Author: Claire

Claire Galea is the Owner and Director of Mariposa Holistic Care, through which she provides holistic care services tailored to her clients' personal needs. She is also in her final year following a Degree in Nursing at the Faculty of Health Sciences, University of Malta. Claire is keen about public education on health-related subjects as well as holistic patient-centered care. She is also passionate about spreading positivity and awareness on various subjects through her blog Student Nurse Life.

First Aid Principles

As mentioned in our introduction to first aid blogpost, the most important first aid principles include preserving life, preventing complications, and promoting recovery. It is as important however to mention that in the case of danger to self, first aid may just be about calling for further assistance. You should avoid ending up a casualty yourself!

Hereunder we are going to cover some of the most common scenarios where first aid principles can be applied…

Unresponsive but Breathing Casualty

A person can become unresponsive when there is an interruption of normal brain activity. This leads to loss of awareness. Common conditions that may cause unresponsiveness include:

ABC compromise that leads to hypoxia
hypoglycaemia which leads to neuroglycopaenia (lack of glucose in the brain)
trauma to the head (brain)
poisoning (self-inflicted poisoning, drug use, or poisoning through bites)
infections leading to life-threatening situations such as sepsis
illnesses/conditions such as a suffering a Myocardial Infarction
certain neurological disorders such as meningitis

First Aid Principles

open airway
check breathing
deal with any visible bleeding rapidly
perform a rapid head-to-toe assessment
remove any restrictive clothing whilst maintaining dignity where possible
place in the recovery position
attempt to maintain normal body temperature
attempt a secondary assessment based on what you can see and information you can gather from bystanders or present relatives
call emergency 112

Casualty Experiencing a Fainting Episode a.k.a. Brief Loss of Consciousness

Fainting a.k.a. syncopal episode or syncope is typically triggered by a sudden loss of blood flow to the brain, leading to loss of consciousness and loss of muscle control. Fainting is characterised by:

pale, cold, clammy skin (signalling lack of blood circulation)
slow pulse
usually regains consciousness again after a couple of seconds

First Aid Principles

Once casualty regains consciousness following a fainting episode:

remove tight clothing
elevate casualty’s legs to ensure better circulation and promote blood flow and oxygen to the brain
ensure that the area is ventilated well
identify possible cause
maintain casualty’s body temperature
provide reassurance
monitor ABCs
call for medical assistance as required

NOTE: following a fainting episode, tell the casualty to stand up very slowly so as to avoid recurrence.

Casualty Experiencing a Seizure

While seizures can result due to a disorder, they can be triggered by issues affecting the brain’s normal activity, such as in cerebral hypoxia (lack of oxygen in the brain), fever, and head trauma. Signs of a seizure include:

face twitching
lip smacking
staring spells
drooling / frothing at the mouth
producing abnormal sounds such as snoring and grunting
spasms that usually affect an individual limb
uncontrollable muscle spasms
convulsions

First Aid Principles

start timing the seizure
protect the casualty’s head by cushioning it
provide protection from any possible danger
remove any restrictive clothing if possible, maintaining patient dignity
DO NOT RESTRAIN CASUALTY
DO NOT ATTEMPT TO PUT ANYTHING IN THE CASUALTY’S MOUTH
note time when seizure stops
provide first aid as mentioned further above in the Unresponsive but Breathing Casualty section after seizure stops

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ERC Guidelines 2021 Excerpts on Adult Basic Life Support

The European Resuscitation Council has produced updated ERC Guidelines 2021 on adult basic life support with the aim of increasing confidence and encouraging individuals to act immediately when witnessing a cardiac arrest. Unfortunately, to this day, failing to recognise a cardiac arrest earlier on remains a barrier to saving more lives.

The following are excerpts from the ERC Guidelines 2021 which may help save lives. Link to the original document will be provided at the bottom of the article for full document reference.

How to recognise cardiac arrest

– Start CPR in any unresponsive person with absent or abnormal
breathing.

- Slow, laboured breathing (agonal breathing) should be considered a sign of cardiac arrest.

– A short period of seizure-like movements can occur at the start of
cardiac arrest. Assess the person after the seizure has stopped: if
unresponsive and with absent or abnormal breathing, start CPR.

High quality chest compressions

– Start chest compressions as soon as possible.
- Deliver compressions on the lower half of the sternum (‘in the centre of the chest’).
- Compress to a depth of at least 5 cm but not more than 6 cm.
- Compress the chest at a rate of 100-120/min with as few interruptions as possible.
- Allow the chest to recoil completely after each compression; do not lean on the chest.
- Perform chest compressions on a firm surface whenever feasible.
– Continue CPR until an AED (or other defibrillator) arrives on site and is switched on and attached to the victim.
- Do not delay defibrillation to provide additional CPR once the defibrillator is ready.

Rescue breaths

– Alternate between providing 30 compressions and 2 rescue breaths.
- If you are unable to provide ventilations, give continuous chest compressions.

When and How to use an aed

– As soon as the AED arrives, or if one is already available at the site of the cardiac arrest, switch it on.
- Attach the electrode pads to the victim’s bare chest according to the position shown on the AED or on the pads.
- If more than one rescuer is present, continue CPR whilst the pads are being attached.
– Follow the spoken (and/or visual) prompts from the AED.
- Ensure that nobody is touching the victim whilst the AED is analysing the heart rhythm.
- If a shock is indicated, ensure that nobody is touching the victim.
– Push the shock button as prompted. Immediately restart CPR with 30 compressions.
- If no shock is indicated, immediately restart CPR with 30 compressions.
- In either case, continue with CPR as prompted by the AED. There will be a period of CPR (commonly 2 min) before the AED prompts for a further pause in CPR for rhythm analysis.

Foreign Body Airway Obstruction

– Suspect choking if someone is suddenly unable to speak or talk, particularly if eating.
- Encourage the victim to cough.
- If the cough becomes ineffective, give up to 5 back blows:
1. Lean the victim forwards.
2. Apply blows between the shoulder blades using the heel of one hand
- If back blows are ineffective, give up to 5 abdominal thrusts:
1. Stand behind the victim and put both your arms around the upper part of the victim’s abdomen.
2. Lean the victim forwards.
3. Clench your fist and place it between the umbilicus (navel) and the ribcage.
4. Grasp your fist with the other hand and pull sharply inwards and upwards.
– If choking has not been relieved after 5 abdominal thrusts, continue alternating 5 back blows with 5 abdominal thrusts until it is relieved, or the victim becomes unconscious.
- If the victim becomes unconscious, start CPR.

References

European Resuscitation Council Guidelines 2021: Basic Life Support (2021). Retrieved from https://cprguidelines.eu/assets/guidelines/European-Resuscitation-Council-Guidelines-2021-Ba.pdf on 6th September 2022

European Resuscitation Council Guidelines 2021: Executive summary (2021). Retrieved from https://cprguidelines.eu/assets/guidelines/European-Resuscitation-Council-Guidelines-2021-Ex.pdf on 6th September 2022

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Emergency Nursing Practice – Introduction to First Aid

Emergency nursing practice requires the nurse to provide immediate emergency care and interventions to preserve the life of individuals experiencing acute illness or injury.

Emergency nursing practice aims to:

Preserve Life through identification and management of life-threatening conditions
Prevent Complications to avoid deterioration of patient’s condition (eg. choking, cardiac arrest, & bleeding)
Promote Recovery by providing reassurance and comfort to the patient, seeing that the patient gets medical attention, as well as managing pain through interventions such as immobilising a fractured limb

What is the 1st thing you should do in Emergency Nursing Practice?

Assess the situation from a distance and look out for any possible danger
Determine what the emergency is and the extent of the emergency eg. number of apparent casualties.

Then use the S.A.F.E. approach…

Safety Tips for Emergency Nursing Practice

BLEEDING – protect yourself from blood and other body fluids by using non-sterile gloves, or use non-touch technique eg. by holding the patient’s own hand onto the bleeding wound
HAZARDS – careful about things such as being in a busy road, being close to hazardous substances, or harmful situations; avoid becoming a casualty yourself!
CROWDS – be careful not to get pinned in!
AGGRESSIVE BEHAVIOUR – aggressiveness could be the result of non-organic problems such as due to current emergency

**Hazardous Substances** – Retrieved from https://www.principalpeople.co.uk/blog/2015/08/working-with-substances-that-are-hazardous-to-health on 3rd September 2022

Emergency Situations Requiring Special Attention…

CAR CRASH EMERGENCY – extra precautions include switching off the vehicle, pulling up the handbrake, removing the keys from ignition, and looking out for other vehicles
FIRE EMERGENCY – if fire has spreaded drastically, do not attempt to go in…call for assistance if it looks too dangerous
ELECTRIC SHOCK EMERGENCY – prior to attempting any first aid procedures, switch off the main and use a non-conductor to remove the electrical object in contact with the patient
DROWNING EMERGENCY – you are NOT expected to jump into the water to save a patient if not confident enough

Calling for an Ambulance

You should call an ambulance:

if you are dealing with a serious situation eg. car crash, fire emergency, and/or multiple casualties
if you are dealing with a situation where a life or a limb may be lost eg. difficulty breathing, severe chest pain, choking, and/or unconsciousness
if you are in doubt

If you are calling for an ambulance (Malta & Gozo):

dial 112
ask for an ambulance
stay calm
mention what happened, where it happened, and who you are
answer any questions in detail
DO NOT BE THE FIRST TO HANG UP!

