how many units of continuing education
weeks?
units a nurse should have in 3 years?
A. Removing from its darkened container exposes the
A. 35 units
medicine to the light and its potency will decrease after
8 weeks.
Q. Who is responsible in disposing sharps? Q. The degree of injection when giving subcutaneous insulin
injection on a site where you can grasp 1 inch of tissue?
A. Whoever used the sharps.
A. 45 degrees
Q. Where will you put infectious linen? Q. What is the best position in applying eye medications?
A. Red plastic bag designed to disintegrate when exposed A. Sitting position with head tilt backwards
to heat.
Q. The worst advice you can give a student nurse with regards to
Q. What does AVPU mean? the use of social networking sites like Facebook?
A. Alert voice pain unresponsive. A. Do not identify yourself as a nurse; Rely on the sites
privacy settings
A. If safety of the public is at risk. A. Water-soluble alginate polythene bag before being placed in
the appropriate linen bag, no more than full.
Q. In a community hospital, an elderly man approaches you and tells Q. Hypoglycaemia in patients with diabetes is more likely to occur
you that his neighbour has been stealing his money, saying when the patients take:
"sometimes I give him money to buy groceries but he didn't buy
groceries and he kept the money" what is your best course of action A. Insulin; Sulphonylureas; Prandial glucose regulators
for this?
A. Raise a safeguarding alert Q. Enteral feeding patient checks patency of tube placement by:
Q. Patients with gastric ulcers typically exhibit this symptom: Q. The doctor prescribes 25mg of a drug to be given by injection.
It is a drug dispensed in a solution of strength 50mg/ml. How
A. Epigastric pains worsens after eating and weight loss many ml should you administer?
A. Abdominal aorta; Circle of Willis Q. The doctor prescribes a dose of 9 mg of an anticoagulant for a
patient being treated for thrombosis. The drug is being supplied in
3mg tablets. How many tablets should you administer?
Q. A patient suffered from stroke and is unable to read and write.
A. 3 tablets
This is called:
A. Dysphasia
Q. Patient has next dose of Digoxin but has a CR=58
Q. A patient is assessed as lacking capacity to give consent if they
A. Omit dose, record why, and inform the doctor are unable to:
A. That she has finalize suicide plan. Q. Recommended preoperative fasting times are:
A. 6-12 hours
Q. You are monitoring a patient in the ICU when suddenly his
consciousness drops and the size of one his pupil becomes smaller
what should you do? Q. The following are signs of a speed shock:
A. Call the doctor; Consider this as an emergency and A. Flushed face; Headache and dizziness; Tachycardia and
prioritize abc fall in blood pressure
Q. What position should you prepare the patient in preop for Q. Compassion in Practice the culture of compassionate care
abdominal Paracentesis? encompasses:
A. Supine with head of bed elevated to 40-50cm A. Care, Compassion, Competence, Communication,
Courage, Commitment
14
Q. Wound proliferation starts after?
Q. In a patient with hourly monitoring, when does a nurse formally
A. 3-24 days document the monitoring?
Q. What do you expect to manifest with fluid volume deficit? A. Every hour
A. High Pulse, low BP Q. You can delegate medication administration to a student if:
A. Nocturia Q. At what stage of the nursing process does the revision of the
care plan occur?
A. Hypnotics
Q. Adequate record keeping for a medical device should provide
evidence of:
Q. In DVT TEDS stockings affect circulation by:
A. A unique identifier for the device, where appropriate; A
A. Increasing blood flow velocity in the legs by full history, including date of purchase and where
compression of the deep venous system. appropriate when it was put into use, deployed or
installed; Any specific legal requirements and whether
these have been met; Proper installation and where it
Q. An overall risk of malnutrition of 2 or higher signifies: was deployed; Schedule and details of maintenance and
repairs; The end-of-life date, if specified
A. High risk of malnutrition
Q. It is unsafe for a spinal tap to be undertaken if the patient:
Q. What is the purpose of The Code? A. Has bacterial meningitis; Papilloedema; Intracranial
mass is suspected; Site skin infection
A. It is a tool for educating prospective nurses and midwives.