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Management of self-injury by autonomous practitioners in a minor injuries setting

Dalam dokumen Welsh Emergency Nurse Practitioner (Halaman 100-143)

Abbreviations: mi: mini-cex; C/CbD: case based discussion; MSF/M: multisource feedback, D/DOPS: direct observations procedural skill, PS: patient survey, AA: Audit assessment tool.

Page 100

UNIT 13: Management of self-injury by autonomous practitioners in a minor injuries

Abbreviations: mi: mini-cex; C/CbD: case based discussion; MSF/M: multisource feedback, D/DOPS: direct observations procedural skill, PS: patient survey, AA: Audit assessment tool.

Page 101

pain management

treatment of wounds

initial psychological assessment

aftercare advice

referral to:

o

mental health services

o

police

o

social services

o

other agencies.

LO 2 – LO 5 Evidence must be given for a minimum of three cases.

If not specifically stated in the assessment information, a plural statement in any assessment criteria means a minimum of two.

For Health and Social Care, Clinical Care, early years Care and the care of Children and Young People:

To meet standards for clinical governance, organisational liability, professional and regulatory requirements, all new units containing assessments that are competence based and are for learners who are employed in, or volunteering in, health and social care, clinical care or childcare settings:

learners must have completed any mandatory H&S training or education required for their job role

context-specific health and safety must be explicitly stated WITHIN individual units.

Other Mappings:

Code 2015.

RCEM CC12, CC6, CC3.4, CC1, CC2, CC3, CAP23, CC16, CC4, CC5, CC17, CC18, CC19, CC21, CC24, PAP6, PAP15, CAP30.

Assessor Requirements:

Registered practitioners with a minimum of two years experience of working in minor injuries settings as:

an emergency nurse/paramedic/advanced care practitioner

Consultant nurse or

Consultants in emergency medicine.

© 2016 Agored Cymru

Abbreviations: mi: mini-cex; C/CbD: case based discussion; MSF/M: multisource feedback, D/DOPS: direct observations procedural skill, PS: patient survey, AA: Audit assessment tool.

Page 102

Self Mutilation [Mental health] [RCEM CAP30]

The EP will be able to evaluate the patient who presents following self-mutilation, assess risk and formulate appropriate management plan

Knowledge Assessment

Methods

NMC:

Outline the risk factors for a suicidal attempt C, Mi, PE, A

Know the national guidelines for self harm

Outline the powers that enable assessment and treatment of patients following self harm or suicidal ideation as defined in the Mental Health Act

C, Mi, PE,A

Skills

Take a psychiatric assessment supported by scoring tool to assess risk of further harm (Becks scale for suicidal inventory, SAD PERSONS, Australian Mental Health Triage Scale)

D, Mi, C PE, A

Behaviour

Liaise promptly with psychiatric services as appropriate C PE, A

Show compassion and patience in the assessment and management of those who have suicidal intent

C, M PE, A

Anaphylaxis [RCEM CMP1]

The EP will be able to identify patients with anaphylactic shock, assess their clinical state, initiate immediate resuscitation and refer in a timely manner

Knowledge Assessment

Methods

NMC

Identify physiological perturbations causing anaphylactic shock C, Mi, PS,

A

Recognise clinical manifestations of anaphylactic shock C, Mi, PS,A

Elucidate causes of anaphylactic shock C, Mi, PS,A

Know anaphylaxis guidelines C, Mi, PS A

Skills

Recognise clinical consequences of acute anaphylaxis Mi, C, PS, A

Perform immediate physical assessment (laryngeal oedema, bronchospasm, hypotension)

Mi, C, D, PS, A

Institute resuscitation (adrenaline/Epinephrine), oxygen, IV access, fluids) Mi, C, D, PS, A

Refer in an appropriate timely manner PE, A

Be an ILS/ ALS provider PE, A

Behaviour

Exhibit a calm and methodical approach C, Mi, PE, A

Abbreviations: mi: mini-cex; C/CbD: case based discussion; MSF/M: multisource feedback, D/DOPS: direct observations procedural skill, PS: patient survey, AA: Audit assessment tool.

