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The Royal Marsden Manual of Clinical Nursing Procedures, Student Edition [10th Edition]
 1119532965, 9781119532965, 9781119532989, 9781119532972

Table of contents :
Detailed table of contents

Foreword to the tenth edition

Preface to the Student edition

Preface to the Professional edition

Acknowledgements

List of contributors

Quick reference to the procedure guidelines

How to use your manual

About the companion website

1 The context of nursing

Part One Managing the patient journey

2 Admissions and assessment

3 Discharge care and planning

4 Infection prevention and control

Part Two Supporting patients with human functioning

5 Communication, psychological wellbeing and safeguarding

6 Elimination

7 Moving and positioning

8 Nutrition and fluid balance

9 Patient comfort and supporting personal hygiene

10 Pain assessment and management

11 Symptom control and care towards the end of life

12 Respiratory care, CPR and blood transfusion

Part Three Supporting patients through the diagnostic process

13 Diagnostic tests

14 Observations

Part Four Supporting patients through treatment

15 Medicines optimization: ensuring quality and safety

16 Perioperative care

17 Wound management

Part Five Looking after ourselves so we can support patients

18 Self-care and wellbeing

Appendix: Standards of Proficiency for Registered Nurses List of abbreviations

Index

Citation preview

The Royal Marsden Manual of

Clinical Nursing Procedures

Student Edition

The Royal Marsden Manual of

Clinical Nursing Procedures Tenth Edition

Edited by Sara Lister RN, BSc (Hons), PGDAE, MSc, Dip, MA, MBACP Head of Pastoral Care and Psychological Support The Royal Marsden NHS Foundation Trust

Justine Hofland RN, BSc (Hons), ANP, MSc, PG Dip, ILM Level 5 Formerly Divisional Clinical Nurse Director Cancer Services The Royal Marsden NHS Foundation Trust

Hayley Grafton RN, BSc (Hons), CPPD ITU Chief Nursing Information Officer The Royal Marsden NHS Foundation Trust with

Catherine Wilson PhD, MSc, BSc (Hons), PG Dip (Ed), RN, ONC, RNT Formerly Head of School, The Royal Marsden School The Royal Marsden Hospital NHS Foundation Trust



This edition first published 2021 © 2021 The Royal Marsden NHS Foundation Trust Edition History © The Royal Marsden NHS Foundation Trust: previous editions published 1992, 1996, 2000, 2004, 2008, 2011, 2015 All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, except as permitted by law. Advice on how to obtain permission to reuse material from this title is available at http://www.wiley.com/go/permissions. The right of Sara Lister, Justine Hofland and Hayley Grafton with Catherine Wilson to be identified as the authors of the editorial material in this work has been asserted in accordance with law. Registered Office(s) John Wiley & Sons, Inc., 111 River Street, Hoboken, NJ 07030, USA John Wiley & Sons Ltd, The Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, UK Editorial Office 9600 Garsington Road, Oxford, OX4 2DQ, UK For details of our global editorial offices, customer services, and more information about Wiley products visit us at www.wiley.com. Wiley also publishes its books in a variety of electronic formats and by print-on-demand. Some content that appears in standard print versions of this book may not be available in other formats. Limit of Liability/Disclaimer of Warranty The contents of this work are intended to further general scientific research, understanding, and discussion only and are not intended and should not be relied upon as recommending or promoting scientific method, diagnosis, or treatment by physicians for any particular patient. In view of ongoing research, equipment modifications, changes in governmental regulations, and the constant flow of information relating to the use of medicines, equipment, and devices, the reader is urged to review and evaluate the information provided in the package insert or instructions for each medicine, equipment, or device for, among other things, any changes in the instructions or indication of usage and for added warnings and precautions. While the publisher and authors have used their best efforts in preparing this work, they make no representations or warranties with respect to the accuracy or completeness of the contents of this work and specifically disclaim all warranties, including without limitation any implied warranties of merchantability or fitness for a particular purpose. No warranty may be created or extended by sales representatives, written sales materials or promotional statements for this work. The fact that an organization, website, or product is referred to in this work as a citation and/or potential source of further information does not mean that the publisher and authors endorse the information or services the organization, website, or product may  provide or recommendations it may make. This work is sold with the understanding that the publisher is not engaged in rendering professional services. The advice and strategies contained herein may not be suitable for your situation. You should consult with a specialist where appropriate. Further, readers should be aware that websites listed in this work may have changed or disappeared between when this work was written and when it is read. Neither the publisher nor authors shall be liable for any loss of profit or any other commercial damages, including but not limited to special, incidental, consequential, or other damages. Library of Congress Cataloging-in-Publication Data Names: Lister, Sara E., editor. | Hofland, Justine, editor. | Grafton, Hayley, editor. | Wilson, Catherine, editor. Title: The Royal Marsden manual of clinical nursing procedures / edited by Sara Lister, RN, BSc (Hons), PGDAE, MSc, Dip, MA, MBACP, Head of Pastoral Care and Psychological Support, The Royal Marsden NHS Foundation Trust, Justine Hofland, RN, BSc (Hons), ANP, MSc, PG Dip, ILM Level 5, Divisional Clinical Nurse Director, Cancer Services, The Royal Marsden NHS Foundation Trust, Hayley Grafton, RN, BSc (Hons), CPPD ITU, Chief Nursing Information Officer, The Royal Marsden NHS Foundation Trust, with Catherine Wilson, PhD, MSc, BSc (Hons), PG Dip (Ed), RN, ONC, RNT, Head of School, The Royal Marsden School, The Royal Marsden Hospital NHS Foundation Trust. Other titles: Manual of clinical nursing procedures Description: Tenth celebratory edition. | Hoboken, NJ : Wiley-Blackwell, 2021. | Includes bibliographical references and index. Identifiers: LCCN 2020050693 (print) | LCCN 2020050694 (ebook) | ISBN 9781119532965 (paperback) | ISBN 9781119532989 (adobe pdf) | ISBN 9781119532972 (epub) Subjects: LCSH: Nursing care. | Nursing–Technique–Handbooks, manuals, etc. | Nursing. Classification: LCC RT41 .R77 2021 (print) | LCC RT41 (ebook) | DDC 610.73–dc23 LC record available at https://lccn.loc.gov/2020050693 LC ebook record available at https://lccn.loc.gov/2020050694 Cover Design: Wiley Cover Images: Labor Omnia Vincit Crest is a registered Trademark of The Royal Marsden NHS Foundation Trust. All images courtesy of The Royal Marsden NHS Foundation Trust. Set in 9/10pt Lexia by SPi Global, Pondicherry, India

10 9 8 7 6 5 4 3 2 1

Brief table of contents Forewordxvii Acknowledgementsxviii List of contributors

xix

Quick reference to the procedure guidelines

xxiii

How to use your manual

xxv

About the companion website

1 The context of nursing

Part One  Managing the patient journey

xxviii 1 13

2 Admissions and assessment

15

3 Discharge care and planning

47

4 Infection prevention and control

69

Part Two  Supporting patients with human functioning

131

5 Communication, psychological wellbeing and safeguarding

133

6 Elimination

205

7 Moving and positioning

283

8 Nutrition and fluid balance

339

9 Patient comfort and supporting personal hygiene

403

10 Pain assessment and management

457

11 Symptom control and care towards the end of life

497

12 Respiratory care, CPR and blood transfusion

539

Part Three  Supporting patients through the diagnostic process

657

13 Diagnostic tests

659

14 Observations

719

Part Four  Supporting patients through treatment

801

15 Medicines optimization: ensuring quality and safety

803

16 Perioperative care

937

17 Wound management

1029

vi 

Brief table of contents

Part Five  Looking after ourselves so we can support patients 

1061

18 Self-care and wellbeing

1063

Appendix: Standards of Proficiency for Registered Nurses

1085

List of abbreviations

1089

Index1093

Detailed table of contents Forewordxvii Acknowledgementsxviii List of contributors xix Quick reference to the procedure guidelines xxiii How to use your manual xxv About the companion website xxviii

Overview2

Evidence-based approaches Cardiovascular examination Anatomy and physiology Related theory Evidence-based approaches Abdominal examination Anatomy and physiology Related theory Evidence-based approaches Post-procedural considerations

Background2

References44

1 The context of nursing

Context of nursing Political context Unwarranted variation NHS Long Term Plan Professional context Patient safety and quality of care New roles

1 2 2 3 3 3 3 5

Evidence-based practice 7 What is evidence-based practice? 7 Evidence-based practice and The Royal Marsden Manual of Clinical Nursing Procedures8 Structure of the manual

9

Structure of the chapters

9

Finally9 References10

Part One

Managing the patient journey

13

2 Admissions and assessment

15

Overview16 Inpatient assessment and the process of care 16 Definition16 Related theory 16 Evidence-based approaches 18 Post-procedural considerations 23

3 Discharge care and planning

32 34 34 34 36 38 38 38 41 43

47

Overview48 Discharge care and planning Definition Related theory Clinical governance

48 48 48 48

Discharging patients from hospital: internal procedures Evidence-based approaches Pre-procedural considerations Post-procedural considerations Complications

49 49 51 52 52

Interface between primary and secondary care: external processes 56 Related theory 56 Evidence-based approaches 56 Complications 56 Complex discharges 56 Definition56 Related theory 58 Evidence-based approaches 59 Discharge to a nursing home 59 Related theory 59 Complications 59 Discharge planning at the end of life 59 Evidence-based approaches 59 Pre-procedural considerations 59 Informal carers Definition Related theory Evidence-based approaches

62 62 62 65

Observation24 Definition 24

The role of voluntary services Related theory

65 65

Physical assessment Definition Anatomy and physiology Related theory Evidence-based approaches Clinical governance Pre-procedural considerations Respiratory examination Anatomy Physiology Related theory

References66

25 25 25 26 26 28 28 28 28 28 28

4 Infection prevention and control

69

Overview70 Infection prevention and control 70 Definitions70 Anatomy and physiology 70 Related theory 76 Evidence-based approaches 77 Clinical governance 77

viii 

Detailed table of contents

Hand hygiene Definition Related theory Evidence-based approaches Pre-procedural considerations Hand washing Evidence-based approaches Use of alcohol-based handrub Evidence-based approaches Surgical hand antisepsis Evidence-based approaches Personal protective equipment (PPE) Definition Related theory Donning theatre attire Evidence-based approaches

80 80 80 81 82 83 83 85 85 86 86 92 92 92 100 100

Specific patient-related procedures 107 Standard precautions 107 Related theory 107 Aseptic technique 107 Definition107 Related theory 107 Pre-procedural considerations 107 Nursing care of patients with suspected or known infection: managing safe care 109 Related theory 109 Evidence-based approaches 110 Isolation procedures 111 Definition111 Source isolation 111 Definition111 Related theory 111 Evidence-based approaches 111 Post-procedural considerations 115 Protective isolation 115 Definition115 Related theory 115 Evidence-based approaches 116 Post-procedural considerations 117 Environmental hygiene and the management of waste in the healthcare environment Definition Related theory Waste disposal Related theory Clinical governance Management of soiled linen in the healthcare environment Related theory

118 118 118 120 120 120 120 120

Prevention and management of inoculation injury Related theory Complications

125 125 126

References126

Part Two

Supporting patients with human functioning 5

Communication, psychological wellbeing and safeguarding

131

133

Overview134 Communication134 Definition 134

Anatomy and physiology Related theory Evidence-based approaches Clinical governance Pre-procedural considerations Principles of communication

134 134 135 141 143 144

Providing information and making shared decisions Definition Related theory Evidence-based approaches Pre-procedural considerations Principles of providing information to a patient

147 147 147 147 148 148

Communicating with specific populations 151 Communicating with people with acquired communication disorders151 Definitions151 Related theory 151 Evidence-based approaches 151 Pre-procedural considerations 152 Principles of communicating with people with aphasia 152 Principles of communicating with people with impaired speech (dysarthria) 153 Principles of communicating with people with impaired voice (dysphonia) 153 Principles of communicating with people who are blind or partially sighted 154 Principles of communicating with people who are deaf or hard of hearing 154 Communicating with people who are worried or distressed 155 Related theory 155 Evidence-based approaches 155 Pre-procedural considerations 155 Psychological wellbeing 157 Definition157 Related theory 157 Adjustment161 Definition161 Related theory 161 Denial and collusion 162 Definitions 162 Related theory 162 Evidence-based approaches 162 Complications 163 Anxiety and panic 163 Definition163 Anatomy and physiology 163 Related theory 163 Evidence-based approaches 164 Pre-procedural considerations 165 Depression168 Definition 168 Related theory 168 Evidence-based approaches 168 Pre-procedural considerations 169 Anger, aggression and violence 171 Definition171 Related theory 171 Evidence-based approaches 172 Clinical governance 172 Pre-procedural considerations 172 Post-procedural considerations 174 Delirium175 Definition175 Related theory 175 Evidence-based approaches 175 Clinical governance 176 Pre-procedural considerations 176 Post-procedural considerations 177

Detailed table of contents 

Dementia177 Definition177 Related theory 177 Evidence-based approaches 177 Clinical governance 177 Pre-procedural considerations 177 Referring on to psychological support services 179 Evidence-based approaches 179 Safeguarding, mental capacity and the Mental Health Act 180 Safeguarding180 Definition 180 Related theory 180 Evidence-based approaches 180 Clinical governance 188 Principles of safeguarding 188 Mental Capacity Act (2005) 189 Definition 189 Related theory 189 Clinical governance 192 Pre-procedural considerations 192 Principles of mental capacity assessment 192 Post-procedural considerations 193 Deprivation of Liberty Safeguards (2009) 193 Definition 193 Related theory 193 Clinical governance 195 Pre-procedural considerations 195 Principles relating to deprivation of liberty 195 Post-procedural considerations 195 Mental Health Act (2007)  195 Related theory 195 Evidence-based approaches 197 Pre-procedural considerations 197 Principles of using the Mental Health Act 197 Post-procedural considerations 197 Interface between the Mental Health Act (2007) and the Mental Capacity Act (2005) 198 Related theory 198 References

6 Elimination

199

205

Overview206 Normal elimination Urinary elimination Definition Anatomy and physiology Faecal elimination Definition Anatomy and physiology Assisting patients with elimination Evidence-based approaches Clinical governance Pre-procedural considerations

206 206 206 206 206 206 206 208 208 208 209

Altered urinary elimination Urinary incontinence Related theory Penile sheaths Evidence-based approaches Pre-procedural considerations Urinary catheterization Evidence-based approaches Clinical governance Pre-procedural considerations Suprapubic catheterization Evidence-based approaches Related theory Post-procedural considerations

212 212 212 212 212 213 214 214 215 215 224 224 225 225

Intermittent catheterization Evidence-based approaches Related theory Pre-procedural considerations Catheter-associated complications Bladder irrigation Definition Evidence-based approaches Pre-procedural considerations Post-procedural considerations Nephrostomy tubes and ureteric stents Related theory Evidence-based approaches Clinical governance Pre-procedural considerations Post-procedural considerations and  complications Surgical urinary diversions Definition Evidence-based approaches

ix 225 225 225 225 230 230 230 230 232 235 236 236 236 236 237 237 240 240 240

Altered faecal elimination 243 Diarrhoea243 Definition 243 Related theory 243 Pre-procedural considerations 244 Faecal incontinence 245 Definition 245 Related theory 245 Constipation248 Definition 248 Anatomy and physiology 248 Related theory 248 Evidence-based approaches 248 Pre-procedural considerations 250 Insertion of a nasogastric drainage tube 252 Evidence-based approaches 252 Clinical governance 252 Pre-procedural considerations 252 Enema administration 256 Definition 256 Evidence-based approaches 256 Clinical governance 256 Pre-procedural considerations 256 Suppositories258 Definition 258 Related theory 258 Evidence-based approaches 258 Pre-procedural considerations 259 Digital rectal examination 260 Definition 260 Evidence-based approaches 260 Clinical governance 261 Pre-procedural considerations 261 Digital removal of faeces 262 Definition 262 Related theory 262 Evidence-based approaches 262 Clinical governance 263 Pre-procedural considerations 263 Stoma care Definition Related theory Evidence-based approaches Clinical governance Pre-procedural considerations Pre-procedural assessment and care Post-procedural considerations Complications

264 264 264 267 267 267 270 272 277

References277

x 

Detailed table of contents

7 Moving and positioning

283

Overview284 Moving and positioning: general principles Definition Anatomy and physiology Evidence-based approaches Clinical governance Pre-procedural considerations Prevention of falls Definition Related theory Evidence-based approaches Risk factors Positioning a patient: in bed Evidence-based approaches Positioning a patient: sitting up in bed Evidence-based approaches Positioning a patient: side-lying Evidence-based approaches Moving a patient from sitting to standing Evidence-based approaches Positioning a patient: in a chair or wheelchair Evidence-based approaches Walking Definition Related theory Evidence-based approaches

284 284 284 284 286 286 287 288 288 288 288 289 289 290 290 291 291 293 293 295 295 296 296 296 296

Moving and positioning an unconscious patient Definition Anatomy and physiology Evidence-based approaches

297 297 298 298

Moving and positioning a patient with an artificial airway Definition Evidence-based approaches Clinical governance Pre-procedural considerations Post-procedural considerations

299 299 299 299 299 303

Moving and positioning a patient with respiratory compromise303 Definition303 Anatomy and physiology 303 Evidence-based approaches 303 Positioning a patient to maximize ventilation/perfusion matching303 Anatomy and physiology 303 Evidence-based approaches 304 Positioning a patient to minimize the work of breathing 304 Anatomy and physiology 304 Evidence-based approaches 305 Pre-procedural considerations 305 Positioning a patient to maximize the drainage of secretions 306 Anatomy and physiology 306 Pre-procedural considerations 306 Moving and positioning a patient with neurological impairment307 Definition307 Anatomy and physiology 307 Related theory 310 Evidence-based approaches 311 Positioning a neurological patient with tonal problems in bed 312 Pre-procedural considerations 312 Positioning a neurological patient with tonal problems in a chair 316 Pre-procedural considerations 316

Post-procedural considerations

318

Moving and positioning a patient with actual or suspected spinal cord compression or spinal cord injury Definition Anatomy and physiology Related theory Evidence-based approaches Pre-procedural considerations Post-procedural considerations

320 320 320 320 322 323 329

Moving and positioning a patient with raised intracranial pressure 330 Definition330 Anatomy and physiology 330 Related theory 330 Evidence-based approaches 330 Pre-procedural considerations 331 Moving and positioning a patient with an amputation 331 Definition331 Related theory 331 Evidence-based approaches 331 Pre-procedural considerations 333 Post-procedural considerations 334 Complications 334 References336

8 Nutrition and fluid balance

339

Overview340 Fluid balance Definition Anatomy and physiology Evidence-based approaches Clinical governance Pre-procedural considerations Post-procedural considerations Complications

340 340 340 343 349 350 355 355

Nutritional status 357 Definition357 Anatomy and physiology 357 Related theory 358 Evidence-based approaches 358 Clinical governance 361 Pre-procedural considerations 361 Post-procedural considerations 365 Provision of nutritional support: Oral Evidence-based approaches Clinical governance Pre-procedural considerations Post-procedural considerations

365 365 367 367 370

Nutritional management of patients with  dysphagia371 Definition371 Evidence-based approaches 371 Enteral tube feeding Definition Related theory Evidence-based approaches Pre-procedural considerations Nasogastric tube insertion Evidence-based approaches Clinical governance Pre-procedural considerations Post-procedural considerations

372 372 372 372 372 375 375 375 375 379

Detailed table of contents 

Complications Enteral tube removal Pre-procedural considerations Post-procedural considerations Enteral tube care Evidence-based approaches Percutaneous endoscopically placed gastrostomy (PEG) placement and care Pre-procedural considerations Post-procedural considerations Complications Silicone gastrostomy stoma plugs Definition Administration of enteral tube feed Pre-procedural considerations Post-procedural considerations Complications Enteral feeding tubes: administration of medication Evidence-based approaches Post-procedural considerations

381 381 381 382 382 382

Parenteral nutrition Definition Related theory Evidence-based approaches Post-procedural considerations Complications

395 395 395 395 396 396

References

398

9

Patient comfort and supporting personal hygiene

382 382 387 388 388 388 389 389 391 391 391 391 393

403

Overview404 Personal hygiene Definition Anatomy and physiology Evidence-based approaches Pre-procedural considerations

404 404 404 404 408

Sleep promotion in a hospitalized patient Definition Anatomy and physiology Related theory Evidence-based practice

416 416 416 417 417

Patient environment Related theory Pre-procedural considerations

418 418 419

Eye care Definition Anatomy and physiology Related theory Evidence-based approaches Pre-procedural considerations

423 423 423 425 425 426

Ear care Definition Anatomy and physiology Related theory Evidence-based approaches

433 433 433 434 434

Mouth care Definition Anatomy and physiology Related theory Evidence-based approaches Clinical governance Pre-procedural considerations Post-procedural considerations

437 437 437 438 439 444 444 449

References450

xi

10 Pain assessment and

management457

Overview458 Pain458 Definition 458 Anatomy and physiology 458 Related theory 459 Evidence-based approaches 461 Pre-procedural considerations 465 Pain management Evidence-based approaches Pre-procedural considerations Post-procedural considerations Complications

467 467 469 473 473

Regional analgesia: local anaesthetic nerve blocks and infusions Definition Anatomy, physiology and related theory Evidence-based approaches Clinical governance

473 473 474 474 475

Epidural analgesia Definition Anatomy and physiology Evidence-based approaches Pre-procedural considerations Post-procedural considerations Complications Removal of an epidural catheter Post-procedural considerations

475 475 475 475 478 480 481 481 483

Entonox administration Definition Related theory Evidence-based approaches Clinical governance Pre-procedural considerations Complications

485 485 485 485 486 486 489

Non-pharmacological methods of  managing pain Psychological interventions Physical interventions

489 489 490

References

492

11

Symptom control and care towards the end of life

497

Overview

498

End-of-life care Definition Anatomy and physiology Related theory Evidence-based approaches Clinical governance Pre-procedural considerations

498 498 498 499 499 503 505

Symptom control 516 Dyspnoea (shortness of breath) 516 Definition516 Evidence-based approaches 516 Pre-procedural considerations 517 Nausea and vomiting 518 Definition 518 Anatomy and physiology 519 Related theory 519 Evidence-based approaches 519 Insertion of a nasogastric drainage tube 522

xii 

Detailed table of contents

Ascites522 Definition 522 Anatomy and physiology 522 Related theory 522 Evidence-based approaches 523 Clinical governance 524 Pre-procedural considerations 524 Post-procedural considerations 527 Complications 527 Terminal sedation Definition Evidence-based approaches Pre-procedural considerations

527 527 527 527

Care after death (last offices) Definition Related theory Evidence-based approaches Clinical governance Pre-procedural considerations Post-procedural considerations

528 528 528 529 529 529 534

References535

12 Respiratory care, CPR and

blood transfusion

539

Overview540 Respiratory therapy Definition Anatomy and physiology Evidence-based approaches

540 540 540 542

Oxygen therapy Definition Evidence-based approaches Clinical governance Pre-procedural considerations Post-procedural considerations Complications

543 543 543 544 544 550 552

High-flow oxygen via a nasal cannula Definition Evidence-based approaches

552 552 552

Humidification555 Definition555 Anatomy and physiology 555 Related theory 555 Evidence-based approaches 555 Pre-procedural considerations 555 Non-invasive ventilation 556 Definition556 Related theory 556 Evidence-based approaches 557 Clinical governance 558 Pre-procedural considerations 558 Post-procedural considerations 564 Complications 564 Chest drain management Definition Anatomy and physiology Related theory Chest drain: insertion Evidence-based approaches Clinical governance Pre-procedural considerations Post-procedural considerations Chest drain: suction Evidence-based approaches

564 564 565 565 566 566 567 567 572 574 574

Chest drain: changing the bottle Evidence-based approaches Post-procedural considerations Complications Chest drain removal Evidence-based approaches

576 576 578 579 579 579

Tracheostomy and laryngectomy care 581 Definition 581 Anatomy and physiology 581 Related theory 581 Evidence-based approaches 582 Clinical governance 583 Pre-procedural considerations 583 Tracheostomy: dressing and tube tape or tie change 590 Evidence-based approaches 590 Tracheostomy: suctioning 592 Evidence-based approaches 592 Clinical governance 593 Pre-procedural considerations 593 Complications 595 Tracheostomy: changing an inner cannula 596 Evidence-based approaches 596 Complications 597 Tracheostomy: changing a tube 597 Evidence-based approaches 597 Pre-procedural considerations 598 Complications 600 Tracheostomy: applying a speaking valve 600 Evidence-based approaches 600 Pre-procedural considerations 601 Complications 602 Tracheostomy: decannulation 602 Evidence-based approaches 602 Pre-procedural considerations 603 Complications 605 Tracheostomy: emergency care and recannulation 605 Evidence-based approaches 605 Pre-procedural considerations 605 Laryngectomy608 Related theory 608 Laryngectomy: humidification 608 Evidence-based approaches 608 Laryngectomy: communication 608 Evidence-based approaches 608 Laryngectomy: care and emergency management 609 Evidence-based approaches 609 Basic life support Definition Anatomy and physiology Related theory Evidence-based approaches Clinical governance Pre-procedural considerations Defibrillation Evidence-based approaches Clinical governance Pre-procedural considerations Post-procedural considerations Complications

612 612 612 613 615 615 616 619 619 620 620 625 625

Transfusion of blood and blood components Definition Anatomy and physiology Related theory Evidence-based approaches Clinical governance Pre-procedural considerations Post-procedural considerations Complications: general

626 626 626 626 627 632 637 644 645

Detailed table of contents 

Complications: pulmonary Complications: minor transfusion reactions Complications: major transfusion reactions Complications: delayed transfusion reactions

647 648 648 648

References650

Part Three

Supporting patients through the diagnostic process 13 Diagnostic tests

657

659

Overview660 Diagnostic tests 660 Definition660 Related theory 660 Evidence-based approaches 660 Clinical governance 661 Pre-procedural considerations 662 Post-procedural considerations 663 Blood sampling Definition Evidence-based approaches Pre-procedural considerations

664 664 664 665

Venepuncture: obtaining blood samples from a peripheral vein 667 Definition667 Anatomy and physiology 667 Evidence-based approaches 668 Clinical governance 669 Pre-procedural considerations 669 Post-procedural considerations 676 Complications 676 Blood cultures 677 Definition677 Related theory 677 Evidence-based approaches 677 Clinical governance 677 Pre-procedural considerations 678 Post-procedural considerations 679 Cerebrospinal fluid obtained by lumbar puncture Definition Anatomy and physiology Related theory Evidence-based approaches Post-procedural considerations Complications

679 679 680 680 681 682 682

Specimen collection: swab sampling Definition Related theory Evidence-based approaches Clinical governance Pre-procedural considerations Post-procedural considerations

683 683 683 683 683 683 692

Specimen collection: urine sampling Definition Related theory Evidence-based approaches Pre-procedural considerations Post-procedural considerations

692 692 693 693 693 698

Specimen collection: faecal sampling Definition

698 698

Related theory Evidence-based approaches Pre-procedural considerations Post-procedural considerations

xiii 698 698 698 698

Specimen collection: respiratory tract secretion sampling700 Definition700 Related theory 700 Evidence-based approaches 700 Clinical governance 701 Post-procedural considerations 702 Specimen collection: pleural fluid Definition Anatomy and physiology Related theory Evidence-based approaches

702 702 702 702 702

Endoscopic investigations 702 Definition 702 Gastroscopy702 Definition 702 Anatomy and physiology 703 Evidence-based approaches 703 Clinical governance 703 Pre-procedural considerations 704 Post-procedural considerations 704 Complications 704 Colonoscopy705 Definition705 Anatomy and physiology 705 Evidence-based approaches 705 Clinical governance 705 Pre-procedural considerations 705 Post-procedural considerations 706 Complications 706 Cystoscopy706 Definition706 Anatomy and physiology 706 Evidence-based approaches 707 Pre-procedural considerations 707 Post-procedural considerations 707 Complications 708 Liver biopsy Definition Anatomy and physiology Evidence-based approaches Pre-procedural considerations Post-procedural considerations Complications

708 708 708 708 709 709 709

Radiological investigations: X-ray 710 Definition710 Evidence-based approaches 710 Clinical governance 710 Pre-procedural considerations 710 Magnetic resonance imaging (MRI) 710 Definition710 Evidence-based approaches 710 Pre-procedural considerations 711 Procedure 712 Post-procedural considerations 712 Computed tomography (CT) Definition Evidence-based approaches Pre-procedural considerations Procedure Post-procedural considerations

712 712 712 713 713 713

References714

xiv 

Detailed table of contents

14 Observations

719

Overview720 Observations720 Definition 720 Evidence-based approaches 720 Clinical governance 722 Pre-procedural considerations 723 Pulse (heart rate) Definition Anatomy and physiology Evidence-based approaches Pre-procedural considerations Post-procedural considerations

723 723 723 727 728 730

Electrocardiogram (ECG) 730 Definition730 Anatomy and physiology 730 Evidence-based approaches 731 Clinical governance 733 Pre-procedural considerations 733 Post-procedural considerations 737 Blood pressure Definition Related theory Evidence-based approaches Pre-procedural considerations Post-procedural considerations

738 738 738 740 742 745

Respiration and pulse oximetry Definitions Anatomy and physiology Related theory Evidence-based approaches Pre-procedural considerations Post-procedural considerations Complications

745 745 746 748 750 754 757 757

Peak flow 757 Definition757 Anatomy and physiology 757 Related theory 758 Evidence-based approaches 758 Clinical governance 758 Pre-procedural considerations 758 Post-procedural considerations 761 Temperature762 Definition 762 Anatomy and physiology 762 Related theory 763 Evidence-based approaches 764 Pre-procedural considerations 765 Post-procedural considerations 767 Urinalysis768 Definition 768 Anatomy and physiology 768 Evidence-based approaches 770 Pre-procedural considerations 772 Post-procedural considerations 773 Blood glucose 773 Definition773 Anatomy and physiology 774 Evidence-based approaches 776 Clinical governance 777 Pre-procedural considerations 778 Post-procedural considerations 781 Neurological observations Definition Anatomy and physiology

781 781 781

Related theory Evidence-based approaches Pre-procedural considerations Post-procedural considerations

782 788 788 796

References

796

Part Four

Supporting patients through treatment 15 Medicines optimization:

ensuring quality and safety

801

803

Overview804 Medicines management Definitions Legislation relating to medicines Supply of medicines Key principles for administration of medicines Medication errors: definition and causes Clinical governance

804 804 806 809 811 815 815

Self-administration of medicines Definition Related theory

817 817 817

Controlled drugs Definition Clinical governance Post-procedural considerations

817 817 817 825

Routes of administration Enteral (oral) administration Definition Related theory Evidence-based approaches Pre-procedural considerations Topical administration Definition Related theory Evidence-based approaches Pre-procedural considerations Post-procedural considerations Complications Transdermal (percutaneous) administration Definition Related theory Evidence-based approaches Pre-procedural considerations Post-procedural considerations Complications Rectal administration Definition Related theory Evidence-based approaches Vaginal administration Definition Related theory Evidence-based approaches Pre-procedural considerations Post-procedural considerations Pulmonary administration Definition Related theory Pre-procedural considerations Post-procedural considerations

827 827 827 828 829 830 834 834 834 834 834 836 836 836 836 836 836 836 838 838 838 838 838 838 838 838 839 839 839 840 840 840 840 841 846

Detailed table of contents 

Complications Ophthalmic administration Definition Related theory Evidence-based approaches Pre-procedural considerations Post-procedural considerations Nasal administration Definition Related theory Evidence-based approaches Pre-procedural considerations Post-procedural considerations Otic administration Definition Related theory Evidence-based approaches Pre-procedural considerations Post-procedural considerations

846 846 846 846 846 847 850 850 850 850 850 850 852 852 852 852 852 852 854

Parenteral administration (injections and infusions) Definitions Anatomy and physiology Evidence-based approaches Pre-procedural considerations Pre-procedural considerations Intra-arterial injections and infusions Definition Intra-articular injections and infusions Definition Intrathecal administration of medication Definition Intradermal injection Definition Evidence-based approaches Pre-procedural considerations Subcutaneous injection Definition Related theory Evidence-based approaches Pre-procedural considerations Post-procedural considerations Complications Subcutaneous infusion Definition Evidence-based approaches Pre-procedural considerations Post-procedural considerations Complications Intramuscular injections Definition Evidence-based approaches Pre-procedural considerations Intravenous injections and infusions Definition Anatomy and physiology Related theory Evidence-based approaches Clinical governance Pre-procedural considerations Post-procedural considerations Complications

854 854 854 854 854 857 863 863 863 863 863 863 863 863 863 863 865 865 865 865 866 867 867 867 867 867 868 873 874 874 874 874 875 877 877 877 878 879 880 882 898 898

Peripheral cannulas Definition Anatomy and physiology Evidence-based approaches Clinical governance Pre-procedural considerations Post-procedural considerations Complications

898 898 898 899 901 902 911 914

xv

Infiltration and extravasation Definitions Related theory Evidence-based approaches Clinical governance Pre-procedural considerations Post-procedural considerations Complications

915 915 915 916 918 919 924 925

References

927

16 Perioperative care

937

Overview

938

Pre-operative care Definition Related theory Evidence-based approaches Clinical governance Patient information and education Related theory Evidence-based approaches Consent Definition Evidence-based approaches Clinical governance Physical pre-operative preparation Definition Related theory Mechanical and pharmacological thromboembolism prophylaxis Definition Related theory Pre-operative fasting Definition Related theory Skin preparation Definition Related theory Marking skin for surgery Definition Related theory Pre-operative pregnancy testing Related theory Clinical governance Prevention of toxic shock syndrome from tampon use Definition Related theory Latex sensitivity and allergy Related theory Clinical governance Pre-operative theatre checklist Related theory

938 938 938 938 951 952 952 952 952 952 952 953 953 953 953

Intraoperative care Definition Anaesthesia Definition Evidence-based approaches Clinical governance Pre-procedural considerations Airway management Definition Related theory Theatre Related theory Laparoscopic surgery Definition Related theory Pre-procedural considerations Complications

973 973 973 973 973 975 975 976 976 976 977 977 978 978 978 978 979

954 954 954 961 961 961 961 961 962 962 962 962 963 963 964 964 964 964 964 964 965 965 965

xvi 

Detailed table of contents

Robotic surgery Related theory Clinical governance Endoscopy Definition Related theory Positioning the patient on the table Evidence-based approaches Infection prevention Evidence-based approaches Clinical governance Pre-procedural considerations Post-anaesthetic care unit (PACU) Definition Evidence-based approaches Pre-procedural considerations Post-procedural considerations Complications

979 979 979 980 980 980 982 982 983 983 983 983 992 992 992 992 998 998

Post-operative care 999 Definition 999 Evidence-based approaches 999 Post-operative observations 1000 Evidence-based approaches 1000 Clinical governance 1000 Haemodynamic instability 1000 Related theory 1000 Evidence-based approaches 1000 Ineffective breathing pattern 1001 Related theory 1001 Evidence-based approaches 1001 Fluid balance 1001 Definition1001 Evidence-based approaches 1001 Surgical drains 1001 Definition1001 Related theory 1002 Evidence-based approaches 1002 Surgical wounds 1017 Definition1017 Related theory 1017 Complications 1018 Urinary output and catheters 1020 Related theory 1020 Evidence-based approaches 1020 Bowel function 1020 Related theory 1020 Evidence-based approaches 1020 Nutrition1020 Related theory 1020 Evidence-based approaches 1021 Post-operative pain 1021 Evidence-based approaches 1021 Immobility1021 Related theory 1021 Ongoing care on discharge 1021 Related theory 1021 References1022

17 Wound management

1029

Overview1030 Wounds1030 Definition1030

Anatomy and physiology Related theory Evidence-based approaches Pre-procedural considerations Post-procedural considerations

1030 1032 1042 1042 1043

Pressure ulcers Definition Anatomy and physiology Evidence-based approaches

1043 1043 1044 1044

Surgical wounds 1053 Definition1053 Evidence-based approaches 1053 Removal of sutures or clips 1053 Evidence-based approaches 1053 Pre-procedural considerations 1053 Post-procedural considerations 1055 Negative pressure wound therapy 1055 Definition1055 Evidence-based approaches 1055 Pre-procedural considerations 1056 Post-procedural considerations 1057 References1058

Part Five

Looking after ourselves so we can support patients  18 Self-care and wellbeing

1061

1063

Overview1064 Self-care and wellbeing Definitions Related theory Evidence-based approaches

1064 1064 1064 1069

Mindfulness1072 Definition 1072 Related theory  1072 Evidence-based approaches 1072 Pre-procedural considerations 1073 Problem solving 1073 Eating and drinking Related theory Evidence-based approaches

1073 1073 1074

Physical wellbeing and musculoskeletal health1077 Related theory 1077 Evidence-based approaches 1077 Post-procedural considerations 1081 References1081 Appendix: Standards of Proficiency for Registered Nurses List of abbreviations Index

1085 1089 1093

Foreword I

t is my great pleasure as the Acting Chief Nurse of The Royal Marsden NHS Foundation Trust to introduce the tenth Student Edition of The Royal Marsden Manual of Clinical Nursing Procedures. As a Royal Marsden cancer trained nurse, a contributor and a clinical user of the manual for many years, I am honoured to have been asked to introduce this edition. The manual is internationally renowned and used by nurses across the world to ensure their practice is evidence based and effective. It is essential that we are able to critically analyse our judgements in the light of current knowledge. For all of us working with patients and their families or significant others, there is an imperative to question and renew our practice using the many sources of knowledge available to us. In the busy world of clinical practice in a ward or unit, or in the community, it can be challenging to find time to search for the evidence and this is where the Student Edition of The Royal Marsden Manual of Clinical Nursing Procedures is a real practical help. As in the ninth edition, reviewing the evidence or sources of knowledge has been made explicit, with each level of evidence graded. This grading provides the reader with an understanding of whether the reference comes from a randomized controlled trial, national or international guidance, or expert opinion. Nursing care in any setting is a combination of sensitive therapeutic relationships coupled with effective clinical care based on the best evidence that exists. Some areas of practice have attracted international research, such as cardiopulmonary resuscitation and infection prevention and control; other areas of practice have not attracted such robust research and therefore it is more of a challenge to ensure evidence-based care. Each time a new edition of the manual is prepared, we reflect on the gaps in research and knowledge; this provides the impetus to develop new concept analyses and further research studies. As student nurses, you will continue to build upon your skills and knowledge and become contributors to new evidence-based care and practice. This new Student Edition incorporates a breadth of tools to support your learning, including objectives at the beginning of each chapter and a variety of learning activities that will either test your knowledge or prompt you to consider how you may

apply what you are learning in practice. In addition, the procedures were tried out by the student nurses at King’s College London while on placement at the hospital to ensure they worked in practice. As you look at the list of contributors to the manual, you will see that this edition has continued to be written by nurses who are experts and active in clinical practice. This has the double advantage of ensuring that this manual reflects the reality of practice and ensuring that nurses at The Royal Marsden NHS Foundation Trust are frequently reviewing the evidence and reflecting upon the care they provide. A textbook devoted to improving and enhancing clinical practice needs to be alive to the clinical practitioner. You will see that this edition has continued the improvements made to the format in recent editions, including many more figures and photographs to make the manual more effective in clinical care. As I commend this tenth Student Edition of The Royal Marsden Manual of Clinical Nursing Procedures to you, I am aware that it will be used in many different countries and settings. Having had the privilege of visiting and meeting nurses across the world, I know that there are more commonalities than differences between us. The common theme is, of course, the need to ensure that we as nurses provide personalized care that is sensitively planned and that it is based on the best available evidence. The Student Edition of The Royal Marsden Manual of Clinical Nursing Procedures is a wonderful resource for such evidence and I hope it will be widely used in all clinical settings across the world. Finally, I would like to congratulate the editors, Sara Lister, Justine Hofland, Hayley Grafton and particularly Catherine Wilson, for their excellent work preparing this edition. I would also like to thank all the nurses and allied health professionals at The Royal Marsden Hospital who have worked so hard on this tenth edition. Mr Andrew Dimech Acting Chief Nurse The Royal Marsden NHS Foundation Trust

THE ROYAL MARSDEN MANUAL OF CLINICAL NURSING PROCEDURES

Acknowledgements W

riting a textbook of such breadth and complexity as this is never the task of only a few. Over a hundred healthcare professionals who either work for or are associated with The Royal Marsden NHS Foundation Trust have contributed to updating the content of the tenth edition of The Royal Marsden Manual of Clinical Nursing Procedures. Our thanks go to them for their contribution, particularly for making the time to research and write outside their clinical roles. Dr Catherine Wilson has taken the Professional Edition of The Royal Marsden Manual of Clinical Nursing Procedures and transformed it into an essential interactive learning resource for student nurses at any point in their training. The other three editors are grateful for the educational and nursing expertise that she has generously given to the production of this edition  –  it has been invaluable. Our sincere thanks also go to Julia Hubbard, Professor of Clinical Health Education, and Dr Jane Blowers, Senior Lecturer and Professional Lead for Pre-registration Nursing, both at the School of Health Sciences, University of East Anglia, who advised and gave guidance on the content of the revised student nurse curriculum to reflect the Nursing and

Midwifery Council’s Future Nurse: Standards of Proficiency for Registered Nurses (2018). We acknowledge The Royal Marsden NHS Foundation Trust as an organization. The trust’s ongoing commitment to excellence in every aspect of patient care is evident in its continued support of this project, which has now been going for over 30 years. Our continued thanks go to our publisher, John Wiley & Sons, and specifically to Magenta Styles, who has continually championed the manual and guided us to produce a textbook that meets the needs of today’s student nurses. Thanks also to Alison Nick, our project editor, and to Hazel Bird, copy editor, who both have been supportive, and whose intelligent and thoughtful attention to detail has been nothing short of phenomenal. Finally, we acknowledge the role of our clinical colleagues, our student nurses, and our former patients and their families and friends, who have shaped our thinking and from whom we have learned so much. Sara Lister, Justine Hofland and Hayley Grafton with Catherine Wilson Editors

List of contributors Chapter 1 The context of nursing Sara Lister RN, BSc (Hons), PGDAE, MSc, Dip, MA, MBACP Head of Pastoral Care and Psychological Support

Chapter 2 Admissions and assessment

Jennie Baxter BSc (Hons), MSc, CPsychol Counselling Psychologist Lauren Blackburn BSc Occupational Therapist

Lorraine Guinan RN, INP, ANP, BSc (Hons), MSc Formerly Advanced Nurse Practitioner, Head and Neck

Jill Cooper MBE, MSc, Dip COT Formerly Head Occupational Therapist

Victoria Ward RN, INP, ANP, BN (Hons), MSc Transformation Project Manager

Edwina Curtis BA, BSW Head of Adult Safeguarding

Elizabeth Hendry RN, BN (Hons), PG Dip Formerly Ward Sister

Lisa Dvorjetz BSc (Hons), DPsych Counselling Psychologist

Emma Masters RN, BSc, MSc Formerly Advanced Nurse Practitioner, Teenage and Young Adults

Linda Finn RSCN, RHV Named Nurse Children and Adult Safeguarding

Andrew Rayner RN, BSc (Hons), INP, PG Dip Divisional Clinical Nurse Director, Clinical Services

Danielle Gaynor DClinPsych Family Specialty Clinical Psychologist

Emma Thistlethwayte RN, BSc (Hons) Transplant Clinical Nurse Specialist, Teenage and Young Adult

Beverley Henderson RN, BSc (Hons), PG Dip Clinical Nurse Specialist, Psychological Support

Manuela Trofor RN, MSc Matron, Medical Day Unit

Charmaine Jagger BSc (Hons) Highly Specialist Speech and Language Therapist

Charlotte Weston RN, BSc (Hons), MSc Formerly Lead Nurse, Teenage and Young Adults

Lucy Keating RMN BMedsci Psychiatric Liaison Team Manager, Central and North West London NHS Foundation Trust

Claire White RN, BSc (Hons) Acting Matron, Cancer Services

Chapter 3 Discharge care and planning Caroline Watts RN, BSc (Hons), PG Dip, MSc, INP, ANP Nurse Lead for Transformation Emma Collard PG Cert, BSc (Hons), Dip HE Matron, Palliative Care Connie Lewis CQSW Discharge Lead

Chapter 4 Infection prevention and control Pat Cattini RN, MSc Lead Nurse and Deputy Director, Infection Prevention and Control Martin Kiernan RN, ENB 329, MPH Visiting Clinical Fellow, Richard Wells Research Centre, University of West London, and Director of Clinical Research and Education, GAMA Healthcare

Chapter 5 Communication, psychological wellbeing and safeguarding Justin Grayer BSc, PG Dip, DClinPsych Consultant Clinical Psychologist and Lead for Adult Psychological Support Team

Lauren Leigh-Doyle BSc (Hons) Highly Specialist Speech and Language Therapist Sara Lister RN, BSc (Hons), PGDAE, MSc, Dip, MA, MBACP Head of Pastoral Care and Psychological Support Raj Mathiah RN, BSc Clinical Nurse Specialist Liaison, Psychiatry and Adult Psychological Support Asim Mohammed MBBS, Psych Med, Dip HE Locum Consultant Psychiatrist, Adult Psychological Support Service

Chapter 6 Elimination Rebecca Martin MSc, BSc (Hons), RN, INP Urology Lead Nurse and Advanced Nurse Practitioner Gemma Allen BSc (Hons), PG Cert, PG Dip Practice Educator in Critical Care Katy Hardy BSc (Hons), RN, NIP Colorectal Clinical Nurse Specialist Claire McNally RN, BSC (Hons) Uro-oncology Clinical Nurse Specialist

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List of contributors

Jacqueline McPhail RN, PG Cert, Dip M, ENB 338 Stoma Care Clinical Nurse Specialist

Farzana Carvalho RN, BSc (Hons), MSc Clinical Nurse Specialist, Pain Management

Bradley Russell MSc, BSc (Hons), RN, SCP Urology Surgical Care Practitioner

Caroline Dinen RN, BSc (Hons) Clinical Nurse Specialist, Pain Management

Laura Theodossy PG Dip, RN Lecturer Practitioner

Chapter 11 Symptom control and care towards the end of life

Chapter 7 Moving and positioning Carolyn Moore MCSP Formerly Superintendent Physiotherapist

Anna-Marie Stevens RN, DClinP, MSc, BSc (Hons), Certificate in Oncology Nurse Consultant, Palliative Care

Jill Cooper MBE, MSc, Dip COT Formerly Head Occupational Therapist

Anne Doerr BA Chaplain

Siobhan Cowan-Dickie MCSP, BSc (Hons), MSc Clinical Specialist Physiotherapist Living with and Beyond Cancer

Alistair McCulloch MA Lead Chaplain

Lucy Dean BSc (Hons), MCSP Physiotherapist, Sarcoma Lead Joanne Jethwa BSc (Hons), MCSP Specialist Physiotherapist in Neuro-oncology and Complex Rehabilitation Jessica Whibley BSc (Hons), MCSP Physiotherapist Respiratory Lead Leanne Williams BSc (Hons), MSc, MCSP Clinical Specialist Physiotherapist, Neuro-oncology and Complex Rehabilitation

Chapter 8 Nutrition and fluid balance Clare Shaw BSc (Hons), PG Dip, PhD Consultant Dietitian Laura Askins BSc, PG Dip Formerly Senior Specialist Dietitian Grainne Brady BSc (Hons), MRes Clinical Lead Speech and Language Therapist Lucy Eldridge BSc (Hons), MSc Head of Nutrition and Dietetics Olivia Kate Smith BSc (Hons) Formerly Senior Specialist Dietitian Laura Theodossy PG Dip, RN Lecturer Practitioner Heather Thexton RN, BSc (Hons) Senior Staff Nurse, Critical Care Unit

Chapter 9 Patient comfort and supporting personal hygiene Suzanna Argenio-Haines RN, BA (Hons), Dip Practice Educator, Clinical Education Team Helena Aparecida de Rezende RN, PG Cert, MSc Formerly Practice Educator, Clinical Education Team Rhiannon Llewelyn, RN, BN (Hons) Staff Nurse, Critical Care Unit

Chapter 10 Pain assessment and management Suzanne Chapman RN, BSc (Hons), MSc Clinical Nurse Specialist, Pain Management

Pedro Mendes BSc, RN Lead Nurse, Interventional Radiology Jodie Rawlings RN, BN Formerly Senior Staff Nurse, Critical Care Unit Laura Theodossy PG Dip, RN Lecturer Practitioner

Chapter 12 Respiratory care, CPR and blood transfusion Louise Davison Dip HE, BN, RN Matron, Acute Oncology Service, Clinical Assessment Unit and Royal Marsden Macmillan Hotline Wendy McSporran RN, BSc (Hons), PG Dip Advanced Transfusion Practitioner Grainne Brady BSc (Hons), MRes Clinical Lead Speech and Language Therapist Catherine Forsythe Dip HE, BSc (Hons), RN Practice Educator, Critical Care Unit Olivia Ratcliffe RN, BSc, MSc Formerly Lead Nurse, Sepsis and Acute Kidney Injury

Chapter 13 Diagnostic tests Andrew Dimech RN, BN, MSc, Dip Deputy Chief Nurse Andreia Fernandes RN, BSc, MSc Clinical Nurse Specialist Gynaecology Oncology Firza Gronthoud MD, MRCPath Formerly Consultant Microbiologist Lilian Li BSc (Hons), MSc, IPresc Lead Antimicrobial Pharmacist Barbara Witt RN Nurse Phlebotomist

Chapter 14 Observations Filipe Carvalho RN, BSc (Hons), PG Dip, MSc, INP Advanced Nurse Practitioner in Colorectal Surgery Emma-Claire Breen RN, BSc (Hons) Senior Staff Nurse and Clinical Practice Facilitator, Critical Care Unit

List of contributors 

Zoë Bullock RN, BSc (Hons), PG Dip, PG Cert Formerly Senior Staff Nurse and Practice Education Facilitator, Critical Care Unit Sonya Hussein RN, BSc (Hons) Senior Staff Nurse and Clinical Practice Facilitator, Critical Care Unit Elodie Malard RN Sister, Critical Care Unit Yara Osman De Oliveira RN, BSc (Hons) Sister, Critical Care Unit Marie Parsons RN, BSc (Hons), PG Dip Senior Staff Nurse and Clinical Practice Facilitator, Critical Care Unit Heather Thexton RN, BSc (Hons) Senior Staff Nurse, Critical Care Unit

Chapter 15 Medicines optimization: ensuring quality and safety Lisa Barrott RN, BSc (Hons), MSc Formerly Chemotherapy Nurse Consultant Emma Foreman MRPharmS, MSc, IPresc, BSc (Hons) Consultant Pharmacist Jatinder Harchowal MRPharmS, MSc, BPharm (Hons) Chief Pharmacist and Clinical Director Kulpna Daya Reg Pharm Tech, MSc, Dip Pharmacy Operation Manager and Education & Development Technician Lisa Dougherty OBE, RN, MSc, DClinP Formerly editor of The Royal Marsden Manual of Clinical Nursing Procedures and Nurse Consultant Lorraine Hyde RN, ONC, BSc (Hons) Matron/Lead Nurse, Medical Day Unit Gema Munoz-Mozas RN, ONC, BSc (Hons), MSc Lead Vascular Access Nurse Hannah Overland RN, BSc (Hons), MSc Matron/Lead Nurse, Medical Day Unit Suraya Quadir MRPharmS, MBA, MSc, BPharm (Hons) Lead Pharmacist, Governance and Education & Training/ Medication Safety Officer

Chapter 16 Perioperative care Justine Hofland RN, BSc (Hons), ANP, MSc, PG Dip, ILM Level 5 Formerly Divisional Clinical Nurse Director, Cancer Services Hayley Grafton RN, BSc (Hons), CPPD ITU Chief Nursing Information Officer Pascale Gruber MBBS, MSc, FRCA, MRCP, FFICM, EDIC Consultant in Anaesthesia and Intensive Care Medicine, and Clinical Director, Surgery and Inpatients Tina Kitcher RN, Dip Practice Educator and Theatre Sister Lian Lee RN, BSc, MSc, AdvDip OT Nurg Matron, Theatres and Endoscopy

xxi

Chapter 17 Wound management Jenni MacDonald BSc (Hons), RN, BSc TVN, MSc, PGCert Formerly Lead Nurse, Tissue Viability and Harm Free Care Kumal Rajpaul MSc, BSC (Hons), Dip HE, RN Assistant Director of Nursing and Patient Experience, Hounslow and Richmond Community NHS Trust

Chapter 18 Self-care and wellbeing Sara Lister RN, BSc (Hons), PGDAE, MSc, Dip, MA, MBACP Head of Pastoral Care and Psychological Support Lorraine Bishop MSc, Dip, Dip MBCT Formerly Staff Counsellor and Psychotherapist Lucy Eldridge BSc (Hons), MSc Dietetic Team Leader Jayne Ellis RN, BSc (Hons) Managing Director, EF Training Tracey Shepherd MSc, MCSP, SRP Moving and Handling Practitioner, Health Ergonomics Consultancy Ltd Sara Wright DCR(r), BSc (Hons) Freelance Moving and Handing Practitioner

Additional contributors

The authors and John Wiley & Sons are hugely grateful to the following staff and students for their help in the development of this edition. The Nursing and Midwifery Clinical Practice Council at Oxford University Trust were very generous with their time and feedback on the content of the ninth edition of The Royal Marsden Manual of Clinical Nursing Procedures. This informed the changes and additions we made for the tenth edition as well as confirming for us what should remain. We would like to extend a large thank-you to them. We would like to thank the following student nurses and nursing staff who helped to ‘test’ the revised procedures: Student nurses (King’s College London)

Practice educators (Royal Marsden NHS Foundation Trust)

Ade Ajayi Ciara Doogan Rebecca Ellis Jodie Fowler Terrie Gemal Rianna Norman Filipa Santos Amber Simon

Sue Argenio-Haines Catherine Forsythe Rathai Kanagendram

For the first time, the online version will include videos of some of the procedures. Hayley Grafton led the production of these videos with assistance from the following staff at The Royal Marsden NHS Foundation Trust: Jackson Young from the Marketing and Communications Team And the following clinical staff: Sue Argenio-Haines Zoë Bullock Lala Dizon Catherine Forsythe Ali Hill Sara Lister Jenni Macdonald

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List of contributors

Rebecca Martin Lorraine McHugh, who was a fabulous volunteer patient Clare McNally Pedro Mendes Amber Simon (student nurse) Short Form Film were a great company to work with and we would like to thank them for their flexibility and patience.

Finally, special mention and sincere thanks to Julia Hubbard, Professor of Clinical Health Education, and Dr Jane Blowers, Senior Lecturer and Professional Lead for Pre-registration Nursing, both at the School of Health Sciences, University of East Anglia, who advised and gave guidance on the content of the revised student nurse curriculum to reflect the Nursing and Midwifery Council’s Future Nurse: Standards of Proficiency for Registered Nurses (2018).

Quick reference to the procedure guidelines F

or more information on personal protective equipment (specified as the first item in the procedure guideline equipment lists where relevant), see page 92 in Chapter 4: Infection prevention and control.

Abdominal examination 41 Abdominal paracentesis 525 Application of a two-piece cervical collar 323 Applying and removing a disposable apron 96 Artificial eye care: insertion 429 Artificial eye care: removal 430 Aseptic technique example: changing a wound dressing 108 Assisting a patient to walk 296 Basic life support 622 Bedbathing a patient 409 Blood component administration 641 Blood components: collection and delivery to the clinical area 639 Blood cultures: peripheral (winged device collection method)678 Blood glucose monitoring 778 Blood pressure measurement (manual) 743 Blood product request 639 Cardiovascular examination 37 Care after death 530 Care of a patient who is vomiting 521 Caring for the patient in the anaesthetic room 976 Carrying out clinical procedures in a seated posture (e.g. cannulation) 1080 Changing the balloon water and checking the volume of a balloon gastrostomy 386 Chest drain: assisting insertion 570 Chest drain: changing the bottle 576 Chest drain: removal 579 Chest drainage: suction 575 Cleaning a hard surface without recontamination 119 Clip removal 1054 Closed drainage systems: changing a vacuum bottle 1005 Commencing bladder irrigation 233 Commode use: assisting a patient 211 Contact lens removal: hard lenses 430 Contact lens removal: soft lenses 431 Continent urinary diversion stoma: self-catheterization 242 Continuous positive airway pressure (CPAP) 561 Digital rectal examination 261 Digital removal of faeces 263 Donning a sterile gown and gloves: closed technique 103 Donning sterile gloves: open technique 100 Drainage systems: changing the dressing around the drain site for both open and closed drains 1004 Dressing a wound 1042 Early mobilization of a patient with spinal considerations328 Electrocardiogram (ECG) 735 Enema administration 257 Enteral feeding tubes: administration of feed using an enteral feeding pump 389 Enteral feeding tubes: administration of medication 392 Enteral feeding tubes: unblocking 394

Entonox administration 487 Epidural exit site dressing change 480 Epidural sensory blockade: assessment 478 Extravasation management: peripheral cannula 922 Eye irrigation 428 Eye swabbing 427 Faecal sampling 699 Feeding an adult patient 369 Fluid input: measurement 350 Fluid output: monitoring/measuring output from bowels353 Fluid output: monitoring/measuring output from drains 352 Fluid output: monitoring/measuring output from gastric outlets, nasogastric tubes or gastrostomy 353 Fluid output: monitoring/measuring output from stoma sites 354 Fluid output: monitoring/measuring output if the patient is catheterized 350 Fluid output: monitoring/measuring output if the patient is not catheterized 351 Hand decontamination using an alcohol-based handrub 85 Hand washing 84 Handover in the post-anaesthetic care unit (PACU): scrub nurse or operating department practitioner to recovery practitioner 994 High-flow oxygen therapy 553 Insertion of a faecal management system 246 Insertion of a nasogastric drainage tube 254 Insertion of an oropharyngeal airway 621 Insertion of a silicone gastrostomy stoma plug 388 Irrigation of the external auditory canal using an electronic irrigator 435 Jejunostomy feeding tube care including dressing change387 Laryngectomy care 610 Log rolling a patient with suspected or confirmed cervical spinal instability (above T6) 325 Log rolling a patient with suspected or confirmed thoracolumbar spinal instability (T7 and below) 326 Lumbar puncture: care of the patient post-procedure 681 Making an occupied bed 421 Making an unoccupied bed 419 Management of dyspnoea (breathlessness) 517 Measuring and applying antiembolic stockings 959 Measuring the weight and height of a patient 362 Medication: administration by inhalation using a metered dose or dry powder inhaler 843 Medication: administration by inhalation using a nebulizer 844 Medication: continuous infusion of intravenous drugs 889 Medication: controlled drug administration 825 Medication: ear drop administration 852 Medication: eye administration 849 Medication: injection (bolus or push) of intravenous drugs 894 Medication: injection administration 862

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Quick reference to the procedure guidelines

Medication: intermittent infusion of intravenous drugs Medication: intradermal injection Medication: intramuscular injection Medication: multidose vial: powder preparation using a venting needle Medication: multidose vial: powder preparation using the equilibrium method Medication: nasal drop administration Medication: oral drug administration Medication: single-dose ampoule: powder preparation Medication: single-dose ampoule: solution preparation Medication: subcutaneous administration using a CME Medical T34 syringe pump (previously McKinley) Medication: subcutaneous infusion of fluids Medication: subcutaneous injection Medication: topical applications Medication: transdermal applications Medication: vaginal administration Mouth care Mouth care for a patient with dentures Moving a patient from sitting to standing: assisting the patient Nasogastric intubation with tubes using an internal guidewire or stylet Negative pressure wound therapy Nephrostomy tube: weekly dressing and bag change and sample collection Neurological observations and assessment Obtaining a clean-catch urine sample from an ileal conduit Operating theatre procedure: maintaining the safety of a patient during surgery Oxygen therapy Pain assessment Peak flow reading using a manual peak flow meter Penile sheath application Percutaneous endoscopically placed gastrostomy (PEG) tube ongoing care Peripheral cannula insertion Positioning a neurological patient with tonal problems in a chair Positioning a neurological patient with tonal problems in bed Positioning a patient: in a chair or wheelchair Positioning a patient: lying down to sitting up Positioning a patient: side-lying Positioning a patient: sitting up in bed Positioning a patient: supine Positioning a patient with an amputation Positioning an unconscious patient or a patient with an artificial airway in side-lying Positioning an unconscious patient or a patient with an artificial airway in supine Pre-operative care: checking that the patient is fully prepared for surgery Protective isolation: entering an isolation room Protective isolation: preparing an isolation room Pulse measurement Putting on and removing a disposable mask or respirator Putting on and removing non-sterile gloves Putting on or removing goggles or a face-shield Radiologically inserted gastrostomy (RIG) tube care Removal of a nasogastric drainage tube

891 863 876 859 861 851 832 858 857 870 869 866 835 837 839 446 448 293 376 1056 237 793 271 989 547 466 760 213 382 905 317 314 295 292 291 290 289 333 301 300 971 117 116 728 98 93 99 384 255

Removal of a nasogastric feeding tube 381 Removal of T-fasteners 385 Respiratory assessment and pulse oximetry 755 Respiratory examination 32 Safe disposal of foul, infected or infested linen 124 Safe management of patients in the post-operative care unit (PACU) 994 Shaving the face: dry electric shaver 415 Shaving the face: wet shave 414 Slipper bedpan use: assisting a patient 209 Source isolation: entering an isolation room 113 Source isolation: leaving an isolation room 114 Source isolation: preparing an isolation room 112 Source isolation: transporting infected patients outside a source isolation area 115 Sputum sampling 701 Stoma bag change 270 Suppository administration 259 Surgical scrub technique using an alcohol-based handrub89 Surgical scrub technique using soap and water 87 Suture removal 1053 Swab sampling: ear 684 Swab sampling: eye 685 Swab sampling: nose 685 Swab sampling: penis 687 Swab sampling: rectum 687 Swab sampling: skin 688 Swab sampling: throat 689 Swab sampling: vagina 690 Swab sampling: wound 691 Terminal sedation 527 Tracheostomy: changing a tube 598 Tracheostomy: changing an inner cannula 596 Tracheostomy: decannulation 603 Tracheostomy: dressing and tube tape/tie change 591 Tracheostomy: emergency management 605 Tracheostomy: insertion and removal of a speaking valve 601 Tracheostomy: suctioning a patient (single-use suction catheter) 594 Tympanic temperature measurement 766 Urinalysis: reagent strip 772 Urinary catheter bag: emptying 228 Urinary catheter removal 229 Urinary catheterization: female 221 Urinary catheterization: intermittent self-catheterization patient guidance: male 226 Urinary catheterization: intermittent self-catheterization patient guidance: female 227 Urinary catheterization: male 219 Urine sampling: 24-hour urine collection 697 Urine sampling: catheter specimen of urine 695 Urine sampling: midstream specimen of urine: female 694 Urine sampling: midstream specimen of urine: male 693 Urine sampling: sampling from an ileal conduit 696 Venepuncture671 Washing a patient’s hair in bed 412 Working at low or floor level 1079 Working in a seated position: office work 1080 Working with a patient lying in a bed or on another raised supportive surface 1079 Wound drain removal: closed drainage system 1007 Wound drain shortening for closed drainage systems 1011 Wound drain shortening for open drainage systems 1009

How to use your manual Features contained within your manual The overview pages give summaries of the topics covered in each part.

Part Two Supporting patients withhuman functioning

Elimination Rebecca Martin with Gemma Allen, Katy Hardy, Claire McNally, Jacqueline McPhail, Bradley Russell and Laura Theodossy

11 Symptom control and care towards the end of life 499

8 Nutrition and fluid balance 341

12 Respiratory care, CPR and blood transfusion 541

CATHETER NEPHROSTOMY SUPPOSITORY

ELIMINATION NASOGASTRIC DIARRHOEA URINARY

Procedure guidelines

FAECAL

10 Pain assessment and management 459

7 Moving and positioning 285

BEDPAN

6 Elimination 205

BLADDER STOMA

9 Patient comfort and supporting personal hygiene 405

ENEMA COMMODE

5 Communication, psychological wellbeing and safeguarding 133

Every chapter begins with a set of learning outcomes, which gives a summary of the topics covered in the chapter. Next there is a list of procedures found within the chapter.

6

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How to use your manual

The Standards of Proficiency for Registered Nurses (NMC 2019) list the knowledge, skills and behaviours that every nurse must have. Each chapter relates to different proficiencies, so the relevant ones are listed in the being an accountable professional sections. THE ROYAL MARSDEN MANUAL OF CLINICAL NURSING PROCEDURES

Being anaccountable professional At the point of registration, the nurse will: 2. Use evidence-based, best practice approaches to undertake the following procedures: 2.1 take, record and interpret vital signs manually and via technological devices 2.3 set up and manage routine electrocardiogram (ECG) investigations and interpret normal and commonly encountered abnormal traces 2.5 manage and interpret cardiac monitors, infusion pumps, blood glucose monitors and other monitoring devices

Overview

T

his chapter discusses the following observations: pulse, electrocardiogram (ECG), blood pressure, respiration, pulse oximetry, peak flow, temperature, urinalysis, blood glucose and neurological observations. For each observation discussed, the chapter provides a definition, a rationale, a summary of governance and professional issues, a procedure guideline and a guide to problem solving.

2.7

undertake a whole body systems assessment including respiratory, circulatory, neurological, musculoskeletal, cardiovascular and skin status 2.10 measure and interpret blood glucose levels 2.12 undertake, respond to and interpret neurological observations and assessments 2.13 identify and respond to signs of deterioration and sepsis Future Nurse: Standards of Proficiency for Registered Nurses (NMC 2018)

• a clearly documented plan that identifies which observations should be taken and how frequently, taking into consideration the diagnosis, the patient’s treatment plan and any co-morbidities • observations taken at least once every 12 hours, unless specified otherwise by senior staff or the patient’s medical team (NICE2018).

National Early Warning Score andstandardizing communication

Observations DEFINITION

The term ‘observation’ refers to the physical assessment of a patient, which in addition to vital signs and specialized assessments (such as neurological observations) includes a review of wounds, intravenous therapy, wound drains and pain (Adam etal. 2017, Sprigings and Chambers2017) (note that the latter topics are discussed elsewhere in this manual). The term ‘vital signs’ is traditionally used in the context of the collection of a cluster of physical measurements, such as pulse, respiration rate, temperature, blood pressure, pulse oximetry and more recently level of consciousness (Jarvis etal. 2015).

EVIDENCE-BASED APPROACHES

Rationale

The taking of patient observations forms a fundamental part of the assessment process (Churpek etal. 2017; see also Chapter2: Admissions and assessment). The findings and results will help to determine the level of care a patient requires and to establish whether an intervention is needed to prevent the patient deteriorating (Uppanisakorn etal. 2018).

Indications

Observations are usually undertaken:

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• to act as a baseline and to help determine a patient’s usual range (Bickley2016) • to assist in recognizing whether a patient’s condition is deteriorating or improving (Keep etal. 2016) • to assess the effectiveness of interventions (Hodgson et al. 2017).

Principles ofcare

Adult patients in acute hospital settings should have: • observations taken when they are admitted or initially assessed (including on transfer from one ward or area to another)

Caring for acutely unwell patients can be daunting and challenging; however, early detection of changes in observations helps to identify patients who are at risk of clinical deterioration. Early detection may provide an opportunity to intervene and avoid further deterioration (Adam etal. 2017, Tait etal. 2015). Various early warning scores have been created and used across UK hospitals to assist with the identification of critically ill patients and improve patient safety (Farenden etal. 2017). However, in 2012, and with the view of facilitating a standardized approach, the Royal College of Physicians (RCP) introduced a physiological scoring system called the National Early Warning Score (NEWS). This simple scoring system relies on healthcare staff performing patient observations (respiratory rate, heart rate, blood pressure, peripheral oxygen saturation, temperature and fluid balance) and informing medical staff and/or critical outreach teams of deviations from the norm (Keep etal. 2016). The total score helps to identify not just patients who are at risk and require immediate assessment but also those who are being safely managed, supporting clinical decision making and improving patient outcomes (NICE2018). More recently, in December 2017, the RCP updated its 2012 NEWS and published NEWS2 (Figure 14.1) with the aim of improving the recognition of clinical deterioration in adults due to sepsis and hypercapnic respiratory failure (NICE 2018). The updated version now includes a new oxygen saturation scoring system for such patients and recognizes the patient’s level of consciousness as an important sign of clinical deterioration (RCP 2017a). A final score of 5 or more identifies patients who require further assessment and early intervention, and this can help to prevent further clinical deterioration and potentially death (NICE2018). Once a patient ‘triggers’, they are usually referred to critical care outreach teams or medical emergency teams, who are available in most hospitals to provide support to staff, assess the patient, initiate any required interventions, and avert or assist in critical care admissions (NICE2018, RCP 2017a). The use of NEWS has been shown to help nurses improve and focus their recognition of patients who may need further support and monitoring; therefore, it is important that time is taken to accurately calculate the score and act accordingly (Adam et al.

Chapters 2–17 each contain multiple learning activities: • Learning into practice asks you to consider issues within your practice environment. • Case studies provide learning around a particular patient case. • Clinical applications ask you to consider how you would apply your knowledge to a clinical situation. • Stretch activities are primarily for more senior students. These activities include more nuanced, advanced issues to consider, learn more about and reflect upon.

Learning Activity 2.1 Learning into practice 1 Is there a model of nursing or care underlying the format and structure for patient admissions in your clinical area? What is it? 2 Critically appraise how it affects the assessment process. 3 Reflect on your daily practice and identify whether you are carrying out the types of assessment identified in Box2.2. 4 Consider the rationales for and the pros and cons of these different types of assessment.

Learning Activity 2.5 Case study What would you expect to find in relation to the following issues, on initial examination of Angus McKay (see Learning Activity 2.3)? Remember that Angus has presented with shortness of breath and a productive cough. Initial investigations suggest he has pneumonia. 1 Respiratory rate 2 Respiratory rhythm 3 Respiratory effort 4 Cyanosis 5 Sputum See the answers on the companion site of this student edition: www.royalmarsdenmanual.com/student10e.

Learning Activity 2.4 Clinical application Try to observe at least five different people carrying out clinical assessments of patients in your clinical area. As you do this: • Note their questioning technique, and observe and listen to the patients’ responses. • Ask the professionals to explain their thinking and rationale for their history-taking and clinical-assessment practice. • Discuss with them their impressions, decisions and diagnoses arising from their clinical assessment. Then write a reflective account of one observed assessment, identifying your learning and what skills or techniques you would adopt as a result of the observation and use in the future.

How to use your manual 

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Stretch Activity Further your thinking and learning about clinical practice Identify which tools are in use to support nursing assessment of patients on admission to your clinical area (e.g. nutrition assessment tool, pressure ulcer risk tool, frailty tool, oral health tool, falls assessment tool, or bowel or stool assessment tool). 1 Ask your tutor or supervisor whether alternative assessment tools have been developed (e.g. for pressure ulcers, consider the Waterlow Score, the Braden Risk Assessment tool or PURPOSE-T). 2 Source a small range of tools related to a specific nursing assessment. 3 Find relevant literature about the tools’ development and critically read published evidence about their eff ectiveness. 4 Critically evaluate and compare the tools, identifying the advantages and disadvantages of each. 5 Discuss your findings with your tutor and supervisor.

Your manual is full of photographs, illustrations and tables.

The website icon indicates that you can find more learning exercises on a topic by visiting the companion website: www.royalmarsdenmanual.com/ student10e.

About the companion website

Don’t forget to visit the companion website for this book:

www.royalmarsdenmanual.com/student10e

There you will find valuable material designed to enhance your learning, including: • Answers to the learning activities in the book • ‘Drag and drop’ sequencing exercises • Label the diagram • Glossary of key terms • References and websites for further reading There is also an instructor companion website:

www.royalmarsdenmanual.com/instructor10e

There you will find additional materials, including: • PowerPoints of figures and procedure guidelines

The context of nursing

NURSING QUALITY PROFESSIONAL

Sara Lister

CARE CLINICAL EVIDENCE

1

After reading this chapter, you should: 1 Understand how the 10th edition of The Royal Marsden Manual of Clinical Nursing Procedures is organised 2 Understand the importance of evidencebased care in effective, safe nursing and clinical practice 3 Have considered the current political, cultural and professional contexts in which nursing is delivered and how these contexts influence patient care 4 Appreciate the value of skilled, personalised, compassionate nursing in patients’ experience of care

INTRODUCTION EVIDENCE BASE CULTURE SAFETY NHS

COMPASSION CONTEXT

The Royal Marsden Manual of Clinical Nursing Procedures: Student Edition, Tenth Edition. Edited by Sara Lister, Justine Hofland and Hayley Grafton with Catherine Wilson. © 2021 The Royal Marsden NHS Foundation Trust. Published 2021 by John Wiley & Sons Ltd. Student companion website: www.royalmarsdenmanual.com/student10e Instructor compaion website: www.royalmarsdenmanual.com/instructor10e

THE ROYAL MARSDEN MANUAL OF CLINICAL NURSING PROCEDURES

Overview

T

his introductory chapter presents an overview of the current context of nursing and outlines the purpose of the book, providing details of how it has been structured to reflect the NMC’s Standards Framework for Nursing and Midwifery Education (2019). It also includes an explanation of the system used to grade the evidence that supports the clinical procedures and an overview of the learning activities provided within each chapter.

Background The first edition of The Royal Marsden Manual of Clinical Nursing Procedures was produced in the early 1980s as a core procedure manual for safe nursing practice within The Royal Marsden Hospital, the world’s first cancer hospital. Implicit behind that first edition was the drive to ensure that patients received the very best care, including clinical procedures carried out with professional expertise combined with an attitude of respect and compassion. This vision is still at the forefront of nursing in The Royal Marsden today, reflected in three of the themes of The Royal Marsden’s Nursing, Allied Health Professional and Pharmacy Strategy 2020–2024 (Box 1.1). Box 1.1  Themes of The Royal Marsden’s Nursing, Allied Health Professional and Pharmacy Strategy 2020–2024 1 Create a first-class experience for all patients 2 Provide outstanding quality in patient care and treatment 3 Inspire, educate and develop our workforce

Context of nursing It is argued that the role of the nurse is as essential in responding to the healthcare needs of society today as it was over 30 years ago. In the current Leading Change, Adding Value: A Framework for Nursing, Midwifery and Care Staff (NHS England 2016) it is stated that: Though the world has changed, our values haven’t. As nursing, midwifery and care staff we know that compassionate care delivered with courage, commitment and skill is our highest priority. It is the rock on which our efforts to promote health and well-being, support the vulnerable, care for the sick and look after the dying is built. (NHS England 2016, p.5) However, in 2021 the context of nursing is different in many ways from that in 1984, when the very first manual was published. In this chapter, two specific influences are identified: political and professional.

Political context

Nurses are the largest group of employees in the NHS, so the context of nursing in the 21st century is shaped by the situation in the NHS. The aforementioned Leading Change, Adding Value: A Framework for Nursing, Midwifery and Care Staff (NHS England 2016) (Figure  1.1) was based on the NHS’s Five Year Forward View (NHS England 2014), which highlighted the changes taking place in society: • changes in personal health needs and preferences as we live longer with increasingly complex and more long-term conditions, as well as a need to take increased responsibility for our own wellbeing

Figure 1.1  Leading Change, Adding Value: A Framework for Nursing, Midwifery and Care Staff. Source: Reproduced from NHS England (2016) with permission of the NHS.

Health an

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Better experience Better use of resources

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CHAPTER 1 The context of nursing

• changes in technology and developments in medical research with opportunities arising from these advances that need to be embraced to further enhance treatment and care • reductions in funding provision because of the global recession that began in 2008.

UNWARRANTED VARIATION

One of the core principles of the NHS when it was founded 70 years ago was that it should ‘meets the needs of everyone’ (NHS Liverpool Heart and Chest Hospital 2018, p.1; see also NHS England 2018a). This has continued to guide the development of the NHS; however, as identified in the Five Year Forward View (NHS England 2014), changes in society are contributing to three distinct gaps that, if they are not addressed, will impact the longterm provision of healthcare and increase inequalities: • Health and wellbeing: a focus on prevention is needed or the inequalities in health will continue to grow and the budget for healthcare will need to be spent on avoidable illness and not on the development of new treatments. • Care and quality: health needs will go unmet unless we reshape care, harness technology and address variations in quality and safety (NHS England 2018b, p.8). • Funding and efficiency: without efficiencies, a shortage of resources will hinder care services and progress (NHS England 2018b, p.8). An implicit part of the role of nursing is therefore to be an integral part of closing these gaps, whether at a strategic, national level or locally at the bedside or in the outpatient department. It is suggested that the impact of these gaps is exaggerated because of ‘unwarranted variations’, which is ‘a term used to describe in­equalities that cannot be justified by variations in geography, demography or infrastructure’ (NHS England 2018b, p.9). At a local level, nurses can be involved in challenging unwarranted variations in the ways shown in Box 1.2.

NHS LONG TERM PLAN

The NHS Long Term Plan (NHS England 2019) sets out a new service model for the 21st century. This responds to ‘concern – about funding, staffing, increasing inequalities and pressures from a growing and ageing population’ and optimistically holds ‘the possibilities for continuing medical advance and better outcomes of care’ (NHS England 2019, p.6). The plans set out have various implications for nursing. The key chapters of the NHS Long Term Plan with direct relevance to nursing practice in an acute setting are set out in Table 1.1 with reference to the chapters in this manual that might be of specific

Box 1.2  Unwarranted variation: turning intention into action • Taking a closer look at what we do: for example, benchmarking our procedures against the evidence-based procedures in The Royal Marsden Manual of Clinical Nursing Procedures. • Uncovering activities that we need to change, add or take away. • Challenging established practice because we understand that service can be delivered in a better way: for example, using the online version of The Royal Marsden Manual of Clinical Nursing Procedures to upload and disseminate agreed examples of good practice across an organization. • Striving for high-value care: for example, reviewing equipment and the medication involved in procedures, or exploring whether procedures are being carried out by the most appropriate member of the team. Source: Adapted from NHS England (2018b, p.11) with permission of the NHS.

significance to nurses who are involved in implementing new ways of working.

Professional context

There are many factors influencing the professional context of nursing in 2020. The two highlighted here are patient safety and quality of care, and new roles required to respond to the increasing demand for services.

PATIENT SAFETY AND QUALITY OF CARE

Core to nursing, wherever it takes place, is the commitment to caring for individuals and keeping them safe, so wherever the procedures are used, they are to be carried out within the framework of the Nursing and Midwifery Council’s Code (NMC 2018a). One of the original purposes of The Royal Marsden Manual of Clinical Nursing Procedures was to promote patient safety through standardized and evidence-based approaches to care. Patient safety is an essential part of nursing care that aims to prevent avoidable errors and patient harm. The Royal College of Nursing (RCN) (2019) highlights four key factors that are important in patient safety: 1 Developing a culture of safety: this involves promoting attitudes and behaviours that encourage staff to learn from preventable incidents, which will make it less likely that the incident will happen again. Organizations fostering a proactive approach to patient safety should be open, just and informed, and reporting and learning from error should be the norm (Carthy and Clarke 2009). 2 Designing for reliability: this involves making healthcare more reliable  –  that is, taking a standard approach to patient care, agreeing to ways of working based on research and evidence where it is available, and agreeing at an organizational level to apply that knowledge to practice. 3 Taking a systemic approach to work: the system of work – which includes equipment, devices, medication and information systems  – makes a considerable difference to quality and safety. Changes to the design of physical things can make a big difference to how well people work. For example, the interfaces of devices, control panels, packaging and lighting levels can improve the speed, accuracy and reliability of a procedure. 4 Human factors: this refers to the way teams work together and the culture that influences how they act. The discipline of human factors can be defined as enhancing clinical performance through an understanding of the effects of teamwork, tasks, equipment, workspace, culture, organization of human behaviour and abilities, and application of that knowledge in clinical settings (Clinical Human Factors Group 2019). To paraphrase Ives and Hillier (2015), nurses within healthcare are one of healthcare’s greatest sources of strength and the science of human factors and ergonomics is about providing a system which allows them to work to the very best of their ability to provide safe, high-quality care for patients. Adapted by the RCN, the consultancy Leadership Management and Quality’s Human Factors Model (Figure  1.2) illustrates the interaction between the direct factors – dexterity (mental or physical), awareness/memory, distraction/concentration and decision (in the orange circle) – that impact performance and therefore the patient experience and the potential factors – stress, fatigue, safety culture, communication, teamwork, leadership and work environment (in the teal circle) – which have the potential to make the situation either better or worse. The interventions or managing factors (green circle) manage the effect of the potential factors and improve the direct factors (RCN 2019). The interventions or managing factors are many, both at the organizational and the individual levels. The Royal Marsden Manual of Clinical Nursing Procedures has a role at the organizational level, providing standardized procedures on which training can be based, and at the individual level, supporting the development of problem prevention and problem solving through the acquisition of knowledge associated with clinical processes.

3

THE ROYAL MARSDEN MANUAL OF CLINICAL NURSING PROCEDURES

Table 1.1  The NHS Long Term Plan (NHS England 2019) and The Royal Marsden Manual of Clinical Nursing Procedures New ways of working identified in the NHS Long Term Plan with direct relevance to nursing practice

Relevant chapter(s) in The Royal Marsden Manual

Related content in The Royal Marsden Manual

Chapter 1: A New Service Model for the 21st Century Personalized health budget and self-care

Chapter 5: Communication, psychological wellbeing and safeguarding

Information giving and decision making.

Same-day emergency care and clinical standards for critical illness

Chapter 12: Respiratory care, CPR and blood transfusion Chapter 13: Diagnostic tests See the Professional edition, Chapter 17: Vascular access devices: insertion and management

Nursing procedures for emergency care, e.g. CPR.

Improved discharge

Chapter 3: Discharge care and planning

Processes and procedures for arranging discharge with Social Services.

All chapters

The foundation of this textbook is to provide evidence-based procedures and to underpin rationale for the day-to-day procedures used by nurses in the acute setting with the aim of promoting quality care for the best outcome. This is discussed in more detail in the section below.

Chapter 18: Self-care and wellbeing

This chapter specifically considers strategies to help nurses cope with the pressures of working in the NHS.

n/a

This theme is not specifically addressed; however, references are made where appropriate to digital support for procedures, plus the online version of the manual is continually being enhanced.

Chapter 3: Further Progress on Care Quality and Outcomes Whole chapter

Chapter 4: NHS Staff Will Get the Backing They Need Workforce changes, including increased flexibility and access to professional development to help manage the pressures of working in the NHS Chapter 5: Upgrading Technology and Digitally Enabling the NHS Whole chapter

Figure 1.2  The Human Factors Model. Source: Adapted from RCN (2019) with permission of the Royal College of Nursing. Potential factors

Direct factors Stress ip sh

Interventions

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Professional competency

The development of clinical competency is an integral part of delivering safe care; the Nursing and Midwifery Council’s Code states that nurses must: • have the knowledge and skills for safe and effective practice without direct supervision • keep their knowledge and skills up to date throughout their working life • recognize and work within the limits of their competence (NMC 2018a). The Nursing and Midwifery Council (NMC) ‘has a duty to review the standards of proficiency it sets for the professions it registers on a regular basis to ensure that standards remain contemporary and fit for purpose in order to protect the public’ (NMC 2018b, p.3). In fulfilling this duty, it published Future Nurse: Standards of Proficiency for Registered Nurses (NMC 2018b) (Figure 1.3). This document details the knowledge and skills that all registered nurses must demonstrate when caring for people of all ages and across all care settings, reflecting what the public can expect nurses to know and be able to do in order to deliver safe, compassionate and effective nursing care. These proficiencies have a legal standing, fulfilling Article 5(2) of the Nursing and Midwifery Order 2001, which requires the NMC to establish standards of

CHAPTER 1 The context of nursing

Figure 1.3  Future Nurse: Standards of Proficiency for Registered Nurses. Source: Reproduced from NMC (2018b) with permission of the Nursing and Midwifery Council.

Future nurse: Standards of proficiency for registered nurses Published 17 May 2018

Box 1.3  The seven platforms of Standards of Proficiency for Registered Nurses 1 2 3 4 5 6 7

Being an accountable professional Promoting health and preventing ill health Assessing needs and planning care Providing and evaluating care Leading and managing nursing care and working in teams Improving safety and quality of care Co-ordinating care

proficiency necessary for nurses to be admitted to each part of the register and for safe and effective practice under that part of the register (NMC 2018b). The proficiencies are designed to apply across all fields of nursing practice (adult, child, mental health and learning disabilities), ‘because registered nurses must be able to meet the person-centred, holistic care needs of the people they encounter in their practice who may be at any stage of life and who may have a range of mental, physical, cognitive or behavioural health challenges’ (NMC 2018b, p.60). The proficiencies are grouped around seven platforms (Box 1.3). These reflect what the nursing profession expects a newly registered nurse to know and be capable of doing safely and proficiently at the start of their career (NMC 2018b). In addition, there are two annexes that describe what registered nurses should be able to demonstrate they can do at the point of registration in order to provide safe nursing care. Annex A specifies the communication and relationship management skills required, and Annex B specifies the nursing procedures that registered nurses must demonstrate that they are able to perform safely (NMC 2018b). The revised Standards of Proficiency for Registered Nurses (NMC 2018b) have affected the education and training of nurses, requiring a new curriculum and the inclusion of additional skills to prepare students to safely and competently fulfil the wide variety of nursing roles available to them at and after registration (Figure 1.4).

The chapters in this student edition of The Royal Marsden Manual of Clinical Nursing Procedures map onto the NMC proficiencies in Annex B of the Standards of Proficiency for Registered Nurses (NMC 2018b); these are detailed in the Appendix of this manual. The manual provides theory and exploration of anatomy and physiology relating to nursing procedures, recognizing that competence is not just about knowing how to do something but also about understanding the rationale for doing it and the impact it may have on the patient. Learning activities, based on clinical experience, are provided within each chapter to encourage readers to apply the principles of a procedure to a clinical situation or a patient scenario, and to help readers to test their knowledge.

NEW ROLES

The changes in demand for healthcare and the limited resources (particularly staff) available to provide it have prompted government, employers and the profession to consider new roles. These new roles could potentially provide a faster route to solving staffing problems and offer career development opportunities, which could also help to improve retention. These include expanding physician associate and advanced nurse practitioner roles and the new nursing associate roles (King’s Fund 2018).

Nursing associates

The report Raising the Bar: Shape of Caring  –  A Review of the Future Education and Training of Registered Nurses and Care Assistants (Health Education England 2015), led by Lord Willis, made recommendations for the education of nurses and care assistants. One of the key areas it identified was the skills gap between care assistants and registered nurses (NMC 2018c). The nursing associate role, announced by Ben Gummer, Health Minister, in 2015, was developed to address this gap: The new nursing support role is expected to work alongside healthcare support workers and fully qualified nurses to deliver hands on care, ensuring patients continue to get the compassionate care they deserve. Nursing associates will

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THE ROYAL MARSDEN MANUAL OF CLINICAL NURSING PROCEDURES

Figure 1.4  Summary of key changes to the standards for nurses. Source: Reproduced from NHS Employers (2018) with permission of the NHS.

KEY CHANGES TO THE STANDARDS FOR NURSES

Student supervision and assessment

YOUR FUTURE NURSES

Programme Content

Students are assigned a practice supervisor, practice assessor and an academic assessor.

The Nursing and Midwifery Council (NMC) has reviewed and updated the standards of proficiency for registered nurses and the standards for education and training. The new standards have been developed to reflect the changing role that nurses will play in the future.

The new proficiencies and nursing procedures apply to all fields of nursing practice. They emphasise the importance of good communication and relationship management skills, such as de-escalation strategies and techniques.

Practice supervisors can be any registered health and social care professional and contribute to the student’s record of achievement. Practice assessors cannot simultaneously be the supervisor for the same student.

There is no longer a limit to the number of learning hours spent in simulation. Assessment of practice is outcome focused and evidence based.

Students are no longer required to spend 40% of their time being supervised. The level of supervision can decrease as student proficiency and confidence increases. Students can undertake procedures to provide person-centred care without direct oversight once they are proficient.

Supervisors and assessors receive ongoing training and support to carry out these roles.

Students will learn to undertake venepuncture, cannulation and blood sampling.

The new standards have a greater emphasis on leadership, multi-disciplinary working and working across different settings. The new standards will be ready for use from 28 January 2019.

Newly qualified registrants can access community prescribing course (V150) straight away.

All programmes offered by Approved Education Institutions must be aligned to the new standards by September 2020.

Qualified nurses can access the advanced prescribing course (V300) after one year’s experience.

The new standards for nurses are grouped under seven platforms 1. Being an accountable professional

2. Promoting health and preventing ill health

3. Assessing needs and planning care

4. Providing and evaluating care

support nurses to spend more time using their specialist training to focus on clinical duties and take more of a lead in decisions about patient care. (Department of Health and Social Care 2015) The NMC is the regulator for these new roles and has set out standards of knowledge and skills expected of a nursing associate for safe and effective practice (NMC 2018c). The Standards of Proficiency are structured in a similar way to those for registered nurses and are based around six platforms (Box 1.4). The procedures that it is expected a nursing associate will be able to undertake competently on registration are defined in Annex B of the Standards of Proficiency, which states: ‘Nursing associates are expected to apply evidence-based best practice across all procedures. The ability to carry out these procedures, safely, effectively, with sensitivity and compassion is crucial to the provision of person-centred care’ (NMC 2018c, p.15). It is hoped that this manual will be a resource for nursing associates in helping them to develop the understanding necessary to apply evidence-based practice to all the procedures they undertake. Trainee nursing associates are advised to select procedures and material from this student edition of the manual relevant to their role. Always ask for clarification and guidance from your educational institution, tutor or clinical supervisor if you are unsure whether a particular procedure or skill is relevant to the qualified nursing associate role.

5.

6.

7.

Leading and managing nursing care and working in teams

Improving safety and quality of care

Co-ordinating care

Box 1.4  Standards of Proficiency for Nursing Associates • Platform 1: Being an accountable professional • Platform 2: Promoting health and preventing ill health • Platform 3: Provide and monitor care • Platform 4: Working in teams • Platform 5: Improving safety and quality of care • Platform 6: Contributing to integrated care

Advanced nurse practitioners

‘New solutions are required to deliver healthcare to meet the changing needs of the population. This will need new ways of working, new roles and new behaviours’ (NHS England 2017, p.1). Advanced clinical practice roles are seen as an essential part of these solutions (Nuffield Trust 2016). A multiprofessional advanced clinical practice framework has been developed to define advanced clinical practice and set out the core capabilities expected across professions and care settings to foster the development of these new roles in a consistent way to ensure safety, quality and effectiveness (NHS England 2017) (see Box 1.5). Developing new roles and taking responsibility for new procedures have obvious risks attached and, although every individual nurse is accountable for their own actions, every healthcare

CHAPTER 1 The context of nursing

Box 1.5  Definition of advanced clinical practice Advanced clinical practice is defined as follows: Clinical practice is delivered by experienced, registered health and care practitioners. It is a level of practice characterized by a high degree of autonomy and complex decision making. This is underpinned by a master’s level award or equivalent that encompasses the four pillars of clinical practice, leadership and management, education and research, with demonstration of core capabilities and area specific clinical competence. Advanced clinical practice embodies the ability to manage clinical care in partnership with individuals, families and carers. It includes the analysis and synthesis of complex problems across a range of settings, enabling innovative solutions to enhance people’s experience and improve outcomes. (NHS England 2017, p.7) Source: NHS England (2017). Reproduced with permission of the NHS.

Box 1.6  The traditional hierarchy of evidence 1 Systematic reviews and meta-analyses 2 Randomized controlled trials with definitive results (i.e. confidence intervals that do not overlap the threshold, a clinically significant effect) 3 Randomized controlled trials with non-definitive results (i.e. a suggested clinically significant effect but with confidence intervals overlapping) 4 Cohort studies 5 Case-control studies 6 Cross-sectional surveys 7 Case reports Source: Adapted from Greenhalgh (2014, p.41).

