Medical-Surgical Nursing ( PDFDrive.com ).pdf

This book is designed to provide a broad overview and practical understanding of principles related to adult nursing. Using a systems approach, the book is designed to provide a comprehensive application of relevant anatomy and physiology that will inform the medical and surgical practice of nursing.

Acknowledgements

Common Principles Underlying Medical and Surgical Nursing Practice Chapter 1 Principles of nursing assessment
Principles of intravenous therapy
Principles of nutritional care
Principles of perioperative nursing
Principles of high-dependency nursing
Principles of emergency nursing
Nursing care of conditions related to the skin
Nursing care of conditions related to the respiratory system Anne Marie Corroon, MSc, PGDip Ed, RGN, Assistant Professor
Nursing care of conditions related to the circulatory system Kate Olson, MA, PG Dip, RN, RNT, Senior Lecturer
Nursing care of conditions related to the digestive system Joanne Cleary-Holdforth, MSc, BSc, RGN, RM, Lecturer
Nursing care of conditions related to the urinary system
Nursing care of conditions related to the neurological system
Nursing care of conditions related to haematological disorders Mairead Ni Chonghaile, MSc, BNS, RGN, Transplant Co-ordinator
Nursing care of conditions related to the musculoskeletal system
Nursing care of conditions related to reproductive health Debra Holloway, MSc, BA (Hons), RGN, Nurse Consultant in Gynaecology

Mary Nevin, MSc, BNS (Hons), RNT, RGN, Clinical Nurse Instructor School of Nursing and Midwifery. Julia Kneale, MSc, BSc, RN, Senior Lecturer, Faculty of Nursing Faculty of Health.

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CourseSmart

Why – to explain the purpose of nursing assessment and why it is critical to the quality of patient care. The principles of nursing assessment presented in this chapter are consistent with national guidelines from the professional nursing council in Ireland, An Bord Altranais, and in Great Britain the Nursing and Midwifery Council (NMC).

The purpose of nursing assessment

The assessment is the first step in determining the patient's health status and their current and long-term needs. The patient's current problems (actual problems) and problems that may develop in the future (potential problems) must be identified so that the care plan can be tailored to the individual patient's needs.

Assessment frameworks

Obtaining information about the patient's medical history is essential to placing the current problem or illness in context (Kaufman 2008). The depth of patient assessment will depend on their condition and the urgency of the clinical situation (Tagney 2008).

Interviewing and obtaining a health history

Whether the patient lives alone or lives together, has an informal caregiver or provides care to someone else. Current community or home services – does the patient have home help or meals on wheels, attend a day center or receive support from a public health nurse (or community nurse) or other staff.

Physical examination

During the first meeting between a nurse and a patient, some patients may find it difficult to disclose problems and may be reluctant to do so until they know the nurse and have established a trusting relationship with her. For example, one helpful way for the nurse to communicate to the patient that there will be more opportunities to discuss problems is to say, "If you remember anything else later, let me know and we can chat then."

Clinical observation

A closing question such as 'Is there anything else we haven't covered that you would like to discuss?' enables patients to provide additional information.

Assessment tools

One useful way for the nurse to let the patient know that there will be further opportunities to discuss issues is by saying, for example. Another example of such a tool is the patient distress self-assessment tool developed by the National Comprehensive Cancer Network (2011) in America.

Rapid assessment of the acutely ill patient

Other assessment tools are used to identify patients at risk for, for example, developing pressure ulcers. Therefore, pressure ulcer risk assessment tools serve as a guide, but the nurse's own clinical judgment should also be considered.

Track and Trigger’

Depending on how acute or unstable the patient's condition is, some examples of rapid assessment systems are described here.

Alert®

Cardiopulmonary resuscitation

Documenting patient assessment and record-keeping

The information collected during an assessment when the patient is first admitted to hospital or visits an outpatient clinic for the first time should be recorded. Continuous or continuous patient assessment when monitoring to evaluate changes in a patient's condition under changing conditions should also be recorded and nursing actions documented.

