OSCE

PREPARATION
MANUAL
for NURSES

EDITION 1

JANUARY 2016

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 OVERVIEW

What is OSCE?

The OSCE is designed to assess your ability to competently apply your professional nursing
or midwifery skills and knowledge in the UK. It is set at the level expected of nurses and
midwives as they enter the professional (at the point of registration). This means you must
show that you are capable of applying knowledge to the care of patients at the level expected
of a newly registered nurse or midwife.

The examination is testing your ability to apply knowledge to the care of patients rather than
how well you can remember and recite facts. All the scenarios and any questions relate to
current best practice and you should answer them in relation to published evidence and not
according to local arrangements.

Assessment criteria

The OSCE is made up of six stations, each lasting 15 minutes with an additional five minutes
preparation time. Four stations will be scenario based and relate to the holistic patient centred
assessment, planning, implementation and evaluation stages of nursing and midwifery care.
Two stations will be testing practical clinical skills. Please remember you will have done
these nursing or midwifery competencies many times before. Make sure that you read the
station instructions carefully. Do not be afraid to look at them again if you are unsure. You
will not be penalised for this

Typical skills which may be tested either on their own or within a nursing/midwifery scenario
include:
 vital signs
 calculating drug dosages
 intramuscular and subcutaneous injections
 basic life support - cardio-pulmonary resuscitation (adult, child, baby )
 safe disposal of sharps
 medication administration
 peak flows
 wound care
 hand hygiene

Communication skills

Communication is central to nursing and midwifery practice and will always be assessed
during the OSCE's. They will assess the full range of communication skills (verbal, nonverbal
and written) by observing the interaction between the candidate and a simulated patient (this
may be an actor or a nursing manikin) and also by assessing your nursing or midwifery
documentation.

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The examiner will assess your approach to the simulated patient all through the examination,
and they will award marks for communication skills such as:
 clearly explaining care, diagnosis, investigations and or treatments.
 involving the patient in decision-making
 communicating with relatives and health care professionals
 seeking and obtaining informed consent
 active listening
 dealing appropriately with an anxious patient or relatives
 giving clear instructions on discharge
 giving advice on lifestyle, health promotion or risk factors.
 demonstrating compassion and care during communication
 clear documentation which meets current NMC guidelines
 professional behaviour

You should speak to the simulated patient as you would any patient are meeting for the first
time. If you are being assessed using a nursing manikin please remember to verbalises you
actions and reasons for actions in the same way you would with a real patient.

Approach to the patient

 introduce yourself and explain or clarify the purpose of the nursing or midwifery
encounter.
 check what the patient wants you to call them
 be polite, respectful, non-judgemental and maintain the patient's dignity
 be empathic and acknowledge the patient's emotions or concerns and show sensitivity
to any discomfort.
 be sensitive to personal space - sit at an appropriate distance from the actor and be
aware of their body language. If you move too close and the role player moves back,
you are too close
 treat a nursing manikin as you would a real patient.

Explaining and advising

 establish what the patient already knows and or wants to know
 explain clearly what you are going to do and why, so the patient can understand
 remember to always check if the patient has any questions
 offer appropriate reassurance
 do not alarm the patient but you must be able to explain the need for urgent action if
it is required.
 always check the patient has understood
 do not routinely over-simplify names for parts of the body. It is reasonable to expect
most people will know common body name such as 'bladder', 'ovary', 'womb' and

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 'vein'. If you doubt a patients understanding, check and alter your approach to meet
the patient's individual needs. This is an important skill.
 treat a nursing manikin as you would a real patient

Involving patient in management

 respect patient autonomy and help the patient to make a decision based on available
information and advice. This includes competent explaining skills as above
 explain information and its implications so the patient can make an informed choice
about any nursing or midwifery actions.
 check the patient's understanding and feelings about the proposed nursing or
midwifery interventions. They may not always agree with your proposed plan of
care.
 treat a nursing manikin as you would a real patient

Nursing Assessment
You should be able to undertake an accurate nursing assessment and make a reasoned plan of
care if required. You should be able to:
 Assess the patient's nursing problems accurately.
 Listen attentively to the patient's problems and concerns
 Use clear language and question at a comfortable pace
 Clarify and check information and summarise understanding
 Be able to plan holistic safe and effective care based on your nursing assessment and
best practice.

FREQUENTLY ASKED QUESTIONS

1. When do I book my exam?

You can only begin the OSCE stage of the Overseas registration process once you have
received a decision letter from the NMC which will then enable you to contact us. The NMC
will inform usof a candidate's eligibility to take the OSCE. We are only able to book
candidates who have received this letter.

2. What happens next?

Once the candidate enters our process they will receive a link and password to pay, following
this a link to our online booking service will be sent. The candidate chooses a date for the test
which best suits them. They will have access to all our online resources and E-Library
following payment.

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3. How many test days are there?
The test centre is able to run OSCE’s 5 days a week. The University currently has the
capacity to run approximately 4000 individual tests per year. Dates are available throughout
the year and can be accessed to book via our secure examination booking system.
Test date - definitions:
Open – test date is open and has availability to book
Full - test date is fully booked
Closed – Date reserved for pre arranged trust or agency bookings
Please note, test dates are closed 14 days in advance to allow sufficient time for candidates to
prepare

4. How long does the test take?

All information is available to you in our e-learning library once you have booked and paid
for your test.

5. How much does the test cost?

The test costs £992.

6. How much will a resit cost?

A part resit will cost £496 and a full resit will cost £992.

7. Can I change my test date?

We allow rescheduling your test, but this has to happen at least 72 hours before your test
date. Should you notify us after this period your test fee will not be refunded as per the
university's refund policy.

8. What are the documents I need to bring on the actual test date?
Two (2) forms must be downloaded in NILE: Health Questionnaire and Confidentiality
Agreement. These forms must be printed off and brought on the actual test date.

Along with these, you must bring the Original Documents you submitted online during the
application stage. These documents include the following:
 Original passport that was submitted as part of your application and the new version if
this has now expired.
 Original birth certificate
 Any change of name documents (marriage certificate, civil partnership and deed of
name change)
 Original police clearance certificates from all the countries or states that you have
resided or practised in since the age of 18
 Original diploma or degree certificate

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  Registration certificates from all the countries or states that you have practiced and/or
registered with
 Original police clearance certificates that were submitted as part of your application
NOTE: We will not accept photocopies of any of the documents listed above.

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ASSESSMENT

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 ASSESSMENT

Assessment is a systematic, deliberate and interactive process that underpins every aspect of
nursing care. It is the process by which the nurse and patient together identify needs and
concerns. It is seen as the cornerstone of individualized care, a way in which the uniqueness
of each patient can be recognized and considered in the care process.

Principles of assessment

1. It is patient focused, being governed by the notion of an individual’s actual, potential

and perceived needs
2. It provides baseline information on which to plan the interventions and outcomes of
care to be achieved
3. It facilitates evaluation of care given and is a dimension of care that influences
outcome and potential survival
4. It is a dynamic process that starts when problems or symptoms develop, which
continues throughout the care process, accommodating continual changes in the
patient’s condition and circumstances.
5. It is essentially an interactive process in which the patient actively participates
6. Optimal functioning, quality of life and the promotion of independence should be
primary concerns
7. The process includes observation, data collection, clinical judgment and validation of
perceptions
8. Data used for the assessment process are collected from several sources by a variety
of methods, depending on the healthcare setting

Types of patient assessment

1. Mini assessment – a snapshot view of the patient based on a quick visual and physical
assessment. Consider patient’s ABC (airway, breathing and circulation), then assess
mental status, overall appearance, level of consciousness and vital signs before
focusing on the patient’s main problem.
2. Comprehensive assessment – an in-depth assessment of the patient’s health status,
physical examination, risk factors, psychological and social aspects of the patient’s
health that usually takes place on admission or transfer to a hospital or healthcare
agency. It will take into account the patient’s previous health status prior to
admission.
3. Focused assessment – an assessment of a specific condition, problem, identified risks
or assessment of care, for example, continence assessment, nutritional assessment,
neurological assessment, following a head injury, assessment for day care, outpatient
consultation for a specific condition.
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4. Ongoing assessment – continuous assessment of the patient’s health status
accompanied by monitoring and observation of specific problems identified in a mini,
comprehensive or focused assessment.

Structure of assessment

 The structure of assessment should take into consideration the specialty and care
setting and also the purpose of the assessment
 When caring for individuals with cancer, assessment should be carried out at key
points during the cancer pathway and dimensions of assessment should include
background information and assessment preferences, physical needs, social and
occupational needs, psychological well-being and spiritual well-being.
 Functional health patterns provide a comprehensive framework for assessment, which
can be adapted for use within a variety of clinical specialties and care settings.

Methods of assessment

 It should elicit both subjective and objective assessment data.

 An assessment interview must be well structured and progress logically in order to
facilitate the nurse’s thinking and to make the patient feel comfortable in telling their
story.
 Specific assessment tools should be used, where appropriate, to enable nurses to
monitor particular aspects of care, such as symptom management (pain, fatigue), over
time. This will help to evaluate the effectiveness of nursing interventions whilst often
providing an opportunity for patients to become more involved in their care.

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 ASSESSMENT PROCEDURE

Done after reading the chart and scenario:

1. Declare environment is safe. Check floor and under the bed for cable wires, water
spillages and any other obstacles that may cause slips and trips.
2. Perform hand washing. (Verbalize step by step)
3. Introduce yourself.
4. How do you want me to call you?
5. Confirm patient’s identity. Check wrist band for name, Date of Birth and hospital
number. Ask for any allergies.
OSCE TIP: Always remember IAL (Identity, Allergy, Allergy to Latex and others) in
every station
6. Do OBS (TPR BP). Check equipment if clean, safe and if maintenance check was done
and current. Ask permission to touch patient’s wrist for RR and PR check. Do not inform
patient that you are taking RR.

For subdural hematoma, include neuro OBS (GCS, papillary reaction and limbs)

For falls, include neuro obs and falls assessment. Explain the need for possible diagnostic
procedures like CT scan as standard protocol for fall patients. Assess need for referral to
PT/OT

PHYSIO 3 2 1 0 1 2 3
PARAMETERS
Respiration rate ≤8 9-11 12-20 21-24 ≥25
Oxygen ≤91 92-93 94-95 ≥96
Saturations
Any Yes No
supplemental
Oxygen
Temperature ≤35.0 35.1- 36.1- 38.1- ≥39.1
36.0 38 39
Systolic BP ≤90 91- 101- 111- ≥220
100 110 219
Heart Rate ≤40 41-50 51-90 91-110 111- ≥131
130
Level of Alert Verbal,
Consciousness Pain,
Unresponsive

NEWS Score Frequency of monitoring Clinical Response

0 Minimum 12 hourly  Continue routine
NEWS monitoring
with every OBS
1-4 Minimum 4-6 hourly  Inform RN who must
assess the patient

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  RN to decide if
increase frequency of
monitoring and/or
escalation of clinical
care is required
5 or more or 3 in one Increase frequency to  RN to urgently
parameter minimum of 1 hourly inform the medical
team caring for the
patient
 Urgent assessment by
a clinician with core
competencies to
assess acutely ill
patients
 Clinical care in an
environment with
monitoring facilities
7 or more Continuous monitoring of  RN to immediately
vital signs inform the medical
team caring for the
patient at least at
Specialist registrar
level
 Emergency
assessment by a
clinical team with
critical care
competencies which
includes a practitioner
with advanced airway
skills
 Consider transfer to
Clinical care to a
level 2 or 3 facility
(e.g. HDU or ITU)

Coma Scale
Response
Best Motor response 6 Obeys command
5 localizes pain
4 normal flexion
3 abnormal flexion
2 extension
1 none
NT not testable
Verbal Response 5 oriented
4 confused
3 words (inappropriate)
2 sounds (incomprehensible)

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 1 none
NT not testable

T – ET tube or TT
Eye opening 4 spontaneous
3 to sound
2 to pain
1 none
NT not testable

C – eyes closed by swelling

Limb movement
Response
Legs Normal power
Mild weakness
Severe weakness
Spastic flexion
Extension
No response
Arms Normal power
Mild weakness
Severe weakness
Extension
No response
NOTE: Record Right and Left separately if there is a difference between the two sides.

