Nursing the Patient Archives - Student Nurse Life

Patient Safety and Use of Restraints

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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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The Nursing Process

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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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Nursing Diagnosis

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Nursing diagnosis is the nurse’s clinical judgment about a patient’s response to actual or potential health conditions or needs.

Medical Diagnosis vs Nursing Diagnosis

*Medical Diagnosis*…	Nursing Diagnosis…
points to a particular disease or medical condition	focuses on the patient’s needs
is based on the physiological or medical condition	focuses on the patient’s physiological and/or psychological response to changes in health
is also concerned with the aetiology of the disease	addresses potential problems

Types of diagnosis include:

Actual Diagnosis – diagnosis of the problem/s present at the time of patient assessment
Potential Diagnosis – diagnosis of a potential problem which may arise from the patient’s actual diagnosis
Health Promotion Diagnosis – diagnosis in relation to altered behaviours towards healthy living

NANDA’s Nursing Diagnoses

NANDA International, officially founded in 1982 and previously known as the North American Nursing Diagnosis Association, is a professional organisation of nurses aiming to standardise nursing terminology.

The current structure of NANDA’s nursing diagnoses is referred to as Taxonomy II and has three levels: Domains (13), Classes (47) and Diagnoses (237) (Herdman & Kamitsuru, 2018).

NANDA nursing diagnosis — Retrieved from https://en.wikipedia.org/wiki/NANDA_International on 1st June 2022

Models of Nursing Care

Activities of Daily Living
Adaptation
Self Care
Goal Attainment

Activities of Daily Living

nursing diagnosis adl's — Retrieved from https://info.eugeria.ca/en/have-you-heard-of-adls/ on 1st June 2022

Roy’s Adaptation Model

nursing diagnosis — Retrieved from https://schoolworkhelper.net/the-roy-adaptation-model-health-environmentsociety-nursing/ on 1st June 2022

Orem’s Theory of Self Care

Retrieved from https://www.pinterest.com/pin/443886107007181690/ on 1st June 2022

King’s Goal Attainment Model

Retrieved from https://pmhealthnp.com/kings-goal-attainment/ on 1st June 2022

Nursing Diagnosis Care Plan – Based on the ADL

Activities of Daily Living	Assessment	Diagnosis	Implementation	Evaluation
Maintaining a safe environment
Communication
Breathing
Eating & Drinking
Elimination
Washing & Dressing
Controlling Temperature
Mobilisation
Working & Playing
Sexuality
Sleeping
Death
Education
Discharge

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Patient Hospital Admission

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Patient hospital admission refers to the admission and acceptance of a patient into a health facility with the aim of staying under observation, undergoing necessary diagnostic investigations, and receiving required medical or surgical treatment. Patient hospital admission can be either elective – where a procedure is planned beforehand, or an emergency.

Elective Admission

In an elective patient hospital admission, a healthcare professional agrees with the patient on a convenient date for admission. This enables the patient to prepare in advance for the procedure.

Emergency Admission

In an emergency patient hospital admission, the patient is usually brought in by relatives or friends in a critical condition. In such an admission, the patient is usually transported by a wheelchair or a stretcher to an adequate ward for immediate evaluation and treatment.

Elective Patient Hospital Admission Procedure

Welcome the patient and any accompanying relatives to the ward and introduce yourself and any other present HCPs
Gather all required documents such as admission papers and other important information or documentation from the accompanying nurse
Confirm patient identity through given details
Ensure that the patient and accompanying relatives feel welcomed and comfortable
Gather any additional required information by the patient and/or the accompanying relatives
Provide a hospital bed located at an ideal room for the patient in question, based on the patient’s health requirements and condition
Provide assistance to the patient to change into pyjamas or hospital gown and ensure identification bracelet and any other required tags eg. allergy bracelet is provided
Take baseline vital signs and document
Collect any required specimens if needed
Administer any urgent medications
Ensure patient valuables are taken care of
Ensure informed consent is obtained, signed by the patient
Inform relatives about visiting hours and about anything that they may need to bring in for the patient on their next visit
Following relatives’ departure from the ward, orient patient to the ward and to the surrounding environment
Provide nursing care based on The Nursing Process
Input the patient’s particulars in the admission and discharge book
Document admission into the patient’s nursing documentation sheet
Input ward state (bed availabilities), risk of pressure injuries and any required equipment based on the patient’s admission condition into the online system

