REVIEW MANUAL
Source: The Royal Marsden Ninth Edition (Part 1)
NMC COMPUTER BASED TEST
(CBT)
CLINICAL NURSING PROCEDURES
ASSESSMENT AND DISCHARGE
ASSESSMENT
- Is the systematic and continuous collection, organisation
validation and documentation of information (Berman et
al. 2010).
- It is a deliberate and interactive process that underpins
every aspect of nursing care (Heaven and Maguire 1996).
- It is the process by which the nurse and patient
together identify needs and concerns. It is seen as the
corner-stone of individualised care, a way in which the
uniqueness of each patient can be recognised and
considered in the care process (Holt 1995).
PRINCIPLES OF ASSESSMENT
1. Patient assessment is patient focused, being govern by
the notion of an individuals actual, potential and
perceived needs.
2. It provides baseline information on which to plan the
interventions and outcomes of care to be achieved.
3. It facilitates evaluation of the care given and is a
dimension of care that influences a patients outcome
and potential survival.
4. It is a dynamic process that starts when problems or
symptoms develop, and continues throughout the care
process, accommodating continual changes in the
patients condition and circumstances.
5. It is essentially an interactive processing which the
patient actively participates.
6. Optimal functioning, quality of life and the promotion of
independence should be primary concerned.
7. The process include observation, data collection, clinical
judgment and validation of perceptions.
8. Data used for the assessment process are collected from
several sources by a variety of methods, depending on
the healthcare setting.
9. To be effective, the process must be structured and
clearly documented.
- An effective assessment will provide the nurse with
information on the patients background, lifestyle, family
history and the presence of illness or injury (Crouch and
Meurier 2005).
- The nursing assessment should focus on the patients
response to a health need rather than disease process
and pathology (Wilkinson 2007).
The process of assessment requires nurses to make accurate
and relevant observations, to gather, validate and organise
data and to make judgments to determine care and
treatment needs. It should have physical, psychological,
spiritual, social and cultural dimensions, and it is vital that
these are explore with the person being assessed.
The purpose of nursing assessment is to get a complete
picture of the patient and how they can be helped.
EVIDENCE-BASED APPROACHES
DATA COLLECTION
- Is the process of gathering information about the patients
health needs. This information is collected by means of
interview, observation and physical examination and consist
of both OBJECTIVE and SUBJECTIVE data.
OBJECTIVE DATA
- Are measurable and can be detected by someone other
than the patient. They include vital signs, physical signs
and symptoms, and laboratory results.
SUBJECTIVE DATA
- Are based on what the patient perceives and may include
descriptions of their concerns, support network, their
awareness and knowledge of their abilities/disabilities, their
understanding of their illness and attitude to and readiness 1
for learning (Wilkinson 2007).
Nurses working in different settings rely on different
observational and physical data. A variety of methods have
been developed to facilitate nurses in eliciting both objective
and subjective assessment data on the assumption that, if
assessment is not accurate, all other nursing activity will also
be inaccurate.
LEGAL AND PROFESSIONAL ISSUES
NHS Knowledge and Skills Framework (DH 2004a)
- States that the specific dimensions of assessment and
care planning to meet peoples health and wellbeing
needs and assessment and treatment planning related
to the structure and function of physiological and
psychological system are core to nursing posts in all
settings.
- Staff will need to be aware of their legal obligations and
responsibilities, the rights of the different people
involved, and the diversity of the people they are
working with.
- Nurses have an obligation to record details of any
assessments and reviews undertaken and provide clear
evidence of the arrangements that have been made for
future and on-going care (NMC 2010). This should also
include details of information given about care and
treatment.
POINTS FOR CONSIDERATION
1. COGNITIVE AND PERCEPTUAL ABILITY
COMMUNICATION
The nurses needs to assess the level of sensory functioning with
or without aids/support such as hearing aid(s), speech aid(s),
glasses/contact lenses, and the patient capacity to use and
maintain aids/support correctly. Furthermore, it is important to
assess whether there are or might be any potential language or
cultural barriers during this part of assessment. Knowing the norm
within the culture will facilitate understanding and lessen
miscommunication (Galanti 2000).
(POINTS FOR CONSIDERATION cont..)
INFORMATION
During this part of assessment, the nurse will assess the patients
to comprehend the present environment without showing level of
distress. This will help establish whether there are any barriers to
the patients understanding their condition and treatment. It may
help them to be in a position to give informed consent.
NEUROLOGICAL
It is important to assess the patients ability to reason logically and
decisively, and determine that he or she is able to communicate in
a contextually coherent manner.
PAIN
To provide optimal patient care, the assessor needs to have
appropriate knowledge of the patients pain and an ability to identify
the pain type and location. Assessment of a patients experience of
pain is crucial component in providing effective pain management.
Dimond (2002) asserts that it is un acceptable for patients to
experience unmanaged pain or for nurses to have inadequate
knowledge about pain. Pain should be measured using an
assessment tool that identifies the quality and/or quality of one or
more of the dimensions of the patients experience of pain.
Australian and New Zealand College of Anaesthetists 2005, Jensen
et al. 2003, Rowbotham and Macintyre 2003
Assessment should also observe for signs for neuropathic pain,
including descriptions such as shooting, burning, stabbing,
allodynia (pain associated with gentle touch).
2. ACTIVITY AND EXERCISE
RESPIRATORY
Respiratory pattern monitoring addresses the patients breathing
pattern, rate and depth.
In this section it is also important to assess and monitor smoking
habits. It is helpful to document the smoking habit in the format of
pack-years. A pack-year is a term used to describe the number of
cigarettes a person has smoked over time. One pack- year is
defined 20 manufactured cigarettes (one-pack) smoked per day
for 1 year. At this point in the assessment, it would be a good
opportunity, if appropriate, to discuss smoking cessation. A recent
meta-analysis indicates that if interventions are given by nurses to
their patients with regard to smoking cessation the benefits are
greater (Rice and Stead 2008).
CARDIOVASCULAR
A basic assessment is carried out and vital signs such as pulse
(rhythm, rate and intensity) and blood pressure should be noted.
Details of cardiac history should be taken for this part of the
assessment. Medical conditions and experience of previous surgery
should be noted.
PHYSICAL ABILITIES, PERSONAL HYGIENE/ MOBILITY/
TOILETING, INDEPENDENCE WITH ACTIVITIES OF DAILY LIVING
The aim during this part of assessment is to establish the level of
assistance required by the person to tackle activities of daily living
such as walking steps/stairs. An awareness of obstacles to safe
mobility and dangers to personal safety is an important factor and
part of the assessment.
The nurse should also evaluate the patients ability to meet
personal hygiene, including oral hygiene, needs. This should
include the patients ability to make arrangements to preserve
standards of hygiene and the ability to dress appropriately for
climate, environment and their owned standard of self-identity.
3. ELIMINATION
GASTROINTESTINAL
During this part of the assessment it is important to determine a
baseline with regard to independence.
Is the patient able to attend to their elimination needs
independently and is he/she continent?
What are patients normal bowel habits?
Are bowel movements within the patients own normal
pattern and consistency?
Does the patient have any underlying medical conditions
such as Crohns disease or irritable bowel syndrome?
How does this affect of patient?
GENITOURINARY
This assessment is focused on the patients baseline observations with
regard to urinary continence/incontinence. It is also important to note