Conclusion

A nursing assessment may also identify a patient's problems that should be referred for further evaluation by an appropriate health care professional, such as a physical therapist, dietitian, social worker, speech therapist, or occupational therapist. The implications for practice are therefore the following: if documentation is to serve as a key communication tool between nurses and other caregivers for sharing information gathered during assessment, care must be taken to ensure that there are no gaps in the documentation of patient assessment. .

The importance of nursing documentation is emphasized by policy makers and professionals in Ireland (An Bord Altranais, 2002), the UK (NMC, 2009) and internationally (Wang et al. 2011). However, evidence from a review of quality audits of nursing documentation in current clinical practice has revealed some shortcomings (Wang et al. 2011).

Introduction

Drug formulation

Excipients

Liquids and solids

How the body handles drugs: Pharmacokinetics

Absorption

Drug administration

15Crushing or breaking tablets

The fat content of the meal may also be important, either because the drugs dissolve in fat (e.g. isotretinoin) or because fat stimulates bile secretion, which increases drug absorption (e.g. griseofulvin) (Schmidt & Dalhoff 2002). For example, calcium-enriched orange juice impairs the absorption of fluoroquinolones (Neuhofel et al. 2002).

Distribution

For example, tetracyclines are not absorbed in the presence of calcium-containing foods such as dairy products and digoxin is not absorbed with a high-fiber meal. For most medications, it is important to maintain a constant relationship between medication and meals so that plasma concentrations of the drug do not vary from day to day.

Drug elimination

Visit www.wileyfundamentalseries.com/medicalnursing and read Reflective Question 2.2 to think more about this topic. Visit www.wileyfundamentalseries.com/medicalnursing and read Reflective Question 2.3 to think more about this topic.

Drug excretion

To maintain the drug's concentration within the therapeutic range, the dosing interval for many drugs is approximately one half-life. The time it takes to reach steady state is 4-5 times the drug's elimination half-life (Endrenyi 2007).

Therapeutics

National Patient Safety Agency (2010) Preventing Dose Loading Fatalities: Rapid Response Report NPSA/2010/. Retrieved May 31, 2011 from http://www.nrls.npsa.nhs.uk/patient-safety-data. 2002). 2006) Pharmacological and clinical aspects of the use of antiepileptic drugs in the elderly. 2008) systematic review of nursing administration of medication via enteral tubes in adults.

Anatomy and physiology of the veins

Parenteral therapy is the administration of drugs or fluids by any route other than the oral or rectal route and includes the intravenous and subcutaneous routes (Royal College of Nursing [RCN] . 2010). Intravenous therapy is now an integral part of the professional practice of most nurses and requires knowledge and skills (RCN 2010).

Veins of the peripheral circulation

Veins of the central venous circulation

Overview of vascular access devices

Administration of intravenous therapy

Preparation of intravenous therapy

Administration of the drug by intermittent infusion can be via a 'Y' set or can be piggybacked (via a needle-free injection port) or a burette set with a chamber capacity of 100 or 150 ml, but only if the primary infusion is of sufficient quality. a compatible fluid (Turner & Hankins 2010). They are usually used when maximum concentration of the drug in the vital organs is required.

Principles of administration

Drug delivery by direct injection can be via cannula through a resealable needleless injection cap, through an extension set, or through the injection site of an administration set if the ongoing infusion is compatible in order to further dilute the drug and to reduce the local chemical. irritation (Dougherty & Ansell 2011). If the infusion fluid is incompatible with the drug, the administration set can be switched off and a compatible solution can be used as a flush (NPSA 2007).

Infusion devices

The volume for infusion is limited to the size of the syringe used in the device, usually a 60 ml. The plunger of the syringe is propelled forward by the pump at a controlled rate and is calibrated in milliliters per hour (MHRA 2010).

Principles of infection prevention

These devices are often used for symptom management and palliative care (Dickman et al. 2007; Quinn 2008). Care should be taken when prescribing a syringe driver as they have been implicated in medication errors (Dickman et al. 2007; NPSA 2010).

