Important medical documentation

Please read the information from this file, will help you to refresh your medical knowledge
for nursing job in UK
First Aid Awareness:

What is First Aid?

The care given before emergency medical help arrives Can literally mean the difference
between life and death But knowing the correct thing to do if someone has a nosebleed
or cut is also important.
A blocked airway can kill someone in three to four minutes. However, it can take more
than eight minutes for an ambulance to arrive. So a simple procedure such as opening
someone's airway can save their life while they're waiting for emergency medical help.
This is known as First Aid.
Bleeding
What is it?
The severity of bleeding depends on the location, size and depth of the wound causing it.
If the bleeding's severe, it can be dramatic and distressing.
First Aid aims
Control bleeding Minimise shock Prevent infection Prevent cross-infection between the
casualty and yourself If necessary, arrange for casualty to go to hospital.
Actions
Check whether there's an object embedded in the wound If there's nothing embedded,
press on wound with your hand, ideally over a clean pad, and secure with a bandage.
Raise wound above level of casualty's heart If blood seeps through the bandage, put
another one on top If blood comes through second bandage, remove both and apply a
fresh one If there's an object embedded in the wound do not remove it. Instead, firmly
push together the edges of the wound to try to stem blood loss.
Burns and scalds
What are they?
Burns are caused by dry heat and scalds are caused by wet heat. Both burns and scalds
damage the body by removing the layer of skin that protects the body from infection.
Symptoms
Extreme pain Shock, depending on severity of burn Swelling around site of burn Redness
and blistering Charred skin on a very deep burn.
11
First Aid aims
Halt the burning Alleviate pain Minimise risk of infection.
Actions
Stop the burning by applying running cold water to site of burn for at least ten minutes
Cover wound using a clean pad or cling film to prevent infection Remove any jewellery
near burn site Treat for shock
Nose bleeds
What causes them?
Sneezing and blowing Infection High blood pressure Head injury.
Actions
Sit the casualty down, leaning forward. Ask them to breathe through their mouth. Pinch
the soft part of their nose (or they can do it themselves) for ten minutes. Reassure them.
If the bleeding doesn't stop after ten minutes, pinch the nostrils again for two further
periods of ten minutes. If the nosebleed is severe or the bleeding doesn't stop after 30
minutes, call 999.
Bone, joint, muscle
Topics covered in this section:
Back injuries Broken limbs Head injuries Sprains and strains.
Back injuries
What are they?
The spine or backbone protects the spinal cord, which controls many body functions. Back
injuries can be caused by pinching or displacement of nerves, or by spinal fracture.
Symptoms
If you suspect a spinal injury after an awkward fall or awkward injury, look for:
Localised tenderness around the back or neck Shooting pains in the casualty's limbs
Limbs feeling heavy or tingling Loss of sensation in limbs below the level of injury
Breathing difficulties.
First Aid aims
Prevent further injury Get casualty to hospital.
Actions
If casualty is conscious Call 999 Do not attempt to move casualty Offer reassurance
Steady and support casualty's head in your hands.
I f casualty is unconscious Check airway and breathing Place casualty in modified reIf
casualty stops breathing Open airway Check for breathing again Give resuscitation until
help arrives Call 999. covery position if you have help Call 999.
Broken limbs
What are they?
Broken bones always need professional attention, but there's action you can take
immediately to help the casualty. Because children tend to put their arms out as they fall,
arms, elbows and wrists are where breaks tend to occur.
Symptoms
Intense pain Inability to use the limb Bruising or deformity at site of the break.
Actions
Broken arm Sit casualty down Ask them to support injured arm with other hand Put a
pad between arm and chest Put injured arm in a sling Place a broad-fold bandage over
sling and around arm and chest Take child to hospital Call 999.
Broken leg Lay the casualty down and support leg at ankle and knee joints by hand if an
ambulance is expected soon, or on a chair if not Steady injured leg with padding Put
rolled-up blankets outside injured limb and between legs Keep the casualty warm Call
999
Head injuries
What are they?
Head injuries may produce concussion, i.e. a period of unconsciousness followed by
complete recovery.
Other head injuries may produce compression of the brain, which is life threatening. A
head wound can indicate deeper damage, such as a skull fracture.