whether there is any penile or vaginal discharge or bleeding.
4. NUTRITION
ORAL CARE
As part of inpatient admission assessment, the nurse should obtain
an oral health history that include oral hygiene beliefs, practices
and current state of oral health. During this assessment it is
important to be aware of treatments and medications that affect
the oral health of the patient.
2
HYDRATION
An in-depth assessment of hydration and nutritional status will provide
the information needed for nursing interventions aimed at maximising
wellness and identifying problems for treatment. The assessment
should ascertain whether the patient has any difficulty eating or
drinking. During the assessment the nurse should observe signs of
dehydration, for example dry mouth, dry skin, thirst or whether the
patient shows any signs of altered mental state.
NUTRITION
A detailed diet history provides insight into a patients baseline
nutritional status. Assessment includes questions regarding
chewing or swallowing problems, avoidance of eating related to
abdominal pain, changes in appetite, taste or intake, as well as
use of a special diet or nutritional supplements. A review of past
medical history should identify any relevant conditions and
highlight increased metabolic needs, altered gastrointestinal
function and the patients capacity to absorb nutrients.
NAUSEA AND VOMITING
During this part of assessment you want to ascertain whether the
patient has any history of nausea and/or vomiting. Nausea and
vomiting can cause dehydration, electrolyte imbalance and
nutritional deficiencies (Marek 2003), and can also affect the
patients psychosocial well-being. They may become withdrawn,
isolated and unable to perform their usual activities of daily living.
5. SKIN
A detailed assessment of a patients skin may provide clues to
diagnosis, management and nursing care of the existing problem.
A careful skin assessment can alert the nurse to cutaneous probles
as well as systematic diseases. In addition, a great deal can be
observed in a persons face, which may give insight to his or her
state of mind.
6. CONTROLLING BODY TEMPERATURE
This assessment is carried out to establish baseline temperature and
determine if the temperature is within normal range, and whether
there might be intrinsic factors for altered body temperature.
(CONTROLLING BODY TEMPERATURE cont.)
It is important to note whether any changes in temperature are in
response to specific therapies (e.g. antipyretic medication,
immunosuppressive therapies, invasive procedures or infection
(Bickley et al. 2013)). White blood count should be recorded to
determine whether it is within normal limits.
7. SLEEP AND REST
This part of assessment is performed to find out sleep and rest
patterns and reasons for variation. Description of sleep patterns,
routines and interventions applied to achieve a comfortable sleep
should be documented. The nurse should also include in the
presence of emotional and/or physical problems that may interfere
with sleep.
8. STRESS AND COPING
Assessment is focused on the patients perception of stress and on
his or her coping strategies. Support system should be evaluated
and symptoms of stress should be noted. It includes the
individuals reserve or capacity to resist challenge to self-integrity,
modes of handling stress. The effectiveness of a persons coping
strategies in terms of stress tolerances may be further evaluated
(adapted from Gordon 1994)
9. ROLES AND RELATIONSHIP
The aim is to establish the patients own perception of the roles
and responsibilities in their current life situation. The patients role
in the world and their relationship with others are important to
understand. Assessment in this area includes finding out about the
patients perception of the major roles and responsibilities they
have in life, satisfaction or disturbances in family, work or social
relationships. An assessment of home life should be undertaken
which should include how they will cope at home post discharge
from hospital and how those at home will cope while they are in
hospital, for example dependants, children or animals and if there
are any financial worries.
10. PERCEPTION/CONCEPT OF SELF
BODY IMAGE/SELF-ESTEEM
Body image is highly personal, abstract and difficult to describe. The
rationale for this section is to assess the patients level of
understanding and general perception of self. This includes their
attitudes about self, perception of abilities (cognitive, affective or
physical), body image, identity, general sense of worth and general
emotional pattern. An assessment of body posture and movement, eye
contact, voice and speech patterns should also be included.
11. SEXUALITY AND REPRODUCTION
Understanding sexuality as the patients perceptions of their own body
image, family roles and functions, relationships and sexual function can
help the assessor to improve assessment and diagnosis of actual or
potential alterations in sexual behavior and activity.
Assessment in this area is vital and should include relevant
feelings about the patients own body, their need for touch,
interest in sexual activity, how they communicate their sexual
needs to a partner, if they have one, and the ability to engage in
satisfying sexual activities.
This may also be an opportunity to explore with the patient issues
related to future reproduction if this is relevant to the admission.
12. VALUES AND BELIEFS
RELIGIOUS, SPIRITUAL AND CULTURAL BELIEFS
The aim is to assess the patients spiritual, religious, and cultural
needs to provide culturally and spiritually specific care while
concurrently providing a forum to explore spirituals strengths that
might be used to prevent problems or cope with difficulties.
Assessment is focused on the patients values and belief, including
spiritual beliefs, or on the goals that guide his or her choices or
decisions. A patients experience of their stay in hospital may be
influenced by their religious beliefs or other strongly held principles,
cultural background or ethnic origin. It is important for nurses to have
knowledge and understanding of the diverse cultures of their patients
and take their different practices into account.
13. HEALTH PERCEPTION AND MANAGEMENT
RELEVANT MEDICAL CONDITIONS, SIDE EFFECTS/COMPLICATION
OF TREATMENTS
Assessment of the patients perceived pattern of health and well-
being and how health is managed should be documented here.
Any relevant history of previous health problems, including side-
effects of medication, should be noted. Examples of other useful
information that should be documented are compliance with
medication regimen, use of health promotion activities such as
regular exercise and if the patient has annual check-ups.
POST-PROCEDURAL CONSIDERATIONS
3
DECISION MAKING AND NURSING DIAGNOSIS
The purpose of collecting information through the process of
assessment is to enable the nurse to make a series of clinical
judgments, which are known in some circumstances as nursing
diagnoses, and subsequently decisions about the nursing care
each individual needs. The decision-making process is based upon
the clues observed, analysed and interpreted and it has been
suggested that expert nurses assess the situation as a whole and
make judgments and decisions intuitively (Hedberg and Satterlund
Larsson 2003, King and Clark 2002, Peden McAlpine and Clark
2002), reflecting Benners (1984) renowed novice-to-expert theory.
Nursing diagnosis is a term which describes both a clinical
judgment that is made about an individuals response to health or
illness, and the process of decision making that leads to that
judgment. The importance of thorough assessment within this
process cannot be overestimated. The gathering of comprehensive
and appropriate data from patients, including the meanings
attributed to events by the patient, is associated with greater
diagnostic accuracy and thus more timely and effective
intervention (Alfaro-LeFevre 2014, Gordon 1994, Hunter 1998).
PLANNING AND IMPLEMENTING CARE
Nursing diagnosis provide a focus for planning and implementing
effective and evidenced-based care. This process consists of
identifying nursing-sensitive patient outcomes and determining
appropriate interventions (Alfaro-LeFevre 2014, Shaw 1998, White
2003).
To determine the immediate priorities and recognize
whether patient problems requiring nursing careor
whether a referral should be made to someone else.
To identify the anticipated outcome for the patient,
noting what the patient will be able to do and within
what time frame. The use of measurable verbs that
describe patient behavior or what the patient says
facilitates the evaluation of patient outcomes.