Figure 1.5  Hierarchy of evidence pyramid for nursing. Source: Adapted from Glover et al. (2006) with permission of Lei Wang.

organization has to assume vicarious liability for the care, treatment and procedures that take place. An organization will have expectations of all of its nurses in respect of keeping patients, themselves and the environment safe. There are obvious ethical and moral reasons for this: ‘Nurses have a moral obligation to protect those we serve and to provide the best care we have available’ (Wilson 2005, p.118). Clinical governance has therefore become an integral part of day-to-day nursing work; for this reason, the clinical governance implications of the areas of practice have been integrated into each chapter of this edition of the manual.

ty ali

The moral obligation described above extends to the evidence upon which we base our practice. Nursing now exists in a healthcare arena that routinely uses evidence to support decisions, and nurses must justify their rationales for practice. Whereas, historically, nursing and specifically clinical procedures were based on rituals rather than research (Ford and Walsh 1994, Walsh and Ford 1989), over the past 30 years evidence-based practice (EBP) has formed an integral part of practice, education, management, strategy and policy in healthcare. As Draper (2018) states, ‘as the global demand for healthcare services increases exponentially, it has never been more important to demonstrate clinical effectiveness to achieve the best outcomes … while ensuring value for money” (p.2480). Research has played a key role in identifying the specific interventions that lead to the best outcomes, or, in other words, identifying the evidence to underpin clinical practice – that is, evidence-based practice.

What is evidence-based practice?

EBP was first described by David Sackett, a pioneer in introducing EBP in UK healthcare, as follows: [EBP is] the conscientious, explicit and judicious use of current best evidence in making decisions about the care of the individual patients. The practice of evidence-based medicine [or nursing] means integrating individual clinical expertise with the best available external clinical evidence from systematic research. (Sackett et al. 1996, p.72) A hierarchy of evidence (Box 1.6) has been developed to provide an indication of the strength of the evidence and therefore, by implication, its usefulness for evidence-based and evidenceinformed decision making and clinical practice (Draper 2018, Ingham-Broomfield 2016).

Qu

Evidence-based practice

Critically appraised topics (evidence syntheses)

of

evi

de

nc

e

Systematic reviews

Critically appraised individual articles (article synopses) Randomized controlled trials (RCTs) Cohort studies Case-controlled studies Case series/reports Background information/expert opinion

Glover et al. (2006) present for nursing research a hierarchy of evidence as a pyramid (Figure 1.5), with the seventh level or base of the pyramid being ideas, opinions, anecdotes and editorials. Other sources (e.g. Ingham-Broomfield 2016) have created similar pyramids, and it must be noted that the pyramids vary slightly between authors, organizations and professions. These hierarchies assume that the most robust evidence is that derived from systematic reviews and meta-analyses of large-scale randomized controlled studies (Draper 2018, Greenhalgh 2014, Ingham-Broomfield 2016). However, they provide no means of including qualitative research studies (Greenhalgh 2014) or those seeking to answer questions about patients’ experiences or concerns (Del Mar et al. 2013). Draper (2018) therefore proposes that typologies of evidence are a more appropriate way of defining the quality of evidence. Petticrew and Roberts (2003) propose the following features to be used in evaluating evidence: effectiveness, service delivery, salience, safety, acceptability, cost-effectiveness, appropriateness and satisfaction. Glasby et al. (2007) propose a different approach suggesting three different types of evidence: theoretical, empirical and experiential (Box 1.7).

7

8

THE ROYAL MARSDEN MANUAL OF CLINICAL NURSING PROCEDURES

Box 1.7  A typology of evidence to inform practice • Theoretical evidence: ideas, concepts and models used to describe an intervention, and explain how and why it works. • Empirical evidence: information about the actual use of the intervention, its effectiveness and outcomes when it is used. • Experiential evidence: information about people’s experiences of the intervention or service. Source: Adapted from Glasby et al. (2007, p.434).

This typology is reflective of the seminal work of Carper (1978), who delineated four different forms of knowing encompassed in clinical expertise in nursing. These are: • empirical evidence • aesthetic evidence • ethical evidence • personal evidence. The issue of determining which evidence is acceptable in practice is evident throughout this manual, where clinical expertise and guidelines inform the actions and rationales of the procedures. Indeed, these other types of evidence are highly important as long as we can still apply scrutiny to their use. Porter (2010) describes a wider empirical base upon which nurses make decisions and argues for nurses to take into account and be transparent about other forms of knowledge, such as ethical, personal and aesthetic knowing, echoing Carper (1978). By doing this, and through acknowledging limitations to these less empirical forms of knowledge, nurses can justify their use of them to some extent. Furthermore, in response to Paley’s (2006) critique of EBP as a failure to holistically assess a situation, nursing needs to guard against cherry picking (i.e. ensuring that EBP is not brandished ubiquitously and indiscriminately) and know when judicious use of, for example, experiential knowledge (as a form of personal knowing) might be more appropriate. Evidence-based nursing (EBN) and EBP are differentiated by Scott and McSherry (2009) in that EBN involves additional elements in its implementation. EBN is regarded as an ongoing process by which evidence is integrated into practice and clinical expertise is critically evaluated against patient involvement and optimal care (Scott and McSherry 2009). For nurses to implement EBN, four key requirements are required (Scott and McSherry 2009): 1 to be aware of what EBN means 2 to know what constitutes evidence 3 to understand how EBN differs from evidence-based medicine and EBP 4 to understand the process of engaging with and applying the evidence. We contextualize our information and decisions to deliver best practice for patients; that is, the ability to use research evidence and clinical expertise, together with the preferences and circumstances of the patient, is essential to arrive at the best possible decision for a specific patient (Guyatt et al. 2004). Knowledge can be gained that is both propositional  –  that is, from research  –  and non-propositional  –  that is, implicit knowledge derived from practice (Rycroft-Malone et al. 2004). In more tangible, practical terms, evidence can be drawn from a number of different sources, and this pluralistic approach needs to be set in the context of the complex clinical environment in which nurses work in today’s NHS (Pearson et  al. 2011, Rycroft-Malone et  al. 2004). Rycroft-Malone et  al. (2004) proposed that the evidence

that informs clinical nursing practice can be considered as arising from four main sources: 1 research 2 clinical experience, expertise and tradition 3 patients, clients and carers 4 the local context and environment (Pearson et al. 2011, RycroftMalone et al. 2004). These four sources have all informed the evidence base that is integral to this manual, which acknowledges that ‘in reality practitioners draw on multiple sources of knowledge in the course of their practice and interaction with patients’ (Rycroft-Malone et al. 2004, p.88).

Evidence-based practice and The Royal Marsden Manual of Clinical Nursing Procedures

The evidence that informs clinical nursing procedures is integral to The Royal Marsden Manual of Clinical Nursing Procedures. It is critically discussed in the sections within each chapter on ‘related theory’ and ‘evidence-based approaches’. In these sections, the source of evidence (reflecting the sources described by RycroftMalone et al. 2004) is indicated in the rationale that supports the steps in procedures. In previous editions, the level on the research hierarchy was also included, in an attempt to represent the robustness of the evidence. In this edition, that nomenclature has been dropped for two reasons: because the hierarchy does not include qualitative studies, some of which are significant in informing nursing practice, and because the hierarchy does not recognize the quality of a study, just the methodological approach. The following key is used to indicate the sources of evidence: • Clinical experience (E) Encompasses expert practical know-how, gained through working with others and reflecting on best practice. Example: (Dougherty 2008, E). This is drawn from the following article that gives an expert clinical opinion: Dougherty, L. (2008) Obtaining peripheral vascular access. In: Dougherty, L. & Lamb, J. (eds) Intravenous Therapy in Nursing Practice, 2nd edn. Oxford: Blackwell. • Patient (P) Gained through expert patient feedback and extensive experience of working with patients. Example: (Diamond 1998, P). This was gained from a personal account of care written by a patient: Diamond, J. (1998) C: Because Cowards Get Cancer Too. London: Vermilion. • Context (C) Can include audit and performance data, social and professional networks, local and national policy, guidelines from professional bodies (e.g. the RCN) and manufacturers’ recommendations. Example: (NMC 2018a, C). This reference is: NMC (2018a) The Code: Professional Standards of Practice and Behaviour for Nurses, Midwives and Nursing Associates. London: Nursing and Midwifery Council. • Research (R) Evidence gained through research. Example: (Stevenson et al. 2017, R). Stevenson, J.C., Emerson, L. & Millings, A. (2017) The relationship between adult attachment orientation and mindfulness: A systematic review and meta-analysis. Mindfulness, 8, 1438–1455. In the text, the source will be represented as shown in Box 1.8. If there is no written evidence to support clinical experience or there are no guidelines to justify undertaking a procedure, the text will be referenced as an ‘E’ but will not be preceded by an author’s name. Through this process, it is hoped that the reader will be aware of the source of the evidence upon which the care of patients is based and continue to critically evaluate their practice, engaging in research and audit where there are gaps or where best practice is not confirmed.

CHAPTER 1 The context of nursing

Box 1.8  Examples of sources • Clinical experience and guidelines (Dougherty 2008, E) • Patient (Diamond 1998, P) • Context (NMC 2018a, C) • Research (Stevenson et al. 2017, R)

Structure of the manual The chapters have been organized into five broad sections that represent – as far as possible – the needs of a patient along their care pathway. The first section, ‘Managing the patient journey’, presents the generic information that a nurse needs for every patient who enters the acute care environment. The second section, ‘Supporting patients with human functioning’, relates to the support a patient may require with normal human functions such as elimination, nutrition and respiration, and includes procedures relevant to those areas. The third section, ‘Supporting patients through the diagnostic process’, relates to all aspects of supporting a patient through the diagnostic process, from simple procedures such as taking a temperature to preparing a patient for complex procedures such as a liver biopsy. The fourth section, ‘Supporting patients through treatment’, includes procedures related to specific types of treatment or therapies a patient is receiving. An additional final section and chapter has been added focusing on the wellbeing and self-care of the nurse. This has been included for two reasons. Firstly, the new NMC Standards of Proficiency for Registered Nurses state that self-care is a professional responsibility: ‘in order to respond to the impact and demands of professional nursing practice, [nurses] must be emotionally intelligent and resilient individuals, who are able to manage their own personal health and wellbeing, and know when and how to access support’ (NMC 2018b, p.3). Secondly, there is a common tendency for nurses and other care workers to become ‘invisible patients’ because their own needs are often ignored or pushed to the bottom of the list (Sheridan 2016). The health and wellbeing of those who care for patients is being recognized as one of the most important aspects of enabling them to care safely (Sign Up to Safety 2019). The final chapter is included to provide accessible strategies that any nurse or care worker can put into practice.

Structure of the chapters The structure of the chapters is consistent throughout the manual. The core of each chapter is the procedures or guidelines. The other sections provide supporting information so that each procedure can be carried out with understanding of the clinical, technical, physiological, psychological and professional knowledge and evidence from which it has been developed. In each chapter there are the following elements: • Overview: as the chapters are large and have considerable content, each one begins with an overview to guide the reader, informing them of the scope and the constituent sections of the chapter. • Definition: each section begins with a definition of the terms and an explanation of the aspects of care, with any technical or difficult concepts explained. • Anatomy and physiology: if it is necessary to understand the anatomy or physiology of a part of the body to perform a procedure, then the chapter or section includes a discussion of the related anatomy and physiology. If appropriate, this is illustrated with diagrams so the context of the procedure can be fully understood by the reader (e.g. electrical functioning of the heart to explain how electrocardiography works).

• Related theory: if it is necessary to understand theoretical principles in order to understand a procedure, then these are included (e.g. theory of communication). • Evidence-based approaches: these sections provide background information and present the research and expert opinion in the relevant area. If appropriate, the indications and contraindications are included, as are any principles of care. • Clinical governance: these sections outline any professional guidance, law or other national policy that may be relevant to the procedures. If relevant, this also includes any professional competences or qualifications required in order to perform the procedures. Any risk management considerations are also included in these sections, including principles of harm-free care. • Pre-procedural considerations: when carrying out any procedure, there are certain actions that may need to be completed, or equipment prepared, or medication given, before the procedure begins. These are made explicit under this heading. • Procedure: each chapter includes the current procedures that are used in the acute hospital setting. They have been drawn from the daily nursing practice at The Royal Marsden NHS Foundation Trust. Only procedures about which the authors have knowledge and expertise are included. Each procedure gives detailed, step-by-step actions, supported by rationales. Where available, the known evidence underpinning these rationales is indicated. • Problem solving and resolution: if relevant, each procedure is followed by a table of potential problems that may be encountered while carrying out the procedure as well as suggestions as to the cause, prevention and any action that may help to resolve the problem. • Post-procedural considerations: care for the patient does not end with the procedure. This section details any documentation the nurse may need to complete, education and information that needs to be given to the patient, and ongoing observations or referrals to other members of the multiprofessional team that may be required. • Complications: any ongoing problems or potential complications associated with the procedure are discussed in a final section. Evidence-based suggestions for resolution are also included. • Illustrations: colour illustrations have been used to demonstrate the steps of some procedures. These will enable the nurse to see in greater detail, for example, the correct position of the hands or the angle of a needle. • Websites and references: many of the chapters have a list of related websites (available on the companion website: www. royalmarsdenmanual.com/student10e) that can be consulted for further information. All of the chapters end with a reference list. Only texts from the past 10 years have been included, unless they are seminal texts.

Finally This book is intended as a reference and a resource, not as a replacement for practice-based education. None of the procedures in this book should be undertaken without prior instruction and subsequent supervision from an appropriately qualified and experienced professional. We hope that The Royal Marsden Manual of Clinical Nursing Procedures will continue to be a resource to help nurses deliver high-quality care that maximizes the wellbeing and improves the health outcomes of patients in acute hospital settings. To paraphrase the quote from Leading Change, Adding Value (NHS England 2016, p.5) near the beginning of this chapter, compassionate care delivered with courage, commitment and skill is our highest priority as nurses. This is made more explicit in Commitment 4 of Leading Change, Adding Value (NHS England 2016, p.21), which highlights the importance of putting the person at the centre of care (Box 1.9).

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THE ROYAL MARSDEN MANUAL OF CLINICAL NURSING PROCEDURES

Box 1.9  Commitment 4: We will focus on individuals experiencing high value care We will ensure that individuals are always supported to influence and direct their own healthcare decisions, so that they are confident that ‘no decision is taken about me without me’. Care planning should involve the development of a personalized plan for each individual who is entering, leaving or transitioning care environments whether within a hospital, in their own home, care home or rehabilitation unit. We need to encourage people to take more responsibility for their health by focusing on personalized care planning, self-management and behaviour change. Source: Adapted from NHS England (2016) with permission of the NHS.

It is important to remember that even if a procedure is very familiar to us and we are very confident in carrying it out, it may be new to the patient, so time must be taken to explain it and gain consent, even if this is only verbal consent: ‘the views of the person [receiving the treatment] should also be taken into account when choosing which treatment is most likely to be successful for

REFERENCES

Carper, B. (1978) Fundamental patterns of knowing in nursing. Advances in Nursing Science, 1(1), 13–23. Carthy, J. & Clarke, J. (2009) The ‘How to Guide’ for Implementing Human Factors in Healthcare. Patient Safety First. Available at: https://chfg.org/ how-to-guide-to-human-factors-volume-1 Clinical Human Factors Group (2019) What Are Clinical Human Factors? Available at: https://chfg.org/what-are-clinical-human-factors Del Mar, C., Hoffman, T. & Glasziou, P. (2013) Information needs, asking questions, and some basics of research studies. In: Hoffman, T., Bennett, S. & Del Mar, C. (eds) Evidence Based Practice across the Health Professions, 2nd edn. Sydney: Churchill Livingstone Australia, pp. 16–37. Department of Health and Social Care (2015) Nursing Associate Role Offers New Route into Nursing. Available at: https://www.gov.uk/ government/news/nursing-associate-role-offers-new-route-into-nursing Diamond, J. (1998) C: Because Cowards Get Cancer Too. London: Vermilion. Dossey, B.M., Keegan, L. & Guzzetta, C.E. (2005) Holistic Nursing: A Handbook for Practice, 4th edn. Sudbury, MA: Jones & Bartlett. Dougherty, L. (2008) Obtaining peripheral vascular access. In: Dougherty, L. & Lamb, J. (eds) Intravenous Therapy in Nursing Practice, 2nd edn. Oxford: Blackwell. Draper, J. (2018) Healthcare education research: The case for rethinking hierarchies of evidence (editorial). Journal of Advanced Nursing, 74, 2480–2483. Ford, P. & Walsh, M. (1994) New Rituals for Old: Nursing through the Looking Glass. Oxford: Butterworth-Heinemann. Glasby, J., Walshe, K. & Harvey, G. (2007) Making evidence fit for purpose in decision-making: A case-study of the hospital discharge of older people. Evidence & Policy, 3(3), 425–437. Glover, J., Izzo, D., Odato, K. & Wang, L. (2006) EBM Pyramid. Hanover, NH / New Haven, CT: Dartmouth University / Yale University. Greenhalgh, T. (2014) How to Read a Paper: The Basics of Evidence Based Medicine, 5th edn. London: BMJ Books. Guyatt, G., Cook, D. & Haynes, B. (2004) Evidence based medicine has come a long way. BMJ, 329(7473), 990–991. Health Education England (2015) Raising the Bar: Shape of Caring  –  A Review of the Future Education and Training of Registered Nurses and Care Assistants. Available at: https://www.hee.nhs.uk/sites/default/ files/documents/2348-Shape-of-caring-review-FINAL.pdf Ingham-Broomfield, R. (2016) A nurses’ guide to the hierarchy of research designs and evidence. Australian Journal of Advanced Nursing, 33(3), 38–43. Ives, C. & Hillier, S. (2015) Human Factors in Healthcare: Common Terms. Clinical Human Factors Group. Available at: http://s753619566. websitehome.co.uk/wp-content/uploads/2018/06/chfg-human-factorscommon-terms.pdf King’s Fund (2018) Examining the Evidence for New Roles in Health and Social Care. Available at: https://www.hee.nhs.uk/sites/default/files/

an individual’ (NMC 2018a, p.38). The diverse range of technical procedures to which patients may be subjected should act as a reminder not to lose sight of the unique person undergoing such procedures and the importance of individualized patient assessment in achieving this. When a nurse Encounters another What occurs is never a neutral event A pulse taken Words exchanged A touch A healing moment Two persons Are never the same (Anon. in Dossey et al. 2005) Nurses have a central role to play in helping patients to manage the demands of the procedures described in this manual. It must not be forgotten that for the patient, the clinical procedure is part of a larger picture, which encompasses an appreciation of their unique experience of the reason they have needed nursing care in the first place. documents/Examining%20the%20evidence%20for%20new%20 roles%20in%20health%20and%20care.pdf NHS Employers (2018) Key Changes to the Standards for Nurses. Available at: https://www.nhsemployers.org/-/media/Employers/Publications/ Workforce-Supply/Key_Changes_to_the_standards_for_nurses.pdf NHS England (2014) NHS England: Five Year Forward View. London: NHS England. NHS England (2016) Leading Change, Adding Value: A Framework for Nursing, Midwifery and Care Staff. Available at: https://www.england. nhs.uk/wp-content/uploads/2016/05/nursing-framework.pdf NHS England (2017) Multi-professional Framework for Advanced Clinical Practice in England. Available at: https://www.hee.nhs.uk/sites/default/ files/documents/Multi-professional%20framework%20for%20 advanced%20clinical%20practice%20in%20England.pdf NHS England (2018a) About the NHS. Available at: https://www.nhs.uk/ using-the-nhs/about-the-nhs/principles-and-values NHS England (2018b) Leading Change, Adding Value: A Framework for Nursing, Midwifery and Care Staff  –  A Learning Tool to Support All Nursing, Midwifery and Care Staff to Identify and Address Unwarranted Variation in Practice. Available at: https://www.england.nhs.uk/ wp-content/uploads/2018/05/lcav-e-learning-tool-v1.pdf NHS England (2019) NHS Long Term Plan. Available at: https://www. longtermplan.nhs.uk/wp-content/uploads/2019/01/nhs-long-term-planjune-2019.pdf NHS Liverpool Heart and Chest Hospital (2018) 70 NHS Facts. Available at: https://www.lhch.nhs.uk/media/5967/nhs70-facts.pdf NMC (Nursing and Midwifery Council) (2018a) The Code: Professional Standards of Practice and Behaviour for Nurses, Midwives and Nursing Associates. Available at: https://www.nmc.org.uk/standards/code NMC (2018b) Future Nurse: Standards of Proficiency for Registered Nurses. Available at: https://www.nmc.org.uk/globalassets/sitedocuments/ education-standards/future-nurse-proficiencies.pdf NMC (2018c) Standards of Proficiency for Nursing Associates. Available at: https://www.nmc.org.uk/globalassets/sitedocuments/educationstandards/print-friendly-nursing-associates-proficiency-standards.pdf NMC (2019) Standards Framework for Nursing and Midwifery Education. Available at: https://www.nmc.org.uk/standards-for-education-andtraining/standards-framework-for-nursing-and-midwifery-education Nuffield Trust (2016) Reshaping the Workforce to Deliver the Care Patients Need. Available at: https://www.nuffieldtrust.org.uk/research/reshapingthe-workforce-to-deliver-the-care-patients-need Paley, J. (2006) Evidence and expertise. Nursing Enquiry, 13(2), 82–93. Pearson, A., Field, J. & Jordan, Z. (2011) Evidence-Based Clinical Practice in Nursing and Health Care: Assimilating Research, Experience, and Expertise. Oxford: Wiley-Blackwell. Petticrew, M. & Roberts, H. (2003) Evidence, hierarchies and typologies: Horses for courses. Journal of Epidemiology & Community Health, 57(7), 527–529.

CHAPTER 1 The context of nursing

Porter, S. (2010) Fundamental patterns of knowing in nursing: The challenge of evidence-based practice. ANS Advances in Nursing Science, 33(1), 3–14. RCN (Royal College of Nursing) (2019) Patient Safety and Human Factors. Available at: https://www.rcn.org.uk/clinical-topics/patient-safety-andhuman-factors Rycroft-Malone, J., Seers, K., Titchen, A., et  al. (2004) What counts as evidence in evidence-based practice? Journal of Advanced Nursing, ­ 47(1), 81–90. Sackett, D.L., Rosenberg, W.M., Gray, J.A., et al. (1996) Evidence based medicine: What it is and what it isn’t. BMJ, 312(7023), 71–72. Scott, K. & McSherry, R. (2009) Evidence-based nursing: Clarifying the concepts for nurses in practice. Journal of Clinical Nursing, 18(8), 1085–1095.

Sheridan, C.B. (2016) The Mindful Nurse: Using the Power of Mindfulness and Compassion to Help You Thrive in Your Work. Galway, NY: Rivertime Press. Sign Up to Safety (2019) Did You Know that Nearly Everyone’s Job Affects the Safety of Patients? Available at: https://www.signuptosafety.org.uk/ nearly-everyones-job-affects-safety Stevenson, J.C., Emerson, L. & Millings, A. (2017) The relationship between adult attachment orientation and mindfulness: A systematic review and meta-analysis. Mindfulness, 8, 1438–1455. Walsh, M. & Ford, P. (1989) Nursing Rituals, Research and Rational Actions. Oxford: Heinemann Nursing. Wilson, C. (2005) Said another way: My definition of nursing. Nursing Forum, 40(3), 116–118.

11

Part One Managing the patient journey 2 Admissions and assessment  15 3 Discharge care and planning  47 4 Infection prevention and control  69

Admissions and assessment

HOLISTIC INPATIENT EXAMINATION INDIVIDUALIZED

IMPLEMENTATION

REFERRAL OBSERVATION

RESPIRATORY

PERSON-CENTRED

Lorraine Guinan and Victoria Ward with Elizabeth Hendry, Emma Masters, Andrew Rayner, Emma Thistlethwayte, Manuela Trofor, Charlotte Weston and Claire White

DIAGNOSIS ABDOMINAL

ASSESSMENT CARDIOVASCULAR CARE EVALUATION DOCUMENT PLAN

2

After reading this chapter and undertaking the learning activities within it, you should: 1 Know the importance of undertaking a person-centred, holistic nursing assessment, in collaboration with the patient and their family 2 Understand the principles of designing a person-centred care plan for patients in order to establish and instigate appropriate, effective, safe and compassionate nursing care 3 Apply evidence-based, best-practice approaches to the clinical assessment of the respiratory, cardiovascular and gastrointestinal systems

Key terms are highlighted in the text in pink. Glossary definitions of these terms can be found on the companion site of this student edition: www.royalmarsdenmanual.com/ student10e.

Procedure guidelines 2.1 Respiratory examination 2.2 Cardiovascular examination

2.3 Abdominal examination

The Royal Marsden Manual of Clinical Nursing Procedures: Student Edition, Tenth Edition. Edited by Sara Lister, Justine Hofland and Hayley Grafton with Catherine Wilson. © 2021 The Royal Marsden NHS Foundation Trust. Published 2021 by John Wiley & Sons Ltd. Student companion website: www.royalmarsdenmanual.com/student10e Instructor compaion website: www.royalmarsdenmanual.com/instructor10e

THE ROYAL MARSDEN MANUAL OF CLINICAL NURSING PROCEDURES

Being an accountable professional 16

At the point of registration, the nurse will: 1. Use evidence-based, best practice approaches to take a history, observe, recognise and accurately assess people of all ages: 1.1 mental health and wellbeing status 1.2 physical health and wellbeing

2. Use evidence-based, best practice approaches to undertake the following procedures: 2.7 undertake a whole body systems assessment including respiratory, circulatory, neurological, musculoskeletal, cardiovascular and skin status 2.8 undertake chest auscultation and interpret findings Future Nurse: Standards of Proficiency for Registered Nurses (NMC 2018)

Overview

T

his chapter gives an overview of inpatient assessment, the process of care and the importance of observation in the assessment process. Assessment forms an integral part of patient care and is considered to be the first step in the process of individualized nursing care. It provides information that is critical to the development of a plan of action that enhances personal health status. Early and continued assessments are vital to the success and management of patient care. It is critical that nurses have the ability to assess patients and document and communicate their findings in a systematic way. The patient’s age, health and mode of presentation will determine the extent of the physical assessment required (Innes et al. 2018). Observation – coupled with one or more of cardiovascular, respiratory or abdominal examinations  –  is discussed in this chapter. See Chapter  14: Observations for information on neurological assessment.

Figure 2.1  Phases of the nursing process. Source: Reproduced from Weber and Kelley (2014) with permission of Lippincott Williams & Wilkins.

Assessment

Inpatient assessment and the process of care To appropriately care for a patient within the hospital setting or the community, the nurse must assess the patient in order to develop a care plan tailored to the individual (Saxon and Lillyman 2011). The nursing process is an organized, systematic and deliberate approach that aims to improve standards in nursing care (Rush et al. 1996). This process is cyclical, ongoing and generally used in conjunction with various theoretical nursing models or philosophies. The process is both holistic and problem solving; each stage is intimately interconnected with the other stages and is explicable only by reference to the whole – used in partnership with the patient and their family. This process, similar to those used in problem solving and scientific reasoning, incorporates assessment, diagnosis, planning, implementation and evaluation phases, as demonstrated in Figure  2.1 and Table 2.1 (Pratt and Van Wijgerden 2009). Each step of the nursing process depends on the accuracy of the preceding step. This nursing process has evolved over the past decades and is now used by nurses throughout the world as a framework for providing individualized, person-centred care.

DEFINITION

Assessment is the systematic and continuous collection, organization, validation and documentation of information (Berman et al. 2010).

Diagnosis or clinical judgement

Evaluation

Planning

Implementation

Table 2.1  Phases of the nursing process Phase Title

Description

1

Assessment

Collecting objective and subjective data

2

Diagnosis

Analysing subjective and objective data to make a professional nursing judgement

3

Planning

Determining outcome criteria and developing a plan

4

Implementation Carrying out the plan

5

Evaluation

Assessing whether the outcome criteria have been met and revising the plan as necessary

Source: Reproduced from Weber and Kelley (2014) with permission of Lippincott Williams & Wilkins.

RELATED THEORY

Nurses perform assessments on patients to inform professional judgements on what care is required. Assessment takes place from the time a nurse encounters the patient and is ongoing, continuing until discharge from the nurse’s care. Nurses use various tools to facilitate the process of assessment (Crouch and Meurier 2005).

A health assessment involves the collection and analysis of data in order to identify the patient’s problems. The nursing health assessment incorporates a comprehensive health history and a complete physical examination, both of which are used to evaluate the health status of a person; it is a deliberate

CHAPTER 2 Admissions and assessment

and interactive process. The need to solicit information, understand the findings and apply knowledge can initially be daunting to the new nurse. Regardless of who collects the data, a total health assessment is needed when a patient first enters the healthcare system. The nursing assessment should focus on the patient’s response to a health need rather than disease process and pathology (Wilkinson 2007). The process of assessment requires nurses to make accurate and relevant observations and to gather, validate and organize data; this process supports the nurse in making judgements to determine care and treatment needs. The nursing assessment should include physical, psychological, spiritual, social and cultural dimensions; it is vital that these dimensions are explored with the person being assessed. Effective patient assessment is integral to the safety, continuity and quality of patient care. The main principles of assessment fulfil the nurse’s legal and professional obligations in practice (Table 2.2).

to indicate their subjective experience more easily, gives them an increased sense of participation (Kearney  2001) and prevents them from being distanced from the process by nurses rating their symptoms and concerns (Brown et al. 2001). Many authors have demonstrated the advantages of increasing patient participation in assessment by the use of patient self-assessment questionnaires (Rhodes et al. 2000). The methods used to facilitate patient assessment are important adjuncts to assessing patients in clinical practice. There is a danger that too much focus can be placed on the framework, system or tool, preventing nurses from thinking about the significance of the information that they are gathering from the patient (Harris et al. 1998). Rather than following assessment structures and prompts rigidly, it is essential that nurses utilize their critical thinking and clinical judgement throughout the process in order to continually develop their skills in eliciting information about patients’ concerns and use this to inform care planning (Edwards and Miller 2001).

Assessment tools

Structure of assessment

Assessment tools in clinical practice can be used to assess a patient’s general needs – for example, via the Supportive Care Needs Survey (Bonevski et  al.  2000)  –  or to assess a specific problem – for example, via the Oral Assessment Guide (Eilers et al. 1988). The choice of tool depends on the clinical setting, although, in general, the aim of using an assessment tool is to link the assessment of clinical variables with the measurement of clinical interventions (Frank-Stromborg and Olsen 2004). To be useful in clinical practice, an assessment tool must be simple and acceptable to patients, have a clear and interpretable scoring system, and demonstrate reliability and validity (Brown et al. 2001). The use of patient self-assessment tools appears to facilitate the process of assessment in a number of ways. It enables patients

Table 2.2  Principles of assessment 1

Assessment is patient focused, being governed by the notion of an individual’s actual, potential and perceived needs.

2

It provides baseline information from which to plan the interventions to be used and decide the outcomes of care to be achieved.

3

It facilitates evaluation of the care given and is a dimension of care that influences a patient’s outcome and potential survival.

4

It is a dynamic process that starts when problems or symptoms develop and continues throughout the care process, accommodating continual changes in the patient’s condition and circumstances.

5

It is an interactive process in which the patient actively participates.

6

Optimal functioning, quality of life and the promotion of independence should be primary concerns.

7

The process includes observation, data collection, clinical judgement and validation of perceptions.

8

Data used for the assessment process are collected from several sources by a variety of methods, depending on the healthcare setting.

9

To be effective, the process must be structured and clearly documented.

Source: Adapted from Alfaro-LeFevre (2014), NMC (2018), Teytelman (2002), White (2003).

Structuring patient assessment is vital to monitoring the success of care and detecting the emergence of new problems. There are many conceptual frameworks or nursing models, such as Roper’s model for assessing activities of daily living (Roper et  al.  2000), Orem’s self-care model (Orem et  al.  2001) and Gordon’s functional health patterns framework (Gordon, 1994). There remains, however, much debate about the effectiveness of such models for assessment in practice, with some arguing that individualized care can be compromised by fitting patients into a rigid or complex structure (Kearney  2001, McCrae  2012). Nurses therefore need to take a pragmatic approach and utilize assessment frameworks that are appropriate to their particular area of practice. The framework of choice at The Royal Marsden NHS Foundation Trust is based on Gordon’s functional health patterns framework (Box 2.1; Gordon 1994). This framework facilitates an assessment that focuses on patients’ and families’ problems and functional status; the framework applies clinical cues to interpret deviations from the patient’s usual patterns (Johnson 2000). Gordon’s functional health patterns framework is applicable to all levels of care, allowing problem areas to be identified. Information derived from the patient’s initial functional health patterns is crucial for interpreting both the patient’s and their family’s pattern of response to disease and treatment.

Types of patient assessment

There are several types of assessment, including mini assessment, comprehensive assessment, focused assessment and on­going assessment (Box 2.2).

Box 2.1  Gordon’s functional health patterns • Health perception and health management • Nutrition and metabolism • Elimination • Activity and exercise • Sleep and rest • Cognition and perception • Self-perception and self-concept • Coping and stress tolerance • Roles and relationships • Sexuality and reproductivity • Values and beliefs Source: Adapted from Gordon (1994) with permission of Mosby / Elsevier.

17

THE ROYAL MARSDEN MANUAL OF CLINICAL NURSING PROCEDURES

Box 2.2  Types of patient assessment

18

Mini assessment A snapshot view of the patient based on a quick visual and physical assessment. Consider the patient’s ABC (airway, breathing and circulation), then assess mental status, overall appearance, level of consciousness and vital signs before focusing on the patient’s main problem. Comprehensive assessment An in-depth assessment of the patient’s health status, risk factors, and psychological and social aspects of health, along with a physical examination; it usually takes place on admission or transfer to a hospital or healthcare agency. It also considers the patient’s health status prior to admission. Focused assessment An assessment of a specific condition, problem, identified risk or care need  –  for example, continence assessment, nutritional assessment, neurological assessment following a head injury, assessment for day care or outpatient consultation for a specific condition. Ongoing assessment Continuous assessment of the patient’s health status accompanied by monitoring and observation of specific problems identified in a mini, comprehensive or focused assessment. Source: Ahern and Philpot (2002), Holmes (2003), White (2003).

Learning Activity 2.1   Learning into practice 1 Is there a model of nursing or care underlying the format and structure for patient admissions in your clinical area? What is it? 2 Critically appraise how it affects the assessment process. 3 Reflect on your daily practice and identify whether you are carrying out the types of assessment identified in Box 2.2. 4 Consider the rationales for and the pros and cons of these different types of assessment.

EVIDENCE-BASED APPROACHES

Collecting data

Data collection is the process of gathering information about the patient’s health needs. Information for assessment is collected by means of: • interview • observation • physical examination. This information can consist of both objective and subjective data. Objective data are measurable and can be detected by someone other than the patient. Objective data include vital signs, physical signs and symptoms, and laboratory results. Subjective data are based on what the patient perceives. Subjective data may include descriptions of the patient’s concerns, their support network, their awareness and knowledge of their abilities/disabilities, their understanding of their illness, and their attitude to and readiness for learning (Wilkinson 2007). While the patient is the primary source of information, data may be elicited from a variety of secondary sources including family, friends, other healthcare

professionals and the patient’s medical records (Kozier  2012, Walsh et al. 2007). Assessment is the first and most critical step of the nursing process; it should be systematic and scientific, and should aim to obtain as much accurate and relevant information or data about the patient as possible. Inadequate data or omissions may lead to inaccurate or incorrect judgements.

Assessment interviews

Communication is vital to assessment. It is important to build a good rapport with the patient. The initial assessment interview not only allows the nurse to obtain baseline information about the patient but also facilitates the establishment of a therapeutic relationship (Crumbie  2006). It is vital that the nurse demonstrates interest and respect to the patient from the very start of the interview. Some of the information requested is likely to be of a searching and intimate nature, which may be difficult for the patient to disclose. The nurse should emphasize the confidential nature of the discussion and take steps to reduce anxiety and ensure priv­ acy; the patient may modify their words and behaviour depending on the environment. Taking steps to establish trust and develop the relationship early on will set the scene for effective and accurate information exchange (Silverman et al. 2013). Interviewing is a skill and an art; it should be both patient centred and clinician centred. The clinician seeks to elicit the full story of the patient’s symptoms but must also collect key information in order to complete the assessment and develop a plan. Allowing patients to lead the interview process allows clinicians to understand patients’ thoughts, ideas and concerns without adding their own perspective (see Chapter  5: Communication, psychological wellbeing and safeguarding). In contrast, a clinician-centred or symptom-focused interview is used to elicit specific information in order to identify a disease or problem. Evidence suggests that patients are best served by integrating the two styles as the combination of the two approaches conveys the caring attributes of respect, empathy, humility and sensitivity (Fortin et  al.  2012, Haidet and Paterniti 2003). The interview should be open ended, drawing on a range of techniques to cue patients to tell their stories; active listening, guided questioning, non-verbal affirmation, empathetic responses, validation and reassurance are all useful tools (Bickley and Szilagyi 2017).

Observation

Observation is the conscious, deliberate use of the physical senses to gather data from the patient and the environment. For an initial assessment, these observations may include vital signs, physical signs and symptoms, and laboratory results. These are all measurable and objective.

Physical examination

Physical examination is a systematic assessment of all body systems and is concerned with identifying strengths and deficits in the patient’s functional abilities. Physical examination elicits both objective and subjective data as it combines elements of both interviewing and observation. It is important to remember that physical examination can be viewed with some anxiety as patients can feel vulnerable, exposed and apprehensive. Good communication (both verbal and non-verbal), together with observational skills, is key, as are ensuring that the environment is appropriate and that all required equipment is readily available.

Principles of an effective nursing assessment

The admitting nurse is responsible for ensuring that an initial assessment is completed when the patient is admitted. The patient’s needs, identified following this process, must then be documented in their care plan. Box  2.3 discusses each area of assessment, indicating points for consideration and suggesting questions that it may be helpful to ask the patient as part of the assessment process.

CHAPTER 2 Admissions and assessment

Box 2.3  Points for consideration and suggested questions for use during the assessment process 1  Cognitive and perceptual ability Communication The nurse needs to assess the level of sensory functioning with or without aids/support (such as hearing aid(s), speech aid(s), glasses or contact lenses) and the patient’s capacity to use and maintain aids/support correctly. Furthermore, it is important during this part of the assessment to assess whether there are or might be any potential language or cultural barriers. Knowing the norm within the patient’s culture will facilitate understanding and lessen miscommunication (Galanti 2000). • How good are the patient’s hearing and eyesight? • Is the patient able to express their views and wishes using appropriate verbal and non-verbal methods of communication in a manner that is understandable by most people? • Are there any potential language or cultural barriers to communicating with the patient? For further information see Chapter 5: Communication, psychological wellbeing and safeguarding. Information During this part of the assessment, the nurse will assess the patient’s ability to comprehend the present environment without showing levels of distress. This will help to establish whether there are any barriers to the patient’s understanding of their condition and treatment. It may help them to be in a position to give informed consent. • Is the patient able and ready to understand any information about their forthcoming treatment and care? Are there any barriers to learning? • Is the patient able to communicate an understanding of their condition, plan of care and potential outcomes/responses? • Will they be able to give informed consent? Neurological It is important to assess the patient’s ability to reason logically and decisively, and determine that they are able to communicate in a contextually coherent manner. • Is the patient alert and orientated to time, place and person? For further information see Chapter 14: Observations. Pain To provide optimal patient care, the assessor needs to have appropriate knowledge of the patient’s pain and an ability to identify the pain type and location. Assessment of a patient’s experience of pain is a crucial component in providing effective pain management. Dimond (2002) asserts that it is unacceptable for patients to experience unmanaged pain or for nurses to have inadequate knowledge about pain. Pain should be measured using an assessment tool that identifies the quantity and/or quality of one or more of the dimensions of the patient’s experience of pain. During the assessment, the nurse should also observe for signs of neuropathic pain, including descriptions such as shooting, burning or stabbing, and descriptions consistent with allodynia (pain associated with gentle touch) (Jensen et al. 2003, Rowbotham and MacIntyre 2003, Schug et al. 2015). • Is the patient pain free at rest and/or on movement? • Is the pain a primary complaint or a secondary complaint associated with another condition? • What is the location of the pain and does it radiate? • When did it begin and what circumstances are associated with it? • How intense is the pain, at rest and on movement? • What makes the pain worse and what helps to relieve it? • How long does the pain last – for example, continuous, intermittent? • Ask the patient to describe the character of the pain using quality/sensory descriptors, such as sharp, throbbing or burning. For further details regarding pain assessment, see Chapter 10: Pain assessment and management. 2  Activity and exercise Respiratory Respiratory pattern monitoring addresses the patient’s breathing pattern, rate and depth. • Does the patient have any difficulty breathing? • Is there any noise when they are breathing, such as wheezing? • Does breathing cause them pain? • How deep or shallow is their breathing? • Is their breathing symmetrical? • Does the patient have any underlying respiratory problems, such as chronic obstructive pulmonary disease, emphysema, tuberculosis, bronchitis, asthma or any other airway disease? • If appropriate, discuss smoking cessation. For further details see Chapter 12: Respiratory care, CPR and blood transfusion. Cardiovascular A basic assessment is carried out and vital signs such as pulse (rhythm, rate and intensity) and blood pressure should be noted. Details of cardiac history should be taken for this part of the assessment. Medical conditions and experience of previous surgery should be noted. • Does the patient take any cardiac medication? • Do they have a pacemaker? (continued)

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Box 2.3  Points for consideration and suggested questions for use during the assessment process (continued)

20

Physical abilities; personal hygiene, mobility and toileting; independence with activities of daily living The aim during this part of the nursing assessment is to establish the level of assistance required by the person to tackle activities of daily living such as walking and use of stairs. An awareness of obstacles, level of independent mobility and dangers to personal safety is an important factor and part of the assessment. • Is the patient able to stand, walk and go to the toilet? • Is the patient able to move up and down, roll and turn in bed? • Does the patient need any equipment to be mobile? • Has the patient good motor power in their arms and legs? • Does the patient have any history of falling? • Can the patient take care of their own personal hygiene needs independently or do they need assistance? • What type of assistance do they need – for example, do they need help with mobility or fine motor movements such as doing up buttons or shaving? It might be necessary to complete a separate manual handling risk assessment – see Chapter 7: Moving and positioning. 3 Elimination Gastrointestinal During this part of the assessment, it is important to determine a baseline with regard to independence. • Is the patient able to attend to their elimination needs independently and is the patient continent? • What are the patient’s normal bowel habits? Are bowel movements within the patient’s own normal pattern and consistency? • Does the patient have any underlying medical conditions, such as Crohn’s disease or irritable bowel syndrome? • Does the patient have diarrhoea or are they prone to having – or currently having – constipation? • How does this affect the patient? For further discussion see Chapter 6: Elimination. Genitourinary This part of the assessment is focused on the patient’s baseline observations with regard to urinary continence/incontinence. It is also important to note whether there is any penile or vaginal discharge or bleeding. • Does the patient have a urinary catheter in place? If so, note the type, size and date of insertion. If the patient previously had a urinary catheter, note the date it was removed. Urinalysis results should also be noted here. • How often does the patient need to urinate (frequency)? • How immediate is the need to urinate (urgency)? • Do they wake in the night to urinate (nocturia)? • Are they able to maintain control over their bladder at all times (incontinence – inability to hold urine)? For further discussion see Chapter 6: Elimination. 4  Nutrition and oral care Oral care As part of the inpatient admission assessment, the nurse should obtain an oral health history that includes oral hygiene beliefs and practices, and current state of oral health. During this assessment it is important to be aware of treatments and medications that affect the oral health of the patient. If deemed appropriate, use an oral assessment tool to perform the initial and ongoing oral assessments. • Lips – are they pink, moist and intact? • Gums – are they pink, with no signs of infection or bleeding? • Teeth – are there dentures, a bridge, crowns or caps? For details on how to conduct a full oral assessment, see Chapter 9: Patient comfort and supporting personal hygiene. Hydration An in-depth assessment of hydration will provide the information needed for nursing interventions aimed at maximizing wellness and identifying problems for treatment. The assessment should ascertain whether the patient has any difficulty drinking. During the assessment, the nurse should observe signs of dehydration – for example, dry mouth, dry skin, thirst or whether the patient shows any signs of an altered mental state. • Is the patient able to drink adequately? If not, why not? • How much and what does the patient drink? • Note the patient’s alcohol intake in the format of units per week (see Figure 2.2). • Also note their caffeine intake, measured in number of cups per day. Nutrition A detailed diet history provides insight into a patient’s baseline nutritional status. Assessment includes questions regarding chewing or swallowing problems; avoidance of eating related to abdominal pain; changes in appetite, taste or intake; and the use of a special diet or nutritional supplements. A review of past medical history should identify any relevant conditions and highlight increased metabolic needs, altered gastrointestinal function and the patient’s capacity to absorb nutrients. • What is the patient’s usual daily food intake? • Do they have a good appetite?

CHAPTER 2 Admissions and assessment

• Are they able to swallow/chew the food – any dysphagia? • Is there anything they don’t or can’t eat? • Have they experienced any recent weight changes or taste changes? • Are they able to eat independently? (adapted from Arrowsmith 1999, BAPEN and Malnutrition Advisory Group 2000, DH 2005) For further information on hydration and nutrition, see Chapter 8: Nutrition and fluid balance. Nausea and vomiting During this part of the assessment, the nurse should ascertain whether the patient has any history of nausea and/or vomiting. Nausea and vomiting can cause dehydration, electrolyte imbalance and nutritional deficiencies (Marek  2003), and can also affect a patient’s psychosocial wellbeing. They may become withdrawn, isolated and unable to perform their usual activities of daily living. • Does the patient feel nauseous? • Is the patient vomiting? If so, what are the frequency, volume, content and timing? • Does nausea precede vomiting? • Does vomiting relieve nausea? • When did the symptoms start? Did they coincide with changes in therapy or medication? • Does anything make the symptoms better? • Does anything make the symptoms worse? • What is the effect of any current or past antiemetic therapy, including dose, frequency, duration, effect and route of administration? • What is the condition of the patient’s oral cavity? (adapted from Perdue 2005) For further discussion see Chapter 6: Elimination. 5 Skin A detailed assessment of a patient’s skin is an essential part of the admission and care process. The ASSKING bundle is a tool that can be used to help staff and patients to monitor skin concerns and proactively reduce the risk of developing a pressure ulcer. Documenting each aspect of the ASSKING checklist can help to achieve this (MacDonald and RMH Pressure Ulcer MDT Collaborative 2019). ASSKING stands for: A S S K I N G

ssessment of risk kin inspection and care upport surface selection and use eep your patient moving ncontinence and moisture care utrition and hydration management iving information

For further information see Chapter 17: Wound management. 6  Controlling body temperature This assessment is carried out to establish the patient’s baseline temperature, determine whether the temperature is within the normal range, and ascertain whether there might be intrinsic or extrinsic factors causing altered body temperature. It is important to note whether any changes in temperature are in response to specific therapies (e.g. antipyretic medication, immunosuppressive therapies, invasive procedures or infection) (Bickley and Szilagyi  2017). White blood count should be recorded to determine whether it is within normal limits (see Chapter 14: Observations). • Is the patient feeling excessively hot or cold? • Have they been shivering or sweating excessively? 7  Sleep and rest This part of the assessment is performed to find out sleep and rest patterns and reasons for variation. The nurse should document the patient’s description of their sleep patterns and routines, and the habits they use to achieve a comfortable sleep. The nurse should also include the presence of emotional and/or physical problems that may interfere with sleep. • Does the patient have enough energy for desired daily activities? • Do they tire easily? • Do they have any difficulty falling asleep or staying asleep? • Do they feel rested after sleep? • Do they sleep during the day? • Do they take any aids to help them sleep? • What are their normal hours for going to bed and waking? (continued)

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Box 2.3  Points for consideration and suggested questions for use during the assessment process (continued)

22

8  Stress and coping This assessment is focused on the patient’s perception of stress and their coping strategies. Support systems should be evaluated and symptoms of stress should be noted. This assessment includes the individual’s reserve or capacity to resist challenges to selfintegrity, and their modes of handling stress. The effectiveness of a person’s coping strategies in terms of stress tolerances may be further evaluated. • What are the things in the patient’s life that are stressful? • What do they do when they are stressed? • How do they know they are stressed? • Is there anything they do to help them cope when life gets stressful? • Is there anybody they go to for support? (adapted from Gordon 1994) 9  Roles and relationships It is important to understand the patient’s role in the world and their relationships with others. Assessment in this area includes finding out about the patient’s perceptions of the major roles and responsibilities they have in life, and about satisfaction and/or disturbances in their family, work and/or social relationships. An assessment of home life should be undertaken and must include how the patient will cope at home post-discharge, how those at home (e.g. dependants, children and/or animals) will cope while they are in hospital, and whether they have any financial concerns. • Who is at home? • Are there any dependants? (Include children, pets and anybody else the patient cares for.) • What responsibilities does the patient have for the day-to-day running of the home? • What will happen if they are not there? • Do they have any concerns about their home while they are in hospital? • Are there any financial issues related to their hospital stay? • Will there be any issues related to employment or study while they are in hospital? 10  Perception/concept of self This assessment concerns body image or self-esteem. Body image is highly personal, abstract and difficult to describe. The rationale for this section is to assess the patient’s level of understanding and general perception of self. This includes their attitudes about self, their perception of their abilities (cognitive, affective and physical), their body image, their identity, their general sense of worth and their general emotional pattern. An assessment of body posture and movement, eye contact, voice and speech patterns should also be included. • How do you describe yourself? • How do you feel about yourself most of the time? • Has it changed since your diagnosis? • Have there been changes in the way you feel about yourself or your body? 11  Sexuality and reproduction Understanding sexuality as the patient’s perceptions of their own body image, family roles and functions, relationships and sexual function can help the assessor to improve assessment and diagnosis of actual or potential alterations in sexual behaviour and activity. • Are you currently in a relationship? • Has your condition had an impact on the way you and your partner feel about each other? • Has your condition had an impact on the physical expression of your feelings? • Has your treatment or current problem had any effect on your interest in being intimate with your partner? 12  Values and beliefs This area concerns the patient’s religious, spiritual and cultural beliefs. The aim is to assess the patient’s needs in this area to provide culturally and spiritually specific care while concurrently providing a forum to explore spiritual strengths that might be used to prevent problems or cope with difficulties. A patient’s experience of their stay in hospital may be influenced by their religious beliefs or other strongly held principles, cultural background or ethnic origin. • Are there any spiritual or cultural beliefs or practices that are important to you? • Do you have any specific dietary needs related to your religious, spiritual or cultural beliefs? • Do you have any specific personal care needs related to your religious, spiritual or cultural beliefs (e.g. washing rituals, dress)? 13  Health perception and management This assessment concerns any relevant medical conditions, side-effects and complications of treatment. The nurse should document the patient’s perceived pattern of health and wellbeing and how their health is managed. Any relevant history of previous health problems, including side-effects of medication, should be noted. Examples of other useful information that should be documented are compliance with medication regimen, use of health promotion activities (such as regular exercise) and whether the patient has annual check-ups. • What does the patient know about their condition and planned treatment? • How would they describe their current overall level of fitness? • What do they do to keep well: exercise, diet, annual check-ups or screening?

CHAPTER 2 Admissions and assessment

Figure 2.2  Examples of 1 unit of alcohol. Source: Drinkaware (2019). Reproduced with permission of Drinkaware.

23

What does 1 unit of alcohol look like? 218ml

Standard 4.5% cider You shouldn’t regularly exceed

76ml

Standard 13% wine

25ml

Standard 40% whiskey

250ml

Standard 4% beer

250ml

Standard 4% alcopop (275ml)

14

UNITS

per week

Learning Activity 2.2  Clinical application Conducting an initial assessment on a patient being admitted to hospital can sometimes become a lengthy ‘question and answer’ activity, with the nurse asking many questions using the admissions framework as a template, and the patient providing relatively brief, focused answers. Consider an alternative approach to the admission of Mrs Beth Jones, aged 78, being admitted for gynaecological surgery for postmenopausal bleeding. The medical notes and letters to the GP inform you that she lives in a bungalow with her 85-year-old husband, who has mild dementia. Beth is his main carer. Beth has osteoarthritis and has undergone bilateral hip and right-knee replacements in the past. She also has diverticular disease, for which she takes Fybogel. Write down some ways you could conduct Beth’s assessment to minimize the use of closed, short questions. See the answers on the companion site of this student edition: www.royalmarsdenmanual.com/student10e.

POST-PROCEDURAL CONSIDERATIONS

Care planning

The purpose of collecting information through the process of assessment is to enable the nurse to make a series of clinical judgements (which are known in some circumstances as nursing diagnoses), and subsequently decisions about the nursing care each individual needs. Nursing diagnoses provide a focus for planning and implementing effective and evidence-based care. This process consists of identifying nursing-sensitive patient outcomes and determining appropriate interventions (AlfaroLeFevre 2014, Shaw 1998, White 2003). The key steps are: • To determine the immediate priorities and recognize whether the patient’s problems require nursing care or whether a referral should be made to someone else. • To identify the anticipated outcome for the patient, noting what the patient will be able to do and within what time frame. The use of ‘measurable’ verbs that describe patient behaviour or what the patient says facilitates the evaluation of patient outcomes (Box 2.4). • To determine the nursing interventions – that is, what nursing actions will prevent or manage the patient’s problems so that the patient’s outcomes may be achieved.

Box 2.4  Examples of measurable and non-­ measurable verbs for use in outcome statements Measurable verbs (use these to be specific) • state, verbalize, communicate, list, describe, identify • demonstrate, perform • will lose, will gain, has an absence of • walk, stand, sit Non-measurable verbs (do not use) • know • understand • think • feel Source: Reproduced from Alfaro-LeFevre (2014) with permission of Lippincott Williams & Wilkins.

• To record the care plan for the patient, which may be written or individualized from a standardized (sometimes called ‘core’) care plan or a computerized care plan. Outcomes should be patient focused and realistic, stating how the outcomes or goals are to be achieved and when the outcomes should be evaluated. Outcomes may be short, intermediate or long term, enabling the nurse to identify the patient’s health status and progress (stability, improvement or deterioration) over time. Setting realistic outcomes and interventions requires the nurse to distinguish between nursing diagnoses that are life threatening or an immediate risk to the patient’s safety, and those that may be dealt with at a later stage. It is important to continue to assess the patient on an ongoing basis while implementing the care planned. Assessing the patient’s current status prior to implementing care will enable the nurse to check whether the patient has developed any new problems that require immediate action. During and after any nursing intervention, the nurse should assess and reassess the patient’s response to care. The nurse will then be able to determine whether changes to the patient’s care plan should be made immediately or at a later stage. If there are any patient care needs that require immediate action  –  for example, consultation or referral to a doctor  –  recording the actions taken is essential. Involving the patient and their family or friends will promote the patient’s wellbeing and self-care abilities. The use of clinical docu­mentation in the nursing shift report, or ‘handover’, will help to ensure that the care plans are up to date and relevant (Alfaro-LeFevre 2014, White 2003).

THE ROYAL MARSDEN MANUAL OF CLINICAL NURSING PROCEDURES

Evaluating care Learning Activity 2.3

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Learning into practice Core care plans and care pathways are increasingly being used to plan and deliver patient care. These are primarily created to reflect the medical diagnosis linked to a standardized treatment or management protocol. However, patients will have additional, individual needs for nursing care that lie outside the core care plan, so it is vitally important that nurses are able to create a person-centred care plan for their patients to supplement those documented in any pre-designed document. Mr Angus McKay is 64 years old and has presented with shortness of breath and a productive cough. Initial investigations suggest he has pneumonia. Intravenous (IV) antibiotics and an IV infusion have been commenced. On admission, he states that he has unintentionally lost a stone in weight in the past month. The medical team has started to investigate some possible causes of these symptoms. Angus is a dairy farmer and lives with his wife and adult son some 30 miles away. Develop a care plan to include: 1 Problems that Angus may be concerned about 2 Goals of care 3 Nursing interventions See the answers on the companion site of this student edition: www.royalmarsdenmanual.com/student10e.

Effective evaluation of care requires the nurse to critically analyse the patient’s health status to determine whether the patient’s condition is stable, has deteriorated or has improved. Seeking the patient’s and their family’s views in the evaluation process will facilitate decision making. By evaluating the patient’s outcomes, the nurse is able to decide whether changes need to be made to the care planned. Evaluation of care should take place in a structured manner and on a regular basis by a registered nurse.

Documentation

Nurses have a professional responsibility to ensure that healthcare records provide an accurate account of treatment, care planning and delivery, and are viewed as a tool of communication within the team. There should be clear evidence of the care planned, the decisions made, the care delivered and the information shared (NMC 2018) (Box  2.5). The content and quality of record keeping are a measure of standards of practice relating to the skills and judgement of the nurse (NMC 2018).

Observation DEFINITION

Observation is the conscious, deliberate use of the physical senses to gather data from the patient and the environment. Observation occurs whenever the nurse is in contact with the patient. At each patient contact, it is important for the nurse to

Box 2.5  The Royal Marsden NHS Trust’s guidelines for nursing documentation (2011) (adopted in line with NMC 2018) Assessment and care planning 1 The first written assessment and the identification of the patient’s immediate needs must begin within 4 hours of admission. This must include any allergies or infection risks of the patient and the contact details of the next of kin. 2 The following must be completed within 24 hours of admission and updated as appropriate: • nutritional, oral, pressure ulcer and manual handling risk assessments; • other relevant assessment tools, for example pain and wound assessment or a venous thromboembolism (VTE) assessment. 3 All sections of the nursing admission assessment must be completed at some point during the patient’s hospital stay along with the identification of the patient’s care needs. If it is not relevant or if it is inappropriate to assess certain functional health patterns (e.g. if the patient is unconscious) then the reasons should be indicated accordingly. The ongoing nursing assessment should identify whether the patient’s condition is stable, has deteriorated or has improved. 4 Wherever possible, care plans should be written with the involvement of the patient, in terms that they can understand, and include: • patient-focused, measurable, realistic and achievable goals; • nursing interventions reflecting best practice; • relevant core care plans that are individualized, signed, dated and timed. 5 Update the care plan with altered or additional interventions as appropriate. 6 The nursing documentation must be referred to at shift handover so it needs to be kept up to date. Principles of assessment 1 Assessment should be a systematic, deliberate and interactive process that underpins every aspect of nursing care (Heaven and Maguire 1996). 2 Assessment should be seen as a continuous process (Cancer Action Team 2007). Structure of assessment 1 The structure of a patient assessment should take into consideration the speciality and care setting and also the purpose of the assessment. 2 Functional health patterns provide a comprehensive framework for assessment, which can be adapted for use within a variety of clinical specialities and care settings (Gordon 1994). Methods of assessment 1 Methods of assessment should elicit both subjective and objective assessment data. 2 An assessment interview must be well structured and progress logically in order to facilitate the nurse’s thinking and to make the patient feel comfortable in telling their story.

CHAPTER 2 Admissions and assessment

3 Specific assessment tools should be used, where appropriate, to enable nurses to monitor particular aspects of care, such as symptom management (e.g. pain, fatigue), over time. This will help the nurse to evaluate the effectiveness of nursing interventions and it also often provides an opportunity for patients to become more involved in their care (O’Connor and Eggert 1994). Decision making 1 Nurses should be encouraged to provide a rationale for their clinical judgements and decision making within their clinical ­practice (NMC 2018). Planning and implementing care 1 When planning care, it is vital that nurses recognize whether patient problems require nursing care or whether a referral should be made to someone else. 2 When a nursing problem has been recognized, the anticipated outcome for the patient must be identified in a manner that is specific, achievable and measurable (NMC 2018). 3 Nursing interventions should be determined with the aim of addressing the nursing need and achieving the desired outcomes. Evaluating care 1 Nursing care should be evaluated using measurable outcomes on a regular basis with interventions adjusted accordingly. 2 Progress towards achieving outcomes should be recorded in a concise and precise manner. Using a method such as charting by exception can facilitate this (Murphy 2003). Documenting and communicating care 1 The content and quality of record keeping are a measure of standards of practice relating to the skills and judgement of the nurse (NMC 2018). 2 In addition to the written record of care, the important role that the handover plays in the communication and continuation of patient care should be considered, particularly when considering the role of electronic records.

try to develop a sequence of observations. These might include the following:

The components of a thorough health history are (Bickley and Szilagyi 2017):

1 On approaching the patient, observe for signs of distress, such as pallor, laboured breathing, and behaviours indicating pain or emotional distress. 2 Scan the area for safety hazards, such as any floor spillages. 3 Look at the equipment, such as urinary catheter, intravenous pumps, oxygen and monitors. 4 Notice other people in the area – who is there and how do these people interact with the patient? 5 Observe the patient more closely for physical data such as skin temperature, breath sounds, drainage and dressing odours, condition of drains and dressings, and need for repositioning (Wilkinson 2007).

• chief complaint • history of chief complaint • past medical history • family history • social history • systems review.

Accurate measurements of the patient’s vital signs provide ­crucial information about body functions (see Chapter  14: Observations).

Physical assessment Patient assessment should be systematic; it can be defined as the systematic collection of information concerning the patient’s health status with the aim of identifying the patient’s current health status, actual and potential health problems, and areas for health improvement (Estes 2013).

DEFINITION

Physical examination is the systematic assessment of all body systems; it is concerned with identifying strengths and deficits in the patient’s functional abilities. Physical assessment provides objective data that can be used to validate the subjective data gained when taking the patient’s history (Wilkinson 2007). The patient’s history is one of the most important components of a physical assessment; the history guides the nature of  the physical assessment that needs to be carried out (Peacock 2004).

The findings of the history will determine which body system to examine and what investigations are required; the nurse will determine whether a focused or comprehensive physical examination is required based on the patient’s clinical presentation (Baid 2006). The aims of the physical examination are: • to identify potential diagnoses • to make a diagnosis • to obtain information on the patient’s overall health status • to enable additional information to be obtained about any symptoms reported by the patient • to detect changes in the patient’s condition • to evaluate how the patient is responding to interventions • to establish the patient’s fitness for surgery or anaesthetic (Abbott and Ranson 2017; Crouch and Meurier 2005). During the physical assessment, a systematic approach is taken to build on the patient’s history, using the key assessment skills of inspection, palpation, percussion and auscultation (Figure 2.3).

ANATOMY AND PHYSIOLOGY

When examining an area of the body, it is essential to understand the basic anatomy of that area. This will ensure that the appropriate system is examined and that the findings of the examination are understood. It will also help in the formation of differential diagnoses and in ensuring that appropriate investigations are ordered.

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26

Figure 2.3  Physical assessment framework. Source: Reproduced from Baid (2006) with permission of MA Healthcare Limited. Identification of purpose of physical assessment

Health history

Focused assessment

Comprehensive assessment

Inspection

Alongside history taking and investigations, physical assessment is essential to helping a patient from their presenting complaint to diagnosis and treatment. Successful assessment requires critical thinking skills and a good knowledge base to decide which assessments to make, how much information is needed and how to get the information (Wilkinson 2007). The clinical reasoning model permits the clinician to question and examine an existing problem in order to formulate and critically analyse a comprehensive hypothesis, elaborate strategies, establish a diagnosis and initiate a treatment (Barrows and Pickell 1991). This model represents a step-by-step approach to the clinical decision-making process (Walsh 2006b); it is ‘the art of thinking about your thinking while you’re thinking so as to make your thinking more clear, precise, accurate, relevant, consistent, and fair’ (Paul 1988, pp.2–3). The systems that this chapter will cover are respiratory, cardiovascular and abdominal. Neurological examination is covered in Chapter 14: Observations.

EVIDENCE-BASED APPROACHES

Palpation

Rationale

Percussion

Before commencing a physical assessment, a detailed health history should be taken. The patient’s present complaints, the findings of the history taking, and the nurse’s knowledge of anatomy and physiology will determine which body system to examine and what investigations are required (Price et  al.  2000). Furthermore, it is also important to consider the patient’s entire problem, including from social and psychological perspectives (Barrows and Pickell 1991). Each system-based examination is divided into the following categories:

Auscultation

Interpretation of clinical findings

Recognition of abnormality

RELATED THEORY

Differential diagnosis

• inspection (looking) • palpation (feeling) • percussion (tapping) • auscultation (listening).

Inspection

Clinical decision making

Learning Activity 2.4 Clinical application Try to observe at least five different people carrying out ­clinical assessments of patients in your clinical area. As you do this: • Note their questioning technique, and observe and listen to the patients’ responses. • Ask the professionals to explain their thinking and ­rationale for their history-taking and clinical-assessment practice. • Discuss with them their impressions, decisions and diagnoses arising from their clinical assessment. Then write a reflective account of one observed assessment, identifying your learning and what skills or techniques you would adopt as a result of the observation and use in the future.

Inspection is simply observing the patient while looking for the presence or absence of physical signs that confirm or refute the differential diagnoses obtained from the history (Dover et al. 2018). A general survey of the patient should include observations of posture, gait, height and weight, posture, mood and alertness (Bickley and Szilagyi 2017). Prior to taking a history, the nurse should introduce themselves to the patient and define their role. The patient may be particularly worried that the examination will identify a serious problem so it is important to build a rapport and trust. The nurse should provide the patient with their full attention and use appropriate facial expressions. After introducing themselves, the nurse should ask the patient open-ended questions to facilitate conversation (Jarvis 2016). Closed questions can be used to ask for specific information and clarifying questions can be used where appropriate. The nurse must ensure the patient feels confident to share information. During the interview and the physical examination, the nurse should continue to observe the patient’s behaviour, general demeanour and appearance. Having the opportunity to take the patient’s history often allows subtle clues about their health to be identified. For example, a patient’s voice can provide important clues about neurological and respiratory functions (Baid 2006). The precise points to consider during inspection are informed to some extent by the history; however, inspection starts as soon as the nurse first sees the patient. This is called the ‘global view of the patient’, ‘general survey’ or ‘first impression’ (Innes et al. 2018).

CHAPTER 2 Admissions and assessment

Inspection will then continue throughout the physical examination (Seidel et  al.  2011). Typically, the first impression includes looking at the patient as a whole, examining the nails, skin and eyes, and assessing vital signs (Rushforth  2009, Swartz  2014, Tidman 2018). The following should be considered: • General appearance: are they well kept? Are they wearing appropriate clothing? • Nutrition: do they look well nourished? • Pain: do they appear to be in any pain? What is their facial expression? • Nausea and vomiting: are they retching? • Posture and gait: how do they get into the room? Walk? Limp? Wheelchair? • Orientation: are they orientated to time and place? (see Chapter 14: Observations) • Consciousness: what is their level of consciousness? (see Chapter 14: Observations) • Symmetry: are they moving both sides of their body symmetrically? • Speech: is their speech impaired? Once inspection has been completed, the nurse should move on to the system(s) of concern and examine the area(s) closely.

Palpation

Palpation requires use of the whole hand (including the palm and the full length of the fingers) using touch to feel and assess an area (Bickley and Szilagyi 2017, Rushforth 2009, Swartz 2014). This includes assessment of: • texture • tenderness • temperature • contours • pulse • lymph nodes • moisture • mobility.

Auscultation

Auscultation involves listening to various sounds in the body using a stethoscope (Bickley and Szilagyi 2017, Rushforth 2009). A stethoscope is a medical device and has a bell and a diaphragm (Figure 2.4), which is often used to listen to internal sounds of the

Table 2.3  Different sounds heard on percussion Sound

Quality

Example of source

Flat

Soft, high-pitched, dull sound

Thigh

Dull

Medium-level, thud-like sound

Liver, spleen

Resonant

Loud, low-pitched, hollow sound

Lung

Hyperresonant

Very loud, low, booming, hollow sound

No normal organ

Tympanic

Loud, high-pitched, drum-like sound

Gastric air bubble

Source: Adapted from Bickley and Szilagyi (2017), Rushforth (2009).

Figure 2.4  Stethoscope.

Diaphragm Bell

The order of palpation is not important unless there is an area of pain or tenderness, in which case always examine that area last. There are two variations of palpation: light palpation and deep palpation: • Light palpation requires a gentle touch, depressing the skin with one hand to a maximum of 2 cm (Rushforth 2009). When lightly palpating, temperature, tenderness, texture, moisture, elasticity, pulsation and any superficial organs or masses should be assessed (see Figure 2.21). • Deep palpation uses the same technique as light palpation but often two hands are used, one on top of the other at a depth of around 4 cm, as illustrated in Figure 2.22. When palpating deeply, internal organs and masses should be assessed. As the nurse palpates, they should watch the patient’s face assessing for any discomfort or tenderness (Rushforth 2009).

Binaural

Percussion

Percussion helps to identify organs, allowing assessment of size and shape. The technique is done by laying the tip and first joint of the middle finger flat on the patient, ensuring that no other part of the finger or hand is touching the patient. The joint is then struck in a quick, fluid movement with the fingertip of the middle finger of the other hand (Bickley and Szilagyi 2017), as illustrated in Figure 2.20. The sound produced by the impact is heard as percussion tones called ‘resonance’ (Seidel et al. 2011). The percussion technique is the same for all the structures of the body. The sound produced through percussion can help to identify whether the structures are solid or filled with liquid or air (Table 2.3). It takes experience and practice to be able to hear and identify the different sounds.

Tubing

Eartips

27

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28

human body. The bell should be used to hear low-pitched sounds, for example murmurs; the diaphragm should be used when listening to high-pitched sounds, for example bowel sounds. A goodquality stethoscope will aid diagnosis as more subtle sounds will be heard clearly.

Figure 2.5  Structures of the respiratory system. Source: Reproduced from Peate et al. (2014) with permission of John Wiley & Sons, Ltd.

CLINICAL GOVERNANCE

As in all aspects of care, nurses must be aware of their ethical and legal responsibilities when assessing patients. Issues of honesty and confidentiality are frequently encountered during assessment (Wilkinson 2007).

Consent

The Royal College of Nursing (2017) states that registered nurses must ensure consent is obtained and clearly documented prior to commencing any procedure or treatment. Before gaining consent, information about the procedure should be given to the patient in a clear, honest and jargon-free manner (NMC 2018). According to Burns et al. (2011), there are three main components of valid consent. To be competent (or to have the capacity) to give consent, the patient must:

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• understand the information that has been given • believe that information • be able to retain and evaluate the information so as to make a decision.

PRE-PROCEDURAL CONSIDERATIONS

Prior to commencing a patient assessment, the nurse should prepare the physical environment, taking into consideration the patient’s privacy and dignity (Smith and Rushton 2015).

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Equipment

Prior to the examination, the nurse should ensure the environment is at a suitable temperature and prepare the appropriate equipment. Good preparation of equipment is essential for a competent physical assessment (Crouch and Meurier  2005). The following equipment may be useful as part of a physical examination: • pen torch • stethoscope • examination couch • tongue depressor • ruler (must measure in centimetres and be at least 10 cm long).

during inhalation and exhalation (Bickley and Szilagyi 2017). In order for this to happen smoothly, they are covered in two serous membranes: the visceral pleura and the parietal pleura (Bickley and Szilagyi 2017). The space between these two membranes can occasionally become filled with substances such as air, blood and fluid (Rushforth 2009). The lungs are within the thorax and are protected by the ribcage, which surrounds them; when examining the lungs, it can be helpful to use the thorax as a point of reference when describing the location of findings (Figure 2.7).

Patient preparation

PHYSIOLOGY

During the physical assessment, the use of sheets, blankets and gowns will help to minimally expose the area being examined, maximizing privacy and dignity. Whatever system(s) are being examined, the nurse should organize their steps to minimize the number of times the patient needs to change position (Rushforth  2009). The nurse must consider whether the patient has any needs requiring specific adjustments, whether the patient requires translation and the possibility of a chaperone (Donnelly and Martin 2016).

Respiratory examination ANATOMY

The respiratory system consists of an upper and lower airway (Figure  2.5). The upper airway starts with the nasopharynx and the oropharynx, then continues to the laryngopharynx and the larynx (Rushforth 2009). The lower airway starts at the trachea, which divides into two bronchi; these then divide into lobar bronchi, then secondary bronchi, tertiary bronchi, terminal bronchioles, respiratory bronchioles and alveolar ducts (Rushforth 2009). The right lung is made up of three lobes: upper, middle and lower. The left lung only has two lobes: upper and lower (Figure 2.6). The lungs are not stationary but expand and contract

The respiratory system has two main functions: delivery of oxygen to cells and removal of carbon dioxide, which accumulates as a result of cellular metabolism (Moore 2007). The control of ventilation is either voluntary or involuntary. The former involves regulation of the respiratory muscles (intercostal muscles and diaphragm) via the central nervous system. Involuntary control of the respiratory muscles occurs via the respiratory centre (medulla oblongata and pons) in the brain (Moore  2007). Stimulation of the respiratory centre occurs when carbon dioxide levels in arterial blood become elevated. Detection of raised carbon dioxide levels results in an increase in the rate and depth of breathing to aid carbon dioxide removal. Hence, in normal pathology, the trigger for breathing is carbon dioxide (hypercapnia) and not oxygen levels. It is important to note that in a patient with chronic obstructive pulmonary disease (COPD), the trigger for respiration is hypoxia (low oxygen levels). This is due to chronically elevated carbon dioxide levels. Consequently, patients with COPD are at risk of respiratory arrest if over-­ oxygenated (Moore 2007).

RELATED THEORY

The purpose of the respiratory assessment is to further refine the differential diagnoses identified from the patient history. The respiratory assessment will also assess the adequacy of gas

CHAPTER 2 Admissions and assessment

Figure 2.6  Lung, fissures and lobes. RUL, right upper lobe; RML, right middle lobe, RLL, right lower lobe; LUL, left upper lobe; LLL, left lower lobe.

Figure 2.7  Structures of the chest and thorax.

29

Larynx Trachea

Apex of lung

Clavicle

Right lung

Acromion process Scapula Manubrium

RUL

LUL

Horizontal fissure Oblique fissure

Sternum Left lung Xiphoid

RML LLL

RLL

Ribs

Anterior view

(a)

Inspiratory descent

Anterior view

(a)

Left lung

Clavicle Acromion process Thoracic vertebrae

LUL Spinous process of T3

Scapula

RUL

Right lung

LLL

RLL Ribs

Inspiratory descent

(b)

(b)

Posterior view

exchange, the delivery of oxygen to the tissues and the removal of carbon dioxide (Moore 2007). The order of examination for the respiratory system is: • inspection • palpation • percussion • auscultation. Both the anterior (front) and the posterior (back) chest must be examined and the same techniques are used for both sides.

Inspection Respiratory rate

Posterior view

• Rhythm: examples of abnormal rhythms include Kussmaul respirations (rapid deep breathing, as seen in states of acidosis such as diabetic ketoacidosis) and Cheyne–Stokes respirations (apnoeic episodes often seen towards the end of life). • Effort: use of accessory muscles (shoulders and sternocleidomastoid muscles), nasal flaring and pursed lip breathing.

Skin colour

When inspecting skin colour, signs to look out for include: • Peripheral cyanosis: this is usually evident in the skin and nail beds and is indicative of poor circulation. • Central cyanosis: this is usually evident in a bluish tinge of the tongue and lips, and is indicative of circulatory or ventilator problems.

Sputum

When inspecting the respiratory rate, consider the rate, rhythm and effort. Signs to look out for include:

If the patient has a productive cough, inspection of the sputum can help to ascertain possible causes (Fisher and Potter  2017). The following can be indicative:

• Rate: tachypnoea (more than 18 breaths per minute) can be indicative of respiratory distress (acute asthma attack, pain, anxiety). Bradypnoea (less than 10 breaths per minute) can indicate a reduced level of consciousness, opioid overdose or depression of the respiratory centre.

• Purulent, yellow or green: infection. • Mucoid, clear, grey or white: COPD or asthma. • Serous, clear, pink or frothy: pulmonary oedema. • Blood: malignancy, pulmonary embolus, clotting disorders or infection.

THE ROYAL MARSDEN MANUAL OF CLINICAL NURSING PROCEDURES

Table 2.4  Examples of chest deformities

30

Normal adult The thorax in the normal adult is wider than it is deep. Its lateral diameter is larger than its anteroposterior diameter.

Learning Activity 2.5  Case study What would you expect to find in relation to the following issues, on initial examination of Angus McKay (see Learning Activity 2.3)? Remember that Angus has presented with shortness of breath and a productive cough. Initial investigations suggest he has pneumonia. 1 Respiratory rate 2 Respiratory rhythm 3 Respiratory effort 4 Skin colour 5 Sputum

Funnel chest (pectus excavation) Possible cause: Marfan syndrome Note the depression in the lower portion of the sternum. Compression of the heart and great vessels may cause murmurs.

See the answers on the companion site of this student edition: www.royalmarsdenmanual.com/student10e.

Barrel chest Possible cause: asthma or chronic obstructive pulmonary disease (COPD) Note the increased anteroposterior diameter. This shape is normal during infancy and often accompanies ageing and COPD.

Chest deformities

Some examples of chest deformities are barrel chest, pigeon chest, funnel chest and flail chest (Table 2.4). Also check for the presence of any scars that could be indicative of previous lung surgery, ­radiotherapy tattoos or previous chest drains (Moore 2007).

Legs

Inspect the legs for any evidence of pulmonary oedema, calf swelling (indicative of a deep vein thrombosis) or erythema nodosum (which can be seen in tuberculosis, sarcoidosis or streptococcal throat infections) (Fisher and Potter 2017).

Anteriorly displaced sternum

Palpation Lymph nodes

Part of palpation when examining the respiratory system is to examine the lymph nodes in the neck. Patients often present with a lump or enlarged lymph nodes (lymphadenopathy), which can be an important sign of infection or malignancy (Dover et al. 2018). To do this, stand behind the patient and examine both sides of the neck at the same time. Use your middle and index fingers to softly palpate in circular movements the lymph nodes in the positions illustrated in Figure 2.8.

Depressed costal cartilages

Ribs close together

Ribs widely spaced

Chest expansion

To assess for chest expansion and symmetry, adopt the position shown in Figure 2.9 and ask the patient to take a deep breath in. You should be able to see your thumbs move an equal distance apart. Reduced expansion may be indicative of fibrosis, consolidation, effusion or pneumothorax (Fisher and Potter 2017).

Spinal convexity to the right (patient bending forward)

Tactile fremitus

Fremitus is the palpable vibration of the patient’s voice through the chest wall (Bickley and Szilagyi  2017). See Figures  2.10 and 2.11 for the appropriate locations to feel for fremitus. Compare the two sides of the chest, using the ball or ulnar surface of your hand (Bickley and Szilagyi  2017). The vibrations felt should be symmetrical and will decrease as you work down the chest wall. Fremitus is usually decreased or absent over the precordium. Asymmetry could indicate:

Expiration Inspiration

• consolidation • emphysema • pneumothorax • plural effusion (Rushforth 2009). Faint or absent fremitus in the upper thorax could indicate: • obstruction of the bronchial tree • fluid • obesity (Rushforth 2009).

Percussion

Pigeon chest (pectus carinatum) Possible cause: severe childhood asthma Note that the sternum is displaced anteriorly, increasing the anteroposterior diameter. The costal cartilages adjacent to the protruding sternum are depressed. Thoracic kyphoscoliosis Note that the abnormal spinal curvatures and vertebral rotation deform the chest. Distortion of the underlying lungs may make interpretation of lung findings very difficult. Traumatic flail chest Multiple rib fractures may result in paradoxical movements of the thorax. As descent of the diaphragm decreases intrathoracic pressure, on inspiration (breathing in) the injured area caves inward; on expiration (breathing out), it moves outward.

When percussing and auscultating, each side of the chest should be compared. To do this, percuss and auscultate in a ladder-like pattern in the positions shown in Figure 2.12.

CHAPTER 2 Admissions and assessment

Figure 2.8  The lymph nodes of the head and neck.

Figure 2.10  Locations for feeling fremitus: back.

31

Preauricular

1

2

1

2

Posterior auricular Occipital

3

4

Superficial cervical

3

4

Tonsillar Submental Submandibular

Posterior cervical Supraclavicular

Figure 2.11  Locations for feeling fremitus: front.

Deep cervical chain

External lymphatic drainage Internal lymphatic drainage (from mouth and throat)

1

Figure 2.9  Position of hands to assess for chest expansion.

1

2

2

3

3

Figure 2.12  Ladder pattern for percussion and auscultation of the chest.

6 7

1

1

2

2

3

3

4

4

5

5

6 7

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32

Resonance is heard over normal aerated lung tissue. There are two main types of percussion notes, which are associated with different lung pathologies. The two notes are dullness and hyperresonance (Fisher and Potter 2017): • Dullness: heard over solid organ or fluid; can be indicative of a pleural effusion, consolidation or pleural thickening. • Hyper-resonance: heard over hyper-inflated lung tissue or where there is air in the pleural space; can be indicative of a pneumothorax or COPD.

Table 2.5  Examples of adventitious sounds Breath sound

Description

Potential cause

Wheeze

High-pitched, hissing sound

Airway narrowing (bronchospasm or airway swelling), e.g. acute asthma attack

Stridor

High-pitched sound, usually on inspiration

Life threatening: due to laryngeal or tracheal obstruction, e.g. choking or anaphylaxis

Coarse crackles

Low-pitched, bubbling, gurgling sound

Pneumonia, bronchiectasis or fluid overload

Fine crackles

High-pitched, popping sound

Restrictive and obstructive diseases, e.g. pulmonary fibrosis

Rhonchi

Continuous, low-pitched, snoring sound

Problems causing obstruction of the trachea or bronchi, e.g. bronchitis

Auscultation

Auscultation should be performed using the bell of the stethoscope (see Figure 2.4) on both the anterior and the posterior chest.

Breath sounds

Normal breath sounds are also known as ‘vesicular breath sounds’; they are soft and are louder and longer on breathing in (inspiration) compared with breathing out (expiration) (Talley and O’Connor  2006). Bronchial breaths sound different; they have a hollow quality and are audible throughout expiration (Talley and O’Connor 2006). There is often a short, silent gap between inspiration and expiration (Bickley and Szilagyi 2017). Adventitious sounds are added sounds on top of breath sounds. See Table 2.5 for examples of adventitious sounds. Vocal resonance can also be assessed as this will give an indication of the lungs’ ability to transmit sound. The method of doing this is to ask the patient to say ‘99’ while auscultating over the chest. The patient’s voice will become clearer in an area of consolidation while their voice will become muffled if there is a pleural effusion (Fisher and Potter  2017). This can be repeated while asking the patient to whisper ‘99’ (whispering pecto­ riloquy); increased transmission of sound will be heard over areas of consolidation.

EVIDENCE-BASED APPROACHES

Rationale

Information obtained from the patient’s history, the differential diagnoses identified, and the nurse’s knowledge of anatomy and physiology will help to inform when it is appropriate to do a respiratory physical examination. Some examples of presentations that would lead to a respiratory examination are: • dyspnoea • cough • chest pain • wheezing.

Procedure guideline 2.1  Respiratory examination Essential equipment • Personal protective equipment • Stethoscope • Examination couch Action

Rationale

Pre-procedure 1 Introduce yourself to the patient, explain and discuss the procedure with them, and gain their consent to proceed.

To ensure that the patient feels at ease, understands the procedure and gives their valid consent (NMC 2018, C).

2 Gain the patient’s verbal consent.

Consent must be gained before any procedure takes place (NMC 2018, C).

3 Make sure the patient is warm and comfortable and sitting on the edge of the bed or on a chair.

To ensure that both the anterior (front) and posterior (back) thorax and lungs can be examined (Bickley and Szilagyi  2017, E).

4 Expose the patient from head to waist while maintaining privacy and dignity.

To allow a thorough examination (Talley and O’Connor 2006, E).

Procedure 5 Wash and dry hands.

To prevent the spread of infection (NHS England and NHSI 2019, C).

General inspection 6 Take a global view of the patient.

See ‘Inspection’ above.

CHAPTER 2 Admissions and assessment

7 Look at the patient’s skin and nails. Feel the texture, temperature and turgor of the skin.

Abnormalities of the skin and nails can be an indication of a variety of different conditions, for example heart disease, lung disease, cyanosis and/or anaemia (Bickley and Szilagyi 2017, Rushforth 2009). Look for tobacco staining (Innes and Tiernan 2018). E

8 Press either side of the patient’s finger (first digit) firmly To assess capillary refill; this can give an indication of the status between your finger and thumb for 5 seconds and then let of circulation (Paterson and Dover 2018). Normal return is 2 go. Count how many seconds it takes for the colour to return. seconds. E 9 Ask the patient to hold out their arms with their wrists flexed To assess for flapping tremor; a fine tremor can be a side-effect and their palms facing forwards for 1 minute. of high-dose beta-agonist bronchodilators. A coarse flapping tremor of the outstretched hands is seen in patients with carbon dioxide retention (Innes and Tiernan 2018, E). 10 Look at the patient’s eyes.

To assess for any abnormalities, particularly looking for any signs of hypercholesterolaemia (corneal arcus or xanthelasma) or anaemia (conjunctival pallor). Look for any signs of unilateral ptosis or pupillary constriction, which may constitute Horner’s syndrome (Innes and Tiernan 2018, E).

11 Look at and in the patient’s mouth.

The mouth can give a snapshot of the patient’s general state of health. Look for signs of malnutrition, dehydration, infection, central cyanosis and any sores (Bickley and Szilagyi 2017). Look for signs of mouth breathing and upper respiratory tract infection (Innes et al. 2018). E

12 Look at and in the patient’s nose.

To assess for nasal flare, deviated septum and nasal polyps (Talley and O’Connor 2006, E).

13 Listen to the patient’s breathing.

To assess for any audible wheeze or stridor (Bickley and Szilagyi 2017, E).

14 Look at the patient’s neck.

To assess whether accessory muscles are being used and whether the trachea is at the midline (Bickley and Szilagyi 2017, E).

15 Check the patient’s jugular venous pressure (JVP). To do this, ensure the patient is positioned at 30–45° and ask them to turn their head away from you. Measure the JVP (number of centimetres vertically from the sternal angle to the upper border of pulsation). (For more information, see the section ‘Steps for measuring the JVP’ below.)

To check for a raised JVP, which can indicate pulmonary hypertension, tension pneumothorax or large pulmonary embolism (Innes and Tiernan 2018, E).

16 Palpate the trachea gently with your index finger and thumb.

To ensure it is at the midline with no deviation (Innes and Tiernan 2018, E).

17 Palpate the head and neck nodes (see Figure 2.8).

To assess for enlarged nodes; this can be a sign of malignancy or infection (Dover et al. 2018, E).

Posterior chest 18 Inspect the patient’s chest.

To assess for any scars, masses, deformities and asymmetry (Bickley and Szilagyi 2017, E).

Palpation 19 Lightly palpate the chest.

To assess for any signs of tenderness, pain or masses (Bickley and Szilagyi 2017, Rushforth 2009, E).

20 Place your thumbs at the level of the 10th rib either side of the spine with your fingers fanned out towards the lateral (side) chest. Ask the patient to take a deep breath in (see Figure 2.9).

To assess chest expansion (Bickley and Szilagyi 2017, Rushforth 2009, Talley and O’Connor 2006, E).

21 Place the edge of your palm and little finger on the patient’s chest at the points seen in Figure 2.10 and ask the patient to say ‘99’. Assess both sides of the chest together using both hands.

To assess for tactile fremitus (Bickley and Szilagyi 2017, Rushforth 2009, Talley and O’Connor 2006, E).

Percussion 22 Percuss the chest (see Figure 2.12).

To assess for normal resonance in the lungs and identify any abnormalities (Bickley and Szilagyi 2017, E). (continued)

33

THE ROYAL MARSDEN MANUAL OF CLINICAL NURSING PROCEDURES

Procedure guideline 2.1  Respiratory examination (continued) 34

Action

Rationale

Auscultation 23 Auscultate the lungs using the diaphragm of the stethoscope (see Figure 2.12).

To assess for vesicular breath sounds and any adventitious sounds (Bickley and Szilagyi 2017, E).

Anterior chest 24 Inspect the patient’s chest.

To assess for any scars, masses, deformities and asymmetry (Bickley and Szilagyi 2017, E).

Palpation 25 Lightly palpate the chest

To assess for any signs of tenderness, pain or masses (Bickley and Szilagyi 2017, Rushforth 2009, E).

26 Place your thumbs along each costal margin at about the fifth or sixth rib with your fingers fanned out towards the lateral chest. Ask the patient to take a deep breath in.

To assess chest expansion (Bickley and Szilagyi 2017, Rushforth 2009, Talley and O’Connor 2006, E).

27 Place the edge of your palm and little finger on the patient’s chest at the points seen in Figure 2.11 and ask the patient to say ‘99’. Assess both sides of the chest together using both hands.

To assess for tactile fremitus (Bickley and Szilagyi 2017, Rushforth 2009, Talley and O’Connor 2006, E).

Percussion 28 Percuss the anterior chest (see Figure 2.12).

To assess for normal resonance in the lungs and identify any abnormalities (Bickley and Szilagyi 2017, E).

Auscultation 29 Auscultate the lung using the bell of the stethoscope for the apex of the lung (above the clavicle) and the diaphragm of the stethoscope for the rest of the chest (see Figure 2.12).

To assess for vesicular breath sounds and any adventitious sounds (Bickley and Szilagyi 2017, E).

Post-procedure 30 Document fully.

Accurate records should be kept of all discussions and/or assessments made (NMC 2018, C).

31 Report any abnormal findings to a senior nurse or to medical Patients should be cared for as part of a multidisciplinary staff. team and, where appropriate, patient care should be referred to another more experienced practitioner (NMC 2018, C). 32 Clean the equipment used and wash hands.

To prevent the spread of infection (NHS England and NHSI 2019, C).

33 Explain findings to the patient.

The patient should be told, in a way they can understand, the information they want or need to know about their health (NMC 2018, C).

34 Discuss plan of care with the patient.

Where possible, patients should be involved in planning their care (NMC 2018, C).

35 Additional bedside investigations: assess vital signs, and inspect sputum and send for microbiology, culture and sensitivity.

This additional information can be used to assess the adequacy of gas exchange (Fisher and Potter 2017, E).

36 Order further investigations as needed to include blood, chest X-ray and lung function tests.

This additional information can further refine the differential diagnoses (Fisher and Potter 2017, E).

Cardiovascular examination ANATOMY AND PHYSIOLOGY

The heart is a muscular organ that delivers blood to the pulmonary and systemic systems (Mills et al. 2018) (Figure 2.13). A good understanding of the vascular system of the heart is important.

RELATED THEORY

When carrying out a cardiovascular assessment, the order of examination is: • inspection • palpation • auscultation.

CHAPTER 2 Admissions and assessment

Figure 2.13  Structure of the heart. Source: Reproduced from Peate et al. (2014) with permission of John Wiley & Sons, Ltd.

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Figure 2.14  Location of the internal jugular veins within the sternomastoid muscles in the neck.

35

Internal carotid artery External carotid artery

Sternomastoid

Common carotid artery

External jugular vein

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Internal jugular vein

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Subclavian vein

5LJKWYHQWULFOH

8 Inspect the legs and ankles for any sign of peripheral oedema, poor circulation or peripheral vascular disease. Observe for a shiny, hairless appearance of the skin on the legs, and examine the feet and legs for pain, swelling, discoloration, ulceration and temperature (Mills et al. 2018).

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Note that percussion is not part of a cardiovascular assessment. Many symptoms that necessitate a cardiac examination can be life threatening, so first take a moment to assess whether the patient is well enough for a full examination or whether they need immediate treatment in order to be stabilized first (Rushforth 2009).

Part of cardiovascular inspection is measuring the jugular venous pressure (JVP) (Figure 2.14). JVP reflects the pressure in the right atrium and is a good indicator of cardiac function (Powell 2006). To measure JVP, locating the right internal jugular vein is paramount. The vein runs deep within the sternomastoid muscle so it is not directly visible (Bickley and Szilagyi  2017). Instead, it can be located by looking for its pulsation within the sternomastoid muscle (Bickley and Szilagyi 2017) (Figure 2.14).