18
Head injuries can be broadly classified into three categories:
Skull fracture Cerebral compression Concussion
Convulsions
What are they?
In children, seizures (sometimes called fits or convulsions) are usually caused by raised
body temperature.
Symptoms
These include obvious signs of fever, such as hot, flushed skin, sudden loss of
consciousness, convulsive movements, such as jaw clenches, and the body becoming rigid.
First Aid aims
Treat casualty for unconsciousness Protect casualty while unconscious Arrange for
medical help where necessary.
Actions
Minor fit
Sit casualty down, reassure them and remove any dangerous objects from around them.
Major fit Try to prevent any harm but don't restrain the casualty Clear any dangerous
objects from around them Loosen clothing where possible and protect their head. Further
action When the convulsions are over, ensure the person's airway is open and check their
breathing. Place the person in the recovery position. Sponge their skin with tepid water
to help keep them cool.
Diabetic emergency
What is it?
Abnormal fluctuations in blood sugar can lead to someone with diabetes becoming
unwell and, if untreated, losing consciousness.
There are two conditions associated with diabetes:
Hypoglycaemia (low blood sugar) Hyperglycaemia (high blood sugar),
A First Aider is most likely to encounter hypoglycaemia, which affects brain function and
can lead to unconsciousness if untreated.
Hypoglycaemia: Raise blood sugar level as quickly as possible Get casualty to hospital, if
necessary. Hyperglycaemia: Get casualty to hospital as soon as possible.
Actions
Hypoglycaemia: Sit casualty down Offer casualty food or a sweet drink If theres an
improvement, offer more to eat or drink Keep casualty resting Call 999. Hyperglycaemia:
Call 999.
Epileptic seizure
What is it?
Epileptic seizures are due to recurrent, major disturbances of brain activity. Just before a
seizure the person affected may have a brief warning period with, for example, a strange
feeling, or a particular smell or taste.
Symptoms
Symptoms of a minor epileptic fit may include sudden blankness, twitching limbs and
strange noises, for example, smacking of lips.
A major fit may involve sudden loss of consciousness, absence of breathing, convulsive
movements, such as jaw clenches, and the body becoming rigid.
First Aid aims
Treat casualty for unconsciousness Protect casualty while unconscious Arrange for
medical help, if necessary.
Actions
Protect casualty from their surroundings to avoid injury Allow seizure to run its course
and keep monitoring the casualty Once seizure is over, place casualty in recovery position
Keep reassuring casualty and monitor their condition Call an ambulance if casualty has
the following conditions: - Is unconscious for more than ten minutes - The seizure
continues for more than five minutes - They have repeated seizures - It's their first seizure
- If they're not aware of any reason for the seizure.
Poisoning and allergic reactions
Topics covered in this section:
Anaphylaxis Bites and strings Poisoning.
Anaphylactic shock
What is it?
Anaphylaxis is an extreme allergic reaction to certain foods, insect stings or drugs, which
results in rapid chemical changes in the body.
Symptoms
Blood vessels dilate, producing red, blotchy skin Air passages become constricted,
resulting in breathing difficulties Face and neck may swell Heart, brain and lungs may
suffer from a dramatic drop in oxygen supply Casualty may wheeze and gasp for air.
First Aid aims
Get emergency help Resuscitate, if necessary.
Actions
Call 999 and give any details you have of cause of reaction Help the casualty to sit in a
position that helps with breathing Loosen any tight clothing Check to see if the casualty is
carrying medication (i.e. adrenaline, to combat the effects of their allergy) and encourage
them to use it.
Further Actions
If the casualty loses consciousness: Lie them down Open the airway Prepare to start
resuscitation Place them in recovery position.
Respiratory problems
Topics covered in this section:
Asthma Choking.
Asthma
What is it? Asthma is caused by a swelling of the airway linings. The airways narrow down,
causing breathing difficulties.
Symptoms
Severe breathing difficulties Wheezing Distress and anxiety Exhaustion from the effort
of breathing Grey/blue skin Dry cough.
First Aid aims
Ease casualty's breathing Get emergency help, if needed.
Choking
What is it?
A severe obstruction is when a person is unable to speak, cry, cough or breathe. A mild
obstruction is when a person finds it difficult to breath, but is able to speak, cry, cough or
breathe. They are able to clear the obstruction without help.
First Aid aims
Relieve the obstruction Arrange for medical help if necessary.
Actions
First stage - Back blows Give up to five blows between the shoulder blades with the heel
of your hand Check the mouth quickly after each one and remove any obvious
obstruction.