For asthma, peak flow. Ask if the patient has used the equipment before. If yes, ask her if
he could demonstrate how to use it properly. And note areas for improvement on its use.

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 Measuring peak expiratory flow
a. Explain the procedure to the patient. The patient can sit while performing the test
b. Demonstrate the procedure
c. Establish best or predicted PEF ideally within 2 years
d. Wash your hands (can be with an alcohol based hand rub)
e. Assemble equipment. Make sure the pointer on the meter is set at the starting
position of the scale
f. Position patient sitting upright ideally in a chair with arms and without wheels
during peak expiratory flow test as it could cause dizziness.
g. Patient must take a deep breath to full inspiration and seal the mouthpiece with
his lips and teeth around the mouthpiece.
h. Ask the patient to hold the mouthpiece horizontally to keep his fingers clear of the
sliding pointer and ask to keep his tongue clear of the mouthpiece to prevent
blocking the airflow
i. Ask him to breathe out as hard and fast as possible like a short, sharp huff not
longer than half a second each short breath. (Peak flow is reached within about a
tenth of a second.
j. Ask the patient not to spit air into the meter as this artificially raises the reading
k. Make a note of the reading and return the sliding pointer back to the starting
position.
l. Repeat 2 more times and note the readings. If the 2 best reading are more than
40 L/min apart, ask the patient to perform further blows.
m. After giving bronchodilator, you will need to wait before taking another PEF
reading. Time will vary depending on the drug used.
n. Dispose the mouthpiece according to local policy.
o. Wash hands
p. Document highest of the three readings
q. Report any concerns to manager or senior staff member
r. Ensure that the person responsible for the patient’s care is aware of the readings
to decide if any alterations to treatment or management are required.

7. Assess reason of hospitalization

Assess presence of pain or any discomfort. Ask if he wanted to attend to it first before
continuing with the assessment. (Giving of pain medications) NOTE: Check last dose
meds given at MAR chart.
PQRST of pain (Precipitating factors /Palliation/Provocation, Quality/Quantity,
Radiation, Severity, Timing)
Ask are you taking any medications right now? What sort of drugs?

To provide optimal patient care, the assessor needs to have appropriate knowledge of the
patient’s pain and an ability to identify the pain type and location. Assessment of a
patient’s experience of pain is a crucial component in providing effective pain
management. It is unacceptable for patients to experience unmanaged pain or for nurses

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 to have inadequate knowledge about pain. Pain should be measured using an assessment
tool that identifies the quantity and/or quality of one or more of the dimensions of the
patient’s experience of pain.

Questions to ask related to pain:

 Are you pain free at rest and/or on movement?
 Is the pain a primary complaint or a secondary complaint associated with another
condition?
 What is the location of the pain and does it radiate?
 When did it begin and what circumstances are associated with it?
 How intense is the pain, at rest and on movement?
 What makes the pain worse and what helps to relieve it?
 How long does the pain last, for example, continuous, intermittent, for stomach
conditions, with meals, before or after meals?
 Ask the patient to describe the character of pain using quality or sensory descriptions
(sharp, throbbing, burning)

8. Assess the 12 areas for ADL. (Focus on the 6 areas mentioned in the OSCE exam)

a. Maintaining Safe Environment

During this part of the assessment the nurse will assess the patient’s ability to
comprehend the present environment without showing levels of distress. This will
help to establish whether there are any barriers to the patient understanding their
condition and treatment. It may help them to be in a position to give informed
consent.

Questions to ask
 Do you know where you are?
Introduce the facility: hospital, Ward, location of toilet, use of call bell
 Do you know what the date and time is?
If no, orient to date and time
 Have you had any falls before?
If yes, reason of falls (dizziness, problems with gait and balance)
What he is doing when he fell?
Did he lost his consciousness or had an injury resulting from the fall (hip fracture,
bruises, concussions)
 Assess if the patient is able and ready to understand any information about their
forthcoming treatment and care and any barriers to learning
 Assess if able to communicate understanding of their condition, plan of care, and
potential outcomes or responses
 Assess if able to give informed consent

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b. Communication

The nurse needs to assess the level of sensory functioning with or without aids or
support such as hearing aids, speech aids, glasses or contact lenses, and the patient’s
capacity to use and maintain aids or support correctly. Furthermore, it is important to
assess whether there are or might be any potential language or cultural barriers during
this part of the assessment. Knowing what the norm within the culture will facilitate
understanding and lessen miscommunication problems.

Assessment focused on:

 Ability to comprehend and use information
 The sensory functions and neurological functions

Questions to ask:
 How good is your hearing and eyesight?
 Do you wear glasses?
If you see glasses or contact lenses, ask if it’s used all the time or for reading
purposes only. Ask if he wants to use it now.
 Do have any hearing aids?
 Do you have any hearing problems?
 Previous surgeries or procedures concerning eyes and ears.
 Assess if the patient is able to express their views and wishes using appropriate
verbal and nonverbal methods of communication in a manner that is
understandable by most people
 Assess if there are any potential language or cultural barriers to communicating
with the patient and provide options to facilitate or bridge such barrier or gap
 Assess need for interpreter

c. Breathing

Respiratory pattern monitoring addresses the patient’s breathing pattern, rate and
depth. It is important to assess and monitor smoking habits. It is helpful to document
the smoking habit in the format of pack years. A pack year is a term used to describe
the number of cigarettes a person has smoked over time. One pack-year is defined as
20 manufactures cigarettes (one pack) smoked per day for 1 year. At this point in the
assessment, it would be a good opportunity, if appropriate, to discuss smoking
cessation.

Questions to ask:
 Are you normally short of breath?
 Note if there is any noise when they are breathing such as wheezing? If
stethoscope is available in the testing room, assess and auscultate breath sounds
 Does breathing cause you pain?

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  Assess how deep or shallow their breathing is
 Check if breathing is symmetrical
 Has your shortness of breath become worse in the past week?
 Do you experience any other symptoms when you are short of breath?
 Have you tried smoking?
 Any other environmental factors that could trigger your respiratory condition
(asthma)
 Does the patient have any underlying respiratory problems such as COPD,
emphysema, TB, asthma, bronchitis, or any other airway disease?
 For persistent shortness of breath, explain the need to be referred to respiratory
specialist

d. Eating and drinking

As part of the nutrition assessment, the nurse should obtain an oral health history that
includes oral hygiene beliefs, practices and current state of oral health. During this
assessment it is important to be aware of treatments and medications that affect the
oral health of the patient.

Also, an in-depth assessment of hydration and nutritional status will provide the
information needed for nursing interventions aimed at maximizing wellness and
identifying problems for treatment. The assessment should ascertain whether the
patient has any difficulty eating or drinking. During the assessment the nurse should
observe signs of dehydration, for example dry mouth, dry skin, thirst or whether the
patient shows any signs of altered mental state.

Moreover, a detailed diet history provides insight into a patient’s baseline nutritional
status. Assessment includes questions regarding chewing or swallowing problems,
avoidance of eating related to abdominal pain, changes in appetite, taste or intake, as
well as use of a special diet or nutritional supplements. A review of past medical
history should identify any conditions and highlight increased metabolic needs,
altered gastrointestinal function and the patient’s capacity to absorb nutrients.

Areas to focus on:

 The pattern of food and fluid consumption relative to metabolic need
 Actual or potential problems related to fluid balance, tissue integrity

Questions to ask:
 Are you able to drink adequately? If not, explain why not.
 How much and what do you often drink?
 Have you experienced any decline in your appetite recently?
If yes, how much on average have you been eating a day?
What do you think may trigger this decline?

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 Do you feel nauseous if you try taking in food? Fluids?
 How much would you normally eat?
 Are you able to swallow or chew the food? (dysphagia)
 Is there anything you don’t or can’t eat?
 Have you experienced any taste changes? If yes, ask any new medications taken
 Have you been managing to drink fluids?
 Have you lost any weight recently?
 Do you drink any alcohol?
If yes, how often and how much?
Ask for any medications he might be taking now to see if it can be affected by
alcohol intake
Note the patient’s alcohol intake in the format of units per week and the caffeine
intake measured in the amount of cups per day.
 Do you wear dentures?
Does it perfectly fit you or it needs adjustment?
 Do you have any missing teeth or loose teeth (important for risk of aspiration)
 Explain to patient that we would need to obtain his height and weight.
 Inform patient that he will be put on red tray (for patients who require assistance
in feeding or eating)
 If there is difficulty in swallowing or decrease in food and fluid intake, inform the
patient of the need to inform the doctor for nutritional review and proper
management be done.

Nausea and vomiting

In this part you want to ascertain the patient has any history of nausea and/or
vomiting. Nausea and vomiting can cause dehydration, electrolyte imbalance and
nutritional deficiencies and it can also affect a patient’s psychosocial well-being.
They may become withdrawn, isolated and unable to perform their usual activities
of daily living.

Questions to ask:
 Do you feel nauseous?
 If already vomited, assess the frequency, volume, content and timing
 Does nausea precede vomiting?
 Does vomiting relieve nausea?
 When did the symptoms start? Did they coincide with changes in therapy or
medication?
 Does anything make the symptom better?
 Does anything make the symptoms worse?
 What is the effect of any current or past antiemetic therapy including dose,
frequency, duration, effect, route of administration?

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  What is the condition of the patient’s oral cavity?

e. Elimination

It is important to determine a baseline with regard to independence. It is focused on

the patient’s baseline observations with regard to continence or incontinence. Note
also whether there is any penile or vaginal discharge or bleeding. Does the patient
have urinary catheter in situ? If so, list the type and size. Note the date catheter was
inserted and/or removed.

Also, a detailed assessment of a patient’s skin may provide clues to diagnosis,

management and nursing care of the existing problem. A careful skin assessment can
alert the nurse to cutaneous problems as well as systemic diseases. In addition, a great
deal can be observed in a person’s face which may give insight to his or her state of
mind.

Areas to focus on:

 Excretory patterns (bowel, bladder, skin)
 Excretory problems such as incontinence, constipation, diarrhea, and urinary
retention may be identified

Questions to ask:

 Can you be able to attend to your elimination needs independently?

 Are you continent? Able to hold urine or bowel?
 How often do you normally have your bowels open?
 When was the last time?
If exceeded 3 days and is unusual (or any other unusual change in pattern of BM),
ask if he would like you to inform the doctor about it so it could be dealt with
accordingly
Ask what was done to initiate bowel movement? (eating fibrous diet, increase
water intake)
 Was there any difference with the bowel movement the last time? Was there any
mucous, loose stool, constipation or presence of blood?
 Do you have any problems passing urine?
 Any discoloration, blood and unusual smell noted in your urine?
 Are you usually independent in going to the toilet?
 Explain that as part of the admission process, it is expected to collect urine sample
as specimen. Give reassurance that it is a routine procedure
 Does the patient have any underlying medical conditions such as Crohn’s disease
or irritable bowel syndrome?
 Does the patient have diarrhea or is he prone to or have constipation?
 How often does the patient need to urinate (frequency)

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  How immediate is the need to urinate? (urgency) to assess ability to hold urine
 Do you wake up at night to urinate? (Nocturia) common for DM patients
 Do you have any wounds or sore places in the skin?
 Do your wounds heal normally or slower than usual?
 Assess for any dryness, redness, or swelling of the skin, also for any presence of
pressure sores

Grades of Pressure Ulcers

1 – non-blanchable erythema of intact skin
2 – presents clinically as an abrasion or blister
3 – superficial lesions
4 – deep lesions, extensive destruction, tissue necrosis or damage to muscle, bone
and supporting structures

Pressure Ulcer Assessment Tools

Norton Scale
Patients with a score of 14 or below are considered to be at greatest risk of
pressure ulcer development. A score of 14-18 is not considered at risk but will
require reassessment and a score of 18-20 indicates minimal risk. The cut-off
point of at risk patients was later raised to 15 or 16 by Norton.

