This assignment will analyse the three aspects of care in which a student nurse attended to a patient during their placement within the community, whilst also analysing the evidence base and rationale for each aspect of care.
It is important for every nurse to practice the values which are essential to compassionate care when working in the healthcare field. This is known as the ‘6C’s’ which are care, compassion, competence, communication, courage and commitment, as these are the principles that establish nursing (NHS England, 2013).
It is also necessary for the nurse to adopt particular models of problem solving and care planning when going into practice. The assessment, planning, implementing, and evaluating approach, also acknowledged as the ‘APIE’ model (Jura and Walsh, 1967) is an approach frequently used by nurses when implementing care plans. This approach supports a systemic and accurate approach to patient care and incorporates an integrated perspective of care.
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In order to preserve confidentiality and safeguard said patient’s identity adhering to the Nursing and Midwifery Council (NMC, 2015), this patient will be specified as Mrs M. Mrs M was a 46-year-old diabetic patient living with her husband. She had developed a large, abscess on her left thigh which had been surgically removed and required daily wound care. Mrs M has had a history of reoccurring abscesses which limit her everyday life. Abscesses are collection of pus which in most cases are inflamed. They can arise in any structure as well as any cutaneous site. Abscesses can occur anywhere on the body; however, the most common locations are the face, neck, buttocks, thigh, axillae and perineum (Jean Bologna, 2004).
As a result of Mrs M being a type 2 diabetic mellitus (T2DM) patient with a severely malnourished diet, she was at a much greater risk of being afflicted with an abscess. T2DM is a condition with several complications which result from inflammation, immune dysfunction and hyperglycaemia. T2DM is also associated with asymptomatic bacteriuria (ASB), UTI’s and other non-sexually transmitted genital infections. It was also suspected that Mrs M had developed a urinary tract infection as a result of the sodium glucose cotransporter-2 (SGLT2) inhibitors she had been prescribed. Research studies have indicated patients who are treated with SGLT2 inhibitors are at a significantly higher risk of developing a urinary tract infection (DRCP, 2014). Mr’s M was also at risk of cardiovascular disease due to her uncontrolled diabetes mellitus. T2DM increases the possibility of cardiovascular disease by reason of cardiovascular risk in patients with diabetes being consecutive across the range of levels of systolic blood pressure (ACCORD, 2010).
The first aspect of care that the student will discuss is that of handwashing. Under supervision by a registered nurse, the student nurse was able to introduce herself to the patient (Kate Granger, 2013), the student nurse and RN then proceeded to washing their hands before beginning procedures. Hand hygiene is a fundamental part of good hygiene practice whilst in the community and it provides substantial benefits such as reducing infections and cross-contamination. Hand washing has been proven to minimize the risk of respiratory infections (Ryan et al, 2001). It was fundamental for both the student nurse and RN to adhere to the handwashing guideline procedures of the Royal Marsden (2015). Before beginning handwashing, any jewellery still worn must be removed. It has been instructed by the English Department of Health for all nurses to put into action a ‘bare below the elbow’ dress code. Bruises on hands must be covered with waterproof dressing (WHO, 2009). Nail polish and false nails must never be worn whilst on duty. Nails must also be neat and shortened as long nails conceal bacteria that is not removed by handwashing. It is also advised to run the tap at a flow rate as this will inhibit splashing. If splashing occurs, micro-organisms from the plug holes could be transferred. (NHS Estates 2001). Running the water until your hand becomes hot will allow the soap to be more effectual, breaking down excrement and bacteria. (DH 2001). Wet your hands and wrists as this will help the water to quickly mix with the soap to accelerate handwashing. The next step is to apply liquid soap and water to the surface of your hands, this is because liquid soap is more effective in removing dirt. Soap tablets are more likely to become polluted, which can transmit micro-organisms. You must then rub your hands together for a minimum of 10 seconds, focusing mainly on the inside of your fingers and thumbs. This technique is to guarantee that all areas of the hands are cleansed. Areas missed can be a determinant of cross-infection (Fraise and Bradley, 2009). The next step is to rinse hands completely as soap debris can lead to the skin becoming irritated. Skin which has been injured or irritated is more likely to become infected with pathogenic bacteria, leading to cross contamination (DH, 2001) You must then turn off the tap using your wrist, elbow or paper towel to avoid recontamination of the hand. Post procedure, you must dry your hands with a paper towel. It is not advised to leave your hand to air dry as damp hands strengthen the multiplication of bacteria (DH. 2001). Once paper towel has been used, it must be disposed in a black bag in a foot operated waste bin. Using a foot operated waste bin prevents contamination of the hand (DH. 2013).