Emergency Patient Hospital Admission Procedure

Perform hand hygiene
Gather emergency equipment– vital signs apparatus, resuscitation trolley, oxygen, venepuncture equipment, suction apparatus, and an adequate bed in a suitable location based on the patient’s condition
Welcome the patient and accompanying relatives to the ward and introduce yourself and any other present HCPs
Gather all required documents such as admission papers and other important information or documentation from the accompanying nurse
Confirm patient identity through given details
Assess patient’s overall condition efficiently
Receive patient into a previously prepared bed, keeping the patient’s current condition in mind
Provide assistance to the patient to change into pyjamas or hospital gown and ensure identification bracelet and any other required tags eg. allergy bracelet is provided
Take baseline vital signs and observe further the patient’s overall appearance and reaction, level of consciousness, skin integrity, pain, breathing pattern, and any other complaints, and document
Collect relevant history from the patient or accompanying relatives
Ensure informed consent is obtained, signed by the patient (include detailed information about required emergency procedures is given to ensure informed consent)
Ensure patient valuables are taken care of
Inform relatives about visiting hours and about anything that they may need to bring in for the patient on their next visit
Following relatives’ departure from the ward, orient patient to the ward and to the surrounding environment
Collect any required specimens if needed
Administer prescribed medications
Input ward state (bed availabilities), risk of pressure injuries and any required equipment based on the patient’s admission condition into the online system
Document admission into the patient’s nursing documentation sheet

The Nurse’s Role in the Admission Process

Ensure the patient’s physical and emotional needs are met
Ensure the patient is assigned to a bed adequate to his/her personal needs and condition
Ensure that the patient’s admission report is completed
Ensure the patient is assessed using The Nursing Process
Provide a holistic approach to patient care based on the Activities of Daily Living guide whilst considering the patient’s psychological, social, spiritual, and cultural needs
Ensure the patient’s comfort and aim to reduce anxiety in both the patient and accompanying relatives

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

Transferring the Patient

During a hospital stay, the patient may require transferring from one ward to another within the same healthcare facility.

Transfer in

In a Transfer-In, a patient is moved from one unit to another, eg. from a medical to a surgical ward.

When a patient is being transferred in:

ensure a suitable bed is available to receive the patient
ensure all necessary equipment depending on the patient’s condition is readily available
ensure the patient, accompanying nurse, and any accompanying relatives are received warmly
ensure correct handover, transfer of notes, and any patient personal belongings are received from the accompanying nurse
confirm patient identity with accompanying nurse
clarify any queries pertaining to the patient’s condition
introduce yourself and other present HCPs to the patient and accompanying relatives
assess patient’s overall condition efficiently
ensure the patient is assessed using The Nursing Process
orient patient and relatives to the ward and to the surrounding environment
input ward state (bed availabilities), risk of pressure injuries and any required equipment based on the patient’s admission condition into the online system, including time of admission
document transfer into the patient’s nursing documentation sheet

Transfer Out

In a Transfer-Out, the patient can be transferred from one ward to another, or from one facility to another.

When transferring a patient out:

confirm transfer with receiving unit
assess the patient’s condition
arrange for a nurse to accompany the patient
plan for an appropriate transferring vehicle if required
collect all patient data
reduce the patient’s and accompanying relatives’ anxiety by explaining reason for transfer
obtain informed written consent for transfer
assist in the packing of the patient’s personal belongings
ensure patient’s medication, diagnostic results, and transfer notes, are all compiled as required
assist patient in dressing up adequately for the transfer
assist patient into a wheelchair or stretcher, and into an ambulance, if required
ensure patient’s notes and belongings are handed over to the accompanying nurse
input ward state (bed availabilities), risk of pressure injuries and any required equipment based on the patient’s admission condition into the online system, including time of transfer
document transfer into the patient’s nursing documentation sheet

Discharging the Patient from the Hospital

Discharge planning should start shortly after the patient is admitted, and is usually done at the discretion of the medical team, based on the patient’s overall health condition, or if the patient requests to be discharged. The patient and his/her relatives should always be informed about intended discharge plans.

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