NVQ evidence

Sunday, August 20, 2006

Uncovered PCs and Ranges

Unit X19 Prepare and undertake agreed clinical activities with clients in acute care settings

Element X19.1 Prepare clients for clinical activities


PC	1	The correct necessary documents and records for the clinical activity are ready for use.	This is important because this facilitates the easy flow of any procedure as well as presents a professional approach to activities. Documentation must pertain to the specific client as if they do not, inappropriate care, if not fatal care could be given to a client.
	2	Before the activity starts, the essential resources for the clinical activity are prepared ready for use.	COVERED
	3	Before any actions are taken, the client’s consent to the activity is confirmed.	COVERED
	4	Where the client and advocate do not give consent to the activity, advice is sought from an appropriate member of the care team without delay.	If a client or client's advocate say no to a procedure then it is the role of the worker to report this. Any activity carried out when there is not validly consented constitutes assault. It is very important that an accountable practitioner is involved as soon as possible to answer any questions that are outside the role of the worker.
	5	The client is offered appropriate support and information in preparation for the activity in a manner appropriate to them.	COVERED
	6	Client behaviour and condition is observed and monitored throughout contact and any unexpected change or aspect which gives cause for concern is reported to an appropriate member of the care team without delay.	It is very important that the worker understands what the effects of any given treatment as this can give indications for what is normal in the given instance. If there are deviations from the norm with a procedure, it is very important that Accountable Partitioners are contacted as they can then act accordingly.
	7	Any questions from the client and advocate are answered correctly and in a manner, and at a level and pace, appropriate to them.	COVERED
	8	Where the client and advocate raise questions which are beyond the worker’s responsibility, further appropriate advice or assistance is sought before undertaking the activity.	It is not the role of the worker to answer questions that are outside their role. Even if the worker knows the answer, this is still the case. Support workers are not Accountable for their practice. They are responsible. If any incorrect information is given by the worker, then the Practitioner is vicariously accountable for this. If there is any doubt then the Practitioner should be informed as soon as possible.
	9	The reasons for any particular forms of dress and protection are explained in a manner appropriate to the client.	It is very important to explain the specific types of dress that are required for certain clinical procedures for a number of reasons. An individual may feel threatened by the wearing of gloves and apron for example. It may be that they feel that they have an infection that the medical fraternity are not telling them about. It must be explained that the wearing of protective clothing is merely precautionary and universal. It is also important that their protective qualities are emphasised as being two way.

	10	Where there are contra-indications before starting the activity, the preparation is halted and advice sought from the appropriate member of the care team with minimum delay.	It is very important that contra-indications are noted before any procedure is commenced as beginning without prior consultation may cause harm to the individual. Also, there are accountability issues that may arise if nothing is done. The practitioner must be informed as there may be steps that she/he may need to take before the procedure may begin. The procedure may even have to be forgone altogether. Also, the worker may not be the best person to undertake the task
	11	The client is offered the opportunity to use toilet facilities prior to the activity when this is appropriate.	This is important as it increase the likelihood of a smooth procedure without causing the client discomfort. There is also a clinical reason for this. Some procedures require asepsis. If the procedure needs to be temporality, then all sterile areas including wounds need to be covered and all sterile fields covered. It may be necessary for new procedure packs to be opened. This is expensive so prior toileting helps to reduce this.
	12	The client is assisted to reach as comfortable a position as possible given the constraints of the activity.	COVERED
Range	1	Clinical activities: a) care of lesions and applications of dressings
		b) elimination	COVERED
		c) extended personal care
		d) tube feeding
		e) obtaining specimens	COVERED
		f) undertaking physical measurements and monitoring	COVERED
	2	Essential resources: a) for the activity to be undertaken	COVERED
	2	b) necessary protective clothing	COVERED

Uncovered PCs and Ranges

Unit X19 Prepare and undertake agreed clinical activities with clients in acute care settings

Element X19.2 Undertake clinical procedures, treatments and dressings


PC	1	Hands are cleansed effectively before and after the activity.	COVERED
	2	The client is informed of the activities being undertaken during the procedure, treatment or dressing in a manner which is sensitive to their needs and concerns and is at an appropriate level and pace.	COVERED
	3	The procedure, treatment and dressing is carried out using the correct technique and at an appropriate time according to the plan of care.	COVERED
	4	The client is given appropriate support throughout.	COVERED
	5	Client behaviour and condition is observed and monitored throughout contact and any unexpected change or aspect which gives cause for concern is reported to an appropriate member of the care team without delay.	Prior knowledge of the client is very helpful as this facilitates noticing any changes in behaviour that may be relevant. Also quick reporting of changes is very important as, if there is any action that is required that is outsider the role of the worker, then this can be actioned more quickly. Any adverse reaction must be recorded in the client’s care plan
	6	Particular observation and monitoring of the client is carried out at the time intervals specified in the plan of care.	Certain procedures require monitoring after they have been undertaken. These will be requested by the registered practitioner who has undertaken or requested the procedure.
	7	Any condition or behaviour which may signify adverse reactions to the activity is reported without delay and action appropriate to the client’s condition is taken.	See above
	8	Following the activity, the client is assisted to reach as comfortable a position as possible given their current state of health.	COVERED
	9	The outcomes of the activity are recorded correctly using the required format and reported to the appropriate member of the care team.	It is important that this occurs because the accountable practitioner needs s to know what is happening with clients. Any action that has been undertaken that can have an effect on the client’s health status must be reported and recorded for this reason.