The Vital Functions of the Human Body

The human body’s primary vital systems are the Respiratory (lungs), Circulatory (heart) and the Brain (oxygenated).

Retrieved from https://www.freepik.com/premium-vector/human-anatomy-internal-organ-set-with-brain-lungs-with-heart_13011199.htm on 4th September 2022

The respiratory system includes the Airway and Breathing
Circulation includes the Heart, Blood Vessels, and Blood
The Brain includes the Neurological aspect of it

Anything affecting the ABCD of the patient can be life-threatening, requiring prompt action so that life is preserved!

Airway Problems

obstruction by patient’s own tongue during unconsciousness period
foreign body obstruction in a choking patient
swelling of the airway due to an allergic reaction (anaphylactic shock) or inhalation of chemicals
facial trauma following a maxillofacial injury

NOTE: The tongue in an unresponsive casualty can easily obstruct the airway. Hypoglycaemia and overdose are the two main causes of airway obstruction by tongue.

Breathing Problems

compromised airway as mentioned above
respiratory issues such as asthma
cardiac issues such as congestive heart failure causing fluid build-up in the lungs
chest injuries eg. in which ribs are broken, which then puncture the lungs
environmental issues eg. strangulation, suffocation and/or drowning

Circulation Problems

compromised airway and breathing problems as mentioned above
internal bleeding
external bleeding
additional causes of shock
cardiac illness eg. cardiac arrest, congestive heart failure, or myocardial infarction

Neurological Problems a.k.a. Neurological Disabilities

compromised airway, breathing, and circulatory problems as mentioned above, leading to lack of oxygen in the brain and body
neurological disorders eg. cerebrovascular accident or central sleep apnea
brain injury following head trauma
hypoglycaemia (low blood glucose level)
poisoning
serious infections
serious illnesses that lead to organ failure

Assessing the Patient

Initial Patient Assessment

Immediately identify and address life-threatening (ABCD) problems with the aim of preserving life
Is the patient responsive? SHAKE & SHOUT & use AVPU scale
Is the patient unresponsive? Check if his airway is obstructed, perform head-tilt chin-lift maneuver
Is he breathing? Look, Listen & Feel!
Are there evident serious bleeding signs eg. blood on the floor, blood on chest, abdomen, pelvis, thighs? REMEMBER: 50% Blood Loss = Unconscious Patient!
Is the patient exhibiting signs of shock? (pale & cold, clammy skin; fast weak radial pulse, fast shallow breathing, weak & lethargic)

SHAKE & SHOUT – Retrieved from https://slideplayer.com/slide/4331579/ on 4th September 2022

UNRESPONSIVE & NOT BREATHING = START CPR IMMEDIATELY

SERIOUS BLEEDING = PUT PRESSURE ON THE WOUND TO STOP BLEEDING

Emergency Nursing Practice Techniques that help Clear Airway Obstruction

Manual techniques:

No side effects, no equipment required – use the head tilt chin lift technique or the jaw-thrust maneuver.

Simple Adjuncts:

Minimal side effects – use of a hollow tube that holds tongue in place.

ENDOTRACHEAL INTUBATION (eti):

A medical procedure in which a tube is placed in the trachea via the mouth or nose. If performed wrongly, this may kill the casualty.

Airways:

Ventilation of the larynx with a laryngeal tube or mask.

SOMETHING STUCK IN WINDPIPE = HEIMLICH MANEUVER

sECONDARY PATIENT ASSESSMENT

A secondary patient assessment is performed with the aim to identify conditions that can worsen the primary issue – the 4 B’s…

Breathing
Bleeding
Burns
Bones

A secondary patient assessment can be performed in the following order:

Step 1: Complaint – signs & symptoms

Step 2: Perform a head-to-toe assessment using the D.O.T.S. method:

Deformities
Open Wounds
Tenderness
Swelling

Step 3: Vital Signs – include an accurate respiratory rate and pulse rate

Step 4: History – use the acronym S.A.M.P.L.E.

Signs of Breathing Problems

Dyspnoea – check for visual breathing distress and use of accessory muscles
Noisy Breathing
Abnormal Breathing Pattern – notice the patient’s breathing rate and rhythm
Cyanosis – check for bluish discolouration of the patient’s skin due to lack of oxygen circulation in the body
Disorientation and Confusion
Unusual Aggressiveness
Respiratory Arrest a.k.a. respiratory failure – patient may stop breathing

Signs of Circulatory Problems

Pale, Cold, Clammy Skin
Internal / External Bleeding
Rapid Shallow Breathing
Fast OR Very Slow Pulse
Inability to Palpate Radial Pulse (located at the wrist)
Cardiac Arrest (heart stops pumping blood)

Signs of Neurological Problems

Weakness, Paralysis or Loss of Sensation within the Limbs
Assymetry within the patient’s Face
Unequal and/or Unreactive Pupils
Seizures
Disorientation or Confusion
Unusual Aggressiveness
Altered Level of Response (patient may also be drowsy)

Summary…

Check ABCs
Gather Signs & Symptoms
Head to Toe Assessment (D.O.T.S.)
Measure Vital Signs (RR & PR)
History (S.A.M.P.L.E.)

Retrieved from https://www.alucansa.com/showroom/?ss=5_6_4_26_36&pp=basic+first+aid+training&ii=2293819 on 5th September 2022

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Transcultural Nursing

In transcultural nursing, the nurse needs to be sensitive to cultural differences whilst focusing on the patients as individuals, with their own needs and preferences. Transcultural nursing requires that the nurse is respectful towards the patient’s culture by not being afraid to ask, listen to their beliefs, and provide related healthcare practices wherever possible.

Ethical Principles Related to Patient Respect

As members of the professions, nurses and midwives must:
1.1.1 Respect the dignity and individuality of patients
1.1.2 Respect the cultural needs and values of patients
1.1.6 Within their sphere of responsibilities, ensure that patients are given adequate, correct, and timely information in a culturally sensitive manner enabling them to make a free and informed choice towards the provision of their own care.
Council for Nurses and Midwives Malta (2020)

Standards of Professional Conduct

Nurses and midwives must:
1.2.1 …Respect individual differences that do not discriminate against patients based on religion, gender, sexual orientation, political, or other opinion, disability, age or any other factor.
1.2.2 Recognise and respect the uniqueness of every patient and adapt the care given according to the patient’s biological, psychological, social, emotional and spiritual status and needs.
1.2.5 Communicate with patients about their care plan and give them information in a manner they can understand. Nurses and midwives must make use of available services to ensure effective communication.
1.2.8 Ensure that political, religious, cultural or other belifs are not imposed on the patient. Nurses and midwives should intervene if they witness other health care members doing this.
Council for Nurses and Midwives Malta (2020)

Foreign Population Increase in Malta

Foreign population increase in Malta has multiple implications, including social composition of the community (specific material organisation of workers into a class society through the social relations of consumption and reproduction), as well as social cohesion (strength of relationships and the sense of solidarity among members of a community).

A 2019 study among health, education and social work professionals pointed the following challenges and concerns in this regard:

lack of knowledge amongst professionals
an overwhelming feeling by the existing diversity and multiple religions
anxiety in relation to fear of not wanting to offend another unintentionally
fear about one part or the other imposing one’s own customs / worldviews onto the other

Religious Composition of the Maltese Population

Whilst to date there is no official precise data about the religious composition of the Maltese population, it is believed that currently:

up to 94% are Catholic (including Greek Catholic, Coptic Catholic, and Syro-Malabar)
up to 7% are Muslims
Christian churches (Orthodox, Oriental, Anglican, Reformed, Evangelical / Pentecostal)
small religious communities (Buddhists, Baha’is, Hindus, Jews, Sikh, Neo-Pagan, and African Religions)

For a practical guide outlining the different needs of individuals coming from different backgrounds, check out the Living Together In Malta – Handbook.

