Behind the Rituals
All posts from: September 2011
Should you routinely record respiratory rate? What do you think?
Measurement of respiratory rate should be undertaken meticulously, following local protocols and EWS guidelines. It is necessary to count the number of respirations in a minute. If patients realise their breathing is being watched, the rate may actually increase. To avoid this, healthcare professionals can pretend to check the radial pulse while, at the same time, counting the respiratory rate.
- Critical illness: it is an important component of the ABCDE approach;
- Ascertaining a baseline respiratory rate for comparison;
- Monitoring changes in oxygenation or in respiratory rate.
- Evaluating response to treatment, for example, following administration of a beta-2 agonist in the treatment of asthma.
- Jevon P (2010) How to ensure patient observations lead to prompt identification of tachypnoea. Nursing Times;106: 2, 2010.
Author Phil Jevon is resuscitation officer and clinical skills lead, Manor Hospital, Walsall.
Does it matter which way up a rectal suppository is inserted? What do you think?
Rectal suppositories are conveniently shaped medicated solid preparations for insertion into the rectum. They can vary in weight and usually consist of solid vegetable oil that dissolves at body temperature. Suppositories are manufactured in a torpedo shape with a pointed end (apex) and a blunt end. The blunt end is often concave forming a useful indention for the tip of a finger to push against.
The rectal route of drug medication is relatively painless and particularly useful for patients who are fasting or nil-by-mouth before or after surgery and for patients who are unable to tolerate oral medication
due to nausea and or vomiting. Suppositories also provide a useful route for medication in children who have needle phobia. Suppositories may be used for both local and systemic effect.
Historically suppositories were inserted pointed end first until the publication of a small study by Abd-El-Maeboud et al (1991) who recommended that suppositories were inserted blunt end first. The research suggests that suppository retention is more easily achieved if suppositories are inserted blunt end first because the squeezing action of the anal sphincter against the apex pushes (sucks) the suppository into the rectum. The research was pivotal in informing clinical practice culminating in clinical text books advocating a blunt end in first for suppository insertion.
However, if a suppository for local effect is inserted blunt end first using the anal sphincter to assist with insertion there is no guarantee that the suppository will be in contact with the bowel wall. Suppositories need body heat in order to dissolve and become effective. This could subject the patient to an ineffective, undignified and invasive procedure.
On the other hand, patients administering their own suppository may find blunt end more acceptable as there no need to insert the finger into the anal canal to push it in. This lends weight to inserting the blunt end first - especially if the suppository is for a systemic effect, as rectal absorption is more effective lower in the rectum as veins draining from this part of the rectum join the internal iliac veins. This means medication returns directly to the inferior cava, bypassing the portal circulation.
Gaye Kyle is the chair of the ACA education committee
Should hospital nebuliser masks be single-use items? What do you think?
It is important that nebuliser chambers are clean and dry before use. Medication is delivered directly to the lungs and could, if contaminated, be a source of infection. To ensure appropriate hygiene nebulisers are either single use, denoted by the symbol, and disposed of after each administration, or single-patient use, enabling nebulisers to be washed and dried in between treatments. It is important that single-use devices are not re-used as the durability of the product often diminishes after one use, resulting in poor performance (and therefore potentially poor drug delivery).
Cost consideration is an issue: single-use nebulisers, although often cheaper per item, can be more costly per inpatient episode. In A&E it may be cheaper to use single-use equipment, whereas in ward areas single-patient nebulisers may be a more cost-effective choice. Nursing staff time can be an additional resource consideration if regular washing is needed. However, if patients are expected to continue nebulised therapy after discharge their stay in hospital can be an ideal opportunity to teach them correct use, and delegating responsibility for cleaning to them supports self-management and independence.
Carol Kelly is a senior lecturer at Edge Hill University, Lancashire.