	10	Waste materials or equipment are disposed of in an appropriate safe manner and place.	All clinical waste must be disposed in yellow clinical waste bags. These must then be tied, when three quarters full, using black plastic bag ties and placed in the clinical waste bin. Non-clinical waste is placed in a black plastic non-clinical waste bag and placed in the non-clinical waste bin when three quarters full. All sharps should be placed in a sharps bin. When this is three quarters full. This must be sealed and this fact must be signed for and dated on the bin. On it’s assembly, the bin should have been signed and dated by the assembler as well as having the setting where the bin is to be used. When it has been shut, it must be placed in the clinical waste bin.
	11	Records completed by the worker are accurate, legible and complete.	COVERED
Range	1	Procedures, treatments and dressings: a) care of lesions and the applications of dressings
		b) elimination	COVERED
		c) extended personal care
		d) tube feeding
	2	Adverse reactions related to:
		a) the client’s condition
		b) the procedure being undertaken	COVERED

Uncovered PCs and Ranges

Unit X19 Prepare and undertake agreed clinical activities with clients in acute care settings

Element X19.3 Obtain and test specimens from clients

PC	1	Hands are cleansed effectively before and after the activity.	COVERED
	2	The client is informed of the activities related to obtaining specimens in a manner which is sensitive to their needs and concerns and is at an appropriate level and pace.	COVERED
	3	Any questions from the client are answered correctly or referred to the appropriate member of the care team.	COVERED
	4	The specimen is collected using the correct technique and at an appropriate time according to the plan of care.	COVERED
	5	The client is given appropriate support throughout.	COVERED
	6	Client behaviour and condition is observed and monitored throughout contact and any unexpected change or aspect which gives cause for concern is reported to an appropriate member of the care team without delay.	Prior knowledge of the client is very helpful as this facilitates noticing any changes in behaviour that may be relevant. Also quick reporting of changes is very important as, if there is any action that is required that is outsider the role of the worker, then this can be actioned more quickly. Any adverse reaction must be recorded in the client’s care plan
	7	Particular observation and monitoring of the client is carried out at the time intervals specified in the plan of care.	See above
	8	Any condition or behaviour which may signify adverse reactions to the procedure is reported without delay and action appropriate to the client’s condition is taken.	This is very important because that reaction could be dangerous to the client and result in serious injury or death if nothing is done about it. It is very important to have the client and the advance we actions that can occur that with me specific procedure. It is important to involve an account the practitioner at because they have they hire knowledge base and that of the worker as well as being accountable for any procedure that is under taken. All adverse reactions must be recorded in the client’s care plan as well as being the report did to be accountable practitioner.
	9	Where the worker is unable to obtain the specimen, this is correctly recorded and the appropriate member of the care team informed without delay.	It is very important to report with failure To collect a specimen that is a requested. If it is not, there could keep an assumption that it has already been taken. There may have been a problem with the collection of the specimen. If this is the case, then the appropriate accountable practitioner may have other ideas and solutions to opt taming the specimen.

	10	Specimens are labelled correctly for the individual, the relevant documentation attached and they are put in the correct place for storage, collection or transportation.	Specimens should have the following information on them:- Date Time of collection Type of specimen Client name Client Date of birth Hospital number Hospital Location The form should have all the above plus:- Examination requested Any other relevant required such as results of any urine analysis or any underlying conditions that the individual has. Once they are collected, labelled and packaged correctly, they must be placed in the correct designated place for collection. If they are urgent, then special measures, such as arranging for them to be fast tracked to be processed.
	11	Specimens are tested correctly, the results accurately recorded in the required format and reported to the appropriate member of the care team.	Some specimens are not suitable to be tested at ward level. They need special testing under laboratory conditions. Urine may be tested at ward level for such things as pH, blood, protein, ketones, nitrites, leukocytes etc. This is explained further in
	12	Following the activity, the client is assisted to reach as comfortable a position as possible given their current state of health.	It is very important that clients are returned as comfortable position as possible. Some tests, such as lumber puncture require the client to remain lying flat for 4 hours post procedure. In this case, then the individual need to be made as comfortable as possible but within these constraints
	13	After use, equipment and materials are cleaned and returned to the correct location for storage, sterilisation and transportation, and waste is disposed of in an appropriate safe manner and place.	All disposable materials must be done appropriately. If these have been in contact with body product, then they need to be placed in a yellow clinical waste bag. If they have not been in contact with body products, then they can be disposed of in a black non-clinical waste bag. Any sharp must be disposed of in a sharps bin, irrespective of them having come into contact with body products or not; Anything that requires Autoclaving need to be put in the CCSD bag (blue).
Range	1	Tests: a) urinalysis
	1	b) blood sugar analysis	COVERED
	2	Specimens: a) urine
		b) faeces
		c) sputum
		d) exudates
		e) blood	COVERED
	3	Adverse reactions related to:
		a) the client’s condition
		b) the specimen being taken	COVERED