The impact of hand hygiene in preventing risks of infection can be increased by showing people how to apply hand hygiene procedures correctly. The Royal Marsden (2015) has a handwashing technique guideline which if followed correctly, will minimise the risk of cross contamination. The first step of the handwashing technique is to first rub the palm of your hands together. Then massage the back of your hand with the palm of your other hand and your fingers intertwined. The next step is to rub your hands palm to palm with your fingers intertwined, then rub the back of your fingers to the opposing side of your palms with your fingers interlaced. Immediately after, you rub your thumbs with each of them grabbed tightly while using a rotatory movement. Lastly, rub your wrists with the opposing hand and thoroughly rinse your hands with water.
Being out in the community meant that there was not always a safe area to wash your hands. So, the other alternative of alcohol-based hand rub had to be used at times. The first line of procedure when using alcohol hand rub is to dispense the amount of hand rub which has been indicated in the manufacturer’s instructions into the palm of only one hand. The reason being that too much hand rub will take much longer to dry and too little will not disinfect the hand sufficiently. Once alcohol hand rub has been adequately applied, rub alcohol onto the surface of the hands, until hands are dry. This is to make sure that all areas of the hand have been decontaminated. Alcohol hand rub is a disinfectant that acts very rapidly and evaporates quickly. This will prevent contamination of equipment, whilst facilitating the appliance of gloves (WHO, 2009).
Personal protective equipment also known as ‘PPE’ must be used by the student nurse to help protect them whilst carrying out particular tasks that may require them coming into contact with bodily fluids or blood that may contain contagious agents. PPE includes gloves, aprons, sheets, and once used must be discarded. Not using PPE correctly can lead to cross contamination (RCN 2016).
The second care aspect the student will discuss is that of measuring and recording blood pressure. There are two methods of blood pressure measurements; direct and indirect. The primary blood pressure measurement method used whilst being out in the community was the indirect method using the auscultatory sphygmomanometers device (Bern et all, 2007). The manual auscultatory blood pressure requires obstructing the artery using a pressurized cuff and then discharging the pressure steadily. immediately upon the systolic blood pressure exceeding cuff pressure, blood returns back into the arteries, throughout systole, which will permit a pulse to palpate and to produce fluctuation in the artery (Levick, 2010). As the cuff pressure plummets, the sounds desist as the artery stays open during the pulse movement (Kacmerek et all, 2005). Stage 1 of the Korotkoff sounds is known as a systolic blood pressure and a stage 5 is known as a diastolic blood pressure. However in some cases, the Korotkoff sounds may extend in some patients till the cuff is thoroughly deflated; This serves as Stage 4 in the diastolic blood pressure. (William et al. 2004)
Before beginning the clinical observation, it was compulsory for the student nurse to thoroughly explain and discuss the following procedure that was about to be carried out before gaining consent from the patient (NMC, 2015). This is to provide that the patient comprehends what the procedure will entail and gives their legitimate consent (NMC 2015). Once the procedure had been thoroughly explained to the patient, blood measurements were ready to be carried out by the student nurse. The student nurse had to verify that the environment in which the clinical observation was going to be carried out was a relaxed and pleasant environment; as the mental state of the patient and temperature of the environment can cause variations in blood pressure readings (O’Brien et al. 2003). The student nurse also had to make sure that the patient was seated in a comfortable chair with back support, for a minimum of 5 minutes preceding to measuring the patients’ blood pressure. The reason being that resting for 5 minutes will guarantee an optimal reading and this is also to facilitate comparisons to be drawn with prior blood pressure results (NICE, 2011a).
The first step to the procedure is to wrap the sphygmomanometer cuff around the arm of the patient, making sure sleeves are rolled up. The bladder of the cuff must be focused over brachial artery and above the elbow. The lower corner of the cuff has to be approximately 2-3 cm above the brachial artery pulsation (O’Brein et all. 2003). This is to achieve a careful reading and to also make sure the artery could be conveniently palpated. The student also had to make sure that patient was relaxed and wasn’t talking or eating clinical procedure was being carried out; as any sudden movement can cause a deceitfully high blood pressure (BHS 2006). The next step was to palpate the brachial artery and at the same time draw air into the cuff using the bulb. Once the pulse could not be felt anymore, the cuff was promptly inflated a further 20-30mmHg. It is highly recommended to palpate the artery preceding to acquiring a blood pressure, the reason being that it detects a better position for the stethoscope placement (Valler-Jones and Wedgbury, 2005). The student nurse then slowly deflated the cuff and noted the point at which the pulse became measurable again. This gives the systolic blood pressure an approximate measurement. The student then completely deflated the cuff and waited for approximately 30 seconds. This is to allow the venous congestion to resolve (O’Brien et all. 2003). Once 30 seconds had ended, The student nurse then firmly placed the diaphragm of the stethoscope onto the patient’s arm over the brachial artery where the pulse was palpable; this is because the diaphragm has a larger exterior and is more accessible to grasp in place, also applying pressure with the stethoscope may congest the artery to a certain degree. The next step was to inflate the cuff once more to 20-30 mmHg above the predicted systolic blood pressure to guarantee a factual measurement. The air in the cuff was then released slowly at an exact rate of 2-3 mmHg per pulsation until the palpating sounds could be perceived. The student nurse had to be cautious not to deflate the cuff rapidly as this may conclude in imprecise readings (O’Brien et all, 2003). While the cuff was slowly deflating, the student nurse had to carefully listen to the Korotkoff sounds until the sound completely disappeared; this is to ensure accurate diastolic blood pressure and to make sure any irregularities are noted. Once the Korotkoff sounds could no longer be heard, the student nurse was then able to quickly deflate the cuff to prevent congestion of the veins.