Physical Scor Mental Scor Activity Scor Mobility Scor Incontinent Scor
conditio e Conditio e e e e
n n
Good 4 Alert 4 Ambulant 4 Full 4 Not 4
Fair 3 Apathetic 3 Walk or 3 Slightly 3 Occasionall 3
help limited y
Poor 2 Confused 2 Chairboun 2 Very 2 Usually or 2
d limited urine
Very 1 Stuporou 1 Bedfast 1 Immobil 1 Doubly 1
Bad s e

Waterlow Scale
It defines a score of 11-15 as being at risk, 16-20 as high risk and over 20 as very
high risk.
Gender 1 – Male
2 – Female
Age 1 – 14 to 49
2 – 50 to 64
3 – 65 to 74
4 – 75 to 80
5 – 80+
Build 0 – Average
1 – Above average
2 – Obese
3 – Below average

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Appetite ( only one) 0 – Average
1 – poor
2 – NGT or fluids only
3 – NBM or anorexic
Visual Assessment of Skin (one or 0 – Healthy
more) 1 – Thin and fragile
1 – Dry
1 – edematous
1 – clammy
2 – previous pressure sore or scarring
2 – discoloured
3 – broken
Mobility (only one) 0 – fully
1 – restless or fidgety
2 – apathetic
3 – restricted
4 – inert (due to decrease consciousness
or traction)
5 – chairbound
Continence (only one) 0 – continent or catheterized
1 – occasional incontinence
2 – incontinent of urine
2 – incontinent of feces
3 – doubly incontinent
Tissue malnutrition (one or more) 2 – smoking
2 – anemia
5 – peripheral vascular disease
5- cardiac failure
8 - cachexia
Neurological deficit (depends on 4-6 DM, CVA, MS, motor or sensory,
severity) paraplegia, epidural
Major Surgery trauma (up to 48 hours 2 – above waist
post op) 5 – ortho, below waist, spinal, or more
than 2 hours on theatre table
Medications 4 – cytotoxics, high dose steroids, anti
inflammatory

Braden Scale
It is based on six subscores which are scored from 1 to 4 depending on the
severity of the condition with the exception of friction and shearing which is
scored only up to 3. The total score is then added up with a possible range of 6 to
23. The lower the score, the higher the risk of developing a pressure ulcer.
Hospital patients are at risk if their score is 16 or below.

1 2 3 4
Sensory Completely Very limited Slightly No
perception limited limited impairment
moisture Constantly Very moist Occasionally Rarely moist

20
 moist moist
activity Bedfast chairfast Walks Walks
occasionally frequently
mobility Completely Very limited Slightly No limitations
immobile limited
nutrition Very poor Probably adequate Excellent
inadequate
Friction and Problem Potential No apparent
shear problem problem

f. Washing and dressing

The nurse should also evaluate the patient’s ability to meet personal hygiene,
including oral hygiene needs. This should include the patient’s ability to make
arrangements to preserve standards of hygiene and the ability to dress appropriately
for climate, environment and their own standards of self-identity.

 Do you usually wash and dress yourself? Do you do it at daytime or night time?
Do you prefer warm or cold water for your wash?
 Would you prefer a male or female nurse to assist you with personal hygiene if
required?
 Inform that if assistance is required, using the call bell would help
 Assess degree or level of assistance required (doing up buttons, brushing hair)

g. Controlling body temperature

It is carried out to establish baseline temperature and determine if the temperature is

within normal range, and whether there might be intrinsic or extrinsic factors for
altered body temperature. It is important to note whether any changes in temperature
are in response to specific therapies (antipyretic medications, immunosuppressive
therapies, invasive procedures or infection)

Questions to ask:
 Are you warm enough in this room?
 Do you feel the cold easily?
 If having fever, ask if antipyretic or any other medication has been taken to
address it, check the MAR as well.
 Ask if what other measures are being done to reduce temp

h. Mobilisation

Its aim is to establish the level of assistance required by the person to tackle activities
of daily living such as walking and steps/ stairs. An awareness of obstacles to safe

21
 mobility and dangers to personal safety is an important factor and part of the
assessment.

Areas to focus on:

 The ADLs requiring energy expenditure, including self-care activities, exercise
and leisure activities
 The status of major body systems involved with activity and exercise is evaluated,
including the respiratory, cardiovascular, and musculoskeletal systems

Questions to ask:

 Are you able to walk around independently?

 Are you able to move up and down, roll and turn in bed?
 Do you use a cane, frame, walker or any assistive devices?
 Assess if patient has good motor power in their arms and legs
 How far can you usually walk?
 Do you experience any shaking or unsteady gaits while walking?
 Do you experience difficulty initiating a walk or when stopping?
 Do you drive?
 Assess what type of assistance do they need: help with mobility or fine motor
movements such as doing up buttons or shaving
 Fall assessment tool
Do you feel steady on your feet?
If needs assistance, ask if the patient would mind to be referred to an OT or PT
Give health education on importance of using the call bell for assistance
Assess for any contractures or fractures that could affect mobility

i. Working and playing

 What would you like to do on your spare time?

 Have you been able to do these activities recently?
 Discuss if he would like to call his family if he would like to bring some of his
belongings
 Discuss resources available in the hospitals and how to access this (radio,
television)
 Volunteer to bring books or journals from the library

j. Expressing sexuality

Understanding sexuality as the patient’s perceptions of their own body image, family
roles, and functions, relationships and sexual function can help the assessor to
improve assessment and diagnosis of actual or potential alterations in sexual
behaviour and activity.

22
 Assessment in this area is vital and should include relevant feelings about the
patient’s own body, their need for touch, interests in sexual activity, how they
communicate their sexual needs to a partner, if they have one, and the ability to
engage in satisfying sexual activities.

This may also be an opportunity to explore with the patient issues related to future
reproduction if this is relevant to admission.

Area to focus on:

 The person’s satisfaction or dissatisfaction with sexuality patterns and
reproductive functions
 Concerns with sexuality may be identified

Questions to ask
 Are you currently in a relationship?
 How long have you been married?
 Is your wife fit and well?
 Do you have any children?
 Has your condition had an impact on the way you and your partner feel about each
other?
 Has your condition had an impact on the physical expression of your feelings?
 Has your treatment or current problem had any effect on your interest in being
intimate with your partner?

k. Sleeping

It is carried out to obtain sleep and rest patterns and reasons for variation. Description
of sleep patterns, routines, and interventions applied to achieve a comfortable sleep
should be documented. The nurse should also include the presence of emotional
and/or physical problems that may interfere with sleep.

 What is your normal sleeping pattern?

 How many pillows do you need to sleep with?
 Do you have any shortness of breath or any problems in breathing when asleep or
when lying down? Like sleep apnea, snoring, sleep walking, orthopnea
 Do you sleep with lights on or lights off?
 What is your bedtime routine? Like having hot bath, drink a glass of milk, cup of
tea
 Do you take any night sedation? Remind that sleeping pills, antihistamines and
other sedatives should not be taken with alcohol.
 Do you have enough energy for desired ADLs?
 Do you tire easily?

23
  Do you have any difficulty falling asleep or staying asleep?
 Do you feel rested after sleep?
 Do you sleep during the day?
 What are your normal hours for going to bed and waking?

l. Death and dying

Question to ask:
 Do you follow any religion?
Consider Advance directives, DNACPR, UFTO, spiritual and religious beliefs

9. Inform that initial assessment is done. Emphasize that ongoing assessment is

necessary during entire hospital stay.
10. Give the call bell. Instruct how and when best to use it. Showing and trying how it is
activated may be essential.
11. Ask if he wants the side rails to be up.
12. Ensure patient is safe, comfortable in his position, bed at lowest position, can
reach the table or assistive devices

NOTE: Perform hand washing or hand rub accordingly every before and after patient contact

OSCE TIPS:

 For pre and post op patients who wish to drink water, check chart if still on Nil by
Mouth status. If not, inform the patient that you will still need to verify with his
doctor if he will be allowed to take any fluids or food.
 For asthma patients, check the side table for any cigarette sticks or lighter. Health
teaching on No smoking within the hospital premises especially in the room where
there is piped-in Oxygen is a must. You can confiscate these and inform the
patient you will give it to his relatives BUT ASK PERMISSION AND EXPLAIN
IN THE NICEST AND MOST PROFESSIONAL WAY POSSIBLE
 For patients who are in pain and is requesting for a pain medication, if you are
unsure when the last dose was given, inform the patient that you will still need to
verify the time the medication was last given. Usually, pain medications given
orally kicks in 30 minutes to an hour, if the time the med was given has not pass
this time yet, inform the patient to wait for some time to allow the drug to fully
take effect.
 If glasses or spectacles or hearing aids are found in the side table, ask the patient if
he wishes to use them during the assessment.

24
 Nutrition Screening in Adults

AIM

To quickly identify patients who may be at risk of malnutrition. As all patients are potentially
at risk of disease related malnutrition, all patients should be screened when first admitted to
hospital and at regular intervals thereafter.

Malnutrition Universal Screening Tool (MUST)

It is a valid and reproducible tool that can be used in all adult-care settings in both primary
and secondary care. It has five steps:

1. Measure height and weight and calculate the BMI score

 If height could not be measured:
o Use recently documented or self reported height (if reliable and realistic)
o If the subject does not know or is unable to report his or her height, use
one of the alternative measurements to estimate height (ulnar length, knee
height or demispan)
o Estimating height from ulnar length: measure between the point of the
elbow (olecranon process) and the midpoint of the prominent bone of the
wrist (styloid process)
 If height and weight cannot be obtained
o Use mid upper arm circumference (MUAC) measurement to estimate BMI
category
o Estimating BMI from MUAC: left arm should be bent at the elbow at 90
degrees angle, with the upper arm held parallel to the side of the body.
Measure the distance between the bony protrusion on the shoulder
(acromion) and the point of elbow (olecranon process). Mark the midpoint.
Ask the subject to let the arm hang loose. Measure around the upper arm at
the marked point, making sure the tape measure is snug but not tight.
o If MUAC is <23.5 cm, BMI is likely to be <20 kg/m2
o If MUAC is >32.0 cm, BMI is likely to be >30 kg/m2
 If height, weight or BMI cannot be obtained
o The following criteria, which relate to them, can assist your professional
judgment of the subject’s nutritional risk:
 BMI – thin, acceptable weight, overweight. Obvious wasting (very
thin) and obesity (very overweight) can also be noted
 Unplanned weight loss – clothes and/or jewelry have become loos
fitting (weight loss); history of decreased food intake, reduced
appetite or swallowing problems over 3-6 months; presence of
underlying disease or psychosocial or physical disabilities likely to
cause weight loss

25
  Acute disease effect – no nutritional intake or no likelihood of any
intake for more than 5 days.

2. Note the recent percentage weight loss and score using the MUST table
If recent weight loss cannot be calculated, use self reported weight loss (if reliable and
realistic). Another useful way to monitor weight change in someone who cannot
easily be weighed is to use the percentage change in mid upper arm circumference
(see below); this will be similar to the percentage change in weight or BMI over the
same period of time.
3. Establish the acute disease effect score
4. Add the scores from steps 1, 2, and 3 together to obtain an overall risk of malnutrition
5. Use management guidelines and/or local policy to develop a care plan

BMI Score Weight loss score Acute disease effect score

0 - > 20 (>30 obese) kg/m2 0 - <5% 2 – if the patient is acutely
1 – 18.5 to 20 1 – 5 to 10 ill and there has been or is
2 - <18.5 2 - >10 likely to be no nutritional
intake for >5 days

Management guidelines (STEP 5)

Low Risk (0): Routine clinical care Repeat Screening:

 Hospital – weekly
 Care homes – monthly
 Community – annually for special
groups (e.g. those >75 years)
Medium Risk (1): Observe  Document dietary intake for 3 days if
the patient is in hospital or a care home
 If improved or adequate intake – little
clinical concern; if no improvement –
clinical concern – follow local policy
Repeat screening
 Hospital – weekly
 Care homes – at least monthly
 Community – at least every 2 to 3
months
High Risk (2 or more): Treat  Refer to dietitian, nutrition support team
or implement local policy
 Improve and increase overall nutritional
intake
 Monitor and review care plan
 Hospital – weekly
 Care homes – monthly
 Community – monthly
All Risk Categories  Treat underlying condition and provide

26
 help and advice on food choices, eating,
and drinking when necessary
 Record malnutrition risk category
 Record need for special diets and
follow local policy
Obesity  Record presence of obesity. For those
with underlying conditions, these are
generally controlled before the
treatment of obesity.