Uncovered PCs and ranges

Unit X19 Prepare and undertake agreed clinical activities with clients in acute care settings

Element X19.4 Measure and monitor the physical characteristics and conditions of clients


PC	1	The client is informed of the nature of the measurement and what is involved, in a manner which is sensitive to their needs and concerns and is at an appropriate level and pace.	Not telling the client the nature of the measurement constitutes assault, so it is very important that they are fully informed of what the test is for before it is commenced. It is also very important to pitch the delivery of the information at a level that the client understand that is not patronising to them.
	2	Any questions from the client are answered correctly or referred to the appropriate member of the care team.	COVERED
	3	Measurements are taken using the correct technique and at the appropriate time according to the plan of care.	It is important that all tests are take using a standardised method as then extraneous variable are kept to a minimum. Also it increases accuracy of results. It is very important that results are as accurate as possible as vital decisions are made on the basis of tests.
	4	The client is given appropriate support throughout.	COVERED
	5	Client behaviour and condition is observed and monitored throughout contact and any unexpected change or aspect which gives cause for concern is reported to an appropriate member of the care team without delay.	See above
	6	Particular observation and monitoring of the client is carried out at the time intervals specified in the plan of care.	See above
	7	Measurements are accurately interpreted, correctly recorded using the required format and reported to the appropriate member of the care team.	See above. Reporting results is very important as well as recording them correctly as they the Accountable Practitioner is then informed of the progress of the client.
	8	Where any change or unexpected occurrence is observed from taking the measurement or the measurement is difficult to take or to interpret the results, advice is sought without delay.	The quick notification of changes in condition is very important as this can result in necessary action may be taken as quickly as possible.

	9	Any condition or behaviour which may signify adverse reactions to the measurement is reported without delay and action appropriate to the client’s condition taken.	Knowledge of the client and the significance of changes in behaviour/condition are very important here as then action can be taken quickly. Some changes can be indicative of life threatening results
	10	Following the activity, the client is assisted to reach as comfortable a position as possible given their current state of health.	COVERED
	11	Records completed by the worker are accurate, legible and complete.	COVERED
Range	1	Measurement and monitoring of:
		a) temperature, pulse, respiration	COVERED
		b) blood pressure	COVERED
		c) height, weight, girth
		d) peak flow
		e) fluid balance	COVERED
	2	Adverse reactions related to:
		a) the client’s condition
		b) the physical measurement being taken	COVERED

Uncovered Ranges

X19.1

Range 1

a) care of lesions and applications of dressings

Aseptic technique
Equipment
Sterile Dressing pack
0.9% Normal saline
hypo-allergenic tape
Appropriate dressings

1 Explain and discuss the procedure with the patient to ensure that patient understand the procedure and is then able to give informed consent
2 Wash and dry hands and apply gloves and apron to prevent cross-infection
3 Clean trolley with hot water and detergent and clean paper towels to provide a clean working surface.
4 Place all the equipment required for the procedure on the bottom shelf of the clean dressing trolley to maintain the top shelf as the clean working surface.
5 Prepare client as necessary. Optimize comfort whilst ensuring that the treatment site is accessible. If the client is in an open ward setting, close curtains around bed space. Maximise client dignity as much as possible. Screening the area allows any airborne pathogens to settle before any sterile supplies are opened.
6 Wash and dry hands and apply gloves and apron to reduce cross-infection risk
7 Take the trolley to the patient, disturbing curtain/fixtures a little as possible to minimize airborne contamination.
8 Loosen the dressing tape of any dressings that are already in situ to facility their full removal later.
9 Remove gloves and wash and dry hands again and clean hands with a bacterial alcohol hand rub to reduce the risk of wound infection.
10 Check the pack is sterile in that the packet is not damaged, wet and opened to ensure the use of sterile products only.
11 Open the sterile dressings pack and open it out, touching the corners of the pack as little as possible to keep the risk of transfer of infection minimized
12 Open out all other required sterile products, ensuring that they are all intact, unopened and undamaged prior to opening.
13 Re-cleanse hands with alcohol rub as they can become contaminated by touching the outer rappings of the products.
14 Use the inverted disposable bag in the dressings pack like a glove to re-arrange the sterile field as required and use the bag to remove the old dressings if required. Stick the bag on the trolley.
15 Where appropriate, poor open the normal saline and poor into galipot provided. The normal saline should be warmed prior to use as this speeds up the time for the healing process to recommence. The heeling process only works when the wound is at body temperature. Removing the dressings and cleaning the wound with cold normal saline stops the healing process.
16 Apply the sterile gloves, touching only the inside wrist end to reduce infection risk. The use of gloves is preferred over forceps as the allow more precision as well as reduce the risk of trauma
17 Where wounds need irrigating, clean from centre of wound to outside so that infected material from the outside to the wound contaminated the epithelialising bed of the wound.
18 Use a wipe then discard method as to reduce infection risk.
19 Dry around the area and apply the required dressings fixing them on as necessary
20 Ensure that the patient is returned to a comfortable position.
21 Dispose of all clinical waste in that they yellowed clinical waste bag, includes gloves and apron to reduce infection risk.
22 Wash and dry hands
23 Apply gloves and clean trolley with detergent and dry as before.
24 Wash and dry hands
25 Record any information that is required in the client’s care plan such as:-
• What was carried out
• What material was used
• Any reference numbers of any surgical equipment used.

