Section 4 Fundamental procedures
4.1 General principles
This section discusses how nurses can further broaden and expand their knowledge of the person as an individual.
Admission to hospital
Prior to admission to hospital the patient may have come into contact with the ambulance service or paramedic team (prehospital care), his GP, the primary healthcare team or the police. He may have referred himself to the local A&E department or the minor injuries unit or be a booked admission from home.
In the A&E department the first impressions of the hospital are formed. An A&E nurse may undertake the initial assessment and a decision may be made as to the urgency/priority of the case.
The transfer to the ward may have been a lengthy process and the patient may have been in A&E for a number of hours before being admitted. In addition, the patient may have been waiting a long time before being admitted from home. On admission to the ward, a welcoming approach, good communication, effective use of assessment tools, observation, measurement, interviewing and documentation (nursing process) skills are paramount (see Section 2).
Discharge planning
This is a process of developing a plan of care for a patient who is transferred from one environment to another. The significance of early discharge planning cannot be overestimated. The average length of hospital admission has been reduced dramatically owing to advances in technology, financial considerations and contracting requirements of purchasers. Discharge planning should be initiated prior to admission and should include the following:
Patients and their families/partners to be informed of the requirements on discharge.
It should be designed to promote self-care or to assist with care needs when necessary.
Involvement of the multidisciplinary team.
The patient’s physical, psychological, social, cultural and economic needs.
The degree of support needed at home after discharge, which should be to a safe and adequate environment.
Planning on who will look after the patient.
Consideration for those patients who may have specific care needs:
Consideration of the need for external agencies to be involved. Assessment of needs at home may involve the:
Discharge should not be a matter of chance. There is the potential for patients to occupy beds unnecessarily due to late decisions regarding discharge.
Occasionally the discharge process may not proceed as planned or may be delayed. Patients may take their own discharge against medical advice and this should be documented accordingly. Some patients receiving a bad prognosis may prefer to go home and plans may need to be set up at short notice.
Transfer of a patient
Transfer of patients does not only involve moving the patient within the hospital, for example to imaging department, theatres but also externally to other hospitals. This may be due to bed shortage within the admitting hospital or need for specialist care and treatment. The ‘scoop and run’ principle of transferring patients is both inappropriate and unsafe in transporting the patient from A to B. Prior to transfer of the patient there are a number of factors to take into consideration.
When the staff of the referring centre feel uncomfortable with the course of the illness/injury.
When it is first realized that the patient requires care in a specialist centre.
Important factors of safe transfer
Patient should be accompanied by experienced nursing and medical staff.
Appropriate equipment and vehicle are sought and utilized.
Patient fully assessed, stabilized and staff prepared prior to transfer.
All investigations accompany patient on transfer.
All drugs and delivery systems are readily available and prepared for immediate use.
Monitoring systems and battery back-up are familiar to accompanying staff.
Continuous monitoring and assessment during transfer.
Knowledge of area transferring patient to. If another hospital, phone ahead and ensure a member of staff waiting at agreed point. For example, a porter waiting in A&E dept.
Organizational and transfer decision-making factors
A designated consultant is responsible for the decision to transfer a patient. They should ensure that:
Accompanying staff
An experienced doctor, experienced in resuscitation, airway management, ventilation and organ support with previous transfer experience.
An experienced nurse, operating department practitioner or paramedic experienced in transfer of patients.
Current staffing levels in many hospitals mean that this level of assistance is not always available.
Transferring hospital should provide medical indemnity, and personal medical defence cover is also recommended.
Departure checklist
Are appropriate equipment and drugs available?
Ambulance service notified of transfer and patient’s condition, nature of transfer.
Bed confirmed at receiving hospital.
Medical notes, X-rays and investigations available.
The issue that has led to a decrease in the need for inter-hospital transfer is the development of systems to transmit the images of a CT scan from one hospital to another. This allows the hospital to send the CT images via a phone-line (telemedicine) to the specialist neuro-centre where the images can be assessed. The specialist neurologist can then decide whether transport of the patient to the specialist centre is indicated.