Inspection

Steps for measuring the JVP

Ideally the patient should be positioned between 30° and 45° and the patient’s chest should be exposed to enable a comprehensive assessment. Note that due to the condition of the patient, the patient may be uncomfortable or in pain; in such cases, the assessment should be adjusted to meet the needs of the patient. It can be helpful to visualize the structure of the heart as you undertake inspection. 1 Observe the patient for signs of distress, pain or breathlessness. 2 Starting at the hands, assess for cold extremities. Inspect the nails for any unusual changes, such as koilonychia or splinter haemorrhages. Assess capillary refill time (it should be less than 2 seconds). See Procedure guideline 2.2: Cardiovascular examination for further information. 3 Assess skin for turgor, temperature and any rashes or lesions on hands or arms. 4 Observe the patient’s face; assess the conjunctiva for signs of anaemia and xanthelasmata around the eyes. Xanthelasmata are fatty deposits that typically present as yellow plaques around the eyes (Nair and Singhal  2018). They can indicate hyperlipidaemia, thyroid dysfunction or diabetes mellitus (Gangopadhyay et al. 1998). 5 Observe for any flushing of the skin on the face. Look at the tongue and mucous membranes for any signs of central cyanosis. 6 Observe the exposed chest for scars, bruising, trauma, surgery or asymmetry (Mills et  al.  2018, Powell  2006, Talley and O’Connor 2006). 7 Inspect for heaves or thrills. These are ventricular movements that may be visible over the heart.

1 Make the patient comfortable. 2 Raise the patient’s head to an angle of approximately 30° (up to a 45° angle). 3 Turn the patient’s head slightly away from the side you are inspecting. 4 Use tangential lighting and examine both sides of the neck. Identify the external jugular vein on each side, then find the internal jugular venous pulsations. 5 Focus on the right internal jugular vein. Look for pulsations in the suprasternal notch. Distinguish the pulsations of the internal jugular vein from those of the carotid artery (carotid pulsations are palpable and have a more vigorous thrust with a single outward component; additionally, these pulsations are not eliminated by pressure on the veins at the sternal end of the clavicle, and the height of the pulsations is unchanged by the position of the chest and by inspiration). 6 Identify the highest point of pulsation in the right jugular vein. Extend a long rectangular object or card horizontally from this point and a centimetre ruler vertically from the sternal angle, making an exact right angle (as demonstrated in Figure  2.15). Measure the vertical distance in centimetres above the sternal angle. This is usually less than 3–4 cm (Bickley and Szilagyi 2017).

Palpation

The palpable pulse in an artery reflects the pressure wave generated by the ejection of blood into the circulation from the left ventricle. When taking a pulse assess: • Rate: the number of pulses occurring per minute. • Rhythm: the pattern or regularity of pulses.

THE ROYAL MARSDEN MANUAL OF CLINICAL NURSING PROCEDURES

Figure 2.15  Measuring a jugular venous pressure.

Figure 2.16  Auscultation points and location of the heart valves.

36 2nd left interspace: pulmonic area

2nd right interspace: aortic area

• Volume: the perceived degree of pulsation. • Character: an impression of the pulse waveform or shape. The rate and rhythm of the pulse are usually determined at the arterial artery; use the larger pulses (brachial, carotid or femoral) to assess pulse volume and character (Mills et al. 2018). A weak pulse can be a sign of various conditions, including decreased cardiac output (Rushforth 2009). A bounding pulse can indicate an increased cardiac output, which can be present in hypertension and anaemia (Rushforth 2009). Pulses on each side of the body should be compared simultaneously if possible. There are two exceptions to this: the popliteal pulse and the carotid pulses. The nurse will need to use both hands to assess each popliteal pulse; the carotid pulses should always be palpated separately, as doing both together may make the patient feel faint. The nurse should feel across the chest for evidence of pain, heaves, thrills and lifts. Lifts and heaves are forceful cardiac contractions that can result in transient movement of the sternum and/ or ribs and if present will be felt through the flat of the hand being lifted rhythmically during palpation (Bickley and Szilagyi  2017). They can be a sign of an enlarged ventricle or atrium or sometimes a ventricular aneurysm (Bickley and Szilagyi  2017). Thrills are vibrations that can be felt from light palpation over the chest, usually over the areas of the heart valves, and are the result of a loud heart murmur. They will be felt most clearly using the ball of the hand palpating in the area of the murmur and may feel like a buzzing or vibration (Bickley and Szilagyi 2017). The nurse should palpate the apical impulse (point of maximum impulse). Start from the fifth intercostal space, inside the mid-clavicular line (Camm and Camm 2016). If the impulse is difficult to find, the patient should be asked to roll slightly onto their left side. Observe the apical impulse for size, amplitude, location, impulse and duration.

Auscultation

When auscultating, the heart sounds should be characterized and identified, as should any added sounds and/or murmurs (Mills et  al.  2018). All elements of the cardiac cycle can be heard on auscultation and thus it is important to identify all of them (Camm and Camm  2016). The sound of the beating heart is often described as ‘lub dub’ and is caused by the closure of valves (Powell 2006). The ‘lub’, which is also referred to as ‘S1’, is the sound made when the mitral and tricuspid valves are closing; it is often heard best over the apex. The ‘dub’ or ‘S2’ is the sound

Lower left sternal border: tricuspid area

Apex: mitral area

made when the aortic and pulmonary valves close (Camm and Camm  2016, Powell  2006) and can be heard well across the precordium. There are extra sounds that can sometimes be heard called ‘S3’ and ‘S4’. S3 is occasionally heard immediately after S2 and is caused by the vibration of rapid ventricular filling (Mills et  al.  2018). S4 can rarely be heard immediately before S1 and marks atrial contraction. Both of these sounds can indicate a change in ventricular compliance (Bickley and Szilagyi 2017). Murmurs can be heard in a number of different conditions; they are caused by turbulent blood flow. While murmurs are sometimes harmless, they can indicate valvular heart disease (Bickley and Szilagyi 2017). Heart sounds and murmurs that originate in the four valves radiate widely; see Figure 2.16 for an illustration of the relevant auscultation points. Assessment of carotid bruits is an important component of cardiovascular assessment. Bruits are often described as ‘whooshing’ sounds and can indicate atherosclerotic arterial disease (Bickley and Szilagyi 2017).

EVIDENCE-BASED APPROACHES

Rationale

The patient’s health history and the nurse’s knowledge of anatomy and physiology will help to guide when it is appropriate to do a cardiovascular physical examination. The list of presentations that may lead to a cardiovascular examination is vast; some examples include: • chest pain • palpitation • leg ulcer • breathlessness • oedema • dizziness.

CHAPTER 2 Admissions and assessment

Procedure guideline 2.2  Cardiovascular examination Essential equipment

37

• Personal protective equipment • Stethoscope • Examination couch • Pen torch • Ruler Action

Rationale

Pre-procedure 1 Introduce yourself to the patient, explain and discuss the procedure with them, and gain their consent to proceed.

To ensure that the patient feels at ease, understands the procedure and gives their valid consent (NMC 2018, C).

2 Gain the patient’s verbal consent.

Consent must be gained before any procedure takes place (NMC 2018, C).

3 Check that the patient has an empty bladder.

A full bladder will interfere with the examination (Walsh 2006b, E).

4 Make sure the patient is warm and comfortable and ideally have them in the supine position, with their head at 30–45° and their arms by their sides.

This is the optimum position from which to assess the jugular venous pressure (JVP) (Talley and O’Connor 2006, E).

5 Expose the patient from head to waist while maintaining privacy and dignity. You will also need access to their legs.

To allow a thorough examination (Talley and O’Connor 2006, E).

Procedure 6 Wash and dry hands.

To prevent the spread of infection (NHS England and NHSI 2019, C).

General inspection 7 Take a global view of the patient.

See ‘Inspection’ above.

8 Look at the patient’s skin and nails. Feel the texture, temperature and turgor of the skin.

Abnormalities of the skin and nails can be an indication of a variety of different conditions, for example heart disease, endocarditis, hypercholesterolaemia and/or anaemia (Bickley and Szilagyi 2017, Tidman 2018). Also look for tobacco staining. E

9 Press the patient’s fingernail (on the first digit) firmly between your finger and thumb for 5 seconds and then let go. Count how many seconds it takes for the colour to return to the nail.

To assess the capillary refill; this can give an indication of the status of circulation (Paterson and Dover, 2018). Normal return is 2 seconds. E

10 Look at the patient’s eyes.

To assess for any abnormalities, particularly looking for any signs of hypercholesterolaemia or anaemia (Talley and O’Connor 2006, E).

11 Look at and in the patient’s mouth.

The mouth can give a snapshot of the patient’s general state of health. Look for signs of malnutrition, infection, central cyanosis and any sores (Innes et al. 2018, E).

12 Ask the patient to turn their head to the left, use tangential lighting and locate the highest pulsation point of the internal jugular vein (see Figure 2.15). Place a ruler vertically from the sternal angle, then use a tongue depressor placed horizontally to make a right angle from the pulsation to the ruler. The JVP is measured in centimetres and the measurement is where the tongue depressor meets the ruler.

To assess the JVP (Bickley and Szilagyi 2017, E).

13 Inspect the precordium.

To assess for scars, deformities, heaves, lifts and the apical impulse (Bickley and Szilagyi 2017, E).

14 Inspect the legs.

To assess for signs of venous disease and ischaemic changes (Mills et al. 2018, E).

Palpation 15 Palpate the pulses.

To assess cardiac output (Rushforth 2009, E).

16 Palpate the chest.

To assess for tenderness, heaves, lifts and thrills (Bickley and Szilagyi 2017, Rushforth 2009, E). (continued)

THE ROYAL MARSDEN MANUAL OF CLINICAL NURSING PROCEDURES

Procedure guideline 2.2  Cardiovascular examination (continued) 38

Action

Rationale

17 Palpate with the finger tips the fifth intercostal space, inside the mid-clavicular line.

To assess the apical impulse (Bickley and Szilagyi 2017, Rushforth 2009, E).

Auscultation 18 Listen with the bell of the stethoscope to the carotid pulse.

To assess for bruits (Bickley and Szilagyi 2017, E).

19 Auscultate at the aortic, pulmonary, tricuspid and mitral valves (see Figure 2.16) with the diaphragm of the stethoscope.

To assess S1 and S2 (Bickley and Szilagyi 2017, Camm and Camm 2016, E).

20 Auscultate at the aortic, pulmonary, tricuspid and mitral valves (see Figure 2.16) with the bell of the stethoscope.

To assess for S3, S4 and murmurs (Bickley and Szilagyi 2017, Camm and Camm 2016, E).

21 Ask the patient to roll partially onto their left side and listen with the bell of the stethoscope to the apical impulse.

To assess for a mitral murmur (Bickley and Szilagyi 2017, Camm and Camm 2016, E).

22 Ask the patient to sit up and lean forward, exhale completely and hold their breath. Listen with the diaphragm of the stethoscope to the apical impulse and along the left sternal border. Make sure to tell the patient to start breathing normally again.

To assess for an aortic murmur and pericardial friction rubs (Bickley and Szilagyi 2017, Camm and Camm 2016, Rushforth 2009, E).

23 Ask the patient to sit up and listen to the lung bases with the To assess for lung congestion, which can be caused by heart diaphragm of the stethoscope. failure (Rushforth 2009, E).

Post-procedure 24 Document fully.

Accurate records should be kept of all discussions and/or assessments made (NMC 2018, C).

25 Report any abnormal findings to a senior nurse or to medical Patients should be cared for as part of a multidisciplinary staff. team and, where appropriate, patient care should be referred to another more experienced practitioner (NMC 2018, C). 26 Clean the equipment used and wash hands.

To prevent the spread of infection (NHS England and NHSI 2019, C).

27 Explain findings to the patient.

The patient should be told, in a way they can understand, the information they want or need to know about their health (NMC 2018, C).

28 Discuss plan of care with the patient.

Where possible, patients should be involved in planning their care (NMC 2018, C).

Abdominal examination Learning Activity 2.6  Case study Miss Jennifer Murphy is 72 years old and has been referred by her GP for investigation after a 10-day history of mild intermittent chest pain during and following moderate daily activities, such as housework and gardening. You are about to carry out a cardiac assessment of Jennifer. 1 Suggest the position Jennifer should be placed in to facilitate a thorough examination. 2 When assessing Jennifer’s circulation, the time taken for capillary refill is 2 seconds. Is this normal? 3 Jennifer’s jugular venous pressure (JVP) measures 3 cm. Is this high? 4 Jennifer’s pulse rate is regular and of a good volume; the rate is 82 beats per minute. Can you comment on this? 5 Describe the steps you would take to perform the auscultation phase of the assessment. See the answers on the companion site of this student edition: www.royalmarsdenmanual.com/student10e.

ANATOMY AND PHYSIOLOGY

The abdominal cavity houses large parts of the gastrointestinal (GI) system, the renal system and the reproductive system. It is therefore important to have an understanding of the anatomy and physiology of all three systems when examining the abdomen. The GI system includes the entire GI tract as well as the accessory organs (Figure 2.17). When examining the abdominal area, it is important to be able to visualize which organs are in which quadrant. This will help to form possible differential diagnoses. The physiology of the GI system is covered in Chapter  6: Elimination and Chapter 8: Nutrition and fluid balance.

RELATED THEORY

A full abdominal examination combines the following techniques: • inspection • auscultation • percussion • palpation. The assessment of the abdomen starts with inspection, followed by auscultation, then percussion and palpation. Auscultation is performed prior to percussion and palpation to avoid abdomen

CHAPTER 2 Admissions and assessment

Figure 2.17  Organs of the gastrointestinal system. Source: Reproduced from Peate et al. (2014) with permission of John Wiley & Sons, Ltd.

39

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and small bowel manipulation, which may change findings (Fritz and Becker Weilitz 2016).

Inspection

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Figure 2.18  The four quadrants of the abdomen. LLQ, left lower quadrant; LUQ, left upper quadrant; RLQ, right lower quadrant; RUQ, right upper quadrant.

Externally, the abdomen should appear flat and symmetrical. The most common causes of abdominal distension are: • fat in obesity • flatus in pseudo-obstruction or bowel obstruction • faeces in subacute obstruction or constipation • fluid in ascites (accumulation of fluid in the peritoneal cavity) • tumours (especially ovarian) or distended bladder • the foetus in pregnancy • functional bloating (often in irritable bowel syndrome) (Plevris and Parks 2018). Look at the abdomen for any abnormally prominent veins on the abdominal wall suggestive of portal hypertension or vena cava obstruction. Any abdominal swelling, scars and stomas should also be noted (Plevris and Parks  2018). The umbilicus position can sometimes help to identify why there is distension.

Auscultation

Bowel sounds should be listened for in all four quadrants of the abdomen (Figure  2.18). Bowel sounds are often described as ‘clicks’ or ‘gurgles’ and it should be possible to hear 5–35 clicks in 1 minute. Listening for up to 2 minutes may be required for someone with hypoactive bowel sounds (Fritz and Becker Weilitz 2016). Bowel sounds are often described as active (i.e. normal), absent, hypoactive or hyperactive. Absence of bowel sounds may indicate bowel obstruction and hyperactive bowel sounds may be present if patients are having altered bowel function.

RUQ

LUQ

RLQ

LLQ

THE ROYAL MARSDEN MANUAL OF CLINICAL NURSING PROCEDURES

40

Assessment of bruits is an important component of physical assessment. Bruits are often described as ‘whooshing’ or harsh intermittent sounds and can indicate atherosclerotic arterial disease (Bickley and Szilagyi  2017). If the bruits are over the renal artery, it can be a sign of renal artery stenosis (Bickley and Szilagyi  2017). See Figure  2.19 for stethoscope positioning.

Figure 2.20  Percussion technique during abdominal examination.

Percussion

Percussion is used to detect air, fluid, faeces, organs and masses (Walsh 2006a). Predominantly, the abdomen should have a distribution of tympany and dullness – tympany where there is gas in the GI tract and dullness where other organs and faeces lie (Bickley and Szilagyi 2017). Large areas of dullness may indicate organomegaly (enlarged organs), a tumour or ascites (Bickley and Szilagyi 2017). Percussion is also used to locate and measure the size of the liver (Fritz and Becker Weilitz  2016). A normal liver measures 6–12 cm (Talley and O’Connor 2006). See Figure 2.20 for the relevant percussion technique. (a)

Palpation

Percussion requires indirect tapping of the abdomen to assess the size of the organs and to check for the presence of air or fluid, or air-filled or solid masses (Fritz and Becker Weilitz 2016). If a mass is found, palpation should be used to gather more information about it. Talley and O’Connor (2006) suggest that the following information should be included when describing a mass: • site • tenderness • size • surface • edge • consistency • mobility • whether it has a pulse or not. Likewise, if an organ is found, it should be described. The spleen and kidneys are not normally palpable if they are not enlarged but

Figure 2.19  Stethoscope positioning for auscultating bruits.

(b)

Figure 2.21  Light palpation during abdominal examination.

Renal artery Aorta Iliac artery

Femoral artery

a normal liver edge can sometimes be felt (Talley and O’Connor  2006). If palpable, it should feel soft, regular and smooth with a well-defined border (Talley and O’Connor  2006). See Figures 2.21 and 2.22 for light and deep palpation techniques to be used during abdominal examination.

CHAPTER 2 Admissions and assessment

Figure 2.22  Deep palpation during abdominal examination.

EVIDENCE-BASED APPROACHES

Rationale

The patient’s health history and the nurse’s knowledge of anatomy and physiology will help to guide when it is appropriate to do an abdominal physical examination. The list of presentations that may lead to an abdominal examination is vast; as discussed in the anatomy and physiology section, they could involve the GI, renal and/or reproductive systems. Some examples include: • abdominal pain • nausea and/or vomiting • change in bowel habits • weight change • jaundice • bleeding • dysuria/urgency or frequency • flank pain • suprapubic pain.

Procedure guideline 2.3  Abdominal examination Essential equipment • Personal protective equipment • Stethoscope • Examination couch • Pen torch • Tongue depressor Action

Rationale

Pre-procedure 1 Introduce yourself to the patient, explain and discuss the procedure with them, and gain their consent to proceed.

To ensure that the patient feels at ease, understands the procedure and gives their valid consent (NMC 2018, C).

2 Gain the patient’s verbal consent.

Consent must be gained before any procedure takes place (NMC 2018, C).

3 Check that the patient has an empty bladder.

A full bladder will interfere with the examination (Walsh 2006a, P).

4 Make sure the patient is warm and comfortable and ideally have them in the supine position, with their arms by their sides.

If the patient is uncomfortable or cold the abdominal muscles will be tense (Rushforth 2009). The supine position helps to relax the abdominal muscles and is the optimum position for abdominal palpation (Talley and O’Connor 2006). E

5 Expose the patient from nipple to pubis, maintaining patient dignity at all times.

To ensure a thorough examination. E

Procedure 6 Wash and dry hands.

To prevent the spread of infection (NHS England and NHSI 2019, C).

General inspection 7 Take a global view of the patient.

See ‘Inspection’ above.

8 Look at the patient’s skin and nails. Feel the texture and turgor of the skin.

Abnormalities of the skin and nails can be an indication of a variety of different conditions, for example bowel disease, malnutrition, liver disease, dehydration and/or anaemia (Bickley and Szilagyi 2017, Dover et al. 2018, Tidman 2018, E).

9 Ask the patient to extend their arms, flex their wrists and part their fingers. Ask them to stay in this position for 15 seconds.

To assess for liver flap; this can be a sign of liver and/or renal failure (Talley and O’Connor 2006, E).

10 Look at the patient’s eyes.

To assess for any abnormalities, particularly looking for any signs of jaundice, hypercholesterolaemia and anaemia (Talley and O’Connor 2006, E). (continued)

41

THE ROYAL MARSDEN MANUAL OF CLINICAL NURSING PROCEDURES

Procedure guideline 2.3  Abdominal examination (continued) 42

Action

Rationale

11 Look at the patient’s nose.

To assess for signs of telangiectasia, which can indicate liver disease (Bickley and Szilagyi 2017, E).

12 Look at and in the patient’s mouth

The mouth can give a snapshot of the patient’s general state of health. Look for signs of malnutrition, infection and any sores (Innes et al. 2018, E).

13 Smell the patient’s breath.

To assess for signs of fetor (unpleasant-smelling breath) (Talley and O’Connor, 2006). Sweet-smelling breath can be a sign of ketoacidosis. E

14 Ask the patient to shrug their shoulders and lightly palpate, using the finger tips, directly above the clavicle.

To assess for a raised supraclavicular lymph node, which can indicate gastrointestinal malignancy (Talley and O’Connor 2006, E).

15 Move to the foot of the bed to inspect the abdomen.

Assessing the abdomen from different angles will help to identify any abnormalities (Walsh 2006a, E).

16 Observe the contour of the abdomen and position of the umbilicus.

To assess for asymmetry or distension, peristalsis and/or pulsations (Bickley and Szilagyi 2017, Walsh 2006a, E).

17 Move to the side of the bed and observe the contour of the abdomen tangentially.

This will allow any subtle changes in contour to be observed (Cox 2004, E).

18 Look at the patient’s skin.

To assess for any signs of spider naevi, striae, scars, caput medusa, bruising and rashes (Plevris and Parks 2018, E).

Auscultation 19 Using the diaphragm of the stethoscope, listen in all four quadrants for 1 minute each.

To assess for bowel sounds (Bickley and Szilagyi 2017, E). Bowel sounds normally occur every 5–10 seconds but frequency varies (Plevris and Parks 2018, E).

20 Using the bell of the stethoscope, listen over the aortic, renal, iliac and femoral arteries (see Figure 2.19).

To assess for bruits (Bickley and Szilagyi 2017, E).

Percussion 21 Percuss in the nine areas of the abdomen.

To listen for a normal distribution of tympany and dullness (see Table 2.3) (Bickley and Szilagyi 2017, E).

22 Percuss for liver span. To do this, percuss upwards, starting in the right lower quadrant at the mid-clavicular line. Stop when you hear the dullness of the liver. Next percuss down, starting from the intersection of the nipple line and the mid-clavicular line; stop when the sound changes from the resonant lung to the dull liver. Measure between those two points.

To assess the size and location of the liver (Walsh 2006a, E).

23 The above technique can be employed to percuss the spleen, bladder and kidneys.

Not routinely done but may be useful if abnormality, in particular organomegaly, is suspected. E

24 Percuss from the midline out to the flanks for dullness. Keep your finger on the site of dullness in the flank, ask the patient to turn onto their opposite side and then percuss again. If the area of dullness is now resonant, shifting dullness is present.

To assess for shifting dullness (Plevris and Parks 2018, E).

Palpation 25 Lightly palpate the abdomen using one hand. Look at the patient’s face at all times, to ensure they are not in discomfort.

To assess for tenderness, rebound tenderness, superficial organs and masses (Talley and O’Connor 2006, E).

26 Deeply palpate the abdomen.

To assess the organs, identify deeper masses and define masses that have already been discovered (Talley and O’Connor 2006, E).

27 Palpate for the liver. To do this, place your left hand in the small of the patient’s back and your right in the right lower quadrant pointing towards the upper left quadrant. Ask the patient to take a deep breath and palpate up. If nothing is felt, move up towards the liver and repeat until you reach the ribcage.

To assess for hepatomegaly or gallbladder tenderness (known as Murphy’s sign) (Plevris and Parks 2018, E).

CHAPTER 2 Admissions and assessment

28 Palpate for the spleen. Ask the patient to tip slightly onto their right side. Start from the umbilicus region and mimic the technique above, moving towards the spleen.

To assess for splenomegaly (Plevris and Parks 2018, E).

29 Palpate for the kidneys. Do each kidney separately. For the right side, stand on the right side of the patient, place your left hand just below the 12th rib and lift up. Place your other hand on the right upper quadrant of the abdomen. Ask the patient to take a deep breath. As they do, press your right hand deeply into the abdomen, trying to feel the kidney between your hands. Repeat for the left side, standing on the left of the patient.

To assess for kidney enlargement; if the kidney is normal, it is not usually palpable (Plevris and Parks 2018, E).

30 Lightly palpate each costovertebral angle (the area directly overlying the kidneys) for tenderness; if none is felt, place one hand flat over the costovertebral angle and strike the hand firmly with the other fist.

Pain can indicate pyelonephritis (Bickley and Szilagyi 2017, E).

43

Post-procedure 31 Document fully.

Accurate records should be kept of all discussions and/or assessments made (NMC 2018, C).

32 Report any abnormal findings to a senior nurse or to medical staff.

Patients should be cared for as part of a multidisciplinary team and, where appropriate, patient care should be referred to another more experienced practitioner (NMC 2018, C).

33 Clean the equipment used and wash hands.

To prevent the spread of infection (NHS England and NHSI 2019, C).

34 Explain the findings to the patient.

The patient should be told, in a way they can understand, the information they want or need to know about their health (NMC 2018, C).

35 Explain the plan of care to the patient.

Where possible, patients should be involved in planning their care (NMC 2018, C).

POST-PROCEDURAL CONSIDERATIONS

Documentation

Nurses should ensure that the following components are documented: • rationale for examination • patient’s consent to examination • type of examination performed • findings from the examination • plan of care.

As with all record keeping, documentation in relation to physical examinations should be clear, concise, accurate and without jargon or abbreviations (NMC 2018). Record keeping should include evidence of clinical reasoning in order to identify patients’ needs for nursing care. While this becomes more automatic with experience, it should always be possible for a nurse to explain how they arrive at a decision about an individual within their care (Gordon 1994, Putzier and Padrick 1984, Rolfe 1999).

Stretch Activity Further your thinking and learning about clinical practice Identify which tools are in use to support nursing assessment of patients on admission to your clinical area (e.g. nutrition assessment tool, pressure ulcer risk tool, frailty tool, oral health tool, falls assessment tool, or bowel or stool assessment tool). 1 Ask your tutor or supervisor whether alternative assessment tools have been developed (e.g. for pressure ulcers, consider the Waterlow Score, the Braden Risk Assessment tool or PURPOSE-T). 2 Source a small range of tools related to a specific nursing assessment. 3 Find relevant literature about the tools’ development and critically read published evidence about their effectiveness. 4 Critically evaluate and compare the tools, identifying the advantages and disadvantages of each. 5 Discuss your findings with your tutor and supervisor.

THE ROYAL MARSDEN MANUAL OF CLINICAL NURSING PROCEDURES

Now Test Yourself 44

If you would like to test your learning further, there are additional questions on the companion site of this student edition: www.royalmarsdenmanual.com/student10e.

REFERENCES

Abbott, H. & Ranson, M. (2017) Clinical Examination Skills for Health Professionals. Glasgow: M&K Update. Ahern, J. & Philpot, P. (2002) Assessing acutely ill patients on general wards. Nursing Standard, 16, 47–54. Alfaro-LeFevre, R. (2014) Applying Nursing Process: The Foundation for Clinical Reasoning. Philadelphia: Lippincott Williams & Wilkins. Arrowsmith, H. (1999) A critical evaluation of the use of nutrition screening tools by nurses. British Journal of Nursing, 8, 1483–1490. Baid, H. (2006) The process of conducting a physical assessment: A nursing perspective. British Journal of Nursing, 15(13), 710–715. BAPEN & Malnutrition Advisory Group (2000) Explanatory Notes for the Screening Tool for Adults at Risk of Malnutrition. London: British Association for Parenteral and Enteral Nutrition, Malnutrition Advisory Group. Barrows, H. & Pickell, G. (1991) Developing Clinical Problem-Solving Skills. London: Norton Medical Books. Berman, A., Kozier, B. & Erb, G.L. (2010) Kozier and Erb’s Fundamentals of Nursing. Frenchs Forest, NSW: Pearson. Bickley, L.S. & Szilagyi, P.G. (2017) Bates’ Guide to Physical Examination and History Taking, 12th edn. Philadelphia: Wolters Kluwer. Bonevski, B., Sanson-Fisher, R., Girgis, A., et al. (2000) Evaluation of an instrument to assess the needs of patients with cancer. Cancer, 88, 217–225. Brown, V., Sitzia, J., Richardson, A., et al. (2001) The development of the Chemotherapy Symptom Assessment Scale (C-SAS): A scale for the routine clinical assessment of the symptom experiences of patients receiving cytotoxic chemotherapy. International Journal of Nursing Studies, 38, 497–510. Burns, E.A., Korn, K., Whyte, J., et al. (2011) Oxford American Handbook of Clinical Examination and Practical Skills. New York: Oxford University Press. Camm, C.F. & Camm, A.J. (eds) (2016) Clinical Guide to Cardiology. Oxford: Wiley Blackwell. Cancer Action Team (2007) Holistic Common Assessment of Supportive and Palliative Care Needs for Adults with Cancer: Assessment Guidance. London: Cancer Action Team. Cox, C.L. (ed) (2004) Physical Assessment for Nurses. Oxford: Blackwell. Crouch, A.T. & Meurier, C. (eds) (2005) Health Assessment. Oxford: Blackwell. Crumbie, A. (2006) Taking a history. In: Walsh, M. (ed) Nurse Practitioners: Clinical Skills and Professional Issues, 2nd edn. Edinburgh: ButterworthHeinemann, pp.14–26. DH (Department of Health) (2005) Choosing a Better Diet: A Food and Health Action Plan. London: Department of Health. Dimond, B. (2002) Legal Aspects of Pain Management. Dinton, UK: Quay Books. Donnelly, M. & Martin, D. (2016) History taking and physical assessment in holistic palliative care. British Journal of Nursing, 25(22), 1250–1255. Dover, A.R., Innes, J.A. & Fairhurst, K. (2018) General aspects of examination. In: Innes, J.A., Dover, A.R. & Fairhurst, K. (eds) Macleod’s Clinical Examination, 14th edn. London: Elsevier, pp.19–36. Drinkaware (2019) What Is an Alcoholic Unit? Available at: https://www. d r i n k aw a r e . c o . u k / a l c o h o l - f a c t s / a l c o h o l i c - d r i n k s - u n i t s / what-is-an-alcohol-unit Edwards, M. & Miller, C. (2001) Improving psychosocial assessment in oncology. Professional Nurse, 16, 1223–1226. Eilers, J., Berger, A.M. & Petersen, M.C. (1988) Development, testing, and application of the Oral Assessment Guide. Oncology Nursing Forum, 15, 325–330. Estes, M.E.Z. (2013) Health Assessment and Physical Examination, 5th edn. New York: Delmar Cengage Learning.

Fisher, E. & Potter, J. (eds) (2017) Respiratory Examination. Available at: www.oxfordmedicaleducation.com/category/clinical-examinations/ respiratory-examination Fortin, M., Stewart, M., Poitras, M.E., et al. (2012) A systematic review of prevalence studies on multimorbidity: Toward a more uniform methodology. Annals of Family Medicine, 10(2), 142–151. Frank-Stromborg, M. & Olsen, S.J. (eds) (2004) Instruments for Clinical Healthcare Research. Sudbury, MA: Jones & Bartlett. Fritz, D. & Becker Weilitz, P. (2016) Abdominal assessment. Home Healthcare Now, 34(3), 151–155. Galanti, G.A. (2000) An introduction to cultural differences. Western Journal of Medicine, 172, 335–336. Gangopadhyay, D.N., Dey S.K., Chandra, M., et al. (1998) Serum lipid profile in xanthelasma. Indian Journal of Dermatology, 43, 53–56. Gordon, M. (1994) Nursing Diagnosis: Process and Application. St Louis, MO: Mosby. Haidet, P. & Paterniti, D.A. (2003). Building a history rather than taking one: A perspective on information sharing during the medical interview. Archives of Internal Medicine, 163(10), 1134–1140. Harris, R., Wilson-Barnett, J., Griffiths, P. & Evans, A. (1998) Patient assessment: Validation of a nursing instrument. International Journal of Nursing Studies, 35, 303–313. Heaven, C.M. & Maguire, P. (1996) Training hospice nurses to elicit patient concerns. Journal of Advanced Nursing, 23, 280–286. Holmes, H.N. (ed) (2003) Three-Minute Assessment. Philadelphia: Lippincott Williams & Wilkins. Innes, J.A., Dover, A.R. & Fairhurst, K. (2018) General aspects of history taking. In: Innes, J.A., Dover, A.R. & Fairhurst, K. (eds) Macleod’s Clinical Examination, 14th edn. London: Elsevier, pp.9–18. Innes, J.A & Tiernan, J. (2018) The respiratory system. In: Innes, J.A., Dover, A.R. & Fairhurst, K. (eds) Macleod’s Clinical Examination, 14th edn. London: Elsevier, pp.75–92. Jarvis, C. (2016) Pocket Companion for Physical Examination and Health Assessment, 7th edn. St Louis, MO: Elsevier. Jensen, T.S., Wilson, P.R. & Rice, A.S. (2003) Clinical Pain Management: Chronic Pain. London: Arnold. Johnson, T. (2000) Functional health pattern assessment on-line: Lessons learned. Computers in Nursing, 18, 248–254. Kearney, N. (2001) Classifying nursing care to improve patient outcomes: The example of WISECARE. Nursing Times Research, 6, 747–756. Kozier, B. (2012) Fundamentals of Nursing: Concepts, Process, and Practice. Harlow, UK: Pearson. MacDonald, J. & RMH Pressure Ulcer MDT Collaborative (2019) aSSKINg Bundle Assessment Document NR592. London: The Royal Marsden NHS Foundation Trust. Marek, C. (2003). Antiemetic therapy in patients receiving cancer chemotherapy. Oncology Nursing Forum, 30, 259–271. McCrae, N. (2012) Whither nursing models? The value of nursing theory in the context of evidence-based practice and multidisciplinary health care. Journal of Advanced Nursing, 68, 222–229. Mills, N.L., Japp, A.G. & Robson, J. (2018) The cardiovascular system. In: Innes, J.A., Dover, A.R. & Fairhurst, K. (eds) Macleod’s Clinical Examination, 14th edn. London: Elsevier, pp.39–74. Moore, T. (2007) Respiratory assessment in adults. Nursing Standard, 21(49), 48–56. Murphy, E.K. (2003) Charting by exception. AORN Journal, 78, 821–823. Nair, P.A. & Singhal, R. (2018) Xanthelasma palpebrarum: A brief review. Clinical, Cosmetic and Investigational Dermatology, 11, 1–5. NHS England and NHSI (NHS Improvement) (2019) Standard Infection  Control Precautions: National Hand Hygiene and Personal Protective  Equipment Policy. Available at: https://improvement.nhs.uk/ documents/4957/National_policy_on_hand_hygiene_and_PPE_2.pdf

CHAPTER 2 Admissions and assessment

NMC (Nursing and Midwifery Council) (2018) The Code: Professional Standards of Practice and Behaviour for Nurses, Midwives and Nursing Associates. Available at: https://www.nmc.org.uk/standards/code O’Connor, F.W. & Eggert, L.L. (1994) Psychosocial assessment for treatment planning and evaluation. Journal of Psychosocial Nursing and Mental Health Services, 32, 31–42. Orem, D.E., Taylor, S.G. & Renpenning, K.M. (2001) Nursing: Concepts of Practice. St Louis, MO: Mosby. Paterson, R. & Dover, A.R. (2018) The deteriorating patient. In: Innes, J.A., Dover, A.R. & Fairhurst, K. (eds) Macleod’s Clinical Examination, 14th edn. London: Elsevier, pp.339–346. Paul, R. (1988). What, then, is critical thinking? Paper presented at the Eighth Annual and Sixth International Conference on Critical Thinking and Educational Reform, Rohnert Park, CA. Peacock, S. (2004) Systematic health assessment: A case study. Practice Nursing, 15(6), 270–274. Peate, I., Nair, M. & Wild, K. (2014) Nursing Practice: Knowledge and Care. Chichester: Wiley Blackwell. Perdue, C. (2005) Understanding nausea and vomiting in advanced cancer. Nursing Times, 101, 32–35. Plevris, J. & Parks, R. (2018) The gastrointestinal system. In: Innes, J.A., Dover, A.R. & Fairhurst, K. (eds) Macleod’s Clinical Examination, 14th edn. London: Elsevier, pp.93–118. Powell, A. (2006) The cardiovascular system. In: Walsh, M. (ed) Nurse Practitioners: Clinical Skills and Professional Issues, 2nd edn. Edinburgh: Butterworth-Heinemann, pp.98–119. Pratt, R.J. & Van Wijgerden, J. (2009) Nursing care of patients with tuberculosis In: Schaaf, H.S. & Zumla, A.I. (eds) Tuberculosis: A Comprehensive Clinical Reference. London: Elsevier, pp.711–717. Price, C.I.M., Han, S.W. & Rutherford, I.A. (2000) Advanced nursing practice: An introduction to physical assessment. British Journal of Nursing, 9(22), 2292–2296. Putzier, D.J. & Padrick, K.P. (1984) Nursing diagnosis: A component of nursing process and decision making. Topics in Clinical Nursing, 5, 21–29. Rhodes, V.A., McDaniel, R.W., Homan, S.S., et al. (2000) An instrument to measure symptom experience: Symptom occurrence and symptom distress. Cancer Nursing, 23, 49–54. Rolfe, G. (1999) Insufficient evidence: The problems of evidence-based nursing. Nurse Education Today, 19, 433–442. Roper, N., Logan, W.W. & Tierney, A.J. (2000) The Roper-Logan-Tierney Model of Nursing: Based on Activities of Living. New York: Churchill Livingstone. Rowbotham, D.J. & MacIntyre, P.E. (2003) Clinical Pain Management: Acute Pain. London: Arnold.

Royal College of Nursing (2017) Principles of Consent: Guidance for Nursing Staff. Available at: https://www.rcn.org.uk/professionaldevelopment/publications/pub-006047 Rush, S., Fergy, S. & Weels, D. (1996) Professional development: Care planning – Knowledge for practice. Nursing Times, 92, 18–23. Rushforth, H. (2009) Assessment Made Incredibly Easy! London: Lippincott Williams & Wilkins. Saxon, A. & Lillyman, S. (eds) (2011) Developing Advanced Assessment Skills: Patients with Long-Term Conditions. Keswick, UK: M&K Publishing. Schug, S.A., Palmer, G.M., Scott, D.A., et al. (2015) Acute Pain Management: Scientific Evidence, 4th edn. Australian and New Zealand College of Anaesthetists and Faculty of Pain Medicine. Available at: http://fpm. anzca.edu.au/documents/apmse4_2015_final Seidel, H.M., Ball, J.W., Davis, J.E., et al. (2011) Mosby’s Guide to Physical Examination, 7th edn. New York: Mosby Elsevier. Shaw, M. (1998) Charting Made Incredibly Easy. Springhouse, PA: Springhouse. Silverman, J., Kurtz, S.M. & Draper, J. (2013) Skills for Communicating with Patients. London: Radcliffe. Smith, J. & Rushton, M. (2015) How to perform respiratory assessment. Nursing Standard, 30(7), 34–36. Swartz, M.H. (2014) Textbook of Physical Diagnosis: History and Examination, 7th edn. Philadelphia: Elsevier Saunders. Talley, N.J. & O’Connor, S. (2006) Clinical Examination: A Systematic Guide to Physical Diagnosis. Sydney: Churchill Livingstone Australia. Teytelman, Y. (2002) Effective nursing documentation and communication. Seminars in Oncology Nursing, 18, 121–127. Tidman, M.J. (2018) The skin, hair and nails. In: Innes, J.A., Dover, A.R. & Fairhurst, K. (eds) Macleod’s Clinical Examination, 14th edn. London: Elsevier, pp.283–293. Walsh, M. (2006a) Abdominal disorders. In: Walsh, M. (ed) Nurse Practitioners: Clinical Skills and Professional Issues, 2nd edn. Edinburgh: Butterworth-Heinemann, pp.139–157. Walsh, M. (2006b) Nurse Practitioners: Clinical Skills and Professional Issues, 2nd edn. Edinburgh: Butterworth-Heinemann. Walsh, M., Crumbie, A. & Watson, J.E. (2007) Watson’s Clinical Nursing and Related Sciences. New York: Baillière Tindall / Elsevier. Weber, J.R. & Kelley, J.H. (2014) Health Assessment in Nursing, 5th edn. Philadelphia: Lippincott Williams & Wilkins. White, L. (2003) Documentation and the Nursing Process. Clifton Park, NY: Thomson / Delmar Learning. Wilkinson, J.M. (2007) Nursing Process and Critical Thinking. Upper Saddle River, NJ: Pearson Prentice Hall.

Answers Answers to the learning and stretch activities are available on the companion site of this student edition: www.royalmarsdenmanual. com/student10e.

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Discharge care and planning

HOME PRIMARY ASSESSING PERSON-CENTRED

MULTIDISCIPLINARY

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CO-ORDINATING

Caroline Watts with Emma Collard and Connie Lewis

PLANNING SECONDARY CONTINUITY SOCIAL COMMUNITY

DISCHARGE TRANSITION FAMILY

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After reading this chapter and undertaking the learning activities within it, you should: Know the importance of proactively planning a patient’s discharge within the context of a patient-centred, multidisciplinary team approach Understand the processes required to safely discharge a patient from an acute hospital setting and your role in facilitating this Appreciate the role of the discharge co-ordinator and the community and primary care teams in supporting a safe discharge, and know the information they require to ensure that patients experience a seamless transition in care Know what constitutes a ‘complex discharge’ and the steps required to facilitate access to funding, placements and suitable packages of care Understand how to facilitate a rapid discharge for patients at the end of life, to assist them to achieve their goal to be in their preferred place of care Key terms are highlighted in the text in pink. Glossary definitions of these terms can be found on the companion site of this student edition: www.royalmarsdenmanual.com/ student10e.

The Royal Marsden Manual of Clinical Nursing Procedures: Student Edition, Tenth Edition. Edited by Sara Lister, Justine Hofland and Hayley Grafton with Catherine Wilson. © 2021 The Royal Marsden NHS Foundation Trust. Published 2021 by John Wiley & Sons Ltd. Student companion website: www.royalmarsdenmanual.com/student10e Instructor compaion website: www.royalmarsdenmanual.com/instructor10e

THE ROYAL MARSDEN MANUAL OF CLINICAL NURSING PROCEDURES

Overview

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his chapter addresses the planning and process of discharging patients from hospital. Discharge planning is a routine feature of healthcare systems worldwide and is recognized as the foundation of patients’ successful transitions from hospital to home (Pellett 2016). The aim of this multidisciplinary process of assessing, planning and co-ordinating patients’ care needs prior to their leaving hospital is to ensure continuity of care with a safe and timely discharge. While discharge planning is a universal priority for all acute inpatient facilities (McNeil  2016), the process and pace of discharge planning have changed beyond all recognition (Lees-Deutsch  2017). The increasing pressure on inpatient beds has meant that despite the clear benefits of reducing the time a patient occupies a hospital bed, ‘achieving it has proven difficult’ (NHSI 2018, p.3) and effective discharge planning therefore remains one of the major challenges facing the NHS today (Winfield and Burns 2016). Both internal and external planning processes are included in this chapter. External planning processes are those associated with the interface between primary and secondary care. They include processes related to complex discharges (including for patients with additional needs), discharge to a nursing home and discharge at the end of life.

Discharge care and planning DEFINITION

Discharge planning is a complex process (Wallace et  al.  2017) that is not a discrete event with one model of care but a transitional one with many factors involved (Chenoweth et  al.  2015). The process should take into account a patient’s physical, psychological, social, cultural, economic and environmental needs. It involves not only patients but also families, friends, informal carers, the hospital multidisciplinary team, and the community health and social services teams.

RELATED THEORY

The evidence suggests that a structured discharge plan tailored to the individual is best practice (McNeil  2016). Guidance from the National Institute for Health and Care Excellence (NICE) (2015) emphasizes this person-centred approach by highlighting the importance of information sharing between the patient, their family or carers, and all health and social care practitioners involved to ensure a safe and co-ordinated transition. Patients need to be considered as equal partners in the process where the foundations for decisions are based on what is important to the individual and their needs and preferences (Weiss et  al.  2015). This approach also promotes the highest possible level of independence for the patient, their partner and their family by encouraging appropriate self-care activities and participation in the discharge planning process. The roles of both family members and informal caregivers are crucial in supporting the discharge planning process, as Mabire et al. (2018) indicate. Therefore, providing the patient and their family with information, knowledge and confidence in their care before they leave hospital is an essential component of discharge preparation. Evidence suggests, however, that during a patient’s hospitalization, family and carers often receive limited communication and education regarding the care of their loved ones after discharge (Cacchione 2018). This can leave patients unprepared for the transition home; they can feel a sense of abandonment (Wallace et  al.  2017) and are rendered more likely to require a readmission. It is therefore vital that nurses and other members of the multidisciplinary team discuss with the patient and their family how they will manage their condition after their discharge and offer appropriate teaching and support to enable self-care. The use of patient information sheets to aid this process has

been found to be effective and may help both patients and their families feel more prepared for discharge from hospital (New et al. 2016). Assessment of patients’ individual needs for discharge is of particular importance when considering transfer from an acute care setting. The NICE (2015) guidance indicates that practitioners should work together ‘to identify factors that could prevent a safe, timely transfer of care from hospital’ (p.12). Assessing risk and the prompt sharing of pertinent concerns regarding a patient’s physical, psychological or cognitive ability enables earlier intervention from the multidisciplinary team, thereby helping to ensure patient safety and wellbeing (Lees-Deutsch et  al.  2016). Staff should have a clear understanding of their roles and responsibilities and work collaboratively (Elliott and DeAngelis  2017). The NICE (2015) guidance recommends that the multidisciplinary team should be identified as soon as a person is admitted and that there should be regular contact with the community team to provide co-ordinated and planned ongoing support. To achieve the best continuity of care after discharge, there needs to be effective communication across all disciplines, and with the patient and their family (New et  al.  2016, Mabire et al. 2018). This ensures that the patient’s wishes are heard and acted upon appropriately (Winfield and Burns 2016). Co-ordination of discharge care planning should be led by a ‘single health or social care practitioner’ (NICE 2015, p.10); this nominated person is often a key worker or discharge co-ordinator. A key worker is a single named person who has agreed with the patient to be their first point of contact for support, information and care planning. Discharge co-ordinators are, in general, health or social care professionals who have both hospital and community experience. Their role is to advise, help with planning and assist the co-ordination of the differing care providers that the patient may need when they leave hospital, particularly when their nursing and care needs are complex (Lees 2013).

CLINICAL GOVERNANCE

Legal, professional and safeguarding issues in  discharge planning

There is a requirement in discharge planning for nurses to share information about patients with health and social care providers in the community. Nurses need to ensure they use safe communication procedures so that information is only shared with those who require it. Failing to apply good information governance processes could result in information being shared inappropriately and the breaching of a patient’s right to confidentiality. Patients need to be supported and encouraged to make their own decisions; where a patient lacks capacity, the need to share information must be based on a consideration of risk and the person’s best interests (this is discussed in more detail in Chapter  5: Communication, psychological wellbeing and safeguarding in the section about the Mental Capacity Act (2005)).

Risk management

Delays in discharge contribute substantially to the financial and capacity pressures facing the NHS, as do readmissions (Winfield and Burns  2016). The total number of NHS hospital beds in England has more than halved in the past 30 years while the number of patients has increased significantly (Ewbank et al. 2017). Anticipating and managing potential delays via proactive planning therefore helps the NHS and other healthcare providers to use their limited resources most effectively, and, more importantly, can improve a patient’s quality of life (Alper et  al.  2017). Planning care for discharge and involving patients and their families is therefore important in keeping disruption to a minimum to ensure inpatient facilities are maximized and patients move in a seamless fashion back into the community. Delayed and/or ineffective discharge planning has been shown to have detrimental effects on patients’ psychological and physical wellbeing and their illness experience (Lees 2013).

CHAPTER 3 Discharge care and planning

Figure 3.1  A patient leaving hospital. Source: Reproduced with permission of Getty Images.

Additionally, evidence suggests that inadequate discharge planning in older people leads not only to adverse health outcomes but also to an increased risk of hospital readmission (Chenoweth et  al.  2015, Pellett  2016). Older people with dementia or other cognitive impairment are likely to experience an extended length of stay in hospital because of more complex organizational arrangements and an increase in the support needed on discharge (Challis et al. 2014). Elderly patients in acute care do not always get enough opportunity to mobilize and are highly likely to acquire ‘deconditioning syndrome’, where their bone mass and muscle strength are reduced. Up to 65% of older patients experience this type of decline during hospitalization (British Geriatrics Society  2017). This may result in increased risk of falls, constipation, incontinence, depression, swallowing problems and pneumonia (Arora  2017). Reducing this risk by implementing proactive planning to ensure timely and safe discharge is therefore paramount; nurses’ key role in achieving this is emphasized by The Queen’s Nursing Institute (QNI) (2016), which suggests that nurses are ‘at the heart of effective discharge planning’ (p.35).

Discharging patients from hospital: internal procedures EVIDENCE-BASED APPROACHES

Despite the fact that improved discharge planning has been a consistent recommendation in health policy and research, there is no commonly agreed model for the process of discharge (Waring et  al.  2014). The process for discharging patients at ward level should, however, be standard for all simple discharges across the hospital. NHS Improvement (NHSI) (2015) has developed a toolkit on discharge planning and highlighted key elements that are essential for both elective and emergency admissions: • Specify a date and time of discharge as early as possible within the period of care. • Identify whether a patient has simple or complex discharge planning needs. • Identify what the patient’s individual discharge needs are and how these will be met. • Define the specific clinical criteria that a patient must meet for discharge.

NHSI (2015) also says: ‘A specific targeted discharge date and time reduces a patient’s length of stay, emergency readmissions and pressure on hospital beds’ (p.2). Discharge dates in elective care can be planned prior to admission; if patients have attended a pre-assessment appointment, discharge needs should be identified at this point to allow effective planning and to enable clinical staff to notify appropriate services in advance of admission (NICE 2015). Advance planning is not possible in emergency or unscheduled care so in these circumstances robust systems of patient assessment are crucial to gather relevant patient information early (Lees-Deutsch et  al.  2016). An estimated date of discharge can then be agreed for everyone to work towards. The date may change depending on clinical and individual patient needs since changes in patients’ medical conditions require ongoing reassessment and should be the foundation of decisions about timing (Weiss et al. 2015). The expected date of discharge should therefore be continually reviewed based on the consultant’s judgement as to when the patient is likely to have recovered sufficiently to go home. This is best done by establishing the clinical criteria for discharge, which are the functional and physiological parameters that the patient must achieve before discharge (NHSI  2018). These criteria enable ­everyone to focus on the same factors, which helps in communication and facilitates more effective discharge planning. Due to the rapidly aging population, the increasing number of people living with long-term conditions (such as dementia) and the decreasing number of hospital beds, the pressure to discharge patients quickly is a continuous challenge for the NHS (Ewbank et  al.  2017). As a result, there have been many recent reports, recommendations and initiatives to improve discharge planning from statutory and voluntary bodies (e.g. Healthwatch England 2015, NHS England 2016, NICE 2015, QNI 2016, Royal Voluntary Service 2014). The SAFER Patient Flow Bundle (NHSI 2017a) is a structured approach that uses five elements of best practice to improve discharge planning (Figure 3.2). The Red to Green approach, which works in tandem with the SAFER Patient Flow Bundle, also highlights those days when a patient receives little or no intervention that progresses them towards discharge; these days progress them towards discharge (Figure 3.3). Green days are of value to a patient as they receive care that contributes towards them getting home. By using this approach, hospitals can see where there are blockages in their discharge processes and make changes for improvement. For example, a high number of patients may have red days because they are waiting for a scan before discharge. By reviewing the radiology scheduling, the hospital could implement changes to fast-track patients who are awaiting discharge, which could prevent discharge delays. Nurse-led and criteria-led discharge have both been developed within the past decade as ways to expedite timely discharge for patients. Both require the clinical parameters for a patient’s discharge to be clearly defined; once these have been met, discharge can be facilitated by a competent member of staff (Lees-Deutsch and Robinson  2018). For nurse-led discharge to be undertaken, nurses require specific training to ensure competency in the continuing assessment of patients for discharge, whereas criteria-led discharge is an approach that can be used by a range of professionals. Criteria are often developed from clinical guidelines for specific conditions (Cundy et al. 2017) and their use can appropriately inform practitioners about the patient’s clinical readiness for discharge. However, effective discharge extends beyond the use of criteria in isolation (Lees-Deutsch and Gaillemin  2018) and nurses must focus on their accountability for delivering holistic care throughout the discharge planning process. Introducing frameworks and approaches to discharge planning can support the process and improve efficiency, organization and overall satisfaction of patients and staff (Lees-Deutsch and Gaillemin  2018). Such methods help to reduce time lags in the traditional discharge process, thereby reducing length of stay and improving patient safety.

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THE ROYAL MARSDEN MANUAL OF CLINICAL NURSING PROCEDURES

Figure 3.2  The SAFER Patient Flow Bundle. Source: NHSI (2017a). Reproduced with permission of the NHS.

The SAFER Patient Flow Bundle Introduction SAFER is a practical tool to reduce delays for patients in adult inpatient wards (excluding maternity).

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The SAFER bundle blends five elements of best practice. It’s important to implement all five elements together to achieve cumulative benefits. It works particularly well when it is used in conjunction with the ‘Red and Green Days’ approach. When followed consistently, length of stay reduces and patient flow and safety improves.

The SAFER patient flow bundle S - Senior Review. All patients will have a senior review before midday by a clinician able to make management and discharge decisions. A – All patients will have an Expected Discharge Date (EDD) and Clinical Criteria for Discharge (CCD), set by assuming ideal recovery and assuming no unnecessary waiting. F - Flow of patients to commence at the earliest opportunity from assessment units to inpatient wards. Wards routinely receiving patients from assessment units will ensure the first patient arrives on the ward by 10 am. E – Early discharge. 33% of patients will be discharged from base inpatient wards before midday. R – Review. A systematic multi-disciplinary team (MDT) review of patients with extended lengths of stay (>7 days – also known as ‘stranded patients’) with a clear ‘home first’ mind set.

S - Senior Review. All patients should have a senior review before midday: ◼ Use simple rules to standardise ward and board round processes. ◼ Minimise variation between individual clinicians and clinical teams to ensure all patients receive an effective daily senior review. ◼ Daily review undertaken by a senior clinician able to make management and discharge decisions is essential seven days a week. ◼ Effective ward and board rounds are crucial to decision making and care co-ordination.

Figure 3.3  Red and Green Bed Days. Source: NHSI (2017b). Reproduced with permission of the NHS.

Red and Green Bed Days Introduction ‘Red and Green Bed Days’ are a visual management system to assist in the identification of wasted time in a patient’s journey. Applicable to in-patient wards in both acute and community settings, this approach is used to reduce internal and external delays as part of the SAFER patient flow bundle. It is not appropriate for high turnover areas such as Emergency Departments, Assessment Units, Clinical Decision Units/Observation Units, and Short Stay Units where using Red and Green on an hours/minutes basis may be more appropriate.

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A Red day is when a patient receives little or no value adding acute care. The following questions should be considered: • Could the care or interventions the patient is receiving today be delivered in a non-acute setting? • If I saw this patient in out-patients, would their current ‘physiological status’ require emergency admission? If the answers are 1. Yes and 2. No, then this is a ‘Red bed day’ Examples of what constitutes a Red bed day: • A planned investigation, clinical assessment, procedure or therapy intervention does not occur.

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A Green day is when a patient receives value adding acute care that progresses their progress towards discharge. A Green day is a day when everything planned or requested gets done. A Green day is a day when the patient receives care that can only be in an acute hospital bed.

• The patient is in receipt of care that does not require an acute hospital bed. • The medical care plan lacks a consultant approved expected date of discharge. • There are no consultant approved physiological and functional clinical criteria for discharge in the medical care plan. A RED day is a day of no value for a patient

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A GREEN day is a day of value for a patient

CHAPTER 3 Discharge care and planning

Principles of care

It is essential that nurses are aware of their organization’s local discharge procedures, policies and protocols and are able to identify when a patient’s discharge needs may be complex; the principles of addressing these are covered below in this chapter. When planning a patient’s discharge from hospital, it is important for nurses to consider that, however well it is structured, discharge can have complex emotional aspects for the patient and their family (Teodorczuk 2016). Engaging patients and their carers and families at all stages is therefore an essential part of any discharge planning system as it enables a focus on patients’ individual holistic needs. This ultimately ensures not only patients’ continued safety but also their general wellbeing (Elliott and DeAngelis 2017).

PRE-PROCEDURAL CONSIDERATIONS

There are certain issues that need to be addressed for all patients, such as transport to enable them to return home and timely prescribing of medications to take home so that they are ready for discharge. NHSI (2015) suggests that checks for all discharge issues should be finalized 48 hours prior to discharge. It is also important to ensure that follow-up arrangements have been made. These may include a clinic appointment or referral to a district nurse for a specific procedure. Figure 3.4  An example of a tablet dispenser.

Equipment

Patients will frequently require equipment to enable them to return home. Ensuring that all required equipment is available and in working order before discharge facilitates a smooth transition to home (Elliott and DeAngelis 2017). The equipment needs of each patient should be assessed at pre-admission and throughout their stay to ensure nothing is omitted. Patients may require new additional services at home, such as oxygen, which should be prescribed using the appropriate national Home Oxygen Order Form (HOOF) and the Initial Home Oxygen Risk Mitigation Form (IHORM). In 2017, NHS England changed the process for ordering home oxygen to make it safer as it had been found that patients were not always being asked to sign consent forms when they were started on oxygen (NHS Sunderland Clinical Commissioning Group  2017). The IHORM was therefore introduced to reduce the risk of a serious incident occurring when medicinal oxygen is installed in a home environment. Before a patient is initiated on oxygen, the clinician must ask the patient some relevant questions in order to ensure they understand the risks and give informed consent. The HOOF and IHORN forms need to be faxed to the local oxygen supplier but often the task of ordering oxygen is completed by the patient’s local clinical commissioning group, which usually has details on its website along with the facility to download forms. It is useful to know how the local procedures work and to ensure consideration is given to the monitoring and reviewing of the patient on oxygen once at home.

Pharmacological support: medication on discharge

Before a patient is discharged, the nurse needs to ensure that the patient and, where appropriate, the carer are competent to selfadminister medication at home. Evidence suggests that there are often limited resources in hospitals to ensure patients who are capable of self-care regarding medication maintain their independence (QNI 2016) so supportive measures must be considered. In some areas, tablet dispensers are provided, particularly for those who have difficulty opening containers or who lack competency in remembering which tablets to take when (Figure 3.4). If carers and/or community nurses are involved in giving a patient medication at home, a medicines administration record (MAR chart) should be given on discharge, clearly stating the name of the drug, the dose and frequency, and any special instructions (Figure 3.5). Special considerations are required for medications prescribed for pumps and drivers (e.g. for patients who require end-of-life care or symptom management), and in such circumstances local policies should be referred to.

Figure 3.5  A sample medicines administration chart. Name

Purpose of medication

Dose

Frequency

Special instructions

Metoclopramide

Anti-sickness

10 mg

Up to 3 times a day

Take if feeling nauseous

Amoxicillin

Antibiotic – to treat infection

500 mg

3 times a day

Do not miss a dose and ensure the course of treatment is completed (take all of the tablets prescribed)

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THE ROYAL MARSDEN MANUAL OF CLINICAL NURSING PROCEDURES

Non-pharmacological support: nutrition

In some cases, patients may be receiving nutrition via feeding tubes, known as ‘enteral feeding’. The common routes for enteral feeding in the community are:

52

• radiologically inserted gastrostomy (RIG) • percutaneous endoscopically placed gastrostomy (PEG) • jejunostomy • nasogastric (NG). Dietitians and/or nutrition nurses normally facilitate arrangements for these patients when they are going home. It is import­ ant that community teams including nurses and dietitians are contacted in advance of a patient being discharged with supportive feeding in situ to ascertain what information and support they need to facilitate the patient’s safe and timely discharge home.

Specific patient needs on discharge

It is important to recognize that some patients will have additional needs due to their status or health condition – for example, a continuing disability, learning difficulties, a mental ‘illness’ or dementia. Patients who live alone or who have limited financial resources also need specific consideration to ensure their needs are met and that they are not vulnerable to further problems once discharged. There may be practical issues about the transfer home that patients have not considered themselves while in hospital. If, for example, the patient lives alone or is very frail, simple tasks such as shopping may be very difficult. Some trusts have services to provide food packs for elderly patients (QNI 2016) but otherwise arrangements will need to be made prior to discharge to ensure the patient has adequate food provisions. Talking to the patient about what they will need and how they will manage is essential. Carers, family and neighbours should be involved and appropriate local agencies and services considered. Age UK (www.ageuk.org.uk) provides information and support for older people. Its factsheet on hospital discharge gives useful advice for patients about practical issues to consider when leaving hospital (Box 3.1). Each year, almost a third of people over the age of 65 fall (NICE 2018). Where patients are frail or at risk of falls, ensuring that they know that a community pendant alarm system or other personal alarm system can be installed may provide them and their family with some reassurance. Information regarding these alarms and local providers is usually held by the local authority (see Chapter 7: Moving and positioning for more information). For many dependent adults, adaptive technologies provide a means to independent living and a decrease in reliance on support from family members or more costly social services.

Accommodation considerations on discharge

On discharge, consideration may need to be given to patient accommodation, such as the suitability of the accommodation and alterations required. The hospital occupational therapy team usually leads on this and makes a domiciliary visit to ensure appropriate aids (e.g. hand rails) are put in place and changes are made to facilitate the safe transition of the patient home. A home visit may also be necessary to ensure the property is habit­ able – for example, if the patient’s property is in a poor state or there are issues in relation to hoarding. This may need to be done by or with social services. Where the patient is a home-owner, however, the housing department may be less likely to intervene, in which case it is up to the patient and their family to address such issues. It is also possible that prior to admission a patient will have been homeless, or they may become homeless during their hospital stay. The patient may need to be supported to access accommodation through the local authority homelessness team. As part of the process, the patient will need to provide evidence of eligibility for social housing, which will require specific supporting documentation. It is worth noting that all housing assessments are carried out online, which can be difficult for patients who have

Box 3.1  Practical issues for older people when leaving hospital Attention to practical issues is vital for a safe and smooth discharge: • Has your carer been given sufficient notice for your discharge date/time? • Do you have, and are you wearing, suitable clothes for the journey home? • Is a relative collecting you or is hospital transport required? • Do you have house keys and money if travelling home alone? • Will medication be ready on time? This is usually enough for the next seven days. Has your medication changed since admission? Have changes been explained to you and your carer? Do you know whether some prescribed items are only to be taken in the short term? • Have you and your carer received training to use new aids or equipment safely and effectively? Will they be there when you get home? • Do you have a supply of continence products to take home as agreed, know when to expect the next delivery and how to order supplies? • Is your GP and other community health staff aware of your discharge date and support your need from them? Has a discharge summary with details of any medication changes been forwarded to the practice? • If returning to your care home, has the manager been informed of the date and likely time of your arrival? Are you to take a copy with you or will staff forward copies of your care plan and medication needs to them promptly? Source: Age UK (2019). Reproduced with permission of Age UK.

little or no knowledge of computers, so extra support is needed for such patients to prevent delay in discharge.

Assessment and recording tools

The use of a discharge checklist or centralized discharge planning record that can be accessed by all hospital staff can aid the process and facilitate rapid transfer of information between teams (Lees 2013, Winfield and Burns 2016). The same checklist can be used for all patients whether they have simple or complex discharge needs, as it minimizes omissions or duplication in discharge actions and ensures a good record of the planning process. An example of a discharge checklist is given in Figure 3.6.

POST-PROCEDURAL CONSIDERATIONS

Every patient leaving hospital should receive a discharge summary that is completed by their clinical team, and a copy should be sent to their GP within 24 hours of the patient being discharged (NHS England 2018). This facilitates improved continuity of care as it is the primary mode of communication between the hospital care team and those who will be providing the aftercare once the patient is at home (Alper et  al.  2017). The plan should include an update about the patient’s clinical condition and treatment, information about medications and arrangements for follow-up care.

COMPLICATIONS

Delayed discharges

A discharge delay is when a patient remains in hospital beyond the date agreed by the multidisciplinary team and beyond the time when they are medically fit to be discharged. Occasionally the discharge process may not proceed as planned; a discharge may be delayed for a number of reasons and a system should be in place to record this. For every patient who is ‘delayed’, NHS

Figure 3.6  Example of a discharge checklist.

Discharge checklist Discharge Criteria 1.

2.

Yes

No

Patient is alert and orientated/within patient’s ‘normal status’

Yes

No

Patient/carer demonstrates understanding of treatment and care needs and their concerns have been discussed

Yes

No

Patient/carer is aware of warning signs and when to contact hospital

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Mobility/Activities of Daily Living Patient’s usual level of independence attained or suitable for discharge

Yes

No

Elimination Patient is voiding urine without difficulty and within expected pattern and urine output satisfactory

Yes

No

Yes

No

Yes

No

N/A

Nutritional supplements supplied and explained to patient

Yes

No

N/A

Enteral feeding tube e.g. PEG in situ with no signs of complications

Yes

No

N/A

Nausea and Vomiting Patient reports no nausea or vomiting, or controlled to acceptable level

Yes

No

Wound and/or Potential Infection Temperature between 36.0°C and 37.5°C

Yes

No

Surgical wound(s): signs of wound infection absent (no erythema, swelling or discharge)

Yes

No

N/A

Surgical wound(s): Patient is aware of type of sutures/clips and arrangements for removal if required

Yes

No

N/A

Patient aware of arrangements for wound care/dressing and has been given any dressing required

Yes

No

N/A

Cognitive and Perceptual Status

Pain Patient reports pain free/pain is controlled at an acceptable level

3.

Respiratory status O2 sats above 95% on air; respiratory rate between 12–20 bpm or within patient’s normal range if pre-existing respiratory disease

4.

Cardiovascular status Pulse within patient’s normal range (rate/rhythm/volume) Blood pressure within patient’s normal range

5.

6.

Patient’s bowel movements are within patient’s expected pattern 7.

8.

9.

N/A

Nutrition Patient is eating and drinking

Comments

53

Figure 3.6  (continued) 10.

54

11.

12.

Clinically Fit for discharge Clinical discharge parameters met OR Patient deemed medically fit by clinical team

Yes

No

Patient’s side effects/complications are managed and the patient’s condition is stable for discharge

Yes

No

CVADs patent with no signs of complications and/or peripheral cannula removed

Yes

No

N/A

Yes

No

N/A

Patient/carer demonstrates understanding of purpose of medications and how to administer

Yes

No

N/A

If required, patient has medicine administration card to facilitate selfmedication at home

Yes

No

N/A

Patient has equipment for injections e.g. sharps box if required

Yes

No

N/A

Patient has been returned their own medication (including CDs)

Yes

No

N/A

Yes

No

N/A

Yes

No

N/A

Yes

No

Patient has been given written information regarding their condition, treatment and/or equipment

Yes

No

Patient knows contact details of Key Worker/RMMH/Ward

Yes

No

Yes

No

N/A

Referrals made and activated for appropriate community support (e.g. social services, district nurse) if required

Yes

No

N/A

Letters/information as required for GP, district nurse, practice nurse given to patient

Yes

No

N/A

Yes

No

Medication TTOs (including nutritional supps./ dressings/CDs and fridge items) given to patient with prescription sheet signed by nurse and patient with copy for GP

Property and Equipment All required equipment in place/ arranged for discharge and patient/carer aware e.g. home oxygen, appliances, nebulisers Patient has had their property and valuables returned

13.

14.

15.

Information Provision Patient has been given Discharge summary

Follow up and community support Patient has date and time of next appointment or treatment booked

Transport Suitable transport agreed and arranged

16.

N/A

Specific discharge requirements Specific checklists completed if required e.g. for palliative care patient

Additional comments

Date:

Signature:

Print name:

Designation:

CHAPTER 3 Discharge care and planning

Box 3.2  Example of a form documenting discharge against me dical advice Name: Hospital No: Address: I wish to discharge myself against medical advice and accept full responsibility for my actions. Signed: Date: Time: Statement to be signed by the Doctor I have discussed with the patient the medical reasons why he/she should remain in the hospital. Signed: This form should be filed with the patient’s medical records

trusts are required to report the delay to their commissioners. It is the responsibility of the health authorities, in collaboration with local authorities, to monitor and address any issues that result in delays in the transfer of patients from an acute bed to their home or a community bed, such as a care home bed or rehabilitation bed. Trusts closely monitor bed activity and reporting varies from weekly to daily in the winter months.

Discharge against medical advice

Patients may take their own discharge against medical advice and this should be documented accordingly using the hospital’s appropriate form (Box 3.2). When patients are assessed as requiring care or equipment but decline these, this does not negate the nurse’s duty to ensure a discharge is safe. A discussion should take place with the patient, and their carer if applicable, to assess how they intend to manage without the required care and/or equipment in place. It is crucial that the appropriate community services are made aware of assessed needs that are not being met through patient choice or lack of resources. It is critical that the community teams who will be supporting the patient when they return home are notified; where possible, this should be in writing, enclosing a copy of any form documenting discharge against medical advice.

Readmission following discharge

Premature discharge or discharging the patient to an environment that does not meet their needs may result in them being readmitted to hospital (Alper et al. 2017). Evidence demonstrates that tailored discharge planning can reduce readmission rates and length of stay but that a significant proportion of patients return to hospital within a month due to complications or unplanned care (Teodorczuk 2016). Readmissions are costly and put patients at a higher risk of acquiring infections, of medication errors and of deconditioning, and their impact is therefore negative for both patients’ quality of life and the healthcare system (Sheridan et  al.  2017). Addressing readmissions by ensuring patients have well-planned and co-ordinated discharge is therefore essential. The elderly are particularly at risk of readmission following discharge (Lees-Deutsch 2016). Research commissioned by the

Learning Activity 3.1  Case study Mrs Margaret Sharpe, aged 87, has been admitted to an acute medical ward with drowsiness. She is undergoing investigations, but all the results so far suggest the problem is caused by side-effects of prescribed medication and mild dehydration. She is married to George, aged 92, and they live in a twobedroomed fourth-floor flat with a lift. Margaret and George have three adult married children and eight grandchildren. The family live within five miles of Margaret and George and keep a fairly close eye on their parents. George has moderately severe vascular dementia, and Margaret is usually his main carer. Margaret has three long-standing medical problems that she has learned to live with: urinary stress incontinence and urgency, mild cardiac failure resulting in breathlessness and a chronic right-leg ulcer. Currently Margaret and George do not receive any regular care from social services. A community nurse visits twice a week to dress Margaret’s leg ulcer. 1  Who is responsible for planning Margaret’s discharge? 2  What potential problems may develop during Margaret’s admission, and how could these be avoided? 3  Apart from Margaret, who should be involved in discharge planning? The test results confirm that Margaret’s drowsiness was the result of mistakenly using George’s diuretics (double Margaret’s own prescribed dose), with resulting dehydration and electrolyte imbalance. These effects have now been corrected, and the medical staff confirms that Margaret can be discharged home in two days’ time, after an echocardiogram has been carried out. 4  Suggest at least two interventions which could enhance Margaret’s and George’s safety at home, the  need for which should be assessed before discharge. 5  What is one of the biggest risks to Margaret’s discharge date being deferred? 6  Margaret’s discharge will be tomorrow. She has some visitors by her bed. What final checks are required before the end of the evening shift? See the answers on the companion site of this student edition: www.royalmarsdenmanual.com/student10e.

Royal Voluntary Service (2014) estimated that people aged 75 and older are more than twice as likely as those younger to be readmitted to hospital, if they are not given enough support on discharge. This is particularly true for those who live alone or have long-term healthcare needs. Patients with dementia similarly have higher readmission rates possibly due to the ­ fact that they are less likely to benefit from discharge education, self-care instructions or to report symptoms (Teodorczuk 2016). NICE (2015) guidelines consider referral back to relevant community-based care practitioners and a call or visit from ­ a  community-based nurse or GP within 72 hours of discharge to mitigate the possibility of readmission for those at high risk. It  is essential that nurses understand the negative impact of ­readmission in order to ensure timely and safe discharge with maximum continuity of care.

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THE ROYAL MARSDEN MANUAL OF CLINICAL NURSING PROCEDURES

Interface between primary and secondary care: external processes RELATED THEORY

56

NHS Continuing Healthcare

When a patient with complex and ongoing health or social care needs is ready to be safely discharged from acute care, it is very important that this should happen in a timely manner. It is therefore helpful for nurses to have an understanding of the processes involved in determining the funding for healthcare services and the options available for patients once they have been discharged back into the community. NHS Continuing Healthcare funding exists to provide a package of ongoing care that is arranged and funded solely by the NHS. It should be awarded only when an individual has been assessed as having a primary health need and it is provided to support the care that people need over an extended period of time as a result of disability, accident or illness, to address both physical and mental health needs (DH 2018). The National Framework for NHS Continuing Healthcare and NHS-Funded Nursing Care (DH 2018) provides guidance and structure on the principles and processes of funding. To be eligible, patients must be assessed by a multidisciplinary team to determine the complexity and intensity of their need and the help they require. The assessment process for NHS Continuing Healthcare should not be allowed to delay hospital discharge (DH 2018) but it is essential for patients’ holistic needs to be placed at the heart of the assessment process as they are frequently facing significant changes in their life and a positive experience of the assessment process is therefore crucial. There is also a legal obligation to inform patients of their right to be assessed for NHS Continuing Healthcare funding, and this can best be done by referring them to an online resource booklet on the Department of Health and Social Care’s website (https://www.gov.uk/government/organisations/ department-of-health-and-social-care).

Intermediate care and re-ablement services

It is recognized that older inpatients have longer lengths of stay despite proactive discharge planning due to their complex needs (Mabire et al. 2018). This increases the risk of adverse events following their discharge, and initiatives to aid the transition period from hospital to home are therefore important elements in discharge preparation. Following a hospital stay, intermediate-care teams may provide a period of intensive care and/or rehabilitation, which may take place in a care home or in the individual’s own home. Intermediate care aims to prevent hospital admissions, support faster recovery from illness or injury, support timely discharge from hospital, and maximize independent living (NICE 2017). Unlike NHS Continuing Healthcare, it is likely to be limited to a maximum of 6 weeks but there are local variations in practice. Intermediate care requires a person-centred approach, involving patients and carers in all aspects of assessment, goal setting and discharge planning. Re-ablement is a similar service that aims to help people regain their independence following an illness or injury. It is a community-based service that provides assessment and interventions to people in a residential setting such as a care home or a rehabilitation unit. The aim is to optimize individuals’ wellbeing by working in partnership with them to enable confidence and independence in activities of daily living and other practical tasks (NICE 2017). Services are delivered by a multidisciplinary team but most commonly by healthcare professionals or care staff if the service is within a care home. Re-ablement teams are usually made up of the following disciplines: • social workers • occupational therapists

• physiotherapists • rehabilitation support workers • community nurses. For patients requiring a long-term package of care, it must be made clear to the patient and/or their family that they will be financially assessed and as a result may be charged for the service. In some local authorities, if the patient is assessed as ‘selffunding’, social services may only then offer a signposting service to private care providers.

EVIDENCE-BASED APPROACHES

If a patient does not meet the criteria for NHS Continuing Healthcare, they may still receive assistance with personal care and domestic tasks through social services. This can be through a re-ablement service or a long-term package of care. Where a patient is assessed as requiring care from social services to ­enable them to return home, the trust should notify the local authority (social services) using the Assessment Notification form and the Discharge Notification form (these forms will be available from the discharge team or social services).

Assessment and recording tools

The local authority will require an Assessment Notification (formerly known as Section  2) no later than 72 hours prior to discharge, but this should be done at the earliest opportunity (see Figure 3.7 for an example). (Again, contact the discharge team or social services for this form.) How the local authority responds to the Assessment Notification may depend on what local arrangements are in place. Many local authorities have a social worker or social work department within the hospital trust, and this person or team is usually part of the discharge team. Their role is to facilitate the setting up of care packages for discharge. Other authorities may require additional assessments, such as occupational therapy or medical reports, to enable them to set up the care. It is not uncommon for local authorities to request an NHS Continuing Healthcare checklist to be completed as part of the process to assess whether the patient might be entitled to NHS Continuing Healthcare funding. When the patient has been assessed and is ready for discharge, a Discharge Notification (formerly known as a Section 5) should be sent to the local authority at least 24 hours before the patient leaves hospital (see Figure 3.8 for an example). Nurses need to be aware of the importance of the timeliness of completing this social services documentation and facilitate this being done as soon as possible to avoid discharge delays.

COMPLICATIONS

If the patient becomes unwell or their care needs change significantly prior to discharge, it is the responsibility of the discharge co-ordinator to inform the local authority to put on hold any arranged social services by sending a Withdrawal Notification form (again, contact the discharge team or social services for this  form). Once a revised discharge date is confirmed, new Assessment Notification and Discharge Notification forms must be sent to re-establish the services to prevent discharge delay. If a patient is already in receipt of an existing care package and it needs to be re-started without any changes on discharge, Social Services must be informed at least 24 hours prior to discharge to facilitate restarting the existing care package.

Complex discharges DEFINITION

For patients requiring specific support on discharge, proactive and systematic planning is essential (Winfield and Burns 2016). A complex discharge may be considered when: • a large package of care involving various agencies is required • the patient’s needs have changed since admission, with different services requiring co-ordination

Figure 3.7  Example of a Social Services Assessment Notification form.

ASSESSMENT NOTICE TO LOCAL AUTHORITY To be completed no later than 2 days before discharge It is best practice to send this assessment notice as soon as social care requirement is identified (As required under the Care Act 2014, schedule 3, para (1) (1)) NHS No: Part A: Patient Details

Hospital No:

Title:

Given Name:

Address:

House Name/No.: Address Line 1: Address Line 2: City/Town: Postcode: Local Authority:

Does the patient live alone?

Family Name:

Preferred Name:

DOB:

Sex:

Patient Email: Patient Land Line No: Patient Mobile No: Other Nos:

If No, who do they live with?

Immigration Status:

Dependants:

Ethnicity:

Interpreter needed? First Language: (if not English) Part B: Carer or Key Contact Details (may be next of kin, carer, family member, friend, etc - as appropriate) Name: Tel/Mob: Relationship to Patient: Who is the main carer for the patient? If other, please specify: Religion:

Other:

Part C: General Practitioner Details GP Name: Practice Name: GP Address: Tel: Part D: Hospital Details and Patient’s Proposed Discharge Date Date of Admission: Anticipated Discharge Date: The Royal Marsden Hospital: Ward Name: Chelsea site

Ward Tel No:

Sutton site Lead Clinician

Reason for Admission:

Planned Admission?

Part E: Patient Consent for Referral/Information Sharing What is patient’s capacity to give consent to this referral? Additional information regarding capacity to consent: Has patient consented to this referral? Additional Information regarding consent: Can Carer or Key Contact be contacted for discussion regarding the patient? Part F: Referral Information Have you considered whether or not to provide NHS Continuing Health Care (CHC), if so, what was the result of your consideration? Reason for referral: Accommodation: Relevant Medical Information: Details of existing support: Has the occupational therapy report been completed? Part G: Patient's View (e.g. What support do you think you will need when you leave hospital?) Part H: Carer or Key Contact's View (e.g. What support do they think the patient/carer will need when they leave hospital?) Part I : Risk Factors Are there any safety issues for workers visiting on the ward or at home? If yes what are they? Part J: Referrer Referrer’s name: Job Role: Date & Time: Email:

Fax: Tel:

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THE ROYAL MARSDEN MANUAL OF CLINICAL NURSING PROCEDURES

Figure 3.8  Example of a Social Services Discharge Notification form.

DISCHARGE NOTICE TO LOCAL AUTHORITY

58

To be issued to Social Care at least one day in advance of the confirmed hospital discharge date It is best practice to send this discharge notice as soon as the discharge date has been agreed (As required under the Care Act 2014 schedule 3, para 2 (1) (b)) Confirmation of Discharge Date (as agreed by MDT) Has Patient been informed of discharge date? Has Carer/Key Contact been informed of discharge date? NHS No:

If no, please explain why? If no, please explain why? Hospital No:

Part A: Patient Details Title:

Given Name:

Address:

House Name/No.: Address Line 1: Address Line 2: City/Town: Postcode: London Local Authority:

Family Name:

Preferred Name:

DOB:

Sex:

Part B: Confirmation of Referring Hospital/Ward Details Hospital: Lead Clinician:

The Royal Marsden

Chelsea Site

Ward Name: Admitted on:

Ward Tel:

Diagnosis on Discharge: Part C: Confirmation of Health and/ or Social Care Requested for Discharge The following health and/or Social Care required will be available on the expected date of discharge: Equipment to be provided at home: Part D: Notice Status Assessment Notice sent to Social Care with admission details confirmed? Social Care assessment completed? Date Discharge Notice completed Has the occupational therapy report been sent to Social Care? Part E: Patient Consent for Information Sharing/Referral What is patient’s capacity to give consent to this referral? Additional information regarding capacity to consent: Has patient consented to this referral? Additional Information regarding consent: Can Carer or Key Contact be contacted for discussion regarding the patient? Part F: Referrer Referrer’s name: Job Role: Email: Date & Time:

• the family and/or carer require intensive input into discharge planning considerations (e.g. psychological interventions) • the patient is entitled to NHS Continuing Healthcare and requires a package of care on discharge • the patient requires repatriation • there is dispute among the family about where the patient should be discharged to or what their care needs are • the patient is homeless.

RELATED THEORY

Patients who have specific social or specialized care needs, who have funding issues or who require a change of residence may

Fax: Tel:

have a complex discharge need (Lees-Deutsch et  al.  2016) and may require referral to the hospital’s discharge team. Hospital trusts may have different titles for staff within the discharge team, but essentially their role is to co-ordinate plans among all involved by liaising with the multidisciplinary team both within the hospital and in the community. In this way they act as ‘knowledge brokers’ to facilitate sharing and co-ordination (Waring et al. 2014). If a patient has dementia or a learning disability, the approach to their discharge needs to be carefully planned and tailored to meet their specific additional needs (Poole et  al.  2014). If, for example, the patient has been assessed as lacking capacity to make a decision under the Mental Capacity Act (2005) about

CHAPTER 3 Discharge care and planning

where they should live, then a ‘best interest’ decision must be made, ensuring that family and carers are involved. Where the patient is assessed as lacking capacity and has no relatives or friends and so is ‘un-befriended’ (as defined by the Mental Capacity Act 2005), a referral should be made to a local independent mental capacity advocacy service to ensure the patient gets the required support (Mental Capacity Act 2005). Where there is a concern that a person has a degree of cognitive impairment, it can easily be assumed that they cannot return home or that they need care. These assumptions should be challenged and decisions made on the basis of a needs assessment, which should include a mental capacity assessment. The assessment should evidence that the principles of the Mental Capacity Act (2005) have been applied and that any decisions have been made in the person’s best interests. For more detailed information on the principles of capacity and safeguarding, see Chapter 5: Communication, psychological wellbeing and safeguarding.

EVIDENCE-BASED APPROACHES

NICE (2015) recommend several key principles of care and support that should be considered for more complex patients during the transition from a healthcare facility to home: • Person-centred care: see everyone as an individual, involve families and carers, and identify those at risk. • Communication and information sharing: provide appropriate information in the right format at the right time and ensure discussions take place with all involved. • Discharge co-ordinator: a dedicated individual who works with the multidisciplinary team and involves carers and families in discussions about the care being proposed. • Develop a discharge plan: this should include details about the person’s condition, medicines and practicalities of daily living, and should detail which services and sources of support are involved. • Plan for care following discharge: ensure follow-up arrangements are made and communicated effectively. • Readmission risk: ensure those at risk of readmission are referred to appropriate community-based health and social care teams prior to discharge. For patients who may have additional needs on discharge, it is worth exploring what support services may be available and identifying what services were in place prior to admission. For example, if the person has a learning disability, they may have a learning disability nurse in the community. If so, involving the nurse in the patient’s discharge will ensure a safer transition for the patient by enabling access to a professional who has knowledge and expertise in the field of learning disabilities but also in the needs of the patient.

Principles of care

A comprehensive assessment is initially required to ascertain a patient’s discharge needs. Joined-up inter-professional care and good carer partnerships can then be established to facilitate safe and seamless transfer of care of the patient from the hospital back to the community (Teodorczuk et al. 2015) (Table 3.1).

Discharge to a nursing home RELATED THEORY

Despite the ageing population and pressure on acute hospital beds, care home admission from hospital is a transition pathway that is poorly understood and little researched (Harrison et  al.  2017). Discharging a patient to a care or nursing home requires careful thought as the decision to move into a care home is complex and often difficult and traumatic for individuals and their families (Lord et al. 2016). The impact on a patient and their family or carer may be significant, particularly where the person lives with a partner or family member and the move would be a loss for both of them. A thorough multidisciplinary assessment is

essential, taking into account the individual needs of the patient and their family or carer and exploring all the options before deciding on a care or nursing home. Harrison et al. (2017) suggest that it is important in aiding the process to ensure that significant discussions are documented, to include opportunistic conversations that nurses and others have with patients and their families. This ensures decisions and actions are recorded and it also facilitates better continuity of care. In most cases, the family or carer will look for a care home placement. This can be quite a daunting process and it is worth providing a list of questions and things to look for when assessing a care or nursing home (Table  3.2). Additionally, the local clinical commissioning group will be able to provide the family with a list of registered nursing homes for them to view.

COMPLICATIONS

Nursing and care home placements can be delayed while waiting for funding to be approved or waiting for a suitable bed to become available and it may therefore be necessary to consider an interim placement. It is important that the patient and their carers are aware that there may be time limits on the stay in hospital so they will be required to find a suitable placement within an agreed timescale. Many hospitals have a policy to support staff where patients and their carers are delaying the process of arranging a nursing home placement.

Discharge planning at the end of life EVIDENCE-BASED APPROACHES

The National Palliative and End of Life Care Partnership (2015) has set out a framework for end-of-life and palliative care based on key ambitions for the dying person which also relate to carers, families and those important to them. This extends to all aspects of care, including care planning, and is very important when a patient is being discharged for end-of-life care. The condition of a person nearing the end of life may change rapidly, so it is essential that choices are made, decisions are reached and community services are accessed without delay to ensure a timely and smooth transition of care from hospital to home or hospice. Discharging a patient at the end of life is often complex and multifactorial and requires a multidisciplinary team approach ­ allowing flexibility and responsiveness to the situation. Figure 3.9 shows an example of a checklist that can be used to help structure the process.

PRE-PROCEDURAL CONSIDERATIONS

It is important in the first instance to contact relevant community teams to highlight the need for a rapid response to any referrals being made. Community nursing, the community palliative care team and, where appropriate, the community matron should be notified at the earliest opportunity. A fast-track NHS Continuing Healthcare funding application may need to be submitted to access funding for care provision. This process is used to gain immediate access to funding to allow healthcare professionals to arrange urgent care packages, enabling patients to be cared for and to die in their preferred place, whether it is at home, in a nursing home or in a hospice (Thomas 2017).

Equipment

The patient may also require essential equipment to enable them to return home, such as a profiling bed, commode or hoist. These can often be accessed via the local community nursing team and should be ordered at the first available opportunity. Thomas (2017) found that 25% of discharges were delayed due to problems with the delivery of equipment to patients’ homes. Once care and equipment are in place and discharge is proceeding, a medical review should take place and a discharge summary should be written with a copy provided to the patient, their GP, community nurses and the community palliative care team. Telephone contact with all of the above is essential to ensure they are in receipt

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Table 3.1  Procedure for the assessment process for complex discharges 1 Nurse conducts a comprehensive assessment on admission (a) Identify whether the patient has simple or complex needs.

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(b) Refer to relevant members of the hospital multidisciplinary team.

For example, occupational therapist, physiotherapist, social services or discharge co-ordinator

(c) Liaise with current community services to ascertain current support (if any).

For example, district nurse or community palliative care team.

2 Multidisciplinary team discuss the case at the ward multidisciplinary meeting (a) Appoint a discharge co-ordinator.

• To act as discharge planning lead for all social services and NHS Continuing Healthcare referrals. • To act as a point of contact for discharge concerns. • To plan and prepare the family meeting or case conference and to arrange a chairperson and minute-taker for the meeting. • To meet the patient, their carers and their family. • To work in conjunction with multidisciplinary team. • To liaise with the patient’s named nurse.

(b) Formulate a discharge plan.

• Formulate a discharge plan based on the patient’s assessed needs. • Agree assessments required by the multidisciplinary team. • Agree home visits required (e.g. occupational therapist home visit and functional report).

(c) Set a provisional discharge date.

• Agree a provisional discharge date and time frames. This will only be an approximate date, depending on care needs, equipment, etc. It should be reviewed regularly with the multidisciplinary team. • Discharges should not be arranged for a Friday or a weekend, when skeleton social and care services are in place.

3 Discharge co-ordinator arranges family meeting or case conference (a) Invite the patient, their family, their carers and all appropriate healthcare professionals, including community staff where possible.

• Discuss the patient’s needs and the services and equipment required, and agree preferred and appropriate place of discharge. • If the patient is not returning to their own neighbourhood, a GP will be required to take the patient on as a temporary resident so this must be arranged. • Agree all relevant social services and NHS Continuing Healthcare referrals required. • Discuss any specific and special issues (e.g. infection status, IV therapy, need for syringe pump) to establish an appropriate plan. Notify community services.

4 Ward staff or discharge team make referrals to appropriate community services • Refer to community health services.

To include district nurses, community palliative care team, community physiotherapists etc. • Ascertain whether the district nurse is able to undertake any necessary clinical procedures in accordance with their local trust policy (e.g. on care of skin-tunnelled catheters) and make alternative arrangements if not. • Arrange for night sitters via the district nurse if required.

• Refer to Social Services.

The Social Services Assessment Notification (see Figure 3.7 for an example) must be sent at the earliest opportunity and no later than 72 hours prior to discharge.

• Request equipment from community nurse after discussion with patient and family.

For example, hoist, hospital bed, pressure-relieving mattress or cushion, commode or nebulizer. Additionally: • Ascertain the type of accommodation the patient lives in so that the equipment ordered will fit appropriately. • It is important to specify where the patient will be cared for – for example, ground or first floor.

• Request home oxygen if required.

Medical team to complete Home Oxygen Ordering Form (HOOF) and Initial Home Oxygen Risk Mitigation Form (IHORM) for oxygen cylinders and concentrators at home. Fax or email to relevant oxygen supplier.

CHAPTER 3 Discharge care and planning

5 Ward staff or discharge team confirms the discharge date and finalizes the community arrangements (a) Confirm provisional discharge date.

The provisional date is agreed with the patient and their family and/or informal carer(s). The actual date will then depend on when the following community services can be arranged: • social services package of care • district nurse • re-ablement service • nursing home or residential home placement • hospice bed • rapid response • equipment and home oxygen.

(b) Confirm equipment agreed and delivery date.

Ensure the family is informed of the delivery date and knows to contact the ward to confirm receipt of the equipment in the patient’s home.

(c) Confirm start date for care and fax or email details.

For example, Social Services, community nurse or community palliative care. • Community care referral forms need to be faxed or emailed to district nurses at least 48 hours prior to discharge. • The Discharge Notification (see Figure 3.8 for an example) must be sent at least 48 hours prior to discharge. • In some situations, family members are able to bridge the gap before a package of care starts to enable the patient to be discharged sooner. This action should be talked through with the patient and the family to ensure they are able to provide the care needed and that they will not be putting themselves or the patient at risk. • Confirm the agreed discharge date with the patient and their family.

6 Ward staff or discharge team co-ordinates the hospital discharge processes (a) Arrange transport and assess need for escort and/or oxygen during transport.

• Assess specific needs for transport – i.e. specify whether the patient needs a walker, chair or stretcher, and/or oxygen or an escort. • Arrange for a do not resuscitate (DNR) form if required for ambulance crew.

(b) Arrange discharge medication.

• Determine whether the patient will self-medicate and requires a selfmedication chart or dosette box. • Confirm the name of the person who will provide the prompt or give the medication to the patient at home. • Ensure take-home medication is prescribed and given to the patient or carer with explanations. • Ensure nutrition supplements, dressings and medical appliances are prescribed, ordered and given to the patient or carer with explanations. • If the patient has hospital equipment (e.g. a syringe pump) ensure it is clearly marked for return to the hospital with written instructions for the patient, carer or district nurse.

(c) Make arrangements for suitable access and provision for patient on arrival home.

• Check access issues (e.g. front door keys and steps) and ensure heating has been organized and food will be provided.

(d) Ensure patient has follow-up arrangements made.

• Next inpatient or outpatient appointment.

7 Confirm arrangements 24 hours prior to discharge (a) Telephone community services and confirm any special needs of the patient.

For example, infection status update or confirmation of hospital equipment required by patient.

8 After discharge, ward nurse or discharge co-ordinator makes a follow-up phone call to the patient (as agreed)

of all the information they require to take over the care of the patient in the community and to make sure that home visits are requested.