c) extended personal care

Extended Personal Care

Eye Care
Mouth Care
Skin Care

Eye Care

Eye care is the practice of assessing, cleaning or irrigating the eye and/or the instillation of prescribed ocular preparations (administered by a Registered Nurse)

Eye care may be necessary in order to:-

Relieve pain and discomfort
Prevent or treat infection
Prevent further injury to the eye injury
Detect disease at an early stage
Prevent damage to the cornea in sedated or unconscious patients

Action	Rationale
Explain the procedure to the patient	To ensure full comprehension and the giving of information to make a valid consent
Assist client to the correct position:- Head well supported and tilted back Preferably lying	To help to reduce sudden unexpected movement in the client.
Maintain an optimum light level to enable maximum observation whilst not dazzling the client	To maximize observation
Wash hands using antibacterial hand wash and dry thoroughly and apply plastic apron and sterile gloves.	To reduce cross-infection
If one eye is infected, attend to the non-infected or less-infected eye first	To reduce cross-infection
Always bathe with eyes closed first	This reduces risk of cross-infection as well as helps to prevent corneal damage.
Using sterile water on a clean piece of gauze, ask the client to look up and gently swab the lower eye from nasal corner outwards	If the swab is too wet, fluid can run down the cheek causing discomfort as well as increased risk of infection. This motion reduces risk of swabbing fluid into the lacrimal punctum, or into the other eye.
Ensure that the swab edge avoids the lid margin`	To avoid touching the sensitive cornea.
Repeat as necessary to remove discharge. Use a new swab for each sweep	To reduce cross infection
Repeat for upper eye lid, slightly everting it and asking the client to look down	To effectively remove any foreign material fro the eye and reduce cross-infection.
When both eyes are both clean and dry, assist client to comfortable positions
Remove all disposable equipment and wash and dry hands	To reduce cross infection
Record procedure, noting any changes or abnormalities detected	To monitor trends and maintain good documentation practice

Mouth Care

Mouth care should be part of ALL clients’ care. It is a very important part of fundamental care. Its purpose is as follows:-

General comfort of the client
Prevent and control infection
Optimize dental and soft tissue condition

Wherever possible, clients should be encouraged to be as self caring as possible when dealing with oral hygiene. Where not able to be fully self-caring, clients should be offered a choice as to whether to have it or not which is a client right. Clients who have increased need for assistance with oral care are:-

Individuals who have Oxygen therapy (clients who are on oxygen therapy should have humidified oxygen after 24 hours of continuous use)
The elderly (the oral cavity can become dry and sore very quickly which can lead to increased infections.)
Clients on antibiotics and chemotherapy. (Despite killing the unwanted, these can also reduce the number of flora in the individual as a whole, including in the mouth)
Clients with Parkinson’s disease
Clients with swallowing difficulties (ie individuals who have had strokes, head injuries or nervous/muscular atrophy)
Children
Individuals who are nil by mouth for any length of time due to medical regimens

Types of mouth care available.

Tooth brush and paste.

This may be sufficient for most individuals. Some may require assistance with the use of these. It must be remember that client must be given a receptacle to spit out afterwards
All dental surfaces should be brushed as well as the inter-dental spaces. The gums need to be lightly brushed also. If coated, then the tongue can also have a light brushing.

Sponge sticks and water

With individuals who are elderly or have particularly delicate mouths, then these can provide a useful, less aggressive alternative to a tooth brush. Medicated mouth washes can be used for short periods but their prolonged use can result in reduction of oral flora and development of a sore mouth.
Glycerine coated sticks can be good to encourage the production of saliva but there prolonged use can inhibit its production.
This method, in particular, needs to be used with clients who are fully compliant as the sponge may be bitten off the end of the stick which could then be ingested or inhaled with life threatening consequences.

