5 Nursing practice
admission and beyond
• To understand the admission process and rationale for information required on admission
• To understand how admission influences the care planning process
• To be able to explore the role of the nurse and other professionals within the admission process
• To be able to identify learning opportunities from the admission process
• To understand the importance of infection control within the admission process and throughout the care of a medical patient
Introduction
This chapter aims to prepare you for what may be your first contact with a patient on your medical placement – their admission. It will describe the admission process and help you to identify how you can be involved in the admission process and meet your learning outcomes, whether you are in your first year or your final placement prior to joining the register. It will also cover some important aspects of infection control which need to be addressed on admission and throughout your patient's journey.
Admitting a patient is an opportunity to be involved at the start of the care planning process and the preparations you made in Chapter 1 will enable you to now put this knowledge into practice. This chapter will also form the basis for the following chapters on risk assessment and the assessment of patients’ vital signs and changing health status, which are often an integral part of a patient's admission as well as their ongoing care.
Depending on where your placement learning experience is, your patients could be admitted from a number of different areas.
If you are placed on a medical admission unit, the majority of your patients will come from the accident and emergency (A&E). There may also be an arrangement with local GPs that patients can be referred to the on-call medical team and admitted directly to the admissions unit rather than go through A&E.
On a medical ward, your patients may be admitted from a number of different areas. Most will come from the admissions unit or directly from A&E if there isn't an admissions unit in your hospital. Some patients may be admitted directly from the out-patient department if the doctor feels they are unwell and need to stay in hospital for treatment or investigations.
Other patients may have been day patients in a medical investigations unit, for example for an endoscopy, and are too unwell to be discharged home the same day. They may also be transferred from another ward if their needs will be better met in your placement area. This might be because the nature of their medical problem is the specialty of your ward or they have specialist needs, for example a need for barrier nursing for infection control reasons and your ward has a single room available.
In an intermediate care or virtual ward setting, your patient could be transferred to you from a medical ward or they may be admitted from home following an assessment from their GP or community matron.
Admitting a patient requires a specific set of skills including communication, patient assessment, documentation, prioritising and delegating. You are likely to have competencies and/or learning outcomes associated with all of these skills. The competencies from the Nursing and Midwifery Council (NMC; 2010a) Domains – Professional Values, Communication and Interpersonal Skills, Nursing Practice and Decision Making – will all be particularly relevant to patient admission.
Speak to your mentor and find out all the different places your patients are likely to be admitted from. Maybe you could visit some of these areas or arrange to spend some time in them if they are not already a part of your placement learning experience (see Ch. 4 for examples of a patient's journey).
Depending on where you are placed, a patient being admitted to your area may have been in another area of the hospital for a few days already, but other patients may have only been in hospital for a few hours before they get to you.
Imagine how it may feel for a patient when they are admitted to hospital in an emergency. What sort of emotions and anxieties might they have? If you have a friend or family member who has been a patient in hospital, ask if they would be happy to tell you about how it felt.
Now think how it might feel to be moving from one area, such as the admissions unit, to another area, such as a hospital ward. What could you do to make the process easier for the patient?
Think of all the different areas of a hospital a patient may move between – A&E, out-patient clinic, ward, X-ray department – and how a patient may feel moving from one area to another often within a short space of time.
The admission process
A certain amount of information will have been collected about your patient in the department they started their journey in. Usually this will consist of at least their:
A member of staff from the area your patient is being admitted from will accompany the patient and ‘handover’ their care to you. The handover in this case is when the nurse from the area transferring the patient to you hands over or communicates verbally all the information they have about the patient, their plan of care and treatment required so that you can continue to provide care to the patient.
The handover process is vital in ensuring that all the necessary information about the patient is communicated to the receiving nurse, so that the transfer of care happens as smoothly as possible. (For more information about handover and skills required to hand over successfully, see Ch. 8.)
Discuss with your mentor how you can be involved in the handover of a patient being admitted to your area. Think about the information you are likely to need to know in order to provide care for your patient and then, when you have the opportunity to be involved in receiving a handover, listen to how this information is communicated and subsequently recorded.
When taking handover from the nurse transferring the patient, you will need to know the following:
• Why the patient was admitted and when.
• The medical team caring for the patient and contact number.
• What the patient has been told about their provisional diagnosis.
• Vital signs on transfer and frequency of monitoring.
• Nursing interventions required, e.g. wound care, fluid balance monitoring, blood sugar monitoring.
• Treatment given prior to transfer.
• Planned treatment and/or investigations.
• Results of any investigations so far.
• Problems identified so far, e.g. pain, incontinence, pressure ulcers, and interventions required.
• Estimated date of discharge.
• Social circumstances of the patient.
• Any referrals that have been made, e.g. specialist team/nurse, social worker, physiotherapist.
• Patient's next of kin and whether they have been informed of admission.
Chapter 8 includes more information about the different types of nursing handover and their importance.
Orientating your patient to the ward is extremely important. Informing them of the ward name and their whereabouts in the hospital can help to reassure them and help them to inform any relatives or friends that may call them wishing to visit. Knowing the ward routine, the location of toilets, bathrooms, where they can store their personal belongings and how to call for the nurse are all essential for the patient to know to help them feel in control of their situation.
