1 Medical nursing in context
• To introduce the student to terminology they may come ascross in medical nursing
• To introduce the student to various healthcare personnel they may meet during a medical placement
• To consider key principles of medical nursing
• To determine what knowledge and skills the student will need to understand in order to care for a patient with a medical condition
This chapter aims to give you a basis on which to begin to build your learning outcomes for a medical placement. It will help you to start to understand the role of the nurse in medicine and the other key professionals involved. It is also an opportunity to ensure that your knowledge of medical conditions is up to date in preparation for the many varied and exciting opportunities that await you in your medical placement.
Working on a medical ward, no one day is the same. There is not one set ‘type’ of patient that we look after, and although the medical ward on which I work is meant to be a respiratory medical ward, there is a huge and varied range of conditions and illnesses that we treat. When coming on duty, there is always the anticipation of not knowing what patients I will be looking after, what skills I will need to look after them and overall what my day will be bringing.
Caring for patients with a variety of illnesses, some of which can be acutely ill having come straight from A&E or ITU, is challenging, interesting and rewarding, and continuously develops my nursing skills and knowledge.
Medicine and medical nursing can be characterised by the non-invasive nature of its diagnostic investigations and treatments. Advancing technology in imaging techniques has meant that many conditions can be diagnosed by X-ray or scanning leading to prompt treatment and care. The ever increasing development of drug therapies has also meant that many previously untreatable acute and long-term conditions can now be cured or managed much more successfully. This has resulted in a better quality of life for many of those living with long-term conditions.
The following online resource follows the development of significant advances in medicine such as medical imaging, the discovery of penicillin, insulin and other drug therapies. Spend some time looking through the resources and developing your knowledge of what medicine is all about.
http://resources.schoolscience.co.uk/abpi/history/history10.html (accessed July 2011).
Nursing patients with medical conditions requires a team approach, therefore it is important that you begin to understand the roles of all the different professionals who may be involved in the care of the medical patient in your placement area. Table 1.1 explains some of the main healthcare professionals you will be working alongside. In order to complete your learning outcomes and competencies for your medical placement, you will need to work with a range of professionals and with different members of the nursing team in your placement area. This will not only ensure that you succeed in achieving your outcomes but will also ensure that you have a rounded and varied experience within your medical placement. The following quote from a third-year final placement student shows the benefit of working as part of a team:
When my mentor was away I would then work with any senior member of staff. This made me realise that there is a pool of knowledge in these qualified nurses. For one to get this knowledge, one needed to take initiative, be proactive and challenging. This also enabled me to be able to work in a multidisciplinary team which I found very interesting as we exchanged ideas.
Table 1.1 Who's who on a medical placement
| Matron | The matron will be a registered nurse with experience in the specialty for which they cover. They will usually have worked as a ward manager or senior sister previously. They have overall responsibility for a number of ward areas Department of Health – Modern matrons in the NHS – a progress report on the role of the modern matron: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4008127 |
| Ward manager, senior sister, charge nurse | The ward manager/sister or charge nurse is a registered nurse with experience in the specialty of the ward. This person is in charge of the ward and you will be accountable to them during your placement. The ward manager is responsible for ensuring that the care delivered is of high quality and that the staffing and supplies are appropriate for the area. They will also be in charge of the shift when they are on duty The Nursing and Midwifery Council: http://www.nmc-uk.org/ |
| Senior registered nurse, junior sister, senior staff nurse | A senior registered nurse or junior sister will deputise in the absence of the ward manager and will usually be in charge of the shift when they are on duty The Nursing and Midwifery Council: http://www.nmc-uk.org/ |
| Registered nurse (RN), staff nurse | The RNs or staff nurses will make up most of the staffing establishment on the ward and will have varying levels of experience The Nursing and Midwifery Council: http://www.nmc-uk.org/ |