Page 103 Septic Shocked Patient (combined RCEM CMP4 & CMP 5)

The EP will be able to identify a shocked patient, who may present with Severe Sepsis or Major Trauma and assess their clinical state, prioritise, seek urgent help /referral to appropriate centre and understand the requirement for

resuscitation.

Knowledge Assessment

Methods

NMC

Recalls the pathophysiology of shock for sepsis and hypovolaemia C, Mi, PE, A Identify physiological perturbations that define shock and understand the

patho-physiology of its cause

C, Mi, PE, A

Recalls the sepsis 6 bundle PE, A

Skills

Perform immediate (physical) assessment (A,B,C) Mi, D, PS, PE, A

Recognise the need for immediate referral PS, PE, A

Recognise immediate resuscitation measures required and initiate/refer (oxygen, iv access, fluid resuscitation)

Mi, D, PS, PE, A

Arrange simple monitoring of vital signs (BP, pulse & respiratory rate, temp, urine output) & initiate investigations &life saving measures whilst waiting e.g.

oxygen therapy, iv access and fluids

Mi, D, PS, PE, A

Behaviour

Exhibit calm and methodical approach to assessing the critically ill/injured patient

C, Mi PS, PE, A

Calls for prompt assistance as appropriate from : ED team, WAST 999 ambulance, colleagues, critical care outreach services

PS, PE, A

Abbreviations: mi: mini-cex; C/CbD: case based discussion; MSF/M: multisource feedback, D/DOPS: direct observations procedural skill, PS: patient survey, AA: Audit assessment tool.

Page 104

Assessment Documents

Consultation Assessment Proforma (mini-cex)

This provides a structure for the learner to have their consultation skills assessed. The guidance for what should be considered during the assessment & assessing the performance can be found in the overarching clinical consultation competency.

Case details: Presenting Complaint: Male / Female Age:

Please tick one column for each statement & rationalise score. If a section does not apply, please mark it N/A (non applicable)

Not yet competent Competent

Rationale for Score Given

1 Demonstrates ability to quickly build a therapeutic relationship with the patient:

a Introduces self b Good eye contact c Speaks at a volume that

the patient can hear d Speaks with tone & speed

of speech that demonstrates a empathetic, interested and non-judgemental approach

e Explains necessary information in language that the patient understands f Checks patient

understanding g Gives the patient an

opportunity to ask questions

2 Elicits relevant history for a specific problem in a

structured way, giving patients time to answer questions posed.

3 Demonstrates an ability to use a systematic/ structured approach to physical examination of the patient a Appropriate vital signs

b Look

c Listen d Feel

e Move

4 Identifies those patients requiring analgesia and administers appropriate pain relief

5 Demonstrates an ability to interpret findings from history

± clinical examination and obtains relevant investigative studies

6 Documents data accurately in an organised and succinct format

7 Demonstrates clinical decision

Abbreviations: mi: mini-cex; C/CbD: case based discussion; MSF/M: multisource feedback, D/DOPS: direct observations procedural skill, PS: patient survey, AA: Audit assessment tool.

Page 105 making skills

8 Formulates diagnosis based on logical progression of data 9 Offers sound rationale for

clinical decisions to both the patient and assessor 10 Develops and implements a

timely therapeutic

management plan consistent with

a physical need b psychological need c age & developmental

changes

d family considerations e referral to other health

care professionals f community resources g appropriate follow up 11 Demonstrates safe

management of the patient regardless of the outcome 12 Demonstrates independence

in clinical decision making

13 Identified strong areas of consultation

14 Suggested areas for improvement for next consultation

15 other comments

OVERALL ASSESSMENT AND RATIONAL Overall assessment

not yet competent / competent Rationale

Assessor Name: Signature Designation Date:

Trainee’s Signature

Abbreviations: mi: mini-cex; C/CbD: case based discussion; MSF/M: multisource feedback, D/DOPS: direct observations procedural skill, PS: patient survey, AA: Audit assessment tool.

Page 106

Case Reviews Guidance Note

Patient records can be used in professional portfolio as long as they are completely anonymised.

Anonymising the record can be achieved by:

1. photocopying the record,

2. covering the necessary data using sticky labels or tippex 3. re-photocopying and placing this copy in the portfolio

4. shredding the original photocopy or placing in confidential waste.