Once your patient is settled into their bed and orientated to the ward, you will need to prioritise their needs accordingly. If the patient has been transferred from another setting within the same hospital or organisation, some of their assessments and care planning may already have been completed. If this is the case it is essential that you check all of this and make yourself familiar with the patient's care plans and ensure that they are still relevant.
For many patients you will need to begin with a full assessment to inform your care planning.
You may find that the documentation used when admitting a patient will be arranged to fit with a particular nursing model, for example Roper, Logan and Tierney's (2000) ‘activities of daily living’. It is vital that completing such documentation is not seen as merely a paper exercise but as an essential opportunity to learn about your patient, their actual and perceived needs and an opportunity to start to plan their care.
Refresh your memory about the nursing process discussed in Chapter 1 and reflect on how this happens within your placement area. Which members of staff assess patients, when and how is care planned and implemented and how often is it evaluated? Find out where all of the patients’ assessments are documented and familiarise yourself with the paperwork used in your placement area.
Patient assessment
Your initial assessment of your patient needs to inform yourself and your colleagues of the patient's actual and potential problems and the plan of care to address these problems. The assessment will also help to determine your priorities in caring for your patient. Your assessment will often include all or some of the following, depending on your placement area:
• Confirming patient details, e.g. date of birth, GP, next of kin.
• Assessment of needs based on a nursing model, e.g. activities of daily living.
• Physical assessment of skin condition, mobility, wound condition.
• Risk assessments, e.g. falls risk, pressure ulcer risk, malnutrition risk.
• Collection and testing of specimens, e.g. urine sample, stool sample, MRSA swabs, wound swabs.
• Measurement of the patient's weight, height and calculation of body mass index.
Assessment of vital signs and risk assessment will be covered in detail in Chapters 6 and 7. This section will focus on the assessment of your patients’ needs and care planning.
The initial assessment of your patient can be quite lengthy so it is important that you plan for this to take place when there is sufficient time. For example, if meals are about to be served it may be appropriate to complete some of the assessments, such as measuring vital signs and taking any details about dietary needs and assistance required with eating and drinking, before the meal is served and then complete the remaining assessments afterwards. Also, if your patient is in pain or requires urgent treatment or intervention, this should take priority along with checking of vital signs and confirming their personal details.
In some circumstances your patient will not be able to take part in the assessment. They may be confused and unable to understand or answer your questions or they may be unconscious or too drowsy. They may also be very unstable and too unwell to hold a full conversation. When this is the case, it is important that you complete all the physical assessments, checking of vital signs, collection of swabs and specimens, etc., with your patient and then use other sources to complete the nursing needs part of your assessment.
Your placement area is likely to have a standardised set of questions to ask which
Speak to your mentor and identify an opportunity to observe or take part in a patient assessment. Find out which aspects of assessment above are carried out in your placement area and which nursing model is used to structure the assessment. Read up on this model to refresh your memory.
form the basis of the patient's nursing needs assessment. Appendix 4 in Holland et al (2008) has questions to consider during the assessment stage of care planning based on the activities of daily living model.
Consider how you may find out information about your patient's abilities and needs if they are not able to tell you themselves.
Some of the possible sources of information to help complete your assessment will be:
Talking to family, friends, carers of your patient.
Transfer documents or a phone call to the care home your patient lives in.
Information already recorded in the medical/nursing notes from the patient or family.
Previous admissions and assessments made which are filed in the patient's notes.
Contacting social services or care agencies if the patient is in receipt of a care package at home.
Contacting the patient's GP – this will be particularly useful if you have any queries about previous medical conditions, medications, etc.
Care planning
In Chapter 1, the nursing process was introduced as a systematic way of assessing, planning, implementing and evaluating nursing care (see Habermann & Uys 2005). This same process is reflected in care planning.
Nursing care plans are paper or electronic documents used to help direct the care we give to patients, detailing what the patient's actual or potential problems are, the goals we are aiming for and the care required to achieve these goals. Every organisation will have a slightly different system with regards to how they produce their care plans, where they store them and how they record their evaluation of them.
When you arrive in your placement area, speak to your mentor about the system used and take some time to familiarise yourself with the paperwork used. Some examples of nursing care plan documents can be found in Holland et al (2008). Most care planning documents will have space to document the patient's actual or potential problems and then the nursing actions required to care for the patient. The date of review and evaluation will also be recorded on the care plan.
Standardised care plans which are preprinted for a specific condition are used in some areas. They have the advantage of reducing the time required to write the care plan and also ensure that the standard of care received by all patients with a similar condition is the same. But they don't allow for individual variation and not all patients will have the same needs, even if they have the same medical problem. Consequently, if you are using standardised care plans, it is important that you take the time to individualise them as appropriate to meet your patient's needs.
The alternative to standardised care plans are hand-written ones that are developed specifically for an individual patient. They can be tailored to meet the specific needs of the patient and address all of the needs your patient may have. It is essential, though, that such care plans are evidence-based and written by a nurse who understands not only the condition of patients but also the patients themselves.