27
 Neurological Observations

Assessing consciousness

 Consciousness cannot be measured directly. It can only be assessed by observing

a person’s behaviour in response to different stimuli.
 The response the patient gives indicates the level at which the sensory information
has been translated within the central nervous system

Neurological Observations includes:

 Assessment of conscious level

 Limb assessments
 Pupil size and reaction to light
 Vital signs

Glasgow Coma Scale

 It is universally used to assess conscious level in the acute phase of brain injury
and should be charted as a graph to enable easy identification of a change in the
patient’s condition. It is more accurate in assessing altered levels of consciousness
due to cerebral trauma than medical causes of coma.

Eye opening

It looks at the arousal mechanisms and control of the eyes in the brainstem. Even when brain
damage is severe, all patients who survive will eventually open their eyes (usually 2 to 4
weeks). Spontaneous eye opening merely indicates that the arousal mechanisms in the brain
stem are active but does not necessarily mean that the patient is aware.

SCORE DESCRIPTION CRITERION

4 Spontaneous Observed before you
approach the patient or speak
to him or her
3 Eyes open to sound After spoken or shouted
request (e.g. call the patient’s
name)
2 Eyes open in response to Apply pressure to the finger
pressure tip using a pen or a pencil.
Apply pressure with
increasing intensity up to 10
seconds) until you have
applied the maximum
stimulus, used in order to
minimise the potential for
harm.

NOTE: do not apply a central

stimulus to the supraorbital

28
 nerve when assessing eye
opening, as this will cause
grimacing and eye closure
1 None No eye opening at any time,
in the absence of any
interfering factor. Ensure that
the pressure stimulus is
adequate
NT Not testable If the patient’s eye are closed
due to a local factor such as
swelling

Verbal response

It assesses 2 elements of cerebral functioning: comprehension and transmission of sensory

input and the ability to articulate a reply. An orientated response shows a high degree of
integration within the nervous system. Patient with an ET tube or Tracheostomy tube may be
able to communicate by a means other than a voice to indicate that he or she is orientated
(e.g. by mouthing words or by writing) and should be documented as such.

SCORE DESCRIPTION CRITERION

5 Orientated The patient should know who
he is, where he is, and the
month. If the patient answers
one or more component
wrongly then record him as
confused.
4 Confused Not orientated but the
patient’s communication is
coherent
3 Words Utters occasional words
rather than sentences.
2 Sounds Only moans or groans
1 None No audible response, in the
absence of any interfering
factor
NT Not testable Factors that interfere with
communication (ET tube or
trach tube)

Motor Response

In patients who have suffered traumatic brain injury, this test is the most important prognostic
aspect of the GCS. The record of the patient’s best response indicates the functional state of
the brain as a whole. You should record only responses of the upper limbs, as these are more
reliable than lower limb responses, which could be due to spinal reflexes.

29
 SCORE DESCRIPTION CRITERION
6 Obeying Commands The patient successfully
performs a 2-step action such
as grasping and release of
hand, open mouth and stick
out tongue.

If the patient does not obey

commands, peripheral
stimulus alone is inadequate
to assess the motor
component, and an additional
central stimulus is needed.

1. Trapezius pinch –
place hand over
patient’s shoulder and
press fingers into the
muscles of the
shoulder blade. Apply
pressure with
increasing intensity
for up to 10 seconds
until you are sure that
the response you
observe is the
patient’s best response
2. Supraorbital notch –
apply pressure to
supraorbital notch.
Place hand on the
patient’s forehead
with your thumb over
the upper rim of the
orbit. Feel for the
notch in the
supraorbital margin.
Apply pressure with
increasing intensity
for up to 10 seconds
until you observe best
response. Do not rate
the patient as having
an absence of
response until you
have applied the
maximum stimulus.
5 Localising If the patient responds by
bringing the hand above the
clavicle in an attempt to move

30
 the stimulus away. If the
upper limb does not reach
above the clavicle but does
flex, then the patient is
flexing either normally or
abnormally. In clinical
practice, the assessment of
these non-localising responses
is based on a combination of
both peripheral and central
stimuli.
4 Normal flexion The elbow bends and the arm
moves rapidly away from the
body and away from the
stimulus
3 Abnormal flexion The elbow bends slowly and
the arm comes across the
body (abnormal flexion may
be accompanied by a spastic
flexion)
2 Extension The patient extends the arm a
the elbow (Straightens the
elbow)
1 None No movement in arms or legs,
in the absence of any limiting
factors. You must ensure that
the stimulus is adequate.
NT Not testable If the patient is paralysed or
there are other limiting factors

Pupillary Response

 It is dependent upon intact afferent (optic nerve) and efferent (oculomotor nerve)
function transmitting the light impulse from the retina to the midbrain and to the
papillary musculature
 Dilating pupil indicates an expanding lesion on the same side
 Bilaterally fixed and dilated pupils in patient whose motor response is flexion or
localising suggests the recent occurrence of a seizure.
 Pupil abnormalities are late sign of intracranial complications, and require ICP
monitoring
 Damage to the cervical cord or brachial plexus can cause inequality of the pupils

Assessing direct light response

 Move a bright pen-torch from the outer aspect of the eye towards the pupil. The
pupil should constrict briskly.

31
  Remove the light source. The pupil should dilate to its original size. This
constriction and dilation is the direct light response. Repeat for the other eye.

Limb responses

A difference in responsiveness in one limb, compared to the other, indicates focal brain
damage. Hemiparesis or hemiplegia usually occurs in the limbs on the opposite side to the
lesion. However, they may also affect the limbs on the same side of the lesion due to pressure
on the contralateral hemisphere. This false localising sign is called tentorial herniation
(Kernohan’s notch) syndrome.

Assessing arm responses

 Hold one of the patient’s arms at the wrist and ask her to pull her arm towards her
shoulder against resistance (you should pull in the opposite direction)
 Then ask her to push you hand away, while you provide a force in the opposite
direction. If the patient has a weakness, she will not be able to resist your
movement.

Mild weakness in one arm

 Ask the patient to raise both arms above her head and shut her eyes. If she has
normal power, she will be able to hold her arms in the air.
 If there is a mild weakness of one arm, it will exhibit a drift, by slowly moving
downwards

Assessing leg responses

 Ask the patient if she can raise her leg off the bed and hold it there. If she can, but
the nurse can push it back down to the bed, a mild weakness is indicated. If the
patient can move some muscles within the limb but is not able to raise it against
gravity, severe weakness is indicated.
 Apply a downward pressure to the patient’s ankle with your hand and ask her to
raise her leg. It should not be possible to overcome the patient’s movement.

32
PLANNING

33
 PLANNING AND DOCUMENTATION

Nursing Diagnoses

 It provides a focus for planning and implementing effective and evidence-based care.
 It consists of identifying nursing-sensitive patient outcomes and determining
appropriate interventions that will enable the individual to reach their desired outcome
 When planning care, it is vital to:
 Determine the immediate priorities and recognize whether patient problems
require nursing care or whether a referral should be made to someone else
 Identify the anticipated outcome for the patient, noting what the patient will be
able to do and in what time frame.
 Determine the nursing interventions, that is, what nursing actions will prevent
or manage the patient’s problems so that the patient’s outcomes may be
achieve
 Record the care plan for the patient which may be written or individualized
from a standardized or core care plan or a computerized care plan.

Measurable and non-measurable verbs for use in outcome statements

The following words are helpful in wording your care plans. All interventions and evaluation
must be specific and measurable.

Measurable verbs (To be USED)  State

 Verbalize
 Communicate
 List
 Describe
 Identify
 Demonstrate
 Perform
 Will lose
 Will gain
 Has an absence of
 Walk
 Stand
 Sit
Non-measurable verbs (NOT to be  know
used)  understand
 think
 feel

34
Essentials of Quality Care Plans or Records

 Be patient centered
 Contain the actual work of nurses including education and psychological support
 Reflects the objective clinical judgment of the nurse
 Be logical and sequential
 Be written contemporaneously or as events occur
 Record variances in care
 Fulfill legal requirement

Members of the Multidisciplinary team and their roles

The following are information to support assessment, complete care plans for referral and
transfer of care letter at OSCE:

 Physiotherapist – support in mobilisation and chest physiotherapy, nurse referral can

be done
 Occupational therapy – support with assessing patients individual needs with regards
to ADLs, including washing, dressing, eating, and kitchen assessments. They help
identify equipment to make tasks easier for patients in hospital and at home. Nurse
referral can be done.
 Speech and Language therapy – they support patients with speech and language
problems including swallowing difficulties. Nurse referral can be done
 Discharge planning team – they help organise patients discharges who require care in
the community. Nurse referral can be done.
 Pain team – these are specialist nurses who specialise in acute and chronic pain
management of in- and out- patients. Nurse referral can be done.
 Falls coordinator – all patients who are admitted who have fallen or identified as
being at risk of falls using the falls risk tool on admission are referred to falls
coordinator.
 Respiratory specialist nurse – refer patients with chronic breathing problems for
education and support in hospital and the community
 Diabetes team – a team of specialist nurses who care for diabetic in- and out-patients.
They support diabetic patients who are unstable due to surgical intervention or acute/
chronic disease. Initial referral needs to be made to the Diabetic Registra, there after
you can refer directly to the Diabetic nurses.
 Dieticians – patients identified from the MUST tool that require intervention from the
dieticians, need to be referred by the nursing or medical team.

35
 Care Plan
Patient Details:
NAME
AGE
DATE OF BIRTH
Complete each section. Please write clearly.
NURSING PROBLEM/ NEED/ ACTIVITY OF LIVING:

AIM(S) OF CARE:

RE-EVALUATION DATE:
To be evaluated each shift or if his clinical condition changes

CARE BY NURSE(S) SELF-CARE

Explain and discuss aspects of care to (patient’s name) and (patient’s name) and his next
gain consent for all interventions of kin verbalises their
understanding of his plan of
care
(Assessment) (at least 2 self care actions
related to problem)
(Medication /Treatment / Interventions) Related to assessment,
medication or treatment,
referral
(Monitoring for effects of interventions) (patient’s name) verbalises
that she understands the
education given
(Referral) (patient’s name) will actively
participate in her care plan
Inform and reassure (patient’s name) of his plan of care
Promote (patient’s name)’s knowledge and understanding
of his treatment
Document all care as planned

Nurse Signature Date

36
 SAMPLE CARE PLANS

Pre-Operative Care Plans:

 Pain
 Safety preparation for theatre

Post-Operative Care Plans:

 Pain
 Risk of Respiratory irritation
 Risk for Hemorrhage
 Risk of Infection
 Risk for Falls

Care Plans for Stroke Patients:

 Risk for malnutrition

 Risk for aspiration
 Unable to Feed Self
 Impaired mobility

Care Plans for Asthma Patients:

 Shortness of Breath
 Activity intolerance
 Risk for aspiration during asthma attacks

CARE PLAN 1: PAIN (Pre-op)

Nursing Problem Mrs J is experiencing pain due to appendicitis

Aim(s) of Care Mrs J will state that her pain is manageable and will have a pain
score of less than 3 out of 10
Re-evaluation of Care To be evaluated each shift or if her clinical condition changes
Care by Nurses  Explain and discuss aspects of care to Mrs J and gain consent
for all interventions
 Monitor, report and document Mrs J vital signs 4 hourly
 Observe for verbal and non-verbal signs of pain, using the
pain assessment tool of 0-10
 Administer analgesia as prescribed and record on MAR chart
 Reassess Mrs J pain score 20-30 minutes after drug
administration using the same pain assessment tool and
document
 If pain relief is ineffective escalate to nurse in charge, doctors
and pain team if appropriate using SBAR
 Inform and reassure Mrs J of her plan of care
 Offer alternative management of pain such as position

37
 change, relaxation, TENS and provide literature to support
educations
 Promote Mrs J knowledge and understanding of her treatment
plan, offer time to speak to relatives when required
 Document all care as planned
Self Care  Mrs J and her next of kin verbalizes their understanding of
her plan of care
 Mrs J verbalizes that she understands the pain assessment
tool using the scoring 0-10
 Mrs J demonstrates use of call bell when she requires
analgesia
 Mrs J verbalizes that she understands the education given
 Mrs J will actively participate in her care plan

CARE PLAN 2: Pain (POST OP)