Effective Transcultural Nursing

The key to effective Transcultural Nursing is to:

be aware of your own cultural and religious biases – your worldview is made up of your own language, religion, point of view, culture, and family traditions. It is how you view other individuals and the reality around you – your perception
do not make assumptions – people are different even within their own cultures and religions; do not label individuals – get to know the person individually
overcome language barriers – getting to know some words in different languages helps build a therapeutic relationship with the patients
get to know basic cultural and religious literacy – basic things may not appeal to all cultures…eg. in Islam, to greet a person of the opposite sex put your hand on your chest rather than a handshake; Hindus greet each other by saying the word Namaste, holding their hands in the Namaste position and touching their forehead as a sign of respect
understand that all groups are heterogeneous (different) – diversity between people practicing the same religion or culture
build trust between you and the patient – show interest in their culture and religion, and assist where necessary, so they can practice their beliefs/culture, whenever possible
be prudent – show that you care for the patient with their own individuality
listen and discuss with the patient – build a therapeutic nurse-patient relationship

NOTE: An interfaith calendar can help you practice Transcultural Nursing even better by providing you with all important dates for most religions and cultures. You can check out an interfaith calendar at https://livingtogether.mt/

Reference

Council for Nurses and Midwives Malta (2020). Code of Ethics and Standards of Professional Conduct for Nurses and Midwives. Retrieved from https://deputyprimeminister.gov.mt/en/department-of-health-services/nursing-services/Documents/Legal%20Framework/Code%20of%20Ethics%20and%20Standards%20of%20Professional%20Conduct%20for%20Nurses%20and%20Midwives%20-%20Final.pdf on 25th June 2022

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Patient Safety and Use of Restraints

Despite constant awareness on patient safety, patients are unfortunately still suffering unnecessary consequential harm. As healthcare providers we need to ensure that the services we offer to our patients are safe, effective, caring, responsive, and well led. We need to communicate efficiently and lead by example in all areas of patient care.

Patient Safety is a health care discipline that emerged with the evolving complexity in health care systems and the resulting rise of patient harm in health care facilities. It aims to prevent and reduce risks, errors and harm that occur to patients during provision of health care. A cornerstone of the discipline is continuous improvement based on learning from errors and adverse events…
Patient safety is fundamental to delivering quality essential health services…
To ensure successful implementation of patient safety strategies; clear policies, leadership capacity, data to drive safety improvements, skilled health care professionals and effective involvement of patients in their care, are all needed.
WHO, 2019.

Patient Safety Issues

Healthcare-Associated Infections

Each year, about 1 in 25 U.S. hospital patients is diagnosed with at least one infection related to hospital care alone; additional infections occur in other healthcare settings.
CDC, 2017.

Hand hygiene, antimicrobial stewardship, and other protocols, seem to be directly related to the rate and prevalence of healthcare-associated infections, including surgical site infections.

Antibiotic Resistance and Stewardship

Each year in the United States, at least 2.8 million people get an antibiotic-resistant infection, and at least 35,000 people die.
CDC, 2019.

We seem to be headed towards a situation in which antibiotics are rendered useless – a situation which we may be encountering sooner than we expect. This is due to current antibiotic prescription practices, lack of new antibiotic development, and the speed with which pathogens are developing resistance to currently available antibiotics.

Hand Hygiene

Whilst hand hygiene has been proven as the first line of defence against infection, it is still one of the least used tactics, as clearly shown in compliance rates.

Personal Protective Equipment

Lately, in 2020, due to the outbreak of COVID-19, nursing unions worldwide have pushed towards better protective gear and safety precautions, along with increased education and training about treating patients in a safe, effective manner.

Workforce Safety

Adequate nurse-to-patient staffing ratios protect our patients’ right to nursing care and safety. Problem is, in many clinical areas, there is no adequate nurse-to-patient staffing ratio, and this is leading to physical and psychological issues amongst healthcare employees. Ensuring safety of the workforce and within the workplace itself is crucial in ensuring patient safety.

Medication Errors

Medication errors are among the most common medical errors, harming at least 1.5 million people every year.
Institute of Medicine of the National Academies, 2007.

Medication errors to not just jeopardise patient safety; they also lead to unnecessary increased costs. Most medication errors can be avoided through better communication between the patient and the healthcare provider, or between the pharmacist and the patient, as well as adequately following medication-related protocols.

Transition of Care

Transitions of care happen with every physical transfer of patient and change of physician or nurse handover. For optimum transition of care, communication is critical. Information needs to be provided accurately with each transition in a way so that patient care can start right away without the need to read through documentation prior to physically assessing and communicating with the patient.

Patient Engagement

Patients need to be involved in their treatment plans and processes. As healthcare professionals we need to empower our patients so that they become allies in their own care, serving as another layer of defence against safety issues.

For this to happen, one needs to consider the patient’s health literacy so the information given by the healthcare professional is both understood and followed as required.

Pressure Injuries

Pressure injuries can be avoided through multiple efforts. Adequate nursing assessments need to be carried out as per recommendations, especially during bathing time. Thorough patient assessments can help determine risks for pressure injuries, and in such case, ulcer relief equipment needs to be available and sought to avoid unnecessary issues.

Through education on the prevention of pressure injuries along with providing patient-centered care, unnecessary complications can be avoided.

Patient Falls

More than one-third of in-hospital falls result in injury, including serious injuries such as fractures and head trauma.
Agency for Healthcare Research & Quality, 2019.

Through patient-centered care, the needs of each patient can be identified, noted, and met. Optimum communication in transition of care ensures that patient falls are reduced to a minimum.

Information Technology issues

Whilst health IT aims to quicken processes, aggregate and analyse data efficiently and improve outcomes, actual implementation has shown that the scope of technology’s reach has been much shorter than anticipated. This has led to a situation conducive to human error, jeopardising patient safety in the process.

To avoid such situation, technology should be enhanced so it can be used to improve communication within and between multidisciplinary teams, promote timely care, and provide data in a way which enhances monitoring and evaluation of patient care.

Use of Restraints

Use of restraints may seem to be unnecessary measures which take a patient’s personal freedom away. However, in certain situations, restraining a patient is the only way in which the patient’s safety can be ensured.

Use of restraints include:

Physical Restraints: interventions or devices which prevent the patient from moving freely, restricting normal access to his/her own body
Chemical Restraints: use of drugs to restrict patient movement or behaviour (drug or dosage in such case isn’t an approved standard of treatment for the patient’s condition).

patient safety and use of restraints — Retrieved from https://www.myamericannurse.com/use-restraints/ on 12th June 2022

NOTE: The following are NOT considered as restraints, but as safety interventions: orthopaedic supportive devices, age-appropriate protective equipment eg. strollers and helmets, keeping bed side-rails up as a precautionary measure in case of a seizure, and devices used to temporarily immobilise a patient for a diagnostic procedure.

Ethical Issues

Obligations & Duties – as healthcare professionals, identifying our moral obligations to others can help us determine our course of action in any given situation
Avoiding Harm – as healthcare professionals, our main aim and basis for good practice should always be that of avoiding harm to our patients
Assessing Consequences of Action – prior to use of restraints we should always assess the balance between benefits vs harm
Autonomy & Rights – we need to respect the individual’s rights to make their own decisions (if having the mental capacity to do so) and respect for the rights of others

Legal Issues

Does the patient lack capacity in relation to the matter in question?
Is it truly necessary to restrain the patient in order to prevent harm to the patient?
Have you considered the likelihood of the patient being harmed and the seriousness of that harm?

Risks related to Use of Restraints

A supine restrained position may increase the risk of aspiration
A prone restrained position may increase the risk of suffocation
An improperly secured above-the-neck vest may increase the risk of strangulation (if patient slips through the side rails)
Restraints may cause psychological trauma or resurface traumatic memories
Restraints can cause serious injuries and even death

Reducing the Risks…

ensure that a physical restraint is applied safely and appropriately
frequently monitor patients with any type of restraint
provide reassurance, support, and frequent contact to relieve a restrained patient’s fear and anxiety
monitor vital signs to determine how the patient is responding to the restraint
nurses need to receive hands-on training on the use and appropriate application of all types of restraints prior to being required to apply them, which training should be reinforced periodically

NOTE: Use of restraints should not be made part of a routine protocol, but an exceptional event!

The Role of the Nurse in Use of Restraints

Nurses must weigh the risks of using a restraint – restraints may cause physical or psychological trauma. Which is the best option? Is there a possibility of addressing the issue at hand without restraints and in a different way eg. through communication leading to reduction of anxiety?
Restraints should be used as a last resort. Nurses should explore alternatives such as having staff or family members to sit with the patient, using distractions or de-escalation strategies, and reassurance.
If use of restraints is necessary, a provider order must be obtained. However, this will not determine future need for restraints. Nurses should update and revise the patient’s care plan with the aim of reducing restraining measures and episodes.

Elevated Supervision ~ Constant Watch

ELEVATED SUPERVISION IN PSYCHIATRIC NURSING

In psychiatric nursing, constant watch by a professional staff member is recommended when the patient is at risk of harming self or others, as well as to observe the patient’s behaviour.