The risks to the patient
Lack of appropriate equipment in the transfer vehicle if an unforeseen incident occurs en route.
Breakdown of the transfer vehicle while transferring patients – and lives have been lost.
The vibration of the transport vehicle can cause either hypertension or cardiovascular depression.
Acceleration forces in an ambulance can lead to transient hypertension and arrhythmias.
The overall responsibility of the nurse during transfer is the patient’s safety.
Preoperative care
This may take place in a pre-operative clinic. If in hospital the nurse needs to provide safe care for patients prior to surgery. This includes ensuring a positive experience and outcome for the preoperative patient. As part of preoperative care the nurse needs to consider patient participation and partnership:
Shared decision-making, inclusion of the patient.
Information giving (verbal or written) including education about the forthcoming operation (preferably 10–14 days preoperatively), explanations of any drugs and pain management preferences, specific postoperative equipment or techniques that may be employed.
Good communication skills; preoperative communication/visiting, identifying the barriers to good communication, e.g. anxiety and stress.
Identify culture differences in interpretation and understanding. Spiritual requirements should be explored.
Develop an effective nurse–patient relationship. Assessment of the patient’s understanding and explanation of words and phrases used during information giving should be undertaken.
The opportunity to ask questions.
Informed consent (see p. 49). The nurse needs to ensure that the patient comprehends what is likely to happen to him. The nurse must act in the patient’s best interests.
Screening prior to surgery
Screening prior to anaesthetic and surgery is an essential part of patient preparation. There are many specific investigations and preparations that are required for different types of surgery, e.g. of the bowel; these are detailed in Section 5. There are also standard test results that will enhance the surgeon’s understanding of the patient’s general condition prior to surgery:
Baseline clinical observations: blood pressure, temperature, pulse, respiratory rate and urine analysis.
Laboratory tests: full blood count (FBC), to ensure normal haemoglobin to enhance postoperative recovery, blood crossmatched for transfusion, blood urea, creatinine and electrolyte (U&E) levels to check renal function.
Further investigations, if necessary, may involve chest/abdominal X-ray, ECG, lung function tests and a CT scan.
Perioperative care
Care in the period before going to theatre may include the following:
Ongoing physical and psychological care.
Skin or bowel preparations (may need to commence 48 hours preoperatively).
Nil by mouth for 4–6 hours is safest since the stomach and small intestine should be empty of the last meal by this time.
IV cannulation and infusion if relevant.
Preoperative checks and premedication: this is to ensure patient safety so name bands are mandatory. A premedication may not be required and this is generally considered on an individual basis.
Consider the removal of wigs, hairpieces, jewellery (can cause burns if diathermy is used; wedding rings can be covered with tape), dentures, glasses, contact lenses and prostheses. Removal should be delayed as long as possible to maintain body image.
The removal of make-up and nail varnish is essential as these prevent the observation of true skin colour and the recording of oxygen saturation monitoring is affected by nail varnish.
Preparation of the bed area for return of the patient (see below).
Escorting patient to the operating theatre: ideally this should be done by the named nurse.
Transportation to the operating theatre: the patient should be allowed to sit up whether travelling on a bed or trolley.
Reception in the operating theatre complex: the patient is generally received from the ward nurse in a reception area and ‘handed over’ to the theatre nurse, then taken to the anaesthetic room when the anaesthetist is ready.
It is important to highlight that having to undergo surgery is one of the most stressful events in a person’s life. The significance of the nurse’s knowledge and skill in providing a safe and meaningful preoperative experience for the surgical patient can never be overestimated.
Postoperative care
There is a range of activities that nurses need to undertake when caring for postoperative patients. There are also specialist areas of surgery, e.g. bowel and thoracic surgery, which require more specific care and these are covered in Section 5:
The patient is placed in the recovery room attached to theatre. The patient’s condition is assessed and he is nursed in the lateral recovery position to minimize risks of aspiration until fully conscious, when he can be transferred back to the ward.