Nursing Problem Mrs J is experiencing pain due to recent appendectomy

Aim(s) of Care Mrs J will state that her pain is manageable and will have a pain
score of less than 3 out of 10
Re-evaluation of Care To be evaluated each shift or if her clinical condition changes
Care by Nurses  Explain and discuss aspects of care to Mrs J and gain consent
for all interventions
 Monitor, report and document Mrs J vital signs 4 hourly
 Observe for verbal and non-verbal signs of pain, using the
pain assessment tool of 0-10
 Observe surgical site or wound for redness, swelling,
drainage, oozing, offensive odour.
 Administer analgesia as prescribed and record on MAR chart
 Reassess Mrs J pain score 20-30 minutes after drug
administration using the same pain assessment tool and
document
 If pain relief is ineffective escalate to nurse in charge, doctors
and pain team if appropriate using SBAR
 Inform and reassure Mrs J of her plan of care
 Offer alternative management of pain such as position
change, relaxation, TENS and provide literature to support
educations
 Promote Mrs J knowledge and understanding of her treatment
plan, offer time to speak to relatives when required
 Document all care as planned
Self Care  Mrs J and her next of kin verbalizes their understanding of
her plan of care
 Mrs J verbalizes that she understands the pain assessment
tool using the scoring 0-10
 Mrs J demonstrates the use of call bell when she requires
analgesia
 Mrs J verbalizes that she understands the education
 Mrs J will actively participate in her care plan
38
 CARE PLAN 3: RISK for MALNUTRITION

Nursing Problem Mrs J is at risk of malnutrition due to decreased appetite and

feelings of nausea and vomiting
Aim(s) of Care Mrs J will have a MUST score of 0 and verbalize increased
appetite accompanied by absence of nausea and vomiting
Re-evaluation of Care To be evaluated each shift or if her clinical condition changes
Care by Nurses  Explain and discuss aspects of care to Mrs J and gain consent
for all interventions
 Assess Mrs J using the MUST nutritional tool weekly or
upon change in clinical condition, action as per protocol
 Weigh Mrs J weekly, calculating BMI and record. Action as
per MUST guidelines or local policy
 Ensure Mrs J is given assistance to choose her meals
 Monitor and record food and fluid intake
 Review intake 6 hourly
 Administer prescribed antiemetics as necessary pre-meals
 Refer to Dietician if necessary
 Observe for signs of malnutrition (e.g. loose ring band,
clothes and dentures, muscle wasting, apathy)
 Inform and reassure Mrs J of her plan of care
 Promote Mrs J knowledge and understanding of her treatment
plan, offer time to speak to relatives when required
 Document all care as planned
Self Care  Mrs J and her next of kin verbalizes their understanding of
her plan of care
 Mrs J verbalizes that he understands the MUST nutritional
tool
 Mrs J demonstrates use of call bell when she requires
assistance in feeding
 Mrs J verbalizes that she understands the education given
 Mrs J will actively participate in her care plan

Care Plan 4: Unable to Feed Self

Nursing Problem Mrs J is unable to feed himself without supervision due to left
sided hemiparesis following a stroke
Aim(s) of Care Mrs J will have a MUST score of 0 and will show improved
independence in feeding self
Re-evaluation of Care To be evaluated each shift or if her clinical condition changes
Care by Nurses  Explain and discuss aspects of care to Mrs J and gain consent
for all interventions
 Assess Mrs J using the MUST nutritional tool weekly or
upon change in clinical condition, action as per protocol
 Weigh Mrs J weekly, calculating BMI and record. Action as
per MUST guidelines or local policy

39
  Ensure Mrs J is given assistance to choose her meals
 Place Mrs J on the red tray system and inform kitchen staff
 Offer Mrs J a soft diet and ensure all fluids are thickened
with ‘Resource’, ensuring it is syrup consistency.
 Give Mrs J time to enjoy his meals, monitoring his swallow
as he eats.
 Monitor and record food and fluid intake
 Review intake 6 hourly
 Refer to OT for assessment and provision of proper eating
equipment
 Suggest use of specialized spoon and fork for stroke patients
 Refer to Dietician if necessary
 Observe for signs of malnutrition (e.g. loose ring band,
clothes and dentures, muscle wasting, apathy)
 Promote Mrs J knowledge and understanding of her treatment
plan, offer time to speak to relatives when required
 Document all care as planned
Self Care  Mrs J and her next of kin verbalizes their understanding of
her plan of care
 Mrs J verbalizes that he understands the MUST nutritional
tool
 Mrs J demonstrates use of call bell when she requires
assistance in feeding
 Mrs J verbalizes that she understands the education
 Mrs J will actively participate in her care plan

Case Plan 5: Risk of Aspiration

Nursing Problem Mrs J is at risk for aspiration due to left sided hemiparesis
following a stroke
Aim(s) of Care To reduce the risk of aspiration
Re-evaluation of Care To be evaluated each shift or if her clinical condition changes
Care by Nurses  Explain and discuss aspects of care to Mrs J and gain consent
for all interventions
 Assess Mrs J using the MUST nutritional tool weekly or
upon change in clinical condition, action as per protocol
 Weigh Mrs J weekly, calculating BMI and record. Action as
per MUST guidelines or local policy
 Ensure Mrs J is given assistance to choose her meals
 Place Mrs J on the red tray system and inform kitchen staff
 Offer Mrs J a soft diet and ensure all fluids are thickened
with ‘Resource’, ensuring it is syrup consistency.
 Give Mrs J time to enjoy his meals, monitoring his swallow
as he eats.
 Monitor and record food and fluid intake
 Review intake 6 hourly
 Refer to OT for assessment

40
  Suggest use of specialized spoon and fork for stroke patients
 Refer to Dietician if necessary
 Observe for signs of malnutrition (e.g. loose ring band,
clothes and dentures, muscle wasting, apathy)
 Promote Mrs J knowledge and understanding of her treatment
plan, offer time to speak to relatives when required
 Document all care as planned
Self Care  Mrs J and his next of kin verbalizes their understanding of
her plan of care
 Mrs J verbalizes that he understands the MUST nutritional
tool
 Mrs J demonstrates use of call bell when she requires
assistance in feeding
 Mrs J verbalizes that she understands the education
 Mrs J will actively participate in her care plan

Care Plan 6: Risk of Respiratory Irritation

Nursing Problem Mrs J is at risk of respiratory irritation from anaesthesia, pain and
discomfort and decreased mobility following exploratory
laparoscopy
Aim(s) of Care Mrs J will have a respiratory rate of 12 to 20 breaths per minute
and his breathing to be normal in depth and pattern
Re-evaluation of Care To be evaluated each shift or if her clinical condition changes
Care by Nurses  Explain and discuss aspects of care to Mrs J and gain consent
for all interventions
 Monitor and record vital signs especially respirations and
oxygen saturation as per local policy for post-operative
patients:
-Every 15 minutes for first hour
-Every 30 minutes for 2nd hour
-Hourly for 4 hours
 Administer oxygen as prescribed
 Observe for signs of tachypnea, respirations below 12,
prolonged capillary refill time. Report to Nurse in Charge,
Surgical team and outreach team
 If NEWS score is 4 or above inform Nurse in Charge,
Surgical team and outreach team, and review observations
every 15 minutes
 Refer to Physiotherapist
 Ensure Mrs J is in a position to allow for maximum chest
expansion
 Assess Mrs J’s level of pain using the pain score of 0-10
before breathing exercises and administer pain relief if
required
 Encourage Mrs J to take a deep breath, hold it for 3-5 seconds
and then breath out, supporting his wound with a pillow as he
does this
 Inform and reassure Mrs J of her plan of care
41
  Promote Mrs J knowledge and understanding of her treatment
plan, offer time to speak to relatives when required
 Document all care as planned
Self Care  Mrs J and her next of kin verbalizes their understanding of
her plan of care
 Mrs J verbalizes that she understands to use her call bell
when she requires assistance
 Mrs J verbalizes when her pain is well controlled and he is
able to carry out the deep breathing independently
 Mrs J states that she understands the need for deep breathing
exercises
 Mrs J states that she will be involved in his physiotherapy
plan, and setting targets
 Mrs J states that she will sit out in the chair for a minimum of
2 hours a day
 Mrs J verbalizes that she understands the education given
 Mrs J will actively participate in her care plan

CARE PLAN 7: Risk for Hemorrhage (Post-Op)

Nursing Problem Mrs J is at risk of post-operative hemorrhage following

exploratory laparoscopy
Aim(s) of Care Mrs J will have stable vital signs, clean, dry and intact operative
signs with no signs of bleeding
Re-evaluation of Care To be evaluated each shift or if her clinical condition changes
Care by Nurses  Explain and discuss aspects of care to Mrs J and gain consent
for all interventions
 Monitor and record vital signs especially respirations and
oxygen saturation as per local policy for post-operative
patients:
-Every 15 minutes for first hour
-Every 30 minutes for 2nd hour
-Hourly for 4 hours
 Observe for signs of tachypnea, respirations below 12,
prolonged capillary refill time. Report to Nurse in Charge,
Surgical team and outreach team
 If NEWS score is 4 or above inform Nurse in Charge,
Surgical team and outreach team, and review observations
every 15 minutes
 Observe for signs of excessive pain, reduced urinary output,
abdominal distension, swelling to extremities with
discoloration. Report any abnormalities to Nurse in Charge,
Surgical team and outreach team.
 Observe wound site in line with observations, if bleeding
present apply pressure dressing and inform Nurse in charge
surgeons.
 Promote Mrs J knowledge and understanding of her treatment
plan, offer time to speak to relatives when required

42
  Document all care as planned
Self Care  Mrs J and her next of kin verbalizes their understanding of
her plan of care
 Mrs J verbalizes that she understands to use her call bell
when she requires assistance
 Mrs J will verbalizes she understands the procedures being
carried out
 Mrs J states that she will report to staff if she is feeling dizzy
or in pain
 Mrs J verbalizes that she understands the education given
 Mrs J will actively participate in her care plan

CARE PLAN 8: FALLS

Nursing Problem Mrs J is at risk for fall due to impaired mobility

Aim(s) of Care To reduce the risk of Mrs J falling
Re-evaluation of Care To be evaluated each shift or if her clinical condition changes
Care by Nurses  Explain and discuss aspects of care to Mrs J and gain consent
for all interventions
 Complete a falls assessment within 6 hours of admission
 Assess for the need for 1:1 nursing care
 Give Mrs J and her family a copy of the leaflet on preventing
falls made by the hospital, giving them time to ask any
questions
 Ensure Mrs J has footwear or slipper socks on when
mobilising
 Place call bell within reach for assistance
 Refer to OT/PT for rehabilitation
 Assess home condition and family relations in mobility
assistance prior to discharge
 Educate patient and family importance of assistance at home
to prevent falls
 Inform and reassure Mrs J of her plan of care
 Promote Mrs J knowledge and understanding of her treatment
plan, offer time to speak to relatives when required
 Document all care as planned
Self Care  Mrs J and her next of kin verbalizes their understanding of
her plan of care
 Mrs J verbalizes that she understands to use her call bell
when she requires assistance in mobilising
 Mrs J state that she gains confidence to increase her mobility
through support from physiotherapy input daily
 Mrs J and her family will identify the support that will be
needed to facilitate a safe discharge
 Mrs J verbalizes that she understands the education given
 Mrs J will actively participate in her care plan

43
 Care Plan 9: Shortness of breath

Nursing Problem Mrs J is experiencing shortness of breath due to asthma.