Ideally care plans should be written in conjunction with the patient, but this will not always be possible depending on the condition of the patient. Some patients will be too unwell to take part and others may not wish too. It is important that, even if the patient is not involved in planning their care, you try to establish how involved they want to be in their overall treatment plan: for example, do they want to know what investigations are planned and why? For some patients, knowing all the details will help to relieve their anxieties, but for others it may cause more distress and they would rather only know when there are definite results to be given or decisions to be made.
Infection prevention and control in your medical placement
The infection control status of your patient is an important aspect of the handover you receive when the patient is admitted as it may affect the physical environment your
Case history 5.1 A patient with a chest infection
Ian is a 68-year-old man with chronic obstructive pulmonary disease (COPD). He lives alone and has a carer once a day to help him wash and dress. His daughter visits daily to help him prepare meals. He has long-term oxygen therapy at home and rarely leaves the house – when he does he requires a wheelchair. He has developed an infective exacerbation of his COPD and his GP sent him to A&E yesterday as he was not responding to oral antibiotics. He has been admitted to hospital and transferred to your ward.
Ian is breathless, his respiratory rate is 28 breaths/min and he is unable to speak in full sentences. His oxygen saturations are 92% on 2 litres of oxygen. Ian speaks English and understands why he is in hospital. He is currently receiving intravenous antibiotics to treat his chest infection and intravenous fluids as his breathlessness is reducing his ability to drink adequately and his increased respiratory rate means his insensible fluid loss is increased.
Imagine you are assessing Ian using the Roper, Logan and Tierney model.
1. Which activities of daily living do you think he will require assistance to maintain at the moment?
2. What do you think his actual and potential problems may be?
3. Try to write a care plan for each of these problems and consider how you would evaluate whether Ian has met the goals set in his care plans.
(See page 82 for answers.)
patient is placed in. For example, if you are placed on a ward and your patient has an infection that could be passed on to other patients, they may need to be nursed in a single room. You also need to know what precautions you may need to take to protect yourself and your patient.
Infection control will be an essential aspect of any placement area you are working in. It also forms a large part of the Essential Skills Clusters (NMC 2010b) which contain competencies you must achieve at all levels throughout your training in infection prevention and control. At entry level to the register it will be expected that:
• You can identify and take effective measures to prevent and control infection in accordance with local and national policy.
• You can maintain effective standard infection control precautions and apply and adapt these to the needs and limitations in all environments.
• You can provide effective nursing interventions when someone has an infectious disease including the use of standard isolation techniques.
• You can fully comply with hygiene, uniform and dress codes in order to limit, prevent and control infection.
• You can safely apply the principles of asepsis when performing invasive procedures and be competent in aseptic technique in a variety of settings.
• You can act, in a variety of environments including the home care setting, to reduce risk when handling waste, including sharps, contaminated linen and when dealing with spillages of blood and other body fluids.
Most organisations will have a policy or procedure regarding how information about infection control is communicated, to ensure that those who need to know the infection control status of a patient are able to obtain the information easily, but at the same time ensuring the confidentiality of such sensitive information. Consequently, you need to be careful about where you are physically in the placement area when discussing infection control issues as you may not want other patients or relatives to overhear such sensitive information.
Look at the competencies you have for your medical placement and identify which ones are related to infection control. As you work through this section, try to identify how you may achieve these and then discuss this with your mentor.
Speak to your mentor about the infection control policies and procedures in the organisation you are placed in and where you can access these. Take some time to make yourself familiar with them and find out about the procedure for transferring a patient between areas and admitting a patient that has an infection control need.
You are likely to have received lectures about infection control and may have been assessed in the classroom or simulation sessions on hand hygiene or adhering to other important aspects of infection control, for example aseptic wound dressing techniques.
Now that you have commenced your medical placement you will begin to realise that infection control principles are continually being applied. It is important to understand why infection control is so high on the agenda.
What have you heard about in the media concerning infection control and health care? Look at the following Website to read some of the high-profile media stories of recent years:
http://www.bbc.co.uk/search/news/infection_control (accessed July 2011).
Consider how your patients may feel if they are coming into hospital for the first time and have heard or read some of the media stories about infection control. Look around your placement environment; are there any posters or leaflets that may reassure patients that infection control is a priority for staff? Is there anything you could do to reassure your patients?
Reducing healthcare-associated infections
In 2007 the Department of Health introduced ‘Saving Lives’, a programme to reduce healthcare-associated infections through a series of high-impact interventions. High-impact interventions relate to key clinical procedures or care processes where the risk of infection could be reduced if the procedure or process is performed correctly. Each high-impact intervention is presented as a ‘care bundle’ or a set of clinical actions that can be adapted to the care environment, whether it is a hospital ward or department or a nursing home. The aim is to ensure consistency of care across care environments and to provide tools for organisations to measure through audit of their practice (see Box 5.1).
Box 5.1 High-impact intervention care bundles and their aims
Central venous catheter care bundle: to reduce the incidence of catheter-related bloodstream infection.
Peripheral venous cannula care bundle: to reduce the incidence of peripheral intravenous cannula infections.