The record should be anonymised of the following data:

1. all health board, hospital, department or unit identification data including consultant name 2. date and time of arrival and any other timings in the record

3. patient’s name, date of birth, address, GP details & next of kin

4. details of any other including family members or friend’s names which have documented in the record 5. all names and signatures apart from own

Whilst removing this data, is it useful to ensure a note is made of the patient’s age and sex. And if an x-ray has been taken, what the report showed and if this was at variance to you or your clinical supervisor.

The review or reflection should comment on the following findings as per medical model:

Documentation of:

1. own name ~ both printed and signed

2. time consultation completed and if delivered by self, time treatment completed and patient discharged Documentation with reference to presence and quality of information recorded, some should be referenced to latest literature (e.g. NICE head injury guidance) or departmental guidelines:

1. age, sex and who patient was accompanied by 2. Presenting Complaint (PC)

3. History of presenting complaint (HPC) with context and mechanism of injury e.g. tripped, FOSH 4. Past medical history

5. Drug history 6. Allergies

7. Clinical examination: on examination using as appropriate:

a. Look b. Listen c. Feel d. Move

8. Investigations including how this concurs with the report 9. Diagnosis

10. Treatment

11. Plan/after care advice

Abbreviations: mi: mini-cex; C/CbD: case based discussion; MSF/M: multisource feedback, D/DOPS: direct observations procedural skill, PS: patient survey, AA: Audit assessment tool.

Page 107

DEMONSTRATION OF PROCEDURAL SKILLS (DOPS) /VERIFICATION OF KNOWLEDGE

This proformas facilitates the mentor being able to assess and document the knowledge base of the individual and the practical skills required to enable management of the patient’s injuries e.g. insertion of local anaesthetics, wound closure, removal of foreign bodies and interpretation of assessments such as x-ray, reflex testing.

Communication with patient

• Awareness of cultural and ethical factors

• Ability to perform clinical examination or procedural skill

• Consideration of patient and professionalism demonstrated

Name & Qualifications

Skill or knowledge being assessed:

please indicate achievement

needs further development competent excellent

Give rationale for & evidence to support decision

Assessors name (print) Designation & Qualifications Assessing Qualification Signed

Date

Abbreviations: mi: mini-cex; C/CbD: case based discussion; MSF/M: multisource feedback, D/DOPS: direct observations procedural skill, PS: patient survey, AA: Audit assessment tool.

Page 108

ENP DOCUMENTATION ASSESSMENT AUDIT

In the curriculum, the learner is expected to undertake at least 1 audit of their own work using one of the audit proformas. These proformas have also been found useful for mentors to assess the documentation and be able to detail the number of cases have reviewed providing robust evidence of assessments undertaken.

For all uses, the proforma provides standardisation, enable excellence to be recognised and for any deficits an action plan for improvement developed.

The following audit forms have been developed to enable the practitioner to evaluate their record keeping:,

“ The quality of your record keeping is a reflection of the standard of your professional practice. Good record keeping is a mark of the skilled and safe practitioner, whilst careless or incomplete record keeping often highlights wider problems with the individual’s practice” (2005) .

 Hand and wrist

 Elbow

 Shoulder

 Knee

 Ankle & foot (below knee)

 Facial injury which includes nasal injury

 Head injury

 Eye injury

 Wounds

The following are still to be developed: neck injury, back injury, truncal injury.

Each proforma has been developed to meet the requirement of the most common injuries, it is recognised that not all components are required for each case e.g. a patient who sustains a direct blow to their hand would not normally require an assessment from their SCJ to fingertip, but standard practice would indicate that they require an

assessment from joint above to joint below; therefore the individual using the form has to determine what is necessary and be able to rationalise why other components were not used.

Anecdotally it has been reported by the mentors that these work well in practice and that these also act as a

reminder for their own record keeping.

Abbreviations: mi: mini-cex; C/CbD: case based discussion; MSF/M: multisource feedback, D/DOPS: direct observations procedural skill, PS: patient survey, AA: Audit assessment tool.