The bed area has been prepared and includes:
A significant aspect of a surgical nurse’s role is to reduce the risk of postoperative complications for patients. Surgical complications carry a potential risk to a person’s recovery, as well as incurring significant financial costs. Some of the more common postoperative complications are:
It is necessary for the nurse to undertake regular monitoring of the patient and ensure the correct postoperative instructions are adhered to.
Special nursing considerations
These may include an assessment of the patient’s risk of DVT formation and instigating preventive measures such as:
Ensuring patient cooperation through education.
Encouraging deep breathing and coughing at regular intervals, movement around the bed.
Administration of postoperative heparin/warfarin.
Effective observation and monitoring of peripheral circulation.
Other considerations during the postoperative period can be found elsewhere in the book and include:
Palliative care
Palliative care is the active total care of patients whose disease is not responsive to curative treatment, encompassing both the patient and their family/carers. Issues of death and dying are often not discussed with ease. It is important that health professionals develop skills and strategies for caring for the dying patient and his family.
The principles of palliative care originally focused on patients with advanced cancer but the scope has broadened and it is now offered to patients with a wide range of life-threatening illnesses such as multiple sclerosis, motor neuron disease, AIDS, chronic circulatory or respiratory disease.
Kinghorn & Gamlin (2001) state that palliative care:
Affirms life and regards death as a normal process.
Neither hastens nor postpones death.
Provides relief from pain and other distressing symptoms.
Integrates the psychological and spiritual aspects of patient care.
Offers a support system to help patients live as actively as possible until death.
This care takes place in hospitals and is an integral part of all clinical practice. The quality of palliative care in the hospital setting is of crucial importance despite the rapid growth of hospices and home care schemes.
The key principles underpinning palliative care comprise:
Care which encompasses both the patient and those who matter to them.
Emphasis on open and sensitive communication, including adequate information about diagnosis and treatment options.
Respect for patient autonomy and choice.
Focus on quality of life which includes good symptom control and nursing care.
The role of the nurse is central to the care of the dying patient and family. It requires the utmost sensitivity and attention to detail. Many dying patients wish to remain independent for as long as possible. The nurse is in a position to offer:
Skilled, supportive care to patients and families.
Sensitive nursing care enabling the patient to remain independent for as long as possible.
Reporting of presenting symptoms and monitoring of symptom control.
www.macmillan.org.uk/home.aspx contains some useful information in relation to health professionals and palliative care.
Nursing intervention in common symptoms
There are some aspects of symptom control that will be directly helped by skilled nursing:
Anorexia – providing extra nutrition will not prolong life; liaise with the dietitian for ideas on presentation and supplements.
Mouth care – assess the oral cavity; can be helped with ice cubes, boiled lemon sweets or fresh pineapple chunks.
Constipation – a high-fibre diet is inappropriate; appropriate use of laxatives, privacy for defaecation and mobilization for as long as possible.
Dyspnoea – involves relaxation and a range of pharmacological interventions.
Fungating wounds – sight and smell; need to eradicate smell and use a dressing that is cosmetically acceptable to the patient.
Emotional care
Emotional care relies on openness and sharing the truth about the illness. The patient will feel loss and grief for the lack of:
Spiritual care
Spiritual care gives the patient and family an opportunity to examine the impact of the illness on their belief systems. They need to be given the opportunity to ask questions:
Staying with this sort of spiritual pain and not being afraid of the questions is a helpful response. Offering the support of a relevant religious figure may not be appropriate for all but listening and being present will be appreciated.
Cultural diversity
Making nursing practice relevant to people of many cultures is a constant challenge to the nurse. Cultures differ with regard to:
Social needs
The nurse needs to ensure that patients and families have adequate information regarding the benefits to which they may be entitled. This includes:
Death/dying
The majority of people would prefer to die at home but this is not always feasible and only about 25% of people in the UK do so. Maintaining comfort is paramount, and the last few days of life are likely to be spent in bed:
Some people fear terrible pain or dying in a dramatic fashion and the nurse can do much to reassure and comfort the patient.