| Healthcare assistant (HCA), healthcare support worker (HCSW) | HCAs/HCSWs are non-registered staff who support the RNs and provide basic care to patients. They may or may not have had any formal training NHS Careers Website detailing the role of the healthcare assistant: http://www.nhscareers.nhs.uk/details/Default.aspx?Id=485 |
| Assistant practitioner | This is a relatively new role which requires the person to have completed a foundation degree or similar qualification. They are usually trained in a variety of clinical skills, e.g. cannulation and catheterisation, so that they can provide increased support to the RNs on the ward NHS Careers Website detailing the role of the assistant practitioner: http://www.nhscareers.nhs.uk/details/Default.aspx?Id=2030 |
| Phlebotomist | The phlebotomist will usually attend the ward daily to take blood samples requested by doctors or nursing staff NHS Careers Website detailing the role of the phlebotomist: http://www.nhscareers.nhs.uk/details/Default.aspx?Id=252 |
| Physiotherapist (physio/PT) | The physio may be attached to one ward or cover a number of areas. Nursing or medical staff will refer any patients to them for assessment and assistance with mobility, rehabilitation and respiratory problems The Chartered Society of Physiotherapy: http://www.csp.org.uk/ |
| Occupational therapist (OT) | The OT will also usually cover a number of different ward areas. Their role is to maximise people's independence through a variety of methods including adaptive equipment and home modification. Nursing and medical staff will refer patients to them for assessment of their needs while planning for discharge The British Association of Occupational Therapists: http://www.cot.co.uk/Homepage/ |
| Speech and language therapist (SLT/SALT) | The SLT will cover a number of ward areas and will receive referrals from nursing or medical staff to assess patients who may be having problems with swallowing or communication difficulties The Royal College of Speech and Language Therapists: http://www.rcslt.org/ |
| Ward clerk/ward receptionist | The ward clerk will be based on the ward and will usually be at a reception desk, nurses’ station or an office on the ward. They will be an invaluable source of information about anything, from knowing how to contact a member of the team to where things are kept on the ward. Their role varies but may include greeting visitors to the ward, answering telephone queries, requesting and maintaining patient notes while they are on the ward and general administrative duties NHS Careers Website explaining the role of the ward clerk: http://www.nhscareers.nhs.uk/details/Default.aspx?Id=782 |
| Housekeeper | The ward housekeeper will be responsible for ensuring that the ward environment is kept clean and tidy (although a domestic team will also provide the cleaning). They may be responsible for ensuring that stock levels are maintained and that equipment is in good working order |
| Social worker (SW) | Social workers are usually allocated to individual patients but may be attached to a particular ward or area. Patients who may require support to look after themselves when they are discharged should be referred to the social worker for assessment The General Social Care Council: http://www.gscc.org.uk/ |
| Clinical nurse specialists, e.g. tissue viability nurse, diabetes nurse specialist |
A clinical nurse specialist is a registered nurse in a senior position who has developed their knowledge and skills within a particular clinical specialty to an advanced level The Nursing and Midwifery Council: http://www.nmc-uk.org/ |
| Radiographer | A radiographer is a registered practitioner who produces images of different internal body parts using a range of techniques such as X-ray, computed tomography (CT) scanning and magnetic resonance imaging (MRI) scans The Society of Radiographers: http://www.sor.org/ |
| Consultant physician | A consultant physician is a doctor with many years of experience and specialist knowledge and skills in a particular area of medicine, e.g. endocrinology or gastroenterology. They will have passed special exams (MRCP) to become a member of the Royal College of Physicians The Royal College of Physicians: http://www.rcplondon.ac.uk/ |
(All Websites last accessed July 2011)
Look at the resources alongside each profession in Table 1.1 to learn more about their roles, training and professional values.
Before you begin your medical placement it will be helpful to understand some of the common health problems patients on a medical ward may have. This will help you to know what to expect, understand some of the terminology used and have an insight into what your patient and their family/carers are experiencing. This section covers many of the common conditions you will come across and some of the basic information you will need to know.
Begin by revising the normal anatomy and physiology of the respiratory system (see further reading list for a selection of physiology books to use).
Table 1.2 gives examples of some common respiratory health problems you may come across on your medical placement along with resources to help you learn more about each of them.