Page 109

HAND/WRIST

1 2 3 4 5 6 7 8 9 10

ENP Initials

Printed Name

Signature

Date

Time

PC Clear

HPC Context

MOI

Time Since Injury

Hand Dominance

Occupation

Pain Score & Analgesia

PMH

DH

Allergies

Tetanus

HITS /Protection Assessment

Examination: Look Diagram

Deformity

Bruising

Swelling

Wounds

Infection

Lymphangitis

Cascade Of Fingers

Examination: Feel

Radial Pulse / CRT

Sensation Radial, Median, Ulna

Axillary Nerve

Bony Tenderness Phalanges

Metacarpals

Scaphoid, ST & Telescoping

Other Carpals

Distal Radius/Ulna Inc Styloids

Shaft Radius & Ulna

Elbow 4 Points

Humeral Head Neck & Shaft

SCJ, ACJ, Scapula

Examination: Move

Phalanges: F/E/Fist/FDS/FDP/

Extensors

2 To 5 MCPJ: F/E/Abd/Ad

1st MCPJ:F/E/Abd/Add/Opp

Tip & Base Little Finger

IPJ Thumb: F/E

Finkelstein Test

Pincer Grip

Wrist: DF/PF/UD/RD

Elbow: F/E/S/P

Shoulder: F/E/Abd/Ad/H- Abd/

H-Add/IR/ER/ Apley Scratch

Impression

Appropriate X-Ray

Clear Interpretation Of X-Ray

Diagnosis Made

Appropriate Treatment

Appropriate After Care: Follow Up

Verbal

Patient Information Leaflet

Abbreviations: mi: mini-cex; C/CbD: case based discussion; MSF/M: multisource feedback, D/DOPS: direct observations procedural skill, PS: patient survey, AA: Audit assessment tool.

Page 110

ELBOW

1 2 3 4 5 6 7 8 9 10

ENP Initials

Printed Name

Signature

Date

Time

PC Clear

HPC Context

MOI

Time Since Injury

Hand Dominance

Pain Score & Analgesia

PMH

DH

Allergies

Tetanus

HITS/Protection Assessment

Examination: Look Diagram

Deformity

Bruising

Swelling

Wounds

Infection

Lymphangitis

Examination: Feel

Radial Pulse

Sensation Radial, Median, Ulna

Bony Tenderness Metacarpals

Scaphoid, ST & Telescoping

Distal Radius/Ulna Inc Styloids

Shaft Radius & Ulna

Medial Epicondyle

Lateral Epicondyle

Olecranon

Radial Head

Humeral Head Neck & Shaft

SCJ, ACJ, Scapula

Examination: Move

Elbow: F/E/S/P

Wrist: DF/PF/UD/RD

Shoulder: F/E/Abd/Add/ H-

Abd/H-Ad/IR/ER/ Apley Scratch

Impression

Appropriate X-Ray

Clear Interpretation Of X-Ray

Positive X-Ray Finding

Diagnosis Made

Appropriate Treatment

Appropriate After Care: Follow Up

Verbal

Patient Information Leaflet

Abbreviations: mi: mini-cex; C/CbD: case based discussion; MSF/M: multisource feedback, D/DOPS: direct observations procedural skill, PS: patient survey, AA: Audit assessment tool.

Page 111

SHOULDER INJURY

1 2 3 4 5 6 7 8 9 10

ENP Initials

Printed Name

Signature

Date

Time

PC Clear

HPC Context

MOI

Time Since Injury

Hand Dominance

Pain Score & Analgesia

PMH

DH

Allergies

safeguarding Assessment

Examination: Look Diagram

Deformity

Bruising

Swelling

Wounds

Examination: Feel

Radial Pulse

Sensation Radial, Median, Ulna

Regimental Badge

Bony Tenderness

SCJ, ACJ & Clavicle

Scapula

C/Spine

Humeral: Head / Neck

Humeral Shaft

4 Points Elbow

Scaphoid, ST & Telescoping

Length Radius/Ulna Inc Styloids

Carpal Bones

Metacarpals

Examination: Move

Shoulder :F/E/Abd/Ad/ H-abd/Had/IR

/ER/ Apley Scratch

C/Spine: F & L Flexion, Ext, Rotation >

45

Elbow X 4

Impression

X-ray Justified

X-ray Interpreted

Diagnosis Made

Appropriate Treatment

Appropriate After Care: Follow Up

Verbal

Patient Information Leaflet

Abbreviations: mi: mini-cex; C/CbD: case based discussion; MSF/M: multisource feedback, D/DOPS: direct observations procedural skill, PS: patient survey, AA: Audit assessment tool.