ELEVATED SUPERVISION IN NURSING (SPECIALLING NURSING)

Nursing care may be required on a one-to-one basis if the patient has so many needs that nursing assistance is required at all times. One-to-one nursing a.k.a. specialling nursing in such cases requires that the patient is kept within sight at all times of the day and night. This helps in reducing the risk and incidence of patient harm.

Whilst specialling nursing can feel intrusive and restrictive, it can be a therapeutic intervention through patient-centered care.

To ensure patient safety as well as your own…

ensure a good handover from the nurse in charge, including the reason why 1:1 nursing has been implemented
inform yourself about your patient’s recent days at the hospital through patient notes and documentation
participate in discussions with the patient’s family, carers, and other healthcare staff
liaise with the multi-disciplinary team and ensure the patient attends all due appointments and required tasks
ensure clarification about break time and who is to provide cover whilst on break
document in detail, including patient speech content, behaviour, risks, and attitude to being under constant watch

Specialling Nursing Patient Care

communicate with the patient and provide reassurance
assist with personal hygiene and other personal needs such as wearing of hearing aids, glasses, dentures, as well as toileting
promote mobilisation where possible so as to maintain daytime activity and stimulation, leading to better nights where the patient can sleep better
liaise with other personnel where need be so as to provide the patient with any cultural and spiritual needs
communicate with carers about the patient’s needs and assist them with any concerns
always keep in mind the patient’s preferences to activities of daily living; What is their normal routine like? Does the patient have any preferences with regards to bathing and dressing up? What are the patient’s food preferences? How is the patient’s usual bowel routine? Does the patient ask for painkillers? How is the patient’s mobility? Any activities of interest that the patient can continue to practice whilst hospitalised? In case of inappropriate or difficult behaviour, how is this usually managed?

constant watch Hospital Policies

most clinical areas have their own SOPs – Standard Operational Procedures; always ask if they exist, and if they do, read them, understand them, and if unclear, ask for clarifications
challenge related malpractice
provide daily patient review on the need for constant watch and the different levels of elevated supervision as should be explained in the SOP; get the GP or consultant to sign and review patient on a daily basis

References

Agency for Healthcare Research & Quality (2019). Patient Safety 101. Retrieved from https://psnet.ahrq.gov/primer/falls on 12th June 2022.

Centers for Disease Control and Prevention (2019). Antibiotic Resistance. Accessed from https://www.cdc.gov/winnablebattles/report/HAIs.html on 11th June 2022.

Centers for Disease Control and Prevention (2017). Healthcare-Associated Infections (HAIs). Accessed from https://www.cdc.gov/winnablebattles/report/HAIs.html on 11th June 2022.

Institute of Medicine of the National Academies (2007). Preventing Medication Errors. DOI: https://doi.org/10.17226/11623

World Health Organization (2019). Patient Safety. Assessed from https://www.who.int/news-room/fact-sheets/detail/patient-safety on 11th June 2022.

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Antibiotic Resistance and Antimicrobial Stewardship

Antibiotics are medicines that can treat bacterial infections, but at the same time upset microbial ecology, causing an alteration in the normal bacterial flora of the patient. Antibiotics cannot treat viral infections such as the common cold or the flu. Some organisms are sensitive or resistant to a given antibiotic, whilst others acquire resistance. How? If antibiotics are taken when they are not truly needed or beneficial to the individual, they can stop working. This is referred to as antibiotic resistance.

Antibiotic Resistance

Antibiotics may be:

Broad Spectrum Antibiotics: active against both gram +ve and gram -ve bacteria
Narrow Spectrum Antibiotics: active against gram -ve bacteria only
Bacteriocidal – kill bacteria in a direct way
Bacteriostatic – slow the reproduction of bacteria

Antibiotic resistance happens when an antibiotic loses its ability to kill or control bacterial growth in an effective way, thus leading to bacterial growth within the presence of therapeutic levels of the antibiotic.

Similarly, bacteria may undergo structural changes in its DNA, with different bacteria exchanging DNA information, leading to further antibiotic resistance.

Retrieved from https://www.zmescience.com/science/breastmilk-protects-antibiotic-resistance-836533/ on 10th June 2022

Antibiotic Pressure in Hospitals

Antibiotic use is concentrated in hospitals, making it easy for resistant bacteria to proliferate in the hospital setting as well as in the patients themselves. Unresponsive therapy for resistant organisms leads to an increase in treatment time, making cross-infections more likely to occur. This causes increased antibiotic-resistant hospital infections.

Nosocomial pathogens include bacteria, viruses and fungal parasites. WHO estimates that approximately 15% of all hospitalised patients suffer from such infections. During hospitalisation, the patient is exposed to pathogens found in the surrounding environment, healthcare staff, and other infected patients. Nosocomial pathogens, which are often resistant to the antibiotics in current use, include:

Staphylococcus aureus (S. aureus / MRSA)
Enterococci
Klebsiella / Enterobacter / Serratia
Pseudonomas Aeruginosa / Acinetobacter

Retrieved from https://courses.cdc.train.org/Module6B_Principles_Transmission-BasedPrecautions_LTC/mod_6b_principles_of_transmission_based_precautions_lesson_2_33_multidrug_resistant_organisms.html on 10th June 2022

Carbapenem-Resistant Enterobacteriaceae (CRE)

Carbapenem-Resistant Enterobacteriaceae (CRE) are strains of bacteria which are resistant to carpabenem – an antibiotic class, which is used to treat severe infections. CRE are also resistant to most other commonly used antibiotics, and in some cases, to all available antibiotics.

CRE can spread and share their antibiotic-resistant qualities with healthy bacteria in the body, possibly causing infections in the bladder, blood, or other areas. Unfortunately, when such infections happens, it’s very hard and at times impossible to treat effectively.

Retrieved from https://apic.org/monthly_alerts/cre-the-nightmare-bacteria/ on 10th June 2022

Methicillin-Resistant Staphylococcus Aureus (MRSA)

MRSA is a type of bacteria resistant to widely used antibiotics, making infections with MRSA harder to treat than other bacterial infections.

Retrieved from https://www.ukm.my/umbi/news/mrsa-the-superbug/ on 10th June 2022

Antimicrobial Resistance (AMR)

Antimicrobial resistance can be reduced through prudent and rational antibiotic use. This can be achieved through programmes aimed at preventing and containing healthcare associated infections and antimicrobial resistant organisms.

Global Action Plan on Antimicrobial Resistance (WHO)

Antibiotics are life-saving. However, they are only effective when working against the organism causing the infection. Antibiotics should be prescribed and used with responsibility, so as not to contribute to the ever-increasing antimicrobial resistance.

Antibiotic resistance causes:

slower response to therapy
increased risk of infection
additional investigations
unnecessary treatments
use of broad-spectrum antimicrobials which increase cost and may lead to potential adverse reactions
increased morbidity and mortality
increased risk of infection spreading across the hospital and the community
longer hospital stay
longer absence from work

Antimicrobial Stewardship (AMS)

Through Antimicrobial Stewardship, we can do our part in ensuring we use antibiotics correctly so that they remain active for future generations.

Question everything…

Is an antibiotic really necessary to treat the patient?
If yes, does the choice of antibiotic follow the hospital antibiotic prescribing guidelines?
Have microbiology samples been taken and sent to the lab and the results reviewed?
Is the antibiotic of choice being administered through the correct route, for the correct duration, and at the correct dose?
Is a daily review on antibiotic use being performed so as to see if it can be stepped down from IV to oral or stopped?

The Role of the Nurse in Antimicrobial Stewardship

nurses make up a big part of the healthcare workforce
nurses are the ones mostly present around the patients
nurses are patient advocates
nurses are involved in patient education, infection prevention and control, monitoring of antibiotic use, and medication prescription and management of the patient
nurses are a part of the multidisciplinary team that sees to the patient’s needs
nurses work within multiple levels in local clinical settings
nurses have a key role in safeguarding the effectiveness of antibiotics fur future generations

Thus…

Nurses NEED to be recognised as influential members of the multidisciplinary team in the fight against antimicrobial resistance whilst assuring antimicrobial stewardship.

Through leadership skills, nurses can support infection prevention and control, antimicrobial stewardship and public health.