Other methods

Vitamin C tablets can be very good for cleaning the mouth.
Natural yoghurt can be used quite effectively when the individual has opportunistic oral infections such as candida. They have the added benefit of restoring the client’s flora, not just in the mouth, but in the whole of the gastro-intestinal tract.
Pineapple juice can be used in moderation as a mouth cleaner. It must be noted that only pure pineapple juice must be used as sugar may be added. Also, care must be taken that only fresh juice is used.
Ice cream has mouth cleaning properties as well as being cold with can stimulate swallowing. Care must be taken not to give ice cream to individuals who need thickened fluids as it melts on entering the mouth thus becoming a liquid, thus becoming a danger to the client.

Skin Care

Purpose

Prevention of infection
Prevention and/or reduction of pressure areas
Temperature maintenance
Removal of dead skin and other waste products
Reduction of body odour
Promotion of self-dignity

Where possible, clients should be allowed to be self-caring with skin care. Where this is not possible, then this should be carried out maintaining the client’s dignity at all time. Clients’ choices and individual preferences should be listened to and acted upon. If these choices and preference conflict with nursing research or accepted nursing practice and could cause damage to the worker or the client themselves, then this should be pointed out to them in a sensitive manner, acknowledging that they have the right to choose their own individual care.

Procedure

Discuss the procedure with the client, explaining what they want and if this is possible to happen with regard to present resources.
Collect the relevant equipment:-

Wash cloth/flannel
Bowl of water (water should be between 35 and 40 degrees Celsius or to clients choice
Soap
Towel
Other toiletries of the clients choice and other equipment necessary

Take the equipment to the client
Ensure privacy by shutting any doors or drawing curtains as necessary
Don latex gloves and apron in accordance with universal precautions
Allow the client to test water where possible as to see if the water is the correct temperature for them.
Wash face first, offering the use of soap if requested. Do not allow soap to go into the eye as this is not only very painful but also detrimental to the cornea
Do not use excessive amounts of soap as this can cry the skin
Always wash off soap
Change water before/after washing genital area to reduce the spread of infection.
Do not rub dry to hard as this can cause skin sheering. Patting the skin dry with a towel
Apply any creams as directed by Registered Nurse
Change any soiled or wet linen
After the procedure is finished, assist client to a comfortable condition as necessary.

d) tube feeding

Tube feeding

Enteral feeding is used when a client is unable to swallow or is unable to meet dietary needs orally.

There are two main types of enteral feeding methods:-

Nasogastric
Percutaneous endoscopic gastronomy (PEG)

Nasogastric tube feeding

A tube with a weight on the end of it is passed thought the nose and then need be swallowed by the patent when it reaches the back of the throat. This then is then passed into the stomach. An x-ray need to be taken to establish if the tube is in the stomach and not in the lungs or anywhere where is should not be.
This method of feeding is only suitable if the client can comply with the procedure and weather they are able to physically swallow the device.
This is the most common form of enteral feeding
Short term, usually post surgery
The tube can be very narrow and can be highly susceptible to blocking. If this occurs, carbonated water or fizzy drinks can be used to un-block it.

PEG feeding

A small hole is made in the wall of the abdomen and into the stomach into which a catheter is passed.
This usually requires a general anaesthetic. This has risks attached to it in itself so, as a second option, a local anaesthetic may be considered.
The lumen of the tube is larger than that of a nasogastric tube. However, there is still a risk of blockage which can be unblocked as mentioned above.
The entry site in the abdomen has now been proven best to be left uncovered as using a dressing as normal practice has been found to cause more infections than it prevents. Dressings should only be used in remedial circumstances.

Procedure

Establish with Registered Practitioner when and what the client need to be given.
Gain informed consent with the client by explaining the procedure and ensuring that the client understands
Check that the feed is well mixed and is in date and is the feed that has been prescribed.
Turn off the feeding pump and unscrew the joint between the PEG catheter and the giving set.
Remove the used bottle.
Unscrew the top of the new bottle and place the giving set on the end of the new bottle. Ensure that the thread is located correctly on the bottle as incorrect location can cause air to enter the bottle and the pump failing.
Invert the bottle and allow an small amount of fluid to fall into the viewing chamber.
Prime the tube so that no air enters the clients stomach when the feed commences.
Re-attach the tube to the PEG tube and place the inverted bottle into the pump as required
Ensure that the speed to the pump is set at the prescribed speed.
Ensure that the giving set is set to fully on as this will cause the pump to fail.
Turn on the pump and regularly observe to monitor if it is working correctly and to not any problems
Record actions and what has used/initiated in the relevant part of the client’s care plan.

Flushing the tube

The tube needs to be flushed before and after feeds. Within the regimens of the feeding regime may be the need to give an amount of water prescribed.