(PLANNING AND IMPLEMENTING CARE Cont..)
To determine the nursing interventions, that is, what
nursing actions will prevent or manage the patients
problems so that the patients outcomes may be
achieved.
To record the care plan for the patient which may be
written or individualized from a standardized/core care
plan or a computerized care plan.
EXAMPLES OF MEASURABLE AND NON-MEASURABLE VERBS FOR
USE IN OUTCOME STATEMENTS
MEASURABLE VERBS (use these to be specific)
State; verbalize; communicate; list; describe; identify
Demonstrate; perform
Will lose; will gain; has an absence of
Walk; stand; sit
NON-MEASURABLE VERBS (do not use)
Know
Understand
Think
Feel
EVALUATING CARE
Effective evaluation of care requires the nurse to critically analyse
the patients health status to determine whether the patients
condition is stable, has deteriorated or improved. Seeking the
patients and familys views in the evaluation process will facilitate
decision making. By evaluating the patients outcomes, the nurse
is able to decide whether changes need to be made to the care
planned. Evaluation of care should take place in a structured
manner and on a regular basis by a Registered Nurse. The
frequency of the evaluation depends on the clinical environment
within which the individual is being cared for as well as the nature
of the nursing diagnosis (problem) to which the care relates.
DOCUMENTING
Nurses have a professional responsibility to ensure that healthcare
records provide an accurate account of treatment, care planning and
delivery, and are viewed as a tool of communication within the
team. There should be a clear evidence of the care planned, the
decision made, the care delivered and the information shared (NMC
2010, p.8). The content and quality of record keeping are a
measure of standards of practice relating to the skills and
judgment of the nurse (NMC 2010).
OBSERVATION
Observation is the conscious, deliberate use of the physical senses
to gather data from the patient and the environment. It occurs
whenever the nurse is in contact with the patient. At each patient
contact, it is important to try and develop a sequence of
observations. These might include the following:
1. As you enter the room, observe the patient for signs of
distress.
2. Scan for safety hazards.
3. Look at the equipment.
4. Scan the room-who is there and how do these people
interact with the patient.
5. Observe patient more closely for data such as skin
temperature, breath sounds, drainage/dressing odours,
condition of dressing, drains, need for repositioning
(Wilkinson 2007).
PHYSICAL ASSESSMENT/EXAMINATION
Physical assessment serves a number of purposes (Crouch and
Meurier 2005).
To obtain information on the patients overall health status.
To enable additional information to
be obtained about any
symptoms reported by the patient.
To detect changes in a patients condition.
To evaluate how the patient is responding to interventions.
EVIDENCE-BASED APPROACHES
The patients health history and the nurses knowledge of anatomy
and physiology will help guide when it is appropriate to do a
physical examination and which system is to examine. From the
history, a list of differential diagnoses will have been generated
and the examination should seek to confirm, refute or further
establish that a differential diagnosis is a possibility (Douglas and
Bevan 2013). There are four aspects of physical examination:
1. Inspection simply observing the patient.
2. Palpation requires the use the whole hand including
the palm and the full length of the fingers to feel and
assess (Bickleyet al. 2013, Rushforth 2009).
3. Percussion helps to identify organs, allowing
assessment of size and shape.
4. Auscultation involves listening to various sounds in the
body using a stethoscope (Bickley et al. 2013, Rushforth
2009).
4
LEGAL AND PROFESSIONAL ISSUES
As in all aspects of care, nurses must be aware of their ethical
and legal responsibilities when assessing patients. Issues of
honesty and confidentiality are frequently encountered during
assessment (Wilkinson 2007).
INFECTION PREVENTION AND CONTROL
MECHANISMS OF INFECTION
Whether or not a particular infectious agent will cause an infection in
any given circumstance is dependent on many different factors,
including how easily that agent can be transmitted, its pathogenicity
(which is its ability to cause disease) and its virulence (which
determine the severity of the infection produced ) (Gillespie and
Bamford 2012). It is generally accepted that for infection to occur,
certain linked requirements need to be met; these links are often
referred to as the chain of infection (Damani 2011).
MODES OF TRANSMISSION
DIRECT CONTACT person-to-person spread of infectious agents
through physical contact between people. It can be prevented
through good hand hygiene, the use of barriers such as aprons
and gloves and non-touch technique for aseptic procedures
(Loveday et al. 2014).
INDIRECT CONTACT occurs when someone comes into contact with
a contaminated object. Transmission is prevented by effective
cleaning, decontamination and good hand hygiene (DH/HPA 2008).
DROPLET TRANSMISSION when people cough, sneeze or even
talk, they expel droplets of respiratory secretions and saliva.
Transmission is prevented through isolating the affected patient
and using masks, aprons and gloves to provide a barrier. May also
be reduced through good hand hygiene.
(MODES OF TRANSMISSION Cont)
AIRBORNE TRANSMISSION involves droplets or particles
containing infectious agents, but on a small enough scale that the
particles can remain suspended in the air for long periods of time.
Infections spread via this route include measles and chickenpox.
Prevention is as for droplet transmission.
PARENTERAL TRANSMISSION this is a form of contact
transmission, where blood or body fluids containing infectious
agents, come into contact with mucous membranes or exposed
tissue. In healthcare, this can occur through transplantation or
infusion (which is why blood and organs for transplantation are
screened for blood borne viruses such as HIV). Transmission is
prevented by good practice in handling and disposing of sharps
and the appropriate use of protective equipment, including eye
protection (UK Health Departments 1998). A European Union
directive recently incorporated into UK Legislation requires the use
of safe needle-free devices wherever possible in order to reduce
the risk of inoculation injury (Health and safety Executive 2013) .
FAECAL-ORAL TRANSMISSION this occurs when an infectious
agent present in the faces of an infected person is subsequently
ingested by someone else and enters their gastrointestinal tract.
Transmission is prevented through isolating any patient with
symptoms of gastroenteritis; effective hand hygiene by both staff
and patients with soap and water (as many of these organism are
less susceptible to alcohol); appropriate use of gloves and aprons;
and good food hygiene (DH/HPA 2008).
VECTOR TRANSMISSION many diseases are spread through the
action of a vector, most often an insect that travels from one
person to another to feed. This route is not currently a concern in
healthcare in England, but in some areas of the world, for example
where malaria is endemic, protecting patients from vectors such as
mosquitoes is an important element of nursing care.
SYMPTOMS OF INFECTION
HEAT the site of the infection may feel warm to the
touch, and the patient may have a raised temperature.
PAIN at the site of the infection.
SWELLING at the site of the infection.
REDNESS at the site of the infection.
FEELING of general malaise.
In GASTROINTESTINAL INFECTION abdominal pain and
tenderness; nausea; diarrhea and/or vomiting (Goering
et al. 2012).
In URINARY TRACT INFECTION frequency of
micturition; often confusion in the elderly; loin pain
and/or abdominal discomfort (Goering et al. 2012).
EVIDENCE-BASED APPROACHES
The principle of all infection prevention and control is preventing
the transmission of infectious agents.
The infection prevention and control policies of health and social care
providers are based on generic risk assessments of their usual client or
patient group and should be adhered to unless there are strong
reasons to alter procedures for a particular individuals care.
In such circumstances, the advice of the infection prevention and
control team (IPCT) should be sought first. Nurses working in
organizations without an IPCT should identify the most appropriate
source from which to seek advice, preferably before it is needed.
LEGAL AND PROFESSIONAL ISSUES
In England, the Health and Safety at Work etc. Act 1974 is the
primary piece of Legislation relating to the safety of people in the
workplace. It applies to all employees and employers, and requires
them to do everything that is reasonable and practicable to
prevent harm coming to anyone in the workplace. It requires
employers to provide training and appropriate protective
equipment and employees to follow the training that they have
received, use the protective equipment provided, and report any
situations where they believe inadequate precautions are putting
anyones health and safety at serious risk. This dovetails with the
requirements of the Nursing and Midwifery Council (NMC 2015) for
nurses to promote and protect the well-being of those in their care
and to report concerns in writing if problems in the environment of
care are putting people at risk.
The NMC Code (NMC 2015) states that all nurses must work within
the limits of their competence. This means, for example, not
carrying out aseptic procedures without being competent nad
confident that they can be carried out without increasing the risk
of introducing infection through lack of knowledge or technique.
COMMUNICATION
Communication is a universal word with many definition, many of
which describe it as a transfer of information between a source
and a receiver (Kennedy Sheldon 2009); that is, the sending and
receiving of verbal and non-verbal messages between two or more 5
people (de Vito 2013). In nursing, this communication primarily
interpersonal; the process by which compassion and support are
offered and information, decisions and feelings are shared
(McCabe and Timmins 2013).
EVIDENCE-BASED APPROACHES
Effective communication is widely regarded to be a key determinant of
patient satisfaction, compliance and recovery (Dwamena et al. 2012,
Webster and Bryan 2009), yet poor communication is one of the most
common causes of complaints in healthcare (DH 2013, Strachan 2004).
Nurses need to communicate effectively with patients in order to
deliver individualized safe care and treatment and to manage
psychosocial concerns appropriately.
LISTENING is a skill often assumed to be natural. Rarely would
we consider that we were physically unable to listen and perhaps
this makes us pay little attention to this crucial skill area.
How to let someone know you are listening to them?
Non-verbal encouragement e.g. head nodding, body
position, eye contact.
Verbal responses
Questioning
Paraphrasing
Clarifying
Summarizing
Empathy
LEGAL AND PROFESSIONAL ISSUES
There are number of legal and professional concepts and issues
that impact on effective communication and psychological support.
These include:
(LEGAL AND PROFESSIONAL ISSUES Cont) DEPRESSION