Table 1.2 Common respiratory health problems
| Chronic obstructive pulmonary disease (COPD) | COPD is characterised by obstruction of airflow into the lungs. It is usually progressive and irreversible. It includes chronic bronchitis and emphysema. The main cause of COPD is smoking Chronic bronchitis is ‘inflammation of the bronchi’, resulting in increased mucus production obstructing the airways, producing phlegm and a cough Emphysema results from the alveoli in the lungs losing their elasticity causing them to narrow and obstruct the airways. Symptoms include shortness of breath National Institute for Health and Clinical Excellence (NICE) guideline – Chronic obstructive pulmonary disease: management of chronic obstructive pulmonary disease in adults in primary and secondary care: http://guidance.nice.org.uk/CG101/Guidance/pdf/English British Lung Foundation: http://www.lunguk.org British Thoracic Society: http://www.brit-thoracic.org.uk |
| Asthma | Asthma is a reversible obstructive disease of the lower airway, characterised by inflammation of the airways and increased mucus production. This can be caused by an internal trigger, e.g. stress, or an external trigger, e.g. pollen. Symptoms include wheezing, coughing, difficulty in breathing and chest tightness Asthma UK: http://www.asthma.org.uk |
| Tuberculosis (TB) | TB is a bacterial infection caused by Mycobacterium tuberculosis. Respiratory TB is the most common infection but it can affect other parts of the body. Symptoms of respiratory TB include fever, cough, night sweats, weight loss and blood-stained sputum NICE guideline – Clinical diagnosis and management of tuberculosis, and measures for its prevention and control: http://guidance.nice.org.uk/CG33/ |
| Pneumonia | Pneumonia is inflammation of a part or all of one or both lungs, usually caused by infection NHS Choices information and video on pneumococcal disease and its effects: http://www.nhs.uk/conditions/pneumonia/Pages/Introduction.aspx NHS Choices information and patient story video on the experience of having pneumonia: http://www.nhs.uk/Conditions/Pneumonia/Pages/Symptoms.aspx |
(All Websites last accessed July 2011)
Table 1.3 lists some of the common neurological health problems you will come across in your medical placement along with resources to help you learn more about each of them.
Table 1.3 Common neurological health problems
| Cerebral vascular accident (CVA) or stroke, transient ischaemic attack (TIA) | A stroke happens when the blood supply to a part of the brain is interrupted by either a clot (ischaemic stroke) or a bleed (haemorrhagic stroke) resulting in the brain cells in that part of the brain dying. Symptoms include weakness of one or more limbs, problems with speech and facial drooping. Stroke is a medical emergency A TIA is when the blood supply to a part of the brain is interrupted temporarily and the symptoms of the stroke resolve usually within minutes or hours. A TIA is an important warning sign that a person could be at risk of a stroke The Stroke Association: http://www.stroke.org.uk NICE guideline – Stroke, diagnosis and initial management of acute stroke & transient ischaemic attack: http://guidance.nice.org.uk/CG68/NICEGuidance/pdf/English NICE quality standards for stroke: http://www.nice.org.uk/guidance/qualitystandards/stroke/strokequalitystandard.jsp The National Stroke Strategy from the Department of Health: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_081062 NHS Choices Website: look at the videos to help you spot the signs of a stroke and hear the story of a stroke survivor: http://www.nhs.uk/NHSEngland/NSF/Pages/Nationalstrokestrategy.aspx |
| Multiple sclerosis (MS) | Multiple sclerosis is a chronic progressive disease characterised by the destruction of the myelin sheath which surrounds the peripheral nerves, affecting the ability of the nerve cells and brain to communicate with each other. Symptoms include dizziness, fatigue, visual problems, problems with balance, numbness, pins and needles, stiffness of muscles or muscle spasms, speech and swallowing problems The Multiple Sclerosis Society: http://www.mssociety.org.uk Department of Health – The national service framework for long-term conditions: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4105361 NICE guideline – Multiple sclerosis: management and treatment of multiple sclerosis in primary and secondary care: http://guidance.nice.org.uk/CG8/NICEGuidance/pdf/English NHS Choices Website information and a video about living with MS: http://www.nhs.uk/Conditions/Multiple-sclerosis/Pages/Living-with.aspx |
