1: Your job and its organization

Section 1 Your job and its organization

1.1: Organizing your work

1.2: Emergency situations

1.1 Organizing your work

The work of a nurse will vary from day to day and from hospital to hospital but the following factors should be considered in all cases:

You should have a good working knowledge of all your patients: you should know who they are, where in the ward they are lodged and the principal diagnosis for each patient.

If you are in charge of the ward, you should make a point of seeing all your patients each day.

Do not be afraid to ask for advice from the sister, doctor or student. It is far better to ask too often than to struggle on not knowing if you are doing the right thing and feeling more and more inadequate.

If you are not getting enough support from management, then your ward sister or equivalent person needs to be informed.

Organize your off-duty time so that you get enough rest and sleep and ensure that you cook for yourself properly.

Keep in contact with your friends; carry on with hobbies and interests, which will maintain your contact with the world outside nursing.

The role of the ward nurse

In caring for the patient:

Provides total individualized holistic patient care.

Gatekeeper of psychological/physiological care.

Has ability to prioritize care.

Care of relatives and significant others.

Record observations/documentation of care.

Care for IV and other invasive lines.

Key role in the checking, administration and understanding of drugs, wound care, pain management.

Works within the MDT:

– Medical and surgical teams

– Physiotherapist

– Occupational therapist

– Social worker

– Radiologist

– Medical technicians

– Other departments, e.g. theatres.

Takes part in ethical and moral decision-making.

Key role in team building, which involves working together to benefit patient care.

Is open to changing practices and innovations.

Plays major role in communicating with others.

Undertakes and assists with evidence-based care (incorporating all types of knowledge detailed later).

Personal and professional development:

Has awareness of self-development.

Keeps a personal development portfolio.

Encourages and supports others to do courses.

Supports and educates less-qualified colleagues.

Areas open for consideration as to the role of the nurse:

– Environment – where we work, no natural light, confined space, television, teaching room.

– Management styles – dogmatic, authoritarian, laissez-faire influences on practice.

– Resources available – confined to monitoring equipment, dressings and drugs available.

– Medical practices and doctors – have the final say, nurses need to express their views so that we are effective advocates for patients.

– Advances in technology – often these impinge on our practice as patients are ill, but need to understand and appreciate that interventions and technologies cannot and do not save all patients.

– Knowledge of nurses – confines practice to level of knowledge/education.

– Government legislation.

Multi-skilling:

– Increased autonomy – professionalism of nurses.

– Diversions of the nurse’s role, e.g. taking of bloods, cost-effectiveness, is it economics rather than caring for patients?

The legal implications in practice, e.g. litigation of extended role.

The scope of professional practice – the rules governing healthcare professionals.

It is important to remember and be aware of the outside influences that often govern how we practice and how we would like to practice.

The multidisciplinary team

Medical staff

Overall responsibility for patient treatment and management.

Generally, each patient is under a specialist consultant related to the patient’s condition.

Physiotherapist

Assist with patients’ respiratory function.

Preserve existing motor skills, restore mobility, and consider the role of all limbs whether strong or weak.

Work towards reducing stiffness, contractions and spasticity.

Re-educate motor function, coordination and balance.

Occupational therapist

Restore patients’ ability to perform activities of daily living – relearn practical skills if necessary.

Evaluate patients’ perceptual and cognitive functions.

Adapt objects that improve daily living activities.

Assess the need for modifications to the home.

Speech and language therapist

Assess patients’ swallowing and gag ability.

Provide specialized speech therapy, communication advice and aids to assist speech, if required.

Dietitian

Advise on nutritional and fluid requirements – whether it should be liquid, thickened or pureed food.

Advise regarding enteral or parenteral feeding requirements and regimens.

Social worker

May discuss long-term or short-term care options with patient and family.

Support families and patients by assisting with social and financial issues.

Arrange benefits.

Provide carers with home adjustments.

Other staff

Secretarial support may be required.

Porters may be involved in transporting patients’ specimens day and night.

Local chaplains, priests or relevant official of all religions, when there is a need for their services.

A designated ward-clinical pharmacist is invaluable but may not be available in all areas.

Technicians responsible for the equipment to service, repair and develop equipment.

Working as a team

Teamwork is vital if care is to be carried out expertly and efficiently in any clinical area. The team consists of not only the doctors and nurses and those disciplines mentioned above but also many other personnel from both within and outside the hospital. These may include:

Specialist hospitals.

Laboratories, e.g. technicians, laboratory staff.

Support staff, e.g. phlebotomists, ECG technicians.

Specialist nurses, e.g. diabetic, wound care, resuscitation, pain.

Other wards/departments, e.g. pharmacy, X-ray.

Community carers.

Helping agencies.

Primary healthcare teams.

Relatives and friends.

Ambulance personnel.

Liaison and effective communication within the team are essential to ensure optimum patient care.

Communicating with other team members (multidisciplinary)

Communication is recognized as an important aspect of healthcare with far-reaching effects. It is an essential and integral part of the care nurses provide. Communication needs to be clear and it involves verbal and non-verbal messages that convey feelings and information.