Professional responsibility for effective communication.

Depression is a broad and heterogeneous diagnosis. Central to it is
a depressed mood and/or loss of pleasure in most activities (NICE
Confidentiality andappropriate disclosure of information
about the patient. 2009b). Depression is often accompanied by symptoms of anxiety,
and can be short-lived (sometimes dependent upon physical
Consent communicating about a procedure and ensuring
that a patient is fully cognizant of what it involves. symptoms) or chronic.

Assessment of an individuals
mental capacity to engage
in care and treatment. SYMPTOMS THAT INDICATE A DIAGNOSIS OF CLINICAL
DEPRESSION
MENTAL CAPACITY ACT 2005
BEHAVIOURAL
The Mental Capacity Act (2005) sets out clear guidance and has
produced a code of practice to support professionals working Tearfulness
weith people who may have impairment in their capacity. Irritability
Social withdrawn
COMMUNICATING WITH THOSE WHO ARE WORRIED OR Changes to sleep patterns
DISTRESSED Lowered appetite
Lack of libido
Interpersonal communication is the process of discussion between Fatigue

healthcare professionals and patients and carers, which allows Diminished activity

patients and carers to explore issues and arrive at decisions (NICE Attempts at self-harm or suicide
2004).
PHYSICAL
Related Theory
Exacerbation of pre-existing pains
Patients will naturally have an emotional response to serious Pains secondary to increased muscle tension
illness. At its most mild, this is seen as sadness and worry. At its Agitation and restlessness
most serious, however, patients experience severe psychological Changes in weight
responses such as adjustment reactions, anxiety states or
6
depression (NICE 2004). COGNITIVE

EVIDENCE-BASED APPROACHES Poor concentration

Reduced attention
Research evidence suggests that nurses and other healthcares Pessimistic thoughts
should listen to all of the concerns, even those that have no Recurring negative thoughts about oneself, past and
resolution (Booth et al. 1999, Pennebaker 1993). Nurses should future
inquire about the resources (help) that patients have around Mental slowing
themselves what would help, before the health worker offers Rumination
advice, information or reassurance (Booth et al. 1999, Tate 2010).
EMOTIONAL
Pre-procedural consideration
Feelings of guilt
Patients need privacy to discuss emotions and worries: they also Worthlessness
need time. Nurses, therefore, should create the conditions for Deserving of punishment
patients to describe their worries. Lowered self-esteem
Loss of confidence
COMMUNICATING WITH THOSE WITH SPECIFIC PSYCHOLOGICAL Feeling of helplessness
NEEDS Suicidal ideation

DENIAL AND COLLUSION Pre-procedural considerations

Denial is a complex phenomenon (Vos and Haes 2010) and can be
considered a mechanism for slowing down and filtering the
absorption of traumatic information, allowing for avoidance of
painful or distressing information (Goldbeck 1997).
Collusion is when two or more parties develop a shared,
sometimes secret understanding that may involve withholding
information from another person.
Related theory
Pharmacological Support there are four main types of
antidepressant: tricyclic, monoamine oxidase inhibitors (MAOI),
selective serotonin reuptake inhibitors, (SSRI) and serotonin-
norepinephrine reuptake inhibitors (SNRI) (RCPsych 2013).
Non-pharmacological Support Nurses can be involved in assessing
depression in patients with physical illness. NICE guidance sets out a
step model for managing a patient with depression.

Diagnosis of any potentially life-threatening illness is experience in

Initiate the conversation, develop rapport.


many different ways and can cause strong emotional responses. Develop a person-centred communication style.
Patients are likely to feel a degree of distress and experience a
and acceptance of behavior,
Show understanding, caring
wide range of emotions that may be lessened if healthcare including tears or anger.
professionals (HCPs) are truthful and open with patients about
Encourage patient to identify their own abilities or
their diagnosis and prognosis. strategies for coping with the situation.
PATIENT COMPORT AND END-OF-LIFE CARE
PERSONAL HYGIENE
Maintaining levels of good personal hygiene is essential for all patients
during their stay in hospital (Massa 2010). Hygiene is the science of
health and its maintenance. Personal hygiene is the self-care by which
people attend to such functions as bathing, toileting, general body
hygiene and grooming. Hygiene is a highly personal matter determined
by individual values and practices. It involves care of the skin, hair,
nails, teeth, oral and nasal activities, eyes, ears, and perianal and
perianal-genital areas (Berman et al. 2010).
END-OF-LIFE CARE
There is considerable ambiguity surrounding the terms end-of- life
care, palliative care and terminal care and they are often used
interchangeably but are not synonymous.
PALLIATIVE CARE is the active, total care of the patient whose
disease is not responsive to curative treatment. Control of pain, of
other symptoms and of social, psychological and spiritual problems
is paramount. Palliative care affirms life and regards dying as a
normal process: it neither hastens nor postpones death (European
Association for Palliative Care 2014).
END-OF-LIFE CARE (EOLC) encompasses the holistic assessment and
management of physical care, pain and other symptoms which includes
the provision of psychological, social, financial, spiritual and practical
support for both the patient and their family/cares in their place of
choice, during the last year of life and includes care given after
bereavement (National Council for Palliative Care 2008).
A component of palliative care has been defined as care that helps
all those with advanced, progressive, incurable conditions to live
as well as possible until they die. It enables the supportive and
palliative care needs of both patient and family to be identified and
met throughout the last phase of life and into bereavement.
TERMINAL CARE care that is given during the terminal phase.
This is an ill-defined period of irreversible declines that signifies
imminent death. This is usually a period of several days but may
be as short as a few hours; occasionally this can be as long as a
couple of weeks (Maltoni and Amadori 2001).
Related Theory
Enabling people to die in comport and with dignity is hugely
important for the patient, their families and cares and is a core
function of the NHS (NEoLCP 2011).
The End of Life Care Strategy (DH 2008) set guidance aimed at
improving care and choices for all people regardless of their
diagnosis and place of care. The principal aims are to improve the
quality of care for those approaching the end of their life and to
enable greater choices and control about their place of care and
death. The strategy, which focuses on the role of health and social
care, states that high-quality EOLC should be available wherever
the person maybe: at home, in a care home, in hospital, in a
hospice or elsewhere (DH 2008).
The National End of Life Care Programme (NEoLCP 2010) was
developed to implement the strategy.
The programme advocates the following core principles for
delivery of EOLC.
Treat individuals with dignity and respect.
Provide information and support to families and cares.
Recognize andrespect an individuals spiritual and
religious needs.
Provide effective pain and symptom management.
Provide care after death.
Ensure care is person centred and integrated.
Provide a safe, comfortable environment for care.
CARE BEFORE DEATH
Recognition of the dying phase care of the dying patient starts
with a recognition from the multi-professional team that the
terminal phase has begun. This has been cited as perhaps the
single most important factor in enabling the achievement of all the
factors associated with a good death (Faull and Nyatanga 2012).
It has been suggested that the following characteristics are central
to a good death from medical, nursing and patient perspectives.
Control
Comfort
Closure
Trust in healthcare providers
Recognition of impending death
An honouring of personal beliefs and values (Kehl 2006)
7
Four basic criteria for recognizing the terminal phase are widely
acknowledged. The presence of two or more of the following,
commonly preceded by a progressive period of decline and where
no other reversible cause is present, is said to denote the terminal
phase of life.
The patient is unable to get out of bed.
The patient is semi-comatose.
The patient is only able to take sips of fluid.
The patient is no longer able to take tablets.
ADVANCE DECISIONS TO REFUSE TREATMENT (ADRT)
These allow people who are 18+ years to make a legal decision to
refuse, in advance, a proposed treatment or the continuation of
that treatment, if at the relevant time the person lacks the
capacity to consent to it. ADRTs can only be made by those who
are deemed to have the mental capacity to do so, and allow only
for the refusal of treatments they cannot enforce the provision
of specified treatments in the same circumstances (DH 2012).
Advance decisions to refuse treatment must be in writing, be signed
and witnessed, and must expressly state that the decisions stands
even if the persons life is at risk (DH 2012). They can be withdrawn
verbally or in writing and are not considered valid if the person has
conferred Lasting Power of Attorney on another person.
Post-procedural considerations
Nursing care does not end when the death of the patient occurs; it
extends beyond death to provide care for the deceased person
and support to their family and cares (NNCG 2011). This physical
care given by nurses following death in hospitals has been
traditionally referred to as last offices (Care after death).