36
Second stage - Abdominal thrusts If obstruction is still present, give up to five abdominal
thrusts Place a clenched fist above the casualty's navel, grasp your fist with your other
hand and pull inwards and upwards Check the mouth quickly after each one.
Resuscitating an Adult
What is it?
This technique is for an adult casualty who is unresponsive and isn't breathing normally. If
you're on your own, call an ambulance before you start resuscitation.
Actions
Check for vital signs Check for response - Gently shake the casualty's shoulder and ask if
they're all right If there's no response, shout for help and open the casualty's airway
Check for breathing - Look for chest movement, listen for sounds of breathing and feel for
casualty's breath on your cheeks Do this for ten seconds Give chest compressions.
Giving chest compressions Place your hands on centre of casualty's chest and, with the
heel of your hands (which should be linked one over the other), press down 30 times.
Depress chest to a third of its depth (4-5cm) Do this at a rate of 100 times a minute After
performing 30 chest compressions, tilt the casualty's head and lift their chin Give two
rescue breaths.

40
Further action
Continue this sequence until emergency help arrives or the casualty starts to show some
response.

What is adult abuse?

Abuse is a violation of an individuals human and civil rights by another
person or persons. It may consist of a single act or repeated acts. It may be
physical, verbal or psychological, it may be an act of neglect or an omission to
act, or it may occur when a vulnerable person is persuaded to enter into a
financial or sexual transaction to which he/she has not consented or cannot
consent. Abuse can occur in any relationship and may result in significant
harm to, or exploitation of, the person subjected to it.
Who is an abuser?
Often an unequal power relationship, whether physical, emotional or financial, exists
between the abused and the abuser. But anyone can be an abuser.
Staff Volunteers
Friends
Family
Neighbours
Other service users
Strangers.
Kinds of abuse
There are many ways in which a person can be mistreated, harmed or distressed.
The following kinds of abuse are distinguished:
Physical abuse
 Hitting, slapping Punching, kicking Forcing, included force feeding , Inappropriate use of
restraint, The use of incorrect moving and handling techniques, The misuse of
medication.
Sexual abuse
Inappropriate behaviour including offensive language sexual teasing and inflicting
pornography on an individual.
Financial or material abuse
Misuse of a persons money, property or possessions Refusing a person access to his/her
own money, property or possessions Extortion of money, property or possessions through
theft Failing to account satisfactorily for the use of a persons money, property or
possessions Pressure in connection with wills, property, inheritance, etc. Misuse or
misappropriation of property, possessions or benefits (e.g. personal income included in
with the household income
The following are examples of neglect:
Lack of adequate food and fluids, Lack of adequate heating/lighting, Lack of appropriate
medical care, Being allowed to take unwarranted unreasonable risks, Poor
hygiene/cleanliness, Lack of attention to toe and finger nails, Lack of attention to teeth
(natural or false).
Discriminatory abuse
Racist remarks , Sexist remarks, Comments about disability, Other forms of harassment,
Slurs or similar treatment, Deprivation of normal social contact and cultural identity.

What is a pressure ulcer?

An area of localised damage to the skin and underlying tissue caused by
pressure, shear, friction and/or a combination of these.
Other names pressure ulcer may also be known as a:
Bed sore
Pressure sore
Pressure injury,
or Decubitus ulcer.
Grade 1
In a grade 1 pressure ulcer, the damage is confined to the epidermis, and could present as:
 Red discolouration of the skin that has not faded after 10 minutes of pressure relief.
Localised heat over the reddened area. Oedema (swelling). Induration (a hardening of the
skin due to the accumulation of lymph fluid)
Grade 2
Grade 2 pressure ulcers can present in one of two ways:
1. Partial-thickness skin loss, going through the epidermis and penetrating the cuboidal
cells of the dermis. The maximum depth of a grade 2 ulcer is 2mm. This wound looks like a
graze, and fluid leaks out of the wound. 2. A blister formation.
Grade 3
In a grade 3 pressure ulcer, there is full-thickness skin loss, involving damage to or necrosis
of the subcutaneous tissue; the damage now extends into the fatty tissue and/or muscle.
The depth of the wound in terms of centimetres is irrelevant, as this can vary depending
on the location of the ulcer (e.g. over the ankle bone compared to the buttock).
Grade 4
In a grade 4 pressure ulcer, there is extensive destruction of all tissues down to bone and
tendons, which are now exposed to sight or touch