A few patients find the last days intolerable and it is compassionate for the medical and nursing team to offer medication that will help relieve this.
The majority of patients become sleepy and this merges into drowsiness and unconsciousness.
Cheyne–Stokes breathing may occur (periods of apnoea followed by more respirations, a cycle which continues until breathing stops).
Potential organ donation
Many patients in the UK die or suffer prolonged dependency because of a lack of organs for transplantation. Therefore, if a young or middle-aged patient with a fatal condition has healthy kidneys, liver, heart or corneas, it might be relevant to discuss organ donation with the medical team. Suitable organ donors include:
Victims of severe head injury.
Severe subarachnoid or intracerebral haemorrhage.
In the case of corneal donation, any young patient with healthy eyes or a rapidly fatal illness.
Patients who are unsuitable organ donors:
Where brain death is uncertain.
Where there has been significant hypotension or hypoxia during a fatal illness.
Where there is a history of previous disease affecting the potential donor organ (e.g. hypertension, diabetes, hepatitis B, alcohol abuse).
Where the patient has received drugs or other treatment which might have affected the organs to be transplanted.
In the case of the kidneys, where there is persistent oliguria.
What to do after the patient has died
The family should be able to spend as much time with the dead person as they want.
The doctor or GP will be called to certify the death.
Date and time of death are recorded.
There is no need for children to be excluded from this time.
Inform surrounding patients of the death.
If a doctor has not seen the patient within 14 days before the death, a postmortem examination may be needed.
Last offices
This is the care given to a deceased patient, which is focused on fulfilling religious and cultural beliefs as well as health and safety and legal requirements. It should be remembered that this is the final demonstration of respectful, sensitive care given to the patient:
It is important that the nurse knows in advance the cultural values and religious beliefs of the family, as there are considerable cultural variations between people of different faiths, ethnic backgrounds and national origins in their approach to death and dying.
Individual preferences should be determined and patients should be encouraged to talk about how they may wish to be treated upon dying. If in doubt, consult the family members.
Catheters and other appliances should be removed (except in a coroner’s case – a medical enquiry into the cause of death) and any dentures replaced.
Orifices that are leaking fluid should be packed with gauze.
Relatives should be asked whether jewellery should be left on or taken off.
Wash the patient, unless requested not to do so for religious/cultural reasons. It may not be acceptable for the nurse to undertake this task or sometimes, a relative may want to help.
The body is dressed in nightwear, a shroud or other garments selected by the family.
The body needs to be labelled (if in an institution) on one wrist, one ankle and on the outside of the shroud, with an identification bracelet and the property identified and stored.
Wrap the body in a mortuary sheet and secure the sheet with tape.
Tape a notification of death card on the outside of the sheet (refer to hospital policy for details).
Request the portering staff to remove the body.
Screen off appropriate areas from view of other patients when the body is being removed.
Update nursing records, transfer property and patient records to the appropriate administrative department.
A death certificate will be issued the next day from the hospital and needs to be registered within 5 days at the registrar’s office in the district in which the death took place.
Bereavement
A nurse working with dying patients needs to have an understanding of bereavement. For some, death may have been sudden or unexpected; for others the result of a long illness and expected. Bereavement is an individual response and it will be different for each individual suffering loss. There have been many models and theories of grief which help to understand and support people who have been bereaved (see Kinghorn & Gamlin 2001).
Grief is not an illness, it is a pattern of reactions that take place while the person adjusts to the death of his loved one.
Caring for family
Caring for people whose relatives have died suddenly and unexpectedly is one of the most difficult and challenging events for healthcare professionals. The nurse is not expected to be a bereavement counselor, but to be there for the relative before the patient has died. A well-managed death will help with the emotional health of a family. Listening and understanding imply concern and care while acknowledgement of their pain and sorrow may help relatives to move forward.