| Epilepsy | Epilepsy is a tendency to have recurrent seizures (fits) caused by a sudden burst of electrical activity within the brain disrupting the normal communication between brain cells Epilepsy Action: http://www.epilepsy.org.uk NICE guideline – The epilepsies: the diagnosis and management of the epilepsies in adults and children in primary and secondary care: http://guidance.nice.org.uk/CG20/NICEGuidance/pdf/English NHS Choices Website for information about epilepsy and a video of a person living with epilepsy: http://www.nhs.uk/conditions/Epilepsy/Pages/Introduction.aspx |
| Dementia | Dementia is a progressive syndrome characterised by memory loss, problems with thinking, judgement, understanding and language. There are many different types of dementia. The most common type of dementia in the UK is Alzheimer's disease. The second most common type in the UK is vascular dementia The Alzheimer's Disease Society: http://www.alzheimers.org.uk NICE guideline – Dementia: supporting people with dementia and their carers in health and social care: http://guidance.nice.org.uk/CG42/NICEGuidance/pdf/English NICE dementia quality standards: http://www.nice.org.uk/guidance/qualitystandards/dementia/dementiaqualitystandard.jsp Social Care Institute for Excellence Dementia Gateway: http://www.scie.org.uk/publications/dementia/index.asp The National Mental Health Development Unit: Let's Respect resources: http://www.nmhdu.org.uk/our-work/mhep/later-life/lets-respect/ |
(All Websites last accessed July 2011)
Using the resources in Table 1.3 and any of your own resources, for each of the conditions:
1. Find out how it feels to be living with these neurological health problems (you may also want to look at some of the videos on http://www.patientvoices.org (accessed July 2011) or the ones in the Website list at the end of the chapter).
2. Think about how these health problems would affect your ability to work, study and maintain relationships.
Begin by revising the normal anatomy and physiology of the cardiovascular system. The following Website, which includes a video of how the heart works, may help:
http://www.bhf.org.uk/heart-health/how-your-heart-works.aspx (accessed July 2011).
Table 1.4 lists some of the common cardiac health problems you will come across in your medical placement along with some resources to help you learn more about them.
Table 1.4 Common cardiac health problems
| Heart failure | Heart failure is a result of the heart no longer pumping effectively, usually as a result of damage to the heart muscle, e.g. a heart attack. This results in an accumulation of blood and fluid within organs and tissues. Some patients may have either left-sided heart failure (left ventricular failure) or right-sided heart failure depending on where the damage to the heart muscle is The British Heart Foundation information about living with heart failure: http://www.bhf.org.uk/heart-health/conditions/heart-failure.aspx |
| Atrial fibrillation (AF) | Atrial fibrillation is characterised by a rapid and abnormal heart rhythm as a result of the right atrium of the heart quivering rather than contracting. It can be caused by hypertension, heart valve disease, overactive thyroid and excessive alcohol. Atrial fibrillation is a major cause of stroke The British Heart Foundation. Read about atrial fibrillation and listen to the examples of a normal and abnormal heart rhythm: http://www.bhf.org.uk/heart-health/conditions/atrial-fibrillation.aspx |
| Hypertension | Hypertension or high blood pressure is when blood pressure is constantly elevated, usually above 140 mmHg/85 mmHg. Listen to this podcast to learn more about what high blood pressure is: http://soundcloud.com/bhf/blood-pressure-the-facts |
| Pulmonary embolism (PE) | A pulmonary embolism is the result of a blood clot blocking the blood supply to the lungs. It is an emergency and can result in sudden death in some cases NHS Choices Website with information on pulmonary embolism: http://www.nhs.uk/conditions/pulmonary-embolism/pages/introduction.aspx |
| Deep vein thrombosis (DVT) | A DVT is the result of a blood clot forming in a vein in the leg. It increases the risk of developing a pulmonary embolus NHS Choices Website with information about DVT, its treatment and prevention: http://www.nhs.uk/conditions/Deep-vein-thrombosis/Pages/Introduction.aspx NICE guideline – Venous thromboembolism – reducing the risk: http://guidance.nice.org.uk/CG92/Guidance/pdf/English |
(All Websites last accessed July 2011)
Using the resources in Table 1.4 and any of your own resources, for each of the above conditions:
Table 1.5 lists some of the common kidney (renal) health problems you will come across in your medical placement along with some resources to help you learn more about them.