Aim(s) of Care Mrs J will have a respiratory rate of 12 to 20 breaths per minute
and her breathing to be normal in depth and pattern
Re-evaluation of Care To be evaluated each shift or if her clinical condition changes
Care by Nurses  Explain and discuss aspects of care to Mrs J and gain consent
for all interventions
 Monitor and record vital signs especially respirations and
oxygen saturation as per local policy
 Auscultate lungs for breath sounds
 Measure the peak expiratory flow pre and post medication
 Administer oxygen as prescribed
 Check the MAR for due nebulisation to be administered as
prescribed
 Observe for signs of tachypnea, respirations below 12,
prolonged capillary refill time. Report to Nurse in Charge,
physiotherapist and consultant
 If NEWS score is 5 or above inform Nurse in Charge,
physiotherapist and consultant, and review observations
every 15 minutes
 Refer to Physiotherapist if needed
 Ensure Mrs J is in a position to allow for maximum chest
expansion
 Encourage deep breathing exercises
 Promote Mrs J knowledge and understanding of her treatment
plan, offer time to speak to relatives when required
 Document all care as planned
Self Care  Mrs J and her next of kin verbalizes their understanding of
her plan of care
 Mrs J verbalizes that she understands to use her call bell
when she requires assistance
 Mrs J states that she understands the need for deep breathing
exercises and proper positioning
 Mrs J states that she will be involved in his physiotherapy
plan, and setting targets
 Mrs J demonstrates correct use of peak flow meter
 Mrs J identifies allergens that precipitate an attack
 Mrs J demonstrates that she is able to administer her
nebulisers and record her peak flow pre and post medications
as per hospital policy of self-administration of medications
 Mrs J verbalizes that she understands the education given
 Mrs J will actively participate in her care plan

Care Plan 10: Risk for Infection (Post-Op)

Nursing Problem Mrs J is at risk for infection following exploratory laparoscopy

Aim(s) of Care Mrs J will have stable vital signs, clean, dry and intact operative

44
 signs with no signs of infection
Re-evaluation of Care To be evaluated each shift or if his clinical condition changes
Care by Nurses  Explain and discuss aspects of care to Mrs J and gain consent
for all interventions
 Monitor and record vital signs especially respirations and
oxygen saturation as per local policy for post-operative
patients:
-Every 15 minutes for first hour
-Every 30 minutes for 2nd hour
-Hourly for 4 hours
 Observe for signs of infection such as pain, fever, pus
formation, redness, swelling, foul odour, oozing discharges
on the operative site.
 Report any abnormalities to Nurse in Charge, Surgical team
and outreach team.
 Administer antibiotics as prescribed
 Perform wound dressing regularly using aseptic technique.
 Promote Mrs J knowledge and understanding of her treatment
plan, offer time to speak to relatives when required
 Document all care as planned
Self Care  Mrs J and her next of kin verbalizes their understanding of
her plan of care
 Mrs J verbalizes that she understands to use her call bell
when she requires assistance
 Mrs J will verbalizes she understands the procedures being
carried out
 Mrs J verbalizes that she understands the education given
 Mrs J will actively participate in her care plan

CARE PLAN 11: SAFE PREPARATION FOR THEATRE (PRE-OP)

Nursing Problem Mrs J has appendicitis and requires safe preparation for theatre
Aim(s) of Care Mrs J will verbalise that he feels safely prepared for theatre
Re-evaluation of Care To be evaluated each shift or if his clinical condition changes
Care by Nurses  Explain and discuss aspects of care to Mrs J and gain consent
for all interventions
 Monitor and record baseline observations
 Escalate if NEWS above 4 or any abnormalities to anesthetist
 Ensure MRSA results are obtained pre-operatively
 Obtain MSU and complete urinalysis
 Measure Mrs J for antiembolic stockings and verbalize its use
and importance after surgery
 Ensure consent form is completed by surgeon prior to theatre
 Complete pre-operative checklist
 Ensure height and weight is documented
 Inform and reassure Mrs J of her plan of care
 Promote Mrs J knowledge and understanding of her treatment

45
 plan, offer time to speak to relatives when required
 Document all care as planned
Self Care  Mrs J and her next of kin verbalizes their understanding of
her plan of care and the need for surgery
 Mrs J verbalises that he will inform the nurses caring for him
when he has passed urine and demonstrates understanding of
how to produce an MSU
 Mrs J demonstrates an understanding for giving consent
 Mrs J verbalizes that she understands the education given
 Mrs J will actively participate in her care plan

46
IMPLEMENTATION

47
 MEDICATION ADMINISTRATION

Key Principles

 Medicines only to be administered by trained and competent Trust staff who have
medical, nursing, midwifery, ODP qualifications against a valid Trust prescription
(order).
 Medicines must only be administered against a valid Trust prescription (order)
 Exemptions to this are:
 Patient Group Directions (PGDs)
 Verbal orders
 Students must never administer or supply medicinal without direct supervision
 Do not crush or break coated or unscored tablets, or those labelled “slow-release”
or “sustained-action”, as this may affect the delivered dose and absorption.
Crushing tablets will make their use unlicensed, so do so only with the approval of
the pharmacist and/or prescriber.
 Never break tablets unless they are scored; use a tablet splitter to break scored
tablets, otherwise you could give an inaccurate dose
 Some medicines may be administered via NGT, a jejuna tube or a PEG tube. Ask
the pharmacist for an appropriate suspension, otherwise there is a risk of blocking
the tube.
 Ensure that NGT is correctly positioned in the stomach before administering
medicines by this route; follow local policy for administration via enteral tubes
 For liquid preparations, shake the bottle before pouring the liquid. Pour any
liquids into a measuring pot on a flat surface and read the graduations at eye level
for accuracy.

OSCE TIPS

 Remember to verbally describe what you are doing and why. Read out the chart and
explain what you are checking or giving
 Complete the documentation and use the correct codes
 Interact and question the manikin as you would a patient
 The examiner will answer on behalf of the manikin
 Complete all safety checks for the administration of medicine
 Ask the addressograph label from the examiner
 Check the drugs prescribed if consists components that the patient is allergic to
 If drugs are not given, document reasons on the last page of the drug chart
 CHECK BNF and CHART before administering any medications. KNOW YOUR
DRUGS.
 It may be awkward to verify the name, hospital number, date of birth and address of
the patient during drug administration. However, explain to the patient that it is
necessary for the safety of his care

48
 For anything you are unsure of like inconsistencies, incomplete prescription DO NOT
GIVE THE MEDICATION. Explain to the patient that you will not give the
medication temporarily as you will still need to verify it with the consultant or a
senior nurse, again for the safety of his care
 Read chart completely before administration, checking that all details are completed
 Check all documentation before administering drugs, including cross checking with
Observation chart
 Check the patients identity verbally against the drug chart and wrist band
 Do a visual check of your drug trolley to check you have everything you may need
 Check expiry dates on ALL medications
 If you are unsure of any medications, use the BNF
 Check your patients knowledge about their medications
 Explain all medications when administering them and the reasons that your patient is
taking them
 If drugs are on the PRN side please offer them to your patient
 Check pain score even if medications are not due

49
 MEDICATION ADMINISTRATION PROCEDURE

1. Declare environment is safe

2. Perform hand hygiene
3. Introduce yourself.
4. How do you want me to call you?
5. Confirm patient’s identity. Check wrist band for name, Date of Birth and hospital
number. Ask for any allergies.
OSCE TIP: Always remember IAL (Identity, Allergy, Allergy to Latex and others) in
every station
6. Explain the procedure to the patient and gain consent
7. Read and verify every information in the prescription chart from the first to the
last page
8. Check if all blanks are filled and addressograph labels are placed
9. If no addressograph labels, tell the patient you will attach the addressograph
label after your encounter.
10. Check what medications are given and to be given
11. Verify if due medications are not previously given as prn medication or now dose
12. Check vital signs when you reach the Oxygen Therapy page then continue
verification
13. Perform hand washing after reading the chart
14. Prepare the materials needed.
15. Check the BNF about the drug information of the drug you are about to give.
16. Select the required medication and check the expiry date
17. Empty the required dose into a medicine container
18. Take the prescription chart to the patient and confirm their identity
19. Evaluate the patient's knowledge of the medication being offered
20. Assist the patient to a sitting position where possible. A side‐lying position may
also be used if the patient is unable to sit
21. Administer the drug as prescribed
22. Offer a glass of water, if allowed, assisting the patient where necessary
23. Stay with the patient until they have swallowed all the medication
24. Educate patient on how the drug works, its side effects, adverse effects and other
special instructions needed.
25. Emphasize use of call bell to ask for assistance when uncomfortable side effects
kicks in
26. End conversation professionally
27. Give the call bell. Instruct how and when best to use it. Showing and trying how it is
activated may be essential.
28. Ask if he wants the side rails to be up.
29. Ensure patient is safe, comfortable in his position, bed at lowest position, can
reach the table or assistive devices
30. Do after care
31. Perform hand washing

50
32. Document the medications given per hospital protocol

51
 Administration of Syrup or Suspensions

 Wash your hands. Remove the lid from the bottle and fit the bung from the
syringe. Push the syringe into the hole on the top of the bung. These syringes do
not work with Luer lock needles. Do not use a parenteral syringe for giving oral
medicines; instead, use a specific oral syringe.
 Turn the bottle upside down and slowly withdraw the correct amount of liquid.
Check that no air bubbles have entered the syringe. Give the medicine
immediately after drawing it from the bottle
 With the patient sitting upright, gently tip the patient’s head back and administer
the medicine under or above the tongue. If unable to sit, assist the patient into a
side-lying position to ease swallowing and prevent aspiration.

Administration via sublingual route

 Some medicines are given sublingually. The medicine is quickly absorbed due to the
rich blood supply in the mouth.

Administration via buccal route

 These should be placed between the cheek and the upper gum. Medicines given by
this route are likewise absorbed via the rich blood supply of the mouth.

52
 CONTROLLED DRUGS

Dispensing a Controlled Drug

• With the 2nd RN take the correct drug out of the controlled drug cupboard
• With the 2nd RN check the stock level against the last entry in the ward record book
• With the 2nd RN check the appropriate dose, concentration/strength(e.g. 10mg in 1ml)
and formulation against the prescription chart, remove the dose from the box/bottle
and place into an appropriate container.
• Return the remaining stock to the cupboard and lock the cupboard
• Enter the date, dose, new stock level and the patients name in the ward record book,
ensuring that both you and the second RN sign the entry

Administering Controlled Drugs

• With the 2nd RN, take the prepared dose to the patient and check the patients identity.
• Ask the patient if they have any allergies, checking their response against the
prescription chart.
• Check when the patient last had the medication against the prescription chart
• Administer the drug. If given orally, wait until the patient has swallowed the
medication

Post-administration of Controlled Drugs

 The prescription chart is signed by the nurse responsible for administering the
medication and the RN who witnessed the administration
 Check the patient after administration for effectiveness and/or toxicity
 If the drug is given via a syringe pump, return to check the infusion (for rate) and site
(for signs of any local complications) and document in the appropriate records

Points to Remember:
• CD register entry of stock controlled drugs
• Enter the receipt of controlled drugs into the ward CD register immediately on receipt
of the drugs.
• A separate page must be used for each formulation of drug and strength.
• Make entries chronologically in the CD register.
• Do not cross out any mistakes but bracket them and initial and date the mistake then
make a new entry on a new line.
• Ward staff should check CD stock balances at least every 24 hours. A record
indicating that this check has been carried out must be kept in the Controlled Drugs’
Register confirming the stock is correct. The entry must be dated and signed by two
qualified nurses/ midwives/ ODPs.

What to do if stock balance of controlled drugs is wrong?

• Contact the ward pharmacist.

53
• The ward pharmacist should review the CD entries and if the discrepancy is minor
may amend, date and sign the CD register to correct the balance.
• If the discrepancy is more significant then a Trust incident form should be completed
and the nurse in charge of the ward and should be informed.

54
 OSCE MARKING CRITERIA FOR MEDICINE ADMINISTRATION

CANDIDATE NAME: PASS REQUIRES FEEDBACK

IMPROVEMENT
Demonstrates environment is safe
Demonstrates hand hygiene in line with
policy
Hello my name is…
Uses effective communication skills to
explain to the patient what procedure
they are doing
Checks the drug trolley is equipped with
what they need before starting –
verbalises actions
Assesses patient and asks appropriate
questions to ascertain patients
knowledge
Checks drug chart reading it completely,
checking patient details, weight, height,
allergies, etc. Verbalising actions
Assesses patient and asks appropriate
questions to ascertain patients
knowledge
Checks drug chart reading it completely,
checking patient details, weight, height,
allergies etc. Verbalising actions
Demonstrates 5Rs (Right patient, time,
drug, route, dose)
Check BNF if unsure of the drugs they
are administering
Dispenses drugs as per protocol,
demonstrating correct checks, expiry
dates on box and blister packs
Checks the patient is in the correct
position to receive drugs
Checks that the patient has water or
suitable drink to take medications
Checks the patients wrist band alongside
chart, checking allergies etc.
Checks the patients knowledge of the
medications to be given
Administers the drugs safely, waiting for
the patient to take the medications
Ends the encounter professionally –
explain any follow up observations in
view of medications and any action to be
taken
Performs hand hygiene
55
Shows positive non-verbal and verbal
communication throughout, displaying
the 6 Cs.