Renal haemodialysis catheter care bundle: to reduce the incidence of renal dialysis catheter-related bloodstream infection.
Care bundle to prevent surgical site infection: to reduce the incidence and consequences of surgical site infection.
Care bundle to prevent ventilation-associated pneumonia: to reduce the incidence of ventilation-associated pneumonia.
Urinary catheter care bundle: to reduce the incidence of urinary tract infections related to short-term and long-term indwelling urethral catheters.
Care bundle to reduce the risk from Clostridium difficile: to reduce the risk of infection from, and the presence of, C. difficile by outlining guidance for prevention and management.
Care bundle to improve the cleaning and decontamination of clinical equipment: to improve the cleanliness and decontamination of near-patient equipment, to help reduce the risk of healthcare-associated infection and cross-contamination, to embed the importance of cleaning into the everyday work routine of the ward, to improve patient confidence.
Antimicrobial prescribing care bundle: to outline an approach to safe and rational antimicrobial prescribing in the healthcare setting and a method of auditing it.
Reducing the risk of infections in chronic wounds care bundle: to reduce the risk and incidence of chronic wound infections and chronic wound-related bloodstream infections.
Enteral feeding care bundle: to reduce the risk of infection associated with enteral feeding.
The aim of the high-impact interventions is to provide safe care, reduce healthcare-associated infections and to ensure that care is not just measurable but that clinical staff can receive rapid feedback regarding their care in these specific areas to ensure that they are aware of any changes they might need to make to meet the standards within the interventions.
Spend some time looking at the NHS ‘Clean, Safe, Care’ Website, familiarising yourself with the high-impact intervention care bundles and the evidence base for each one:
http://www.clean-safe-care.nhs.uk (accessed July 2011).
Infection control teams
Every organisation has an infection control team and the size of the team will depend on how large the organisation is. Most infection control teams will incorporate a doctor and infection control nurses whose roles are to provide advice to medical teams caring for patients with infectious diseases, advice on the nursing care of patients with infectious diseases and the precautions needed to prevent the spread of infection to other patients. Education and training of all staff within the organisation and ensuring that the organisation meets requirements set by the Department of Health will also be a large part of their role. Many medical placement areas will also have a permanent member of nursing staff who has responsibility to work closely with the infection control team and this nurse is often called a link nurse. It is the duty of the link nurse to disseminate information and teaching to the rest of the ward staff to ensure that quality and safety of care of patients remains up to date and effective.
Infection prevention and control throughout the medical patient's journey
Most medical wards comprise of bays and side rooms which are utilised in a variety of ways depending on the client group. On a medical ward there will be some patients who will require isolation due to infection; this is usually called barrier nursing. If a patient is being nursed in a side room because they have an infection that could be transmitted to another patient, you will see a notice on the outside of the door. This acts as a warning but also will provide information about what protective equipment you should be wearing when entering the room. It is standard for the equipment to be provided by the entrance of the room. The notice will not have a diagnosis but will outline the types of precautions that need to be taken prior to entering the room. The type of isolation required will be dependent on the organism that is causing the infection and its method of transmission. See Wilson's Infection Control in Clinical Practice (2006) for information on common types of infection, their method of transmission and isolation precautions required in the clinical setting.
If a patient is discharged home from the room, special cleaning will be required before another patient can be looked after in that room. Please check with your mentor to make sure that you know how equipment should be cleaned.
The conditions in Box 5.2 are ones you are likely to come across on your medical placement and would often require the patient to be barrier nursed.
Box 5.2 Commonly encountered infections in a medical placement area
Clostridium difficile
C. difficile is an anaerobic, Gram-positive bacterium and patients usually suffer from foul-smelling diarrhoea containing blood/mucus, fever, leucocytosis and abdominal pain following antibiotic therapy. The condition is mild and a full recovery is usual, however older patients may become seriously ill (Damani 2003). To diagnose this condition, faecal specimens are sent to the laboratory. C. difficile produces spores that cannot be disinfected using alcohol gel and, therefore, soap and water must be used. Any patient with C. difficile should be isolated and personal protective equipment should be worn inside the room by staff and visitors and removed before leaving the room to prevent contamination outside of the room. Hospitals will have policies and care bundles for this condition and you need to ensure that you are aware of these.
Tuberculosis
Tuberculosis is an infection caused by Mycobacterium tuberculosis and is usually a pulmonary disease, however it can occur in other organs but this is rare. Tuberculosis is an airborne disease and you should follow the precautions for airborne diseases in your local policy. The patient will be isolated in a side room that has effective ventilation for this condition and you will need to wear a special mask when you enter the room. It is important that you wear the identified masks correctly and ask staff to teach you the correct technique. The treatment for this condition lasts months and patients are usually looked after by a community-based team in their own home. This community team will work closely with the patients when they require admission to an acute medial ward.
Methicillin-resistant Staphylococcus aureus (MRSA)
MRSA is a condition that is well publicised in the news and may cause you some concern. Staphylococcus aureus is common in skin and tissue infection and many healthy people carry it in their nose, throat and skin. The problem arises when the S. aureus is resistant to most commonly used antibiotics and requires the use of intravenous antibiotics. When MRSA is diagnosed, the infection control team will advise the doctors to prescribe the correct antibiotic (Damani 2003). Every hospital will have a policy for screening patients for MRSA and you need to make yourself aware of the policy. The screening for MRSA involves swabs being taken from the patient's throat, nose and perineum and sent to microbiology. There will be protocols for treatment and you will need to ensure that you ask your mentor about these.