CARE AFTER DEATH
The term last offices only applies to the physical care of the
deceased body. Care after death is a broader term that better
reflects a multicultural society and also embraces all the differing
nursing task involved, including the outgoing support of the family
and carers (NNCG 2011). Even though they have die, patients are
still referred to as patients or people throughout this section.
LEGAL AND PROFESSIONAL ISSUES
Nurses should be aware of the legal requirements for care of
patients after death as it is essential that correct procedures are
followed (Green and Green 2006). It is particularly important that
nurses are aware of deaths that require referral to the coroner as
this will facilitate the correct personal care and enable nurses to
prepare the family for both a potential delay in the processing of
the MCCD and also the possibility of a post-mortem examination
(NNCG 2011).
OBSERVATION
The term observation refers to the physical assessment of a
patient, including assessment of wounds, intravenous therapy,
wound drains, pain and vital signs collection and specializes
assessments such as neurological observations (Zietz and
McCutcheon 2006). Vital signs are traditionally used in the
context of the collection of a cluster of physical measures, such as
pulse, respiration, temperature and blood pressure, and more
recently pulse oximetry.
PRINCIPLES OF CARE
Adult patients in acute hospital setting should have:
Observations taken when they are admitted or initially
assessed (Including on transfer to a ward setting from
critical care or transfer from one ward to another).
A clearly documented plan which identifies which
observations should be taken and how frequently
subsequent observations should be done. This plan
should take into consideration:
- The diagnosis
- Plan for patients treatment
- Any co-morbidities which may affect their health
(NICE 2007a).
All patients in hospital should have their observations
taken at least once every 12 hours, unless specified
otherwise by senior staff (NICE 2007a).
LEGAL AND PROFESSIONAL ISSUES
Nurses are accountable and responsible fpr providing optimum
care for their patients. The Nursing and Midwifery Council (NMC)
The Code provides the main source of professional accountability
for nurses (NMC 2015). It is essential that nursing staff objectively
examine the information gathered from assessments and
observations, including the patients baseline, as well as any
information previously recorded (Crounch and Meurier 2005).
Pre-procedural considerations
Equipment all practitioners need to be aware of the strengths and
limitations of the devices they are using and need to have adequate
training on the use of all equipment. They must ensure that the
devices are validated, checked, maintained and recalibrated regularly
according to the manufacturers instructions (NICE
2011a).
PULSE (HEART RATE)
A persons pulse rate can be influenced by several factors
including ae, gender, exercise, pyrexia, medications,
hypovolaemia, stress, positioning, pathology, hormones and
electrolytes (Field 2008, Kozier et al. 2008).
Normal pulse rate per minute at various ages
Age Approximate range
1 week-3 months 100-160
3 months-2 years 80-150
2-10 years 70-110
10 years-adult 55-90
BLOOD PRESSURE
Blood pressure may be defined as the force of blood inside the
blood vessels against the vessel walls (Marieb and Hoehn 2010).
SYSTOLIC PRESSURE is the peak pressure of the left ventricle
contracting and blood entering the aorta, causing it to stretch and
therefore in part reflects the function of the left ventricle (Marieb
and Hoehn 2010).
DIASTOLIC PRESSURE is when the aortic valve closes, blood flows
from the aorta into the smaller vessels and the aorta recoils back. This
is when the aortic pressure is at its lowest and tends to reflect the 8
resistance of the blood vessels (Marieb and Hoehn 2010).
NORMAL BLOOD PRESSURE Normal blood pressure ranges
between 110-140 mmhg systolic and 70-80 mmhg diastolic at rest
(Marieb and Hoehn 2010).
HYPOTENSION is generally in adults as a systolic blood pressure
below 100mmhg (Marieb and Hoehn 2010). A low blood pressure
may indicate orthostatic hypotension, that is, sudden drop in blood
pressure when the patient rises from a supine or sitting position.
HYPERTENSION is defined as blood pressure of 140/90mmhg or
greater. Factors leading to hypertension include gender, genetic
factors and age, alongside risk factors such as obesity, lack of
exercise, smoking and high caffeine and alcohol intake (Patton and
Thibodeau 2009).
Post-procedural considerations
IMMEDIATE CARE notify medical staff of an abnormal blood pressure
result. As the treatment will depend on what is causing the
abnormality, and its severity, it is important that practitioners try to
ascertain the possible cause for the physiological change in blood
pressure (Kisiel and Perkins 2006). Hypovolaemia will require fluid
replacement and, if persistent, then inotropes and other cardiovascular
drugs may be necessary (Hinds and Watson 2009).
ONGOING CARE if the patient is hypertensive and in primary
care, they will require at least monthly blood pressure
measurement and more frequently if it is accelerated hypertension
or there are any further concerns (NICE 2011a). Additionally, it will
be necessary to give lifestyle advice on, for example, eating
healthily and smoking cessation (NICE 2011a). If the hypotension
is orthostatic then advise the patient to change position slowly so
the baroreceptors and sympathetic nervous system have time to
adapt the blood pressure to each stage (Marieb and Hoehn 2010).
RESPIRATION AND PULSE OXIMETRY
The major function of the respiratory system is to supply the cells
of the human body with oxygen and to remove carbon dioxide, in
order that they can continue to function effectively (Tortora and
Derrickson 2011). Respiration is composed of four processes:
PULMONARY VENTILATION the movement of air into
and out of the lungs to continually
refresh the gases
there, commonly called breathing.
TRANSPORT OF RESPIRATORY GASES transport of
oxygen from the lungs to the cells, and of carbon
dioxide from the cells to
the lungs, accomplished by the
cardiovascular system.
INTERNAL RESPIRATION movement of oxygen from
blood to the cells and of carbon dioxide
from the cells to
the blood (Marieb and Hoehn 2010).
HYPOXIA AND HYPERCAPNIA
HYPOXIA is defined as inadequate oxygen delivery to the tissues.
Signs of hypoxia include tachypnea, dyspnea, tachycardia,
restlessness and confusion, headache, mild hypertension and
pallor; irregular breathing, cyanosis, hypotension, altered level of
consciousness, blurred vision and eventual respiratory arrest
(Beachery 2012).
Hypoxia can have various causes, and based on this, can be
classified into four types (Marieb and Hoehn 2010, Tortora and
Derrickson 2011).
1. Hypoxaemic hypoxia caused by a low PO2 in arterial
blood as a result of breathing air with inadequate
oxygen (such as at high altitude) or abnormal
ventilation/perfusion matching in the lungs (due to
airway obstruction or fluid in the lungs). Carbom
monoxide poisoning can also cause this.
2. Anaemic hypoxia caused by too little functioning
haemoglobin being present in the blood which reduces
the transport of oxygen to the cells (such as
haemorrhage or anaemia).
3. Ischaemic hypoxia caused when blood flow to a
specific area is inadequate to supply enough oxygen,
even though PO2 and Hb-O2 levels are normal (due to
embolism or thrombosis).
4. Histotoxic hypoxia caused by the cells being unable to
use the oxygen that has been delivered; this can ccur as
aresult of poisons such as cyanide.
HYPERCAPNIA is an elevated level of carbon dioxide level in the
blood. Signs include tacypnoea (eventually becoming bradyypnoea
as it worsens), dyspnea, tachycardia, hypertension, headaches,
vasodilation, drowsiness, sweating and a red colouration (Beachey
2012).
Patients with hypercapnia will require urgent medical attention and