What causes pressure ulcers?

The causes of pressure ulcers In this section, we will look at the main causes and
contributory factors of pressure ulcers, including both the intrinsic and extrinsic factors
that can increase the risk where the pressure ulcers are most likely to appear. Objectives
By the end of this section, you will be able to:
List the major extrinsic factors increasing the risk of pressure ulcer development. List the
major intrinsic factors increasing the risk of pressure ulcer development List the areas of
the body where pressure ulcers are most likely to develop. Identify the common factors
that place individuals at greatest risk of developing pressure ulcers based on the above.
Main intrinsic factors
The main intrinsic factors that can make an individual more vulnerable to pressure ulcers
include, but are not restricted to, those listed below:
Ageing As people get older, they are more likely to be:
Experiencing one or more medical conditions Taking one or more types of medication
Incontinent Malnourished Dehydrated, and Limited in their mobility. Suffering from
poor circulation, due to hardening of the arteries. As we age, the skins integrity reduces
by way of slower cell regeneration (renewal), and by the reduction in the production of
collagen and elastin (giving the skin its strength and elasticity) and of sebum, thereby
making the skin dryer, less protected, less supple and therefore more vulnerable to
damage.
Dehydration If the person does not drink enough liquids, their body and their skin - will
not produce enough collagen and elastin. This will slow down cell regeneration.
Dehydrated skin is easier to damage, as it loses its elasticity.

17
Disease Certain diseases, such as diabetes and heart disease, mean that an individual has
poorer circulation and so is more likely to develop pressure damage.
Such individuals are also more prone to wound infections, due to reduced circulation (i.e.
white blood cells) to the wound bed.
Incontinence We have already seen that incontinence can speed up the development of
pressure ulcers, due to maceration of the skin.
Lack of mobility Limited mobility allows the pressure to be focused on one part of the
body for a long time. Limited mobility can be the result of: Pain on movement Surgical
intervention (e.g. traction equipment, ventilation tubes, IV lines, a catheter, and so on).
Sedation and analgesia, including epidural injections Reduced levels of consciousness.
Trauma, particularly fractures
Malnutrition As a group, the elderly are most at risk of malnutrition, which can be
aggravated by illness, disease or chronic wounds/infections.
Malnutrition leads to weight loss and physical weakness, and also prevents tissue repair.
Because the individual is weak, they are more prone to:
Reduced mobility Increased risk of pressure damage (due to reduced padding caused
by muscle and fat loss over the bodys bony prominences) Higher risk of infection Poor
healing.
Other intrinsic factors
Other factors about the service user that should be taken into account when considering
their vulnerability to pressure ulcers are listed below.
Medication
Some medications, such as steroids, can make the skin thin and fragile or nonviable,
making it vulnerable to rapid breakdown.
Neurological
impairment Damage to the service users nerves, such as that caused by a spinal injury,
learning disabilities or dementia, can lead to:
Reduced sensation Loss of motor power.
In addition, severe or terminal illness can reduce the instinct or the ability to move. Poor
posture If the person spends a long time slumped over in a chair, they will be putting more
pressure on their bottom and the legs inappropriately, thereby increasing the risk of
developing a pressure ulcer in these areas. R educed level of consciousness Individuals
with learning difficulties and/or dementia are less likely to be aware of their surroundings,
and so more likely to sit in the same position for long periods of time.
Those affected by high fever or head injuries may also have impaired levels of
consciousness.
Skin condition
A poor skin quality is more prone to breakdown, and so more prone to pressure ulcers and
slower healing rates.