Many patients are screened for MRSA on admission to hospital and this may be something you are required to do during your initial patient assessment. It is usually patients who are thought to be most at risk of having MRSA (i.e. those who have been in hospital in the last 12 months and those who live in care homes) who are screened.
Find out what the local policy and procedures are for MRSA screening. Which patients are screened and when? What happens to the patient while you are waiting for MRSA swab results?
Ask your mentor to show you how to take swabs for MRSA and identify an opportunity where you will be able to do this. Find out how to label the swabs correctly and the correct procedure for sending them to the laboratory.
The following link will take you to a tutorial and video demonstration in talking a nose swab for MRSA:
http://www.cetl.org.uk/learning/MRSA_swab_technique/player.html (accessed July 2011).
Hand hygiene is one of the core principles of infection control and the most effective way of preventing the spread of infections such as MRSA and C. difficile. We are used to washing our hands if they look dirty, before we eat or after we have been to the toilet but we may not always be washing our hands effectively. According to the Essential Skills Clusters (NMC, 2010b), demonstrating effective hand hygiene is a competency that must be achieved by your first progression point.
Watch the following video clip demonstrating the six-step hand hygiene technique and then spend some time practising it for yourself:
http://www.youtube.com/watch?v=vYwypSLiaTU (accessed July 2011).
Health professionals are now encouraged to use alcohol-based hand gels to decontaminate their hands before and after each patient activity. In hospitals, most beds have a holder with hand gel at the end of the bed. You will also see them on the walls in most departments. Some nurses will carry around a small bottle of gel attached to their uniform. It is also common practice to see hand gel at entrances to wards and departments to encourage relatives and visitors to clean their hands before coming in.
Alcohol-based gels will not kill all bacteria though, and if your hands are visibly dirty you should always wash them with soap and water. Alcohol-based gels are not effective against C. Difficile or norovirus, so if your patient has diarrhoea or vomiting you must always wash your hands following the six-step technique with soap and water.
The World Health Organisation (2009) has created a resource called ‘Five moments’ which details the five moments during your care of a patient that require your hands to be cleaned. The resource can be accessed via the Infection Prevention Society Website:
http://www.ips.uk.net (accessed July 2011).
Also read the article by Sax et al (2007) which describes the rationale behind the five moments.
From your classroom-based simulation and lectures you will start to have an understanding of the standard precautions to take and practices that you must adopt when coming into contact with a patient's blood or body fluids. These practices should be used all of the time.
Aseptic technique
There will be opportunities to practise your aseptic technique within your medical placement and competencies associated with aseptic technique are aligned with your second progression point (Essential Skills Clusters; NMC 2010b). There are many procedures which require the principles of asepsis – cannula care, wound dressings and insertion of a urinary catheter, to name a few.
Discuss with your mentor the opportunities within your placement for using aseptic technique and identify appropriate opportunities for you to observe and/or be involved in these.
If you are a first-year student, you may feel nervous about undertaking an aseptic technique (e.g. for a wound dressing) and it is important that you are knowledgeable about the procedure and have had opportunities to observe this in practice. You will need to undertake an aseptic technique under the direct supervision of a registered nurse. Before you undertake the procedure, ensure that you have read the plan of care and gained the patient's consent.
Watch the tutorial at the following link demonstrating and explaining the rationale behind an aseptic dressing technique:
http://www.cetl.org.uk/learning/aseptic-dressing-technique/player.html (accessed July 2011).
Take some time to find out where personal protective equipment (e.g. gloves, aprons, goggles) are stored on the ward. Also familiarise yourself with the sluice and equipment used to collect specimens and the procedures for disposing of blood and body fluids within your placement area. Look at Rennie-Meyer (2007) for information on how to use personal protective equipment and management of waste.
Reflect on an aseptic procedure that you have been able to undertake. Ask your mentor for feedback on how you did. What aspects of the technique did you find difficult and are there opportunities for you to practise this in a simulated environment at the university or with your mentor or practice experience facilitator?
Infection control affects every part of a medical patient's journey and it should factor into everything you do for your patients.
You may find that you need to revise some of your learning about infectious diseases and prevention of infection in hospital – now would be a good time to do this. Even as a registered nurse you will be required to undertake annual training in infection control to keep you up to date with current practice.
The e-learning resources at http://www.corelearningunit.nhs.uk (accessed July 2011) are used by many trusts as mandatory update training and contain two short courses on infection prevention. They can be accessed by students. You are required to register the first time you access the site and will need to select the health authority and trust you are working in.
You may be unsure of some of the diagnoses that you encounter and therefore you may not understand how infections are transmitted. It is really important that you ask questions about a patient's diagnosis – remember, no question is silly. It is important that you keep yourself and the patient safe on the ward.