close monitoring as hypercapnia will cause respiratory acidosis
(Beachey 2012). Patients with chronic hypercapnia, such as those
who have chronic obstructive pulmonary disease (COPD), will have
at least partially adapted to the chronically high levels of carbon
dioxide; oxygen therapy needs to be administered with caution in
these patients as they are at risk of hypercapnic respiratory failure
(ODriscoll et al. 2008).
PULSE OXIMETRY is an effective method of monitoring for
hypoxaemia and will immediately alert the practitioner to a fall in
arterial oxygen saturation, often even before any obvious
symptoms are displayed(Higginson and Jones 2009), Moore 2007).
It also provides useful information about heart rate (Jevon and
Ewens 2000). Pulse oximetry provides continuous and non-
invasive monitoring of the oxygen saturation from haemoglobin in
arterial blood (Moore 2007).
METHODS OF ASSESSING RESPIRATION
Airway assessment
Breathing assessment
Skin colour
Use of accessory muscles
Rhythm, rate and depth of respiration
Shape and expansion of the chest
General condition or distress of the patient
Pulse oximetry
TEMPERATURE
Body temperature represents the balance between heat
production and heat loss (Marieb and Hoehn 2010). If the rate of
heat generated equates to the rate of heat lost, the core body
temperature will be stable (Tortora and Derrickson 2011). All body
tissues produce heat depending on how metabolically active they
are. When the body is resting, most heat is generated by the
heart, liver, brain and endocrine organs (Marieb and Hoehn 2010). 9
HYPOTHERMIA (lowered body temperature) is defined as a core
temperature of 35C (Frink et al. 2012) that causes the metabolic rate
to decrease (Trim 2005). Hypothermia may be classified as mild (32-
35C), moderate (28-32C) and severe (less than 28C) (Cuddy 2004).
Hypothermia occurs when the body loses more heat and is
subsequently unable to maintain homestasis (Neno 2005).
HYPERTHERMIA sudden temperature elevations usually indicate
infection, making it prudent to perform a directed physical
examination and, if indicated, obtain appropriate cultures and
institute antibiotics.
Non-infectious causes of hyperthermia
Alcohol withdrawal
Anticholinergic drugs
Allergic drug or transfusion reaction
Autonomic insufficiency
Crystalline arthritis (gout)
Drug allergy
Heat stroke
BLOOD GLUCOSE
Blood glucose is the amount of glucose in the blood (Brooker
2010). Normally blood glucose levels stay within narrow limits
throughout the day: 4-8 mmol/L (millimoles per litre) (NICE 2004).
Normal target blood glucose ranges
Children and young people Adults >18 years of age
<18 years of age
Preprandial blood glucose Preprandial blood glucose
Levels 4-8 mmo/L level 4-7 mmo/L
Postprandial blood glucose Postprandial blood glucose
Levels of less than 10 mmo/L Levels of less than 9 mmo/L
(BLOOD GLUCOSE Cont)
HYPERGLYCAEMIA it is defined as a random blood glucose of
more than 11.1 mmol/L (WHO/IDF 2006).
HYPOGLYCAEMIA is described as ablood glucose level that is
unable to meet the metabolic needs of the body (Marini and
Wheeler 2012), normally lower than 4 mmol/L (Wallymahmed
2007). Hypoglycaemia is an acute complication of diabetes that
increases morbidity, mortality and economic costs of diabetes and
can decrease quality of life (Fidler et al. 2011, Liu et al. 2012).
MEDICINES MANAGEMENT
The Medicines and Healthcare products Regulatory Agency (MHRA
2004) defines medicines management as the clinical, cost-effective
and safe use of medicines to ensure patients get the maximum benefit
from the medicines they need, while at the same time minimizing
potential harm. All Registered Nurses have a professional responsibility
with regard to procurement, prescription, supply and disposal of
medicines as defined in the NMC Standards for Medicines Management
(NMC 2010a). They must ensure the patient understands what
medicines they are taking, the indication for the medication and any
likely side-effects.
EVIDENCE BASE FOR MEDICINES MANAGEMENT IN PRACTICE
Good medicines management is essential to assure high standards
in the clinical care of patients. When delivered effectively, it can
reduce the risk of medication errors and serious adverse drug
reactions and prevent unnecessary delays for the patient at the
point of discharge.
All aspects of a medicines use must be managed with a
multidisciplinary approach to ensure it is supported by a strong
evidence base and that safety and well-being of the patient remain
paramount (NMC 2015, Shepherd 2002a).
LEGAL METHODS FOR PRESCRIBING MEDICINES
The medicines Act 1968 states that only authorized healthcare
practitioners can legally prescribe medicines in the UK. It provides
all prescribers with a framework for which medicines require a
prescription and which medicines can be available to the public
without a prescription and under what circumstances. All
medicines administered in hospital must be considered prescription
only. This is because administration, whether by a nurse or by a
patient to themselves, may only take place in accordance with one
or more of the following processes:
Patient-specific direction
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
Standing orders
Homely remedy protocol
Prescription form (NMC 2010a, pp.13-19)
NURSE PRESCRIBING AND PATIENT GROUP DIRECTIONS
As nurses have undertaken increasingly specialized roles, the need
for them to have powers to prescribe has become more apparent.
The report of the Advisory Committee on Nurse Prescribing (DH
1989) initially recommended a limited nurses formulary for
community nurses and health visitors.
VERBAL ORDERS
The NMC (2010a) clearly states that a verbal order is not acceptable on
its own. n exceptional circumstances, where the medication (NOT
including controlled drugs) has been previously prescribed and the
prescriber is unable to issue a new prescription, but where changes to
the dose are considered necessary, the use of information technology
(such as fax or email) may be used but the prescriber must confirm
any changes to the original prescription(NMC 2010a, p.28). This
should be followed up by a new prescription, signed by the prescriber
confirming the changes, within a maximum of 24 hours. The changes
must be authorized before the new dosage is administered (NMC
2010a).
MEDICINES RECONCILIATION
It has been defined by the Institute for Healthcare Improvement as
the process of creating the most accurate list possible of all
medications the patient is taking-including drug name, dosage,
frequency and route-and comparing that list against the
physicians admission, transfer, and/or discharge orders, with the
goal of providing correct medications to the patient at all transition
points within the hospital (www.ihi.org).
SAFE STORAGE OF MEDICINES
The report The Safe Secure Handling of Medicines: A Team
Approach (RPSGB 2005) details that the responsibility for
establishing and maintaining a system for the security of 10
medicines should that of the senior pharmacist in the hospital.
They should do this in consultation with senior nursing staff and
appropriate medical staff. The appointed nurse in charge of the
area will have the responsibility of ensuring that the system is
followed and that the security of medicines is maintained.
SECURITY
All drugs should be stored in locked cupboards with separate
storage for internal medicines, external medicines, controlled
drugs and medicines needing refrigeration or storage in a freezer.
Diagnostic reagents, intravenous and topical agents should also be
kept separately in individual storage.
STABILITY
No medical preparation should be stored where it may be subject
to substantial variations in temperature, for example not in direct
sunlight.
The normal temperature ranges for storage are as follows:
COLD STORAGE products to be stored between 2C and 8C.
or between 8C and 15C.
ROOM TEMPERATURE for products that need to be stored at
room temperature or not above 25C (MHRA 2001).