Weight
As we have seen, a malnourished, underweight person is at very high risk of pressure
ulcers. Also bear in mind that an overweight individual with a high body mass index (BMI)
will most likely be malnourished, due to an unhealthy diet.
If the individual is also largely immobile, then their risk of developing pressure ulcers will
be even higher, due to the rapid destruction of subcutaneous adipose (fat) tissue, as it
does not have a blood supply.

NICE guidance The NICE guidance states that patients are one of the
following:
No risk At risk
At elevated risk
This should be kept in mind when using risk assessment tools, and supports the view that
they should be used with caution.
Taking action
Once an individual has been identified as being at risk of a pressure ulcer, action must
be taken. This action can take a number of forms, including:
Assessing the need for any specialist equipment and then ensuring that it is provided and
used properly Carrying out appropriate and ongoing repositioning of the individual both
regularly and as and when needed. Accurate and timely documentation (i.e. assessments,
care plans, evidence of implementation such as turn charts, evaluations, and re-
assessments).
But what if the service user comes into the care setting or hospital with an existing
pressure ulcer?
Assessing a pressure ulcer The NICE guidelines on assessing an existing pressure ulcer
provide details of two key tasks:
How to assess the pressure ulcer
The pressure ulcer should be closely examined in order to establish its:
Cause
Site and location
Dimensions EPUAP grade (1 4), and Malodour
If there is an open wound, is there any malodour?

29
It should also be checked for:
The amount and type of any exudate Any local signs of infection The skin surrounding
the pressure ulcer Any undermining or tracking, sinus or fistula. The service user should
also be asked how much pain the pressure ulcer is causing them.
What findings to record
The assessment should be fully documented in the Patients Notes/Care Plan, including
its:
Estimated surface area EPUAP grade.
A photograph and a tracing of the pressure ulcer should be included. This is also useful
practice when monitoring the ulcer for healing or deterioration.
Note: Every pressure ulcer graded as 2 or above must be recorded as a clinical incident, in
accordance with NICE guidance.
Remember that pressure ulcers at grades 2, 3 and 4 would require wound management, as
set out in the Wound Management module.
Ongoing checks
The individuals skin should be assessed regularly, on a schedule best suited to the
individuals vulnerability and condition, based on the findings on assessment.
Where feasible, individuals should also be encouraged to inspect their own skin, using a
mirror if necessary.
Where they cannot do this for themselves, their carers should be encouraged to make
these regular checks.
All the vulnerable areas should be inspected every time, especially on those who lack
mental capacity to tell you if they have any sores anywhere.
All findings during skin checks should be recorded in the service users records.
Pressure reduction: Minimum provision Every individual and especially those who are
most vulnerable to pressure ulcers - should have 24-hour access to pressure relieving
devices and strategies.
In its guidelines, NICE sets out the minimum provisions for the reduction of pressure:
Every individual with a pressure ulcer graded 3 or 4 and those with comorbidities such as
diabetes, heart disease or a terminal illness, should as a minimum have access to either of
the following: - A high specification foam mattress and an alternating air overlay mattress,
or - A full replacement alternating air mattress (e.g. sophisticated systems such as, for
example, alternating dynamic mattress, low air loss, air flotation, viscous fluid).
Pressure Reduction: Other equipment There is a range of other items of equipment
available to help reduce pressure, including:
Bed cradles Electrically-operated profiling bed frames Foam wedges Hoists
Leg troughs Orthotic devices
Note
Do not rest a patients legs on pillows to elevate their heels off the bed, as this reduces
the circulation to and from the feet, thereby creating non-viable tissue and increasing the
risk of pressure ulcers.
This will also increase the risk of the patient developing a deep vein thrombosis (DVT),
which could be life threatening.
For similar reasons, footstools should be avoided. Pressure-relieving equipment:
Factors to consider
1. Pressure-relieving equipment can:
Enhance individual care, and Promote individual mobility, comfort and recovery.
It must not, however, be used as a substitute for individual repositioning and good nursing
care.
2. When considering pressure-relieving equipment, do not concentrate solely on the
mattress (although this is important): cushions are important too.
Every surface used by the individual over a 24-hour period should be considered, as it has
been established that chair-bound patients are more at risk than those who are bedfast.
Selecting pressure-relieving devices
The selection of devices to relieve pressure on an individual should be based upon:
The results of the individuals risk assessment, including an assessment of their general
health, skin and weight
The individuals lifestyle and abilities Any critical care needs
Their acceptability to and comfort for the individual
How well they help in repositioning the individual Their cost.
The grade of the ulcer will determine the level of equipment required (e.g. grades 3 and 4
will require alternating air systems automatically).
At every assessment, the selected devices should be considered and, if necessary, changed
in response to any altered level of risk, change in condition or the needs of the individual.