Page 112

ANKLE / FOOT / BELOW KNEE

1 2 3 4 5 6 7 8 9 10

ENP Initials

Printed Name

Signature

Date

Time

PC Clear

HPC Context

MOI

Time Since Injury

Pain Score & Analgesia

PMH

DH

Allergies

Tetanus

Safeguarding Assessment

Examination: Look Diagram

Deformity

Bruising

Swelling

Wounds

Infection

Lymphangitis

Examination: Feel

Pulses Dorsalis Pedis

Posterior Tibialis

Sensation

Bony Tenderness MTs 1 - 5 Inc 5th Styloid

Tarsal Bones X 7

Ankle: MM & LM

Tibia & Fibula IncShaft &

Head/Neck Fib

Calf/Achilles Tenderness

Examination: Move

Flexion

Extension

Inversion

Eversion

Ant Drawer/Tilt Test

Symonds Test

Mantles

Impression

Appropriate X-Ray Meets Ottawa Rules

X-ray Interpreted

Diagnosis Made

Appropriate Treatment

Appropriate After Care: Follow Up

Verbal

Patient Information Leaflet

Abbreviations: mi: mini-cex; C/CbD: case based discussion; MSF/M: multisource feedback, D/DOPS: direct observations procedural skill, PS: patient survey, AA: Audit assessment tool.

Page 113

KNEE INJURY

1 2 3 4 5 6 7 8 9 10

ENP Initials

Printed Name

Signature

Date

Time

Age > 55 Female

PC Clear

HPC Context (consider hip inj/complaint)

MOI

Time Since Injury

Locking Before / After Injury

Giving Way Before/ After Injury

Pain Score & Analgesia

PMH

Previous Knee Injury

DH

Allergies

Tetanus

Safeguarding Assessment

Examination: Look Diagram

Deformity

Bruising

Swelling

Onset of swelling

Effusion

Onset of effusion

Wounds

Infection/Lymphangitis

Examination: Feel

Pulses Dorsalis Pedis

Posterior Tibialis

Sensation

Bony Tenderness Patella

Joint Margin

Femoral Condyles

Tibial Plateau

Tibial Tuberosity

Fibula Head & Neck

Shaft Tibia / Fibula & Femur

Other Feel Anterior Joint

Posterior Joint

Patella Tendon

Ligament/Other Testing MCL / LCL @ 0 & 30°

ACL/PCL Lachman & Drawer

Grinding Test

Examination: Move SLR

Flexion

Extension

Rotation of hip @ 90 flexion

Impression

Appropriate X-Ray Meets Ottawa Rules

Clear XR Interpretation

Diagnosis Made

Treatment Appropriate

Appropriate After Care: Follow Up

Verbal advice

Patient Information Leaflet

Abbreviations: mi: mini-cex; C/CbD: case based discussion; MSF/M: multisource feedback, D/DOPS: direct observations procedural skill, PS: patient survey, AA: Audit assessment tool.

Page 114

FACIAL/HEAD INJURY

1 2 3 4 5 6 7 8 9 10

Printed Name

Signature

Date

Time

PC Clear

HPC Context

MOI

Time Since Injury

Loss Of Consciousness

Otorrhoea

Rhinorrhoea

Seizures

Headache

Vomiting

Amnesia Pre Injury

Bite Affected

Paraesthesia

Vision affected: Diplopia/

blurred Neck pain

Pain Score & Analgesia

PMH / DH / Allergies Coagulation state

Safeguarding Assessment

Examination: GCS

Pupil Reaction

Spo2

Vital Signs

Examination: Look Diagram

Panda Eyes

Battles Sign

Deformity

Swelling

Septal Haematoma

Gingival Haemorrhage

Haemotympanium

Wounds

C/Spine Central

Shoulders In Alignment

Examination: Feel: sensation

Bilateral: forehead, cheek,

mandible, bottom lip

Bony Tenderness Skull Boggy swelling

Cervical Spine

Orbits

Maxilla

Mandible

Zygoma

Nasal Bones

Cranial Nerves II - XII

Examination: Move Rotation L & R (>45°)