Do not be afraid of discussing patients’ illnesses with them or their relatives in as much detail as is appropriate (remember that it is unethical to disclose sensitive information, such as a diagnosis of cancer, to the relatives without telling the patient). Effective communication makes a positive contribution to an individual’s recovery by acting:

As a buffer against fear and confusion.

As a relief of anxiety and stress.

To help decrease pain and reduce the number of complications and side-effects.

To improve compliance.

As a way of improving coping ability.

To enhance convalescence.

When you go off duty do not forget you must tell the nurse responsible about any problems a particular patient may have or any care that you have been unable to achieve on your shift.

The nursing hand-over

At the beginning of each shift, in most wards, there normally takes place a general nursing hand-over whereby all staff from that shift are present. At the end of this general hand-over, a nurse will be allocated to a particular group of patients for that shift. At the patient’s bedside, the current nurse may give additional information about their care, treatment, drug therapy, next of kin, etc., the purpose being to ensure that information relevant to that patient’s care is provided and thus minimize any disruption in patient care and uphold continuity of care. Typically, during this process, the bedside nurse uses a universally applied structure that reiterates the care plan format thus incorporating the patient bedside observation, nursing, drug and medical charts.

At the initial phase of each hand-over, the nurse begins by giving a basic overview of the:

Patient’s age.

Past medical history.

Reason for admission.

Length of stay in the ward.

Major events that have occurred during admission.

Physical, psychological and social hand-over.

Care planning and documentation

When caring for patients, a daily nursing care plan is produced. This involves a systematic patient assessment which is carried out at the beginning of the day shift or on patient admission; goals of care and a report is then written at the end of the shift regarding whether the goals of care have been met or further interventions need to be considered. The night staff will re-evaluate the patient’s planned care and write a report at the end of their shift. The structure and choice of care plan may vary depending on the clinical practice area in which you are based; however, many clinical practice areas follow the Roper, Logan and Tierney model. It is important to note that whichever care plan is used, as a healthcare professional, you must familiarize yourself with, understand and implement your care accordingly.

Computers on the wards

The application of computer technology within a ward setting can be seen as important, widespread and diverse. Its application to patient care within the ward environment is the key to success and therefore a fundamental insight and understanding of its use is required by healthcare practitioners.

The ward is sometimes a complex environment with rapidly changing patients, personnel, policies and procedures. Ward care can be a demanding environment and may require an enormous amount of data collation, report writing and auditing with much of this information undergoing repeated transcription. Therefore, it is apparent that one of the vital reasons for computerizing a ward environment is to minimize duplication of data entry and allowing the healthcare professional to focus upon the patient. Computers within a ward setting can:

Detect variations in physiological parameters.

Identify important aspects of care or service.

Monitor and report the important aspects of care by collecting and organizing the data for each indicator.

Assess the action and document improvement.

Communicate the relevant information in report form.

Process correlations in a short period of time and store results.

1.2 Emergency situations

Early warning scoring (EWS)

Patients often have abnormal physiological values present in the 24 hours previous to a cardiac arrest; most commonly observed is a tachycardia, an altered level of consciousness, derangement in heart rate, blood pressure, arterial oxygen saturation and urinary output.

The EWS is used to aid early detection of patients’ deteriorating conditions on acute general or surgical wards. The EWS is a simple scoring system to be used at ward level utilizing routine observations taken by nursing staff. Nurses are identifying those patients at risk of deterioration and then scored according to their physiological parameters:

Blood pressure.

Respiratory rate.

Sedation level.

Combining these with basic observations of the airway, breathing and circulation (ABC), measure of fluid balance and neurological status forms the basis of this simple system of early detection. Deviations from the normal score points and a total is calculated. A total score of 3 or more generally results in the patient’s condition being reviewed by ward medical staff and help sought from the outreach team or medical emergency team (MET) if appropriate.

The development of outreach/medical emergency team (MET)

The increased cost of critical care and a national nurse shortage prompted the Government publication ‘Comprehensive Critical Care’ (Department of Health 2002b). The report prompted hospitals across the country to concentrate on introducing early warning scores. This was a directive as there have been concerns regarding the capacity problem in the provision of critical care facilities in acute care trusts. Therefore, there was growing concern about the management of critically ill patients outside the intensive care setting. Attempting to reduce what was often referred to as sub-optimal care prior to admission to critical care areas it was decided to provide expert advice in the management of these patients.

The comprehensive critical care (Department of Health 2002b) report recommended that critical care services should provide for those patients who were critically ill and patients at risk of critical illness and those recovering from it. This stimulated the setting up of a number of critical care outreach programmes across the country. The wards were given criteria based on physiological abnormalities similar to the EWS. If a patient met the criteria then ward nurses were prompted to inform the doctor and in some cases contact the outreach team to attend the patient.

Another approach to this problem of sub-optimal care was the concept of MET. This often consists of nursing and medical staff trained in resuscitation. Ward staff are able to call the MET for patients with abnormal physiological variables or specific conditions such as shock, excessive bleeding or upper respiratory obstruction (Table 1.1). The aim of this style of team is early recognition and this prompts treatment of those patients at risk of cardiac arrest.