Assessment and recording tools

The introduction of Electronic Palliative Care Co-ordination Systems (EPaCCS) has enabled the recording and sharing of people’s care preferences and key details about their care at the end of life. A national initiative is the ReSPECT plan

(https://www.resus.org.uk/respect), which is designed to try to ensure that people get the right care and treatment in an anticipated future emergency in which they no longer have the capacity to make or express choices. It incorporates both patient preferences and clinical judgement, and provides health and care professionals responding to an emergency with a summary of recommendations to help them make immediate decisions about the person’s care and treatment. The ReSPECT plan is created through conversations between

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Table 3.2  Questions and things to look for when assessing a care or nursing home First impressions

• Is the home easy for family and friends to visit, particularly those who have to rely on public transport? • Does the home have its own transport? • Is the main area accessible for people with disabilities, e.g. those with wheelchairs or who are poor sighted or hard of hearing? • Do the staff answer the door promptly? • Do the staff appear friendly and welcoming? • Do there appear to be several members of staff on duty? • Do the residents look well cared for and clean? • Is there an up-to-date registration certificate on display? Note: it is usual to sign a visitors’ book on arrival.

The accommodation

• Are the home and the rooms clean and fresh? • Are the rooms single or shared? • Do the rooms have en suite facilities? • Can you bring your own furniture and personal belongings? • Where are the nearest toilets and are they accessible? • Is there a telephone in the room and/or mobile phone reception? • Is there a Wi-Fi connection? And is there a fee for this? • Are there quiet areas to sit in? • What are the mealtimes? • Is there a choice of meals and diets? • Is there a laundry service on site?

Personal needs

• How often do the hairdresser, dentist, chiropodist, religious support and GP visit? • Does a resident change GP if they move from the local area? • Where are medications stored? • Are there newspapers easily available? • What activities are available to facilitate continuation of hobbies? • Does the home arrange outings? • Are there quiet areas for family and friends to visit? • Can they stay for meals? • Is there an overnight room where they can stay?

Finances and contracts

• What are the fees? • What services do the fees include, e.g. chiropody, hairdresser? • What are the terms and conditions? • Is there a reduction if the patient is admitted to hospital or goes on holiday? • What is the notice period or procedure for terminating a contract? • When is the room available from?

Nursing needs

• How many qualified nursing staff are on duty day and night (in a nursing home)? • How often do qualified nursing staff review a resident (in a nursing home)? • How often does the community nursing team visit and review residents (in a care home)? • What is the daily care routine? • If the patient has very specific nursing needs, how will they be managed? Refer to the list given by the ward staff on the patient’s specific healthcare needs. • How often does the community palliative care team visit? • How often is the GP or doctor in the home? • Although a difficult thing to consider, is the home able to support patients to remain in the home for end-of-life care?

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a person and their health professionals, and decisions are recorded on a form. The information includes patients’ personal priorities for care and agreed clinical recommendations about care and treatment that could help to achieve the outcome that they would want, that would not help or that they would not want. A regional version for London is Coordinate My Care (https://www.coordinatemycare.co.uk). Both initiatives allow healthcare professionals to record patients’ wishes within an electronic personalized urgent care plan that can be seen by GPs, community teams, emergency and ambulance services; the plan can then guide the care they provide. These care plans can be accessed by the out-of-hours and emergency services, which helps to reduce the number of inappropriate hospital admissions in the last year of life.

Informal carers DEFINITION

An informal carer can be defined as someone who helps another person, usually a relative or friend, in their day-to-day life. This is not the same as someone who provides care professionally or through a voluntary organization (NICE 2016).

RELATED THEORY

It is important to recognize that patients do not usually manage their condition in isolation but in the context of their daily lives with people who provide their support network at home, such as family, friends, colleagues and neighbours (Wallace et al. 2017).

CHAPTER 3 Discharge care and planning

Figure 3.9  Checklist for patients being discharged home for urgent palliative care.

Name:

Hospital No:

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Patients Being Discharged Home for Complex/urgent Palliative CareChecklist for Discharge This form should be used to assist with planning an urgent/complex discharge home for a patient with terminal care needs. It should be used in conjunction with the Discharge Policy. Sign and date to confirm when arranged and equipment given. Document relevant information in the discharge planning section of the nursing documentation. Document if item or care is not applicable. Appoint a designated discharge lead: Name: …………………………………… Designation: ……………………………Contact No:………. Date & Time

Signature & print name

Patient / Family Issues Meeting with patient/family to discuss plans for discharge Continuing Healthcare funding discussed and information leaflet given. Level of care required has been discussed and agreed. Role of community services (district nurses and community palliative care team) has been discussed and consent obtained for referral if needed. Consent obtained if in area & Coordinate My Care record created or updated. Upload DNaCPR form onto CMC record if this has been discussed with patient & there is a DNaCPR form on EPR. Continuing Healthcare application/Fast Track form commenced by Discharge Team & completed by MDT. Fast Track form can be found on the intranet under Discharge support/NHS continuing healthcare & can be accessed on T-drive under each ward/Dept. Contact Discharge team when complete for form to be sent to relevant CCG. Communication with District Nurse Referral made to District Nurses using the Community Services Referral Form. Equipment has been requested (delete as appropriate): - Electric, profiling hospital bed - Pressure relieving mattress - Pressure relieving seat cushion - Commode/urinal/bed pan - Hoist/sling/sliding sheets - Other ……………………………..…… Communication with Community Palliative Care Team Referral made to Community Palliative Care Team Communication with GP and Community Palliative Care Medical Team-Medical Responsibilities (Hospital medical team to organise -the nurse to confirm when arranged) Registrar to discuss patient’s condition with GP and request home visit for as soon as possible after discharge. Oxygen: HOOF & IHORM (Consent) forms to be completed by the medical team & faxed to relevant company. Please access website below for a list of the oxygen companies & their geographical area. https://www.pcc-cic.org.uk/article/homeoxygen -order-form Registrar or Specialist Nurse to discuss with the Community Palliative Care team the patient’s needs and proposed plan of care.

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Figure 3.9  (continued)

Date & Time

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Signature & print name

Adequate supply of drugs prescribed for discharge (TTOs) including crisis drugs e.g. s/c morphine, midazolam. Authorisation for drugs to be administered by community nurses. Please refer to Subcutaneous Drugs policy and complete the discharge checklist for the McKinley T34 syringe pump. ‘Ambulance transfer of palliative care patients’ document completed for Ambulance Crew.

EquipmentHas confirmation been received from a family member or the community equipment service provider that the equipment has been delivered to the discharge address? Provide an adequate supply of: -

dressings

-

water/sodium chloride for injection (if going home with end of life care medications for subcutaneous use)

-

sharps bin

-

continence aids

-

supply of needles and syringes

Transport (confirm by ticking appropriate boxes)

CHECK OTHER DISCHARGE DOCUMENTATION

Escort (family/nurse) Discussed with family that if the patient dies during the journey, the ambulance crew will not attempt resuscitation. Discharge destination in this event has been agreed. DNaCPR form provided? Written Information and Documentation A discharge summary will need to be completed prior to discharge. The discharge letter must be printed & given to a pharmacist to check the medication list is complete & accurate. Medical summary given to patient or relative. Medical discharge summary sent to GP, Community Palliative Care Team and District Nursing Team. Prescription sheet of authorisation for drugs to be administered by community nurses. Faxed to District Nurse, GP and Community Palliative Care Team. Copies of HOOF & IHORM faxed to GP for information only. Patient/carer given list of contact numbers of community services (including night service)-Discharge information sheet. Medication list, stating reasons for drugs, given and explained to patient/ relative. All documentation sent to community services is scanned onto EPR and filed in patient’s medical records. Signature/print name of designated ward based discharge lead: ……………………….… Date/Time………………………………….. File this form in the patient’s records on discharge.

CHAPTER 3 Discharge care and planning

Engaging and involving both patients and those who support them in an unpaid capacity as equal partners is central to successful discharge planning, and this is clearly recognized in the NICE (2015) guideline on discharge from hospital to the community for adults with identified social care needs. The hospital discharge process can be a critical time for informal carers, placing an increasing burden of care on them, particularly if they do not feel involved in the discharge process (Harrison et  al.  2016). It may be the first time they have been confronted with the reality of their role and the effect it may have on their relationship with the person needing care, their family and their employment. The emotional toll on carers may result in early readmission of the patient and it is therefore vital to involve carers as partners in the discharge planning process. Carers may have different needs from patients and there may be conflicting opinions about how the patient’s care needs can be met. It is not uncommon for patients to report that their informal carer is willing to provide all care whereas the carer is not in agreement with this. Healthcare professionals should allow carers sufficient time and provide appropriate information to enable them to make decisions to promote a successful and seamless transfer from hospital to home (Cacchione  2018). If carers are involved as equal partners throughout the process, they can provide valuable information about the person’s needs and circumstances beyond medical conditions or physical needs. This means discharge planning can be more comprehensive and may reduce the likelihood of the person being readmitted to hospital (NICE 2016).

Learning Activity 3.2  Case study Mr Michael Pearson is 67 years old and has widespread bowel cancer. He is married to Sophie and they have no children. Michael’s prognosis is very short – probably a matter of days to, at most, a couple of weeks. He has been in hospital for the past fortnight. Initially he was admitted for symptom relief and for assessment for further palliative treatment, but it is now clear and agreed that his condition is rapidly worsening and that further anti-cancer treatment would be futile. The medical team has held an honest discussion with Michael and Sophie to explain the situation. Following the conversation, Michael has asked whether he may go home to die. Michael and Sophie live in a semi-detached house with a downstairs cloakroom, including a toilet and small wash handbasin. There is a double bed upstairs. Michael’s main problem is pain in his abdomen, which is being controlled by morphine infusion via a 24-hour syringe pump. He is feeling very tired and becomes short of breath if he tries to exert himself. He is passing urine into a bottle when in bed; he is now too weak to walk to the bathroom, but for the past couple of days he has been helped to the bathroom in a wheelchair for his hygiene needs. A rapid discharge is required. Identify what should be addressed in order to facilitate Michael to achieve his goal to be at home. To help you organize your thoughts, you might like to create a mind-map or use the five priorities for care of the dying (see Leadership Alliance for the Care of Dying People 2014). See the answers on the companion site of this student edition: www.royalmarsdenmanual.com/student10e.

EVIDENCE-BASED APPROACHES

Under the Care Act (2014), carers are entitled to their own assessment and many support services can be provided, including respite, at no charge. The Act represents the most significant reform of care in many years by putting people and their carers in control of their own support (People First 2018). The aim is to ensure that people and their carers are supported in a practical way by providing information, financial and other support, helping carers to remain at work and to care for themselves. It is particularly important that carers who will be taking on the role for the first time when their family member leaves hospital are made aware of the benefits and support available to them from their local authority, since ‘deciding to care or continue caring for someone who is coming out of hospital . . . can be very difficult’ (Carers UK 2018, p.1). Often the first step in raising their awareness might be as simple as letting them know that the role they play with their family member is that of a carer: many people would see themselves as a spouse, child or grandchild rather than a carer. In addition to understanding that adult carers may be unaware of the support available, it is important to recognize that in some families children take on a caring role, and their needs may go unrecognized. Young carers may struggle with the responsibilities of providing care to parents, and without appropriate support they may feel isolated and distressed (Carers UK 2018). Support for young carers has increased under the Children and Families Act (2014), which aims to ensure that all children and young people are able to access the right support and provision to meet their needs. When a patient is discharged, provided consent is gained from the parents, it is important to inform community health and social care providers that young carers are involved. This will enable young carers to access additional support services so they can continue in their vital role.

The role of voluntary services RELATED THEORY

In many areas, voluntary sector providers have begun to forge ways to deliver efficient, high-quality, patient-centred care. Partnerships between the NHS and the voluntary sector help to facilitate a smooth transition from hospital to the community by providing ongoing support for patients in their own homes (Rivers  2015). When planning discharge for a patient who is elderly or has special needs, it is worth exploring what voluntary services are available locally that could provide support to enable timely discharge and help to prevent a hospital readmission. Examples of services provided by the voluntary sector are shown in Box 3.3, but it is important to consider what is available locally. The provision of practical help, either with personal care or with functional tasks around the home, can give the patient confidence that they will be able to cope and can provide ongoing emotional support once the patient is at home.

Box 3.3  Examples of services provided by the voluntary sector in the community • Personal care – e.g. bathing and dressing • Practical help at home e.g. gardening and cleaning • Daily help – e.g. cooking a meal or shopping • Independent living services – these provide functional support, e.g. transport to enable people to attend hospital appointments, and mobility aids such as wheelchairs • Short-term support-at-home services  –  these provide a range of short-term support once a patient has been discharged from hospital to help them regain their confidence, e.g. collecting prescriptions and shopping

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Stretch Activity Further your thinking and learning about clinical practice

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• Identify five key points that you have learned from this chapter that you will apply to your clinical practice. • Consider what steps could be taken in your clinical area to help prevent deconditioning syndrome, especially in the elderly. Discuss your ideas with your supervising nurse. • Ask whether you may assist in the discharge planning activities associated with a patient in your clinical area. Depending on your seniority, you may wish to focus on a complex discharge. • Ask whether it would be possible to spend a day with the discharge co-ordinator to learn more about their role. • Ask whether you may attend a multidisciplinary meeting where patients’ discharges are discussed. Note the role of each member of the team. • Observe an occupational therapist carrying out an assessment of a patient prior to discharge (e.g. an assessment of their home situation). • Observe the rapid discharge process for a patient at the end of life. • Write a critical reflection about the discharge of a patient that you have observed or been involved in. Do some further reading relevant to the patient’s medical condition, the treatment they have received and any co-morbidities that are affecting their circumstances. Draw out from the reflection and your reading any key points to learn, in order to improve the care of future patients.

Now Test Yourself If you would like to test your learning further, there are additional questions on the companion site of this student edition: www.royalmarsdenmanual.com/student10e.

REFERENCES

Age UK (2019) Factsheet 37: Hospital Discharge. Available at: https://www. ageuk.org.uk/globalassets/age-uk/documents/factsheets/fs37_ hospital_discharge_fcs.pdf Alper, E., O’Malley, T. & Greenwald, J. (2017) Hospital Discharge and Readmission. UpToDate. Available at: https://www.uptodate.com/ contents/hospital-discharge-and-readmission Arora, A. (2017) Time to move: Get up, get dressed, keep moving. NHS England, 24 January. Available at: https://www.england.nhs.uk/blog/ amit-arora British Geriatrics Society (2017) Deconditioning Awareness. Available at: https://www.bgs.org.uk/resources/deconditioning-awareness Cacchione, P. (2018) Engaging caregivers during hospitalizations to improve hospital transitions: The CARE Act. Clinical Nursing Research, 27(3), 255–257. Care Act (2014) Available at: www.legislation.gov.uk/ukpga/2014/23/ contents/enacted Carers UK (2018) Coming Out of Hospital. Available at: https://www. carersuk.org/images/Factsheets/Coming_out_of_hospital_-_England_ April_2019.pdf Challis, D., Hughes, J., Xie, C. & Jolley, D. (2014) An examination of factors influencing delayed discharge of older people from hospital. International Journal of Psychiatry, 29, 160–168. Chenoweth, L., Kable, A. & Pond, D. (2015) Research in hospital discharge procedures addresses gaps in care continuity in the community, but leaves gaping holes for people with dementia: A review of the literature. Australasian Journal on Ageing, 34(1), 9–14. Children and Families Act (2014) Available at: www.legislation.gov.uk/ ukpga/2014/6/contents/enacted Cundy, T., Sierakowski, K., Manna, A., et al. (2017) Fast-track surgery for uncomplicated appendicitis in children: A matched case control study. ANZ Journal of Surgery, 87(4), 271–276. DH (Department of Health and Social Care) (2018) National Framework for NHS Continuing Healthcare and NHS-Funded Nursing Care. Available at: https://www.gov.uk/government/publications/national-frameworkfor-nhs-continuing-healthcare-and-nhs-funded-nursing-care Elliott, B. & DeAngelis, M. (2017) Improving patient transitions from hospital to home: Practical advice from nurses. Nursing, 47(11), 58–62.

Ewbank, L., Thompson, J. & McKenna, H. (2017) NHS Hospital Bed Numbers: Past, Present and Future. King’s Fund. Available at: https:// www.kingsfund.org.uk/publications/nhs-hospital-bed-numbers Harrison, J.D., Greysen, R.S., Jacolbia, R., et  al. (2016) Not ready, not set  .  .  .  discharge: Patient-reported barriers to discharge readiness at an academic medical center. Journal of Hospital Medicine, 11(9), 610–614. Harrison, K., MacArthur, J., Garcia Garrido, A., et  al. (2017) Decisions affecting discharge from hospitals directly to care homes. Nursing Times, 113(6), 29–32. Healthwatch England (2015) Safely Home: What Happens when People Leave Hospitals and Care Settings? Available at: https://www. healthwatch.co.uk/report/2015-07-21/safely-home-what-happens-whenpeople-leave-hospital-and-care-settings Leadership Alliance for the Care of Dying People (2014) One Chance to Get  it Right. Available at: https://assets.publishing.service.gov.uk/ government/uploads/system/uploads/attachment_data/file/323188/ One_chance_to_get_it_right.pdf Lees, L. (2013) The key principles of effective discharge planning. Nursing Times, 109(3), 18–19. Lees-Deutsch, L. (2016) A framework to discharge frail older people. Nursing Times, 112(37/38), 13–15. Lees-Deutsch, L. (2017) Principles for Discharge from Acute Medicine Units. Society for Acute Medicine. Available at: https://www. acutemedicine.org.uk/wp-content/uploads/2010/06/Prinicples-fordsicharge-from-ACute-Medicine-Units.pdf Lees-Deutsch, L. & Gaillemin, O. (2018) Dispelling myths around nurseled and criteria-led discharge. Nursing Times, 114(4). Available at: https://www.nursingtimes.net/clinical-archive /patient-safety/ dispelling-myths-around-nurse-led-and-criteria-led-discharge/7023726. article Lees-Deutsch, L. & Robinson, J. (2018) A systematic review of criteria-led patient discharge. Journal of Nursing Care Quality, 34(2), 121–126. Lees-Deutsch, L., Yorke, J. & Caress, A. (2016) Principles for discharging patients from acute care: A scoping review of policy. British Journal of Nursing, 25(20), 1135–1143. Lord, K., Livingston, G., Robertson, S. & Cooper C. (2016) How people with dementia and their families decide about moving to a care home

CHAPTER 3 Discharge care and planning

and support their needs: Development of a decision aid, a qualitative study. BMC Geriatrics, 16(1), 68. Mabire, C., Dwyer, A., Garnier, A. & Pellet, J. (2018) Meta-analysis of the  effectiveness of nursing discharge planning interventions for older  inpatients discharged home. Journal of Advanced Nursing, 74, 788–799. McNeil, A. (2016) Using evidence to structure discharge planning. Nursing Management (Springhouse), 47(5), 22–23. Mental Capacity Act (2005) Available at: https://www.legislation.gov.uk/ ukpga/2005/9/contents National Palliative and End of Life Care Partnership (2015) Ambitions for  Palliative and End of Life Care: A National Framework for Local Action  2015–2020. Available at: http://endoflifecareambitions.org.uk/ wp-content/uploads/2015/09/Ambitions-for-Palliative-and-End-of-LifeCare.pdf New, P., McDougall, K.E. & Scroggie, C.P. (2016) Improving discharge planning communication between hospitals and patients. Internal Medicine Journal, 46(1), 57–62. NHS England (2016) Monthly Delayed Transfers of Care Data, England, March 2016. Available at: https://www.england.nhs.uk/statistics/ wp-content/uploads/sites/2/2016/05/March-16-DTOC-SPN.pdf NHS England (2018) NHS Standard Contract 2017/18 and 2018/19 Service Conditions [January 2018 edition]. Available at: https://www.england. nhs.uk/publication/nhs-standard-contract-201718-and-201819service-conditions-full-length NHSI (NHS Improvement) (2015) Quality, Service Improvement and Redesign Tools: Discharge Planning. Available at: https://improvement. nhs.uk/documents/2100/discharge-planning.pdf NHSI (2017a) SAFER Patient Flow Bundle. Available at: https:// improvement.nhs.uk/resources/safer-patient-flow-bundle-implement NHSI (2017b) Red2Green Campaign. Available at: https://improvement. nhs.uk/improvement-offers/red2green-campaign NHSI (2018) Guide to Reducing Long Hospital Stays. Available at: https://improvement.nhs.uk/documents/2898/Guide_to_reducing_ long_hospital_stays_FINAL_v2.pdf NHS Sunderland Clinical Commissioning Group (2017) Updated Home Oxygen Order Forms & Consent/ Initial Home Oxygen Mitigation Form IHORM. Available at: https://www.sunderlandccg.nhs.uk/about-us/ prescribing/home-oxygen NICE (National Institute for Health and Care Excellence) (2015) Transition between Inpatient Hospital Settings and Community or Care  Home Settings for Adults with Social Care Needs [NICE Guideline  NG27].  Available at: https://www.nice.org.uk/guidance/ ng27/resources/transition-between-inpatient-hospital-settings-andcommunity-or-care-home-settings-for-adults-with-social-care-needs-pdf1837336935877 NICE (2016) Transition between Inpatient Hospital Settings and Community or Care Home Settings for Adults with Social Care Needs [NICE Quality Standard QS136]. London: National Institute for Health and Care Excellence.

NICE (2017) Intermediate Care including Reablement [NICE Guideline NG74]. London: National Institute for Health and Care Excellence. NICE (2018) NICE Impact: Falls and Fragility Fractures. London: National Institute for Health and Care Excellence. Pellett, C. (2016) Discharge planning: Best practice in transitions of care. British Journal of Community Nursing, 21(11), 542–548. People First (2018) Care Act 2014. Available at: https://www.peoplefirstinfo. org.uk/money-and-legal/care-act-2014 Poole, M., Bond, J., Emmett, C., et  al. (2014) Going home? An ethnographic study of assessment capacity and best interests in people with dementia being discharged from hospital. BMC Geriatrics, 14(56), 14. QNI (The Queen’s Nursing Institute) (2016) Discharge Planning: Best Practice in Transitions of Care. Available at: https://www.qni.org.uk/ wp-content/uploads/2016/09/discharge_planning_report_2015.pdf Rivers, S. (2015) Supporting discharge using a volunteer scheme. Nursing Times, 111(23/24). Available at: https://www.nursingtimes.net/roles/ older-people-nurses /supporting-discharge-using-a-volunteerscheme/5085417.article Royal Voluntary Service (2014) Going Home Alone: Counting the Cost to Older People and the NHS. Available at: https://www.royalvoluntaryservice. org.uk/Uploads/Documents/Reports%20and%20Reviews/Going_ home_alone.pdf Sheridan, E., Thompson, C., Pinheiro, T., et al. (2017) Optimizing transitions of care: Hospital to community. Healthcare Quarterly, 20(1), 45–49. Teodorczuk, A. (2016) Understanding safe discharge of patients with dementia from acute hospital. British Journal of Hospital Medicine, 77(3), 126–127. Teodorczuk, A., Mukaetova-Ladinska, E., Corbett, S. & Welfare, M. (2015) Deconstructing dementia and delirium hospital practice: Using cultural historical activity theory to inform education approaches. Advanced Health Science Theory Practice, 20, 745–764. Thomas, C. (2017) Improving hospital discharge for patients at the end of life. Nursing Times, 113(11). Available at: https://www.nursingtimes. net/clinical-archive/end-of-life-and-palliative-care/improving-hospitaldischarge-for-patients-at-the-end-of-life/7021751.article Wallace, A., Papke, T., Devisson, E., et al. (2017) Provider opinions and experiences regarding development of a social support assessment to inform hospital discharge: The going home toolkit. Professional Case Management, 22(5), 214–226. Waring, J., Marshall, F., Bishop, S., et al. (2014) An ethnographic study of knowledge sharing across the boundaries between care processes, services and organisations: The contributions to ‘safe’ hospital discharge. Health Services and Delivery Research, 2(29), 1–160. Weiss, M., Bobay, K., Bahr, S., et al. (2015) A model for hospital discharge preparation: From case management to care transition. Journal of Nursing Administration, 45(12), 606–614. Winfield, A. & Burns, E. (2016) Let’s all get home safely: A commentary on NICE and SCIE guidelines (NG27) transition between inpatient hospital settings and community or care home settings. Age and Ageing, 45, 757–760.

Answers Answers to the learning and stretch activities are available on the companion site of this student edition: www.royalmarsdenmanual. com/student10e.

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4

Infection prevention and control VIRUS

STERILE HAND WASHING C. DIFFICILE DECONTAMINATION

PATHOGENS

Pat Cattini with Martin Kiernan

CLEANLINESS ISOLATION E. COLI

SCRUB

HCAI

INFECTION MICROBIOLOGY

1 2

3

4 5

After reading this chapter and undertaking the learning activities within it, you should: Understand how pathogens cause infection and how particular infections are spread Know the importance of hand hygiene and other precautions to minimize the risk of patients acquiring healthcare-associated infections Be able to describe the precautions that may need to be taken to minimize the risk of infection transmission when a patient is colonized or infected with microorganisms that may pose a risk to others Understand how to support and care for patients who have an infection or who need protective isolation Know the actions to take in the event of a sharps injury

Key terms are highlighted in the text in pink. Glossary definitions of these terms can be found on the companion site of this student edition: www.royalmarsdenmanual.com/ student10e.

Procedure guidelines 4.1 Hand washing 4.2 Hand decontamination using an alcohol-based handrub 4.3 Surgical scrub technique using soap and water 4.4 Surgical scrub technique using an alcohol-based handrub 4.5 Putting on and removing non-sterile gloves 4.6 Applying and removing a disposable apron 4.7 Putting on and removing a disposable mask or respirator 4.8 Putting on or removing goggles or a face-shield 4.9 Donning sterile gloves: open technique 4.10 Donning a sterile gown and gloves: closed technique

4.11 Aseptic technique example: changing a wound dressing 4.12 Source isolation: preparing an isolation room 4.13 Source isolation: entering an isolation room 4.14 Source isolation: leaving an isolation room 4.15 Source isolation: transporting infected patients outside a source isolation area 4.16 Protective isolation: preparing an isolation room 4.17 Protective isolation: entering an isolation room 4.18 Cleaning a hard surface without recontamination 4.19 Safe disposal of foul, infected or infested linen

The Royal Marsden Manual of Clinical Nursing Procedures: Student Edition, Tenth Edition. Edited by Sara Lister, Justine Hofland and Hayley Grafton with Catherine Wilson. © 2021 The Royal Marsden NHS Foundation Trust. Published 2021 by John Wiley & Sons Ltd. Student companion website: www.royalmarsdenmanual.com/student10e Instructor compaion website: www.royalmarsdenmanual.com/instructor10e

THE ROYAL MARSDEN MANUAL OF CLINICAL NURSING PROCEDURES

Being an accountable professional At the point of registration, the nurse will: 9. Use evidence-based, best practice approaches for meeting needs for care and support with the prevention and management of infection, accurately assessing the person’s capacity

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Overview

T

his chapter begins with an explanation of the causes of infection and then focuses on healthcare-associated infections (HCAIs), specifically describing the steps to be taken to minimize the risk of individuals acquiring infections while receiving healthcare. The chapter gives an overview of key principles, terminology and definitions, and describes the standard precautions that must be taken with patients at all times regardless of their known infection status. It also covers additional precautions that may be required because the patient is colonized or infected with micro-organisms that may pose a particular risk to others, or because they are particularly vulnerable to infection themselves. The chapter additionally describes the specific precautions that must be taken during invasive procedures, in particular aseptic technique.

for independence and self-care and initiating appropriate interventions Future Nurse: Standards of Proficiency for Registered Nurses (NMC 2018)

Figure 4.1  The chain of infection: a useful tool for seeing how to prevent transmission.

Susceptible host

Portal of entry

Infectious agent

Transmission

Reservoir

Portal of exit

Infection prevention and control DEFINITIONS

Infection prevention and control

‘Infection prevention and control’ has been defined as the clinical application of microbiology in practice (RCN 2017); it is a collective term for activities intended to protect people from infection. Such activities may form part of everyday life, such as washing hands after using the toilet or before preparing food. However, the term is most often used in relation to healthcare, with reference in particular to avoiding patients acquiring preventable infections.

Healthcare-associated infection

A healthcare-associated infection (HCAI) is any infection acquired as a result of healthcare contact. It has replaced the term ‘hospital-acquired infection’ to recognize that not all healthcare is given in a hospital. Such infections are also known as ‘nosocomial’ infections.

ANATOMY AND PHYSIOLOGY

Pathogens are what cause infection. It is important to understand types of pathogen, how they spread and what kinds of environment are favourable for their growth so that effective infection prevention and control measures can be put in place.

Causes of infection

The term ‘infectious agent’ is often used to describe anything that may be transmitted from one person to another, or from the environment to a person, and subsequently cause an infection or parasitic infestation. Distinct types of infectious agent act differently and have different impacts on the infected individual. For example, whether a particular infectious agent will cause an infection in any given circumstance is dependent on many factors, including how easily that agent can be transmitted, its pathogenicity (its ability to cause disease) and its virulence (the severity of the infection produced) (Gillespie and Bamford 2012). The susceptibility of the patient to infection is also a significant influence.

To practice effective infection prevention and control, it is helpful to understand the ‘chain of infection’ (Damani 2011). This is a helpful model to use when considering how infection can be prevented, as it shows how it is possible to break the ‘links’ in the chain. For an infection to exist, there must be an organism (pathogen) and it must be able to get into a susceptible host, multiply and exit. It may need a place to hide (reservoir) while waiting for the next susceptible host. Figure 4.1 illustrates the chain of infection and Table 4.1 lists the links with examples of how infection can be prevented at each link. The major groups of micro-­ organisms are described below.

Types and classification of micro-organisms

Historically, the classification of micro-organisms was based on physical characteristics such as their size, shape or ability to retain a particular stain to make them visible under the microscope. Some of these distinctions are still useful, but classification is increasingly based on genetic characteristics, as increasingly sophisticated analysis techniques (such as genomic sequencing) reveal the actual relationships between organisms. This can lead to confusion as new discoveries lead to species being reclassified and renamed. For example, ‘methicillin-­ resistant’ Staphylococcus aureus is now ‘meticillin-resistant’ and Clostridium difficile is now termed Clostridioides difficile. It should also be noted that there can be a wide variety of characteristics within each species, leading to significant variations in the severity of infection caused by different strains of the same organism. An example of this is Group A Streptococcus pyogenes, which is a common cause of sore throat but can also cause skin conditions such as erysipelas, scarlet fever, toxic shock syndrome and necrotizing fasciitis. Another is Escherichia coli, which is carried in the gut of all mammals with no ill effects but whose toxinproducing O157:H7 strain can cause serious illness. In printed text, the names of bacteria are written in italics, with the name of the genus capitalized and the species in lower case, for example Staphylococcus aureus. The abbreviation ‘spp.’ is used to refer to all of the species of a genus, for example Klebsiella

CHAPTER 4 Infection prevention and control

Table 4.1  Links in the chain of infection Link

Definition

Example

Examples of breaking the chain

Infectious agent

A potentially pathogenic microorganism or other agent

• Smallpox • Staphylococcus aureus or any other bacteria

• Vaccination – for example, we no longer need to worry about the virus that causes smallpox or how it is transmitted as it does not exist (except in some top-secret laboratories) • Removal of infectious agents through cleaning • Destruction of micro-organisms through sterilization of equipment • Using antibiotics to treat patients with bacterial infections

Reservoir

Any location where micro-organisms hide, exist or reproduce

• Humans • Dust in the healthcare environment • Sink drains

• Cleaning/decontamination of equipment and the environment • Use of handwash basins for hand washing only • Flushing low-use taps and showers • Minimizing the number of people present in high-risk situations such as surgery

Portal of exit

The route by which the infectious agent leaves the reservoir

• Diarrhoea and vomit may carry norovirus • Droplets expelled during coughing or sneezing may contain flu

• Asking a patient with active tuberculosis infection to wear a mask in communal areas of the hospital

Mode of transmission

The way the infectious agent is spread (see definitions section above)

• Contact • Enteric • Droplet • Airborne • Parenteral

• Hands • Diarrhoea • Sneezing • Nebulizer or intubation • Needle stick injury

Portal of entry

The route by which the infectious agent enters a new host

• Organisms introduced into a normally sterile part of the body through use of an invasive device • Intravenous line into the bloodstream • Urinary catheter breaching the bladder • Inhalation of airborne pathogens into the lungs

• Avoiding unnecessary invasive devices • Using strict aseptic technique • Staff members wearing masks when dealing with infectious agents that may be inhaled

Susceptible host

The person that the infectious agent enters has to be susceptible to infection

• The very old and very young are more susceptible • Underlying chronic illnesses

• Ensuring adequate nutrition and personal hygiene • Vaccination – this will often completely prevent or significantly reduce the likelihood of an infection developing

spp. This section gives an overview of the different types of organism that may be encountered in a healthcare environment as well as the differences between and within the types.

Table 4.2  Examples of how the human microbiome can be protective

Bacteria

Bacteria

Comments

Gut flora including Bacteroides spp., Bifidobacterium spp., Enterobacter spp., Klebsiella spp., Enterococcus spp. and Escherichia coli

Disturbance though antibiotics, surgery or chemotherapy may have far-ranging effects on the human body, including obesity, inflammatory bowel diseases, antibiotic-associated diarrhoea and cancer.

Skin flora including Staphylococcus epidermidis, Staphylococcus aureus, diphtheroids and Candida spp.

A healthy, intact, normal resident skin flora means that pathogenic organisms are less likely to settle on the skin and cause infection.

Vaginal flora including Lactobacillus spp. and diphtheroids

Babies born per vagina are more likely to have their skin colonized with the ‘right’ organisms, which reduces problems with skin and allergies.

Bacteria are probably the most important group of micro-­ organisms in terms of infection prevention and control because they are responsible for the majority of opportunistic infections in healthcare. A healthy human being will typically be host to a quadrillion (1000 trillion or 1015) bacteria – around ten times as many organisms as there are cells in the human body – and we need most of these to survive. The so-called human microbiome is increasingly being recognized as an essential part of human health (Bhalodi et al. 2019, Young  2017) and a variety of conditions  –  such as Crohn’s disease, ulcerative colitis, irritable bowel syndrome, obesity, type 2 diabetes, Parkinson’s disease, chronic fatigue syndrome, arthritis and even asthma – may all be related to disturbance of the balance of micro-organisms in the gut, although the question remains as to whether this is a cause or effect (Otter 2014, Tosh and McDonald 2012, Wang et al. 2017). See Table 4.2 for examples of how the human microbiome can be protective. In normal circumstances, the relationship between bacteria and their host is symbiotic and the organisms are considered to be

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THE ROYAL MARSDEN MANUAL OF CLINICAL NURSING PROCEDURES

The presence of an organism in a specimen result does not on its own imply that an infection has occurred. Any laboratory results must always be interpreted in association with an assessment of the patient’s condition and symptoms, which will guide the need for treatment. Morphology

Bacterial cells are much smaller and simpler than human cells; this small size means that bacteria do not have separate structures (such as a nucleus) within their cells. The structure of the cell wall determines another important distinction in medically significant bacteria: whether they are gram positive or gram negative. The ‘gram’ in these terms refers to Gram staining, named after its Dutch inventor, Hans Christian Gram (1853–1938), who devised the stain in 1884. The structure of the cell wall determines whether or not the bacteria are able to retain a particular stain in the presence of an organic solvent such as acetone. This structure also determines other characteristics of the bacteria, including their susceptibility to particular antibiotics, so knowing whether the cause of a bacterial infection is ‘gram positive’ or ‘gram negative’ can help to determine appropriate treatment (Goering et al. 2012). The structures of the two different types of cell wall are shown in Figure 4.2. Other structures visible outside the cell wall may include pili, which are rigid tubes that help the bacteria attach to host cells (or, in some cases, other bacteria for the exchange of genetic mater­ ial); flagellae, which are longer, mobile projections that can help bacteria to move around; and capsules, which can provide protection or help the bacteria to adhere to surfaces. These are illustrated in Figure 4.3. The presence or absence of different structures plays a part in determining an organism’s pathogenicity – that is, its ability to cause an infection and the severity of that infection (Goering et al. 2012). A final bacterial structure to consider is the spore. Bacteria reproduce via a process called ‘binary fission’ – they create a copy of their genetic material and split themselves in two, with each ‘daughter’ cell being an almost exact copy of the ‘parent’ (there are mechanisms by which bacteria can transfer genetic material between cells and so acquire characteristics such as antibiotic resistance, but they are beyond the scope of this chapter). Some bacteria, notably the Clostridia, have the capacity, in adverse conditions, to surround a copy of their genetic material with a tough coat called a ‘spore’. Once the spore has been formed, the parent

Figure 4.2  (a) Gram-positive and (b) gram-negative bacterial cell walls. Source: Adapted from Elliot et al. (2007) with permission of John Wiley & Sons. Peptide side chain Lipoteichoic acid

Protein

Sugar subunit

Peptidoglycan

72

commensal (i.e. their presence does not cause the host any problems) and mutually beneficial; however, if the host has lowered resistance or a bacteria gains access to a different site, it can become an opportunistic pathogen. For example, E. coli from the gut may cause a urinary tract infection (with associated symptoms) if it enters the urethra and ascends the urinary tract. Despite the fact that we are surrounded by unquantifiable numbers of bacteria in our world, relatively few are pathogenic to us. There is an important balance to be struck in our home lives; we should not try to disinfect everything we come into contact with, and indeed many things around us are going to be contaminated (money, cash point buttons, our mobile phones and the handles on public transport, to name a few). If we are healthy and have good immunity and intact skin, this will often be of little consequence to us as long as we follow simple precautions such as practising hand hygiene, environmental hygiene (cleaning) and food hygiene. For a patient receiving interventional healthcare, however, things can be very different and we need to do as much as possible to ensure items introduced into the care environment are free of pathogens. Our increasing understanding of the normal commensal micro-organisms in humans suggests that restoring and maintaining the microbiome may provide a key to preventing colonization and infection, including with multi-drug-resistant organisms (Otter 2014, Tosh and McDonald 2012), which can be ‘selected out’ when exposed to antibiotics. This means that bac­ teria that are sensitive to the antibiotics are killed but any resistant ones are left to replicate and become the dominant type. A developing form of treatment is the ‘faecal microbiota transplant’, or stool transplant, which involves replacing the stool in an affected gut with stool from a healthy donor. This has been shown to be very effective for treatment of intractable C. difficile (van Nood et al. 2013) and may be helpful in other conditions. Sometimes a patient will be ‘colonized’ with a species of bac­ teria, which means it is present but not causing them harm. However, if the bacteria are transferred to another patient and gain access to a portal of entry, that person may suffer harm, so there is a need for effective precautions. Whether or not any particular situation will result in an infection depends on a wide range of factors and these are not always predictable. What is certain is that bacterial infections cannot occur when bacteria are not present, hence the importance of measures designed to min­ imize the risk of transmission.

Cell wall

Lipopolysaccharide

Outer membrane Cell wall Lipoprotein Peptidoglycan

Protein (a) Gram-positive

Inner membrane

Cytoplasmic membrane

Cytoplasmic membrane

Phospholipid

Phospholipid (b) Gram-negative

CHAPTER 4 Infection prevention and control

Table 4.3  Medically significant bacteria

Figure 4.3  Bacterial structures. Cytoplasm

Spherical

Rod-shaped

Gram positive

Staphylococcus aureus Streptococcus spp.

Clostridioides difficile Clostridium tetani Bacillus spp.

Gram negative

Neisseria meningitidis Neisseria gonorrhoeae

Escherichia coli Pseudomonas aeruginosa Klebsiella pneumoniae Acinetobacter baumannii Salmonella spp. Legionella pneumophila

Ribosomes Pili Nucleoid Cytoplasmic membrane

Cell wall

Capsule

Flagellum

cell dies and disintegrates, leaving the spore to survive until conditions are suitable for it to germinate into a normal, ‘vegetative’ bacterial cell, which can then reproduce (Goering et  al.  2012). Spores are extremely tough and durable. They are not easily destroyed even by boiling or via the alcohol-based handrubs widely used for hand hygiene, hence the need to physically remove them from the hands by washing with soap and water when caring for a patient with C. difficile infection. Commonly used disinfectants containing quaternary ammonium compounds (such as benzalkonium chloride) are ineffective against spores. Some bacteria produce toxins, which are proteins released by the bacteria that can increase the severity of disease. Endotoxins are pieces of the cell wall of gram-negative bacteria; these initiate a strong immune response from the body, which can cause catastrophic damage. For example, endotoxins of Neisseria menin­ gitidis cause the breakdown of blood vessels, leading to anoxic tissue and the need for amputation. Antibiotics may kill the bacteria but in doing so flood the body with deadly endotoxins. Some medically significant bacteria are listed in Table  4.3. A few bacteria do not easily fit into the gram-positive/negative dichotomy. The most medically significant of these are the mycobacteria, which have a waxy coat and are responsible for diseases including tuberculosis and leprosy (Goering et al. 2012). Culture and sensitivity testing

When a sample arrives in the laboratory, it is put onto agar plates to culture any organisms present. The site of the specimen and clinical information may dictate which tests are deployed and what media are used, which is why it is very important to fill out the microbiology request form with as much detail as possible (for more detail see Chapter 13: Diagnostic tests). The provision of accurate and comprehensive information assists the micro­ biologist in interpreting the findings in the laboratory and simple information, such as the site of the specimen (if a wound), the type of urine, recent travel and current antibiotic use, can also be helpful.

Different types of agar plate may be used to grow different bacteria. Once the organism has been grown, it can be subjected to further tests to identify it, including a gram stain to see whether it is gram positive or gram negative, examination for the presence of pus cells and sensitivity testing. Sensitivity testing usually involves spreading the organism over an agar plate that contains small antibiotic discs. If the bacteria grow all the way up to the disc, they are resistant to that antibiotic. A ‘zone of inhibition’ around the disc implies they are sensitive to the antibiotic and that the antibiotic may be used to treat that infection. A faster and more modern technique to identify and speciate microbes involves the use of matrix-assisted laser desorption ionization time-offlight mass spectrometry (MALDI-TOF MS) (Croxatto et al. 2012). Modern laboratories use molecular technology to diagnose patients without the need for culture. These techniques include polymerase chain reaction (PCR) and enzyme immuno-assay.

Viruses

Viruses are much smaller, and even simpler, than bacteria. Nobel laureate Peter Medawar is said to have described viruses as ‘bad news wrapped in protein’ and indeed they are little more than a protein capsule containing some genetic material. They rely on other organisms for their survival and reproduce within a host cell, using the cell’s own mechanisms to reproduce, which leads to the death of the host cell (Goering et al. 2012). The life cycle of a virus is illustrated in Figure 4.4. The small size of viruses (e.g. poliovirus is only 30 nanometres across) means that most are smaller than the wavelengths of visible light. They can only be ‘seen’ with a specialist instrument such as an electron microscope, which will only be available in a very few hospital microbiology laboratories. Diagnosis of viral infections is normally based on the patient’s symptoms, with confirmation by laboratory tests designed to detect either the virus itself or antibodies produced by the patient’s immune system as a response to infection (Goering et al. 2012). Modern laboratories use PCR to amplify the genes in the sample to make them detectable quickly. There are viruses that specifically infect humans, other animals or plants, or even bacteria. This is one characteristic that can be used in classifying them. However, the main basis for classification is by the type of genetic material they contain – DNA (deoxyribonucleic acid) or RNA (ribonucleic acid), in either a double or single strand. Other characteristics include the shape of the viral particle and the sort of disease caused by infection (Gillespie and Bamford 2012). A final point to consider in relation to viral structure and infection prevention and control is the presence or absence of a lipid envelope enclosing the viral particle. Viruses that have a lipid envelope, such as herpes zoster virus (responsible for chickenpox and shingles), are much more susceptible to destruction by alcohol than those without. Norovirus and rotavirus, which are common causes of viral gastroenteritis (WHO 2009a), are examples of viruses without a lipid envelope. For this reason, alcohol hand sanitizers are not recommended during outbreaks of norovirus in hospitals.

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Figure 4.4  The viral life cycle. RNA, ribonucleic acid. Source: Adapted from Perry (2007) with permission of John Wiley & Sons. By cytolysis (no envelope)

By budding forming envelope

Nucelus

74

Release

Infecting virus

Capsids form around nucleic acid

Protozoa

Protozoa are single-celled animals, some species of which are medically important parasites of human beings, particularly in tropical and subtropical parts of the world, where diseases such as malaria are a major public health issue. Unlike bacteria, their relationship with humans is almost always parasitic. The life cycles of protozoa can be complex and may involve stages in different hosts. Medically important protozoa include Plasmodium spp., the cause of malaria; Giardia spp. and Cryptosporidium spp., which can cause gastroenteritis; and Trichomoniasis spp., which is a sexually transmitted cause of vaginitis (Gillespie and Bamford 2012). The most common routes of infection of protozoa are by consuming them in food or water or via an insect vector such as a mosquito (Goering et  al.  2012). Cross-infection in the course of healthcare is uncommon but not unknown.

Helminths

Assembly Receptor Synthesis of viral messenger RNA. Synthesis of viral protein for new capsids. Synthesis of viral nucleic acid

Attachment

Replication Capsid shed

Uncoating

Penetration

‘Helminths’ is a generic term for parasitic worms. A number of worms from three different groups affect humans: tapeworms (cestodes), roundworms (nematodes) and flukes (trematodes). Transmission generally occurs via ingestion of eggs or larvae, or infected animals or fish, but some are transmitted via an insect vector and some, notably the nematode Strongyloides spp., have a larval stage that is capable of penetrating the skin (Gillespie and Bamford 2012). Helminth infections can affect almost every part of the body, and the effects can be severe. For example, Ascaris worms can cause bowel obstruction if there are large numbers present; Brugia spp. and Wuchereria spp. obstruct the lymphatic system and eventually cause elephantiasis as a result; and infection with Toxocara spp. (often after contact with dog faeces) can result in epilepsy or blindness (Goering et  al.  2012). However, cross-infection in healthcare is not normally considered a significant risk.

Arthropods Fungi

Like bacteria, fungi exist in many environments on earth, including occasionally as commensal organisms on human beings. Fungi are familiar to us as mushrooms and toadstools and the yeast that is used in brewing and baking. They also have many uses in the pharmaceutical industry, particularly in the production of antibiotics. Fungi produce spores, both for survival in adverse conditions, as bacteria do, and to provide a mechanism for dispersal in the same way as plants (Goering et al. 2012). A few varieties of fungi are able to cause opportunistic infections in humans. These are usually found in one of two forms: either as single-celled yeast-like forms, which reproduce in a similar fashion to bacteria (by dividing or budding), or as plant-like filaments called ‘hyphae’. A mass of hyphae together forms a ‘mycelium’. Some fungi may appear in either form, depending on environmental conditions. Fungal infections are referred to as ‘mycoses’. Superficial mycoses, such as ringworm and thrush (Candida albicans), usually involve only the skin or mucous membranes and are normally mild, if unpleasant; however, deeper mycoses involving major organs can be life threatening. These occur in patients who have severely impaired immune systems and may be an indicator of such impairment; for example, pneumonia caused by Pneumocystis jirovecii (previously carinii) is considered a clinical indication of AIDS (acquired immune deficiency syndrome). Superficial infections are generally transmitted by physical contact, whereas deeper infections can result from spores being inhaled. This is why it is important to ensure that patients with impaired immunity are protected from situations where the spores of potentially pathogenic fungi, such as Aspergillus spp., are likely to be released, for example during building work (Goering et al. 2012).

Arthropods (insects) are most significant in infectious disease in terms of their function as vectors of many viral, bacterial, protozoan and helminth-caused diseases. Some flies lay eggs in the skin of mammals, including humans, and the larvae feed and develop in the skin before pupating into the adult form, whereas some, such as lice and mites, are associated with humans for the whole of their life cycle. Such arthropod infestations can be uncomfortable, and there is often significant social stigma attached to them, possibly because the creatures are often visible to the naked eye. The activity of the insects and the presence of their saliva and faeces can result in quite severe skin conditions that are then vulnerable to secondary fungal or bacterial infection (Goering et al. 2012).

Lice

Species of Pediculus infest the hair and body of humans, feeding by sucking blood from their host. The adult animal is around 3 mm long and wingless, moving by means of claws. It cannot jump or fly, and dies within 24 hours if away from its host, so cross-infection normally occurs via direct contact or transfer of eggs or adults through sharing personal items (Cummings et al. 2018).

Scabies

Scabies is caused by the mite Sarcoptes scabiei, an insect less than 1 mm long that burrows into the top layers of skin. The female mites lay eggs in these burrows and the offspring can spread to other areas of the body. Infestation usually starts around the wrists and in between the fingers because acquisition normally occurs via close contact with an infected individual (e.g. by holding hands). The burrows are visible as a characteristic rash in the areas affected. The skin starts to itch a few weeks after infes-

CHAPTER 4 Infection prevention and control

tation, which is a reaction to the faeces of the mite. A delay in recognition can lead to mass infestation, especially within families or in settings where there is a lot of interpersonal care, such as a nursing home. In immunocompromised hosts and those unable to practise normal levels of personal hygiene, very high levels of infestation can occur, often with thickening of the skin and the formation of thick crusts. This is known as ‘Norwegian scabies’ and is associated with a much higher risk of cross-infection than the normal presentation. Scabies is most often associated with long-stay care settings, but there have been outbreaks associated with more acute healthcare facilities (Cassell et al. 2018). Treatment with scabicide must be co-ordinated to ensure untreated hosts do not reinfect those already treated.

Prions

Prions are thought to be the causative agents of a group of diseases called transmissible spongiform encephalopathies (TSEs), the most well known of which are Creutzfeldt–Jakob disease (CJD) and its variant (vCJD) (Table  4.4). These are fatal neuro­ degenerative diseases with a lengthy incubation period (up to 50 years) and no conventional host response, making them difficult to detect. TSEs can be naturally occurring, inherited or acquired (Table 4.4). They are characterized by ‘plaques’ in the brain that are surrounded by holes that give the appearance of a sponge, hence the name. The causative ‘organism’ is a prion, defined in 1982 by Stanley Prusiner as a proteinaceous infectious particle resistant to procedures that modify nucleic acid. From an infection control perspective, the key point is that prions contain no genetic material; therefore, it can be argued that they are not alive and so cannot be killed. Control is achieved via recognition of risk and physical removal through cleaning procedures. Prions are not affected by routine decontamination processes such as autoclaving or chemical disinfection. This has led to extensive reviews of decontamination procedures in the UK with increased emphasis on effective washing to remove any residual organic material, and on the tracking of instruments to individual patients to facilitate any look-back exercise. Modern decontamination services are now capable of removing prions from the surface of even complex instruments; however, where risk is identified, single-use instruments are usually recommended, especially for neurological work. In the 1990s there was a lot of concern about the emergence of vCJD, which was associated with consumption of contaminated beef from cattle who had bovine spongiform encephalopathy

Table 4.4  Types of transmissible spongiform encephalopathies Type

Examples

Idiopathic (just happens for no clear reason)

Sporadic (classical) CJD Sporadic fatal insomnia

Inherited (genetic)

Familial CJD Gerstmann–Sträussler–Scheinker syndrome and variants Fatal familial insomnia

Acquired

Derived from humans: • kuru (cannibalism) • iatrogenic CJD (contaminated medical devices or blood products) Derived from bovines: vCJD (diet – meat infected with bovine spongiform encephalopathy)

CJD, Creutzfeldt–Jakob disease; vCJD, variant Creutzfeldt–Jakob disease.

(BSE). With intense input from public health initiatives and what was then called the Ministry of Agriculture, Fisheries and Food, beef was made safe again. However, UK citizens born before 1992 are still considered at risk of vCJD due to its long incubation period. There were also several cases of CJD associated with contaminated medical products, such as human pituitary hormone, dura mater grafts and medical instruments. For this reason, all patients undergoing surgery should be assessed for risk of CJD by asking the following questions: • Do you have a blood family member who has suffered from CJD? • Have you ever received hormones derived from a human pituitary gland (e.g. growth hormone)? • Have you ever had a corneal transplant or a dura mater graft? • Have you been told that ‘you may be at risk of CJD for public health purposes’? A patient with CJD or vCJD is not infectious to other people under routine circumstances so no special precautions are required other than if dealing with cerebrospinal fluid (CSF). A spillage of CSF should be cleaned up with a strong disinfectant such as 10,000 ppm of chlorine.

Sources of infection

An individual may become infected with organisms already present on their body (endogenous infection) or introduced from elsewhere (exogenous infection). The majority of HCAIs are endogenous, hence the importance of procedures such as effective skin decontamination prior to invasive procedures (NHS England and NHSI 2019).

Indicators and effects of infection

Generally, infection is said to have occurred when infectious agents enter a normally sterile area of the body and cause symptoms as a result. There are obvious exceptions (e.g. the digestive tract is not sterile, being home to trillions of micro-organisms, but many types of infectious gastroenteritis are caused by particular organisms entering this area), but this is a useful working definition. The symptoms of infection are listed below. Not all symptoms will be present in all cases, and it should be noted that many symptoms are caused by the body’s response to infection and so may not be present in severely immunocompromised patients (Fishman 2011).

Symptoms of infection

The cardinal signs of inflammation will often be present: • Heat: the site of the infection may feel warm to the touch, and the patient may have a raised temperature. • Pain: at the site of the infection. • Swelling: at the site of the infection. • Redness: at the site of the infection • Loss of function: the affected area may not work properly. In addition, there may be other signs, such as: • pus • raised white cells in blood results • raised C-reactive protein (CRP) in blood results • altered blood gases • feeling of general malaise • aching joints • abdominal pain and tenderness • nausea, diarrhoea and/or vomiting • oliguria or anuria • urinary frequency and/or pain on passing urine (strangury) • confusion (notably in the elderly) • loin pain. It is important to look for these clinical signs of infection before making a diagnosis based on the result of a specimen alone.

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RELATED THEORY

Healthcare-associated infection

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An HCAI is acquired while receiving care in a hospital or other healthcare setting and must not have been present prior to that episode of healthcare; 6.6% of people who go into hospital in the UK will develop an HCAI. The figure for Europe is about 4 million people every year, with around 37,000 deaths occurring as a direct result (PHE 2017). The majority of these infections result from the procedures and interventions that patients undergo as treatment, such as insertion of invasive devices, surgery or the administration of antimicrobials that alter natural bacterial flora; all of these ultimately breach the body’s natural defences and thereby increase vulnerability to infection. The greater the number of devices and the longer they are in situ, the more likely it is that an infection will occur. If the patient is also immunocompromised, the infection risk can be much higher. One report found that patients receiving treatment under oncology or haematology specialities were almost four times as likely to have an HCAI (a similar rate to those in intensive care units) compared to other patients in the same hospital and were twice as likely to be receiving an antibiotic (PHE 2018a). In addition, bringing many vulnerable people together in a healthcare setting increases the likelihood of exposure to infection and the risk of cross-infection. Patients are often expected to share a room and bathroom facilities with those who may be ­carrying infection or different normal flora to them. This can lead to cross-infection, for example a patient who has diarrhoea may contaminate a shared toilet, thereby passing the infection to ­others using the same facilities. The greater the number of patients that staff are caring for and the greater their workload, the greater the risk of cross-infection between patients. Overcrowding, lack of time and lack of facilities also contribute to non-compliance with best practice (Borg 2003, Eiamsitrakoon et al. 2013, Harbarth et al. 1999, Kampf et al. 2009, WHO 2009a).

Prevalence of healthcare-associated infection

The national Point Prevalence Survey of Healthcare-Associated Infections and Antimicrobial Use in European Acute Care Hospitals (ECDC 2016), conducted by Public Health England and the European Centre for Disease Prevention and Control, identified a prevalence rate of 6.6% (PHE 2017) (Figure 4.5). In acute hospitals, 1 in 15 patients had an HCAI on the day of survey, with the highest prevalence rates in intensive care units (17.6% of patients) followed by surgery (8.5%) and medicine (5.8%). The most common types of infection were pneumonia and lower respiratory tract infection, urinary tract infections, and surgical site infections. There was very little change from the patterns seen from the previous survey, conducted in 2011 (ECDC  2013). While bacteraemia (bacteria infecting the bloodstream) was less common, it can still have serious consequences for patients. Of the infections identified, gram-negative bacteria species were responsible for 35% of bloodstream HCAIs, which justifies the focus of national prevention strategies in this area. The most commonly isolated micro-organisms were E. coli (18.9%), S. aureus (17.6%), C. difficile (8.1%), Pseudomonas aeru­ ginosa (7.8%), Klebsiella pneumoniae (4.9%) and Enterobacter cloacae (2.8%). E. coli was the most commonly isolated microorganism in urinary tract infections (50.9%), whereas S. aureus was the most commonly isolated micro-organism in pneumonia and lower respiratory tract infections (19.3%), surgical site infections (30.2%) and bloodstream infections (19.2%).

The challenge of antimicrobial resistance

Over the past century, there have been many changes in the types of organism that cause problems in healthcare, largely mirroring advances in medicine. The advent of penicillin and then other antibiotics in the 1940s allowed such advances in medicine and surgery. More complex surgery became possible, such as surger-

Figure 4.5  Results from the national Point Prevalence Survey in ESPAUR, 2016. Source: Data from English Surveillance Programme for Antimicrobial Utilisation and Resistance (ESPAUR): Report 2018 (PHE 2018a). Bone and joint 1% Bloodstream infection 7%

Cardiovascular 1% Catheter-related inflections 1% Central nervous system 1% Ear, nose and throat 3% Gastrourinary 7%

Urinary tract infection 17%

Systemic infection 13%

Pneumonia 29%

Surgical site infection 15% Skin and soft tissue 5%

Reproductive 0%

Box 4.1  Tackling Drug-Resistant Infections Globally: Final Report and Recommendations (O’Neill 2016) ‘The magnitude of the problem is now accepted. We estimate that by 2050, 10 million lives a year are at risk due to the rise of drug-resistant infections if we do not find proactive solutions now to slow down the rise of drug resistance. Antibiotics are a special category of antimicrobial drugs that underpin modern medicine as we know it: if they lose their effectiveness, key medical procedures (such as gut surgery, caesarean sections, joint replacements, and treatments that depress the immune system, such as chemotherapy for cancer) could become too dangerous to perform.’

ies requiring implants (joint replacements) or organ transplants, and patients were able to tolerate treatments such as chemotherapy. More and more patients began to survive previously untreatable conditions, largely due to the ability to treat complications such as infection. With the increasing use of antibiotics, new challenges began to emerge, including C. difficile infections (CDI) in the 1970s and epidemic strains of meticillin-resistant S. aureus (MRSA) in the 1980s. During the 1990s and early 2000s there was a significant rise in both MRSA and CDI in the UK. Concerted effort engineered by the UK government saw impressive reductions in both these infections (DH 2019); however, the 2000s saw a rise in the prevalence of gram-negative organisms with increasing resistance to antibiotics and an associated increase in untreatable infections. It is fair to argue that increasing antimicrobial resistance is the biggest challenge to healthcare across the world. As stated by the UK Chief Medical Officer Professor Dame Sally Davies, ‘We have reached a critical point and must act now on a global scale to slow down antimicrobial resistance’ (DH  2014) (see also Box 4.1).

CHAPTER 4 Infection prevention and control

Nurses, along with other healthcare workers, have a duty to reduce the burden of antimicrobial resistance though effective infection prevention in their everyday work and help to preserve antimicrobials for future generations. An infection prevented means an antibiotic not required. The term ‘antimicrobial stewardship’ is widely used to describe efforts to improve and rationalize antimicrobial prescribing. Much of this effort is targeted at doctors, who are the main prescribers of antimicrobials. Examples include the Start Smart – Then Focus toolkit (PHE  2015) and Antimicrobial Stewardship: Systems and Processes for Effective Microbial Medicine Use (NICE 2015), which exist to improve antimicrobial prescribing and develop a wider understanding of antimicrobial stewardship. ‘Start smart’ means: • not starting antimicrobial therapy unless there is clear evidence of infection (ideally supported by appropriate microbiology samples) • following local antibiotic guidance and taking into account a clear allergy history • ensuring review dates and rationales for prescribing are all clearly documented. ‘Then focus’ means: • reviewing the clinical diagnosis and continuing need for antimicrobials at 48–72 hours • then clearly documenting a prescribing decision to stop, switch (from intravenous to oral), change (to a narrower-spectrum antibiotic in light of microbiology results), continue (and document the next review date) or use outpatient parenteral antibiotic therapy. Nurses also have an important role in antimicrobial stewardship even if they are not themselves prescribers. This should include not being afraid to question the use of antimicrobials and encouraging good documentation.

Current infection challenges

In the UK, E. coli has increasingly been implicated as a source of bloodstream infection, as can be seen in Figure  4.6. E. coli and other gram-negative bloodstream infections caused by organisms such as Klebsiella spp. and P. aeruginosa are subject to mandatory reporting and reduction targets. A significant proportion of these isolates are showing increasing resistance to antimicrobials, which makes recognition and reduction of risk factors very important in controlling their spread. Such gram-negative infections seem predominantly to originate in the community and are often associated with older age, dehydration and urinary tract problems. Examples include an elderly gentleman with an enlarged prostate that leads to repeated urinary tract infection and an elderly lady becoming dehydrated because she is not drinking due to anxiety about incontinence (PHE 2018b).

EVIDENCE-BASED APPROACHES

With good infection prevention and control practice, many HCAIs can be prevented. This has been demonstrated by the significant reductions in MRSA bloodstream infection in English NHS hospitals between 2005 and 2018 (PHE 2018b, 2018c) and the dramatic fall in the number of cases of C. difficile infection in England (PHE 2018b, 2018d). These reductions were achieved via the systematic application and monitoring of established practices for the prevention and control of infection, including diligent hand hygiene and correct aseptic technique. The use of effective infection prevention practices, including hand hygiene, environmental cleaning and care of invasive devices, leads to less cross-transmission, less infection, and less need for antimicrobials and other remedial treatments. It is therefore safer for patients and more cost-effective, and it contributes to reducing the burden of antimicrobial resistance. Infection prevention and control underpins the clinical practices of all disciplines of healthcare and is fundamental to patient safety. As in other disciplines, robust evidence should underpin

and improve practice and be used to ensure patients are receiving optimal care. However, it is not always possible to carry out robust randomized controlled trials (RCTs) to evidence all interventions and in some cases it is very difficult to ascertain which of several interventions implemented concurrently has made a difference. For example, hand hygiene must be accepted as good practice on the basis of the results of a multitude of non-RCT studies (Pittet et al. 2000) and experience. One of the most favoured means of presenting best practice is in the form of ‘care bundles’. It can even be argued that a set of measures implemented during an outbreak comprises an ‘outbreak bundle’. A care bundle is a group of evidence-based interventions that have been put together to be practised consistently with the intention that if all the elements are undertaken together, a particular outcome will occur – or, in the case of infection prevention, will not occur. The bundle normally consists of around five elements, each of which have robust evidence indicating that, if they are implemented reliably, for every patient, on every occasion, they will result in the most benefit of all possible interventions (Rochon et al. 2017). In the UK, in 2005 the Department of Health issued Saving Lives, which is a package of ‘high impact interventions’. This bundle was put together to reduce infection in key target areas including peripheral vascular devices, central vascular access devices, urinary catheters, surgical wound infection, ventilatorassociated pneumonia and nasogastric feeding. The tools were reviewed and reissued by the Infection Prevention Society in 2017. The suite of tools covers: • prevention of ventilator-associated pneumonia • prevention of infections associated with peripheral vascular access devices • prevention of infections associated with central venous access devices • prevention of surgical site infection • prevention of infections in chronic wounds • prevention of urinary-catheter-associated infections • promotion of stewardship in antimicrobial prescribing.

CLINICAL GOVERNANCE

Hygiene Code

Infection prevention and control in England is underpinned by the Health and Social Care Act (2008), which has been summar­ ized in a separate code of practice (DH  2015a). Known as the Hygiene Code, this mandates a set of responsibilities to healthcare providers including hospitals, general practitioners, dentists and care homes. This legislation is monitored and enforced by the Care Quality Commission (CQC), which assesses care providers against the requirements of the Code during periodic inspections. Each provider must be registered with the CQC and declare compliance with the 10 criteria of the Hygiene Code. These criteria are summarized in Table 4.5. All healthcare organizations are required to appoint a senior manager to the role of ‘director of infection prevention and control’, or DIPC (DH 2003). This person must have the seniority to be able to influence the board of directors to ensure that infection prevention is accorded the highest priority. All but the smallest healthcare providers should have (or have access to) an infection prevention and control team, who will advise on day-to-day aspects of infection prevention. The team will usually consist of one or more nurses trained in infection prevention along with a consultant microbiologist or infection control doctor and an antimicrobial pharmacist. Some teams will have additional staff working in audit, surveillance, or data collection and analysis. The role of the infection prevention and control team is varied but principally involves providing advice, education and support to healthcare professionals, caregivers and the wider organization to ensure patient and staff safety is maintained and risks are minimized.

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Figure 4.6  E. coli bacteraemia rates in England, 2015/2016. Source: NHS Improvement (2017). © Crown copyright.

70

people out of every

100,000 will acquire an E. coli bacteraemia

78

Rate per 100,000 population

Trends in rates of E. coli bacteraemia 80 60 40 20 2

2

3

2 01

4

3 01

2

2

5

2

4 01

6

/1

/1

/1

/1

/1

1 01

5 01

2

Financial year

Adult male rate

Adult female rate

51

50

Elderly male rate

824

Elderly female rate

568

adult males out of every

adult females out of every

elderly males out of every

elderly females out of every

(age 45–64)

(age 45–64)

(age ≥85)

(age ≥85)

100,000

100,000

100,000

100,000

Gastrointestinal Unknown

6% 24%

Other source

14%

Hepatobiliary

11%

73%

45% UTI

© Crown copyright 2016

Professional responsibility

In England, nurses must be aware of the measures that are in place in their workplace to ensure compliance with the Hygiene Code. For example, many hospital trusts have a programme of regular visits to clinical areas by senior staff, who carry out inspections against the criteria of the Code as if they were external assessors. This programme ensures that senior staff are familiar with the Code and that everyone is familiar with the

600 mL per day

Opaque drainable bag with viewing option

Urostomy

Urine and mucus

Two-piece clear urostomy bag with tap

Urine: 0.5 mL/kg/h

Clear or opaque urostomy bag with tap, plus a urostomy night bag

Double-barrelled wet colostomy

Urine, mucus and faecal output

Two-piece system with a high-output pouch, or a urostomy pouch

First few days urine only, then soft stool with the urine

One- or two-piece beige pouch with viewing option, plus a high-output night bag

Type of stoma

Source: Adapted from Adams et al. (2012).

• Peristomal skin: presence of any erythema, broken areas, rashes, pain or itchiness. • Stoma/skin margin (mucocutaneous margin): sutures intact, tension on sutures and separation of stoma edge from skin (mucocutaneous separation). Any abnormalities should be reported to the stoma care nurse and medical staff (Black 2011b). Viewing the stoma may be difficult for the patient, who may be very aware of other people’s reactions to it. The patient’s reaction to their stoma should be observed and recorded. Colostomy function

Typically in the first few days, a sigmoid colostomy will produce haemoserous fluid and flatus. By day 5 there should be some faecal fluid and then by day 7–14 some semi-formed stool. A closed appliance can be used once the output has thickened up. Rarely, a stoma may be formed in the transverse colon, usually as a result of an emergency procedure (Cronin 2012), and in such cases only a small amount of water will be reabsorbed from the faecal matter, so the stool will be less formed. Therefore, a drainable pouch will be required. Patients with a sigmoid colostomy (ostomates) should generally be advised to have a balanced and mixed diet. To avoid constipation, ostomates are advised to take adequate oral fluids and fibre in the form of five portions of fruit and vegetables per day (Burch 2011c). If either constipation or loose stool is a problem, then dietary intake should be reviewed. Ostomates may find that their colostomy is usually active at particular times of the day, but ultimately the only means of gaining control with a sigmoid colostomy is by using a plug system or by regular irrigation. Stoma care nurses will need to assess patients for their suitability for using either a plug system or irrigation. The patient’s consultant must approve of irrigation for the patient. Ileostomy function

Typically, for the first few days, the stoma will produce haemoserous fluid and flatus. By days 5–10 there will be brown faecal ­matter. The fluid output after surgery can be as much as 1500 mL every 24 hours but this should gradually reduce to 500–850 mL every 24 hours as the bowel settles down (Black 2016). It is important that fluid balance recordings are made and serum electrolytes are measured as patients are at risk of sodium, potassium and/or magnesium depletion (Goodey and Colman 2016). Sometimes the output from a stoma remains high (>1000 mL every 24 hours), which may be due to the amount of small bowel removed during surgery or an underlying bowel condition; these patients require careful management. Patients who continue to have a high output from their stoma may need to be managed by specialist teams that

include gastroenterologists, dietitians and stoma care nurses in order to provide ongoing support (Slater 2012). The effluent from an ileostomy takes on a porridge-like consistency when a normal intake of food is established (Burch 2011c). A drainable appliance is therefore used. The effluent contains enzymes, which will excoriate the skin (Burch 2011b); therefore, if the pouch leaks, it must be changed promptly to prevent skin breakdown. The effluent cannot be controlled but may vary throughout the day. Patients with ileostomies often find that the output is thicker first thing in the morning and after meals, or the output is looser with reduced dietary intake (Burch 2011c). Output can vary between watery, loose and soft stool depending on the time of day and what the patient has eaten. Sometimes medication that reduces peristaltic action, for example codeine or loperamide, may be used to control excessive watery output. If using loperamide, this should be taken half an hour to an hour before food in order to achieve an optimal effect. Urostomy or ileal conduit function

Urine will dribble from the stoma every 20–30 seconds and it will start to drain immediately. Normal output is 1500–2000 mL every 24 hours but it may be less after periods of reduced fluid intake, for example at night. Urinary stents (fine-bore catheters) may be in place, from the ureters past the anastomosis and out of the stoma. They are placed to maintain patency and protect the suturing until primary healing is completed (Geng et  al.  2009, Leach 2015). Stents usually remain in situ for 7–14 days depending on the surgeon and patient factors such as condition of the stoma, previous radiotherapy and renal function.

Body image

Stoma formation creates many issues for patients and many struggle with body image. Studies suggest that this is often ­overlooked (Wallace  2016). The circumstances in which the stoma is formed will influence psychological recovery (Di Gesaro 2016). Communication is key and it is important to allow the patient and their family to discuss their concerns and anxieties. Therefore, stoma care nurses play a vital role in supporting the patient and their family. It is important to promote patient independence and acceptance.

Diet

Initially, all patients will start with sips of water, then move on to free fluids, and then to a light diet. In the absence of nausea and vomiting, they can proceed with building up their dietary intake. Colostomists and urostomists should be encouraged to eat a wide variety of foods and drink 1.5–2 L of fluids each day. People’s digestive systems react in individual ways to different foods and so it is important that patients try a wide range of foods on several

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274

occasions and that none should be specifically avoided (Burch 2011c). Patients can then make decisions about different foods based on their own experiences. Explanations should be given of how the gut functions, how it has been changed since surgery and the effects certain foodstuffs may cause. However, patients with an ileostomy should use caution with foods that will increase output as these may cause a high-output stoma. A person with an ileostomy should also be aware of what to do if the output is watery for longer than 24 hours (Goodey and Colman  2016). The normal output from an ileostomy should be toothpaste-like or porridge-like in consistency and the patient should empty the pouch approximately six to eight times a day (approximately 600–800 mL in 24 hours) (Cronin 2013). If the patient has watery stool for over 12 hours, they should consider increasing the amount of starch in their diet, such as white bread, white pasta, white rice, noodles and potatoes. They should avoid fibre, and in particular they should reduce their intake of fruit (including fruit juice) and green leafy vegetables. In addition, they can stagger eating and drinking so that they are not doing both at the same time, spacing them at least half an hour apart (Goodey and Colman 2016). The patient should have been prescribed some medication to reduce diarrhoea, such as loperamide. They should take this in accordance with instructions from their prescriber. Loperamide needs to be taken half an hour before each meal to slow the bowel down (Goodey and Colman 2016). If a person with an ileostomy has had a watery output for more than 24 hours or consistently has a watery output, they should contact their stoma care nurse or doctor. They must be aware of the symptoms of dehydration, such as headaches, dizziness, thirst, reduced and darker-coloured urine, cramps and tingling in the hands (Goodey and Colman 2016). Patients may be at risk of acute kidney injury if the dehydration continues. In particular, their electrolytes (sodium, potassium and magnesium) are likely to be outside normal parameters. An ileostomy patient can help to rehydrate themselves by making up a rehydration solution (Box 6.6) and drink a litre of this during the course of 24 hours. They should reduce their intake of tea and coffee and not take any fizzy drinks (Goodey and Colman 2016). Patients with colostomy or ileostomy formation do not have the same control as with an anal sphincter, so passage of wind cannot be controlled. High-fibre foods such as beans and pulses produce wind as they are broken down in the gut; hence, individuals who eat large quantities of these foodstuffs may be troubled by wind. There are several non-food causes of wind, such as chewing gum, eating irregularly and drinking fizzy drinks, and these should be considered before blaming a particular food. Eating yoghurt or drinking buttermilk may help to reduce wind for these patients. Green vegetables, pulses and spicy food are examples of foods that may cause colostomy and ileostomy output to increase or become watery. Boiled rice, smooth peanut butter, apple sauce and bananas are some of the foods that may help to thicken stoma output (Black 2000, Burch 2011c). Some foods, for example tomato skin and pips, may be seen unaltered in the output from an ileostomy. Celery, dried fruit, nuts, fibrous fruit (such as mango) and potato skins are some of the foods that can temporarily block ileostomies (Burch 2011c). The blockage is usually related to the amount eaten and the offending Box 6.6  An example of an oral rehydration solution: St Mark’s rehydration solution • 6 level teaspoons (5 mL spoonfuls) or 20 g of glucose powder • Half a teaspoon (2.5 mL) or 2.5 g of sodium bicarbonate • 1 level teaspoon (5 mL spoonful) or 3.5 g of salt • 1 L of tap water • The patient may add squash or cordial to flavour the solution. Source: Cronin (2013), Goodey and Colman (2016).

food can be tried at another time in small quantities, ensuring it is chewed well and not eaten in a hurry. There are no dietary restrictions with a urostomy, although bowel activity may be temporarily affected if a portion of the ileum has been used for the stoma. It must be stressed, however, that an adequate fluid intake must be maintained to minimize the risk of urinary tract infection due to a shortened urinary tract. The recommended fluid intake for all individuals is 1.5–2 L per day (Burch  2011c). Fluid intake should be increased in hot weather and at times when there is an increase in sweating, for example with exercise or fever. Patients should be made aware of certain foods that may cause a change to the usual character of the urine. For example, beetroot, radishes, spinach and some food dyes may discolour urine; some drugs may also have this effect, for example metronidazole and nitrofurantoin. Similarly, following consumption of asparagus or fish, urine may develop a strong odour.

Fear of malodour

This is a common fear for patients with bowel stomas, often based on hearsay or experience with other ostomates in hospital or the community. Appliances are odour free when fitted correctly. Flatus may be released via charcoal filters, and deodorizers are available. The individual must be reassured, however, that any problems that occur post-operatively will be investigated, with a good possibility of their being solved by such means as the use of alternative appliances (Black 2016).

Sex and the ostomate

The possibility of sexual impairment for both men and women after stoma surgery depends on the nature of the operation and the ensuing damage to the nerves and tissues involved. The psychological impact of the surgery and its effect on the individual’s body image must also be taken into consideration. Surgery that results in physical sexual disability will have psychological repercussions, while some sexual difficulties may be of psychological origin (Humphreys 2017, Reese et al. 2014, Williams 2012). Impairment may be permanent or temporary. In the latter case, resolution of the difficulty may take anywhere up to 2 years. Pre- and post-operative counselling should be offered for both patient and partner. All patients may experience loss of libido and sexual desire. Females having cystectomy for cancer will in most cases require anterior exenteration and vaginal reconstruction. This includes removal of the urethra and a vaginal reconstruction, which affects both vaginal length and blood supply to the vagina and clitoris. Consequent sexual dysfunction occurs and patients must be counselled accordingly in the pre-operative period (Zippe et  al.  2004). In males, ejaculatory disturbances occur following cystectomy so men facing this surgery should be offered sperm banking prior to surgery. Erectile dysfunction is a common complication of all pelvic surgery and there are a number of treatment options available. These include oral medications, such as phosphodiesterase type 5 inhibitors (PD5 inhibitors), sublingual apomorphine, intraurethral and intracavernosal injections, vacuum devices and penile implants (Broholm et al. 2014, Geng et al. 2010, NHSBSA 2018e, Park et al. 2015). Patients with persistent erectile dysfunction should be referred for penile rehabilitation. Female sexual dysfunction after colorectal and pelvic surgery is common (Bregendahl et al. 2015, Burch 2016). Typically, a loss of libido and satisfaction occurs. Female patients may experience dyspareunia; this may be due to narrowing or shortening of the vagina, a reduction in the volume of vaginal secretions or changes in genital sensations (Reese et al. 2014). The use of a lubricant, adopting different positions during penetrative intercourse or encouraging greater relaxation by extending foreplay may help to resolve painful intercourse (Humphreys 2017).

Planning for discharge

Discharge planning for a patient with a stoma should commence once the patient is admitted. It is important to set a provisional discharge date and set realistic goals with the patient. Prior to discharge, ideally the patient should have returned to their prior

CHAPTER 6 Elimination

a stoma. Indeed, in a survey of 100 patients following stoma formation, 56% felt that support was needed for the first 6 months, indicating the ongoing need for professional advice and support for a substantial amount of time after stoma surgery (Wallace 2016). Continuity of care for these patients is crucial. Effective communication and collaboration between healthcare professionals are key to psychological adaptation and successful rehabilitation (Borwell 2009, Di Gesaro 2016). See Figure 6.34 for an example of a discharge checklist.

level of independence, be eating a normal diet and be competent in stoma care. Family or close friends are likely to require support and information so that they are in a position to help the ostomate and this should be provided as much as possible before discharge. If family or close friends are involved during all stages of stoma surgery, and patients are well informed, patients are better able to adapt to life with a stoma (ASCN 2016, Cronin 2012). Acceptance of the stoma is a gradual process and, on discharge from hospital, patients may only be beginning to adapt to life with

Figure 6.34  An example of a stoma discharge checklist. Source: Reproduced with permission of The Royal Marsden.

Stoma Care Discharge Letter Please write details or affix label

Name: Address:

GP: Address:

Post code Telephone No:

Post code Telephone No:

Date of Birth:

Next of Kin:

275

Diagnosis: Previous Medical History : Operation: Date of Operation: Type of Stoma: Admission Date:

Discharge Date:

Appliance Details: Please include; Manufacturer, Product name, Order code and quantity given/ordered (details can be found on the product box or on the appliance itself)

Delivery Arrangements:

Additional Information: (i.e. is patient self caring; sutures in-situ; peristomal skin condition; current bowel action, any significant information relating to stoma care capabilities)

Telephone No: Fax No:

Community Stoma Care Nurse: Signature:

Form Completed By: (Please print)

Ward: Stoma Care Nurse :

Telephone No:

Date: Telephone No:

276

Figure 6.35  Ostomy observational index. Source: Reproduced with permission of Dansac Ltd.

Ostomy Forum- Observation index Stoma

0004960282.INDD 276

Status

Skin

Condition

Output

Consistency

A

Normal

above skin level

A

Normal

as rest of skin

A

Normal

B

Flush

mucosa level with the skin

B

Erythema

red

B

Fluid

C

Retracted

below skin level

C

Macerated

excoriated; moist

C

Thick

D

Prolapsed

notable increasing length of stoma

D

Eroded

excoriated; moist and bleeding

D

Solid

E

Hernia

bowel entering parastomal space

E

Ulcerated

skin defect reaching in to subcutaneous layer

E

Hard

F

Stenosis

tightening of stoma orifice

F

Irritated

irritant causing skin to be inflamed, sore, itchy and red

F

High output

Uro>2500ml/24 hrs Ileo>1500ml/24 hrs

G

Too low output

Uro2s or peripheries cold to touch; respiratory rate >20 breaths per min; NEWS ≥5; 45° passive leg raising suggests fluid responsiveness. Yes

No

Algorithm 2: Fluid Resuscitation

Initiate treatment • Identify cause of deficit and respond. Give a fluid bolus of 500 ml of crystalloid • (containing sodium in the range of 130–154 mmol/l) over less than 15 minutes.

Assess the patient’s likely fluid and electrolyte needs • History: previous limited intake, thirst, abnormal losses, comorbidities. • Clinical examination: pulse, BP, capillary refill, JVP, oedema (peripheral/pulmonary), postural hypotension. • Clinical monitoring: NEWS, fluid balance charts, weight. • Laboratory assessments: FBC, urea, creatinine and electrolytes. Yes

Can the patient meet their fluid and/or electrolyte needs orally or enterally?

Ensure nutrition and fluid needs are met Also see Nutrition support in adults (NICE clinical guideline 32).

No

348

Reassess the patient using the ABCDE approach Does the patient still need fluid resuscitation? Seek expert help if unsure

Yes

Does the patient have complex fluid or electrolyte replacement or abnormal distribution issues?

Look for existing deficits or excesses, ongoing abnormal losses, abnormal distribution or other complex issues.

No

No

Does the patient have signs of shock? Yes

Yes

>2000 ml given?

Yes

No

Seek expert help

Algorithm 3: Routine Maintenance

Existing fluid or electrolyte deficits or excesses Check for: dehydration • fluid overload • hyperkalaemia/ • hypokalaemia Estimate deficits or excesses.

Give maintenance IV fluids Normal daily fluid and electrolyte requirements: 25–30 ml/kg/d water • 1 mmol/kg/day sodium, potassium*, chloride • 50–100 g/day glucose (e.g. glucose 5% contains • 5 g/100ml).

No

Give a further fluid bolus of 250–500 ml of crystalloid

Algorithm 4: Replacement and Redistribution

Reassess and monitor the patient Stop IV fluids when no longer needed. Nasogastric fluids or enteral feeding are preferable when maintenance needs are more than 3 days.

Ongoing abnormal fluid or electrolyte losses

Redistribution and other complex issues

Check ongoing losses and estimate amounts. Check for: vomiting and NG tube loss • biliary drainage loss • high/low volume ileal stoma • loss diarrhoea/excess colostomy • loss ongoing blood loss,e.g. • melaena sweating/fever/dehydration • pancreatic/jejunal fistula/stoma • loss urinary loss,e.g. post AKI • polyuria.

Check for: gross oedema • severe sepsis • hypernatraemia/ • hyponatraemia renal, liver and/or • cardiac impairment. post-operative fluid • retention and redistribution malnourished and • refeeding issues Seek expert help if necessary and estimate requirements.

Prescribe by adding to or subtracting from routine maintenance, adjusting for all other sources of fluid and electrolytes (oral, enteral and drug prescriptions)

Monitor and reassess fluid and biochemical status by clinical and laboratory monitoring

* Weight-based potassium prescriptions should be rounded to the nearest common fluids available (for example, a 67 kg person should have fluids containing 20 mmol and 40 mmol of potassium in a 24-hour period). Potassium should not be added to intravenous fluid bags as this is dangerous. ‘Intravenous fluid therapy in adults in hospital’, NICE clinical guideline 174 (December 2013. Last update December 2016)

© National Institute for Health and Care Excellence 2013. All rights reserved.

CHAPTER 8 Nutrition and fluid balance

guidance can be found in the section on algorithms for intravenous fluid therapy in adults in NICE (2017a). See also Figure 8.8. Synthetic colloid fluids containing hydroxyethyl starch have previously been utilized in fluid replacement. However, the relative benefits and risks of these have come under scrutiny and it was decided by the European Medicines Agency (2013) that production and use of these be suspended. If a colloid is deemed to be necessary, NICE (2017b) recommends human albumin 4.5% for use only in patients with sepsis and shock.

increased mortality. This can be avoided by using a buffered salt solution such as compound sodium lactate (also called Hartmann’s solution) (Finfer et al. 2010, Gross et al. 2017). Recent studies have compared saline and buffered salt solutions in relation to adverse renal events (Self et al. 2018, Semler et al. 2018). No difference was found in mortality rates, but buffered solutions were found to be less harmful to patients with poor renal function. With regard to fluid resuscitation, the current recommended practice is to attempt to restore normovolaemia with crystalloids (Resuscitation Council 2015, Rhodes et al. 2017) but avoid dextrose as this can rapidly dilute plasma sodium and lead to the redistribution of fluid from the intravascular space and because it may cause hyperglycaemia. Albumin administration is suggested as a supplement to crystalloids in sepsis (NICE  2017a, Rhodes et al. 2017) but is contraindicated in traumatic brain injury (Gross et  al.  2017). The Resuscitation Council (UK) (2015) and NICE (2017b) suggest a bolus of 500 mL of warmed crystalloid solution (e.g. Hartmann’s solution or 0.9% sodium chloride) over less than 15 minutes if the patient is hypotensive. Use smaller volumes (e.g. 250 mL) for patients with known cardiac failure or trauma and use closer monitoring (listen to the chest for crackles after each bolus). Rhodes et al. (2017) recommend 30 mL/kg within the first 3 hours for sepsis-induced hypoperfusion. A wide variation in practice can be evident across trusts and even individual departments. NICE (2017a) offers clear, standardized guidance with regard to intravenous fluid administration for adult patients in hospital (excluding patients with diabetes, severe liver or renal disease, pregnant women and patients under the age of 16 years). A summary and useful form of this

Rationale Indications

Any patient who has shown signs or symptoms of a fluid imbalance, who has undergone surgery or acute illness that has led to critical care admission, or who is at significant risk of acute kidney injury should have their fluid intake and output monitored and fluid balance calculated on an hourly basis (Davies et  al.  2015). The decision to monitor fluid balance should be a multidisciplinary one; however, it is usually the responsibility of the bedside nurse, healthcare worker or nursing associate to ensure this is done accurately.

CLINICAL GOVERNANCE

The Code (NMC 2018) clearly states that unambiguous and accurate records must be kept; this includes fluid balance charts (Figure 8.9). Nurses should have an understanding of the mechanisms of fluid balance and identify potential imbalances and the problems associated with them.

Figure 8.9  Example of a fluid balance chart. Time

Input Oral

0800 0900 1000 1100 1200 1300 1400 1500 1600 1700 1800 1900 2000 2100 2200 2300 2400 0100 0200 0300 0400 0500 0600 0700

110 50

Enteral 40 40

+

Parenteral 50 50

+

+

Add up these figures each hour to get hourly total

Total Input 220 380

Hour Total 220 160

20 20

+

Fluid Balance

Output

=

+ Add the hourly total to previous input total to get total input

Urine 50 45

+

Gastric losses 20 Nil

+

Bowels BNO BO/solid

+

Drains 75 20

+

Add up these figures each hour to get hourly total

Hour total

Total output 145 210

145 65

=

+ Add the hourly total to previous output total to get total output

+75 +170

Subtract total output from total input to calculate fluid balance (may be a negative number)

349

THE ROYAL MARSDEN MANUAL OF CLINICAL NURSING PROCEDURES

PRE-PROCEDURAL CONSIDERATIONS

motion, vomiting and so on. It is helpful to provide a cup with markings showing volume. It is important to note that patients may have other means of urine output, for example an ileal conduit, ureteric stents, suprapubic catheterization or a neobladder. The same concepts can be used to measure the output in such cases, by attaching a urometer to the catheter or urostomy bag.

In order to monitor fluid balance, both input and output must be accurately measured. Below are procedural guidelines for measuring input and output. If the patient is awake, able to take oral fluids and mobile, they must be educated about the fact that their fluid balance is being monitored and each drink must be recorded, as should each episode of passing urine, bowel

Procedure guideline 8.1  Fluid input: measurement Essential equipment • Personal protective equipment • Fluid balance chart • Appropriate pumps for fluid or feeding • Cup with markings Action

Rationale

Pre-procedure

350

1 Introduce yourself to the patient, and explain and discuss the procedure with them. Educate the patient about the fact that their fluid input is being monitored and ask them to communicate any oral intake. Additionally, obtain their consent to continue this monitoring. It can be helpful to provide a cup with millilitre markings or a diagram with estimated volumes.

To ensure the patient is aware of the need to record any oral intake so this can be noted accurately (Baraz et al. 2009, R; Georgiades 2016, E). To ensure that the patient feels at ease, understands the procedure and gives their valid consent (NMC 2018, C).

2 Obtain a fluid balance chart and complete the patient’s details and the date commenced, or add the necessary document to the appropriate electronic documentation system.

To ensure the chart is labelled with the details of the correct patient, allowing accurate documentation (Powell-Tuck et al. 2011, C).

3 Ensure pumps are available for continuous intravenous fluids and nasogastric tube or jejunostomy feeds.

To enable accurate hourly recording of intake (Reid et al. 2004, E).

Procedure 4 Measure oral fluid intake hourly, noting it on the fluid balance chart (see Figure 8.9).

To obtain an accurate real-time fluid balance status (Davies et al. 2015, R; Sumnall 2007, E).

5 Note any enteral or parenteral intake.

To obtain an accurate real-time fluid balance status and ensure all possible inputs are considered (Davies et al. 2015, R; Smith and Roberts 2011, E).

6 Add together the values for oral, enteral and parenteral intake for the hour.

To assess hourly fluid intake (Davies et al. 2015, R; Scales and Pilsworth 2008, E).

7 Add this value to the cumulative total for intake (see Figure 8.9).

To assess total intake and enable calculation of the fluid balance (Scales and Pilsworth 2008, E).

Post-procedure 8 Once output totals have been calculated (see Procedure guidelines 8.2–8.7), subtract output from input.

To calculate fluid balance (Powell-Tuck et al. 2011, C).

9 Document this on the chart.

To ensure accurate documentation (NMC 2018, C).

Procedure guideline 8.2  Fluid output: monitoring/measuring output if the patient is catheterized Essential equipment • Personal protective equipment • Urometer • Fluid balance chart Action

Rationale

Pre-procedure 1 Introduce yourself to the patient, explain and discuss the procedure with them, and gain their consent to proceed.

To ensure that the patient feels at ease, understands the procedure and gives their valid consent (NMC 2018, C).

CHAPTER 8 Nutrition and fluid balance

2 Determine the relevant sources of fluid output (see Table 8.3) and note them on the fluid balance chart.

To ensure all possibilities have been considered and to ensure accurate (as far as possible) output determination (Scales and Pilsworth 2008, E).

3 Wash hands thoroughly and/or use an alcohol-based handrub and apply personal protective equipment necessary for handling body fluids.

To appropriately decontaminate hands and avoid cross-contamination (NHS England and NHSI 2019, C).

Procedure 4 Explain to the patient that it is necessary to monitor their urine output and that you will be doing so every hour.

To ensure that the patient is not alarmed by frequent observation and that they are kept informed about their current care (Bryant 2007, E).

5 Attach a urometer to the catheter using an aseptic technique (see Procedure guideline 4.11: Aseptic technique example: changing a wound dressing).

To allow accurate assessment of hourly urine output. E To prevent cross-infection (Loveday et al. 2014, R).

6 Each hour, on the hour, note the volume of urine in the urometer, recording this on the fluid balance chart.

To determine urine output and to keep accurate records of this, enabling the assessment of fluid balance (Scales and Pilsworth 2008, E).

7 Empty the urometer into the collection bag (until the bag is three-quarters full; this will then need emptying).

To ensure the urometer is empty for the next hour’s determination and that there is no backflow of urine. E

8 Add recorded urine output to the other values for output, giving an hourly total.

To allow for fluid balance determination. E

Post-procedure 9 Once all output has been determined and noted on the chart, calculate the total hourly output and then subtract the total output from the total input. 10 Document all values on the chart and record any other actions relating to your findings in the patient’s notes.

To calculate hourly fluid balance. E

To ensure accurate documentation (NMC 2018, C).

351

Procedure guideline 8.3  Fluid output: monitoring/measuring output if the patient is not catheterized Essential equipment • Personal protective equipment • Measuring jugs (with volume indicators) • Bedpan, urinary bottles or commode • Scales Action

Rationale

Pre-procedure 1 Introduce yourself to the patient, explain and discuss the procedure with them, and gain their consent to proceed.