Cleaning of the site

Intermittent infusion sets should be discarded after each use and should not be hung up to avoid reuse (Pratt et al. 2007; RCN 2010). Blood sets should be changed at least every 12 hours and after every other unit of blood (McClelland 2007; Pratt et al. 2007; RCN 2010).

Maintaining a closed intravenous system

Administration sets should be changed depending on the way they are used (intermittent or continuous therapy), the type of device and the type of solution. Administration sets used for lipid emulsions and parenteral nutrition should be replaced at the end of the infusion or within 24 hours of the start of the infusion (Pratt et al. 2007; RCN 2010).

Maintaining patency

If the vascular access device is replaced, all tubing must also be replaced (Pratt et al. 2007). All solution administration sets and stopcocks used for continuous infusions should be changed every 72 hours unless clinically indicated, for example, when drug stability data (insulin leaching into plastic) indicate otherwise.

Managing complications

Phlebitis

Prevention includes appropriate device and vein selection and further dilution of medications, along with regular site monitoring (Jackson 1998; Lamb & Dougherty 2008; Morris 2011). If bacterial phlebitis is suspected, the insertion site should be swabbed and the cannula tip sent to a microbiology laboratory (Lamb & Dougherty 2008).

Infiltration and extravasation

Bacterial – when the site becomes contaminated due to poor hand washing or poor aseptic technique. The cannula is removed at the early signs of phlebitis, and hot or cold compresses can be applied to the affected area.

Thrombosis

Sepsis

Circulatory overload and dehydration

Speed shock

Blood transfusion therapy

2009) Aftercare and management of central venous access devices. eds), central venous catheters (pp. 221–37). Chichester: Wiley-Blackwell. 2009) Infiltration and extravasation: update on prevention and management. 2006) Central venous access devices: care and management. eds), Intravenous therapy in nursing practice, 2nd edn. eds), The Royal Marsden Hospital Manual of Clinical Nursing Procedures, 8th Edition (Chapter 16). eds), The Royal Marsden Hospital Manual of Clinical Nursing Procedures, 8th Edition (Chapter 18).

Nutritional screening and assessment

A balanced diet should provide sufficient nutrients in the form of energy, protein, vitamins and minerals that are needed to keep an individual healthy. During illness or following surgery, an individual's nutritional requirements may change and at these times ensuring adequate levels of nutrition is vital to provide the body with sufficient nutrients to aid recovery.

Nutritional screening

Nurses are responsible for ensuring that patients in their care receive the appropriate type and level of assistance necessary to ensure that their nutritional needs are met by the oral, artificial enteral, or parenteral route, as appropriate.

Nursing action plans

Nutritional assessment

A person's current nutritional status: their weight, when they last ate, and what constitutes their normal diet. This will affect the patient's ability to eat, and possibly the ability to obtain and prepare food.

Calculating nutritional requirements

Accurate fluid balance is essential so that changes in hydration status are not mistaken for changes in actual body weight. Dietary assessment: where the focus will be on an individual's actual intake from food, oral nutritional supplements, enteral nutrition, or parenteral nutrition.

Dietary guidelines

Effect of illness on nutrition

Medical condition

Side effects of medication

Psychological status

Other issues

Refeeding syndrome

Process of starvation

Antiemetics before meals. Constipation – treat as above. Offer food that is tasty, well presented and in small portions. Offer meals in a peaceful atmosphere. Poor oral hygiene Poorly fitting dentures that make eating difficult and can lead to mouth ulcers. Oral thrush (candida), which makes eating painful and affects the taste of food.

Effect of surgery on nutrition

Those patients who are classified as being at high risk of developing refeeding syndrome (box 4.3) should be restarted on a low protein and energy intake. Supplying such low levels of nutrition initially will very likely result in suboptimal fluid levels, and therefore supplemental intravenous fluids may be required.