Time management, prioritising and delegation
Throughout the admission process and your initial patient assessment you will be identifying a number of needs your patient has, but you may not be able, or be the most appropriate person, to meet all of these needs. First, it is important to identify the other members of the team that should be involved in your patient's admission and assessment.
Look back to the ‘who's who’ in Chapter 1 and try to identify which members of staff might be involved in the admission of a patient to your placement area.
Other healthcare professionals such as physiotherapists, occupational therapists and speech language therapists may be involved in making an initial assessment of the patient on admission if the primary problem the patient has relates to their specialty. For other patients it will be the responsibility of the nurses and doctors admitting the patient to make a referral to the appropriate therapist or specialist nurse when it is identified that they can help to meet a patient's needs.
There will also be other members of the nursing team you are working in who will help you to meet the needs of your patient,
Speak to your mentor and find out what the referral process is to different specialists within your placement area – how do you refer, when do you refer? Discuss with your mentor how you can become involved in making a referral for one of your patients.
both during admission and your initial assessment and throughout care.
As you progress through your training towards registration as a nurse, your learning outcomes will increasingly incorporate skills such as time management, prioritising and delegation. For example, the Essential Skills Clusters for Nurses (NMC 2010b) state that at entry level to the register you will need to be able to demonstrate that you can do the following:
• Act autonomously and take responsibility for collaborative assessment and planning of care delivery with the person, their carers and their family.
• Work within the context of a multiprofessional team and work collaboratively with other agencies when needed to enhance the care of people, communities and populations.
• Refer to specialists when required.
• Prioritise the needs of groups of people and individuals in order to provide care effectively and efficiently.
• Take an effective role within the team adopting the leadership role when appropriate.
• Act as an effective role model in decision making, taking action and supporting others.
• Work within the requirements of the code (NMC 2008) in delegating care and when care is delegated to you.
• Take responsibility and be accountable for delegating care to others.
• Prepare support and supervise those to whom care has been delegated.
• Recognise and address deficits in knowledge and skill in yourself and others and take appropriate action.
Your learning outcomes or competencies may require you to demonstrate that you are able to competently manage a caseload of patients under the supervision of a registered nurse. You will progress towards this by starting out managing one aspect of a patient's care, managing the care of one patient throughout your shift and so on until you are confident and competent in managing a larger caseload. Your mentor will support you to progress to this level. Managing the care of one patient or a group of patients will require planning your time effectively and this is not always an easy skill.
A good place to start may be discussing the following with your mentor:
• What your experiences of time management are – do you have any transferable skills?
• What, if any, strategies you employ to manage your time.
• How your mentor manages their time. It is a good idea to ask more than one mentor or registered nurse as different strategies work for different individuals.
You will probably have reflected that some of the factors contributing to this shift running well included the following:
• Good communication and information sharing between all team members.
• Work was prioritised appropriately.
• Work was delegated among the team appropriately.
• Everyone in the team knew their roles and what was expected of them.
Prioritising care is an important skill to learn, and as you progress through your training you will have the opportunity to observe many registered nurses and care assistants prioritising their care. This is a skill you can practise before you are required to lead a team or manage the care of a number of patients.
Once you have received the handover for a group of patients, take a few minutes to think about the priorities for these patients and then talk this through with your mentor and explain what you think the priorities for the shift should be. Your mentor can then discuss this with you and provide the rationale for anything they may have prioritised differently.
Your patients can also help you in prioritising care. For example, if you are assisting a group of patients in their personal care in the morning, some of them may be ready to get washed and dressed while others may prefer to stay in bed a little longer or have a bath or shower later in the day. By establishing what your patients want to do alongside what you have established as your clinical priorities (e.g. a patient being discharged home or going to another department for an investigation), you can begin to prioritise your care appropriately. It is important to keep your patients informed as you prioritise care. If they would like you to assist them right away but you have another patient that takes clinical priority, it will help the patient who needs to wait if they understand why you can't assist them right away and how long it is likely to be before someone can assist them.
Delegation can be very difficult as a student nurse but a good starting point is to think about how you would like to be asked to do something. Would you like someone to ask you politely and give you a rationale for what they are asking you to do?
Think about role models that you respect and how they delegate. Ask your mentor how they learnt to delegate and about the strategies they employ.
Top tips to consider when delegating:
Be clear yourself about the task you wish to delegate.
Is the person you are delegating to competent to do this task?
Is the task a routine part of their role or is this something they wouldn't usually do?
What other tasks is this person already doing?
Be specific when telling the person what you want them to do.
Keep checking with them that they are happy to continue.
Ask them to report back to you when they have finished and agree a review time.
Prioritising and delegating
Imagine that your mentor is supervising you in managing a group of patients on a medical ward. You are in effect the team leader for the shift. She has agreed that you can delegate work to her and the care assistant working with you. You are on an early shift and have the following patients to care for:
A 55-year-old male patient with C. difficile being nursed in a side room.
A female patient with COPD who is due to be discharged home today. Transport has been booked to take her home and home oxygen has been arranged. The doctors need to complete a discharge summary for her GP letter and the nursing team need to make a district nurse referral. Her husband is waiting for her at home.