The way in which families receive news of their loved ones’ deaths can seriously affect how they grieve and cope. Therefore, nurses’ response can play a valuable part in the recovery process and there is a need to understand and be able to meet relatives’ needs (Purves & Edwards 2005). These include:
Meeting bereaved people on their arrival.
Knowing the loved one’s condition – accurate information about their loved one’s death.
Notification of death by someone who uses a sympathetic tone of voice using the appropriate terms, e.g. ‘dead’ as others such as ‘he has passed away’ but is open to misinterpretation.
Helpfulness of actions – families need to know that all appropriate action has been taken to save their loved ones.
Knowledge, education and training.
Recognizing abnormal grief
It is important to recognize abnormal grief and to refer to specialist help. Most of the country is now covered by local bereavement services:
4.2 Psychological issues
Promoting rest and sleep
Sleep can be defined as an altered state of consciousness from which a person can be aroused by stimuli of sufficient magnitude. The function of sleep is far from clear. It is considered as restorative and energy conserving, as protein synthesis and cell division for the renewal of tissues take place predominantly during the time devoted to rest and sleep. Sleep is needed to avoid the psychological problems resulting from inadequate sleep which might hinder recovery and if the function of sleep is correctly assumed, then sleep deprivation could be considered as a stressor, over and above those physical and emotional traumas already suffered.
During an average night’s sleep individuals pass through four or five sleep cycles, each cycle lasting about 90–100 minutes. Within the sleep cycle, five successive stages have been defined by their distinctive characteristics. The first four stages of sleep are called collectively non-rapid eye movement (NREM) sleep and demonstrate a progressive increase in the depth of sleep. Stage five is called rapid eye movement (REM) sleep, or paradoxical sleep, and is associated with dreaming, learning and memory.
Perpetual awakening and sleep interruption have been associated with increased anxiety, irritability and disorientation, which may have a negative influence on recovery. Total sleep deprivation for 48 hours can result in changes such as:
Reduction in motivation and willingness to perform tasks which could include mobilization and other aspects of self-care.
Lethargy, irritability and disorientation and confusion.
Recommendations for minimizing sleep interruption in patients are listed in Box 4.1.
Box 4.1 Minimizing sleep interruptions in patients
• Turn off maximum number of lights, especially at night.
• Keep noise to a minimum (switch off suction equipment, reduce talking and whispering).
• Offer cotton wool balls for patients’ ears.
• Continually reassess the need to interrupt patients’ sleep to perform observations.
• Perform as many nursing observations as possible together.
• Chart amount of uninterrupted sleep per shift and evidence of sleep stages.
• Communicate the patients’ need to sleep to other professionals.
• Use knowledge of patients’ normal sleeping patterns and supportive family relationships to optimize environment for sleep.
• Administer analgesics and sedatives according to the patients’ felt need and monitor events.
Psychological disturbances
These can influence recovery in many ways:
Eating can be a way of finding comfort during periods of insecurity, depression, loneliness and boredom.
Anorexia nervosa can be a way of coping with hate or anger towards a parent or fear of maturity.
Changes in roles within a family or society can cause psychological disturbances. Personal identity and functioning in a social setting can have an influence on recovery and might involve passive or active neglect of the patient’s own needs.
Social and economic status can influence recovery due to the following:
In low-income families food concerns are often of a low priority.
Surviving in very poor housing.
Families may have financial problems which compound the problem of maintaining health and recovery.
Elderly people can become anxious over issues concerning diet, or become ill, confused or forgetful. Understanding the elderly clientele means:
The cost of caring to the nurse
Working closely with dying patients can cause emotional distress for the nurse and can be painful. Nurses need adequate support systems in both their professional and personal lives. The nurse needs to recognize internal signs of stress and develop strategies for coping:
Spacing of holidays and time off is important to recharge lost energy.