Preoperative care

Postoperative care

Nutritional support

Supplementing oral intake

Nursing responsibility for oral nutrition

Enteral tube feeding

Providing an adequate and timely level of nutritional support is essential to maximize the patient's nutritional status and recovery from illness. Just as nutritional support is increased according to a step-by-step approach, it makes sense to decrease it according to the same approach.

Parenteral feeding

However, it is essential to consider the risks associated with artificial nutritional support as the provision of nutritional care via enteral or parenteral feeding tubes is not without complications. Therefore, the balance of risk versus benefit must be considered for each patient before starting nutritional support.

Physiology associated with infection

Infection prevention and control is a fundamental element of nursing practice, and all health care professionals have a responsibility to adhere to evidence-based guidelines for infection control in clinical settings. A healthcare-associated infection is defined as “a localized or systemic condition resulting from an adverse reaction to the presence of an infectious agent or its toxins and.

Colonisation versus infection

Transmission of infection

Port of exit: any body opening that allows an infectious agent to escape (eg, mouth, nose, rectum, or break in the skin). Portal of entry: any body opening that allows entry of an infectious agent (eg nose, mouth, eyes, mucous membranes, a surgical or non-surgical break in the skin, or medical devices such as urethral catheters that bypass the body's natural defenses).

Overview of common microbiology and pathogenic organisms

Bacteria

Viruses

Fungi

Frequently encountered pathogenic microorganisms

Methicillin-resistant Staphylococcus aureus

Glycopeptide-resistant enterococci

Other healthcare-associated infections: Clostridium difficile

Infection control principles

Standard precautions

Patient placement Empiric precautions

Patient movement and transfer

Hand hygiene

Before touching
Before clean/
After touching a
After touching patient

To protect you from colonization with patient/client germs that may be present on surfaces/objects in the patient's environment and to protect the healthcare environment from bacterial spread. Clean your hands after touching an object or furniture when staying in the patient's environment without touching the patient/client.

PPE for healthcare workers

Clean your hands immediately before accessing a critical site of infectious risk to the patient (eg, a mucous membrane, non-intact skin, an invasive medical device) 3. Clean your hands as soon as the task that involves a risk of exposure to body fluids, is completed (and after glove removal).

Asepsis

Decontamination

Decontamination of the environment

Equipment

Equipment must always be cleaned before maintenance and must be marked with a decontamination certificate indicating this. It should only be used on an individual patient during a single procedure and then discarded.

Dishes and eating utensils

On the packaging of medical devices and equipment there is a sign "for single use only" (Figure 5.7). A medical device intended for use on a single patient, such as a nebulizer tube, means that the device can be used for more than one episode of use on only one patient.

Uniforms

The Medicines and Healthcare Products Regulatory Agency advises that a device intended for single use only should not be reused.

Laundry and linen

Healthcare waste management

Sharps waste management

Isolation of patients

Transmission-based precautions

Droplet precautions (Table 5.4) are applied, in addition to standard measures, to prevent transmission of infectious agents spread through close respiratory or mucous membrane contact with respiratory droplets (i.e. droplets of large particles of larger size than 5 µm generated by coughing, sneezing or talking). Airborne precautions (Table 5.4) apply, in addition to standard precautions, to prevent the transmission of infectious agents that are transmitted from person to person via the airborne route.

Isolation signs

Contact precautions are used to prevent transmission of epidemiologically important organisms that are spread by direct or indirect contact, for example multidrug-resistant organisms such as MRSA (Table 5.4). Examples of infections for which airborne precautions should be used are infectious pulmonary and laryngeal tuberculosis during sputum-inducing procedures, multidrug-resistant pulmonary tuberculosis, chicken pox (varicella zoster virus), measles (rubella virus), infection with rubella (German measles virus) hemorrhagic fever (Lassa, Ebola, Marburg and Crimean-Congo viruses).

Care bundles

The patient area and the area surrounding the patient should be cleaned daily in the normal manner. In accordance with contact precautions, the patient must wear a respirator when leaving the room.