To ensure that the patient feels at ease, understands the procedure and gives their valid consent (NMC 2018, C).

2 Determine the relevant sources of fluid output (see Table 8.3) and note them on the fluid balance chart.

To ensure all possibilities have been considered to ensure accurate (as far as possible) output determination (McGloin 2015, E; Scales and Pilsworth 2008, E).

Procedure 3 Explain to the patient that it is necessary to measure their urine output.

To ensure that the patient knows that any urine they pass needs to be measured in order to record output and to obtain their co-operation in ensuring accuracy of measurement (Georgiades 2016, E).

4 Provide the patient with bedpans or a commode, even if able to mobilize to the bathroom; ask them to place the bedpan over the toilet bowl; ask them to inform you of each episode.

To ensure the urine is kept for measuring and not disposed of (Georgiades 2016, E).

5 Use personal protective equipment required for body fluids when handling used bottles or bedpans.

To prevent cross-infection (NHS England and NHSI 2019, C).

6 Place bedpan or bottle onto the scales, subtracting the appropriate value to compensate for the weight of the item.

To obtain the amount of urine in grams, which equates to the same in millilitres. E (continued)

THE ROYAL MARSDEN MANUAL OF CLINICAL NURSING PROCEDURES

Procedure guideline 8.3  Fluid output: monitoring/measuring output if the patient is not catheterized (continued) Action

Rationale

7 If no scales are available, use a jug with volume markings; pour the urine into a jug (using standard precautions), noting the level of urine.

To measure urine volume. E

8 Once noted, dispose of urine appropriately.

To prevent contamination and/or cross-infection (Loveday et al. 2014, R).

9 Record the value on the fluid balance chart, adding this to the rest of the output values for the hour.

To determine fluid output for the hour (McGloin 2015, E).

Post-procedure 10 Once all output has been determined and noted on the chart, calculate the total hourly output and then subtract the total output from the total input.

To calculate hourly fluid balance. E

11 Document all values on the chart and record any other actions relating to your findings in the patient’s notes.

To ensure accurate documentation (NMC 2018, C).

Procedure guideline 8.4  Fluid output: monitoring/measuring output from drains Essential equipment • Personal protective equipment • Measuring jugs (with volume indicators) • Tape and/or pen

352

Action

Rationale

Pre-procedure 1 Introduce yourself to the patient, explain and discuss the procedure with them, and gain their consent to proceed.

To ensure that the patient feels at ease, understands the procedure and gives their valid consent (NMC 2018, C).

2 Determine the relevant sources of fluid output (see Table 8.3) and note them on the fluid balance chart.

To ensure all possibilities have been considered to ensure accurate (as far as possible) output determination (McGloin 2015, E).

3 Wash hands and/or use an alcohol-based handrub and apply To appropriately decontaminate hands and prevent cross-conpersonal protective equipment necessary for handling body tamination (NHS England and NHSI 2019, C). fluids.

Procedure 4 Explain to the patient that the output from the drains will be monitored hourly.

To inform the patient about their current care and to ensure they are not alarmed by the frequent observations (Liaw and Goh 2018, R).

5 If the drain is drainable, empty the contents into a jug, noting To determine the volume of the fluid drained. E the volume. 6 If it is not possible to drain the fluid out of the bag, use some tape (stuck along the length of the bottle) and/or a suitable pen and mark the level the fluid reaches each hour. Date and time each marking.

To determine drainage each hour. To ensure consistency in reading and to communicate to other members of the multidisciplinary team regarding drainage (Sumnall 2007, E).

7 Note volume/drainage on fluid balance chart.

To determine drainage each hour (McGloin 2015, E).

8 Add this figure to the rest of the output values for the hour.

To accurately determine total fluid lost each hour (McGloin 2015, E).

Post-procedure 9 Once all output has been determined and noted on the chart, calculate the total hourly output and then subtract the total output from the total input. 10 Document all values on the chart and record any other actions relating to your findings in the patient’s notes.

To calculate hourly fluid balance (Davies et al. 2015, R).

To ensure accurate documentation (NMC 2018, C).

CHAPTER 8 Nutrition and fluid balance

Procedure guideline 8.5  F  luid output: monitoring/measuring output from gastric outlets, nasogastric tubes or gastrostomy Essential equipment • Personal protective equipment • Urometer • Measuring jugs (with volume indicators) • Bile drainage bag/gastrostomy drainage bag Action

Rationale

Pre-procedure 1 Introduce yourself to the patient, explain and discuss the procedure with them, and gain their consent to proceed.

To ensure that the patient feels at ease, understands the procedure and gives their valid consent (NMC 2018, C).

2 Determine the relevant sources of fluid output (see Table 8.3) and note them on the fluid balance chart.

To ensure all possibilities have been considered to ensure accurate (as far as possible) output determination (McGloin 2015, E).

3 Wash hands and/or use an alcohol-based handrub and apply To appropriately decontaminate hands and prevent crosspersonal protective equipment necessary for handling body contamination (NHS England and NHSI 2019, C). fluids.

Procedure 4 Explain to the patient that it is necessary to monitor drainage every hour.

To inform the patient of their current care and interventions (Liaw and Goh 2018, R).

5 Ensure the gastric outlet device has a drainage bag attached. To collect any output for measurement. E 6 If instructed, leave the bag open to drain (this may differ depending on the patient’s condition).

To enable drainage. E

7 Drain contents into marked jug every hour (if quantity allows), using standard precautions.

To determine volume. E

8 Attach a urometer if output is high.

To ensure accurate reading and for ease of measuring. E

9 Note volume on fluid balance chart, adding this value to the rest of the output values for that hour.

To enable determination of fluid balance (McGloin 2015, E; Sumnall 2007, E).

Post-procedure 10 Once all output has been determined and noted on the chart, calculate the total hourly output and then subtract the total output from the total input.

To calculate hourly fluid balance (McGloin 2015, E).

11 Document all values on the chart and record any other actions relating to your findings in the patient’s notes.

To ensure accurate documentation (NMC 2018, C).

Procedure guideline 8.6  Fluid output: monitoring/measuring output from bowels Essential equipment • Personal protective equipment • Measuring jugs (with volume indicators) • Scales • Bedpan or commode • Flexi-Seal rectal tube (if required) Action

Rationale

Pre-procedure 1 Introduce yourself to the patient, explain and discuss the procedure with them, and gain their consent to proceed.

To ensure that the patient feels at ease, understands the procedure and gives their valid consent (NMC 2018, C).

2 Determine the relevant sources of fluid output (see Table 8.3) and note them on the fluid balance chart.

To ensure all possibilities have been considered to ensure accurate (as far as possible) output determination (McGloin 2015, E).

3 Wash hands and/or use an alcohol-based handrub and apply personal protective equipment necessary for handling body fluids.

To appropriately decontaminate hands and prevent cross-­ contamination (NHS England and NHSI 2019, C). (continued)

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THE ROYAL MARSDEN MANUAL OF CLINICAL NURSING PROCEDURES

Procedure guideline 8.6  Fluid output: monitoring/measuring output from bowels (continued) Action

Rationale

Procedure 4 Explain to the patient that it is necessary to monitor the volume of fluid excreted, including that from the bowel, particularly if the stool is loose/watery.

To keep the patient informed about their current care and observations, to ensure co-operation in monitoring fluid output (Liaw and Goh 2018, R).

5 Provide the patient with bedpans or a commode, even if able to mobilize to the bathroom; ask them to place the bedpan over the toilet bowl; ask them to inform you of each episode.

To enable inspection and measurement of fluid lost via the bowel. E

6 If the stool is loose enough, this can be transferred into a jug and the volume measured. Alternatively, weigh the bedpan as per local policy.

To quantify fluid output from stool (Scales and Pilsworth  2008, E).

7 If the stool is formed and it is not possible to accurately quantify, still note on fluid balance chart that bowels were opened.

To take into account any insensible losses (Shepherd 2011, E).

8 A rectal tube may be suitable in some patients; refer to local policy regarding the use of rectal tubes. Note any output on the fluid balance chart.

To ensure correct use of tube and to quantify any fluid losses from the bowel. E

9 Add losses to the previous losses for the hour.

To calculate hourly fluid output (Shepherd 2011, E).

Post-procedure 10 Once all output has been determined and noted on the chart, calculate the total hourly output and then subtract the total output from the total input.

To calculate hourly fluid balance (Shepherd 2011, E).

11 Document all values on the chart and record any other actions relating to your findings in the patient’s notes.

To ensure accurate documentation (NMC 2018, C).

354

Procedure guideline 8.7  Fluid output: monitoring/measuring output from stoma sites Essential equipment • Personal protective equipment • Measuring jugs (with volume indicators) Action

Rationale

Pre-procedure 1 Introduce yourself to the patient, explain and discuss the procedure with them, and gain their consent to proceed.

To ensure that the patient feels at ease, understands the procedure and gives their valid consent (NMC 2018, C).

2 Determine the relevant sources of fluid output (see Table 8.3) and note them on the fluid balance chart.

To ensure all possibilities have been considered to ensure accurate (as far as possible) output determination (McGloin 2015, E).

3 Wash hands and/or use an alcohol-based handrub and apply personal protective equipment necessary for handling body fluids.

To appropriately decontaminate hands and prevent crosscontamination (NHS England and NHSI 2019, C).

Procedure 4 Explain to the patient that you are monitoring hourly output.

To ensure the patient understands why their stoma is being checked hourly. To ensure they are up to date with current care (Liaw and Goh 2018, R).

5 Check that the stoma bag is drainable; if not, change it (see Procedure guideline 6.20: Stoma bag change).

To ensure ease of draining the bag’s contents and to reduce the number of times the adhesive flange is removed, in order to protect the skin. E

6 Using protective equipment such as incontinence pads, empty the contents of the stoma bag into the measuring jug, noting the volume.

To determine output from the stoma for 1 hour. E

7 Dispose of contents using protective equipment, adhering to local policy.

To ensure correct disposal of contents and prevent crossinfection (Loveday et al. 2014, R).

CHAPTER 8 Nutrition and fluid balance

8 Note the volume of the stool on the chart; add this to any other losses for the hour.

To ensure correct documentation of output and allow calculation of fluid balance (NICE 2017a, C).

9 Add the hourly total (all outputs) to the cumulative output (see Figure 8.9).

To enable fluid balance determination (Shepherd 2011, E).

Post-procedure 10 Once all output has been determined and noted on the chart, calculate the total hourly output and then subtract the total output from the total input.

To calculate hourly fluid balance. E

11 Document all values on the chart and record any other actions relating to your findings in the patient’s notes.

To ensure accurate documentation (NMC 2018, C).

Problem-solving table 8.1  Prevention and resolution (Procedure guidelines 8.1, 8.2, 8.3, 8.4, 8.5, 8.6 and 8.7) Problem

Cause

Prevention

Action

Non-compliance or lack of co-operation from patients

Usually misunderstanding or lack of education regarding the importance of monitoring fluid balance

Effective patient education and teaching.

Determine effective teaching methods. Considering individual needs, for example poor hearing or illiteracy. Re-educate the patient, using appropriate means.

Inability to record input due to lack of pumps to regulate intravenous fluids or enteral feeds

Not available, unable to use or inappropriate

Request more equipment from appropriate sources, or request training.

Calculate drip rates on free-flowing fluids to ensure correct hourly input calculated.

Insensible losses

Inability to measure some losses

Not applicable.

Note on chart if perspiration is excessive, if patient is pyrexial, or if bowels were opened and immeasurable, to highlight possible inaccuracy in fluid balance.

Leaking drains

Inevitable with some drains

Inevitable with some drains; however, the surrounding opening may require further suturing. Request a surgical review if necessary.

Use stoma bag or wound drainage bag to collect drainage, to enable measurement.

Incorrect fluid balance calculation

Incorrect fluid input determination, incorrect fluid output determination or incorrect calculation

Appropriate teaching and education for nurses performing these procedures; check competence. Encourage use of a calculator if needed.

Ensure nurses are educated appropriately and that they access information and education if they are unsure of a procedure or technique.

POST-PROCEDURAL CONSIDERATIONS

Every hour, the findings of fluid input/output monitoring should be recorded; any deficit or change in fluid balance should be reported. Any imbalance noted will require action and a management plan. The nurse recording the fluid balance should have an appreciation of the importance of fluid imbalance management and should notify the appropriate person of any imbalance.

COMPLICATIONS

Correct fluid balance monitoring is essential in the successful management of actual or potential fluid balance disturbances (Jevon and Ewens 2012). Over- or underestimation of a patient’s fluid status could lead to incorrect management, resulting in fluid overload (hypervolaemia), dehydration (hypovolaemia) (Davies et al. 2015, Pinnington et al. 2016) and/or electrolyte disturbances, all of which will ultimately lead to organ dysfunction.

Fluid overload (hypervolaemia)

Underestimating fluid balance may lead to continued or increased administration of intravenous fluids, which if monitored incorrectly could result in circulatory overload. Excess intravenous fluid administration is not the only cause of circulatory overload, which can also result from acute renal failure, heart failure or excessive sodium intake (Rhoda et al. 2011). In health, homeostatic mechanisms exist to compensate and redistribute excess fluids; however, in ill health, these mechanisms are often inadequate, leading to increasing circulatory volumes. As the volume within the circulatory system rises, so does the hydrostatic pressure, which, when excessive, results in leaking of fluid from the vessels into the surrounding tissues. This is evident as oedema, initially apparent in the ankles and legs (Figure  8.10) or buttocks and sacrum if the patient is in bed. This can progress to generalized oedema, where even the tissues

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Figure 8.10  Foot and ankle oedema.

Normal foot and ankle

356

Mild oedema

Moderate to severe oedema

surrounding the eyes become puffy and swollen. A bounding pulse and an increased blood pressure are also signs of fluid overload, as are an increased cardiac output and raised central venous pressure (Gross et al. 2017). One of the most dangerous symptoms of fluid overload is pulmonary oedema, which occurs when rising hydrostatic pressure within the vessels leads to congestion within the pulmonary ­circulation, causing fluid to leak into the lungs and pulmonary tissues (Chioncel et  al.  2015). This presents with respiratory symptoms, including shortness of breath, increased respiratory rate, a cough (Tidy 2018) (often associated with pink, frothy sputum), and finally reduced oxygen saturations due to inadequate gaseous exchange at the alveolar level (Tidy 2018). Left untreated, this can be fatal as the lungs fail to provide essential cells and organs with oxygen; this eventually leads to organ dysfunction and then failure. Cardiac dysfunction can result from fluid overload, not only from the reduced availability of oxygen to the cardiac cells due to the pulmonary oedema, but also from the increase in volume, which causes the cardiac muscle to stretch, leading to cell damage and inability to contract effectively (Tidy 2018). Treatment of hypervolaemia involves restricting fluid intake, monitoring electrolytes and using diuretics in an attempt to offload some of the excess fluid (Thomsen et al. 2012). Vasodilators may also be considered to reduce the pressure in the vessels in patients with congestive heart failure. If these mechanisms fail, it may be necessary to use renal replacement therapy to drive the fluid out of the circulation. In some cases, fluid overload is part of the disease process. However, with effective monitoring, fluid balance recording and assessment, it may be possible to avoid the devastating complications.

Dehydration (hypovolaemia)

Dehydration implies a negative fluid balance: when the fluid output exceeds the fluid intake (Jevon 2010). Overestimation of the fluid balance may lead to inadequate replacement of lost fluids. Dehydration can, however, be caused by a loss of fluids to ‘third spaces’ such as ascites or lost due to a reduction in colloid osmotic pressure (hypoalbuminaemia) (Frost 2015) – losses that are not easy to account for. Fluid balance charts should therefore always be used in association with physical assessment of the patient, weight measurement and laboratory results.

There are three categories of dehydration (Mentes and Kang 2013) – isotonic, hypertonic and hypotonic – each related to the type of fluid and solutes lost. Isotonic describes the loss of both water and sodium from the ECF; hypertonic is excessive loss of water only, which leads to a rise in ECF sodium, causing a shift in fluid from the intracellular space to the extracellular. Hypotonic dehydration results from excessive sodium loss, particularly with the overuse of diuretics or in the case of high-output ileostomies (Chan et al. 2018, Welch 2010). Dehydration can ultimately cause a reduction in circulating volume (Tortora and Derrickson  2017). As with any change in a homeostatic state, in health the body has the ability to compensate but in ill health these mechanisms are often inadequate. Untreated dehydration will quickly lead to a drop in blood pressure and a rise in heart rate (to compensate for the fall in blood pressure). A fall in blood pressure will initially lead to inadequate renal perfusion, causing a rise in metabolites, acidosis, acute kidney injury and eventual toxaemia. If this is untreated, other organs will suffer from poor perfusion, possibly resulting in ischaemia, organ dysfunction and eventually organ failure (Adam et al. 2017). Additional signs and symptoms of dehydration are thirst, weight loss, decreased urine output, dry skin and mucous membranes, fatigue and increased body temperature (Rhoda et al. 2011). Treatment of dehydration includes the replacement of lost fluid and electrolytes but caution must be exercised. If the dehydration is mild, slower fluid replacement is advised, in order to prevent further complications in shifts in electrolytes. However, if hypovolaemia exists with the signs and symptoms of circulatory shock, low blood pressure and organ dysfunction, aggressive fluid replacement is advised (Jevon 2010, NICE 2017a). By restoring circulatory volume with fluid administration or resuscitation, renal perfusion can be improved and acute kidney injury may be prevented (Perner et al. 2017).

Acute kidney injury

Acute kidney injury (which can be due to a multitude of causes) is a common feature in the acutely or critically unwell patient and will require even more careful approaches to monitoring and maintenance of fluid balance (Goldstein 2014). The National Confidential Enquiry into Patient Outcome and Death (NCEPOD  2009) reviewed the care delivered to patients with acute kidney injury and found that 50% received suboptimal care. NICE responded to these findings by producing guidance for the prevention, detection and management of acute kidney injury (NICE  2013). The relevant recommendations from this guidance include the need for reliable monitoring of urine output and early recognition of oliguria. The KDIGO (2012) grading system also reinforces the need for accurate and reliable fluid balance monitoring, particularly monitoring urine output (Table 8.5). All assessments, investigations and results require the healthcare professional undertaking them to have an appreciation and understanding of the implications of the findings so they can act accordingly.

Table 8.5  Kidney Disease: Improving Global Outcomes (KDIGO) staging classification Stage

Serum creatinine

Urine output

Stage 1

1.5–1.9 × baseline

60 years) Plus consider an additional 2–2.5 mL per °C in temperatures above 37°C

Note: these guidelines will not always be appropriate for patients who are severely ill or who are outside the body mass index range of 18.5–30 kg/m2 (Gandy 2014). Source: Data from Arends et al. (2017) and Todorovic and Mafrici (2019). Reproduced with permission of PENG – Parenteral and Enteral Nutrition Group (www.peng.uk.com) of the British Dietetic Association (www.bda.uk.com).

CHAPTER 8 Nutrition and fluid balance

and calculating drug dosages, such as for anaesthesia and ­chemotherapy. All patients should have their height and weight measured on admission to hospital, and weight should be measured at regular intervals during their hospital stay according to local policy and individual clinical need. When height cannot be measured, it may be estimated using ulna length, which has been shown to have a moderate correlation with height (Madden et al. 2008). See also the section on preprocedural considerations below.

CLINICAL GOVERNANCE

Discrepancies in recording patient bodyweight, as well as using inaccurate or inappropriate weighing equipment, can have a negative impact on patient care (Clarkson 2012). This can increase the risk of errors in diagnosis, interventions, treatment and/or medication dosage. Weight should be recorded in patients’ medical notes at the time the measurement is taken.

PRE-PROCEDURAL CONSIDERATIONS

Check that the patient is able to stand or sit on the appropriate scales. The patient should remove outdoor clothing and shoes before being weighed and having their height measured. When obtaining a height measurement, check that the patient is able to stand upright while the measurement is taken. For patients who are unable to stand, height may be determined by measuring ulna length and using conversion tables (see Figure  8.12). If neither height nor weight can be measured or obtained, BMI can be estimated using the mid-upper arm circumference (MUAC) (BAPEN 2018a, Benítez Brito et al. 2016). It may not be possible to weigh patients who cannot be moved or are unable to sit or stand. Alternative methods to obtain weight should be explored, for example bed scales (which can be placed under the wheels of the bed), scales as an integral part of a bed or a patient hoist with a weighing facility.

Equipment Scales

Scales (either sitting or standing) must be calibrated and positioned on a level surface. If electronic or battery scales are used then they must be connected to the mains or have appropriate working batteries prior to the patient getting on the scales.

Stadiometer

These are devices for measuring height and may be mounted on weighing scales or wall mounted.

Tape measure

This is required if estimating height from ulna length or MUAC or for measurement of waist circumference. The tape measure

should use centimetres, and it must be disposable or made of plastic that can be cleaned with a detergent wipe between patient uses.

Assessment tools

Identification of patients who are malnourished or at risk of malnutrition is an important first step in nutritional care. There are a number of screening tools available that consider different aspects of nutritional status. National screening initiatives have demonstrated that 25% of patients admitted to hospital were found to be at risk of malnutrition  –  18% high risk and 7% medium risk (BAPEN  2012a). Particular diagnoses, such as cancer, increase the risk of malnutrition. All patients who are identified as at risk of malnutrition should undergo a nutritional assessment. Subjective Global Assessment (SGA) and patient-generated SGA (PG-SGA) are comprehensive assessment tools that necessitate more time and expertise to carry out than most screening tests and therefore are more likely to be used by those with specialist skills, for example dietitians. The Malnutrition Universal Screening Tool (MUST) (BAPEN 2018a) is an example of a screening tool that is based on the patient’s BMI, weight loss and illness score; it is less time consuming and easier to use. Other tools may be specific to the patient’s age or diagnosis; for example, the Mini Nutrition Assessment (MNA) is used in the elderly and the Royal Marsden Nutrition Screening Tool is used for patients with cancer (Kondrup et al. 2003, Shaw et al. 2015). The most important feature of using any screening tool is that patients identified as having a nutritional deficit or concern, or as requiring intervention have a ­nutritional care plan initiated and are referred to a dietitian for further advice if appropriate.

Measurement of waist circumference

Table  8.7 shows the waist circumference measurements for men and women at which there is an increased relative risk of heart disease, type 2 diabetes and cancer. In some populations, waist circumference may be a better indicator of risk than BMI, e.g. in persons of Asian descent. In very obese patients (those with a BMI above 35 kg/m2), waist circumference adds little to the predictive power of disease risk (National Obesity Forum 2016).

Table 8.7  Waist circumference measurements Increased risk

Substantially increased risk

Men

≥94 cm

≥102 cm

Women

≥80 cm

≥88 cm

Figure 8.12  Conversion chart for estimating height from ulna length. Source: Reproduced from BAPEN (2018b) with permission. Height Men (0.9% • other gases: 0.07%. Inspired air at sea level has a total atmospheric pressure of 101.3 kPa (760 mmHg). According to Dalton’s law, where there is a mixture of gases, each gas exerts its own pressure as if there were no other gases present (Jones and Berry 2015). The pressure of an individual gas in a mixture is called the ‘partial pressure’ and is denoted as Pa. This is followed by the symbol of the gas. For example, the partial pressure of oxygen is written as PaO2 (Tortora and Derrickson  2017). The partial pressures of the three main gases in the air are as follows: • oxygen: 0.21 × 101.3 = 21.3 kPa (159.8 mmHg) • carbon dioxide: 0.03 × 101.3 = 3.0 kPa (22.8 mmHg) • nitrogen: 0.78 × 101.3 = 79.0 kPa (592.6 mmHg) The partial pressure controls the movement of oxygen and carbon dioxide between the atmosphere and the lungs, the lungs and the blood, and finally the blood and the cells.

Gaseous exchange

Gases move by diffusion. Diffusion is the movement of gas molecules from an area of relatively high partial pressure to an area of low partial pressure (Tortora and Derrickson 2017). Oxygen diffuses from the alveoli, where the partial pressure is highest, into the pulmonary capillaries, where it is lower. From here it continues to travel, and as the partial pressure changes it diffuses into the tissues and finally the mitochondria of the cells. The waste product carbon dioxide diffuses in the same way back from the cells to the alveoli, where the partial pressure of carbon dioxide is lowest (Figure 12.2).

Systemic veins

Systemic arteries

Tissues

Tissues PaCO 2 > 5.9 kPa PaO 2 < 5.3 kPa

Inspired air encounters water vapour as it is warmed and humidified in the upper airways of the respiratory tract. Water vapour exerts its own partial pressure of 6.3 kPa (47 mmHg), which must be subtracted from the total atmospheric pressure to give the corrected total atmospheric pressure (Brady 2018): • corrected total atmospheric pressure: 101.3  –  6.3 = 95 kPa (713 mmHg) This figure of 95 kPa is then used to find the partial pressures of each gas: • oxygen: 0.21 × 95 = 20.0 kPa (150.0 mmHg) • carbon dioxide: 0.03 × 95 = 2.9 kPa (21.8 mmHg) As oxygen continues to pass down the respiratory tract to the  alveoli, it encounters carbon dioxide leaving the respiratory tract. This exerts a partial pressure of approximately 5.3 kPa (40.0 mmHg). This in turn must be subtracted to determine the correct value for oxygen (Jones and Berry  2015, O’Driscoll et al. 2017). For example: • corrected partial pressure of oxygen: 20.0 kPa (150.0 mmHg) – 5.3 kPa (40.0 mmHg) = 14.7 kPa (110 mmHg)

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Oxygen transportation

Kaufman and Dhamoon 2018). Decreases in the following cause the curve to shift to the left:

• Dissolved in the plasma (serum): only 2–3% (0.03 mL O2 per 100 mL of plasma) is carried in this way as oxygen is not very soluble (Marieb and Hoehn 2018). It is expressed as the PaO2. • Bound to the haemoglobin of the red blood cells: 95–98% of oxygen is carried in this way; it is measured as the percentage of haemoglobin saturated with oxygen. Each gram of haemoglobin can carry 1.34 mL of oxygen per 100 mL blood (Thomas and Lumb 2012). It is expressed as the SaO2 when measured from arterial blood gas. When pulse oximetry is used, it is expressed as SpO2.

• body temperature (due to exposure to cold, near drowning or trauma) • hydrogen ion content (due to alkalaemia) • carbon dioxide (due to hyperventilation) • 2,3-DPG.

Oxygen is carried in the blood in two ways:

Haemoglobin is composed of haem (iron) and globulin (protein). Each haemoglobin molecule has four binding sites, each able to carry one molecule of oxygen. A haemoglobin molecule is said to be fully saturated when oxygen is bound to all four molecules. When fewer than four are attached, the haemoglobin is said to be partially saturated (Jones and Berry  2015). The bond between haemoglobin and oxygen is represented by the oxygen disassociation curve and is affected by various physiological factors that shift the curve to the right or left (Figure 12.3).

Oxyhaemoglobin curve shift to the right

When a shift occurs to the right, there is reduced binding of oxygen to haemoglobin and oxygen is given up more easily to the tissues. Oxygen saturation of the haemoglobin molecule will be lower (Collins et al. 2015, Kaufman and Dhamoon 2018). Increases in the following cause the curve to shift to the right: • body temperature (due to infection or sepsis) • hydrogen ion content (acidaemia), known as the Bohr effect (due to sepsis or other shock conditions) • carbon dioxide (due to sepsis or pulmonary disease) • 2,3-diphosphoglycerate (2,3-DPG) (an enzyme found in the red bloods cells that affects haemoglobin and oxygen binding).

Oxyhaemoglobin curve shift to the left

When a shift occurs to the left, there is an increase in the binding of oxygen to the haemoglobin, oxygen is given up less easily to the tissues and cellular hypoxia can occur (Jones and Berry 2015,

Figure 12.3  Oxyhaemoglobin dissociation curve. With a PaO2 of 8 kPa and more, saturations will remain high (flat portion of curve). The middle red line is the normal position of the curve. 2,3-DPG, 2,3-diphosphoglycerate.

H+ PaCO 2 Temperature 2-3-DPG



60



Saturation (%)

Right shift

40



80



542

H+ ↓ PaCO 2 ↓ Temp↓ 2-3-DPG ↓

Oxygen uptake in the lungs is shown by the upper flat part of the curve. When the PaO2 is between 8.0 and 13.3 kPa (60–100 mmHg), the haemoglobin molecule is saturated with more than 90% ­oxygen. At this point of the curve, large changes in the PaO2 lead to small changes in the SaO2 because the haemoglobin is almost completely saturated. The lower part of the curve shows the release of oxygen from the haemoglobin molecule to the tissues. Oxygen is given up very easily to the tissues and small changes in the PaO2 cause major changes to the SaO2 (Marieb and Hoehn 2018). A patient’s PaO2 must therefore be kept above 8 kPa (60 mmHg) to prevent hypoxia and cell death (Jones and Berry 2015). ‘Hypoxaemia’ is the term used to describe a low partial pressure of oxygen within the blood. In addition to measuring the partial pressure of oxygen within the arterial blood, the fraction of inspired oxygen is also considered (FiO2). This represents the percentage of oxygen participating in gas exchange. Room air has a FiO2 of 0.21 (21%); therefore, any additional oxygen inhaled will increase the FiO2. If a patient is receiving large concentrations of oxygen therapy and is hypoxaemic, this may indicate a problem within the lungs caused by a ventilation/perfusion (V/Q) mismatch, a shunt, alveolar hypoventilation, decreased partial pressure of oxygen or decreased diffusion (Sarkar et al. 2017).

Oxygen consumption

At rest, the normal oxygen consumption rate is approximately 200–250 mL per minute. As the available oxygen per minute in an average-sized man is about 700 mL, this means there is an oxygen reserve of 450–500 mL per minute (MacIntyre 2014). Factors that increase the consumption of oxygen include fever, sepsis, shivering, restlessness and increased metabolism (Semenza 2012). It is difficult to say at which absolute level oxygen therapy is necessary, as each situation should be judged by the clinical condition of the patient and their oxygen requirements. Generally speaking, additional oxygen will be required when the PaO2 has fallen to 8 kPa (60 mmHg) or less (O’Driscoll et al. 2017), as measured on an arterial blood gas sample.

Carbon dioxide excretion

The second function of the respiratory system is to excrete ­carbon dioxide from the lungs during expiration in order to maintain a normal level of carbon dioxide in the blood (4.5–6.0 kPa or 34–45 mmHg). Carbon dioxide has a direct effect on the respiratory centre in the brain (Marhong and Fan 2014). As the carbon dioxide level rises and diffuses from the blood into the cerebrospinal fluid (CSF), it is hydrated and carbonic acid is formed. The acid then dissociates and hydrogen ions are liberated. Because there is no bicarbonate in the CSF to buffer the hydrogen ions, the pH of the CSF falls, which excites the central chemoreceptors, resulting in an increased respiratory rate (Cheng and Jusof 2018, Marieb and Hoehn 2018).

Left shift

100

Oxygen utilization

EVIDENCE-BASED APPROACHES

20

Respiratory assessment 0

0

5

8

10

15 kPa

O2 partial pressure 37.5

60

75

112 mmHg

During normal respiration, eating, drinking and speaking in full sentences are effortless. The first stage of a respiratory assessment is to observe the patient for the following: • general colour and appearance (ashen, cyanosis, pallor or sweating)

CHAPTER 12 Respiratory care, CPR and blood transfusion

• position adopted by the patient to assist breathing • use of accessory muscles • work of breathing at rest and on movement • respiratory rate • respiratory pattern • ability to speak in full sentences • additional audible breath sounds (Wild and Peate 2012). A thorough patient history and physical assessment will help to determine what the underlying cause of the respiratory concern may be. Additional investigations such as a chest X-ray, arterial blood gas analysis, and a computed tomography (CT) scan or ventilation/perfusion (V/Q) scan may also be necessary to aid diagnosis. Having made a comprehensive assessment, the immediate cause of respiratory insufficiency should be corrected where possible. The cause may be directly related to respiratory function or a secondary effect of another process. For example, the patient may be in severe pain and good pain management may allow them to breathe deeply and cough more effectively, improving respiratory function. Conversely, an opioid overdose may result in decreased or absent respiration, and treatment will include supporting respiration and administering the antidote to the opioid. Regardless of the cause, respiratory function needs to be supported while the underlying condition is being treated (O’Driscoll et al. 2017). Respiratory therapy therefore includes a variety of interventions, such as: • pharmacological management, including oxygen therapy • bronchodilators • analgesia • antidotes to drug toxicity • antimicrobials for infections of the respiratory tract • support and guidance on smoking cessation. Surgery may be indicated to repair a ruptured diaphragm or to manage trauma of the thoracic cavity. Some patients may require insertion of a tracheostomy tube or chest drain, or a stent or shunt for superior vena cava obstruction (for example). Finally, positioning (see Chapter 7: Moving and positioning) and physio­ therapy play a major role in improving respiratory function (English 2015). Any person who is unable to maintain tissue oxygenation requires supplemental oxygen until they are able to manage again on room air.

Oxygen therapy DEFINITION

Table 12.1  Common causes of respiratory failure Type 1 respiratory failure (hypoxaemic)

Type 2 respiratory failure (hypercapnic)

• COPD • Pneumonia • Pulmonary oedema • Pulmonary fibrosis • Asthma • Pneumothorax • Pulmonary embolism • Pulmonary arterial hypertension • Pneumoconiosis • Granulomatous lung diseases • Cyanotic congenital heart disease • Bronchiectasis • ARDS • Fat embolism syndrome • Kyphoscoliosis • Obesity

• COPD • Severe asthma • Drug overdose or sedative drugs • Poisoning • Myasthenia gravis • Polyneuropathy • Poliomyelitis • Primary muscle disorders • Porphyria • Cervical cordotomy • Head and cervical cord injury • Primary alveolar hypoventilation • Obesity hypoventilation syndrome • Pulmonary oedema • ARDS • Myxoedema • Tetanus

ARDS, acute respiratory distress syndrome; COPD, chronic obstructive pulmonary disease. Source: Adapted from Feller-Kopman and Schwartzstein (2017), Kayner (2012).

• during and after conscious sedation or anaesthesia if the patient is unable to maintain their own airway or maintain oxygen saturations between 94% and 98% (or 88–92% if at risk of hypercapnic respiratory failure) (O’Driscoll et al. 2017). Any of the above conditions can lead to respiratory failure, of which there are two types (Brady 2018): • Type 1 is referred to as ‘hypoxaemic respiratory failure’ (failure to oxygenate the tissues), where the PaO2 is less than 8 kPa (60 mmHg) while the carbon dioxide (PaCO2) is normal or low. • Type 2 is referred to as ‘hypercapnic respiratory failure’ (raised carbon dioxide) or ‘respiratory pump failure’, where the PaCO2 is greater than 6 kPa (45 mmHg). Alveolar ventilation is insufficient to excrete carbon dioxide and this is accompanied by hypoxaemia. Table 12.1 outlines some of the common causes of the different types of respiratory failure.

Oxygen therapy is the administration of oxygen at concentrations greater than that in ambient air (21%), with the intention of treating or preventing the symptoms and manifestations of hypoxia (McCoy 2013).

Contraindications

EVIDENCE-BASED APPROACHES

• Patients at risk of hypercapnic respiratory failure (e.g. those with chronic obstructive pulmonary disease) should receive prescribed titrated oxygen to maintain oxygen saturations of 88–92%. • The administration of high concentrations of fractional inspired oxygen (FiO2) for prolonged periods of time can cause absorption atelectasis (incomplete lung inflation) and oxygen toxicity. • Supplemental oxygen should be administered with caution to patients with paraquat poisoning and those who have previously received bleomycin chemotherapy due to the risk of pulmonary toxicity and bleomycin-induced pneumonitis. • Bacterial contamination associated with certain nebulization and humidification systems is a possible hazard. • Fire hazard is increased in the presence of increased oxygen concentrations.

Rationale Indications

Oxygen is indicated for any condition that causes hypoxaemia. For example: • during cardiac or respiratory arrest • for initial treatment during critical illness (anaphylaxis, shock, sepsis, carbon monoxide poisoning, major head injury, status epilepticus, major pulmonary haemorrhage, near drowning, etc.) • during serious illness when hypoxaemia is suspected or has been confirmed (e.g. acute asthma, pneumonia, pulmonary embolism, pulmonary oedema, pleural effusion lung cancer or worsening lung fibrosis)

No specific contraindications to oxygen therapy exist (Bein et al. 2016), but the following precautions need to be considered (GOLD 2017, Moore 2016, NICE 2018a, O’Driscoll et al. 2017):

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Anticipated patient outcomes

CLINICAL GOVERNANCE

• Care should be taken with high concentrations of oxygen when using a defibrillator in a cardiorespiratory arrest or during elective cardioversion. • All oxygen delivery systems should be checked at least once per day.

Competencies

Oxygen delivery

The patient will achieve the desired oxygen saturations with the least amount of supplementary oxygen necessary.

NHS Improvement (2018a) highlights the concerns surrounding delivery of oxygen therapy via cylinders. The valve mechanism in place to address fire prevention has led to an unintended consequence in that staff may believe oxygen is flowing when it is not. It has also been reported that staff have been unable to turn the oxygen flow on in an emergency. In a recent 3-year period, over 400 incidents involving incorrect operation of oxygen cylinder controls were reported to the National Reporting and Learning System (NHS Improvement 2018a). It follows that nursing staff must be adequately trained to administer oxygen therapy and their competency should be assessed. They should check and document that a device is being used appropriately and that the flow and/or concentration of oxygen is as prescribed and appropriate to the patient’s need (O’Driscoll et al. 2017). Nursing and physiotherapy staff may assess patients and may initiate and monitor oxygen therapy within the prescribed parameters; an exeception to this would be in an emergency, when oxygen should be given first and prescribed later (Dhruve et al. 2015).

Governance

Clinical governance leads should audit current practice and develop local policies and evidence-based guidelines (Dixon and Jones 2017) to ensure that: • oxygen is administered and prescribed according to national guidance from the British Thoracic Society (O’Driscoll et al. 2017) • all equipment is regularly checked for safety • staff are adequately trained to use equipment and troubleshoot it when problems occur.

Risk management

The use of medical equipment relating to oxygen therapy should be monitored as identified within local medical equipment policies. All incident reports relating to oxygen therapy and equipment should be reviewed by local risk management committees to identify themes and trends, and propose appropriate risk reduction measures to prevent reoccurrence and improve patient safety (MHRA 2013).

PRE-PROCEDURAL CONSIDERATIONS

544

Ensure a prescription is in place before administering any oxygen (unless in an emergency situation). Pulse oximetry monitoring equipment must be readily available in all clinical areas where oxygen may be administered (O’Driscoll et al. 2017).

Equipment

Oxygen is an odourless, tasteless, colourless and transparent gas that is slightly heavier than air. Oxygen supports combustion so there is always a danger of fire in the presence of a spark or naked flame when oxygen is being used. The following safety measures should be remembered (Dhruve et al. 2015): • Oil or grease around oxygen connections should be avoided. • Alcohol, ether and other inflammable liquids should be used with caution near oxygen. • No electrical device should be used in or near an oxygen tent. • Oxygen cylinders should be kept secure, in an upright position and away from heat. • There must be no smoking in the vicinity of oxygen. • A fire extinguisher should be readily available.

Any oxygen components:

delivery

system

will

include

these

basic

• oxygen supply: from either a piped supply or a portable cylinder (portable cylinders range from size C to size J and contain compressed gas held at high pressure; size C is for ambulatory use whereas size J is for use at the bedside when a piped supply is not available) • reduction gauge: to reduce the pressure to atmospheric pressure • flowmeter: a device that controls the flow of oxygen in litres per minute (L/min) • tubing: disposable tubing of varying diameters and lengths • mechanism for delivery: a mask or nasal cannula • humidifier (optional): to warm and moisten the oxygen before administration. Nasal cannula

A nasal cannula (Figure 12.4) consists of two plastic prongs that are inserted inside the anterior nares and supported on a light frame. A nasal cannula can be used when the patient requires a low concentration of oxygen (between 24% and 35%) with flow rates of 1–4 L/min. While Table  12.2 shows oxygen concentrations in relation to flow when oxygen is delivered via a nasal cannula, the actual uptake of oxygen and its subsequent effect on blood oxygen and carbon dioxide levels cannot be accurately predicted due to the variation in a patient’s rate and pattern of breathing (O’Driscoll et al. 2017). Medium concentrations of oxygen up to 44% (6 L/min) can be used but are often not well tolerated due to nasal irritation of the mucous membranes. As an alternative to a mask, the nasal cannula may seem less claustrophobic; is generally more comfortable; and does not interfere with eating, drinking or communication. There is also no risk of rebreathing carbon dioxide (Brill and Wedzicha 2014). Simple face-mask

Simple face-masks (Figure  12.5) are medium-concentration masks that entrain the air from the atmosphere, delivering a ­variable oxygen concentration (anything from 40% to 60%; Table  12.3). These masks are useful for patients with type 1

Figure 12.4  Nasal cannula.

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Table 12.2  Approximate oxygen concentrations related to flow rates of nasal cannulas Oxygen flow rate (L/min)

Oxygen concentration delivered (%)

1

24

2

28

3

32

4

36

5

40

6

44

Figure 12.6  Reservoir mask (non-rebreathe mask).

Figure 12.5  Simple face-mask.

Figure 12.7  Venturi attachments.

Table 12.3  Approximate oxygen concentrations related to flow rates of simple face-masks Oxygen flow rate (L/min)

Oxygen concentration delivered (%)

2

24

4

35

6

50

8

55

10

60

12

65

15

70

r­espiratory failure who need a higher percentage of oxygen ­temporarily while the cause of their hypoxia is treated. As with the nasal cannula, the actual oxygen concentration delivered is not accurate as it differs depending on the set flow rate and the patient’s rate and depth of breathing (O’Driscoll et al. 2017). Using less than 5 L/min is not recommenced due to the possible build-up and rebreathing of carbon dioxide, caused by the low flow and resistance to breathing against the mask (Brill and Wedzicha  2014, Herren et  al.  2017). If the patient requires more than 60% oxygen (10 L/min), expert help should be sought as the patient may require more invasive respiratory support.

Reservoir mask (non-rebreathing mask)

Reservoir masks (Figure  12.6) are similar to simple face-masks with the addition of a reservoir bag. They allow oxygen to be delivered at concentrations between 60% and 90% when used at a flow rate of 10–15 L/min. Oxygen flows into the bag (the bag should be inflated with oxygen prior to use) and mask during inhalation while, on exhalation, air is diverted out of the mask’s side valves. A separate one-way valve prevents expired air from flowing back into the reservoir bag and the rebreathing of carbon dioxide. As with the nasal cannula and simple face-mask, the actual concentration of oxygen delivered varies depending on the patient’s breathing rate and pattern, as well as the mask fit (O’Driscoll et al. 2017). Note that if the oxygen flow is less than 10 L/min, carbon dioxide can accumulate in the reservoir bag, resulting in an increase in carbon dioxide inhalation (Herren et al. 2017) and a failure to meet the patient’s oxygen requirements. This device is usually used during an emergency situation and in the presence of expert nursing and medical support. It may also be used as a short-term measure before more invasive respiratory support is instituted. Venturi mask (fixed performance mask or high-flow mask)

The Venturi mask (composed of a simple face-mask and a Venturi adaptor) delivers high-flow oxygen when the oxygen flow rate is set above the minimum rate printed on the side of the  attachment (Figure  12.7). The adaptors are colour coded

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Table 12.4  Total gas flow from Venturi masks at different oxygen flow rates Set oxygen flow (L/min)

24% Venturi (L/min)

28% Venturi (L/min)

35% Venturi (L/min)

40% Venturi (L/min)

60% Venturi (L/min)

15

84

82

30

12

67

50

24

56

41

10 8

89

6

67

4

102

2

51

46

44

Source: Adapted from O’Driscoll et al. (2017) with permission of BMJ Publishing Group, Ltd.

Figure 12.8  Tracheostomy mask.

non-invasive ventilation, or use of continuous positive airway pressure) may be preferred. Tracheostomy mask

Tracheostomy masks (Figure  12.8) perform in a similar way to the simple face-mask. The mask is placed over the tracheostomy tube or laryngectomy stoma. Oxygen needs to be humidified to prevent drying of airways and secretions since the patient’s natural mechanisms of humidification have been bypassed ­ (NTSP  2013). For more information, see the section below on humidification. A summary of the oxygen devices discussed and their advantages and disadvantages can be found in Table 12.5.

Pharmacological and non-pharmacological support

The following measures should be prescribed or offered to help improve a patient’s respiratory status (GOLD 2017, NICE 2018b, O’Driscoll et al. 2017), where relevant:

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according to the percentage of oxygen they deliver and are available in the following concentrations: 24%, 28%, 35%, 40% and 60%. The Venturi effect ensures an accurate concentration of oxygen is delivered regardless of the proportion of air drawn into the attachment and the flow of oxygen delivered (providing it is above the minimum stated). Unlike in the devices mentioned previously, the oxygen concentration delivered is not affected by the patient’s rate and depth of breathing. Because of the accur­ acy in oxygen delivery offered by these masks, the 24% and 28% Venturi masks are suited to patients at risk of hypercapnic respiratory failure (Brill and Wedzicha  2014, O’Driscoll et al. 2017). Venturi masks are also suitable for patients with an increased respiratory rate (more than 30 breaths per minute) who require an increased inspiratory flow. It is suggested that for such patients the flow rate is increased by 50% from the minimum printed on the side of the attachment to help overcome this demand (O’Driscoll et al. 2017). For example, increasing the oxygen flow from 2 to 4 L/min on a 24% Venturi mask doubles the total inspiratory flow from 51 to 102 L/min. As shown in Table 12.4, when a high oxygen flow is used with a higher oxygen concentration adaptor, the total flow decreases dramatically, which may not be suitable for a patient in extremis. In this scenario, a different type of oxygen delivery (such as high-flow oxygen via a nasal cannula,

• antimicrobials if pneumonia is suspected or during exacerbations of chronic obstructive pulmonary disease (COPD) associated with purulent sputum • oral or inhaled therapy (such as bronchodilators, steroids and mucolytics) for patients with asthma and COPD • opioid analgesia for patients with intractable breathlessness caused by their underlying disease • pharmacological products and nicotine replacement therapies to aid smoking cessation • pneumococcal vaccination and annual influenza vaccination for susceptible and immunocompromised patients • physiotherapy and pulmonary rehabilitation for patients with COPD to aid physical mobility, clearance of secretions and deep breathing exercises.

Specific patient preparation

The patient should be provided with an explanation as to why oxygen therapy is indicated, what device is to be used (such as a mask or nasal cannula) and the importance of keeping the device in place. If the patient is mobile, portable cylinders should be readily available to allow oxygen therapy to continue while the patient attends to toileting and personal care away from their bed space. The patient should be educated about the hazards of oxygen and the dangers of smoking, naked flames, aerosol sprays and petroleum-based products used within their immediate vicinity. The nurse should instruct the patient to report symptoms such as increasing shortness of breath, difficulty breathing, anxiety, distress, nausea, or a dry mouth, nose or throat.

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Table 12.5  Summary of oxygen devices Oxygen concentration Device

Low

Medium

High

Advantages

Disadvantages

Nasal cannula







Comfortable and well tolerated. Patient can eat, drink and communicate easily. No risk of rebreathing carbon dioxide.

Can cause drying and irritation of airways when higher flow rates are used.

Simple face-mask







Generally well tolerated when used for a short Can cause build-up of carbon dioxide period of time (hours rather than days). when used at a flow rate of 5 L/min) can minimize symptoms of dryness and improve patient tolerance. Although there is no evidence to support the use of humidification in patients receiving low-flow oxygen therapy or those receiving it in the short term, it should always be considered for patients where the natural pathway of humidification is bypassed (those with an altered airway such as a tracheostomy, laryngectomy or endotracheal tube) (McNulty and Eyre  2015). Adequately heated and humidified oxygen therapy

In a water humidification chamber, inspired gas is forced over a heated reservoir of water, actively humidifying the oxygen or air. Hot water bath humidifiers are more efficient for providing humidification in patients who are mechanically ventilated or who are on high-flow oxygen therapy (McNulty and Eyre  2015, NTSP 2013). However, they are associated with higher costs and potential hazards (Gaffney and Dalton 2018).

Aerosol generators

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Figure 12.11  Heat and moisture exchanger for a tracheostomy tube. (a) Swedish nose. (b) Trachphone.

(a)

Figure 12.12  Heat and moisture exchanger for a laryngectomy.

(b)

Figure 12.13  Heat and moisture exchanger for a ventilation circuit.

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Non-invasive ventilation DEFINITION

Non-invasive ventilation (NIV) is the application of positive ­airway pressure using a mechanical device via an external (i.e. non-invasive) interface such as a face-mask, nasal mask or ­helmet. It has become a standard of care in many forms of acute respiratory failure and can provide more immediate relief of respiratory symptoms when compared to standard therapy ­ (Brill  2014, Davison et  al.  2016). Maintenance of positive ­pressure throughout the respiratory cycle can have numerous ­benefits, such as relieving dyspnoea, improving oxygenation, optimizing gas exchange and reducing the work of breathing (Ireland et al. 2014).

The term NIV is often used interchangeably to refer to both a method of respiratory support and a mode of ventilation. For the purpose of this section, NIV is used in the context of a method of respiratory support unless otherwise specified.

RELATED THEORY

NIV has been established as a useful and safe method of respiratory support in individuals with a variety of aetiologies of respiratory compromise, such as acute respiratory failure, exacerbations of COPD and acute cardiogenic pulmonary oedema (Corrêa et  al.  2015). If initiated in a timely manner and competently

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­ anaged, NIV may be used as a strategy to prevent tracheal m ­intubation and mechanical ventilation in appropriately selected patients and may thus reduce mortality and morbidity (NCEPOD 2017). NIV may be indicated for patients with respiratory compromise if they are conscious, co-operative and able to tolerate the  interface used to deliver this type of ventilation (i.e. facemask, nasal mask or helmet). Patients who present with acute  respiratory failure, especially in the presence of ­hypercapnia, may have symptoms of drowsiness; however, ­providing they have the ability to protect their airway, NIV can be a useful and effective management strategy (Vadde and Pastores 2016).

EVIDENCE-BASED APPROACHES

NIV as a method of respiratory support is the maintenance of positive pressure throughout the respiratory cycle when the patient is breathing spontaneously. It provides an additional option of therapy between conventional oxygen therapy and controlled, invasive ventilation. Advances in NIV devices, the development of more comfortable interfaces, and improvements in patient monitoring and care during NIV delivery have contributed to the increased use of NIV within a variety of clinical settings (Corrêa et al. 2015). The aims of NIV therapy are to improve gas exchange, reduce  the work of breathing, relieve dyspnoea and prevent atelectasis (incomplete lung inflation). These outcomes are achieved by: • Increasing functional residual capacity (FRC), which is the amount of gas left in the lungs at the end of normal expiration available for pulmonary gas exchange. In acute lung injury where gaseous exchange is severely inhibited, NIV increases the FRC by reopening collapsed alveoli and improving ventilation and oxygenation (Chowdhury et al. 2012). • Improving the ventilation/perfusion ratio: under-ventilation of the lungs can lead to intrapulmonary shunting (blood passing through the lungs without being oxygenated). NIV helps to decrease this by reducing the degree of ventilation/perfusion (V/Q) mismatch (Davison et al. 2016). • Improved lung compliance (elasticity) of the lungs: in respiratory failure, the lungs become much stiffer and less compliant and breathing can become more difficult. Reduction in lung volume below a certain level results in airway collapse, hypoventilation and reduced gaseous exchange. The increase in transpulmonary pressure required to overcome this can be achieved by NIV (Demoule et al. 2016). • Increasing lung volume (alveolar volume): NIV maximizes alveolar recruitment, leading to an increase in the surface area of the alveoli available for gaseous exchange (Demoule et  al.  2016). Therefore, oxygen requirements can be reduced and the work of breathing relieved. Other benefits include the preservation of the ability to speak, cough, clear secretions and swallow while warming and humidifying inspired air via natural upper airway mechanics (Davison et al. 2016).

Rationale Indications

NIV methods are usually commenced to improve lung expansion and are indicated in the presence of clinically significant pulmonary atelectasis when other forms of therapy, such as high-flow oxygen therapy, incentive spirometry, chest physiotherapy and deep breathing exercises, have been unsuccessful. Success of NIV will be influenced by patient selection, underlying pathology, severity of respiratory compromise, interface tolerance and presence of other organ dysfunction (Brill 2014). The clinical presentations that may benefit from NIV therapy are outlined in Box 12.1.

Box 12.1  Clinical presentations that may require non-invasive ventilation (NIV) • Acute respiratory failure (Beitler et  al.  2016, Ozsancak Ugurlu et al. 2016, Vadde and Pastores 2016) • Acute exacerbation of COPD (Schnell et al. 2014) • Post-surgical respiratory failure (Cammarota et  al.  2011, Ferrer and Torres  2015), except in cases of laryngeal trauma or recent tracheal anastomosis • Immunocompromised patients (Cortegiani et  al.  2017, Ferreira et al. 2015, Huang et al. 2017, Schnell et al. 2014) • Obstructive sleep apnoea (Gulati et al. 2015) • Obesity hypoventilation syndrome (Bry et al. 2018) • Acute cardiogenic oedema (Masa et al. 2016) • Neuromuscular disease (NICE 2016) • Cystic fibrosis (Rodriguez-Hortal et al. 2017) • Chest wall deformities (Davies et al. 2018) • Post-extubation difficulties (Lin et al. 2014) • Weaning difficulties (Yeung et al. 2018) • Patients ‘not for intubation’ but who still have a need for aggressive or supportive interventions for reversible respiratory clinical presentations (Vadde and Pastores 2016)

Contraindications

Contraindications to the use or application of NIV include: • recurrent pneumothoraces or untreated pneumothorax • inability to maintain own airway (Corrêa et al. 2015) • upper airway obstruction secondary to tumour involvement (Vadde and Pastores 2016) • recent facial or head and neck surgery (not necessarily a contraindication if using helmet NIV or CPAP) • facial burns • epitaxis • excessive secretions or ineffective cough (Olivieri et al. 2015) • vomiting or high risk of aspiration (Vadde and Pastores 2016) • haemodynamic instability or shock • cardiac arrhythmias • any condition where an elevated intracranial pressure is undesirable or where reduction in cerebral blood flow is inappropriate (Backhaus et al. 2017).

Assessment

Patient assessment and early escalation to NIV are paramount in ensuring the success of the therapy and avoiding further deterior­ ation in respiratory function (which may result in the patient requiring intubation). A trial period of NIV is often useful to predict its effectiveness (Demoule et al. 2016). Patients who meet the criteria for NIV should have therapy initiated within 60–120 minutes of an acute presentation or deterior­ ation (Davison et al. 2016). A comprehensive initial assessment and timely review following NIV initiation can help to identify predictors for patients who may fail a NIV trial and allow for prompt intubation. NIV failure can be identified by (Corrêa et al. 2015): • lack of improvement in gas exchange within 2 hours (Olivieri et al. 2015) • inability to correct dyspnoea • increased fatigue • incapacity to manage copious secretions • interface discomfort and/or intolerance • agitiation • anxiety • haemodynamic instability • progression of respiratory failure.

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Figure 12.14  Positive end-expiratory pressure (PEEP) valves.

Anticipated patient outcomes

increase lung volume (Vargas et al. 2018). Devices that generate NIV support can broadly be divided into two categories:

• increased capillary oxygen saturations (SpO2): oxygen should be prescribed to achieve a target saturation of 94–98% for most acutely ill patients or 88–92% for those at risk of hypercapnic respiratory failure (e.g. patients with COPD) (Davison et al. 2016) • decreased administration of supplementary oxygen to achieve targeted oxygen saturation range (Davison et al. 2016) • reduced dysopnea, aiming for a respiratory rate of under 30 breaths per minute (Brill and Wedzicha 2014) • achievement of exhaled tidal volumes (Vt) of 6 mL/kg of ideal bodyweight (Corrêa et al. 2015) • effective secretion clearance as a consequence of humidification, deep breathing and coughing • improvement of breath sounds on auscultation • increased peak flow • improvement in chest radiography • ability to wean the patient off the NIV mask or helmet and maintain an improvement of respiratory status with lower oxygen requirements.

• continuous flow with a continuous level of pressure (e.g. CPAP) • variable flow with two levels of pressure (e.g. BIPAP).

The anticipated patient outcomes of NIV include:

CLINICAL GOVERNANCE

Competencies

NIV respiratory support is being delivered in an increasingly wide variety of hospital settings, such as (Masa et al. 2016):

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• critical care units • high-dependency units • step-down units • intermediate-care units • recovery departments • emergency departments • respiratory wards. Close and thorough clinical assessment is of paramount importance when caring for a patient receiving NIV. It is recommended that staff caring for these patients have formal education and training, with a competency-based assessment to ensure safe standards of care (NCEPOD  2017). Physiological monitoring is not a substitute for clinical assessment, and patients should be observed regularly.

PRE-PROCEDURAL CONSIDERATIONS

Equipment Non-invasive ventilation devices

Non-invasive devices provide a specific level of positive pressure during the respiratory cycle to prevent alveolar collapse and

It is recommended that settings are started at low pressures and titrated to physiological parameters, patient comfort and device synchronicity (Vadde and Pastores 2016). Continuous positive airway pressure (CPAP)

In this mode, pressure is delivered at a constant level throughout the respiratory cycle through the use of a fixed or adjustable exhalation valve (known as a ‘PEEP valve’) (Figure 12.14). PEEP (positive end-expiratory pressure) prevents alveoli from collapsing and thus increases lung diffusion area and gas exchange, and reduces the work of breathing (Roth et al. 2018). Bilevel positive airway pressure (BIPAP)

BIPAP devices provide two levels of support during the respiratory cycle. An inspiratory pressure (higher pressure) is delivered on inhalation (IPAP), while an expiratory pressure (lower pressure) is provided on exhalation (EPAP). This mode of ventilation is a common choice for patients with hypercapnic respiratory failure, patients with COPD and patients with sleep disorders such as obstructive sleep apnoea (OSA). The upper airways are splinted and the respiratory muscles are assisted during inspiration, thereby reducing the work of breathing and dyspnoea (Demoule et al. 2016, Stickle 2018). Patients who use NIV in the long term for chronic conditions such as COPD and OSA will often have their own devices at home, which they can bring in with them if a stay in the acute setting is necessitated, for example in the presence of acute exacerbations of COPD (Davies et al. 2018). When NIV is used in conjunction with usual care, such as bronchodilators, there is an overall reduction in the likelihood of these patients requiring intubation by up to 50% (Stickle 2018). Within the hospital setting, in the presence of an acute clinical presentation of respiratory compromise, BIPAP modes of ventilation are often delivered using mechanical ventilator devices that have the option of supporting invasive and non-invasive modes, often within a critical care unit or high-dependency unit.

NIV interface options

There are a variety of interfaces available for delivering NIV therapy, including nasal masks, face-masks, full face-masks ­ (Figure  12.15) and helmets (Figure  12.16). The ideal interface should ensure a good seal to optimize effectiveness while maintaining patient comfort and compliance. The first few hours of NIV are extremely important and continuous application is crucial in increasing the likelihood of success

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Figure 12.15  Non-invasive ventilation (NIV) patient interfaces.

a transparent mask made of polyvinyl chloride, polycarbonate or thermoplastic. Unintentional leaks around the interface can interfere with the effectiveness of the therapy and cause irritation to the eyes. Most interfaces come with a fitting gauge to ensure correct sizing and minimize this issue. Other strategies include tightening the straps, adjusting the position of the mask, adjusting the ­volume of air in the mask and optimizing the patient’s head position. A certain amount of pressure is required when fitting the mask to keep it in place and form a seal (Brill 2014). Too much pressure can lead to discomfort, intolerance and skin integrity issues, particularly on the nasal bridge and ears. This can be minimized by ensuring the patient’s skin is clean and dry, applying pressurerelieving dressings and relieving the pressure of the mask, where possible. Non-invasive helmets

Figure 12.16  Non-invasive ventilation (NIV) helmet.

Non-invasive helmets or hoods are transparent devices made from latex-free polyvinyl chloride with a soft collar neck seal; they do not come in contact with the patient’s face (Figure  12.16). Helmets have the advantage of avoiding skin integrity issues and improving patient comfort independent of face morphology (Liu et  al.  2016). Patients are also able to drink freely, communicate and expectorate.

CPAP

The set-up and use of CPAP is described in Procedure ­guideline  12.3: Continuous positive airway pressure (CPAP). Its  use should be considered only with a co-operative patient who can maintain their airway and control secretions with an  adequate cough reflex. The patient should be able to coordinate their breathing with the ventilator and breathe unaided for several minutes if CPAP is delivered via a ventilator (Stickle 2018). CPAP requires the following equipment:

of NIV. Some of the issues that patients may experience include (Patel et al. 2016): • discomfort • pressure intolerance with difficulty exhaling • air leaks • claustrophobia • skin breakdown (particularly over the bridge of the nose when using masks) • upper airway dryness • eye irritation. Interface-related problems are common reasons for poor adaptation and NIV intolerance. This can cause an increase in respiratory rate and minute volume, which can lead to poor synchronicity with the device (Spoletini and Hill 2016). Good nursing and multi­ disciplinary care are essential to improving interface tolerance. Non-invasive masks

Non-invasive masks are made from a combination of a soft ma­­ terial (polyvinyl chloride, polypropylene, silicone, silicone elastomer or hydrogel) that forms the seal against the patient’s face and

• A ventilation device that can generate a flow of pressurized breathable gas and oxygen at variable rates  –  for example, Dräger’s CPAP bellows (Figure  12.17), Breas Medical Ltd’s NIPPY or Philips’ Respironics. • A bacterial–viral filter (not a heat and moisture exchanger) (Figure  12.18). This filter provides protection against various particles including bacteria, viruses and water droplets. It also helps to protect the patient, the equipment and the breathing circuit from contamination. • Ventilation device tubing. Consider active humidification if delivering NIV or CPAP through a face-mask or nasal mask, to optimize mucocillary clearance. • A CPAP mask (face-mask or nasal mask) or CPAP helmet with securing straps (see Figures 12.15 and 12.16). • A positive end-expiratory pressure (PEEP) valve of the prescribed level. Available fixed PEEP valves range from 5 cmH2O to 20 cmH2O (see Figure 12.14).

Assessment and recording tools

While a patient is on CPAP, it is essential to monitor their respiratory rate, cardiovascular status (blood pressure and heart rate), pulse oximetry (SpO2) and fluid balance at least hourly. It is also vital to carry out regular arterial blood gas (ABG) sampling. Clinical features that should be assessed are: • chest wall movement • co-ordination of respiratory effort with the ventilator • accessory muscle recruitment • general assessment – whether the patient is sweating, clammy or dyspnoeic • auscultation of the chest for air entry and additional breath sounds • patient comfort • neurological status – signs of confusion or tiredness.

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Figure 12.17  Continuous positive airway pressure (CPAP) bellows.

• Although patients may need a few hours of therapy to achieve the full benefit, there should be a noticeable improvement in the above physiological parameters within 2 hours if the NIV (in this case CPAP) is likely to be effective (Cortegiani et al. 2017, Davison et  al.  2016). If there is no improvement within 2–4 hours, NIV should be discontinued and invasive ventilation considered.

Pharmacological support

Depending on the clinical presentation necessitating the use of NIV or CPAP, and also the patient’s ability to tolerate the chosen interface, pharmacological support may increase the success rate of NIV management: • Diuretics may be given if pulmonary oedema is present (Schnell et al. 2014). • Bronchodialators may be given in patients with COPD or asthma, or in the presence of acute respiratory distress (Masa et al. 2016). • Antimicrobials may be given if patients have suspected or confirmed clinical indicators of a respiratory infection (Masa et al. 2016). • Steroids may be given in patients with acute or chronic exacerbations of COPD (Olivieri et al. 2015). • In some cases, small doses of sedatives or anxiolytics may be a valuable option if patients are overly distressed, tachypnoeic, uncomfortable or experiencing claustrophobia that may lead them to refuse ongoing NIV or CPAP despite adequate explanation and reassurance (Hilbert et  al.  2015). This must be done with caution as it may lead to loss of airway protection and/or depression of respiratory drive. Therefore, this will require increased levels of monitoring to ensure patient safety and may warrant transferring the patient to a critical care or highdependency area (Liu et al. 2016).

Non-pharmacological support

There are a number of measures that can be initiated to help support patients during the use of NIV, such as:

Figure 12.18  Bacterial–viral filter.

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• For some patients, the presence of a relative, a nurse or another healthcare professional may help to relieve the distress caused by NIV or CPAP. • Optimizing patient positioning in bed by sitting the patient upright or in a semi-recumbent position to at least 30° can relieve the symptoms of breathlessness (Corrêa et al. 2015). • It is important to ensure the most favourable type, size and fit of the chosen interface (Hilbert et al. 2015). • If appropriate and clinically feasible, patients can be offered a break from the chosen interface by switching them to an alternative level of respiratory support, such as high-flow oxygen therapy (Brill 2014). • Ensuring the trigger sensitivity, pressurization level and compatibility of the device tubing are appropriate will optimize synchronicity (Brill 2014).

Specific patient preparation Education

CPAP can cause distress to patients, especially due to the tightfitting mask, while the hood can seem claustrophobic. If possible, a clear and concise description of how the therapy works should be provided either verbally or via an information leaflet. Time spent fitting the interface and building the patient’s confidence is well invested (Brill 2014). As with any procedure, consent needs to be gained before treatment can commence. Allow time for the patient to express any concerns or fears they have regarding treatment. Acutely hypoxic patients may not comprehend the relevance of the therapy and so it should be explained to their relatives or carers so they can reassure the patient.

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Procedure guideline 12.3  Continuous positive airway pressure (CPAP) Essential equipment • Personal protective equipment • Dräger bellows or similar device (see Figure 12.17) • Compressed medical gas supply (air with or without oxygen, depending on the particular device) • CPAP helmet or mask • CPAP circuit and/or tubing • Humidification system (mask only) with temperature control • Pulse oximeter Action

Rationale

Pre-procedure 1 Introduce yourself to the patient, explain and discuss the procedure with them, and gain their consent to proceed.

To ensure that the patient feels at ease, understands the procedure and gives their valid consent (NMC 2018, C).

2 Assess the patient’s consciousness level.

To obtain a baseline and be able to assess the patient for changes in condition (see Chapter 14: Observations). E A reduction in level of consciousness or altered mental status may indicate hypoxaemia. E

3 Observe and record the following: a respiratory function b respiratory rate c work of breathing d colour, skin and mental status e oxygen saturation (SpO2).

To obtain a baseline of respiratory function. E To observe for any change in respiratory function. E

4 Explain the principles of CPAP to the patient and their family and demonstrate the system to them.

To minimize anxiety, increase knowledge and aid in patient compliance. E

5 Discuss with the doctor or advanced nurse practitioner whether it is appropriate to insert an arterial cannula for ongoing assessment of arterial blood gases (ABGs).

In order to monitor the partial pressures of serum oxygen and carbon dioxide and the acid/base balance, to evaluate the effectiveness of the intervention. E

6 Observe and record the patient’s cardiovascular function, including: a heart rate b blood pressure c temperature d central venous pressure (if patient has a central venous access device).

To obtain a baseline in order to assess any change in conditions (see Chapter 14: Observations). E

7 Assess and record the patient’s fluid balance: a input b output c accumulative balance d overall fluid balance e daily weight.

To obtain a baseline of fluid balance (see Chapter 8: Nutrition and fluid balance). E To enable an assessment of dehydration, fluid overload and renal function (Beitler et al. 2016, E).

8 Assess the patient’s level of anxiety and compliance with treatment (the patient’s ability to cope with the treatment).

To enable an assessment to be made and an evaluation of the suitability of CPAP therapy (Dres and Demoule 2016, E).

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Procedure 9 Set up the CPAP circuit as per the manufacturer’s instructions.

To prepare the equipment for use. E

10 Ensure the patient is comfortable, sitting in a semirecumbent position, ideally with their head elevated to a 30–45° angle (or sitting in a supportive chair).

To promote comfort and aid lung expansion and breathing (Brill 2014, E).

11 Explain to the patient how the mask or helmet is to be applied.

To relieve anxiety and to reassure the patient. E To aid the patient’s compliance with CPAP. E (continued)

THE ROYAL MARSDEN MANUAL OF CLINICAL NURSING PROCEDURES

Procedure guideline 12.3  Continuous positive airway pressure (CPAP) (continued) Action

Rationale

If using a mask 12 Ensure the correct size is selected for the patient by using the manufacturer’s guide or measurement device.

To relieve anxiety and to reassure the patient. E To aid the patient’s compliance with CPAP. E

13 Connect the mask to the circuit and ensure the settings are correct. Commence the flow of gases.

To ensure the correct set-up of the circuit and to check gases are flowing through the circuit prior to initiation of treatment. E

14 Place the mask over the patient’s nose and mouth; applying a little pressure, hold the mask in place, ensuring there are no leaks. Allow the patient a short time to get used to the pressure and mask.

To allow the patient time to adapt to the change in pressure and the feeling of the tight-fitting mask. E

15 Once the patient is comfortable and settled, apply the straps.

To retain the mask in place and aid patient comfort (Vargas et al. 2018, E).

16 Apply tissue protective dressings around vulnerable pressure points as required, e.g. nose, ears, back of head and neck.

To alleviate pressure and prevent tissue breakdown (Scott 2017, E).

If using a helmet 17 Using a two-person technique, stretch the seal around the bottom of the helmet and lower the helmet over the patient’s head.

Two people are usually required to stretch the seal enough to lower the helmet over the patient’s head comfortably. E

18 Attach the straps, ensuring patient comfort.

The helmet will begin to lift once pressure is applied. E

19 Close the safety valve or outlet and allow the pressure to build up within the helmet until the valve remains closed.

The helmet requires time to fill and expand. Once the helmet is full, the pressure within it will keep the valve closed. E

20 Ensure a good seal and that no leaks are present. Inflate the inner neck cuff if applicable.

To ensure a tight seal in order for the system to function optimally (Vargas et al. 2018, E).

Post-procedure 21 Give further explanation to the family or next of kin of how CPAP works and the importance of their presence and participation in communication.

To relieve anxiety and support and reassure the family and patient. E

22 Reassure the patient constantly.

To relieve patient anxiety and promote co-operation. E

23 Discuss with the medical team the use of medication that might aid patient compliance with CPAP therapy and administer it as necessary.

Prophylactic administration of small doses of anxiolytic can aid compliance with CPAP therapy (Hilbert et al. 2015, E).

24 Continue observation of vital signs and work of breathing. If patient is tiring, notify the doctor.

To prevent acute respiratory deterioration and to inform the doctor in a timely manner in order to intubate the patient to avoid a respiratory arrest (Davison et al. 2016, C).

Problem-solving table 12.3  Prevention and resolution (Procedure guideline 12.3)

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Problem

Cause

Prevention

Action

Airway is not maintained

Deteriorating respiratory or neurological function and/or the patient is tiring

Use NEWS2 scoring to identify deterioration early. Insert a nasopharyngeal airway (Figure 12.19).

Regular monitoring of respiratory function including skin colour, breathing pattern, respiratory rate, oxygen saturation and blood gases. Discuss changes with medical or anaesthetic staff.

Aspiration

Inability to maintain own airway

Request speech and language therapy (SLT) assessment.

Observe and assess the patient closely. After discussion with medical staff, a nasogastric tube may be inserted to reduce gastric distension.

Continuous pressure from the CPAP system can lead to insufflation of air into the stomach, causing aspiration

Keep the patient nil by mouth and insert a nasogastric tube.

As above.

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Problem

Cause

Prevention

Action

Mask or helmet incorrectly sealed

Incorrect size of mask or helmet

Use appropriate size of mask or helmet.

Alter mask or helmet position to correct the issue and ensure comfort. Ensure the mask or helmet is the correct size. Alter the position to ensure a correct seal.

Helmet not inflating or patient finding it difficult to breathe with mask

Disconnection of tubing Not connected to piped oxygen

Switch on all audible alarms on equipment. Clarify alarm parameters with medical or senior nursing staff. Keep bed space tidy and free from clutter. If possible, ensure bed space is close to or visible from the nurse station.

Ensure a nurse is present with the patient at all times. Observe the patient and CPAP system closely to ensure the equipment is working optimally and that there is no failure of the system.

Eyes are dry or sore, or patient develops conjunctival oedema (all three issues only apply to face-mask CPAP)

Air leak from mask High-flow oxygen causing the eyes to dry out Facial pressure from mask causing oedema

Protect eyes from drying out. Use correct size of mask or helmet for patient.

Ensure the mask or helmet is well sealed with no leaks. Apply pressure-relieving padding around the mask. Carry out regular eye care (see Chapter 9: Patient comfort and supporting personal hygiene). Adjust the mask to the patient’s facial contours. Alter and position the mask as comfortably as possible. Position padding around the head strap to relieve pressure.

Dry mouth

CPAP system uses a very high oxygen flow, which has a drying effect

Provide adequate oral hydration.

Carry out regular mouth care. Give the patient regular sips of water, ice to suck or drinks (as much as the patient is able to take). Humidify the oxygen if using a face-mask.

Non-compliance with CPAP equipment

Anxiety

Calm, informative communication.

Inform the patient of any changes taking place. Communicate with the patient’s family, keep them informed and involve them in care and communication with the patient. Inform the doctor of the patient’s anxiety level. Administer prescribed anxiolytic agent if required.

Inability to eat

Gastric distension due to CPAP Loss of appetite Distress caused by respiratory status and CPAP Nausea and vomiting

Provide small but regular easily managed (soft) oral diet or supplement drinks.

Encourage dietary intake and oral supplementary fluids. If patient is unable to take these orally, refer to dietitian as an alternative method of feeding may be considered, for example enteral feeding via nasogastric or jejunal tube or intravenous feeding (parenteral nutrition). Administer an antiemetic. Encourage and reassure the patient.

Mask or helmet restriction.

Provide means of non-verbal communication.

Reassure the patient and ensure they are comfortable.

Ask a relative, carer or healthcare assistant to stay with the patient.

Encourage the patient to communicate, and explain how they can use non-verbal means of communicating (e.g. letter board, tablets). Reassure the patient.

Inability to communicate effectively Feelings of isolation

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Figure 12.19  Nasopharyngeal airway and safety pin.

Learning Activity 12.3 Clinical application 1 Assist with the set-up of high-flow nasal oxygen. Ask the patient about the sensation and how comfortable this is. Make a note of the effectiveness of this intervention. 2 Ask whether you can spend some time with a specialist respiratory nurse to observe continuous positive airway ­ pressure (CPAP) and bilevel positive airway pressure (BIPAP) in practice. 3 Find out as much as you can from the clinical experts at your current placement location about how patients requiring non-invasive ventilation (NIV) are nursed and cared for in acute settings. 4 Talk to a patient to learn first hand about their experience of NIV. 5 Write a reflection in your Practice Assessment Document, highlighting points of new learning that you can take forward into your future practice.

Chest drain management POST-PROCEDURAL CONSIDERATIONS

Immediate care

It is important to maintain a high level of monitoring while encouraging the patient to maintain good lung expansion by sitting upright and expectorating as required. CPAP can cause the oral mucosa to dry out with prolonged use, leading to an increased risk of infection, so it is essential that regular mouth care is ­provided. Regular ABG sampling can be used to assess the ­effectiveness of the treatment as well as to guide any changes required to either oxygen concentration or PEEP. As with all patients requiring an increased level of support, an accurate fluid balance chart should be maintained to ensure that fluid overload does not occur (Beitler et al. 2016).

Documentation

Document all the vital signs and monitoring as well as the patient’s response to CPAP or NIV treatment.

Education of the patient and relevant others

It is worth discussing with the patient and their family or carer that intermittent use of CPAP is sometimes beneficial and that  if  it is required again, this does not necessarily indicate deterioration.

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DEFINITION

A chest drain is a length of flexible tubing commonly made from PVC or silicone. Chest drains come in a variety of sizes ranging from 6 to 40 French (Fr) and often incorporate a radio-opaque strip that enables X-ray detection. The proximal end is inserted into the pleura and has a number of holes, which facilitate ­drainage. The distal end is connected to the drainage system (Figure 12.20).

Figure 12.20  A chest drain and underwater seal bottle are used to drain a left pleural effusion. Collapsed left lung Right parietal pleura Left pleural effusion

COMPLICATIONS

With any circuit that includes the use of PEEP, there is the ­possibility of reduction in cardiac output due to an increase in intrathoracic pressure. However, spontaneous ventilation decreases both the incidence and the severity of this complication if patients have had their fluid balance optimized (Cortegiani et al. 2017). There is also a risk of gastric insufflation (blowing of air causing gastric distension), which can lead to vomiting and aspiration, although the risk is minimized when PEEP is used in awake patients or by the insertion of an orogastric or nasogastric tube (Vadde and Pastores 2016). Preventative pressure dressings should be considered in underweight patients or those with bony facial prominences. There should also be regular skin checks to ensure that the tight-fitting face-mask required for CPAP is not compromising the skin integrity of vulnerable areas on the bridge of the nose and over the ears (Scott 2017).

Right visceral pleura

Intrapleural drain Left parietal pleura Mattress suture

Oscillation of water with respiration

Sterile water

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Figure 12.21  The relationship between the pleural ­membranes, chest wall and lungs. Thoracic wall (chest wall) Trachea

Lung Visceral pleura

Pleural cavity Parietal pleura Diaphragm

ANATOMY AND PHYSIOLOGY

Each lung is surrounded by a double membrane called a pleura. The outer membrane is the parietal pleura, which is attached to the thoracic (chest) wall and contains nerve receptors that detect pain. The inner membrane is the visceral pleura, which adheres to the lung and covers the lung fissures, hilar bronchi and blood vessels (Figure 12.21) (Tortora and Derrickson 2017). The pleurae help to maintain the negative pressure required to prevent the lung from collapsing. Before inspiration, the pressure within the pleural space is equal to −5 cmH2O. During inspiration, there is a decrease in intrapleural pressure due to the diaphragm being drawn down and the outward expansion of the chest. The pressure falls to −7.5 cmH2O, which causes air to be drawn in for gaseous exchange. During expiration, the lung returns to its preinspiratory state by elastic recoil, with collapse of the chest wall and diaphragm and the exhalation of gas. The intrapleural pressure subsequently rises to −4 cmH2O (Noorani and AbuOmar  2018). If either of the pleura is damaged, partial or total lung collapse will occur due to loss of the normally negative pressure (Woodrow 2013). The space that exists between the parietal and visceral pleurae is commonly known as the pleural space, pleural cavity or potential space. While approximately 1 to 2 L of serous fluid moves across the thin and porous pleural membranes each day, only 3–5 mL of fluid actually fills the space. The serous fluid allows the pleurae to move in unison with the chest wall on inspiration and enables the membranes to be held closely together by surface tension forces (George and Papagiannopoulos  2016). The amount of fluid present in the pleural space is maintained by the  oncotic and hydrostatic pressures across the pleurae and lymphatic drainage network (Chadwick et al. 2015). Disruption in this balance results in an accumulation of fluid within the pleural space.

RELATED THEORY

Drainage is required for patients who are symptomatic of excess air (pneumothorax) or fluid (pleural effusion) within the pleural space. Chest drains may also be inserted to drain blood (haemothorax), lymph (chylothorax) or pus (empyema), or a combination of air and fluid (Mao et al. 2015).

Pleural effusion

The mechanisms by which pleural effusions develop are c­ omplex, but they generally occur when the rate of filtration ­overwhelms

Box 12.2  Causes of transudative and exudative pleural effusions Transudative pleural effusion • Left ventricular failure • Liver cirrhosis • Nephrotic syndrome • Peritoneal dialysis or continuous ambulatory peritoneal dialysis • Hypoproteinaemia (e.g. severe starvation) • Hypothyroidism • Mitral stenosis Causes of exudative pleural effusion • Malignant disease • Infectious diseases, including tuberculosis • Parapneumonic effusions • Pulmonary embolism • Pancreatitis • Collagen vascular diseases: rheumatoid arthritis, systemic lupus erythematosus, benign asbestos effusion • Drug-induced primary pleural disease: nitrofurantoin, amiodarone, procarbazine, methotrexate, bleomycin, metronidazole, phenytoin or beta blockers • Injury after cardiac surgery, pacemaker implantation, myocardial infarction, blunt chest trauma or angioplasty Source: Adapted from Na (2014), Saguil et al. (2014).

the rate of lymphatic clearance resulting in an excessive amount of fluid in the pleural space (Chadwick et al. 2015). Pleural effusions are classified as either transudative or exudative. A transudative pleural effusion occurs when the balance of hydrostatic forces influencing the formation and absorption of pleural fluid is altered to favour pleural fluid accumulation. The permeability of the capillaries to proteins is normal. In contrast, an exudative pleural effusion develops when the pleural surface and/or the local capillary permeability are altered. There are many causes of transudative and exudative effusions, as outlined in Box 12.2. Pleural effusion develops in nearly half of all patients with metastatic disease. The most common cancers that cause malignant pleural effusions are adenocarcinomas; other carcinomas of the lung, breast and ovaries; and lymphoma (Egan et al. 2014). Patients with pleural effusion usually present with a number of symptoms and signs (Na  2014, Saguil et  al.  2014). Symptoms include the following: • dyspnoea • chest pain (may be mild or severe and is often worse on deep inspiration; it is typically described as a sharp or stabbing pain) • cough (usually dry and unproductive). Signs include the following: • unequal chest expansion • tracheal deviation may be seen with a very large pleural effusion • decreased tactile and vocal fremitus • dull to percussion • diminished air entry on auscultation.

Pneumothorax

Pneumothorax can be defined as air in the pleural cavity that causes the lung to collapse due to a loss in negative pressure (Tschopp et al. 2015). A pneumothorax occurs as the result of the processes described in Table 12.7. Pneumothoraces can therefore be classified as iatrogenic, traumatic, primary spontaneous and secondary spontaneous (Tschopp et al. 2015).

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Table 12.7  Causes of pneumothorax Cause

Notes

Breach of the integrity of either pleural layer, causing direct or indirect communication between the atmosphere and the pleural space

Many procedures performed in an intensive care or emergency setting can result in an iatrogenic pneumothorax. Examples of these procedures include incorrect chest tube insertion, mechanical ventilation therapy, central venous catheterization, cardiopulmonary resuscitation, lung or liver biopsy, or surgery. A blunt or penetrating trauma to the chest wall, diaphragm or bowel may cause a traumatic pneumothorax.

Communication between the alveolar spaces and the pleura

This can occur spontaneously and is most common in tall, thin males (primary spontaneous pneumothorax). It can also occur secondarily to underlying lung conditions such as asthma, chronic bronchitis, tuberculosis, pneumonia, cystic fibrosis or carcinoma of the lung (secondary spontaneous pneumothorax).

Gas-producing organisms in the pleural space

Micro-organisms that produce gas will cause an increase in the amount of air within the pleura and subsequent pneumothorax.

Source: Adapted from Cardillo et al. (2016), Hassan and Shaarawy (2018).

Box 12.3  Signs and symptoms of pneumothorax and tension pneumothorax Symptoms of a pneumothorax

Signs of a pneumothorax

• Dyspnoea • Acute pleuritic chest pain • Shoulder tip pain • Restlessness, anxiety

• Tachypnoea • Tachycardia • Subcutaneous emphysema • Decreased tactile and vocal fremitus • Hyper-resonance on percussion • Absent or diminished breath sounds

Signs and symptoms of a tension pneumothorax (in addition to those listed above) • Acute respiratory distress • Hypoxia • Hypotension • Tracheal deviation away from the affected side • Asymmetrical chest expansion • Engorged neck veins • Reduced breath sounds Source: Adapted from Cardillo et al. (2016), Tschopp et al. (2015).

The symptoms of a pneumothorax are proportional to its size and depend on the degree of pulmonary reserve. Common signs and symptoms are listed in Box 12.3.

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Tension pneumothorax

A tension pneumothorax is the complete collapse of a lung as the intrapleural pressure becomes greater than the atmospheric pressure during both inspiration and expiration (Tschopp et al. 2015). A breach in the pleura creates a one-way valve, which allows air to progressively accumulate within the pleural space with each inspiration (Woodrow 2013). As the amount of air in the pleural space increases, the lung becomes compressed, the mediastinum shifts and venous return to the heart decreases, causing cardiac arrest (Woodrow  2013). A tension pneumothorax is therefore a life-­ threatening emergency that requires immediate treatment (RCUK 2015). Diagnosis of a simple pneumothorax can be confirmed on a chest X-ray, which should be taken during inspiration (MacDuff et  al.  2010). However, diagnosis of a tension pneumothorax is based on clinical history and examination alone. It is a medical emergency and should be treated urgently without the need for diagnostic imaging. Ultrasound can be performed at the bedside so

long as it does not delay treatment (MacDuff et al. 2010, RCUK 2015). Supportive therapy should be given until needle decompression or chest drain insertion is performed. This may include sitting the patient upright and giving oxygen therapy to maintain saturations between 94% and 98% (O’Driscoll et al. 2017, Woodrow 2013).

Haemothorax

Haemothorax is a collection of blood within the pleural space, usually as a result of injury to the heart, lungs or major vessels within the thoracic cavity, or in a patient who has bled on anticoagulation therapy (Patrini et al. 2015).

Haemopneumothorax

Haemothorax may also be associated with pneumothorax, in which case it is called ‘haemopneumothorax’. Depending on the amount of blood or air in the pleural cavity, a collapsed lung can lead to respiratory and haemodynamic compromise (Patrini et al. 2015).

Empyema

Empyema is defined as pus in the pleural space. It may occur following rupture of an abscess within the lung, pneumonia, ­ ­pulmonary tuberculosis or an infection following thoracic surgery (McCauley and Dean 2015).

Chylothorax

Chylothorax is a collection of lymphatic fluid within the pleural space, usually resulting from disruption of the thoracic duct or its tributaries (Alamdari et al. 2018). The fluid is usually milky and contains a high level of triglycerides (>110 mg/dL), an essential feature for its diagnosis (Bender et al. 2016). Chylothorax can be split into traumatic (thoracic surgery or penetrating trauma) and non-traumatic/spontaneous (congenital, neoplastic, infectious or obstructive) classifications (Bender et al. 2016).

Chest drain: insertion EVIDENCE-BASED APPROACHES

Management of excess fluid or air within the pleural space is dependent on the size and complexity of the effusion or pneumothorax, the patient’s symptoms and the presence of any underlying disease (Tschopp et al. 2015). Fine needle aspiration using a needle and syringe is recommended by the British Thoracic Society for primary spontaneous pneumothoraces or small freeflowing effusions (Davies et al. 2010, Hassan and Shaarawy 2018, MacDuff et al. 2010) and this would be carried out by an appropriately trained clinician. Chest drain insertion is recommended for patients with secondary spontaneous pneumothoraces, failed fine needle aspiration for primary spontaneous pneumothoraces, malignant effusions, or complicated accumulations of fluid that are causing the patient to be symptomatic (Davies et  al.  2010, MacDuff et  al.  2010, Mahmood and Wahidi  2013); this would

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again be carried out by an appropriately trained clinician with the assistance of a nurse. While both are common procedures, they are not without risk. Chest drain insertion should be carried out in a clean area using a strict aseptic technique and with adequate monitoring available (Adlakha et al. 2016, Havelock et al. 2010). The sections below relate to chest drain insertion; needle aspiration would only be carried out by a doctor or highly trained nurse and is beyond the scope of this manual.

Rationale

Ventilation and the normal mechanics of breathing become compromised as the abnormal collection of fluid or air compresses the lung, or as the negative pressure within the chest cavity is altered, causing partial or complete collapse of the affected lung (Tschopp et al. 2015). Needle aspiration and chest drain insertion are methods used to remove the collection of air, serous fluid, pus, lymph or blood from the pleural space, restoring the negative pressure within the chest cavity and allowing the lung to reexpand (Noorani and Abu-Omar 2018).

Indications

Chest drain insertion is indicated in the following circumstances (Noorani and Abu-Omar  2018, Porcel  2018a, Yousuf and Rahman 2018): • pneumothorax • pleural effusion • empyema • traumatic haemopneumothorax • chylothorax • post-operatively following thoracotomy, oesophagectomy or cardiac surgery • bronchopleural fistula.

Contraindications

No contraindications exist for a patient with a tension pneumothorax (MacDuff et  al.  2010). The risks and benefits should be weighed up for all other patients, and expert advice and guidance sought if required. The procedure should be carried out by a healthcare professional with extensive and relevant ultrasound skills (Havelock et al. 2010). Depending on the nature of the problem (e.g. a loculated pleural effusion), it may be preferential for the procedure to be carried out by an experienced radiologist. Absolute contraindications

Chest drain insertion is absolutely contraindicated if the patient does not consent to the procedure and they are not at risk of imminent cardiac arrest. Relative contraindications

Chest drain insertion has the following relative contraindications (Havelock et al. 2010, Porcel 2018b, Ravi and McKnight 2018): • abnormal blood clotting screen or low platelet count; it is good practice to correct any coagulopathy or thrombocytopenia prior to chest drain insertion; ideally, international normalized ratio (INR) should be less than or equal to 1.5 and platelets above 50 × 109/L • differential diagnosis between pneumothorax and bullous lung disease needs to be investigated • any previous surgery involving the thoracic cavity on the side of the proposed intervention • diaphragmatic hernia • localized skin infection, or cutaneous metastatic cancerous deposits at the site of the drain insertion.

Principles of care

The following principles should be adhered to (Havelock et al. 2010, Porcel 2018b, Woodrow 2013): • Maintain sterility of the chest drainage system and avoid introduction of bacteria into the pleural space.

• Maintain a negative intrapleural pressure by keeping the system patent and airtight. • Keep the system upright and below chest level, and prevent water and/or pleural fluid re-entering the pleural space. • Drain the fluid slowly and prevent pain and/or re-expansion pulmonary oedema. • Monitor the patient’s observations/NEWS2 and pain score, and escalate any change or concerns regarding the patient’s condition. • Monitor the drain for swinging, bubbling, and the amount and type of fluid drained. • Remove the drain as soon as it has reached the predefined therapeutic goal, or when it has become non-functioning.

CLINICAL GOVERNANCE

Pleural aspiration and chest drain insertion should only be inserted by healthcare professionals who have had relevant training and are deemed competent, or who have adequate supervision by an experienced clinician (Havelock et al. 2010). The use of ultrasound guidance is advocated when performing pleural aspiration or inserting a chest drain to prevent injury to adjacent organs. Practitioners must be competent in the use of the ultrasound equipment (Adlakha et al. 2016, Havelock et al. 2010). It is also advisable that there should be a clinical lead identified for the training of all staff involved in chest drain insertion. Clinical policies regarding chest drain insertion and management should be implemented and followed by both medical and nursing staff. Incidents regarding chest drain insertion and management should be reported to risk management teams, and processes should be reviewed regularly.

Consent

Prior to commencing chest tube insertion, the procedure should be explained fully to the patient and written consent gained and recorded in accordance with national guidelines (Havelock et al. 2010). The General Medical Council guidelines for consent state that it is the responsibility of the doctor carrying out a procedure, or an appropriately trained individual with sufficient knowledge of the procedure, to explain its nature and the risks associated with it. The exception to this is during an emergency when chest drain insertion is indicated to prevent further clinical deterioration and cardiac arrest. In this scenario, verbal consent should be gained if possible and documented (GMC  2008). Associated risks include visceral injury, pneumothorax, pain, haemorrhage, infection, drain blockage, drain dislodgment and procedure failure (Havelock et al. 2010, Yousuf and Rahman 2018).

Competencies

All staff caring for patients undergoing chest drain insertion and those managing a patient with an exisiting chest drain should have undertaken the relevant local training and be deemed competent. The basis of these competencies should include the following (Mallet et al. 2013): • knowledge of the indications for chest drain insertion • knowledge of the potential complications regarding insertion and having a chest drain in situ • knowledge of how to manage any potential complications • familiarity with the equipment and the ability to set it up for insertion, change the chest drain bottle while in situ, and remove the drain effectively and safely.