Patient Management

understand the difference between colonisation and infection
perform hand hygiene before and after touching a patient and surroundings
ensure environmental cleaning procedures are complete and consistent
assess patients for risk of acquiring and transmitting an infection
ensure correct collection of microbiological specimens if clinical need is indicated
encourage targeted interventions to reduce unnecessary use of antibiotics
ensure the use of most narrow-spectrum antibiotics are used to treat a patient’s infection
review and recognise if treatment is not in line with microbiological result
document findings
facilitate discharge planning

Medication management

recognise if patients are able to tolerate oral intake and so could change from IV to oral antimicrobials
ensure timely administration of antimicrobials at the right rate and follow up on missed doses
ensure that antimicrobials which perform optimally within a specific therapeutic level are in line with recommendations
monitor patient to ensure intended therapeutic effect of antimicrobial
recognise allergies and side effects
document clearly and accurately the generic name, dose, time, route, reason for administration, review, and stop date, as well as each administration
dispose of unused antimicrobials correctly

Antibiotic Allergies

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HIV Infection and AIDS

HIV Infection (human immunodeficiency virus) damages the immune system. AIDS (acquired immune deficiency syndrome) is the disease caused by the damage incurred by HIV. Many of the clinical features of HIV Infection and AIDS can be attributed to the profound immune deficiency that develops in HIV-infected patients. AIDS is the most serious stage of HIV, leading to death over time.

Stages of HIV Infection

HIV infection and AIDS — Retrieved from https://www.icliniq.com/articles/hiv-and-aids/hiv on 8th June 2022

Rapid Initiation of Antiretroviral Therapy (ART) & Management of Early HIV Infection

provide prompt treatment through initiation of antiretroviral therapy (ART) following the diagnosis of acute and early HIV infection
choose one of the following antiretroviral regimens: REGIMEN 1: dolutegravir plus tenofovir & emtrictabine OR lamivudine bictegravir-tenofovir alafenamide-emtricitabine; REGIMEN 2: ritonavir-boosted darunavir plus tenofovir and either emtricitabine or lamivudine
chosen treatment needs to be continued indefinitely

NOTE: individuals who choose not to commit to lifelong ART need to be closely monitored: CD4 cell count and viral load testing every 3 months + provided with counseling on the high risk of transmission when viral RNA levels are very high.

Retrieved from https://www.poz.com/pdfs/POZ_2021_HIV_Drug_Chart_high.pdf on 8th June 2022

Chronic HIV Infection Without AIDS

AIDS and Advanced HIV Infection

Advanced HIV Infection is confirmed when the CD4 cell count is <50 cells/microL.

AIDS is the outcome of chronic HIV infection and consequent depletion of CD4 cells. AIDS is confirmed when the CD4 cell count is <200 cells/microL OR there is presence of any AIDS-defining condition as listed further below.

AIDS-defining conditions are opportunistic illnesses which occur more frequently or increasingly severe due to immunosuppression. These conditions are mainly opportunistic infections, but do also include malignancies as well as conditions without clear alternative etiology.

AIDS-Defining Conditions

Retrieved from https://www.hiv.uw.edu/page/qb/question/basic-primary-care/staging-initial-evaluation-monitoring/4 on 8th June 2022

Complications Medical Management

Complication	Medical Management
Pneumocystis Pneumonia	trimethoprim-sulfamethoxazole (TMP-SN)
Mycobacterium Avian Complex	azithromycin OR clarithromycin
Cryptococcal Meningitis	IV amphotericin B
Severe Chronic Diarrhoea	octreotide acetate (Sandostatin)
Depression	psychotherapy + imipramine OR desipramine OR fluoxetine
Weight Loss	appetite stimulants + oral supplements

NOTE: When the patient achieves immune reconstitution (eg. increase in CD4 cell count of >200 cells/microL) with antiretroviral therapy and shows no signs of AIDS-defining conditions, they are considered as no longer having AIDS.

AIDS Nursing Care Plan

Promote Skin Integrity – encourage skin care: teach patients to avoid scratching and to use non-abrasive non-drying soaps and to apply non-perfumed moisturisers; encourage regular oral care; encourage washing of the perineal area following bowel movements using non-abrasive soap and water
Monitor for Normal Bowel Patterns – monitor for frequency and consistency of the patient’s stools and note any patient complaints of abdominal pain or cramping
Prevent Infection – monitor for physical signs of infection as well as through laboratory test results
Promote Activity Tolerance – encourage the patient to plan daily routines with the aim of maintaining balance between activity and rest
Maintain Thought Processes – encourage the patient’s relatives and friends to speak to the patient in simple, clear words, and to allow sufficient time for the patient to respond to questions
Improve Airway Clearance – teach and promote coughing exercises, deep breathing, postural drainage, percussion and vibration exercises in 2-hour intervals so as to prevent secretion stasis and to promote airway clearance
Relieve Pain and Discomfort – encourage use of soft cushions and foam pads for comfort, and if necessary, administer NSAIDs and Opioids to lessen pain
Improve Nutritional Status – encourage the patient to consume foods which are easy to swallow, and to avoid rough, spicy and sticky foods

Transmission Means of HIV Infection

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Human Sexuality & Sexually Transmitted Infections

Human Sexuality is one of the fundamental drives behind every person’s feelings, thoughts, and behaviors. It incorporates biological reproduction, psychological and sociological representations of self, and orients a person’s attraction to others whilst shaping the brain and body to be pleasure-seeking. One needs to keep in mind however that with sexual contact comes the risk for sexually transmitted infections (STIs). More than 1 million sexually transmitted infections are acquired every day across the world, most of which are asymptomatic.

Human Sexuality Definitions

assigned gender at birth – based on biologic, genetic, and anatomic factors
gender identity – how the person self-identifies
gender role – based on society’s expectations of gender
gender expression – how the person self-presents to the outside world
sexual orientation – based on the person’s sexual preference arousal orientation
early adolescence – puberty: 10-14 years of age where body changes occur
middle adolescence – 14-18 years of age
late adolescence – 18+ years of age

Adolescent Sexuality

Typically, adolescents start to experience conflicts between their emerging sexuality and their families, peers, culture, and society’s approach to human sexuality. Commonly, developing adolescents are presented with role modeling, sex education and related information based on heterosexual focus. Homosexuality is commonly still associated with social or religious taboo. This imbalance can only be lessened through family connectedness, school social support, and community support for LGBTIQ+ individuals.

Signs of Adolescent Sexual Maturity & Health

ability to live according to their own values
taking responsibility of their own behaviour
practicing effective decision-making
exhibit critical thinking skills
understanding that sexual development with or without reproduction or sexual experiences is a part of human development
seek to expand their knowledge in terms of sexuality and reproduction
interact with all genders respectfully and appropriately
understanding their own gender identity and sexual orientation whilst respecting others with different gender identities and sexual orientations
expressing sexuality in a way which connects to their own values
expressing love and intimacy appropriately
developing and maintaining meaningful relationships, steering away from exploitative and manipulative relationships
practice communication and skills in a way which enhances their relationships with others

Human Sexuality & Related Health Issues

pregnancy – may be unplanned or leading to unfavourable outcomes
contraception
STIs
HIV
victimisation

Healthcare-Related Barriers to Human Sexuality

inaccurate or limited sex education
lack of confidentiality
lack of normalisation
lack of respect
assumptions
inadequate questioning
asking without actually listening
using jargon in patient education
inability to link issues eg. alcohol possibly leading to unsafe sex
lack of promotion of preventative measures
lack of (or knowledge about) community resources

Male Sexual Dysfunction

changes start to commonly be experienced from 40+ years of age
decreased libido
erectile dysfunction – risk factors include obesity, smoking, leading a sedentary lifestyle, diabetes mellitus, chronic kidney disease, cardiovascular disease, psychological factors, neurological factors, endocrine disorders, and medications such as diuretics, SSRIs, clondine, methyldopa, and illicit drug use
ejaculatory disorders – premature or delayed ejaculation, anejaculation (complete absence of ejaculation), and male anorgasmia (inability to orgasm)

Female Sexual Dysfunction

40% of women worldwide report sexual health problems
problems in relation to libido, arousal, orgasm and resolution
problems related to the endocrine system – estrogen deficiency have been associated with sexual function changes; dryness, vulvo-vaginal mucosa thinning, lacerations, and pain
risk factors include relationship satisfaction, fatigue and stress, work and life issues, age, menopause, psychiatric disorders, medications (SSRIs)
gynaecological issues – pregnancy and childbirth, pelvic organ prolapse, incontinence, endometriosis, and uterine fibroids
endocrine disorders
hypertension
neurologic diseases eg. Multiple Sclerosis and Parkinsons’ Disease
obesity and body image
medications – SSRIs, Nicotine, Alcohol, and Opioids

Diagnoses & Diagnostic Criteria

female sexual interest and arousal disorder OR
female orgasmic disorder OR
genitopelvic pain OR
penetrative disorder OR
substance-induced disorder

medical history
physical exam
hormonal testing

Sexually Transmitted Infections (STIs)

More than 1 million sexually transmitted infections (STIs) are acquired every day worldwide, the majority of which are asymptomatic. Each year there are an estimated 374 million new infections with 1 of 4 STIs: chlamydia, gonorrhoea, syphilis and trichomoniasis.
WHO, 2021