Caring for people in later life

In light of this demographic growth, it is suggested that 'older adults are now the primary business of hospital care' (Mezey et al. 2006, p. 2). Older people have complex health needs arising from the interplay of acute and chronic problems, including syndromes particularly relevant to later life (Inouye et al. 2007).

Older people in the acute care setting

Specifically, older people are at greater risk of the following when hospitalized (Hickman et al. 2007; Eliopolous 2010): Therefore, the provision of acute nursing care for older people is multifaceted and includes the facilitation of transitions across the continuum of care.

Nursing assessment and the older adult

The older person should be involved in planning and evaluating his or her care throughout the hospital stay. The assessment should also include the older person's family or carer, in line with the relationship-centred approach to care mentioned earlier.

Care of the older person with confusion in the acute care setting

Effective communication is essential to ensure that there are no misunderstandings about the elderly person's needs and wishes, and to avoid that the patient becomes tired of the investigation process. Referrals must be made after consultation with the patient and with respect and support for the person's right to make decisions and accept or refuse treatment.

Definition

The presence of dementia or delirium creates particular challenges for older people, families/carers and staff in a context focused on acute problems and technological aspects of care. One of the most challenging aspects of dementia care often encountered by nurses in the acute setting is caring for people who exhibit challenging behaviour.

Medications and the older person

Each patient's cognitive functioning should be assessed as an integral part of the overall assessment process described earlier. Polypharmacy is “prescribing, administering, or using more drugs than are clinically indicated for a given patient” (Charles & Lehman 2010, p. 262).

Falls and fall prevention

Medications for the Elderly: Implementing the Medication-Related Aspects of the NSF for the Elderly. Nursing challenges for older people in acute care. 2007) User participation in health and social care research: voices, values and evaluation.

The nature of dying

This is a time of stress not only for the patient who is dying, but also for the patient's family as they come to terms with their impending loss. Having an awareness of these situations potentially contributes to the quality of care for the patient and family members.

Comfort at the end of life

It is a part of life that brings with it many challenges, not only for the person who is dying, but also for the family and staff who care for the dying person. It is not uncommon for the dying patient to feel lonely and isolated, which increases the need for members of the interdisciplinary field to increase their sensitivity to each individual situation.

Dyspnoea

For the purposes of this chapter, the following sections will provide an overview of the management of dyspnea, death sounds, and pain.

93Benzodiazepines

Death rattle

Hyoscine hydrobromide should be used with caution in the treatment of a fatal convulsion because of its tendency to induce drowsiness as it crosses the blood-brain barrier. Evidence suggests that initiation of anticholinergic drugs before the onset of a fatal stroke is important for its successful pharmacologic management.

Pain and pain management in the last 48–72 hours of life

If the patient has adverse side effects of morphine, an alternative opioid can be used. If the patient has acute renal failure, another opioid may be more appropriate.

Communication at the end of life

Responding to the patient's feelings Identify and accept the patient's response Planning and follow-up Planning for the future. Enjoying the remaining time with the family member Preparing for death Fulfilling the patient's wishes.

Ethics and end of life care

The problems associated with the decision whether to withdraw or withhold artificial nutrition or hydration in patients nearing the end of life are influenced by the patient and their family, together with the ethical and moral values of the health care professionals involved. The use of antimuscarinic drugs in the management of death rattles: evidence-based guidelines for palliative care. 2000).

General issues and anaesthesia

It provides basic information about the role of the theater practitioner and covers three areas of perioperative practice (anesthesia, scrubbing and recovery) and the delivery of effective patient care. The role of a perioperative physician (nurse or operating room physician) is multifaceted as it includes clinical care, advocacy, risk management, and quality assurance.

Preoperative assessment

Preparation of the environment

Forced air warming suits, such as the Bair Hugger (Arizant Inc, MN, USA), and the more conservative approach of additional cotton blankets and foil wrap insulation are options. Active warming of the patient includes warming of intravenous fluids and the use of either an electrically powered heating mattress or a forced air heating system.