PRE-PROCEDURAL CONSIDERATIONS

Equipment Drain size

In the past, the use of a large-bore chest drain (>14 Fr) (Figure 12.22) was recommended to prevent blockage of the drain by viscous malignant or infected fluid. Although there is currently no consensus on the optimal chest drain size, the British Thoracic

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Figure 12.22  Large-bore chest drain.

Figure 12.24  Underwater chest drainage system.

Figure 12.23  (a) Pigtail drain with (b) magnification of the end.

(a)

(b)

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Society advocates the use of small, flexible catheters (10–14 Fr) for the drainage of most simple effusions and pneumothoraces, and recommends that they are inserted using the Seldinger technique (Mahmood and Wahidi  2013, Porcel  2018b). Small-bore drains may be straight, angled or coiled at the end (pigtail; Figure 12.23). Pigtail drains have the advantage of a thread that, when pulled, creates the pigtail effect to hold the drain firmly in place. Small-bore drains can easily be flushed to prevent blockage, have fewer complication rates, and are generally more comfortable and tolerable for patients (Mahmood and Wahidi 2013). Large-bore chest drains (≥20 Fr) may be inserted for ongoing air leaks, pneumothoraces caused by mechanical ventilation, haemothoraces and post-operative drainage of the chest cavity (Porcel 2018a). Drains larger than 24 Fr should be inserted using a blunt dissection technique. Trocars should no longer be used as they are associated with high complication rates and leave patients with an unsightly scar (Havelock et al. 2010).

Drainage systems

There is a wide variety of drainage systems available to drain effusions or pneumothoraces; however, the single-bottle, underwaterseal drainage system can be used for the majority of situations (Figure  12.24). The underwater seal occurs when the screw-top lid is removed and sterile water is poured into the chest drain bottle up to the fluid line. The long length of tubing supplied in the pack is attached to the distal end of the chest drain, and the other end is inserted into the screw-top port and immersed 2–3 cm below the level of the water (Havelock et al. 2010).

There is a second port, which acts as a venting aid and is either exposed to air or attached to a suction unit. Venting prevents the build-up of pressure in the chest drainage system and aids evacuation of air or fluid from the lungs. The underwater seal maintains the negative intrapleural pressure and acts as a one-way valve, preventing the backflow of air into the pleural space (George and Papagiannopoulos 2016). Other multi-chamber or digital drainage systems may also be used. The three-chamber system consists of a collection chamber, a water-seal chamber and a suction chamber, all of which are interconnected. Suction can be applied to assist in the management of an ongoing air leak. Digital systems are able to monitor for air leaks and can maintain and adjust the negative pressure accordingly without the use of external suction (Porcel  2018a). Manufacturers’ instructions should be followed to guide set-up and aid maintenance of the system. A dry drainage system that incorporates a one-way Heimlich valve can also be used to facilitate early discharge home in ambulatory patients (Woodrow 2013). The ambulatory bag (Figure 12.25) must be primed prior to use to ensure that the Heimlich valve is working. This can be done by flushing air through the valve using a 50 mL syringe and inspecting for slight bag inflation.

Pharmacological support

Surrounding tissue and nerve fibres are damaged during chest drain insertion, which may cause the patient significant pain throughout and after the procedure. Supportive treatment in the form of oxygen and analgesia should therefore be given before and after drain insertion, and prior to drain removal. Unless contraindicated, opioid analgesia should be prescribed and administered to ensure the patient is able to tolerate the drain and subsequent drainage of fluid, and also to allow them to breathe deeply and cough effectively (Noorani and Abu-Omar 2018, Woodrow 2013).

Specific patient preparation

The patient’s baseline observations and NEWS2 score must be recorded prior to the procedure. A chest X-ray should be performed and reviewed by the practitioner to confirm the site of the pneumothorax or effusion to be drained. CT (computed tomography) imaging may also be required for uncertain or complex cases (Davies et al. 2010, Hooper et al. 2010). The exception to this is for patients who have signs and symptoms of a tension pneumothorax when immediate needle decompression or chest drain insertion is required (MacDuff et  al.  2010). The British

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Thoracic Society strongly advocates the use of ultrasound guidance during chest drain placement (Havelock et al. 2010). To minimize the risk of bleeding, patients should temporarily stop their usual anticoagulation therapy, and drain insertion

Figure 12.25  Ambulatory chest drain bag with Heimlich valve.

should be delayed until their INR is below 1.5 (Havelock et al. 2010, Porcel 2018b). Platelet and coagulation abnormalities should be corrected as per local policy or as advised by a haematologist. Chest drains are usually inserted in an area known as the ‘triangle of safety’ (Figure 12.26). This is the triangle outlined by the anterior border of the latissimus dorsi, the lateral border of the pectoralis major, a line superior to the horizontal level of  the nipple, and an apex below the axilla. Drains may be placed outside this area under ultrasound or radiology guidance (Mahmood and Wahidi  2013). Depending on the area for ­insertion, patients may be placed in a supine, 45° position with the arm on the affected side abducted, externally rotated

Figure 12.26  Triangle of safety. Source: Laws et al. (2003). Reproduced with permission of BMJ Publishing Group, Ltd.

Triangle of safety

Figure 12.27  Alternative positions for chest drain insertion. (a) Supine on the bed with the arm on the affected side placed behind the head away from the chest wall or abducted to 90°. (b) Resting over an adjacent table supported by a pillow in front. (c) On the side with the lung to be drained uppermost.

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(b)

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and placed behind their head (Figure  12.27a). Alternatively, patients may sit upright on the side of the bed leaning over an adjacent table, with arms resting on a pillow in front of them (Figure  12.27b), or lie on their side (Figure  12.27c) (Adlakha et al. 2016).

Education

Nurses caring for patients with chest drains must be familiar with their management and keep up to date with current guidelines, local policies and protocols (Havelock et  al.  2010, Noorani and Abu-Omar 2018).

Procedure guideline 12.4  Chest drain: assisting insertion For the purpose of this chapter, only the procedure for inserting small-bore chest drains using the Seldinger technique shall be discussed. Only trained and competent personnel should carry out the procedure; however, nurses should be familiar with the process as they are often required to assist. Essential equipment Some of the equipment below may be available in kit form. • Personal protective equipment, including sterile gloves, gown, mask and hat • Portable ultrasound machine, sterile ultrasound jelly and sterile ultrasound probe cover • Sterile chest drain pack containing gallipot, disposable towel and forceps • Skin antiseptic solution, for example 2% alcoholic chlorhexidine • Ideally a split fenestrated sterile drape design with a large clear plastic window surrounding the aseptic field to allow optimal views of the hemithorax • Sterile gauze swabs • A selection of syringes (5, 10 and 20 mL) and safety needles (21–25 G) • Local anaesthetic • Scalpel and blade • Suture (e.g. Mersilk 2.0 or 3.0) • Instrument for blunt dissection (e.g. curved clamp) • Guidewire with dilators (in most Seldinger drain packs) • Chest drain • Connecting tubing • Closed drainage system (including 500 mL sterile water if underwater seal bottle is being used) • Occlusive dressing • Chest drain clamps × 2 Medicinal products • Local anaesthetic, such as lidocaine 1% (up to 3 mg/kg), is usually infiltrated. In addition, epinephrine may be used to aid homeostasis and allow larger doses of lidocaine to be administered. Levobupivacaine 0.25% may also be used to prolong post-procedure anaesthesia. • Conscious sedation may be considered for certain patients if it is unlikely that they will be able to tolerate the procedure with oral analgesia and local anaesthetic alone. Titrated doses of intravenous midazolam and opioid analgesia may be given by practitioners experienced in conscious sedation to achieve the desired effect. The aim is for the patient to be able to tolerate the procedure but remain conscious throughout. Practitioners should be trained in immediate life support and ideally have airway skills. Patients must be appropriately monitored throughout the procedure and drug-reversal agents (flumazenil and naloxone) should be readily available in case required (Academy of Medical Royal Colleges 2013, American Society of Anesthesiologists 2018, Havelock et al. 2010). Action

Rationale

Pre-procedure 570

1 Introduce yourself to the patient, explain and discuss the procedure with them, and ensure the operator has gained their consent to proceed (if the patient is conscious and able to consent).

To ensure that the patient feels at ease, understands the procedure and gives their valid consent (NMC 2018, C).

2 Decontaminate hands.

To minimize the risk of healthcare-associated infection (NHS England and NHSI 2019, C).

3 Ensure the patient has intravenous access that is patent.

For patient safety in the event of an acute deterioration (Yousuf and Rahman 2018, C).

4 Administer analgesia at least half an hour before the procedure.

To minimize pain during the procedure and to ensure the patient is able to co-operate (Noorani and Abu-Omar 2018, C).

5 Clean and prepare a trolley, placing the equipment on the bottom shelf.

To ensure the trolley is clean and all equipment required is available. E

6 Prime the underwater seal drainage bottle with sterile water and fill to the fluid line.

To create negative pressure and prevent the backflow of fluid or air into the pleural space (Woodrow 2013, C).

7 Decontaminate hands with an alcohol-based handrub again.

To minimize the risk of infection (NHS England and NHSI 2019, C).

CHAPTER 12 Respiratory care, CPR and blood transfusion

8 Assist the operator by opening up packs/equipment as instructed, maintaining a sterile environment throughout.

To minimize the risk of infection. E

9 Assist the operator to scan the chest using real-time ultrasound.

To confirm the side of the effusion or pneumothorax (Yousuf and Rahman 2018, C).

10 Position the patient in preparation for the procedure. The patient may be positioned supine on the bed with the arm on the affected side placed behind their head away from the chest wall, or abducted to 90° (see Figures 12.26 and 12.27a). Alternatively, position the patient on their side with the lung to be drained uppermost (see Figure 12.27c). If the patient is able to sit upright, they can be positioned resting over an adjacent table supported by a pillow in front (see Figure 12.27b).

To facilitate insertion of the chest drain and prevent injury to adjacent organs (Adlakha et al. 2016, C). To ensure optimal patient comfort. E

Procedure 11 Assist the practitioner as requested.

To ensure the procedure is carried out as smoothly and quickly as possible. E

12 Observe the patient throughout the procedure, paying attention to their respiratory and cardiovascular status. Monitor the patient’s respiratory rate and pattern, movement of the chest wall, oxygen saturations, colour, blood pressure and heart rate. Inform the practitioner inserting the drain of any concerns or change in the patient’s condition.

To monitor for signs of acute deterioration and complications associated with the procedure (Woodrow 2013, C).

13 Communicate with the patient during the procedure and explain what is happening at each stage.

To minimize anxiety (Woodrow 2013, C).

During the procedure Using a sterile procedure throughout, the practitioner prepares the skin using a cleansing solution before infiltrating the surrounding area with local anaesthetic. Using ultrasound guidance, the drain is inserted into the pleural space using a Seldinger technique. Prior to unclamping the drain, the distal end is attached to the drainage system (tubing, bottle and sterile water) and the proximal end is secured to the skin and subcutaneous tissue using an anchor suture. For large-bore drains, a mattress suture may also be required (see Figure 12.28). The drain site should be cleaned and dressed using a specifically designed adhesive-dressing-based fixation system, or covered with gauze and an occlusive dressing. The drain can then be unclamped (Havelock et al. 2010, Woodrow 2013).

Post-procedure 14 Check the drain is well secured at the exit site using an anchor suture and occlusive dry dressing.

To prevent accidental disconnection or removal of the drain (Havelock et al. 2010, C; Jeffries 2017, C).

15 Check the whole drainage system and ensure all connections are secure. Tape the connection between the chest drain and tubing with an H-shaped dressing (see Figure 12.30).

To secure the connection and prevent accidental disconnection. E To ensure there are no leaks that will prevent re-expansion of the lung, or accidental introduction of a pneumothorax (Woodrow 2013, C).

16 Assist the patient into a comfortable position in bed, ensuring the drain and tubing are not occluded or kinked.

To optimize patient comfort and ensure the system is not occluded or kinked, which would prevent drainage (Woodrow 2013, C).

17 Check the patient’s observations/NEWS2 score and document.

To observe for any change or deterioration in the patient’s condition (RCP 2017, C).

18 Give further analgesia if required.

To ensure patient comfort (Woodrow 2013, C).

19 Monitor for bubbling in the chest drain bottle. Report any unexpected bubbling immediately to the practitioner who inserted the drain, or a senior member of staff.

Bubbling is to be expected with a pneumothorax but should not be present with a pleural effusion (Woodrow 2013, C). Bubbling may indicate an air leak or introduction of a pneumothorax and should be urgently investigated (Woodrow 2013, C).

20 Record either the presence or absence of bubbling on the chest drain observation chart. Inform medical or surgical staff when the bubbling ceases.

To keep an accurate record of the status of the chest drain (Woodrow 2013, C). A chest drain inserted for drainage of a pneumothorax will stop bubbling once all the excess air has been dispensed and the lung has reinflated (Porcel 2018b, C).

21 Do not clamp a bubbling chest drain.

Clamping a bubbling chest drain could cause a life-threatening tension pneumothorax (Porcel 2018b, C).

(continued)

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Procedure guideline 12.4  Chest drain: assisting insertion (continued)

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Action

Rationale

22 Monitor for swinging of fluid in the tubing and record its presence or absence on the chest drain observation chart.

To keep an accurate record of the status of the chest drain (Woodrow 2013, C). The absence of fluid swinging within the tube may indicate a blocked drain (Chadwick et al. 2015, C).

23 Monitor the amount and appearance of any fluid drained and record this on the chest drain observation chart.

To keep an accurate record of the status of the chest drain, and the amount and type of fluid drained (Woodrow 2013, C).

24 If the drain has been inserted to drain fluid, allow a maximum of 1.5 L of fluid to be drained in the first hour then clamp. It may be advisable to drain smaller volumes, especially if the patient is petite or frail. Stop draining if the patient begins to cough, complains of chest pain or has vasovagal symptoms.

To prevent re-expansion pulmonary oedema (Havelock et al. 2010, C).

25 Dispose of waste appropriately.

To reduce the risk of sharps injury and cross-infection (NICE 2017, C).

26 Educate the patient on the need to keep the drainage bottle upright and below chest level, and to avoid any pulling of the drain.

To prevent drained fluid re-entering the pleural space, or any accidental disconnection or removal of the chest drain (Woodrow 2013, C).

27 Advise the patient to report any concerns or change in breathing.

To detect any change or deterioration in the patient’s condition early. E

28 Record chest drain status and patient observations/NEWS2 score 5 minutes and 1 hour after drain insertion, then to a minimum of 4-hourly thereafter. Repeat observations before and after drainage.

To detect any change or deterioration in the patient’s condition and ensure timely escalation to senior staff if required (RCP 2017, C).

29 Escort the patient to radiology for a post-drain insertion chest X-ray.

To rule out any post-procedural complications and observe the position of the drain (Porcel 2018b, C).

30 Cleanse hands with an alcohol-based handrub.

To minimize the risk of cross-infection (NHS England and NHSI 2019, C).

POST-PROCEDURAL CONSIDERATIONS

Table 12.8  Chest drain observations

Immediate care

Observation Detail

The nurse should monitor the patient’s observations and NEWS2 score immediately after insertion to check for any signs of respiratory or cardiovascular compromise. The patient should also be observed for changes in their breathing pattern or increasing shortness of breath (Woodrow 2013). Any change in condition or deterioration in the patient’s observations or NEWS2 score warrants immediate escalation and review by a senior member of staff (RCP 2017). This may include the practitioner who inserted the chest drain or members of the clinical team. Radiological imaging (chest X-ray) should be performed to determine where the drain is placed and the status of the pneumothorax or effusion (Porcel  2018b). The drain should be monitored for the features outlined in Table 12.8, and the monitoring should be documented on the relevant chart. As described in Table  12.8, ongoing bubbling indicates the presence of an air leak, which should be investigated immediately (Woodrow 2013). The drain and tube should be inspected thoroughly down to the level of the underwater seal to eliminate any external problems such as loose tubing connections, poor seal around the drain insertion site or tube migration outside the chest wall. If no loose connections are found, a chest X-ray or CT scan will be required to determine the position of the chest drain and rule out a pleural tear (Havelock et  al.  2010, Porcel  2018b). Depending on the cause of the leak, the chest drain may need to be removed and another reinserted. An on­­ going air leak may also warrant low-pressure thoracic suction (see Procedure guideline  12.5: Chest drainage: suction). See Problem-solving table 12.4 for further guidance on the prevention and recommended actions for problems associated with a chest drain.

Bubbling

Indicates air is still present in the pleural space. Bubbling should decrease and eventually stop as the pneumothorax resolves and the lung reinflates. If bubbling continues, an air leak may be present. Causes of air leaks include: • un-resolving pneumothorax • an eyelet on the drain may be outside the chest wall, allowing air to be drawn into the system on inspiration • inadequate drain size inserted • disconnection at the connection site between the drain and tubing • poor seal around the entry site to the lung • pleural tear. Note: a bubbling chest drain should never be clamped (even during intra-hospital transfer to the radiology department, for example).

Swinging

Indicates the drain is patent and sitting within the pleural space. If swinging is absent, this may indicate that the drain is blocked, kinked or sitting up against the pleural wall.

Draining

Drainage will not occur if the drain is inserted for a pneumothorax. If the drain stops draining a pleural effusion, it may either require removal or indicate that the drain is blocked and requires flushing.

Source: Adapted from Chadwick et al. (2015), Havelock et al. (2010), Mohammed (2015), Porcel (2018b), Woodrow (2013).

CHAPTER 12 Respiratory care, CPR and blood transfusion

Figure 12.28  Mattress suture.

Dressing the insertion site

If a specifically designed adhesive fixation dressing is not avail­ able, a simple dry dressing (low-linting gauze) may be applied around the drain and secured with adhesive tape or an occlusive dressing. Strapping should be avoided as it can restrict chest movement. The dressing should be kept dry and clean, and changed daily or as required. The skin around the drain site should be inspected daily to ensure it is clean, dry, and free from maceration and infection (Havelock et al. 2010, Jeffries 2017).

Ongoing care Clamping of chest drains Pneumothorax

Figure 12.29  Omental tag.

A bubbling chest drain should never be clamped, as clamping will prevent air leaving the pleural space, which has the potential to cause a tension pneumothorax (Woodrow  2013). The drain should remain unclamped even when patients are mobilizing or being transported to other departments within the hospital. The only time a bubbling chest drain should be momentarily clamped is in the event of accidental disconnection, if there is damage to the drainage bottle or to locate a leak in the drainage system (Mohammed 2015, Woodrow 2013).

Learning Activity 12.4

Figure 12.30  H-shaped securing tape.

Securing the drain

Purse-string sutures are no longer advised due to the skin trauma and unsightly scar that they cause. A mattress suture (Figure 12.28) is preferred as it offers a more natural closure once the drain is removed and ultimately less scarring. It is recommended that all drains, regardless of size, should have an anchor suture inserted to prevent them pulling and falling out (Havelock et al. 2010, Porcel 2018b). The drain may also be secured to the surrounding skin with a specifically designed adhesive fixation dressing or an omental tag (Figure 12.29) (Havelock et al. 2010). The drains and connections should be checked to ensure that they are secure and the drain tubing is not kinked or looped. An ‘H’ dressing (Figure  12.30) should be applied to re-enforce the connection between the drain and the tubing while allowing the connection to be visualized at regular intervals.

Learning into practice Mr Jimmy Jones is 23 years old and has been admitted to your ward for observation following a fall while rock climbing. A computed tomography (CT) scan indicates that he has fractured five ribs on his left-hand side. You have just carried out some observations on Jimmy and note that his heart rate is 110 beats per minute, his respiration rate has increased from 24 to 33 per minute and his oxygen saturation has dropped from 98% to 94%. He is breathing shallowly. You note that Jimmy has become a little agitated and is complaining of increasing pain in his shoulder-tip area. You report all this information as a matter of urgency to the medical team: investigations are ordered. A pneumothorax is diagnosed, and a chest drain is to be inserted. Answer the following questions: 1 Is insertion of a chest drain a clean or aseptic procedure? 2 What position should Jimmy be in for the procedure? 3 Before the procedure starts, what should you do? 4 How far in advance of the procedure should opioid analgesia be given? Choose an option. A 5 minutes B 10 minutes C 15 minutes D 30 minutes E 60 minutes 5 What kind of fluid is placed into the drainage bottle? 6 What would your role be during the procedure? 7 Afterwards, what specific observations and actions would be required? See the answers on the companion site of this student ­edition: www.royalmarsdenmanual.com/student10e.

Pleural effusion

Drainage of a pleural effusion should be controlled by clamping the chest drain intermittently. Davies et  al. (2010) recommend draining off a maximum of 1500 mL in the first hour after insertion, then 1500 mL every 2 hours thereafter. Draining large ­volumes

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Figure 12.31  High-volume, low-pressure suction unit (thoracic suction adaptor).

Thoracic suction may be indicated for this group of patients (Tschopp et al. 2015). If indicated, appropriately trained staff should set up the system and advice should be sought from a specialist if required. The addition of suction to the drainage system increases the negative pressure, enhancing lung re-expansion. A high-volume, low-­ pressure thoracic suction unit (Figure 12.31) should be applied to a single-chamber chest-drain bottle, using pressure in the range of 10–20 cmH2O (1–2 kPa) (Havelock et al. 2010, Zisis et al. 2015). Suction should be applied and the pressure increased gradually to prevent lung tear (George and Papagiannopoulos 2016). When the tubing is attached to the suction port of the chest drain bottle, the suction must remain on at all times. However, the suction tubing can be disconnected from the port to allow the patient to mobilize away from the bed space. Once suction has been discontinued, the tubing must be disconnected from the port before the suction is turned off. Turning off the suction and leaving the tubing attached to the port of the underwater-seal chest-drain bottle could potentially cause a tension pneumo­ thorax (Havelock et al. 2010). Most suction units are fitted with a disposable air filter capsule between the vacuum connector and the filter capsule mount. The filter prevents cross-infection and should be changed after use in each patient. Direct connection between the chest drain bottle and the high-flow, low-pressure suction unit without an Figure 12.32  Chest drain on suction.

574

may cause re-expansion pulmonary oedema as the lung rapidly re-expands. It may therefore be advisable to drain off smaller volumes (500 to 1000 mL), especially if the patient is petite or frail. Drainage can either be slowed down or clamped temporarily if the patient experiences pain, starts coughing, experiences vasovagal symptoms or has a drop in blood pressure. Coughing usually subsides within 15 minutes, analgesia can be administered to help with pain, and an IV fluid bolus can be given if the patient becomes haemodynamically unstable. The chest drain should be unclamped in the event of an acute clinical ­deterioration (Havelock et al. 2010) and expert help sought immediately.

Stripping and milking of chest drains

Stripping and milking of chest tubes to keep tubing patent increases the negative pressure in the intrathoracic cavity to −100 to −400 cmH2O. Such an increase in negative pressure may harm lung tissue; therefore, milking or stripping of chest tubes on a routine basis should be avoided (Mohammed  2015). If a chest drain becomes blocked, the tubing should be flushed or replaced.

Chest drain: suction EVIDENCE-BASED APPROACHES

The evidence for connecting low-pressure thoracic suction to an underwater-seal chest-drain bottle to assist in the management of a pneumothorax is controversial, despite the widespread use of this technique in clinical practice (Havelock et  al.  2010). While 70% of pneumothoraces resolve within 3 days after chest drain insertion, up to 30% continue to have an ongoing air leak.

CHAPTER 12 Respiratory care, CPR and blood transfusion

i­ ntermediate suction jar or canister can lead to patient injury, loss of effective suction, and contamination of the hospital vacuum system, posing an infection control risk. An intermediate suction canister must therefore be attached between the thoracic suction unit and the underwater-seal chest-drain bottle to prevent contamination of the thoracic suction unit filter (MHRA  2010) (Figure 12.32).

While ambulatory chest drainage bags with a built-in Heimlich valve cannot be attached to suction, ambulatory digital chest drainage systems monitor the negative pressure within the t­horacic space and adjust the suction pressure accordingly. Multi-chamber chest drain bottles have a built-in suction control compartment that is controlled by either an underwater seal or external suction. The manufacturer’s instructions must be followed.

Procedure guideline 12.5  Chest drainage: suction Essential equipment • Personal protective equipment • Thoracic high-volume, low-pressure suction unit (see Figure 12.31) • Two lengths of suction tubing measuring 1–2 metres each • Suction canister • Portable suction unit to be kept at the patient’s bedside in the event of clinical deterioration and need for emergency/ resuscitation equipment (if only one suction port available) Action

Rationale

Pre-procedure 1 Introduce yourself to the patient, explain and discuss the procedure with them, and gain their consent to proceed.

To ensure that the patient feels at ease, understands the procedure and gives their valid consent (NMC 2018, C).

2 Cleanse hands with an alcohol-based handrub.

To minimize the risk of infection (NHS England and NHSI 2019, C).

Procedure 3 Remove the usual high-pressure suction unit from the wall suction outlet. Insert the specifically designed highvolume, low-pressure thoracic suction unit into the wall suction outlet instead.

To ensure the correct unit is used. Using the wrong suction unit at high pressures will cause trauma to the lung tissues (Woodrow 2013, C).

4 Attach one end of a length of suction tubing to the high-volume, low-pressure thoracic suction unit and attach the other end to the suction canister.

To prevent contamination of the thoracic suction unit filter with pleural fluid. E A wet filter could block the system, which has the potential to cause a tension pneumothorax (MHRA 2010, C).

5 Attach a length of suction tubing from the suction canister and turn the suction on. Occlude the end of the tubing and check for the presence of low-pressure suction.

To check the suction unit is working properly. E

6 Connect the suction tubing (leave one end attached to the suction canister) to the suction port of the chest drain bottle. Adjust the suction pressure to 10 cmH2O.

To allow the lung to slowly re-expand without damaging the lung tissues or causing the patient pain or distress (George and Papagiannopoulos 2016, C).

7 Monitor for bubbling, swinging and draining of fluid (see Table 12.8), and document.

To monitor and record the chest drain status (Woodrow 2013, C).

8 Check the patient’s observations/NEWS2 and document.

To detect any change or deterioration in the patient’s condition and ensure timely escalation to senior staff if required (RCP 2017, C).

9 Slowly titrate the suction up to the pressure prescribed, or to a pressure that the patient can tolerate (maximum of 20 cmH2O)

To allow the lung to slowly re-expand without damaging the lung tissues or causing the patient pain or distress (George and Papagiannopoulos 2016, C).

Post-procedure 10 If the patient needs to leave their bed space, disconnect the suction tubing from the chest drain suction port. Reconnect it when the patient is back at their bed space. Ensure the tubing is properly reconnected and the suction unit is on at the prescribed pressure.

To ensure a patent and safe system. If the tubing is reattached but suction is not turned on, air is unable to escape from the bottle, which could result in a tension pneumothorax. E

11 Record the addition of suction and the set pressure on the chest drain observation chart and in the nursing documentation.

To keep an accurate record of the amount of pressure applied. E

12 Observe for any change in the patient’s respiratory status and recheck the patient’s observations/NEWS2. Escalate any concerns or deterioration immediately.

To identify any concerns or clinical deterioration early and ensure timely escalation to senior staff if required (RCP 2017, C; Woodrow 2013, C).

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Chest drain: changing the bottle EVIDENCE-BASED APPROACHES

The drainage bottle should be changed when it is threequarters full, if there is any damage to the container, or if the tubing has been accidentally disconnected from the chest drain

(Woodrow 2013). If there are any concerns about atmospheric air entering the system during the bottle or tubing change, ask the patient to gently cough to get rid of any air within the p ­ leural space. The drainage bottle and hazardous waste contents should be disposed of as per local infection control policy (Woodrow 2013).

Procedure guideline 12.6  Chest drain: changing the bottle Essential equipment • Personal protective equipment • Cleaning solution (e.g. chlorhexidine in 70% alcohol) • Tape • Sterile chest drain bottle • Sterile water • Chest drain non-toothed clamps × 2 • Procedure pack Action

Rationale

Pre-procedure 1 Introduce yourself to the patient, explain and discuss the procedure with them, and gain their consent to proceed.

To ensure that the patient feels at ease, understands the procedure and gives their valid consent (NMC 2018, C).

2 Cleanse hands with soap and water or an alcohol-based handrub.

To minimize the risk of cross-infection (NHS England and NHSI 2019, C).

Procedure

576

3 Follow the manufacturer’s instructions for opening and filling the bottle with sterile water up to the fluid line.

To ensure the drainage system is properly set up with enough water to fully immerse the drainage tube and create an underwater seal (Woodrow 2013, C).

4 Undo the taping that secures the chest drain to the chest drain tubing. Do not disconnect at this stage.

To allow disconnection of the tubing from the chest drain. E

5 Clamp the chest drain close to the chest wall with two clamps. Clamp the drain for the shortest possible period of time needed to change the tubing and bottle.

To prevent air entering the chest cavity (Woodrow 2013, C). Clamping the drain for long periods of time may increase the risk of pneumothorax (Woodrow 2013, C).

6 Remove the old tubing and bottle and clean the chest drain connection. Attach the new tubing to the chest drain.

To prevent bacterial contamination of the new tubing. E

7 Immerse the distal end of the tubing into the new chest drain bottle and ensure it is 2–3 cm below the level of the water.

To create an underwater seal (Havelock et al. 2010, C).

8 Ensure all connections are secure before removing the clamps.

To prevent accidental disconnection. E

9 Tape the connection between the chest drain and tubing with an H-shaped dressing (see Figure 12.30).

To secure the connection and prevent accidental disconnection. E

10 Cleanse hands with soap and water or an alcohol-based handrub.

To minimize the risk of cross-infection (NICE 2017, C).

Post-procedure 11 Record the addition of the new bottle on the chest drain observation chart and in the nursing documentation.

To keep an accurate record of the amount of fluid drained since insertion (Woodrow 2013, C).

12 Observe for any change in the patient’s respiratory status and recheck the patient’s observations/NEWS2. Escalate any concerns or deterioration immediately.

To identify any concerns or clinical deterioration early and ensure timely escalation to senior staff if required (RCP 2017, C; Woodrow 2013, C).

CHAPTER 12 Respiratory care, CPR and blood transfusion

Problem-solving table 12.4  Prevention and resolution (Procedure guidelines 12.4, 12.5 and 12.6) Problem

Cause

Prevention

Action

Lack of drainage

Kinking, looping or pressure on the tubing may block and impede drainage

Educate the patient on care of the drain and how to position themselves to prevent occlusion or kinking of the drain tubing. Secure the tubing to the patient to prevent kinking or looping using an omental tag.

Check the tubing and unkink or unloop as required. Reposition the patient.

Excess fluid in the pleural space may have fully drained

None necessary.

Perform a chest X-ray to check if excess fluid has been adequately drained. Remove drain if required.

Drain is not swinging

Drain or tubing blocked by viscous fluid or tissue

Flush drain on a regular basis if fluid is viscous and likely to block the drain or tubing.

Gently flush the chest drain with sterile normal saline 0.9% to unblock.

Underwater seal drain not bubbling as expected

Drain occluded

Monitor for bubbling post-insertion. Ensure the tubing is not kinked or looped, and that the system is patent. Ensure the drain is open and not clamped.

Check the tubing and unkink or unloop it as required. Flush the drain to ensure it is patent and not blocked. Unclamp the drain if it is found to be clamped.

Drain not correctly placed

The practitioner inserting the drain should ensure correct landmarking and effective drain insertion.

Perform a chest X-ray to check the position of drain. Discuss with radiology if the drain requires repositioning, or if removal and reinsertion of the drain is required.

Continuous bubbling in chest drain bottle

Air leak in system

Check the bottle for bubbling and swinging, and check integrity of the chest drain system regularly. Ensure all connections are secure.

Check for any loose connections throughout the chest drain system. Check the drain insertion site to determine whether the drain has moved. The eyelets of the drain may be exposed to the atmosphere, allowing air to enter. Perform a chest X-ray to check the position of the drain and status of the effusion or pneumothorax. Prepare for drain removal and reinsertion if required.

Ooze from drain site

Bleeding or infection

Remove the dressing at least once daily, clean and re-dress, and document any concerns. Review the need for the drain daily with senior staff, and remove it as soon as possible.

Remove the dressing, observe the site and take a wound swab. Clean and re-dress the site. Discuss with medical/surgical team whether antimicrobial therapy is indicated. Remove the drain as soon as it is no longer required (if the lung has reinflated or the effusion has been adequately drained).

Fluid leaking from around the drain site

Bypassing of fluid from around the drain site due to blockage of the drain

Flush the chest drain regularly if the fluid is viscous and likely to block the drain.

Gently flush the chest drain using sterile normal saline 0.9% to unblock it. If unable to unblock, removal and reinsertion of a new drain may be required.

Accidental disconnection of the drainage tubing from the chest drain

Connections not secure

Secure the connection using an H-shaped dressing (see Figure 12.30).

Immediately apply a clamp to the drain above the site of disconnection. Re-establish the connection as soon as possible. The tubing may need to be changed if it was contaminated during disconnection. (continued)

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Problem-solving table 12.4  Prevention and resolution (Procedure guidelines 12.4, 12.5 and 12.6) (continued) Problem

Cause

Prevention

Action As soon as the drain and tubing are connected, remove the clamp and ask the patient to cough gently to aid removal of air. If a pneumothorax is present and the bottle was bubbling prior to disconnection, the drain can be unclamped and temporarily submerged in a sterile bottle of water until a new system is set up. Reassure the patient. Report the incident to the clinical team and ask them to review the patient. Consider performing a chest X-ray to assess whether a pneumothorax is present. Record the incident in the relevant records and nursing documentation.

Chest drain falls out

Drain not secure

Check the drain insertion site regularly. Ensure the anchoring stitch is still intact. Apply a clear dressing over the chest drain site and consider the use of an omental tag to secure the tubing onto the patient’s surrounding skin.

Immediately pull the mattress suture closed (if present) and cover it with an occlusive sterile dressing. Check the patient’s observations/ NEWS2 and escalate immediately if the patient is clinically deteriorating or there are any concerns. Inform the clinical team and ask for an immediate review. If the patient is stable, perform a chest X-ray to determine whether a pneumothorax has been caused. If the patient is clinically deteriorating and has signs and symptoms of a pneumothorax or tension pneumothorax, call the medical emergency team and prepare for urgent drain reinsertion or needle decompression. Reassure the patient.

Patient complains of pain

Drain pulling at site

Secure the drain to the patient’s skin using an omental tag to prevent pulling. Administer appropriate analgesia on a regular basis.

Reposition the tube and secure it using an omental tag to prevent the drain pulling. Administer analgesia as prescribed. Escalate to the clinical team if prescribed analgesia is not sufficient.

578 POST-PROCEDURAL CONSIDERATIONS

Documentation

Clearly document in the patient’s nursing notes the date, type and size of drain inserted, and for what indication. The status of the drain should be documented at least 4-hourly to determine whether there is evidence of bubbling, swinging or draining of fluid. The type and volume of fluid should also be recorded on a specific chest drain observation chart (Havelock et  al.  2010). If low-pressure thoracic suction is used, regularly check and document the suction pressure used (Woodrow 2013). Bottle changes and drain removals should also be recorded in both the nursing notes and the chest drain observation chart. Monitor patient observations/NEWS2 score regularly to ensure the patient is stable and there are no signs of clinical deterioration. Observations should be recorded every 5 minutes for the first

15 minutes following drain insertion and then reduced slowly over the next few hours to a minimum frequency of 4-hourly (Woodrow 2013). The patient’s pain score should also be recorded and analgesia given as required (Woodrow 2013).

Education of the patient and relevant others

Educate the patient as to why the chest drain is required and, if possible, teach the patient how to look after the drain. They should be taught to keep the drain below chest level at all times and ensure the bottle is kept upright and does not fall over (Havelock et al. 2010, Woodrow 2013). If suction is indicated, the patient can be taught how to disconnect the suction tubing from the suction port on the underwater-seal chest-drain bottle, to allow them to mobilize away from the bed space. They should be instructed to reconnect it or call the nurse to assist with reconnection on their return. When resting in bed, the patient should

CHAPTER 12 Respiratory care, CPR and blood transfusion

be encouraged to lie in a position that prevents the tubing being occluded or kinked. The patient should also be encouraged to report any change in their breathing while the chest drain is in place.

COMPLICATIONS

Complications of chest drains include (Mao et al. 2015, Ravi and McKnight 2018):

• The volume of fluid draining into the chest-drain bottle is minimal, usually between 100 and 500 mL per day (Chadwick et al. 2015). • There is no evidence of respiratory compromise or failure. • There is no coagulation deficit or increased risk of bleeding (check the latest coagulation results prior to removal). • In many cases, radiological evidence of the absence of air or fluid within the pleural space will be required before removal.

The patient should be offered analgesia at least 30 minutes prior • incorrect placement (extrapleural, intrapulmonary or sub-­ to chest drain removal (Woodrow 2013) before being placed in a comfortable position in bed that allows the nurse to gain access to diaphragmatic) the drain insertion site. The Valsalva manoeuvre (asking the • drain dislodgement patient to hold their breath, bear down and breathe against a • puncturing of adjacent organs: lung, stomach, spleen, liver, closed glottis) should be taught and practised before the drain is heart or great vessels removed (Mohammed 2015). • pulmonary laceration (haemorrhage or fistula) Small-bore pigtail drains should have the holding thread cut or • pneumothorax released (depending on the make and manufacturer) so as to • haemorrhage uncoil the drain within the pleural space and allow removal. Both • infection large-bore and small-bore drains will have an anchor suture, • mechanical obstruction which should be cut prior to removal. Large-bore chest drains • surgical emphysema may also have an additional mattress suture to help seal the inci• re-expansion pulmonary oedema. sion site immediately after the drain is removed. After removing the anchor suture, the chest drain should be Chest drain removal removed with a brisk, firm movement while the patient performs the Valsalva manoeuver on the third expiratory breathe. If a matEVIDENCE-BASED APPROACHES tress suture is present, a second nurse should tie this closed at The decision to remove a drain is usually made by a clinician the same time as the drain is removed (Havelock et  al.  2010). based on the following criteria: Chest drains inserted for pneumothorax do not need to be clamped during the removal process. • There is an absence of air bubbles in the underwater-seal chestA follow-up post-removal chest X-ray is required to ensure no drain bottle, usually noted when the patient exhales forcibly or air has been allowed to enter during the removal process with coughs. This will coincide with expiration in a patient who is formation of a subsequent pneumothorax (Woodrow 2013). being mechanically ventilated with positive pressure.

Procedure guideline 12.7  Chest drain: removal The removal technique is dependent on the type of chest drain used. While only one nurse is required to remove a small-bore chest drain, two nurses are required to facilitate safe removal of a large-bore chest drain. One is required to remove the drain while the other ties the mattress suture to close and seal the site. Essential equipment • Personal protective equipment • Sterile dressing pack containing gallipot, gauze and a sterile towel • Cleaning solution, for example 0.9% sodium chloride • Stitch cutter • Sterile occlusive dressing Action

Rationale

Pre-procedure 1 Introduce yourself to the patient, explain and discuss the procedure with them, and gain their consent to proceed.

To ensure that the patient feels at ease, understands the procedure and gives their valid consent (NMC 2018, C).

2 Cleanse hands with soap and water or an alcohol-based handrub.

To minimize the risk of infection (NHS England and NHSI 2019, C).

3 Encourage the patient to practice the Valsalva manoeuvre before the chest drain is removed. The Valsalva manoeuvre requires the patient to hold their breath, bear down and breathe against a closed glottis at the end of expiration.

To ensure the patient understands and is able to perform the Valsalva manoeuvre prior to drain removal. E To increase the intrathoracic pressure, reducing the possibility of air re-entering the pleural space during drain removal (Cerfolio et al. 2013, C).

4 Administer analgesia at least half an hour before the procedure.

To minimize any pain during the procedure (Woodrow 2013, C).

5 Discontinue suction if in use and disconnect the suction tubing from the suction port.

To reduce the number of tubes and amount of equipment in the surrounding area. E

6 Cleanse hands with soap and water or an alcohol-based handrub.

Hands need to be cleansed before and after each patient contact to minimize the risk of infection (NHS England and NHSI 2019, C).

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Procedure guideline 12.7  Chest drain: removal (continued) Action

Rationale

7 Prepare a trolley for the procedure. Open the sterile procedure pack onto the top of a clean trolley using aseptic technique, then open the stitch cutter, gallipot and occlusive dressing onto the sterile field. Pour the cleaning solution into the gallipot.

To ensure all equipment required is prepared prior to starting the procedure. E

8 Assist the patient into a position that facilitates drain removal while ensuring patient comfort.

To aid patient comfort and ensure easy removal of the chest drain (Woodrow 2013, C).

9 Place a protective pad underneath the patient.

To absorb any leakage from the drain during removal. E

Procedure 10 Cleanse hands with an alcohol-based handrub and apply apron and gloves.

Hands need to be cleansed before and after each patient contact to minimize the risk of infection (NHS England and NHSI 2019, C).

11 Remove the dressing from around the drain site. Examine what size of drain has been used and which sutures are present: either a large-bore drain with a mattress suture and anchor suture (requires two nurses) or a fine-bore drain with only an anchor suture (requires one nurse).

To prepare for drain removal and determine how many nurses are required to perform the procedure. E

Large-bore drain 12 To remove a large-bore drain, two nurses are required: one to remove the drain and the other to seal the site. The first nurse loosens the mattress suture, exposing the ends to be tied on removal of the drain.

To prepare the drain and ensure it is ready for removal. E

13 The second nurse cuts the anchor suture and ensures the drain is mobile and ready to be removed.

To prepare the drain and ensure it is ready for removal. E

14 The second nurse asks the patient to take two deep breaths and then perform the Valsalva manoeuvre at the end of expiration on the third breath. While the patient performs the Valsalva manoeuvre, the second nurse pulls out the drain steadily and smoothly.

Performing the Valsalva manoeuvre at the end of expiration increases intrathoracic pressure, preventing air flowing into the intrathoracic cavity and the formation of a new pneumothorax (Cerfolio et al. 2013, C).

15 The first nurse pulls and ties the mattress suture while the drain is simultaneously removed.

To close and seal the drain site, preventing the entry of air and formation of a pneumothorax (Havelock et al. 2010, C).

16 Ask the patient to breathe normally after the drain is removed.

To assess if there is any air escaping from suture/drain site. E

Fine-bore drain

580

17 One nurse is required to remove a fine-bore drain. The anchor suture should be cut and the drain prepared ready for removal. If a pigtail drain is in place, the nurse will need to follow the manufacturer’s instructions to unlock the device, usually by either cutting or unlocking the thread.

Following the manufacturer’s instructions ensures correct removal and reduces the risk of pain, trauma and the formation of a pneumothorax secondary to incorrect removal technique. E

18 The nurse should remove the drain in a smooth but brisk fashion while the patient performs the Valsalva manoeuvre (see above) on the third expiratory breath.

Performing the Valsalva manoeuvre at the end of expiration increases intrathoracic pressure and prevents air flowing into the intrathoracic cavity and the formation of a new pneumothorax (Cerfolio et al. 2013, C).

19 The drain site should immediately be covered with sterile gauze until an occlusive dressing can be applied.

To close and seal the drain site, preventing the entry of air and formation of a pneumothorax (Havelock et al. 2010, C).

20 Ask the patient to breathe normally after the drain is removed.

To assess if there is any air escaping from suture/drain site. E

Post-procedure 21 Clean around the site with 0.9% sodium chloride and apply an occlusive dressing.

To clean the site and prevent air entry by forming an airtight seal. E

22 Dispose of waste appropriately, remove gloves and clean hands.

To ensure safety and reduce the risk of infection (NICE 2017, C).

CHAPTER 12 Respiratory care, CPR and blood transfusion

23 Assist the patient into a comfortable position.

To ensure patient comfort and aid respiration. E

24 Monitor the patient’s respiratory status and observations/ NEWS2. Escalate any concerns or deterioration immediately.

To identify any concerns or clinical deterioration early, and ensure timely escalation to senior staff if required (RCP 2017, C; Woodrow 2013, E).

25 Document removal of the drain on the chest drain chart and in the nursing documentation.

To maintain accurate patient records (NMC 2018, C).

26 Escort the patient for a chest X-ray following drain removal.

To check that a pneumothorax has not reformed or been introduced during removal (Porcel 2018a, C).

27 Monitor the wound site and change the dressing as required.

To monitor for signs of infection (Havelock et al. 2010, C).

Tracheostomy and laryngectomy care DEFINITION

A tracheostomy is the creation of a permanent or temporary opening (stoma) in the anterior wall of the trachea to facilitate ventilation (Figure 12.33). The opening is commonly made at the level of the second or third cartilaginous rings and is usually maintained by the use of a tracheostomy tube (Adam et al. 2017). A tracheostomy may be created surgically or percutaneously, and as either an elective (planned) or non-elective (unplanned/emergency) procedure. A total laryngectomy is the surgical removal of the larynx (Figure 12.33). The end of the trachea is stitched to the skin of the anterior neck and forms a permanent and irreversible stoma. The upper airway is no longer connected to the trachea and lungs, and all ventilation takes place via the laryngectomy stoma (Bonvento et al. 2017). Because the larynx has been removed, the patient is unable to phonate using their vocal cords so alternative methods of communication and voice facilitation must be used instead (Ward and Van As-Brooks 2014). Regardless of whether the newly created stoma is permanent or temporary, a patient with a tracheostomy or laryngectomy may be referred to as a ‘neck breather’ or as having an ‘altered airway’.

Figure 12.33  (a) Anatomy of the head and neck. (b) Tracheostomy. (c) Laryngectomy. (a)

Pharynx Epiglottis Larynx Vocal cords Trachea Oesophagus

(b)

ANATOMY AND PHYSIOLOGY

Figure 12.33a shows the anatomy of the neck. The larynx, situated at the top of the trachea, houses the vocal cords and is the point of transition between the upper (mouth, nose and pharynx) and lower airways. It is made up of six cartilage segments, the largest of which is called the thyroid cartilage. Attached to the entrance of the larynx is the epiglottis, a large elastic cartilage that closes over the glottis during swallowing, protecting the lower airway from aspiration. At the inferior end is the cricoid cartilage, which attaches to the trachea, a large cylindrical structure approximately 11 cm long. The trachea is made up of C-shaped hyaline cartilage anteriorly and a membranous portion posteriorly; this composition provides reinforcement and protection while allowing the trachea to collapse slightly as food passes down the oesophagus. The trachea then divides at the carina to form the right and left main stem bronchi of the lungs (Tortora and Derrickson 2017).

RELATED THEORY

Approximately 5000 surgical tracheostomies and 15,000 percutaneous tracheostomies are performed each year in England (Wilkinson et  al.  2014). Despite the increasing numbers of altered airways being performed, several reports recognize key themes of poor tracheostomy care and a lack of care pathways, resulting in harm to patients, prolonged hospital stay and poor survival to hospital discharge (Bonvento et  al.  2017, Mortimer and Kubba 2017, Wilkinson et al. 2014). While nurses carry out a significant amount of care for patients with an altered airway, a multidisciplinary team approach is essential to co-ordinate

Tracheostomy tube in situ

(c)

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Permanent stoma

and plan safe and effective care before and after stoma formation (Bonvento et al. 2017, Wilkinson et al. 2014). Speech and language therapists (SLTs) play a pivotal role in the assessment and management of patients’ impaired swallowing

THE ROYAL MARSDEN MANUAL OF CLINICAL NURSING PROCEDURES

and speech, especially in patients who have undergone a total laryngectomy (Bonvento et  al.  2017). Specialized physiotherapists are skilled in mobilization, rehabilitation, humidification techniques and the general care of tracheostomies. Patients may have difficulty with an altered body image and need psychological support, not only from the professionals closely involved in their care but also potentially from a formal psychological support team. Other key support teams include ENT (ear, nose and throat) and head and neck clinical nurse specialists, rehabilitation teams,  dietitians, critical care outreach teams, anaesthetists (in the event of an airway emergency), and discharge co-ordinators and community teams (for patients with altered airways who are going home).

EVIDENCE-BASED APPROACHES

Types of tracheostomy

A temporary tracheostomy may be performed surgically in theatre or percutaneously in a critical care environment. The tracheostomy may be formed because the patient is unable to maintain their own airway and/or clear their own secretions, because they are expected to require ventilator support for longer than 7–10 days, or because they are expected to be a slow respiratory wean from the mechanical ventilator (Cosgrove and Carrie  2015). It may also be formed during certain head and neck surgeries to allow access to the upper airways. The tracheostomy tube will be removed as soon as the patient has recovered and can safely maintain their own airway again. A permanent tracheostomy is required when it is unlikely that the patient will be able to maintain their own airway or manage their own secretions because of an underlying disease or condition that is likely to be progressive or irreversible. Examples of such conditions include certain cancers of the head and neck, a neuromuscular disorder, a cerebral vascular accident or following a traumatic head injury (Cheung and Napolitano 2014). In these examples, other than the creation of the tracheostomy stoma, the patient’s anatomy is not surgically altered and the upper airway remains connected to the trachea. Following complete surgical removal of the larynx (total laryngectomy), the trachea is sutured in position to form a permanent stoma, known as a laryngectomy stoma. Because the patient’s anatomy has been permanently altered, there is no longer any connection between the upper airways and the trachea, and the patient will breathe through the laryngectomy stoma for the remainder of their life (Ceachir et al. 2014).

Percutaneous tracheostomy

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The percutaneous method most commonly used is known as percutaneous dilatational tracheostomy (PDT). It enables the pretracheal tissues to be incised under local anaesthesia. A sheath is inserted into the trachea between the cricoid and the first tracheal ring, or between the first and second rings. A series of conical dilators are slipped over a guidewire, progressively dilating the trachea until the stoma is dilated enough to allow insertion of a tracheostomy tube (Cheung and Napolitano 2014). Percutaneous tracheostomies are more cost-effective and are associated with fewer complications than surgical tracheostomies and so are becoming increasingly popular (Cheung and Napolitano  2014). They also have the additional benefits of rapid stoma closure and healing following decannulation ­(tracheostomy tube removal), with patients being left with a smaller and less visible scar (Batuwitage et al. 2014). They are frequently performed in the critical care setting as an early ­intervention after initiation of mechanical ventilation (Cosgrove and Carrie 2015).

Surgical tracheostomy

Surgical tracheostomy is ideally performed in the operating theatre under a general anaesthetic. The procedure is usually elective (planned) and performed during head and neck surgery, or during

surgery for other conditions where the patient is expected to have a prolonged period of mechanical ventilation post-operatively (e.g. gastro-oesophagectomy). A surgical tracheostomy can also be performed in a critical care environment under local anaesthetic during a life-threatening airway emergency as a non-elective procedure (unplanned). The tracheostomy is usually sited over the second and third, or third and fourth tracheal cartilages. Depending on the type of incision made, temporary stay sutures may be placed to ensure the trachea can easily be recannulated if the tracheostomy tube is accidentally dislodged before an adequate tract has formed. Traction of the sutures helps to keep the trachea open and prevents soft tissues from obscuring the stoma, facilitating recannulation (Lee et al. 2015).

Rationale Indications

Tracheostomies and laryngectomies are carried out to maintain a patent airway and facilitate effective ventilation. Indications for both are listed in Tables 12.9 and 12.10 respectively.

Table 12.9  Indications for a tracheostomy Indication

Detail

Airway maintenance or protection

Acute upper airway obstruction (e.g. by a foreign object or oedema of the soft tissues) may make emergency short-term tracheostomy essential. More lasting damage to the upper airway (e.g. from chemical or inhalation burns) may require long-term tracheostomy.

Laryngeal pathology or prolonged upper airway obstruction (e.g. head and neck surgery)

Some maxillofacial and head and neck procedures make it necessary to secure the patient’s airway without obstructing the mouth and pharynx.

Tracheal toilet

A patient who has a poor cough and cannot clear their secretions may require a tracheostomy.

Prolonged intubation (>7–10 days)

Prolonged endotracheal intubation carries a high risk of damage to the soft tissues of the mouth, pharynx and trachea. It reduces the patient’s ability to communicate and increases the work of breathing by extending the dead space. Tracheostomy reduces or removes the risk of tissue damage, facilitates lip reading and reduces the work of breathing by shortening the dead space, so promoting the process of weaning from mechanical ventilation.

Delayed return of glottic reflexes

Patients with reduced function in cranial nerves V, VII, IX, X or XII, with damage to the brain stem or a reduced consciousness level, may be unable to maintain a patent airway or protect their airway from aspiration of food, drink and saliva. Short- or long-term tracheostomy may be indicated.

Source: Adapted from Bonvento et al. (2017), Cheung and Napolitano (2014), Hyzy and McSparron (2018), NTSP (2013).

CHAPTER 12 Respiratory care, CPR and blood transfusion

Table 12.10  Indications for a laryngectomy Indication

Detail

Malignancy

Laryngectomy can be a curative treatment for laryngeal cancer or malignancy of adjacent structures.

Nonfunctioning larynx

A functional laryngectomy may be performed if the larynx is no longer functioning and where aspiration is severe and life threatening. This may occur following previous treatments for head and neck cancers.

Post-trauma laryngeal stenosis

Laryngectomy may be performed for severe laryngeal trauma or stenosis when other surgical techniques have not been effective.

Source: Adapted from Ceachir et al. (2014).

Contraindications

Relative contraindications for tracheostomy include: • severe localized skin infection • uncorrected coagulopathies • tracheomalacia • an inability to extend the neck due to an underlying condition (e.g. cervical fusion or cervical spine instability). They may also include conditions that obscure or distort the neck anatomy, such as a short and/or obese neck, previous neck  surgery, tumour, haematoma or thyromegaly (Hyzy and McSparron 2018, ICS 2014).

CLINICAL GOVERNANCE

Competencies

NCEPOD recommends that all nurses involved in the care of patients with an altered airway should be competent in the management of the tracheostomy or laryngectomy, including the actions to take in an emergency (Wilkinson et al. 2014). All procedures should be undertaken in accordance with local policies and protocols, and only after approved training, supervised practice and competency assessment. The core skills related to caring for a patient with an artificial airway are detailed in Box 12.4. Box 12.4  Core skills required to care for a patient with an artificial airway Tracheostomy

Laryngectomy

• Maintaining airway (monitoring tube placement and patency) • Humidification • Tube tie (tube holder) change • Suctioning • Inner cannula change • Cuff pressure measurement • Psychological support and education • Discharge planning

• Maintaining airway (monitoring stoma patency) • Humidification • Care of the stoma • Changing baseplate, laryngectomy tube or heat moisture exchanger cassette • Caring for the voice prosthesis (cleaning and testing for leakage) • Caring for the tracheooesophageal puncture (emergency dislodgement of the voice prosthesis or stoma gastric tube) • Psychological support and education • Discharge planning

Source: Adapted from NTSP (2013), Wilkinson et al. (2014).

In addition, NCEPOD recommends that nurses are trained in the recognition and management of common airway complications including tracheostomy tube dislodgement, and airway obstruction in tracheostomy and laryngectomy. Written algorithms to support the emergency management of a laryngectomy airway and a blocked or dislodged tracheostomy tube (Figure 12.34) should be available at the patient’s bedside, along with signage detailing the patient’s current airway status (Figure  12.35). Emergency equipment should also be readily available at the bedside (NTSP  2013); this is discussed further below. The algorithms should not only include the practical steps required to manage the airway emergency but also details of who to call to assist. This may include teams or individuals specialized in anaesthetics and airway management; critical care and resuscitation; and ENT or head and neck surgery.

Risk management

Tracheostomy tube information should be readily available detailing the type, size and date of tube insertion, in addition to any other information that may be required in an emergency (Wilkinson et al. 2014). This is often referred to as either the ‘tracheostomy passport’ or ‘altered airway passport’. Similar information should be available regarding laryngectomy stoma patency and method of communication. Signage for the bedside is useful to provide instant recognition of the presence of an altered airway and its type and duration (Figure 12.35). Each altered airway or head and neck ward should have at least one altered airway trained nurse (band 5+) on duty who has passed a trust-approved altered airway competency standard. At the beginning of each shift, each patient with an altered airway should be assessed to determine: • why the patient has an altered airway • whether the patient’s anatomy has been surgically altered so that ventilation via the upper airways is no longer possible (i.e. laryngectomy) • in the case of tracheostomy, when it was performed and whether the stoma was performed surgically or percutaneously • the type and size of the tracheostomy tube or laryngectomy stoma (the latter of which may or may not have a tube) • the appearance of the stoma site • the amount and consistency of secretions • the patient’s swallowing and cough reflexes • the patient’s weaning plan • the patient’s method of communication.

PRE-PROCEDURAL CONSIDERATIONS

Equipment

Caring for a patient with a tracheostomy requires the availability of various pieces of equipment, outlined in Box  12.5. These should be readily available at the patient’s beside. Additional equipment required for patients with a laryngectomy is listed in Box 12.6.

Tracheostomy tubes

Tracheostomy tubes are made of silicone, plastic or metal, and therefore differ considerably in rigidity, durability and kink resistance. However, the majority of tracheostomy tubes are manufactured from plastics of varying types, some of which become softer at body temperature (e.g. polyvinyl chloride construction). Most tracheostomy tubes come in a sterile pack with an obturator to assist with insertion. The obturator should be removed as quickly as possible after insertion as it completely occludes the tracheostomy tube when in place (NTSP 2013). The main components of a tracheostomy tube are predominantly universal. Most are dual lumen incorporating an outer tube and inner cannula, with a universal diameter of 15 mm at the upper aspect to allow connection to other equipment. Most tubes also have a neck flange to which tube ties or tapes can be attached;

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Figure 12.34  (a) Emergency tracheostomy management algorithm. (b) Emergency laryngectomy management algorithm. Source: Reproduced with permission from the National Tracheostomy Safety Project (www.tracheostomy.org.uk).

Emergency tracheostomy management – Patent upper airway Call for airway expert help Look, listen & feel at the mouth and tracheostomy A Mapleson C system (e.g. ‘Waters circuit’) may help assessment if available Use waveform capnography when available: exhaled carbon dioxide indicates a patent or partially patent airway

Is the patient breathing?

No

Yes

Call Resuscitation Team CPR if no pulse / signs of life

Apply high-flow oxygen to BOTH the face and the tracheostomy

Assess tracheostomy patency Remove speaking valve or cap (if present) Remove inner tube Some inner tubes need re-inserting to connect to breathing circuits

Can you pass a suction catheter?

The tracheostomy tube is patent

Yes

Perform tracheal suction Consider partial obstruction Ventilate (via tracheostomy) if not breathing Continue ABCDE assessment

No Deflate the cuff (if present) Look, listen & feel at the mouth and tracheostomy Use waveform capnography or Mapleson C if available

Tracheostomy tube partiallly obstructed or displaced

Yes Is the patient stable or improving?

Continue ABCDE assessment

No REMOVE THE TRACHEOSTOMY TUBE Look, listen & feel at the mouth and tracheostomy. Ensure oxygen re-applied to face and stoma Use waveform capnography or Mapleson C if available

Call Resuscitation team CPR if no pulse / signs of life

No

Primary emergency oxygenation

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Standard ORAL airway manoeuvres Cover the stoma (swabs / hand). Use: Bag valve mask

Is the patient breathing?

Yes

Continue ABCDE assessment

Secondary emergency oxygenation Attempt ORAL intubation Prepare for difficult intubation Uncut tube, advanced beyond stoma

Oral or nasal airway adjuncts Supraglottic airway device e.g. LMA

Tracheostomy STOMA ventilation Paediatric face mask applied to stoma LMA applied to stoma

(a)

Attempt intubation of STOMA Small tracheostomy tube / 6.0 cuffed ETT Consider Aintree catheter and fibreoptic scope / bougie / airway exchange catheter

National Tracheostomy Safety Project. Review date 1/4/16. Feedback & resources at www.tracheostomy.org.uk

CHAPTER 12 Respiratory care, CPR and blood transfusion

Figure 12.34  (continued)

Emergency laryngectomy management Call for airway expert help Look, listen & feel at the mouth and laryngectomy stoma A Mapleson C system (e.g. ‘Waters circuit’) may help assessment if available Use waveform capnography whenever available: exhaled carbon dioxide indicates a patent or partially patent airway

Is the patient breathing?

No

Yes

Apply high-flow oxygen to laryngectomy stoma if any doubt whether patient has a laryngectomy, apply oxygen to face also*

Call Resuscitation Team CPR if no pulse / signs of life

Assess laryngectomy stoma patency Most laryngectomy stomas will NOT have a tube in situ Remove stoma cover (if present) Remove inner tube (if present) Some inner tubes need re-inseting to connect to breathing circuits Do not remove a tracheoesphageal puncture (TEP) prosthesis

The laryngectomy stoma is patent Perform tracheal suction Consider partial obstruction Ventilate via stoma if not breathing Continue ABCDE assessment

Yes

Can you pass a suction catheter? No Deflate the cuff (if present) Look, listen & feel at the laryngectomy stoma or tube Use waveform capnography or Mapleson C if available

Is the patient stable or improving?

Yes

Continue ABCDE assessment

No REMOVE THE TUBE FROM THE LARYNGECTOMY STOMA if present Look, listen & feel at the laryngectomy stoma. Ensure oxygen is re-applied to stoma Use waveform capnography or Mapleson C if available

Call Resuscitation Team CPR if no pulse / signs of life

Yes

No Is the patient breathing?

Primary emergency oxygenation

Laryngectomy stoma ventilation via either Paediatric face mask applied to stoma LMA applied to stoma

Continue ABCDE assessment

Secondary emergency oxygenation

Attempt intubation of laryngectomy stoma Small tracheostomy tube / 6.0 cuffed ETT Consider Aintree catheter and fibreoptic scope / bougie / airway exchange catheter

Laryngectomy patients have an end stoma and cannot be oxygenated via the mouth or nose * Applying oxygen to the face and stoma is the default emergency action for all patients with a tracheostomy National Tracheostomy Safety Project. Review date 1/4/16. Feedback & resources at www.tracheostomy.org.uk

(b)

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Figure 12.35  Bed signage. (a) Tracheostomy. (b) Laryngectomy. Source: Reproduced with permission from the National Tracheostomy Safety Project (www.tracheostomy.org.uk).

This patient has a

This patient has a

TRACHEOSTOMY

LARYNGECTOMY

There is a potentially patent upper airway (Intubation may be difficult)

and CANNOT be intubated or oxygenated via the mouth

Surgical / Percutaneous

Follow the LARYNGECTOMY algorithm of breathing difficulties

Performed on (date)

.......................

Performed on (date)

Hospital / NHS number

...................

Notes: Indicate tracheostomy type by circling the relevant figure. Indicate location and function of any sutures. Laryngoscopy grade and notes on upper airway management. Any problems with this tracheostomy.

Emergency Call: Anaesthesia ICU

.......................

Tracheostomy tube size (if present) .......

Tracheostomy tube size (if present) .......

Hospital / NHS number

...................

Notes:

Percutaneous ENT

There may not be a tube in the stoma. The trachea (wind pipe) ends at the neck stoma

Björk Flap Slit type

MaxFax Emergency Team

Emergency Call: Anaesthesia ICU

(a)

Box 12.5  Essential equipment required for tracheostomy care

ENT

MaxFax Emergency Team

www.tracheostomy.org.uk

www.tracheostomy.org.uk

(b)

Figure 12.36  Tracheal dilator.

In an emergency • Personal protective equipment: gloves, aprons and eye protection • Resuscitation equipment/trolley: bag valve mask, endotracheal tubes, laryngeal mask airway (LMA), laryngoscope and blade, bougie and Cook exchange catheter • Advanced airway equipment/trolley • Fibreoptic scope • Waveform capnography At the patient’s bedside • Oxygen supply and equipment: tracheostomy mask, reservoir mask and tubing • Suction device with a selection of fine-bore suction catheters and Yankauer suction tips • Bottle of sterile water In a ‘tracheostomy box’ at the patient’s bedside (and to accompany the patient on any transfers)

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• Cuffed tracheostomy tube of the same size as the patient’s current tube • Cuffed tracheostomy tube at least half a size smaller • 10 mL syringe • Tracheal dilator (Figure 12.36) • Suture cutter • Scissors • Water-soluble lubricating gel • Spare tracheostomy tapes • Cuff pressure manometer (Figure 12.37) • Catheter mount • Inner cannula(s)

without disturbing the stoma site. Removal of the inner cannula allows immediate relief of life-threatening airway obstruction in  the  event of a blocked tracheostomy tube due to tenacious ­secretions. For this reason, dual-lumen tubes are recommended as they are inherently safer (Wilkinson et  al.  2014). Disposable ­single-use inner tubes are available from certain manufacturers; these minimize the risk of cross-infection as no cleaning is required. Tubes vary in their length and shape, and are sized according to their internal diameter in millimetres. The type of tube chosen will depend on the size of the trachea and the needs of the individual patient. A selection of commonly used tube types are described below and grouped in the following categories:

Source: Adapted from McGrath et al. (2012), NTSP (2013).

• the presence or absence of a cuff • the presence or absence of a hole or ‘fenestration’ • specialist-function tubes.

the ties or tapes are then fitted around the patient’s neck to secure the tracheostomy. The outer tube of a dual-lumen tracheostomy maintains the patency of the airway, while the inner tube (which fits snugly inside  the outer tube) can be removed for cleaning or changing

Cuffed tracheostomy tubes

Cuffed tracheostomy tubes (Figures 12.38 and 12.39) are singleuse tracheostomy tubes that when inflated provide an airtight seal, facilitating effective ventilation and protecting the lower ­respiratory tract against aspiration. Some are of a ‘high-volume,

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Figure 12.37  Cuff pressure manometer.

Figure 12.38  Cuffed tracheostomy tube in situ. Source: Reproduced with permission from the National Tracheostomy Safety Project (www.tracheostomy.org.uk).

Figure 12.39  Portex® Blue Line Ultra® tracheostomy tube shown with introducer.

Box 12.6  Additional equipment required for laryngectomy In a ‘laryngectomy box’ at the patient’s bedside • The contents kept in a ‘tracheostomy box’ (see Box 12.5) • Spare laryngectomy tube • Tilley’s forceps (angled forceps used to remove crusts or plugs of mucus from in and around the stoma) • Pen torch (or access to a light source) • Micropore or Elastoplast tape for patients with a tracheooesophageal puncture, to secure the catheter keeping the puncture patent • 14 Fr red rubber catheter to be used in the event of accidental voice prosthesis dislodgement Source: Adapted from NTSP (2013).

low-pressure’ design, which distributes the pressure evenly on the tracheal wall and aims to minimize the risks of tracheal ulceration, necrosis and stenosis at the cuff site (Cipriano et al. 2015). To further reduce these risks, the cuff pressure should not exceed 25 cmH2O (NTSP 2013). The pressure should be checked at least once per shift or more regularly if there is any change in the patient’s clinical condition or if there are concerns regarding the patient’s airway (Wilkinson et al. 2014). The cuff is kept inflated in  the immediate post-operative phase, during mechanical

­ entilation, if the patient has a reduced consciousness level or if v there are concerns regarding aspiration (NTSP  2013). Once the patient is awake and able to follow commands, the cuff can be deflated as part of the weaning plan. The cuff should always be  deflated when a speaking valve or decannulation plug is in place (Mitchell et al. 2013). Cuffed tubes with subglottic port

These are single-use tracheostomy tubes that have an additional port for aspiration of subglottic secretions (above the cuff) (Figure 12.40). They are often used for the prevention of ventilator-associated pneumonia in critically ill patients but are also indicated for some patients to enable effective clearance of secretions accumulating above the tracheostomy tube (Hess and Altobelli 2014). Uncuffed tracheostomy tubes

Uncuffed tubes (Figure  12.41) are predominantly used for longterm patients who are able to protect their own airway due to ­having an adequate cough and gag reflex (Hess and Altobelli 2014). An uncuffed tube removes the risk of tracheal damage and can

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Figure 12.40  Portex® Blue Line Ultra® Sucationaid tracheostomy tube.

Figure 12.41  Uncuffed tracheostomy tube in situ. Source: Reproduced with permission from the National Tracheostomy Safety Project (www.tracheostomy.org.uk).

Figure 12.43  Fenestrated uncuffed tube in situ. Source: Reproduced with permission from the National Tracheostomy Safety Project (www.tracheostomy.org.uk).

be  used in the weaning and decannulation process and to aid swallowing and communication with the concomitant use of a speaking valve. Fenestrated tracheostomy tubes

Tubes may also be fenestrated or non-fenestrated. A fenestrated uncuffed tube (Figure 12.42) is a double-lumen tracheostomy tube with holes or fenestrations midway down the outer tube. If a fenestrated inner tube (often a different colour to highlight the fenestration) is used, air can move through the fenestrations and past the vocal cords within the larynx (Figure 12.43), facilitating voice production (Hess and Altobelli 2014). Fenestrated cuffed tubes

A fentestrated tube that incorporates a cuff is particularly useful for weaning as it provides the benefits of both the cuffed tube and the fenestrated uncuffed tube. These are most suited to patients who require periods of both cuff inflation (to protect the airway) and cuff deflation (to enable a speaking valve to be used). Specialist-function tracheostomy tubes Longer length tracheostomy tubes

Figure 12.42  Portex® uncuffed fenestrated tracheostomy tubes with red inner tube to highlight that the inner tube is also fenestrated.

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The standard design of tracheostomy tube may be unsuitable for some patients because of the short length and angulation of the tube. Extra proximal length is needed for patients with a deep-set trachea (i.e. large neck due to obesity, goitre or neck mass). Extra distal length may be needed for patients with tracheal problems but who have normal neck anatomy (i.e. tracheomalacia or tracheal stenosis). For these types of patient, a flexible (reinforced) tracheostomy tube with an adjustable flange (Figure 12.44) can be used (Hess and Altobelli 2014). It is important that the length of the adjustable flange is documented in the patient’s tracheostomy passport on insertion and after any adjustments are made. Additionally, the position of the flange should be checked and documented daily (NTSP 2013). Metal tubes

Metal tubes are not commonly used but may still be seen in older patients who have had a permanent tracheostomy (Figure 12.45).

Tracheostomy sutures

Sutures are usually applied to either side of the tracheostomy tube flange and attached to the patient’s skin for at least 7 days after tracheostomy insertion (7–10 days if percutaneous) (Hess

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and Altobelli 2014). The sutures help to secure the tube until the stoma has formed around the tracheostomy, increasing safety and preventing accidental decannulation. As described earlier, a stay suture may also be placed when a surgical tracheostomy is formed to increase safety and allow rapid reintubation in the event of an accidental decannulation. The ends of the stay sutures are normally taped onto the patient’s chest and labelled ‘DO NOT REMOVE’. The stay sutures can be removed by a suitably trained professional either after decannulation or during the first tube change (Mitchell et al. 2013).

Tracheostomy humidification

Humidification of an altered airway is essential since the natural mechanisms of humidification, warming and filtration normally provided by the upper airways are bypassed. A lack of humidification will cause drying of the airway, depressed mucociliary function and increased viscosity of mucous secretions (Tortora and Derrickson  2017). As well as being uncomfortable for the patient, it can impair secretion removal and cause infection, micro-atelectasis (collapse of the alveoli) or tracheostomy tube

Figure 12.44  Portex® Uniperc® adjustable flange tracheostomy tube with Soft Seal® cuff and inner cannula.

occlusion (NTSP  2013). Providing adequate humidification to patients with a tracheostomy tube is therefore imperative in maintaining a safe airway and preventing acute deterioration (Wilkinson et al. 2014). Humidification can be provided to patients using a disposable nebulizer set with sterile 0.9% sodium chloride (approximately 5 mL). It can be delivered using an aerosol-driven nebulizer, or it can be attached to the oxygen or air supply with a flow rate high enough for the liquid to form humidification droplets. The nebulizer is administered using a specific tracheostomy mask every 2–4 hours, or more frequently in patients with more tenacious secretions (NTSP 2013). Where possible, a heated circuit should be used to provide humidification to patients who require continual oxygen therapy. A heat and moisture exchanger (HME) such as a ‘Swedish nose’ (see Figure 12.11a) can be connected directly onto the tracheostomy tube to provide humidification. A humidification bib can also be worn by a patient with a well-established tracheostomy. Both of these devices mimic the function of the upper airways by helping to filter and warm inspired air (Wong et al. 2016). Some devices, such as the TrachPhone and ProTrach DualCare valve, assist with both communication and humidification. The cuff should be disposed of every 24 hours, or sooner if saturated with secretions (NTSP 2013).

Tracheostomy adaptations for communication

Since the larynx is bypassed in patients with a tracheostomy, phonation is not typically possible unless some adaptations are made to the tube. This can often be one of the most difficult aspects for a patient with an altered airway, causing significant angst and frustration. Alternative methods of communication should be facilitated as soon as possible; one or more of the methods listed in Box  12.7 can be used (Bonvento et  al.  2017, Tang and Sinclair 2015).

Tracheostomy speaking valves

There are a range of speaking valves (Figures  12.46 and  12.47) available that, when placed on the end of the tracheostomy tube, will redirect air on expiration from the lungs through the larynx, facilitating voice production. If a cuffed tracheostomy is in place, the cuff must be fully deflated before a speaking valve is placed, otherwise there will no longer be a patent airway and the patient will not be able to breathe (Hess and Altobelli 2014).

Figure 12.45  (a) Jackson silver tube. (b) Negus silver tube. (a)

(b)

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Box 12.7  Methods of communication for patients with a tracheostomy Non-verbal methods of communication • Lip reading • Facial expression and gestures • Coded eye blink or hand gestures • Alphabet board, picture board or phrase book • Notepad or wipeable board and pen • Tablet or smartphone Verbal methods of communication for patients with a tracheostomy tube • Cuff deflation with speaking valve, with or without the insertion of a fenestrated tube Source: Adapted from NTSP (2013), Tang and Sinclair (2015).

Figure 12.46  Rusch speaking valve.

ale and importance of suctioning, positioning and strengthening the patient’s cough. For patients with long-term tracheostomy needs, early education is vital. Supporting an individual with a tracheostomy of any type requires an understanding of the impact the tracheostomy tube has on the patient’s airway, communication and swallowing, and knowing how to manage potential complications. Education will be both practical (i.e. through demonstration with the patient’s own tracheostomy, possibly using mirrors) and provided through the use of leaflets, posters and pictures. Practical tracheal suctioning on a specialized mannequin and examining tracheostomy tubes can also be beneficial. As with all elements of tracheostomy care, a multidisciplinary approach is advocated (Wilkinson et  al.  2014). Patient education will come from various sources, including clinical nurse specialists, nursing, medical and surgical staff, SLTs, physiotherapists and community teams.

Tracheostomy: dressing and tube tape or tie change EVIDENCE-BASED APPROACHES

Rationale

Tracheostomy dressing and tube tie or tape change is carried out to keep the surrounding skin clean and dry and free from infection and pressure damage. It also helps to keeps the tracheostomy tube secure, preventing accidental decannulation.

Indications

Figure 12.47  Passy Muir valve.

The tracheostomy stoma directly exposes the trachea to the environment and so is a potential route for infection. Secretions can cause irritation and maceration of the surrounding skin, and the tracheostomy tube itself may cause pressure damage to the patient’s neck area. To prevent tissue damage and wound breakdown, the site should be inspected regularly and cleaned and dried as required (Everitt  2016a). A specific foam tracheostomy dressing may be used to help absorb secretions, prevent pressure ulcers and increase patient comfort. The dressing should be changed at least every 24 hours or more frequently if required (Dawson 2014). All tracheostomy tubes must be secured with the use of tube tapes or ties (ICS 2014, Mitchell et al. 2013). These are attached to either side of the flange and connected at the side or back of the patient’s neck. They should be changed if they become soiled or wet.

Contraindications

Occasionally the ENT surgical team may request that the original dressing be left and not changed for a specific period of time. This is usually due to the increased risk of bleeding associated with new stoma formation. They may also request that tube tapes or dressings are not used if a surgical flap has been made and there is concern that any pressure from the dressing or tapes may restrict blood flow and cause the flap to fail (Mitchell et  al.  2013). In this scenario, the tube must be sutured in place and great care taken that the tube is not accidentally dislodged.

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Principles of care

Specific patient preparation Education

Patient education is paramount to providing quality care. In the initial post-operative or post-procedure phase, this may be purely to aid comfort and relaxation, explaining and stressing the ration-

Changing a tracheostomy dressing requires two people: one to hold and secure the tracheostomy tube while the other removes, cleans and then reapplies the tube tapes and new dressing (Dawson  2014). The stoma site should be cleaned thoroughly with 0.9% sodium chloride and allowed to air dry before an appropriate tracheostomy dressing is applied. This should be a foam dressing with a cross-shaped incision to fit around the tracheostomy tube (ICS  2014). For patients with secretions that tend to accumulate around the stoma, a specialized barrier product can be used to protect the skin and prevent tissue breakdown (Dawson  2014). Once the dressing is in place, the tube tapes

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should be reapplied (or renewed if soiled or wet). The tapes should be tight enough that they keep the tube secure, but not so tight that they are uncomfortable for the patient. As a guide, two fingers should fit comfortably between the patient’s neck and the tapes (Dawson 2014, NTSP 2013).

Anticipated patient outcomes

The skin around the stoma and neck area will remain clean and dry, and free from infection and tissue damage. Additionally, the tube will remain firmly in place, reducing the risk of accidental decannulation.

Procedure guideline 12.8  Tracheostomy: dressing and tube tape/tie change Essential equipment • Personal protective equipment • Dressing tray or trolley • Sterile procedure pack • Cleaning solution, such as 0.9% sodium chloride • Tracheostomy dressing • Tracheostomy tube tapes or ties • Gauze Medicinal products • Analgesia (if the patient finds the procedure painful) • Barrier cream Action

Rationale

Pre-procedure 1 Introduce yourself to the patient, explain and discuss the procedure with them, and gain their consent to proceed.

To ensure that the patient feels at ease, understands the procedure and gives their valid consent (NMC 2018, C).

2 Ensure enough nurses are present. This is a clean procedure and requires two nurses.

To ensure patient safety and reduce the risk of accidental decannulation or loss of the patient’s airway (Dawson 2014, C).

3 Cleanse hands with soap and water or an alcohol-based handrub.

To minimize risk of infection (NHS England and NHSI 2019, C).

4 Help the patient to sit in a semi-recumbent position with the neck slightly extended.

To ensure patient comfort and allow easy access to the neck area (NTSP 2013, C).

5 Prepare the dressing tray or trolley for the procedure. Open the sterile procedure pack and open the tracheostomy dressing and tapes/ties onto the sterile sheet. Pour the cleaning solution over the gauze.

To ensure all equipment required is available and prepared prior to starting the procedure. E

Procedure 6 Cleanse hands with an alcohol-based handrub and put on disposable plastic apron, gloves and eye protection.

To minimize the risk of cross-infection (NHS England and NHSI 2019, C). Manipulation of the patient’s airway may cause the patient to cough. Eye protection should therefore be worn (NICE 2017, C).

7 The first nurse holds onto the tracheostomy tube while the second nurse removes the tracheostomy tube tapes/ties.

To ensure the tracheostomy tube is not accidentally dislodged during the procedure (Dawson 2014, C).

8 The first nurse continues to hold onto the tracheostomy tube (until the end of step 12) while the second nurse removes the soiled dressing from around the tube and disposes of it directly into the clinical waste bag.

To minimize the risk of cross-infection (NICE 2017, C).

9 The second nurse cleans around the stoma with 0.9% sodium chloride using gauze, and allows it to air dry.

To remove wet or dried secretions from the stoma site (ICS 2014, C).

10 The second nurse applies barrier cream if required.

To protect the skin (Dawson 2014, C).

11 The second nurse replaces the tracheostomy dressing.

To increase patient comfort and protect the skin (Everitt 2016a, C).

12 The second nurse reapplies or replaces the tracheostomy tapes/ties, checking that one or two fingers can be placed between the tapes/ties and the neck once the tapes/ties are secure.

To secure the tracheostomy tube, ensuring it is not too loose or too tight (Dawson 2014, C).

13 Ask the patient whether the tracheostomy dressing and tapes/ties are comfortable.

To ensure patient comfort. E (continued)

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Procedure guideline 12.8  Tracheostomy: dressing and tube tape/tie change (continued) Action

Rationale

14 Remove apron, gloves and eye protection and dispose of them in a clinical waste bag. Cleanse hands with soap and water or an alcohol-based handrub.

To minimize the risk of infection (NHS England and NHSI 2019, C).

Post-procedure 15 Monitor the patient’s respiratory status and observations/ NEWS2. Escalate any concerns or deterioration in condition or NEWS2 immediately.

Tracheostomy: suctioning EVIDENCE-BASED APPROACHES

To identify any concerns or clinical deterioration early, and ensure timely escalation to senior staff if required (RCP 2017, C).

Figure 12.48  Tracheal suction using a fine-bore suction catheter.

Rationale

An effective cough requires closure then reopening of the glottis once an adequate intrathoracic pressure has been achieved. The mechanism of closing the glottis is compromised in patients with a tracheostomy tube, and so these patients are unable to generate the high flows required for coughing (Barnett 2012). In addition, the lack of natural warmth and humidification usually provided by the upper airways can increase sputum load or make secretions tenacious and difficult to expectorate (McNulty and Eyre 2015). Thick and dry secretions can block the tracheostomy tube and cause airway obstruction. Tracheal suction is therefore a critical part of tracheostomy care and all professionals caring for patients with altered airways should be competent in the procedure (Wilkinson et al. 2014).

Indications

Suctioning can cause significant patient distress and is associated with airway changes and cardiovascular instability. It should therefore only be performed when indicated and not at fixed intervals (Barnett 2012). Frequency should be determined on an individual patient basis with the aim of clearing airway secretions when the patient is not able to do so themselves, ensuring airway patency. A careful assessment of the patient should be carried out to determine the following: • whether the patient is able to clear their own secretions through the use of a good, strong cough • the location of any secretions • whether these secretions could be reached by the suction catheter • how detrimental these secretions might be for the patient.

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Suctioning may be indicated if the following are present (Everitt 2016a, NTSP 2013): • prominent audible or visible secretions • reduced oxygen saturations • increased respiratory rate or effort • increased or ineffective cough • use of accessory muscles for breathing • restlessness • patient request.

Contraindications

While there are no absolute contraindications, suctioning may be painful and distressing for the patient and can be complicated by (Bonvento et al. 2017, ICS 2014, Pathmanathan et al. 2014): • hypoxaemia • bradycardia and cardiovascular compromise • alveolar collapse and atelectasis (incomplete lung inflation)

• tracheal mucosal damage • bleeding • possible introduction of infection.

Infection risk

Standard precautions must be used at all times when suctioning; this includes wearing an apron, gloves and eye protection (NICE 2017). As with all procedures, hands should be decontaminated with soap and water or an alcohol-based handrub before and after contact with the patient, and all equipment disposed of in the clinical waste. All disposable equipment used for suctioning (e.g. suction tubing and canister) presents an infection control risk due to the presence of bacteria. Equipment should therefore be dated and changed regularly, as per the manufacturer’s recommendations or local policy (Wilkinson et al. 2014).

Method of suctioning

Suctioning should be performed with an inner tube (nonfenestrated) in place (Morris et al. 2015) using a fine-bore suction ­catheter of the appropriate size (Figure  12.48). Instillation of 0.9%  sodium chloride to ‘aid’ suctioning is not recommended (Pathmanathan et al. 2014). The routine use of ‘deep suctioning’ is also discouraged due to the risk of hypoxia, mucosal damage, inflammation, bleeding and airway occlusion (Barnett  2012, Greenwood and Winters 2014, NTSP 2013). If deep suctioning is required, the patient should be pre-oxygenated (see the section on specific patient preparation below) and the whole procedure should take no longer than 10 ­seconds to prevent hypoxia and patient distress (NTSP 2013). Shallow suctioning, where the catheter is inserted no further than the distal end of the tracheostomy tube, is preferred

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Box 12.8  Formula used to determine the correct suction catheter size

Figure 12.49  Oral suction using a Yankauer suction tip.

In the following, Fr (French) refers to the size of the catheter. 2

size of tracheostomy tube in Fr suction catheter size in Fr

2

For example: 2



8 2

12 Fr suction catheter

Source: Adapted from Greenwood and Winters (2014), NTSP (2013), Pathmanathan et al. (2014).

CLINICAL GOVERNANCE

Competencies

(Dawson 2014). Patients should be encouraged to cough ­secretions up to the tracheostomy tube if they are able, and these are then cleared through the use of shallow suctioning (ICS 2014). Any difficulty in passing the suction catheter should prompt ­further investigation as it may be that the tube is blocked or m ­ isplaced and requires immediate attention (Cosgrove and Carrie  2015, ICS  2014, NTSP  2013). Oral suctioning may also be required; this can be achieved by using a rigid Yankauer suction catheter tip (Figure 12.49).

Anticipated patient outcomes

The patient’s airway will remain patent through the use of suction to help clear excess secretions that the patient is not able to expectorate. Suctioning should be performed in a manner that causes the least possible amount of distress for the patient.

All staff caring for patients with an altered airway should be aware of the indications and risks of suctioning. They should be trained and assessed as competent in doing so safely before performing the procedure unsupervised (Wilkinson et al. 2014). They should also be aware of the different types of suction device available, and be able to assemble, maintain and use them safely.

PRE-PROCEDURAL CONSIDERATIONS

Equipment Suction unit

A low-volume, high-pressure suction unit should be used for tracheal suctioning, with the pressure set between 13 and 20 kPa (100–150 mmHg) (NTSP 2013). The lowest possible suction pressure should be used to prevent hypoxia, mucosal trauma and atelectasis. Prior to the procedure being performed, the suction unit should be turned on at the correct suction pressure and the system checked to ensure the suction is working prior to use.

Figure 12.50  Components of a closed-circuit catheter. The control valve locks the vacuum on or off. The catheter is protected inside an airtight sleeve. A T-piece connects the device to the tracheal tube.

Removable cap Catheter

Black line

593 T-piece

Irrigation port Lock–unlock control valve

Suction connection

Protective catheter sleeve

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A suction canister should be placed in between the suction unit and the suction tubing to collect the fluid and secretions suctioned. After the procedure, a small amount of sterile water should be suctioned to clear the tubing of secretions. The canister, tubing and bottle of sterile water should be changed every 24 hours to prevent bacterial growth and contamination, and all equipment should be dated and checked daily, even when not in regular use.

Suction catheters

Choosing the correct suction catheter size depends on the size of the tracheostomy tube. As a guide, the diameter of the suction catheter should not exceed half of the internal diameter of the ­tracheostomy tube. The formula in Box 12.8 can be used to determine the correct size catheter. Most suction catheters are single use and should be disposed of immediately after each use in the clinical waste. However, within a critical care setting, a closed-circuit suction system may be used for patients being mechanically ventilated. In a closed-circuit system, the catheter is sealed in a protective plastic sleeve (Figure 12.50)

and is connected to the ventilator circuit, and can remain within the circuit unit until it requires changing. A closed-circuit system helps to reduce the risk of infection caused by bacterial contamination of the catheter (Pathmanathan et al. 2014). In addition, it reduces the risk of hypoxia and the loss of positive end-expiratory pressure (PEEP) by removing the need to break or disconnect the ventilator circuit. These circuits are usually changed every 72 hours or as per the manufacturer’s recommendation (NTSP 2013).

Specific patient preparation

Patients who are mechanically ventilated and are receiving high concentrations of oxygen may benefit from being pre-oxygenated prior to the procedure (Greenwood and Winters 2014, NTSP 2013). This involves the delivery of 100% FiO2 to the patient for 1 minute prior to passing the suction catheter. The procedure should always be explained to the patient and verbal consent gained (if the patient is conscious). If required, the patient should be repositioned to ensure their comfort and allow easy access to the tracheostomy tube.

Procedure guideline 12.9  Tracheostomy: suctioning a patient (single-use suction catheter) Essential equipment • Personal protective equipment • Suction unit (wall or portable) • Suction canister and tubing • Sterile suction catheters of assorted sizes • Sterile bottled water (labelled ‘suction’ with opening date) Action

Rationale

Pre-procedure

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1 Introduce yourself to the patient, explain and discuss the procedure with them, and gain their consent to proceed.

To ensure that the patient feels at ease, understands the procedure and gives their valid consent (NMC 2018, C).

2 This is a clean procedure.

To ensure patient safety (NTSP 2013, C).

3 Cleanse hands with soap and water or an alcohol-based handrub.

To minimize the risk of infection (NHS England and NHSI 2019, C).

4 Help the patient to sit in a semi-recumbent position with the neck slightly extended.

To ensure patient comfort and allow easy access to the neck area (NTSP 2013, C).

5 Ensure the following are readily available in case required: • oxygen supply and masks/tubing • resuscitation trolley • emergency airway trolley • bedside tracheostomy box • additional staff.

To ensure patient safety in the event of an airway emergency (NTSP 2013, C).

6 If the secretions are tenacious, consider nebulizing 0.9% sterile sodium chloride or other prescribed mucolytic agents.

To loosen dry and thick secretions (Bonvento et al. 2017, C).

7 If the patient is oxygen dependent, pre-oxygenate them for a period of 1 minute.

To minimize the risk of hypoxia (Greenwood and Winters 2014, C).

8 If the patient has a fenestrated outer tube, ensure that a plain (non-fenestrated) inner tube is inserted prior to suctioning.

Suctioning via a fenestrated inner and outer tube may cause trauma to the tracheal wall (Morris et al. 2015, C).

Procedure 9 Cleanse hands with an alcohol-based handrub and put on disposable plastic apron, gloves and eye protection.

To minimize the risk of cross-infection (NHS England and NHSI 2019, C). Manipulation of the patient’s airway may cause the patient to cough. Eye protection should therefore be worn (NICE 2017, C).

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10 a Turn the suction on and ensure that the pressure is set to an appropriate level. It should not exceed 20 kPa (150 mmHg). b  Select the correct size of catheter (see Box 12.8).

To minimize the risk of atelectasis and mucosal trauma (ICS 2014, C; NTSP 2013, C).

11 Keeping the suction catheter in the sterile pack, open the end and attach it onto the suction tubing. The suction catheter should not be removed from the sterile pack until ready.

To keep the catheter as sterile as possible, minimizing the risk of cross-infection. E

12 Apply an additional clean disposable glove onto the dominant hand.

To facilitate easy disposal of the suction catheter after use and minimize the risk of cross-infection. E

13 Remove oxygen therapy (if applicable).

To allow access to the tracheostomy tube. E

14 If performing a shallow suction: remove the catheter from the sterile pack and introduce it into the tracheostomy tube. Ask the patient to cough, then apply suction as secretions meet the catheter. Suction is created by placing a thumb over the suction port. If performing a deep suction: introduce the catheter to about one-third of its length (approximately 10–15 cm) or until the patient coughs. If resistance is felt, withdraw the catheter 1–2 cm before applying suction then slowly withdraw the catheter out.

Suction is only applied on withdrawal and never on insertion to reduce the risk of mucosal trauma (NTSP 2013, C). The catheter should go no further than the carina and should be withdrawn slightly before suction is applied to prevent trauma (Greenwood and Winters 2014, C).

15 Suction the patient for no more than 10 seconds.

Prolonged suctioning may result in acute hypoxia, cardiac arrhythmias, mucosal trauma and significant distress for the patient (NTSP 2013, C).

16 Wrap the catheter around the dominant hand and then pull the glove back over the soiled catheter. Discard immediately into the clinical waste.

Wrapping the soiled catheter up in the glove minimizes the risk of cross-infection. E Catheters are single use and should be disposed of as per infection control guidelines. E

17 Repeat the procedure until the airway is clear. No more than three suction passes should be made during any one suction episode (unless in an emergency, such as tube occlusion). A new suction catheter should be used each time, and the patient should be allowed sufficient time to recover in between each suction.

To minimize the risk of hypoxia, minimize the risk of infection, and cause minimal distress for the patient (NTSP 2013, C).

A catheter that is too small a diameter may not be effective in removing thick secretions. A catheter that is too big will occlude the tube, cause hypoxia and distress the patient (NTSP 2013, C).

Post-procedure 18 Reapply oxygen therapy (if applicable).

To prevent hypoxia. E

19 Clear the suction tubing of secretions by dipping it into the sterile water bottle and applying suction until the solution has rinsed the tubing through.

To loosen and flush secretions that have adhered to the inside of the suction tubing (NTSP 2013, C).

20 Remove apron, gloves and eye protection and dispose of them in the clinical waste. Cleanse hands with soap and water or an alcohol-based handrub.

To minimize the risk of infection (NHS England and NHSI 2019, C).