SAFE ADMINISTRATION OF MEDICINES
All nurses who administer medicines must be familiar with and
adhere to the Standards for Medicines Management (NMC 2010a).
To achieve safe administration the nurse must have a sound
knowledge of the therapeutic use, usual dose, side-effects,
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)
RECORD OF ADMINSTRATION
The nurse must document a clear, accurate and immediate record
of all medicines administered, intentionally withheld or refused by
the patient, ensuring all written entries and signatures are clear
and legible (NMC 201b). If any medication is withheld or refused
by a patient, the reasons must be documented.
SINGLE OR DOUBLE CHECKING OF MEDICINES
Medicines can be prepared and administered by a single qualified nurse
or by two nurses checking (known as double checking). There are
certain times when double or second checking is required. It is
recommended that for the administration of controlled drugs, a
secondary signature is required (NMC 2010a). The NMC Standards for
Medicines Management also states that wherever possible two
registrants should check medication to be administered intravenously,
one of whom should also be the registrant who the administer the
intravenous medication (NMC2010a, p.34).
SEVEN KEY ACTIONS TO IMPROVE MEDICATION SAFETY
1. Increase reporting and learning from medication
incidents.
2. Implement NPSA safer medication practice
recommendations.
3. Improve staff skills and competencies.
4. Minimize dosing errors.
5. Ensure medicines are not omitted.
6. Ensure the correct medicines are given to the correct
patients.
7. Document patients medicine allergy status.
Consent must be given willingly.
Consent must be informed.
The person must have the capacity to consent to the
procedure in question.
CONTROLLED DRUGS
Controlled drugs are those drugs that are listed in Schedule 2 of
the Misuse of Drugs Act 1971 and are subject to the controls
stipulated in the Act, for example diamorphine, morphine,
amphetamines, benzodiazepines, The use of controlled drugs in
medicine is permitted by the Misuse of Drugs Regulations and
related regulations.
LEGISLATION
Medicines Act 1968 The Act and the regulations made under
the Act set out the requirements for the legal sale, supply and
administration of medicines.
Misuse of Drugs Act 1971 for reasons of public safety, the
Misuse of Drugs Act controls the export, import, supply and
possession of dangerous or otherwise harmful drugs to prevent
abuse as most are potentially addictive or habit forming as well as
harmful.
Misuse of Drugs (safe Custody) Regulations 1973 these
regulations control the storage of controlled drugs. The level of
control of storage depends on the premises in which they are
being stored and the schedule of the drug.
Misuse of Drugs Regulations 2001 under these regulations
controlled drugs are classified into five schedules, each
representing a different level of control.
Controlled Drugs (Supervision of Management and Use)
Regulations 2006 these regulations set out the requirements
for certain NHS bodies and independent hospitals to appoint an
accountable officer. The duties and responsibilities of the
accountable officer are to improve the management and use of
controlled drugs. These regulations also allow the periodic
inspection of premises.
Misuse of Drugs and Misuse of Drugs (safe Custody)
(Amendment) regulations 2007 these regulations give
accountable officers authority to nominate persons to witness the
destruction of controlled drugs within their organization. They also
allow operating department practitioners to order, possess and
supply controlled drugs. In addition, they set out changes to the
record keeping for controlled drugs, with requirements for
recording in the controlled drug register the person (the patient),
patients representative or a healthcare professional) collecting the
Schedule 2 controlled drug. If it is a healthcare professional, there
is a requirement for the name and address of that person.
CONSENT
NHS Choices (2012) defines consent as: the principle that a
person must give their permission before they receive any type of
medical treatment.
EVIDENCE-BASED APPROACH
There are different types of consent in healthcare: written, verbal 11
(explicit) and non-verbal (implied or implicit) (DH 2009b). The
Department of Health (DH 2009b) and professional bodies
including the Nursing and Midwifery Council (NMC) and General
Medical Council (GMC) have produced comprehensive guidance
about consent (GMC 2008, NMC 2013). The DH guidance (DH
2009) includes information about what consent is, by whom and in
what circumstances.
PRINCIPLE OF CARE
Unless it is emergency, the gaining of consent should be treated
as a process rather than a one-off event (DH 2009b). For major
operations, it should be considered good practice to gain a
persons consent to the proposed procedure well in advance
ideally prior to pre-assessment when there is time to respond to
the persons questions and provide adequate information so that
the person has time to develop an understanding to allow an
informed decision to be made (Hughes 2011).
LEGAL AND PROFESSIONAL ISSUES
It is accepted that when a patient gives valid consent, this is valid
indefinitely unless withdrawn by the patient; therefore no specific time
limit is designated from signature to procedure (Hughes 2011).
For consent to be valid, it must encompass several factors.
Consent must be given willingly.
Consent must be informed.
The person must have the capacity to consent to the
procedure in question.
All healthcare professionals should be aware of the different types
of consent and the importance of ensuring that the person
understands what is going to happen to them and what is
involved. Healthcare professionals should also be familiar with
their local hospital consent policy and be aware of and understand
what to do if people refuse care or treatment or when consent is
not valid or is no longer valid.
 Q&A
Q. You are a registered nurse in a community giving health
education to a patient and you notice that the student nurse is
using his cell phone to text, what should you do?
A. Politely signal the student and encourage him by
actively including him in the discussion.
Q. A nurse is having trouble with doing care plans. Her team
members are already noticing this problem and are worried of the
consequences this may bring to the quality of nursing care
delivered. The problem is already brought to the attention of the
nurse. The nurse should:
A. Accept her weakness and take this challenge as an
opportunity to improve her skills by requesting lectures
from her manager.
Q. Why is it essential to humidify oxygen used during respiratory
therapy?
A. Oxygen is a dry gas which can cause evaporation of
water from the respiratory tract and lead to thickened
mucus in the airways, reduction of the movement of cilia
and increased susceptibility to respiratory infection.
Q. When using nasal cannulae, the maximum oxygen flow rate
that should be used is 6 litres/min. Why?
A. Higher rates can cause nasal mucosal drying and may
lead to epistaxis.
Q. What should be included in your initial assessment of your
patients respiratory status?
A. Observe the patients breathing for ease and comfort,
rate and pattern.
Q. Why should healthcare professionals take extra care when
washing and drying an elderly patients skin?
A. As the skin of an elder person has reduced blood supply,
is thinner, less elastic and has less natural oil. This
means the skin is less resistant to shearing forces and
wound healing can be delayed.
Q. What is the best way to prevent a patient who is receiving an
enteral feed from aspirating?
A. Sit them at least at a 45 angle.
Q. What specifically do you need to monitor to avoid complications and
ensure optimal nutritional status in patients being enterally fed?
A. Blood glucose levels, full blood count, stoma site and
bodyweight.