Continuous training and education for stimulation.
Take time to debrief with a colleague.
Concise written recording can be therapeutic and help the letting go of a particularly stressful situation.
Being honest and sharing vulnerabilities will help a team relate and work well together.
4.3 Cultural issues
A patient’s stay in hospital may be influenced by a number of factors, e.g. religious beliefs or other strongly held principles, cultural background, ethnic origins and the availability of traditional foods. Whatever a person’s ethnic and cultural background, food can play a role in maintaining good health but it will often have an important social or religious significance as well.
Some religious or cultural diets prohibit certain foods and have festivals which require strict fasting. Others require different activities following death. It is important for nurses to have knowledge and understanding of the diverse cultures currently resident in Britain and take their different practices into account.
Some religious beliefs may refuse specific treatments. Jehovah’s Witnesses, Christian Scientists and members of other minority sects may refuse specific treatments such as blood transfusion. You should explain the nature of the treatment to such patients but if it is refused the doctor should be informed and the patient should sign a declaration to that effect. The patient’s wishes must then dictate what treatment he then receives.
Knowledge of clientele
When caring for patients it is important to take account of the context in which a patient lives, as well as the situations in which the patient’s health problems arise (Kozier et al. 2004). This involves being:
Culturally sensitive – knowledge of health traditions among diverse cultural groups (race, gender, sexual orientation, ethnicity, socioeconomic status, educational attainment, religious affiliation). It is essential to identify a patient’s beliefs, needs and values, be able to phrase questions and develop trust.
Culturally appropriate – to give patients the best possible healthcare taking into consideration their special needs.
A nurse who knows the groups of patients they care for and their specific needs implies:
Non-prejudice towards their patients despite their medical condition, his or her heritage or generalizations about groups of people.
Non-stereotyping according to culture or ethnicity, e.g. assuming that all groups are alike.
Non-discrimination as all patients should be treated the same despite race, ethnicity, gender, social class.
Consideration of their individual needs relating to:
4.4 Infection and its control
Infection control prevents the spread of infection in the community and in hospital.
Immunization
Immunization is based on exposure to:
Weakened or dead disease-producing microorganisms (in the form of vaccines).
The poisons (toxins) they produce, rendered harmless by heat or chemical treatment (then called toxoids).
These will cause an individual to produce the same antibodies that would develop if the person had actually contracted the disease. Armed with the special memory that is unique to the immune system, these antibodies will ‘recognize’ the specific microorganisms, should they attack in the future, and destroy them.
The widely administered types of immunization are:
Infection control practices
Patients who are admitted to a ward environment are immunologically vulnerable and invariably have a reduced immune response. This may be due to the individual patient’s general condition, their inability to take nutrition or fasting practices in hospital. It might be due to prescribed treatments or drug therapies. Listed in Section 1 are a number of areas that nurses new to the ward environment must be made aware of, so that they may take measures in addressing the patient’s potential vulnerabilities as a result of a reduced immune response. In addition, healthcare professionals must be fully cognizant of other areas that put patients at risk of obtaining a hospital-acquired infection.
Bacteria (prokaryote cells)
The prokaryote or bacterium is a single-celled organism; it consists of a nucleus which contains the DNA, a cell wall, plasma membrane, flagella and other structures:
The cell wall is made up of carbohydrates and amino acids called peptidoglycans, and determines the Gram-positive or Gram-negative staining properties of bacterial cells.
The plasma membrane is a rigid external layer of material, which forms the cell wall, which protects the cell against white blood cells and helps the bacterium to adhere to surfaces.
Spores – the ability to produce spores by enclosing their cells in a resistant casing which is difficult to destroy by heat or chemicals. They are formed when the bacterium is exposed to adverse environmental conditions, e.g. no food, high/low temperature or a reduction in oxygen. When conditions improve the spores germinate and the cell starts to multiply. In this way bacteria can survive for very long periods.
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