Table 1.5 Common kidney (renal) health problems
| Acute kidney injury (AKI) | Acute kidney injury is a sudden and rapid decrease in kidney function resulting in an inability to maintain fluid, electrolyte and acid–base balance. It is staged 1–3 reflecting the extent of the kidney damage. AKI is often reversible The Renal Association Website with clinical practice guidelines for the diagnosis, treatment and management of AKI: http://www.renal.org/Clinical/GuidelinesSection/AcuteKidneyInjury.aspx |
| Chronic kidney disease (CKD) | Progressive and irreversible decrease in kidney function resulting in an inability of the kidneys to maintain fluid, electrolyte and acid–base balance. It is staged 1–5 with stage 5 being complete kidney failure requiring transplantation or dialysis The Renal Association Website with clinical practice guidelines on the detection, monitoring and care of patients with CKD: http://www.renal.org/Clinical/GuidelinesSection/Detection-Monitoring-and-Care-of-Patients-with-CKD.aspx Kidney Dialysis Information Centre Website aimed at helping those living with dialysis: http://www.kidneydialysis.org.uk/ A video on You Tube uploaded by NHS Choices about living with dialysis: http://www.youtube.com/watch?v=WZosHub0MOQ NICE quality standards for chronic kidney disease: http://www.nice.org.uk/aboutnice/qualitystandards/qualitystandards.jsp |
| Pyelonephritis | An acute or chronic bacterial infection of the kidney which has ascended from the urinary tract. A severe kidney infection is often referred to as urosepsis |
(All Websites last accessed July 2011)
Using the resources in Table 1.5 and any of your own resources, find out:
Table 1.6 lists some of the common endocrine and gastrointestinal health problems you will come across in your medical placement along with some resources to help you learn more about them.
Table 1.6 Common endocrine and gastrointestinal health problems
| Diabetes mellitus | Diabetes is a long-term condition caused by having too much glucose (sugar) in the blood. It is classified as type 1 or type 2. Type 1 diabetes occurs when the body fails to produce insulin, which must be replaced by daily injections. Type 2 diabetes occurs when the body does not produce enough insulin or the body cells are unable to react to the insulin produced (insulin resistance). Type 2 is more common, its onset tends to be later in life and it is associated with obesity NICE quality standards for diabetes: http://www.nice.org.uk/guidance/qualitystandards/diabetesinadults/diabetesinadultsqualitystandard.jsp Diabetes UK Website with information about living with diabetes: http://www.diabetes.org.uk |
| Alcoholic liver disease | Alcoholic liver disease is the term used to describe a range of conditions and symptoms that develop when the liver has been extensively damaged by alcohol. There are three stages of alcoholic liver disease – alcoholic fatty liver disease, alcoholic hepatitis and cirrhosis NHS Choices Website that describes the stages of alcoholic liver disease, its symptoms and management: http://www.nhs.uk/conditions/liver_disease_(alcoholic)/pages/introduction.aspx The British Liver Trust Website which includes information about how the liver works and how to look after your liver: http://www.britishlivertrust.org.uk/home/the-liver.aspx |
| Peptic ulcer disease | Peptic ulcer disease is the term used to refer to an open sore in either the stomach (a gastric ulcer) or the duodenum (a duodenal ulcer) NHS Choices Website with information about peptic ulcer disease: http://www.nhs.uk/conditions/peptic-ulcer/pages/introduction.aspx NICE guideline – Managing dyspepsia in adults in primary care. Dyspepsia refers to the symptoms of epigastric pain, heartburn and other upper gastrointestinal symptoms that are associated with peptic ulcer disease: http://guidance.nice.org.uk/CG17 |
| Crohn's disease, ulcerative colitis | Crohn's disease is a chronic inflammatory condition that can affect all or any portion of the gastrointestinal tract. It commonly affects the lower part of the small intestine and large intestine. The inflammation extends through all layers of the intestine wall. It has a wide range of symptoms which can remit and relapse Ulcerative colitis is a chronic inflammatory condition affecting the lining of the large intestine causing diarrhoea and rectal bleeding A Website designed to provide resources to patients and health professionals on inflammatory bowel disorders such as Crohn's disease and colitis: http://www.crohns.org.uk/ Crohn's and Colitis UK Website for people living with inflammatory bowel conditions: http://www.nacc.org.uk/content/home.asp |
(All Websites last accessed July 2011)
Using the resources in Table 1.6 and any of your own resources, find out how common the conditions are and what resources and support are available to patients living with these health problems in your own area.