This can be done between steps 4 and 5 above.

Procedure

Attach an inverted catheter-tipped 50ml syringe to the end of the PEG (or Nasogastric) tube
Ensure, at this point, that the gate on the tube is off.
Pour the required amount of fluid into the syringe and open/close the gate as open.
Remove the syringe and either close the end of the tube or reattach feed and re-commence as necessary
Record all activity and amounts in the relevant part of the client’s care plan (ie on a fluid chart.)

X19.2

Range1

a) care of lesions and the applications of dressings

See X19.1 range 1a

c) extended personal care

e) tube feeding

Range 2

a) the client’s condition

General observation of clients

Observation of clients is a very important part of care. Individuals, especially in an acute care setting, can change very rapidly from one moment to the next. Subtle changes can be indicative of some very dangerous medical conditions.

The following can indicate that problems may be imminent:-

Changes in general appearance of the client

Flushed àpyrexia, stroke, infection, pre-ichtal
PailàMI, chest pain, faint, hypovolaemia/bleeding
CyanosedàReduce Oxygen saturations
ClammyàMI, chest pain, hypoglycaemia
SweatyàMI, chest pain, hyperglycaemia

Changes in behaviour/mood

Anxious for no reasonà pre-ichtal, pre-CVE, pre-TIA
Disorientationà pre-ichtal, pre-CVE, pre-TIA, dementia, infection, Blood sugar imbalance
Suddenly quiet/noisy à pre-ichtal, pre-CVE, pre-TIA, dementia, infection, Blood sugar imbalance
Extrovert/introvertà pre-ichtal, pre-CVE, pre-TIA, dementia, infection, Blood sugar imbalance, pain
Unusual/bazaar behaviour à pre-ichtal, pre-CVE, pre-TIA, dementia, infection, Blood sugar imbalance, pain, needing the toilet
Violent, aggressiveàpre-ichtal, pre-CVE, pre-TIA, dementia, infection, Blood sugar imbalance, pain, needing the toilet

Changes in clinical observations

Changes in respiratory rate

increaseàinfection, trauma, pre-event (ie, cardiac, cerebral vascular) needing the toilet, hypovolaemia/bleeding, anxiety
decreaseàcerebral vascular damage, opiate administered
shallowàshock
deepà insufficient Oxygen intake,
wheezyàallergen present, chest infection, asthma
labouredàinsufficient Oxygen intake,
irregularàanxiety

Changes in blood pressure

both figures increase significantlyàStoke, anxiety
both figures decrease significantlyàhypovolaemia/bleeding, poor cardiac output
decreasing blood pressure on standingàdehydration, old age, Parkinson’s disease, long periods of lying/sitting down.
significant increases in systolic accompanied by significant increases in diastolic readingsàVascular insufficiencies
significant increases in diastolic accompanied by significant increases in systolic readingsàVascular insufficiencies
Significantly increased blood pressure in one arm onlyàdissecting aortic aneurism (usually associated with EXTREME pain in chest radiating through to the back)

Changes in pulse rate

increaseàhypovolaemia/bleeding, infection, cardiac problems, certain medication, shock, MI
decreaseàcardiac problems, opiate use, digoxin use, stroke
irregularàAtrial fibrillation, other cardiac problems,
differences between radial pulse and apex beatà atrial fibrillation, poor cardiac output
thready (slight, difficult to detect)àshock, poor cardiac output, hypotension
bounding (very strong)àhigh blood pressure, stoke

Changes in temperature

increasedàfever, infection, brain injury, general malaise, stroke
decreasedàhypothermia, MI, shock,
swinging pyrexia (temperature fluctuates between normality and pyrexia)àburst or bursting abscess

Changes in pulse oximatry

decreasedàcompromised airway, asthma, COPD, opiate use, Oxygen administration not working properly
increased àcleared airway, Oxygen administration is successful

X19.3

Range 1

Tests:

a) urinalysis

Urinalysis

Urine is a mixture of the some of the products of digestion (urea) and excess water. Blood is filtered by the kidneys and the waste is collected with the excess water in the bladder where it is stored until there is sufficient to warrant it being voided.

When urine is in the bladder, it is sterile.

Procedure

1 The test sticks required for urinalysis should be stored in accordance with the manufacture’s instruction. Those used in the Trust need to be stored in the container provided as it has a desiccant in the lid which helps to prevent the denaturising of the sticks. The sticks contain enzymes. This helps to ensure reliable results.

2 Explain procedure and gain consent from client. This ensures that the client understands and then ensures that any consent given is valid.

3 Wash and dry hands and apply gloves and apron in accordance with universal precautions.

4 Obtain a fresh, clean urine specimen from the client. It is important the specimen is fresh as urine deteriorates rapidly once it is passed.