Table 1.1 Medical emergency team calling criteria

Acute change in:	Physiology:
Airway	Threatened
Breathing	All respiratory arrests
	Respiratory rate < 5/min
	Respiratory rate > 36/min
Circulation	All cardiac arrests
	Pulse rate < 40 beats/min
	Pulse rate > 140 beats/min
	Systolic blood pressure < 90 mmHg
Neurology	Sudden decrease in level of consciousness
	Decrease in GCS of > 2 points
	Repeated or prolonged seizures
Other	Any patient causing concern who does not fit the
	above criteria

The majority of hospital trusts provide critical care education for ward-based staff. Different forms of outreach services have evolved depending on the local priorities and resources. Ward staff undertaking the acute life-threatening events recognition and treatment (ALERT) course generally used this to provide education for ward nurses and junior doctors (Smith et al 2002). The whole basis of the programme is to improve ward nurses’ knowledge of vital signs and identification of patients at risk, in an attempt to reduce the number of patients requiring admission to critical care.

Assessment of the acutely ill patient

When a patient’s condition is deteriorating, it is important to consider the following in conjunction with the medical emergency guidelines given above:

Airway – is it clear, obstructed or protected, is the patient using their accessory muscles? Consider the pattern of breathing, is the chest and abdomen moving in the same direction? Is there an expiratory wheeze (collapse during expiration), any snoring (partial obstruction by the tongue)? Gurgling may indicate secretions, vomit or blood is in the upper airway, inspiratory stridor is an indication of an obstruction above the larynx. Is the chest expanding?

Breathing – is the patient distressed or using their accessory muscles, is the patient talking in full sentences, is the respiratory rate high or low (12–15 normal), is the patient cyanosed, what is the oxygen saturation? Obtain a stethoscope and listen to the patient’s chest, are there any rattling noises (indicating secretions). Bronchial breathing, is it absent or reduced (may indicate a pneumothorax, a medical emergency) or pleural effusion, is air entry equal on both sides?

Circulation – is the patient pale or cyanosed (may indicate peripheral vein collapse and may be difficult to cannulate) or haemorrhage, what is the patient’s conscious level and urine output? BP may be normal so it is not a good indicator of shock (see later), more significant is pulse pressure which is the difference between systolic and diastolic and should be between 35 and 45. If increased suggestive of arterial vasoconstriction and reduced indicative of vasodilatation and sepsis. Is the pulse bounding (sepsis) or weak (reduced cardiac output)? Check the capillary refill time, should be less than 2 seconds.

Disability – check A = if patient spontaneously alert, V = responding to verbal stimulus, P = responding to painful stimuli, U = unresponsive. Check BM level, pupil reactions to light (bilateral pin point drug overdose, opiates, brain stem involvement, stroke). Unilateral dilated unresponsive to light (brain stem death, cancer, lesion, cerebral oedema), GCS if time.

Examination – thorough physical examination after correction of any compromise to ABCD is secured:

– Hypothermia from theatre

– Electrolytes, U&Es, K+, Na

– Fluids – fluid balance chart, input and output, increase in weight

– GIT – abdomen, surgery, drains, blood loss, wound infection, bowel habits sounds

– Haematology – clotting, haemoglobin (Hb), white blood count (WBC)

– Lines – source of sepsis, IV, drains, catheters, etc.

– Medication – prescribed drugs given, nephrotoxic drugs given, monitored digoxin/vacomycin, drug interactions, allergies.

Return to EWS to recognize any further deterioration and review if score improves by 4 or more, deteriorates by 2 or more, GCS drops 2 or more regardless of other observations.

Cardiac arrest

This is the cessation of cardiac mechanical activity with no clinical cardiac output. If immediate cardiopulmonary resuscitation (CPR) is not started, death or serious cerebral damage will result. Nursing staff should promote CPR training and be the driving force behind a hospital’s resuscitation team.

Cardiac arrest may be primary or secondary.

Primary: sudden cessation of cardiac function

Myocardial infarction.

Electric shock.

Drugs, e.g. potassium.

Secondary: non-intrinsic cardiac causes

Asphyxia, hypoxia, hypercarbia.

Exsanguination.

Central nervous system failure.

Metabolic/electrolyte disorders.

Temperature extremes.

Acute anaphylaxis.

Cardiac arrest is usually associated with one of four rhythms:

Ventricular fibrillation (VF).

Pulseless ventricular tachycardia (VT).

Electromechanical dissociation (EMD) – absent mechanical activity despite a coordinated ECG waveform; this is diagnosed infrequently.

Basic life support

The airway, breathing and circulation must be assessed before initiating active interventions:

A – Airway maintenance. Is the airway secure, free of vomit or debris? A Guedel’s airway may be inserted.

B – Breathing. Maintain breathing using appropriate shield or bag and mask.

C – Chest compression or external cardiac massage (ECM).

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Tags: A Nurses Survival Guide to the Ward

Jun 15, 2016 | Posted by admin in NURSING | Comments Off

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