Through these clinical observations it was discovered that Mrs M had a systolic blood pressure of 142mmHg and a diastolic blood pressure of 90mmHg, which placed Mrs M in the stage 1 high blood pressure category. Mrs M also had a pulse rate of 120 beats per minute and a temperature of 39. The student nurse then documented Mrs M’s results and compared them to Mrs M’s previous readings; to identify and risk or problems which may have arisen (NMC, 2010). Mrs M’s has a history of high blood pressure due to her being a diabetic with an uncontrolled diet, therefore her blood pressure readings were not distinctive.
Once clinical observations had been carried out, the nurse informed the patient that the procedure had been completed; this is to provide comfort for the patient (Major and Holmes, 2008). The student nurse then proceeded to washing her hands, to reduce the risk of contamination (Fraise and Bradley, 2009).
Mrs M was then referred to a doctor and through this referral was diagnosed with a urinary tract infection. All the symptoms Mrs B was experiencing such as high temperature, frequent urge to urinate and pain in her lower abdomen were a result of her UTI. A specimen urine sample also had to be taken from Mrs M in order to confirm diagnosis of the UTI. After analysis of the urine sample, it showed that Mrs M’s urine had a sediment and unpleasant smell, which was indication of an infection (Dougherty & Lister, 2011), which confirmed the Doctor’s diagnosis. Mr’s M was then prescribed with levofloxacin, an antibiotic to treat the urinary tract infection.
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The third care aspect that the student will discuss is that of the non-touch aseptic technique. The non-touch aseptic technique, also know as ‘ANTT’ is a specific method of the aseptic technique with a unique theoretical and practice framework (NICE, 2012). The non-touch aseptic method is used to protect the patient from insanitation. This is achieved by guaranteeing the asepsis of key-parts and key-sites by guarding the patient from the nurse and environmental infection. The NHS trust is dedicated to minimizing infections associated with healthcare, for this reason compliance of the Health and Social Care Act 2008 ‘Code of Practice on the prevention and control of infections and related guidance’ must be demonstrated. (Department of Health, 2010).
‘ANTT’ requires changing a patient’s dressing without directly touching the wound or any of the area’s that may come into contact with the wound. The location of the wound will usually determine whether the wound is dressed or not. In Mrs M’s case, she had an open wound from where her abscess had been removed, so required a hydrofiber dressing to fill her abscess cavity. The method of ‘ANTT’ used by the student nurse for dressing Mrs M’s wound was the standard ‘ANTT’ method, which is required when procedures are short and simple. Due to her religious beliefs, Mrs M had requested for only female nurse’s to dress her wound. It is fundamental to always be considerate of the patient’s cultural and religious belief as it contributes in promoting their human rights and dignity. Anxiety in the patient will also be reduced when they turn to their faith during health care challenges (NCBI, 2019)
For every aspect of care given, the nurse must gain consent before proceeding (NMC, 2015). To adhere to the non-touch aseptic technique, hands must first be decontaminated either by handwashing or the use of alcohol-based hand rub and a single use apron must be worn. The nurse must create a suitable and spacious working environment, non-sterile gloves and single use disposable apron must then be worn before opening the sterile dressing pack. Apron and gloves must be worn during the procedure in order to protect the uniform from becoming infected with potentially harmful organisms which could have been passed on from the patient (Dougherty and Lister, 2008). Before beginning, all equipment that will be used during the procedure had been gathered and placed on the sterile tray. This is to ensure that the nurse stays on the sterile field, which will fundamentally minimize the risk of cross-contamination. The best practice is to use a sterile trolley, whilst in the community sterile trays were primarily used to hold equipment due to its portability. The patient’s dressing was then removed carefully to reduce pain and skin damage, and placed into a sterile clinical waste bag to further minimize the risks of infection. Gloves contaminated with the soiled dressing were then removed, followed by hands being decontaminated again before applying sterile gloves.