Patient safety

Consent required by junior staff Wrong side/site marked on patient Error reading case notes. Error on operation sheet Error on consent Error in case notes.

Anaesthesia

Before any intervention, the patient will be connected to basic monitoring equipment, usually non-invasive blood pressure, oxygen saturation and electrocardiography. Wrong side listed on the operating list Error in recording the decision in the case notes Error in the operating list.

Endotracheal intubation

Laryngeal mask airway

Patients are rendered unconscious by the administration of an intravenous induction agent or by inhalation of an anesthetic vapor (gas induction). Before administering the induction drug, the anesthetist will often (except with rapid sequence induction or if a difficult airway is expected) give an opiate, usually fentanyl.

Laryngoscopy

It is inserted down the right side of the tongue, displacing it to the left. The third element of the triad - analgesia - is required to prevent the patient's sympathetic nervous system from responding to the painful stimulus.

Roles of circulating and scrub practitioners

Aseptic technique/infection control

Wet dusting is the cleaning of flat surfaces (eg trolley surfaces, work surfaces and anesthesia machines) to remove dust from the perioperative environment prior to the start of the operating list (Gruendemann & Mangum 2001). Ventilation, temperature and humidity levels are checked every morning by scrub and circulating doctors before the start of the operating list.

Accountability

Scrubbers and the surgical team should follow their theater policy for their scrubbing procedure. All forms of hand washing and use of personal protective equipment (PPE) can reduce the risk of hospital-acquired infection and infections at the surgical site.

The sterile field

Patient positioning

Surgical sutures

Surgical needles

Surgical dressings

Surgical drains

Surgical instruments

Surgical specialities

Recovery

Are the patient's chest movements symmetrical? see the text for more information about the early warning score). Is the patient bradycardic (<50 beats per minute) or tachycardic (>100 beats per minute).

Postoperative nausea and vomiting

Pain management

All medications administered in the recovery area must be documented in the patient's recovery plan. Smith, C. (2005) Care of the patient during surgery. 2001) Validation of modified early warning scores in medical admissions.

The high-dependency environment

Critical care is essential and costs the National Health Service (NHS) over £700 million per year (Department of Health 2010). It is also widely recognized that the cost of critical care has continued to rise.

Current policy in high-dependency care

The National Institute for Health and Clinical Excellence (NICE) (2007) guidelines for the care of adults with acute illness provide evidence-based recommendations for the recognition and management of acute illness in the hospital setting. NICE (2007) also endorsed the recommendation of the National Critical Care Forum (2003; National Information Forum and Critical Care Stakeholder Forum 2007) for a physiological 'Track and Trigger' system.

Technological developments in high-dependency care

Trace and trigger scores are sometimes referred to as early warning scores, modified early warning scores, or even patient risk scores. In the UK, a national NHS score (NEWS) is currently being developed and undergoing a period of consultation (Prytheron et al. 2010).

The role of the nurse as a member of the high-dependency team

Nursing assessment and monitoring of the highly dependent patient

Airway

Breathing

Circulation

Disability

Exposure

Respiratory assessment, monitoring and intervention

History-taking

Primary data Airway patency

In the chest, symmetry of movement and use of accessory muscles should be assessed (Epstein et al. 2003). Palpation is a sophisticated skill used to obtain data using touch, where the hands are used to compare both sides of the chest (Epstein et al. 2003).

Secondary data

Chest auscultation is a fundamental aspect of the respiratory assessment as it provides critical information about the condition of the lungs (Epstein et al. 2003). The diaphragm of the stethoscope is usually used to listen for breath sounds, while the bell is used for low-frequency sounds such as heart sounds.

Respiratory interventions Oxygen therapy

Cardiovascular assessment, monitoring and intervention

Primary data Inspection

Blood pressure refers to the pressure on the artery wall when the heart is either contracting (ventricular systole) or in the relaxation phase (ventricular diastole). There are many causes of hypotension that can affect the highly dependent patient, including hemorrhage, hypovolemia, sepsis, and shock (Dellinger et al. 2008).