A 35-year-old female with diabetes mellitus who is due insulin before breakfast.
A 56-year-old female with dyspnoea booked for a bronchoscopy at some point today.
A 44-year-old female who has had unstable vital signs overnight and has a high early-warning score.
A 60-year-old female with a chest infection who has been stable overnight and is waiting to be reviewed by the respiratory team.
It is now 8.30 a.m., breakfast is being served and patients are starting to get up and wash and dress for the day. The morning medicines still need to be administered. Consider the following:
1. Think of the needs of each patient. Which patients will require attention as a priority?
2. Is there any more information you will need in order to prioritise your care?
3. Which patients could you delegate to the care assistant working with you?
4. What priority will you give to meeting the needs of each patient and who of the three of you is the best person to meet those needs?
(See page 86 for answers.)
Summary
The admission of a patient is a great opportunity to begin using your nursing skills and knowledge, in particular your communication and assessment skills. As you progress through your training, your skills in managing time and your workload will also increase and you will find that your competencies and learning outcomes will start to reflect this. This chapter has given you the basis for a patient assessment on admission which should help you to identify both possible learning outcomes and learning opportunities while on your medical placement. Developing your knowledge and skills in infection control will be a set of skills that are transferable to all of your other placements and your medical placement is a good place to start to develop these skills. By now you should be able to identify where your learning needs are in relation to infection control and be working with your mentor in order to meet these.
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Centre for Excellence in Teaching and Learning – contains video tutorials of a variety of clinical skills aimed at student nurses: http://www.cetl.org.uk (accessed July 2011).
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Answers
Case history 5.1: a patient with a chest infection
Care plans for some of the problems you may have identified for Ian
• Ian is breathless due to his long-term condition exacerbated by a chest infection.
• Ian's mobility is reduced due to his breathlessness and his long-term condition.
• Ian has difficulty communicating due to his breathlessness.
• Ian has a reduced appetite and is dehydrated.
• Ian may have difficulty getting to the toilet due to his breathlessness.
• Ian may require assistance with personal hygiene due to his breathlessness.
• Ian is at risk of developing a fever due to his chest infection.
Ian's nursing care plans
Problem: Ian is breathless due to his long-term condition exacerbated by a chest infection.
Goal: To restore normal breathing pattern.
| Nursing action | Rationale |
|---|---|
| Administer prescribed oxygen at 2 L | Oxygen is a drug Its potency in treating hypoxia is often underestimated and, if given inappropriately, is lethal |
| Help Ian to understand why oxygen therapy is important for him | To ensure concordance with therapy and reduce any anxieties Ian may have |
| Encourage Ian to sit upright for lung expansion, in a comfortable position with support and pillows | Making use of his full lung capacity will aid breathing |
| Monitor and document Ian's observations of his vital signs | To promptly identify any deterioration in his condition |
| Observe for cyanosis | Cyanosis is a sign of poor oxygen perfusion and will signify a deterioration in his condition |
| Administer any medication as prescribed and keep Ian fully informed | To optimise treatment of chest infection and ensure that Ian knows what medication he is taking and why |
| Ask Ian to provide a sputum specimen for culture and sensitivity and explain why this is important and provide tissues and a sputum pot | To identify type of bacterial infection and start appropriate antibiotic therapy |
| Place Ian's call bell within easy reach | Ian's mobility will be restricted due to his breathlessness so he will require assistance with some activities of daily living. Ian may also be anxious and will be reassured if he can summon help quickly |
| Refer Ian to the physiotherapist | Chest physiotherapy will help Ian to clear his chest of secretions and expectorate Gently mobilising with assistance when he can will help his recovery |
| Inform the nurse in charge or doctor of any change in Ian's condition | To ensure prompt attention if there is a deterioration in Ian's condition |
Problem: Ian's mobility is reduced due to his breathlessness and his long-term condition.
Goal: For Ian to be able to mobilise as well as he could prior to his chest infection.
| Nursing action | Rationale |
|---|---|
| Ensure all Ian's personal belongings are close at hand | To enable Ian to be as independent as possible without needing to mobilise |
| Ensure his nurse call bell is within reach at all times | To allow Ian to call for assistance when he needs it and reduce anxiety |
| When Ian is able to, establish his baseline mobility – how far does he usually need to walk at home? | To enable realistic goal setting |
| Refer to physiotherapist | To improve mobility once well enough |
| Encourage Ian to mobilise as he feels able to, with assistance | To maintain his independence and encourage mobility as his condition improves |
| Monitor Ian's pressure areas on a regular basis and discuss pressure-relieving techniques with Ian | To prevent complications of immobility and early identification of any skin/tissue damage |
Problem: Ian has difficulty communicating due to his breathlessness.
Goal: To ensure Ian's needs are met while he is finding it difficult to communicate.
| Nursing action | Rationale |
|---|---|
| Ensure Ian's nurse call bell is within reach at all times | To allow Ian to call for assistance when he needs it and reduce anxiety |
| Give full explanations to Ian about what is happening and why | To reduce the number of questions Ian will need to ask |
| When talking to Ian, use closed questions and limit the number of questions asked to those that are essential | To reduce the amount of information that Ian needs to give |
| Gain Ian's consent to ask a person close to him for information about his previous abilities, etc., if he is unable to give such information | To enable you to plan Ian's care and goals without Ian needing to undergo a lengthy assessment |
Problem: Ian has a reduced appetite and is dehydrated.