21 Monitor the patient’s respiratory status and observations/ NEWS2. Escalate any concerns or deterioration in condition/NEWS2 immediately.

To identify any concerns or clinical deterioration early, and ensure timely escalation to senior staff if required (RCP 2017, C).

COMPLICATIONS

Hypoxia

The act of suctioning reduces vital volume from the lungs and upper airways. Each suctioning procedure should last no longer than 10 seconds to decrease the risk of tracheal damage and hypoxia (NTSP 2013). Ventilator disconnection or removal of the oxygen supply will also add to the risk of hypoxia prior to suctioning. This risk can be reduced by pre-oxygenating the lungs with 100% oxygen, either manually or via a ventilator (Greenwood and Winters 2014).

Cardiac arrhythmias

Arrhythmias may be brought about by the onset of hypoxaemia, or a vagal reflex due to tracheal stimulation by the suction catheter (Bonvento et al. 2017).

Raised intracranial pressure

This may occur if the suction catheter causes excessive ­tracheal  stimulation and results in coughing and an increase in  the patient’s intrathoracic pressure, both of which can compromise cerebral venous drainage (Greenwood and ­ Winters 2014).

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Tracheal mucosal damage

Damage may be caused by using a catheter that is too big, using too high a suction pressure or passing a suction catheter down through a fenestrated inner tube (NTSP  2013). Unnecessary ‘deep’ suctioning may also contribute to mucosal damage.

Figure 12.51  Tracheostomy inner tube change.

Tracheostomy: changing an inner cannula EVIDENCE-BASED APPROACHES

Rationale

Tracheostomy tubes with an inner cannula are inherently safer than ones without an inner cannula and are therefore advocated (NTSP 2013). Regular checking and changing of the inner cannula allows for visual inspection of secretions and assists in assessment regarding humidification, reducing the risk of airway obstruction.

Indications

The inner cannula should be removed regularly and inspected for patency (Cosgrove and Carrie  2015). Indications for inspection include: • signs of respiratory distress • increased work of breathing • a drop in oxygen saturations • any other sign of clinical deterioration (NTSP 2013).

Contraindications

There are no contraindications for inspecting or changing an inner tube. However, inner cannulas should only be used with the tracheostomy they are designed for.

Principles of care

The inner cannula should be removed (Figure 12.51), inspected and changed if required. Although this should be done at regular intervals, the frequency of inspection will depend on the volume

and tenacity of the patient’s secretions. Patients with copious secretions may require 2-hourly inner tube changes, while a patient with a good cough and minimal secretions will require much less frequent checks. The timing should be determined ­following assessment of the patient and their secretions, and ­documented in the tracheostomy passport. Inner cannulas should either be cleaned or disposed of after each use according to the manufacturer’s recommendations.

Anticipated patient outcomes

The altered airway will remain patent and free from secretions, which have the potential to obstruct the tracheostomy tube. The inner cannula change will be done confidently and efficiently, causing the patient minimal distress and anxiety.

Procedure guideline 12.10  Tracheostomy: changing an inner cannula Essential equipment • Personal protective equipment • Sterile dressing pack • Cleaning solution, such as 0.9% sodium chloride • Inner cannula of the same size as the tracheostomy tube • Tracheostomy tube brush cleaner (if the patient has a reusable inner tube) • Gallipot Action

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Rationale

Pre-procedure 1 Introduce yourself to the patient, explain and discuss the procedure with them, and gain their consent to proceed.

To ensure that the patient feels at ease, understands the procedure and gives their valid consent (NMC 2018, C).

2 This is a clean procedure.

To ensure patient safety (NTSP 2013, C).

3 Cleanse hands with soap and water or an alcohol-based handrub.

To minimize the risk of infection (NHS England and NHSI 2019, C).

4 Ensure the following are readily available in case required: • emergency oxygen and equipment (masks, tubing) • suction and equipment (suction catheters and Yankauer suction tips) • resuscitation trolley • emergency airway trolley • bedside tracheostomy box • additional staff.

To ensure patient safety if unable to secure the airway with the new tube (NTSP 2013, C).

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5 Help the patient to sit in a semi-recumbent position with the neck slightly extended.

To ensure patient comfort and allow easy access to the neck area (Dawson 2014, C).

6 Pre-oxygenate the patient if they are known to desaturate off oxygen.

To minimize the risk of hypoxia (Greenwood and Winters 2014, C).

7 Prepare a dressing tray or trolley for the procedure. Open the sterile procedure pack and empty the tracheostomy inner tube onto the sterile sheet. If a reusable inner tube is being used, pour normal saline 0.9% into a gallipot and open a tracheostomy tube brush cleaner.

To ensure all equipment required is prepared prior to starting the procedure. E

Procedure 8 Cleanse hands with an alcohol-based handrub and put on disposable plastic apron, gloves and eye protection.

To minimize the risk of cross-infection (NICE 2017, C).

9 Remove the inner cannula and dispose of it in the clinical waste. If non-disposable inner tube is used, remove it and place it on the sterile sheet.

To minimize the risk of cross-infection (NICE 2017, C).

10 Immediately place the new inner tube in position and ensure it is secured in the ‘locked’ position.

To re-establish the airway and ensure the inner cannula is secure. E

11 Check that the patient is comfortable and they are at ease with their breathing.

To ensure patient comfort. E

12 If a reusable inner tube is used, clean the old tube with normal saline 0.9% and the brush cleaner. Do not leave the inner tube to soak. The tube should be dried thoroughly then placed in a clean container for future use.

Soaking tubes in stagnant cleaning solutions may cause bacterial colonization and subsequent cross-infection (Cosgrove and Carrie 2015, C).

13 Remove apron, gloves and eye protection and dispose of them in the clinical waste, along with the old procedure pack. Cleanse hands with an alcohol-based handrub.

To minimize the risk of infection (NICE 2017, C).

Post-procedure 14 Monitor the patient’s respiratory status and observations/ NEWS2. Escalate any concerns or deterioration in condition/ NEWS2 immediately.

To identify any concerns or clinical deterioration early, and ensure timely escalation to senior staff if required (RCP 2017, C). Changing an inner tube is potentially hazardous and may cause respiratory problems. E

15 Document the inner cannula change time, in addition to the tenacity and volume of the secretions.

To ensure all staff are aware of the tracheostomy care that has been performed and how often the inner tube requires checking or changing. E

COMPLICATIONS

If the patient has any difficulty breathing or shows any signs of clinical deterioration during or after the procedure, expert help should be called immediately and the emergency algorithm for an altered airway followed (see Figure 12.34). The same applies if the inner cannula cannot be advanced.

Tracheostomy: changing a tube EVIDENCE-BASED APPROACHES

Rationale

Changing a tracheostomy tube involves the removal of the old tracheostomy tube and its replacement with a new device.

Indications

Changing a tracheostomy tube is indicated as follows (Greenwood and Winters 2014, Hess and Altobelli 2014, NTSP 2013): • when the tracheostomy tube has been in place for 30 days, or  as  per the manufacturer’s recommendations (Hess and Altobelli 2014) • changing from a non-fenestrated to a fenestrated tracheostomy tube to facilitate weaning and improve communication

• downsizing the tracheostomy tube if the patient is clinically improving • changing from an uncuffed tube to a cuffed tube if the patient requires mechanical ventilation • to replace a faulty, ill-fitting or displaced tube.

Contraindications

The decision to change a tracheostomy tube will be made after weighing up the risks and benefits and after discussion and agreement with the multidisciplinary team. Contraindications may include (NTSP 2013): • time since formation: changing a tracheostomy tube too soon after formation is contraindicated as the tract may not have healed adequately and can create a false passage • poor visualization of the tracheostomy tract and inadequate lighting or exposure • lack of emergency equipment • practitioner inexperience or lack of availability of staff competent in airway management • patient is on high ventilator settings or has high oxygen requirements • patient is receiving radiotherapy to the neck or has done in the past 2 weeks

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• patient is nearing the end of their life • patient refuses or is not co-operative.

Principles of care

The first tracheostomy tube change must be performed by a practitioner who is not only competent in tracheostomy tube placement but also has advanced airway management and intubation skills (ICS 2014). Except in emergencies, the first change should not be performed for 72 hours following a surgical tracheostomy or for 7–10 days following a percutaneous tracheostomy (Mitchell et al. 2013). This is to allow the tract between the skin and the trachea to develop. Removal of the tracheostomy tube before this time may result in complete loss of the patient’s airway if there is difficulty recannulating the tracheostomy. This procedure requires the presence of a second practitioner who is trained in tracheostomy care and who is able to summon more expert help if required. Subsequent changes should be performed by practitioners trained in tube changes, and always with a second practitioner present who is competent in tracheostomy care (ICS 2014). Unless it is an emergency situation, the procedure should be well planned in advance. All equipment, including emergency equipment and intubation drugs, should be immediately accessible. Appropriate medical support should also be readily available if the tube change does not go to plan. The tube change may be performed using a ‘blind insertion’ technique for well-established stomas, or it may be guided using a bougie, an exchange catheter or a guidewire. A guided technique allows the tube to be exchanged over the guide, reducing the risk of creating a false passage (ICS 2014). It is particularly useful for newly created stomas and for patients with a large neck

(NTSP 2013). A fibreoptic scope may also be used to assist with the insertion and confirm the correct placement of the new tube (NTSP  2013). The tube change should be documented in the patient’s records along with any adverse events and when the next tube change is due.

Anticipated patient outcomes

The procedure will be well planned with all the necessary equipment immediately available and suitably trained personnel present to ensure patient safety. The tracheostomy tube will be changed confidently and efficiently, causing the patient minimal distress and anxiety.

PRE-PROCEDURAL CONSIDERATIONS

Prior to tube change, the following questions should be asked: • Is this the best time to be doing this procedure? • Am I the best person to do it? • Have I got all the essential equipment required? • Is there appropriate support available if required? If the answer to all of the questions above is ‘yes’, then it is safe to proceed with the procedure. The practitioner should talk through the details of the procedure with all staff involved and ensure all members are familiar with what to do if the exchange does not go to plan. The procedure should always be explained to the patient and verbal consent gained (if the patient is conscious). The patient should be repositioned to allow easy access to the tracheostomy stoma. This can be achieved by lying the patient supine or at 45°, with a towel or pillow under their shoulders and the neck extended (NTSP 2013).

Procedure guideline 12.11  Tracheostomy: changing a tube Essential equipment • Personal protective equipment • Sterile dressing pack • New tracheostomy tube for insertion • Lubricating gel • Stitch cutter (if flange sutures are still present) • 10 mL syringe • Bougie, exchange catheter or guidewire (if a guided technique is to be used) • Cleaning solution, such as 0.9% sodium chloride • Tracheostomy foam-based dressing • Tracheostomy tapes/ties • Cuff manometer • Gauze Emergency equipment

598

• Oxygen and masks/tubing • Suction, suction catheters and Yankauer suction tips • Resuscitation trolley • Emergency airway trolley • Fibreoptic scope • Bedside tracheostomy box • Intubation drugs • Additional staff Action

Rationale

Pre-procedure 1 The first tracheostomy change should be carried out by a practitioner trained in advanced airway and intubation skills. Subsequent changes should be carried out by practitioners competent in tube change. In both cases, a second appropriately trained person should assist.

To ensure that the most appropriately trained member of staff performs the procedure, ensuring patient safety (ICS 2014, C).

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2 The patient should be nil by mouth for 6 hours (solids) and for 2 hours (fluids) prior to the tube change. If the patient has a nasogastric tube, this should be aspirated prior to the procedure.

Any manipulation of the airway may cause the patient to vomit, increasing the risk of aspiration. Keeping the patient nil by mouth will reduce this risk (NTSP 2013, C).

3 Introduce yourself to the patient, explain and discuss the procedure with them, and gain their consent to proceed.

To ensure that the patient feels at ease, understands the procedure and gives their valid consent (NMC 2018, C).

4 Cleanse hands with an alcohol-based handrub.

To minimize the risk of infection (NHS England and NHSI 2019, C).

5 Ensure all emergency equipment is immediately available.

In case it is not possible to secure the airway with the new tube (ICS 2014, C).

6 Help the patient to sit in a semi-recumbent position with the neck extended. It may be necessary to place a rolled towel under the patient’s shoulders to further extend the neck.

To allow easy access to the neck area. E To bring the trachea closer to the skin and stretch the stoma opening to aid tube reinsertion (NTSP 2013, C).

7 Pre-oxygenate the patient if they are known to desaturate off oxygen.

To reduce the risk of hypoxia (NTSP 2013, C).

8 Prepare a dressing tray or trolley for the procedure. Open the sterile procedure pack and open the new tracheostomy tube and its contents onto the sterile sheet.

To ensure all equipment required is prepared prior to starting the procedure. E

9 If the new tracheostomy is cuffed, fully inflate the cuff using a 10 mL syringe. Once satisfied the cuff is functioning correctly, deflate the cuff prior to insertion.

To ensure there is no air leak and the cuff does not spontaneously deflate. E

10 Insert the obturator into the new tube, checking that it can be easily removed.

To become familiar with removing the obturator prior to insertion. E

11 Lubricate the new tube sparingly with a lubricating jelly and place it onto the sterile sheet.

To facilitate insertion and maintain sterility (Hess and Altobelli 2014, C).

Procedure 12 Cleanse hands using an alcohol-based handrub and apply disposable plastic apron, gloves and eye protection.

To minimize the risk of infection (NHS England and NHSI 2019, C).

13 Encourage the patient to cough and suction any secretions as required from the oral cavity (see Figure 12.49). Aspirate the subglottic port if present.

To reduce the risk of pooled secretions sitting above the cuff entering the lungs when the cuff is deflated (NTSP 2013, C).

14 Remove the inner cannula.

To assist with the outer tube removal. E

15 While one practitioner holds the tube, the other practitioner should unfasten the tube tapes and remove the sutures (if applicable).

To secure the tube and ensure it is not accidentally removed before the right time (NTSP 2013, C).

16 If the tracheostomy tube is cuffed, gently deflate the cuff, providing additional suctioning if required.

To prevent secretions from entering the lungs when the cuff is deflated (NTSP 2013, C).

17 Check both practitioners and the patient are happy to proceed prior to removing the tube. Provide reassurance to the patient as required.

To ensure patient safety at all times. E To reassure the patient and ease any anxiety. E

18 Administer conscious sedation as required and as prescribed.

Conscious sedation relaxes the patient and reduces the risk of coughing (NTSP 2013, C). Coughing can result in unwanted closure of the tracheostomy stoma. E

19 If a guided technique is being used, insert the guide into the tracheostomy tube.

To maintain the patency of the stoma (NTSP 2013, C).

20 Gently remove the old tube from the patient’s neck while asking the patient to exhale. Remove it using a brisk, ‘out and downwards’ movement. Place it directly into the clinical waste bag.

To reduce the risk of cross-infection (NICE 2017, C).

21 Put traction on the stay sutures if present, or use tracheal dilators if required.

To maintain the patency of the trachea and prevent soft tissues from obstructing the stoma (Lee et al. 2015, C).

22 Quickly clean around the stoma with 0.9% sodium chloride and dry it gently with gauze. Apply barrier cream if required.

To clean the skin, reducing the risk of infection and tissue damage (ICS 2014, C). (continued)

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Procedure guideline 12.11  Tracheostomy: changing a tube (continued) Action

Rationale

23 If using a blind technique: insert the clean tube with the obturator in place using an ‘up and over’ action. Remove the obturator immediately.

Introduction of the tube is less traumatic if directed along the contour of the trachea (Greenwood and Winters 2014, C). The patient cannot breathe while the obturator is in place as it completely occludes the tracheostomy tube (NTSP 2013, C).

24 If using a guided technique: railroad (thread) the new tracheostomy tube over the guide and into the stoma. Once satisfied, remove the guide as quickly as possible.

To guide insertion of the new tube into the stoma and prevent the creation of a false passage (NTSP 2013, C). The patient cannot breathe properly while the guide is in place. E

25 Whether using a blind technique or a guided technique: insert the inner tube and ensure it is in a ‘locked’ position.

The presence of an inner tube increases safety as it can be quickly removed and replaced if it becomes obstructed with tenacious secretions or a sputum plug (NTSP 2013, C).

26 If the tube is cuffed, gently inflate the cuff and check the pressure using a cuff manometer. The cuff pressure should be 15–25 cmH2O (10–18 mmHg).

Too low a pressure will cause a cuff leak, resulting in ineffective ventilation and protection from aspiration. Too high a pressure may cause tracheal stenosis, tracheomalacia, tracheo-oesophageal fistula or an arterial fistula (ICS 2014, C; NTSP 2013, C).

27 Insert the tracheostomy dressing around the tube if required.

A foam dressing will protect the skin and prevent tissue damage (Everitt 2016a, C).

28 Secure the tracheostomy tube with the tapes/ties. Ensure one or two fingers can be comfortably inserted between the tapes and the patient’s skin.

To secure the tube without causing the patient discomfort (Dawson 2014, C).

29 Check that the patient is comfortable and they are at ease with their breathing.

To ensure patient comfort and to assess for any signs of incorrect tube placement. E

30 Remove apron, gloves and eye protection and dispose of them in the clinical waste bag, along with the procedure pack and all other disposable equipment used. Cleanse hands with an alcohol-based handrub.

To minimize the risk of infection (NHS England and NHSI 2019, C).

Post-procedure 31 Assess the airway by checking the following: • no evidence of breathing problems • bilateral chest movement • exhaled air felt through the end of the tracheostomy • air entry heard on auscultation • suction catheter able to pass though tube • for difficult procedures, capnography or a fibreoptic scope can be used to confirm placement.

To ensure the new tracheostomy is sitting in the trachea and the patient is being ventilated or oxygenated (NTSP 2013, C).

32 Monitor the patient’s respiratory status and observations/ NEWS2. Escalate any concerns or deterioration in condition/NEWS2 immediately.

To identify any concerns or clinical deterioration early, and ensure timely escalation to senior staff if required (RCP 2017, C).

33 Document the tracheostomy tube change, including the new tube make and size. Document any problems observed during the procedure.

To ensure all staff are aware of the new tube size and type (NMC 2018, C).

600 COMPLICATIONS

Changing a tracheostomy tube is a high-risk procedure and may result in the loss of an airway. All staff involved should stay calm and reassure the patient as necessary. There should be no delay in seeking expert or additional help if required, or in following the emergency algorithm for an altered airway if necessary (see Figure 12.34) (ICS 2014, NTSP 2013). The patient should be oxygenated in between attempts and the stoma kept open using dilators or by putting traction on the stay sutures (Lee et al. 2015). If there is difficulty recannulating the stoma then insertion of a tube half a size smaller should be attempted (Mitchell et al. 2013). The tube should never be forced, and blind insertion of a guide into the stoma after the tube has been removed should only be considered in an emergency. The NTSP (2013) recommends the use of a

fibreoptic scope and airway exchange catheter as a second line if recannulation using a tube one size smaller is unsuccessful.

Tracheostomy: applying a speaking valve EVIDENCE-BASED APPROACHES

Rationale

The inability to communicate verbally can be extremely frustrating and upsetting a patient. Following initial formation of the tracheostomy, the patient may have a period of being nursed with the cuff up if they require mechanical ventilation. As the patient weans from the ventilator and the stoma becomes established, the cuff can be intermittently deflated and a speaking valve

CHAPTER 12 Respiratory care, CPR and blood transfusion

attached. In addition to restoring the patient’s voice, the presence of a speaking valve helps to restore a more normalized physiology for respiration, can enhance swallowing, promotes the clearance of secretions through the mouth, and facilitates weaning and decannulation (Sutt et al. 2015). The speaking valve trial should be discussed and agreed by the multidisciplinary team, with a clear plan regarding how long and how often the speaking valve should be in place in a 24-hour period.

Indications

Inserting a speaking valve is indicated where (Morris et al. 2015): • the patient’s secretion load is minimal and they have an effective cough • the patient does not require positive pressure mechanical ventilation.

Contraindications

Inserting a speaking valve may be contraindicated in patients who (Hess and Altobelli 2014, Morris et al. 2015): • are at high risk of aspiration • have a high secretion load • have severe upper airway obstruction • have a decreased consciousness level • cannot tolerate having their cuff down.

Principles of care

Depending on why the tracheostomy has been formed and the status of the patient, they may cope with having the cuff down

and a speaking valve may be attached fairly quickly and for long periods of time. Some may actually feel their breathing is easier and prefer this set-up. It can, however, cause a significant increase in a patient’s work of breathing, and some patients with a large tube or narrow trachea may find it difficult to cope with the speaking valve due to reduced airflow around the tube (Bonvento et al. 2017). In this situation, consider downsizing the tracheostomy tube or changing it to an appropriate tube with a fenestrated inner cannula (Morris et al. 2015).

Anticipated patient outcomes

The patient will be able to tolerate having the cuff down and the speaking valve on for the prescribed length of time. The presence of the speaking valve will aid communication and facilitate weaning.

PRE-PROCEDURAL CONSIDERATIONS

Specific patient preparation

The procedure should always be explained to the patient and verbal consent gained. The patient should be counselled prior to the procedure and warned that their breathing may feel very different and that they may cough considerably when the cuff is deflated initially. If required, the patient should be repositioned to ensure their comfort and allow easy access to the tracheostomy tube. Prior to the cuff being deflated, the patient should be encouraged to cough and clear secretions. Suction may also be required. If a patient has a subglottic port, secretions should be aspirated using a 10 mL syringe prior to the cuff being deflated (Morris et al. 2015).

Procedure guideline 12.12  Tracheostomy: insertion and removal of a speaking valve Essential equipment • Personal protective equipment • Sterile dressing pack • Speaking valve • 10 mL syringe • Cuff manometer • Suction, suction catheters and Yankauer suction tips • normal saline 0.9% Action

Rationale

Pre-procedure 1 Discuss the possibility of a speaking valve trial with the multidisciplinary team.

To ensure the multidisciplinary team agree to the speaking valve trial. E

2 This is a clean procedure and requires the presence of two nurses.

To ensure patient safety (NTSP 2013, C).

3 Introduce yourself to the patient, explain and discuss the procedure with them, and gain their consent to proceed.

To ensure that the patient feels at ease, understands the procedure and gives their valid consent (NMC 2018, C).

4 Cleanse hands with soap and water or an alcohol-based handrub.

To minimize the risk of infection (NHS England and NHSI 2019, C).

5 Help the patient to sit in a semi-recumbent position with neck slightly extended.

To ensure patient comfort and allow easy access to the neck area (NTSP 2013, C).

Procedure 6 Cleanse hands using an alcohol-based handrub and apply disposable plastic apron, gloves and eye protection.

To minimize the risk of infection (NHS England and NHSI 2019, C).

7 Prepare a dressing tray or trolley for the procedure. Place the speaking valve and a 10 mL syringe onto the sterile sheet.

To ensure all equipment required is prepared prior to starting the procedure. E

8 Encourage the patient to cough and suction secretions in the mouth or from above the cuff if necessary. If the tube has a subglottic port, aspirate gently using a 10 mL syringe.

To prevent pooled secretions entering the lungs when the cuff is deflated (NTSP 2013, C). (continued)

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Procedure guideline 12.12  Tracheostomy: insertion and removal of a speaking valve (continued) Action

Rationale

9 If the tracheostomy tube is cuffed, gently deflate the cuff using a clean 10 mL syringe on expiration while simultaneously providing suction.

Providing suction while the cuff is deflated helps to clear any secretions that remain, reducing the risk of aspiration (Morris et al. 2015, C; NTSP 2013, C).

10 Reassure the patient as required.

The patient may cough for a period of time after cuff deflation, which may cause them to panic and worsen their breathing. E

11 Apply the speaking valve directly onto the tracheostomy tube. Ask the patient to inhale through the tracheotomy tube and exhale through their mouth.

To encourage air to flow past the vocal cords and aid phonation. E

12 Ask the patient to say ‘ah’ or count from one to five. If the patient’s voice sounds wet, ask them to cough and clear secretions. If the problem persists, remove the speaking valve and ask them to cough and clear secretions again. Provide suction as required.

Deflating the cuff can move secretions into the upper airways; these need to be cleared (Morris et al. 2015, C).

13 Monitor the patient closely during the speaking valve trial. Remove the speaking valve if: • the patient shows signs of respiratory distress • the patient’s oxygen saturations fall • there is an evident wheeze or stridor • the patient is unable to vocalize • the patient looks fatigued • the patient requests it.

A change in breathing or evidence of clinical deterioration requires immediate removal of the speaking valve and reinflation of the cuff (Morris et al. 2015, C).

14 Depending on how the patient copes with the speaking valve, make a weaning plan with the multidisciplinary team.

To ensure a collaborative approach to weaning. E

15 At the end of the speaking valve trial, re-perform steps 2–6, then remove the speaking valve.

As above. To end the speaking valve trial. E

16 Use the 10 mL syringe to reinflate the cuff and check the pressure using the cuff manometer. The pressure should be between 15 and 25 cmH2O (10–18 mmHg).

To ensure the cuff is sufficiently inflated to prevent aspiration, but not overinflated so as to cause damage to the trachea (NTSP 2013, C).

17 Check that the patient is comfortable and they are at ease with their breathing.

To ensure patient comfort. E

Post-procedure

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18 Monitor the patient’s respiratory status and observations/NEWS2. Escalate any concerns or deterioration in condition/NEWS2 immediately.

To identify any concerns or clinical deterioration early, and ensure timely escalation to senior staff if required (RCP 2017, C).

19 Clean the speaking valve using normal saline 0.9% and leave it to air dry. Store it in an airtight container.

To minimize bacterial colonization and prevent infection (Everitt 2016a, C).

20 Document how long the cuff was down and if the speaking valve was tolerated. Document any other concerns or details that may assist the multidisciplinary team.

To communicate to the multidisciplinary team the details of the cuff-down speaking valve trial. E

COMPLICATIONS

Deflating the cuff and inserting a speaking valve may cause respiratory distress. If at any time the patient experiences difficulty in breathing, is unable to vocalize, or begins to sound wheezy or stridulous, the speaking valve should be removed immediately and the patient reassessed (Hess and Altobelli  2014, Morris et al. 2015). The speaking valve should also be removed if there is any evidence of aspiration or if the patient cannot cope with their secretions.

Tracheostomy: decannulation EVIDENCE-BASED APPROACHES

Rationale

Prior to decannulation, the patient should have been appropriately weaned and be able to tolerate having the cuff down with

either a speaking valve or a heat and moisture exchanger on ­permanently. It may also be appropriate to trial an occlusion or decannulation plug for 12–24 hours (NTSP 2013). This is a small plastic plug or cap that fits onto the outer tube of either a fenestrated or a non-fenestrated tracheostomy tube (Figure  12.52). It completely blocks off the tracheostomy tube and diverts air around the tube and into the patient’s nose and mouth instead. Patients may find this stage difficult as airway resistance is high, and so it may not be well tolerated. As with all care pathways related to tracheostomies, a multidisciplinary approach is required and all members should be involved in the decision to decannulate (Bonvento et al. 2017).

Indications

Decannulation can be considered if there are no concerns regarding the patient’s ability to maintain their own airway once the tracheostomy tube is removed and if the patient meets the following

CHAPTER 12 Respiratory care, CPR and blood transfusion

Figure 12.52  Decannulation plug.

criteria (Cheung and Napolitano  2014, Global Tracheostomy Collaborative 2013, NTSP 2013, Singh et al. 2017): • the airway is patent above the level of the stoma • the pathological process necessitating the insertion of the tracheostomy tube has been resolved • the patient is conscious and able to follow commands • the patient is able to tolerate having the cuff down for long periods of time • the patient does not have copious secretions • the patient can cough and clear their secretions effectively • the patient has an effective swallow • the patient is cardiovascularly stable • no new lung infiltrates appear on chest X-ray • the multidisciplinary team agrees to decannulation.

Contraindications

Decannulation is contraindicated if any of the above criteria have not been met.

Principles of care

The process should be undertaken or supervised by a practitioner who is competent in recannulation and airway management. The

procedure should be well planned and performed at an appropriate time of the day when experienced staff are present (Dawson 2014, ICS 2014). Undiagnosed damage to the trachea  –  including stenosis, tracheomalacia and granuloma – may result in a failed decannulation (Cipriano et al. 2015, ICS 2014). It is important, therefore, that the patient is closely monitored for a period of time after decannulation, to ensure they remain stable and are able to maintain their own airway.

Anticipated patient outcomes

The patient will be able to maintain their own airway once the  tracheostomy tube has been removed and will show no signs of clinical deterioration, in particular respiratory distress or tiring.

PRE-PROCEDURAL CONSIDERATIONS

Equipment

A tracheostomy box, with a new tracheostomy tube and all emergency equipment (oxygen, suction and a fibreoptic scope), should be available at the bedside and in working order. A resuscitation and advanced airway trolley should be easily accessible if required.

Specific patient preparation

The procedure should always be explained to the patient and verbal consent gained. If required, the patient should be ­ ­repositioned to ensure their comfort and allow easy access to the tracheostomy tube. The patient should be nil by mouth for at least 6 hours after eating solids and 2 hours after consuming fluids (NTSP 2013). This is to minimize the risk of vomiting and aspiration.

Procedure guideline 12.13  Tracheostomy: decannulation Essential equipment • Personal protective equipment • Sterile dressing pack • 10 mL syringe • Stitch cutter (if sutures are present) • Occlusive dressing • Tracheostomy box • Oxygen, mask and tubing • Suction, suction catheters and Yankauer suction tips • Stethoscope • Resuscitation trolley (ensure nearby or know how to access) • Advanced airway trolley (ensure nearby or know how to access) • Fibreoptic scope (ensure nearby or know how to access) • Normal saline 0.9% solution • Gallipot • Gauze Action

603 Rationale

Pre-procedure 1 Discuss decannulation with the multidisciplinary team.

To ensure the multidisciplinary team agree to the patient being decannulated and are readily available if required. E

2 This procedure requires the presence of two nurses.

To ensure patient safety (NTSP 2013, C).

3 Introduce yourself to the patient, explain and discuss the procedure with them, and gain their consent to proceed.

To ensure that the patient feels at ease, understands the procedure and gives their valid consent (NMC 2018, C).

4 Cleanse hands with soap and water or an alcohol-based handrub.

To minimize the risk of infection (NHS England and NHSI 2019, C). (continued)

THE ROYAL MARSDEN MANUAL OF CLINICAL NURSING PROCEDURES

Procedure guideline 12.13  Tracheostomy: decannulation (continued) Action

Rationale

5 Help the patient to sit in a semi-recumbent position with the neck slightly extended.

To ensure patient comfort. E Extending the neck will make removal of the tube easier (NTSP 2013, C).

6 Apply oxygen therapy via either a nasal cannula or a face-mask (if required).

To reduce the risk of hypoxia (O’Driscoll et al. 2017, C).

7 Prepare a dressing tray or trolley for the procedure. Open the procedure pack and pour normal saline 0.9% solution into a gallipot. Prepare the dressing to be applied over the tracheostomy stoma.

To ensure all equipment required is prepared prior to starting the procedure. E

Procedure 8 Cleanse hands using an alcohol-based handrub and apply disposable plastic apron, gloves and eye protection.

To minimize the risk of infection (NHS England and NHSI 2019, C).

9 Encourage the patient to cough and suction any secretions as required.

To minimize the risk of aspiration (Morris et al. 2015, C).

10 While one nurse holds onto the tracheostomy tube, the second nurse removes the tapes and any sutures present at the flange, and deflates the cuff (if still inflated).

To ensure the tube is not accidentally dislodged before the right time. E To prepare the tube for decannulation. E

11 Check both practitioners and the patient are happy to proceed prior to removing the tube. Provide reassurance to the patient as required.

Good communication increases patient safety. E To minimize patient anxiety. E

12 Remove the tube on maximal inspiration.

To reduce the risk of alveolar collapse (Global Tracheostomy Collaborative 2013, C).

13 Clean the stoma site using normal saline 0.9% soaked gauze then allow it to air dry.

To clean the skin and minimize the risk of infection (Global Tracheostomy Collaborative 2013, C).

14 Bring together the top and bottom of the stoma to ensure an optimal seal is achieved. Secure with gauze and an occlusive dressing.

To encourage the stoma to close and ensure all ventilation takes place via the upper airways. E Covering the stoma also reduces the risk of infection by ensuring dust and particles are not inhaled directly into the respiratory tract. E

15 Check that the patient is comfortable and is at ease with their breathing.

To ensure patient comfort. E

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16 Monitor the patient’s respiratory status and observations/ NEWS2. Escalate any concerns or deterioration in condition/ NEWS2 immediately.

Removal of a tracheostomy tube is a high-risk procedure. The patient may not be able to maintain their own airway and may require emergency recannulation or intubation. Patients should be monitored closely and the situation escalated immediately if there are any concerns (NTSP 2013, C).

17 Encourage the patient to hold their hand over the stoma dressing when they speak or cough.

To prevent the occlusive dressing being dislodged and to divert air through the vocal cords, aiding phonation and communication (NTSP 2013, C).

18 Inform the patient that the stoma may take 7–14 days to heal over and close.

To increase patient understanding and appreciation of how long the stoma will take to heal. E

19 Document what date and time the patient was decannulated, and any issues or concerns arising during or after the procedure.

To ensure all members of the multidisciplinary team are aware of when the patient was decannulated and to help plan future care. E

20 Renew the dressing every 24 hours or more frequently if required. Monitor the size of the stoma daily.

To minimize infection, promote wound healing and monitor stoma closure (Global Tracheostomy Collaborative 2013, C).

21 Keep the tracheostomy box at the patient’s bedside for a further 48 hours post-decannulation.

To allow easy access to the emergency equipment if the patient deteriorates and requires emergency recannulation (Global Tracheostomy Collaborative 2013, C).

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COMPLICATIONS

The main complication that can arise post-decannulation is the patient’s inability to maintain their own airway, which may not become evident until a few hours after decannulation. For this reason, the tracheostomy box and emergency equipment should be kept by the patient’s bedside for at least 24 hours (Global Tracheostomy Collaborative  2013). If there are any concerns about the patient, they should be escalated immediately and preparations made for recannulation.

Tracheostomy: emergency care and recannulation EVIDENCE-BASED APPROACHES

Rationale

Patients with an altered airway (or who have recently been decannulated) who present with signs of airway, breathing or circulatory problems should be escalated immediately and assessed by an experienced and appropriate practitioner.

Indications

The following indications would give cause for concern and necessitate immediate management (ICS 2014, NTSP 2013): • a dislodged tracheostomy • overt signs of respiratory distress (pale, sweaty, clammy, cyanosed, increased work of breathing, tachypnoea, using accessory muscles) • silent breathing, or grunting, snoring or stridor • reduced or falling oxygen saturations • restlessness, agitation or confusion • tachycardia or hypotension • blood-stained secretions (haemoptysis).

Contraindications

There are no contraindications to managing a patient who has airway compromise and subsequent breathing problems.

Principles of care

A patient’s airway may become compromised for a variety of reasons. The compromise may be secondary to an underlying condition or disease, such as cancer of the head and neck. It may be that the patient already has an altered airway that has occluded due to tenacious secretions, and requires suctioning or change of the inner cannula. It may be that the tracheostomy tube has become partially or completely dislodged, or the patient may have failed decannulation due to an underlying problem such as tracheomalacia and require recannulation. All of the above require immediate management and escalation to an expert practitioner versed in airway management. Algorithms produced by the NTSP (2013) can be used to guide practitioners in the emergency management of altered airways (see Figure 12.34).

Anticipated patient outcomes

The patient will have a patent airway and be able to ventilate and oxygenate, preventing further deterioration or cardiopulmonary arrest.

PRE-PROCEDURAL CONSIDERATIONS

All staff should remain calm and reassure the patient as required. Staff should work together but with clear leadership, communicating what actions need to be taken and when. There should be no delay in escalating the situation to the relevant teams, and staff should be encouraged to call the resuscitation team if the patient is deteriorating or expert help is delayed. The resuscitation and advanced airway trolley should be brought to the patient’s bedside along with a fibreoptic scope in order to deal with the emergency (NTSP 2013).

Procedure guideline 12.14  Tracheostomy: emergency management Essential equipment • Personal protective equipment • Oxygen supply plus bag valve mask and a selection of oxygen masks and tubing • Suction, suction catheters and Yankauer suction tips • Resuscitation trolley • Advanced airway trolley • Tracheostomy box • Fibreoptic scope Action

Rationale

Pre-procedure 1 Introduce yourself to the patient, explain the situation and reassure them as much as possible.

To ensure the patient is kept informed and reassured. E

2 Cleanse hands using an alcohol-based handrub and apply personal protective equipment.

To minimize the risk of infection (NHS England and NHSI 2019, C).

Procedure 3 Assess whether the patient is breathing. If not, call the resuscitation team and commence cardiopulmonary resuscitation (CPR).

A patient who is not breathing requires immediate CPR (RCUK 2015, C).

4 If the patient is breathing, apply high-flow oxygen therapy (reservoir mask at 15 L/min to both the face and the stoma or tube).

To reduce the risk of hypoxia (O’Driscoll et al. 2017, C). (continued)

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Procedure guideline 12.14  Tracheostomy: emergency management (continued) Action

606

Rationale

5 Call for expert help.

To get additional and expert help early (NTSP 2013, C).

6 Assess the patency of the tracheostomy tube, if present. If there is not a tracheostomy tube in place, proceed to step 8.

To determine whether there is any air flow in or out of the tracheostomy tube (NTSP 2013, C).

7 Remove the decannulation cap, speaking valve, or heat and moisture exchanger (if present).

To remove any potential source of obstruction (Morris et al. 2015, C).

8 Remove the inner tube (if present).

To determine whether an occluded inner tube is the source of the obstruction (Cosgrove and Carrie 2015, C).

9 Pass a suction catheter down the tracheostomy tube or stoma and apply suction.

To determine the patency of the tube and remove a sputum plug if present (NTSP 2013, C).

10 If the suction catheter can be passed, the tube is patent. Repeat suction if a sputum plug is the likely cause.

To remove any secretions that may be obstructing the airway (NTSP 2013, C).

11 If the suction catheter cannot be passed, deflate the cuff (if present) and reassess the patient.

Deflating the cuff will allow air to flow past the cuff in the event of a completely obstructed tracheostomy tube (NTSP 2013, C). This will also help to assess whether it is the tube that is causing the problem. E

12 Ventilate the patient using either a bag valve mask or a Mapleson C system (water circuit). These can either be applied directly onto the patient’s face using an anaesthetic mask or attached directly onto the tracheostomy tube.

To ventilate the patient while the cause is being investigated or treated. By attempting to ‘bag’ or ventilate via the tracheostomy tube, its patency can simultaneously be assessed (ICS 2014, C; NTSP 2013, C).

13 If the patient stabilizes or improves, continue to ventilate and oxygenate until expert help arrives and the tracheostomy tube can be assessed.

To prevent hypoxia (NTSP 2013, C; O’Driscoll et al. 2017, C).

14 If the patient continues to deteriorate, the tracheostomy tube needs to be removed.

It is safer to remove the tracheostomy tube and ventilate the patient by other means if there is no ventilation via the altered airway (NTSP 2013, C).

15 Prepare to remove the tracheostomy tube by removing any external sutures and tube tapes.

To allow removal of the tube (NTSP 2013, C).

16 Quickly remove the tube and cover the stoma with gauze and an occlusive dressing, or with a gloved hand.

To allow effective ventilation of the upper airways. E

17 Continue to ventilate using any of the methods described in step 12.

To prevent hypoxia (ICS 2014, C; NTSP 2013, C).

18 Prepare to either intubate the patient orally or recannulate the stoma using an endotracheal tube or a size smaller tracheostomy tube.

To secure an appropriate airway in the patient (Mitchell et al. 2013, C).

19 Use a fibreoptic scope and perform a guided insertion if able.

To minimize the risk of causing a false passage, especially if the patient’s airway is known to be difficult (NTSP 2013, C).

20 Once the airway has been inserted, inflate the cuff and secure the endotracheal tube or tracheostomy tube in place with tapes or ties.

To secure the airway. E

21 Continue to ventilate using a bag valve mask or water circuit until the patient is able to ventilate spontaneously and stabilizes. Administer supplemental oxygen as required.

To ensure the patient is being ventilated and oxygenated (NTSP 2013, C).

22 Check the patient’s observations/NEWS2 and document. Aim for oxygen saturations of 94–98% (or 88–92% if the patient is at risk of hypercapnic respiratory failure).

To ensure the patient is not being over- or under-oxygenated (O’Driscoll et al. 2017, C).

23 Consider performing an arterial blood gas and chest X-ray.

To ensure the post-event patient assessment is thorough. E

24 Assess how the patient is ventilating and oxygenating and determine whether they require further respiratory support in a high-dependency or intensive care unit.

To ensure the patient is being cared for in the most appropriate clinical area. E

Post-procedure 25 Monitor the patient’s respiratory status and observations/ NEWS2 frequently until they are stable. Escalate any concerns or deterioration in condition/NEWS2 immediately.

To identify any concerns or clinical deterioration early, and ensure timely escalation to senior staff if required (RCP 2017, C).

CHAPTER 12 Respiratory care, CPR and blood transfusion

Problem-solving table 12.5  Prevention and resolution (Procedure guideline 12.14) Problem

Cause

Prevention

Action

Profuse tracheal secretions

Local reaction to tracheostomy tube or infection (as below)

Ensure vigilant care of the tracheostomy or stoma. Keep the patient well hydrated. Ensure good infection control practice and take standard precautions at all times when carrying out any aspect of care for a patient with an altered airway.

Suction frequently and ensure secretions are kept thin and loose. Check inner tube frequently and change if required. Consider use of saline or mucolytic nebulizers if secretions are tenacious. Ensure vigilant care of the surrounding skin to keep it as clean and dry as possible. Use a foam dressing and change it frequently. Send a sputum sample to microbiology to ensure it is not infected. Give antimicrobials if indicated and prescribed.

Lumen of tracheostomy tube occluded

Tenacious or dried sputum or blood occluding tube

Provide humidification via an HME or warmed and humidified oxygen therapy. Check and change inner tubes frequently. Suction the patient as required. Encourage the patient to report if they notice any change or difficulty with their breathing.

Call for help from the resucitation team. Apply high-flow oxygen over the nose and mouth and over the tracheostomy tube. Remove the speaking valve or HME immediately. Remove the inner tube. Suction the patient. Deflate the cuff (if applicable). Remove the tracheostomy if the above interventions have failed and the patient is deteriorating. Ventilate and oxygenate the patient using a bag valve mask or water circuit until a new altered airway has been inserted.

Tracheostomy tube accidentally dislodged

Tracheostomy tapes not adequately secured Tracheostomy tube not secured by staff during procedures or moving and handling of the patient

Ensure the tracheostomy tapes are secure at all times with a maximum of one or two finger spaces between the skin and tapes. Always hold the tracheostomy tube while turning, moving or mobilizing the patient. Educate the patient and staff about safe mobilization and manual handling of patients with an altered airway. The person who holds and secures the tube should lead the manoeuvre and give clear commands regarding when it is safe to move.

Call for expert help or the resucitation team, depending on how newly formed the tracheostomy tube is and the condition of the patient. Oxygenate the patient via the nose and mouth and via the stoma. Prepare a new tracheostomy tube and promptly insert it. If there are any concerns regarding the risk of forming a false passage, the tube should be checked by an appropriate clinician using a fibreoptic scope.

Emergency equipment with spare tubes, lubricant, tracheostomy dilators etc. should always be readily available at the patient’s bedside, in the tracheostomy box. Ensure the resuscitation trolley, the advanced airway trolley and the fibreoptic scope are readily available. Ensure an appropriately trained practitioner changes the tube and a second competent practitioner assists. Discuss the plan of action for the team to take if recannulation is not possible. Ensure all members are aware of their role and actions to be taken.

Remain calm and summon expert help or call the resucitation team. Apply high-flow oxygen over the patient’s stoma site and the nose and mouth. Lubricate the tube well and attempt to reinsert it at various angles. If unsuccessful, attempt to insert a smaller-size tracheostomy tube. If this is impossible, keep the tracheostomy tract open using tracheal dilators or put traction on the stay sutures if present. Do so until expert help arrives. Monitor the patient and observations continuously. If the patient’s condition deteriorates, begin ventilation using a bag valve mask over the patient’s nose and mouth while occluding the stoma with a dressing or gloved hand.

Unpredicted shape or Unable to angle of stoma insert a clean tracheostomy tube during tube change or after accidental dislodgment

(continued)

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Problem-solving table 12.5  Prevention and resolution (Procedure guideline 12.14) (continued) Problem

Cause

Prevention

Action Once the tube has been successfully inserted, it may be necessary for an expert to look via a fibreoptic scope and check no false passage was created during the procedure and the tube is cannulating the trachea.

Tracheal bleeding

Trauma to the trachea during tube change or from suctioning, bleeding from a tumour, erosion into a blood vessel, or uncorrected coagulopathies

Ensure vigilant care of the tracheostomy or stoma. Avoid frequent and multiple suctions if not indicated. Correct any coagulopathies.

Minimal bleeding should be monitored and reported to the multidisciplinary team. The tracheostomy cuff should be inflated to protect the airway if there is perfuse bleeding, and the patient escalated immediately. Perform suction as required.

Infection

Upper airway defences are bypassed in patients with a tracheostomy, predisposing patients to a higher risk of lower respiratory tract infection

Ensure good infection control practice and take standard precautions at all times when carrying out any aspect of care for patients with an altered airway.

Obtain a sputum sample or swab the stoma site and send the sample to microbiology. Give empirical antibiotics as per local microbiology guidelines.

HME, heat and moisture exchanger.

Laryngectomy RELATED THEORY

Patients who have undergone a total laryngectomy may require a cuffed tracheostomy tube for the first 24 hours following their operation or until they have been weaned off ventilation. Once the tracheostomy tube has been removed, the ear, nose and throat (ENT) surgeon will decide whether a laryngectomy tube is required for stoma patency. For patients with no laryngectomy tube in place, the nurse must be extremely vigilant, assessing the bare stoma frequently to ensure that it is not at risk of stenosis. A stenosed stoma will restrict the patient’s breathing and hinder the removal of secretions (Sharma et al. 2016). The stoma should be sufficiently large, ideally 15 × 15 mm in diameter. Less than 10 mm is deemed critical (Sharma et al. 2016). There are various stoma patency devices available, including laryngectomy tubes, stoma studs and stoma buttons (Figure 12.53). The ENT surgical team, clinical nurse specialist and speech and language therapist (SLT) can help to guide which device should be used.

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Laryngectomy: humidification EVIDENCE-BASED APPROACHES

As with patients who have a tracheostomy, humidification for ­laryngectomy patients is essential since the natural mechanisms of humidification, warming and filtration of inspired air normally provided by the upper airways are permanently bypassed (Clarke et al. 2016). The following choices are available: • Humidification systems: a heat and moisture exchanger (HME) consists of a laryngectomy tube or baseplate/housing that attaches to the neck and contains a filter cassette (Figure 12.53b and c). This system is highly recommended as it provides

­ aximum protection and humidification of the airway. There m are a range of types of filter and baseplate. • Stoma covers: these filter and humidify inhaled air and are available in a variety of sizes and attachments (Figure 12.53d).

Laryngectomy: communication EVIDENCE-BASED APPROACHES

The following options are available (Everitt  2016c, NTSP  2013, Zenga et al. 2018): • Surgical voice restoration (SVR) allows communication to be restored via the use of a voice prosthesis, which may also be referred to as a valve. See below for further information. • Oesophageal voice involves moving air into the oesophagus either by inhaling or injecting air into the back of the mouth.  Instead of the vocal cords vibrating, the walls of the pharynx vibrate. Sound then moves into the mouth, where recognizable speech is produced by the articulators (i.e. the tongue, lips and palate). Patients are asked to imagine gulping air into their mouth, beginning to swallow but returning the air to their mouth in a controlled manner. Oesophageal voice has previously been described as ‘burped speech’ and usually the patient can achieve a small number of words in one breath. • An artificial larynx involves using a battery-powered device that is placed against the neck or cheek, or intraorally. When a button is pushed, a vibration occurs in the head of the device and it is this vibration through the tissues that creates sound as the patient mouths words. SVR has become the most popular means of restoring communication, with success rates of up to 90% reported (Zenga et al. 2018). SVR entails creating a puncture between the posterior wall of the trachea and the anterior wall of the oesophagus, into which a one-way voice prosthesis is placed. By occluding the

CHAPTER 12 Respiratory care, CPR and blood transfusion

Figure 12.53  Larnyngectomy devices. (a) Laryngecomy tube. (b) Baseplate. (c) Filter cassette. (d) Stoma covers. (e) Shower aid. (f) Tilley’s forceps. (a)

(d)

(b)

(c)

(e)

(f)

stoma, pulmonary air is diverted through the prosthesis into the oesophagus, where the walls vibrate to make sound (Ward and Van As-Brooks 2014). The prosthesis is a silicone device that fits into the tracheooesophageal puncture (TEP) and acts as a one-way valve, preventing food and drink from entering the trachea from the oesophagus (Zenga et al. 2018). Patients can have the puncture created during their laryngectomy operation, in which case it is called a ‘primary puncture’. Post-operatively, patients with a primary puncture may have a catheter or a stoma gastric tube in place in the TEP, which enables the puncture to remain patent. Once healing has occurred, the stoma gastric tube is removed and the prosthesis can be placed into the TEP (secondary voice prosthesis placement). Alternatively, a voice prosthesis may be placed at the time of TEP creation; however, it will not be used for a period of time, until adequate healing has occurred (primary voice prosthesis placement). If patients are required to wait for their puncture following the laryngectomy surgery – for example, due to an extended laryngectomy – they are likely to have a ‘secondary puncture’. A secondary puncture may involve primary or secondary placement and can be done in the operating theatre under general anaesthetic or in the outpatient setting under local anaesthetic (Noel et al. 2016).

Laryngectomy: care and emergency management EVIDENCE-BASED APPROACHES

Rationale

The aim of routine and emergency laryngectomy care is to (Everitt 2016b, NTSP 2013): • maintain the patency of the laryngectomy stoma • provide humidification • keep the stoma clean and free from infection • aid voice restoration.

Indications

The patient’s laryngectomy stoma should be cleaned regularly and any crusts removed to ensure they are not aspirated and to ensure that the stoma remains unobstructed and patent. An HME or humidification bib should be used to heat and humidify inspired air.

Contraindications

There are no contraindications to providing laryngectomy care, especially in the initial post-operative phase, when the patient may not yet be able to care for their stoma independently.

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Procedure guideline 12.15  Laryngectomy care Essential equipment • Personal protective equipment • Sterile dressing pack • Tilley’s forceps (see Figure 12.53) • Ruler • Laryngectomy tube (see Figure 12.53) • Heat and moisture exchanger (HME) or humidification bib • Suction, suction catheters and Yankauer suction tips • 0.9% sodium chloride • Low-linting gauze Optional equipment • Baseplate Action

Rationale

Pre-procedure 1 This is a clean procedure.

To ensure patient safety (NTSP 2013, C).

2 Introduce yourself to the patient, explain and discuss the procedure with them, and gain their consent to proceed.

To ensure that the patient feels at ease, understands the procedure and gives their valid consent (NMC 2018, C).

3 Cleanse hands with soap and water or an alcohol-based handrub.

To minimize the risk of infection (NHS England and NHSI 2019, C).

4 Help the patient to sit in a semi-recumbent position with the neck slightly extended.

To ensure patient comfort. Extending the neck will allow easy access to the laryngectomy stoma (NTSP 2013, C).

5 Prepare a dressing tray or trolley for the procedure. Open the sterile procedure pack and any additional equipment required (tube, baseplate etc.). Pour the cleaning solution over the low-linting gauze.

To ensure all equipment required is prepared prior to starting the procedure. E

Procedure

610

6 Cleanse hands using an alcohol-based handrub and apply disposable plastic apron, gloves and eye protection.

To minimize the risk of infection (NHS England and NHSI 2019, C).

7 Clean around the stoma with 0.9% sodium chloride using low-linting gauze. If required, use Tilley’s forceps to remove any dried secretions or crusts from around the stoma. Allow the stoma to air dry.

To remove wet or dried secretions from the stoma site. E

8 Measure the laryngectomy stoma and document the size in the patient’s laryngectomy passport.

To check for tracheal stenosis (Sharma et al. 2016, C).

9 If required, insert a laryngectomy tube. (The speech and language therapist will determine what size to use and document this in the patient’s laryngectomy passport.)

To maintain patency or to help shape the laryngeal stoma (Everitt 2016b, E).

10 A baseplate may also be considered. This can be inserted around the stoma to house a HME cassette. A humidification bib or scarf is another alternative.

To facilitate phonation and/or humidification (Everitt 2016b, E; NTSP 2013, C).

11 Remove apron, gloves and eye protection and dispose of them in the clinical waste. Cleanse hands with soap and water or an alcohol-based handrub.

To minimize the risk of infection (NHS England and NHSI 2019, C).

Post-procedure 12 Monitor the patient’s respiratory status and observations/ NEWS2. Escalate any concerns or deterioration in condition/ NEWS2 immediately.

To identify any concerns or clinical deterioration early, and ensure timely escalation to senior staff if required (RCP 2017, C).

13 Discuss any concerns with the multidisciplinary team.

To ensure the multidisciplinary team is involved in all aspects of the care of patients with a laryngectomy (NTSP 2013, C).

CHAPTER 12 Respiratory care, CPR and blood transfusion

Problem-solving table 12.6  Prevention and resolution (Procedure guideline 12.15) Problem

Cause

Prevention

Action

Breathing difficulties

Mucus plug or reduced airflow due to secretions Reduction in stoma size

Regularly check and clean the stoma. Ensure adequate humidification over the stoma. Regularly administer nebulizers. Encourage the patient to carry out steam inhalation if the secretions are tenacious. Encourage regular mobilization to assist in the clearing of secretions. Regularly measure the stoma’s size.

Check the stoma and clean it if mucus plugs or crusts have formed. If a laryngectomy tube is in place, remove it and clean the tube. Administer normal saline 0.9% nebulizer. Measure the stoma and consider insertion of a stoma button or laryngectomy tube (refer to SLT if required). Seek expert help if the patient is deteriorating and the above interventions have not helped with their breathing difficulties.

Bleeding from stoma

Bleeding may be caused by trauma to the trachea from cleaning or suctioning, or a lack of humidification

Check and clean the stoma as required. Suction the patient only when absolutely necessary. Encourage the patient to cough and wipe away secretions. Ensure humidification of the laryngectomy stoma. Regularly administer nebulizers.

If the bleeding is profuse and there is a risk of aspiration of blood into the lungs, a small tracheostomy tube should be inserted and the cuff inflated to protect the airway. Seek expert help and ask for an urgent review.

Chest infection

Possible aspiration if the patient has a transoesophageal puncture

Monitor for signs and symptoms of chest infection. Monitor the speaking valve for patency and size. Clean the speaking valve to reduce the risk of secretions accumulating.

Check for leakage from the voice prosthesis (see ‘Voice prosthesis falls out accidentally’ below). Contact the team or SLT for an urgent assessment if leakage is suspected. Keep the patient nil by mouth until reviewed.

Stoma shrinkage

Laryngectomy stoma reduced in size

Regularly measure the stoma’s size.

Insert a laryngectomy tube or stoma button. Escalate to the team and SLT and ask for a patient review.

Voice prosthesis falls out accidentally

Voice prosthesis not adequately secured or accidentally removed

Ensure that care is taken when cleaning the stoma and valve to reduce the risk of it falling out.

Insert a red rubber tube (Figure 12.54) (14 Fr catheter) or dilator. If using a red rubber tube, tie a knot in the end of the tube and secure the end onto the neck or chest wall using tape. Check for leakage around the tube or dilator (encourage several sips of coloured liquid or milk and watch for leakage; use a good torch or light to see clearly). If leakage is noted, commence thickened drinks to reduce the risk of a chest infection. Contact the SLT for an urgent review. If unable to insert the red rubber tube or dilator, contact ENT team immediately. Check the patient has removed the voice prosthesis from the airway; if not, the patient should be seen by the ENT team to check the prosthesis is not still in the airway.

Voice difficulties

Voice prosthesis blocked or not working

Clean the voice prosthesis regularly

ENT, ear, nose and throat; SLT, speech and language therapist.

Clean the voice prosthesis with a brush. If this does not help, contact the SLT.

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Figure 12.54  Red rubber tube, base plate with a heat and moisture exchanger, and a laryngectomy tube.

CPR guidelines in the UK are researched and implemented by the Resuscitation Council UK (RCUK 2015). These are based on the European Resuscitation Council’s guidelines, which were last updated and republished in 2015 (ERC 2015).

ANATOMY AND PHYSIOLOGY

The heart

Learning Activity 12.5  Case study Mrs Hazel Bennett, aged 68, is to return to your ward later this morning from the critical care unit (CCU) following surgery for laryngeal cancer. She has undergone a laryngectomy and therefore has a permanent tracheostomy. The staff nurse on the CCU has informed you that Hazel has a cuffed tracheostomy tube in situ and is able to cough fairly effectively, although she needs some suctioning at times. 1 What preparations and bedside equipment need to be in place before Hazel returns from the CCU? 2 What observations of the neck area should be carried out at the beginning of each shift? 3 24 hours later, Hazel’s secretions are becoming increasingly viscous. Suggest one intervention to assist Hazel with this problem. 4 List the people and/or teams that will be involved in Hazel’s care (in addition to the surgical and ward nursing staff and the catering assistants).

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See the answers on the companion site of this student edition: www.royalmarsdenmanual.com/student10e.

Basic life support DEFINITION

Cardiopulmonary resuscitation (CPR) is an emergency procedure involving cardiac compressions and manual ventilation. The aim of CPR is to preserve cardiac output and maintain oxygenation of the brain in a person in cardiac arrest until further measures can be taken to restore spontaneous breathing and blood circulation (RCUK 2015). Resuscitation is the emergency treatment of any condition in which the brain fails to receive enough oxygen.

The heart is made up of four chambers: two upper atria and two lower ventricles. The right atrium receives deoxygenated blood from the systemic venous circulation. From the right atrium, blood flows into the right ventricle, which pumps it back to the lungs via the pulmonary artery. Carbon dioxide is released and oxygen is absorbed within the lungs. This blood, which is now oxygenated, returns to the heart via the pulmonary vein and empties into the left atrium. The blood then passes into the left ventricle, which pumps it into the aorta and the arterial systemic circulation (Waugh and Grant 2014). The atrioventricular septum completely separates the right and left sides of the heart. From shortly after birth, the two sides of the heart never directly communicate, with blood flowing from the right side to the left side via the lungs only. However, the right and left atria and the right and left ventricles work together, contracting simultaneously (Marieb and Hoehn 2018). To prevent the backflow of blood, the heart has four valves. The valves open and close in response to pressure changes as the heart contracts and relaxes (Tortora and Derrickson  2017). The valve between the right atrium and ventricle is known as the tricuspid valve, while the valve between the left atrium and ventricle is called the mitral valve. The pulmonary valve prevents backflow of blood from the pulmonary artery into the right ventricle. Likewise, the aortic valve sits within the aorta and prevents regurgitation into the left ventricle.

The cardiac conduction system

The sinoatrial (SA) node is the natural pacemaker of the heart. It releases an electrical stimulus at a regular rate that will vary depending on whether the body is at rest or in action. As each stimulus passes through the myocardial cells, it creates a  wave of contraction, which spreads rapidly through both atria  and is known as ‘atrial depolarization’ (Tortora and Derrickson 2017). The rapidity of atrial contraction is such that around 100 million myocardial cells contract in less than one-third of a second. When the electrical stimulus from the SA node reaches the atrioventricular (AV) node, within the septum, it is delayed briefly so that the contracting atria have enough time to pump the blood into the ventricles. Once the atria are empty of blood, the valves between the atria and ventricles close. At this point, the atria begin to refill and the electrical stimulus passes through the AV node and the bundle of His, along the left and right bundle branches, and finally terminates in the Purkinje fibres within the ventricles. In this way, all the myocardial cells (around 400 million) in the ventricles receive an electrical stimulus, which causes them to contract (Marieb and Hoehn 2018). This process is known as ‘ventricular depolarization’ and also happens in less than onethird of a second. As the ventricles contract, the right ventricle pumps blood to the lungs, where carbon dioxide is released and oxygen is absorbed, while the left ventricle pumps blood into the coronary and arterial circulation via the aorta. At this point the ventricles are empty, the atria are full and the valves between them are closed. Prior to the process starting again, the SA and AV nodes must recharge. This process is known as ‘atrial and ventricular repolarization’. The SA and AV nodes recharge while the atria and ventricles are refilling with blood (Herring and Paterson  2018). This process takes less than one-third of a second, resulting in a minimal pause in heart function. The times given for the three different stages are based on a heart rate of 60 beats per minute, or 1 beat per second.

CHAPTER 12 Respiratory care, CPR and blood transfusion

The three stages of a single heart beat are therefore: • atrial depolarization • ventricular depolarization • atrial and ventricular repolarization (Tortora and Derrickson 2017).

Pathophysiology of cardiopulmonary arrest

Cardiac arrest occurs when the cardiac output of the heart stops due to cessation of its mechanical activity. This is usually as a Figure 12.55  Cardiac arrest rhythms. (a) Asystole: nonshockable. (b) Pulseless electrical activity (PEA): nonshockable. (c) Pulseless ventricular tachycardia (VT): shockable. (d) Ventricular fibrillation (VF): shockable. Source: Reproduced from RCUK (2015).

result of heart disease, such as coronary heart disease, cardiomyopathy, aortic valve stenosis, cardiac arrhythmias or congenital heart abnormalities.

RELATED THEORY

Cardiac arrest implies a sudden interruption of cardiac output. It may be reversible with appropriate treatment (RCUK 2015). The four arrhythmias that are found in cardiac arrest are: • asystole (Figure 12.55a) • pulseless electrical activity (PEA) (Figure 12.55b, although PEA can look like any rhythm that would normally be compatible with life) • pulseless ventricular tachycardia (VT) (Figure 12.55c) • ventricular fibrillation (VF) (Figure 12.55d). For the purposes of resuscitation guidelines, these rhythms are divided into two groups: • VF and pulseless VT require defibrillation (shockable rhythms). • Asystole and PEA do not require defibrillation (non-shockable rhythms).

Potentially reversible causes of a cardiopulmonary arrest

(a)

During cardiac arrest, potential causes or aggravating factors for which specific treatment exists should be considered. There are eight reversible causes of arrest, four of which begin with the letter H and four of which begin with the letter T; this can be useful in aiding memory (Table 12.11).

Hypoxia

For normal cell respiration, the body requires a constant supply of oxygen. When this is interrupted for more than 3 minutes (except when there is severe hypothermia), lactic acidosis and cell death occur. This can rapidly lead to cardiorespiratory arrest if left untreated. Patients may become severely hypoxic due to acute respiratory failure, airway obstruction or acute lung injury. Hypoxia in cardiac arrest is treated by ensuring that the patient’s lungs are adequately ventilated with as near to 100% oxygen as possible. The patient also receives good-quality chest compressions, which deliver oxygenated blood to the major organs (RCUK 2015). (b)

Hypovolaemia

Hypovolaemia in adults results in PEA and is usually caused by severe blood loss. The most common causes of severe blood loss are: • trauma • surgical procedure • gastrointestinal mucosa erosion • oesophageal varices • clotting abnormality • peripheral vessel erosion (e.g. by tumour). (c)

Although blood loss may be overt, it may not become apparent until the patient collapses. The treatment for hypovolaemia is identifying and stopping the source of fluid or blood loss, and replacing the circulating volume with the appropriate fluid. A large-scale Cochrane review found no evidence that the use of colloids improves a patient’s survival compared to the use of Table 12.11  Reversible causes of cardiac arrest

(d)

Hs

Ts

• Hypoxia • Hypovolaemia • Hypokalaemia, hyperkalaemia and other metabolic disorders • Hypothermia

• Thrombosis: coronary or pulmonary • Tamponade • Toxicity: poisoning and drug intoxication • Tension pneumothorax

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crystalloids (Lewis et al. 2018). Both colloids and crystalloids are solutions used to restore circulating volume. Colloids have larger molecules than crystolloids and can be synthetic (e.g. starches, dextrans or gelatins) or naturally occurring (e.g. albumin or fresh frozen plasma). Crystalloids are salt based (e.g. saline or Hartmann’s solution) and contain smaller molecules than colloids. Furthermore, due to the considerable expense of colloids, fluid resuscitation is normally started with a crystalloid (e.g. 0.9% sodium chloride or compound sodium lactate solution). An acute loss of 30–40% of total blood volume (1500–2000 mL) will require blood product replacement. This will become a life-saving therapy if more than 40% (>2000 mL) of the total blood volume is lost (Shander et al. 2013).

Hypokalaemia, hyperkalaemia and other metabolic disorders

An imbalance of potassium affects both the nerve conduction and the muscular function of the heart. A severe rise or fall in potassium can cause arrhythmias, which will cause cardiac arrest. Hypokalaemia is defined as plasma potassium below 3.5 mmol/L. It may be classified as (RCUK 2015): • mild: 6 months

Planned therapy < 6 months

Venous assessment

Good

Peripheral access

Vesicant/irritant

Venous assessment

Venous assessment

Poor

CVAD

Good

Planned therapy > 6 cycles

Planned therapy < or = 6 cycles

Poor

Peripheral access

CVAD

Good

Peripheral access

Poor

CVAD

If marked deterioration in peripheral venous access during treatment then consider CVAD

restoration of tissue permeability within 24–48 hours (Doellman et al. 2009, INS 2016). The usual dose is 1500 international units (BNF 2019a). It should be injected within 1 hour of extravasation, ideally through the intravenous device delivering the enzyme to the same tissue (Pérez Fidalgo et al. 2012, Weinstein and Hagle 2014). Hyaluronidase is recommended for use with specific chemotherapy agents, specifically vinca alkaloids (Pérez Fidalgo et al. 2012; Polovich et al. 2014) and also taxanes (Pérez Fidalgo et al. 2012). Note that hyaluronidase increases the absorption of local anaesthetic. Therefore, if local anaesthetic has been applied to the area (e.g. Ametop gel prior to cannulation) within 6 hours of extravasation, the patient should be monitored for signs and symptoms of systemic anaesthesia, such as increased pulse rate and decreased respirations, and the doctor should be informed immediately (BNF 2019a).

Corticosteroids

While corticosteroids were advocated as a treatment for anthracycline extravasation in the past, due to their action on inflammatory processes, there is no evidence that tissue damage in extravasation is secondary to inflammation (Buter et al. 2019). As a result, they are not usually recommended, except in large-­ volume extravasations of oxaliplatin (Pérez Fidalgo et  al. 2012, Polovich et al. 2014). However, given as a cream, they can help to reduce local trauma and irritation (Stanley 2002) and are often recommended in this form.

Dimethylsulphoxide (DMSO)

DMSO is a topically applied solvent that may improve systematic absorption of vesicants. It acts as a potent free radical scavanger that rapidly penetrates tissues and prevents DNA damage (Doellman et al. 2009, Pérez Fidalgo et al. 2012). Reports on the clinical use of topical DMSO show it is effective and well tolerated in extravasation (Bertelli 1995, Pérez Fidalgo et al. 2012). However, this is based on the use of a high-dose (99%) solution, which is

not always available (Pérez Fidalgo et  al. 2012). Side-effects of DMSO include itching, erythema, mild burning and a characteristic breath odour (Bertelli 1995).

Granulocyte-macrophage colony-stimulating factor

Granulocyte-macrophage colony-stimulating factor (GM-CSF) is a growth factor. It is effective in accelerating wound healing and inducing formation of granulation tissue (El-Saghir et  al. 2004, Ulutin et al. 2000).

Non-pharmacological support Stopping infusion or injection and aspirating the drug

It appears that most authors agree that aspirating as much of the drug as possible, as soon as extravasation is suspected, is beneficial (Polovich et al. 2014, Rudolph and Larson 1987, Weinstein and Hagle 2014) and can help to lower the concentration of the drug in the area (Goolsby and Lombardo 2006). However, withdrawal is only possible immediately during bolus injections, because if the drug were being delivered via an infusion, this would need to be stopped and a syringe attached in an attempt to aspirate. Aspiration may be successful if extravasation presents as a raised blister, but it may be unsuccessful if the tissue is soft and soggy (Stanley 2002). In practice, it may achieve little and often distresses the patient (Gault and Challands 1997). The likelihood of withdrawing blood, as suggested by Ignoffo and Friedman (1980), is small and the practitioner may waste valuable time attempting this, which could lead to delay in the rest of the management procedure.

Removing the device

Some clinicians advocate that the peripheral vascular access device be left in situ in order to instil the antidote into the affected tissues via the device (Kassner 2000, Stanley 2002, Weinstein and Hagle 2014). However, others recommend that the peripheral device should be removed to prevent any injected solution increasing the size of the affected area (Rudolph and Larson 1987). There appears

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to be no research evidence to support either practice. It is therefore important to adhere to local institutional policies.

Application of hot or cold packs

Cooling appears to be a better choice, with the exception of the vinca alkaloids and some non-cytotoxic drugs, than warming (Bertelli 1995, Buter et  al. 2019). Cold causes vasoconstriction, localizing the extravasation and perhaps allowing time for the local vascular and lymphatic systems to contain the drug (INS 2016). It should be applied for 15–20 minutes, 3–4 times a day for up to 3 days (Polovich et  al. 2014, Wilkes 2018). Heat promotes healing after the first 24 hours by increasing the blood supply (Polovich et al. 2014, Weinstein and Hagle 2014). It also decreases local drug concentration, increasing the blood flow, which results in enhanced resolution of pain and reabsorption of any localized swelling.

Elevation of limb

Elevation of the limb is widely recommended as it minimizes swelling (Buter et  al. 2019). This can be achieved by use of a Bradford sling, but this is usually recommended when the extravasation has occurred in the hand. Gentle movement should be encouraged to prevent adhesion of damaged areas to underlying tissue (Gabriel 2008, INS 2016).

Surgical techniques

It is now recognized that a plastic surgery consultation should form part of the management procedure in order to consider debridement of the affected area, although there are no standard procedures for surgical management (Boulanger et  al. 2015). Surgical intervention should be considered, especially if the lesion is larger than 2 cm, if there is significant residual pain 1–2 weeks after extravasation or if there is minimal healing 2–3 weeks after injury despite local therapeutic measures (Goolsby and Lombardo 2006, Pérez Fidalgo et  al. 2012). A liposuction cannula can be used to aspirate extravasated material, and subcutaneous fat or a flush-out technique can remove the extravasated drug without resorting to excision and skin grafting.

Management of infiltration

Treatment is often dependent upon the severity of the infiltration. There should be ongoing observation and assessment of the infiltrated site. The presence and severity of the infiltration should be documented. Infiltration statistics should include frequency, severity and type of infusate. The infiltration rate should be calculated according to a standard formula (INS 2016, RCN 2016).

Procedure guideline 15.25  Extravasation management: peripheral cannula This procedure relates specifically to the management of extravasation of a drug from a peripheral cannula. Essential equipment • Personal protective equipment • Gel packs × 2: one to be kept in the fridge and one available for heating (an electric heating blanket can be used while the pack is heating) • 2 mL syringe • 25 G needle • 23 G needle • Alcohol swabs • Documentation forms • Copy of extravasation management procedure • Patient information leaflet • Prescription chart Medicinal products • Hyaluronidase (1500 international units) and 2 mL sterile water for injection • Hydrocortisone cream 1% (15 g tube) • Savene (dexrazoxane) (optional) • DMSO (dimethylsulphoxide) topical solution (99%) Action

Rationale

Pre-procedure 1 Introduce yourself to the patient, explain and discuss the procedure with them, and gain their consent to proceed.

To ensure that the patient feels at ease, understands the procedure and gives their valid consent (NMC 2018, C).

2 Wash hands with bactericidal soap and water or an alcohol-based handrub.

To minimize the risk of infection (DH 2007, C; Fraise and Bradley 2009, E).

Procedure 3 Stop the injection or infusion immediately, leaving the cannula in place.

To minimize local injury. To allow aspiration of the drug to be attempted (Polovich et al. 2014, C; RCN 2016, C).

4 Aspirate any residual drug from the device and suspected extravasation site.

To minimize local injury by removing as much drug as possible (but only attempt if appropriate). Subsequent damage is related to the volume of the extravasation, in addition to other factors (Polovich et al. 2014, C; RCN 2016, C).

CHAPTER 15 Medicines optimization: ensuring quality and safety

5 Consider removing the cannula.

Some sources recommend doing this to prevent the device from being used for antidote administration (Rudolph and Larson 1987, E). Others state that the cannula may be used to instil antidote to the affected tissue (Kassner 2000, E; Stanley 2002, E; Weinstein and Hagle 2014, E).

6 Consider contacting the extravasation team and whether the flush-out technique would be appropriate (see Figure 15.54).

Flush-out is most effective if undertaken as soon as extravasation is suspected (Dionyssiou et al. 2011, E).

7 Collect an extravasation pack and take it to the patient.

It contains all the equipment necessary for managing extravasation (Dougherty 2010, E; Stanley 2002, E).

8 Either: For Group A drugs (see Table 15.12): • Draw up 1500 international units of hyaluronidase in 1 mL sterile water for injection and inject volumes of 0.1–0.2 mL subcutaneously at points of the clock around the circumference of the area of extravasation.

This is the recommended agent for Group A drugs. The warm pack speeds up absorption of the drug by the tissues (Polovich et al. 2014, Weinstein and Hagle 2014, E).

• Apply warm pack. Or: For Group B drugs (see Table 15.12) (except those listed below): • Apply cold pack or ice instantly.

To localize the area of extravasation, slow cell metabolism and decrease the area of tissue destruction. To reduce local pain (Polovich et al. 2014, C).

Or: If extravasation is with any of the following category B drugs: mitomycin C, doxorubicin, idarubicin, epirubicin, actinomycin D: • Draw around the area of extravasation with an indelible pen. • Put on gloves. • Apply a thin layer of DMSO topically to the marked area using the small plastic spatula in the lid of the bottle. Allow it to dry. • Apply gauze. • This should be applied within 10–25 minutes.

DMSO is the recommended agent for these anthracyclines and helps to reduce local tissue damage (Bertelli 1995, E, Pérez Fidalgo et al. 2012, C).

Or: If extravasation of doxorubicin, epirubicin, idarubicin or daunorubicin occurs (i.e. 5 mL or more peripherally or any volume from a central venous access device) then stop use of the cold pack, do not apply DMSO and contact a member of the extravasation team to advise on use of dexrazoxane. 9 Where possible, elevate the extremity and/or encourage movement.

Cooling and DMSO interfere with the efficacy of dexrazaxone and it should be administered as soon as possible after extravasation of these drugs (El-Saghir et al. 2004, E; Langer et al. 2000, E). To minimize swelling and prevent adhesion of the damaged area to underlying tissue, which could result in restriction of movement (Buter et al. 2019, E).

Post-procedure 10 Inform a member of the medical staff at the earliest opportunity and administer any other prescribed antidotes, for example dexrazoxane.

To enable actions differing from agreed policy to be taken if considered in the best interests of the patient. To notify the doctor of the need to prescribe any other drugs. E

11 Apply hydrocortisone cream 1% twice daily, and instruct the patient on how to do this. Continue as long as erythema persists.

To reduce local inflammation and promote patient comfort (Stanley 2002, E).

12 Where appropriate, apply DMSO every 2 hours on day 1 and then every 6 hours for up to 7 days (patients will need to have this prescribed as a ‘to take out’ (TTO) and continue treatment at home where necessary).

To help reduce local tissue damage (Bertelli 1995, E).

13 Heat packs (for Group A drugs) should be reapplied after initial management for 2–4 hours. Cold packs (for Group B drugs) should be applied for 15–20 minutes, 3–4 times a day for up to 3 days.

To localize the steroid effect in the area of extravasation. To reduce local pain and promote patient comfort (Bertelli 1995, E).

(continued)

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Procedure guideline 15.25  Extravasation management: peripheral cannula (continued) Action

Rationale

14 Provide analgesia as required.

To promote patient comfort. To encourage movement of the limb as advised. E

15 Dispose of waste in appropriate containers.

To ensure safe disposal and avoid laceration or injury to other staff (EASHW 2010, C; HWR 2005, C).

16 Document the following details, in duplicate in your nursing documentation and on the DATIX incident form that is used: a patient’s name/number b ward/unit c date and time d signs and symptoms e cannulation site (on diagram) f drug sequence g drug administration technique, i.e. bolus or infusion h approximate amount of the drug extravasated i diameter, length and width of extravasation area j appearance of the area k step-by-step management with date and time of each step performed and medical officer notification

l patient’s complaints, comments and statements m indication that the patient information sheet has been given to the patient n follow-up actions required over subsequent days o whether photograph was taken p if required, when patient referred to plastic surgeon q signature of the nurse.

To provide an immediate and full record of all details of the incident that may be referred to if necessary. To provide a baseline for future observation and monitoring of the patient’s condition. To comply with professional guidelines (RCN 2016, C; RPS 2019a, C; Schulmeister 2009, E; Weinstein and Hagle 2014, E).

17 Explain to the patient that the site may remain sore for several days.

To reduce anxiety and ensure continued co-operation. E

18 As part of the follow-up, all patients should receive written information explaining what has occurred, what management has been carried out, what they need to look for at the site and when to report any changes. For example, increased discomfort, peeling or blistering of the skin should be reported immediately.

To detect any changes as early as possible and allow for a review of future management. This may include referral to a plastic surgeon (Gault and Challands 1997, E; Polovich et al. 2014, C; RCN 2016, C).

19 Observe the area regularly for erythema, induration, blistering or necrosis. Where appropriate, take photographs. Inpatients: monitor daily.

To detect any changes at the earliest possible moment (RCN 2016, C).

20 If blistering or tissue breakdown occurs, begin dressing techniques and seek advice regarding wound management.

To minimize the risk of a superimposed infection and increase healing (Naylor 2005, E).

21 Depending on size of lesion, degree of pain and type of drug, consider referral to plastic surgeon.

To prevent further pain and other complications, as chemically induced ulcers rarely heal spontaneously (Dougherty 2010, E; Polovich et al. 2014, C).

POST-PROCEDURAL CONSIDERATIONS

Ongoing care

Follow-up will be dependent on the patient’s needs and the degree of damage. Assessment should be carried out using a standardized tool (INS 2016) and include inspection and management of the area of extravasation, skin integrity, the presence of pain and other symptoms (such as impaired mobility or sensation in the limb) (Table 15.16). If damage has occurred, it will be affected by the site, the amount of drug, the concentration of the agent and whether the drug binds to DNA or not (Polovich et al. 2014). Blistering may occur within 24 hours (e.g. with vinorelbine) or ulceration may occur over a period of days to weeks (e.g. with epirubicin), and extravasation wounds may be complicated by tissue ischaemia related to endothelial damage (Naylor 2005).

The type of injury will dictate the type of dressing. Assessment of the wound should include the position and size of the wound, the amount and type of tissue present, the amount and type of exudate, and the extent and spread of erythema (Naylor 2005). If the flush-out technique has been undertaken then the incisions should be dressed using a dressing that allows the fluid to continue to leak from the site, for example Mepitel. It is also important to recognize the impact on the patient’s psychological and situational dynamics, which may diminish their quality of life (Gonzalez 2013).

Documentation

An extravasation must be reported and fully documented as it is an adverse incident and the patient may require follow-up care (RCN 2016). The Oncology Nursing Society lists the key elements

CHAPTER 15 Medicines optimization: ensuring quality and safety

Table 15.16  Grading scale for monitoring extravasation Grade

1

2

3

4

5

Skin colour

Normal

Pink

Red

Blanched area surrounded by red

Blackened

Skin integrity

Unbroken

Blistered

Superficial skin loss

Tissue loss and exposed subcutaneous tissue

Tissue loss and exposed bone/ muscle with necrosis/crater

Skin temperature

Normal

Warm

Hot

Oedema

Absent

Non-pitting

Pitting

Mobility

Full

Slightly limited

Very limited

Pain

Grade using a scale of 0–10 where 0 = no pain and 10 = worst pain

Temperature

Normal

Immobile

Elevated (indicate actual temperature)

Education of the patient and relevant others

Patients should always be informed when an extravasation has occurred and be given an explanation of what has happened and what management has been carried out (INS 2016, McCaffrey Boyle and Engelking 1995). An information sheet should be given to patients with instructions on what symptoms to look out for and when to contact the hospital during the follow-up period (Gabriel 2008).

when intravenous medication is administered, it is often considered more of an issue in this context. An allergic reaction is a response to a medication or solution to which the patient is sensitive and may be immediate or delayed (Lamb and Dougherty 2008, Perucca 2010). Clinical features may start with chills and fever, with or without urticaria, erythema and itching. The patient may then go on to experience shortness of breath with or without wheezing, then angioneurotic oedema and in severe cases anaphylactic shock (Lamb and Dougherty 2008). Prevention is achieved by assessing and recording patient allergies (drug, food and products) and applying allergy identification wristbands (NPSA 2008a, Perucca 2010). In the event of an allergic reaction, the infusion should be stopped immediately, the tubing and container changed, and the vein kept patent. The doctor should be notified and any required interventions undertaken (Lamb and Dougherty 2008).

COMPLICATIONS

Circulatory overload (isotonic fluid expansion)

of vesicant extravasation documentation (Polovich et  al. 2014) (Box 15.18). Statistics on the incidence, degree, causes and corrective action should be monitored and analysed (Gonzalez 2013, INS 2016, Pérez Fidalgo et  al. 2012). Finally, records may be required in the case of litigation, which is now on the increase (Doellman et al. 2009, Dougherty 2003, Masoorli 2003).

If the extravasation is not managed correctly then an injury will result. In certain circumstances, in spite of managing an extravasation, an injury can still result and must be dealt with on an individual basis. Following the flush-out technique, it may be necessary to administer prophylactic antibiotics to prevent local infection (although this is rare).

Allergic reaction

Allergic reaction is a complication associated with any medication administration. However, because it happens more rapidly

Box 15.18  Key elements of vesicant extravasation documentation • Date and time the extravasation occurred • Type and size of vascular access device • Length and gauge of needle (ports only) • Location of device • Details of how patency was established before and during administration (description and quality of blood return) • Number and location of all cannulation attempts • Vesicant administration method (e.g. bolus or infusion) • Estimated amount of extravasated drug • Symptoms reported by the patient • Description of device site (e.g. swelling or redness) • Assessment of limb (where applicable) for range of movement • Immediate nursing interventions • Follow-up interventions • Patient information

A critical and common complication of intravenous therapy is circulatory overload, or ‘isotonic fluid expansion’. It is caused by infusion of fluids of the same tonicity as plasma into the vascular circulation, for example 0.9% sodium chloride. As isotonic solutions do not affect osmolarity, water does not flow from the extracellular to the intracellular compartment. The result is that the extracellular compartment expands in proportion to the fluid infused (Weinstein and Hagle 2014). Because of the electrolyte concentration, no extra water is available to enable the kidneys to selectively excrete and restore the balance. Circulatory overload can also occur due to: • infusing excessive amounts of sodium chloride solutions • large-volume infusions running over multiple days • rapid fluid infusion into patients with compromised cardiac, liver or renal status (Lamb and Dougherty 2008, Macklin and Chernecky 2004). Prevention includes thorough assessment of the patient before commencing intravenous therapy, close monitoring of the patient, maintaining infusion rates as prescribed and the use of infusion devices where required (Lamb and Dougherty 2008). If circulatory overload is detected early, the patient should be sat upright (Macklin and Chernecky 2004). Treatment consists of withholding all fluids until excess water and electrolytes have been elim­ inated by the body and/or administration of diuretics to promote rapid diuresis (Weinstein and Hagle 2014). However, careful moni­­toring should be continued to prevent the occurrence of isotonic contraction (where there is loss of fluid and electrolytes isotonic to the extracellular fluid, such as blood and large volumes of fluid from diarrhoea and vomiting) (Weinstein and Hagle 2014). If fluid administration is allowed to continue unchecked, it can result in left-sided heart failure, circulatory collapse and cardiac arrest (Dougherty 2002).

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Dehydration

Dehydration may be categorized as either hypertonic or hypotonic contraction and may be caused by underinfusion. Hypertonic contraction occurs when water is lost without ­corresponding loss of salts (Weinstein and Hagle 2014) and occurs in patients unable to take sufficient fluids (the elderly, unconscious patients and incontinent patients) or who have excessive insensible water loss via skin and lungs or as a result of certain drugs in excess. Hypotonic contraction occurs when fluids containing more salt than water are lost; this results in a decrease in osmolarity of the extracellular compartment (Weinstein and Hagle 2014). It is important that nurses recognize the symptoms of overinfusion or underinfusion; certain factors should be considered when monitoring patients (Weinstein and Hagle 2014) (Table 15.17).

Speed shock

Speed shock is a systemic reaction that occurs when a substance foreign to the body is rapidly introduced into the circulation (Perucca 2010, Weinstein and Hagle 2014). This complication can manifest following administration of intravenous bolus injections or when large volumes of fluid are given too rapidly (Perucca 2010). It should not be confused with pulmonary oedema, which relates to the volume of fluid infused into the patient. Rapid, uncontrolled administration of drugs will result in toxic concentrations reaching vital organs (Lamb and Dougherty 2008). Toxicity may be manifested via an exaggeration of the usual pharmacological actions of the drug or via signs and symptoms spe-

cific to that drug or class of drugs. The most extreme toxic response that can occur if a drug is given at a dose or rate exceeding that recommended is termed the ‘lethal response’. Signs of speed shock include: • flushed face • headache and dizziness • congestion of the chest • tachycardia and fall in blood pressure • syncope • shock • cardiovascular collapse (Perucca 2010, Weinstein and Hagle 2014). Prevention of speed shock involves the nurse having knowledge of the drug and the recommended rate of administration. When commencing an infusion using gravity flow, check that the solution is flowing freely before adjusting the rate and monitoring regularly (Perucca 2010). Movement of the patient or the device within the vessel can cause the infusion to flow more or less freely after a few minutes of setting the rate (Weinstein and Hagle 2014). For high-risk medications, an electronic flow-­ control device is recommended (RCN 2016). Although most pumps have an anti-free-flow mechanism, always close the roller clamp prior to removing the set from the pump (MHRA 2006a, Pickstone 1999). If speed shock occurs, the infusion must be slowed down or discontinued. Medical staff should be notified immediately and the patient’s condition treated as clinically indicated (Perucca 2010).

Table 15.17  Monitoring overinfusion and underinfusion Type of fluid or electrolyte imbalance

Patients at risk

Signs and symptoms

Treatment

Circulatory overload (isotonic fluid expansion)

Early post-operative or post-trauma patients, older people, those with impaired renal and cardiac function, and children

• Weight gain • A relative increase in fluid intake compared to output • A high bounding pulse pressure, indicating a high cardiac output • Raised central venous pressure measurements • Peripheral hand vein emptying time longer than normal (peripheral veins will usually empty in 3–5 seconds when the hand is elevated and will fill in the same length of time when the hand is lowered to a dependent position) • Peripheral oedema • Hoarseness • Dyspnoea, cyanosis and coughing due to pulmonary oedema and neck vein engorgement

If detected early: withhold all fluids until excess water and electrolytes have been eliminated by the body and/ or administer diuretics to promote rapid diuresis

Dehydration (hypertonic contraction or hypotonic contraction)

Hypertonic: elderly, unconscious or incontinent patients Hypotonic: • Infants are at greatest risk, especially if they have diarrhoea • Patients with loss of salt from various sources: excess diuresis, fistula drainage, burns, vomiting or sweating

Hyper/hypotonic contraction: weight loss Hypercontraction: • Thirst (although this may be absent in the elderly) • Irritability and restlessness, and possible confusion • Diminished skin turgor • Dry mouth and furred tongue Hypocontraction: • Negative fluid balance • Weak, thready, rapid pulse rate • Increased ‘hand filling time’ • Increased skin turgor

Replace fluids and electrolytes

CHAPTER 15 Medicines optimization: ensuring quality and safety

Learning Activity 15.8  Clinical application 1 Explain what ‘extravasation’ means. 2 What is a vesicant? 3 Chemotherapy agents are typical vesicants, but there are several other drugs that are frequently used in clinical practice settings that fall into this category. Name at least five non-chemotherapy vesicants that you might meet in clinical practice. 4 Identify eight categories of patient who are at greater risk of extravasation. 5 What are the signs and symptoms of extravasation? 6 How are a flare reaction and vessel irritation different from extravasation? 7 What immediate action should be taken if extravasation is suspected? See the answers on the companion site of this student edition: www.royalmarsdenmanual.com/student10e.

Stretch Activity Further your thinking and learning about clinical practice A patient who has recently had chemotherapy treatment for cancer has developed herpes zoster (shingles). He has been prescribed intravenous acyclovir 8-hourly, due at 06.00, 14.00 and 22.00. You are on night duty and the ward is very busy: a patient has just died and you and your colleagues are busy with the relatives and meeting the other patients’ hygiene and elimination needs, and carrying out the oral drugs round. At 12.15am the shift leader realizes that the 10pm dose of acyclovir has not been given. 1 Is this a drug error? 2 Is this error likely to result in patient harm? 3 Ask whether you can attend a medicine error meeting. Consider whether you can identify any pattern to the drug errors being reported at this meeting. For example, are they prescription, wrong patient, wrong drug, wrong time or wrong dose errors? 4 Consider the investigation process that has been carried out. Usually this is a ‘root cause analysis’. Identify some of the underlying factors in drug errors and reflect on how this insight can assist you to avoid some of the most frequent types of drug error. 5 Find out the local policy where you are currently working for reporting drug errors (e.g. DATIX reporting). 6 Discuss with your practice supervisor and tutor the issue of drug errors, to help you understand risk factors and how these can be mitigated. Reflect on how this activity could help you to avoid making drug errors. See the answers to questions 1 and 2 on the companion site of this student edition: www.royalmarsdenmanual.com/student10e.

Now Test Yourself If you would like to test your learning further, there are additional questions on the compasnion site of this student edition: www.royalmarsdenmanual.com/student10e.

Websites Please visit www.royalmarsdenmanual.com/student10e for website links.

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CHAPTER 15 Medicines optimization: ensuring quality and safety

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Watt, S. (2003) Safe administration of medicines to children: Part 2. Paediatric Nurse, 15(5), 40–44. Webster, J., Clarke, S., Paterson, D., et al. (2008) Routine care of peripheral intravenous catheters versus clinically indicated replacement: Randomised controlled trial. BMJ, 337(7662), 157–160. Weinstein, S. & Hagle, M.E. (2014) Plumer’s Principles and Practices of Intravenous Therapy, 9th edn. Philadelphia: Lippincott Williams & Wilkins. Wells, S. (2008) Venous access in oncology and haematology patients: Part two. Nursing Standard, 23(1), 35–42. Wendler, M.C. (2003) Effects of Tellington touch in healthy adults awaiting venipuncture. Research in Nursing & Health, 26 (1), 40–52. Werawatganon, T. & Charuluxanun, S. (2005) Patient controlled intravenous opioid analgesia versus continuous epidural analgesia for pain after intra-abdominal surgery. Cochrane Database of Systematic Reviews, 1, CD004088. Westbrook, J., Woods, A., Rob, M., et al. (2010) Association of interruptions with an increased risk of severity of medication administration errors. Archives of Internal Medicine, 170(8), 683–690. Westbrook, J., Rob, M., Woods, A. & Parry, D. (2011) Errors in the administration of intravenous medications and the role of correct procedures and nurse experience. BMJ Quality & Safety, 20, 1027–1034. Wheatley, R., Schug, S. & Watson, D. (2001) Safety and efficacy of post­ operative epidural analgesia. British Journal of Anaesthesia, 87(1), 47–61. Whittington, Z. (2008) Pharmacological aspects of intravenous therapy. In: Dougherty, L. & Lamb, J. (eds) Intravenous Therapy in Nursing Practice, 2nd edn. Oxford: Blackwell, pp.117–140. Whittlesea, C. & Hodson, K. (eds) (2018) Clinical Pharmacy and Therapeutics, 6th edn. London: Elsevier. WHO (World Health Organization) (2004) Immunization in Practice: Module 6  –  Holding an Immunization Session. Geneva: World Health Organization. WHO (2008) Medicines: Safety of Medicines  –  Adverse Drug Reactions. Available at: https://www.who.int/medicines/regulation/medicinessafety/M_SBN_Jun18.pdf?ua=1 or https://apps.who.int/medicinedocs/ en/d/Jh2992e/2.html Wilkes, G. (2011) Chemotherapy: Principles of administration. In: Yarbro, C.H., Wujcik, D. & Holmes Gobel, B. (eds) Cancer Nursing: Principles and Practice, 7th edn. Sudbury, MA: Jones & Bartlett, pp.390–457. Wilkes, G. (2018) Chemotherapy: Principles of administration. In: Yarbro, C.H., Wujcik, D. & Holmes Gobel, B. (eds) Cancer Nursing: Principles and Practice, 8th edn. Burlington, MA: Jones & Bartlett, pp.417–496. Wilson, K. & Sullivan, M. (2004) Preventing medication errors with smart infusion technology. American Journal of Health System Pharmacists, 61(2), 177–183. Witt, B. (2010) Vein selection. In: Phillips, S., Collins, M. & Dougherty, L. (eds) Venepuncture and Cannulation. Oxford: John Wiley & Sons, pp.91–107. Workman, B. (1999) Safe injection techniques. Nursing Standard, 13(39), 47–52. Wright, D., Begent, D., Crawford, H., et al. (2017) Medicines Management of Adults with Swallowing Difficulties. Guidelines. Available at: https:// www.guidelines.co.uk/dysphagia/swallowing-difficulties-medicationmanagement-guideline/453844.article Wright, K. (2010) Do calculation errors by nurses cause medication errors in clinical practice? A literature review. Nurse Education Today, 30(1), 85–97. Yuan, R. & Cohen, M.J. (1985) Lateral antebrachial cutaneous nerve injury as a complication of phlebotomy. Plastic and Reconstructive Surgery, 76(2), 299–300. Zeind, C.S. & Carvalho, M.G. (eds) (2018) Applied Therapeutics: The Clinical Use of Drugs, 11th edn. Philadelphia: Wolters Kluwer.