Secondary data Central venous pressure

A manual reading will provide information about the regularity of the pulse and its strength and volume, but conditions such as atrial fibrillation may go undetected when the pulse is read from automated blood pressure monitors (Moore & Woodrow 2009). This can be useful in determining perfusion efficiency in vital organs such as the brain and kidney (Jevon & Ewens 2007).

Cardiovascular interventions Fluid replacement therapy

It is generally accepted that a urine output of more than 0.5 ml/kg per hour represents adequate renal perfusion. Inotropes are drugs that increase cardiac contractility and cardiac output, and drugs such as adrenaline, noradrenaline and dobutamine are commonly used to support the patient's blood pressure in HDU (Trim & Roe 2004).

Neurological assessment, monitoring and intervention

A maximum score of 5 indicates full orientation, while a score of 4 means the patient is confused. A score of 2 indicates abnormal flexion, which is often misidentified by nurses (Heron et al. 2001), and a score of 1 indicates no response to pain.

Neurological interventions Sedation

Intensive Care Society (1997) Standards for Intensive Care. 2004) Physical Examination and Health Assessment, 4th ed. 2010) ABCDE: evaluation of the critically ill patient. 2007) Management of the Mechanically Ventilated Patient, 2nd edn. 2010) ViEWS – towards a national early warning score for the detection of elderly deteriorating patients.

Historical context of emergency nursing

This chapter presents an overview of the role of the health care team in emergency care, rapid triage, and the very broad and diverse nature of the types of medical, surgical, social, and behavioral conditions treated in emergency departments (EDs). Ask your mentor or preceptor to demonstrate the systematic initial assessment and management of the trauma patient in a simulated clinical situation (although during trauma care training the sequence is presented in a longitudinal process of events, whereas in the actual clinical situation many of these activities occur simultaneously).

Triage

Triage is a brief face-to-face encounter rather than a consultation, should occur within 15 minutes of patient arrival or registration, and usually requires less than 5 minutes of contact (College of Emergency Medicine et al. 2011). The Manchester Triage Group has produced a list of presentation flow charts for virtually all conditions that present to the ED.

Common surgical emergencies

These flowcharts provide a framework by which the most appropriate clinical priority can be determined. Visit www.wileyfundamentalseries.com/medicalnursing and read Reflective Question 10.1 to think more about this topic.

Common medical emergencies

Patient assessment in the ED

Secondary assessment includes a review of the ABCDE and continues with the FGHI aspect of memory (Steinmann 2010; Box 10.2). A detailed history is taken either after this evaluation or simultaneously, depending on the patient's condition.

Advanced life support

A Airway (provide cervical spine support in trauma patients) – color of the patient, is the airway open?, is the patient in distress. C Circulation – patient color, heart rate, rhythm and force, blood pressure, capillary refill time, blood loss, urine output.

Assessment and stabilisation of emergency trauma conditions

Management of the critically injured patient requires rapid assessment and early intervention with life-saving therapy. The Advanced Trauma Life Support (ATLS) method was developed by the American College of Surgeons and provides a framework for the care of the trauma patient.

Minor trauma

The hallmark of the ATLS program is a systematic, concise approach to early care in the 'golden hour' after injury, and is characterized by the need for rapid assessment and resuscitation, which are its fundamental principles (American College ). or Surgeons 2004).

Burns

Calculate the required fluid replacement from the time of the burn and not from the patient's arrival in the ED – use 2–4 mL × the percentage of total body surface area burned × the patient's weight (kg). In case of burns to the hands or fingers, Flamazine is applied and the hand is placed in a burn bag (transparent plastic) to facilitate movement of the fingers.

Head injuries

All ED physicians involved in the evaluation of head injury patients should be able to assess the presence and absence of risk factors and the need for CT imaging (National Institute for Health and Clinical Excellence 2007). The evaluating physician should take a history, perform an examination, and, if necessary, refer the patient to radiology.