56
EVALUATION

57
 GUIDELINES IN COMPLETING TRANSFER OF CARE LETTER

 ALWAYS REFER TO YOUR NURSING ASSESSMENT

 Complete the reason for admission including confirmed diagnosis
 Document the date of the original admission assessment
 Identify nursing needs:
 what are his current nursing needs?
 What interventions, observations, nutritional support are they requiring?
 Nursing approached/ interventions
 What observations are being carried out?
 What assessments are you making and frequency?
 What plan of care are you implementing?
 What referrals have you made?
 Drugs given
 What drugs has your patient had?
 Drugs omitted
 What drugs have not been given and reasons why
 Patient allergies or other risks identified
 What allergies does your patient have and what reaction does the medication/
food/ topical treatments have on the patient?
 Is the patient at risk for falls?
 Are their pressure areas intact? (presence of pressure ulcers)
 What is his MUST score?
 Are they for Resuscitation?
 Do they have any special needs?
 Do they have any implanted devices? Pacemaker/ defib/ metal work (previous
surgical history)
 Do they have any problems with alcohol or drugs?
 Moving and handling – do they require any assistance?
 Identified potential areas for patient education
 Nutritional support – dieticians, speech and language referral
 Increased alcoholic or drugs intake – drug and alcohol referral, detox regime
 Uncontrolled or new diabetic – diabetes team referral
 New anticoagulant therapy – pharmacy referral and clinic appointment for
follow up
 Falls risk – referral to falls coordinator
 Identified actual or potential problems which may delay or affect discharge to home
 Social circumstances – do they live alone? Have they got support or care
packages? Can they cope at home?
 Physiotherapy - Has their mobility changed?

58
  Occupational therapy – do they need any equipment at home? Change in
function?
 Nutrition – are they going home with enteral feeding? TPN?
 Wounds – do they need follow up care in the community by the Practice Nurse
or district nurse?
 Opportunities for developing self care
 Involving patient in all care (promoting independence)
 Goal setting with the patient and their families
 Occupational therapy to assess ADL – providing equipment which promotes
independence or supports relatives and carers to care for the patient safely
 Nutritional or dietary advice - Providing literature to support aspects of care

59
CLINICAL SKILL

60
 ASEPTIC TECHNIQUE

DEFINITION

It refers to a method used to maintain asepsis and protect patients from infection. It is a
procedure for ensuring asepsis and for preventing the transfer of potentially pathogenic
microorganisms to a susceptible body sites and the sterile parts of devices in contact with a
susceptible site, are not contaminated during procedures.

PROCEDURE

1. Prepare the patient and environment

Ward cleaning activities should be minimized (or stopped). Draw the curtains for
privacy. Position the patient comfortably. Close the windows. Expose the body area
required. These should be done at least 30 minutes prior the procedure.
2. Declare environment is safe
3. Perform hand hygiene
4. Introduce yourself.
5. How do you want me to call you?
6. Confirm patient’s identity. Check wrist band for name, Date of Birth and hospital
number. Ask for any allergies.
OSCE TIP: Always remember IALP (Identity, Allergy, Allergy to Latex and others,
Pain) in every station

7. Explain the procedure to the patient and gain consent

Refer to the patient’s notes as necessary. For example, read the wound dressing plan

8. Perform hand hygiene

Wash and dry your hands. Close the tap using your elbows or paper towels. Dispose
paper towels in the general (black) waste bag.

9. Clean the working area

Use detergent or alcohol-based wipes to clean all areas then allow surface to dry.
Verbalize that the trolley should be cleaned with soap and water every 24 hours and
supposing that it has been cleaned already with soap and water for that day, you will
use Clinell wipes to cleam your working area. Clean top shelf first then legs with one
Clinell wipe and dispose to black bin. Then, clean the bottom shelf and foot legs with
another Clinell wipe.

10. Select and check equipment

Check the expiry dates of the sterile packs and fluids and check that the packaging is
intact. Materials to be used: sterile pack, sterile cleaning fluid, clean and sterile
gloves, alcohol gel, extra waste bag (orange), dressing material, extra gauze if needed.

11. Gather equipment

61
 Place all gathered equipment in the lower shelf or in tray if used. Warm any wound
cleansing fluids to body temperature to reduce cooling of the wound bed.

12. Put on apron

Put the neck strap over your head and then tie the straps up at the back.

13. Perform hand hygiene

Clean your hands by decontaminating with alcogel or by handwashing.

14. Re-assess pain score

This is to ensure patient is comfortable during the procedure

15. Loosen the dressing now

You can use bare hands if you see that the dressing is clean with no blood. But if you
have a bloody dressing you can use clean gloves.

16. Open the sterile pack

Open the outside of the sterile pack and let the inner sterile pack slide out onto the
trolley surface with the folded sides uppermost. Avoid contaminating the clean
surface of the trolley or sterile field with any part of your body.

17. Unfold the sterile pack

Hold the paper by the corner edges only in unfolding the sterile pack. If the sterile
pack you are using does not contain a waste bag, attach a waste bag to the side of the
trolley now.

18. Arrange the materials within your pack using the orange waste bag
To maintain sterility of the pack, you can use the orange waste bag using aseptic non-
touch technique to arrange the materials found inside your sterile wound care pack.

19. Remove the dressing

You can use the same orange waste bag to remove the dressing and invert it inside out
afterwards before placing it to the side of the trolley nearest the patient.

20. Assess the wound

The best time to check and assess the wound is at this junction. You should verbalize
your assessment and provide health education when necessary.

21. Open any other equipment

Open any sterile equipment into the sterile field, without touching the sterile field
with the equipment’s non-sterile outer packaging.

22. Arrange the pack contents on the sterile field

62
 Arrange the items on the sterile field using either a pair of sterile forceps or if a sterile
waste bag is included in the pack, by putting this over your hand like a glove.

23. Removing a dressing

You can keep the sterile bag over your hand to remove a loosened, soiled dressing,
and then invert the bag so that the dressing is inside it. Also, if you used sterile
forceps to arrange the sterile field, you can use these to remove the dressing and
discard these with the dressing into the waste bag. If you need greater dexterity, you
can wear clean gloves to remove it and dispose it to infective (orange) bags before
proceeding.

24. Attach the waste bag to the trolley

Attach the bag to the side of the trolley between you and the patient so that you will
not need to stretch across the trolley to dispose of waste. Pull the edge of the bag open
so that you can easily drop in used items.

25. Perform hand hygiene

26. Open any cleaning solution
If opening a saline sachet, clean the perforation area with an alcohol swab first,
allowing it to dry for 30 seconds. You can say that supposing the cleaning solution
has been dried for 30 seconds then proceed to the next step.

27. Pour the cleaning solution

Tear the perforation and pour the fluid into the sterile container on the sterile field,
avoiding splashing.

28. Clean your hands

Clean hands using alcohol based handrub.

29. Put on sterile gloves

Put on sterile gloves while avoiding contamination.

30. Place the sterile towel to make a sterile field near the wound area
Check patient is comfortable while making a sterile field.

31. Avoid contaminating sterile gloves or other sterile items

Do not touch any part of the patient’s body. Do not touch the bed, other furniture,
your own face or hair, or any other non-sterile areas. Once any equipment has been
contaminated, you must discard it and not return it to the sterile field.

32. Carry out the aseptic technique

Observe patient all throughout. Drop used items into the waste bag during the
procedure so that the sterile field remains as clean as possible. Use one wipe
technique in cleaning the wound. One hand should remain clean and the other hand

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 should remain sterile. Be sure to wipe the wound with dry gauze after wiping it with
sterile saline solution.

33. After the procedure

Check that the patient is comfortable before leaving the bedside when the procedure is
complete.

34. Remove and dispose gloves

Put the gloves into your sterile field then fold all used equipments together.

35. Dispose of waste

Put all remaining disposable items into the waste bag.

36. Place call bell within reach of the patient

This is to maintain patient safety. Provide health teachings on when the dressing
should be changed next: usually every 3 days or if the dressing is already soiled and
soaked with blood and other discharges. Provide also health educations on signs of
infection and to report it to the nurses and other members of the healthcare team. If
such case is suspected, inform of possible swab test done for culture.

37. Dispose orange waste bag to the orange bin

38. Remove and dispose apron
Pull forward on the front of the side of the apron, without touching your clothing, to
break the apron waist straps. Roll apron up, without touching your clothing. Then
snap the neck of the apron, avoid pulling against your neck. Dispose of the apron
according to local policy. (**clinical skills**)

In the NILE video, pull the waist straps then the neck straps then roll it downwards
without touching your clothing.

39. Wash your hands

40. Clean the trolley using same technique
41. Make a Wound Care Plan

OSCE TIPS:

 If you miss out equipment and you are on sterile gloves, you can ask the examiner to
act as assistant and get the missed item for you.
 During the OSCE, sterile packs may be expired. Just verbalize that in normal
instances, you wouldn’t use the packs but for Exam purposes you will use it to carry
out the procedure.
 At the end of the procedure, the examiner will ask you if you miss out anything, take
this opportunity to inform him of any missed out steps in the procedure
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 If in any case you think you contaminated yourself, explain to the examiner that you
contaminated yourself and at normal circumstance you will and should not carry
along and use the same contaminated equipment. All contaminated items must be
discarded.
 Watch the video on Wound Dressing in NILE
 Watch the proper hand washing technique video in NILE
 Even performing hand rub, use the proper hand washing technique.
 It is important to verbalize how to prepare the environment for the procedure (closing
the windows, stopping any ward cleaning environment while drawing of curtains
should be enacted.
 Maintain patient dignity and privacy at all times
 Checking all items are intact and expiry dates
 Stating that you have considered preparation of the environment prior to the
procedure
 Checking status of pain before you prepare your equipment
 Ask your patient if they have any allergies and check their wrist band *remember
allergies relating to latex and dressings
 Check documentation to see if they have an existing wound care plan
 Explain all aspects of care to the patient and give time to answer questions
 Think about how you will describe the wound to the patient
 Educate them on what to look for with regards to infection and also what they can and
can’t do: For example, they can shower
Dependant on operation, they must be able to do an emergency stop before driving
again and check with their insurance company.

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 HAND HYGIENE

Critical Points for Hand Hygiene

 Immediately before each episode of direct patient contact or care including clean or
aseptic technique
 Immediately after each episode of direct patient contact or care
 Immediately after contact with body fluids, mucous membrane or non-intact skin
 Immediately after other activities or contact with objects or equipment in the
immediate patient environment that may result in the hands becoming contaminated.
 Immediately after the removal of gloves

General Principles

 In order to be able to thoroughly decontaminate your hands, including the wrists, wear
short-sleeved clothing when delivering patient care
 Cover any cuts or abrasions with a waterproof dressing, to minimise the risk of cross-
infection by pathogenic microorganisms
 Ensure that your nails are cut short
 Remove all wrist jewellery and hand jewellery before delivering care
 You must carry out hand washing with soap and water in preference to other types of
hand decontamination if your hands are visibly soiled or after direct contact with the
patient and his environment.
 Bar soap for handwashing should not be used as this may harbour and encourage the
growth of microorganisms.
 Alcohol based hand rub or gel provides a good alternative to handwashing with soap
and water as it is effective, quicker to use, well tolerated on skin, and should be
available at the point of care in all healthcare facilities.
 Hands should be washed with soap and water after several applications of alcohol
hand rub or gel.
 Alcohol hand rub or gel should not be used on hands that are visibly soiled.
 Antiseptic solutions are not recommended for routine hand washing as regular use has
been linked to skin damage. It is used when a higher level of hand hygiene is
necessary (surgical procedure)
 Nailbrushes are not recommended for routine social handwashing. They can act as
vector for transferring microorganisms from one person to another. For surgical
procedures, it is essential to use single use nail brushes.
 Emolient hand cream should be used regularly

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 PROPER HAND WASHING TECHNIQUE

1. Wet hands first

2. Apply soap or cleanser
3. Lather soap well for a minimum of 10 to 15 seconds, ensuring hands remain outside
of the running water.
4. Rub hands palm to palm
5. Rub palm of one hand over the other hand with fingers interlaced then vice versa
6. Interlace fingers and rub vigorously
7. Interlock the fingers in opposing palms and rub to decontaminate back of the fingers
8. Rub each thumb in each palm, rotating and vice versa
9. Rub fingertips of one hand in other palm, rotating and vice versa
10. Rub each wrist, vice versa
11. Rinse hands and wrists thoroughly in running water
12. Turn off hand operated taps with paper towels or elbows
13. Dry hands thoroughly using paper towels

OSCE TIPS:

 Perform hand washing at all stations except planning and evaluation.