It was also important for the nurse to keep a satisfactory level of communication with the patient and also listen attentively while the procedure took place as this reassured the patient, and good communication is also extensively believed to crucial for patient gratification, agreement and improvement (Dwamena et al.2012). The wound was then cleaned with an alcohol swab to avoid infection. A skin protectant sealant was then applied onto the wound to manage and protect the damaged skin, before then carefully filling the abscess cavity with a hydrofiber dressing. Studies have shown that hydrofiber dressings are associated with promoting faster wound healing and reducing perceived pain in comparison to other wound dressings (NCBI 2013). A barrier film was then placed onto the dressing, to keep the hydrofiber dressing in place and to protect the wound from becoming contaminated with potentially harmful organisms.
Once procedure was finished, the student nurse then proceeded to completing documentation. It is necessary for the nurse to keep accurate records stating care planned, decisions made, care delivered, and information shared between the patient and nurse adhering to the (NMC 2010) guidelines, including date and time and followed by a signature. This record must then be countersigned by a registered nurse. Record keeping are a measure of standards of practice relating to the skills and judgement of the nurse (NMC, 2010). Another fundamental consideration is the legal implication of record keeping. For example, If Mrs M was to make a complaint against the nurse, the record would be the only evidence that the nurse has fulfilled their duty of care to the patient. Law courts adopt the believe that if something has not been documented then it never happened. Therefore, nurses have a professional and legal duty to always keep records.
In summary, the student has carried out the following care aspects following analysis of evidence based and rationale of each aspect. Citation is important when writing an evidence based report to confirm that the appropriate research has been carried out, along with giving credit to the other researchers and acknowledgment of their work. Paraphrasing is also important as it demonstrates sufficient understanding and interpretation of the source.
- Alimov, V., Lovecchio, F., Sinha, M., Foster, K. and Drachman, D. (2013). Use of a Silver-Containing Hydrofiber Dressing for Filling Abscess Cavity Following Incision and Drainage in the Emergency Department. Advances in Skin & Wound Care, 26(1), pp.20-25.
- Delves-Yates, C. (2015). Essentials of nursing practice. Los Angeles: Sage.
- De Sousa, F. and O’Connor, J. (2012). Aseptic non-touch technique (ANTT) – competency training and assessment. Healthcare infection, 17(4), pp.143-144.
- Elliott, W.J. (2011). Effects of Intensive Blood-Pressure Control in Type 2 Diabetes Mellitus. Yearbook of Cardiology, 2011, pp.67–69.
- England.nhs.uk. (2019). [online] Available at: https://www.england.nhs.uk/6cs/wp-content/uploads/sites/25/2015/03/introducing-the-6cs.pdf- (Accessed 15/08/19)
- Geerlings, S., Fonseca, V., Castro-Diaz, D., List, J. and Parikh, S. (2014). Genital and urinary tract infections in diabetes: Impact of pharmacologically-induced glucosuria. Diabetes Research and Clinical Practice, 103(3), pp.373-381.
- Grossman, E., Messerli, F.H. and Goldbourt, U. (2000b). High Blood Pressure and Diabetes Mellitus. Archives of Internal Medicine, [online] 160(16), p.2447. Available at: https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/485426- (Accessed 25/08/19)
- NHS Choices (2019). Overview – Abscess. [online] NHS. Available at: https://www.nhs.uk/conditions/abscess/ (Accessed 16/09/19)
- Nmc.org.uk. (2019). The Code: Professional standards of practice and behaviour for nurses, midwives and nursing associates. [online] Available at: https://www.nmc.org.uk/standards/code/- (Accessed 13/08/19)
- Patterson, J. and Andriole, V. (1998). Bacterial Urinary Tract Infections in Diabetes. The Journal of Urology, p.293.
- Rcni.com. (2019). Ethics | RCN. [online] Available at: https://rcni.com/hosted-content/rcn/fundamentals-of-end-of-life-care/ethics- (Accessed 14/09/19)
- Rcni.com. (2019). Personal protective equipment | RCN. [online] Available at: https://rcni.com/hosted-content/rcn/first-steps/personal-protective-equipment- (Accessed 15/09/19)
- Rcni.com. (2019). Principles of record keeping | RCN. [online] Available at: https://rcni.com/hosted-content/rcn/first-steps/principles-of-record-keeping- (Accessed 14/08/19)
- Royalmarsdenmanual.com. (2019). The Royal Marsden Manual of Nursing Procedures Ninth Edition – Home Page. [online] Available at: http://www.royalmarsdenmanual.com/ – (Accessed 15/09/19)
- Smith, S. (2009). A review of hand-washing techniques in primary care and community settings. Journal of Clinical Nursing, 18(6), pp.786-790.
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