5 Immerse the test area of the strip in the urine and immediately remove it. Tap the excess fluid of the stick.

6 Holding the stick at an angle, as to avoid the contamination of different squares with urine from others, wait the prescribed time. Compare the stick with the chart. If the stick is read too early then the reagents may not have had sufficient time to react thus giving invalid results.

Table of conditions that are detectable via uninalysis

Abnormal constituent	Name of condition	Possible causes
Glucose	Glycosuria	Diabetes Mellitus, may also be raised in trauma, and cardiac damage
Protein	Proteinuria	sometimes in pregnancy, hy proetind diates, heart failure, severe hypoertenion, infction, asymptomatic renal disease
ketone bodies	Ketonuria	Starvation, untreated diabetes mellitus
Haemoglobin	Haemoglobinuria	Transfusion reaction, haemolytytic anaemis, sever burns
Bile pigment	Bilirubinuria	Liver disease, bile duct obstruction
Erythrocytes	Haematuria	Bleeding urniatary tract, kidney stones, infection, trauma.
Leurcocytes pyuria	Pyuria	Urinary tract infection

Range 2

Specimens:

a) urine

As mentioned above, urine is normally sterile when inside the body. It is only when it exits the body that it begins to grow bacteria. However, there are several factors that can contribute to micro-organisms can track up from the urethra into the bladder where they adhere to the wall of the bladder and multiply.

To treat these micro-organisms, it is necessary to find out what type of organism is growing in the baler. A specimen is required so that these may be determined. To this end, asepsis should be strived for when collecting specimens.

Furthermore, the organisms in the actual bladder are usually the ones that are of interest to medical staff. The organism in the urethra are not of as much interest to medical staff. To this end, only the middle part of the specimen is of interest. In the first and last portion of urine which is passed, epithelial cells can slough off and invalidate the specimen.

Mid-stream specimen of urine

Procedure.

1. Discuss the procedure client to encourage co-operation and to gain a valid, informed consent.

2. Wash hands and apply latex gloves and disposable apron

3. Encourage client to wash around the meatus. Where this is not possible assist client with this, ensuring that the are is dry.

4. Ask the client to waste the first portion of urine passed.

5. Ask the client to pass some urine into a sterile container, reiterating that it is very important that the inside of the container should not be touched as this would introduce extraneous bacteria.

6. Ask client to waste the last sector of the urine.

7. When the specimen has been passed, decant it into a suitable container. This trust uses a boric acid crystal container system. The specimen pot has a specifically titrated quantity of boric acid crystals that is only compatible with 20ml of urine. If any more or any less urine is placed into the container, then this will invalidate the specimen. It is therefore essential that only 20ml of urine is placed in the container.

8. Remove gloves and apron and discard them in a yellow clinical waste bag.

9. Ensure that the container is labelled correctly and placed in the correct micro-biology form.

10. Record in the relevant part of the client’s care plan that the procedure has been carried out and that the specimen has been sent to the laboratory.

Catheter specimen of urine

(assuming that the client is already catheterised)

Follow previous procedure steps 1-3

4 Clamp catheter for 20 minutes

5 Using an alcohol wipe, clean the port at the top of the catheter bag and allow to dry

6 Using a needle and syringe, insert the needle into the port and withdraw off the required amount of urine.

7 Decant urine into the sterile container and dispose of the needle and syringe in a sharps bin.

Follow remaining steps of the procedure above.

b) faeces

Faeces is the insoluble part of digestion

Unlike urine, it naturally contains micro-organisms. Sometimes, pathogens in food can result in problems such as diarrhoea. It is sometimes, therefore necessary for a specimen to be take so that the nature of the pathogen can be determined.

Also, doctors may need to know the fat content of faeces.

Procedure for taking a faeces specimen

1. Discuss with the procedure with the client so a valid, informed consent can be gained.

2. Provide the client with a clean container or commode in which to have their bowels open. Ask the client not to pass urine in the same container as the faeces. Provide alternative arrangements, such as a bottle, for this purpose if this is an issue.

3. Allow the client time to do this.

4. When they have finished, don wash hand and apply gloves and apron.

5. Place an amount of faeces in a sterile container.

6. Remove gloves and apron, place in a yellow clinical waste bag and wash hands.

7. Label and place in a micro-biology form and send to laboratory for processing

8. Record activity in care plan and that the specimen has been sent.

c) sputum

Sputum is the thick gelatinous secretions of the lungs that is coughed up when the client has a chest infection. Its collection is necessary to ascertain which antibiotics will be most effective to combat the infection.

Procedure

1. Discuss with client to ensure co-operation and that a valid, informed consent is obtained.

2. Give the client a sterile container.

3. Ask them to cough and produce some sputum

4. Ask them spit the sputum into the pot.

5. Label pot and place it in a labelled micro-biology form and send it to the laboratory.

6. Record activity in the client’s care plan and that a specimen has been sent to the laboratory.

d) exudates

Collection of Exudate
Exudate should be collected in a sterile container or on a sterile swab. It may not be sterile itself but this is still best practice.