Table 1.7 lists some of the common haematological health problems you will come across in your medical placement along with some resources to help you learn more about them.
Table 1.7 Common haematological health problems
| Anaemia | Anaemia is a decrease in the number of red blood cells or amount of haemoglobin carried by red blood cells. There are many different types of anaemia including iron-deficiency anaemia and pernicious anaemia (vitamin B12 deficiency) The Pernicious Anaemia Society Website provides advice and support for those with pernicious anaemia: http://www.pernicious-anaemia-society.org/ NHS Choices Website where a search for anaemia will bring up the many different types of anaemia, their causes, symptoms and treatment: http://www.nhs.uk |
| Sickle cell anaemia | Sickle cell anaemia is a genetic disorder where red blood cells can become hard, sticky and sickle (crescent) shaped causing premature death of the blood cells and anaemia. A sickle cell crisis occurs when blood cells clog up a blood vessel, reducing oxygen supply and causing damage to nearby tissues and organs The Sickle Cell Society Website providing information and support to people with Sickle cell anaemia: http://www.sicklecellsociety.org/ NHS Choices Website containing information about sickle cell anaemia and a video of a person with sickle cell talking about how they cope with the disease: http://www.nhs.uk/conditions/sickle-cell-anaemia/pages/introduction.aspx |
| Human immuno-deficiency virus (HIV), acquired immunodeficiency syndrome (AIDS) | HIV is a retrovirus which attacks the body's own immune system, leaving the body susceptible to infection and other serious illness such as cancer. HIV infects CD4 cells which are responsible for fighting infection and, although the body will continue to produce CD4 cells, as they are destroyed by the virus they will decline in number leading to failure of the immune system AIDS is the term used to describe this late stage of HIV when the immune system has failed and the person has contracted a serious life-threatening illness such as pneumonia NHS Choices Website with information about how HIV is contracted and how it attacks the immune system: http://www.nhs.uk/conditions/hiv/pages/introduction.aspx Health Talk Online Website which includes real life stories of people living with HIV: http://www.healthtalkonline.org/Intensive_care/HIV/People/Stories |
(All Websites last accessed July 2011)
Using the resources in Table 1.7 and any of your own resources, find out what the risk factors are for the health problems and who may be more likely to suffer from them.
Many of the core skills required for caring for a patient with medical problems will be the same whichever area of nursing you choose to work in. As you progress through your training you will find that your transferable skills are invaluable in helping you to settle in and adapt to a new placement area. However, all areas will work in a slightly different way depending on the local policy and procedures, and the needs of your patients will change depending on why they are in hospital and the medical conditions they have.
In medical nursing you are likely to be presented with a group of patients with widely differing medical problems and your ability to manage this diverse group of patients is a skill you will soon start to acquire.
Dignity should be a key consideration in the planning and delivery of care to your patients. You are probably aware of the many media stories in recent years in the UK describing episodes of care where patients’ dignity was not maintained.
Look at the following link to read about some of the dignity issues that have been highlighted in the media recently:
http://www.bbc.co.uk/search/news/?q=dignity%20in%20NHS (accessed July 2011).
Most nurses will say that they always treat their patients as individuals and respect their dignity, however it is important to take time to really think about this.
What does dignity mean to you?
Think of your own personal experiences of hospital or primary care. This could be when you were a patient or when a close friend or relative was in hospital. What was important to you or your loved one in this situation?
How did staff ensure that your dignity was maintained or, if they didn't, what could they have done differently?
There are a number of different definitions of dignity. Here are two examples.