Forward Flexion

Lateral Flexion L & R

Extension

Eyes: H movement

Impression / Diagnosis

Appropriate Treatment

Appropriate After Care: Follow Up

Verbal

Head injury PIL given

Abbreviations: mi: mini-cex; C/CbD: case based discussion; MSF/M: multisource feedback, D/DOPS: direct observations procedural skill, PS: patient survey, AA: Audit assessment tool.

Page 115

EYE INJURY

1 2 3 4 5 6 7 8 9 10

ENP

Printed Name Signature Date Time Age Sex Occupation PC

HPC: Context Of Injury

Time Since Injury Mechanism Of Injury Blurred Vision Double Vision Pain Score & Analgesia

PMH DH Allergies Tetanus

SH: Accompanied By

Safeguarding Assessment O/E:

Visual Acuity Eye Washout pH

Look: Picture:

External Eye Sub-Tarsal

Conjunctiva & Sclera Limbus

Iris Cornea

Pupils: Size Contour Move: Movements Of Eye 'H'

Fluorescein Stain & Findings Eye Washout (If Appropriate) Impression / Diagnosis Appropriate Treatment

Plan:

Discharge

Patient Information Leaflet

Abbreviations: mi: mini-cex; C/CbD: case based discussion; MSF/M: multisource feedback, D/DOPS: direct observations procedural skill, PS: patient survey, AA: Audit assessment tool.

Page 116

WOUND

1 2 3 4 5 6 7 8 9 10

Printed Name

Signature

Date

Time

PC Clear

HPC Context

MOI

Time Since Injury

PMH

DH

Allergies

Tetanus

Pain Score

Safeguarding Assessment

Examination:

Look Diagram

Size

Site

Lay eg Transverse

Active Bleeding

Dermis Breached

Base Of Wound Visible, no

deep structures involved

Bruising

Signs Of Infection

Lymphangitis

Examination:

Feel

Vascular

Status Distal To Wound / CRT

Sensation Deficit Distal To Wound

Examination:

Move Distal To Wound

Ligaments Stressed

Tendons Intact

Impression

Appropriate X-Ray

Clear Interpretation Of X-Ray

Diagnosis Made

Treatment Wound Cleaning Solution

Local Anaesthetic

Wound Closure Method

End Result e.g. good opposition

Primary Dressing

Secondary Dressing

Method For Securing

Sling If Appropriate

Appropriate After Care:

Follow Up

Verbal - Sepsis & Wound

Management

Patient Information Leaflet

Abbreviations: mi: mini-cex; C/CbD: case based discussion; MSF/M: multisource feedback, D/DOPS: direct observations procedural skill, PS: patient survey, AA: Audit assessment tool.

Page 117

CHEST INJURY

1 2 3 4 5 6 7 8 9 10

ENP Initials

Printed Name

Signature

Date

Time

PC Clear

HPC Context

MOI

Time Since Injury

Pain Score & Analgesia

PMH

DH

Allergies

Tetanus

Safeguarding assessment

Full vital signs: temperature, pulse, resps, BP, oxygen sats,

Examination: Look Diagram

Deformity

Bruising

Swelling

Bilateral equal expansion Trachea central Flail segment

Wounds/abrasions

Examination: Feel (bony

tenderness and crepitus) SCJ, Clavicle, ACJ

Sternum Ribs (posterior,

anterior and lateral)

Bilateral equal

expansion

Stress rib cage lateral

& AP

Thoracic spine

Abdo: tender & rigid

Breath sounds Equal air entry

wheeze

crackles

Impression

Appropriate X-Ray (if able to

request)

X-ray Interpreted (if

appropriate)

Diagnosis made

Appropriate Treatment

Appropriate After Care: Follow Up

Verbal

Patient Information

Leaflet

Dalam dokumen Welsh Emergency Nurse Practitioner (Halaman 100-143)