Answers Answers to the learning and stretch activities are available on the companion site of this student edition: www.royalmarsdenmanual. com/student10e.

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16

Perioperative care

1

THEATRE

OPERATION ANAESTHETIC

Justine Hofland with Hayley Grafton, Pascale Gruber, Tina Kitcher and Lian Lee

STERILE DRAINAGE INFECTION ANTIEMBOLIC

PERIOPERATIVE PATIENT

WOUND PROCEDURE DRESSING SURGERY

2 3

4

After reading this chapter and undertaking the learning activities within it, you should: Understand the importance of assessing and preparing patients in advance of planned surgery to improve their perioperative experience and postoperative outcomes Know the principles of pre-operative care to ensure that patients are ready to safely undergo surgical procedures Appreciate the precautions taken when surgical procedures are performed, to protect patients from undue harm, reduce the risk of complications and promote positive outcomes Know in principle how to care for postoperative patients and prepare them for discharge from hospital

Key terms are highlighted in the text in pink. Glossary definitions of these terms can be found on the companion site of this student edition: www.royalmarsdenmanual.com/ student10e.

Procedure guidelines 16.1 Measuring and applying antiembolic stockings 16.2 Pre-operative care: checking that the patient is fully prepared for surgery 16.3 Caring for the patient in the anaesthetic room 16.4 Operating theatre procedure: maintaining the safety of a patient during surgery 16.5 Handover in the post-anaesthetic care unit (PACU): scrub nurse or operating department practitioner to recovery practitioner

16.6 Safe management of patients in the post-operative care unit (PACU) 16.7 Drainage systems: changing the dressing around the drain site for both open and closed drains 16.8 Closed drainage systems: changing a vacuum bottle 16.9 Wound drain removal: closed drainage system 16.10 Wound drain shortening for open drainage systems 16.11 Wound drain shortening for closed drainage systems

The Royal Marsden Manual of Clinical Nursing Procedures: Student Edition, Tenth Edition. Edited by Sara Lister, Justine Hofland and Hayley Grafton with Catherine Wilson. © 2021 The Royal Marsden NHS Foundation Trust. Published 2021 by John Wiley & Sons Ltd. Student companion website: www.royalmarsdenmanual.com/student10e Instructor compaion website: www.royalmarsdenmanual.com/instructor10e

THE ROYAL MARSDEN MANUAL OF CLINICAL NURSING PROCEDURES

Overview 938

C

are of patients undergoing any surgical procedure has three main phases: pre-operative (prior to the procedure), intra­ operative (during the procedure) and post-operative (immediately following completion of the procedure). Pre-operative care is delivered over two (or more) different episodes of contact with the patient. The first is pre-assessment, which usually takes place within days (in elective or semi-elective surgery), but sometimes minutes or hours (in emergency surgery), before the surgery. The aims of this phase are to assess the patient, carry out any necessary investigations to ensure they are physically and mentally able to have the procedure, and provide information about the anaesthetic and proposed surgery. The second is the immediate phase prior to the commencement of the procedure. The aims of this phase are to ensure the patient is prepared adequately for the surgical procedure and to mitigate any associated risks. Intraoperative care usually consists of three phases: induction of anaesthesia, surgery and finally the recovery of the patient within the post-anaesthetic care unit (PACU). As care within surgery is delivered by a multidisciplinary team, a thorough hand­ over of the patient is essential at every stage. Finally, the care continues beyond the intraoperative phase when the patient receives post-operative care both before and after discharge from hospital. The amount and complexity of post-operative care required will vary significantly according to the nature of the surgery (e.g. minor, major, laparoscopic or robotic) and the physical, mental and social status of the patient.

Pre-operative care DEFINITION

Pre-operative care is the physical and psychosocial care provided to patients to help them prepare to safely undergo surgery. Psychosocial preparation includes assessing and managing patient stress, educating patients, and gaining informed consent for the procedure. Physical preparation is concerned with the prevention of peri- and post-operative complications (Liddle  2012, Turunen et al. 2017). The pre-operative phase of care begins when the patient is informed of the need for surgery and subsequently makes the decision to undergo the procedure. This phase may be slightly longer for a patient undergoing a minor day procedure.

RELATED THEORY

Optimal pre-operative care is underpinned by thorough assessment and planning. While physical preparation is concerned with the prevention of peri- and post-operative complications (Malley et al. 2015), attention should also be given to the patient’s psychosocial needs and how the surgical procedure may affect their overall wellbeing. The patient’s pre-assessment includes a medical or adequately trained nurse review, which may prompt further diagnostic intervention or investigations (Boehm et  al.  2016). Pre-assessment aims to assess the patient’s fitness for surgery; provide information to the patient and their family about their upcoming anaesthetic and surgery; and provide advice about diet, exercise and lifestyle (e.g. smoking and alcohol cessation) to ensure the patient is fit and optimized for surgery. Pre-assessment is important in preparing patients physically and mentally for surgery, and it is key in improving post-operative outcomes and reducing cancellations on the day of surgery (Pritchard 2012). Optimizing any co-morbidities pre-operatively that may affect the perioperative care of the patient is a key part of the review. The patient’s current health status, performance and quality of life need to be considered, and the benefits of the surgery must outweigh the potential risks (Wood et al. 2016).

Traditionally, patients were admitted to hospital 1–2 days preoperatively to allow for appropriate assessment, tests and investigations to be completed prior to their surgery; as such, they were not pre-assessed in dedicated clinics. However, once they were admitted it was frequently found that patients were presenting with complicated, newly identified or inappropriately managed co-morbidities, so surgeries were often delayed or cancelled. It was also found that a large number of cancelled operations occurred because patients did not arrive for their scheduled operation fasted. Some did not arrive because the date provided was inconvenient (due to childcare or work-related concerns) or the surgery was no longer wanted or needed. In light of this, pre-operative assessment (POA) clinics were established to address these issues. The POA and planning carried out in these clinics aim to improve patient care and safety but also make the most efficient use of theatre resources and ward beds (K. Yu et al. 2017). POA is an essential part of the planned surgical care pathway. Subsequently, it has been found that providing patients with a time and place to explore their concerns and gain the information they need has increased the attendance of patients and therefore made more effective use of operating theatre time and other associated resources (NHS England 2017, NHS Modernization Agency 2003). Any data obtained during the POA provides the foundation for producing an individualized patient care plan. This may consider the patient’s frailty, risk of post-operative cognitive dysfunction, risk of infection, risk of pressure damage and risk of venous thromboembolism (VTE). A conversation with the patient during this POA is an effective way to increase the patient’s awareness of certain risk factors (Almodaimegh et al. 2017, Haymes 2016). The perioperative care documentation forms an important communication tool for the perioperative practitioners. It provides detailed records of the care delivered to the patient during their surgical journey. These records are maintained and handed over to various practitioners during each perioperative phase of care. Depending on the complexity of the surgery, the POA can be undertaken either during a face-to-face conversation or via telephone clinics, which are increasingly nurse led.

EVIDENCE-BASED APPROACHES

Principles of care

POAs provide an effective screening process and help to identify the patient’s overall risk of surgery-related complications. A POA should include three key stages: 1 comprehensive pre-operative history taking 2 physical examination 3 pre-operative investigations.

Pre-operative history taking Medical history

A patient’s medical history is an important component of any preoperative evaluation. The history should start with current illness. This starts with the reason why the patient is having the planned procedure. It is important to include how the patient first presented with the symptoms of the condition, and any treatments that have been provided. It is important to obtain details of treatments such as previous chemotherapy or radiotherapy within the health history. A full history of current and previous medical problems should also be taken. The history should also include a complete review of the  patient’s systems in order to look for undiagnosed disease or  inadequately controlled chronic disease (see Chapter  2: Admissions and assessment). Diseases associated with an increased risk of surgical complications include respiratory and cardiac disease, malnutrition, and diabetes mellitus (Böhmer et al. 2014, Song et al. 2015). Diseases of the cardiovascular and respiratory systems are the most relevant in respect of a patient’s

CHAPTER 16 Perioperative care

fitness for anaesthesia and surgery (Kolh et  al.  2016, Kraiss et al. 2015). It is valuable to obtain information such as dates of diagnosis, severity, ongoing treatment and any history of hospitalization for the disorders. A clear record of the patient’s medical history produces the foundations for a substantial plan of care. ‘This ensures the patient’s surgical journey is effective, reducing the risk of suboptimal management and increasing safety with the least possible distress for the patient and their significant others’ (Walsgrove 2011, p.33).

Family history

Asking the patient about illnesses that run in their family, such as hypertension, coronary artery disease, stroke, diabetes and hypercholesterolaemia, will alert the anaesthetist to any potential medical problems. A family history of adverse reactions associated with anaesthesia should also be obtained.

Surgical and anaesthetic history

A history of previous major surgeries and recent anaesthetics gives the assessor a comprehensive idea of the fitness of the patient. It is vital to find out about previous anaesthetic problems, such as post-operative nausea and vomiting. Patients with a history of bleeding complications should be carefully assessed for coagulation disorders (Gilbert-Kawai and Montgomery 2017), and a history of adverse anaesthetic reactions (in a patient or family members) should raise concerns about susceptibility to malignant hyperthermia (Chan et  al.  2017). Patients susceptible to malignant hyperthermia (a rare, life-threatening progressive hyperthermic reaction during anaesthesia) require an anaesthesia consultation, appropriate preparation of the operating room, and adequate equipment and expertise in the event of a reaction during surgery. The Association of Anaesthetists of Great Britain and Ireland (AAGBI) (2011, 2013) offers guidance on the management of a malignant hyperthermia crisis (Figure 16.1). The American Society of Anesthesiologists (ASA) (2014) has developed a scale with which to classify patients on the basis of their existing co-morbidities (Table  16.1). The scale is a wellestablished scoring tool that is useful for calculating patient risk of anaesthetic complications in relation to existing conditions (Doyle and Garmon 2019, Helkin et al. 2017).

Medications and allergies

A full list of the patient’s current medications, including over-thecounter medications as well as vitamin and herbal supplements, is essential. Many medications interact with anaesthetic agents or negatively affect the patient in the intra- or post-operative period. These include anticoagulants, diabetic medications, calcium channel antagonists, beta blockers and some antidepressants. If a patient is taking steroids or opiates, these require careful titration intra- or post-operatively. Generally, administration of most drugs should be continued up to and including on the morning of an operation, although some adjustments to dosage may be required (e.g. for antihypertensives and insulin). Some drugs should be discontinued pre-operatively, potentially days or weeks prior to surgery (Figure  16.2). Any monoamine oxidase inhibitors should be withdrawn 2–3 weeks before surgery because of the risk of interactions with drugs used during anaesthesia. The use of the oral contraceptive pill should be discontinued at least 4 weeks before elective surgery because of the increased risk of venous thrombosis. An assessment of any medications or herbal treatments that a patient consumes is included as part of the POA, and a decision is made on whether a further haematological work-up is required before surgery (Tassler and Kaye 2016). Some herbal supplements may have to be discontinued prior to surgery (Abe et al. 2014, Wang et al. 2015). Attributable side-effects of herbal medicines include cardiovascular instability, electrolyte disturbance, coagulation disturbance, coagulation disorder, endocrine effects, hepatotoxicity and renal failure (Batra and Rajeev 2007, Byard 2010).

The patient’s allergy status should be obtained and specific details of reactions recorded in the care plan (particularly allergies to rubber products and to foods associated with latex reactions, such as bananas, avocados, kiwis, apricots and chestnuts). Medication ‘intolerance’ should also be documented to avoid severe side-effects such as nausea and vomiting. A history of previous anaphylactic reactions should be thoroughly documented to avoid potential incidents. Patients who are allergic to latex will need to be first on the theatre list, and theatre staff will need to be alerted to avoid complications (see ‘Latex sensitivity and allergy’ below).

Social history

A social history encompasses social situations such as home life and occupation. It provides a general picture of the social practices of the patient that may affect their fitness for surgery but also influence their recovery. A patient’s past and current occupational background will provide an insight into their home and financial situation, as well as potential occupational disorders such as respiratory or musculoskeletal problems. Understanding the patient’s support systems (e.g. in their family or the wider community) is important. It will provide clues to potential ‘road blocks’ for a timely discharge. If the patient is found to have little or no available support in the community, the POA practitioner will have the opportunity to initiate any necessary discharge planning or social services referrals prior to admission. This will allow the patient to avoid any potential delays in their discharge. The social history component of the POA includes a further assessment of smoking, drug and alcohol use. Long-term abuse of alcohol, tobacco products or drugs can result in organ damage, related medical complications, and therefore a higher incidence of perioperative morbidity and mortality. Intra- and post-operative events such as delirium tremens (an acute episode of delirium) are considered medical emergencies. Alcohol

It is important to assess the amount of alcohol the patient consumes on a daily or weekly basis. Alcohol guidelines from the Department of Health (DH) (2016) recommend that both men and women should not drink more than 14 units of alcohol each week. Excessive alcohol consumption is a risk factor for post-operative delirium and withdrawal symptoms. Smoking

It is important to assess smoking behaviour. There is strong evidence to suggest that higher risks and worse surgical outcomes occur when a patient continues to smoke (ASH 2016). Smoking causes increased cardiorespiratory complications, more intensive care admissions, higher rates of mortality, higher rates of wound infections and poorer wound healing after surgery (Thomsen et  al.  2014). The POA practitioner should assess the length of time an individual has smoked, the number of tobacco products smoked per week, and the pattern of their smoking (i.e. times of day, and whether they smoke alongside specific activities, such as waking up, going to sleep or managing stress). Pre-operative smoking cessation is important, and help with this should be offered during the assessment. Smoking cessation before elective surgery can significantly improve post-operative outcomes (Prestwich et al. 2017). The extent of smoking-related effects is dependent upon the amount and the length of time of smoking. Smokers have hyper-reactive airways that lead them to become more susceptible to incidents of laryngospasm and bronchospasm. They have an increased chance of developing postoperative lung infections due to a compromised ability to clear secretions. Post-operative healing is also affected by smoking as nicotine is a vasoconstrictor. Action on Smoking and Health (ASH) (2016) states that stopping smoking prior to surgery can reduce risks and improve outcomes. The National Institute for Health and Care Excellence (NICE) (2018b) offers guidance on

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Figure 16.1  Malignant hyperthermia crisis: AAGBI safety guideline. Source: Adapted from AAGBI (2011) with permission of the Association of Anaesthetists.

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Malignant Hyperthermia Crisis AAGBI Safety Guideline Successful management of malignant hyperthermia depends upon early diagnosis and treatment; onset can be within minutes of induction or may be insidious. The standard operating procedure below is intended to ease the burden of managing this rare but life threatening emergency.

1

Recognition

2

Immediate management

3

Monitoring & treatment

• Unexplained increase in ETCO2 AND • Unexplained tachycardia AND • Unexplained increase in oxygen requirement (Previous uneventful anaesthesia does not rule out MH) • Temperature changes are a late sign • • • • • •

STOP all trigger agents CALL FOR HELP. Allocate specific tasks (action plan in MH kit) Install clean breathing system and HYPERVENTILATE with 100% O2 high flow Maintain anaesthesia with intravenous agent ABANDON/FINISH surgery as soon as possible Muscle relaxation with non-depolarising neuromuscular blocking drug

• Give dantrolene • Initiate active cooling avoiding vasoconstriction

2.5 mg/kg immediate iv bolus. Repeat 1 mg/kg boluses as required to max 10 mg/kg

• TREAT:

For a 70 kg adult

• Hyperkalaemia: calcium chloride, glucose/insulin, NaHCO3¯

• Initial bolus: 9 vials dantrolene 20 mg (each vial mixed with 60 ml sterile water)

• Arrhythmias: magnesium/amiodarone/metoprolol AVOID calcium channel blockers interaction with dantrolene

• Further boluses of 4 vials dantrolene 20 mg repeated up to 7 times.

• Metabolic acidosis: hyperventilate, NaHCO3¯ • Myoglobinaemia: forced alkaline diuresis (mannitol/furosemide + NaHCO3¯); may require renal replacement therapy later • DIC: FFP, cryoprecipitiate, platelets • Check plasma CK as soon as able

4

Follow-up

DANTROLENE

• • • • • •

Continuous monitoring Core & peripheral temperature ETCO2 SpO2 ECG Invasive blood pressure CVP Repeated bloods ABG U&Es (potassium) FBC (haematocrit/platelets) Coagulation

Continue monitoring on ICU, repeat dantrolene as necessary Monitor for acute kidney injury and compartment syndrome Repeat CK Consider alternative diagnoses (sepsis, phaeochromocytoma, thyroid storm, myopathy) Counsel patient & family members Refer to MH unit (see contact details below)

The UK MH Investigation Unit, Academic Unit of Anaesthesia, Clinical Sciences Building, Leeds Teaching Hospitals NHS Trust, Leeds LS9 7TF. Direct line: 0113 206 5270. Fax: 0113 206 4140. Emergency Hotline: 07947 609601 (usually available outside office hours). Alternatively, contact Prof P Hopkins, Dr E Watkins or Dr P Gupta through hospital switchboard: 0113 243 3144.

Your nearest MH kit is stored This guideline is not a standard of medical care. The ultimate judgement with regard to a particular clinical procedure or treatment plan must be made by the clinician in the light of the clinical data presented and the diagnostic and treatment options available. © The Association of Anaesthetists of Great Britain & Ireland 2011

CHAPTER 16 Perioperative care

Table 16.1  Modified American Society of Anesthesiologists physical status classification system Class

Physical status

Example

I

A healthy patient

A fit patient with an inguinal hernia

II

A patient with mild systemic disease

A patient with essential hypertension and mild diabetes without end organ damage

III

A patient with severe systemic disease that is a constant threat to life

A patient with angina and moderate to severe chronic obstructive pulmonary disease (COPD)

IV

A patient with an incapacitating disease that is a constant threat to life

A patient with advanced COPD and cardiac failure

V

A moribund patient who is not expected to live 24 hours with or without surgery

A patient with a ruptured aortic aneurysm and a massive pulmonary embolism

VI

A declared brain-dead patient whose organs are being removed for donor purposes

(Brain dead is defined as irreversible brain damage causing the end of independent respiration, regarded as indicative of death.)

E

Emergency case

(An emergency exists when delay in treatment of the patient would lead to a significant increase in the threat to life or a body part.)

Source: Adapted from American Society of Anesthesiologists (2014).

stopping smoking interventions and services. The POA is an ideal opportunity to explore the smoking habits of the patient and provide advice on cessation.

Physical examination

Within the POA, the physical examination should build on the information gathered during the history taking. Baseline vital signs and physical assessment should be completed by a trained assessor. All patients should receive a thorough cardiovascular and pulmonary examination and should be asked about chronic or recent infections. The physical examination should pay specific attention to the respiratory and cardiovascular systems, as they are the systems that are most directly influenced by anaesthetics throughout the surgery and during the post-operative recovery period (Wijeysundera and Sweitzer 2015). Examination of further organ systems, such as abdominal or neurological systems, should also be completed if indicated by the patient’s history. For example, patients with known alcohol or drug abuse should be further examined for hepatic and neurological impairments. Patients with identified chronic organ diseases, such as congestive heart failure or chronic obstructive pulmonary disease, should be evaluated for any uncompensated disease. Patients with a history of heavy alcohol use should be assessed for signs of chronic liver disease with concomitant concern for post-­ operative alcohol withdrawal syndromes and delirium. Any abnormality detected in the review of all body systems (see the section on physical assessment in Chapter  2: Admissions and assessment) should be characterized, investigated and addressed prior to surgery (particularly a new cough, fever or symptoms of an infection). Finally, any airway problems must be recognized and addressed during the POA. The anaesthetic assessment also includes any cardiovascular, hepatic or pulmonary impairment; bleeding disorders; significant history of reflux or a hiatus hernia; and breathing difficulties such as sleep apnoea, paroxysmal nocturnal dyspnoea or orthopnoea. A failure to provide adequate ventilation can lead to hypoxia, a common anaesthetic problem that can result in morbidity and mortality during the perioperative phase. An airway assessment includes: • range of motion of the neck and jaw • mouth opening, including ability to protrude lower incisors in front of the upper incisors • dentition (condition of teeth) • history of temporomandibular joint dysfunction and other airway abnormalities.

If there are any problems with the airway, the anaesthetist needs to be informed so that appropriate equipment can be ordered for the day of surgery. Alert the anaesthetist if the patient has previously experienced a difficult intubation or if they currently have: • diseases that may affect the airway • co-morbidities • surgical/radiotherapy scarring of the head, neck or media­ stinum • difficult or noisy breathing • morbid obesity • a poor mouth opening • a rigid or deformed neck • a receding chin or an overbite (Ong and Pearce 2011). Further explanation of physical assessment can be found in Chapter 2: Admissions and assessment and Chapter 3: Discharge care and planning.

Pre-operative investigations Laboratory investigations

Investigations are often ordered to establish baseline values, support or refute differential diagnoses, and support or monitor the management of existing disease processes. Laboratory tests should be ordered based on information obtained from both the patient history and the physical examination (Table 16.2). They should also take into account the patient’s age and the complexity of the surgical procedure. NICE (2016b) offers an evidence-based guide for the ordering and use of routine pre-operative testing in elective surgeries. The investigations are based on ASA status (see Table 16.1), the age of the patient and their co-morbidities.

Non-laboratory investigations Electrocardiograms

A standard 12-lead electrocardiogram (ECG) (Figure 16.3) is frequently performed if indicated by the age of the patient, risk factors, co-morbidities or findings of the physical examination. The patient’s ASA grading (see Table 16.1) and the surgical grading of the planned surgery may also indicate an ECG. The proportion of patients with an abnormal ECG increases with age and the presence of co-morbidities. An ECG can also be completed to establish a baseline prior to surgery for post-operative comparison. Imaging: chest X-ray

A chest X-ray can give the practitioner valuable information to support or refute potential diagnoses or further assess the

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THE ROYAL MARSDEN MANUAL OF CLINICAL NURSING PROCEDURES

Figure 16.2  Guide to preoperative medication.

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Medication to Continue Pharmacological class of medication Gastro-intestinal System

Query

Pre-operative management H2 antagonists e.g. ranitidine Continue but for cimetidine see comments

Medication to Omit Comments

Cimetidine: Caution: can lead to increased bupivacaine toxicity. Has been shown to raise plasma lidocaine levels, especially when used as an anti-arrhythmic

Proton pump inhibitors e.g. lansoprazole, omeprazole Aminosalicylates. e.g. mesalazine, sulphasalazine Cardiovascular System

Alpha antagonists e.g. doxazosin

Continue all, EXCEPT alfuzosin

Continue for anti-hypertensive indication but for urological indication see comments

Stop alfuzosin 24 hours prior to operation

Anti-arrythmics e.g. digoxin, amiodarone, flecainide

Refer to anaesthetist if hypokalaemic, hypomagnesaemic or hypercalcaemic

Beta-blockers e.g. atenolol, bisoprolol, metoprolol, propranolol

Avoid stopping suddenly. Continue IV if prolonged NBM

Calcium antagonists e.g. amlodipine, nifedipine, diltiazem Centrally acting antihypertensives e.g. clonidine, moxonidine Loop and Thiazide Diuretics e.g. Correct any electrolyte imbalances furosemide, bendroflumethiazide, prior to surgery bumetamide, indapamide Nitrates e.g. isosorbide mononitrate, isosorbide dinitrate, glyceryl trinitrate (GTN)

CHAPTER 16 Perioperative care

Figure 16.2  (continued) Pharmacological class of medication

Pre-operative management

Comments

Potassium channel activator e.g. nicorandil ACE inhibitors e.g. lisinopril, ramipril, enalapril: omit 24 hours prior to major surgery except for patients with exisiting heart failure – discuss with anaethetist Angiostensin receptor II antagonists e.g. losartan, candesartan, irbesartan Aspirin

Patients taking aspirin for primary prevention of heart disease can stop 7 days before surgery. All others please follow local perioperative anti-platelet drug guidelines

Clopidogrel (Plavix) and prasugrel (Effient)

See local perioperative anti-platelet drug guidelines Discuss all patients taking these drugs with consultant anaesthetist. DO NOT STOP IN RECENT CORONARY STENTS (3 months for bare metal, and 12 months for drug eluting)

Dipyridamole

Discuss with surgeons. If procedure high risk, omit on day of surgery

Low-molecular-weight heparin e.g. tinzaparin, enoxaparin

See local anticoagulant guidelines. Therapeutic dose should not be given less than 24 hours before surgery

Potassium sparing diuretics e.g. spironalactone, amiloride, coamilofruse, co-amiloride

Omit on day of surgery. May contribute to hyperkalaemia post-op

Oral anticoagulant e.g. warfarin, phenidione

See local perioperative anticoagulation guidelines Patients having minor procedures may be able to continue after discussion with surgical team

Respiratory System

Aminophylline / Theophylline Inhalers e.g. salbutamol, beclometasone

Optimize treatment at pre-operative assessment

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Figure 16.2  (continued)

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Pharmacological class of medication Central Nervous System

Pre-operative management

Comments

Anti-epileptics e.g. phenytoin, sodium valproate, carbamazepine, lamotrigine, topiramate, tiagabine

For epilepsy MUST continue. Very important to maintain therapeutic concentrations to avoid seizures.

Antipsychotics e.g. chlorpromazine, haloperidol, olanzapine, risperidone

Clozapine: stop on the day of operation Please note the last dose should be administered no later than 8 pm on the night before surgery; can increase VTE risk and hypotension

For clozapine see notes

Barbiturates e.g. phenobarbital Benzodiazepines e.g. diazepam, temazepam, lorazepam Opioid analgesics e.g. morphine, methadone, codeine, fentanyl

Consult anaesthetist to plan post-op analgesia. Must confirm dose of methadone with usual prescribing doctor/dispensing chemist.

Paracetamol Parkinson’s treatment e.g. cocareldopa, co-beneldopa, cabergoline, selegiline, entacapone, procyclidine

Continue oral medications up to 2 hours before surgery. Must inform anaesthetist of patients on antiParkinsonian medicines. Selegiline interacts with pethidine to cause hyperpyrexia and CNS toxicity.

Selective serotonin re-uptake Inhibitors (SSRIs) e.g. paroxetine, fluoxetine, citalopram, sertraline Venlafaxine (Effexor), Mirtazapine (Zispin) Lithium

Check levels pre-op. Continue for minor surgery. Discuss with anaesthetist plan for major surgery. Restart ASAP post-op

Tricyclic antidepressants e.g. amitriptyline, lofepramine, dosulepin

Continue, but increased risk of arrhythmias

Anti-dementia drugs e.g. donepezil, rivastigmine, galantamine (acetylcholinesterase inhibitors)

May prolong neuromuscular blockade and exaggerate muscle relaxation with succinylcholine-type muscle relaxants. Alert anaesthetist to the potential for prolonged neuromuscular blockade.

CHAPTER 16 Perioperative care

Figure 16.2  (continued) Pharmacological class of medication

Pre-operative management

Comments Omit rivastigmine and glantamine 24–48 hours prior to surgery. It is recommended to stop donepezil 2–3 weeks prior to surgery; however these patients may not return to their baseline mental function, so it may be unethical to stop

Infections

Endocrine System

Clozapine

Stop 12 hours pre-op. Restart ASAP; if discontinued for longer than 48 hours contact pharmacist for advice

Monoamine-oxidase inhibitors (non-reversible) e.g. phenelzine, isocarboxazid, tranylcypromine

Stop 14 days pre-op (discuss with psychiatrist). If not withdrawn, inform anaesthetist

Reversible MAOIs e.g. moclobemide

Last dose 24 hours before surgery

Antibiotics, antifungals, antivirals HIV antiretroviral drugs e.g. ritonavir

Wherever possible, treatment should not be interrupted due to concerns with developing resistance

Corticosteroids e.g. prednisolone

May need additional hydrocortisone bolus intra/post-operation:

(Current or stopped within last 3 months) See above for more details

Minor surgery: 25 mg hydrocortisone at induction (or usual oral dose) Moderate surgery: 25 mg hydrocortisone at induction (or usual oral dose) then 25 mg hydrocortisone TDS for 24 hours and then restart usual steroid dose Major surgery: 50 mg hydrocortisone at induction (or usual oral dose) then 50 mg TDS hydrocortisone for 48–72 hours and then restart usual steroid dose

Desmopressin (DDAVP) Continue but see comments

Continue and discuss with endocrinologist consultant for specialist advice in the peri-operative period

Hormone antagonists e.g. tamoxifen, anastrazole

Specialist advice should be sought; VTE risk is increased

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Figure 16.2  (continued)

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Pharmacological class of medication

Pre-operative management Hormone replacement therapy (HRT)

Comments Specialist advice should be sought; VTE risk is increased

Levothyroxine (thyroxine) Progesterone-only oral contraceptives

Thromboprophylaxis and TEDS

Combined oral contraceptives (i.e. containing oestrogen) See above for more details

Consult gynae team on individual patient basis

Oral antidiabetics e.g. glibenclamide, glipizide, gliclazide, tolbutamide, pioglitazone Insulin

Omit 4 weeks prior to major surgery; institute thromboprophylaxis and TEDS as per local VTE guidelines. Advise on alternative family planning See local diabetic guidelines

See local diabetic guidelines Refer to anaesthetist. Continue until morning of surgery. Omit morning dose and breakfast Minor surgery: Restart s/c insulin post-op with first meal Major surgery: Omit breakfast and S/C insulin and start intravenous sliding-scale insulin

Metformin

See local diabetic guidelines

Bisphosphonates eg. alendronate, risedronate

Restart when patient can sit upright and swallow the tablets whole with a glass of water

For strontium see comments Malignant Disease Drugs to prevent adverse effects and e.g. allopurinol Immunosuppression Immunosuppressants e.g. azathioprine, ciclosporin, mycophenolate, tacrolimus

For strontium: stop 14 days prior to operation Seek advice from oncologist/ haematologist

Seek advice from oncologist/ haematologist

CHAPTER 16 Perioperative care

Figure 16.2  (continued) Pharmacological class of medication

Musculoskeletal and Joint Diseases

Pre-operative management

Comments

Cytotoxics e.g. alkylating agents, antimetabolites

Seek advice from oncologist/ haematologist

Baclofen COX II inhibitors e.g. celecoxib

Continue if important for patients Continue if patient is taking

DMARDS e.g. methotrexate for rheumatoid arthritis, penicillamine

Continue unless at risk of renal complications. Discuss with specialist

Non-steroidal anti-inflammatory Increased risk of bleeding. Reduce drugs (NSAIDs) e.g. diclofenac, intake if symptoms permit ibuprofen Minor surgery: continued if needed

Major surgery: if increased risk of post-op bleeding or when a bleed could result in significant problems, stop pre-op • For drugs with a short half-life (e.g. diclofenac, ibuprofen, indomethacin) stop 1 day pre-op • For drugs with a longer halflife (e.g. naproxen) stop 3 days pre-op Restart when risk of bleeding no longer significant

Complimentary Alternative Medicines

Ideally these should be stopped at least 2 weeks prior to surgery. Refer to local guidance and consult local pharmacy services

Homoeopathic Medicines

If the dilution of the remedy is not known or less than 12c or 24c then it may contain active ingredients and could potentially interact with conventional medicines. Therefore it should be stopped 2 weeks prior to surgery

Nutrition and Blood

Drugs for nutrition (e.g. iron, folic acid, calcium, magnesium): continue unless specifically advised not to

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Table 16.2  Pre-operative laboratory tests

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Pre-operative test

Rationale

Haematology Full blood count (FBC), including haemoglobin and haematocrit

Patients with a history of: • smoking • malignancy • respiratory disease • cardiac disease. These patients may be at increased risk of anaemia and polycythaemia.

White blood cell count

Patients with a history of: • recent chemotherapy and/or radiotherapy • malignancy • recent infection. These patients may have either raised or lowered white blood cell count.

Platelet count

Platelet count should be checked in patients with a history of: • bleeding tendencies • renal or hepatic disease • recent treatment with chemotherapy.

Coagulation screening, including prothrombin and activated partial thromboplastin time

This is not recommended unless the patient: • is taking anticoagulants • has a history of bleeding disorders • has a history of post-surgical bleeding • has a bleeding history (such as liver disease or malignancy) (Chee et al. 2008).

Group and save or cross-match

Having the blood tested prior to the date of surgery gives the blood bank more time to find the appropriate blood required for the specific patient. Patients with unusual blood typing or rare antibodies may need to have blood specially obtained from a national blood bank, and having the sample collected in advance will decrease the chance of errors and of the patient having their surgery postponed

Serum biochemistry Glycosylated haemoglobin (HbA1c) level

Patients presenting with a history of: • steroid use • obesity • cardiovascular disease • symptoms suggestive of diabetes. The HbA1c provides a more accurate measurement of the patient’s long-term glucose control and compliance compared with random glucose testing.

Baseline serum creatinine Patients with a history of: and blood urea nitrogen • renal dysfunction level • diabetes • cardiovascular disease • obesity • use of medications such as steroids or diuretics. Liver function tests, such as albumin

Patients presenting with: • liver disease • malignancy • alcohol abuse • malnutrition • jaundice. The liver and kidneys aid the metabolism and elimination of many anaesthetics and medications. Therefore, it is vital to ensure these are checked pre-operatively to ensure adequate organ function.

Electrolyte levels

Electrolyte levels should be checked pre-operatively in patients with a history of: • renal dysfunction • diabetes • malignancy • malnutrition • vomiting or diarrhoea • use of medications such as diuretics or chemotherapy. These patients may require pre-operative prescribing of supplements such as potassium to optimize their electrolyte levels prior to surgery. Electrolyte imbalances such as hypokalaemia or hyponatraemia can be life threatening.

CHAPTER 16 Perioperative care

Pre-operative test

Rationale

Other tests Thyroid function testing

Patients with a history of: • hypothyroidism • hyperthyroidism. Patients with untreated or severe thyroid disease are at increased risk of developing ‘thyroid storm’ (dangerously raised heart rate, blood pressure and temperature) relating to the stress of surgery or illness (Weinberg et al. 1983).

Urinalysis

Patients presenting with symptoms of a urinary tract infection or those presenting for procedures of the urinary tract, e.g. cystoscopy.

Pregnancy testing

Pregnancy testing should be completed based on the findings of the medical history and the date of the last menstrual cycle. This should ideally be done on the day of admission unless the patient suspects she might be pregnant during pre-assessment.

Figure 16.3  An example of a 12-lead electrocardiogram (ECG).

severity of a specific disease. Patients presenting with history of cardiovascular or respiratory symptoms or with disease processes should have a chest X-ray completed pre-operatively. If the patient has had a chest X-ray within the past 6 months, it does not need to be repeated unless new problems have arisen or the existing problems have worsened. Cardiopulmonary exercise testing

Older et  al. (1993) introduced the concept of cardiopulmonary exercise testing (CPET) (Figure  16.4). CPET is a dynamic, noninvasive test involving the use of an exercise bicycle (cycle ergometer) where the work rate is gradually and imperceptibly increased in a stepped or ramped manner until the patient is unable to continue. This enables examination of the ability of the patient’s cardiorespiratory system to adapt to a ‘stress’ situation of increased oxygen demand, in effect mimicking the conditions of surgery. CPET relies upon accurate breath-by-breath measurements of pulmonary gas exchange through a mouthpiece that measures

respiratory gas exchange. In addition, electrocardiography, blood pressure, pulse oximetry and heart rate are monitored during the exercise. From the CPET, two key indicators are derived: the body’s maximum oxygen uptake (VO2 max) and the point at which anaerobic metabolism exceeds aerobic metabolism (anaerobic threshold, or AT). Together these broadly indicate the ability of the cardiovascular system to deliver oxygen to the peripheral tissues and the ability of the tissues to use that oxygen. In addition, the AT has been shown to be a useful predictor of post-operative cardiac complications in abdominal surgery (Lanier et al. 2018). CPET is often referred to as the gold standard for measuring exercise tolerance. It enables clinicians to triage patients to the appropriate level of care after surgery, allowing the efficient use of intensive care facilities (Mezanni 2017). It also assists surgeons in assessing treatment options more easily. The patient is then in a better position to evaluate their own risk–benefit ratio for surgery and thus make a more informed decision on consent for an operation (Guazzi et al. 2017).

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Figure 16.4  Cardiopulmonary exercise testing (CPET).

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Indications for CPET include: • to estimate the likelihood of perioperative morbidity and mortality and contribute to pre-operative risk assessment • to inform the processes of multidisciplinary shared decision making and consent • to guide clinical decisions about the most appropriate level of perioperative care (ward versus critical care) • to direct pre-operative referrals and interventions so as to optimize the detection and management of co-morbidities • to identify previously unsuspected pathology • to evaluate the effects of neoadjuvant cancer therapies, including chemotherapy and radiotherapy • to guide prehabilitation and rehabilitation training programmes • to guide intraoperative anaesthetic practice (Levett et al. 2018, p.486).

Further referrals

During the POA, it is often deemed necessary to refer the patient for further expert assessment or advice. This is helpful in providing valuable information regarding the patient’s condition and creating an appropriate plan of action for the patient in the perioperative or post-operative period. When referral is deemed necessary, patients are seen by a specialist to further assess whether they are in the optimum condition for the desired surgery and/or whether their health can be ‘optimized’ prior to surgery to improve their post-operative outcomes.

Anticipated patient outcomes

POA and planning is a holistic process, and the anticipated patient outcome is to ensure that the patient is safe to proceed with anaesthesia and surgery and/or optimize their health for surgery.

POA clinics and anaesthetists play an important role in ensuring the patient’s surgical plan becomes a reality. This is a collaborative decision-making process in which clinicians and patients work together to select tests, treatments and management that are based on clinical evidence and the patient’s informed preferences. POA clinics have several key objectives, referred to by the Royal College of Anaesthetists (RCoA) (2019): • Provide the opportunity to further explain and discuss the upcoming surgery and recovery phase with the patient, with the aim of minimizing any fears, anxieties or stress and therefore aiding recovery. • Assess the patient’s fitness for the surgery, anaesthesia and post-operative recovery. This is achieved through a comprehensive medical history, physical examination and the ordering of appropriate investigations (NICE 2016b). • Identify any co-morbidities that may require intervention prior to admission and surgery and that are likely to affect the intra- and post-operative care of the patient, such as discontinuation of anticoagulants or implementation of antihypertensive medications. • Assist in ensuring that the patient is in optimum health prior to surgery, making further referrals to secondary care specialists as necessary, such as cardiologists. • Identify the need for and arrange for the supply of any specialist equipment (e.g. bariatric equipment or critical care bed), and ensure that any other special requirements are planned for. • Provide information to the patient about any specific pre-­ operative preparation that may be required (e.g. fasting or bowel preparation). This may require involving members of the multidisciplinary team, such as clinical nurse specialists, physiotherapists or dietitians. • Give the patient a point of contact for further questions or concerns, or if they want to postpone or cancel the surgery. • Provide the patient with information on what to expect in the post-operative period. This may include leaflets and videos to help the patient understand the planned procedure. They should also talk to the anaesthetist about pain control, intubation and potential critical care admission. • Provide any assistance with health promotion activities such as smoking cessation, weight loss and alcohol awareness that will help to improve the patient’s outcome in the perioperative and post-operative periods. This may include further referrals to primary care services, such as stop smoking services or dietetic advice. • Identify any cultural, religious or communication needs of the patient. • Assess older patients for risk of post-operative delirium (AAGBI 2014). • Conduct individualized admission and discharge planning, ensuring that the patient and carer(s) know what to expect. This facilitates earlier discharge and enables follow-up care to be undertaken in the primary care setting. • Identify patients who might benefit from a targeted exercise program prior to surgery (i.e. prehabilitation). • Clearly define the risks of surgery and counsel patients on the risks of post-operative mortality and morbidity. • Provide the appropriate pre-operative documentation to the multidisciplinary team (Liddle 2013, NICE 2016b, Oakley and Bratchell 2010). A thorough POA results in good clinical outcomes and an enhanced patient experience, as evidenced by the success of the Enhanced Recovery Partnership Programme. This initiative has transformed elective surgical care pathways across the NHS since 2009 (DH 2011) (Box 16.1). It also minimizes length of hospital stay through: • reduced cancellations due to patient ill health or DNAs (did not attend) • increased number of same-day surgery admissions • earlier discharge.

CHAPTER 16 Perioperative care

Box 16.1  The Enhanced Recovery Programme The Enhanced Recovery Programme includes the following. • Pre-operative assessment, planning and preparation before admission: –– optimization of health (including encouraging patients to exercise and eat well) and pre-existing medical conditions (e.g. diabetes) –– discharge planning –– information giving. • Reduction of the physical stress of the operation: –– use of minimally invasive surgical techniques (e.g. laparoscopic) –– individualized goal-directed fluid therapy –– use of quick-offset anaesthetic agents, allowing quick recovery –– prevention of hypothermia –– use of effective, opiate-sparing analgesia to facilitate early mobilization (e.g. nerve blocks) –– minimization of the risk of post-operative nausea and vomiting –– minimization of the use of drains and nasogastric tubes. • Post-operative rehabilitation: –– early nutrition –– early mobilization –– early removal of catheters –– post-operative education and support (e.g. with stoma care) –– follow-up advice and support.

CLINICAL GOVERNANCE

The POA should generally only be performed by one of the following trained professional groups: • a nurse or operating department practitioner • an anaesthetist • a doctor. However, this list is not exhaustive due to the ever-expanding clinical complexity of surgical patients. The role of a POA practitioner is broad (Box 16.2), and they should be competent in the following three principles of care (as previously outlined): • conducting a comprehensive health history • conducting a physical examination • ordering appropriate laboratory and non-laboratory investigations. Additionally, a POA practitioner should have knowledge of the Enhanced Recovery Programme (see Box 16.1) if it is required to support the patient along their perioperative care pathway. The AAGBI (2018) states that trained POA staff ‘play an essential role when, by working to agreed protocols, they screen and assess patients for fitness for anaesthesia and surgery’ (p.6). Although they are not qualified to make the final decision about a patient’s fitness for surgery, they play an important role in ‘identifying potential problems’ (p.6). Non-complicated patients often do not require further assessment by an anaesthetist until the day of admission. Patients considered complicated by the trained assessor are further reviewed by an anaesthetist. This is supported by Kenny (2011), who found that approximately 20% of patients assessed by pre-assessment nurses were referred to the anaesthetic clinic. Of these referrals, half were due to the discovery of poorly controlled, undiagnosed or complex health problems and half were due to the nature of the surgery required. While the POA can be performed by non-anaesthetic personnel such as nurses, it is vital that the anaesthetist in charge of the patient’s case is aware of the patient’s co-morbidities.

Box 16.2  Role of the assessor in the pre-operative assessment (POA) clinic • Work to guidelines and competencies agreed by anaesthetists, surgeons and other allied health professionals to ensure a consistent approach. • Take a targeted history and conduct a relevant physical examination of the patient, including airway assessment. • Refer patients who fall outside the agreed criteria to the anaesthetist, who may then make further referrals. • Arrange and perform investigations in accordance with local and national guidance (NICE 2016b). • Ensure that the results of tests are evaluated and address any abnormal investigation results with the available anaesthetist, surgeon and/or primary care professional, according to local guidelines. • Refer patients back to primary care or another healthcare professional to optimize their medical condition, according to local guidelines. • Take responsibility for following up referrals to ensure the patient remains in the pre-operative system. • Liaise actively with the anaesthetic department. • Arrange and co-ordinate any assessment and/or investigations needed nearer the time of surgery. Take responsibility for all communication with the patient throughout their pre-operative journey. • Commence necessary planning for the perioperative stay and ensure a timely discharge. • Identify factors that may influence the dates of surgery offered, for example school holidays. • Collate all information prior to surgery and ensure that the multidisciplinary documentation is available for anaesthetists to see at least 48 hours prior to admission. • Communicate the approximate length of an operation, any special requirements and essential resources to the waiting list office, bed management office, operating theatre department and/or theatre scheduler. • Contact all patients who fail to attend POA to identify the reason. Act on the reason, following local protocols for the management of DNAs (did not attend) in POA.

Learning Activity 16.1 Clinical application You are on placement in the pre-operative assessment clinic, working alongside Dan de Sanchez, an advanced nurse practitioner. 1 A patient telephones the unit to ask whether it is really necessary to come in for their appointment, as they are busy at work and it will require them to take more time off. Dan takes the call, but while he does so you start to make a mental checklist of all the advantages of a pre-operative assessment. Identify five reasons for a patient to attend. 2 A 72-year old patient, Mr Peter Raphael, has arrived for assessment prior to a cystoscopy and biopsy of the bladder. He is a retired factory worker. He has smoked 40 cigarettes per day ‘for at least 30 years’ and has a 2-month history of haematuria. What information should be shared with Peter about the benefits of smoking cessation pre-operatively? 3 Dan commences his assessment of Peter. What is involved? See the answers on the companion site of this student edition: www.royalmarsdenmanual.com/student10e.

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Patient information and education 952

• refamiliarize patients with what they have already been told • enhance patient and carer involvement in the patient’s treatment and condition.

RELATED THEORY

Patients undergoing surgery have information and supportive care needs before and after their surgery. Providing information to patients is considered a crucial element of their surgical pathway. Patients require information that is meaningful for them as individuals. It is necessary to educate patients on the nature of the benefits and risks of procedures so they can be involved in the decision-making process and enabled to give fully informed consent. Accurate, reliable and complete information plays a pivotal role in helping patients to make informed decisions.

EVIDENCE-BASED APPROACHES

Principles of care

The way in which information is delivered and understood will help to determine whether a patient’s actual post-operative experiences are congruent with the expected ones. Therefore, it is essential that information is provided at the right time and in a variety of formats. Information materials must contain scientifically reliable information and be presented in a form that is acceptable and useful to patients (i.e. suitable for the patient’s educational level). Providing patient education has been found to be extremely beneficial by reducing anxiety levels and promoting wellbeing (Guo 2015), which may ultimately result in patients requiring less analgesia. It is important that any form of education is tailored to individual patients. There are currently three main forms of patient education: face to face, paper based and web based (Table 16.3).

Verbal communication

Any verbal information should be supported by paper-based or web-based written information from reliable, evidence-based sources and tailored to the patient’s educational level. Written patient information in particular can: • help patients to gain a greater understanding of surgery and what is expected of them • ensure patients arrive on time and are properly prepared for surgery (e.g. pre-operative fasting) • increase patient confidence, improving their overall experience

Consent DEFINITION

Consent can be defined as permission for something to happen or agreement to do something. NHS Choices (2016) states that ‘consent to treatment means a person must give permission before they receive any type of medical treatment, test or examination’.

EVIDENCE-BASED APPROACHES

There are different types of consent in healthcare: written, verbal (explicit) and non-verbal (implied or implicit). The requirement to gain consent has two purposes, one legal and the other clinical (Richardson  2013). Sufficient evidence-based information must be provided to the patient to allow them to make a balanced and informed decision about their care and treatment (GMC 2008, 2014, RCN 2017).

Principles of care

It is important to recognize that seeking consent for a surgical intervention is not merely the signing of a form. It is the process of providing the information that enables the patient to make a decision to undergo a specific treatment. Consent should be a considered and informed decision-making process. For major operations, it is good practice to gain a person’s consent to the proposed procedure well in advance, ideally prior to pre-assessment. This allows time to respond to the person’s questions and provide adequate information so that the person has time to develop an understanding and thereby make an informed decision (Hughes  2011). For patients with learning disabilities or mental health problems, it is advisable that a relative or carer is present so that consent, capacity and any reasonable adjustments (e.g. to equipment or psychological support) can be discussed depending on the needs of the patient (RCN 2017). For consent to be valid, it must be given voluntarily and freely, without pressure or undue influence, by an appropriately informed person who has the capacity to consent to the intervention in question (NMC 2018, RCN 2017). Informed consent is a legal requirement (Montgomery v Lanarkshire Health Board 2015).

Table 16.3  Forms of patient education Patient education

Definition

Advantages

Disadvantages

Face to face

Includes any education delivered verbally by a healthcare provider to a single patient or group of patients. This remains the most common form of patient education. See ‘Verbal communication’ below.

• Can be tailored to individual patient needs

• Time consuming • Consistency problems • Relies on the patient’s ability to absorb, understand and retain the verbal information

Paper based

Includes any written information, such as patient information leaflets.

• Can develop comprehensive educational materials that are consistently presented • Patients can refer back to the materials

• Unable to tailor to individual patient needs

Web based

Includes any verbal or written patient information. Examples include web-based seminars, patient groups, programmes of care, interactive websites, podcasts, and videos (e.g. on YouTube).

• Wide-ranging and current information • Variety of teaching formats • Patient empowerment: patients can search for information themselves, look up research and help to generate questions for healthcare professionals. • Available 24 hours a day • Can develop comprehensive educational materials that are consistently presented • Patients can refer back to the materials • Can be accessed all over the world

• Potential for inaccurate information • Lack of access • Poor quality of online resources • Security and privacy issues

CHAPTER 16 Perioperative care

While the validity of consent does not depend on the way in which it is given (RCN 2017), it is good practice to use forms for written consent where an intervention such as surgery is to be undertaken. Most hospitals’ local consent policies will require written consent to be obtained in these circumstances. However, the procedure and risks must be written down for the patient to read and understand, before signing the form; their signature alone does not make the consent valid. For example, if a person’s signature to confirm their consent is gained immediately before the surgical procedure is due to start, at a time when they may be feeling particularly vulnerable, this would raise concerns about its validity (GMC 2014, RCN 2017). Furthermore, patients should not in any situation be given routine pre-operative medication before being asked for their consent to proceed with the treatment (RCN 2017).

CLINICAL GOVERNANCE

It is accepted that when a patient gives valid consent, this is valid indefinitely unless it is withdrawn by the patient; therefore, no specific time limit is designated from signature to procedure (Hughes 2011). However, it is good practice to confirm the patient’s wishes if significant time has elapsed since the initial process. The patient is entitled to withdraw consent at any time (Hughes 2011). For consent to be valid, it must encompass several factors: • Consent must be given willingly: this means without pressure or undue influence to either undertake or not undertake treatment. • Consent must be informed: the person must have an understanding of the procedure and the purpose behind it, and have been given relevant information about the benefits and risks of the procedure as well as potential alternatives. This information needs to be explained or presented in a way that is meaningful and easy to understand by the person in a variety of formats (both verbal and written) to enable them to make an informed decision. • The person must have the capacity to consent to the procedure in question: that is, they must have the ability to understand and retain the information provided, especially around the consequences of having or not having the procedure (NMC 2018, RCN 2017). An assessment of a person’s capacity must be based on their ability to make a specific decision at the time it needs to be made, and not their ability to make a decision in general (DH 2009). Under the Mental Capacity Act (2005), which became fully effective in England and Wales in 2007, a person must be presumed to have capacity unless it is established that they lack capacity. If there is any doubt, then the healthcare professional should assess the capacity of the patient to make a decision in general (see Chapter  5: Communication, psychological wellbeing and safeguarding). During every discussion about consent, it is important to provide all relevant information about the procedure and its implications. In particular, discussions should include information on the following: • the patient’s diagnosis and prognosis • options for treatment, including non-operative care and the option of no treatment • the purpose and expected benefit of the treatment • the likelihood of success • the clinicians involved in the patient’s treatment • the risks inherent with the procedure, however small the possibility of their occurrence • all potential side-effects and complications • the consequences of non-operative alternatives • potential follow-up treatment (RCS 2014).

• For patients who are expected to be transferred to the intensive care or high-dependency unit after surgery, offer for them to visit the unit beforehand. • Explain that the patient’s bed may be moved when they return to the ward so they can be observed more closely by nursing staff immediately after surgery. • Discuss analgesia. • Measure the patient for antiembolism stockings (see Procedure guideline  16.1: Measuring and applying antiembolic stockings), foot impulse devices and/or intermittent pneumatic compression devices (NICE 2018a). • Explain the importance of deep breathing and coughing, regular gentle leg exercises and early mobilization to reduce the risk of complications such as chest infection, deep vein thrombosis and pulmonary embolism. • Explain the need for post-operative physiotherapy.

Competencies

All healthcare professionals should be aware of the different types of consent and the importance of ensuring that patients understand what is going to happen to them and what is involved. Healthcare professionals should also be familiar with their local hospital consent policy and be aware of and understand what to do if people refuse care or treatment, or when consent is not valid or is no longer valid. Current guidance states that the person obtaining consent must either be capable of performing the procedure themselves or have received specialist training in advising patients about the procedure (GMC 2014). The person who obtains the patient’s consent for surgery should ideally be the surgeon performing the procedure. The anaesthetist should also discuss with the patient the risks related to the chosen method of anaesthesia and obtain consent from them (Hughes 2011).

Physical pre-operative preparation DEFINITION

Physical pre-operative preparation is concerned with reducing harm and complications in the peri- and post-operative period (NHSI 2018, Scott et al. 2007).

RELATED THEORY

For many patients, waiting for surgery can be a stressful time. Where possible, having someone to sit with patients before surgery (perhaps a relative) may help to reduce anxiety. Patients with learning disabilities or mental health problems can find new environments difficult, so it is preferable if the person with them is familiar. Upon the patient’s admission to the clinical area, a patient identity band (see below) should be placed on their dominant arm with printed information, in line with recommendations from NHS Improvement (NHSI) (2018). Any assessments not performed at the pre-assessment clinic should be completed and documented by the admitting practitioner. The following risk assessments should be included as part of pre-operative patient checks and recorded in the perioperative care documentation (this is not an exhaustive list, as dependent on institutional protocol):

The patient and their family should also be provided with information on post-operative care and expected recovery. This should include the following:

• pressure ulcer • venous thromboembolism (VTE) • falls • nutrition screening • baseline observations are required and should be recorded: –– blood pressure –– pulse –– respirations –– temperature –– oxygen saturations • blood glucose (if appropriate).

• Explain what patients can expect to have in situ after surgery, such as intravenous lines or drains, and pumps that may sound alarms.

Box  16.3 outlines additional safety measures that may be necessary.

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Box 16.3  Pre-operative patient safety measures

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• Identity bands • Antiembolic stockings and prophylactic anticoagulation • Pre-operative fasting • Skin preparation • Marking skin for surgery • Pre-operative pregnancy testing • Preventing toxic shock syndrome from tampons • Assessment for latex allergy • Comprehensive pre-operative checks

Figure 16.5  Pulmonary embolism.

Red blood cells

Thrombus

Healthy blood flow

Box 16.4  Information to be included on an identity band • Date of birth in the format dd-mmm-yyyy (e.g. 01-Mar-2013) • Name (surname first in capitals followed by the first name with the first letter in capitals, e.g. MARSDEN, William) • Patient’s 10-digit NHS number

Identity bands

Identity bands (or name bands) are fundamental in the identification of patients. Patient misidentification contributes to errors and is a cause of patient safety incidents with potentially grave consequences. NHS Improvement (2018) highlights the importance of name bands. Since 1 July 2011, it has been mandatory for all hospitals to have electronically printed name bands. Key information should be clearly labelled on a patient’s name band (NPSA 2007); see Box 16.4 for details. Where possible, colour coding for individual risks should be avoided. If a healthcare organization believes colour coding is necessary to alert healthcare professionals to a known risk (e.g. patient allergy), then the National Patient Safety Agency (2007) recommends the use of only one colour: red.

Figure 16.6  Deep vein thrombosis.

Blood clot travels from site where it was formed

Blood clot forms in a vessel

Mechanical and pharmacological thromboembolism prophylaxis DEFINITION

Venous thromboembolism (VTE) is a condition where a thrombus (clot) forms within a vein (often the deep veins of the lower limbs). It can be very dangerous as the clot can dislodge and travel in the blood to the pulmonary circulation (NICE 2016c).

RELATED THEORY

VTE is normally caused by stasis of blood within a vessel, trauma to a vessel or an increase in the ability of the blood to clot (Figures 16.5 and 16.6). This most frequently happens in the deep veins of the leg, when it is termed a ‘deep vein thrombosis’ or DVT. If one of these clots dislodges from the leg and travels to the lungs via the bloodstream, it is called a ‘pulmonary embolus’ or PE (Figure 16.7); this can be a fatal event (NICE 2018a). Potential clinical signs of DVT and PE are outlined in Box 16.5. Prevention of post-operative VTE is considered a quality and patient safety measure in most mandated quality-improvement initiatives. Various interventions have been used for prophylaxis of VTE (Roberts and Lawrence  2017). These include mechanical devices such as graduated antiembolic stockings (Figure 16.8), intermittent pneumatic compression (IPC) devices, and pharmacological agents such as unfractionated heparin, low-molecular-weight heparin and fondaparinux. Most of the strategies employ a combination of mechanical methods and pharmacological agents (Ma et al. 2017). NICE (2018a) guidance on venous thrombosis recommends that all patients admitted to hospital must have a VTE risk assessment. They should then be reassessed within 24 hours of admission.

Figure 16.7  Thrombus. Left lung

Clot in blood vessel

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A specific risk assessment tool (NICE 2018a) (Figure 16.9) forms the basis of hospitals’ local patient perioperative documentation in the management of VTE. Venous thrombosis risk factors include the following: • surgery, including day surgery, where total anaesthetic and surgery time is over 90 minutes, or 60 minutes if the surgery involves the pelvis or lower limbs • immobility, for example prolonged bedrest • active cancer • severe cardiac failure or recent myocardial infarction • acute respiratory failure • older age (i.e. elderly) • previous history of DVT or PE Box 16.5  Signs of deep vein thrombosis or pulmonary embolism • Complaints of calf or thigh pain • Erythema, warmth, tenderness and abnormal swelling of the calf or thigh in the affected limb • Numbness or tingling of the feet • Dyspnoea, chest pain or signs of shock • Pain in the chest, back or ribs that gets worse when the patient breathes in deeply • Coughing up blood

• acute infection or inflammation • diabetes • smoking • obesity • gross varicose veins • paralysis of lower limbs • clotting disorders • hormone replacement therapy • oral contraceptives (Swanepoel et al. 2018). All patients requiring an inpatient stay for surgery should have prophylactic treatment to reduce the risk of DVT, which may include prophylactic anticoagulation (e.g. low-molecular-weight heparin) and mechanical compression methods. Antiembolic stockings (see Figure  16.8) are the most common mechanical compression method, but extremely high-risk patients may also use intermittent pneumatic compression devices or venous foot pumps (NICE 2018a) in the intraoperative and post-operative periods (Figure  16.10). If antiembolic stockings are contraindicated (Box 16.6) then alternative forms of mechanical compression may need to be considered by the surgical team. Patients should be given verbal and written information before surgery about the risks of VTE and the effectiveness of prophylaxis (NICE 2018a) (see Figure 16.11 for an example of a patient information leaflet). It is estimated that 10–40% of patients undergoing major surgery will develop a DVT, with the risk increasing to 40–60% of patients undergoing major orthopaedic surgery (Flevas et al. 2018).

Figure 16.8  Antiembolic stockings. (a) Thigh length. (b) Knee length.

(a)

(b)

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Figure 16.9  Example of a venous thromboembolism (VTE) risk assessment form. Source: Reproduced from DH (2010) with permission of the National Institute for Health and Care Excellence.

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RISK ASSESSMENT FOR VENOUS THROMBOEMBOLISM (VTE) All patients should be risk assessed on admission to hospital. Patients should be reassessed within 24 hours of admission and whenever the clinical situation changes.

Assess all patients admitted to hospital for level of mobility (tick one box). All surgical patients, and all medical patients with significantly reduced mobility, should be considered for further risk assessment.

Review the patient-related factors shown on the assessment sheet against thrombosis risk, ticking each box that applies (more than one box can be ticked). Any tick for thrombosis risk should prompt thromboprophylaxis according to NICE guidance. The risk factors identified are not exhaustive. Clinicians may consider additional risks in individual patients and offer thromboprophylaxis as appropriate.

Review the patient-related factors shown against bleeding risk and tick each box that applies (more than one box can be ticked). Any tick should prompt clinical staff to consider if bleeding risk is sufficient to preclude pharmacological intervention.

Guidance on thromboprophylaxis is available at: National Institute for Health and Clinical Excellence (2010) Venous thromboembolism: reducing the risk of venous thromboembolism (deep vein thrombosis and pulmonary embolism) in patients admitted to hospital. NICE clinical guideline 92. London: National Institute for Health and Clinical Excellence. http://www.nice.org.uk/guidance/CG92

This document has been authorised by the Department of Health Gateway reference no: 10278

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Figure 16.9  (continued)

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RISK ASSESSMENT FOR VENOUS THROMBOEMBOLISM (VTE) Mobility – all patients

Tick

Tick

Tick

(tick one box)

Surgical patient

Medical patient expected to have ongoing reduced mobility relative to normal state

Assess for thrombosis and bleeding risk below

Medical patient NOT expected to have significantly reduced mobility relative to normal state Risk assessment now complete

Thrombosis risk Patient related

Tick Admission related

Active cancer or cancer treatment

Significantly reduced mobility for 3 days or more

Age >60

Hip or knee replacement

Dehydration

Hip fracture

Known thrombophilias

Total anaesthetic + surgical time >90 minutes

Obesity (BMI >30 kg/m2)

Surgery involving pelvis or lower limb with a total anaesthetic + surgical time >60 minutes

One or more significant medical comorbidities (e.g. heart disease; metabolic, endocrine or respiratory pathologies; acute infectious diseases; inflammatory conditions)

Acute surgical admission with inflammatory or intra-abdominal condition

Personal history or first-degree relative with a history of VTE

Critical care admission

Use of hormone replacement therapy

Surgery with significant reduction in mobility

Tick

Use of oestrogen-containing contraceptive therapy Varicose veins with phlebitis Pregnancy or 2)

Lumbar puncture/epidural/spinal anaesthesia expected within the next 12 hours

Acute stroke

Lumbar puncture/epidural/spinal anaesthesia within the previous 4 hours

Thrombocytopaenia (platelets< 75 × 109/L) Uncontrolled systolic hypertension (230/120 mmHg or higher) Untreated inherited bleeding disorders (such as haemophilia and von Willebrand’s disease) © Crown copyright 2010

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Figure 16.10  Intermittent compression device and boots.

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Box 16.6  Contraindications for antiembolism stockings • Suspected or proven peripheral arterial disease • Peripheral arterial bypass grafting • Peripheral neuropathy or other causes of sensory impairment • Local condition in which stockings may cause damage, such as fragile tissue-paper skin • Allergy to the material of manufacture • Severe leg oedema • Major limb deformity or unusual leg size or shape preventing correct fit • Venous ulcers, wounds or pressure ulcers (not an absolute contraindication, but caution is required) Source: Adapted from NICE (2018a).

Mechanical compression methods reduce the risk of DVT by about two-thirds when used as monotherapy and by about half when added to pharmacological methods (Bates et  al.  2012, Roderick et al. 2005). Mechanical VTE prophylaxis will be continued until the patient no longer has significantly reduced mobility relative to their normal or anticipated mobility (NICE 2018a). Graduated antiembolic stockings promote venous flow and reduce venous stasis not only in the legs but also in the pelvic

veins and inferior vena cava (Pavon et  al.  2016). There are two types of graduated antiembolic stocking: knee high and thigh high (see Figure  16.8). Thigh-length  stockings appear to have superior efficacy; however, practical issues such as patient acceptability may prevent their wide use in clinical practice (Wade et al. 2016, 2017). Stockings should be applied according to the manufacturer’s instructions and must be removed daily to assess the condition of the skin and tissues. Alternatively, an intermittent pneumatic compression device provides sequential application of external compression on the lower extremities. It is believed to increase pulsatile venous flow (Pavon et al. 2016). This leads to improved emptying of the veins, decreasing venous pressure and increasing the arteriovenous pressure gradient, with subsequent increase in arterial flow.

Figure 16.11  Example of a patient information sheet for deep vein thrombosis (DVT). Source: Adapted from Royal Marsden NHS Foundation Trust (2010) with permission of The Royal Marsden NHS Foundation Trust.

When I am in hospital what will be done to help prevent a VTE? • Stay hydrated – if you are allowed to do so, drink plenty of fluid. However, if you are not allowed to do this, the doctors will give you fluids via a vein.

Blood clot prevention A guide for patients and carers

• Move around – keep mobile as much as you can. The physiotherapist will teach you some appropriate leg exercise. • Anti-embolic stockings – If the doctor decides that you would be suitable for these, the nursing staff will fit you with a pair of stockings. • Intermittent calf pumps – some surgical patients will have a special device which fits like a cuff around each calf (a bit like a blood pressure cuff). This will inflate and deflate alternately. These are designed to help prevent clot formation in the calf. They are not necessary for all surgical patients. • Medication (anticoagulants) – your doctor might consider it necessary to prescribe you an anticoagulant (blood-thinning) drug to reduce your risk of developing a blood clot. Depending on the type of surgery you may be asked to continue this medication for 28 days following the operation. Not all methods mentioned above are appropriate for all patients. Your doctor will assess which methods are most suitable for you as an individual. If you are already taking blood-thinning medication such as warfarin please tell your doctor.

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Procedure guideline 16.1  Measuring and applying antiembolic stockings Essential equipment

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• Personal protective equipment • Disposable tape measure (patient specific) • Antiembolic stocking sizing chart • Patient records/documentation Action

Rationale

Pre-procedure 1 Assess and record in the patient’s documentation the patient’s risk factors for VTE (DVT and PE).

All patients admitted to hospital should undergo a risk assessment for venous thrombosis to determine the most appropriate thromboprophylaxis (Farge et al. 2013, R; NICE 2018a, C; SIGN 2014, C). The higher the number of risk factors, the greater the risk of VTE (NICE 2018a, C; SIGN 2014, C).

2 Assess and record in the patient’s documentation the patient’s suitability for antiembolic stockings, identifying whether the patient has any contraindications to wearing antiembolic stockings (see Box 16.6).

To comply with national guidelines and hospital policy/ guidelines. To ensure that antiembolic stockings are used appropriately (All Wales Tissue Viability Nurse Forum 2009, E; Farge et al. 2013, E; NICE 2018a, C; SIGN 2014, C).

3 Introduce yourself to the patient, explain and discuss the procedure with them, and gain their consent to proceed.

To ensure that the patient feels at ease, understands the procedure and gives their valid consent (NMC 2018, C).

Procedure 4 Perform hand hygiene and put on an apron prior to the procedure.

To prevent cross-infection (NHS England and NHSI 2019, C).

5 Measurement for thigh-length stockings: a Measure upper thigh circumference at the widest part of the thigh (Action figure 5a). b Measure calf circumference at the widest part of the calf (Action figure 5b). Note: refer to individual manufacturers’ instructions to ensure that no other measurements are necessary, e.g. length of leg. c Consult the product packaging to determine the appropriate size. • If right and left legs measure differently, order two different stocking sizes. • If thigh or calf circumference is greater than that stocked by the manufacturer, then refer to local trust guidelines to determine the appropriate course of action. In some cases, knee-length stockings may be more appropriate. Measurement for knee-length stockings: a Measure calf circumference at the widest part of the calf. Note: refer to individual manufacturers’ instructions to ensure that no other measurements are necessary, e.g. length of leg. b Consult the product packaging to determine the appropriate size. c If the right and left legs measure differently, order two different stocking sizes. Order two pairs of stockings.

To comply with the manufacturer’s instructions. E Incorrect sizing causes swelling and bruising to ankles and can constrict blood supply, leading to long-term complications. E

6 Apply the stockings: a Insert hand into stocking as far as the heel pocket. b Grasp centre of heel pocket and turn stocking inside out to heel area. c Position stocking over foot and heel, ensuring the patient’s heel is centred in the heel pocket (Action figure 6a). d Pull a few inches of the stocking up around the ankle and calf (Action figure 6b). e Continue pulling the stocking up the leg as described in the manufacturer’s instructions. When using thigh-length stockings, the top band rests in the gluteal furrow. f Smooth out wrinkles. g Align the inspection window to fall under the toes (toes should not stick out).

To ensure the appropriate size of stocking is fitted correctly. E Thigh-length stockings are difficult to put on and can roll down, creating a tourniquet just above the knee that restricts blood supply, so patient monitoring and/or assistance should take place to ensure that stockings are fitted smoothly, are not rolled down or have the top band folded down (SIGN 2014, R; Todd 2015, R; Wounds UK 2015, R).

It has also been suggested that 15–20% of patients cannot effectively wear thigh-length antiembolic stockings because of unusual limb size or shape (SIGN 2014, C).

(continued)

Procedure guideline 16.1  Measuring and applying antiembolic stockings (continued) Action

Rationale

Post-procedure 960

To ensure that the patient understands how to fit and wear stockings, including self-care measures and what to report to the nurse so as to detect complications early (e.g. pressure ulcers or circulation difficulties of wearing antiembolic stockings) (NICE 2018a, C; Wade et al. 2017, R).

7 Document the leg measurements and the size of stockings applied in the nursing records. Instruct the patient and provide written information about the following: a reasons for wearing antiembolic stockings b how to fit and wear stockings c what to report to the nurse, e.g. any feelings of pain or numbness and any skin problems d skin care: wash and dry legs daily, applying emollient if clinically indicated e reasons for early mobilization and adequate hydration f reasons for not crossing legs or ankles: to prevent constriction of blood supply g length of time that the stockings should be worn, e.g. stockings should be removed for a maximum of 30 minutes daily and worn until the patient returns to their usual level of mobility.

(a)

(b)

Action Figure 5  Measure (a) thigh circumference and (b) mid-calf circumference.

(a)

(b)

Action Figure 6  (a) Ensure the heel is centred in the heel pocket. (b) Pull the stocking up over the ankle.

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Table 16.4  Predisposing factors for aspiration under general anaesthesia Learning Activity 16.2  Case study Mrs Elizabeth James, aged 61, has been admitted for a vaginal hysterectomy later this morning. The ward manager asks you to measure Elizabeth for thigh-length antiembolic stockings and put them on her. 1 What steps do you take in order to perform this task? 2 What advice do you give Elizabeth about the stockings? During this procedure, you suspect that Elizabeth has forgotten or perhaps not retained some of the information about her forthcoming operation. After you have put the stockings on, you stay with her and explore what information about the surgery she wishes to know. 3 List some of the key information you expect Elizabeth will want to know about the surgery. 4 What communication approaches will you use to ensure Elizabeth understands the information? See the answers on the companion site of this student edition: www.royalmarsdenmanual.com/student10e.

Pre-operative fasting DEFINITION

Pre-operative fasting is defined as a prescribed period of time before a procedure when patients are not allowed oral intake of liquids or solids.

RELATED THEORY

General anaesthesia carries the risk of the patient inhaling gastric contents during induction, due to airway reflexes (such as coughing or laryngospasm) or gastrointestinal motor responses (such as gagging or recurrent swallowing) (AAGBI 2010). Aspiration of gastric contents can result in respiratory problems (including aspiration pneumonitis and aspiration pneumonia) or at worst acute respiratory failure and death (Van de Putte et al. 2017). Risk factors for aspiration are outlined in Table 16.4, and Box 16.7 outlines current best practice pre-operative fasting guidelines for healthy adults undergoing elective surgery. It is important to be aware that several factors can delay gastric emptying (Van de Putte et al. 2017). These include: • reduced consciousness level • systemic opiate therapy • recent history of difficulty eating, swallowing or digesting food • recent history of dyspepsia (heartburn), particularly on lying down or bending over • upper gastrointestinal surgery • anxiety • pregnancy or labour • abdominal pain • renal failure • diabetes. There are various techniques that can be used to prevent gastric aspiration during the induction period. These include a rapidsequence induction/endotracheal intubation technique, or awake endotracheal intubation technique, which may be useful to prevent this problem during the induction of anaesthetic. The American Society of Anesthesiologists (2011) has recognized that fasting times may be prolonged due to alterations in the operating list. Some alterations are unavoidable, but patients should be kept informed of changes to the theatre list and those without disorders of gastric emptying allowed to continue drinking clear fluids up to 2 hours prior to rescheduled surgery (Box 16.8)

Patient factors

Operation factors Anaesthetic factors

Increased gastric content

Intestinal obstruction Non-fasted Drugs Delayed gastric emptying

Lower oesophageal sphincter incompetence

Hiatus hernia Gastro-oesophageal reflux Pregnancy Morbid obesity Neuromuscular disease

Decreased laryngeal reflexes

Head injury Bulbar palsy

Sex

Male

Age

Elderly

Procedure

Emergency Laparoscopic

Position

Lithotomy

Airway

Difficult intubation Gas insufflation

Maintenance

Inadequate depth

Source: Adapted from King (2010).

Box 16.7  Pre-operative fasting guidelines • 6 hours fasting from solid food, provided the last meal is light (refer to local trust guidelines for examples of suitable light meal). • Sweets, including lollipops, are solid food. A minimum preoperative fasting time of 6 hours is recommended. • Tea and coffee with milk are acceptable up to 6 hours before surgery. • Clear fluids (those through which newsprint can be read) are acceptable up to 2 hours before (see Box 16.8). • Patients being fed by nasogastric or gastrostomy tube should have their feed stopped 6 hours prior to surgery and water 2 hours prior to surgery. • It is recommended that chewing gum is avoided on the day of surgery; however, check local guidelines. • Regular medication taken orally should be continued preoperatively unless there is advice to the contrary. Patients can have up to 30 mL of water orally to help them take medication. Source: Adapted from NICE (2020).

(Powell-Tuck et al. 2011). Where patients have disorders of gastric emptying or where the theatre time is difficult to ascertain, patients should be offered mouthwashes to keep their mouths moist and intravenous fluids considered if not contraindicated for the surgery being performed (e.g. liver surgery).

Skin preparation DEFINITION

The purpose of pre-operative skin preparation is to remove visible contaminants and to reduce the levels of naturally occurring skin flora, particularly Staphylococcus aureus, so as to reduce the risk of surgical site infection (Wicker and O’Neill 2010). Surgical site preparation is the treatment of the intact skin of the intended surgical site and surrounding area, and this takes place once the patient is in the operating room, on the operating table (Allegranzi et al. 2016).

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RELATED THEORY

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Normal bacterial flora live in the nose, groin, armpit, gut, skin and hair of everybody. Organisms may become pathogenic when they move out of their normal area on the body to an open wound (Wicker and O’Neill 2010). NICE (2019) guidelines advise patients to shower or have a bath using soap either the day before or on the day of surgery. While there is no evidence concerning patient theatre attire, NICE (2019) advises that patients are given a clean theatre gown to wear and asked to remove their own clothing (depending on the operation). Theatre gowns should maintain the  patient’s comfort and dignity while allowing easy access to the operative site. Furthermore, theatre gowns avoid placing the patient’s own clothes at risk of contamination from blood, body fluid and washout fluids (Pudner 2010). The most widely used antiseptic skin preparation agents are 2% chlorhexidine gluconate and iodophors (e.g. povidone-iodine) in alcohol-based solutions. These are effective against a wide range of bacteria, fungi and viruses (NICE 2019). NICE (2019) has set out recommendations for surgical site preparation; these can be found in Table 16.5. Currently, some preparation solutions also contain colouring agents, which are helpful for indicating where the products have been applied (WHO 2018). Box 16.8  Examples of clear fluids • Water • Tea or coffee without milk • Fruit or herbal tea • Fruit squash • Polycal diluted half and half with water • Fortijuice • Enlive (clear liquids only)

Surgical site hair removal

Pre-operative hair removal is used to prevent surgical site infection or to prevent interference with the incision site (Lefebvre et  al.  2015). NICE (2019) guidance advises against routine hair removal in order to reduce the risk of surgical site infection. Hair removal should only be carried out if necessary (Loveday et al. 2014), which minimizes the potential risk of skin trauma. To further reduce the risk of skin trauma, the use of clippers instead of razors has been proposed (NICE  2019, Shi et  al.  2017). Table 16.6 illustrates specific considerations to be made during skin preparation and explains the best practice of hair removal.

Marking skin for surgery DEFINITION

Skin marking is carried out to unambiguously identify the intended site of surgical incision. Any markings should be arrows; should be drawn with an indelible, latex-free marker pen; and should extend to, or near to, the exact incision site (Figure 16.12).

RELATED THEORY

The surgeon may need to mark an area of the body for surgery (e.g. a limb to be operated on) or the position of an organ (e.g. a specific kidney in a patient undergoing a nephrectomy). Marking the surgical site is essential for the planning of any surgical procedure and for the prevention of wrong-site surgery (Table 16.7) (Bathla et  al.  2017). The incidence of wrong-site surgery is low but any error can be devastating and in some cases fatal. The marking should be undertaken by the surgeon performing the operation or a competent deputy (i.e. an individual capable of performing the procedure themselves) who will be present at the Figure 16.12  Example of skin marked for surgery.

Table 16.5  Options for antiseptic skin preparation Choice of antiseptic skin preparation

When

Alcohol-based solution of chlorhexidine

First choice unless contraindicated or the surgical site is next to a mucous membrane

Aqueous solution of chlorhexidine

If the surgical site is next to a mucous membrane

Alcohol-based solution of povidone-iodine

If chlorhexidine is contraindicated

Aqueous solution of povidone-iodine

If both an alcohol-based solution and chlorhexidine are unsuitable

Source: Adapted from NICE (2019).

Table 16.6  Hair removal prior to surgery Principle

Rationale

Electric clippers with a single-use disposable head should be used

Clippers do not come into contact with the skin and therefore reduce the risk of cuts and abrasions (NICE 2019, C; Pudner 2010, R). A single-use head prevents cross-infection (AORN 2008, C). Electric clippers with single-use disposable heads are the most cost-effective method of hair removal (NICE 2019, C).

If hair removal is required to facilitate access or view of the surgical site then, where possible, this should be undertaken on the day of surgery

Earlier removal would allow time for the hair to regrow (NICE 2019, C).

Only hair interfering with the surgical procedure should be removed

To prevent unnecessary trauma and shaving (NICE 2019, C; Shi et al. 2017, R).

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Table 16.7  Pre-operative marking recommendation How should marking be carried out?

• Use an indelible marker pen. • Mark an arrow that extends to, or near to, the incision site. • This mark must remain visible after the application of skin preparation and after the application of theatre drapes.

Where should be marked?

• Any surgical operations involving one side (laterality) of the body should be marked at, or near, the intended incision. • For digits on the hand or foot, the mark should extend to the specific digit.

Who should be involved in the pre-operative marking?

• Marking must be carried out by the operating surgeon or by a nominated deputy who will be present in the operating theatre at the time of the patient’s procedure. • Pre-operative marking of the intended site should involve the patient and/or their family members or significant others wherever possible.

When should marking be carried out?

• The marking of the surgical site should be carried out on the ward or in the day care area prior to the patient’s transfer to the operating theatre. • The marking should take place before pre-medication.

Verification of the mark

The surgical site mark should subsequently be checked against the patient’s documentation, such as consent form or X-ray. This check should confirm the mark is (a) correctly located and (b) still legible. This check should occur at each transfer of the patient’s care and end with a final verification prior to commencement of surgery. Confirmation of the site marking happens at the following pre-operative stages: • when ward staff are preparing the patient for the operating room • when ward staff hand over the patient to the anaesthetic practitioner • during the ‘Sign In’ stage of the WHO Surgical Safety Checklist (see ‘Intraoperative care: anaesthesia’ below) by the anaesthetist and anaesthetic practitioner (before any needle-to-skin in the anaesthetic room) • during the ‘Time Out’ stage of the WHO Surgical Safety Checklist, when the patient is on the operating table before the surgical procedure begins (carried out by the operating surgeon with the presence of all team members). All team members should be involved in checking the mark.

Source: Adapted from Bathla et al. (2017), NPSA (2005).

surgery, to ensure the correct site is marked; the site should be checked against the patient’s consent form (Schäfli-Thurnherr et al. 2017). The mark should be an arrow, drawn with an indelible, latex-free marker pen, and should extend to, or near to, the exact incision site. The majority of surgical site marking pens contain gentian violet ink, which has antifungal properties (Maley and Arbiser 2013, Wise et al. 2016). Other types of marker pen include permanent ink markers, which despite their lack of antifungal properties have not been found to affect the sterility of the surgical field (Zhao et  al.  2009). Marking must be undertaken before pre-medication or anaesthesia so that patients can be involved in ensuring the mark is in the correct place. It needs to remain visible after the application of antiseptic (aqueous or alcohol-based) skin preparation (e.g. povidone-iodine or chlorhexidine) and after the application of theatre drapes (Mears et al. 2009). The surgical site mark should not be easily removed with skin preparation but should not be so permanent as to last weeks or months after the surgical procedure. Following surgery, once the wound has healed, residual traces of the marker pen can be gently removed using warm, soapy water. It is important not to rub too hard to prevent irritating the skin or sinking the ink deeper into skin tissues, making it harder to extract. This process may need to be repeated over a series of days. There are circumstances where marking may not be appropriate: • emergency surgery • surgery on teeth or mucous membranes • bilateral procedures such as tonsillectomy or squint surgery • situations where laterality of surgery will be confirmed during the procedure (NPSA 2005). If a patient refuses pre-operative skin marking, local policy should be followed and documentation should clearly state that the patient refused marking, particularly on the WHO Surgical Safety Checklist (see ‘Intraoperative care: anaesthesia’ below). There are some situations in which a specialist nurse may mark the skin. For example, stoma therapists mark the position on the

patient’s skin that is the optimum place for the stoma to be placed (see Chapter 6: Elimination).

Pre-operative pregnancy testing RELATED THEORY

There is an increased risk of miscarriage, stillbirth or low birthweight when a patient undergoes surgery during pregnancy (Balinskaite et al. 2017). It is possible that this is caused by surgical manipulation and the patient’s underlying medical condition rather than exposure to anaesthesia. Prior to consenting to surgery, all female patients who have commenced menstruation (menarche) need to be informed of the risks surgery may pose to a pregnancy (NICE 2016b). The clinician performing the procedure or the appropriately delegated representative (i.e. an individual capable of performing the procedure themselves) is responsible for informing patients of the risks of surgery and is therefore responsible for ensuring that a female patient has had her pregnancy status assessed (NICE  2016b). Once she has been informed of the risks, the patient will need to take responsibility for her own contraception (NICE 2016b). All female patients of child-bearing age should be considered for pregnancy testing if they express a concern that they may be pregnant or are undergoing gynaecology surgery (NICE 2016b). Any pregnancy testing requires informed consent and documentation in the patient’s medical record, including test results or patient refusal, and the responsible surgical team must be informed prior to the initiation of the surgery (NICE 2016b). If a previously unknown pregnancy is detected, the risks and benefits of the surgery can be discussed with the patient. Surgery may be postponed or, if the decision is made to go ahead, the anaesthetic and surgical approaches can be modified if necessary (NPSA 2010). In emergency situations, confirmation of pregnancy should not delay treatment and should be taken into account within the clinical assessment of risk.

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CLINICAL GOVERNANCE

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The practice of checking and documenting current pregnancy status in the immediate pre-operative period has been shown to be inconsistent (NPSA 2010). Pre-operative assessment may take place weeks in advance of a planned operation but pregnancy status may change in the intervening time, so pregnancy status must be rechecked by asking the patient in the immediate preoperative period on the ward and documented in the perioperative records used by staff performing the final clinical and identity checks (NICE 2016b, NPSA 2010). If there is a chance the patient could be pregnant, a test should be carried out again at this point.

Prevention of toxic shock syndrome from tampon use

first reported cases of TSS involved women who were using tampons during menstruation (Eckert and Lentz 2012), and this risk must be taken into account in relation to surgery. Female patients of menstruating age therefore need to be made aware of the dangers of using tampons, which can cause infection leading to TSS. At the time of admission, it is important to ask female patients whether they are menstruating and to highlight the dangers of using tampons during surgery. If tampons are left in situ for longer than 6 hours, infection may develop. Nurses can offer a sanitary pad as an alternative.

Latex sensitivity and allergy RELATED THEORY

Latex is a natural rubber composed of proteins and added chemicals. Its durable, flexible properties give it a high degree of protecStaphylococcal toxic shock syndrome (TSS) is a rare, life-­ tion from many micro-organisms, which makes it an ideal fibre to use for many healthcare products. It currently provides the best threatening systemic bacterial infection, historically associated protection against infection in the healthcare field. It is found in with the use of superabsorbent tampons. TSS is characterized the following products: by high fever, hypotension, rash and multiorgan dysfunction (NHS 2016). • gloves • airways RELATED THEORY • intravenous tubing TSS occurs when the bacteria Staphylococcus aureus and • stethoscopes Streptococcus pyogenes, which normally live harmlessly on the • catheters skin, enter the bloodstream and produce poisonous toxins. These • wound drains toxins cause severe vasodilation, which in turn causes a large • dressings and bandages (HSE 2018). drop in blood pressure (shock), resulting in dizziness and confuSome of the proteins in the natural rubber latex can cause sension. They also begin to damage tissue, including skin and sitivity and allergic reactions, and the incidence of latex hypersenorgans, and can disturb many vital organ functions. If TSS is left sitivity seems to be increasing (Wu et al. 2016). Powdered gloves untreated, the combination of shock and organ damage can result can create the greatest risk as proteins leak into the powder, in death. Symptoms usually occur together and get progressively which can become airborne when gloves are removed, and inhalworse over time. They include: ing the powder may lead to respiratory sensitization. The amount • high fever of latex exposure needed to produce sensitization is unknown. • vomiting Sensitivity can be described as the development of an immuno• diarrhoea logical memory for specific latex proteins, which can be asympto• severe muscle aches matic. A substance that causes sensitization is one that is capable • feeling extremely weak or dizzy of causing an allergic reaction in certain people. Allergy is the • sunburn-like rash. visible manifestation of the sensitivity (e.g. hives, rhinitis, conjunctivitis or anaphylaxis), which can be serious and potentially TSS can also affect men and children, and currently nonmenlife threatening (Table 16.8) (Hauk 2018, HSE 2018). strual TSS is more common (Sharma et al. 2018). However, the

DEFINITION

Table 16.8  Allergic reactions Reaction*

Description

Symptoms

Irritation

Irritant contact dermatitis, a non-allergenic reaction caused by soaps, gloves, glove powder and hand creams

Dry, crusty and itchy skin Rashes and inflammation

Type I reaction: immediate hypersensitivity – occurs within minutes and can fade rapidly after removal of the latex

Immediate hypersensitivity, sometimes called immunoglobulin E response; caused by exposure to proteins in latex on glove surface and/or bound to powder

Most severe reaction Wheal and flare response Irritant and allergic contact Dermatitis Facial swelling Rhinitis Urticaria Respiratory distress and asthma Rarely, anaphylactic shock

Type IV reaction: delayed hypersensitivity – usually occurring within 6–48 hours of contact

Sometimes known as ‘allergic contact dermatitis’, caused by exposure to chemicals used in latex manufacturing

Red, raised, palpable area with bumps, sores and cracks

* Type II and type III reactions are not relevant to latex. Source: Adapted from AORN (2018), HSE (2018).

CHAPTER 16 Perioperative care

Once sensitization has taken place, further exposure will cause symptoms to recur, and increasing exposure to latex proteins increases the risk of developing allergic symptoms (HSE 2018). Therefore, sensitivities and allergies should be treated in the same way (Hauk 2018). Routes of exposure include: • direct external contact (i.e. with gloves or other latex products) • airborne exposure • direct contact with the mucous membranes • internal patient exposure from healthcare provider use of nat­ ural rubber latex gloves during surgical procedures • internally placed devices (e.g. wound drains) (AORN 2018). Latex allergies are classified as irritant contact dermatitis, type I and type IV reactions (see Table 16.8).

CLINICAL GOVERNANCE

Healthcare providers have an ethical responsibility to prevent latex sensitization; because there is no cure, protection must be paramount. Employers should have a latex allergy policy and procedure, which should provide information and instruction on measures to identify patients at risk, patient education, interventions to reduce undue latex exposure, recognizing symptoms of sensitization and the action to be taken if a sensitization is suspected (HSE 2018). Assessment and monitoring for symptoms of latex allergy in both conscious and unconscious patients are required at all stages of perioperative care. The assessment should cover the following known risk factors for latex allergy: • history of multiple surgeries beginning at an early age (e.g. spina bifida or urinary malformation) • history of hayfever or asthma • history of an allergic reaction to latex: for example, a history suggestive of reactivity to latex may be gained by anecdotal accounts of swelling or itching of the lips when blowing up balloons or following dental examinations, or swelling and itching of the hands when using household gloves • history of an allergic reaction during an operation • past experience of itchy skin, skin rash or redness when in contact with rubber products • past skin irritation from an examination by a doctor or dentist wearing rubber gloves • past sneezing, wheezing or chest tightness when exposed to rubber (AORN 2010). If a suspected or confirmed latex sensitivity or allergy is found, this information must be documented in the patient’s medical notes and communicated to all members of the healthcare team and departments that the patient may visit, including theatre, recovery, pathology and radiology (Liberatore 2019). Box 16.9 outlines the pre-operative actions to be taken when a patient has a potential or confirmed latex allergy. The anaesthetist will need to be informed so that decisions can be made regarding potential allergy prophylaxis pre-operatively. A latex-safe environment is recommended – one where every reasonable effort has been made to prevent high-allergen and airborne latex sources from coming into direct contact with affected individuals. Latex-free alternative items should be collected and stored in a quick-access location for ease of access and identification. At present, best practice dictates that patients with a suspected or confirmed latex allergy be scheduled first on the morning list because it is assumed that the inactivity in the room during the previous evening hours causes the content of latex-coated powder in the ambient air to be lowest in the morning (AORN 2018, Hauk 2018). Further guidance may be sought online from the Association of periOperative Registered Nurses (www.aorn.org).

Box 16.9  Pre-operative actions to be taken when patients have a potential or confirmed latex allergy • Notify operating theatre of potential or confirmed latex allergy 24–48 hours (or as soon as possible) before the scheduled procedure. • Identify the patient’s risk factors for latex allergy and communicate them to the healthcare team. • Schedule the procedure as the first case of the day if the facility is not latex safe. • Plan for a latex-safe environment of care. • The theatre must be cleaned with latex-free gloves and equipment. • All latex products must be removed or covered with plastics so that the rubber elements are not exposed. • All healthcare staff in direct contact with the patient must wear vinyl gloves during procedures and in the vicinity of the patient. • Use latex-free replacements for all latex-containing items used by surgeons and anaesthetists. • A latex-free contents box or trolley (containing stock of all latex-free products that will be required during surgery and anaesthetic) should be ready in every theatre department and recovery room. There should be a list of all latex-free equipment (including each item’s manufacturer) available in the box or trolley. • Notify the surgeon if no alternative product is available. • Notify the anaesthetist if a latex-containing product must  be us