The Royal College of Nursing (RCN; 2008a) definition of dignity:
Dignity is concerned with how people feel, think and behave in relation to the worth or value of themselves and others. To treat someone with dignity is to treat them as being of worth, in a way that is respectful of them as valued individuals. In care situations dignity may be promoted or diminished by: the physical environment; organisational culture; the attitudes and behaviour of the nursing team and others; and the way in which care activities are carried out. When dignity is present people feel in control, valued, confident, comfortable and able to make decisions for themselves. When dignity is absent people feel devalued and lacking in control and comfort. They may lack confidence and be unable to make decisions for themselves. They may feel humiliated, embarrassed or ashamed. Dignity applies equally to those who have capacity and to those who lack it. Everyone has equal worth as human beings and must be treated as if they are able to feel, think and behave in relation to their own worth or value. The nursing team should, therefore, treat all people in all settings, and of any health status, with dignity, and dignified care should continue after death.
The Social Care Institute for Excellence (2009) definition is based on the standard dictionary definition of dignity:
A state, quality or manner worthy of esteem or respect; and (by extension) self-respect. Dignity in care, therefore, means the kind of care, in any setting, which supports and promotes, and does not undermine, a person's self-respect regardless of any difference.
The following link will take you to the Social Care Institute for Excellence Dignity in Care Website which has, among other resources, an overview of selected research on what dignity means: http://www.dignityincare.org.uk (accessed July 2011).
Have a look at these different definitions. How closely do they match your own definition of dignity?
The RCN (2008b), in their ‘Dignity at the heart of everything we do’ campaign, suggests using the three Ps when considering dignity – places, people, processes (Box 1.1).
This involves thinking about the physical environment in which you are providing care (e.g. privacy, cleanliness) and the organisation in which you work (e.g. positive staff attitudes, good leadership, teamwork and resources).
This involves looking at yourself and others and the way in which you communicate with each other and with patients and visitors (e.g. listening, being polite, introducing yourself, providing information and explanations, challenging undignified practice, role modelling and reflecting on your behaviour).
Maintaining a patient's dignity can be very difficult within the medical ward and sometimes you may have to act as a patient's advocate while caring for them.
It is important that nurses feel able to challenge each other and colleagues if they feel that a patient's dignity is being compromised. For example, it is easy to become complacent and forget that all patients are individuals with feelings and needs.
An important part of maintaining dignity is meeting the cultural and spiritual needs of your patients. You are likely to meet many patients with differing values and beliefs based upon their religious, cultural, spiritual and personal backgrounds.
How will you know the cultural and spiritual needs of your patients? Having a basic knowledge of the main religious and cultural groups in the geographical area of your placement will help you begin to understand your patients’ needs but it is important to remember that no two patients are alike. Patients who are members of the same religious group or from the same cultural background may have widely differing beliefs on the same issues, and how they wish their needs to be met while they are in hospital may also be very different. The best way to find out what your patients’ needs are is to ask them. If your patients are not able to tell you themselves then you could ask someone who knows them well.
Find out about the predominant cultural groups in the geographical area of your placement.
Now do some research about these groups – do they have any specific cultural or religious needs that would need to be taken into account if they were in hospital? Do they have any specific beliefs or values about health and illness?
The following Websites may be a good starting place as they have information about the beliefs of the main religious groups and some good practice guidelines for cultural awareness in health care: http://www.ethnicityonline.net and http://www.culturediversity.org/ (accessed July 2011).
Your placement area will link with a chaplaincy service which is designed to provide patients and staff with support whatever their religious beliefs. They will be able to access religious leaders within the community from different religions for patients and their families if requested.
The final section of this chapter will introduce you to the concept of nursing models and the nursing process. You will find that these underpin the way nursing care is planned, delivered and evaluated wherever your medical nursing placement may be. A good understanding of these before you begin your placement will help you to identify where your learning needs are in relation to assessing and planning patient care as these are a key part of the organisational aspects of care, essential skills cluster (Nursing and Midwifery Council 2010) that many of your competencies and learning outcomes will be based on.
Nursing models are theoretical frameworks designed to assist you in systematically assessing your patients’ needs and planning their care appropriately. There are many different nursing models, and different placement areas will use different ones to base their patient care on. Before you commence your placement it is useful to be aware of the more popular models used.