Follow-up on discharge

Assessment and stabilisation of adverse behavioural presentations

Care of the critically ill and dying patient in the ED

During a clinical internship, nursing students will experience or witness the emergency care of patients with a wide variety of acute and potentially life-threatening trauma injuries, acute medical/surgical, and behavioral problems. They will gain an understanding of the role of the nurse in the emergency care team and observe or participate in the skills of triage, rapid assessment, resuscitation, care of the dying/dead patient and support of family and friends.

The structure and function of the skin

This chapter provides an overview of the anatomy, physiology and related disorders of the skin. It consists of loose connective tissue and fat, which provides padding and protection of the bony prominences. As the individual ages, the elasticity and resilience of the skin is reduced (Waller & Maibach 2005).

Maintaining normal tissue integrity

Skin assessment

Setting and equipment

The patient’s history

Note other features such as itching, burning, scaling or blistering, whether the lesions are raised (papular) or flat (macular), ulcerated or pigmented, and whether the edges of the lesions are well defined. Also note the lesions for plaques, crusts, scabs, hives, bullae, pustules, cysts or vesicles (Cole & Gray-Miceli 2002).

Diagnosis

Hair and nail care – note the texture, colour, brittleness, hair loss and presence of parasites when assessing the hair; note the length, colour, symmetry, thickness and hygiene, as well as deformities, pitting and splinter bleeding when assessing the nails. Check the skin for colour, texture, temperature, moisture, erythema (redness), integrity, sensation and lesions (Figure 11.2).

Investigations

Treatments

Emollients

Topical steroids

Common skin diseases

Rashes

Some patients experience psychological distress, depression and low self-esteem due to the physical appearance of their skin (Green 2011). It is important for patients to understand that psoriasis is neither contagious nor curable, but phototherapy and systemic medications can help reduce flare-ups.

163Aetiology

It manifests as inflammation of the subcutaneous tissue, which may result in blistering (Trent et al. 2001). Many of the benign lesions do not require specific treatment, but observation is important to detect changes in the lesions.

Wound healing

Diagnosis is made by histopathological examination of a biopsy specimen of the lesion, as this is considered the gold standard for diagnosis (Freak 2005). For malignant lesions, treatment may include surgical excision, cryosurgery, radiation therapy, and photodynamic therapy, depending on the nature and severity of the lesion.

Early inflammation

Patients should be educated to maximize their ability to live with the condition, and it is important to emphasize that the condition is not contagious. Observation of lesions is also important here, particularly changes in size, shape, colour, bleeding or crusting (Freak 2005).

Late inflammation

Production of granulation tissue

Angiogenesis

Epithelialisation

Contraction

Remodelling

Wound assessment

Location

Size

Stage of the wound and depth of tissue involved

Wound edges and wound bed

It should be pale, moist and salmon pink in colour, and its presence indicates normal wound healing (Fletcher 2007). During assessment, the types and percentages of the different tissues within the wound bed should be documented.

Nature of wound drainage

Odour

Amount of pain or discomfort

Wound management

Surgical wounds

Principles of wound management

Pressure ulcers

The impact of external mechanical forces on tissue viability

Risk assessment

Pressure ulcer prevention Repositioning

Support surfaces

This can be in the form of a pressure redistribution pad, which should be chosen based on the individual needs of the patient. The patient should not be exposed to long periods of sitting outdoors, as this also increases the risk of developing a pressure ulcer.

Nutrition

Skin care

European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory Panel (2009) Prevention and Treatment of Pressure Ulcers: Quick Reference Guide. 2005) Enteral nutrition in the prevention and treatment of pressure ulcers: a systematic review and meta-analysis. 1996) Biochemical analysis of acute and chronic wound environments.

Anatomy and physiology

Chronic respiratory diseases are often associated with a negative impact on quality of life in terms of physical functioning, anxiety, depression and social isolation. Nurses are well placed to address the complex care needs required to improve the quality of life of these patients.

Function of the respiratory system

Respiratory tract

Mechanics of respiration

Control of respiration