Procedure

Explain procedure to gain an informed valid consent
Wash hands
Collect all necessary equipment (glove, apron, collection device [swab, syringe], collection container, sterile field if necessary)
Wash hands and apply gloves and apron
Collect specimen, endeavouring to maintain asepsis, in the requisite collection device.
Ensure the client is comfortable as possible and ensure that all stages of the procedure are discussed prior to their application.
Label and dispatch the specimen as require, recording the fact of its collection and dispatch in the relevant part of the client’s care plan.
Dispose of all waste materials in the appropriate disposal bin (see Application of Dressings

Range 3

Adverse reactions related to:

a) the client’s condition

see X19.2 range 2a

X19.4

Range 1

Measurement and monitoring of:

c) height, weight, girth

Taking Physical measurement

Weight

Girth

Height

Weight

Weighing clients is very important for the following reasons:-

It provides a benchmark on admission by which any changes can be measured
It is factor of Body Mass Index which can be used in establishing whether in individual has weigh problems and remedial action can be taken.
It provides as basis for the delivery of specific treatments.

Equipment

Weighing scales suitable for the client. Free standing scales, seat scales and hoist scales are available.
Client specific moving and handling equipment as prescribed
Suitable footwear and clothing for client

Procedure

Explain the procedure to the client to ensure that any consent is given validly.
Prepare the equipment and ensure it is working properly to ensure validity of results and smooth procedure. Set to zero as necessary.
Ensure that all attire that is warn by the client is both practical for the purpose, to optimize health and safety, and that is maintains the client’s dignity to the maximum.
Using any prescribed moving and handling equipment necessary, ensure that client uses scales as required in the correct manner.
Observe weight
Assist client, as necessary, off scales back to a comfortable position to for them.
Record on the appropriate part of the client’s care plan, ie a weight chart. Report to Registered Practitioner as required.

Notes

If a client is on a weighing regime, then the procedure must be undertaken at the same time of day and wearing the same or similar garments. Weigh is best measured post maturition.
Weight is very often used for clients with cardiac failure as fluid retention is one of the main problems of the condition.

Body mass index is a comparison of a client’s weight to their height. It is calculated thus:-

Body mass index = Weight (kg)

Height (m)²

Although this can be a useful tool, it has limitations because muscle wasting and water retention can mask the client’s actual weight.

Height

Height is usually measured while the client is standing, bare foot using a wall mounted ruler. This is usually measured in metres or centimetres.

Where this is not possible, a demi-span can be taken. This involves measuring from the index finger to the middle of the sternum with the arm stretched out to the side. This measurement doubled is equates approximately to a clients height.

Girth

This is the length of the circumference of any given area of the body. This can include the abdomen, the arms, the calves, etc.

It is best to under take this measurement at the same time of the day and at the same point on the area in question. This can be achieved by marking the skin with a special skin marking pen. This must be a specific pen for marking skin as inks from other pens may cause problems such as blood sepsis.

d) peak flow

Peak Flow
Peak Flow

Peak Expiratory flow rate is the measurement of the rate at which air is exhaled from the lungs through the mouth.

It is recommended that Peak Flow readings are taken morning and evening pre and 30 minutes post nebuliser/inhalers.

Factors affecting Peak Flow
• Age
• Sex
• Ethnic group
• Underlying aetiology [asthma, COPD, emphysema]
Procedure guidelines for recording Peak Flow
Equipment
• Peak Flow meter
• Clean mouth piece
• Chart for recording the result
Procedure
• Explain the procedure to the patient and obtain consent to ensure that the patient understands and has the information to make a valid consent.
• Establish patient’s current and best or predicted peak flow to provide a benchmark and make a comparison.
• Wash and dry hands to minimize cross infection.
• Collect and assemble equipment. Ensure that a new mouthpiece that is client specific so that cross infection risks are minimized
• Position client as is usual for them to have reading taken. Research recommends sitting where possible. This helps towards consistency of readings
• Zero meter for accuracy of readings.
• Ask client to breath through meter as hard as possible
• Note results
• Repeat twice more and record the results
• Return client to comfortable position
• Discard used mouthpiece and wash and dry hands to minimize cross infection.
• Return peak flow meter to storage for next use
• Determine highest reading. Note results in correct part of the client’s care plan (ie Peak Flow Chart)
• Report results as necessary

2 Adverse reactions related to:

a) the client’s condition

see X19.2 Range 2a

posted by alanpjack # 10:19 PM

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NVQ evidence

Sunday, August 20, 2006

Uncovered Ranges

X19.1

Range 1

Skin Care

PEG feeding

Procedure

X19.2

Range1

Range 2

General observation of clients

X19.3

Range 1

Range 2

Range 3

Archives