Goal: For Ian to have adequate fluid and dietary intake.
| Nursing action | Rationale |
|---|---|
| Maintain strict food and fluid balance monitoring Inform Ian about this and provide Ian with the rationale |
To allow prompt identification of a reduced food and fluid intake and an imbalance in intake/output To enable sharing of information with other team members, e.g. dietician |
| Ensure a malnutrition risk assessment (e.g. MUST) has been undertaken and referral to dietician as appropriate | To identify whether Ian is malnourished or at risk of malnourishment and referral for specialist advice from dietician and supplements or fortified meals as needed |
| Encourage Ian to eat and drink, finding out his likes and dislikes and times of the day he would usually eat or drink | If Ian does not feel like eating or drinking you could encourage him with small amounts of foods that he likes and at regular intervals rather than set mealtimes |
| Monitor and document Ian's observations of his vital signs | To identify promptly any deterioration in Ian's condition, e.g. hypovolaemia |
| Inform the nurse in charge or doctor if Ian's diet or fluid intake are below the normal limits | To allow prompt treatment of any complications |
| Administer intravenous therapy as prescribed and ensure that a cannula care plan is in place for this | To treat dehydration and prevent complications associated with an intravenous cannula |
| Keep Ian informed of his condition | To reduce anxiety and enhance concordance with treatment |
MUST, malnutrition universal screening tool
Problem: Ian may have difficulty getting to the toilet due to his breathlessness.
Goal: To ensure Ian is able to use the toilet when he needs to.
| Nursing action | Rationale |
|---|---|
| Ensure his nurse call bell is within reach at all times and is responded to promptly | To allow Ian to call for assistance when he needs the toilet |
| If Ian is happy to use a urinal bottle to pass urine, ensure one is within reach at all times and is removed promptly when he has used it | To allow Ian to pass urine at his bedside to conserve energy |
| Assist Ian to the bathroom to use the toilet when necessary, using a wheelchair to take him to and from the toilet and portable oxygen | To allow Ian to use the toilet in private within the limits of his mobility and breathlessness |
Problem: Ian may require assistance with personal hygiene due to his breathlessness.
Goal: To assist Ian to manage his personal hygiene until is able to do so independently.
| Nursing action | Rationale |
|---|---|
| Offer Ian assistance to wash by his bedside or with portable oxygen in the bathroom if he prefers | To maintain Ian's privacy and dignity and allow him a choice about how to meet his needs |
| Encourage Ian to do what he can for himself and offer assistance with anything he is unable to manage | To maintain Ian's independence while ensuring his needs are met |
| Ensure all the items he requires for washing and dressing are within reach | To enable Ian to be independent |
| Offer Ian the opportunity to meet his personal hygiene needs at any time during the day, when he feels he has the energy to | To help Ian conserve his energy and allow him a choice about when his needs are met |
Problem: Ian is at risk of developing a fever due to his chest infection.
Goal: For Ian's temperature to be maintained within normal parameters.
| Nursing action | Rationale |
|---|---|
| Monitor Ian's vital signs at least 4 hourly, including temperature | To allow early detection and treatment of a fever |
| Administer antipyretic medication as prescribed | To treat and prevent the development of a fever |
| Use non-pharmacological methods of cooling as appropriate, e.g. electric fan, minimal bedding, loose clothing | To help reduce Ian's temperature and ensure he is comfortable |
| Assist Ian to meet his personal hygiene needs as required | To keep Ian comfortable |
| Monitor Ian's fluid intake and output and encourage his oral fluid intake | To allow early detection and treatment of dehydration |
Activity: prioritising and delegating
These are some of the things you may have considered when prioritising and delegating the care of your six patients:
• Your first priority would need to be the 44-year-old female patient who has been unstable overnight. It would be recommended that you review the patient with your mentor to determine her immediate needs and call for support from the medical team as necessary. This will then determine a large part of your workload for the shift.
• Your 35-year-old female patient requiring insulin before breakfast is also a priority as breakfast is currently being served. This could be delegated to your mentor or another registered nurse while you are meeting the needs of your first patient.
• You could ask the care assistant working with you to check on your patient in the side room to ensure they are comfortable and to check that the other four patients are managing with their breakfast.
• The next priority is for the medication to be administered. This could be delegated to your mentor.
• The care assistant could help to ensure that your patient being discharged is ready to go while you complete the district nurse referral and ensure her doctor completes the discharge summary.
• You could then assist your patient who is due to have a bronchoscopy to ensure she is prepared for when the porters arrive.
• Either you or your mentor will need to accompany the respiratory team when they arrive to assess your patient with a chest infection to ensure you are aware of her treatment plan.
• You should be liaising frequently with your mentor and the care assistant working with you to keep updated on the progress of your six patients. For example, has your patient with C. difficile had any episodes of diarrhoea and is he maintaining his fluid balance? What are the vital signs of all of your patients?