Sexually Transmitted Infections’ preventative approach is based on the following 5 major strategies:

providing accurate risk assessments along with education and counseling to individuals at risk of acquiring STIs on how these can be avoided
vaccinating individuals at risk of acquiring STIs for vaccine-preventable STIs in the pre-exposure period
identifying symptomatic and asymptomatic individuals with STIs
providing efficacy in the diagnosis, treatment, counseling, and follow-up of individuals with STIs
providing evaluation, treatment and counseling of sex partners of the individuals with STIs

Risk Factors for Sexually Transmitted Infections

new sex partner in the past 60 days
multiple sex partners or sex partner with multiple concurrent sex partners
sex with partners recently treated for a STI
inconsistent or no condom use outside a mutually monogamous sexual partnership
having sex for money or drugs
sexual contact with sex workers
sexually active adolescents
men sexually active with other men (higher risk for HIV and other viral and bacterial STIs)
transgender men and women
patients with HIV infections (some STIs can increase HIV transmission)
pregnant women are not at increased risk for STIs, however, due to potential for high morbidity and poor fetal outcomes following maternal infection, pregnant women should be screened for STIs at the first prenatal visit

Counseling for Sexually Transmitted Infections Risk Reduction

discuss risks related to sexual behaviours
assess the patient’s understanding and beliefs in relation to STI transmission
assess circumstances which may be affecting the patient’s sexual behaviour
assess the patient’s willingness to change risky behaviour
negotiate behavioural goal attainable through smaller steps

Vaccination

Hepatitis A

Hepatitis A is a liver infection caused by the hepatitis A virus, which is found in the stool and blood of infected individuals. Hepatitis A can be prevented through vaccination.

Vaccination for Hepatitis A is recommended for:

men who have sexual contact with other men
individuals who use injection and non-injection drugs
individuals with chronic liver disease
individuals with close contact to Hepatitis A infected persons
individuals travelling to countries in which Hepatitis A is endemic

NOTE: barrier methods eg. condom use do not prevent acquisition of Hepatitis A.

sexually transmitted infections — Retrieved from https://sexualhealth.gov.mt/content/hepatitis-0 on 8th June 2022

Hepatitis B

Hepatitis B is a liver infection caused by the hepatitis B virus. It is spread through blood, semen, or other body fluids from an infected person to a non-infected person. Hepatitis B can be prevented through vaccination.

Vaccination for Hepatitis B is recommended for:

sexually active adolescents
adults having unprotected sex with infected partners
having unprotected sex with multiple partners
having a history of STIs
men having sexual contact with other men
individuals who make use of injected drugs

Human Papillomavirus

Human Papillomavirus (HPV) is the most common sexually transmitted infection. Whilst it is usually harmless, some of its type can lead to cancer and/or genital warts. Multiple HPV vaccines are available for the prevention of HPV infection in women – the types of infection which causes 70% of cervical cancers, as well as those causing most genital warts.

Human Papillomavirus Vaccination is recommended for:

females from 9-26 years of age
males from 9-26 years of age who are sexually active with other men
immunocompromised individuals eg. those with HIV infection

Neisseria Species

Neisseria Meningitidis a.k.a. meningococcus, is a Gram-negative bacterium which can cause meningitis and other forms of meningococcal disease, including meningococcemia – life-threatening sepsis. Whilst Neisseria species are not STIs, Neisseria Meningitidis can be transmitted through close contact such as through kissing and sexual contact.

Vaccination for Neisseria Meningitidis is recommended for:

men having sexual contact with other men
HIV infected individuals

Condom Use & Antimicrobial-Based Prevention

Condoms

When used consistently and correctly, condoms are highly effective in preventing HIV and other sexually transmitted diseases such as gonorrhea, chlamydia, trichomonas, genital herpes, human papillomavirus, and syphillis.

Pre-exposure prophylaxis

Pre-exposure prophylaxis (PrEP) contains two antiretroviral medicines used to treat people who have a HIV infection: tenofovir disoproxil fumarate a.k.a. TDF, and emtricitabine a.k.a. FTC. In combination, TDF/FTC drugs suppress the virus in people living with HIV.

Post-Exposure Prophylaxis (PEP) of Bacterial STI

Post-Exposure Prophylaxis (PEP) is a short course of HIV medicines taken very soon after a possible exposure to HIV to prevent the virus. PEP should be used only in emergency situations and must be started within 72 hours after a recent possible exposure to HIV.

PEP is a combination of three drugs to be taken once or twice a day for 28 days: tenofovir, emtricitabine (one pill), and either raltegravir or dolutegravir.

suppressive therapy

Suppressive therapy for genital herpes simplex virus (HSV) can be provided through valacyclovir (500mg daily). I helps decrease the risk of transmission of HSV to an uninfected partner.

topical microbicides

HIV topical microbicides are products with anti-HIV activity incorporating a direct-acting antiretroviral agent which, when applied to the vagina or rectum, can help prevent sexual acquisition of HIV in women and men. Topical microbicides may meet the prevention needs of individuals and groups for whom oral daily forms of pre-exposure prophylaxis (PrEP) have not been acceptable.

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Gynaecological Nursing

Gynaecological nursing focuses on diseases and disorders primarily or uniquely found in women.

Warning Signs

Unusual Vaginal Discharge – yellow, green, or grey discharge accompanied by a foul odour
Abnormal Vaginal Bleeding – possibly caused by pregnancy, hormonal imbalance, or fibroids
Discomfort Whilst Urinating – damaged or weakened pelvic floor tissue
Pelvic Pain – sharp pain may be an indication of infection, ruptured ovarian cyst, or an ectopic pregnancy, while constant pain may be caused by uterine fibroids
Constant Fatigue – possibly caused by endometriosis, which is a condition in which tissue similar to the womb lining grows in other areas eg. the ovaries and the fallopian tubes
Pain During Intercourse – may present as deep pelvic pain or soreness in the genital area, possibly due to vaginal dryness, uterine fibroids, or infections
Unexplained Weight Loss – possible cancer sign
Leg Pain – ovarian cancer causes swelling due to fluid build-up produced by the tumour

gynaecological nursing — Retrieved from https://www.sunrisehospitals.in/watch-out-for-these-10-signs-of-cervical-cancer/ on 4th June 2022

Treatment Indications

Uterine fibroids a.k.a. leiomyomas are non-cancerous growths of the uterus, usually appearing during childbearing years. Fibroids tend to shrink during menopause.

(Image retrieved from https://www.uclahealth.org/fibroids/what-are-fibroids on 4th June 2022)

Cervical polyps are reddish, purplish, or greyish growths commonly shaped like a finger, bulb or stem, that can be found on the cervical canal. Polyps typically measure between a few millimeters to several centimeters.

(Image retrieved from https://www.healthnavigator.org.nz/health-a-z/c/cervical-polyps/ on 4th June 2022)

Endometriosis is a chronic inflammatory oestrogen-dependent condition in which the presence of endometrial glandular tissue can be found outside the uterus.

(Image retrieved from https://nitubajekal.com/endometriosis/ on 4th June 2022)

In Adenomyosis, endometrial tissue grows into the uterine muscular wall, acting normally during each menstrual cycle. Adenomyosis however causes the uterus to enlarge, often causing excrutiating pain and heavy periods.

(Image retrieved from https://www.cloudninefertility.com/blog/symptoms-causes-and-treatment-for-adenomyosis on 4th June 2022)

Cancer of the Uterus, Ovary, Cervix, or Endometrium.

(Image retrieved from http://www.humanillnesses.com/original/U-Z/Uterine-and-Cervical-Cancer.html on 4th June 2022)

In an Ectopic Pregnancy, the fertilized egg does not reach the uterus as it normally does. Instead, it gets attached to the cervix, abdominal cavity or fallopian tube.

(Image retrieved from https://www.kjkhospital.com/ectopic-pregnancy/ on 4th June 2022)

Intrauterine Adhesions are bands of fibrous tissue which form in the endometrial cavity, usually following a uterine procedure. They are often associated with menstrual abnormalities as well as infertility.

(Image retrieved from http://nezhat.org/treatment-of-infertility/infertility-determining-a-diagnosis/ on 4th June 2022)

Ovarian Cysts are fluid-filled sacs in an ovary or on its surface.

(Image retrieved from https://www.kjkhospital.com/ovarian-cysts/ on 4th June 2022)

Medical Management of certain Gynaecological Issues

Uterine Bleeding can be managed medically by use of an IUD (Intrauterine Device), hormonal medications such as oestrogen, progesterone, and oral contraceptives, and non-hormonal medications such as NSAIDs.
Pelvic Organ Prolapse can be medically managed by pelvic floor muscle training, vaginal pessaries, and adopting a healthy lifestyle which includes smoking cessation and maintaining an ideal body weight.
Fibroids can be medically managed through watchful waiting – an ideal approach for asymptomatic women where they are required to track any symptoms and undergo regular pelvic exams to monitor fibroids, until the menopause period where these usually shrink.
Endometriosis can be medically managed through over-the counter pain medications.

