Behind the Rituals
All posts from: August 2011
Can nurses assess patients with suspected swallowing problems or do they have to be referred to a speech and language therapist? What do you think?
“Nurses can and should assess the basic swallowing of their patients. Nurses should provide an environment suitable for a patient to consume fluid, this means ensuring they are upright, preferably in a seated position, with good upper balance. A patient should be tried with a small amount of water, and observations for coughing, gurgling, wet voice should be undertaken. If a nurse suspects a patient is having difficulty safely swallowing, many trust’s will provide a further nursing assessment, which has been supported by the SLT, this will enable you to carry out a further assessments. Referrals should only be made to a SLT once there is a validated concern relating to these initial assessments, for the specialist support.”
Neil Wilson is a senior lecturer and admissions tutor in pre-registration adult nursing at Manchester Metropolitan University.
Do partners of expectant mothers need to wear full scrubs during child birth? What do you think?
My initial short answer would be no, what a ridiculous idea! For those of us privileged to be involved with the everyday miracle that is childbirth, whether that is in a hospital or home setting, the idea that in normal circumstances the mum and babe need to be somehow protected from the father or partner is nonsense. I would suggest he or she needs to be clean, and it’s always helpful if they are sober and not loaded with something infectious, but generally in my experience the need for full scrubs is negligible!
However, there may be circumstances when scrubs are required, e.g. where delivery is taking place in a hospital theatre environment, where scrubs are part of the routine infection control procedure, or where the mother’s immune system is at risk where all involved with the delivery may need to “scrub up”.
In these examples, scrubs would be a specific requirement for a particular situation. To suggest that as a general rule fathers should wear full scrubs during child birth suggests perhaps too much exposure to American television, with little thought as to how it may be enforced!
Having had to diplomatically suggest to a father that underwear at the least was the accepted mode of dress for him in the birthing pool, I could anticipate there may be problems getting him into full scrubs!!
B Knight, midwife
Are nasal cannulas the best way to deliver oxygen to patients with COPD? What do you think?
The use of nasal cannulas is common for patients with chronic obstructive pulmonary disease (COPD). This is often patient choice, as cannulas allow them to eat, drink and speak, and are often more comfortable than masks when they are receiving oxygen for long periods of time. Cannulas can also feel less claustrophobic, which is an important consideration for a patient experiencing breathlessness.
A note of caution however. Nasal cannulas may not be suitable in acute exacerbations of COPD. Oxygen administration is described as controlled or uncontrolled. Nasal cannula, simple face masks and non-rebreathe masks are uncontrolled, while fixed high-flow concentration masks such as Venturi deliver controlled oxygen.
The amount of oxygen a patient receives from an uncontrolled device depends on variables including depth and rate of breathing, which can alter during acute episodes and produce unexpectedly high concentrations of inspired oxygen. This issue is important, especially for patients with chronic hypercapnia, and can lead to serious or even fatal consequences. These patients require controlled oxygen therapy during an acute phase. This allows oxygen of a known concentration to be delivered and titrated according to the patient’s oxygen saturation (target saturation 88-92%) irrespective of breathing pattern, without the risk of hyperoxia and worsening hypercapnia (BTS, 2008). Nasal cannulas can be substituted once the patient has stabilised.
Carol Kelly is a senior lecturer at Edge Hill University, Lancashire.
- British Thoracic Society Emergency Oxygen Guideline Group (2008) Guideline for emergency oxygen use in adult patients. Thorax; 63: Supp VI: vi1-vi73.
Should tap water be used to cleanse wounds? What do you think?
One of my abiding memories is of a nurse sending a patient with a post-operative pilonidal sinus excision wound for a shower and then irrigating the wound with a sachet of sterile normal saline before applying a dressing. There have been many reviews of wound cleansing which demonstrate a variety of solutions, fluid volumes and delivery techniques such as syringes of differing gauges with or without a needle.
A Cochrane update (2010) reinforced its original conclusion that using tap water (straight from the tap, boiled and cooled, or distilled) in adult acute wounds does not result in more wound infection than normal saline. They also remind us that there is little “strong evidence” that cleanings per se reduces infection or affects healing rates.
Studies have focused on chronic, acute and traumatic wounds. In the community people with leg ulcers routinely have their legs washed in a lined container with many benefits to patients’ comfort, skin care and general well being. Unanswered questions include cleansing for immune-compromised patients (but they are more likely to be on antibiotics which complicates studies) and comparing showering with administration of fluids via a syringe or other delivery device. A DoH letter circulated in 2010 expressed concern about the cleanliness of taps and sinks which may warrant further investigation in bathing facilities
The major question is whether the wound needs to be cleansed at all; if the surrounding skin is managed the wound may well be best left moist and warm as long as there is not an excess of chronic wound exudate or debris in the wound bed.
Ritualistic practice arises from a lack of engagement with the literature, lack of time for practice based discussions and adherence to a procedure that is not thought through logically. Many patients could shower and if the facilities were appropriate there is scope for a great reduction in costs.
Irene Anderson is a Reader in Learning and Teaching in Healthcare Practice and Programme Tutor, Tissue Viability, University of Hertfordshire
Should patients requiring vital signs monitoring every four hours be woken at 2am to have their observations recorded? What do you think?
Recording patient observations is an important part of nursing routine and an essential skill to be able to detect changes in the patient’s condition. A “one-off” or isolated observation is of little use unless compared to recent trends in clinical status. If a nurse is concerned about a patient enough to be motivated to carry out four hourly observations then that patient should be woken to have those observations recorded. However, nurses should also feel empowered and confident enough to be able to adapt their routine to reflect a patient’s progression towards recovery.
Sleep is an important component of patient recovery and one of the most essential activities of daily living. Sleep deprivation is associated with delirium, which in turn has a negative effect on patient rehabilitation. This leads to increased length of stay in hospital, which corresponds with increased cost and, most importantly, is unpleasant for the patient. Nurses should be able to carry out an “end of bed” observation without waking a sleeping patient. That is, be able to assess whether the patient has a patent airway, observe respiratory pattern and count the respiratory rate and be able to detect whether the patient is well perfused and, therefore, whether the patient has a adequate cardiac output. Nurses should also trust their instinct and if they feel the patient is deteriorating the question they should ask themselves should be whether four hourly observation is enough or should the patient be monitored more regularly or even continuously. At this point medical or critical care intervention should be sought.
David Jones, Charge Nurse, Critical Care.