Selecting the right mattress In terms of the mattress, consider if there is a need for an
expensive, dynamic mattress, or will a static mattress provide adequate support?
Remember that the grade of the ulcer will be the determining factor.
Then, when choosing a mattress for an individual, ensure that:
The mattress does not elevate the individual to an unsafe height a risk common with the
combined use of a static and an air overlay mattress, in conjunction with bed rails. Refer to
the guidance on the previous screen.
The individual is within the recommended weight range for the mattress.
A lightweight patient will not have the weight to expel air out of the mattress, and will be
then lying on a hard surface.
In such cases, a low-air-loss mattress should be selected. An alternating pressure mattress
with permanently-inflated head cells does not cause occipital damage.
Unsafe height Overlay mattresses can raise the height of the bed by 15 to 20cm.
This may reduce the individuals independence, but Safety should not be compromised if
the beds side rails are used.
Turning the mattress
Many static mattresses should be turned regularly, to ensure that they continue to offer
maximum support to the individual. This should be done in accordance with the
manufacturers recommendations.
The most effective method of turning the mattress is flip and rotate: that is, to turn the
mattress over both lengthways and sideways.
First flip the mattress over by lifting the short end at the head of the bed and moving it
through 180%. This short end then ends up face down at the bottom of the bed. You then
rotate the mattress on its long edge, so that the new bottom edge comes back to the top
but stays face down.
The ideal surface For maximum effect in the prevention of pressure ulcers, the ideal
surface would:
Be comfortable and acceptable to the individual Provide an acceptable level of even
weight distribution (clinically effective) Promote free movement of air to minimise the
build-up of heat and moisture Be easily maintained: for example, it can be wiped down in
situ, or have covers that can be removed for laundering

33
Have cover fabrics with a two-way stretch, in order to minimise the risk of shear and
friction Be user-friendly Provide value for money.

Repositioning techniques
Introduction The regular repositioning of an individual is the key component in both
preventing and helping to treat a pressure ulcer.
In this section, we will look at why this simple task is so effective, and how to achieve best
results by its use.
Objectives By the end of this section, you will be able to:
State the purpose of repositioning individuals on a regular basis. Describe the 30 tilt
technique and list its advantages.

34
Describe the five key positions for individuals who are recumbent. State the importance
of matching the chair to the individual. Describe the four key positions for seated
individuals. Describe how individuals can reposition themselves. Repositioning: What to
do To help prevent the development of pressure ulcers in vulnerable individuals, you need
to:
Ensure the correct and frequent positioning of an individual in bed, in a chair or in a
wheelchair. Teach individuals and carers how to redistribute the individuals weight
correctly. Encourage mobilisation and passive movements by the individual. Minimise
pressure on the individuals bony prominences. Consider the maximum time that the
individual should be in the sitting position: i.e. two hours. Consider the frequency of
repositioning in bed: i.e. up to 4-hourly, depending on how quickly the patients skin
marks.
Record each repositioning of the individual on a repositioning schedule or chart. Describe
what action an individual can take to help relieve pressure.
Repositioning: Disadvantages The conventional preventative measure is to make sure that
the individual is repositioned every two hours, in order to:
Make sure the individual is comfortable Reduce pressure on a particular part of the body
Check the individuals skin condition.
There are a number of problems with the conventional repositioning:
 Repositioning can be distressing and disorientating for the individual. It can also disrupt
the individuals activities, such as eating, reading, or watching TV. Repositioning increases
the risk of skin trauma by friction and shear. Repositioning increases the risk of back
injury for those carrying out the task. It could be impractical for home carers who have no
training in lifting and positioning techniques