Q. What factors are essential in demonstrating supportive
communication to patients?
A. Listening, clarifying the concerns and feelings of the
patient using open questions.
Q. NMC requires in the UK how many units of continuing education
units a nurse should have in 3 years?
A. 35 units
Q. What would make you suspect that a patient in your care had a
urinary tract infection?
A. The patient has spiked a temperature, has a raised
white cell count (WCC), has new-onset confusion and
the urine in his catheter bag is cloudy.
Q. What steps would you take if you had sustained a needle stick
injury?
A. Gently make the wound bleed, place under running water
and wash thoroughly with soap and water. Complete an
incident form and inform your manager. Co-operate with
any action to test yourself or the patient for infection with a
blood borne virus but do not obtain blood or consent for
testing from the patient yourself; this should be done by
someone not involved in the incident.
Q. If you were told by a nurse at handover to take standard
precautions what would you expect to be doing?
A. Using appropriate hand hygiene, wearing gloves and
aprons when necessary, disposing of used sharp
instruments safely and providing care in a suitably clean
environment to protect yourself and the patients.
Q. You believe that an adult you know and support has been a victim
of physical abuse that might be considered a criminal offence. What
should you do to support the police in an investigation?
A. Make an accurate record of what the person has said to
you. 12
Q. A young mother who delivered 48hrs ago comes back to the
emergency department with post partum haemorrhage. What type
of PPH is it?
A. Secondary post partum haemorrhage.
Q. What do you mean by MRSA?
A. Methicillin-resistant staphyloccocus aureus
Q. Who will you inform first if there is a shortage in supplies in
your shift?
A. Immediate nurse manager
Q. You are to take charge of the next shift of nurses. Few minutes
before your shift, the in charge of the current shift informed you
that two of your nurses will be absent. Since there is a shortage of
staff in your shift, what will you do?
A. Ask from your manager if there are qualified staff from
the previous shift that can cover the lacking number for
your shift while you try to replace new nurses to cover.
Q. As you visit your patient during rounds, you notice a thin child
who is shy and not mingling with the group who seemed to be
visitors of the patient. You offered him food but his mother told
you not to mind him as he is not eating much while all of them are
eating during that time. As a nurse, what will you do?
A. Raise the situation to your head nurse and discuss with
her what intervention might be done to help the child.
Q. What could be the reason why you instruct your patient to retain on
its original container and discard nitroglycerine meds after 8
weeks?
A. Removing from its darkened container exposes the
medicine to the light and its potency will decrease after
8 weeks.
Q. Who is responsible in disposing sharps?
A. Whoever used the sharps.
Q. Where will you put infectious linen?
A. Red plastic bag designed to disintegrate when exposed
to heat.
Q. What does AVPU mean?
A. Alert voice pain unresponsive.
Q. When will you consider giving out information of the patient to
a police officer?
A. If safety of the public is at risk.
Q. For an average person from Uk who has non-insulin dependent
diabetes, how many servings of fruits and vegetables per day
should they take?
A. 5 servings
Q. A relative of the patient was experiencing vomiting and diarrhea
and wished to visit her mother who was admitted. As a nurse, what
will you advise to the patient's relative?
A. There should be 48 hours after active symptoms should
disappear prior to visiting patient.
Q. As a nurse, what health teachings will you give to a COPD
patient?
A. Encourage to stop smoking; Administer oxygen
inhalation as prescribed; Enroll in a pulmonary
rehabilitation programme.
Q. In a community hospital, an elderly man approaches you and tells
you that his neighbour has been stealing his money, saying
"sometimes I give him money to buy groceries but he didn't buy
groceries and he kept the money" what is your best course of action
for this?
A. Raise a safeguarding alert
Q. On physical examination of a 16 year old female patient, you
notice partial erosion of her tooth enamel and callus formation on
the posterior aspect of the knuckles of her hand. This is indicative
of:
A. Self-induced vomiting and she likely has bulimia nervosa
Q. Patients with gastric ulcers typically exhibit this symptom:
A. Epigastric pains worsens after eating and weight loss
Q. Commonly aneurysms can develop on?
A. Abdominal aorta; Circle of Willis
Q. A patient suffered from stroke and is unable to read and write.
This is called:
A. Dysphasia
Q. The degree of injection when giving subcutaneous insulin
injection on a site where you can grasp 1 inch of tissue?
A. 45 degrees
Q. What is the best position in applying eye medications?
A. Sitting position with head tilt backwards
Q. The worst advice you can give a student nurse with regards to
the use of social networking sites like Facebook?
A. Do not identify yourself as a nurse; Rely on the sites
privacy settings
Q. Which bag do you place infected linen?
A. Water-soluble alginate polythene bag before being placed in
the appropriate linen bag, no more than full.
Q. In the News observation system, what is AVUP?
A. Assessment for the level of consciousness.
Q. Normal heart rate for 1 to 2 years old?
A. 80 - 110 beats per minute
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Q. What advice do you need to give to a patient taking Allopurinol?
A. Drink 8 to 10 full glasses of fluid every day, unless your
doctor tells you otherwise; Store allopurinol at room
temperature away from moisture and heat; Avoid being
near people who are sick or have infections
Q. Safeguarding is the responsibility of:
A. Health care assistants; Registered nurses; Doctors
Q. Hypoglycaemia in patients with diabetes is more likely to occur
when the patients take:
A. Insulin; Sulphonylureas; Prandial glucose regulators
Q. Enteral feeding patient checks patency of tube placement by:
A. Aspirating gastric juice and then checking for ph <4 X-ray
Q. A doctor prescribes an injection of 200 micrograms of drug. The
stock bottle contains 1mg/ml. How many ml will you administer?
A. 0.2 ml
Q. The doctor prescribes 25mg of a drug to be given by injection.
It is a drug dispensed in a solution of strength 50mg/ml. How
many ml should you administer?
A. 0.5 ml Dose Prescribed: Dose /ml - 25:50=0.5
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?
A. 3 tablets
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. Understand information about the decision and

Q. Patient is post op liver biopsy which is a sign of serious remember that information; Use that information to
complication make a decision; Communicate their decision by talking,
using sign language or by any other means
A. Nausea and vomiting; Bleeding

Q. Hospital discharge planning for a patient should start:

Q. A suicidal Patient is admitted to psychiatric facility for 3 days when
suddenly he is showing signs of cheerfulness and motivation. A. On the admission assessment
The nurse should see this as:

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
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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. Only under close, direct supervision

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

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

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

A. Vaginal bleeding; Positive pregnancy test; Shoulder tip

pain Q. When do you gain consent from a patient and consider it valid?
Q. What medications would most likely increase the risk for fall? A. Only if a patient has the mental capacity to give consent.

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.