 Even when you use hand rub, you need to perform the same hand washing
technique
 You can use hand gels for Basic Life Support Station
 Do not forget to verbalize how you do your hand washing

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 IM OR SUBCUT INJECTIONS

Different Sites for IM Injections

 Deltoid Muscle (Upper Arm Muscle)

Completely expose the upper arm. You will give the injection in the center of an
upside down triangle. Feel for the bone that goes across the top of the upper arm. This
is called the acromion process. The bottom of it will form the base of the triangle. The
point of the triangle is directly below the middle of the base at about the level of the
armpit. The correct area to give an injection is in the center of the triangle, 1 to 2
inches below the acromion process. This site should not be used if the person is very
thin or the muscle is very small.

 Dorsogluteal Muscle (buttocks)

Expose one side of the buttocks. With an alcohol wipe draw a line from the top of the
crack between the buttocks to the side of the body. Find the middle of that line and go
up 3 inches. From that point, draw another line down and across the first line, ending
about halfway down the buttock. You should have drawn a cross. In the upper outer
square, you will feel a curved bone. The injection will go in the upper outer square
below the curved bone. Do not use this site for infants or children younger than 3
years old. Their muscles are not developed enough.

 Ventrogluteal Muscle
Place palm of hand on the patient’s opposite greater trochanter (right hand on left
hip). The index finger is then extended to the anterior superior iliac spine to make a V.
Injection in the center of the V will ensure the injection is given to the gluteus medius
muscle.

 Rectus femoris
Measure a hand’s breadth from the greater trochanter and the knee joint, which
identifies the middle third of the quadriceps muscle.

 Vastus lateralis
It is the outer muscle of the thigh beside the femur bone.

Equipments needed

 70% Alcohol Swab

 Needle
 Syringe
 Drug to be Administered

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  Clinically clean receiver or tray
 Apron
 Non-sterile Gloves
 Sharps Bin
 Drug Chart

Procedure

1. Declare environment is safe

2. Perform hand hygiene
3. Introduce yourself.
4. How do you want me to call you?
5. Confirm patient’s identity. Check wrist band for name, Date of Birth and hospital
number. Ask for any allergies.
OSCE TIP: Always remember IAL (Identity, Allergy, Allergy to Latex and others) in
every station
6. Explain the procedure to the patient and gain consent
7. Read and verify every information in the prescription chart from the first to the last
page
8. Check if all blanks are filled and addressograph labels are placed
9. If no addressograph labels, tell the patient you will attach the addressograph label
after your encounter.
10. Check what medications are given and to be given
11. Verify if due medications are not previously given as prn medication or now dose
12. Check vital signs when you reach the Oxygen Therapy page then continue verification
13. Perform hand washing after reading the chart
14. Prepare the materials needed.
15. Check the BNF about the drug information of the drug you are about to give.
16. Select the required medication and check the expiry date
17. Bring all materials needed near the patient
18. Take the prescription chart to the patient and confirm their identity
19. Assess again for any known allergies
20. Evaluate the patient's knowledge of the medication being offered
21. Assist the patient comfortably in bed. Preferably in a high back or semi high back
rest position if tolerated.
22. Perform hand hygiene following correct technique
23. Apply non sterile gloves
24. Check the following: Right drug, dose, time, route, diluent, and validity of the
procedure
25. Prepare the drug in the syringe using aseptic non-touch technique. Use a filter needle
or 23 gauge needle if drawing up medication from the glass ampoules.
26. Change needles after drawing up from bottle.
27. Leave ampoules in injection tray with prepared injection
28. Remove clean gloves

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29. Remove appropriate garment to expose injection site.
30. Perform hand hygiene
31. Apply new unsterile gloves.
32. Assess injection site for inflammation, edema, infection and skin lesions
33. Clean injection site with swab saturated with 70% isopropyl alcohol using one wipe
technique and allow to dry for 30 seconds.
34. With non dominant hand, stretch the skin slightly around the injection site.
35. Holding the syringe in the dominant hand like a dart, inform the patient and quickly
plunge the needle at an angle of 90 degrees into the skin until about 1 cm of the
needle is left showing
36. Pull back the plunger, if no blood is aspirated, depress the plunger at approximately
every 10 seconds and inject the drug slowly.
37. If blood appears, withdraw the needle and get a new set of needle. You might have hit
an artery or went deeper and not a muscle.
38. Withdraw the needle after administration.
39. Apply gentle pressure
40. Do not massage area
41. Do not recap the needle and dispose it properly to the sharps bin
42. Do after care
43. Position patient comfortably in bed
44. Place call bed with the patient
45. Perform hand hygiene
46. Document the medication administration in the MAR.

70
BASIC LIFE SUPPORT

71
 BASIC LIFE SUPPORT

Cardiac Arrest

 Implies a sudden interpretation of cardiac output. It may be reversible with

appropriate treatment
 Caused by four arrhythmias
 Asystole
 Ventricular fibrillation (VF)
 Pulseless ventricular tachycardia (VT)
 Pulseless Electrical Activity (PEA)
 8 common causes of arrest (4H and 4T)
 Hypoxia
Common causes of being hypoxic
 Acute respiratory failure
 Airway difficulties
 Acute lung injury
 Severe anemia
 Neuromuscular disorders

When the body’s supply of oxygen is interrupted for more than 3 minutes, cell
death occurs, followed by lactic acidosis and very rapidly a CP arrest.

 Hypovolemia
Common causes of severe blood loss
 trauma
 surgical procedure
 GI mucosa erosion
 Esophageal varices
 Peripheral vessel erosion (usually due to tumor)
 Clotting abnormality

Treatment is identifying and stopping the source of fluid or blood loss and
replacing the circulating volume with the appropriate fluid. Fluid resuscitation
is normally started with a crystalloid (Plain NSS) or colloid (Gelofusin). Blood
is likely required if blood loss exceeds 1500 to 2000 mL.

 Hypothermia
It should be suspected in any submersion or immersion injury. A person who
was normothermic at the onset of cardiac arrest may become hypothermic.

 Hypo or hyperkalemia

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 Potassium is closely linked with muscle and nerve excitation, any imbalance
may affect both the nervous conduction and the muscular working of the heart.
A severe rise or fall in return may cause arrest arrhythmias.

Causes of hypokalemia
 GI fluid losses
 Urinary fluid losses
 Drugs that affect cellular potassium (e.g. antifungal agents like
amphotericin)

Patients who are most at risk of hyperkalemia are those with renal failure or
Addison’s disease. Immediate treatment is to give intravenous calcium. This
has the effect of protecting the myocardium during the cardiac arrest.

 Thromboembolism
Massive pulmonary embolus is the most common cause. Thrombolysis,
cardiopulmonary bypass and operative removal of the clot are the options for
definitive treatment.

 Tension pneumothorax
It is the sudden collapse of the lungs, usually under pressure, which results in
severe change in intrathoracic pressure and cessation of the heart as a pump.
Most common causes are:
 Trauma
 Acute lung injury
 Mechanical ventilation of the newborn

Immediate treatment is the insertion of a large bore cannula into the second
intercostals space at the midclavicular line of the affected side.

 Tamponade (cardiac tamponade)

It is an acute effusion of fluid in the pericardial space and as it enlarges, the
heart is splinted and finally cannot beat. The fluid is usually blood but can be
malignant or infected fluid. The most common cause is trauma.

Immediate treatment is the insertion of a catheter or surgical drainage of the

fluid. After drainage, the cause of the tamponade should corrected (e.g.
antibiotic therapy for infection or surgical repair of myocardial laceration).

 Toxicity (metabolic or drug induced)

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 CASE SCENARIOS

SCENARIO 1

You are a staff nurse working on an elderly care ward. Mr A is an elderly gentleman who was
admitted during the night after a fall at home. He is a little bit confused, which is unusual for
him but during more lucid moments he is extremely anxious about the welfare of his wife for
whom he is the primary carer.

Due to his quick departure from his house, he hasn’t got his medications or any clothes. He
can’t tell you the names of the medication but he is taking something for his heart, something
to help him sleep and Paracetamol for joint pain particularly his arthritic knees. He normally
walks with a stick, but this is at home. He is complaining of feeling “quite stiff” after his
“tumble” and is reluctant to get out of bed.

His vital signs are: T 38 C, RR 22 cpm, Oxygen saturation 98%, BP 165/90, HR 93 bpm and
irregular. ECG shows fast artial fibrillation. His pallor is “flushed” and he doesn’t stop
talking to you whilst you are taking his observations, despite you requesting silence for the
procedure. He also looks extremely thin and tells you he is “off his food lately”. He has two
daughters but they live miles away.

SCENARIO 2

Admitted to ward C7 at 11 am from the A and E department under the care of Mr Jah,
hepatobillary team, bleep number 152 453.

A 45 year old lady called Joanna Brown admitted to general surgical ward with abdominal
pain. Her pain score on admission to the ward is 6. She has no allergies. Joanna was swabbed
for MRSA in the Emergency Department and has no other Special needs, or implanted
devices.

Joanna is married with 2 children, and lives with her husband in a 3 bedroom house. Joanna
works as a teaching assistant full time. She is practicing Catholic and White British. Her
husband is the next of kin and lives at the same address.

Joanna has a previous history of depression and had a cholecystectomy 3 years ago. Her
general health is good. She takes Citalopram 20 mg once a day. Her provisional diagnosis is
Pancreatitis. Both her husband and her are aware of her provisional diagnosis. Joanna is
worried about her children and husband being at home without her.

Joanna is normally healthy but has had pain for about 4 days prior to admission accompanied
by nausea and vomiting. So she has not slept well. Her urine output is concentrated and she
has not had her bowels open for 2 days. She has not eaten for a few days and has only been
tolerating water in small amounts. Joanna does not drink alcohol. Joanna weighs 65 kg and is
1.62 m in height.

74
Upon arrival to the ward she is able to transfer to bed independently, with assistance of 1
nurse. She has IV fluids in progress so needs some help with her ADLs. Joanna has no
history of pain or falls.

SCENARIO 3

Tom Jackson, a 78 year old widower, has been admitted to the elderly assessment ward
following an episode of severe breathlessness. He is a retired mill worker and has been
treated by his GP for chronic chest condition with inhalers and tablets. He says he is a bit
confused with the inhalers and tablets. He lives alone in a terraced house since the death of
his wife some 12 months ago. The house is rather damp and is in need of some repairs and
modernisation as he only has a coal fire in the downstairs room. His only daughter lives a few
miles away and visits once or twice a week with his two grandchildren.

He smokes 10-15 cigarettes a day even though he is rather wheezy and his coughing keeps
him awake at night. He used to enjoy a visit to the local pub but finds the walking too
troublesome now as even going from room to room is difficult at times. He says that he has
lost some weight since his wife dies as he cannot shop or cook very well. His daughter does
not bring prepared meals with her when she visits but he prefers plain food so doesn’t always
eat them.

Over the last few days, he has felt too tired to shave himself or wash his hair. He has to stop
many times during the interview assessment to rest and cough. You note that his respirations
are rapid and that he has a loose cough and is expectorating some sputum.

SCENARIO 4

Mrs. Morgan is 68 years old and was admitted overnight following a fall. A CT Scan has
diagnosed a Subdural hematoma. She has a history of Atrial Fibrillation and has been taking
warfarin for 2 years. Mrs Morgan has no history of falls and this is her first admission to
hospital for 2 years.

Mrs Morgan is quite unsteady on her feet and describes feeling dizzy. She is very anxious
and is accompanied by her husband who is also anxious and asking lots of questions.

Mrs Morgan was admitted to the ward from the A and E department at 8am this morning, it is
now 9am. She is currently NBM but is complaining of feeling really thirsty. There is a litre
bag of Hartmans solution in progress intravenously. Mrs Morgan is also complaining of
headache, with a pain score of 5.

75