Gynaecological Procedures

Hysteroscopy

Hysteroscopy is a surgical procedure which allows the examination of the uterine cavity. A hysteroscope is inserted into the uterus through the vagina and cervix. Indications for a hysteroscopy include:

Symptom Investigation – heavy periods, post-menopause bleeding, pelvic pain
Diagnosis – to enable the diagnosis of polyps, fibroids and other possible issues
Treatment – removal of polyps, displaced IUDs, intrauterine adhesions, and fibroids through a myomectomy.

UFE – Uterine Artery/Fibroid Embolisation

Uterine Fibroid Embolisation (UFE) is a minimally invasive procedure commonly performed by a radiologist, used to treat fibroid tumors of the uterus that may cause heavy menstrual bleeding, pain, and pressure on the bladder or on the bowels. UFE uses fluoroscopy to guide the delivery of embolic agents to the uterus and fibroids to block the arteries which provide blood to the fibroids. Lack of bloodflow to the fibroids causes them to shrink. It promotes preservation of the uterus.

Laparoscopy

Uterine Laparoscopy is a diagnostic method used in the case of unexplained pelvic pain, unexplained infertility, or a history of pelvic infection. Alternatively, Laparoscopy can also provide treatment through the removal of ovaries and ovarian cysts, adhesions, fibroids, and uterus. It can also provide endometrial tissue ablation to help lessen menstrual flow. Laparoscopy can be used to treat uterine prolapse, blood flow blocking in the case of fibroids, and ectopic pregnancies.

Pelvic Floor Surgery

In a vaginal prolapse, muscles supporting the organs in a woman’s pelvis weaken, causing the uterus, urethra, bladder or rectum to droop down into the vagina. In certain cases, organs may actually protrude out of the vagina. Physiotherapy may help in certain cases, however, sometimes surgery may be required so the pelvic organs are put back in place. This is done through the vagina or through laparoscopy.

Retrieved from https://www.kegel8.co.uk/articles/pelvic-surgery/prolapse-surgery.html on 4th June 2022

Hysterectomy

A hysterectomy is a surgical procedure in which a woman’s uterus (or part of) is removed. Connected organs such as the fallopian tubes, ovaries, and cervix may also be removed during the same procedure. Hysterectomies are considered to be major surgeries and so are carried out electively through the abdomen, vagina, or laparoscopically.

Perioperative Gynaecological Nursing Care

Perioperative Gynaecological Nursing Care refers to patient care in the preoperative, intraoperative and postoperative period. Perioperative care should be based on the nursing process framework.

Preoperative care

GOALS

Preoperative care should aim to:

reduce surgical morbidity
minimise delays and cancellations
assess and optimise the patient’s health and fitness status
anticipate possible complications and prepare for their eventuality
facilitate anaesthesia planning
reduce patient anxiety by providing related information, answering any related questions, and address any concerns that the patient may have about perioperative care

PATIENT HISTORY

compile the patient’s medical history, including personal and family diseases, allergies, health-related habits, socioeconomic status, and past hospitalisation experiences
compile the patient’s surgical history, including information about previous operations and anaesthetic tolerance
compile gynaecologic and obstetric history, including current issue complaints, information about the menstrual cycle, past pregnancies, use of birth control, sexual history, smear test, infections, and breast diseases

EXAMINATION

Physical examination of the patient in the preoperative period helps to establish whether the current disease or issue is causing the patient to be instable or experience exacerbations. A preoperative physical examination should include:

vital signs
physical observation
airway and lung auscultation
cardiac auscultation (including rhythm determination)
neurologic condition
abdominal and pelvic examination

GYNAECOLOGIC EXAMINATION

breast, abdomen and pelvic organ examination, all of which can be supplemented by detailed assessment of the uterus via an ultrasound scan
endometrial sampling in women with abnormal uterine bleeding or abnormal endometrial imaging
cervical cancer screening
pregnancy test for women in childbearing age

PSYCHOLOGIC CONSIDERATIONS

feeling vulnerable may cause women to experience negative feelings which include fear of the unknown, fear of pain, and fear of the illness itself
provide a relaxed and private setting
ask open-ended questions in a non-judgemental way
do not make assumptions about the patient, including assumptions related to patient sexuality
ensure all questions the patient may have are answered clearly and understood well

INVESTIGATIONS

blood tests should include CBC, fasting and blood glucose, kidney function, serum electrolytes, blood group, liver function test, INR
ECG and stress test
chest x-ray
ultrasound
CT scan
MRI

PREOPERATIVE GYNAECOLOGICAL NURSING CARE

gain informed consent
review pre-op physical preparation eg. skin, bowels, NBM, cessation of medications, use of drugs, alcohol and smoking
explain what happens in the operating theatre
discuss post-operative routines such as routines related to respiratory care (coughing exercises), leg exercises (promoting venous return), early ambulation, pain control, fluids and nutrition
ensure patient has allergy and ID bracelets on
record baseline vital signs prior to transfer to the operating theatre
ensure jewellery and valuables are removed prior to transfer
ensure nail polish and makeup are removed prior to transfer
ask about any dentures and loose teeth, hearing aids etc – ensure their safety prior to transfer
ensure patient is put NBM at the right time
administer thromboprophylactic treatment
ensure patient has a bath or shower with antimicrobial soap
ensure hair removal is done – avoid abrasions by using hair clipping rather than shaving
ensure patient relatives know about the approximate length of surgery waiting time
ensure administration of prophylactic antibiotic 30 minutes prior to surgery

Intraoperative Care

The intraoperative period covers the time from when a patient is transferred to the operating room until being admitted to the post-anaesthesia care unit. During this period, the nurse acts as the patient’s main advocate.

In intraoperative care, the following should be ensured:

safe patient care
safe environment
limited traffic in and out of the operating theatre
correct use of surgical attire to promote staff safety, maintain sterility and cleanliness
correct patient positioning to reduce unnecessary injury due to prolonged surgery time
adherence to surgical count policy
adherence to sterility so as to reduce the risk of wound contamination and possible post-op surgical site infections
bladder catheterisation through the use of an intermittent stainless steel catheter may be needed (based on surgeon’s preference); catheterisation is carried out when the patient is asleep but before the first incision is made
draping serves as a barrier to endogenous and exogenous sources of contamination, thus reducing the risk of SSIs, as well as extends the sterile field for the placing of sterile instruments and supplies

WHO SURGICAL SAFETY CHECKLIST

PATIENT POSITIONING

Lithotomy positioning allows optimum exposure and surgical access to the perineum for vaginal surgeries. Potential issues with Lithotomy positioning include skin breakdown, nerve damage, musculoskeletal injury, and circulatory compromise.

Supine positioning is ideal for pelvic surgeries such as in open hysterectomy. Potential issues with Supine Positioning include skin breakdown, lumbar strain, nerve injury, and circulatory compromise.

NOTE: If the patient is put in the Trendelenburg Position, the patient may also be at risk of respiratory compromise.

Retrieved from https://nurseslabs.com/patient-positioning/ on 5th June 2022

Retrieved from https://slidetodoc.com/patient-positioning-rachel-brightthomas-consultant-surgeon-wahnhst-r/ on 5th June 2022

ELECTROCAUTERY

Electrocautery is a procedure which uses heat from an electric current to destroy abnormal tissue eg. tumors or lesions. It may also be used to control bleeding during surgery or after an injury.

Retrieved from https://www.itcindia.org/high-frequency-surgical-equipment/ on 5th June 2022

DIATHERMY BURN

Diathermy is a surgical technique which uses heat generated by an electrical current to cut tissue or seal blood vessels. Accidental diathermy burns can cause unsightly scarring which may limit motion in affected joints or function of other tissues.

INTRAOPERATIVE HYPOTHERMIA PREVENTION

Under surgical conditions, the body becomes at risk of hypothermia due to exposure and impairment of the body’s normal thermoregulatory response. This results in accelerated heat loss.

An individual with hypothermia experiences drug metabolism impairment, coagulation, increased bleeding, and wound infection.

Methods to maintain normothermia under intraoperative circumstances include warming through forced air blanket, and administration of warmed IV fluids.