Read up on the following three nursing models. Look at the differences between the three and take note of the assumptions they are based on and how they are used in practice:
1. Roper, Logan and Tierney's activities of daily living model (Roper et al 2000).
2. Orem's self-care model (Cavanagh 1991).
3. Roy's adaptation model (Roy 2008).
One of the most widely used models in the UK is the Roper, Logan and Tierney activities of daily living model of nursing. This model is based on the model of living and acknowledging the indisputable fact that patients/clients still have to continue ‘living’ while they are receiving nursing care (Roper et al 2000). It sees the individual as being on a continuum between dependence and independence in each of the 12 activities of daily living. Where the individual is on the continuum can be influenced by five factors: biological, psychological, sociocultural, environmental and politicoeconomic (Holland et al 2008). Each of these factors needs to be taken into consideration when assessing your patient.
The 12 activities of daily living are:
Look back at some of the conditions referred to earlier in the chapter. Consider how each of the following conditions may affect a patient's ability to maintain their independence in the 12 activities of daily living:
The nursing process was first introduced in the 1960s as a way of describing the systematic process used by nurses to provide care (Yura & Walsh 1967, Habermann & Uys 2005). The nursing process has four phases: assessment, planning, implementation and evaluation.
Assessing your patient allows you an opportunity to determine what their actual and potential problems may be. Some of these problems may be related to their medical problem, for example shortness of breath due to a chest infection, but others may relate to your patient's psychological, social, spiritual or cultural needs. This is where nursing assessment differs from the medical model which is based purely on the medical needs of the patient. Consequently, your assessment needs to be based on a discussion you have with your patient about their current needs and their perceived needs relating to what is happening to them.
Following your assessment, you can then plan the goals you expect your patient to achieve. Ideally these would be set in conjunction with the patient but this may not always be possible, especially early in their admission when they are acutely unwell. By setting goals with your patient, they know what to expect and can feel part of the care process which in turn enables them to have control over what is happening to them. If they are not able to be involved in the setting of goals, try as often as possible to ensure they are aware of the goals you have set. The goals you set may be short term, but can also be longer term goals depending on the needs of the patient and the length of time they are expected to stay in hospital.
Once you have set a goal to achieve, you need to carry out appropriate interventions to help your patient reach their goal. Some of these goals will be task orientated, for example giving an appropriate medication; others may involve educating your patient about lifestyle factors that affect their health or ways to manage their condition in the long term. It is essential that all your interventions are evidence-based.
The final part of the process is evaluating the plan you have made to determine whether or not progress has been made or a goal has been reached. Again, your patient is an integral part of the evaluation as they will be able to tell you how they are feeling in relation to the problems identified initially and whether they feel these are still problems for them.
The nursing process does not end after the problems have been evaluated. It is a continuous cycle of evaluating, identifying what are still actual or potential problems and planning and intervening to achieve your goals. As your patient's condition can change very quickly, you will find yourself completing this cycle on a daily basis, sometimes even more often.
The nursing process can be applied to many nursing actions, not just planning care. For example, a patient tells you they need to go to the toilet – you immediately assess how they are going to get to the toilet and plan what you need to do to meet their immediate need. You then put that into action, for example supporting the patient to walk to the toilet or providing a commode, and evaluating whether that was the best course of action.
By applying the process to all of the patient's actual and potential needs, we are ensuring that the care they receive is planned with the patient, evidence-based and based on what the patient actually feels is a problem, and regularly reviewed and updated. Documenting this care on care plans ensures that all members of the team are aware of the patient needs and how to meet them and provides us with a structure to evidence what we have done for the patient as accountable practitioners. You will find more information on assessing patients and care planning in Chapter 5.
This introductory chapter to medical nursing should have given you the opportunity to ensure that your knowledge of medical conditions is up to date, allowing you to begin applying this knowledge in practice once you commence your medical placement. You should also now be able to begin to plan the kinds of learning opportunities that are available to you within the team caring for a medical patient. As you now commence your placement, you can build on your knowledge of nursing models and the nursing process and develop your skills in assessing, planning, implementing and evaluating the care of a medical patient.
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