OPEN SURGERY VS LAPAROSCOPY

Type of surgery and incision made for gynaecological issues depend on:

uterine size
possible required exploration of the upper abdomen
past incisions
cosmetic considerations

Open Surgery Approach

Advantages	Disadvantages
uterine size, fibroid size and extensive adhesions do not pose any limiting issues	longer recovery and rehabilitation period
promotes prolapse repair if required	increased risk of bleeding and infection
enables extensive exploration if needed	usually more painful

Laparoscopic Approach

Advantages	Disadvantages
shorter inpatient treatment duration	increased length of surgery
quicker return to normal activities	increased risk of bladder or ureter injury
associated with long term better quality of life	requires high laparoscopic surgical skills
enables diagnosis and treatment of additional pelvic diseases	use of carbon dioxide gas for abdomen inflation causes pain in the lower chest and up into the shoulder area post-op
reduced bleeding and infection risk

Vaginal Approach

Advantages	Disadvantages
shortest operation time	limited by uterine size, presence of pelvic adhesions, and previous surgeries
short recovery period and quicker discharge from hospital	limited ability to examine the fallopian tubes and ovaries
lowest cost
no scarring
reduced need for pain medication

Postoperative Care

Postoperative care is the management of a patient following a surgical intervention. Postoperative care extends from the immediate postoperative period in the operating room and post-anasthaesia care unit, to the days following surgery.

Postoperative care aims to prevent complications eg. infection, promote healing, and rehabilitation of the patient towards better quality of life. Postoperative care should be managed through the use of the nursing process. The extent of this period depends on the patient’s pre-surgical health status, type of surgery performed, and whether the surgical procedure was performed in a day-surgery setting or in the hospital.

Discharge Criteria

PATIENT CONDITION

stable vital signs
conscious state (same as pre-anaesthesia)
pain control
mobility (same as pre-anaesthesia)
manageable nausea, vomiting or dizziness
oral food and drink tolerance
passing of urine / urinary catheter in situ
discharge authorised by a member of the medical team
responsible adult availability to transport patient and accompany home in a suitable vehicle

PATIENT MONITORING & EDUCATION

vaginal flow monitoring – brownish discharge may be present for a few weeks
incision should be kept clean and dry to avoid it becoming infected
soft loose-fitting clothes should be worn due to incision tenderness
deep breathing exercises
leg exercises
flatus should be tackled with walking and warm fluid intake
prevention of constipation through dietary fibre intake
straining avoidance (including for bowel movement purposes)
avoidance of sexual intercourse for 4-6 weeks
avoid inserting items in the vagina

HOSPITAL DISCHARGE REQUIREMENTS

provide the patient with written and verbal instructions about post-op care
provide the patient with advice on resumption of regular medication
provide the patient with information on when to resume normal daily activities
provide the patient with a contact place and telephone number in the case of emergency care need

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The Nursing Process

The nursing process is a systematic guide to patient-centered care through 5 sequential steps: assessment, diagnosis, planning, implementation, and evaluation.

Retrieved from https://nurseslabs.com/nursing-diagnosis/ on 7th November 2021

Characteristics of the Nursing Process

Dynamic & Cyclic – a process in which each phase interacts with and is influenced by the other phases
Open & Flexible – easily adaptable to different circumstances and emergencies
Universally Acceptable – allows nurses to practice nursing with all individuals within any type of practice setting
Patient Centered -the nursing process approach requires care respectful of and responsive to the individual patient’s needs, preferences, and values; the nurse functions as a patient advocate, enables the patient to make informed decisions, and maintains patient-centered engagement within the healthcare setting
Problem Oriented – aims to tackle arising and possible problems
Interpersonal & Collaborative – provides the basis for the therapeutic process in which the nurse and patient respect each other as individuals, both of them learning and growing due to the interaction
Systematic – has an ordered sequence of activities, each of which depends on the accuracy of the activity that precedes it whilst influencing the activity following it
Goal Directed – the interaction between the nurse and the patient is based on a common goal
Planned – provides a basic structure on which nursing care can be provided
Holistic – takes into account all aspects of the patient

Benefits of the Nursing Process

Improves the patient’s quality of care
Promotes active patient participation in own health through continuous evaluation
Promotes nursing efficiency through better time and resource use
Saves time and energy through the creation of a care plan to follow up with
Reduces omissions and duplications
Acts as a guide outlining consistent and responsive care
Helps in identifying the patient’s goals and required strategies
Promotes collaboration in the management of the patient’s health-related problem
Promotes positive patient outcomes
Promotes patient safety
Promotes patient satisfaction

Step 1: Assessment

collect and document data on the patient’s health status
identify the patient’s strengths as well as limitations
repeat continuously throughout the nursing process

Step 2: Diagnosis & Planning

sort and analyze data collected on assessment
identify actual, potential, or health promotion nursing diagnosis
put together a nursing care plan tackling identified diagnosis

Step 3: Implementation

implement the nursing care plan with the aim of achieving the required goals and outcomes
continue carrying out assessments evaluating the patient’s response to treatment and care
modify where necessary
document

Step 4: Evaluation

perform at specific intervals and continue until patient achieves health goals or is discharged
target the restoration of self-care abilities if required
assess the client’s response to the carried out nursing interventions
assess response to goals and/or planned outcome criteria documented in the Diagnosis phase
determine the patient’s progress towards aimed goals and the effectiveness of the nursing care plan being carried out

Nursing Care Plan Example…

Retrieved from https://www.pinterest.ph/pin/611222980657579285/ on 7th November 2021

Nursing Care Plan Template…

Retrieved from https://www.pinterest.com/pin/732679433111887637/ on 7th November 2021

NOTE: While it is still being barely done, it is a great idea to implement the Nursing Process into your nursing documentation, including the words Assessment, Diagnosis, Planning, Implementation, and Evaluation.

Nursing Plan Examples based on the Nursing Process

Scenario: Patient Presenting with Hypothyroidism

Risk of Malnutrition

ASSESSMENT:

assess how hypothyroidism is currently being controlled
assess patient’s weight
assess whether the patient is taking enough fibre in her dietary intake so as to prevent constipation
check BMI and assess whether patient is at risk of obesity
ask about daily caloric intake

DIAGNOSIS:

imbalanced nutrition

PLANNING:

aim for more nutritious lower caloric intake and weightloss or weight maintenance, depending on the patient’s current weight status

IMPLEMENTATION:

educate patient about the risk of obesity which comes with hypothyroidism
teach patient the importance of planning meals beforehand
teach patient the importance of taking frequent smaller meals rather than a big meal
encourage patient to keep a food diary so all nutritional and caloric intake can be monitored and adjustments may be made
involve dietitian if necessary, who can help provide meal plans to prevent over-eating
encourage exercising
encourage fluid intake
ensure the patient has a good support system through family or friends who can help by offering support

EVALUATION:

compare patient weight with previous weight readings
maintain fluid intake and output charting
review food diary
review care plan

Risk of Constipation

ASSESSMENT:

ask patient how much stools are being passed and whether constipation is being experienced

DIAGNOSIS:

constipation

PLANNING:

aim to reduce constipation, which is a side effect of hypothyroidism

IMPLEMENTATION:

encourage patient to drink more water
encourage exercise
encourage increased fibre intake
if necessary, a stool softener such as Movicol may be recommended

EVALUATION:

review situation with the patient
review care plan

Possible Lack of Health Literacy about Hypothyroidism

ASSESSMENT:

talk to the patient and assess health literacy in general and about hypothyroidism

DIAGNOSIS:

lack of health literacy

PLANNING:

teach patient about the condition and the importance of medicine compliance for life

IMPLEMENTATION:

explain in simple terms what hypothyroidism is
explain that since her body is not producing enough thyroid hormone, this needs to be taken orally
explain that thyroxine needs to be taken for life, and that it shouldn’t be stopped even if one is feeling well
explain that follow-ups are very important since clinicians need to ensure that a therapeutic dose of thyroxine is achieved and maintained

EVALUATION:

question the patient about the information you have relayed, and ensure that adequate knowledge has been grasped
re-explain where needed

Possibility of Fatigue

ASSESSMENT:

assess patient for fatigue
if fatigue is being experienced, explain that it is one of the side-effects of hypothyroidism

DIAGNOSIS:

fatigue

PLANNING:

aim for better performance during the day and adequate rest during the night

IMPLEMENTATION:

encourage patient to rest frequently, spacing daily activities throughout the day
encourage patient to notice at what times it feels easier to maintain activities, so that better day planning can be implemented according to their energy levels
reassure patient and encourage not to push themselves too much, but to go along with their capabilities
teach patient that exercise, although may feel too tiring, helps in muscle build-up and strength

EVALUATION:

assess if patient is feeling better with regards to fatigue
re-evaluate care plan and adjust where necessary

Patient Prone To Feeling Cold

ASSESSMENT:

ask if patient is feeling cold often, and check whether any skin issues are arising due to coldness

DIAGNOSIS:

patient feeling cold

PLANNING:

aim for better clothing options/planning and advise regarding skin breakdown

IMPLEMENTATION:

encourage patient to always carry with an extra jumper or jersey, and to avoid going out when it is very cold or late in the evening if possible
teach patient to prevent skin breakdown by encouraging use of soap for sensitive skin and adequate skin care

EVALUATION:

re-assess situation
re-evaluate care plan and adjust if necessary

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